Posterior Abdominal Wall and Diaphragm Flashcards
psoas major M attachments
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.)
psoas major M innervation and action
i. Innervation—L2-4 (via lumbar plexus)
ii. Actions—bilaterally flexes thigh at hip & unilaterally side bends trunk to the same side
psoas minor M attachments
i. Proximal Attachment—lateral aspects of vertebral bodies of T12-L1
ii. Distal Attachment—pectineal line (via superior pubic ramus)
psoas minor M innervation and actions
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
quadratus lumborum M attachments
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
quadratus lumborum M innervation and actions
i. Innervation—T12-L4
ii. Actions—extends and laterally lexes vertebral column, fixes rib 12 during inspiration
iliacus M attachments
i. Proximal attachment—iliac fossa of pelvis
ii. Distal attachment—lesser trochanter of femur (via common tendon with psoas major M)
iliacus M innervation and actions
i. Innervation—femoral N.
ii. Actions—flexes thigh at hip
psoas major M and iliacus M
a. have close relationships with many abdominal structures
i. Kidneys, ureters, cecum, sigmoid colon, pancreas, posterior abdominal nerves
iliopsoas pain
i. performed to help with differential diagnosis
1. Patient lies on unaffected side and extend opposite leg against resistance
psoas syndrome
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
borders of the respiratory diaphragm
i. Xiphisternal joint
ii. Costal margin
iii. Vertebral body of T12
what are the 3 origins of the diaphragm and where do they insert?
a. 3 peripheral origins insert on the central tendon:
i. sternal origin
ii. costal origin
iii. vertebral origin
R and L crus
a. meet at aortic hiatus
i. Right crus—longer, forms the muscular esophageal hiatus
ii. Left crus—shorter, more lateral
caval opening
T8
IVC
R phrenic N
lymphatics from liver
esophageal hiatus
T10
esophagus
anterior and mosteiro vagal trunks
esophageal branches of L gastric A
aortic hiatus
T12
aorta
thoracic duct
azygous vein
sternocostal hiatus
superior epigastric vessel
arcuate ligaments and what goes thru them
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
parasternal hernias
i. Sternocostal triangle
ii. Located b/w the sternal and costal parts of the diaphragm
pleuroperitoneal hernias
i. Lumbocostal triangle
ii. Located b/w the 12th rib and the diaphragm
congenital diaphragmatic hernia
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
hiatal hernia
- protrusion of part of the stomach into the mediastinum through the esophageal hiatus
- occur most often after middle age
a. possibly due to weakening of the muscular portion of diaphragm
paraesophageal hernia
a. cardia remains in position
i. usually no regurgitation of gastric contents
b. fundus extends thru hiatus
sliding hiatal hernia
a. abdominal esophagus, cardia, and fundus of the stomach slide superiorly into the thorax
b. some regurgitation of gastric contents may occur
blood supply to the superior surface of the diaphragm
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
blood supply to the inferior diaphragm
i. inferior phrenic A—off of aorta
1. right—passes posterior to IVC
2. left—passes posterior to esophagus
motor innervation to the diaphragm
i. phrenic N
1. C3, 4, 5—keep the diaphragm alive
2. Some branches run with the inferior phrenic A
3. Only motor innervation
sensory innervation to the diaphragm
i. Central portion—central tendon
1. Phrenic N
ii. Peripheral portion
1. Intercostal N
lymphatics to the superior portion of the diaphragm
i. Anterior diaphragm
1. Anterior diaphragmatic nodesparasternal nodes
ii. Posterior diaphragm
1. Posterior diaphragmatic nodesmediastinal nodes
lymphatics to the inferior portion of the diaphragm
i. Celiac nodes
ii. Superior lumbar nodes
cisterna chyli
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
celiac LN cluster
liver, stomach, spleen, pancreas, upper duodenum
superior mesenteric LN cluster
lower duodenum, jejunum, ileum, colon
inferior mesenteric LN cluster
colon
internal iliac LN cluster
lower rectum to anal canal (above pectinate line), bladder, vagina, prostate
para-aortic LN cluster
testes, ovaries, kidneys, uterus
superficial inguinal LN cluster
anal canal (below pectinate line), skin below umbilicus, scrotum
deep inguinal LN cluster
lower extremity
greater and lesser sac of the peritoneal cavity
i. greater sac—accessed by incision to the anterior abdominal wall
ii. lesser sac (omental bursa)—posterior to stomach and lesser omentum
supra colic compartment
stomach, liver, spleen
infra colic compartment
a. small intestine, ascending and descending colon
b. further divided by the mesentery of the small intestine into right and left infracolic spaces
parabolic gutters
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
