General Flashcards
Which tumours are associated with adrenal metastasis?
Lung and breast
Adrenaline vs Noradrenaline
Adrenaline Alpha and Beta Noradrenaline predominantly alpha Alpha - peripheral vasoconstriction Beta - cardiac chronotropic and inotropic
What is dopexamine
Splanchnic vasodilator
Scaly, thick and greasy appearance.
Keratin plugs
Seborrhoeic Keratoses
Name 4 clinical features of a mass/swelling that make it suspicious of being a sarcoma
> 5cm soft tissue mass
Deep / Intramuscular Location
Rapidly Growing
Painful
Ewings vs Osteosarcoma
Ewings is a diaphyseal, small round tumour.
Radiologically - Onion Skin appearance- represneting lysis with periosteal elevation.
Osteosarcoma is usually a tumour of the metaphysis (osteoblastic cell origin)
Radiologically - sunburst appearance = sclerotic destruction
Discuss Anterior Interosseus Nerve
Topography
Innervation
Topography:
Branch of the emdian nerve —> travels along anterior interossues membrane of the forear between flexor pollicus longus and flexor digitorum profondus ending at pronator quadratus
Innervates:
Flexor Pollicis Longus
Pronator Quadratus
Radial Half - FDP
Anion Gap
Calc
Causes
Calculation (Na+K+)-(Cl+HCO3)
Normal 10-18
Low Anion Gap
hypoalbuminaemia, increased cations (MG++, Ca++, IgG),
Normal Anion Gap - Hyperchloraemic
Bicarb Loss, Renal Tubular Acidosis (moreso in type II), Drugs (Acetozolamide), Chloride Injection, Addison’s Disease (Type IV RTA)
High Anion Gap
Lactate, Ketoacidosis, Urate, Exogenous Acids
Causes of delayed gastric emptying
Neuronal:
Vagotomy, Diabetic Gastroparesis (Vagal Nerve Disruption)
External Compression:
Pancreatic masses abutt the duodenum thereby delaying ewmptying,
Internal Obstruction:
Distal Gastric Malignancies, Pyloric Stenosis
Ileostomy
Location
Construction
Complications
Location: Triangle between ASIS, Umbilicus and symphysis pubis.
Construction: 2cm incision, stoma length 2.5 cm, spouted, one third between umbilicus and ASIS.
Complications: Dermatitis, necrosis, prolapse, retraction, high output
Normal stoma output: 5-10 ml/kg/24 hour period. If >20 ml/kg/24 hour period —> IV fluids and supplementation
Vagina lymph vessel drainage:
Superior
Inferior
Superior - drain into the internal + external iliac nodes
Inferior - drain into the superficial inguinal nodes
Contents of jugular foramen
Bones forming jugular foramen
Bones: Posterior Occipital bone + Petrous portion of temporal bone
Contents - CN IX, X, XI. Inferior Petrosal Sinus, Sigmoid Sinus, Meningieal arteries (from occipital and ascending pharyngeal artery)
Contents of Superior Orbital Fissure
CN III, IV, VI
Recurrent meningeal artery
Superior Opthalmic Vein
V1 - Lacrimal, Frontal and Nasociliary
What do each of these secrete:
Parietal Cells
Chief Cells
Surface Mucosal Cells
Parietal Cells - HCl, Ca, Na, Mg, IF
Chief Cells - Pepsinogen
Surface Mucosal Cells - Mucus and Bicarbonate
Dep Peroneal nerve
Course
Action
What (sometimes) atraumatic condition can it become compromised in?
L4-S2
Branch of common peroneal nerve at lateral aspect of fibula. Travels in anterior leg comparment. passes ankle anteriorly between two malleoli where it bifurcates:
Pre - Bifurcation: - Tibialis anterior, enxtensor hallucis longus, extensor digitorum longus, peroneus tertius
Lateral - Branch supplies extensor hallucis brevis and extensor digitorum brevis
Medial - cutaneous branch innervating skin at the webspace between 1st and 2nd digits
Acts to - evert foot, dorsiflex ankle and extend toes
It can become compromised in compartment syndrome of the anterior compartment
Berry’s Sign
Absence of carotid pulse due to thyromegaly
Thyroid Malignancy:
Psammoma Bodies
Skull Metastases
Elderly females
Pappilary - Psammoma Bodies. Picked up via FNA
Lymphatic spread
Follicular - Not well picked by FNA –> need hemithyroidectomy. Haematogenous spread (bones)
Anaplastic - Elderly females. Poor prognosis. palliative debulking
Otosclerosis
Patho
Treatment
Fixation of stapes to oval window
Treatment involes stapedectomy + prosthesis insertion
Pethidine caution in…
Renal patients
It has a toxic metabolite which accumulates in renal dysfunction —> Muscle twitching and convulsions
Pharyngeal Pouch
True diverticulum (Zenker’s)
Involves all layers of mucosa.
Posteromedial herniation between thyropharyngeus and cricopharyngeus
Discomfort after eating - think..
Chronic Mesenteric Ischaemia
Mesenteric Vascular Disease
Acute Mesenteric Ischaemia - Embolic. Sudden onset pain, vomiting and diarrhoea
Acute on chronic - Post-prandial discomfort –> Acute
Mesenteric Venous Thrombosis –> Picture of weeks. Symptoms present when arterial inflow is compromised
Low flow mesenteric infarction –> inotrope use, intercurrent cardiovascular compromise
Describe rectus sheath
Above costal margin –> Aponeurosis of external oblique aponeurosis
Between costal margin and arcuate line –> Anterior rectus sheath - External oblique aponeurosis + anterior internal oblique aponeurosis. Posterior rectus sheath- Posterior internal oblique aponeurosis + Transversus abdominus
Below arcuate line –> There is no posterior rectus sheath. External and internal oblique aponeurosis alongside transversus abdominus form anterior rectus sheath. posterior to this is transversalis fascia then peritoneum.
Arcuate line is 1/2 between umbilicus and pubic crest
Transfusion protocol in major haemorrhage due to trauma
1:1:1 - Packed Red Cells, FFP and platelets
What are adrenal rests
Adrenal rests - ectopic adrenal tissue.
Commonly located on broadligament or spermatic cord.
Extensor retinaculum
Attachments
Structures superficial to retinaculum
Tunnels
Tendons (8)
Attachments -
Medial - pisiform and triquetral
Lateral - Radius
Superficial structures -
Basilic + cephalic vein
Dorsal cutaneous branch of ulnar nerve
Superficial branch of radial nere
Tunnels -
6 tunnels in total.
Tendons-
Enxtensor Carpi Ulnaris, Extensor Digiti Minimi, Extensor Digitorum and indicis, extensor pollicis longus, extensor carpi radialis longus tendon, extensor carpi radialis brevis tendon, abductor pollicis longus, extensor pollicis brevis tendon .
What muscles are innervated by median nerve
Forearm
Distal forearm
Hand
Forearm - Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor pollicis longus, flexor digitorum profondus (radial half)
Distal forearm - palmar cutaneous branch
Hand -
LOAF - Lateral 2 lumbricals, opponens pollicis, abductor pollicis previs, flexor pollicis brevis
Sensory innervation to thumb and lateral 2.5 fingers
Management of Renal Cell Carcinoma
T1 Malignancy - Partial Nephrectomy + Adjuvant chemotherapy
T2 Malignancies - Total radical nephrectomy. Patients need early venous control prior to resection to rpesent tumour seeding.
JVP
Absent a waves
Large a waves
cannon waves
prominent v waves
slow y descent
steep y descent
JVP rises during inspiration
Fixed Raised JVP
Absent A Waves - AF
Large A Waves - Right ventricular hypertrophy, triscupid stenosis
Cannon Waves - Complete Heart Block
Prominent v waves - Tricuspid Regurgitation
Slow y descent - Tricuspid stenosis, Right Atrial Myxoma
Steep y descent - Right ventricular failure, Constrictive pericarditis, Tricuspid regurgitation
JVP rises during inspiration - Kussmaul’s sign of constrictive pericarditis
Fixed Raised JVP - Superior Vena Cava Obstruction
Factors favouring EVAR
Long neck of aneurysm (For fusiform aneurysms - neck is the unaffected proximal portion of artery)
Good Groin Vessels
Straight Iliac Vessels
Billous Vomiting in Neonate - Rule out
Briefly describe embryological problem
What happens in the abdomen
Investigations
Intestinal Malrotation (+volvulus)
Normal embryology involves intestine entering abdominal cavity at 4 weeks –> Then a 270 degree rotation so the:
- caecum is in the RLQ
- DJ flexure is to the left of vertebrae
In intestinal malrotation - there is a missing 90% rotation –> the duodenal loop is adjacent to the caecum with Lads Bands fixing it in place.
Then the intestine undergoes 720 degree rotation –> volvulus.
Investigations :
US - Abdomen: See where the SMA is in relation to the SMV (Normally SMA on left of SMV)
Contrast abdominal scan: see where the DJ flexure is (usually to the left of vertebral bodies)
What is the ligament of treitz
Ligament of Treitz:
Suspensory ligament arising from right crus of diaphragm and attaching at the DJ flexure and usually at the 3rd + 4th parts of duodenum
Microscopic difference between
Thyroid:
Follicular Adenoma
Follicular carcinoma
Carcinoma has invasion of the capsule whereas adenoma do not.
Posterior Interossus Nerve
Origin
Topography
Muscles Innervated
Origin - Division of the radial nerve (occurs by lateral epicondyle between brachialis and brachioradialis)
Crosses supinator where it formally becomes the posterior interossues nerve
Innervates - Supinator + Extensor carpi ulnaris
Extensor digitorum, indices, digiti minimi, extensor pollicis longus + brevis, abductor pollicis longus
Testicular Tumours
RFs
Investigations
RFs- Cryptorchidism, Kinefelter’s, Infertility, FH, Mumps orchitis
Investigations - US, Tumour markets, CT- TAP for staging
Classically Categorised:
Seminoma (40 year olds) - AFP -ve, HCG <20% +ve, LDH <20% +ve
Germ Cell (non-seminoma) (<30 year olds) - 70% AFP +ve, 40% HCG +ve
Cranial Nerve IX and X Muscle exceptions
IX - This innervates Stylopharyngues - muscle for swallowing. All other pharyngeal muscles are innervated by Vagus nerve
This is because the stylopharyngeus develops from III pharyngeal arch. CN IX is also developed from this arch.
X - Cricothyroideus is innervated by the external laryngeal nerve. All other laryngeal muscles are innerated by Recurrent laryngeal nerve
This is because Cricothyroideus originates from arch IV alongside the vagus nerve. the RLN originates from arch VI
Causes of dysphagia
Extrinsic: Mediastinal Masses, Cervical Spondylosis
Oesophageal Wall: Achalasia, Diffuse oesophageal Spasm, Hypertensive Lower Oesophageal Sphincter
Intrinsic: Stricture, Schatzki Ring, malignancy, Oesophagal Web
Neurological: CVA, Bulbar Palsy, Multiple Sclerosis, Parkinson’s Disease, Myasthaenia Gravis
On Sentinel Node Biopsy of breast what might you find?
Isolated Tumour Cells or Evidence of Micrometastases
Isolated Tumour Cells - Do not require axillary clearance
Micrometastases - Depends on the extend of nodes involved. If there are lots of suspect nodes then FNA of theese nodes is the first thing to do.
In practice –> Positive SNLB usually equates to axillary node clearance
Current best practice.
Varicose Veins
i) Investigation
ii) Treatment
i) hand held doppler and then Venous Duplex
ii)
1- Endothermal Ablation
2- Sclerotherapy
3 - surgery (trendelenberg procedure)
Obturator Nerve
Roots
Topography
Actions
Roots - L2 ,3 and 4
Topography - roots combine in psoas major and descend to lateral sacral margin –> Cros sacroiliac joint –> Descend through obturator internus entering the obturator groove. Lies lateral to internal iliac vessel + ureter
Actions -
Cutaneous - Medial thigh
Motor - External obturator, Adductor magnus - upper portion, Adductor Longus, Adductor Brevis and gracilis.
Options if common bile duct has been opened/damaged?
i) T Tube insertion and closure of the bile duct over it
ii) Cholecoduodenostomy
iii) Cholecojejunostomy
Options for relieving malignant obstructive jaundice (pancreatic head ca / cholangiocarcinoma)
i) ERCP
ii) PTC + Drainage + Stent Insertion
Tongue Lymph Drainage
Anterior two thirds:
Ipsilateral Drainage
Posterior Third:
Bilateral Drainage
Tip of tongue: Submental –> Deep cervical
Midtongue: Submandibular –> Deep cervical
Posterior tongue: Deep cervical
Tongue innervation + Nerve topography
Anterior Two thirds:
Lingual nerve - originates as a branch of mandibular nerve (V3). passes tensor veli palitini –> joined by chorda tympani (facial nerve CN VII). Courses by junction of vertical/horizontal mandibular ramus –> passes by the third molar .
The Trigeminal Portion –> Sensation (General Sensory)
The Facial Portion –> Taste (Special Sensory
Posterior Third
Glossopharyngeal nerve - Sensation + Taste (General and special senory)
Why may you have a normal ph acute mesenteric emobolus?
The bowel infarct –> Lowers pH
Vomiting –> Raises pH
Four mechanisms of vomiting
Gag - Touch Receptors in throat (CN IX), Pharyngeal Cosntrictors (CNX + CNIX for stylopharyngeus)
Labyrnthine disorders - Motion Sickness
Stomach and duodenal distension - stretch receptors
Central (brain) - chemically induced (drugs etc.)
PR Bleeds
Source:
Darker Blood
Dark Blood
Fresh red Blood
Melaena
Investigations
Darker Blood - Right sided bleed
Dark Blood - Left sided bleed
Fresh red Blood - Distal bleeding (haemorrhoids)
Melaena - Upper GI
Investigations:
When blood –> Flexi Sig first. If no lesion then consider colonoscopy
When blood + unstable –> Stabilise + CT Angio
When melaena –> OGD
When to admit for acute lower GI bleeding
Age >60
Significant Co-Morbidity
Unstable
Profuse bleeding
Aspirin/NSAID use
Surgical options for splenic flexure malignancies:
Obstructed
Non-Obstructed
Obstructed -
i) Stenting
ii) Extended Right Hemicolectomy. This involves taking the middle colic vessels (SMA) too unlike a right hemicolectomy. An ileo-colic anastamosis is fashioned. In general when performing resective colorectal surgery the arteries are followed and taken to ensure lymph nodes are removed as these are usually in close proximity to the arteries.
Non-obstructed -
i) Extended Right Hemi
ii) Left hemi
iii) Transverse colectomy (old-fashioned)
Rectal Cancer
What is the margin requirement
What precludes the use of Anterior Resection
What is TME
What surgery for obstructed rectal cancer
What additional treatment can be offered to rectal cancer patients (surgery, chemo + ?)
Margin - 2cm margin requirement
Anterior resection is precluded if there is sphincter involvement or if the margin would involve the sphincter –> The surgery of choice would be an APER (Abdomino-Perineal Resection)
TME - total mesenteric excision. This involves the dissection of mesorectal fat + lymph nodes
Obstructive rectal tumours –> Defunctioning Loop Colostomy( Differs from colonic tumours where aim can be to resect and anastamose immediately if safe)
Rectal cancer can be treated with radiotherapy as it is extraperitoneal
Management of Weber Fractures
Weber Fractures - malleolar fractures
A - Below syndesmosis. Full Weight Bearing with ankle boot
B - At level of syndesmosis. If stable (Unimalleolar) then ankle boot and mobilise. If unstable - Below knee plaster and no weight bearing for six weeks
C - Above level of syndesmosis - Inherently unstable. Fixation, syndesmosis reconstruction with screws.
By what mechanism does ECF Volume depletion cause Metabolic Alkalosis
Losing significant bodily fluid through vomiting or diuretics results in a loss of Na+ + Cl-
This leads to RAAS activation –> aldosterone causes increased ENaC channels so more Sodium crosses from lumen into cells.
Luminal K+ channels upregulated so potassium is lost to the lumen.
Na+K+ATPase at interstitial side of cells is upregulated —> K+ is moved into the cell whereas Na+ is moved into interstitium.
These three transporter changes lead to an increase loss of K+ to the collecting duct lumen and a preservation of Na+
Loss of K+ Leads to K+/H+ Buffering. K+ moves from cells into ECF in exchange for H+ —–:> Alkalosis
Brisk duodenal ulcer
Treatment
Brisk Duodenal Ulcer - Usually posteriorly sited and invading the gastroduodenal artery. Duodenal ulcer pain occurs several hours after eating.
Treatment:
Resuscitate
Surgery - Laparotomy –> Duodenotomy. Underrunning the ulcer by biting above and below ulceration point which will also occlude artery. Transverse closure
Gastric Ulcer Surgical Management
Antral ulcer
Lesser Curve Ulcer
Antral Ulcer- Partial Gastrectomy (If underunning doesn’t work)
Lesser curve ulcer - Partial Gastectomy / Under Running (Usually involves Left gastric artery)
Some patients will need a total gastrectomy.
Size threshold for surgical repair of rotator cuff tear
> 2 cm
Where do the rotator cuff muscles attach
Lesser Tuberosity - Subscapularis (subscapualr fossa)
Greater Tuberosity - Supraspinatus (supraspinatus fossa), Infraspinatus (infraspinatus fossa), Teres Minor (lateral border)
Neer Classification
For proximal humeral fractures
Described as 2,3 or 4 part depending on how many fragments
- Greater Tuberosity
- LEsser Tuberosity
- ARticular Surface
- SHaft
Supports for the uteres
Central Perineal Tendon - Perineal body. This is essential. Extends between vagina and anus.
Round ligament - Uterine horns –> through inguinal canal –> mons pubis
Transverse Cervical/ Cardinal Ligament - Attaches to obutrator fascia on pelvc side wall
Uterosacral ligament - from uterus to anterior aspect of sacrum
what is the broad ligament
The broad ligament is a fold of peritoneum that envelops the uterus, ovaries and fallopian tubes.
It folds over the fundus of the uterus forming the:
Mesometrium (covers the uterus)
Mesovarium (covers the ovaries)
Mesosalpinx (covers the fallopian tubes)
investigating large bowel obstruction
First line:
DRE, AXR, ?Rigid Sigmoidoscopy
Then:
CT- AP
If inconclusive –> Gastrograffin follow through
Impending signs of perf in LBO
Caecal >12 cm
Competent Ileocaecal valve
Caecal tenderness
Managing local anaesthetic toxicity
Max Doses
Intralipid:
Bolus- 1.5 ml/kg over 1 minute
Infusion - 0.25 ml/kg/minute
If prilocaine is used then administere methylene blue
1st dose - neat/ 2nd dose w/adrenaline
Lignocaine - 3 mg/kg. 7 mg/kg
Bupivicaine - 2 mg/kg 2 mg/kg
Prilocaine - 6 mg/kg 9 mg/kg
Prilocaine
Procedures for lymphodoema
Homans - skin preserving procedure ( where skin is good). Skin flaps formed and then underlying subcutaneous tissue excised
Charles - skin and underlying subcut tissue all excised down to fascia. split skin grafts are applied. used for poor overlying skin condition.
Lymphonvenous anastamosis - exclusively for proximal obstruction + good distal lymphatics. Anastamoses between distal lymph structure and deep vein.
Why is tissue black in gangrene?
Hb degeneration and deposition of iron sulphide
Best test for vWD
Bleeding Time (factor VIII may also be low)
vWD can be Autosomal Dominant:
Type I - Quantitative deficiency of vWF
Type 2 - Qualitative impariment of synthesis of vWF
Autosomal Recessive
Type 3 - Absolute deficiency in vWF
Causes of diarrhoea
Campylobacter
Shigella
Salmonella
EColi
Yersinia
Vibrio Cholera
Camp - Most common. Gram Negative Rod (comma shaped). Reactive Arthritis, GBS
Shigella - Gram negative bacilli. Dysentry
Salmonella - Gram negative, facultative anaerobe, enterobactericiae.
ECOLI - ETEC, EIEC, EHEC
Yersinia Enterocolitica - Gram Negative coccobacilli. Terminal Ileitis - mimic Crohn’s/ Appendicitis.
Cholera - Gram Negative Rods. Watery diarrhoea
Sartorius
Supplied by Anterior Femoral Nerve (L2-L3)
ASIS –> proximal tibia
Flexes - knee and hip
Medially rotates femur.
Which Coag factors to the following influence:
Heparin
Warfarin
Liver Disease
Disseminated Intravascular Coagulation
Heparin - 2,9, 10, 11
Warfin - 2, 7, 9 , 10
Liver disease - 1, 2 , 5 , 7, ,9, 10, 11
DIC - 1, 2, 5, 8, 11
Lymphatic drainage of male genitalia
To the:
Inguinal Nodes
Iliac Nodes
Where is the external sphincter (urethral) in males?
Where does sperm enter urethra?
Deep Inguinal Nodes - Spongy urethra, Glans Penis
Iliac Nodes - membranous urethra, prostatic urethra
External Sphincter surrounds - Membranous urethra (membranous urethra extends from prostate –> perineal membrane)
Where does sperm enter urethra - prostatic urethra
Colonic Polyp Risk (colonoscopy)
Low
Medium
High
Low:
1-2 adenomas - < 1 cm No follow Up
Medium:
3-4 adenomas/ 1 adenoma >1cm - 3 year follow up
High:
5 or more Adenomas/ 3 adenomas + 1 being >1cm - 1 year follow up
Infective organism:
Large bowel ulcers and necrosis
EnteroInvasive E Coli
Structures passing through the Parotid Gland
Facial Nerve (superficial)
Retromandibular Vein ( next most superficial)
External Carotid Artery (deep to the vein)
Auriculotemporal nerve
What is diaphragm disease
Due to long term NSAID use
Small bowel becomes seperated into compartments where there is thickened circular mucosal abd submucosal membranes —> focal areas of small callibre lumens –> frequent small bowel obstructions
Which nerve is responsible for flexing thumb
Solely median nerve
Forearm - flexor pollicis longus
Hand - flexor pollicis brevis
What drain is used surgically after CBD exploration?
T Tube:
Latex. This is to induce a fibrotic reaction so a tract will form
What is sibson’s fascia?
Fascia overlying the apex of both lungs
C7-first rib (inbetween thoracic cage + parietal pleura)
Right Lung Anatomy
Three Lobes - Seperated by oblique and transverse fissure
Azygous Vein - Just above hilum
Superior vena cava + inominate vein - Groove is further above hilum
Oesophagus - Behind Hilum
Inominate Artarey - Near apex
IVC groove- near lower part of the oesophageal groove
Left Lung Anatomy
Two lobes - Seperated by oblique fissure
Groove for aortic arch - Above HIlum
Groove for subclavian artery - Furhter Above hilum
Groove for descendign aorta - behind hilum
Oesophagus - lower part of the lung
JVP Deflections
a
c
v
x
y
Ascents
a - trial contraction
c - ventricular contration
v - atrial venous filling
Descents
x - atrial relaxation
y - ventricular filling / atrial emptying
Superficial peroneal nerve
Deep peroneal nerve
Arise when common peroneal bifurcates between fibula and peroneus longus
Superficial -
peroneal longus and brevis
Cutaneous - lateral lower third of leg and most of dorsum of foot (except lateral foot which is supplied by sural nerve and medial leg which is supplied by saphenous nervee)
Deep -
Tibilaris anterior, peroneus tertius, Extensor hallucis longus, extensor digitorum longus + brevis
Terminates into medial and lateral branches
Cutaneous supply - first web space
Psoas Major and Minor
Major - originates from lumbar vertebrae and attaches onto lesser trochanter
Innervated - Anterior Rami of L1-L3
Minor - High lumbar origin and attaches to pubic crest (superior)
Innevated - anterior rami of L1
Blood tests for carcinoid tumours
Urine Tests
Chromogranin A
Neuron Specific Enolase
Substance P
Gastrin
Urine-
5 HIAA
5 Hdyroxytriptamine
Tumour Genetics Colorectal
FAP
HNPCC
Cowden
Peutz Jehger
FAP - APC mutations (TS Gene)
HNPCC - MSH2, MLH1, PMS2 + GTBP (Amsterdam Criteria, DNA Mismatch repair Genes)
Cowden - PTEN (Autosomal Dominant)
Peutz Jehger - LKB1, STK11
Divisions of the laryngeal cavity
Vestibule - Superior to vestibular folds
Ventricle - between vestibular folds and vocal cord
Infraglottic - vocal cord to cricoid cartilage
Muscles of the larynx (6/7)
Posterior Cricoarytenoid - Abduct vocal fold
Lateral Cricoarytenoid - Adduct Vocal fold
Thyroarytenoid - Relax Vocal Fold
Transverse + Oblique Arytenoids - Close Rima Glottidis
Vocalis - Relaxes posterior part of vocal ligament and tenses anterior part of vocal ligament
Cricothyroid - Tenses vocal ligament (Innervated by External Laryngeal Nerve)
Vascular Supply of Larynx
Lymph Drainage
Superior and Inferior Laryngeal Arteries ( branches of superior and inferior thyroid arteries )
Superior and inferior Laryngeal veins drain into the Superior and Middle thyroid veins Respectively
Lymph Drainage of Larynx:
Supraglottic - Upper Deep Cervical
Subglottic - Prelaryngeal + Pretracheal + Inferior Deep Cervical
Vocal Cords don’t have lymphatic drainage
Femoral Triangle:
Borders
Structures
Borders:
Lateral - Femoral Vein
Medial - Lacunar Ligament
Anterior - Inguinal Ligament
Posterior - Pectineal ligament
Structures:
Lymphatic Vessels, Cloquet’s Lymph Node
Desmoid Tumours
Associated with which GI Disorder
What Structures do they arise from
Associated with FAP (APC Tumour Suppressor Gene Mutations)
They are proliferations of myofibroblasts arising from Musculoaponeurotic Structures
Male Genital injuries
i) Meatal Haematoma, Perineal Haematoma, Urinary Retention
ii) High Riding Prostate, Perineal Oedema/ Haematoma, Pelvic Fracture
iii) haematuria, suprapubic pain, inability to retrieve all irrigation through bladder
i) Bulbar Urethral Rupture
ii) Membranous Urethral Rupture
iii) Bladder Rupture
For Urethral Injury:
Ix - Ascending Urethrogram
Mx - Surgical Suprapubic Catheter
For Bladder Injury:
Intraperitoneal - Laparotomy
Extraperitoneal - Conservative
Diaphragmatic Apertures:
T12
T10
T8
T12 - Aortic
T10 - Oesophageal
Oesophagus + Vagus Trunks
T8 - Caval
IVC +Right Phrenic Nerve
Classifying Open Fractures
What should be empirically done
Gustillo and Anderson Classification System:
I Low Energy wound <1cm
II - >1cm wound with modeate soft tissue damage
IIIA - High Energy (>1cm) + Adequate tissue coverage
IIIB - High Energy (>1cm) + Inadequate soft tissue coverage
IIIC - High Energy (>1cm) + Arterial Injury
Empirically - Tetanus Prophylaxis + Broad Spectrum Abx + Check neurovascular status + Debride and lavage
p53 germline mutations –> Cancer<45
Li-Fraumeni Syndrome
p53 is a tumour suppressor gene
Individuals develop sarcoma <45 years old
Gardner Syndrome
APC Gene Mutations
Multiple Polyposis
Supernumeray Teeth
Jaw + Skull Osteoma
Hypertrophic Retinal Pigment
Thyroid Cancer
Cutaneous Lesions
Which hormones are reduced in stress response?
Insulin
Oestrogen
Testosterone
Superior Vena Cava
Formation
What joins before entering right atrium?
Sites of collateralisation in SVCO
Forms from - Right and left Inominate veins ( these respectively form from Internal + Subclavian Veins)
Azygous vein forms before entring right atrium - Forms from union of ascending lumbar veins and subcostal veins.
Collateralisation -
Primarily Azygous
Internal Thoracic Vein - originates at superior epigastric vein and terminates in brachiocephalic vein
Long thoracic Vein - drains from serratus anterior and pectoralis major to axillary vein. A connection between LTV and superficial epigastric vein (the thoracoepigastric vein) alows shunting
Median Nerve
Which branches supply what
Median nerve supplies:
Flexor Carpi Radialis, Palmaris Longus, Flexor Digitorum Superficialis
Anterior interosseus nerve: (branch given off in upper forearm) (Deep forearm muscles)
Lateral part of flexor digitorom profondus, flexor pollicus longus, pronator quadratus
Palmar Cutaneous Branch: (given off in the forearm) s
Sensation to thenar eminence
Recurrent Muscular Branch: (hand branch given off just after flexor retinaculum) Opponens Pollicis, Abductor Pollicis Brevis, Flexor Pollicis Brevis)
Digital Cutaneous branch: (hand branch given off just after flexor retinaculum) Lateral lumbricals,
Blood Supply to CBD
Hepatic Artery and branches of Gastroduodenal artery
Hepatobiliary Triangle
Medially - Common Bile Duct
Inferiorly - Cystic Duct
Superiorly - Inferior Lobe of liver
Contents Cystic Artery
Workup in oesophogeal Ca
Staging CT
Diagnostic Laparascopy –> look for peritoneal disease
PET CT
If none of these are positive then proceed to consider for surgery
Distal Ca –> Ivor Lewis Two stage
Proximal –> Mckeown three stage
Blood supply to rectum
What is the extraperitoenal rectum Surrounded by?
Fascia surrounding rectum
Three arteries
Superior - From IMA
Middle - From Internal Iliac
Inferior - From Internal Pudendal (branch of internal iliac)
Extraperitoneal rectum is surrounded by - Mesorectal fat containing lymph nodes (hence need for total mesorectal excision)
Anterior rectal fascia - Denonvillers
Posterior rectal Fascia - Waldeyers
Innervation of the infrahyoid strap muscles
Sternohyoid - Ansa cervicalis
Sternothyroid - Ansa Cervicalis
Thyrohyoid - C1 Spinal nerve (through hypoglossal nerve)
Omohyoid - Superior belly - Superior root of ansa cervicalis - C1)
Inferior Belly - Ansa Cervicalis
Ansa cervicalis - Cervical plexus exists in carotid triangle
- Two roots - Superior Originates from C1, Inferior orginiates from C2+C3
Ligamentous Anatomy of the Ankle Joint
Medial -
Lateral - 3 components
Between Tibia and Fibula - 4 components
Medial - Deltoid Ligament
Lateral - Lateral ligament complex: 3 components
Anteriotalofibular ligament
Calcaneofibular ligament
Posteriotalofibular ligament
Syndesmosis - ligament complex between distal fibula and tibia - 4 components
Anterior-inferior tibiofibular ligament
Transverse tibiofibular ligament
Interosseus membrane
Posterior-Inferior tibiofibular ligament
X Ray indicators of Ankle Syndesmotic Injury
Decreased tibiofibular overlap
Lateral/Medial joint clear space
Lateral Talar Shift
principles for operating in acute cholecystitis
<48 hours surgery is a good idea
>5 days - surgery is best left deferred to 3 months to allow inflammation to settle
Mucinous colorectal cancer at young age
Family history
Likely to be Lynch Syndrome or HNPCC
Immunlogics and their uses
Bevacizumab
Trastazumab
Imatinib
Basiliximab
Cetuximab
Bevacizumab (anti-VEGF) - Colorectal, Renal, Glioblastoma
Trastazumab (anti-HER2) - Breast
Imatinib (TK inhibitor) - GIST, CML
Basiliximab (IL2 R) - Post renal transplant
Cetuximab (Epidermal Growth Factor Receptor inhibitor) - Colorectal
Fistulae
When is it safe to conersvatively manage?
Drug therapy for high output fistula
Contraindication to probing perianal fistulae
How to delinieate fistula tract?
Conservative management - In the absence of IBD or distal obstruction
Octreotide si used to reduce pancreatic secretions in the context of high output fistulae
Perianal fistulae should not be probed in teh context of acute inlammation
Fistula anatomy can be delineated using CT and barium studies
Management of Liver Metastases
Patients with good physiological reserve - Chemotherapy + Surgical Resection
5 Year Survival can be as good as 20%
With poor physiological reserve - Radiofrequency ablation
Glucocorticoids
At a cellular level - MOA
Metabolic effects
Regulatory Effects
They bind to intracellular receptors -these migrate to the nucleus acting as transcription factors
Metabolic:
Decrease uptuake and utilisation of glucose –> increase gluconeogenesis
Increase protein catabolism
Potentiate lipolysis
Regulatory:
Negative Feedback on hypothalamus
Prevent vasodilation and fluid loss from vessels
Increase osteoclastic activity/ Decrease osteoblastic activity
Decrease inflammation (Decrease B/T Cell clonal expansion)
Hip Joint
Vascular Supply
Gold Standard Investigation for fractures if plain films are inconclusive
Internal Fixation, Hemiarthroplasty or THR
Vascular Supply - Medial and lateral femoral circumflex arteries (branches of profunda femoris) which go onto anastamosis and enter the joint capsule at the posterior neck base.
Ligament of teres provides small blood supply
Imaging - MRI is gold standard if plain radiographs aren’t good enough however in practice CT is sought
internal fixation - Young displaced/undisplaced, Elderly undisplaced
Hemiarthroplasty - Displaced and poor baseline mobility/ cognitive impariment/ medically unfit
THR - Displaced and good baseline mobility/ no cognitive impairment/ medically fit
Colonic cancers with threatened resection margin mangement
Rectal cancers with threatened resection margin management
Colonic cancers with threatened resection margin mangement - Primary Resection
Rectal cancers with threatened resection margin management - Long course chemotherapy.
Nerve most commonly injured during superficial parotidectomy
Greater Auricular Nerve
- ascending branch fo cervical plexus arising from 2nd and 3rd cervical nerves
- Ascends sternoclediomastoideus coming underneath the platysma muscle
- Branches into anterior and posterior overly the parotid.
Pancreatic Adenocarcinoma
RFs
Most common Location
Ix
Mx
RFs- Smoking, Diabetes, Adenoma, FAP
Most commonly in the head of pancreas
Ix - USS, CT Scan
IF on CT it is deemed unresectable no further staging
IF on CT it is deemed resectable –> PET/CT, ERCP/MRI, Staging Laparoscopy (peritoneal disease)
Mx -
Head - Whipple’s
Body/Tail - Distal Pancreatectomy
Adjuvant Chemotherapy
ERCP
Contents of the popliteal fossa
Most Medial
Artery
Vein
Tibial Nerve
Common Peroneal Nerve
Soemtimes sural nerve
Most Lateral
What level do the following branches come off the aorta?
Coeliac
Superior Mesenteric
Inferior Mesenteric
Coeliac - T12
Superior Mesenteric - L1
Inferior Mesenteric - L3
What level do the following branches come off the aorta?
Inferior phrenic
Lumbar
Median Sacral
Inferior phrenic - T12
Lumbar - L1-L4
Median Sacral - L4
What level do the following branches come off of the aorta?
Middle suprarenal
Renal
Gonadal
Common Iliac
Middle suprarenal - L1
Renal - L1-L2
Gonadal - L2
Common Iliac - L4
Colles Fracture
Dinner fork deformity
Transverse distal radius fracture
Dorsal displacement and angulation
Smiths Fracture
(reverse colles’)
Distal Radius transverse fracture
Volar angulation of fragment
Bennett’s Fracture
Intraarticular fracture of 1st MCP
Triangular fragment at ulnar base of metacarpal
Monteggia Fracture
Ulnar fracture
Proximal radioulnar joint dislocation
Galeazzi Fracture
Radial shaft fracture
Dislocation of distal radioulnar joint
Barton’s Fracture
Distal Radius fracture (Colles or Smiths)
with
radiocarpal dislocation
what nerve is responsible for otalgia post-tonsillar surgery
Glossopharyngeal nerve
What is the most common site of intessusception paediatric?
Ileo-caecal - This is usually maanged by fluroscopically guided air insufflation
Ileo-ileal is less common but needs a laparotomy
Origins of gluteal arteries
Gluteal Nerves
Inferior gluteal artery - anterior trunk of internal iliac artery
Superior gluteal artery - posterior trunk of internal iliac artery
Superior Gluteal Nerve - L4, L5, S1
Inferior Gluteal Nerve - L5, S1, S2
Epigastric Pain and Audible Bruit
Median Arcuate Ligament Syndrome:
The median arcuate ligament of the diaphragm compresses the coelic trunk and coeliac ganglia.
Pain realted to meals.
Aortic Aneurysm - Iliac Involvement
Open Repair
What is the level of the transpyloric plane
Contents of the transpyloric plane (13)
Transpyloric plane - L1!
Pylorus of the stomach
Left Kidney Hilum + Right Kidney Hilum (Note right lower than left)
Gall bladder fundus
Pancreatic Neck
Duodenojejunal Fixture
Superior Mesenteric Artery
Portal Vein
Left and right Colic Flexure
Roof of the transverse mesocolon
2nd part of the duodenum
Upper Part of conus medullaris
Spleen
Functional Renal Imaging
DMSA
Diethylene-triamine-penta-acetic acid
MAG 3 Renogram
Micturating Cystourethrogram
Intravenous Urography
PET/CT
DMSA - Localises in the renal cortes. –> Cortical defects, scarring, Ectopic or aborrhent kidneys.
Diethylene-triamine-penta-acetic acid DTPA - Glomerular Filtration Agent. Provides useful information about eGFR
MAG 3 Renogram - Secreted by tubular cells so good for imaging kidney in patients with existing renal impairment.
Micturating Cystourethrogram - Assessment of bladder reflux. Bladder filled with contrast via catheter
Intravenous Urography - Good for renal function, and detection of urinar tract calculi
PET/CT - Staging
Statistical Tests:
T Test
Fishers Exact Test
Spearmans Rank Test
Mann Whitney U Test
Bonferroni Test
T Test - normal distribution
Fishers Exact Test - determines the signfificance of athe deviation from null hypothesis.
Spearmans Rank Test - significant relationship between two sets of data
Mann Whitney U Test - nonparametric test of the null hypothesis that sample from one group is equally likely to be lesser than or greather than sample from another group
Bonferroni Test - counteracts problems of multiple comparisons
Brachial PLexus Questions
In which fascia are the upper 3 rami of the brachial plexus contained within pre-axillary artery?
Which part of the axillary artery does the plexus surround?
where are the cords formed?
Which divisions form which cords?
They are contained within the pre-vertebral fascia
The plexus surrounds the second aprt of the axillary artery
Cords are formed in the Axilla
Cords:
Posterior Cord - Dorsal divsions of C5- C8 (Upper, Middle and half of Lower Trunk)
Medial Cord- Ventral divisions of C8-T1 (Lower Trunk)
Lateral Cord - Ventral Divisions of C5-C7 (Upper and middle trunk)
Brachial Plexus Questions:
What are the terminal nerves of the brachial plexus (not branches)?
What forms the:
Long Thoracic Nerve
Dorsal Scapular Nerve
Upper Subscapular Nerve
Thoracodorsal Nerve
Lower Subscapular Nerve
Axillary Nerve
Suprascapular Nerve
Nerve to subclavius
Lateral pectoral Nerve
Musculocutaneous Nerve
Medial Cutaneous nerve of the arm
Medial cutaneous nerve of the forearm
Ulnar Nerve
Terminal Nerves are - Radial Nerve ( From Posterior Cord)
Median nerve (Lateral and Medial Cord)
Derived from:
Roots:
Posterior-
Long Thoracic Nerve- C5-C7
Dorsal Scapular Nerve - C5
Anterior -
Nerve to Subclavius - C5-C6
Trunks:
Suprascapular Nerve - Upper Trunk
Cords :
Upper Subscapular Nerve - Posterior Cord
Thoracodorsal Nerve - Posterior Cord
Lower Subscapular Nerve - Posterior Cord
Axillary Nerve - Posterior Cord
Lateral pectoral Nerve - Medial and Lateral Cord
Musculocutaneous Nerve - Lateral Cord
Medial Cutaneous nerve of the arm - Medial Cord
Medial cutaneous nerve of the forearm - Medial Cord
Ulnar Nerve - Medial Cord
Describe Subclavian Steal syndrome
Stenosis/ Occlusion of subclavian artery, proximal to the origin of the veryebral artery.
What surgery for Conjugated hyperbilirubinaemia in baby?
Biliary atresia:
Kasai procedure - Roux-en-Y portojejunostomy
if this fails —> Liver transplant
Phrenic Nerve Topography
C3- C5
Left:
Deep to prevertebral fascia across scalenus anterior
Crosses anterior to part 1 of subclavian artery
Posterior to Subclavian vein and Internal Thoracic —> enters the thorax
Lateral to left subclavian, aortic arch and left ventricle.
Anterior to lung hilum and pierces diaphragm
Right:
Deep to prevertebral fascia across sclaneus anterior
Croses anterior to 2nd part of subclavian artery
Posterior to Subclavian vein and Internal Thoracic —> enters the thorax
Travels anterior to right vagus and laterally to SVC
passes over R atrium and exits through the caval opening at T8 of diaphragm
Cancer arising of the kidney due to long term inflammation?
Squamous Cell Carcinoma
Scalenus Anatomy
Innervation
Which structures pass through
Scalenus Anterior Medius and Posterior
-Anterior and medius both insert onto first rib
Posterior inserts onto second rib
Innervation:
Spinal Nerves C4-C6
Brachial Plexus and subclavian artery both pass inbetween scalenus anterior and medius
Why use bupivicaine post-operatively over lidocaine?
It has a much longer duration of action than lignocaine and therefore can provide longlasting wound-site analgaesia
What would be the LA of choice in regional block?
Prilocaine - this is much less cardiotoxic
Basilic Vein Path
Cephalic Vein Path
Basilic - is Medial.
Originates from dorsla venous network —> passes most of the way superficially.
Anterior to the antecubital fossa —> joins the cephalic vein the the median cubital vein
Pierces the biceps fascia
Ascending medially it becomes the axillary vein
Cephalic - is Lateral
Ascends lateralyl from the dorsal venous network. Travels lateral to antecubital fossa.
Into Deltopectoral triangle inbetween pectoralis and deltoid
Empties into axillary vein
Prostate Disease-Which lobe
BPH
Carcinoma
Prostate
Arterial Supply
Venous Drainage
Lymph Drainage
BPH - Median Lobe
Carcinoma - Posterior Lobe
Arterial Supply - Inferior Vesical Artery (branch of internal iliac)
Venous Drainage - Prostatic Venous PLexus ( to paravertebral veins)
Lymph Drainage - internal iliac (+sacral)
When are hepatocellular adenomas resected?
>5 cm due to risk of rupture
or
In males due to high risk of malignancy
Coeliac Artery
Branches of coeliac artery
Level of coeliac artery from aorta
Level - T12
Branches:
Left Gastric - Oesophageal and stomach branches
Common Hepatic - Proper hepatic (branches into left and right hepatic- right giving off cystic artery), Right Gastric, Gastroduodenal (branches into r. gastroepiploic + superior pancreticoduodenal)
Splenic Artery - Dorsal pancreatic, Short Gastric, Left gastro-omental, Greater Pancreatic
Anatomy of the foot arches
Longitudinal:
Posteriorly supported by calcaneum
Laterally- passes over cuboid bone and lateral two metatarsal bones
Medially - head of talus (summit) between the subtentaculum tali and navicular bone. Anterior pillar is navicular, cuneiforms and medial three metatarsals.
Transverse:
Between Anterior tarsus and posterior metatarsus.
What constitutes:
Sub Talar Joint
Facet on lower surface of talus body + Posterior facet on the upper surface of calcaneus
Synovial
What constitutes:
Talocalcaneonavicular joint
Anteroinferiorly the navicular bone communicates with the subtentaculum tali of the calcaneus (Posteroinfeiorly) to provide a place for communication of the Talus to sit.
Hip Joint
Intracapsular ligamnets
Extra Capsular Ligaments
Majority of blood supply to head of femur?
Intrcapsular -
Transverse Ligament
Ligament of Teres
Extracapsular:
Ilofemoral
Pubofemoral
Ischofemoral
Medial and lateral circumflex femoral arteries (both branches of profunda femoris/ inferior gluteal artery)
Which strucures pass through
Inferior Sciatic Foramen
Superior Sciatic Foramen
Both
They are divided by sacrospinous ligament.
Lesser (Anterior - ischium tuberosity, Superior - Sacrospinous ligament + spine of ischium, Posterior - sacrotuberous ligament)
Obturator Internus Tendon
Greater (Anterior - greater sciatic notch of ilium, Posterior- sacrotuberous ligament, Inferior - sacrospinous ligament + ischial spine, superior - anterior sacroiliac ligament)
Nerves- sciatic, Superior (above piriformis) and inferior gluteal nerves, posterior femoral cutaneous nerve, nerve to quadratus femoris, nerve to obturator internus)
Arteries + Veins - Superior Gluteal A +V, Inferior Gluteal A+V, )
Both
Pudendal Nerve
Internal Pudendal A+V
Nerve to obturator internus
Deep Perineal Pouch
Anatomical Location
Contents
Anatomical location:
Bounded inferiorly by inferior fascia of urogenital diaphragm and superiorly by superior fascia of urogenital diaphragm
Contents:
Urethral sphincter
Transversus Perinei
Nerves - Dorsal nerve of penis, perineal nerve branches
Vessels - Urethral artery, deep artery of penis, dorsal artery of penis, origin of artery to bulb of penis
Left Common Carotid Anatomy
Thorax -
Neck -
Originates from arch of aorta -
Thorax - In contact with trachea, recurrent laryngeal nerve and oesophagus
Left brachiocephalic vein passes anteriorly in front of it
Neck -
Runs beneath SCM and enters anterior triangle
In carotid sheath with - vagus nerve, and (lateral to ) internal jugular vein
vertebral artery and thoracic duct lie posterior to the artery in the neck
Bifurcate at level of C3 vertebrae/ upper border of throid cartilage
Right Common Carotid -
Same except :
Branch of brachiocephalic trunk.
No thoracic duct on the right side
Sulphur Granules and Gram Positive Organisms - Histology
Actinomycosis
- Forms multiple sinuses
The sulphur granules (round or oval basophilic masses)
Within what time should an open fracture be internally fixated?
72 hours
Malignant Fibrous Histiocytoma
Four SubTypes
Treatment
Subtypes:
Storiform - Pleomorphic
Myxoid
Giant Cell
Inflammatory
Treatment:
Surgical resection + pseudocapsule resection
Chemotherapy
Large pathological deposit in bone
?management
Surgical Fixation - to prevent fractures
When do you consider surgery for polyps?
Incomplete excision of malignant polyp (endoscopically)
Malignant sessile polyp
Malginant peduncalated polyp with submucosal invasion
Polyops with poorly differentiated carcinoma
Familial polyposis syndromes
Growth Plate Fracture Classifications
SALTER
I S traight through growth plate
II A bove and through growth plate
- *III B** elow and through growth plate
- *IV T** hrough metaphysis epiphysis + growth plate
V E Everyything (crush injury)
Which space does LP go?
Subarachnoid
Popliteal Fossa
Borders
Contents
Borders:
Lateral: Biceps femoris, Lateral head of gastroc and plantaris
Medial - Semimembranosis and semitendinosis, medial head of gastroc
Floor - Popliteus, Femur
Roof - Superficial and deep fascia
Contents:
Vascular: Popliteal artery, Popliteal Vein, Short Saphenous Vein
Nerves: posterior cutaneous nerve of thigh, tibial nerve, genicular branch of of obturator nerve
Which vein is related to:
Sural Nerve
Saphenous Nerve
Sural nerve:
Short Saphenous Vein: Lateral side of foot. Passes inferio-lateral to the lateral malleolus. Enters popliteal fossa between gastroc heads.
Saphenous Nerve:
Long saphenous Vein: Medial side of foot. Passes anterior to medial malleolus. Traverses the medial posterior femoral epicondyle. Migrates laterally on anterior thigh.
Common extracolonic manifestation of FAP
Duodenal and gastric polyps
Paediatric Neck Masses:
Cyst above the hyoid
Cyst below the hyoid
Anterior to SCM at the angle of mandible
Posterior to SCM
Cyst above the hyoid - dermoid - heterogenous appearane
Cyst below the hyoid - Thyrogossal cyst - thin walled and anechoic
Anterior to SCM at the angle of mandible - branchial cyst - failure of obliteration of usualy 2nd arch. anechoic. can become infected
Posterior to SCM - cystic hygroma - can be closely aassocated with surrounding structures. lymphatic malformation
Paediatric fluid management
100 ml/kg/day - first 10 kg
50 ml/kg/day - second 10 kg
20 ml/kg/day - subsequent kgs
Neonates:
First day- 50-60 ml /kg/day
Second day - 70 - 80 ml/ kg / day
Third day - 80 - 100 ml /kg / day
fourth day - 100-120 ml/kg/day
5-8 days - 120-150 ml /kg / day
Oxygen Dissociation Curve
Causes of Right Shift
Causes of left shift
Right shift - Reduced affinity for oxygen –> increased oxygen delivery
High
High H+ (Acidosis)
High temp
High 2-3 DPG
CO2
Left shift - higher affinity for oxygen–> lower oxygen delivery
Low
Low H+ (alkalosis
Low Temp
Low 2-3 DPG
DPG - is high in conditions where there is reduced oxygen delivery to tissues - High Altitude, Low Hb
Tymus Histology
ARterial Supply
Venous Drainage
Encapsulated Lobular Structure originating from III and IV pharyngeal arches
Cortex - Lymphocytes
Medulla - Concentric epithelial cells with keratinsed centre
Arterial Supply:
Internal mammary artery (or pericardiophrenic arteries)
Venous Supply:
Left Brachiocephalic vein
Scaphoid abdomen
Abdomen sucked inwards:
Think diaphragmatic hernia in newborn
management of diverticular stricture + LBO
Laparatomy and hartmann’s
Dilating - contraindicated
Stenting - often not useful
Wound healing - Predominant Cell Types
Inflammation
Regeneration
Remodelling (Contraction)
Inflammation
Neutrophils. Early phase (first week)
Regeneration
Fibroblasts. (8 weeks)
Microvascularisation
Remodelling (Contraction)
Differentiated fibroblasts.
Microvessels regress so the scar looks pale.
Exposure to vinyl chloride
Hepatic Angiosarcoma
Ileostomy effluent
Na - 126 mmol/ L
K+ - 22 mmol/L
Contents of Cavernous Sinus
O TOM CAT
Ophthalmic nerve
Trochlear Nerve
Ophthalmic nerve (V1)
Maxillary nerve (V2)
Internal Carotid Artery
Abducens Nerve
Foramen of Munro
Magendie
Lushka
Munro:
Lateral Ventircles into Third ventricle
lushka:
Anteromedial apertures of the fourth ventricle
magendie:
Posteriorinferor of the fourth ventricle
what provides sensory innervation to posterior thigh
Posterior Cutaneous Nerve of thigh:
Direct branch of Sacral PLexus
SMA
Origin from Aorta
Branches
L1
Inferior Pancreatico-duodenal artery
Jejunal and Ileal Arcades
ileocolic
right colic
middle colic
Musculocutaneous Nerve
Origin?
Action?
Origin: Branch of Lateral Cord of brachial plexus
Action:
Continues into forearm as lateral cutaneous nerve of forearm
Innervates - coracobrachialis, brachialis, biceps brachii
Structures passing through foramen ovale
Through which bone is the foramen
Sphenoid bone
OVALE
O - tic ganglion
V - V3 Mandibular nerve
A - accessory meningeal artery
L - lesser petrosal nerve
E- missary veins
Location and content of following skull foramina
Ovale
Ovale (sphenoid)
Otic Ganglion, V3, Accessory Meningeal Art., Lessor Petrosal Nerve, Emissary Veins
Spinosum
Spinosum (Sphenoid)
Middle Meningeal Artery, Meningeal branch of mandibular nerve
Rotundum
Rotundum (Sphenoid)
V2
Foramen Lacerum - Location and contents
Lacerum (Sphenoid)
ICA, Nerve + Art. of pterygoid canal
Jugular Foramen - Location and Contents
Jugular (temporal)
Inf. Petrosal Sinus, IX, X, XI, Sigmoid Sinus (becomes Int. jug), Meningeal branches of occipital and ascend. pharyngeal art.
Foramen Magnum - location and contents
Foramen Magnum (occipitaL)
Medulla oblongata, Ant. + Post. Spinal Art. , Vert. Art
Stylomastoid Foramen - Location and contents
Stylomastoid Foramen (Temporal)
Stylomastoid Artery, CNVII
Superior Orbital Fissure - Location and contents
Superior Orbital Fissure (Sphenoid)
III, IX, V1, Recurrent meningeal artery, VI, Superior Ophthalmic Vein
Lymph Drainage of Auricle (Ear)
Lateral upper Half
Cranial Superior half
Lower half and lobule
Lateral upper Half - Superficial parotid
Cranial Superior half - deep cervical + Mastoid
Lower half and lobule - Superficial cervical
parotid malignancy:
perineural skip lesions
Most common
derived from secretory portion
perineural skip lesions - Adenoid Cystic Carcinoma
35% 5 year survival. Tendency for visceral spread
Most common- Mucoepidermoid carcinoma
Don’t usually metastasise
derived from secretory portion - Adenocarcinoma
Pharyngeal Pouch is between?
Diverticulum between cricopharyngeus and thyropharyngeus
Oesophagus:
Arterial
Venous
Lymphatic
Beginning and termination
Location of strictures
Upper Third:
Arterial - Inferior Thyroid Artery
Venous - inferior thyroid vein
lymph - Deep cervical
Middle Third:
Arterial - Aortic Branches
Venous - Azygous
Lymph - Mediastinal
Lower Third:
Arterial - Left Gastric
venous - left gastric
lymph - gastric
Begins - C6, Ends , T11
Strictures:
Cricoid, Aortic Arch, Left Bronchus, Oesophageal Hiatus
Urine Calcium-Creatinine Clearance in :
Primary Hyperparathyroidism
Familial Hypocalciuric Hypercalcaemia
Primary Hyperparathyroidism (Kidneys try to remove calcium)
>0.01
Familial Hypocalciuric Hypercalcaemia (Autosomal Dominant loss of calcium sensing –> High PTH despite high calcium, normal calcium resorption despite high calcium)
<0.01
Drug Causes of Gynaecomasti
Digoxin, Cimetidine, Dopamine receptor antagonists, Methyldopa, Cannabis, Oestrogens, Anabolic Steroids, Spiro, Finasteride
Heroin Isoniazid etc. rare causes
Branches of External Carotid Artery
MASS FLOP
Maxillary
Ascending Pharyngeal
Superior Thyroid Artery
Superficial temporal artery
Facial Artery
Lingual artery
Occipital Artery
Posterior Auricular Artery
Branches of subclavian artery
VIT C&D
Verterbral
Internal thoracic
Thyrocervical Trunk ( Inferior Thyroid, Suprascapular, Transverse Cervical)
Costocervical Trunk (superficial intercostal + deep cervical)
Dorsal Scapular (joins with transverse cervical) becoming Transverse Cervical –> Superficial and Deep descending branches
What is in cryoprecipitate
VIII
Fibrinogen
XIII
vWF
What is anular ligament?
What articulates with the capitulum?
What articulates with trochloea?
Anular ligament- Proximally located liagment between ulnar and radius to permit supination and pronation movements at the proximal radioulnar joint
Capitulum - Distal end of humerus. This articulates with the concave groove on the radius head
Trochlea - articulates with ulnar.
Occluded posterior nasal airway in newborns
choanal atresia
Cyanotic episodes when feeding
Bilateral pulmonary infiltrates
CVP Reading
<18 mmHg
>18 mmHg
<18 mmHg = ARDS (fat embolus, sepsis, acute pancreatitis, trauma, lung injury, head injury)
Low tidal volume ventilation, diuresis
>18mmHg = Pulmonary Oedema
Margins for melanoma resection
Breslow thickness score:
1mm - 1cm margin
1-2mm - 1-2cm margin
3-4mm - 2-3 cm margin
>4mm - 3 cm margin
Lymph resection + isolated limb chemotherapy infusion as adjuncts
Malignancy Arising as a result of chronic oedema
Lymphangiosarcoma
- these are agressive lesions
What happens to the rectal stump
Ventilation
What are the three cerebral areas responsible for ventilation and what do they respond to?
Any non-cerebral areas involved?
Medulla Oblongata
This responds to increased interstitial H+ to increase ventilation (to blow off CO2). The Apneustic Centre in pons instigates inspiration whereas the Pneumotaxic Centre, also in the pons, inhibits inspiration.
Peripheral chemoreceptors are in the carotids and arch of aorta –> these respond to arterial pO2, pCO2 and H+
Ulnar Nerve
Origin
Innervates? (10)
Relationship to ulnar artery
Topography
Origin - C8 T1, derived from medial cord of plexus
Innervates:
Muscular Branch - Flexor Carpi Ulnaris+ Flexor Digitorum Profondus (medial)
Deep Branch- Flexor Digiti Minimi
Abductor Digiti Minimi
Opponens Digiti Minimi
Adductor pollicis
Interossei Muscles
Medial 2 lumbricals (III and IV)
Flexor Pollicis Brevis
Palmaris brevis
Also - Dorsal cutaneous branch, palmar cutaneous branch, Superficial (medial digits) branch
Medial to the ulnar artery
Topography:
Medial side of upper arm then passes posterior to medial epicondyle
Pierces two heads of flexor carpi ulnaris and travels deep to this near the ulna bone
where does the chorda tympani arise and from what?
Inside the facial canal from the facial nerve - so not effected in facial nerve lesion at the parotid
Facial Nerve Topography
order of canals through whence it travels?
3 branches within facial canal?
2 branches immediately after exits the temporal bone?
branches of facial nerve at parotid gland?
I) It enters the internal adutiory meatus travles through the facial canal and then exits via the stylomastoid foramen
ii) Greater petrosal nerve, nerve to stapedius and chorda tympani
iii) Posterior auricular nerve, branch to posterior belly of digastric +stylohyoid muscle
iv) temporal, zygomatic, buccalis, marginal mandibular nerve, cervical
Sensory innervation of the mouth
Inferior Molars
Inferior Canines and incisors
Gingiva and supportive structures
Upper teeth
Generally - upper teeth by the maxillary nerve
and lower teeth by the mandibular nerve
Lower Teeth:
Molars - inferior alveolar nerve
Canines and incisors - Incisive branch of inferior alveolar
gingiva and supportive - lingual nerve
Upper teeth:
Superior alveolar plexus:
Molars - Posterior Superior alveolar nerve (SAN)
premolars - middle SAN
front teeth - anterior SAN
Giant Cells most commonly arise from?
Macrophages
- Giant cells are collections of distinct cell types
Any distant metastases in oesophageal/gastric ca?
Not for surgery and chemotherapy reserved for young and fit
Below which blood pressure does renal autoregulation of flow fail?
<80 systolic blood pressure
WHat is a:
Bankart Lesion
Hill Sachs Lesion
Bankart Lesion - avulsion of anterior glenoid labrum
Hill Sachs Lesion - chondral impaction on posteriosuperior humeral head from contact with glenoid rim
What stimulates insulin release(6)
Glucose
Amino Acids
Secretin/CCK/Gastrin
Vagal Cholinergic Action
Fatty Acids
Beta adrenergic drugs (blockers block release)
Ansa Cervicalis
Origin
What fascia is it posterior to
What does it innervate
Origin - C1 (superior root), C2-3 (inferior root)
Posterior to - Pretracheal fascia
Innervates - sternohyoid, sternothyroid, omohyoid
Anal Sphincter
Smooth and striated components
Nervous supply
Smooth muscle- upper two thirds of anal canal
Striated muscle - superficial to smooth muscle but surrounds the entire canal
Nerve supply- inferior rectal branch of pudendal nerve and perineal nerve
Radial Nerve
Origin
Innervates
Branches
Origin: Posterior Cord of brachial plexus, C5 to T1
Innervates:
main branch -Triceps, Anconeus, Brachioradialis, Extensor Carpi Radialis
posterior interossues nerve (deep branch)- Supernator, extensor carpi ulnaris, extensor digitorum, extensor digitorum, extensor indicis, extensor digiti minimi, extensor pollicis longus and brevis, abductor pollicis longus
sensory -
Axilla
aBoundries
Contents
Boundaries:
Anterior - pec major,
Posterior - lat dorsi
Medial - serratus anterior + chest wall
Lateral - Humeral Head
Contents:
Long Thoracic Nerve
Thoracodorsal Trunk
Axillary Vein
Intercostobrachial nerves
Lymphatics
Lymphatic drainage
Inferior to the dentate line
Superior to the dentate line
Inferior to the dentate line - Inguinal lymph nodes
Superior to the dentate line - Mesorectal
Which genetic condition do you see plexiform neurofibromas?
NF Type I - can cause accelerated growth of limb
5 investigations for incidental adrenal lesions
Beyond which size lesion shoudl you worry?
Morning and midnight plasma cortisol
Dex Suppression Test
24 Hour urinary cortisol
24 hour urinary catecholamines
Serum potassium, aldosterone and renin
>4cm is 25% risk of malignancy
Absence Vas Deferens?
Cystic Fibrosis
Inguinal Canal
Borders
Contents
Where do the testes lymph drain
Borders:
Anterior - Aponeurosis of external Oblique
Posterior - Transversalis Fascia
Floor - Ingiinal Ligament and Lacunar Ligament (medially)
Roof - Arching fibres of the transversus abdominus and internal oblique
Superficial ring - External Oblqieu
Deep ring - Transversalis Fascia
Contents
3 Fascia - External Spermatic Fascia (External oblique), Cremasteric Fascia (internal oblique), Internal Spermatic Fascia (transversalis fascia)
3 Arteries - Testicular Artery, Artery to vas, Cremasteric Artery
2 Veins - Testicular Vein (Left into left renal, right into IVC), Pampiniform Plexus,
3 Others - Vas Deferens, Lymphatics
3 Nerves - Genitofemoral, Ilioinguinal, Iliohypogastric
Where do testes drain to? - para aortic
What is the inverse of odds ratio?
Number needed to treat
Smooth abdominal swelling in child - no worrying features. Mobile
Mesenteric cyst
- usually need to be surgically removed
- can undergo torsion rupture
hyposplenism blood film (4)
Howell - Jolly body
Target Cells
Pappenheimer cells
Irregularly contracted erythroyctes
What do you incise for median sternotomy?
Interclavicular ligament + interclavicular fossa
Sternum with bone saw
pericardium
Masounieve Fracture
Medial malleoulus Fracture
Spiral fracture of proximal 1/3 fibula
dorsal tibiofibular syndesmosis
key anatomical deformities of tallipes equinovarus (5)
Adductes and inverted calcaneus
Wedged shaped calcaneal articular surface +head of talus
tibio-talar plantar flexion
medial talar neck inclination
medially displaced navicular and cuboid
Parathyroid neoplasms:
Most common cause?
Indications for surgery in primary hyperparathyroidism?
Commonly - adenoma
Indication for surgery:
Ca++ >1 above normal
Calciuria >400 mg/day
Decreased creatinine clearance
Life threatening hypercalcaeima
Nephrolithiasis
<50 years age
Neuromuscular symptoms
Reduction in bone mineral density
what regulates ion exchange in the salivary glands?
Aldosterone
Management of traumatic pneumothorax and why?
Chest drain - Usually in context of traumatic pneumothorax there is damage to lung parenchyma = High chance of tension pneumo development
Describe the trendelenberg procedure
Head tild and legs abducted
Oblique incision medial to artery
Ligation of tributaries
Saphenofemoral junction double ligated
Stripping of vein proximal (knee or upper calf)
Muscles attaching to the greater trochanter of femur
POGGGO
Piriformis
Obturator Internus
Gemelli, Gluteus medius, Gluteus Minimus
Obturator Externus
What is the blood supply to the omentum
Left Gastroeipoloic Artery (branch of splenic)
Right Gastroepiploic Artery (branch of gastroduodenal)
What is common liver fluke?
Disease?
Fasciola Hepatica
Disease:
Two - Acute - fever, abdo pain, rash, and hepatomegaly
Chronic - Obstructive jaundice due to worm maturing in bile ducts
What enters the IVC and at what level?
Inferiorly:
I LIKE TO RISE SO HIGH
Common Iliacs fuse at L5
Lumbar veins L1-L5
Right Gonodal vein (Left generally drains into Left renal vein) L2
Suprarenal veins and renal veins L1
Hepatic vein, inferior phrenic vein T8 - also caval hiatus (diaphragmatic)
Body Fluid Volumes
60% of a person is fluid
Intracellular - 60%
Extracellular - 40%
Plasma - 5%
Interstitial - 24%
Transcellular - 3%
Treatments for meconium ileus
PR Contrast (diagnostic and therapeutic)
N-Acetyl Cysteine Enemas
Nerve fibres:
A alpha
A beta
B fibres
C Fibres
A alpha - Motor proprioception
A beta - touch and pressure
A delta - myelinated pain fibres
B fibres - autonomic
C Fibres - unmyelinated c fibres
Red streaks and tender mass on limb?
Lymphadenitis
External urethral sphincter supply
Supplied by pudendal branches (S2-S4)
Pudendal nerve also supplies - external anal sphincter + cutaneous innervation to the perineum
Structures posterior to the medial malleolus
Anterior to medial malleolus
Posterior to lateral malleolus:
Posterior to medial malleolus:
Tibialis Posterior Tendon
Flexor Digitorum Longus
Posterior Tibial Artery
Tibial Nerve
Hallucis Longus
Anterior to medial malleolus:
tibialis anterior tendon
great saphenous vein
Posterior to lateral malleolus:
short saphenous vein, sural nerve (superficial)
peroneus longus tendon, peroneus brevis tendon (deep)
Lichen Sclerosus - pathophysiology
Treatment
Pathophysiology - Abnormal fibroblast proliferation
Treatment:
1 - High dose corticosteroid
2 - Calcineurin inhibitors (Tacrolimus)
3- Retinoids, methotrexate, steroid injections, photopherapy, cyclophosphamide
Which sarcomas metastasise to lymphatics
SCARE
Synovical Sarcoma
Clear Cell Sarcoma
Angiosarcoma
Rhabdomyosarcoma
Epitheloid sarcoma
Which drug prevents conversion of plasminogen to plasmin?
Tranexamic Acid
Which clotting factors are particularly heat sensitive?
Factor V
Factor VIII
Hence FFP is frozen
Branches of the external carotid artery
Some anatomists like freaking out poor medical students
Superior Thyroid Aryery
Ascending Pharyngeal
Linguial Artery
Facial Artery
Occipital Artery
Posterior Auricular
Maxillary Artery
Superior Temporal Artery
Staging for perthe’s disease
catterall staging system
I - Clinical + Histological
II - Sclerosis +/- cystic changes
III - Loss of integrity of femoral head
IV - Loss of acetabular integrity
Muscular Compartments of lower limb
Anterior Compartment
innervated by - Deep Peroneal Nerve
Tibialis Anterior, Peroneus Tertius, Extensor Hallucis longus, Extensor Digitorum Longus
Peroneal Compartment
innervated by - Superficial peroneal nerve
peroneus longus, peroneus brevis
Superficial Posterior compartment
innervated by - tibial nerve
Gastrocnemius, Soleus
Deep posterior compartment
innervated by - tibial nerve
flexor digitorum longus, flexor hallucis longus, tibialis posterior
What is laplace’s law?
hollow circumferential organs:
total wall tension depends on:
i) circumference of wall
ii) Thickness of wall
iii) wall tension
Adrenal Anatomy
Arterial Supply
Venous drainage
Adrenal Relations
Adrenal Arteries:
Superior from inferior phrenic artery
middle from aorta
inferior from renal artery
Adrenal Veins:
Left - into renal vein (as for testicular vein)
right - directly into IVC
Adrenal Relations:
Right: Posterior - Diaphragm, Anterior - Hepatorenal pouch + bare area of liver, Inferior - Kidney, Medial - IVC
Left: Posterior - diaphragm crus , Inferior - kidney, Anterior - pancreas and splenic vessels
What is a hadfield’s procedure
Total Duct Excision (For mammary duct ectasia)
Anterior and posterior relations of carotid sheath
Anterior:
Hypoglossal Nerve
Ansa Cervicalis
Omohyoid Muscle
Only on right - Recurrent laryngeal nerve
Posterior:
C6 - Cervical Sympathetic Chain
C7 - vertebral artery, thoracic duct
Inferior thyroid artery
Why might gastritis cause anaemia?
Which form of gastritis is foveolar hyperplasia associated with?
factors increasing gastric acid production?
Factors decreasing Gastric Acid production?
(where are these produced)
Anaemia: Loss of parietal cells - Loss of intrinsic factor production - loss of B12 absorption - macrocytic anaemia
Foveolar hyperplasia - Reflux gastritis –> due to bile reflux into the stomach
factors increasing gastric acid production?
Vagal stimulation, histamine, gastrin
Factors decreasing Gastric Acid production?
Cholecystokinin, secretin, somatostatin
Gastrin - G cells in antrum of stomach
CCK - I Cells in small intestine
Secretin - S Cells in small intestine
Somatostatin - D Cells in pancreas/stomach
Vasoactive intestinal peptide - small intestine/ pancreas
Difference between gastroschisis and omphalocele?
Gastroschisis - Right of umbilicus
Bowel outside of abdominal wall not covered by peritoneum
Omphalocele (Exomphalos) - Through umbilicus.
The protruding GI organs are covered by peritoneum
The lifecycle and treatment of :
Ascariasis
Enterobius Vermicularis
Strongyloidiasis
Anclyostoma Duodenale
Giardiasis
Cryptosporidium
Life Cycle
Treatment
Ascariasis (roundworm)
Ingestion -> lung migration -> cough and autodigest
Mebendazole
Anclyostoma Duodenale (Hookworm)
Skin penetration -> Lung migration -> cough and autodigest -> Hooked to small intestine luminal wall
Mebendazole
Strongyloides
Skin penetration -> lung migration -> Cough and autoingest
Mebendazole
Enterobius Vermicularis
Oral ingestion. Pruritis Ani.
Mebendazole
Giardiasis
Ingestion of cysts
Metronidazole
Cryptosporidium
Ingestion of cysts
Metronidazole
Dose of heparin for:
Vascular Bypasses
Cardiopulmonary bypasses
Vascular Bypasses
3000 units prior to cross clamping
Cardiopulmonary bypasses
30,000 units priot to initiating bypass
Amputation
Removal of femoral condyles
Retention of patella
Gritti Stokes Amputation
Patella is swung posteriorly to cover distal femoral surface
Gross Thyroid Anatomy
Vascular supply of thyroid
Arterial
Venous
Apex of thyroid cartilage to 4/th/5th tracheal ring. R + L lobe with isthmus in the middle.
Arterial:
Superior Thyroid (first branch of external carotid)
Inferior thyroid (from thryocervical trunk - subclavian artery)
Venous SUpply:
Superior and Middle thyroid vein - Into Internal Jugular Vein
Inferior thyroid vein - into brachiocephalic veins
Flexor tendons in carpal tunnel (9)
4 FDP
4 FDS
1 Flexor Pollicis Longus
Types of electrosurgical current
Blend - Less power than cutting. Alternates between cutting and coagulating
Coagulate - Modulated current with high peak voltage.
Cut - High power and current. Little thermal damage
Fulgurate - Electrode not in contact with tissue. Low amplitude/ high voltage. Local superifical tissue destruction
Dessicate - Electrode in contact with tissue. Low current/ high voltage. Loss of cellular water but not protein
Descending Thoracic Aorta
Relations
branches
Relations
Anterior - Left Lung root, Pericardium, Oesophagus, Diaphragm
Posterior - Vertebral Column, Azygos Vein,
Right - Hemi Azygos Veins, Thoracic Duct
Left - Left Pleura and lung
Branches
Bronchial Artery, Mediastinal Artery, Posterior Intercostal ARteries, Oesophageal Arteries
Sympathetic Ganglia Locations
Cervical
Thoracic
Lumbar
Damage to which causes:
Horner Syndrome
Ejaculatory problems
Cervical:
Superior - C2,C3
Middle - C6
Stellate - C7
Thoracic ganglia are segmentally arrange
Lumbar ganglia - descend posterior to median arcuate ligament of diaphragm and lie anterior to vertebrae and medial to psoas
Horner Syndrome - T1
Ejaculatory problems - L1
Relations of the caecum
Posterior:
Psoas, Gonadal Vessels, Ureter, Iliacus, Femoral nerve, genitofemoral nerve,
Anterior:
Greater Omentum
Thoracic Duct
Where does it enter thorax
What is it continuation of
What does it drain
What importantly doesnt it drain
Relation to oesopahgus
Thoracic Duct:
Enters the thorax alongisde the oesophagus at the oesophageal hiatus of T12
It is a continuation of the cisterna chlyii
The lymphatics of the left head and neck drain directly into the thoracic duct, which itself drains into the left brachiochephalic vein. the right side of the head and neck drain into the right lymphatic duct which drains into the mediastinal duct and then into the right brachiocephalic vein
It lies posterior to the oesphagus then passing to the left at T5
Actions of PTH
Bone - Osteoblasts binding –> inreased RANKL expression –> Activation of osteoclasts —> increase resorption
Kidney - Resorption of calcium and mangesium from DCT. Decreased resorption of phosphate
GI - PTH increases Vit D activation –> increased GI calcium absorption
Localised oesophageal tumours with no mets:
SCC vs ADenocarcinoma
For SCC trial of chemoradithoerapy can be curative whereas for Adenocarcinoma surgery is the only curative option
WHy does H Pylori cause increased acid production?
How can the duodenum have ulcers with H Pylori infection
Urease enzyme hyrdrolyzes urea –> Ammonia
Ammonia causes antral G cells to produce more gastrin
H Pylori itself causes ulcers due to chronic inflammatory changes. The duodenum comes to have these changes when it becoems colonsed. This occurs when the duodenal mucosa undergoes metaplasia as a result of excess acid –> then allowing the H Pylori organisms to colonise the metaplastic tissue
ureter anatomy
Releation to iliac vessels and uterine artery
Blood Supply
Releation to iliac vessels and uterine artery:
Anterior to iliac bifurcation, posterior to uterine artery
Blood Supply:
Segmental: Renal, aortic, gonadal, common iliac, internal iliac
Features of MEN conditions
Digastric nervous supply
Anterior - Mylohyoid Nerve
Posterior - Facial Nerve
Which artery do the following branch from?
Superior Cerebellar Artery
Anterior Inferior Cerebellar Artery
Posterior inferior cerebellar artery
Basilar Artery
Superior Cerebellar Artery
Anterior Inferior Cerebellar Artery
Vertebral ARtery
Posterior inferior cerebellar artery
Branches of:
Vertebral Artery
Basilar Artery
Internal Carotid Artery
Vertebral Artery
Anterior Spinal ARtery, Posterior Spinal ARtery, Posterior Inferior Cerebellar Artery
Basilar Artery
Superior Cerebellar Artery, Anterior Inferior cerebellar Artery, Pontine ARteries, Labyrynthine ARtery, Posterior cerebral artery
Internal Carotid Artery
PComm,Anterior Cerebral Artery (AComm exists between htese two), Middle Cerebral ARtery, Anterior Choroidal ARtery
Seminoma Subtypes (4)
Classical (lmyphocyte infiltrate in stroma)
Spermatocytic (tumour cells remember spermatocytes)
Anaplastic
Syncitiotrophoblast Giant Cells
Attachments of the extensor retinaculum of the wrist
Medial - pisiform and triquetral
Lateral - Radius
Management of Low Grade DCIS vs LCIS
DCIS - WLE
LCIS - Monitoring
Drug Causes of hyper uricaemia (8)
Ciclosporin
Alcohol
Nicotinic Acids
Thiazides
Loop Diuretics
Ethambutol
Aspirin
Pyrazinimide
Which muscles form the pes anserinus?
Where is it?
Sartorius
Gracilis
Semintendinosis
It is on the anteromedial proximal extermitiy of the tibia
Quadrangular Space
Borders
Contents
Borders:
Lateral - humerus, Superior - subscapularis + teres minor, Inferior - teres major, Medial - tricpes long head
Content:
Axillary Nerve
Posterior Circumflex ARtery
Branches of the axillary artery
Relations of axillary artery
First Part: Superior Thoracic ARtery
Above Pec Minor
Axillary artery + vein enclosed within the axillary sheath.
Anterior - Clavipectoral fascia, Posterior - Serratus Anterior, Long thora nerve, first intercostal space.
Second Part: Thoraco-acromial and lateral thoracic arteries
Behind Pec minor
Here the cords relate to the artery true to their names.
Third Part: Subscapular, anterior circ and posterior circ arteries
Inferior to pec minor
Posterior - subscapularis, lat dorsi, teres major
Relations of brachiocephalic artery
Where does it bifurcate
Right brachiocephalic vein + vagus - laterally
trachea - posteromedially
inferior thyroid vein - anteriorly
Bifurcates at level of sternoclavicular joint
What is para- amino hippuric acid (PAH) used to measure?
Renal Plasma Flow
What does sistrunks procedure involve
Thyroglossal Cysts:
Involves resection of:
cyst, track, central hyoid portion + wedge of tongue muscle behind hyoid resection
TB or Sarcoid?
Asteroid Bodies
Extensive Necrosis
Asteroid Bodies - Sarcoidosis
Extensive Necrosis - Tuberculosis
When do you offer long course neoadjuvant chemoradiotherapy for rectal cancer??
T4 tumours
Where are the following valves located in CXR?
Tricuspid
Mitral
AOrtic
Tricuspid - 5th ICS on right
Mitral - 4th ICS on left
AOrtic - 3rd ICS on right
lymph drainage of female internal genitalia
Ovaries
Uterine Fundus
Uterine Body
Cervix
Ovaries - Para aortic
Uterine Fundus - Para aortic + Inguinal
Uterine Body - Iliac Lymph nodes
Cervix - Presacral, Internal Iliac and External Iliac
Management of Axillary Vein Thrombosis
Acute - Catheter GUided tPA
Heparin / Warfarin if chronic
Hepatocellular Carcinoma
Staging System?
Treatment?
Barcelona Clinical Liver Classification
0 - <2 cm - resection
A - >3 cm / <3 nodules. radiofrequency ablation or transplant
B - >3 nodules. Transarterial chemoembolisation
C - Advanced tumours/ Portal vein invasion. Sorafenib
D - supportive
Air fluid level in chest in baby
Bronchogenic Cyst
This should be CTd
Thorascopic Resection at 6 weeks
Subclavian Artery Branches
Vertebral Artery
Internal Thoracic Artery
Thyrocervical Trunk
Costalcervical Trunk
Dorsal Scapular Artery
Cellular characteristic of Hurthle Cell Tumours
OXyphil Cells
Scanty Thyroid Colloid
This is a form of follicular
Where do the following genitalia structures arise/drain?
Artery of Vas Deferens
Creamsteric Artery
Pampinofrm Plexus
Artery of Vas Deferens - Inferior Vesical Artery (from internal iliac artery)
Creamsteric Artery - Inferior Epigastric Artery (from external iliac artery)
Pampinofrm Plexus - Venous Plexus (into testicular vein - left into renal vein, right directly into IVC)
Best and worst prognostically Hodgkin’s Lymphoma’s?
Alll Hodgkin’s Lymphoma’s
Best - Lymphocyte Rich
Worst - Lymphocyte Deplete
Other Subtypes:
Nodular Sclerosing
Mixed Cellularity
Nodular Lymphocyte - predominant
Which fascia contains the base of the penis?
Bucks Fascia
Erb’s Vs Klumpke’s Palsy
Klumpke’s: (C7-T1)
Claw Hand (MCP extension/ IP flexion)
Loss of sensation over medial forearm/hand
Horner’s Syndrome
Loss of wrist flexors
Erb’s Palsy: (C5-C6)
Waiter’s Tip
Extended Elbow,
Pronates Forearm
Adducted and internally rotated shoulder
Impairment to - wrist extensors, Elbow flexor, external rotators
Muscles innervated by buccal branch of CN VII (6)
Buccal (Buccal membrane - mouth)
Zygomaticus Minor
Risorius
Buccinator
Levator Anguli Oris
ORbicularis
Nasalis
Common Carotid:
Pulse palpable at -
Bifurcates at -
Palpable at C6 against the transverse process of vertebra
Bifurcates at C4
Merkel Cell Tumour
Histologically
Related to?
Treatment
Histologically :
Sheets + nodules of hyperchromatic epithelial cells with ++ mitosis and apoptosis
Lymphovascular invasion
Related to sunlight damaged skin
Treatment:
Surgical excision (1 cm margin)
+ SLNB if >10mm lesion
Adjuvant radiotherapy
Which RLN has a more superiorly situated course?
The RIGHT
Remeber that this one arches around the subclavian posteriorly, whereas the left branches more distally and branches->arches around the anterior aspect of the arch of the aorta
Arterial Supply to the nose
Sphenopalatine Artery (Maxillary ARtery )
Greater Palatine Artery (Maxillary Artery)
Facial Artery (Anteriorly)
Most Bleeding from Keisselbach’s Plexus
Goodsalls Rule
Anterior fistulae - internal opening opposite the external opening
Posterior fistulae - curved track that passes toward the midline (6 o clock)
Constirctions of oesophagus (ABCD)
Arch of Aorta
Left Main Bronchus
Cricoid Cartilage
Diaphragmatic Hiatus
Cryotherapy shouldn’t be used for..
Radiotherapy shouldn’t be used for..
in context of cutaneous malignancy
Cryotherapy - shouldnt be used for deep lesions
Radiotherapy - shouldnt be used for lesions in regions which are prone to radionecrosis (nose)
in DIC which components of clotting are depleted fastest
V, VIII and Platelets
Signet Ring Cell proliferation in stomach
Linitis Plastica
- Stomach Doesnt Distent on OGD
The oesophagus doesn’t have which mucosal layer?
Serosa
Effects of Adrenaline
Alpha -
Peripheral Vasoconstriction
Insulin inhibition
Glycogenolysis in liver/muscle and glycolysis in muscle
Beta -
1 - Cardiac chronotrope + inotrope, increased renin secretion
2 - Skeletal muscle vasodilation + coronary artery vasodilation. Bronchodilation
Glucagon secretion, ACTH secretion, Lipolysis in adipose tissue
Muscles Supplied by the Ansa Cervicalis
Ghost Thought Someone Stupid Shot Irene
Geniohyoid
Thyrohyoid
Superior Omohyoid
Sternothyroid
Sternohyoid
Inferior Omohyoid
Common peroneal nerve
Roots
Where does it bifurcate
Roots - L4 - S2
Where does it bifurcate
Bifurcates at neck of fibula after descending posterior to biceps femoris into lateral part of popliteal fossa
Retromandibular Vein
What are its tributaries
Where does it go
Arises from the joining of the maxillary vein and superficial temporal vein
Descends through the parotid gland
Associations with anal fissure
STI
IBD
Leukaemia
TB
DTPA vs MAG3
DTPA - good for assessment of GFR
MAG3 - good for assessment of renal function in patients with known impairment
Which structures lie in the free border of lesser omentum?
Hepatic Artery, CBD and Portal Vein
Contrainidications to surgical resection in lung malignancy?
SVCO
FEV1 <1.5L
Malignant Pleural Effusion
Vocal Cord Paralysis
Tumor near hilum
contents of porta hepatis
Common hepatic Duct
Hepatic Artery
Portal Vein
Nerve Fibres
Lymphatic Drainage
Calculating NNT?
1/(Control rate - Experimental Rate)
Digastric Muscle innervation
Anterior Belly - Mylohoid Nerve
Posterior Belly - Facial Nerve
Sessile Serated Polyps
Best management?
These are more commonly found on the right
Should be removed
Displaced Anatomical Humeral Head Fractures require…
Hemiarthroplasty
- Due to high risk of AVN
Lesions giving early para-aortic lymphadenopathy
Ovarian
Testicular
Uterine Fundus
Contents of superior mediastinum
Arch of aorta
SVC
Brachiocephalic Veins
Thoracic Duct
Trachea
Oesophagus
Thymus
Vagus Nerve
Left RLN
Phrenic Nerve
Contents of middle mediastinum
Aortic Root
Pericardium
Heart
Arch of azygos vein
Main Bronchi
Contents of :
Anterior Mediastinum
Posterior Mediastinum
Anterior:
Thymic remnants, LNs, Fat
Posterior:
Oesophagus, Thoracic Aorta, Azygos Vein, Thoracic Duct, Vagus Nerve, Sympathetic Nerve Trunks, Splanchnic Nerves
Rockall Score
WHen?
Components?
Following Endoscopy for UGI haemorrhage
Components:
A Age
B BP
C Co-morbidities
D Diagnosis
E vidence of bleeding
Kocher Criteria for Septic Arthritis
WIFE
WCC >12
I - inability to weight bear
Fever
ESR >40
Lateral Hip rotators
Nerve supplies
Piriformis - Ventral Rami of S1/S2
Obturator Internus - Nerve to obturator internus
Superior Gemellus - Nerve to obturator internus
Inferior Gemellus - Nerve to quadrator Femoris
Quadrator Femoris - Nerve to quadrator Femoris
Drug Treatment for Colonic Pseudoobstruction
Neostigmine
Basal Cell Carcinoma Margin for Excision
5 mm
Neck Surface Anatomy
C3 - Hyoid
C4 - Thyroid Cartilage Notch
C6 - Cricoid
What are the attachments of the spleen?
Ileorenal Ligament (to the posterior abdominal wall)
Gastrosplenic ligament ( to the stomach)
Hydrocele treatment in :
adults
children
Adults - lords/ jabourlay’s - plication/otomy of sac + ligation of PPV
Children - ligations of PPV
management for biliary leak post lap chole
ERCP + Stent
Biliary Decompression as an adjunct to curative pancreatic surgery
ERCP + Stent
Do not surgically bypass them
Features of von hippel-lindau syndrome
Cerebellar hameangiomas
Retinal Haemangiomas
renal cysts
phaeochromocytomas
extra-renal cysts: epididymal, pancreatic, hepatic
endolymphatic sac
Enterocutaneous fistula at the umbilicus due to….
Failure of obliteration of omphalpmesenteric duct
Indications for surgery in hyperparathyroidism
Age >50
Serum Calcium > 1 above mornal
hypercalciuria >400 mg/day
Creatinine clearance <30%
Renal stones
Neuromuscular Symptoms
Reduction in bone density
Pink Serous Fluid discharge after laparatomy?
Think about early dehiscence
Management of sudden full dehiscence
Analgaesia,
IV fluid,
IV abx
Cover wound with saline gauze
Return to theatre STAT
Which nerve wraps around the middle meningeal artery>
Auriculotemporal nerve - branch of the mandibular nerve.
Mass posterior to angle of mandible
Parotid Gland Tumour
Double Stranded DNA Virus
Single Stranded RNA Virus
DS DNA - HEP B
SS RNA - HEPC + HIV
Where is bucks fascia
Bucks fascia is continuous with the external spermatic fascia into the penis
Musculocutaneous Nerve
Roots
Innervates
Topography
Roots - C5-C&
Innervates - Biceps, Brachialis, Corachobrachialis
topography -
Arises from lateral cord (C5-C7) of brachial plexus. Travels between the heads of the biceps muscles. Then inbetween biceps and brachialis.
Terminates in forearm as the lateral cutaneous nerve of the arm
Does UC affect the anal canal
No It starts from the rectum. Spares the anal canal and the transition zone
CXR features of aortic disruption
Trachea deviated to the right
Left Bronchus depression
Most disruption is in proximal descending aorta
Greater Sciatic Foramen
Boundaries
Contents
Boundaries:
Anterolateral - Greater sciatic notch of ilum
Posteriomedial - sacrotuberous ligament
Inferior - Sacrospinous ligament
Superior - Anterior sacroiliac ligament
Contents:
Nerve:
Sciatic nerve
Superior + inferior gluteal nerves
Pudendal Nerve
Posteror Femoral Cutaneous Nerve
Nerve to quadrator femoris
Nerve to obturator internus
Vessels:
Superior + Inferior Gluteal Vessels
Internal pudendal vessels
Which breast cancer is more common in women breast feeding or who are pregnant
Inflammatory Carcinoma
- THese are more aggressive
Popliteal pulse disappears when leg fully extended
Popliteal fossa entrapment syndrome
main differential here would be adductor canal compression syndrome
Bariatric Surgery Selection Criteria
>40 BMI
>35 + Other significant disease that can be helped with wieght loss
6 months of other measures have not helped
Fit for surgery
Commit to follow up + specialist management
BEst way to assess for upper airway compression?
Flow Volume Loop
Anaerobic Organism complicating difficult operations>
Bacteroides Fragilis - Gram Neg, Anaerobe, Rod Shaped
Involved in majority of peritoneal infections
Branches of the external iliac artery
Inferior Epigastric Artery (Anastamoses with superior epigastric artery, which is a branch of internal thoracic artery)
Deep Circumflex Iliac ARtery
Terminates as Femoral Artery
Obstructive Jaundice in the context of HIV patient likely to be due to…
Sclerosing Cholangitis 2o to - CMV, Cryptosproidium or Microsporidia
Branches of the posterior cord of the brachial plexus
Subscapular Nerves ( Subscapularis)
T - horacodorsal
A - xillary
R - adial
What does serotonin do to vessels?
Intact vessels - Vasodilation
Damaged vessels/tissue - vasoconstriction
Four drugs commonly associated with parotid enlargement
Thiouracil
Isoprenaline
Phenylbutazone
Oestrogen Contraceptic pills
What is a:
Pilon Fracture
Pilon Fracture - Distal Tibia including the articular surface with ankle
Tilloux Fracture - Child fracture involving the distal tibial epiphysis. Is an avulsion fracture due to the anterior tibiofibular ligament pull in an abduction injury.
Which Cord of the brachial plexus do the following nerves come from?
Axillary Nerve
Medial Pectoral Nerve
Lateral Pectoral Nerve
Medial Brachial Cutaneous Nerve
Medial Antebrachial Cutaneous Nerve
Subscapular Nerves
Thoracodorsal nerve
Posterior Cord (C5-T1) Posterior divisions of all trunks) - Subscapular Nerves, Thoracodorsal Nerve, Axillary Nerve
Lateral Cord (C5-C7 Ventral Divisions of Upper and Middle Trunk)
Lateral Pectoral Nerve
Medial Cord (C8-T1 ventral Divisions of lower trunk)
Medial Pectoral Nerve
Medial Brachial Cutaneous Nerve
Medial ANtebrachial Cutaneous Nerve
where are most anal fissures?
Posterior midline (90%)
Anterior midline (10%)
Nephroblastoma vs Nueroblastoma distinguishing features
nephroblastoma:
(Wilm’s) Arise from the kidney.
Associated with Hypertension
No Calcification on CT
Neuroblastoma:
Arise from neural crest (often from adrenal Gland)
Calcification on CT
Ventricular Tachycardia
Drug therapies
Amiodarone
Lidocaine
Procainamidwe
NOT VERAPAMIL
Drug cause of SIADH
Carbamezapine, SSRIs, Sulfonylureas, TCAs, vincristine, cyclophosphamide
Sites of ectopic testes
Superficial Inguinal Pouch
Base of Penis
Femoral Triangle
Perineum
Multifocal high grade dysplasia of oesophagus Treatment?
Resection
In old patients might be a place for local treatment - Endoscopic resection, photodynamic therapy
Strangulation risk
Femoral
Indirect Inguinal
Direct Inguinal
Femoral - 40%
Indirect Inguinal - Greater than direct inguinal
Direct Inguinal - 3%
Post Test Probability
Post Test Odds/ (1+ Post Test Odds)
Way of calculating the prevalence of a condition in a population that have had an intervention
where are most gastrinomas found?
Three hallmark features for diagnosis of gastrinoma
Duodenum, then pancreas
Features:
Fasting hypergastrinaemia
Increased basal acid output
Secretin Stimulation Positive
What is the remnant of the urachus?
What is the arterial supply to the bladder?
What is the venous drainage of the bladder?
What is the lymph drainage of the bladder?
Median umbilical ligament
Arteries supplying the bladder:
Inferior and superior vesical arteries from the internal iliac artery
Venous drainage of the bladder:
Vesicoprostatic venous plexus -> drains into the internal iliac vein
Lymph drainage of the bladder:
External iliac nodes (lesser so to the internal and obturator nodes)
indications for CABG
Conduits for CABG
LMS/ LAD/ Left Circ
Triple Vessel Disease
Diffuse Disease
Conduits
Internal Mammary Artery
Radial ARtery
Long Saphenous Veins
Basophilic and mucoid material between intimal elastic fibers of an artery?
Cystic Medial Necrosis
Seen in age related degeneration + marfan’s syndrome
ABx MOA
Inhibiting Cell Wall FOrmation
Inhibiting Protein Synthesis
Inhibiting DNA Synthesis
Inhibiting RNA Synthesis
Cell Membrane
Inhibiting Cell Wall FOrmation
Penicillin, Cephalosporin, Glycopeptide
Inhibiting Protein Synthesis
50S - Macrolide, Linezolid, Chloramphenicol
30 S - Aminoglycloside, Tetracycline,
Inhibiting DNA Synthesis
DNA Gyrase - Fluroquunilone
Metronidazole, Sulphonamide, Trimethoprim
Inhibiting RNA Synthesis
Rifampicin
cell Membrane
Polymxin
Nerve Roots
SUperior gluteal nerve
Inferior Gluteal Nerve
Superior - L4- S1
Inferior - L5 - S2
relations of submandublar gland
Superficial:
Lymph Nodes
Facial Vein
Marginal mandibular nerve + cervical Nerve
Deep:
Facial Artery
Mylohyoid Muscle + Hypoglossus
Wartons duct
Lingual nerve
Submandibular Ganglion
Hypoglossal nerve
Femoral Nerve
Roots
Innervates
Roots - L2 - L4
Innervates : Lateral cutaneous nerve of thigh, Intermediate cutaneous nerve of thigh, Saphenous nerve
Vastus muscles, Quad femoris, Sartorius, Pectineus
Calculating Relative risk
Experimental Event Rate / Control Event Rate = Relative Risk
Testing for HIV
HIV PCR
p24 antigen test
Breast Anatomy
ARterial Supply
Venous Drainage
Lymph Drainage
Arterial Supply:
Internal Mammary
External Mammary (lateral breast)
Anterior intercostal arteries
Thoraco-acromial artery
Venous Drainage:
Superficial venous plexus –> subclavian, axillary and intercostal veins
Lymph -
Axillary Nodes
Internal mammary chains
Crohn’s Rectal Disease
Can’t make an ileoanal pouch- lots of cx
Need end stoma
Muscles attaching to the radius
Radial Tuberosity - Biceps Brachii
Body: Upper third - Supinator, FDS, FPL
Middle third - Pronator Teres
Lower part - Pronator quadratus + Supinator tendon
Lower end:
3 Grooves for tendons:
Extensor muscles (carpi, pollicis longus, indices)
Pressure for pneumoperitoneum
7-15 mmHg
Right Coronary ARtery supples:
Left Coronary Artery Supplies:
Right Coronary ARtery supples:
RA
Part of RV
SA node (usually), AV Node
Posterior Third of interventricular septum
Left Coronary Artery Supplies:
LA
LV
Part of RV
SA node (less usually)
anterior two thirds of interventricular septum
Coronary Sinus
Where is it
What drains into it
Posterior part of coronary groove
Receives blood from:
great cardiac vein on left
middle cardiac vein on right
small cardiac vein on right
Which veins drain the loose areolar tissue of scalp?
Emisary veins (potential for spread of infection to cranial cavity)
Perforated appendicitis - where is fluid most likely to collect
pelvis
Which muscle relaxants do not cause histamine release
Verocuronium + Suxamethonium
Where does sciatic nerve bifurcate and what into
Bifurcates at superior aspect of the popliteal fossa:
Tibial Nerve
and Commmon Peroneal NErve
Mediators of acute inflammation
Serotonin
Histamine
Prostaglandin
Leukotrienes
TNF
Interleukins
Structures within the right atrium
Musculi Pectinati
Crista Terminalis
Fossa Ovalis
opening of coronary sinus
Causes of pruritis ani
Systemic - DM, High Bili, Aplastic Anaemia, Leukaemia
Mechanical - diarrhoea, constipation, anal fissure
Infections- Stds
Dermatological disease
Drugs - Quinidine, Colchicine
Treatment of cyclical mastalgia
Evening primrose oil, flax seed oil
Danazol, tamoxifen
Scrotal Sensation
Anterior - Ilioinguinal Nerve (L1)
Posterior - Pudendal Nerve ( S2-S4)
Branchial Cyst
Cystic Hygroma
Locations on examination?
Branchial Cyst - Anterior to SCM
Cystric Hygroma - Posterior to SCM
Structures anterior to posterior in the hilar area:
Right Lung
Left Lung
Right Lung
1. Superior to hilum : SVC, Azygos Vein, Inominate Artery
2. Behind the hilum:pulmonary ligament, Oesophagus (Superiorly). IVC (inferiorly just anterior to oesophagus )
Left Lung
1. Superior to hilum: Arch of aorta, Subclavian artery, left inominate vein
2. Behind the hilum: pulmonary ligament, descending aorta, oesophagus (inferiorly)
NPI Equation
(0.2 x size of tumour) + Nodes + Grade
Nodes:
0 nodes = 1
1-3 nodes = 2
>3 nodes = 3
Grade:
1=1
2=2
3=3
How to differentiate between Anclyostoma Duodenale + Ascariasis infections?
Anclyostoma - stool microscopy just larvae (if you’re lucky)
Ascariasis - worms and eggs
Myocardial Action Potential
Rapid Depolarisation - Na+ Influx
Early repolarisation - K+ Efflux
Plateue - Slow Ca++ Influx
Final repolarisation - K+ Efflux
Monteggia vs Galeazzi
Montegia - Ulnar Fracture + Proximal radioulnar dislocation
Galeazzi - Radial Fracture + Distal radioulnar dislocation
Structures passing posterior to lateral malleolus
Peroneus longus and brevis
Actinomycysosis
Best Diagnosis?
Gram Positive Anaerobic Bacilli
Diagnosis is through open drainage and culturing of material
Jugular Anatomy
External
Internal
External - Superficial to SCM
Internal - Deep to SCM in carotid sheath medial to common carotid.
External:
Formed from joining of posteior division of retromandibular vein + Posterior auricular vein
joins subclavian vein and then internal joins more medially to form inominate vein
Cervical Drainage
Through broad ligament to external iliac nodes
Uterosacral fold to presacral
Accompanying uterine vessels to internal iliac
Which structures are superior/deep to the extensor retinaculum
What are the attachments of the retinaculum
Superficial - Veins(cephalic and basilic veins) and Nerves (Dorsal cutaneous of ulnar nerve + Superficial of radial nerve)
Deep - Tendons
Attachments
Ulnar side - Psisform And triquetrium
Radial side - radial bone
Axillary LNs
If palpable/image confirmed lymphadenopathy?
If no lymphadenopathy?
If palpable/image confirmed lymphadenopathy then proceed to FNAC
If no lymphadenopathy then Sentinel Lymph Node biopsy at surgery
Axillary Artery:
Parts
Branches
From upper border of first rib (underneath the clavicle) to lower border of teres major
Parts:
1 - Superior to pec minor.
Associated with brachial plexus and axillary vein
2 - Behind pec minor
Cords of the plexus location are synonymous with their names here
3 - Inferior to pec minor
Branches
High Thoracic
Thoracoacromial
Lateral thoracic
Subscapular
Posterior circumflex
Anterior circumflex
Where does the chorda tympani unite with the lingual nerve?
Near the lateral pyerygoid
Which pharnygeal arches are the following structures derived from:
Superior parathyroid glands
Inferior parathyroid glands
Superior - Fourth Pharyngeal Arch
Inferior - Third Pharyngeal Arch
Structures at risk in carotid surgery
Hypoglossal Nerve
Greatuer Auricular Nerve
Superior Laryngeal Nerve
Common Facial + Internal Jugular Vein
Why might the APTT be long in someone with Anti Phospholipid Syndrome?
They might have Lupus Anticoagulant.
ALthugh in vivo this is prothrombotic, in vitro it increases APTT
From where does the scaphoid bone get its blood supply?
From its distal end via a small branch of the radial artery
What goes through:
Caval Hiatus
Oesophageal Hiatus
Aortic Hiatus
Caval - IVC + Right Phrenic
Oesophageal - Oesophagus + Vagal trunks
Aortic - Aorta + Thoracic Duct
Nerves at risk in submandinbular gland excision
Hypoglosal Nerve
Lingual Nerve
Marginal Mandibular Nerve
Limited liver mets in colorectal malignancy….
Chemotherapy + Resection.
Radiofrequency ablation for those not fit for surgery
Actions of corticosteroids
Metabolic
Decreased uptake/utilisation of glucose
Increased gluconeogenesis
Increased hyperglycaemia
Increased protein catabolism
Lipolysis
Regulatory
Negative feedback on hypothalamus
CNS - decreased vasodilation/ decreased fluid exudation
Decreased osteoblastic/ Increased osteoclastic
Decreased inflammation
Branches of the vagas nerve
Right - Recurrent laryngeal at the level of Right Subclavian artery in neck
Left - RLN at level of aortic arch
Both give off:
Superior and Inferior cervical cardiac branches
Right - Both Posterior to subclavian
Left - Superior branch between arch of arota and trachea
Whereas inferior tracks along with the vagus
Thoracic and cardiac branches (in thorax)
Where do the different rotator cuff muscles attach to fibrous capsule
Superior - Supraspinatus
Anterior - Subscapularis
Posterior - Teres Minor + Infraspinatus
left renal vein interesting anatomy
It crosses the aorta just inferior to the SMA
Receives tributaries from the testicular vein, suprarenal vein + inferior phrenic vein
Level is at about L1/L2
Feeding in oesophageal perforation
Should be through TPN as any other feeding can cause delayed healing or leak through perforation
Treatment of pancreatitic pseudocyst
Endoscopic or radiological cystgastrostomy
nerve roots for
Superior Gluteal nerve
Inferior Gluteal nerve
SGN - L4 - S1
IGN - L5 - S2
What muscle is associated with the pudendal canal?
Which space is it located within?
Obturator Internus
Ischioanal fossa
Bacteria most commonly associated with synergistic gangrene
E Coli + Bacteroides
Where are musculi pectinati predominantly ofund
Right atrium - internal muscular ridges on the anterolateral surface of the chamber
Lymph drainage of ureter
Upper - Para Aortic
Lower - Common Iliac
Flattened Face =
Le Fort 2 or Le Fort 3 fracture
What is in the lung pleural reflection?
Bronchus, Pulmonary Artery, Pulmonary Vein
Relations of Coeliac Trunk
Anterior - Lesser Omentum
Right - Right coeliac ganglion + caudate lobe of liver
Left - Left coeliac ganglion + gastric cardia
Inferiorly - pancreas + renal vein
Laparotomy approach in children
Transverse Supra Umbilical incision
Trotter’s Triad
Nasopharyngeal Carcinoma
Unilateral Conductive Hearing Loss
Ipsilateral Facial Pain
Ipsilateral Palatal Paralysis
Thoracic Duct Path
Starts at joining of left and right lumbar trunk + intestinal trunk (cisterna chylii)
Traverses diaphragm through aortic hiatus then ascends between aorta and azygos vein
Terminates in the left inominate vein
Process of gastric dumping syndrome
Load enters the jejunum fast –> Water enters the lumen –> Distension of the jejunum and then diarrhoea
Also causes insulin release (hypoglycaemia )
Salter Harris Classification System
I ( Straight) - Through Physis
II (Above) - Through physis and above to involve metaphysis
III ( Lower) - Through physis and below to involve epiphysis
IV (Through) - Through metaphysis, physis and epiphysis
V (Everything Ruined) - Crush / Compression
Ansa Cervicalis
Roots
Innervates
Location
Roots - Upper C1, Lower C2-C3
Innervates - Sternohyoid, Sternothyroid, Omohyoid - innervation comes from inferior part of muscle
Location - Anterior to carotid sheath within the pre tracheal fascia
Where do these arteries originate?
Artery of Vas
Cremasteric Artery
Artery of Vas - Inferior Vesicular Artery
Cremasteric Artery - Inferior epigastric artery
What does mandibular nerve innervate (motor)
Masseter
Temporalis
Medial and Lateral Pterygoid
Tensor Veli Palatini
Tensor Tympani
Mylohyoid
Anterior belly of digastric
Quadratus Lumborum
Origin
Insertion
Action
Innervation
Origin - Medial aspect of iliac crest and iliolumbar ligament
Insertion - 12th Rib
ACtion - Pulls rib cage inferiorly. Lateral flexion of spine
Innervation - Anterior Rami of T12-L3
Multiple lytic / lucent appearances on X Ray
(Soap Bubble)
Osteoclastoma (Giant Cell Tumour)
Where is the coeliac plexus
What contribuets to it
Plexus is at T12/L1 inbetween oesopahgus (anterior) and aorta (posterior)
It receives contributions from Greater splanchnic nerves, lesser splanchnic nerves, Vagus Nerves and Phrenic Nerves
Innervation to external urethral sphincter
Autonomic Control of the bladder
Innervation to internal urethral sphincter
External -Pudendal Nerve (L2-L4)
Autonomic control of bladder - Hypogastric plexuses
Internal - Sympathetic fibers from T10 - L2 through inferior hypogastric plexus
How does tranexamic acid work>
Inhibits plasmin which is responsible for fibrin degradation
Location of the brcahial plexus in the neck
Roots enclosed within an extension of prevertebral fascia
Deep to platysma, omohyoid, transverse cervical artery + supra clavicular nerves.
Causes of avascular necrosis
Plastic RAGS
Plastic Rags
Pancreatitis
Lupus
Alcohol
Steroids
Trauma
Idiopathic, Infection
Caisson Disease, Collagen Vascular Disease
Radiotherapy, RA
Amyloid
Gaucher Disease
Sickle Cell Disease
Directions of External Carotid Branches
Anterior:
Superior Thyroid
Lingual
Facial
Posterior:
Occipital
posterior auricular
Deep:
Ascending Pharyngeal
Where is the intercostal bundle
Lies in the subcostal groove
Vein is most superior (least easily damaged)
Artery
Nerve (most inferior)
Cutaneous innervation of foot
Dorsolateral
lateral plantar
dorsum
first web space
proximo-medial
heel
Dorso-lateral - Sural
Lateral Plantar - Lateral Plantar Nerve
Dorsum - Superficial peroneal
First Web Space - Deep Peroneal
Proximo-medial - Saphenous nerve
Heel - Calcaneal Branch of Tibial Nerve
Treatment of haematocele?
Surgical Exploration + Repair through scrotal approach
Where does the cervical sympathetic chain lie?
Between the:
Carotid Sheath (anteriorly)
Prevertebral Fascia (Posteriorly)
Biceps Femoris
Origin
Insertion
Innervation
Blood Supply
Origin - Ischial Tuberosity (long), Linea aspera/ Supracondylar ridge of femur (short)
Insertion - Fibular Head
Innervation - Sciatic nerve (Tibial - Long, Common Peroneal - Short)
Blood Supply - Profunda Femoris, Inferior Gluteal, Superior Politeal Branches
What influences release of histamine from enterochromaffin cells in stomach?
Elevated Serum Gastrin
Grading of knee collateral injury
1 - Soem fibre disruption, no laxity (Conservative)
2 - Some ligament laxity (casting/ splinting)
3 - Joint instability, ligament is torn (Surgical Reconstruction)
Statistics:
Likelihood ratio for positive test result
likelihood ratio for negative test result
PTR - Sensitivity/ (1-specificity)
NTR - (1-sensitivity)/specificity
Describe lesser omentum
Double layer of peritoneum extending from liver to the -stomach and duodenum
Divided into two portions: hepatogastric ligament (attaches to lesser curve of stomach), hepatoduodenal ligament
WIthin the folds - left and right gastric arteries
hepatic artery, CBD, Portal vein, LNs, and hepatic plexuses
Describe Greater Omentum
Double layer of peritoneum extending from greater curvature of stomach over the top of the small intestines and then coming back to cover the transverse colon
Subdivisions: Gastrophrenic, Gastrocolic, +Gastrosplenic Ligament
Blood Supply - Left (from splenic artery) and Right (gastroduodenal branch) Gastropeiploic Arteries
Posterior Triangle of neck contents
Nerves:
- Accessory nerve, phrenic nerve
- Trunks of brachial plexus
Cervical Plexus Branches - Supraclavicular nerve, Transverse Cervical Nerve, Greater Auricular Nerve, Lesser occipital nerve
vessels:
EJV, Subclavian artery
Muscles;
Inferior belly of omoyhyoid, Scalene
Lymph Nodes;
supraclavicular, occipital
What is the only muscle of the foot not innervated by the tibial nerve?
Extensor Digitorum brevis ( Common Peroneal nerve)
Pituitary Anatomy
In the sella turcica of the sphenoid bone. Covered by dura here. Originates from rathkes pouch (pharynx)
Anterior side conected to hypothalamus by portal vein whereas posterior side connected via neurones
anterior hormones:
GH, LH, FSH, ACTH, MRH, TSH
posterior hormones:
ADH, Oxytocin
Sciatic nerve topography
Convergence of L4-S3 Anterior rami at the inferior border of piriformis and emerges through the inferior part of greater sciatic foramen
From here it descends underneath gluteus maximus
Splits into Common peroneal + Tibial nerve superior to popliteal fossa
Anterior Interosseus Nerve Injury
Loss of pronation of the arm (pronator quadratus)
Loss of flexion of lateral fingers and thumb (FPL + FDP)
Greater Sac
Lesser Sac
Greater Sac
Peritoneum encasing the majority of the intraperitoneal abdomen (save the lesser sac)
Lesser Sac
Is the encasing of the cavity that is formed by the greater and lesser omentum.
Margins:
Anterior - Quadrate lobe of liver, stomach, lesser omentum, gastrocolic ligament
Posterior - left kidney, adrenal gland, pancreas
Inferior - Greater Omentum
Superior - Liver
Lateral - Spleen and ligaments anterior/posterior to the spleen
lateral malleolus
Posterior structures
Posterior:
Peroneus longus and brevis tendons
Sural nerve
Short Saphenous Vein
Causes of thrombocytopenia
Severe
Moderate
Severe- ITP, TTP, DIC, Haem Malignancy
Moderate -
HIT
Drugs - quinine, diuretics, sulphonamide, thiazide, aspirin
Alcohol
liverdisease
hypersplenism
Viruses
Pregnancy
SLE/Antiphospholipid Syndrome
B12 Deficiency
What are the branches of the maxillary artery
Inferior alveolar
Middle meningeal
Adductor Longus
Origin
Insertion
Innervation
Origin - Anterior body of pubis
Insertion - middle third of linea aspera
Innervation - Obturator Nerve (L2-L4)
Adults:
Where does spinal cord terminate
Where does dural sac end
Spinal cord - L1 (L3 in newborns)
Dural Sac - S2
Laxatives
Bulk forming laxatives
Osmotic Laxatives
Stimulant Laxatives
Bulk forming laxatives
Bran, Psyllium, Methylcellulose
Osmotic Laxatives
magnesium sulphate, magnesium citrate, sodium phosphate, sodium sulphate, potassium tartate, polyethylene glycol, docusate
Stimulant Laxatives
Senna
Picosuphate
ricinoleic acid
bisacodyl
Types of DCIS
Comedo - Linear branching microcalcificaition
Cribiform, micropapillary - multifocal
Pectoralis Major
Origin
Insertion
Nerve SUpply
Actions
Pectoralis Minor
Origin
Insertion
Nerve SUpply
Actions
Major
Origin - medial two thirds of clavicle, manubrium and sternocostal angle
Insertion - lateral edge of bicipital groove of humerus
Nerve SUpply - Lateral Pectoral nerve
Actions - Adducts + Medial ROtates humerus
Minor
Origin - Costochondral Junctions of third to fith ribs
Insertion - Coracoid process of scapula ( medial border+ superior surface)
Nerve SUpply - Medial + Lateral Pectoral Nerve
Actions - Draws scapula inferiorly/ anteriorly against thoracic wall.
What drains into the
SMV
IMV
SMV - up to the splenic flexure
IMV - beyond the splenic flexure
Regarding Nerve Transection Injuries - what is the prognosis/ course of action
Clean Simple Transection
Complicated Transection
Clean Simple Transection - the proximal axon will degenerate back to the first node of ranvier. Wallerian degeneration will causae the distal axon to degenerate too.
The proximal axon will grow at a rate of 1mm per day
Complicated Transection -
Axonal growth will be impaired in the setting of fracture, haemorrhage, infection etc…
Therefore practice is to delay approximation of the distal+proximal axons for a few weeks
Where does the female urethra drain lymphatic wise too
Internal Iliac Nodes
Where is a hypervascular bone primary most likely to come from
Kidney
Main difference between T Tests/ Fishers + Chi
T Test - Compares normally distributed data
Fishers + Chi - Tests categorical data
Quadrate lobe
Functionally part of left lobe of liver
Anatomically associates with right lobe of liver
Oesophagogastric Junction Tumours
Type 1 - true oesophageal (barrett’s)
Type 2 - of the gastric cardia/ intestinal metaplasia
Type 3 - Sub cardial cancers that spread across the junction
Depending on staging these are treated by oesaphogogastrectomy
Innervation of lacrimal duct
PNS
Greater Petrosal nerve (Branch of CNVII in the facial canal) –> Pterygopalatine ganglion —> gland innervated through zygomatic / lacrimal branches of maxillary nerve
What is the thoracic outlet?
Where the subclavian vein, artery and brachial plexus exit the thorax.
In between first rib and the clavicle
Which nerve supplies abductor pollicis longus?
Radial
Ear Nerves:
What supples sensation to external ear?
What innervates stapedius?
What innervates tensor tympani?
What supples sensation to external ear? - Greater Auricular Nerve (Cervical Plexus C2-C3) + Auriculotemporal nerve ( Mandibular Nerve)
What innervates stapedius?
Nerve to stapedius ( CN VII)
What innervates tensor tympani?
CN V
Composition of cervical canglion
Superior : C1 - C4
Middle: C5- C6
Inferior: C7-C8
Any rupture of urethra from membarnous urethra onwards … Where doe urine accumulat?
Connective tissue of the scrotum:
Fascia adherence prevents urine from going posteriorly or laterally so it tracks retrograde
Borders of the
Deep Perineal prouch
Superficial Perineal Pouch
Muscles of perineal body
Deep Perineal pouch
Superiorly - fascia of perineal floor
Inferiorly - Perineal membane
Superficial perineal pouch
Superficial - perineal membrane
Inferiorly - Superficial perineal fascia
perineal body:
Just superior to the anus.
Muscles - Levator Ani, Bulbospongiosus, Transverse perineal muscles, External Anal Sphincter, External urethral sphincter.
Duke Classification System
A - Confined to bowel
B - Involving bowel wall
C - Nodal Mets
D- Distant mets
Biopsy features of barret’s oesophagus
Goblet Cell metaplasia
Oesphageal Glands
Which rectal cancer patients require neoadjuvant radiochemotherapy
T4
Radial Nerve Injury in the :
Shoulder
Arm
Forearm
Shoulder - Triceps Long Head
Arm - Impairment to elbow extension
Forearm - Wrist, finger extension and supination
Contents of
Superficial perineal Pouch
Deep Perineal Pouch
Deep:
Urethral Sphincter
Urethra
Vagina
Deep Transverse Perineal Muscle
Superficial:
Erectile Tissue
Superficial Transverse, Ischiocavernosus, bulbospangiousis
Bartholin’s Glands
Levator Ani Muscles
Three paired muscles - pubococcygeus, puborectalis, ileococcygeus
Perineal Body to pubic bodies of hip bone(anterior), to obturator internus (lateral), ischial spines of hip bone (posterior)
Relations of the prostate gland
Anterior - Venous PLexus, Pubic Symphysis
Posterior - Denonvilliers Fascia, Rectum, Ejaculatory Ducts,
Lateral - Venous Plexus, Levator ani
First Line therapy for Nasopharyngeal Carcinoma
Radiotherapy
Tetralogy of Fallot
Feature
VSD
Overarching Aorta
Right Ventricular Hypertroply
RV outflow Obstruction
Right to left shunting
Oxyphil Cells on thyroid histology =
Follicular carcinoma
Thing in relation to carotids
Inferior thyroid artery passes posterior to common carotids
Thoracic Duct crosses the left common carotid
Recurrent laryngeal nerve crosses the right common carotid
larynx:
Superior to vestibular folds
Between vestibular folds, superior to vocal cords
vocal cords to inferior bord of cricoid cartilage
Vestibule - Superior to vestibular folds
VEntricle - Between vestibular folds, superior to vocal cords
Infraglottis - vocal cords to inferior bord of cricoid cartilage
Differentiating feature of
Central Horner’s
Pre Ganglionic Horner’s
Post ganglionic Horner’s
Central Horner’s - Anhidrosis of ipsilateral face arm trunk
- *Pre** Ganglionic Horner’s - Anhidrosis of ipsilateral face
- *Post ganglionic Horner’s -** Anhidrosis of NOTHING
Which surgical device is good for managing splenic bleeding?
Argon plasma coagulation system
Which arteries make up kiesselbach’s plexus?
Greater Palatine artery + SPhenopalatine Artery
(Both Maxillary Artery Branches - From ECA)
What is a bankart lesion
Injury to anterior inferior glenoid labrum
This can cause recurrent anterior shoulder dislocation
Renal Tubular Acidosis
Type 1
Type 2
Type 4
Type 1 (Distal Tubule) - Impaired H+ Secretion, Hypokalaemia
Type 2 (Proximal Tubule)- Impaired Bicarb Reabsorption, Hypokalaemia
Type 4 (Collecting Ducts) - Addison’s/Ald Resistance
Hyperkalaemia
If the external fistula opening is at th following o clock where can you expect to find the internal opening
2 o clock
4 o clock
7 o clock
11 o clock
2 o clock + 11 o clock are anterior - so the internal opening will be in a straight line from the external opening at the same o clock trajectory.
4 o clock + 7 o clock are posterior - so the internal opening will be in the midline at 6 o clock after havine a curvilinear route
What are the posterio/medial relations of the left lobe of liver?
Proximal stomach + abdominal oesophagus
Which valves have chordae tendinae
Mitral and Tricuspid
Mitral - 2 Cusps (one anterior)
Which two cranial nerves originate from between the posterior cerebral artery and the superior cerebellar artery
Trochlear Nerve + Occuluomotor nerve
Which clotting constituents are consumed most quickly in DIC
V, VIII and platelets
Layers of bowel wall
Mucosa
Submucosa
Submucosal Plexus (Meissner’s)
Muscular Layer (First circular and then longitudinal - Auerbach’s plexus is in between them)
Serosa
Dark blood on aspiration in priapism?
This indicates low flow priapism - the penis needs to be decompressed by further aspiration
Where are the motor root fibers of the trigeminal nerve?
In the pons - distinctly not part of the trigeminal ganglion
Carcinoid Tumours - management
<2 Cm And in the appendix
>2 cm
<2 cm and in appendix - Just appendicectomy
>2 cm - Radioisotipe scanning.
If radioisotope scanning demonstrates –> lymph involvement then right hemi
if margins on histology demonstrate compromise –> right hemi
Contents of anterior triangle of neck
Submandibular Gland
Supra and infrahyoid muscles, Digastric Muscle
Carotid Sheath ( Vagus, Carotid, Jugular)
Ansa Cervicalis,
Internal Jugular Vein, External jugular Vein, Anterior Jugular Vein
Associations of oesophageal atresia
Distal tracheoosophageal fistula is teh common varient
Associated with VACTERL (Vertebral anomalies, anal atresia, cardiac anomalies, thracheosophageal fistula/esophageal fistula, renal anomalies, limb defecvts).
Long Thoracic Nerve
Ventral rami of C5- C7 —> inferior route iether infront or behind middle scalene muscle.
Descends overlying the serratus anterior muscle
Renal stoens associated with…
inborn errors of metabolism
purine metabolism disorders
infection
inborn errors of metabolism - Cystine (radio-dense)
purine metabolism disorders - Uric Acid (radiolucent)
infection - Struvite (radio-dense)
In children - are teratomas usually malignant or benign
Benign - so if there is a testicular mass in a child with ?metastatic disease its probably not teratoma
Where does the root of the :
Right lung pass
Left Lung Pass
Right lung - SVC and Right Atrium
Left Lung - Desceinding Aorta, Aortic arch
Pancreatic Relations
Posterior:
IVC, CBD, Renal Veins, SMA, SMV, Portal Vein, Diaphram, Psoas, Kidney, Adrenal, Aorta
Anteror:
1st Part of Duodenum, Pylorus of stomach, Gastroduoednal ARtery, SMA + SMV, Stomach, DJ Flexure, Splenic Hilum
Superior:
Coeliac Trunk, SPlenic artery, Common Hepatic ARtery
Mutation associated with
FAP
Lynch
Cowden
MYH associated Polyposis
Peutz jehgers
FAP - APC
Lynch - DNA mismatch repair genes
Cowden - PTEN
MYH associated polyposis - MYH
Peutz Jehgers - STK11
Management of >1 cm sessile serrated polyps
Polypectomy
Fracture Healing Stages
Clot and haematoma formation
Clot Organisation ( Collagen)
Bone production from periosteum
Cartilage production (mesenchymal cells)
Callus formation ( connective tissue + hyaline cartilage)
Endochondrol ossification of cartilage
Trabecular bone formation –> Compact bone by osteoclast mediated resorption of trabecular bone
types of colonic peristalsis
what does circular muscle do
what does longitudinal muscle do
Colonic peristalsis:
Mas movement - waves of peristalsis through the whole colon
Segmental Contraction - Local contractions to maximise absorption
Antiperstaltic contractions - slow down food bolus toward ileum
Circular muscle - contracts behind food bolus
longitudinal muscle - propels food bolus forwards
WHere do the following originate
Long Head BIceps
Long Head Triceps
Long head biceps - Supragelnoid Tubercle
Long head Triceps - Infraglenoid tubercle
Iliacus
Origin
Insertion
Innervation
Action
Arterial Supply
Origin - Superior 2/3 of iliac fossa
Insertion - Lesser trochanter of femur
Innervation - Femoral nerve
Action - Thigh Flexor
Arterial Supply - Femoral Artery
What are the end branches of posterior tibial artery
Medial and lateral planter arteries
Hip Fracture management
Subtrochanteric
Reverse Oblique
Inter-Trochanteric
Subtrochanteris - Intramedullary Nail
Reverse Oblique - Intramedullary Nail
Inter-trochanteric - DHS / IM Nail if unstable
Spinal Cord Lesions: Signs and causes
Dorsal Column
Spinothalamic
Central Cord Lesion
Osteomyelitis
Infarction
Cord Compression
Brown- Sequard
Dorsal Column - Vibration and proprioception lost. Tabes Dorsalis, SACD
Spinothalamic - Loss of pain/temp. Syringomyelia
Central Cord Lesion - Syringomyelia
Osteomyelitis - Cervical region / Thoracic Region. Usually back pain
Infarction - 2o to aortic surgery..Doral Columns Signs
Cord Compression - UMN signs. Malignancy, haematoma, fracture
Brown- Sequard - Hemisection of spinal cord. Ipsilateral paralysis, loss of proprioception and fine discrimination. Contralateral loss of pain and temp
What test can be used to compare two or more sets of non-parametric data?
Kruskal Wallis One way variance test
Relations of the IVC
Anterior:
Small Bowel,
1 + 3 of duodenum
Head of pancreas,
Liver, Bile Duct
RIght common iliac, Right gonadal artery
Posterior:
right renal artery, right psoas, right sympathetic chain, coeliac ganglion
Borders of anatomical snuffbox
Posterior - EPL
Anterior - APL, EPB
Proximal- Radial Styloid Process
Distal - Apex of snuffbox
Floor - Scaphoid + trapezium
layers of periosteum
Outer -Fibrous layer (Fibroblasts)
Inner - Cambium layer ( osteogenic - containing osteoid progenitor cells)
Sharpey’s fibers connect it to bone
What are the compartments of the knee joint
Bursae of knee joint
Anterior
Lateral
Medial
Which meniscus is attached to respective collateral ligament
Compartments
Tibiofemoral
Patellofemoral
Bursae of knee joint
Anterior - Prepatellar Bursa, Deep Infrapatellar bursa (tibia and patellar ligament, Superficial infrapatellar bursa (tibial tuberosity and skin)
Lateral - Between: i) lateral Gastroc and joint capsule, ii) lat colat lig + biceps tendon, iii) lat colat lig + popliteus tendon
Medial - Between: i) medial gastroc + joing capsule ii) medial colat lig + pes anserius tendons, iii) membranosus + medial tibial condyle + medial gastroc head
Medial meniscus is attached to respective collateral ligament
Musculocutaneous nerve continues into the forearm as the..
Lateral cutaneous nerve of the forearm
Adductor Canal
Lateral- Vastus Medialis
Posterior - ADductor Longus and MAgnus
Anterior - Sartorius
Contents - Saphenous Neve, Superficial Femoral Vein, Superficial Femorl ARtery
Drugs to manage VT
Amiodarone
Lidocaine
Procainamide
Brachial Plexus
What are the roots of the BP ensheathed within in neck?
What structures overly the brachial plexus in the neck?
In the neck the BP is enclosed within an extension of the prevertebral fascia
In the neck the brachial plexus is deep to:
Platysma, Supraclavicular Nerves, Inferior belly of omohyoid, Transverse Cervical Artery.
They then pass deep to the clavicle and suprascapular vessels on the way into the axilla
Why is facial vein more at risk than facial artery in submandibular gland surgery?
The facial vein is more superficial a structure - it descends on the surface of the mandible and then superficial to the gland itself.
The facial artery ascends from deep to the artery. then overlies the mandible
Branches of the mandibular nerve
Auriculotemporal
Lingual
Inferior Alveolar
Nerve to mylohoid
Mental
What are the subtriangles of teh anterior neck triangle?
Submandibular (Digastric) - Gland, Nodes, Facial A+V, CNXII
Digastric Muscle
Muscular - Strap Muscles, EJV
Omohyoid Muscle (Anterior - Mylohyoid(CN V3), Posterior - Facial)
Carotid - Sheath, Ansa Cervicalis
List Some Cardiac Inotropes
Phosphodiesterase Inhibitors
Adrenaline
Noradrenaline
Dopamine
Dobutamine
Bladder cancer Treatment
Superficial - TURBT
Superficial but high grade/risk, recurrence - intravesical chemotherapy
>T2 - radical cystectomy
Lymphatic Drainage of:
Scrotum
Testes
Prostate
Scrotum - Inguinal
Testes - Para- Aortic
Prostate - Internal Iliac
Ligaments of the Liver
Ligamentum Teres
Remnant umbilical vein - joins left portal vein branch in porta hepatis
Ligamentum Venosum (Posterior)
Remnant of ductus venosus -
Falciform Ligament
Double peritoneal fold from umbilicus to anterior hepatic surface where divides into coronary and left triangular ligaments
Pelvic Floor Muscles
Floor
Lateral Wall
Where is the perineal body
Pelvic Floor:
Floor - Levator Ani (Pudendal Nerve - Pubococcyg., iliococcyg, puborectalis), Coccygeus
Lateral Wall - Piriformis + Obturator Internus
The perineal body is inbetween the urogenital and rectal hiatus
Anatomical boundaires of the perinuem
Diamond shaped structure
Anteriorly - Pubic Symphysis
Posteriorly - Tip of coccyx
Laterally - inferior pubic rami, inferior ischial rami and sacrotuberous ligament
Muscles of the perineal body
Levator Ani
Bulbospongiosus
Superficial and deep transverse perineal muscles
external anal sphincter
external urethral sphincter
Nerves associated with pharyngeal arches
I - Trigeminal
II - Facial
III - Glossopharyngeal
IV - Vagus
VI - Vagus + RLN
Which abdominal viscera are retroperitoneal?
Adrenals, Kidneys, Ureters
Aorta + IVC
Rectum
Duodenum ( except proximal 2cm ), oesopahgus, pancreas
Colon - not transverse or sigmoid
Which muscles cross the internal jugular vein?
Omohyoid
Sternocleidomastoideus
Lymph Drainage of the female urethra
Internal Iliac Node (Whole length of the urethra)
Branches of thoracoacromial artery
Pectoral - Breast and Pectorals
Acromial - Deltoid and joint capsule
Clavicular - sternoclavicular joint
Deltoid - travels between pec major and deltoid in deltopectoral groove
Structures passing behind the medial malleolus:
Anterior to Posterior
Anterior :
Tibialis Posterior
Flexor Digitorum Lonugs
Posterior Tibial Vein
Posterior Tibial Artery
Nerve
Flexor Hallucis Longus
Treatments for extravasation injury
Doxirubicin
Contrast media, TPN, Vinca Alkaloids
Vinca Alkaloids ALone
Doxirubicin - COld Compress
Contrast media, TPN, Vinca Alkaloids - Hyaluridonase
Vinca Alkaloids ALone - Warm Compress
Breast Treatment
When to use chemo
When to use radio
Chemo:
Downstaging
>Grade 3 Lesions
Axillary node Disease
Radio:
WLE
Post Mastectomy - Large lesion, High Grade Lesion, vascular invasion
What is in the middle mediastinum (5)
Pericardium
Heart
Aortic Root
Arch of azygos vein
Primary bronchi
Defect in osteopetrosis
Osteoclast function impaired
- So defective bone resorption
Cardiac Surgery Qs
Incisions
Cardiopulmonary bypass - What is cannulated
How much heparin
Conduits for bypass
Incisions - Midline sternotomy/ Left Submammary Incision
Cannulated - Aortic Roots + Right Atrium
Heparin - 30,000 iU of unfractionated
Bypass Conduits-
Internal mammary, Radial, Long saphenous
Borders of the triangular interval
Content
Medial - Long head of triceps
Lateral - Shaft of humerus
Superiorly - Teres major
Transmits the radial nerve from the axilla into the arm
HIV Testing: Window for positivity
p24 antigen
Antibody
p24 antigen : 3-4 weeks
Antibody: 4-6 weeks
Glasgow Pancreas Score
P - PaO2 <8
A - Age >55
N - Neutrophils >15
C - Calcium <2.0
R - enal Urea >10
E - Enzymes LDH Raised / AST raised
A - ALbumin >32
S - Hyperglycaemic
Stucturs in the right atriu
Musculi Pectinati
Crista Terminalis
Opening of coronary sinus
Fossa Ovalis
Artery Locations:
Anterior Tibial
Posterior Tibial
Peroneal
Anterior TIbial - In the anterior compartment (very close to deep peroneal nerve)
Posterior Tibial - In the deep posterior compartment - more medial
Peroneal - In the deep posterior compartment - more lateral
Both of these are very close to the fibula + tibial nerve (their veins are either side of the tibial nerve)
Difference histologically between necrosis apoptosis
Necrosis:
Cell Membrane Problems
Lysosomes
Cellular Swelling
Inflammation
Apoptosis:
Fragments of nucleus
No inflammation
Cell Membrane Intact
No lysosomes
Structures posterior to medial malleolus:
Anterior to posterior
Tom Dick and Very Nervous Harry
Tibialis Posterior
Flexor Digitorum Profundus
Tibial Artery and Vein
Tibial Nerve ( supplies all intrinsic foot apart from Extensor hallucis Longus - Common peroneal Nerve)
Flexor Hallucis Longus
Borders of the tympanic cavity
Lateral - Tympanic membrane
Medial - Bulge formed by facial nerve/ lateral wall of inner ear
Roof - Temporal bone
Floor - Temporal Bone (known as jugular wall) related to internal jugular
Anterior Wall - bony plate. auditory tube + tensor tympani. related to ICA
Posterior wall - mastoid wall borders the cavity from mastoid air cells. Mastoid antrum is a connection the air cells
Borders of the antecubital fossa
Where does the brachial artery bifurcate
Where does the ulnar artery lie in relation nerve
Lateral - Brachioradialis
Medially - Pronator Teres
Superiorly - Line between the humeral condyles
Floor - Supinator + Brachialis
Contents - Medial to lateral - bicept tendon -> brachial artery -> median nerve
Brachial artery bifurcates - radial head
Ulnar artery is lateral to ulnar nerve
Layers of the SCALP?
Skin
Dense Connective Tissue
Epicranial APoneurosis
Loose Areolar Tissue ( Emissary Veins here)
Periosteum
Pterygopalatine Fossa
Borders
Contents
Borders:
Anterior- Posterior wall of maxillary sinus
Posterior - Sphenoid bone (pterygoid process)
inferior - palatine bone and canal
Superior - inferior orbital fissue
medial - perpendicular plate of palatine bone
lateral - pterygomaxillary fissure
Contents:
Maxillary Nerve (Foramen Rotundum opens here)
Maxillary artery
Pterygopalatine ganglion (Greater petrosal nerve of VII)
Infratemporal Fossa
Borders
Contents
Borders:
Lateral - Mandible condyle/ramus
medial - lateral pterygoid plate, palatine + superior constrictor muscles
anterior - posterior body of maxillary sinus
posterior - carotid sheath
roof - sphenoid wing
floor - medial pterygoid
contents
related to ovale and spinosum
medial and lateral pterygoids
mandibular nerve, otic ganglion, chorda tympani,
maxillary artery + vein
Middle Meningeal vein (Artery is associated with the roof)
vertebral Column
Arches-
Pedicles -
Lamina -
Spinous Processes -
Rib articulations
Arches - exend posteriorly from the body to create the vertebral foramen through which spinal cord is transmitted
Pedicles - Body to transverse process
Lamina - transverse to spinous process
SPinous Processes - Posterior most structure in the vertebrae. Cervical are bifid
Rib -
Superior + inferior demi facet - either side of vertebral body articulates with inferior/superior rib
Costal facet of transverse spinous process - articulates with rib corresponding to that vertebrae
Which back muscles are involved in rotating the head?
Of the deep spinal muscles:
What are the intermediate and deep ones
Splenius Capitis + Cervicis
Intermediate : Medial to lateral
Spinalis, Longissimus, Iliocostalis
Deep:
Multifidus + Semispinalis
Forearm Compartments
Anterior Superficial:
Flexor Carpi Ulnaris
Palmaris Longus (median nerve deep to this near wrist)
Flexor carpi Radialis
Pronator Teres
Anterior Intermediate:
Flexor Digitorum Superficialis
Anterior Deep:
Flexor Digitorum Profundus, Flexor Pollicis Longus, Pronator Quadratus
Posterior Superficial:
Brachioradialis
Extensor Carpi Radialis longus + brevis
Extensor Digitorum
Extensor Digiti Minimi
Extensor carpi ulnaris
Anconeus
Posterior Deep:
Supinator
Abductor Pollcis Longus
Extensor Pollicis Longus + Brevis
Extensor indicis proprius
Which flexor of the arm is innervated atypically?
Brachioradialis - innervated by the radial nerve
Nerves of lumbar plexus (6)
Lumbar Plexus : L1-L4
IlioHypogastric - L1. Internal Oblique + Transversus Abdom.
Ilioinguinal - L1. Internal Ob + Transvers. Abd. Enters inguinal canal by piercing through the internal oblique
Genitofemoral - L1-L2. Genital Branch - Cremaster Musc.
Lateral Cutaneous Nerve of Thigh - L2-L3
Obturator Nerve- L2-L4. Obt. Extern, Adduct Long + Mag + Brev. (sometimes pectineus) + Gracilis
Femoral Nerve - L2-L4. Quad Femor. Vastus Musc. Sartorius. Pectineus. Iliacus
Branches of thyrocervical trunk
Inferior Thyroid
Suprascapular
Transverse Cervical
The subscapular artery from the axillary artery (3rd part) anastamoses with the suprascapular + transverse cervical
Branches of the costocervical trunk
superficial intercostal
deep cervical
What happens to the dorsal scapular artery?
Dorsal Scapular Artery:
Joing the superficial cervical artery (Thyrocervical Trunk and becomes:
Transverse Cervical This has superficial and deep branches
Branches of the sacral plexus
S1-S4 (sciatic receives lumbar roots L4-L5)
Superior Gluteal Nerve - L4, L5, S1 Glut Med+ Min. TFL
Inferior Gluteal Nerve - L5 S1 S2. GLut Max
Sciatic Nerve - L4 - S3. Posterior thigh muscles + Part of aductor magnus. All muscles of lower leg via common peroneal + tibial branches
Posterior Cutaneous nerve of the thigh - S1 - S3
Pudendal Nerve - S2-S4. External urethral + anal sphincter. Levator Ani + perineal muscles
Nerve to piriformis
Nerve to quadrator femoris
Nerve to obturator internus
Piriformis
Nerve - Nerve to piriformis
S2-S4 to Lesser trochanter
What do the following anastamose with + Signficance:
Inferior Thyroid Artery
Deep Cervical Artery
Dorsal Scapular Artery
Inferior Thyroid Artery
Anastamoses with the superior thyroid artery –> This is significant in Subclavian Steal as retrograde flow happens through this link
Deep Cervical Artery
Descending branch of occipital artery –> Again another site of collateralisation in Subclavian Steal
Dorsal Scapular Artery
Circumflex Scapula Artery (from subscapular artery) + Suprascapular artery –> Forms the scapular anastamosis.
