100 must important GA conceptions - 1 File Download

Dr. Mavrych, MD, PhD, DSc [email protected]

100 must important GA conceptions

Dr. Mavrych, MD, PhD, DSc

Dr. Bolgova, MD, PhD

Understand first, then memorize and apply


l Dear students, you can use this presentation like a guide during your

preparing for GA exams.

l It does NOT cover all material of the Gross Anatomy course.

l To complete GA material you should work with ALL professor�s

presentations.

l Good Luck and All the best!

Dr. Mavrych


1. Lumbar puncture (tap) and

Epidural anesthesial When lumbar puncture is

performed, the needle enters the subarachnoidspace to extract cerebrospinal fluid (CSF) or to inject anesthetic to epidural space.

l The needle is usually inserted between L3/L4 or L4/L5. Level of horizontal line through upper points of iliac crests.

l Remember, the spinal cord may ends as low as L2 in adults and does end at L3 in children and dural sac extends caudally to level of S2.



l Patients typically have history of back pain that may radiate down to the lower limb.

l Herniation of disc usually occurs in lumbar (L4/L5 orL5/S1) or cervical regions (C5/C6 or C6/C7) of individuals younger than age 50.

l Herniated lumbar disc usually compreses the nerve root one number below: traversing root (e.g., the herniation L4/L5 will compress L5 root).

l The pain begins soon after patient lifted some heavy thing.

l Lower limb reflexes are decreased on the affected side

2. Herniated IV disc


3. Abnormal curvatures of the

spine

l Kyphosis is an exaggeration of

the thoracic curvature that may

occur in elderly persons as a result

of osteoporosis (multiply

compression fracture of vertebral

bodies) or disk degeneration.

l Lordosis is an exaggeration of the

lumbar curvature that may be

temporary and occurs as a result

of pregnancy, spondylolisthesis

or potbelly.

l Scoliosis is a complex lateral

deviation, or torsion, that is

caused by poliomyelitis, a leg-

length discrepancy, or hip disease.

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adults

kidseen L3/L4

L4/L5. kids

When lumbar puncture unctu is performed, the needle enters the subarachnoidspace to extract cerebrospinal fluid (CS(CSF) or to inject anesthetic to epidural space.

Spinal cord ends L2: Conus Medullaris

End Dura Sac S2: Cauda Equina w/ Filum terminale

8 cervical SN (above)

12 thoracic SN

5 lumbar SN

5 Sacral SNs

1 coccygeal SN

(below body)

12

34 5

6*5

7

dura matter 7subdural space 8Arachnoid matter 9

10*10*

434

12

Arachnoid matter 9subdural space 8spacdura mattersubd

Conus medullaris

Cauda Equina w/ FT

back pain that may radiate down to the lower limb.

curs in lums in lumbar () or cervical regions

compreses the nerve root one number below:

Anterior longitudinal ligament protects 9-3oclock around vertebral bodyPosterior longitudinal ligament protects 6oclock vertebral archherniations are typically posterior laterally (4-5 or 7-8oclock)

ALL

PLL

osteoporosis

Lordosis is ais an exaggeration of the

lumbar curvature th

Kyphosis is anKyphosis is an exaggeration of

the thoracic curvature ththe thoracic cu

temporary an

of pregnancy, spondylolisthesis

or potbelly.

Degenerative osteoarthritis:

Spondylosis: immobility or fusion of vertebral joints

Spondylolysis: degeneration of articulating part of vertebrae

Spondylolisthesis: forward displacement of vertebrae

Lamina= front smooth of arches

Pedicles= attachment of bodies to arches

Processes= protuberances and "attachments" (articular=restricts movement, spinous &

transverse muscle attachment & movement)

facets= attachments of other vertebrae or bones

Body=large part where attachment of intervertebral disc (gelatinous nucleus pulposus,

peripheral anulus fibrosus)

Scoliosis is a cis a complex lateral

deviation, or torsion, th

d by poliomyelitis, a leg-

length discrepancy, or hip disease.

Leg lengths:

short bone:

Coxa Vara

<100deg

Long bone:

Coxa Valga

>130deg


4. Upper limb fractures:

Humerus fractures

Sites of potential injury to major

nerves in fractures of the humerus:

1. Axillary nerve and posterior

humeral circumflex artery at the

surgical neck.

2. Radial nerve and profunda brachii

artery at midshaft. Midshaft

fracture affect origin of brachialis

muscle.

3. Brachial artery and median nerve

at the supracondylar region.

4. Ulnar nerve at the medial

epicondyle.


Fracture of distal radius:

l Transverse fracture within the distal 2 cm of

the radius. Most common fracture of the

forearm (after 50).

l Smith's fracture results from a fall or a blow

on the dorsal aspect of the flexed wrist

and produces a ventral angulation of the

wrist. The distal fragment of the radius is

ANTERIORLY displaced.

l Colles' fracture results from forced

extension of the hand, usually as a result of

trying to ease a fall by outstretching the

upper limb. Distal fragment is displaced

DORSALLY - �dinner fork deformity�.

Often the ulnar styloid process is avulced

(broken off)


Scaphoid fracture

l Occurs as a result of a fall onto the palm when the hand is abducted

l Pain occurs primarily on the lateral side of the wrist, especially during wrist extension and abduction

l Scaphoid fracture may not show on X-ray films for 2 to 3 weeks, but a deep tenderness will be present in the anatomical snuffbox.

l The proximal fragment may undergo avascular necrosisbecause the blood supply is interrupted.


Boxer�s fracture

l Necks of the metacarpal

bones are frequently

fractured during fistfights.

l Typically, fractures of 2d and

3d metacarpals are seen in

professional boxers, and

fractures of 5th and sometimes

4th metacarpals are seen in

unskilled fighters.


Mallet or Baseball Finger

l This deformity results from the DIP joint suddenly

being forced into extreme flexion (hyperflexion)

when, for example, a baseball is miscaught or a

finger is jammed into the base pad.

l These actions avulse the attachment of the

extensor digitorum tendon to the base of the

distal phalanx. As a result, the person cannot

extend the DIP joint. The resultant deformity bears

some resemblance to a mallet.


5. Rotator cuff muscles � SITS

l Support the shoulder joint by

forming a musculotendinous

rotator cuff around it

l Reinforces joint on all sides

except inferiorly, where

dislocation is most likely

Rotator cuff muscles are:

l Supraspinatus

l Infraspinatus

l Teres minor

l SubscapularisRight humerus


Quadrangular Space: teres major, teresminor, long head biceps brachii, humerus

deep

Posterior between triceps brachii

cubital fossa

ulnar epicondylar grooveposteriorly and medial toolecranon

surgical neck.

midshaft. M

origin of brachialis Posterior

originoriginbetween

origin of bracorigin of bratriceps

f brachialis f brachialis brachii

ialis ialis

muscle.

origPosterior

origorigorigPosterior

origorig

supracondylar region.

medial

epicondyle.

ure of distal radius:

Smith's fracture

dorsal aspect of thof the flexed wrist

Colles' fracture from forced

extension of thof the hand, u

Scaphoid fracture

t of a fall onto the palm

Pain occurs primarily on the lateral side of thof the wrist,

deep tenderness will bwill be present in the anatomical snuffbox.

avascular necrosis

Extension & abduction of wrist

proximal carpal fracture

deep radial artery could be compromised

Necks of the metacarpal

bones

2dally, fractures of and

3d metacarpals are seen in

professional boxers, aners, and

5thfractures of and sometimes

4th metacarpals are seen in

unskilled fighters.

Brawler's Fracture

Boxer's Fracture

Mallet or Baseball Finger

the DIP joint su

ion (hyperflexion)

extensor digsor digitorum tendon tosor digitorum

Forced Flexion of DIP

Supraspinatus l

Infraspinatus l

Teres minor l

SubscapularislRight humerus

Initiate Abduction, Suprasacular n

Lat rotation, Suprascapcular n

Lat rotation, Axillary n

Med. rotation, Upper & Lower

Subscapular ns


6. Abduction of the upper limb

l (0°-15°) Abduction of the upper extremity is initiated by the supraspinatus muscle (suprascapularnerve).

l (15°-110º) Further abduction to the horizontal position is a function of the deltoid muscle (axillary nerve).

l (110°-180°) Raising the extremity above the horizontal position requires scapular rotation by action of the trapezius (accessory nerve CNXI) and serratus anterior (long thoracic nerve).


Subacromial bursitis &

Tearing of supraspinatus tendon

l Subacromial bursitis (inflammation of

the subacromial bursa) is often due to

calcific supraspinatus tendinitis,

causing a painful arc of abduction.

l The same symptoms will be in case of

inflammation or trauma of the

supraspinatus tendon (MRI !torn!

tendon)


7. Three Elbows: Student's elbow(Subcutaneous olecranon bursitis)

l The olecranon, to which the triceps tendon attaches distally, is easily palpated. It is separated from the skin by only the olecranon bursa,which allow the mobility of the overlying skin.

l Repeated excessive pressure and

friction may cause this bursa to

become inflamed, producing a

friction subcutaneous olecranon

bursitis.


Tennis elbow

(Lateral epicondylitis)

l Lateral epicondylitis: repeated forceful flexion and extension of the wrist resulting strain attachment of common extensor tendon andinflammation of periosteum of lateral epicondyle. Pain felt overlateral epicondyle and radiates down posterior aspect of forearm. Pain often felt when opening a door or lifting a glass

l Origins of following muscles may be affected:

1. Extensor Carpi Radialis Longus & Brevis

2. Extensor Digitorum

3. Extensor Digiti Minimi

4. Extensor Carpi Ulnaris


Golfer�s elbow

(Medial epicondylitis)

l Medial epicondylitis is

inflammation of the common

flexor tendon of the wrist

where it originates on the

medial epicondyle of the

humerus.

l Origins of following muscles may be affected:

1. Pronator Teres

2. Flexor Carpi Radialis

3. Palmaris Longus

4. Flexor Carpi Ulnaris


8. Arterial anastomoses

around the scapula

l Blockage of the Subclavian or Axillary artery can be bypassed by anastomoses between branches of the Thyrocervical and Subscapular arteries:

l Transverse cervical

l Suprascapular

l Subscapular

l Circumflex scapular


supraspinatus muscle ((suprascapularnerve).

(0°-15°)

(15°-110º)

deltoid muscle ((axillary nerve).

(110°-180°)

trapezius ((accessory nerve CNXI) and serratus anterior ((long thoracic nerve).

6. Abduction of the upper limbSubacromial bursitis &

Tearing of supraspinatus tendon

calcific supraspinatus tendinitis,

causing a painful arc of abduction.

inflammation or trauma of

Supraspinatus tendon is most commonly ruptured.

ws: Student's elbow(Subcutaneous olecranon bursitis)

The olecranon, to which the triceps tendon attaches d

olecranon bursa,

Repeated excessive pressure and

friction m this bursa to

become inflamed, p

Tennis elbow

(Lateral epicondylitis)

forceful flexion and extension of the wrist resulting strain attachment of common extensor tendon andinflammation of periosteum of lateral epicondyle. Pain felt overlateral epicondyle and radiates down posterior asrior aspect of forearm.

Extensor Carpi Radialis Longus & Brevis

Extensor Digitorum2.

Extensor Digiti Minimi3.

Extensor Carpi Ulnaris4.

1.1.

Golfer�s elbow

(Medial epicondylitis)

Medial epicondylitis is

inflammation of the common

flexor tendon

Pronator Teres

Flexor Carpi Radialis2.

Palmaris Longus3.

Flexor Carpi Ulnaris4.

1.

Extends and abducts

the hand

Extends and adducts

the hand

Extends fingers and wrist

Radial n

Pronates forearm

Flexes and abducts wrist

flexes wrist

flexes and adducts WristUlnar n

(Median n)

Blockage of the Subclavian or Axillary artery by anastomoses between branches of the Thyrocervical and Subscapular artearteries:

off subscapular

off thyrocervical trunk

Suprascapular a above the Transverse Superior

Scapular Ligament anastamoses with the

Circumflex Scapular a from the triangular space

(Teres major/minor and long head biceps brachii)


9. Cubital fossal Contents from lateral to medial:

1. Biceps brachii tendon

2. Brachial artery

3. Median nerve

l Subcutaneos structures from lateral to

medial:

1. Cephalic vein

2. Median cubital vein: joins cephalic and basilic veins

3. Basilic vein

l Sites of venipuncture is usually median cubital vein because:l Overlies bicipital aponeurosis, so deep

structures protected

l Not accompanied by nerves


10. Carpal Tunnel Syndrome

l Results from a lesion that reduces the size of the carpal tunnel (fluid retention, infection, dislocation of lunate bone)

l Median nerve � most sensitive structure in the carpal tunnel and is the most affected

l Clinical manifestations: l Pins and needles or anesthesia

of the lateral 3.5 digits

l palm sensation is not affected because superficial palmar cutaneous branch passes superficially to carpal tunnel

l Apehand deformity - absent of OPPOSITION


11. Test of the proximal and

distal interphalangeal joints

l PIP � FDS

l DID - FDP


12. Lesion of UL nerves

Upper Brachial Palsy

l Injury of upper roots and trunk

l Usually results from excessive increase in the angle between the neck and the shoulder stretching or tearing of the superior parts of the brachial plexus (C5 and C6 roots or superior trunk)

l May occur as birth injury from forceful pulling on infant's head during difficult delivery


Upper Brachial Palsy (Erb-Duchenne palsy)

· In all cases, paralysis of the muscles of the

shoulder and arm supplied by C5 and C6 spinal

nerves (roots) of the upper trunk.

· Combination lesions of axillary, suprascapular

and musculocutaneous nerves with loss of the

shoulder mm and anterior arm.

· As result patient has �waiter�s tip� hand:

· adducted shoulder

· medially rotated arm

· extended elbow

· loss of sensation in the lateral aspect of the

upper limb


Lower Brachial Palsy

(Klumpke paralysis)

l Injury of lower roots and

trunk

l May occur when the upper

limb is suddenly pulled

superiorly: stretching or

tearing of the inferior parts

of the brachial plexus (C8

and T1 roots or inferior

trunk)

l E.g., grabbing support

during falling from height

or as a birth injury, or

TOS � thoracic outlet

syndrome


9. Cubital fossa Anterior Elbow joint

MEDIALLATERAL

Biceps Brachii m (flex and supinate forearm)

O: Longhead supraglenoid tubercle, Shorthead

coracoid process)

I: to Radial Tuberosity

1. Biceps brachii tendon

2. Brachial artery

3. Median nerve

Cephalic vein1.

Median cubital vein: jo: joins cephalic 2.

and basilic veins

Basilic vein3.

s of venipuncture is median cubital vein

Venous blood is darker/purpleish and flows passively

Arterial blood is cherry red and has a pulse

10. Carpal Tunnel Syndrome

reduces the sithe size of the carpal tunnel (f

Median nerve �

Cubital Tunnel Syndrome: Compression of ulnar epicondylar groove via tendon of Flexor

Carpi Ulnaris, Ulnar n is compressed: Claw hand and weakened adduction of wrist

Recurrent Median n to Thenar ms are affected

Clinical manifestations: Pins and needles or anesthesia l

of the lateral 3.5 digits

palm sensation is not affected l

because superficial palmar cutaneous branch passes superficially to carpal tunnel

Apehand deformity - absent l

of OPPOSITION

ULNAR TUNNEL SYNDROME: Compression at the wrist between pisiform and hook of hamate

carpal bones causes hypoesthesia of medial 1.5 fingers and weakened instrinsic ms (Partial Claw

hand bc flexors of forearm are unaffected)

Proximal Interphalangeal joint

Flexor Digitorum Superficialis

Median n

Distal Interphalangeal Joint

DIPS- Flexor Digitorum Profundus

Ulnar and Median ns

DIP

stal interphalangeal joints

MCPs- Lumbricals

Metacarpal phalangeal joint

Injury of upper roots and trunk

increase in the angle between theen the neck and the shoulder str

xus (C5 and C6 roots ooots or superior trunk)

Birth injury or Fall causes

Superior Trunk Damage:

Erb's Palsy

(Erb-Duchenne palsy)

C5 and C6 spinal

nerves (roots) of the upper trunk.

�waiter�s tip�

adducted shoulder·

medially rotated arm·

extended elbow· Wrist flexed

Axillary C5-C6

Musculocutaenous C5-7

Median C6-T1

Inferior Trunk damage C8-T1

xus (C8

and T1 roots or inferior

trunk)

the upper

limb is suddenly pulled

superiorly: str

grabbing support

during falling from height

or as a birth injury, or

TOS � thoracic ouacic outlet

syndrome

Full hand paralysis (open extended hand), ulnar and

median n damage, thumb is extended bc radial n still good


Lower Brachial Palsy

(Klumpke paralysis)

l All intrinsic muscles of the handsupplied by the C8 and T1 roots of the lower trunk affected.

l Combination lesions of ulnarnerve (�claw hand�) and mediannerve (�ape hand�)

l Loss of sensation in the medial aspect of the upper limb and medial 1,5 fingers.

l May include a Horner syndrome


Injury to musculocutaneous

nerve

l Usually results from lesions of lateral cord

l Greatly weakens flexion of elbow (biceps and brachialis muscles) and supination of forearm (biceps muscle)

l May be accompanied by anesthesia over lateralaspect of forearm


Cutaneous innervation

of the hand

Dorsum: 1,5-U and 3,5 R Palm: 1,5-U and 3,5 M

In reality, in case of superficial branch of

radial nerve lesion it will be skin deficit

between 1 & 2 digits on the dorsum of the

hand ONLY because of nerve overlapping


13. Cardiac catheterization

l The femoral artery is used for cardiac catheterization

l It can be cannulated for left cardiac angiography & also for visualizing the coronary arteries � a long, slender catheter is inserted percutaneously and passed up the external iliac artery, common iliac artery, aorta, to the left ventricle of the heart


14. Injury of the gluteal region

Fractures of Femoral Neck

l A common fracture in elderly women with osteoporosis is fracture ofthe femoral neck.

l Fractures of the femoral neck cause shortness and lateral rotation of the lower limb.

l Fractures of the femoral neck often disrupt the blood supply to the head of the femur.

l At present time the best way in case of femoral neck fracture is hip replacement.


Avascular necrosis

of femoral head

l Transcervical fracture disrupts blood supply to the head of the femur via retinacular arteries (from medial circumflex femoral artery) and may cause avascular necrosis of the femoral head if blood supply through the ligament to the head is inadequate.


Ulnar and Median Nerve Lesions

s of ulnarnerve (�claw hand�) a and mediannerve (�ape hand�)

Median n lesion: Ape hand/benediction with lateral 3 digits are extended, wrist is extended

Ulnar n lesion: Claw hand with medial 2 digits extended

Radial n lesion: Drop Wrist with flexion of the wrist

Injury to musculocutaneous

nerve

flexion(bi(biceps and brachialis

muscles) and supination of forearm (bi(biceps muscle)

Greatly we of atly weakens flexion of (bielbow (bi(bi(biceps a(bi(biceps a

of lateral cord

Lateral musculocutaneous n of forearm

weakened adduction (coracobrachialis m)

superficial branch of

radial nerve leerve lesion it will be skin deficit

between 1 & 2 digits on the dorsum of the

hand O

Cutaneous innervation

of the hand

femoral artery is used for cardiac catheterization

for left cardiac angiography & also for visualizing the coronary arteries �

A catheter can also be passed through a peripheral vein (femoral vein) into IVC, the

R atrium, R ventricle, pulm trunk and pulm arteries. Intracardiac pressures, blood

samples, and visualization of great vessels using Xray

13. Cardiac catheterization

(femoral vein)

the gluteal region

Fractures of Femoral Neck

use shortness and lateral rotation

Coxa Vara <100deg

Fractures of neck and head of femur will disrupt the cruciate anastamosis that includes the medial circumflex

femoral a & ascending and transverse lateral circumflex femoral aa with Retinacular branches that anastamose

with the acetabular branch of obturator a within Ligamentum Teres


Injury to sciatic nerve

l Weakened hip extension and knee flexion

l Footdrop (lack of dorsiflexion)

l Flail foot (lack of both dorsiflexion and plantar flexion)

l Cause of injury:caused by improperly placed gluteal injections but may result from posterior hip dislocation


Posterior hip dislocations

l They are most common. A head-on

collision that causes the knee to

strike the dashboard may dislocate

the hip when the femoral head is

forced out of the acetabulum.

l The joint capsule ruptures inferiorly

and posteriorly (fracture of ishium),

allowing the femoral head to pass

through the tear in the capsule

(tearing of ishiofemoral lig.) and

over the posterior margin of the

acetabulum onto the lateral surface

of the ilium, shortening and

medial rotating the limb.


Superior gluteal

nerve injuryl The superior gluteal nerve

may be injured during surgery, posterior dislocation of the hip or poliomyelitis.

l Paralysis of the gluteus medius and gluteus minimusmuscles occurs so that the ability to pull the pelvis up and abduction of the thigh are lost.

Trendelenburg sign:

l If the superior gluteal nerve on the right side is injured, the left pelvis falls downward when the patient raises the left foot off the ground.

l Note that side is contralateral to the nerve injury.

Right

superior

gluteal nerve

injury

Normal


Injury to inferior gluteal nerve

l Weakened hip extension(gluteus maximus), most noticeable when climbing stairs or standing from a seated position

l Cause of injury: posterior hip dislocation, surgery in this region


Injury of obturator

nerve

l Difficulty adducting thigh

(e.g., crossing legs while

sitting)

l Decreased sensation

over upper medial thigh

l Cause of injury: anterior

hip dislocation, radical

retropubic prostatectomia


l Avulsion fractures occur where muscles are attached - ischial tuberosities

Hamstrings muscles:

1. Biceps femoris

2. Semitendinosus

3. Semimembranosus

l Action: extension of hip joint and flexion of knee joint

l Nerve supply � Tibial nerve (short head of biceps femoris is supplied by the common fibularnerve)

15. Avulsion fractures

of the hip bone and

hamstrings muscles


Injury to sciatic nerve

Cause of injury:

& Piriformis syndrome: Trucker's

who sit all day piriformis m

compress n, numbness and tingling

to the affected side.

Gluteal injections should be done with palm over

greater trochanter, pinky on ASIS and middle finger on

mid axillary line, thumb point posteriorly, the V between

middle and ring finger is site of injection.

Posterior hip dislocations

n. A head-on

collision th the knee to

strike the dashboard may dislocate

the hip when the femoral head is

forced out of the acetabulum.

congenital dislocations are more common in females > males

The joint capsule ruptures inferiorly

and posteriorly (f

Posterior dislocations can damage the sciatic n.

(tearing of ishiofemoral lig.)

shortening and

medial rotatinganterior

pubofemoral lig

may also tear

bc it is weakest

Trendelenburg sign:

superior gluteal nerve on

Paralysis of thof the gluteus medius and gand gluteus minimus

Superior gluteal

nerve injurypossibly also due to Piriformis syndrome

Patient stands and raises

L leg, if the L leg drops, it

is standing right leg nerve

injury

Injury to inferior gluteal nerve

hip extension(gluteus maximus),

Inferior gluteal n passes through inferior

piriformis fossa with the sciatic n,

posterior femorial cutaneous n, Superior

gluteal a & v, pudendal n, and internal

pudendal a & v

passes through superior piriformis fossa w/ inferior gluteal a & v

Injury of obturator

nerve

ulty adducting thigh

Decreased sensation

over upper medial thigh

Difficulty adducting thulty adducting th

anterior

hip dislocation, ra

passes through obturator

canal that is covered by

obturator membrane in

obturator foramenAffects Obturator externus, Adductor longus,

brevis, magnus (paritally), pectineus, gracilis

lateral rotation weakness and poor adduction

15. Avulsion fractures

of the hip bone and

hamstrings muscles

tearing off

Hamstrings muscles:

ed - ischial tuberosities

(long head)

Pseudohamstrings: Adductor Magnus (obturator & tibal ns), Biceps femoris ms (tibial &

common peroneal ns)

extension of hiof hip joint and flexion of knee joint

Tibial nerve (sh

Waddleing Gait (lateral leg swing/drag)


16. Structures under inguinal

ligament:

l From lateral to medial side:

l Iliopsoas muscle

l Femoral nerve

l Femoral artery

l Femoral vein

l Femoral canal


Femoral hernia

l A femoral hernia passes below

inguinal ligament through the femoral

ring into the femoral canal to form a

swelling in the upper thigh inferior and

lateral to the pubic tubercle

l The hernial sac may protrude through

the saphenous hiatus into the

superficial fascia

l A femoral hernia occurs more

frequently in females and is dangerous

because the hernial sac may become

strangulated

l An aberrant obturator artery is

vulnerable during surgical repair

Inguinal lig.


17. Knee joint injuries:

Unhappy triad

l Because the lateral side of the knee is struck more often (e.g., in a football tackle), the tibial collateral ligament is the most frequently torn ligament at the knee.

l The unhappy triad of athletic knee injuries involves:

1. Tibial collateral ligament

2. Medial meniscus

3. Anterior cruciate ligament


Tibial collateral ligament

(medial collateral ligament)

l Broad flat band

extending from medial

epicondyle of femur to

medial condyle and

shaft of tibia

l Blends with capsule and

firmly attaches to

medial meniscus

l Limits extension and

abduction of leg at

knee


Fibular collateral ligament

(lateral collateral ligament)

l Rounded cord between

lateral epicondyle of femur

and head of fibula

l Does NOT blend with joint

capsule and does NOT

attach to lateral meniscus

l Limits extension and

adduction of leg at knee


Rupture of the

cruciate ligaments

l With rupture of the anterior cruciate ligament, the tibia can be pulled forward excessively on the femur, exhibiting anterior drawer sign.

l In the less common rupture of the posterior cruciate ligament, the tibia can be pushed backward excessively on the femur, exhibiting posterior drawer sign.


Femoral Triangle: Superior inguinal ligament, Medially adductor longus m,

laterally sartorius m, it lies on top of pectinius m and iliopsoas ms

Inguinal lig serves as flexor retinaculum. Psoas m and Femoral n pass from pelvis

to anterior thigh, External iliac becomes femoral vessels

The inguinal canal runs perpendicular to the femoral canal

Deep inguinal lymph nodes

& great saphenous v br

w/ circumflexes &perforating br

Sartorius m

Adductor magnus m

FAFV

FN A femoral hernia passes below

inguinal ligament through thugh the femoral

ring into thinto the femoral canal to form a

swelling in the upper thigh inferior and

lateral to the pubic tubercle

in females

An aberrant obturator artery

Laceration of the Femoral a can be compensated by the perforating branch of femoral aand the lateral superior genicular a that anastamoses with the descending lateralfemoral circumflex a.Femoral v ligation can be compensated via the great saphenous v

17. Knee joint injuries:

Unhappy triad


Medial meniscus2.

Anterior cruciate ligament3.

Tibial co1.

MCL, MM, ACL tears

the lateral side of the knee is struck more often

tibial collateral ligament is the most frequently torn ligament at the knee.


(medial collateral ligament)

medial

epicondyle of femur to

medial condyle and

shaft of tibia

Limits extension and

abduction of leg at

knee

Fibular collateral ligament

(lateral collateral ligament)

lateral epicondyle of femur

and head of fibula

Does NOT blend with joint

capsule and does NOT

attach to lateral meniscus

Limits extension ansion and

adduction of leg at knat knee

mly attaches to

medial meniscus

Rupture of the

cruciate ligaments

anterior drawer sign.

the anterior cruciate ligament,

posterior cruciate ligament,

posterior drawer sign.

drawer sign is movement of the leg inopposition of the femur 5mm

Loop of bowel gets pulled downward into femoral canal, aberrant obturator a offexternal iliac would cross bowel and becomes vulnerable


Prepatellar bursa

Suprapatellar bursa

l Prepatellar bursa: between

superficial surface of patella

and skin. May become

inflamed and swollen

(prepatellar bursitis).

l Suprapatellar bursa: superior

extension of synovial cavity

between distal end of femur

and quadriceps muscle and

tendon. Usual place for intra-

articular injections. May

become inflamed and swollen

(suprapatellar bursitis).


Knee jerk reflex

l The patellar reflex is tested by tapping the patellar ligament with a reflex hammer to elicit extension at the knee joint. Both afferent and efferent limbs of the reflex arch arein the femoral nerve (L2-L4).

l Knee jerk reflex:tests spinal nerves L2-L4.


18. Ankle joint injuries:

Ankle sprains

l Sprains are the most common ankle injuries

l A sprained ankle is nearly always an inversion injury, involving twisting of the weight-bearing plantarflexed foot.

l The lateral ligament (anterior talofibular ligament) is injured because it is much weaker than the medial ligament.

l In severe sprains, the lateral malleolus of the fibula may be fractured.


Pott�s fracture

l It is fracture-dislocations of the ankle joint

l Reason - forced eversion(abduction) of the foot

l The Deltoid ligament avulses the medial malleolus and after that fibula fractures at a higher level

Pott's fracture


Ankle jerk reflex

l Achilles tendon reflex is

tested by tapping the

calcaneal tendon to elicit

plantar flexion at the ankle

joint.

l Both afferent and efferent

limbs of the reflex arc are

carried in the tibial nerve

(S1, S2).

l Ankle jerk reflex: tests

spinal nerves S1-S2.


19. Injures of the leg and foot:

Fracture of the fibular neckl May cause an injury to the common

peroneal nerve, which winds laterally around the neck of the fibula.

l This injury results in paralysis of all muscles in the anterior and lateralcompartments of the leg(dorsiflexors and evertors of the foot) and loosing sensation on the dorsum of the foot.

l Causing foot drop.


Prepatellar bursa

Suprapatellar bursa

Prepatellar bursa:

e of patella

Suprapatellar bursa: superior

extension of synovial cavity

between distal end of femur

and quadriceps muscle anscle and

tendon. e for intra-

articular injections.

Posterior to Rectus femoris mand vastis intermedialis m

articularisgenu m

Knee jerk reflex

femoral nerve (L2-L4).

Rectus femoris m

Ankle sprains

inversion injury,

Sprains are thare the most common ankle injuries

The lateral ligament (anterior talofibular ligament) is inis injured

In severe sprains, the lateral of thmalleolus of thof the fibula may be

fractured.

Pott�s fracture

eversion(abduction) of the foot

Deltoid ligament avulses the medial malleolus and aand after that fibula fractures at aat a higher level

Eversion injury is Deltoid ligament at medial malleolus

Ankle jerk reflexCalcaneous Tendon Reflex

plantar flexion at th

tibial nerve

(S1, S2).

Fracture of the fibular neckcommon

peroneal neral nerve, w

paralysis of alof all muscles in the anterior and lateralcompartments of thof the leg(dorsiflexors and evertors of the foot) and loosing sensation on the dorsum of the foot.

Causing foot drop.l

Flexors take over (Plantar flexion)


Rupture of the Achilles tendon

and Triceps surae muscle

l Avulsion or rupture of the calcaneal

(Achilles) tendon disables the triceps

sure muscle (gastrocnemius & soleus)

so that the patient cannot plantar flex

the foot.

Triceps surae muscle:

l 2 Heads of Gastrocnemius m.

l 1 Head - Soleus muscle

l Plantaris

l small fusiform belly with long thin tendon;

l sometimes may become hypertrophy


Plantar Fasciitis (calcaneal spur)

l Plantar fasciitis is the

most common hindfoot

problem in runners. It

causes pain on the

plantar surface of the

foot and heel.

l Point tenderness is

located at the proximal

attachment of the plantar

aponeurosis to the

medial tubercle of the

calcaneus and on the

medial surface of this

bone.


20. Injury of tibial nerve

l In popliteal fossa: loss of plantar flexion of foot (mainly gastrocnernius and soleusmuscles) and weakenedinversion (tibialis posterior muscle), causing calcaneovalgus.

l Inability to stand on toes

l Loss of sensation and paralysis of intrinsic muscles of the sole of the foot

l Popliteal fossa from superficial to

deep, contains:

l Tibial nerve

l Popliteal vein

l Popliteal artery


On soil of the foot there are two terminal

branches of tibial n:

l Medial plantar nerve supplies:

1. Abductor hallucis,

2. Flexor hallucis brevis

3. Flexor digitorum brevis

4. 1st lumbrical muscles

l skin of medial 3.5 digits

l Lateral plantar nerve supplies:

l All intrinsic plantar muscles which

are not innervated by medial plantar

nerve

l skin of lateral 1.5 digits


21. Breast:

Carcinoma of the Breast

l Carcinomas of the breast are malignant tumors, usually adenocarcinomas arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules

l 1. It enlarges, attaches to suspensory(Cooper�s) ligaments, and produces shortening of the ligaments, causing depression or dimplingof the overlying skin.


Lymphatic drainage

of the breast

l It is important because of its role in the metastasis of cancer cells.

l Most lymph (> 75%), especially from the lateral breast quadrants, drains to the axillary lymphnodes, initially to the anterior (pectoral) nodes for the most part.

l Most of the remaining lymph, particularly from the medial breast quadrants, drains to the parasternal lymph nodes or to the opposite breast.

75% 25%


Rupture of the Achilles tendon

and Triceps surae muscle

cle (gastrocnemius & soleus)

tient cannot plantar flex

Triceps surae muscle:

2 Heads of Gastrocnemius m.l

1 Head - Soleus musclel

Plantaris l

Plantar Fasciitis (c

pain on the

plantar surface

t the proximal

attachment of the plantar

aponeurosis

Injury of tibial nerve

In popliteal fossa:

calcaneovalgus.

Inability to stand on toesInabilitInabilit

sole of the foot

Femoral vessels after passing through adductor haitus/Hunter's canal, Sartorius canal, to become popliteal vessels

Popliteal Fossa is bordered by Semitendinosus, Semimembranosus, Bicepsfemoris, and quadracepts (gastronemius, plantaris, and soleus ms)

Common Fibular/Common Peroneal n does not pass in poplitealfossa, instead it goes around neck of fibula

Medial plantar nerve

Lateral plantar nerve

SOLE OF FOOT TIBAL n BRANCHES

Adductor hallucis (oblique & transverseheads), Quadratus Plantae, Flexor Digitiminimi, abductor digiti minimi, DABs,PADs, lateral 3 lumbricals

21. Breast:

Carcinoma o

t are malignant tumors, usually adenocarcinomas arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules

1. It enlarges, attaches to suspensory(Cooper�s) ligaments, and produces shortening of the ligaments, cants, causing

plingdepression or dimplingof the overlying skin.

Suspensory/Cooper's lig sround the lobules of mammary glands.

Lymphatic drainage

of the breast

metastasis of cancer cells.

Most lymph (> 75%), especially from the lateral breast quadrants, drains to the axillary lymphnodes,

the remaining lymph, particularly from the medial breast quadrants, drains to the parasternal lymph nodes or to the opposite breast.

Lymph from breast->Interpectoral "Rotter's" lymph nodes -> axillary lymph nodes->clavicular nodes-> R lymphatic duct or L Thoracic duct -> subclavian vs ->brachiocephalic vs -> SVC-> heartRotter's nodes are a way breast cancer can metastasize by bypassing axillary nodes

$$Million dollar space: Retromammary space behind Pect Major or betweenfat pad and Pect Major for insertion of breast implants


Mastectomy

l Radical mastectomy, a more extensive surgical procedure, involves removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region.

1. During a radical mastectomy, the long thoracic

nerve may be lesioned during ligation of the lateral

thoracic artery. A few weeks after surgery, the

female may present with a winged scapula and

weakness in abduction of the arm above 90°

because serratus anterior m. paralysis.

2. The intercostobrachial nerve may also be

damaged during mastectomy, resulting in skin

deficit of the medial arm.


Breast infection

l Mastitis is an infection of the tissue

of the breast that occurs most

frequently during the time of

breastfeeding (1 to 3months after the

delivery of a baby).

l This infection causes pain, swelling,

redness, and increased temperature

of the breast.

l It can occur when bacteria, often from

the baby's mouth, enter a milk duct

through a crack in the nipple.

l It can occur in women who have not

recently delivered as well as in women

after menopause.


22. Thoracic wall & Diaphragm:

Intercostal spaces

Intercostal blood vessels and nerves:

l run between the internal intercostal and innermost intercostal muscles in the costal groove

l arranged from superior to inferior as vein, artery, nerve

l Most vulnerablestructures � intercostal nerve and posterior intercostal artery because they are not covering by ribs.


Diaphragm:

Paralysis of half and ruptures

l Paralysis of the half of the Diaphragm may result from injury or operative division of the phrenic nerve of same side

l It can be detected radiologically.

l Paradoxical movement: dome of diaphragm of injured side pushed superiorly by abdominal viscera during inspiration instead of descending


Phrenic nerve

l Arises from the anterior branches C3-C5 nerves and lies in front of the anterior scalene muscle.

l Runs anterior to the root of the lung, whereas the vagus nerve runs posterior to the root of the lung.

l Innervates the fibrous pericardium, the mediastinal and diaphragmatic pleurae(sensory innervation), and the diaphragm for motorand its central tendon for sensory.


Diaphragmatic ruptures

l Diaphragmatic injuries are

relatively rare and result from

either blunt trauma or

penetrating trauma.

l Presently, 80-90% of blunt

diaphragmatic ruptures result

from motor vehicle crashes.

l The majority (80-90%) of blunt

diaphragmatic ruptures have

occurred on the left side.

l Blunt trauma typically produces

large radial tears measuring 5-15

cm, most often at the

posterolateral aspect of the

diaphragm.


Mastectomy

lves removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region.

winged scapula and

weakness in abduction of the arm above 90°

because serratus anterior m. paralysis.

, the long thoracic

nerve may bemay be lesioned d

intercostobrachial nerve may amay also be

damaged during mastectomy, resulting in skin

deficit of the medial arm. T2 intercostal n branch givessensation to skin of axilla andmedial cutaneous arm

Mastitis is anis an infection of the tissue

of the breast th

breastfeeding

This infection causes pain, swelling,

redness, and increased temperature

of the breast.

hen bacteria, often from

the baby's mouth, enter a milk duct

Intercostal spaces

run between the internal intercostal and innermost intercostal muscles in the costal groove

rom superior to inferior as vein, artery, nerve

Skin->Fascia->Fat->External Intercostal m \\ //->Internal Intercostals // \\-> Intercostal VAN-->Innermost Intercostals == -> Fascia -> Parietal Pleura-->

Thoracocentesis: Ribs 9-10 (9th intercostal space), above rib avoid VAN, remove fluid inpleural cavityPericardiocenetesis: Left 5-6th intercostal space near sternum, Infrasternal (xiphoid) angle upto left shoulder for Cardiac Tamponade due to Pleural effusion

Diaphragm:

Paralysis of the half of the Diaphragm

the phrenic nerve

Paradoxical movement:

of injured side pushed superiorly by abdominal viscera during inspiration instead of descending

dome of diaphragm of in of injured side pushed superiorly

C3, 4, 5 keeps the Diaphragm alive!

Phrenic nerve

rom the anterior branches C3-C5 nerves and lies in front of the anterior scalene muscle.

Runs anterior to the root of the lung, w, whereas the vagus nerve runs posterior to the root of the lung.

Innervates the fibrous pericardium, the mediastinal and diaphragmatic pleurae(sensory innervation), and the diaphragm for motorand its central tendon for sensory.

I ate 10 eggs at noon! Vessels entering the diaphragmInferior vena cava T8Esophagus T10Aorta T12

Diaphragmatic ruptures

blunt trauma or

penetrating trauma.

motor vehicle cracrashes.

left sidleft side.

posterolateral aspect of thof the

diaphragm.

Bochdalek Hernia: common hernia on the posterolateral L side of diaphragm,fatal congenital hernia that causes pulmonary hypoplasia.Morgangi Hernia: rare hernia on anteromedial R side of diaphragm, not fatal bcmusculature typically creates spincterSliding hernia: Stomach slides up through diaphragm bc of short esophagusRolling/paraesophageal hernia stomach slides up next to esophagus

Flail Chest: One or more broken ribs in two separate placesupon inspiration the broken area will sink in as chest wall moves outupon expiration the broken area will push out as chest wall moves inDangerous bc lungs can be punctured


23. Cardiac hypertrophy

l Left atrial enlargement

(hypertrophy) secondary to

mitral valve failure may

compress on the

esophagus and manifest

as dysphagia (difficulty in

swallowing).

l It may be observed as a

filling defect in the

esophagus by barium

swallow on the lateral

thoracic X-Ray


Cardiac Shadow

Right border is formed by:

1. SVC,

2. Right atrium

Left border is formed by:

1. Aortic arch

2. Pulmonary trunk

3. Left auricle

4. Left ventricle

P-A projection


24. Auscultation of Heart

Valves

Right 2 ICS

PSL

Left 5 ICS

MCL

Left 4 ICS

PSL

Left 2 ICS

PSL


Auscultation sites for

mitral and aortic murmurs

A heart murmur is heard downstream from the valve:

l stenosis is orthograde direction from valve

l insufficiency is retrograde direction from valve


25. Conducting System

of the Heartl Sinoatrial (SA) node

l site where contraction of heart muscle is initiated (pacemaker of the heart)

l situated in the upper part of the sulcus terminalis just near to the opening of the SVC

l Atrioventricular (AV) node

l the AV node receives impulses from the SA node; situated in the lower part of the atrial septum near coronary sinus

l Atrioventricular bundle of His

l descends from the AV node to the membranous portion of the ventricular septum where it divides into the left and right bundle branches

l Right bundle branch � passes down to reach the moderator band - right ventricle

l left bundle branch � passes down left side of ventricular septum


26. Blood supply of the Heart:

Right coronary artery (RCA)

l It supplies major parts of the rightatrium and the right ventricle.

l It anastomoses with the marginal branch of the left coronary artery posteriorly

Branches:

1. Anterior cardiac branches �supplies the right atrium

2. Nodal branch � supplies the (1) SAnode, (2) AV node

3. Marginal artery � supplies the right ventricle

4. Posterior interventricular artery �supplies (1) diafragmatic (inferior) surface of both ventricles and (2) posterior 1/3 of the IV septum


23. Cardiac hypertrophy

Left atrial enlargement

(hypertrophy) secondary to

mitral valve failure may

compress on thon the

esophagus and mand manifest

as dysphagia (d

mitral valve failure/tenting keepscauses mitral regurgitation into Latrium during systole, pressuredilates the LA as well asdecreases BP causing heart towork harder to pump blood toaorta resulting in hypertrophy

Right border is fois formed by:

1. SVC,

2. Right atrium

Left border is fois formed by:

1. Aortic arch

2. Pulmonary trunk

3. Left auricle

4. Left ventricle

VALVE ANAT. LOCATION AUSCULTATION SITE• P 3rd CC 2nd LT ICS• A 3rd ICS 2nd RT ICS• M 4th CC cardiac apex (5th Lt ICS MCL)• T 4th ICS Rt inferior most ST (5th RT ICS)• (3344) (2255)

24. Auscultation of Heart

ValvesAuscultation sites for

mitral and aortic murmurs

regurgitation

Stenosis RegurgiationAortic Systole (HOOT Dub) Aortic Diastole (Lub hoot)Pulm Systole (HOOT Dub) Pulm Diastole (Lub hoot)Tricuspid Diastole (Lub hoot) Tricuspid Systole (hoot Dub)Mitral Diastole (Lub hoot) Mitral Systole (hoot Dub)

25. Conducting System

of the HeartSinoatrial (SA) node

the upper part of the sulcus terminalis ju

Atrioventricular (AV) node

Triangle of Koch: Location of AV node in R AtriaValve of coronary sinus (Thebesian) & IVC (Valve of Eustice) meetto form tendon of todaro, which joins the Septal leaflet of Tricuspid valve

Crista Terminalis separatespectinate muscles w/ sinusvenarum

Atrioventricular bundle of His

descends from the AV node to the l

membranous portion of the ventricular septum where it divides into the left and right bundle branches

Right bundle branch � pa� passes down to moderator band - right reach the

ventricle

left bundle bl dle branch � padle b � passes down left side of ventricular septum

Septomarginal trabeculae

Purkinje Fibers throughout walls of ventriclesstimulate contractile cells

26. Blood supply of the Heart:

Right coronary artery (RCA)

Anterior cardiac branches �supplies the right atrium

Nodal branch � su� supplies the (1) SAnode, (2) AV node

Marginal artery � su� supplies the right ventricle

Posterior interventricular artery �supplies (1) diafragmatic (inferior) surface of both ventricles and (2and (2) posterior 1/3 of the IV septum

Small cardiac vein

Middle cardiac vein


Left coronary artery

(LCA)

Branches:

1. Anterior (descending)

interventricular artery � most

common place of MI descends in the

anterior interventricular sulcus and

provides branches to the (1) anterior

heard wall, (2) anterior 2/3 of IV

septum, (3) bundle of His, and (4)

apex of the heart.

2. Circumflex artery � winds around the

left margin of the heart in the

atrioventricular groove to anastomose

with the right coronary artery

posteriorly; supplies the left atrium

and left ventricle


Blood supply of the conducting

system

l SA node � RCA

l AV node � RCA

l AV bundle (and moderator band)- LCA


27. Congenital cardiac defects:

Atrial Septal Defect (ASD)l It is less frequent than

VSD

l It results from failure to close of the foramen ovale after birth (failure of the septum primum and septum secundum to fuse)

l Postnatally, ASDs result in left-to-right shunting(between right and left atrium) and are non-cyanotic conditions.

l If it is small, has no clinical significance & if large - necessary surgical repair


Ventricular Septal

Defect (VSD)

l Ventricular septal defect (VSD) is the most common of the congenital heart defects

l It may be found in the membranous part of the ventricular septum and results from failure to fuse of the membranous portion with the muscular portion of the ventricular septum

l In this case, present left�to-right shunt (right ventricular hypertrophy (RVH)) and again non-cyanotic.

l Necessary surgery for large defects


Patent Ductus Arteriosus (PDA)

l It results from failure of the ductus arteriosus (a connection between the pulmonary trunk and aorta) to constrict and close after birth.

l Prostaglandin E and low O2 tension sustain patency of the ductus arteriosus in the fetal period.

l PDA is common in premature infants and in cases of maternal rubella infection.

l Left �to-right shunt increased pressure in pulmonary circulation (pulmonary hypertension) and is non-cyanotic

l Treatment: surgical division and ligationimperative. In great danger is left recurrent nerve (wrapping aorta arch). Injure of this nerve results in hoarseness.


Aneurysm of the aorta

l Aneurysm of the aortic arch:compresses the left recurrent laryngeal nerve, leading to coughing, hoarseness, and paralys is of the ipsilateral vocal cord. It may cause dysphagia (difficulty in swallowing), resulting from pressure on the esophagus, and dyspnea (difficulty in breathing), resulting from pressure on the trachea, root of the lung, or phrenic nerve

l Aneurysm of the thoracic aortamay compress and tug on the trachea with each cardiac systole so that the aneurysm can be felt by palpating the trachea at the sternal notch (T2).


Anterior (descending)

interventricular artery � most

common place of MI

Circumflex artery

"Widow Maker"

Blood supply of the conducting

system

SA node � RCA

AV node � RCA

AV bundle (and AVmoderator band)-mo LCA

27. Congenital cardiac defects:

Atrial Septal Defect (ASD)

foramen ovale after bfter birth (failure of the septum primum and septum secundum to fuse)

less frequent

left-to-right shunting

If it is small, has no clinical significance & if large - necessary surgical repair

Ostium secundum: MOST common resorption of lower septum primum or incomplete septum secundumleaves open foramen ovaleOstium primum: non fusion of septum primum with septum intermedium leaves open foramen primumHypoplastic L heart syndrome: premature closure of FO leaving underdeveloped L heart

Patent Foramen Ovale

Ventricular Septal

Defect (VSD)

most common of the congenital heart defects

membranous part of the ventricular septum and results from failure to fuse of the membranous portion with the muscular portion of the ventricular septum

Muscular VSD rarest when there is a holein the trabeculated inferior ventricle wall(fatal)

Great cardiac vein

Great cardiac v, middle cardiac v, small cardiac v, L marginal v drain into Coronary Sinus which empties in Triangle of Koch at RA

Patent Ductus Arteriosus (PDA)

(a connection between the pulmonary trunk and aorta) to) to constrict and close after birth.

Left �to-right

Ductus arteriosus (fetal lung bypass from pulmonary trunk to aorta) should immediatelyclose post birth by contraction of muscular wall and become lig. arteriosus, L recurrentlaryngeal n (CNX) wraps around it. Increase BP post birth creates increased BP in pulmcirculation, less blood to body slightly decreases O2

Aneurysm of the aort

ent: surgical division and ligationimperative. In great danger is left recurrent nerve (wr(wrapping aorta arch). Injure of this nerve results in hoarseness.

, le, leading to coughing, paralys is of the ipsilateral vocal cord. It may cause dysphagia (difficulty in swallowing), resulting from pressure on the esophagus, and dyspnea (difficulty in breathing), resulting from

ot of

Aneurysm of the th

the aorta the aorta

Aneurysm of the aortic arch:l

compresses the left recurrent , lelaryngeal nerve, le, le, le, le, leading to

coughing, hoarseness, and ocal paralys is of the ipsilateral vocal

cord. It may cause dysphagia lting (difficulty in swallowing), resulting gus, from pressure on the esophagus,

lty in and dyspnea (difficulty in from breathing), resulting from

ot of pressure on the trachea, root of the lung, or phrenic nerve

Aneurysm of the thoracic aortaAneurysm of the ththe thoracic aortaf the thoracic aol

may compress and tug on the trachea with each cardiac systole so that the aneurysm can be felt

hea at the by palpating the trachea atsternal notch (T2(T2).

L Recurrent Laryngeal n innervates Intrinsic Laryngeal ms: Posteriorcricoarytenoid (PCA)-abducts vocal cords*, Transverse arytenoid-whisper,Thyroarytenoid-low pitch, vocalis-opera singer

When a MI occurs, a coronary bypassgraft can be completed using theinternal thoracic artery (used to be Greatsaphenous v)

l


Abdominal aortic aneurysm

l It is a localized dilatation of the

aorta. It is typically happened

just above of the bifurcation at

level of L4 and crossed by 3rd

part of duodenum.

l Pulsations of a large aneurysm

can be detected to the left of

the midline at the umbilical

region.

l Acute rupture of an abdominal

aortic aneurysm is associated

with severe pain in the

abdomen or back (mortality rate

is nearly 90%).

l Surgeons can repair an

aneurysm by opening it and

inserting a prosthetic graft.


Coarctation of the Aortal It results from congenital

narrowing of the aorta distal to the offshoot of the left subclavian artery.

l Cardinal clinical sign: higher blood pressure in the upper limbs compared to the lower limbs.

l Coarctation of the aorta results in the intercostal arteries providing collateral circulation between the internal thoracic artery and the thoracic aorta to provide blood supply to the lower parts of the body

l Coarctation of the Aorta characteristic X-ray picture:serrated appearance of inferior borders of ribs (rib notching)


28. Aspiration of Foreign

Bodies & Bronchopulmonary

segmentsAspiration of Foreign Bodies:

l Inhalation of FB�s (e.g. pins, parts of teeth, screws, nuts, bolts, toys) into the lower respiratory tract is common, especially in children

l More likely to enter the rightprimary bronchus and pass into the middle or lower lobe bronchi

l If the vertical position of the body, the foreign body usually falls into the posterior basal segment of the right inferior lobe.


Right lung:

10 bronchopulmonary segments

Superior lobe:

1. Apical

2. Anterior

3. Posterior

Middle lobe:

4. Lateral

5. Medial

Inferior lobe:

6. Superior

7. Anterior basal

8. Posterior basal

9. Lateral basal

10.Medial basal

1

8

97

6 4

5

2

3

10


Left lung:


Superior lobe:

1. Apicoposterior

2. Anterior

3. Superior lingular

4. Inferior lingular

Inferior lobe:

5. Superior

6. Anterior basal

7. Posterior basal

8. Lateral basal

9. Medial basal

1

3 5

7

89

6

2

4


29. Lung diseases:

Pneumonia

l Pneumonia is an inflammation

of the lung, caused by an

infection or chemical injury to the

lungs.

l Three common causes are

bacteria, viruses and fungi.

l Symptoms: cough, chest pain,

fever, and difficulty in breathing.

l Chest x-rays: areas of opacity

(seen as white) of the lung

parenchyma and enlargement of

bronchomediastinal lymph

nodes (mediastinal widening).


Abdominal aortic aneurysm

just above of the bifurcation at

3rdlevel of L4 and crossed by

part of duodenum.

Pulsations of a large aneurysm

can be detected to the left of

the midline at that the umbilical

region.

Acute rupture of anof an abdominal

aortic aneurysm is associated

with severe pain in the

abdomen or back (mortality rate

is nearly 90%).

prosthetic graft.

Coarctation of the AortaCoarCoarcongenital

narrowing of thof the aorta distal to the offshoot of the left subclavian artery.

higher blood pressure in the upper limbs compared to the lower limbs.

intercostal arteries pries providing collateral circulation between the internal thoracic artery antery and the thoracic aorta

Coarctation of the Aorta characteristic X-ray picture:serrated appearance of inferior borders of ribs (rib notrib notching)

Preductal stenosis proximal to ductus arteriosus causes deoxygenated blood w/low BP to the body (life threatening)Postductal stenosis w/ obliterated ductus ateriorsus is more common

28. Aspiration of Foreign

Bodies & Bronchopulmonary

segments

More likely to enter the rightprimary bronchus and pand pass into the middle or m lower lobe bronchi

posterior basal segment of thof the right inferior lobe.

Laying down on back, it will go into posterior superior lobeLiquids (Mendleson syndrome) will go to BOTH superiorsegmental bronchus of Lower Lobes (SULL)

minal a

If the vertical position of

Right lung:


Left lung:


surrounds cardiac notch

29. Lung diseases:

Pneumonia

Pneumonia is an inflammation

of the lung, caused by an

infection or chemical injury to the

lungs.

bacteria, viruses and fungi.

Chest x-rays: areas ofeas of opacity

enlargement of

bronchomediastinal lymph

nodes

Symptoms: cough, chest pain,

fever, and difficulty in breathing.


Bronchogenic Carcinoma

l Arises in the mucosa of the large bronchi

l Produces as persistent, productive cough or hemoptysis

l Early metastasis to thoracic(bronchomediatinal) lymph nodes

l Hematogenous spread to the brain, bones, lungs, suprarenal glands

l A tumor at the apex of the lung (Pancoast tumor) may result in thoracic outlet syndrome


Bronchogenic carcinoma

may lead to:

1. Thoracic outlet syndrome (TOS)

l It can cause pressure on the lower trunk of the brachial plexus C8-T1 and subclavian artery by cervical rib or pancoast tumor. It results in pain down the medial side of the forearm and hand and atrophy of the intrinsic hand muscles)

2. Horner syndrome:

l miosis - constriction of the pupil due to paralysis of the dilator pupillae muscle

l ptosis - drooping of the eyelid due to paralysis of the superior tarsal muscle

l hemianhydrosis - loss of sweating on one side

11

22


Bronchogenic carcinoma

may lead to:

3. Superior vena cava syndrome, which causes dilation of the head and neck veins, facial swelling, and cyanosis

4. Dysphagia as a result of esophageal obstruction

5. Hoarseness as a result of recurrent laryngeal nerve involvement

6. Paralysis of the diaphragm as a result of phrenic nerve involvement

33


Qs about Auscultation

and penetrated wounds

l To listen to breath sounds of the

superior lobes of the right and left

lungs, the stethoscope is placed on

the superior area of the anterior

chest wall (above the 4th rib for the

right lung & above 6th for the left

one).

l For breath sounds from the

middle lobe of the right lung, the

stethoscope is placed on the

anterior chest wall between the 4th

and 6th ribs

l For the inferior lobes of both

lungs, breath sounds are primarily

heard on the posterior chest wall.

4

6


30. Open pneumothorax &

pleura

l It is entry of air into a pleuralcavity causing lung collapse.

l Open pneumothorax � due to stab wounds of the thoracic wall which pierce the parietal pleura so that the pleural cavity is open to the outside air via the lung or through the chest wall.

l Air moves freely through the wound during inspiration and expiration. During inspiration, air enters the chest wall and the mediastinum will shift toward other side and compress the opposite lung. During expiration, air exits the wound and the mediastinum moves back toward the affected side.


Pleura & Pleural Cavity

l 1. Cervical pleura may be affected in case of improper subclavian venipuncture.

l 2. Costodiaphragmatic Recess is deepest place in pleural cavity, around the chest wall, there are two rib interspaces separating the inferior limit of parietal pleural reflections from the inferior border of the lungs and visceral pleura:

1. Midclavicular line - between ribs 6-8

2. Midaxillary line - between ribs 8-10

3. Paravertebral line between ribs 10-12

2


Bronchogenic Carcinoma

the mucosa of the large bronchi

s as persistent, productive cough or hemoptysis spitting bloodEarly metastasis to thoracic

spittingtasis to tasis to thorthor

(bronchomediatinal) lymph nodes

malignant cellsspread through blood

A tumor at the apex of the lung ( ) m) mng (Pancoast tumor) m) may ) mresult in thoracic outlet syndrome

1. Thoracic outlet syndrome ((TOS)

use pressure on the lower trunk of thof the brachial plexus C8-T1 and subclavian artery by cervical rib or pancoast tumor. pain down thown the medial side of the forearm and hand and atrophy oatrophy of atrophy othe intrinsic hand muscles)

2. Horner syndrome: compression of cervicalsympathetic trunk

Long ciliary n of CNV1-> SNS brf the dilator

pupillae muscle

pseudoptosis bc NOT CNIII lesionSNS compression to smooth ms

to paralysis of the superior tarsal ralysis of the supralysis of the supe supere supersuperior tauperior tarior tarsal rior tarsal lesion

tarsal tarsal muscle

tion of the pupil sympathetic

tion of the pupition of the pupitrunk

pupil pupil miosis - co- constriction ofsymp

ction ofction o

ptosis - d- drooping of the eyelid d

hemianhydrosis - loSNS

ianhydroianhydrocompression

ydrosisydrosis - lo- lo- loss of sweating compression

- loss of- loss ofto

oss of sss of ssmooth

s of sweatins of sweatinms

eating eating on one side Sweat glands are SNS

3. Superior vena cava syndrome, dilation of thof the head and neck veins, facial swelling, and cyanosis

4. Dysphagia

5. Hoarseness as a ras a result of recurrent lat laryngeal nerve rent laryn

6. Paralysis of the diaphragm as a ras a result of phrenic nerve in

Blue Face & arm

Blue arm

out Auscultation

and penetrated wounds

of

breath sounds of the of the

superior lobes

the superior area of the anterior

chest wall e the 4th(above the 4 rib for the

ove 6thright lung &lung & above 6 for the left

one).

breath sounds from the rom the

middle lobe of the right lung,

the 4thbetween the 4

and 6thand 6 ribs

inferior lobes of both

lungs, breath sounds are primarily

heard on the posterior chest wall.

Stab Wounds & Open pneumothorax:Straight in air can move in and out with each respiratory cycle, No air trapping (listen to ventilation of wound)At an angle air can move in with inspiration BUT with expiration skin acts as flap and closes trapping air inside collapsing the lung

pen pneumothorax &

It is entry of air into a pleuralcavity causing lung collapse.

mediastinum will shift toward other side and compress the opposite lung. D

1. Cervical pleura may bmay be affected in case of improper subclavian venipuncture.

Midclavicular line - between rieen ribs 6-81.

Midaxillary line - between rieen ribs 8-102.

Paravertebral line between rieen ribs 10-123.

2. Costodiaphragmatic Recess is deepest place in pleural cavity, a

Costodiaphragmatic Recess is where fluid isretained during pleural effusion


Nerve supply of the pleura

Parietal Pleura � sensitive to general sensibilities (pain, temperature, touch, and pressure) - somatic sensoryinnervation:

l costal pleura � intercostal nerves block may be used to decrease thoracic pain

l mediastinal pleura � phrenic nerve

l diaphragmatic pleura � phrenic nerve over the domes and lower 6 intercostal nerves around the periphery

Visceral Pleura � sensitive to stretch but insensitive to general sensibilities; autonomic nerve supply from the pulmonary plexus


31. Mediastinum

Superior mediastinum

l Improperly done sternal puncture may affect structures related to the posterior surface of the manubrium sternum:

l In upper part �Left brachiocephalic vein

l In lower part �Aortic arch


Thoracic duct

l Function � conveys to the blood all lymph from the lower limbs, pelvic cavity, abdominal cavity, left side of the thorax, left side of the head & neck, and left upper limb (3/4 of the body)

Tributaries � at the root of the neck

l Left jugular lymph trunk

l Left subclavian lymphtrunk

l Left bronchomediastinallymph trunk


Constrictions of the esophagus

There are sites where ingested foreign bodies can lodge or where strictures may develop following ingestion of caustic fluids, common sites of esophageal carcinoma

1. C6 - where the pharynx joins the upper end (6" from the upper incisors)

2. T4-T5 - where the aortic arch and left main bronchus cross its anterior surface (10" from the upper incisors)

3. T10 - where it passes through the diaphragm into the stomach (16" from the upper incisors)

1

2

3


32. Anterior abdominal wall

l The liver and gallbladderare in the right upper quadrant;

l The stomach and spleenare in the left upper quadrant;

l The cecum and appendixare in the right lower quadrant;

l The end of the descending colon and sigmoid colon are in the left lower quadrant.


Referred abdominal pain

l Pain arising out of the foregut derived structures is referred to the epigastric region.

l Pain arising out of the midgut derived structures is referred to the umbilical region.

l Pain arising out of the hindgut derived structures is referred to the hypogastric region.


Parietal Pleura � se� sensitive to general sensibilities (pain, temperature, touch, and pressure) - somatic sensoryinnervation:

ParieParie

intercostal nerves

phrenic nerve

Visceral Pleura

autonomic nerve surve supply from the pulmonary plexus

Cervicothoracic Stellate Gangion down to T11 and Subcostal sympathetic ganglion comprise the thoracicsympathetic trunkInnervate muscles of the ribs, abdominal wall, pulmonary and cardiac plexus, and esophageal plexusVagus CNX assists plexus of thorax for vocal cords and swallowing, and gives off recurrent laryngeal andsuperior external laryngeal to the larynx muscles

Azygous vein and ascendingaortic archesTrachea and Pulmonary arterybifurcationsesophagus and thoracic ductchange directions (cross over)

Ribs 1-2 down to transverse thoracicplane (T2)/Plane of ludwig/angle of louis

Superior mediastinump

Thoracic duct A Duck between 2 GoosesThoracic duct between azygos v and esophagus

lood all lymph from throm the lower limbs, pelvic cavity, abdominal cavity, left side of the thorax, left side of the head & neck, and left upper limb ((3/4 of the body)

Left jugular lymph trph trunk

Left subclavian lymphl

trunk

Left bronchomediastinall

lymph trunk

Tributaries � at � at the root of the neck

Left Left jugularl

R lymphatic duct drains 1/4 of body from R jugularlymph trunk, R subclavian lymph trunk, and Rbronchomediastinal lymph trunk

Constrictions of the esophagus

Pericardial sinus: behind pulm trunk and aorta place fingers toclamp/ligate great vessels during surgical procedures

1. C6 - w- where the pharynxr end (6" from the

upper incisors)

2. T4-T5 - w- where the aortic arch and left main bronchus cross

rface (10" from the upper incisors)

3. T10 - w- where it passes through the diaphragm

ach (16" from the upper incisors)

foreign bodies cadies can lodge or

25cm long/10in Barium swallow allows Xray visualization

15cm

22.5-27.5cm

40cm

uids, common sites of esophageal carcinoma

32. Anterior abdominal wall

The liver and gallbladderare in the right upper quadrant;

The stomach and spleenare in the left upper quadrant;

The cecum and appendixare in the right lower quadrant;

The end of the descending colon and sigmoid colon are in the left lower quadrant.

Layers of abdominal wall: Skin, Camper's Fascia, Scarpa's Fascia, Galludets Fascia (superficial Ext oblique), Ext Oblique m \\//, (deep ext oblique, superficial int oblique),Inter Oblique m //\\, (deep int oblique, superficial transversalis ab), Transversalis abdominus m, deep TA fascia, Extraperitoneal fat, parietal peritoneum.Arcuate line is where lateral abdominal ms tendons merge with Rectus abdominus (linea semilunaris), Above arcuate line int oblique superficial fascia is above rectus abdominus (3 layersof fascia), Below arcuate line ALL fascias above rectus abdominis (6 layers) typically inferior to umbilicus

RH LHE

RL LLU

HRI LI

foregut

epigastric regric region.

demidgut

umbilical region.

hindgut

hypogastric region.


Nerve supply of the

anterior abdominal wall

l Therefore totally 7 nerves: lower 5 intercostals, 1subcostal and L1(iliphypogastric and ilioinguinal) nerves supply the anterior abdominal wall.

l L1 can be anaesthetized by injecting 1 inch (2.5 cm) superior to the anterior superior iliac spine.

l All nerves and deep blood vessels lie in the neurovascular plane: between internal oblique and transversus muscles


Arterial supply of the anterior

abdominal wall:

Important SUPERFICIAL

ARTERIES (supply skin) are:

1. Superficial epigastric

2. Superficial circumflex iliac

Important DEEP ARTERIES lie in the neurovascular plane:

1. Superior epigastric

2. Posterior intercostals arteries

3. Lumbar arteries

4. Deep circumflex iliac artery

5. Inferior epigastric


33. Herniations

Hernia consist of 3 parts:

l Hernial sac is a pouch (diverticulum) of peritoneum and has a neck and a body

l Hernial contents may consist of any structure found in the abdominal cavity (more offen �loops of small intestine and piece of omentum major)

l Hernial coverings are formed from the layers of the abdominal wall through which the hernial sac passes


Transversalis fascia is the FIRST

STRUCTURE which is crossed by

any abdominal hernia


Indirect Inguinal Hernia

l Indirect inguinal hernia is the most common form of hernia and is believed to be congenital in origin (boys 0-3 years).

l It passes through the deep inguinal ring lateral to the inferior epigastric vessels, inguinal canal, superficial inguinal ring and descend into the scrotum.

l An indirect inguinal hernia is about 20 times more common in males than in females, and nearly 1/3 are bilateral.

l It is more common on the right(normally, the right processus vaginalis becomes obliterated after the left; the right testis descends later than the left).


Direct Inguinal Hernia

l Direct inguinal hernia composes about 15% of all inguinal hernias.

l During a direct inguinal hernia, the abdominal contents will protrude through the weak area of the posterior wall of the inguinal canal medial to the inferior epigastric vessels in the inguinal [Hesselbach's] triangle and after that through superficial inguinal ring. It never descends into the scrotum.

l It is a disease of old men with weak abdominal muscles. Direct inguinal hernias are rare in women, and most are bilateral.


Nerve supply of the

anterior abdominal wall

5 intercostals, 1subcostal and L1(iliphypogastric and ilioinguinal

neurovascular plane: between internal oblique and transversus muscles

Arterial supply of the anterior

abdominal wall:

Superficial epigastric

Superficial circumflex iliacfrom femoral a

SUPERFICIAL

ARTERIES ((supply skinly skin) a

internal thoracic a

from femoral a just pastfemoral ring (inguinal lig)

external iliac a

Portal Caval anastamosis of paraumbilical veins off hepatic portal v with superficialepigastric veins (Caput Medusae- swiggly veins on belly button)

T5-T11T12L1

Superior epigastric

Posterior intercostals arteries

Deep circumflex iliac artery external

artery artery

Inferior epigastricInferior epInferioior epigastricior epigastricjust

rtant DEEP ARTERIES lie in the neurovascular plalar plane:

Hernial sac is a pis a pouch (diverticulum) of peritoneum and has a neck and a body

Hernial contents may comay consist of any structure found in the abdominal cavity (more offen �loops of small intestine

Hernial coverings are foare formed from the layers of the abdominal wall through which the hernial sac passes

33. Herniations Transversalis fascia is this the FIRST

STRUCTURE which is crossed by

any abdominal hernia

TIE ICETransversalis Fascia becomes Internal Spermatic FasciaInternal Oblique m & Fascia becomes Cremasteric m & FasciaExternal Oblique fascia becomes External Spermatic Fascia

Surrounds the Spermatic cord within the inguinal canal:3 as: cremasteric (inferior epigastric), ductus deferans (internal iliac-inferior vesicle),gonadal a (aorta)3 ns: genital br (motor genitofemoral), ANS, ilioinguinal3 others: Pampiniform plexus (IVC and Lrenal), Ductus Deferens, LymphaticsProcess Vaginalis/Gubernaculum

aponerocis of internaloblique fascia andtranversalis fascia

Indirect inguinal hernia is this the most common form

congenital in origin

ses through the deep inguinal ring lateral to the inferior epigastric vessels, inguinal canal, superficial inguinal ring and descend into the scrotum.

mon infemales, and nearly 1/3 are bilateral.

20 times more common inmon in males than in

the right

Insert finger into superficial inguinal ring, if you can feel hernia at TIP of finger than it is indirect hernia at the lateral inguinal fossa.If you can feel something lateral to finger it is direct hernia pushing towards Hesselbach's triangle (medial inguinal fossa between medial and lateralumbilical folds. The inferior epigastric vessels reside within Lateral umbilical fold (functional), the inferior border is the inguinal lig.

Direct inguinal hernia composes about 15% of all inguinal hernias.

protrude through the weak area of the posterior wall of the inguinal canal

[Hesselbach's] triangle

disease of old men with weak abdominal muscles. Di


34. Peritoneal structures:

Lesser omentum

Consist of 2 ligaments:

l hepatogastric

l hepatoduodenal

Contents :

l Right & Left gastric vessels

l Connective and fatty tissue

and Portal triad:

l Bile duct

l Portal vein

l Proper hepatic artery


Epiploic (winslow�s) foramen

l Anteriorly: The free border of the hepatoduodenal ligament, containing portal triad (DVA).

l Posteriorly: IVC

l Superiorly: Caudate lobe of the liver.

l Inferiorly: The 1st

part of the duodenum.


Douglas (rectouterine) pouch

l Rectouterine pouch (pouch of Douglas):deeper point of peritoneal space in vertical position of the female body between the rectum and the cervix of uterus.

l It is space of the pelvic abscess location.


Culdocentesis

l Culdocentesis is aspiration of fluid from the cul-de-sac of Douglas (rectouterine pouch) by a needle puncture of the posterior vaginal fornix near the midline between the uterosacral ligaments

l Because the rectouterine pouch is the lowest portion of the female peritoneal cavity, it can collect inflammatory fluid (pelvic abscess).


35. Smart Table

FOREGUT MIDGUT HINDGUT

Esophagus

Stomach

Duodenum (1st and

2nd parts)

Liver

Pancreas

Biliary apparatus

Gallbladder

Duodenum (2nd, 3rd,

4th

parts)

Jejunum

Ileum

Cecum (with

Appendix)

Ascending colon

Transverse colon

(proximal 2/3)

Transverse colon

(distal 1/3)

Descending colon

Sigmoid colon

Rectum (anal canal

above pectinate line)


FOREGUT MIDGUT HINDGUT

Artery: CA Artery: SMA Artery: IMA

Parasympathetic

innervation: vagus

nerves, CNX

Parasympathetic

innervation: vagus

nerves, CNX

Parasympathetic

innervation: pelvic

splanchnic nerves, S2-S4

Sympathetic

innervation:

�Preganglionics: greater

splanchnic nerves, T5-T9

�Postganglionics:

celiac ganglion

Sympathetic

innervation:

�Preganglionics: lesser

splanchnic nerves, T10-

T11

�Postganglionics:

superior mesenteric

ganglion

Sympathetic

innervation:

�Preganglionics: lumbar

splanchnic nerves, L1-L2

�Postganglionics: inferior

mesenteric ganglion

Sensory Innervation:

DRG T5-T9


DRG T10-T11


DRG L1-L2

Referred Pain:

Epigastrium

Referred Pain:

Umbilical

Referred Pain:

Hypogastrium


Lesser omentum

2 ligaments:

hepatogastricl

hepatoduodenall

Right & Left gastric vessels

Portal triad:

Bile ductl

Portal veinl

Proper hepatic arteryl

Site of Pringles Manuver to block blood supply to liver and investigateLiver bleeds: block Hepatic Artery Proper, Hepatic Portal Vein, and CommonBile Duct. Use thumb anterior, and index posterior within Winslow foramen.If R side bleeds: aberrant R Hepatic artery from SMAIf L side bleeds: aberrant L Heptatic artery from L GastricIf double bleed accessory arteries come from elsewhere.

Epiploic (winslow�s) foramen

Douglas (rectouterine) pouch In women only!

deeper point of peritoneal space in vertical position oition of the female body between the rectum and thand the cervix of uterus.

l pelvic It is space of the abscess location.

Culdocentesis

aspiration of fluid from the cul-de-sac of Douglas (r

posterior vaginal fornix

Vesicouterine pouch

Males have a vesicorectal pouch, fluid can accumulate in these peritoneal areas if there is a pelvic abscess.Morrison's pouch is where fluid accumulates if the person is lying down (between kidney and liver)

1st part duodenum issuspended by greateromentum and hepatoduodenal lig

Retroperitoneal Organs: SAD PUCKERSuprarenal glands, Aorta, Duodenum (2-3rd), Pancreas, Ureters, Colon, Kidneys, Esophagus, RectumDPC are secondary retroperitoneal

2nd part of duodenum iswhere Spincter of Oddi/Ampula of Vader/majorpapilla of the Wirsung majorPancreatic duct emptiesalong with the common bileduct

IMV to splenic v tohepatic portal v to liverto IVCSMV joins splenic v toform hepatic portal v


36. Posterior gastric ulcer

1. Posterior gastric ulcer may erode through the posterior wall of the stomach into the Omental bursa (Lesser peritoneal sac) and affect pancreas resulting in referred pain to the back.

2. Erosion of splenic artery is very common in posterior gastric ulcers as well because of the proximity of the artery to this wall.


37. Congenital diaphragmatic

hernia

l Hernia of stomach or intestine through a posterolateral defect in diaphragm(foramen of Bochadalek).

l It is seen in infants and the mortality rate is high because of left lung hypoplasia.


38. Sliding hiatal hernia

l A sliding hiatal hernia which

occurs in individuals past

middle age is caused by

the hernia of cardia of the

stomach into the thorax

through the esophageal

hiatus of the diaphragm.

l This can damage the vagal

trunks as they pass through

the hiatus and resulting in

hyposecretion of gastric

juice.


39. Meckel's diverticulum

l Meckel's diverticulum is a congenital anomaly representing a persistent portion of the vitellointestinal duct.

l This condition is often asymptomatic but occasionally becomes inflamed if it contains ectopic gastric, pancreatic, or endometrialtissue, which may produce ulceration.

l Meckel's diverticulum is located on the Ileum about 2 feet (61 cm) before the ileocecal junction and SMA supply it. It occurs in 2% of patients and is about 2 inches(5 cm) long.

l The diverticulum is clinically important because diverticulitis, liberation, bleeding, perforation, and obstruction are complications requiring surgical intervention and frequently mimicking the symptoms of acute appendicitis.


40. Features of the large

intestine

Features of the large intestine:

1. Appendices epiploic

2. Sacculations (haustrations)

3. Taeniae coli

l The taeniae coli meet together at the base of the appendix where they form a complete longitudinal muscle coat for the appendix.


Colon

l The ascending colon lies retroperitoneally and lacks a mesentery.

l It is continuous with the transverse colon at the right (hepatic) flexure (1) of colon.

l The transverse colon (3) has its own mesentery called the transverse mesocolon (intraperitoneal position).

l It becomes continuous with the descending colon at the left (splenic) flexure (2) of colon.

l The sigmoid colon (4) is suspended by the sigmoid mesocolon (intraperitoneal position).

1

3

4


36. Posterior gastric ulcer

Posterior gastric ulcer may erode through the posterior wall of the stomach into the Omental bursa

pancreas resulting inlting in referred pain to the back.

Erosion of splenic artery is very common in

37. Congenital diaphragmatic

hernia

posterolateral defect in diaphragm(foramen of Bochadalek).

Improper fusion of pleuroperitonealmembranes with septum transversarusMost L sided bc liver and R side closes first.

It is seen in infants and the mortality rate is high because of left lung hypoplasia.

Fundus of stomach through

esophageal

hiatus of thof the diaphragm.

Often due to shortened esophagus

38. Sliding hiatal hernia

Meckel's diverticulum is ais a congenital anomaly representing a persistent portion of the vitellointestinal duct.

Meckel's diverticulum is lois located on the Ileum about 2 feet (61(61 cm) before the ileocecal junction and SMA supply it. It occurs in 2% of pof patients and is about 2 inches(5 cm) long.

diverticulitis, liberation, bleeding, perforation, and obstruction are complications requiring surgical intervention and frequently mimicking the symptoms of acute appendicitis.

commonly presents at 2yo, 2:1 males to females

Outpouch of intestines into rectum

Appendices epiploic

Sacculations (haustrations)

Taeniae coli

The tal niae coli meet The taeniae cotogether at the base of the appendix where they form a complete longitudinal muscle coat for the appendix.

Colonf the large

intestine

ascending colon lies retroperitoneally and laand lacks a mesentery.

transverse colon at the right (hepatic) flexure (1)

transverse colon (3) has its own mesentery called the transverse mesocolon

descending colon at the left (splenic) flexure (2)

The sigmoid colon (4) is suspended by the sigmoid mesocolon

Ascending colon (R colic a, iliocolic a w/ appendicular a-SMA)Transverse colon (Middle colic a, marginal a-SMA)Descending colon (L colic a-IMA)Sigmoid colon (Sigmoid branches of IMA)Rectum (Superior Rectal a from IMA, Inferior and medial rectal-internal iliac a)


41. Pain of Appendicitis

l In appendicitis, first pain is referred around the umbilicus. Visceral pain in the appendix is produced by distention of its lumen or spasm of its muscle.

l The afferent pain fibers enter the spinal cord at the level of T10 segment, and a vague referred pain is felt in the region of the umbilicus.

l Later if parietal peritoneum gets involved, and then the pain is shifted laterally to the Mc Burney�s point. Here the pain is precise, severe, and localized (second pain)


Mc Burney's point

l This point indicates the surface marking of the base of the appendix.

l It is a point at the junction between the lateral 1/3 and medial 2/3 of a line joining the right anterior superior iliac spine with the umbilicus.


42. Volvulus

l Because of its extreme mobility,

the Jejunum, Ileum and

Sigmoid colon sometimes

rotates around its mesentery.

It results in avascular necrosis

corresponding part of interstine.

l This may correct itself

spontaneously, or the rotation

may continue until the blood

supply of the gut is cut off

completely.


43. Hirschsprung's Disease

l It is a rare congenital abnormality that results in obstruction because the intestines do not work normally.

l It is commonly found in Down Syndromechildren.

l The inadequate motility is a result of an aganglionic section (congenital absentsof postganglionic parasympathetic neurons inside of the intestinal wall) of the intestines resulting in megacolon.

l In a newborn, the main signs and symptoms are failure to pass a meconium stool within 1-2 days after birth, reluctance to eat, bile-stained (green) vomiting, and abdominal distension.

l Treatment is removal of the aganglionic portion of the colon.


44. Branches of Abdominal aorta

and Mesenteric ischemia

l Celiac trunk (CA) originates from the aorta at the lower border of T12 vertebra

l Superior mesenteric arteryoriginates at the lower border of L1 vertebra

l Renal arteries originate at approximately L2 vertebra

l Inferior mesenteric arteryoriginates at L3 vertebra

l Two terminal branches are common iliac arteries at the level of L4 vertebra


CELIAC ARTERY (TRUNK)

l Origin: T12, just below the

aortic opening of the

diaphragm.

l The CA passes above the

superior border of the

pancreas and then divides

into three retroperitoneal

branches:

l Left gastric artery (1)

l Common hepatic artery (2)

l Splenic artery (3)

2

3

1


41. Pain of Appendicitis

first pain is referred around the umbilicus.

T10 seg10 segment, a

Later if parietal peritoneum gets involved, and then the pain is shifted laterally to the Mc Burney�s point. He

McBurney's point lies 2/3 from umbilicus to ASIS OR 1/3 from ASIS to umbilicus

base of the base of appendix.

Mc Burney's point

42. Vol2. Volvulus

Jejunum, Ileum and

Sigmoid colon sometimes

rotates around its mesentery.

avascular necrosis

corresponding part of interstine.

43. Hirschsprung's Disease

NCCs did not travel correctly to the colon resulting in lack ofinnervation to the large bowel, no parastalic movements results inmegacolon

It is a rare congenital abnormality that results in obstruction because the intestines do not work normally.

Down Syndromemales>females

aganglionic section (co(congenital absentsof postganglionic parasympathetic neurons inside of the intestinal wall) of the intestines resulting in megacolon.

are failure to pass a meconium stool

and abdominal distension.

44. Branches of Abdominal aorta

and Mesenteric ischemia

T12 vertebra

Celiac trunk (CA)

Superior mesenteric artery

L1 vertebra

Renal arteriesL2 vertebra

Inferior mesenteric arteryL3 vertebra

Two terminal branches are common iliac arteries at the level of L4 vertebra

Ovarian/testicular (gonadal) as arise between L2-3

CELIAC ARTERY (TRUNK)

Left gastric artery (1)

Common hepatic artery (2)l

Splenic artery (3)l

igin: T12, just below the

aortic opening of the

diaphragm.

between crura ofdiaphragm


Left gastric artery

l The left gastric artery (1)

courses upward to the left to

reach the lesser curvature of

the stomach and may be

subject to erosion by a

penetrating ulcer of the

lesser curvature of the

stomach.

Branches:

l Esophageal branches (2) - to the abdominal part of the esophagus

l Gastric branches (3) supply

the left side of the lesser

curvature of the stomach and

make anastomosis with right

gastric artery.

2

3

1


Common hepatic artery

l The common hepatic artery

(1) passes to the right to

reach the superior surface of

the first part of the duodenum,

where it divides into its two

terminal branches:

l Proper hepatic artery (2)

l Gastroduodenal artery (3)

1

2

3


Proper hepatic arteryl Proper hepatic artery (1) gives

off right gastric artery (2) and

then ascends within the

hepatoduodenal ligament of the

lesser omentum to reach the

porta hepatis, where it divides

into the right (4) and left (3)

hepatic arteries.

l The right and left arteries enter the

two lobes of the liver, right

hepatic artery gives cystic artery

(5) to the gallbladder.

l Right gastric artery (2) supplies

the right side of the lesser

curvature of the stomach where it

anastomoses the left gastric

artery.

54

3

21


Gastroduodenal artery

l Gastroduodenal artery (1)

descends posterior to the first

part of the duodenum (may be


penetrating ulcer in this place)

and divides into two branches:

l Right gastroepiploic artery (2)

(supplies the right side of the

greater curvature of the

stomach where it anastomoses

the left gastroepiploic)

l Superior pancreaticoduodenal

arteries (3) (supply the head of

the pancreas, where they

anastomoses the inferior

pancreaticoduodenal arteries

from the SMA).

1

2

3


Ligature of the hepatic artery:

l The hepatic artery may be ligated proximal to the origin of its gastroduodenal branch, a collateral circulation to the liver is established through the left and right gastricarteries, left and right gastroepiploic and gastroduodenal arteries.

l The right hepatic artery may be mistakenly ligated during holecystectomy in Calot triangle together with the cystic artery, right lobe hepatic necrosis commonly occurs.


Splenic artery

l Splenic artery (1) runs a

tortuous horizontal course to

the left along the upper border

of the pancreas, behind the

peritoneum of the posterior

wall of the lesser sac, forming a

part of the stomach bed.

l The splenic artery may be


penetrating ulcer of the

posterior wall of the stomach

into the lesser sac.

l N.B. The splenic vein runs a more straight course below the artery and behind of the pancreas.

1


Left gastric artery

Esophageal branches (2

Gastric branches (3

the lesser curvature of

the stomach an

ct to erosion by a

penetrating ulcer

Common hepatic artery

the superior surface of

the first part of the duodenum,

o its two

terminal branches:

Proper hepatic artery (2)l

Gastroduodenal artery (3)l

Proper hepatic artery

right gastric artery (2

then ascends within th

lesser omentum

o the right (4) and left (3)

hepatic arteries.

two lobes of the liver, ri, right

hepatic artery gives cystic artery

(5) to thto the gallbladder.

Right gastric artery (2) supplies

the right side of the lesser

curvature of thof the stomach where it

anastomoses the left gastric

artery.

OFF Common Hepatic a of Celiac Trunk OFF Common Hepatic a of Celiac Trunk

Gastroduodenal artery

descends posterior to the first

part of thof the duodenum

and divides into two branches:

Right gastroepiploic artery (2

greater curvature

Superior pancreaticoduodenal

arteries (3 head of

the pancreas, w

Ligature of the hepatic artery:

collateral circulation to the liver is established through the left and right gastricarteries, left and right gastroepiploic and gastroduodenal arteries.

right hepatic artery may be mistakenly ligated during holecystectomy in Calot triangle together

cystic artery, right lobe hepatic necrosis

Anastamoses of the L gastric, Lgastroepiploic, and Lgastroduodenalarteries with the R side will causeretrograde flow into the proper hepaticartery to supply the liver

Splenic artery

3rd off Celiac Trunk

2nd off Celiac Trunk1st off Celiac Trunk

Splenic artery (1) runs aruns a

tortuous

upper border

of the pancreas, behind the

peritoneum of thof the posterior

wall of the lesser sac, forming a

part of the stomach bed.

erosion by aby a

penetrating ulcer of thof the

posterior wall of thof the stomach

into the lesser sacer sac.

N.B. The splenic vein runs aruns a more straight course below the artery and behind of the pancreas.


Splenic artery

l Splenic (1) a. is retroperitoneal

until it reaches the tail of the

pancreas, where it enters the

splenorenal ligament to enter

the hilum of the spleen.

Branches:

l Branches to the spleen (2)

l Branches to the neck, body, and

tail of pancreas (3)

l Left gastroepiploic (4) artery that

supplies the left side of the

greater curvature of the stomach

where it anastomoses the right

gastroepiploic

l Short gastric (5) branches that

supply fundus of the stomach

5

43

1 2


SMA Branches:

l (1) Inferior pancreaticoduodenal arteries

l (2)Jejunal and (3) Ileal branches

l (4) Ileocolic artery

l Ascending branch

l Anterior cecal artery

l Posterior cecal artery

l (5) Appendicular artery

l (6) Right colic artery

l (7) Middle colic artery

17

6

5

4

3

2


IMA Branches:

l (1) Left colic artery

l (2) Sigmoid arteries

l (3) Superior rectal artery

3

2

1


Mesenteric ischemial Atherosclerosis, which slows the

amount blood flowing through arteries, is a frequent cause of chronic mesenteric ischemia.

l Ischemia occurs when blood cannot flow through arteries as well as it should, and intestines do not receive the necessary oxygen to perform normally. Mesenteric ischemia usually involves SMA and small intestine.

l Mesenteric ischemia primarily affects organs which locate far away from anastomoses with CA & IMA. Usually blood supply of the Jejunum and Ileum is most compromised.

l Mesenteric ischemia typically occurs in people older than age 60 with history of smoking and high cholesterol level.


45. Biliary system & gallstones

l Bile is secreted by the liver cells, stored, and concentrated in the gallbladder and later it is delivered to the duodenum.

l The gallbladder lies in it�s fossa on the visceral surface of the liver right side of quadrate lobe.

l It stores and concentrates bile, which enters and leaves it through the cystic duct.

l The cystic duct joins the common hepatic (from left and right hepatic) due to form the common bile duct.


Biliary system

l The common bile duct descends in the hepatoduodenal ligament, then passes posterior to the firstpart of the duodenum

l It penetrates the head of the pancreas where it joins the main pancreatic duct and they form the hepatopancreatic ampulla (sphincter of Oddi), which drains into posteromedial wall the second part of the duodenum at the major duodenal papilla


BRANCHESSplenic artery BRANCHEStery

is retroperitoneal

until it reaches the tail of the

pancreas, w

splenorenal ligament to eto enter

the hilum of the spleen.

Branches to the spleen (2)

Branches to the neck, body, and

tail of pancreas (3

Left gastroepiploic (4) artery thrtery that

supplies the left side of the

greater curvature ofture of the stomach

where it anastomoses the right

gastroepiploic

Short gastric (5) branches thhes that l

supply fundus of the stomach

SMA Branches:

(1) Inferior pancreaticoduodenal

(2)Jejunal and (3) Ileal branches

(4) Ileocolic

(6) Right colic artery

(7) Middle colic artery l

rior cecal artery

(5) Appendicular artery

SUPERIOR MESENTERIC ARTERY (midgut)

Marginal artery anastamoses the iliocolic a,vasa recta-SMA, with the L colic, sigmoid aand vasa recta of the IMA

INFERIOR MESENTERIC ARTERY

IMA Branches:

(1) Left colic arteryl

(2) Sigmoid arteriesl

(3) Superior rectal artery l

Mesenteric ischemiaAtherosclerosis, w

a frequent cause of chronic mesenteric ischemia.

hen blood cannot flow

intestines do not receive the necessary oxygen to

lves SMA and small intestine.

f the Jejunum and Ileum is most compromised.

age 60 with hwith history of smoking and high cholesterol level.

45. Biliary system & gallstones

cystic a from R hepatic a

Calot's Triangle

ated in the gallbladder

hepaticgallbgallbstored, and co, and concentrated in

delivered to the duodenum. hepaticdelideliadelivedelive

the visceral surface of the liver right side of quadrate lobe.

cystic duct.

duct joins the common hepatic (from left and right hepatic) due to form the common bile duct.

Biliary system

mon bile duct common descends innds in the atoduodenal ligamenthepatodu ,

ses then passes posterior to the firstpart of the duodenumduo

ates the head of the It penetrates tpancreas where it wheere it joins the main

tic ductpancreatic d and thand they form the ancreatic ampulla hepatopancre

(sphincter of Odd(sphincter or of Oddi), which drains of Oddr of Odd of Oddi)into posteromedial wall the second part of thof the duodenum at the major duodenal papilla

Sphincter of Oddi

Ampula of Vader

SphincterSphincter of OddiOddiOddi

AmpAmpula of Vader

Tumor in the head of the pancreas can block the duct and cause jaundice

Blockage of the cystic or common bile duct via gall stones can cause gall bladder rupture w/ refered

pain to the shoulder (C3-5 phrenic n), and backflow of pancreatic enzymes that digest the pancreas

and the spleen via splenic artery branches


Cholelithiasis (gallstones)

l The distal end of the hepato-

pancreatic ampulla (Bile duct) is the

narrowest part of the biliary passages

and is the common site for impaction

of gallstones.

l As result of common hepatic (1), bile

duct (2), or hepatopancreatic

ampulla (3) obstruction patient will

have yellow eyes and jaundice

l Gallstones may also lodge in the

cystic duct. A stone lodged in the

cystic duct (4) causes biliary colic

(intense, spasmodic pain in the

gallbladder) but doesn't produce

jaundice.

1

2

3

4


Gallstones

l The fundus [1] of the gallbladder is in contact with the transverse colonand thus gallstones erode through the posterior wall of the gallbladder and enter the transverse colon. They are passed naturally to the rectum through the descending colon and sigmoid colon.

l Gallstones lodged in the body [2] of the gallbladder may ulcerate through the posterior wall of the body of the gallbladder into the duodenum(because the gallbladder body is in contact with the duodenum) and may be held up at the ileocecal junction, producing an intestinal obstruction.

2

1


46. Nerve supply of the liver

and gallbladder

l Sensory innervation of the liver: by the rightphrenic nerve (C3-C5). Pain may radiate to the right shoulder.

l The liver receives parasympathetic innervation from the vagi nerves (CNX), reaching it through the celiac plexuses around the supplying arteries. The preganglionic fibers synapse on the cells of the uxtramural plexuses in hilum of the liver and shot postganglionic fibers supply organs.

l Sympathetic fibers of preganglionic neurons T5-T9 segments (IML) come through the sympathetic trunk and form greater splanchnicnerves. They contribute to the celiac plexus, where postganglionic neurons are located. Branches of celiac plexus reach the liver wrapping around the branches of the celiac artery.


47. Portal Hypertension &

Portocaval shunts

l Portal hypertension is a common clinical condition, and for this reason portal-systemic anastomoses should be remembered.

l [1] Extrahepatic portocaval shunt for the treatment of portal hypertension: the splenic vein may be anastomoses to the left renal vein after removing the spleen.

l [2] Intrahepatic portocaval shunt : between portal vein and hepatic veins


Large intestine metastases &

Portocaval anastomosis

l Metastases of the Large intestine

cancer typically rich the Liver via

portal venous system: Rectum -

IMV - splenic vein - portal vein -

Liver

l If there is an obstruction to flow

through the portal system (portal

hypertension), blood can flow in a

retrograde direction and pass

through anastomoses to reach the

caval system. Sites for these

anastomoses include:

l (1) esophageal veins

l (2) paraumbilical veins

l (3) rectal veins


Esophageal anastomosis

l Anastomosis between the tributaries of the left gastric vein (portal vein) and the tributaries of the azygous vein (SVC) in the wall of the lower end of the esophagus.

l In portal hypertension these veins enlarge in the wall of the esophagus and later burst into the lumen of the esophagus (esophageal varices) resulting in hematemesis (vomiting red blood).


Cholelithiasis (gallstones)

Gall stone in the cystic duct will cause backflow to the gall bladder (burst)

BUT NOT jaundice bc Common bile duct is still releasing bile properly to the stomach

The distal end of the hepato-

pancreatic ampulla (Bile duct) is this the

narrowest part of thof the biliary passages

and is the common site for impaction

of gallstones.

common hepatic (1), bile

duct (2), or hepatopancreatic

ampulla (3) obstruction patient will

have yellow eyes and jaundice

cystic duct (4) causes biliary colic

(intense, spasmodic pain in the

gallbladder) but doesn't produce

jaundice.

Gallstones

The fundus [1] of the gallbladder is in contact with the transverse colon

tones erode through the posterior wall of the gallbladder and enter the transverse colon. T

tones lodged in the body [2] of the gallbladderthe posterior wall of the body of the gallbladder into the duodenum

be held up at the ileocecal junction, producing an intestinal obstruction.

46. Nerve supply of the liver

and gallbladder

(C3-C53-C5right

phrenic nerve (( ). ((C3-C53-C5). Pain may radiate to the right shoht shoulder.

celiac plexuses

parasympathetic innervation

Sympathetic fibers

greater splanchnicnerves. T celiac plexus,

Sensory innervation

47. Portal Hypertension &

Portocaval shunts

Portal hypertension is a is a common clinical condition,

[1] Extrahepatic portocaval shunt

splenic vein may bmay be anastomoses to the left renal vein after refter removing the spleen.

[2] Intrahepatic portocaval shunt : between portal vein and hepatic veins

Diverting blood from portal venous system to the systemic venous system by creating a

communication between the hepatic portal vein and the IVC.

Side to side shunts connecting the portal system to the IVC, End to side connection with

separation and connection of end and head of portal caval system to IVC. And typical

splenorenal central shunt all allow portion of blood to IVC to decrease flow to liver.

Large intestine metastases &

Portocaval anastomosis

Metastases of thof the Large intestine

cancer Liver via

portal venous system: Rectum -tum -

IMV - splenic vein - portal vein -

Liver

obstruction to flow

through the portal system (portal

hypertension), blood can flow in a

retrograde di and pade direction and pass

through anastomoses to reach the

caval system. Si. Si

(1) esophageal veins l

(2) paraumbilical veinsl

(3) rectal veinsl

Esophageal anastomosis

Anastomosis between theen the tributaries of the left gastric vein (portal vein) and thand the tributaries of the azygous vein (SVC) in thin the wall of the lower end of thof the esophagus.

gus (esophageal varices) rehematemesis (vo(vomiting red blood).

Esophageal branches of the L Gastric v will anastomose with azygous(4) R, L and middle colic vs anastamose with

Renal, suprarenal and gonadal vs, No clinical

name however represents as varicocele on the

abdomen


Umbilical anastomosis

l Anastomosis between the paraumbilical veins (portal vein) and the superior and inferior epigastric veins (SVC and IVC) in anterior abdominal wall around the umbilicus.

l In portal hypertension, this anastomosis gets enlarged and dilated veins form �caput Medussae� around the umbilicus.


Rectal anastomosis

l Anastomosis between the superior rectal vein (inferior mesenteric vein and then portal vein) and inferior rectal vein which drains into the internal iliac vein (from IVC system).

l In portal hypertension (chronic alcoholics) this anastomosis gets dilated resulting in internal hemorrhoids and bleeding per anus from superior rectal vein.


48. Pancreas:

Head and uncinate process

l The head of the pancreasrests within the C-shapedarea formed by the duodenum and is traversed by the common bile duct.

l It includes the uncinate process which is crossed by the superior mesenteric vessels.


Cancer of the head

of the pancreas

· Cancer of the head of the pancreas compresses the bile duct and results in OBSTRUCTIVE TYPE OF JAUNDICE.

· Pain will be conveyed to sensory neurons T5-T9 dorsal root ganglia via celiac plexus and greater splanchnic nerve.

· This type of jaundice is NOTusually associated with fever.

· Hepatitis also causes jaundice but is associated with the fever.


Neck of the pancreas

l Posterior to the neck of the pancreas is the site of formation of the PORTAL VEIN.

l (1)Splenic vein joins with (2)superior mesenteric vein to form (3) portal vein.

3

2

1


Body of the pancreas

l The body passes to the left and anterior to the (1)aorta and the (2) left kidney.

l The (3) splenic artery undulates along the superior border of the body of the pancreas with the splenic vein coursing posterior to the body.

3

2

1


Umbilical anastomosis

paraumbilical veins (po(portal vein) and the superior and inferior epigastric veins (SVC and IVC) in

�caput Medussae� around thund the umbilicus.

Rectal anastomosis

superior rectal vein (inferior mesenteric vein and then portal veintal vein) ainferior rectal vein which drains into the internal iliac vein (from IVC system).

Superior Rectal vein (IMV) anastomoses with middle and inferior rectal vs (internal iliac v &

internal pudendal v) during portal hypertension Rectal varices (Hemorrhoids)

Internal hemorrhoids are painless superior to pectinate line at internal rectal venous plexus.

External hemorrhoids are painful due to blockage of external rectal venous plexus, where

Nociceptors (pain) are located.

48. Pancreas:

Head and uncinate process

1st part of Duodenum

2nd part of

duodenum

3rd part of duodenum

4th part of duodenum

1st-3rd parts of

duodenum

head of the pancreas

traversed by the common bile duct.

by the superior mesenteric vessels.

l It iIt includes the uncinate process which ishich is crossed by the

Cancer of the head

of the pancreas

Cancer of thof the head of the pancreas compresses the bile duct and reand results in OBSTRUCTIVE TYPE OF JAUNDICE.

Pain will bwill be conveyed to sensory neurons T5-T9 dorsal root ganglia via celiac plexus and greater splanchnic nerve.

Hepatitis also caalso causes jaundice but is associated with the fever.

NOTusually associated with fever.

If the cancer blocks the Wirsung duct, it can cause pancreatic enzymes to digest the

pancreas and the spleen via splenic artery.

Neck of the pancreas

Posterior to thto the neck of thof the pancreas is the site of formation of the PORTAL VEINL VEIN.

(1)Splenic vein joins with (2)superior mesenteric vein to form (3) portal vein.

Body of the pancreas

The body passes to the left and anterior to the (1)aorta and thand the (2) left kidney. posterior to the stomach

splenic artery undulates along the superior border of thof the body of the pancreas with the splenic vein coursing posterior to the bodhe body.

The splenic artery is tortuous and has branches

going down to perforate the pancreas.


Tail of the pancreas

l The tail of the pancreas enters the splenorenal ligament to reach the hilum of the spleen.

l It is the only part of the pancreas that is intraperitoneal.

l Tail of the pancreas may be mistakenly removed during spleenectomy (ligation of splenic artery and vein) and resulting in sugar diabetes because it contains a lot endocrine cells.


Arterial supply of the

pancreas

Head and Duodenum:

l (1) Superior pancreaticoduodenal arteries -branches of gastroduodenal artery.

l (2) Inferior pancreaticoduodenal arteries - branches of SMA

l This region is important for collateral circulation because there are anastomoses between these branches of the CA and SMA.

Neck, Body, and Tail of the pancreas:

l Pancreatic branches of the (3) Splenic artery.

1

2

3


Annular Pancreasl Annular pancreas is caused by

malformation during the

development of the pancreas,

before birth.

l Occurs when the ventral and dorsal

pancreatic buds form a ring around

the duodenum, thereby causing an

obstruction of the duodenum and

polyhydramnios

l Symptoms:

1. Feeding intolerance in newborns

2. Fullness after eating

3. Nausea and bile-stained vomiting

l Half of cases are not diagnosed

until symptoms occur in adulthood.


49. Spleen:

Rapture of the Spleen

l Rapture of the spleen may be result of the left 9th and 10th ribs fracture or blunt trauma of the left upper abdomen.

l The spleen is a peritoneal organ in the upper left quadrant that is deep to the left 9th, 10th, and 11th

ribs.

l The spleen follows the contour of rib 10 (axis of the spleen).

l When blood collected deep to the diaphragm phrenic nerveirritates and pain may irradiate to left shoulder.

l When spleen is ruptured, it cannot be sutured therefore removing is required.


Relations of the Spleen and

Left Kidney

l The spleen follows the contour of 10th riband extends from the superior pole of the left kidney to just posterior to the midaxillary line.

l The border between spleen and upper pole of the left kidney is 11th rib.


50. Kidney:

Dimensions and position

l During life, kidneys are reddish brown and measure approximately 11-12 cm in length, 5-6 cm in width, and 2.5-3 cm in thickness.

l They are extending from the level of T12 to the level of L3, the right kidney lying about2-3 cm lower than the left one.

l The lateral border of the kidney is convex. Its medial border is convex at both ends but concave in the middle where there is the hilum of the kidney (L1).


Tail of the pancreas

enters the splenorenal ligament to reto reach the hilum of the splespleen.

the only part of the pancreas that is intraperitoneal.

mistakenly removed during spleenectomy (ligation of splenic artery and vein) and reand resulting in sugar diabetes

Endocrine pancreas contains

islet of langerhans that secretes

insulin (B cells glucose uptake)

and glucagon (A cells glucose

release)

Arterial supply of the of the

pancreas

- bra- branches of SMA

(1) Superior l

arteries -pancreaticoduodenal ries -branches of gas of gastroduodenal

rtery.artery.

(2) Inferior pancreaticoduodenal (2) Inferior pancreaticoduodenal l

- braarteries - bra- bra- bra- bra- branches of SMA

Pancreatic branches of the (3) Splenic artery.

Off Common

Hepatic a of

Celiac trunk

Off celiac trunk

Annular PancreasAnnular pancreas is cais caused by

malformation during the

development of the pancreas,

before birth.

the ventral and dorsal

pancreatic buds form a ring around

the duodenum, th, thereby causing an

obstruction of the duodenum and

polyhydramnios

Polyhyrdaminos (>1500mL) AF in the amnion bc the fetus is unable to

drink and recycle it. Also caused by esophageal atresis.

(Projectile vomiting)

after eating

bile-stained vomiting

are not diagnosed (Projectile

bile-stained vbile-stained v

are not diagnare not dvomiting)

ined vomitingined vomiting

t diagnosed osed

49. Spleen:

Rapture of the Spleen

and 10th ribs fracture or bor blunt trauma of the left upper abdomen.

RUPTURE

that isthat isin the upper left quadrant that isupper left quadrant that isthat isthat isthat isthat is 9th, 10th, a, and 11thp to the left deep to th , and 1

ribs.

phrenic nerveirritates and pain may irradiate to left shoulder.

When spl n is ruptured, it hen spleen is rucannot be sutured therefore removing is reis required.

Prenatally the spleen is primary source for hematopoiesis, post birth it is site of RBC

sequester, destruction, and filtration, it produces lymphoctyes and immune

surveillance, it recycles iron and globin. (Not vital organ)

The spleen has gastric, colic, renal, and costal impressions. It contains many

lymphatic nodules, red pulp (blood sinuses) and white pulp (germinal centers).

Relations of the Spleen and

Left Kidney

leen follows 10ththe contour of rib

and extends from the superior pole of the left kidney to just posterior to the midaxillary line.

The border between spleen and upper pole of the left kidney

11this rib.

50. Kidney:

Dimensions and position

parietal lateral plate mesoderm

11-12 cm in length, 5-6 cm in width, and 2.5-3 cm in thicin thickness.

el of T12 to the level of L3, the right kidney lying about2-3 cm lower than the left one.

hilum of the kidney (L1).

Hilum of the kidney contains the renal v

(front), renal a (middle), and ureter (back).

Kidneys are intermediate mesoderm from

mesonephric duct and metanephric cap.


Anterior relations

of the right kidney

1. Right suprarenal gland

2. 2nd part of the duodenum

3. Right lobe of the liver

4. Right colic flexure

5. Small intestine


Anterior relations

of the left kidney

1. Left suprarenal gland

2. Stomach

3. Spleen

4. Body of pancreas and splenic vessels

5. Descending colon

6. Small intestine


Renal (Gerota) fascia

l Enclosing the perinephric fat is

a membranous condensation

of the extraperitoneal fascia -

the renal fascia (3).

l The suprarenal glands (4) are

also enclosed in this fascial

compartment, usually

separated from the kidneys by

a thin septum.

l N.B. The renal fascia must

be incised in any surgical

approach to this organ.

3

4


Perinephric abscess

l Most infections of the perinephric space occur as a result of extension of an ascending urinary tract infection, commonly in association with nephrolithiasis or tuberculosis.

l Perinephric abscess typically descends down between 2 sheets of the renal fascia along the psoas major muscle.

l In case if abscess locates behind of the psoas major muscle it descendsdown and may affect hip joint.

l If abscess spreads up it�ll reach the diaphragm and irritate phrenic nerve. As result patient will feel pain in shoulder region.


51. Nephrolithiasis

l Renal calculi are solid concretions

(crystal aggregations) formed in the

kidneys from dissolved urinary minerals.

l There are several types of kidney

stones. The majority are calcium

oxalate stones, followed by calcium

phosphate stones.

l Kidney stones typically leave the body

by passage in the urine stream, and

many stones are formed and passed

without causing symptoms.

l If stones grow to sufficient size before

passage (at least 2-3 mm), they can

cause obstruction of the ureter (renal

colic).


3 constrictions of ureter:

l Ureter located on the anterior surface of the Psoas major muscle and has 3 constrictions:

l 1st constriction is at the pelviureteric junction (level of L1)

l 2d constriction lies at the level of pelvic brim (level of the sacroiliac joint)

l 3d constriction appears where ureter lies obliquely in the wall of urinary bladder (level of ischial spine)

1

2


rightright kidneykidney

L2 L1

pyramidalsemilunar

Suprarenal glands/adrenal glands have 3 sources of

bloody supply: Phrenic artery (superior), aorta (mid),

and renal artery (inferior)

Pouch of Morison

left kidney

APICAL

ANTEROSUPERIOR

ANTEROINFERIOR

INFERIOR

APICAL

POSTERIOR

INFERIOR

segments of posterior kideny

ascending colon to

transverse colon

Renal (Gerota) fascia

the perinephric fat is

a membranous condensation

of the extraperitoneal fascia -

suprarenal glands (4) are

also enclosed in this fascial

compartment, u

The renal fascia must

be incised in any surgical

approach to this organ.

Paranephric fat surrounds the

renal fascia and collagen bundles

thether the renal vessels and

kidneys in a fixed position even

though supine to erect

movements (~3cm) occurs during

inspiration.

Perinephric abscess

ult of extension of an ascending urinary tract infection, co

descends down between 2 sheets of the renal fascia along the psoas major muscle.

if abscess locates behind of the psoas major muscle it descendsdown and mand may affect hip joint.

If abscess spreads up it�ll reach the diaphragm and irrand irritate phrenic nerve. As result patient will feel pain in shoulder region.

Pus around the kidney within the perinephric/renal fascia

loosely attached renal fascia in anterior and posterior

layers can allow extension of abscess

51. Nephrolithiasis

Renal calculi are soare solid concretions

(crystal aggregations) formed in the

kidneys from dissolved urinary minerals.

es of kidney

stones. T calcium

oxalate stones, foes, followed by calcium

phosphate stostones.

ally leave the body

by passage in the urine stream, and

many stones are formed and passed

without causing symptoms.

If stones grow to

age (at least 2-3 mm), they can

cause obstruction of the ureter (renal

colic).

Kidney stones that can form and become located in

the calices of the kidneys, ureters or bladder.

Renal colic is abdominal pain that courses down from

loin to groin as stone moves anteroinferiorly.

ons of ureter:

pelviureteric junction

pelvic brim

urinary bladder

3 constrictions o3 constrictions o

Short renal v and Long renal a

Long renal v and short renal a


Staghorn calculi

l Renal stone that develops in the

renal pelvis and greater calices,

and in advanced cases has a

branching configuration which

resembles the antlers of a stag.

l Staghorn calculi are composed of

magnesium ammonium

phosphate, which forms in urine

that has an abnormally high pH

(above 7.2).

l This high pH usually develops

because of recurrent urinary tract

infection with microorganisms

such as Proteus mirabilis.


52. Suprarenal glands

l They are endocrine glands

having cortex and medulla.

l The adrenal cortex [1]

secretes aldosterone,

corticosteroids and

genital hormones.

1

2

l The chromaffin cells of the adrenal medulla [2]

secrete two catecholamines: epinephrine and

norepinephrine, which affect smooth muscle, cardiac

muscle, and glands in the same way as sympathetic

stimulation.

l Sympathetic stimulation or hypersecretion of catecholamines (tumor of adrenal medulla or sympathetic chain ganglia) resulting in: episodes of tachycardia, sweating and high blood pressure.


Unpaired tributaries of IVC

l The right renal (1) vein is much shorter than the left. Both veins lie anterior to the corresponding artery in hilum of kidneys.

l The long left renal vein (2)is joined by the left suprarenal (3) and leftgonadal (4) (testicular orovarian) veins before it reached IVC.

l Right suprarenal vein and right gonadal vein drain directly to IVC (unpaired IVC tributaries).

1

2

3

4


53. Varicocele

l It is enlargement of the pampiniform plexus that produces a wormlike scrotal mass and enlargement of the spermatic cord. Varicocele may be reason of low sperm count.

l Varicocele formation is usually on the left side and may disappear in supine position of the body.

l Varicocele may indicate kidney disease or may signal a retro peritoneal malignancy obstructing the testicular vein.


Pampiniform plexus

l Each testicular or ovarian vein is formed by coalescence of a pampiniform plexus: the testicular at the deep inguinal ring, the ovarian at the margin of the superior aperture of the pelvis.

l The veins run accompanied by the corresponding arteries. The left pampiniform plexus enters the left renal vein; the right one enters directly the IVC inferior to the renal vein.

l That is why varicocely (engorgement of the pampiniform plexus that produces a scrotal mass) is more often located on the left.


54. Hydrocele

l The tunica vaginalis testis or other remnants of the processus vaginalis may form a hydrocele or hematocele.

l In spermatic cord it is smooth sausage-shaped structure that persists under gentle compression and isn�t disappear in supine position.

l In the scrotum with transillumination, a hydrocele produces a reddish glow, whereas light will not penetrate other scrotal masses such as a hematocele, solid tumor, or herniated bowel.


Staghorn calculi

renal pelvis and greater calicter calices,

branching cg configuration whing confi

magnesium ammonium

phosphate, which forms in urine

that has an abnormally high pH

e of recurrent urinary tract

infection with microorganisms

such as Proteus mirabilis.

Nephroptosis: Drop kidney >3cm when standing, suprarenal glands stay in place within perinephric fat, ureters coil/kink.

Ectopic kidneys: abnormal location and formation congenitally.

Horseshoe kidney: inferior poles of kidneys fuse during embryonic development and are inhibited from ascending by IMA

Pancake kidney: inferior and superior poles of kidneys fuse into disc shape organ, also inhibited by IMA.

Pelvic kidney: failure of ascent of kidneys so they remain in pelvic region still attached to embryological renal vessels off common iliacs.

Renal agenesis (absent of kidneys) is common cause of oligohydraminos (<400mL AF) that can lead to pulmonary hyperplasia.

Hydronephrosis: extreme dilation of renal pelvis and calices due to obstruction of renal ureters, typically due to accessory renal vessels.

52. Suprarenal glands

endocrine glands

having cortex and medulla.

,

corticosteroids and

genital hormones.

The adrenal cortex [1]

secretes aldosterone,

The chromaffin cells of the adrenal medulla [2]

secrete two catecholamines: epinephrine and

norepinephrine, w

Sympathetic stimulation or hor hypersecretion of catecholamines ((tumor of adrenal medulla or sympathetic chain ganglia) re) resulting in: episodes of tachycardia, sweating and high blood pressure.

Congenital Adrenal Hyperplasia (CAH):

excessive androgen production bc of cortex

hyperplasia causing virilization of female genitals

h blood pressure.h blood pressure.

Congenital Adrenal Hyperplasia (CAH):

excessive androgenandrogenandrogen production bc of cortex

hyperplasia causing virilization of female genitals

Unpaired tributaries of IVC

right renal (1) vein isvein is much shorter

The long left renal vein (2)is joined by the left suprarenal (3) and leftgonadal (4)

Right suprarenal vein avein and right gonadal vein drvein drain directly to IVC

3. Varicocele53. Var3. Var

Nutcracker Syndrome: L Renal v passed UNDER the SMA

and ABOVE Aorta. Compression will cause backflow into the

L gonadal vein to pampiniform plexus.

.

May be mistaken for Hydrocele (fluid/blood) within tunica

vaginalis of the scrotum, but when lying down Hydrocele

DOES NOT Disappear!

enlargement of thof the pampiniform plexus that produces a wormlike scrotal mass

the left side and mand may disappear in supine position of the body.

Pampiniform plexus

ach testicular or ovarian vein is formed by coalescence of a pampiniform plexum plexus: the

That is why varicocely (engorgement of the pampiniform plexus that produces a scrotal mass) is mis more often located on the left.

54. Hydrocele

tunica vaginalis testis ostis or other remnants of the processus vaginalis may form a hydrocele or hematocele.

transillumination, a hydrocele produces a reddish glow, whereas light will not penetrate other scrotal masses such as a hematocele, solid tumor, or herniated bowel.

Testicular torsion is twisting of the testis within the

scrotum, it can cause ischemia to the blood vessels

and must be corrected quickly or may lose testis.

spermatocele

Cryptochidism: failure of testis to descend by age 6-9mo can cause infertility


55. Hemorrhoids:

Venous drainage from rectum

l Above pectinate line: superior

rectal vein [1] into portal

system [2].

l Below pectinate line: inferior

rectal vein [3] into inferior

vena cava [4].

1

2

3

4


External hemorrhoids

l Hemorrhoids are masses that

typically protrude from anus

during defecation.

l Hemorrhoids are commonly

associated with constipation,

extended sitting and straining at

the toilet, pregnancy, and

disorders that hinder venous return.

l 1. External hemorrhoids are

dilated tributaries of the inferior

rectal veins (IRV) BELOW THE

PECTINATE LINE and are painful

because the mucosa is supplied by

somatic afferent fibers of the

inferior rectal nerves (from

pudendal).

1

1


Internal hemorrhoids

l 2. Internal hemorrhoids are dilated tributaries of the superior rectal veins (SRV) ABOVE THE PECTINATE LINE and are not painful because the mucosa is supplied by visceral afferent fibers.

l Internal hemorrhoids frequently develop in chronic alcoholics because of liver cirrhosisand portal hypertension syndrome.

2

2

2


56. Perineal pouches:

Deep perineal pouch

The deep perineal pouch is

formed by the fasciae and

muscles of the urogenital

diaphragm.

It contains:

1. Sphincter urethrae

muscle

2. Deep transverse

perineal muscle

3. Bulbourethral

(Cowper) glands (in

the male only) - ducts

perforate perineal

membrane and enters

bulbar urethra.


Superficial perineal pouch1. Ischiocavernosus muscle � related to the Crus of the

penis (Male) & Crus of the clitoris (Female)

2. Bulbospongiosus muscle � related to the Bulb of vestibule (Female) & Bulb of the penis (Male)

3. Superficial transverse perineal muscle � related to the Perineal body (both genders)

1

2

3


Urine leaks

l After a crushing blow or a

penetrating injury, the spongy

urethra commonly ruptures

within the bulb of the penis, and

urine leaks into the superficial

perineal pouch.

l The superficial perineal fascia

keeps urine from passing into the

thigh or the anal triangle, but after

distending the scrotum and penis,

urine can pass over the pubis into

the anterior abdominal wall deep

to the deep layer of superficial

abdominal fascia.


55. Hemorrhoids:

Venous drainage from rectum

Above pectinate linate line: superior

rectal vein [1] into portal

system [2].

Below pectinate linate line: inferior

rectal vein [3] into inferior

vena cava [4].

PAINFUL

PAINLESS

External hemorrhoids

protrude from anus

during defecation.

constipation,

extended sitting and straining at

the toilet, pregnancy, and

disorders that hinder venous return.

BELOW THE

PECTINATE LINE and aand are painful

Internal hemorrhoids

are dilated tributaries of the superior rectal veins (SRV) ABOVE THE PECTINATE LINE and aand are not painful

frequently develop in chronic alcoholics because of liver cirrhosisand portal hypertension

56. Perineal pouches:

Deep pouchperineal

the fasciae and

muscles of the urogenital

diaphragm.

1. Sp1.1. Sp1. Sphincter urethrae

muscle

2.2.2. Deep transverse

perineal muscle

3.3. Bulbourethral

(Cowper) glands (inds (in

the male only) -) - ducts

perforate perineal

membrane and enters

bulbar urethra.

Superficial perineal pouchIschiocavernosus muscle �

Bulbospongiosus muscle �

Superficial transverse perineal mneal muscle �

Essential for integrity of the pelvic floor, Damage leads to prolapse of uterus, rectum, and urinary bladder

Males: between bulb of penis and anus, Females: between vagina and anus

Episiotamies in mediallateral incisions are made to widen pouch for labor, and to fix prolapses.

Bound laterally by Ishiopubic rami

& deep internal pudendal vessels

and pudendal n (dorsal VAN)

Bound inferiorly by perineal membrane and superiorly by pelvic diaphragm.

Dorsal neurovascular structures

of the glans penis and clitoris

Urine leaks

After a crushing blow or a

penetrating injury, the spongy

urethra commonly ruptures

within the bulb of the penis, an, and

urine leaks into thinto the superficial

perineal pouch.

The superficial perineal fascia

keeps urine from parom passing into the

thigh or the anal triangle, but after

distending the scrotum and penis,

urine can pass over the pubis into

the anterior abdominal wall deep

to the deep layer of superficial

abdominal fascia.Fractures of the pelvic girdle can rupture the intermediate urethra and

cause extravasation of urine and blood into deep peritoneal pouch that may

pass through urogenital hiatus to bladder and prostate.

Straddle injury or false passage of catheter

Congenital persistence of allantois into urachus of the umbilicus can cause

urine to leak from belly button.


57. Ischiorectal abscess

2

3

l Ischiorectal abscess [1] is an important surgical condition which usually results from spread of an infection through the external sphincter ani into the ischiorectal fossa [2].

l Ischiorectal abscess is a surgical

emergency which should be

immediately drained by a wide cruciate

incision through the skin of the base of

the fossa to avoid fistula formation.

l A surgeon should avoid lateral wall of

ischiorectal fossa because here located

Pudendal (Alcock's) canal [3] with

pudendal nerve and internal pudendal

artery.1


58. Cystocele

(hernia of bladder)

l Loss of bladder support in

females by damage to the

pelvic floor during childbirth

(e.g., laceration of perineal

muscles or a lesion of the

nerves supply).

l It can result in protrusion of

the bladder onto the

anterior vaginal wall and

loss of urine when a women

strains or coughs.


59. Paracentesis of Urinary

Bladder

Suprapubic aspiration:

l Urine can be removed from the bladder without penetrating the peritoneum by inserting a needle JUST ABOVE the pubic symphysis.

l The needle passes successively through skin, superficial and deep layers of superficial fascia, linea alba, transversalis fascia, extraperitoneal connective tissue, and wall of the bladder.


60. Prostate tumors:

Prostate cancer

l It usually begins in the posterior lobe of the gland, and early stages are often asymptomatic, may be found during digital rectal examination.

l Prostatic malignancies tend to metastasize to vertebrae and the brain because the prostatic venous plexus has numerous connections with the vertebral venous plexus via sacral veins.

A

P

M


Benign hypertrophy of the

prostate (BHP)

l BHP is common in men after middle age.

l Prostate adenoma (benign hypertrophy) usually involves median lobe.

l BHP is a common cause of urethral obstruction, leading to nocturia (need to void during the night), dysuria(difficulty and/or pain during urination), and urgency(sudden desire to void).

l The prostate is examined for enlargement and tumors by DIGITAL RECTAL examination.


Prostatectomy

l A prostatectomy may be performed through a suprapubic [1] or perineal [2] incision or transurethrally [3].

l Because of damage to nerves in the capsule of the prostate and around the urethra (cavernosus nerves) can cause impotence (erectaile dysfunction) and/or urinary incontinence.

l Pelvic splanchnic nerves may be injured in case of intensive dissection of pelvic lymph nodes (prostatic cancer ectomy) and as result autonomic innervation of derivate of hindgut may be affected.

12

3

Transurethral

resection of the

prostate = TURP


57. Ischiorectal abscess

rom spread of an infection through the external sp cter ani into the rnal sphincter anischiorectal fossa [2].

surgical

emergency which shhich should be

immediately drained

uld avoid lateral wall of

ischiorectal fossa because here located

Pudendal (Alcock's) canal [3] with

pudendal nerve and internal pudendal 1 artery.

a to avoid fistula formation.

Fistulas are abnormal connections of organs and

tissues, Ischiorectal abscesses can travel to both sidess

and spread infection through the fat fad that raps

posteriorly around the rectum. Incisions must be made

as medial as possible. If Pudental canal is affected

there will be no arousal. Abscesses are also prone to

supralevator, internsphincteric, or perianal.

58. Cystocele

(hernia of bladder)

Loss of bladder support in

females by daby damage to the

pelvic floor during chring childbirth

protrusion of

the bladder onto the

anterior vaginal wall and

loss of urine when a hen a women

strains or coughs.

In extreme cases it can lead to

vaginal prolapse

59. Paracentesis of Urinary

Bladder

Suprapubic aspiration:Su

by inserting a needle JUST ABOVE the pubic symphysis.

Suprapubic cystotomy of a full bladder, as the

empty bladders lies just at height of pubis

does not transverse peritoneum

60. Prostate tumors:

Prostate cancer

ally begins in the posterior lobe of thof the gland, and early stages are often asymptomatic, may be found during digital rectal examination.

tatic malignancies tend to metastasize to vertebrae and the brain because thuse the prostatic venous plexus has nhas numerous connections with the vertebral venous plexus via sacral veinral veins.

Benign hypertrophy of prostate (BHP) is

common after middle age in majority of males

distorts the prostatic urethra (middle lobe).

Malignant tumors are irregular and hard and

often found in posterior lobe due to its

proximity to seminal vesicles and lymph.

Full bladder during exam tokeep prostate in place

Benign hypertrophy of the

prostate (BHP)

Prostate adenoma (be(benign hypertrophy) usually involves median lobian lobe.

nocturia (ne(need to void during the night), dysuria(difficulty and/or pain during urination), and urgency(sudden desire to void).

typically middle lobe Prostatectomy

suprapubic [1] or perineal [2] incision orsion or transurethrally [3].

allows preservation ofneurovasculature

Transurethral

of the resection of th

prostate = TURPTUR

Posterior lobe is mostly metastatic and spreads via Batson's plexus (male has lower back pain)

DIGITAL RECTAL examination.


61. Male urethra

Prostatic 1st part

l It is the widest and the most dilatable part.

l It is spindle shaped (middle part is dilated)

l Its posterior wall presents the following features:

1. Seminal colliculus

2. Openings of the 2 ejaculatory ducts are seen on each side on the seminal colliculus.

3. Ducts of the prostate gland open into the male urethra


Membranous 2nd part

l Passes through the urogenital diaphragm to enter the bulb of the penis

l It is the shortest, NARROWEST and the least dilatable part

l It is surrounded by the external sphincter urethra

l Bulbourethral glands lie posterolateral to this part inside of urogenital diaphragm (deep perineal pouch)


Spongy 3rd part

l Longest part: average 15 cm in length.

l Passes through the bulband corpus spongiosum of the penis to open at the external urethral orifice on the tip of the glans penis.

l There are two dilatations � bulbar fossa (in the beginning) and navicular fossa (in the glans penis)

l Ducts of the bulbourethral glands open into the floor of the spongy part in its beginning


2 sphincters of the urethra

1. Internal urethral sphincter is made of smooth muscles in the neck of the bladderand has sympatheticinnervation

2. External urethral sphincter has skeletal muscle fibers and surrounds the membranous part of urethra, supplied by the perineal branch of the pudendal nerve

1

2


62. Ejaculatory duct

l It is a very narrow duct

2 cm long

l Formed by union of

ductus deferens and

duct of seminal vesicle

l It serve to passage of

seminal fluid from

ductus deferens to

prostatic urethra.


63. Pudendal nerve (S2-S4)

l It is PRINCIPAL SOMATIC (motor and sensory) nerve to supply perineum.

l Lies against ischial spine as it passes through lesser sciatic foramen to traverse pudendal canal on lateralwall of ischiorectal fossa.

Branches:

l 1. Inferior rectal nerve

l Supplies external anal sphincter muscle and skin around anus

l 2. Perineal nerve

l Deep branch is motor nerve to muscles of urogenital triangle.

l Superficial branch gives cutaneous posterior scrotal/labial branches.

l 3. Dorsal nerve of penis or clitoris

l Supplies body, prepuce, and glans of penis or clitoris

1

2

3


61. Male urethra

Prostatic 1atic 1st part

s the widest and the most dilatable part.

Seminal colliculus

Openings of the 2 ejaculatory ducts are seare seen on each side on the seminal colliculus.

Ducts of the prostate gland open into the male urethra

opening of seminal glands

ductus deferens

Seminal vesicles secrete alkaline fructose solution that nourishes and provides energy for the sperm.Prostate gland secretes a milky fluid (20% of semen volume) and plays role in sperm activation.Bulbourethral glands (cowper's glands) secrete mucous solution that neutralizes urine within the urethra.

Membranous 2ous 2nd part

urogenital diaphragm to eto enter the bulb of the penis

shortest, NARROWEST and the least dilatable part

It is surrounded by the external sphincter urethra

(deep perineal pouch)

Spongy 3ngy 3rd part

Longest part: avart: average 15 cm in length.

bulband corpus spongiosum of the penis to open at the external urethral orifice on the tip of the glans penis.

bulbar fossa (in(in the beginning) and navicular fossa (in(in the glans penis)

The 1st and 2nd parts of the urethra are urogenital endoderm and the external urethra meatus is ectodermThe ductus deferens is intermediate mesoderm of the remaining mesonephric duct/tubules

2 sphincters of the urethra

Internal urethral cter is made of sphincter is

smooth muscles incles in the neck of the bladderand has sympatheticinnervation

External urethral sphincter has skeletal muscle fibers and surrounds the membranous part opart of urethra, su

pudendal nerve

Muscle of the bladder is Detrusor m, the urinary trigone is where theentrance of the 2 ureters and exit of bladder meet. Internal urethralsphincters are involuntary.

62. Ejaculatory duct

ery narrow duct

2 cm long

union of

ductus deferens and

duct of seminal vesicle

63. Pudendal nerve (S2-S4)

PRINCIPAL SOMATIC ((motor and sensory) nerve to supply perineum.

ugh lesser sciatic foramen to traverse pudendal canal on lateralwall of ischiorectal fossa.

Inferior rectal nerve

Supplies external anal sphinctel incter hincter

2. Perineal nerve

Deep branch is motor nerve to muscles l

of urogenital triangle.

Superficial branch gives cutaneous l

posterior scrotal/labial branches.

3. Dorsal nerve of penis or clitoris

Supplies body, prepuce, and glans of l

penis or clitoris

CREMASTERIC REFLEX: Genitofemoral nerve L1-2, Genital branch: within inguinal canal with the cremasteric m and fascia acts asmotor division to pull testis up. Femoral branch is the sensory division of the reflex that is stimulated by touch and temperature


Pudendal nerve block

l To relieve pain for the mother and prepare for an episiotomy, a pudendal nerve block may be administered during early labor.

The nerve may be blocked in 2 ways either:

1. by piercing the vaginal wallposterolaterally near the ischial spine or

2. percutaneously along the medial side of the ischial tuberosity.

l Note: Pain from uterine contractions is

unaffected because pelvic visceral

pain is carried by afferent fibers

accompanying autonomic nerve fibers.


64. Nerve supply of pelvic

viscera

Parasympathetic innervation:

l Preganglionic neurons are located in sacral parasympathetic n. (S2-S4) in the spinal cord.

l Their processes run into pelvic splanchnic nerves and relay with postganglionic neurons located inside of pelvic organs in the intramural plexus.

Sympathetic innervation:

l Sympathetic fibers of preganglionic neurons T12-L2 segments (IML) come through the sympathetic trunk and form sacral splanchnicnerves.

l They contribute to the inferior hypogastric plexus, where postganglionic neurons are located. Branches of inferior hypogastric plexus reach organs wrapping around the branches of the internal iliac artery.

Sensory innervation:

l The sensory fibers from S2-S4 dorsal root ganglia move together with parasympathetic and carry pain sensations from the organs.


Micturition reflex

Facilitating emptying:

l Parasympathetic fibers (pelvic splanchnic nn.) stimulateDETRUSOR MUSCLE [1] contraction and involuntary relax internal sphincter [2].

l Somatic motor fibers (pudendal nerve) cause voluntary relaxation of external [3] urethral sphincter.

Inhibiting emptying:

l Sympathetic fibers (sacral splanchnic nn.) inhibit detrusor muscle [1] and stimulate internal sphincter [2].

1

2

3


65. Erection and ejaculation l Afferent fibrous: Dorsal nerve of penis or clitoris from

Pudendal nerve (DRG S2-S4)

l Efferent fibrous:

l Erection: Parasympathetic fibers (S2-S4) from the Pelvic splanchnic nerves dilate arteries supplying erectile bodies of the penis, allowing them to fill with blood. Somatic motor (S2-S4) fibrous from the pudendal nerves cause contraction of ischiocavernosus and bulbospongiosus muscles to press the root of the penis and relax external urethral sphincter.

l Ejaculation: Sympathetic fibers (L1-L2) from the Inferior hypogastric plexus (Sacral splanchnic nerves) cause contraction of smooth muscle of epididymis, ductus deferens, seminal vesicles, and prostate; sympathetic nerve fibers stimulate internal urethral sphincter to prevent semen from entering bladder or urine entering prostatic urethra.


66. Cryptorchism

l Undescended testes

(cryptorchism) when the testes

fail to descend into the scrotum.

This normally occurs within 3

months after birth.

l The undescended testes may be found in the abdominal cavity or in the inguinal canal.

l If neglected, malignant transformation may occur in the undescended testis.

l N.B. In case of cryptorchism, spermatogenesis is arrestedand the spermatogenic tissue is damaged leading to permanent sterility in bilateral cases.


67. Torsion of the spermatic

cord

Main components of the spermatic cord:

l Ductus deferens

l Testicular artery � direct branch of Aorta

l Pampiniform plexus to become single testicular vein (right ! IVC, left ! Left renal vein)

l Torsion of the spermatic cord produces acute pain with swelling because of twisting of testicular artery that can result in testicular avascular necrosis.

l Repair requires a high scrotal incision to untwist the cord, and the testis is sutured to the scrotal septum to prevent recurrence.


Pudendal nerve block

relieve pain for thfor the mother and prepare for an episiotomy, a

vaginal wallposterolaterally near the ischial spine or

2. percutaneously along thlong the medial side of the ischial tuberosity.

Doctors hand is placed between the baby's head and the pudendal nerve.

64. Nerve supply of pelvic

viscera

Parasympathetic innervation:

Preganglionic(S2-S4)

pelvic splanchnic nerves postganglionic neurons lorons located inside of pelvic organs in the intramural pleral plexus.

Sympathetic innervation:

nepreganglionic T12-L2 the sympathetic trunk and form sacral splanchnic

nerves.

inferior hypogastric pletric plexus, wpostganglionic neurons arerons are located. Bra

Sensory innervation:

from S2-S4 dorsal root ganglia move together with parasympathetic and caand carry pain sensations fro

PNS Pelvic Splanchnic nerves to intramural plexus

SNS Sympathetic Trunk to Sacral Splanchnic nerves to inferior hypogastric plexus

Sensory DRG ride with PNS for PAIN

Micturition reflex

Facilitating emptying:

ers (pelvic splanchnic nn.) stimulate

ers (pudendal nerve) cause voluntary relaxation of external [3] u[3] urethral sphincter.

and involuntary relax sphincter [2].

Inhibiting emptying:

ers (sacral splanchnic nn.) in.) inhibit detrusor muscle [1] and stimulate internal sphincter [2cter [2].

[1] DETRUSOR MUSCLE [1] [1DETRUSOR MUSCLE [1] [1] contraction and in and involuntary relax internal sphinc

PNS & Pudendal to pee!

SNS to stop!

65. Erection and ejaculation

Pudendal nerve (DRG S2-S4)

Pelvic splanchnic nerves

pudendal nerves

and relax external urethral sphincter.

us (Sacral splanchnic nerves) contraction of smooth muscle of epididymis, ductus deferens, seminal vesicles, and prostate; sympathetic nerve fibers stimulate internal urethral sphincter to pto prevent semen from entering bladder or urine entering prostatic urethra.

1. Erection: PNS S2-4 fill blood, Ischiocavernosus m keeps erect, and bulbospongiosus m

prevents venous drainage.

2. Emission: SNS move sperm from epididymis and cause gland secretions

3. Ejaculation: SNS Closure of Internal sphincter, contraction of urethral m and

bulbospongiosus m

4. Remission: blood leaves

66. Cryptorchism

Undescended testes

This normally occurs within 3

months after bifter birth.

found in the abdominal cavity or in the inguinal canal.

malignant transformation may omay occur in the undescended testis.

spermatogenesis is arrested

67. Torsion of the spermatic

cord

ces acute pain with swelling because of twisting of testicular artery that cathat can result in testicular avascular necrosis.

untwist the cord, a, and the testis is sutured to the scrotal septum to prevent recurrence.


68. Lymphatic drainage of the

male viscera

n Testis & epididymis � lumbar

lymph nodes

n Scrotum � superficial inguinal

nodes

n Penis:

n skin - superficial inguinal nodes

n glans � deep inguinal nodes

n body and roots � internal iliac

nodes

n Prostate gland & bladder - internal

iliac nodes

n Anal canal:

n above pectinate line - internal iliac

n below pectinate line - superficial

inguinal nodes


Lymphatic drainage from the

female visceran Ovary and uterine tubes � to Lumbar

lymph nodes

n Uterus:

n lateral angle and teres ligament �Superficial inguinal lymph nodes

n fundus and upper part of the body- Lumbar lymph nodes

n lower part of the body - External iliac lymph nodes

n cervix - External & Internal iliac

n Vagina:

n Superior to hymen - to External & internal iliac

n Inferior to hymen - to Superficial inguinal nodes

n All external genitalia (with exception -glans clitoris) - Superficial inguinal lymph nodes

n Glans clitoris � Deep inguinal


69. Arterial supply of the uterus

and Hysterectomy

The uterus is almost exclusively

supplied by the uterine arteries

[1] (from internal iliac artery):

l Uterine a. crosses pelvic floor in

cardinal ligament [2]

l Ureter passes superior and

anterior to uterine artery[3]

l Ascending branch [4] of uterine

artery comes along lateral wall of

uterus within broad ligament.

2

1

3

4

Note: During hysterectomy ureter in the

greatest risk because of close relations

with uterine artery and cervix of the

uterus.


Hysterectomy

l Hysterectomy is surgical removing of the

uterus and may include removing of the cervix

(total) and the vagina (radical).

l Blood supply to the ovaries is saved in case of

partial hysterectomy ovarian suspensory

ligament should be left intact because contain

ovarian artery (direct branch of abdominal

aorta) and vein.

l In case of total hysterectomy (with cervix)

pelvic splanchnic nerves may be affected.

That�s resulting in bladder dysfunction

because of detrusor urine muscle loose

parasympathetic innervation.


70. Parts of the uterine tube

l Uterine partl Pierces uterine wall to

open into uterine cavity

l Isthmusl Narrowest part of tube

just lateral to uterus

l Ampullal Medial continuation of

infundibulum comprising about half of uterine tube

l Usual site of fertilization

l Infundibuluml Funnel-shaped expansion

of lateral end, fringed with fimbriae

l Overlies ovary and receives oocyte at ovulation


Hysterosalpingography

l The instillation of

viscous iodine

through the

external os [1] of

the uterine cervix

allows the lumen of

the cervical canal

[2], the uterine

cavity [3], and the

different parts of

the uterine tubes

[4] to be visualized

on X-ray.

1

2

34


68. Lymphatic drainage of the

male viscera

Testis & epididymis � lumbar

lymph nodes

Scrotum � superficial inguinal

nodes

Penis:

skin - superficial inguinal nodesn

glans � deep inguinal nodesn

body and roots � internal iliac n

nodes

Prostate gland &land & bladder - internal

iliac nodes

Anal canal:

above pectinate line - internal iliacn

below pectinate line - superficial n

inguinal nodes

Deep inguinal nodes-> superficial inguinal nodes-> internal & external iliac nodes-> lumbar nodes-> paraaortic nodes-> thoracic duct

Ovary and uterine tubes � to� to Lumbarlymph nodes

Uterus:

lateral angle and teand teres ligament �n

Superficial inguinal lymph nph nodes

fundus and upper part opart of the bodyn

- Lumbar lymph noph nodes

lower part opart of the body - External n

iliac lymph noph nodes

cervix - External & Internal iliacn

Vagina:

Superior to hymen - to External & n

internal iliac

Inferior to hymen - to Superficial n

inguinal nodes

All external genitalia (w(with exception -glans clitoris) - Superficial inguinal lymph nodes

Glans clitoris � Deep inguinaln

69. Arterial supply of the uterus

and Hysterectomy

uterine arteries

[1] (from internal iliac artery):

Ureter passes below the Uterineartery (bridge over water)

Uterine a anastamosis withOvarian a from aorta on lateralsides of the uterus. Both need tobe taken out so that the pt does notbleed out..The Uterine a is homologous to theductus deferens a in males and theOvarian a is the testicular a inmales

l Hysterectomy is suis surgical removing of the

uterus and mand may include removing of the cervix

(total) and thand thand th vagina (radical).and thand the vagina (ra

Blood supply to the ovaries is saved in case of Blood supply to the ovaries is sal

partial hysterectomy ovarian suspensory

ligament should bould be left intact because contain

ovarian arian artery rian ar

se of total hysterectomy (with cervix)

pelvic splanchnic nerves may bemay be affected.

That�s resulting in bladder dbladder dysfunctionlting in bladder d

because of detrusor uusor urine m

etic in

rine muscle rine m loose

etic inparasympathetic in

No contraction of bladder and no relaxation ofinternal sphincter.

f the uterine turine tuberine tu

l

oviduct, fallopian tube, ovarian tube...

l Uterine part

Isthmus

Ampulla

Infundibulum

fimbriae

Overlies ocyte at

rlies ovary and Overlies ovl

receives oocyte cyte at cyte receives oocyte

Cornua of the uterus

Hysterosalpingography

Ampulla is the site of ectopic pregnancy if the fertilized

ovum does not make its way to the fundus of the uterus.

The Uterine Triad: Fallopian tube, Round lig of uterus (inguinal

canal), and ovarian lig come off the fundus of the uterus.

tion of

viscous iodine

through the

external os [1] of

the uterine cervix

allows the lumen of

the cervical canal

[2], th, the uterine

cavity [3], a, and the

different parts of

the uterine tubes

[4] to bto be vto be visualized

on X-ron X-rn X-ray.n X-raon X-raon X-ra

Can be used to detect uterine tube

obstructions or malformations of uterus/

vagina (bicornate uterus)


71. Branches of the Internal

iliac artery

Anterior Division Posterior Division

1. Obturator 1. Iliolumbar

2. Umbilical 2. Lateral sacral

3 Inferior gluteal 3. Superior gluteal

4. Internal pudendal

5. Inferior vesical (males)

or

Vaginal (females)

6. Middle rectal

7. Uterine (females)


Internal iliac artery


72. Fracture of the

anterior cranial fossa

l Fracture of the anterior cranial

fossa (Cribriform plate of the

Ethmoid bone) is suggested by

anosmia, periorbital bruising

(raccoon eyes), and CSF leakage

from the nose (rhinorrhea).


73. Cranial Malformations

l [A] Scaphocephaly: premature

closure of the sagittal suture, in

which the anterior fontanelle is small

or absent, results in a long, narrow,

wedge-shaped cranium.

l [C] Oxycephaly: premature closure

of the coronal suture results in a

high, tower-like cranium.

l When premature closure of the

coronal or the lambdoid suture occurs

on one side only, the cranium is

twisted and asymmetrical, a condition

known as plagiocephaly [B].


74. Epidural hematoma

l Skull fracture near pterion often

causes epidural hematoma from

torn middle meningeal artery

(foramen spinosum).

l Unconsciousness and death are

rapid because the bleeding

dissects a wide space as it strips

the dura from the inner surface of

the skull, which puts pressure on

the brain.

l An epidural hematoma forms a

characteristic biconvex pattern

on computed tomography

images.


76. Infection of the Cavernous

sinus

Structures which may be affected by cavernous sinus thrombosis:

1. Structures that pass throughsinus directly:

Ø Internal carotid artery (in case of laceration - arteriovenous fistula)

Ø Abducens nerve CN VI (in case of lesion - internal squint)

2. Structures on lateral wall of sinus:

Ø Oculomotor nerve (CN III)

Ø Trochlear nerve (CN IV)

Ø V1

Ø V2


71. Branches of the Internal

iliac artery

aberrant or accessory arteries are common in obturator, inferior vesicle

w/ superiorvesicle of bladder

ductus deferens

bladder

urachus

bladder

obturator canal

to medial sacral a

gluteus maximus

gluteus med & min

coccygeus m

genitals

between lumosacral trunk & S1

to medial sacral a

goes back up

alcock's canal

Internal iliac arteryInternal iliac artery

to medial

gluteus maximusmaxi

gluteus

72. Fracture of the

anterior cranial fossa

(Cribriform plate of the

Ethmoid bone)

anosmia, periorbital bruising

(raccoon eyes), and CSF leakage

from the nose (rhinorrhea).

73. Cranial Malformations

[A] Scaphocephaly: premature

closure of the sagittal suture, in

long, narrow,

wedge-shaped cracranium.

[C] Oxycephaly: premature closure

of the coronal suture

high, tower-like cracranium.

coronal or the lambdoid suture occurs

on one side only, the cranium is

twisted and asymmetrical, a condition

known as plagiocephaly [B]

Craniosyntosis-FGFR2 gene mt

74. Epidural hematoma

torn middle meningeal artery

(foramen spinosum)

Unconsciousness and death are

rapid because thuse the bleeding

dissects a wide space as it strips

the dura from the inner surface of

the skull, which puts pressure on

the brain.

ristic biconvex pattern

Bean Bleed

Subdural Hematoma: blood spread over brain, Shaken Baby

Syndrome, coup and counter coup injuries, cause bleeding from

bridging veins

can push uncus through foramen magnum and compress CNIII causing pupillary

dilation (SNS) bc no PNS to constrictor, eye points down and out (CNVI and IV take

over), ptosis bc levator palpebrae m

pterionSkull fracture near

76. Infection of the Cavernous

sinus

cavernous sinus thrus thrombosis:

Internal carotid artery

Abducens nerve CN VI

Oculomotor nerve (CN III)

Ø Trochlear nerve (CN IV)

Ø V1

Ø V2

Medial Rectus adduction takes over (cross-eyed) initially, if bleed persists

then lateral wall structures will be affected: loss of eye movements and

visual acuity. Loss of sensory to face


Dangerous triangle of the face

l The middle third of the face is a "danger area� because infection there may produce thrombophlebitis of the facial vein that can spread to the cavernous sinus via ophthalmic veins or pterygoid venous plexus.

l Septicemia leads to meningitis and cavernous sinus thrombosis, both of which can cause neurological damage and are life-threatening.


77. Pituitary gland tumors and

transsphenoidal operation

l Pituitary tumors [1] may extend

superiorly through opening in the

diaphragma sella, producing

disturbances in endocrine system.

l Superior extension of a tumor may

cause visual deficit owing to pressure

on the optic chiasm [2], the place

where the optic nerve fibers cross.

l The transsphenoidal operation is the

most common operation for a pituitary

tumor. The surgical approach for it is

through the nose, nasal cavity and

sphenoidal sinus [3]. This surgical

approach provides the best exposure

of the tumor at the lowest risk.

12

3


Hormones of the pituitary

gland

l Releasing and inhibiting factors

from neurosecretory cells of the

hypothalamus reach pituitary

gland thought special capillary

network � hypophyseal portal

system and control the production

of adenohypophyseal hormones

(ACTH, FSH, LH, TSH, prolactin

and somatotropin).

l Hormones of neurohypophysis

(ADH and Oxytocin) are secreted

in hypothalamus and transported

through axons to pituitary gland.


78. Trigeminal nerve

l Skin of face supplied by branches of the three divisions of the [1] TRIGEMINAL NERVE (CN V)

l Except for a small area over the angle of the mandiblewhich is supplied by the [2] great auricular nerve(C2-C3) � cervical plexus

2

1

Infraorbital

foramen


79. Bell's palsy

l It is idiopathic unilateral facial

paralysis.

l Terminal branches of CN VII

may be injured by parotid

cancer or inflammation

(parotitis) by surgery to

remove a parotid tumor

(stylomastois foramen).

l Manifestations:

l unable to close lips and eyelids on affected side

l eye on affected side is not lubricated (dry eye)

l unable to whistle, blow a wind instrument, or chew effectively

l facial distortion due to contractions of unopposed contralateral facial

muscles


80. Epistaxis

l Epistaxis (nosebleed) most often occurs from the anterior nasal septum (Kiesselbach's area), where branches of the sphenopalatine, anterior ethmoidal, greater palatine, and superior labial (from facial) arteries converge.


Dangerous triangle of the face

Facial v (cheeks)-> angular v (lateral nose)-> opthalmic v (super& inferior eye)-> Cavernous sinus (BRAIN)

swelling of v w/ blot

clot that goes to brain

thrombophlebitis o

Septicemia leads to meningitis and cavernous sinus thrombosis,

are life-threatening. bacterial infection response

77. Pituitary gland tumors and

transsphenoidal operation

Pituitary tumors [1

disturbances in endocrine sysine system.

Superior extension of a tumor may

cause visual deficit owing to pressure

on the optic chiasm

The transsphenoidal operation is the

most common operation for a pituitary

tumor. Th

through the nose, nasal cavity and

sphenoidal sinus [3][3]. This surgical

approach provides the best exposure

of the tumor at the lowest risk.

Hormones of the pituitary

gland

Releasing and inhibiting factors

from neurosecretory cells of the

hypothalamus

rk � hypophyseal portal

system and coand control the production

of adenohypophyseal hormones

neurohypophysis

(ADH and Oxytocin) are secreted

in hypothalamus and transported

through axons to pituitary gland.

ACTH-> adrenal gland-> cortisol

FSH-> follicles of ovaries

LH-> ovaries and leydig cells

TSH-> thyroid gland for release of T4&T3 TH

Prolactin-> mammary gland

Somatotrophin-> GH -> bones and muscles

.

ADH/Vasopressin to collecting duct and DCT of nephron-> water reabsorption

Oxy to uterus for uterine contractions and orgasm

78. Trigeminal nerve

CNV1: sensory to forehead, sinuses, nose, dilator pupillae (SNS) and sensory

blinking reflex, (VII is motor)

CNV2: sensory to cheeks, nose, upper mouth, tears (SNS/PNS)

CNV3: sensory to chin, lower mouth, ant 2/3 tongue (taste is VII), ears, scalp,

muscles of mastication

Skin of face su

angle of the mandiblewhich is supplied by the [2] great auricular nerve(C2-C3) �

79. Bell's palsy

unilateral facial

paralysis.

Terminal branches of CN VIIl

injury as passes

through parotid gland

w/ retromandibular v

and external carotid a

unable to close lips and eyelids on affected side

eye on affected side is not lubricated (dry eye)l

unable to whistle, blow a wind instrument, or chew effectivelyl

facial distortion due to contractions of unopposed contralateral facial l

muscles

Lesion of CNVII at internal acoustic meatus causes no saliva/tears, hyperacoustics (stapedius m),

imbalance and distorted hearing (CNVIII)

Lesion past geniculate ganglion causes hyperacoustics and Bell's

Lesion at chorda tympani causes no taste, no saliva from submandibular& sublingual glands

Lesion at stylomastoid foramen causes Bells

(stylomastois forois foramen)

80. Epistaxis

(nosebleed) most often occurs from the anterior nasal septum (Kiesselbach's area),

sphenopalatine,

greater palatine,

Splenopalantine and Greater palantine as are most vulnerable bc

they are in Atrium of middle meatus

Can be corrected using CNXI

spinal accessory n transplant


81. Sinusitis

Sphenoiditis

l Relationships of the

sphenoidal sinus are clinically

important ; because of potential

injury during pituitary

surgery and the possible

spread of infection.

l Infection can reach the sinuses

through their ostia from the

nasal cavity or through their

floor from the nasopharynx.

l Infection may erode the walls to

reach the cavernous sinuses,

pituitary gland, optic nerves,

or optic chiasma


Ethmoiditis

l Infection in the ethmoidal

sinuses can erode the medial

wall of the orbit, resulting in

orbital cellulites that can

spread to the cranial cavity.

l In orbital cavity infection may

erode structures related to the

medial orbital wall:

l Medial rectus muscle

l Superior oblique muscle

l Nasociliary nerve


83. Cheeks

l Form the lateral, movable walls of

the oral cavity and the zygomatic

prominences of the cheeks over the

zygomatic bones.

l Buccinator [1] � principal muscle

of the cheek.

l Buccal pad of fat � encapsulated

collection of fat superficial to

buccinator.

l Parotid duct [2] from Parotid gland

[3] perforate buccinator and opens in

inner surface of the cheek right

opposite 2nd upper molar tooth

2

1

3


84. Movements at the TMJs

All 4 muscles of

mastication are

innervated by V3:

1. Temporalis �

elevation &

retraction

2. Masseter -

elevation

3. Medial

pterygoid -

elevation

4. Lateral

pterygoid -

protrusion

Note: In case of mandibular nerve

damage mandible (when it is

protruded) deviate toward the side of

lesion because of Lateral pterygoid

weakness.


85. Innervation of the tongue

1. Sensory anterior 2/3: general � lingual n. (V3),

taste � chorda tympani (CNVII)

2. Sensory posterior 1/3: general and taste �

glossopharyngeal (CNIX)

3. Motor � hypoglossal (CNXII)

Ø A lesion of the chorda tympani � lose of the taste

sensation anterior 2/3 of the tongue

Ø A lesion of the lingual nerve � lose of both

general and taste sensation anterior 2/3 of the

tongue

Ø A lesion of CN XII (hypoglossal canal) allows the

contralateral, unparalyzed genioglossus muscle to

pull the protruded tongue toward the paralyzed side

(deviation and atrophy of the tongue).


86. Gag reflex

l Touching the posterior part of the

pharynx results in muscular

contraction of each side of the

pharynx - gag reflex:

l Afferent limb: CN IX

l Efferent limb: CN X

l Injury to the

GLOSSOPHARYNGEAL NERVE

(CN IX) will result in a negative

gag reflex


81. Sinusitis

Sphenoiditis

sphenoidal sinus are clare clinically

important ; because of potential

injury during pituitary

surgery and thand the possible

spread of infection.

Infection may erode the walls to

reach the cavernous sinuses,

pituitary gland, optic nerves,

or optic chiasma

Ethmoiditis

Infection in the ethmoidal

sinuses can ecan erode the medial

wall of thof the orbit, resulting in

orbital cellulites that cathat can

spread to the cranial cavity.

medial orbital wall:

Medial rectus musclel

Superior oblique musclel

Nasociliary nervel

No adduction, no down and out rotation of the eye,

and constricted pupils w/ lack of corneal reflex

(sensory: touch eye and no blink)

83. Cheeks

Buccinator [1]

Parotid duct [2] from Parotid gland

site 2ndopposite 2 upper molar

84. Movements at the TMJs

1. Temporalis �

2. Masseter -

Temporal Maxillary Junction

3. Medial

pterygoid

4. Lateral

pterygoid

Only muscle to

open jaw/mouth

mandibular nerve

V3:

Strong

closes jaw

Tensor veli palatini m prevents inhale of food and equalizes the air

pressure to protect tympanic membrane

Tensor tympani dampens the sound from chewing

85. Innervation of the tongue

Sensory anterior 2/3: g al � lingual n. (V3),

taste � chorda tympani (CNVII)

Sensory posterior 1/3: ge: general and taste �

glossopharyngeal (CNIX)

Motor � h� hypoglossal (CNXII)

bc chorda tympani runs with lingual n

lesion of CN XII (hypoglossal canal)

ral, unparalyzed genioglossus muscle to

pull the protruded tongue toward the paralyzed side

(deviation and atrophy of the tongue).

Lick your wounds

weaker unparalyzed genioglossus m is

unable to maintain contraction of

tongue out, the opposite side takes

over and pushes tongue to the side of

lesion.

86. Gag reflex

Touching the soft palate or posterior pharynx will be sensed

via CNIX pharyngeal branch (afferent) and stimulate a

response (efferent) through CNX pharyx, larynx, and palate

ms to "gag"

rent limb: CN X

Afferent limb: CN IXl

Efferent liml

GLOSSOPHARYNGEAL NERVE

(CN IX) will rewill result in a negative

gag reflex No longer sensed


87. Palatine tonsils

l Receives main blood supply

from tonsillar branch of

facial artery

l Drained by lymph vessels

mainly to jugulodigastric

lymph node, which is body's

most frequently enlarged

lymph node

l Nerve supply: tonsillar

plexus of nerves formed by

branches of CN IX and CN X


Tonsillitis

l During palatine tonsillectomy, the

peritonsillar space facilitates tonsil

removal, except after capsular

adhesion to the superior constrictor.

l If the glossopharyngeal nerve

CNIX is injured, taste and general

sensation from the posterior 1/3 of

the tongue are lost.

l Hemorrhage may occur, usually

from the tonsillar branch of the

facial artery; if the superior

constrictor is penetrated, a high

facial artery or tortuous internal

carotid artery may be injured.


88. Muscles of Soft Palate

1. Tensor veli palatini and

2. Levator veli palatini � elevates

the soft palate during swallowing

to prevent food entering to the

nasopharynx

3. Palatoglossus and

4. Palatopharyngeus � depress

soft palate and pulls walls of

pharynx superiorly

5. Uvular muscle � shortens uvula

and pulls it superiorly


89. Lymph drainage from face

structures

1. Preauricular (parotid ) (on front

of auricle) receive lymph from

anteriolateral part of scalp

(including eyelids)

2. Submandibular (in digastric or

submandibular ") � from all air

sinuses, nose and adjacent

cheek, upper lip and lateral

parts of lower lip.

3. Submental (in submental ") �

from the chin, tip of the tongue

and central part of the lower

lip.

1

23


90. Blow-out fracture

l A blow-out fracture of the

orbital floor typically is not

involve the orbital rim and is

caused by blunt trauma to the

orbital contents (e.g., by a

handball). Content of orbital

cavity blow-out in maxillary

sinus.

l Blow-out fractures may damage:

1. Inferior rectus muscle

2. Infraorbital nerve (from

maxillary V2)

3. Infraorbital artery

(hemorrhaging).


91. Muscles of the orbit

Muscle Action Innerva-

tion

Superior rectus Elevates and adducts

pupil

CN III

Inferior rectus Depresses and adducts

pupil

CN III

Medial rectus Adducts pupil CN III

Lateral rectus Abducts pupil CN VI

Superior oblique Depresses and abducts

pupil

CN IV

Inferior oblique Elevates and abducts

pupil

CN III

Levator pulpebra superior Elevates upper eyelid CN III


87. Palatine tonsils

es of CN IX and CN and CN X

tonsillar branch of

facial artery

Drained by lymph vessels

mainly to jugulodigastric

lymph node,

Found between Faucel Pillars and become highly inflamed during infection

Tonsilectomy and adenoectomy can risk the tonsilar a and v.

.

Pharyngeal, Tubal, Palatine, Lingual Tonsils (Waldeyer's ring of lymph tissue)

palatine tonsillectomy, the

peritonsillar space facilitates tonsil

removal, ex

glossopharyngeal nerve

CNIX is inis injured, taste and general

sensation from throm the posterior 1/3 of

the tongue are lost.

Tonsillitis

88. Muscles of Soft Palate

Tensor veli palatini

Levator veli palatini �

CNV3 prevents inhalation of food & equalizes

pressure to protect tympanic membrane

Palatoglossus

Palatopharyngeus

Uvular muscle �

CNX innervation via pharyngeal branch

ALLOWS EFFICIENT SWALLOWING!

Lesion to Vagus can be seen as Uvula deviation to

opposite of lesion

89. Lymph drainage from face

structures

Preauricular ((parotid ) (on front

of auricle) receive lyeive lymph from

anteriolateral part of scalp

Submandibular (in digastric or

submandibular ") � from alrom all air

sinuses, nose and aand adjacent

cheek, upper lip and lateral

parts of lower lip.

Submental (in submental ") �

from the chin, tip of the tongue

and central part of the lower

lip.

Swallowing has 3 stages:

1. chew to create bolus (CNV3), tongue rise to hard palate (CNX, IX, VII, XII),

hyoid elevates, and fauceal pillars up and back

2. Seal nasopharynx w/ soft palate and epiglottis (CNX)

3. constrictors contract and pull up larynx to push bolus down

Triangles of neck:

Carotid: post digastric, omohyoid, SCM contain internal jugular v, common

carotid a, and vagus

Submandibular/submental: growth of lip can be throat cancer (CNVII, XII)

Muscular: isthmus of thyroid larynx and trachea

Posterior: Trapezius, SCM, clavical contain ext jugular v, and brachial plexus

90. Blow-out fracture

orbital floor

-out fracture of the

d by blunt trauma to the

orbital contents (e

all). Content of orbital

cavity blow-out in maxillary

sinus.

1. Inferior rectus muscle

Infraorbital nerve (from 2.

maxillary V2)

Infraorbital artery 3.

(hemorrhaging).

No look down, no sensation to upper mouth and

bleeding from branch of external carotid a

Branches of External Carotid Artery

Some = Superior Thyroid A.

Angry = Ascending Pharyngeal A.

Lady = Lingual A.

Found = Facial A.

Out = Occipital A.

P = Posterior Auricular A.

M = Maxillary A.

S = Superficial Temporal A.

91. Muscles of the orbit

Superior rectus Elevates and adductsE CN III

pupil

Inferior rectus Depresses and adductsD CN III

pupilpupil

Medial rectusMedial rectus Adducts pupilAAdducts pupil CN III

Lateral rectusLateral rectus Abducts pupilAAbducts pupil CN VI

Superior oblique Depresses and abductsD CN IV

pupilpupil

Inferior oblique Elevates and abductsE CN III

pupilpupil

Levator pulpebra superior Elevates upper eyelidE CN III


92. Strabismus

Oculomotor Nerve Palsy (CNIII)

l Oculomotor Nerve Palsy

(external squint) affects most of the

extraocular muscles

l Manifestations:

l ptosis,

l fully dilated pupil,

l and eye is fully depressed and

abducted (�down and out�) due to

unopposed actions of superior

oblique and lateral rectus,

respectively.


Trochlear Nerve Palsy (CNIV)

l Lesions of this nerve or its nucleus

cause paralysis of the superior

oblique and impair the ability to turn

the affected eyeball infero-medially

(pupil look superio-laterally)

l The characteristic sign of trochlear

nerve injury is diplopia (double

vision) when looking down (e.g.,

when going down stairs)

l The person can compensate for the

diplopia by inclining the head

anteriorly and laterally toward the side

of the normal eye.


Abducens Nerve Palsy (CNVI)

l Abducens Nerve Palsy

(internal squint). Injury to abducens

nerve ® paralysis of lateral rectus

® inability to abduct the affected

eye

l Affected eye is fully adducted by

the unopposed action of the medial

rectus that is supplied by CN III


93. Horner syndrome

l Penetrating injury to the neck,

Pancoast tumor, or thyroid carcinoma

may cause Horner syndrome by

interrupting ascending preganglionic

sympathetic fibers anywhere between

their origin in the T1 segment (IML) of

spinal cord and their synapse in the

Superior cervical ganglion.

l It includes the following signs:

l Constriction of the pupil (miosis)

l Drooping of the superior eyelid

(ptosis),

l Redness and increased temperature

of the skin (vasodilation)

l Absence of sweating (anhydrosis)


94. Otitis Media

l Hearing is diminished because of

pressure on the eardrum and

reduced movement of the ossicles.

l Taste may be altered because the

chorda tympani is affected.

l Infection spreading posteriorly

cause mastoiditis.

l Infection that spreads to the

middle cranial fossa can cause

meningitis or temporal lobe

abscess, and infection moving

through the floor may produce

sigmoid sinus thrombosis.


Perforation of the

Tympanic Membrane l May result from otitis media and is

one of several causes of middle ear

(conduction) deafness

l Causes: foreign bodies in external

acoustic meatus, excessive pressure

(as in diving), trauma

l Because chorda tympani directly

relates to the posterior surface of the

tympanic membrane it may be

damaged and resulting in loss of

taste over anterior 2/3 of the tongue

and secretion of the sublingual and

submandibular glands

l Minor perforation heal spontaneously;

large ones require surgical repair


92. Strabismus

Oculomotor Nerve Palsy (CNIII)

Eyes are not aligned

ptosis,

fully dilated pupil,

ye is fully depressed and

abducted (�down and out�)

s of superior

oblique and lateral rectus,

Eyes are looking in opposite directions

levator palpebrae superioris is out

.

constrictor pupilae (PNS) is out

Trochlear Nerve Palsy (CNIV)

use paralysis of the superior

oblique

No cheating muscle (down and out)

person will turn head to mimic contraction

inferior oblique is

unopposed so eye looks

up and out

Abducens Nerve Palsy (CNVI)

lateral rectus

® inability to abduct th

Affected eye is fully adducted

the unopposed action of the medial

rectus th

93. Horner syndrome Sympathetic trunk compression

Constriction of the pupil (miosis)

Drooping of the superior eyelid

(ptosis),

Redness and increased temperature

of the skin (vasodilation)

Absence of sweating (anhydrosis)

PNS

sup. tarsal mparalysis

94. Otitis Media

Hearing is diminished because ofuse of

pressure on the eardrum and

reduced movement of the ossicles.

Middle ear inflammation

CNVII

CNVIII

Taste may bmay be altered because the

chorda tympani

mastoiditis.

middle cranial fossa can cacan cause

meningitis or teor temporal lobe

abscess,

sigmoid sinus thrombosis.

Perforation of the

Tympanic Membrane otitis media

s of middle ear

(conduction) deafness

foreign bodies in external

acoustic meatus, excessive pressure

(as in diving), trauma

Causes: ses: ll

loss of

taste over anterior 2/3 of the tongue

and secretion of the sublingual and

submandibular glands

Minor perforation heal spontaneously;

large ones require surgical repair

Umborefracted cone of light

Pars flaccida

pars tensa

Anterior inferior incisions based on cone of light for surgery


95. Thyroid and parathyroid

glands Hormones:

l The thyroid gland is the body's largest endocrine

gland. It produces thyroid hormone (T3 & T4),

which controls the rate of metabolism (increase

the temperature of the body), and calcitonin, a

hormone controlling calcium metabolism (reduce

blood calcium Ca2+).

l After total thyroidectomy may develop lower

temperature of the body and hypercalcemia.

l The hormone produced by the parathyroid

glands, parathormone (PTH), controls the

metabolism of phosphorus and calcium in the

blood (increase Ca2+ level).


Anatomical relations

of the thyroid gland

l Anterolateral �

infrahyoid muscles

l Posterolateral �

COMMON CAROTID

ARTERY [1]

l Medial � larynx,

TRACHEA [2],

pharynx, esophagus,

cricothyroid muscle,

recurrent laryngeal

nerve [3]

l Posterior �

parathyroid glands

[4]

1

3

1

1


CS of the neck


Median cervical cyst

l Usually presents as a painless

midline mass on the anterior aspect

of the neck just below of the hyoid

bone and moves during

swallowing together with thyroid

gland because of relation with

pretracheal layer of cervical fascia

and infrahyoid muscles of the neck.

l Remanent of the thyroglossal canal

(thyroid gland originally from

epithelium of the tongue).

l Treatment: surgical excision


Variation of parathyroid

glands position

l The superior parathyroid

glands, more constant in

position than the inferior ones.

l The inferior parathyroid

glands are usually near the

inferior poles of the thyroid

gland, but they may lie in

various positions

l In 1-5% of people, an inferior

parathyroid gland is deep in

the superior mediastinum

inside the thymus because of

common embryonic origin.


96. Larynx

Cavity of the Larynx - 2 Folds:

l Vestibular folds [1] (false vocal

cords)

l Vocal folds [2] (true vocal cords)

Ø Rima vestibuli � gap between the

vestibular folds

Ø Rima glottidis [3] � gap between

the vocal folds anteriorly and

vocal processes of the arytenoid

cartilages posteriorly is most

narrow place in the larynx (it

limits size of intubation tube

during endotrachial anaesthesia)

3

12

1

2


95. Thyroid and parathyroid

glands

The thyroid gland is this the body's largest endocrine

gland. It produces thyroid hormone (T3 & T4),

te of metabolism (increase

the temperature of the body), and calcitonin, a

ism (reduce

blood calcium Ca2+). decrease osteoclasts

increase osteoclasts

total thyroidectomy may demay develop lower

temperature of thof the body and hypercalcemia.

parathyroid

glands, parathormone (PTH),

lood (increase Ca2+ level).

Superior thyroid a off external common carotid and inferiorthyroid gland off thyrocervical trunk of subclavianExternal laryngeal n w/ superior thy a & Recurrent laryngeal nw/ inferior thy a

Anatomical relations

of the thyroid gland o t e t y o d g a d

infrahyoid muscles

COMMON CAROTID

ARTERY

edial � la� larynx,

TRACHEA [2],

pharynx, esophagus,

cricothyroid muscle,

recurrent laryngeal

nerve [3]

MediaMedial

Posterior �

parathyroid glands

[4]

Recurrent laryngeal n to laryngeal ms (PCA*) abducts vocal cordsExternal laryngeal n to cricothyroid for high pitch

CS of the neck

Buccopharyngeal membrane

RETROPHARYNGEAL SPACE

Alar Fascia

DANGER ZONE

Prevertebral fascia

Carotid Sheath

& CNX

Retropharyngeal area allows infection to spread to posterior mediastinum

DANGER ZONE allows infection to spread to abdomen

Median cervical cyst

painless

midline mass on the anterior aspect

of the neck just below of the hyoid

bone and moves during

swallowing

thyroglossal canal

surgical excision

Variation of parathyroid

glands position

superior parathyroid

glands, more constant in

position than the inferior ones.

The inferior parathyroid

glands are usually near the

inferior poles of the thyroid

gland, but they may lie in

various positions

, an inferior

parathyroid gland island is deep in

the superior mediastinum

inside the thymus

This makes surgery dangerous bc parathyroid

glands are essential for life as Ca2+ is needed

for neuronal pathways, bones, muscle

contractions, etc....

96. Larynx

Vestibular folds [1

Vocal folds [2]

Morgangni ventricle between them

Rima vestibuli

Rima glottidis [3] � ga� gap between

the vocal folds an

Piriform recess at hyoid-> epiglottis is where small sharp objects get stuck

Zenker's Diverticulum is outpouch of pharynx at inferior constrictor where food gets caught

in killians triangle and gets infected leading to hallitosis (bad breath)


Muscles of the Larynx

Abductors

l Posterior cricoarytenoid �

abducts vocal folds (the only

abductors of the vocal folds)

l It is innervated by recurrent

laryngeal nerve (CNX

vagus).

Ø Interruption of recurrent

laryngeal nerve results in

hoarseness because the

corresponding vocal fold

does not abduct and deviate

toward the midline.


Cricothyrotomy

l A cricothyrotomy is an emergency

procedure that relieves an airway

obstruction (e.g. swallowed foreign

bodies or abnormal tissue growths).

l A hollow needle is inserted into the

midline of the neck, just below the

thyroid cartilage (needle

cricothyrotomy).

l More frequently, a small incision is made

in the skin over the Cricothyroid

membrane, and another one is made

through the membrane between the

cricoid and thyroid cartilage. A tube

that enables breathing is inserted through

the incision.


98. Retropharyngeal space

l It is interval between pharynx

(Bucco-pharyngeal fascia)

and prevertebral fascia

l May provide a passageway of

infection from pharynx to

posterior mediastinum

(mediastinitis !90%!mortality!

rate).


99. Axillary sheath

l Derived from the prevertebral

fascia

l Encloses the subclavian artery

and brachial plexus as they

emerge in the interval between the

scalenus anterior and medius

muscles (Interscalenus space)

l Extends into the axilla


100. Posterior Triangle of the

Neck

l Veins � external jugular vein,

subclavian vein.

l Arteries � occipital artery.

l Nerves � Accessory nerve (XI),

trunks of the brachial plexus, branches

of cervical plexus, phrenic nerve.

l Lymph nodes � superficial cervical

nodes along external jugular vein.

CN XI (accessory nerve) supply:

l Sternocleidomastoid muscle - face

looks upward to the opposite side

l Trapezius - superior fibers elevate,

middle fibers retract, and inferior fibers

depress scapula.

CN XI


Good Luck!


Abductors

Posterior cricoarytenoid �l

recurrent

laryngeal nerve (CNXrve (CNX

vagus).

hoarseness

Most intrinsic ms of the larynx

Superior Laryngeal n gives

branches to internal (vocal cords)

and external to cricothyroid ms

(high pitch)

lesion causes weak low pitch voice

Transverse arytenoid (whisper), Thyroarytenoid (low pitch), vocalis (opera singer)- ADDUCTORS

Muscles of the Larynx Cricothyrotomy

an emergency

procedure that relieves an airway

obstruction (e.g

A hollow needle is inserted into the

midline of the neck, just below the

thyroid cartilage

More frequently, a small incision is made

in the skin over the Cricothyroid

membrane, and another one is made

through the membrane between the

cricoid and thyroid cartilage. A. A tube

that enables breathing is inserted through

the incision.

98. Retropharyngeal space

( haryngeal fasciaBucco-pharyn )

Between Buccopharyngeal fascia and Alar fascia of Carotid sheathsbetween pharynx

BetweenBetween Buccopharyngeal fascia and Alar fascia of Carotid sheaths

infection rom pharynx to from p

mediastinum posterior media

DANGER ZONE: Alar Fascia to prevertebral fascia and

infection spreads farther to abdomen

99. Axillary sheath

(

subclavian artery

and brachial plexus as they

emerge in the interval between the

scalenus anterior and medius

muscles

Extends into the axilla

BRACHIAL PLEXUS BRANCHES:

MARMU, LT, DS, SS, SC, LP, MP, AP, USS, TD, LSS, Mca, Mcf

100. Posterior Triangle of the

Neck

� external jugular vein,

subclavian vein.

� occipital artery.

Clavical, SCM, Trapezius

External Jugular v, Brachial Plexus

� Accessory nerve (XI),

Lymph nodes

Sternocleidomastoid muscle - f

- seziusTrapezius

Carotid Triangle of the Neck:

Posterior digastric, omohyoid, SCM

Contains: Internal jug v, common carotid, CNX

100 must important GA conceptions - 1 File Download

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