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Clinical Anatomy Tute Questions > Week 3 - finished > Flashcards

Week 3 - finished Flashcards

1
Q
  1. Name the parts of a typical rib.
A
  • The rib head
    o With superior and inferior demi-facets for artic with bodies of vertebrae.
  • The neck
  • The tubercle (CT joint)
  • The body or shaft of the rib is thin, flat and curved
  • The rib angle is the most prominent part, posteriorly, and the point at which the rib curves anteriorly. Is where fracture is most likely to occur.
  • The costal groove is found in the inferior border and protects the intercostal nerve and
    vessels.
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2
Q
  1. List the true, false, and floating ribs. Explain why they are so named.
A

True Ribs
o R1-7
o Costal cartilages attach directly to the sternum

False Ribs
o R8-10
o They articulate with the sternum via the costal cartilages of the rib above

Floating ribs
o R11-12
o Do not attach to the sternum at all.

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3
Q
  1. List the articulations of the ribs and describe the varying kinematics at each.
A

Costal vertebral joint (CV)
o Rib head with the demifacets on the posterolateral aspects of adjacent vertebral bodies and the IVD between them.
o The crest of the head is attached to the IVD by the intraarticular (or interosseous) ligament. This ligament is within the joint and divides it into two synovial cavities
o Typical rib articulates with the same vertebrae and vertebrae ABOVE. Ie rib is named for the inferior vertebrae.

Costotransverse Joints (CT)
   o Plane synovial joints
   o Formed between the tubercle of the typical rib and the facet on the tip of the
transverse process (TP) of the corresponding vertebra.
The costochondral (CC) joints are formed between the cup-shaped end of the rib and the
costal cartilage. These joints are synchondroses surrounded by periosteum.
The chondrosternal (CS) joints are formed between the anterior portion of the costal
cartilage of ribs one to seven and the articular notches of the sternum. The first CS joint
is a synchondrosis . The remaining CS joints are synovial.
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4
Q
  1. With which vertebrae do ribs 1, 8 and 10 articulate?
A

Rib 1:
T1

Rib 8:
T7 and T8

Rib 10:
T10 only

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5
Q
  1. Rib motion may be described as ‘bucket handle’, ‘pump handle’ or calliper. Which ribs demonstrate which types of movements? Why does this difference occur?
A

Pump Handle. The upper ribs (R1-6) elevate during
inspiration, increasing the diameter of the thoracic
cage in an anterior-posterior direction.

Bucket handle. The lower ribs elevate and move
more laterally, increase the diameter of thoracic
cage transversely (laterally)

Calliper. Ribs 11 and 12. Due to no articulation
with the sternum

  • It is generally proposed that the axis of rib motion
    is a line running through the centre of the CV and CT joints.
  • In the upper ribs, the orientation of this axis is largely in the coronal plane.
  • Lower in the thoracic spine, the TPs are angled posteriorly, so the axis lies in a more frontal plane.
  • This change in orientation of the axis of motion causes differences in the motion available in upper compared to lower ribs.
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6
Q
  1. How does costal cartilage change with age?
A

In young = soft, less likely to absorb force, more prone to visceral injury.

In the elderly = all interchondral joints tend to become fibrous and fuse. They may also become brittle and calcify reducing the overall elasticity off the thoracic cage.

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7
Q
  1. List the attachments of the abdominal diaphragm
A

Origin:
Continuous sheet, which can be split into three parts.
Sternal Part: 2 Muscular slips that attach to the xiphoid process

Costal Part: Wide muscular slips that attach to the internal surfaces of the inferior 6 ribs and their costal cartilages.

Lumbar Part: Crura from bodies L1-3 (together giving median arcute ligament. + Medial and lateral arcuate ligs to TP’s and R12.

Insertion:
Central Tendon, that resembles a three leaf clover

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8
Q
  1. Usually each phrenic nerve supplies one hemidiaphragm exclusively, but right and left phrenic nerves are not identical. Describe the path of each phrenic nerve through the thorax to its insertion into the diaphragm.
A

Phrenic nerves originate from C3-5 nerve roots and form at the lateral border of anterior scalene at the level of the superior border of the thyroid cartilage.
It descends obliquely with the IJV across anterior scalene, deep to the prevertebral fascia.
Enters the superior mediastinum between subclavian artery and brachiocephalic (subclavian) vein.
They pass anterior to the roots of the lungs.

  • Right phrenic nerve
    o The right phrenic nerve passes along the right side of the brachiocephalic vein and vena cava and pericardium over the right atrium.
    o It descends on the right of the IVC to the diaphragm.
  • Left phrenic nerve
    o The left descends between the left subclavian and common carotid arteries.
    o It crosses the left surface of the arch of the aorta, anterior to the left vagus.
    o It descends over the root of the lung, runs along the fibrous pericardium, superficial to the left heart and reaches the diaphragm.
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9
Q
  1. The phrenic nerve carries motor supply to the diaphragm. It also carries sensory fibres. What do these sensory fibres innervate?
A

Supplies sensory fibres to:

  • The pericardium
  • The mediastinal pleura.
  • The medial part of diaphragm
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10
Q
  1. List the origin, insertion, action and nerve supply of the external intercostal muscles.
A

Origin:
Inferior border of ribs. Fibers run: infero-anteriorly (hands in pockets, fingers down) Anteriorly muscle fibers are replaced by aponeurosis (at costal cartilage).

Insertion:
Superior border of ribs.

Innervation:
Intercostal nerves

Action:
Elevates ribs during forced inspiration.

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11
Q
  1. List the origin, insertion, action and nerve supply of the internal intercostal muscles.
A

Origin:
Inferior border of ribs. Fibers run: infero-posterior (hands on hips, fingers down) Posteriorly the muscle fibres are replaced by an aponeurosis (At back not front, opposite of external).

Insertion:
Superior border of ribs.

Innervation:
Intercostal nerves

Action:
Inter-chondrol: elevator of the ribs (between cartliage)
Interosseous: Depressor. (b/w bone) Important for preperception

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12
Q
  1. List the muscles of inspiration.
A 
Diaphragm
Intercostals (Internal, external, innermost)
Scalenes (Anterior, Middle, Posterior)
SCM
Pec Major and Minor
Subclavius
(Abdominals, TA, IO, EO, RA, forced expiration)
(QL, stabilises diaphragm)
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13
Q
  1. Which muscles are used in quiet respiration, and which ones are used in forced respiration?
A

Quiet respiration:

  • External intercostals
  • Diaphragm
  • Levator costarum

Forced respiration:

  • Scalenes (Anterior, Middle, Posterior)
  • SCM
  • Pec Major and Minor
  • Subclavius
  • (Abdominals, TA, IO, EO, RA, forced expiration)
  • (QL, stabilises diaphragm)
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14
Q

Doris has continued to experience pain over the past 6 weeks. It is now dull and intermittent in nature. It is unaffected by respiration but more prominent when lying in bed at night.
Case history reveals a long history of indigestion and asthma, for which she uses pulmicort and ventolin. She has been hospitalised on a handful of occasions for protracted bouts of asthma but is unsure what medications she was given.

A

xx

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15
Q
  1. Which muscles could be responsible for lateral chest wall pain?
A
  • Intercostals
  • Serratus anterior
  • Diaphragm
  • Lat dorsi
  • EO and IO
  • Pec minor
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16
Q
  1. Why is radiculopathy unusual in the thoracic spine?
A

Because the intervertebral foramen is much larger and the exiting thoracic spinal nerves are much smaller, so even if there is something encroaching on the intervertebral foramen there will be no compression of the exiting nerve root.

17
Q
  1. List the contents of the intercostal spaces. How are these contents arranged?
A

Intercostal Vein, artery and nerve (in this order, sup to inf, VAN)

Sheltered in the costal groove of the
rib above.

From posterior, the nerves run between the parietal pleura and the internal intercostal membrane. Near the angles of the ribs they pass between innermost and internal intercostals.

18
Q
  1. Why is this patient at risk of compression fracture of the vertebral body?
A

55 year old woman. Post-menopausal osteoporosis (affects spongy bone)
o Generally over 60 yo.

Pulmicort= preventer= corticosteroid, therefore risk of bone weakening, with long standing use.

Indigestion: Possible if bad enough, not eating as much, poor nutrition (esp: Ca and Vit D for this case)

Other risk factors:
  o Caucasian/ Asian
  o Caffiene
  o Genetics
  o Seizure medication
  o Anti-depresants
  o Lifestyle (WB exercise etc)
  o Endocrine

If three of these, significant increased risk.

19
Q
  1. How does bone density change with increasing age?
A

Peak bone mass is achieved in the 20’s, after this it starts to decrease. This is related to sex hormones.

20
Q
  1. What factors other than age and drug use may influence bone density?
A
  • Sedentary lifestyle (WB needed for bone growth)
  • Insufficient Ca, phosphate or Vit D
    o Underweight, eating disorders.
  • Smoking, excess caffeine or alcohol
  • Hormone levels (ie menopause)
  • Anti-depressents (eg. chronic pain suffers)
  • Secondary causes: cancer, COPD, renal failure, endocrine disease (thyroid, pth etc), liver disease, RA etc)
    o Think about anyone who does more tissue damage then expected.
21
Q
  1. Which ribs are most commonly fractured? Where is the rib most commonly fractured?
A
  • The middle ribs are the ones most commonly fractured.
    o The most commonly fractured ribs are the 7th and 10th
  • The weakest part of a rib is just anterior to its angle, but a fracture can occur anywhere.
22
Q
  1. What complications may be associated with single rib fractures? The usual treatment for a fracture is to immobilise it. Would you immobilise a single rib fracture?
A

Complications:
- Splenic or abdominal injuries (with fractures of any ribs 7-12)
- Pneumothorax
- Hemothorax
- Cylithorax (lymph fluid)
- Pulmonary laceration
- If lower ribs, diaphragmatic herniation
- Rare:
o Aortic, subclavian, cardiac or brachial plexus injuries (Only if R1 or 2 fractured, can happen with high speed deceleration)

Treatment:
o Not much they can do.
o Manual treatment
o Elastic rib

23
Q
  1. In severe trauma it is possible to break more than one rib in more than one place. This is called a flail chest. How does a flail chest influence respiratory effort and function?
A

The flail segment moves in the opposite direction as the rest of the chest wall.
This so-called “paradoxical motion” can increase the work and pain involved in breathing.
The “flail” segment, doesn’t move with the rest of the chest wall.

24
Q
  1. To which regions can the different parts of the pleura refer pain?
A

Visceral pleura is virtually insensitive to pain. (just fyi, nerve supply is same as lungs, pulmonary plexuses, these contain parasympathetic fibres from the vagus nerve and
sympathetic fibres from the sympathetic trunks. )

o CAN GET REFERAL FROM SYMPATHETICS= T1-6

Parietal plura is pain sensitive and takes its nerve supply from the intercostals and phrenic nerves.
o Can cause local pain
o And pain referred to the associated dermatomes (thoracic/abdo wall or neck/shoulder)

Referred pain never crosses the midline.

25
Q

What is the viscerosomatic reflex?

A

Visceral dysfunction causing changes in the musculoskeletal system, via its neural innervations.

“Visceral disturbances often cause increased musculoskeletal tension in the somatic structures innervated from the corresponding spinal level through viscerosomatic reflexes.”
(Ward, p.563)

Sympathetic phenomena

26
Q
  1. Describe the anatomy of the sympathetic nervous system in the thoracic region.
A
  • The pre-ganglionic cell bodies of the sympathetic nervous system are only found in the lateral horn (intermediolateral cell column) found in the spinal cord from T1 to L2(3).
  • The post-ganglionic cell bodies are found in the paravertebral ganglia forming the sympathetic trunks extending from cranium to coccyx and the prevertebral ganglia found in plexuses surrounding the major branches of the abdominal aorta (celiac ganglia, mesenteric ganglia).
  • Presynaptic fibres exit through the IVF to T1-L2 with the anterior rami of the nerve root then pass to the sympathetic trunks through white rami communicans.
27
Q
  1. What visceral structures can refer pain to the T6 region?
A 
Pain referrals:
T1 - 4: The head and neck
T1 - 6: The heart and lungs.
  o Heart T1-4
  o Pericardium
T5 - 9: All upper abdominal viscera: stomach, duodenum, liver, gallbladder, pancreas and
spleen.
T10 - 11: The remainder of the small intestines, right colon, upper ½ of ureters and gonads.
T10-L1: Kidneys
T12 - L2: Left colon, lower ½ of ureters, bladder, prostate, uterus, genitalia
T2-8: Upper extremity
  o Sweat glands etc?
T11-L2: Lower extremity
Therefore:
Pleura
Pericardium
Stomach
Duodenum
Anything forgut derived (stomach, duodenum, spleen, celiac arteries supply the foregut, anything via the celiac trunk T1-T6, liver, gall bladder, pancreas)
28
Q
  1. What structures form the tunnel through which the

neurovascular bundle of the upper extremity pass?

A

Thoracic outlet has 4 parts:

Sternocostovertebral space

  • Rib 1 and T1
  • Sternum

Scalane triangle

  • Anterior and middle scalene
  • Rib 1

Costoclavicular space
- Clavicle and R1+2

Coracopectoral space
- Pec minor and coracoid process w/ R1+2

Clinical Anatomy Tute Questions (12 decks)

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