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Muscular System
Suresh Agarwal, M.D.
Muscular System
• Neuromuscular
Physiology
• Neuromuscular
Disorders
• Compartment
Syndrome
• Rhabdomyolysis
www.health-res.com/EX/08-05-01/als1.jpg
Page 3
Neuromuscular Physiology: The
Motor Unit
• Lower Motor Neurons = Alpha Motor Neurons
• Alpha Motor Neuron Cell Bodies
– Cranial Musculature:
In the Brainstem
– Somatic Cells: In the
Anterior Horn of the Spinal Cord
• Nerve Roots
• Plexus
• Peripheral Nerves
• Terminal Ramifications
palrehab.net/images/spin20.jpg
• Motor Neuron Synapse
Page 4
The Motor Unit
•
Neuromuscular Junction
•
Presynaptic Acetylcholine Release
•
Postsynaptic Acetylcholine
Binding
education.vetmed.vt.edu/Curriculum/VM8054/Labs/
Lab10/IMAGES/MOTOR%20END%20PLATES%20SMAL
L%201.jpg
– Increases Muscle End-Plate
Potential
– Threshold Level > Depolarizes
•
Calcium Ions Released from
Sarcoplasmic Reticulum
•
Excitation-Contraction Coupling >
Muscle Contraction
•
Acetylcholine Degraded by
Cholinesterase
bp3.blogger.com/_v2GFIISzHOU/SAjilu3b8kI/A
AAAAAAAASk/3BRF9vWKgYY/s400/NeuroMuscular+Junction.jpg
Page 5
Neuromuscular Disorders
• Neuromuscular diseases leading to critical illness
– Guillain-Barre Syndrome
– West Nile Virus Acute Flaccid Paralysis Syndrome
– Myasthenia Gravis
• Neuromuscular diseases caused by critical illness
– Critical Illness Polyneuropathy & Myopathy
www.factmonster.com/images/ES
CI342MUSSYS002.gif
Page 6
Neuromuscular Disorders
• Acute Inflammatory Demyelinating
Polyradiculoneuropathy (a.k.a. Guillain-Barre Syndrome)
• Motor >>Sensory Peripheral Neuropathy
• Monophasic
• Nadir at 4 weeks
• Immune mediated
• Exact etiology unknown
• Demyelinating Neuropathy
www.infiniteunknown.net/wpcontent/uploads/2009/11/guillain-barresyndrome.jpg
• Primary Axonopathy
Page 7
Guillain-Barre Syndrome
• ? Preceding disease or
condition
• Gangliosides
• Campylobacter jejuni
upload.wikimedia.org/wikipedia/commons/thumb/b/
ba/Campylobacter.jpg/450px-Campylobacter.jpg
Page 8
Guillain-Barre Syndrome
• Clinical Findings
Myelin
– Subacute
– Progressive weakness
– Starts in legs
– Sensory complaints
– No objective sensory
deficits
upload.wikimedia.org/wikipedia/commons/c/c1/Myeli
nated_neuron.jpg
absent
– Diminished or
deep tendon reflexes
drdavis.typepad.com/.a/6a00d834525ed16
9e201156f86664c970c-320pi
Page 9
Guillain-Barre Syndrome
• CSF findings, around 2nd week
– Elevated protein
– No pleocytosis
neuromuscular.wustl.edu/pics/diagrams/emg/gb
srecov.gif
Page 10
Guillain-Barre Syndrome
Electrodiagnostic Studies
• Motor and Sensory Nerve
Conduction Studies
• Needle Electromyography
• Findings:
– Segmental nerve
demyelination
– Multifocal conduction
blocks
graphics8.nytimes.com/images/200
7/08/01/health/adam/9238.jpg
– Slow Conduction Velocity
– Consistent with a
Peripheral Neuropathy
Page 11
Guillain-Barre Syndrome
• Management
• Vent support
• Autonomic Dysfunction
• Immunotherapy
– Plasma exchange
– High dose IVIg
• Rehabilitation
repairstemcell.files.wordpress.com/2009/03/mspic.jpg
Page 12
West Nile Virus
• West Nile Virus Acute Flaccid Paralysis Syndrome
– Flavivirus
– Birds and mosquitoes (Culex)
– Late summer or Fall
media.publicbroadcasting.net/kera/ne
wsroom/images/3197830.jpg
www.nature.com/nrmicro/journal/v4/n1/i
mages/nrmicro1326-f2.jpg
Page 13
West Nile Virus
3 Different Clinical Manifestations
1. Asymptomatic infection
2. Mild febrile syndrome West Nile
Fever
•
approx. 20%
•
3 – 6 days duration
3. Neuroinvasive disease West Nile
t2.gstatic.com/images?q=tbn:vSeOC3WZ2
meningitis or encephalitis
•
approx. 1 in 150
Wee0M:http://news.bbc.co.uk/nol/shared/s
pl/hi/health/03/travel_health/diseases/img/
westnile.jpg
Page 14
West Nile Virus
• Acute Flaccid Paralysis Syndrome
– “poliomyelitis-like”
– Ventral Horns and Ventral Roots
– Acute
– Asymmetrical
– Flaccid
– No Sensory Deficits
– No diffuse reflex deficits
– No bowel or bladder
www.tmin.ac.jp/english/dept/07/neuro
logy2.jpg
dysfunction
Page 15
West Nile Virus – Acute Flaccid
Paralysis Syndrome
• Electrodiagnostic testing
– Normal sensory potentials
– No findings of segmental demyelination
(unlike Guillain-Barre)
– Low amplitude muscle action potentials I
n affected areas
– Significant denervation changes in
affected areas
• MRI
• CSF
– Mild pleocytosis (lymphocytic)
– Mild to Moderate increase in protein
www.brown.edu/Courses/Bio_160/Projects
– No change in glucose
2000/Polio/Reflexcopy.jpg
Page 16
West Nile Virus – Acute Flaccid
Paralysis Syndrome
• Diagnosis
• Treatment
– Reverse-transcriptase
PCR (insensitive)
– Supportive
– Antibody-capture
ELISA (IgM)
– ?Antiretroviral
medications
– ?IVIg
• Prognosis for recovery of
strength is poor
www.co.klamath.or.us/healthDept/
images/mosquito.jpg
Page 17
Myasthenia Gravis
• Autoimmune attack on
acetylcholine receptor
• Fluctuating weakness
• Progressive with sustained
exertion
• Incidence:
– Early adulthood:
–
Women > Men
– Later adulthood:
–
Women = Men
www.hakeemsy.com/main/files/images/MyastheniaGravis.JPG
Page 18
Myasthenia Gravis
• Clinical Presentation
• Muscle fatigue
– Worst with prolonged exertion
• Ocular muscles
– Ptosis
– Diplopia
• Bulbar muscles
– Dysphagia
– Dysarthria
• Respiratory Failure
Page 19
Myasthenia Gravis
• Diagnosis
• Clinical presentation
• Edrophonium testing
• Electrophysiologic studies
– Repetitive nerve stimulation
• Antibody Testing
– Acetylcholine receptor
www.mda.org/publications/images/q
10-3_ach.jpg
– Muscle specific receptor tyrosine kinase (MuSK)
Page 20
Myasthenia Gravis
•
Myasthenic Crisis
•
– 20% of patients with MG
– Sensitive to Nondepolarizing
agents
– Respiratory failure
– Resistant to Depolarizing
agents
– Precipitating factors
• Bronchopulmonary processes
• Aspiration
• Sepsis
• Surgical procedures
• Immune modulation tapering
Neuromuscular blocking agents
•
Thymomas
– More fulminate disease
– 30% of patients with
myasthenic crisis
• Corticosteroids
• Pregnancy
• Certain Drugs
Page 21
Myasthenia Gravis
• Treatment
– Immunomodulating Methods
• Plasma exchange (short-term)
– Myasthenic crisis
– Surgical preparation
– Increased strength after 2 to 3 exchanges
• IVIg (short-term)
– Alternative to plasma exchange
– Possible longer period until onset of effect
• Corticosteroids
– Occasionally used
– Prolonged crises
– Transient increase in weakness
Page 22
Myasthenia Gravis
• Treatment
Acetylcholine Receptor
– Cholinesterase inhibitors
• Cholinergic Crisis
– Possible increase in weakness
– Muscle fasciculations
– Muscarinic symptoms
• Avoid repeated/escalating doses
• Discontinue after intubation
upload.wikimedia.org/wikipedia/commons/6/6e/Nicoti
nic_Acetylcholine_receptor.png
Page 23
Myasthenia Gravis
• Thymus
– Abnormal in 75%
– Thymoma in 25%
• Benign
• Malignant
• Thymectomy
– Necessary for thymoma
– Controversial for patients without know thymic
abnormalities
www.aurorahealthcare.org/health
– Disease course often abates
Page 24
gate/images/si2141.jpg
Critical Illness Polyneuropathy &
Myopathy
• Generalized weakness
• Axonal
• Predisposing Factors
– Critical Illness
– Sepsis
– Multiple system organ failure
• Prolonged mechanical ventilation
www.pathologyoutlines.com/images/softtissue/06_13.jpg
Page 25
Critical Illness Polyneuropathy &
Myopathy
• Common Antecedents
– Sepsis
– Multiple System Organ Failure
• Pathophysiology
– ICU days
– Number of invasive procedures
– Hyperglycemia
– Hypoalbuminemia
– Severity of MSOF
– Neuromuscular Blocking Agents
– Corticosteroids
Page 26
Critical Illness Polyneuropathy &
Myopathy
• Clinical Features
– Muscle weakness and
wasting
• Deep Tendon Reflexes
– Diminished or absent
– Parasthesias
– Distal Sensory Loss
vasculitis.med.jhu.edu/typesof/images/Muscle
_waste_MPA.jpg
Page 27
Critical Illness Polyneuropathy &
Myopathy
• Nerve Conduction
– Normal nerve conduction
speed
– Decreased muscle action
potential amplitude
– Decreased sensory nerve
action potential amplitude
• Needle Electrode
– Denervation
www.nature.com/nrneurol/journal/v5/n7/i
mages/nrneurol.2009.75-f1.jpg
• Histopathology
– Primary axonal
degeneration
Page 28
Critical Illness Polyneuropathy &
Myopathy
• Prognosis
– Underlying critical illness
– Increased ventilator
dependence
– Functional recovery in
several months
Ulnar Nerve
Compression
• Padding and Positioning to prevent compression
neuropathies
meddb.eznetpublish.ihealthspot.com/portal
s/2/MedicalLibraryAssets/Medical/CubitalTu
nnel_small.jpg
Page 29
Compartment Syndrome
• Open or Closed Fractures
• Fixed Compartment
• Tissue edema and bleeding
• Blood flow impeded
– Capillaries
– Arterioles
• Factors effecting tissue necrosis
– Amount of Pressure
– Duration of increased pressure
– Sensitivity of the tissue to
ischemia
Right Buttock Compartment Syndrome
casesjournal.com/content/figures/1
757-1626-2-190-3.gif
Page 30
Compartment Syndrome
• Tissue Ischemia
Necrotic Muscle
– Nervous tissue
• Functional abnormalities
after 30 minutes
• Irreversible damage
after 12 to 24 hours
– Muscle
• Functional abnormalities
after 2 to 4 hours
• Irreversible damage
after 4 to 12 hours
www.operationgivingback.facs.org/stuff/con
tentmgr/files/a384bb3c7b77e154ad25c613
6d7be344/miscdocs/lab_manual_extremity
_chapter_4__2_.pdf
• Increased capillary permeability -> Edema
Page 31
Compartment Syndrome
• Risk factors
– Severity of fracture
– Extent of soft tissue injury
– Compressive devices
• Anti-shock trousers
• Tourniquets
– Systemic hypotension
www.nexternal.com/medtech/images/MastP
ants.jpg
Page 32
Compartment Syndrome
• Most common location =
Anterior Compartment of the Lower Leg
Usually from closed tibia fracture
• Other sites
– Thigh
– Arm
– Buttock
– Foot
orthoinfo.aaos.org/figures/A00204F01.
Page 33
Compartment Syndrome
• Diagnosis
• Clinical
– Tense compartment to palpation
– Severe pain with passive range of
motion
– Severe compartment tenderness
– Impaired sensory exam
– Decreased distal perfusion
– Pulseless = Too Late
• Extensive tissue necrosis present
– Serial Exams are Critical
Page 34
www.hopkins-arthritis.org/physiciancorner/cme/rheumatologyrounds/images/rounds11/slide22.jpg
Compartment Syndrome
• Measurement of Compartment Pressures
– Unresponsive patients
– Pressure > 30 to 45 =
Indication for Fasciotomies
– Diastolic BP –
Compartment Pressure
< 30 = indication for
Fasciotomies
www.hopkins-arthritis.org/physiciancorner/cme/rheumatologyrounds/images/rounds11/slide22.jpg
Page 35
Compartment Syndrome
• Treatment
– Surgical Fasciotomies
– Fasciotomy within 12
hours = 68% normal
functional result
– Hydration
– Monitor electrolytes
– Monitor for infection of
fasciotomy sites
upload.wikimedia.org/wikipedia/commons/d/da/
Fasciotomy_leg.jpg
Page 36
Lower Leg Fasciotomies
• 2 incisions
• 4 compartments
Anterolateral Incision
• Anterolateral Incision
Anterolateral Incision
img.medscape.com/pi/emed/ckb/orthopedic_surg
ery/1230552-1270542-199.jpg
Page 37
Lower Leg Fasciotomies
• Medial Incision
• Incision 1 fingerbreadth posterior to medial edge of the
tibia
Posteriomedial Incision
• Liberal Length
Posteriomedial Incision
• Avoid saphenous vein
• Divide fibers of soleus from
tibia
• Neurovascular bundle
img.medscape.com/pi/emed/ckb/orthopedic_surger
y/1230552-1270542-169.jpg
Page 38
Upper Leg Fasciotomies
• 3 Compartments
– Anterior
– Posterior
– Medial
• Compartment syndrome rare
• 3 compartments blend with the
hip
• Lateral incision usually
sufficient
• Occasionally requires medial
incision
www.operationgivingback.facs.org/stuff/contentmgr/
files/a384bb3c7b77e154ad25c6136d7be344/miscd
ocs/lab_manual_extremity_chapter_4__2_.pdf
Page 39
Foot Compartment Syndrome
4 Compartments
• Interosseus or Intrinsic Compartment
– 4 intrinsic muscles between 1st and 4th
metatarsals
• Medial Compartment
– Abductor hallicus and flexor
hallicus brevis
• Central or Calcaneal Compartment
– Flexor digitorum brevis, quadratus
plantae, and the adductor hallicus
• Lateral Compartment
– Flexor digiti minimi brevis, www.operationgivingback.facs.org/stuff/contentmg
abductor digiti minimi
r/files/a384bb3c7b77e154ad25c6136d7be344/mis
cdocs/lab_manual_extremity_chapter_4__2_.pdf
Page 40
Foot Compartment Syndrome
-
• Up to 10% of calcaneal
fractures
• 41% of crush injuries to
the foot
• No classic sign of CS
• Most reliable sign:
tense bulging tissue
www.operationgivingback.facs.org/stuff/contentmgr/fil
es/a384bb3c7b77e154ad25c6136d7be344/miscdocs/
lab_manual_extremity_chapter_4__2_.pdf
Page 41
Forearm and Hand Fasciotomies
• Compartment syndromes are less
common than in the leg
• Supracondylar humerus fx >
antebrachial compartment syndrome
• Anterior compartment realeased
with volar incision
• Dorsal incision if necessary
img.medscape.com/pi/emed/ckb/orthopedic_surgery/12
30552-1268992-1269081-126919.jpg
Page 42
img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1268992-1269081-1269193.jpg
Hand Fasciotomies
Thenar and Hypothenar Compartment Fasciotomies
• Compartment syndrome of
the hands is rare
– ? From Trauma
– More often iatrogenic
(A-line or IV infiltrate)
• 10 Osseofascial Compartments
jmedicalcasereports.com/content/figur
es/1752-1947-1-6-2.gif
Dorsal Interosseus Compartment Fasciotomies
– Carpal tunnel release
– 1 or 2 dorsal incisions
• No sensory nerve symptoms
• Pressure > 20mmHg = CS
jmedicalcasereports.com/content/figur
es/1752-1947-1-6-1.jpg
Page 43
Rhabdomyolysis
• Damage to skeletal muscle
– Crush
• Injures cells
• Decreases perfusion
– Metabolic
– Cell lysis due to edema
•
Calcium in sarcoplasmic
reticulum
– Muscle contractions
• Depletes ATP
• Neutrophils migrate
– Increased inflammatory
response
• Muscle compresses local
structures > Compartment
Syndrome > Decreased
Perfusion
• Muscle cells release
potassium, phosphate,
myoglobin, creatine kinase and
uric acid
• Damage to mitochondrion
– Reactive oxygen species
Page 44
Rhabdomyolysis
• Myoglobin
– Nephrotoxic
• Muscle swelling
– Intravascular volume deficit
– Renal hypoperfusion
• Uric acid
– Precipitates in renal tubules
• Myoglobin
– Accumulates in renal tubules
Page 45
Rhabdomyolysis
• Myoglobinuria
– Plasma myoglobin > 1.5 mg/dL
– Myoglobin casts cause
nephron obstruction
– Urine Acidification
• Tea-colored urine
• Urine dipstick + for blood
• Urine – for red blood cells
on microscopy
lifeinthefastlane.com/wpcontent/uploads/2009/12/image_34.jpg
Page 46
Rhabdomyolysis
• Management
– Replete Volume
– Mannitol
• Increases flushing of
myoglobin from renal tubules
• Effective radical scavenger
– Sodium bicarbonate
• Alkalization of Urine
bioephemera.com/wpcontent/uploads/2007/06/jimstanisg1.jpg
• Decreases cast formation
• Decreases direct toxic effect of
myoglobin on the renal tubules
Page 47
Myositis Ossificans
• Severe blunt trauma
• Intra-muscular hematoma
• Delayed ossification of the soft
tissue
• Suspected to be due to
premature return to strenuous
activity
• Most common sites:
- arms
- quadriceps
• Treatment
- Conservative
- Rarely, surgical debridement
www.radiologyassistant.nl/images/thmb
_4acef1936b33836.jpg
Page 48
Image Sources
• bp2.blogger.com/_OY2fM522a9Y/SBZ0DYml2xI/AAAAAAAABA4/K
XVlqSv6hA8/s400/icu.gif
• bp3.blogger.com/_v2GFIISzHOU/SAjilu3b8kI/AAAAAAAAASk/3BRF
9vWKgYY/s400/Neuro-Muscular+Junction.jpg
• bioephemera.com/wp-content/uploads/2007/06/jimstanisg1.jpg
• casesjournal.com/content/figures/1757-1626-2-190-3.gif
• ccforum.com/content/figures/cc2978-1.jpg
• dericbownds.net/uploaded_images/myoglobin.jpg
• download.thelancet.com/images/journalimages/01406736/PIIS0140673609600398.fx1.lrg.jpg
• drdavis.typepad.com/.a/6a00d834525ed169e201156f86664c970c320pi
Page 49
Image Sources
• education.vetmed.vt.edu/Curriculum/VM8054/Labs/Lab10/IMAGES/
MOTOR%20END%20PLATES%20SMALL%201.jpg
• graphics8.nytimes.com/images/2007/08/01/health/adam/9238.jpg
• img.medscape.com/pi/emed/ckb/orthopedic_surgery/12305521268992-1269081-1269193.jpg
• img.medscape.com/pi/emed/ckb/orthopedic_surgery/12305521268992-1269081-1269194.jpg
• img.medscape.com/pi/emed/ckb/orthopedic_surgery/12305521270542-169.jpg
• img.medscape.com/pi/emed/ckb/orthopedic_surgery/12305521270542-199.jpg
• img.medscape.com/pi/emed/ckb/pediatrics_general/13313411331932-982711-1723745.png
• jmedicalcasereports.com/content/figures/1752-1947-1-6-1.jpg
Page 50
Image Sources
• jmedicalcasereports.com/content/figures/1752-1947-1-6-2.gif
• lifeinthefastlane.com/wp-content/uploads/2009/12/image_34.jpg
• Luis and Ng Journal of Medical Case Reports 2007
1:6 doi:10.1186/1752-1947-1-6
• meddb.eznetpublish.ihealthspot.com/portals/2/MedicalLibraryAssets
/Medical/CubitalTunnel_small.jpg
• media.publicbroadcasting.net/kera/newsroom/images/3197830.jpg
• media-2.web.britannica.com/eb-media/75/2975-050-0D5D3A36.jpg
• neuromuscular.wustl.edu/pics/diagrams/emg/gbsrecov.gif
• news.bbc.co.uk/nol/shared/spl/hi/health/03/travel_health/diseases/i
mg/westnile.jpg
• news.stanford.edu/news/2007/january10/gifs/botulismsr_art.jpg
Page 51
Image Sources
• orthoinfo.aaos.org/figures/A00204F01.jpg
• palrehab.net/images/spin20.jpg
• pds13.egloos.com/pds/200907/27/61/e0077661_4a6dba
08992cc.jpg
• pubs.ext.vt.edu/2911/2911-7041/L_IMG_fig11.jpg
• repairstemcell.files.wordpress.com/2009/03/ms-pic.jpg
• stevens.scripps.edu/images/toxin1.jpg
• Textbook of Critical Care. Fink MP, Abraham E, Vincent
JL, Kochanek P (ed) 5th
• ed : Philadelphia : Elsevier Saunders, 2005
Page 52
Image Sources
•
Trauma, 4th edMattox KL, Feliciano DV, Moore EE, eds. New York, NY:
McGraw-Hill, 2000
•
t3.gstatic.com/images?q=tbn:2X93fjZWWgfDUM:http://www.ncbi.nlm.nih.go
v/bookshelf/picrender.fcgi?book=gene&part=hna&blobname=hna-Fig1.jpg
•
upload.wikimedia.org/wikipedia/commons/4/41/Creatine_kinase.PNG
•
upload.wikimedia.org/wikipedia/commons/6/6e/Nicotinic_Acetylcholine_rece
ptor.png
•
upload.wikimedia.org/wikipedia/commons/c/c1/Myelinated_neuron.jpg
•
upload.wikimedia.org/wikipedia/commons/d/da/Fasciotomy_leg.jpg
•
upload.wikimedia.org/wikipedia/commons/thumb/b/ba/Campylobacter.jpg/45
0px-Campylobacter.jpg
•
vasculitis.med.jhu.edu/typesof/images/Muscle_waste_MPA.jpg
Page 53
Image Sources
• wendyusuallywanders.files.wordpress.com/2008/01/mgdroop.jpg
• www.aofoundation.org/AOFileServerSurgery/MyPortalFiles?FilePath
=/Surgery/en/_img/surgery/FurtherReading/PFxM2/1.6-11.jpg
• www.aurorahealthcare.org/healthgate/images/si2141.jpg
• www.brighamandwomens.org/neurology/Images/NeuromuscularDisease.jpg
• www.brown.edu/Courses/Bio_160/Projects2000/Polio/Reflexcopy.jp
g
• www.bu.edu/bridge/archive/2005/04-29/photos/competition01.jpg
• www.cdc.gov/ncidod/EID/vol8no12/images/02-0532_1t.jpg
• www.cerb.fr/imagespm/reins.jpg
Page 54
References
• www.co.klamath.or.us/healthDept/images/mosquito.jpg
• www.defendingfoodsafety.com/uploads/image/Botulism%203.jpg
• www.defendingfoodsafety.com/uploads/image/Botulism%205.jpg
• www.defendingfoodsafety.com/uploads/image/Botulism%206.jpg
• www.defensenutrition.com/lp/muscle_and_body_recovery_formula_
_with_shilajit/images/muscle.jpg
• www.factmonster.com/images/ESCI342MUSSYS002.gif
• www.hakeem-sy.com/main/files/images/MyastheniaGravis.JPG
• www.health-res.com/EX/08-05-01/als1.jpg
• www.hopkins-arthritis.org/physician-corner/cme/rheumatologyrounds/images/rounds11/slide22.jpg
Page 55
References
• www.hughston.com/hha/b_17_2_1b.jpg
• www.infiniteunknown.net/wp-content/uploads/2009/11/guillain-barresyndrome.jpg
• www.infomedsa.ch/images/cf200.png
• www.lib.uiowa.edu/hardin/md/pictures22/cdc/PHIL_2290_lores.jpg
• www.marlerblog.com/botulism.jpg
• www.mda.org/publications/images/q10-3_ach.jpg
• www.moondragon.org/obgyn/graphics/hypotonia.jpg
• www.nature.com/nrmicro/journal/v4/n1/images/nrmicro1326-f2.jpg
Page 56
References
• www.nature.com/nrneurol/journal/v5/n7/images/nrneurol.2009.75f1.jpg
• www.newagetouch.com/blog/wpcontent/uploads/2008/08/muscle_man_running.jpg
• www.nexternal.com/medtech/images/MastPants.jpgwww.pssjournal.
com/content/figures/1754-9493-3-11-5-l.jpg
• www.nlm.nih.gov/medlineplus/images/brain.jpg
• www.operationgivingback.facs.org/stuff/contentmgr/files/a384bb3c7
b77e154ad25c6136d7be344/miscdocs/lab_manual_extremity_chapt
er_4__2_.pdf
• www.pathologyoutlines.com/images/softtissue/06_13.jpg
• www.podiatrytoday.com/files/imagecache/normal/photos/compartme
nt1.jpg
Page 57
www.nationalreviewofmedicine.com/images/issue/2007/may30/4_Ponderer_10.jpg
References
• www.radiologyassistant.nl/images/thmb_4acef1936b338
36.jpg
• www.reflexologyprof.com/Newsletter/images/thymus_refl
ex.png
• www.teachtech.co.th/shop/pictures/product/21557.gif
• www.tmin.ac.jp/english/dept/07/neurology2.jpg
• www.uihealthcare.com/topics/medicaldepartments/pediat
rics/copingwithintensivecareunit/images/ventilator.gif
• z.about.com/d/create/1/0/c/o/-/-/0160.jpg
Page 58
www.nationalreviewofmedicine.com/images/issue/2007/may30/4_Ponderer_10.jpg