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Describe anatomy of the radial artery

Commences as one of the two terminal branches of the brachial artery, located medical to the biceps tendon

3 parts
proximal--between its origin and the distal extent of the antecubital fossa
middle---extends from the antecubital fossa up to the origina of the tendons of brachioradialis, extenso carpi radialis longus and extensor carpi radialis brevis...
distal part-- which runs from the origin of these tendons to the wrist crease


Main nerves at risk during harvesting of radial

Lateral cutaneous nerve of the forearm (C5-C6)--carries sensory fibres to the lateral aspect of the forearm

Superficial radial nerve (nerve roots C7-C8), which crosses the anatomical snuff box and carries sensory fibres to the thenar eminence


Describe the anatomy of the phrenic nerve

Phrenic nerve originates from the C3 C4 and C5 nerve roots and courses down through the neck lying anterior to scalenous anterior

Passes posterior to the subclavian artery and medial to the internal mammary artery to lie on the lateral surface of the pericardium

Right phrenic passes through the inferior vena cava opening in the diaphragm at the level of T8

Left phrenic nerve pierces the muscular part of the left hemi-dirphragm.


How is dominance of the coronary artery system determined

Artery from which the posterior descending artery originates (not the vessel which supplies the greater absolute myocardial mass)

Right dominant system occurs in 80-85%
Left in 10-15%
Co dominant in 5%.

Left dominance more often in males and bicuspid valve


Describe the coronary venous drainage system

Majority of veins drain via the coronary sinus into the right atrium

Coronary sinus is a continuation of the great cardiac vein and the change is denoted by the valve of Vieussens and entry of the oblique vein of the left atrium (the vein of Marshall)

Thesbian veins and larger anterior veins drain directly into the right atrium, bypassing the coronary sinus


Describe location of atrioventricular node

Within the triangle of koch

Boundaries of the triangle of koch include
a) tendon of todaro
b) hinge of the septal leaflet of the tricuspid valve
c) superior margin of the coronary sinus

The membranous septum lies just superior to the triangle of koch and is where the bundle of HIS penetrates to enter the muscular septum.


Describe the structure of the mitral valve

1) Leaflets
2) Papillary muscles
a) the anterolateral papillary muscle has a single head and takes its blood supply from the circumflex artery
b) the posteromedial papillary muscle has multiple heads and takes its blood supply from the right coronary artery
3) Chordae tendineae:
a) Primary (free edge chordae) which run from the papillary muscles to the free edge of the leaflets
b) secondary (strut chordae) which run from the papillary muscles to the roughened zone of the ventricular surface of the leaflet
c) tertiary (basal chordae) which run from the papillary muscles or ventricular wall to the bases of the leaflets.


Describe the location of the oblique and transverse pericardial sinuses

oblique sinus lies posterior to the left atrium, between the 4 pulmoanry veins and medial to the inferior vena cava

transverse sinus lies behind the aorta and pulmonary trunk and in front of the superior vena cava and left atrial appendage


Describe the course and landmarks of the long saphenous vein

Commences just anterior and superior to the medial malleolus
continues up medical aspect of lower leg before turning slightly posteriorly at the superior aspect of gastrocnemius
passes medial to knee joint (5 cm posterior to the medial aspect of the patella)
Continues up to the medial aspect of the thigh to drain the common femoral vein at the saphenofemoral junction.
The SFJ location 3 cm inferior and 3 cm medial to the femoral artery pulsation.


List veins of the heart

Coronary sinus
small cardiac vein
middle cardiac vein
Great cardiac vein


Describe infraclavicular approach to exposure to axillary artery

Horizontal skin incision 2 cm below middle 3rd of clavicle.
split pec major fascia and reveal clavipectoral fascia
sharply dissect axillary sheath
divide pec minor as needed but try to avoid it.
artery lies superior and deep to vein--best exposed by mobilizing and retracting vein inferiorly
Thoracoacromial artery may need ligation
obtain proximal and distal control
use a 8 to 10 mm dacron graft and a 3/8 connector


Describe the left phrenic nerve

Between the Left subclavian artery and the Left common carotid artery.
Crosses the arch anterior and to the left of the vagus.
Continues anterior to the root of the lung and passes over the pericardium of the left ventricle and through diaphragm


What does the recurrent nerve supply

All the intrinsic muscles of the larynx except cricothyroid muscle and sensory function below the vocal folds


What is path of Left vagus

Left Vagus starts posterior of the L-CCA and enters the chest between the L-CCA and L-SCA. Gives recurrent laryngeal nerve which goes around the arch (near ligamentum arteriosium) posterior and medical to the CCA.


What are tests of hemolysis

peripheral blood smear--sperocytes
Increased LDH
decreased haptoglobin
increase indirect Biliubin
increased Hemglobin in urine (Dark--increased hemosiderine, urobiliogen)
bone marrow biopsy


Where is Bundle of HIS

Penetrates central fibrous body to reach the membranous septum to lie on the crest of muscle ventricular septum just beneath the commissure between the right and non-coronary cusps of the aortic valve


What is nodule of arantius

fibrous core at the free edge of the leaflet, usually located centrally.


What is papillary muscle blood supply

Anteriolateral---circumflex, LAD,

posteriormedial--usually has multiple head, most supply from from the RCA only


How much does mitral annulus contract during systole

reduces its cross sectional area by 20-40%


List Chordae of mitral valve

Primary--free edge. Run from the papillary muscle to the free edge of the leaflets

Secondary--strut chordae--run from papillary muscle to the roughened zone on the ventricular surface of each leaflet

tertiary---run from the papillary muscle to ventricular free wall to the base of leaflets


What are leaflets of tricuspid valve

anterior leaflet (largest)
posterior (smallest)


What are two muscles to identify when harvesting the radial artery

Flexor carpi radialis
*often see the flexor pollicis longus


Describe the anatomy of LITA

List branches and terminal branches

Originates from the first part of the subclavian courses down posterior aspect of chest wall approximately 2 cm lateral to the left sternal edge.

1) intercostal branches; 2) Perforating branches (supply pectoralis) 3) sternal branches) 4) percariophrenic (supplies lateral aspect of pericardium).
Terminates at 6th intercostal space
a. superior epigastic, supplies superior aspect of the anterior abdominal wall.
b. Muscuophrenic--supplies branches to the 6 to 10th intercostal spaces.

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