Week 3 Flashcards
- actions of the upper and lower limb - blood supply to the limb - arm & elbow joint - lymph drainage of the limbs - neurological examination of the limbs - thrombosis, embolism & infarction (117 cards)
1
Q
In standing relaxed, what prevents forward sway?
A
periodic calf contraction
2
Q
Which 3 muscle groups are involved in standing upright?
A
- erector spinae
- thigh muscles
- calf muscles
3
Q
What percentage of the time walking is spent on the swing phase?
A
40%
4
Q
Name the 8 phases of gait.
A
1) heel strike (initial contact)
2) loading response (foot flat)
3) mid-stance
4) terminal stance (heel off)
5) pre-swing (toe off)
6) initial swing
7) mid-swing
8) terminal swing
5
Q
In the terminal stance, what draws the body forwards over the ankle?
A
momentum
6
Q
If you are in a terminal stance, with the left foot about to land, which structure in the right foot draws the calcaneus anteriorly and heightens the arch?
A
plantar aponeurosis
7
Q
In the pre-swing phase, where the left ankle is just reaching the ground, which muscles of the right and left ankle are at work, and what position does it give them? Which nerves are involved?
A
RIGHT ANKLE plantar flexion (tibial nerve) - gastrocnemius - soleus (- tibialis posterior)
LEFT ANKLE dorsiflexion (deep fibular nerve) - tibialis anterior - extensor digitorum longus - extensor hallucis longus
8
Q
Which nerve supplies the muscles of the toes involved in the powerful push off of pre-swing?
A
medial plantar branch of tibial
9
Q
Which nerve supplies the hamstrings?
A
sciatic nerve
10
Q
In which phase of gait are the hamstrings active?
A
preswing
11
Q
Which 2 muscles abduct the hip to keep the balance of the pelvis when standing on one foot?
A
- gluteus medius
- gluteus minimus
12
Q
Which 5 muscles support the plantar arches of the weight-bearing foot when standing on one foot?
A
- flexor digitorum longus
- tibialis anterior
- tibialis posterior
- fibularis longus
- intrinsic muscles of the foot
13
Q
Which 4 muscles are heavily involved when walking of uneven ground?
A
- tibialis anterior
- tibialis posterior
- fibularis longus
- fibularis brevis
14
Q
Which muscle does the musculocutaneous nerve pierce?
A
coracobrachialis
15
Q
Which nerve supplies the brachioradialis muscle?
A
radial nerve
16
Q
Which nerve passes between the brachialis and brachioradialis?
A
radial nerve
17
Q
To what does the radial collateral ligament attach distally?
A
the annular ligament
18
Q
Name the 3 branches of the aortic arch.
A
- brachiocephalic trunk
- left common carotid artery
- left subclavian artery
19
Q
Where does the brachiocephalic trunk branch off?
A
behind the right sternoclavicular joint
20
Q
Which muscles respectively divide the subclavian and axillary arteries into 3 parts?
A
SUBCLAVIAN ARTERY
anterior scalene muscle
AXILLARY ARTERY
pectoralis minor
21
Q
What are the 4 branches of the subclavian artery?
A
- vertebral artery
- thyrocervical trunk
- costocervical trunk
- internal thoracic artery
22
Q
Which two branches of the which artery anastomose around the surgical neck of the humerus?
A
posterior and anterior circumflex humeral arteries from the axillary artery
23
Q
Through which gateway of the shoulder does the profunda brachii artery go through?
A
the lower triangular space
24
Q
Which artery anastomoses with the inferior ulnar collateral artery?
A
anterior ulnar recurrent artery
25
From which artery does the radial collateral artery come?
profunda brachii
26
Which structures are supplied by the posterior interosseous artery?
forearm extensors
27
Between which 4 structures does the ulnar artery enter the hand?
- between 2 layers of flexor retinaculum
| - between the pisiform and the hook of the hamate
28
Which palmar arch and branch arise from the ulnar artery?
- superficial palmar arch
| - deep palmar branch
29
Which arteries are given off by the common palmar digital arteries?
the proper palmar digital arteries
30
What forms the dorsal carpal arch?
- dorsal carpal branches
| - posterior interosseal branches
31
Which of the basilic and cephalic vein is medial?
the basilic vein
32
Give the 3 points to feel arterial pulses in the upper limb.
- bicipital groove
- cubital fossa
- wrist anterolateral surface
(- anatomical snuff box)
33
Where do the basilic and cephalic veins respectively join with which deep veins?
BASILIC VEIN
lower border of teres major
brachial vein, forms axillary vein
CEPHALIC VEIN
clavipectoral triangle
axillary vein
34
What is the name of the veins that connect superficial veins to deep veins?
perforating veins
35
At what point does the axillary vein become the subclavian vein?
1st rib
36
What are the two terminal branches of the abdominal aorta, and what do they supply?
left and right common iliac arteries
lower limbs and pelvic regions
37
Which artery is deep to the inguinal ligament?
external iliac artery
38
Through which gateway of the hip do the internal iliac arteries enter the gluteal region?
Greater sciatic foramen (above and below piriformis)
39
Internal iliac arteries act as collateral circulation to the lower limb should either of which two structures become blocked?
- femoral artery
| - external iliac artery
40
Which branches does the femoral artery give off?
- superficial epigastric artery
- superficial circumflex iliac
- external pudendal arteries
- profunda femoris
41
Which artery runs between adductor longus and magnus?
profunda femoris
42
Give two other names for the adductor canal.
Hunter's canal or Subsartorial canal
43
Give the anterolateral, posterior and medial borders of the adductor canal.
ANTEROLATERAL BORDER
vastus medialis
POSTERIOR BORDER
- adductor longus
- adductor magnus
MEDIAL BORDER
- sartorius
- lamina vastoassuctoria
44
Which structures are supplied by branches of the obturator artery?
- head of acetabulum
- hip adductors
- knee
- skin of medial thigh
45
Where is the blood supply to the head of the femur derived from?
- circumflex femoral arteries
| - obturator artery
46
Which artery of the lower limb is the second most common site of aneurysm?
popliteal artery
47
How many genicular branches does the popliteal arteries give off and what are their names?
5
- superior lateral
- inferior lateral
- superior medial
- middle
- inferior medial
48
Between which two muscles does the anterior tibial artery descend?
- tibialis anterior
| - extensor digitorum longus
49
At which 2 structures of the foot can pulse be taken?
- behind the medial malleolus
| - 1st metatarsal space
50
Between the heads of which muscle does the small saphenous vein penetrate the deep fascia of the leg?
Gastrocnemius
51
What does the femoral vein end as?
the external iliac vein
52
Which 3 factors help venous return to the hear against gravity? (NOT INCLUDING VALVES)
- muscle pump
- arterial pulsation
- negative intrathoracic pressure
53
Define lymph nodes.
small nodules that filter and phagocytose particulate matter with he help of macrophages and lymphocytes
54
Name 3 groups of palpable superficial lymph nodes.
- cervical
- axillary
- inguinal
55
Which structures do deep lymph nodes accompany?
arteries
56
Where do the basilic and cephalic lymph nodes respectively drain to?
BASILIC
superficial and deep cubital lymph nodes
CEPHALIC
apical axillary nodes
(also for some deltopectoral and deep brachial nodes)
57
Which structures do the axillary lymph nodes drain?
- upper limb
- adjacent shoulder and neck regions
- breast
- posterior and anterior thoracic wall
- anterior abdominal wall (above umbilicus)
- skin of the back (above iliac crests)
58
Which 3 axillary group of nodes drain to the central axillary nodes?
- anterior (pectoral)
- lateral (humeral)
- posterior (subscapular)
59
Highlight the route of lymph from the central axillary nodes back to the venous system.
apical axillary nodes --> supraclavicular nodes --> subclavian lymph trunk --> (for the left side: thoracic duct -->) junction between internal and subclavian veins
60
Which nerve could be damaged during biopsy of the pectoral axillary nodes?
long thoracic nerve
61
Which vein do the medial superficial lymph vessels which drain the medial side of the dorsum of the foot and sole of foot and leg follow?
great saphenous vein
62
Which nodes first filter the lymph from the small saphenous vein? Which nodes does it then drain into?
popliteal lymph nodes 1st, then deep inguinal nodes
63
Which structures drain to the superficial inguinal nodes?
- anterior abdominal wall (under umbilicus)
- skin of back (below line of iliac crests)
- perineum
- gluteal region
- superficial lower limb
64
Where does lymph from the superficial inguinal nodes drain to?
either deep inguinal nodes or external iliac nodes
65
Give the boundaries of the femoral ring.
ANTERIORLY
the medial part of the inguinal ligament
MEDIALLY
lacunar ligament
LATERALLY
septum between the femoral canal and the femoral vein
POSTERIORLY
pectineus muscle and fascia
66
What is the name of the inferior entrance of the thoracic duct?
cysterna chyli
67
What is Pyrogov's venous angle
the junction between the subclavian and internal jugular veins
68
In the inspection part of the neurological examination of the upper limb, what are you looking for?
- posture of the limb
- any asymmetry
- symmetry, size and shape of the muscles
- scars or bruising
- any abnormal movements
- fasciculations
69
Name 2 conditions in which muscle tone could be decreased.
- cerebral palsy
- premature birth
- after severe infections (meningitis)
- MS
- brain or spinal cord injuries
- Down's syndrome
- muscular distrophy
- myasthaenia gravis
70
Which 6 movements do you test in the screening assessment of power of the neurological examination of the upper limb? Which muscles and nerve do each of these movements refer to?
- shoulder abduction (deltoid C5)
- elbow flexion (biceps C5/6)
- elbow extension (triceps C7)
- wrist extension (radial and ulnar extensors C6/7)
- finger abduction (intrinsic muscles C8/T1)
- thumb abduction (abductor pollicis brevis C8/T1)
71
How is the path upper motor neurons follow called?
corticospinal tracts
72
Define muscle tone.
The muscle's resistance to passive stretch during resting state
73
Which 3 upper limb tendon reflex do you check in a neurological examination?
- biceps reflex
- triceps reflex
- brachioradialis reflex
74
Which sensations do each of the two main sensory pathways of the upper limb carry information about?
DORSAL COLUMNS
- proprioception
- vibration
- light touch
- two-point discrimination
SPINOTHALAMIC TRACT
- pain
- temperature
- some light touch
75
Which objects would you use in a full assessment of sensation of a neurological examination of the upper limb?
- disposable neurological pin
- cotton wool
- vibrating tuning fork (128Hz)
- cold spray
76
What is a glove and stocking pattern?
The fact that symptoms of peripheral neuropathy usually start at the extermities: the hand and foot
77
What is mononeuritis multiplex?
a type of peripheral neuropathy where there is damage to several areas of the same nerve
78
Which two tests are not done routinely in the assessment of coordination of a neurological examination of the upper limb?
- finger to finger
| - fine movements
79
What are the most common causes of tremor at rest and on action?
at rest: Parkinson's disease
| on action: physiological tremors
80
Define thrombus, thrombosis, phlebothrombosis, thrombophlebitis, embolus and infarct.
THROMBUS
a solidification of blood contents that forms within the vascular system during life
THROMBOSIS
the pathological process of formation of a thrombus with the non-interrupted vascular system
PHLEBOTHROMBOSIS
venous thrombosis
THROMBOPHLEBITIS
when an inflamed vein causes trombosis
EMBOLUS
detached intravascular solid, liquid or gaseous mass that is carried by the blood to a site distant from its origin
INFARCT
an area of ischaemic necrosis caused by occlusion of arterial supply or venous drainage in a particular tissue
81
Name the 3 factors involved in the pathogenesis of thrombosis.
- endothelial injury
- abnormal blood flow
- hypercoagulability
82
Give 4 examples of where thrombi can form following endothelial injury. Give 5 other potential bases for endothelial injury.
- left ventricle at sites of MI
- on ulcerated plaques in advanced atherosclerosis
- injured endocardium (cardiac surgery, myocarditis)
- valves with inflammatory valve disease, and prosthetic valves
- radiation injury
- chemical agents (endo- and exogenous)
- bacterial toxins and endotoxins
- immunologic injuries
- neoplastic involvement
83
What is the initial step in the pathogenesis of a thrombus (endothelial injury)? What molecules released by which cells are responsible for this reaction?
Vasoconstriction
caused by endothelins released by endothelial cells surrounding the site of injury
84
In primary haemostasis, which three factors released by granules in platelets that have adhered to the site of injury are chemotactic agents?
- ADP
- TXA2 (Thromboxane A2)
- Pf4 (platelet factor IV)
85
Which 3 proteins allow aggregation of plateletsas a haemostatic plug? What are each of their deficiencies called?
- von Willebrand's factor (vWF) on collagenous tissue at site of injury --> von Willebrand's disease
- glycoprotein Ib (GpIb) on platelets to attach to vWF --> Bernard-Soulier syndrome
- GpIIb-IIa complex to attach indirectly to other platelets via fibrinogen --> Glanzmann's thrombasthenia
86
What does thrombin activation cause?
fibrin polymerisation
87
Which two antithrombotic molecules are released after secondary haemostasis?
- t-PA
| - thrombomodulin
88
What alterations in the normal blood flow promote endothelial cell damage, and in what way?
turbulence and stasis
- disrupt laminar flow
- prevent the dilution of coagulation factors
- retard the inflow of inhibitors of clotting factors
89
What is hypercoagulability?
an alteration of the blood coagulation mechanism that in some way predisposes thrombosis
90
Name three primary and three high risk secondary causes of hypercoagulability.
PRIMARY
- Leiden mutation (mutation in the factor V gene)
- antithrombin III deficiency
- protein C and S deficiency
HIGH RISK SECONDARY
- bed rest
- MI
- tissue damage
- carcinoma
- prosthetic valves
91
Where would you find a mural thrombus?
In the lumen of the heart or of the aorta
92
What are the three most frequent places in which to find an arterial thrombus, from most frequent to least frequent?
- coronary artery
- cerebral artery
- femoral artery
93
How would you differentiate visually between an arterial and a venous thrombus?
ARTERIAL THROMBUS
grey white
VENOUS THROMBUS
dark red/purple
94
Which type of thrombus is invariably occlusive?
Venous thrombus
95
What are the 4 possible fates of a thrombus?
- resolution
- embolisation to lung
- propagation towards heart
- organised and recanalised, then incorportated into wall
96
What are the clinical correlations of arterial thrombi?
- loss of pulses distal to thrombus
- 4Ps: perishing cold, pale, painful, paraesthesia
- eventual death of tissue and gangrene
97
Which symptoms are associated with superficial phlebothrombosis?
- congestion
- swelling
- pain
- tenderness
(- only rarely: embolus)
98
What is Homan's sign?
discomfort behind the knee on forced dorsiflexion of foot
99
What two drugs can you give to treat thrombosis? What are their respective routes and speed of onset?
- heparin (IV or subcutaneous, fast onset)
| - warfarin (orally, slow onset: 1 day)
100
What total percentage of embolisms do thromboembolisms represent?
99%
101
What type of embolisms are caused at more than 95% by thrombi within the large deep veins of the legs?
pulmonary embolisms
102
What is a saddle embolus?
A pulmonary embolus lodged at the bifurcation of an artery
103
What is pulseless electrical activity?
A rhythm found using an ECG, but where pulses are not palpable. usually followed by instantaneous death
104
What are the two main pathophysiologic consequences of a pulmonary embolism?
- respiratory compromise
| - haemodynamic compromise
105
What shape would a pulmonary infarct take on a chest X-Ray
a wedge, light grey shape on the lungs
106
Give 4 causes of systemic emboli less common than thrombi within the heart.
- ulcerated atherosclerotic plaque
- aortic aneurysm
- infective endocarditis
- valvular or aortic protheses
107
What is the total percentage of systemic emboli that lodge into either the lower or upper limbs?
lower limbs: 70-75%
upper limbs: 7-8%
--> 77--83%
108
Give 4 causes of barotrauma
- delivery or abortion
- pneumothorax
- injury to the lungs/chest wall
- caisson disease or decompression sickness
109
What is the treatment for "the bends"
acute caisson disease --> recompression chamber
110
What % of people with severe skeletal injury manifest clinical signs of fat embolism?
1%
111
Describe the pathogenesis of fat embolism.
MECHANICAL OBSTRUCTION
microagregates of neutral fat causes occlusion
CHEMICAL INJURY
free fatty acids released from fat globules result in toxic injury to the vascular endothelium
112
When do symptoms of fat embolism appear?
after 24-72hrs
113
What does the pulmonary microcirculation from a victim of amniotic fluid embolism contain?
- epithelial squames from foetal skin
- lanugo hair
- fat from vernix caseosa
- mucin from foetal respiratory or GI tract
114
What follows profound respiratory difficulty in amniotic fluid embolism?
convulsions
115
Which condition(s) cause(s) 99% of infarcts? What are the other causes?
thrombosis and embolism
- vasospasm
- expansion of atheroma
- compression of a vessel
- twisting of the vessels
- traumatic rupture
116
Give four factors that influence development of an infarct.
- nature of the vascular supply
- rate of development of occlusion
- vulnerability to hypoxia
- oxygen content of blood
117
How would you differentiate between an infarct from a venous occlusion and that from an arterial occlusion?
VENOUS OCCLUSION
red (haemorrhagic)
in loose tissues and tissues with dual circulation
ARTERIAL OCCLUSION
white (anaemic)
in solid organs
