Block 1 review. When the serratus anterior is paralyzed owing to injury to the long thoracic nerve,...

Block 1 review

When the serratus anterior is paralyzed owing to injury to the long thoracic nerve, the medial border of the scapula moves laterally and posteriorly away from the thoracic wall, giving the scapula the appearance of a wing.

Due to loss of Innervation-long thoracic nerve

The primary clinical manifestation of accessory nerve palsy is a marked ipsilateral weakness when the shoulders are elevated (shrugged) against resistance.

The deltoid is a common site for the intramuscular injection of drugs.

The axillary nerve runs transversely under cover of the deltoid at the level of the surgical neck of the humerus.

The deltoid atrophies when the axillary nerve (C5 and C6) is severely damaged.

Four of the scapulohumeral muscles supraspinatus, infraspinatus, teres minor, and subscapularis (referred to as the SITS muscles) are called rotator cuff muscles because they form a musculotendinous rotator cuff around the glenohumeral joint.

Collateral circulation: Subclavian artery-----Suprascapular artery--------circumflex

scapular artery----subscapular artery----axillary artery

All lymphatics from the upper limb drain into lymph nodes in the axilla.

The 20-30 axillary nodes are generally divided into five groups on the basis of location

1. humeral (lateral) nodes 2. pectoral (anterior)

nodes 3. subscapular (posterior)

nodes 4. central nodes 5. apical nodes

The symptoms are very similar to the pain from hitting your funny bone. 

Median Cubital Vein

Roof of the fossa :

Containing the Median cubital vein.

This is a communication between

Cephalic

And

Basillic veins

• Boundries Medially

-Extensor pollicis longus tendon

Laterally Abductor pollicis longus tendon Extensor pollicis brevis tendon

• Clinical importance 1- Scaphoid bone 2- Radial pulsation

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The carpal tunnel is formed anteriorly at the wrist by a deep arch formed by the carpal bones and the flexor retinaculum.

The hand is supplied by the ulnar, median, and radial nerves.

Compression of the ulnar nerve may occur at the wrist where it passes between the pisiform and the hook of the hamate.

Pulled elbow or Nursemaid's elbow

The sudden pulling of the upper limb tears the distal attachment of the anular ligament, where it is loosely attached to the neck of the radius.

A 29-year-old man comes in with a stab wound, cannot raise his arm above horizontal, and exhibits a condition known as winged scapula.• Which of the following structures of the brachial plexus would most likely be damaged?

(A) Medial cord (B) Posterior cord (C) Lower trunk (D) Roots (E) Upper trunk

A 21-year-old woman walks in with a shoulder and arm injury after falling during horseback riding. Examination indicates that she cannot adduct her arm because of paralysis of which of the following muscles?

(A) Teres minor (B) Supraspinatus (C) Latissimus dorsi (D) Infraspinatus (E) Serratus anterior

An 18-year-old boy involved in an automobile accident presents with arm that cannot abduct. His paralysis is caused by damage to which of the following nerves?

(A) Suprascapular and axillary (B) Thoracodorsal and upper subscapular (C) Axillary and musculocutaneous (D) Radial and lower subscapular (E) Suprascapular and dorsal scapular

A patient has a torn rotator cuff of the shoulder joint as the result of an automobile accident. Which of the following muscle tendons is intact and has normal function?

(A) Supraspinatus (B) Subscapularis (C) Teres major (D) Teres minor (E) Infraspinatus

A patient bleeding from the shoulder secondary to a knife wound is in fair condition because there is vascular anastomosis around the shoulder. Which of the following arteries is most likely a direct branch of the subclavian artery that is involved in the anastomosis?

(A) Dorsal scapular artery (B) Thoracoacromial artery (C) Circumflex scapular artery (D) Transverse cervical artery (E) Suprascapular artery

Formed by the union of the dorsal vein of the great toe and the dorsal venous arch of the foot.

Ascends anterior to the medial malleolus.

Passes posterior to the medial condyle of the femur

Femoral nerve and its (terminal) branches.

Femoral sheath and its contents:Femoral arteryFemoral veinDeep inguinal

lymph nodes

NAVaL(Lateral to medial)

If right gluteus medius and minimus muscles are paralyzed, the unsupported left side of the pelvis falls (sags) instead of rising; normally, the pelvis rises.

Footdrop and loss of eversion

May cause sensory loss over lateral leg and dorsum of foot

CausesDirect trauma as

nerve passes superficially around neck of fibula

Structures That Pass Behind the Medial Malleolus Beneath the Flexor Retinaculum From Medial to Lateral

1.Tibialis posterior tendon 2.Flexor digitorum longus 3.Posterior tibial artery 4.Tibial nerve 5.Flexor hallucis longus( TOM DICK AND HARRY)

More common >60 years

In female for osteoporosis

Supplied mainly by Medial circumflex femoral artery by its retinacular branches

Blood supplied through round ligament of femur(br. Of Obturator) is grossly inadequate.

The lateral ligament is injured because it is much weaker than the medial ligament.

The anterior talofibular ligament part of the lateral ligament is most vulnerable and most commonly torn during ankle sprains.

During a sports medicine physical by a local family physician, a young woman is tested for stability of her joints before try-outs for the high school team. Which of the following ligaments is important in preventing forward displacement of the femur on the tibia when the weight-bearing knee is flexed?

A. Medial meniscusB. Tibial collateral ligamentC. Fibular collateral ligamentD.Posterior cruciate ligamentE. Anterior cruciate ligament

A patient arrives at the emergency department with a knife blade embedded in his gluteal region. Radiographic examination reveals that the tip of the knife is against the upper border of the greater sciatic foramen. Which of the following nerves is most likely to have been injured?

A. Inferior glutealB.ObturatorC.PudendalD.SciaticE.Superior gluteal

Intercostal space and vessels Breast Pleura lungs

Segmental innervation (dermatomes) of thoracic wall. Spinal nerve C5 supplies skin at the level of

the clavicles . Anteriorly, the dermatome immediately

inferior to the C5 dermatome is that of spinal nerve T1.

Dermatomes C6 to C7 are located mostly in the upper limbs

Dermatome T4 includes the nipple. Dermatome T10 includes the umbilicus.

Intercostal Nerve Block

This procedure, an intercostal nerve block, involves infiltration of the anesthetic around the intercostal nerve trunk and its collateral branches.

Indications Intercostal nerve block is indicated for repair

of lacerations of the thoracic and abdominal walls, for relief of pain in rib fractures, and to allow pain-free respiratory movements.

Procedure

Relations of Breast Blood vessels Lymphatic drainage

Breast Quadrants

Carcinoma of the Breast

Different parts of pleura Pleural reflection Recess:Costodiaphragmatic recess Thoracentesis Nerve supply

1. Costomediastinal recesses

2. Costodiaphragmatic recesses

MCL MAL Vertebral Lungs : 6th rib 8th rib 10th vert Pleura : 8th rib 10 th rib 12 th

vert

To obtain a sample of pleural fluid or to remove blood or pus or air

To avoid damage to intercostal nerve and vessels, needle is inserted superior to rib, high enough to avoid collateral branches

It is performed at Mid-Axillary Line, one or two intercostal spaces below the fluid level but not below the ninth intercostal space.

The ideal site is eighth, or ninth intercostal space, and this site avoids possible accidental puncture of the lung, liver, spleen, and diaphragm.

The parietal pleura is sensitive to pain, temperature, touch, and pressure and is supplied as follows:

The costal pleura is segmentally supplied by the intercostal nerves.

The mediastinal pleura is supplied by the phrenic nerve.

The diaphragmatic pleura is supplied over the domes by the phrenic nerve and around the periphery intercostal nerves.

Relations of lungs Impressions on medial surface of lungs Bronchopulmonary segment Trachea Blood vessels Nerve supply

1.Pulmonary artery

2. Two pulmonary veins

3. Main bronchus 4. Bronchial

vessels 5. Nerves and

lymphatics.

Has its own Bronchus Has its own Pulmonary

artery (Blue) Drains to multiple

pulmonary veins (Red) between segments

So, each segment has its own bronchus and artery but not its own vein

If food, liquids, or foreign bodies are aspirated, they often will lodge in the right mainstem bronchus.

Because right bronchus is wider and shorter and runs more vertically than left bronchus

Encountered by dentists Aspiration of piece of tooth, filling

material, or a small instrument.If the endotracheal tube used for intubation is inserted too far, it usually lodges in the right mainstem bronchus. This allows ventilation of the right lung, but leaves the left lung useless.

2 sets of Blood Supply

1.Pulmonary Vessels: for Gas Exchange

2. Bronchial Vessels: for blood supply to lung substance like any other organ

Your patient presents with pneumonia. Examination of lateral-view chest films reveals that the pneumonia is localized just inferior to the horizontal fissure. Where would the pneumonia most likely be localized?

 A. Inferior lobe of the left lungB. Inferior lobe of the right lungC. Middle lobe of the right lungD. Middle lobe of the left lungE. Superior lobe of the left lung

A 20-year-old man was stabbed in the back with a knife that just nicked his right lung halfway between its apex and diaphragmatic surface. Which part of the lung was most likely injured? 

A.  Middle lobeB. Inferior lobeC. Cardiac notchD. LingulaE.  Superior lobe

A thoracentesis is performed to aspirate an abnormal accumulation of fluid in a 28 year old patient with pleural effusion. A needle should be inserted at the mid axillary line between which of the following two ribs so as to avoid puncturing the lung

A.Ribs 2 and 4B.Ribs 4 and 6C.Ribs 6 and 8D.Ribs 8 and 10E.Ribs 10 and 12