Podcast
Questions and Answers
The afferent and efferent limbs of the knee jerk reflex are both located in the femoral nerve (L2-L4).
The afferent and efferent limbs of the knee jerk reflex are both located in the femoral nerve (L2-L4).
True (A)
Which muscle is primarily affected by an injury to the inferior gluteal nerve?
Which muscle is primarily affected by an injury to the inferior gluteal nerve?
What is the most common type of ankle injury?
What is the most common type of ankle injury?
An injury to the superior gluteal nerve affects the same side of the body as the injury.
An injury to the superior gluteal nerve affects the same side of the body as the injury.
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An ankle sprain is almost always an ______ injury, involving a twisting of the weight-bearing plantarflexed foot.
An ankle sprain is almost always an ______ injury, involving a twisting of the weight-bearing plantarflexed foot.
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Which ligament is most commonly injured in an ankle sprain?
Which ligament is most commonly injured in an ankle sprain?
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What are the three main muscles that make up the hamstrings?
What are the three main muscles that make up the hamstrings?
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Avulsion fractures often occur at the ______, where muscles are attached.
Avulsion fractures often occur at the ______, where muscles are attached.
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Match the following terms to their corresponding descriptions:
Match the following terms to their corresponding descriptions:
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Match the following nerves with their corresponding muscles:
Match the following nerves with their corresponding muscles:
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The plantaris muscle is always present and is a significant contributor to foot movement.
The plantaris muscle is always present and is a significant contributor to foot movement.
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Injury to the tibial nerve in the popliteal fossa can lead to a condition called ______, where the foot is abnormally angled outward.
Injury to the tibial nerve in the popliteal fossa can lead to a condition called ______, where the foot is abnormally angled outward.
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Which muscle(s) are primarily responsible for plantar flexion of the foot?
Which muscle(s) are primarily responsible for plantar flexion of the foot?
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Match the following terms related to foot movement with their definitions:
Match the following terms related to foot movement with their definitions:
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What is the primary symptom of a fracture of the fibular neck that involves the common peroneal nerve?
What is the primary symptom of a fracture of the fibular neck that involves the common peroneal nerve?
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Carcinoma of the breast always originates from the epithelial cells of the lactiferous ducts.
Carcinoma of the breast always originates from the epithelial cells of the lactiferous ducts.
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What is the most common type of breast cancer?
What is the most common type of breast cancer?
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Which nerve is responsible for innervating the muscles that control dorsiflexion and eversion of the foot?
Which nerve is responsible for innervating the muscles that control dorsiflexion and eversion of the foot?
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What is the primary function of the suspensory (Cooper's) ligaments in relation to the breast?
What is the primary function of the suspensory (Cooper's) ligaments in relation to the breast?
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The majority of lymphatic drainage from the breast occurs through the axillary lymph nodes.
The majority of lymphatic drainage from the breast occurs through the axillary lymph nodes.
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What is the significance of lymphatic drainage in the context of breast cancer?
What is the significance of lymphatic drainage in the context of breast cancer?
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The ______ lymph nodes receive most of the lymphatic drainage from the lateral breast quadrants.
The ______ lymph nodes receive most of the lymphatic drainage from the lateral breast quadrants.
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Match the breast cancer surgery types with their respective descriptions:
Match the breast cancer surgery types with their respective descriptions:
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What structure is potentially at risk of damage during a radical mastectomy?
What structure is potentially at risk of damage during a radical mastectomy?
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A modified radical mastectomy involves the removal of all lymph nodes in the axilla.
A modified radical mastectomy involves the removal of all lymph nodes in the axilla.
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How does the shortening of Cooper's ligaments contribute to the appearance of the breast?
How does the shortening of Cooper's ligaments contribute to the appearance of the breast?
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Sliding hiatal hernia is more common in younger individuals.
Sliding hiatal hernia is more common in younger individuals.
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What is the congenital anomaly that represents a persistent portion of the vitellointestinal duct?
What is the congenital anomaly that represents a persistent portion of the vitellointestinal duct?
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The presence of ectopic gastric, pancreatic, or endometrial tissue in Meckel's diverticulum can lead to ______.
The presence of ectopic gastric, pancreatic, or endometrial tissue in Meckel's diverticulum can lead to ______.
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Which of the following is NOT a potential complication of Meckel's diverticulum?
Which of the following is NOT a potential complication of Meckel's diverticulum?
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Match the anatomical features of the large intestine to their descriptions:
Match the anatomical features of the large intestine to their descriptions:
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What is the main reason for the high mortality rate in infants with congenital diaphragmatic hernias?
What is the main reason for the high mortality rate in infants with congenital diaphragmatic hernias?
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What part of the stomach herniates into the thorax in a sliding hiatal hernia?
What part of the stomach herniates into the thorax in a sliding hiatal hernia?
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A sliding hiatal hernia can lead to an increased production of gastric juice.
A sliding hiatal hernia can lead to an increased production of gastric juice.
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Which of the following structures is NOT supplied by the right coronary artery?
Which of the following structures is NOT supplied by the right coronary artery?
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Aortic stenosis is heard downstream from the aortic valve.
Aortic stenosis is heard downstream from the aortic valve.
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The ______ artery supplies the posterior 1/3 of the interventricular septum.
The ______ artery supplies the posterior 1/3 of the interventricular septum.
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Match the following coronary artery branches with their primary function:
Match the following coronary artery branches with their primary function:
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Which of the following structures is supplied by the circumflex artery?
Which of the following structures is supplied by the circumflex artery?
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What is the direction of blood flow for a murmur caused by insufficiency?
What is the direction of blood flow for a murmur caused by insufficiency?
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The anterior interventricular artery supplies the anterior 2/3 of the ______ septum.
The anterior interventricular artery supplies the anterior 2/3 of the ______ septum.
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The left coronary artery branches into the anterior interventricular and circumflex arteries.
The left coronary artery branches into the anterior interventricular and circumflex arteries.
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Study Notes
100 Must Important GA Conceptions
- This presentation is a guide for preparing for a Gross Anatomy (GA) exam.
- It does not cover all the material from the entire Gross Anatomy course.
- To fully prepare, students must also review all the professor's presentations.
Lumbar Puncture (Tap) and Epidural Anesthesia
- During lumbar puncture, a needle is inserted into the subarachnoid space to extract cerebrospinal fluid (CSF) or inject anesthesia.
- The needle is typically inserted between vertebrae L3/L4 or L4/L5, through a horizontal line running through the upper points of the iliac crests.
- In adults, the spinal cord usually ends near L2; in children, it ends at L3. The dural sac extends caudally to the level of S2.
- Before the procedure, the patient should be assessed for increased intracranial pressure to prevent cerebellar tonsil herniation through the foramen magnum.
Herniated IV Disc
- Herniated discs typically occur in the lumbar region (L4/L5 or L5/S1) or cervical region (C5/C6 or C6/C7) in individuals younger than 50.
- Herniations may follow degenerative changes in the annulus fibrosus or result from sudden compression of the nucleus pulposus.
- Herniated lumbar discs usually affect the nerve root below the herniation. For example, a herniation at L4/L5 will compress the L5 nerve root.
Abnormal Curvatures of the Spine
- Kyphosis is an exaggerated curvature of the thoracic spine, which may result from osteoporosis or disk degeneration, especially in elderly individuals.
- Lordosis is an exaggerated curvature of the lumbar spine, sometimes temporary and may occur during pregnancy or obesity.
- Scoliosis is a complex lateral or torsional deviation of the spine, potentially caused by conditions like poliomyelitis, leg-length discrepancy, or hip disease.
Upper Limb Fractures: Humerus
- Key areas for potential nerve injury in humerus fractures:
- Axillary nerve and posterior humeral circumflex artery at the surgical neck
- Radial nerve and profunda brachii artery at midshaft
- Brachial artery and median nerve at the supracondylar region
- Ulnar nerve at the medial epicondyle
Fracture of Distal Radius
- Smith's fracture (flexion fracture of the radius) results from a fall or blow to the dorsal aspect of the flexed wrist, causing ventral angulation of the distal radius fragment.
- Colles' fracture (extension fracture of the radius) results from forced extension of the hand, typically during a fall, resulting in dorsal displacement of the distal radius fragment, often presenting as a "dinner fork deformity".
- The ulnar styloid process may also be fractured.
Scaphoid Fracture
- A scaphoid fracture typically occurs from a fall onto the palm of the hand with the wrist abducted.
- Pain usually occurs primarily on the lateral side of the wrist during wrist extension and abduction.
- Scaphoid fractures might not show immediately on X-rays, sometimes not appearing for 2-3 weeks.
- Snuffbox tenderness is a possible symptom.
- Avascular necrosis of the proximal fragment might occur due to interrupted blood supply.
Boxer's Fracture
- Boxer's fractures are typically fractures of the 2nd, 3rd, or 5th metacarpals resulting from fistfights.
- The 4th metacarpal is also sometimes affected.
- Professional boxers are often affected.
Rotator Cuff Muscles
- The rotator cuff muscles (SITS): supraspinatus, infraspinatus, teres minor, and subscapularis support the shoulder joint, reinforcing the glenohumeral joint across all sides, except inferiorly.
- The muscles are critical for shoulder stability and dislocation prevention.
Abduction of the Upper Limb
- Shoulder abduction is initially performed by the supraspinatus muscle (suprascapular nerve), from 0° to 15°.
- The deltoid muscle (axillary nerve) is involved in shoulder abduction from 15° to 110°.
- Further abduction beyond the horizontal plane (110° to 180°) requires scapular rotation, primarily involving the trapezius muscle (accessory nerve CNXI) and serratus anterior (long thoracic nerve).
Subacromial Bursitis
- Subacromial bursitis is inflammation in the subacromial bursa, often due to calcific supraspinatus tendinitis, causing pain, particularly during abduction.
Medial (Golfer's Elbow) and Lateral (Tennis Elbow) Epicondylitis
- Medial epicondylitis: inflammation of the common flexor tendon at the medial epicondyle of the humerus—often associated with forearm pain.
- Lateral epicondylitis: repeated forceful flexion and extension of the wrist resulting in strain of the common extensor tendon and inflammation of the periosteum of the lateral epicondyle—frequently causing pain over the lateral epicondyle, radiating down the posterior aspect of the forearm.
Arterial Anastomoses Around the Scapula
- Blockage of the subclavian or axillary artery can be bypassed by anastomoses between branches of the thyrocervical and subscapular arteries.
- Anastomoses occur via the transverse cervical, suprascapular, subscapular, and circumflex scapular arteries.
Cubital Fossa
- From lateral to medial, the cubital fossa contains: the biceps brachii tendon, brachial artery, and median nerve.
- The superficial structures from lateral to medial are: cephalic vein, median cubital vein, and basilic vein.
- The median cubital vein is a typical venipuncture site due to its location over the bicipital aponeurosis, thus avoiding deep structures and nerves.
Carpal Tunnel Syndrome
- Carpal tunnel syndrome results from a lesion reducing the carpal tunnel size. Factors include fluid retention, infection, or lunate bone dislocation.
- The median nerve, the most sensitive structure in the carpal tunnel, is the primary structure affected.
- Symptoms include pins and needles, or anesthesia in the lateral three and a half digits. Palm sensation is not affected.
- Apehand deformity is absent in the affected area.
Test of Proximal and Distal Interphalangeal Joints
- PIP (proximal interphalangeal): tested by FDS (flexor digitorum superficialis)
- DIP (distal interphalangeal): tested by FDP (flexor digitorum profundus).
Lesion of UL Nerves: Upper Brachial Palsy
- Injury to upper roots and trunk of the brachial plexus (C5 and C6) usually results from excessive stretching.
- This leads to superior trunk injury, and may be caused by birth injury, from forceful pulling on an infant's head during difficult delivery.
Upper Brachial Palsy (Erb-Duchenne Palsy)
- Erb-Duchenne palsy results in paralysis of shoulder and arm muscles supplied by C5 and C6 spinal nerves.
- This is frequently accompanied by adducted shoulder, medially rotated arm, and extended elbow positions.
- There is often loss of sensation in the lateral aspect of the upper limb.
Lower Brachial Palsy (Klumpke Palsy)
- This involves the lower trunk of the brachial plexus, affecting C8 and T1 spinal roots.
- It can occur when the upper limb is suddenly pulled superiorly, stretching or tearing the inferior parts of the brachial plexus.
- Involves the intrinsic muscles of the hand, leading to a "claw hand" due to ulnar nerve involvement and an "ape hand" due to median nerve involvement.
- There may be accompanying sensory deficits in the medial part of the upper limb.
- Horner syndrome may be involved in the disorder.
Injury to Musculocutaneous Nerve
- Lesions of the lateral cord often cause extensive weakness in elbow flexion and forearm supination, due to the biceps and brachialis muscles' disruption.
- Sensory impairment/anesthesia can be over the lateral aspect of the forearm.
Cutaneous Innervation of the Hand
- The dermatomes of the hand are innervated by the radial, median, and ulnar nerves.
Avascular Necrosis of Femoral Head
- Avascular necrosis (AVN) of the femoral head is a common fracture in elderly women with osteoporosis, most frequently occurring after a transcervical fracture.
- The transcervical fracture disrupts blood supply to the femoral head, leading to AVN if the blood supply through the ligament to the head is inadequate.
Knee Joint Injury: Unhappy Triad
- The unhappy triad involves injuries to the medial collateral ligament (MCL), medial meniscus, and anterior cruciate ligament (ACL).
- The lateral aspect of the knee is more commonly affected in injuries.
- The tibial collateral ligament is most frequently affected in these injuries.
Fibular Collateral Ligament (Lateral Collateral Ligament)
- The fibular collateral ligament (LCL) is a rounded cord between the lateral condyle of the femur and the head of the fibula.
- It does not attach to the lateral meniscus.
- It limits extension and adduction of the leg at the knee.
Rupture of the Cruciate Ligaments
- With anterior cruciate ligament rupture, the tibia can be pulled forward excessively on the femur, exhibiting an anterior drawer sign.
- In the less common rupture of the posterior cruciate ligament, the tibia may be pulled backward excessively, exhibiting a posterior drawer sign.
Prepatellar and Suprapatellar Bursa
- The prepatellar bursa is located between the patellar surface and the skin. Inflammation causes prepatellar bursitis.
- The suprapatellar bursa is located superior to the patella, between the distal end of the femur and the quadriceps muscle. Inflammation causes suprapatellar bursitis.
- Locations where intra-articular injections are introduced are often within the suprapatellar bursa.
Knee Jerk Reflex
- The patellar reflex is tested by tapping the patellar ligament and evaluates the spinal nerves L2-L4.
- Afferent and efferent limbs of the stretch reflex arch are positioned within the femoral nerve.
Ankle Joint Injury: Ankle Sprains
- Ankle sprains are most commonly caused by inversion injuries, involving twisting of the weight-bearing plantarflexed foot.
- The lateral ligaments (especially the anterior talofibular ligament) are more prone to injury due to weakness in comparison with the medial ligament.
- The lateral malleolus of the fibula may be fractured in severe sprains.
Pott's Fracture
- Pott's fracture is a fracture-dislocation of the ankle occurring due to forced eversion or inversion of the foot.
- The medial ligament may avulse or tear at the medial malleolus, and a higher level of fibula fracture may occur due to excessive force.
Ankle Jerk Reflex
- The ankle jerk reflex tests the S1 and S2 spinal nerves.
- The stretch reflex arch (afferent and efferent limbs) is carried in the tibial nerve.
Injury of the Gluteal Region: Piriformis Syndrome
- Piriformis syndrome may occur due to piriformis muscle inflammation or spasm causing gluteal pain and possibly mimicking sciatica.
- The piriformis muscle is key to understanding relationships in the gluteal region and determining blood vessel and nerve actions, such as hip supination.
Injury to Sciatic Nerve
- The sciatic nerve injury can result in weakened hip extension and knee flexion, as well as footdrop due to the lack of dorsiflexion and plantar flexion.
- The injury is frequently caused by improperly placed gluteal injections or posterior hip dislocation.
Superior Gluteal Nerve Injury
- Superior gluteal nerve injury during surgery, posterior hip dislocation, or poliomyelitis can cause paralysis in the gluteus medius and minimus muscles.
- Loss of these muscles' function leads to a "waiter's tip" hand position.
Injury to Inferior Gluteal Nerve
- Inferior gluteal nerve injury typically results in weakened hip extension, most notably noticeable when climbing stairs or standing.
- This can be a result of posterior hip dislocation or surgery in the hip region.
Avulsion Fractures of the Hip Bone and Hamstring Muscles
- Avulsion fractures commonly occur at the ischial tuberosities at the hamstring muscle attachment.
- The hamstring muscles consist of the biceps femoris, semitendinosus, and semimembranosus, involved in hip extension and flexion of the knee.
- The tibial nerve (short head of biceps femoris) and common fibular nerves are implicated in this area.
Femoral Sheath and Femoral Hernia
- The femoral sheath, derived from transversalis fascia and iliacus fascia, enters the thigh deep to the inguinal ligament.
- It's separated into 3 compartments enclosing the femoral artery, vein, and canal, thus accommodating lateral to medial compartmentalization.
Femoral Hernia
- A femoral hernia occurs when a portion of the intestine protrudes through the femoral ring into the femoral canal.
- More common in females than males, particularly related to increased abdominal pressure during pregnancy.
- This hernia is potentially dangerous, because strangulation can occur.
Rupture of the Achilles Tendon and Triceps Surae Muscle
- Avulsion or rupture of the Achilles tendon (calcaneal tendon) disrupts the triceps surae muscle (gastrocnemius and soleus), preventing plantar flexion.
- The cause can be due to forceful plantar flexion activity.
- The triceps surae muscle has two heads of gastrocnemius and one soleus head.
- The small, thin plantaris tendon may be absent or slightly developed.
Injury to Tibial Nerve
- Damage to the tibial nerve in the popliteal fossa often compromises plantar flexion of the foot, resulting from the gastrocnemius and soleus muscle impairment.
- There might be associated weakness in inversion (tibialis posterior muscle).
- Inability to stand on toes (plantar flexion) typically represents this injury.
Fracture of the Fibular Neck
- Fibular neck fracture commonly involves damage to the common peroneal nerve, leading to paralysis of the muscles in the anterior and lateral compartments of the leg.
- This injury often results in a footdrop.
Breast Carcinoma
- Carcinomas of the breast are malignant tumors, typically adenocarcinomas, arising from the epithelial cells of the lactiferous ducts.
- A common presenting symptom is enlargement of the breast, attaching to Cooper's ligaments and generating skin dimpling.
Lymphatic Drainage of the Breast
- Most breast lymph (over 75%) drains to axillary lymph nodes, particularly the anterior (pectoral) nodes.
- Medial breast quadrants typically drain into parasternal lymph nodes or to the opposite breast.
Mastectomy
- Radical mastectomy is a surgical procedure removing the breast, pectoral muscles, much of the overlying fat and fascia, alongside lymph nodes in the axilla and pectoral region.
- During radical mastectomy, possible damage to the long thoracic nerve due to lateral thoracic artery ligation may occur, resulting in winged scapula and weakness in abduction of the arm beyond 90°.
- The intercostobrachial nerve may be damaged during a mastectomy, leading to numbness/paresthesia in the medial arm.
Breast Infection (Mastitis)
- Mastitis is an infection of the breast tissue, often occurring during breastfeeding (usually between 1 and 3 months postpartum).
- Often causes pain, swelling, redness, and elevated temperature in the breast.
- Bacteria, particularly from the baby's mouth, are frequently transferred to the milk ducts via cracked nipples.
- Mastitis may occur in women who haven't recently delivered or postpartum.
Diaphragm Paralysis and Ruptures
- Paralysis of one side of the diaphragm may be caused by injury or during surgery. This may be clinically detected by radiological methods.
- Paradoxical movements of the dome of the diaphragm may happen where the injured side is pushed superiorly by abdominal viscera, during inspiration, rather than descending.
- Diaphragmatic ruptures frequently occur from blunt trauma, specifically motor vehicle crashes and result in left lateral-sided rupture in most cases.
Cardiac Hypertrophy
- Left atrial enlargement (hypertrophy) secondary to mitral valve failure can compress the esophagus, leading to swallowing difficulties (dysphagia).
- This can manifest in barium-filling during esophageal X-ray procedures.
Cardiac Shadow
- The right border of the cardiac shadow is primarily formed by the superior vena cava (SVC) and right atrium.
- The left border is primarily formed by the aortic arch, pulmonary trunk, left auricle, and left ventricle.
Auscultation of Heart Valves
- The heart valves can be auscultated by listening to their sounds in different intercostal space positions on the anterior chest.
- Aortic valve: right 2nd intercostal space, right parasternal line.
- Pulmonary valve: left 2nd intercostal space, left parasternal line.
- Tricuspid valve: left lower sternal border.
- Mitral valve: left 5th intercostal space.
Auscultation Sites for Mitral and Aortic Murmurs
- Stenosis is associated with an orthograde sound flow from the valve.
- Insufficiency is associated with a retrograde sound flow from the valve.
- These sounds can be heard over the chest in various locations depending on whether the murmur is due to mitral or aortic malfunction, which might be systolic or diastolic.
Blood Supply of the Heart: Right Coronary Artery (RCA)
- The RCA supplies major portions of the right atrium and ventricle.
- It anastomoses with the marginal branch of the left coronary artery (LCA) at the posterior aspect of the heart.
- Branches of RCA: anterior cardiac branches, sinoatrial (SA) node, atrioventricular (AV) node, marginal artery, and posterior interventricular artery.
Left Coronary Artery (LCA)
- The LCA supplies major portions of the left ventricle, left atrium, and anterior interventricular septum.
- It also distributes branches into the anterior interventricular sulcus and provides branches to the anterior wall of the heart, anterior 2/3 of intraventricular septum, bundle of His, and apex of the heart.
- Branches of the LCA: anterior interventricular artery and circumflex artery.
Blood Supply of the Conducting System
- The sinoatrial (SA) node has blood supply from the right coronary artery (RCA).
- The atrioventricular (AV) node is supplied by the RCA.
- The conducting system's AV bundle (and moderator band) receives blood supply from the left coronary artery (LCA).
Aspiration of Foreign Bodies and Bronchopulmonary Segments
- Aspiration of foreign bodies, such as pins, parts of teeth, screws, or nuts, is a common occurrence, especially in children, into the lower respiratory tract.
- The foreign object is most likely to lodge in the right primary bronchus, passing into the middle or lower lobe bronchi, frequently ending up in the posterior basal segment of the inferior lobe.
Right Lung: 10 Bronchopulmonary Segments
- The right lung has 10 bronchopulmonary segments, which have specific anatomical details regarding their position and connections to the bronchi, blood vessels, and nerves.
Left Lung: 9 Bronchopulmonary Segments
- The left lung has 9 bronchopulmonary segments, which have specific anatomical details regarding their position and connections to the bronchi, blood vessels, and nerves.
Lung Diseases: Pneumonia
- Pneumonia is an inflammatory lung condition resulting from infection (bacteria, viruses, or fungi). This condition causes cough, chest pain, fever, and breathing difficulties..
- Chest X-rays often show areas of opacity (white areas) in the lung parenchyma, alongside enlargement of the bronchomediastinal lymph nodes (mediastinal widening).
Bronchogenic Carcinoma
- Bronchogenic carcinoma arises from the mucosa of large bronchi, often associated with persistent cough, productive cough, or hemoptysis (coughing up blood).
- Early metastasis is to the thoracic lymph nodes, and hematogenous spread to certain organs is also possible.
- A tumor at the apex of the lung (Pancoast tumor) may result in thoracic outlet syndrome.
Qs about Auscultation and Penetrated Wounds
- The 4th rib on the right and 4th rib on the left of the chest wall above mark the superior lobe of the lungs for auscultation.
- The middle lobe is situated between the 4th and 6th ribs.
- The inferior aspect of the lung, typically localized across the posterior chest wall, is the portion to auscultate for sounds emanating from the inferior lobes, respectively.
Open Pneumothorax
- Open pneumothorax occurs when the pleural cavity is opened to the outside air.
- This commonly occurs from stab wounds to the thoracic wall, piercing the parietal pleura and allowing air to enter the pleural cavity.
- Movement of the mediastinum (heart) shifts during both inspiration and expiration. During inspiration, air enters the chest wall and the mediastinum shifts toward the opposite side; during expiration, air exits the chest wall, and the mediastinum returns to its original position.
Nerve Supply of the Pleura
- Parietal pleura: receives innervation from intercostal nerves and phrenic nerve. It is sensitive to general sensations like pain, temperature, touch, and pressure - hence somatic sensory innervation.
- Medial pleura: receives innervation from intercostal nerves; it is sensitive to general sensations.
- Diaphragmatic pleura: receives innervation from peripheral phrenic nerves; it is sensitive to general sensations.
- Visceral pleura: receives innervation from the pulmonary plexus; it is sensitive to stretch but is insensitive to general sensitivities.
Anterior Abdominal Wall
- The liver and gallbladder are in the right upper quadrant.
- The stomach and spleen are in the left upper quadrant.
- The cecum and appendix are in the right lower quadrant.
- The descending and sigmoid colon are in the left lower quadrant.
Referred Abdominal Pain
- Epigastric pain is frequently associated with foregut structures.
- Umbilical pain is commonly associated with midgut derived structures.
- Hypogastric pain is frequently associated with hindgut derived structures.
Transversalis Fascia
- Transversalis fascia is the outermost layer in the abdominal wall.
- It is the first structure crossed when an abdominal hernia is present.
Indirect Inguinal Hernia
- An indirect inguinal hernia occurs in males more often than females due to a congenital weakness in the deep inguinal ring.
- It usually arises with the inguinal canal in the lateral aspect, superior to epigastric vessels.
- It commonly occurs in male babies under the age of three.
Direct Inguinal Hernia
- Direct inguinal hernia, occurring in older men, occurs through the weak abdominal wall in the Hesselbach's triangle, medial to the inferior epigastric vessels and the inguinal ring.
- The hernia does not transverse into the scrotum.
Lesser Omentum
- A double-layered peritoneal fold connects the lesser curvature of the stomach and the proximal part of the duodenum to the liver.
- The omentum consists of hepatoduodenal and hepatogastric ligaments.
- It contains the portal triad of the bile duct, common hepatic artery, and portal vein; right and left gastric vessels; connective and fatty tissue.
Epiploic (Winslow's) Foramen
- The epiploic foramen (Winslow's foramen) is a short passage connecting the lesser sac to the greater sac.
- Bounded anteriorly by the hepatoduodenal ligament (containing the portal triad), posteriorly by the inferior vena cava (IVC), superiorly by the caudate lobe of the liver, and inferiorly by the first part of the duodenum.
Douglas (Recto-uterine) Pouch
- Douglas pouch (rectouterine pouch) is the deepest part in the female pelvic cavity, located between the uterus and the rectum.
- It is a common location for pelvic abscesses.
Culdocentesis
- Culdocentesis is a procedure using a needle to collect fluid from the cul-de-sac of Douglas (rectouterine pouch).
- The collection site is the posterior vaginal fornix in the lower pelvis, and its purpose is to detect infection. This may be inflammatory pelvic fluid.
Everything about Foregut, Midgut, and Hindgut
- Foregut structures include the esophagus, stomach, duodenum (first and second parts), liver, pancreas, biliary apparatus, and gallbladder.
- Midgut structures include the duodenum (2nd, 3rd, and 4th parts), jejunum, ileum, cecum, appendix, ascending colon, and transverse colon (proximal 2/3).
- Hindgut structures include the transverse colon (distal 1/3), descending colon, sigmoid colon, and rectum.
Foregut, Midgut, and Hindgut Nerve Supply
- Foregut nerve supply: parasympathetic from vagus nerves (CNX), and sympathetic from greater splanchnic nerves, T5-T9.
- Midgut nerve supply: parasympathetic from vagus nerves (CNX), sympathetic lesser splanchnic nerves, T10-T11.
- Hindgut nerve supply: parasympathetic pelvic splanchnic nerves, S2-S4, and sympathetic lumbar splanchnic nerves, L1-L2.
Posterior Gastric Ulcer
- Posterior gastric ulcers can erode into the pancreas, resulting in referred pain to the back.
- Splenic artery is often close to the posterior gastric ulcer and prone to erosion.
Congenital Diaphragmatic Hernia
- Congenital diaphragmatic hernia (CDH) is the protrusion of abdominal contents through a posterolateral defect in the diaphragm into the chest cavity.
- This condition commonly involves the left side of the diaphragm.
- Affected infants are typically born with high rates of mortality as a result of respiratory difficulties frequently resulting from left lung hypoplasia.
Sliding Hiatal Hernia
- A sliding hiatal hernia occurs when the superior border of the stomach protrudes into the thorax through the esophageal hiatus, due to weakened or lax esophageal hiatal muscular wall, which is commonly associated with older adults.
- This condition can cause disturbance to the vagal trunks, which pass through the esophageal hiatus, potentially leading to hypo-secretion of gastric juices.
Meckel's Diverticulum
- Meckel's diverticulum is a remnant of the vitellointestinal duct, located in the distal ileum, roughly 2 feet away from the ileocecal junction.
- The diverticulum is approximately 2 inches long in the ileum and contains ectopic tissue (gastric, pancreatic, or even endometrial) potentially prone to inflammation, bleeding, perforation, and obstruction, mimicking appendicitis symptoms.
Features of the Large Intestine
- Appendices epiploicae are small, fatty pouches along the large intestine.
- Haustrations (sacculations) are pouch-like features along the large intestine wall.
- Taeniae coli are three distinct longitudinal bands of smooth muscle found along the large intestine.
- These features are essential for identifying large intestine anatomy.
Pain of Appendicitis
- Initial appendicitis pain often starts in the umbilical area.
- Visceral pain fibers from the appendix enter the spinal cord at the T10 segment.
- As the inflammation progresses and the peritoneum becomes involved, the pain shifts to the McBurney's point, becoming more localized and intense.
McBurney's Point
- McBurney's point is located one-third of the distance from the anterior superior iliac spine to the umbilicus on the right side of the abdomen.
- It is important for the localization of acute appendicitis pain.
Volvulus
- Volvulus is the twisting of the bowel around its mesentery, potentially leading to obstructed blood supply to the affected section of the gastrointestinal tract.
- It can affect the small intestine or sigmoid colon, and in the most severe cases, it can interrupt the intestinal blood supply completely.
- In most instances, the twisting corrects itself spontaneously.
Hirschsprung's Disease
- Hirschsprung's disease is a congenital disorder characterized by the absence of ganglion cells in the distal colon.
- This condition causes functional obstruction of the distal colon and leads to dilation and inflammation, or megacolon.
- Affected newborns often present with symptoms including failure to pass meconium, feeding intolerance, bile-stained vomiting, and abdominal distension.
Branches of the Abdominal Aorta
- The celiac trunk, superior mesenteric artery (SMA), renal arteries, and inferior mesenteric artery (IMA) originate from the abdominal aorta.
- The celiac trunk emerges at the lower border of T12, and the SMA originates at the lower border of L1. These locations provide crucial reference in abdominal anatomy.
- Renal arteries arise at approximately L2, and the IMA originates at L3. These arteries are essential for delivering blood to the gastrointestinal tract and other abdominal organs.
Celiac Artery (Trunk)
- The celiac trunk is a short artery that branches from the abdominal aorta at approximately T12-L1.
- It divides proximally into three main arteries: the left gastric artery, the common hepatic artery, and the splenic artery.
- These branches supply the stomach, liver, pancreas, and spleen with blood.
Left Gastric Artery
- The left gastric artery (1) arises from the celiac trunk and ascends to the left, supplying the abdominal part of the esophagus.
- It courses upward into the left portion of the lesser curvature of the stomach.
- Its branches, esophageal and gastric branches, supply the abdominal esophagus's blood supply and the left side of the stomach's lesser curvature.
- It anastomoses with the right gastric artery.
Common Hepatic Artery
- The common hepatic artery (CHA) is a branch from the celiac trunk, branching into the proper hepatic artery (PHA) and gastroduodenal artery (GDA).
- The PHA supplies blood to the liver; the GDA supplies blood to the first part of the duodenum, pancreas head (superior pancreaticoduodenal arteries), and the right side of the greater curvature of the stomach through their branches (right gastroepiploic artery).
Proper Hepatic Artery
- The proper hepatic artery (PHA) is a branch from the common hepatic artery, traveling within the hepatoduodenal ligament.
- It supplies the liver through its branches, the right and left hepatic arteries.
- A branch of the PHA, which supplies the gallbladder with blood, is the cystic artery.
- It anastomoses with the left gastric artery.
Gastroduodenal Artery
- The gastroduodenal artery (GDA) branches from the common hepatic artery and proceeds posterior to the first part of the duodenum.
- It supplies the duodenum, pancreas head (superior pancreaticoduodenal arteries), and the right side of the greater curvature of the stomach.
- The artery's branches anastomose with the left gastroepiploic artery (a branch of the splenic artery).
Ligature of the Hepatic Artery
- The hepatic artery (HA) may be ligated proximal to the origin of its gastroduodenal (GDA) branch, creating collateral circulation through other vessels—right and left gastric arteries, right and left gastroepiploic and gastroduodenal arteries.
- The right hepatic artery is potentially vulnerable during cholecystectomy in the Calot triangle; the possible ligation here may lead to right lobe hepatic necrosis.
Splenic Artery
- The tortuous splenic artery (SA) travels anterior to the lower border of the pancreas, behind the posterior wall of the lesser sac.
- The artery branches to the spleen, and also to the neck, body, and tail of the pancreas.
- The left gastroepiploic (gastroomental) artery is a significant branch providing blood supply to the left portion of the greater curvature.
- Short gastric branches supply the fundus of the stomach; this gives rise to significant anastomoses with the right gastroepiploic artery, a branch off the gastroduodenal artery.
Splenic Artery Branches
- This artery's primary branches include those that supply the spleen itself.
- Additional branches supply the adjacent parts of the stomach, such as the gastroepiploic branches, and portions of the pancreas, such as the pancreatic branches.
Branches of SMA
- Inferior pancreaticoduodenal arteries are branches of the superior mesenteric artery (SMA).
- Branches include ileocolic artery, jejunal and ileal branches, appendicular artery, anterior and posterior cecal arteries, and right and middle colic arteries.
Branches of IMA
- The inferior mesenteric artery (IMA) branches into the left colic artery, and branches to the sigmoid and superior rectal arteries.
Mesenteric Ischemia
- Mesenteric ischemia occurs if blood flow through mesenteric arteries is compromised, usually happening in people over 60, frequently due to atherosclerosis.
- It has associated symptoms including pain, vomiting, and abdominal distress, mainly in the small intestine.
Abdominal Aortic Aneurysm (AAA)
- AAA is the localized dilatation of the abdominal aorta, most frequently emerging above the bifurcation, just above the aortic bifurcation, and typically crosses the third portion of the duodenum.
- Pulsations are a hallmark symptom that's clinically detectable to the left of the midline in the umbilical region.
- Acute AAA rupture involves severe abdominal or back pain; mortality is high, nearly 90%, needing urgent surgical repair by opening the aorta and grafting the aneurysm with a prosthetic device.
Biliary System
- The biliary system is a network of organs and ducts involved in the production, storage, and transport of bile to the duodenum for digestion.
- Bile is produced by liver cells.
- It's stored and concentrated in the gallbladder.
- Bile leaves the gallbladder via the cystic duct and joins the common hepatic from the left and right hepatic ducts to form the common bile duct, finally emptying into the duodenum.
Cholelithiasis (Gallstones)
- Gallstones can lodge in the distal end of the hepatopancreatic ampulla, common bile duct (CBD), or cystic duct, causing obstructive jaundice.
- Symptom presentation includes jaundice (yellowing of the skin and eyes), possibly accompanied by biliary colic (severe, spasmodic pain in the right upper quadrant).
Gallstones
- Gallstones can lodge within the gallbladder body, potentially perforating the duodenum (posterior wall) and causing intestinal obstruction.
- They might lodge in the cystic duct, resulting in intense, spasmodic biliary colic, while typically not causing jaundice.
Nerve Supply of the Liver and Gallbladder
- Sensory innervation of the liver and gallbladder is predominantly supplied by the right phrenic nerve (C3-C5).
- Associated pain may radiate to the right shoulder.
- Parasympathetic fibers come from the vagi nerves (CNX) via the celiac plexus, affecting hepatic tissues through intramural plexus.
- Sympathetic innervation involves T5-T9 segments (IML) through greater splanchnic nerves and is routed through celiac plexus branches.
Portal Hypertension
- Portal hypertension is a condition marked by elevated blood pressure within the hepatic portal system. An enlarged spleen is a common sign.
- Treatment techniques like portacaval shunt involve the splenic vein anastomoses to left renal veins after spleen removal.
Portocaval Anastomosis
- Portocaval anastomosis is the formation of new connections between portal and caval venous systems.
- Sites for these anastomoses include esophageal veins, thoracoepigastric veins, and rectal veins.
- Enlarged veins in these locations may lead to esophageal varices, caput medusae, and internal hemorrhoids, all indicative of portal hypertension.
Esophageal Anastomosis
- Esophageal anastomoses happen between tributaries of the left gastric vein and tributaries of the azygos vein in response to portal hypertension.
- These anastomoses enlarge the esophageal wall veins, frequently bursting into the esophageal lumen and resulting in hematemesis (vomiting blood).
Umbilical Anastomosis
- Anastomoses between paraumbilical and superior/inferior epigastric veins are found in umbilical regions of the anterior abdominal wall.
- In instances of portal hypertension, the enlarged and dilated veins form a caput medusae around the umbilicus.
Rectal Anastomosis
- Rectal anastomosis occurs between superior rectal vein tributaries (from the inferior mesenteric vein) and inferior rectal vein tributaries, that drain into internal iliac veins.
- These anastomoses enlarge in portal hypertension, resulting in internal hemorrhoids, presenting as bleeding per anus.
Pancreas: Head and Uncinate Process
- The head of the pancreas sits within the C-shaped duodenum and contains the uncinate process, which extends inferiorly and is crossed by the superior mesenteric vessels (important during surgery).
Cancer of the Head of the Pancreas
- Cancer in the pancreatic head region typically compresses the bile duct, leading to obstructive jaundice.
- Such a presentation doesn't typically include pain or fever, differing from hepatitis, which is more commonly associated with both.
Neck of the Pancreas
- The neck of the pancreas lies posterior to the portal vein's formation site.
- The splenic vein and superior mesenteric vein join to form the portal vein in this region.
Body of the Pancreas
- The body of the pancreas is situated anterior to the aorta and left renal artery, characterized by its undulating course above the superior border of the pancreatic body.
- The splenic artery and vein follow an undulating path adjacent to the superior border of the pancreatic body and are situated posterior to the body.
Tail of the Pancreas
- The tail of the pancreas is located within the splenorenal ligament, positioned beside the hilum of the spleen
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