Thorax Flashcards
Chest pain is the most important symptom of what
Cardiac disease
What else may chest pain occur with
Pulmonary disease, intestinal, gallbladder, and musculoskeletal disorders
What do people with heart attack describe their chest pain as
Crushing substernal pain that does not disappear with rest
Why is the 1st rib rarely fractured
Protected
First rib fracture is commonly viewed as a hallmark of severe injury in ___ trauma
Blunt
When the first rib is broken things crossing its superior aspect may be injured. What is there
Brachial plexus of nerves and subcclavian vessels that serve the upper limb
What ribs are most commonly fractured
Middle
Most common cause of rib fracture
Blow or crushing injuries
What is the weakest part of the rib
Just anterior to its angle. However direct violence may fracture a rib anywhere
What is of concern with broken end of rib
Injure internal organs such as a lung and or spleen
Fractures of the lower ribs may damage what
Diaphragm
What may a lower rib tear in the diaphragm cause
Diaphragmatic hernia
Why are rib fractures painful
Broken parts move during respiration, coughing, laughing, and sneezing.
Flail chest
Multiple rib fractures may allow a sizable segment of the anterior and,or lateral thoracic wall to move freely ,,
In flail chest, the loose segment of the wall moves _____
Paradoxically
(Inward on inspiration and outward of expiration)
If flail chest painful
YES VERYYYY and affects oxygenation of the blood
Thoracotomy
Surgical creation of an opening through the thoracic wall to enter a pleural cavity
Anterior thoracotomy
H shaped cuts through the perichondrium of one or more costal cartilages and then shelling out segments to get access to thoracic cavity
Where may posterolateral thoracotomy
5th-7th intercostal spaces
When doing the posterolateral thoracotomy why is the patient on their side with arm abducted
Elevates and laterally rotates the inferior angle of scapula, allowing access as high as the 4th intercostal space.
Is the neuromuscular bundle above of below rib
Above
Rib retraction
To do surgery through one intercostal scape
Incision for pneumonectomy
Bigger H shaped incision to incise superficial aspect of the periosteum that ensheaths the rain, strip the periosteum from the rib and then excise a wide segment of the rib to gain better access
In the absence of rib, an incision can be made through deep aspect of periosteal sheath , spacing the adjacent intercostal muscles
After the operation the missing pieces of the ribs regenerate from the intact periosteum although imperfectly
Supernumerary ribs
Cervical or lumbar
What percentage of population has cervical ribs
1-2
How remove cervical rib
Trans axillary approach
___ ___ provide resilience to the thoracic cage preventing many blows from fracturing the sternum and ribs
Costal cartilages
Can chest compression in kids produce injury in thorax even without rib breaks. Why
Yea
Amazing elasticity
Why are costal cartilages radiologically opaque in older people
Calcification
Lose elasticity and become brittle
CPR more likely to break ribs in kids or old people
Old
Costochondral lose elasticity
Someone int heir 40s presents with hard lump in pit of stomach
Ossified diploid process
Why try to avoid ossified siphoned process in surgery
Result in heterotropic ossification of the upper part of the incision
A fracture if the eternal body is usually a ____ fracture
Comminuted
What is a comminuted fracture
Lots of little pieces
In stern alone fracture why is displacement of bone fragments uncommon
Sternum is invested by deep fascia and the eternal attachments of the pectoralis major muscles
What is the most common site of eternal fractures in elderly is at the eternal angle where the manubriosternal joint has fused . What does this fracture result in
Dislocation of the manbriosternal joint
Why is the mortality rate associated with sternal fractures 25-45% (sternal contusion)
Underlying visceral injury
Heart and or lung injury
Median sternotomy
Sternum is divided in the median plane and retracted
Flexibility of ribs and costal cartilages enables spreading of the halves of the sternum
Why do median sternotomy
Gain access to the thoracic cavity for surgical operations in the mediastinum
Coronary artery bypass grafting
Removal of tumors in superior lobes of the lungs
What is more painful after surgery. Median sternotomy or muscle splitting thoracotointercostal space incision
Muscle splitting
Why do sternal bone biopsy
Breadth and subcutaneous position
For transplantation or detection of metastatic cancer and blood dyscrasias
How does the sternum develop
Through fusion of bilateral, vertical condensations of precartilaginous tissue, sternal bands or bars
Complete sternal cleft
Sternum of fetus does not fuse
What is associated with sternal cleft
Actopia cordis
Partial sternal cleft
Involves manubrium and superior half of body. V or U shaped
Repaired during infancy
Sternal foremen
Hole, dont confuse for bullet hole
Is perforation of diploid process in old people of concern
No
Anterior protruding diploid process neonates
Not a prob no surgery
What is the thoracic inlet . Why is it called that
Superior thoracic aperature
Bc noncirculating substances (air and food) may enter the thorax only through this aperature
Thoracic outlet
Emphasizing the arteries and t1 spinal nerves that emerge from the thorax through this aperture to enter the lower neck and upper limbs
Thoracic outlet syndrome
Emerging structures are affected by obstructions of the superior thoracic aperture
Rib dislocation ( slipping rib)
Displacement of the costal cartilage from the sternum -sternocostal joint or displacement of the inter Honduras joints
Complications of rib dislocation
Pressure on or damage to nearby nerves, vessels, and muscles
Displacement of interchondral joints is usually unilateral and involves ribs _ _ and _
8 9 10
Trauma sufficient to displace ribs 8 9 and 10 often injured what else
Diaphragm, and or liver
SEVERE PAIN esp in inspiration
Can you see a displaced interchondral joint
Yea its a lump
Paralysis to diaphragm is due to injury to its motor supply, the _ nerve
Phrenic
If right phrenic nerve is damaged, are both domes of the diaphragm effected
No just the right
One can detect a paralyzed diaphragm radiographically by noting its ___ movement
Paradoxical
If paralyzed. How does the diaphragm move on inspiration and expiration
Inspiration -ascends in response to being pushed superiority by the active contralateral dome
Expiration-descends in response to passive pressure of lungs
What breast changes occur during menstrual cycle
Branching of lactiferous ducts
Mammary glands are prepared for secretion mid pregnancy. When do they start producing milk
Shortly after baby is born
Colostrum
Creamy white to yellowish premilk fluid , it may secrete from the nipples during the last trimester and beginning of nursing
What is colostrum rich in
Protein, immune agents, growth factor affecting the infants intestines
Multiparous woman breast
Large and pendulous
Elderly woman breasts
Small bc decreased fat and atrophy of glandular tissue
The breast is divided into 4 quadrants for examining
Superolateral, superomedial, inferolateral, inferomedial
Hard irregular mass felt in the superior medial quadrant of the breast at the 2 o clock position 2.5 cm front he margin of the areola
Carcinoma of the breast is usually ___
Adenocarcinoma
From epithelial cells of the lactiferous ducts in mammary gland lobules
Interference with dearmal lymphatics by cancer may cause ___
Lymphedema in skin of breast
What may lymphedema of breast cause in breast
Deviation of nipple and thickened leather like appearance of the skin
What is peau d’orange sign
Prominent puffy skin between dimpled pores gives it an orange peel appearance
Lymphedema
Inflammatory breast cancer
Large dimples in breast
Cancerous invasion of the glandular tissue and fibrosis which causes shortening or places traction on suspensory ligaments.
Subareolar breast cancer
Causes retraction of nipple by a similar mechanism involving the lactiferous ducts
How does breast cancer spread
Lymph vessels to lymph nodes
Describe spread of breast cancer
Communications among lymphatic pathways and among axillary, cervical, and parasternal nodes may cause metastasis from the breast to develop in the supraclavicular lymph nodes , the opposite breast, or abdomen
Most lymphatic drainage of the breast is to the ___ nodes
Axillary
Most common site of breast metastasis
Axillary nodes
Enlargement of palpable axillary nodes is suggestive of what
Possibility of breast cancer and may be key to early detection
Where else may breast cancer pass besides axilllary if axillary nodes not enlarged but still cancer
Infraclavicular, supraclavicular, or directly into the systemic circulation
Removal or destruction of axillary lymph nodes
Lymphedema in the ipsilateral upper limb which also drains through the axillarylymph nodes
Describe venous spread of breast cancer to vertebrae and cranium and brain
The posterior intercostal veins drain into the azygos,hemi—azygos system of veins alongside the bodies of the vertebrae and communicate with the internal vertebral venous plexus surrounding the spinal cord
Contiguous spread of breast cancer
Breast cancer cells invade the retromammary space , attach to or invade the pectoral fascia overlying the pectoralis major, or metastasize to the interpectoral nodes……in this case the breast will elevate when the muscle contracts
Breast elevates when muscle contracts (patient place hands on hips and press while pulling elbows forward to tense her pectoral muscles)
Clinical sign of advanced breast cancer
Mammography
Radiographic study of the breast , which is flattened to extend the area that can be examined and reduce thickness, making it more uniform for increased visualization
How do carcinomas appear on mammography
Large, jagged density
Clinical breast cancer
Mammography-jagged large density
Skin thickened over tumor
Nipple depressed
In classic mammography,, denser structures appear ___
Light
Xeromammography denser structures appear __
Dark
MRI on breast
Further examination and rule out false positives
Incision along inferior cutaneous crease
Scar hidden
Simple Mastectomy
Breast removed down to retromammary space
Nipple and areola may be spared and immediate reconstruction usually
Radical mastectomy
Removal of breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in axilla and pectoral region
Lumpectomy and quadrantectomy
Only tumor and surrounding tissue removed
Breast conserving surgery
FOLLOW WITH RADIATION
Polymastia
Breast supernumerarcy
Polythelia
Accessory nipple
Where are extra nipple or breast
Usually in axillary fossa or anterior abdominal wall
Mole that changes a darker color during pregnancy in axillary fossa also fat around it gets bigger with lactation
May be accessory boob
Small supernumerary breasts may appear anywhere along the ___ crest extending from axilla to Groin
Mammary
Amastia
No breast development
No breast tissue, nipple or areola
1.5% of breast cancer is in __
Men 1000 men a year in USA
With male breast cancer, where does it usually mtasticize
Axillary lymph nodes but also bone, pleura, lung, liver, and skin
What may indicate a malignant tumor in men
Visible and,or palpable subareolar mass or secretion from a nipple
Breast cancer in males invades what
Axillary nodes, pectoral fascia, pectoralis major
Breast cancer is uncommon in men. Why is is severe
Usually detected after extensive metastasis
Gynecomastia
Breast hypertrophy in males after puberty (a little is normal at puberty )
Cause of gynecomastia
Drugs (treatment with diethylstilbestrol for prostate cancer)
Change in metabolism of sex hormones from liver (imbalance estrogen and androgen)
Gynecomastia is a symptom. What could it be a symptom of
Suprarenal or testicular cancers
Klinefelter
Characteristics of klinefelter
XXY
Small testes and long lower limbs
Because of the inferior slope of the 1st pair of ribs and superior thoracic aperture they form, the ___ and the ___ _ _ __ project through this opening into the neck, posterior to the inferior attachments of the sternocleidomastoid
Cervical pleura
Apex of the lung
How may the apex of the lung and pleural sacs be injured and what can this cause
Wounds to the base of the neck resulting in pneumothorax
Why does the cervical pleura reach a higher area in infants and kids
Shorter necks
What ages is the cervical pleura at increased risk of injury
Infancy and childhood
What are the three regions that the pleura descends inferior to the costal margins, where an abdominal incision might inadvertently enter a pleural sac
Right part of infrasternal angle
Right and left costovertebral angles
The small areas of pleura exposed int he costovertebral angles inferomedial to the 12th ribs are posterior to the __ _ __ ___
Poles of the kidney
Why is the pleura in danger inferomedial to the 12th ribs
A pneumothorax may occur , for example, form an incision in the posterior abdominal wall when surgical procedures expose a kidney to trauma
Atelectasis
If dissension is not maintained in alveoli their inherent elasticity will cause them to collapse
Primary atelectasis
Failure of lung to inflate at birth
Secondary atelectasis
Collapse if a previously inflated lung
Why do lungs remain distended even when the airway passages are open
The outer surface of the lungs (visceral pleura) adhere to the inner surface of the thoracic walls (parietal pleura) as a result of the surface tension provided by the pleural fluid
The elastic recoil of the lungs causes the pressure in the pleural cavities to be _____
Subatmospheric
The pressure in the pleural cavities
-2mm Hg
The pressure in pleural cavities is what during inspiration
-8 mm Hg
How does a bullet cause the lung to collapse
Punctures thoracic wall and parietal pleura, admitting air and causing lung to collapse
Order of pleura from outside to inside of lung
Parietal, visceral
If a penetrating wound opens through the thoracic wall or the surface of the lungs, why will air be sucked into the pleural cavity
The negative pressure
What happens when air is sucked into the lungs
Surface tension adhering visceral to parietal pleura (lung to thoracic wall) will be broken and the lung will collapse, expelling most of its air bc of its inherent elasticity (recoil)
The pleural cavity is normally a “potential space” what is it when the lung collapses
A real space
If one lungs collapses, does the other? Why?
No bc they do not communicate
Laceration or rupture of the surface of a lung(and its visceral pleura) or penetration of the thoracic wall (and itsparietal pleura) reuslts in _____ and the entrance of air into the pleural cavity
Hemorrhage
How will a collapsed lung appear radiographically
Lung occupies less volume (elevation of the diaphragm above its usual levels, intercostal space narrowing(ribscloser together), and displacement of the mediastinum (mediastinal shift) and the pulmonary cavity does not increase in size during inspiration
Collapsed lung will be more white and surrounded by more radiolucent(black) air
Describe mediastinal shift with collapsed lung
Shifts to the affected side.
Most evident by the air filled teachea within it
In open chest surgery, how is respiration and lung inflation maintained
Incubating the trachea with a cuffed tube and using a positive pressure pump, varying the pressure to alternately inflate and deflate the lung
Pneumothorax
Entry of air into the pleural cavity
How may someone get pneumothorax
Bullet into parietal pleura
Rupture of a pulmonary lesion into the pleural cavity (bronshopulmonary fistula)
Fractured ribs may tear visceral pleura and lung
How may someone get hydrothorax
Pleural effusion
How may someone get hemothorax
Chest wound, blood may also enter the pleural cavity
Hemothorax results more commonly from injury to a major ______ or ____ ___- than from laceration of the lung
Intercostal or internal thoracic vessel
If both air and fluid(eg. hemopneumothorax) accumulate int he pleural cavity, what will be seen radiographically
Air-fluid level or interface (sharp line, horizontal regardless of the patients position, indicating the upper surface of the fluid)
Thoracentesis
Insert a hypodermic needle through an intercostal space into the pleural cavity to obtain a sample of fluid or to remove blood or pus
When doing a thoracentesis, how do you avoid damage to the intercostal nerve and vessels
Needle is inserted superior to the rib, high enough to avoid collateral branches
During thoracentesis, the needle passes through the intercostal muscles and costal parietal pleura into the pleural cavity. When the patient is in the ___ position, intrapleural fluid will accumulate in the ____ recess
Upright
Costodiaphragmatic
During thoracentesis, inserting the needle into the __ intercostal space in the mid axillary line during expiration will avoid the inferior border of the lung
9th
During a thoracentesis why should the needle be angled upward
To avoid penetrating the deep side of the recess (a thin layer of the diaphragmatic parietal pleura and diaphragm overlying the liver)
Major amounts of air, blood, serous fluid, pus, or any combo of these in the pleural cavity are removed by what?
Insertion of a chest tube
For inserting a chest tube, a short incision is made in the _ or _ intercostal space in the mid axillary line
5 6
A chest tube may be directed superiorly (toward cervical pleura)for removal of ____ or inferiorl (toward the costodiaphragmatic recess)y for removal of ___
Air
Fluid
Removal of air from a collapsed lung allows what
Reinflation
Failure to remove fluid from lung causes what
Lung to develop a resistant fibrous covering that inhibits expansion unless it is peeled off
What is lung decortication?
Lung develops a resistant fibrous covering that inhibits expansion unless it is peeled off
Why may one get lung decortication?
Hydrothorax
Pleuritis
Inflammation of the pleura
What conditions may obliterate the pleural cavity
Pleutiris or pleurectomy
Does obliteration of the pleural cavity cause appreciable functional consequences
No
However, obliteration of the pleural cavity may produce _ during exertion
Pain
Pleurodesis
Adherence of parietal and visceral pleura with an irritating powder or sclerosis agent
Why perform a pleurectomy and pleurodesis
Prevent recurring spontaneous secondary atelectasis caused by chronic pneumothorax or malignant effusion resulting from the lung disease
Thorascopy
Diagnostic or therapeutic, or to take biopsy , excise pathological formations , drainage, treatments
Procedure in which pleural cavity is examined with a thoracoscope
Where make an incision for a thoracoscopy
Small incision into he pleural cavity via 1- 3 intercostal spaces
During normal inspiration and expiration, the normally smooth and moist pleura makes no sound. During auscultation of someone with pleuritis (pleurisy), what is the case
Lung surfaces are rough. Resulting friction (pleural rub) is detectable with a stethescope
What do you hear during auscultation of an inflamed lung
Pleural rub
Sound like a clump of hairs being rolled between the fingers
Pleural adhesion
Parietal and visceral layers adhere
What causes pleural adhesion
Inflammation pleuritis
Signs of acute pleuritis
Sharp, stabbing pain, especially on exertion, ugh as climbing stairs, when the rate and depth of respiration maybe increased even slightly
What are some variations in lobes of the lung
Oblique or horizontal fissures may be incomplete or absent in some specimens , with consequent reductions in the number of lobes
An extra fissure could divide lung
Left lung sometimes has 3 lobes and right only 2
Accessory lobe
What is the most common accessory lung lobe
Azygos lobe , appears in the right lung in 1% of ppl
Where is an accessory azygos lobe
Superior to the hilum of the right lung, separated front he rest of the lung by a deep groove lodging the arch of the azygos vein .
What is the normal, healthy color of lungs
Light pink
Who has lungs that are dark and mottled and why
Adults who live in urban or agricultural areas, especially smokers bc of accumulation of carbon and dust particles in the air and irritants in tobacco that are inhaled
How do lungs remove carbon from gas exchanging surfaces and deposit it in the inactive ct which supports the lung, or lymph nodes receiving lymph from the lung
Lymph from he lungs carries special cells (phagocytes)
Why do we auscultation the lungs
Assess airflow through the tracheobronchial tree into the lobes of the lung
Why do we percuss the thorax
Tell whether tissues are air filled (resonant)
Filled with fluid(dull) or solid (flat sound
How do you auscultate the inferoposterior part of the inferior lobe (base of the lung)
Stethescope to the posterior thoracic wall at the level of the 10th thoracic vertebra
The __ main bronchus is wider and shorter and runs more vertically
Right
Aspirated foreign bodies are more likely to lodge in the branches of the __ bronchus
Right
Bronchoscope
An endoscope for inspecting the interior of the tracheobronchial tree
What is the carina
Ridge between the orifices of the right and left main bronchus
Why would the carina be distorted, widened posteriorly and immobile
If the tracheobronchial lymph nodes in the angle between the main bronchi re enlarged bc cancer have metastasized from a bronchogenic carcinoma
What are morphological changes int he carina seen during bronchoscope useful for
Differential diagnosis
The mucous membrane covering the carina is one of the most sensitive areas of the tracheobronchial tree and is associated with the ___ ____
Cough reflex
If someone aspirates a peanut and coughs, when does the coughing stop
When peanut passes carina
If the choking victim is inverted to use gravity to get the peanut out, why would they cough?
Lung secretions pass carina
Pneumonectomy
Remove whole lung
Lobectomy
Remove lobe
Segmentectomy
Remove bronchopulmonary segment
What does blockage of a segmental bronchus cause
Segmental atelectasis
Prevent air from reaching the bronchopulmonary segment it supplies , air in blocked segment will be gradually absorbed into the blood, the segment will collapse
In segmental atelectasis(volume loss) may initially cause what? Then what?
Mediastinal shift to the side of the atelectasis
But ipsilateral segments may expand to compensate for the reduced volume of the collapsed segment
Obstruction of a pulmonary artery by blood
Embolus
What causes a pulmonary artery embolus
Blood clot, fat globule, air bubble travels in the blood to the lungs from a. Leg vein (ex. After compound fracture)
Explain path of embolus starting in the leg
Leg vein to right side of heart to a lung through pulmonary artery
Pulmonary embolism
Embolism that blocks a pulmonary artery
Immediate result of PE
Partial of complete obstruction of blood flow to the lung
Results in lung or sector of lung to be ventilated with air but not perfumed with blood
What happens when a large embolus occluded a pulmonary artery
Acute respiratory distress bc major decrease in oxygenation of blood
Right heart may becomes dilated bc volume of blood arriving cant be pushed along (acute cor pulmonale)
Acute cor pulmonale
Right side of heart becomes dilated bc blood arriving cant be pushed through the pulmonary circuit
Acute respiratory distress from a large embolus can cause death in ____
Minutes
A medium size embolus may block an artery supplying a bronchopulmonary segment. What does this cause
Pulmonary infarct, an area of necrotic dead lung
Why is a PE less likely to cause infarction in a physically active person
Physically active people -a collateral circulation often exists and develops
Anastomoses with branches of the bronchial arteries abound in the region of the terminal bronchioles
Chronic congestion(ill ppl) and PE
In ill people with impaired circulation in the lung , PE results in infarction
What happens when an area of visceral pleura is also deprived of blood in
Inflamed (pleuritis) and irritates to become fused to the sensitive parietal pleura
Describe pain from the parietal pleura
Referred to the cutaneous distribution of the intercostal nerves to the thoracic wall or, in the case of inferior nerves, to the anterior abdominal wall
In pleural adhesion, the lymphatic vessels in the lung and visceral pleura may _____ with the parietal lymphatic vessels that drain into the axillary lymph nodes
Anastomoses
What do carbon particles in the axillary lymph nodes provide evidence for?
Pleural adhesion
Why does someone spit blood or blood stained sputum
Bronchial or pulmonary hemorrhage
In 95% of cases of spitting blood, the bleeding is from what?
Branches of the bronchial arteries
What is the most common cause of spitting blood
Bronchitis, lung cancer, pneumonia, tb, pulmonary embolism, bronchiectasis
What i the main cause of lung cancer
Cigarette smoke
Where do most lung cancers arise
Mucosa of the large bronchi and produce a persistent, productive cough or hemoptysis
Hemoptysis
Spitting blood
Early metastasis of lung cancer
Bronchopulmonary nodes
Common sites of lung cancer hematogenous metastasis
Brain, bones, lungs, suprarenal glands
Hematogenous spread of lung cancer
Tumor invade systemic circulation, then transported in pulmonary veins to the left heart, aorta, and these structures
What lymph nodes are enlarged whe bronchogenic carcinoma develops owing to metastasis of cancer cells from the tumor
Supraclavicular lymph nodes
Why were supraclavicular lymph nodes called sentinel nodes
Their enlargement alerted the physician to the possibility of malignant disease in the thoracic and or abdominal organs
What are sentinel nodes now
Node or nodes that first receive lymph draining from a cancer containing area, regardless of location following injection of dye or radioactive tracer
What may lung cancer involving the phrenic nerve cause
Paralysis of one half of the diaphragm (hemidiaphragm)
What nerve may be involved in apical lung cancer
Recurrent laryngeal nerve bc of its close relationship with the apex of the lung
Signs that there is recurrent laryngeal nerve involvement
Hoarseness owing to paralysis of a vocal fold (cord) bc the recurrent laryngeal nerve supplies all but one of the laryngeal nerves
Why is the visceral pleura insensitive to pain
Receives no nerves of general sensation
Why is parietal pleura EXTREMELY sensitive to pain
Richly supplied by branches of the intercostal and phrenic nerves
What is pain from pleura felt like
Projected to dermatology supplied by the same spinal (posterior root) ganglia and segments of the spinal rod
What kind of pain results from irrigation of the costal and peripheral parts of the diaphragmatic pleura
Local pain and referred pain to the dermatologist of the thoracic and abdominal walls
What kind of pain is felt with irritation of the mediastinal and central diaphragmatic areas of parietal pleura
Referred pain to the root of the neck and over the shoulder (C3-c5)
Why do a PA radiograph of the thorax
To examine respiratory, cardiovascular structures and thoracic wall
Why take a deep breath and hold when taking a PA radiograph of chest
Causes diaphragmatic domes to descend , filling the lungs with air (increasing radiolucency) and moving the inferior margins of the lungs into the costodiaphragmatic recess
How will you see pleural effusions on a PA chest radiograph
The inferior margins should appear as sharp acute angles
Pleural effusions accumulate here and do not allow the inferior margin to descend into the recess and the usual rediolucent air density is replaced by hazy radiopacity
How does lobar disease, such as pneumonia appear on a PA radiograph of chest
Localized, relatively radiodense areas that contrast with the radiolucency of the remainder of the lung
How is a PA radiograph viewed
As if facing the patient , an AP view
In older people costal cartilages May be calcified
Especially inferior cartilages
In the radiograph, inferior ribs are obscured by the ___
Diaphragm
In OA projections, the right and left domes of the diaphragm are separated by what
The central tendon, which is obscured by the heart
The __ dome of the diaphragm, is usually half an intercostal space higher than the __. Why
Right
Left
Liver on right
The areas obscured in PA projections are usually visible in lateral radiographs.
Yup
In a lateral projection, the middle and inferior thoracic vertebrae are visible, although they are partially obscured by the ___
Ribs
Can also see three parts of sternum
Lateral radiographs
Allow better viewing of a lesion of anomaly confined to one side of the thorax
In a lateral projection, both domes of the diaphragm are often visible as they arch superiorly from the sternum. A lateral radiograph is made using a lateral projection, with the side of the thorax against the film cassette or x ray detector and the upper limbs elevated over the head
Ok
Transverse thoracic plane
Divides superior and inferior mediastinum
Does the thoracic plane depend on gravity
No mainly in terms of bony body wall
The level of the viscera relative to the subdivision of the mediastinum depends on the position of the person(gravity). When a person is supine, the viscera are ___ relative to the subdivisions of the mediastinum than when. A person is upright
Higher
More superior
Gravity pulls the viscera__
Down
Anatomical descriptions traditionally describe the level of the viscera as if the person was ___
Supine
In the supine position: the arch of the aorta lies ___ to the transverse plane
Superior
In the supine position the bifurcation of the trachea is transacted by the __ ___ ___
Transverse thoracic plane
In the supine position: the central dtendon of th diaphragm lies at the level or what
Xiphisternal junctional and vertebra t9
When sitting upright: the arch of the aorta is ___ y the transverse thoracic plans
Transected
When sitting upright: the tracheal bifurcation lies ___ to the transverse thoracic plane
Inferior
When sitting upright: the central tendon of the diaphragm may fall to the level of the middle of what
The xiphoid process and t9-t10 IV discs
Why is all this important
Must know when doing radiological examinations in the erect and supine position.
When lying on side?
Mediastinum sags toward the lower side under the pull of gravity
Mediastinoscope
Endoscope, surgeons can see much of the mediastinum and conduct minor surgical procedures.
Where do surgeons insert a mediastinoscope
Small incision at the root of the neck, just superior to the jugular notch of the manubrium, into the potential space anterior to the trachea
What can you see from a mediastinoscope
View or biopsy mediastinal lymph nodes to determine if cancer calls have metasticized to them
Anterior thoracotomy
Mediastinum can also be explored and biopsies when remove part of a costsal cartilage
Widening of the mediastinum
After trauma, head on collision
Hemorrhage in mediastinum from lacerated vessels such as the aorta of SVC
What specific conditions widen the mediastinum
Malignant lymphomas
Hypertrophy of the heart (CHF)
What is the pericardial sinus
After pericardial sac is opened anteriorly, a finger can be passes through the transverse pericardial since posterior to the ascending aorta and pulmonary trunk
By passing a surgical clamp or a ligature around these large vessels, inserting the tubes of a corona bypass machine, and then tightening the ligature
Surgeons can stop or divert the circulation of blood in these arteries while performing cardiac surgery, such as coronary artery bypass
After ascending the entire thoracic part of the IVC is enclosed by _____ (2cm)
Pericardium
The __ __ must be opened to expose the terminal part of the IVC
Pericardial sac
Is the same true for the SVC
Yup
Pericarditis
Inflammation of the pericardium
What does pericarditis cause
Chest pain and makes the serous pericardium rough
Usually the smooth opposing layers of the serous pericardium make no detectable sound during auscultation.. what happens if there is pericarditis what happens
Friction of the roughened surface may sound like the rustle of silk upon auscultation over the left sternal border and upper ribs (pericardial friction rub)
A chronically inflamed and thickened pericardium may ____
Calcify
Does calcification effect cardiac efficiency
Yes
Pericardial effusion
Passage of fluid from pericardial capillaries into the pericardial cavityor an accumulation of pus
Result of pericardial effusion
Heart becomes compressed (unable to expand and fill fully) and ineffective
Noninflammatory pericardial effusions often occur with what
CHF
What does CHF cause
Venous blood returns to the heart at a rate that exceeds cardiac output, producing right cardiac hypertension
Describe the fibrous pericardium
Tough, inelastic closed sac that contains the heart , normally the only occupant other than a thin lubricating layer of pericardial fluid
If extensive pericardial effusion exists, the compromised volume of the sac does not allow full expansion of the heart, limiting what
The amount of blood the heart can receive, which in turn reduces cardiac output
Cardiac tamponade
Heart compression
Is potentially lethal condition bc heart volume is increasingly compromised by the fluid outside the heart but inside the pericardial cavity
Hemopericardium
Blood in the pericardial cavity
What does hemopericardium produce
Cardiac tamponade
What may cause hemopericardium
Perforation of a weakened area of heart muscle owing to a previous MI or heart attack, from bleeding into the pericardial cavity after cardiac operations or from stab wounds
Why is hemopericardium especially lethal
High pressure involved and the rapidity with with which the fluid accumulates
Heart is increasingly compressed and circulation. Fails
In cardiac tamponade, the veins of the neck and face become engorged because of the backup of blood, beginning where the SVC enters the pericardium
T
How may someone get a pneumopericardium
In patients with pneumothorax, air or gas in the pleural cavity, the air may dissect along CT planes and enter the pericardial sac
PeriCardiocentesis
Drainage of fluid fromt he pericardial cavity
Why may you need cardiocentesis
Receive cardiac tamponade
In pericardiocentesis, a wide bore needle may be inserted through the _ or _ intercostal space near the sternum
5, 6
This approach to the pericardial sac is possible because the cardiac notch on the _ lung and the shallowed notch in the leftpleural sac leave part of the pericardial sac exposed-the bare area of the pericardium
Left
The pericardial sac may also be reached via the xiphoid star angle by passing the needle _______
Superoposteriorly
Needle avoids the lung and pleura and enters the pericardial cavity…but take care not to puncture the internal thoracic artery of its terminal branches
In acute cardiac tamponade from hemopericardium, an emergency _____ may be performed so that the pericardial sac may be incised to immediately relieve the tamponade and establish stasis of the hemorrhage
Thoracotomy
Abnormal folding of the embryonic heart tube to the left instead of the right may cause the position of the heart to be completely ___.
Reversed
Dextrocardia
Apex misplaced to right instead of left
What is dextrocardia associated with
Mirror image positioning of the great vessels and arch of the aorta
Situs inversus
General transposition of the thoracic and abdominal viscera
Minimal accompanying cardiac defects and heart functions normally
Isolated dextrocardia
Transposition may affect only the heart
Congenital anomaly may be complicated b severe cardiac anomalies such as transposition of the great arteries
The usual pattern of branches of the arch of the aorta is present in __% of ppl
65
Variations in the origin of the branches of the arch are fairly common
Ok
In approximately 27% of people, the _ common carotid originates from the brachiocephalic trunk
Left
In 2.5 % of people a brachiocephalic trunk fails to form . What happens in these peopl
The four arteries, right and left common carotid and subclavian arteries originate independently from the arch of the aorta
In 5% of people the left vertebral artery originates from the arch of the ____
Aorta
In 1.2% of people both the right and left ____ __ originate from the arch
Brachiocephalic trunks
Retro-esophageal right subclavian artery
Sometimes arises as the last(most left) branch of the arch of the aorta .. it crosses posterior to the esophagus to reach the right upper limb
A retroesophageal right subclavian artery may compress the the ____, causing what
Esophagus, causing difficulty in swallowing (dysphagia)
Thyroid ima artery
Accessory artery may arise from the arch of the aorta or the brachiocephalic artery
The most superior part of the arch of the aorta is usually __ cm inferior to the superior border of the manubrium but it may be more superior or inferior
2.5 cm
Right arch of the aorta
Sometimes the arch curves over the root of the right lung and passes inferiorly on the right side,
In some cases
The abdominal arch after passing over the root of the right lung passes posterior to the esophagus to reach its usual position on the left side
Double arch of the aorta
Forms a vascular ring around the esophagus and trachea…may compress trachea and affect breathing
Surgery for double arch of the aorta
Surgical division of the vascular ring
The distal part of the ascending aorta receives a strong thrust of blood when the left ventricle contracts. Bc its wall is not yet reinforced by fibrous pericardium, an ___ may develop
Aneurysm
How do you recognize an aortic aneurysm on a MR angiogram or chest film
Enlarged area of the ascending aorta silhouette
How do patients with aneurysm of ascending aorta present
Chest pain that radiates to the back
Difficulty breathing
Why would an ascending aneurysm cause difficulty breathing
Aneurysm may exert pressure on the trachea , esophagus, and recurrent laryngeal nerve
Coarctationof the aorta
The arch of the aorta or thoracic aorta has an abnormal narrowing that diminishes the caliber of the aortic lumen, producing an obstruction to blood flow to the inferior part of the body
What is the most common site for coarctation
Near the ligamentum arteriosum
When the coarctation is inferior to the ligamentum arteriosum (postductal coarctation), what happens
A good collateral circulation usually develops between the proximal and distal party’s of the aorta through the intercostal and internal thoracic arteries
Is a postductal coarctation compatible with life
Yes bc the collateral circulation carries blood to the thoracic aorta inferior to the stenosis
In postductal coarctation can you see the collateral vessels superficially
Yea they can become so large that they cause notable pulsation in the intercostal spaces and erode the adjacent surfaces of the ribs, which is visible in radiographs of the thorax
What does the recurrent laryngeal nerve supply
All intrinsic muscles of the larynx, except one
What may injure the recurrent laryngeal nerve
Any investigative procedures, or disease processes in the superior mediastinum
What happens when injure recurrent laryngeal nerve
Affect voice difficulty swallowing
Explain the course of the left recurrent laryngeal nerve
Winds around the arch of the aorta and ascends between the trachea and esophagus
Due to the course of the recurrent laryngeal nerve it may be involved in what
A bronchiogenic or esophageal carcinoma , enlargement of mediastinal lymph nodes or an aneurysm of the arch of the aorta
What happens to recurrent laryngeal nerve if there is an aneurysm of the arch of the aorta
May be stretched
Why are the impressions produced in the esophagus by adjacent structures of clinical importance
The slower passage of substances at these sites
Impressions indicate where swallowed foreign objects are most likely to lodge and where a stricture may develop, for example after the accidental drinking of a caustic liquid such as lye
The thoracic duct is thin walled and usually dull white in living people. It may be ___ making it hard to identify
Colorless
What is the thoracic duct vulnerable to
Damage when doing investigative and or surgical procedures int he posterior mediastinum
Laceration of the thoracic duct
Lymph escapeinto the thoracic cavity
Lymph or chyle from the lacteals of the intestine may also enter the pleural cavity producing chylothorax
Chylothorax
Lymph and chyle from lacteals of intestine enter the pleural cavity
How can we remove lymph and chyle from thorax
Needle tap, thoracentesis, or tie off the thoracic duct
Why are variations of the thoracic duct common
Superior part of the duct represents the original left member of a pair of lymphatic vessels in the embryo. Sometimes two thoracic ducts are present for a short distance
The azygos, hemi-azygos, and accessory hemiazygos veins offer alternate means of venous drainage from the thoracic, abdominal and back regions when obstruction of the IVC occurs
In some people, an accessory azygos. Vein parallels the azygos vein on the right side
Other people have no hemiazygos vein on the right side
Sometimes the azygos system receives all the blood from the IVC except that from the liver…in these people the azygos system drains nearly all the blood inferior to the diaphragm , except from the digestive tract
Obstruction of the SVC superior to the trance of the azygos vein
Blood can drain inferiorly into the veins of the abdominal wall and return to the right atrium through the azygos venous system and the IVC
When is the thymus a prominent feature of the superior mediastinum
Infancy and childhood
In some infants, the thymus may compress the ___
Trachea
As puberty is reached, the thymus begins to ____
Diminish in size
By adulthood, what happens to the thymus
Replaced by adipose tissue and is often scarcely recognizable, however it continues to produce t lymphocytes
Aortic angiogram
Catheter is passed into the ascending aorta cia the femoral or brachial artery in the inguinal or elbow region, under fluoroscopic control the tip of the catheter is placed just in size the opening of a coronary artery
Aortic angiogram made by injecting radioopaque contrast material into the aorta and into openings of the arteries arising from the arch of the aorta
Cardiovascular shadow
Important bc changes in the shadow may indicate anomalies or functional disease
PA right border of the cardiovascular shadow
Right brachiocephalic vein, SVC, right atrium
PA left border of the cardiovascular shadow
Terminal part of the arch of the aorta, pulmonary trunk, left auricle and left ventricle
The left inferior part of the cardiovascular shadow presents the region of the __
Apex
The typical anatomical apex, if present, of often __ to the shadow of the diaphragm
Inferior
Three major cardiovascular shadows occur, depending on body habitus. What are they
Transverse type, oblique type, vertical type
Transverse type of CV shaddow
Obese people, pregnant and infants
Oblique type of CV shadow
Most people
Vertical type of CV shadow
Present in people with narrow chests
What radiology is commonly used to examine the thorax
CT MRI
Before CT are taken of the mediastinum, what is done
Injection of iodine contract . Breast cancer cells have an unusual affinity for iodine
CT is sometimes combined with mammography to examine the
Breasts
MRI is usually better for detecting and delineating soft tisssue lesions
Good for lymph nodes of the mediastinum of the mediastinum and roots of the lungs by means of both planar and reconstructed images
Transverse CT and MRI are always from what orientation
Physician at patients feet
Cardiac catheterization
Radioopaque catheter is inserted into a peripheral vein and passes under fluoroscopic control into the right atrium, right ventricle, pulmonary trunk and pulmonary arteries
What can we get from cardiac catheterization
Intracranial pressure
Blood samples may be taken
If radioopaque contrast medium is injected, can be followed through heart and great cellls
Cineradiography/cardiac ultrasonography
Can be performed to observe the flow of dye in real time. Permit the study of circulation through he functioning heart and are helpful in the study of congenital defects(like cardiac cath)
The right primordial atrium is represented int he adult by the __ ___
Right auricle
The definitive atrium is enlarged by incorporation of most of the embryonic ___ ___
Sinus venosus
The coronary sinus is also a derivative of this __ __
Venous sinus
The part of the venous sinus incorporated into the primordial atrium becomes the what
The smooth walled sinus venarum of the adult right atrium into which all the veins drain, including the coronary sinus
Crista terminalis
Line of fusion of the primordial atrium and the sinus venarum INTERNALLY
Sulcus terminalis
Line of fusion of the primordial atrium and the sinus venarum EXTERNALLY
Where is the SA node
Just in front of the opening of the SVC at the superior end of the crista terminalis
Before birth the valve of the IVC directs most of the oxygenated blood returning from the placenta in the umbilical vein and IVC toward the oval foramen in the interatrial septum throug which it passes into he left atrium
The oval foramen has a flap like valve that permits a right to left shunt of blood but prevents a left to right shunt
At birth when a baby takes its first breath the lungs expand with air and pressure in the right atrium falls below that in the left atrium
Consequently, the oval foramen closes for its first and last time and its valve usually fuses with the interatrial septum
The closed oval foramen is represented in the postnatal interatrial septum b the depressed oval fossa
The border of the oval fosssa surrounds the fossa
The floor of hte fossa is formed by the valve of the oval foramen
The rudimentary IVC valve, a semilunar crescent of tissue, has no function after birth .it varies considerably in size and is occasionally absent
Why is pain from an abscess or tumor int he popliteal fossa usually severe
The deep popliteal fascia is strong and limits expansion
Where do popliteal abscesses spread
Superiorly and inferiorly because of the toughness of the popliteal fascia
Why is it hard to feel te popliteal pulse
Bc the popliteal artery is deep
How do you palpate the popliteal pulse
Person in prone position with the knee flexed to relax the popliteal fascia and hamstrings
Feel in the inferior part of the fossa where the popliteal artery is related to the tibia
What is weakening or loss of the popliteal pulse a sign of
Femoral artery obstruction
Popliteal aneurysm
Dilation of all or part of the popliteal artery
What does popliteal aneurysm cause
Edema and pain in the popliteal fossa
How can you distinguish a popliteal aneurysm from other masses
Palpable pulsation (thrills) and abnormal arterial sounds (bruits) detectable with a stethoscope
The popliteal artery lies deep to the ___ nerve,
Tibial
A popliteal aneurysm may stretch the __ nerve or compress its blood supple (vasa varosum)
Tibial
If a popliteal aneurysm stretches the tibial nerve where do you feel pain?
Skin overlying the medial aspect of the calf, ankle, or foot
Fractures of the distal femur or dislocation of the knee may rupture the __ artery, resulting in ____
Popliteal
Hemorrhage
An injury to the poplitealartery and vein may cause what
Ateriovenous fistula
If the femoral artery must be ligated, blood can bypass the occlusion through the ___ anastomses and reach the popliteal artery distal to the ligation
Geniculate
Why is injur to the tibial nerve uncommon
Deep and protected position in the popliteal fossa
What may injure the tibial nerve
Deep lacerations
Posterior dislocation of the knee joint
What happens with severance of the tibial nerve
Produce paralysis of the flexor muscles int he leg and the intrinsic muscles in the sole of the foot
Unable to plantarflex their ankle or flex their toes
Loss of sensation on the sole of foot
The fascial compartments of the lower limbs are generally ___ spaces , ending proximally and distally at the joints
Closed
Bc the septa and deep fascia of the leg forming the boundaries of the leg compartments are strong, the increased volume consequent to infection with ____- increases compartmental pressure
Suppuration (pus formation)
Inflammations within the anterior and posterior compartments of the leg spread chiefly in a ___direction ; however a purulent infection int he lateral compartments of the leg can ___ proximally I tot he popliteal fossa, presumably along the course of the fibular nerve
Distal
Ascend
Fasciotomy
Incision of fascia may be necessary to relieve pressure and debride pockets of infection
Shin splints
Edema and pain in the area of the distal two thirds of the tibia-result from repetitive microtrauma of the tibialis anterior which causes small tears in the periosteum covering the shaft of the tibia and/or of fleshy attachments to the overlying deep fascia of the leg
Shin splints are a mild form of __ __ __
Anterior compartment syndrome
What causes shin splints
Traumatic injury or athletic overexertion of msucles in the anterior compartment, especially TA, by untrained persons
Often persons who lead ___ lives develop shin splints when they participates in long distance walks
Sedentary
Shin splints also occur in trained runners who do not do warm up or cool down. Why
Muscles in the anterior compartment swell from sudden overuse and the edema and muscle-tendon inflammation reduce the blood flow to muscles. The swollen muscles are painful and tender to pressure
The foot of humans are relatively exerted (probated) so that the soles lie more fully on the ground. What is this pronation a result of
Medial migration of the distal attachment of the fibular is longus across the sole of the foot and the development of a fibular is tertius that is attached to the base of the 5th metatarsal.
What is the most often injured nerve of the lower limb and why
Common fibular nerve
It is superficial
Winds subcutaneously around the fibular neck, leaving it vulnerable to direct trauma
The common fibular nerve may be injured when the __ joint is injured or dislocated
Knee
Severance of the common fibular nerve causes what
Flaccid paralysis of all muscles in the anterior and lateral compartments of the leg (dorsiflexors of ankle and evertors of foot)
The loss of dorsiflexion of the ankle causes ___
Footdrop
Footdrop makes the leg look
Too long (the toes don’t clear the ground)
What conditions may result in a lower limb that is too long, functionally (for example, pelvic tilt and spastic paralysis or contraction fo the soleus) what are the three means of compensating for this problem
- Waddling gait
- Swing outgait
3.high stepping steppage gait
Waddling gait
Individual leans to the side opposite the long limb, hiking the hip
Swing out gait
Long limb is swung out laterally (abducted) to allow the toes to clear the ground
High stepping steppage gait
Extra flexion is employed at the hip and knee to raise the foot as high as necessary to keep the toes from hitting the ground
Bc the dropped foot makes it difficult to make the heel strike the ground first as in a normal gait, a steppage gait is commonly employed int he case of flaccid paralysis
Sometimes an extra kick is added as the free limb swings forward in an attempt to flip the forefoot upward just before setting the foot down
The braking action normally produced by eccentric contraction of the dorsiflexors is also lost in flaccid paralysis foot drop
Therefore the foot is not lowered to the ground in a controlled manner after heel strike; instead the foot slaps the ground suddenly, producing a distinctive clop and greatly increasing the shock both received by the forefoot and transmitted up the tibia to the knee
Individuals with a common fibular nerve injury
May also experience a variable loss of sensation on the anterolateral aspect of the leg and the dorsomedial of the foot
Excessive use of the muscles supplied by the deep fibular nerve (skiing, running, dancing) may cause what
Deep fibular nerve entrapment
Muscle injury and edema in the anterior compartment..causing compression of the deep fibular nerve and pain in the anterior compartment
Compression of the deep fibular nerve by tight fitting ski boots for example, may occur where the nerve passes deep to what
Inferior extensor retinaculum and extensor hallucis brevis
Where does pain occur with a deep fibular nerve entrapment
Dorsum of the foot and radiates to the wed space between the 1st and 2nd toes
Ski boot syndrome
Deep fibular nerve entrapment often caused by ski boots
Who also gets deep fibular nerve entrapment and why
Soccer players and runners and can also result from tight shoes
Chronic ankle sprains may produce recurrent stretching of the _____ ____ nerve
Superficial fibular
What may entrapment of the superficial fibular nerve cause
Pain along the lateral side of the leg and the dorsum of the ankle and foot . Also numbness and paresthesia with increases in activity
Fabella
Close to its proximal attachment the lateral hear of the gastrocnemius may contain a sesamoid bone
What does the fabella articulate with
Lateral femoral condyle
What percent of people have a fabella
3-5%`
Calcaneal tendinitis
Inflammation of the calcaneal tendon
Calcaneal tendinitis constitutes what percent of running injuries
9-18%
Microscopic tears of collagen fibers in the tendon, particularly just superior to its attachment to the calcaneus results in ___,
Tendinitis
Pain of calcaneal tendinitis
Pain during walking especially when wearing rigid soled shoes
Calcaneal tendinitis often occurs during ___ activities..especially what
Repetitive
People who take up running after prolonged inactivity or suddenly increasing training intensity
OR POOR FOOTWEAR
Who gets rupture of the calcaneal tendon
Poorly conditioned people with a history of calcaneal tendinitis
How is the rupture of calcaneal tendon experienced
An audible snap during a forceful push off (plantarflexion with the knee extended) followed immediately by sudden calf pain and sudden dorsiflexion of the plantarflexed foot
In a completelyruptured calcaneal tendon, what is palpable
Gap 1-5 cm proximal to the calcaneal attachment
What muscles are affected by a ruptured calcaneal tendon
Gastrocnemius, soleus, and plantaris
Calcaneal tendon rupture is probably the most severe acute muscular problem of the leg. How are they effected
Can’t plantarflex against resistance and passive dorsiflexion is excessive
Ambulatory is possible only when the limb is laterally rotated, rolling over the transversely placed foot during the stance phase without push off
Ok
With rupture calcaneal tendon where is bruising and where is there a lump
In the malleolar region and a lump usually appears in the calf owing to shortening of the triceps surae
The ankle jerk reflex/triceps surae reflex, is a — tendon reflex
Calcaneal
The calcaneal reflex tests the _ and _ nerve roots
S1 s2
What happens if s1 nerve root is injured or compressed
Ankle reflex is virtually absent
If the muscles of the calf are paralyzed, the calcaneal tendon is ruptured, or normal push off can still be accomplished by the actions of what
The gluteus Maximus and hamstrings in extending the knee
Bc the push off from the forefoot is not possible, those attempting to walk in the absence of plantarflexion often rotate the foot as far ____ as possible during the stance phase to disable passive dorsiflexion and allow a more effective push off through hip and knee extension exerted at the midfoot
Laterally
What is the gastrocnemius strain from
Partial tearing of the medial belly of the gastrocnemius at or neat its musculotendinous junction
Who gets gastrocnemius strain
People over 40
What causes gastrocnemius strain
Overstretching the muscle by concomitant full extension of the knee and dorsiflexion of the ankle joint.
How do patients present with gastrocnemius strain
Abrupt onset of stabbing pain is followed by edema and spasm of the gastrocnemius
Calcaneal bursitis (retro-achilles bursitis) results from what
Inflammation of the deep bursa of the calcaneal tendon located between the calcaneal tendon and the superior part of the posterior surface of the calcaneus
Presentation of calcaneal bursitis
Causes pain posterior to the heel and occurs commonly during long-distance running , basketball, and tennis
Caused by excessive friction on the bursa as the tendon continuously slides over it
How does blood return from the leg
A venous plexus deep to the triceps surae is involved in the return of blood from the lef
When a person is standing, what does venous return from the leg depend on
Muscular activity of the triceps surae
How does muscle move superiorly when standing
Musculovenous pump Contraction of the calf muscles pumps blood superiorly in the deep veins
The musculovenous pump is improved by what
The deep fascia that invests the muscles like an elastic stocking
What percent of people have an accessory soleus
3%
Where is an accessory soleus
As a distal belly medial to the calcaneal tendon
Clinical problem of accessory soleus
Associated with pain and edema (swelling) during prolonged exercise
Where do you palpate the posterior tibial pulse
Between the posterior surface of the medial malleolus and the medial border of the calcaneal tendon
Why is it important to have the patient invert their foot what taking a posterior tibial pulse
The posterior tibial artery passes deep to the flexor retinaculum
If don’t invert the foot and try to take the posterior tibial pulse
May think its absent!
Why are both posterior tibial arteries palpated for pulse at the same time
Idk
Occlusive peripheral artery disease
Should measure posterior tibial pulse
Sign is absence of posterior tibial pulse in people over 60
In the normal population how many people don’t have a posterior tibial pulse
15%
Intermittent claudation
Leg pain and cramps, develops during walking and siappears after rest
May result in ischemia of the leg msucles caused by narrowing or occlusion of the leg arteries
