Surface Anatomy Of Heart PDF

Surface Anatomy Of Heart By: Dr. ABDELHAMID ELSIFY MBBCH, M.SC. MD ASSOCIATE PROFESSOR OF ANATOMY & EMBRYOLOGY HEAD OF ANATOMY-HISTOLOGY DEPARTMENT 3/18/2023...

Surface Anatomy Of Heart By: Dr. ABDELHAMID ELSIFY MBBCH, M.SC. MD ASSOCIATE PROFESSOR OF ANATOMY & EMBRYOLOGY HEAD OF ANATOMY-HISTOLOGY DEPARTMENT 3/18/2023 Dr.ABDELHAMID 1  Learning Objectives Knowledge & understanding By the end of this lecture the student should be able to: Outline the surface marking of the borders of the heart Outline the surface marking of cardiac valves &their auscultatory areas. Clinical points 3/18/2023 Dr.ABDELHAMID 2 Surface marking of the borders of the heart  The upper border is marked by a straight line joining the points (A)& (B) Point (A) at the lower border of the left 2nd costal cartilage about 1.3 cm from the sternal margin. Point (B) at the upper border of the right 3rd costal cartilage 1.3 cm from the sternal margin.  The lower border is marked by a straight line joining:(C)& (D) Point (C) at the lower border of the right 6th costal cartilage 2 cm from the sternal margin. Point (D) at the apex of the heart in the left 5th intercostal space 9 cm from the midsternal line. Dr.ABDELHAMID Surface marking of the borders of the heart The right border is marked by a line joining: (B)& (C) slightly convex to the right, The maximum convexity is about 3.8 cm from the median plane in the fourth space. The left border is marked by a line joining: (A)& (D) fairly convex to the left.  Atrioventricular groove is marked by a line drawn from the sternal end of left 3rd costal cartilage to the sternal end of right 6th costal cartilage.  Note: The area of the chest wall overlying the heart is called the precordium. Dr.ABDELHAMID Surface marking of cardiac valves &the auscultatory areas Valve Surface Marking Auscultatory Area Pulmonary A horizontal line, behind the Left 2nd intercostal space near the upper border of left 3rd costal sternum cartilage and adjoining part of the sternum Aortic A oblique line, behind the left Right 2nd intercostal space near margin of the sternum at the level the sternum of the lower border of the left 3rd costal cartilage Mitral An oblique line, behind the left over the apex of the heart in the half of the sternum opposite the left 5th intercostal space at the left 4th costal cartilage midclavicular line. Tricuspid A vertical line, behind the right left of the lower part of the half of the sternum opposite the sternum near the 5th intercostal 4th and 5th spaces space. DR.ABDELHAMID 5 Surface marking of the borders of the heart DR.ABDELHAMID 6 Surface marking of cardiac valves &the auscultatory areas DR.ABDELHAMID 7 Surface marking of cardiac valves &the auscultatory areas DR.ABDELHAMID 8  Conclusion:  The ability to visualize how the deep anatomic structures in the thorax are related to surface features is fundamental to a physical examination.  The figures have been created to show landmarks on the body's surface that can be used to locate deep structures and to assess function by auscultation and percussion. 3/18/2023 Dr.ABDELHAMID 9 C l i n i c a l C o rr e l a t e s  Marfan syndrome: An autosomal dominant connective tissue disorder that affects microfibrils and elastin in connective tissue throughout the body. Clinical manifestations: 1. Tall stature, spine deformities. 2. Heart valve defects: mitral valve prolapse 3. Aortic dissections, aortic aneurysm 4. Joint hypermobility 5. Eyes (lens subluxation). 3/18/2023 Dr.ABDELHAMID 10  Case Problem : A 6-year-old boy is brought to the physician by his mother because of a 3- month history of episodic chest pain and shortness of breath on exertion. He is at the 99th percentile for height and 40th percentile for weight. Examination shows a high- arched palate, long and slender upper extremities, and elbows and knees that can be hyperextended. Cardiac examination shows a grade 2/6 late systolic, crescendo murmur with a midsystolic click. The murmur is most likely to be heard best over which of the following labeled areas? a) Area A b) Area B c) Area C d) Area D e) Area E f) Area F g) Area G 3/18/2023 Dr.ABDELHAMID 11  Any Questions? 3/18/2023 Dr.ABDELHAMID 12  References: 1-Gray’s Anatomy for students; Richard drake et al; 4th. edition 2-Clinical Anatomy by Regions; by Richard Snell 9th edition. 3-https://www.amboss.com/ 3/18/2023 Dr.ABDELHAMID 13  Thank You 3/18/2023 Dr.ABDELHAMID 14  Anatomy Of The Heart Part I (External Features) By: Dr. ABDELHAMID ELSIFY MBBCH, M.SC. MD ASSOCIATE PROFESSOR OF ANATOMY & EMBRYOLOGY HEAD OF ANATOMY-HISTOLOGY DEPARTMENT 2/27/2023 Dr.ABDELHAMID 1  Learning Objectives Knowledge & understanding By the end of this lecture the student should be able to: Describe the Heart regards: Position Shape, Apex, Base, Surfaces &Borders Supply (arterial,venous&nerve) Clinical points 2/27/2023 Dr.ABDELHAMID 2 Heart (position, axis & apex) Position: The heart lies obliquely in middle mediastinum 1/3 of it lies 1 to the right & 2/3 to the left of the median plane. 3 Its long axis is directed downwards, forwards and to the left. 4 Its apex lies in the left 5th 5 intercostal space 3.5 inches from 3.5 inches median plane 2/27/2023 Dr.ABDELHAMID 3 Heart (Shape, surfaces & borders ) The heart is Cone shaped Base of the heart is directed backwards and to the right. Apex of heart is directed downwards, forwards and to the left. Sternocostal surface is directed anteriorly. Diaphragmatic surface is directed inferiorly 4 borders: right, left, superior & inferior 2/27/2023 Dr.ABDELHAMID ٤ Heart (Base) Base ( posterior ) surface: Formed by the back of both atria, mainly the left atrium. Bounded inferiorly by the coronary sulcus which lodges the coronary sinus. The base lies opposite the bodies of thoracic vertebrae TV to TVIII in supine position and TVI to TIX when standing. The Esophagus lies immediately posterior to the base of heart. 2/27/2023 Dr.ABDELHAMID ٥ Heart (Base) 2 right & 2 left pulmonary veins pierce the base to open into cavity of left atrium Right & left pulmonary arteries run along the upper border of the base 2/27/2023 Dr.ABDELHAMID ٦ Heart (Diaphragmatic surface) Left ventricle forms its left 2/3 Right ventricle forms its right 1/3 Posterior interventricular groove lodges (contains): 1. Posterior interventricular branch of right coronary a. 2. Middle cardiac vein 2/27/2023 Dr.ABDELHAMID ٧ Sterno-costal ( anterior) surface: Divided by coronary sulcus into : a) atrial portion : formed mostly by right atrium as the part formed by left atrium is masked by the pulmonary trunk & ascending aorta except the left auricle appears forward. 2/27/2023 Dr.ABDELHAMID ٨ Sterno-costal ( anterior ) surface b) Ventricular portion: Divided by anterior interventricular sulcus into right 2/3 formed by right ventricle & left 1/3 formed by left ventricle. So the apex of the heart is formed by left ventricle only. 2/27/2023 Dr.ABDELHAMID ٩ Grooves on sternocostal surface 1. Anterior part of coronary sulcus lodges : a) Right coronary artery b) Anterior cardiac veins crossing the sulcus to open directly into Rt. atrium 2. Anterior interventricular sulcus lodges: a) Anterior interventricular a. branch of left coronary b) Great cardiac vein 2/27/2023 Dr.ABDELHAMID ١٠ Identify 2/27/2023 Dr.ABDELHAMID 11 Identify 2/27/2023 Dr.ABDELHAMID ١٢ Arterial Supply of the Heart Heart is supplied by right & left coronary arteries which are branches from the ascending aorta. They are called coronaries as they surround the ventricles as a crown surrounds the head 2/27/2023 Dr.ABDELHAMID ١٣ Right coronary artery Arises from anterior aortic sinus Runs in the coronary sulcus downwards till the inferior border of heart  backwards to posterior part of coronary sulcus Ends by anastomosing with the circumflex branch of left coronary 2/27/2023 Dr.ABDELHAMID ١٤ Branches of Right coronary artery 1. Marginal artery  runs along the inferior border of heart  supplies right ventricle 2. Posterior interventricular artery (PDA)  runs in posterior interventricular sulcus supplies both ventricles & posterior 1/3 of interventricular septum 3. Small unnamed brs.  to supply walls of pulmonary trunk & ascending aorta & right atrium. 4. Special branches to supply both SA node & AV node. 2/27/2023 Dr.ABDELHAMID ١٥ Left coronary artery Larger in diameter than right coronary Left Coronary Arises from left posterior aortic sinus artery Runs between the root of pulmonary trunk & left auricle to reach the upper end of ant. Circumflex interventricular sulcus where it ends by giving 2 artery brs. Ends by dividing into circumflex artery & Anterior anterior interventricular artery Interventricular Artery(LAD) 2/27/2023 Dr.ABDELHAMID ١٦ Branches of left coronary artery 1. Small brs. to supply the walls of both ascending aorta & pulmonary trunk. 2. Anterior interventricular artery (LAD)  to supply anterior wall of both ventricles & anterior 2/3 of interventricular septum. 3. Circumflex arteryruns backwards in posterior part of coronary sulcus  to supply posterior wall of both left atrium& left ventricle. 2/27/2023 Dr.ABDELHAMID ١٧ Applied Anatomy Coronary arteries are considered as physiological end arteries, however anatomically coronaries & their branches do anastomose, but the sites of anastomosis can not provide an effective collateral circulation if a large artery is obstructed. Coronary anastomosis is poor in young age but become more relatively efficient as one gets older. 2/27/2023 Dr.ABDELHAMID 18 Applied Anatomy Is sudden coronary occlusion more dangerous if it occurs at young age or in old age & WHY? 2/27/2023 Dr.ABDELHAMID 19 Venous drainage of the heart  Most veins of the heart accompany the arteries.  Most cardiac veins end in the Coronary Sinus which: is a wide venous channel. lies in the posterior part of the coronary sulcus. ends into the cavity of right atrium. 2/27/2023 Dr.ABDELHAMID ٢٠ Coronary sinus Receives the following tributaries: 1. Great cardiac v. 2. Middle cardiac v. 3. Small cardiac v. 4. Posterior v. of left ventricle 5. Oblique v. of left atrium 2/27/2023 Dr.ABDELHAMID 21 Veins which do not open into the Coronary sinus Anterior cardiac veins  few veins which drain the anterior wall of right ventricle & open directly into the right atrium. Venae cordis minimi  minute veins in the muscle layer of each chamber & open directly into the cavity of that chamber. 2/27/2023 Dr.ABDELHAMID 22 Nerve supply of the heart Heart is supplied by autonomic (sympathetic & parasympathetic nerves) through the superficial & deep cardiac plexuses. Superficial cardiac plexus lies below the arch of aorta Deep cardiac plexus lies in front of tracheal bifurcation 2/27/2023 Dr.ABDELHAMID 23  Conclusion:  Coronary arteries are considered as functional end arteries, however anatomically coronaries & their branches do anastomose, but the sites of anastomosis can not provide an effective collateral circulation if a large artery is obstructed.  Coronary anastomosis is poor in young age but become more relatively efficient as one gets older. 2/27/2023 Dr.ABDELHAMID 24 C l i n i c a l C o rr e l a t e s  Coronary artery disease  The severity depends on the size and location of the artery involved and whether or not the blockage is complete.  Partial blockages may produce pain (angina) during or after exercise.  Complete Occlusion of a major coronary artery leads to an inadequate oxygenation of an area of myocardium and cell death (i.e. myocardial infarction). 2/27/2023 Dr.ABDELHAMID 25 C l i n i c a l C o rr e l a t e s  If the coronary artery disease is too severe to be treated by coronary angioplasty, surgical coronary artery bypass grafting may be necessary.  The Great Saphenous Vein in the lower limb is harvested and used as an autologous graft.  The Internal Thoracic or Radial Arteries can also be used for this purpose. 2/27/2023 Dr.ABDELHAMID 26 C l i n i c a l C o rr e l a t e s  Clinical terminology for coronary arteries  Anterior interventricular artery, is termed the left anterior descending artery (LAD).  Posterior interventricular artery, is termed the posterior descending artery (PDA). 2/27/2023 Dr.ABDELHAMID 27  Case Problem : A 39-year-old woman comes to the physician because of an 8-month history of progressive fatigue, shortness of breath, and palpitations. She has a history of recurrent episodes of joint pain and fever during childhood. She emigrated from India with her parents when she was 10 years old. Cardiac examination shows an opening snap followed by a late diastolic rumble, which is best heard at the fifth intercostal space in the left midclavicular line. This patient is at greatest risk for compression of which of the following structures? a) Thoracic duct b) Trachea c) Vagus d) Hemiazygos vein e) Esophageus 2/27/2023 Dr.ABDELHAMID 28  Any Questions? 2/27/2023 Dr.ABDELHAMID 29  References: 1-Gray’s Anatomy for students; Richard drake et al; 4th. edition 2-Clinical Anatomy by Regions; by Richard Snell 9th edition. 3-https://www.amboss.com/ 2/27/2023 Dr.ABDELHAMID 30  Thank You 2/27/2023 Dr.ABDELHAMID 31 Anatomy of Upper Limb Ulnar Artery By Dr. Hassan Mohammed Rizk (Ph.D.) Associate Professor of Human Anatomy and Embryology  Objectives: by the end of this lecture the student must understand the following knowledge: LIMBLIMB ▪ Identify and demonstrate the following: OF UPPER 1)Ulnar artery. ▪ Regarding: UPPER 1)Origin. 2)Termination. VESSELS 3)Course and Relation. 4)Branches and Distribution. Ulnar artery By Dr. Hassan Rezk September 7, 2024 2  Case Study UPPER VESSELS LIMBLIMB OF UPPER Angiography of occluded right ulnar artery Ulnar artery By Dr. Hassan Rezk September 7, 2024 3  Introduction Map for the Arterial Supply of the Whole Upper Limb UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 4  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 5  Objective 1: Ulnar Artery LIMBLIMB Anterior Compartment of Posterior Compartment of the OF UPPER the Forearm Forearm 1. Superficial group. 1. Superficial group. Muscles 2. Intermediate group. 2. Deep group. 3. Deep group. UPPER 1. Ulnar artery. 1. Posterior interosseous artery. Arteries 2. Radial artery. 2. Anterior interosseous artery. VESSELS 1. Median nerve. 1. Deep radial nerve (Posterior interosseous Nerves 2. Ulnar nerve. nerve). 3. Superficial Radial nerve. 2. Superficial Radial nerve. Ulnar artery By Dr. Hassan Rezk September 7, 2024 6  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 7  Objective 1: Ulnar Artery LIMBLIMB In the cubital fossa. Origin: One of the two terminal branches of the brachial artery. At the level of the neck of the radius. OF UPPER Enters palm by passing superficial to the flexor retinaculum, Lateral to: 1.Pisiform bone. 2.Ulnar nerve. Termination in the forearm: Here, it divides into: 1-Superficial terminal division. UPPER 2-Deep terminal division. 1. Separated from median nerve by deep (ulnar) head of pronator teres. 2. Descends along the medial aspect of forearm. VESSELS 3. Covered by Flexor carpi ulnaris so as it is not easily palpable. Course and the important 4. It lies superficial to: Flexor digitorum profundus. relations: 5. Its relation to ulnar nerve: 1) In upper 1/3: separated from the nerve by a wide gap. 2)In lower 2/3: the artery lies lateral to the nerve. Ulnar artery By Dr. Hassan Rezk September 7, 2024 8  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 9  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 10  Objective 1: Branches of Ulnar Artery 4 named pairs + 1 unnamed (muscular) 2 pairs High up at elbow, 2 pairs Low down at wrist LIMBLIMB 1) Two ulnar recurrent arteries (anterior & posterior): at elbow Ascends upward anterior & posterior to medial epicondyle. End anastmosing with ulnar collateral arteries. Share in the anastmoses around the elbow joint. OF UPPER 2) Muscular branches: for muscles of the anterior compartment. 3) Common interosseous artery: at elbow UPPER Soon (about 1 cm.), it divides into A. Anterior Interosseous Artery B. Posterior Interosseous Artery: see the posterior compartment of the forearm. 4) Two Ulnar carpal arteries (dorsal & palmar) (anterior & posterior): at wrist VESSELS Arise from ulnar artery before crosses the flexor retinaculum. Share in the Palmar (anterior) & Dorsal (posterior) Carpal Arches to supply the wrist. 5) Two terminal divisions: at wrist Superficial terminal division. Deep terminal division. Ulnar artery By Dr. Hassan Rezk September 7, 2024 11  UPPER VESSELS LIMBLIMB OF UPPER Anterior view of the right forearm Ulnar artery By Dr. Hassan Rezk September 7, 2024 12  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 13  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 14  LIMBLIMB Objective 1: Common Interosseous Artery (1) Anterior Interosseous Artery ORIGIN: From common interosseous artery. COURSE: OF UPPER Descends downwards and vertically along the anterior surface of the interosseous membrane. Between: ▪ Flexor digitorum profundus medially. ▪ Flexor pollicis longus laterally. Accompanied with anterior interosseous nerve from median nerve. UPPER TERMINATION: Above the upper border of pronator quadratus, it pierces interosseous membrane. Terminates anastmosing with posterior interosseous artery. VESSELS BRANCHES: (1) Muscular branches: to deep layer of anterior compartment of the forearm. (2) Nutrient branches: to radius and ulna. (3) Numerous Perforator branches: which perforate the interosseous membrane to supply deep muscles of the posterior compartment (4) Descending branch: To end in palmar carpal arch to supply the wrist joint. Ulnar artery By Dr. Hassan Rezk September 7, 2024 15  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 16  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 17  LIMBLIMB Objective 1: Common Interosseous Artery (2) Posterior Interosseous Artery ORIGIN: From common interosseous artery in the anterior compartment. COURSE: Passes posteriorly over the upper border of the interosseous membrane. OF UPPER It appears in the posterior compartment between: Superiorly: Supinator. Inferiorly: Abductor Pollicis Longus. Then it receives the termination of the anterior interosseous artery. UPPER TERMINATION: in Dorsal carpal arch. BRANCHES: VESSELS (1) Interosseous Recurrent artery: Ascends upward, posterior to lateral epicondyle. End anastmosing with middle collateral artery. Share in the anastmoses around the elbow joint. (2) Muscular branches: to the muscles of posterior compartment Ulnar artery By Dr. Hassan Rezk September 7, 2024 18  LIMBLIMB OF UPPER Interosseous recurrent artery Posterior view of the right forearm UPPER VESSELS Ulnar artery By Dr. Hassan Rezk September 7, 2024 19  Summary for the Branches of the Arteries of the Forearm Ulnar artery Radial artery LIMBLIMB 1) Two ulnar recurrent arteries (anterior & posterior): 1) Radial recurrent artery: Arise from ulnar artery near its origin. Arise from radial artery near its origin. Ascends upward in relation to medial epicondyle Ascends upward in anterior to lateral (anterior & posterior). epicondyle. End anastmosing with ulnar collateral arteries. End anastmosing with radial collateral artery. Share in the anastmoses around the elbow OF UPPER Share in the anastmoses around the elbow joint. joint. 2) Muscular branches: for muscles of the anterior 2) Muscular branches: for muscles of the anterior compartment. compartment. 3) Common interosseous artery: 3) Superficial palmar artery: Arise from ulnar artery near its origin. UPPER Arise from radial artery in the middle of the Soon (about 1 cm.), it divides into forearm mainly. A. Anterior Interosseous Artery Enters palm of the hand superficial to thenar B. Posterior Interosseous Artery: see the muscles. posterior compartment of the forearm. Ends anastmosing with superficial terminal VESSELS branch of ulnar to form superficial palmar arch. 4) Two Ulnar carpal arteries (dorsal & palmar): Arise from ulnar artery before crosses the 4) Palmar carpal artery: flexor retinaculum. Arise from radial artery before winding the Share in the Palmar & Dorsal Carpal Arches to lateral aspect of the wrist. supply the wrist. Share in the Palmar Carpal Arch to supply the wrist. Ulnar artery By Dr. Hassan Rezk September 7, 2024 20  Clinical Correlation LIMBLIMB OF UPPER See Anastomoses of Upper Limb UPPER VESSELS Ulnar artery By Dr. Hassan Rezk September 7, 2024 21  Case Scenario (Staff Question) LIMBLIMB The 58-year-old convenience store operator had received a superficial bullet wound to the soft tissues on the medial side of the elbow in an attempted robbery. A major nerve was OF UPPER repaired at the site where it passed behind the medial epicondyle. Bleeding was stopped from an artery that accompanied the nerve in its path toward the epicondyle. Vascular repair was performed on this small artery because of its important role in supplying blood to the UPPER nerve. Which of the following arteries was most likely repaired? A. The profunda brachii. VESSELS B. The radial collateral artery. C. The superior ulnar collateral artery. D. The anterior ulnar recurrent artery Ulnar artery By Dr. Hassan Rezk September 7, 2024 22  Reference LIMBLIMB OF UPPER Gray's anatomy for students, 3rd edition. ISBN: 978-0-7020-5131-9 Copyright© 2015, 2010, 2005 by Churchill Livingstone, an imprint of Elsevier Inc. UPPER Chapter 7 VESSELS Ulnar artery By Dr. Hassan Rezk September 7, 2024 23  UPPER VESSELS LIMBLIMB OF UPPER Ulnar artery By Dr. Hassan Rezk September 7, 2024 24 Anatomy of Upper Limb Anastomoses of Upper Limb By Dr. Hassan Mohammed Rizk (Ph.D.) Associate Professor of Human Anatomy and Embryology  Objectives: by the end of this lecture the student must understand the following knowledge: LIMBLIMB ▪ Identify and demonstrate the following: 1) Anastomoses at different parts of Upper Limb OF UPPER 2) Superficial Palmar Arch. 3) Deep Palmar Arch. UPPER 4) Anastomoses in the fingers. ▪ Regarding: VESSELS 1) Site. 2) Formation. 3) Branches. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 2  Important Note LIMBLIMB OF UPPER ▪ This lecture is required in all theoretical exams and OSPE. ▪ Any other data mentioned in the lab will be required in OSPE ONLY. UPPER VESSELS Ulnar artery By Dr. Hassan Rezk September 7, 2024 3  Case Study UPPER VESSELS LIMBLIMB OF UPPER Modified Allen test Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 4  General Objective. Interruption of the blood flow to the upper limb LIMBLIMB The blood flow to the upper limb can be interrupted by: 1. Penetrating wounds. Involving arteries. OF UPPER 2. Ligation of the arteries in amputation operations. 3. Thrombosis in the lumen of the arteries. 4. Compression be tumor or enlarged L.N. There are many adequate collateral circulation (Anastmoses) around: UPPER 1. Shoulder Joint. 2. Elbow Joint. VESSELS 3. Wrist Joint. Interruption of the main arteries of the upper limb is NOT followed by tissue necrosis or gangrene. It can take days or weeks for the collateral vessels to open sufficiently to provide the distal part of the limb with the same volume of blood as previously supplied by the main artery. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 5  General Objective. Anastomosis LIMBLIMB ▪ Anastomosis: is direct communication between neighboring vessels. OF UPPER ▪ Two types: 1) Arterio-arterial anastomosis. 2) Arterio-venous anastomosis. UPPER ▪ Arterio-arterial anastomosis can be found in the following sites:-  At the base of brain:-e.g. circulus arteriosus. VESSELS  In abdomen:-e.g. arteries of stomach & those of intestine.  Around joints of limbs.  In hand & foot. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 6  Upper Limb Anastomosis Upper Limb Collateral Circulation LIMBLIMB 1. Anastomosis around Scapula. 2. Anastomosis around surgical neck of the humerus. OF UPPER 3. Anastomosis around elbow joint. UPPER 4. Anastomosis around wrist joint. VESSELS 5. Anastomosis in the Palm. 6. Anastomosis in the Fingers. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 7  Objective 1: Anastomosis Around Scapula LIMBLIMB Site In the infraspinous fossa of the scapula 1. From 3rd part Axillary artery: OF UPPER ▪ it gives subscapula artery that gives circumflex scapular artery. ▪ Runs along the lateral border of scapula. 2. From 1st part of Subclavian artery, it gives thyrocervical trunk that gives Arteries forming a. Suprascapular artery: UPPER ▪ Appears at the upper border of scapula b. Deep branch of Transverse (superficial) cervical artery: VESSELS ▪ Descends along the medial border of scapula. Importance Acts as a collateral circulation in case of 1st or 3rd parts of axillary artery obstruction. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 8  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 9  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 10  Objective 2: Anastomosis Around Surgical Neck of Humerus LIMBLIMB Site Around surgical neck of the humerus. 1. From 3rd part Axillary artery: OF UPPER a. Anterior circumflex humeral artery: ▪ Runs anterior to surgical neck of the humerus. Arteries b. Posterior circumflex humeral artery: UPPER forming ▪ Runs posterior to surgical neck of the humerus. ▪ It gives a descending branch. VESSELS 2. From brachial artery, ▪ It gives profunda brachii artery, which gives Ascending branch. Importance Acts as a collateral circulation in case of brachial artery obstruction. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 11  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 12  Objective 3: Anastomosis Around Elbow LIMBLIMB Site Around medial & Lateral Epicondyles of the Humerus OF UPPER (a) Anastomoses Around Medial (b) Anastomoses Around Lateral Epicondyle Epicondyle Anterior: anterior division of Anterior: anterior division of inferior Ulnar collateral artery radial collateral artery. Posterior: Posterior: posterior division of Superior UPPER Arteries forming 1. posterior division of inferior radial (middle) collateral artery. ulnar collateral artery. 2. superior ulnar collateral artery Anterior: anterior ulnar Anterior: radial recurrent artery. VESSELS recurrent artery. Inferior Posterior: posterior ulnar Posterior: interosseous recurrent recurrent artery. artery. Importance Acts as a collateral circulation in case of radial or ulnar artery obstruction. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 13  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 14 Anastomoses Around Wrist Joint  Objective 4: Palmar Carpal Arch (Cruciate Anastomosis) LIMBLIMB Site In front of lower ends of radius & ulna. 1. From Ulnar artery: a. Anterior interosseous artery: OF UPPER ▪ It is a branch from common interosseous artery. ▪ It gives descending branch. b. Palmar carpal artery: ▪ Runs horizontal & lateral. Arteries UPPER forming 2. From Radial artery: a. Palmar carpal artery: ▪ Runs horizontal & medial. VESSELS b. Recurrent palmar artery: ▪ Runs upwards. Importance Acts as a collateral circulation in case of radial or ulnar artery obstruction. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 16  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 17  Objective 5: Dorsal Carpal Arch LIMBLIMB Site Behind lower ends of radius & ulna. OF UPPER 1. From Ulnar artery: a. Posterior interosseous artery: ▪ It is a branch from common interosseous artery. b. Dorsal carpal artery: UPPER Arteries ▪ Runs horizontal & lateral. forming 2. From Radial artery: a. Dorsal carpal artery: VESSELS ▪ Runs horizontal & medial. Importance Acts as a collateral circulation in case of radial or ulnar artery obstruction. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 18  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 19  LIMBLIMB 1) Three dorsal metacarpal arteries: 2nd, 3rd & 4th dorsal metacarpal arteries. Each, will divide to two dorsal digital arteries. OF UPPER To supply the adjacent sides of: ✓ Index & middle fingers. ✓ Middle & ring fingers. ✓ Ring & little fingers. UPPER 2) Dorsal digital artery: It may arise from: VESSELS ✓ Dorsal carpal of ulnar artery. ✓ 4th dorsal metacarpal artery. ✓ Dorsal carpal arch. To supply the medial side of the little finger. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 20 Anastomoses in Palm & Fingers  Objective 6: Superficial Palmar Arch LIMBLIMB Site ▪ Superficial to the long flexor tendons. OF UPPER ▪ Deep to palmar aponeurosis (deep fascia of the palm). ▪ It is distal to deep palmar arch. 1. From Ulnar artery: a. Superficial terminal artery: ▪ It is one of two terminal branches of ulnar artery. UPPER Arteries 2. From Radial artery: forming a. Superficial palmar branch: ▪ Branch from radial artery in the forearm. VESSELS Importance Acts as a collateral circulation in case of radial or ulnar artery obstruction. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 22  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 23  LIMBLIMB OF UPPER (1) (2) UPPER VESSELS Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 24  LIMBLIMB (1) Palmar digital artery: to the medial side of the little finger. OF UPPER (2) Common palmar digital arteries: Are three in number (1st,2nd & 3rd from lateral to medial) They are joined by three palmar metacarpal arteries (from the deep palmar arch). Then, each bifurcates into medial & lateral proper palmar digital arteries to enter the fingers. UPPER To supply: a. lateral side of little finger b. both sides of ring and middle fingers VESSELS c. medial side of index finger Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 25  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 26  Objective 7: Deep Palmar Arch LIMBLIMB Site ▪ Deep to the long flexor tendons. ▪ Direct related to palmar surface of metacarpal bone. OF UPPER ▪ It is proximal to superficial palmar arch. 1. From Ulnar artery: a. Deep terminal artery: ▪ It is one of two terminal branches of ulnar artery. UPPER Arteries 2. From Radial artery: forming ▪ The radial artery terminates anastomosing with deep terminal branch of ulnar artery. VESSELS Importance Acts as a collateral circulation in case of radial or ulnar artery obstruction. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 27  Radial artery Ulnar artery LIMBLIMB Superficial Palmar Branch Superficial terminal branch of Ulnar artery OF UPPER Deep terminal branch UPPER Radial artery of Ulnar artery Deep Palmar Arch VESSELS Superficial Palmar Arch Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 28  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 29  LIMBLIMB (1) Three palmar metacarpal arteries: OF UPPER which join the common palmar digital arteries from the superficial palmar arch. (2) Three perforating branches: UPPER which pass posteriorly between the heads of origin of the dorsal interossei muscles. VESSELS to anastomose with the dorsal metacarpal arteries from the dorsal carpal arch. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 30  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 31  Objective 8: Anastomosis in the Fingers LIMBLIMB Site ▪ Sides, nail beds & Tips of fingers OF UPPER Finger Palmar Surface Dorsal Surface Two princips pollicis 1st dorsal metacarpal Thumb (from radial artery) (from radial artery) Arteries forming 1. Radialis indicis (radial artery) 1. 1st dorsal metacarpal (radial artery) UPPER Index 2. 1st common palmar digital 2. 2nd dorsal metacarpal artery. Middle 1st & 2nd Common palmar digital 2nd & 3rd dorsal metacarpal artery. Ring 2nd & 3rd Common palmar digital. 3rd & 4th dorsal metacarpal artery. VESSELS 1. 3rd Common palmar digital. 1. 4th dorsal metacarpal artery. Little 2. Palmar digital artery (ulnar artery). 2. Dorsal digital artery. Importance Acts as a collateral circulation in case of radial or ulnar artery obstruction. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 32  UPPER VESSELS LIMBLIMB OF UPPER Palmar Surface of the Hand Dorsal Surface of the Hand Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 33  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 34  Clinical Correlation Modified Allen test LIMBLIMB ▪ Aim: to evaluate the adequacy of the palmar collateral circulation through the radial and ulnar arteries. OF UPPER ▪ Steps: 1) The patient is asked to elevate the hand (or form a fist) to drain the palmar arterioles and capillaries. 2) Pressure is applied to the radial and ulnar arteries simultaneously to occlude palmar perfusion; the palm should appear pale if the arterial occlusion is complete. UPPER 3) Pressure over one of the arteries is released while occlusion of the other is maintained. 4) The palm is observed for at least 15 seconds. https://youtu.be/MTqUG4TUeIo ▪ Results: VESSELS 1) If palmar hyperemia occurs, palmar collateral circulation is considered adequate. 2) If the palm remains pale, palmar collateral circulation is inadequate. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 35  UPPER VESSELS LIMBLIMB OF UPPER Positive Allen test due to lack of collateral circulation Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 36  Case Scenario (Staff Question) LIMBLIMB A 54-year-old man is admitted to the emergency department with severe chest pain. Electrocardiographic evaluation reveals a myocardial infarction. Due to the severity of the OF UPPER infarction, a coronary artery bypass surgery using a radial artery graft is proposed. Which of the following tests should be performed during physical examination prior to the bypass graft operation? UPPER A. Allen test. B. Triceps reflex. VESSELS C. Tinel test. D. Brachioradialis reflex. E. Biceps reflex Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 37  Case Scenario (Staff Question) LIMBLIMB The 58-year-old butcher came to the emergency department with bleeding from the OF UPPER fingers. Physical examination revealed deep cut wound along the medial side of the middle finger. Which of the following dorsal metacarpal arteries UPPER was most likely to be injured? A. 1st. VESSELS B. 2nd. C. 3rd. D. 4th. Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 38  Reference LIMBLIMB OF UPPER Gray's anatomy for students, 3rd edition. ISBN: 978-0-7020-5131-9 Copyright© 2015, 2010, 2005 by Churchill Livingstone, an imprint of Elsevier Inc. UPPER Chapter 7 VESSELS Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 39  UPPER VESSELS LIMBLIMB OF UPPER Anastomoses of Upper Limb By Dr. Hassan Rezk September 7, 2024 40 Anatomy of Upper Limb Radial Artery By Dr. Hassan Mohammed Rizk (Ph.D.) Associate Professor of Human Anatomy and Embryology  Objectives: by the end of this lecture the student must understand the following knowledge: LIMBLIMB ▪ Identify and demonstrate the following arteries: OF UPPER 1)Radial artery in forearm. 2)Radial artery in hand. ▪ Regarding: UPPER 1)Origin. VESSELS 2)Termination. 3)Course and Relation. 4)Branches and Distribution. Radial artery By Dr. Hassan Rezk September 7, 2024 2  Case Study UPPER VESSELS LIMBLIMB OF UPPER Angiography of occluded right radial artery Radial artery By Dr. Hassan Rezk September 7, 2024 3  Introduction Map for the Arterial Supply of the Whole Upper Limb UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 4  UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 5  Objective 1: Radial Artery LIMBLIMB Anterior Compartment of Posterior Compartment of the OF UPPER the Forearm Forearm 1. Superficial group. 1. Superficial group. Muscles 2. Intermediate group. 2. Deep group. 3. Deep group. UPPER 1. Ulnar artery. 1. Posterior interosseous artery. Arteries 2. Radial artery. 2. Anterior interosseous artery. VESSELS 1. Median nerve. 1. Deep radial nerve (Posterior interosseous Nerves 2. Ulnar nerve. nerve). 3. Superficial Radial nerve. 2. Superficial Radial nerve. Radial artery By Dr. Hassan Rezk September 7, 2024 6  UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 7  Objective 1: Radial Artery in the forearm LIMBLIMB In the cubital fossa. Origin: One of the two terminal branches of the brachial artery. At the level of the neck of the radius. OF UPPER Termination in Passes round the lateral side of the wrist. the forearm: Then, it enters to the anatomical snuff box where its pulsations are palpable. UPPER ▪ Separated from median nerve by the superficial head of pronator teres. ▪ Descends along the lateral aspect of forearm. Course and the ▪ In the upper 2/3 of forearm: covered by Brachioradialis. VESSELS important ▪ In the lower 1/3 of forearm: covered by skin & fascia. relations: ▪ Its relation to superficial radial nerve (NOT RADIAL NERVE): In the middle 2/3 of forearm: the nerve lies lateral to the artery. In the upper & lower 1/3 of forearm: artery is separated by a wide gap from the nerve. Radial artery By Dr. Hassan Rezk September 7, 2024 8  UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 9  LIMBLIMB OF UPPER Anterior view of the right forearm UPPER VESSELS Radial artery By Dr. Hassan Rezk September 7, 2024 10  UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 11  Objective 1: Branches of Radial Artery in the forearm 3 single named + 1 unnamed (muscular) 1 High up at elbow, 2 Low down at wrist LIMBLIMB 1) Radial recurrent artery: at elbow Ascends upward in anterior to lateral epicondyle. End anastmosing with radial collateral artery. OF UPPER Share in the anastmoses around the elbow joint. 2) Muscular branches: for muscles of the anterior compartment. UPPER 3) Superficial palmar artery: at wrist Enters palm of the hand superficial to thenar muscles. Ends anastmosing with superficial terminal branch of ulnar to form superficial palmar arch. VESSELS 4) Palmar radial carpal artery: at wrist Arise from radial artery before winding the lateral aspect of the wrist. Share in the Palmar Carpal Arch to supply the wrist. Radial artery By Dr. Hassan Rezk September 7, 2024 12  UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 13  Objective 2: Radial Artery in hand 2.A. In Dorsum. 2.B. In Palm. LIMBLIMB ▪ Enters the dorsum of the Passes round the lateral side of the wrist. OF UPPER Then, it enters to the anatomical snuff box where its pulsations are palpable. hand ▪ Termination in the It runs in the 1st interosseous space. It leaves the dorsum of the hand to enter the palm by passing between the two UPPER dorsum of the hand: heads of the 1st dorsal interosseous muscle. VESSELS ▪ Entry & termination in the By passing between the two heads of the adductor pollicis. Then, it curves medially deep to long flexor tendons. palm of the hand It anastmoses with deep branch of ulnar artery to form deep palmar arch. Radial artery By Dr. Hassan Rezk September 7, 2024 14  UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 15  Objective 2: Branches of Radial Artery in hand LIMBLIMB A. In dorsum of the Hand B. In palm of the Hand OF UPPER 1) Dorsal Carpal artery: 1) Princeps pollicis artery: Passes medially. It is the main (major) arterial supply to It anastmoses with dorsal carpal artery of the thumb. ulnar artery. To form dorsal carpal arch around the UPPER wrist joint. 2) 1st dorsal metacarpal artery: 2) Radialis indicis artery: It gives two dorsal digital arteries. It runs on the radial side of the index VESSELS Supply the adjacent sides of the index and finger. thumb fingers. Radial artery By Dr. Hassan Rezk September 7, 2024 16  UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 17  Clinical Correlation LIMBLIMB OF UPPER See Anastomoses of Upper Limb UPPER VESSELS Radial artery By Dr. Hassan Rezk September 7, 2024 18  Case Scenario (Staff Question) LIMBLIMB A 59-year-old woman is admitted to the hospital in a state of shock. During physical examination, several lacerations are noted in her forearm and her radial pulse is absent. OF UPPER Where is the most typical place to identify the radial artery immediately after crossing the wrist joint? A. Between the two heads of the first dorsal interosseous muscles. UPPER B. At the anatomic snuffbox. VESSELS C. Below the tendon of the flexor pollicis longus. D. Between the first and second interosseous muscle. E. Between the first interosseous muscle and the adductor pollicis longus Radial artery By Dr. Hassan Rezk September 7, 2024 19  Reference LIMBLIMB OF UPPER Gray's anatomy for students, 3rd edition. ISBN: 978-0-7020-5131-9 Copyright© 2015, 2010, 2005 by Churchill Livingstone, an imprint of Elsevier Inc. UPPER Chapter 7 VESSELS Radial artery By Dr. Hassan Rezk September 7, 2024 20  UPPER VESSELS LIMBLIMB OF UPPER Radial artery By Dr. Hassan Rezk September 7, 2024 21  Anatomy Of Pericardium By: Dr. ABDELHAMID ELSIFY MBBCH, M.SC. MD ASSOCIATE PROFESSOR OF ANATOMY & EMBRYOLOGY HEAD OF ANATOMY-HISTOLOGY DEPARTMENT 3/20/2023 Dr.ABDELHAMID 1  Learning Objectives Knowledge & understanding By the end of this lecture the student should be able to: Describe the Pericardium regards: Definition 3:00 Types and layers of pericardium Sinuses of serous pericardium Supply (arterial & nerve) Clinical points 3/20/2023 Dr.ABDELHAMID 2 The pericardium Definition: a Fibroserous sac which surrounds the heart & the roots of its big vessels It consists of 2 sacs : 1. Outer fibrous sac fibrous pericardium sterno-periicardial lig 2. Inner double layered sac  serous pericardium visceral parietal 3/20/2023 Dr.ABDELHAMID 3 Idea of serous pericardium Serous pericardium is like the balloon and the heart is like the hand fist pushing into the balloon 3/20/2023 Dr.ABDELHAMID 4 Fibroserous Pericardium & Layers of Cardiac Wall Endocardium Myocardium Visceral pericardium Fibrous pericardium Parietal pericardium 3/20/2023 Dr.ABDELHAMID Pericardial cavity 5 Three attachments of the fibrous pericardium 1. Fibrous pericardium is connected to the back of sternum by two sternopericardial ligaments 2. Fibrous pericardium is attached inferiorly to the central tendon of the diaphragm So, the fibrous pericardium helps to keep the heart in position. 3. Fibrous pericardium blends with the adventitia of the big vessels (ascending aorta, pulmonary trunk & SVC) so, helps to keep mouths of these vessels always opened unaffect.ed by the heart or lung movements. 3/20/2023 Dr.ABDELHAMID 6 Functions of fibrous pericardium 1. Maintains a constant position for the heart. 2. Being non elastic, it prevents over distension of the heart 3. Keeps the mouths of blood vessels opened not affected by cardiac or respiratory movements 3/20/2023 Dr.ABDELHAMID 7 Attachments of the fibrous pericardium Fibrous pericardium blends with adventitia of big vessels Fibrous pericardium is attached to diaphragm 3/20/2023 Dr.ABDELHAMID 8 Pericardial Sinuses 14 or 16 Pocket-like recess of the pericardial cavity Transverse sinus = lies anterior to the venous end of the heart (SVC) and upper border of the left atrium and posterior to the arterial end of heart (ascending aorta + pulmonary trunk). Oblique sinus = a blind sac posterior to the left atrium between the openings of pulmonary veins and IVC. 3/20/2023 Dr.ABDELHAMID 9 Pericardial Sinuses When the pericardium is opened anteriorly during surgery, a finger placed in the transverse sinus separates arteries from veins. A hand placed under the apex of the heart and moved superiorly into the oblique sinus. 3/20/2023 Dr.ABDELHAMID 10 Functions of the serous pericardium 19:35 Functions of the serous pericardium: 1. Lubrication of the heart, preventing friction during its movements. 2. Prevents adhesions between the heart and the surrounding organs. N.B. the pericardial cavity contains a thin film of serous fluid secreted by the cells of the serous pericardium 3/20/2023 Dr.ABDELHAMID 11 Blood supply of the pericardium Fibrous pericardium & parietal serous 20:23 23 pericardium are supplied by brs. from: 1. Internal thoracic. a 2. Pericardiacophrenic.a 3. Musculophrenic. a 4. Direct pericardial brs. From descending thoracic aorta Visceral pericardium like the heart from coronary arteries 3/20/2023 Dr.ABDELHAMID 12 Nerve supply of the pericardium 24:56 Fibrous pericardium & parietal serous pericardium are supplied by the phrenic nerves , so they are sensitive to pain Visceral layer of serous pericardium like the heart is supplied by autonomic nerves (sympathetic & parasympathetic) , so it is not sensitive to pain 3/20/2023 Dr.ABDELHAMID 13 Cardiac shadow in normal adult chest X-ray Aortic knuckle 28:55 Normal adult chest x-ray 3/20/2023 Dr.ABDELHAMID 14  Conclusion: Functions of the fibrous pericardium  Maintains a constant position for the heart  Being non elastic, it prevents over distension of the heart  Keeps the mouths of blood vessels opened not affected by cardiac or respiratory movements Functions of the serous pericardium: 1. Lubrication of the heart preventing friction during its movements 2. Prevents adhesions between the heart & the surrounding organs 3/20/2023 Dr.ABDELHAMID 15 C l i n i c a l C o rr e l a t e s 30:14  Pericardial effusion  Normally, only a tiny amount of fluid is present between the visceral and parietal layers of the serous pericardium. In certain situations, this space can be filled with excess fluid (pericardial effusion).  Because the fibrous pericardium is a relatively fixed structure that cannot expand easily, a rapid accumulation of excess fluid within the pericardial sac compresses the heart (cardiac tamponade), resulting in biventricular failure.  Removing the fluid with a needle inserted into the pericardial sac can relieve the symptoms. 3/20/2023 Dr.ABDELHAMID 16 C l i n i c a l C o rr e l a t e s  Constrictive pericarditis  Abnormal thickening of the pericardial sac (constrictive pericarditis) can compress the heart, impairing heart function and resulting in heart failure.  The diagnosis is made by inspecting the jugular venous pulse in the neck. In normal individuals, the jugular venous pulse drops on inspiration. In patients with constrictive pericarditis, the reverse happens and this is called Kussmaul's sign. Treatment often involves surgical opening of the pericardial sac. 3/20/2023 Dr.ABDELHAMID 17  Case Problem : A 40-year-old man is brought to the emergency department because of acutely worsening shortness of breath and a 5-day history of stabbing chest pain. The pain worsens when lying down, and he is unable to take a deep breath. For the past 10 days, the patient has had a fever with cough and a runny nose. He appears pale and diaphoretic. His temperature is 38.5°C (101.3°F), pulse is 110/min, and respirations are 30/min. His blood pressure is 110/75 mm Hg during expiration and 90/65 mm Hg during inspiration. The jugular veins are distended and there is 2+ pitting edema below the knees. The lungs are clear to auscultation. Which of the following is the most likely cause of this patient's findings? a) Pulmonary artery occlusion b) Mediastinal compression by air c) Pleural fluid accumulation d) Pericardial fluid accumulation 3/20/2023 Dr.ABDELHAMID 18 e) Distributive shock  Any Questions? 3/20/2023 Dr.ABDELHAMID 19  References: 1-Gray’s Anatomy for students; Richard drake et al; 4th. edition th 2-Clinical Anatomy by Regions; by Richard Snell 9 edition. 3-https://www.amboss.com/ 3/20/2023 Dr.ABDELHAMID 20  Thank You 3/20/2023 Dr.ABDELHAMID 21 Anatomy Of Great Blood Vessels Of Thorax By: Dr. ABDELHAMID ELSIFY MBBCH, M.SC. MD ASSOCIATE PROFESSOR OF ANATOMY & EMBRYOLOGY HEAD OF ANATOMY-HISTOLOGY DEPARTMENT  Learning Objectives Knowledge & understanding By the end of this lecture the student should be able to: Describe the anatomical details with clinical correlates of the following structures: ❑Thoracic aorta ❑Pulmonary trunk ❑Brachiocephalic veins ❑SVC&IVC 8/25/2024 Dr.ABDELHAMID 2 The ascending aorta ❑The ascending aorta: is contained within the pericardial sac which also surrounds the pulmonary trunk in a common sheath. ❑The origin of the ascending aorta is the aortic orifice, at the level of the lower border of the 3rd. left costal cartilage, posterior to the left half of the sternum. Moving superiorly, slightly forward and to the right, the ascending aorta continues to the level of the 2nd. right costal cartilage. At this point, it enters the superior mediastinum and is then referred to as the arch of the aorta. Dr.ABDELHAMID The ascending aorta DR.ABDELHAMID 4 The ascending aorta ❑Immediately above the aortic valve, the ascending aorta presents three small outward bulges opposite the semilunar cusps of the aortic valve. These are the aortic sinuses. Where the right and left coronary arteries originate from the anterior and left posterior aortic sinuses, respectively. Dr.ABDELHAMID Arch of aorta and its branches The arch of the aorta is present in the superior mediastinum. It begins when the ascending aorta emerges from the pericardial sac and courses upward, backward, and to the left as it passes through the superior mediastinum, ending on the left side at the lower border of vertebra T4 The arch is initially anterior and finally on the left side of the trachea. Three branches arise from the superior border of the arch of the aorta; at their origins, all three are crossed anteriorly by the left brachiocephalic vein. Dr.ABDELHAMID Arch of aorta and its branches 8/25/2024 Dr.ABDELHAMID 7 Branches of Arch of aorta 1-Brachiocephalic trunk. It is the largest of the three branches. Above the right sternoclavicular joint, the brachiocephalic trunk divides into: right common carotid artery right subclavian artery. These arteries mainly supply the right 1/2 of the head and neck and the right upper limb, respectively. Dr.ABDELHAMID Branches of Arch of aorta 2- Left common carotid artery. It ascends through the superior mediastinum along the left side of the trachea. It supplies the left 1/2 of the head and neck. 3-Left subclavian artery. It ascends through the superior mediastinum along the left side of the trachea. It supplies the the left upper limb. Thyroid ima artery may arise from brachiocephalic trunk or as a direct branch from arch of aorta. It contributes to the vascular supply of the thyroid gland. Dr.ABDELHAMID Ligamentum arteriosum The ligamentum arteriosum is a short fibrous band which connects the left pulmonary artery with arch of aorta, distal to the origin of the left subclavian artery. It is important in embryonic circulation, when it is a patent vessel (the ductus arteriosus) which allows blood to bypass the lungs during development. The vessel closes soon after birth and forms the ligamentous arteriosum. 1- Anterior relations Superficial cardiac plexus. 2- Posterior relations Left recurrent laryngeal nerve. Dr.ABDELHAMID Descending Thoracic aorta ❑ The descending thoracic aorta begins at the lower border of vertebra T4 , where it is continuous with the arch of aorta. ❑ It ends anterior to the lower border of vertebra T12 , where it passes through the aortic hiatus of the diaphragm. ❑ It lies to the left side of the vertebral column superiorly, it approaches the midline inferiorly, lying directly anterior to the lower thoracic vertebral bodies. ❑ Throughout its course, it gives off a number of branches, which are summarized in Table 3.3. Dr.ABDELHAMID Branches of Descending Thoracic Aorta 8/25/2024 Dr.ABDELHAMID 12 Coarctation of Aorta Clinical picture: Brachial artery pressure is markedly increased and femoral artery pressure is decreased. 8/25/2024 Dr.ABDELHAMID 13 Pulmonary trunk Pulmonary trunk ❑ Course and surface marking: 1. It is about 5 cm long. 2. It begins at the pulmonary orifice of the right ventricle behind the 3rd. Left costal cartilage. 3. It ends in the concavity of the aortic arch behind the 2nd. Left costal cartilage by dividing into right &left pulmonary arteries. 4. Its root presents 3 sinuses just above its valve cusps ( 2 anterior &one posterior) Dr.ABDELHAMID 15 Pulmonary trunk ❑ Relations: Pulmonary trunk lies within the fibrous pericardium in the middle mediastinum. It is enclosed with the ascending aorta in a common tube of serous pericardium - Right relations Right auricle + right coronary artery - Left relations Left auricle + left coronary artery Dr.ABDELHAMID 16 Branches of Pulmonary trunk ❑ Right pulmonary artery: 1. Longer & larger than the left one 2. Runs behind the ascending aorta &SVC ❑ Left pulmonary artery: is connected to the aortic arch by ligamentum arteriosum Dr.ABDELHAMID 17 Brachiocephalic veins ❑ Each brachiocephalic vein is formed by the union of the internal jugular and subclavian veins posterior to the medial end of the corresponding clavicle. ❑ Both unite to form the SVC posterior to the lower border of the 1st right costal cartilage near to the sternum. ❑ Both lie in the superior mediastinum and both have NO valves. ❑ The right brachiocephalic vein: It is short (2.5 cm long ) and has a vertical course. Right relations Right phrenic nerve. Right pleura and lung. Dr.ABDELHAMID 18 Brachiocephalic veins Relations of Left Brachiocephalic vein Tributaries of Brachiocephalic veins Left Brachiocephalic Vein ❑ The left brachiocephalic vein: It is (5 cm long ) and has an oblique course. It runs downwards and to the right behind the upper ½ of manubrium sterni. ❑ Relations: the vein crosses anterior to the 3 big branches of aortic arch Dr.ABDELHAMID 22 Tributaries of Brachiocephalic veins ❑ Common tributaries: 1. Internal jugular vein 2. Subclavian vein 3. Inferior thyroid vein 4. Vertebral vein 5. Internal thoracic vein 6. First posterior intercostal vein ❑ Special tributaries of: left superior intercostal vein to the left one. Note: Right superior intercostal vein drains in the azygos vein. Dr.ABDELHAMID 23 Superior vena cava (SVC) ▪ Superior vena cava is a large venous channel (7 cm long )which collects venous blood from the upper half of the body and drains it into the right atrium. ▪ It is formed by the union of the right and left brachiocephalic veins behind the lower border of the sternal end of the 1st right costal cartilage. ▪ It pierces the pericardium opposite the 2nd right costal cartilage. ▪ It terminates by opening into the upper part of the right atrium behind the 3rd right costal cartilage. ▪ It has no valves. Right relations Right phrenic nerve. Right pleura and lung. Its upper ½ lies in the superior mediastinum and its lower ½ lies in the middle mediastinum within the fibrous pericardium. Dr.ABDELHAMID 24 Tributaries of Superior vena cava (SVC) 1. Right &left brachiocephalic veins 2. The azygos vein arches over the root of the right lung and opens into the back of superior vena cava at the level of the 2nd. right costal cartilage, just before the SVC enters the pericardium. Dr.ABDELHAMID 25 Superior vena cava (SVC) Tributaries of Superior vena cava (SVC) Dr.ABDELHAMID 27 Inferior vena cava (IVC) ❑ The intrathoracic part of IVC is short (0.5 inch long). ❑ Lies in the middle mediastinum within the fibrous pericardium. ❑ It pierces the central tendon of diaphragm opposite T8 one inch to the right side of midline and immediately enters the inferior part of right atrium. Right relations Right phrenic nerve. Right pleura and lung. Dr.ABDELHAMID 28 Inferior vena cava (IVC) Dr.ABDELHAMID 29 Azygos venous system(had been taken in M1)  Case Problem : A 61-year-old man comes to the physician because of a 5-month history of sharp, shooting pain in both legs. Twenty years ago, he had a painless ulcer on his penis that resolved without treatment. He has no history of serious illness. Examination shows small pupils that constrict with accommodation but do not react to light. Sensation to pinprick and light touch is decreased over the distal lower extremities. Patellar reflexes are absent bilaterally. His gait is unsteady and broad-based. This patient is at increased risk for which of the following complications? a) Atrioventricular block b) Mitral valve regurgitation c) Penile squamous cell carcinoma d) Cerebral artery septic embolism e) Inflammatory poly arthritis f) Thoracic aorta aneurysm 8/25/2024 Dr.ABDELHAMID 31 Any Questions?  References: 1- Gray’s Anatomy for students; Richard drake et al; 4th. edition 2-Clinical Anatomy by Regions; by Richard Snell 9th edition. 3-https://www.amboss.com/ Thank You Anatomy of Upper Limb Suprascapular and Brachial Arteries By Dr. Hassan Mohammed Rizk (Ph.D.) Associate Professor of Human Anatomy and Embryology  Objectives: by the end of this lecture the student must understand the following knowledge: VESSELS OF UPPER LIMB ▪ Identify and demonstrate the following arteries: 1)Suprascapular artery. 2)Brachial Artery ▪ Regarding: 1)Origin. 2)Termination. 3)Course and Relation. 4)Branches and Distribution. Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 2  Case Study VESSELS OF UPPER LIMB Computed Tomography Angiography (CTA) of occluded right brachial artery Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 3  Introduction Map for the Arterial Supply of the Whole Upper Limb VESSELS OF UPPER LIMB Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 4 VESSELS OF UPPER LIMB Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 5  Suprascapular Artery VESSELS OF UPPER LIMB Origin: From thyrocervical trunk from subclavian artery. At the base of the neck. Termination: Anastmosing with the branches of axillary artery (SEE THE LECTURE OF ANASTMOSIS) Course and Passes backwards. the important Enter the shoulder by passing above the Suprascapular ligament (dose not pass relations: through the Suprascapular foramen). Enters supraspinous fossa, then through spinoglenoid notch into infraspinous fossa. Accompanied by Suprascapular nerve. Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 6 VESSELS OF UPPER LIMB Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 7  A M L P VESSELS OF UPPER LIMB Right superior view of the Shoulder Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 8 VESSELS OF UPPER LIMB Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 9  Brachial Artery VESSELS OF UPPER LIMB Anterior Compartment of Arm Posterior Compartment of Arm 1. Biceps brachii. Muscles 2. Coraco-brachialis. Triceps brachii 3. Brachialis 1. Profunda brachii artery. Arteries Brachial artery 2. Ulnar collateral artery. 1. Musculocutaneous nerve. 2. Axillary nerve. 3. Median nerve. Nerves 4. Ulnar nerve.. 1. Ulnar nerve. 5. Radial nerve. 2. Radial nerve. (in the lower part of the compartment). Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 10 VESSELS OF UPPER LIMB Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 11  L M Brachial Artery VESSELS OF UPPER LIMB Origin: Direct continuation of Axillary artery. At the level of distal (lower) border of teres major. Termination: In the cubital fossa. At the level of the neck of the radius. It divides into: 1. Ulnar artery: that runs medially. 2. Radial artery: that runs laterally. Anterior View of Whole Course and the Brachial artery is superficial along its course. Upper Limb It is covered by skin & fascia (dangerous position). important Showed three arteries at Has a triple relation with the median nerve: the same line (yellow, relations: ▪ In the upper 1/3 of arm: the nerve lies lateral to the artery. blue & red continuation) ▪ In the middle 1/3 of arm: the nerve crosses the artery superficially. & two arteries (green ▪ In the lower 1/3 of arm: the nerve lies medial to the artery. divisions) Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 12 VESSELS OF UPPER LIMB Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 13  L M VESSELS OF UPPER LIMB Anterior View of right arm & cubital fossa Showed triple relation between brachial artery & median nerve Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 14 VESSELS OF UPPER LIMB Neck of radius Suprascapular and Brachial Arteries By Dr. Hassan Rezk August 29, 2024 15  Branches of Brachial Artery VESSELS OF UPPER LIMB 1) Profunda Brachi artery (Deep Brachial artery): ▪ Largest & 1st branch near the origin of the brachial artery. ▪ Winds backwards to appear in the triangular interval with radial nerve. ▪ Runs in the spiral groove accompanied by radial nerve. ▪ It is the main arterial supply to the posterior compartment. ▪ It gives: 1. Muscular branches to triceps brachi. 2. Anterior (radial) collateral artery. in relation to lateral epicondyle of the humerus. 3. Posterior (middle) collateral arteries: 2) Nutrient artery: to supply the humerus.