ROAMS 10th Edition | Review of All Medical Subjects THE MOST TRUSTED BOOK FOR \NEET (NATIONAL ELIGIBILITY-CUM-ENTRANCE TEST)/AIPGMEE DNB (DIPLOMATE IN NATIONAL BOARD) FMG (FOREIGN MEDICAL GRADUATE TEST) “AIIMS, PGI, UPSC & ALL OTHER PGMEE/STATE EXAMS V.D. AGRAWAL REETU AGRAWAL ADITYA MEDICAL BOOKS PVT. LTD.ROA (Review of All Medical Subjects) i i 4 A A Concise Review for PGMEE 10th Edition Dr. VD. Agrawal, pcx Attending Consultant Pediatrics, Max Hospital, Shalimar Bagh, Delhi Dr. Reetu Agrawal, pnp, mvams Attending Consultant (Anaesthesiology), Max Hospital, Shalimar Bagh, Delhi Salient features of this edition Concise review of all subjects & Special high yield points at the end of the book. » Highlighted high yielding facts and mnemonics, useful charts. Particularly useful for gaick revision before all exams (NEBT/AIPGEE, AIMS, DNB, FMG, JIPMER, PGI, UPSC, MAHE, BHU and all other ‘State exams) Matters from Journals on Recent Topics Prototype Clinical Vignettes at the end of each subjects.‘0th Edition: 2013 Published by: ADITYA MEDICAL BOOKS PVT. LTD. Aditya Medical Books Pvt.Ltd 2/4. Awadh Complex 5 Cantt. Road,adj. Shubham Cinema Lucknow, India -226001 E-mail: adityamedical@gmail.com Website: www.medicalbookseller.com © 2013-14 Dr. V.D. Agrawal & Dr. Reetu Agrawal 5 [No part ofthis publication should be reproduced stored ina retrieval system, oF transmitted in any form of by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prlarwatlan penission ofthe publisher. ‘Tos book fas been published on good faith thatthe material provided by authors) is original. Every effort is made to ensure accuracy of materia, but he publisher, printer and author wil not be held responsible for any inadvertent error(s). in case of any dispute, all legal matters to be settled under Lucknow Jurisdiction only staan Exclusive rights reserved by Aditya Medical Books Pvt Ltd for publication, promotion and distribution. No castiron guarantee is given that this baokis totally fee from errors of any kind. Ifthere are errors, they are a ingpite of our best efforts, The author or the publisher will nat be responsible Tor these unintended errors. : NOTICE “The author and the publisher ofthis work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted : atthe time of publication. However, in view ofthe possibilty of human errors or changes in medical slences, neither the author nor the publisher warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsiblity for any ertars ar omissions (forthe results obtained from use of the information contained in this work, Readers are advised to Confirm the information contained herein with ather sources, Computer Typeset by: ISBN : 978-81-89926-79-3 Geeta Malhotra (Trehan Apt, Bhiwadi, Rajasthan) | Neetu Jindal (Laxminager, Dei) Printed at: ‘S7B-8t- 80026-73-3 | Salasar Imaging Systems, |1 . Anatomy . Physiology . Biochemistry }. Genetics and Molecular Biology . Pathology . Microbiology /. Parasitology . Laboratory Medicine . Pharmacology ). Forensic Medicine (Juris) Social and Preventive Medicine (SPM) . Statistics 3. Medicine . Skin & Veneral Diseases . Surgery 53-96 97-123 124-136 137-165, 166-194 195 -202 203-213 214-250 251-276 277-319 320-331 332-388, 387-407 408-451 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. .. Obstetrics . Gynaecology . Ophthalmology . ENT Orthopaedics Paediatrics Radiology Anesthesiology Intensive/Critical Care Psychiatry Oncology Haemotology Syndromes Useful Mnemonics Important Points 452-481 482-499 500-528 529-553 554-579 580-618 619-643 644-667 668-679 680-699 700-742 743-765 766-774 775-780 781-791Ca Dito nor nv Dig, Dx. NE Doc RyorTit Sx Pig loc Toc Cle Ace! to Nc, mic R, Vs Supt, Ds, dls a Ms, mis BIL orbit. Ipsit. UIL orut Conti Aw Kias Vis AdIE, adie cu Alworalw Mim Carcinoma/Cancer denotes heading due to Increase, High Nerve Decrease , low Diagnosis Allexcept Drug of Choice Treatment Surgery Prognosis, Investigation of Choice Prophylaxis Treatment of Choice Complication According to ‘Chemotherapy Most Common Radiotherapy Versus (= against) ‘Superficial Disease or Disease Reaction block by, inhibited by Muscie Bilateral 'psiateral Unilateral Contalateral Associated with Known as Vessel Adverse effects Contra indication Associated with Management bin or bw cur FA AD FFA oM cro oy soLc MN SM Hoc BM oT HS HD BM HS NHL sqcc LN Pac MG MN we LD AR Between Clinica features Fatty Acid ‘Autosomal Dominant Free Fatty Acid Failure to Thrive Diabeties Melitus Connective tissue disease Comvix ‘Small cell lung carcinoma Malnutriéon ‘Smooth muscle Hepato Cellular Carcinoma Bone marrow, basement membrane Intraocular Tension Hereditary Spherocytosis, Hodgkin's Disease Bone marrow, basement membrane Wilm’s Tumour Hereditary Spherocytosis Non-Hodgkin's Lymphoma Intracranial Tension ‘Squamous Cell Carcinoma Lymph node Primary Biliary Cirrhosis Myasthenia Gravis ‘Malnutrition Wegner’s Granulomatosis Interstitial Lung Disease Indication ‘Autosomal RecessiveBLOOD VESSELS (ARTERIES/VEINS) Source of Hemorrhage/Bleeding in nisi Middle meningeal artery Beidgingltiploe veins ‘Soh dural bemarzhoge (SDH) © Sub arachanoid hemortha Rupture of congenital Berry (san) ‘aneurysm Tennis bal injury to eye ‘Cruising « Bpistas Submucous venous plexus, sphenopalatine artery © During tonsillectomy Paratosilar veins, tonsilarand ascending palatine aneies © Tracheostomy {sthmus and inferior thyroid © Heinoptysis,Broaciectsis — Bronchil artery 9 Gastic ulcer Lt gastric, splenic artery © Duodenal uler Gastoduodenal artery © Hemmorhoids ‘Submucous venous plexus (med by SRV+ IRV) © Refopibic prostatectomy ‘Dorsal venous plemus © Hysterectoay Internal iliac artery © Menstruation Spica arteries > Sphenopalatne artery i also Was" artery of epistais" Longest branch fom on ofthe lteral(or lenticular) tite branch of MCA artery is also Has " Charcot artery of cerebral hemorrhage" LAD isa Nas "widow maker" artery Named arteries © Heubner's Artery —- Recurrent branch of ACA. © Artery of Adam Kweiez — Extends bw T9 and TH © Artery of Epistxis — Sphenopalatine artery Preferred Artery for © Cannulstion = Radial a. and femoral a © Cerebral angiography (4 vessel angiography) ~ Both intemal carotids + both vertebrals are used - Vertebral arteries are approached by percutaneous catheterization, which is done by passing 2 catheter through femoral artery © Carotid angiography is performed by direct needle puncture of internal carotid arteries, © Coronary angiography is done by passing a catheter through the femoral artery up into the aorta til the base of the ascending aorta, Judkin's method isa method of selective coronary arery catheterization utilizing the standard Seldinger technique through @ percutaneous femoral artery. ‘© Coronary artery bypass graft (CABG) : Internal mammary graft is most favored fb radial artery grait. Preferred Veins for © Injecting dye fluorescein angiography -- Ante-cubital vein (peripheral vein) © Venesection -- Long saphenous vein, n (when CVP has to be monitored) © Forii injections — Median cubital vein © For TPN (iv alimentation ) © Injecting dye in phlebography Dorsal metatarsal vein © Best vein for CABS graft —- Saphenous vein, Basile ve Forearm veins. Other imp facts from arteries © Quadrigeminal artery supplies tectum of midbrain, © Deep optic artery is a central branch of riddle cerebral artery (MCA) © Blood supply of facial nerve is —~ maxillary a. © Stenosis of subclavian artery is common in First part. rupture © Mic site of aortic transection/ traumatic aortic is aortic isthmus just distal to left subclavian a, (88-95%) {ligamentum arteriosum & brachiocephalic a. fixes aorta inthis region] © Splenic artery is a direct and largest branch of —Coeliae trunk © Right gastroepiploic artery isa branch of gastroduodenal artery.© Ascent of horse shoe kidney is prevented by--Inferior mesenteric artery © Abberent obturator artery isa br. of + Inferior epigastric artery. © ‘Middle meningeal artery is branch of ~» Maxillary artery (ist pa. © Nutrient artery of fibula is > Peroneal artery. © Lt phrenic nerve is accompanied by —> Internal thoracic arery. Veins : Important Points © Infection of angular vein can lead to thrombosis of ‘cavemous sinus © Inferior jugular vein surface markings a ar lobule (upper end) to the medial end of clavicle (lower end). © Vitelline veins give rise to -> Portal vein, hepatic vein, sinusoids, © Venous sinuses are sub-fascial in location ANATOMICAL FACTS. 130-160 am Thoracic duct 45 cot Femur 45em Vas deferens 45 em, Esophagus 25cm Urcter em Opticnene Sem, Inguinal canal, 4.em ‘Anal canal Female urethra 4.en, ANATOMY BASICS Large arteries, arterioles and capillaries © NoSM, no contraction dilatation, © More elastic tisues & SM, 1 Resistance vessels Highest mean velocity is een in aorta Windkessl vessel ~ distal portion of aorta and larger arteries (they have more recoil an elasticity) > Maximum pressure drop oceur in - ama rsres and arterioles “Resistance vessels arterioles and small arteries “Msn ttl crass sectional area = caplaries (lowest velocity) “Capacitance vessel - veins (contin 50% of crating Sood volume) “> Compliance is mae veins > cota arteries. Sania mets fund in al blood vessels except vis “> Vasa vosorun is blood vessels ples suplyng Blood vessel. End arteries Arteries whieh do not anastomose their neighbours. ‘© Central artery of Retina (Absolute end artery) © Central branches of cerebral a. © Vase reeta of mesenteric a © Arteries of spleen liver, kidneys, lungs & metaphysis of ong bone.Capillaries © Types : There are 3 main types of capillaries: 1. Continuous (M/c type) 2. Fenestrated 3. Sinusoidal 1, Continuous © Endothelial cells provide an unintecrupted lining, and onty allow small molecules, lke water and ions to diffuse through fight junctions which leave gape of enjoined membrane ‘hich are called intercellular clefts. Tight junctions can be further divided into two subtypes: a) Those with numerous transport vesicles that are primarily found in skeletal muscles, fingers, gonads, and skin 'b) Those with few vesicles that are primarily found in the CNS. These capillaries are @ constituent of the BBB, 2, Fenestrated - © Fenestrated capillaries have pores in the endothelial cells (60-80 nom in diameter) that allow small molecules and limited amounts of protein to difuse © Found inthe renal glomerulus, vasa recta of renal medulla, endocsine glands, pancreas intestinal villi, and renal glomeruli 3. Sisal © Sinusoidal capillaries are a special type of fenestrated capillaries (open pore /discontinuous type) that have larger ‘openings (30-40 pam in diameter in the endothelium. Highly permeable ito fenestrations © Sinusoids are found in the liver, lymphoid tissue, endocrine ongans, and hematopoietic organs such as the bone marrow and the spleen. (but not in skeletal muscle) © They may connect arteriole with venule (spleen, bone marrow), Venule with venue (lver} Lymph Capillaries (Lymphatics) © Have a discontinuous basement membrane. (No visible “fenestrations in lymphatic endothelium.) © Contain valves. © Junction b/w endothelial cells are open. No tight intercellular connection © Lymphatics are NOT present in :- Brain, Bye, cornea, articular cartilage, Internal ear (CNS), Lens, epithelia, placenta, sclera bone marrow, splenic pulp , glotis, epidermis, (but +nt in dermis) Anatoiny Arteriovenous shunts (Shunt vessels) © Rich A-V anostomosis are found in skin of nose ips, ear lobule, 2. mucase, thyroid gland, palmar skin © They are under autonomic control inskin, They regulate the regional blood flow, BP, temperature (‘hermoregulation. Anastomosis Arteries do not end always in capillaries, they unite with one another forming anastomosis. Sites of potential anastomosis are coronaries, cortical arteries, and arteries around joints. ‘Types and examples LE 4 :labial bravches of facial a. intercostal a., uterine/ ovarian arteries, arterial arcades in mesentry, arteries of greater and lesser curvature of stomach, palmar and plantar arches. 2, Convergent : Vertebral arteries to form basilar artery. Transverse : Blw two ACA, biw radial & ulnar arteries, at wrist, Veins which do not have muscular tissues © Dural sinuses and pial veins © Veins of matemal part of placenta © Retinal veins © Veins of spongy bones © Venous spaces of erectile tissue of penis Veins which do not have valves © S¥C and VO © ‘Very small veins of diameter <2mm © Hepatic, renal, ovarian, uterine, cerebral, emissary, pulmonary and umbilical veins > Portal venous system is a valveless system ° Poral cretion is seen in~ liver and ptucary (iypophvsis cerebri) Counter curent multiplier sytem is seen in- Kidney (LOH) cand Vasa recta of tests Veins containing oxygenated blood © Pulmonary vein ‘© Umbilical veins Arteries of the body which carry deoxygenated blood © Pulmonary artery © Umbilical arteryArteries of the body where Pco, > Po, 6 Pulmonary artery © Gast atery Retroperitoneal Structures © Head of pancreas, most of duodenum © Aorta and IVC with branches © Cisterna chyli, LN and vessels © Kidneys! ureters, Suprarenal glands “> Posterior surface of pancreas i related with teretination of superior mesenleric vein and beginning of portal vein. DANGEROUS AREA OF BODY © Doucer urea oj scalps the layer ofloose areolar tissue of seatp because emissary veins open here which may transmit infection to venous sinuses. ° : ve Ciliary body ° “ Olfactory area © Durger crew fore. Infection of the lower part of nose ad upper ip cny be nsmited to cavernous sins by facial vein & its communications (superior ophthalmic vein and deep facial vein). STRUCTURES FORMING VARIOUS BED ee a Becopharyngea facia Pharyago basa fascia (by lover syloglos) Sup consicer mls, Palato-ghangess Tonsillar Glossopharyngeatn 2 Stomach, ‘Lt caus, one of diaphragn ye Lesser sc. ie elo rep) ‘Lt aeal oper metal, Pancreas (vansverely, Spleen (uper lateral) fee eccn! Splenic exure of colon © Pancreatic Splenic vin (nota) ‘Aon & origin sup, mesenteric renal vessels Li kidney [Lt Supeaenal gland ‘Lc enus of dpa BONES & JOINTS. Parts of a Long Bone ‘Along bone is composed of 4 pars, From centre to outwards these are © Diaphysis © Metaphysis ‘© Bpiphyseal growth plate (physis) © Epiphysis Diaphysis Iselongsted shaft of along bone which oss from primary centre, TB and syphilis begin in the middle of shaft. It is the strongest portion of the bone. Haversian systent is found in diaphysis. Metaphysis Epiphyseal end ofa diaphysis. Richly supplied by hair pin’ bends of arteries, Area of geatest growth velocity in bone. Common site of osteomyelitis in children, Prone to trumatic necrosis, and avascular necrosis Epiphyseal plate/ Growth Plate (Physis) ‘Woeperats epiphysis fom metaphysis, is cartlagenous pate responsible for growth in length. Itis the zone of endochondral ossification in an actively growing bone or the epiphyseal scar ina filly grown bone. Epiphysis End or tip ofbone which ossfy from secondary centre. © Nutrient artery enters a Jong bone through diaphysis through an oblique canal & yors towards the growing ends. It supplies medullary cavity, cancellous bone in the shaft, and inner 2/3rd of cortex. ‘© Numerous metaphyseal and epiphyseal arteries supply the ends of bones. © Growing ends ofthe bone ae those where 2" centre appears fist & fuses last. Proximal end of humerus tibia and fibula and distal end of radius, ulna and femur are growing end, © A primary centre forms diaphysis and secondary centre forms epiphysis © Bone grow in thickness by euultiglication of cells in periosteum’ perichondriumTypes of Epiphysis ‘Head of femur, lower end of 1, Pressure Aricular radius, condyles of dia, bead of humerus 2, Traction Nowatticuae © fochaner of emia, 9° SE 1 Tubeicles (greaterfiessed of ~Iaanens, mastoid process Epiphsis atthe bead of ist coe 3, Aberrant Norabiays resent Plotogeniical med res api, > 5 paired bones having pressre epipyses at both ends are = Humerus, radius, femur bia, fibula, Appearance of Ossification centres Ossification takes place by centre of ossification, which may be primary (1") & secondary (2°). Primary centre appears before birth, usually during 7-8th week of IUL; the 2° centre appears afer birth except of fower end of femur which appears just before birth (9th month). Important Primary centres & age of appearance (fetal life) © Feaur shaft - 7th week © Humerus.radiuswulna, tibia shaft - 8th week © Ischium - 3rd month © Pubis- 4th month © Caleaneuen 5th month (3-5 months, or before viability) After viablty the 1° centres are given below © Talus-6-Tth month © Femur, lower end - 9 month (aust before birth) © Tibia, upper end -9 month aust before birth Atbith in ori a full erm newbom max" 5 ossification centres are present. These are - lower end of fernur, tibial tuberosity, calcaneus, talus. and cuboid (all in the lower limb). Appearance of 2° centres Ossitication of earpal bone is important. Ithelps in determining bone age. Time of appearance of ossification centre fr capitate is 2nd mo, hammateis end of 3rd mo, triquetralis 3rd yr, lunate is 4th yr, scaphoid/trapeziumitrapezoid in 4-5 yrs, pisiform 10-12 yr re aoe No. of 0 2 4 bones HQ eT HL +S, All ww bone appear) Ossification of bones/Bone formation Seen in rani facial bones, clavicle & Tntramembranoas mandible ‘Endochondral © Suen in most other bones. is © Occurs in hyatine cartilage, © Hylie model of bones tplced by bone Membranous bones Examples are facial bones, skull vault bones Pneumatic bones Bones containairfilled spaces. Examples are maxilla, elmoid, sphenoid, frontal, mastoid /temporal { Mnemonic: MESF-M 1st4 form para nasal sinuses} ‘Types of bone Cancellous/Spongy / trabecular bones ‘©. Present in flat bones/ end of long bones, © Acefto Wolf's law all trabeculae of cancellous bone are arranged along the line of stress. © Mic affected by osteoporosis becoz they are more 1etabolically active than cortical bone Cortical/compact bones ©. Present in shaft of long bones (diaphysi). © Foversion canals ae present which runs longitudinally & cocenttically. These canals together with lamellae form osteon. © Follincnn's ronal are transverse or horizontal channels blw Haversian canal and & medullary cavity © Spiral arrangement of fibres in osteon can withstand with severe twisting strains. Sesamoid bones © Develop in tendons. They are in the form of nodules embedded in tendons and joint capsules. © They ossify after birt, © No periosteum, no Haversian system, no medullary eavily. AnatomyROAMS © They are either articular (patella, pisiform) or non-articular (abel). © Function : To minimize friction to modify pressure! direction of pull of a muscle, aids in maintaining local circulation Pecularities of clavicle © No medullary cavity © Only long bone which lies horizontally. © Ist long bone to ossify. © Ossilies fiom 2 primary centres. © Only long bone to ossify in membrane. CARTILAGE © Specialized connective tissue © Matrix is made up of glycosaminoglycans (hyaluronate, chondroitin sulphate), proteoglycans, CAM © Fitrocartlage contains type I collagen , al other cartilages contain type 2 collagen, is avascular, non-nervous laste structure but tends to calify in elderly. detiewlar cartlageis atype of hyaline cartilage which is devoid of nerves, vessels, peri-chondrium (0 it has no regenerative power), and assification/ calcification. [Mnemonic : In articular cartilage No CalPROVEN] © Water content + es with Ting age © Nourished by diffusion, © Cartilage may become calcified. Tendency of calification is seen in white fibrocartilage and hyaline cartilage. Ligaments : Fibrous bands which connects bone to hone. position and movements sensor > Tendon: 31 membrane lines whole ofthe interior of joint excep articular surface covered by hyaline cartilage ithas poor nerve supply > Cartilage Fave no vessel, no nerves (insensitive), no phat Contains anttngiogenic factor > Capsule & Ligaments : Rich nerve supply and Blood suppl: Acute sensitive painttreches{ watch dog action of eapsuleto protect the joint from any sri) Cartilages : Types (Most abundant 6 All ctilaginous bone are preformed in hyaline c~. Tendency to caeify ater 40 yrs = Embryonic, epiphyseal pate + Aroula, Anjteoid, Thyroid + K(Costal = Tracheal & bronchial + Cartilage of nose & larynx [BLANKET] 1 Hyaline 2. Ribrocacilage = Menise = Ihervercbra dice = fnrartiuar iso abrun (Glenod labrum at shoulder & acetabuae labrum a hip joins) -- Symphysis + Actomioclavcular joint [MILIA] + Carilage in aicleesternal ear, EAM, eustachian tube. = Inlet of ry, coniclt, ewform = piel 3. Elastic Endochoncral ossification occurs in hyaline cartilage > Fibrolastic cartilage isthe only cartilage which contains collagen ype I, 0 it is me cartilage to asf. JOINTS : Classification/ Types Synovial joint 1 Hinge jot Elbow, Ankle, interphalangeal joints. (Onis flexion & extension posible 2, Ellipse joint ‘Wis, all MCPs, Adanto occipital 3. Pivot (trochotd) ft Sup & Inf. radioulnar J, Alanto-axia 4 Condytar/ Kae, TM join offaw. Bsondylar 5. Sadtejt. Thunb (frtCMO,semclavieur, caleanencuboia,incude-maleus 3 6 Ball& Socket Shoulder, hip, alo sslcaneonaviular, incado-stapedial Fibrous joint 1. Sve are peculiar to skull ‘Bones are connected by the interosseus ligament. Examples ate distal Tibiofibular Jt, Foot plate of stapes with oval ‘window (tympanestapedial syndesmosis) 3. Gomplosis Peg & socket joint ): e.g. tooth in its socket (dentatoalveolar joint). |Cartilaginous joint Joint is surrounded by flbrous capsule which is lined by synovial membrane. Classified into 2 acco cartilages covering articular surfaces:- 1, Primary (Synchondvosis ‘hyaline cartilage joint) E.g. growth plate (ow epiphysis and digphysis of growing ‘ong bones), spheno-oceipital joint, first chondrosteral, costochondal joint(synostosis) 2, Secondary (Symphyses or fibrocartilaginons joint) ~ Symphysis pubis, menvériasternat joint, intervertebral joins, sacrococeygeal joints (symphysis ment isnot atrue symphysis), aeromioclavicular joint. ‘} Ininerpharynageotjoints, capsule is absent on dorsal sides Ear ossciles from ouside to inside are MIS —- malleus, Incus, tapes. They are articulated with each otter by provi joins: > Vomer-sphenoidal junction is syndyless (Its awedge and _groove type of sure) Growth plate is an example of primary cartilagenous joout Movements at Cervical (Neck) Joint © Allanto-ocepital jt. Blexion only © Atlanto-axil jt: Rotation of axis (298-54?) © Other cervical: Flexion & extension Shouider (Glenohumeral) Joint © Synoviel joint of ball and socket variety © Joint is unstable because head of humerus is 3 to 4 times larger tian shallow glenoid cavity (4:1 dispropom ) © Glenoid labrum (ting of fibrocartilage) covers glenoid cavity © Most important factor i stability o soup of muscles > ligaments intis tone of different Factors protecting the joint © Rotator cuif(musculotendinous cuff) Formed by blending of 4 tendons SITS : Supraspinatus, Infraspinatus, Teres minor, and Subscapularis. Cult is Aeficient inferiorly. Of these, SIT Insert into greater tubercle of humerus and participate in S (abduction) {T (lateral rotation) & while subscaputaris causes medial rotation & adduction of arm. [Teres major also causes medial rotation, adduction, © Long tendon of biceps prevents upward displacement, It is intracapsular (invested in synovial membrane). © Coracoacromial ligament {es surface for movement & protects superior aspect of joint Movements atthe shoulder the joint © Adduction: By pectoralis major + LD. Itis limited beclof little surface of humerus is available for this movement. © Abductio ~ Abduction (Ist 15° is initiated by -> Supraspinatus ~ But main abductor (15°to 90°) is + Deltoid, = Serratus anterior & trapezius assist in > overhead abduction (90°to 180°) Humerus & scapula move in ratio of 2:1 (120°: 60°) throughout the abduction. Abduction fixates at 90° (because no further articular surface is available on humerus). 180° of abduction is possible only with iat rotation of humeris © Flexion: Clavicularhead of pectoralismajor+ anterior fibres of deltoid Shoulder is the mic joint to dislocate and to undergo recurrent dislocations % Shoulder joint is the m/e joint which is surgically “approached from the front. © Paint Are Syndrome : Pain in shoulder & upper arm during the mid range of ¢leno-humeral abduction. Caused by euinor far’ tendinitis! calcification of supraspinatus tendon; subacromial bursitis, # of the greater tuberosity. Acromioclavicular Joint © Articulating surfaces are covered with fbrocanilage © Coracoclavicular ligament consist of conoid and rapezoid ligaments. fe extremely strong and is principal factor in providing stability to joint and is responsible for ransmitting weight of UL & scapula to clavile © Movts are passive = Elevation (shrugging of shoulder): produced by uppet fibres of Trapezius + Levator scapulae & rhomboids, ~ Depression of scapula: Lowes fibers of trapezius + LD Ankle (Talocrural) joint © Synovial joint ofhinge variety © Dettoidigament is attached to talycaleaneonavicular joint. It is a very strong triangular ligament and is crossed by tendons of tibialis posterior and FDL. © Devsiflexiow is produced mainly by -~Tibialis anterior; assisted by Pt ©. Plantar flexion is produced by gastrocnemius & soleus. © Sprains of the ankle are amos always abduction sprains Anatomyof the subtalar joint ~ Inversion sprain leads to rupture of lateral collateral ‘igament ~ Eversion sprain leads to tearing of deltoid ligament © In Potts # subluxation commonly there is an isolated # of lateral malleolus Joints of foot © Inversion and eversion takes place at subtalar joint and TEN joint © Inversion is produced by —- Tibialis anterior, tibialis posterior, FHL,FDL © Eversion produced mainly by--peroneus longus & brevis; assisted by Bi, EDL, EHL © Dorsiflexion is produced mainly by -— Tibialis anterior, assisted by BL. © Deltoid ligament is attached to TON joint. © Triple arthrodesis involves fusion of TN + TC+ CC joint. © Pes planus or fatfoot is d/to— Collapse of MLA (medial longitudinal arch) © Pes cavusis high arch foot (av claw foot) is aw unduly high MLA (There is dorsiflexion of MTP joints and plantar Alexion of 1 joins). Ci seen in poliomyelitis © Brivionjs an adventitious bursa located over medial side of Ist MT head. Medial longitudinal arch of the foot © Formned by calcaneus + talus + navicular + cunieform + ‘medial 3 MT heads. TCN (talo-calcaneo-navicular) is the main joint. { MLA is NOT formed by cuboid and phalanges,} © Talus isthe keystone (head of talus forms summit) © Plantar calcaneonavicular! Spring ligament is important in maintaining MLA of the foot. Lateral longitudinal arch of the foot © Formed by calcaneus + cuboid + lateral 2 MT (4th and Sth) bones. Caleaneacuboid joint is the main joint © Caleaneum is the Keystone. Arch is meant mainly for transmission of weight and thrust from ground, © Plantar caleaneocuboid ligament is important in maintaining LLA ofthe foot “> Transverse arch i maintained by tendon of peroneus longus and tibialis posterior. LYMPHATICS AND L/D. ‘© Lymphatics usually accompany their blood vessels. ‘© Lymphatics are not found in brain, choroid, internal ea, © Primary lymphoid organs are --- Thymus and bone marrow. © Secondary lymphoid organs are ~~ Spleen, LN, tonsils, ‘payers patches, bone marrow. L/D of Breast © Sub areolar plexus of Sappy Lies just beneath the areola, It drains breast, nipple and ‘areola through deep lymphaties © 75% lymph from breast ultimately goes to axillary LN. Majority of lymphatics ftom lateral quadrant accompany axillary tail and drain mainly into the pectoral group of LN (carliest affected), Superolateral quadrant ofthe breast is Inle affected in breast cancer. Thoracic duct Thoracic duct isthe largest lymphatic channel inthe body. It recieves tributaries from-— In thorax Inneck ~ Lt intercostal LN ~ Lt jugular lymph trunk ~ Bil. descending thoracic trunk ~ Lt subclavian lymph ‘rank — B/L ascending lumbar trunk ~ Lt bronchomediastinal lymph trunk — Posterior mediastinal nodes LUD of Esophagus © Cervical part ~partracheal & deep cervical LN ‘© Thoracic part — posteriot mediastinal LN © Abdominal part paracardial group of left gastric LN Lymphatics draining into deep cervical group of LN in neck © Tonsils — Jugulo-digastric LN. © Tongue — Jugulo-omohyoid © Thyroid and parotid — deep cervical LN Lymphatics draining genital organs © Obturator LN — Cervix, © Pre-aortic-— Fundus & upper part ofuterus, fallopian tube, ovary testis, © Para-aortic Fallopian tube, ovary, testis© Common ifiac —- Receives afferent from extemal & internal iliac nodes and send their efferents to lateral aortic. % LD of Cx and wterur ic ¢0 external & internal iliac, ‘obturator, parametrial LN (but NOT to deep inguinal nodes) LD of stomach ito panereaticosplenie nodes, Lymph nodes which are usually benign occipital, posterior urea, shot inguinal LN Structure which ae usualy! by intemal iliae a 6 Allelic viseera «© Anal canal above pectinate ine 6 Lower part of body of uterus © Back of high, buttocks © Deep layer of ahd wall (aeaumbiliel portion) ‘© Membranousurehra «Prostate, base of UB 8 Cx, vagina © Deeper pars of perineum © Prostate membranous urethra Whole female urethra © Uterus, Cx, deep v Supertciat inguinal LN Deep inguinal LN «Penis (except glans) © Glans of penis 6 Perianal subcutaneous tissue (LN of Cloquet) © Anal canal below pectinate © Clitoris line © Lymphatics from lower © Coma of werus extremities «© Ixthnie part of FT, «© Penile (poney) urethra Round ligament of eras ‘© Superficial perineum, © Scrotum 6 Vulva and inferior vagina © Bigioe FASCIA © Superficial fascia of anterior abdominal wall Fascia of Camper: Below umbilicus super. fatty layer Fascia of Scarpa: Below umbilicus deep membranous layer. © Colles’ fascia: Membranous layer (deep layer) of Superficial fascia of perineum, © Gallaudet fascia: Deep fascia of perineum or its continuation. © Fascia lata: Deep fascia of thigh © Buck's fascia: Deep fascia of penis © Fascia of Denonvilliers: Separates post. surface of prostate from rectum Also Was prostatoperitoneat membrane or rectovesical fascia © Fascia of Waldeyer: Condensation of pelvic fascia behind rectum. Itattaches the lower part of rectal ampull to sacrum and encloses sup. rectal vessels Anatomy © Deep cervical fascia fascia Coli) Deep fascia ofthe neck is condensed to form — (8) Investing layer lies deep to platysrae, forms collar (b) Pretracfeal layer — forms false capsule of thyroid land to enclose it. It is thickened posteriorly to suspend ligament of Berry which causes movement of all thyroid swelling with deglutition. (©). Prevertebral layer continue as axillary sheath, (Fascia around the brachial plesus) (@)_ Carotid sheath — condensation of the fibrous alveolar tissue around the main wis ofthe neck ie. common and internal carotid artery , IV and vagus nerve. (€) Buccopharyngeal fascia, Pharyngobasilar fascia Hypogasitic sheath is a condensation of endopelvie {fascia. Lateral ligament of Bladder, werosacral, and trans cervical ligaments are constituents of hypopasric sheath “Fascia of Gerota covers Kidney and adrenal glad ott hae 2 layers — nerirlaor is Was fascia of Todt and postrir layer ‘walled fascia of Zckerkandl > Sion’ fascia suprapleural mondvaxe which covers apex of ing "Fascia Bulb or Tenon's capsule i he fascial sheath of eyeball hich extonds from optic nerve f0selerocorneal junction. SALIVARY GLANDS Be Niece SS Parotid Auriculotemporel Stensen’s duct Purely bof 5+ Q serous eserptrvol Opens in vestibule of * tr of hia otic mouth opp. upper 2nd eanelia role Pieresbuccinstor Sub CTbeof? Wharton's duct Mixed mandibular (bres fom + (cerous> (ub. SSN) Opens in leer of mucinous) marily) mouth on summit of sulbingual papilla (on cach side of eum) Sublingual CT eof? Bartholinduct_——_-Mixed but Rivinus duct mainly + mucinous Wharton’ duet! ai ety in oor of south Lacrimat Greater petrol Laerimal duet by. of facia ov + (Loerinalms) vin Direoted downward, plygopalitine backward & laterally ganglia aadopensinint meas of nose (BLD]«© Aurizulotemporal br. of mandibular av. is postganglionic ‘ & sectetomotor to parotid sland uae Sybewo)— Masilay 0 GSPIf7 Prego. ° Lara paras grein Hay laine ‘fe gaan «© Sectetomotor relay to acimal & nace glands. Geniculate ganglia Fibres of GSPN arise here (in course af ficial nv) but they relay to lacrimal gland via sphertopaetine ganglia Nodose ganglion ‘The nodose ganglion (ganglion ofthe trunk; inferior ganglion af vagus nerve) iseylindrica in form, 2.5 em, in length. Visceral afferent in function carrying sensation of heat, larynx, lungs & alinientary tract from the pharynx tothe trans. colon, © Ciliary ganglion is located near the apex of orbit between the optic nerve and tendon of lateral rectus muscle. Post ganglionic fibres passes through short ciliary nerves ~ supplies sphincter pupllae and ciliaris muscle. © Superior cervical ganglion isthe largest gan neck. © ‘Stllate gamslion is formed by fusion of lower cervical & Ist thoracic ganglion, Damage toit can lead to Horner's syndrome. NERVES Named Nerves © Nerwus intermedius of Wrisberg Sensory component of facial nv (Caties taste sensation from ant 2 tongue & general sensation from external acoustic canal) © Nervous spinosus ‘Meningeal branch of mandibular nerve which passes -10 through foramen spinosum. © Jacobson's nerve: ‘Tympanic branch of 9th ny. It forms tympanic plexus in middle ear & enters the petrous bone through tympanic canaliculus, © Amoldi/Alderman’s nerve ‘Auricular branch of vagus © Fidian nerve Or nerve to pterygoid canal (br. of 7th) is formed in foramen Jacerum by br. of GSPN containing parasympathetic secretomotor fibers + DPN (fiom cervical ganglia) carrying sympathetic vasoconstrictor fibres + Provides autonomic n/s to nasal sinuses (Nerve of Hay fever). Vidian neurectomy is done in Vasomotor rhinitis, © Nerve of Latarjet: Branch of mainy anterior gastric nerve, Cut in SV but preserved in HSV. © Criminal nerve af Grassi Branch of posterior gastric nerve which supply fundus It should be cut & dissected in highly selective vagotomy(HSV) to avoid recurrent peptic ulceration, © Nervi erigentes: Parasympathetic efferents 5; 5, are motor to detrusor ‘muscle and inhibitory to bladder sphinetors © Nerve of Kuntz: Grey rami running upward from 2d thoracic nerve. ‘igeminal newalgia (Tie Douloureux) ~ Ie sharp, parexysmal tl, exrwciaing pain in dis bution of wigeminal nerve (usally Wor 13) “Slur newalgin— His the neralga of phenopalatinegaglon ‘There is shar nasa pain nthe dsrbuton of anterior emda Muscles sty nse cervical are — Info, inferior bel of mahyoi, sternal, torneo 4 Nico sin around wiles T, vestral rams, “Greater awielar nerve supplies — sin over the angle of ow (ance & parotid crea) Inferior abieolar verve sup of agate, lower lip, czars Neo pona is ~ mandibular my, ~ myloigoid a, anterior belly > Swerer alveolar nerves are branches of maxillary nervePetrosal Nerves Greater 6 Fit branch of facial yerve, superficial) 6 arises fom geniculate ganglion GSPN 6 Itjoins DPN in foramen lacerum & forms nerve to plerygoid canal © Supplies lacrimal glands, nasal, mucous glands ;—ofPhx, palate Leser © Biol tympanic lexus supercial pases via otic eanpion dough TSPN———aurcuotemporal bof mandbulr neve © Supplicsparaid Deep/DPN © Ds.afsympatetic plexus around ICA © Contains cevial symp fire “Faternal/ 9 Inconstant bof sympathetic plus around EPN ‘mide meningeal 2 S Distribution of Vagus Nerve © in jugular foramen ; Meningeal & auricular branch © Inneck (Laryngeal nerves) i semen Saperiér LY / _t i = Ei IntemalNREREN LeRLN Other branches to carotid, phan, heart me Ri ExtLN —Criothyrcid Accompany superior roid Internal Sensoryto laryngeal Peres IN ‘mucosa above VC yrolyoid membrane RERLN —Allintinsicm/s of Lx rises from the vagus at except erica, the Vo Rt. subclavian 2, Sensory below VC, vos around it & then Branches deep ascends up cardiac plexus, trachea, esophus, inferior constictr, LERLN —Allintinsie mis ofLx drives from he vagus in except rico, ‘the mediastinum, at the Sensory below VC, Lo aartc are, loops Branches to deep around it & then ascends centlineplerus, aches, ino the neck esophagus, inferior constrictor, % Suvorior LY relate superior thyroid artery LNs closely related inferior tyro ater orl medal surface of thyroid gland. } Thenon recwrontrigh recurrent LN iar anomaly whi it atv aberent right subclavian rtery. % sina glo is the narrowest part of lary A poe ste of ‘hak in fh bone obstruction. Main rk IL car be severed ‘wl rmeing fk bone from this roa, > Galen's anastomosis is a crmecton bly SLN and RLN. [For details of nerves and their branches students are advised! 40 60 through VDA's anatomy charts by the same author] Distribution of Facial Nerve © Branches within she facial canal 1. GSPN 2. CT (Chorda tympani) 3. Nerve to stapedius © Branches at its exit rom the stylomastoid foramen 1. Posterior auricular 2. Posterior belly of diagastric 3. Nerve to stylohyoid mvs © Terminal brawches in face 1. Temporal 2. Zygomatic 3. Buccal 4, Marginal mandibular 5. Cervical “> Anterior belly of digastric i iby mandibular nerve > Muscles of facial expression are s/by facia! nerve, but {evatorpalpebrae supsrioris by oculomotor nerve > Facial nerve is supplied by maxillary artery. > Greater superficial petrasal nerve (GSPN) isthe ft bof facial nerve it artes from geniculte ganglion. ‘© Nis of pyramidalis muscle subcostal nerve © Pain of acute ethmoiditis is transmitted by nasociliary © Anterior and middle superior alveolar nerve isa branch of ~infia-orbital nerve, a branch of maxillary nerve © Posterior superior alveolar nerve is a direct branch of maxillary nerve "1Sensory Distribution of Nerves DERNATOES AND CUTANEOUS NERVES OF BODY‘Ato Muscin Nene wins “(deep bd) Poinal sons Caseot —_arelboy Isjuy/) medal ssn piconl, ‘ate condyle mens Ms FCU, panty FOR, Ae esltot Tardy ore Jeson bat ply, aps deformity ateliow, abi tel synitome Sensory Meial 1 Toss finger palmar surice Cf Claw ad Tests ulnar nerve (Tests nad) Card test Jury ot wrist Injury ot wrist Tryin Rial! S06CT Late C78T1 Spiral groove! ) mid arm cen (edit root ‘Cause Superficial Capa mel Saturday night injuries sirome pay # lowerend Compression on Labourers neve Largest ranch of radi, OTUs, Bye of the bead = tree nln Dislocation of im injections, luna semitunar_ # shaft of humerus Ms FDP(metial ABR, OP Inet wisps affered 4) rele ind Atelbow tn asila ‘oamalestession Supesconisar —_Cuch palsy of elbow fflowerend daca? wpper A ueres,” end hue, Splins Knuckle Bender — Cockup application aight lateral condyle wed ‘omiguet ramen, (Ochsner chsping A mit-freom es 4) Pointing index : “> Medion nerw is aio called labourer’ nerve bse it cons (aa Moai coarse movement of hand > Ulnar ner aio called musician's nore (because it controls Fee ‘Allthemis sty ne movenent of and) saal ‘Ulnar nerve hat 20 the worst and radial nerve has gr the Best Supine, Tens prognass inner rep : nd "> Weakness in powerri i sen in a spiral groove do parais of ECR Pronto symtrme, Wrst rp, Ar wis, ular nerve very superficial & erefore vlrerable Handof Finger drop, ‘compression (Gigo's Canal Syndrome). Resuls in ow hand Benediction Thumb drop forty deformity Simian hand Ape Ching ‘ i oorunean Clinical Tests of Median nerve lesion is dto Ba thenar © Tinel’s sign eminence (lat : op ea aa Percussion of flexor retinaculum results in tingling sense in the distribution of median nerve, (© Phalen’stestinancuver Puimaraspect+ Dorsal aspect of ‘Flexion or hyperextension of the wrist for one minute railed oflseal Tateral 3% fingers aggravates pain and parasthesia 3¥6fingers © Cuff compresion test of Gilliatt and Wilson Pain and parasthesia aggravated when a BP cuffs applied to the arm & when compression is applied > Systolic BP. Nerve Plexuses © Coeliae plexus (Solar plexus): oe Situated on the aorta and surrounds coeliac trunk and root (nb to flly of SMA. Plexus is anteromedial to sympathetic chain fix index and © Superior hypogastric plexus : snide fnge) Lies in front of bfureation of aorta © Inferior hypogastric plexus Contains pelvie splanchnic nerves 13 —N/s of Hand ‘Median Nerve ‘Ulnar Nerve my dates Dupe tiekeoiet 2 Sensory supply © Median ny - Palmar skin of lateral 3% digit, nail bed & dorsal skin of distal phalanx of lateral 3% dist. © Ulnar nv - Dorsum of skin of medial 1% digit, Palmar aspect of medial 1% digits. Nail bed & dorsal skin over distal phalanges of medial 1% digits. ‘© Radial nv - Skin of dorsum of lateral 3¥ digits (excluding al bed & skin of lateral 23rd of dorsum of hand). Brachial Plexus fedial root of MEDIAN cutaneous n: of arm: A. of fc She f (aR! Aypeicrme vank wins and pee i Pine owl 00M este Hei / tenet ewe an) Ge —_ Kellett Aadcee Abas FD, feu) almanac / mo “All small muscles of hand (tenar hypothenar inerssei and Junbrical) are supplied by C8, TI nerve roots All thenar muscles (FPB, OP, AbPjare by median nerve except ‘adductor pollicis whichis soy ulnar nerve % Thumb i used 10st muscles of handMuscilocuianeous C5670 Radial 56,7871 Mid shaft homers ; (rire groove) Median 36,7801 aS Ulnar car Groove behind medi epicondye Axillary nerve (C5- C6) © Injured ini surgical neck (upper end of shaft) ofhumers, anterior dislocation of shoulder, and # head of humerus © Deltoid m/s paralysis > Loss of rounded contour of shoulder (Flat shoulder), poor abduction, © Paralysis of teres minor & sensory loss over lower half of deltoid is seen, > Long thoracie nerve or nerve fo serratus anterior is also called —Nerve of Bell Anatomical neck of humerus is the articular margin bv head & shaft % 3 branches of radial nerve in spiral groove are —br. to lateral head of triceps, medial head of triceps, and Musculocutaneous nerve (C5,6,7) © Nerve of anterior compartment of arm © Branch of lateral cord of brachial plexus © It supplies : BBC —- Biceps brachii, Brachialis, and Corachobrachiatis © ‘tcontinues as lateral cutaneous nerve of forearm © Lesion results in ~ Loss of supination, biceps jerk, loss of sensation over Intra border of forearm. ~ J flexion at elbow. Nis of Hip joint ‘Ace/ to Hilton’s law hip joint is supplied by 3 nerves of pelvic girdle & LL 1. Femoral av via nerve to rectus femoris 2. Sciatic nv via nv to quadratus femoris 3. Amt division of obturator ny Cranial Nerves (CN) and their pecularities © Olfactory Olfactory pathway to the highest cortical centre is ipsilateral, All other sensory paths have crossed cortical representation © Trochlear Only CN to emerge from dorsal aspect of brainstem. Longest intracranial course. Motor . Only CN to undergo complete internal decussation before emerging, supplies contralateral SO mis © Trigeminal Largest nerve Passes through Mecke's cave. © Vagus } Longest cranial nerve in body, most extensive distibution © Facial Mic cranial nerve to be paralysed, longest course through bony canal of skull © Abducent Miccranial nerve affected in raised ICT, cerebral anewrysm (along with ocwiomotor) © 3rd & 4th cranial nerves attach to midbrain, Sth to pons, 6th Tt, tho junction of pons and medulla, 9th 10th, 11, 12th attach to medulla CN nuclei & their functional columns Sensory © SSA —CN2,8 © SVA(BA) —CN1,7,9,10 Motor © Somatic efferent column €N3, 4,6, Ls, 12 (Oculomotor, trochlear, abducent, hypoglossal, spinal accessory) © BE(SVE) CN, 7,9, 10, cranial accessory Tracts solitarius is eared to gustaton NT give rise to xara nerves Nine Ten Seven (10,7) dare—16 ROAMS SOME IMPORTANT MONONEUROPATHIES Newe = Supra ef, seapular Long“ GC, those n lone of all Radial. Cy, Post, cg interossoous by ofradial Ulan, CT, Mediann C.-T, Anterior Cy, interosseous of median Femoral, yy Lael yy cutaneous nerve (LCN) of high a br of femora lateral tan of scapula Paralysis of eras anterior 4 Winging of scapula Wrist drop Coss of tum & Finger extension) Cheiragia parasthetica (Parestresia & sensory loss over ‘thumb dito lesion of dorsal digital branches) Finger drop reative sparing of wrist, Extended MCP + flexed IP joins of fingers 4 (Claw hand ‘Cubital tunnet syndrome Carpal conned syndrome ‘Loss of pinch grip Knee buckling (Quadticep femoris & Ilopsoas paralyzed ‘Absent knee jerk Weaknessatopty ‘of ancerir thigh is Meralgia paresthetica Dysesthesc hyperpathia of Intel thigh Causelremark 4 Injured near supraseapular etch Loss of overhead bution also Saturday night palsy (acute compression), injured in spiral groove Finger & thumb paralyzed Paralysis of ‘umbsieals, more mated in low lear nv. aly. Deep termina bis purely motor which may be compressed in Guyon's canal (isokammate canal) in injury eat elbow In acromegaly, amyloidosis, DM Iypottyroidism Paresis of flexion of terminal phalanx, index and dale finger Proximal to inguinal ligament ‘Normal Knee jek Tingling, numbness of skin PCNofithigh S1-S3 Sensory loss over Sacral ‘plexus posterior midline of injury thigh Oburator Ly L, Loss ofadietion of hip, Sensory deficit over medial thigh. Seiten. Fail foot Severeleg/ Near siti notch hamstring weakness Deenperoneal Ly-S, Foot drop (loss of Neck of fibula a dorsiflexion oftoes (Ant, tibial and everson of fos, 1m) 4 Inabitty to stand on heel Post ibiatn, 15-8, Tarsal tunmel Medial malleotes syndrome in tarsal tunel, in aR ¥ LIGAMENTS, TENDONS, TRIANGLES, ANGLES Ligaments Fibrous bands which connects bone to bone © Deltoid ligament is attached to talocalcaneonavicular CN) joint and tibia. Tt is composed of tibiocalcaneal ligament & tibionavicular ligament © Coracoclavicutar Ligament is extremely strong & is the main factor in providing stability to acromioclavicular joint, © Lacunar! ament isa crescent shaped extension of fibres at the medial end ofthe inguinal ligament © Cooper's Pectineal) ligament isaextension of fbres from lacunar ligament aloag pecten pubis of pelvie brim © Gastrosplenic ligament contains short gastric vessels. © Leino- renal ligament contains splenic vessels & tail of pancreas. © Phrenico-colic ligament supports anterior end of spleen & prevents its downward displacement. © Struthers ligament isan inconstant ligament that extends bw the shaft of the humerus and the medial epicondyle of the humerus © Pubourethral ligament found in female © Puboprostatic ligament is found in male “F li.feroral ligament (Ligament of Bgelow) is one ofthe strongest ligament of the Body Spring. ligament (plantar calcaneonaviculartigansent) is a strong ligament which supports TCN joint (anterior subtalar joint from ventromedial sideTENDONS, Connects muscle to bone © Tendon of Todaro: It forms boundry of Koch's triangle © Conjoint tendon: Is formed by fusion of lower fibres of 10+ TA. Also k/as fal inguinalis > Tendoceleaneus isthe thickest and strongest tendon of the body + FHL tendon passes below the sustantculum tai > Pesanserinus is combined tendinous osertion of srtorins, gracilis and somitendinosus TRIANGLES ( A) © A of Doom Bordered by the vas deferens medially, gonadal vessels, laterally, and peritoneal edge posteriorly, contains the the femoral nerve, and the genital branch of the genitofemoral external iliac vessels, the deep circumflex iliac ve © Nof auscultation Bounded by 2 muscles and scapula Superiorly ~ Trapezius, Inferiorly — Latissimus dorsi and Laterally ~ medial wall of Scapula Rib 7 and Rhomboideus major lie in the floor of A Koch's 4 Is an important landmark for AV node. Boundaries include Tendon of Todaro, Coronary sinus, and Base or septal leaflet ring of Tricuspid valve. © Calot's A Is bounded by cystic duct (right), common hepatic duct (left) & porta hepatis (forms base). Comains cystic artery, right hepatic artery, accessory right hepatic artery and accessory bile duets. {s an important landmark during cholecystectomy © Trautmann’s 6 Bounded by -- bony labyrinth (anteriorly), Siemoid sinus (posteriorly)& Superior petrosal sinus or dura (above) Lumbar 4 of Petit Potential site for lumbar hernia Bounded by lateral border of LD (medisiy), Posterior border of external oblique fpasteriorly) & Mine crest which forms the hase (inferiorly) © Dettopectoral A Infractavicular fossa, ANGLES. © Renal ang! + Formed b/w 12th rib and erector spinae, © Sternal angle: Second costal cartilage joins to sternum at this level (also k/as angle of Louis) © Cites angle: also W/as Sinodural angle, situated bin the sigmoid sinus and middle fossa dura plat. © Solid angle: Area where three bony semicircular canals meet. © Alpha angle: The angle between the visual and the optic axes as they cross at the nodal point ofthe eye © Kappa angle: The angle formed by pupillary axis and visual axis atthe pupil. © Cobb angle: Angle measuring scoliosis on a radiograph. © Angle ofinclination : Angle formed by intersecting femoral neck angle (NA) with axis drawa through shaft of femur (SA) This angle normally varies b/w 90° and 160°, with an average of 135°. © Urethrovesical angle is tke £ biw the female urethra and the posterior vesical wall, normally about 90°-100° harrowing of this 2 in eystocoel predisposes to siress twinary incontinence © Aperture / angle of female pubic arclvsubpubic angle is 80°85" in female & 50°-60° in male © Greater sviatie notch is wider in female (75°) than male (60°) ©. Subpubie angle is 80°-100° in gynaecoid pelvis. MUSCLES © fultpennate musele isa muscle in which te fiber bundles converge to several tendons © Amyoplasia s congenital absence of a ins. Scen in Poland syndrome (undeveloped pectoralis ns). © Multiunit smooth mis are seen in iris. © Quadricepss femoris isa composite group of m's © Inf. Oblique is only extrinsic m/s of eye, which does not take origin from Anmulus of Zinn, (orbit) Subcutaneous muscles Platysma, Dartos, Palmaris brevis, Corrugator cutis ani, Suiareolar muscles of nipple, muscles of scalp ae—18 ‘Musculocutaneousis Radial. is proprioceptive motor ‘Addutor —Postetior division of bial part of sciatic magus obturlorn (adductor hamsting at) Par) ‘Femoral nerve (ant. fibres) Obturator n. (post. fibres) Mylohyoid be of Facial (post bly) manila (at ely) FPS —_Mellanauperciathead) Ulnar (exp brad) FDP Anterior meroeseus be. of Ula (modi al) Median (lateral al) Biceps tibial division of seats. Common bala femoris (ong head) (Gon xd) Composite (Hybrid) Muscles “Muscle supplied by two different motor nerves with different 100 values is called a composite or hybrid muscle, Examples ae. 1. Adductor magnus 2. Flexor digitorum profundus 3. Pectoralis major Cruciate Muscles Mascles in which fasciculi are crossed 1 Stemocleidomastoid 2Masseter 3.Adductor magnus 4, Oblique arytenoid muscles Ms of Mastication ‘© Temporal: Retraction ‘© Lat pterygoid: Depressor (side to side movt, yawning) © Medial pterygoid: Elevator (©. Masseter: Elevator (Tonic spasm e.g, intetamus causes lock jaw) > Prornion & Lateral (de tose mvt by media an lateral ergot > Depressor of Mandible (opening of Ja) + Digastri Genito enilyoi Lat pergoid > Opening of duitry tube Whe lever pala contract, Digastric Muscles ‘Mis in which there are 2 bellies with two different origins 3 4 Named Muscles 200900022000 eo Muscles of 2. Guy Ropes 3 Muscles are inserted into the upper part of medial surface of tibia from 3 different compartment of thigh 2 3. Octiptofrontalis (Occipital & frontal belly) i 2. Omohyoid (Anterior & posterior belly) Mis fibres in ligament of rete Digastrc (Anterior & posterior belly) Boxer's m/s + Serratus anterior Mis of marriage —> Medial rectus Mis of honeymoon — Sartorius Swing mis > Pronatus quadratus Climbing m/s > Latisimus dorsi ‘M/s of divorce ~> Lateral rectus ‘MS of rape or anti rape -> Gracilis(gracelius) Tailor m/s -> Sartorius ‘Red nls > Postural muscles White m/s —> Extra ocular m/s Spurt m/s > Brachialis Shunt nvs —> Brachioradialis, Mis used in Grinning (Risorius), Smiling /laughing: (zygomaticus major) and in Grief: (Depressor anguli ois) Genioglosss is ele safety muscle of tongue. (Fan shaped ‘and forms main bull of rongua) > Paseriorcrcoorteoidis called safety muscles of lars (causes abduction of vocal carts) > loiyod forms Buccal diaphragm. Inspiration : Diaphragm is major ms. > ext. 1C> sealene, sternomastoid (Accessory muscles) Expiration :- Mainly passive > m/s of ant hdominal wall, (Rectus abdominis) > Internal IC Sartorius - belongs to ant, compartment (5 - nv to ilium, bof femoral nv) Gractis - belong to medial compartment (ws -nv of pubis, br of obturator nv) Semitendinosus - belongs to post. compt. (nis = nv of ischium, br. of sciatic nv)M/s of 3 compartments of thigh/leg Adductorslongus, brevis, Obturator Medial Addctor magnus, asi, pstingas Antroe! Sartorius, gniceps femoris Feral Extensor (vas & acs emer) Posteroc! Harstrings(SMST, long head Tibial part Flexar _ofbiceps ferris, iil head of sciatic ofadévtoroagns) Leg Antesion Tibias neon EHL,EDL, An ial Peroneus tee (seep peroneal Lateral/ —Peoneusfongus & brevis Supetcial Peroneal eros Pestedor Siperfcial mace asco "Tibial eve semis Soles, plants) 6,83) Deep muscles (popltews, FDL, (als called FHL, bialsposterion) post. ibial ) © All muscles of anterior compartment of thigh cause extension of knee except sartorius which causes flexion © Major factor in preventing forward leaning of trunk during walking is gluteus maximus m/s, It helps in rising from. sitting position and is the chief extensor at hip joint, Flexion of Trunk (Lumbar spine) is carried by : Rectus Abdominis Lat flexion of trunk: ipsi/L Ext, Oblique + Cont /L 1.0 Rotation of trunk : Combined action of EOHO. 20 > Quadriceps femoris : Composed of rectus femoris & 3 vast, i i chief extensor at knee joint and supplied by femoral me + Quadratus femoris: Powerf lateral rotator of thigh and supplied by L5,$1 (fom sacral plexus) > Biceps femoris: Wien kneeissemifleced-Bicepsfemorisisa lateral rotator oftegand S.M.& ST are media etaorofleg. Whenhipisextended Bicersfomorsisalateralrotetorothigh Attachment on iotibial tract = ‘Tensor fascia lata Gluteus maximus, Vastu lateralis (some part) Iiotibial tract stabilizes the knee both in extension and partial flexion, {n leaning forward it knee. is main support of Anatomy © Attachments o Sustanticuluen tai Slip of tibialis posterior tendon 2. Plantar caleaneo-navicular (Spring) ligament 3. Medial caleaneal ligament 4, Superficial fibres of delioidtigament. FHL tendon passes below S~ © Lateral rotators of thigh Quadtatus femoris, piriformis, obturator internus, gemilli are main m/s Others are gluteus maximus, and sartorius > Tibial collateral ligament is degenerated tendon ofAdductor mags. Fibular collateral ligament is degenerated tendon of peroneus longus > Obliguepopiealigamentsderived fom senimembronosts % Palmas longusmascle is adegenerating muscle itis absent in 196 of subjects Ws in relation to scapula © Mb arising from tip of coracoid process ~ Shortheadof biceps, coracobrachialis, pectoralis minor © Retractor of scapula are ~-Trapezius, chomboidews major and minor © Trapezius muscle steadies scapula: ~ Its upper fibre + Levator scapulae elevate scapula (hugging) ~ Middle bres + Rhomboideus retract scapula ~ Upper & Lower # Serratusantetior involved in abduction fam >90" © Difficulty in shrugging of shoulder is seen io injury to spinal acessory nerve & in posterior 4 incision dito stemocleidomastoid paralysis. Upper Limb Muscles © Lumbricals: arise from FDP and cause fiexion at MCP + extension at I joints (lesion eauses claw hand) © Radka! (lateral) collateral ligament Fac-shaped ligament which gives origin to supinator, ECR brevis © Ulnar (medial) collateral ligament Triangular-shaped ligament which gives origin to flexor DS, Related to ulnar nerve, flexor CU & triceps. 19ey) ROAMS ATTACHMENT OVER BONES Humerus, meal epicondyle Common flexor 1 origin Humerus, tteralepicondyle Common extensor origin Rail wberosity Biceps bach Una tuberosiy Brachiais iyloid proces of tadus _Brachioraitis oe insertion Styloid process of ulna lar collateral ligament Pisioem bone Flexor CU, Pssokammate ligament Rib It Scalenus anterior, Suprapleurel Scalenus medius membrane ib, 20 Scalenus posterior ASIS Sartorius Lateral end of inguinal ligament Femur, lesser irochares, _Psoas major, iiscus enue, greater wochanter —Giteus medi, ‘ini, Al lateral oats of fing except auratus Structures Piercing 2 Museatocsssnevms nerve pierces ~- Caracobrachials is > Posterior inerosscons nerve pierces — Supine. > Median nrve pierces — Promutor teres. % lasernol lavengeal nerve (IL) pierces -- Thyrolyoid membrane > Parotid duc pieces» Buccinair > Siructrepictcing clavipecora fiscia — Tharaeooesomial vessels, Laterl pectoral nerve & fomphaties Cephalic vein [Me TLC] STRUCTURES PASSING THROUGH — FORAMINA/CONTENTS OF © Structures passing through foramina in orbit Superior Upperpat 1. CN 4,5 (om manna!) bit 2, Sapir opti vein Sesare SOF) 5 Recurent meningeal ach of cote Lome borer provides aahment to conmon tedious ig of Zin. Middle pat Nessa (CN 3 (visions, 6 Lower art Inferior open ein Sympthatic leses Interior 1. Zyzomatic rene bial 2 Ineo vessels fsure 1OF) 3. Maxillay neve (ziMte} 44 sary vein Optic anal ~ Optic ace, sympathetic aves © Oph = ev © Optic foramen —issituated between Lesser wing and Body of sphenoid (LB) © Choroid issure of eve ~—Hlyaloid artery © Sinus of Morgagni {Semilunar space b/w base of skull & sup. constrictor) ~ Auditory tube ~ Levator palati ~ Ascending palatine a, [Mz ALA] © Between superior and middle constrictor : ~ Stylopharyngeus ms its nerve (CN9) © Carotid sheath ~ Internal jugular vein, ~ Common carotid artery (ICA in upper part) — Vagos. (Note: Sympathetic trunk is outside} Carotid canal ICA ‘Mandibular canalijoramen ; Inf. alveolar nervelvessels, Incisive foramen; Greater palatine vis & nasopatatine 1, Foramen rotund ~ Maxillary nerve 22000 Foramen ovale ~ Mandibular nerve = Accessory meningeal artery = Lesser peteosal nerve = Bmissary vein, [Ovale - MALE] © Foramen spinosian + Middle meningeal a. & ¥. = Emissary vein ~ Nervous spinosus (MENINGEAL branch of mandibular nerve) [MEN]© Foramen lacerum - iw petrous & sphenoid. Lower part is filled with cartilage while upper part transmits ICA. © Hypoglossal canal ~ Hyposlossa a & its meningeal branch ~ Meningeal branch of ascending pharyngeal artery. ~ Emissary vein © Jugula foramen + Antpart + Inferior petrosa sits ~ Middle part: CN 9,10, 11 + Meningeal br. of ascending pharyngeal artery. = Posterior part: - Occipital a. + JV emissary vein [Note : CN 12 passes through hypoglossal canal] © Intervertebral foramen = Radicular a = Spinal nerves (© Structures in relation fo cavernous sinus (Contents of C8) Sirutuesteaversng lateral wall of SCN 24, VV, (above downwards} 3 Structures pieccing rof of af CS ON3A,ICA © Foramen magnum transmits ~ Narrow ant part: Apical ligament of dens, vertical band of eruciate lig, membrana tectoria + Wider post part: 4th partof vertebral a, spinal accessory 1. symp plexus, spinal vessels ~ Sub arachanoid space: lowest part of medulla oblongata, 3 meninges, © Sacral canal ~ Cauda equina (nerve fibres) ~ Filum terminale (end of spinal cord) ~ Spinal meninges (dura, arachnoid) So lower sacral nerve pierce the dura, arachnoid at $, level © Structures emerging at sacral hiatus S,, A pair of eoceygeal nerve, Filum terminale © Structures passing through lesser seiaic foramen ~ Pudendal nerve ~ Int. pudendal vessels + Nerve and Tendon of Obturator internus (PENT) Of these PIN passes through Greater sciatic foramen PI passes through pudendal canal "> Foramen ransversoriumis presente transverse proces of cervcu/verchrae. transmits vertebral vessels & sympathetic plerus (C1-C0) Dorel canal isan opening in caverns sinus ond transmits abdcen nerve Sternberg’ canal is located amers-medial to forumorroandin & isdio incomplete fk of rater wing ofphenoid wi he re spenoid Aw spantancous CSF leaks & meningocoele > Foramen of Yesalias (oF emissary sphenoidel foramen) ‘transmits emissary ein > ‘Wide neural foramina are seen in —-Newrofibromatoxis Diencophalon —Thalamus, (Talaman hypothe cephalon) Midorain | Cruseerebri substantia ‘@eseneephlon) igea : —— Tegmen 8 inden Myelenephalon Medulla {®krobencepalo) Metenceplon Pons, cereballan © Metathalamus is made up of medial & lateral geniculate bodies (MGBYLGB), © Epithalamus contain pineal body, Habenulartrigone, post commissure, optic cup © Lateral ventricles develop from telencephalon (and form cavity of cerebrum) © 3rd ventricle develops from diencephalon © Retina isan outgrowth of diencephalon © Mesencephalon (midbrain) is at junction blw middle and posterior cranial fossa, © Superior coticuls is present in upper midbrain and EWN of oculomotor nerve is situated here © Inferior coticulus is present in lower midbrain and trochlear ‘nerve nucleus is situated here. © Facial colliculus is present at level of pons a—— 22 ROAMS © Rhomboid fossa is a diamond shaped floor of 4th ventricle formed by medulla and pons. % Bosal plate oftewal be : gives rise to motor nuclei Alar plate of neural ube: gives sensory nclel (somatic afferent columns) + cerebral hemisphere & cerebellum % Roof plate ofnesral tbe : ependsmal cells, choroid ples of Iptoral, 3 & th ventricle + Parvocelilar pathway’ fron! LGB to visual cortex is most sensitive forthe stinulas of colour contrast Brain Stem © Gaze centres = The gaze centres for horizontal movements of the eyes are located in pons near the abducent nucfeus in PPR (para-median pontine reticilr formation) = The gaze centres for vertical movements ofthe eyes are located inthe midbrain in rostral interstitial nucleus of MLF, nucleus of Cajal, and neurons of tegmentum Lesion produces paralysis of vertical (upward/downward) gaze, [Mnemonic HPVM] © ‘The MLF (medial longitudinal fasciculus) plays a role in co-ordination of vertical & horizontal conjugate movements of the eyes. U/L Lesions of MLF produce internuclear ophthalmoplegia, © Attention centre: The locus coeruleus, which contains largest concentration of NA melanin containing neurons, functions as attention centre Cerebellum © Cerebellum is connected to brain stem by three cerebellar peduncles (CPs). Mid brain = by superior CP Pons by middle CP Medulla by inferior CP © Parts of cerehellam: Part | Formed by union’ ‘Archi Flcelonodslar Pryjetstomm———‘Swaying, lobe tingula— fasigns positional ets Polo Asteriorlate Contos poste, Nis embotformis tone cre + nu globes movements Neo Midlelbe Fine movements Pst pining, ‘dysmetria, dyssynergia, typotona © Cerebellar cortex = Cerebellat cortex has 3 layers, which contain five cell types [ Does not include bipolar cells] 1. Outermost molecular layer: Stellate , Basket cells 2. Middle layer ~- Purkinje cells 3. Inner (deeper/gramulat) layer : Granule, Golgi cells ~ Purkinje cells are the only output eels (efferent) from the cerebellum and they are alway’ inhibitory (GABArgic). The remaining four cells are afferent in nature. = Mossy fibres excite > Granule cells -» excite the remaining four cells via the parallel fibres Climbing & Mosy fibres ore excitatory inna (hereare2 main inns tothe cerebellum) % AMfreat calls which ore te basket ells (located in moletlar layer), Stlae cells (located in euperfcil layer) and Golgi cell (an gra layer) are example ofirhibior interneurons. Bipolar calls are preset the carebral (NOT erebellar) cortex cand retin, In gry mater of CNS dendrite tre grows mas" in the postnatal We Neocortex © Also called neopallium or isocorte. © The neocortex is part ofthe cerebral cortex (along with the archicortex and paleocortex, which ae cortical parts ofthe limbic system), © Long term memory is stored in neocortex. In all maramals, it isinvolved in “higher functions" such as sensory perception, generation of motor commends, spatial reasoning, conscious thought and language. Hippocampus © ‘The FORNIX is a band of nerve fibers that connects the frippocampus to the hypothalamus. © The hippocampus is responsible for sending information to "appropriate pars ofthe cerebrom for long-term memory. © The manimillary bodies are a pair of small round lobes located at the end ofthe fornix, Neostraitum © The siriatum, also Was the neostriatum or strate nucleus, isa subcortical (ie, inside, rather than onthe outside) part of the forebrain © The neostriatum isthe entryway into the basal ganglia and is the site of many of the neurological defects involving basal ganglia function i | | t | | i { { | | | | | | | 1 | | | {