Gross Anat Block C

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Gross Anat Block C
2012-12-10 18:40:19
abdomen lower limb

Gross Anatomy Block C
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  1. abdominal cavity
    • extends from respiratory diaphragm to the pelvic inlet
    • lined with peritoneum
  2. pelvic cavity
    • extends from pelvic inlet to pelvic diaphragm/ pelvic floor muscles
    • has intraperitoneal and extraperitoneal portions
  3. abdominopelvic cavity
    continuous from respiratory diaphragm to pelvic diaphragm
  4. boundaries of abdominopelvic cavity
    • superior: thoracic diaphragm
    • inferior: pelvic diaphragm composed of the pelvic floor musculature
    • anterior & lateral: abdominal muscular wall
    • posterior: vertebral column, posterior abdominal wall muscles (psoas major, quadratus lumborum, iliacus, transversus abdominus, obliques)
  5. false pelvis
    • greater pelvis OR pelvis major
    • resides superior to the pelvic brim
    • superior pelvic aperature (AKA pelvic inlet) is inferior border
    • from iliac crest to pelvic brim
  6. true pelvis
    • lesser pelvis OR pelvis minor
    • inferior pelvic aperature (pelvic outlet) closed by pelvic diaphragm muscles is inferior border
    • contains pelvic viscera
    • from pelvic brim to pelvic floor muscles
  7. superior pelvic aperature
    • ringed completely by bony border known as the pelvic brim
    • inferior border of false pelvis
  8. linea terminalis
    bony edge of the pelvic inlet
  9. inferior pelvic aperature
    • pelvic outlet
    • anterior border: ischiopubic rami (bone)
    • posterior border: sacrotuberous ligament
    • inferior border: muscles
  10. landmarks of anterior abdominal wall
    • linea alba
    • linea semilunaris
    • rectus abdominus
    • tendinous intersections
    • anterior iliac crest
    • anterior superior iliac spine
    • inguinal ligament
    • pubic tubercle
  11. visible muscles of anterior abdominal wall
    • rectus abdominus
    • serratus anterior
    • external oblique
    • pyramidalis (80%)
  12. important vertebral levels
    • T3: sternal notch
    • T4/5: sternal angle of Louis
    • T9/10: xiphisternal joint
    • L3 body: subcostal plane
    • L3/4 disc: transumbilical plane
    • L5/S1: sacral promontory (posterior aspect of superior pelvic aperature)
  13. abdominal quadrants
    • right upper quadrant
    • left upper quadrant
    • right lower quadrant
    • left lower quadrant
  14. anatomical abdominal subdivisions
    • right hypochondriac region
    • epigastric region
    • left hypochondriac region
    • right lateral region
    • umbilical region
    • left lateral region
    • right inguinal region
    • hypogastric region
    • left inguinal region
  15. clinical abdominal subdivisions
    • right upper quadrant
    • mid-epigastric region
    • left upper quadrant
    • right midabdominal region
    • peri-umbilical region
    • left midabdominal region
    • right lower quadrant
    • suprapubic region
    • left lower quadrant
  16. contents of RUQ
    • right lobe of liver
    • gallbladder
    • stomach - pylorus
    • duodenum - parts 1 to 3
    • pancreas head
    • right suprarenal gland
    • right kidney
    • right colic (hepatic) flexure
    • ascending colon - superior part
    • transverse colon - right half
  17. contents LUQ
    • liver - left lobe
    • spleen
    • stomach
    • jejunum & proximal ileum
    • pancreas - body & tail
    • left kidney
    • left suprarenal gland
    • left colic (splenic) flexure
    • transverse colon - left half
    • descending colon - superior half
  18. contents of RLQ
    • cecum
    • vermiform appendix
    • most of ileum
    • ascending colon - inferior part
    • right ovary
    • right ureter - abdominal part
    • right spermatic cord - abdominal part
    • uterus (if enlarged)
    • urinary bladder (if very full)
  19. contents of LLQ
    • sigmoid colon
    • descending colon - inferior part
    • left ovary
    • left uterine tube
    • left ureter - abdominal part
    • left spermatic cord - abdominal part
    • uterus (if enlarged)
    • urinary bladder (if very full)
  20. abdominal wall boundaries
    • superior: costal margin, ribs 11 & 12, xiphoid process & diaphragm
    • inferior: pelvic girdle
    • posterior: lumbar & vertebrae & IV discs
    • anterolateral: muscles & aponeurotic walls
  21. arterial supply of the anterior abdominal wall
    • superior epigastric artery: continuation of the internal thoracic artery
    • inferior epigastric artery: ascends off the external iliac artery
    • deep circumflex iliac artery: branch of the external iliac artery to the iliac region
  22. venous drainage of the anterior abdominal wall
    • primary drainage to axillary & femoral veins
    • large system of veins & lymphatics
    • primary connecting veins: superficial epigastric vein & thoracoepigastric vein
  23. abdominal dermatomes
    • T7 to T9: superior to umbilicus
    • T10: around umbilicus at transumbilical plane (L3/4 disc)
    • T11-12, L1: inferior to umbilicus
  24. innervation of the abdominal wall, skin & musculature
    • thoracoabdominal nn: intercostal nerves T7-T11
    • subcostal nn: T12
    • iliohypogastric nn: L1
    • ilioinguinal nn: L1
  25. layers of abdominal wall
    • skin
    • camper's fascia
    • scarpa's fascia
    • external oblique muscle & fascia
    • internal oblique muscle & fascia
    • transverse abdominal muscle & fascia
    • transversalis fascia
    • extraperitoneal fat
    • parietal peritoneum
  26. external oblique m.
    • origin: external surface of ribs 5-12
    • insertion via aponeurosis: rectus sheath anterior lamina, linea alba, xiphoid process, anterior half of iliac crest (outer lip), ASIS, inguinal ligament, pubic tubercle, pubic symphysis, pubic crest, pectineal line of the pubic
    • fibers course inferior & medial
    • innervation: thoracoabdominal nerves (T7-11), subcostal nerves (T12)
  27. rectus abdominus m.
    • origin: xiphoid process, outer surface of the costal cartilage (5-7th ribs)
    • insertion: pubic crest
    • fibers run essentially vertically; separated by linea alba
    • innervation: thoracoabdominal n (T7-11), subcostal n (T12)
  28. internal oblique m.
    • origin: thoracolumbar fascia, anterior 2/3 of iliac crest, lateral 1/2 of inguinal ligament
    • insertion: linea alba, inferior border of ribs 7-12, xiphoid process, pectineal line of the pubis via conjoined tendon, pubic crest
    • fibers course superiorly & medially
    • innervation: thoracoabdominal nn, subcostal nn, iliohypogastric nn, ilioinguinal nn
  29. transversus abdominus m.
    • origin: internal surfaces of 7-12th costal cartilages, thoracolumbar fascia, anterior 2/3 of inner lip of iliac crest, lateral 1/3 of inguinal ligament
    • insertion: linea alba, pectineal line of pubic via conjoined tendon, pubic crest
    • fibers course from lateral to medial
    • innervation: thoracoabdominal nn, subcostal nn, iliohypogastric nn, ilioinguinal nn
  30. pyramidalis m.
    • small, triangular muscle
    • absent in ~20% of population
    • tenses linea alba
    • found within rectus sheath
  31. conjoined tendon
    • combined insertion of internal oblique & transverse abdominis muscles on pecten of the pubis medially
    • joins rectus sheath
  32. rectus sheath: above the arcuate line
    • anterior: skin, campers fascia, scarpa's fascia, aponeurosis of internal & external oblique mm.
    • posterior: aponeurosis of internal oblique & transverse abdominis mm, transversalis fascia, extraperitoneal fat, parietal peritoneum
  33. rectus sheath: below arcuate line
    • anterior: all muscle aponeurosis sheets move anteriorly
    • posterior: transversalis fascia, extraperitoneal fat, parietal peritoneum
  34. inguinal ligament
    free inferior margin of aponeurosis of external oblique muscle passing from ASIS to pubic tubercle
  35. inguinal canal
    • passageway through abdominal wall formed by aponeuroses of abdominal muscles
    • has openings at both ends
  36. deep (internal) inguinal ring
    evagination of transversalis fascia residing LATERAL to inferior epigastric artery
  37. superficial (external) inguinal ring
    opening in aponeurosis of external oblique muscle MEDIAL to inferior epigastric artery
  38. abdominal wall functions
    • supports & protects abdominal viscera
    • flex & rotate the trunk
    • maintains posture
    • alters intraabdominal pressure through expansion & compression
    • participates in respiration, vocalization, coughing, sneezing, urination, defecation, partuition
  39. peritoneal surface of the anterior abdominal wall
    • median umbilical ligament - urachus
    • medial umbilical ligament - obliterated umbilical artery
    • lateral umbilical ligament - inferior epigastric vessels
  40. peritoneum
    • highly convoluted, serous membrane with 2 continuous layers
    • parietal layer: lines abdominal wall
    • visceral layer: covers abdominal viscera
  41. intraperitoneal organs
    almost completely enclosed within visceral peritoneum
  42. extraperitoneal organs
    • extend to and only partially covered by parietal peritoneum
    • bladder, uterus, prostate, seminal vesicles, rectum, part of ureters
  43. peritoneal mesenteries
    • peritoneal fold that connects an intraperitoneal organ to the posterior body wall
    • allows movement while providing support
    • contain blood & lymph vessels, nerves & fat
  44. peritoneal ligament
    • double layer of peritoneum that connects an organ to an organ or to the abdominal wall
    • ex. falciform ligament (liver to anterior abdominal wall)
  45. secondary retroperitoneal structures
    • no longer suspended on mesentery but rather attached to wall by parietal peritoneal layer
    • distal 2nd & 3rd portions of duodenum
    • ascending colon
    • descending colon
  46. peritoneal cavity
    • potential space
    • peritoneal fluid - lubricant absorbed through lymphatic vessels
    • closed in males
    • open in females at uterine tube (uterine cavity - vagina)
  47. divisions of the peritoneal cavity
    • lesser sac: ometal bursa; posterior to the lesser omentum, stomach & liver
    • greater sac: main part of peritoneal cavity in front of organs
  48. omenta
    • double-layered fold of peritoneum enclosing fat
    • greater omentum: travels from the stomach & first portion of the duodenum; passes over the transverse colon; covers multiple organs
    • lesser omentum: travels between liver & stomach
  49. greater omentum
    gastrosplenic ligament + gastrophrenic ligament + gastrocolic ligament
  50. functions of the greater omentum
    • prevents visceral peritoneum from adhering to parietal peritoneum
    • cushions abdominal organs against injury
    • forms insulation against body heat loss
    • often forms adhesions adjacent to an inflammed organ, walling it off to protect other viscera
  51. lesser omentum
    • hepatogastric ligament + hepatoduodenal ligament
    • extends from liver to the lesser curvature of the stomach & first part of the duodenum
    • leading edge contains portal triad (portal vein, hepatic artery, bile duct)
  52. portal triad
    • portal vein
    • hepatic artery
    • bile duct
  53. omental forament
    • Foramen of Winslow
    • opening posterior to the free edge of  lesser omentum
    • allows communication between greater sac and lesser sac
  54. hepatoduodenal ligament
    • free edge of the lesser omentum
    • contains portal triad (bile duct, proper hepatic artery & portal vein)
  55. referred pain of appendicitis
    • initial pain is in the T10 dermatome around the umbilicus (same spinal level which innervates the appendix)
    • delayed pain is due to parietal peritoneal inflammation & localizes to site of infection
  56. pectineal ligament
    • Cooper's ligament
    • runs on pectineal line
  57. Poupart's ligament
    reflected edge of inguinal ligament which does NOT run on bone
  58. conjoined tendon
    medial end of internal oblique fascia + medial end of transversalis fascia inserting on medial pectineal line & pubic crest
  59. lacunar ligament
    connects inguinal ligament to pectineal ligament
  60. inguinal canal
    • runs parallel to medial half of inguinal ligament
    • ends superiorly at the internal inguinal ring
    • opens inferiorly at the external inguinal ring
  61. contents of inguinal canal
    • spermatic cord or round ligament
    • ilioinguinal n. (L1)
  62. external inguinal ring
    • orifice created by the aponeurosis of the external oblique muscles
    • spermatic cord will head to scrotum
    • round ligament will dead-end in labia
    • indirect or direct hernia may exit scrotum here
  63. internal inguinal ring
    • lateral, superior, posterior end of the inguinal canal
    • internal oblique m. ranges more superiorly allowing the spermatic cord to dive through the transversalis fascia
  64. posterior wall of inguinal canal
    • lateral 2/3: weak; only formed by transversalis fascia
    • medial 1/3: reinforced by conjoined tendon & reflected inguinal ligament (Poupart's ligament)
  65. roof of the inguinal canal
    formed by overarching fibers of the internal oblique & transversus abdominus mm.
  66. floor of the inguinal canal
    inguinal ligament & lacunar ligament (medially) and Poupart's ligament in the medial 1/3
  67. deep inferior epigastric vessels
    branch off the anterior/medial surface of the external iliac or proximal common femoral vessels to run anterior in the preperitoneal space & onto the anterior abdominal wall along the backside of the rectus abdominus mm.
  68. indirect inguinal hernias
    • arise lateral to epigastric vessels
    • exit the abdomen through the internal ring & run along w/ spermatic cord (or round ligament) through canal & out the external rind
  69. direct inguinal hernias
    • arise in the inguinal floor of Hasselbech's triangle medial to the epigastric vessels
    • stretch the full thickness of the abdominal wall (may include intra-abdominal contents)
    • enter the canal & exit only through the external inguinal ring
  70. femoral hernias
    • may not be covered by a typical peritoneal sac
    • descends beneath the inguinal ligament through the femoral canal
    • medial to the femoral vein
    • lateral to the lacunar ligament
    • posterior border - pubic ramus & Cooper's ligament
  71. femoral canal
    femoral n, a, & v
  72. ventral hernias
    • incisional: commonly related to wound infections
    • non-incisional: umbilical, epigastric (higher in midline), spigelian (exits at lateral border of rectus, medial border of external oblique)
  73. examining for hernias
    • standing position with or without straining
    • lying flat relaxed to feel for defect
    • lying positiong straining to feel for bulge
    • half sit-up to look for bulging
    • compare sides
  74. layers of scrotum
    cutaneous sac: heavily pigmented sac + dartos tunic
  75. Dartos fascia
    • continuous anteriorly with the membranous layer of anterior abdominal fascia (Scarpa's)
    • continuous posteriorly with the superficial perineal fascia (Colles')
  76. sensory innervation
    • posterior surface - posterior scrotal nerves from pudendal n (S2,3,4), scrotal branches of the posterior femoral cutaneous n, & perineal n
    • anterior surface - ilioinguinal n, genital branch of genitofemoral n (L1,2)
  77. contents of spermatic cord
    • ductus deferens
    • testicular artery
    • artery of the ductus deferens
    • cremasteric artery
    • pampiniform plexus
    • sympathetic nerve fivers
    • genital branch of genitofemoral n
    • lymphatic vessels
    • visceral afferent n
  78. digestive system
    all organs related to nutritional absorption
  79. alimentary canal
    • passage from the mouth to the anus
    • maximal surface area for nutritional absorption
    • includes mouth, pharynx and GI tract
  80. components of alimentary canal
    • esophagus
    • stomach
    • duodenum (first part of small bowel)
    • small bowel - jejunum & ileum
    • large bowl (colon) - cecum, ascending, transverse, descenging & sigmoid
    • rectum
    • anus
  81. layers of the alimentary tract components
    • lumen
    • mucosa
    • submucosa
    • inner circular muscle fibers
    • outer longitudinal muscle fibers
    • serosa - visceral peritoneum
  82. esophagus
    • NO serosal covering
    • cervical, thoracic, abdominal portions
  83. esophageal hiatus
    • T10 level
    • through muscular portion of diaphragm
  84. hiatus for inferior vena cava
    • T9 level
    • through central tendon of diaphragm
    • do not want muscular interference with venous blood flow
  85. aortic hiatus
    • T12 level
    • behind diaphragm
  86. regions of the stomach
    • fundus
    • cardia
    • body
    • pylorus
    • antrum
  87. characteristics of internal stomach
    • rugae: internal folds which act to mix food and stomach acid into chyme to initiate digestion, especially of proteins
    • pylorus: controls rate of gastric emptying
  88. gastroesophageal reflux disease
    • distal esophagus: prone to adenocarcinoma especially in people with GERD
    • gastroesophageal junction/lower esophageal sphincter: NOT a real muscular sphincter; depends on presence of the diaphragmatic hiatus to stay closed
  89. duodenum
    • bulb: first part, ascending
    • 2nd, 3rd & 4th portions: retroperitoneal
    • major duodenal papilla: drains main pancreatic duct & common bile duct
    • minor duodenal papilla: drains accessory pancreatic duct
  90. characteristics of jejunum
    • high plicae
    • long vasa recta
    • single arcade
  91. characteristics of ileum
    • low plicae
    • short vasa recta
    • multiple arcades
  92. characteristics of large bowel
    • tenia coli
    • epiploic appendages (fat lobules)
    • haustra (sacs)
  93. colonic divisions
    • cecum (ileocecal valve & appendix)
    • ascending/right colon
    • hepatic flexure
    • transverse colon
    • splenic flexure
    • descending/left colon
    • sigmoid colon
  94. cecal anatomy
    • ileocecal valve
    • appendiceal orifice
    • ileocolic artery - terminal branch of the superior mesenteric artery
    • mesoappendix
    • appendiceal artery - a branch of ileocolic artery
  95. positions of vermiform appendix
    • retrocecal: 65% of population
    • pelvic: 30% of population; 80% of appendicitis cases
  96. rectosigmoid junction
    • peritoneal reflection back onto sigmoid colon
    • NO serosa in rectum (pelvic structure)
  97. accessory digestive organs
    • salivary glands - sublingual, submandibular, parotid
    • liver
    • gallbladder
    • pancreas
  98. contents of portal triad
    • common bile duct
    • proper hepatic artery - 20% of arterial blood flow to liver
    • hepatic portal vein - 80% of hepatic venous drainage
  99. hepatic venous outflow
    • right hepatic vein
    • middle hepatic vein
    • left hepatic vein
    • all three empty into the inferior vena cava
  100. bare area of the liver
    • NOT covered by peritoneum
    • lined by coronary ligaments
    • back wall of liver where hepatic venous outflow is visible
  101. functions of the liver
    • the bile ducts, hepatic arteries & portal veins form three parallel networks throughout the liver
    • the liver secretes digestive enzymes & acts to detoxify the blood
  102. function of gallbladder
    • stores a small amount of bile, concentrates it
    • excretes bile when CCK (cholecystokinin) is released by the stomach in the presence of digested fats
  103. cholelithiasis
    • gallstones
    • stones can be made of cholesterol OR bile
    • they obstruct the drainage of the gallbladder causing pain
    • gallstones can drop into the common bile duct obstructing its drainage & causing pancreatitis
  104. pancreas
    • accessory digestive organ
    • resides in the retroperitoneum behind the stomach
    • acts as an exocrine gland (digestive) and endocrine gland (systemically active enzymes - insulin)
    • contains main & accessory pancreatic ducts
    • drains into the 2nd portion of the duodenum via the minor & major papillae
    • lies anterior to the superior mesenteric artery & vein
  105. spleen
    • non-digestive abdominal organ
    • intraperitoneal organ deep in posterior left upper quadrant
    • serves as lymphoid organ & blood filter
  106. retroperitoneum
    • adrenals - secrete epinephrine, norepinephrine, cortisol, dopamine, sex steroid precursors
    • kidneys
    • ureters
    • retroperitoneal & pelvic structures
    • blood filtration, urination & endocrine functions
  107. renal/urinary system
    • serves to remove excess water, salts, & waste
    • returns nutrients & chemicals to the blood
  108. paths of ureters
    • water under the bridge: ureters cross under the gonadal vessels at the mid psoas
    • waterfall over the cliff: ureter crosses over the iliac vessels just below the pelvic brim
    • water under the bridge again: ureters cross under the uterine artery medial to the origin of the uterine artery as well as medial to the artery of the vas deferens (posterolateral to the vas deferens itself)
  109. adrenal glands
    • suprarenal glands
    • part of endocrine system
    • secrete epinephrine, norepinephrine, dopamine, corticosteroid & sex steroid precursors
  110. arterial supply of adrenal glands
    • superior suprarenal arteries off the inferior phrenic a.
    • middle suprarenal arteries off the aorta
    • inferior suprarenal artery off the renal artery
  111. venous drainage of the adrenal glands
    • right suprarenal vein into the IVC
    • left suprarenal vein into the left renal vein
  112. abdominal aortic vasculature
    • unpaired arterial branches: celiac a, superior mesenteric a, inferior mesenteric a
    • paired parietal branches: inferior phrenic aa, 4 pairs of lumbar aa
    • paired visceral branches: renal aa, suprarenal aa, gonadal (ovarian or testicular) aa
  113. major arteries supplying abdominal organs
    • celiac trunk: foregut
    • superior mesenteric a: midgut
    • inferior mesenteric a: hindgut
  114. abdominal organs of foregut
    • liver
    • stomach
    • pancreas
    • spleen
    • 1 & 2nd part of duodenum
  115. abdominal organs of midgut
    • 3rd & 4th parts of duodenum
    • head of the pancreas
    • small intestine
    • ascending & transverse colon
  116. abdominal organs of hindgut
    • descending colon
    • sigmoid colon
    • superior part of rectum
  117. unpaired anterior arterial branches of the abdominal aorta
    • celiac artery: to liver, stomach, spleen, pancreas, first & second parts of duodenum
    • superior mesenteric artery: to head of pancreas, small bowel, ascending colon & proximal 2/3 transverse colon
    • inferior mesenteric artery: to descending & sigmoid colon & superior rectum
  118. termination of abdominal aorta
    bifurcation at L4 vertebral level into two common iliac arteries
  119. abdominal venous systems
    • systemic venous drainage: drains viscera of retroperitoneum, pelvis & lower extremities
    • portal venous drainage: drains gut
  120. abdominal systemic venous drainage
    • RIGHT: adrenal & gonadal veins drain into the inferior vena cava
    • LEFT: adrenal & gonadal veins drain into the renal vein
    • right common iliac vein joins left common iliac vein & median sacral vein to form IVC
    • left renal vein crosses over the aorta
    • gonadal vessels run over the ureter in the retroperitoneum
  121. abdominal venous vasculature
    • portal vein
    • splenic vein
    • inferior mesenteric vein
    • superior mesenteric vein
  122. porto-systemic anastomoses
    • esophageal veins: shunt from left gastric vein up to esophagus to azygos system
    • periumbilical region: from deep paraumbilical veins to superficial epigastric veins
    • from right, left & middle colic veins to renal, suprarenal, gonadal & lumbar veins
    • superior rectal veins shunt to middle & inferior rectal veins
  123. abdominal autonomic innervation
    • vagus nerves: provide parasympathetic innervation
    • splanchnic nerves: carry sympathetic & parasympathetic fibers
  124. colonic parasympathetic innervation
    • ascending & transverse colon: innervated by vagus nerve plexes parasympathetics
    • descending & sigmoid colon: innervated by pelvic splanchnic nerve parasympathetics
  125. sympathetic innervation
    • greater splanchnic nerve: to celiac ganglia
    • lesser splanchnic nerve: to superior mesenteric ganglia
    • least splanchnic nerve: to aortico-renal ganglia
    • lumbar splanchnic nerve: fibers to inferior mesenteric ganglia
  126. enteric nervous systems
    visceral nerve plexes are in the wall of the alimentary canal
  127. lymphatic system
    • specialized component of the circulatory system
    • only present in higher vertebrates which have an extensive vascular system
    • high intravascular pressure results in fluid seepage from the capillaries - lymphatic system combats this problem
  128. lymph
    • transparent, clear (usually slightly yellow) watery, often opalescent liquid found in the lymphatic vessels
    • constantly moving around the body without a central pump; circulates by means of movement of the body's muscles
    • bathes the cells, provides oxygen & nutrients, carries away metabolic byproducts & toxins from cells
  129. function of the lymphatic system
    • collect & return excess interstitial fluid from the extracellar space (plasma protein to blood) to help maintain fluid balance or homeostasis
    • absorb & transport fat or water-soluble lipids from the small intestine to the circulatory system
    • protect the body via the immune system so that it can reject foreign proteins and cells; defend the body by producing lymphocytes
    • spread of infections & cancer
  130. lymphangitis
    • inflammation of lymphatic vessels
    • bacterial infection that has spread from its initial site to nearby glands
    • symptoms: chills, fever, swelling of lymph glands; red lines may appear on arms & legs
    • "blood poisoning"
  131. lymphedema
    accumulation of lymph fluid, often in the form of swelling of the arms or legs, that occurs when lymph vessels or lymph nodes are blocked or removed
  132. elephantiasis
    • an advandced case of lymphedema
    • blockage of lymph vessels by parasites or other means
  133. lymph vessels
    • lymph capillaries
    • collecting vessels
    • lymphatic trunks
    • lymphatic ducts
  134. organization of lymphatic system
    • diffuse lymphatic tissue
    • lymph nodules
    • lymph nodes
  135. lymph capillaries
    • start as microscopic close-ended branching & anastomosing tubes
    • have larger lumen, thinner walls & greater permeability than blood capillaries
  136. lymph capillaries are present in high concentrations in:
    • dermis
    • glands
    • small intestines
    • serous membranes
    • mucous membranes
    • synovial membranes
  137. collecting vessels
    • formed by the union of several lymph capillaries
    • can be distinguished from lymph capillaries by their beaded appearance due to presence of valves
    • can be characterized as either afferent (towards a lymph node) or efferent (away from a lymph node)
    • collecting vessels will empty into lymph nodes
    • flow is the result of compressive forces & valves to prevent backflow
  138. lymph nodes
    • found throughout the body
    • approximately 500-1500 lymph nodes in the human lymphatic system
    • round or kidney-shaped organs
    • range in size; appear pink in the living (brownish in cadavers)
  139. function of lymph nodes
    • as lymph percolates through the lymph nodes, debris, pathogens & antigens are filtered out
    • fixed macrophages engulf particles, bacteria or antigens
    • filtering mechanism: one of the most important body defenses against infections disease
  140. lymph trunks
    • formed by the union of several efferent lymph vessels
    • increase in size as they approach the venous system
  141. types of lymph trunks
    • subclavian trunks: drain right & left upper extremities
    • jugular trunks: drain right & left portions of head & neck
    • bronchomediastinal trunks: drain right & left lungs and mediastinum
    • lumbar trunks: drain right & left suprarenal glands, kidneys & gonads; areas drained by common, internal & external iliac nodes & superficial inguinal nodes
    • intestinal drunks: drains organs supplied by three unpaired arterial branches of the aorta
  142. terminal lymph vessels
    • thoracic duct & right lymphatic duct
    • formed by the union of several lymph trunks
  143. thoracic duct
    • drains the left half of the head, neck & thorax along with the left upper extremity and the entire body below the diaphragm
    • begins as a dilated sac called the cisternae chyli
    • ascends up the right side of the body & passes through the aortic hiatus of the diaphragm
    • crosses to the left side at level of T5 & ascends up to the neck
    • joins the venous system at the junction of the left internal jugular vein & left subclavian vein
  144. cisternae chyli
    receives lymph from the lumbar & intestinal lymph trunks
  145. right lymphatic duct
    • smaller & shorter than the thoracic duct
    • drains the right jugular trunk from the head & neck, right subclavian trunk from the upper extremity, and right bronchomediastinal trunk from the right thorax
    • drains into the venous system at the junction of the right internal jugular & right subclavian vein
  146. general lymph drainage
    skin - superficial lymph nodes - deep lymph nodes - lymph trunks - terminal vessels
  147. superficial lymph nodes
    • cervical nodes: receive lymph from head & neck
    • axillary lymph nodes: receives lymph from upper extremities & trunk superior to umbilicus
    • superficial inguinal lymph nodes: receive lymph from lower extremities, pelvic area, and trunk below the umbilicus
  148. deep lymph nodes
    • celiac nodes: (T12) receives lymph from stomach, 1st part of duodenum, gallbladder, esophagus, part of pancreas
    • superior mesenteric nodes: (L1) receives lymph from parts of duodenum, pancreas, ileum, jejunum, appendix, ascending colon, proximal 2/3 of the transverse colon
    • inferior mesenteric nodes: (L3) receive lymph from distal 1/3 of the transverse colon, descending colon, sigmoid colon, superior part of rectum
    • lumbar nodes: (L4) receive lymph from the kidneys, suprarenal glands, abdominal wall, testes & ovaries
  149. para-aortic nodes
    lumbar nodes (also considered to be central deep lymph nodes)
  150. pre-aortic nodes
    • central nodes
    • celiac, superior mesenteric & inferior mesenteric nodes
  151. lymph drainages of skin of lower extremities
    superficial inguinal nodes - lumbar nodes
  152. lymph drainage of uterus
    • fundus: lumbar nodes
    • upper body: lumbar nodes
    • lower body: external iliac nodes
    • round ligament: superficial inguinal nodes
  153. lymph drainage of ovaries
    lumbar nodes
  154. lymph drainage of cervix
    • anteriorly: internal & external iliac nodes
    • posteriorly: sacral nodes
  155. lymph drainage of vagina
    • upper 3/4: internal iliac nodes
    • lower 1/4: superficial inguinal
  156. lymph drainage of penis & scrotum
    superficial inguinal nodes
  157. lymph drainage of testes
    lumbar nodes
  158. lymph drainage of rectum
    • superior: inferior mesenteric nodes
    • middle: internal iliac nodes
    • inferior: internal & common iliac nodes
  159. lymph drainage of anal canal
    • superior: internal iliac nodes
    • inferior: superficial inguinal nodes
  160. lymph drainage of stomach
    • area 1: left gastric nodes
    • area 2: right gastroomental nodes & pyloric nodes
    • area 3: left gastroomental nodes & pancreatiosplenic nodes
    • area 4: right gastric nodes & pyloric nodes
  161. functions of the pelvic girdle
    • bear the weight of the upper body when sitting or standing
    • transfer that weight from the axial to the appendicular skeleton for standing or walking
    • provide attachment for muscles of posture, locomotion & those of abdominal wall
    • support & protect viscera
  162. male pelvis
    • general structure: thick & heavy
    • greater pelvis: deep
    • lesser pelvis: narrow & deep
    • pelvic inlet: heart-shaped
    • pelvic outlet: comparitively small
    • pubic arch/subpubic angle: narrow
    • obturator forament: round
    • acetabulum: large
  163. female pelvis
    • general structure: thin & light
    • greater pelvis: shallow
    • lesser pelvis: wide & shallow
    • pelvic inlet: oval & rounded
    • pelvic outlet: comparatively large
    • pubic arch/subpubic angle: wide
    • obturator foramen: oval
    • acetabulum: small
  164. shapes of pelvis
    • android: most common in males
    • gynecoid: most common in females
    • platypelloid: uncommon in both sexes
  165. joints of the pelvis
    • sacroiliac: synovial
    • pubic symphysis: secondary cartilaginous with interpubic disc
    • lumbosacral: secondary cartilaginous (intervertebral disc); synovial (zygopophysial joints)
  166. ligaments of the pelvis
    • anterior & posterior sacroiliac
    • iliolumbar
    • sacrotuberous
    • sacrospinous
    • superior & inferior (arcuate) pubic
    • inguinal
    • lacunar
    • pectineal
  167. spondylolysthesis
    anterior displacement of L5 vertebra; breaking of pars interarticularis & sliding forward
  168. spondolysis
    fracture of pars interarticularis without sliding
  169. muscles of pelvic wall with nerve supply
    • iliacus: femoral nerve (L2,L3,L4)
    • obturator internus: n. to obturator internus (L5,S1,S2)
    • piriformis: branches of S1,S2 spinal nn.
  170. muscles of pelvic diaphragm with nerve supply
    • levator ani: n. to levator ani (S4) [puborectalis, pubococcygeus, iliococcygeus]
    • coccygeus: branches S4,S5 spinal nn.
  171. pelvic fascia
    • parietal: lines muscles forming walls & floor of the pelvis
    • visceral: directly ensheathes the pelvic organs
    • endopelvic: between pelvic & parietal; loose areolar & ligaments (dense fibrous tissue containing collagen, elastic fibers & some smooth muscles fibers)
  172. perineal body (central tendon of perineum)
    • located at the midpoint of the line joining the ischial tuberosities (central point of perineum)
    • lies deep to the skin posterior to the vestibule or bulb of the penis & anterior to the anus and anal canal
    • site of convergence and interlacing of fibers of several muscles (bulbospongiosus, external anal sphincter, superficial & deep transverse perineal, slips of muscle from external urethral sphincter, levator ani & external anal sphincter)
  173. boundaries of the ischioanal fossa
    • lateral: obturator internus m with fascia containing pudendal (Alcock's) canal
    • medial: external anal sphincter m & sloping pelvic diaphragm
    • superior: pelvic diaphragm
    • posterior: sacrotuberous ligament & gluteus maximus m.
    • anterior: bodies of pubic bones
  174. fascia of the urogenital triangle
    • superficial perineal fascia: fatty layer (Campers) & membranous layer (Colles')
    • deep perineal fascia: investing/Gallaudet's (invests muscles of perineum) & perineal membrane
  175. boundaries of superficial perineal pouch
    • superior: perineal membrane (deep perineal fascia)
    • inferior: Colles' fascia (membranous superficial perineal fascia)
    • lateral: ischiopubic rami
  176. contents of male superficial perineal pouch
    • bulb of penis
    • crura of penis
    • ischiocavernosus mm.
    • bulbospongiosus m.
    • superficial transverse perineus mm.
    • proximal part (bulb) of spongy urethra
    • deep and superficial perineal branches of internal pudendal vessels & pudendal nerve
  177. boundaries of deep perineal pouch
    • superior: superior fascia of urogenital diaphragm
    • inferior: perineal membrane
    • lateral: inferior portion of obturator internus m. with its fascia
  178. contents of male deep perineal pouch
    • membranous (intermediate) part of urethra
    • deep transverse perineus mm.
    • bulbourethral glands
    • deep perineal branches of the internal pudendal vessels & the pudendal nerve
    • dorsal artery and nerve of the penis
  179. pudendal nerve
    • ventral rami of S2, S3, & S4
    • inferior rectal n: motor & sensory to rectum, lower part of anal canal & skin
    • superficial branch of perineal nerve: sensory to posterior scrotum and posterior labial branches
    • deep branch of perineal nerve: motor to mm of superficial and deep perineal pouches
    • dorsal nerve of penis (clitoris): sensory
  180. urinary bladder position
    • bladder normally pelvic organ
    • in children - found in abdominal cavity
    • position changes depending on degree of fullness
    • lifts peritoneum from anterior wall as it rises, allowing access to retropubic space
  181. bladder facts
    • when filled, the bladder has a capacity of over 500 mL
    • usually enters greater pelvis by 6 years of age
    • not located entirely within the pelvis until after puberty
    • walls of bladder composed of detrusor m.
    • involuntary internal urethral spinchter: formed by muscle fibers toward neck of bladder
    • uvula of bladder: slight elevation of trigone (more prominent in older men - enlargement of prostate)
  182. male urethra
    • prostatic: 3-4 cm
    • membranous: 1-1.5 cm
    • penile (spongy): 15 cm
  183. benign prostatic hypertrophy
    • common cause of urethral obstruction
    • median lobe enlarges the most
    • begins around age 45 and occurs in 80% of all men by age 80
    • cancer of prostate usually involves posterior lobe
  184. seminal vesicles
    • contribute about 60% of seminal fluid
    • secretion high in fructose (easily metabolized by sperm)
  185. ejaculatory duct
    vas deferens + duct of seminal vesicle
  186. fascial continuities
    • superficial fascia: superficial penile - dartos - colles'
    • deep fascia: deep penile (Buck's) - Gallaudet's - perineal membrane
  187. rectum facts
    • upper limit: where sigmoid mesocolon disappears (S3)
    • lower limit: pelvic floor
    • taeniae coli spread out to form longitudinal layer of smooth muscle
    • epiploic appendages disappear
    • ampulla: widest part, just above pelvic floor
    • transverse folds of Houston
  188. anal canal facts
    • part of GI tract below pelvic diaphragm
    • pectinate line: "watershed area" that divides upper 2/3 and lower 1/3
    • anal columns: longitudinal folds of mucosa in upper 2/3
    • anal valves: semilunar folds of tissue connecting anal columns
    • anal sinuses: recesses superior to valves containing mucous glands
  189. internal anal sphincter
    • thickening of circular muscular layer
    • involuntary: ANS control
    • surrounds upper 2/3 of anal canal
  190. external anal sphincter
    • voluntary: inferior rectal n.
    • on each side of inferior 2/3 of anal canal
  191. pectinate line
    • epithelium above columns: columnar, sensitive to stretch, derived from endoderm, arterial supply from superior rectal artery, venous drainage by superior rectal vein, lymphatic drainage to pararectal lymph nodes along superior rectal artery
    • epithelium below columns: stratified squamous, senstitive to pain, touch & temperature, derived from ectoderm (proctodeum), arterial supply from inferior rectal artery, venous drainage by inferior rectal vein, lymphatic drainage to superficial inguinal nodes
  192. palpable structures on rectal exam: male
    • prostate & seminal vesicles
    • rectal neoplasms
    • pelvic surface of sacrum & coccyx
    • ischial spines & tuberosities
    • enlarged internal iliac lymph nodes
    • pathological thickening of ureters
    • ischioanal abscesses
    • inflammed appendix (in pelvis)
  193. palpable structures on rectal exam: female
    • cervix of uterus
    • rectal neoplasms
    • pelvic surface of sacrum & coccyx
    • ischial spines & tuberosities
    • enlarged internal iliac lymph nodes
    • pathological thickening of the ureters
    • ischioanal abscesses
    • inflammed appendix (in pelvis)
  194. branches of internal iliac artery (male)
    • posterior division
    • iliolumbar
    • lateral sacral
    • superior gluteal
    • anterior division
    • umbilical - superior vesical
    • obturator
    • middle rectal
    • inferior vesical
    • internal pudendal
    • inferior gluteal
  195. contents of female superficial perineal pouch
    • bulbospongiosus mm.
    • bulbs of the vestibule
    • ischiocavernosus mm
    • crura of the clitoris
    • superficial transverse perineus mm
    • greater vestibular glands
    • urethra & vagina pass through
    • deep & superficial perineal branches of internal pudendal vessels and pudendal nerves
  196. contents of female deep perineal pouch
    • sphincter urethrae m.
    • deep transverse perineus mm
    • urethra & vagina pass through
    • deep perineal branches of the internal pudendal vessels & pudendal nerves
    • dorsal artery & dorsal nerve of the clitoris
  197. uterus facts
    • consists of body & cervix
    • has anteverted, anteflexed position
    • walls of body of uterus: perimetrium, myometrium, endometrium
    • cervix is mostly fibrous
    • has passive & ligamentous support
  198. ligaments of the uterus
    • broad ligament of the uterus: double layer of peritoneum that extends from the sides of the uterus to the lateral walls & floor of pelvis
    • round ligament of the uterus: remnant of gubernaculum ovarii
    • ligament of the ovary: remnant of gubernaculum ovarii
    • suspensory ligament of the ovary: superior extension of broad ligament
    • cardinal/transverse cervical ligament: dense fibrous thickening of endopelvic fascia that extends from uterine cervix & lateral parts of fornix of vagina to lateral walls of the pelvis
    • uterosacral ligament: dense fibrous thickening of endopelvic fascia that passes from sides of cervix to middle of sacrum
    • pubocervical ligament: dense fibrous thickening of endopelvic fascia that passes from pubis to cervix
  199. portions of broad ligament of the uterus
    • mesosalpinx: between uterine tubes & mesovarium
    • mesometrium: between mesovarium & cardinal / transverse cervical ligament
    • mesovarium: between ovary & posterior portion of broad ligament
  200. vagina facts
    • distensible musculotendinous tube, usually collapsed
    • has fornices which surround cervix of uterus (anterior, posterior, 2 lateral)
    • opens into vestibule
    • passes through pelvic diaphragm and superficial & deep perineal pouches
  201. uterine tube facts
    • about 10 cm long
    • opens into peritoneal cavity (female peritoneal cavity is NOT closed)
    • four parts: infundibulum, ampulla, isthmus, intramural
  202. ovary facts
    • located on posterior aspect of broad ligament suspended by mesovarium
    • ovarian vessels, nerves & lymphatics pass through suspensatory ligament of the ovary
    • tethered to the uterus by the ovarian ligament
  203. branches of internal iliac artery: female
    • posterior division
    • iliolumbar
    • lateral sacral
    • superior gluteal
    • anterior division
    • umbilical - superior vesical
    • obturator
    • middle rectal
    • uterine
    • vaginal (inferior vesical in male)
    • internal pudendal
    • inferior gluteal
  204. perineal body
    • wedge of fibromuscular tissue that lies between the lower vagina & the anal canal
    • AKA central tendon
    • lies deep to the skin & subcutaneous tissues
    • provides attachments for most perineal muscles
    • supports posterior wall of  the vagina
    • attaches to the posterior border of the perineal membrane
  205. median episiotomy
    • incision into the posterior vaginal wall back to divide perineal body (but not as far as deep fibers of external anal sphincter)
    • bloodless & painless
    • limited expansion
  206. mediolateral episiotomy
    • incision into posterior vaginal wall posterolaterally into ischioanal fossa
    • allows greater expansion, but is more difficult to repair and greater chance of infection
  207. lumbar plexus
    • subcostal n (T12)
    • iliohypogastric n (L1)
    • ilioinguinal n (L1)
    • genitofemoral (L1, L2)
    • lateral femoral cutaneous n (L2, L3)
    • femoral n (L2, L3, L4)
    • obturator n (L2, L3, L4)
    • lumbosacral n (L4, L5)
  208. iliohypogastric n
    • L1
    • motor to: internal abdominal oblique, transverse abdominis
    • sensory to: skin of gluteal region, skin of inguinal & pubic regions
  209. genitofemoral n
    • L1, L2
    • genital branch: accompanies round ligament of uterus through inguinal canal (female); contained within spermatic cord (male)
    • genital - sensory to: labia majora & scrotum
    • genital - motor to: cremaster m (male); NOTHING in female
    • femoral - sensory to: part of upper anterior thigh
  210. ilioinguinal n
    • L1
    • motor to: internal abdominal oblique, transversus abdominus
    • sensory to: skin over medial & proximal part of upper thigh; skin of mons pubis & anterior part of labia majora (female); anterior part of scrotum (male)
  211. lateral femoral cutaneous nerve
    • L2, L3
    • crosses beneath inguinal ligament near the anterior superior iliac spine
    • sensory to: lateral portion of the thigh
    • NO motor component
  212. femoral nerve
    • L2, L3, L4
    • motor to: iliacus, quadriceps femoris, sartorius, pectineus
    • sensory to: anterior thigh, anterior & medial side of leg, medial side of foot, hip & knee joints
  213. obturator nerve
    • L2, L3, L4
    • motor to: adductor longus, adductor brevis, adductor magnus, gracilis, obturator externus
    • sensory to: medial area of thigh, hip & knee joints
  214. lumbosacral trunk
    • L4, L5
    • carries lumbar spinal cord segments into the sacral plexus
    • crosses posterior aspect of the pelvic brim
    • contributes to several nerves arising from the sacral plexus
    • serves as landmark - superior gluteal artery passes between it & ventral ramus of S1
  215. nerve supply of abdominal & pelvic organs
    GVA & GVE
  216. general concepts of the ANS
    • visceral motor (GVE)
    • effector cells: smooth muscle, cardiac muscle & glands
    • two neuron chain
    • preganglionic: myelinated
    • postganglionic: unmyelinated
  217. sympathetic nervous system
    • thoracolumbar
    • short preganglionics
    • long postganglionics
    • fight or flight
  218. parasympathetic nervous system
    • cranial-sacral
    • long preganglionics
    • short postganglionics
    • resting & digesting
  219. sympathetic ganglia
    • sympathetic chain ganglia
    • prevertebral ganglia: celiac, superior mesenteric, inferior mesenteric, aorticorenal
  220. function of sympathetic nervous system in abdomen & pelvis
    • inhibit peristalsis
    • vasoconstriction
    • contract internal urethral sphincter
    • increase sphincter tone
    • release adrenalin into blood stream
    • ejaculation
  221. function of parasympathetic nervous system in abdomen & pelvis
    • peristalsis
    • decrease sphincter tone
    • increase digestive secretions
    • contract detrusor muscle
    • erection
  222. source of sympathetics in abdomen & pelvis
    • IMLCC from T5-L2 segments of spinal cord
    • thoracic splanchnics
    • lumbar splanchnics
    • sacral splanchnics
  223. source of parasympathetics in abdomen & pelvis
    • vagus n (CN X)
    • pelvic splanchnics (S2, S3, S4)
  224. abdominal splanchnics
    • thoracic: sympathetic
    • lumbar: sympathetic
    • pelvic: parasympathetic
    • sacral: sympathetic
  225. thoracic splanchnic nerves
    • greater splanchnic n - T5 to T9
    • lesser splanchnic n - T10 to T11
    • least splanchnic n - T12
  226. synapses of thoracic splanchnic nerves
    • greater splanchnic n - celiac ganglion
    • lesser splanchnic n - superior mesenteric ganglion
    • least splanchnic n - aorticorenal ganglion
  227. organs supplied by celiac artery
    • esophagus
    • stomach
    • duodenum
    • liver
    • gallbladder
    • spleen
    • pancreas
  228. contents of celiac plexus
    • celiac ganglia
    • greater splanchnic nn (preganglionic sympathetics, general visceral afferent nn)
    • postganglionic sympathetics
    • vagus nn (preganglionic parasympathetics)
  229. contents of superior mesenteric plexus
    • superior mesenteric ganglion
    • lesser splanchnic nn (preganglionic sympathetics, general visceral afferent nn)
    • postganglionic sympathetics
    • vagus nn (preganglionic parasympathetics)
  230. contents of inferior mesenteric plexus
    • inferior mesenteric ganglion
    • upper 2 lumbar splanchnic nn (preganglionic sympathetics, general visceral afferent nn)
    • postganglionic sympathetics
  231. pelvic plexus
    • AKA inferior hypogastric plexus
    • hypogastric nerves
    • lower 2 lumbar splanchnic nerves
    • pelvic splanchnic nerves
    • sacral splanchnic nerves
  232. visceral pain
    • general visceral afferents (GVA) travel back from the organ to the CNS along with the GVE fibers supplying the specific organ
    • generally, those GVA fibers from thoracic organs & abdominal organs travel back to CNS with sympathetics
    • GVA fibers from pelvic organs travel back to the CNS with parasympathetics (pelvic splanchnics)
  233. teratology
    • study of frequency, causation & development of congenital malformations
    • some malformations are genetic; other are caused by adverse environmental circumstances (teratogens)
  234. Teratogen Fun Facts
    • organogenesis (18-60 days): Most sensitive period
    • a variety of teratogens cause the same malformation
    • a variety of malformations can be caused by the same agent
    • susceptibility depends on the genotype of the conceptus
    • manifestations of deviant development are dose dependent
    • most malformations are due to interaction between genetic & environmental factors
    • teratogenic agents may not be deleterious to maternal organism
  235. actions of teratogens
    • unrecoverable cell death
    • increase cell cycle
    • slowing or cessation of differentiation
    • physical constriction & vascular insufficiency
    • interference with the formation & development of tissue
    • inhibited cell migration & cell communication
  236. etiology of malformed live births
    • 20% genetic mendelian
    • 10% chromosomal
    • 5% environmental (infections, maternal disorders, therapeutic radiation, drugs & chemicals)
    • 65% UNKNOWN
  237. Percent likelihood of pregnancy survival to term
    • 0-6 days (preimplantation): 25%
    • 7-13 days (postimplantation): 55%
    • 14-20 days: 73%
    • 3-5 weeks: 79.5%
    • 4-7 weeks: 96%
    • 18-21 weeks: 97.5%
    • 22-25 weeks: 98.39%
    • 26-29 weeks: 98.69%
    • 30-33 weeks: 99.98%
    • 34-37 weeks: 99.26%
    • 38+ weeks: 99.32%
  238. teratogens
    • adverse environmental circumstances
    • ionizing radiation
    • infections
    • metabolic imbalance
    • drugs & environmental chemicals
  239. ionizing radiation
    • Diagnostic or therapeutic (controlled) NOT a nuclear event
    • Exposure is measured in millirads
    • Microcephaly: 10-100 rads (10000 millirads to even get close)
    • Leukemia: 1 rad link (1000 millirads)
  240. probable teratogen infections
    • toxoplasmosis
    • syphilis
    • cytomegalovirus: early - fatal; late - blindness, cerebral palsy, mental retardation
    • HIV - transmission though no obvious malformations
    • varicella
    • Fifth disease
    • Rubella virus
  241. teratogenic effects of drugs is dependent on:
    • the gestational age at the time of exposure
    • the duration of the exposure
    • the genotype of the mother & fetus
    • the dose reaching the embryo/fetus
  242. most structural defects caused by teratogens occur from exposure:
    • 20-55 days after fertilization/ 35-70 days after last menstrual period
    • exposure after 10 weeks development doesn't usually cause malformations except with alcohol, tetracycline, iodine & ACE inhibitors
  243. FDA Drug Teratogen Classification
    • Category A: human studies demonstrate no fetal risks (WONT see many of these)
    • Category B: no animal or human studies showing fetal risk
    • Category C: no adequate human studies showing adverse fetal effects
    • Category D: fetal risk, but benefits clearly outweigh risks
    • Category E: proven fetal risks (contraceptive methods x2)
  244. movements of the hip joint
    • flexion - extension
    • medial rotation - lateral rotation
    • abduction - adduction
  245. movement of the knee joint
    • flexion - extension
    • medial rotation - lateral rotation
  246. movement of the ankle joint
    dorsiflexion - plantarflexion
  247. movement of the transverse tarsal joint
    inversion - eversion
  248. boundaries of the femoral triangle
    • superior: inguinal ligament
    • medial: adductor longus muscle
    • lateral: sartorius muscle
    • floor: pectineus (medial) & iliopsoas (lateral)
    • contents: femoral artery, vein, & nerve
  249. femoral sheath
    • extension of transversalis fascia onto thigh
    • contents: femoral artery, femoral vein, femoral canal with lymphatics
  250. femoral canal
    empty space containing lymphatics
  251. major structures in the femoral triangle
    • femoral n
    • femoral a
    • femoral v
    • empty space (femoral canal)
    • lymphatics
  252. major structures in femoral sheath
    • femoral a
    • femoral v
    • femoral canal with lymphatics
    • NOT femoral n
  253. boundaries of the femoral ring
    • medial: lacunar ligament
    • lateral: femoral vein
    • anterior: inguinal ligament
    • posterior: pectineal ligament
  254. muscles in anterior compartment of thigh
    • quadriceps femoris (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)
    • sartorius
    • pectineus
    • iliopsoas
  255. muscles in medial compartment of thigh
    • adductor longus
    • adductor brevis
    • adductor magnus
    • gracilis
  256. muscles in posterior compartment of thigh
    • semimembranosus
    • semitendinosis
    • biceps femoris
  257. gluteal muscles
    • gluteus maximus
    • gluteus medius
    • gluteus minimus
  258. gluteus maximus
    • origin: ilium, posterior to posterior gluteal line, dorsal portion of sacrum & coccyx, sacrotuberous ligament
    • insertion: iliotibial tract, gluteal tuberosity
    • nerve: inferior gluteal nerve
    • action: extends thigh, lateral rotation
  259. gluteus medius
    • origin: ilium between anterior & posterior gluteal lines
    • insertion: lateral surface of greater trochanter
    • nerve: superior gluteal n
    • action: abduct & medially rotate hip joint; keep pelvis level when walking
  260. gluteus minimus
    • origin: ilium between anterior & inferior gluteal lines
    • insertion: anterior surface of greater trochanter
    • nerve: superior gluteal nerve
    • action: abduct & medial rotate hip joint; keep pelvis level when walking
  261. nerve supply of lateral rotators of hip joint
    • piriformus: S1, S2
    • superior gemellus: n. to obturator internus (L5, S1, S2)
    • obturator internus: n. to obturator internus (L5, S1, S2)
    • inferior gemellus: n. to quadratus femoris (L4, L5, S1)
    • quadratus femoris: n. to quadratus femoris (L4, L5, S1)
    • obturator externus: obturator n (L2, L3, L4)
    • gluteus maximus: inferior gluteal (L5, S1, S2)
    • sartorius: femoral (L2, L3, L4)
  262. innervation of hip joint
    • femoral n.
    • obturator n.
    • n. to quadratus femoris
    • superior gluteal n.
  263. structures passing through the lesser sciatic foramen
    • obturator internus tendon
    • n. to obturator internus (L5, S1, S2)
    • pudendal n (S2, S3, S4)
    • internal pudendal a/v
  264. structures passing through the greater sciatic foramen
    • superior gluteal a/v
    • superior gluteal n (L4, L5, S1)
    • inferior gluteal a/v
    • inferior gluteal n (L5, S1, S2)
    • n. to quadratus femoris (L4, L5, S1)
    • sciatic n (L4, L5, S1, S2, S3)
    • posterior femoral cutaneous (S1, S2, S3)
    • n. to obturator internus (L5, S1, S2)
    • pudendal n (S2, S3, S4)
    • internal pudendal a/v
  265. aneuploidy
    • any deviation from the human diploid number of 46 chromosomes
    • principle cause: non-disjunction of chromosomes during cell division (results in an unequal distribution of one pair of homologous chromosomes to the daughter cells)
  266. Turner's syndrome
    • 45, XO (monosomy) - female phenotype
    • 99% - spontaneous abortion
    • PCGs migrate toward developing gonad & degenerate shortly after arrival - sterile
    • gonads fail to differentiate (no ovaries, only gonadal streaks)
    • FSH & LH levels in blood elevated
    • placental & maternal estrogens influence development of paramesonephric duct system (Y is absent, no MIS)
    • no androgens produces - mesonephric ducts regress
    • neither breast development nor menstruation occur at puberty (lack functioning ovaries)
  267. symptom of Turner's syndrome
    • short
    • ocular defects
    • webbing of neck
    • broad chest
    • microthelia
    • coarctation of aorta
    • cubitus valgus
    • abdominal moles
    • ovarian dysgenesis
    • osteoporosis
    • lymphedema
  268. Kleinfelter's syndrome
    • 47, XXY (trisomy) - male phenotype
    • testes present, but small
    • Leydig cells produce low levels of testosterone
    • hyalinization of seminiferous tubules
    • azoospermia
    • 40% have gynecomastia
    • often tall, slender with disproportionately long lower limbs, sparse body hair (eunuchism)
    • Y present - TDF, AMH/MIS and androgens
  269. ambiguous genitalia in genetic males
    • small penis
    • urethral opening along penis or below penis
    • small scrotum with any degree of separation, resembling labia
    • undescended testes
  270. ambiguous genitalia in genetic females
    • enlarged clitoris
    • urethral opening anywhere along surface of clitoris
    • labia may be fused, resembling a scrotum
    • infant may be thought to be male with undescended testes
  271. true hermaphrodite
    • 46, XX (70%)
    • 46, XY (10%)
    • 46, XX, 46, XY (20%)
    • ovotestis forms if both medulla & cortex of the indifferent gonads develop
    • ovarian & testicular tissue either on same or different sides
    • phenotype may be male or female; external genitalia always ambiguous
  272. pseudohermaphroditism
    • unlike true hermaphrodites, only have gonads of one sex
    • gonads & sex chromosomes indicated one sex while external genitalia exhibit at least some traits of the other sex (ambiguous genitalia)
    • classified according to histological appearance of gonads
    • caused by sex hormone anomalies (abnormal levels of sex hormones OR abnormalites in sex hormone receptors)
  273. female pseudohermaphroditism
    • 46, XX - genetically female
    • ovaries, uterus & oviducts develop normally
    • effects are principally virilization of external genitalia (clitoral enlargement & partial fusion of labia majora)
    • cause: congenital adrenal hyperplasia; exposure of female fetuses to excessive androgens
  274. male pseudohermaphroditism
    • 46, XY - genetically male
    • can be caused by testosterone deficiency (genetic defects in testosterone production; hypoplasia of Leydig cells)
    • can be caused by 5alpha-reductase deficiency (absence of dihydrotestosterone; external genitalia appear to be female; normal testes)
  275. androgen insensitivity syndrome
    • 46, XY - female phenotype
    • testes present & functioning (secrete testosterone & mullerian inhibiting substance)
    • tissues of external genitalia lack receptors to respond to androgens produced
    • female genitalia
  276. hip joint
    • ball & socket joint
    • site of articulation between head of femur & acetabulum
    • ligament stability: strong anteriorly (iliofemoral, pubofemoral); weak posteriorly (ischiofemoral)
    • possible actions: flexion, extension, abduction, adduction, medial & lateral rotation
  277. ligaments of the hip
    • iliofemoral ligament: anterior Y shaped ligament between intertrochanteric line & AIIS; AKA ligament of Bigalow
    • pubofemoral ligament: anterior; inferior to iliofemoral ligament; attaches to obturator crest; wraps inferiorly around neck of femur to attach posteriorly
    • ischiofemoral ligament: posterior; broad attachment to posterior hip bone; tapers down towards neck of femur
  278. blood supply to hip joint
    • artery to head of femur (branch of obturator a.)
    • medial circumflex femoral artery (branch of deep femoral a.)
    • lateral circumflex femoral artery (branch of deep femoral a.)
    • reticular vessels towards neck & head of femur
  279. hip fractures
    • intertrochanteric line: does not disturb blood supply (outside of capsulte)
    • intercapsular: subcapital fracture will sever blood vessels & lead to osteonecrosis
  280. flexion at hip joint
    • iliopsoas
    • tensor fasciae latae
    • rectus femoris
    • sartorius
    • pectineus
  281. extension at hip joint
    • gluteus maximus
    • semimembranous
    • semitendinous
    • biceps femoris
    • adductor magnus (hamstring part)
  282. abduction at hip joint
    • gluteus medius
    • gluteus minimus
    • tensor fasciae latae
    • sartorius
  283. adduction at hip joint
    • adductor longus
    • adductor brevis
    • adductor magnus (adductor part)
    • pectineus
    • gracilis
  284. medial rotation at hip joint
    • gluteus medius
    • gluteus minimus
    • tensor fasciae latae
  285. lateral rotation at hip joint
    • piriformis
    • superior gemellus
    • obturator internus
    • inferior gemellus
    • obturator externus
    • quadratus femoris
    • gluteus maximus
    • sartorius
  286. innervation of hip joint
    • femoral n
    • obturator n
    • n to quadratus femoris
    • superior gluteal n
  287. boundaries of popliteal fossa
    • supero-lateral: biceps femoris m
    • supero-medial: semimebranous & semitendinosus mm
    • infero-lateral: lateral head of gastrocnemius m
    • infero-medial: medial head of gastrocnemius m
  288. contens of popliteal fossa
    • termination of small saphenous vein
    • popliteal a & branches
    • popliteal v & branches
    • tibial nerve
    • common fibular n
    • posterior femoral cutaneous n
    • popliteal lymph nodes
    • lymphatic vessels
  289. arteries of popliteal fossa
    • superior lateral & medial genicular aa - above condyles
    • inferior lateral & medial genicular aa - below condyles
    • middle genicular a
  290. anterior compartment of leg
    • muscles: tibialis anterior, extensor digitorum longus m, fibularis tertius m, extensor hallucis longus m
    • nerve: deep fibular n,
    • artery: anterior tibial a.
    • common function at ankle joint: dorsiflexion
  291. lateral comparment of leg
    • muscles: fibularis longus & fibularis brevis
    • nerve: superficial fibular n
    • artery: perforating branches from fibular a.
    • common function at ankle joint: weak plantar flexion
    • common function at foot: eversion
  292. posterior compartment of leg
    • superficial muscles: gastrocnemius, soleus, plantaris
    • deep muscles: popliteus, flexor hallucis longus, flexor digitorum longus, tibialis posterior
    • nerve: tibial nerve
    • arteries: posterior tibial & fibular aa
    • common function at ankle joint: plantarflexion (exception - popliteus)
  293. structures behind medial malleolus
    • tibialis posterior m
    • flexor digitorum longus m
    • posterior tibial a
    • posterior tibial v
    • tibial n
    • flexor hallucis longus m
  294. knee joint
    • synovial modified hinge
    • possible actions: flexion, extension, medial & lateral rotation
    • three articulations: femorotibial (2) & femoropatellar; fibula NOT involved
    • medial & lateral femoral condyles + medial & lateral tibial condyles
    • stability depends on ligaments between femur & tibia and surrounding muscles & tendons
  295. flexion at knee joint
    • sartorius
    • gracilis
    • semimembranosus
    • semitendinosus
    • biceps femoris
    • gastrocnemius
    • plantaris
    • popliteus
  296. extension at knee joint
    • rectus femoris
    • vastus medialis
    • vastus intermedius
    • vastus lateralis
  297. medial rotation at knee joint
    • sartorius
    • gracilis
    • semimembranosus
    • semitendinosus
  298. lateral rotation at knee joint
    popliteus (unlocking)
  299. extracapsular collateral ligaments of knee
    • lateral collateral ligament (LCL): prevents outward (varus) stress
    • medial collateral ligament (MCL): prevents inward (valgus) stress; attaches to medial meniscus
  300. intracapsular cruciate ligaments of knee
    • anterior cruciate ligament (ACL): prevents hyperextension; prevents anterior displacement of tibia on fixed femur
    • posterior cruciate ligament (PCL): prevents hyperflexion; prevents posterior displacement of tibia on fixed femur
  301. drawer signs
    • anterior drawer test: free tibia slides anterior from fixed femur; ruptured ACL
    • posterior drawer test: free tibia slides posteriorly from fixed femur; ruptured PCL
  302. bursae of the knee
    • suprapatellar bursa: superior extension of synovial cavity between femur & quadriceps tendon (continuous with joint)
    • prepatellar bursa: housemaid's knee
    • subcutaneous (superficial) & deep infrapatellar bursae: clergyman's knee
  303. terrible triad
    torn MCL, ACL, & menisci
  304. innervation of knee joint
    • femoral n (L2, L3, L4) - to anterior knee
    • tibial n (L2-S3 from sciatic n) - to posterior knee
    • common fibular n (L2-S2 from sciatic n) - to lateral knee
    • obturator n (L2, L3, L4) - to medial knee