ANT 1003 Unit 1

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Thorax
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1

divisions of the thoracic cavity

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  1. right pleural cavity
  2. left pleural cavity
  3. mediastinum
2

boundaries of the thoracic cavity

  1. the ribs
  2. sternum
  3. vertebral column, and
  4. the diaphragm
3

thoracic vertebrae

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  1. has a heart-shaped vertebral body, with a long spinous process;
  2. have four articular facets (contact other vertebrae); two superior face posteriorly, two inferior face anteriorly;
  3. have six costal facets (contact ribs); two superior articulate with heads of their own ribs, two inferior articulate with heads of ribs below, two transverse articulate with tubercles of their own rib;
  4. have a circular vertebral foramen that houses the spinal cord and broad laminae that overlap the vertebrae below;
  5. an intervertebral foramina is formed on each side between adjacent vertebrae, allowing structures (spinal nerves and blood vessels) to pass in and out of the vertebral canal.
4

ribs

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  1. all twelve pairs articulate with the vertebral column posteriorly; the anterior ends are composed of costal cartilage;
  2. The head of the rib is expanded and presents two articular surfaces separated by a crest.
  3. The neck is a short flat region of bone that separates the head from the tubercle.
  4. The tubercle projects posteriorly from the junction of the neck with the shaft and consists of two regions, an articular part and a nonarticular part.
  5. The body (shaft) is generally thin and flat; the superior margin is smooth and rounded, whereas the inferior margin is sharp.
  6. The shaft bends forward just laterally to the tubercle at a site termed the angle.
  7. The inferior margin of the internal surface is marked by a distinct costal groove.
5

true, false, and floating ribs

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  1. the upper seven ribs (I-VII) are true ribs, having costal cartilages that articulate directly with the sternum;
  2. the remaining five pairs of ribs (VIII-XII) are false ribs; their costal cartilages merge with those of the ribs above
  3. the lowest two pairs of ribs (XI and XII) are floating ribs, having no anterior connection with other ribs or with the sternum;
6

distinct features of the first rib

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  1. the superior surface of is characterized by the scalene tubercle, which separates two smooth grooves;
  2. the anterior groove houses the subclavian vein, and the posterior groove houses the subclavian artery
7

sternum

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  1. the manubrium is the broad superior component of the sternum; its superior surface bears a jugular notch in the midline, which lies between two clavicular notches, which articulate with the clavicles;
  2. the body of the sternum is flat; its anterior surface is marked by transverse ridges called sternebrae; the lateral margins of the body of the sternum have articular facets for costal cartilages;
  3. the xiphoid process is the smallest part of the sternum. Its shape is variable: it may be wide, thin, pointed, curved, or perforated. It begins as a cartilaginous structure, which becomes ossified in the adult.
8

sternal angle

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  1. the manubriosternal joint can be palpated easily; it angles posteriorly on the body of the sternum, forming the sternal angle;
  2. marks the site of articulation of rib II with the sternum; this used as a reference for counting ribs since rib I is impalpable due to obstruction from bone and tissues.
9

costotransverse joints

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  1. synovial joints between the tubercle of a rib and the transverse process of the related vertebra;
  2. stabilized by two strong extracapsular ligaments that span the space between the transverse process and the rib on the medial and lateral sides of the joint;
  3. the costotransverse ligament is medial to the joint and attaches the neck of the rib to the transverse process.
  4. the lateral costotransverse ligament is lateral to the joint and attaches the tip of the transverse process to the roughened nonarticular part of the tubercle of the rib.
10

intervertebral disc

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  1. a spinal shock absorber, lying between the layers of hyaline cartilage at the symphysis between adjacent vertebral bodies
  2. consists of an outer anulus fibrosus (collagen and fibrocartilage), which surrounds a central nucleus pulposus (gelatinous)
  3. protrusision of the nucleus pulposus through the anulus fibrosis is called a herniated disc, and cause put painful pressure on the spinal cord
11

longitudinal ligaments

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  1. two long ligaments attached along their length to the vertebral bodies and intervertebral discs that stabilize the spine
  2. The anterior longitudinal ligament is attached to the base of the skull and extends to the anterior surface of the sacrums;
  3. the posterior longitudinal ligament is on the posterior surface of the vertebral bodies and lines the anterior surface of the vertebral canal
12

thoracic apertures

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  1. the superior thoracic aperture is formed by the the body of vertebra TI, the medial margin of rib I, and the manubrium; it houses structures that pass between the neck and the thorax.
  2. the inferior thoracic aperture is defined by the body of vertebra TXII, rib XII and the distal end of rib XI, the distal cartilaginous ends of ribs VII to X, and the xiphoid process; it is closed by the diaphragm, which structures passing between the abdomen and thorax must pierce or pass posteriorly.
13

diaphragm

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  1. a thin musculotendinous structure that fills the inferior thoracic aperture and separates the thoracic cavity from the abdominal cavity;
  2. primarily functions in breathing; it depresses as it contracts, increasing thoracic volume and bringing air into the lungs; it elevates as it relaxes, decreasing thoracic volume and allowing air out of the lungs;
  3. arterial supply comes from the pericardiacophrenic, musculophrenic, superior phrenic arteries, intercostal arteries (above), and the inferior phrenic arteries (branch from the abdominal aorta below);
  4. venous drainage of the diaphragm is by veins that generally parallel the arteries; the veins drain into: the brachiocephalic veins, the azygos system, the left suprarenal vein, or the inferior vena cava;
  5. innervation of the whole diaphragm (including the crura) comes from the phrenic nerves.
14

openings of the diaphragm

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  1. the caval opening (T8) contains the inferior vena cava and branches of the right phrenic nerve;
  2. the esophageal hiatus (T10) contains the esophagus, and anterior and posterior vagal trunks;
  3. the aortic hiatus (T12) contains the aorta and the thoracic duct.
15

mediastinum

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  1. dissected by the transverse thoracic plane crossing horizontally through TIV/TV
  2. the superior mediastinum contains the superior vena cava (SVC), brachiocephalic veins, arch of the aorta, thoracic duct, trachea, esophagus, vagus nerve, left recurrent laryngeal nerve, phrenic nerve, and the thymus gland.
  3. the inferior mediastinum is further divided into anterior, posterior, and middle by the pericardial sac.
    1. anterior contains remnants of the thymus gland, lymph nodes, fat, and connective tissue;
    2. middle contains the heart, pericardium, phrenic nerves, roots of the great vessels, arch of the azygos vein, and main bronchi;
    3. posterior contains the esophagus, thoracic aorta, azygos and hemiazygos veins, thoracic duct, vagus
      nerves, sympathetic trunk, and splanchnic nerves.
16

pleural cavities

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  1. during development, the lungs grow out of the mediastinum, becoming surrounded by the pleural cavities; as a result, the outer surface of each organ is covered by pleura.
  2. parietal pleura is associated with the walls of the cavity.
  3. visceral pleura is associated with the surface of the lung.
17

pleural recesses

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  1. the potential space of the pleural cavities are not completely occupied by the lungs, resulting in recesses that are important for accommodating changes in lung volume during breathing;
  2. the costodiaphragmatic recesses are largest, lying inferiorly between the thoracic wall and diaphragm; they are deepest after expiration and shallowest after inspiration;
  3. a costomediastinal recess occurs on each side where costal pleura is opposed to mediastinal pleura; the largest is on the left side in the region overlying the heart.
18

major structures passing between the abdomen and thorax

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  1. the inferior vena cava and branches of the right phrenic nerve pass through the caval opening of the diaphram (T8)
  2. the esophagus, and anterior and posterior vagal trunks pass through esophageal hiatus of the diaphragm (T10)
  3. the aorta and the thoracic duct pass through the aortic hiatus of the diaphragm (T12)
19

breasts

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  1. a collection of specialized tissue overlying the pectoralis major muscle, consisting of mammary glands and associated skin and connective tissues;
  2. mammary glands are modified sweat glands that consist of consist of a series of ducts and secretory lobules;
  3. lactiferous ducts form from the convergence of 15-20 mammary glands
  4. each duct enlarges to form a lactiferous sinus, which serves as a reservoir for milk during lactation;
  5. each duct opens onto the nipple, which surrounded by a circular pigmented area of skin termed the areola.
  6. suspensory ligaments formed by condensed connective tissue help to support the breast;
  7. the retromammary space is formed by a layer of loose connective tissue, separating the breast from the underlying fascia and providing some degree of movement.
  8. the axillary tail may perforate deep fascia and extend as far superiorly as the apex of the axilla, which is important for clinicians to consider when examining the breast.
20

blood supply and lymphatic drainage of the breast

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  1. vascular supply can occur by multiple routes; laterally, vessels from the axillary artery; medially, branches from the internal thoracic artery; the second to fourth intercostal arteries.
  2. veins draining the breast parallel the arteries and ultimately drain into the axillary, internal thoracic, and intercostal veins.
  3. lymphatic drainage occurs mostly via vessels that drain laterally and superiorly into axillary nodes (to subclavian trunks); rest is into parasternal nodes (to bronchomediastinal trunk) deep to the anterior thoracic wall; some may drain into intercostal nodes (to thoracic duct or bronchomediastinal trunks).
21

breast cancer

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  1. one of the most common malignancies in women; develops in the cells of the acini, lactiferous ducts, and lobules; most frequently occurs in the upper lateral quadrant of the breast;
  2. tumor staging means defining the (a) size of primary tumor, (b) site of primary tumor, (c) number and sites of lymph node spread, (d) organs to which the tumor may have spread;
  3. lymphatic obstruction and tumor growth pull on connective tissue in the breast, resulting in the appearance of an orange peel texture (peau d'orange) on the surface of the breast;
22

significance of the transverse thoracic plane

  1. passes through the sternal angle;
  2. divides the mediastinum;
  3. is where the arch of the aorta begins and ends;
  4. is where the superior vena cava enters the heart;
  5. is the level at which the trachea bifurcates;
  6. marks the superior limit of the pulmonary trunk.
23

descending aorta

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  1. continues from the arch of the aorta, descending through the thoracic cavity giving off several branches;
  2. the pericardial branches are small vessels to the posterior surface of the pericardial sac;
  3. the bronchial branches are usually two left from the thoracic aorta and one right bronchial artery from the third posterior intercostal artery or the superior left bronchial artery;
  4. the esophageal branches are four or five vessels from the anterior aspect of the thoracic aorta, which form a continuous anastomotic chain;
  5. the mediastinal branches are several small branches supplying lymph nodes, vessels, nerves, and areolar tissue in the posterior mediastinum;
  6. the posterior intercostal arteries are usually, nine pairs of vessels branching from the posterior surface of the thoracic aorta supplying lower nine intercostal spaces;
  7. the superior phrenic arteries are small vessels from the lower part of the thoracic aorta supplying the posterior part of the superior surface of the diaphragm;
  8. the subcostal artery is the the lowest pair of branches from the thoracic aorta located inferior to rib XII.
24

brachiocephalic veins

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  1. formed on each side by the internal jugular and subclavian veins; the left side crosses the midline and joins with the right to form the superior vena cava;
  2. tributaries to the right brachiocephalic vein include the vertebral, first posterior intercostal, and internal thoracic veins; the inferior thyroid and thymic veins may also drain into it.
  3. tributaries to the left brachiocephalic vein include the vertebral, first posterior intercostal, left superior intercostal, inferior thyroid, and internal thoracic veins; it may also receive thymic and pericardial veins.
25

internal thoracic arteries

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  1. each arises as a major branch of the subclavian artery in the neck; descends vertically through the superior thoracic aperture and along the deep aspect of the anterior thoracic wall.
  2. branches into the superior epigastric artery, which continues inferiorly into the anterior abdominal wall; the musculophrenic artery, which passes along the costal margin, goes through the diaphragm, and ends near the last intercostal space.
26

posterior intercostal arteries

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  1. supplied by the superior intercostal artery (upper two) or the descending thoracic aorta (lower nine)
  2. have branches that supply various components of the thoracic wall; have branches that accompany lateral cutaneous branches of the intercostal nerves to superficial regions.
27

anterior intercostal arteries

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  1. arise directly from the internal thoracic artery (upper six) or musculophrenic artery (bottom three), a branch of the internal thoracic artery;
  2. usually have two branches in each each intercostal space; one passes below the margin of the upper rib; the other passes above the margin of the lower rib and meets a collateral branch of the posterior intercostal artery.
28

azygos vein

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  1. formed by the union of the ascending lumbar veins and right subcostal veins at around the level of T12-L2
  2. enters the thorax through the aortic hiatus of the diaphragm to join the superior vena cava
  3. tributaries include right superior intercostal vein, fifth to eleventh right posterior intercostal veins, the hemiazygos vein, the accessory hemiazygos vein, esophageal veins, mediastinal veins, pericardial veins, and right bronchial veins.
29

hemiazygos vein

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  1. arises at the junction between the left ascending lumbar vein and the left subcostal vein;
  2. enters the thorax through the left crus of the diaphragm (or aortic hiatus) to enter the azygos vein;
  3. tributaries include the lowest four or five left posterior intercostal veins, esophageal veins, and mediastinal veins.
30

accessory hemiazygos vein

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  1. descends on the left side of the mediastinum, then crosses the vertebral column to join the azygos vein, the hemiazygos vein, or both;
  2. usually also has a connection superiorly to the left superior intercostal vein;
  3. tributaries include the fourth to eighth left posterior intercostal veins and sometimes the left bronchial veins.
31

dermatomes

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  1. the area of skin supplied by a single spinal cord level, or on one side, by a single spinal nerve;
  2. highest dermatome on anterior chest is T2
  3. the dermatome of the nipple is T4
  4. the dermatome of the xiphoid process is T6
  5. the dermatome of the umbilicus is T10
  6. the dermatome of the pubic symphysis is L1
32

scapula

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  1. a large, flat triangular bone with a lateral angle marked by a shallow glenoid cavity, which articulates with the head of the humerus to form the glenohumeral joint;
  2. has large triangular-shaped roughening (the infraglenoid tubercle) inferior to the glenoid cavity (attachment for the long head of the triceps brachii) and a less distinct supraglenoid tubercle superior to the glenoid cavity (attachment for the long head of the biceps brachii muscle);
  3. a prominent spine subdivides the posterior surface of the scapula into a superior supraspinous fossa and an inferior infraspinous fossa;
  4. the acromion, arches over the glenohumeral joint and articulates with the clavicle;
  5. the greater scapular notch lies between the lateral angle of the scapula and the spine;
  6. the costal surface of the is unremarkable, being characterized by a shallow concave subscapular fossa over much of its extent;the costal surface, together with its related muscle (subscapularis), moves freely over the underlying thoracic wall;
  7. the superior border is marked on its lateral end by the coracoid process, a hook-like structure that pro­jects anterolaterally, and
    immediately medially, the suprascapular notch.
33

pectoralis major muscle

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  1. origin medial half of clavicle and anterior surface of sternum, first seven costal cartilages, aponeurosis of external oblique
  2. insertion lateral lip of intertubercular sulcus of humerus
  3. innervation medial and lateral pectoral nerves
  4. function adduction, medial rotation, and flexion of the humerus at the shoulder joint
34

pectoralis minor muscle

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  1. origin anterior surfaces of the third, fourth, and fifth ribs, and deep fascia overlying the related intercostal spaces
  2. insertion coracoid process of scapula
  3. innervation medial pectoral nerves
  4. function depress tip of shoulder; protract scapula
35

subclavius muscle

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  1. origin rib I at junction between rib and costal cartilage
  2. insertion groove of inferior surface of middle third of clavicle
  3. innervation nerve to subclavius
  4. function pull clavicle medially to stabilize sternoclavicular joint; depress tip of shoulder
36

cervical rib

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  1. an abnormal accessory rib articulating with vertebra CVII; the anterior end attaches to the superior border of the anterior aspect of rib I; occur in about 1% of the population
  2. the cervical band from a cervical rib is one cause of thoracic outlet syndrome by putting upward stresses on the lower parts of the brachial plexus as they pass over the cervical band and related cervical rib
37

external intercostal muscle

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  1. origin inferior margin of rib above
  2. insertion superior margin of rib below
  3. innervation intercostal nerves (T1–T11)
  4. function support intercostal space; move ribs superiorly (most active during inspiration)
38

internal intercostal muscle

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  1. origin at lateral edge of costal groove of rib above
  2. insertion superior margin of rib below deep to the attachment of the related external intercostal
  3. innervation intercostal nerves (T1–T11)
  4. function support intercostal space; moves ribs inferiorly most active during expiration
39

innermost intercostal muscle

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  1. origin medial edge of costal groove of rib above
  2. insertion internal aspect of superior margin of rib below
  3. innervation intercostal nerves (T1–T11)
  4. function with internal intercostal muscles
40

subcostales muscle

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  1. origin internal surface (near angle) of lower ribs
  2. insertion internal surface of second or third rib below
  3. innervation related intercostal nerves
  4. function to depress ribs
41

transversus thoracis

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  1. origin inferior margins and internal surfaces of costal cartilages of ribs II-VI
  2. insertion inferior aspect of deep surface of body of sternum, xiphoid process, and costal cartilages of ribs IV–VII
  3. innervation related intercostal nerves
  4. function depress costal cartilages
42

flail chest

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  1. produced when multiple ribs are fractured in multiple places, causing a free floating segment in the thoracic wall;
  2. during deep inspiration, the flail segment moves in the opposite direction to the chest wall, preventing full lung expansion and creating a paradoxically moving segment;
  3. if a large enough segment of chest wall is affected, ventilation may be impaired and assisted ventilation may be required until the ribs have healed.
43

pleural effusion

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  1. occurs when excess fluid accumulates within the pleural space, compromising the lung and possibles causing it to collapse;
  2. fluid often will be aspirated to determine the cause, which can include infection, malignancy, cardiac failure, hepatic disease, and pulmonary embolism;
  3. a large pleural effusion needs to be drained to allow the collapsed part of the lung to reexpand and improve breathing
44

pneumothorax

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  1. occurs when gas or air collects within the pleural cavity, causing the lung to collapse due to the tissue elasticity of the parenchyma, impairing the lung function.
  2. occasionally, the gas within the pleural cavity may accumulate to such an extent that the mediastinum is “pushed” to the opposite side, compromising the other lung. This is termed a tension pneumothorax and requires urgent treatment.
45

dextrocardia and situs inversus

  1. the normal aortic arch courses to the left of the trachea and passes over the left main bronchus;
  2. a right-sided arch of aorta is rare and may be asymptomatic. It can be associated with dextrocardia (right-sided heart);
  3. in some instances, it may be associated with complete situs inversus (left-to-right inversion of the body's organs).
46

cephalic vein

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  1. originates over anatomical snuffbox at the base of the thumb;
  2. crosses the elbow, then passes up the arm into the clavipectoral triangle;
  3. passes into the axilla by penetrating deep fascia just inferior to the clavicle joins the axillary vein;
  4. drains the lateral and posterior parts of the hand, the forearm, and the arm.
  5. at the elbow, the cephalic and basilic veins are connected by the median cubital vein
47

axillia

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  1. inferior margin of the anterior wall is the anterior axillary skin fold, which overlies the lower margin of the pectoralis major;
  2. inferior margin of the posterior wall is the posterior axillary skin fold, which overlies the teres major and latissimus dorsi;
  3. the floor is the dome of skin between the posterior and anterior axillary skin folds the axilla;
  4. the inlet is formed by the lateral margin of rib I, the superior margin of the scapula, and the posterior margin of the clavicle;
  5. Passing through the axilla are the major vessels, nerves, and lymphatics of the upper limb. The space also contains the proximal parts of two muscles of the arm, the axillary process of the breast, and collections of lymph nodes, which drain the upper limb, chest wall, and breast.
48

roots of brachial plexus

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  1. C5
    • gives off dorsal scapular nerve,
    • contribution to phrenic nerve, and
    • contribution to long thoracic nerve
  2. C6
    • gives off contribution to long thoracic nerve
  3. C7
    • gives off contribution to long thoracic nerve
  4. C8
  5. C9
49

trunks of the brachial plexus

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  1. superior (C5, C6)
    • gives off nerve to subclavius and
    • suprascapular nerve
  2. middle (C7)
  3. inferior (C8, T1)
50

divisions of the brachial plexus

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  1. the superior, middle, and inferior trunks all split into anterior and posterior divisions
  2. all the posterior divisions merge together to form the posterior cord
  3. the anterior divisions from middle and superior trunks merge to form the lateral cord
  4. the anterior division from the inferior trunks continues to become the medial cord
51

cords of the brachial plexus

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  1. lateral
    • gives off lateral pectoral nerve
  2. posterior
    • gives off the axillary nerve,
    • superior subscapular nerve,
    • thoracodorsal nerve, and
    • inferior subscapular nerve
  3. medial
    • gives off the medial pectoral nerve,
    • medial cutaneous nerve of arm,
    • medial cutaneous nerve of forearm,
52

terminal roots of the brachial plexus

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  1. musculocutaneous nerve (from lateral cord)
  2. median nerve (from lateral and medial cords)
  3. ulnar nerve (from medial cord)
  4. radial nerve (from posterior cord)
53

dorsal scapular nerve

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  1. origin C5 root
  2. spinal segments C5
  3. function motor (rhomboid major, rhomboid minor)
54

long thoracic nerve

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  1. origin C5, C6, C7 roots
  2. spinal segments C5, C6, C7
  3. function motor (serratus anterior)
55

suprascapular nerve

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  1. origin superior trunk
  2. spinal segments C5, C6
  3. function motor (supraspinatus, infraspinatus)
56

nerve to subclavius

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  1. origin superior trunk
  2. spinal segments C5, C6
  3. function motor (subclavius)
57

lateral pectoral nerve

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  1. origin lateral cord
  2. spinal segments C5, C6, C7
  3. function motor (pectoralis major)
58

musculocutaneous nerve

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  1. origin lateral cord
  2. spinal segments C5, C6, C7
  3. function motor (all muscles in anterior compartment of the arm, including the biceps brachii, brachialis, and coracobrachialis); sensory (skin on lateral side of forearm)
59

medial pectoral nerve

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  1. origin medial cord
  2. spinal segments C8, T1
  3. function motor (pectoralis major, pectoralis minor)
60

medial cutaneous of arm nerve

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  1. origin medial cord
  2. spinal segments C8, T1
  3. function sensory (skin on medial side of distal one-third of arm)
61

medial cutaneous of forearm nerve

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  1. origin medial cord
  2. spinal segments C8, T1
  3. function sensory (skin on medial side of forearm)
62

median nerve

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  1. origin medial cord
  2. spinal segments C6, C7, C8, T1
  3. function motor (all muscles in anterior compartment of forearm except flexor carpi ulnaris and medial half of flexor digitorum profundus, three thenar muscles of thumb and two lateral lumbrical muscles); sensory (skin over palmar surface of lateral three and one-half digits and over lateral side of palm and middle of wrist)
63

ulnar nerve

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  1. origin medial cord
  2. spinal segments C8, T1
  3. function motor (all intrinsic muscles of hand except three thenar muscles and two lateral lumbricals; flexor carpi ulnaris and medial half of flexor digitorum profundus in forearm); sensory (skin over palmar surface of medial one and one-half digits and associated palm and wrist, and skin over dorsal surface of medial one and one-half digits)
64

superior subscapular nerve

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  1. origin posterior cord
  2. spinal segments C5, C6
  3. function motor (subscapularis)
65

thoracodorsal nerve

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  1. origin posterior cord
  2. spinal segments C6, C7, C8
  3. function m otor (latissimus dorsi)
66

inferior subscapular nerve

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  1. origin posterior cord
  2. spinal segments C5, C6
  3. function motor (subscapularis, teres major)
67

axillary nerve

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  1. origin posterior cord
  2. spinal segments C5, C6
  3. function motor (deltoid, teres minor); sensory (skin over upper lateral part of arm)
68

radial nerve

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  1. origin posterior cord
  2. spinal segments C5, C6, C7, C8
  3. function motor (all muscles in posterior compartments of arm and forearm); sensory (skin on posterior aspects of arm and forearm, lower lateral surface of arm, and dorsal lateral surface of hand)
69

gynecomastia

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  1. the normal breast in men is rudimentary and consists only of small ducts, often composed of cords of cells, that normally do not extend beyond the areola; breast cancer can occur in men.
  2. gynecomastia is an enlargement or swelling of breast tissue in males. It is most commonly caused by male estrogen levels that are too high or are out of balance with testosterone levels.
70

winged scapula

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  1. injury to the long thoracic nerve is commonly caused by a stab wound or during radical mastectomy or thoracic surgery;
  2. it results in paralysis of the serratus anterior muscle and inability to elevate the arm above the horizontal;
  3. this produces a winged scapula in which the vertebral (medial) border of the scapula protrudes away from the thorax.
71

thoracostomy

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  1. a small incision of the chest wall, allowing for the insertion of a tube, usually with direct ultrasound guidance;
  2. indicated for air or fluid trapped in the thorax between the lung and the chest wall (pleural cavity);
  3. done for pneumothorax, hemothorax, hemopneumothorax, malignant pleural effusion empyema, hydrothorax, and after thoracic surgery;
  4. tube position is usually between the anterior axillary and midaxillary anatomical lines in the fourth or fifth intercostal space.
72

median sternotomy

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  1. involves making a vertical incision in the sternum from just below the sternal notch to the distal end of the xiphoid process.
  2. allows access to the heart, pericardium, great vessels, anterior mediastinum, thymus, and lower trachea; if the incision is extended laterally it gives access to the subclavian and carotid arteries; also used for removal of retrosternal goiter or during esophagectomy;
  3. injury to vessels can occur without proper precautions, in particular to the brachiocephalic veins;
  4. bleeding from the branches of the internal thoracic artery can occur and needs to be controlled;bone fractures may occur due to the traction that is applied to the upper ribs when the sternum is opened;
  5. a partial sternotomy can also be performed, with the incision involving only the upper part of the sternum.
73

innervations of intercostal nerves

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  1. the thoracic wall;
  2. the brachial plexus (anterior ramus of T1);
  3. cutaneous innervation of the upper medial arm (lateral cutaneous branch of the second intercostal nerve);
  4. muscles, skin, and peritoneum of the abdominal wall (lower intercostal nerves)
74

slipping rib syndrome

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  1. slipping rib syndrome is an infrequent cause of thoracic and upper abdominal intermittent pain;
  2. thought to arise from hypermobility of the rib cartilage of the false and floating ribs;
  3. may cause a disruption and allows the costal cartilage tips to subluxate and irritate the intercostal nerves.
75

rib separation

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  1. ribs attach to the sternum at the costochondral joints, which are made of cartilage; rib separation occurs when the rib separates at this joint;
  2. also known as a costochondral separation; this is most commonly caused by blunt force trauma to the chest.
76

sternal bone marrow study

  1. the subcutaneous position of the sternum makes it possible to place a needle through the hard outer cortex into the medullary cavity containing bone marrow;
  2. once the needle is in this position, bone marrow can be aspirated; evaluation of this material under the microscope helps clinicians diagnose certain blood diseases such as leukemia.
77

thoracic outlet syndrome

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  1. a condition involving compression of neurovascular structures such as brachial plexus and subclavian vessels in the thoracic outlet (between the clavicle and the first rib);
  2. caused by abnormal insertion or spasm of the anterior and middle scalene muscles, a cervical rib articulating with CVII and attaching to rib I, a fractured clavicle, or physical trauma and repetitive strain injury;
  3. symptoms include pain, numbness, tingling, and weakness in the upper limb; treatment involves physical measures, medications, and surgery.
78

intercostal nerve block

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  1. local anesthesia of intercostal nerves (intercostal nerve block) produces analgesia in patients with chest trauma and patients requiring anesthesia for a thoracotomy, mastectomy, or upper abdominal surgical procedures;
  2. under ultrasound guidance, a needle is advanced into the subcostal groove, followed by an injection with a local anesthetic; depending on the type of anesthetic used, analgesia may be short- or long-acting;
  3. complications may include puncture of the parietal pleura and an ensuing pneumothorax; bleeding may also occur if the artery or vein is damaged during the procedure.
79

injuries to the brachial plexu

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  1. require extensive clinical examination; assessment of individual nerve functions can be obtained by nerve conduction studies and electromyography, which measure the latency of muscle contraction when the nerve is artificially stimulated;
  2. usually the result of blunt trauma producing nerve avulsions and disruption; devastating for the function of the upper limb and require months of rehabilitation for even a small amount of function to return;
  3. direct pulling injuries tend to affect the roots of the brachial plexus; severe trauma to the first rib usually affects the trunks; glenohumeral joint dislocation tends to affect the divisions and cords.
80

Erb-Duchenne paralysis

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  1. upper brachial trunk injury (C5, C6) caused by a birth injury during a breech delivery or a violent displacement of the head from the shoulder such as might result from a fall from a motorcycle or horse;
  2. results in a loss of abduction, flexion, and lateral rotation of the arm, producing a waiter’s tip hand
81

Klumpke paralysis

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  1. lower brachial trunk injury (C8, T1) caused during breech delivery (birth palsy or obstetric paralysis), a cervical rib (cervical rib syndrome), or by abnormal insertion or spasm of the anterior and middle scalene muscles (scalene syndrome);
  2. causes supination of the the forearm is supinated and flexsion of the wrist and fingers, producing a claw hand
82

Saturday night palsy

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  1. a form of radial neuropathy caused by hanging the arm over the armrest of a chair for a prolonged period (as if one were intoxicated);
  2. compresses of the radial nerve and causes wrist drop, numbness (back of the hand and wrist), and inability to voluntarily straighten the fingers.
83

phrenic nerve palsy

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  1. the diaphragm is not flat; rather, it “balloons” superiorly on both sides, forming left and right hemidiaphragms
  2. in cases of phrenic nerve palsy, diaphragmatic paralysis ensues, which is manifested by the elevation of the affected hemidiaphragm.
84

diaphragmatic paradox

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  1. the diaphragm normally moves downwards during inspiration and upwards during expiration;
  2. in diaphragmatic paradox, it moves upwards during inspiration and downwards during expiration;
  3. caused by weakening of inspiratory muscles, pyopneumothorax (pus and air inside pleural cavity), hydropneumothorax (watery fluid and air inside pleural cavity), and in newborns with spinal muscular atrophy.
85

lungs

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  1. organs of respiration and lie on either side of the mediastinum surrounded by the right and left pleural cavitie
  2. the convex base rests on the diaphragm; a pointed apex extends into neck; the root is a collection of tubular structures that passes through the hilum to connect to the medianstinum;
  3. the pulmonary trunk from the right ventricle branches into left and right pulmonary arteries, which carry deoxygenated blood to the lungs; superior and inferior pulmonary veins from each lung carry oxygenated blood to the left ventricle
  4. bronchial arteries (one right, two left) arise from thoracic aorta and supply oxygenated blood to non-respiratory pulmonary tissues; bronchial veins run parallel to arteries, and empty into (a) the pulmonary veins or left atrium or (b) the azygos vein on the right or superior intercostal vein or hemiazygos vein on the left;
  5. receive visceral afferent and efferent nerves originating from the sympathetic trunks and vagus nerve, which branch into an anterior plexus (in front of root) and a posterior plexus (behind the root); nerves from the vagus constrict the bronchioles; those from the sympathetic trunks dilate them.
86

pleura

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  1. pleural cavity is lined mesothelium and an associated layer of supporting connective tissue; together, they form the pleura
  2. visceral pleura is associated with the surface of the lung;
  3. parietal pleura is associated with the surface of the lung and is divided into four parts; the costal part, the diaphragmatic part, the mediastinal part, and the cervical part (dome of pleura or pleural cupola).
87

comparison of right and left lungs

the right lung:

  1. three lobes (upper, middle, lower);
  2. two fissures (horizontal and oblique);
  3. three lobar bronchi and ten segmental bronchi;
  4. larger and heavier, shorter and wider (higher right dome of the diaphragm and inclination of the heart to the left).

the left lung:

  1. two lobes (upper, lower);
  2. one fissure (oblique);
  3. has two lobar bronchi and eight to ten segmental bronchi;
  4. has a cardiac notch (a deep indentation of the anterior border of the superior lobe of the left lung).
88

trachea

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  1. a flexible tube that conducts air to the lungs extending from vertebral level C6 down to level T4 or T5;
  2. within the mediastinum, it bifurcates into the right and left main bronchi which carry air to the lungs;
  3. held open by posterior-facing, C-shaped transverse cartilage rings in its wall; has a smooth muscle posterior wall.
89

bronchi

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  1. passageways that conduct air from the trachea to the lungs
  2. main (primary) bronchi branch from the trachea; the right is wider and more vertical than the left, which is why inhaled foreign bodies tend to lodge on the right side more;
  3. lobar (secondary) bronchi branch from the main bronchi, each supplying a lobe; three on the right, two on the left
  4. segmental (tertiary) bronchi branch from the lobar bronchi to supply each bronchopulmonary segment; 10 on the right, 8 to 10 on the left
90

bronchopulmonary segments

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  1. the area of lung supplied by a segmental bronchus and its accompanying pulmonary artery branch;
  2. tributaries of pulmonary vein pass intersegmentally between margins of segments;
  3. there are ten in each lung; some of them fuse in the left lung; each is shaped like an irregular cone
  4. represent the smallest functionally independent region of a lung and the smallest area of lung that can be isolated and removed without affecting adjacent regions;
91

pericardium

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  1. a fibroserous sac surrounding the heart and the roots of the great vessels; consists of fibrous and serous pericardium;
  2. fibrous pericardium is a tough connective tissue outer layer that defines the boundaries of the middle mediastinum
  3. serous pericardium is thin and consists of two layers;
    1. the parietal layer lines the inner surface of the fibrous pericardium
    2. the visceral layer adheres to the heart and forms its outer covering
  4. arterial supply comes from branches from the internal thoracic, pericardiacophrenic, musculophrenic, and inferior phrenic arteries, and the thoracic aorta.
  5. venous drainage enters the azygos system of veins and the internal thoracic and superior phrenic veins
  6. nerves arise from the vagus nerve [X], the sympathetic trunks, and the phrenic nerves
  7. somatic sensation is carried by somatic afferent fibers in the phrenic nerves; “pain” related to a pericardial problem may be referred to the supraclavicular region of the shoulder or lateral neck area.
92

fibrous pericardium

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  1. a cone-shaped bag with its base on the diaphragm and its apex continuous with the adventitia of the great vessels
  2. attached at its base to the central tendon of the diaphragm and to a small muscular area of the diaphragm on the left side
  3. attached anteriorly to the posterior surface of the sternum by sternopericardial ligaments; help to retain the heart in its position in the thoracic cavity
93

serous pericardium

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  1. a double layered covering of the heart; the parietal layer lines the inner surface of the fibrous pericardium; the visceral layer adheres to the heart
  2. the parietal layer is continuous with the visceral layer around the roots of the great vessels, forming two reflections
  3. the oblique pericardial sinus is the U-shaped reflection surrounding the pulmonary veins
  4. the transverse pericardial sinus is the reflection separating the arteries and veins
94

pericardial effusion

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  1. only a tiny amount of fluid is normally present between the visceral and parietal layers of the serous pericardium;
  2. in pericardial effusion, excess fluid builds up, and restricts ventricular filling, causing biventricular failure (cardiac tamponade);
  3. to relive symptoms, a needle is inserted into the pericardial sac in order to remove fluid and reduce pressure.
95

constrictive pericarditis

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  1. abnormal thickening of the pericardial sac; usually only involving parietal pericardium, but can also involve visceral;
  2. in normal individuals, the jugular venous pulse drops on inspiration; in patients with constrictive pericarditis, the reverse happens (Kussmaul's sign);
  3. compresses the heart, restricts diastolic filling, impairs heart function and results in heart failure; treatment often involves surgical opening of the pericardial sac
96

surfaces of the heart

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  1. the base is the posterior surface of the heart containing the left atrium, a portion of the right atrium, and the proximal parts of the great veins (SVC, IVC, and the pulmonary veins)
  2. the apex of the heart is formed by the inferolateral part of the left ventricle
  3. the anterior surface consists mostly of the right ventricle, with some of the right atrium and left ventricle;
  4. the diaphragmatic surface consists of the left ventricle and a small portion of the right ventricle separated by the posterior interventricular groove
  5. the left pulmonary surface consists of the left ventricle and a portion of the left atrium
  6. the right pulmonary surface faces the right lung, is broad and convex, and consists of the right atrium
97

atrial septal defect

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  1. defects in the interatrial septum allow blood to pass between heart chambers from higher pressure to lower pressure; this is clinically referred to as a shunt;
  2. atrial septal defects (ASD) allows oxygenated blood to flow from the left atrium into the right atrium, resulting in volume overload in the right-sided circulation;
  3. many patients with ASD are asymptomatic, but in some cases the ASD may cause symptoms and needs to be closed surgically or by endovascular devices
  4. increased blood flow to the right atrium leads to right atrial and right ventricular hypertrophy and pulmonary trunk enlargement, resulting in pulmonary arterial hypertension
98
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fossa ovalis

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  1. a depression visible in the septum just above the orifice of the inferior vena cava
  2. marks the location of the embryonic foramen ovale, which is an important part of fetal circulation
99

ductus arteriosus

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  1. in the superior mediastinum; important in embryonic circulation, when it is a blood vessel (the ductus arteriosus);
  2. during development it connects the pulmonary trunk to the arch of the aorta, allowing blood to bypass the lungs, which are not yet functional;
  3. closes soon after birth and forms the ligamentous connection observed in the adult.
100

trabeculae carneae

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  1. numerous muscular, irregular structures found on the walls of the inflow portion of the right ventricle
  2. some trabeculae carneae (papillary muscles) have only one end attached to the ventricular surface; the other end attaches to tendon-like cords (chordae tendineae), which connect to the cusps of the tricuspid valve.
  3. contraction of the papillary muscles attached to the cusps by chordae tendineae prevents evertion into the right atrium
101

ventriculoseptal defect

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  1. most common of congenital heart defects are those that occur in the ventricular septum, ventriculoseptal defects (VSD);
  2. lesions are most frequent in the membranous portion of the septum and they allow blood to flow from the left ventricle (higher pressure) to the right ventricle (lower pressure), which is referred to as a shunt.
  3. leads to right ventricular hypertrophy, increased pulmonary blood flow, elevated arterial pulmonary pressure, and increased blood volume returning to the left ventricle, causing its dilation;
  4. increased pulmonary pressure in most severe cases may cause pulmonary edema; if large and left untreated, VSDs can produce marked clinical problems that might require surgery.
102

heart valves

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  1. heart valves are cusped closures that separate the heart chambers and prevent backflow during systolic phases
  2. atrioventricular valves (AV) separate atria from ventricles and are associated with chordae tendineae
  3. the tricusped (right AV) valve has three cusps and separates the right atrium and ventricle
  4. the mitral (left AV) valve has two cusps and separates the left atrium and ventricle
  5. semilunar valves separate ventricles from great vessels and are associated with nodules
  6. the pulmonary valve has three cusps and separates the right ventricle from the pulmonary arteries
  7. the aortic valve has three cusps and separates the left ventricle from the aorta
103

cardiac conduction system

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  1. impulses begin at the sinu-atrial node (the cardiac pacemaker), located near the superior vena cava; excitation signals spread across the atria, causing the muscle to contract
  2. the wave of excitation in the atria stimulates the atrioventricular node, located within the atrioventricular septum near the tricusped valve.
  3. the atrioventricular bundle (Bundle of His) is a direct continuation of the atrioventricular node, following along the interventricular septum before splitting into right and left bundles;
  4. the right bundle branch continues on the right side of the interventricular septum toward the apex of the right ventricle;
  5. the left bundle branch passes to the left side of the muscular interventricular septum towards the apex of the left ventricle;
  6. both bundle branches split off into Purkinje fibers; this network of specialized cells spreads through the ventricles to supply the musculature, including the papillary muscles
104

root of a lung

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  1. a pulmonary artery,
  2. two pulmonary veins,
  3. a main bronchus,
  4. bronchial vessels,
  5. nerves, and
  6. lymphatics
105

pulmonary ligament

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  1. a thin blade-like fold of pleura projects inferiorly from the root of the lung and extends from the hilum to the mediastinum;
  2. stabilizes the position of the inferior lobe and accommodates the down-and-up translocation of structures in the root during breathing.
106
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107

esophageal plexus

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  1. as the the right and left vagus nerves approach the esophagus, each divides into several branches that spread over this structure, forming the esophageal plexus;
  2. the anterior vagal trunk is on the anterior surface of the esophagus, mainly from fibers originally in the left vagus nerve;
  3. the posterior vagal trunk is on the posterior surface of the esophagus, mainly from fibers originally in the right vagus nerve;
  4. the vagal trunks continue on the surface of the esophagus as it passes through the diaphragm into the abdomen
108

splanchnic nerves

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  1. greater splanchnic nerve arises from T5-T9 or T10 thoracic ganglia travel to the celiac ganglion;
  2. lesser splanchnic nerve arises from T9-T10 or T11 thoracic ganglia travel to aorticorenal ganglion;
  3. least splanchnic nerve is absent in 40% of individuals, when present, arises from T12 thoracic ganglion and travels to the renal plexus.
109

spinal cord length

  1. in adults, it extends from the foramen magnum to the disc between vertebrae LI/LII
  2. in neonates, it extends to LIII but can reach as low as vertebra LIV
110

meninges

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  1. three connective tissue coverings that surround the brain and spinal cord within the cranial cavity and vertebral canal
  2. the pia mater is the innermost meningeal layer; it enmeshes blood vessels on the surfaces of the brain and spinal cord;
  3. the arachnoid mater is a flimsy, weblike layer connected to the pia mater by trabeculations;
  4. the dura mater is a tough, fibrous, outermost layer that provides protection to the brain and spinal cord;
  5. the subarachnoid space between the arachnoid layer and the pia mater that is filled with cerebrospinal fluid (CSF)
  6. the subdural space is a potential space between the arachnoid and the dura that contains fluid
  7. the epidural space is a potential space external to the dura that contains the internal vertebral venous plexus and fat.
111

thoracic duct

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  1. begins as a confluence of lymph trunks in the abdomen, forming a dilated sac (the cisterna chyli) which drains the abdominal viscera and walls, pelvis, perineum, and lower limbs;
  2. the principal channel through which lymph from most of the body is returned to the venous system; empties into the junction of the left subclavian and left internal jugular veins.
112

crura of the diaphragm

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  1. tendinous structures that extend below the diaphragm to the upper lumbar vertebrae
  2. together, the right crus and left crus form a tether for muscular contraction of the diaphragm
  3. phrenic nerves supply motor innervation to the entire diaphragm, including the crura
113

coronary sinus

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  1. lies in the coronary sulcus, which separates the atria from the ventricles; opens into the right atrium, medially to the opening of the inferior vena cava
  2. the largest vein draining the heart; receives the great, middle, and small cardiac veins; the oblique vein of the left atrium; and the posterior vein of the left ventricle
114

different names for coronary vessels

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  1. the left coronary artery is also called the left main stem vessel
  2. the anterior interventricular artery is also called the left anterior descending artery (LAD).
  3. the posterior interventricular artery is also called the posterior descending artery (PDA).
115

recurrent laryngeal nerves

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  1. branch from the vagus nerve [X]; loop around the subclavian artery (right) and the arch of the aorta (left), then ascend between the trachea and esophagus and enter the larynx
  2. pass through ligaments that bind the thyroid gland to the trachea and the cricoid cartilage of the larynx; this must be considered when surgically operating on the thyroid gland
116

disc herniation

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  1. the intervertebral discs consist of a central mucoid substance (nucleus pulposus) surrounded by a fibrocartilaginous lamina (annulus fibrosus), which act as shock absorbers for the spine;
  2. a herniated (slipped) disc is a protrusion of the nucleus pulposus through the annulus fibrosus into the intervertebral foramen or vertebral canal, causing compression of the spinal nerve roots
  3. commonly occurs posterolaterally where the annulus fibrosus is not reinforced by the posterior longitudinal ligament and frequently affects the lumbar region
117

zygapophysial joints

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  1. a set of synovial, plane joints between the articular processes of two adjacent vertebrae
  2. there are two joints in each spinal motion segment and each is innervated by the recurrent meningeal nerves
  3. each pair of joints guide and limit movement of the spinal motion segment
118

rhomboid major muscle

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  1. spinous processes of TII to TV
  2. medial border of scapula between spine and inferior angle
  3. dorsal scapular nerve (C4, C5)
  4. retract (adduct) and elevate the scapula
119

rhomboid minor muscle

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  1. lower ligamentum nuchae, spinous processes of CVII and TI
  2. medial border of scapula at spine of scapula
  3. dorsal scapular nerve (C4, C5)
  4. retract (adduct) and elevate scapula
120

levator scapulae muscle

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  1. transverse processes of CI to CIV
  2. upper portion medial border of scapula
  3. C3 to C4 and dorsal scapular nerve (C4, C5)
  4. elevate scapula
121

latissimus dorsi muscle

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  1. spinous processes of TVII to LV and sacrum, iliac crest, ribs X to XII
  2. floor of intertubercular sulcus of humerus
  3. thoracodorsal nerve (C6 to C8)
  4. extend, adduct, and medially rotate the humerus
122

brachialis muscle

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  1. anterior of humerus (medial and lateral surfaces) and adjacent intermuscular septae
  2. tuberosity of the ulna
  3. musculocutaneous nerve (C5, C6); contribution by radial nerve (C7) to lateral part
  4. flexes the forearm at the elbow joint
123

coracobrachialis muscle

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  1. apex of coracoid process of the scapula
  2. linear roughening on midshaft of humerus on medial side
  3. musculocutaneous nerve (C5, C6, C7)
  4. flexes the arm at the glenohumeral joint
124

teres major muscle

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  1. posterior surface of the inferior angle of the scapula
  2. medial lip of the intertubercular sulcus on anterior humerus
  3. inferior subscapular nerve (C5, C6, C7)
  4. medially rotates and extends the arm at the glenohumeral joint; stabilization of glenohumeral joint
125

teres minor muscle

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  1. posterior surface of the scapula immediately adjacent to the lateral border of the scapula
  2. inferior facet on the posterior surface of the greater tubercle of the humerus
  3. axillary nerve (C5, C6)
  4. laterally rotates the arm at the glenohumeral joint; stabilization of glenohumeral joint (rotator cuff muscle)
126

fibrous joints

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  1. a type of joint that is joined by fibrous tissue, has no joint cavities, and permits little movement.
  2. sutures occur only in the skull where adjacent bones are linked by a thin layer of connective tissue termed a sutural ligament
  3. gomphoses occur only between the teeth and bone; short collagen tissue fibers in the periodontal ligament run between the root of the tooth and the bony socket
  4. syndesmoses are joints in which two adjacent bones are linked by a ligament (e.g. the interosseous membrane, which links, for example, the radius and ulna in the forearm)
127

cartilaginous joints

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  1. a type of joint that is united by cartilage, has no joint cavity, and permits little movement.
  2. synchondroses occur where two ossification centers in a developing bone remain separated by a layer of cartilage (e.g. the growth plate that occurs between the head and shaft of developing long bones)
  3. symphyses occur where two separate bones are interconnected by cartilage (e.g. the pubic symphysis between the two pelvic bones, intervertebral discs between vertebrae)
128

synovial joints

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  1. joints in which skeletal components are separated by a narrow articular cavity, have layer of cartilage (usually hyaline) covering the articulating surfaces, and are surrounded by a joint capsule consisting of an inner synovial membrane and an outer fibrous membrane
  2. pivot joints allow movement around one axis that passes longitudinally along the shaft of the bone; permit rotation (e.g. atlanto-axial joint)
  3. ball and socket joints allow movement around multiple axes; permit flexion, extension, abduction, adduction, circumduction, and rotation (e.g. hip joint)
129

shoulder dislocation

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  1. glenohumeral joint is extremely mobile, providing a wide range of movement at the expense of stability; once the joint capsule and cartilage are disrupted, the joint is susceptible to further recurrent dislocations.
  2. anterior dislocation occurs most frequently due to a lack of ligamentous support and dynamic stabilization; it is usually associated with an isolated traumatic incident;
  3. posterior dislocation is rare; when seen, it commonly involves vigorous muscle contractions, which may be associated with an epileptic seizure caused by electrocution;
130

axillary vein

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  1. begins at lower margin of the teres major muscle; continuation of the basilic vein;
  2. passes through axilla medial and anterior to axillary artery and becomes the subclavian vein;
  3. tributaries generally follow the branches of the axillary artery; other tributaries include brachial veins that follow the brachial artery and the cephalic vein.
131

subclavian vein

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  1. continuation of the axillary vein, beginning at the lateral margin of rib I
  2. crosses the base of the posterior triangle; joined by the external jugular, suprascapular, and transverse cervical veins
  3. ends by joining with the internal jugular vein to form the brachiocephalic vein near the sternoclavicular joint
132

cephalic vein

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  1. originates over the anatomical snuffbox at the base of the thumb; passes laterally around the distal forearm to reach the anterolateral surface of the limb, and then continues proximally;
  2. crosses the elbow, then passes up the arm into a triangular depression (clavipectoral triangle), then joins the axillary vein;
  3. connects to the basilic vein at the elbow by the median cubital vein, which crosses the roof of the cubital fossa
133

basilic vein

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  1. originates from the medial side of the dorsal venous network of the hand
  2. passes on the posteromedial surface of the proximal forearm, crossing onto the anterior surface just below the elbow; continues to penetrate deep fascia about midway up the arm;
  3. ends at lower margin of the teres major muscle where it becomes the axillary vein;
  4. connects to the cephalic vein at the elbow by the median cubital vein, which crosses the roof of the cubital fossa
134

median cubital vein

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  1. crosses the roof of the cubital fossa at the elbow;
  2. connects to the cephalic vein to the basilic vein;
  3. commonly used for venipuncture and blood transfusion.
135

deltoid muscle

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  1. inferior edge of the spine of the scapula, lateral margin of the acromion, anterior border of lateral clavicle
  2. deltoid tuberosity of humerus
  3. axillary nerve (C5, C6)
  4. abducts arm; flexes arm (clavicular fibers); extends arm (posterior fibers)
136

supraspinatus muscle

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  1. medial supraspinous fossa of the scapula and the deep fascia that covers the muscle
  2. superior facet on the greater tubercle of the humerus
  3. suprascapular nerve (C5, C6)
  4. laterally rotates arm at the glenohumeral joint; stabilization of glenohumeral joint (rotator cuff muscle)
137

infraspinatus muscle

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  1. medial infraspinous fossa of the scapula and the deep fascia that covers the muscle
  2. middle facet of posterior greater tubercle of the humerus
  3. suprascapular nerve (C5, C6)
  4. laterally rotates arm at the glenohumeral joint; stabilization of glenohumeral joint (rotator cuff muscle)
138

biceps brachii muscle

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  1. supraglenoid tubercle of scapula (long head) and apex of coracoid process (short head)
  2. radial tuberosity
  3. musculocutaneous nerve (C5, C6)
  4. flexes of the forearm at the elbow joint, supinate the forearm; accessory flexor of the arm at the glenohumeral joint
139

triceps brachii muscle

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  1. infraglenoid tubercle of scapula (long head); posterior surface of humerus (medial head); posterior surface of humerus (lateral head)
  2. olecranon of the elbow
  3. radial nerve (C6, C7, C8)
  4. extends the forearm at the elbow joint; can also extend and adduct the arm at the shoulder joint (long head)
140

trapezius muscle

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  1. superior nuchal line, external occipital protuberance, ligamentum nuchae, spinous processes of CVII to TXII
  2. lateral one third of clavicle, acromion, spine of scapula
  3. accessory nerve [XI] (motor); C3 and C4 (proprioception)
  4. rotates scapula during abduction of humerus above horizontal; upper fibers elevate, middle fibers adduct, and lower fibers depress scapula
141

supinator muscle

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  1. lateral epicondyle of humerus, radial collateral and anular ligaments (superficial layer); supinator crest of the ulna (deep layer)
  2. lateral surface of radius superior to the anterior oblique line
  3. posterior interosseous nerve (C6, C7)
  4. supinates the forearm
142

rotator cuff muscles

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  1. subscapularis,
  2. supraspinatus,
  3. infraspinatus, and
  4. teres minor
143

frozen shoulder syndrome

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  1. common disorder that causes pain, stiffness, and loss of normal range of motion in the shoulder;
  2. usually begins with injury or soft tissue inflammation, typically due to overuse injuries such as bursitis or tendinitis of the rotator cuff;
144

carpal tunnel

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  1. a passageway formed anteriorly at the wrist by a deep arch formed by the carpal bones and the flexor retinaculum
  2. forms a passage for four tendons of the flexor digitorum profundus, the four tendons of the flexor digitorum superficialis, and the tendon of the flexor pollicis longus, and the median nerve
145

carpal tunnel syndrome

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  1. an entrapment syndrome caused by pressure on the median nerve within the carpal tunnel; may be caused by overuse, swelling of the tendons and tendon sheaths (e.g., rheumatoid arthritis), and cysts arising from the carpal joints
  2. causes pain and pins-and-needles sensations in the distribution of the median nerve; weakness and loss of muscle bulk of the the arm muscles may also occur; treatment is aimed at reducing the inflammation and removing any repetitive insults that produce the symptoms.
146

anatomical snuffbox

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  1. a triangular depression formed on the posterolateral side of the wrist and metacarpal I by tendons passing into the thumb;
  2. lateral border is formed by the tendons of the abductor pollicis longus and extensor pollicis brevis;
  3. medial border is formed by the tendon of the extensor pollicis longus;
  4. floor of the impression is formed by the scaphoid and trapezium, and the distal ends of the tendons of the extensor carpi radialis longus and extensor carpi radialis brevis.
  5. the radial artery passes though the anatomical snuffbox; parts of the superficial branch of the radial nerve and the origin of the cephalic vein pass subcutaneously over it.
147
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148

dermatomes of the hand

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  1. the median nerve innervates the palmar surface of the first three and one-half digits (thumb, index, middle, ring) and the tips of the same digits.
  2. the ulnar nerve innervates the palmar and dorsal sufaces of the last one and one-half digits (pinky, ring)
  3. the radial nerve innervates the dorsal surface of the first three and one-half digits, except the tips
149

cubital fossa

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  1. an important area of transition between the arm and the forearm; located anterior to the elbow joint and is a triangular depression formed between two forearm muscles;
  2. base of the triangle is an imaginary horizontal line between the medial and lateral epicondyles; the bed or floor of the fossa is formed mainly by the brachialis muscle;
  3. major contents of the cubital fossa, from lateral to medial, are (a) the tendon of the biceps brachii muscle, (b) the brachial artery, and (c) the median nerve
150

nerve lesions due to humerus fracture

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  1. fracture at the surgical neck would affect the axillary nerve
  2. fracture at the shaft would affect the radial nerve (wrist drop)
  3. fracture at the medial epicondyle would affect the ulnar nerve (claw hand)
  4. fracture at the supracondylar region would affect the median nerve
151

brachial artery

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  1. begins as a continuation of the axillary artery at the lower border of the teres major muscle;
  2. medial in the proximal arm, lateral in distal arm, then crosses anterior to the elbow joint,
  3. branches of the brachial artery in the arm include those to adjacent muscles and two ulnar collateral vessels, the profunda brachii artery and arteries to the humerus;
  4. terminates just distal to the elbow joint where it divides into the radial and ulnar arteries
152

radial artery

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  1. originates from the brachial artery at the neck of the radius and passes along the lateral aspect of the forearm;
  2. radial pulse can be felt by gently palpating the radial artery against the underlying muscle and bone;
  3. branches in the hand to provide the major blood supply to the thumb and lateral side of the index finger.
153

ulnar artery

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  1. originates from the brachial artery at the neck of the radius and passes along the medial aspect of the forearm;
  2. although larger than the radial artery, often remains tucked under the flexor carpi ulnaris tendon, and is not easily palpable;
  3. branches in the hand to provide the major blood supply the medial three and one-half digits.
154

coronary arteries

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  1. the right coronary artery originates from the right aortic sinus of the ascending aorta, enters the coronary sulcus and travels towards base of the heart, branching into:
  2. the atrial branch passes in the groove between the right auricle and ascending aorta, gives off the sinu-atrial nodal branch to supply the sinu-atrial node;
  3. the right marginal artery is given off at the inferior margin of the heart and continues along this border toward the apex of the heart;
  4. the posterior interventricular branch lies in the posterior interventricular sulcus and is given off at the base of the heart just after a small branch to the atrioventricular node.
  5. the left coronary artery originates from the left aortic sinus of the ascending aorta, enters the coronary sulcus and emerges behind the pulmonary trunk, dividing into:
  6. the anterior interventricular branch descends obliquely toward the apex of the heart in the anterior interventricular sulcus
  7. the circumflex branch, which courses toward the left in the coronary sulcus, ends before reaching the posterior interventricular sulcus;
  8. a large branch, the left marginal artery, usually arises from it and continues across the rounded obtuse margin of the heart.
155

coronary veins

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  1. the great cardiac vein (anterior interventricular vein) begins at the apex of the heart ascends through the anterior interventricular sulcus into the coronary sulcus, continues onto the base of the heart and enlarges to form the coronary sinus, which enters the right atrium;
  2. the middle cardiac vein (posterior interventricular vein) begins near the apex of the heart and ascends in the posterior interventricular sulcus toward the coronary sinus
  3. the small cardiac vein begins in the lower anterior coronary sulcus between the right atrium and right ventricle, continues onto the base of the heart where it enters the coronary sinus;
  4. the right marginal vein may join the small cardiac vein along its course or enter the right atrium directly;
  5. the posterior cardiac vein lies on the posterior surface of the left ventricle to the left of the middle cardiac vein; it either enters the coronary sinus directly or joins the great cardiac vein
  6. the anterior veins of the right ventricle (anterior cardiac veins) arise on the anterior surface of the right ventricle, cross the coronary sulcus and enter the anterior wall of the right atrium
  7. the smallest cardiac veins (venae cordis minimae or veins of Thebesius) drain directly into the cardiac chambers, they are numerous in the right atrium and right ventricle, occasional in the left atrium, and rare associated in the left ventricle.
156

myocardial infarction

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  1. occurs when one of the heart's coronary arteries is blocked suddenly or has extremely slow blood flow, usually resulting from the formation of a blood clot (thrombus), which typically forms inside a coronary artery that already has been narrowed by atherosclerosis;
  2. most frequently involves the anterior wall (78%); most common coronary artery affected is the left anterior descending (LAD) branch (also called the anterior interventricular branch).
157

mechanism for perceiving heart pain in T1-T4 dermatomes

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  1. when cardiac cells die during a myocardial infarction, pain fibers (visceral afferents) are stimulated; these visceral afferent fibers follow sympathetic fibers that innervate the heart and enter the spinal cord between the T1 and T4 levels;
  2. at this level, somatic afferent nerves from spinal nerves T1 to T4 also enter the spinal cord via the posterior roots; both types of afferents synapse before ascending to the somatosensory areas of the brain that represent the T1 to T4 levels;
  3. the brain is unable to distinguish clearly between the visceral sensory distribution and the somatic sensory distribution and therefore the pain is interpreted as arising from the somatic regions rather than the visceral organ (i.e., the heart)
158

sites of listening for heart sounds

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  1. the tricuspid valve is heard just to the left of the lower sternum near the fifth intercostal space;
  2. the mitral valve is heard over the apex of the heart in the left fifth intercostal space at the midclavicular line;
  3. the pulmonary valve is heard over the medial end of the left second intercostal space;
  4. the aortic valve is heard over the medial end of the right second intercostal space.
159

sympathetic trunks

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  1. the sympathetic autonomic division of the PNS leaves thoracolumbar regions of the spinal cord with the somatic components of spinal nerves T1 to L2;
  2. on each side, paravertebral sympathetic trunks extend from the base of the skull to the inferior end of the vertebral column where they converge anteriorly at the ganglion impar;
  3. each trunk is attached to the anterior rami of spinal nerves and becomes the route by which sympathetics are distributed to the periphery and all viscera
  4. along the trunks are segmentally arranged ganglia formed from collections of postganglionic cell bodies where the preganglionic neurons synapse with postganglionic neurons.
160

ramus communicans

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  1. connect the paravertebral sympathetic trunks to the anterior rami of spinal nerves
  2. anterior rami are connected to the sympathetic trunk by a white ramus communicans, which carries myelinated preganglionic sympathetic fibers;
  3. the sympathetic trunk or a ganglion is connected to the anterior ramus by a gray ramus communicans, which contains nonmyelinated postganglionic sympathetic fibers.
161

cardiac skeleton

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  1. four dense, fibrous connective tissue rings surrounding the two atrioventricular orifices, the aortic orifice and opening of the pulmonary trunk; they are the anulus fibrosus;
  2. the right fibrous trigone is a thickened area of connective tissue between the aortic ring and right atrioventricular ring; the left fibrous trigone is between the aortic ring and the left atrioventricular ring;
  3. help to maintain the structural integrity of the openings, provide points of attachment for the cusps, separate musculature of the atria and ventrices, serve to electrically isolate the atria from the ventricles.
162

moderator band

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  1. a single specialized trabeculum that connects the lower portion of the interventricular septum to the base of the anterior papillary muscle;
  2. carries a portion of the cardiac conduction system, the right bundle of the atrioventricular bundle, to the anterior wall of the right ventricle
163

superior intercostal veins

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  1. the left superior intercostal vein receives the second, third, and fourth posterior intercostal veins, usually the left bronchial veins, and sometimes the left pericardiacophrenic vein;
  2. the upper posterior intercostal veins on the right side may come together and form the right superior intercostal vein, which empties into the azygos vein
164

ligamentum arteriosum

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  1. located in the superior mediastinum and is important in embryonic circulation, when it is a patent vessel (the ductus arteriosus);
  2. during development, it connects the pulmonary trunk with the arch of the aorta and allows blood to bypass the non-functional lungs;
  3. closes soon after birth and forms the ligamentous connection observed in the adult.
165

thymus

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  1. an asymmetrical, bilobed structure lying immediately posterior to the manubrium of the sternum; upper extent can reach into the neck, the lower portion typically extends into the anterior mediastinum.
  2. involved in the early development of the immune system, the thymus is a large structure in the child, begins to atrophy after puberty, and shows considerable size variation in the adult
  3. arteries to the thymus consist of small branches originating from the internal thoracic arteries; venous drainage is usually into the left brachiocephalic vein.
  4. lymphatic drainage returns to multiple groups of nodes at one or more of the following locations: along the internal thoracic arteries, at the tracheal bifurcation, and in the root of the neck.
  5. the parathyroid glands develop from the third pharyngeal pouch, which also forms the thymus. The thymus is therefore a common site for ectopic parathyroid glands and, potentially, ectopic parathyroid hormone production.
166

mitral valve disease

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  1. usually a mixed pattern of stenosis (narrowing) and incompetence (insufficient function), leading to a poorly functioning valve and subsequent heart changes: (a) left ventricular hypertrophy; (b) increased pulmonary venous pressure; (c) pulmonary edema; and (d) enlargement (dilation) and hypertrophy of the left atrium.
  2. mitral vale stenosis can be congenital or acquired; in the latter, the most common cause is rheumatic fever.
167

aortic valve disease

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  1. both aortic stenosis (narrowing) and aortic regurgitation (backflow), can produce marked heart failure; stenosis is the most common type of cardiac valve disease and results from atherosclerosis causing calcification of the valve leaflets.
  2. can also be caused by postinflammatory or postrheumatic conditions; these may lead to aortic regurgitation such as infective endocarditis, degenerative valve disease, rheumatic fever, or trauma.
168

tetralogy of Fallot

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  1. the most common cyanotic congenital heart disorder diagnosed soon after birth,
  2. classically consists of four abnormalities (PRO-V): (a) pulmonary stenosis, (b) right ventricular hypertrophy (c) overriding aorta, and (d) ventricular septal defect (VSD),
  3. underdevelopment of the right ventricle and pulmonary stenosis reduce blood flow to the lungs, leading to reduced volume of oxygenated blood returning to the heart;
  4. the defect in the interventricular septum causes mixing of oxygenated and nonoxygenated blood, which is then delivered to tissues, resulting in poor oxygenation and cyanosis.
  5. infants can present with cyanosis at birth or develop episodes of cyanosis while feeding or crying (tet spells); most require surgical intervention, namely cardiopulmonary bypass
169

lumbar vertebrae

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  1. the five lumbar vertebrae are distinguished from vertebrae in other regions by their large size; also, they lack facets for articulation with ribs;
  2. the transverse processes are generally thin and long, with the exception of those on vertebra LV, which are massive and somewhat cone shaped for the attachment of iliolumbar ligaments to connect the transverse processes to the pelvic bones;
  3. the vertebral body of a typical lumbar vertebra is cylindrical and the vertebral foramen is triangular in shape and larger than in the thoracic vertebrae.
170

ligamentum nuchae

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  1. a continuation of the supraspinous ligament, extending from from vertebra CVII to the skull;
  2. supports head, resists flexion and facilitates returning the head to the anatomical position; broad lateral surfaces and the posterior edge provide attachment for adjacent muscles (e.g. trapezius)
171

thoracolumbar fascia

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  1. covers the deep muscles of the back and trunk; critical to the overall organization and integrity of the region; and blends with the medial attachments of the latissimus dorsi and serratus posterior inferior muscles;
  2. the posterior layer is thick attaches to the spinous processes of the lumbar vertebrae and sacral vertebrae and to the supraspinous ligament;
  3. the middle layer is attached medially to the transverse processes of the lumbar vertebrae and intertransverse ligaments; inferiorly, it is attached to the iliac crest and, superiorly, to the lower border of rib XII;
  4. the anterior layer covers the anterior surface of the quadratus lumborum muscle and is attached medially to the transverse processes of the lumbar vertebrae, inferiorly, it is attached to the iliac crest and, superiorly, it forms the lateral arcuate ligament for attachment of the diaphragm.
  5. the posterior and middle layers come together at the lateral margin of the erector spinae; the anterior layer joins at the lateral border of the quadratus lumborum.
172

erector spinae muscles

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  1. spinous processes of T9 to T12 thoracic vertebrae, medial slope of the dorsal segment of illiac crest
  2. spinous processes of T1 and T2 thoracic vertebrae and the cervical vertebrae
  3. posterior branch of spinal nerve
  4. extends the vertebral column
  5. includes three muscle groups (iliocostalis lumborum, thoracis, and cervicis; longissimus thoracis, cervicis, and capitis; spinalis thoracis, cervicis, and capitis)
173

foramen magnum

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  1. the largest foramen in the skull, located in the deepest part of the posterior cranial fossa, surrounded by the occipital bone
  2. the spinal cord passes through superiorly to continue as the brainstem; as do the vertebral arteries, the meninges, and the spinal roots of the accessory nerve [XI].
174

vertebral artery

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  1. first branch of the subclavian artery; ascends medially to the anterior scalene muscle and enters the foramen in the transverse process of vertebra CVI;
  2. passes through the foramina of vertebrae CV to CI. At the superior border of vertebra CI, the artery turns medially and crosses the posterior arch of vertebra CI; from here it passes through the foramen magnum to enter the posterior cranial fossa.
175

number of vertebrae

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  1. there are approximately 33 vertebrae, which are subdivided into five groups based on morphology and location;
  2. the 7 cervical vertebrae between the thorax and skull are characterized mainly by their small size;
  3. the 12 thoracic vertebrae are characterized by their articulation with the ribs;
  4. the 5 lumbar vertebrae support the posterior abdominal wall and are characterized by their large size;
  5. the 5 sacral vertebrae fused into one single bone called the sacrum, which articulates on each side with a pelvic bone;
  6. inferior to the sacrum is a variable number, usually 4 coccygeal vertebrae, which fuse into a single small triangular bone called the coccyx.
176

number of spinal nerves

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  1. There are approximately 31 pairs of spinal nerves named according to their position;
  2. eight cervical nerves (C1 to C8)
  3. twelve thoracic nerves (T1 to T12)
  4. five lumbar nerves (L1 to L5)
  5. five sacral nerves (S1 to S5)
  6. one coccygeal nerve (Co)
177

ganglion impar

  1. the sympathetic part of the autonomic division of the PNS leaves thoracolumbar regions of the spinal cord with the somatic components of spinal nerves T1 to L2;
  2. on each side, a paravertebral sympathetic trunk extends from the base of the skull to the inferior end of the vertebral column where the two trunks converge anteriorly to the coccyx at the ganglion impar.
178

subarachnoid space

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  1. the space between the between the arachnoid and pia mater contains CSF; strands of tissue (arachnoid trabeculae) connect the two layers and suspend large blood vessels between them;
  2. extends farther inferiorly than the spinal cord; the spinal cord ends at approximately the disc between vertebrae LI and LII, whereas the subarachnoid space extends to approximately the lower border of vertebra SII;
  3. largest in the region inferior to the terminal end of the spinal cord, where it surrounds the cauda equina; CSF can be withdrawn from the subarachnoid space in the lower lumbar region without endangering the spinal cord.
179

filum terminale

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  1. the distal end of the spinal cord (the conus medullaris) is cone shaped; fine filament of connective tissue (the filum terminale) continues inferiorly;
  2. the upper part (filum terminale internum) reaches as far as the lower border of SII; it is continuous above with the pia mater and contained within a tubular sheath of the dura mater;
  3. the lower part (filum terminale externum) closely adheres to the dura mater; it extends downward from the apex of the tubular sheath and is attached to the back of the first segment of the coccyx.
180

sternoclavicular joint

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  1. one of three joints of the shoulder complex;
  2. occurs between proximal end of the clavicle and the clavicular notch of the manubrium of the sternum together with a small part of the first costal cartilage;
  3. it is stabilized by the sternoclavicular, interclavicular, and costoclavicular ligaments.
181

acromioclavicular joint

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  1. one of three joints of the shoulder complex;
  2. a small synovial joint between an oval facet on the medial surface of the acromion and a similar facet on the acromial end of the clavicle;
  3. it is stabilized by the acromioclavicular and coracoclavicular (comprised of the trapezoid and conoid ligaments) ligaments.
182

glenohumeral joint

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  1. one of three joints of the shoulder complex;
  2. a synovial ball and socket articulation between the head of the humerus and the glenoid cavity of the scapula; it is multiaxial with a wide range of movements provided at the cost of skeletal stability;
  3. it is stabalized by the glenohumeral, coracohumeral, and transverse humeral ligaments,
183

points of transition between the subclavian, axillary, and brachial arteries

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  1. the subclavian artery, the major blood vessel supplying the upper limb, becomes the axillary artery as it crosses the lateral margin of rib I and enters the axilla
  2. the axillary artery becomes the brachial artery of the arm as it crosses the inferior margin of the teres major muscle
184

dually innervated muscles

  1. the brachialis (musculocutaneous nerve and radial nerve)
  2. the trapezius (accesory nerve and C3 and C4 dorsal rami)
  3. the levator scapulae muscle (C3 to C4 and dorsal scapular nerve)
185

fractures of the radius and ulna

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  1. Monteggia's fracture is a fracture of proximal ulna and an anterior dislocation of the head of the radius at the elbow;
  2. Galeazzi's fracture is a fracture of the distal the radius and subluxation of the head of the ulna at the wrist;
  3. Colles' fracture is a fracture, and posterior displacement, of the distal end of the radius (often due to falling and landing on wrist)
186

blood pressure measurement

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  1. a sphygmomanometer is a device that inflates a cuff around the midportion of the arm to compress the brachial artery against the humerus;
  2. a cuff is inflated so it exceeds the systolic blood pressure (greater than 120 mm Hg), and the stethoscope is placed over the brachial artery in the cubital fossa and listens (auscultates) for the pulse;
  3. as the pressure is reduced below the systolic blood pressure, the pulse becomes audible as a regular thumping sound;
  4. when the pressure is less than that of the diastolic blood pressure, the audible thumping sound becomes inaudible.
  5. using the scale on the sphygmomanometer, the patient's blood pressure can be determined; the normal range is 90–120/60–80 mm Hg (systolic blood pressure/diastolic blood pressure).
187

pulled elbow

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  1. a disorder that typically occurs in children under 5 years of age; also refered to as nursemaids elbow; commonly caused by a sharp pull of the child's hand;
  2. the not-yet-developed head of the radius and the laxity of the anular ligament of the radius allow the head to sublux from this cuff of tissue, causing severe pain;
  3. treated easily by supination and compression of the elbow joint; when the radial head is relocated the pain subsides and the child can continue with normal activity.
188

“tennis” or “golfer's” elbow

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  1. people who are involved in sports such as golf and tennis can develop an overuse strain of the origins of the flexor and extensor muscles of the forearm resulting in epicondylitis and pain is typically around the epicondyles
  2. tennis players usually have pain on the lateral epicondyle and common extensor origin; in golfers it occurs on the medial epicondyle and common flexor origin.
189

pronator teres muscle

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  1. medial epicondyle and adjacent supra-epicondylar ridge (humoral head), medial side of coronoid process (ulnar head)
  2. roughening on lateral surface, midshaft, of radius
  3. median nerve (C6, C7)
  4. pronation of forearm
190

pronator quadratus muscle

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  1. linear ridge on distal anterior surface of ulna
  2. distal anterior surface of radius
  3. median nerve (anterior interosseous nerve) (C7, C8)
  4. pronation of forearm
191

Lister's tubercle

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  1. also known as the dorsal tubercle of the radius, located on the distal end of the radius
  2. serves as a pulley for the tendon of the extensor pollicis longus muscle, separating it from the extensor digitorum and the extensor carpi radialis brevis muscles
192

palmar aponeurosis

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  1. a triangular condensation of deep fascia that covers the palm and is anchored to the skin in distal regions
  2. the apex is continuous with the palmaris longus tendon or anchored to the flexor retinaculum; fibers radiate to extensions at the bases of the digits that project into each.
  3. vessels, nerves, and long flexor tendons lie deep to the palmar aponeurosis in the palm.
193

cubital tunnel syndrome

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  1. results from compression on the ulnar nerve in the cubital tunnel behind the medial epicondyle (funny bone), causing numbness and tingling in the ring and little fingers.
  2. the tunnel is formed by the medial epicondyle, ulnar col-lateral ligament, and two heads of the flexor carpi ulnaris muscle and transmits the ulnar nerve and superior ulnar collateral or posterior ulnar recurrent artery.
194

serratus anterior muscle

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  1. lateral surfaces of upper 8–9 ribs and deep fascia overlying the related intercostal spaces
  2. costal surface of medial border of scapula
  3. long thoracic nerve (C5, C6, C7)
  4. protraction and rotation of the scapula; keeps medial border and inferior angle of scapula opposed to thoracic wall
195

sternocleidomastoid muscle

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  1. upper anterior surface of manubrium of sternum (sternal head); superior surface of medial one-third of clavicle (clavicular head)
  2. lateral one-half of superior nuchal line (sternal head); ateral surface of mastoid process (clavicular head)
  3. accessory nerve [XI] and branches from anterior rami of C2 to C3 (C4)
  4. tilt head toward shoulder on same side rotating head to turn face to opposite side, draw head forward
196

subclavian artery

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  1. the first part ascends to the medial border of the anterior scalene muscle from either the brachiocephalic trunk on the right side or directly from the arch of the aorta on the left side; it has numerous branches.
  2. the second part passes laterally between the anterior and middle scalene muscles, and one branch may arise from it.
  3. the third part emerges from between the anterior and middle scalene muscles to cross the base of the posterior triangle, crossing the lateral border of rib I where it becomes the axillary artery and continues into the upper limb.
  4. a single branch (the dorsal scapular artery) may arise from the third part of the subclavian artery.
197

axillary artery

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  1. continuation of the subclavian artery; begins at the lateral margin of rib I
  2. has six branches; the superior thoracic artery (first part), the thoraco-acromial artery and the lateral thoracic artery (second part), the subscapular artery, the anterior circumflex humeral artery, and the posterior circumflex humeral artery (third part);
  3. ends at the inferior margin of the teres major muscle where it becomes the brachial artery
198

bicipital aponeurosis

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  1. a flat connective tissue membrane between the medial side of biceps brachii muscle tendon and deep fascia of the forearm
  2. covers and protects the the brachial artery and the median nerve anteriorly in the distal part of the cubital fossa
199

olecranon

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  1. large projection of bone that extends proximally from the ulna with an articular anterolateral surface;
  2. contributes to the formation of the trochlear notch, which articulates with the trochlea of the humerus;
  3. superior surface is marked by a large roughened impression for the attachment of the triceps brachii muscle;
  4. posterior surface is smooth, shaped somewhat triangularly, and can be palpated as the “tip of the elbow.”
  5. forms the lateral border of the cubital tunnel, a passageway for the ulnar nerve
200

medial epicondyle of the humerus

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  1. a major palpable bony protuberance on the medial side of the elbow, projecting medially from the distal end of the humerus;
  2. it bears a large oval impression for the attachment of muscles in the anterior compartment of the forearm;
  3. forms the lateral border of the cubital tunnel, a passageway for the ulnar nerve.
201

radial groove of the humerus

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  1. a shallow groove on the middle part of the posterior surface and adjacent part of the anterolateral surface of the humerus;
  2. passes diagonally down the bone and parallel to the sloping posterior margin of the deltoid tuberosity;
  3. houses the radial nerve and the profunda brachii artery
202

radial tuberosity

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  1. a large blunt projection on the medial surface of the radius immediately inferior to the neck;
  2. much of its surface is roughened for the attachment of the biceps brachii tendon;
  3. its inferior margin forms the starting point for the oblique line of the radius, which continues diagonally across the shaft
203

ulnar tuberosity

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  1. the largest of multiple roughenings at the apex of the triangular anterior surface of the coracoid process;
  2. attachment site for the brachialis muscle
204

brachioradialis

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  1. proximal part of lateral supraepicondylar ridge of humerus and adjacent intermuscular septum
  2. lateral surface of distal end of radius
  3. radial nerve (C5, C6) before division into superficial and deep branches
  4. accessory flexor of elbow joint when forearm is midpronated
205

posterior branches of spinal nerves

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  1. innervate the intrinsic muscles of the back and adjacent skin;
  2. cutaneous distribution extends into the gluteal region of the lower limb and the posterior aspect of the head
206

spinal nerves

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  1. a spinal segment is the area of the spinal cord that gives rise to the posterior and anterior rootlets, which become the posterior and anterior roots that join to form a spinal nerve;
  2. the posterior root contains the processes of sensory neurons carrying information to the CNS; cell bodies are clustered in a spinal ganglion at the distal end of the posterior root;
  3. the anterior root contains motor nerve fibers, which carry signals away from the CNS; cell bodies are in anterior regions of the spinal cord;
  4. each spinal nerve divides, as it emerges from an intervertebral foramen, into two major branches: a small posterior ramus (innvervate back) and a large anterior ramus (innervate most everything else expect head).
207

cauda equina

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  1. the collection of lumbar, sacral, and coccygeal nerve roots passing inferiorly to the end of the spinal cord (conus medullaris) reach their exit points from the vertebral canal;
  2. derives its name from its horsetail-like appearance;
  3. compression results in cauda equina syndrome which may cause prevent permanent and irreversible damage to the compressed nerve roots.
208

brachiocephalic trunk

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  1. the first branch of the arch of the aorta; the largest of the three branches (the others being the left common carotid and the left subclavian);
  2. at the level of the right sternoclavicular joint, divides into right common carotid artery, and right subclavian artery;
  3. occasionally branches into the thyroid ima artery, which contributes to the vascular supply of the thyroid gland.