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100 must importantGA conceptions
Dr. Mavrych, MD, PhD, DSc
Dr. Bolgova, MD, PhD
Understand first, then memorize and apply
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Dear students, youcanusethis presentationlikeaguideduring yourpreparing for GA exams.
It does NOT cover all material of theGross Anatomy course. TocompleteGA material youshouldwork with ALL professor’s
presentations.
GoodLuck andAll thebest!Dr . Mavrych
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1. Lumbar puncture (tap) and
Epidural anesthesia When lumbar puncture isperformed, the needleenters the subarachnoidspace to extractcerebrospinal fluid (CSF)or to inject anesthetic to
epidural space. The needle is usually
inserted between L3/L4 orL4/L5. Level of horizontalline through upper pointsof iliac crests.
Remember, the spinal cord
may ends as low as L2 inadults and does end at L3in children and dural sacextends caudally to level ofS2.
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Patients typically have historyof back pain that may radiatedown to the lower limb.
Herniation of disc usuallyoccurs in lumbar (L4/L5 or L5/S1) or cervical regions(C5/C6 or C6/C7) ofindividuals younger than age50.
Herniated lumbar disc usuallycompreses the nerve root onenumber below: traversing root(e.g., the herniation L4/L5 willcompress L5 root).
The pain begins soon afterpatient lifted some heavy thing.
Lower limb reflexes aredecreased on the affected
side
2. Herniated IV disc
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3. Abnormal curvatures of the
spine Kyphosis is an exaggeration of
the thoracic curvature that may
occur in elderly persons as a result
of osteoporosis (multiply
compression fracture of vertebralbodies) or disk degeneration.
Lordosis is an exaggeration of the
lumbar curvature that may be
temporary and occurs as a result
of pregnancy, spondylolisthesisor potbelly.
Scoliosis is a complex lateral
deviation, or torsion, that is
caused by poliomyelitis, a leg-
length discrepancy, or hip disease.
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4. Upper l imb fractures:
Humerus fracturesSites of potential injury to major
nerves in fractures of the humerus:
1. Axillary nerve and posterior
humeral circumflex artery at thesurgical 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.
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Fracture of distal radius: Transverse fracture within the distal 2 cm of
the radius. Most common fracture of the
forearm (after 50).
Smith's fracture results from a fall or a blowon the dorsal aspect of the flexed wrist
and produces a ventral angulation of the
wrist. The distal fragment of the radius is
ANTERIORLY displaced.
Colles' fracture results from forced
extension of the hand, usually as a result oftrying 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)
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Scaphoid fracture Occurs as a result of a fall onto
the palm when the hand isabducted
Pain occurs primarily on thelateral side of the wrist,especially during wrist extensionand abduction
Scaphoid fracture may not showon X-ray films for 2 to 3 weeks,but a deep tenderness will bepresent in the anatomicalsnuffbox.
The proximal fragment mayundergo avascular necrosisbecause the blood supply isinterrupted.
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Boxer’s fracture Necks of the metacarpal
bones are frequently
fractured during fistfights.
Typically, fractures of 2d
and3d metacarpals are seen in
professional boxers, and
fractures of 5th and sometimes
4th metacarpals are seen in
unskilled fighters.
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Mallet or Baseball Finger 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.
These actions avulse the attachment of theextensor 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.
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5. Rotator cuff muscles – SITS Support the shoulder joint by
forming a musculotendinous
rotator cuff around it
Reinforces joint on all sides
except inferiorly, where
dislocation is most likely
Rotator cuff muscles are:
Supraspinatus
Infraspinatus
Teres minor
SubscapularisRight humerus
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6. Abduction of the upper limb (0°-15°) Abduction of the
upper extremity is initiatedby the supraspinatusmuscle (suprascapular nerve).
(15°-110º) Further abductionto the horizontal position is afunction of the deltoidmuscle (axillary nerve).
(110°-180°) Raising theextremity above thehorizontal position requiresscapular rotation by actionof the trapezius (accessorynerve CNXI) and serratusanterior (long thoracic
nerve).
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Subacromial bursitis &
Tearing of supraspinatus tendon Subacromial bursitis (inflammation of
the subacromial bursa) is often due to
calcific supraspinatus tendinitis,
causing a painful arc of abduction.
The same symptoms will be in case ofinflammation or trauma of the
supraspinatus tendon (MRI→ torn
tendon)
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7. Three Elbows: Student's elbow
(Subcutaneous olecranon bursitis) The olecranon, to which the triceps
tendon attaches distally, is easilypalpated. It is separated from theskin by only the olecranon bursa,
which allow the mobility of theoverlying skin.
Repeated excessive pressure and
friction may cause this bursa to
become inflamed, producing a
friction subcutaneous olecranon
bursitis.
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Tennis elbow
(Lateral epicondylitis) Lateral epicondyli tis: repeated
forceful flexion and extension of thewrist resulting strain attachment ofcommon extensor tendon and
inflammation of periosteum oflateral epicondyle. Pain felt over lateral epicondyle and radiatesdown posterior aspect of forearm.Pain often felt when opening adoor or lifting a glass
Origins of following muscles may
be affected:1. Extensor Carpi Radialis
Longus & Brevis
2. Extensor Digitorum
3. Extensor Digiti Minimi
4. Extensor Carpi Ulnaris
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Golfer’s elbow
(Medial epicondylitis) Medial epicondyli tis is
inflammation of the common
flexor tendon of the wrist
where it originates on the
medial epicondyle of thehumerus.
Origins of following musclesmay be affected:
1. Pronator Teres
2. Flexor Carpi Radialis3. Palmaris Longus
4. Flexor Carpi Ulnaris
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8. Arterial anastomoses
around the scapula Blockage of the
Subclavian or Axillaryartery can be bypassedby anastomoses
between branches ofthe Thyrocervical andSubscapular arteries:
Transverse cervical
Suprascapular
Subscapular
Circumflex scapular
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9. Cubital fossa Contents from lateral to medial:
1. Biceps brachii tendon
2. Brachial artery
3. Median nerve
Subcutaneos structures from lateral tomedial:
1. Cephalic vein
2. Median cubi tal vein: joins cephalicand basilic veins
3. Basilic vein
Sites of venipuncture is usually mediancubital vein because: Overlies bicipital aponeurosis, so deep
structures protected
Not accompanied by nerves
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10. Carpal Tunnel Syndrome Results from a lesion that
reduces the size of the carpaltunnel (fluid retention, infection,dislocation of lunate bone)
Median nerve – most sensitive
structure in the carpal tunneland is the most affected
Clinical manifestations: Pins and needles or anesthesia
of the lateral 3.5 digits
palm sensation is not affectedbecause superficial palmar
cutaneous branch passessuperficially to carpal tunnel
Apehand deformity - absentof OPPOSITION
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11. Test of the proximal and
distal interphalangeal joints
PIP – FDS
DID - FDP
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12. Lesion of UL nerves
Upper Brachial Palsy Injury of upper roots and trunk
Usually results from excessiveincrease in the angle between theneck and the shoulder stretching or
tearing of the superior parts of thebrachial plexus (C5 and C6 roots orsuperior trunk)
May occur as birth injury fromforceful pulling on infant's headduring difficult delivery
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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 theshoulder 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
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Lower Brachial Palsy
(Klumpke paralysis) Injury of lower roots and
trunk
May occur when the upper
limb is suddenly pulled
superiorly: stretching ortearing of the inferior parts
of the brachial plexus (C8
and T1 roots or inferior
trunk)
E.g., grabbing supportduring falling f rom height
or as a birth injury, or
TOS – thoracic outlet
syndrome
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Lower Brachial Palsy
(Klumpke paralysis) All intrinsic muscles of the hand
supplied by the C8 and T1 roots ofthe lower trunk affected.
Combination lesions of ulnar nerve (“claw hand”) and mediannerve (“ape hand”)
Loss of sensation in the medialaspect of the upper limb andmedial 1,5 fingers.
May include a Horner syndrome
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Injury to musculocutaneous
nerve Usually results from lesions
of lateral cord
Greatly weakens f lexion ofelbow (biceps and brachialismuscles) and supination offorearm (biceps muscle)
May be accompanied by
anesthesia over lateralaspect of forearm
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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 deficitbetween 1 & 2 digi ts on the dorsum of the
hand ONLY because of nerve overlapping
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13. Cardiac catheterization
The femoral artery isused for cardiaccatheterization
It can be cannulatedfor left cardiacangiography & alsofor visualizing thecoronary arteries – along, slender catheteris insertedpercutaneously and
passed up theexternal iliac artery,common iliac artery,aorta, to the leftventricle of the heart
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14. Injury of the gluteal region
Fractures of Femoral Neck
A common fracture inelderly women withosteoporosis is fracture of the femoral neck.
Fractures of the femoral
neck cause shortness andlateral rotation of the lowerlimb.
Fractures of the femoralneck often disrupt the bloodsupply to the head of thefemur.
At present time the best wayin case of femoral neckfracture is hip replacement.
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Avascular necrosis
of femoral head
Transcervical fracturedisrupts blood supply tothe head of the femur viaretinacular arteries (frommedial circumflex femoral
artery) and may causeavascular necrosis of thefemoral head if bloodsupply through the ligamentto the head is inadequate.
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Injury to sciatic nerve
Weakened hipextension and kneeflexion
Footdrop (lack ofdorsiflexion)
Flail foot (lack ofboth dorsiflexion andplantar flexion)
Cause of injury:
caused byimproperly placedgluteal injectionsbut may result fromposterior hipdislocation
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Posterior hip dislocations 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.
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.
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Superior gluteal
nerve injury The superior gluteal nerve
may be injured during surgery,posterior dislocation of thehip or poliomyelitis.
Paralysis of the gluteus
medius and gluteus minimusmuscles occurs so that theability to pull the pelvis upand abduction of the thighare lost.
Trendelenburg sign:
If the superior gluteal nerve on
the right side is injured, the leftpelvis falls downward when thepatient raises the left foot off theground.
Note that side is contralateral tothe nerve injury.
Right
superior
gluteal nerve
injury
Normal
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Injury to inferior gluteal nerve
Weakened hip extension(gluteus maximus), mostnoticeable when climbing
stairs or standing from aseated posit ion
Cause of in jury: posteriorhip dislocation, surgery inthis region
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Injury of obturator
nerve
Difficulty adducting th igh
(e.g., crossing legs while
sitting)
Decreased sensation
over upper medial thigh
Cause of injury: anterior
hip dislocation, radical
retropubic prostatectomia
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Avulsion fractures occurwhere muscles areattached - ischialtuberosities
Hamstrings muscles:
1. Biceps femoris
2. Semitendinosus
3. Semimembranosus
Action: extension of hip
joint and flexion of knee joint
Nerve supply – Tibialnerve (short head ofbiceps femoris is suppliedby the common fibular nerve)
15. Avulsion fractures
of the hip bone and
hamstrings muscles
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16. Structures under inguinal
ligament:
From lateral tomedial side:
Iliopsoas muscle
Femoral nerve Femoral artery
Femoral vein
Femoral canal
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Femoral hernia
A femoral hernia passes below
inguinal ligament through the femoral
ring into the femoral canal to form a
swelling in the upper thigh inferior andlateral to the pubic tubercle
The hernial sac may protrude through
the saphenous hiatus into the
superficial fascia
A femoral hernia occurs more
frequently in females and is dangerousbecause the hernial sac may become
strangulated
An aberrant obturator artery is
vulnerable during surgical repair
Inguinal lig .
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17. Knee joint injuries:
Unhappy triad
Because the lateral side of theknee is struck more often(e.g., in a football tackle), thetibial collateral ligament is
the most frequently tornligament at the knee.
The unhappy triad of athleticknee injuries involves:
1. Tibial collateral l igament
2. Medial meniscus
3. Anterior cruciate ligament
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Tibial collateral ligament
(medial collateral ligament)
Broad flat band
extending from medial
epicondyle of femur to
medial condyle andshaft of tibia
Blends with capsule and
firmly attaches to
medial meniscus
Limits extension and
abduction of leg at
knee
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Fibular collateral l igament
(lateral collateral ligament)
Rounded cord between
lateral epicondyle of femur
and head of fibula
Does NOT blend with jointcapsule and does NOT
attach to lateral meniscus
Limits extension and
adduction of leg at knee
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Rupture of the
cruciate ligaments
With rupture of the anteriorcruciate ligament, the tibiacan be pulled forwardexcessively on the femur,
exhibiting anterior drawersign.
In the less common rupture ofthe posterior cruciateligament, the tibia can bepushed backward excessively
on the femur, exhibitingposterior drawer sign.
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Prepatellar bursa
Suprapatellar bursa
Prepatellar bursa: between
superficial surface of patella
and skin. May become
inflamed and swollen
(prepatellar bursitis).
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).
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Knee jerk reflex
The patellar reflexis tested by tappingthe patellarligament with a
reflex hammer toelicit extension atthe knee joint. Bothafferent andefferent limbs ofthe reflex arch arein the femoral
nerve (L2-L4).
Knee jerk reflex:tests spinal nervesL2-L4.
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18. Ankle joint injuries:
Ankle sprains
Sprains are the most commonankle injuries
A sprained ankle is nearlyalways an inversion injury,
involving twisting of the weight-bearing plantarflexed foot.
The lateral ligament (anteriortalofibular ligament) is injuredbecause it is much weaker thanthe medial ligament.
In severe sprains, the lateralmalleolus of the fibula may befractured.
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Pott’s fracture
It is fracture-dislocations of
the ankle joint Reason - forced eversion
(abduction) of the foot
The Deltoid ligamentavulses the medialmalleolus and after thatfibula fractures at ahigher level
Pott's fracture
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Ankle jerk reflex
Achilles tendon reflex is
tested by tapping the
calcaneal tendon to elicit
plantar flexion at the ankle joint.
Both afferent and efferent
limbs of the reflex arc are
carried in the tibial nerve
(S1, S2).
Ankle jerk reflex: tests
spinal nerves S1-S2.
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19. Injures of the leg and foot:
Fracture of the fibular neck May cause an injury to the common
peroneal nerve, which windslaterally around the neck of thefibula.
This injury results in paralysis of allmuscles in the anterior and lateralcompartments of the leg(dorsiflexors and evertors of thefoot) and loosing sensation on thedorsum of the foot.
Causing foot drop.
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Rupture of the Achilles tendon
and Triceps surae muscle
Avulsion or rupture of the calcaneal
( Achilles) tendon disables the triceps
sure muscle (gastrocnemius & soleus)
so that the patient cannot plantar flexthe foot.
Triceps surae muscle:
2 Heads of Gastrocnemius m.
1 Head - Soleus muscle
Plantaris
small fusiform belly with long thintendon;
sometimes may becomehypertrophy
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Plantar Fasciitis (calcaneal spur)
Plantar fasciitis is the
most common hindfoot
problem in runners. It
causes pain on the
plantar surface of thefoot and heel.
Point tenderness is
located at the proximal
attachment of the plantar
aponeurosis to themedial tubercle of the
calcaneus and on the
medial surface of this
bone.
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20. Injury of tibial nerve
In popliteal fossa: loss ofplantar flexion of foot (mainlygastrocnernius and soleusmuscles) and weakened
inversion (tibialis posteriormuscle), causingcalcaneovalgus.
Inabili ty to stand on toes
Loss of sensation andparalysis of intrinsic musclesof the sole of the foot Popliteal fossa from superficial to
deep, contains:
Tibial nerve
Popliteal vein
Popliteal artery
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On soil of the foot there are two terminal
branches of tibial n:
Medial plantar nerve supplies:
1. Abductor hallucis,2. Flexor hallucis brevis
3. Flexor digitorum brevis
4. 1st lumbrical muscles
skin of medial 3.5 digits
Lateral plantar nerve supplies: All intrinsic plantar muscles which
are not innervated by medial plantar
nerve
skin of lateral 1.5 digits
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21. Breast:
Carcinoma of the Breast
Carcinomas of thebreast are malignanttumors, usuallyadenocarcinomasarising from theepithelial cells of thelactiferous ducts in themammary glandlobules
1. It enlarges, attachesto suspensory(Cooper‘s) ligaments,and producesshortening of theligaments, causingdepression or dimplingof the overlying skin.
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Lymphatic drainage
of the breast
It is important becauseof its role in themetastasis of cancercells.
Most lymph (> 75%),especially from thelateral breastquadrants , drains tothe axillary lymphnodes, initially to theanterior (pectoral)nodes for the most
part. Most of the remaining
lymph, particularly fromthe medial breastquadrants, drains to theparasternal lymphnodes or to theopposite breast.
75% 25%
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Mastectomy
Radical mastectomy, a more extensive surgicalprocedure, involves removal of the breast, pectoralmuscles, fat, fascia, and as many lymph nodes aspossible in the axilla and pectoral region.
1. During a radical mastectomy, the long thoracicnerve 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.
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Breast infection
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).
This infection causes pain, swelling,
redness, and increased temperature
of the breast.
It can occur when bacteria, often from
the baby's mouth, enter a milk ductthrough a crack in the nipple.
It can occur in women who have not
recently delivered as well as in women
after menopause.
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22. Thoracic wall & Diaphragm:
Intercostal spaces
Intercostal blood vesselsand nerves:
run between theinternal intercostal andinnermost intercostal
muscles in the costalgroove
arranged from superiorto inferior as vein,artery, nerve
Most vulnerablestructures – intercostalnerve and posteriorintercostal arterybecause they are notcovering by ribs.
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Diaphragm:
Paralysis of half and ruptures
Paralysis of the halfof the Diaphragmmay result from injuryor operative division of
the phrenic nerve ofsame side
It can be detectedradiologically .
Paradoxicalmovement: dome ofdiaphragm of injuredside pushed superiorlyby abdominal visceraduring inspirationinstead of descending
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Phrenic nerve
Arises from the anteriorbranches C3-C5 nerves andlies in front of the anteriorscalene muscle.
Runs anterior to the root ofthe lung, whereas the vagusnerve runs posterior to theroot of the lung.
Innervates the fibrouspericardium, themediastinal anddiaphragmatic pleurae(sensory innervation), andthe diaphragm for motor and its central tendon forsensory.
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Diaphragmatic ruptures
Diaphragmatic injuries are
relatively rare and result from
either blunt trauma or
penetrating trauma.
Presently, 80-90% of blunt
diaphragmatic ruptures resultfrom motor vehicle crashes.
The majority (80-90%) of blunt
diaphragmatic ruptures have
occurred on the left side.
Blunt trauma typically produceslarge radial tears measuring 5-15
cm, most often at the
posterolateral aspect of the
diaphragm.
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23. Cardiac hypertrophy Left atrial enlargement
(hypertrophy) secondary to
mitral valve failure may
compress on theesophagus and manifest
as dysphagia (difficulty in
swallowing).
It may be observed as a
filling defect in the
esophagus by barium
swallow on the lateral
thoracic X-Ray
P A j ti
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Cardiac Shadow
Right border is formed by:
1. SVC,2. Right atrium
Left border is formed by:
1. Aortic arch2. Pulmonary trunk
3. Left auricle
4. Left ventricle
P-A projection
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24. Auscultation of Heart
Valves
Right 2 ICS
PSL
Left 5 ICS
MCL
Left 4 ICS
PSL
Left 2 ICS
PSL
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Auscultation sites for
mitral and aortic murmurs
A heart murmur is heard downstream from the valve: stenosis is orthograde direction from valve
insufficiency is retrograde direction from valve
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25. Conducting System
of the Heart Sinoatrial (SA) node site where contraction of heart muscle is
initiated (pacemaker of the heart)
situated in the upper part of the sulcusterminalis just near to the opening ofthe SVC
Atrioventr icular (AV) node the AV node receives impulses from the
SA node; situated in the lower part ofthe atrial septum near coronary sinus
Atrioventr icular bundle of His
descends from the AV node to themembranous portion of the ventricularseptum where it divides into the left andright bundle branches
Right bundle branch – passes down toreach the moderator band - rightventricle
left bundle branch – passes down leftside of ventricular septum
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26. Blood supply of the Heart:
Right coronary artery (RCA) It supplies major parts of the right
atrium and the right ventricle.
It anastomoses with the marginalbranch of the left coronary arteryposteriorly
Branches:
1. Anterior cardiac branches – supplies the right atrium
2. Nodal branch – supplies the (1) SAnode, (2) AV node
3. Marginal artery – supplies the rightventricle
4. Posterior interventricular artery – supplies (1) diafragmatic (inferior)surface of both ventricles and (2)posterior 1/3 of the IV septum
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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 theatrioventricular groove to anastomose
with the right coronary artery
posteriorly; supplies the left atrium
and left ventricle
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Blood supply of the conducting
system SA node – RCA
AV node – RCA
AV bundle (andmoderator band)- LCA
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27. Congenital cardiac defects:
Atrial Septal Defect (ASD) It is less frequent than
VSD
It results from failure toclose of the foramenovale after birth (failure ofthe septum primum andseptum secundum tofuse)
Postnatally, ASDs resultin left-to-right shunting(between right and left
atrium) and are non-cyanotic conditions.
If it is small, has noclinical significance & iflarge - necessary surgicalrepair
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Ventricular Septal
Defect (VSD) Ventricular septal defect
(VSD) is the most commonof the congenital heart defects
It may be found in the
membranous part of theventricular septum andresults from failure to fuse ofthe membranous portion withthe muscular portion of theventricular septum
In this case, present left–to-
right shunt (right ventricularhypertrophy (RVH)) andagain non-cyanotic.
Necessary surgery for largedefects
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Patent Ductus Arteriosus (PDA) It results from failure of the ductus
arteriosus (a connection between thepulmonary trunk and aorta) to constrict andclose after birth.
Prostaglandin E and low O2 tension sustainpatency of the ductus arteriosus in the fetalperiod.
PDA is common in premature infants and incases of maternal rubella infection.
Left –to-right shunt increased pressure inpulmonary circulation (pulmonary
hypertension) and is non-cyanotic Treatment: surgical division and ligation
imperative. In great danger is left recurrentnerve (wrapping aorta arch). Injure of thisnerve results in hoarseness.
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Aneurysm of the aorta
Aneurysm of the aortic arch:compresses the left recurrentlaryngeal nerve, leading tocoughing, hoarseness, andparalys is of the ipsilateral vocal
cord. It may cause dysphagia(difficulty in swallowing), resultingfrom pressure on the esophagus,and dyspnea (difficulty inbreathing), resulting frompressure on the trachea, root ofthe lung, or phrenic nerve
Aneurysm of the thoracic aortamay compress and tug on thetrachea with each cardiac systoleso that the aneurysm can be feltby palpating the trachea at thesternal notch (T2).
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Abdominal aortic aneurysm
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.
Pulsations of a large aneurysm
can be detected to the left of
the midline at the umbilical
region.
Acute rupture of an abdominal
aortic aneurysm is associated
with severe pain in theabdomen or back (mortality rate
is nearly 90%).
Surgeons can repair an
aneurysm by opening it and
inserting a prosthetic graft.
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Coarctation of the Aorta It results from congenital
narrowing of the aorta distal to theoffshoot of the left subclavianartery.
Cardinal clinical sign: higher blood
pressure in the upper limbscompared to the lower limbs.
Coarctation of the aorta results inthe intercostal arteries providingcollateral circulation between theinternal thoracic artery and thethoracic aorta to provide blood
supply to the lower parts of thebody
Coarctation of the Aortacharacteristic X-ray picture:serrated appearance of inferiorborders of ribs (rib notching)
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28. Aspiration of Foreign
Bodies & Bronchopulmonary
segments Aspiration of Foreign Bodies:
Inhalation of FB’s (e.g. pins,parts of teeth, screws, nuts,bolts, toys) into the lowerrespiratory tract is common,especially in children
More likely to enter the rightprimary bronchus and pass intothe middle or lower lobebronchi
If the vertical position of thebody, the foreign body usuallyfalls into the posterior basalsegment of the right inferiorlobe.
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Right lung:
10 bronchopulmonary segments
Superior lobe:
1. Apical2. Anterior
3. Posterior Middle lobe:
4. Lateral5. MedialInferior lobe:
6. Superior 7. Anterior basal8. Posterior basal9. Lateral basal10.Medial basal
1
8
97
6 4
5
2
3
10
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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 basal8. Lateral basal9. Medial basal
1
3 5
7
89
6
2
4
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29. Lung diseases:
Pneumonia Pneumonia is an inflammation
of the lung, caused by an
infection or chemical injury to the
lungs.
Three common causes are
bacteria, viruses and fungi.
Symptoms: cough, chest pain,
fever, and difficulty in breathing.
Chest x-rays: areas of opacity
(seen as white) of the lungparenchyma and enlargement of
bronchomediastinal lymph
nodes (mediastinal widening).
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Bronchogenic Carcinoma
Arises in the mucosa of thelarge bronchi
Produces as persistent,
productive cough orhemoptysis
Early metastasis to thoracic(bronchomediatinal) lymphnodes
Hematogenous spread to thebrain, bones, lungs,
suprarenal glands A tumor at the apex of the
lung (Pancoast tumor ) mayresult in thoracic outletsyndrome
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Bronchogenic carcinoma
may lead to:1. Thoracic outlet syndrome (TOS)
It can cause pressure on the lowertrunk of the brachial plexus C8-T1and subclavian artery by cervical
rib or pancoast tumor. It results inpain down the medial side of theforearm and hand and atrophy ofthe intrinsic hand muscles)
2. Horner syndrome:
miosis - constriction of the pupildue to paralysis of the dilator
pupillae muscle ptosis - drooping of the eyelid due
to paralysis of the superior tarsalmuscle
hemianhydrosis - loss of sweatingon one side
11
22
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Bronchogenic carcinoma
may lead to:3. Superior vena cava
syndrome, which causesdilation of the head andneck veins, facial swelling,and cyanosis
4. Dysphagia as a result ofesophageal obstruction
5. Hoarseness as a result ofrecurrent laryngeal nerveinvolvement
6. Paralysis of the
diaphragm as a result ofphrenic nerve involvement33
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Qs about Auscultation
and penetrated wounds 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).
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
For the inferior lobes of both
lungs, breath sounds are primarily
heard on the posterior chest wall.
4
6
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30. Open pneumothorax &
pleura It is entry of air into a pleural
cavity causing lung collapse.
Open pneumothorax – due to stabwounds of the thoracic wall whichpierce the parietal pleura so thatthe pleural cavity is open to theoutside air via the lung or throughthe chest wall.
Air moves freely through thewound during inspiration andexpiration. During inspiration, airenters the chest wall and the
mediastinum will shift toward otherside and compress the oppositelung. During expiration , air exitsthe wound and the mediastinummoves back toward the affectedside.
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Pleura & Pleural Cavity 1. Cervical p leura may be affected in
case of improper subclavianvenipuncture.
2. Costodiaphragmatic Recess isdeepest place in pleural cavity, aroundthe chest wall, there are two ribinterspaces separating the inferiorlimit of parietal pleural reflections fromthe inferior border of the lungs andvisceral pleura:
1. Midclavicular line - between ribs 6-82. Midaxillary line - between ribs 8-10
3. Paravertebral line between ribs 10-12
2
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Nerve supply of the pleuraParietal Pleura – sensitive to general
sensibilities (pain, temperature, touch,and pressure) - somatic sensoryinnervation:
costal pleura – intercostal nervesblock may be used to decreasethoracic pain
mediastinal pleura – phrenic nerve
diaphragmatic pleura – phrenic nerveover the domes and lower 6 intercostalnerves around the periphery
Visceral Pleura – sensitive to stretch butinsensitive to general sensibilities;autonomic nerve supply from thepulmonary plexus
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31. Mediastinum
Superior mediastinum Improperly done
sternal puncturemay affectstructures related
to the posteriorsurface of themanubriumsternum:
In upper part – Leftbrachiocephalic
vein In lower part –
Aort ic arch
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Thoracic duct
Function – conveys to theblood all lymph from thelower limbs, pelvic cavity,abdominal cavity, left side
of the thorax, left side ofthe head & neck, and leftupper limb (3/4 of thebody)
Tributaries – at the root of theneck
Left jugular lymph trunk Left subclavian lymph
trunk
Left bronchomediastinallymph trunk
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Constrictions of the esophagusThere are sites where ingested
foreign bodies can lodge orwhere strictures may developfollowing ingestion of causticfluids, common sites of
esophageal carcinoma
1. C6 - where the pharynx joinsthe upper end (6" from theupper incisors)
2. T4-T5 - where the aortic archand left main bronchus cross
its anterior surface (10" from theupper incisors)
3. T10 - where it passes throughthe diaphragm into thestomach (16" from the upperincisors)
1
2
3
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32. Anterior abdominal wall
The liver and gallbladder are in the right upperquadrant;
The stomach and spleen
are in the left upperquadrant;
The cecum and appendixare in the right lowerquadrant;
The end of the descendingcolon and sigmoid colonare in the left lowerquadrant.
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Referred abdominal pain
Pain arising out of theforegut derived structuresis referred to the
epigastric region.
Pain arising out of themidgut derived structuresis referred to theumbilical region.
Pain arising out of thehindgut derivedstructures is referred tothe hypogastric region.
Nerve supply of the
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Nerve supply of the
anterior abdominal wall
Therefore totally 7 nerves:lower 5 intercostals, 1subcostal and L1(iliphypogastric andilioinguinal) nerves supply
the anterior abdominal wall. L1 can be anaesthetized by
injecting 1 inch (2.5 cm)superior to the anteriorsuperior iliac spine.
All nerves and deep blood
vessels lie in theneurovascular plane:between internal obliqueand transversus muscles
Arterial supply of the anterior
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Arterial supply of the anterior
abdominal wall:
Important SUPERFICIAL
ARTERIES (supply skin) are:
1. Superficial epigastric
2. Superficial circumflex iliac
Important DEEP ARTERIES lie inthe neurovascular plane:
1. Superior epigastric
2. Posterior intercostals arteries
3. Lumbar arteries
4. Deep circumflex iliac artery
5. Inferior epigastric
33 Herniations
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33. Herniations
Hernia consist of 3 parts:
Hernial sac is a pouch(diverticulum) of peritoneum andhas a neck and a body
Hernial contents may consist ofany structure found in the
abdominal cavity (more offen – loops of small intestine andpiece of omentum major)
Hernial coverings are formedfrom the layers of the abdominalwall through which the hernial
sac passes
T li f i i th FIRST
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Transversalis fascia is the FIRST
STRUCTURE which is crossed by
any abdominal hernia
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Indirect Inguinal Hernia
Indirect inguinal hernia is the mostcommon form of hernia and is believedto be congenital in origin (boys 0-3years).
It passes through the deep inguinal ring
lateral to the inferior epigastricvessels, inguinal canal, superficialinguinal ring and descend into thescrotum.
An indirect inguinal hernia is about 20times more common in males than infemales, and nearly 1/3 are bilateral.
It is more common on the right(normally, the right processus vaginalisbecomes obliterated after the left; theright testis descends later than the left).
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Direct Inguinal Hernia
Direct inguinal hernia composesabout 15% of all inguinal hernias.
During a direct inguinal hernia,the abdominal contents willprotrude through the weak area of
the posterior wall of the inguinalcanal medial to the inferiorepigastric vessels in the inguinal[Hesselbach's] triangle and afterthat through superficial inguinalring. It never descends into thescrotum.
It is a disease of old men withweak abdominal muscles. Directinguinal hernias are rare in women,and most are bilateral.
34 P it l t t
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34. Peritoneal structures:
Lesser omentum
Consist of 2 ligaments:
hepatogastric
hepatoduodenal
Contents : Right & Left gastric
vessels
Connective and fattytissue
and Portal triad:
Bile duct
Portal vein
Proper hepatic artery
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Epiploic (winslow’s) foramen
Anteriorly: The freeborder of thehepatoduodenalligament, containingportal triad (DV A).
Posteriorly: IVC
Superiorly: Caudate
lobe of the liver .
Inferiorly: The 1st
part of theduodenum.
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Douglas (rectouterine) pouch
Rectouterine pouch(pouch of Douglas):deeper point of
peritoneal space invertical position of thefemale body between therectum and the cervix ofuterus.
It is space of the pelvic
abscess location.
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Culdocentesis
Culdocentesis isaspiration of fluid fromthe cul-de-sac ofDouglas (rectouterinepouch) by a needle
puncture of theposterior vaginalfornix near the midlinebetween the uterosacralligaments
Because therectouterine pouch is
the lowest portion ofthe female peritonealcavity, it can collectinflammatory fluid(pelvic abscess).
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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)
FOREGUT MIDGUT HINDGUT
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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
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36. Posterior gastric ulcer
1. Posterior gastric ulcer mayerode through the posteriorwall of the stomach into the
Omental bursa (Lesserperitoneal sac) and affectpancreas resulting inreferred pain to the back.
2. Erosion of splenic artery is
very common in posteriorgastric ulcers as wellbecause of the proximity ofthe artery to this wall.
37 Congenital diaphragmatic
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37. Congenital diaphragmatic
hernia
Hernia of stomach orintestine through aposterolateral defect
in diaphragm(foramen ofBochadalek).
It is seen in infantsand the mortality rate ishigh because of left
lung hypoplasia.
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38. Sliding hiatal hernia
A sliding hiatal hernia which
occurs in individuals past
middle age is caused by
the hernia of cardia of thestomach into the thorax
through the esophageal
hiatus of the diaphragm.
This can damage the vagal
trunks as they pass throughthe hiatus and resulting in
hyposecretion of gastric
juice.
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39. Meckel's diverticulum
Meckel's diverticulum is a congenitalanomaly representing a persistent portion ofthe vitellointestinal duct.
This condition is often asymptomatic butoccasionally becomes inflamed if it containsectopic gastric, pancreatic, or endometrial
tissue, which may produce ulceration. Meckel's diverticulum is located on the
Ileum about 2 feet (61 cm) before theileocecal junction and SMA supply it. Itoccurs in 2% of patients and is about 2 inches(5 cm) long.
The diverticulum is clinically importantbecause diverticulitis, liberation, bleeding,perforation, and obstruction are complicationsrequiring surgical intervention and frequentlymimicking the symptoms of acuteappendicitis.
40 Features of the large
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40. Features of the large
intestine
Features of the large intestine:
1. Appendices epiploic
2. Sacculations(haustrations)
3. Taeniae coli
The taeniae coli meettogether at the base ofthe appendix where theyform a complete
longitudinal muscle coatfor the appendix.
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Colon
The ascending colon liesretroperitoneally and lacks amesentery.
It is continuous with thetransverse colon at the right(hepatic) flexure (1) of colon.
The transverse colon (3) hasits own mesentery called thetransverse mesocolon(intraperitoneal position).
It becomes continuous with thedescending colon at the left
(splenic) flexure (2) of colon. The sigmoid colon (4) is
suspended by the sigmoidmesocolon (intraperitonealposition).
1
3
4
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41. Pain of Appendicitis
In appendicitis, first pain isreferred around the umbilicus.Visceral pain in the appendix isproduced by distention of itslumen or spasm of its muscle.
The afferent pain fibers enterthe spinal cord at the level ofT10 segment, and a vaguereferred pain is felt in the regionof the umbilicus.
Later if parietal peritoneum
gets involved, and then the painis shifted laterally to the McBurney’s point. Here the painis precise, severe, and localized(second pain)
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Mc Burney's point
This point indicatesthe surface markingof the base of theappendix.
It is a point at the
junction between thelateral 1/3 andmedial 2/3 of a line
joining the rightanterior superior iliacspine with theumbilicus.
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42. Volvulus
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.
This may correct itself
spontaneously, or the rotation
may continue until the blood
supply of the gut is cut off
completely.
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43. Hirschsprung's Disease
It is a rare congenital abnormality thatresults in obstruction because theintestines do not work normally.
It is commonly found in Down Syndromechildren.
The inadequate motility is a result of anaganglionic section (congenital absentsof postganglionic parasympatheticneurons inside of the intestinal wall) of theintestines resulting in megacolon.
In a newborn, the main signs andsymptoms are failure to pass a
meconium stool within 1-2 days afterbirth, reluctance to eat, bile-stained(green) vomiting, and abdominaldistension.
Treatment is removal of the aganglionicportion of the colon.
44 Branches of Abdominal aorta
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44. Branches of Abdominal aorta
and Mesenteric ischemia
Celiac trunk (CA) originatesfrom the aorta at the lowerborder of T12 vertebra
Superior mesenteric arteryoriginates at the lower
border of L1 vertebra Renal arteries originate at
approximately L2 vertebra
Inferior mesenteric arteryoriginates at L3 vertebra
Two terminal branches are
common iliac arteries atthe level of L4 vertebra
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CELIAC ARTERY (TRUNK)
Origin: T12, just below the
aortic opening of the
diaphragm.
The CA passes above the
superior border of thepancreas and then divides
into three retroperitoneal
branches:
Left gastric artery (1)
Common hepatic artery (2) Splenic artery (3)
2
3
1
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Left gastric artery
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 thelesser curvature of the
stomach.
Branches:
Esophageal branches (2) - tothe abdominal part of theesophagus
Gastr ic branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery.
2
3
1
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Common hepatic artery
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:
Proper hepatic artery (2)
Gastroduodenal artery (3)
1
2
3
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Proper hepatic artery 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.
The right and left arteries enter the
two lobes of the liver , right
hepatic artery gives cystic artery
(5) to the gallbladder .
Right gastric artery (2) suppliesthe right side of the lesser
curvature of the stomach where it
anastomoses the left gastric
artery.
54
3
21
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Gastroduodenal artery
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:
Right gastroepiploic artery (2)
(supplies the right side of the
greater curvature of the
stomach where it anastomoses
the left gastroepiploic)
Superior pancreaticoduodenal
arteries (3) (supply the head of
the pancreas, where they
anastomoses the inferior
pancreaticoduodenal arteries
from the SMA).
1
2
3
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Ligature of the hepatic artery:
The hepatic artery may beligated proximal to the originof its gastroduodenal branch,a collateral circulation to theliver is established throughthe left and right gastric
arteries, left and rightgastroepiploic andgastroduodenal arteries.
The right hepatic arterymay be mistakenly ligatedduring holecystectomy in
Calot triangle together withthe cystic artery, right lobehepatic necrosis commonlyoccurs.
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Splenic artery
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 apart of the stomach bed.
The splenic artery may be
subject to erosion by a
penetrating ulcer of the
posterior wall of the stomach
into the lesser sac.
N.B. The splenic vein runs amore straight course below theartery and behind of thepancreas.
1
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Splenic artery
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: Branches to the spleen (2)
Branches to the neck, body, and
tai l of pancreas (3)
Left gastroepiploic (4) artery that
supplies the left side of the
greater curvature of the stomachwhere it anastomoses the right
gastroepiploic
Short gastric (5) branches that
supply fundus of the stomach
5
43
1 2
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SMA Branches:
(1) Inferiorpancreaticoduodenalarteries
(2)Jejunal and (3)Ileal branches
(4) Ileocolic artery
Ascending branch
Anterior cecal artery
Posterior cecal artery
(5) Appendicularartery
(6) Right colic artery
(7) Middle colic artery
17
6
5
4
3
2
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IMA Branches:
(1) Left colic artery
(2) Sigmoid arteries
(3) Superior rectal artery
3
2
1
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Mesenteric ischemia Atherosclerosis, which slows the
amount blood flowing through arteries, isa frequent cause of chronic mesentericischemia.
Ischemia occurs when blood cannot flowthrough arteries as well as it should, and
intestines do not receive the necessaryoxygen to perform normally. Mesentericischemia usually involves SMA and smallintestine.
Mesenteric ischemia primarily affectsorgans which locate far away fromanastomoses with CA & IMA. Usually
blood supply of the Jejunum and Ileum ismost compromised.
Mesenteric ischemia typically occurs inpeople older than age 60 with history ofsmoking and high cholesterol level.
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45. Biliary system & gallstones
Bile is secreted by the liver cells,stored, and concentrated in thegallbladder and later it isdelivered to the duodenum.
The gallbladder lies in it’s fossa
on the visceral surface of theliver right side of quadrate lobe.
It stores and concentrates bile,which enters and leaves itthrough the cystic duct.
The cystic duct joins the
common hepatic (from leftand right hepatic) due to formthe common bile duct.
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Biliary system
The common bile duct descends in
the hepatoduodenal ligament,then passes posterior to the firstpart of the duodenum
It penetrates the head of thepancreas where it joins the mainpancreatic duct and they form the
hepatopancreatic ampulla(sphincter of Oddi), which drainsinto posteromedial wall thesecond part of the duodenum at themajor duodenal papilla
Cholelithiasis (gallstones)
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Cholelithiasis (gallstones)
The distal end of the hepato-
pancreatic ampul la (Bile duct) is the
narrowest part of the biliary passages
and is the common si te for impaction
of gallstones.
As result of common hepatic (1), bile
duct (2), or hepatopancreatic
ampulla (3) obstruction patient will
have yellow eyes and jaundice
Gallstones may also lodge in the
cystic duct. A stone lodged in thecystic duct (4) causes biliary colic
(intense, spasmodic pain in the
gallbladder) but doesn't produce
jaundice.
1
2
3
4
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Gallstones
The fundus [1] of the gallbladder isin contact with the transverse colonand thus gallstones erode through theposterior wall of the gallbladder andenter the transverse colon. They arepassed naturally to the rectum
through the descending colon andsigmoid colon.
Gallstones lodged in the body [2] ofthe gallbladder may ulcerate throughthe posterior wall of the body of thegallbladder into the duodenum
(because the gallbladder body is incontact with the duodenum) and maybe held up at the ileocecal junction,producing an intestinal obstruction.
2
1
46. Nerve supply of the liver
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and gallbladder
Sensory innervation of the liver: by the rightphrenic nerve (C3-C5). Pain may radiate to ther ight shoulder .
The liver receives parasympathetic innervation
from the vagi nerves (CNX), reaching it throughthe celiac plexuses around the supplying arteries.The preganglionic fibers synapse on the cells ofthe uxtramural plexuses in hilum of the liver andshot postganglionic fibers supply organs.
Sympathetic f ibers of preganglionic neurons
T5-T9 segments (IML) come through thesympathetic trunk and form greater splanchnicnerves. They contribute to the celiac plexus,where postganglionic neurons are located.Branches of celiac plexus reach the liver wrappingaround the branches of the celiac artery.
47. Portal Hypertension &
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Portocaval shunts
Portal hypertension is acommon clinical condition, andfor this reason portal-systemicanastomoses should beremembered.
[1] Extrahepatic portocavalshunt for the treatment ofportal hypertension: thesplenic vein may beanastomoses to the left renalvein after removing the
spleen. [2] Intrahepatic portocaval
shunt : between portal veinand hepatic veins
Large intestine metastases &
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Portocaval anastomosis
Metastases of the Large intestine
cancer typically rich the Liver via
portal venous system: Rectum -
IMV - splenic vein - portal vein -
Liver
If there is an obstruction to flowthrough 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:
(1) esophageal veins
(2) paraumbilical veins
(3) rectal veins
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Esophageal anastomosis
Anastomosis between thetributaries of the left gastricvein (portal vein) and thetributaries of the azygousvein (SVC) in the wall of thelower end of the esophagus.
In portal hypertension theseveins enlarge in the wall of theesophagus and later burstinto the lumen of the
esophagus (esophagealvarices) resulting inhematemesis (vomiting redblood).
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Umbilical anastomosis
Anastomosis between theparaumbilical veins (portalvein) and the superior andinferior epigastric veins(SVC and IVC) in anteriorabdominal wall around theumbilicus.
In portal hypertension, thisanastomosis gets enlargedand dilated veins form “caputMedussae” around theumbilicus.
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Rectal anastomosis
Anastomosis between thesuperior rectal vein(inferior mesenteric veinand then portal vein) andinferior rectal vein whichdrains into the internal iliac
vein (from IVC system). In portal hypertension
(chronic alcoholics) thisanastomosis gets dilatedresulting in internalhemorrhoids and bleedingper anus from superior
rectal vein.
48. Pancreas:
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Head and uncinate process
The head of the pancreasrests within the C-shapedarea formed by theduodenum and istraversed by the commonbile duct.
It includes the uncinateprocess which is crossedby the superiormesenteric vessels.
Cancer of the head
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of the pancreas
Cancer of the head of thepancreas compresses the bileduct and results inOBSTRUCTIVE TYPE OFJAUNDICE.
Pain will be conveyed to sensoryneurons T5-T9 dorsal rootganglia via celiac plexus andgreater splanchnic nerve.
This type of jaundice is NOTusually associated with fever .
Hepatitis also causes jaundicebut is associated with thefever .
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Neck of the pancreas
Posterior to theneck of thepancreas is the siteof formation of thePORTAL VEIN.
(1)Splenic vein joins with (2)superiormesenteric vein toform (3) portal vein.
3
2
1
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Body of the pancreas
The body passes to theleft and anterior to the (1)aorta and the (2) leftkidney.
The (3) splenic arteryundulates along thesuperior border of thebody of the pancreas withthe splenic vein coursingposterior to the body.
3
2
1
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Tail of the pancreas
The tail of the pancreasenters the splenorenalligament to reach thehilum of the spleen.
It is the only part of thepancreas that isintraperitoneal.
Tail of the pancreas maybe mistakenly removedduring spleenectomy(ligation of splenic artery
and vein) and resulting insugar diabetes because itcontains a lot endocrinecells.
Arterial supply of the
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pancreas
Head and Duodenum:
(1) Superiorpancreaticoduodenal arteries -branches of gastroduodenalartery.
(2) Inferior pancreaticoduodenal
arteries - branches of SMA This region is important for
collateral c irculation becausethere are anastomoses betweenthese branches of the CA andSMA.
Neck, Body, and Tail of thepancreas:
Pancreatic branches of the (3)Splenic artery.
1
2
3
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Annular Pancreas Annular pancreas is caused by
malformation during the
development of the pancreas,
before birth.
Occurs when the ventral and dorsal
pancreatic buds form a ring aroundthe duodenum, thereby causing an
obstruction of the duodenum and
polyhydramnios
Symptoms:
1. Feeding intolerance in newborns
2. Fullness after eating
3. Nausea and bile-stained vomiting
Half of cases are not diagnosed
until symptoms occur in adulthood.
49. Spleen:
R t f th S l
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Rapture of the Spleen
Rapture of the spleen may beresult of the left 9th and 10th ribsfracture or blunt trauma of theleft upper abdomen.
The spleen is a peritoneal organ
in the upper left quadrant that isdeep to the left 9th, 10th, and 11th
ribs.
The spleen follows the contour ofrib 10 (axis of the spleen).
When blood collected deep to the
diaphragm phrenic nerveirritates and pain may irradiate toleft shoulder .
When spleen is ruptured, itcannot be sutured thereforeremoving is required.
Relations of the Spleen and
L ft Kid
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Left Kidney
The spleen followsthe contour of 10th riband extends from thesuperior pole of theleft kidney to just
posterior to themidaxillary line.
The border betweenspleen and upperpole of the left kidney
is 11th rib.
50. Kidney:
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Dimensions and position
During life, kidneys arereddish brown and measureapproximately 11-12 cm inlength, 5-6 cm in width, and2.5-3 cm in thickness.
They are extending from thelevel of T12 to the level of L3,the right kidney lying about2-3 cm lower than the leftone.
The lateral border of thekidney is convex. Its medial
border is convex at both endsbut concave in the middlewhere there is the hilum ofthe kidney (L1).
Anterior relations
f th i ht kid
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of the right kidney
1. Right suprarenal gland
2. 2nd part of theduodenum
3. Right lobe of the liver
4. Right colic flexure
5. Small intestine
Anterior relations
f th l ft kid
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of the left kidney
1. Left suprarenal gland
2. Stomach
3. Spleen
4. Body of pancreas andsplenic vessels
5. Descending colon
6. Small intestine
R l (G t ) f i
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Renal (Gerota) fascia
Enclosing the perinephric fat is
a membranous condensation
of the extraperitoneal fascia -
the renal fascia (3).
The suprarenal glands (4) are
also enclosed in this fascial
compartment, usually
separated from the kidneys by
a thin septum.
N.B. The renal fascia must
be incised in any surgicalapproach to this organ.
3
4
P i h i b
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Perinephric abscess
Most infections of the perinephricspace occur as a result of extensionof an ascending urinary tractinfection, commonly in associationwith nephrolithiasis or tuberculosis.
Perinephric abscess typicallydescends down between 2 sheets ofthe renal fascia along the psoasmajor muscle.
In case if abscess locates behind ofthe psoas major muscle it descendsdown and may affect hip joint.
If abscess spreads up it’ll reach thediaphragm and irritate phrenicnerve. As result patient will feel painin shoulder region.
51 N h lithi i
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51. Nephrolithiasis
Renal calculi are solid concretions
(crystal aggregations) formed in the
kidneys from dissolved urinary minerals.
There are several types of kidney
stones. The majority are calcium
oxalate stones, followed by calcium
phosphate stones.
Kidney stones typically leave the body
by passage in the urine stream, and
many stones are formed and passed
without causing symptoms. If stones grow to sufficient size before
passage (at least 2-3 mm), they can
cause obstruction of the ureter (renal
colic).
3 t i ti f t
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3 constrictions of ureter:
Ureter located on the anteriorsurface of the Psoas majormuscle and has 3 constrictions:
1st constriction is at thepelviureteric junction (level of L1)
2d constriction lies at the level ofpelvic brim (level of the sacroiliac
joint)
3d constriction appears whereureter lies obliquely in the wall ofurinary bladder (level of ischial
spine)
1
2
Staghorn calc li
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Staghorn calculi
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.
Staghorn calculi are composed of
magnesium ammonium
phosphate, which forms in urine
that has an abnormally high pH
(above 7.2).
This high pH usually developsbecause of recurrent urinary tract
infection with microorganisms
such as Proteus mirabilis.
52 Suprarenal glands
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52. Suprarenal glands
They are endocrine glands
having cortex and medulla.
The adrenal cortex [1]
secretes aldosterone,
corticosteroids and
genital hormones.
1
2
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. Sympathetic stimulation or hypersecretion of
catecholamines (tumor of adrenal medulla orsympathetic chain ganglia) resulting in: episodes oftachycardia, sweating and high blood pressure.
Unpaired tributaries of IVC
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Unpaired tributaries of IVC
The right renal (1) vein ismuch shorter than the left.Both veins lie anterior to thecorresponding artery inhilum of kidneys.
The long left renal vein (2)is joined by the leftsuprarenal (3) and leftgonadal (4) (testicular or ovarian) veins before itreached IVC.
Right suprarenal vein andright gonadal vein draindirectly to IVC (unpairedIVC tributaries).
1
2
3
4
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53. Varicocele
It is enlargement of thepampiniform plexus thatproduces a wormlike scrotalmass and enlargement of thespermatic cord. Varicocelemay be reason of low spermcount.
Varicocele formation is usuallyon the lef t side and maydisappear in supine positionof the body.
Varicocele may indicatekidney disease or may signala retro peritoneal malignancyobstructing the testicularvein.
Pampiniform plexus
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Each testicular or ovarian vein isformed by coalescence of apampiniform plexus: thetesticular at the deep inguinalring, the ovarian at the margin ofthe superior aperture of the
pelvis. The veins run accompanied by
the corresponding arteries. Theleft pampiniform plexus entersthe left renal vein; the right oneenters directly the IVC inferiorto the renal vein.
That is why varicocely(engorgement of the pampiniformplexus that produces a scrotalmass) is more often located onthe left.
54 Hydrocele
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54. Hydrocele
The tunica vaginalis testis orother remnants of the processusvaginalis may form a hydroceleor hematocele.
In spermatic cord it is smooth
sausage-shaped structure thatpersists under gentlecompression and isn’t disappearin supine position.
In the scrotum withtransillumination, a hydroceleproduces a reddish glow,
whereas light will not penetrateother scrotal masses such as ahematocele, solid tumor , orherniated bowel.
55. Hemorrhoids:
V d i f t
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Venous drainage from rectum
Above pectinate line: superior
rectal vein [1] into portal
system [2].
Below pectinate line: inferior
rectal vein [3] into inferior
vena cava [4].
1
2
3
4
E t l h h id
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External hemorrhoids
Hemorrhoids are masses that
typically protrude from anus
during defecation.
Hemorrhoids are commonly
associated with constipation,extended sitting and straining at
the toilet, pregnancy, and
disorders that hinder venous return.
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
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Internal hemorrhoids
2. Internal hemorrhoidsare dilated tributaries of thesuperior rectal veins(SRV) ABOVE THE
PECTINATE LINE and arenot painful because themucosa is supplied byvisceral afferent fibers.
Internal hemorrhoids
frequently develop inchronic alcoholicsbecause of liver cirrhosisand portal hypertensionsyndrome.
2
2
2
56. Perineal pouches:
Deep perineal pouch
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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 (inthe male only) - ducts
perforate perineal
membrane and enters
bulbar urethra.
Superficial perineal pouch1 I hi l l t d t th C f th
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1. Ischiocavernosus muscle – related to the Crus of thepenis (Male) & Crus of the clitoris (Female)
2. Bulbospongiosus muscle – related to the Bulb ofvestibule (Female) & Bulb of the penis (Male)
3. Superficial transverse perineal muscle – related to thePerineal body (both genders)
1
2
3
Urine leaks
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Urine leaks
After a crushing blow or a
penetrating injury, the spongy
urethra commonly ruptures
within the bulb of the penis, and
urine leaks into the superficialperineal pouch.
The superficial perineal fascia
keeps ur