TABLE OF CONTENTS

High-Yield Step 1
1. Subacromial Bursitis
2. Scapular Anastomoses
3. Lesion of Upper Limb Nerves

Anatomy 4.
5.
Upper Limb Fractures
Epicondylitis
6. Carpal Tunnel
7. Lumbar Puncture & Epidural Anesthesia
8. Abnormal Curvatures of the Spine & Intervertebral
D Disc Herniation
9. Avascular Necrosis of Femoral Head
10. Femoral Sheath and Hernia
11. Knee Joint Injuries
12. Avulsion Fracture of the Hip
13. Gluteal Region Injuries
14. Triceps Surae Injury
15. Fibular Neck Fracture
 TABLE OF CONTENTS

High-Yield Step 1
16. Ankle Injuries
17. Fracture of the Anterior Cranial Fossa
18. Cranial Malformations

Anatomy 19.
20.
Intracranial Hemorrhages
Infection & Thrombosis of the
Cavernous Sinus
21. Horner Syndrome
22. Median Cervical Cyst
23. Cricothyrotomy
24. Bell's Palsy
25. Testing of Extraocular Muscles
26. Blowout Fracture
27. Cranial Nerve Palsy
28. Infection of the Paranasal Sinuses
29. Gag Reflex
30. Carcinoma of the Breast
31. Cardiac Hypertrophy
 TABLE OF CONTENTS

High-Yield Step 1
32. Auscultation of the Heart Valves
33. Blood Supply of the Heart
34. Aspiration of Foreign Bodies, Bronchopulmonary

Anatomy S
35.
Segments
Lung
36. Pneumothorax
37. Anterior Abdominal Wall
38. Sliding Hiatal Hernia
39. Peptic Ulcers
40. Gallstones
41. Portal Hypertension
42. Meckel's Diverticulum
43. Appendicitis
44. Volvulus
45. Hirschsprung's Disease
46. Mesenteric Ischemia
47. Diseases of the Pancreas
 TABLE OF CONTENTS

High-Yield Step 1
48. Injury to the Diaphragm
49. Abdominal Aortic Aneurysm
50. Kidney Stones

Anatomy 51.
52.
Inguinal Hernias
Rectouterine Pouch
53. Varicocele
54. Hemorrhoids
55. Rupture of the Male Urethra
56. Cystocele
57. Prostate Tumors
58. Hydrocele & Hematocele of the Testes
59. Cryptorchidism
REVIEW OUTLINE

1. Causes & Symptoms

Subacromial
2. Painful Arc Syndrome
Bursitis
3. X-Ray Imaging
Subacromial Bursitis [Link]

Inflammation of the subacromial bursa caused by calcific supraspinatus tendinitis

Leads to painful arc syndrome – pain during 50-130° abduction

Knowledge Check [Link]

Which bursa can become irritated due to calcium deposits in the supraspinatus
tendon?

Explain the painful arc syndrome.

Knowledge Check [Link]

Which bursa can become irritated due to calcium deposits in the supraspinatus
tendon?

Subacromial bursa

Explain the painful arc syndrome.

Pain during 50–130° of abduction due to the supraspinatus tendon

being in intimate contact with the inferior surface of the acromion
References [Link]

Slide 2
• Shoulder: <a href="[Link] College</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• X-ray: <a href="[Link] <a
href="[Link] BY-SA 3.0 DE</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Subclavian a.

Arterial
Anastomoses 2. Axillary a.

around the
Scapula 3. Collateral circulation & direction of blood flow

4. Occlusion
Arterial Anastomoses around the Scapula [Link]

Subclavian a. Axillary a.
Arterial Anastomoses around the Scapula [Link]

Subclavian a. Axillary a.
Arterial Anastomoses around the Scapula [Link]

Subclavian a. Axillary a.
References [Link]

Slides 2-4: <a href="[Link] Häggström</a>,

Public domain, via Wikimedia Commons
OUTLINE

1. Upper Brachial Palsy (Erb-Duchenne Palsy)

● Cause
● Nerves affected
● Motor & sensory deficits
● Waiter’s tip position

2. Lower Brachial Palsy (Klumpke Paralysis)

● Cause
● Nerves affected
● Motor & sensory deficits
● Claw hand
● Ape hand

3. Musculocutaneous Nerve Injury

● Cause
● Nerve affected
● Motor & sensory deficits
Upper Brachial Palsy (Erb-Duchenne Palsy) [Link]

Caused by an excessive increase in the angle between the neck and shoulder

B C D T R
Upper Brachial Palsy (Erb-Duchenne Palsy) [Link]

Nerves Affected “Waiter’s Tip” Position

Dorsal scapular n. (C5) Suprascapular n. (C5-C6) Long thoracic n. (C5-C7)

Adducted
Musculocutaneous n. (C5-C7) Axillary n. (C5-C6) Medially shoulder
rotated arm

Levator
Extended
scapulae elbow

Flexed digits
(& wrist*)

Sensory Deficits
Lateral aspect of
upper limb
Biceps brachii

Brachialis Supraspinatus Teres minor

Infraspinatus
Lower Brachial Palsy (Klumpke Paralysis) [Link]

Occurs when limb is pulled superiorly (e.g. grabbing support when falling from height)

B C D T R
Lower Brachial Palsy (Klumpke Paralysis) [Link]

Nerves Affected Extension of MCP joints

Ulnar n. (C8-T1) Median n. (C5-T1) Flexion of IP joints

Claw Hand

Unable to abduct
or oppose thumb

Ape Hand

Sensory Deficits
Medial aspect of
upper limb & digits
Musculocutaneous Nerve Injury [Link]

Nerve Affected B C D T R

Musculocutaneous n. (C5-C7)

Coracobrachialis

Biceps brachii
Motor & Sensory Deficits
• Elbow flexion
• Forearm supination
• No sensation over lateral
Brachialis
forearm
Knowledge Check [Link]

A 32-year-old man fell off his roof and landed head first on his right shoulder. He
was unable to abduct his shoulder, his arm was medially rotated and elbow
extended along with numbness on the lateral aspect of his forearm. Which aspects
of the brachial plexus could possibly be injured?

A. C5-C6
B. C8-T1
C. Superior trunk
D. Inferior trunk
E. A&C
Knowledge Check [Link]

A 32-year-old man fell off his roof and landed head first on his right shoulder. He
was unable to abduct his shoulder, his arm was medially rotated and elbow
extended along with numbness on the lateral aspect of his forearm. Which aspects
of the brachial plexus could possibly be injured?

A. C5-C6
B. C8-T1
C. Superior trunk
D. Inferior trunk
E. A&C
Knowledge Check [Link]

A patient comes into the clinic with an extended metacarpophalangeal joint and
flexed interphalangeal joint at the 4th and 5th digits at rest. Which nerve is
affected?

A. Musculocutaneous nerve
B. Median nerve
C. Radial nerve
D. Ulnar nerve

Which muscles are being unopposed and causing this resting position?

A. Flexor carpi radialis & flexor carpi ulnaris

B. Flexor digitorum superficialis & profundus
C. Flexor digitorum superficialis & palmaris longus
D. Flexor carpi radialis & flexor digitorum profundus
E. All of the above
Knowledge Check [Link]

A patient comes into the clinic with an extended metacarpophalangeal joint and
flexed interphalangeal joint at the 4th and 5th digits at rest. Which nerve is
affected?

A. Musculocutaneous nerve
B. Median nerve
C. Radial nerve
D. Ulnar nerve

Which muscles are being unopposed and causing this resting position?

A. Flexor carpi radialis & flexor carpi ulnaris

B. Flexor digitorum superficialis & profundus
C. Flexor digitorum superficialis & palmaris longus
D. Flexor carpi radialis & flexor digitorum profundus
E. All of the above
References [Link]

Slides 2 & 4
• <a href="[Link] by User:Mikael Häggström via Wikimedia
Commons

Slide 3
• Waiter’s Tip Position: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Muscles:
<ahref="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 5
• Muscles: <a href="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons
• Claw Hand: <a href="[Link] <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• Ape Hand: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 6
• Brachial Plexus: <a href="[Link] by User:
Mikael Häggström via Wikimedia Commons
• Muscles: <a href="[Link] Vandyke
Carter</a>, Public domain, via Wikimedia Commons
REVIEW OUTLINE

1. Humeral Fractures
● Location
● Compromised innervation & arterial supply

2. Distal Radial Fractures

Upper Limb ● Smith’s fracture

● Colles fracture

Fractures 3. Scaphoid Fracture

● Cause
● Symptoms
● Compromised arterial supply

4. Boxer’s Fracture
● Cause
● Professional vs unskilled boxers
 Humeral Fractures [Link]

Surgical Neck
Subclavian a.
Midshaft
Axillary n. Axillary a.
Supracondylar Region
Humeral circumflex a.
Radial n.
Medial Epicondyle
Deep brachial a.

Brachial a.

Ulnar collateral a.

Median n.

Ulnar n.
Humeral Fractures [Link]

Surgical Neck Midshaft Supracondylar Region Medial Epicondyle

Distal Radial Fractures [Link]

Smith’s Fracture

Flexion fracture of the radius

Distal Radial Fractures [Link]

Colles Fracture

Extension fracture of the radius

Scaphoid Fracture [Link]

Scaphoid Fracture

Caused by falling onto palm when wrist is abducted

Pain in anatomical snuffbox
Often misdiagnosed as a sprained wrist
Avascular necrosis of proximal scaphoid

Radial a.
Boxer’s Fracture [Link]

Boxer’s Fracture

Fracture of the necks of the metacarpal bones

2nd & 3rd metacarpals in professional boxers, 4th & 5th metacarpals in unskilled boxers
Knowledge Check [Link]

A 45-year-old man presents with right shoulder pain, swelling, and difficulty
moving his shoulder after a free heavy weight lifting session at the gym. Which
structure on the humerus is fractured?

a. Shaft
b. Medial epicondyle
c. Supracondylar region
d. Surgical neck

Which nerve is more likely to be

compromised in this type of fracture?

a. Median nerve
b. Axillary nerve
c. Ulnar nerve
d. Radial nerve
Knowledge Check [Link]

A 45-year-old man presents with right shoulder pain, swelling, and difficulty
moving his shoulder after a free heavy weight lifting session at the gym. Which
structure on the humerus is fractured?

a. Shaft
b. Medial epicondyle
c. Supracondylar region
d. Surgical neck

Which nerve is more likely to be

compromised in this type of fracture?

a. Median nerve
b. Axillary nerve
c. Ulnar nerve
d. Radial nerve
Knowledge Check (ANSWER) [Link]

A patient falls on an outstretched hand and comes into the clinic two weeks later
because of persistent pain in the wrist/palm. Upon palpation, the patient presents
with deep tenderness in the anatomical snuffbox. You order an X-ray to confirm
your diagnosis. Find the fracture and name the carpal bone that is affected.

So – scaphoid
Long – lunate
To – triquetrum
Pinky – pisiform
Here – hamate
Comes – capitate
The – trapezoid
Thumb – trapezium

BONUS: Label the rest of the carpal

bones.
Knowledge Check (ANSWER) [Link]

A patient falls on an outstretched hand and comes into the clinic two weeks later
because of persistent pain in the wrist/palm. Upon palpation, the patient presents
with deep tenderness in the anatomical snuffbox. You order an X-ray to confirm
your diagnosis. Find the fracture and name the carpal bone that is affected.

So Tra
p
Long ez i
um
Tra
To Ha
ma
p ez o
id

C
ap
te
Pinky

i
ta

oid
te
Here i fo
rm

h
Pi s

ap
Comes etr
um

Sc
u te
Tri
q na
The Lu

Thumb

BONUS: Label the rest of the carpal

bones.
References [Link]

Slide 2
• Humerus: <a href="[Link] Public domain, via Wikimedia Commons
• Arterial Supply: <a href="[Link] College</a>, <a href="[Link] BY
3.0</a>, via Wikimedia Commons

Slide 3
• Surgical Neck: <a href="[Link] <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Shaft: <a href="[Link] Heilman, MD</a>, <a href="[Link] BY-SA 4.0</a>, via
Wikimedia Commons
• Supracondylar Region: <a href="[Link] Heilman, MD</a>, <a href="[Link] BY-SA 3.0</a>,
via Wikimedia Commons
• Medial Epicondyle: <a href="[Link] <a href="[Link]
BY-SA 4.0</a>, via Wikimedia Commons

Slide 4
• X-Ray: <a href="[Link] Trauma Limb Reconstr</a>, <a href="[Link] BY 4.0</a>,
via Wikimedia Commons
• Smith’s Fracture: [Link]

Slide 5
• X-Ray: <a href="[Link] Monfils</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Colles Fracture: [Link]

Slide 6
• Hand: <a href="[Link] Servier</a>, <a href="[Link]
sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
• X-Ray: <a href="[Link] Jarraya, Daichi Hayashi, Frank W. Roemer, Michel D. Crema, Luis Diaz,
Jane Conlin, Monica D. Marra, Nabil Jomaah, and Ali Guermazi</a>, <a href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 7
• Hand Punch: [Link]
• X-Ray: <a href="[Link] Philippe Lessard</a>,
<a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 8
• <a href="[Link]
<a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 9
• <a href="[Link] Heilman, MD</a>,
<a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

Medial & 1. Causes

Lateral 2. Affected Structures

Epicondylitis 3. Sensory & Motor Deficits

Medial Epicondylitis (Golfer’s Elbow) [Link]

Repeated forceful flexion of the wrist → inflammation of the common flexor tendon &
the medial epicondyle

Medial
epicondyle
of humerus

Anterior view
"-itis" = inflammation
Lateral Epicondylitis (Tennis Elbow) [Link]

Repeated forceful flexion & extension of the wrist → inflammation of the common
extensor tendon & the lateral epicondyle

*Supinator

Posterior view
"-itis" = inflammation
Knowledge Check [Link]

Golfer’s elbow is also known as _____ and occurs to due overuse of the ____
muscles of the wrist.

A. Medial epicondylitis; extensor

B. Lateral epicondylitis; extensor
C. Medial epicondylitis; flexor
D. Lateral epicondylitis; flexor

Explain the cause of lateral epicondylitis and what symptoms may present in a
patient.
Knowledge Check [Link]

Golfer’s elbow is also known as _____ and occurs to due overuse of the ____
muscles of the wrist.

A. Medial epicondylitis; extensor

B. Lateral epicondylitis; extensor
C. Medial epicondylitis; flexor
D. Lateral epicondylitis; flexor

Explain the cause of lateral epicondylitis and what symptoms may present in a
patient.

Repeated forceful flexion & extension of the wrist

Pain over lateral epicondyle that radiates down posterior forearm & wrist
References [Link]

Slide 2
• Muscles:
<ahref="[Link]
g">CFCF</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Arm: [Link]

Slide 3
• Muscles:
<ahref="[Link]
g">CFCF</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Arm: [Link]
• Woman Opening Door: [Link]
REVIEW OUTLINE

1. Causes

2. Nerve Affected

Carpal Tunnel 3. Sensory & Motor Deficits

Syndrome 4. Ape Hand

5. Phalen’s Maneuver
 Carpal Tunnel Syndrome [Link]

Normal Lunate Dislocation

↓ in size of the carpal tunnel due to inflammation, fluid
retention, infection, fractures or trauma to the wrist

Recurrent branch

Palmar cutaneous branch

Carpal Tunnel Syndrome [Link]

Ape Hand

Phalen’s Maneuver (Wrist Flexion Test)

Unable to abduct
or oppose thumb

Digital Cutaneous Branch

Palmar Cutaneous Branch

(unaffected)
Knowledge Check [Link]

During carpal tunnel syndrome, which nerve is affected?

In the hand, which muscles receive motor innervation from that nerve and how
would deficits present in a patient with carpal tunnel syndrome?

Who is more at risk for carpal tunnel syndrome, men or women? Why?
Knowledge Check [Link]

During carpal tunnel syndrome, which nerve is affected?

Median nerve

In the hand, which muscles receive motor innervation from that nerve and how
would deficits present in a patient with carpal tunnel syndrome?

Motor: opponens pollicis, abductor pollicis brevis, flexor pollicis brevis, lumbricals 1-2
→ loss of thumb opposition & abduction, thenar atrophy, reduced grip & pinch strength

Who is more at risk for carpal tunnel syndrome, men or women? Why?
Women are 3x more likely to suffer from carpal tunnel syndrome
→ Smaller carpal tunnel
→ Hormonal changes increasing fluid retention
Re eren e oo amp om

Slide 2
• Hand/Wrist: <a href="[Link] via Wikimedia
Commons
• X-Ray Normal: <a href="[Link]
Häggström</a>, CC0, via Wikimedia Commons
• X-Ray Dislocation: <a href="[Link] Heilman, MD</a>

Slide 3
• Muscles:
<ahref="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Ape Hand: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Phalen’s Maneuver: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Sensory Hand: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

2. Nerve Affected

Carpal Tunnel 3. Sensory & Motor Deficits

Syndrome 4. Ape Hand

5. Phalen’s Maneuver
REVIEW OUTLINE

Lumbar 1. Location – Vertebral Level, Space

Puncture & 2. Level of Spinal Cord & Cauda Equina

Epidural
3. Potential Complications (Lumbar
Anesthesia Puncture)
 Lumbar Puncture & Epidural Anesthesia [Link]

Lumbar Puncture Epidural Anesthesia

Epidural space

Subarachnoid space

- - - end of spinal cord (L2)

& beginning of cauda equina
 Lumbar Puncture [Link]

Potential Complications

↑ intracranial pressure + lumbar puncture = ↑ pressure gradient between posterior

fossa & spinal canal → herniation of cerebellar tonsils through foramen magnum
Knowledge Check [Link]

A 45-year-old woman comes into the clinic complaining of a fever, neck pain,
sleepiness, vomiting, and light sensitivity. Based on the symptoms, you suspect
meningitis and decide to perform a lumbar puncture.

At which vertebral level do you insert the needle and why?

In which space do you insert the needle and why?

Knowledge Check [Link]

A 45-year-old woman comes into the clinic complaining of a fever, neck pain,
sleepiness, vomiting, and light sensitivity. Based on the symptoms, you suspect
meningitis and decide to perform a lumbar puncture.

At which vertebral level do you insert the needle and why?

Below the spinal cord: L3-L4, L4-L5

In which space do you insert the needle and why?

Subarachnoid space
References [Link]

Slide 2
• Lumbar Puncture:
<ahref="[Link]
Research UK</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Epidural Anesthesia: [Link]

Slide 3
• Chiari Malformation: <a href="[Link] above</a>,
<ahref="[Link] BY 2.0</a>, via Wikimedia Commons
• MRI: <a href="[Link]
Chiari_malformation_and_herniated_cerebellum.jpg">Basket of Puppies</a>, <a href="[Link]
sa/3.0">CC BY-SA 3.0</a>, via Wikimedia Commons
REVIEW

Lumbar
Puncture &
Epidural
Anesthesia
REVIEW OUTLINE

Abnormal
Curvatures of 1. Types & Causes of Curvatures

the Spine & 2. Location & Direction of Herniation

Intervertebral
3. Herniation Complications
Disc Herniation
 Abnormal Curvatures of the Spine [Link]

Scoliosis
Complex lateral deviation or torsion

Caused by poliomyelitis,
leg-length discrepancy or hip disease

Normal Scoliosis
 Abnormal Curvatures of the Spine [Link]

Lordosis
Exaggeration of lumbar curvature

Caused by pregnancy, spondylolisthesis

or pot-belly

Normal Lordosis
 Abnormal Curvatures of the Spine [Link]

Kyphosis

Exaggeration of thoracic curvature

Caused by osteoporosis or disc degeneration

Normal Kyphosis
Herniated IV Disc [Link]

Causes
Degenerative changes to
annulus fibrosus

Sudden compression of
nucleus pulposus

Location & Direction

Most commonly in lumbar
& cervical spines

Occurs posterolaterally PLL

due to PLL
ALL
Herniated IV Disc [Link]

L1 nerve exiting intervertebral foramen

L2 nerve in lateral recess

Knowledge Check [Link]

An 85-year-old woman with osteoporosis comes into the clinic presenting with a
humpback due to an abnormal curvature of the thoracic spine. Which condition
does she present with?

a. Lordosis
b. Kyphosis
c. Scoliosis

A 29-year-old pregnant woman suffers from an exaggerated inward curve of the

lumbar spine. Which condition does she present with?

a. Lordosis
b. Kyphosis
c. Scoliosis
Knowledge Check [Link]

An 85-year-old woman with osteoporosis comes into the clinic presenting with a
humpback due to an abnormal curvature of the thoracic spine. Which condition
does she present with?

a. Lordosis
b. Kyphosis
c. Scoliosis

A 29-year-old pregnant woman suffers from an exaggerated inward curve of the

lumbar spine. Which condition does she present with?

a. Lordosis
b. Kyphosis
c. Scoliosis
Knowledge Check [Link]

Intervertebral discs often herniate in the cervical and lumbar spines. What is the
reasoning for this?

A 65-year-old man presents with low back pain, muscle weakness, and tingling
down the anterior and medial thigh. You order an MRI and confirm a disc herniation
at the level of L2-L3. Which spinal nerve is affected and why?
Knowledge Check [Link]

Intervertebral discs often herniate in the cervical and lumbar spines. What is the
reasoning for this?

Mobility: cervical & lumbar spines > thoracic spine

Forcible hyperextension of the neck (whiplash) = rupture disc

A 65-year-old man presents with low back pain, muscle weakness, and tingling
down the anterior and medial thigh. You order an MRI and confirm a disc herniation
at the level of L2-L3. Which spinal nerve is affected and why?

L5 affected – L4 exits through intervertebral

foramen & L5 located in lateral recess within spinal canal
 References [Link]

Slide 2
• Normal vs Scoliosis: <a
href="[Link]
Servier</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Scoliosis Patient & X-Ray: <ahref="[Link]
HR</a>, <a href="[Link] BY 2.0</a>, via Wikimedia Commons

Slide 3
• Normal vs Lordosis: <a
href="[Link]
Servier</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Lordosis Patient: <a href="[Link] CC0, via Wikimedia Commons

Slide 4
• Normal vs Kyphosis: <a
href="[Link]
Servier</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Kyphosis Patient: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 5
• Superior View of Disc: [Link]
• Sagittal View of Vertebral Column: <a href="[Link] Servier</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Scan: <a href="[Link]
>Φωτογραφία ασθενούς Δρ. Χαράλαμπου Γκούβα (Dr. Harrygouvas)</a>, Public domain, via Wikimedia Commons

Slide 6
• <a href="[Link] Nascari and
Alan Sved</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

Abnormal
Curvatures of 1. Types & Causes of Curvatures

the Spine & 2. Location & Direction of Herniation

Intervertebral
3. Herniation Complications
Disc Herniation
REVIEW OUTLINE

1. Causes
Avascular
Necrosis of 2. Disrupted Blood Supply

Femoral Head
3. X-Ray
Avascular Necrosis of Femoral Head [Link]

Acetabular branch
(a. to head of femur)

Obturator a.

Normal
Retinacular a.

Medial circumflex femoral a.

Lateral
circumflex Profunda femoris a.
femoral a.

Transcervical fracture

Osteoporosis
Knowledge Check [Link]

An 84-year-old woman comes into the clinic complaining of groin pain. She tells the doctor that she recently
underwent surgical correction of a femur fracture and that her surgeon was concerned with avascular
necrosis of the femoral head.

When fractured, which structure is associated with this condition?

A. Greater trochanter
B. Head of the femur
C. Femoral neck
D. Lesser trochanter

Which arteries are affected and where do they branch from?

Which artery still supplies the head of the femur but may be inadequate?
Knowledge Check [Link]

An 84-year-old woman comes into the clinic complaining of groin pain. She tells the doctor that she recently
underwent surgical correction of a femur fracture and that her surgeon was concerned with avascular
necrosis of the femoral head.

When fractured, which structure is associated with this condition?

A. Greater trochanter
B. Head of the femur
C. Femoral neck
D. Lesser trochanter

Which arteries are affected and where do they branch from?

Retinacular arteries that branch of medial circumflex femoral artery

Which artery still supplies the head of the femur but may be inadequate?

Acetabular branch of the obturator artery (artery to the head of the femur)
References [Link]

Slide 2
• Femur: <a href="[Link]
[Link]">Laboratoires Servier</a>, <a href="[Link] BY-SA
3.0</a>, via Wikimedia Commons
• X-Ray: <a href="[Link] original
uploader was Eucla at French Wikipedia.</a>, <a href="[Link] BY-SA
3.0</a>, via Wikimedia Commons
• Normal vs Osteoporosis: <a href="[Link]
[Link]">Laboratoires Servier</a>, <a href="[Link] BY-SA
3.0</a>, via Wikimedia Commons
Knowledge Check [Link]

The femoral sheath is formed by the continuation of which abdominal fascia?

What are the contents of the femoral sheath from lateral to medial?
Knowledge Check [Link]

The femoral sheath is formed by the continuation of which abdominal fascia?

Transversalis fascia

What are the contents of the femoral sheath from lateral to medial?

Femoral artery – femoral vein – femoral canal

Knowledge Check [Link]

Why are femoral hernias more common in females than males?

Which artery is vulnerable during a surgical femoral hernia repair? Why?

Knowledge Check [Link]

Why are femoral hernias more common in females than males?

Females have a wider pelvis leading to a larger femoral canal

Which artery is vulnerable during a surgical femoral hernia repair? Why?

Aberrant (accessory) obturator artery due to it’s proximity to the femoral canal
References [Link]

Slide 2
• <a href="[Link] Vandyke Carter</a>, Public domain, via
Wikimedia Commons

Slide 3
• Femoral Triangle: <a href="[Link] Vandyke Carter</a>, Public
domain, via Wikimedia Commons
• Femoral Hernia: <a
href="[Link]
femoral/</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Femoral vs Inguinal Hernia: <a
href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 4
• Femoral Hernia: <a
href="[Link]
femoral/</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Femoral vs Inguinal Hernia: <a
href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Unhappy Triad

2. Rupture of Cruciate Ligaments

Knee Joint
Injuries
3. Suprapatellar, Prepatellar & Infrapatellar Bursae

4. Knee Jerk Reflex

Unhappy Triad [Link]

Valgus force
Unhappy Triad [Link]
Rupture of Cruciate Ligaments [Link]

ACL
Other Causes of PCL Tears
PCL Direct hit to knee
Person lands on flexed
knee

Anterior View Posterior View

Rupture of Cruciate Ligaments [Link]

Anterior Drawer Test

Posterior Drawer Test

Normal ACL Tear
Suprapatellar, Prepatellar & Infrapatellar Bursae [Link]

Prepatellar Bursitis

Intra-arti
cular
injection
Knee Jerk Reflex [Link]

Tests spinal nerves L2-L4 through afferents

and efferent limbs of the femoral nerve

Patellar
ligament

⎻ Sensory neuron
⎻ Interneuron
⎻ Excitatory efferent neuron
⎻ Inhibitory efferent neuron
Knowledge Check [Link]

A 21-year-old soccer player collided with his teammate, causing an extensive valgus force on
his right knee. After physical examination, you confirm that he is displaying a positive anterior
drawer test and a positive valgus stress test.

Which two ligaments were most likely injured/torn?

• ACL
• PCL
• MCL
• LCL

Based on the anatomy of the MCL, which other structure was most likely
compromised?

A. LCL
B. Lateral meniscus
C. PCL
D. Medial meniscus
Knowledge Check [Link]

A 21-year-old soccer player collided with his teammate, causing an extensive valgus force on
his right knee. After physical examination, you confirm that he is displaying a positive anterior
drawer test and a positive valgus stress test.

Which two ligaments were most likely injured/torn?

• ACL
• PCL
• MCL
• LCL

Based on the anatomy of the MCL, which other structure was most likely
compromised?

A. LCL
B. Lateral meniscus
C. PCL
D. Medial meniscus
Knowledge Check [Link]

You are an emergency response worker at a Lake Tahoe ski resort. During your
shift one Saturday afternoon, you respond to a skier who hit a rock on the slops.
The skier is grasping their right knee, complaining of sharp pain in the knee joint.
After physical examination, you observe that there is increased anterior
translation of the femur relative to the tibia in his injured leg.

Based on the translation of the leg bones, which ligament was most likely injured?

A. ACL
B. PCL
C. MCL
D. LCL
Knowledge Check [Link]

You are an emergency response worker at a Lake Tahoe ski resort. During your
shift one Saturday afternoon, you respond to a skier who hit a rock on the slops.
The skier is grasping their right knee, complaining of sharp pain in the knee joint.
After physical examination, you observe that there is increased anterior
translation of the femur relative to the tibia in his injured leg.

Based on the translation of the leg bones, which ligament was most likely injured?

A. ACL
B. PCL
C. MCL
D. LCL
Knowledge Check [Link]

Why are intra-articular injections normally inserted laterally into the suprapatellar bursa?

During a physical examination, you use the reflex hammer to assess the patient’s knee jerk
reflex.

A. Where do you tap the reflex hammer?

B. Under normal circumstances, what action will occur at the knee joint?

C. Which spinal nerves are being tested?

Knowledge Check [Link]

Why are intra-articular injections normally inserted laterally into the suprapatellar bursa?

Suprapatellar bursa is a superior extension of the synovial cavity

During a physical examination, you use the reflex hammer to assess the patient’s knee jerk
reflex.

A. Where do you tap the reflex hammer?

Patellar ligament

B. Under normal circumstances, what action will occur at the knee joint?

Extension of the knee

C. Which spinal nerves are being tested?

L2-L4
REVIEW OUTLINE

Avulsion 1. Avulsion Fracture

Fracture of 2. Hamstring Muscles

the Hip Bone

& Hamstring 3. Clinical Manifestations
Muscles
 Avulsion Fracture of the Hip Bone & Hamstring Muscles [Link]

Occurs where muscles are attached (e.g. ischial tuberosity for hamstring muscles)

Clinical Manifestations
Hip or posterior thigh pain
Ischial Abnormal gait
tuberosity Swelling of buttocks
Impaired hip extension & knee flexion

Biceps femoris
Actions Innervation
Hip extension Tibial n. except for
Semitendinosus & knee flexion short head of
biceps femoris
(common fibular n.)
Semimembranosus
Knowledge Check [Link]

What is an avulsion fracture?

An avulsion fracture of the ischial tuberosity would impair which group of

muscles? Which actions would be impaired?
Knowledge Check [Link]

What is an avulsion fracture?

When a piece of bone that is attached to a tendon or ligament separates from the
rest of the bone

An avulsion fracture of the ischial tuberosity would impair which group of

muscles? Which actions would be impaired?

Impairs the hamstring muscles (biceps femoris, semitendinosus,

semimembranosus)
→ Impaired hip extension & knee flexion
References [Link]

Slide 2
• <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

Avulsion 1. Avulsion Fracture

Fracture of 2. Hamstring Muscles

• Actions
the Hip Bone • Innervation

& Hamstring 3. Clinical Manifestations

Muscles
REVIEW OUTLINE

1. Piriformis Syndrome

Gluteal 2. Sciatic Nerve Injury

Region
Injuries
3. Superior Gluteal Nerve Injury

4. Inferior Gluteal Nerve Injury

Piriformis Syndrome [Link]

Piriformis

inflammation/spasm compressing the sciatic n.

Symptoms similar to sciatica

Pain, tingling, numbness in buttocks
that can extend down posterior thigh,
leg & foot
Increased pain when walking up stairs
or after prolonged sitting

Sciatic n.
Landmark
Superior gluteal n./a./v.
Piriformis

Inferior gluteal n./a./v.

Sciatic Nerve Injury [Link]

Sciatica Improper Gluteal Injection Posterior Hip Dislocation

Safe area

Herniated IV disc
compressing the
Gluteus maximus
sciatic nerve
Gluteus medius

Sciatic n.
Sciatic Nerve Injury [Link]

Sciatic n.
Weakened hip extension & knee flexion
Posterior thigh
Hamstring portion of
adductor magnus Foot Drop

Tibial n.
Inability to
Posterior leg dorsiflex foot
Intrinsic muscles of
the foot

Common fibular n.

Anterior & lateral leg Flail Foot (inability to dorsiflex

Intrinsic muscles of & plantarflex foot)
the foot
Superior Gluteal Nerve Injury [Link]

Trendelenburg Gait

Superior gluteal n.

Gluteus medius

Gluteus minimus

Lose the ability to pull the

pelvis up & abduct the thigh

Pelvis drops on contralateral

side of injury

Causes
Surgery
Greater trochanter fracture
Posterior hip dislocation
Poliomyelitis
Inferior Gluteal Nerve Injury [Link]

Inferior gluteal n. Weakened hip extension

Gluteus maximus Most noticeable when

climbing stairs or standing
from seated

Causes
Surgery
Posterior hip dislocation
Knowledge Check [Link]

A patient presents to your clinic complaining of “pins and needles” in her toes and
sole of her left foot, and altered sensation (paresthesia) in her left calf.
Additionally, she admits that she is experiencing a sharp pain in the center of her
buttocks. You determine that she is suffering from piriformis syndrome.

1. Identify the function of the piriformis muscle.

A. Internal rotation of the hip

B. Hip extension
C. External rotation of the hip
D. Hip abduction
E. Hip flexion
Knowledge Check [Link]

A patient presents to your clinic complaining of “pins and needles” in her toes and
sole of her left foot, and altered sensation (paresthesia) in her left calf.
Additionally, she admits that she is experiencing a sharp pain in the center of her
buttocks. You determine that she is suffering from piriformis syndrome.

1. Identify the function of the piriformis muscle.

A. Internal rotation of the hip

B. Hip extension
C. External rotation of the hip
D. Hip abduction
E. Hip flexion
Knowledge Check [Link]

2. Piriformis syndrome is a result of inflammation or spasm of the piriformis

muscle, ultimately causing compression of which nerve?

A. Superior gluteal nerve

B. Inferior gluteal nerve
C. Nerve to piriformis
D. Nerve to quadratus femoris
E. Sciatic nerve

3. The piriformis muscle also serves as a landmark for which two nerves? Select
all that apply.

• Superior gluteal nerve

• Inferior gluteal nerve
• Nerve to piriformis
• Nerve to quadratus femoris
• Pudendal nerve
Knowledge Check [Link]

2. Piriformis syndrome is a result of inflammation or spasm of the piriformis

muscle, ultimately causing compression of which nerve?

A. Superior gluteal nerve

B. Inferior gluteal nerve
C. Nerve to piriformis
D. Nerve to quadratus femoris
E. Sciatic nerve

3. The piriformis muscle also serves as a landmark for which two nerves? Select
all that apply.

• Superior gluteal nerve

• Inferior gluteal nerve
• Nerve to piriformis
• Nerve to quadratus femoris
• Pudendal nerve
Knowledge Check [Link]

Based on the anatomy of the gluteal region, which quadrant is safest to administer intragluteal
injections?

A. Superior lateral quadrant

B. Superior medial quadrant
C. Inferior lateral quadrant
D. Inferior medial quadrant

One week after you administered an intragluteal injection, your patient returns complaining of
weakness “in his right hip”. You observe him walking and notice that he displays ‘hip drop’ on
his left side during gait.

1. Which muscles are responsible for stabilizing the pelvis during gait? Select all that apply.

• Gluteus maximus
• Piriformis
• Gluteus medius
• Tensor fascia latae
• Gluteus minimus
• Quadratus femoris
Knowledge Check [Link]

Based on the anatomy of the gluteal region, which quadrant is safest to administer intragluteal
injections?

A. Superior lateral quadrant

B. Superior medial quadrant
C. Inferior lateral quadrant
D. Inferior medial quadrant

One week after you administered an intragluteal injection, your patient returns complaining of
weakness “in his right hip”. You observe him walking and notice that he displays ‘hip drop’ on
his left side during gait.

1. Which muscles are responsible for stabilizing the pelvis during gait? Select all that apply.

• Gluteus maximus
• Piriformis
• Gluteus medius
• Tensor fascia latae
• Gluteus minimus
• Quadratus femoris
Knowledge Check [Link]

2. Which nerve was most likely damaged during the intragluteal injection,
ultimately leading to the gait deficits?

A. Femoral nerve
B. Nerve to piriformis
C. Superior gluteal nerve
D. Inferior gluteal nerve
E. Sciatic nerve

3. The clinical sign that the patient is presenting with is known as:

A. Piriformis syndrome
B. Trendelenburg gait
C. Ataxia
Knowledge Check [Link]

2. Which nerve was most likely damaged during the intragluteal injection,
ultimately leading to the gait deficits?

A. Femoral nerve
B. Nerve to piriformis
C. Superior gluteal nerve
D. Inferior gluteal nerve
E. Sciatic nerve

3. The clinical sign that the patient is presenting with is known as:

A. Piriformis syndrome
B. Trendelenburg gait
C. Ataxia
Knowledge Check [Link]

You are working the night shift when a patient who was a passenger in a car
accident comes to the emergency room. Upon examination, you determine that
they are suffering from a posterior hip dislocation. Which nerves can be injured as
a result of the hip dislocation? Select all that apply.

• Superior gluteal nerve

• Inferior gluteal nerve
• Nerve to piriformis
• Nerve to quadratus femoris
• Pudendal nerve
Knowledge Check [Link]

You are working the night shift when a patient who was a passenger in a car
accident comes to the emergency room. Upon examination, you determine that
they are suffering from a posterior hip dislocation. Which nerves can be injured as
a result of the hip dislocation? Select all that apply.

• Superior gluteal nerve

• Inferior gluteal nerve
• Nerve to piriformis
• Nerve to quadratus femoris
• Pudendal nerve
References [Link]

Slide 2
• <a href="[Link] Roberts</a>, <a
href="[Link] BY 2.0</a>, via Wikimedia Commons

Slide 3
• Sciatica: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Gluteal Injection: <a href="[Link] Johannes Sobotta</a>, Public domain, via
Wikimedia Commons
• Posterior Dislocation: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 4
• Nerves: <a href="[Link] Vandyke Carter</a>, Public domain, via Wikimedia Commons
• Foot Drop: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 5
• Muscles: <a href="[Link] College</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• Tredelenburg Gait: <a href="[Link] Bhimji</a>, <a
href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 6
• <a href="[Link] Roberts</a>, <a
href="[Link] BY 2.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Piriformis Syndrome
• Cause
• Symptoms
• Landmarks

Gluteal 2. Sciatic Nerve Injury

• Cause
• Symptoms
Region • Other implicated structures

Injuries 3. Superior Gluteal Nerve Injury

• Causes
• Symptoms
• Trendelenburg gait

4. Inferior Gluteal Nerve Injury

• Causes
• Symptoms
REVIEW OUTLINE

1. Rupture of the Calcaneal (Achilles) Tendon

Injury to
Triceps Surae
Muscle 2. Injury to the Tibial Nerve in the Popliteal Fossa
Rupture of the Calcaneal (Achilles) Tendon [Link]

Triceps Surae Muscle Innervation

Tibial n.
Gastrocnemius (2 heads)

Soleus Calcaneal (Achilles) tendon

Plantaris (may be absent)

Ruptured Normal
Clinical Manifestations

Inability to plantarflex the

foot

Pain & swelling around

heel/ankle

Inability to ”push off”

injured leg while walking
Injury to Tibial Nerve in the Popliteal Fossa [Link]

Clinical Manifestations

• Inability to plantarflex the foot &

weakened inversion*

• Inability to stand on toes

• Calcaneovalgus
o Opposing muscles dorsiflex & evert
the foot
▪ Tibialis anterior*, EHL, EDL
(dorsiflexion)
▪ Fibularis longus & brevis (eversion)
Knowledge Check [Link]

A patient presents to your clinic complaining of painful swelling in the distal calf.
Upon physical examination, they are unable to plantar flex at the ankle.

1. Which tendon was likely ruptured?

A. Tibialis posterior
B. Calcaneal
C. Fibularis longus
D. Tibialis anterior
Knowledge Check [Link]

A patient presents to your clinic complaining of painful swelling in the distal calf.
Upon physical examination, they are unable to plantar flex at the ankle.

1. Which tendon was likely ruptured?

A. Tibialis posterior
B. Calcaneal
C. Fibularis longus
D. Tibialis anterior
Knowledge Check [Link]

2. The calcaneal (Achilles) tendon contains tendons from the triceps surae
muscle. Which 3 muscles make up the tricep surae structures? Select all that
apply.

• Medial head of gastrocnemius

• Lateral head of gastrocnemius
• Plantaris
• Soleus
• Tibialis posterior

3. The triceps surae muscles are innervated by which nerve?

A. Sciatic nerve
B. Common fibular nerve
C. Deep fibular nerve
D. Superficial fibular nerve
E. Tibial nerve
Knowledge Check [Link]

2. The calcaneal (Achilles) tendon contains tendons from the triceps surae
muscle. Which 3 muscles make up the tricep surae structures? Select all that
apply.

• Medial head of gastrocnemius

• Lateral head of gastrocnemius
• Plantaris
• Soleus
• Tibialis posterior

3. The triceps surae muscles are innervated by which nerve?

A. Sciatic nerve
B. Common fibular nerve
C. Deep fibular nerve
D. Superficial fibular nerve
E. Tibial nerve
Knowledge Check [Link]

A patient presents with a Baker’s cyst (fluid-filled swelling at the back of the knee)
causing compression of the tibial nerve within the popliteal fossa.

1. Which muscles could possibly be affected in this case? Select all that apply.

• Plantarflexors
• Dorsiflexors
• Evertors
• Invertors

2. What position will the foot be in if those muscles aren’t receiving proper
innervation?
Knowledge Check [Link]

A patient presents with a Baker’s cyst (fluid-filled swelling at the back of the knee)
causing compression of the tibial nerve within the popliteal fossa.

1. Which muscles could possibly be affected in this case? Select all that apply.

• Plantarflexors
• Dorsiflexors
• Evertors
• Invertors

2. What position will the foot be in if those muscles aren’t receiving proper
innervation?

Dorsiflexed & elevated

References [Link]

Slide 2
• Ruptured Tendon: <a href="[Link]
Da Oger</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia
Commons
• Calf Muscles: <a href="[Link] Vandyke Carter</a>, Public
domain, via Wikimedia Commons

Slide 3
• Popliteal Fossa: <a href="[Link] Johannes Sobotta</a>,
Public domain, via Wikimedia Commons
• Tibial Nerve: <a href="[Link] Vandyke Carter</a>, Public
domain, via Wikimedia Commons
REVIEW OUTLINE

1. Rupture of the Calcaneal (Achilles) Tendon

• Muscles of the Triceps Surae
Injury to • Innervation to the Triceps Surae
• Clinical Manifestations
Triceps Surae
Muscle 2. Injury to the Tibial Nerve in the Popliteal Fossa
• Clinical Manifestations
REVIEW OUTLINE

1. Affected Nerves

Fracture of 2. Affected Muscles

the Fibular 3. Foot Drop

Neck 4. X-Ray Imaging

Fracture of the Fibular Neck [Link]

Common fibular (peroneal) n.

Superficial fibular (peroneal) n.

Deep fibular (peroneal) n.

Fibula

Tibia
Fracture of the Fibular Neck [Link]

Superficial fibular (peroneal) n.

inability to evert the foot & extend toes

Deep fibular (peroneal) n.

inability to dorsiflex the foot & extend toes

Foot Drop
Fracture of the Fibular Neck [Link]
Knowledge Check [Link]

You are working at an outpatient clinic when a 64-year-old woman presents with
an altered gait. She is displaying an inability to lift the foot off the ground during
the swing phase of gait. While taking her history, she indicates that she suffered
from a proximal fibular fractures 6 months ago.

Based on the patient’s history, the fibular fracture most likely will lead to damage
to which nerve?

A. Sciatic nerve
B. Common fibular nerve
C. Deep fibular nerve
D. Superficial fibular nerve
E. Tibial nerve
Knowledge Check [Link]

You are working at an outpatient clinic when a 64-year-old woman presents with
an altered gait. She is displaying an inability to lift the foot off the ground during
the swing phase of gait. While taking her history, she indicates that she suffered
from a proximal fibular fractures 6 months ago.

Based on the patient’s history, the fibular fracture most likely will lead to damage
to which nerve?

A. Sciatic nerve
B. Common fibular nerve
C. Deep fibular nerve
D. Superficial fibular nerve
E. Tibial nerve
Knowledge Check [Link]

2. The common fibular nerve supplies which compartment of the leg? Select all
that apply.

• Anterior
• Posterior
• Lateral

3. The patient’s foot drop is a result of an inability to do which actions?

• Dorsiflexion
• Plantarflexion
• Eversion
• Inversion
Knowledge Check [Link]

2. The common fibular nerve supplies which compartment of the leg? Select all
that apply.

• Anterior
• Posterior
• Lateral

3. The patient’s foot drop is a result of an inability to do which actions?

• Dorsiflexion
• Plantarflexion
• Eversion
• Inversion
References [Link]

Slide 2
• Bones: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Muscles: <a
href="[Link]
Stax</a>, <a href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 3
• Muscles: <a
href="[Link]
Stax</a>, <a href="[Link] BY 4.0</a>, via Wikimedia Commons
• Foot Drop: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 4
• <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Affected Nerves

Fracture of 2. Affected Muscles

the Fibular 3. Foot Drop

Neck 4. X-Ray Imaging

REVIEW OUTLINE

1. Ankle Sprains

Ankle Joint
Injuries 2. Pott’s Fracture

3. Ankle Jerk Reflex

Ankle Sprains [Link]

Most common ankle injury

• Inversion injury with twisting of the weight-bearing plantarflexed foot

Anterior talofibular ligament

Calcaneofibular ligament

Posterior talofibular ligament

Fracture of the
lateral malleolus
Pott’s Fracture [Link]

• Forced inversion of the foot avulses

the lateral malleolus
Pott’s Fracture [Link]

Forced eversion of the foot causing a fracture of the fibula or medial malleolus

Fracture of the
medial malleolus

Fibular fracture

Tear of medial
ligament

Medial (deltoid) ligament

Ankle Jerk Reflex [Link]

Also known as the calcaneal tendon reflex or triceps surae reflex

Tests spinal nerves S1-S2 through afferents and efferent limbs of the
tibial nerve

Calcaneal/Achilles
tendon

Tibialis anterior
Triceps surae

⎻ Sensory neuron
⎻ Interneuron
⎻ Excitatory efferent neuron
⎻ Inhibitory efferent neuron
Knowledge Check [Link]

A skydiver was returning to the ground when his parachute was delayed when
opening. As a results, his landing was much more forceful than intended. The large
force of his landing caused exaggerated inversion of his right ankle.

Based on the mechanism of injury, which ligament was most likely injured?

A. Anterior talofibular ligament

B. Posterior talofibular ligament
C. Calcaneofibular ligament
D. Anterior interior tibiofibular ligament
E. Talocalcaneal ligament
Knowledge Check [Link]

A skydiver was returning to the ground when his parachute was delayed when
opening. As a results, his landing was much more forceful than intended. The large
force of his landing caused exaggerated inversion of his right ankle.

Based on the mechanism of injury, which ligament was most likely injured?

A. Anterior talofibular ligament

B. Posterior talofibular ligament
C. Calcaneofibular ligament
D. Anterior interior tibiofibular ligament
E. Talocalcaneal ligament
Knowledge Check [Link]

A football player was tackled by his opponent. The force of the collision caused a
valgus force on the player’s ankle, causing excessive eversion of the foot and an
upper fibular fracture.

Based on the mechanism of injury causing excessive eversion, which ligament

was most likely torn?

A. Anterior talofibular ligament

B. Posterior talofibular ligament
C. Calcaneofibular ligament
D. Medial (deltoid) ligament
Knowledge Check [Link]

A football player was tackled by his opponent. The force of the collision caused a
valgus force on the player’s ankle, causing excessive eversion of the foot and an
upper fibular fracture.

Based on the mechanism of injury causing excessive eversion, which ligament

was most likely torn?

A. Anterior talofibular ligament

B. Posterior talofibular ligament
C. Calcaneofibular ligament
D. Medial (deltoid) ligament
Knowledge Check [Link]

During a physical examination, you use the reflex hammer to assess the patient’s
ankle jerk reflex.

A. Where do you tap the reflex hammer?

B. Under normal circumstances, what action will occur at the ankle joint?

C. Which spinal nerves are being tested?

Knowledge Check [Link]

During a physical examination, you use the reflex hammer to assess the patient’s
ankle jerk reflex.

A. Where do you tap the reflex hammer?

Calcaneal/Achilles tendon

B. Under normal circumstances, what action will occur at the ankle joint?

Plantarflexion of the ankle

C. Which spinal nerves are being tested?

S1-S2
References [Link]

Slide 2
• <a href="[Link]
Servier</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia
Commons

Slide 3
• <a href="[Link] <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 4
• Achilles Tendon: <a href="[Link] Da
Oger</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Reflex Arc: <a href="[Link] Nascari and Alan
Sved</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Ankle Sprains
• Cause

Ankle Joint
• Implicated ligaments

Injuries 2. Pott’s Fracture

• Cause
• Implicated ligaments & structures

3. Ankle Jerk Reflex

REVIEW OUTLINE

1. Foramina of the Anterior Cranial Fossa

Fracture of 2. Contents of the Cribriform Plate
Anterior 3. Causes

Cranial Fossa 4. Clinical Presentation

Fracture of the Anterior Cranial Fossa [Link]

Olfactory nerves (CN I)

Causes
• Blunt trauma or direct blow to head, penetrating injuries

Clinical Presentation
• Anosmia (loss of smell)
• Epistaxis (nosebleeds)
• Periorbital bruising (raccoon eyes)
• CSF rhinorrhea
• Vision disturbances

Foramen
cecum
Sagittal View

Cribriform
plate

Superior View
Knowledge Check [Link]

1. Name the foramina within the anterior cranial fossa. Which structures are vulnerable to
injury during a fracture of the anterior cranial fossa?
Knowledge Check [Link]

1. Name the foramina within the anterior cranial fossa. Which structures are vulnerable to
injury during a fracture of the anterior cranial fossa?

Foramen cecum, cribriform plate of the ethmoid bone

Olfactory nerve (CN I), optic nerve (CN II),

arteries contributing to
Kiesselbach’s plexus

Foramen
cecum

Cribriform
plate
References [Link]

Slide 2 & 4
• Superior view of internal skull: image created by [Link]
• Blood vessels: <a href="[Link] Johannes
Sobotta</a>, Public domain, via Wikimedia Commons
• Olfactory nerves: <a href="[Link] J.
Lynch, medical illustrator</a>, <a href="[Link] BY 2.5</a>, via
Wikimedia Commons
REVIEW OUTLINE

1. Foramina of the Anterior Cranial Fossa

Fracture of 2. Contents of the Cribriform Plate
Anterior 3. Causes

Cranial Fossa 4. Clinical Presentation

REVIEW OUTLINE

1. Fontanelles

2. Sutures of the Skull

3. Sagittal Craniosynostosis &

Cranial Scaphocephaly

Malformations 4. Coronal Craniosynostosis &

Brachycephaly

5. Coronal Craniosynostosis &

Anterior Plagiocephaly

6. Lambdoid Craniosynostosis &

Posterior Plagiocephaly
Fontanelles [Link]

Lateral View of Newborn Skull

Sutures of the Skull [Link]

Lambda
Pterion

Coronal suture
Lambdoid suture

Squamous suture
Bregma

Sagittal Lateral View

suture

Superior View Posterior View

Fontanelles [Link]

Sagittal Craniosynostosis & Scaphocephaly Anterior

fontanelle
• Premature closing of sagittal suture resulting in
long, narrow, wedge-shaped cranium with
frontal bossing
Sagittal
suture

Posterior
fontanelle

Superior View

Lateral View Superior View

Fontanelles [Link]

Coronal Craniosynostosis & Brachycephaly Anterior

fontanelle
• Premature closing of both coronal sutures
resulting in flat forehead and high tower-like
cranium
Coronal
suture

Posterior
fontanelle

Superior View

Anterior View Lateral View

Fontanelles [Link]

Coronal Craniosynostosis & Anterior Plagiocephaly Anterior

fontanelle
• Premature closing of coronal suture on one side
resulting in flat forehead on affected side, frontal
bossing on unaffected side, Harlequin deformity
Coronal
suture

Posterior
fontanelle

Superior View

Superior View
Anterior View
Fontanelles [Link]

Lambdoid Craniosynostosis & Posterior Plagiocephaly Anterior

fontanelle
• Premature closing of lambdoid suture on one side
resulting in frontal and occipital bossing, trapeze
appearance from superior view
Lambdoid
suture

Posterior
fontanelle

Superior View

Superior View Posterior View

Knowledge Check [Link]

1. A newborn infant has a large anterior fontanelle that remains open for a longer duration
than expected. Physical examination reveals a somewhat elongated head shape. The sagittal
suture appears prematurely closed. Which cranial malformation is most likely responsible
for this presentation?

a) Anterior plagiocephaly
b) Brachycephaly
c) Posterior plagiocephaly
d) Scaphocephaly

2. A 9-month-old infant is brought to the clinic with a visibly flattened forehead and a high
and wide cranium. The coronal sutures appear prematurely fused. Which cranial
malformation is most likely responsible for this presentation?

a) Anterior plagiocephaly
b) Brachycephaly
c) Posterior plagiocephaly
d) Scaphocephaly
Knowledge Check [Link]

1. A newborn infant has a large anterior fontanelle that remains open for a longer duration
than expected. Physical examination reveals a somewhat elongated head shape. The sagittal
suture appears prematurely closed. Which cranial malformation is most likely responsible
for this presentation?

a) Anterior plagiocephaly
b) Brachycephaly
c) Posterior plagiocephaly
d) Scaphocephaly

2. A 9-month-old infant is brought to the clinic with a visibly flattened forehead and a high
and wide cranium. The coronal sutures appear prematurely fused. Which cranial
malformation is most likely responsible for this presentation?

a) Anterior plagiocephaly
b) Brachycephaly
c) Posterior plagiocephaly
d) Scaphocephaly
References [Link]

Slide 2
• <a href="[Link] College</a>,
<a href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 3
• Skull images created by [Link]

Slide 4-7
• Superior view of fontanelles: <a
href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Head drawings made by Gabriella Alagha

Slide 9
• Head drawings made by Gabriella Alagha
REVIEW OUTLINE

1. Fontanelles

2. Sutures of the Skull

3. Sagittal Craniosynostosis &

Cranial Scaphocephaly

Malformations 4. Coronal Craniosynostosis &

Brachycephaly

5. Coronal Craniosynostosis &

Anterior Plagiocephaly

6. Lambdoid Craniosynostosis &

Posterior Plagiocephaly
REVIEW OUTLINE

1. Epidural Hemorrhage
Intracranial 2. Subdural Hemorrhage
Hemorrhages 3. Subarachnoid Hemorrhage
Intracranial Hemorrhages [Link]

Epidural hemorrhage Subdural hemorrhage

Dura mater

Arachnoid mater
Intracerebral
Pia mater hemorrhage

Subarachnoid
hemorrhage

Frontal/Coronal View
Intracranial Hemorrhages [Link]

Epidural hemorrhage

Middle
meningeal
artery

Frontal View
Clinical Presentation
• Loss of consciousness followed by
lucid interval (apparent normalcy)
• Unequal pupil size
• Headaches, nausea, vomiting,
seizures, vision disturbances
Intracranial Hemorrhages [Link]

Subdural hemorrhage
Bridging veins

Frontal View
Clinical Presentation
• Undetected initially → increased
intracranial pressure → herniation of
brain through foramen magnum
• Headaches, nausea, vomiting,
seizures, vision disturbances
Intracranial Hemorrhages [Link]

Subarachnoid hemorrhage

Frontal View
Clinical Presentation
• Thunderclap headache
• Loss of consciousness
• Stiff neck
• Nausea, vomiting, seizures, visual Subarachnoid space
disturbances
 Intracranial Hemorrhages [Link]

Epidural hemorrhage Subdural hemorrhage

• Between bone & • Between meningeal
periosteal dura mater dura mater &
• Loss of conscious arachnoid mater
followed by lucid interval • Initially undetected
• CT: lens-shaped, distinct until increases in
borders intracranial pressure
• Middle meningeal artery • CT: crescent-shaped
• Bridging cerebral veins

Intracerebral
Subarachnoid hemorrhage
hemorrhage
• Between arachnoid
& pia mater
• Thunderclap
headache, stiff neck
• CT: diffuse or
localized areas Frontal/Coronal View
• Blood vessels in
subarachnoid space
Knowledge Check [Link]

1a. A 28-year-old male patient presents to the emergency department following a motor vehicle
accident. He sustained a severe head injury when his car collided with another vehicle. On
examination, he is conscious but appears confused. He has a visible scalp laceration over the right
parietal region. A CT scan of the head reveals a biconvex, hyperdense lesion in the right
frontotemporal region with no midline shift. What is the patient’s diagnosis?

a) Epidural hemorrhage
b) Subdural hemorrhage
c) Subarachnoid hemorrhage
d) Intracerebral hemorrage

1b. Which vessel is impacted during this type of hemorrhage?

2. How do the clinical manifestations of an epidural and subarachnoid hemorrhage

differ?
Knowledge Check [Link]

1a. A 28-year-old male patient presents to the emergency department following a motor vehicle
accident. He sustained a severe head injury when his car collided with another vehicle. On
examination, he is conscious but appears confused. He has a visible scalp laceration over the right
parietal region. A CT scan of the head reveals a biconvex, hyperdense lesion in the right
frontotemporal region with no midline shift. What is the patient’s diagnosis?

a) Epidural hemorrhage
b) Subdural hemorrhage
c) Subarachnoid hemorrhage
d) Intracerebral hemorrage

1b. Which vessel is impacted during this type of hemorrhage?

Middle meningeal artery

2. How do the clinical manifestations of an epidural and subarachnoid hemorrhage

differ?

Epidural hemorrhage – loss of consciousness followed by lucid interval

Subarachnoid hemorrhage – thunderclap headache, stiff neck
Knowledge Check [Link]

3. Which intracranial hemorrhage corresponds with each of the CT scans below? How would you
describe their appearance?
Knowledge Check [Link]

3. Which intracranial hemorrhage corresponds with each of the CT scans below? How would you
describe their appearance?

Subarachnoid hemorrhage Subdural hemorrhage Epidural hemorrhage

Diffuse areas of blood in Crescent-shaped Lens-shaped
subarachnoid space
 References [Link]

Slide 2
• Intracranial hemorrhages: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 3
• Intracranial hemorrhages: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Lateral view of skull: <a href="[Link] J. Lynch, medical illustrator</a>, <a href="[Link] BY
2.5</a>, via Wikimedia Commons
• Middle meningeal artery: <a href="[Link] <a href="[Link] BY-SA 4.0</a>, via
Wikimedia Commons
• CT scan: <a href="[Link] <a href="[Link] BY-SA 3.0</a>, via Wikimedia
Commons

Slide 4
• Intracranial hemorrhages: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Veins: <a href="[Link] <a href="[Link] BY 4.0</a>, via Wikimedia Commons
• CT scan: <a href="[Link] Heilman, MD</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 5
• Intracranial hemorrhages: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Images created by [Link]
• CT scan: <a href="[Link] Heilman, MD</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 6
• Intracranial hemorrhages: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 9
• CT scan of subarachnoid hemorrhage: <a
href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• CT scan of subdural hemorrhage:
• CT scan of epidural hemorrhage: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Epidural Hemorrhage
Intracranial 2. Subdural Hemorrhage
Hemorrhages 3. Subarachnoid Hemorrhage
REVIEW OUTLINE

Infection & 1. Venous Drainage of the Head

Thrombosis of 2. Contents of the Cavernous Sinus

the Cavernous 3. Causes

Sinus 4. Clinical Presentation

Infection & Thrombosis of the Cavernous Sinus [Link]

Superior ophthalmic v.

Cavernous
sinus

Inferior ophthalmic v.

Facial v.

Danger triangle of face

Venous Drainage
 Infection & Thrombosis of the Cavernous Sinus [Link]

Superior
Cavernous sinus ophthalmic v.

Emissary v.
Inferior
ophthalmic v.
Pterygoid venous plexus

Maxillary v.

Deep facial v.

Retromandibular v. Lateral View of Dural Venous Sinuses

Facial v.

Post. Ant.
Common facial v.

Internal jugular v. Venous Drainage

Lateral View
 Infection & Thrombosis of the Cavernous Sinus [Link]

O TOM CAT Frontal/Coronal View

Infection & Thrombosis of the Cavernous Sinus [Link]

Causes Clinical Presentation

• Infection (staph aureus – bacterial) • Increased intracranial pressure
• Aneurysm & tearing of ICA • Fever
• Hypercoagulable states • Pain or degree of paralysis with eye
• Thrombophlebitis of facial v. movements (CN III, IV, VI)
• Poorly controlled diabetes (mucormycosis • Loss of facial sensation (CN V1 & V2)
Rhizophus – fungal) • Absent corneal reflex (CN V1)

Facial v.
Knowledge Check [Link]

1. Which of the following cranial nerves does NOT pass through

the cavernous sinus?

a) Oculomotor n. (CN III)

b) Trochlear n. (CN IV)
c) Maxillary n. (CN V2)
d) Abducens n. (CN VI)
e) Facial n. (CN VII)

2. A 29-year-old male patient presents with a swollen face, fever, and double vision. Upon examination, you
notice that the left side of his face is markedly swollen, and he has developed proptosis (bulging of the eye),
ophthalmoplegia (inability to move the eye), and chemosis (conjunctival edema) in the left eye. He reports a
recent dental infection. Imaging studies reveal thrombosis within the left cavernous sinus. Thrombosis of
which vein most commonly leads to thrombosis of the cavernous sinus in this patient?

a) Inferior petrosal sinus

b) Superior ophthalmic vein
c) Facial vein
d) Transverse sinus
e) Maxillary vein
Knowledge Check [Link]

1. Which of the following cranial nerves does NOT pass through

the cavernous sinus?

a) Oculomotor n. (CN III)

b) Trochlear n. (CN IV)
c) Maxillary n. (CN V2)
d) Abducens n. (CN VI)
e) Facial n. (CN VII)

2. A 29-year-old male patient presents with a swollen face, fever, and double vision. Upon examination, you
notice that the left side of his face is markedly swollen, and he has developed proptosis (bulging of the eye),
ophthalmoplegia (inability to move the eye), and chemosis (conjunctival edema) in the left eye. He reports a
recent dental infection. Imaging studies reveal thrombosis within the left cavernous sinus. Thrombosis of
which vein most commonly leads to thrombosis of the cavernous sinus in this patient?

a) Inferior petrosal sinus

b) Superior ophthalmic vein
c) Facial vein
d) Transverse sinus
e) Maxillary vein
 References [Link]

Slide 2
• Veins of the face: Image created by [Link]
• Facial and ophthalmic veins: <a href="[Link] Vandyke Carter</a>, Public domain, via
Wikimedia Commons

Slide 3
• Lateral view of veins: Created by Gabriella Alagha
• Lateral view of dural venous sinuses: Image created by [Link]

Slide 4
• Contents of cavernous sinus: <a href="[Link] Kuybu, MD and
Diana</a>, <a href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 5 & 7
• Frontal view of cavernous sinus: <a href="[Link] Vandyke Carter</a>, Public domain,
via Wikimedia Commons
• Facial and ophthalmic veins: <a href="[Link] Vandyke Carter</a>, Public domain, via
Wikimedia Commons
REVIEW OUTLINE

Infection & 1. Venous Drainage of the Head

Thrombosis of 2. Contents of the Cavernous Sinus

the Cavernous 3. Causes

Sinus 4. Clinical Presentation

REVIEW OUTLINE

1. Causes

Horner 2. Clinical Signs

Syndrome 3. Diagnosis

4. Sympathetic Innervation of the Eye

 Horner Syndrome [Link]

Sympathetic Innervation of the Eye

Superior
cervical
ganglion

Middle
cervical
ganglion

Inferior
cervical
ganglion
 Horner Syndrome [Link]

Sympathetic Innervation of the Eye

Levator palpebrae superioris

Superior tarsal
CN III – Oculomotor n.
Horner Syndrome [Link]

Caused by interruption of the sympathetic pathway due to damage to first, second, or third
order neurons in the brain, neck or eye

Diagnosis
• Cocaine test
o Inhibits reuptake of NE
• Hydroxyamphetamine test
o Causes release of stored NE
from post-ganglionic fibers

Clinical Signs
• Miosis (constriction of pupil)
• Ptosis (drooping of eyelid)
• Absence of sweating in the face
• Sinking of eyeball in bony cavity
Knowledge Check [Link]

What are the 4 classic clinical signs for Horner’s syndrome?

1. Sinking of eyeball
2. Ptosis
3. Absence of sweating in face
4. Miosis

Which of the following cranial nerves are responsible for providing sympathetic innervation to the
eye? Select all that apply.

• III – Oculomotor n.
• V1 – Ophthalmic n.
• IIII – Trochlear n.
• VI – Abducens n.

How do they differ in their innervation?

• Oculomotor n. – innervates superior tarsal to keep eyelid open

• Ophthalmic n. – innervates iris muscles to dilate pupils
Knowledge Check [Link]

What are the 4 classic clinical signs for Horner’s syndrome?

1. Sinking of eyeball
2. Ptosis
3. Absence of sweating in face
4. Miosis

Which of the following cranial nerves are responsible for providing sympathetic innervation to the
eye? Select all that apply.

• III – Oculomotor n.
• V1 – Ophthalmic n.
• IIII – Trochlear n.
• VI – Abducens n.

How do they differ in their innervation?

• Oculomotor n. – innervates superior tarsal to keep eyelid open

• Ophthalmic n. – innervates iris muscles to dilate pupils
References [Link]

Slide 2
• <a href="[Link] <a href="[Link] BY 2.5</a>,
via Wikimedia Commons

Slide 3
• <a href="[Link] College</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 4
• Upper eye region: <a href="[Link] College</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• Nerve pathways of the eye: <a href="[Link] J. Lynch, medical
illustrator</a>, <a href="[Link] BY 2.5</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

Horner 2. Clinical Signs

Syndrome 3. Diagnosis

4. Sympathetic Innervation of the Eye

REVIEW OUTLINE

1. Causes

Median 2. Development of the Thyroid Gland

Cervical Cyst 3. CT Imaging

4. Treatment
Median Cervical Cyst (Thyroglossal Cyst) [Link]

Painless midline mass on the anterior surface of the neck at the level of the hyoid bone
• Remnant of the thyroglossal duct

Treatment
• Surgical excision
Knowledge Check [Link]

Failure of complete obliteration of which endodermal structure will lead to a median

cervical cyst?
Knowledge Check [Link]

Failure of complete obliteration of which endodermal structure will lead to a median

cervical cyst?

Thyroglossal duct
References [Link]

Slide 2
• Cyst on patient: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• CT scan: <a
href="[Link]
Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, and Salahudin Tayeb
Elnaas</a>, <a href="[Link] BY 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

Median 2. Development of the Thyroid Gland

Cervical Cyst 3. CT Imaging

4. Treatment
REVIEW OUTLINE

1. Purpose

2. Structures
Cricothyrotomy • Cricothyroid membrane
• Median cricothyroid ligament

3. Tracheostomy
Cricothyrotomy [Link]

Emergency procedure where a skin incision is made through the cricothyroid

membrane/median cricothyroid ligament to relieve an airway obstruction
Cricothyrotomy [Link]

Tracheostomy
Knowledge Check [Link]

During your ER rotation, you are asked to perform an emergency cricothyrotomy.

1. During this procedure, you would make a skin

incision over the ________________ membrane or more
specifically, the ________________________ ligament.

2. Identify both structures on the image.

Knowledge Check [Link]

During your ER rotation, you are asked to perform an emergency cricothyrotomy.

1. During this procedure, you would make a skin

cricothyroid
incision over the ________________ membrane or more
median cricothyroid
specifically, the ________________________ ligament.

2. Identify both structures on the image.

References [Link]

Slide 2
• External larynx: <a href="[Link] Remesz (wiki-pl: Orem, commons:
Orem)</a>, <a href="[Link] BY-SA 2.5</a>, via Wikimedia Commons
• Sagittal larynx: <a href="[Link]
College</a>, <a href="[Link] BY 3.0</a>, via Wikimedia Commons
• Breathing tubes: <a href="[Link] D. Peter, Wiehl, GermanyDiese Datei
aus meinem Archiv habe ich unter der<a href="[Link] BY 3.0 DE</a>, via
Wikimedia Commons

Slide 3
• Tracheostomy sagittal: <a href="[Link] Heart Lung and Blood Institute
(NIH)</a>, Public domain, via Wikimedia Commons
• Tracheostomy anterior: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 4
• <a href="[Link] Remesz (wiki-pl: Orem, commons: Orem)</a>, <a
href="[Link] BY-SA 2.5</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Purpose

2. Structures
Cricothyrotomy • Cricothyroid membrane
• Median cricothyroid ligament

3. Tracheostomy
REVIEW OUTLINE

Bell’s 1. Causes

2. Schematic of CN VII – Facial Nerve

Palsy 3. Clinical Manifestations

Bell’s Palsy [Link]

Idiopathic unilateral facial paralysis (75% of facial nerve lesions)

• Due to inflammation, compression or damage to the facial n.

Motor
Internal acoustic meatus
- Muscles of facial expression
- Stapedius

Special sensory

Petrotympanic - Taste to anterior 2/3 of tongue

fissure

Parasympathetic
(preganglionic fibers)

Stylomastoid foramen - Lacrimal gland

- Sublingual & submandibular gland
- Nasal, palatine & pharyngeal mucous glands

General sensory

- Auricle, retroauricular region

Bell’s Palsy [Link]

Idiopathic unilateral facial paralysis (75% of facial nerve lesions)

• Due to inflammation, compression or damage to the facial n.
Clinical Manifestations
Injury to terminal branches:
• Impaired muscles of facial
expression
• Facial distortion (unopposed
contralateral facial muscles)

Injury within facial canal:

• Symptoms above
• Dry eye (no lubrication) Left sided lesion
• Loss of taste from anterior 2/3
of tongue
• Loss of secretion from
submandibular
& sublingual glands
• Hyperacusis (paralysis of stapedius)
Knowledge Check [Link]

Explain the symptomatic differences between an injury to the facial nerve within the
facial canal versus an injury to the terminal branches.
Knowledge Check [Link]

Explain the symptomatic differences between an injury to the facial nerve within the
facial canal versus an injury to the terminal branches.

Injury to terminal branches:

• Impaired muscles of facial expression
• Facial distortion

Injury within the facial canal:

• Dry eyes
• Loss of taste to anterior 2/3 of tongue,
• Impairment of the submandibular & sublingual glands
References [Link]

Slide 2
• <a href="[Link] J. Lynch, medical
illustrator</a>, <a href="[Link] BY 2.5</a>, via Wikimedia
Commons

Slide 3
• Schematic of facial nerve: <a
href="[Link] J. Lynch, medical
illustrator</a>, <a href="[Link] BY 2.5</a>, via Wikimedia
Commons
• Patient: <a
href="[Link]
Kamphuis</a>, <a href="[Link] BY-SA 4.0</a>, via
Wikimedia Commons
REVIEW OUTLINE

Bell’s 1. Causes

2. Schematic of CN VII – Facial Nerve

Palsy 3. Clinical Manifestations

REVIEW OUTLINE

Extraocular Muscles
Testing of the • Superior rectus
• Inferior rectus
Extraocular • Medial rectus
• Lateral rectus

Muscles • Superior oblique

• Inferior oblique
Testing of the Extraocular Muscles [Link]

SO SR Lateral View (R) LPS

MR LR

IR IO

Superior View (R)

Anterior View (R)

Testing of the Extraocular Muscles [Link]

SO SR Lateral View (R) LPS

MR LR

IR IO

Superior View (R)

Anterior View (R)

Testing of the Extraocular Muscles [Link]

RIGHT EYE

SR IO

LR MR

IR SO

Superior View (R)

LPS
Anterior View (R)
Testing of the Extraocular Muscles [Link]

SR IO

LR MR

IR SO

CLINICAL TESTING
Right Eye

MUSCLE ACTIONS
Right Eye
Knowledge Check [Link]

1. You are testing the extraocular muscles and their innervation in a patient who periodically
experiences double vision. When you ask them to turn their right eye inward toward their
nose and look downward they are able to look inward, but not down. Which muscle is
impacted?

BONUS: Which nerve is most likely

involved?

a. CN IV– Trochlear n.
b. CN III – Oculomotor n.
c. CN II – Optic n.
d. CN VI – Abducens n.
Knowledge Check [Link]

1. You are testing the extraocular muscles and their innervation in a patient who periodically
experiences double vision. When you ask them to turn their right eye inward toward their
nose and look downward they are able to look inward, but not down. Which muscle is
impacted?

Superior oblique

BONUS: Which nerve is most likely

involved?

a. CN IV– Trochlear n.
b. CN III – Oculomotor n.
c. CN II – Optic n.
d. CN VI – Abducens n.
Knowledge Check [Link]

1. If a person looking outward away from their nose is unable to look down, which muscle
may be impacted?

2. You are asked to check the integrity of the inferior oblique muscle in the right eye of a
patient. Starting with the eyes directed straight ahead, you would have the patient look:
a. Inward, toward the nose and downward
b. Inward, toward the nose and upward
c. Toward the nose in a horizontal plane
d. Laterally in a horizontal plane
e. Outward, away from the nose and downward
Knowledge Check [Link]

1. If a person looking outward away from their nose is unable to look down, which muscle
may be impacted?

Inferior rectus

2. You are asked to check the integrity of the inferior oblique muscle in the right eye of a
patient. Starting with the eyes directed straight ahead, you would have the patient look:
a. Inward, toward the nose and downward
b. Inward, toward the nose and upward
c. Toward the nose in a horizontal plane
d. Laterally in a horizontal plane
e. Outward, away from the nose and downward
 References [Link]

Slide 2 & 3
• Superior view: <a href="[Link] J. Lynch, medical illustrator</a>, <a
href="[Link] BY 2.5</a>, via Wikimedia Commons
• Lateral view: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Muscle actions: <a href="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 4
• Superior view: <a href="[Link] J. Lynch, medical illustrator</a>, <a
href="[Link] BY 2.5</a>, via Wikimedia Commons
• Eye: Eye by SumiTomohiko, [Link] CC BY 1.0 [Link]
• Muscle actions: <a href="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 5
• Muscle Actions: <a href="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons
• Eye: Eye by SumiTomohiko, [Link] CC BY 1.0 [Link]

Slide 7
• Superior view: <a href="[Link] J. Lynch,
medical illustrator</a>, <a href="[Link] BY 2.5</a>, via Wikimedia Commons
• Eye: Eye by SumiTomohiko, [Link] CC BY 1.0
[Link]

Slide 9
• Eye by SumiTomohiko, [Link] CC BY 1.0
[Link]
REVIEW OUTLINE

Extraocular Muscles
Testing of the • Superior rectus
• Inferior rectus
Extraocular • Medial rectus
• Lateral rectus

Muscles • Superior oblique

• Inferior oblique
REVIEW OUTLINE

1. Causes

Blowout 2. Bones of the orbit

Fracture 3. Paranasal sinuses

4. Complications
Bones of the Orbit [Link]

Frontal

Sphenoid

Ethmoid

Lacrimal

Palatine

Maxilla

Zygomatic
Blowout Fracture [Link]
Blowout Fracture – Complications [Link]

1) Orbital contents into maxillary sinus

2) Nasal bone fractures

Frontal CT
Blowout Fracture – Complications [Link]

1) Orbital contents into maxillary sinus

X-Ray

2) Nasal bone fractures

Frontal CT
Blowout Fracture – Complications [Link]

3) Pain or numbness along cheek, ala of nose & upper lip

4) Intra-orbital bleeding – protrusion of eyeball
Infraorbital foramen

Infraorbital a/v/n.

V2 – Maxillary Nerve

Maxillary Artery
Blowout Fracture – Complications [Link]

5) Infection spread to cavernous sinus

Knowledge Check [Link]

1. Which of the following bones make up the inferior and medial orbital surfaces that are
vulnerable during a blowout fracture? Select all that apply and specify which ones make
up the inferior versus medial surfaces.
a. Ethmoid
b. Sphenoid
c. Lacrimal
d. Maxilla
e. Frontal
f. Zygomatic

2. Fracture of the inferior floor of the orbit would cause contents to leak into which of the
following paranasal sinuses?
a. Ethmoid air cells
b. Sphenoid sinus
c. Frontal sinus
d. Maxillary sinus
Knowledge Check [Link]

1. Which of the following bones make up the inferior and medial orbital surfaces that are
vulnerable during a blowout fracture? Select all that apply and specify which ones make
up the inferior versus medial surfaces.
a. Ethmoid
Frontal Palatine
b. Sphenoid
c. Lacrimal Sphenoid Maxilla
d. Maxilla
Ethmoid Zygomatic
e. Frontal
f. Zygomatic
? Lacrimal

2. Fracture of the inferior floor of the orbit would cause contents to leak into which of the
following paranasal sinuses?
a. Ethmoid air cells
b. Sphenoid sinus
c. Frontal sinus
d. Maxillary sinus
 References [Link]

Slide 2
• <a href="[Link] J. Lynch, medical illustrator</a>, <a href="[Link] BY 2.5</a>, via Wikimedia
Commons

Slide 3
• Paranasal sinuses: <a href="[Link] College</a>, <a href="[Link] BY 3.0</a>, via Wikimedia
Commons
• Skull: <a href="[Link] J. Lynch, medical illustrator</a>, <a href="[Link] BY 2.5</a>, via
Wikimedia Commons

Slide 4
• CT scan: <a href="[Link] Heilman, MD</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Paranasal sinuses: <a href="[Link] College</a>, <a href="[Link] BY 3.0</a>, via Wikimedia
Commons

Slide 5
• X-Ray & CT: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Paranasal sinuses: <a href="[Link] College</a>, <a href="[Link] BY 3.0</a>, via Wikimedia
Commons

Slide 6
• Sensory of the face: <a href="[Link] <a href="[Link] BY-SA 4.0</a>, via Wikimedia
Commons
• Maxillary nerve: <a href="[Link] John Charles Boileu</a>, Public domain, via Wikimedia Commons
• Maxillary artery: <a href="[Link] Vandyke Carter</a>, Public domain, via Wikimedia Commons
• Paranasal sinuses: <a href="[Link] College</a>, <a href="[Link] BY 3.0</a>, via Wikimedia
Commons

Slide 7
• Ophthalmic vein: <a href="[Link] Vandyke Carter</a>, Public domain, via Wikimedia Commons
• Cavernous sinus: <a href="[Link] Kuybu, MD and Diana</a>, <a
href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 9
• Skull: <a href="[Link] J. Lynch, medical illustrator</a>, <a
href="[Link] BY 2.5</a>, via Wikimedia Commons
• CT scan: <a href="[Link] Heilman, MD</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

Blowout 2. Bones of the orbit

Fracture 3. Paranasal sinuses

4. Complications
REVIEW OUTLINE

Cranial Nerve Nerves

• CN III – Oculomotor n.
Palsy of the • CN IV – Trochlear n.
• CN VI – Abducens n.
Orbit
Cranial Nerve Palsy (Orbit) [Link]

A. impaired
R L B. unopposed
CN III – Oculomotor Nerve
1. Ptosis 3. Dilation of pupil
A. Levator palpebrae superioris A. Sphincter pupillae

B. Orbicularis oculi 2. Position of eye: abducted & depressed B. Dilator pupillae

A. Superior rectus B. Superior oblique

A. Medial rectus B. Lateral rectus

A. Inferior rectus

A. Inferior oblique

Right Eye Lateral View (R)

Cranial Nerve Palsy (Orbit) [Link]

A. impaired
B. unopposed
CN IV – Trochlear Nerve
2. Diplopia
R L • Double vision when looking
down
• To compensate for diplopia: tilt
head anteriorly & laterally
towards normal side
1. Position of eye: adducted & elevated

A. Superior oblique B. Inferior oblique

CN VI – Abducens Nerve

R L Right Eye

Position of eye: adducted

A. Lateral rectus B. Medial rectus Lateral View (R)

Knowledge Check [Link]

1. You are testing the extraocular muscles and their innervation in a patient who periodically
experiences double vision and their right eye is adducted and elevated. Which nerve and
muscle are most likely involved?

2. A patient presents to your clinic with drooping of the left eyelid. Her left eye is abducted
and depressed. The pupils are dilated and do not react to light. Which nerve is most likely
involved?
Knowledge Check [Link]

1. You are testing the extraocular muscles and their innervation in a patient who periodically
experiences double vision and their right eye is adducted and elevated. Which nerve and
muscle are most likely involved?

CN IV – Trochlear nerve
Superior oblique muscle

2. A patient presents to your clinic with drooping of the left eyelid. Her left eye is abducted
and depressed. The pupils are dilated and do not react to light. Which nerve is most likely
involved?

CN III – Oculomotor nerve

 References [Link]

Slides 2
• Muscle actions: <a href="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons
• Eye: Eye by SumiTomohiko, [Link] CC BY 1.0 [Link]
• Lateral view of muscles: <a href="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons
• Sphincter and dilator pupillae: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 3
• Eye: Eye by SumiTomohiko, [Link] CC BY 1.0 [Link]
• Lateral view of muscles: <a href="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons
• Muscle actions: <a href="[Link] <a
href="[Link] BY 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

Cranial Nerve Nerves

• CN III – Oculomotor n.
Palsy of the • CN IV – Trochlear n.
• CN VI – Abducens n.
Orbit
REVIEW OUTLINE

1. Paranasal Sinuses & Drainage

Infection of the 2. Sinusitis vs Pansinusitis
Paranasal 3. Infection of Ethmoid Sinuses
Sinuses 4. Infection of Maxillary Sinuses
Infection of the Paranasal Sinuses [Link]

Sinusitis: inflammation & swelling of the mucosa of the sinuses

Pansinusitis: involves all paranasal sinuses

Frontal sinus

Sphenoid sinus

Ethmoidal air cells

Maxillary sinus
Infection of the Paranasal Sinuses [Link]

Ethmoid bone
Severe infection: blindness, optic neuritis

Optic canal
Ophthalmic a.

CN II – Optic n.
Infection of the Paranasal Sinuses [Link]

Maxillary sinus → most commonly infected due to size & location of opening into the nasal cavity
Infection of the Paranasal Sinuses [Link]
Knowledge Check [Link]

1. An infection of which paranasal sinus may impact the optic nerve and ophthalmic
artery?

a. Frontal sinus
b. Sphenoid sinus
c. Ethmoid sinus
d. Maxillary sinus

2. Which paranasal sinus is most commonly infected and why?

Knowledge Check [Link]

1. An infection of which paranasal sinus may impact the optic nerve and ophthalmic
artery?

a. Frontal sinus
b. Sphenoid sinus
c. Ethmoid sinus
d. Maxillary sinus

2. Which paranasal sinus is most commonly infected and why?

Maxillary sinus – due to size (large) & location of the opening into the nasal
cavity (superomedial)
References [Link]

Slide 2
• Paranasal sinuses: <a href="[Link] College</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• Infected sinuses: <a href="[Link]
Servier</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 3
• Sagittal view: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Paranasal sinuses: <a href="[Link] College</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 4
• Bones of the orbit: <a href="[Link] J. Lynch, medical illustrator</a>, <a
href="[Link] BY 2.5</a>, via Wikimedia Commons
• Superior view of orbit: <a href="[Link] Vandyke Carter</a>, Public domain, via Wikimedia
Commons

Slide 5
• <a href="[Link] Vandyke Carter</a>, Public domain, via
Wikimedia Commons

Slide 6
• <a href="[Link] <a
href="[Link] BY 2.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Paranasal Sinuses & Drainage

Infection of the 2. Sinusitis vs Pansinusitis
Paranasal 3. Infection of Ethmoid Sinuses
Sinuses 4. Infection of Maxillary Sinuses
REVIEW OUTLINE

1. CN IX – Glossopharyngeal n.
2. CN X – Vagus n.
3. CN V3 – Mandibular n.
4. CN XII – Hypoglossal n.
Gag Reflex 5.
6.
Solitary nucleus
Spinal trigeminal nucleus
7. Nucleus ambiguus
8. Motor trigeminal nucleus
9. Hypoglossal nucleus
Gag Reflex [Link]

Motor Sensory
Afferent Limb (Sensory)
CN IX – Glossopharyngeal n. Dorsal View of
Brainstem

1. Tactile stimulation of
oropharynx, posterior 1/3 of
tongue, palatine tonsils, uvula

3. Nucleus
ambiguus
2. Solitary
nucleus
Nasopharynx
2. Spinal
Oropharynx trigeminal
nucleus
Laryngopharynx
 Gag Reflex [Link]

Motor Sensory
Efferent Limb (Motor)
CN X – Vagus n. Dorsal View of
Brainstem

4. Contraction of pharyngeal constrictor

muscles & elevation of soft palate

1. Tactile stimulation of
oropharynx, posterior
1/3 of tongue, palatine
tonsils, uvula

Superior
3. Nucleus
Middle ambiguus
2. Solitary
Inferior nucleus

Posterior View Cricopharyngeus

of Pharynx 2. Spinal
trigeminal
UMN lesion = asymmetric palate elevation (failure to elevate on opposite side of lesion + nucleus
deviation towards side of lesion) OR LMN lesion (3 → 4) = asymmetric palate elevation
(failure to elevate on side of lesion + deviation away from side of lesion)
 Gag Reflex [Link]

Motor Sensory
Efferent Limb (Motor)
CN V3 – Mandibular n. Dorsal View of
Brainstem

5. Mandibular depression &

protrusion (opening of jaw)

1. Tactile stimulation of
oropharynx, posterior
1/3 of tongue, palatine
tonsils, uvula

3. Nucleus
ambiguus
2. Solitary
Lateral pterygoid
nucleus
4. Motor
Medial pterygoid
trigeminal 2. Spinal
nucleus trigeminal
UMN lesion = jaw deviation towards opposite side of lesion nucleus
LMN lesion (4 → 5) = jaw deviation towards side of lesion
 Gag Reflex [Link]

Motor Sensory
Efferent Limb (Motor)
CN XII – Hypoglossal n. Dorsal View of
Brainstem

5. Tongue thrust

1. Tactile stimulation of
oropharynx, posterior
1/3 of tongue, palatine
tonsils, uvula

3. Nucleus
ambiguus
2. Solitary
4. Hypoglossal nucleus
nucleus

2. Spinal
trigeminal
UMN lesion = tongue deviation towards opposite side of lesion nucleus
LMN lesion (4 → 5) = tongue deviation towards side of lesion
Knowledge Check [Link]

Draw the pathway of the gag reflex. Write down which nerves and nuclei are involved and the
response they produce under normal conditions.
Knowledge Check [Link]

Draw the pathway of the gag reflex. Write down which nerves and nuclei are involved and the
response they produce under normal conditions.

1. CN IX – Glossopharyngeal nerve
Tactile stimulation of oropharynx, posterior 1/3 of
4. Hypoglossal nucleus
tongue, palatine tonsils, uvula
5. CN XII – Hypoglossal nerve
2. Solitary nucleus or spinal trigeminal nucleus
Tongue thrust
3. Nucleus ambiguus
Sensory
Motor

4. CN X – Vagus nerve 4. Motor trigeminal nucleus

Contraction of pharyngeal
constrictors & elevation of soft palate 5. CN V3 – Mandibular nerve
Depression & protrusion of the mandible
References [Link]

Slide 2
• Sagittal head & neck: <a href="[Link] College</a>,
<a href="[Link] BY 3.0</a>, via Wikimedia Commons
• Mouth & tongue: <a
href="[Link] <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• Brainstem: <a href="[Link] User:mcstrotherderivative work: Mcstrother</a>, Public
domain, via Wikimedia Commons

Slide 3
• Posterior pharynx: <a href="[Link] Johannes Sobotta</a>, Public domain, via Wikimedia
Commons
• Mouth & tongue: <a
href="[Link] <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• Brainstem: <a href="[Link] User:mcstrotherderivative work: Mcstrother</a>, Public
domain, via Wikimedia Commons

Slide 4
• Pterygoid muscles: <a href="[Link] Vandyke Carter</a>, Public domain, via Wikimedia
Commons
• Brainstem: <a href="[Link] User:mcstrotherderivative work:
Mcstrother</a>, Public domain, via Wikimedia Commons

Slide 5
• Hypoglossal nerve: <a href="[Link] Vandyke Carter</a>,
Public domain, via Wikimedia Commons
• Brainstem: <a href="[Link] User:mcstrotherderivative work:
Mcstrother</a>, Public domain, via Wikimedia Commons
REVIEW OUTLINE

1. CN IX – Glossopharyngeal n.
2. CN X – Vagus n.
3. CN V3 – Mandibular n.
4. CN XII – Hypoglossal n.
Gag Reflex 5.
6.
Solitary nucleus
Spinal trigeminal nucleus
7. Nucleus ambiguus
8. Motor trigeminal nucleus
9. Hypoglossal nucleus
REVIEW OUTLINE

1. Carcinoma of the Breast

Carcinoma of 2. Lymphatic Drainage of the Breast

the Breast

3. Mastectomy
 Carcinoma of the Breast [Link]

Malignant tumors (adenocarcinomas) arising from epithelial cells of lactiferous ducts in

mammary gland lobules
Tumor enlarges & attaches to the
suspensory ligament shortening it
 Lymphatic Drainage of the Breast [Link]

Parasternal

Anterior axillary (pectoral)

Posterior axillary
(subscapular)

Lateral axillary (humeral)

75% 25%
 Mastectomy [Link]

Removal of the breast, pectoral muscles, fat, fascia & lymph nodes in the axilla &
pectoral region

Winged scapula
Knowledge Check [Link]

Which lymph nodes are primarily responsible for lymphatic drainage of the breast?

a. Parasternal
b. Anterior axillary (pectoral)
c. Posterior axillary
d. Lateral axillary (humeral)

A 43-year-old woman with a history of breast cancer undergoes a double

mastectomy and after surgery, she presents with a winged scapula. Why did this
happen?
Knowledge Check [Link]

Which lymph nodes are primarily responsible for lymphatic drainage of the breast?

a. Parasternal
b. Anterior axillary (pectoral)
c. Posterior axillary
d. Lateral axillary (humeral)

A 43-year-old woman with a history of breast cancer undergoes a double

mastectomy and after surgery, she presents with a winged scapula. Why did this
happen?

Injury to the long thoracic nerve causing paralysis of serratus anterior

 References [Link]

Slide 2
Breast Anatomy: <a
href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
Breast Appearance Cancer: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
Mammogram: <a href="[Link] When using this image
in external sources it can be cited as:[Link] staff (2014). &quot;Medical gallery of Blausen Medical 2014&quot;. WikiJournal of
Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.</a>, <a href="[Link] BY
3.0</a>, via Wikimedia Commons

Slide 3
<a href="[Link] Bliss (Illustrator)</a>, Public domain, via Wikimedia
Commons

Slide 4
Woman Mastectomy: <a
href="[Link] Illustrator</a>, Public
domain, via Wikimedia Commons
Long Thoracic N.: <a
href="[Link]
g">Internet Archive Book Images</a>,
No restrictions, via Wikimedia Commons
Winged Scapula: <a href="[Link]
at the English-language Wikipedia</a>, <a href="[Link] BY-SA
3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Carcinoma of the Breast

Carcinoma of 2. Lymphatic Drainage of the Breast

the Breast

3. Mastectomy
REVIEW OUTLINE

1. Compensatory Hypertrophy

2. Hypertension

Cardiac 3. Athletic Training

Hypertrophy 4. Atrial Septal Defect

5. Valvular Heart Disease

Cardiac Hypertrophy [Link]

Abnormal enlargement of the cardiac muscle (atria or ventricles) due to increased or

prolonged stress on the heart
Compensatory hypertrophy: ↑ demands
= ↑ in size

Causes
Hypertension
Intense athletic training
Cardiac Hypertrophy [Link]

Abnormal enlargement of the cardiac muscle (atria or ventricles) due to increased or

prolonged stress on the heart
Compensatory hypertrophy: ↑ demands
= ↑ in size

Causes
Hypertension
Intense athletic training
Atrial septal defect
Cardiac Hypertrophy [Link]

Abnormal enlargement of the cardiac muscle (atria or ventricles) due to increased or

prolonged stress on the heart
Compensatory hypertrophy: ↑ demands
Regurgitation/Insufficiency Stenosis = ↑ in size

Causes
Hypertension
Intense athletic training
Atrial septal defect
Valvular heart disease
Knowledge Check [Link]

Pulmonic valve stenosis may lead to hypertrophy of which chamber of the heart?

a. Right atrium
b. Right ventricle
c. Left atrium
d. Left ventricle
Knowledge Check [Link]

Pulmonic valve stenosis may lead to hypertrophy of which chamber of the heart?

a. Right atrium
b. Right ventricle
c. Left atrium
d. Left ventricle
References [Link]

Slide 2
• <a href="[Link] Public domain, via
Wikimedia Commons

Slide 3
• <a href="[Link] Capac</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 4
• <a href="[Link] Public domain, via
Wikimedia Commons
REVIEW OUTLINE

1. Compensatory Hypertrophy

2. Hypertension

Cardiac 3. Athletic Training

Hypertrophy 4. Atrial Septal Defect

5. Valvular Heart Disease

REVIEW OUTLINE

1. Auscultation Sites

Auscultation of
Heart Valves
2. Heart Murmurs
Auscultation of Heart Valves [Link]

1. Aortic valve
Right second intercostal space

2. Pulmonary valve
Left second intercostal space

3. Erb’s point
Left third intercostal space

4. Tricuspid valve
Left fourth or fifth intercostal space

5. Mitral valve
Left fifth intercostal space
 Auscultation of Heart Valves [Link]

Heart Murmurs
Occurs due to turbulent blood flow

Stenosis – valves unable to fully open

Orthograde blood flow

Regurgitation – valves unable to fully close

Retrograde blood flow

Systolic Murmur Diastolic Murmur

Knowledge Check [Link]

The sound associated with tricuspid stenosis in a 40-year-old male would be best
heard at which location on the anterior chest wall?

a. Below the left nipple

b. In the right second intercostal space
c. Over the apex of the heart
d. Over the sternal angle
e. In the left fourth or fifth intercostal space

The heart sound associated with the mitral valve is best heard:

a. In the jugular notch

b. In the second left intercostal space
c. In the second right intercostal space
d. In the fifth left intercostal space
e. To the right of the xiphoid process
Knowledge Check [Link]

The sound associated with tricuspid stenosis in a 40-year-old male would be best
heard at which location on the anterior chest wall?

a. Below the left nipple

b. In the right second intercostal space
c. Over the apex of the heart
d. Over the sternal angle
e. In the left fourth or fifth intercostal space

The heart sound associated with the mitral valve is best heard:

a. In the jugular notch

b. In the second left intercostal space
c. In the second right intercostal space
d. In the fifth left intercostal space
e. To the right of the xiphoid process
Knowledge Check [Link]

Elevated systolic blood pressure in the right ventricle suggests stenosis of which
valve?

a. Aortic
b. Mitral
c. Pulmonary
d. Tricuspid

During examination of a 62-year-old man, the senior resident tells you to put your
stethoscope on the right second intercostal space and listen for a clearly audible
murmur. You hear it distinctly and know it must be associated with severe
stenosis of which valve?

a. Aortic
b. Mitral
c. Pulmonary
d. Tricuspid
Knowledge Check [Link]

Elevated systolic blood pressure in the right ventricle suggests stenosis of which
valve?

a. Aortic
b. Mitral
c. Pulmonary
d. Tricuspid

During examination of a 62-year-old man, the senior resident tells you to put your
stethoscope on the right second intercostal space and listen for a clearly audible
murmur. You hear it distinctly and know it must be associated with severe
stenosis of which valve?

a. Aortic
b. Mitral
c. Pulmonary
d. Tricuspid
References [Link]

Slide 2, 3
• <a href="[Link] <a
href="[Link] BY 2.5</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Auscultation Sites
• Aortic valve
• Pulmonary valve

Auscultation of • Erb’s point

• Tricuspid valve

Heart Valves • Mitral valve

2. Heart Murmurs
• Causes
• Valvular stenosis vs regurgitation
• Systolic vs diastolic murmurs
REVIEW OUTLINE

1. Right Coronary Artery (RCA)

Blood Supply 2. Left Coronary Artery (LCA)

of the Heart
3. Clinical Relevance
Right Coronary Artery [Link]

Branches of the right coronary artery:

SA nodal

Right marginal
Right ventricle, apex

Posterior interventricular
Inferior aspect of right & left
ventricle, posterior 1/3 of IVS

AV nodal
Left Coronary Artery [Link]

Branches of the left coronary artery:

Circumflex branch
Left atrium & ventricle

Anterior interventricular/LAD
Right & left ventricles, anterior 2/3 of IVS
apex
Collateral Circulation between the Coronary Arteries [Link]

Right coronary artery

• SA nodal
• Right marginal
• Posterior interventricular
• AV nodal

Left coronary artery

• Circumflex branch
• Anterior interventricular/LAD
Clinical Relevance [Link]

Coronary Artery Disease (CAD)

Caused by coronary atherosclerosis leading to blockage & reduction of blood flow

CABG Coronary Angioplasty

LAD (40-50%)
RCA (30-40%)
Circumflex branch of LCA (15-20%)
Myocardial Infarction
Coronary Angiogram [Link]

Left coronary artery

Circumflex branch
Anterior interventricular/LAD
Knowledge Check [Link]

Blockage of which of the following arteries would lead to ischemia of the apex of the heart?

a. Anterior interventricular/LAD
b. Left circumflex branch
c. Posterior interventricular
d. Right marginal
e. Right coronary

Blockage of blood flow in the proximal part of the anterior interventricular artery could deprive
a large area of heart tissue of blood supply, unless a substantial retrograde flow into this
artery develops via an important anastomosis with which other artery?

a. Left circumflex branch

b. Left marginal
c. Posterior interventricular
d. Right coronary
e. Right marginal
Knowledge Check [Link]

Blockage of which of the following arteries would lead to ischemia of the apex of the heart?

a. Anterior interventricular/LAD
b. Left circumflex branch
c. Posterior interventricular
d. Right marginal
e. Right coronary

Blockage of blood flow in the proximal part of the anterior interventricular artery could deprive
a large area of heart tissue of blood supply, unless a substantial retrograde flow into this
artery develops via an important anastomosis with which other artery?

a. Left circumflex branch

b. Left marginal
c. Posterior interventricular
d. Right coronary
e. Right marginal
References [Link]

Slide 2, 3, 4
• <a href="[Link] Medical Art</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 5
• Myocardial Infarction: <a href="[Link] Medical
Communications, Inc.</a>, <a href="[Link] BY 3.0</a>, via Wikimedia
Commons
• CABG: <a href="[Link] Kebert &amp;
[Link]</a>, <a href="[Link] BY-SA 4.0</a>, via
Wikimedia Commons
• Angioplasty: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 6
• Angiogram: <a href="[Link] A Pantaleo,
Anna Mandrioli, Maristella Saponara, Margherita Nannini, Giovanna Erente, Cristian Lolli and Guido Biasco :
Development of coronary artery stenosis in a patient with metastatic renal cell carcinoma treated with
sorafenib. BMC Cancer, 2012, 12:231 doi:10.1186/1471-2407-12-231Published: 11 June 2012</a>, <a
href="[Link] BY 2.0</a>, via Wikimedia Commons
• Angiogram Before & After: <a
href="[Link]
Jer5150</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Right Coronary Artery (RCA)

• SA nodal artery
• Right marginal artery
• Posterior interventricular artery
• AV nodal artery

Blood Supply 2. Left Coronary Artery (LCA)

• Circumflex branch

of the Heart • Anterior interventricular artery/left anterior descending

3. Clinical Relevance
• Coronary artery disease
• Myocardial infarction
• Coronary artery bypass graft (CABG)
• Coronary angioplasty
REVIEW OUTLINE

1. Foreign Bodies

2. Right Lung

Aspiration of
Foreign Bodies &
Bronchopulmonary
3. Left Lung
Segments

4. Clinical Significance
Aspiration of Foreign Bodies [Link]

Inhalation of a foreign object causing an obstruction in the lower respiratory tract

Right Primary Bronchus Left Primary Bronchus

Wider & shorter Narrower, longer
 Aspiration of Foreign Bodies [Link]

Secondary (Lobar) Bronchi

Left superior
lobar bronchus
Right superior
lobar bronchus

Left inferior
Right middle lobar bronchus
lobar bronchus

Right inferior
lobar bronchus
 Bronchopulmonary Segments [Link]

Anatomical & functional unit with its own pulmonary artery & tertiary bronchus

Right Lung Left Lung

Superior Lobe Superior Lobe

Apical Apicoposterior
Anterior Anterior
Posterior* Superior lingular
Inferior lingular
Middle Lobe
Lateral Inferior Lobe
Medial Superior
Posterior basal
Inferior Lobe Medial basal
Superior* Lateral basal
Anterior basal Anterior basal
Posterior basal
Lateral basal
Medial basal
 Bronchopulmonary Segments [Link]

Anatomical & functional unit with its own pulmonary artery & tertiary bronchus

Tumor

Surgical Treatment
Pulmonary resection
(lung segmentectomy)
 Bronchopulmonary Segments [Link]

Anatomical & functional unit with its own pulmonary artery & tertiary bronchus

Tumor

Surgical Treatment
Lobectomy
Knowledge Check [Link]

A 4-year-old girl is brought in with coughing, and you are told by her mother that she had been
playing with some beads and had apparently aspirated one (gotten it into her airway). Where
would you expect it to most likely be?

a. Apicoposterior segmental bronchus of left lung

b. Left main bronchus
c. Lingular segment of left lung
d. Right main bronchus
e. Terminal bronchiole of right lung

Because of its angle with the trachea and size of the main bronchus, a bronchoscope would
pass more readily into which lung?

a. Left
b. Right
Knowledge Check [Link]

A 4-year-old girl is brought in with coughing, and you are told by her mother that she had been
playing with some beads and had apparently aspirated one (gotten it into her airway). Where
would you expect it to most likely be?

a. Apicoposterior segmental bronchus of left lung

b. Left main bronchus
c. Lingular segment of left lung
d. Right main bronchus
e. Terminal bronchiole of right lung

Because of its angle with the trachea and size of the main bronchus, a bronchoscope would
pass more readily into which lung?

a. Left
b. Right
References [Link]

Slide 2
• <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 3, 4
• <a href="[Link] J. Lynch, medical illustrator</a>, <a
href="[Link] BY 2.5</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Foreign Bodies
• Right vs left primary bronchi

2. Right Lung

Aspiration of • Superior lobe (apical, anterior, posterior)

• Middle lobe (lateral, medial)
Foreign Bodies & • Inferior lobe (superior, anterior basal, posterior
basal, lateral basal, medial basal)
Bronchopulmonary
3. Left Lung
Segments • Superior lobe (apicoposterior, anterior, superior
lingular, inferior lingular)
• Inferior lobe (superior, posterior basal, medial
basal, lateral basal, anterior basal)

4. Clinical Significance
• Pulmonary resection
• Lobectomy
REVIEW OUTLINE

1. Pneumonia

Lung
Diseases 2. Bronchogenic Carcinoma
 Pneumonia [Link]

Inflammation of the alveoli due to infection (bacteria, virus or fungi) or chemical injury

Symptoms
Cough
Chest pain
Fever
Difficulty breathing
Pneumonia [Link]

Normal Pneumonia
 Bronchogenic Carcinoma [Link]

Refers to any type of lung cancer that mostly arises in the mucosa of the large bronchi

Symptoms
Persistent cough
Hemoptysis
Bronchogenic Carcinoma [Link]
Knowledge Check [Link]

What is pneumonia?

Inflammation of the alveoli

Pneumonia can be caused by:

a. Bacteria
b. Virus
c. Fungi
d. All the above

Explain where and how a bronchogenic carcinoma may metastasize to other areas of the body.
Knowledge Check [Link]

What is pneumonia?

Inflammation of the alveoli

Pneumonia can be caused by:

a. Bacteria
b. Virus
c. Fungi
d. All the above

Explain where and how a bronchogenic carcinoma may metastasize to other areas of the body.

1. It may metastasize to the bronchial lymph nodes then to other thoracic and
supraclavicular lymph nodes
2. Tumor cells may invade the pulmonary veins to enter the left side of the heart
to the aorta to other areas such as the brain, bones, lungs, and suprarenal
glands
References [Link]

Slide 2
• Alveoli: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Chest X-Ray: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 3
• Normal: <a href="[Link] Rosen from USA</a>, <a
href="[Link] BY-SA 2.0</a>, via Wikimedia Commons
• Pneumonia: <a href="[Link] Rosen from USA</a>, <a
href="[Link] BY-SA 2.0</a>, via Wikimedia Commons

Slide 4
• Radiograph of small cell carcinoma in lungs by Yale Rosen, [Link] CC by 2.0
[Link]

Slide 5
• Alveoli with blood supply: <a
href="[Link]
ung,_the_pulmonary_alveoli_are_spherical_outcroppings_of_the_respiratory_bronchioles_and_are_the.png">LadyOfHats</a>, CC0, via Wikimedia
Commons
• Heart: <a href="[Link] Yaddah</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Pneumonia
• Causes
• Symptoms
• X-Ray
Lung • Histology

Diseases 2. Bronchogenic Carcinoma

• Causes
• Symptoms
• Metastases
REVIEW OUTLINE

1. Causes

2. Pressure Within Pleural Cavity

Pneumothorax 3. CT - Normal vs Pneumothorax

4. Hemothorax vs Hydrothorax

5. Treatment options
 Pneumothorax [Link]

Entry of air into the pleural cavity causing the lung to collapse

Causes
Penetrating stab wound or bullet
Fractured rib
Rupture of a pulmonary lesion
Lung disease

Types
Primary spontaneous
Secondary spontaneous
Traumatic

Pleural cavity

Parietal pleura
Visceral pleura
 Pneumothorax [Link]

Entry of air into the pleural cavity causing the lung to collapse

Normal: atmospheric pressure > pressure

within pleural cavity

Puncture: ↑ pressure within pleural cavity

Pleural cavity

Parietal pleura
Visceral pleura
Pneumothorax [Link]

Normal Pneumothorax
Hemothorax vs Hydrothorax [Link]

Hemothorax (hemo = blood) Hydrothorax (hydro = fluid)

Pleural effusion
Treatment Options [Link]

Thoracentesis

Needle inserted in the 9th

intercostal space at midaxillary line

Upright position allows fluid to

accumulate in costodiaphragmatic
recess

Chest Tube

Incision in the 5th or 6th intercostal

space at midaxillary line

Tube directed superiorly (air

removal) or inferiorly (fluid/blood
removal)
Knowledge Check [Link]

Explain how a pneumothorax occurs and the pressure changes that occur within the
pleural cavity.

When air enters the pleural cavity causing the lung to collapse

Normal: atmospheric pressure is greater than the pressure in the pleural cavity
Pneumothorax: air enters the pleural cavity increasing the pressure in the pleural cavity

You are called to perform a thoracentesis (remove fluid from the pleural cavity). If you
are to avoid injuring lung or neurovascular elements, where would you insert the
aspiration needle?

a. The top of the 8th intercostal space at midclavicular line

b. The bottom of the 8th intercostal space at the midclavicular line
c. The top of the 9th intercostal space at the midaxillary line
d. The bottom of the 9th intercostal space at the midaxillary line
Knowledge Check [Link]

Explain how a pneumothorax occurs and the pressure changes that occur within the
pleural cavity.

When air enters the pleural cavity causing the lung to collapse

Normal: atmospheric pressure is greater than the pressure in the pleural cavity
Pneumothorax: air enters the pleural cavity increasing the pressure in the pleural cavity

You are called to perform a thoracentesis (remove fluid from the pleural cavity). If you
are to avoid injuring lung or neurovascular elements, where would you insert the
aspiration needle?

a. The top of the 8th intercostal space at midclavicular line

b. The bottom of the 8th intercostal space at the midclavicular line
c. The top of the 9th intercostal space at the midaxillary line
d. The bottom of the 9th intercostal space at the midaxillary line
References [Link]

Slide 2, 3
• <a href="[Link] CC0, via Wikimedia
Commons

Slide 4
• Normal: <a
href="[Link]
3).jpg">Mikael Häggström</a>, CC0, via Wikimedia Commons
• Pneumothorax: <a href="[Link] Cases</a>, <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 5
• Hemothorax: <a
href="[Link]
Y</a>, <a href="[Link] BY 3.0</a>, via Wikimedia Commons
• Hydrothorax: <a href="[Link] Heilman, MD</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 6
• Thoracentesis: <a href="[Link] Heart,
Lung and Blood Institute</a>, Public domain, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

2. Pressure Within Pleural Cavity

Pneumothorax 3. CT - Normal vs Pneumothorax

4. Hemothorax vs Hydrothorax

5. Treatment options
• Thoracentesis
• Chest tube
REVIEW OUTLINE

1. Abdominal Quadrants

Anterior 2. Abdominal Regions

Abdominal
Wall

3. Referred Abdominal Pain

 Abdominal Quadrants [Link]

Right Upper Right Lower Left Upper Left Lower

Quadrant (RUQ) Quadrant (RLQ) Quadrant (LUQ) Quadrant (LLQ)

RUQ LUQ

RLQ LLQ
Abdominal Regions [Link]

RH
RL
RI
RH E LH
E
U
P/H

RL U LL LH
LL
LI

RI P/H LI
Referred Abdominal Pain [Link]

Referred Abdominal Pain Regions

RH E LH

RL U LL

RI P/H
P LI
Referred Abdominal Pain [Link]

Referred Abdominal Pain Regions

RH E LH

RL U LL

RI P/H
P LI
Referred Abdominal Pain [Link]

Referred Abdominal Pain Regions

RH E LH

RL U LL

RI P/H
P LI
Knowledge Check [Link]

The four abdominal quadrants are created following which two lines/planes? Select all that
apply.

a. Midclavicular line
b. Median plane
c. Subcostal plane
d. Transumbilical plane
e. Transtubercular plane

The nine abdominal regions are created following which three lines/planes? Select all that apply.

a. Midclavicular line
b. Median plane
c. Subcostal plane
d. Transumbilical plane
e. Transtubercular plane
Knowledge Check [Link]

The four abdominal quadrants are created following which two lines/planes? Select all that
apply.

a. Midclavicular line
b. Median plane
c. Subcostal plane
d. Transumbilical plane
e. Transtubercular plane

The nine abdominal regions are created following which three lines/planes? Select all that apply.

a. Midclavicular line
b. Median plane
c. Subcostal plane
d. Transumbilical plane
e. Transtubercular plane
Knowledge Check [Link]

A young patient comes into the clinic complaining of pain in the epigastric region of the
abdomen. Where is this pain most likely coming from?

a. Foregut
b. Midgut
c. Hindgut

Where would you most likely feel referred pain from the midgut?

a. Umbilical region
b. Epigastric region
c. Pubic/hypogastric region
Knowledge Check [Link]

A young patient comes into the clinic complaining of pain in the epigastric region of the
abdomen. Where is this pain most likely coming from?

a. Foregut
b. Midgut
c. Hindgut

Where would you most likely feel referred pain from the midgut?

a. Umbilical region
b. Epigastric region
c. Pubic/hypogastric region
References [Link]

Slide 2
• <a href="[Link] <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 3
• <a href="[Link] <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 4
• Regions: <a href="[Link] <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• Referred Pain: <a href="[Link] College</a>,
<a href="[Link] BY 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Abdominal Quadrants
• Right upper quadrant
• Right lower quadrant
• Left upper quadrant
• Left lower quadrant

Anterior 2. Abdominal Regions

Abdominal •
•
Right hypochondrium
Right flank/lateral region

Wall & •
•
Right inguinal
Epigastric

Referred Pain •
•
Umbilical
Pubic/hypogastric
• Left hypochondrium
• Left flank/lateral region
• Left inguinal

3. Referred Abdominal Pain

• Foregut
REVIEW OUTLINE

Sliding 1. Causes

Hiatal 2. Anterior & Posterior Vagal Trunks

Hernia
3. CT & X-Ray Imaging
Sliding Hiatal Hernia [Link]

Causes

Normal

Hiatal Hernia
Sliding Hiatal Hernia [Link]
Knowledge Check [Link]

A 77-year-old man presents to the emergency department complaining of chest pain, acid reflux and
difficulty swallowing. You perform a barium swallow to determine if there are any abnormalities in the upper
GI tract. Results are shown below.

Using the image, identify the hiatal hernia.

Which structure passes through the esophageal sphincter in

a sliding hiatal hernia?

Cardia of the stomach

Explain how this may lead to hyposecretion of gastric juices.

Knowledge Check [Link]

A 77-year-old man presents to the emergency department complaining of chest pain, acid reflux and
difficulty swallowing. You perform a barium swallow to determine if there are any abnormalities in the upper
GI tract. Results are shown below.

Using the image, identify the hiatal hernia.

Which structure passes through the esophageal sphincter in

a sliding hiatal hernia?

Cardia of the stomach

Explain how this may lead to hyposecretion of gastric juices.

Damage to the anterior and posterior vagal trunks since they

pass through the esophageal hiatus
References [Link]

Slide 2
• Normal vs Hiatal Hernia: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• <a href="[Link] © 2008 Elsevier Inc.</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 3
• CT Scan: <a href="[Link] Heilman, MD</a>, <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• X-Ray: <a href="[Link] Farhat and Daryn
Towle</a>, <a href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 4
• <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

Sliding 1. Causes

Hiatal 2. Anterior & Posterior Vagal Trunks

Hernia
3. CT & X-Ray Imaging
REVIEW OUTLINE

1. Causes & Symptoms

2. Gastric Ulcers

Peptic
Ulcers 2. Duodenal Ulcers
Peptic Ulcers [Link]

Causes

Symptoms
Posterior Gastric Ulcer [Link]

Erosion/Perforation
Posterior Gastric Ulcer [Link]

Erosion/Perforation
Lesser Curvature Ulcer [Link]

Erosion/Perforation
Duodenal Ulcers [Link]

Erosion/Perforation
Knowledge Check [Link]

Explain the relationship between posterior gastric ulcers and pancreatitis.

The posterior gastric ulcer may erode through the stomach wall and invade into the pancreas
causing inflammation and referred pain.

A 60-year-old male executive who has a history of chronic gastric ulcers was admitted to the
ER exhibiting signs of a severe internal hemorrhage. He was quickly diagnosed with
perforation of the posterior wall of the stomach and erosion of an artery behind it. The artery is
most likely the:

a. Common hepatic
b. Splenic
c. Gastroduodenal
d. Left gastric
e. Celiac trunk
Knowledge Check [Link]

Explain the relationship between posterior gastric ulcers and pancreatitis.

The posterior gastric ulcer may erode through the stomach wall and invade into the pancreas
causing inflammation and referred pain.

A 60-year-old male executive who has a history of chronic gastric ulcers was admitted to the
ER exhibiting signs of a severe internal hemorrhage. He was quickly diagnosed with
perforation of the posterior wall of the stomach and erosion of an artery behind it. The artery is
most likely the:

a. Common hepatic
b. Splenic
c. Gastroduodenal
d. Left gastric
e. Celiac trunk
Knowledge Check [Link]

A patient was diagnosed with a bleeding ulcer of the lesser curvature of the stomach. Which
artery is most likely involved?

a. Gastroduodenal
b. Left gastric
c. Splenic
d. Common hepatic
e. Superior pancreaticoduodenal

A patient was diagnosed with a bleeding ulcer on the first part of the duodenum. Which artery
is most likely involved?

a. Gastroduodenal
b. Left gastric
c. Splenic
d. Common hepatic
e. Superior pancreaticoduodenal
Knowledge Check [Link]

A patient was diagnosed with a bleeding ulcer of the lesser curvature of the stomach. Which
artery is most likely involved?

a. Gastroduodenal
b. Left gastric
c. Splenic
d. Common hepatic
e. Superior pancreaticoduodenal

A patient was diagnosed with a bleeding ulcer on the first part of the duodenum. Which artery
is most likely involved?

a. Gastroduodenal
b. Left gastric
c. Splenic
d. Common hepatic
e. Superior pancreaticoduodenal
References [Link]

Slide 2
• Ulcer in Stomach: <a
href="[Link]
>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Esophagogastroduodenoscopy: <a href="[Link] Public
domain, via Wikimedia Commons

Slide 3
• Sagittal View Abdomen: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Referred Pain Chart: <a href="[Link] College</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 4, 5
• Sagittal View Abdomen: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Arterial Supply: <a href="[Link] M DePace, PhD</a>, <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 6
• <a href="[Link] M DePace, PhD</a>, <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes & Symptoms

2. Gastric Ulcers
• Posterior Gastric Ulcer
Peptic • Lesser Curvature Ulcer
• Erosion/perforation

Ulcers 2. Duodenal Ulcers

• Erosion/perforation
REVIEW OUTLINE

1. Collection Sites

2. Role of Bile

Gallstones
(Cholelithiasis) 3. Types of Gallstones

4. Symptoms

5. Diagnosis & Treatment

 Gallstones (Cholelithiasis) [Link]

Role of Bile

Two Types of Gallstones

Hepatopancreatic ampulla
(sphincter of Oddi)
Duodenum
 Gallstones (Cholelithiasis) [Link]

Symptoms

Hepatopancreatic ampulla
(sphincter of Oddi)
Duodenum
 Gallstones (Cholelithiasis) [Link]

Symptoms

Hepatopancreatic ampulla
(sphincter of Oddi)
Duodenum
Gallstones (Cholelithiasis) [Link]

Gallstones within the Gallbladder (GB)

Impaction of the GB

Inflammation of the GB
Gallstones (Cholelithiasis) [Link]

Diagnosis & Treatment

Ultrasonography
Cholecystectomy
Knowledge Check [Link]

What is the role of bile?

What are the two types of gallstones? How can we differentiate between them?

Explain why inflammation of the gallbladder would irritate the phrenic nerve
and why the pain could present in the right shoulder.
Knowledge Check [Link]

What is the role of bile?

• Helps digest fasts

• Carries waste

What are the two types of gallstones? How can we differentiate between them?

1. Cholesterol stones: yellow in color, cholesterol

2. Pigment stones: dark in color, bilirubin

Explain why inflammation of the gallbladder would irritate the phrenic nerve
and why the pain could present in the right shoulder.

Phrenic nerve provides sensory innervation to the GB and irritation would

cause pain in dermatomes C3-C5.
 References [Link]

Slide 2
• Biliary system: <a href="[Link]
Research UK uploader</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Cholesterol stones: Small Gallstone by Keith Roper, [Link] CC by 2.0
[Link]
• Pigment stones: <a href="[Link] (The Scope) at English
Wikipedia</a>, <a href="[Link] BY 2.5</a>, via Wikimedia Commons

Slide 3
• Biliary system: <a href="[Link]
Research UK uploader</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 4
• Gallbladder: <a href="[Link] Public domain, via Wikimedia
Commons
• Jaundice: <a href="[Link] James</a>, <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 5
• Ultrasound: <a
href="[Link]
© Nevit Dilmen</a>, <a href="[Link] BY-SA 3.0</a>, via Wikimedia
Commons
• Cholecystectomy: <a href="[Link]
Public domain, via Wikimedia Commons
REVIEW OUTLINE

1. Collection Sites
• Gallbladder
• Cystic duct
• Common bile duct
• Hepatopancreatic ampulla

2. Role of Bile

Gallstones •
•
Lipid digestion
Waste

(Cholelithiasis) 3. Types of Gallstones

• Cholesterol stones
• Pigment stones

4. Symptoms
• Gallbladder
• Cystic duct
• Common bile duct

5. Diagnosis & Treatment

REVIEW OUTLINE

1. Causes

2. Portocaval Anastomoses

Portal
Hypertension 3. Other Symptoms

4. Distal Splenorenal Shunt

Portal Hypertension [Link]
Portal Hypertension [Link]

Portocaval Anastomoses

1) Esophageal anastomosis

Tributaries of
azygos v.

Left gastric v.

Hepatic portal v.
Portal Hypertension [Link]

Portocaval Anastomoses

1) Esophageal anastomosis

2) Umbilical anastomosis
Portal Hypertension [Link]

Portocaval Anastomoses

1) Esophageal anastomosis

2) Umbilical anastomosis

3) Rectal anastomosis
Portal Hypertension [Link]

Portocaval Anastomoses

1) Esophageal anastomosis

2) Umbilical anastomosis

3) Rectal anastomosis

Other Symptoms
Portal Hypertension [Link]

Distal Splenorenal Shunt

Splenic v. Splenic v.

Hepatic Hepatic
portal v. portal v.

IVC IVC

Left renal v. Left renal v.

Before Shunt After Shunt

Knowledge Check [Link]

Group the following veins with their portocaval anastomoses.

Paraumbilical v. Esophageal
Inferior rectal v.
Left gastric v. Umbilical
Azygos v.
Superior & inferior epigastric v. Rectal
Superior rectal v.

During a distal splenorenal shunt, the splenic vein is detached from the ______ vein and
attached to the _____ vein.

a. Hepatic portal, right renal

b. Inferior vena cava, left renal
c. Inferior vena cava, right renal
d. Hepatic portal, left renal
Knowledge Check [Link]

Group the following veins with their portocaval anastomoses.

Paraumbilical v. Esophageal
Inferior rectal v.
Left gastric v. Umbilical
Azygos v.
Superior & inferior epigastric v. Rectal
Superior rectal v.

During a distal splenorenal shunt, the splenic vein is detached from the ______ vein and
attached to the _____ vein.

a. Hepatic portal, right renal

b. Inferior vena cava, left renal
c. Inferior vena cava, right renal
d. Hepatic portal, left renal
References [Link]

Slide 2
• <a href="[Link] Vandyke Carter</a>, Public domain, via Wikimedia Commons

Slide 3
• Esophageal anastomosis: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Esophageal varices: Esophageal varices being banded, showing white ball sign and wale sign by Samir,
[Link] CC by
3.0 [Link]

Slide 4
• Caput medusae: <a href="[Link] Yang, M.D., Ph.D., and Ding-Shinn
Chen, M.D.</a>, Attribution, via Wikimedia Commons
Slide 5
• Internal hemorrhoids: <a
href="[Link]
.com/en</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

2. Portocaval Anastomoses

Portal
• Esophageal anastomoses
• Umbilical anastomoses
• Rectal anastomoses
Hypertension 3. Other Symptoms

4. Distal Splenorenal Shunt

REVIEW OUTLINE

1. Causes

Meckel’s
2. Rule of 2s

Diverticulum
3. Clinical Relevance
Meckel’s Diverticulum [Link]

Rule of 2s

Clinical Relevance

Treatment
Knowledge Check [Link]

A 18-year-old male arrives to the emergency department presenting with pain in the lower right
quadrant. You suspect appendicitis or Meckel’s diverticulum and order a CT scan to confirm a
diagnosis. CT suggests Meckel’s diverticulum.

Which early derivative of the GI system is responsible for this condition?

Vitellointestinal duct (omphalo-enteric duct/yolk stalk)

Although often asymptomatic, explain how Meckel’s diverticulum may produce pain that mimics
appendicitis.
Knowledge Check [Link]

A 18-year-old male arrives to the emergency department presenting with pain in the lower right
quadrant. You suspect appendicitis or Meckel’s diverticulum and order a CT scan to confirm a
diagnosis. CT suggests Meckel’s diverticulum.

Which early derivative of the GI system is responsible for this condition?

Vitellointestinal duct (omphalo-enteric duct/yolk stalk)

Although often asymptomatic, explain how Meckel’s diverticulum may produce pain that mimics
appendicitis.

Perforation may occur due to ectopic gastric or pancreatic tissue that may be within the
mucosa causing ulceration and inflammation.
References [Link]

Slide 2
• <a href="[Link]
<a href="[Link] BY-SA 3.0</a>, via
Wikimedia Commons
REVIEW OUTLINE

1. Causes
• Vitellointestinal duct (omphalo-enteric duct)

Meckel’s
2. Rule of 2s
• Incidence
• Location
Diverticulum • Length

3. Clinical Relevance
• Symptoms
• Treatment
REVIEW OUTLINE

1. Causes

2. CT Scan

3. Referred Pain
Appendicitis
4. Treatment
Appendicitis [Link]

Causes
Appendicitis [Link]

Treatment
Knowledge Check [Link]

A 27-year-old woman reported to the emergency department with abdominal pain that began in the peri-
umbilical region and has now localized to the right lower quadrant. You suspect appendicitis and order a
blood test and CT scan to confirm your diagnosis.

Explain the cause of appendicitis and how it can lead to inflammation of the appendix.

Hyperplasia of lymphatic follicles that occlude the lumen. This prevents the secretions from leaving the
appendix causing inflammation

Explain why pain begins in the periumbilical region then occurs in the right lower quadrant.

Vague pain from afferent fibers that enter the spinal cord at T10. As the appendix swells, it can
irritate the parietal peritoneum causing localized pain.

What is the name of the area where localized pain is occurring?

Knowledge Check [Link]

A 27-year-old woman reported to the emergency department with abdominal pain that began in the peri-
umbilical region and has now localized to the right lower quadrant. You suspect appendicitis and order a
blood test and CT scan to confirm your diagnosis.

Explain the cause of appendicitis and how it can lead to inflammation of the appendix.

Hyperplasia of lymphatic follicles that occlude the lumen. This prevents the secretions from leaving the
appendix causing inflammation

Explain why pain begins in the periumbilical region then occurs in the right lower quadrant.

Vague pain from afferent fibers that enter the spinal cord at T10. As the appendix swells, it can
irritate the parietal peritoneum causing localized pain.

What is the name of the area where localized pain is occurring?

McBurney’s point
References [Link]

Slide 2
• Inflamed Appendix: <a
href="[Link]
/en</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• CT Scan: <a href="[Link] Heilman, MD</a>, <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 3
• Dermatome Map: <a href="[Link] Stephan
([Link] Public domain, via Wikimedia Commons
• McBurney’s Point: <a
href="[Link] Häggströmde la
traducción Ortisa</a>, <a href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes
• Young people vs older people

2. CT Scan

3. Referred Pain
Appendicitis • Peri-umbilical region
• McBurney’s point

4. Treatment
• Antibiotics
• Appendectomy
REVIEW OUTLINE

1. Causes

2. Risk Factors

Volvulus
3. Symptoms

4. Diagnosis

5. Treatment Methods
Volvulus [Link]

Volvulus of the Sigmoid Colon

Risk Factors

Symptoms
Volvulus [Link]

Treatment

CT Scan X-Ray
Knowledge Check [Link]

A 48-year-old female presents to the emergency department with abdominal distension and
pain, constipation, and bloody stool. Based on the symptoms, you suspect a volvulus but order
a CT to confirm your diagnosis. The results are demonstrated in the image below.

Locate the volvulus on the CT scan.

Which two procedures would you perform to

accurately diagnose and correct the volvulus?
Knowledge Check [Link]

A 48-year-old female presents to the emergency department with abdominal distension and
pain, constipation, and bloody stool. Based on the symptoms, you suspect a volvulus but order
a CT to confirm your diagnosis. The results are demonstrated in the image below.

Locate the volvulus on the CT scan.

Which two procedures would you perform to

accurately diagnose and correct the volvulus?

Sigmoidoscopy & colonoscopic detorsion

References [Link]

Slide 2
• Cartoon Volvulus: <a href="[Link] Heilman, MD</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Non-Necrotic Volvulus: <a href="[Link] CC0, via Wikimedia
Commons
• Necrotic Volvulus: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 3
• CT Scan: <a
href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• X-Ray: <a href="[Link] CC0, via Wikimedia
Commons

Slide 4
• <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes
• Children vs adults

2. Risk Factors

Volvulus
3. Symptoms

4. Diagnosis
• CT Scan
• X-Ray

5. Treatment Methods
REVIEW OUTLINE

1. Causes

Hirschsprung’s 2. Risk Factors

Disease 3. Symptoms

4. Treatment Methods
Hirschsprung’s Disease [Link]

(descending & sigmoid)

Parasympathetic Innervation
Hirschsprung’s Disease [Link]

(descending & sigmoid)

Risk Factors

Symptoms

Treatment
Knowledge Check [Link]

A 34-hour-old male neonate born at 39 weeks’ gestation presents with abdominal distension
and a failure to pass meconium after 24 hours. You suspect Hirschsprung’s disease.

Which organs of the GI tract are normally affected in this condition?

Descending colon, sigmoid colon, or rectum

Which plexuses of the parasympathetic nervous system are affected? Select all that apply.

a. Inferior hypogastric plexus

b. Myenteric (Auerbach’s) plexus
c. Inferior mesenteric plexus
d. Abdominal aortic plexus
e. Submucosal (Meissner’s) plexus
Knowledge Check [Link]

A 34-hour-old male neonate born at 39 weeks’ gestation presents with abdominal distension
and a failure to pass meconium after 24 hours. You suspect Hirschsprung’s disease.

Which organs of the GI tract are normally affected in this condition?

Descending colon, sigmoid colon, or rectum

Which plexuses of the parasympathetic nervous system are affected? Select all that apply.

a. Inferior hypogastric plexus

b. Myenteric (Auerbach’s) plexus
c. Inferior mesenteric plexus
d. Abdominal aortic plexus
e. Submucosal (Meissner’s) plexus
References [Link]

Slide 2
• <a
href="[Link]
edicine_(1906)_(14757309595).jpg">Internet Archive Book Images</a>, No restrictions, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

Hirschsprung’s 2. Risk Factors

Disease 3. Symptoms

4. Treatment Methods
REVIEW OUTLINE

1. Causes

2. Risk Factors
Mesenteric 3. Symptoms
Ischemia 4. Diagnosis

5. Treatment Methods
Mesenteric Ischemia [Link]

Risk Factors

Symptoms
(acute)
(chronic)
(chronic)
Mesenteric Ischemia [Link]

Diagnosis

Treatment Methods
Knowledge Check [Link]

What are the main causes of mesenteric ischemia?

Embolism, thrombosis, or atherosclerosis

Which arteries are affected in mesenteric ischemia?

a. Jejunal arteries
b. Arcades
c. Ileal arteries
d. Vasa recta
e. Superior mesenteric artery
Knowledge Check [Link]

What are the main causes of mesenteric ischemia?

Embolism, thrombosis, or atherosclerosis

Which arteries are affected in mesenteric ischemia?

a. Jejunal arteries
b. Arcades
c. Ileal arteries
d. Vasa recta
e. Superior mesenteric artery
References [Link]

Slide 2
• <a href="[Link] em</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 3
• <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

2. Risk Factors
Mesenteric 3. Symptoms
Ischemia 4. Diagnosis

5. Treatment Methods
REVIEW OUTLINE

1. Pancreatic Cancer

Diseases of
2. Accidental Removal of the Tail of the Pancreas
the Pancreas
3. Annular Pancreas
Pancreatic Cancer [Link]

Cancer of the Head of the Pancreas

x
Pancreatic Cancer [Link]

Whipple Procedure (Pancreatoduodenectomy)

Pancreatic Cancer [Link]

Cancer of the Neck & Body of the Pancreas

NECK
Pancreatic Cancer [Link]

Cancer of the Neck & Body of the Pancreas

x
Pancreatic Cancer [Link]

Cancer of the Neck & Body of the Pancreas

Treatment
Accidental Removal of the Tail of the Pancreas [Link]
Annular Pancreas [Link]

Symptoms
Knowledge Check [Link]

Explain how cancer of the head of the pancreas can lead to obstructive jaundice and pancreatitis.

The surgical removal of the _____ may lead to the accidental removal of the tail of the pancreas.

a. First part of the duodenum

b. Quadrate lobe of the liver
c. Portion of the stomach
d. Spleen
e. Gallbladder

Which outgrowths during embryological development are responsible for

producing an annular pancreas?
Knowledge Check [Link]

Explain how cancer of the head of the pancreas can lead to obstructive jaundice and pancreatitis.

• Obstructive jaundice: due to obstruction of the common bile duct or hepatopancreatic ampulla
• Pancreatitis: due to bile entering the pancreatic duct

The surgical removal of the _____ may lead to the accidental removal of the tail of the pancreas.

a. First part of the duodenum

b. Quadrate lobe of the liver
c. Portion of the stomach
d. Spleen
e. Gallbladder

Which outgrowths during embryological development are responsible for

producing an annular pancreas?

Ventral and dorsal pancreatic buds

References [Link]

Slide 2
• <a href="[Link] When using this image in external sources it can be cited
as:[Link] staff (2014). &quot;Medical gallery of Blausen Medical 2014&quot;. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN
2002-4436.</a>, <a href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 3
• <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 4
• <a href="[Link] When using this image in external sources it can be cited
as:[Link] staff (2014). &quot;Medical gallery of Blausen Medical 2014&quot;. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN
2002-4436.</a>, <a href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 5
• <a href="[Link] Public
domain, via Wikimedia Commons

Slide 6
• <a href="[Link] Klinikum</a>, <a
href="[Link] BY-SA 3.0 DE</a>, via Wikimedia Commons

Slide 7
• <a href="[Link] College</a>,
<a href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 8
• <a href="[Link] Suckale,
Michele Solimena</a>, <a href="[Link] BY 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Pancreatic Cancer
• Head of the pancreas
• Whipple procedure (pancreatoduodenectomy)
• Neck & body of the pancreas

Diseases of • Distal pancreatectomy

2. Accidental Removal of the Tail of the Pancreas

the Pancreas • Splenectomy

3. Annular Pancreas
• Cause
• Symptoms
REVIEW OUTLINE

1. Paralysis of ½ of the Diaphragm

Injury to the
Diaphragm 2. Diaphragmatic Ruptures
Paralysis of ½ of the Diaphragm [Link]

Caused by injury (surgery, trauma or disease) to the

phrenic nerve on the same side

Paradoxical Movement
Normal inspiration
Paralysis of the right phrenic nerve - injured side
pushed superiorly by abdominal viscera
Paralysis of ½ of the Diaphragm [Link]

Caused by injury (surgery, trauma or disease) to the

phrenic nerve on the same side

Paradoxical Movement
Normal expiration
Paralysis of the right phrenic nerve - injured side
pushed inferiorly due to positive pressure in
lungs
Diaphragmatic Ruptures [Link]

Caused by blunt or penetrating trauma (e.g. motor vehicle accidents) due to sudden
increase in intrathoracic or intra-abdominal pressure

80-90% of ruptures occur on the left side posterolaterally

Lumbocostal triangle
(Bochdalek’s foramen)
Knowledge Check [Link]

A 45-year-old woman suffered a left phrenic nerve injury after cardiac surgery.
Explain paradoxical movement and the position of the diaphragm during
inspiration and expiration.

Where are diaphragmatic ruptures more likely to occur and why?

Knowledge Check [Link]

A 45-year-old woman suffered a left phrenic nerve injury after cardiac surgery.
Explain paradoxical movement and the position of the diaphragm during
inspiration and expiration.

Inspiration – left side pushed superiorly as the right side is pushed inferiorly
Expiration – left side pushed inferiorly as the right side is pushed superiorly

Where are diaphragmatic ruptures more likely to occur and why?

Left side due to the liver attenuates compressive forces on the right side

Posterolaterally due to the lumbocostal triangle (Bochdalek’s foramen)

References [Link]

Slide 2, 3
• <a href="[Link] Vandyke Carter</a>, Public domain, via Wikimedia
Commons

Slide 4
• <a href="[Link] original uploader was Lauroma at Portuguese
Wikipedia.</a>, Public domain, via Wikimedia Commons
• <a href="[Link] Vilallonga, Vicente
Pastor, Laura Alvarez, Ramon Charco, Manel Armengol and Salvador Navarro</a>, <a
href="[Link] BY 2.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Paralysis of ½ of the Diaphragm

• Causes
• Affected nerve

Injury to the • Paradoxical movement

Diaphragm 2. Diaphragmatic Ruptures

• Causes
• Location
• Lumbocostal triangle
REVIEW OUTLINE

1. Causes

2. Symptoms

Abdominal 3. Diagnosis

Aortic
Aneurysm 4. Treatment
Abdominal Aortic Aneurysm [Link]

Causes

Symptoms

With rupture – 90% mortality rate:

L4
Abdominal Aortic Aneurysm [Link]

Diagnosis

L3

L4
Abdominal Aortic Aneurysm [Link]

Treatment

Open Abdominal Surgery Endovascular Aneurysm Repair (EVAR)

Knowledge Check [Link]

A 48-year-old female smoker with a history of atherosclerosis and hypertension presents with
deep and persistent abdominal pain. Upon palpation, you feel a pulse towards the left of the
umbilicus. You suspect an abdominal aortic aneurysm and order a CT scan to confirm your
diagnosis.

Identify the abdominal aortic aneurysm on the CT.

At which vertebral level do these aneurysms

most likely occur?

L4

Upon examination, you realize the aneurysm

is 2.3 inches long. Does this require repair?
Knowledge Check [Link]

A 48-year-old female smoker with a history of atherosclerosis and hypertension presents with
deep and persistent abdominal pain. Upon palpation, you feel a pulse towards the left of the
umbilicus. You suspect an abdominal aortic aneurysm and order a CT scan to confirm your
diagnosis.

Identify the abdominal aortic aneurysm on the CT.

At which vertebral level do these aneurysms

most likely occur?

L4

Upon examination, you realize the aneurysm

is 2.3 inches long. Does this require repair?

Yes because it’s greater than 1.9 inches (open abdominal surgery or EVAR)
References [Link]

Slide 2
• Thoracic vs Abdominal: <a
href="[Link] Institutes of Health</a>,
Public domain, via Wikimedia Commons

Slide 3
• CT: <a href="[Link] de Villeneuve</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Ultrasound: <a
href="[Link]
[Link]">Mikael Häggström, M.D. - Author info - Reusing images- Conflicts of interest: NoneMikael
HäggströmConsent note: Written informed consent was obtained from the individual, including online
publication.</a>, CC0, via Wikimedia Commons

Slide 4
• Open Surgery: <a
href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• EVAR: <a href="[Link] Institutes of
Health</a>, Public domain, via Wikimedia Commons

Slide 5
• <a href="[Link] Heilman, MD</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

2. Symptoms

Abdominal
• No rupture vs rupture

3. Diagnosis

Aortic • Palpation
• Medical imaging

Aneurysm 4. Treatment
• Watchful waiting
• Open abdominal surgery
• Endovascular aneurysm repair
REVIEW OUTLINE

1. Causes

2. Common Lodge Sites

Kidney Stones
3. Symptoms
(Nephrolithiasis)
4. Treatment
Kidney Stones [Link]
Kidney Stones [Link]
Kidney Stones [Link]

Symptoms
Kidney Stones [Link]

Treatment
Knowledge Check [Link]

On the radiograph below, identify the kidney stones.

Knowledge Check [Link]

On the radiograph below, identify the kidney stones.

Knowledge Check [Link]

On the image below, identify and name the three narrow areas where kidney stones are likely
to become lodged.
Knowledge Check [Link]

On the image below, identify and name the three narrow areas where kidney stones are likely
to become lodged.

1. Ureteropelvic junction

2. Ureteral crossing of iliac vessels

3. Ureterovesical junction
References [Link]

Slide 2
• Kidney stones in kidney: <a href="[Link] When using this image in external
sources it can be cited as:[Link] staff (2014). &quot;Medical gallery of Blausen Medical 2014&quot;. WikiJournal of Medicine 1 (2).
DOI:10.15347/wjm/2014.010. ISSN 2002-4436.</a>, <a href="[Link] BY 3.0</a>, via Wikimedia Commons
• Kidney stones: <a
href="[Link]
D0%BA%D0%B0%D0%BC%D0%B5%D1%9A%D0%B0_5.jpg">Jakupica</a>, <a href="[Link] BY-SA 4.0</a>, via
Wikimedia Commons

Slide 3
• Urinary system: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 4
• <a href="[Link] College</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 5
• X-Ray: <a href="[Link] Rhodes from
Asheville</a>, <a href="[Link] BY 2.0</a>, via Wikimedia Commons
• CT: <a href="[Link] Heilman, MD</a>, <a href="[Link]
BY-SA 3.0</a>, via Wikimedia Commons

Slide 6, 7
• Urinary system: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 8
• <a href="[Link] Nevit Dilmen</a>, <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

2. Common Lodge Sites

• Ureteropelvic junction
• Ureteral crossing of iliac vessels
• Ureterovesical junction
Kidney Stones
3. Symptoms
(Nephrolithiasis) • Referred pain chart

4. Treatment
• Medications
• ESWL
• Surgery
REVIEW OUTLINE

1. Indirect Inguinal Hernia

Inguinal
Hernias 2. Direct Inguinal Hernia
Indirect Inguinal Hernia [Link]

Most common form of hernias (~75% of abdominal hernias)

Congenital due to patency of the processus vaginalis

Deep inguinal ring

Inguinal canal

Superficial inguinal ring

Transversalis fascia

Scrotum Occurs lateral to inferior Internal oblique

External oblique
epigastric artery External oblique aponeurosis
Spermatic cord
Small intestine
 Direct Inguinal Hernia [Link]

Accounts for 15% of inguinal hernias

Caused by weak abdominal muscles

Hesselbach’s triangle Transversalis fascia

Occurs medial to inferior Internal oblique
External oblique
epigastric artery External oblique aponeurosis
Spermatic cord
Superficial inguinal ring Small intestine
Knowledge Check [Link]

A man is moving into a new house and during the process lifts a large chest of drawers. He
feels a severe pain in the lower right quadrant of his abdomen. Surgery is indicated and during
the surgery, the surgeon open the inguinal region and finds a hernial sac with intestine
projecting through the abdominal wall and lateral to the inferior epigastric vessels. The hernia
was diagnosed as:

a. A direct inguinal hernia

b. A femoral hernia
c. An indirect inguinal hernia
d. A congenital inguinal hernia

What are the borders of Hesselbach’s triangle?

Knowledge Check [Link]

A man is moving into a new house and during the process lifts a large chest of drawers. He
feels a severe pain in the lower right quadrant of his abdomen. Surgery is indicated and during
the surgery, the surgeon open the inguinal region and finds a hernial sac with intestine
projecting through the abdominal wall and lateral to the inferior epigastric vessels. The hernia
was diagnosed as:

a. A direct inguinal hernia

b. A femoral hernia
c. An indirect inguinal hernia
d. A congenital inguinal hernia

What are the borders of Hesselbach’s triangle?

Medially - rectus abdominis

Laterally - inferior epigastric vessels
Inferiorly - inguinal ligament
References [Link]

Slide 2
• Spermatic cord & scrotum: <a
href="[Link]
Archive Book Images</a>, No restrictions, via Wikimedia Commons
• Hesselbach’s triangle: <a href="[Link] Vandyke Carter</a>, Public
domain, via Wikimedia Commons
REVIEW OUTLINE

1. Indirect Inguinal Hernia

• Causes
• Deep inguinal ring
• Inguinal canal

Inguinal • Superficial inguinal ring

• Scrotum

Hernias 2. Direct Inguinal Hernia

• Causes
• Hesselbach’s triangle
• Superficial inguinal ring
REVIEW OUTLINE

1. Location
Rectouterine
Pouch (Pouch
of Douglas)
2. Culdocentesis
Rectouterine Pouch (Pouch of Douglas) [Link]
 Rectouterine Pouch (Pouch of Douglas) [Link]

Culdocentesis
Knowledge Check [Link]

Explain the difference between the vesicouterine and rectouterine pouches.

Vesicouterine pouch – between the bladder and uterus

Rectouterine pouch – between the uterus and rectum, location of pelvic abscess

You are asked to perform a culdocentesis on a 45-year-old female patient with a

pelvic abscess. Where will you insert the needle?
Knowledge Check [Link]

Explain the difference between the vesicouterine and rectouterine pouches.

Vesicouterine pouch – between the bladder and uterus

Rectouterine pouch – between the uterus and rectum, location of pelvic abscess

You are asked to perform a culdocentesis on a 45-year-old female patient with a

pelvic abscess. Where will you insert the needle?

Through the vaginal canal and posterior vaginal fornix into the rectouterine
pouch
References [Link]

Slide 2, 3
• <a href="[Link] When using
this image in external sources it can be cited as:[Link] staff (2014). &quot;Medical gallery of Blausen Medical
2014&quot;. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.</a>, <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Location
Rectouterine • Rectouterine pouch
• Vesicouterine pouch
Pouch (Pouch
of Douglas)
2. Culdocentesis
• Pelvic abscess
REVIEW OUTLINE

1. Causes

2. Symptoms

Varicocele 3. Diagnosis

4. Treatment
Varicocele [Link]
Varicocele [Link]

Causes
Varicocele [Link]

Symptoms

However:
Varicocele [Link]

Diagnosis

Ultrasound
Treatment

CT
Knowledge Check [Link]

Engorgement of the ____________ leads to a worm-like scrotal mass.

Explain why a varicocele can lead to fertility issues.

Why do varicoceles mostly occur on the left side?

Knowledge Check [Link]

Engorgement of the ____________ leads to a worm-like scrotal mass.

Pampiniform venous plexus (PVP)

Explain why a varicocele can lead to fertility issues.

The PVP cools blood within the testicular artery before it enters into the
testicles allowing an optimal temperature for good sperm production.
Enlargement of this plexus overheats the testicles, lowering sperm
production/function.

Why do varicoceles mostly occur on the left side?

The left testicular vein enters the left renal vein at a 90° angle making it more
susceptible to obstruction/reversal of flow.
References [Link]

Slide 2
• Pampiniform venous plexus: <a
href="[Link] Archive Book
Images</a>, No restrictions, via Wikimedia Commons
• Tributaries IVC: <a href="[Link] John Charles Boileau</a>, Public
domain, via Wikimedia Commons

Slide 3
• Varicose veins: <a href="[Link] modified from Varicose [Link] of
National Heart Lung and Blood Institute (NIH)</a>, <a href="[Link] BY-SA 3.0</a>, via
Wikimedia Commons
• Tributaries IVC: <a href="[Link] John Charles Boileau</a>, Public
domain, via Wikimedia Commons

Slide 4
• Pampiniform venous plexus: <a
href="[Link] Archive Book
Images</a>, No restrictions, via Wikimedia Commons

Slide 5
• CT: <a
href="[Link]
>Hellerhoff</a>, <a href="[Link] BY-SA 4.0</a>, via
Wikimedia Commons
• Ultrasound: <a href="[Link]
Mak and Wen-Sheng Tzeng</a>, <a href="[Link] BY 3.0</a>, via
Wikimedia Commons
REVIEW OUTLINE

1. Causes
• Pampiniform venous plexus
• Testicular vein (left renal vein, IVC)

2. Symptoms

Varicocele
• Fertility & the pampiniform venous plexus

3. Diagnosis
• Computed topography (CT)
• Ultrasonography

4. Treatment
REVIEW OUTLINE

1. Venous Drainage & Sensory Innervation of the

Rectum/Anus

2. Causes

Hemorrhoids 3. Internal Hemorrhoids

4. External Hemorrhoids
Hemorrhoids [Link]

Venous Drainage & Sensory

Innervation of the Rectum/Anus

Pectinate line
Hemorrhoids [Link]

Two Types
1.
2.

Pectinate line
Internal Hemorrhoids [Link]
External Hemorrhoids [Link]
Knowledge Check [Link]

Describe the venous drainage of the rectum.

Explain why internal hemorrhoids are mostly painless whereas external hemorrhoids are
painful.
Knowledge Check [Link]

Describe the venous drainage of the rectum.

• Internal venous plexus → superior rectal v. → inferior mesenteric v. → splenic v. →

hepatic portal v.
• External venous plexus → inferior rectal v. → internal pudendal v. → internal iliac v. →
common iliac v. → IVC

Explain why internal hemorrhoids are mostly painless whereas external hemorrhoids are
painful.

• Internal venous plexus – superior to pectinate line, innervated by visceral

afferent n.
• External venous plexus – inferior to pectinate line, innervated by somatic
afferent n.
References [Link]

Slide 2, 3
• <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 4
• Grades internal hemorrhoid: <a href="[Link] Dr.
A. Herold, End- und Dickdarm-Zentrum Mannheim</a>, <a href="[Link] BY
3.0</a>, via Wikimedia Commons
• Rectum & anus: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 5
• Rectum & anus: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Thrombosed external hemorrhoid: <a href="[Link]
Gebbensleben, York Hilger and Henning Rohde</a>, <a href="[Link] BY
2.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Venous Drainage & Sensory Innervation of the

Rectum/Anus
• Superior & inferior rectal veins
• Visceral & somatic afferent fibers

2. Causes

Hemorrhoids 3. Internal Hemorrhoids

• Location
• Symptoms

4. External Hemorrhoids
• Location
• Symptoms
REVIEW OUTLINE

1. Fascial Layers of the Perineum

Rupture of
the Male 2. Areas of Urine Leakage

Urethra
Rupture of the Male Urethra [Link]
Rupture of the Male Urethra [Link]
Rupture of the Male Urethra [Link]

Symptoms

Treatment
Knowledge Check [Link]

A 43-year-old presents with abdominal tenderness and pain, difficulty urinating, and swelling around the
scrotum. You suspect a urethral injury so you inject a dye into the urethra and order an X-ray. The results
demonstrate urine within the scrotum, penis, and anterior abdominal wall.

Which part of the urethra is ruptured?

Which layer of fascia has also been ruptured?

a. Scarpa’s fascia
b. Dartos fascia
c. Buck’s fascia
d. Colle’s fascia

Explain why urine won’t leak into the anal triangle.

Knowledge Check [Link]

A 43-year-old presents with abdominal tenderness and pain, difficulty urinating, and swelling around the
scrotum. You suspect a urethral injury so you inject a dye into the urethra and order an X-ray. The results
demonstrate urine within the scrotum, penis, and anterior abdominal wall.

Which part of the urethra is ruptured?

Spongy urethra

Which layer of fascia has also been ruptured?

a. Scarpa’s fascia
b. Dartos fascia
c. Buck’s fascia
d. Colle’s fascia

Explain why urine won’t leak into the anal triangle.

Due to the continuation of the superficial (Colle’s) perineal fascia with the deep
(Buck’s) perineal fascia
References [Link]

Slides 2, 3, 4
• <a href="[Link] Anatomy and
PhysiologyOpenStax</a>, <a href="[Link] BY 4.0</a>, via Wikimedia
Commons
REVIEW OUTLINE

1. Fascial Layers of the Perineum

• Scarpa’s fascia

Rupture of • Buck’s fascia

• Dartos fascia

the Male
• Colle’s fascia

2. Areas of Urine Leakage

Urethra • Superficial perineal pouch

• Scrotum & penis
• Anterior abdominal wall
REVIEW OUTLINE

1. Intra-abdominal Pressure

2. Causes

Cystocele 3. Symptoms

4. Treatments
Cystocele [Link]
Cystocele [Link]

Causes
Cystocele [Link]

Symptoms

Treatments
Knowledge Check [Link]

A 34-year-old woman presents to the clinic complaining of heaviness and discomfort

within the vagina as well as urinary incontinence. She mentions that she has given birth
three months ago and the heaviness has been getting progressively worse since she
started going back to the gym. You conduct a pelvic exam and find a grade 2 cystocele
and weakness in her pelvic floor muscles.

What is a cystocele?

What could be causing weakness in the pelvic floor muscles?

Knowledge Check [Link]

A 34-year-old woman presents to the clinic complaining of heaviness and discomfort

within the vagina as well as urinary incontinence. She mentions that she has given birth
three months ago and the heaviness has been getting progressively worse since she
started going back to the gym. You conduct a pelvic exam and find a grade 2 cystocele
and weakness in her pelvic floor muscles.

What is a cystocele?

Protrusion of the bladder onto the anterior vaginal wall

What could be causing weakness in the pelvic floor muscles?

• Damage to the pelvic floor muscles and perineal muscles

• Trauma to the pudendal nerve that innervates those muscles
• Rupture of fascia supporting pelvic organs
References [Link]

Slide 2
• <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 3
• Perineum: <a
href="[Link] <a
href="[Link] BY 3.0</a>, via Wikimedia Commons
• Sagittal pelvis: <a
href="[Link]
College</a>, <a href="[Link] BY 3.0</a>, via Wikimedia Commons

Slide 4
• Cystocele: <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons
• Pessaries: <a href="[Link] Public domain, via
Wikimedia Commons
REVIEW OUTLINE

1. Intra-abdominal Pressure

2. Causes

Cystocele 3. Symptoms

4. Treatments
REVIEW OUTLINE

1. Prostate Cancer

Prostate 2. Benign Prostatic Hyperplasia (BPH)

Tumors
3. Digital Rectal Examination (DRE)

4. Treatment Methods
Prostate Cancer [Link]

Symptoms
• Early stages:
• Advanced stages:

Prostate with Tumor

Healthy Prostate
Benign Prostatic Hyperplasia (BPH) [Link]

Symptoms
Digital Rectal Examination (DRE) [Link]
Prostate Tumors [Link]

Treatment Methods
Knowledge Check [Link]

Prostate cancer often begins in the _____ lobe whereas benign prostatic hyperplasia involves
the _____ lobe of the prostate.

a. Median; posterior
b. Anterior; median
c. Posterior; median
d. Median; anterior

Explain why prostatic malignancies tend to metastasize to the vertebrae.

Why can a prostatectomy lead to impotence and/or urinary incontinence?

Knowledge Check [Link]

Prostate cancer often begins in the _____ lobe whereas benign prostatic hyperplasia involves
the _____ lobe of the prostate.

a. Median; posterior
b. Anterior; median
c. Posterior; median
d. Median; anterior

Explain why prostatic malignancies tend to metastasize to the vertebrae.

Because the prostatic venous plexus has numerous connections with the vertebral
venous plexus.

Why can a prostatectomy lead to impotence and/or urinary incontinence?

A prostatectomy can cause damage to the nerves within the capsule of the
prostate.
References [Link]

Slide 2
• <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 3
• <a href="[Link] <a
href="[Link] BY-SA 4.0</a>, via Wikimedia Commons

Slide 4
• <a href="[Link] C., Finn, S., Armstrong, J.
et al.</a>, <a href="[Link] BY 4.0</a>, via Wikimedia Commons

Slide 5
• <a
href="[Link]
svg">Cancer Research UK uploader</a>, <a href="[Link] BY-SA 4.0</a>,
via Wikimedia Commons
REVIEW OUTLINE

1. Prostate Cancer
• Location
• Symptoms
• Areas of metastasis

Prostate 2. Benign Prostatic Hyperplasia (BPH)

• Location
• Cause
Tumors • Symptoms

3. Digital Rectal Examination (DRE)

4. Treatment Methods
• Prostatectomy
REVIEW OUTLINE

1. Tunica Vaginalis
Hydrocele & 2. Causes

Hematocele 3. Diagnosis

of the Testes 4. Treatment Methods

Hydrocele & Hematocele of the Testes [Link]

Hydrocele
Hydrocele & Hematocele of the Testes [Link]

Hydrocele

Hematocele
Hydrocele & Hematocele of the Testis [Link]

Diagnosis

Treatment
Knowledge Check [Link]

What’s the difference between a hydrocele and hematocele? How can you differ between
the two?

Explain the difference between a communicating and non-communicating hydrocele.

Knowledge Check [Link]

What’s the difference between a hydrocele and hematocele? How can you differ between
the two?

A hydrocele is due to an accumulation of serous fluid whereas a hematocele is due to an

accumulation of blood within the tunica vaginalis.

Transillumination can be performed and if there’s a red glow, this would indicate a
hydrocele.

Explain the difference between a communicating and non-communicating hydrocele.

• Communicating – caused by a persistent processus vaginalis that allows fluid

from the abdomen to enter the tunica vaginalis

• Non-communicating – caused by excess fluid from the abdomen after the

testes have descended into the scrotum
References [Link]

Slide 2, 3
• Normal: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons

Slide 4
• Scrotal swelling: <a
href="[Link]
et Archive Book Images</a>, No restrictions, via Wikimedia Commons
• Ultrasound: <a href="[Link] Häggström, M.D.
- Author info - Reusing images- Conflicts of interest: NoneMikael HäggströmConsent note: Written informed consent was
obtained from the individual, including online publication.</a>, CC0, via Wikimedia Commons
REVIEW OUTLINE

1. Tunica Vaginalis
Hydrocele & 2. Causes

Hematocele 3. Diagnosis

of the Testes 4. Treatment Methods

REVIEW OUTLINE

1. Causes

2. Location

Cryptorchidism 3. Risk Factors

4. Long-Term Consequences

5. Treatment Methods
Cryptorchidism [Link]
Cryptorchidism [Link]

Risk Factors

Long-Term Consequences

Treatment Methods
Knowledge Check [Link]

What is cryptorchidism?

Explain how cryptorchidism can lead to impaired spermatogenesis.

Knowledge Check [Link]

What is cryptorchidism?

When one or both testes do not descend into the scrotum & is not retractable

Explain how cryptorchidism can lead to impaired spermatogenesis.

Testicles need to be below body temperature to produce optimal sperm, however, if the
testicle remains in the body, it can cause lower sperm count and quality.
References [Link]

Slide 2
• Forms of Cryptorchidism: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
• Ultrasound: <a href="[Link]
Häggström, M.D. - Author info - Reusing images- Conflicts of interest: NoneMikael HäggströmConsent note: Written informed
consent was obtained from the individual, including online publication.</a>, CC0, via Wikimedia Commons

Slide 3
• Forms of Cryptorchidism: <a href="[Link] <a
href="[Link] BY-SA 3.0</a>, via Wikimedia Commons
REVIEW OUTLINE

1. Causes

2. Location

Cryptorchidism 3. Risk Factors

4. Long-Term Consequences

5. Treatment Methods