Interval 1 Flashcards
0
Q
where does clavicle articulate?
A
manubrium medially and acromion process of scapula laterally
1
Q
location of suprasternal notch
A
superior margin of the manubrium of the sternum
2
Q
what is the most frequently broken bone?
A
clavicla because it is the only bone that transmits forces directly from the upper limb to the thorax
3
Q
significance of the sternal angle
A
1) ridge at junction of the manubrium and the body of the sternum
2) marks the level of articulation of the second rib with the sternum
3) transverse plane passing through the sternal angle will pass through the intervertebral disk between 4 and 5th thoracic vertebrae
4) marks position where: 1) trachea bifurcates into right and left bronchi w/in the thoracic cavity; 2) arch of aorta begins and ends; 3) SVC penetrates the pericardium to enter the heart
4
Q
how many ribs do we have?
A
12
5
Q
How do we classify the ribs?
A
7 true (articulate individually via their costal cartilages with the sternum) 8-10 are "false"--> costal cartilages that articulate with a more superior costal cartilage and contribute to the costal margin 11 and 12 are called "floating" because they do not articulate with the sternum or with the transverse process of thoracic vertebrae (they are embedded in musculature of the abdominal wall)
6
Q
what rib articulates with the sternal angle?
A
2nd rib!
7
Q
what are the spaces between the ribs and how are they named?
A
intercostal spaces and named for the rib above
8
Q
3 parts of sternum
A
1) manubrium
2) body
3) xiphoid process
9
Q
notes about manubrium:
A
contains the jugular notch, articulates with the medial end of each clavicle at the sternoclavicular joins, and articulates with costal cartilages of the first two ribs
10
Q
notes about body of sternum:
A
body articulates with the manubrium at the sternal angle
costal cartilage of second rib articulates that the sternal angle
costal cartilages of ribs 3-7 articulate with the body inferior to the sternal angle
11
Q
notes about xiphoid process:
A
articulates with the body and provides an attachment site for the diaphragm and the abdominal musculature
lowest of the anterior thoracic midline bony structures
thin, cartilaginous inferior end of the sternum
12
Q
costal margin
A
lower boundary of thoracic cage and is formed by cartilages or ribs 7-10 as well as by the 11 and 12th rib laterally
13
Q
iliac crest
A
superior margin of the pelvic bones
14
Q
where does the iliac crest end anteriorly
A
Anterior superior iliac spine
15
Q
highest point of iliac crest corresponds to what vertebrae
A
L4 (imp. for administering spinal anesthesia and performing a lumbar puncture)
16
Q
where do costal margins end?
A
L3
17
Q
skin is composed of which two layers?
A
epidermis (stratified squamous epithelium)
dermis (loose connective tissue and dense irregular connective tissue)
18
Q
where is the superficial fascia?
A
aka hypodermis
immediately deep to the skin
composed of loosely packed, randomly oriented collagen fibers and fat cells and gives the skin mobility
19
Q
what courses in superficial fascia?
A
superficial arteries, veins, lymphatics and nerves
20
Q
what is below the superficial fascia?
A
deep fascia!
present as a series of membranous sheets of connective tissue of varying density that intimately invest muscle, bone, neurovascular structures, and/or surround organs
21
Q
2 divisions of the nervous system
A
CNS and PNs
22
Q
two divisions of PNS
A
1) somatic nervous system
2) autonomic nervous system
23
Q
Do sensory nerves of the SNS and ANS have similar structures and courses?
A
yes
24
what actions do SNS and ANS control?
SNS- voluntary actions
| ANS- involuntary actions
25
what do SNS and ANS innervate?
SNS innervates body wall structures- skeletal muscle
| ANS innervates viscera (internal organs)- smooth and cardiac muscle
26
how many nerves does the somatic nervous system use?
one nerve system
27
how many nerves does the ANS use?
2 nerve system (nerve arises in the SC, but it must first synapse with a second autonomic nerve, outside the CNS, which then innervates the target organ)
first nerve: pre-ganglionic or pre-synaptic fiber
second nerve: post-ganglionic or postsynaptic fiber
28
NT of SNS and receptor?
SNS releases Acetylcholine to bind to N1 (nicotinic acetylcholine receptor)
29
NT and receptor of the ANS?
1st nerve: uses acetylcholine to bind to receptor on second neuron (N2 receptor- nicotinic acetylcholine receptor)
2nd nerve: uses acetylcholine (PNS) to bind to muscarinic receptors on target OR norepinephrine (Sympathetic) to bind to alpha and beta adrenergic recetpros on its target
30
how many spinal nerves? cranial?
31 pairs of spinal nerves
| 12 pairs of cranial nerves
31
spinal nerves vs. cranial nerves (motor and sensory)
spinal nerves and their branches contain both motor and sensory
cranial nerves contain different combinations of motor and sensory fibers and can be entirely motor or entirely sensory
32
nerve fibers in dorsal root vs. nerve fibers in ventral root
dorsal root: AFFERENT or sensory
derived from neural crest
dendrites of these dorsal root neurons arise in the periphery and their axons end in the spinal cord
their cell bodies are outside the spinal cord, clustered into a dorsal root ganglion
Ventral roots: EFFERENT or motor (cell bodies of motor axons are all derived from the neural tube; they are found in gray matter inside the spinal cord, mainly int he ventral horn and their axons extend to their target organs)
33
Branches of spinal nerve
cutaneous and muscular
34
what do cutaneous branches supply?
contain both sensory and motor fibers
supply a specific dermatome (area of skin supplied by all the branches of a single spinal nerve)
contain neuronal processes from a variety of sensory receptors in the epidermis and dermis
they also contain postganglionic sympathetic (motor) axons to smooth muscle and glands in the dermix
35
what do muscular branches supply?
a specific myotome- the muscle mass supplied by the branches of a single spinal nerve
mixed branches of spinal nerves (sensory and motor)
contain sensory neuronal processes from sensory receptors in skeletal muscle, and motor axons that make the skeletal muscles contract
36
3 important muscles of the chest
1) pectoralis major
2) pectoralis minor
3) serratus anterior
37
what nerve innervates the serratus anterior?
long thoracic nerve (unusual because it innervates it superficially; most muscles are innervated by nerves entering from the deep surface); exposed location of this nerve puts it at risk during axillary surgury
38
3 layers of intercostal muscles
1) external intercostals
2) internal intercostals
3) innermost intercostals
39
origin of external and internal innercostal muscles
inferior border of rib and insert on the superior border of the rib below
external is superficial to the internal
external and internal intercostals begin and end at different locations within the intercostal space so that they are off register relative to each other
40
where do external intercostals extend to?
external intercostals extend from tubercles of the ribs to the costo-chondral junction (where the bony portion of the rib meets the cartilaginous portion)- (thin membranes extend from muscle to fill out the deficiencies in the layers)
41
where do internal intercostals extend to?
extend from angles of the rubs to the sternum (thin membranes extend from muscle to fill out the deficiencies in the layers)
42
transverse thoracis?
found on the inner surface of the removed piece of thoracic cage originating from the sternum and inserting upon ribs 2-6
43
where do the intercostal vessels and nerves pass?
pass between the internal intercostal and the innermost layer in what is known as a neurovascular plane
44
which way do the fibers of the external intercostal muscles go?
inward
| "hands in pockets"
45
which way do the fibers of the internal intercostal muscles go?
they are at right angle to the external intercostals (they go out)
46
innermost intercostal muscle fibers
run same as internal intercostals
| found primarily laterally
47
which nerves innervate the intercostal muscles and the skin or the thoracic wall?
INTERCOSTAL NERVES- ventral rami of the T1-T11 spinal nerves AND
SUBCOSTAL NERVE- ventral ramus of T12
48
Arterial supply of thoracic wall
branches of a pair of internal thoracic arteries and the descending aorta
49
Anterior intercostal arteries
arise from the internal thoracic artery or a branch of it (the musculophrenic artery)
supplies the anterior thoracic wall
50
where does the internal thoracic artery branch from?
subclavian artery
51
posterior intercostal arteries
supply the posterior and lateral thoracic walls
| arise mainly from the descending aorta
52
Which veins drain the thoracic wall
tributaries of the internal thoracic veins and the azygos system drain the thoracic wall (ANTERIOR INTERCOSTAL VEIN, POSTERIOR INTERCOSTAL VEIN, AND Azygos and HEMIAZYGOS VEIN)
53
anterior intercostal veins drain what and empty into what?
anterior intercostals veins drain the anterior chest wall and empty into the internal thoracic veins which drain into the brachiocephalic veins
internal thoracic veins run with the internal thoracic arteries
54
posterior intercostal veins drain what and empty into what?
posterior intercostal veins drain the posterior and lateral thoracic walls and empty into the hemiazgos veins on the left and the azygos vein on the right
55
order of bundle (neurovascular)?
VAN
| vein, artery, nerve (superior to inferior)
56
axillary process or tail of brest
small part of breast that has extended along the inferolateral edge of the pectoralis major muscle toward the axillary fossa
57
what muscle does the breast lay on?
2/3 of breast rests on the pectoral fascia covering the pectoralis major
1/3 of breast rests on the fascia covering the serratus anterior muscle
58
what is the space between the breast and the deep pectoral fascia and what does it allow?
loose connective tissue plane or potential space
| RETROMAMMARY SPACE OR BURSA; it allows the breast some degree of movement on the deep pectoral fascia
59
what are the suspensory ligaments?
suspensory ligaments of cooper: attach the mammary glands to the dermis of the overlying skin; they help support mammary gland lobule
60
what is the greatest prominence of the breast and what is it surrounded by?
nipple and surrounded by circular pigmented area, areola
61
what drains the lobules in the breast?
the breast contains 15-10 lobules of glandular tissue; each lobule is drained by a lacteriferous duct, which opens independently on the nipple
just deep to the areola, each duct has a dilated portion (lactiferous sinus)
62
clinical sign of advanced malignant disease of the breast?
cancer of the breast may invade the retromammary space and thereby attach to the deep fascia and the pectoralis major muscle; contraction of the pectoralis major muscle can cause the breast to move superiorly
63
2 main sources of blood to the breast?
1) medial source: BRANCHES OF THE INTERNAL THORACIC ARTERY
2) lateral source: arises from the axillary artery and from the cutaneous branches of the posterior intercostal arteries
64
venous drainage of the breast?
1) internal thoracic vein
2) axillary vein (main venous drainage)
2) azygous vein
65
spread of breast cancer to the vertebral column or brain.....
azygos vein has a free and valve-less communication with the vertebral venous plexus
66
lymphatic drainage of the breast:
approx 75% is via lymphatic vessels that drain laterally and superiorly into axillary nodes (axillary lymph nodes--> subclavian lymphatic trunk; right side returns to venous system via right lymphatic duct and left breast returns to venous system via thoracic duct)
*** remember there is a lymphatic communication with the contralateral breast**
remaining drainage is laterally and superiorly into parasternal nodes (deep to the anterior thoracic wall and associated with the internal thoracic artery)
67
How do you explain involvement of axilla in breast cancer?
The involvement of the axilla is typical sign of cancerous spread to the axillary lymph nodes, the most common sites of metastases from cancer of the breast. however, because of the free communication between lymph nodes inferior and superior to the clavicle and between the axillary and cervical lymph nodes, metastases from the breast may develop in the supraclavicular lymph nodes, the opposite breast, in the chest (parasternal nodes) or in the abdomen.
68
why do you get dimpling of the skin of the breast and its fixation (doesn't respond to gravity when bend over)?
the dimpling and fixation of the skin to the tumor implies cancerous invasion of the suspensory ligaments of cooper that anchor the gland to the skin. dimpling and orange-peel like appearance of the skin, retraction and elevation of the nipple, and signs of cancerous spread to suspensory ligaments of the breast, obstruction of cutaneous lymphatics, and involvement of lactiferous ducts--> advanced inflammatory breast cancer
69
what is involved in radical masesctomy procedure? What imp. nerves should be identified and preserved??
the purpose of a radical surgical operation generally is the removal of the lymphatics in the drainage areas of the primary cancers occurring in the region of question; removal of entire breast containing tumor, the overlying skin, the underlying muscles and their fascia in whcih invasion and metastases are likely to occur relatively early in the course of the disease, and all of the axillary lymphatics
1. skin over the tumor and of the dome of the breast
2. breast tissue; pectoralis major and minor muscles
3. upper part of anterior sheathe of the rectus abdominus muscle
4. nerves to pectoral muscles
5. intercostobrachial nerve
6. thoracoacromial vessels
7. all tributaries to the axillary vein from the breast and axilla (subscapular vein may be preserved)
8. axillary lymph nodes and vessels with the fat in which they are embedded
MUST PRESERVE: BRACHIAL PLEXUS AND LONG THORACIC NERVE
70
8 layers of the abdominal wall
8. Peritoneum (a friction reducing mesothelium)
7. extraperitoneal fat/ fascia
6. transversalis fascia
5. transversus abdominis
4. internal oblique
3. external oblique
2. superficial/deep fascia
1. skin
71
2 layers of the superficial fascia
```
outer layer (fatty layer): Camper's fascia (contains fat; continuous with superficial fascia everywhere)
inner layer (membranous layer): Scarpa's fascia (lacks fat)--> continuous with superficial perineal fascia (Colles' fascia) covering the perineum and with superficial penile fascia covering penis and clitoris
```
72
What is camper's fascia continuous with?
superficial fascia everywhere
73
what is scarpa's fascia continuous with?
continuous with superficial perineal fascia (colles' fascia) covering the perineum and with superficial penile fascia covering the penis and clitoris; also continuous with dartos fascia of the scrotum
74
what does the dartos fascia contain?
dartos fascia of the scrotum contains the dartos muscle (smooth muscle that functions to help regulate the thermal environment of the testis)
75
external abdominal oblique m.
flat muscle arising from ribs 4-12
eight attachments to the ribs interdigitate with the attachments of serratus anterior (upper five) and latissimus dorsi (lower three)
fibers run in
76
internal abdominal oblique m
smaller and thinner than external
| fibers run superiorly and medially (perpendicular to the external)
77
transversus abdominus
inserts on an aponeurosis and contributes to the rectus sheath, ending in the midline of the linea alba
fibers run horizontal
78
transversalis fascia
deep to the transversus abdominus muscle and in contact with the rectus abdominus muscle below the arcuate laine
79
rectus abdominus
aponeuroses of the external oblique, internal oblique, and transverse abdominus muscles envelope this muscle to form rectus sheath
80
arcuate line
demarcates the upper 3/4 from the 1/4 part of rectus abdominus
located midway between umbilicus and public bones, this line also serves as the point where the inferior epigastric vessels enter the rectus sheath
81
extensive bruising over the lower part of the right rectus muscle; deep swelling--> collection of blood. which blood vessel most likely is ruptured? in what layer of the abdominal wall is the bleeding located?
inferior epigastric artery and/or the accompanying vein is the vessel most likely ruptured
bleeding is located in the extraperitoneal fascia between the peritoneum and the fascia transversalis (layer within which the inferior epigastric vessels are contained as they ascend on the anterior abdominal wall inferior to the arcuate line)
82
rectus sheath
sleeve for the rectus abdominus muscle formed by the aponeuroses (flat tendons) of the 3 anterolateral abdominal muscles
superior 3/4 covered by sheath front and back
inferior 1/4 is covered only in front
83
linea alba
raphe (visible line or ridge)- not a ligament
84
above arcuate line components of rectus sheath
anterior: aponeuroses of external and internal
posterior: aponeuroses of internal and transverse
85
below arcuate line components of rectus sheath
all three layers go in front (anterior) of rectus
86
inguinal canal
superior to the inguinal ligament; site where male gonad protruded itself through anterior layers of the abdominal wall; pathway that allowed testes to descend into the scrotum
87
posterior wall of the inguinal canal
transversalis fascia; consists of the deep inguinal ring (a fault in transversalis fascia whcih forms the posterior opening of the inguinal canal)
88
inferior epigastric artery and vein are _________ to the deep inguinal ring
MEDIAL
89
pulsations of which artery form useful landmark during surgery for determining the location of deep inguinal ring
inferior epigastric artery
90
anterior wall of the inguinal canal
aponeurosis of the external oblique muscle (final layer traversed by the testis as it exits the inguinal canal)
91
superficial inguinal canal is in what layer
aponeurosis of the external oblique
92
inferior epigastric a. and v. are ______ to the superficial inguinal ring
LATERAL
93
floor of the inguinal canal is formed by the _______
inguinal ligament
94
roof of the inguinal canal is formed by the ________
arched muscle fibers of the transversus abdominus and internal oblique muscles
95
which layer of abdominus muscle does not contribute to the spermatic fasciae?
transversus abdominus muscle (testis passes under the transversus abdominus)
96
layers of the spermatic fascia and their abdominal layer origins:
1) skin (SKIN)
2) dartos tunic (Colles' fascia) (SUPERFICIAL FASCIA- MEMBRANOUS LAYER OF SCARPA)
3) external spermatic fascia (EXTERNAL OBLIQUE M)
4) cremasteric fascia (from fascia of internal oblique)
5) internal spermatic fascia (from fascia transversalis)
6) tunica vaginalis tesis (from peritoneum)
97
cremasteric muscle
consists of fibers of the internal oblique muscle that extend along the spermatic cord
helps regulate the thermal environment of the tesis
98
what pass through the inguinal canal?
ductus deferens in males and round ligament in females (along with a remnant of the processus vaginalis)
99
what is the round ligament of uterus?
runs from fundus of uterus, through the anterior abdominal wall and ends blindly in the labia majora
100
superficial ring transmits what in both sexes?
ilioinguinal nerve
101
differences in the superficial inguinal canal in males and females?
haitus is a ring in males
| triangle of females
102
what does the superficial inguinal canal transmit?
spermatic cord in males and round ligament of uterus in females
103
what is the conjoined tendon?
fusion of aponeuroses of the transversus abdominus and the internal obliques (attaches to the public bone posterior to the superficial inguinal ring)
104
inguinal ligament is formed from what layer?
aponeurosis of the external oblique (
105
does the external inguinal ring dialate when tensed by contraction of the external oblique muscle?
no
106
processus vaginalis
connection between the scrotal and peritoneal cavities in the embryo; usually obliterated during the first year of life; it the tunnel persists, the peritoneal cavity, in effect, extends along the cord into the scrotum
107
indirect inguinal hernia
generally seen in infants and children
processus vaginalis remains
bowel can squeeze from abdomen lateral to the inferior epigastric vessels and come to lie along the cord or in the scrotum
if herniated bowel cannot be returned to the abdomen, it may become strangulated and its blood supply obliterated, a condition that requires prompt surgical relief
108
direct inguinal hernia
more common in adults than indirect, but indirect hernias are still the most common type in adults
protrude through posterior wall of the inguinal canal medial to the inferior epigastric a. and v.
more likely to tear through transversalis fascia and cremasteric fascia therefore, they are usually covered by external spermatic fascia and lie adjacent to the contents of the spermatic cord and the obliterated processus vaginalis at the superficial inguinal ring
109
why do older men get hernias?
loss of muscle tone weakens the ability of the anterior abdominal wall to effectively resist increases in intra-abdominal pressure particularly in the area of the inguinal canal where the structures making up the wall are discontinuous
AND dec. in size of the contents of the spermatic cord, result in increased space within the canal
110
Hesselbach's triangle
where direct hernias come through
bounded laterally by the inferior epigastric artery
medially by the rectus abdominis muscle
inferiorly by the inguinal canal
111
hernia
protrusion of a structure, the viscus, or organ from the cavity in which it is contained
112
nerves that innervate the abdominal musculature
inferior intercostal nerves (t11 and 12) and iliohypogastric and ilioinguinal nerves (L1)
