1
Q
Brachial plexus roots to nerves
A
C5 - T1
ventral rami
C5/6 upper trunk
C7 middle trunk
C8/T1 lower trunk
each trunk divides into ant and post divisions
post trunks combine to post cord
ant of upper and middle make lateral cord
ant of lower makes medial cord
lateral cord divides into musculocutaneous and median nerves
posterio divides into axillary and radial nerves
medial splits into ulna and other half joins lateral split making up median nerve
2
Q
Brachial plexus injuries
A
upper brachial plexus injury - neck extended away from shoulder causes stretching of upper nerve roots: birth (shoulder dystocia), trauma = erb’s palsy
lower brachial plexus - pulls arm suddenly upwards e.g. falling or during birth
3
Q
Erb’s palsy
A
C5/C6 weakness
- biceps, brachialis, deltoid
waiter’s tip posture
4
Q
KLumpe’s palsy
A
C8/T1 palsy
claw hand
intrinsic muscle weakness
5
Q
Horner’s syndrome
A
loss of sympathetic innervation
sympathetic chain T1-L2
nerves going to ganglia - ascend through 3 ganglia in neck: stellate, middle cervical and superior cervical - above this sympathetic nerves travel within walls of blood vessels
signs:
- ptosis
- miosis
- anhydrosis
- enophthalmos
Causes:
- syringomyelia, brachial plexus trauma, pancoast tumour, carotid artery dissection
6
Q
anterior shoulder muscles
A
deltoid - lateral clavicle into acromium, axillary nerve - winds round proximal humerus
serratus anterior - medial border of scapula around rib cage, long thoracic nerve (runs behind axillary line) if impaired causes winged scapula
pectoralis minor - ribs 2-4, attaches to corocoid process, medial pectoral nerve
pectoralis major - medial clavicle and sternum, attaches to medial prox humerus, innervated medial/lateral pectoral nerve
7
Q
posterior muscle groups
A
deltoid - acromium and scapula spine, attaches tubercle of humerus. abduction 15 degrees to 90 degrees
trapezius - top of cervical vertebra to T12, attach to spine of scapula, CN XI (accessory)
latissimus dorsi - lower thoracic and lumbar spinous proccesses, inserts into medial aspect of humerus, long scapula nerve
8
Q
median nerve
A
NO muscles in upper arm
pronator teres - medial humerus to lateral radius
anterior forearm muscles EXCEPT flexor carpi ulnaris and flexor digitorum profundus 4+5 - ulnar
thenar muscles
lumbricals
sensation
brachial plexus down anterior humerus across centre elbow joint down anterior forearm
9
Q
median nerve lesions
A
supracondylar fractures - children
carpal tunnel syndrome
10
Q
musculocutaneous nerve
A
motor in upper arm
biceps
brachialis
coracobrachialis
descends down anterior humerus more laterally to median
11
Q
ulnar nerve
A
no muscles in upper arm
flexor carpi ulnaris
flexor digitorum profundus (4,5)
intrinsic muscles of hand EXCEPT thenar and lumbricals 3/4 ulnar side, others median
sensory
goes behind medial epicondyle of humerus along ulnar
12
Q
ulnar nerve lesions
A
entrapment at elbow
trauma - blunt or penetrating at wrist
claw hand
worse with more distal lesions (ulnar paradox)
hand of benediction
13
Q
radial nerve
A
triceps
brachioradialis
supinator
posterior forearm extensors
abductor pollicis longus
sensory
winds around back of humerus
14
Q
radial nerve lesion
A
saturday night palsy - pressure on radial nerve against back of chair
direct trauma
supracondylar #
15
Q
Upper limb reflexes
A
biceps C5-6
brachioradialis C5-6
triceps C7-8
finger C8
16
Q
Sensory supply to hand
A
Ulnar nerve (C8-T1) innervates ulnar border of hand and 1.5 fingers
Median nerve does rest of palm and tips of thumb and index/middle/half ring finger
Radial dorsum of hand radial side to PIPJ thumb/index/middle/half ring fingers
17
Q
Carpal tunnel
A
9 tendons:
- flexor digitorum profundus x4
- flexor digitorum superficialis x4
flexor pollicis longus
median nerve
flexor retinaculum - hook of hamate to trapezium
palmar cutaneous branch of median nerve - superficial to flexor retinaculum, not affected in carpal tunnel syndrome
18
Q
Muscles of hand
A
thenar - adbuctor pollicis brevis, opponens pollicis, flexor pollicis brevis ALL innervated by median nerve
hypothenar - abductor digiti minimi, opponens digiti minimi and flexor digit minimi brevis - ALL innervated by ulnar
interossei - palmar and dorsal row, MCs to proximal phalanges, ulnar innervated
lumbricals - arise from flexor digitorum profundus tendon wrap round to dorsum of finger into extensor expansion, bend MCPJ and extend PIPJ/DIPJ, lateral 2 innervated by median, medial 2 innervated by ulnar
19
Q
median nerve test
A
thumb to ceiling - test abductor pollicis brevis
20
Q
ulnar nerve test
A
paper between fingers tests interossei
21
Q
sternoclavicular joints
A
22
Q
acromioclavicular joints
A
acromioclavicular ligaments - grade 1
coracoclavicular ligaments - grade 3
coraco-acromial ligaments - arch across top of glenohumeral joint, protects from superior displacement of humeral head
23
Q
rotator cuff muscles
A
supraspinatus - first 10-15degrees abduction
infraspinatus - external rotation
teres minor - internal rotation
subscapularis -
24
Q
axilla
A
anterior wall: pec major and minor
posterior wall: latissimus dorsi, subscapularis, teres major
medial wall: serratus anterior
contents: axillary artery, cords of brachial plexus, axillary lymphnodes
25
Safe Triangle
Lateral border of pec major
mid axillary line
line though 5th intercostal space
26
The Breast
4 quadrants
lymph drainage significant
27
Elbow joint
capitellum - dome shaped distal humerus opposite radial head
trochlear - saddle shaped articulates with ulnar
olecranon - end of ulnar
radial collateral ligament, ulnar collateral ligament
annular ligament - ulnar around head of radius then back to ulnar, pulled elbow
28
Elbow ossification centres
formation of epiphyses, important in paediatric XR
C - capitellum 1
R - radial head 3
I - internal epicondyle 5
T - trochlear 7
O - olecranon 9
E - external epicondyle 11
29
Flexor muscles of forearm
superficial to deep
pronator teres
flexor carpi radialis
palmaris longus - doesn't pass through flexor retinaculum
flexor carpi ulnaris
flexor digitorum superficialis, inserts into middle phalanx, median nerve
flexor digitorum profundus, inserts into distal phalanx, half median/ulnar
flexor pollicis longus
pronator quadratus
30
Dorsal compartment arm - extensor, supinator and abductor
12 muscles
layer 1 - superificial
- brachioradialus, extensor/supinator, radial nerve
- extensor carpi radialis longus and brevis, wrist extensors
- extensor carpi ulnaris
- anconeus weak elbow extensor
layer 2 - middle
- extensor digitorum
- extensor digiti minimi
layer 3 - deep
- supinator
- abductor pollicis longus
- extensor pollicis longus
- extensor pollicis brevis
- extensor indicis
31
Forearm compartments
- clinical significance for compartment syndrome
- volar and dorsal compartments
- limited by fascia
32
Anatomical snuffbox
inferior border: extensor pollicis brevis and abductor pollicis longus,
superior border: extensor pollicis longus
floor: trapezium and scaphoid
radial nerve
33
Nervous innervation
Lateral cutaneous nerve - L2/3, under ASIS and inguinal ligament to lateral thigh
Femoral nerve - L2/3/4, under inguinal ligament, anterior compartment
Obturator nerve - L2/3/4, medially along pelvic brim, through obturator foramen into medial compartment - adductor muscles
Sciatic nerve - L4-S3, runs down back of pelvis
34
Femoral nerve supply
rectus femorus and satorius
terminal branch is saphenous - sensation to medial lower leg
35
Obturator nerve
36
Sciatic nerve
Runs down posterior thigh, innervates knee flexors - hamstring muscles
Splits superior to popliteal fossa into tibial and common peroneal nerve
37
Femoral triangle
superior border - inguinal ligament
lateral border - medial border sartorius
medial border - medial border adductor longus
contains - femoral artery marks mid point of inguinal ligament
femoral vein medial
femoral nerve lateral
NAVY - lateral to medial
38
Adductors
Main
Adductor magnus (deep), 2/3 down has hunter's/adductors canal, femoral artery goes through
Adductor longus (superficial)
Adductor brevis (superficial)
Gracilis
All innervated by obturator nerve
39
Abductors
Gluteus minimus - posterior iliac crest, insert GT
Gluteus medius - posterior iliac crest, insert GT
Tensor fascia lata - long tendon into distal knee
40
Hip flexors
Psoas - L1-5, inserts lesser trochanter, also internal rotation
Iliacus - iliac crest to lesser trochanter, also internal rotation
Rectus Femoris (part of quadriceps muscle), anterior inferior iliac spine to inserts into patella
41
Hip extensors
Gluteus maximus - iliac crest, inserts laterally in prox femur
Hamstrings - biceps femoris, semimembranus, semitendinosus , ischial tuberosity into proximal tibia
42
Neurological tests
L2 hip flexion
L3 knee extension
L4 ankle dorsi flexion
L5 great toe extension
S1 ankle plantar-flexion/ankle eversion/hip extension
S2 knee flexion
S3-S4 anal wink
reflexes
knee L3/4
ankle S1
43
Anterior thigh
Sartorius - ASIS, inserts prox tibial condyle
Rectus femorus - joins 3 other muscles arising for femur to make up quadriceps, join in quads tendon inserting into patella
Femoral nerve
44
Hamstrings
biceps femoris - 1 head from ischial tuberosity, 1 head from posterior femus, sciatic nerve deep to biceps femoris
semimembranosis (massieve and medial) and semitendinus
Sciatic nerve
S2 knee extension
45
Popliteal fossa
Pes anserinus - tendons from gracilis, semitendinosis and sartorius
Popliteal artery (continuation of femoral artery), medial to vein and nerve
Biceps femoris medial border
Gastrocnemius heads inferior border
46
Bursa in knee
Suprapatella - continuation of knee cavity behind patella either side of quads tendon
Prepatella - superior to patella
Infrapatella bursa
47
Anterior lower leg
Invertor/dorsiflexor - tibialus anterior
evertor/dorsiflexor - peroneal tertius
extensor hallicus longus
extensor digitorum
48
Lateral lower leg
peroneus longus - inserts into base of 1st MT
peroneus brevis - inserts into base of 5th MT - common avulsion # inversion injury
evertors
wrap around lateral malleolus
49
Posterior lower leg
Deep later:
- tibialus posterior
- flexor hallicus longus
- flexor digitorum longus
All tendons run medially to medial malleous
Superficial layer:
- soleus
- gastrocnemius
Insert into calcaneal tendon
50
Foot bones
talus - fits into mortis between fibula and tibia
calcaneum articulates with cuboid laterally then 4th/5th MT
talus articulates anteriorly with navicular then cuneiforms then each with metatarsal
51
Ankle ligaments
lateral ankle:
- anterior talofibular ligament
- posterior talofibular ligament
- calcaneofibular ligament
medial ankle:
- deltoid ligament
52
neck fascia
deep investing fascia, subdermal - jaw around back of skull down to clavicles, surrounds sternocleidomastoid and trapezius separately
visceral deep fascia - surrounds oesophagus, trachea and thyroid, extends down to pericardium, pharynx above
carotid sheath - jugular, common and internal carotid, vagus
pre vertebral fascia - encloses spine and muscles surrounding spine
space between prevertebral and visceral deep fascia is a potential space for spread of infection into mediastinum
53
spinal muscles
flexors anterior to vertebral column
extensors posterior to vertebral column
54
parapharyngeal space
lateral to nasopharynx
from base of skull down to hyoid bone
abscesses usually arise from infections of tonsils, adenoids or teeth
55
submandibular space
potential space
between mylohyoid and deep investing fascia
dental abscesses can spread
Ludwigs angina involves this and sublingual space
56
retropharyngeal space
behind pharyngeal wall - within visceral fascia
contains retropharyngeal lymph nodes
infection from adenoids, teeth
57
sternocleidomastoid muscle
rotates head to opposite side
together extends head
accessory nerve innervation
58
posterior triangle
anterior border posterior sternocleidomastoid, posterior border trapezius, base scalenes
contains lymphnodes
omohyoid crosses
59
anterior triangle
anterior to sternocleidomastoid
split into 4 - 2 above and 2 below hyoid bone
60
supra and infra hyoid bones
4 of each
supra hyoid: hyoid to jaw
- lifting hyoid and larynx, swallowing, holds oesophagus open and wide mouth opening
infrahyoids: depress larynx, swallowing
61
thyroid gland
attached to 2nd and 3rd tracheal rings
anterior to larynx
isthmus below cricothyroid membrane
rich blood supply
parathyroid glands posteriorly
cricothyroid membrane - emergency front of neck access
surgical tracheostomy 2-3rd ring or 3-4th ring
recurrent laryngeal winds behind subclavian from vagus on R, on L winds around ligamentum arteriosum then up to larynx
62
trachea
15-20 incomplete rings
trachealis muscle connects ends of rings
smooth muscle
63
cervical sympathetic
T1 to L2
rami communicantes connect spinal sympathetic chain with each spinal nerve
above T1 no sympathetic outflow
travels upwards through ganglia
sympathetic nerves travel in walls of arteries
64
Cervical sympathetic ganglia
stellate ganglion
65
Horner's syndrome
Lesions:
- spinal cord level e.g. syringomyelia
- root level - brachial plexus injury
- ganglion - penetrating trauma
- lung apex - pancoast tumour
- carotid aneurysm
66
Root of neck
scalenus anterior 3-6 vertebral bodies to first rib
separates subclavian artery (posterior) and vein (anterior)
phrenic nerve runs along scalenus anterior
thoracic duct (only relevant when putting in subclavian line on left) - damage can cause chylothorax (lymph in mediastinum)j
67
jugulo-omogyoid lymph node
enlarged in tongue cancer
68
facial muscles
innervated by CN VII (facial)
frontalis - raising eyebrows, wrinkling forehead
orbicularis oculi
orbicularis oris
buccinator - extends horizontally and inserts into zygoma, holds food in mouth
69
Facial nerve
CN VII, motor, muscles of facial expression
passes through middle ear
exits at stylomastoid foramen
passes through parotid gland
temporal branch - frontalis
zygomatic branch - orbicularis oculi
buccal branch - orbicularis oris
mandibular marginal - jaw
cervical - platysma
70
Trigeminal nerve
CN V, motor and sensory
muscles of mastication
ophthalmic - back of orbit
- supratrochlear: midline medial to orbit
- supraorbtial: lateral to supratrochlar
- lacrimal: lateral top of orbit
- infratrochlar: on nose
- anterior ethmoidal: inside of nose and tip
maxillary - nose
- zygomatricotemporal
- zygomaticofacial
- infraorbital
mandibular - lower jaw
- auricolotemporal branch
- buccal
- mental
71
facial arteries
facial artery - winds underneath mandible, travels up lateral to mouth, ends close to medial eye
superficial temporal artery, extension of external carotid
often affected by GCA
72
facial vein and cavernous sinus
facial vein connects to ophthalmic vein into cavernous sinus
clinical relevance - infection spread posteriorly into cavernous sinus -> thrombosis
73
scalp anatomy
S skin
C connective tissue
A aponeurosis
L loose connective tissue - aponeurosis slides over
P periosteum
Bone
74
scalp attachments
aponeurosis runs from back to front
occipito frontalis muscle attach to aponeurosis
occipital belly attached to bone
frontalis belly only attached to skin and fascia
aponeurosis attached to bone laterally and posterior
not attached anteriorly so haematomas travel to face = bruising
75
sensory supply to anterior neck, occiput and posterior scalp
anterior and posterior divisions o
posterior rami C2/3 = greater occipital nerve, occiput and vertex, lesser occipital
ventral rami from cervical plexus -> greater auricular nerve behind ear
76
sensory supply of external ear
1. auriculotemporal (mandibular)
2. lessor occipital
3. greater auricular (ventral rami cervical plexus)
4. vagus
reflects embryology
77
Temporal fossa
zygomatic arch
temporal done
sphenoid
temporalis muscle - clenches teeth
superficial temporal artery
auriculotemporal branch of mandibular
temporal branch of facial nerve
78
below zygomatic arch
masseter - clenches teeth, zygomatic arch to angle of mandible, motor of trigeminal
parotid - salivary gland, duct leaves anteriorly around masseter into mouth, parasympathetic innervation by glossopharyngeal (otic ganglion)
79
pterygoid muscles
medial - lateral jaw movements, chewing
lateral - protrudes jaw, jaw opening
trigeminal nerve
80
mandibular nerve
leaves via foramen ovale
lingual nerve - to tongue
inferior alveolar nerve - sensation to teeth
chorda tympani, travels with facial nerve into internal acoustic meatus through middle ear, leaves
anterior 2/3 taste sensation to tongue
parasympathetic fibres to submandibular and sublingual salivary glands
81
glossopharyngeal nerve
emerges from skull through jugular foramen
passes around pharynx towards tongue
motor to stylopharyngeus (speech and swallowing)
parasympathetic to parotid glands
visceral sensation from carotid body and carotid sinus
general sensation from parts of ear, upper pharynx and posterior 1/3 tongue
taste posterior 1/3 tongue
82
vagus nerve
CN X
leaves through jugular foramen
enters carotid sheath
extends to colon
mixed nerve
parasympathetic between neck and colon
motor to larynx and pharyngeal muscles
part of gag reflex (efferent pathway, glossopharyneal afferent)
visceral sensation from aortic arch, lungs
83
accessory nerve
CN XI
jugular foramen
some roots from brainstem and upper spinal roots
motor to trapezius and sternocleidmastoid
84
Hypoglossal nerve
CN XII
passes through hypoglossal canal
purely motor
innervates intrinsic and extrinsic tongue muscles
85
Maxillary nerve (branch of trigeminal)
emerges from foramen rotundum
runs along floor of orbit to infraorbital foramen -> continues into infraorbital nerve
important sensory branches
- anterior alveolar nerve (innervate teeth)
- posterior alveolar nerve
- inferior alveolar nerve
sensation to:
- meninges
- most sinuses
- most nasal cavity
- pharyngeal wall
- upper teeth
carries parasympathetic innervation to lacrimal gland
86
Parasympathetic ganglia
- salivation
- tears
- nasal mucosa
- pupil constriction
Parotid gland -> otic ganglion -> CN IX then CN V3
Submandibular -> submand ganglion -> chorda tympani and CN V3
Sublingual -> submand gang -> chorda tympani and CN V3
lacrimal gland and nasal mucosa -> ptserygopalatine gang -> CNVII then CN V3
pupil -> ciliary ganglion -> oculomotor nerve (CN III)
87
pterygopalatine fossa
contains maxillary nerve and pterygopalatine ganglion
sits behind maxillary sinus
88
nasal cavity
medial wall made up of cartilaginous tissue and bone
lateral wall - turbinates, humidifies air
most sinuses drain beneath middle concha
sphenoidal sinus drains behind superior turbinate
nasolacrimal duct drains beneath inferior concha
mostly maxillary innervation
anterior part innervated by anterior ethmoidal nerve
89
Little's area
Kiesselbach's plexus
- sphenopalatine artery
- post and ant ethmoid arteries
- superior labial artery
- greater palatine artery
90
Paranasal sinuses
frontal sinuses (develop at 10yrs)
sphenoid sinuses
maxillary
ethmoid - important source of orbital cellulitis
ethmoid, maxillary, sphenoid present at birth
91
Teeth
8 teeth in full set (half one side)
central incisors - 7
lateral incisors - 8
canine - 10
premolars - 11
first molar - 7
second molar -12
third molar - 20
92
Dental anaesthesia
inferior alveolar nerve block
runs in mandibular foramen
posterior to last molar tooth
covers lower jaw
difficult to anaesthetise upper teeth, either individually
can inject into infraorbital foramen
93
Tongue
hypoglossal nerve - intrinsic and extrinsic muscles
glossopharyngeal nerve - post 1/3 taste and sensation
chorda tympani - taste ant 2/3
lingual nerve - branch of mandibular, normal sensation
94
submandibular gland
underneath mandible near angle
long duct travels anteriorly to midline of caruncle, stones travel down duct, can obstruct
95
Muscular pharynx
3 constrictors
innervated by vagus and glossopharyngeal
swallowing initially voluntary
reflex process follows once bolus reaches pharyngeal wall -> other openings all closed
96
Pharyngeal areas
tonsil - oropharynx (behind uvula)
adenoid - close to eustation tube opening, nasopharynx (behind nasal cavity to bottom of soft palate)
hypopharynx - below nasopharynx to larynx
97
Laryngeal skeleton
epiglottis superiorly
thyroid
arytenoids - action of vocal cords
cricoid
98
Principle functions of the larynx
respiration - opening of cords (abduction), palsy will create stridor
phonation - closing of cords (adduction), palsy will create horse voice
both lost with recurrent laryngeal nerve
99
bones of orbit
superior: frontal
inferior: maxilla (damage in blow out #)
lateral: zygoma
posterior: sphenoid
post med: ethmoid
medial: lacrimal
100
eyelids
orbital septum - diaphragm (fibrous) attaching to upper and lower tarsal plates (cartilaginous)
differentiates between preseptal cellulitis and orbital cellulitis (most commonly from ethmoidal sinus)
eyelashes infront of tarsal plate
meibomian glands posterior to tarsal plate on lid margin - produces lipid secretion, runs along border keeping aqueous tear solution in eyes
101
lacrimal glands
tears produced in lacrimal gland
sits laterally, ducts open into conjunctival sac
produce tear film, moves medially, drains into nasolacrimal duct, opens into inferior concha
102
extraocular muscles
superior, inferior, medial and lateral rectus
superior oblique - top of orbit medial side, through ring and attaches obliquely across eyeball, turns eye towards, abduct, rotates inwards
LR6SO4
occulomotor innervates everything but LR and SO
CN VI palsy - horizontal diplopia
CN IV palsy - vertical diplopia
CN III palsy - down and out, severe diplopia
103
optic nerve
extension of meninges over optic nerve to back of eye
CSF in subarachnoid space - in raised ICP causes pressure increase around optic nerve -> optic atrophy long term, short term -> venous engorgement = papilloedema
104
middle ear
handle of malleus seen on TPM with otoscope
facial nerve passes through middle ear, gives of chorda tympani - combines with mandibular nerve to supply taste to anterior 2/3 tongue
105
inner ear
eustachian tube
cochlea and semi-circular canals
CN VIII
mastoid air cells - previous site of infection causing mastoiditis
106
thoracic aorta
thoracic aorta begins after aortic valve
first branch is RCA and LCA
next branch R
brachiocephalic trunk -> R common carotid and R subclavian
L common carotid
L subclavian -> internal thoracic, vertebral, thyrocervical trunk -> brachial
107
Right subclavian artery branches
1st branch internal thoracic (mammary)
vertebral artery and thyrocervical trunk then brachial artery
108
ligamentum arteriosum
after L subclavian, ligamentum arteriosum - after this point aorta bound firmly to vertebral bodies posteriorly
tears of aorta take place in rapid deceleration injury
descending aorta gives off branches at each subcostal level, small branches penetrate vertebra providing additional layer to spinal cord
artery of adamkiewicz at T8 - supplies thoracic cordv
109
veins of thorax
R subclavian vein, passes over first rib, anterior to ant scalene
external jugular joins then internal jugular, now brachiocephalic vein
L subclavian, external jugular meets then internal jugular meet to make L brachiocephalic
both brachiocephalic veins join to make SVC
azygous vein (right) drains subcostal veins and hemiazygous (left) into SVC at point with brachiocephalic veins meet
thoracic duct ascends on L side of oesophagus and enters between L IJ/EJA
110
Phrenic nerve
C3,4,5
passes behind SVC on R into mediastinum
motor and sensory innvervation to diaphragm and diaphragmatic peritoneum
111
spinal blood supply
anterior spinal artery
posterior spinal arteries branch from vertebral arteries
112
Surface markings of chest
male nipple lies over 4th intercostal space
apex is 2-3cm above clavicle
pleural comes down to 12th rib
113
thoracic plane
divides upper mediastinum from central
manubriosternal angle to T4-5 disc
tracheal bifurcation
azygos veins empties into SVC
pulmonary artery branhces
beginning and end of aortic arch
2nd rib joins manubriosternal joint via costal cartilage
114
thoracotomy
used in loss of output in trauma
enter L side in 5th space into axilla
vertical incision into pericardium (less risk of phrenic nerve injury)
115
abdominal levels
planes on CT
T11 liver, aorta, stomach, spleen
T12 top of L kidney, spleen, diaphragm, aorta, liver, IVC
L1 gall bladder, stomach, duodenum, pancreas, aorta and SMA and portal vein, both kidneys, descending colon, liver
L2 spleen gone, both kidneys, IVC, L renal vein, SMA, portal vein, stomach, liver
L3 liver, stomach, IVC, IMA, psoas muscles
L4 aorta divides into common iliac arteries, small intestine, psoas muscles
L5 common iliac veins (touching vertebrae), common iliac arteries, common ureters
116
L1 key anatomy
SMA and SMV
pancreas
loop of duodenum passes behind pancreatic head
117
abdominal aortic branches
coeliac trunk T12/L1
SMA
L1/2 junction - renal arteries
gonadal arteries
IMA
aorta branches at L4
118
Ureter narrowing/points of obstruction
pelvoureteric junction
crossing of iliac vessels
bladder wall common place to become impacted
119
AXR
small bowel dilated >3cm
large bowel dilated >6cm
120
appendix
normally arises 2cm before ileocaecal valve
position varies
121
inguinal hernias
external iliac artery and vein junction with common femoral artery and vein after inguinal ligament
inferior epigastric artery and vein
lateral to inferior epigastric vessels the vas deferens passes into anterior abdominal wall via deep inguinal ring, anteriorly over these vessels and out through superficial ring into scrotum
indirect hernia goes through internal ring and follow vas deferens
direct hernia starts medially to inferior epigastric through anterior abdominal wall
122
Bladder
trigone smoother than rest of the bladder - different embryological origin, folds of mucosa to prevent flow back
base of trigone into internal urethral sphincter (involuntary) -> external sphincter (volunary)
123
nerve supply of bladder
sympathetic - relaxes bladder and increases internal sphinter tone
stretch receptors in bladder wall give afferent info about bladder filling, once 300-350ml struggle to ignore
parasympathetic - increases detrusor activity, relaxes internal sphincter
initial action voluntary to allow parasympathetic action
pudendal nerve S2-4 - voluntary control of external sphincter
sensation general visceral afferents with sympathetic flow
pelvic splanchnic nerves carry parasympathetic nerves
124
bones of the pelvis
sacrum
ilium
ischium
pubic bone (sup/inf rami)
acetabulum
coccyx
above pelvic inlet = false pelvis
below pelvic inlet = true pelvis
125
pelvic floor
sheet of muscle
funnel shaped structure
separates pelvic cavity from perineum
support abdominopelvic viscera
resistance to increases in abdominal pressure
urinary and faecal continence
urogenital hiatus - passage of urethra
rectal hiatus - passage anal canal
126
sphincters of the anal canal
anal canal separated from rectum by dentate line
internal - autonomic control, smooth muscle
external - voluntary skeletal muscle, pudendal nerve
127
dentate line
above dentate line
- lymphatic drainage to internal iliac
- epithelium is columnar
below dentate line
- lymphatic drainage to superficial inguinal
- squamous epithelium
128
prostate
urethra passes through middle
vas deferens and seminal vesicles join urethra
histologically different zones
- transitional zone - BPH
- peripheral zone - most prostatic malignancies develop
- also central and fibromuscular zone
129
uterus anatomy
fundus at top
body
cervix at bottom
fallopian tube:
- narrow isthmus
- ampulla wider
- infundibulum - finger like fimbriae gathers up ovum post ovulation
130
ectopic pregnancy
most common ampulla
normally motility issue
isthmus more dangerous, narrower and more likely to erode into blood vessel
can also occur muscularly, in cervix, infundibulae, abdominally
131
ovaries
ovarian artery
uterine artery (from internal iliac)
132
meninges
dura mater - continuous with periosteum, veins beneath in subdural space
arachnoid mater beneath is sub-arachnoid space, CSF, gets larger as gets older
pia mater - adherent to brain
top of cranium, sagittal sinus - arachnoid granulations extend into
133
CSF
produced in choroid plexuses in each ventricle
each 140ml+
600-700ml produced/reabsorbed each day
reabsorbed by arachnoid granulations back into venous system
protein 0.3% (0.15-0.45g/L)
glucose 65%
no red cells
0-5 mononuclear cells/mm3
134
Ventricles of brain
2x lateral ventricles
drains into third ventricle via foramen of munro
3rd ventricle sits between R and L thalamus, 2 anterior recesses - supra-optic recess (above chiasm) and infundibular recess (above optic nerve) - susceptible to pressure effects
connected to 4th ventricle via cerebral aqueduct
drains into SAH via foramina
135
CSF circulation
circulates around brain and reabsorbed via arachnoid granulations
can be sampled
136
venous circulation
superior sagittal sinus at top of falx
inferior sagittal sinus at bottom of falx
both join straight sinus -> sigmoid sinuses -> internal jugular vein
137
Cavernous sinuses
O Tom Cat - structures within
oculomotor nerve
trochlear nerve
ophthalmic nerve (V1)
maxillary nerve V2
internal carotid
abducens nerve
venous drainage from face, orbit and lacrimal gland
sepsis can be carried back, cause thrombosis
138
arterial supply of brain
autoregulation - maintains constant cerebral blood flow despite changes in systemic blood pressure
constant cerebral blood flow maintained through MAP 60-160mmHg, above/below autoregulation lost
139
CO2 and cerebral blood flow
higher arterial CO2 -> dilatation of blood vessels in brain -> raised ICP
140
oxygen and cerebral blood flow
higher arterial O2 -> slow but gradual reduction of cerebral blood flow
141
arterial supply of brain
MCA - direct continuation of internal carotid, gives off ophthalmic and ACA
ACA connected with anterior communicating artery (prone to SAH and aneurysm formation)
vertebral arteries travel up through cervical spine in transverse foramina, give off cerebellar arteries, join to make basilar artery
basilar artery -> posterior cerebral artery
PCA connects with MCA via posterior communicating artery
142
cortical areas
pre central gyrus - motor cortex, frontal lobe
post central gyrus - sensory cortex, parietal lobe
Broca's area (dominant hemisphere) - frontal lobe, speech production, expressive dysphasia
Wernicke's area - temporal lobe, language comprehension, receptive dysphasia
143
Middle Cerebral Artery
internal carotid -> MCA
initially moves laterally/horizontally - M1 - lenticulotriate branches, prone to damage in artherosclerotic disease (lacunar infarcts)
then M2 near insula
then M3 near sylvan fissure
144
Stroke syndromes
ACA:
- contralateral leg paresis > arm
- disinhibition
MCA:
- hemiparesis face and upper limb (+/- lower limb)
- sensory loss
- homonymous hemianopia
- dysarthria
- receptive aphasia
in non dominant hemisphere - neglect and dyspraxia
Lacunar strokes
- localised internal capsule defects
- arise from ischaemia from lenticulo-striate circulation
- motor or sensory defects
PCA:
- homonymous hemianopia
- memory impairment
- thalamic syndromes
145
Motor pathway
pre frontal gyrus -> axons through internal capsule -> pons -> DECUSSATE in medulla -> corticospinal tracts -> anterior horn -> motor neurone
146
Central cord syndrome
posterior (dorsal) columns:
- ipsilateral
- loss of proprioception and vibration
corticospinal (pyramidal) tracts:
- motor
- ipsilateral
- loss of motor function
spinothalamic tracts:
- contralateral
- pain and temperatures
- ascending tracts carrying sensation
central cord syndrome:
- generally elderly
- hyperextension
- ligamentum flavum puckers/folds
- causes compression of spinal cord - central area
- fine motor and sensory loss upper limb > lower
147
anterior spinal artery syndrome
only posterior column function affected
148
hemisection of cord
brown sequard syndrome
ipsilateral dorsal and corticospinal loss below
contralateral spinothalamic loss below
149
Visual pathways
- all light from R visual fields cross to L hemisphere
- all light from L visual fields cross to R hemisphere
- nasal visual field nerve supply crosses at optic chiasm
- travel through lateral geniculate body through optic radiating to visual cortex
150
Visual pathway lesions
lesion at optic nerve = monocular blindness
lesion at optic chiasm = bitemporal hemianopia (loss of nasal retina), tunnel vision
lesion at optic radiation (MCA lesion) = homonymous hemianopia
151
oculomotor nerve CN III
medial rectus
inferior oblique
superior rectus
inferior rectus
lesion = down and out
ptosis
mydriasis (dilation)
152
trochlear nerve CN IV
superior oblique
palsy -> outwards and upwards
difficulty looking downwards
difficult going down stairs (vertical diplopia)
153
abducens nerve CN VI
lateral rectus
palsy -> esotropia
caused in raised ICP
154
trigeminal nerve CN V
emerges from pons -> trigeminal ganglion
155
Facial nerve CN VII
facial nerve nuclei in pons - each receives innervation from motor cortex on each side - UPPER part of face
bilateral motor innervation to upper face
leaves pons to internal acoustic meatus (with CN VIII)
runs through middle ear
chorda tympani leaves facial nerve in middle ear (taste sens), joins lingual nerve
through facial canal leaves through stylomastoid foramen to parotid gland, splits into 5 branches
156
Facial nerve lesions
CNS = contralateral weakness with forehead sparing
internal acoustic meatus - small space, accompanied by CN VIII - if swelling e.g. acoustic neuroma can cause palsy
middle ear - facial nerve and chorda tympani affected
stylomastoid foramen - facial nerve, bells palsy
parotid gland - tumour/abscesses
157
shoulder abduction nerve root
C5
158
elbow flexion nerve root
C5,6
159
elbow extension nerve root
C7
160
finger extension nerve root
C7
161
intrinsic muscles of hand nerve root
T1
162
hip flexion nerve root
L2
163
knee extension nerve root
L3
164
foot dorsiflexion nerve root
L4
165
great toe extension nerve root
L5
166
foot plantar flexion nerve root
S1
167
lower motor neurone lesion
wasting
fasciculation
low tone
absent reflexes
168
upper motor neurone
weakness
increased tone
brisk reflexes
169
Pain pathways
skin nocioceptors - prostaglandin release -> thick A gamma fibres to posterior horn (myelinated fast)
also C fibres - medium fibres
ascends via spinothalamic tracts
or transmits as reflex arc through to anterior horn to motor axon causing muscle withdrawal
170
ascending spino-thalamic tract
pain stimulus crosses to opposite side of spinal cord
ascends to thalamus
then to post central gyrus - where it hurts
frontal lobe and limbic system - how it hurts
171
endorphins
released in response to pain
peptides
act on miu receptors
production increased by exercise, emotional state
inhibit pain transmission
act centrally and peripherally
172
points of analgesic action
1. reduce nociceptive stimulation e.g. NSAIDs
2. block transmission of nociceptive nerve fibres e.g. local anaesthetics
3. stimulate antinociceptive pathways - modify pain transmission
4. central action to reduce emotional component of pain
MRCEM primary
flashcards
Decks in class (6)
# Cards
