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Innervation of muscles associated with the upper limb & accesory respiratory muscles
ventral rami of spinal nerves
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erector spinae muscles
deep back muscles
- spinalis capitis, cervicis, thoracis
- longissimus capitis, cervicis, thoracis
- iliocostalis cervicis, thoracis, lumborum
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innervation of deep back muscles
dorsal rami of spinal nerves
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number of vertebrae
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral segments
- 4 coccyx segments
- TOTAL = 33
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vertebral level of reference: T2
sternal notch
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vertebral level of reference: T4
- sternal angle (Angle of Louis/ manubrial-sternal junction)
- level of bifurcation of trachea
- beginning of aortic arch (from ascending aorta)
- end of aortic arch (beginning of descending aorta)
- azygous vein enters superior vena cava
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vertebral level of reference: T10
esophageal hiatus (esophagous passing through the diaphragm)
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vertebral level of reference: L1 or L2
end of spinal cord in an adult
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vertebral level of reference: L4
iliac crest
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vertebral level of reference: S2
end of dural sac, dura, arachnoid, subarachnoid space and CSF
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primary curvatures of the back
- posterior convexity of thoracic and sacral regions of the vertebral column
- present at birth
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secondary curvatures of the back
- posterior concavity of the cervical and lumbar regions of the vertebral column
- develop after birth (child holds head up, begins to walk)
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normal curvature of the back: women
- lumbar curvature is greater in women
- increased lumbar posterior concavity is normal later in pregnancy
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normal curvatures of the back: men
sharper sacral curvature sharper in males
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kyphosis
exaggeration of the posterior convexity in the thoracic region
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causes of kyphosis
- muscular weakness
- structural changes in vertebrae or intervertebral discs
- crush fractures
- tuberculosis
- osteoporosis
- poor posture in adolescents
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"senile kyphosis"
degeneration of intervertebral discs
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"Dowager hump"
kyphosis ("hunchback") seen in elderly women due to osteoporosis
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lordosis
- exaggeration of the posterior concavity in the lumbar region
- characterized by an anterior rotation of the pelvis
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causes of lordosis
- increase in weight of the abdominal contents (eg. pregnancy or large ovarian tumor)
- postural compensation for a thoracic kyphosis
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scoliosis
- lateral deviation of the vertebral column
- found mostly in the thoracic region
- accompanied by rotation of the vertebrae
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causes of scoliosis
- asymmetric muscular weakness (myopathic scoliosis)
- vertebral defects (congenital hemivertebra)
- muscle paralysis due to poliomyelitis
- compensatory - cause by a short leg or hip disease
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abnormal curvatures of the back
- kyphosis
- lordosis
- scoliosis
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typical cervical vertebrae
- C3 - C6
- body with uncinate process
- bifid spinous process
- two transverse processes with transverse foramen
- four articular processes - superior articular facets face posterior and superior; inferior articular facets face anterior and inferior
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C7
- vertebra prominens
- spinous process is NOT bifid, very large, and easily palpable
- transverse foramen small or absent - does NOT transmit the vertebral artery (only accessory vertebral vein)
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C1
- atlas
- no body
- anterior tubercle
- posterior tubercle - attachment for suboccipital triangle muscles; groove for vertebral artery
- superior articular surfacearticulates with occipital condyles (base of skull)
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C2
- axis
- dens/odontoid process - body of C1 developmentally
- bifid spinous process
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uncovertebral joints
- an articulation in the five lower cervical vertebral bodies, formed by the space between one vertebral body and the uncinate process that projects superiorly from the vertebral body immediately below it
- synovial joint
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typical thoracic vertebra
- long spinous processes
- costal facets on sides of body
- costal facets on transverse processes of T1-T10
- costovertebral joints
- costotransverse joints
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costovertebral joints
synovial joint between head of rib and vertebral body
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costotransverse joints
synovial joint between tubercle of rib and transverse process of T1 - T10
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typical lumbar vertebra
- vertebral bodies get progressively larger as your proceed inferiorly
- NO costal facets
- NO transverse foramina
- superior articular process has a rounded mamillary process
- short horizontal spinous processes
- superior articular facets face medially
- inferior articular facets face laterally
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Scotty Dog
- oblique radiograph of lumbar vertebral column
- ear = superior articular process
- eye = pedicle
- front leg = inferior articular process
- back leg = spinous process + inferior articular process
- neck = pars interarticularis
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spondylolysis
- a defect or fracture of the isthmus or pars interarticularis
- no anterior displacement of the vertebral body
- radiographs show that the Scotty dog appears to be wearing a collar at the site of the fracture
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Spondylolisthesis
- a unilateral or bilateral defect or fracture of the pars interarticularis
- accompanied by anterior displacement of the vertebral body
- radiographs show the head of the Scotty dog appears to be separated from the body
- most common between the L5 vertebra and the sacrum
- may stretch roos of lumbosacral spinal nerves in the cauda equina
- patients have bilateral lower back pain that radiates into both lower limbs and weakness in muscles of the legs
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cervical vertebrae: orientation of facets
- superior facets = sup/post
- inferior facets = inf/ant
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cervical vertebra: movement allowed
- flexion/extension
- lateral bending
- rotation
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thoracic vertebrae: orientation of facets
- superior facets = post/lat
- inferior facets = ant/med
- arc centered around vertebral body
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thoracic vertebrae: movements allowed
- lateral bending
- rotation
- flexion/extension
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lumbar vertebrae: orientation of facets
- superior facets = medial
- inferior facets = lateral
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lumbar vertebrae: movements allowed
- flexion/extension
- NO rotation
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anterior longitudinal ligament
anterior to vertebral bodies
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posterior longitudinal ligament
- posterior to vertebral bodies and inside vertebral canal
- anterior to spinal cord
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ligamentum flavum
- between adjacent laminae (posterior of vertebral canal)
- appears yellowish in real life
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interspinous ligaments
between vertebral spines
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supraspinous ligament
- posterior to vertebral spines
- very thick in cervical regions - ligamentum nuchae (attachement for trapezius muscle)
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intervertebral discs
- form cushion between two adjacent vertebrae
- highly innervated
- central nucleau pulposus
- peripheral annulus fibrosus
- two layers of cartilage that cover the superior and inferior aspects of the disc
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annulus fibrosus
- composed of concentrically arranged lamellae made of collagen fibers
- surrounds the nucleus pulposus of intervertebral discs
- helps to stabilize the adjacent vertebral bodies
- acts as a to limit excessive motion
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nucleus pulposis
- semi-fluid consistency
- consists of chondrocytes, collagen fibers, and ground substance
- avascular and not innervated
- fluid consistency of the nucleus deforms under pressure (transmits pressure in all directions)
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herniated discs
- herniation of the nucleus pulposus through a defect in the annulus fibrosus
- discs affected are in the mobile regions of the vertebral column (cervical and lumbar)
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central protrusion
herniation in the midline under the posterior longitudinal ligament
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lateral protrusion
herniation at the side of the posterior longitudinal ligament close to the intervertebral foramen
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suboccipital triangle
deep to the trapezius and the semispinalis capitis muscles
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suboccipital triangle borders
- superiomedially - rectus capitis posterior major
- superolaterally - obliquus capitis superior
- inferolaterally - obliquus capitis inferior
- floor - posterior atlantooccipital membrane and posterior arch of C1
- roof - semispinalis capitis
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rectus capitis posterior major
- origin = spinous process of C2
- insertion = lateral part of inferior nucal line
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rectus capitis posterior minor
- origin = posterior tubercle of posterior arch of C1
- insertion = medial part of inferior nuchal line
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obliquus capitis inferior
- origin = spinous process of C2
- insertion = transverse process of C1
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obliquus capitis superior
- origin = transverse process of C1
- insertion = occipital bone between the superior and inferior nuchal lines
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vertebral artery
- first branch of subclavian artery
- passes through transverse foramina of C6 through C1
- winding course suboccipital triangle
- passes through the dura and the arachnoid to enter the foramen magnum
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suboccipital nerve
- innervates the muscles of the suboccipital triangle
- dorsal ramus of the C1 spinal nerve
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spinal cord
- part of the CNS
- continuation of the medulla oblongata
- extends from the foramen magnum in the skull through the vertebral column in the vertebral canal
- 42-45 cm in length
- occupies the upper 2/3 of the vertebral canal
- terminates inferiorly at the level of L1/L2 intervertebral disc as the conus medullaris
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spinal cord segment
that portion of the spinal cord that gives rise to a single spinal nerve
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spinal nerve
- arises as dorsal and ventral roots from a single spinal cord segment
- each spinal nerve exits through its own intervertebral foramen
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number of spinal nerves
- 8 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 1 coccygeal
- 31 TOTAL
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spinal nerve exits
- C1 through C7 spinal nerves exit above the vertebra with the same name
- C8 spinal nerve exits below C7 vertebra
- Beginning with the T1 spinal nerve, spinal nerves exit below the vertebra of the same name
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To approximate the spinal cord segment at a particular vertebral level
- add one to the vertebral level in lower cervical region
- add two in the upper thoracic region
- add three in the lower thoracic region
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to determine the level of spinal nerve clinically (determine vertebral level entrance for surgery)
- subtract one from the cord segments in lower cervical region
- subtract two in the upper thoracic region
- subtract three in the lower thoracic region
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cervical disc herniations
- less common than lumbar herniation
- discs between C5 and C6 & C6 and C7 are the most susceptible
- lateral protrusions - cause pressure on spinal nerve or its roots
- central protrusions - press on the spinal cord
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lumbar disc herniations
- more common than cervical
- discss between the L4 and L5 & L5 and S1 are usually affected
- region of the cauda equina
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sciatica
- pain distribution down the back and lateral side of the leg, radiating to the sole of the foot
- caused by pressure on the sensory roots of the L5 and S1 spinal nerves
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L4/L5 herniated disc
- L5 motor root impaired
- weakness in dorsiflexion of the ankle
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L5/S1 herniated disc
- S1 motor root impaired
- weakness of plantar flexion of the ankle
- diminished or absent ankle jerk reflex
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spinal cord enlargements
- cervical enlargement (C4 through T1)
- lumbrosacral enlargement (L2 and S3)
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cervical spinal cord enlargement
- C4 through T1 spinal cord segments
- innervation of the upper limb - brachial plexus
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lumbrosacral spinal cord enlargement
- L2 through S3 spinal cord segments
- innervation of the lower limb - lumbar and sacral plexus
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differential growth effects on spinal cord
- in the first trimester, the spinal cord extends the length of the entire body
- in the fetus, the spinal nerves exit the spinal cord horizontally
- the vertebral column grows faster than the spinal cord and the spinal nerves are anchored to their targets
- nerves just elongate as the body develops
- nerves stream vertically at the inferior portion of the spinal canal (cauda equina)
- lumbar cistern - enlargement of the subarachnoid space containing the nerve roots of the cauda equina
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spinal meninges
dura mater + arachnoid mater + pia mater surrounding the spinal cord
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dura mater
- outermost covering of the spinal cord
- composed of dense fibrous and elastic tissue
- completely surrounds the spinal cord forming a sac within the vertebral canal = dural sac/thecal sac
- continuous with the endosteal layer of cranial dura at the foramen magnum
- extends down to S2 where it is continuous with the coccygeal ligament
- extends laterally as dural sleeves of nerve roots and spinal ganglia
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epidural space
- external to the dura mater
- space between the periosteum of the vertebrae and the dura
- contains: fat & loose connective tissue, internal vertebral venous plexus
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subdural space
- potential space deep to the dura
- between the dura and the arachnoid
- contains a thin layer of fluid
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arachnoid mater
- deep to the dura
- connected to pia mater by very delicate tissue strands called atachnoid trabeculae
- follows the dural sac to its termination at S2
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subarachnoid space
- between arachnoid and pia
- contains cerebrospinal fluid (CSF)
- contains the cauda equina and the filum terminale
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lumbar cistern
- enlarged part of subarachnoid space caudal to the conus medullaris
- extends from L2 to S2
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pia mater
- innermost covering of the spinal cord
- ensheathes the spinal arteries
- gives rise to the denticulate ligament
- consists of 20 to 22 toothlike process
- attaches to the inner surface of the dura
- spinal cord is suspended within the dura by the denticular ligament
- extends from foramen magnum to between the T12 and L1 nerve roots
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anterior spinal artery
- from vertebreal arteries
- supplies anterior 2/3 of the spinal cord
- 75% of the blood supply to the spinal cord is from the ASA
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posterior spinal arteries
- from posterior inferior cerebellar arteries
- supply posterior 1/3 of the spinal cord
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radicular arteries & segmental arteries
- branches of vertebral, intercostal, and lumbar arteries
- Artery of Adamkiewicz [great anterior segmental medullary artery]
- most commonly arises at T10 on the left side
- origin is variable (usually T9-T12; left > right)
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vertebral venous plexus
- external and internal vertebral venous plexus
- thin walled
- incompetent valves or valveless
- dependent upon pressure differential, venous blood can flow between the vertebral plexuses and skull, neck, thorax, abdomen, and pelvis
- pathway for metastasis of prostate cancer to the vertebral column and cranial cavity
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lumbar puncture
- to obtain CSF from the lumbar cistern for laboratory examination (appearance, protein, sugar, serology, cell count, bacterial or fungal cultures)
- to administer medications into the subarachnoid space
- to perform myelography
- to measure for evidence of increased intracranial pressure
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lumbar puncture procedure
- patient bends forward to increase intervertebral space
- palpate iliac crest to know where L4 vertebral level is
- insert needle below L4/L5 vertebrae
- - spinal cord ends at L1/L2 disc in adults, L3 in children
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What layers does the needle pass through when doing a lumbar puncture?
- skin
- superficial fascia
- supraspinous ligament
- interspinous ligament
- infraspinous ligament/ ligamentum flavum
- epidural space (containing fatty areolar tissue and the internal vertebral venous plexus)
- dura mater
- subdural space
- arachnoid mater
- subarachnoid space
- CSF in lumbar cistern
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epidural/ caudal block
performed by administering anesthetic through the sacral hiatus, which diffuses through the meninges and anesthetizes the roots of the sacral and coccygeal spinal nerves in the cauda equina
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saddle block
anesthetic is injected directly into the subarachnoid space at L4
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neuron
functional unit of the nervous system
-
components of a neuron
- dentrites
- cell body
- axon
- synaptic terminals
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dendrites
- stimulated by environmental changes or the activities of other cells
- increase surface area for impulses and synapses to occur
- small processes conduct impulses toward neuronal cell body
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cell body
contains the nucleus, mitochondria, ribosomes, etc. of neuron
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axon
- conducts nerve impulses (action potentials) away from the neuronal cell body
- long process - can be many feet long
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synaptic terminals
affect another neuron or effector (muscle, glands, etc)
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types of neurons
- unipolar
- bipolar
- multipolar
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unipolar neuron
- pseudounipolar
- two processes coming from cell body - dendrite (peripheral) and axon (central)
- ex - found in dorsal root ganglion adjacent to spinal cord
- myelinated
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bipolar neuron
- two processes continuous with cell body
- dendrite goes toward cell body; axon coming out of cell body
- not very common
- ex - retinal ganglion, vestibular cells, cochlear cells
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multipolar neuron
- most common type
- many dendrites enter the cell body but only one axon exits
- myelinated
- ex - skeletal muscle
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CNS
consists of the brain and spinal cord
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nucleus
collection of cell bodies in CNS
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ganglion
collection of cell bodies outside of CNS
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peripheral nervous system
consists of cranial nerves and spinal nerves
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autonomic nervous system
consists of SNS and PNS
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vertebral column
- houses the spinal cord and spinal nerves
- intervertebral foramina get bigger toward inferior end of vertebral column
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how many spinal nerves?
31 pairs
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how many cranial nerves?
12 pairs
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where does the spinal cord end?
at the disc between L1 and L2 vertebrae
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afferent
- sensory
- stimulus from periphery runs from receptor to CNS
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efferent
- motor
- impulse goes away from CNS and to an end organ (muscle, etc.)
-
dorsal root
- purely sensory (afferent)
- cell bodies housed in dorsal root ganglion
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ventral root
- purely motor (efferent)
- cell bodies are in ventral horn of spinal cord
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spinal nerve
- union of dorsal and ventral roots
- divides into dorsal ramus and ventral ramus
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dorsal ramus
- sensory and motor
- innervates deep muscles of the back
- goes toward back of body
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ventral ramus
- sensory and motor
- innervates the superficial muscles of the back & appendages
- goes toward front of body
- bigger than dorsal ramus (innervates more of the body)
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dorsal root ganglion
- most located in intervertebral/neural foramina
- exception - in sacrum, located in vertebral canal
-
nerve pathway
route followed by a series of nerve impulses from their origin in one part of the body to their arrival elsewhere in the body
-
simplest nerve pathway
reflex arc
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reflex arc
- simplest nerve pathway
- a rapid, automatic unconscious response to a situation in an attempt to maintain body homeostasis
-
direction of stimulus in a reflex arc
stimulus travels from receptor - dorsal root - synapses with association neuron - ventral root - impulse travels through motor neuron - effector (muscle)
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type of reflexes
- monosynaptic reflex
- polysynaptic reflex
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monosynaptic reflex
- single synapse
- ex - knee jerk reflex
- when tapped, the patellar tendon stretches (also stretches Golgi fibers in muscle)
- sends impulse through ventral ramus - dorsal root ganglion - dorsal root - synapses with motor cell body in ventral horn - causes action potential with nerve in muscle - knee joint extends
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polysnaptic reflex
- flexor/withdrawal reflex
- ex - touching a hot stove
- multiple synapses
- an association neuron connects the afferent and efferent neurons in the spinal cord
- finger touches stove - impulse through sensory fiber (nerve in ventral ramus) - association neuron - motor fiber in ventral ramus - biceps cause hand to jerk away (triceps relax)
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functional nerve components
- general somatic afferent
- general somatic efferent
- general visceral afferent
- general visceral efferent
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general somatic afferent (GSA)
- nerve that conducts sensory impulses/ modalities
- pain, touch, temperature, proprioception
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general somatic efferent (GSE)
- nerves that carry motor impulses
- contraction of skeletal muscles
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general visceral afferent (GVA)
- impulses from organs
- stretch pains, visceral reflexes
- ex - menstrual cramps, getting kicked in the groin, stomach aches
- nonspecific pain
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general visceral efferent (GVE)
- autonomic nervous system
- motor
-
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special visceral afferent
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special visceral efferent
pharyngeal arch musculature
-
denticulate ligament
- lateral extension of the pia
- separates the dorsal roots from the ventral roots
- anchors the cord to the dura between successive nerve roots
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lateral cutaneous branches of ventral rami
innervate skin
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anterior cutaneous branches of ventral rami
sensory innervation of skin
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superior medial branches of dorsal rami
innervate skin (cutaneous)
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superior lateral branches of dorsal rami
innervate deep back muscles
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inferior medial branches of dorsal rami
innervate deep back muscles
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inferior lateral branches of dorsal rami
innervate skin
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greater occipital nerve
- medial branch of dorsal ramus of spinal nerve C2
- somatic afferent (sensory) nerve fibers (GSA)
- sympathetic fibers (GVE)
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suboccipital nerve
somatic efferent (motor) nerve
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nerve plexus
- network of nerve fibers
- site where nerve fibers intermingle and from which a new set of multisegmented peripheral nerves emerge
- formed by ventral rami
- contain motor and sensory nerves
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dermatome
area of the skin that is supplied by a single spinal nerve
-
important dermatomes
- T4 - nipple
- T10 - umbilicus
- L1 - groin
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peripheral nerve field
area of skin supplied by a peripheral nerve (more than one spinal nerve)
-
-
superficial fascia
- separates skin from subcutaneous tissue and fat
- veins, arteries, nerves and lymphatics travel through here
- "a surgeon's friend"
-
deep fascia
- keeps muscle fibers bound together
- separates muscles into compartments
- also keeps nerves and vessels bound to muscle
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subserous fascia
outside of serous membranes (pleura, peritoneal cavity)
-
autonomic nervous system
- visceral motor system (GVE)
- effector cells - smooth muscle, cardiac muscle, and glands
- two neuron chain - pre- and post-ganglionic
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effector cells of ANS
- smooth muscle: digestive tract, vessels, duct systems, uterus, arrector pili muscles in skin, bronchi, genital organs
- cardiac muscle
- glands: sweat glands, salivary glands
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preganglionic neurons
- before synapse
- from CNS
- myelinated - look white
-
postganglionic neuron
- after synapse in ganglion
- unmyelinated - look grey
-
Are sympathetic and parasympathetic systems always found together?
NO
-
two components of autonomic nervous system
- sympathetic
- parasympathetic
-
general somatic efferent system
one neuron from CNS synapses on effector cell (skeletal muscle)
-
general visceral efferent
- preganglionic axon from CNS synapses on cell body in ganglion
- postganglionic axon from ganglion synapses on effector cell (smooth muscle, cardiac muscle, glands)
-
sympathetic nervous system
- origin - thoracolumbar region of CNS (segments T1-L2)
- short preganglionics
- long postganglionics (EXCEPTION - splanchnic nerves)
- fight or flight response
-
parasympathetic nervous system
- origin: cranial-sacral area of CNS (CN 3,7,9,10 & segments S2-S4)
- long preganglionics
- short postganglionics
- rest & digest
-
types of sympathetic ganglia
- sympathetic chain ganglia (paravertebral)
- prevertebral ganglia
-
prevertebral ganglia
- in the abdomen -
- celiac
- superior mesenteric
- inferior mesenteric
- aorticorenal
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sympathetic chain ganglia
- paravertebral: on both sides of the body
- runs the entire length of the spinal cord
- swellings within the chain are caused by cell bodies of postganglionic sympathetic fibers
- only 3 sympathetic chain ganglia in head/neck
-
lateral horn
- intermedial lateral cell column
- "bump" extending from side of grey matter in spinal cord segments T1-L2
- accumulation of cell bodies
- sends out axons through ventral roots (along with somatic motor fibers)
-
intermedial lateral cell column
site of cell bodies for preganglionic sympathetic fibers (VME)
-
white ramus communicans
- communication between ventral ramus and sympathetic chain ganglia
- myelinated (appears white)
- more distal or lateral from spinal cord
-
gray ramus communicans
- communication between postganglionic sympathetic fiber back to ventral ramus
- unmyelinated (appears grey)
- more medial to spinal cord
-
preganglionic sympathetic axon pathways
- ascend up the chain before synapsing at higher ganglion (no lateral horns at cervical level)
- descend down the chain before synapsing at lower level
- pass through chain without synapsing (splanchnic nerves)
- synapse at same level it enters the chain
-
True or False: All spinal nerves are associated with gray rami communicans but only those in the thoracic and upper lumbar regions are associated with white rami communicans.
TRUE
-
greater splanchnic nerve
- composed of sympathetic fibers that did not synapse in sympathetic chain
- travels down through diaphragm to ganglia in the abdomen
-
comparative length of contents of vertebral canal
vertebral canal > sympathetic chain ganglia > spinal cord > IMLCC
-
Horner's Syndrome
- disruption of sympathetic innervation
- due to lesion/compression of one side of the cervical or thoracic sympathetic chain which generates symptoms on ipsilateral side (same side) of body
- ptosis: droopy eyelid
- miosis: constricted pupil
- anhidrosis: decreased sweating
- flushing of the face: dilation of blood vessels
-
CN X
- cranial nerve 10
- Vagus nerve
- supplies parasympathetics in chest
- nucleus - dorsal motor nucleus of X (source of preganglionic cell bodies in brain)
- ganglion - in thoracic abdominal viscera
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Vagus nerve cell body locations
- preganglionic - dorsal motor nucleus of X
- postganglionic - wall of organ
-
sympathetic neurotransmitters
- from preganglionic - ACh
- from postganglionic - NE
- EXCEPTION: postganglionic of sweat glands - ACh
-
parasympathetic neurotransmitters
from preganglion AND postganglionic - ACh
-
general visceral afferent nerves
- travel back from the organ to the CNS along with the GVE fibers supplying the specific organ
- generally those GVA pain fibers from thoracic and abdominal organs travel back to the CNS with sympathetic fibers
- generally the GVA pain fibers from pelvic organs travel back to the CNS with parasympathetic fibers
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somatic pain
- very localized
- causes - trauma
-
visceral pain
- poorly localized
- causes - sudden distension, strong contractions, ischemia
-
ischemia
deprivation of blood supply
-
referred pain
pain originating in one location in the body but perceived by the patient as coming from another location in the body
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referred pain: ischemia in the heart
- inadequate blood supply to myocardium
- patient experiences severe pain over sternum radiating to left shoulder and arm or both shoulders and even root of neck and lower jaw
- GVAs ascend into cardiac nerves and pass via spinal ganglia into cord at levels T1-T4/5
- pain in the arm is accounted for by intercostobrachial nerve (T2) while spread of nervous system accounts for pain in jaw
-
referred pain: acute appendicitis
- visceral pain due to spasm and distension reaches the T10 segment via the lesser splanchnic nerve
- pain is referred to the umbilical region
- later the pain becomes somatic over the T12 & L1 cutaneous region because of the irritation of parietal peritoneum by appendicicit
-
upper limb segments
- shoulder: connected by joints grossly in the shoulder region
- brachium (arm):connected by joints grossly in the elbow and shoulder region
- antebrachium (forearm): connected by joints grossly in the wrist and elbow regions
- manus (hand): connected by numerous joints
-
pectoral girdle
- scapula, clavicle, and articulation to sternum
- needed to attach upper limb to axial skeleton at glenohumeral joint
-
clavicle
- S-shaped
- convex over medial 2/3
- concave over lateral 1/3
- only bony attachment of the upper appendicular skeleton
- to axial skeleton
- movable strut
- transmits all of the forces applied to upper limb
- most frequently broken bone in human body
-
frequency of clavicular fractures
-
clavicular fractures
- medial fracture: less common (2-3%)
- midshaft fracture: most common (70-82%)
- distal fracture: somewhat common (30%)
-
scapula
- triangular, flat bone
- extends from 2nd to 7th rib
-
posterior scapula features
- spine
- supraspinatus fossa - superior, smaller, more concave
- infraspinatus fossa - inferior, larger, flatter
- acromion process - enlargement of the spine as it moves laterally
-
lateral scapula features
- glenoid cavity: pear shaped cavity on lateral border
- where the head of the humerus articulates
-
anterior scapula features
- coracoid process - beak like process projecting anteriorly from the superior border; important for ligament and muscle attachment
- subscapular fossa
-
superior scapula features
superior transverse ligament: spans the suprascapular notch; houses the suprascapular nerve
-
superior transverse scapular ligament
- suprascapular artery travels OVER
- suprascapular nerve travels UNDER
- Army goes over the bridge, Navy goes under the bridge
-
humerus
- head - articulates with scapula at glenohumeral joint
- neck - anatomic vs surgical
- shaft
- greater tubercle - attachment for supraspinatous,
- infraspinatous, and teres minor
- lesser tubercle
- deltoid tuberosity
- intertubercular groove/sulcus
-
Hilton's law
moveable joint is innervated by articular branches of the nerves that supply the muscles acting on the joint and that also supply the skin covering the joint
-
properties of joints
- bony surfaces are rarely in direct continuity
- covered by hyaline cartilage
- exception - acromioclavicular & sternoclavicular joints are covered by fibrous tissue
- covered by a fibrous capsule
- perforated by synovial protrusions (bursae)
- frequently exhibit localized thickenings - intrinsic
- ligaments
- may be reinforced by extrinsic ligamentous and muscular support
-
sternoclavicular joint
- manubrium of sternum articulates with medial end of
- clavicle
- very strong - bone breaks more than joint will be
- affected
- saddle synovial joint - mobility & strength
- articular disk between sufaces absorbs some shock
- four ligaments enforce the joint - anterior sternoclavicular, posterior sternoclavicular, interclavicular, costoclavicular
-
sternoclavicular joints
- anterior sternoclavicular: sternum to clavicle
- posterior sternoclavicular: sternum to clavicle
- interclavicular: connects medial ends of two clavicles; continuous with clavicular disk
- costoclavicular: attaches clavicle to first rib; prevents excessive elevation of shoulder
-
acromioclavicular joint
- acromion of scapula articulates with lateral end of the
- clavicle
- plane synovial joint - separated by incomplete wedge-shaped articular disc
- three ligaments - acromioclavicular, coracoclavicular, coracoarcomial
-
acromioclavicular ligaments
- acromioclavicular: covers joint capsule, strengthens joint superiorly
- coracoclavicular: conoid & trapezoid ligaments; suspends the scapula and upper limb passively from clavicle and maintain joint alignment
- coracoacromial: stretches across scapula from acromion process to coracoid process; not really holding clavicle
-
acriomioclavicular joint separation
- shoulder separation
- grades increase with extent of damaged ligamentation
- type I: sprain of acromioclavicular ligament; no tearing
- type II: acromioclavicular ligament tear; sprained or partial coracoclavicular ligament tear
- type III: both ligments completely torn; complete shoulder separation
-
glenohumeral joint
- ball and socket synovial joint
- most mobile joint in the body
- somewhat unstable due to flat nature of glenoid fossa
- four ligaments - glenohumeral, coracohumeral, transverse humeral, coracoacromial
- glenoid labrum
- tendon of long head of biceps brachii m
- bursae
-
glenohumeral ligaments
- glenohumeral: stabilizes the joint anteriorly; stretches from lateral angle of clavicle to anatomical neck of humerus
- coracohumeral: stabilizes the joint superiorly; spans the base of the coracoid process to the greater tubercle of the humerus
- transverse humeral: spans the intertubercular sulcus; does not actively stabilize the joint
- coracoacromial: provides roof to glenohumeral joint; prevents superior displacement; spans inferior acromion and coracoid process of scapula
-
glenoid labrum
- rings of fiber cartilage around glenoid cavity
- deepen the "cup" to enable the humeral head to sit in place
-
synovial sheath
- pocket of synovial membrane that completely wraps
- around the tendon of the long head of biceps brachii m
- extension of transverse humeral ligament
- permits frictionless movement within intertubercular sulcus
-
bursae
- pockets of synovial membrane and fluid
- enable structures to pass above and below routinely without friction or inflammation
- usually isolatedexist between muscles or between muscles and bone
-
bursae of glenohumeral joint
continuous with joint cavity to cushion the subscapularis
-
glenohumeral joint separation
- shoulder dislocation
- capsule is weakest inferiorly
- clinical descriptions occur relative to infraglenoid tubercle
-
genuine shoulder dislocation
- head of humerus ends up anterior to glenoid cavity
- VERY painful
-
bursitis
- bursa become inflammed (by bone spurs, calcium deposits, etc.) and impede the function for which they were designed
- muscle will slide over a swollen or tender bursa causing pain and friction
-
scapulothoracic joint
- a physiological joint created by the numerous muscles attached to the scapula
- moves the bone on the clavicle at the acromioclavicular joint
-
movement of the shoulder
- elevation: levator scapulae, trapezius (descending fibers), rhomboids, etc.
- depression: trapezius (ascending fibers), gravity
- protraction: serratus anterior
- retraction: rhomboids, trapezius (middle fibers)
- upward rotation: trapezius (ascending and descending)
- downward rotation: latissimus dorsi
-
movements of the humerus
- extension
- flexion
- abduction
- adduction
- lateral rotation
- medial rotation
-
axes of movement of the humerus
- perpendicular to glenoid fossa through humerus head - allows extension & flexion
- parallel to glenoid cavity through head of humerus - abduction & adduction
- through shaft of humerus - lateral & medial rotation
-
circumduction
- four movements in sequence
- flexion - abduction - extension - adduction
-
rotator cuff
- musculotendinous cuff around glenohumeral joint
- anchors the head of the humerus against glenoid fossa
- acts as prime rotators of humerus
- supraspinatus: abduction
- infraspinatus: lateral rotation
- teres minor: lateral rotation
- subscapularis: medial rotation
-
rotator cuff injuries
tears, especially in the supraspintus
-
basic breast information
- major structure on the anterior chest wall
- modified sweat gland
- serves the purpose of secreting and excreting milk
- accessory structure of reproduction
-
the female breast
- 2/3 over pectoralis fascia
- 1/3 over serratus anterior fascia
- retro-mammary space behind breast tissue anterior to pectoralis major
- axillary tail of Spence: lateral extension of breast into arm
- nipple surrounded by areola - usually at 4th intercostal space lateral to mid-clavicular line
-
boundaries of breast tissue
- medial: lateral border of the sternum
- lateral: mid axillary line
- superior: 2nd rib but can extend up to clavicle
- inferior: 6th rib but can be deceptive due to ptosis
-
fascial layers of the breast
- pectoralis major fascia: continous with the fascia of the axilla & anterior abdominal wall
- clavi-pectoral fascia: deep to the pectoralis major and invests the subclavius muscle & pectoralis minor muscle
-
internal anatomy of the breast
- attached to dermis by suspensory ligaments of Cooper
- each lactiferous duct ends in 15-20 lobules which make milk
- lactiferous ducts dilate into lactiferous sinuses deep to the nipple-areolar complex to drain to the surface
-
arterial supply of the breast
- aorta
- internal thoracic artery - medial mammary branches & anterior intercostal arteries
- axillary artery - lateral thoracic artery & thoracoacromial trunk branches
-
venous supply of the breast
- axillary vein
- internal thoracic vein
-
nerve anatomy of the breast
- 4th to 6th intercostal nerves - anterior cutaneous branches & lateral cutaneous branches
- supraclavicular nerves
- sympathetic nerves to the vessels & smooth muscle of the skin and nipple
-
lymphatic drainage of the breast
- first into subareolar lymphatic plexus
- majority of secondary drainage is into the axillary nodal basin
- drains into parasternal nodes to the opposite breast or to inferior phrenic nodes
-
axillary nodal regions
- pectoral: anterior; drain most of the breast
- subscapular: posterior
- humeral: lateral
- central: collects from pectoral, subscapular, and humeral basins
- apical: collects from pectoral, subscapular, humeral, and central basins
-
clinical/surgical levels of axillary lymph nodes
- level I: axillary nodes are lateral to the border of the pectoralis minor muscle
- level II: axillary nodes are deep to the pectoralis minor muscle
- level III: axillary nodes are medial to the border of the pectoralis minor muscle
- - older surgical procedures would remove levels I and II
- - current procedures stop at level I as maximal borders of nodes removed
-
axillary lymphatic drainage
- from axilla into supraclavicular and subclavian nodes
- then into right lymphatic duct or thoracic duct on the left
- subsequently into venous circulation at the junction between the subclavian and internal jugular veins
method for lymphatic and vascular metastases
-
breast cancer
- lifetime incidence of breast cancer in women is currently 1 in 8
- #2 cancer in women (behind lung cancer)
- ductal adenocarcinoma - 90-95%
- lobular adenocarcinoma - 5-10%
- described by quadrants or the clock system
-
incidence of breast cancer by quadrants
- upper inner - 15%
- upper outer - 60%
- lower inner - 5%
- lower outer - 10%
- nipple-areolar complex - 10%
-
diagnosing breast cancer
- physical exam still highly reliable
- many women present with a presumptive diagnosis due to the performance of routine screening mammograms by primary care physicians
-
clinical signs of breast cancer
- venous dilation
- peau d'orange - "orange peel"
- skin dimpling
- nipple retraction - some are anatomically normal; ask length of time
-
axilla
- pyramidal space (narrow at top & wider at bottom)
- inferior to glenohumeral joint
- superior to axillary fascia
- passageway or "distribution center" - neurovascular structures of upper limb
- protected by adducted upper limb
- most vulnerable when arm is abducted
-
axillary pyramid
- apex: "cervicoaxillary canal"
- base: axillary fossa (armpit)
- anterior wall: pectoralis major & pectoralis minor muscles; anterior axillary fold (pectoralis major muscle)
- posterior wall: scapula, subscapularis muscle, posterior axillary fold (latissimus dorsi & teres major muscles)
- lateral wall: intertubercular groove/sulcus
- medial wall: thoracic wall; 1-4 ribs & intercostal muscles; serratus anterior muscle
-
cervicoaxillary canal
- lateral aspect of first rib (on medial side)
- posterior aspect of clavicle
- superior edge of scapule
-
axillary fossa contents
- skin
- subcutaneous tissue
- deep axillary fascia (from arm to thoracic wall)
-
axillary fold
- from pectoralis major muscle
- most inferior part of anterior wall of axilla
-
posterior axillary fold
- from latissimus dorsi and teres major muscles
- most inferior part of posterior wall of axilla
- pinch under armpit
-
contents of axilla
- vessels - axillary artery and vein
- lymphatics
- brachial plexus - nerves (& intercostal brachial nerve)
- FAT
-
axillary sheath
- extension of pre-vertebral (cervical) fascia
- tightly binds nerves and vessels in axillary region
- performing a nerve block in this region requires entering the axillary sheath to administer medicine - all nerves in region will be numbed
-
axillary artery
- continuation of subclavian artery
- begins at lateral border of first rib
- ends at inferior border of teres major muscle
- three parts with six branches
-
branches of axillary artery
- superior thoracic artery
- thoracoacromial artery
- lateral thoracic artery
- subscapular artery
- anterior circumflex humeral artery
- posterior circumflex humeral artery
-
branches of the thoracoacromial artery
- clavicular artery
- acromial artery
- deltoid artery
- pectoral artery
-
branches of subscapular artery
- thoracodorsal artery
- circumflex scapular artery
-
anastomoses
- collateral circulation
- arteries communicating at capillary level to allow blood flow despite occlusions
-
scapular anastomoses
- suprascapular artery can anastomose with dorsal scapular artery
- circumflex scapular artery can anastomose with dorsal scapular artery
- must occur over time to allow body adaptation
-
quadrangular space
- superior: teres minor
- inferior: teres major
- medial: long head of triceps brachii
- lateral: humerus
- content - axillary nerve and posterior circumflex humeral artery
-
triangular space
- superior: teres minor
- inferior: teres major
- lateral: long head of triceps brachii
- contents - circumflex scapular artery
-
triangular interval
- superior: teres major
- medial: long and lateral heads of triceps brachii
- lateral: humerus
- contents - radial nerve and profunda brachii artery
-
brachial plexus
- gives rise to most of the nerves of the upper limb
- extends from neck to axilla
- arises from ventral rami of C5-T1 (roots of the brachial plexus)
- passes between anterior & middle scalene muscles
-
contents of ventral rami of brachial plexus
- GSA: sensory neurons
- GSE: motor neurons
- sympathetic nerves of inferior & middle cervical ganglia
-
prefixed brachial plexus
C4 contribution
-
postfixed brachial plexus
T2 contribution
-
roots of brachial plexus
spinal nerves C5-T1
-
trunks of brachial plexus
- superior: C5 + C6
- middle: C7
- inferior: C8 + T1
-
divisions of brahial plexus
- anterior (2) - supply anterior (flexor) compartments of upper limb
- posterior - supply posterior (extensor) compartments of upper limb
-
chords
- lateral: formed from superior anterior and middle anterior divisions
- posterior: formed from superior, middle, and inferior posterior divisions
- medial: continuation of inferior anterior division
-
branches of lateral cord
- lateral pectoral nerve (C5-C7)
- musculocutaneous nerve (C5-C7)
- lateral root of median nerve
-
branches of posterior cord
- upper subscapular nerve (C5,C6)
- thorocodorsal / middle subscapular nerve (C7-T1)
- lower subscapular nerve (C5,C6)
- radial nerve (C5-T1)
- axillary nerve (C5,C6)
-
branches of medial cord
- medial pectoral nerve (C8,T1)
- medial brachial cutaneous nerve (C8, T1)
- medial antebrachial cutaneous nerve (C8,T1)
- ulnar nerve (C8,T1)
- medial root of median nerve
-
terminal branches of brachial plexus
- musculocutaneous nerve
- median nerve
- ulnar nerve
- axillary nerve
- radial nerve
-
branches of superior trunk
- suprascapular nerve
- nerve to subclavius
-
branches of brachial plexus roots
- C5: dorsal scapular nerve
- C5-7: long thoracic nerve
-
musculocutaneous nerve
- C5-C7
- pierces coracobrachialis
- motor: muscles of anterior compartment of arm
- sensory: becomes lateral antebrachial cutaneous nerve
-
median nerve
- C6-T1
- motor: all but 1 and 1/2 muscles of anterior compartment of forearm; intrinsic thumb muscles; 1st and 2nd lumbricals
- sensory: thumb half of palm, palmar aspect of thumb and 2 and 1/2 fingers and nail beds
-
ulnar nerve
- C8-T1
- motor: 1 and 1/2 muscles of anterior compartment of forearm (flexor carpi ulnaris and ulnar half of flexor digitorum profundus); most intrinsic muscles of the hand
- sensory: digiti minimi half of palmar and dorsal aspect of hand; 1 and 1/2 fingers and nail beds
-
axillary nerve
- C5 and C6
- motor: teres minor and deltoid
- sensory: glenohumeral joint & superolateral arm (superior lateral brachial cutaneous nerve)
-
radial nerve
- C5-T1
- runs in radial groove of posterior humerus
- gives off muscular branches in arm
- motor: all muscles of posterior compartment of arm & forearm
- sensory: posterior & inferolateral arm; posterior forearm; dorsal aspect of hand; thumb and 2 and 1/2 fings and nail beds
-
dermatome
region covered by a single spinal nerve
-
peripheral nerve field
sensory area supplied by a named nerve
-
characteristic brachial plexus injuries
- Herb-Duchenne Palsy
- Klumpke's Palsy
- deltoid atrophy
- wrist drop
- ape-hand posture
- ulnar claw
-
Herb-Duchenne Palsy
- upper trunk lesion (C5-C6)
- "waiter's tip" - hand extended out
-
Klumpke's Palsy
- lower trunk issue (C8-T1)
- ulnar nerve issue
-
deltoid atrophy
- wasting of deltoid
- axillary nerve issue
-
wrist drop
- radial nerve issue
- unable to flex wrist
-
ape-hand posture
- median nerve injury
- upper portion of fingers curved slightly
- thumb is adducted
-
ulnar claw
- ulnar nerve injury
- lose ability to adduct thumb
-
muscular septa
- sheets of deep fascia
- divides muscles into anterior/posterior compartments which are clearly visible
-
-
humerus
- largest bone of the upper limb
- articulates at glenohumeral joint and elbow joints
- head of humerus
- anatomical vs surgical neck
- greater tubercle - attachment of supraspinatus, infraspinatus, and teres minor
- lesser tubercle - attachment of subscapularis
- intertubercular groove - long head of biceps brachii
-
shaft of humerus
- deltoid tuberosity - attachment of deltoid m
- radial groove - radial nerve runs w/ profunda brachii artery
-
condyles of humerus
- capitulum: articulates with head of radius
- trochlea: articulates with proximal head of ulna (trochlear notch)
-
epicondyles of humerus
- medial epicondyle: common flexor origin
- lateral epicondyle: common extensor origin
-
fossas of humerus
- olecranon fossa: receives olecranon of ulna during full extension of elbow
- coronoid fossa: receives coronoid process of ulna during full extension
- radial fossa: accommodates head of radius during forearm flexion
-
ulna
- longer forearm bone
- medial (pinky/digiti minimi side)
- articulates with humerus at elbow
- articulates with radius at radioulnar joints
- NO wrist articulation
-
features of ulna
- trochlear notch: bone contact responsible for flexion & extension
- olecranon process: forms point of elbow, attachment for triceps brachii
- coronoid process: projects anteriorly
- tuberosity of ulna: attachment for brachialis
- radial notch: where head of radius rests
- supinator crest
- supinator fossa: attachment for deep part of supinator m
- head: distal with styloid process
-
radius
- shorter forearm bone
- lateral (thumb) side
- articulates at elbow with ulna & humerus
- articulates at radioulnar & wrist joints
-
features of radius
- head: proximal, articulates with radial notch of ulna
- radial tuberosity: attachment for biceps brachii
- shaft: enlarges distally for articulation with carpal bones
- ulnar notch: articulates with head of ulna
- styloid process: significally distal
- dorsal tubercle: changes the direction of tendons in the hands
-
interosseous membrane
- between radius and ulna
- syndesmosis (fibrous) joint
- helps keep the bones together
- site of origin for many muscles
- transmits forces from radius to ulna
-
elbow joint
- synovial hinge joint
- flexion and extension NOT supination/pronation
- between trochlea of humerus & trochlear notch of ulna and capitulum of humerus & head of radius
-
ligaments of elbow joint
- radial collateral ligament: lateral
- anular ligament: runs around head of radius; keeps it adjacent to ulna
- ulnar collateral ligament: medial
-
bursae of elbow joint
- olecranon bursae - three or four
- bicipitoradial bursa - anterior, at radial tuberosity (where biceps brachii attaches)
-
proximal radioulnar joint
- site of supination/pronation
- between head of radius & ulna (radial notch)
- synovial pivot joint
- anular ligaments: lined with synovial membrane
- sacciorm recess - synovial pocket continuous with synovial membrane of elbow
-
nursemaid's elbow
- dislocation of proximal radioulnar joint
- common in children
- head of radius dislocates out of proximal radioulnar joint by pulling sharply on the arm
-
distal radioulnar joint
- synovial pivot joint
- site of supination/pronation
- sacciform recess: creates smooth movement as radius pivots on ulna & slides over recess
- between ulnar notch of radius & head of ulna
-
ligaments of distal radioulnar joint
- posterior
- anterior
- "triangular" - articular disck covers the head of the ulna & prevents it from contacting carpal bones
-
cubital fossa
triangular depression on anterior aspect of elbow, between epicondyles of humerus
-
boundaries of cubital fossa
- superior: imaginary line connecting epicondyles
- medial: flexor mass from common flexor origin (specifically pronator teres)
- lateral: extensor mass from common extensor origin (specifically brachioradialis)
- floor: brachialis and supinator m
- roof: deep brachial and antebrachial fascia with bicipital aponeurosis
-
contents of cubital fossa
- brachial artery -terminates in radial artery & ulnar artery
- vena comitantes running with nerves
- tendon of biceps brachii
- median nerve
- musculocutaneous nerve
- radial nerve - superficial branch (sensory) & deep branch (motor)
- median cubital vein
-
anatomical snuff box
- small indentation on the lateral proximal surface of the 1st digit's CMC
- created by APL, EPL, and EPB
- abductor pollicis longus
- extensor pollicis longus
- extensor pollicis brevisall innervated by posterior interosseous nerve
- contains superficial radial nerve & radial arteries
-
hypothenar eminence
- base of 5th digit
- visual feature of wrist
-
thenar eminence
- base of first digit
- visual feature of wrist
-
dermatomes of the hand
- C6: thumb and 1/2 of second digit
- C7: 1/2 of second digit, 3rd digit, 1/2 of 4th digit
- C8: 1/2 of 4th digit, 5th digit
-
cutaneous nerves of the wrist & hand
- median: recurrent, lateral, medial, palmer cutaneous, palmar digital (common vs. proper)
- ulnar: palmar cutaneous, dorsal (digital), superficial, deep, palmar digital (common vs. proper)
- radial: dorsal digital
-
carpal bones
- two rows of four bones - proximal & distal
- 8 bones (lateral to medial)
- scaphoid, lunate, triquetrum, pisiform
- trapezium, trapezoid, capitate, hamate
-
scaphoid
- boat shaped
- articulates with radius
- largest of proximal row
- prominent tubercle: attachment for thenar muscles
- most frequently fractures carpal bone
-
scaphoid fracture
- largest articulation with radius
- only receives blood from distal end
- if not diagnosed, avascular necrossis of proximal scaphoid can be seen on x-ray (bone resorption)
-
lunate
articulates with radius
-
triquetrum
- pyramidal shaped
- articulates with articular disc of the distal radioulnar joint
-
pisiform
- sesamoid bone: forms in tendon of flexor carpi ulnaris
- articulates with anterior surface of the triquetrum
- not really a part of radiocarpal joint
-
carpals - proximal row
- scaphoid
- lunate
- triquetrum
- pisiform
-
carpals - distal row
- trapezium
- trapezoid
- capitate
- hamate
-
trapezium
- articulates with 1st and 2nd metacarpals
- prominent tubercle: attachment for thenar muscles
-
trapezoid
"on the insoid"
-
capitate
largest bone of all the carpals
-
hamate
hook of hamate: extends anteriorly
-
metacarpals
- miniature long bones
- between carpals and phalanges
- base, shaft, head
- head articulates with proximal phalanges at knucklse
- 1st MC: shortest & thickest; associated with thumb
- 5th MC: styloid process on dorsolateral aspect is palpable on surface
-
phalanges
- miniature long bones
- each phalanx has base, shaft, head
- 2nd-5th phalanges have three phalanges (proximal, middle, distal)
- 1st digit only has two phalanges (proximal & distal)
-
radiocarpal joint
- wrist joint
- synovial condyloid (ellipsoid) joint
- between distal part of radius & proximal carpal row
- ulna & pisiform do NOT participate (radioulnar disc does)
- numerous synovial folds
- sacciform recess: continuous with joint cavity; extends between radius & ulna; allows for supination/pronation of radius on head of ulna
-
ligaments of radiocarpal joint
- palmar radiocarpal ligament: allows hand to follow radius in pronation/suppination; keeps carpal bones attached to radius
- dorsal radiocarpal ligament: allows hand to follow radius in pronation/suppination; keeps carpal bones attached to radius
- ulnar collateral ligament: medial; attaches to ulnar styloid & triquetrum
- radial collateral ligament: lateral; attaches to radial styloid process & scaphoid
-
movements of radiocarpal joint
- flexion: flexor carpi radialis & flexor carpi ulnaris
- extension: extensor carpi radialis longus, extensor carpi radialis brevis & extensor carpi ulnaris
- abduction: flexor carpi radialis, extensor carpi radialis longus & extensor carpi radialis brevis
- adduction: flexor carpi ulnaris & extensor carpi ulnaris
-
intercarpal joints
- synovial plane (gliding) joint
- augments radiocarpal movements
- pisotriquetral: between individual carpal in proximal & distal rows
- midcarpal: between proximal & distal rows
- capsule is continuous with carpometacarpal joint capsules (except 1st joint capsule)
-
which joint capsules are continuous with intercarpal joint capsules?
- carpometacarpal joint capsules
- NOT radiocarpal joint capsules - infections will not likely spread to wrist
-
carpometalcarpal & intermetacarpal joints
- between distal carpal row & carpal surface of 2nd-5th metacarpal bases
- between adjacent metacarpals on radial & ulnar aspects of bases
- common capsule with intercarpal joints (except 1st joint)
-
ligaments of carpometacarpal & intermetacarpal joints
- dorsal CMC ligament
- palmar CMC ligament
- dorsal IMC ligament
- palmar IMC ligament
- interosseous intermetacarpal ligament
- superficial transverse metacarpal ligament (part of palmar aponeurosis)
- deep transverse metacarpal ligament
-
saddle joint
- first carpometacarpal joint
- synovial joint
- has separate cavity from intercarpal & CMC joint capsules
- between trapezium & base of 1st metacarpal
- few ligaments - unrestricted movement
-
movement at 1st CMC joint
- most mobile, all motions of thumb
- flexion & extension: occur in coronal plane
- abduction & adduction: occur in sagittal plane
- opposition & reposition: pinching 1st & 2nd digit together
- circumduction
- rotation: during opposition
-
metacarpophalangeal joints
- knuckles
- synovial condyloid joint: movement in many directions
- between head of metacarpal & base of proximal phalanges
- each has its OWN synovial cavity
-
movement at 1st metacarpophalangeal joint
- pure hinge
- flexion & extension ONLY
-
movement at 2nd-5th MCP joints
- flexion & extension
- abduction & adduction
- circumduction
-
interphalangeal joints
- synovial hinge joints
- located between head of proximal phalanges & base of middle phalanges AND between head of middle phalanges & base of digital phalanges
- movement limited to flexion & extension
- 1st digit has only one IP joint
- two IP joints in 2nd-5th digits
- each joint has its own capsule
-
ligaments of MCP & IP joints
- collateral ligaments: cordlike; slack during extension, taut during flexion (prevents dislocation)
- palmar ligaments: thick fibrocartilaginous plates; site of attachment for extensor expansion
- deep transverse metacarpal ligament: narrow fibrous band attached to fibrocartilaginous plates; runs across palmar surfaces of 2nd-5th metacarpal bones
-
fascia of the palm
- continous with with antebrachial fascia & fascia of dorsum of hand
- infection in the hand CAN spread to forearm
- thenar fascia: lateral (first digit muscles)
- hypothenar fascia: medial (5th digital muscles)
- digital sheaths
-
digital sheaths
- enclose flexor digitorum superficialis & flexor digitorum profundus tendons in synovial sheaths
- keep fingers tethered
- prevents "bowstringing" of tendons
- 5 annular ligament parts
- 4 cruciform ligament parts
-
palmar aponeurosis
- triangular, immediately deep to skin
- overlies soft tissue & long flexor tendons
- proximally continuous with palmaris longus tendon (median nerve lies deep) & flexor retinaculum
-
compartments of palmar aponeurosis
- hypothenar compartment: formed by medial fibrous septum; fifth digit
- thenar compartment: formed by lateral fibrous septum; thumb
- central compartment - midpalmar space between lateral & medial septae
- adductor compartment - dorsal to thenar compartment
- interosseous compartment: most dorsal compartment
-
carpal tunnel
- deep thickening of antebrachial fascia that converts the anterior concavity of carpus into a tunnel
- roof - transverse carpal ligament
-
canal of Guyon
- formed proximal addition small covering on carpal tunnel
- ulnar tunnel: ulnar nerve & artery pass here
-
contents of carpal tunnel
- flexor digitorum superficialis tendons
- flexor digitorum profundus tendons
- flexor palmaris longus tendon
- synovial sheaths of common flexors (named above)
- median nerve
-
carpal tunnel syndrome
- inflammation of tendons or synovium causes compression of median nerve
- results in impaired movements, problems with sensation, etc.
- test - pin prick of palm (palmar cutaneous branch of median nerve branches BEFORE entering carpal tunnel)
-
extensor retinaculum
- thickening of antebrachial fascia on dorsal surface
- prevents bowstringing of extensor tendons on wrist
- creates osseofibrous tunnels with radius & ulna for passage of tendons & synovial sheaths
-
extensor expansion
- flattening of extensor tendons along the distal MC & phalanges
- triangular aponeurosis that wraps around the phalanges
- forms "hoods" over the head of MC attached to palmar ligaments
- helps smooth extension & flexion
- median band: base of middle phalanx
- two lateral bands: base of distal phalanx
-
anatomical lines of reference
- uses in describing locations of pain, deeper structures, or incisions on the skin
- vertebral lines of reference: anterioxillary line, midaxillary line, posterioraxillary line
- posterior planes/lines of the thorax: posterior median plane, paravertebral plane, midscapular plane, midclavicular line, transplyoric plane, subcostal plane
- anterior planes/lines of the thorax: median plane, sternal plane, parasternal plane
-
vertebral lines of reference
- anterioaxillary line: runs vertically along anterior wall of axilla
- midaxillary line: runs vertically between anterior & posterior axillary lines
- posterioraxillary line: runs vertically along posterior wall of axilla
-
posterior planes/lines of the thorax
- posterior median plane (vertebral line): runs down the spine along the spinal processes
- paravertebral plane: runs down lateral edge of transverse processes where articulation of ribs occurs
- midscapular plane: located at the axis of rotation of the scapula
-
anterior planes/ lines of the thorax
- medial plane: anterior median line, midsternal line; vertically down middle of sternum
- sternal plate: lateral sternal line; at the vertical edge of the sternum
- parasternal plane: located vertically between edge of sternum & midclavicular line
- midclavicular line: vertically down the middle of the clavicle; corresponds to midinguinal line/ inguinal ligament
- transpyloric plane: a transverse/horizontal plane, runs through pylorus of stomach
- subcostal plane: transverse/horizontal plane, runs along bottom of rib cage
-
vertebral levels of landmarks
- suprasternal notch: superior aspect of manubrium of sternum; corresponds to body of T3 vertebra
- sternal angle: Angle of Louis, manubriosternal junction; intervertebral disk between T4&T5
xiphisternal joint: corresponds to intervertebral disc between T9&T10 - subcostal line: inferior aspect of ribs; corresponds to superior aspect of body of L3 vertebra
- umbilicus: body of L4
-
divisions of thoracic cavity
- two pleural cavities (lateral)
- pericardial cavity (inferomedial)
- mediastinum (superomedial)
-
thoracic cavity boundaries
- superior thoracic aperture (thoracic inlet)
- respiratory diaphragm
- surrounded by musculoskeletal thoracic wall
-
thoracic wall
- composed of ribs and costal cartilage
- skeletal boundaries - superior thoracic aperture and inferior thoracic aperture
-
thoracic outlet syndromes
- cervical rib syndrome
- costoclavicular syndrome
-
superior thoracic aperture
- anatomically, thoracic inlet
- clinically, thoracic outlet
- posterior - body of T1
- lateral - 1st rib & costal cartilage
- anterior - superior border of manubrium of the sternum
-
inferior thoracic aperture
- anatomically, thoracic outlet
- posterior - body of T12
- anterior - xiphisternal joint
- lateral - respiratory diaphragm, costal cartilage of 7-10th ribs, 12th rib
-
cervical rib syndrome
- costal processes normally develop from scleratome in thoracic region
- extra ribs can develop in the lumbar region (asymptomatic) or cervical region
- compression of C8 to T1 spinal nerve roots & inferior trunk of brachial plexus can impact motor function and blood flow
-
costoclavicular syndrome
- symptoms - pallor & coldness of skin of upper limb; diminished radial pulse
- symptoms are exacerbated when patient raises & abducts affected arm
- results from compression of subclavian vessels and/or roots of the brachial plexus between clavicle & first rib
-
skeletal boundaries of thoracic wall
- 12 thoracic vertebrae & associated intervertebral discs: posterior
- 12 pairs of ribs & associated costal cartilages: lateral
- sternum
- manubrium: anterior
- xiphoid process: inferior
-
musculature of thoracic walla
- extend between the ribs; are of hyaxial origin (derived from hypomere)
- innervated by ventral rami
- - external intercostal muscles
- - internal intercostal muscles
- - innermost intercostal muscles
-
external intercostal muscles
- from tubercles of ribs to costochondral junctions
- fibers run superior lateral to inferiomedial
- muscles of inspiration - elevate the ribs
- external intercostal membrane: semitransparent membrane that continues from the external intercostal muscles to sternum
-
internal intercostal muscles
- lie deep to external intercostal muscles
- extend from sternum to angles of ribs
- fibers run superior medial to inferiolateral
- muscles of inspiration
- intercostal internal membrane: runs from medial border of ribs (at vertebrae) to costal angles
-
innermost intercostal muscles
- lie deep to internal intercostal muscles
- fibers run in same direction as internal intercostal muscles (superiomedial to inferiolateral)
- separated from internal intercostal muscles by intercostal nerve, artery & vein
-
vasculature of thoracic wall
- arteries coming off of the thoracic aorta
- internal thoracic artery
- posterior intercostal artery
-
internal thoracic artery
- branch off subclavian artery
- runs parasternally (posteriorly on sides of sternum)
- gives rise to anterior intercostal arteries
- divides inferiorly to superior epigastric artery (abdominal wall) and musculophrenic artery (diaphragm)
- can be used in coronary artery replacement
-
posterior intercostal artery
- branch directly off of thoracic aorta
- runs in intercostal spaces (except below T12)
- anastomoses with anterior intercostal arteries
-
venous drainage of thoracic wall
- internal thoracic vein: drains into brachiocephalic veins, then superior vena cava
- intercostal veins: drain into internal thoracic veins or into azygos system
- Azygos system: venous drainage of thoracic cage/body wall; drains into superior vena cava at Angle of Louis (T4 level)
-
intercostal spaces contents
- intercostal veins, arteries, and nerves run between the innermost & internal intercostal muscles in a costal groove (superior to inferior... vein, artery, nerve)
- intercostals give off collaterals, which run off surface of superior border of rib below
- collateral run in inverted order - nerve, artery, vein
- intercostal nerves come from ventral rami of corresponding spinal nerve
-
intercostal nerves
- come from ventral rami of corresponding spinal nerves
- gives off lateral cutaneous branch at axillary line (anterior and posterior branches continue on anteriorly)
- anterior branch of cutaneous branch will give off a lateral & medial branch
- thoracic spinal nerves ONLY supply the costal area
-
thoracocentesis
- used to drain fluid from pleural cavity
- place needly centrally in intercostal spaces inferior to rib ( avoid both intercostal bundles)
- pus, blood, fluid
-
intercostal nerve block
- done to numb area for incisions and fractured ribs
- place needle near the nerve to deliver anesthetic
-
true ribs
ribs 1-7 attach directly to the sternum through their own costal cartilages
-
false ribs
- ribs 8-10
- attach indirectly to sternum through the cartilage of the rib above
-
floating ribs
- ribs 11-12
- have no connection to sternum
- embedded in musculature posteriorly
-
typical ribs
- ribs 3-9 (share general structure)
- head articulates with head of numberically corresponding vertebra & vertebra superior to it via demifacets
- tubercle: articulation with transverse process of numerically corresponding vertebra
- relatively sharp bend in rib (angle)
- costal-chondral junction
- inferior aspect has costal groove for intercostal neurovasculature bundle
-
atypical ribs
ribs 1-2, 10-12
-
1st rib
- single facet for articulation with T1 vertebra ONLY
- short, flat superiorly and inferiorly
- scalene tubercle: attachment for anterior scalene muscle; separated groove for subclavian artery & groove for subclavian vein on superior surface of rib
-
2nd rib
- two facets for articulation with T1&T2 vertebrae
- tuberosity for serratus anterior muscle (superior surface)
-
10th, 11th, 12th ribs
only one facet on heads for articulation with numerically corresponding vertebral body
-
typical articulation of ribs with vertebrae
- only on thoracic vertebrae
- two demifacets on head of rib articulate with numerically corresponding vertebra and with vertebra superior to it (synovial joint supported by various ligaments)
- tubercle of rib articulates with transverse process of numerically corresponding vertebra (synovial costotransverse joint supported by lateral costotransverse ligament, costotransverse ligament, & superior costotransverse ligament)
-
inspiratory respiratory movement
- thoracic cavity increases in volume during inspiration (inhale)
- bucket-handle movement: middle parts of lower ribs elevate laterally increasing the lateral diameter of the thorax
- pump-handle movement: upper ribs elevate increasing the anteroposterior diameter of the thorax
- main movement - diaphragm contracts and pulls down increasing the superior/inferior diameter of the cavity
- exterior & interior intercostal muscles pull up on ribs
-
expiratory respiratory movemtns
- mostly elastic recoil
- accessory respiratory muscles
-
accessory respiratory muscles
- pectoralis major
- serratus anterior
- scalene muscles
- serratus posterior superior
- serratus posterior inferior
- levatores costarum
-
hemothorax
accumulation of blood in thorax
-
pneumothorax
accumulation of air in thorax
-
divisions of intraembryonic coelem
- pericardial cavity
- peritoneal cavity
- two pleural cavities
-
embryonic origin of lungs
endoderm
-
visceral pleura
- from splanchnic mesoderm
- the part of the pleural cavity immediately adjacent to lung (attached to lung surface)
-
pleural cavity
- space between the visceral pleura and parietal pleura
- only a little bit of serous fluid in cavity, NOTHING ELSE
- the lung is NOT inside the pleural cavity, it pushes out into it
-
parietal pleura
- from somatic mesoderm
- outermost surface of pleural cavity
- 4 parts - cervical, costal, diaphragmatic, mediastinal
-
parts of parietal pleura
- cervical pleura: runs along cervical region (above 1st rib)
- costal pleura: runs along & inside of ribs
- diaphragmatic pleura: runs along superior surface of diaphragm
- mediastinal pleura: runs along mediastinum; superior & inferior to hilum
-
endothoracic fascia
- layer of fascia between parietal pleura & thoracic wall
- fat, loose areolar CT
-
hilum
- root of lung
- where parietal & viscerl pleura are continuous
-
pleural reflections
where pleura folds back upon itself & projects on thoracic wall
-
anterior costomedial reflection
- where parietal pleura folds back over as mediastinal pleura
- occurs posterior to sternum
- to left side is the cardiac notch (bare area of pericardium)
-
bare area of pericardium
- area of the heart not covered by pleura
- where anterior portion of pericardium meets the sternum
-
costal lines of pleural reflection
- parietal pleura: crosses 8th rib at midclavicular line; crosses 10th rib at midaxillary line
- lungs/visceral pleura: cross midclavicular line at 6th rib; cross midaxillary line at 8th rib
-
vertebral lines of pleural reflection
- parietal pleura: crosses paravertebral line at 12th rib
- lungs/visceral pleura: cross paravertebral line at 10th rib
-
pleural recesses
- costomediastinal recess: formed to due reflections between costal & mediastinal pleura; posterior to pericardium
- costodiaphragmatic recess: costal pleura coming down sides of pleural cavity to diaphragm & turning into diaphragmatic pleura; where fluids will collect (site of thoracocentesis)
-
innervation of costal pleura
- innervated by branches of the intercostal nerves
- may cause reffered pain to the dermatomes supplied by the respective intercostal nerve
-
mediastinal & diaphragmatic pleura innervation
- central diaphragmatic pleura innervated by branches of phrenic nerve (C3,C4,C5)
- peripheral diaphragmatic pleura innervated by intercostal nerves (sensory)
-
phrenic nerve
- motor innervation to central tendon area of diaphragm
- sensory innervation to mediastinal pleura & diaphragmatic pleura over central tendon
- innervates peritoneum on inferior surface of diaphram
- referred pain to neck and shoulder - dermatome regions of C3,C4,C5
-
left lung: lateral surface
- two lobes: upper & lower lobes separated by oblique fissure
- upper lobe: cardiac notch on anterior aspect; lingula (homologous to middle lobe of right lung); mostly anterior
- lower lobe: mostly posterior
-
left lung: medial surface
- organs leave impression on lungs - sulcus for aortic arch, sulcus for subclavian artery, cardiac notch, esophageal sulcus
- hilum: root of lung; where primary bronchus, pulmonary vein and arteries will enter & exit lung; where visceral & parietal pleura are continuous
- pulmonary ligament: extension of visceral pleura below hilum
-
right lung: lateral surface
- three lobes: upper and middle lobes separated by horizontal fissure; middle and lower lobes separated by oblique fissuresharp anterior surface (apex)
- obtuse posterior surface
-
right lung: medial surface
- hilum: pulmonary artery & vein, etc.
- sulcus for superior vena cava
- sulcus for azygos vein
- sulcus for subclavian artery
- cardiac impression
- eparterial bronchus: supplies the superior lobe of the right lung; arises above the level of pulmonary artery (visible in hilum, differential characteristic)
- pulmonary ligament
-
visualizing lung surface anatomy
- horizontal fissure of right lung: 4th costal cartilage
- oblique fissures of both lungs: 6th costal cartilage
- parietal pleura: 8, 10, 12th ribs
- visceral pleura: 6, 8, 10th ribs
-
x rays of lungs
- air-filled lungs look black
- oblique fissure: major fissure to radiologists
- middle fissure: minor fissure to radiologists
- lower lobe is pimarily posterior
-
respiratory tree
- trachea: divides into two primary bronchi
- primary bronchi: enter lung at hilum
- right primary bronchus - more vertical, shorter, wider (foreign bodies are more likely to lodge here)
- secondary bronchi: lobar bronchi; go into different lobes of lung; three on right, two on left
- segmental bronchi: tertiary bronchi; supply bronchopulmonary segments
-
bronchopulmonary segments
- structural unit of the lung
- 8 in left lung, 10 in right lung
- pyramidal shaped segment of the lung served by a single segmental bronchus
- smalled unit that can be identified and excised (isolated tumors)
- separated from each other by connective tissue septae
- supplied by tertiary branch of pulmonary artery
-
innervation of visceral pleura
- pain free
- no nerves of general sensation
-
innervation of lung
- anterior & posterior pulmonary plexuses
- parasympathetic: fibers from CN X (Vagus nerve) to smooth muscle of bronchial tree; cause bronchoconstriction, vasodilation & autonomic increased secretion of glands
- sympathetic: causes bronchodilation, vasoconstriction & inhibits bronchial glandular secretion
-
epinephrine
- neurotransmitter from post-ganglionic sympathetic fibers
- found within emergency inhalers (bronchodilation)
-
nociception
- detection of tissue damage
- different from general sensations of pain
-
nocioception in lungs
- sensory fibers from viseral pleura & bronchi accompany sympathetic fibers
- mediate nociceptive stimuli
- sensory fibers from visceral pleura (GVA) go back towards spinal cord with sympathetics (GVE)
-
relations of phrenic nerve to vagus nerve
- phrenic nerve runs anterior to hilum
- vagus nerve runs posterior to root of lung
-
auscultation of the lungs
- firmly place the diaphragm of stethoscope on the patient's back
- ask the patient to take a deep open-mouthed breath
- listen for normal (vesicular, bronchial, bronchovesicular) or abnormal (wheezes, crackles, rubs, stridor) breath sounds
-
collapsed lung
- pneumothorax
- air leaks from inside of lung to space between lung & chest wall
- xray shouws dark air leak
-
aortic rupture
- tear in major artery causes hemothorax
- blood in thorax obscures view of ribs
- very "cloudy" radiograph image
-
superficial/subpleural lymphatic plexus
- lies deep to the visceral pleura
- drains lung parenchyma and visceral pleura
- drains into bronchopulmonary (hilar) lymph nodes
-
deep lymphatic plexus
- located in submuscosa of bronchi & peribronchia connective tissue
- drains submucosa of bronchi and adjacent connective tissue
- drains to pulmonary lymph nodes along lobar bronchi, then into bronchopulmonary lymph nodes at hilum
- from bronchopulmonary lymph nodes - tracheobonchial lymph nodes - bonchomediastinal lymph trunks
-
lymphatic drainage of the lung
- right lung: bronchopulmonary nodes, eventually into right lymphatic duct, then venous system
- upper lobe of left lung: drains through bronchomediastinal nodes into thoracic duct, empties into venous system
- lower lobe of left lung: drains to right superior tracheobronchial node & continues on the right sider
-
mediastinum
- "the middle stuff"
- area between pleural cavities
- central compartment of thoracic cavity
- divided into superior & inferior mediastinum
-
superior mediastinum
- from superior thoracic aperture to the transverse thoracic plane
- transverse thoracis plane: line drawn from sternal angle to the intervertebral disc between the T4 and T5 vertebrae
-
inferior mediastinum
- from transverse thoracic plane to diaphragm
- anterior mediastinum: anterior to pericardium
- middle mediastinum: pericardial cavity
- posterior mediastinum: posterior to pericardium
-
contents of superior mediastinum
- thymus
- brachiocephalic veins
- superior vena cava
- arch of aorta: brachiocephalic trunk, left common carotid artery, left subclavian artery
- vagus & phrenic nerves
- cardiac plexus of nerves
- left recurrent laryngeal nerve
- trachea
- esophagus
- thoracic duct
- arch of azygos vein
- prevertebral muscles
-
anterior mediastinum
- subdivision of inferior mediastinum
- area between sternum & pericardial sac
- contains mostly fat
- contents - loose CT, fat, lymphatic vessels & nodes, transverse thoracic muscles, branches of internal thoracic vessels, minor blood vessels
-
middle mediastinum
- subdivision of inferior mediastinum
- defined by pericardial sac
- contents - heart, great vessels, ascending aorta, pulmonary vessels
-
posterior mediastinum
- subdivision of inferior mediastinum
- anterior to T5-T13 vertebrae, posterior to pericardial sac, between parietal pleura
- contents - thoracis (descending) aorta, trachea & bronchi, esophagus, esophageal plexus, thoracic duct, posterior mediastinal lymph nodes, azygos & hemiazygos veins, vagus nerve, thoracic sympathetic trunks, thoracic splanchnic nerves, lymph nodes
-
major veins crossed by gunshot woung to chest (at manubrium)
- left brachiocephalic vein
- arch of aorta or its branches
- trachea
- esophagus
- vertbral column (spinal cord)
-
superior mediastinum borders
- T1 vertebra & manubrium
- disc between T4 & T5 and manubriosternal joint
-
inferior mediastinum borders
- disc between T4 & T5 and manubriosternal joint
- diaphragm
-
sternocostal projections of the heart
- superior border: left 2nd costal cartilage
- right border: right 3rd costal cartilage
- inferior border: right 6th costal cartilage
- left border: left 5th intercostal space
-
atrioventricular groove
- coronary sulcus
- separates atria from ventricles
- where coronary sinus sits
-
arterial pathology
- aneurysm: enlarge
- dissection: tear
- stenosis: narrowed
- occlusion: blocked
- ulcerate: deteriorate
-
pleura
- serous
- parietal - costal, mediastinal, diaphragmatic
- visceral
-
pericardial layers
- external fibrous layer
- internal serous layer - parietal & visceral
-
external fibrous layer of pericardium
- continuous with tunica adventitia of great vessels
- attached anteriorly to sternum via sternopericardial ligaments
-
internal serous layer of pericardium
- parietal layer
- visceral layer - epicardium, lines the heart muscle itself
-
pericardial cavity
- potential space filled with small amount of serous fluid
- if space gets filled with too much fluid, blood etc., heart becomes confined - cardiac tampanade
-
bare area of the cardium
- devoid of pleura
- allows penetration of pericardium without deflating lung (piercing pleura)
-
pericardial sinuses
- serous pericardial reflections
- transverse pericardial sinus: passage between arterial & venous associated reflections; separate aorta & pulmonary trunk from pulmonary veins & SVC
- oblique pericardial sinus: back of right ventricle
-
aortic sinuses
spaces behind valves
-
coronary sinus
blood vessel in coronary groove between atria & ventricle
-
route of blood flow
inferior & superior vena cava - right atrium - tricuspid valve - right ventricle - pulmonary valve - lungs - pulmonary veins from lungs - left atrium - mitral valve - left ventricle - aortic valve - aorta - body!
-
chambers of the heart
- right & left atria (left has thicker muscular wall)
- right & left ventricles (left has thickest muscular wall)
-
wall of heart chambers
- endocardium: thin internal layer
- myocardium: thick muscle layer
- epicardium: thin external layer
-
surfaces of the heart
- diaphragmatic (inferior) surface: L ventricle & a little R ventricle
- sternocostal (anterior) surface: R ventricle
- base (posterior) surface: L atrium + 4 pulmonary veins
- apex: L ventricle, posterior to left 5th intercostal space
-
borders of the heart
- superior border: R&L atria and auricles
- right border: R atrium
- inferior border: R ventricle & some L ventricle
- left border: L ventricle & a little left auricle
-
fibrous skeleton of the heart
- maintains patency/ prevents distension of valves
- provides attachment for valve cusps
- provides attachment for myocardium
- forms electrical "insulator"
-
heart valves
- atrioventricular valves: tricuspid valve, mitral (bicuspid) valve
- semilunar valves: pulmonary valve, aortic valve
-
internal anatomy: right atrium
- pectinate muscles
- sinus venarum: smooth walled portion
- crista terminalis: differentiates between pectinate muscles & sinus venarum
- openings for inferior vena cava, superior vena cava, & coronary sinus
- auricle
- interatrial septum - fossa ovalis (embyological remnant of foramen ovale)
- tricuspid valve
-
internal anatomy: right ventricle
- trabeculae carnae
- septomarginal trabeculae: from interventricular wall to papillary muscles
- papillary muscles (anterior, posterior, septal) & cusps
- chordae tendinae - do NOT pull valve leaflets down
- pulmonary valve
-
internal anatomy: left atrium
- smooth walls
- pectinate muscles ONLY in auricle
- valve of foramen ovale in interatrial septum
- mitral valve
-
internal anatomy: left ventricle
- papillary muscles (anterior & posterior)
- chordae tendinae
- trabeculae carnae in intervetnricular septum
- openings for coronary arteries & valves
- space behind valves - aortic sinus
- aortic valve
-
blood supply to the heart
- right coronary artery - SA node branch (60%), right marginal branch, AV nodal branch, posterior intervetricular branch
- left coronary artery - anterior interventricular artery (with anterior branch) & circumflex branch (with left marginal artery & SA nodal branch 40%)
-
coronary artery variation
- right dominant heart: R coronary artery gives off posterior interventricular branch (66%)
- left dominant heart: L coronary artery gives off posterior interventricular branch from circumflex branch (15%)
- no R coronary artery
- Maravich's heart: circumflex branch runs from R coronary artery (no L coronary artery)
- blockage: atherosclerosis or thrombosis
-
venous drainage of the heart
- coronary sinus - drains directly into R atrium; drains the following veins
- great cardiac vein: runs with anterior interventricular artery in interventricular sulcus; branch - oblique vein of L atrium
- middle cardiac vein: runs with posterior interventricular artery
- small cardiac vein: runs with right marginal artery
- left posterior vein
- left marginal vein
-
intrinsic innervation of the heart
- SA node
- AV node
- AV bundle of His
- right & left bundle branches
- Purkinje fibers (subendocardial branches)
-
extrinsic innervation of the heart
- GVE: sympathetic (T1-T5 spinal cord segments) & parasympathetic (Vagus CN X)
- GVA: pain; returns to uppoer thoracic spinal cord segments with sympathetics (T1-T5)
-
cardiac plexus
- located at bifurcation of the trachea
- postganglionic sympathetics
- preganglionic parasympathetics
- general visceral afferents
-
autonomic function of heart
- sympathetic: increase heart rate, increase force of contraction, dilation of coronary arteries
- parasympathetic: decrease heart rate, decrease force of contraction, constriction of coronary arteries
-
sympathetic pathways of heart
- T1-T5 IMlCC (preganglionic cell bodies)
- sympathetic chain (cervical & T1-T5 - postganglionic cell bodies)
- cardiac plexus
- heart
-
parasympathetic pathways of heart
- dorsal motor nucleus of CN X (Vagus nerve - preganglionic cell bodies)
- cardiac plexus
- postganglionic cell bodies on heart
- heart
-
cardiac cycle
- diastole: period of ventricular elongation & filling
- systole: period of ventricular shortening & emptying
-
heart sounds
- "lub": closure of AV valves
- "dub": closure of semilunar valves
-
auscultation sites of the heart
- aortic valve: right 2nd intercostal space (sternal margin)
- pulmonary valve: left 2nd intercostal space (sternal margin)
- left AV valve: left 5th intercostal space (midclavicular line)
- right AV valve: right 5th intercostal space (sternal margin)
-
referred pain of heart
- angina
- GVAs will travel back to spinal region (T1-T5) with sympathetic fibers
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