Upload
others
View
21
Download
0
Embed Size (px)
Citation preview
Dr. Mavrych, MD, PhD, DSc [email protected]
100 must important GA conceptions
Dr. Mavrych, MD, PhD, DSc
Dr. Bolgova, MD, PhD
Understand first, then memorize and apply
Dr. Mavrych, MD, PhD, DSc [email protected]
l Dear students, you can use this presentation like a guide during your
preparing for GA exams.
l It does NOT cover all material of the Gross Anatomy course.
l To complete GA material you should work with ALL professor�s
presentations.
l Good Luck and All the best!
Dr. Mavrych
Dr. Mavrych, MD, PhD, DSc [email protected]
1. Lumbar puncture (tap) and
Epidural anesthesial When lumbar puncture is
performed, the needle enters the subarachnoidspace to extract cerebrospinal fluid (CSF) or to inject anesthetic to epidural space.
l The needle is usually inserted between L3/L4 or L4/L5. Level of horizontal line through upper points of iliac crests.
l Remember, the spinal cord may ends as low as L2 in adults and does end at L3 in children and dural sac extends caudally to level of S2.
Dr. Mavrych, MD, PhD, DSc [email protected]
Dr. Mavrych, MD, PhD, DSc [email protected]
l Patients typically have history of back pain that may radiate down to the lower limb.
l Herniation of disc usually occurs in lumbar (L4/L5 orL5/S1) or cervical regions (C5/C6 or C6/C7) of individuals younger than age 50.
l Herniated lumbar disc usually compreses the nerve root one number below: traversing root (e.g., the herniation L4/L5 will compress L5 root).
l The pain begins soon after patient lifted some heavy thing.
l Lower limb reflexes are decreased on the affected side
2. Herniated IV disc
Dr. Mavrych, MD, PhD, DSc [email protected]
3. Abnormal curvatures of the
spine
l Kyphosis is an exaggeration of
the thoracic curvature that may
occur in elderly persons as a result
of osteoporosis (multiply
compression fracture of vertebral
bodies) or disk degeneration.
l Lordosis is an exaggeration of the
lumbar curvature that may be
temporary and occurs as a result
of pregnancy, spondylolisthesis
or potbelly.
l Scoliosis is a complex lateral
deviation, or torsion, that is
caused by poliomyelitis, a leg-
length discrepancy, or hip disease.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
adults
kidseen L3/L4
L4/L5. kids
When lumbar puncture unctu is performed, the needle enters the subarachnoidspace to extract cerebrospinal fluid (CS(CSF) or to inject anesthetic to epidural space.
Spinal cord ends L2: Conus Medullaris
End Dura Sac S2: Cauda Equina w/ Filum terminale
8 cervical SN (above)
12 thoracic SN
5 lumbar SN
5 Sacral SNs
1 coccygeal SN
(below body)
12
34 5
6*5
7
dura matter 7subdural space 8Arachnoid matter 9
10*10*
434
12
Arachnoid matter 9subdural space 8spacdura mattersubd
Conus medullaris
Cauda Equina w/ FT
back pain that may radiate down to the lower limb.
curs in lums in lumbar () or cervical regions
compreses the nerve root one number below:
Anterior longitudinal ligament protects 9-3oclock around vertebral bodyPosterior longitudinal ligament protects 6oclock vertebral archherniations are typically posterior laterally (4-5 or 7-8oclock)
ALL
PLL
osteoporosis
Lordosis is ais an exaggeration of the
lumbar curvature th
Kyphosis is anKyphosis is an exaggeration of
the thoracic curvature ththe thoracic cu
temporary an
of pregnancy, spondylolisthesis
or potbelly.
Degenerative osteoarthritis:
Spondylosis: immobility or fusion of vertebral joints
Spondylolysis: degeneration of articulating part of vertebrae
Spondylolisthesis: forward displacement of vertebrae
Lamina= front smooth of arches
Pedicles= attachment of bodies to arches
Processes= protuberances and "attachments" (articular=restricts movement, spinous &
transverse muscle attachment & movement)
facets= attachments of other vertebrae or bones
Body=large part where attachment of intervertebral disc (gelatinous nucleus pulposus,
peripheral anulus fibrosus)
Scoliosis is a cis a complex lateral
deviation, or torsion, th
d by poliomyelitis, a leg-
length discrepancy, or hip disease.
Leg lengths:
short bone:
Coxa Vara
<100deg
Long bone:
Coxa Valga
>130deg
Dr. Mavrych, MD, PhD, DSc [email protected]
4. Upper limb fractures:
Humerus fractures
Sites of potential injury to major
nerves in fractures of the humerus:
1. Axillary nerve and posterior
humeral circumflex artery at the
surgical neck.
2. Radial nerve and profunda brachii
artery at midshaft. Midshaft
fracture affect origin of brachialis
muscle.
3. Brachial artery and median nerve
at the supracondylar region.
4. Ulnar nerve at the medial
epicondyle.
Dr. Mavrych, MD, PhD, DSc [email protected]
Fracture of distal radius:
l Transverse fracture within the distal 2 cm of
the radius. Most common fracture of the
forearm (after 50).
l Smith's fracture results from a fall or a blow
on the dorsal aspect of the flexed wrist
and produces a ventral angulation of the
wrist. The distal fragment of the radius is
ANTERIORLY displaced.
l Colles' fracture results from forced
extension of the hand, usually as a result of
trying to ease a fall by outstretching the
upper limb. Distal fragment is displaced
DORSALLY - �dinner fork deformity�.
Often the ulnar styloid process is avulced
(broken off)
Dr. Mavrych, MD, PhD, DSc [email protected]
Scaphoid fracture
l Occurs as a result of a fall onto the palm when the hand is abducted
l Pain occurs primarily on the lateral side of the wrist, especially during wrist extension and abduction
l Scaphoid fracture may not show on X-ray films for 2 to 3 weeks, but a deep tenderness will be present in the anatomical snuffbox.
l The proximal fragment may undergo avascular necrosisbecause the blood supply is interrupted.
Dr. Mavrych, MD, PhD, DSc [email protected]
Boxer�s fracture
l Necks of the metacarpal
bones are frequently
fractured during fistfights.
l Typically, fractures of 2d and
3d metacarpals are seen in
professional boxers, and
fractures of 5th and sometimes
4th metacarpals are seen in
unskilled fighters.
Dr. Mavrych, MD, PhD, DSc [email protected]
Mallet or Baseball Finger
l This deformity results from the DIP joint suddenly
being forced into extreme flexion (hyperflexion)
when, for example, a baseball is miscaught or a
finger is jammed into the base pad.
l These actions avulse the attachment of the
extensor digitorum tendon to the base of the
distal phalanx. As a result, the person cannot
extend the DIP joint. The resultant deformity bears
some resemblance to a mallet.
Dr. Mavrych, MD, PhD, DSc [email protected]
5. Rotator cuff muscles � SITS
l Support the shoulder joint by
forming a musculotendinous
rotator cuff around it
l Reinforces joint on all sides
except inferiorly, where
dislocation is most likely
Rotator cuff muscles are:
l Supraspinatus
l Infraspinatus
l Teres minor
l SubscapularisRight humerus
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Quadrangular Space: teres major, teresminor, long head biceps brachii, humerus
deep
Posterior between triceps brachii
cubital fossa
ulnar epicondylar grooveposteriorly and medial toolecranon
surgical neck.
midshaft. M
origin of brachialis Posterior
originoriginbetween
origin of bracorigin of bratriceps
f brachialis f brachialis brachii
ialis ialis
muscle.
origPosterior
origorigorigPosterior
origorig
supracondylar region.
medial
epicondyle.
ure of distal radius:
Smith's fracture
dorsal aspect of thof the flexed wrist
Colles' fracture from forced
extension of thof the hand, u
Scaphoid fracture
t of a fall onto the palm
Pain occurs primarily on the lateral side of thof the wrist,
deep tenderness will bwill be present in the anatomical snuffbox.
avascular necrosis
Extension & abduction of wrist
proximal carpal fracture
deep radial artery could be compromised
Necks of the metacarpal
bones
2dally, fractures of and
3d metacarpals are seen in
professional boxers, aners, and
5thfractures of and sometimes
4th metacarpals are seen in
unskilled fighters.
Brawler's Fracture
Boxer's Fracture
Mallet or Baseball Finger
the DIP joint su
ion (hyperflexion)
extensor digsor digitorum tendon tosor digitorum
Forced Flexion of DIP
Supraspinatus l
Infraspinatus l
Teres minor l
SubscapularislRight humerus
Initiate Abduction, Suprasacular n
Lat rotation, Suprascapcular n
Lat rotation, Axillary n
Med. rotation, Upper & Lower
Subscapular ns
Dr. Mavrych, MD, PhD, DSc [email protected]
6. Abduction of the upper limb
l (0°-15°) Abduction of the upper extremity is initiated by the supraspinatus muscle (suprascapularnerve).
l (15°-110º) Further abduction to the horizontal position is a function of the deltoid muscle (axillary nerve).
l (110°-180°) Raising the extremity above the horizontal position requires scapular rotation by action of the trapezius (accessory nerve CNXI) and serratus anterior (long thoracic nerve).
Dr. Mavrych, MD, PhD, DSc [email protected]
Subacromial bursitis &
Tearing of supraspinatus tendon
l Subacromial bursitis (inflammation of
the subacromial bursa) is often due to
calcific supraspinatus tendinitis,
causing a painful arc of abduction.
l The same symptoms will be in case of
inflammation or trauma of the
supraspinatus tendon (MRI !torn!
tendon)
Dr. Mavrych, MD, PhD, DSc [email protected]
7. Three Elbows: Student's elbow(Subcutaneous olecranon bursitis)
l The olecranon, to which the triceps tendon attaches distally, is easily palpated. It is separated from the skin by only the olecranon bursa,which allow the mobility of the overlying skin.
l Repeated excessive pressure and
friction may cause this bursa to
become inflamed, producing a
friction subcutaneous olecranon
bursitis.
Dr. Mavrych, MD, PhD, DSc [email protected]
Tennis elbow
(Lateral epicondylitis)
l Lateral epicondylitis: repeated forceful flexion and extension of the wrist resulting strain attachment of common extensor tendon andinflammation of periosteum of lateral epicondyle. Pain felt overlateral epicondyle and radiates down posterior aspect of forearm. Pain often felt when opening a door or lifting a glass
l Origins of following muscles may be affected:
1. Extensor Carpi Radialis Longus & Brevis
2. Extensor Digitorum
3. Extensor Digiti Minimi
4. Extensor Carpi Ulnaris
Dr. Mavrych, MD, PhD, DSc [email protected]
Golfer�s elbow
(Medial epicondylitis)
l Medial epicondylitis is
inflammation of the common
flexor tendon of the wrist
where it originates on the
medial epicondyle of the
humerus.
l Origins of following muscles may be affected:
1. Pronator Teres
2. Flexor Carpi Radialis
3. Palmaris Longus
4. Flexor Carpi Ulnaris
Dr. Mavrych, MD, PhD, DSc [email protected]
8. Arterial anastomoses
around the scapula
l Blockage of the Subclavian or Axillary artery can be bypassed by anastomoses between branches of the Thyrocervical and Subscapular arteries:
l Transverse cervical
l Suprascapular
l Subscapular
l Circumflex scapular
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
supraspinatus muscle ((suprascapularnerve).
(0°-15°)
(15°-110º)
deltoid muscle ((axillary nerve).
(110°-180°)
trapezius ((accessory nerve CNXI) and serratus anterior ((long thoracic nerve).
6. Abduction of the upper limbSubacromial bursitis &
Tearing of supraspinatus tendon
calcific supraspinatus tendinitis,
causing a painful arc of abduction.
inflammation or trauma of
Supraspinatus tendon is most commonly ruptured.
ws: Student's elbow(Subcutaneous olecranon bursitis)
The olecranon, to which the triceps tendon attaches d
olecranon bursa,
Repeated excessive pressure and
friction m this bursa to
become inflamed, p
Tennis elbow
(Lateral epicondylitis)
forceful flexion and extension of the wrist resulting strain attachment of common extensor tendon andinflammation of periosteum of lateral epicondyle. Pain felt overlateral epicondyle and radiates down posterior asrior aspect of forearm.
Extensor Carpi Radialis Longus & Brevis
Extensor Digitorum2.
Extensor Digiti Minimi3.
Extensor Carpi Ulnaris4.
1.1.
Golfer�s elbow
(Medial epicondylitis)
Medial epicondylitis is
inflammation of the common
flexor tendon
Pronator Teres
Flexor Carpi Radialis2.
Palmaris Longus3.
Flexor Carpi Ulnaris4.
1.
Extends and abducts
the hand
Extends and adducts
the hand
Extends fingers and wrist
Radial n
Pronates forearm
Flexes and abducts wrist
flexes wrist
flexes and adducts WristUlnar n
(Median n)
Blockage of the Subclavian or Axillary artery by anastomoses between branches of the Thyrocervical and Subscapular artearteries:
off subscapular
off thyrocervical trunk
Suprascapular a above the Transverse Superior
Scapular Ligament anastamoses with the
Circumflex Scapular a from the triangular space
(Teres major/minor and long head biceps brachii)
Dr. Mavrych, MD, PhD, DSc [email protected]
9. Cubital fossal Contents from lateral to medial:
1. Biceps brachii tendon
2. Brachial artery
3. Median nerve
l Subcutaneos structures from lateral to
medial:
1. Cephalic vein
2. Median cubital vein: joins cephalic and basilic veins
3. Basilic vein
l Sites of venipuncture is usually median cubital vein because:l Overlies bicipital aponeurosis, so deep
structures protected
l Not accompanied by nerves
Dr. Mavrych, MD, PhD, DSc [email protected]
10. Carpal Tunnel Syndrome
l Results from a lesion that reduces the size of the carpal tunnel (fluid retention, infection, dislocation of lunate bone)
l Median nerve � most sensitive structure in the carpal tunnel and is the most affected
l Clinical manifestations: l Pins and needles or anesthesia
of the lateral 3.5 digits
l palm sensation is not affected because superficial palmar cutaneous branch passes superficially to carpal tunnel
l Apehand deformity - absent of OPPOSITION
Dr. Mavrych, MD, PhD, DSc [email protected]
11. Test of the proximal and
distal interphalangeal joints
l PIP � FDS
l DID - FDP
Dr. Mavrych, MD, PhD, DSc [email protected]
12. Lesion of UL nerves
Upper Brachial Palsy
l Injury of upper roots and trunk
l Usually results from excessive increase in the angle between the neck and the shoulder stretching or tearing of the superior parts of the brachial plexus (C5 and C6 roots or superior trunk)
l May occur as birth injury from forceful pulling on infant's head during difficult delivery
Dr. Mavrych, MD, PhD, DSc [email protected]
Upper Brachial Palsy (Erb-Duchenne palsy)
· In all cases, paralysis of the muscles of the
shoulder and arm supplied by C5 and C6 spinal
nerves (roots) of the upper trunk.
· Combination lesions of axillary, suprascapular
and musculocutaneous nerves with loss of the
shoulder mm and anterior arm.
· As result patient has �waiter�s tip� hand:
· adducted shoulder
· medially rotated arm
· extended elbow
· loss of sensation in the lateral aspect of the
upper limb
Dr. Mavrych, MD, PhD, DSc [email protected]
Lower Brachial Palsy
(Klumpke paralysis)
l Injury of lower roots and
trunk
l May occur when the upper
limb is suddenly pulled
superiorly: stretching or
tearing of the inferior parts
of the brachial plexus (C8
and T1 roots or inferior
trunk)
l E.g., grabbing support
during falling from height
or as a birth injury, or
TOS � thoracic outlet
syndrome
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
9. Cubital fossa Anterior Elbow joint
MEDIALLATERAL
Biceps Brachii m (flex and supinate forearm)
O: Longhead supraglenoid tubercle, Shorthead
coracoid process)
I: to Radial Tuberosity
1. Biceps brachii tendon
2. Brachial artery
3. Median nerve
Cephalic vein1.
Median cubital vein: jo: joins cephalic 2.
and basilic veins
Basilic vein3.
s of venipuncture is median cubital vein
Venous blood is darker/purpleish and flows passively
Arterial blood is cherry red and has a pulse
10. Carpal Tunnel Syndrome
reduces the sithe size of the carpal tunnel (f
Median nerve �
Cubital Tunnel Syndrome: Compression of ulnar epicondylar groove via tendon of Flexor
Carpi Ulnaris, Ulnar n is compressed: Claw hand and weakened adduction of wrist
Recurrent Median n to Thenar ms are affected
Clinical manifestations: Pins and needles or anesthesia l
of the lateral 3.5 digits
palm sensation is not affected l
because superficial palmar cutaneous branch passes superficially to carpal tunnel
Apehand deformity - absent l
of OPPOSITION
ULNAR TUNNEL SYNDROME: Compression at the wrist between pisiform and hook of hamate
carpal bones causes hypoesthesia of medial 1.5 fingers and weakened instrinsic ms (Partial Claw
hand bc flexors of forearm are unaffected)
Proximal Interphalangeal joint
Flexor Digitorum Superficialis
Median n
Distal Interphalangeal Joint
DIPS- Flexor Digitorum Profundus
Ulnar and Median ns
DIP
stal interphalangeal joints
MCPs- Lumbricals
Metacarpal phalangeal joint
Injury of upper roots and trunk
increase in the angle between theen the neck and the shoulder str
xus (C5 and C6 roots ooots or superior trunk)
Birth injury or Fall causes
Superior Trunk Damage:
Erb's Palsy
(Erb-Duchenne palsy)
C5 and C6 spinal
nerves (roots) of the upper trunk.
�waiter�s tip�
adducted shoulder·
medially rotated arm·
extended elbow· Wrist flexed
Axillary C5-C6
Musculocutaenous C5-7
Median C6-T1
Inferior Trunk damage C8-T1
xus (C8
and T1 roots or inferior
trunk)
the upper
limb is suddenly pulled
superiorly: str
grabbing support
during falling from height
or as a birth injury, or
TOS � thoracic ouacic outlet
syndrome
Full hand paralysis (open extended hand), ulnar and
median n damage, thumb is extended bc radial n still good
Dr. Mavrych, MD, PhD, DSc [email protected]
Lower Brachial Palsy
(Klumpke paralysis)
l All intrinsic muscles of the handsupplied by the C8 and T1 roots of the lower trunk affected.
l Combination lesions of ulnarnerve (�claw hand�) and mediannerve (�ape hand�)
l Loss of sensation in the medial aspect of the upper limb and medial 1,5 fingers.
l May include a Horner syndrome
Dr. Mavrych, MD, PhD, DSc [email protected]
Injury to musculocutaneous
nerve
l Usually results from lesions of lateral cord
l Greatly weakens flexion of elbow (biceps and brachialis muscles) and supination of forearm (biceps muscle)
l May be accompanied by anesthesia over lateralaspect of forearm
Dr. Mavrych, MD, PhD, DSc [email protected]
Cutaneous innervation
of the hand
Dorsum: 1,5-U and 3,5 R Palm: 1,5-U and 3,5 M
In reality, in case of superficial branch of
radial nerve lesion it will be skin deficit
between 1 & 2 digits on the dorsum of the
hand ONLY because of nerve overlapping
Dr. Mavrych, MD, PhD, DSc [email protected]
13. Cardiac catheterization
l The femoral artery is used for cardiac catheterization
l It can be cannulated for left cardiac angiography & also for visualizing the coronary arteries � a long, slender catheter is inserted percutaneously and passed up the external iliac artery, common iliac artery, aorta, to the left ventricle of the heart
Dr. Mavrych, MD, PhD, DSc [email protected]
14. Injury of the gluteal region
Fractures of Femoral Neck
l A common fracture in elderly women with osteoporosis is fracture ofthe femoral neck.
l Fractures of the femoral neck cause shortness and lateral rotation of the lower limb.
l Fractures of the femoral neck often disrupt the blood supply to the head of the femur.
l At present time the best way in case of femoral neck fracture is hip replacement.
Dr. Mavrych, MD, PhD, DSc [email protected]
Avascular necrosis
of femoral head
l Transcervical fracture disrupts blood supply to the head of the femur via retinacular arteries (from medial circumflex femoral artery) and may cause avascular necrosis of the femoral head if blood supply through the ligament to the head is inadequate.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Ulnar and Median Nerve Lesions
s of ulnarnerve (�claw hand�) a and mediannerve (�ape hand�)
Median n lesion: Ape hand/benediction with lateral 3 digits are extended, wrist is extended
Ulnar n lesion: Claw hand with medial 2 digits extended
Radial n lesion: Drop Wrist with flexion of the wrist
Injury to musculocutaneous
nerve
flexion(bi(biceps and brachialis
muscles) and supination of forearm (bi(biceps muscle)
Greatly we of atly weakens flexion of (bielbow (bi(bi(biceps a(bi(biceps a
of lateral cord
Lateral musculocutaneous n of forearm
weakened adduction (coracobrachialis m)
superficial branch of
radial nerve leerve lesion it will be skin deficit
between 1 & 2 digits on the dorsum of the
hand O
Cutaneous innervation
of the hand
femoral artery is used for cardiac catheterization
for left cardiac angiography & also for visualizing the coronary arteries �
A catheter can also be passed through a peripheral vein (femoral vein) into IVC, the
R atrium, R ventricle, pulm trunk and pulm arteries. Intracardiac pressures, blood
samples, and visualization of great vessels using Xray
13. Cardiac catheterization
(femoral vein)
the gluteal region
Fractures of Femoral Neck
use shortness and lateral rotation
Coxa Vara <100deg
Fractures of neck and head of femur will disrupt the cruciate anastamosis that includes the medial circumflex
femoral a & ascending and transverse lateral circumflex femoral aa with Retinacular branches that anastamose
with the acetabular branch of obturator a within Ligamentum Teres
Dr. Mavrych, MD, PhD, DSc [email protected]
Injury to sciatic nerve
l Weakened hip extension and knee flexion
l Footdrop (lack of dorsiflexion)
l Flail foot (lack of both dorsiflexion and plantar flexion)
l Cause of injury:caused by improperly placed gluteal injections but may result from posterior hip dislocation
Dr. Mavrych, MD, PhD, DSc [email protected]
Posterior hip dislocations
l They are most common. A head-on
collision that causes the knee to
strike the dashboard may dislocate
the hip when the femoral head is
forced out of the acetabulum.
l The joint capsule ruptures inferiorly
and posteriorly (fracture of ishium),
allowing the femoral head to pass
through the tear in the capsule
(tearing of ishiofemoral lig.) and
over the posterior margin of the
acetabulum onto the lateral surface
of the ilium, shortening and
medial rotating the limb.
Dr. Mavrych, MD, PhD, DSc [email protected]
Superior gluteal
nerve injuryl The superior gluteal nerve
may be injured during surgery, posterior dislocation of the hip or poliomyelitis.
l Paralysis of the gluteus medius and gluteus minimusmuscles occurs so that the ability to pull the pelvis up and abduction of the thigh are lost.
Trendelenburg sign:
l If the superior gluteal nerve on the right side is injured, the left pelvis falls downward when the patient raises the left foot off the ground.
l Note that side is contralateral to the nerve injury.
Right
superior
gluteal nerve
injury
Normal
Dr. Mavrych, MD, PhD, DSc [email protected]
Injury to inferior gluteal nerve
l Weakened hip extension(gluteus maximus), most noticeable when climbing stairs or standing from a seated position
l Cause of injury: posterior hip dislocation, surgery in this region
Dr. Mavrych, MD, PhD, DSc [email protected]
Injury of obturator
nerve
l Difficulty adducting thigh
(e.g., crossing legs while
sitting)
l Decreased sensation
over upper medial thigh
l Cause of injury: anterior
hip dislocation, radical
retropubic prostatectomia
Dr. Mavrych, MD, PhD, DSc [email protected]
l Avulsion fractures occur where muscles are attached - ischial tuberosities
Hamstrings muscles:
1. Biceps femoris
2. Semitendinosus
3. Semimembranosus
l Action: extension of hip joint and flexion of knee joint
l Nerve supply � Tibial nerve (short head of biceps femoris is supplied by the common fibularnerve)
15. Avulsion fractures
of the hip bone and
hamstrings muscles
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Injury to sciatic nerve
Cause of injury:
& Piriformis syndrome: Trucker's
who sit all day piriformis m
compress n, numbness and tingling
to the affected side.
Gluteal injections should be done with palm over
greater trochanter, pinky on ASIS and middle finger on
mid axillary line, thumb point posteriorly, the V between
middle and ring finger is site of injection.
Posterior hip dislocations
n. A head-on
collision th the knee to
strike the dashboard may dislocate
the hip when the femoral head is
forced out of the acetabulum.
congenital dislocations are more common in females > males
The joint capsule ruptures inferiorly
and posteriorly (f
Posterior dislocations can damage the sciatic n.
(tearing of ishiofemoral lig.)
shortening and
medial rotatinganterior
pubofemoral lig
may also tear
bc it is weakest
Trendelenburg sign:
superior gluteal nerve on
Paralysis of thof the gluteus medius and gand gluteus minimus
Superior gluteal
nerve injurypossibly also due to Piriformis syndrome
Patient stands and raises
L leg, if the L leg drops, it
is standing right leg nerve
injury
Injury to inferior gluteal nerve
hip extension(gluteus maximus),
Inferior gluteal n passes through inferior
piriformis fossa with the sciatic n,
posterior femorial cutaneous n, Superior
gluteal a & v, pudendal n, and internal
pudendal a & v
passes through superior piriformis fossa w/ inferior gluteal a & v
Injury of obturator
nerve
ulty adducting thigh
Decreased sensation
over upper medial thigh
Difficulty adducting thulty adducting th
anterior
hip dislocation, ra
passes through obturator
canal that is covered by
obturator membrane in
obturator foramenAffects Obturator externus, Adductor longus,
brevis, magnus (paritally), pectineus, gracilis
lateral rotation weakness and poor adduction
15. Avulsion fractures
of the hip bone and
hamstrings muscles
tearing off
Hamstrings muscles:
ed - ischial tuberosities
(long head)
Pseudohamstrings: Adductor Magnus (obturator & tibal ns), Biceps femoris ms (tibial &
common peroneal ns)
extension of hiof hip joint and flexion of knee joint
Tibial nerve (sh
Waddleing Gait (lateral leg swing/drag)
Dr. Mavrych, MD, PhD, DSc [email protected]
16. Structures under inguinal
ligament:
l From lateral to medial side:
l Iliopsoas muscle
l Femoral nerve
l Femoral artery
l Femoral vein
l Femoral canal
Dr. Mavrych, MD, PhD, DSc [email protected]
Femoral hernia
l A femoral hernia passes below
inguinal ligament through the femoral
ring into the femoral canal to form a
swelling in the upper thigh inferior and
lateral to the pubic tubercle
l The hernial sac may protrude through
the saphenous hiatus into the
superficial fascia
l A femoral hernia occurs more
frequently in females and is dangerous
because the hernial sac may become
strangulated
l An aberrant obturator artery is
vulnerable during surgical repair
Inguinal lig.
Dr. Mavrych, MD, PhD, DSc [email protected]
17. Knee joint injuries:
Unhappy triad
l Because the lateral side of the knee is struck more often (e.g., in a football tackle), the tibial collateral ligament is the most frequently torn ligament at the knee.
l The unhappy triad of athletic knee injuries involves:
1. Tibial collateral ligament
2. Medial meniscus
3. Anterior cruciate ligament
Dr. Mavrych, MD, PhD, DSc [email protected]
Tibial collateral ligament
(medial collateral ligament)
l Broad flat band
extending from medial
epicondyle of femur to
medial condyle and
shaft of tibia
l Blends with capsule and
firmly attaches to
medial meniscus
l Limits extension and
abduction of leg at
knee
Dr. Mavrych, MD, PhD, DSc [email protected]
Fibular collateral ligament
(lateral collateral ligament)
l Rounded cord between
lateral epicondyle of femur
and head of fibula
l Does NOT blend with joint
capsule and does NOT
attach to lateral meniscus
l Limits extension and
adduction of leg at knee
Dr. Mavrych, MD, PhD, DSc [email protected]
Rupture of the
cruciate ligaments
l With rupture of the anterior cruciate ligament, the tibia can be pulled forward excessively on the femur, exhibiting anterior drawer sign.
l In the less common rupture of the posterior cruciate ligament, the tibia can be pushed backward excessively on the femur, exhibiting posterior drawer sign.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Femoral Triangle: Superior inguinal ligament, Medially adductor longus m,
laterally sartorius m, it lies on top of pectinius m and iliopsoas ms
Inguinal lig serves as flexor retinaculum. Psoas m and Femoral n pass from pelvis
to anterior thigh, External iliac becomes femoral vessels
The inguinal canal runs perpendicular to the femoral canal
Deep inguinal lymph nodes
& great saphenous v br
w/ circumflexes &perforating br
Sartorius m
Adductor magnus m
FAFV
FN A femoral hernia passes below
inguinal ligament through thugh the femoral
ring into thinto the femoral canal to form a
swelling in the upper thigh inferior and
lateral to the pubic tubercle
in females
An aberrant obturator artery
Laceration of the Femoral a can be compensated by the perforating branch of femoral aand the lateral superior genicular a that anastamoses with the descending lateralfemoral circumflex a.Femoral v ligation can be compensated via the great saphenous v
17. Knee joint injuries:
Unhappy triad
Tibial collateral ligament
Medial meniscus2.
Anterior cruciate ligament3.
Tibial co1.
MCL, MM, ACL tears
the lateral side of the knee is struck more often
tibial collateral ligament is the most frequently torn ligament at the knee.
Tibial collateral ligament
(medial collateral ligament)
medial
epicondyle of femur to
medial condyle and
shaft of tibia
Limits extension and
abduction of leg at
knee
Fibular collateral ligament
(lateral collateral ligament)
lateral epicondyle of femur
and head of fibula
Does NOT blend with joint
capsule and does NOT
attach to lateral meniscus
Limits extension ansion and
adduction of leg at knat knee
mly attaches to
medial meniscus
Rupture of the
cruciate ligaments
anterior drawer sign.
the anterior cruciate ligament,
posterior cruciate ligament,
posterior drawer sign.
drawer sign is movement of the leg inopposition of the femur 5mm
Loop of bowel gets pulled downward into femoral canal, aberrant obturator a offexternal iliac would cross bowel and becomes vulnerable
Dr. Mavrych, MD, PhD, DSc [email protected]
Prepatellar bursa
Suprapatellar bursa
l Prepatellar bursa: between
superficial surface of patella
and skin. May become
inflamed and swollen
(prepatellar bursitis).
l Suprapatellar bursa: superior
extension of synovial cavity
between distal end of femur
and quadriceps muscle and
tendon. Usual place for intra-
articular injections. May
become inflamed and swollen
(suprapatellar bursitis).
Dr. Mavrych, MD, PhD, DSc [email protected]
Knee jerk reflex
l The patellar reflex is tested by tapping the patellar ligament with a reflex hammer to elicit extension at the knee joint. Both afferent and efferent limbs of the reflex arch arein the femoral nerve (L2-L4).
l Knee jerk reflex:tests spinal nerves L2-L4.
Dr. Mavrych, MD, PhD, DSc [email protected]
18. Ankle joint injuries:
Ankle sprains
l Sprains are the most common ankle injuries
l A sprained ankle is nearly always an inversion injury, involving twisting of the weight-bearing plantarflexed foot.
l The lateral ligament (anterior talofibular ligament) is injured because it is much weaker than the medial ligament.
l In severe sprains, the lateral malleolus of the fibula may be fractured.
Dr. Mavrych, MD, PhD, DSc [email protected]
Pott�s fracture
l It is fracture-dislocations of the ankle joint
l Reason - forced eversion(abduction) of the foot
l The Deltoid ligament avulses the medial malleolus and after that fibula fractures at a higher level
Pott's fracture
Dr. Mavrych, MD, PhD, DSc [email protected]
Ankle jerk reflex
l Achilles tendon reflex is
tested by tapping the
calcaneal tendon to elicit
plantar flexion at the ankle
joint.
l Both afferent and efferent
limbs of the reflex arc are
carried in the tibial nerve
(S1, S2).
l Ankle jerk reflex: tests
spinal nerves S1-S2.
Dr. Mavrych, MD, PhD, DSc [email protected]
19. Injures of the leg and foot:
Fracture of the fibular neckl May cause an injury to the common
peroneal nerve, which winds laterally around the neck of the fibula.
l This injury results in paralysis of all muscles in the anterior and lateralcompartments of the leg(dorsiflexors and evertors of the foot) and loosing sensation on the dorsum of the foot.
l Causing foot drop.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Prepatellar bursa
Suprapatellar bursa
Prepatellar bursa:
e of patella
Suprapatellar bursa: superior
extension of synovial cavity
between distal end of femur
and quadriceps muscle anscle and
tendon. e for intra-
articular injections.
Posterior to Rectus femoris mand vastis intermedialis m
articularisgenu m
Knee jerk reflex
femoral nerve (L2-L4).
Rectus femoris m
Ankle sprains
inversion injury,
Sprains are thare the most common ankle injuries
The lateral ligament (anterior talofibular ligament) is inis injured
In severe sprains, the lateral of thmalleolus of thof the fibula may be
fractured.
Pott�s fracture
eversion(abduction) of the foot
Deltoid ligament avulses the medial malleolus and aand after that fibula fractures at aat a higher level
Eversion injury is Deltoid ligament at medial malleolus
Ankle jerk reflexCalcaneous Tendon Reflex
plantar flexion at th
tibial nerve
(S1, S2).
Fracture of the fibular neckcommon
peroneal neral nerve, w
paralysis of alof all muscles in the anterior and lateralcompartments of thof the leg(dorsiflexors and evertors of the foot) and loosing sensation on the dorsum of the foot.
Causing foot drop.l
Flexors take over (Plantar flexion)
Dr. Mavrych, MD, PhD, DSc [email protected]
Rupture of the Achilles tendon
and Triceps surae muscle
l Avulsion or rupture of the calcaneal
(Achilles) tendon disables the triceps
sure muscle (gastrocnemius & soleus)
so that the patient cannot plantar flex
the foot.
Triceps surae muscle:
l 2 Heads of Gastrocnemius m.
l 1 Head - Soleus muscle
l Plantaris
l small fusiform belly with long thin tendon;
l sometimes may become hypertrophy
Dr. Mavrych, MD, PhD, DSc [email protected]
Plantar Fasciitis (calcaneal spur)
l Plantar fasciitis is the
most common hindfoot
problem in runners. It
causes pain on the
plantar surface of the
foot and heel.
l Point tenderness is
located at the proximal
attachment of the plantar
aponeurosis to the
medial tubercle of the
calcaneus and on the
medial surface of this
bone.
Dr. Mavrych, MD, PhD, DSc [email protected]
20. Injury of tibial nerve
l In popliteal fossa: loss of plantar flexion of foot (mainly gastrocnernius and soleusmuscles) and weakenedinversion (tibialis posterior muscle), causing calcaneovalgus.
l Inability to stand on toes
l Loss of sensation and paralysis of intrinsic muscles of the sole of the foot
l Popliteal fossa from superficial to
deep, contains:
l Tibial nerve
l Popliteal vein
l Popliteal artery
Dr. Mavrych, MD, PhD, DSc [email protected]
On soil of the foot there are two terminal
branches of tibial n:
l Medial plantar nerve supplies:
1. Abductor hallucis,
2. Flexor hallucis brevis
3. Flexor digitorum brevis
4. 1st lumbrical muscles
l skin of medial 3.5 digits
l Lateral plantar nerve supplies:
l All intrinsic plantar muscles which
are not innervated by medial plantar
nerve
l skin of lateral 1.5 digits
Dr. Mavrych, MD, PhD, DSc [email protected]
21. Breast:
Carcinoma of the Breast
l Carcinomas of the breast are malignant tumors, usually adenocarcinomas arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules
l 1. It enlarges, attaches to suspensory(Cooper�s) ligaments, and produces shortening of the ligaments, causing depression or dimplingof the overlying skin.
Dr. Mavrych, MD, PhD, DSc [email protected]
Lymphatic drainage
of the breast
l It is important because of its role in the metastasis of cancer cells.
l Most lymph (> 75%), especially from the lateral breast quadrants, drains to the axillary lymphnodes, initially to the anterior (pectoral) nodes for the most part.
l Most of the remaining lymph, particularly from the medial breast quadrants, drains to the parasternal lymph nodes or to the opposite breast.
75% 25%
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Rupture of the Achilles tendon
and Triceps surae muscle
cle (gastrocnemius & soleus)
tient cannot plantar flex
Triceps surae muscle:
2 Heads of Gastrocnemius m.l
1 Head - Soleus musclel
Plantaris l
Plantar Fasciitis (c
pain on the
plantar surface
t the proximal
attachment of the plantar
aponeurosis
Injury of tibial nerve
In popliteal fossa:
calcaneovalgus.
Inability to stand on toesInabilitInabilit
sole of the foot
Femoral vessels after passing through adductor haitus/Hunter's canal, Sartorius canal, to become popliteal vessels
Popliteal Fossa is bordered by Semitendinosus, Semimembranosus, Bicepsfemoris, and quadracepts (gastronemius, plantaris, and soleus ms)
Common Fibular/Common Peroneal n does not pass in poplitealfossa, instead it goes around neck of fibula
Medial plantar nerve
Lateral plantar nerve
SOLE OF FOOT TIBAL n BRANCHES
Adductor hallucis (oblique & transverseheads), Quadratus Plantae, Flexor Digitiminimi, abductor digiti minimi, DABs,PADs, lateral 3 lumbricals
21. Breast:
Carcinoma o
t are malignant tumors, usually adenocarcinomas arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules
1. It enlarges, attaches to suspensory(Cooper�s) ligaments, and produces shortening of the ligaments, cants, causing
plingdepression or dimplingof the overlying skin.
Suspensory/Cooper's lig sround the lobules of mammary glands.
Lymphatic drainage
of the breast
metastasis of cancer cells.
Most lymph (> 75%), especially from the lateral breast quadrants, drains to the axillary lymphnodes,
the remaining lymph, particularly from the medial breast quadrants, drains to the parasternal lymph nodes or to the opposite breast.
Lymph from breast->Interpectoral "Rotter's" lymph nodes -> axillary lymph nodes->clavicular nodes-> R lymphatic duct or L Thoracic duct -> subclavian vs ->brachiocephalic vs -> SVC-> heartRotter's nodes are a way breast cancer can metastasize by bypassing axillary nodes
$$Million dollar space: Retromammary space behind Pect Major or betweenfat pad and Pect Major for insertion of breast implants
Dr. Mavrych, MD, PhD, DSc [email protected]
Mastectomy
l Radical mastectomy, a more extensive surgical procedure, involves removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region.
1. During a radical mastectomy, the long thoracic
nerve may be lesioned during ligation of the lateral
thoracic artery. A few weeks after surgery, the
female may present with a winged scapula and
weakness in abduction of the arm above 90°
because serratus anterior m. paralysis.
2. The intercostobrachial nerve may also be
damaged during mastectomy, resulting in skin
deficit of the medial arm.
Dr. Mavrych, MD, PhD, DSc [email protected]
Breast infection
l Mastitis is an infection of the tissue
of the breast that occurs most
frequently during the time of
breastfeeding (1 to 3months after the
delivery of a baby).
l This infection causes pain, swelling,
redness, and increased temperature
of the breast.
l It can occur when bacteria, often from
the baby's mouth, enter a milk duct
through a crack in the nipple.
l It can occur in women who have not
recently delivered as well as in women
after menopause.
Dr. Mavrych, MD, PhD, DSc [email protected]
22. Thoracic wall & Diaphragm:
Intercostal spaces
Intercostal blood vessels and nerves:
l run between the internal intercostal and innermost intercostal muscles in the costal groove
l arranged from superior to inferior as vein, artery, nerve
l Most vulnerablestructures � intercostal nerve and posterior intercostal artery because they are not covering by ribs.
Dr. Mavrych, MD, PhD, DSc [email protected]
Diaphragm:
Paralysis of half and ruptures
l Paralysis of the half of the Diaphragm may result from injury or operative division of the phrenic nerve of same side
l It can be detected radiologically.
l Paradoxical movement: dome of diaphragm of injured side pushed superiorly by abdominal viscera during inspiration instead of descending
Dr. Mavrych, MD, PhD, DSc [email protected]
Phrenic nerve
l Arises from the anterior branches C3-C5 nerves and lies in front of the anterior scalene muscle.
l Runs anterior to the root of the lung, whereas the vagus nerve runs posterior to the root of the lung.
l Innervates the fibrous pericardium, the mediastinal and diaphragmatic pleurae(sensory innervation), and the diaphragm for motorand its central tendon for sensory.
Dr. Mavrych, MD, PhD, DSc [email protected]
Diaphragmatic ruptures
l Diaphragmatic injuries are
relatively rare and result from
either blunt trauma or
penetrating trauma.
l Presently, 80-90% of blunt
diaphragmatic ruptures result
from motor vehicle crashes.
l The majority (80-90%) of blunt
diaphragmatic ruptures have
occurred on the left side.
l Blunt trauma typically produces
large radial tears measuring 5-15
cm, most often at the
posterolateral aspect of the
diaphragm.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Mastectomy
lves removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region.
winged scapula and
weakness in abduction of the arm above 90°
because serratus anterior m. paralysis.
, the long thoracic
nerve may bemay be lesioned d
intercostobrachial nerve may amay also be
damaged during mastectomy, resulting in skin
deficit of the medial arm. T2 intercostal n branch givessensation to skin of axilla andmedial cutaneous arm
Mastitis is anis an infection of the tissue
of the breast th
breastfeeding
This infection causes pain, swelling,
redness, and increased temperature
of the breast.
hen bacteria, often from
the baby's mouth, enter a milk duct
Intercostal spaces
run between the internal intercostal and innermost intercostal muscles in the costal groove
rom superior to inferior as vein, artery, nerve
Skin->Fascia->Fat->External Intercostal m \\ //->Internal Intercostals // \\-> Intercostal VAN-->Innermost Intercostals == -> Fascia -> Parietal Pleura-->
Thoracocentesis: Ribs 9-10 (9th intercostal space), above rib avoid VAN, remove fluid inpleural cavityPericardiocenetesis: Left 5-6th intercostal space near sternum, Infrasternal (xiphoid) angle upto left shoulder for Cardiac Tamponade due to Pleural effusion
Diaphragm:
Paralysis of the half of the Diaphragm
the phrenic nerve
Paradoxical movement:
of injured side pushed superiorly by abdominal viscera during inspiration instead of descending
dome of diaphragm of in of injured side pushed superiorly
C3, 4, 5 keeps the Diaphragm alive!
Phrenic nerve
rom the anterior branches C3-C5 nerves and lies in front of the anterior scalene muscle.
Runs anterior to the root of the lung, w, whereas the vagus nerve runs posterior to the root of the lung.
Innervates the fibrous pericardium, the mediastinal and diaphragmatic pleurae(sensory innervation), and the diaphragm for motorand its central tendon for sensory.
I ate 10 eggs at noon! Vessels entering the diaphragmInferior vena cava T8Esophagus T10Aorta T12
Diaphragmatic ruptures
blunt trauma or
penetrating trauma.
motor vehicle cracrashes.
left sidleft side.
posterolateral aspect of thof the
diaphragm.
Bochdalek Hernia: common hernia on the posterolateral L side of diaphragm,fatal congenital hernia that causes pulmonary hypoplasia.Morgangi Hernia: rare hernia on anteromedial R side of diaphragm, not fatal bcmusculature typically creates spincterSliding hernia: Stomach slides up through diaphragm bc of short esophagusRolling/paraesophageal hernia stomach slides up next to esophagus
Flail Chest: One or more broken ribs in two separate placesupon inspiration the broken area will sink in as chest wall moves outupon expiration the broken area will push out as chest wall moves inDangerous bc lungs can be punctured
Dr. Mavrych, MD, PhD, DSc [email protected]
23. Cardiac hypertrophy
l Left atrial enlargement
(hypertrophy) secondary to
mitral valve failure may
compress on the
esophagus and manifest
as dysphagia (difficulty in
swallowing).
l It may be observed as a
filling defect in the
esophagus by barium
swallow on the lateral
thoracic X-Ray
Dr. Mavrych, MD, PhD, DSc [email protected]
Cardiac Shadow
Right border is formed by:
1. SVC,
2. Right atrium
Left border is formed by:
1. Aortic arch
2. Pulmonary trunk
3. Left auricle
4. Left ventricle
P-A projection
Dr. Mavrych, MD, PhD, DSc [email protected]
24. Auscultation of Heart
Valves
Right 2 ICS
PSL
Left 5 ICS
MCL
Left 4 ICS
PSL
Left 2 ICS
PSL
Dr. Mavrych, MD, PhD, DSc [email protected]
Auscultation sites for
mitral and aortic murmurs
A heart murmur is heard downstream from the valve:
l stenosis is orthograde direction from valve
l insufficiency is retrograde direction from valve
Dr. Mavrych, MD, PhD, DSc [email protected]
25. Conducting System
of the Heartl Sinoatrial (SA) node
l site where contraction of heart muscle is initiated (pacemaker of the heart)
l situated in the upper part of the sulcus terminalis just near to the opening of the SVC
l Atrioventricular (AV) node
l the AV node receives impulses from the SA node; situated in the lower part of the atrial septum near coronary sinus
l Atrioventricular bundle of His
l descends from the AV node to the membranous portion of the ventricular septum where it divides into the left and right bundle branches
l Right bundle branch � passes down to reach the moderator band - right ventricle
l left bundle branch � passes down left side of ventricular septum
Dr. Mavrych, MD, PhD, DSc [email protected]
26. Blood supply of the Heart:
Right coronary artery (RCA)
l It supplies major parts of the rightatrium and the right ventricle.
l It anastomoses with the marginal branch of the left coronary artery posteriorly
Branches:
1. Anterior cardiac branches �supplies the right atrium
2. Nodal branch � supplies the (1) SAnode, (2) AV node
3. Marginal artery � supplies the right ventricle
4. Posterior interventricular artery �supplies (1) diafragmatic (inferior) surface of both ventricles and (2) posterior 1/3 of the IV septum
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
23. Cardiac hypertrophy
Left atrial enlargement
(hypertrophy) secondary to
mitral valve failure may
compress on thon the
esophagus and mand manifest
as dysphagia (d
mitral valve failure/tenting keepscauses mitral regurgitation into Latrium during systole, pressuredilates the LA as well asdecreases BP causing heart towork harder to pump blood toaorta resulting in hypertrophy
Right border is fois formed by:
1. SVC,
2. Right atrium
Left border is fois formed by:
1. Aortic arch
2. Pulmonary trunk
3. Left auricle
4. Left ventricle
VALVE ANAT. LOCATION AUSCULTATION SITE• P 3rd CC 2nd LT ICS• A 3rd ICS 2nd RT ICS• M 4th CC cardiac apex (5th Lt ICS MCL)• T 4th ICS Rt inferior most ST (5th RT ICS)• (3344) (2255)
24. Auscultation of Heart
ValvesAuscultation sites for
mitral and aortic murmurs
regurgitation
Stenosis RegurgiationAortic Systole (HOOT Dub) Aortic Diastole (Lub hoot)Pulm Systole (HOOT Dub) Pulm Diastole (Lub hoot)Tricuspid Diastole (Lub hoot) Tricuspid Systole (hoot Dub)Mitral Diastole (Lub hoot) Mitral Systole (hoot Dub)
25. Conducting System
of the HeartSinoatrial (SA) node
the upper part of the sulcus terminalis ju
Atrioventricular (AV) node
Triangle of Koch: Location of AV node in R AtriaValve of coronary sinus (Thebesian) & IVC (Valve of Eustice) meetto form tendon of todaro, which joins the Septal leaflet of Tricuspid valve
Crista Terminalis separatespectinate muscles w/ sinusvenarum
Atrioventricular bundle of His
descends from the AV node to the l
membranous portion of the ventricular septum where it divides into the left and right bundle branches
Right bundle branch � pa� passes down to moderator band - right reach the
ventricle
left bundle bl dle branch � padle b � passes down left side of ventricular septum
Septomarginal trabeculae
Purkinje Fibers throughout walls of ventriclesstimulate contractile cells
26. Blood supply of the Heart:
Right coronary artery (RCA)
Anterior cardiac branches �supplies the right atrium
Nodal branch � su� supplies the (1) SAnode, (2) AV node
Marginal artery � su� supplies the right ventricle
Posterior interventricular artery �supplies (1) diafragmatic (inferior) surface of both ventricles and (2and (2) posterior 1/3 of the IV septum
Small cardiac vein
Middle cardiac vein
Dr. Mavrych, MD, PhD, DSc [email protected]
Left coronary artery
(LCA)
Branches:
1. Anterior (descending)
interventricular artery � most
common place of MI descends in the
anterior interventricular sulcus and
provides branches to the (1) anterior
heard wall, (2) anterior 2/3 of IV
septum, (3) bundle of His, and (4)
apex of the heart.
2. Circumflex artery � winds around the
left margin of the heart in the
atrioventricular groove to anastomose
with the right coronary artery
posteriorly; supplies the left atrium
and left ventricle
Dr. Mavrych, MD, PhD, DSc [email protected]
Blood supply of the conducting
system
l SA node � RCA
l AV node � RCA
l AV bundle (and moderator band)- LCA
Dr. Mavrych, MD, PhD, DSc [email protected]
27. Congenital cardiac defects:
Atrial Septal Defect (ASD)l It is less frequent than
VSD
l It results from failure to close of the foramen ovale after birth (failure of the septum primum and septum secundum to fuse)
l Postnatally, ASDs result in left-to-right shunting(between right and left atrium) and are non-cyanotic conditions.
l If it is small, has no clinical significance & if large - necessary surgical repair
Dr. Mavrych, MD, PhD, DSc [email protected]
Ventricular Septal
Defect (VSD)
l Ventricular septal defect (VSD) is the most common of the congenital heart defects
l It may be found in the membranous part of the ventricular septum and results from failure to fuse of the membranous portion with the muscular portion of the ventricular septum
l In this case, present left�to-right shunt (right ventricular hypertrophy (RVH)) and again non-cyanotic.
l Necessary surgery for large defects
Dr. Mavrych, MD, PhD, DSc [email protected]
Patent Ductus Arteriosus (PDA)
l It results from failure of the ductus arteriosus (a connection between the pulmonary trunk and aorta) to constrict and close after birth.
l Prostaglandin E and low O2 tension sustain patency of the ductus arteriosus in the fetal period.
l PDA is common in premature infants and in cases of maternal rubella infection.
l Left �to-right shunt increased pressure in pulmonary circulation (pulmonary hypertension) and is non-cyanotic
l Treatment: surgical division and ligationimperative. In great danger is left recurrent nerve (wrapping aorta arch). Injure of this nerve results in hoarseness.
Dr. Mavrych, MD, PhD, DSc [email protected]
Aneurysm of the aorta
l Aneurysm of the aortic arch:compresses the left recurrent laryngeal nerve, leading to coughing, hoarseness, and paralys is of the ipsilateral vocal cord. It may cause dysphagia (difficulty in swallowing), resulting from pressure on the esophagus, and dyspnea (difficulty in breathing), resulting from pressure on the trachea, root of the lung, or phrenic nerve
l Aneurysm of the thoracic aortamay compress and tug on the trachea with each cardiac systole so that the aneurysm can be felt by palpating the trachea at the sternal notch (T2).
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Anterior (descending)
interventricular artery � most
common place of MI
Circumflex artery
"Widow Maker"
Blood supply of the conducting
system
SA node � RCA
AV node � RCA
AV bundle (and AVmoderator band)-mo LCA
27. Congenital cardiac defects:
Atrial Septal Defect (ASD)
foramen ovale after bfter birth (failure of the septum primum and septum secundum to fuse)
less frequent
left-to-right shunting
If it is small, has no clinical significance & if large - necessary surgical repair
Ostium secundum: MOST common resorption of lower septum primum or incomplete septum secundumleaves open foramen ovaleOstium primum: non fusion of septum primum with septum intermedium leaves open foramen primumHypoplastic L heart syndrome: premature closure of FO leaving underdeveloped L heart
Patent Foramen Ovale
Ventricular Septal
Defect (VSD)
most common of the congenital heart defects
membranous part of the ventricular septum and results from failure to fuse of the membranous portion with the muscular portion of the ventricular septum
Muscular VSD rarest when there is a holein the trabeculated inferior ventricle wall(fatal)
Great cardiac vein
Great cardiac v, middle cardiac v, small cardiac v, L marginal v drain into Coronary Sinus which empties in Triangle of Koch at RA
Patent Ductus Arteriosus (PDA)
(a connection between the pulmonary trunk and aorta) to) to constrict and close after birth.
Left �to-right
Ductus arteriosus (fetal lung bypass from pulmonary trunk to aorta) should immediatelyclose post birth by contraction of muscular wall and become lig. arteriosus, L recurrentlaryngeal n (CNX) wraps around it. Increase BP post birth creates increased BP in pulmcirculation, less blood to body slightly decreases O2
Aneurysm of the aort
ent: surgical division and ligationimperative. In great danger is left recurrent nerve (wr(wrapping aorta arch). Injure of this nerve results in hoarseness.
, le, leading to coughing, paralys is of the ipsilateral vocal cord. It may cause dysphagia (difficulty in swallowing), resulting from pressure on the esophagus, and dyspnea (difficulty in breathing), resulting from
ot of
Aneurysm of the th
the aorta the aorta
Aneurysm of the aortic arch:l
compresses the left recurrent , lelaryngeal nerve, le, le, le, le, leading to
coughing, hoarseness, and ocal paralys is of the ipsilateral vocal
cord. It may cause dysphagia lting (difficulty in swallowing), resulting gus, from pressure on the esophagus,
lty in and dyspnea (difficulty in from breathing), resulting from
ot of pressure on the trachea, root of the lung, or phrenic nerve
Aneurysm of the thoracic aortaAneurysm of the ththe thoracic aortaf the thoracic aol
may compress and tug on the trachea with each cardiac systole so that the aneurysm can be felt
hea at the by palpating the trachea atsternal notch (T2(T2).
L Recurrent Laryngeal n innervates Intrinsic Laryngeal ms: Posteriorcricoarytenoid (PCA)-abducts vocal cords*, Transverse arytenoid-whisper,Thyroarytenoid-low pitch, vocalis-opera singer
When a MI occurs, a coronary bypassgraft can be completed using theinternal thoracic artery (used to be Greatsaphenous v)
l
Dr. Mavrych, MD, PhD, DSc [email protected]
Abdominal aortic aneurysm
l It is a localized dilatation of the
aorta. It is typically happened
just above of the bifurcation at
level of L4 and crossed by 3rd
part of duodenum.
l Pulsations of a large aneurysm
can be detected to the left of
the midline at the umbilical
region.
l Acute rupture of an abdominal
aortic aneurysm is associated
with severe pain in the
abdomen or back (mortality rate
is nearly 90%).
l Surgeons can repair an
aneurysm by opening it and
inserting a prosthetic graft.
Dr. Mavrych, MD, PhD, DSc [email protected]
Coarctation of the Aortal It results from congenital
narrowing of the aorta distal to the offshoot of the left subclavian artery.
l Cardinal clinical sign: higher blood pressure in the upper limbs compared to the lower limbs.
l Coarctation of the aorta results in the intercostal arteries providing collateral circulation between the internal thoracic artery and the thoracic aorta to provide blood supply to the lower parts of the body
l Coarctation of the Aorta characteristic X-ray picture:serrated appearance of inferior borders of ribs (rib notching)
Dr. Mavrych, MD, PhD, DSc [email protected]
28. Aspiration of Foreign
Bodies & Bronchopulmonary
segmentsAspiration of Foreign Bodies:
l Inhalation of FB�s (e.g. pins, parts of teeth, screws, nuts, bolts, toys) into the lower respiratory tract is common, especially in children
l More likely to enter the rightprimary bronchus and pass into the middle or lower lobe bronchi
l If the vertical position of the body, the foreign body usually falls into the posterior basal segment of the right inferior lobe.
Dr. Mavrych, MD, PhD, DSc [email protected]
Right lung:
10 bronchopulmonary segments
Superior lobe:
1. Apical
2. Anterior
3. Posterior
Middle lobe:
4. Lateral
5. Medial
Inferior lobe:
6. Superior
7. Anterior basal
8. Posterior basal
9. Lateral basal
10.Medial basal
1
8
97
6 4
5
2
3
10
Dr. Mavrych, MD, PhD, DSc [email protected]
Left lung:
9 bronchopulmonary segments
Superior lobe:
1. Apicoposterior
2. Anterior
3. Superior lingular
4. Inferior lingular
Inferior lobe:
5. Superior
6. Anterior basal
7. Posterior basal
8. Lateral basal
9. Medial basal
1
3 5
7
89
6
2
4
Dr. Mavrych, MD, PhD, DSc [email protected]
29. Lung diseases:
Pneumonia
l Pneumonia is an inflammation
of the lung, caused by an
infection or chemical injury to the
lungs.
l Three common causes are
bacteria, viruses and fungi.
l Symptoms: cough, chest pain,
fever, and difficulty in breathing.
l Chest x-rays: areas of opacity
(seen as white) of the lung
parenchyma and enlargement of
bronchomediastinal lymph
nodes (mediastinal widening).
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Abdominal aortic aneurysm
just above of the bifurcation at
3rdlevel of L4 and crossed by
part of duodenum.
Pulsations of a large aneurysm
can be detected to the left of
the midline at that the umbilical
region.
Acute rupture of anof an abdominal
aortic aneurysm is associated
with severe pain in the
abdomen or back (mortality rate
is nearly 90%).
prosthetic graft.
Coarctation of the AortaCoarCoarcongenital
narrowing of thof the aorta distal to the offshoot of the left subclavian artery.
higher blood pressure in the upper limbs compared to the lower limbs.
intercostal arteries pries providing collateral circulation between the internal thoracic artery antery and the thoracic aorta
Coarctation of the Aorta characteristic X-ray picture:serrated appearance of inferior borders of ribs (rib notrib notching)
Preductal stenosis proximal to ductus arteriosus causes deoxygenated blood w/low BP to the body (life threatening)Postductal stenosis w/ obliterated ductus ateriorsus is more common
28. Aspiration of Foreign
Bodies & Bronchopulmonary
segments
More likely to enter the rightprimary bronchus and pand pass into the middle or m lower lobe bronchi
posterior basal segment of thof the right inferior lobe.
Laying down on back, it will go into posterior superior lobeLiquids (Mendleson syndrome) will go to BOTH superiorsegmental bronchus of Lower Lobes (SULL)
minal a
If the vertical position of
Right lung:
10 bronchopulmonary segments
Left lung:
9 bronchopulmonary segments
surrounds cardiac notch
29. Lung diseases:
Pneumonia
Pneumonia is an inflammation
of the lung, caused by an
infection or chemical injury to the
lungs.
bacteria, viruses and fungi.
Chest x-rays: areas ofeas of opacity
enlargement of
bronchomediastinal lymph
nodes
Symptoms: cough, chest pain,
fever, and difficulty in breathing.
Dr. Mavrych, MD, PhD, DSc [email protected]
Bronchogenic Carcinoma
l Arises in the mucosa of the large bronchi
l Produces as persistent, productive cough or hemoptysis
l Early metastasis to thoracic(bronchomediatinal) lymph nodes
l Hematogenous spread to the brain, bones, lungs, suprarenal glands
l A tumor at the apex of the lung (Pancoast tumor) may result in thoracic outlet syndrome
Dr. Mavrych, MD, PhD, DSc [email protected]
Bronchogenic carcinoma
may lead to:
1. Thoracic outlet syndrome (TOS)
l It can cause pressure on the lower trunk of the brachial plexus C8-T1 and subclavian artery by cervical rib or pancoast tumor. It results in pain down the medial side of the forearm and hand and atrophy of the intrinsic hand muscles)
2. Horner syndrome:
l miosis - constriction of the pupil due to paralysis of the dilator pupillae muscle
l ptosis - drooping of the eyelid due to paralysis of the superior tarsal muscle
l hemianhydrosis - loss of sweating on one side
11
22
Dr. Mavrych, MD, PhD, DSc [email protected]
Bronchogenic carcinoma
may lead to:
3. Superior vena cava syndrome, which causes dilation of the head and neck veins, facial swelling, and cyanosis
4. Dysphagia as a result of esophageal obstruction
5. Hoarseness as a result of recurrent laryngeal nerve involvement
6. Paralysis of the diaphragm as a result of phrenic nerve involvement
33
Dr. Mavrych, MD, PhD, DSc [email protected]
Qs about Auscultation
and penetrated wounds
l To listen to breath sounds of the
superior lobes of the right and left
lungs, the stethoscope is placed on
the superior area of the anterior
chest wall (above the 4th rib for the
right lung & above 6th for the left
one).
l For breath sounds from the
middle lobe of the right lung, the
stethoscope is placed on the
anterior chest wall between the 4th
and 6th ribs
l For the inferior lobes of both
lungs, breath sounds are primarily
heard on the posterior chest wall.
4
6
Dr. Mavrych, MD, PhD, DSc [email protected]
30. Open pneumothorax &
pleura
l It is entry of air into a pleuralcavity causing lung collapse.
l Open pneumothorax � due to stab wounds of the thoracic wall which pierce the parietal pleura so that the pleural cavity is open to the outside air via the lung or through the chest wall.
l Air moves freely through the wound during inspiration and expiration. During inspiration, air enters the chest wall and the mediastinum will shift toward other side and compress the opposite lung. During expiration, air exits the wound and the mediastinum moves back toward the affected side.
Dr. Mavrych, MD, PhD, DSc [email protected]
Pleura & Pleural Cavity
l 1. Cervical pleura may be affected in case of improper subclavian venipuncture.
l 2. Costodiaphragmatic Recess is deepest place in pleural cavity, around the chest wall, there are two rib interspaces separating the inferior limit of parietal pleural reflections from the inferior border of the lungs and visceral pleura:
1. Midclavicular line - between ribs 6-8
2. Midaxillary line - between ribs 8-10
3. Paravertebral line between ribs 10-12
2
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Bronchogenic Carcinoma
the mucosa of the large bronchi
s as persistent, productive cough or hemoptysis spitting bloodEarly metastasis to thoracic
spittingtasis to tasis to thorthor
(bronchomediatinal) lymph nodes
malignant cellsspread through blood
A tumor at the apex of the lung ( ) m) mng (Pancoast tumor) m) may ) mresult in thoracic outlet syndrome
1. Thoracic outlet syndrome ((TOS)
use pressure on the lower trunk of thof the brachial plexus C8-T1 and subclavian artery by cervical rib or pancoast tumor. pain down thown the medial side of the forearm and hand and atrophy oatrophy of atrophy othe intrinsic hand muscles)
2. Horner syndrome: compression of cervicalsympathetic trunk
Long ciliary n of CNV1-> SNS brf the dilator
pupillae muscle
pseudoptosis bc NOT CNIII lesionSNS compression to smooth ms
to paralysis of the superior tarsal ralysis of the supralysis of the supe supere supersuperior tauperior tarior tarsal rior tarsal lesion
tarsal tarsal muscle
tion of the pupil sympathetic
tion of the pupition of the pupitrunk
pupil pupil miosis - co- constriction ofsymp
ction ofction o
ptosis - d- drooping of the eyelid d
hemianhydrosis - loSNS
ianhydroianhydrocompression
ydrosisydrosis - lo- lo- loss of sweating compression
- loss of- loss ofto
oss of sss of ssmooth
s of sweatins of sweatinms
eating eating on one side Sweat glands are SNS
3. Superior vena cava syndrome, dilation of thof the head and neck veins, facial swelling, and cyanosis
4. Dysphagia
5. Hoarseness as a ras a result of recurrent lat laryngeal nerve rent laryn
6. Paralysis of the diaphragm as a ras a result of phrenic nerve in
Blue Face & arm
Blue arm
out Auscultation
and penetrated wounds
of
breath sounds of the of the
superior lobes
the superior area of the anterior
chest wall e the 4th(above the 4 rib for the
ove 6thright lung &lung & above 6 for the left
one).
breath sounds from the rom the
middle lobe of the right lung,
the 4thbetween the 4
and 6thand 6 ribs
inferior lobes of both
lungs, breath sounds are primarily
heard on the posterior chest wall.
Stab Wounds & Open pneumothorax:Straight in air can move in and out with each respiratory cycle, No air trapping (listen to ventilation of wound)At an angle air can move in with inspiration BUT with expiration skin acts as flap and closes trapping air inside collapsing the lung
pen pneumothorax &
It is entry of air into a pleuralcavity causing lung collapse.
mediastinum will shift toward other side and compress the opposite lung. D
1. Cervical pleura may bmay be affected in case of improper subclavian venipuncture.
Midclavicular line - between rieen ribs 6-81.
Midaxillary line - between rieen ribs 8-102.
Paravertebral line between rieen ribs 10-123.
2. Costodiaphragmatic Recess is deepest place in pleural cavity, a
Costodiaphragmatic Recess is where fluid isretained during pleural effusion
Dr. Mavrych, MD, PhD, DSc [email protected]
Nerve supply of the pleura
Parietal Pleura � sensitive to general sensibilities (pain, temperature, touch, and pressure) - somatic sensoryinnervation:
l costal pleura � intercostal nerves block may be used to decrease thoracic pain
l mediastinal pleura � phrenic nerve
l diaphragmatic pleura � phrenic nerve over the domes and lower 6 intercostal nerves around the periphery
Visceral Pleura � sensitive to stretch but insensitive to general sensibilities; autonomic nerve supply from the pulmonary plexus
Dr. Mavrych, MD, PhD, DSc [email protected]
31. Mediastinum
Superior mediastinum
l Improperly done sternal puncture may affect structures related to the posterior surface of the manubrium sternum:
l In upper part �Left brachiocephalic vein
l In lower part �Aortic arch
Dr. Mavrych, MD, PhD, DSc [email protected]
Thoracic duct
l Function � conveys to the blood all lymph from the lower limbs, pelvic cavity, abdominal cavity, left side of the thorax, left side of the head & neck, and left upper limb (3/4 of the body)
Tributaries � at the root of the neck
l Left jugular lymph trunk
l Left subclavian lymphtrunk
l Left bronchomediastinallymph trunk
Dr. Mavrych, MD, PhD, DSc [email protected]
Constrictions of the esophagus
There are sites where ingested foreign bodies can lodge or where strictures may develop following ingestion of caustic fluids, common sites of esophageal carcinoma
1. C6 - where the pharynx joins the upper end (6" from the upper incisors)
2. T4-T5 - where the aortic arch and left main bronchus cross its anterior surface (10" from the upper incisors)
3. T10 - where it passes through the diaphragm into the stomach (16" from the upper incisors)
1
2
3
Dr. Mavrych, MD, PhD, DSc [email protected]
32. Anterior abdominal wall
l The liver and gallbladderare in the right upper quadrant;
l The stomach and spleenare in the left upper quadrant;
l The cecum and appendixare in the right lower quadrant;
l The end of the descending colon and sigmoid colon are in the left lower quadrant.
Dr. Mavrych, MD, PhD, DSc [email protected]
Referred abdominal pain
l Pain arising out of the foregut derived structures is referred to the epigastric region.
l Pain arising out of the midgut derived structures is referred to the umbilical region.
l Pain arising out of the hindgut derived structures is referred to the hypogastric region.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Parietal Pleura � se� sensitive to general sensibilities (pain, temperature, touch, and pressure) - somatic sensoryinnervation:
ParieParie
intercostal nerves
phrenic nerve
Visceral Pleura
autonomic nerve surve supply from the pulmonary plexus
Cervicothoracic Stellate Gangion down to T11 and Subcostal sympathetic ganglion comprise the thoracicsympathetic trunkInnervate muscles of the ribs, abdominal wall, pulmonary and cardiac plexus, and esophageal plexusVagus CNX assists plexus of thorax for vocal cords and swallowing, and gives off recurrent laryngeal andsuperior external laryngeal to the larynx muscles
Azygous vein and ascendingaortic archesTrachea and Pulmonary arterybifurcationsesophagus and thoracic ductchange directions (cross over)
Ribs 1-2 down to transverse thoracicplane (T2)/Plane of ludwig/angle of louis
Superior mediastinump
Thoracic duct A Duck between 2 GoosesThoracic duct between azygos v and esophagus
lood all lymph from throm the lower limbs, pelvic cavity, abdominal cavity, left side of the thorax, left side of the head & neck, and left upper limb ((3/4 of the body)
Left jugular lymph trph trunk
Left subclavian lymphl
trunk
Left bronchomediastinall
lymph trunk
Tributaries � at � at the root of the neck
Left Left jugularl
R lymphatic duct drains 1/4 of body from R jugularlymph trunk, R subclavian lymph trunk, and Rbronchomediastinal lymph trunk
Constrictions of the esophagus
Pericardial sinus: behind pulm trunk and aorta place fingers toclamp/ligate great vessels during surgical procedures
1. C6 - w- where the pharynxr end (6" from the
upper incisors)
2. T4-T5 - w- where the aortic arch and left main bronchus cross
rface (10" from the upper incisors)
3. T10 - w- where it passes through the diaphragm
ach (16" from the upper incisors)
foreign bodies cadies can lodge or
25cm long/10in Barium swallow allows Xray visualization
15cm
22.5-27.5cm
40cm
uids, common sites of esophageal carcinoma
32. Anterior abdominal wall
The liver and gallbladderare in the right upper quadrant;
The stomach and spleenare in the left upper quadrant;
The cecum and appendixare in the right lower quadrant;
The end of the descending colon and sigmoid colon are in the left lower quadrant.
Layers of abdominal wall: Skin, Camper's Fascia, Scarpa's Fascia, Galludets Fascia (superficial Ext oblique), Ext Oblique m \\//, (deep ext oblique, superficial int oblique),Inter Oblique m //\\, (deep int oblique, superficial transversalis ab), Transversalis abdominus m, deep TA fascia, Extraperitoneal fat, parietal peritoneum.Arcuate line is where lateral abdominal ms tendons merge with Rectus abdominus (linea semilunaris), Above arcuate line int oblique superficial fascia is above rectus abdominus (3 layersof fascia), Below arcuate line ALL fascias above rectus abdominis (6 layers) typically inferior to umbilicus
RH LHE
RL LLU
HRI LI
foregut
epigastric regric region.
demidgut
umbilical region.
hindgut
hypogastric region.
Dr. Mavrych, MD, PhD, DSc [email protected]
Nerve supply of the
anterior abdominal wall
l Therefore totally 7 nerves: lower 5 intercostals, 1subcostal and L1(iliphypogastric and ilioinguinal) nerves supply the anterior abdominal wall.
l L1 can be anaesthetized by injecting 1 inch (2.5 cm) superior to the anterior superior iliac spine.
l All nerves and deep blood vessels lie in the neurovascular plane: between internal oblique and transversus muscles
Dr. Mavrych, MD, PhD, DSc [email protected]
Arterial supply of the anterior
abdominal wall:
Important SUPERFICIAL
ARTERIES (supply skin) are:
1. Superficial epigastric
2. Superficial circumflex iliac
Important DEEP ARTERIES lie in the neurovascular plane:
1. Superior epigastric
2. Posterior intercostals arteries
3. Lumbar arteries
4. Deep circumflex iliac artery
5. Inferior epigastric
Dr. Mavrych, MD, PhD, DSc [email protected]
33. Herniations
Hernia consist of 3 parts:
l Hernial sac is a pouch (diverticulum) of peritoneum and has a neck and a body
l Hernial contents may consist of any structure found in the abdominal cavity (more offen �loops of small intestine and piece of omentum major)
l Hernial coverings are formed from the layers of the abdominal wall through which the hernial sac passes
Dr. Mavrych, MD, PhD, DSc [email protected]
Transversalis fascia is the FIRST
STRUCTURE which is crossed by
any abdominal hernia
Dr. Mavrych, MD, PhD, DSc [email protected]
Indirect Inguinal Hernia
l Indirect inguinal hernia is the most common form of hernia and is believed to be congenital in origin (boys 0-3 years).
l It passes through the deep inguinal ring lateral to the inferior epigastric vessels, inguinal canal, superficial inguinal ring and descend into the scrotum.
l An indirect inguinal hernia is about 20 times more common in males than in females, and nearly 1/3 are bilateral.
l It is more common on the right(normally, the right processus vaginalis becomes obliterated after the left; the right testis descends later than the left).
Dr. Mavrych, MD, PhD, DSc [email protected]
Direct Inguinal Hernia
l Direct inguinal hernia composes about 15% of all inguinal hernias.
l During a direct inguinal hernia, the abdominal contents will protrude through the weak area of the posterior wall of the inguinal canal medial to the inferior epigastric vessels in the inguinal [Hesselbach's] triangle and after that through superficial inguinal ring. It never descends into the scrotum.
l It is a disease of old men with weak abdominal muscles. Direct inguinal hernias are rare in women, and most are bilateral.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Nerve supply of the
anterior abdominal wall
5 intercostals, 1subcostal and L1(iliphypogastric and ilioinguinal
neurovascular plane: between internal oblique and transversus muscles
Arterial supply of the anterior
abdominal wall:
Superficial epigastric
Superficial circumflex iliacfrom femoral a
SUPERFICIAL
ARTERIES ((supply skinly skin) a
internal thoracic a
from femoral a just pastfemoral ring (inguinal lig)
external iliac a
Portal Caval anastamosis of paraumbilical veins off hepatic portal v with superficialepigastric veins (Caput Medusae- swiggly veins on belly button)
T5-T11T12L1
Superior epigastric
Posterior intercostals arteries
Deep circumflex iliac artery external
artery artery
Inferior epigastricInferior epInferioior epigastricior epigastricjust
rtant DEEP ARTERIES lie in the neurovascular plalar plane:
Hernial sac is a pis a pouch (diverticulum) of peritoneum and has a neck and a body
Hernial contents may comay consist of any structure found in the abdominal cavity (more offen �loops of small intestine
Hernial coverings are foare formed from the layers of the abdominal wall through which the hernial sac passes
33. Herniations Transversalis fascia is this the FIRST
STRUCTURE which is crossed by
any abdominal hernia
TIE ICETransversalis Fascia becomes Internal Spermatic FasciaInternal Oblique m & Fascia becomes Cremasteric m & FasciaExternal Oblique fascia becomes External Spermatic Fascia
Surrounds the Spermatic cord within the inguinal canal:3 as: cremasteric (inferior epigastric), ductus deferans (internal iliac-inferior vesicle),gonadal a (aorta)3 ns: genital br (motor genitofemoral), ANS, ilioinguinal3 others: Pampiniform plexus (IVC and Lrenal), Ductus Deferens, LymphaticsProcess Vaginalis/Gubernaculum
aponerocis of internaloblique fascia andtranversalis fascia
Indirect inguinal hernia is this the most common form
congenital in origin
ses through the deep inguinal ring lateral to the inferior epigastric vessels, inguinal canal, superficial inguinal ring and descend into the scrotum.
mon infemales, and nearly 1/3 are bilateral.
20 times more common inmon in males than in
the right
Insert finger into superficial inguinal ring, if you can feel hernia at TIP of finger than it is indirect hernia at the lateral inguinal fossa.If you can feel something lateral to finger it is direct hernia pushing towards Hesselbach's triangle (medial inguinal fossa between medial and lateralumbilical folds. The inferior epigastric vessels reside within Lateral umbilical fold (functional), the inferior border is the inguinal lig.
Direct inguinal hernia composes about 15% of all inguinal hernias.
protrude through the weak area of the posterior wall of the inguinal canal
[Hesselbach's] triangle
disease of old men with weak abdominal muscles. Di
Dr. Mavrych, MD, PhD, DSc [email protected]
34. Peritoneal structures:
Lesser omentum
Consist of 2 ligaments:
l hepatogastric
l hepatoduodenal
Contents :
l Right & Left gastric vessels
l Connective and fatty tissue
and Portal triad:
l Bile duct
l Portal vein
l Proper hepatic artery
Dr. Mavrych, MD, PhD, DSc [email protected]
Epiploic (winslow�s) foramen
l Anteriorly: The free border of the hepatoduodenal ligament, containing portal triad (DVA).
l Posteriorly: IVC
l Superiorly: Caudate lobe of the liver.
l Inferiorly: The 1st
part of the duodenum.
Dr. Mavrych, MD, PhD, DSc [email protected]
Douglas (rectouterine) pouch
l Rectouterine pouch (pouch of Douglas):deeper point of peritoneal space in vertical position of the female body between the rectum and the cervix of uterus.
l It is space of the pelvic abscess location.
Dr. Mavrych, MD, PhD, DSc [email protected]
Culdocentesis
l Culdocentesis is aspiration of fluid from the cul-de-sac of Douglas (rectouterine pouch) by a needle puncture of the posterior vaginal fornix near the midline between the uterosacral ligaments
l Because the rectouterine pouch is the lowest portion of the female peritoneal cavity, it can collect inflammatory fluid (pelvic abscess).
Dr. Mavrych, MD, PhD, DSc [email protected]
35. Smart Table
FOREGUT MIDGUT HINDGUT
Esophagus
Stomach
Duodenum (1st and
2nd parts)
Liver
Pancreas
Biliary apparatus
Gallbladder
Duodenum (2nd, 3rd,
4th
parts)
Jejunum
Ileum
Cecum (with
Appendix)
Ascending colon
Transverse colon
(proximal 2/3)
Transverse colon
(distal 1/3)
Descending colon
Sigmoid colon
Rectum (anal canal
above pectinate line)
Dr. Mavrych, MD, PhD, DSc [email protected]
FOREGUT MIDGUT HINDGUT
Artery: CA Artery: SMA Artery: IMA
Parasympathetic
innervation: vagus
nerves, CNX
Parasympathetic
innervation: vagus
nerves, CNX
Parasympathetic
innervation: pelvic
splanchnic nerves, S2-S4
Sympathetic
innervation:
�Preganglionics: greater
splanchnic nerves, T5-T9
�Postganglionics:
celiac ganglion
Sympathetic
innervation:
�Preganglionics: lesser
splanchnic nerves, T10-
T11
�Postganglionics:
superior mesenteric
ganglion
Sympathetic
innervation:
�Preganglionics: lumbar
splanchnic nerves, L1-L2
�Postganglionics: inferior
mesenteric ganglion
Sensory Innervation:
DRG T5-T9
Sensory Innervation:
DRG T10-T11
Sensory Innervation:
DRG L1-L2
Referred Pain:
Epigastrium
Referred Pain:
Umbilical
Referred Pain:
Hypogastrium
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Lesser omentum
2 ligaments:
hepatogastricl
hepatoduodenall
Right & Left gastric vessels
Portal triad:
Bile ductl
Portal veinl
Proper hepatic arteryl
Site of Pringles Manuver to block blood supply to liver and investigateLiver bleeds: block Hepatic Artery Proper, Hepatic Portal Vein, and CommonBile Duct. Use thumb anterior, and index posterior within Winslow foramen.If R side bleeds: aberrant R Hepatic artery from SMAIf L side bleeds: aberrant L Heptatic artery from L GastricIf double bleed accessory arteries come from elsewhere.
Epiploic (winslow�s) foramen
Douglas (rectouterine) pouch In women only!
deeper point of peritoneal space in vertical position oition of the female body between the rectum and thand the cervix of uterus.
l pelvic It is space of the abscess location.
Culdocentesis
aspiration of fluid from the cul-de-sac of Douglas (r
posterior vaginal fornix
Vesicouterine pouch
Males have a vesicorectal pouch, fluid can accumulate in these peritoneal areas if there is a pelvic abscess.Morrison's pouch is where fluid accumulates if the person is lying down (between kidney and liver)
1st part duodenum issuspended by greateromentum and hepatoduodenal lig
Retroperitoneal Organs: SAD PUCKERSuprarenal glands, Aorta, Duodenum (2-3rd), Pancreas, Ureters, Colon, Kidneys, Esophagus, RectumDPC are secondary retroperitoneal
2nd part of duodenum iswhere Spincter of Oddi/Ampula of Vader/majorpapilla of the Wirsung majorPancreatic duct emptiesalong with the common bileduct
IMV to splenic v tohepatic portal v to liverto IVCSMV joins splenic v toform hepatic portal v
Dr. Mavrych, MD, PhD, DSc [email protected]
36. Posterior gastric ulcer
1. Posterior gastric ulcer may erode through the posterior wall of the stomach into the Omental bursa (Lesser peritoneal sac) and affect pancreas resulting in referred pain to the back.
2. Erosion of splenic artery is very common in posterior gastric ulcers as well because of the proximity of the artery to this wall.
Dr. Mavrych, MD, PhD, DSc [email protected]
37. Congenital diaphragmatic
hernia
l Hernia of stomach or intestine through a posterolateral defect in diaphragm(foramen of Bochadalek).
l It is seen in infants and the mortality rate is high because of left lung hypoplasia.
Dr. Mavrych, MD, PhD, DSc [email protected]
38. Sliding hiatal hernia
l A sliding hiatal hernia which
occurs in individuals past
middle age is caused by
the hernia of cardia of the
stomach into the thorax
through the esophageal
hiatus of the diaphragm.
l This can damage the vagal
trunks as they pass through
the hiatus and resulting in
hyposecretion of gastric
juice.
Dr. Mavrych, MD, PhD, DSc [email protected]
39. Meckel's diverticulum
l Meckel's diverticulum is a congenital anomaly representing a persistent portion of the vitellointestinal duct.
l This condition is often asymptomatic but occasionally becomes inflamed if it contains ectopic gastric, pancreatic, or endometrialtissue, which may produce ulceration.
l Meckel's diverticulum is located on the Ileum about 2 feet (61 cm) before the ileocecal junction and SMA supply it. It occurs in 2% of patients and is about 2 inches(5 cm) long.
l The diverticulum is clinically important because diverticulitis, liberation, bleeding, perforation, and obstruction are complications requiring surgical intervention and frequently mimicking the symptoms of acute appendicitis.
Dr. Mavrych, MD, PhD, DSc [email protected]
40. Features of the large
intestine
Features of the large intestine:
1. Appendices epiploic
2. Sacculations (haustrations)
3. Taeniae coli
l The taeniae coli meet together at the base of the appendix where they form a complete longitudinal muscle coat for the appendix.
Dr. Mavrych, MD, PhD, DSc [email protected]
Colon
l The ascending colon lies retroperitoneally and lacks a mesentery.
l It is continuous with the transverse colon at the right (hepatic) flexure (1) of colon.
l The transverse colon (3) has its own mesentery called the transverse mesocolon (intraperitoneal position).
l It becomes continuous with the descending colon at the left (splenic) flexure (2) of colon.
l The sigmoid colon (4) is suspended by the sigmoid mesocolon (intraperitoneal position).
1
3
4
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
36. Posterior gastric ulcer
Posterior gastric ulcer may erode through the posterior wall of the stomach into the Omental bursa
pancreas resulting inlting in referred pain to the back.
Erosion of splenic artery is very common in
37. Congenital diaphragmatic
hernia
posterolateral defect in diaphragm(foramen of Bochadalek).
Improper fusion of pleuroperitonealmembranes with septum transversarusMost L sided bc liver and R side closes first.
It is seen in infants and the mortality rate is high because of left lung hypoplasia.
Fundus of stomach through
esophageal
hiatus of thof the diaphragm.
Often due to shortened esophagus
38. Sliding hiatal hernia
Meckel's diverticulum is ais a congenital anomaly representing a persistent portion of the vitellointestinal duct.
Meckel's diverticulum is lois located on the Ileum about 2 feet (61(61 cm) before the ileocecal junction and SMA supply it. It occurs in 2% of pof patients and is about 2 inches(5 cm) long.
diverticulitis, liberation, bleeding, perforation, and obstruction are complications requiring surgical intervention and frequently mimicking the symptoms of acute appendicitis.
commonly presents at 2yo, 2:1 males to females
Outpouch of intestines into rectum
Appendices epiploic
Sacculations (haustrations)
Taeniae coli
The tal niae coli meet The taeniae cotogether at the base of the appendix where they form a complete longitudinal muscle coat for the appendix.
Colonf the large
intestine
ascending colon lies retroperitoneally and laand lacks a mesentery.
transverse colon at the right (hepatic) flexure (1)
transverse colon (3) has its own mesentery called the transverse mesocolon
descending colon at the left (splenic) flexure (2)
The sigmoid colon (4) is suspended by the sigmoid mesocolon
Ascending colon (R colic a, iliocolic a w/ appendicular a-SMA)Transverse colon (Middle colic a, marginal a-SMA)Descending colon (L colic a-IMA)Sigmoid colon (Sigmoid branches of IMA)Rectum (Superior Rectal a from IMA, Inferior and medial rectal-internal iliac a)
Dr. Mavrych, MD, PhD, DSc [email protected]
41. Pain of Appendicitis
l In appendicitis, first pain is referred around the umbilicus. Visceral pain in the appendix is produced by distention of its lumen or spasm of its muscle.
l The afferent pain fibers enter the spinal cord at the level of T10 segment, and a vague referred pain is felt in the region of the umbilicus.
l Later if parietal peritoneum gets involved, and then the pain is shifted laterally to the Mc Burney�s point. Here the pain is precise, severe, and localized (second pain)
Dr. Mavrych, MD, PhD, DSc [email protected]
Mc Burney's point
l This point indicates the surface marking of the base of the appendix.
l It is a point at the junction between the lateral 1/3 and medial 2/3 of a line joining the right anterior superior iliac spine with the umbilicus.
Dr. Mavrych, MD, PhD, DSc [email protected]
42. Volvulus
l Because of its extreme mobility,
the Jejunum, Ileum and
Sigmoid colon sometimes
rotates around its mesentery.
It results in avascular necrosis
corresponding part of interstine.
l This may correct itself
spontaneously, or the rotation
may continue until the blood
supply of the gut is cut off
completely.
Dr. Mavrych, MD, PhD, DSc [email protected]
43. Hirschsprung's Disease
l It is a rare congenital abnormality that results in obstruction because the intestines do not work normally.
l It is commonly found in Down Syndromechildren.
l The inadequate motility is a result of an aganglionic section (congenital absentsof postganglionic parasympathetic neurons inside of the intestinal wall) of the intestines resulting in megacolon.
l In a newborn, the main signs and symptoms are failure to pass a meconium stool within 1-2 days after birth, reluctance to eat, bile-stained (green) vomiting, and abdominal distension.
l Treatment is removal of the aganglionic portion of the colon.
Dr. Mavrych, MD, PhD, DSc [email protected]
44. Branches of Abdominal aorta
and Mesenteric ischemia
l Celiac trunk (CA) originates from the aorta at the lower border of T12 vertebra
l Superior mesenteric arteryoriginates at the lower border of L1 vertebra
l Renal arteries originate at approximately L2 vertebra
l Inferior mesenteric arteryoriginates at L3 vertebra
l Two terminal branches are common iliac arteries at the level of L4 vertebra
Dr. Mavrych, MD, PhD, DSc [email protected]
CELIAC ARTERY (TRUNK)
l Origin: T12, just below the
aortic opening of the
diaphragm.
l The CA passes above the
superior border of the
pancreas and then divides
into three retroperitoneal
branches:
l Left gastric artery (1)
l Common hepatic artery (2)
l Splenic artery (3)
2
3
1
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
41. Pain of Appendicitis
first pain is referred around the umbilicus.
T10 seg10 segment, a
Later if parietal peritoneum gets involved, and then the pain is shifted laterally to the Mc Burney�s point. He
McBurney's point lies 2/3 from umbilicus to ASIS OR 1/3 from ASIS to umbilicus
base of the base of appendix.
Mc Burney's point
42. Vol2. Volvulus
Jejunum, Ileum and
Sigmoid colon sometimes
rotates around its mesentery.
avascular necrosis
corresponding part of interstine.
43. Hirschsprung's Disease
NCCs did not travel correctly to the colon resulting in lack ofinnervation to the large bowel, no parastalic movements results inmegacolon
It is a rare congenital abnormality that results in obstruction because the intestines do not work normally.
Down Syndromemales>females
aganglionic section (co(congenital absentsof postganglionic parasympathetic neurons inside of the intestinal wall) of the intestines resulting in megacolon.
are failure to pass a meconium stool
and abdominal distension.
44. Branches of Abdominal aorta
and Mesenteric ischemia
T12 vertebra
Celiac trunk (CA)
Superior mesenteric artery
L1 vertebra
Renal arteriesL2 vertebra
Inferior mesenteric arteryL3 vertebra
Two terminal branches are common iliac arteries at the level of L4 vertebra
Ovarian/testicular (gonadal) as arise between L2-3
CELIAC ARTERY (TRUNK)
Left gastric artery (1)
Common hepatic artery (2)l
Splenic artery (3)l
igin: T12, just below the
aortic opening of the
diaphragm.
between crura ofdiaphragm
Dr. Mavrych, MD, PhD, DSc [email protected]
Left gastric artery
l The left gastric artery (1)
courses upward to the left to
reach the lesser curvature of
the stomach and may be
subject to erosion by a
penetrating ulcer of the
lesser curvature of the
stomach.
Branches:
l Esophageal branches (2) - to the abdominal part of the esophagus
l Gastric branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery.
2
3
1
Dr. Mavrych, MD, PhD, DSc [email protected]
Common hepatic artery
l The common hepatic artery
(1) passes to the right to
reach the superior surface of
the first part of the duodenum,
where it divides into its two
terminal branches:
l Proper hepatic artery (2)
l Gastroduodenal artery (3)
1
2
3
Dr. Mavrych, MD, PhD, DSc [email protected]
Proper hepatic arteryl Proper hepatic artery (1) gives
off right gastric artery (2) and
then ascends within the
hepatoduodenal ligament of the
lesser omentum to reach the
porta hepatis, where it divides
into the right (4) and left (3)
hepatic arteries.
l The right and left arteries enter the
two lobes of the liver, right
hepatic artery gives cystic artery
(5) to the gallbladder.
l Right gastric artery (2) supplies
the right side of the lesser
curvature of the stomach where it
anastomoses the left gastric
artery.
54
3
21
Dr. Mavrych, MD, PhD, DSc [email protected]
Gastroduodenal artery
l Gastroduodenal artery (1)
descends posterior to the first
part of the duodenum (may be
subject to erosion by a
penetrating ulcer in this place)
and divides into two branches:
l Right gastroepiploic artery (2)
(supplies the right side of the
greater curvature of the
stomach where it anastomoses
the left gastroepiploic)
l Superior pancreaticoduodenal
arteries (3) (supply the head of
the pancreas, where they
anastomoses the inferior
pancreaticoduodenal arteries
from the SMA).
1
2
3
Dr. Mavrych, MD, PhD, DSc [email protected]
Ligature of the hepatic artery:
l The hepatic artery may be ligated proximal to the origin of its gastroduodenal branch, a collateral circulation to the liver is established through the left and right gastricarteries, left and right gastroepiploic and gastroduodenal arteries.
l The right hepatic artery may be mistakenly ligated during holecystectomy in Calot triangle together with the cystic artery, right lobe hepatic necrosis commonly occurs.
Dr. Mavrych, MD, PhD, DSc [email protected]
Splenic artery
l Splenic artery (1) runs a
tortuous horizontal course to
the left along the upper border
of the pancreas, behind the
peritoneum of the posterior
wall of the lesser sac, forming a
part of the stomach bed.
l The splenic artery may be
subject to erosion by a
penetrating ulcer of the
posterior wall of the stomach
into the lesser sac.
l N.B. The splenic vein runs a more straight course below the artery and behind of the pancreas.
1
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Left gastric artery
Esophageal branches (2
Gastric branches (3
the lesser curvature of
the stomach an
ct to erosion by a
penetrating ulcer
Common hepatic artery
the superior surface of
the first part of the duodenum,
o its two
terminal branches:
Proper hepatic artery (2)l
Gastroduodenal artery (3)l
Proper hepatic artery
right gastric artery (2
then ascends within th
lesser omentum
o the right (4) and left (3)
hepatic arteries.
two lobes of the liver, ri, right
hepatic artery gives cystic artery
(5) to thto the gallbladder.
Right gastric artery (2) supplies
the right side of the lesser
curvature of thof the stomach where it
anastomoses the left gastric
artery.
OFF Common Hepatic a of Celiac Trunk OFF Common Hepatic a of Celiac Trunk
Gastroduodenal artery
descends posterior to the first
part of thof the duodenum
and divides into two branches:
Right gastroepiploic artery (2
greater curvature
Superior pancreaticoduodenal
arteries (3 head of
the pancreas, w
Ligature of the hepatic artery:
collateral circulation to the liver is established through the left and right gastricarteries, left and right gastroepiploic and gastroduodenal arteries.
right hepatic artery may be mistakenly ligated during holecystectomy in Calot triangle together
cystic artery, right lobe hepatic necrosis
Anastamoses of the L gastric, Lgastroepiploic, and Lgastroduodenalarteries with the R side will causeretrograde flow into the proper hepaticartery to supply the liver
Splenic artery
3rd off Celiac Trunk
2nd off Celiac Trunk1st off Celiac Trunk
Splenic artery (1) runs aruns a
tortuous
upper border
of the pancreas, behind the
peritoneum of thof the posterior
wall of the lesser sac, forming a
part of the stomach bed.
erosion by aby a
penetrating ulcer of thof the
posterior wall of thof the stomach
into the lesser sacer sac.
N.B. The splenic vein runs aruns a more straight course below the artery and behind of the pancreas.
Dr. Mavrych, MD, PhD, DSc [email protected]
Splenic artery
l Splenic (1) a. is retroperitoneal
until it reaches the tail of the
pancreas, where it enters the
splenorenal ligament to enter
the hilum of the spleen.
Branches:
l Branches to the spleen (2)
l Branches to the neck, body, and
tail of pancreas (3)
l Left gastroepiploic (4) artery that
supplies the left side of the
greater curvature of the stomach
where it anastomoses the right
gastroepiploic
l Short gastric (5) branches that
supply fundus of the stomach
5
43
1 2
Dr. Mavrych, MD, PhD, DSc [email protected]
SMA Branches:
l (1) Inferior pancreaticoduodenal arteries
l (2)Jejunal and (3) Ileal branches
l (4) Ileocolic artery
l Ascending branch
l Anterior cecal artery
l Posterior cecal artery
l (5) Appendicular artery
l (6) Right colic artery
l (7) Middle colic artery
17
6
5
4
3
2
Dr. Mavrych, MD, PhD, DSc [email protected]
IMA Branches:
l (1) Left colic artery
l (2) Sigmoid arteries
l (3) Superior rectal artery
3
2
1
Dr. Mavrych, MD, PhD, DSc [email protected]
Mesenteric ischemial Atherosclerosis, which slows the
amount blood flowing through arteries, is a frequent cause of chronic mesenteric ischemia.
l Ischemia occurs when blood cannot flow through arteries as well as it should, and intestines do not receive the necessary oxygen to perform normally. Mesenteric ischemia usually involves SMA and small intestine.
l Mesenteric ischemia primarily affects organs which locate far away from anastomoses with CA & IMA. Usually blood supply of the Jejunum and Ileum is most compromised.
l Mesenteric ischemia typically occurs in people older than age 60 with history of smoking and high cholesterol level.
Dr. Mavrych, MD, PhD, DSc [email protected]
45. Biliary system & gallstones
l Bile is secreted by the liver cells, stored, and concentrated in the gallbladder and later it is delivered to the duodenum.
l The gallbladder lies in it�s fossa on the visceral surface of the liver right side of quadrate lobe.
l It stores and concentrates bile, which enters and leaves it through the cystic duct.
l The cystic duct joins the common hepatic (from left and right hepatic) due to form the common bile duct.
Dr. Mavrych, MD, PhD, DSc [email protected]
Biliary system
l The common bile duct descends in the hepatoduodenal ligament, then passes posterior to the firstpart of the duodenum
l It penetrates the head of the pancreas where it joins the main pancreatic duct and they form the hepatopancreatic ampulla (sphincter of Oddi), which drains into posteromedial wall the second part of the duodenum at the major duodenal papilla
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
BRANCHESSplenic artery BRANCHEStery
is retroperitoneal
until it reaches the tail of the
pancreas, w
splenorenal ligament to eto enter
the hilum of the spleen.
Branches to the spleen (2)
Branches to the neck, body, and
tail of pancreas (3
Left gastroepiploic (4) artery thrtery that
supplies the left side of the
greater curvature ofture of the stomach
where it anastomoses the right
gastroepiploic
Short gastric (5) branches thhes that l
supply fundus of the stomach
SMA Branches:
(1) Inferior pancreaticoduodenal
(2)Jejunal and (3) Ileal branches
(4) Ileocolic
(6) Right colic artery
(7) Middle colic artery l
rior cecal artery
(5) Appendicular artery
SUPERIOR MESENTERIC ARTERY (midgut)
Marginal artery anastamoses the iliocolic a,vasa recta-SMA, with the L colic, sigmoid aand vasa recta of the IMA
INFERIOR MESENTERIC ARTERY
IMA Branches:
(1) Left colic arteryl
(2) Sigmoid arteriesl
(3) Superior rectal artery l
Mesenteric ischemiaAtherosclerosis, w
a frequent cause of chronic mesenteric ischemia.
hen blood cannot flow
intestines do not receive the necessary oxygen to
lves SMA and small intestine.
f the Jejunum and Ileum is most compromised.
age 60 with hwith history of smoking and high cholesterol level.
45. Biliary system & gallstones
cystic a from R hepatic a
Calot's Triangle
ated in the gallbladder
hepaticgallbgallbstored, and co, and concentrated in
delivered to the duodenum. hepaticdelideliadelivedelive
the visceral surface of the liver right side of quadrate lobe.
cystic duct.
duct joins the common hepatic (from left and right hepatic) due to form the common bile duct.
Biliary system
mon bile duct common descends innds in the atoduodenal ligamenthepatodu ,
ses then passes posterior to the firstpart of the duodenumduo
ates the head of the It penetrates tpancreas where it wheere it joins the main
tic ductpancreatic d and thand they form the ancreatic ampulla hepatopancre
(sphincter of Odd(sphincter or of Oddi), which drains of Oddr of Odd of Oddi)into posteromedial wall the second part of thof the duodenum at the major duodenal papilla
Sphincter of Oddi
Ampula of Vader
SphincterSphincter of OddiOddiOddi
AmpAmpula of Vader
Tumor in the head of the pancreas can block the duct and cause jaundice
Blockage of the cystic or common bile duct via gall stones can cause gall bladder rupture w/ refered
pain to the shoulder (C3-5 phrenic n), and backflow of pancreatic enzymes that digest the pancreas
and the spleen via splenic artery branches
Dr. Mavrych, MD, PhD, DSc [email protected]
Cholelithiasis (gallstones)
l The distal end of the hepato-
pancreatic ampulla (Bile duct) is the
narrowest part of the biliary passages
and is the common site for impaction
of gallstones.
l As result of common hepatic (1), bile
duct (2), or hepatopancreatic
ampulla (3) obstruction patient will
have yellow eyes and jaundice
l Gallstones may also lodge in the
cystic duct. A stone lodged in the
cystic duct (4) causes biliary colic
(intense, spasmodic pain in the
gallbladder) but doesn't produce
jaundice.
1
2
3
4
Dr. Mavrych, MD, PhD, DSc [email protected]
Gallstones
l The fundus [1] of the gallbladder is in contact with the transverse colonand thus gallstones erode through the posterior wall of the gallbladder and enter the transverse colon. They are passed naturally to the rectum through the descending colon and sigmoid colon.
l Gallstones lodged in the body [2] of the gallbladder may ulcerate through the posterior wall of the body of the gallbladder into the duodenum(because the gallbladder body is in contact with the duodenum) and may be held up at the ileocecal junction, producing an intestinal obstruction.
2
1
Dr. Mavrych, MD, PhD, DSc [email protected]
46. Nerve supply of the liver
and gallbladder
l Sensory innervation of the liver: by the rightphrenic nerve (C3-C5). Pain may radiate to the right shoulder.
l The liver receives parasympathetic innervation from the vagi nerves (CNX), reaching it through the celiac plexuses around the supplying arteries. The preganglionic fibers synapse on the cells of the uxtramural plexuses in hilum of the liver and shot postganglionic fibers supply organs.
l Sympathetic fibers of preganglionic neurons T5-T9 segments (IML) come through the sympathetic trunk and form greater splanchnicnerves. They contribute to the celiac plexus, where postganglionic neurons are located. Branches of celiac plexus reach the liver wrapping around the branches of the celiac artery.
Dr. Mavrych, MD, PhD, DSc [email protected]
47. Portal Hypertension &
Portocaval shunts
l Portal hypertension is a common clinical condition, and for this reason portal-systemic anastomoses should be remembered.
l [1] Extrahepatic portocaval shunt for the treatment of portal hypertension: the splenic vein may be anastomoses to the left renal vein after removing the spleen.
l [2] Intrahepatic portocaval shunt : between portal vein and hepatic veins
Dr. Mavrych, MD, PhD, DSc [email protected]
Large intestine metastases &
Portocaval anastomosis
l Metastases of the Large intestine
cancer typically rich the Liver via
portal venous system: Rectum -
IMV - splenic vein - portal vein -
Liver
l If there is an obstruction to flow
through the portal system (portal
hypertension), blood can flow in a
retrograde direction and pass
through anastomoses to reach the
caval system. Sites for these
anastomoses include:
l (1) esophageal veins
l (2) paraumbilical veins
l (3) rectal veins
Dr. Mavrych, MD, PhD, DSc [email protected]
Esophageal anastomosis
l Anastomosis between the tributaries of the left gastric vein (portal vein) and the tributaries of the azygous vein (SVC) in the wall of the lower end of the esophagus.
l In portal hypertension these veins enlarge in the wall of the esophagus and later burst into the lumen of the esophagus (esophageal varices) resulting in hematemesis (vomiting red blood).
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Cholelithiasis (gallstones)
Gall stone in the cystic duct will cause backflow to the gall bladder (burst)
BUT NOT jaundice bc Common bile duct is still releasing bile properly to the stomach
The distal end of the hepato-
pancreatic ampulla (Bile duct) is this the
narrowest part of thof the biliary passages
and is the common site for impaction
of gallstones.
common hepatic (1), bile
duct (2), or hepatopancreatic
ampulla (3) obstruction patient will
have yellow eyes and jaundice
cystic duct (4) causes biliary colic
(intense, spasmodic pain in the
gallbladder) but doesn't produce
jaundice.
Gallstones
The fundus [1] of the gallbladder is in contact with the transverse colon
tones erode through the posterior wall of the gallbladder and enter the transverse colon. T
tones lodged in the body [2] of the gallbladderthe posterior wall of the body of the gallbladder into the duodenum
be held up at the ileocecal junction, producing an intestinal obstruction.
46. Nerve supply of the liver
and gallbladder
(C3-C53-C5right
phrenic nerve (( ). ((C3-C53-C5). Pain may radiate to the right shoht shoulder.
celiac plexuses
parasympathetic innervation
Sympathetic fibers
greater splanchnicnerves. T celiac plexus,
Sensory innervation
47. Portal Hypertension &
Portocaval shunts
Portal hypertension is a is a common clinical condition,
[1] Extrahepatic portocaval shunt
splenic vein may bmay be anastomoses to the left renal vein after refter removing the spleen.
[2] Intrahepatic portocaval shunt : between portal vein and hepatic veins
Diverting blood from portal venous system to the systemic venous system by creating a
communication between the hepatic portal vein and the IVC.
Side to side shunts connecting the portal system to the IVC, End to side connection with
separation and connection of end and head of portal caval system to IVC. And typical
splenorenal central shunt all allow portion of blood to IVC to decrease flow to liver.
Large intestine metastases &
Portocaval anastomosis
Metastases of thof the Large intestine
cancer Liver via
portal venous system: Rectum -tum -
IMV - splenic vein - portal vein -
Liver
obstruction to flow
through the portal system (portal
hypertension), blood can flow in a
retrograde di and pade direction and pass
through anastomoses to reach the
caval system. Si. Si
(1) esophageal veins l
(2) paraumbilical veinsl
(3) rectal veinsl
Esophageal anastomosis
Anastomosis between theen the tributaries of the left gastric vein (portal vein) and thand the tributaries of the azygous vein (SVC) in thin the wall of the lower end of thof the esophagus.
gus (esophageal varices) rehematemesis (vo(vomiting red blood).
Esophageal branches of the L Gastric v will anastomose with azygous(4) R, L and middle colic vs anastamose with
Renal, suprarenal and gonadal vs, No clinical
name however represents as varicocele on the
abdomen
Dr. Mavrych, MD, PhD, DSc [email protected]
Umbilical anastomosis
l Anastomosis between the paraumbilical veins (portal vein) and the superior and inferior epigastric veins (SVC and IVC) in anterior abdominal wall around the umbilicus.
l In portal hypertension, this anastomosis gets enlarged and dilated veins form �caput Medussae� around the umbilicus.
Dr. Mavrych, MD, PhD, DSc [email protected]
Rectal anastomosis
l Anastomosis between the superior rectal vein (inferior mesenteric vein and then portal vein) and inferior rectal vein which drains into the internal iliac vein (from IVC system).
l In portal hypertension (chronic alcoholics) this anastomosis gets dilated resulting in internal hemorrhoids and bleeding per anus from superior rectal vein.
Dr. Mavrych, MD, PhD, DSc [email protected]
48. Pancreas:
Head and uncinate process
l The head of the pancreasrests within the C-shapedarea formed by the duodenum and is traversed by the common bile duct.
l It includes the uncinate process which is crossed by the superior mesenteric vessels.
Dr. Mavrych, MD, PhD, DSc [email protected]
Cancer of the head
of the pancreas
· Cancer of the head of the pancreas compresses the bile duct and results in OBSTRUCTIVE TYPE OF JAUNDICE.
· Pain will be conveyed to sensory neurons T5-T9 dorsal root ganglia via celiac plexus and greater splanchnic nerve.
· This type of jaundice is NOTusually associated with fever.
· Hepatitis also causes jaundice but is associated with the fever.
Dr. Mavrych, MD, PhD, DSc [email protected]
Neck of the pancreas
l Posterior to the neck of the pancreas is the site of formation of the PORTAL VEIN.
l (1)Splenic vein joins with (2)superior mesenteric vein to form (3) portal vein.
3
2
1
Dr. Mavrych, MD, PhD, DSc [email protected]
Body of the pancreas
l The body passes to the left and anterior to the (1)aorta and the (2) left kidney.
l The (3) splenic artery undulates along the superior border of the body of the pancreas with the splenic vein coursing posterior to the body.
3
2
1
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Umbilical anastomosis
paraumbilical veins (po(portal vein) and the superior and inferior epigastric veins (SVC and IVC) in
�caput Medussae� around thund the umbilicus.
Rectal anastomosis
superior rectal vein (inferior mesenteric vein and then portal veintal vein) ainferior rectal vein which drains into the internal iliac vein (from IVC system).
Superior Rectal vein (IMV) anastomoses with middle and inferior rectal vs (internal iliac v &
internal pudendal v) during portal hypertension Rectal varices (Hemorrhoids)
Internal hemorrhoids are painless superior to pectinate line at internal rectal venous plexus.
External hemorrhoids are painful due to blockage of external rectal venous plexus, where
Nociceptors (pain) are located.
48. Pancreas:
Head and uncinate process
1st part of Duodenum
2nd part of
duodenum
3rd part of duodenum
4th part of duodenum
1st-3rd parts of
duodenum
head of the pancreas
traversed by the common bile duct.
by the superior mesenteric vessels.
l It iIt includes the uncinate process which ishich is crossed by the
Cancer of the head
of the pancreas
Cancer of thof the head of the pancreas compresses the bile duct and reand results in OBSTRUCTIVE TYPE OF JAUNDICE.
Pain will bwill be conveyed to sensory neurons T5-T9 dorsal root ganglia via celiac plexus and greater splanchnic nerve.
Hepatitis also caalso causes jaundice but is associated with the fever.
NOTusually associated with fever.
If the cancer blocks the Wirsung duct, it can cause pancreatic enzymes to digest the
pancreas and the spleen via splenic artery.
Neck of the pancreas
Posterior to thto the neck of thof the pancreas is the site of formation of the PORTAL VEINL VEIN.
(1)Splenic vein joins with (2)superior mesenteric vein to form (3) portal vein.
Body of the pancreas
The body passes to the left and anterior to the (1)aorta and thand the (2) left kidney. posterior to the stomach
splenic artery undulates along the superior border of thof the body of the pancreas with the splenic vein coursing posterior to the bodhe body.
The splenic artery is tortuous and has branches
going down to perforate the pancreas.
Dr. Mavrych, MD, PhD, DSc [email protected]
Tail of the pancreas
l The tail of the pancreas enters the splenorenal ligament to reach the hilum of the spleen.
l It is the only part of the pancreas that is intraperitoneal.
l Tail of the pancreas may be mistakenly removed during spleenectomy (ligation of splenic artery and vein) and resulting in sugar diabetes because it contains a lot endocrine cells.
Dr. Mavrych, MD, PhD, DSc [email protected]
Arterial supply of the
pancreas
Head and Duodenum:
l (1) Superior pancreaticoduodenal arteries -branches of gastroduodenal artery.
l (2) Inferior pancreaticoduodenal arteries - branches of SMA
l This region is important for collateral circulation because there are anastomoses between these branches of the CA and SMA.
Neck, Body, and Tail of the pancreas:
l Pancreatic branches of the (3) Splenic artery.
1
2
3
Dr. Mavrych, MD, PhD, DSc [email protected]
Annular Pancreasl Annular pancreas is caused by
malformation during the
development of the pancreas,
before birth.
l Occurs when the ventral and dorsal
pancreatic buds form a ring around
the duodenum, thereby causing an
obstruction of the duodenum and
polyhydramnios
l Symptoms:
1. Feeding intolerance in newborns
2. Fullness after eating
3. Nausea and bile-stained vomiting
l Half of cases are not diagnosed
until symptoms occur in adulthood.
Dr. Mavrych, MD, PhD, DSc [email protected]
49. Spleen:
Rapture of the Spleen
l Rapture of the spleen may be result of the left 9th and 10th ribs fracture or blunt trauma of the left upper abdomen.
l The spleen is a peritoneal organ in the upper left quadrant that is deep to the left 9th, 10th, and 11th
ribs.
l The spleen follows the contour of rib 10 (axis of the spleen).
l When blood collected deep to the diaphragm phrenic nerveirritates and pain may irradiate to left shoulder.
l When spleen is ruptured, it cannot be sutured therefore removing is required.
Dr. Mavrych, MD, PhD, DSc [email protected]
Relations of the Spleen and
Left Kidney
l The spleen follows the contour of 10th riband extends from the superior pole of the left kidney to just posterior to the midaxillary line.
l The border between spleen and upper pole of the left kidney is 11th rib.
Dr. Mavrych, MD, PhD, DSc [email protected]
50. Kidney:
Dimensions and position
l During life, kidneys are reddish brown and measure approximately 11-12 cm in length, 5-6 cm in width, and 2.5-3 cm in thickness.
l They are extending from the level of T12 to the level of L3, the right kidney lying about2-3 cm lower than the left one.
l The lateral border of the kidney is convex. Its medial border is convex at both ends but concave in the middle where there is the hilum of the kidney (L1).
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Tail of the pancreas
enters the splenorenal ligament to reto reach the hilum of the splespleen.
the only part of the pancreas that is intraperitoneal.
mistakenly removed during spleenectomy (ligation of splenic artery and vein) and reand resulting in sugar diabetes
Endocrine pancreas contains
islet of langerhans that secretes
insulin (B cells glucose uptake)
and glucagon (A cells glucose
release)
Arterial supply of the of the
pancreas
- bra- branches of SMA
(1) Superior l
arteries -pancreaticoduodenal ries -branches of gas of gastroduodenal
rtery.artery.
(2) Inferior pancreaticoduodenal (2) Inferior pancreaticoduodenal l
- braarteries - bra- bra- bra- bra- branches of SMA
Pancreatic branches of the (3) Splenic artery.
Off Common
Hepatic a of
Celiac trunk
Off celiac trunk
Annular PancreasAnnular pancreas is cais caused by
malformation during the
development of the pancreas,
before birth.
the ventral and dorsal
pancreatic buds form a ring around
the duodenum, th, thereby causing an
obstruction of the duodenum and
polyhydramnios
Polyhyrdaminos (>1500mL) AF in the amnion bc the fetus is unable to
drink and recycle it. Also caused by esophageal atresis.
(Projectile vomiting)
after eating
bile-stained vomiting
are not diagnosed (Projectile
bile-stained vbile-stained v
are not diagnare not dvomiting)
ined vomitingined vomiting
t diagnosed osed
49. Spleen:
Rapture of the Spleen
and 10th ribs fracture or bor blunt trauma of the left upper abdomen.
RUPTURE
that isthat isin the upper left quadrant that isupper left quadrant that isthat isthat isthat isthat is 9th, 10th, a, and 11thp to the left deep to th , and 1
ribs.
phrenic nerveirritates and pain may irradiate to left shoulder.
When spl n is ruptured, it hen spleen is rucannot be sutured therefore removing is reis required.
Prenatally the spleen is primary source for hematopoiesis, post birth it is site of RBC
sequester, destruction, and filtration, it produces lymphoctyes and immune
surveillance, it recycles iron and globin. (Not vital organ)
The spleen has gastric, colic, renal, and costal impressions. It contains many
lymphatic nodules, red pulp (blood sinuses) and white pulp (germinal centers).
Relations of the Spleen and
Left Kidney
leen follows 10ththe contour of rib
and extends from the superior pole of the left kidney to just posterior to the midaxillary line.
The border between spleen and upper pole of the left kidney
11this rib.
50. Kidney:
Dimensions and position
parietal lateral plate mesoderm
11-12 cm in length, 5-6 cm in width, and 2.5-3 cm in thicin thickness.
el of T12 to the level of L3, the right kidney lying about2-3 cm lower than the left one.
hilum of the kidney (L1).
Hilum of the kidney contains the renal v
(front), renal a (middle), and ureter (back).
Kidneys are intermediate mesoderm from
mesonephric duct and metanephric cap.
Dr. Mavrych, MD, PhD, DSc [email protected]
Anterior relations
of the right kidney
1. Right suprarenal gland
2. 2nd part of the duodenum
3. Right lobe of the liver
4. Right colic flexure
5. Small intestine
Dr. Mavrych, MD, PhD, DSc [email protected]
Anterior relations
of the left kidney
1. Left suprarenal gland
2. Stomach
3. Spleen
4. Body of pancreas and splenic vessels
5. Descending colon
6. Small intestine
Dr. Mavrych, MD, PhD, DSc [email protected]
Renal (Gerota) fascia
l Enclosing the perinephric fat is
a membranous condensation
of the extraperitoneal fascia -
the renal fascia (3).
l The suprarenal glands (4) are
also enclosed in this fascial
compartment, usually
separated from the kidneys by
a thin septum.
l N.B. The renal fascia must
be incised in any surgical
approach to this organ.
3
4
Dr. Mavrych, MD, PhD, DSc [email protected]
Perinephric abscess
l Most infections of the perinephric space occur as a result of extension of an ascending urinary tract infection, commonly in association with nephrolithiasis or tuberculosis.
l Perinephric abscess typically descends down between 2 sheets of the renal fascia along the psoas major muscle.
l In case if abscess locates behind of the psoas major muscle it descendsdown and may affect hip joint.
l If abscess spreads up it�ll reach the diaphragm and irritate phrenic nerve. As result patient will feel pain in shoulder region.
Dr. Mavrych, MD, PhD, DSc [email protected]
51. Nephrolithiasis
l Renal calculi are solid concretions
(crystal aggregations) formed in the
kidneys from dissolved urinary minerals.
l There are several types of kidney
stones. The majority are calcium
oxalate stones, followed by calcium
phosphate stones.
l Kidney stones typically leave the body
by passage in the urine stream, and
many stones are formed and passed
without causing symptoms.
l If stones grow to sufficient size before
passage (at least 2-3 mm), they can
cause obstruction of the ureter (renal
colic).
Dr. Mavrych, MD, PhD, DSc [email protected]
3 constrictions of ureter:
l Ureter located on the anterior surface of the Psoas major muscle and has 3 constrictions:
l 1st constriction is at the pelviureteric junction (level of L1)
l 2d constriction lies at the level of pelvic brim (level of the sacroiliac joint)
l 3d constriction appears where ureter lies obliquely in the wall of urinary bladder (level of ischial spine)
1
2
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
rightright kidneykidney
L2 L1
pyramidalsemilunar
Suprarenal glands/adrenal glands have 3 sources of
bloody supply: Phrenic artery (superior), aorta (mid),
and renal artery (inferior)
Pouch of Morison
left kidney
APICAL
ANTEROSUPERIOR
ANTEROINFERIOR
INFERIOR
APICAL
POSTERIOR
INFERIOR
segments of posterior kideny
ascending colon to
transverse colon
Renal (Gerota) fascia
the perinephric fat is
a membranous condensation
of the extraperitoneal fascia -
suprarenal glands (4) are
also enclosed in this fascial
compartment, u
The renal fascia must
be incised in any surgical
approach to this organ.
Paranephric fat surrounds the
renal fascia and collagen bundles
thether the renal vessels and
kidneys in a fixed position even
though supine to erect
movements (~3cm) occurs during
inspiration.
Perinephric abscess
ult of extension of an ascending urinary tract infection, co
descends down between 2 sheets of the renal fascia along the psoas major muscle.
if abscess locates behind of the psoas major muscle it descendsdown and mand may affect hip joint.
If abscess spreads up it�ll reach the diaphragm and irrand irritate phrenic nerve. As result patient will feel pain in shoulder region.
Pus around the kidney within the perinephric/renal fascia
loosely attached renal fascia in anterior and posterior
layers can allow extension of abscess
51. Nephrolithiasis
Renal calculi are soare solid concretions
(crystal aggregations) formed in the
kidneys from dissolved urinary minerals.
es of kidney
stones. T calcium
oxalate stones, foes, followed by calcium
phosphate stostones.
ally leave the body
by passage in the urine stream, and
many stones are formed and passed
without causing symptoms.
If stones grow to
age (at least 2-3 mm), they can
cause obstruction of the ureter (renal
colic).
Kidney stones that can form and become located in
the calices of the kidneys, ureters or bladder.
Renal colic is abdominal pain that courses down from
loin to groin as stone moves anteroinferiorly.
ons of ureter:
pelviureteric junction
pelvic brim
urinary bladder
3 constrictions o3 constrictions o
Short renal v and Long renal a
Long renal v and short renal a
Dr. Mavrych, MD, PhD, DSc [email protected]
Staghorn calculi
l Renal stone that develops in the
renal pelvis and greater calices,
and in advanced cases has a
branching configuration which
resembles the antlers of a stag.
l Staghorn calculi are composed of
magnesium ammonium
phosphate, which forms in urine
that has an abnormally high pH
(above 7.2).
l This high pH usually develops
because of recurrent urinary tract
infection with microorganisms
such as Proteus mirabilis.
Dr. Mavrych, MD, PhD, DSc [email protected]
52. Suprarenal glands
l They are endocrine glands
having cortex and medulla.
l The adrenal cortex [1]
secretes aldosterone,
corticosteroids and
genital hormones.
1
2
l The chromaffin cells of the adrenal medulla [2]
secrete two catecholamines: epinephrine and
norepinephrine, which affect smooth muscle, cardiac
muscle, and glands in the same way as sympathetic
stimulation.
l Sympathetic stimulation or hypersecretion of catecholamines (tumor of adrenal medulla or sympathetic chain ganglia) resulting in: episodes of tachycardia, sweating and high blood pressure.
Dr. Mavrych, MD, PhD, DSc [email protected]
Unpaired tributaries of IVC
l The right renal (1) vein is much shorter than the left. Both veins lie anterior to the corresponding artery in hilum of kidneys.
l The long left renal vein (2)is joined by the left suprarenal (3) and leftgonadal (4) (testicular orovarian) veins before it reached IVC.
l Right suprarenal vein and right gonadal vein drain directly to IVC (unpaired IVC tributaries).
1
2
3
4
Dr. Mavrych, MD, PhD, DSc [email protected]
53. Varicocele
l It is enlargement of the pampiniform plexus that produces a wormlike scrotal mass and enlargement of the spermatic cord. Varicocele may be reason of low sperm count.
l Varicocele formation is usually on the left side and may disappear in supine position of the body.
l Varicocele may indicate kidney disease or may signal a retro peritoneal malignancy obstructing the testicular vein.
Dr. Mavrych, MD, PhD, DSc [email protected]
Pampiniform plexus
l Each testicular or ovarian vein is formed by coalescence of a pampiniform plexus: the testicular at the deep inguinal ring, the ovarian at the margin of the superior aperture of the pelvis.
l The veins run accompanied by the corresponding arteries. The left pampiniform plexus enters the left renal vein; the right one enters directly the IVC inferior to the renal vein.
l That is why varicocely (engorgement of the pampiniform plexus that produces a scrotal mass) is more often located on the left.
Dr. Mavrych, MD, PhD, DSc [email protected]
54. Hydrocele
l The tunica vaginalis testis or other remnants of the processus vaginalis may form a hydrocele or hematocele.
l In spermatic cord it is smooth sausage-shaped structure that persists under gentle compression and isn�t disappear in supine position.
l In the scrotum with transillumination, a hydrocele produces a reddish glow, whereas light will not penetrate other scrotal masses such as a hematocele, solid tumor, or herniated bowel.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Staghorn calculi
renal pelvis and greater calicter calices,
branching cg configuration whing confi
magnesium ammonium
phosphate, which forms in urine
that has an abnormally high pH
e of recurrent urinary tract
infection with microorganisms
such as Proteus mirabilis.
Nephroptosis: Drop kidney >3cm when standing, suprarenal glands stay in place within perinephric fat, ureters coil/kink.
Ectopic kidneys: abnormal location and formation congenitally.
Horseshoe kidney: inferior poles of kidneys fuse during embryonic development and are inhibited from ascending by IMA
Pancake kidney: inferior and superior poles of kidneys fuse into disc shape organ, also inhibited by IMA.
Pelvic kidney: failure of ascent of kidneys so they remain in pelvic region still attached to embryological renal vessels off common iliacs.
Renal agenesis (absent of kidneys) is common cause of oligohydraminos (<400mL AF) that can lead to pulmonary hyperplasia.
Hydronephrosis: extreme dilation of renal pelvis and calices due to obstruction of renal ureters, typically due to accessory renal vessels.
52. Suprarenal glands
endocrine glands
having cortex and medulla.
,
corticosteroids and
genital hormones.
The adrenal cortex [1]
secretes aldosterone,
The chromaffin cells of the adrenal medulla [2]
secrete two catecholamines: epinephrine and
norepinephrine, w
Sympathetic stimulation or hor hypersecretion of catecholamines ((tumor of adrenal medulla or sympathetic chain ganglia) re) resulting in: episodes of tachycardia, sweating and high blood pressure.
Congenital Adrenal Hyperplasia (CAH):
excessive androgen production bc of cortex
hyperplasia causing virilization of female genitals
h blood pressure.h blood pressure.
Congenital Adrenal Hyperplasia (CAH):
excessive androgenandrogenandrogen production bc of cortex
hyperplasia causing virilization of female genitals
Unpaired tributaries of IVC
right renal (1) vein isvein is much shorter
The long left renal vein (2)is joined by the left suprarenal (3) and leftgonadal (4)
Right suprarenal vein avein and right gonadal vein drvein drain directly to IVC
3. Varicocele53. Var3. Var
Nutcracker Syndrome: L Renal v passed UNDER the SMA
and ABOVE Aorta. Compression will cause backflow into the
L gonadal vein to pampiniform plexus.
.
May be mistaken for Hydrocele (fluid/blood) within tunica
vaginalis of the scrotum, but when lying down Hydrocele
DOES NOT Disappear!
enlargement of thof the pampiniform plexus that produces a wormlike scrotal mass
the left side and mand may disappear in supine position of the body.
Pampiniform plexus
ach testicular or ovarian vein is formed by coalescence of a pampiniform plexum plexus: the
That is why varicocely (engorgement of the pampiniform plexus that produces a scrotal mass) is mis more often located on the left.
54. Hydrocele
tunica vaginalis testis ostis or other remnants of the processus vaginalis may form a hydrocele or hematocele.
transillumination, a hydrocele produces a reddish glow, whereas light will not penetrate other scrotal masses such as a hematocele, solid tumor, or herniated bowel.
Testicular torsion is twisting of the testis within the
scrotum, it can cause ischemia to the blood vessels
and must be corrected quickly or may lose testis.
spermatocele
Cryptochidism: failure of testis to descend by age 6-9mo can cause infertility
Dr. Mavrych, MD, PhD, DSc [email protected]
55. Hemorrhoids:
Venous drainage from rectum
l Above pectinate line: superior
rectal vein [1] into portal
system [2].
l Below pectinate line: inferior
rectal vein [3] into inferior
vena cava [4].
1
2
3
4
Dr. Mavrych, MD, PhD, DSc [email protected]
External hemorrhoids
l Hemorrhoids are masses that
typically protrude from anus
during defecation.
l Hemorrhoids are commonly
associated with constipation,
extended sitting and straining at
the toilet, pregnancy, and
disorders that hinder venous return.
l 1. External hemorrhoids are
dilated tributaries of the inferior
rectal veins (IRV) BELOW THE
PECTINATE LINE and are painful
because the mucosa is supplied by
somatic afferent fibers of the
inferior rectal nerves (from
pudendal).
1
1
Dr. Mavrych, MD, PhD, DSc [email protected]
Internal hemorrhoids
l 2. Internal hemorrhoids are dilated tributaries of the superior rectal veins (SRV) ABOVE THE PECTINATE LINE and are not painful because the mucosa is supplied by visceral afferent fibers.
l Internal hemorrhoids frequently develop in chronic alcoholics because of liver cirrhosisand portal hypertension syndrome.
2
2
2
Dr. Mavrych, MD, PhD, DSc [email protected]
56. Perineal pouches:
Deep perineal pouch
The deep perineal pouch is
formed by the fasciae and
muscles of the urogenital
diaphragm.
It contains:
1. Sphincter urethrae
muscle
2. Deep transverse
perineal muscle
3. Bulbourethral
(Cowper) glands (in
the male only) - ducts
perforate perineal
membrane and enters
bulbar urethra.
Dr. Mavrych, MD, PhD, DSc [email protected]
Superficial perineal pouch1. Ischiocavernosus muscle � related to the Crus of the
penis (Male) & Crus of the clitoris (Female)
2. Bulbospongiosus muscle � related to the Bulb of vestibule (Female) & Bulb of the penis (Male)
3. Superficial transverse perineal muscle � related to the Perineal body (both genders)
1
2
3
Dr. Mavrych, MD, PhD, DSc [email protected]
Urine leaks
l After a crushing blow or a
penetrating injury, the spongy
urethra commonly ruptures
within the bulb of the penis, and
urine leaks into the superficial
perineal pouch.
l The superficial perineal fascia
keeps urine from passing into the
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubis into
the anterior abdominal wall deep
to the deep layer of superficial
abdominal fascia.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
55. Hemorrhoids:
Venous drainage from rectum
Above pectinate linate line: superior
rectal vein [1] into portal
system [2].
Below pectinate linate line: inferior
rectal vein [3] into inferior
vena cava [4].
PAINFUL
PAINLESS
External hemorrhoids
protrude from anus
during defecation.
constipation,
extended sitting and straining at
the toilet, pregnancy, and
disorders that hinder venous return.
BELOW THE
PECTINATE LINE and aand are painful
Internal hemorrhoids
are dilated tributaries of the superior rectal veins (SRV) ABOVE THE PECTINATE LINE and aand are not painful
frequently develop in chronic alcoholics because of liver cirrhosisand portal hypertension
56. Perineal pouches:
Deep pouchperineal
the fasciae and
muscles of the urogenital
diaphragm.
1. Sp1.1. Sp1. Sphincter urethrae
muscle
2.2.2. Deep transverse
perineal muscle
3.3. Bulbourethral
(Cowper) glands (inds (in
the male only) -) - ducts
perforate perineal
membrane and enters
bulbar urethra.
Superficial perineal pouchIschiocavernosus muscle �
Bulbospongiosus muscle �
Superficial transverse perineal mneal muscle �
Essential for integrity of the pelvic floor, Damage leads to prolapse of uterus, rectum, and urinary bladder
Males: between bulb of penis and anus, Females: between vagina and anus
Episiotamies in mediallateral incisions are made to widen pouch for labor, and to fix prolapses.
Bound laterally by Ishiopubic rami
& deep internal pudendal vessels
and pudendal n (dorsal VAN)
Bound inferiorly by perineal membrane and superiorly by pelvic diaphragm.
Dorsal neurovascular structures
of the glans penis and clitoris
Urine leaks
After a crushing blow or a
penetrating injury, the spongy
urethra commonly ruptures
within the bulb of the penis, an, and
urine leaks into thinto the superficial
perineal pouch.
The superficial perineal fascia
keeps urine from parom passing into the
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubis into
the anterior abdominal wall deep
to the deep layer of superficial
abdominal fascia.Fractures of the pelvic girdle can rupture the intermediate urethra and
cause extravasation of urine and blood into deep peritoneal pouch that may
pass through urogenital hiatus to bladder and prostate.
Straddle injury or false passage of catheter
Congenital persistence of allantois into urachus of the umbilicus can cause
urine to leak from belly button.
Dr. Mavrych, MD, PhD, DSc [email protected]
57. Ischiorectal abscess
2
3
l Ischiorectal abscess [1] is an important surgical condition which usually results from spread of an infection through the external sphincter ani into the ischiorectal fossa [2].
l Ischiorectal abscess is a surgical
emergency which should be
immediately drained by a wide cruciate
incision through the skin of the base of
the fossa to avoid fistula formation.
l A surgeon should avoid lateral wall of
ischiorectal fossa because here located
Pudendal (Alcock's) canal [3] with
pudendal nerve and internal pudendal
artery.1
Dr. Mavrych, MD, PhD, DSc [email protected]
58. Cystocele
(hernia of bladder)
l Loss of bladder support in
females by damage to the
pelvic floor during childbirth
(e.g., laceration of perineal
muscles or a lesion of the
nerves supply).
l It can result in protrusion of
the bladder onto the
anterior vaginal wall and
loss of urine when a women
strains or coughs.
Dr. Mavrych, MD, PhD, DSc [email protected]
59. Paracentesis of Urinary
Bladder
Suprapubic aspiration:
l Urine can be removed from the bladder without penetrating the peritoneum by inserting a needle JUST ABOVE the pubic symphysis.
l The needle passes successively through skin, superficial and deep layers of superficial fascia, linea alba, transversalis fascia, extraperitoneal connective tissue, and wall of the bladder.
Dr. Mavrych, MD, PhD, DSc [email protected]
60. Prostate tumors:
Prostate cancer
l It usually begins in the posterior lobe of the gland, and early stages are often asymptomatic, may be found during digital rectal examination.
l Prostatic malignancies tend to metastasize to vertebrae and the brain because the prostatic venous plexus has numerous connections with the vertebral venous plexus via sacral veins.
A
P
M
Dr. Mavrych, MD, PhD, DSc [email protected]
Benign hypertrophy of the
prostate (BHP)
l BHP is common in men after middle age.
l Prostate adenoma (benign hypertrophy) usually involves median lobe.
l BHP is a common cause of urethral obstruction, leading to nocturia (need to void during the night), dysuria(difficulty and/or pain during urination), and urgency(sudden desire to void).
l The prostate is examined for enlargement and tumors by DIGITAL RECTAL examination.
Dr. Mavrych, MD, PhD, DSc [email protected]
Prostatectomy
l A prostatectomy may be performed through a suprapubic [1] or perineal [2] incision or transurethrally [3].
l Because of damage to nerves in the capsule of the prostate and around the urethra (cavernosus nerves) can cause impotence (erectaile dysfunction) and/or urinary incontinence.
l Pelvic splanchnic nerves may be injured in case of intensive dissection of pelvic lymph nodes (prostatic cancer ectomy) and as result autonomic innervation of derivate of hindgut may be affected.
12
3
Transurethral
resection of the
prostate = TURP
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
57. Ischiorectal abscess
rom spread of an infection through the external sp cter ani into the rnal sphincter anischiorectal fossa [2].
surgical
emergency which shhich should be
immediately drained
uld avoid lateral wall of
ischiorectal fossa because here located
Pudendal (Alcock's) canal [3] with
pudendal nerve and internal pudendal 1 artery.
a to avoid fistula formation.
Fistulas are abnormal connections of organs and
tissues, Ischiorectal abscesses can travel to both sidess
and spread infection through the fat fad that raps
posteriorly around the rectum. Incisions must be made
as medial as possible. If Pudental canal is affected
there will be no arousal. Abscesses are also prone to
supralevator, internsphincteric, or perianal.
58. Cystocele
(hernia of bladder)
Loss of bladder support in
females by daby damage to the
pelvic floor during chring childbirth
protrusion of
the bladder onto the
anterior vaginal wall and
loss of urine when a hen a women
strains or coughs.
In extreme cases it can lead to
vaginal prolapse
59. Paracentesis of Urinary
Bladder
Suprapubic aspiration:Su
by inserting a needle JUST ABOVE the pubic symphysis.
Suprapubic cystotomy of a full bladder, as the
empty bladders lies just at height of pubis
does not transverse peritoneum
60. Prostate tumors:
Prostate cancer
ally begins in the posterior lobe of thof the gland, and early stages are often asymptomatic, may be found during digital rectal examination.
tatic malignancies tend to metastasize to vertebrae and the brain because thuse the prostatic venous plexus has nhas numerous connections with the vertebral venous plexus via sacral veinral veins.
Benign hypertrophy of prostate (BHP) is
common after middle age in majority of males
distorts the prostatic urethra (middle lobe).
Malignant tumors are irregular and hard and
often found in posterior lobe due to its
proximity to seminal vesicles and lymph.
Full bladder during exam tokeep prostate in place
Benign hypertrophy of the
prostate (BHP)
Prostate adenoma (be(benign hypertrophy) usually involves median lobian lobe.
nocturia (ne(need to void during the night), dysuria(difficulty and/or pain during urination), and urgency(sudden desire to void).
typically middle lobe Prostatectomy
suprapubic [1] or perineal [2] incision orsion or transurethrally [3].
allows preservation ofneurovasculature
Transurethral
of the resection of th
prostate = TURPTUR
Posterior lobe is mostly metastatic and spreads via Batson's plexus (male has lower back pain)
DIGITAL RECTAL examination.
Dr. Mavrych, MD, PhD, DSc [email protected]
61. Male urethra
Prostatic 1st part
l It is the widest and the most dilatable part.
l It is spindle shaped (middle part is dilated)
l Its posterior wall presents the following features:
1. Seminal colliculus
2. Openings of the 2 ejaculatory ducts are seen on each side on the seminal colliculus.
3. Ducts of the prostate gland open into the male urethra
Dr. Mavrych, MD, PhD, DSc [email protected]
Membranous 2nd part
l Passes through the urogenital diaphragm to enter the bulb of the penis
l It is the shortest, NARROWEST and the least dilatable part
l It is surrounded by the external sphincter urethra
l Bulbourethral glands lie posterolateral to this part inside of urogenital diaphragm (deep perineal pouch)
Dr. Mavrych, MD, PhD, DSc [email protected]
Spongy 3rd part
l Longest part: average 15 cm in length.
l Passes through the bulband corpus spongiosum of the penis to open at the external urethral orifice on the tip of the glans penis.
l There are two dilatations � bulbar fossa (in the beginning) and navicular fossa (in the glans penis)
l Ducts of the bulbourethral glands open into the floor of the spongy part in its beginning
Dr. Mavrych, MD, PhD, DSc [email protected]
2 sphincters of the urethra
1. Internal urethral sphincter is made of smooth muscles in the neck of the bladderand has sympatheticinnervation
2. External urethral sphincter has skeletal muscle fibers and surrounds the membranous part of urethra, supplied by the perineal branch of the pudendal nerve
1
2
Dr. Mavrych, MD, PhD, DSc [email protected]
62. Ejaculatory duct
l It is a very narrow duct
2 cm long
l Formed by union of
ductus deferens and
duct of seminal vesicle
l It serve to passage of
seminal fluid from
ductus deferens to
prostatic urethra.
Dr. Mavrych, MD, PhD, DSc [email protected]
63. Pudendal nerve (S2-S4)
l It is PRINCIPAL SOMATIC (motor and sensory) nerve to supply perineum.
l Lies against ischial spine as it passes through lesser sciatic foramen to traverse pudendal canal on lateralwall of ischiorectal fossa.
Branches:
l 1. Inferior rectal nerve
l Supplies external anal sphincter muscle and skin around anus
l 2. Perineal nerve
l Deep branch is motor nerve to muscles of urogenital triangle.
l Superficial branch gives cutaneous posterior scrotal/labial branches.
l 3. Dorsal nerve of penis or clitoris
l Supplies body, prepuce, and glans of penis or clitoris
1
2
3
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
61. Male urethra
Prostatic 1atic 1st part
s the widest and the most dilatable part.
Seminal colliculus
Openings of the 2 ejaculatory ducts are seare seen on each side on the seminal colliculus.
Ducts of the prostate gland open into the male urethra
opening of seminal glands
ductus deferens
Seminal vesicles secrete alkaline fructose solution that nourishes and provides energy for the sperm.Prostate gland secretes a milky fluid (20% of semen volume) and plays role in sperm activation.Bulbourethral glands (cowper's glands) secrete mucous solution that neutralizes urine within the urethra.
Membranous 2ous 2nd part
urogenital diaphragm to eto enter the bulb of the penis
shortest, NARROWEST and the least dilatable part
It is surrounded by the external sphincter urethra
(deep perineal pouch)
Spongy 3ngy 3rd part
Longest part: avart: average 15 cm in length.
bulband corpus spongiosum of the penis to open at the external urethral orifice on the tip of the glans penis.
bulbar fossa (in(in the beginning) and navicular fossa (in(in the glans penis)
The 1st and 2nd parts of the urethra are urogenital endoderm and the external urethra meatus is ectodermThe ductus deferens is intermediate mesoderm of the remaining mesonephric duct/tubules
2 sphincters of the urethra
Internal urethral cter is made of sphincter is
smooth muscles incles in the neck of the bladderand has sympatheticinnervation
External urethral sphincter has skeletal muscle fibers and surrounds the membranous part opart of urethra, su
pudendal nerve
Muscle of the bladder is Detrusor m, the urinary trigone is where theentrance of the 2 ureters and exit of bladder meet. Internal urethralsphincters are involuntary.
62. Ejaculatory duct
ery narrow duct
2 cm long
union of
ductus deferens and
duct of seminal vesicle
63. Pudendal nerve (S2-S4)
PRINCIPAL SOMATIC ((motor and sensory) nerve to supply perineum.
ugh lesser sciatic foramen to traverse pudendal canal on lateralwall of ischiorectal fossa.
Inferior rectal nerve
Supplies external anal sphinctel incter hincter
2. Perineal nerve
Deep branch is motor nerve to muscles l
of urogenital triangle.
Superficial branch gives cutaneous l
posterior scrotal/labial branches.
3. Dorsal nerve of penis or clitoris
Supplies body, prepuce, and glans of l
penis or clitoris
CREMASTERIC REFLEX: Genitofemoral nerve L1-2, Genital branch: within inguinal canal with the cremasteric m and fascia acts asmotor division to pull testis up. Femoral branch is the sensory division of the reflex that is stimulated by touch and temperature
Dr. Mavrych, MD, PhD, DSc [email protected]
Pudendal nerve block
l To relieve pain for the mother and prepare for an episiotomy, a pudendal nerve block may be administered during early labor.
The nerve may be blocked in 2 ways either:
1. by piercing the vaginal wallposterolaterally near the ischial spine or
2. percutaneously along the medial side of the ischial tuberosity.
l Note: Pain from uterine contractions is
unaffected because pelvic visceral
pain is carried by afferent fibers
accompanying autonomic nerve fibers.
Dr. Mavrych, MD, PhD, DSc [email protected]
64. Nerve supply of pelvic
viscera
Parasympathetic innervation:
l Preganglionic neurons are located in sacral parasympathetic n. (S2-S4) in the spinal cord.
l Their processes run into pelvic splanchnic nerves and relay with postganglionic neurons located inside of pelvic organs in the intramural plexus.
Sympathetic innervation:
l Sympathetic fibers of preganglionic neurons T12-L2 segments (IML) come through the sympathetic trunk and form sacral splanchnicnerves.
l They contribute to the inferior hypogastric plexus, where postganglionic neurons are located. Branches of inferior hypogastric plexus reach organs wrapping around the branches of the internal iliac artery.
Sensory innervation:
l The sensory fibers from S2-S4 dorsal root ganglia move together with parasympathetic and carry pain sensations from the organs.
Dr. Mavrych, MD, PhD, DSc [email protected]
Micturition reflex
Facilitating emptying:
l Parasympathetic fibers (pelvic splanchnic nn.) stimulateDETRUSOR MUSCLE [1] contraction and involuntary relax internal sphincter [2].
l Somatic motor fibers (pudendal nerve) cause voluntary relaxation of external [3] urethral sphincter.
Inhibiting emptying:
l Sympathetic fibers (sacral splanchnic nn.) inhibit detrusor muscle [1] and stimulate internal sphincter [2].
1
2
3
Dr. Mavrych, MD, PhD, DSc [email protected]
65. Erection and ejaculation l Afferent fibrous: Dorsal nerve of penis or clitoris from
Pudendal nerve (DRG S2-S4)
l Efferent fibrous:
l Erection: Parasympathetic fibers (S2-S4) from the Pelvic splanchnic nerves dilate arteries supplying erectile bodies of the penis, allowing them to fill with blood. Somatic motor (S2-S4) fibrous from the pudendal nerves cause contraction of ischiocavernosus and bulbospongiosus muscles to press the root of the penis and relax external urethral sphincter.
l Ejaculation: Sympathetic fibers (L1-L2) from the Inferior hypogastric plexus (Sacral splanchnic nerves) cause contraction of smooth muscle of epididymis, ductus deferens, seminal vesicles, and prostate; sympathetic nerve fibers stimulate internal urethral sphincter to prevent semen from entering bladder or urine entering prostatic urethra.
Dr. Mavrych, MD, PhD, DSc [email protected]
66. Cryptorchism
l Undescended testes
(cryptorchism) when the testes
fail to descend into the scrotum.
This normally occurs within 3
months after birth.
l The undescended testes may be found in the abdominal cavity or in the inguinal canal.
l If neglected, malignant transformation may occur in the undescended testis.
l N.B. In case of cryptorchism, spermatogenesis is arrestedand the spermatogenic tissue is damaged leading to permanent sterility in bilateral cases.
Dr. Mavrych, MD, PhD, DSc [email protected]
67. Torsion of the spermatic
cord
Main components of the spermatic cord:
l Ductus deferens
l Testicular artery � direct branch of Aorta
l Pampiniform plexus to become single testicular vein (right ! IVC, left ! Left renal vein)
l Torsion of the spermatic cord produces acute pain with swelling because of twisting of testicular artery that can result in testicular avascular necrosis.
l Repair requires a high scrotal incision to untwist the cord, and the testis is sutured to the scrotal septum to prevent recurrence.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Pudendal nerve block
relieve pain for thfor the mother and prepare for an episiotomy, a
vaginal wallposterolaterally near the ischial spine or
2. percutaneously along thlong the medial side of the ischial tuberosity.
Doctors hand is placed between the baby's head and the pudendal nerve.
64. Nerve supply of pelvic
viscera
Parasympathetic innervation:
Preganglionic(S2-S4)
pelvic splanchnic nerves postganglionic neurons lorons located inside of pelvic organs in the intramural pleral plexus.
Sympathetic innervation:
nepreganglionic T12-L2 the sympathetic trunk and form sacral splanchnic
nerves.
inferior hypogastric pletric plexus, wpostganglionic neurons arerons are located. Bra
Sensory innervation:
from S2-S4 dorsal root ganglia move together with parasympathetic and caand carry pain sensations fro
PNS Pelvic Splanchnic nerves to intramural plexus
SNS Sympathetic Trunk to Sacral Splanchnic nerves to inferior hypogastric plexus
Sensory DRG ride with PNS for PAIN
Micturition reflex
Facilitating emptying:
ers (pelvic splanchnic nn.) stimulate
ers (pudendal nerve) cause voluntary relaxation of external [3] u[3] urethral sphincter.
and involuntary relax sphincter [2].
Inhibiting emptying:
ers (sacral splanchnic nn.) in.) inhibit detrusor muscle [1] and stimulate internal sphincter [2cter [2].
[1] DETRUSOR MUSCLE [1] [1DETRUSOR MUSCLE [1] [1] contraction and in and involuntary relax internal sphinc
PNS & Pudendal to pee!
SNS to stop!
65. Erection and ejaculation
Pudendal nerve (DRG S2-S4)
Pelvic splanchnic nerves
pudendal nerves
and relax external urethral sphincter.
us (Sacral splanchnic nerves) contraction of smooth muscle of epididymis, ductus deferens, seminal vesicles, and prostate; sympathetic nerve fibers stimulate internal urethral sphincter to pto prevent semen from entering bladder or urine entering prostatic urethra.
1. Erection: PNS S2-4 fill blood, Ischiocavernosus m keeps erect, and bulbospongiosus m
prevents venous drainage.
2. Emission: SNS move sperm from epididymis and cause gland secretions
3. Ejaculation: SNS Closure of Internal sphincter, contraction of urethral m and
bulbospongiosus m
4. Remission: blood leaves
66. Cryptorchism
Undescended testes
This normally occurs within 3
months after bifter birth.
found in the abdominal cavity or in the inguinal canal.
malignant transformation may omay occur in the undescended testis.
spermatogenesis is arrested
67. Torsion of the spermatic
cord
ces acute pain with swelling because of twisting of testicular artery that cathat can result in testicular avascular necrosis.
untwist the cord, a, and the testis is sutured to the scrotal septum to prevent recurrence.
Dr. Mavrych, MD, PhD, DSc [email protected]
68. Lymphatic drainage of the
male viscera
n Testis & epididymis � lumbar
lymph nodes
n Scrotum � superficial inguinal
nodes
n Penis:
n skin - superficial inguinal nodes
n glans � deep inguinal nodes
n body and roots � internal iliac
nodes
n Prostate gland & bladder - internal
iliac nodes
n Anal canal:
n above pectinate line - internal iliac
n below pectinate line - superficial
inguinal nodes
Dr. Mavrych, MD, PhD, DSc [email protected]
Lymphatic drainage from the
female visceran Ovary and uterine tubes � to Lumbar
lymph nodes
n Uterus:
n lateral angle and teres ligament �Superficial inguinal lymph nodes
n fundus and upper part of the body- Lumbar lymph nodes
n lower part of the body - External iliac lymph nodes
n cervix - External & Internal iliac
n Vagina:
n Superior to hymen - to External & internal iliac
n Inferior to hymen - to Superficial inguinal nodes
n All external genitalia (with exception -glans clitoris) - Superficial inguinal lymph nodes
n Glans clitoris � Deep inguinal
Dr. Mavrych, MD, PhD, DSc [email protected]
69. Arterial supply of the uterus
and Hysterectomy
The uterus is almost exclusively
supplied by the uterine arteries
[1] (from internal iliac artery):
l Uterine a. crosses pelvic floor in
cardinal ligament [2]
l Ureter passes superior and
anterior to uterine artery[3]
l Ascending branch [4] of uterine
artery comes along lateral wall of
uterus within broad ligament.
2
1
3
4
Note: During hysterectomy ureter in the
greatest risk because of close relations
with uterine artery and cervix of the
uterus.
Dr. Mavrych, MD, PhD, DSc [email protected]
Hysterectomy
l Hysterectomy is surgical removing of the
uterus and may include removing of the cervix
(total) and the vagina (radical).
l Blood supply to the ovaries is saved in case of
partial hysterectomy ovarian suspensory
ligament should be left intact because contain
ovarian artery (direct branch of abdominal
aorta) and vein.
l In case of total hysterectomy (with cervix)
pelvic splanchnic nerves may be affected.
That�s resulting in bladder dysfunction
because of detrusor urine muscle loose
parasympathetic innervation.
Dr. Mavrych, MD, PhD, DSc [email protected]
70. Parts of the uterine tube
l Uterine partl Pierces uterine wall to
open into uterine cavity
l Isthmusl Narrowest part of tube
just lateral to uterus
l Ampullal Medial continuation of
infundibulum comprising about half of uterine tube
l Usual site of fertilization
l Infundibuluml Funnel-shaped expansion
of lateral end, fringed with fimbriae
l Overlies ovary and receives oocyte at ovulation
Dr. Mavrych, MD, PhD, DSc [email protected]
Hysterosalpingography
l The instillation of
viscous iodine
through the
external os [1] of
the uterine cervix
allows the lumen of
the cervical canal
[2], the uterine
cavity [3], and the
different parts of
the uterine tubes
[4] to be visualized
on X-ray.
1
2
34
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
68. Lymphatic drainage of the
male viscera
Testis & epididymis � lumbar
lymph nodes
Scrotum � superficial inguinal
nodes
Penis:
skin - superficial inguinal nodesn
glans � deep inguinal nodesn
body and roots � internal iliac n
nodes
Prostate gland &land & bladder - internal
iliac nodes
Anal canal:
above pectinate line - internal iliacn
below pectinate line - superficial n
inguinal nodes
Deep inguinal nodes-> superficial inguinal nodes-> internal & external iliac nodes-> lumbar nodes-> paraaortic nodes-> thoracic duct
Ovary and uterine tubes � to� to Lumbarlymph nodes
Uterus:
lateral angle and teand teres ligament �n
Superficial inguinal lymph nph nodes
fundus and upper part opart of the bodyn
- Lumbar lymph noph nodes
lower part opart of the body - External n
iliac lymph noph nodes
cervix - External & Internal iliacn
Vagina:
Superior to hymen - to External & n
internal iliac
Inferior to hymen - to Superficial n
inguinal nodes
All external genitalia (w(with exception -glans clitoris) - Superficial inguinal lymph nodes
Glans clitoris � Deep inguinaln
69. Arterial supply of the uterus
and Hysterectomy
uterine arteries
[1] (from internal iliac artery):
Ureter passes below the Uterineartery (bridge over water)
Uterine a anastamosis withOvarian a from aorta on lateralsides of the uterus. Both need tobe taken out so that the pt does notbleed out..The Uterine a is homologous to theductus deferens a in males and theOvarian a is the testicular a inmales
l Hysterectomy is suis surgical removing of the
uterus and mand may include removing of the cervix
(total) and thand thand th vagina (radical).and thand the vagina (ra
Blood supply to the ovaries is saved in case of Blood supply to the ovaries is sal
partial hysterectomy ovarian suspensory
ligament should bould be left intact because contain
ovarian arian artery rian ar
se of total hysterectomy (with cervix)
pelvic splanchnic nerves may bemay be affected.
That�s resulting in bladder dbladder dysfunctionlting in bladder d
because of detrusor uusor urine m
etic in
rine muscle rine m loose
etic inparasympathetic in
No contraction of bladder and no relaxation ofinternal sphincter.
f the uterine turine tuberine tu
l
oviduct, fallopian tube, ovarian tube...
l Uterine part
Isthmus
Ampulla
Infundibulum
fimbriae
Overlies ocyte at
rlies ovary and Overlies ovl
receives oocyte cyte at cyte receives oocyte
Cornua of the uterus
Hysterosalpingography
Ampulla is the site of ectopic pregnancy if the fertilized
ovum does not make its way to the fundus of the uterus.
The Uterine Triad: Fallopian tube, Round lig of uterus (inguinal
canal), and ovarian lig come off the fundus of the uterus.
tion of
viscous iodine
through the
external os [1] of
the uterine cervix
allows the lumen of
the cervical canal
[2], th, the uterine
cavity [3], a, and the
different parts of
the uterine tubes
[4] to bto be vto be visualized
on X-ron X-rn X-ray.n X-raon X-raon X-ra
Can be used to detect uterine tube
obstructions or malformations of uterus/
vagina (bicornate uterus)
Dr. Mavrych, MD, PhD, DSc [email protected]
71. Branches of the Internal
iliac artery
Anterior Division Posterior Division
1. Obturator 1. Iliolumbar
2. Umbilical 2. Lateral sacral
3 Inferior gluteal 3. Superior gluteal
4. Internal pudendal
5. Inferior vesical (males)
or
Vaginal (females)
6. Middle rectal
7. Uterine (females)
Dr. Mavrych, MD, PhD, DSc [email protected]
Internal iliac artery
Dr. Mavrych, MD, PhD, DSc [email protected]
72. Fracture of the
anterior cranial fossa
l Fracture of the anterior cranial
fossa (Cribriform plate of the
Ethmoid bone) is suggested by
anosmia, periorbital bruising
(raccoon eyes), and CSF leakage
from the nose (rhinorrhea).
Dr. Mavrych, MD, PhD, DSc [email protected]
73. Cranial Malformations
l [A] Scaphocephaly: premature
closure of the sagittal suture, in
which the anterior fontanelle is small
or absent, results in a long, narrow,
wedge-shaped cranium.
l [C] Oxycephaly: premature closure
of the coronal suture results in a
high, tower-like cranium.
l When premature closure of the
coronal or the lambdoid suture occurs
on one side only, the cranium is
twisted and asymmetrical, a condition
known as plagiocephaly [B].
Dr. Mavrych, MD, PhD, DSc [email protected]
74. Epidural hematoma
l Skull fracture near pterion often
causes epidural hematoma from
torn middle meningeal artery
(foramen spinosum).
l Unconsciousness and death are
rapid because the bleeding
dissects a wide space as it strips
the dura from the inner surface of
the skull, which puts pressure on
the brain.
l An epidural hematoma forms a
characteristic biconvex pattern
on computed tomography
images.
Dr. Mavrych, MD, PhD, DSc [email protected]
76. Infection of the Cavernous
sinus
Structures which may be affected by cavernous sinus thrombosis:
1. Structures that pass throughsinus directly:
Ø Internal carotid artery (in case of laceration - arteriovenous fistula)
Ø Abducens nerve CN VI (in case of lesion - internal squint)
2. Structures on lateral wall of sinus:
Ø Oculomotor nerve (CN III)
Ø Trochlear nerve (CN IV)
Ø V1
Ø V2
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
71. Branches of the Internal
iliac artery
aberrant or accessory arteries are common in obturator, inferior vesicle
w/ superiorvesicle of bladder
ductus deferens
bladder
urachus
bladder
obturator canal
to medial sacral a
gluteus maximus
gluteus med & min
coccygeus m
genitals
between lumosacral trunk & S1
to medial sacral a
goes back up
alcock's canal
Internal iliac arteryInternal iliac artery
to medial
gluteus maximusmaxi
gluteus
72. Fracture of the
anterior cranial fossa
(Cribriform plate of the
Ethmoid bone)
anosmia, periorbital bruising
(raccoon eyes), and CSF leakage
from the nose (rhinorrhea).
73. Cranial Malformations
[A] Scaphocephaly: premature
closure of the sagittal suture, in
long, narrow,
wedge-shaped cracranium.
[C] Oxycephaly: premature closure
of the coronal suture
high, tower-like cracranium.
coronal or the lambdoid suture occurs
on one side only, the cranium is
twisted and asymmetrical, a condition
known as plagiocephaly [B]
Craniosyntosis-FGFR2 gene mt
74. Epidural hematoma
torn middle meningeal artery
(foramen spinosum)
Unconsciousness and death are
rapid because thuse the bleeding
dissects a wide space as it strips
the dura from the inner surface of
the skull, which puts pressure on
the brain.
ristic biconvex pattern
Bean Bleed
Subdural Hematoma: blood spread over brain, Shaken Baby
Syndrome, coup and counter coup injuries, cause bleeding from
bridging veins
can push uncus through foramen magnum and compress CNIII causing pupillary
dilation (SNS) bc no PNS to constrictor, eye points down and out (CNVI and IV take
over), ptosis bc levator palpebrae m
pterionSkull fracture near
76. Infection of the Cavernous
sinus
cavernous sinus thrus thrombosis:
Internal carotid artery
Abducens nerve CN VI
Oculomotor nerve (CN III)
Ø Trochlear nerve (CN IV)
Ø V1
Ø V2
Medial Rectus adduction takes over (cross-eyed) initially, if bleed persists
then lateral wall structures will be affected: loss of eye movements and
visual acuity. Loss of sensory to face
Dr. Mavrych, MD, PhD, DSc [email protected]
Dangerous triangle of the face
l The middle third of the face is a "danger area� because infection there may produce thrombophlebitis of the facial vein that can spread to the cavernous sinus via ophthalmic veins or pterygoid venous plexus.
l Septicemia leads to meningitis and cavernous sinus thrombosis, both of which can cause neurological damage and are life-threatening.
Dr. Mavrych, MD, PhD, DSc [email protected]
77. Pituitary gland tumors and
transsphenoidal operation
l Pituitary tumors [1] may extend
superiorly through opening in the
diaphragma sella, producing
disturbances in endocrine system.
l Superior extension of a tumor may
cause visual deficit owing to pressure
on the optic chiasm [2], the place
where the optic nerve fibers cross.
l The transsphenoidal operation is the
most common operation for a pituitary
tumor. The surgical approach for it is
through the nose, nasal cavity and
sphenoidal sinus [3]. This surgical
approach provides the best exposure
of the tumor at the lowest risk.
12
3
Dr. Mavrych, MD, PhD, DSc [email protected]
Hormones of the pituitary
gland
l Releasing and inhibiting factors
from neurosecretory cells of the
hypothalamus reach pituitary
gland thought special capillary
network � hypophyseal portal
system and control the production
of adenohypophyseal hormones
(ACTH, FSH, LH, TSH, prolactin
and somatotropin).
l Hormones of neurohypophysis
(ADH and Oxytocin) are secreted
in hypothalamus and transported
through axons to pituitary gland.
Dr. Mavrych, MD, PhD, DSc [email protected]
78. Trigeminal nerve
l Skin of face supplied by branches of the three divisions of the [1] TRIGEMINAL NERVE (CN V)
l Except for a small area over the angle of the mandiblewhich is supplied by the [2] great auricular nerve(C2-C3) � cervical plexus
2
1
Infraorbital
foramen
Dr. Mavrych, MD, PhD, DSc [email protected]
79. Bell's palsy
l It is idiopathic unilateral facial
paralysis.
l Terminal branches of CN VII
may be injured by parotid
cancer or inflammation
(parotitis) by surgery to
remove a parotid tumor
(stylomastois foramen).
l Manifestations:
l unable to close lips and eyelids on affected side
l eye on affected side is not lubricated (dry eye)
l unable to whistle, blow a wind instrument, or chew effectively
l facial distortion due to contractions of unopposed contralateral facial
muscles
Dr. Mavrych, MD, PhD, DSc [email protected]
80. Epistaxis
l Epistaxis (nosebleed) most often occurs from the anterior nasal septum (Kiesselbach's area), where branches of the sphenopalatine, anterior ethmoidal, greater palatine, and superior labial (from facial) arteries converge.
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Dangerous triangle of the face
Facial v (cheeks)-> angular v (lateral nose)-> opthalmic v (super& inferior eye)-> Cavernous sinus (BRAIN)
swelling of v w/ blot
clot that goes to brain
thrombophlebitis o
Septicemia leads to meningitis and cavernous sinus thrombosis,
are life-threatening. bacterial infection response
77. Pituitary gland tumors and
transsphenoidal operation
Pituitary tumors [1
disturbances in endocrine sysine system.
Superior extension of a tumor may
cause visual deficit owing to pressure
on the optic chiasm
The transsphenoidal operation is the
most common operation for a pituitary
tumor. Th
through the nose, nasal cavity and
sphenoidal sinus [3][3]. This surgical
approach provides the best exposure
of the tumor at the lowest risk.
Hormones of the pituitary
gland
Releasing and inhibiting factors
from neurosecretory cells of the
hypothalamus
rk � hypophyseal portal
system and coand control the production
of adenohypophyseal hormones
neurohypophysis
(ADH and Oxytocin) are secreted
in hypothalamus and transported
through axons to pituitary gland.
ACTH-> adrenal gland-> cortisol
FSH-> follicles of ovaries
LH-> ovaries and leydig cells
TSH-> thyroid gland for release of T4&T3 TH
Prolactin-> mammary gland
Somatotrophin-> GH -> bones and muscles
.
ADH/Vasopressin to collecting duct and DCT of nephron-> water reabsorption
Oxy to uterus for uterine contractions and orgasm
78. Trigeminal nerve
CNV1: sensory to forehead, sinuses, nose, dilator pupillae (SNS) and sensory
blinking reflex, (VII is motor)
CNV2: sensory to cheeks, nose, upper mouth, tears (SNS/PNS)
CNV3: sensory to chin, lower mouth, ant 2/3 tongue (taste is VII), ears, scalp,
muscles of mastication
Skin of face su
angle of the mandiblewhich is supplied by the [2] great auricular nerve(C2-C3) �
79. Bell's palsy
unilateral facial
paralysis.
Terminal branches of CN VIIl
injury as passes
through parotid gland
w/ retromandibular v
and external carotid a
unable to close lips and eyelids on affected side
eye on affected side is not lubricated (dry eye)l
unable to whistle, blow a wind instrument, or chew effectivelyl
facial distortion due to contractions of unopposed contralateral facial l
muscles
Lesion of CNVII at internal acoustic meatus causes no saliva/tears, hyperacoustics (stapedius m),
imbalance and distorted hearing (CNVIII)
Lesion past geniculate ganglion causes hyperacoustics and Bell's
Lesion at chorda tympani causes no taste, no saliva from submandibular& sublingual glands
Lesion at stylomastoid foramen causes Bells
(stylomastois forois foramen)
80. Epistaxis
(nosebleed) most often occurs from the anterior nasal septum (Kiesselbach's area),
sphenopalatine,
greater palatine,
Splenopalantine and Greater palantine as are most vulnerable bc
they are in Atrium of middle meatus
Can be corrected using CNXI
spinal accessory n transplant
Dr. Mavrych, MD, PhD, DSc [email protected]
81. Sinusitis
Sphenoiditis
l Relationships of the
sphenoidal sinus are clinically
important ; because of potential
injury during pituitary
surgery and the possible
spread of infection.
l Infection can reach the sinuses
through their ostia from the
nasal cavity or through their
floor from the nasopharynx.
l Infection may erode the walls to
reach the cavernous sinuses,
pituitary gland, optic nerves,
or optic chiasma
Dr. Mavrych, MD, PhD, DSc [email protected]
Ethmoiditis
l Infection in the ethmoidal
sinuses can erode the medial
wall of the orbit, resulting in
orbital cellulites that can
spread to the cranial cavity.
l In orbital cavity infection may
erode structures related to the
medial orbital wall:
l Medial rectus muscle
l Superior oblique muscle
l Nasociliary nerve
Dr. Mavrych, MD, PhD, DSc [email protected]
83. Cheeks
l Form the lateral, movable walls of
the oral cavity and the zygomatic
prominences of the cheeks over the
zygomatic bones.
l Buccinator [1] � principal muscle
of the cheek.
l Buccal pad of fat � encapsulated
collection of fat superficial to
buccinator.
l Parotid duct [2] from Parotid gland
[3] perforate buccinator and opens in
inner surface of the cheek right
opposite 2nd upper molar tooth
2
1
3
Dr. Mavrych, MD, PhD, DSc [email protected]
84. Movements at the TMJs
All 4 muscles of
mastication are
innervated by V3:
1. Temporalis �
elevation &
retraction
2. Masseter -
elevation
3. Medial
pterygoid -
elevation
4. Lateral
pterygoid -
protrusion
Note: In case of mandibular nerve
damage mandible (when it is
protruded) deviate toward the side of
lesion because of Lateral pterygoid
weakness.
Dr. Mavrych, MD, PhD, DSc [email protected]
85. Innervation of the tongue
1. Sensory anterior 2/3: general � lingual n. (V3),
taste � chorda tympani (CNVII)
2. Sensory posterior 1/3: general and taste �
glossopharyngeal (CNIX)
3. Motor � hypoglossal (CNXII)
Ø A lesion of the chorda tympani � lose of the taste
sensation anterior 2/3 of the tongue
Ø A lesion of the lingual nerve � lose of both
general and taste sensation anterior 2/3 of the
tongue
Ø A lesion of CN XII (hypoglossal canal) allows the
contralateral, unparalyzed genioglossus muscle to
pull the protruded tongue toward the paralyzed side
(deviation and atrophy of the tongue).
Dr. Mavrych, MD, PhD, DSc [email protected]
86. Gag reflex
l Touching the posterior part of the
pharynx results in muscular
contraction of each side of the
pharynx - gag reflex:
l Afferent limb: CN IX
l Efferent limb: CN X
l Injury to the
GLOSSOPHARYNGEAL NERVE
(CN IX) will result in a negative
gag reflex
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
81. Sinusitis
Sphenoiditis
sphenoidal sinus are clare clinically
important ; because of potential
injury during pituitary
surgery and thand the possible
spread of infection.
Infection may erode the walls to
reach the cavernous sinuses,
pituitary gland, optic nerves,
or optic chiasma
Ethmoiditis
Infection in the ethmoidal
sinuses can ecan erode the medial
wall of thof the orbit, resulting in
orbital cellulites that cathat can
spread to the cranial cavity.
medial orbital wall:
Medial rectus musclel
Superior oblique musclel
Nasociliary nervel
No adduction, no down and out rotation of the eye,
and constricted pupils w/ lack of corneal reflex
(sensory: touch eye and no blink)
83. Cheeks
Buccinator [1]
Parotid duct [2] from Parotid gland
site 2ndopposite 2 upper molar
84. Movements at the TMJs
1. Temporalis �
2. Masseter -
Temporal Maxillary Junction
3. Medial
pterygoid
4. Lateral
pterygoid
Only muscle to
open jaw/mouth
mandibular nerve
V3:
Strong
closes jaw
Tensor veli palatini m prevents inhale of food and equalizes the air
pressure to protect tympanic membrane
Tensor tympani dampens the sound from chewing
85. Innervation of the tongue
Sensory anterior 2/3: g al � lingual n. (V3),
taste � chorda tympani (CNVII)
Sensory posterior 1/3: ge: general and taste �
glossopharyngeal (CNIX)
Motor � h� hypoglossal (CNXII)
bc chorda tympani runs with lingual n
lesion of CN XII (hypoglossal canal)
ral, unparalyzed genioglossus muscle to
pull the protruded tongue toward the paralyzed side
(deviation and atrophy of the tongue).
Lick your wounds
weaker unparalyzed genioglossus m is
unable to maintain contraction of
tongue out, the opposite side takes
over and pushes tongue to the side of
lesion.
86. Gag reflex
Touching the soft palate or posterior pharynx will be sensed
via CNIX pharyngeal branch (afferent) and stimulate a
response (efferent) through CNX pharyx, larynx, and palate
ms to "gag"
rent limb: CN X
Afferent limb: CN IXl
Efferent liml
GLOSSOPHARYNGEAL NERVE
(CN IX) will rewill result in a negative
gag reflex No longer sensed
Dr. Mavrych, MD, PhD, DSc [email protected]
87. Palatine tonsils
l Receives main blood supply
from tonsillar branch of
facial artery
l Drained by lymph vessels
mainly to jugulodigastric
lymph node, which is body's
most frequently enlarged
lymph node
l Nerve supply: tonsillar
plexus of nerves formed by
branches of CN IX and CN X
Dr. Mavrych, MD, PhD, DSc [email protected]
Tonsillitis
l During palatine tonsillectomy, the
peritonsillar space facilitates tonsil
removal, except after capsular
adhesion to the superior constrictor.
l If the glossopharyngeal nerve
CNIX is injured, taste and general
sensation from the posterior 1/3 of
the tongue are lost.
l Hemorrhage may occur, usually
from the tonsillar branch of the
facial artery; if the superior
constrictor is penetrated, a high
facial artery or tortuous internal
carotid artery may be injured.
Dr. Mavrych, MD, PhD, DSc [email protected]
88. Muscles of Soft Palate
1. Tensor veli palatini and
2. Levator veli palatini � elevates
the soft palate during swallowing
to prevent food entering to the
nasopharynx
3. Palatoglossus and
4. Palatopharyngeus � depress
soft palate and pulls walls of
pharynx superiorly
5. Uvular muscle � shortens uvula
and pulls it superiorly
Dr. Mavrych, MD, PhD, DSc [email protected]
89. Lymph drainage from face
structures
1. Preauricular (parotid ) (on front
of auricle) receive lymph from
anteriolateral part of scalp
(including eyelids)
2. Submandibular (in digastric or
submandibular ") � from all air
sinuses, nose and adjacent
cheek, upper lip and lateral
parts of lower lip.
3. Submental (in submental ") �
from the chin, tip of the tongue
and central part of the lower
lip.
1
23
Dr. Mavrych, MD, PhD, DSc [email protected]
90. Blow-out fracture
l A blow-out fracture of the
orbital floor typically is not
involve the orbital rim and is
caused by blunt trauma to the
orbital contents (e.g., by a
handball). Content of orbital
cavity blow-out in maxillary
sinus.
l Blow-out fractures may damage:
1. Inferior rectus muscle
2. Infraorbital nerve (from
maxillary V2)
3. Infraorbital artery
(hemorrhaging).
Dr. Mavrych, MD, PhD, DSc [email protected]
91. Muscles of the orbit
Muscle Action Innerva-
tion
Superior rectus Elevates and adducts
pupil
CN III
Inferior rectus Depresses and adducts
pupil
CN III
Medial rectus Adducts pupil CN III
Lateral rectus Abducts pupil CN VI
Superior oblique Depresses and abducts
pupil
CN IV
Inferior oblique Elevates and abducts
pupil
CN III
Levator pulpebra superior Elevates upper eyelid CN III
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
87. Palatine tonsils
es of CN IX and CN and CN X
tonsillar branch of
facial artery
Drained by lymph vessels
mainly to jugulodigastric
lymph node,
Found between Faucel Pillars and become highly inflamed during infection
Tonsilectomy and adenoectomy can risk the tonsilar a and v.
.
Pharyngeal, Tubal, Palatine, Lingual Tonsils (Waldeyer's ring of lymph tissue)
palatine tonsillectomy, the
peritonsillar space facilitates tonsil
removal, ex
glossopharyngeal nerve
CNIX is inis injured, taste and general
sensation from throm the posterior 1/3 of
the tongue are lost.
Tonsillitis
88. Muscles of Soft Palate
Tensor veli palatini
Levator veli palatini �
CNV3 prevents inhalation of food & equalizes
pressure to protect tympanic membrane
Palatoglossus
Palatopharyngeus
Uvular muscle �
CNX innervation via pharyngeal branch
ALLOWS EFFICIENT SWALLOWING!
Lesion to Vagus can be seen as Uvula deviation to
opposite of lesion
89. Lymph drainage from face
structures
Preauricular ((parotid ) (on front
of auricle) receive lyeive lymph from
anteriolateral part of scalp
Submandibular (in digastric or
submandibular ") � from alrom all air
sinuses, nose and aand adjacent
cheek, upper lip and lateral
parts of lower lip.
Submental (in submental ") �
from the chin, tip of the tongue
and central part of the lower
lip.
Swallowing has 3 stages:
1. chew to create bolus (CNV3), tongue rise to hard palate (CNX, IX, VII, XII),
hyoid elevates, and fauceal pillars up and back
2. Seal nasopharynx w/ soft palate and epiglottis (CNX)
3. constrictors contract and pull up larynx to push bolus down
Triangles of neck:
Carotid: post digastric, omohyoid, SCM contain internal jugular v, common
carotid a, and vagus
Submandibular/submental: growth of lip can be throat cancer (CNVII, XII)
Muscular: isthmus of thyroid larynx and trachea
Posterior: Trapezius, SCM, clavical contain ext jugular v, and brachial plexus
90. Blow-out fracture
orbital floor
-out fracture of the
d by blunt trauma to the
orbital contents (e
all). Content of orbital
cavity blow-out in maxillary
sinus.
1. Inferior rectus muscle
Infraorbital nerve (from 2.
maxillary V2)
Infraorbital artery 3.
(hemorrhaging).
No look down, no sensation to upper mouth and
bleeding from branch of external carotid a
Branches of External Carotid Artery
Some = Superior Thyroid A.
Angry = Ascending Pharyngeal A.
Lady = Lingual A.
Found = Facial A.
Out = Occipital A.
P = Posterior Auricular A.
M = Maxillary A.
S = Superficial Temporal A.
91. Muscles of the orbit
Superior rectus Elevates and adductsE CN III
pupil
Inferior rectus Depresses and adductsD CN III
pupilpupil
Medial rectusMedial rectus Adducts pupilAAdducts pupil CN III
Lateral rectusLateral rectus Abducts pupilAAbducts pupil CN VI
Superior oblique Depresses and abductsD CN IV
pupilpupil
Inferior oblique Elevates and abductsE CN III
pupilpupil
Levator pulpebra superior Elevates upper eyelidE CN III
Dr. Mavrych, MD, PhD, DSc [email protected]
92. Strabismus
Oculomotor Nerve Palsy (CNIII)
l Oculomotor Nerve Palsy
(external squint) affects most of the
extraocular muscles
l Manifestations:
l ptosis,
l fully dilated pupil,
l and eye is fully depressed and
abducted (�down and out�) due to
unopposed actions of superior
oblique and lateral rectus,
respectively.
Dr. Mavrych, MD, PhD, DSc [email protected]
Trochlear Nerve Palsy (CNIV)
l Lesions of this nerve or its nucleus
cause paralysis of the superior
oblique and impair the ability to turn
the affected eyeball infero-medially
(pupil look superio-laterally)
l The characteristic sign of trochlear
nerve injury is diplopia (double
vision) when looking down (e.g.,
when going down stairs)
l The person can compensate for the
diplopia by inclining the head
anteriorly and laterally toward the side
of the normal eye.
Dr. Mavrych, MD, PhD, DSc [email protected]
Abducens Nerve Palsy (CNVI)
l Abducens Nerve Palsy
(internal squint). Injury to abducens
nerve ® paralysis of lateral rectus
® inability to abduct the affected
eye
l Affected eye is fully adducted by
the unopposed action of the medial
rectus that is supplied by CN III
Dr. Mavrych, MD, PhD, DSc [email protected]
93. Horner syndrome
l Penetrating injury to the neck,
Pancoast tumor, or thyroid carcinoma
may cause Horner syndrome by
interrupting ascending preganglionic
sympathetic fibers anywhere between
their origin in the T1 segment (IML) of
spinal cord and their synapse in the
Superior cervical ganglion.
l It includes the following signs:
l Constriction of the pupil (miosis)
l Drooping of the superior eyelid
(ptosis),
l Redness and increased temperature
of the skin (vasodilation)
l Absence of sweating (anhydrosis)
Dr. Mavrych, MD, PhD, DSc [email protected]
94. Otitis Media
l Hearing is diminished because of
pressure on the eardrum and
reduced movement of the ossicles.
l Taste may be altered because the
chorda tympani is affected.
l Infection spreading posteriorly
cause mastoiditis.
l Infection that spreads to the
middle cranial fossa can cause
meningitis or temporal lobe
abscess, and infection moving
through the floor may produce
sigmoid sinus thrombosis.
Dr. Mavrych, MD, PhD, DSc [email protected]
Perforation of the
Tympanic Membrane l May result from otitis media and is
one of several causes of middle ear
(conduction) deafness
l Causes: foreign bodies in external
acoustic meatus, excessive pressure
(as in diving), trauma
l Because chorda tympani directly
relates to the posterior surface of the
tympanic membrane it may be
damaged and resulting in loss of
taste over anterior 2/3 of the tongue
and secretion of the sublingual and
submandibular glands
l Minor perforation heal spontaneously;
large ones require surgical repair
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
92. Strabismus
Oculomotor Nerve Palsy (CNIII)
Eyes are not aligned
ptosis,
fully dilated pupil,
ye is fully depressed and
abducted (�down and out�)
s of superior
oblique and lateral rectus,
Eyes are looking in opposite directions
levator palpebrae superioris is out
.
constrictor pupilae (PNS) is out
Trochlear Nerve Palsy (CNIV)
use paralysis of the superior
oblique
No cheating muscle (down and out)
person will turn head to mimic contraction
inferior oblique is
unopposed so eye looks
up and out
Abducens Nerve Palsy (CNVI)
lateral rectus
® inability to abduct th
Affected eye is fully adducted
the unopposed action of the medial
rectus th
93. Horner syndrome Sympathetic trunk compression
Constriction of the pupil (miosis)
Drooping of the superior eyelid
(ptosis),
Redness and increased temperature
of the skin (vasodilation)
Absence of sweating (anhydrosis)
PNS
sup. tarsal mparalysis
94. Otitis Media
Hearing is diminished because ofuse of
pressure on the eardrum and
reduced movement of the ossicles.
Middle ear inflammation
CNVII
CNVIII
Taste may bmay be altered because the
chorda tympani
mastoiditis.
middle cranial fossa can cacan cause
meningitis or teor temporal lobe
abscess,
sigmoid sinus thrombosis.
Perforation of the
Tympanic Membrane otitis media
s of middle ear
(conduction) deafness
foreign bodies in external
acoustic meatus, excessive pressure
(as in diving), trauma
Causes: ses: ll
loss of
taste over anterior 2/3 of the tongue
and secretion of the sublingual and
submandibular glands
Minor perforation heal spontaneously;
large ones require surgical repair
Umborefracted cone of light
Pars flaccida
pars tensa
Anterior inferior incisions based on cone of light for surgery
Dr. Mavrych, MD, PhD, DSc [email protected]
95. Thyroid and parathyroid
glands Hormones:
l The thyroid gland is the body's largest endocrine
gland. It produces thyroid hormone (T3 & T4),
which controls the rate of metabolism (increase
the temperature of the body), and calcitonin, a
hormone controlling calcium metabolism (reduce
blood calcium Ca2+).
l After total thyroidectomy may develop lower
temperature of the body and hypercalcemia.
l The hormone produced by the parathyroid
glands, parathormone (PTH), controls the
metabolism of phosphorus and calcium in the
blood (increase Ca2+ level).
Dr. Mavrych, MD, PhD, DSc [email protected]
Anatomical relations
of the thyroid gland
l Anterolateral �
infrahyoid muscles
l Posterolateral �
COMMON CAROTID
ARTERY [1]
l Medial � larynx,
TRACHEA [2],
pharynx, esophagus,
cricothyroid muscle,
recurrent laryngeal
nerve [3]
l Posterior �
parathyroid glands
[4]
1
3
1
1
Dr. Mavrych, MD, PhD, DSc [email protected]
CS of the neck
Dr. Mavrych, MD, PhD, DSc [email protected]
Median cervical cyst
l Usually presents as a painless
midline mass on the anterior aspect
of the neck just below of the hyoid
bone and moves during
swallowing together with thyroid
gland because of relation with
pretracheal layer of cervical fascia
and infrahyoid muscles of the neck.
l Remanent of the thyroglossal canal
(thyroid gland originally from
epithelium of the tongue).
l Treatment: surgical excision
Dr. Mavrych, MD, PhD, DSc [email protected]
Variation of parathyroid
glands position
l The superior parathyroid
glands, more constant in
position than the inferior ones.
l The inferior parathyroid
glands are usually near the
inferior poles of the thyroid
gland, but they may lie in
various positions
l In 1-5% of people, an inferior
parathyroid gland is deep in
the superior mediastinum
inside the thymus because of
common embryonic origin.
Dr. Mavrych, MD, PhD, DSc [email protected]
96. Larynx
Cavity of the Larynx - 2 Folds:
l Vestibular folds [1] (false vocal
cords)
l Vocal folds [2] (true vocal cords)
Ø Rima vestibuli � gap between the
vestibular folds
Ø Rima glottidis [3] � gap between
the vocal folds anteriorly and
vocal processes of the arytenoid
cartilages posteriorly is most
narrow place in the larynx (it
limits size of intubation tube
during endotrachial anaesthesia)
3
12
1
2
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
95. Thyroid and parathyroid
glands
The thyroid gland is this the body's largest endocrine
gland. It produces thyroid hormone (T3 & T4),
te of metabolism (increase
the temperature of the body), and calcitonin, a
ism (reduce
blood calcium Ca2+). decrease osteoclasts
increase osteoclasts
total thyroidectomy may demay develop lower
temperature of thof the body and hypercalcemia.
parathyroid
glands, parathormone (PTH),
lood (increase Ca2+ level).
Superior thyroid a off external common carotid and inferiorthyroid gland off thyrocervical trunk of subclavianExternal laryngeal n w/ superior thy a & Recurrent laryngeal nw/ inferior thy a
Anatomical relations
of the thyroid gland o t e t y o d g a d
infrahyoid muscles
COMMON CAROTID
ARTERY
edial � la� larynx,
TRACHEA [2],
pharynx, esophagus,
cricothyroid muscle,
recurrent laryngeal
nerve [3]
MediaMedial
Posterior �
parathyroid glands
[4]
Recurrent laryngeal n to laryngeal ms (PCA*) abducts vocal cordsExternal laryngeal n to cricothyroid for high pitch
CS of the neck
Buccopharyngeal membrane
RETROPHARYNGEAL SPACE
Alar Fascia
DANGER ZONE
Prevertebral fascia
Carotid Sheath
& CNX
Retropharyngeal area allows infection to spread to posterior mediastinum
DANGER ZONE allows infection to spread to abdomen
Median cervical cyst
painless
midline mass on the anterior aspect
of the neck just below of the hyoid
bone and moves during
swallowing
thyroglossal canal
surgical excision
Variation of parathyroid
glands position
superior parathyroid
glands, more constant in
position than the inferior ones.
The inferior parathyroid
glands are usually near the
inferior poles of the thyroid
gland, but they may lie in
various positions
, an inferior
parathyroid gland island is deep in
the superior mediastinum
inside the thymus
This makes surgery dangerous bc parathyroid
glands are essential for life as Ca2+ is needed
for neuronal pathways, bones, muscle
contractions, etc....
96. Larynx
Vestibular folds [1
Vocal folds [2]
Morgangni ventricle between them
Rima vestibuli
Rima glottidis [3] � ga� gap between
the vocal folds an
Piriform recess at hyoid-> epiglottis is where small sharp objects get stuck
Zenker's Diverticulum is outpouch of pharynx at inferior constrictor where food gets caught
in killians triangle and gets infected leading to hallitosis (bad breath)
Dr. Mavrych, MD, PhD, DSc [email protected]
Muscles of the Larynx
Abductors
l Posterior cricoarytenoid �
abducts vocal folds (the only
abductors of the vocal folds)
l It is innervated by recurrent
laryngeal nerve (CNX
vagus).
Ø Interruption of recurrent
laryngeal nerve results in
hoarseness because the
corresponding vocal fold
does not abduct and deviate
toward the midline.
Dr. Mavrych, MD, PhD, DSc [email protected]
Cricothyrotomy
l A cricothyrotomy is an emergency
procedure that relieves an airway
obstruction (e.g. swallowed foreign
bodies or abnormal tissue growths).
l A hollow needle is inserted into the
midline of the neck, just below the
thyroid cartilage (needle
cricothyrotomy).
l More frequently, a small incision is made
in the skin over the Cricothyroid
membrane, and another one is made
through the membrane between the
cricoid and thyroid cartilage. A tube
that enables breathing is inserted through
the incision.
Dr. Mavrych, MD, PhD, DSc [email protected]
98. Retropharyngeal space
l It is interval between pharynx
(Bucco-pharyngeal fascia)
and prevertebral fascia
l May provide a passageway of
infection from pharynx to
posterior mediastinum
(mediastinitis !90%!mortality!
rate).
Dr. Mavrych, MD, PhD, DSc [email protected]
99. Axillary sheath
l Derived from the prevertebral
fascia
l Encloses the subclavian artery
and brachial plexus as they
emerge in the interval between the
scalenus anterior and medius
muscles (Interscalenus space)
l Extends into the axilla
Dr. Mavrych, MD, PhD, DSc [email protected]
100. Posterior Triangle of the
Neck
l Veins � external jugular vein,
subclavian vein.
l Arteries � occipital artery.
l Nerves � Accessory nerve (XI),
trunks of the brachial plexus, branches
of cervical plexus, phrenic nerve.
l Lymph nodes � superficial cervical
nodes along external jugular vein.
CN XI (accessory nerve) supply:
l Sternocleidomastoid muscle - face
looks upward to the opposite side
l Trapezius - superior fibers elevate,
middle fibers retract, and inferior fibers
depress scapula.
CN XI
Dr. Mavrych, MD, PhD, DSc [email protected]
Good Luck!
TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.
Abductors
Posterior cricoarytenoid �l
recurrent
laryngeal nerve (CNXrve (CNX
vagus).
hoarseness
Most intrinsic ms of the larynx
Superior Laryngeal n gives
branches to internal (vocal cords)
and external to cricothyroid ms
(high pitch)
lesion causes weak low pitch voice
Transverse arytenoid (whisper), Thyroarytenoid (low pitch), vocalis (opera singer)- ADDUCTORS
Muscles of the Larynx Cricothyrotomy
an emergency
procedure that relieves an airway
obstruction (e.g
A hollow needle is inserted into the
midline of the neck, just below the
thyroid cartilage
More frequently, a small incision is made
in the skin over the Cricothyroid
membrane, and another one is made
through the membrane between the
cricoid and thyroid cartilage. A. A tube
that enables breathing is inserted through
the incision.
98. Retropharyngeal space
( haryngeal fasciaBucco-pharyn )
Between Buccopharyngeal fascia and Alar fascia of Carotid sheathsbetween pharynx
BetweenBetween Buccopharyngeal fascia and Alar fascia of Carotid sheaths
infection rom pharynx to from p
mediastinum posterior media
DANGER ZONE: Alar Fascia to prevertebral fascia and
infection spreads farther to abdomen
99. Axillary sheath
(
subclavian artery
and brachial plexus as they
emerge in the interval between the
scalenus anterior and medius
muscles
Extends into the axilla
BRACHIAL PLEXUS BRANCHES:
MARMU, LT, DS, SS, SC, LP, MP, AP, USS, TD, LSS, Mca, Mcf
100. Posterior Triangle of the
Neck
� external jugular vein,
subclavian vein.
� occipital artery.
Clavical, SCM, Trapezius
External Jugular v, Brachial Plexus
� Accessory nerve (XI),
Lymph nodes
Sternocleidomastoid muscle - f
- seziusTrapezius
Carotid Triangle of the Neck:
Posterior digastric, omohyoid, SCM
Contains: Internal jug v, common carotid, CNX