How to prepare for Clinical/Applied anatomy
Decide type of tissue, Remember normal anatomy, and think what can happen to them, what investigations to do for knowing it, and what can we do to treat/ heal / manage those conditions
Mnemonics for anatomy
How to prepare for Clinical/Applied anatomy
Decide type of tissue, Remember normal anatomy, and think what can happen to them, what investigations to do for knowing it, and what can we do to treat/ heal / manage those conditions
ARTERY (angio=vessels- can be artery, vein or lymphatic, traditionally referred to as artery)
Type and nature of external force → sharp, blunt, chemical, mechanical
Compression >> Pressure >> Crush >> Cut
Obstruction (thrombosis, clot, embolism-- fat / air / foreign body)
Hemorrhage / Bleeding
Ischemia>> Infaction >> Necrosis >> Gangrene
Laceration of palmar arterial arches: The lacerated wounds of palmar arterial arches usually cause profuse and uncontrollable bleeding. The compression of brachial artery against humerus is the most effective method to control the bleeding.
The ligation or clamping of the radial artery or ulnar artery or both proximal to wrist fails to control the bleeding because of connections of these arches with the palmar and dorsal carpal arches.
How to prepare for Clinical/Applied anatomy
Decide type of tissue, Remember normal anatomy, and think what can happen to them, what investigations to do for knowing it, and what can we do to treat/ heal / manage those conditions
VEIN
Valves of veins- Incompetency, regurgitation/reversal
Type and nature of external force → sharp, blunt, chemical, mechanical
Compression >> Pressure >> Crush >> Cut
Obstruction (thrombosis, clot, embolism-- fat / air / foreign body)
Hemorrhage / Bleeding
Swelling, Inflammation / edema= fluid collection /
How to prepare for Clinical/Applied anatomy
Decide type of tissue, Remember normal anatomy, and think what can happen to them, what investigations to do for knowing it, and what can we do to treat/ heal / manage those conditions
MUSCLE
Injury/trauma -- Healing by fibrosis
Overstretch/Overuse/over-weight -- Hypertrophy, Hyperplasia
Wrong direction of force of contraction, twisting injuries
Spasticity, flaccidity
Disuse -- Atrophy,
How to prepare for Clinical/Applied anatomy
Decide type of tissue, Remember normal anatomy, and think what can happen to them, what investigations to do for knowing it, and what can we do to treat/ heal / manage those conditions
NERVE
Branches -- Muscular, cutaneous, articular, vascular, communicating,
Lesions and symptoms accordingly
Injury/trauma
Levels of injuries- neurapraxia, axonotmesis, neurotmesis (Pressure, compression, crushing/cutting)
Tingling, numbness,
Anaesthesia, parasthesia, analgesia, (CENTRAL/PERIPHERAL--UMN LMN)
How to prepare for Clinical/Applied anatomy
Decide type of tissue, Remember normal anatomy, and think what can happen to them, what investigations to do for knowing it, and what can we do to treat/ heal / manage those conditions
FASCIA
Superficial or deep
Modifications of deep fascia- intermuscular septa, ligaments, retinacula, fibrous sheaths,other structures
Compartment syndrome, Palmar aponeurosis thickening-contracture
Fasciotomy
PAD (palmar interossei- adduction
DAD (dorsal interossei- abduction)
Ulnar nerve lesion at the wrist: Produces 'ulnar claw hand'. REMEMBER L LETTER FOR LUMBRICALS
• Ulnar claw hand is characterised by...
a. Hyperextension at the metacarpophalangeal joints and flexion at the interphalangeal joints,
involving the ring and little fingers-more than the index and middle fingers. The little finger is held in extension by extensor muscles. The intermetacarpal spaces are hollowed out due to wasting of the interosseous muscles.
Claw hand deformity is more obvious in wrist lesions as the profundus muscle is spared: This causes marked flexion of the terminal phalanges (action of paradox).
b. Sensory loss is confined to the medial one-third of the palm and the medial ½ fingers including their nail beds. Medial half of dorsum of hand also shows sensory loss.
c. Vasomotor changes: The skin areas with sensory loss is warmer due to arteriolar dilatation; it is also drier due to absence of sweating because of loss of sympathetic supply.
d. Trophic (non-nutritive) changes: Long-standing cases of paralysis lead to dry and scaly skin. The nails crack easily with atrophy of the pulp of fingers.
e. The patient is unable to spread out the fingers (PAD DAB LOST) due to paralysis of the dorsal interossei. The power of adduction of the thumb, and flexion of the ring and little fingers are lost.
It should be noted that median nerve lesions are more disabling. In contrast, ulnar nerve lesions leave a relatively efficient hand.
• The ulnar nerve is also known as the 'musician's nerve' because it controls fine movements of the fingers.
• The ulnar nerve is commonly injured at the elbow, behind the medial epicondyle or distal to elbow as it passes between two heads of flexor carpi ulnaris (cubital tunnel) or at the wrist in front of the flexor retinaculum.
Ulnar nerve injury at the elbow: Flexor carpi ulnaris and the medial half of the flexor digitorum profundus are paralysed.
• Due to this paralysis, the medial border of the forearm becomes flattened. An attempt to produce flexion at the wrist result in abduction of the hand. The tendon of the flexor carpi ulnaris does not tighten on making a fist. Flexion of the terminal phalanges of the ring and little fingers is lost.
• If ulnar nerve is injured at the elbow, the clawing of the fingers is less, because medial half of flexor digitorum profundus (flexor of proximal and distal interphalangeal joints) also gets paralysed. If ulnar nerve is injured at wrist, the clawing of the fingers is more as intact flexor digitorum profundus flexes the digits more. Thus if lesion is proximal (near elbow), clawing is less. On the contrary, if lesion is distal (near wrist), clawing is more. This is called "action of paradox" / ulnar paradox.
• If both ulnar and median nerves get paralysed, there is complete claw hand
The median nerve controls coarse movements of the hand, as it supplies most of the long muscles of the front of the forearm. It is, therefore, called the labourer's nerve. It is also called " eye of the hand" as it is sensory to most of the hand.
• When the median nerve is injured above the level of the elbow, as might happen in supracondylar fracture of the humerus, the following features are seen.
a. The flexor pollicis longus and lateral half of flexor digitorum profundus are paralysed. The patient is unable to bend the terminal phalanx of the thumb and index finger when the proximal phalanx is held firmly by the clinician (to eliminate the action of the short flexors). Similarly, the terminal phalanx of the middle finger can be tested.
b. The forearm is kept in a supine position due to paralysis of the pronators.
c. The hand is adducted due to paralysis of the flexor carpi radialis, and flexion at the wrist is weak.
d. Flexion at the interphalangeal joints of the index and middle fingers is lost so that the index and the middle (to a lesser extent) fingers tend to remain straight while making a fist. This is called pointing index finger occurs due to paralysis of long flexors of the digit.
e. Ape or monkey thumb deformity is present due to paralysis of the thenar muscles.
f. The area of sensory loss corresponds to its distribution in the hand.
g. Vasomotor and trophic changes: The skin on lateral 3½ digits is warm, dry and scaly. The nails get cracked easily.
• Carpal tunnel syndrome (CTS): Involvement of the median nerve in carpal tunnel at wrist has become
a very common entity.
a. This syndrome consists of motor, sensory, vasomotor and trophic symptoms in the hand caused by compression of the median nerve in the carpal tunnel. Examination reveals wasting of thenar eminence (ape-like hand), hypoaesthesia to light touch on the palmar aspect of lateral 3½ digits. However, the skin over the thenar eminence is not affected as the branch of median nerve supplying it arises in the forearm.
b. Froment's sign/ book holding test: The patient is unable to hold the book with thumbs and other fingers.
c. Paper holding test: The patient is unable to hold paper between thumb and fingers.
Both these tests are positive because of paralysis of thenar muscles.
d. Motor changes: Ape- / monkey-like thumb deformity, loss of opposition of thumb. Index and middle fingers lag behind while making the fist due to paralysis of 1st and 2nd lumbrical muscles.
e. Sensory changes: Loss of sensations on lateral 3½ digits including the nail beds and distal phalanges on dorsum of hand.
f. Vasomotor changes: The skin areas with sensory loss is warmer due to arteriolar dilatation; it is also drier due to absence of sweating due to loss of sympathetic supply.
g. Trophic changes: Long-standing cases of paralysis lead to dry and scaly skin. The nails crack easily with atrophy of the pulp of fingers.
h. It occurs both in males and females between the age of 25 and 70. They complain of intermittent attacks of pain in the distribution of the median nerve on one or both sides. The attacks frequently occur at night. Pain may be referred proximally to the forearm and arm. It is more common because of excessive working on the computer(anything excessive, not only computer).
Phalen's test is attempted for CTS.
• Complete claw hand: If both median and ulnar nerves are paralysed, the result is complete claw hand.
Student's elbow: Inflammation of the bursa over the insertion of triceps brachii is called student's elbow. It is common in students as they use the flexed elbow to support the head while attempting hard to listen to the lectures in between their 'naps'.
Tennis elbow: Lateral epicondylitis occurs in players of lawn tennis or table tennis. The extensor muscles of forearm are used to hit the ball sharply, causing rep ea ted microtrauma to the lateral epicondyle and its subsequent inflammation. lt may be a degenerative condition.
Golfer's elbow/medial epicondylitis: Occurs in golf players. Repeated microtrauma to medial epicondyles causes inflammation of common flexor origin and pain in flexing the wrist.
Pulled elbow: While pulling the children by their hands (getting them off the bus) the head of radius may slip out of the annular ligament. Annular ligament is not tight in children as in adults, so the head of radius slips out.
Shoulder joint may be dislocated anteroinferiorly:
The shoulder joint is surrounded by short muscles on all aspects except inferiorly. Since the joint is quite mobile, it dislocates at the unprotected site, i.e. inferiorly.
Boxer's palsy or swimmer's palsy: Serratus anterior causes the movement of protraction. If the long thoracic nerve is injured, the muscle gets paralysed, seen as "winging of scapula". Such a person cannot hit his opponent by that hand. Neither can he make strokes while swimming.
Waiter's tip or policeman's tip: "Taking the tip
quietly" Erb-Duchenne paralysis occurs due to
involvement of Erb's point. At Erb's point, CS, C6
roots join to form upper trunk, two divisions of the
trunk arise and two branches, the suprascapular and
nerve to subclavius also arise.
Wrist drop: Paralysis of radial nerve in axilla or radial sulcus or anterolateral side of lower part of arm or paralysis of its deep branch in cubital fossa leads to wrist drop (see Fig. 8.25).
Cubital tunnel syndrome: Ulnar nerve gets entrapped between two heads of flexor carpi ulnaris muscle, leading to paralysis of medial half of flexor digitorum profundus and muscles of hypothenar eminence, all interossei and adductor pollicis and 3rd and 4th lumbricals. There is clawing of medial two digits, gutters in the hand and loss of hypothenar eminence (see Figs 9.35 and 9.36).
Ulnar canal syndrome/Guyon’s tunnel syndrome: It is
clinical condition, which occurs due to compression of the
ulnar nerve in Guyon’s canal* at wrist. Clinically it presents
as:
(a) Hypoesthesia in medial 1½ fingers, and
(b) Weakness of intrinsic muscles of hand.
*Ulnar tunnel/Guyon’s canal is an osseofibrous tunnel formed by
the pisohamate ligament bridging the concavity between pisiform
bone and hook of hamate.
Volkmann's ischaemic contracture: This condition occurs due to fibrosis of the muscles of the forearm, chiefly the flexors. It usually occurs with injury to the brachial artery in supracondylar fractures of humerus (see Fig. 2.16b).
Dupuytren's contracture: This clinical condition is due to fibrosis of medial part of palmar aponeurosis especially the part reaching the ring and little fingers. The fibrous bands are attached to proximal and middle phalanges and not to distal phalanges. So proximal and middle phalanges are flexed, while distal phalanges remain extended (see Fig. 9.18).
Funny bone: Ulnar nerve is palpable in flexed elbow behind the medial epicondyle. Palpating the nerve gives rise to funny sensations in the medial side of forearm. Since medial epicondyle is part of humerus, it is called humerus or funny bone (see Fig. 2.15).
Pointing finger: Branch of anterior interosseous nerve to lateral half of flexor digitorum profundus is injured in the middle of the forearm. The index finger is affected the most. It remains extended and keeps pointing forwards (despite the fact that remaining three fingers are pointing towards self) (see Fig. 9.39).
Complete claw hand: Complete claw hand is due to injury of lower trunk of brachial plexus especially the root, which supplies intrinsic muscles of hand. The injury is called 'Klumpke's paralysis' . The metacarpophalangeal joints are extended while both the interphalangeal joints of all fingers are actually flexed (see Fig. 9.45).
Trigger finger: It is a clinical condition, in which a finger gets locked in full flexion and can be extended only after excessive voluntary effort or with the help of the other hand.
When extension begins it occurs suddenly and with a click, hence the name—trigger finger.
This condition is caused by the presence of a localized thickening of a long flexor tendon, preventing movement of the tendon within the
fibrous flexor sheath of the digit. When tendon tries to move, its thickened part is caught in the osseofibrous tunnel momentarily. This condition can be relieved surgically by incising the fibrous flexor sheath.
Mallet finger/baseball finger/cricketer’s finger
(Fig. 11.26): The insertion of extensor tendon into the base
of the terminal phalanx may be torn by a forceful blow on
the tip of the finger, which causes sudden and strong
flexion of the phalanx. Occasionally, small flakes of the bone may be avulsed. Consequently the distal phalanx assumes a flexed position with swan neck deformity and voluntary extension is impossible.
This condition commonly occurs in cricketers and baseball players.
Boutonnière (button-hole) deformity (Fig. 11.27): It is opposite to mallet finger deformity. It is characterized by
flexion of proximal interphalangeal (PIP) joint and hyperextension of distal phalanx. It occurs when the flexed
PIP joint pokes through the extensor expansion following rupture of its central portion of dorsal digital expansion due to a direct end on trauma to the finger.
Blood pressure: The blood pressure is universally recorded by auscultating the brachia! artery on the anteromedial aspect of the elbow joint (see Fig. 8.11).
Intravenous injection: The median cubital vein is the vein of choice for intravenous injections, for withdrawing blood from donors, and for cardiac catheterisation, because it is fixed by the perforator and does not slip away during piercing (see Fig. 7.8).
Intramuscular injection: Intramuscular injections are often given into the deltoid. They should be given in the middle of the muscle to avoid injury to the axillary nerve (see Fig. 6.9).
Radial pulse: The radial artery is used for feeling the (arterial) pulse at the wrist. The pulsation can be felt well in this situation because of the presence of the flat radius behind the artery (see Fig. 9.10).
Lister's tubercle: Dorsal tubercle on lower end of posterior surface of radius. This acts as a pulley for the tendon of extensor pollicis longus.
de Quervain's disease is a thickening of sheath around tendons of abductor pollicis longus and extensor pollicis brevis giving rise to pain on lateral side of wrist.
Breast: The breast is a frequent site of carcinoma (cancer). Several anatomical facts are of importance in diagnosis and treatment of this condition. Abscesses may also form in the breast and may require drainage. The following facts are worthy of note.
Incisions into the breast are usually made radially to avoid cutting the lactiferous ducts (see Fig. 3.9).
Cancer cells may infiltrate the suspensory ligaments. The breast then becomes fixed. Contraction of the ligaments can cause retraction or puckering (folding) of the skin.
Infiltration of lactiferous ducts and their consequent fibrosis can cause retraction of the skin.
Obstruction of superficial lymph vessels by cancer cells may produce oedema of the skin giving rise to an appearance like that of the skin of an orange (peau d' orange appearance) (see Fig. 3.16).
Because of bilateral communication s of the lymphatics of the breast across the midline, cancer
may spread from one breast to the other (see Fig. 3.17).
Because of communications of the lymph vessels with those in the abdomen, cancer of the breast may spread to the liver. Cancer cells may 'drop' into the pelvis especially ovary (Krukenberg's tumour) producing secondaries there (see Fig. 3.17).
Apart from the lymphatics, cancer may spread through the veins. 1n this connection, it is important to know that the veins draining the breast communicate with the vertebral venous plexus of veins. Through these communications, cancer can spread to the vertebrae and to the brain (see Fig. 3.17).
Ligaments of Cooper: Fibrous strands extending between skin overlying the breast to the underlying pectoral muscles. These support the gland. Montgomery's glands: Glands beneath the areola of mammary gland.