Lab Manual of Regional Anatomy
(for Student)
Department of Regional Anatomy & Operative Surgery
The 1st Affiliated Hospital of China Medical University
CONTENTS
BACK ....................................................................................................................................... 4
Assignments: ..................................................................................................................... 4
Objectives: ........................................................................................................................ 4
Procedure: ......................................................................................................................... 4
Thoracic wall and lung .............................................................................................................. 7
Assignments: ..................................................................................................................... 7
Objectives: ........................................................................................................................ 7
Procedure: ......................................................................................................................... 8
Mediastinum ............................................................................................................................. 9
Assignments: ..................................................................................................................... 9
Objectives: ........................................................................................................................ 9
Procedure: ......................................................................................................................... 9
Abdominal wall ....................................................................................................................... 11
Assignments: ................................................................................................................... 11
Objectives: ...................................................................................................................... 11
Procedure: ....................................................................................................................... 11
Peritoneum and Peritoneal Cavity ........................................................................................... 14
Assignments: ................................................................................................................... 14
Objectives: ...................................................................................................................... 14
Procedure: ....................................................................................................................... 14
Abdominal Viscera .................................................................................................................. 15
Assignments: ................................................................................................................... 15
Objectives: ...................................................................................................................... 15
Procedure: ....................................................................................................................... 15
Abdominal Viscera Ⅱ ............................................................................................................ 17
Assignments: ................................................................................................................... 17
Objectives: ...................................................................................................................... 17
Procedure: ....................................................................................................................... 17
Posterior abdominal region ..................................................................................................... 19
Assignments: ................................................................................................................... 19
Objectives: ...................................................................................................................... 19
Procedure: ....................................................................................................................... 19
Pelvis ....................................................................................................................................... 21
Assignments: ................................................................................................................... 21
Objectives: ...................................................................................................................... 21
Procedure: ....................................................................................................................... 21
Upper limbs ............................................................................................................................. 23
Assignments: ................................................................................................................... 23
Objectives: ...................................................................................................................... 23
Procedure: ....................................................................................................................... 23
Lower limbs ............................................................................................................................ 26
Assignments: ................................................................................................................... 26
Objectives: ...................................................................................................................... 26
Procedure: ....................................................................................................................... 27
Head & Neck........................................................................................................................... 30
Assignments: ................................................................................................................... 30
Objectives: ...................................................................................................................... 30
Procedure: ....................................................................................................................... 30
BACK
Assignments:
1. Complete the learning module entitled anatomy and imaging.
2. Complete the learning module entitled back.
Objectives:
1. Define the "anatomical position". Using the conventional anatomical
terms, describe the body and the spatial relationships of its parts, for
example dorsal/ventral, medial/lateral, proximal/distal, and
superficial/deep.
2. Recognize and define the standard planes and sections used to
describe parts of the body and the relationships of the various planes
and sections to one another.
3. Describe the general structural plan of the body and the relationships
of the layers, partitions and compartments one encounters when
dissecting from superficial to deep in any particular region.
4. Identify the layers of back; define the “triangle of auscultation”,
“upper lumbar triangle”, and “lower lumbar triangle”.
5. Describe the blood supply and innervations of the back.
6. Describe the construction of the vertebral column.
7. Recognize the anatomical structures related to lumbar puncture.
8. Identify the coverings of the spinal cord and the spinal meninges.
9. Describe the blood supply of the spinal cord.
Procedure:
1. Study laboratory 1 and 2 (human anatomy).
2. Study figures 142-166 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on page 95-97 in the textbook
2). Discuss the questions on page 98-99 in the textbook.
case 1
A 33-year-old woman undergoes a lymph node biopsy of her deep
cervical nodes on the left side of her neck. Immediately following surgery,
she complains of weakness in her left shoulder. On exam, the left
shoulder droops, and she is unable to raise the point of her shoulder. She
denies numbness in her shoulder, back, and neck.
1. What nerve appears to have been inadvertently cut during the
biopsy?
A. Greater occipital n.
B. Spinal n. C3
C. Dorsal scapular n.
D. Accessory n. (Cranial Nerve XI)
E. Cutaneous nn. of the back (dorsal primary rami)
2. In most peripheral nerve injuries, there is usually characteristic
sensory loss, producing numbness in a specific area. Which of the
following best explains why there is no numbness in this case?
A. The motor part of CN XI must have been damaged, while the
sensory part remained intact.
B. The spinal accessory nerve is unique among peripheral nerves
in that it does not carry any sensory fibers whatsoever.
C. Sensory loss is not expected from damage of this nerve
because no peripheral nerve that innervates a skeletal muscle
of the upper limb carries sensory fibers.
D. Nerves that innervate skeletal muscles carry only motor
neurons, and cutaneous sensory nerves carry only sensory
neurons.
3. Since the spinal accessory nerve carries no proprioceptive fibers,
which of the following best explains the ability to execute
coordinated movement of the trapezius muscle?
A. Because the trapezius m. is the only muscle that inserts on the
acromion, allowing for elevation of the shoulder, the central
nervous system does not need proprioceptive feedback for
coordinated movement of that muscle.
B. Proprioceptive fibers from nerves innervating other muscles
that also insert on the clavicle and scapula, including levator
scapulae m., rhomboid major m., rhomboid minor m., and
sublavius m., provide enough sensory information to the
central nervous system that coordinated movement of the
trapezius m. can occur without proprioceptive information
from that muscle.
C. The greater occipital n., a branch of C2, sends proprioceptive
fibers from the nuchal ligament and the trapezius m. to the
central nervous system to allow for coordinated movement.
D. Spinal nerves C3 and C4 carrying proprioceptive fibers
combine with branches of the spinal accessory n. in the
subtrapezial plexus before innervating the trapezius m.
4. Following the spinal accessory nerve from its origin to its
destination in the body, which of the following sequences would best
describe what you would find along the way?
A. Association with the cervical spinal cord, passage through the
jugular foramen, association with proprioceptive fibers,
passage through the foramen magnum, innervation of the
target muscles
B. Association with the C3 and C4 dorsal primary rami, passage
through the foramen magnum, passage through the jugular
foramen, association with proprioceptive fibers in the
subtrapezial plexus, innervation of the target muscles
C. Association with the cervical spinal cord, passage through
foramen magnum, passage through the jugular foramen,
formation of subtrapezial plexus, innervation of target muscle
along with proprioceptive fibers
D. Association with the C3 and C4 ventral primary rami, passage
through the foramen magnum, association with
proprioceptive fibers, passage through the jugular foramen,
formation of the subtrapezial plexus, innervation of the target
muscles
E. Association with the C3 and C4 ventral primary rami, passage
through the foramen magnum along with proprioceptive
fibers, passage through the jugular foramen, disassociation
from proprioceptive fibers at the subtrapezial plexus,
innervation of the target muscles
case 2
A 25-year-old man is brought into the ER with a high fever, lethargy,
and a stiff neck. After taking a history and performing a physical exam,
you strongly suspect meningitis. In order to find the causative agent, you
order a lumbar puncture. Laboratory analysis confirms your suspicion by
showing bacterial growth in the cerebrospinal fluid (CSF). You
administer the appropriate therapy and the patient recovers without any
complications.
1. Where along the vertebral column is a needle inserted for a lumbar
puncture? Which landmark can you use to find this level?
2. During a lumbar puncture, the syringe needle is inserted in the
midline and within the median plane. Why? What structures,
ligaments and others, does the needle traverse before entering the
lumbar cistern?
3. What position is the patient placed in during this procedure? Justify
this anatomically.
4. Following the procedure, the patient complains of a severe headache.
What is the cause of this complication of lumbar punctures?
5. Other than obtaining CSF samples, in what other situations are
lumbar punctures performed?
case 3
You are called to evaluate a newborn infant in the labor and delivery
room. On physical exam you note that the infant has normal vital signs
and appearance with the following exception - you note that the patient
has a bulging cyst-like structure approximately 4 cm in diameter
protruding from his back . You also note that he has limited movement of
the lower extremities and that both feet are plantarflexed and inverted at
the ankle.
1. What are neural tube defects and how often do they occur?
2. What types of anatomical structures can be involved with a case of
spina bifida?
3. How do the various types of neural tube disorders vary in their
presentation?
4. What is the cause of spina bifida?
5. What other complications are associated with this condition?
6. What simple prophylactic therapy can be undertaken prenatally to
prevent such defects?
case 4
Paramedics respond to a report of an 82 year old man unconscious
after a fall. They find the patient on the floor in his house in cardiac arrest.
His wife said that he fell approximately 18 inches from a lift assist device.
The paramedics revive the patient to a normal sinus rhythm using ACLS
protocols (Advanced Cardiac Life Support) but the patient remains
profoundly unconscious. They fully immobilize his spine and transport
him emergently to the hospital. X-ray, CT, and MRI image studies at the
hospital show C1 and C2 fractures with spinal cord injury, resulting in
quadriplegia. T2-T4 spinous processes and several left ribs are also
fractured. The patient never regains consciousness and dies the next day.
1. What is the function of the dens of C2, and why are fractures in this
region so dangerous?
2. What is spinal immobilization, and why is it used?
Thoracic wall and lung
Assignments:
1. Complete the learning module entitled thorax, thoracic wall and
thoracic cavity.
2. Complete the learning module entitled diaphragm.
3. Complete the learning module entitled lung.
Objectives:
1. Describe the surface landmarks of the thoracic wall and the layers of
the thoracic wall.
2. Recognize the boundaries and divisions of the thorax.
3. Recognize the layers of the thoracic wall.
4. Describe the position of the breast, structures and the lymphatic
drainage.
5. Recognize the thoracic cavity.
6. Recognize the position and portion of the diaphragm; Master the
“esophageal hiatus”, the “aortic hiatus”, and the “vena cava
foramen”.
7. Recognize the lung, the root of the lung; describe the structures in
the root of the lung.
8. Recognize the bronchial tree and the pulmonary segments.
Procedure:
1. Study laboratory 18 and 19 (human anatomy).
2. Study planes 167-199 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on page 209-210 (case1, 2, 3), page
215 (case 8) in the textbook
2). Discuss the questions on page 216 (Q1, 2, 3, 4) in the
textbook.
3). Discuss the following cases.
Case 1
During one of your third-year rotations you observe a resident on
your service perform a thoracocentesis to obtain a sample of pleural fluid.
The resident inserts the needle near the lower border of the eighth rib at
the right anterior axillary line and withdraws a few milliliters of fluid.
The next day, during your rounds, the patient complains of tingling and
numbness of the skin of his chest from the level of the eighth rib down
toward the umbilicus on the right side.
① Why is the needle inserted in the eighth intercostal space?
② How would you explain the presence of the parasthesia?
③ What specific structure was likely damaged by the needle,
and how to explain the distribution of the parasthesia?
④ What other structures are associated with the damaged and
how are they arranged? Between which two muscles we can find these
structures?
⑤ Where should the resident insert the needle to avoid the
damage of these structures?
⑥ For what other reasons (besides sampling pleural fluid) might
a thoracocentesis be performed?
Case 2
A twenty-five year old male presents on your emergency room
rotation after sustaining a single gunshot wound (GSW) to the right side
of his chest. Paramedics found the patient awake and combative with a
palpable pulse, systolic BP of 100 mm Hg, and respiratory rate 30/
minute. An occlusive dressing was taped over the entry site in the fifth
intercostal space, midaxillary line. On arrival, the patient's vital signs
were worse. You note that the patient's trachea is deviated to the left, his
jugular veins are distended, he has no breathing sounds on the right side
of his chest, he has palpable crepitus, and on percussion he has
hyper-resonance on the right side of the chest. The resident on call
determines that the patient has a tension pneumothorax and inserts a 14
gauge needle in the right midclavicular line at the second intercostal
space - air is heard escaping. A chest tube is inserted at the fifth
intercostal space in the midaxillary line and connected to a chest drainage
device. The patient was stabilized and transferred to the Trauma Intensive
Care Unit (TICU).
① What might cause the tension pneumothorax?
② Why did the resident insert the chest tube into the fifth intercostal
space?
③ What structures did the chest tube pass through to enter the pleural
cavity?
④ What is tension pneumothorax?
⑤ What are the signs and symptoms of tension pneumothorax?
⑥ What is the appropriate treatment?
Mediastinum
Assignments:
Complete the learning module entitled structures organs in the
mediastinum.
Objectives:
1. Define the “mediastinum”, describe the regions of the mediastinum.
2. Recognize the structures and organs in the mediastinum. Recognize
the neighborhood of the organs in the mediastinum from right and
left lateral view.
3. Master the organs in the superior mediastinum and the characters of
the organs.
4. Recognize the pericardium and pericardial cavity.
5. Master the organs in the posterior mediastinum and the pathway of
the esophagus and the thoracic duct.
6. Recognize the 3 branches of the aortic arch.
Procedure:
1. Study laboratory 20 and 21 (human anatomy).
2. Study planes 200-230 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on page 211-214 (case4, 5, 6, 7) in
the textbook
2). Discuss the questions on page 98-99 (Q5-10) in the textbook.
3). Discuss the following cases:
Case 1
During a routine physical exam for participation in interscholastic
sports, the physician noted that E.S., a twelve-year-old boy, had a long
continuous heart murmur at the second intercostal space near the left
sternal border. A systolic thrill was also noted in the same region. When
questioned, the patient's mother recalled that E.S. had periods of cyanosis
and breathlessness as an infant, but that his previous pediatrician said that
the murmur and the symptoms were nothing to be concerned about. E.S.
also mentioned that he tires easily during physical activity. Chest films
and Doppler ultrasound were ordered. The radiographs indicated slight
left ventricular hypertrophy, and ultrasound revealed a patent ductus
arteriosus. E.S. was scheduled for surgery to ligate the ductus arteriosus.
The surgery resulted in successful ligation of the ductus arteriosus;
however, E.S. experienced hoarseness when speaking following the
procedure. Laryngoscopy revealed paralysis of the left vocal fold.
Questions:
1. What is the arterial duct, and where is the arterial duct located?
2. Normally, when the arterial duct should close? What will happen
if the arterial duct not closed?
3. What likely cause the paralysis of the left vocal fold?
Case 2
Your service has been called to provide consultative support to a
patient who has become unstable during his postoperative phase of
surgery. The patient is currently recovering from a modified radical neck
procedure for carcinoma of the tongue. The patient presents tachycardic
and hypotensive with decreasing urinary output and poor skin turgor. He
is intermittently combative and semi-conscious. On physical exam, you
note the incision line on the left side of his neck to be intact with a bulb
suction device protruding through the incision. The surrounding region of
the neck is edematous, and a palpable mass roughly 8 cm in diameter is
felt. You connect the bulb suction to the wall suction apparatus and
approximately 600 ml of milky white fluid is immediately aspirated from
the wound with a subsequent diminution in the size of the mass. Over the
next few hours, you notice that the patient continues to have worsening
hypotension, and the wound has now drained over 1 liter of milky white
fluid in the period of six hours. The resident diagnosed a chylothorax.
The plan for management includes contacting the thoracic surgery team
and replacing the patient's lost fluid volume.
Question:
1. How would you explain the milky white fluid following this kind
of operation?
2. What is chylothorax?
3. Which lymphatic channel/duct would be involved?
4. What is chylothorax?
5. How to make a definitive diagnosis?
6. What structures drain into the thoracic duct?
7. What lymph nodes can be found in the posterior
Abdominal wall
Assignments:
Complete the learning module entitled abdominal wall & inguinal
region.
Objectives:
1. Recognize and define the abdominal cavity, peritoneal cavity.
Describe the divisions of the anterolateral abdominal wall.
2. Describe the general layers of the anterolateral abdominal wall and
the relationships of the layers, partitions and compartments one
encounters when dissecting from superficial to deep in any particular
region.
3. Describe the blood supply and innervations of the anterolateral
abdominal wall.
4. Recognize the anatomical structures related to incisions on
anterolateral abdominal wall.
5. Recognize and define the inguinal region. Describe the general
layers of the inguinal region and ligaments in this region.
6. Recognize and define the inguinal canal and the 4 walls and 2
openings of it.
7. Recognize and define the inguinal triangle.
Procedure:
1. Study laboratory 35 and 36 (human anatomy).
2. Study plates 231-245 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on your textbook about anterolateral
abdominal wall and inguinal region.
2). Discuss the cases below:
Case 1
A 28-year-old woman in her 36th week of pregnancy arrived in the
emergency room following an automobile accident. Immediately
following the accident she went into labor. The accident had broken her
pelvis such that the emergency room physician deemed a vaginal delivery
would be hazardous. An obstetrician was called, and she agreed with the
ER physician's initial assessment. A Cesarian section was performed,
resulting in the delivery of a healthy baby girl. During the operation, the
obstetrician used a Pfannenstiel incision to open the abdomen. This
incision involves making a transverse, slightly convex cut large enough to
deliver a child at approximately the pubic hairline.
1. What abdominal wall layers must be incised at the pubic hairline
(near the midline) in order to access the abdominal cavity?
2. Why is the incision made in a convex manner instead of straight
across?
3. What vascular structures might be cut during a Pfannenstiel
incision?
4. Where in the abdomen could a surgeon make a large vertical
incision with minimal detrimental effect?
Case 2
A twenty-five year-old female medical student presents to the
emergency room with a complaint of "colicky" periumbilical pain which
has intensified over the last 6-8 hours and now has started to migrate to
the right lower quadrant. The patient reports some initial nausea, and as
the pain has increased she has had increasing emesis and anorexia.
Physical exam demonstrates the patient has no distension, auscultation
reveals hyperactive bowel sounds, and on palpation the patient
demonstrates abdominal guarding and rebound tenderness, and the
muscles of the anterior wall in the right lower quadrant are rigid. In
addition, the patient has a low-grade fever, and laboratory tests reveal a
rising white blood cell count. The attending determines that the patient
has acute appendicitis and prepares to take the student to the O.R. for an
appendectomy. The surgeon asks you the following questions regarding
the surgery.
1. What is McBurney's point?
2. What types of incisions can be made in the abdominal wall?
3. Which of these incisions would be the most ideal for an
appendectomy?
4. When placing an incision in the abdominal wall, what nerves have
to be identified? What would be a consequence of damage to the
nerves?
5. Suppose that the surgeon, in the process of the appendectomy, is
unable to locate the appendix through the small incision he made
in the right lower quadrant, so he decides to extend his incision
several inches superiorly toward the rib cage. What is likely to
result from such a procedure?
6. What nerve is at risk when an incision is made at McBurney's
point? What would be the long-term effects of damage to this
nerve?
Case 3
S.T., a 35-year-old man, was carrying furniture out to a moving van
in preparation for his family's move to a new home. When S.T. strained to
pick up a particularly heavy coffee table, he suddenly felt a sharp pain in
his right groin. Later, he noticed that a painful bulge had developed in his
groin which disappeared when he laid on his back. He did not like going
to the doctor, so he ignored the condition. After several months, the pain
and the bulge in his groin increased and he finally consented to see a
physician. On examination, the physician observed a swelling which
began about midway between the anterior superior iliac spine and the
midline, progressed medially for about 4 cm, and then turned toward the
scrotum . Taking the history and physical findings into account, the
physician made a diagnosis of indirect inguinal hernia and scheduled S.T.
for surgery. The hernia was successfully repaired, and S.T. was released
from the hospital a few days later.
1. What abdominal wall layers must be incised at the pubic hairline
(near the midline) in order to access the abdominal cavity?
2. What defines this hernia as an indirect inguinal hernia rather than
a direct inguinal hernia? List the key features of each.
3. What caused the bulge? What body layers would surround it as it
proceeded into the scrotum and what abdominal layers are they
derived from?
4. Why would it be necessary to repair a hernia like the one
described above as quickly as possible?
5. How is the inguinal canal formed, and which structures are
associated with the inguinal canal in the male? in the female?
6. What is the definition of an inguinal hernia? What is the male to
female ratio of incidence of direct inguinal hernias?
7. What are common causes of direct inguinal hernias?
8. What are the boundaries of Hesselbach's (inguinal) triangle ?
9. Do you know your eponyms? What are the following structures?
(NOTE: FYI only - we will not exam on these)
Poupart's ligament
Cooper's ligament
Gimbernat's ligament
Colles' ligament
Henle's ligament
Hesselbach's ligament
Peritoneum and Peritoneal Cavity
Assignments:
1. Grasp the main structure formed by the peritoneum.
2. Grasp the subarea of the peritoneal cavity.
Objectives:
1. General view of the peritoneum
2. General view of the peritoneal cavity
3. Greater and lesser omentum and the structures they form
4. Ligaments of some complicated vesicles: the liver, the stomach and
the spleen etc.
5. Mesentery of the intestine: the small intestine, the appendix, the
transverse and sigmoid colon.
6. Subarea of the subphrenic space: 8 spaces.
7. Subcolic space: the 2 mesentery sinuses and the 2 paracolic gutters
8. Fold formed by the peritoneum and the corresponding recess
9. Pouch formed by peritoneum in different gender.
Procedure:
1. Study laboratory 37 (human anatomy).
2. Study figures 252A-256, 331-333(interactive atlas).
3. Discuss the next cases in groups
A twenty-five year-old female medical student presents to the
emergency room with a complaint of "colicky" periumbilical pain which
has intensified over the last 6-8 hours and now has started to migrate to
the right lower quadrant. The patient reports some initial nausea, and as
the pain has increased she has had increasing emesis and anorexia.
Physical exam demonstrates the patient has no distension, auscultation
reveals hyperactive bowel sounds, and on palpation the patient
demonstrates abdominal guarding and rebound tenderness, and the
muscles of the anterior wall in the right lower quadrant are rigid. In
addition, the patient has a low-grade fever, and laboratory tests reveal a
rising white blood cell count. The attending determines that the patient
has acute appendicitis and prepares to take the student to the O.R. for an
appendectomy. the appendix was removed and the stump tied. The
abdomen was washed out with warm saline solution. The patient initially
made an uneventful recovery but by day 7 she had become unwell with
pain over her right shoulder and spiking temperatures. This patient had
developed an intra-abdominal abscess.
1. Fortunately for the patient, she was treated before her infection
became life-threatening; however, if she had waited to seek
treatment or if the physicians had not acted quickly on their
suspicions, her infection may have continued to spread in the
peritoneal cavity and the blood stream. Which organ is particularly
at risk for secondary infection in appendicitis and why?
2. Which peritoneal gaps may the intra-abdominal abscess develop?
3. Where are the most common sites for abscess to develop? Why?
4. Why the patient had right shoulder pain?
Abdominal Viscera
Assignments:
1. Complete the learning module entitled liver.
2. Complete the learning module entitled extrahepatic bile ducts.
3. Complete the learning module entitled pancreas.
4. Complete the learning module entitled spleen.
Objectives:
1. Describe the position of the liver.
2. Master the three porta hepatic.
3. Recognize the interhepatic ducts: Glisson system. Hepatic venous.
4. Master the eight liver segments and how to divide it?
5. Recognize the structure of the extrahepatic bile ducts.
6. Recognize the relationship of the gallbladder
7. Master the Calot triangle.
8. Recognize common bile duct, bile drainage.
9. Describe the position, relationship and division of pancreas,
pancreatic duct, blood supply of pancreas..
10. Describe the position of spleen and blood supply of spleen.
11. Master the relationship (diaphragmatic surface, visceral surface)of
spleen.
Procedure:
1. Study laboratory 38 and 39 (human anatomy).
2. Study planes 258-314 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on page 353-360 in the textbook
2). Discuss the questions on page 361-362 in the textbook.
3). Discuss the cases below:
Case 1
M.S., a generally healthy 74-year-old woman, visited her physician
with the following complaints: progressive jaundice over the last week or
so, frequent bowel movements with pale, greasy feces, a lack of energy,
weight loss, and back pain. The physician ordered a series of tests, which
suggested that the jaundice was of an obstructive, not metabolic, nature.
Abdominal ultrasound demonstrated the presence of a growth on the head
of the pancreas, and further tests indicated that the lesion was a pancreatic
carcinoma. After consultation with a surgeon, M.S. elected to have a
cholecystojejunostomy performed to correct the obstruction and prevent
the discomfort and pruritis that usually accompany obstructive jaundice.
The pancreatic tumor was deemed inoperable, and M.S. was referred to
her local hospice for assistance as her disease progressed.
1. How does the tumor in the head of the pancreas relate to the
jaundice experienced by the patient?
2. How might the pancreatic carcinoma relate to M.S.'s back pain?
3. Pancreatic carcinomas frequently metastasize to the liver,
resulting in significant hepatomegaly. Why is the liver a common target
for metastasis?
4. What other organs, due to their proximity to the pancreas, may be
susceptible to invasion by a pancreatic carcinoma?
5. What important structures are at risk for compression by an
expanding pancreatic carcinoma?
Case 2
A forty year old slightly obese female presents to your E.R. with
spasmodic, colicky pain in her right upper quadrant, with some right
shoulder discomfort and accompanying nausea and vomiting. She reports
that she has been running a fever over the past twenty-four hours. On
physical exam you note heart rate 110, blood pressure 110/70, respiratory
rate 20, and temperature 102. She is noticeably uncomfortable on deep
inspiration, and palpation reveals an increase in pain while palpating the
RUQ. The physician suspects that the patient is suffering from an acute
episode of cholecystitis and orders an ultrasound study; the study reveals
a large stone lodged within the cystic duct. The patient is prepped for a
laparoscopic cholecystectomy.
1. What is cholecystitis , and what are some of its causes?
2. What three parts of the gallbladder would be visualized on
ultrasound?
3. Why might the patient experience right shoulder discomfort?
4. During a laparoscopic cholecystectomy the surgeon is responsible
for dissecting out the cystohepatic triangle (of Calot); can you define the
borders of the triangle?
Case 3
A twenty-six year old female presents to your Emergency Room
after a motor vehicle accident. The patient reports that she was a
pedestrian on South University Avenue and while crossing the street was
struck by a car. The patient's only complaints are abdominal tenderness
and left shoulder pain. On physical exam you note that her vital signs are:
blood pressure (BP) 90/60, heart rate (HR) 110, and respiratory rate (RR)
12. Her abdomen is tender on palpation of the left upper quadrant, with a
faint tire mark over that area; in addition you detect crepitus (indicating
fractured ribs) over the 9th, 10th, and 11th ribs on the left side. You order
a CBC which demonstrates an increased white blood count and a
decreased hematocrit. You perform a diagnostic peritoneal lavage (DPL)
and order a CT. The DPL has a bloody drainage (through which you
cannot read a newspaper) and CT confirms a complete splenic rupture
and fractured ribs. The patient is taken to the O.R. for a splenectomy, and
a pneumococcal vaccine is delivered to the patient.
1. What overlying structures protect the spleen?
2. What other structures lie within this quadrant and are at risk for
injury?
3. What is the major arterial supply of the spleen? What other major
branches arise from this artery?
4. What is the major vein that drains the spleen, and what is its
course?
Abdominal Viscera Ⅱ
Assignments:
1. Complete the learning module entitled stomach.
2. Complete the learning module entitled duodenum.
3. Complete the learning module entitled jejunum and ileum.
4. Complete the learning module entitled cecum and appendix.
5. Complete the learning module entitled colon.
6. Complete the learning module entitled portal venous system.
Objectives:
1. Describe the position and relationship of the stomach, duodenum,
jejunum, ileum, cecum, appendix and colon.
2. Master the features of the stomach, duodenum, jejunum, ileum,
cecum, appendix and colon.
3. Master the blood supply, lymphatic drainage and innervations of
these organs.
4. Recognize the portal venous system.
5. Recognize communications between the portal venous system and
caval venous system.
Procedure:
1. Study laboratory 38 and 39 (human anatomy).
2. Study planes 258-268, 282-314 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on page 353-360 in the textbook
2). Discuss the questions on page 361-362 in the textbook.
3). Discuss the cases below:
Case 1
A 48-year-old male with a history of alcoholism is brought into the
ER with severe epigastric pain and hematemesis. Upon physical
examination you find him to be jaundiced and tachycardic with low blood
pressure. Other physical findings include spider nevi (hemangiomas) on
the cheeks, neck, upper extremities, and torso; ascites; splenomegaly; and
tortuous dilated veins radiating from the umbilicus (caput medusae ).
The patient also tells you that he often has bloody stools, which prompts
you to perform a rectal examination during which you find internal
hemorrhoids. After completing your work-up, you correctly make a
diagnosis of alcoholic cirrhosis of the liver.
1. Discuss the etiology of the following symptoms considering the
anatomy of the portal venous system: hematemesis, caput
medusae, internal hemorrhoids.
2. What is the cause of ascites and splenomegaly?
3. Suggest possible treatments for lowering the blood pressure in the
portal system.
Case 2
A 42-year-old business executive was admitted to the hospital after
visiting the emergency room complaining of severe epigastric pain and
pain over her right shoulder. She had a history of gastric ulcer which
had been treated previously with medication, but on questioning, she
admitted that she had been so busy recently that she had forgotten to refill
her prescription and had not taken her medication in some time. As a
result of the history and physical findings, the physician suspected that
she was suffering from a perforated gastric ulcer. Gastroscopy was
performed which confirmed the diagnosis. When the surgeon examined
the patient's stomach during the surgery, she found a small perforation on
the posterior aspect of the body of the stomach near the lesser curvature.
The perforation was repaired and, in addition, a vagotomy was
performed. During the vagotomy, the surgeon found it necessary to cut
the left gastric artery and ligate it.
1. What structures are at risk for damage by gastric juices if a
perforation like the one described above occurs?
2. Why did the patient experience pain over her shoulder as well as
in her abdomen?
3. What is a vagotomy and why was it performed?
4. Since the left gastric artery had to be ligated during the surgery,
how will the stomach obtain an adequate blood supply?
5. Variations in the arteries of the celiac trunk are quite common, and
thus are of particular interest to surgeons working in this area.
Suppose the common hepatic artery originated from the left
gastric artery in this case (an uncommon, but possible, variation)
and the surgeon had to ligate the left gastric artery proximal to the
bifurcation. How would this affect blood flow to the stomach? to
other organs?
Case 3
A fifty-four year old woman presents to your clinic with complaints
of cramping, "colicky" abdominal pain, nausea and vomiting, severe
constipation (obstipation), dizziness, and a fever for the past two days.
Previous surgical history includes an appendectomy. On physical exam
you note that her blood pressure is 75/40, heart rate 130, and her
temperature is 102. Her abdomen is distended, and auscultation reveals
intermittent high-pitched bowel sounds. On light palpation, peritoneal
irritation is demonstrated by the presence of involuntary guarding and
rebound tenderness. You order a CBC (complete blood count) which
demonstrates a white blood cell count of 14,000. You also order an
abdominal X-ray which reveals a small bowel obstruction with dilated
small bowel loops (greater than 3 cm in diameter), multiple air-fluid
levels within the small bowel and a lack of gas in the distal colon and
rectum. The diagnosis of a small bowel obstruction is made, and the
patient is sent to surgery for evaluation .
1. The patient had his small bowel resected and anastomosed, what
should the surgeon take care?
2. How to distinguish the jejunum and ileum in the operation?
Posterior abdominal region
Assignments:
1. Complete the learning module entitled posterior abdominal region.
2. Complete the learning module entitled kidneys and suprarenal
glands.
3. Complete the learning module entitled abdominal aorta.
4. Complete the learning module entitled inferior vena cava.
Objectives:
1. Describe the boundaries of posterior abdominal region.
2. Describe the position, neighbors, blood supply and the captures of
the kidneys. Define the “renal angle”, “renal hilum”, “renal pedicle”,
“renal vascular segments”.
3. Describe the position, neighbors, blood supply of the suprarenal
glands.
4. Describe the course, neighbors, blood supply of the ureters.
5. Describe the course, main branches of the abdominal aorta.
6. Describe the course, main branches of the inferior vena cava.
Procedure:
1. Study laboratory 40 (human anatomy).
2. Study planes 315-333 (interactive atlas).
3. Discuss the next questions in groups
4). Discuss the clinical cases on page 353-360 in the textbook
5). Discuss the questions on page 361-362 in the textbook.
6). Discuss cases below:
Case1
During a football game between two arch rivals, the wide receiver of
one team was involved in a pass pattern across the middle of the field.
The quarterback was being rushed and threw the pass high. The wide
receiver leapt to catch the pass and just as he did so he was "sandwiched"
between the cornerback and free safety. The two defensive players hit the
receiver just below the ribs on the right side, one in front and one from
behind. The receiver managed to hang on to the ball but crumpled to the
turf in pain. At first it was thought that he was just "shaken up," but the
pain in his flank continued and became more severe. He was taken to the
emergency room and examined. His vital signs were slightly elevated, but
within normal range. Plain film X-rays showed no broken bones, but the
margin of the right psoas major muscle was not distinguishable.
Urinalysis showed blood in his urine. An IVP and CT scans were done.
The IVP showed leakage of contrast into the tissue immediately around
the kidney. The hemorrhage was confined to the area immediately around
the kidney and extended medially toward the vena cava. The diagnosis
was that the kidney had been lacerated or ruptured. Immediate surgery
was performed to close the laceration. The player's season ended, but he
recovered uneventfully.
1. Where is the right kidney located in reference to the vertebrae,
ribs, and psoas major muscle?
2. Why was the margin of the psoas major muscle not visible?
3. How did blood get into the urine?
4. What is an IVP?
5. What confined the hemorrhage to the area around the kidney?
6. Where would be the best place to make a surgical incision to
expose the kidney without going into the peritoneal cavity?
Case 2
A 55-year-old woman was found rolling on her kitchen floor, crying
out from agonizing pain in her abdomen. The pain came in waves and
extended from the right loin to the groin and to the front of the right thigh.
An anteroposterior radiograph of the abdomen revealed a calculus in the
right ureter.
1. What causes the pain when a ureteric calculus is present?
2. Why is the pain felt in such an extensive area?
3. Where does one look for the course of the ureter in a radiograph?
4. Where along the ureter is a calculus likely to be held up?
Case 3
An explorer in the Amazon jungle was found alive after having lost
contact with the outside world for six months. On physical examination,
he was found to be in an emaciated condition. On palpation of the
abdomen, a rounded, smooth swelling appeared in the right loin at the end
of inspiration. On expiration, the swelling moved upward and could no
longer be felt. What anatomical structure could produce such a swelling?
Case 4
An examination of a patient revealed that she had a horseshoe
kidney. What anatomical structure prevents a horseshoe kidney from
ascending to a level above the umbilicus?
Pelvis
Assignments:
1. Grasp the relationship of the main pelvic viscera.
2. Grasp the vessel lymph and nerve pathway.
Objectives:
1. General view of the pelvic viscera.
2. Relationship of the viscera with the peritoneum.
3. Ureter and ductus deferens or round ligament of uterus.
4. Space and fascia.
5. Vessel, lymph and nerve.
Procedure:
1. Study laboratory 41 and 44 (human anatomy).
2. Study plates 334～394 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on your textbook about pelvis.
2). Discuss the cases below:
Case 1
You are in the middle of an international rotation in West Africa and
consult with a surgeon on a 35-year old female patient who complains of
irregular and painful menses, and an unexplained abdominal mass. The
patient reports that she has six children. On physical exam you palpate a
large (15 cm in diameter) mass in the lower abdomen. The patient denies
pain on deep palpation, bowel sounds are present and normal. The
surgeon decides to perform an exploratory laparotomy . She advises the
patient that she may have to perform a hysterectomy and makes certain
that the patient understands the consequences of the surgery. On
beginning the surgery, she makes a midline incision up to the umbilicus,
retracts the rectus muscles and fascia and notes that the patient has an
enlarged uterus which is covered with large fibroid tumors. The surgeon
then inspects the ovaries and observes that they are normal in size and
morphology. She then proceeds to perform a hysterectomy. The excised
uterus weighed in at six kilograms.
1. To excise the uterus what ligaments would the surgeon have to cut?
2. What blood vessels would she be concerned about as she performed
the surgery?
3. What other vessel or tube would be of great concern?
Case 2
A 26 year old woman is referred for assessment and treatment of
anal Crohn's disease which was first diagnosed four years ago. Eighteen
months ago she developed a right ischiorectal abscess which was treated
by incision and drainage. A fistulous opening persisted on the right
buttock. The drainage through the right buttock opening occasionally
necessitated wearing a pad. The drainage was slightly odorous,
occasionally blood tinged and non-feculent. She experienced intermittent
perianal discomfort which was associated with tenderness of the right
buttock and increased drainage through the external opening. A second
abscess-fistula developed on the left buttock. The metronidazole was
discontinued after six months because of complaints of numbness and
tingling in the fingers. Six weeks ago she began to notice an intermittent
feculent discharge per vagina. This has been associated with an increase
in perianal and perineal discomfort. The patient was taken to the
operating room for examination under anaesthesia. Digital examination
showed minimal stenosis of the anal canal and mild diffuse induration,
which was most marked anteriorly. A pit was palpable in the anterior
midline of the anal canal, about 1 1/2 - 2 cm from the verge. The external
openings accepted probes which were easily advanced into the anal canal
at a common internal opening in the anterior midline at the level of the
dentate line. The internal anal opening accepted a probe into the vagina.
The vaginal opening was located 2 cm cephalad to the posterior
fourchette. The anal opening was less than 2 mm in size and was not
associated with a cavitating ulcer. The fistulas were trans-sphincteric.
Which muscles were cut in the operation, the person may have
difficulty controlling bowel movements?
Case 3
A twenty-six year old male presents to the E.R. after a motorcycle vs.
car accident. The patient is awake and alert, and reports pain in his
abdomen and pelvis. On physical examination you note that his vital
signs are: heart rate 120, blood pressure 120/60, respiratory rate 30.
Examination also reveals abrasions on his abdominal wall surface and no
signs or presence of blood on his external urethral meatus. Palpation
reveals generalized tenderness over the entire abdominal region. In
addition, the patient shows particular discomfort when you attempt to
assess the stability of his pelvis by placing your hands over his pubic
symphysis and laterally applying pressure over the iliac blades. He does
not have full hip extension and rotation when you assess his mobility
while laying on the exam table. Rectal exam is negative for gross blood,
and the patient has a normally placed prostate.
You then order x-rays of the pelvis in 3 planes (AP, lateral, and
oblique views) to determine if the patient has a fractured pelvis and a flat
plate of the abdomen to determine if the patient has free air in his
abdomen. A diagnostic supraumbilical peritoneal lavage turns out
negative. You suspect internal bleeding due to the abdominal pain, so you
order an angiogram to locate the source. You diagnose a pelvic fracture,
complicated by internal bleeding.
The patient is taken to angiography where a laceration of the internal
pudendal artery is found, and a selective embolization is performed.
External fixation of the pelvis is performed after the bleeding has been
stabilized. Urology has been consulted to ascertain if there was any
urethral injury.
1. which structures will be affected in a fractured pelvis ?
2. What vessels branch off the internal iliac artery?
Upper limbs
Assignments:
1. Complete the learning module entitled upper limbs.
Objectives:
1. Recognize and define the upper limbs.
2. Describe the general layers of the upper limbs.
3. Describe the blood supply and innervations of the upper limbs.
4. Recognize the anatomical structures related to carpal canal.
Procedure:
1. Study laboratory 3 and 10 (human anatomy).
2. Study plates 395-456 (interactive atlas).
3. Discuss the next questions in groups
3). Discuss the clinical cases on your textbook about upper limbs.
4). Discuss cases below:
case 1
A 55-year-old woman was submitted to surgery to remove her left
breast in which a malignant tumor had been found. Following the
mastectomy, her recovery proceeded well, except that she noticed that she
was experiencing weakness in her left shoulder and had considerable
difficulty raising her left arm above her head, even two months after her
surgery. Her husband also noticed that her left scapula seemed to protrude
posteriorly to a greater extent than the one on her right side. This
phenomenon is called a "winged scapula". Concerned, she went to see
her doctor. She was referred to a neurologist, who performed
electromyogrpahy (EMG) and nerve conduction studies to determine the
source of the weakness.
1. What muscle was affected?
A Infraspinatus m,
B Teres major m.
C Pectoralis minor m.
D Serratus anterior m.
E Deltoid m.
2. Which nerve innervates the affected muscle?
A Axillary n.
Medial pectoral n.
C Lower subscapular n.
D Long thoracic n.
E Suprascapular n.
3. The long thoracic n. originates in the region of the brachial plexus,
but which of the following is also true about the long thoracic n.?
A It is a branch of the superior trunk, which itself is formed by
contributions from C5 and C6.
B It is formed by the confluence of the dorsal primary rami of
C5-C7.
C It contains contributions from C5, C6, and C7, and it branches
from the lateral cord of the brachial plexus.
D It is formed by the confluence of branches from nerve roots
C5-C7, which later form the superior and middle trunks of the
brachial plexus.
E It contains contributions from C6, C7, and C8, and it branches
from the posterior cord of the brachial plexus.
4. In cases like this, a test is often done that involves having the
patient press forward against a wall with both hands
simultaneously. What movement is being tested via this maneuver,
and what muscles contribute to that movement?
A Abduction of the arm, assisted by the actions of the serratus
anterior, deltoid, and supraspinatus mm.
B Lateral rotation of the arm, produced by the actions of the
infraspinatus, serratus anterior, and teres minor mm.
C Protraction of the scapula, produced by actions of both the
serratus anterior and pectoralis minor mm.
D Medial rotation and extension of the arm, produced by the
actions of the subscapularis, teres major, and serratus anterior
mm.
5. Without the serratus anterior muscle allowing for lateral rotation
of the scapula, to what angle will the patient's abduction be
limited?
A 15°
B 30°
C 90°
D 120°
E 180°
B
case 2
You are asked to assess the case of a 45-year-old overweight man
who presented to the outpatient room with a three-week history of
weakness in extending his left elbow and wrist, with loss of sensation
over the dorsum of the forearm and posterior aspect of the first
interdigital cleft. The patient has been using a single axillary crutch on
the left side to assist in walking following trauma to his left foot. You
examine him neurologically and confirm the case as that of radial nerve
palsy following compression by the crutch.
1. Which of the following is NOT true about the course of the radial
nerve?
A After leaving the axilla, the nerve passes backwards,
downwards, and laterally, spiraling around the shaft of the
humerus in the radial groove.
B For no part of its course is it directly in contact with the bone,
keeping it safe in the case of a fracture of the humerus
C It pierces the lateral intermuscular septum so that it comes to
lie in front of the lower end of the humerus and is therefore
lateral to the brachialis m. and medial to two muscles of the
forearm (brachioradialis and extensor carpi radialis longus
mm.)
D It enters the region between the upper part of the medial head
and the long head of the triceps brachii muscle and is then
sandwiched between the medial and lateral heads.
2. Choose the two muscles from the following list that are innervated
by the radial nerve.
A Triceps brachii
B Coracobrachialis
C Anconeus
D Brachialis
E Biceps brachii
3. Why will a patient with wrist-drop resulting from radial nerve
injury be unable to perform a power grip?
case 3
A 28-year-old volleyball player fell on her right outstretched arm
during a game. She felt an immediate pain in her wrist, and the
orthopedic surgeon at the emergency room described the deformity in her
right wrist as similar to a "dinner fork." All wrist movements were painful.
A plain radiograph revealed a transverse fracture of the distal end of the
radius, which was tilted backwards and radially. The patient was
diagnosed with a typical Colles' fracture.
1. What bone is LEAST likely to be fractured by a fall on an
outstretched hand?
A Clavicle
B Distal end of the radius
C Ulnar styloid
D Distal phalanx of the thumb
E Surgical neck of the humerus
Scaphoid
2. Which of the following patients would be MOST likely to suffer
from differential radial and ulnar growth subsequent to this type
of injury?
A This 28-year-old patient
B A 38-year-old man
C A 10-year-old girl
D A 67-year old woman
F
case 4
A 28-year-old dentist consults her physician, complaining that she
feels tingling and slight pain in her right hand. The symptoms are
localized to her thumb, index, middle and lateral side of her ring finger.
The sensations are more intense at night or if she overworks. Recently,
she has experienced some weakness in her grasp and finds it more
difficult to hold her instruments. Also, movements of her right thumb are
not as strong as before.
On examination, there is loss of power on certain movements of the
thumb. She has impaired appreciation of light touch and pin pricks to the
thumb, index, middle and lateral side of her ring finger, but sensation to
her palm is not affected. Pressure and tapping over the flexor retinaculum
causes tingling. After a complete examination, the patient is diagnosed
with carpal tunnel syndrome.
1. What is the carpal tunnel? What is contained in it?
2. Two muscles that are affected by carpal tunnel syndrome are the
abductor pollicis brevis and the opponens pollicis. How would
you test their function?
3. Physicians used to think this kind of pain was caused by a
deficiency in the brachial plexus. If this was the case, what roots
or trunks would have to be involved and why is this unlikely to
be the cause of the problem? (Consider both sensory and motor
deficiencies that this patient has.)
4. What causes the symptoms of carpal tunnel syndrome?
5. Although this patient recovered with rest and physical therapy,
some patients do not improve with conservative treatment and opt
for surgery. What structures might be endangered by surgery and
need to be avoided?
Lower limbs
Assignments:
1. Complete the learning module entitled lower limbs.
Objectives:
1. Recognize and define the lower limbs.
2. Describe the general layers of the lower limbs.
3. Describe the blood supply and innervations of the lower limbs.
4. Recognize the anatomical structures related to femoral canal.
Procedure:
1. Study laboratory 11 and 17 (human anatomy).
2. Study plates 457-514 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on your textbook about lower limbs.
2). Discuss cases below:
case 1
B.L., a 65-year-old woman, submitted to cardiac catheterization in
order to measure the pressures in the chambers of her heart. A catheter
was inserted in her right femoral vein in the femoral triangle and floated
through the iliac veins and the inferior vena cava to the right heart, where
diagnostic procedures were performed without incident. Four hours after
completion of the procedure, however, B.L. began to complain of a
painful throbbing in her right groin. Over the course of the next hour, the
pain worsened and she began to experience numbness and tingling in her
right anteromedial thigh and leg. On examination, her right leg felt cool
and a mass was observed in the right groin. No distal pulses could be felt
in the leg. B.L. was immediately taken up to surgery for exploration of
the groin region.
1 Given what you know about the anatomy of the inguinal region
and the anteromedial thigh, what are the risks associated with
catheterization in the groin region?
2 What do you think caused the mass in the patient's groin?
3 How would you explain the numbness and absence of distal
pulses?
4 Why would the femoral vein be used for catheterization instead of
vessels closer to the heart, like the external jugular, for instance?
case 2
A 65-year-old woman with a long history of diabetes has been
suffering from worsening numbness and pain in the right leg and foot.
She was admitted to the hospital as a case of peripheral vascular disease
with neuropathy. The examining physician found that both the dorsalis
pedis pulse and the popliteal pulsations were weak. Neurological
examination revealed an area of skin paresthesia over the lateral aspect of
the right leg. He recommended doing arteriography to assess the extent of
vascular occlusion.
What are the contents of the popliteal fossa?
Where would you feel the popliteal artery pulsation? Why was it
weak in this case?
Pulsation can be felt on deep palpation in the popliteal fossa when the
leg is slightly flexed.
How do you explain the presence of an abnormal sensation of the
lateral aspect of the right leg? Which cutaneous nerve is most
likely involved?
case 3
A 15-year-old girl decided to go out for the cross country team at her
high school, so she started practice with the team in mid-August. After a
couple of days of workouts, she went to her coach complaining of pain in
the anterior portion of her left leg. Her coach told her she probably had
"shin splints" and that if she kept running she would be fine. As the
workout progressed, however, the pain worsened to the point that she was
forced to stop. The pain continued to get worse overnight, so her parents
took her to the emergency room. On examination, the physician found the
leg to be red and swollen. The anterior aspect of the leg was very
sensitive to palpation and felt hard and warmer than other parts of the leg.
Dorsiflexion of the foot and toes was severely limited. The dorsalis pedis
pulse was weak, but sensory loss was noted between the first and second
toes. An intracompartmental pressure measurement was made of the
anterior compartment of the leg, which was found to be alarmingly high.
The patient was taken to surgery and the fascia over the anterolateral
aspect of the leg was incised to relieve the pressure in the anterior
compartment of her leg.
1. What do you think happened to the girl's leg in this case?
2. This condition is called anterior compartment syndrome of the leg.
What about the anatomy of the anterior compartment of the leg
makes it susceptible to this type of injury?
3. How do you explain the sensory loss on the foot? What muscle
outside the anterior compartment could you test to see if there has
been any motor loss as well?
4. Suppose that the pressure in the anterior compartment of the leg
was sufficient to stop blood flow through the anterior tibial artery.
How would you explain the presence of a weak pulse in the
dorsalis pedis artery?
5. What clues would indicate paralysis of the muscles of the anterior
compartment on inspection alone?
case 4
A 24-year-old football player was taken to the emergency room after
receiving a blow to the left leg that resulted in severe pain and inability to
stand up. The attending physician was able to locate a very painful area
just below the knee and suspected a fracture to the fibula. He ordered a
plain AP and lateral x-ray of the leg and knee. A clear spiral fracture in
the left fibular neck and a cracked tibial shaft were shown on the
x-ray. The patient was given analgesics, and a thorough neurological
examination was done. No signs of nerve injury were detected. A plaster
cast was applied, and the patient was discharged.
Which nerve is most likely to be injured in such incidents?
What would the doctor look for to confirm nerve injury?
Which of the two injured leg bones was the primary factor in the
patient's inability to walk and why?
case 5
An 18 year old male arrives in the ED by ambulance. The patient
stated to the paramedics that he was struck by a car several hours prior to
calling 911. He is now complaining of worsening left leg and ankle pain
and is also having increased difficulty walking. Upon arrival in the ED,
his left leg appears deformed proximal to the ankle. Additionally, the
distal 1/3 of his left leg is now mottled and swollen. ED staff is unable to
palpate left dorsalis pedis or posterior tibial pulses. X-rays show fractures
of his left tibia and fibula; his leg continues to swell, and his pain
continues to increase despite medication. The patient is diagnosed with
compartment syndrome of the left lower leg and receives fasciotomies of
all four compartments of his left lower leg as well as his foot. The
patient's pain diminished after the fasciotomies and a weak dorsalis pedis
pulse returned. An arteriogram was performed and showed occlusion of
the patient's left fibular (peroneal) artery in the area of the fractures. It
also showed perfusion of the dorsal arch of the left foot via collateral
circulation. Because circulation was returned to his foot, surgical repair
of the left fibular artery was not pursued.
What is compartment syndrome and how does is occur?
What is a fasciotomy?
Why wasn't this patient's left fibular artery repaired?
case 6
A first year medical student enjoyed running for exercise and relief
of tension. Near the end of a particularly long and strenuous run, she
suddenly developed a severe pain on the bottom of her foot. She
immediately stopped running and sat down to rest; the pain subsided
somewhat, but persisted. Although she rested from running for several
days, the pain did not go away and was particularly apparent if she stood
for long periods in the gross anatomy lab. In frustration, she finally went
to a Sports Medicine Clinic to seek relief.
Clinical evaluation revealed her foot to be normal in size, color and
temperature. There was tenderness on the bottom of her foot from heel to
the heads of the metatarsals, especially just anterior to the calcaneal
tuberosity. Radiological tests revealed no fracture or other bone or joint
deformities. Neurological tests revealed no nerve involvement other than
the pain, which appeared to be related entirely to the soft tissues on the
bottom of her foot.
What soft tissue structures are located on the bottom of the foot
between the calcaneal tuberosity and the heads of the
metatarsals?
What single fibrous structure spans the same bones?
What is the function of the plantar aponeurosis, long plantar,
spring and short plantar ligaments?
Considering the function of these structures and the action of the
foot involved in running, what might be the mode of injury?
How might the condition be treated?
Head & Neck
Assignments:
1. Complete the learning module entitled head and neck.
Objectives:
1. Recognize and define the head and neck.
2. Describe the general layers of the head and neck.
3. Describe the blood supply and innervations of head and neck.
4. Recognize the anatomical structures related to thyroid gland.
Procedure:
1. Study laboratory 22 and 34 (human anatomy).
2. Study plates 1-141 (interactive atlas).
3. Discuss the next questions in groups
1). Discuss the clinical cases on your textbook about head and
neck.
2). Discuss cases below:
case 1
A 30 year old substitute teacher consults her physician, complaining
of a swollen neck. She had first noticed the swelling 3 months ago. Over
the last three months, it had been increasing in size. She also had some
breathlessness. On examination, a solitary swelling of firm consisency
was found on the right side of the larynx and trachea. The small mass was
not attached to the skin and there were no changes to the overlying skin.
The swelling moved upward with swallowing. Further tests showed that
the mass was a carcinoma of the thyroid gland. The mass was surgically
removed.
1. What is the gross form and location of the thyroid gland?
2. Why did the tumor move upward when the patient swallowed?
3. How did the tumor cause breathlessness?
4. Which lymph nodes should the physician examine for metastases
if a malignant tumor is suspected?
5. What structures can be damaged during thyroidectomy if the
surgeon is not careful?
6. Post-operatively, the surgeon carefully ensured that the patient
was speaking properly. Why?
case 2
A 32-year-old woman, who has been diagnosed with having toxic
multinodular goiter for two years, is complaining of increasing shortness
of breath and dysphagia that gets worse when lying in bed. Her usual
complaint of intolerance to hot atmosphere, sweating, weight loss and
emotional irritability has worsened lately. The surgeon assesses her
condition and decides that surgery is indicated. He suggests doing
bilateral subtotal thyroidectomy to relieve symptoms particularly of the
lower parts of the gland. The patient was put on a two-week course of
iodine and antithyroid drugs before the operation to reduce the vascularity
of the thyroid.
1. Why would patients with goiter be likely to have shortness of
breath and dysphagia?
2. Which vessels should be ligated before doing lower subtotal
thyroidectomy?
3. Which structure should be carefully protected from injury during
such an operation?
4. What are the most likely complications that may arise from such
an operation?
case 3
After observing the procedure many times and numerous attempts
on cadavers, you are called on to perform a subclavian catheterization on
a critically ill adult patient in order to monitor her central venous pressure.
An infraclavicular approach on the right side is chosen.
1. Where is the subclavian vein located?
2. What surface anatomical landmarks are critical for guiding
infraclavicular subclavian catheterization?
3. Describe the relationships of the subclavian vein with other
neurovascular structures in the vicinity.
4. Why might a right-sided approach be preferred to a left-sided one
for subclavian catheterization?
case 4
You have been asked to assess the post-operative condition of a 65
year old man who has been surgically treated for carcinoma of the tongue.
Since the tumor was in its early stages, the surgeon has performed a
left-sided hemiglossectomy with block dissection of the left neck. In this
operation all posterior triangle lymph nodes were removed, along with
other structures. The patient was recovering well and was able to move.
1. Which important nerve is likely to be injured in posterior neck
triangle operations? How would you test for its integrity
post-operatively?
2. What other structures are important to consider in such
operations?
3. What groups of lymph nodes might the surgeon remove from the
posterior triangle?
case 5
A medical student was celebrating the end of midterm exams with
her friends in a seafood restaurant when she started feeling a prickling
sensation in her neck after swallowing a large bite of smoked fish. The
pain was getting worse, and attempts to clear it with drinks failed. At the
emergency room a plain X-ray of her neck showed a tiny fish bone
lodged in the lower part of the pharynx. The bone was quickly removed
under general anesthesia, and the patient was discharged a few hours
later.
1. Which are the most usual places for swallowed foreign bodies to
be lodged?
2. What is the piriform recess?
3. Fish bones and other foreign bodies may pierce the mucous
membrane of the recess and cause injury to the internal laryngeal
nerve. What are the possible consequences of this injury?
case 6
A 20-year-old student fell off his bike directly on his head on the
way to school. He was not wearing a helmet and was seen unconscious
when paramedics arrived. At the emergency room his pulse and blood
pressure were weak, and there was no sign of scalp laceration. The doctor
examined his pupils and found that the right was fixed and dilated and
would not react to light. A CT scan was ordered immediately, and a
right-sided epidural hematoma was revealed. The patient was moved to
the intensive care unit, and an emergency evacuation of the hematoma
was planned.
1. What is the source of the epidural hematoma ?
2. Why was there a dilated pupil on the hematoma side ?
3. What are the structures that lie in the lateral wall of the cavernous
sinus?
case 7
A 14 year old male was brought to the emergency room by his
mother. Symptoms of severe headache, photophobia, nausea, vomiting,
fever of 103, and nuchal rigidity (resistance to flexion of the neck) began
the evening before, and progressed rapidly during the night. Suspecting
meningitis, a lumbar puncture was performed. The CSF appeared
purulent and turbid.
CSF lab analysis showed increased protein levels, decreased sugar,
and many polymorphonuclear leukocytes. This confirmed meningitis,
probably bacterial. Culture of the CSF determined the cause to be
Streptococcus pneumoniae. The boy was admitted to the hospital for
antibiotic therapy and close monitoring.
Subsequently, the boy developed a facial nerve palsy, a complication
of the meningitis. His symptoms mimic Bell's Palsy.
1. What is the course of the facial nerve?
2. Where does it emerge from the brain?
3. What foramen does it enter and exit from the skull?
4. What muscles does it innervate?
5. Hyperacusis is noted. What is this? What motor branch of the
facial nerve is affected?
6. Facial pain or lack of sensation implies that which nerve is
affected?
7. The physician orders lubricating eye-drops to be applied as
needed. Why?
case 8
A 65-year-old man complained of inability to shut his right eye,
difficulty in moving food around his mouth and weakness on the same
side of his mouth with slight numbness on the right cheek. The problem
started a few weeks ago following an excisional biopsy of a right facial
lump that proved to be a benign parotid tumor. The surgeon was able to
verify an area of mild numbness on the right cheek. Upon examining
facial muscles, he suspected an injury to facial nerve branches that must
have happened during the biopsy. He suggested intensive physiotherapy
sessions and regular checkups to monitor the patient's progress.
1. How would you explain the patient's numbness on the right
cheek?
2. Which facial muscles do you think are responsible for the patient's
complaints?
3. How would you test for these muscles?
4. What other functions of the facial nerve need to be checked?
case 9
An 18-year-old woman went to see her dentist for a regular checkup.
During the visit, the doctor discovered that her lower third molars
("wisdom teeth"), which had appeared to be erupting fine on her last visit,
had begun to cause crowding in the patient's mouth. He was afraid that
they might eventually cause her discomfort, and since her teeth were
currently straight, he recommended that she have the third molars
extracted. She agreed, and returned the following week for the procedure.
Before the dentist began to work, the patient told him that she had a low
pain tolerance and asked that he make sure that her mouth was fully
anesthetized. The dentist promised that he would take care of it , and then
proceeded to inject the anesthetic in the mucous membrane on both sides
of the patient's mouth. The teeth were removed without incident; however,
when the dentist finished, the patient found that she could not close her
mouth. The dentist apologized, saying that he must have dislocated her
jaw, but that he could fix it easily and she would suffer no lasting effects.
He then reduced the dislocated jaw by pressing downward on the
remaining molars until the mandible slipped back into place. He then
warned her not to attempt to chew any food until the anesthetic had worn
off and she was able to feel her tongue and lower lip again, lest she
damage them by chewing on them.
1. What nerve(s) would need to be anesthetized in order to prevent
pain during a lower third molar extraction?
2. Why were the patient's lower lip and tongue numb?
3. What joint was dislocated during the tooth extraction and how did
this occur?
4. Some patients occasionally experience temporary paralysis of the
muscles of facial expression or of mastication following a dental
procedure. Why do you think this might happen?
5. When dental work is performed on the lower teeth, anesthetic
injected at a single point is often adequate to produce complete local
anesthetization of all the teeth on a given side. The same is not true
for the upper teeth. Why not? How do they have to be anesthetized?
6. What are the anatomical structures that prevent joint dislocation?
case 10
You were asked to assess the case of 20-year-old woman whose
impacted right lower wisdom tooth was surgically removed. The
operation lasted about an hour, and the dental surgeon suspected that
some nerves might have been bruised during the operation. The patient
presented with loss of sensation in the gums of her lower jaw, and her
mouth was slightly dry. You examined taste sensation in the tongue and
found that it was diminished in the anterior two-thirds but it was normal
in the posterior portion.
1. Which nerve is most likely to have been bruised in this patient?
2. How would you explain the patient's complaints?
3. Which nerve is responsible for sensation in the posterior third of
the tongue?
case 11
A 32 year-old patient presents with septic temperatures, frequent
chills, vomiting and intermittent delirium. When lucid, the patient
complains of nausea and severe headache, especially on his right side.
The patient's case history indicates that he had developed a boil on his
right lip six days prior. Earlier in the day, the patient's family physician
administered penicillin to the patient. As the patient did not improve, the
family physician admitted the patient to the hospital. On physical exam,
the patient shows rigidity of his neck muscles, a sign of meningeal
irritation. His right cheek , nose and upper lip are swollen and hard to the
touch. There is some oozing pus from several points along his upper lip.
Extraocular muscle testing shows inability to abduct the right eye. The
patient is diagnosed with infectious cavernous sinus thrombosis
predicated by staphylococcal infection of the subcutaneous tissue of the
upper lip, and partial extraocular paralysis in his right eye.
1. Why would trauma to the cavernous sinus affect ocular muscle
function?
2. What anatomical structures facilitate the spread of the infection to
the cavernous sinus?
3. Discuss a possible course by which the infection spread.
4. Review the innervation to the extraocular muscles. Which nerve
and muscle were affected in this patient?
5. If the patient also presented with ptosis, what muscle and nerve
are likely affected?
case 12
A 46-year-old man who had undergone right-sided pneumonectomy
for carcinoma of the bronchus was seen by his thoracic surgeon as a
follow-up after the operation. The patient said that he felt fit and was
gaining some weight. He noticed that a week ago his right upper eyelid
tended to droop slightly when he was tired at the end of the day. After a
careful physical examination, the surgeon noticed that in addition to the
ptosis of the right eye, the patient's right pupil was constricted and that
his face was slightly flushed on the right side. Further examination
revealed that the skin on the right side of the face appeared to be warmer
and drier than normal. Palpation of the deep cervical lymph nodes
revealed a large hard fixed node just above the right clavicle. The surgeon
made the diagnosis of a right-sided Horner's syndrome which happened
as a result of tumor metastasis to the right sympathetic cervical trunk.
1. How would you explain the right ptosis and pupillary constriction
in this case?
2. The other skin findings in this case could also be explained by
interruption of the sympathetic innervation to sweat glands and blood
vessels.
case 13
An eight year-old boy presents to his physician with a chief
complaint of an earache, fever and some degree of hearing loss. The
patient's case history indicates a recent viral upper respiratory tract
infection. During physical exam, the physician examines the patient
with an otoscope and notes an inflamed tympanic membrane that is
bulging and opacified. Pneumatic otoscopy confirms the presence of fluid
in the middle ear. The patient is diagnosed with acute otitis media, an
infection of the mucoperiosteal lining of the middle ear which has a
relatively sudden onset and short duration.
1. A major factor in the pathogenesis of otitis media is dysfunction
of the auditory (eustachian) tubes. What is the function of the auditory
tubes?
2. If the ventilatory function of the auditory (eustachian) tubes is
compromised, air is resorbed by the middle ear and a negative
pressure, anaerobic environment is created in the middle ear. The
negative pressure may result in aspiration of nasopharyngeal contents,
including bacteria, into the middle ear that then proliferate to cause
otitis media. Which muscle opens the auditory or eustachian tube?
3. What surgical procedures may be used to treat the fluid build-up
in the middle ear?
case 14
A 5-year-old girl was taken to the primary health care physician
because she was having sore throat, high temperature and runny nose.
Symptoms started a couple of days ago and her mother reported that she
also complained of pain in the right ear at night. The doctor examined her
tonsils and found them enlarged, and checked her ears with the otoscope
and saw that both eardrums were congested and looked reddish especially
on the right. He recommended decongestant medication and analgesics
and requested to see the girl again a week later.
1. How would you explain the congestion of both eardrums?
2. If the ear infection was not treated properly, what important
anatomical structures are likely to be affected in the middle ear?
case 15
A 12-year-old boy was admitted to the hospital complaining of a
severe sore throat and bilateral earache. He had a history of frequent
infections of the palatine tonsils, which had all been treated successfully
with antibiotics; however, the infections had become progressively more
severe and he had missed a considerable amount of school. This bout of
tonsillitis was also treated with antibiotics successfully, but the boy's
physician suggested that a tonsillectomy be performed to eliminate the
problem once and for all. The boy was readmitted to the hospital for
surgery two weeks after his most recent infection had cleared up. The
surgery was proceeding well when suddenly there was a massive amount
of bleeding. After a short period, the surgeon was able to locate the
bleeder and ligate it, following which the wound was closed and the
patient's recovery was uneventful.
1. Where is the palatine tonsil located? The lingual tonsil? The
pharyngeal tonsil?
2. What blood vessels are found near the palatine tonsil and may
have been responsible for the bleeding?
3. What nerves are at risk during a tonsillectomy?
4. What lymphatic structures are often secondarily affected in
tonsillitis?
5. How do you explain the patient's complaint about pain in both
ears?