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KICK THE BOARDS USMLE STEP 1

HIGH YEILD ANATOMY POINTS Prepared by Dr. Irfan Mir

KICK THE BOARDS. USMLE STEP 1 ANATOMY


ANATOMY

Prepared by Dr IRFAN MIR

* Kyphosis is an Exaggeration of the thoracic curvature. Can occur in aged person due to osteoporosis or degenerative dis. * Lordosis is an exaggeration of the lumbar curvature which can occur as a result of pregnancy, spondylolisthesis, or potbelly. * Scoliosis is a complex lateral deviation / torsion that can be caused by poliomyelitis, short leg or hip dis. * Atlanto - occipital joint (as in indicating yes by head) is a joint b/w C1 & Occipital Condyles, It have no intervertebral disc Ant and Post Atlanto - occipital membrane limit excessive movement. * Atlanto - Axial joint (as indicating no by head) is the joint b/w C1 and C2 and have no intervertebral disc. The Alar ligament limit excessive movement. * An intervertebral disc consist of Annulus Fibrosus (fibrocartilage) & nucleus pulposus (remnant of embryonic notochord) * Hyperextension of the neck stretches the Ant longitudinal ligament. * C4 and C5 herniated disc compress C6 nerve root and result in week abduction of arm and flexion of forearm. Bicep jerk reflex is effected. * C5 and C6 herniated disc compress C6 nerve root and result into weak extension of wrist. Bicep jerk reflex is effected. * C6 and C7 herniated disc compress C7 nerve root and result into weak flexion of wrist and weak extension of Elbow. Triceps jerk reflex is also effected. * L4 and L5 herniated disc compress L5 nerve root and result into weakness in dorsiflexion of ankle. * L5 & S1 herniated disc compress S1 nerve root and result into weak planter flexion of ankle. Ankle jerk reflex is effected. * Spondylolysis is the fracture of the lamina b/w inferior & superior articular processes with in the lumbar vertebra. * Ankylosing Spondylitis is an inflammatory arthritis generally effecting the lumbar vertebra and sarcoiliac joint, the intervertebral disc (annulus fibrosus) may become ossified, majority of the pt have +ve HLA B27. * Osteomyelitis is an infection may caused by tuberculosis, staphylococcus aureus. * Denticulate ligament are lateral extension of Pia matter which attach to Dura matter & there by suspended the spinal cord with Dural sac. * Trachea and esophagus starts at the level of C6. * Bifurcation of trachea at the level of T4. * Xiphisternal joint present at T9. * Doudenum present at T12 - L1 . * Kidney present at T12 - L3. * Bifurcation of aorta at iliac crest. * Sacral promontory S1. * If great Radicular artery is ligated (which supplies to lower spinal cord) during resection of Aortic aneurysm, the pt may become paraplegic , impotent, and loss voluntary control on bladder and bowel. * Epidural anesthesia ( Caudal ) is use to relief pain during child birth. * Lumbar puncture can be done by insert needle above or below the spinal process of the L4 vertebra. the needle pass through following structure. 1. Skin, 2. Superficial fascia, 3. Supra spinous ligament 4. Interspinous ligament, 5. Ligamentum flucum, 6. Epidural space (contain internal vertebral venous plexus), 7. Duramater, 8. Arachinoid. * Quadreplegia occur due to transection above C3, pt die quickly due to respiratory failure if pherenic nerve is compromised. * Dermotomes :- Clavicle C5, Nipple T4, Medial side of big toe L4, Thumb C6 Umbilicus T10, Lateral surface of foot and little toe S1.

* In Breast Axillary tail superior lateral quadrant is the location where high percentage of tumor occur. * If breast carcinoma lies b/w retro mammary space and pectorial fascia, the contraction of pectoralis major may cause whole breast to move superiorly.

KICK THE BOARDS. USMLE STEP 1 ANATOMY

Prepared by Dr IRFAN MIR

* Suspensory ( cooper's ) ligament provide support for breast, if carcinoma invade the ligament than these ligament may shorten cause dimpling of skin or inversion of nipple. * Axillary vein is chief venous drainage for breast and axillary node drain lymphatics. Blocked lymphatic axillary node in carcinoma cause thick leathery skin (of the involved area). * During Mastectomy the long thoracic nerve must be preserved damage to it paralyze the Serratus ant muscle with resulting Winged scapula. * Thoracostomy may be necessary to drain fluid out of pleural cavity by inserting needle through 4th intercostal space at midaxillary line. (needle should be inserted close to the upper boarder of the rib to avoid VAN because it runs close to lower costal border). * Dilation of the intercostal artery cause erosion of the lower border of the rib (Rib notching) as in the coarctation of aorta. * Dome of diaphragm arches superiorly to the upper border of Rib 5 in mid clavicular line. * During inspiration lung may radiolucent (dark) where as expiration lose radiolucency. * Costodiphragmatic angle (costopheranic angle) should appear sharp in X - Ray film. * Pleuritis involve visceral pleura and is painless (because there is no nerve innervations) vs. Where as Parietal pleura is associated with sharp pain and referred pain ( because it is innervated by intercostal nerve). * Spontaneous Pneumothorax occur when air enter the pleural cavity usually due to a ruptured bleb of the diseased lung. * Open Pneumothorax occur when the parietal pleura is pierced (eg knife wound) upon inspiration air stucks in the pleural cavity. * Tension Pneumothorax may occur as a sequela to an open pneumothorax if the inspired air cannot leave pleural cavity through wound upon expiration. As a result there is collapsed lung on the wounded side and compressed lung on the opposite side due to deflected media stinum. * Compression of the Trachea may be caused by Thyroid Gland enlargement or an Aortic arch aneurysm. * Atelactesis is a collapsed alveoli so they cannot be inflated causes are inflammation or lack of surfactant. Tumor or mucous obstruction cause segmental atelectasis in which heart & mediastinum shift toward a collapsed side. * Bronchiactasis is abnormal dilatation of the bronchi results from damage to bronchial wall. * Emphysema in which retrosternal air space , ant post diameter of the chest wall and flattening of diaphragm on X - Ray. * Bronchogenic Carcinoma tend to effect the upper lobe (ant aspect) and may cause nerve damage 1. Pherenic nerve damage paralysis of diaphragm of one side 2. Recurrent laryngeal nerve Hoarseness (located near the apex of lung) ----------------------------------------------------------------------------------* Inguinal region is the area of weakness of the ant abdominal wall resulting from the penetration of the testes and spermatic cord in male and round ligament of uterus in female during embryonic development. * Cancer of the scrotum metastasize to superficial inguinal node where a cancer of the testes metastasize to deep lumbar node. * Hasselbach's triangle (inguinal triangle) is formed laterally by inferior epigastric artery and vein, medially by rectus abdominus muscle, and inferiorly by inguinal ligament. * Direct Inguinal Hernia protrudes directly through the ant abdominal wall with in Hasselbachs Triangle. it is most common in old man and is distinguished from Indirect Inguinal Hernia by protruding medial to the inferior epigastric artery and vein. * Indirect Inguinal Hernia protrude through the deep inguinal ring to enter the inguinal canal and may exit through the superficial inguinal ring. This type is more common in children & distinguished from direct hernia by protrude laterally to the inferior epigastric artery and vein. It is also distinguished from Femoral Hernia by protruding above and medial to the pubic tubercle.

KICK THE BOARDS. USMLE STEP 1 ANATOMY

Prepared by Dr IRFAN MIR

* Femoral Hernia protrudes through the Femoral canal below the Inguinal ligament. This is more common in female and distinguish from Direct Inguinal Hernia by protruding below and lateral to the pubic tubercle. * Deep Inguinal Ring is an oval opening in the transversalis fascia located lateral to the inferior epigastric artery. * Superficial Inguinal Ring is a triangular defect in aponeurosis in the external oblique muscle located lateral to the pubic tubercle. * Inguinal Canal is a canal that begins at the Deep Inguinal Ring and end at the Superficial Inguinal Ring. This canal transmit spermatic cord in males and round ligament in female . * Transverse Abdominus Muscle does not continuous in scrotal area. * Excess Peritoneal fluid (due to peritonitis / ascitis) Flow downward (normal is upward) through Paracolic Gutter to retro vesicle pouch in male and to recto uterine pouch in female in sitting and standing position where as it flow upward in supine position. * Lesser Omentum consist of hepatodoudenal ligament and hepatogastric ligament . * Greater Omentum hangs down to greater curvature of stomach. * Aneurysm most commonly occur b/w renal arteries and bifurcation of abdominal aorta. * Extra peritoneal structure :- 1. 2nd, 3rd ,4th part of the Doudenum 3. Rectum 5. Kidney, uterus 7. Abdominal aorta 2. Ascending and descending colon 4. head, Neck, Body of Pancreases but not Tail. 6. Supra renal gland 8. Inferior Vena Cava (IVC)

* Right Gonadal and Right Suprarenal Vein drain directly into IVC where as Left Gonadal vein and Left Suprarenal Veindrain into Left Renal Vein. * Left Testicular vericoceal may indicate Left testicular vein occlusion and Left renal vein occlusion due to malignant tumor in kidney. * In hepatic portal sys the term portal refer to vein interposed b/w two cappillary beds (the capillary bed of GI tract portal vein capillary bed of liver). * Liver cirrhosis may result into portal hypertension reverse flow of blood into IVC. * Malignancy of lower 1/3 of esophagus tend to metastasize below the diaphragm to ciliac lymph node. * Sliding Hiatal Hernia occur when esophags and the stomach are pulled through the diaphragm. * Paraesophageal Hiatal Hernia occur when portion of the stomach is pulled up through the diaphragm. * Latarget nerve Vagotomy eliminate stimultion of HCL secretion to stomach. * Dumping $ is rapid emptying of stomach content following partial gastrectomy or vagotomy. * Second part of doudenum recieve Ampulla of Vater. First part of the doudenum is in peritonium cavity most doudenal ulcer occur here. * Villi and Crypt are absent in large intestine. * Liver is divided into right lobe and left lobe by Falciform Ligament. * Liver biopsy performed by needle puncture throught a right intercostal space 8, 9, or 10. * In the adult empty bladder lies in pelvis minor where as in infant it lies in abdomial cavity. * Posterior surface of bladder is related to the rectovesicle pouch, seminal vesicle, ampulla of ductus deferns in male where as in female it is related to vesicouterine pouch, ant wall of vagina. * Base of the bladder in male is related to prostate gland. * If superior wall of the badder is ruptured Urine will leak in peritoneal cavity where as if ant wall of the bladder is ruptured ( because of pelvic fracture etc) urine will leak into Retropubiic space (extra peritoneal). * Prolapse of rectum result from trauma from childbirth or by loss of muscle tone in aged. * Carcinoma of rectum may metastasize to liver because superior rectal vein drain into hepatic portal vein. It may also metestasize to near by structure eg. sacral nerve, prostate, seminal vesicle, urinary bladder, uterus, vagina.

KICK THE BOARDS. USMLE STEP 1 ANATOMY

Prepared by Dr IRFAN MIR

* Prostate consist of 5 lobes ( Right and Left lateral lobe, Right and Left posterior lobe, Median lobe ). Right and Left posterior lobe predispose to malignancy and is the most common malignancy in male. * Prostate Venous Plexus Drain into 1. Internal iliac than to IVC which explain metastasis to heart and lung 2. Vertebral venous plexus which explain metestasis to vertebral column & brain. * Isthmus of the uterus correspond to internal os and is preferred site for C - Section. * Perineal nerve and Dorsal nerve Branch are the branch of the Pudendal nerve supplies to genitalia in both sexes. * Ischeal Tuberosity is the chief land mark to block pudendal nerve. ------------------------------------------------------------------------------------

* Mid Shaft Humerus Fracture may damage Deep brachial artery and Radial nerve. * Trauma may damage compartments (seperated by various sheet) of the limb cause Compartment $ Hemerrhage compress uninjured blood vessel and nerve produce ischemia and atrophy of musculature with painful and weak movement. * Brachial Pluxus have 5 Major Branches 1. Musculocutaneous nerve 2. Axillary nerve 3. Radial nerve 4. Median nerve 5. Ulnar nerve * Axillary nerve damage may cause by the fracture of surgrical neck of the Humerus or dislocation of the shoulder joint Paralysis of deltoid with compromised arm abduction, weak lat rotation of arm, sensory loss of lateral arm. * Long Thoracic nerve injury may cause wound or removal of the lymph node during mastectomy Abduction of arm past horizontal position is compromised. ask pt to face wall and push both arm, you can see that medial angle and inerior angle of scapula of injured site may become prominent called Winging Scapula. * Injury to Brachial plexus in post triangle Erb Duchenne's and Klupke's $. 1. Erb Duchenne (upper trunk) -- C5, C6 - (Musculoskeletal nerve, Suprascapular Nerve, axillary nerve) arm is medially rotated and pronated ( waiters tip ). 2. Klumpkes (lower trunk) -- C8 - T1 -(Medial nerve, Ulnar nerve) loss function of hand & wrist. * Radial nerve injury caused by fracture of humerus and mid shaft extension of the wrist and digits are lost, supination is compromised, sensory loss of posterior arm and forearm and lateral aspect of the dorsum of the hand. Clinically the hand is flexed at the wrist (Wrist Drop). * Median nerve injury at elbow or axilla may be caused by Supracondylar fracture of the humerus weakness of the flexion of the wrist, loss of flexion of wrist, loss of flexion of digits and pronation, thumb paralysis, sensory loss of dorsal aspect of index, middle and half of ring finger, sensory loss of palmar aspect of thumb. * Median nerve injury at wrist may caused by slashing of wrist or Carpal tunnel $ cause paralysis of thumb, sensory Loss of palmer and dorsal aspect of index, middle and half of the ring finger, sensory loss of palmar aspect of thumb clinically Ape hand is observed. * Ulnar nerve injury at elbow or axilla, medial epicondyle of humerus deviation of hand to radial side upon flexion at wrist, flexion of middle and ring finger is lost, abduction adduction of fingers are lost, adduction of thumb is lost, sensory loss of palmar and dorsal aspect of little and half of ring finger. clinically hand has distinctive shape called Claw Hand.

KICK THE BOARDS. USMLE STEP 1 ANATOMY

Prepared by Dr IRFAN MIR

* Ulnar nerve injury at wrist caused by slashing of the wrist flexion of little and ring finger is lost, abduction and adduction of fingers are lost, adduction of thumb is lost, opposition of little is lost, sensory loss of dorsal aspect of little and half of ring finger. Clinically claw hand is observed. * Brachial artery contractures Volkmann's contracture characterize by permenant flexion contractture of the hand and wrist (claw hand). It may also caused by improper plaster cast and compartment $. * Carpel Tunnel $ result from compression of median nerve Flexion and abduction of thumb weakened, Opposition of thumb is lost, Extension of index and middle finger is lost. Sensory loss of index, middle and half of ring finger and palmar aspect of thumb. * Trendelenburg sign :- Patient stands with his back toward examiner and alternatively raises each foot of the ground. If the superior Gluteal nerve of the left side is injured then when pt raise his right foot off the ground the pelvis will fall down. This sign is + ve in superior gluteal nerve injury caused by surgery, polio, hip dislocation, fracture of the neck of the femur. * Inferior gluteal nerve injury Pt lean the body trunk back at heel, cant rise from seated position, climbs stairs or jump. * Obturator nerve injury loss of abduction of thigh and sensory loss of medial thigh. * Femoral nerve injury caused by trauma to femoral triangle weakened flexion of thigh, loss of extension of leg, sensory loss of ant aspect of thigh and medial aspect of leg and foot. * Tibial nerve injury (at popliteal fossa) Planter flexion of foot is lost, Flexion of the toe is lost, inversion of the foot is weakened. Sensory loss of the sole of the foot. Clinically cause dorsiflexion and Eversion of the foot. * Common Peroneal nerve injury cause by blow to the lateral aspect of the leg or fracture of the neck of the fibula Eversion and dorsiflexion of the foot is lost, extension of the toe is lost, sensory loss of the anterolateral aspect of the leg and the dorsum of the foot. Clinically show foot drop and inversion of foot. The pt has high step gait in which the foot is raised higher than normal so that the toe does not hit the ground. In addition the foot is brought down suddenly producing a clopping sound. * Hip dislocation (posteriorly) :- pt present with flexion of lower limb at hip joint adducted, medially rotated shorter limb. where as fracture of the head of the femur result in laterally rotated shorter limb. * Patellar Ligament is struck to ilicit the knee jerk refex. This reflex is blocked when Femoral nerve is damage. * Tibial (medial) collateral ligament torn can be recognized by abnormal passive abduction of the extended leg and prevent abduction of knee joint. * Fibular (lateral) collateral ligament torn prevent adduction of the knee joint & show abnormal passive adduction of extended leg. * Ant Cruciate ligament torn prevent the movement of tibia in reference to femur show abnormal passive ant displacement of tibia (ant draw sign). * Post crutiate ligament torn prevent post movemnet of tibia in reference to femur & show abnormal passive post displacement of tibia (post draw sign). * Combine knee injury (terrible triad) involve tibial collateral ligamnt torn, medial miiscus torn, anterior cruciate ligament torn. * Fracture of the neck of femur Laterally rotated and shortened lower limb. * Fracture of the distal 1/3 of femur shaft Interfere the blood flow to popliteal artery. * Fracture of the lateral melleolus of fibula Inversion of foot (inward movement) * Fracture of the medial melleolus of tibia Eversion of foot (outward movement)

KICK THE BOARDS. USMLE STEP 1 ANATOMY

Prepared by Dr IRFAN MIR

* Carotid body (O2 chemoreceptors) & Carotid sinus (pressure receptors) sensory info is carried by CN IX & X. * Internal jugular vein catheterizaton can be performed in ant triangle. * Injury to CN XI in post triangle Paralysis to trapezius so abduction of the arm past the horizontal position is compromised. * Recurrent Laryngeal nerve damage may result by Thyroidectomy surgery. * Unilateral laryngeal nerve damage Hoarseness and irritability to speak for long period. * Bilateral laryngeal nerve damage Acute breathlessness (dyspnea) * Skull FX of the temporal parietal bone or near pterion Epidural hemorrhage due to middle meningeal artery tearing. Epidural hematoma may cause uncal (transtentorial) herniation which compress CN III cause dilatation and fixed pupil. blood will not appear in CSF. * Blow to head or violent movement of brain Subdural hemorrhage form the bridging veins (superior cerebral veins), blood will accumulate b/w Dura and Arachinoid and does not appear in CSF ( if arachinoid is intact ). * Contusion, laceration injury, or aneurysm rupture Subarachinoid hemorrhage blood may appear in CSF and it irritates meninges cause severe headache, stiff neck, loss of consciousness, (remember major arteries in brain travel with in subarachinoid space and therefore surrounded by CSF). * Intercrebral hemorrhage caused by injury to cerebral artery into brain paranchyma due to stroke, blunt trauma, penetration injury. Blood appear in CSF. -------------------------------------------------------------------------------------------* Axillary nerve injury occur due to shoulder dislocationa or surgical neck of the humerous paralysis of deltid and teres minor, abduction of shoulder is impaired with loss of sensation of lateral upper arm. * Musculocutaneous nerve injury (rare) weakness of elbow flexion and supination of forearm. * Radial nerve injury -- Loss of extension of wrist, digit and supination (Wrist drop) Sensory loss of posterior arm, forearm and lateral dorsum of hand. * Median nerve injury Weakness of flexion of wrist, digit and pronation. Also thumb paralysis. (at elbow & axilla) Sensory loss of dorsal aspect of index, middle, half of ring finger and palmar aspect of thumb. * Median nerve injury Paralysis of thumb (Ape hand). (at wrist) Sensory loss of dorsal aspect of index, middle, half of ring finger and palmar aspect of thumb. * Median nerve compression Weak flexion and abduction of thumb. (Carpal tunnel $) Opposition of thumb is lost. Extension of middle and index finger is lost. Sensory loss of index, middle, half ring finger and palmar aspect of thumb. * Ulnar nerve injury Loss of flexion of little and ring finger. (Claw hand) (at elbow or axilla) Abduction and adduction of finger is lost. Adduction of thumb is lost. medial epicondyle Sensory loss of palmar and dorsal aspect of little and half of ring finger. Deviation of hand to radial side upon flexion of the wrist. * Ulnar nerve injury at wrist Loss of flexion of little and ring finger (Claw hand) (at wrist) Abduction and adduction of finger is lost. Adduction of thumb is lost. Opposition of little finger is lost. Sensory loss of palmar, dorsal aspect of little & half of ring finger.

KICK THE BOARDS. USMLE STEP 1 ANATOMY


Fracture of neck of femur or hip dislocation.

Prepared by Dr IRFAN MIR

* Superficial Gluteal nerve injury + Trendelenburg Sign. * Inferior Gluteal nerve injury Loss of ability to rise from seated Position, climb stairs or jump. (body lean backward) * Femoral nerve injury Weak flexion of thigh and extension of leg. (Trauma to Femoral Triangle) Sensory loss of anterior aspect of thigh and medial aspect of leg and foot.

* Tibial nerve injury Planter flexion of foot is lost. (at popliteal fossa) Flexion of toe and inversion foot is lost (Clinically cause Dorsiflexion and eversion of foot). Sensory loss of sole of foot. * Common Peroneal nerve Dorsiflexion and eversion of foot is lost. (Foot Drop) Extension of toe is lost. Sensory loss of Anterolateral aspect of leg & dorsum of foot.

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