MRCS RECALLS Flashcards
What is the most common organism causing haemolytic uraemic syndrome?
E.coli
What is the most appropriate treatment for entrobius vermicularis?
Albendazole —- if not in the options—- Mebendazole
What organism causes bloody diarrhoea with eggs and cysts in the stool?
Entamoeba hystolitica
What is the drug of choice for treating entamoeba hystolitica?
Metronidazole
What is the most common organism causing disicitis?
Staph.aureus
Define septic arthritis?
Infectious joint inflammation
What is the age incidence of septic arthritis?
Children
What is the most common organism causing septic arthritis?
- Normal patient or non sickler = Staph.aureus
- Sickle cell anaemia patients = Salmonella
What are the diagnostic criteria for septic arthritis?
Footnote
Kocher criteria (Mnemonic; FEW/N)
(1) Fever
(2) ESR > 40
(3) WBC > 12000
(4) Non weight bearing on the affected side
If WBC and ESR don’t meet the Kocher criteria + viral infection = transient tenosynovitis
What is the treatment of septic arthritis?
- Surgical drainage
- Antibiotics (Mnemonic; ceph.co/FG )
(1) Cephalosporin + Co-amoxiclav or
(2) Flucloxacilline + Gentamicin
Mind map for scrotal or testicular swelling
What is the C/P of hydrocele?
(1) large
(2) can not be separated from the testes
(3) painless
(4) transillumination +ve
What is the cause of hydrocele?
+ Adults and may be children = associated with testicular tumour or post traumatic
+ Children = patent processus vaginalis
What is the treatment of hydrocele?
+ Adults = scrotal incision ( Jaboulay operation or Lad operation)
+ Children = inguinal incision ( processus vaginalis ligation)
What is the the other name for epididymal cyst?
Spermatocele
What is the C/P of epidydimal cyst (spermatocele)?
(1) small
(2) can be separated from the testes
(3) painless
(4) transillumination +ve
What is the treatment of epidydimal cyst (spermatocele)?
- either left or excised
- no aspiration
What is the C/P of testicular tumour?
(1) Weight loss
(2) Mets
(3)↑AFB+B-HCG
What is the treatment of testicular tumour?
(1) Orchidectomy via inguinal approach
(2) Bx is contraindicated in testicular tumour
What is the cause of testicular torsion?
Trauma or idiopathic (e.g., long cord)
What is the C/P of testicular torsion?
(1) painful swollen testis, not improved by testicular elevation
(2) elevated testis
(3) lost cremasteric reflex as the cord is compressed but if exaggerated = torsion testicular appendage ( hydatid)
What is the treatment of testicular torsion?
Urgent exploration of both testes + orchidopixy of both testes without investigation
What is the DDx of testicular torsion?
Torsion of testicular appendage (Hydatid)
What is the other name for torsion of testicular appendage?
Torsion of testicular hydatid
What is the age incidence of torsion testicular appendage?
Children
What is the C/P of torsion testicular appendage?
Blue dot sign on the upper pole of testis due to ischaemia of testicular appendage
What is the C/P of haematocele?
(1) painful swollen testis not improved by testicular elevation
(2) normal place testis
What is the treatment of haematocele?
Urgent scrotal exploration + evacuation
What is the most common causative organism of epididymo- orchitis?
< 60 yrs — chlamydia
> 60 yrs — E.coli
What is the cause of epididymo - orchitis?
+ epididymo- orchitis—- post urological procedure
+ orchitis— infection ( viral or parotid)
What is the C/P of epididymo- orchitis?
(1) Fever
(2) Dysuria
(3) Urethral discharge
(4) Unilateral scrotal pain + tender swollen testis
What is the treatment of epididymo - orchitis?
Drug of choice = ciprofloxacilin + Doxycycline
What is the C/P of varicocele?
(1) With RCC
(2) After long standing
(3) Lt > Rt
(4) Bag of worms in the scrotum
Which tumour is associated with varicocele?
RCC
What is the aggravating factor for varicocele?
After long standing
Which side (Lt or Rt) is more affected by varicocele?
Lt > Rt
How do you describe the feeling of varicocele by your hand?
A bag of worms
What is the treatment of varicocele?
(1) Conservative,
(2) Surgical —-
+ indication = affects fertility
+ procedure = testicular veins ligation via inguinal approach
What is the indication of surgery in varicocele?
affects fertility
What is the surgical procedure performed for varicocele?
testicular veins ligation via inguinal approach
What is the complication of vasectomy?
Sperm granuloma
Define sperm granuloma?
Painful scrotal swelling post vasectomy
Define rabdomyosarcoma?
Paratesticular tumour
What is the location of rabdomyosarcoma?
Distal part of spermatic cord
What is the age incidence of rabdomyosarcoma?
Bimodal age = 4 months - 16 yrs
What is the main feature of rabdomyosarcoma?
Liability for L.N spread in 30 - 50 % of patients
What is the percentage of L.N spread in rabdomyosarcoma?
30 - 50% of patients
Urinary tract trauma
What is the incidence of urinary tract injuries associated with pelvic fractures?
85%
Enumerate types of urinary tract injuries.
- Urethral injuries
+ Bulbar urethral injuries
+ Membranous urethral injuries - Bladder rupture
What is the most common urinary tract injury?
Bulbar urethral injury
What is the mode of trauma in bulbar urethral injury?
Straddle injury (i.e., falling astride, such as bicycle riders)
What is the clinical presentation of bulbar urethral injury?
Mnemonic; F/BUP
- Full bladder
- Blood in meatus
- Urine retention
- Perineal haematoma
What is the investigation of choice for bulbar urethral injury?
Ascending cystourethrogram
OR
Alternative: IV urography
What is the management for bulbar urethral injury?
- Suprapubic catheter
- Urethral catheter is contraindicated
What is the clinical procedure that is contraindicated in bulbar urethral injury?
Urethral catheter is contraindicated
What is the mode of trauma of membranous urethral injury?
With pelvic fractures
What is the C/P of membranous urethral injury?
Mnemonic → F/BUP
F: Full bladder
B: Blood in meatus
U: Perineal hematoma
P: PR → High or non-palpable prostate.
What is the investigation of choice for membranous urethral injury?
Ascending cystourethrography
OR
Intravenous urography
What is the management for membranous urethral injury?
Suprapubic catheterization
Urethral catheterization is contraindicated.
What is the clinical procedure that is contraindicated in membranous urethral injury?
Urethral catheterization is contraindicated.
What is the mode of trauma for bladder rupture?
(1) with pelvic fractures
(2) Bladder rupture may occur without trauma after neglected desire of urination, especially after stressful conditions.
What is the clinical presentation of bladder rupture?
Mnemonic → FRESH
F: Free fluid intra-abdominally
R: Retention
E: Empty bladder
S: Suprapubic pain
H:Haematoma
What is one investigation of choice for bladder rupture?
Ascending cystourethrogram
OR
IV urography.
What is the management approach for bladder rupture?
(1) Extraperitoneal: Conservative.
(2) Intraperitoneal: Laparotomy for fear of peritonitis
Lesser sac + Layers of testis
What is the size of the Kidney?
12x6x3 cm
What is the length of the Kidney?
12
What is the width of the Kidney?
6 cm
What is the thickness of the Kidney?
3 cm
What is the location of the Kidneys?
(1) Retroperitoneal organs,
(2) on the upper part of the posterior abdominal wall
(3) In the paravertebral gutter
(4) Opposite— last thoracic vertebra (T12)
— upper 3 lumbar vertebrae (L1-L3)
(4) The Rt kidney is 0.5 inches lower than the Lt because of liver on the Rt
What is the shape of the kidney?
Bean shaped
What are the parts of the Kidney?
- 2 ends (poles): upper and lower; the upper end is nearer to the median plane than the lower.
- 2 borders: lateral convex border and + medial concave border presenting the hilum at its middle.
- 2 surfaces: anterior (related to adjacent organs) and posterior (applied to the posterior abdominal wall).
What is the location of the upper end of the kidney?
The upper end of the
(1) both kidneys is nearer to the median plane(midline) than the lower end.
(2) left kidney is opposite the — 11th rib + upper border of T12;
(3) right kidney is opposite the — 11th space + lower border of T12.
What is the location of the lower end of the kidneys?
- Lt kidney opposite → upper border of L3 + 6.5cm above iliac crest
- Rt Kidney opposite → lower border of L3 + 5cm above iliac crest
Which end of the kidneys is nearer to the median plane, upper or lower?
Upper end
What is the location of the upper end of the right kidney?
Opposite the
(1) 11th space (ICS)
(2) lower border of T12
What is the location of the upper end of the left kidney?
Opposite the
(1) 11th rib
(2) upper border of T12
What is the location of the lower end of the left kidney in relation to the iliac crest?
6.5 cm above iliac crest
None
What is the location of the lower end of the right kidney?
(1) Opposite the lower border of L3,
(2) 5 cm above iliac crest
What is the surgical significance of the relation of the left kidney to the 11th rib and the Rt kidney to the 11th space?
Risk of pneumothorax during nephrectomy
What is the vertebral level of the lower end of the Rt kidney?
Lower border of L3
What is the location of the lower end of the Rt Kidney in relation to the iliac crest?
5cm above iliac crest
What is the shape of the lateral border of both kidneys?
Convex
What is the shape of the medial border of both kidneys?
Concave
What is the content of the medial border of both kidneys?
Hilum at its middle.
What is the other name of the kidney’s hilum?
Pedicle
What is the location of the kidney’s hilum?
- Both Kidneys → the middle of the medial border of the Kidney
- Lt Kidney → L1( mnemonic; Lt one L1)
→ the centre of the hilum lies opposite the lower border of L1 spine, 2 inches from the median plane - Rt Kidney → L1-L2 (mostly L2)
What are the contents of the kidney’s hilum?
What is the surgical significance of the successive order of position of hilar structures of the kidneys?
+ In nephrolithotomy: pelvis of the ureter (posterior surface) is opened
+ in radical nephrectomy: renal vein (anterior surface) is opened
Which structure in the renal hilum is attacked or opened in nephrolithotomy?
Pelvis of the ureter (posterior surface)
Which structure in the renal hilum is attacked or opened in radical nephrectomy?
Renal vein (anterior surface)
What are the relations of the kidneys?
What are the anterior relations of the kidney?
What are the posterior relations of the kidney?
Discuss capsule (covering) of the kidneys?
Enumerate the layers of the capsule (covering) of the kidneys from within outwards.
- True capsule (Fibrous capsule)
- Fatty capsule (Perinephric fat)
- False capsule (Zucker candle fascia or Gerota’s fascia)
What is the other name of the true capsule of the kidneys?
Fibrous capsule
What is the other name of the fatty capsule of the kidneys?
Perinephric fat
What is the other name of the false capsule of the kidneys?
Zucker candle fascia or Gerota’s fascia
What is the structure of the true fibrous capsule of the kidneys?
1.Collagen
2.Elastic fibres
What is the location of the true fibrous capsule of the kidneys?
Closely invests or surrounds the kidneys
What is the origin of the false capsule of the kidneys?
Fascia transversalis
What is the structure of the false capsule of the kidneys?
2 layers:
(1) Fused above the kidney,
(2) Remain separate below to allow ptosis of the kidney
What is the function of the false capsule of the kidneys?
- Encloses both kidneys and suprarenal glands
- Opens inferiorly
What is the feature of the true (fibrous) capsule of the kidneys?
Can be stripped off easily
What is the structure the fatty( perinepheric fat) capsule of the kidneys?
Adipose (fatty) tissue
What are the structures that are enclosed by the true capsule?
Both:
(1) kidneys
(2) suprarenal glands
Where does the false capsule open?
Inferiorly
What is the surgical significance of the capsule (covering) of the kidneys?
What is the role of the capsule (covering) of the kidneys in nephrotosis?
What is the role of the capsule (covering) of the kidneys in renal trauma?
Discuss surface anatomy of the kidneys
Discuss arterial blood supply to the kidneys?
The kidneys are supplied with blood via the renal arteries, which arise directly distal or inferior to the abdominal aorta, immediately distal to the origin of the superior mesenteric artery. Due to the anatomical position of the abdominal aorta (slightly to the left of the midline), the right renal artery is longer, and crosses the vena cava posteriorly.
The renal artery arises perpendicularly from the abdominal aorta just immediately below or distal to the branching of the superior mesenteric artery, roughly at the level of the intervertebral disc between the L1 and L2 vertebrae.
+The right renal artery, which is slightly longer and higher up than the left one, courses posterior to the inferior vena cava, renal vein, head of the pancreas and second part of the duodenum.
+The left renal artery courses more horizontally and posterior to the renal vein, the body of the pancreas and the splenic vein.
The renal artery enters the kidney via the renal hilum. At the hilum level, the renal artery forms an anterior and a posterior division, which carry 75% and 25% of the blood supply to the kidney, respectively. Five segmental arteries originate from these two divisions.
The avascular plane of the kidney (line of Brodel) is an imaginary line along the lateral and slightly posterior border of the kidney, which delineates the segments of the kidney supplied by the anterior and posterior divisions. It is an important access route for both open and endoscopic surgical access of the kidney, as it minimises the risk of damage to major arterial branches.
Note: The renal artery branches are anatomical end arteries – there is no communication between vessels. This is of crucial importance; as trauma or obstruction in one arterial branch will eventually lead to ischaemia and necrosis of the renal parenchyma supplied by this vessel.
What is the origin of the renal artery of both kidneys?
A branch of the abdominal aorta at L1/L2 (mostly L2)
Compare between left renal artery and right renal artery in terms of length?
- Left renal vein is longer than the right renal vein.
- Rt renal artery is longer than the left renal artery.
What is the relation of the renal artery to the renal vein?
Renal artery passes behind renal vein.
What is the relation of the right renal artery to the IVC?
Right renal artery passes behind the IVC.
What is the vertebral level at which the renal artery of both kidneys originates from the abdominal aorta?
L1/L2 (mostly L2)
Discuss venous drainage of the kidneys?
Where does the renal vein drain?
IVC
Compare the lengths of the left and right renal veins.
- The left renal vein is longer than the right renal vein.
- The right renal artery is longer than the left renal artery
What is the relation of the renal vein to the renal artery?
The renal vein passes in front of the renal artery.
What structures does the renal vein pass anterior to?
- renal artery
- aorta.
What is the relation of the renal vein to the superior mesenteric artery?
The renal vein passes behind the superior mesenteric artery.
Clinical notes of the kidneys
Discuss nutcracker syndrome
The kidneys is usually approached surgically through which anatomical region in the abdomen?
Lumber region (loin)
What is the main presenting feature of renal artery stenosis?
What is the location of performance of AV fistula in haemodialysis?
Between redial artery and cephalic vein
What is the surgical significance of the Lt kidney being higher than the Lt in its abdominal position ?
Rib resection may be needed in Lt kidney operations
Why Rt nephrectomy is more dangerous than the Lt?
Due to
1st/ relation of the Rt kidney to the
(1) Biliary duct
(2) 2nd part of the duodenum
(3) Ampulla of Vater
2nd/ short Rt renal vein
Discuss formation of the ureter
What is the location of the ureter?
What is the extension of the ureter?
From the tip of the transverse process of L1 (sacroiliac joint) to L5 (tip of ischial spine)
What is the location of the beginning of the uterus?
- At the pelvic-ureteric junction
- In front of the tip of the transverse process of L1
What is the location of the termination of the ureter?
Postero-superior angle of the urinary bladder
What are the sites of ureteric constrictions?
What is the surgical significance of the sites of ureteric constrictions?
Stone impaction, e.g., vesicoureteric stone.
What is the diameter of each ureteric constriction?
3 mm
What is the length of the ureter?
25 - 30 cm
What is the diameter of the ureter?
6 mm
Discuss parts of the ureter
What is the length of the abd. part of ureter?
12.5 cm
What is the course of the abd. part of ureter?
Each ureter descends vertically behind the peritoneum of the posterior abdominal wall opposite the tips of transverse processes of lower 4 lumbar vertebrae (the same course in both ♂ & ♀).
What is the main feature of abd part of ureter?
Retroperitoneal
What is the vertebral level of abd. part of ureter?
Tips of transverse process of lower 4 lumbar vertebrae (L2-L5)
What are the posterior relations of the abd. part of both ureters?
• Medial border of psoas major & genito-femoral nerve on it.
• Tips of transverse processes of the lower 4 lumbar vertebrae (L2-L5)
What are the anterior relations of the abd. part of both ureters?
Mnemonic; 3
• 3rd part of duodenum
• 3 arteries
- Rt Gonadal vessels: gonadal vessels are medial to ureter then cross anterior then become lateral to the pelvic brim
- Rt colic
- Rt ileocolic
• 3 structures related to the mesentry
- its root
- SMA
- coils of ileum
What is the relation of the gonadal vessels to both ureters?
Mnemonic; MAL
What is the relation of the pelvic part of the ureter to the bifurcation of the common iliac artery?
What are the anterior relations of the abdominal part of both Lt ureters?
. Three arteries:
(1) Left gonadal, which becomes lateral to it at the pelvic brim;
(2) Upper left colic;
(3) Lower left colic.
. It passes behind the fossa intersigmoidae
. Sigmoid mesocolon
. Coils of sigmoid colon
What are the medial relations of the abdominal part of the Rt ureter?
IVC
What are the medial relations of the abdominal part of the Lt ureter ?
Inferior mesentric artery (IMA)
What is the length of the pelvic part of the ureter?
12.5 cm
What is the relation of the pelvic part of the ureter to the bifurcation of the common iliac artery?
It enters the pelvis by crossing in front of the bifurcation of the common iliac artery at the sacroiliac joint or pelvic inlet brim.
What is the relation of the pelvic part of the ureter to the sacroiliac joint?
It enters the pelvis by crossing in front of the bifurcation of the common iliac artery at the sacroiliac joint or pelvic inlet (brim).
What is the relation of the pelvic part of the ureter to the pelvic wall?
It runs downwards and backwards on the side of the pelvic wall until it reaches the ischial spine with the following relations:
- Anterior: peritoneum (it is retro-peritoneal).
- Posterior: internal iliac vessels.
- Lateral: obturator nerve & vessels and the umbilical artery.
What is the relation of the pelvic part of the ureter to the ischial spine?
It runs downwards and backwards on the side of the pelvic wall until it reaches the ischial spine with the following relations:
- Anterior: peritoneum (it is retro-peritoneal).
- Posterior: internal iliac vessels.
- Lateral: obturator nerve & vessels and the umbilical artery.
At the level of the ischial spine ,it curves antero-medially crossing over the levator ani muscle to open into the postero-superior angle of the urinary bladder.
Here its course is different in M & F:
- in M: it is crossed by the vas deferens from lateral to medial.
- in F: it crosses posterior to the uterine artery 2 cm lateral to the cervix
What is the relation of the pelvic part of the ureter to the lavator ani muscle?
At the level of the ischial spine ,it curves antero-medially crossing over the levator ani muscle to open into the postero-superior angle of the urinary bladder.
Here its course is different in M & F:
- in M: it is crossed by the vas deferens from lateral to medial.
- in F: it crosses posterior to the uterine artery 2 cm lateral to the cervix
What is the relation of the pelvic part of the ureter to the urinary bladder?
At the level of the ischial spine ,it curves antero-medially crossing over the levator ani muscle to open into the postero-superior angle of the urinary bladder.
Here its course is different in M & F:
- in M: it is crossed by the vas deferens from lateral to medial.
- in F: it crosses posterior to the uterine artery 2 cm lateral to the cervix
What is the sex difference in the course of the pelvic part of the ureter?
In males, it is crossed by the vas deferens from lateral to medial. In females, it crosses posterior to the uterine artery 2 cm lateral to the cervix.
What is the relation of the pelvic part of the ureter to the vas deferens?
It is crossed by the vas deferens from lateral to medial.
What is the relation of the pelvic part of the ureter to the uterine artery?
It crosses posterior to the uterine artery 2 cm lateral to the cervix.
What is the surgical significance of the relation between the pelvic part of the ureter and the uterine artery?
The ureter passes behind the uterine artery, which can be injured during ovarian excision or hysterectomy.
What is the length of the intramural part of the ureter?
2 cm
What is the course of the intramural part of the ureter?
Runs in an oblique course in the bladder wall.
Discuss blood supply of the ureter?
Blood Supply: (Segmental)
- UPPER 1⁄2 ➔ renal artery.
- MIDDLE 1⁄2 ➔ gonadal, aorta & common iliac, internal iliac
- LOWER 1⁄2 ➔ vesical in male & uterine & vaginal in female & middle rectal
in both
What is the blood supply of the upper 1/2 of the ureter?
Renal artery.
What is the blood supply of the middle 1/2 of the ureter?
Gonadal, aorta & common iliac.
What is the blood supply of the lower 1/2 of the ureter?
Vesical in male & uterine & vaginal in female & middle rectal in both.
What is the blood supply of the lower 1/2 of the ureter in male?
Vesical artery.
What is the blood supply of the lower 1/2 of the ureter in female?
Uterine & vaginal.
What is the blood supply of the lower 1/2 of the ureter in both sexes?
Middle rectal.
What is the main feature of the blood supply to the ureter?
Segmental
What is the site of drainage of the ureter?
Base of the bladder.
What is the structure felt in pelvic (PV) examination at the level of cervix?
The base of the bladder.
What are the sites of identification of the ureter on X-rays?
It runs in front of:
1. Tips of the transverse processes of lumbar vertebrae.
2. Iliosacral joint.
3. Ischial spine.
How to identify the ureter during surgical operations?
1st/Anatomical site:
+ Lies on psoas major.
+ Seen crossing:
(1) The bifurcation of common iliac.
(2) The ischial spine.
2nd/It is not an artery:
since the pulsations are not continuous but peristalsis.
3rd/It is not Psoas minor:
• Psoas Minor: Flat shining tendon.
• Ureter: white cord-like (tubular).
4th/It is not a colon:
• Colon: Blood vessels run circular.
• Ureter: Blood vessels run longitudinally.
What is the best identification guide for the ureter?
The stone.
How should the ureter be mobilized during surgery?
Abdominal ureter should be mobilized medially.
Pelvic ureter should be mobilized laterally (receives its blood supply from lateral side).
What happens to the ureter during surgery?
The ureter remains attached to the undersurface of the peritoneum when the latter is reflected at surgery.
What is a clinical note regarding renal stones?
Renal stones are likely to get impacted through constriction sites → ureteric colic (begins in loin & radiates to groin).
What occurs in case of spasm of the intra-mural part of the ureter?
Pain radiates to external genitalia.
What is the vertebral level where the pain from ureteric stone radiates?
T11-L1
What is the main feature of Leydig Cell tumour?
Gynaecomastia
What is the causative organism of cellulitis or ascending lymphangitis as in the picture?
Group.A - β haemolytic streptococci which is Streptococcus pyogenes
What does MRSA stand for?
Methicillin-resistant Staphylococcus aureus
Define MRSA.
Antibiotic-resistant Staphylococcus aureus, a major nosocomial pathogen that spreads by hands.
(usually of nursing or medical staph)
What are the sites of MRSA?
Mnemonic; N/BAG
(1) Nose
(2) Buttocks
(3) Armpits
(4) Groin
Define MRSA Carrier.
MRSA lives harmlessly on the skin, i.e.,asymptomatic.
What is the mode of transmission of MRSA?
Contact, especially from the hands of nurses or medical staff.
What are the symptoms of MRSA?
1st/ Asymptomatic, discovered only during screening.
2nd/ Mild cases may include
- pain
- reddness
- swelling
- pus
3rd/ Severe cases may include
- fever > 38C
- chills,
- aches,
- dizziness, and
- confusion.
What are the five classic signs of inflammation?
- Redness (rubor),
- Pain (dolor),
- Heat (calor),
- Swelling (tumor),
- Pus
Discuss treatment of MRSA
What is the relationship between bacterial virulence and toxin production?
The bacterial virulence is related to toxin & enzyme production.
What type of anaerobes are all pathogens except Clostridium?
All pathogens are facultative anaerobes except Clostridium; Bacteroids are obligate anaerobes.
What should be done immediately when a child is bitten by a stray dog?
Immediately start the rabies vaccine & give anti-rabies serum.
What disease is caused by Yersinia pestis?
plague.
What type of bacteria is Bacteroides fragilis?
Bacteroides fragilis is a gram-negative obligate anaerobe bacillus of the gut.
What percentage of anaerobic potential infections is Bacteroides fragilis involved in?
It is involved in 90% of anaerobic potential infections.
What type of bacteria is Lactobacillus?
Lactobacillus is a gram-positive facultative anaerobe bacteria (bacilli) present in the vagina & GIT.
What does Lactobacillus produce to affect its environment?
It produces lactic acid making its environment acidic.
What is Proteus mirabilis associated with?
Proteus mirabilis is gram-negative and associated with UTI in
(1) long term catheterization, and
(2) stag horn-stone.
What are the patients carrying more risk of T.B mycobacterium infection?
T.B mycobacterium is common in immune-suppressed patients.
How to decrease the risk of wound infection?
Risk of wound infection can be decreased by:
1. Administration of prophylactic antibiotics.
2. Iodophor impregnated drapes.
What is the most common organism causing resistant pneumonia not responding to antibiotics, especially in transplanted patients,e.g., heart or renal transplant?
< 6 months = CMV
> 6 months = EBV
What are the causative organisms for osteomyelitis?
- Non sickler = staph.aureus
- Sickler = salmonella
What is the causative organism for pneumonia in sicklers?
Streptococcus Pneumoni
What is the causative organism for pyogenic granuloma?
Staphylococcus infections especially staphylococcus aureus
Classification of bacteria
Table of gram +ve bacteria
Mind map for classification of gram +ve cocci
Table of gram -ve bacteria
Table of viruses
Table of parasites
Clostrdium perfringens manifestations + Clostridium difficile treatment
Discuss treatment of clostridium difficile infection
What is necrotising fasciitis?
Advancing soft tissue infection associated with fascial necrosis.
Is necrotising fasciitis common?
It is uncommon but can be fatal, especially in immunosuppressed individuals, such as those with diabetes.
What causes necrotising fasciitis?
It is caused by polymicrobial flora (aerobic and anaerobic), with MRSA also being seen.
What is the most common isolated pathogen in necrotising fasciitis?
Streptococcus is the commonest isolated pathogen, accounting for 15% of cases.
What is Meleney’s gangrene?
It is a form of necrotising fasciitis that is
(1) superficial
(2) located in the trunk.
What is Fournier gangrene?
Necrotizing fasciitis affecting the perineum, where muscles are spared.
What pathogens are involved in Fournier gangrene?
E. coli, mixed flora, and Bacteroids, which produce verotoxin.
What are the clinical manifestations of Fournier gangrene?
Blisters and crepitations, along with general constitutional manifestations.
What treatment is needed for Fournier gangrene?
Aggressive surgical debridement is required.
What is pseudomembranous colitis?
Diarrhoea that occurs after broad-spectrum antibiotics, such as Ciprofoxacin, Cephalosporins, Ampicillin, and Clindamycin.
What causes pseudomembranous colitis?
It is caused by the overgrowth of Clostridium difficile due to the inhibition of normal flora.
What investigations are done for pseudomembranous colitis?
(1) Stool analysis for Cl. difficile toxins
(2) Colonoscopy showing elevated yellow-white plaques (pseudomembrane).
What are the complications of pseudomembranous colitis?
(1) Electrolyte disturbance,
(2) paralytic ileus,
(3) toxic megacolon,
(4) endotoxic shock, and
(5) bowel perforation.
What is the treatment for pseudomembranous colitis?
Metronidazole (oral) or Vancomycin (oral).
For severe cases, Metronidazole (IV) and Vancomycin (oral) are used.
Discuss layers of the anterior abdominal wall?
I) Superficial fascia
1. Camper’s fascia — Superficial fatty layer
2. Scarpaes fascia — Deep membranous layer
II) No deep fascia
III) Muscles
1st/ Lateral muscles
- External oblique muscle and aponeurosis
- Internal oblique muscle and aponeurosis
- Transversus abdominis muscle and aponeurosis
2nd/ Medial muscles: divided by arcuate line into
+Above arcuate line — (a) Anterior rectus sheath
(1) External oblique aponeurosis
(2) Anterior leaflet of internal oblique aponeurosis
— (b) Rectus abdominis muscle
— (c) Posterior rectus sheath —
(1) Posterior leaflet of internal oblique aponeurosis
(2) Transversus abdominis muscle aponeurosis
+Below arcuate line — (a) Anterior rectus sheath — All 3 lateral muscles
(1) External oblique aponeurosis
(2) Internal oblique aponeurosis
(3) Transversus abdominis aponeurosis
— (b) Rectus abdominis muscle
— (c) Fascia transversalis
. no posterior rectus sheath
. fascia transversalis only presents
posteriorto the rectus abdominis
e.g., in pfannensteil incision
3rd/Posterior muscle
- Quadratus lumborum muscle
— alone ( unilateral) action: lateral flexion of vertebral column
— Together (bilateral) action: depression of thoracic cage
IV) Fascia transversalis
V) Extraperitoneal fat — between transversalis fascia and parietal peritoneum
VI) Parietal peritoneum
What is found above the arcuate line?
- Anterior rectus sheath:
- External oblique
- Anterior leaflet of internal oblique
- Rectus abdominis muscle
- Posterior rectus sheath:
- Posterior leaflet of internal oblique
- Transversus abdominis
What is found below the arcuate line?
- Anterior rectus sheath:
- All three flat muscles (EOM, IOM, TAM)
- Rectus abdominis muscle
- Fascia transversalis
No posterior rectus sheath; fascia transversalis only present posteriorly to the rectus abdominis.
What is the relationship of extraperitoneal fat to transversalis fascia?
Extraperitoneal fat is located between the transversalis fascia and the parietal peritoneum.
Enumerate layers of superficial fascia of the anterolateral abdominal wall?
(1) Camper’s fascia → Superficial fatty layer
(2) Scarpa’s fascia → Deep membranous layer
What is the other name for the superficial fatty layer of superficial fascia of anterolateral abdominal wall?
Camper’s fascia
What is the other name for deep membranous layer of superficial fascia of anterolateral abdominal wall?
Scarpa’s fascia
What is the other name for the deep fascia of the abdominal wall?
No deep fascia
Enumerate the lateral muscles of the the anterolateral abdominal wall.
1) External oblique muscle and aponeurosis
2) Internal oblique muscle and aponeurosis
3) Transversus abdominis muscle and aponeurosis
What is the location of the arcuate line?
Midway between the umbilicus and symphysis pubis
What is the significance of the arcuate line?
Divides the abdominal wall muscles: Above arcuate line - Anterior rectus sheath formed of external oblique and anterior leaflet of internal oblique; Below arcuate line - Anterior rectus sheath formed of all three lateral muscles; No posterior rectus sheath but fascia transversalis only present posterior especially in Pfannenstiel incision.
Define hernia
It is a protrusion of a tissue or an organ through the wall of the cavity in which it is normally contained
What is the classification of hernia
Comparison between direct,indirect and femoral hernias
What is the incidence of umbilical hernia?
Infants
What is the incidence of paraumbilical hernia?
Adults
What is paraumbilical hernia?
The defect is in the linea alba.
Where is the defect of paraumbilical hernia?
The defect is in the Linea alba, whatever
- supra-umbilical, and
- infra-umbilical.
What are the risk factors of paraumbilical hernia?
(1) Females,
(2) multiparity, and
(3) obesity.
What is the incidence of Spigelian hernia?
Rare
What is the location of Spigelian hernia?
(1) Between external and internal oblique muscles,
(2) lateral to rectus abdominis,
(3) at the level of arcuate line.
What is the location of gluteal hernia?
Through the greater sciatic foramen.
What is the location of sciatic hernia?
Through the lesser sciatic foramen.
What is the location of lumbar hernia?
Through the superior and inferior lumbar triangle.
What are the boundaries of the lumbar triangle?
- Laterally: external oblique,
- Medially: latissimus dorsi,
- Inferiorly: iliac crest.
What is the location of obturator hernia?
(1) Through obturator foramen
(2) Behind pectineus muscle
What is the incidence of obturator hernia?
♀
What is the clinical presentation of obturator hernia?
- Intestinal obstruction
- Pain → Site → region of obturator nerve distribution;
→ Associated with → leg groin pain;
→ radiation → Ipsilateral knee
What is the repair approach for obturator hernia?
The defect is usually repaired from within the abdomen.
What is the location of incisional hernia?
Sites of previous surgical incisions.
What is the cause of incisional hernia?
(1) Wound infection
(2) Haematoma
What precautionary measure should be taken to minimize chances of incisional hernia?
Jenkins rule should be used in which bites taken at
(1) 1 cm interval
(2) 1 cm from the wound edge
Discuss Jenkins rule?
- Indication → to minimize the following post midline laparotomy
(1) wound dehiscence or
(2) incisional hernia - Technique → Bites taken at 1 cm
(1) interval
(2) from wound edge
What is the indication of Jenkins rule?
To minimize wound dehiscence or incisional hernia following midline incision.
What is the technique in Jenkins rule?
Bites taken at 1cm
(1) intervals
(2) from the wound edge.
Define Littre’s hernia?
Littre’s hernia = Meckel’s diverticulum.
What is the treatment for Littre’s hernia?
Resection of diverticulum + Mesh repair.
Define Amyand hernia?
Mnemonic; A= A
Amyand hernia = Appendix.
Define Richter’s hernia?
The antimesentric border of part of the small intestine wall is herniated to outside through a hernial sac and intrapped in hernia
What is the clinical implication of Richter’s hernia?
One inguinal obstruction as luminal patency is preserved.
Which part of the bowel is affected in Richter’s hernia?
The antimesentric border of part of the small intestine wall
Define Maydl hernia?
Mnemonic; (M)aydl = W
Two W-shaped bowel loops within its sac.
Define sliding hernia?
With any organ.
Define Pantaloon hernia?
Type of direct inguinal hernia; has two parts each is on either side of the inferior epigastric artery.
Discuss boundaries of inguinal canal
Inguinal hernia
What is the direction of inguinal canal?
Downward → Forward →Medially
What is the location of the superficial inguinal ring?
(1) At the external oblique muscle
(2) Above pubic tubercle
What is the location of the deep inguinal ring?
(1) At fascia transversalis
(2) 1/2 inch above midpoint of inguinal ligament
(3) lateral to inferior epigastric vessels.
What is the origin of the diaphragm?
- Sternal → xiphoid process
- Costal → lower costal cartilages
What is the insertion of diaphragm?
Central tendon
What is the nerve supply to the diaphragm?
- Central part → Phrenic nerve ( C3,4,5) sensory and motor
(Mnemonic; C3,4,5 keep the diaphragm alive) - Peripheral part → lower 6 thoracic nerves
What is the innervation of the central diaphragm?
Mnemonic; C3,4,5 keep the diaphragm alive
Phrenic nerve (C3,4,5) motor and sensory
What is the innervation of the peripheral part of the diaphragm?
Lower 6 Thoracic nerves
What are the levels of diaphragmatic openings and what are their contents?
Mnemonic; (V)ery (P)owerful/ (O)n (V)esting/ ATA
What are Bochdaleck and Morgagni hernias?
Congenital diaphragmatic hernia
What are the types of congenital diaphragmatic hernias?
- Bochdäleck hernia
- Morgagni hernia
What is the location of the defect in Bochdaleck hernia?
Pleuroperitoneal membrane
What is the location of the defect in Morgagni hernia?
Septum transversum
What is the location of the Bochdaleck hernia in the diaphragm?
Posterior left
What is the location of the Morgagni hernia in the diaphragm?
Anterior right
What is the incidence of the Bochdaleck hernia?
> Common
What is the incidence of the Morgagni hernia?
< Common
What is the incidence of complications in Bochdaleck hernia?
> Complications
What is the incidence of complications in Morgagné hernia?
< Complications
What is the prognosis of Bochdaleck hernia?
Mnemonic; Bochdaleck=Bad
Bad prognosis
What is the prognosis of Morgagné hernia?
Good
What is the timing of Bochdaleck hernia presentation?
Early
What is the timing of Morgagni hernia presentation?
Late
What is the clinical presentation of Bochdaleck hernia?
(1) Cyanosis
(2) Chest examination → Left side → ↓air entry on the Lt side
→ Right side → displaced apex beat to the Rt
(3) Abdominal examination → scaphoid abdomen
What is the clinical presentation of Morgagné hernia?
(1) Recurrent chest infection
(2) Chest examination → Left side → ↓air entry on the Lt side
→ Right side → displaced apex beat to the Rt
(3) Abdominal examination → scaphoid abdomen
What are the investigations of the Bochdaleck hernia?
Mnemonic; BEX
(1) X-rays,
(2) Barium study,
(3) Echocardiogram
What are the investigations of the Morgagni’s hernia?
Mnemonic; BEX
(1) X-rays,
(2) Barium study,
(3) Echocardiogram
What is the Bochdalek hernia?
A type of congenital diaphragmatic hernia.
What is the Morgagni hernia?
A type of congenital diaphragmatic hernia.
What is the treatment of Bochdaleck hernia?
Abdominal incision with
(1) Reduction of contents
(2) Closure of diaphragm
What is the treatment of Morgagni’s hernia?
Abdominal incision with
(1) Reduction of contents
(2) Closure of diaphragm
What is the DDx of congenital diaphragmatic hernias?
Popliteal fossa
+ Floor of popliteal fossa
(1) Popliteal surface of the femur,
(2) posterior ligament of knee joint
(3) popliteus muscle
+ Roof of popliteal fossa
Superficial and deep fascia
+ Contents (according to the EMRCS)
(1) Popliteal artery and vein
(2) Small saphenous vein
(3) Common peroneal nerve
(4) Tibial nerve
(5) Posterior cutaneous nerve of the thigh
(6) Genicular branch of the obturator nerve
(7) Lymph nodes
+ Clinical notes
In total knee replacement or knee surgery, the popliteal artery is
- the deepest structure amongst the contents of the popliteal fossa
↓
- directly applied to bone
↓
- worry about it in any knee surgery especially in the popliteal fossa
General measures for fracture management
What is the best initial investigation for fractures?
X-ray
What is the best overall investigation for fractures?
CT
What is the best investigation for complex & intra-articular fractures?
CT
Contraindication: metallic prosthesis
What is the best investigation to detect soft tissue injury (ligaments)?
MRI
Contraindication: Claustrophobia
May 2022
A patient had trauma to his ankle. Xray revealed no fracture. Ankle pain persists. The most appropriate investigation is:
A.Stress Xray
B.CT
C.MRI
D.Bone scan
E.Repeat Xray
The correct answer is C.MRI
MRI is done for any ligamentous soft tissue injury or ankle sprain with persistent pain not improving with whatsoever
What should be done if X-ray is not conclusive while investigating for fractures in general?
+ 1st 24 hrs → MRI
+ After 24 hrs → CT
What is the management for an open fracture?
What is the Gustilo-Anderson classification Grade 1?
<1cm wound
What is the Gustilo-Anderson classification Grade 2?
> 1cm wound with moderate soft tissue damage
What is the Gustilo-Anderson classification Grade 3?
> 1cm wound with extensive soft tissue damage
What is the management for Grade 3b open fractures?
Open reduction + external fixation with inadequate soft tissue coverage
What is the management for Grade 3c open fractures?
Immediate vascular repair if <6hrs; Amputation if >6hrs
What is highly contraindicated in open fractures?
Internal fixation due to the risk of infection
What is the management for a simple fracture?
Closed reduction
What is the management for a closed fracture?
Not an emergency: Open reduction, fixation with a cast, internal fixation (nail or plate)
When is nailing preferred over plating for fractures?
Nailing is better where there are adequate stumps of bone on both sides of the fracture
When is plating preferred over nailing for fractures?
Plates are better when the fracture is adjacent to joints with short stumps
Complications of fracture management
What is fat embolism as a systemic complication of fracture management?
A complication causing dyspnea and respiratory failure with tachypnea and rash following orthopedic surgeries.
What is deep venous thrombosis as a systematic complication of fracture management?
A systemic complication of fracture management.
What is hemorrhagic shock as a systematic complication of fracture management??
A complication associated with long bone fractures causing vascular injury and bleeding (e.g., femur fracture causing hematoma).
What is hemarthrosis as a systematic complication of fracture management?
Blood accumulation around the joint after trauma causing joint swelling.
Spontaneous hemarthrosis may be seen in patients with Hemophilia A (factor 8 deficiency).
What is complex regional pain syndrome as a systematic complication of fracture management??
Also known as Sudeck’s atrophy or sympathetic dystrophy, it involves sympathetic overactivity at the fracture site leading to shiny, swollen, and erythematous skin.
What is vascular injury in fracture management as a systematic complication of fracture management?
Absent distal pulsation after fixation of the fracture, managed by removal of the cast and revision of surgery.
What is compartmental syndrome as a systematic complication of fracture management?
A condition treated by 4 compartments fasciotomy through 2 incisions.
What is malunion as a systematic complication of fracture management?
A term used when the bone does not heal properly due to improper alignment or early removal of the cast.
What is nonunion as a systematic complication of fracture management?
Permanent failure of bone healing due to poor blood supply, excessive movement, or infection of the joint causing pseudoarthrosis on X-ray.
What is avascular necrosis as a systematic complication of fracture management?
Def:
Ischemia and necrosis at the fracture site causing stiffness and pain.
Liable sites include
(Mnemonic; FSTK على أغنية نجاح الموجي وفريد شوقي بتاع فستك نو يا فستك نو)
1) neck femur,
2) scaphoid,
3) talus, and
4) knee.
What are the differential diagnoses of post-fracture management complications?
Define Perth’s disease?
Idiopathic avascular necrosis of femoral epiphysis leading to flattened femoral head.
What is the aetiology of Perth’s disease?
Idiopathic
What is the age and sex incidence of Perth’s disease?
6 years Males
What is the C/P of Perth’s disease?
(1) Antalgic gait
(2) Limping
(3) Shortening
(4) Catterall staging:
1 → Clinical and histological features only.
2 → Sclerosis without affection of articular surface.
3 → Affection of femoral head.
4 → Affection of acetabulum.
What is Catterall staging in Perth’s disease?
A system to classify the severity of Perth’s disease.
What are the stages of Catterall staging in Perth’s disease?
1 → Clinical and histological features only.
2 → Sclerosis without affection of articular surface.
3 → Affection of femoral head.
4 → Affection of acetabulum.
What investigations are used for Perth’s disease?
- X-ray shows
(1) flattened femoral head and
(2) crescent sign. - If X-ray is normal, bone scan is better than MRI.
- U/S and specific tests like Ortolani test and Barlow test are also used.
What is the end result of Perth’s disease?
Flattened femoral head
Define developmental dysplasia of the hip (DDH)?
Dysplasia of acetabulum resulting in recurrent dislocation of femoral head.
What are the factors associated with DDH?
(1) Neonate: Breach delivery,
(2) Missed or delayed: limited movement on extreme range of motion (ROM).
(3) Female gender
What are the clinical presentations of DDH in females?
(1) Antalgic gait,
(2) limping,
(3) shortening,
(4) prominent skin crease.
What are the investigations of DDH?
(1) U/S
(2) Specific tests
- Ortolani test
- Barlow test
What is the end result of DDH?
Recurrent femoral head dislocation
Define slipped upper femoral epiphysis (SUFE)?
Slipping of the femoral head.
Who is commonly affected by SUFE?
Adolescent obese children.
What are the clinical signs of slipped upper femoral epiphysis (SUFE)?
(1) Antalgic gait
(2) Limping
(3) Shortening
(4( Limited internal rotation of the hip.
May 2022
A 12-year-old overweight child presented with obvious limping and limited internal rotation. He denies any history of trauma. What is the most accurate diagnosis?
A.Perthes disease
B.Slipped upper femoral epiphysis
C.Developmental dysplasia of the hip
D.Septic arthritis
E.Osteoarthritis
The correct answer is B.Slipped upper femoral epiphysis
What does the X-ray show in SUFE ?
Molten ice cream cone.
Define Osteogenesis imperfecta?
A congenital disorder of type 1 collagen resulting in abnormal
(1) bone formation and
(2) mineralization
What are the C/P of osteogenesis imperfecta?
(1) irregular patches of ossification,
(2) wormian bones, and
(3) multiple fractures.
What is the investigation of osteogenesis imperfecta?
XRs
Define Osteopetrosis?
An autosomal recessive disorder of osteoclasts resulting in harder bone formation.
Characterized by a lack of differentiation between bone cortex and medulla.
What is the investigation of osteopetrosis?
XRs
What is Talipes equinovarus (Club foot)?
A congenital deformity in which
(1) the ankle is dropped and inverted,
(2) occurring bilaterally in 50% of cases and
(3) more common in males.
What is the treatment of Talipes equinovarus (Club foot)?
(1) physiotherapy,
(2) bracing,
(3) casting, and
(4) tendoachilis release.
Define osteoarthritis?
Joint disease due to breakdown of cartilage and bone.
What are the causes of osteoarthritis?
- Previous joint injury and fractures
- Mechanical stress on the joint
- Obesity
What are the X-ray findings in osteoarthritis?
Mnemonic; SCON
- Subchondral sclerosis
- Cyst formation
- Osteophyte
- Narrow joint space
What are the conservative treatments for osteoarthritis?
- Exercise + reduce weight
- Steroids + Intra-articular steroids
- Heat application + Physiotherapy
What are the surgical treatments for osteoarthritis?
Arthroscope or joint replacement.
What is a characteristic lesion for rheumatoid arthritis?
Necrobiotic granuloma
It is an autoimmune inflammatory disorder affecting hand and wrist joints in females mainly after rest.
Define gout?
Deposition of urate crystals in joints causing arthritis.
90% idiopathic, 10% diuretics related.
What is the cause of gout?
(1) Idiopathic 90%
(2) Diuretics related 10%
Common site for gout?
Metatarsophalangeal joint of big toe.
C/P of gout
(1) Joint pain
(2) Renal affection
(3) Tophi of ear lobule
What is the investigation of gout?
Aspirate showing
(1) Negative birefringence,
(2) Needle shaped crystals.
What are the characteristics of gout crystals?
(1) Negative birefringence,
(2) Needle shaped crystals.
What are the treatment options for gout?
NSAIDS + Colchicine.
Define pseudogout?
Deposition of Ca pyrophosphate crystals in joints causing arthritis.
Associated with hyperparathyroidism, hemochromatosis, and Wilson disease.
Enumerate causes of pseudogout?
(1) Hyperparathyroidism
(2) Haemochromatosis
(3) Wilson disease
Common site for pseudogout?
Knee.
What is the C/P of pseudogout?
(1) Joint pain
(2) Renal affection
(3) Tophi of ear lobule
What is the investigation of pseudogout?
Aspirate showing
(1) Positive birefringence,
(2) Rhomboidal shaped crystals.
What are the characteristics of pseudogout crystals?
(1) Positive birefringence,
(2) Rhomboidal shaped crystals.
What is an indicator for pseudogout?
Elevated transferrin level may be used as an indicator for pseudogout as it’s related to hemochromatosis disease.
What are the treatment options for pseudogout?
NSAIDS.
Comparison between
- osteoporosis
- Paget’s disease
- osteomalacia
- Metastasis
Comparison lab. investigation between
- osteoporosis
- Paget’s disease
- osteomalacia
- Metastasis
Define osteoporosis?
(1) Reduced bone density
(2) Normal mineralization.
Common in post-menopausal females, and associated with steroids, smoking, alcohol, and frequent fractures.
What are the risk factors of osteoporosis?
(1) post menopausal females
(2) steroids
(3) smoking
(4) alcohol
What is the C/P of osteoporosis?
Frequent fractures
What are the laboratory findings for osteoporosis?
Normal
(1) Alkaline phosphatase
(2) Calcium
(3) Phosphorus
What is the radiological investigation of osteoporosis?
DEXA scan
Define Paget disease?
Uncontrolled bone turnover caused by disorder in osteoclasts and osteoblasts.
What is the age and sex incidence of Paget’s disease?
Old males
C/P of Paget’s disease
(1) Frequent fractures
(2) Thickened bone
Lab findings in Paget’s disease
What imaging is used for Paget disease?
Skull X-ray shows thickened calvarium.
What is a characteristic finding in Paget disease of the skull?
Thickened calvarium.
Complications of Paget’s disease
(1) predispose to osteosarcoma
(2) Deafness due to skull thickening
Define osteomalacia?
Decreased mineralization of bone due to calcium deficiency.
What are the risk factors of osteomalacia?
Vit.D
(1) deficiency
(2) resistance
C/P of osteomalacia
What are the laboratory findings for osteomalacia?
Dx of osteomalacia
Therapeutic trial of vit.D
What is a therapeutic trial for vitamin D used for?
osteomalacia
What is metastasis in the context of bone?
Bony lesions caused by the spread of a tumor.
Commonly associated with breast cancer and bronchus cancer.
What are the risk factors of bone metastasis?
C/P of bone metastasis
What are the laboratory findings for metastatic bone disease?
Mirel scoring system for fracture in bone metastasis
What is the root value of the lumbar plexus?
Anterior rami of spinal nerves L2-L3 and part of L4
What is the root value of the lumbosacral trunk?
Anterior rami of L4-L5
What is the root value of the sacral plexus?
Root value of the lumbosacral plexus (anterior rami of L4-L5)+ anterior rami of S1-S3 and part of S4
What is the root value of the femoral nerve?
- The femoral nerve is the largest branch of lumbar plexus
- It carries contributions from the dorsal division of the anterior (ventral) rami of L2 to L4 segments of spinal cord.
What is the course of the femoral nerve?
It forms in the abdomen within the substance of psoas major muscle.
It lies in the groove between the psoas major and iliacus muscles outside femoral sheath
It passes through (i.e.,penetrates) psoas major muscle then emerges from its lateral border to reach the anterior compartment of the thigh
It descends posterolaterally through the pelvis to the midpoint of the inguinal ligament
It leaves the abdomen by passing under or behind the inguinal ligament and through the gap between the inguinal ligament and superior margin of the pelvis to enter the femoral triangle ,on the anteromedial aspect of the thigh, lateral to the femoral vessels.
It has a short course of about 2.5 cm below the inguinal ligament.
It ends by dividing into anterior and posterior divisions 2.5 cm below the inguinal ligament
Where is the femoral nerve located in relation to the femoral artery in the femoral triangle?
it is lateral to the femoral artery.
What muscles does the femoral nerve innervate?
+ It innervates all muscles in the anterior compartment of the thigh
(mnemonic;ISQ)
(1) Iliopsoas
(2) Sartorius
(3) Quadriceps femoris muscles
1. Vastus lateralis
2. Vastus intermedius
3. Vastus medialis
4. Rectus femoris
+ In the abdomen, gives rise to branches that innervate the iliacus and Pectineus muscles.
What branches does the femoral nerve give rise to in the abdomen?
It gives rise to branches that innervate the iliacus and pectineus muscles.
What cutaneous (areas of skin) supply does the femoral nerve innervate?
It innervates skin over the
(1) anterior aspect of the thigh,
(2) anteromedial side of the knee,
(3) medial side of the leg, and
(4) medial side of the foot through its branch, the
Saphenous Nerve.
What are the branches of the femoral nerve?
What is the origin of the medial cutaneous nerve of the thigh?
it is one of the two branches of the anterior division of the femoral nerve distal the inguinal ligament, the other branch is the intermediate (anterior) cutaneous nerve of the thigh
What is the course of the medial cutaneous nerve of the thigh?
(1) arises from the femoral nerve distal to the inguinal ligament
(2) travels along the sartorius
(3) pierces through the deep fascia
(4) becomes superficial at the upper 1/3rd of the thigh
What is the function of the medial cutaneous nerve of the thigh?
provides cutaneous innervation to the medial thigh
What is the other name of intermediate cutaneous nerve of the thigh?
(1) intermediate (anterior) femoral cutaneous nerve
(2) anterior cutaneous nerve of the thigh
What is the function of the intermediate cutaneous nerve of the thigh?
innervates anterior thigh
What is the origin of the saphenous nerve?
a purely sensory nerve that arises from the femoral nerve
What is the root value of the saphenous nerve?
L2-L4
What is the course of the saphenous nerve?
(1) It descends in the femoral triangle and accompanies the femoral artery and femoral vein in the adductor canal(Hunter’s canal).
(2) It then travels on the posteromedial border of the knee and at this exact point it is accompanied by saphenous vein and could be injured by placement of the posteromedial portal(used to visualise posterior cruciate ligament and posterior horn of lateral meniscus)
(3) pierces through the medial deep fascia of the knee(fascia lata) between sartorius and gracilis muscles to become subcutaneous.
(4) It travels superficially down the
+ anteromedial lower leg
+ ankle over the medial malleolus
+ 1st metatarsal head
+ dorsum of the foot
What is the function of the saphenous nerve?
Supplies sensation to the skin of the
(1) anteromedial lower leg
(2) ankle over the medial malleolus
(3) 1st metatarsal head
(4) a part of the arch of the foot medially
(5) dorsum of the foot medially
What is the origin of the lateral cutaneous nerve of the thigh?
from the femoral nerve (L2-L3) and is purely sensory
What is the effect (manifestation) of the saphenous nerve entrapment (injury)?
(1) deep thigh ache
(2) Paraesthesia in the cutaneous distribution of nerve
(3) knee pain
What is the root value of the lateral femoral cutaneous nerve of the thigh?
Posterior surface of ventral rami of L2-L3
What is the function of the lateral cutaneous nerve of the thigh?
Purely sensory and Supplies the
(1) Lower lateral quadrant of the gluteal region
(2) anterior and lateral thigh and
(3) lateral knee
What is the course of the lateral cutaneous nerve of the thigh?
The nerve emerges from the lateral border of psoas muscle, anterior to the iliac crest, and passes between iliacus and iliac fascia crossing the iliacus. Enters the thigh posterior or under the lateral end inguinal ligament , medial to the anterior superior iliac spine (ASIS). From there, it becomes superficial and innervates the lateral thigh. The most common site of impingement is under the inguinal ligament.It pierces the fascia lata 10 cm inferior to the ASIS and divides into two branches:
• Anterior branch supplies skin and fascia of the anterolateral surface of the knee
• Smaller posterior branch supplies the skin and fascia on the lateral part of the upper leg between the greater trochanter and distal 1/3rd of the thigh
What is the other name for lateral cutaneous nerve of the thigh entrapment (injury)?
meralgia paraesthetica
What is the origin of the posterior cutaneous nerve of the thigh?
Sacral plexus
What is the other name of the posterior cutaneous nerve of the thigh?
posterior femoral cutaneous nerve
What is the sex incidence of lateral cutaneous nerve of the thigh entrapment?
More common in men
What is the function of the posterior cutaneous nerve of the thigh?
innervates the skin to the posterior
(1) thigh
(2) leg
(2) perineum
What are the risk factors of the lateral cutaneous nerve entrapment?
Mnemonic; SCOPA
(1) Surgery
(2) tight Clothing,
(3) Obesity,
(4) Pregnancy
(5) tense Ascites,
What is the effect (manifestation) of the lateral cutaneous nerve of the thigh entrapment?
(1) It presents with paraesthesia & numbness in the upper lateral thigh on the affected side. (2) Symptoms are worsened by standing and relieved by sitting
(3) Examination reproduces the pain by compression below the anterior superior iliac spine (ASIS) and hip extension. The motor examination is intact.
Thigh muscles
May 2022
Question (21)
A 45-year-old man presents with fever and pain in his right loin and groin.
A soft swelling was noted in his femoral triangle. Diagnosis of a psoas abscess was made. Which of the following statements is most accurate regarding psoas major?
十
A.It arises from the lateral borders of the bodies of T12 to L5
B.It extends the hip
C.It inserts into the greater trochanter of the femur
D.It is innervated from T12 and LI
E.It passes posterior to the capsule of the hip joint
Answer
A.It arises from the lateral borders of the bodies of T12 to L5
What is the root value of the obturator nerve?
The obturator nerve originates from lumbosacral plexus as anterior (ventral) division of ventral rami L2 to L4 segments of spinal cord.
L3 is main segment and L2 is occasionally absent
Knee injuries
May 2022
Q19
A 25-year-old man sustains a twisting injury while playing football. He develops immediate swelling of the knee, and he cannot continue the game. Six months later, he is still not able to play football. His knee feels unsteady and tends to give way. On examination, he has a full range of knee motion. There is a positive anterior draw test and a small effusion. What is the most likely structure damaged?
十
A. Anterior cruciate ligament
B. Lateral collateral ligament
C.Medial collateral ligament
D.Oblique popliteal ligament
E.Posterior cruciate ligament
Answer
A.Anterior cruciate ligament (ACL)
May 2022
Q20
During a game of football, Andrew experienced a twisted injury. The next day emergency house officer found a positive patellar tap. He cannot extend his knee. What is your diagnosis?
十
A.Anterior cruciate ligament injury
B.Knee Dislocation
C.Dislocated patella
D.Bucket handle meniscal tear
E.Lateral collateral ligament injury
Answer
D.Bucket handle meniscal tear
What is the difference between the root value of the obturator and femoral nerves?
The obturator nerve originates from lumbosacral plexus as anterior (ventral) division of ventral rami L2 to L4 segments of spinal cord.
L3 is main segment and L2 is occasionally absent
The femoral nerve is the largest branch of lumbar plexus It carries contributions from the dorsal division of the anterior (ventral) rami of L2 to L4 segments of spinal cord.
Dermatomes of L/L
Specific orthopaedic tests
Bucket handle menisceal tear
FOR READING ONLY
Bucket-handle menisceal tear:
One of the types of menisceal tears, the meniscus separates around its circumference, and the inner margin becomes displaced, often folding over on itself
Appearance:
The tear is named for its resemblance to the handle on a bucket, with the torn portion of the meniscus folding over like a handle
Mechanism of injury:
Meniscus tears, including bucket-handle tears, often occur after twisting injuries, such as planting the knee and foot forcefully and turning too quickly.
What is the course of the obturator nerve?
The branches of the obturator nerve unite in the substance of psoas major
It descends vertically along the posterior abdominal wall,
Emerges from the medial border of the passes through the pelvic cavity, and enters the thigh by passing through the obturator canal.
Bone tumours in general
What is the main segment of the root value of obturator nerve?
L3
What muscles does the obturator nerve innervate?
(1) all muscles in the medial compartment of the thigh, except the part of the adductor magnus muscle that originates from the ischium and the pectineus muscle.
(2) obturator externus muscle
Benign bone tumours
Multiple myeloma
What additional muscle does the obturator nerve innervate?
Obturator externus muscle
Osteosarcoma
What area of skin does the obturator nerve innervate?
It innervates skin on the medial side of the upper thigh.(upper medial thigh)
Osteoclastoma
What is the root value of sciatic nerve?
The sciatic nerve is the largest nerve of the body and carries contributions from L4 to S3.
Ewing sarcoma
What are the two divisions of the sciatic nerve?
The sciatic nerve divides into the common fibular nerve and the tibial nerve.
March fracture
A march fracture, also known as a metatarsal stress fracture, is a type of stress fracture that occurs in the metatarsal bones of the foot, often due to repetitive stress or overuse
What is the root value of common fibular nerve?
The common fibular nerve carries posterior divisions of L4 to S2.
Valgus (Valgum) vs Varus (Varum)
Superficial peroneal nerve + Deep peroneal nerve
Osteomalacia patellae
What is the root value of tibial nerve?
The tibial nerve carries anterior divisions of L4 to S3.
Morton’s neuroma
Stress tarsal fracture (March fracture)
Freiburg disease
What muscles does the sciatic nerve innervate?
The sciatic nerve innervates all muscles in the posterior compartment of the thigh, the part of the adductor magnus originating from the ischium, and all muscles in the leg and foot.
Compare between rheumatoid arthritis and osteoarthritis
What areas of skin does the sciatic nerve innervate?
The sciatic nerve innervates skin on the lateral side of the leg and the lateral side and sole of the foot.
Discuss syndesmosis
A syndesmosis is a type of fibrous joint where two parallel bones are connected by ligaments or an interosseous membrane, providing stability and allowing slight movement. The distal tibiofibular syndesmosis, located in the ankle, is a key example, and injuries to this area are often referred to as “high ankle sprains”.
What is the effect of sciatic nerve injury?
How to investigate ankle joint injuries?
Additional notes for injury of the following nerves
+ sciatic
+ tibial
+ common peroneal
+ superficial peroneal
+ deep peroneal
Discuss Denise- Weber classification
Used for ankle fractures
Type A ankle fractures— below syndesmosis
Type B ankle fractures— at the level of or (trans) syndesmosis
Type C ankle fractures— above syndesmosis
What does the superior gluteal nerve innervate?
The superior gluteal nerve innervates the gluteus medius and minimus muscles, and the tensor fasciae lata muscle.
Discuss management of ankle fractures according to Denise- Weber classification
What is the root value of the superior gluteal nerve?
The superior gluteal nerve carries contributions from the anterior rami of L4 to S1.
Define Pilon ankle fracture
- Comminuted distal tibial fracture needing external fixation between tibia and calcaneum by delta frame
- occurs at the bottom of the tibia(shinbone)which is the tibial plafond,i.e.,tibial articular surface
- involves the weight-bearing surface of the ankle joint -is a saparate injury
Where does the inferior gluteal nerve leave the pelvis?
The inferior gluteal nerve leaves the pelvis through the greater sciatic foramen inferior to the piriformis muscle.
Define Maissoneuve ankle fracture
Spiral distal fibula fracture + disturbed syndesmosis
What does the inferior gluteal nerve innervate?
The inferior gluteal nerve supplies the gluteus maximus.
What is the treatment of Maissoneuve ankle fracture
Treated like type C Denise Weber classification
(1) open reduction
(2) internal fixation
(3) syndesmosis reconstruction
What are the ilio-inguinal and genitofemoral nerves?
They are terminal sensory branches that descend into the upper thigh from the lumbar plexus.
What is the mode of trauma in ruptured Achilles tendon ?
After a blow to the posterior surface of the ankle
Where does the ilio-inguinal nerve originate?
The ilio-inguinal nerve originates from the superior part of the lumbar plexus.
What is the sex incidence in ruptured Achilles tendon
Female
What does the ilio-inguinal nerve innervate?
Its terminal branches innervate skin on the medial side of the upper thigh and adjacent parts of the perineum.
What is the specific test used in ruptured Achilles tendon?
Simmonds Thompson test
Where does the genitofemoral nerve pass?
The genitofemoral nerve passes anteroinferiorly through the psoas major muscle.
Bones of the foot
What does the genital branch of the genitofemoral nerve innervate?
The genital branch innervates anterior aspects of the perineum.
Sinus tarsi
Between talus and calcaneum
What does the femoral branch of the genitofemoral nerve innervate?
The femoral branch innervates skin over the upper central part of the anterior thigh.
Define ankylosing spondylitis
Autoimmune inflammation of the spine joints
Enumerate compartments of the thigh and their nerve and blood supply
What are the associated diseases with ankylosing spondylitis?
(1) Inflammatory bowel disease,especially.UC
(2) Anterior uveitis
(3) Psoriasis
(4) HLA B27
What is the C/P of ankylosing spondylitis?
(1) Back pain
(2) Stiffness
What are the structures that separate the compartments of the lower leg?
What is the treatment of ankylosing spondylitis?
NSAID
Enumerate compartments of the leg and their nerve and blood supply
Define Spondylolysis
Fracture of vertebrae after me mechanical stress
What is the main cause of spondylolysis?
(1) Mechanical stress
(2) After a fall during sport
What is the treatment of spondylolysis?
(1) Conservative
- excercise
-steroids
(2) Surgical fixation or correction
Define spondylolisthesis
Displacement of one vertebra after spondylolysis affecting
1) L5 mainly
2) Sacral vertebrae
What are the vertebrae affected in spondylolisthesis?
1) L5 mainly
2) Sacral vertebrae
What is the feature of spondylolisthesis on the XRs?
Prominent sacrum
What is the treatment of spondylolisthesis?
(1) Conservative
- excercise
-steroids
(2) Surgical fixation or correction
Define spinal canal stenosis
Narrowing of the spinal canal
↓
Pressure on the spinal cord
What is the C/P of spinal stenosis?
Pain relieved by exercise,e.g., walking uphill or riding a bicycle
What is the treatment of spinal canal stenosis?
(1) Conservative
- excercise
-steroids
(2) Surgical fixation or correction
Define facet joint arthrosis
Degeneration of the facet joint of vertebrae
What are the risk factors facet joint arthrosis?
1) heavy work
2) obesity
What are the C/P of facet joint arthrosis?
1) Increased during day and relieved at the end of it
2) Improved by NSAIDs
What are the treatment of facet joint arthrosis?
NSAIDs
Define spina bifida
Failure of development of the
1) Spine
2) Spinal cord
Enumerate types spina bifida
(1) spina bifida occulta
(2) Meningocele
(3) Myelomeningocele
Define spina bifida occulta
A birth mark of hairy patch over the vertebral column
Define meningocele
A sac containing CSF only
Define myelomeningocele
A sac containing CSF + spinal cord
Which type of spina bifida is the most severe form of?
Myelomeningocele
What is the only preventive procedure for all types of spina bifida?
Folic acid supplementation during pregnancy
What is the treatment of all types of spina bifida?
Surgical repair
An incision is made at the marked line on the picture (which is behind lateral malleolus). This incision is most likely to cause injury of which nerve?
Sural nerve
Relations of malleoli and retinacula of ankle and foot
Enumerate structures below (deep to) flexor retinaculum + posterior to medial malleolus
Structures that pass behind the medial malleolus beneath the flexor retinaculum (medial to lateral) + (ant to post)
[Mnemonic;Tom Does Very Nice Hat]
DEEP POSTERIOR COMPARTMENT WITHOUT PERONEAL NERVE
* Tibialis posterior tendon.
* Flexor digitorum longus.
* Posterior tibial vessels.
* Tibial nerve.
* Flexor hallucis longus.
* Synovial sheaths of all the tendons.
Enumerate structures below (deep to) flexor retinaculum
Structures that pass behind the medial malleolus beneath the flexor retinaculum (medial to lateral)
[Mnemonic;Tom Does Very Nice Hat]
DEEP POSTERIOR COMPARTMENT WITHOUT PERONEAL NERVE
* Tibialis posterior tendon.
* Flexor digitorum longus.
* Posterior tibial vessels.
* Tibial nerve.
* Flexor hallucis longus.
* Synovial sheaths of all the tendons.
Enumerate structures posterior to medial malleolus
Structures that pass behind the medial malleolus beneath the flexor retinaculum (medial to lateral)
[Mnemonic; Tom Does Very Nice Hat]
DEEP POSTERIOR COMPARTMENT WITHOUT PERONEAL NERVE
* Tibialis posterior tendon.
* Flexor digitorum longus.
* Posterior tibial vessels.
* Tibial nerve.
* Flexor hallucis longus.
* Synovial sheaths of all the tendons.
What are the structures below (deep to) extensor retinaculum?
ACCORDING TO MRCS IV BOOK:-
Anterior leg compartment muscles
Mnemonic; Tiny Elegant Fire (or pain) Extinguishers
(1) Tibialis anterior,
(2) Extensor hallucis longus,
(3) Fibularis (peroneus) tertius,
(4) Extensor digitorum longus
What are the structures superficial(anterior) to extensor retinaculum + anterior to medial malleolus?
From medial to lateral
(1) beginning of great saphenous vein and lower part of Saphenous nerve (both are anterior to medial malleolus)
(3) superficial peroneal nerve
What are the structures superficial (anterior) to extensor retinaculum?
From medial to lateral
(1) beginning of great saphenous vein
(2) lower part of Saphenous nerve
(3) superficial peroneal nerve
What are the structures anterior to medial malleolus?
From medial to lateral
(1) beginning of great saphenous vein
(2) lower part of Saphenous nerve
What are the structures anterior to lateral malleolus?
Superficial peroneal nerve
What are the structures posterior to lateral malleolus?
(1) peroneus longus
(2) peroneus brevis
(3) short saphenous vein
(4) sural nerve
Lower limb nerves
Lower limbs associated injury
What are the structures injured in posterior hip approach?
(1) Sciatic nerve
Sciatic nerve passes just beneath gluteus maximus muscle and long head of biceps femoris on the posterior surface of the thigh so it might be injured during posterior hip
(2) Inferior gluteal artery
What are the structures injured in distal femur surgery?
Tibial nerve
What are the structures injured in neck of fibula fractures or injury?
Common peroneal nerve
What are the structures injured in Lloyd David position?
Common peroneal nerve
Lloyd Davi’s position is often needed in surgical procedures causing compression of common peroneal nerve
What are the structures injured in fibula fractures or surgery?
Peroneal artery
Posterior scapular spaces
Mnemonic;الكبير(teres major) شايل الصغير(teres minor)
This means teres major (lower border of quadrangular space and medial or upper triangular space) is carrying the teres minor(upper border of quadrangular space and medial or upper triangular space)
Urinary tract stones
Testicular tumours
What structures pass through the greater sciatic foramen above the piriformis muscle?
Superior gluteal nerve, artery, vein.
Prostatic cancer
What structures pass through the lesser sciatic foramen?
Mnemonic; PIN+ obturator internus muscle
(1) Pudendal nerve,
(2) Internal pudendal vessels.
(3) Nerve to obturator internus
(4) Obturator internus muscle tendon,
Urinary tract tumours
What structures pass through the greater sciatic foramen below the piriformis muscle?
Mnemonic; PIN
(1) Sciatic nerve (10% pass through it, < 1% above it)
(2) Inferior gluteal nerve, artery, vein,
(3) Pudendal nerve,
(4) Internal pudendal artery and vein,
(5) Posterior femoral cutaneous nerve,
(6) Nerve to obturator internus and Gemellus superior muscles,
(7) Nerve to quadratus femoris and Gemellus inferior muscles.
What structures pass through both ,the greater and lesser sciatic foramen?
Discuss boundaries of greater sciatic foramen
What is the femoral triangle?
The femoral triangle is a wedge-shaped depression formed by muscles in the upper thigh at the junction between the anterior abdominal wall and the lower limb.
What are the borders of the femoral triangle?
base — inguinal ligament,
medial border — medial margin of the adductor longus muscle,
lateral margin — medial margin of the sartorius muscle.
What forms the floor of the femoral triangle?
Mnemonic; PIA
1) iliopsoas muscle,
2) pectineus muscle,
3) adductor longus muscle.
Where does the apex of the femoral triangle point?
The apex of the femoral triangle
- points inferiorly
- continuous with the adductor canal.
What happens to the femoral artery and vein in the adductor canal?
The femoral artery and vein pass inferiorly through the adductor canal and become the popliteal vessels behind the knee.
What structures are arranged from lateral to medial in the femoral triangle?
Mnemonic; NAV
1) femoral nerve,
2) femoral artery,
3) femoral vein,
4) lymphatic vessels.
Where can the femoral artery be palpated?
1) in the femoral triangle
2) just inferior to the inguinal ligament, 3) midway between the anterior superior iliac spine and the pubic symphysis.
Posterior scapular spaces
Mnemonic;(teres minor) شايل الصغير(teres major) الكبير
This means teres major below is carrying teres minor above
Mid-inguinal point
Midpoint of inguinal ligament
Pubic tubercle relations to hernia
Saphnia varix
Management of head trauma
What is the origin of the phrenic nerve?
The phrenic nerve originates from the anterior rami of cervical spinal roots C3, C4 and C5 .
This can be remembered using the limerick “C3, 4 and 5 keep the diaphragm alive”.
Spinal root C4 provides the main contribution, with lesser contributions from C3 and C5 and some communicating fibres from the cervical plexus.
What is the root value of the phrenic nerve?
The phrenic nerve originates from anterior rami of cervical spinal roots C3, C4 and C5 .
This can be remembered using the limerick “C3, 4 and 5 keep the diaphragm alive”.
Spinal root C4 provides the main contribution, with lesser contributions from C3 and C5 and some communicating fibres from the cervical plexus.
Discuss the course of both Phrenic nerves
What is the course of the phrenic nerve on both sides at its origin?
What is the relation of the phrenic nerve on both sides to the scalenus anterior at its origin?
The phrenic nerve arises at the lateral border of scalenus anterior muscle
What is the course of the phrenic nerve on both sides at the base or root of the neck as it enters the neck?
The phrenic nerve descends inferiorly and obliquely with the internal jugular vein
+ posterolateral to the internal jugular vein
+ over the the anterior surface sclenus anterior muscle
+ beneath or deep to the prevertebral layer of deep cervical fascia(in other texts,the phrenic nerve is superficial to the deep cervical fascia)
It then runs vertically downwards on the cervical pleura to enter the thoracic cavity behind the 1st costal cartilage
What are the relations of the phrenic nerve on both sides at the base or root of the neck on both sides?
The phrenic nerve descends inferiorly and obliquely with the internal jugular vein
+ posterolateral to the internal jugular vein
+ over the the anterior surface sclenus anterior muscle
+ beneath or deep to the prevertebral layer of deep cervical fascia(in other texts,the phrenic nerve is superficial to the deep cervical fascia)
It then runs vertically downwards on the cervical pleura to enter the thoracic cavity behind the 1st costal cartilage
What are the medial relations of Phrenic nerve on both sides at the base or root of the neck as it enters the neck?
The medial relations of the phrenic nerve as it enters the neck involve its proximity to the internal jugular vein and the scalenus anterior muscle. The phrenic nerve travels medially, crossing the anterior surface of the scalenus anterior muscle and lying (posterolateral) to the internal jugular vein,i.e.,the phrenic nerve in both sides is:-
(1) anterior to the scalenus anterior
(2) posterolateral to the internal jugular veins
Elaboration:
Origin and Course:
The phrenic nerve originates from the cervical plexus (C3-C5) and descends vertically in the neck, lying on the anterior surface of the anterior scalene muscle.
Relationship to Internal Jugular Vein:
The phrenic nerve travels adjacent to and posterolateral to the internal jugular vein as it descends in the neck.
Crossing the Scalenus Anterior:
The phrenic nerve passes over the anterior surface of the scalenus anterior muscle, a key landmark in the neck.
Thoracic Entry:
After crossing the scalenus anterior, the phrenic nerve continues its descent and enters the thorax posterior to the subclavian vein.
What is the relation of the phrenic nerve on both sides to the internal jugular vein at the base or root of the neck as it enters the neck?
The phrenic nerve is posterolateral to the internal jugular vein
What is the relation of the phrenic nerve on both sides to the scalenus anterior at the base or root of the neck as it enters the neck?
Anterior to scalenus anterior muscle
What is the relation of the phrenic nerve to the deep cervical fascia at the base or root of the neck as it enters the neck?
Beneath or deep to the prevertebral layer of deep cervical fascia
Which layer of the deep cervical fascia is related to the phrenic nerve on both sides?
Prevertebral layer
The phrenic nerve beneath or deep to the prevertebral layer of deep cervical fascia
What is the relation of the phrenic nerve on both sides to the cervical pleura at the base or root of the neck as it enters the neck?
It runs vertically downwards on the cervical pleura to enter the thoracic cavity behind the 1st costal cartilage
What is the relation of the phrenic nerve on both sides to the 1st costal cartilage at the base or root of the neck as it enters the neck?
It runs vertically downwards on the cervical pleura to enter the thoracic cavity behind the 1st costal cartilage
What is the course of the phrenic nerve on both sides as it enters the thoracic cavity?
What are the relations of the phrenic nerve on both sides as it enters the thoracic cavity?
What is the point at which the course of both phrenic nerves on both sides differs on each side?
When the phrenic nerve enters the thoracic cavity.
What is the best view to check for the distribution of both phrenic nerves on the diaphragm?
The distribution of the phrenic nerve on the diaphragm is best seen on the inferior surface
Discuss the course of the phrenic nerve on each side?
What is the relation of the Rt phrenic to the Rt subclavian artery?
It passes anteriorly over the lateral part of the subclavian artery
At what point the Rt phrenic nerve enters the thoracic cavity behind?
Via the superior thoracic aperture
What is the relation of the Rt phrenic nerve to Rt lung root?
It descends anteriorly along the the Rt lung root
What is the relation of the Rt phrenic nerve to pericardium of the Rt atrium of the heart?
Courses along the pericardium of the Rt atrium of the heart
At which point the Rt phrenic nerve pierces the diaphragm?
IVC opening at T8
Which diaphragmatic surface is inner Atef by the Rt phrenic nerve?
Inferior surface
What is the relation of the Lt phrenic nerve to the Lt subclavian artery?
Passés anteriorly over the medial part of the left subclavian artery
What is the relation of the Lt phrenic nerve to the Lt lung root?
Descends anterior to the Lt lung root
What is the relation of the Lt phrenic nerve to the aortic arch and vagus nerve?
Crosses the aortic arch and bypasses the vagus nerve
What diaphragmatic surface is innervated by the Lt phrenic nerve?
Inferior surface
Nerve injury in the abdomen
Rectum+anal canal
Lymphatic drainage of ovaries,uterus and cervix
Lymphatic drainage of abdomen and pelvis
Hperacute+acute renal transplantation rejection
Urinary bladder+ ureter + prostate+ urethra development
Enumerate layers pierced by LP
- 1st structure to be punctured — epidural fat
- 1st ligament to be punctured — supraspinous ligament
- last ligament punctured — ligamentum flavum
- strongest ligament— ligamentum flavum
- last structure punctured— arachnoid matter
- site reached by LP — arachnoid space
Visual field defect
Skull foramina
Pterion
Mnemonic; FPTS
1) Frontal
2) Parietal
3) Squamous part of temporal
4) Greater wing of sphenoid
Cranial nerves
Origin of cranial nerves
MAP
ABG
For the compensation,we look at PCO2+HCO3:- ↓
(1) Compensated — ↑PCO2+ ↑HCO3 or ↓PCO2+ ↓HCO3
both PCO2 and HCO3 are in the samed direction
(2) Partially compensated —- abnormal PH
(4) Fully or completely compensated— normal PH
(5) Uncompensated—- ↑PCO2+ normal HCO3 or normal PCO2+↑HCO3
↓PCO2+ normal HCO3 or normal PCO2+ ↓HCO3
One value is normal and the other is low or high
(6) Mixed — ↑PCO2+ ↓HCO3 or↓PCO2+↑HCO
Values are in the opposite direction
What is the other name for normal anion gap acidosis?
Hyperchloraemic metabolic acidosis
What are the causes of normal anion gap metabolic acidosis?
Mnemonic;HARDUPS
(1) Hyperalimentation/hyperventilation
(2) Acetazolamide,Ammonium chloride injection,Addison’s disease
(3) Renal tubular acidosis
(4) Diarrhoea,fistula-causing gastrointestinal bicarbonate loss
(5) Ureteral diversion(uretrosigmoidostomy)-causing gastrointestinal bicarbonate loss
(6) Pancreatic fistula/Parentral saline (7)Spironolactone
What are the causes of increased anion gap metebolic acidosis?
Mnemonic;MUDPILES
(1) Methanol,Metformin(Renal failure),Mesentric ischaemia or infarction
(2) Uraemia,i.e.,urate(renal failure or CKD)
(3) Diabeti ketoacidosis,AKA,alcohol
(4) Propylene glycol/Paraldehyde/Phenformin,Paracetamol
(5) Isoniazide/Iron,Infections,Inborn errors of metabolism
(6) Lactic acidosis,i.e.,lactate(shock,hypoxia,burn,sepsis)
(7) Ethylene glycol,Ethanol
(8) Salycilates-Aspirin
N.B:Mesentric ischaemia or infarction is associated with lactic acidosis and metabolic acidosis late in its biochemical presentation
What are the causes of decreased anion gap mtabolic acidosis?
Mnemonic;HYP/HL
(1) Hypoalbuminaemia
(2) Hypercalcaemia
(3) Hypermagnesaemia
(4) Hyper γ-globulinaemia
(5) Hyperviscosity
(6) Halide(bromide or iodide)intoxication
(7) Lithium intoxication
What is the classification of metabolic acidosis secondary to high lactate levels?
(1) Lactic acidosis type A:Perfusion disorders e.g.,shock,hypoxia,burn
(2) Lactic acidosis type B:Metabolic e.g.,Metformin toxicity
Define metabolic alkalosis
Rise in plasma bicarbonate levels
What are the causes of metabolic alkalosis?
Mnemonic:VAD/PHCL/CBC
Problems of the kidney or gastrointestinal tract
(1) Vomiting/Aspiration(e.g., peptic ulcer leading to pyloric stenosis,nasogastric suction)
(2) Diuretics
(3) Primary hyperaldosteronism (4)Hypokalaemia
(5) Carbenoxolone,Liquorice
(6) Cushing syndrome
(7) Bartter’s syndrome
(8) Congenital adrenal hyperplasia
What are the causes of respiratory acidosis?
- COPD
- Decompensation in other respiratory conditions e.g. Life-threatening asthma / pulmonary oedema
- Sedative drugs: benzodiazepines, opiate overdose(e.g.,morphine)
What are the causes of respiratory alkalosis?
Mnemonic:CHEAP
(1) CNS stimulation:stroke,subarachnoid haemorrhage,encephalitis
(2) Hypoxia causing hyperventilation:High altitude,pulmonary embolism
(3) Early salycilate poisoning
(4) Psychogenic:Anxiety leading to hyperventilation
(5) Pregnancy
