LIVE ANATOMY - Facultyfaculty.une.edu/cas/fdaly/PAGross/!LIVEhandout.doc · Web viewAcute sports injuries (e.g., tennis elbow), surgical scars, and tissues under tension frequently

University of New EnglandPhysician Assistant Program

LIVE ANATOMY

Each region of the human body in PAC500 Anatomy will be first introduced in LIVE anatomy. This is done to better

assist students in transferring understanding of the human body into a clinical setting. LIVE anatomy will allow students

an opportunity to bridge the gap between the living anatomy of their peers and the dead anatomy in the cadaver lab. This

approach to learning about the human body will require some different strategies in addition to the ones used in a

traditional course in human anatomy. At the same time, it helps students to develop an appreciation of the importance and

relevance of human anatomy to the clinical setting.

It is critical that the introduction to a body region be on a living person, not from a lecture, text or the lab. In these

sessions, the focus will be on introducing specific anatomy and palpating relevant landmarks. Students will be learning

the specifics of the clinical examination in their clinical assessment course. Following LIVE anatomy and clinical

assessment, students will again study the anatomy, this time in the cadaver lab. During this time, students will study

structures in more detail and they will be investigating deeper within the body. This will not only reinforce the clinical

anatomy students have already learned, but also enables them to enter the cadaver lab having some experience for how

they are going to use anatomy in the assessment of patients.

There will be a handout for each LIVE anatomy session that will include those items for which students will be held

responsible on the LIVE anatomy exam. This exam will be given at the end of the course and LIVE anatomy will count

10% of the overall anatomy course grade. Students will be tested in pairs in an oral practical format. One student will

function as the physician assistant and the other will function as the patient. An examiner will ask the student PA to point

out certain anatomical/clinical landmarks and will be graded on their responses. The students will then change roles and

the examiner will ask the new student PA a different set of questions.

Keep one thing in mind: The purpose of this LIVE anatomy course is to optimize student’s utilization of anatomic

knowledge in a clinical setting. This is not meant to be a clinical anatomy course. We will not be embellishing anatomy

with clinical correlations. That should happen naturally as students go through this course and the clinical assessment

course.

References

Cross (2006) Live Anatomy Handouts, University of New England, unpublished

Montagu (1986) Touching: The Human Significance of Skin (3rd Ed.) Harper & Row

Moore and Dalley (2006) Clinically Oriented Anatomy (5th Ed.) Lippincott, Williams and Wilkins

Moore and Agur (2007) Essential Clinical Anatomy (3rd Ed.) Lippincott, Williams and Wilkins –

Source for all images, unless otherwise noted

Nolan (2003) Clinical Applications of Human Anatomy: A Laboratory Guide, Slack Incorporated

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Protocol for LIVE anatomy

Wear comfortable, loose fitting clothing that allows for direct visualization and palpation by student peers. The best option is to wear shorts and a T-shirt/tank top.

Be sure to bring Moore’s Essential Clinical Anatomy to the LIVE anatomy session.It has most of the pictures needed and/or referred to in this manual.

Students will be working in groups of 2-4 that will be randomly assigned each day. The group assignments expose the students to the maximum number of types and personalities.

This increases the amount of anatomical variation to which students are exposed.All students should act as both patient and student PA.

Be sure to wash your hands before examining each other. The sinks with soap and water are located one the South end of the lab – use them EVERY session.

Inform your partners of any open wounds or lesions that should be avoided during lab exercises.

Work on your partner to find the structures, NOT on yourself.

Treat each other with respect. Honor the boundaries that your partner possesses. These boundaries may be quite different from one person to another.

Ask before you go too far!

It is very important to communicate with each other openly and honestly during examinations. If you feel your partner is being too rough, tell him/her. Treating each other in this respectful fashion during live anatomy will help ensure that you will treat your patients similarly.

If you are uncomfortable being examined by a particular person speak to an instructor. Racial, sexual, or religious bias and all forms of bigotry will NOT be tolerated. See student handbook for university policies for further information http://www.une.edu/studentlife/handbook/pdf/studenthandbook.pdf

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01: Introduction to Palpation and Skin

Discussion of sense of touch and tactility

Palpation practice (inanimate objects)

Palpate various objects in the bags/boxes and describe the "qualities" of those objects. Rather than just identification,

students should be using adjectives like; hard, soft, squishy, smooth, bumpy, malleable, round, square, triangular, brittle,

sharp, serrated, etc.). Students may also describe unknown objects by sight and/or by smell. Students should write down

observations on the supplied unknown sheet, as this will provide a

record of participation.

Be sure to WASH your hands before examining each other

Skin examination

The skin is the largest organ. It is made up of two layers, the epidermis (superficial) and the dermis (deep). These

layers lie superficial to the underlying fascia, which is made up of loose connective tissue and fat. The skin serves three

primary functions:

Protection (from mechanical injury, from invasion of foreign objects, from fluid loss)

Thermoregulation (through sweat and blood vessel diameter regulation)

Sensation (most notably touch, pain, heat and cold)

When examining the skin, notice that hair quantity and hair patterns vary markedly from one part of the body to

another.

Look for direction of hair, amount of hair and types and length of hair.

Notice that the thickness of the skin and its sensitivity varies greatly from one body region to another. This 4

Homunculus – Natural History Museum, London

sensitivity is related to the thickness of the epidermis and to the density of the nerve endings in a given part of the body

(see homunculus above). Some of the most sensitive regions include the lips, fingertips, tongue and external genitalia.

The weight bearing portions of the soles of the feet are particularly insensitive to light touch because of the thickness of

the epidermis.

Notice creases in the skin around mobile body parts. These are related to the function of the underlying joints. Notice

the particularly complex system of creases on the palms. This is a direct result of the sophisticated movements that

makes the human hand unique among the primates. Look at the fingertips and notice the patterns of small ridges on the

skin. These are the fingerprints (dermatoglyphics). Take note of the lines (cleavage, tension) on the skin surface

reflecting the underlying connective tissue components of the skin. These are important in making incisions. Scarring is

minimized if incisions are made parallel to these tension lines.

Take note of any abnormal marks on the skin. Look for scars, tattoos, body piercings, open lesions, etc. Also look

for any warts, moles and freckles or any other discolorations such as "birthmarks".

Notice that in some regions of the skin large veins can be easily visualized. These are especially prominent on the

back of the hand and the anterior aspect of the forearm. On the legs these superficial veins may become distended and

tortuous (due to incompetent valves) and are referred to as varicose veins. Other common sites for varicose veins are at

the knees, within the scrotum, and at the inferior end of the esophagus.

Examine at the fingernails and toenails. These are outgrowths from the skin.

Von Frey Hairs (optional - as time permits)

Take some of the Von Frey hairs and test your partner for 2-point discrimination and detection threshold. The test

subject should not look at the area of skin that is being tested.

Lightly touch the two probes simultaneously to the back of the hand of your partner. Ask your partner if he/she felt

one or two pressure points. If your partner reported one point, spread the tips of the probes a bit further apart, then touch

the back of the partner's hand again. If your partner reported 2 points, push the tips a bit closer together, and test again.

Measure the minimal distance at which your partner reports two points. Skin receptors NOT uniformly distributed around

the body. Some places, such as the fingers and lips, have more touch receptors than other parts of the body, such as the

back. This is one reason why people are more sensitive to touch on their fingers and face than on their backs.

To test the detection threshold of someone, have your partner close his/her eyes. Touch the Von Frey hair to different

places on his/her skin until the “hair” just bends. It is important to press hard enough to just bend the hair. The size of the

hair is calibrated for specific force application and additional force will not be transferred to the patient. Ask your partner

if they felt anything. Change the size of the Von Frey hair and see if your partner can still detect the stimulus. Determine

at which point your partner can no longer detect the stimulus.

The Von Frey concept is based on the principle that a hair pressed against the skin will increase in force applied until

it bends. After bending, the increasing proximity of the probe to the skin will not increase the force applied. After the

initial deflection, the force is fairly constant or declines. This physical fact is used to make a stimulator that can be hand

applied, yet delivers a consistent and reproducible force, even though the hand could not. The force applied is a property

of the hair thickness and material composition.

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After the monofilament contacts the skin at 90°, the probe should be advanced an additional 1/8”. The resulting

flexural bow should be about ¼” from vertical. The more deflection will result in decreased and variable force.

The kit includes 20 hairs of graded sizes, with known clinical significance (see chart below). The set of 20 Von Frey

hairs based on the Semmes Weinstein set of 20 with near logarithmic increase in physical force applied and hence a

linear increase in perceived force applied. This kit is designed for diagnosing pathologies of crude touch sensation in

humans or animals. The Semmes Weinstein addition to that concept (the graded set linear scale of perceived intensity)

has a long and successful clinical record of diagnosing both hypo- and hyper-aesthesia. The probes fold under to a

protected position when not in

use.

6http://www.myneurolab.com/myneurolab/mnl_products_detail.asp?idproduct=337500&catdesc=Animal+Function+%28Pharmacology+or+Neurology%29&CatThreeID=708&CatOneID=7&subcatdesc=Tactile+Sensitivity&idsubcategory=38

Site Threshold Distance

Fingers 2-3 mmUpper Lip 5 mm

Cheek 6 mm

Nose 7 mmPalm 10 mmForehead 15 mmFoot 20 mmBelly 30 mmForearm 35 mmUpper arm 39 mmBack 39 mmShoulder 41 mmThigh 42 mmCalf 45 mm

02: Upper Extremity

Be sure to WASH your hands before examining each other.

With your partner seated comfortably and the back and shoulders exposed, take a few moments to palpate the

structures of the shoulder girdle. Most of the bones of the upper extremity offer a palpable surface enabling the examiner

to identify specific structures. The bones of the shoulder girdle are the clavicle and scapula. The muscles of the shoulder

girdle are those with one attachment on a shoulder girdle bone and the other attachment on the trunk.

Follow the clavicle from its lateral end to medial end. This bone is concave laterally and convex medially. Between

the elevated medial ends of the clavicle is the jugular notch (suprasternal notch).

Palpate the sternoclavicular joint. Determine how the clavicle shifts during elevation and depression of the shoulder,

as well as protraction and retraction of the shoulder. Palpate the

acromioclavicular joint. The lateral end of the clavicle often raises higher

then the acromion. Determine how the clavicle shifts during

flexion/extension of the arm as well as protraction/retraction and

elevation/depression of the shoulder. Feel the motion in this joint as you

passively abduct and rotate the humerus.

Anteriorly, identify the pectoral muscles. The sternal head of pectoralis

major attaches to the sternum and humerus while the clavicular head of

pectoralis major attaches to the clavicle and to the humerus. Palpate this

muscle near its sternal and clavicular attachment where the two heads can

sometimes be identified. Abduct your partner’s arm to about 120 degrees

and note the thick lateral portion

of pectoralis major. Note that this

area of the pectoralis muscle can

be quite sensitive to touch. Deep

inside the deltopectoral (CP-

claviculopectoral triangle -

clavicle, anterior head of deltoid

and clavicular head of pectoralis

major), palpate the coracoid

process of the scapula. In the

female, the inferior portion of the

pectoralis major is covered by

breast tissue. Palpation of the

entire muscle in the male is

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readily performed. Before leaving this area,

palpate the anterior border of the axilla. Identify

the anterior axillary fold made by pectoralis

major.

Palpate the borders the muscles of the

shoulder girdle, namely the superior and inferior

borders of trapezius, superior and inferior borders

of the rhomboids (deep to trapezius), inferior

border of teres major and borders of latissimus

dorsi.

Palpate the borders of the scapula. The

medial border is the most easily identified. The

superior and lateral borders will be more difficult

to palpate because of the overlying musculature.

The superior border of the scapula will be the

most difficult. Next palpate the inferior angle of the scapula. A horizontal line interconnecting the right and left inferior

angle of the scapula would intersect the vertebral

column at T7 vertebral level. Palpate the spine of

the scapula running in a superolateral direction

from the upper third of the vertebral border. The

scapular spine starts medially at the level of T3

vertebra. The spine of the scapula ends with a

large bony prominence (acromion) that

articulates with the lateral end of the clavicle.

When serratus anterior is paralyzed, the medial

border of the scapula moves away from the

thoracic wall giving the appearance of a

“winged” scapula.

Next identify the large deltoid muscle that

forms the rounded contour of the shoulder. This muscle overlies

the distal ends of the muscles making up the rotator cuff. Deltoid

has three distinct bellies, with each serving different functions.

The middle head is the largest and is the strongest humeral

abductor. The anterior and posterior heads assist in humeral

flexion and extension respectively, especially when the arm is

abducted to 90 degrees (horizontal flexion and extension). Identify

these three heads by having your partner abduct, flex and extend

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his/her humerus against your resistance. Deep palpation through the anterior part of middle deltoid, inferior to the

acromion is necessary to feel the greater tubercle of the humerus.

The lesser tubercle of the humerus may be palpated through the anterior deltoid, inferior to the coracoid process of

the scapula. Arm rotation helps to identify the lesser tubercle of the humerus. Between the tubercles, locate the

intertubercular groove of the humerus. Before leaving this area, palpate the posterior border of the axilla. Latissimus dorsi

and teres major muscles make the posterior axillary fold.Moving down to the arm (brachium) notice two large muscle

masses, one anterior and one posterior, separated by the cutaneous lateral and medial bicipital grooves. These cutaneous

grooves are not the same structures as the bicipital

groove of the humerus.

Posterior are three heads of the triceps brachii that

extend the arm and the forearm. Anterior, the biceps

brachii and brachialis (deep to biceps brachii) make up

most of the muscle mass. Note that the biceps brachii is

the strongest supinator of the forearm and the brachialis

is the strongest flexor of the forearm. This point is

important for remembering the distal

attachments/insertion of these muscles. Have the partner

look away from his/her arm and identify the difference

between the biceps brachii and brachialis. To

demonstrate the biceps brachii, have your partner

attempt to supinate his/her flexed forearm against

resistance. To demonstrate the brachialis have him/her

attempt to flex the pronated forearm against resistance. It helps to be able to recognize the biceps brachii tendon and

palpate on either side of it to find

brachialis.

At the elbow, three prominent bony

landmarks can be palpated: the medial

epicondyle of the humerus, the lateral

epicondyle of the humerus and the

olecranon process of the ulna. These three

landmarks form a straight line when the

forearm is extended at the elbow and a

triangle when the forearm is flexed. The

medial epicondyle is the site of common

attachment of the wrist and finger flexors.

Just proximal to the medial epicondyle of the humerus is the medial supracondylar ridge, another site of flexor muscle

attachment. The lateral epicondyle/supracondylar ridge is the site of common attachment of the wrist and finger

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extensors. One muscle of this group (brachioradialis) acts a forearm flexor rather than a forearm extensor. This muscle

makes the large lateral mass in the anterior forearm. Confirm the flexor and extensor attachments by having your partner

flex and extend his/her wrist against resistance.

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Locate the cubital fossa. This space is located between the brachioradialis (distal/lateral) and pronator teres

(distal/medial). The other border of the cubital fossa is an imaginary line between the medial and lateral epicondyles of

the humerus. The biceps brachii tendon and biceps brachii aponeurosis are located in this space. Just distal to the lateral

epicondyle of the humerus palpate the head of the radius. This can be done easily by having your partner alternatively

supinate and pronate his/her forearm.

Moving down to the wrist, first palpate the prominent distal ends of the radius and ulna. There are styloid processes

at the end of each bone. Confirm that the styloid process of the radius extends further distally than that of the ulna.

Palpate the head of the ulna and locate the pisiform bone. The pisiform bone is the distal attachment of the flexor carpi

ulnaris muscle and can be moved from side to side when the hand is relaxed. The hook of the hamate can be palpated

with deep pressure in the medal palm, approximately 1cm distal and lateral to pisiform. Have your partner flex his/her

wrist while holding the little finger and thumb together. On the

anterior aspect of the wrist palpate the following four muscle

tendons (from lateral to medial): flexor carpi radialis tendon,

palmaris longus tendon, flexor digitorum superficialis tendon,

and flexor carpi ulnaris tendon. In approximately 13% of the

population, the palmaris longus tendon is absent. This absence

may be either bilateral (right and left) or unilateral (one side

only).

The anatomical snuffbox lies to the radial side and dorsal on

the hand between the thumb and index finger. By extending your

thumb and at the same time hyperextending your wrist, identify

the three tendons that form the boundaries of this anatomical

snuffbox (or brevis sandwich). They are the abductor pollicis

longus and extensor pollicis brevis in a lateral/anterior position

and the extensor pollicis longus medial/posterior position.

Sometimes a fracture of the

scaphoid presents itself as point

tenderness on the floor of the

anatomical snuffbox. This

relatively common injury can

occur after falling backwards

upon an extended and abducted

wrist, as might happen when ice-

skating.

With the fist clenched and

the wrist extended against

resistance, locate the extensor

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carpi radialis longus just dorsal to the distal end of the radius. This is obscured by the extensor pollicis longus if the

thumb is extended simultaneously. Moving medially locate the tendons of the extensor digitorum and extensor digiti

minimi. This can be accomplished by having your partner wiggle his/her fingers. Note that there are two tendons

associated with the second digit (index finger). The lateral tendon (closer to thumb) belongs to extensor digitorum and

the medial tendon belongs to extensor indicis.

On the palm note the two large muscle masses. These are the thenar and hypothenar eminences associated with the

thumb and little finger respectively. One important nerve is located at a specific site on the thenar eminence. The

recurrent median nerve lies very superficial in the center of this mass. An innocuous superficial wound to the thenar

eminence must be carefully examined to ensure that the nerve is intact. Be sure to test thumb function (flex, abduct,

oppose thumb). The fact that this nerve is often overlooked has led to the nickname the “million dollar nerve”. Place your

partner’s ring finger on his/her thenar eminence to locate the approximate site of the recurrent median nerve.

On the dorsum of the hand, palpate the dorsal interossei lying between the metacarpals. Having your partner abduct

his/her fingers against resistance to facilitate this. There are no muscle bellies between the phalanges, only tendons. The

muscle bellies lie between the metacarpals. The heads of the metacarpals form the knuckles, with the 3 rd metacarpal head

being most prominent.

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03: Arteries, Veins, Nerves and Tendons of the Upper Extremity

Be sure to WASH your hands before examining each other.

Arteries

In the upper limb, the primary arteries are the subclavian, axillary, brachial, radial and ulnar. You will attempt to

locate the subclavian artery in the neck in a later session. The axillary artery is the continuation of the subclavian as it

passes beyond the border of the clavicle/1st rib. You cannot easily feel for this pulse.

The brachial artery is the direct continuation of the axillary as it passes inferior

to the lower border of the teres major. Its pulse can be felt medial to biceps brachii

(see picture). It often helps to palpate deep to the belly of biceps brachii and

superficial to the brachialis to find this artery. The brachial pulse can also be

felt in the floor of the cubital fossa, just medial to the bicipital tendon and just

superior to the medial epicondyle of the humerus. Find the brachial pulse in

your partner.

In the cubital fossa the brachial artery bifurcates into the radial and ulnar

arteries, which run down the anterior aspect of the forearm on the lateral and

medial sides respectively. In about 2% of the population, a superficial ulnar

artery occurs superficial to the bicipital tendon (and to the bicipital

aponeurosis). It can be easily confused for a vein, with potentially disastrous

results. Always check for pulsating "veins" when performing venipunctures in

this region. In addition, about 10% of the population has a superficial radial

artery. This is not usually a problem in venipuncture as arterial pulsations are easily detected.

The radial and ulnar arteries go on to form the superficial and deep palmar

arterial arches within the hand. Both arteries contribute to each arch, but the

ulnar artery is the primary artery of the superficial arch and the radial artery the

primary artery of the deep arch. In your clinical assessment course, you will

learn to do the Allen's test to check for the competency of each of these arteries.

This becomes critical in preparation for hand surgery where the blood supply to

the hand may be compromised.

The radial pulse may easily be felt on the distal aspect of the forearm just

lateral to the tendon of the flexor carpi radialis (towards thumb). Remember that

flexor carpi radialis is the most conspicuous lateral tendon on the anterior aspect

of the forearm. It also helps to remember that radial side = thumb side = lateral

side of the forearm. In some individuals, the radial artery may be able to be

palpated in the anatomical snuffbox. This anatomical landmark is located at the base of the thumb on the side and is

bounded by the tendons of the abductor pollicis longus and extensor pollicis brevis on the anterior/lateral side and by the

tendon of the extensor pollicis longus on the posterior/medial side.

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To find the ulnar pulse, feel for the tendons the distal aspect of the forearm just medial (towards pinkie) to the tendon

of the flexor carpi ulnaris. Remember that flexor carpi ulnaris is the most conspicuous medial tendon on the anterior

aspect of the forearm. Flexor carpi ulnaris inserts into the hook of the hamate, pisiform and the 5 th metacarpal.

Veins

The veins of each extremity can be divided into superficial and deep

veins. We will only be concerned with the superficial veins in LIVE

anatomy, but keep in mind that the two systems have multiple

interconnections. The deep veins run parallel to the arteries and are

usually found as a pair of veins on either side of the artery. Superficial

veins do not necessarily follow the same course are the arteries.

Generally speaking, there are very few superficial arteries associated with the extremities.

On the dorsum of the hand note the dorsal venous network (rete). Emerging from the

lateral aspect of this network and running along the lateral aspect of the forearm and arm is

the cephalic vein. This large vein empties into the axillary vein just medial to the anterior

head of the deltoid, deep within the deltopectoral triangle. It may be absent unilaterally (or

bilaterally) and its size and branching varies greatly. This vein is substantially larger in

athletes. Find this vein on your partner

Emerging from the medial aspect of the dorsal venous network is the basilic vein. This

vein runs along the medial aspect of the forearm and empties into the brachial vein about 1/3

the way up the arm. Find this vein on your partner. In the cubital fossa, the median cubital

vein connects the basilic and cephalic veins and is a common site of venipuncture. The pattern found here varies greatly

from person to person. Remember that in this region you need to be on alert for the presence of superficial arteries.

Running distal to the median cubital vein is the median antebrachial vein of the forearm. There may be several of these

median antebrachial veins. These represent other sites for venipuncture.

Choose a prominent vein on the forearm or hand of your partner and occlude (compress) it with one of your fingers.

With a finger (or thumb) from your other hand, push the blood in the vein proximally toward the heart, thus emptying the

vein. When you release the PROXIMAL digit the blood will backfill (flow distal – away from heart) to a specific point

in the vein and then stop. Remember that veins have valves to ensure that venous blood flows only in one direction.

Lymphatics

The lymphatic system is an extensive and dense network of vessels that return interstitial fluids to the cardiovascular

system. The lymphatics drain extra-cellular fluid, blood plasma and cellular debris from the periphery back into the

venous circulation. Lymphatic vessels are similar to veins, in that they have valves for one-way flow and have relatively

weak walls. Lymph drains centrally either through superficial vessels (for skin) or deep vessels (running along arteries

and veins) towards the brachiocephalic veins. At regular intervals, superficial lymph drains to deep lymph vessels. This

lymphatic fluid is filtered along the way by lymph nodes. These nodes vary greatly in size and are located superficial and

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deep on the body. The superficial lymph nodes can be examined by palpation. Since their size and numbers vary widely

from person to person, it is common not to be able to palpate normal lymph nodes. However if they are inflamed

(fighting infection) or "hot" (metastasizing cancer) they are readily palpable. Lymph nodes are named for the body

regions in which they are located.

Lymph from the hand and forearm flows centrally into cubital lymph nodes, located in the medial aspect of the

cubital fossa. From the cubital lymph nodes, most

lymph flows centrally into the axillary nodes. These

axillary nodes are divided into five groups (brachial,

subscapular, pectoral, central and apical/subclavian).

You may be able to GENTLY palpate two of these

groups. The pectoral axillary nodes can sometimes be

compressed against the lateral aspect of the thoracic

wall high up in the axilla, near the anterior axillary

fold. The subscapular axillary nodes can sometimes

be palpated about midway up the posterior axillary

fold. The brachial axillary nodes, pectoral axillary

nodes and subscapular axillary nodes all drain into

the central axillary nodes, which in turn drain into the

apical/subclavian axillary nodes.

From the subclavian lymph nodes, lymph

continues to drain centrally towards either the

thoracic duct (left) or the lymphatic duct (right). Both

of these ducts drain lymph directly into the

brachiocephalic veins. An alternative route of

lymph flow runs from the deltopectoral nodes

(located in the deltopectoral triangle) to the

subclavian axillary lymph nodes, where it joins

normal lymph flow to the brachiocephalic veins.

Peripheral nerves

The olecranon is often referred to as the "funny bone", defined by the feeling you get when you bang the elbow

and surrounding structures on a hard surface. The funny feeling is due hitting the ulnar nerve that lies just posterior the

medial epicondyle of the humerus, adjacent to the olecranon of the ulna. GENTLY feel for this large ulnar nerve as it

passes posterior to the medial epicondyle of the humerus.

Accidents can compromise the ulnar nerve and other inferior components of the brachial plexus. Typically, this is

an uncommon result when the upper limb is forcefully abducted from the torso. Damage to the ulnar nerve results in

contraction of the internal hand muscles and the characteristic “clawhand”.

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It is more likely that injuries to the upper extremity will affect the superior parts of the brachial plexus, including the

axillary, musculocutaneous and radial nerves. Typically this is a result injury between the neck and the shoulder. The

upper limb takes on the characteristic position of medial rotation, adduction of the shoulder and extension of the elbow.

This is called the “waiter’s tip position”. Damage specifically to the radial nerve results in “wrist drop”, a clinical sign

indicative of paralyzed forearm extensor muscles. The hand and fingers are unable to extend and are more strongly

affected by gravity.

Locate the median nerve as it passes deep to, and just lateral (radial) to, the tendon of the palmaris longus. Injections

into the carpal tunnel are done about one finger medial (ulnar) to the tendon of the palmaris longus. Discuss why is it

important to determine if your partner has palmaris longus in this case. In addition, relocate the recurrent branch of the

median nerve and discuss its function.

Tendons

Locate the following tendons and the position of the appropriate joints for testing reflexes. If there is difficulty

palpating any of the following tendons, have your partner gently contract the appropriate muscle against resistance.

With your partner seated, have partner place his/her palm down on his/her thigh.

Palpate the bicipital tendon in the cubital fossa.

Hold partner’s flexed forearm across and against his/her chest.

Palpate the triceps tendon just above the olecranon.

Partially pronate the forearm and palpate the tendon of the brachioradialis.

(two fingerbreadths proximal to the radial styloid process)

Locate both tendons of the index finger. The tendon of extensor indicis is medial (closer to pinkie) and the lateral

tendon is one of the tendons of extensor digitorum. While holding partner’s hand, palpate the extensor tendons to the

other digits. Follow the tendons and muscles back to their origin on the lateral epicondyle of the humerus. This common

proximal attachment of the forearm extensors will become inflamed and produce pain radiating down the posterior

forearm with repeated forceful flexion and extension of the hand at the wrist joint. The common name for this condition

is tennis elbow, indicative of repetitive use of the superficial extensor muscles of the forearm.

Review the tendons bordering the anatomical snuffbox, including abductor pollicis longus, extensor pollicis brevis

and extensor pollicis longus. Determine the difference between the tendons of abductor pollicis longus and extensor 16

Median nerve injury (benediction harnd)

Ulnar nerve injury (claw hand)Disagree with Moore, p435,468

pollicis brevis.

17

04: REXLAXATION PROCEDURES 1

Be sure to WASH your hands before working with each other.

Suboccipital Hold

The suboccipital muscle group is relatively easy to find. It lies just inferior the base of the skull, in a line from ear to

ear. While the entire muscle group responds positively to pressure in most cases, there is some variation in quality from

one location to another along the muscle attachments.

You will hold the following position with your partner for approximately 20 minutes. Although any position may be

relatively comfortable at the start, correct positioning is critical to last the entire exercise. You should sit comfortably

upright and rest your forearms on the elevated table. Your elbows should be just at the edge of the table and in a position

to bear some of your own weight.

Have your partner lay down face up (supine) on the table, in such a way that you can maintain your position. It is

very likely that his/her feet will hang off the end of the table. Reach under the base of his/her skull and press GENTLY

upwards with your fingertips. Most people will be able to tolerate strong pressure here. Start slowly! Tell your partner

when you are going to start moving or when you need to put down his/her head. Do NOT drop his/her head suddenly!

Your fingers should be placed so that the two distal phalanges of all 4 medial digits are near vertical. Your partner’s head

should be suspended off of the palms of your hands.

Only the weight of the head furnishes the pressure in this situation, keeping your partner in control at all times. The

pressure exerted is your partner’s choice. When doing this exercise too forcefully, the head will have a tendency to roll

away from the fingertips. If you are in the correct position, the only chin will elevate. If you're too high the forehead will

elevate. Make sure you are inferior to the nuchal lines of the skull.

The exact center of the neck is the one spot where you might not get a positive reaction. There is a small hollow

there, right at the top of the spine, below the base of the skull. To some people, pressure on this spot — which is not

actually even muscular — will be enjoyable. To others, it feels too vulnerable, yet there is no danger. Some people can

learn to love it, if they feel comfortable enough. They might prefer pressure on the thick bands of muscle on either side of

the center, or they might prefer it more laterally just behind the mastoid process. Your partner’s preference might be in

the thinner insertions/distal attachments of the tissue, more on the actual skull, or deeper into the muscle bellies inferior

to the nuchal lines. Beware! Your partner won’t want you to stop. After 20 minutes, tell your partner that you are going to

GENTLY put down his/her head. Change positions with your partner and have him/her go through the same suboccipital

hold procedure.

It’s a bit tricky to effectively massage your own suboccipital muscles without a tool. Try using a tennis ball. To some

extent you can roll back and forth on that and get some satisfaction.

References:

http://vancouvermassage.ca/articles/spot-01.php

http://www.healingpeople.com/index.php?option=com_content&task=view&id=598&Itemid=136

18

http://headache.homepainrelief.com/Head&NeckInstructions%20.htm

19

05: Lower Extremity

Be sure to WASH your hands before examining each other.

Start with your partner standing up, facing you. Palpate his/her iliac crest (hip bone) and the iliac tubercle. The

anterior 1/3 of the crest can be easily palpated because it is subcutaneous. The iliac tubercle can be palpated just anterior

and lateral to the highest point on the iliac crest. A horizontal line interconnecting the iliac tubercles (supracristal plane)

would cross the vertebral column at L4

intervertebral disc.

Palpate the anterior superior iliac spine (ASIS) at the anterior end of

the iliac crest. The muscle belly of the tensor fascia lata (TF) lies between the iliac tubercle and the ASIS. Locate this

muscle belly. This is one of two potentially safe intra-muscular injection sites in the gluteal region. An injection here is

very unlikely to damage a vital structure.

Palpate the posterior iliac crest and locate the posterior superior iliac spine (PSIS). These can be found on the lower

part of the back and underlie the two conspicuous "dimples". These dimples also mark the superior margin of the

sacroiliac joint. Just medial and inferior to the PSIS is the superior aspect of the sacroiliac joints. In anatomical position,

the anterior inferior iliac spine (AIIS) is on the same vertical plane as the pubic symphysis and on the same horizontal

plane as the PSIS. The other safe injection site in the gluteal region is the superior lateral quadrant of the buttocks. The

other three quadrants are unsafe because of

underlying structures. Look for the sciatic

nerve and gluteal blood vessels deep to the

gluteus maximus in the gross lab.

20

Have your partner lie on his/her side and rotate his/her thigh medially/laterally while you palpate the very large

greater trochanter of the femur. This bony prominence should be located just proximal to the widest part of the thigh. On

the anterior aspect of the thigh, note the large muscle mass made up of the quadriceps femoris. Palpate quadriceps

femoris and pay particular attention to the distally located vastus medialis (VM). Instruct your partner to contract his/her

quadriceps femoris muscles to extend the leg at the knee as you palpate vastus medialis. Identify the action of this muscle

on the patella (P) and patellar ligament (PL). See if you can trace the sartorius (S) as it runs from the ASIS medially and

inferiorly to attach to the anterior/medial aspect of the tibia just inferior to the knee joint. This muscle will only be readily

identified in very muscular and/or thin individuals.

21

Another large muscle mass in the thigh that is located medially is the adductor group (AD). This muscle group can be

readily defined by adducting the thigh against resistance. The large muscle mass in the posterior aspect of the thigh is

principally made up of the hamstrings. This muscle group both flexes the leg at the knee and extends the thigh at the hip.

Have your partner lie face down with his/her knee flexed to 90 degrees. At the lower part of the thigh you can identify the

semimembranosus and semitendinosus medially and the long and short heads of the biceps femoris laterally. As your

partner contracts the hamstrings against resistance, identify these muscles as they define the superior/medial and

superior/lateral borders of the popliteal fossa in the back of the knee. Inspect and palpate the inferior borders of the

popliteal fossa. These muscles are the medial and lateral heads of gastrocnemius. When examining the knee and popliteal

fossa, be careful not to apply too much pressure to the structures of the popliteal fossa. Look for the sciatic, common

fibular, and tibial nerves plus the popliteal artery and vein in the popliteal fossa in the gross lab.Spend some time

examining the knee. The femoral epicondyles are subcutaneous and can be easily palpated when the knee is flexed or

extended. The adductor tubercle, a small bony prominence for the insertion of adductor magnus, may be felt at the

superior margin of the medial epicondyle of the femur.

Anteriorly, note the patella (kneecap). With the leg extended

and relaxed, move the patella medially and laterally. Locate the patellar base and apex as well as the medial and lateral

margins of the patella. Note the patellar ligament’s inferior attachment to the tibial tuberosity, just proximal to the

anterior tibial crest.

22

The medial and lateral tibial condyles can be palpated anteriorly at the sides of the patellar ligament, especially when

the knee is flexed. On the lateral aspect of the knee and slightly distal, locate the fibular head and neck. The common

fibular (peroneal) nerve lies subcutaneous on the fibular neck. Attempt to palpate the lateral collateral ligament of the

knee. This is readily done if you have your partner cross one leg over the other (ankle on knee). It runs from the inferior

aspect of the femur to the fibular head and feels very cordlike. The medial collateral ligament is not as easily palpated, as

it is thinner and flatter and attached to the medial meniscus.

Drawing your attention to the leg, examine the anterior muscle group. These muscles are the dorsiflexors of the foot

(toe extensors). They are very strong, as their primary function is to "lower" the body weight through the foot and ankle

during gait. The large posterior muscle mass plantarflexes (toe flexors) the foot at the ankle and produces the push-off

power during gait. The two largest and superficial muscles of this group are the gastrocnemius and soleus (triceps surae).

These muscles come together inferiorly to form the calcaneal tendon or Achilles’ tendon. Palpate this structure.

Move to the lateral aspect of the leg and palpate the small lateral group of muscles. These muscles fibularis

(peroneus) longus and fibularis (peroneus) brevis are the everters of the foot. Examine the ankle. Palpate the medial and

lateral malleoli. Note that the lateral malleolus extends further distally and more posteriorly than the tip of the medial

malleolus. Just inferior and posterior to the lateral malleolus palpate the tendons of the fibularis longus and fibularis

brevis. Ask your partner to evert (point sole laterally) his/her foot as you palpate these fibularis tendons.

The

dorsiflexor and plantarflexor tendons are held in place by their overlying retinacula. These connective tissue sleeves often

tear following repeated inversion sprains (by far the most common ankle sprains) and the tendons can be felt pulling

away from the ankle and lateral malleolus. Re-examine the calcaneal tendon. Understand that the ankle joint (the 23

tibiotalar joint) allows for dorsiflexion and

plantarflexion whereas the motions of inversion and

eversion take place at the transverse tarsal (subtalar) and

tarso-metatarsal joints. Passively move your partner’s

foot in these planes while palpating the joints of the

ankle with your other hand. Keep in mind that the

motions of the foot and ankle are very complex and

rotate about three axes: vertical, horizontal and

transverse. Palpate the calcaneus. The calcaneal

tuberosity is posterior and very prominent. Heel spurs

are often associated with the calcaneus at the point were

the plantar ligaments attach to it (anterior). The

calcaneal tuberosity is not readily palpable, but you can

look for it on the skeletons in the lab.

Examine the foot. On the lateral aspect of the

dorsum note the muscle mass. It lies about two fingerbreadths anterior to the lateral malleolus. This is the bellies of

extensor digitorum brevis and extensor hallucis brevis. Just superficial to this muscle mass, locate the tendons of

extensor digitorum longus which run from the lateral anterior leg to the lateral digits. Usually there is a fibularis

(peroneus) tertius that arises from the lateral side of extensor digitorum longus. Fibularis tertius’ tendon inserts into the

base (tuberosity) of the 5th metatarsal. On the medial side of the anterior leg and dorsal foot, locate the tendons of tibialis

anterior (medial) and extensor hallucis longus (lateral). Tibialis anterior inserts into the navicular and medial cuneiform

bones and extensor hallucis longus inserts into the first digit.

Turning your attention to the sole of the foot, note the medial and lateral muscles masses that are similar to the thenar

and hypothenar groups in the hand. The skin on the sole is very thick and relatively insensitive compared to the skin of

the hand. Remember that there is all of the same musculature in the foot as in the hand, and if required to do so from birth

one can perform all hand functions with the feet. Inspect the transverse and longitudinal arches of the foot. Have your

partner stand on the floor with his/her feet about 8 inches apart, toes parallel and pointed forward.

Inspect the toes and note their natural position. Determine if your partner has any hammertoes (permanent flexion of

one of the interphalangeal joints of the toe). Identify if your partner has hallux valgus (deviate 1 st digit toward lateral side

of foot) or hallux varus (deviation of 1st digit medially away from 2nd digit). One surgical technique replace an amputated

thumb utilizes the second toe. Notice that the second toe is more appropriate (size) than the big toe for this purpose.

During gait, the second toe is less important mechanically than the big toe. Ask your partner to abduct his/her toes and

attempt to palpate the dorsal interossei between the metatarsals.

24

06: Tendons, Nerves and Vasculature of the Lower Extremity

Be sure to WASH your hands before examining each other.

Arteries:

The major arteries of the lower extremity are the femoral, deep femoral (profunda femoris), popliteal, anterior tibial,

posterior tibial and fibular (peroneal) arteries. The deep femoral, anterior tibial and fibular arterial pulsations cannot be

easily palpated, but you should be able to locate all other pulses.

The femoral pulse can be felt just below the inguinal ligament. Use your right hand on your partner’s right inguinal

ligament. Place your index finger on the pubic tubercle and your thumb on the anterior superior iliac spine. Approach this

artery from the lateral aspect of the thigh and palpate half way between the anterior superior iliac spine and the pubic

symphysis.

The popliteal pulse can be felt posterior to the knee, deep to the musculature. Have the partner lie prone (face down)

and passively flex his/her leg prior to palpating the pulse. The pulse is most easily felt in the inferior part of the popliteal

fossa in the midline. On occasion, this pulse can be very difficult to palpate. The popliteal artery, a continuation of the

femoral artery, bifurcates into the anterior and posterior tibial arteries just below the knee.

The pulse of the posterior tibial artery can be felt as it passes posterior the medial malleolus at the ankle. Palpate ½

way between the posterior border of the medial malleolus and the medial border of the calcaneal tendon. The artery lies

deep to the flexor retinaculum and the retinaculum must be relaxed by inverting the foot, to feel the pulse. Failure to do

so may lead to an inability to feel the posterior tibial pulse.

The dorsal artery of the foot (dorsalis pedis) is the direct continuation of the anterior tibial artery. Have your partner

25

slightly dorsiflex his/her foot as you attempt to find the artery. The dorsalis pedis pulse can be palpated between the

tendons of the extensor hallucis longus and extensor digitorum longus on the top of the foot. Some healthy individuals

have a congenitally non-palpable dorsalis pedis pulse.

Veins:

The two major superficial veins are the greater and lesser saphenous veins. These are the equivalent to the upper limb

cephalic and basilic veins. The greater saphenous can be seen to originate anterior to the medial malleolus and runs up the

medial aspect of the leg and thigh (along inseam) to join the femoral vein in the femoral triangle below the inguinal

ligament. The great saphenous vein is often harvested to use for arterial grafts within the coronary circulation.

The lesser saphenous begins posterior

to the lateral malleolus and runs up the lateral and then posterior aspect of the

leg and empties into the popliteal vein within the popliteal fossa. The

superficial veins of the lower extremity are often the sites of varicosities. Varicose veins have incompetent valves and

thus run a very tortuous path. In some cases they can be quite painful.

To locate a valve within a vein, place your fingers on a large easily defined vein and occlude it. With a finger (or

thumb) from your other hand, push the blood in the vein proximally toward the heart, thus emptying the vein. When you

release the PROXIMAL digit the blood will backfill (flow distal – away from heart) to a specific point in the vein and

then stop (valve). Remember that veins have valves to ensure that venous blood flows only in one direction.

Lymphatics:

26

Lymphatic vessels drain extra-cellular fluid, blood plasma and cellular debris from the periphery back into the venous

circulation. The lymph drains centrally either through superficial vessels (for skin) or deep vessels (running along arteries

and veins) towards the femoral veins. Lymph nodes are named for the body regions in which they are located. Inflamed

superficial lymph nodes can be examined by palpation, but it is common not to be able to palpate normal lymph nodes.

The first group of lymph nodes that is palpable in the lower limb is the popliteal group. These nodes are located in

the popliteal fossa. GENTLY palpate the popliteal fossa, keeping in mind the important arteries, veins and nerves in this

region. The popliteal lymph nodes drain to the inguinal group of lymph nodes. These are major lymph nodes draining the

lower limb. The inguinal lymph nodes are divided into four groups, 3 superficial groups and 1 deep group. You will only

attempt to palpate superficial nodes.

Just inferior to the inguinal ligament (index finger on pubic tubercle, thumb on ASIS), are the superolateral and

superomedial inguinal lymph nodes. The inferior inguinal lymph nodes are located slightly inferior to the superomedial

inguinal nodes along the great saphenous vein. GENTLY palpate these nodes on your partner. The deep inguinal nodes

are located deep to the inguinal ligament and cannot be palpated.

Nerves:

You will be locating only 1 peripheral nerve in this session and then working on identifying the innervation fields of

other nerves in preparation for the neurological exam.

On the lateral aspect of the knee and slightly distal, locate the fibular head and neck. The common fibular (peroneal)

nerve lies superficial to the fibular neck. See if you can gently palpate this nerve as it crosses the fibular neck. Given this

location, it is the most commonly injured nerve in the human body. Severance of the common fibular nerve results in the

loss of dorsiflexion of the foot at the ankle (footdrop). To compensate for this, individuals may adopt a waddling gate, a

swing-out gait or a steppage gait to keep the toes from dragging on the ground. The braking action of normal gait is lost

and the resulting foot-slapping action of heelstrike produces a distinctive “clop”.

The femoral nerve innervates the anterolateral thigh and lies subcutaneous, just distal to the inguinal ligament. It

maintains a position lateral to the femoral artery, just outside of the femoral sheath in the femoral triangle (FT borders –

sartorius, adductor longus and inguinal ligament). The obturator nerve that innervates the medal thigh lies deep to some

of the adductor muscles. The divisions of the sciatic nerve that innervate the posterior thigh lie deep to the hamstring

muscles. Neither the obturator nor sciatic nerve can be palpated. The sciatic nerve branches into the tibial and common

fibular nerves. The tibial nerve innervates the posterior leg, lies deep to gastrocnemius and cannot be palpated.

The common fibular nerve branches into the deep and superficial fibular nerve. The superficial fibular nerve

innervates the lateral leg and the deep fibular nerve innervates the anterior leg. The deep fibular nerve stretches down to

the dorsal foot and goes on to innervate the skin between the first and second toes. The deep fibular nerve is not palpable

at any point.

27

Tendons / Ligaments:

Have your partner stand and palpate his/her patellar ligament

(tendon) just inferior to the patella. With the leg extended, the

ligament should be fairly loose and able to be passively moved

medial/lateral.

Have your partner sit down and ask him/her to flex his/her

leg at the knee. Support his/her knee with the other knee and re-

examine the patellar ligament. This is a site and anatomical

configuration commonly used to test reflexes. If the patella does

not track properly, it frequently will dislocate laterally.

Attempt to palpate the lateral collateral ligament of the knee.

This is readily done if you have your partner cross one leg over

the other (ankle to knee). The lateral collateral ligament runs

from the inferior aspect of the femur to the fibular head and feels

very cordlike.

The medial collateral ligament is not as easily palpated, as it is thinner and flatter and attached to the medial

meniscus. This fact is the reason that the medial meniscus is often damaged following blows to the lateral fixed knee.

The three structures torn in such injuries are the ACL (anterior cruciate ligament), medial meniscus and medial collateral

ligament (these represent the so called “unhappy triad”).

With your partner still seated, have him/her dorsiflex his/her foot as you palpate the calcaneal tendon posterior to the

ankle.

Have your partner lie supine on the examination table, with his/her head supported on the table and his/her feet

extending off the table as necessary. Slide your partner’s foot towards his/her buttock until the knee is flexed at 90°. Keep

your partner’s foot supported on the examination table. Grasp your partner’s flexed leg with both hands just below the

knee joint. GENTLY pull the tibia away from the buttock while keeping your partner’s foot immobile. This is the

anterior drawer test that determines the functionality of the anterior cruciate ligament. You should not perceive any

motion at the proximal end of the tibia with this test.

While still holding onto your partner’s leg, GENTLY push the tibia towards the buttock while keeping your partner’s

foot immobile on the examination table. This is the posterior drawer test that determines the functionality of the posterior

cruciate ligament. Again, you should not perceive any motion of the proximal end of the tibia with this test.

In the gross lab, we will cut the cruciate ligaments on the knee of one of our cadavers so that you can see the positive

anterior / posterior drawer test.

28

07: Back

Be sure to WASH your hands before examining each other.

Start the back examination by inspecting the midline of the back, from

the skull to the superior sacrum. Make note of any lateral deviation from

midline. Attempt to palpate the spinous processes of C7, spines of T1-T12

vertebrae and the spines of L1-L5 vertebrae. Note the different shapes and

angles of the spinous processes in different regions. The inferior direction of

the thoracic spinous processes can be closely studied on the skeletons in the

gross lab. Two landmarks that can help to orient are:

1 - The inferior angle of the scapula is at the approximate level of T7

vertebra (or T6 spinous process).

2 - A plane connecting the iliac crests lies at L4 vertebral level

(supracristal plane), the site for lumbar puncture.

Inspect the spine from a lateral view and note any irregular curves in

the spine. There should be anterior curvatures (convex) at the neck (cervical

lordosis) and lower back (lumbar lordosis). There should be posterior

curvatures (concave) at the thorax (thoracic kyphosis) and sacrum (sacral

kyphosis). Abnormalities include missing regional curves, exaggerated curves

in the thoracic (humpback / dowager’s hump) or lumbar (hollow back)

regions, and/or lateral curvature (scoliosis).

Locate the vertebra prominens (usually the spinous process of C7

vertebra, sometimes T1 vertebra spinous process). This may be done more

easily if your partner is sitting in a relaxed slouched position. After placing

your fingers on the two vertebrae (C7, T1), GENTLY

rotate your partner’s neck to the left and to the right.

The spinous process of C7 vertebra will move, the

spinous process of T1 vertebra will not. You may

confirm this identification by passively flexing and

extending your partner’s head with motion at C7

vertebra and no motion at T1 vertebra.

The T1 vertebra maintains its position due to its

attachment to the first rib. Superior to C7 vertebra, the

nuchal ligament obscures the spinous processes of

most of the other cervical vertebrae within the nuchal

groove of the neck. Try to locate the spines of C6

vertebra and C2 vertebra in the posterior neck.29

The vertebral column is stabilized by a variety of intervertebral

ligaments, thereby restricting its motion. You will not be able to

palpate these ligaments, but visualizing their location will help to

understand the motion of the vertebral column. There are anterior and

posterior longitudinal ligaments on either side of the vertebral bodies.

There are also interlaminar, intertransverse, interspinous and

supraspinous ligaments connecting adjacent vertebrae. During

extreme flexion or extension of the vertebral column, these ligaments

may become compromised. Whiplash injuries happen with sudden,

forceful extension of the neck and tearing of the anterior longitudinal

ligament.

Review the attachments of the trapezius. Have your partner

shrug his/her shoulders against resistance to demonstrate this muscle.

Review the attachments of the rhomboid muscles. Have your partner

retract his/her scapula as you palpate from

the medial border of the scapula and the

vertebral spines.

Remember, when serratus anterior is

paralyzed, the medial border of the scapula

moves away from the thoracic wall giving

the appearance of a “winged” scapula.

Review the attachments of the latissimus

dorsi. Have your partner push his/her elbow

posterior and medial against resistance to

demonstrate this muscle.

Starting at the top of the thoracic spine,

palpate bilaterally and get a sense for the

variation in thickness and extent of the

paravertebral musculature (erector spinae,

transversospinalis) that runs from the base

of the skull to the pelvic girdle. Locate the

three parts of the erector spinae: spinalis

(medial), longissimus and iliocostalis

(lateral) on either side of the vertebral

column. The posterior median furrow

separates these muscles. Have your partner

extend his/her spine and note that these

30

muscles contract bilaterally. Have your partner (ipsi-) lateral flex (side bend) his/her back and notice unilateral (same

side) contraction. Palpate deep to the erector spinae muscles to locate the transverse thoracic processes and the angle of

the ribs, if possible (in thin partners).

Palpate the sacrum and some of its

landmarks. Palpate the spinous process of

L5 and then move your fingers inferiorly

until you feel the spinous process of S1.

Relocate the dimples over the posterior

superior iliac spines. Locate the S2 sacral

spinous process in the midline between

these dimples. This location is the inferior

limit of the cerebrospinal fluid lumbar

cistern.

Cerebrospinal fluid can be the site of

bacterial infection (meningitis) or

cardiovascular leakage (blood in CSF). It

can also be used to detect a neurological

electrolyte imbalance. There is a blood

brain barrier that actively protects the cerebrospinal fluid and it is difficult to obtain samples from inside the skull.

Luckily, the subarachnoid space in the brain is continuous with the subarachnoid space in the vertebral column. To obtain

a sample of cerebrospinal fluid, a needle is used to puncture the dura and arachnoid of the lumbar cistern. The needle is

inserted between the spines of either L3/L4 or L4/L5 vertebrae. There is little danger of injury to the spinal nerves at this

level and there is no danger to the spinal cord. The spinal cord ends at L2 vertebrae and only the spinal nerve roots

continue inferiorly as cauda equina. Anesthetic can be injected at these sites to have a direct effect on the lumbar and

sacral spinal nerve roots. Anesthetic injected into the lumbar cistern will have a greater effect if injected subarachnoid

rather than epidural. The amount of anesthetic and the position of the patient will also play a large role in the action of the

drug.

Spinal taps can also be used to treat slipped (herniated)

discs, typically in the lumbar region. Because of the size

and location of the posterior longitudinal ligament,

protrusion of the nucleus pulposus usually occurs in a

posterolateral direction. This tends to be the exact location

of the spinal nerve exit from the vertebral canal at each

vertebral level. The gelatinous nucleus pulposus

compresses the spinal nerve and a perception of pain is

experienced.

31

32

08: LIVE ANATOMY REVIEW

Student Supplied Review Questions for Self-Study Review previous handouts for answers

What is the largest human organ?

Where is the anterior superior iliac spine?

Find the medial epicondyle of the humerus.

What muscles make up the shoulder girdle?

What uses the medial epicondyle of the humerus as a common attachment?

Palpate the inferior angle of the scapula.

Name three functions of skin.

Where is the common fibular nerve best palpated?

What structural fracture causes pain in the anatomical snuffbox?

Palpate extensor pollicis longus.

Locate the spine of the scapula.

Where is the posterior superior iliac spine?

Palpate extensor digiti minimi tendon.

Localize the brachial pulse.

What is the common site of attachment for the wrist and finger flexors?

Outline the rhomboids.

What nerve runs posterior to the medial epicondyle of the humerus?

Palpate the lateral border of the scapula.

What is the strongest humeral abductor?

Locate the dorsalis pedis pulse.

Where is the thenar region?

Palpate the acromion process.

Palpate the calcaneal tuberosity.

Palpate flexor carpi radialis tendon.

Which nerve is nicknamed the million-dollar nerve?

What is the location of the million-dollar nerve?

Locate the popliteal fossa.

What are the three elbow bony prominences?

Locate the strongest forearm flexor.

Where is the medial border of the scapula?

Where are dermatoglyphics located?

Palpate soleus.

Where is the cubital fossa?

Name and locate the strongest supinator.

Locate the ulnar groove of the humerus.

Outline trapezius.

Locate pectoralis major.

Palpate the palmaris longus tendon.

Palpate the insertion of semitendinosus.

Locate the common attachment of wrist and hand extensors.

Where are subscapular lymph nodes palpated?

Locate the fibular collateral ligament of the knee.

Trace the boundaries of sartorius.

Which tendons make up the anatomical snuffbox?

Which of the two styloid processes of the wrist extend further?

Where are the supratrochlear lymph nodes located?

Where would you palpate the calcaneal tendon?

What are the attachments of the long and short heads of biceps femoris?

Where is the acromioclavicular joint?

Where is the vertebral border of the scapula located?

33

09: Complementary and Alternative Medicine (CAM)

Today’s session is intended as a brief introduction to complementary and alternative forms of healthcare. Practices

that are now deemed "alternative" were considered standard medical practices for thousands of years previously. Some of

these therapies have been extensively researched and others have not. Currently, over 2500 references for complementary

and alternative medicine can be found in literature searches, including the research journals Science and Nature.

While conventional health care is still thought by many to be the primary option for treating an illness, many people

throughout the world still seek alternative medical solutions to their physical ailments. Much of this acceptance has been

prompted by a worldwide crisis in terms of quality health care. Prohibitively expensive conventional medical care has

prompted people to seek alternative means to cure their ailments. People suffering from chronic conditions or life-

threatening diseases will often seek out alternative treatment when they have exhausted all the possibilities that

conventional care has to offer.

To give some background how these forms of medicine have performed in the past, an outbreak of cholera in Ohio in

1849 proved complementary and alternative medicine validity when only 3% of homeopathic patients died compared

with a mortality rate of 40-70% for those treated with conventional (heroic/allopathic) methods. In 1879, New Orleans

homeopathic medical practitioners treated yellow fever with a mortality rate of 5.6% while the conventional treatment

(heroic/allopathic) yielded a 16% mortality rate.

Most alternative medicine practices fall outside the spectrum of conventional allopathic medicine. Some of the

complementary and alternative medicine practices are briefly explained below:

Acupuncture: Involves stimulating certain acupoints on a person's body to relieve pain, promote healing and overall well-

being.

Allopathic Medicine: Advocates making use of all measures that have proven to be effective in the treatment of disease.

Chiropractic Medicine: Uses spine manipulation and adjustments as a way of treating health conditions.

Heroic Medicine: Inexact medicine using extreme measures to “cure” patients, including bloodletting and amputation.

This was the precursor of the allopathic medicine in practice today.

Holistic Medicine: Treats both the mind and the body as whole, rather than individual parts.

Homeopathic Medicine: A system of natural remedies used to treat disease.

Iridology: The study of the iris of the eye in order to diagnose illness or disease.

Massage Therapy: The manipulation of soft tissue in the body to relieve and prevent pain, stress, and muscle spasm.

Naturopathic Medicine: Focuses on the body's inherent healing powers and works to restore and maintain overall health.

REFLEXOLOGY

Be sure to WASH your hands before examining each other

We are going to focus on reflexology, as novice reflexologists are not likely to injure their partners during these

exercises. Reflexology has been around for the past five thousand years. It has roots in China, but evidence has been

found indicating that reflexology was also used in Egypt as far back as 2300 B.C.

Many people seek reflexology for relaxation and to improve their health and well-being. It is thought that by pressing

points on the feet, impulses are sent through “pathways” to certain areas of the body, increasing energy and health in

those areas. It is believed that there is a "vital energy" that is circulating between organs of the human body that

penetrates into every living cell. During treatments, patients may even feel tingling sensations in the parts of the body to

which the impulses are being sent. If someone has a problem in a particular organ, a reflexologist will press on the

corresponding reflex zone and the person will experience pain. This pain is claimed to originate from the deposition of

crystals in the reflex zone and, with massage, these crystalline structures can be broken down and the pain relieved.

Reflexology is thought to help anxiety, asthma and allergies, chronic pain, diarrhea and constipation, high blood pressure,

migraine headaches, premenstrual syndrome (PMS), skin problems, and stress. In Great Britain, reflexology is covered as

part of the National Health Service. In Switzerland, nurses use reflexology with terminally ill cancer patients to reduce

pain.

For the most of the part, the reflexology massage is pleasant and soothing. There may be discomfort in some places

that is an indication of congestion or imbalance in a corresponding part of the body. Reflexology can help relax your

partner and is believed to stimulate the body's healing mechanisms. Massage reflex points on your partner’s feet, hands

and /or ears to see if you can find tender spots and note problem areas. Use the following reflexology charts to explore

your partner’s feet, hands and/or ears. A course of treatment varies in length depending on the need of the body, but in

this case you will spend about 20 minutes for the session and then change roles. As you are changing roles, talk with each

other about the treatment. Ask your partner if she/he ever had a problem with the structure that is reflexively related to the

tender spot you located. Were there points of pain? Was there any body tingling during the treatment? Does either of

these correspond to any known conditions?

Reflexologists use a combination of foot, hand and ear reflexology to obtain the most accurate results. Most scientists and

medical professionals consider reflexology to be a pseudo-science, offering no more benefits than ordinary massage. They

claim there are no reliable scientific studies proving its effectiveness as a medical treatment, or that there is any form of

link between specific areas of the feet and the various organs of the body. Furthermore, the 'crystalline structures'

rationale is not sustained by current understanding of physiology. There is no scientific evidence that healing can be

achieved by it or that the claimed "energies" and their supposed pathways through the body even exist.

Prominent skeptic Stephen Barrett, M.D., contends there is no scientific support for any of the theories of

Reflexology. He refers to several scientific studies that have shown Reflexology is no better than random chance

detecting medical problems. In "Reflexology: A Closer Look", Dr. Barrett concludes "Reflexology is based on an absurd

theory... Claims that reflexology is effective for diagnosing or treating disease should be ignored. Such claims could lead

to delay of necessary medical care..."

reflexology.html

reflexology.html

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http://aboutreflexology.com/charts.htm

10: Eye and Eye Adnexa

Be sure to WASH your hands before examining each other

To start, instruct your partner to look straight ahead and focus on a fixed object in the distance (about 20 feet away).

Inspect the position of the eye in the orbit. Note if the visual axes are parallel and if the eyes are held steady.

Notice that there are three prominent features on the surface of the eyeball, the sclera, the iris and the pupil. Inspect

the opaque sclera and note the color of the tissue. You may be able to see numerous small blood vessels throughout the

sclera. Note if the obvious vessels are engorged or dilated. The cornea is a thick clear structure overlying the iris and

pupil. The limbus is the site where the sclera meets the cornea. A very thin layer of cells covers much of the sclera and

passes back into the orbit and is reflected up (and down) onto the deep surfaces of the eyelids. This transparent layer of

cells is the conjunctiva. It has its bulbar (eyeball) attachment at the limbus.

Inspect the colored iris and note the color variation from periphery to center, and from eye to eye. In the center of the

iris, you can see the black pupil through which light enters the eye. Inspect the pupil and determine if the pupils of both

eyes match in size and shape. The pupils should remain stable as long as the light levels remain stable. Muscles attached

to the iris control the diameter of the pupil and alter the amount of light entering the eye. Deep to the iris and pupil lies a

thick clear lens. Muscles attached to the suspensory ligaments of the lens contract to change its shape, allowing you to

focus on nearby

objects

(accommodation).

Use a pen light in a darkened area of the room to check pupillary reflexes. Quickly illuminate only one eye (right)

without illuminating the other (left) eye. Observe the pupillary constriction in each eye and confirm that they match in

response. Shift to the other side and do the same procedure for the left eye. Again observe the pupillary constriction in

each eye.

Extra-ocular muscle function is evaluated by observing eye movement produced by isolated eye muscles. Positioning

of the eye so that individual muscles can only act on a single axis (perpendicular) of motion is critical to test the muscles.

There are six extra-ocular muscles that move the eye: superior rectus, inferior rectus, medial rectus, lateral rectus, superior

oblique, and inferior oblique. The rectus muscles shift gaze in the direction of the muscle name (superior rectus shifts gaze

superior). The oblique muscles shift gaze in the opposite direction of the muscle name, especially when the gaze is

adducted (medial shift).

One

or more

of the extra-ocular muscles may be paralyzed with head injury or problems with the brainstem. No matter the cause, the

result will be double vision (diplopia). Complete oculomotor nerve lesion affects most of the extra-ocular muscles,

including the muscles of the upper eyelid and the pupil. The pupil would be fully dilated, depressed and abducted. A

lesion of the abducent nerve results in paralysis of the lateral rectus muscle. This time, correct pupillary elevation and

dilation would be maintained although the pupil would be fully adducted.

Eye adnexa refers to the accessory structures of the visual system. You will need your partner’s help in order to see

all of the following structures. Ask for your partner to pull out his/her own eyelid and to move his/her eyes around in the

orbital cavity to improve your view.

First inspect the upper and lower eyelids (palpebrae). They are separated from one another by the palpebral fissure

and contact each other at the medial and lateral canthi (corners). Notice that there are hairs (eyelashes) emerging from each

eyelid. A small sebaceous gland (ciliary gland) for the eyelashes is associated with each eyelid. Inflammation of the ciliary

gland results in a sty on the edge of the eyelid. There is also a dense connective tissue band (tarsal plate) that supports the

superior eyelid. Within the plate, there are additional glands. These tarsal glands make an oily secretion that prevents the

eyelids from sticking together and prevents the lacrimal fluid from leaking out of the eye. Eyelid paralysis is the result of

lesion of one of two cranial nerves, either the oculomotor nerve (upper eyelid) or the facial nerve (lower eyelid). In either

case, the eyelid droops (ptosis) in response to decreased muscle tone.

The lacrimal gland sits in the upper lateral portion of the orbit. This gland is responsible for the majority of tears that

are secreted. The tears protect the eyeball surface from desiccation and microbial invasion. The tears run across the

eyeball from superior lateral to inferior medial where they collect in the lacrimal lake. From there, tears run into the nose

via the nasolacrimal duct.

Focusing your attention on the medial aspect of the orbit, locate a small fleshy mass. This is the lacrimal caruncle.

Protruding just lateral and deep to the lacrimal caruncle, find the plica semilunaris. Have your patient slowly look laterally

and the plica semilunaris will appear to emerge out from under the caruncle. Both of these structures provide connective

tissue and bony attachment for the conjunctiva. The lacrimal caruncle and the plica semilunaris lie on the floor of the

space referred to as the lacrimal lake, the portion of the orbit where tears collect.

Just lateral to the lacrimal lake locate a small elevation on the upper and lower eyelid. These are the lacrimal papillae.

Atop each papilla there is a small opening, the lacrimal punctum. The lacrimal puncta lead to the lacrimal canaliculi.

These structures drain tears into the lacrimal sac, which in turn drains inferiorly through the nasolacrimal duct into the

inferior meatus of the nasal cavity.

11: Neck

Be sure to WASH your hands before examining each other

Start by having your partner sit comfortably facing you. Inspect his/her neck from the body of the mandible to the

superior border of the clavicle. A very thin muscle (platysma), attached to the skin, covers this entire area. Locate the

large sternocleidomastoid (SCM) muscle that divides the neck into two spaces, anterior triangle and posterior triangle.

The external jugular vein runs superficial to sternocleidomastoid. Try to locate this superficial vein that tends to be

prominent in singers and other musicians. Ask your partner to take a deep breath and hold it to assist in your location of

this vein.

Sternocleidomastoid runs from the

medial end of the clavicle and manubrium

superiorly to insert just posterior to the ear

on the mastoid process of the temporal bone.

Palpate the margins of this muscle. Ask your

partner to rotate his/her head to one side and

slightly elevate his/her chin.

Examine the contralateral (opposite side)

sternocleidomastoid while your partner’s

head is rotated and locate the space between clavicular and sternal heads of sternocleidomastoid. This space is called the

lesser supraclavicular triangle and is a site of internal jugular vein puncture (cannulation for diagnosis).

The anterior triangle of the neck uses sternocleidomastoid, the mandible and the midline of the neck as its boundaries.

Inside the anterior triangle are another 4 triangles of the neck, each with specific boundaries and contents that can be

clinically important.

The submandibular “triangle” is located just inferior to the mandible and is

bounded by the anterior and posterior digastric muscles as well as the mandible.

This space contains the submandibular gland and the facial artery.

The submental triangle is located inferior to the chin (mental protuberance)

and is bounded by the anterior digastric, hyoid bone and midline of the neck.

This is the site of the submental lymph nodes, which you are unlikely to palpate.

The muscular triangle is located directly inferior to the submental triangle. It

is bounded by the midline of the neck, sternocleidomastoid and omohyoid. It

contains the laryngeal and thyroid structures of the neck.

The carotid triangle is located inferior to the angle of the mandible. It is

bounded by sternocleidomastoid, posterior digastric and omohyoid. This triangle is relatively easy to locate, as it is the

location of the strong carotid pulse. GENTLY palpate your partner’s carotid pulse. Located in very close proximity to the

common carotid artery are the vagus nerve (CN X) and the carotid sinus, both of which help to regulate heart rate.

Stimulation of this area can have a depressive effect on heart rate, which is one possible treatment for heart fibrillation.

Remember those complementary and alternative medical (CAM) procedures. This one definitely has an effect! The

common carotid artery bifurcates (splits) into the external and internal carotid arteries in the carotid triangle, specifically

at C4 vertebral level. Palpate the angle of the mandible and feel for the internal carotid pulse, just deep to the ramus of

the mandible. The internal carotid artery pulse may be difficult to locate at this site.

While your partner is still seated, move to a position behind him/her. Be careful here and be sure to tell your

partner what you are going to do! Palpate the angle of the mandible again and your fingers anteriorly along the body of

the mandible towards the mental protuberance. Once there, move your fingers inferiorly from the mandible to GENTLY

palpate the hyoid bone. This bone sits at the posterior part of the submandibular angle. Attempt to palpate it bilaterally

and move it around. Have your patient swallow to facilitate finding the hyoid. By pushing GENTLY on one side, the

greater and lesser horns of the hyoid can be palpated on the contralateral side.

There are a number of structures to be palpated in the midline of the anterior triangle. Move your fingers

inferiorly from the hyoid bone to GENTLY palpate the thyroid notch on the midline (very conspicuous in men) on the

superior border of the thyroid cartilage (at the level of C5 vertebra). Locate the intervening thyrohyoid membrane and

move inferior to the laryngeal prominence (Adam’s apple). Have your partner swallow again and confirm that the thyroid

cartilage moves as the hyoid bone moves. This cartilage is one of several sexually dimorphic structures in humans.

Run your finger inferiorly along the thyroid cartilage until you come to a gap between it and the next structure.

The floor of this “gap” is made up of the cricothyroid membrane. The next

inferior rigid structure is the cricoid cartilage. Slide your fingers inferior to the

cricoid cartilage and GENTLY palpate the trachea in the suprasternal notch.

Tracheal rings 2-4 are covered over by the thyroid isthmus just anterior to the

trachea. If you are having difficulty palpating the tracheal rings, have your

partner swallow again to move the laryngeal structures. You may feel the

thyroid isthmus move during swallowing. The thyroid isthmus is the site of

tracheotomy (temporary) and tracheostomy (permanent) incisions. Palpate the

thyroid gland with the two lobes on either side of the trachea. This may be

difficult due to the infra-hyoid muscles covering the lateral lobes of the thyroid

gland. With the posterior approach, you can usually feel the posterior margin

of the lateral lobes of the thyroid gland, deep to the thin infrahyoid muscles.

Lymphatics of the neck are located throughout the neck triangles and surrounding sternocleidomastoid. The

retroauricular (mastoid) lymph nodes are located just posterior to the ear (auricle) and the parotid lymph nodes are located

just anterior to the ear. Both of these nodes drain into the superficial cervical nodes, overlying the sternocleidomastoid

about 1/3 inferior to its mastoid attachment. The superficial cervical nodes drain into the superior deep cervical nodes

(deep to sternocleidomastoid). The superior deep cervical nodes drain into the inferior deep cervical nodes. The

submental lymph nodes drain into the submandibular lymph nodes and subsequently drain into the inferior deep cervical

(jugulo-omohyoid) nodes. Once lymph is in the inferior deep cervical lymph nodes, it drains into either the lymphatic

duct (right) or the thoracic duct (left) to reach the subclavian veins. The supraclavicular lymph nodes, present just lateral

to the clavicular attachment of the sternocleidomastoid, also drain into either the thoracic or lymphatic duct.

Palpate along the anterior margin of the sternocleidomastoid from the manubrium to the mastoid process of the

temporal bone. Also palpate along the inferior margins of the mandible from the auricle (ear) to the mental protuberance.

Feel for any of the lymph nodes. Sometimes superior deep cervical nodes can be felt just anterior to the anterior margin

of the sternocleidomastoid and inferior to parotid or submandibular nodes. Remember, it is common not to be able to

palpate normal lymph nodes.

Next, palpate the external occipital protuberance and move your fingers inferior along the nuchal ligament to

vertebra prominens. Palpate the superior portion of the trapezius running from the superior nuchal line of the occipital

bone to superior scapular spine. The anterior margin of the trapezius, the posterior margin of the sternocleidomastoid and

the clavicle form the posterior triangle. The posterior triangle can be divided into two smaller triangles, with each with

specific boundaries and contents that can be clinically important.

The occipital triangle has sternocleidomastoid, trapezius and omohyoid as its boundaries. Several large nerves are

located within this triangle, including the spinal accessory nerve (CN XI) and the ventral rami of the brachial plexus.

The greater supraclavicular triangle has omohyoid,

sternocleidomastoid and the superior border of the clavicle as its

boundaries. This triangle is separated from the lesser supraclavicular

triangle by the clavicular head of sternocleidomastoid. The greater

supraclavicular triangle is the site where the subclavian pulse can be

felt just deep to the superior border of the clavicle. This is also the

site of venipuncture for central line placement for prolonged

cardiovascular procedures. The pleura of the lungs and the subclavian

artery are in danger of puncture in this tight space.

12: Ear, Nose & Mouth

Be sure to WASH your hands before examining each other

The ear is made up of three parts: external ear, middle ear, and inner ear. You will examine the external ear on each

other and the middle and inner ear as models in the gross anatomy lab. The external ear is made up of the auricle (pinna)

and external auditory canal. The auricle is the elastic cartilage, conch shell-shaped structure on the lateral head.

With your partner comfortably seated and facing you, examine your partner’s auricle to determine if both ears are

symmetrical. Palpate the entire pinna and confirm that it is made up primarily of firm elastic cartilage covered with skin.

The earlobe (lobule) also contains some subcutaneous fat. The prominent outer rim of the ear is the helix. Just anterior to

the helix, within the pinna, is the antihelix. The scapha separates the helix from the antihelix and the cymba separates the

antihelix from the external auditory meatus. The tragus is another prominent feature of the external ear that overlies the

entrance (anterior) to the external auditory canal. All of these folds together make the concha of the ear. Other structures

that can be harder to see on everyone are the anti-tragus (inferior to the tragus) and the auricular (Darwin’s) tubercle (if

present). The auricular tubercle is a thickening of the helix at the junction of the upper and middle third of the ridge that

comes in a variety of shapes. There are three muscles that move our ears, the anterior auricular, superior auricular and

posterior auricular muscles. Some people can even use these muscles to voluntarily wiggle their ears. Give it a try!

The middle and internal ear cannot be viewed externally. An

otoscope would assist you in viewing the tympanic membrane and looking for signs of middle ear infection or torn

membranes. Middle ear infections tend to be the result of blockage of the pharyngeotympanic (Eustachian/auditory) tube.

Swelling of the mucous membrane or an infection of the nasopharynx (or adenoid/pharyngeal tonsil) will result in

blocked drainage from the air-filled middle ear. In turn, this leads to middle ear infection (otitis media) and swelling of

the tympanic membrane. This painful condition causes the alteration of vibrations and affects hearing (muffled sound).

Lesions of some cranial nerves can also affect hearing. Paralysis of stapedius, due to loss of facial nerve (CN VII)

innervation, results in excessively acute hearing. The paralyzed muscle no longer modulates the oscillations of the ossicle

(stapes) and all subsequent sounds are effectively amplified.

Examine your partner’s nose. The external features include the tip, alar nasi (broad wings extending from the tip),

nasal septum and the anterior naris (opening, nostril) that leads to the nasal cavity. The upper lip has a prominent groove

http://www.emedmag.com/html/pre/dia/11_03.asphttp://pinna.hawkelibrary.com/anatomicalvariations/1_9_R

called the philtrum. Inspect this nasolabial fold and check for symmetry in both depth and definition.

The first part of the nasal cavity is the vestibule and it is lined with skin rather than mucosa. Similar to most skin

throughout the body, it contains hair. The nose serves several functions including: olfaction, respiration, and filtration for

inhaled particulate matter, humidification and warming of inspired air, plus the drainage site of various secretions.

Note the location of the paranasal sinuses. The paranasal sinuses include the frontal, ethmoid, sphenoid and maxillary

sinuses. These air filled cavities are lined with mucosa and most effectively drain inferiorly into the nasal cavity. The

maxillary sinuses are the exception, with a small superomedial drain (ostium) that is non-functioning in anatomical

position. Even small amounts of congestion can block this drain and result in a maxillary sinus infection. The resulting

pressure and pain are transmitted through the trigeminal nerve (CN V2). On the CT, note the upper molar teeth in close

proximity to the maxillary sinuses. Any molar pathology can easily pass into these spaces as well.

With your partner comfortably seated and facing you, examine your partner’s temporomandibular joint. Place your

fingers anterior to the tragus to feel for the mandibular condyle. Ask your partner to open and close his/her mouth as you

examine the joint bilaterally. You should be able to feel the anterior gliding motion when your partner fully opens his/her

mouth and the posterior glide when closing his/her mouth. Ask your partner to clench and unclench their teeth as you

palpate immediately superior and anterior to the angle of the mandible and the temporal fossa (above zygomatic arch).

The masseter

muscle can be palpated at

the edge of the mandible as the muscle overlying the ramus. The temporalis muscle is palpated in the temporal fossa

superior to the zygomatic arch. Both of these muscles work together to elevate the mandible and close the mouth.

Determine if the muscles move symmetrically while closing and opening the mouth.

Next, inspect the margins of the mouth. Notice that the lips are muscular folds that surround the opening into the oral

cavity. Notice the dramatic change in the color and texture of the lip skin as it approaches the mouth. The skin becomes

thinner and hairless on the lips and this is referred to as the vermillion border. The mouth is made up of several sensitive

regions (remember homunculus), some of which you will need your partner’s assistance to view. Before we go any

further, can you find Cupid’s bow? The closed lips resemble a compound bow (for arrows) lying on its back.

Ask your partner to open his/her lips and expose the gums (gingivae) and teeth. There are supposed to be 32 teeth in

the adult, but dental surgery often decreases that number. Count the teeth that are exposed in your partner. Notice the

edge of the gums are scalloped in appearance and had numerous interdental papillae. Ask your partner to gently reflect

his/her lower lip and notice the rich vascular mucosa. On the internal surface of both the upper and lower lips there is a

mucosal fold in the midline, the labial frenulum. Ask your partner to pull their lips out and down (and up) to show this

attachment.

Inspect your partner’s tongue while it is relaxed on the floor of the oral cavity. Determine if it is symmetrical from

side to side in regards to muscle mass. Have your partner stick out his/her tongue and note the numerous papillae on the

dorsal surface. Some of these papillae will look like small white dots on the red surface of the tongue. When your partner

protrudes his/her tongue, note if it deflects to one side. Examine the undersurface of the tongue. You should easily

observe the prominent lingual frenulum on the midline. Notice that on either side of the frenulum there is a prominent

vein located just deep to the mucosa. These are the deep lingual veins. They can be used as a site of rapid drug ingestion

due to the thin mucosa and rich vascular supply. Typically this is the site for life saving vasodilator (nitroglycerin) pills.

Near

the

inferior attachment of the lingual frenulum, notice two papillae just lateral of midline. The submandibular salivary ducts

open into these papillae. Ask your partner to imagine biting into a very sour lemon and see whether or not there is saliva

secreted through these openings. Next, show your partner a slice of lemon and squeeze a few drops into your own mouth.

Observe if this affects the saliva secretion of the submandibular glands. Finally, take a slice of lemon and place a small

drop of lemon juice into your partner’s mouth. Again see how this affects the saliva secretion of the submandibular

glands. The paired submandibular glands can be

palpated just medial to the mandible, overlying tense

extrinsic tongue muscles. Ask your partner to press

his/her tongue against the back of the upper incisors

and then palpate these glands against the internal

mandibular body (about 1/3 posterior). You can

palpate your own sublingual glands by dragging your

tongue down the posterior surface of your lower

medial incisors and then move your tongue to one

side or the other over the floor of your mouth. Each

gland will feel round and firm and sometimes quite

asymmetrical in size. Finally, palpate the parotid

glands. These paired salivary glands lie posterior to

the ramus of the mandible and are superficial.

Ask your partner to open his/her mouth widely and examine the posterior oral cavity. Look at the back of the mouth

and locate the uvula (the thing that hangs down).

Determine that the position of the uvula is midline

when at rest. Ask your partner to say “AAAHHH”.

Watch how the position of the uvula shifts in

response to phonation and respiration. Inspect the

lateral walls of the oropharynx and observe where

the soft palate reaches the pharynx and tongue.

Notice the two prominent folds (anterior/posterior

pillars). They are also called the palatoglossal

(anterior) and palatopharyngeal (posterior) folds/arches. In the space between the anterior and posterior arches, you

should be able to see the palatine tonsils between these two pillars. Be sure to ask your partner if he/she had his/her

tonsils removed if you can’t find the them between the pillars.

Nerve blocks for dental surgery can be performed in a variety of locations, depending upon which zones of the oral

cavity require the work. Between the 2nd and 3rd upper molars, the greater palatine nerve (CN V2) emerges to innervate the

posterior hard palate, the mucosa and the posterior on the ipsilateral (same) side. A nasopalatine nerve (CN V 2) block,

with an injection just posterior to the upper incisors, results in anesthesia of the anterior hard palate, mucosa and the

anterior incisors and canine teeth on both sides. An inferior alveolar nerve block requires an injection of part of the

mandibular division of the trigeminal nerve (CN V3). The dentist feels for the lingula of the mandible on the internal

surface of the ramus and injects near that site. All of the ipsilateral mandibular teeth are anesthetized well as the mucosa,

mandible and skin of the mental region of the face.

13: Head & Face

Be sure to WASH your hands before examining each other

Begin with the head examination by

comparing its position to the neck. Have your

partner sit in a comfortable position facing you.

The head should be on the midline and be held

steady. Palpate for the following landmarks on

the head: external occipital protuberance,

glabella, nasion, zygomatic arch, mental

protuberance, angle of the mandible and

mastoid process of the temporal bone. These are

sites of bony sutures or muscular attachment.

Try to recall which muscles are attached at each

location. Inspect the skin of the forehead and

the location of the eyebrows. Ensure that the

structures are symmetrical. Ask your partner to

raise their eyebrows and watch for uneven

motion. Examine the palpebral fissures and

determine if they are symmetrical and evenly

open (check the height with a ruler). The upper

eyelid (palpebrae) should not cover the pupil

and in some individuals it does not cover any

part of the iris. The eye should be centrally

located within the orbit with uniform amount of sclera on either side of the iris. Ask

your partner to perform the following motions: close his/her eyes tightly, smile, purse

lips, frown. All motions should be symmetrical. Inspect the face for uniformity of

color and note if one location of the face (right, left, forehead, upper jaw, lower jaw)

is flushed or especially dry/clammy.

Bell’s Palsy is a condition in which the facial nerve (CN VII) is injured and the

ipsilateral facial muscles become paralyzed. This condition may be due to an infection

of the parotid gland. The facial nerve passes through the encapsulated gland on its

way to the facial muscles. The affected facial area appears to droop, including the

eyebrow, upper eyelid and corner of the mouth. Because the eyelids do not close

tightly, tears often leak from the orbit. The person is not able to eat effectively

because he/she is unable to keep the cheek tight against the teeth. Affected individuals will have altered speech and a

tendency to wipe at the tears and saliva that leak due to inadequate seals.

Try to GENTLY palpate the infraorbital nerve as it passes out of the skull, onto the maxilla. Locate this nerve by

placing a finger on your partner’s zygomatic process at the anterior end. Slowly shift medially to the face, inferior to the

orbit. Move approximately one fingerbreadth medial and inferior to the anterior part of the zygomatic arch. At this point

your finger should overlay the infraorbital nerve (CN V2) and the infraorbital foramen of the maxilla. Be careful. Too

much pressure on this point is painful! You may also be able to locate the smaller supraorbital (CN V1) and mental (CN

V3) nerves using a similar method. From the zygomatic arch, move medially and superior to the orbit to find the

supraorbital nerve. Move along the body of the mandible to just lateral to the mental protuberance to find the mental

nerve. Both the supraorbital and mental nerves are substantially smaller than the infraorbital nerve and are less likely to

cause the extreme pain response.

Attempt to locate some of the terminal branches of the external carotid artery. The superficial temporal artery and

some of its branches can be located in the

temporal fossa, anterior to the ear and

superior to the zygomatic arch. The main

artery is located just anterior to the tragus of

the external ear. This is the pulse point that

anesthesiologists use to monitor patients.

Some branches of the superficial temporal

artery can be felt at the origin / superior

(distal) attachment of temporalis, just

superior to pterion of the skull. This is a

potentially dangerous area for arteries. Blows

to the head can rupture the middle meningeal

artery (deep to pterion) and lead to intracranial hemorrhage. Left untreated, this arterial bleed can result in death within a

few hours.

Palpate the facial artery pulse as it passes over the mandibular base just anterior to the insertion of masseter.

Occlusion of this artery has little major consequence due to the large anastomosis with nearby vessels.

Lymphatics of the head are named based upon location or nearby structures. Lymph from the scalp drains either

through the occipital (posterior), retroauricular/mastoid (lateral) or parotid (anterior) lymph nodes. Lymph from the face

drains through the buccal (upper jaw), submental (anterior lower jaw) and submandibular (posterior lower jaw) lymph

nodes. From each of these subcutaneous lymph nodes, lymph drains into the superficial cervical nodes and then into the

superior deep cervical nodes, lying deep to sternocleidomastoid. The superior deep cervical nodes drain into the inferior

deep cervical nodes and from there it drains into either the lymphatic duct (right) or the thoracic duct (left) to reach the

subclavian veins. Of all these nodes, the submental node tends to be one of the most active. It is one that often “heats up”

in association with cancer of the tongue.

Next session: We will be working on thoracic structures.

Please wear clothing that allows for direct visualization and palpation.

The ideal option is a tank top.

14: Respiratory Thorax

Be sure to WASH your hands before examining each other

While you obviously cannot directly examine the lungs by palpation, you can listen to them through the chest wall.

Therefore, it is important to know the precise location of the lungs and other organs, as they would be projected onto the

thoracic wall. Start with your partner seated comfortably facing you. Inspect the sternum and note if it is flat, indented or

bowed out. Examine the suprasternal (jugular) notch and confirm that it is located at T2 vertebral level. Examine the

sternoclavicular joints and palpate the medial end of the clavicle as you move the joint through its range of motion.

Locate the sternal angle (of Louis – T4 vertebral level – also the level of the tracheal bifurcation/carina) on your

partner, between the manubrium and the body of the sternum. Move your finger laterally until you find the second rib.

The space below rib 2 is the second intercostal space, as these spaces are numbered according to the rib located

superiorly. Next palpate the xiphoid process at the inferior most part of the sternum. The xiphoid becomes calcified with

age and that may lead to “unusual” bumps. The lower margin of the fifth rib is at the level of the xiphisternal joint (T9

vertebral level). Locate the rest of the ribs and intercostal spaces through palpation on your partner. It is more easily done

on thinner partners, but it should still be possible in all partners. Combine groups as necessary.

The first rib lies inferior to the clavicle can only be indirectly palpated posterior to the clavicle (midclavicular).

Occasionally, cervical ribs increase the number of ribs in the thorax (1%). They are clinically significant as they may

compress the inferior trunk of the brachial plexus and the subclavian vessels. Relocate the second rib and "walk down"

the ribs and intercostal spaces with your fingers. Move slightly laterally as you descend as the ribs are quite close together

at the sternum. The first seven (true) ribs articulate directly with the sternum using their costal cartilages. Palpate the

inferior margin of the ribs close to the sternum to feel for the costal cartilage. This cartilage contributes to the elasticity of

the ribcage. It starts to calcify with age, leading to a more rigid thorax and decreased respiratory capacity. Ribs 8-10 (false

ribs) articulate with the costal cartilage of rib seven. Ribs 11-12 are unattached to the sternum and called floating ribs.

The tip of rib 11 can be GENTLY palpated anteriorly, while the tip of rib 12 can best be GENLTY palpated from the

back.

Have your partner lie face down on the examination table and attempt to palpate

the ribs posteriorly. Locate rib 12 and then “walk up” the ribs and intercostal spaces

moving superolateral. Next, palpate the spinous processes of the vertebrae. Start by

locating the spinous process of C7 (vertebrae prominens – moves with neck rotation

and flexion). Count superior and inferior to locate as many vertebrae as you can. Look

at a skeleton to appreciate the relationship of the ribs between the thoracic vertebrae

and the sternum. The ribs attach at a higher point on the thoracic vertebrae than they

seem to attach anteriorly on the sternum. Also, realize that these vertebral levels are

different than the dermatome levels.

Locate the triangle of auscultation. The inferior lateral border of the trapezius, the

superior lateral border of the latissimus dorsi and the medial border of the scapula

(rhomboid major) bound this space. The floor of the triangle of auscultation is made

by the 6th intercostal space between ribs 6 & 7. Have your partner slump forward

while in a sitting position that will enlarge this space and allow for less muffled lung

sounds.

Imaginary vertical lines are clinically important to help locate structures throughout the thorax. These lines divide the

thorax into identifiable regions. Starting anteriorly find the anterior median (midsternal) line on the anterior midline. It

runs from the jugular notch through the umbilicus toward the pubic symphysis. Close to this line tends to be the location

of the cardiac valves of the heart. The midclavicular line, that divides the clavicle into equal lengths, runs just lateral to

the rectus abdominus muscles of the abdomen (semilunar lines) and divides the inguinal ligament in half. Close to the

midclavicular lines are the location of the breast tissue. The anterior axillary line is a vertical line dropped from the

anterior axillary fold, made by pectoralis major. This represents the anterior wall of the armpit. The midaxillary line

divides the armpit into anterior and posterior halves using a vertical line dropped from the apex of the axilla. This line is

also used to define the inferior extent of the lungs and pleura in the lateral thorax. The posterior axillary line represents

the posterior axillary fold of the armpit and is made by latissimus dorsi and teres major. A vertical line dropped from the

posterior axillary fold limits this space. The scapular lines run along the medial border of the scapula and continue as a

vertical line dropped from the inferior angle of the scapula. The scapular lines tend to closely parallel the midclavicular

lines. The posterior median (midvertebral) line is on the posterior midline.

With you partner seated comfortably in front of you and his/her hands

resting on his/her thighs, observe your partner’s quiet breathing. Determine

which part of the breathing cycle takes longer (inhalation/exhalation) as you count the respiratory rate. Place your hands

on your partner’s chest in anterior and posterior positions. Note the deflection of the ribs during respiration during quiet

breathing. Ask your partner to breathe deeply for a few breaths and again note the rib deflection. Move your hands to the

right and left false ribs (ribs 8-10) and monitor his/her breathing. Note the transverse deflection of the ribs, especially

during deep breathing.

Surface projections of the pleural spaces and the lungs reflect the differences on the left and right. The pleural

reflections along the midclavicular line extend

to rib 8, along the midaxillary line they extend

to rib 10 and along the scapular line the

reflections extend to rib 12. Along the sternum

and costal cartilage, the pleural reflections run

parallel to one another from rib 1 to rib 4.

Inferior to rib 4, the left pleura is deflected further left because of the

heart, but it is not until rib 6 that the right pleural reflection is deflected

further right. The parietal pleura is extremely sensitive to pain that will

be referred to the thoracic or abdominal wall. Irritation to the mediastinal pleura may be referred to the root of the neck

and shoulder due to the phrenic nerve.

The lung boundaries match the pleural reflections along the sternum and costal cartilage (rib 6 on right, rib 4 on left),

but they do not match along the bodies of the ribs. The lung boundaries along the midclavicular line extend only down to

rib 6, along the midaxillary line to rib 8 and the scapular line to rib 10.

Entry of air (or blood, intercellular fluid or lymph) into the pleural cavity results in a pneumothorax. (hemo-,

hydro-, chylo-) and subsequent collapsed lung. The surface tension adhering the parietal and visceral pleura is

compromised and the lung collapses on its own due to inherent elasticity. Care needs to be taken resolving these pleural

issues because of the location of the intercostal and collateral intercostal nerves and vessels. Needles should be inserted in

the center of the intercostal space (rather along a rib) to assure the preservation of the innervation and blood supply.

Next session: We will continue working on thoracic structures.

Please wear clothing that allows for direct visualization and palpation.

The ideal option is a tank top.

The arrowheads in Panel A show the position of the collapsed lung. In Panel B, the arrowheads indicate the re-inflated lung and the position of the chest tube.

Tariq, Sadaf (2006) NEJM 354 (19): 2046

15: Cardiovascular Thorax

Be sure to WASH your hands before examining each other

While you obviously cannot directly examine the heart by palpation, you can listen to it’s valves and feel it’s beat

through the thoracic wall. It is important to know the precise location of the heart and its valves to fully evaluate the

heart. Have your partner sit comfortably in front of you and review the thoracic landmarks that were used to examine the

lungs. Locate the sternoclavicular joints, suprasternal notch, sternal angle, xiphoid process, xiphisternal joint, true ribs 2-

6 and intercostal spaces 2-5. Relocate the imaginary vertical lines defining regions of the thorax: anterior median

(midsternal), midclavicular, anterior axillary lines.

Locate the heart as projected onto the

anterior chest wall. Outline the heart on your

partner using the

washable markers

provided. The superior

border of the heart lies

posterior to the sternum.

Find the inferior margin

of costal cartilage 2 on

the left and the inferior

margin of costal

cartilage 2 on the right.

A line drawn across the

sternum at this level

represents the superior border of the heart.

The right border of the heart is made up

entirely by the right atrium. The superior vena cava runs down the right side of the sternum to the 2nd costal cartilage

where it enters the right atrium. The right atrial border then continues down to the 6 th costal cartilage to the point where

the inferior vena cava enters from below. Draw the right border of the atrium lies just lateral to the lateral border of the

sternum with a slight curve to the right between the 2nd and 6th costal cartilage.

The inferior border of the heart rests on the thoracic diaphragm. Draw it as it runs from the right 6 th costal cartilage,

posterior to the sternum to the left 5 th intercostal space on the midclavicular line. This left position is the apex of the left

ventricle.

The left border of the heart completes the outline of the heat by connecting the superior and inferior borders of the

heart. It runs from the left 5th intercostal space on the midclavicular line to the 2nd costal cartilage on the left sternum

border.

Identify and mark the locations of the 4 heart valves. The aortic valve is located posterior to the sternum along the

anterior median line at the level of the 3rd intercostal space. Superior and slightly to the left, the pulmonary valve is

located at the 3rd sternochondral junction posterior to the left border of the sternum. The triscupid valve is located

posterior to the sternum at the 5th sternochondral joint along the anterior median line of the thorax. The bicuspid (mitral)

valve is located posterior to the left border of the sternum at the 4th sternochondral joint.

Now, appreciate the

differences between the anatomic

locations of the heart valves and

where to place a stethoscope when

listening to heart sounds. These

do not match the regions where

you would hear the heart sounds

because the valves are protected by

the sternum. Bone is extremely

difficult through which to hear.

The aortic valve is best heard in

the 2nd intercostal space on the

right side of the sternum. The

pulmonary valve is best heard

directly across the sternum in the

left 2nd intercostal space adjacent to

the sternum. The tricuspid valve

(between right heart chambers) can

be heard in the LEFT 5th intercostal

space along the border of the

sternum. The bicuspid (mitral)

valve is best heard at the apex of the heart. This is

located that the 5th intercostal space on the left

midclavicular line.

Next locate the great vessels as projected onto

the anterior chest wall. The aortic arch lies posterior

to the sternal angle on the left border of the sternum.

Just inferior to the aortic arch, and slightly to the

left, lies the pulmonary trunk (arteries). About 1-2

fingers lateral to the sternum, these 2 major vessels

form the aortic and pulmonary “knuckles” of the radiograph. Just below the “knuckles”, a small portion of the left atrium

appears in the 3rd intercostal space and posterior to the 4th rib. The remainder of the left border of the heart is made up of

Bijl, van den Brink (2005) NEJM 353(7): 712

the left ventricle. The right border of the heart can be seen posterior to the sternum as a slight bulge in the 4 th and 5th

intercostal space on the right.

Finally, check your partner’s heart rate.

You could use any of the upper or lower

extremity pulse points that we have already

located in the body. You can also find an

apical heartbeat to determine the heart rate.

The apical heartbeat is located in either the

4th or 5th intercostal space on near the left

midclavicular line of the thorax. The heart is

innervated with autonomic nerves to

maintain a normal heart rate. The heart is

insensitive to touch, temperature or sharp

pain, but pain due to ischemia can be felt

instantaneously. This pain information is not transmitted through the autonomic motor nerves. Instead, the heart refers

pain to the thoracic wall through the intercostal nerves (primarily left). Pain may be perceived in left thoracic areas or in

the left upper extremity due to those left intercostal nerves joining the spinal cord between T1-T5 spinal levels. If you

think back to your dermatome map, these spinal nerve

levels correspond with the thorax and upper extremity.

As a final thought, be careful if your examination

gives you the exact opposite results from what you expect.

Leads on electrocardiograms may be mixed or images may

be mislabeled. On occasion, the thorax is where the error

lies. During development, the heart is supposed to take up

a position on the left side of the thorax. Occasionally, it

resides on the right and the individual will have right-sided

heart sounds. Individuals can live completely normal lives

with dextrocardia (right heart) or situs inversus (inverted

location). These conditions usually only come to light as

other clinical issues need to be addressed.

Next session:

We will continue working on abdominal structures.

Please wear clothing to allow for visualization.

The ideal option is a tank top.Spigelman (1994)

NEJM 330(9): 606

16: Abdomen

Be sure to WASH your hands before examining each other

Abdominal exams are an important and challenging component of the physical exam. Start with your partner lying

comfortably in a supine position. Inspect the anterior abdominal wall and observe if it is flat, distended, scarred, bruised

or if there are dilated veins present. Inspect the umbilicus (at L3/L4 intervertebral disc level) on the anterior median line.

Note if the umbilicus is off-center, inverted or everted. Remember that the dermatome that innervates this level is the T10

spinal nerve. Ask your partner to cross his/her arms over his/her chest and then lift his/her shoulders off the table.

Determine if it is possible to see the lateral border of the rectus abdominus muscles (semilunar lines) and the tendinous

insertions of the rectus muscle near the umbilicus.

Note the locations of important abdominal landmarks used to lay out the lines necessary for reference. Palpate the

xiphoid process of the sternum and note its location. Remember this process may be calcified in older individuals. From

this point, trace (with your finger) the margins of the infrasternal angle and move laterally along the costal margin on

either side. Palpate the inferior margin of rib 10 and follow it to the midaxillary line. Palpate the iliac crests and the

anterior superior iliac spine (ASIS) to locate the inguinal ligament. Remember that the inguinal ligament connects to the

anterior superior iliac spine and the pubic tubercle. The inguinal groove is a skin crease that lies just superficial to the

inguinal ligament.

The anterior abdominal wall can be divided into either 4 quadrants or 9 regions using a series of vertical and

horizontal lines that intersect at identifiable anatomical landmarks. These two clinical reference systems used for locating

organs relative to the abdominal wall. On one partner, draw the two lines of the 4-quadrant system using the washable

markers provided. On the other partner, draw the 4 lines of the 9-region system. Representations of different organ

systems will be drawn on each student using the lines and other anatomical landmarks are reference points.

The 4-quadrant system requires two lines intersecting at the umbilicus. Locate the xiphoid process and the umbilicus

and draw a vertical anterior median line/plane (AML/P) to connect these structures with a line that extends towards the

pubic symphysis (on pelvic midline). A horizontal transverse umbilical line/plane (TUL/P) intersects the umbilicus as it

extends from the right midaxillary line to the left midaxillary line. These lines define the right upper quadrant (RUQ), left

upper quadrant (LUQ), right lower quadrant (RLQ), and left lower quadrant (LLQ).

The right upper quadrant is the location of the liver, gall bladder, duodenum, right kidney, head of the pancreas and

the hepatic (right) colic flexure. The left upper quadrant contains the stomach, spleen, left kidney, body of the pancreas

and the splenic (left) colic flexure. The lower right quadrant is the location of the appendix, cecum, right ovary, right

ureter and ascending colon. The lower left quadrant contains the left ovary, left ureter, descending/sigmoid colons.

The 9-

region system

requires 2 additional lines to create smaller spaces. We are going to stick with bony landmarks to locate the next lines,

but additional vertical and horizontal lines are based upon soft structures in the abdomen. On the un-marked partner,

locate the center point of the clavicle and the center point of the inguinal ligament (inguinal groove). Draw a vertical line

between both of these locations on the right and the left sides of the abdomen to represent the midclavicular (midinguinal)

lines/planes. Approximately 1 inch medial to the midclavicular lines are the semilunar lines, made by the lateral margin

of rectus abdominis. These semilunar lines can be used as the vertical lines/planes of the 9-region system as well (see

Netter 268 – no need to mark).

The first of the horizontal lines is the subcostal line/plane (SCL/P) that runs from the lowest extent of the 10 th costal

cartilage on the right to the lowest extent of the 10 th costal cartilage on the left. Draw in the subcostal line and confirm

that it aligns with L2/L3 intervertebral disc. Just about 1 inch above this line lies the transpyloric line/plane (TUL/P) that

runs through the center of the pyloric canal (of the stomach) and the inferior border of the costal cartilage of rib 8 (see

Netter 268 – no need to mark). Another way to locate the transplyoric line/plane is to make a horizontal line

½ way between the xiphisternal joint and the umbilicus at the L1 vertebral level.

The second horizontal line is the transtubercular line/plane (TTL/P) that interconnects the right and left iliac tubercles

(L5 vertebral level). Draw this line approximately 1 inch below the transtubercular line/plane is the interspinous

line/plane. This horizontal line runs between the anterior superior iliac spines and may be used in place of the

intertubercular line/plane (see Netter 268 – no need to mark).

No matter which of the two horizontal lines (subcostal/transpyloric and transtubercular/interspinous) are chosen,

the resulting 9 regions will be smaller than the 4 quadrants, yet still contain specific organs. The right/left hypochondriac

regions are located deep to the ribcage. In between them is the epigastric region in the intrasternal angle. The middle

regions are arranged so that the right/left lumbar (flank) regions on either side of the umbilical region. The inferior

regions are named for the inguinal ligament (right/left inguinal or groin) and the hypogastric (suprapubic) region centrally

located.

Locate the abdominal organs in either the 9-region or 4-quadrant system. You are only going to draw some of the

organs in the outlined spaces. Draw the stomach and kidneys or the liver, pancreas and spleen on your partner.

STOMACH

Outline the boundaries

of the stomach in the left

hypochondriac, epigastric

and umbilical regions of the

abdomen (mostly in upper

left quadrant). The cardinal

orifice/sphincter (entry to

stomach) lies posterior to the

left 6th costal cartilage at

T10/T11 intervertebral disc.

The fundus of the stomach extends slightly superior, deep to the left rib 5. The greater curvature of the stomach runs from

the fundus to the left 10th costal cartilage and through the superior parts of the umbilical region in the infrasternal angle

(inferior to the subcostal line). The pyloric part of the stomach sits at the L1 vertebral level, just inferior to the

transpyloric line. The pyloric sphincter crosses to the right side of the abdomen, exactly on the transpyloric line (L1

vertebral level).

KIDNEYS

Outline the boundaries

of both kidneys in the

right/left lumbar (flank)

regions. This can be done

from the anterior, but it will

help to locate the organs

from a posterior direction.

Ask your partner to prone

and locate the kidneys deep

to ribs 11-12. The left kidney

(2x3inches) is centered on the junction between the transpyloric line and the left scapular line. The hilum of the kidney

and the renal arteries are located at L2 vertebral level. The abdominal aorta bifurcates about 2 inches below this level at

L4 vertebra. The right kidney sits mostly below the transpyloric line on the right scapular line. It is approximately the

same size as the other, but it is located about 1 inch (2.5cm) below the level of the left kidney. In thin partners, the right

kidney will descend during deep inspiration. Ask your partner to take a deep breath and determine if you can feel a firm,

smooth, rounded mass shifting inferiorly on your partner. As your partner exhales, the right kidney will shift back into its

normal position.

PANCREAS/SPLEEN

Outline the borders of the spleen in the left

hypochondriac region. The spleen is about the size of

the kidneys (2x3inches) with the long axis parallel to

ribs 9-11 along the posterior abdominal wall. It is rarely

palpable unless it is enlarged due to infection.

The pancreas lies along the transpyloric line. The

tail extends to the left hypochondriac region near the

hilum of the spleen. The head of the pancreas sits below

the transpyloric line at the L2 vertebral level in the

umbilical region, just to the right of the anterior median line.

No pancreatic structures are palpable.

LIVER

The liver occupies most of the upper right quadrant and

spills over to the left side of the abdomen. It sits inferior to the

diaphragm and deep to ribs 7-11 on the right. The inferior

border of the liver follows the costal margin on the right at the

axillary lines. As the liver extends towards the left, it fills the

infrasternal angle through the Epigastric regions and reaches

the left midclavicular line. Ask your partner to inspire deeply to try to

palpate the liver as it moves. Just inferior to the right costal

margin/cartilage, throughout the upper right quadrant, you should be

able to palpate a smooth, firm edge to the liver as it descends during

inspiration.

As a final exercise, locate and mark McBurney’s point on all

partners. This point is superficial to the appendix and a likely site of

emergency abdominal access for acute inflammation of the appendix.

Start by tracing a line (with your finger) between the right anterior

superior iliac spine and the umbilicus (spinoumbilical line). Where

the transtubercular line/plane crosses the right midclavicular

line/plane is the site of McBurney’s point. This point is 2/3 of the

distance from the umbilicus to the ASIS along the spinoumbilical line and is the site of maximum abdominal tenderness

due to appendicitis.

17: Referred Pain

The presumption that pain originates at the site of that stimulus is usually correct, but this may not always be the

case. Often the cause of pain is at the exact location that pain is perceived. This is somatic pain and it is described as

sharp, cutting, fast and easily localized. For example, knee pain usually comes from the knee itself, whether it is skinned

in a fall, the articular cartilage wears away through disease or the meniscus tears due to external forces.

But, at times, knee pain comes from a healthy knee. It may really be hip pain that is perceived at the knee or poor

mechanics in the foot that lead to knee pain. This can be nearly as sharp and quick, although it may be harder to localize.

When pain is perceived in a location other than the site of painful stimulus, it is called referred pain. It's defined as pain

from a malfunctioning or diseased area of the body, perceived in another area, often far from the origin. Referred pain is

quite common.

Abdominopelvic organs are a common source of referred pain. In these situations, the pain perception is not like

somatic pain. Visceral pain is described as vague, hard to localize, deep-seated and dull. In the case where abdominal pain

is referred to another area, it can be difficult to determine the original location of the pain stimulus. Often visceral pain

will be experienced as somatic pain at a distant site distant away from the affected organ. For example, myocardial

ischemia is often referred to the upper left chest wall, down the inside of the left arm and forearm. It may also extend to

the left side of the head.

Somatic pain transmissions are sent by the nervous system indicating to the brain that a specific area hurts. The

reasons for referred pain are not completely known, yet somehow related is the fact that when there's pain in these (and

other!) areas and action must be taken. Referred pain may indicate a problem that is not so obvious. Any of the following

situations should be treated as emergency situations: sudden, sharp abdominal pain; chest, neck or shoulder pain; swollen

and tender abdominal regions. Although less critical, the following should also be treated by a physician: recurrent,

persistent or increasing abdominal pain, especially when accompanied by shortness of breath, dizziness, bleeding,

vomiting or a high fever.

Abdominal pain has the unusual ability to travel along nerves and emerge at sites strangely distant from the source of

the problem. Pain related to gallbladder inflammation can spread through the right phrenic nerve to the right thorax and

right shoulder/arm. Pain from the spleen can spread through the left phrenic nerve to the left shoulder and neck. Pain

from a pancreas disorder may radiate posteriorly between the shoulder blades. Pain from the throat may be perceived in

the middle ear.

Specific Examples of Referred Pain

http://www.mayoclinic.com/health/abdominal-pain/DG00013

Umbilical pain

Pain near the umbilicus can be related to a small intestine disorder or an inflammation of your appendix.

(appendicitis)

Epigastric pain

Pain associated with stomach disorders (Gastro Esophageal Reflux Disease - GERD, peptic ulcer, esophageal hiatal

hernia) is perceived here. Persistent pain in this area may also signal a problem with your upper small intestine

(duodenum), pancreas or gallbladder.

Left Hypochondriac pain

It's uncommon to experience pain here, although it suggests colon, stomach, spleen or pancreas problems.

Right Hyopchondriac pain

Intense pain in this region is often related to inflammation of the gallbladder (gallstones, cancer). The pain may extend to

the center of the abdomen and/or penetrate to the back. Occasionally, an inflamed pancreas (pancreatitis) or duodenum

can cause pain in this area as well.

Suprapubic (Hypogastric) pain

Pain that spreads to either side may signify a colon disorder (irritable bowel syndrome). For women, pain in this area may

also indicate a urinary tract infection or pelvic inflammatory disease.

Left Inguinal pain

Pain here most often suggests a problem in the lower colon, where food waste is expelled. Possible causes include

inflammatory bowel syndrome, Crohn’s disease or an infection in the colon known as diverticulitis.

Right Inguinal pain

Inflammation of the colon may cause pain in your lower right abdomen. The pain of appendicitis initially will be spread

over the entire lower right quadrant. Eventually it usually localizes to McBurney’s point on the spinoumbilical line at the

union of the right midclavicular and transtubercular lines. If the appendix gets clogged or obstructed, it may become

inflamed. Without treatment, an infected appendix can burst and cause a serious infection (peritonitis). Appendicitis may

also cause nausea, vomiting, loss of appetite, fever, and the urge to defecate.

Other organs also refer visceral pain to somatic regions. The heart refers pain to the left shoulder/arm, the lungs refer

pain to the thoracic wall and diaphragm and the brain refers pain to the meninges.

After amputation of a limb, an amputee continues to have an awareness of the limb and to experience sensations from

it. These phantom limb sensations are also present in children born without a limb, suggesting that perception of our

limbs is 'hard-wired' into our brain and that sensations from the limbs become mapped onto these brain networks as we

develop. If phantom limb sensations are normal then so is

Another pain phenomenon that is difficult to describe is trigger points. Trigger points are concentrated fascicles

inside a larger muscle that often are the sites of acute trauma or repetitive injury. Examples of these injuries would

include holding a telephone receiver between the ear and shoulder; prolonged bending over a table; sitting in chairs with

poor back support, improper height of arm rests; and moving boxes using improper body mechanics. Acute sports injuries

(e.g., tennis elbow), surgical scars, and tissues under tension frequently found after spinal surgery and hip replacement

may also predispose a patient to the development of trigger points.

Trigger points produce local somatic pain and may refer pain in a specific pattern. Typically, trigger points involve

the postural muscles of the neck, back and pelvis. Palpation of a sensitive bundle of muscle fiber, firmer than normal, is

usually associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or

cause radiation of pain outward in concentric circles from that site. The area of perceived pain is usually much larger than

the actual site of stimulation. Referred pain is an important characteristic of a trigger point. It differentiates a trigger point

from a tender point, which is associated with pain at the site of palpation only. Tender points are not associated with

referred pain and occur in the insertion zone of muscles, not in taut bands in the muscle belly.

Localization of a trigger point is based on the individual’s sense of feel, assisted by his/her partner’s expressions of

pain. Palpation of a trigger point will elicit pain over the palpated muscle and/or cause radiation of pain toward the zone

of reference in addition to a twitch (withdrawal) response. The commonly encountered locations of trigger points and

their pain reference zones are consistent.

Examples of the three directions in which trigger points (Xs) may refer pain (dark): (A) Peripheral projection of pain

from suboccipital and infraspinatus trigger points. (B) Mostly central projection of pain from biceps brachii trigger

points with some pain in the region of the distal tendinous attachment of the muscle. (C) Local pain from a trigger

point in the serratus posterior inferior muscle.

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A B C

For trigger points in the acute stage of formation (before additional pathologic changes develop), effective treatment

may be delivered through manual methods. The goal of manual therapy is to train the patient to effectively self-manage

the pain and dysfunction. However, manual methods are more likely to require several treatments and the benefits may

not be as fully apparent for a day or two when compared with injections. The patient should be placed in a comfortable

or recumbent position to produce muscle relaxation.

Be sure to WASH your hands before examining each other

Have your partner partner lie prone on the examination table. Working in the locations indicated, try to locate a

trigger point in one of the large postural muscles of the back. Use alternating pressure between two fingers to confirm the

location of the palpable nodule of the trigger/tender point. As the trigger/tender point is palpated, ask your partner to

describe the sensation. If it’s painful, have him/her describe the exact location of the pain to determine if it is being

referred to a different location. There are normally about 20 tender/trigger points in the body. Determine how many of

these points your partner has.

Some studies have found that injection with lidocaine has been shown to be effective in patients who have

symptomatic active trigger points that produce a twitch (withdrawal)

response to pressure and create a pattern of referred pain. Stretching the

affected muscle group immediately after injection further increases the

efficacy of trigger point therapy. An injectable solution of 1% lidocaine

or 1% procaine is usually used. Several other substances, including

diclofenac (Voltaren), botulinum toxin type A (Botox), and

corticosteroids, have been used in trigger-point injections. It is

important to remember that these substances have been associated with

significant myotoxicity. We will not be injecting our partners today.

Most frequent locations of myofascial trigger points

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Cross-sectional schematic drawing of flat palpation to localize and hold the trigger point.http://www.aafp.org/afp/20020215/653.html

18: Head / Neck, Thorax and Abdomen TAP Review

Student Supplied Review Questions for Self-Study

Point to the tragus.

Where is the lacrimal punctum?

Palpate the three heads of the sterno-cleidomastoid muscle.

Point to the alar nasi.

Where would you find palpebrae?

Palpate the maxillary sinus.

Where is the mental region?

Where is the conjunctiva?

Palpate the thyroid gland.

Where is the anterior pillar?

Where is Darwin’s tubercle?

Gently palpate the hyoid bone.

Point to the helix.

Where is plica semilunaris?

Outline the anterior triangle.

Locate the canthus.

Which pulse can be felt in the anterior triangle?

Point to the philtrum.

Locate the parotid gland.

Locate the lacrimal gland.

What makes the borders of the posterior triangle?

Where is the vermillion border?

What is the function of the lens muscles?

Gently palpate the suprathyroid notch.

Locate the uvula.

What vessel is located near the ear?

What structure carries tears to the nose?

Where is the limbus?

What structure lies just posterior to the tonsils?

What is the sclera?

What is the function of the lacrimal punctum?

Palpate the submandibular glands.

Where is kidney pain usually felt?

Palpate the zygomatic arch.

Which lymph node “heats-up” due to lung cancer?

Locate the caruncle.

Where is the subcostal plane?

Point to where the gall bladder refers pain.

Where is a common site of varicosities in men?

Locate the triangle of auscultation.

Stomach problems my refer pain to which region?

Why are the first seven ribs known as true ribs?

What borders the hypochondriac region (lines)?

What structures are located at T4 vertebral level?

Where is McBurney’s point?

Where is the xiphisternal joint?

Locate the epigastric region.

Why are ribs 8-10 known as false ribs?

At which level is the angle of the scapula?

Locate the 7 vertical thoracic lines.

Where would you listen to the aortic valve?

How floating ribs exist in a normal human?

What is the importance of the angle of Louis?

Where would you listen to the pulmonary valve?

Which lines describe the 9 abdominal regions?

Locate the manubrium.

Where is the suprasternal notch?

Where is an enlarged liver palpated?

Which lines divide the abdomen into 4 quadrants?

Where is the transplyoric plane?

Where does the diaphragm refer pain?

Where is the angle of Louis?