SAMSONPLAB ACADEMY Bow Business Centre Bow Road 153-159 E3 2SE, London Telephone: +44(0)2089800039 Mobile: +447436582971 Email: info@samsonplab.co.uk ANATOMY LECTURE NOTES 2017 BLOOD SUPLY OF THE UPPER LIMB 1. On the right side: artery’---> Brachial artery---> radial and ulnar artery---> which form the palmer arch------ > digital arteries NB: The brachiocephalis truncus gives branch to common carotid artery and the subclavian artery gives branch to vertebral artery2. On the left side direct from the aorta branches off common carotid artery and subclavian artery. 2. VENOUS SYSTEM A. Deep veins B. Superficial veins DEEP VENOUS BLOOD FLOW Palmer metacarpal --->deep palmer veins---->Radial and ulnar veins-------- Brachial vein------- > Axillary vein—subelavian——— >brachiocephalic—— SVC———> Right atrium SUPERFICIAL VEINS 1, BASILIC VEIN: 2. CEPHALIC VEIN Both of which drain into brachial vein ------- > subclavian vein ----- brachiocephalic -----~ Superior vena cava The aorta has the following parts: aortic arch, thoracic aorta and the abdominal aorta. The abdominal aorta divides into right and left common iliac. The commoniliac then divide into external and internal iliac arteries. The external iliac supplies the lower limb while the internal iliac artery supplies the productive organs. LOWER LIMB VEINS 1. Superical veins «Great saphenous vein- Located on the medical aspect of the leg «Great saphenous vein drains into femoral vein + Short saphenous vein- Located on the lateral aspect of the leg «Short saphenous vein drains into popliteal vein then the popliteal vein continues into femoral vein 2. Deep Veins. «Anterior tibialis drains into popliteal vein «Posterior tibialis drains into\popliteal vein Femoral vein drainsjinto external iliac vein which drains into the inferior vena cava «The popliteal veinis formed when the anterior and posterior, tibialis join together; The inferior vena cava takes blood back to the heart.SPECIAL NERVES: 4. C = lel Innervates the 1. muscles of expression 2. anterior 2/3 of taste and oral cavity. 2, TRIGEMINAL NERVE = 5th Nerve « Responsible for sensation 1, in the face 2. motor functions such as biting and chewing * Each trigeminal nerve (one on each side of the pons) has three major branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3). * The ophthalmic and maxillary 'nerves are purely sensory, and the mandibular nerve has ¢utanéous and motor functions.Ophthalmic nerve (Vi): * divides into three branches: frontal, lacrimal and nasociliary. Frontal Forehead and scalp. (senscalp>) Upper eyelid and its conjunctiva Lacrimal Lacrimal gland nasociliary Dorsum of the nose. Frontal and ethmoidal sinus r Supreoritel _Supratrochioar “OPHTHALMIC NERVE ewe serv eS, Tentorial branch Supetior orbit fissure Postetir Frontal nave estereror ethmoidl nerves ciliary Long TRicewma ganglion Short cliory GaNation ay Lecrimal Communicating branch from ach the zygomatic nerve carrying a parasympathetic bres from a= the plorygopalatine ganglion.Maxillary nerve (V2): Principal functions of sensation from the maxillary, nasal cavity, sinuses, the palate and subsequently that of the mid-face Maxillary nerve branches and innervation: BRANCH STRUCTURES INNERVATED ‘Superior Anterior Alveolar nerve upper incisors and canine & labial gingiva of these teeth | Superior Middle’ Alveolar nerve Superior Posterior Alveolar nerve premolars, middle half of 1st molar & buccal gingiva of these teeth distal half of first molar and rest of molars & buccal gingiva of these teeth Greater palatine nerve) palatal gingiva’of molars & premolars Sphenopalatine or nasopalatine nerve palatal gingiva of incisors & caninesMandibular (V3) The mandibular nerve gives off the following branches: BRANCH STRUCTURES INNERVATED Inferior alveolar nerve (ID nerve) lower teeth and their buccal mucosa’ ‘Mental nerve In the area of the premolars the ID nerve gives off the mental nerve which passes through the mental foramen and supplies the lower lip, chin and buccal mucosa of lower incisors the anterior 2/3 of tongue—-> general sensation, lingual gingiva of all lower teeth and sublingual tissues Long buccal nerve Supplies the buccal gingiva of lower molars and the cheek Auriculotemporal | Parts of the ear and skin over ear + Temporalis » Masseter + Medial and tio} lateral pterygoid:Specific nerve damage: 1. 2, 3. 4 oa T4 is level of nipples 710 is umbilicus C4 over acromioclavicular joint Diaphragmatic nerve is usually irritated in peritonitis causing shoulder tip pain. Also known as phrenic nerve: Claw hand is a sign of ulnar nerve damage. Usually the little finger and ring finger are affected Wrist drop is a sign of radial nerve damage. Carpal tunnel syndromevis a sign of median nerve damage and compression is at the level of the wrist. Phalen’s test or tinnel test can be used to make the diagnosis of carpal tunnel syndrome. The nerve is compressed in the carpal tunnel and treatment can be conservative or surgical (by Incision of the flexor retinaculum) Foot dropican be caused by both peroneal nerve and sciatica nerve. Sciatica is a term usually used to describe the lower back pain radiating all the way down the led up to knee or below it.ORTHOPAEDIC ANATOMY. Radial nerve innervates All extensors of hand |.e. extension of wrist, fingers, elbows Therefore radial nerve palsy causes wrist drop’ ron, Innervates all intrinsic hand muscles, except the LOAF which are innervates by the median nerves. Therefore ulnar palsy if claw hand’ 1. Shoulder abduction: * Deltoid muscle * Axillary *c5 2. Elbow flexion: * Biceps * Musculocutaneous nerve” + c5) C6! * Testing: Ask the patient to flex the elbow against resistance 3. Elbow extension: * Triceps muscle * Radial nerve “cr * Testing: Ask the patient to extend the elbow against resistance4. Finger Extension: Extensor Digitorium communis’ Radial “ah Testing: Ask the patient to extend the finger at the metacarpophalagneal joint with the forearm and hand well supported in a neutral position and apply resistance just proximal to the proximal interphalagneal joint - Finger flexion: Flexer digitorium profundus & superficialis Median & Ulnar, * C8 Flexer digitorium profundus flexes the distal interphalangeal joint Flexer digitorium superficialis flexes the proximal interphalangeal joint Testing: Asking the patient to grip your fingers and resist as you attempt to open up the palms 6. Finger abduction : * First dorsal interosseous muscle: * Ulnar) “a ce* Testing: Ask the patient to open the fingers and try to close the fingers against resistance 7. Thumb abduction: * Abductor Pollicis Brevis * Median ° Fr C@ * Testing: Patient lifts thumb toward ceiling against resistance. 8. Finger Adduction: * Second Palmar interossei muscle * Ulnar °T1 cto * Testing: Ask ask the patient to spread their finger and you push against resistance. ‘Shoulder Muscles: 1, Rhomboid muscley Testing: Pulling arm backward while the hands is on waist and move elbow backwards on resistance 2. Sérratus Anterior muscles: Testing: Imagine you are pushing a car. In this position you are using the serratus anerior muscle3. Supraspintus: * Suprascpular nerve. * Testing: Lifting arms sideways between 60 and 120 degrees. 4, Infraspinatus muscle: * Testing: With a flexed elbow, move the arm inwards Flexor pollicis loungus: * Flexes thumb Hip flexion « lliopsoas muscle + Femoral nerve’ o U4, L2, S34; Hip Extension * Gluteus Muscle Inferior gluteal nerve « L5$1S2 Knee extension «13, L4; * Femoral nerve’ * Quadriceps muscleDorsiflexion foot « LS; + Tibialis anterior muscle « Deep Peroneal nerve Knee Flexion: * Hamstring muscle * Sciatic nerve (foot drop) * 15, S1 Plantar fi {the fod * Gastrocnemius muscle * Posterior tibialis nerve St Dorsi-flexion of the foot: * Gastrocnemius muscle * Posterior tibialis nerve S41 Reflexes 2. Triceps — Radial nerve— C7, ~3. Finger flexion Median and Ulnar nerves—C8_ 4. Knee reflex— Femoral nerve— L3, L4 5. Ankle reflex— $1, $2DERMATOME FOR LOWER LIMB: L1_ Pocket L2_ Inner thigh L3 Knee L4 Medial malleoli L5 Lateral Dorsum of the foot S1 Sole Saddle area kn ja Upper limb C4 = tip of shoulder C5 = bicep C6 = thumb C7 = Middle finger C8 = Little fingerLYMPH NODES DRAINAGE 1. The cervix of the uterus;lymph drains into the para-aortic lymph nodes 2. Vulva lymph drains into superficial Inguinal lymph nodes ----- >then into deep inguinal lymph nodes 3. Body of the uterus drains into external iliac lymph nodes Fundus of the uterus drains into para-aortic lymph nodes Ovaries drain into para-aortic lymph nodes’ aan Superior half of the rectum drains into para rectal lymph nodes --->then into inferior mesenteric lymph nodes 7. Lower half of the rectum drains into internal iliac and sacral group of LN. 8. Testes drain into para aortic lymph nodes 9. Superficial Inguinal Lymphinodes drains from penis, scrotum, perineum, buttock, vulva’and abdominal wall below the umbilicus. 10. Usually the superficial lymph nodes drain into deep inguinal then into externa! iliac and then into para-aortic 11. 12. EXTERNAL ILIAC LYMPH NODES: drains from the glans of the penis, prostate, upper vagina, fundus of the bladder. Prostate drains into into external iliac 13. INTERNAL ILIAC NODES: drains from deeper perineum, urethra, buttock and back of the thigh.14. PARAAORTIC LYMPH NODES drains from ovaries; testes and superior rectum 15, SUPERFICIAL CERVICAL LYMPH NODES: lower part of auricular and parotid region. 16. ANTERIOR CERVICAL LYMPH NODES: lower part of the larynx, thyroid gland and upper part of the trachea. LYMPH NODES OF THE FACE SUBMENTAL LYMPH NODES: drains from the floor of the mouth, apex of the tongue and lower lip then goes to deep cervical lymph nodes. LYMPHATIC VESSELS FO THE TONGUE -Apical of the tongue or tip =submental -Lateral margin of the tongue= submaxilary lymph nodes -basal of the tongue =superior deep cervical LN SUBMAXILARY OR SUBMANDIBULAR LYMPH NODES= nasal cavity and gums, cheek, upper lip, lateral part of the lip, medial palpabrae commissure, lateral part of the lower lip. SUBMENTAL LYMP NODES: lower lip and floor of the mouth and apex of the tongue. BREAST: mainly drain into axillary lymph nodes PRE-AURICULAR: EyelidSAMSONPLAB ACADEMY. Bow Business Centre Bow Road 153-159 E32SE, London Telephone: +44(0)2089800039 4) Mobile: +447940433068 Qy _ ) of TT yo 1.Which nerve supplies the serratus horde? ca) Long thoracic nerve y b. Radial nerve ae) c. Axillary nerve a e. Lower subscapylar ndfye Median nery 2. Which aS the biceps muscle? Ulnar nerve Femoral nerve S 4 Which nerve supplies the extensor carpi radialis longus muscle? ~ Ca) Radial nerve b. Ulnar nerve c. Median nerve d. Axillary nerve ¢. Posterior interosseous nerve Anatomy PLAB 1 SBA4, Which nerve supplies the pronator teres muscle? a. Axillary nerve ( b.) Median nerve c. Long thoracic nerve d. Medial cutaneous nerve of arm e. Posterior interosseous nerve S 5. Which nerve supplies the flexor carpi ulnaris? > a) Ulnar nerve al b. Median nerve c. Long thoracie nerve d. Medial cutaneous nerve of arm e. Posterior interosseous nerve 6. A.46 year old man with insulin-dependenggiadpfes mellitus (Type 1) complains of pain in his left eye with doubla@iMon. His pupil is dilated and the eye is inferiorly and laterally. Tere ig Yilso ptosis. Which nerve is affected? Y . Trochlear . Facial Optic |. Trigeminal Oculomoto; SV 7.437 year < ‘outs well, complains of numbness on the right id side of h a watery right eye, She was previously well. There is a loss lsolabial fold and the right forehead creases. She is unable to vghleilespr show her teeth on the right but sensation is normal. Which nel i Bore fected? ) Facial Nerve C \ b. Abducens Nerve c. Optic Nerve d. Trigeminal Nerve e. Vagus Nerve 8. A 70-year old lady on prednisolone for rheumatoid arthritis complains of a painful eye and rash. There is a vesicular rash involving the right 2 Anatomy PLAB 1 SBAconjunctiva and right forehead, which is very tender to touch, Which nerve is affected? a, Abducens nerve b. Optic nerve (® Trigeminal nerve d, Oculomotor nerve e. Vagus nerve <) 9. A70 year old man complains of diplopia great precisely when > downstairs. There are diminished eye movements on the | at the eye is unable to move to the inferior and medial real nerve is affected? Trigeminal nerve Oculomotor nerve Facial nerve Abducens nerve s Pyare (pupilland visual acuity is reduced feft eye compared with the right eye. There is no ptosis. axe] ‘affected? (@ Oculomotor nerve . Optic nerve . Vagus nerv 6) c. d. Olfactoryaa e. Facial. €) Trochlear nerve ( iv) 4 10, A 24 year old lady has blurring “e ‘She has a mildly (dilated\left Fas s Walk steadily. He noticed that when his tongue protrudes, it the right and he cannot easily move the tongue from side to ich nerve is affected? \ a. Ist Cranial nerve b. 2nd Cranial nerve c, 3rd Cranial nerve +(@) 12th Cranial nerve e. 5th Cranial nerve ILA a retired manager presents with headache, dizziness and Anatomy PLAB 1 SBA12. A 63 year old patient who woke up from sleep noticing drooping and weakness of the right side of the face and he is unable to raise the right eyebrow. Which nerve is affected? a. lst Cranial nerve b. 6thCranial nerve c. 3rd Cranial nerve <) 4) 7th Cranial nerve QR e. 2nd Cranial nerve \ 13. A 41 year old chef complains of impairment of taste wacke ; ell. On iW nerve examination, smell and taste sensations are mildly reduced is affected? ¥ (a.) Ist Cranial nerve b. 2nd Cranial nerve ©. 3rd Cranial nerve 4. 4th Cranial nerve Y e. Sth Cranial nerve ( 14, A 44 year old taxi driver ersea TWh headache and vomiting. On examination, patients jaw ¢ right when opened. There is reduced facial sensation on theft side of the face with loss of corneal a. Ist Cranial b. 2nd Crani ve c. 3rd Ci e d. 4th, lerve ®) al nerve 15. fear old male who is known to have IDDM (‘Iype 1 diabetes) with diplopia on looking to the left and is unable to abduct the sye. Which nerve has been affected? S a. Ist Cranial nerve ~() 6th Cranial nerve c. 3rd Cranial nerve d. 4th Cranial nerve e. 10th Cranial nerve Anatomy PLAB 1 SBA16. A 45 year old labourer has difficulty in swallowing. On examination there was impaired movement of the palate, which is pulled to the right on saying ‘Ah’. Gag reflex is absent. Which nerve is affected? a. 3rd Cranial nerve b. Ist Cranial nerve c. 4th Cranial nerve ~(@) 10th Cranial nerve 4) e. Sth Cranial nerve Q 17. A 43 year old lady who had a car accident and got hit of SZ complains of swollen knee and an inability to flex the terior draw test is positive. Which of the following is the most lik sis? a, Posterior cruciate ligament rupture ¢b) Anterior cruciate ligament rupture Q) c. Patellar fracture d. Collateral ligament injury e. Meniscal injury \ 18. A 14 year old boy has been rine knee pain. In the A&E he presents with increased pain. He adi playing football a few hours before but didn’t injure him; n Xéxamination, the left tuberosity is prominent with tenderness in # er third)of the patellar tendon. X-ray shows an enlarged and fri tuberosity. What is the most likely diagnosis? a. Anterior Qo rupture 8 ongmaca e's disease c. Co igament injury teral ligament injury year old footballer kicked the ball with his left foot and soon experienced a sharp pain in the right knee. Right knee extension is litnited and he is unable to weight bear. X-ray of left knee is normal. ‘What is the most likely diagnosis? a. Dislocation of patella b. Patellar fracture <(@) Meniscal injury d. Ruptured patellar tendon e. Anterior cruciate ligament rupture Anatomy PLAB 1 SBA20. A 31 year old male presents to the A&E following a fall on the knee. The knee is held in flexion but there is no knee swelling or signs of ligament injury. X-Ray is normal. Which nerve has been affected? (a) Femoral nerve b. Axillary nerve c. Musculocutaneus nerve XQ) d. Brachial nerve Q e, Ulnar nerve 21. A 22 year old student with recurrent pain and swelling a&jhe knee, which is increased following exercise. The knee seems «Q beStocked. What is the most likely diagnosis? a. Dislocation of patella x) b. Patellar fracture ©) Meniscal injury d. Ruptured patellar tendon Yr e. Osteochondritis desiccans © 22. A 25 year old female compli Pin in the inner side of her right thigh. She was diagnosed wi gi ovarian mass on the right. Which nerve is responsible for this rong = oFastric nerve an branch of splanchnic nerve ‘udenda nerve foman comes with an ulcerated lesion 3 cm in the labia majora. is the lymphatic drainage of this area? C Y a. External iliac (b) Superficial inguinal LN c. Para-aortic 4, Tliac e. Aortic Anatomy PLAB | SBA24. A 35 year old construction worker is diagnosed with (indirect | inguinal hernia. Which statement below best describes it? a. Passes through the superficial inguinal ring only b. Lies above and lateral to the pubic tubercle c. Does not pass through the superficial inguinal ring d. Passes through the deep inguinal ring S e. It lies below and medial to the pubic tubercle Y 25. Which artery runs in the anterior interventricular grSMye? a. Acute marginal branch 4 b) Left anterior descending artery es c. Septal branches d. Circumflex artery v e. Right coronary artery Y 26. A 16 year old boy foll a RTA was brought to the Emergency department with a swellin; deformity in his right thigh. Exam: airway is patent and is fo have a pulseless leg. Which structure is involved in this act? 4@) Fe < b, PREM tibial artery S Dorsalis pedis man sat cross-legged for about 30mins. After this he was unable dorsiflexion his left foot and had loss of sensation in the web space G between the big toe and the 2"¢ toe. He also has sensory loss on the same side of the foot after 2 hours. Which of the following was affected? a. Femoral nerve b. Seral nerve (c.) Peroneal nerve Anatomy PLAB | SBAd. Sciatic nerve 28. A 35 year old male typist who suffered a scaphoid fracture was treated with a scaphoid cast. After 2 weeks when the cast was removed for a review of the X-ray, it was found that he had problems in moving the thumb, index and middle fingers. What would you suggest as the management for the recent problem? a.) Release of flexor retinaculum S b. Release of common flexor sheath c. Release of palmar sheath AY d. Ulnar nerve release e. Fasciotomy ~» 29. A 67 year old lady with an ulcer on the Which is the single most appropriate LN involved? a, External iliac LN ° Y b. Pre-aortic LN c. Aortic LN vw v@) Inguinal LN ae) e. Tiac LN 30. The artery ae the ant right ventricular wall. What is the single most tiate option? Te marginal branch Ift anterior descending artery > Coronary sinus 4, Circumflex artery c X . e. Right coronary artery 31. The artery that runs along the left atrio-venrticular groove. What is the single most appropriate option? a. Left internal mammary artery b. Left anterior descending artery Anatomy PLAB | SBAc. Circumflex artery 4d. Left main stem (LMS) post descending artery e. Diagonal branch 32. A patient came to the Emergency after he had banged his car quite a few times on reversing. He was complaining of seeing double while he tried to look back during the process of reversing the car, he als complains of double vision on looking at an outward gaze. nerve is involved? .) Abducent nerve AY . Trochlear nerve . Oculomotor nerve ~» |. Optic nerve & e. Trigeminal nerve » ae + @ Anatomy PLAB 1 SBA