Posterior Abdominal Wall and Diaphragm

Question 1

psoas major M attachments

Answer 1

i. Proximal Attachment—lateral aspects and transverse processes of vertebral bodies of L12-L5
ii. Distal Attachment—Lesser Trochanter of Femus (via common tendon with iliacus M.)

Question 2

psoas major M innervation and action

Answer 2

i. Innervation—L2-4 (via lumbar plexus)

ii. Actions—bilaterally flexes thigh at hip & unilaterally side bends trunk to the same side

Question 3

psoas minor M attachments

Answer 3

i. Proximal Attachment—lateral aspects of vertebral bodies of T12-L1
ii. Distal Attachment—pectineal line (via superior pubic ramus)

Question 4

psoas minor M innervation and actions

Answer 4

i. Innervation—L1-2
ii. Actions—depresses 12th rib, fixes 12th rib during deep inspiration, bilaterally assists with trunk extension, unilaterally side bends trunk to same side

Question 5

quadratus lumborum M attachments

Answer 5

i. Proximal attachment—iliac crest and iliolumbar ligament

ii. Distal attachment—medial half of interior border of the 12th rib, tips of lumbar transverse processes

Question 6

quadratus lumborum M innervation and actions

Answer 6

i. Innervation—T12-L4

ii. Actions—extends and laterally lexes vertebral column, fixes rib 12 during inspiration

Question 7

iliacus M attachments

Answer 7

i. Proximal attachment—iliac fossa of pelvis

ii. Distal attachment—lesser trochanter of femur (via common tendon with psoas major M)

Question 8

iliacus M innervation and actions

Answer 8

i. Innervation—femoral N.

ii. Actions—flexes thigh at hip

Question 9

psoas major M and iliacus M

Answer 9

a. have close relationships with many abdominal structures

i. Kidneys, ureters, cecum, sigmoid colon, pancreas, posterior abdominal nerves

Question 10

iliopsoas pain

Answer 10

i. performed to help with differential diagnosis

1. Patient lies on unaffected side and extend opposite leg against resistance

Question 11

psoas syndrome

Answer 11

i. Presentation:
1. Lumbosacral pain
2. Difficulty standing up straight
3. Pain in the contralateral gluteal region
4. Radiation of pain down the lower extremity
a. Usually stopping at the knee
ii. May mimic herniated disc
iii. Differential diagnosis:
1. Appendicitis, colon cancer, diverticulitis, hip dysfunction
2. Consider psoas syndrome if:
a. L1 or L2 is rotated left, and SB right
b. Body flexed at waist and SB left
c. Pain radiating down right leg

Question 12

borders of the respiratory diaphragm

Answer 12

i. Xiphisternal joint
ii. Costal margin
iii. Vertebral body of T12

Question 13

what are the 3 origins of the diaphragm and where do they insert?

Answer 13

a. 3 peripheral origins insert on the central tendon:
i. sternal origin
ii. costal origin
iii. vertebral origin

Question 14

R and L crus

Answer 14

a. meet at aortic hiatus
i. Right crus—longer, forms the muscular esophageal hiatus
ii. Left crus—shorter, more lateral

Question 15

caval opening

Answer 15

T8
IVC
R phrenic N
lymphatics from liver

Question 16

esophageal hiatus

Answer 16

T10
esophagus
anterior and mosteiro vagal trunks
esophageal branches of L gastric A

Question 17

aortic hiatus

Answer 17

T12
aorta
thoracic duct
azygous vein

Question 18

sternocostal hiatus

Answer 18

superior epigastric vessel

Question 19

arcuate ligaments and what goes thru them

Answer 19

a. posterior origins of the diaphragm form arcuate ligaments which form opening for posterior abdominal wall structures
i. median arcuate ligament—aortic hiatus
ii. medial arcuate ligament—gap for psoas major M
iii. lateral arcuate ligament—gap for quadratus lumborum M

Question 20

parasternal hernias

Answer 20

i. Sternocostal triangle

ii. Located b/w the sternal and costal parts of the diaphragm

Question 21

pleuroperitoneal hernias

Answer 21

i. Lumbocostal triangle

ii. Located b/w the 12th rib and the diaphragm

Question 22

congenital diaphragmatic hernia

Answer 22

i. 1/2500 live births
ii. etiology:
1. failure of pleuroperitoneal membranes to fuse with other components of the diaphragm
iii. presentation:
1. respiratory distress and cyanosis in the first minutes or hours of life
a. later presentation is possible
b. respiratory distress may be severe and can be associated with circulatory insufficiency
2. unusually flat abdomen

Question 23

hiatal hernia

Answer 23

1. protrusion of part of the stomach into the mediastinum through the esophageal hiatus
2. occur most often after middle age
   a. possibly due to weakening of the muscular portion of diaphragm

Question 24

paraesophageal hernia

Answer 24

a. cardia remains in position
i. usually no regurgitation of gastric contents
b. fundus extends thru hiatus

Question 25

sliding hiatal hernia

Answer 25

a. abdominal esophagus, cardia, and fundus of the stomach slide superiorly into the thorax
b. some regurgitation of gastric contents may occur

Question 26

blood supply to the superior surface of the diaphragm

Answer 26

i. pericardiacophrenic A—come off of internal thoracic A
ii. musculophrenic A—come off of internal thoracic A
iii. superior phrenic A—off of aorta

Question 27

blood supply to the inferior diaphragm

Answer 27

i. inferior phrenic A—off of aorta
1. right—passes posterior to IVC
2. left—passes posterior to esophagus

Question 28

motor innervation to the diaphragm

Answer 28

i. phrenic N
1. C3, 4, 5—keep the diaphragm alive
2. Some branches run with the inferior phrenic A
3. Only motor innervation

Question 29

sensory innervation to the diaphragm

Answer 29

i. Central portion—central tendon
1. Phrenic N
ii. Peripheral portion
1. Intercostal N

Question 30

lymphatics to the superior portion of the diaphragm

Answer 30

i. Anterior diaphragm
1. Anterior diaphragmatic nodesparasternal nodes
ii. Posterior diaphragm
1. Posterior diaphragmatic nodesmediastinal nodes

Question 31

lymphatics to the inferior portion of the diaphragm

Answer 31

i. Celiac nodes

ii. Superior lumbar nodes

Question 32

cisterna chyli

Answer 32

i. dilation at the end of the thoracic duct
ii. collects lymph from intestinal lymphatic trunks and lumbar lymphatic trunks
iii. retroperitoneal structure
1. lies posterior to the aorta around vertebral levels L1-2

Question 33

celiac LN cluster

Answer 33

liver, stomach, spleen, pancreas, upper duodenum

Question 34

superior mesenteric LN cluster

Answer 34

lower duodenum, jejunum, ileum, colon

Question 35

inferior mesenteric LN cluster

Answer 35

colon

Question 36

internal iliac LN cluster

Answer 36

lower rectum to anal canal (above pectinate line), bladder, vagina, prostate

Question 37

para-aortic LN cluster

Answer 37

testes, ovaries, kidneys, uterus

Question 38

superficial inguinal LN cluster

Answer 38

anal canal (below pectinate line), skin below umbilicus, scrotum

Question 39

deep inguinal LN cluster

Answer 39

lower extremity

Question 40

greater and lesser sac of the peritoneal cavity

Answer 40

i. greater sac—accessed by incision to the anterior abdominal wall
ii. lesser sac (omental bursa)—posterior to stomach and lesser omentum

Question 41

supra colic compartment

Answer 41

stomach, liver, spleen

Question 42

infra colic compartment

Answer 42

a. small intestine, ascending and descending colon

b. further divided by the mesentery of the small intestine into right and left infracolic spaces

Question 43

parabolic gutters

Answer 43

i. areas b/w lateral aspects of ascending and descending colon and the posterior abdominal wall
ii. allows for free communication b/w the supracolic and infracolic compartments
iii. phrenicocolic ligament—prevents the spread of fluid superiorly