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MSK Final > Blue Boxes > Flashcards

Blue Boxes Flashcards

1
Q

Rib fractures (1st, middle, lower)

A

1st rib is rarely fractured, when it is, brachial plexus injuries and subclavian impingments can occur
Middle ribs - most common, weakest just anterior to angle
Lower ribs- may tear diaphragm

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2
Q

Flail chest

A

multiple rib fractures

paradoxical movements with respiration

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3
Q

thoracotomy is the surgical opening of

A

Anteriorly - thoracic chest - H shaped cut through perichondrium
5th-7th intercostal spaces, posterolaterally (abduct patients arm, lateral recumbent) - pneumonectomy

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4
Q

supernumarary ribs

A

normally 12 ribs each side, some people have
Cervical ribs (.5-2%)
Lumbar ribs
Failure of 12th pair to form

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5
Q

protective function and aging of costal cartilages

A

prevents fracturing from blows (although injury still occurs)
costal cartilages brittle in old folks

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6
Q

ossified xiphoid process occurs at what age

A

partially ossifices in early 40s

complaints of hard lump in pit of stomach

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7
Q

sternal fractures

A

rare- usually comminuted (multiple)
displacement of fragments uncommon due to fascia
eldery - sternal angle where manubriosternal joint is fused
primary concern is heart/lung injury

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8
Q

median sternotomy is used in what procedures

A

split in median plane and retracted
coronary artery bypass
tumors in superior lobe of lung

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9
Q

sternal biopsy done by

A

bone marrow needle biopsy

evaluate for metastatic cancer, blood dyscrasias

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10
Q

sternal anomolies

A

normal development involves fusion of bilateral vertical condensation of sternal band/bars (precartilaginous tissue)
partial clefts - can be repaired by direct apposition/fixation
complete cleft may result in ectopia cordis
perforation (sternal foramen) - not clinically significant, shows up in xrays
pectus excavatum/pectus cavinatum
perforated xiphoid process in elderly
anteriorly protruding xiphoid process in neonates does not require correction

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11
Q

Thoracic outlet syndrome

A

arteries and T1 spinal nerves emerge from thorax

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12
Q

dislocation of ribs

A

common in body-contact sports
dislocation of sternocostal joint
dislocation of interchondral joint occurs unilaterally at ribs 8,9,10 and trauma may affect underlying structures

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13
Q

separation of ribs

A

dislocation of costochondral junction
3rd-10th ribs usually tears pericondrium and periosteum
overrides rib above causing pain

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14
Q

paralysis of diaphragm

A

phrenic nerve damage will affect one half (each dome has separate nerve supply)
if this has occured, paradoxical movement of affected dome will be noted

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15
Q

dyspnea

A

individuals with respiratory problems/heart failure will have difficulty breathing (dyspnea)
will utilize their accessory respiratory muscles to assist in expansion of thoracic cavity
lean on knees/arms of a chair to fix pectoral girdle

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16
Q

extrapleural intrathoracic surgical access

A

loose, thin endothoracic fascia
separation from costal parietal pleura lining the thoracic wall allows intrathoracic access to extrapleural structures (lymph nodes) without opening and contaminating pleural cavity around lungs)

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17
Q

herpes zoster infection of spinal cord

A

causes classic dermatomally distributed skin lesion known as shingles
described as painful af
virus invades ganglion, producing sharp burning pain in dermatome supplied by involved nerve - skin becomes red and vesicular eruptions occur

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18
Q

intercostal nerve block

A

local anesthesia produced by injected anesthetic agent around intercostal nerves between paravertebral line and are of required anesthesia

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19
Q

changes in breasts

A

branching of lactiferous ducts occurs during menstrual periods and pregnancy
colostrum (premilk) may be secreted during third trimester, rich in protein, immune agents and growth factor for intestines
multiparous women - breasts become large and pendulous
elderly - small because decrease in fat and atrophy of glandular tissue

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20
Q

breast quandrants

A

superiomedial
Superiolateral
inferolateral
inferomedial

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21
Q

carcinoma of the breast

A 
typically adenocarcinomas (glandular cancer) arising from epithelial cells of lactiferous ducts 
lymphedema (caused by interference with lymphatic drainage by cancer) may cause 
Peau d'orange sign 
fingertip size dimples (from shortening of supsensory ligaments) 
retraciton of nipples

breast cancer typically spreads by lymphatic vessels (most of which goes to axillary LN)

if breast elevates when pectoral muscle contracts, cancer has advanced enough to invade retromammary space (overlying pectoral fascia)

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22
Q

mammography

A

radiographic examination of the breasts
carcinoma appears as large, jagged density
skin thickening in area over tumor

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23
Q

surgical incisions of breast

A

typically done at inferior quadrants - less vascular structures
inferior cutaneous crease best aesthetic results, crease may hide incisions
areolar incisions are made radially to either side of nipple or circumferentially

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24
Q

simple masectomy

A

breast is removed down to retromammary space

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25
Q

radical masectomy

A

removal of breast, pectoral muscles, fat, fascia, as many LN as possible in axilla and pectoral regions

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26
Q

polymastia

A

supernumary breasts
usually mistaken for nevus until color change during pregnancy, may lactate

can appear anywhere down milk line (from axilla to groin)

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27
Q

polythelia

A

accessory nipple

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28
Q

breast cancer in men

A

Accounts for 1.5% of BC
metastasizes to bone, pleura, lung, liver, skin, pectoral fascia
visible/palpable subareolar mass or secretion from nipple may indicate malignant tumor
frequently goes undetected until metastasis has occured

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29
Q

gynecomastia

A

breast hypertrophy in males after puberty
rare, may be age/drug related (diethylstilbesterol for prostate cancer)
may result from imbalance between estrogenic and androgenic hormones or from a change in metabolism of sex hormones by liver (therefore, gynecomastia may indicate suprarenal/testicular cancers)

40% of klinefelters experience gynecomastia

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30
Q

injuries of cervical pleura and apex of lung

IGNORE UNTIL CP

A

lungs and pleural scs may be injured in wounds to the base of the neck (cervical pleura and apex of lung project through opening of first ribs)
results in pneumothorax (air in pleural cavity)
especially vulnerable in children as cervical pleura reaches higher levels

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31
Q

Injury to other parts of pleurae

IGNORE UNTIL CP

A

pleura descend past costal margin in three areas
right part of infrasternal angle
right and left costovertebral angles
pneumothorax may occur from an incision in these areas

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32
Q

pulmonary collapse

IGNORE UNTIL CP

A

atelectasis - primary - lung does not inflate at brith
secondary - collapse of inflated lung

distension of lungs can be disrupted by a penetrating wound, causing the lungs normal elasticity to pull it free from the pleural cavity (also due to air filling negative pressure of pleural cavity and disrupting surface tension forces of pleural fluid)

pleural sacs do not communicate, so one lung may collapse without concomitant collapse of the second lung

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33
Q

Pneumothorax,hydrothorax, hemothorax

IGNORE UNTIL CP

A

pneumothorax - entry of air into the pleural cavity from penetrating wound of parietal pleura, rupture of pulmonary lesions, fractured ribs

Hydrothorax - significant amount of fluid in pleural cavity

Hemothorax - blood in the pleural cavity (commonly due to injury to major intercostal/internal thoracic vessel)

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34
Q

Thoracentesis procedure and use

IGNORE UNTIL CP

A

insertion of hypodermic needle through an intercostal space into pleural cavity to obtain sample of fluid/remove blood or pus

must avoid intercostal nerve and vessles by inserting superior to rib (typically 9th intercostal space) angled upward

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35
Q

insertion of chest tube

IGNORE UNTIL CP

A

used to remove fluid/air/pus/ from pleural cavity
incision made at 5th or 6th intercostal space and tube is inserted, connected to special pump

removal of air allows reinflation of collapsed lung

failure to remove fluid may cause fibrosis to occur (requires lung decortication) to fix

36
Q

Pleurectomy and Pleurodesis

IGNORE UNTIL CP

A

pleurectomy - obliteration of the pleural cavity (by surgery but disease can do it too) does not produce any functional problems

Pleurodesis - coating of irritating agent to parietal and visceral layers of pleura to induce adhesion to prevent spontaneous secondary alectasis

37
Q

thoracoscopy

IGNORE UNTIL CP

A

examine pleural cavity with thorascope

can take biopsies and disrupt adhesions/ remove plaques

38
Q

how is the clavicle different from other long bones?

A

more varied than most other long bones

thicker in manual laborers

39
Q

Fracture of clavicle

A

especially common in children - often caused by FOOSH transmitting force up arm (greenstick facture in younger children = bone is broken but does not separate)

sternocleidomastoid elevates medial fragment
trapezius is unable to hold up lateral fragment because weight of upper limb, patients will carry limb in opposite arm

40
Q

Ossification of clavicle

A

clavicle is first long bone to ossify (via intramembranous ossification in middle)
ends of clavicle later pass through a cartilaginous phase (endochondral ossification) and these are the last epiphyses of long bones to fuse

sometimes fusion between ossficiations centers fails to occur, creating bony defect between lateral and medial thirds of clavicle - if unsure radiograph bilaterally

41
Q

fracture of scapula

A

usually result of severe trauma (vehicular accidents)
require little treatment because scapula is covered on both sides by muscles
most fractures invovle protruding subcutaneous acromion

42
Q

fractures of humerus (just read)

A

most injuries of proximal end fracture surgical neck of humerus - common in eldery due to osteoporosis (axillary n involvement)

humeral fractures can often present as impacted fractures, where one fragment is driven into the spongy bone of another *patient may have some use of arm

avulsion fractures of the greater tubercle usually result form falls on the acromion - muscles tend to pull limb into medial rotation

transverse fracture results from trauma - deltoid muscle will carry the proximal fragment laterally

spiral fractures of humeral shaft may result from a FOOSH

(radial n involvement if radial groove is damaged)

intercondylar fracture results from falling on flexed elbow - olecranon separates medial and lateral parts of condyle of humerus
(median n for distal end injuries an d ulnar n for medial epicondyle injuries)

Fractures usually heal well, humerus is surrounded by muscle and has a well developed periosteum

43
Q

fractures of radius and ulna

A

typically these bones fracture together
if one bone is fractured, typically the nearest joint will be dislocated

Fracture of the distal end of the radius is common in adults over 50

44
Q

colle sfracture

A

complete transverse fracture of the distal 2cm of radius - common FOOSH injury
ulnar styloid process often avulsed causing dinner fork deforming (hand has the soft curve of a fork)
fracture may extend through epiphyseal plate in children and may misalign during healing

45
Q

Fracture of scaphoid

A

most frequently fractured carpal bone - fall on palm when hand is abducted
often misdiagnosed as severely sprained wrist
avascular necrosis of proximal fragment of scaphoid may occur (bone death)
could produce degenerative joint disease of wrist

46
Q

Fracture of hamate

A

may result in non-union due to traction of attached muscles
ulnar nerve near hook may be damaged - grip strength will be decreased
ulnar a may also be damaged

47
Q

fracture of metacarpals

A

metacarpals are closely bound and have good blood supply - tend to heal well
boxers fracture - fracture of the 5th metacarpal (closed and abducted fist) will cause head of bone to rotate over distal end of shaft producing flexion deformity

48
Q

fracture of phalanges

A

common in distal phalanges - because of close relationship of phalangeal fractures to flexor tendons, the bone fragments must be carefully realigned to restore normal function

49
Q

absence of pectoral muscles

A

usually sternocostal part is uncommon but no disability occurs as a result
anterior axillary fold will be absent

In poland syndrome - both pectoralis major and minor are absent, breast hypoplasia and absence of two to four rib segments are also seen

50
Q

paralysis of serratus anterior

A

injury to long thoracic n
causes medial border of scapula to move laterally and posteriorly away from thoracic wall
gives scapula the appearance of a wing
arm cannot be abducted above horizontal position because serratus anterior is needed to rotate glenoid cavity upward

51
Q

triangle of auscultation borders and use

A

superior border of latissimus dorsi
medial border of scapula
inferolateral border of trapezius

used to listen to lungs

52
Q

injury to spinal accessory n

A

marked ipsilateral weakness when shoulders are elevated against resistance

53
Q

injury of thoracodorsal n

A

supplies the latisimmus dorsi
passes inferiorly along posterior wall of axilla
if damaged, patient will be unable to raise trunk with upper limbs or use an axillary crutch because the lat forms a muscular sling between the arm and trunk

54
Q

injury to dorsal scapular n

A

supplies the rhomboids - if damaged, scapula on affected side will be further from midline than unaffected side

55
Q

injury to axillary n

A

causes deltoid to atrophy
axillary n is usually injured during fracture of surgical neck of humerus
shoulder will appear flattened
loss of sensation over lateral side of proximal part of arm (supplied by the superior lateral brachial cutaneous n, a branch of the axillary)

56
Q

fracture-dislocation of proximal humeral epiphysis

A

caused by direct injury to shoulder of child/adolescent may produce this fracture as the joint capsule is stronger than the epiphyseal plate
if severe enough, shaft of humerus is displaced but humeral head retains its normal relationship in glenoid cavity

57
Q

Rotator cuff injuries

A

injury or disease may affect rotator cuff and produce instability in the glenohumeral joint
may be trauma to one of SITS muscles - supraspinatus tendon is most commopnly ruptured
degenerative tendonitis of the rotator cuff is common in older people

58
Q

arterial anastomoses around scapula

A

dorsal scapular, suprascapular and subscapular arteries contribute to arterial anastomoses around the scapula

direction of blood flow in the subscapular a is reversed when if the axillary a is ligated/has undergone stenosis, enabling blood to reach third part of axillary a

the subscapular a receives anastomoses from the suprascapular, dorsal scapular and intercostal aa
slow occlusion of axillary often enables sufficient blood collateral circulation (whereas sudden occlusion will not)

59
Q

compression of the axillary a

A

compression of the third part of the axillary a against the humerus may be necessary when profuse bleeding occurs

additionally, compression can be done at the origin of the axillary a by exerting downward pressure in the angle between the clavicle and the inferior attachment of the sternocleidomastoid muscle

60
Q

aneurysm of axillary a

A

first part of axillary a may enlarge and compress the trunks of the brachial plexus, causing pain and anesthesia in the areas of the skin
common in pitchers and quarterbacks

61
Q

injuries to axillary v

A

wounds in the axilla often involve axillary v due to its exposed position
when arm is abducted, vein overlaps axillary artery anteriorly
air emboli may form making this injury dangerous

62
Q

role of axillary v in subclavian vein puncture

A

subclavian vein punctures involve placing a catheter through the axillary vein as it crosses the first rib
here, axillary v is superficial (anterior and inferior) to axillary artery
branches of brachial plexus begin to surround artery at this point (aka dont nick it)

63
Q

enlargement of axillary LN

A

infection in the upper limb can cause axillary nodes to enlarge and become tender and inflamed (lymphangitis)
humeral group usually first
lymphangitis is characterized by the development of warm, red, tender streaks in skin

infections in pectoral region also enlarge axillary LN

enlargement of apical nodes may obstruct cephalic vein superior to the pectoralis minor

64
Q

dissection of axillary LN

A

excision and analysis of axillary LN are often necessary for staging and determining appropriate treatment for cancer

lymphatic drainage of the upper limb may be impeded after removal of axillary nodes (lymphedema)

during axillary node dissection, two nerves are at risk of injury 1) long thoracic nerve and 2) thoracodorsal n

65
Q

Variations in brachial plexus

A

Prefixed brachial plexus - contributions are made from C4-C8 (instead of C5-T1) - trunk of plexus may be compressed by the 1st rib

Postfixed brachial plexus - C6-T2

66
Q

brachial plexus injuries

A

injuries to brachial plexus affect movements and cutaneous sensations in upper limb

injuries to superior part of the brachial plexus usually results from an excessive increase in the angle between the neck and shoulder - makes limb hang by side stuck in medial rotation - Erb-Duchenne palsy

67
Q

acute brachial plexus neuritis

A

neuro disorder that is characterized by sudden onset of severe pain around shoulder, usually at night followed by muscle weakness and sometimes atrophy

68
Q

compression of cords of the brachial plexus

A

may result from prolonged hyperabduction of the arm while working overhead
n compressed between coracoid process of scapula and pectoralis minor tendon

can cause ischemia of upper limb and distension of the superficial limbs

69
Q

Klumpke paralysis

A

injuries to the inferior parts of the brachial plexus - occur when upper limb is suddenly pulled superiorly, like when a babys arm is pulled during delivery
can result in claw hand

70
Q

brachial plexus block

A

injection of anesthetic into or around axillary sheath blocks impulses of peripheral nerves
all deep structures of upper limb, skin distal to middle arm

71
Q

bicipital myotactic reflex

A

biceps reflex routinely examined by placing thumb on biceps tendon and tapping examiners nail bed - produces involuntary contraction of the biceps

positive response confirms the integrity of musculocutaneous n and C5, C6 spinal cord segments

Excessive, diminished, or prolonged (hung) responses may indicate CNS/PNS nervous system disease or metabolic disorders

72
Q

Biceps tendinitis

A

tendon of long head of biceps brachii is enclosed in synovial sheath that moves in the intertubercular sulcus

inflammation of the tendon is usually the result of repetitive microtrauma common in throwing sports

73
Q

Dislocation of Tendon of long head of biceps brachii

A

tendon of the long head of the biceps can be partially or completely dislocated from the intertubercular sulcus
dislocation may occur in youths during traumatic separation of the proximal epiphysis of the humerus or older pople with history of tendinitis
usually a popping/catching sensation is felt during arm rotation

74
Q

rupture of tendon of long head of biceps brachii

A

usually results from wear and tear of inflamed tendon as it moves back and forth in the intertubercular sulcus

rupture involves tendon being torn from its attachment at the supraglenoid tubercle of scapula associated with a snap/pop

popeye deformity results - muscle belly forms a ball near center of distal part
forceful flexion of the arm against excessive resistance or prolonged tendonitis from repetitive overhead motions

75
Q

interruption of blood flow in brachial a

A

brachial a can be compressed medial to humerus near middle of arm

because cubital anastomeses, brachial a may be clamped distal to deep brachial a without producing tissue damage because ulnar/radial a will still receive sufficient bloodflow through this anastomoses

however sudden occlusion/laceration will result in ischemia of elbow/forearm within hours and produce a flexion deformity

76
Q

Fracture of humeral shaft

A

midhumeral fracture may injure radial n in radial groove of shaft
supra-epicondylar fracture (distal) may be displaced over the proximal fragment by brachialis and triceps and damage any of the nerves/vasculature in this area

77
Q

Injury to musculocutaneous n

A

although protected in axilla, if the musculocutaneous n is lacerated the coracobrachialis, biceps, and brachialis will be paralyzed

weak flexion at shoulder
flexion of elbow and supination of forearm severely weakened (but not lost)

weak flexion and supination can still occur through brachioradialis and supinator (radial n innervated)

78
Q

Injury to radial n in arm

A

injury superior to branches to triceps will result in paralysis of triceps, brachioradialis, supinator, and extensor muscles of wrist and fingers

injury in radial groove results in weakened triceps and paralysis of muscles of posterior compartment of forearm - wrist drop syndrome

79
Q

venipuncture in cubital fossa

A

cubital fossa is common site for sampling and transfusion of blood and intravenous injections

median cubital vein lies on top of deep fascia of bicipital aponeurosis, protecting the brachial a and median n

cardiac caths for sampling great vessels and chambers of the heart/coronary angiography are also accessibly by the median cubital vein

80
Q

variation in the veins in cubital fossa

A

median antebrachial vein divides into median basilic vein and median cephalic vein in 20% of the population

either the median cubital vein or median basilic vein will cross superficial to the brachial a so both will be suitable for drawing blood

81
Q

elbow tendonitis or lateral epicondylitis

A

elbow tendonitis follows repetitive use of superficial extensor muscles of forearm
felt over lateral epicondyle and radiates down posterior surface of the forearm

82
Q

mallet or baseball finger

A

sudden severe tension on long extensor tendon may avulse part of its attachment to the phalanx

results from DIP joints being forcefully flexed (hyperflexed)

as a result, person cannot extend DIP joint which looks like a mallet

83
Q

Fracture of olecranon

A

fall on elbow combined with contraction of triceps brachii
fracture olecranon is pulled away by active and tonic contractions of triceps
avulsion fracture - pinning is usually required, healing is slow and cast must be worn for a long time

84
Q

Synovial cyst of wrist

A

nonpainful cyst containing mucinous fluid may appear on dorsum of hand due to mucoid degeneration

usually close to and communicate with synovial sheaths on dorsum of hand

cystic swelling of common flexor synovial sheath on anterior aspect of wrist can enlarge enough to produce compression of the median n by narrowing the carpal tunnel

85
Q

high division of brachial a

A

sometimes, brachial a will divide more proximally

ulnar/radial a begin in superior and middle part of arm and median n passes between them

86
Q

superficial ulnar a

A

in 3% of the population, ulnar a descends superiorly to flexor muscles, can be felt/be visible

do not mistake for a vein and puncture/inject drugs

MSK Final (21 decks)

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