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Flashcards in Anatomy Deck (166):
1

What does the bony pelvis consist of?

2 hip bones
Sacrum
Coccyx

2

What is each hip bone a fusion of?

Ilium
Ischium
Pubis

3

What is the ischiopubic ramus made up of?

Both ischium and pubis

4

What ligament attaches to the pubic tubercle?

Inguinal ligament

5

Where does the inguinal ligament attach between?

The ASIS and pubic tubercle

6

Where are the ischial spines palpable?

On vaginal examination, at about a finger breadth into the vagina (approx. 4 and 8oclock positions)-also pudendal nerve

7

Where are the attachments of the sacrospinous ligament?

Sacrum and ischial spine

8

Where are the attachments of the sacrotuberous ligament?

Sacrum and ischial tuberosity

9

What is the function of the sacrotuberous and sacrospinous ligaments?

Ensure inferior sacrum is not pushed superiorly when weight is suddenly transferred vertically through vertebral column (eg. jumping, later pregnancy)

10

What 2 foraminae do the sacrotuberous and sacrospinous ligaments form?

Greater and lesser sciatic foraminae

11

What forms the pelvic inlet?

Sacral promontory
Ilium
Superior pubic ramus
Pubic symphysis

12

What forms the pelvic outlet?

Pubic symphysis
Ischiopubic ramus
Ischial tuberosities
Sacrootuberous ligaments
Coccyx

13

What part of the pelvic cavity does levator ani form?

Pelvic floor- musculofascial inferior part

14

What are the functions of the pelvis?

Upper body support
Transference of weight from vertebral column to femurs
Attachment for muscles of location and abdo wall
Attachment for external genitalia
Protection of pelvic organs and associated structures
Passage for childbirth

15

What are the key differences between the female and male pelvis?

AP and transverse diameters are larger
Subpubic angle is wider
Pelvic cavity is shallower

16

What is moulding?

The movement of one bone over another to allow the foetal head to pass through the pelvis during labour

17

Moulding is allowed due to the presence of what?

Sutures and fontanelles

18

What is the vertex?

An area of foetal skull- outlined by the anterior and posterior fontanelles and the parietal eminences

19

Which is longer-the occipofrontal diameter or the biparietal?

Occipitofrontal

20

At the pelvic inlet, is the transverse of AP diameter wider?

Transverse

21

The foetus should enter the pelvic cavity facing what direction?

Either right or left (transverse)

22

What is the station?

The distance of the foetal head from the ischial spines
-ve means head is superior, +ve means head is inferior

23

What should the foetal head do whilst descending through the pelvic cavity?

Rotate
Be in a flexed position e.g. chin on chest

24

At the pelvic outlet is the AP or transverse diameter wider?

AP

25

In what position should the baby ideally leave the pelvic cavity?

Occipitoanterior position

26

During delivery should the foetal head be in flexion or extension?

Extension

27

What happens once baby's head is delivered?

There is a further rotation so that the shoulders and rest of the baby can then be delivered

28

What parts of the female reproductive system are within the pelvic cavity?

Ovaries
Uterine tubes
Uterus
Superior part of vagina

29

What parts of the female reproductive system are within the perineum?

Inferior part of vagina
Perineal muscles
Bartholin's glands
Clitoris
Labia

30

Fluid collection in the pouch of Douglas can be drained via a needle passed through what in females?

Posterior fornix of the vagina

31

What is the broad ligament of the uterus?

Double layer of the peritoneum

32

Where does the broad ligament extend between?

The uterus and the lateral walls and floor of the pelvis

33

What is the function of the broad ligament?

Helps maintain the uterus in its correct midline position

34

What is contained within the broad ligament?

The uterine tubes and the proximal part of the round ligament

35

What is the round ligament?

An embryological remnant

36

Where does the round ligament attach?

The lateral aspect of the uterus, and passes through the deep inguinal ring to attach to the superficial tissue of the female perineum

37

Where does implantation of the zygote occur?

Body of the uterus

38

What 3 layers of support hold thee uterus in place?

Number of strong ligaments e.g. uterosacral ligaments
Endopelvic fascia
Pelvic floor muscles e.g. levator ani

39

What are the two most common positions of the uterus?

Anteverted
Anteflexed

40

What are some normal variations in position of the uterus?

Retroverted
Retroflexed

41

What state are the walls of the vagina usually in?

Collapsed

42

What zone is sampled during a cervical smear?

Squamo columnar junction (transformation zone)

43

Do the uterine tubes usually lie symmetrically?

No

44

What is a bilateral salpingo-oophorectomy?

Removal of both uterine tubes and ovaries

45

What is a unilateral salpingectomy?

Removal of one of the uterine tubes

46

Where are the fimbriae open?

Into the peritoneal cavity

47

What size and shape are the ovaries?

Almond like

48

What do the ovaries secrete?

Oestrogen and progesterone in response to FSH and LH

49

Where do ovaries develop?

Posterior abdominal wall and move onto the lateral wall of pelvis, then onto the round ligament

50

Where is the ovum released?

Directly into the peritoneal cavity to be picked up by the fimbriae of the uterine tube

51

What is the fornix?

Space around the cervix

52

What are the 4 parts of the fornix?

Anterior
Posterior
2 Lateral

53

What is the perineum divided into?

Superficial and deep pouches

54

What is the levator ani muscle made up of?

Number of small muscles
Skeletal

55

What does levator ani form?

The majority of the pelvic diaphragm with its fascial coverings

56

What does levator ani provide?

Continual support for the pelvic organs

57

Describe the contractions of levator ani

Tonic contraction
Reflexively contracts further during situations of increased intra-abdominal pressure

58

What can be a factor in the development of prolapse of the pelvic organs?

Weakness of levator ani

59

What is the nervous supply to levator ani?

Nerve to levator ani
S3,4,5 sacral plexus

60

What nerve supplies the perineal muscles?

Pudendal nerve

61

What is the perineal body?

Bundle of collagenous and elastic tissue into which the perineal muscles attach

62

What is the perineal body important for?

Pelvic floor strength

63

Where is the perineal body located?

In perineum, just deep to skin

64

Where are the Bartholins glands located?

Perineum, just lateral to vaginal orifice on both sides

65

Where does the bed of breast extend from?

Ribs 2-6
Lateral border of sternum to mid-axillary line

66

Where do breasts lie on?

Deep fascia covering pec major and serratus anterior

67

What lies between the fascia and breast?

Retromammary space

68

How are breasts attached to skin?

Firmly via suspensory ligaments

69

Where does most lymph from the breast drain to?

Ipsilateral axillary nodes, then to supraclavicular nodes

70

Where can lymph from inner breast quadrants drain to?

Ipsilateral and contralateral lymph nodes

71

Where can lymph from the lower inner breast quadrant drain to?

Abdominal lymph nodes

72

What is the axilla?

Pyramidal pathway between arm and chest

73

What does the axilla contain?

Brachial plexus branches
Axillary artery (& branches) and axillary vein (& tributaries)
Axillary lymph nodes
All embedded in axillary fat

74

What do breast surgeons use to describe the extent of axillary node clearance?

'Levels' of axillary nodes

75

What are the levels of the axillary lymph nodes?

Level I – inferior and lateral to pectoralis minor
Level II – deep to pectoralis minor
Level III – superior and medial to pectoralis minor

76

What is the adnexae?

Ovaries and fallopian tubes

77

What nerve fibres are involved in the pelvis?

Sympathetic
Parasympathetic
Visceral afferent

78

What nerve fibres are involved in the perineum?

Somatic motor
Somatic sensory

79

What are the nerve fibres associated with uterine cramping?

Sympa/parasympathetic (hormonal)

80

What are the nerve fibres associated with uterine contraction?

Sympa/parasympathetic (hormonal)

81

What are the nerve fibres associated with pelvic floor muscle contraction?

Somatic motor

82

What are the nerve fibres associated with pain from adnexae?

Visceral afferents

83

What are the nerve fibres associated with pain from uterus?

Visceral afferents

84

What are the nerve fibres associated with pain from vagina?

Visceral afferents (pelvic part)
Somatic sensory (perineum)

85

What are the nerve fibres associated with pain from the perineum?

Somatic sensory

86

Describe the pain sensation from the superior aspect of pelvic organs/touching the peritoneum

Visceral afferents
Run alongside sympathetic fibres
T11-L2
Pain perceived as suprapubic

87

Describe the pain sensation from the inferior aspect of pelvic organs/not touching the peritoneum

Visceral afferents
Run alongside parasympathetic fibres
S2,3,4
Pain perceived in S2,S3,S4 dermatome (perineum)

88

Describe the pain sensation from structures crossing from pelvis to perineum e.g. urethra, vagina (above levator ani)

Visceral afferents
Parasympathetic
S2,3,4

89

Describe the pain sensation from structures crossing from pelvis to perineum e.g. urethra, vagina (below levator ani)

Somatic sensory
Pudendal nerve
S2,3,4-localised pain within perineum

90

At what level does spinal cord become cauda equina?

L2 vertebra

91

At what level does the SA space end?

S2

92

Is there a likely risk of infection in spinal/epidural anaesthetic?

No

93

What does the needle pass through in a spinal anaesthetic?

Supraspinous ligament
Interspinous ligament
Ligamental flavum
Epidural space (fat + veins)
Dura mater
Arachnoid mater
SA space

94

What does the needle pass through in an epidural anaesthetic?

Supraspinous ligament
Interspinous ligament
Ligamental flavum
Epidural space (fat + veins)

95

What happens to the sympathetic outflow below L2 level?

Sympathetic ganglia receive fibres from L2 level via sympathetic chain
Distribute them via connections with lumbar, sacral and coccygeal spinal nerves

96

What does spinal anaesthetic effect?

All spinal nerves and their named nerves (containing sympathetic fibres) below level of injection

97

What does the blockade of sympathetic tone to all arterioles in lower limb result in?

Vasodilation:
skin of lower limbs lookds flushed
Warm lower limbs
Reduced sweating
All signs that spinal anaesthetic is working

98

What must be watched for in spinal anaesthetic?

Hypotension

99

What does the pudendal nerve supply?

Somatic motor and sensory structures of the perineum

100

Where does the pudendal nerve originate?

Branch of sacral plexus : S2,3,4

101

What does a pudendal nerve block do?

Anaesthetise majority of perineum

102

What is a pudendal nerve block useful for?

Episiotomy incision
Forcepss use
Perineal stitching post delivery

103

Describe the course of the pudendal nerve

Exits pelvis via greater sciatic foramen
Passes posterior to sacrospinous ligament
Re-enters pelvis/perineum via lesser sciatic foramen
Travels in pudendal canal (passageway within obturator fascia) within internal pudendal artery and vein, and nerve to obturatory internus
Branches to supply structures of perineum

104

What can be used as a landmark to administer block?

Ischial spine

105

What can cause pudendal nerve of sphincter damage during labour?

Branches of pudendal nerve can be stretched with resultant stretch of nerve fibres
Fibres within the levator ani (puborectalis) or external anal sphincter muscle could be torn and as a result, the muscle weakened from 1st to 3rd degree
Weakened pelvic floor and faecal incontinence could result

106

What is an episiotomy?

Posterolateral (mediolateral) incision
Made into the relatively safe fat filled ischioanal fossa and avoids incision extending into rectum

107

What are the layers of the anterolateral abdominal wall?

Skin
Superficial Fascia
Anterior: Rectus Sheath, Rectus Abdominis
Lateral: External oblique, Internal oblique, Transversus Abdominis

108

What are the attachments of the external obliques?

Between lower ribs and iliac crest, pubic tubercle and linea alba

109

What is the linea alba?

Midline interweaving of aponeuroses of anterolateral abdominal wall muscles

110

The fibres of external obliques run in the same direction as what?

External intercostals

111

What are the attachments of the internal obliques?

Between lower ribs, thoracolumbar fascia, iliac crest and linea alba

112

The fibres of internal obliques run in the same direction as what?

Internal intercostals

113

Where does transversus abdominis attach between?

Lower ribs, thoracolumbar fascia, iliac crest and linea alba

114

What do the tendinous intersections of the rectus abdominis do?

Divide each rectus abdominis into 3 or 4 smaller muscles to improve mechanical efficiency

115

Where does the linea alba run from?

Xiphoid process to the pubic symphysis

116

What is the rectus sheath?

Combined aponeuroses of anterolateral abdominal wall muscles surrounding rectus abdominis muscles

117

When undertaking a suprapublic incision, such as in lower segment C-section, what is cut from the anterior and posterior rectus sheath?

Anterior rectus sheath only

118

Describe the nerve supply to the anterolateral abdominal wall

Enter from lateral direction
7-11th intercostal nerves: become thoracoabdominal nerves
Subcostal (T12)
Iliohypogastric (L1)
Iliolingual (L1)

119

Where does the nerve supply to the anterolateral abdominal wall travel?

In plane between internal oblique and transversus abdominis

120

What is the blood supply to the anterior abdominal wall?

Superior epigastric arteries
Inferior epigastric arteries

121

Describe the superior epigastric arteries

Continuation of internal thoracic
Emerges at superior aspect of abdo wall
Lies posterior to rectus abdominis

122

Describe the inferior epigastric arteries

Branch of external iliac artery
Emerges at inferior aspect of abdo wall
Lies posterior to rectus abdominis

123

What is the blood supply to the lateral abdominal wall?

Intercostal and subcostal arteries

124

Describe the intercostal and subcostal arteries

Continuations of posterior intercostal arteries
Emerge at lateral aspect

125

How should you aim to minimise traumatic injury to muscle fibres when making an incision?

Incise in same direction as muscle fibre

126

When incising muscle, what should be aimed for?

Minimise traumatic injury to muscle fibres
Avoid damaging nerves
Avoid interrupting blood supply

127

What is done to the rectus muscles in a LSCS incision?

Separated from each other in a lateral direction, moving them toward their nerve supply

128

What layers are cut/moved in an LSCS?

Skin and fascia
(anterior) Rectus sheath
Rectus abdominis – separate the muscles laterally
Fascia and peritoneum
Retract bladder (a urinary catheter is usually already inserted)
Uterine wall
Amniotic sac

129

What layers need stitched closed in an LSCS?

Uterine wall with visceral peritoneum
Rectus sheath
(Fascial layer if increased BMI)
Skin

130

What layers are opened in a laparotomy?

Skin and fascia
Linea alba (a structure rather than a layer)
Peritoneum

131

What layers need stitched closed in a laparotomy?

Peritoneum & Linea alba
Fascia (if increased BMI)
Skin

132

What complications can occur in a laparotomy as it is relatively bloodless?

Can mean that healing is not as good
Increases the chance of wound complications e.g. dehiscence, incisional hernia

133

What must be avoided if a lateral port is required?

Inferior epigastric artery

134

In a laparotomy how can the position of the uterus be manipulated?

By grasping the cervix with forceps inserted through the vagina

135

What is the route of the inferior epigastric artery?

Branch of external iliac artery
Emerges just medial to the deep inguinal ring- ring located halfway between ASIS and pubic tubercle
Then passes in a superomedial direction posterior to the rectus abdominis

136

What is an abdominal hysterectomy?

Removal of the uterus via an incision in the abdominal wall (A)
Often same incision as for LSCS

137

What is a vaginal hysterectomy?

Removal of uterus via the vagina

138

How can the ureter be differentiated from the uterine artery in a hysterectomy to avoid damaging it?

Ureter passes inferior to artery (water under bridge)
Ureter will vermiculate when touched

139

What is the pelvic floor made up of?

Pelvic diaphragm
Muscles of perineal pouches
Perineal membrane

140

What makes up the pelvic diaphragm?

Levator Ani
Coccygeus

141

What does levator ani attach?

Pubic bones, ischial spines and tendinous arch of levator ani
Perineal body, coccyx and walls of organs in midline

142

What are the 3 parts of levator ani?

Puborectalis
Pubococcygeus
Iliococcygeus

143

What innervates levator ani?

Pudendal nerve and nerve to levator ani

144

Where does the deep perineal pouch lie?

Below the fascia covering the inferior aspect of the pelvic diaphragm
Above the perineal membrane

145

What is contained within the deep perineal pouch?

Part of urethra (and vagina in females)
Bulbourethral glands in males
NVB for penis/clitoris
Extensions of ischioanal fat pads and muscles

146

Where does the perineal membrane attach?

Laterally to the sides of the pubic arch, closing the urogenital triangle

147

Where is the superficial perineal pouch in males?

Below the perineal membrane

148

What is contained within the superficial perineal pouch in males?

Root of penis:
-Bulb- corpus spongiosum, crura-corpus cavernosum
-Associated muscles- bulbospongiosus and ischiocavernosus
Proximal spongy urethra
Superficial transverse perineal muscle
Branches of internal pudendal vessels and pudendal nerve

149

What is contained within the superficial perineal pouch in females?

Female erectile tissue and associated muscle:
-Clitoris and crura-corpus cavernosum
-Bulbs of vestibule-paired
-Associated muscles- bulbospongiosus and ischiocavernosus
Greater vestibular glands
Superficial transverse perineal muscle
Branches of internal pudendal vessels and pudendal nerve

150

What are the functions of the pelvic floor?

Support to pelvic organs- normally tonically contracted, actively contracts in coughing etc
Helps maintain continence:
-urinary (external urethral sphincter, compressor urethrae, levator ani)
-faecal (tonic contraction of puborectalis bends anorectum anteriorly, active contraction maintains continence after rectal filling)

151

What can cause injury to pelvic floor?

Pregnancy
Childbirth
Chronic constipation
Obesity
Heavy lifting
Chronic cough or sneeze
Previous injury to pelvic/pelvic floor
Menopause

152

What does continence depend on?

Urinary bladder neck support
External urethral sphincter
Smooth muscle in urethral wall

153

Describe vaginal prolapse

Herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia
Presents as lump in vaginal wall
Can be urethro/cysto/recto/entero-cele

154

Describe uterine prolapse

Descent of uterus
1st, 2nd, 3rd degree
Dragging sensation
Feeling of lump
Urinary incontinence

155

Describe sacrospinous fixation

Sutures placed in sacrospinous ligament
Just medial to the ischial spine
To repair cervical/vault descent
Performed vaginally
Risk of injury to pudendal NVB and sciatic nerve

156

Describe incontinence surgery

Trans-obturator approach
Mesh through obturator canal
Space in obturator foramen for passage of obturator NVB
Create a sling around the urethra
Incisions through vagina & groin

157

Where do the majority of arteries of pelvis and perineum arise from, and what are the exceptions?

From internal iliac artery
Exceptions:
Gonadal artery- L2 abdominal aorta
Superior rectal artery- continuation of inferior mesenteric

158

What is the medial umbilical fold a remnant of?

Umbilical artery

159

Where are most branches of the arteries in the male perineum from, and what is the exception?

Internal pudendal
Anterior scrotal artery is exception as comes from external iliac

160

Where do anastomoses occur in the female reproductive system?

Between uterine and ovarian artery, and between uterine and vaginal artery

161

Where do most pelvic and perineal veins drain to?

Internal iliac vein
Some via superior rectal into hepatic portal system, some via lateral sacral veins into internal vertebral venous plexus

162

Why does ureter damage occur more on the left than the right?

As the right is constant and usually crosses external iliac, whereas the left is more medial and crosses common iliac
51% of ureter damage occurs lateral to cervix during uterine artery division

163

What is the lymphatic drainage of the superior pelvic viscera?

External iliac nodes
Common iliac, aortic, thoracic duct, venous system

164

What is the lymphatic drainage of the inferior pelvic viscera?

Deep perineum
Internal iliac nodes
Common iliac, aortic, thoracic duct, venous system

165

What is the lymphatic drainage of the superficial perineum?

Superficial inguinal lymph nodes

166

What is the gonadal lymphatic drainage?

Lumbar (aortic/caval) nodes