Anatomy Flashcards
(166 cards)
1
Q
What does the bony pelvis consist of?
A
2 hip bones
Sacrum
Coccyx
2
Q
What is each hip bone a fusion of?
A
Ilium
Ischium
Pubis
3
Q
What is the ischiopubic ramus made up of?
A
Both ischium and pubis
4
Q
What ligament attaches to the pubic tubercle?
A
Inguinal ligament
5
Q
Where does the inguinal ligament attach between?
A
The ASIS and pubic tubercle
6
Q
Where are the ischial spines palpable?
A
On vaginal examination, at about a finger breadth into the vagina (approx. 4 and 8oclock positions)-also pudendal nerve
7
Q
Where are the attachments of the sacrospinous ligament?
A
Sacrum and ischial spine
8
Q
Where are the attachments of the sacrotuberous ligament?
A
Sacrum and ischial tuberosity
9
Q
What is the function of the sacrotuberous and sacrospinous ligaments?
A
Ensure inferior sacrum is not pushed superiorly when weight is suddenly transferred vertically through vertebral column (eg. jumping, later pregnancy)
10
Q
What 2 foraminae do the sacrotuberous and sacrospinous ligaments form?
A
Greater and lesser sciatic foraminae
11
Q
What forms the pelvic inlet?
A
Sacral promontory
Ilium
Superior pubic ramus
Pubic symphysis
12
Q
What forms the pelvic outlet?
A
Pubic symphysis Ischiopubic ramus Ischial tuberosities Sacrootuberous ligaments Coccyx
13
Q
What part of the pelvic cavity does levator ani form?
A
Pelvic floor- musculofascial inferior part
14
Q
What are the functions of the pelvis?
A
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
Q
What are the key differences between the female and male pelvis?
A
AP and transverse diameters are larger
Subpubic angle is wider
Pelvic cavity is shallower
16
Q
What is moulding?
A
The movement of one bone over another to allow the foetal head to pass through the pelvis during labour
17
Q
Moulding is allowed due to the presence of what?
A
Sutures and fontanelles
18
Q
What is the vertex?
A
An area of foetal skull- outlined by the anterior and posterior fontanelles and the parietal eminences
19
Q
Which is longer-the occipofrontal diameter or the biparietal?
A
Occipitofrontal
20
Q
At the pelvic inlet, is the transverse of AP diameter wider?
A
Transverse
21
Q
The foetus should enter the pelvic cavity facing what direction?
A
Either right or left (transverse)
22
Q
What is the station?
A
The distance of the foetal head from the ischial spines
-ve means head is superior, +ve means head is inferior
23
Q
What should the foetal head do whilst descending through the pelvic cavity?
A
Rotate
Be in a flexed position e.g. chin on chest
24
Q
At the pelvic outlet is the AP or transverse diameter wider?
A
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
