Clinical Correlations Compendium

Upper Limb
Thoracic outlet syndrome: Compression of subclavian artery and lower trunk ofbrachial plexus, can be caused by cervical rib Winging of scapula: Damage to serratus anterior or long thoracic nerve Cannot hold purse under arm: Corachobrachialis problems (pierced by musculocutaneous nerve) Supracondylar fracture: Results in claw hand Wrist drop: Cannot extend wrists, damage to radial nerve (or one of its branches), humeral fracture from behind Arc Syndrome: Inflammation of subacromial bursa, pain between 60-120 of rotation, bursas of supraspinatus Anterior inferior dislocation of shoulder: Most common type of dislocation, 1st muscle to be damaged is supraspinatus Loss of sensation over regimental badge area: Damage to axillary nerve (can be caused by fracture of surgical neck of humerus [can also damage posterior circumflex humeral] Popeye defect: Long head of biceps brachii detaches from supraglenoid tubercle Radical mastectomy: T2 nerve (intercostobrachial nerve) can possibly be damaged Axillary lymph node removal: Long thoracic, thoracodorsal nerve, are possible to be damaged Strain of muscles around epicondyles o Medial: Golf elbow o Lateral: Tennis elbow Damage to median nerve: Results in ape hand (cannot oppose thumb, or abduct it) Saturday night palsy /Crutch syndrome: Compression of radial nerve resulting in temporary compression of radial nerve, resulting in wrist-drop Allens Test: To test circulation of hand, compress both radial and ulnar arteries (both sides of wrist), hands should lose colour release one side, blood should return via collateral circulation Tinels Test: Ulnar nerve is tapped in groove, positive when tingling sensation is felt down arm _____: White->blue->red Lunate dislocation: Most common carpal bone to be dislocated, results in damage to median nerve (carpal tunnel syndrome like symptoms) Scaphoid fracture: Radial artery can be damaged, proximal avascular necrosis (as opposed to distal), since scaphoid receives blood from distal to proximal. Poor blood supply either way, can take time for it to appear as fracture on X-ray Erb-Duchenne Palsy: Damage to upper trunk of brachial plexus (C5,C6,{C7}), caused by a sudden increase of the angle between the head and shoulder (child-birth, motor vehicle accident) arm is extended, adducted and pronated (Waiters Tip position)

Klumpke palsy: Damage to lower trunk of Brachial plexus, caused by a sudden increase of the angle between the arm and the body (like falling and grabbing a tree branch), results in claw-hand (4th and 5th digits) Colles Fracture: Fracture of lower end of radius resulting in the fragment being displace (tilted) posteriorly, producing a bump described as the dinner fork deformity Smiths Fracture: Distal fragment of radius is displaced (tilted) anteriorly (also can be called reverse Colles fracture Fracture of hamate: Often hook is fractured, results in damage to ulnar nerve Hand of benediction: Injury to median nerve, cannot flex 1st three digits when attempting to make a fist, damage to median nerve (part of flexor digitorum profundus not working)

Lower Limb
Meralgia Parasthetica: Inflammation of inguinal ligament causes compression of lateral cutaneous nerve of thigh, resulting in tingling, numbness, burning pain in lateral part of thigh Femoral Hernia: Contents of abdomen (usually small intestine) slips through the femoral ring into the femoral canal (more common in women than men since women have wider pelvises). Femoral ring has stiff boundaries, resulting in strangulation of herniated tissue, potentially causing tissue death. Must be surgically repaired. Abnormal obturator artery: Obturator artery can lie on lacunar ligament where it can be damaged upon surgical repair of femoral hernia Injury to saphenous nerve: Quadriceps muscles are paralyzed, knee cannot be extended, sensory loss over anterior and medial sides of lower part of leg, medial border of foot (up to base of toe) Injury to obturator nerve: Anterior dislocation of hip, abdominal hernia through obturator foramen, rarely injured in penetrating wounds. All adductors are paralyzed except hamstring part of adductor magnus, minimal cuntaneous sensory loss on medial side of thigh Best site of intramuscular injection in gluteal region is the superior-lateral quadrant (poorly placed intramuscular injections can cause damage to sciatic nerve Damage to sciatic nerve: Can be damaged by penetrating wounds, fractures of pelvis, (complete) dislocation of hip, poorly placed intramuscular injection. Results in paralysis of hamstring muscles (weak flexion possible because of sartorius and gracilis), paralysis of all muscles below the knee, weight of foot causes foot drop. Loss of sensation below knee except for medial border of foot (up to base of big toe). Sciatica: Pain along sensory distribution of the sciatic nerve. Pain in posterior part of thigh, posterior and lateral aspects of leg and lateral part of foot. Caused by prolapse of intervertebral disc, with pressure on one or more roots of lumbar and sacral spinal nerves. Can be caused by an intra-pelvic tumour, or inflammation of sciatic nerve or its branches. Deep fibular nerve injury: Results in weakness of ankle dorsiflexion, no extension of all toes, sensory damage only in webbing between first and second digits (interdigital cleft)

Superficial fibular nerve injury: Loss of eversion of foot (lateral leg muscles), loss of sensation over dorsal skin of foot except interdigital cleft b/t 1st and 2nd toes, medial and lateral borders of foot Damage to common fibular (peroneal) nerve: Can occur by injury of neck of fibula, muscles of anterior and lateral compartments of leg, opposing (posterior flexors and inverters) muscles cause plantarflexion and inversion of foot. Foot drop + inversion = equinovarus. Sensory loss occurs down the anterior and lateral sides of leg and dorsum of the foot and toes, including medial side of the big toe. Tibial nerve injury: Muscles of back of leg and sole of foot are paralyzed, opposing muscles (dorsiflexors, and chief everters) cause dorsiflexion and eversion of foot calcaneovalgus. Loss of sensation from sole of foot and lateral border of foot. Compartment Syndrome: Increased pressure in muscle compartment due to fluid and the inability of deep fascia to expand. Swelling in the compartment causes the increased pressure which compresses muscles, blood vessels and nerves. It can block blood flow resulting in permanent damage to muscle and nerves (can lead to avascular necrosis), surgical intervention is needed where a longitudinal incision is made through fascia to relieve pressure. Wound left open for 2-3 days (covered w/ sterile dressing). Shin splints: Pain along or just behind tibia, caused by too much force placed on shinbone and connective tissue attaching muscles to it. Common in stop-and-start activities, most cases can be treated with self-care (rest, ice) Mortons Neuroma: Most common form of nerve entrapment in the foot. Entrapment in this case means thickening of connective tissue around the nerve (common digital nerve) (fibroma) as it passes under the intermetatarsal ligament of 3rd (or sometimes 2nd) webspace. Presents with pain while walking, or wearing shoes Puncture wound to sole of foot can lead to severe bleeding if deep plantar arch is injured Pes planus: Flat feet (no/low arches of foot) can lead to pain due to decreased protection of nerves/blood vessels on sole of foot->Can result in Metatarsalis. Not everyone with flat feet will develop metatarsalis. Pes cavus: Abnormally high arches Talipes (Club Foot): Most common kind is talipes equinovarus (foot plantarflexed, inverted, adducted). Walking becomes painful, weight is borne on lateral side of feet. Varicose veins: Result from incompetent valves that allow blood to pass from deep to superficial veins, causing dilatation. o If veins dilated on medial side->Varicose veins of GSV, lateral->SSV o Genetic factor in varicose veins Saphena Varix: Dilation of GSV at sapheno-femoral joint (bad sapheno-femoral valve). Blue bulge appears, looks like femoral hernia, but unlike a femoral hernia it will disappear when lying down GSV commonly used for myocardial revascularization, but since it is a vein, must cut off valves, or run it backwards. (Internal thoracic artery and radial artery are most common sources) Saphenous cutdown: Incision anterior to medial malleolus (don't cut saphenous nerve) in order to access GSV for IV fluid infusion (done when other veins [like median cubittal] cannot be accessed)

Deep vein thrombosis: Very dangerous. Causes: Venous stasis, injury to vessel wall, hypercoagulable state. Coagulation occurs, and can detach. It will pass through the veins, through the heart, then get stuck in pulmonary vessels (narrower), causing cardiopulmonary arrest, then death. Fat embolism: Fracture of shaft of femur can damage femoral vein, surrounding fat droplets can enter the circulation causing problems similar to DVT Air embolism: Air enters circulatory system, can cause blockages->myocardial infarction, stroke Medial collateral ligament tear: Blow on lateral side of knee Lateral collateral ligament tear: Blow on medial side of knee Unhappy triad: Blow on lateral side of knee while foot is fixed: Medial collateral ligament tear, damage to medial meniscus, twisting of tibia in opposite direction (ACL tear) Arthroscopy: Small incision allows light and camera into leg to repair ACL/PCL surgically while being minimally invasive Hallux valgus: Lateral deviation of great toe (swelling of bursa) Hallux rigidis: Stiff (and swollen) toe Potts fracture: Oblique fracture of lower end of fibula, horizontal fracture of medial malleolus Drawer Sign: Anterior for ACL tear (more common) (tibia displaced forward), Posterior for PCL tear (tibia displaced backward) Lateral ankle sprain: More common, excessive inversion of plantar flexed foot. Anterior talofibular ligament most likely to rupture Medial ankle sprain: Less common, since deltoid/medial ligament is so strong. If it does occur, it is due to excessive eversion, and can also lead to avulsion of medial malleolus. Fracture to cuboid: Fibularis longus may be damaged If sustenaculum of calcaneum is broken, can cause damage to flexor hallucis longus, resulting in loss of flexion at ip joint for big toe

Thorax
Flail chest: Loss of stability of thoracic cage, occurring when a segment of the anterior or lateral thoracic wall moves freely due to multiple rib fractures. The loose segment moves in on inspiration, outward on expiration. Painful, and impairs ventilation, affecting oxygenation of blood, and causing respiratory failure Thoracic outlet syndrome: Compression of lower trunk of brachial plexus and subclavian artery just under clavicle. Can be caused by cervical rib, can result in pain, numbness in last 3 fingers and inner forearm, weakening/loss of radial pulse Internal thoracic artery is a good choice for revascularization for coronary bypass because although it is a medium sized artery, it has a high amount of elasticity, and less muscle (normally it is other way around), easily accessible, less related to age related pathology, luminal diameter is large enough to supply coronary arteries, has low sympathetic index, so wont undergo stenosis or vasospasm so easily. Other choices would be radial artery (will vasospasm), or GSV (a vein) Herpes Zoster: Viral infection, virus travels along course of nerve, rashes seen only on one dermatome, if facial nerve: Ramsay-heart syndrome

Tx: Isolate, childhood vaccinations to varicella Intercostal nerve block: Block main branch since it is musculocutaneous (collateral branch is motor only), make sure not to puncture pleural cavity->can have pneumothorax Thoracocentesis: Patient should be in sitting position, hold breath, needle goes in 9th ic space along midaxillary line, needle should be passed through lower portion of space (main nerve on upper portion) Hiccoughs are caused by irritation of diaphragm Most dangerous (but also rare) form of diaphragmatic hernia is Costovertebral trigone (Bockdalek triangle) Horners Syndrome: Loss of sympathetic nerve supply to neck due to pressure on T1/Stallate gangion by apex of lung (due to tumour). Symptoms are ipsilateral (same side), pupil constriction occurs (dilation prevented), no/reduced sweating, droopy eyelids Apical segment of lower lobe, posterior segment of upper lobe are common sites for lung abscesses Sternal puncture: Sternum contains red bone marrow throughout life, and is easily accessible Median Sternotomy: Division of sternum in median plane->allows access to mediastinal contents Sliding esophageal hernia (paraesophageal hernia) ->May occur in middle-aged persons with weak musculature around the esophageal opening Paralysis of Half of diaphragm: Injury or operative division of phrenic nerve of same side. Detected radiologically->paradoxical movement (diaphragm of paralyzed side moves up upon inspiration (instead of down). Dome of diaphragm of injured side pushed superiorly by abdominal viscera during inspiration instead of descending Pneumothorax, hemothorax, hydrothorax, chylothorax-> Fluid in the lungs (air,blood,water,lymph) Tension pneumothorax: Air enters pleura, but cannot leave (accumulates), pressure increases o Diaphragm is depressed o Mediastinal shift (trachea deviation) o Increased heart rate o Decreased blood pressure (decreased venous return, engorged neck vein) o Long can collapse o Emergency, can be fatal, must drain fluid with wide bore needle at 5th IC space, midclavicular line Pleuritis (Pleurisy): Inflammation of pleura, adherence of parietal and visceral pleura (decreased fluid in pleural cavity), can be heard as a pleural rub. Horners Syndrome: Loss of sympathetic nerve supply to neck due to pressure on T1/Stallate gangion by apex of lung (due to tumour). Symptoms are ipsilateral (same side), pupil constriction occurs (dilation prevented), no/reduced sweating, droopy eyelids Apical segment of lower lobe, posterior segment of upper lobe are common sites for lung abscesses Costal and Peripheral diagphragmatic pleura local pain, and referred pain along the same dermatome Mediastinal and central diaphragmatic pleura referred pain to the root of the neck and over the shoulder

Bronchoscopy: Nose->Oropharynx->Larynx->Trachea Tumours can be identified by either X-ray or CT scan Pneumonia: Inflammation of lungs (viral, bacterial, mycoplasma) Tuberculosis: Micobacterium tuberculosis; spreads by sputum->Can travel across segments Pancoasts / Superior pulmonary sulcus tumour: Tumour of apex of lung, can compress subclavian vessels, brachiocephalic vein, phrenic nerve, recurrent laryngeal nerve, vagus nerve o Also compresses sympathetic ganglia (at stellate ganglion)->Horners Syndrome Pulmonary embolism (air, fat, blood clot] o Tx: Heparin->Anti-coagulant (for blood clot embolism [thromboembolism] or surgical removal Auscultation of Lungs o Listen with stethoscope o Tap over lungs with finger on chest Air: Resonant sound Fluid: Dull sound Solid: Flat sound Pericardial Tamponade: Increased pericardial fluid causes compression of heart (since fibrous layer does not expand) Pericarditis: No fluid in pericardial sac Pericardiocentesis: Draining fluid from pericardial cavity o 5th, 6th ic space, close to lateral border of sternum (Heart not covered by lung 4th-6th ic space, cardiac notch) o Xiphicostal angle Aortic knuckle (arch of aorta on X-ray) Coarction of Aorta: Narrowing of lumen (usually after three major arch branches. Decreased circulation to lower body, but still get some due to anastomoses with internal thoracic arteries and descending thoracic aorta through intercostal arteries o Will see enlarged posterior intercostal arteries o Pulsatile scapula o Makes deeper costal grooves PDA (Patent Ductus Arteriosis) Aortic aneurism (abnormal dilatation) compresses surrounding structures Cardiomegaly: Heart is too big, causes problems (if it is left atrium, can compress esophagus) ALCAPA: Anomalous left coronary artery arising from pulmonary artery: Very rare, usually fatal (one rare case that girl lived to 17 years) LAD is most likely coronary artery to become occluded (followed by RCA) Kyphosis: Hunching of upper spine (hunchback), associated with old age and osteoporosis Lordosis: Exaggerated lumbar curve (osteomalacia is associated). Pregnant women may have temporary lordosis Scoliosis: Lateral deviation of spine, can be caused by erosion of vertebral bodies (can be caused by aortic aneurism), muscular paralysis

Spondylolisthesis: Slipping of one vertebra onto the one below it. Usually L5->S1, results in compression of spine Klippel-Feil: Short, stiff neck due to reduced number of cervical vertebrae. Low hairline, limited neck mobility Hangmans fracture: Fracture of pedicles of axis (C2 vertebra) Prolapsed nucleus pulposus can compress the spinal nerve below it-> pain along dermatome: Herniated disk Lumbar puncture / Spinal Tap: Needle into subarachnoid space (below L1), safest from L3 to L5. Performed in order to sample CSF, inject drugs or antibiotics

Abdomen
Appendicitis: Can feel referred pain along T10 dermatome (around umbilicus) Never make incision along linea semilunares, since the nerves are there, will paralyze rectus abdominis Incision along linea alba is not optimal since, being connective tissue, it heals slowly, and can result in postoperative hernias Paramedian incision: Skin, superficial fascia, deep fascia, anterior wall of rectus sheath, push rectus abdominis laterally, fascia transversalis, parietal peritoneum, abdominal cavity o Suture the layers separately when done o Best option, since it will heal faster, and cannot have postoperative hernia since rectus abdominis is intact Pfunnelstein incision (Suprapubic incision): Through lower part of abdomen with a convex upward incision (minimizes nerve injury. Used during C-sections McBurneys Point: 2/3 of the way down an imaginary line drawn from umbilicus to ASI, it is the point representing the base of the appendix (tenderness here might mean appendix problems) Murphys sign: Pain upon palpitation of 9th costal cartilage indicating inflammation of gallbladder Direct Inguinal Hernia: Usually old age and weakened conjoint tendon are factors. Abdominal contents are pushed through posterior wall of inguinal canal, rarely reaches scrotum, lump can be seen by superior inguinal ring Indirect Inguinal Hernia: Congenital, remnant of processus vaginalis. Contents pass through deep ring, usually reach base of scrotum. Omphalocoele: Failure of intestines to go back down into peritoneum, failure of the fixing of normal umbilical hernia Rectouterine pouch (of Douglas) is a site for ectopic pregnancy, it is also the site where all peritoneal fluid will drain while standing To remove ectopic pregnancy or fluid, can pass a needle through the posterior fornix

Epiploic hernias are problematic, since it is difficult to make an incision through any of its borders. Intestine must be decompressed. Gastric ulcers: Excess HCl can cause structural damage to walls o Can invade lesser sac, invading pancreas, splenic artery (which can lead to rupture and hemorrhage) o Can be caused by Helicobacter pylori Vagotomy: Do if too much ulcer pain, but causes loss of function of smooth muscle movement) Must remove pyloric sphincter to enlarge pyloric opening, or ligate stomach w/jejunum Selective vagotomy: Spare the nerve of letarjet (allows smooth muscle contraction), cut rest of nerves Gastrectomy: Must try to remove as many lymph nodes as possible (even though getting them all is surgically impossible-> watch out for arteries Hiatal hernias: o Sliding: Eso in straight line with cardiac end of stomach, results in reflux of gastric secretions into eso (repeated can cause Barretts esophagus) while supine o Fundus is herniated, no reflux Hemorrhoids: Above pectinate line: Internal, below pectinate line: external (more painful due to somatic innervation) Colitis: Inflammation of colon Colestomy: Terminal ileum, colon, rectum, anal canal are removed o Ileostomy: Artificial cutaneous opening between ileum and skin of anterolateral abdominal wall Paralysis/weakening of pubo-rectal sling can result in fecal incontinence Per rectal exam: Normally, prostate should be smooth, but hypertrophy or cancer of prostate can make it bumpy/rough. In females, can feel if there is fluid in the rectouterine pouch Piles: o Internal: Above pectinate line, superior rectal veins are dilated, painless but can bleed profusely, and can prolapse o External: Below pectinate line-> Inferior rectal veins are dilated, painful, but not much blood Anal fissure: Damage to valve (constipation, hard feces) Anal fistula: Abscess in anal canal, can burst in ischiorectal fossa, or skin Splenectomy: Watch out for tail of pancreas (which contains Islets of Langherans, where (glucagon producing), (insulin producing), and cells are located Damage (rupture) of spleen should be suspected with blunt force injury to lower left ribs Accessory spleen: Droplets of spleen tissue in peritoneal folds (ligaments) Splenomegaly Enlargement of spleen (<3x normal size) Nutcracker syndrome: Compression of Left renal vein between SMA and Ab ao (one of them is dilated (aneurysm)) Pancreatic cancer is most likely to occur in the head of the pancreas, can result in compression of bile duct

Obstructive jaundice: Bile is not reaching duodenum, goes into blood. In this case the liver is fine, but jaundice occurs Annular pancreas: Embryologically, the pancreas has a bifurcated ventral bud, and the two fuse with dorsal bud to make a ring around the 2nd part of duodenum. Results in compression of 2nd part of duodenum, can be detected by ultrasound. Often presents with polyhydramnios. Pancreatitis: Acute and chronic types, can have referred pain along epigastric region and along back. Can be caused by alcoholism or gallstones (colelithias). Range of symptoms, increased BP (chronic), diabetes mellitus, nausea, vomiting. Liver cirrhosis: Hepatocytes are replaced by fibrous tissue, constricts blood vessels, leads to portal hypertension, esophageal varices (and hemitemisis), hemorrhoids, caput medusa. Liver will have a rough, nodulated feel, instead of being smooth. Hepatitis: Viral infection of liver Cholelithias (gallstones) often impact in the pancreaticohepatic ampulla Approaching kidney from posterior aspect. Make incision below renal angle. Renal angle is a line between 12th rib and lateral border of erector spinae. (Above is costodiaphragmatic recess) Nutcracker syndrome: Compression of Left renal vein between SMA and Ab ao (one of them is dilated (aneurysm)). Can cause dilation of left testicular vein or pampiniform venous plexus, resulting in varicocele (more common on left side) Inferior accessory renal artery (IARA) can compress ureter, which can result in accumulation of urine in calyces or renal pelvis->can result in hydronephrosis Tumours->Tendency to spread along renal veins Renal pain: Dull ache->causing severe pain along T12 dermatome, so pain referred along flank and along anterior abdominal wall Transplanted kidneys are kept in iliac fossa, renal artery is ligated to internal iliac artery, renal vein to external iliac vein Cushings syndrome: Excess secretion of glucocorticoids (can be from increased growth of zona fasciculata ex. cancer of adrenal gland) Addisons: Decreased level of cortical hormones Pheochromocytoma: Tumour in the medulla (increased amount of catecholamines) Horseshoe shaped kidney: Fusion of developing kidneys. As they ascend, they are stopped by the IMA (at the isthmus of horseshoe kidney) Volvulus: Sigmoid colon can twist, causing intestinal obstructions. Occurs most readily in sigmoid colon

Pelvis and Perineum

Tailors buttocks: Inflammation of bursa over ischial tuberosity Pudendal block: To anaesthetize contents of perineum. Palpate ischial spine, inject anaesthetic (in women, done through wall of vagina)

Loss of fibres from levator ani can result in herniation (very rare) Episiotomy (first should do pudendal block): Incision of vaginal opening to make it wider to ease childbirth o Medial: From posterior of vaginal orifice to perineal body. Afterward, must fix perineal body quickly and properly, else it could result in prolapse of uterus into vagina, also if cut extended too far can damage external anal sphincter. So a better choice would be o Mediolateral incision (preferred): Avoids cutting perineal body and ex anal sphincter Damage to base of bulb of penis can cause rupture of urethra leading to extravasation of urine (into superficial perineal pouch up to anterior abdominal wall Prostatectomy: Must watch out for injury to cavernous nerve and prostate plexuscan lead to impotence Hydrocele: Accumulation of excess fluid b/t visceral and parietal layers of tunica vaginalis Varicocele: More common on left side (blockage of left renal artery) results in dilated testicular veins (or a tributary) Torsion of testes: Twisting of testis and their vesselsDecreased blood supplyIschemia/Necrosis Vasectomy: Done in upper part of pelvis, before entering inguinal canal. Can ligate (possible for recanalization), or cut To examine prostate: Per rectal exam, ultrasound , CT scan, blood (increased serum acid phosphatase and serum PSA [prostate specific antigen] are indicative of adenocarcinoma) Biopsy of prostate is done through urethra (transurethral resection of prostate; TURP) Possible for spread of prostatic carcinoma to cranial cavity by passage through vein of batson into internal vertebral plexus, then up to cranial cavity Cryptorchidism: Undescended testes Ectopic testes: Can have testes in abnormal places (ASI for example) Cystocele: Herniation of bladder into vagina through pubocervical fascia Suprapubic cystotomy: Puncture bladder, removal of urinary caliculi or small tumours Ectopic vesicae: Failure in development of lower abdominal wall, can see bladder If anterversion angle is too great, uterus can become retroverted resulting in prolapse of uterus into the vagina External os of cervix is most common site for cancer since it is where there is a transition of epithelium types Culdocentesis: Aspiration of fluid from rectouterine pouch through posterior fornix of vagina Implantation of blastocyst occurs on posterior wall of body of uterus Gartners duct: Remnant of mesonephric (Wolffian) duct in femalesIf fluid filled, then is Gartners cyst Prolapse of uterus: Can be caused by weakened ligaments (broad, round, transverse, ovarian), damaged perineal body, age, menopause, weakened muscles of urogenital diaphragm (sphincter urethrae, deep transverse perinii) or pelvic diaphragm (levator ani, coccygeus) Fibromyoma: Benign neoplasm of female genital tract from smooth muscle. May cause urinary frequency, dysmenorrhea, abortion, or obstructed labour

Endometriosis: Endometrial tissue outside of uterus (ie in uterine wall, ovaries, or elsewhere). Frequently forms cyst containing altered blood. Cervical cancer: HPV is a major factor. From epithelium of cervix (external os). Pap smear, ultrasound, sometimes per rectal exam can be done to test. Sometimes it is necessary to remove uterus, can metastasize to lungs, liver, bone, and extrapelvic lymph nodes Hysterectomy: Removal of uterus. Can be done from abdominally or vaginally. Must ligate uterine artery (watch out for utreter). Complications: Osteoporosis due to estrogen Immotile cilia syndrome (Kartegeners): Effects dynein arms of microtubules, therefore can have loss of or decreased fertility (and respiratory tract infections). Women who are fertile have increased risks for ectopic pregnancies Tubal ligation: Prevents sperm from meeting ova, safer than hysterectomy. Ligate tubes (allows for recanalization) Infections of female genital tract can pass to peritoneal cavity Major cause of infertility is due to blocks in uterine tubes (infection: salpingitis) Ectopic pregnancies can be dangerousCan rupture leading to severe hemorrhage. Can also mimic symptoms of appendicitis Histerosalpingography: Inject radiopaque dye into uterus to see patency (or lack thereof) of uterine tubes Iliac crest can be used to help fix broken scaphoids (also a source for bone marrow) If there is no tendinous arch, parts of levator ani may not be there, can have herniation into ischiorectal fossa During childbirth, most likely part of levator ani to tear is the pubococcygeus part Prostatectomy and impotence: Cavernous nerve supplies erectile tissue of penis, has both symp (L1,L2ejaculation) and parasymp (S2,S3,S4erection) compenents. Injury to the cavernous nerve results in impotence Enlarged hepatic nodes may press on and obstruct the portal vein Enlargement of mesenteric nodes can occur in typhoid fever, tuberculous ulceration, and malignant tumours

Neck
Fluid in fascial spaces of neck can transmit infection (except the space b/t investing layer and muscular part of pretracheal layer which ends at manubrium) Fluid in retropharyngeal space can compress esophagus and trachea Retropharyngeal abscess: Pus perforates prevertebral layer of deep cervical fascia, and enters the retropharyngeal space, producing a bulge in the pharynx, may cause dysphagia (difficulty swallowing), dysarthria (difficulty speaking). Also air from a ruptured trachea/bronchus/esophagus (pneumomediastinum) can pass superiorly in the neck.

Torticollis (wry neck): Head is rotated in opposite direction, tilted toward problematic SCM. Can be congenital: Fibrous tissue tumour develops in SCM shortly after birth. Can be acquired: Head is pulled during difficult birth (muscular torticollis)May result in hematoma. Treat by removal of tissue, or surgical relaxation Phrenic nerve block: Done prior to operating on lung. Phrenic nerve lies on scalene anterior, so inject anaesthetic over scalene anterior to block it Cervical dystomia: Abnormal tonicity of cervical muscles (SCM, trap)Spasmodic torticollis. Often develops in adulthood EJV prominence: Usually only visible superior to clavicle for a short distance. If it can be seen throughout the course of the neck can be indicative of heart failure, obstruction of SVC, enlarged supraclavicular lymph nodes or intrathoracic pressure Nerve block over midpoint of posterior side of SCM will numb most of the neck region (Great occipital nerve, greater auricular nerve, transverse cervical nerve, suprascapular nerve CCA occlusion can be caused by atheromatous plaque, causing decreased blood to brain, resulting in stroke/TIA. Can be fixed either by endartorectomy (old way, complicated, removal of plaque) or by stint (favourable method nowCarotid stint) Aneurysms of subclavian vein most often arise in 3rd part, can compress brachial plexus Subclavian steal syndrome: Vertebral arteries on one side steals blood through the anastomosis to supply its half. Allows for collateral circulation if there is a blockage of subclavian artery before it gives any branches. Malignancies in deep cervical lymph nodes, IJV is usually removed together with nodes in a surgical procedure called block dissection of cervical nodes IJV Puncture: Needle and catheter can be inserted. Use right IJV since it is larger and straighter (usually). Palpate CCA, insert needle into IJV just lateral to it at 30 angle aiming at the apex of the triangle between the sternal and clavicular heads of SCM, needle directed inferolaterally toward ipsilateral nipple Never perform total thyroidectomy, leave at least some posterior thyroid so that the parathyroids are not damaged (can result in tetany due to alterations of neuromuscular junction) During thyroidectomy, must ligate superior and inferior thyroid arteries (and maybe arteria thyroidia ima [from arch of aorta]). o External laryngeal nerve runs with superior thyroid artery and the two are close together away from thyroid, and apart close to it, so ligate superior thyroid a. close to thyroid. o Recurrent laryngeal nerve runs with inferior thyroid artery, and the two are apart away from the thyroid, and close together near the thyroid, so ligate the inf thy a. far from the thyroid Goiter: Enlargement of thyroid gland (often) due to iodine deficiency (lump mid-neck). The swelling can compress trachea (dyspnea), larynx (loss of speech, cough or wheezing), esophagus (dysphagia). Neck veins can be distended causing dizziness. Can be treated by radioactive iodine to shrink gland, or by thyroidectomy Graves Disease: Autoimmune disease causing overstimulation of thyroid glandHyperthyroidism. Eyeballs protrude (exophthalmos/proptosis), thyroid enlargement, insomnia, irritability, weight loss, increased appetite, heat intolerance, increased perspiration, brittle hair, muscle weakness,

palpitations, nervousness, hand tremors are symptoms. Can be treated by antithyroid medication, radioactive iodine, thyroidectomy Hashimotos Disease: Autoimmune thyroiditis (hypothyroidism)Immune system destroys thyroid gland. Symptoms: Fatigue, dry skin, muscle weakness, cramps, slow heartbeat, weight gain, constipation Papillary carcinoma of thyroid: Most common type of thyroid tumour, usually presents as nodule in thyroid gland (more common in females than males). Symptoms: Lump on side of neck, hoarse voice, difficulty swallowing. Should have thyroidectomy, after which patients are treated with radioactive iodine, take thyroid hormone supplements for life Food going into larynx falls into vestibular folds, throwing larynx into spasmsPerform abdominal thrusts (increased abdominal pressure causes elevation of diaphragm which compresses lungs, and ideally expels the object. If this fails, must to thracheotomy Tracheotomy/Tracheostomy: Transverse incision through skin, superficial fasica (+platysma), investing layer of deep fascia, push sternohyoid and sternothyroid aside, push isthmus down, cut 2nd or 3rd tracheal rings o Watch out for inferior thyroid veins which arise from a venous plexus on the thyroid gland and descend anterior to the trachea o Arteria thyroidea ima extending from arch of aorta (or b-ceph trunk) ascending to isthmus of thyroid gland o In children, this can damage left brachiocephalic vein or thymus, since in children these are higher up (whereas in adults they are lower) o In infants, must be careful not to puncture posterior wall o Probably better to make incision through cricothyroid membrane to avoid risk to thyroid Laryngeal recurrent nerves are vulnerable during thyroidectomy. Unilateral damage to recurrent laryngeal nerves results in hoarsness of voice, bilateral damageLoss of voice Damage to external laryngeal nerve results in monotonous voice due to paralyzed cricothyroid (cannot vary tension of vocal fold) Adenoids: (In children)- Enlarged pharyngeal tonsils (roof of naso pharynx), which block choanae Infections can spread from middle ear to nasopharynx, and vice versa through tubal tonsils. Can cause hearing problems if infection travels from nasopharynx to middle ear Tonsillitis: Inflammation of tonsils causing their enlargements Tonsillectomy: Removal of tonsils. Can have risk of hemorrhage due to high blood supply to palatine tonsils, must watch out for glossopharyngeal nerve and internal carotid artery (by lateral wall of palatine tonsils) Waldeyers ring: Formed by 4 tonsils: Pharyngeal, lingual, tubal, palatine Small fish bones (or smuggled diamonds) can be lodged into the piriform/smugglers recess Zenkers diverticulum: Hernia of mucosa of pharynx through gap between cricopharyngeus and thyropharyngeus due to loss of coordination of those two muscles Horners syndrome: Compression of stallate ganglion (ie by apical tumour of lung (Pancoasts tumour)) resulting in ptosis (due to paralysis of superior ptosis muscle), constriction of pupils

(paralysis of pupil dilators), enapthalmosis (sunken-in eyes), anhydrosis (loss of sweating). Symptoms are seen on ipsilateral side. Sentinal lymph nodes run along transverse cervical lymph nodes. Any carcinoma of thorax or abdomen will go to these

Head
Infection of / abscess in parotid gland is painful since false capsule (dense connective tissue) cannot expand Freys syndrome: Damage to (parotid gland or) auriculotemporal nerve can result in improper healing where the great auricular nerve merges with the auriculotemporal nerve, so upon presentation with food, salivation occurs (normal) as well as sweating over parotid gland (abnormal, due to the communication between great auricular with auriculotemporal nerves) Mumps: Viral infection of parotid gland. If untreated, can cause degeneration of seminiferous tubules Siolography: Visualization of a ductal system Can administer drugs under the tongue, since they will be readily absorbed and will go into deep lingual vein Frenectomy: Cutting of frenulum linguae, can be done when it is too short (tongue-tie) which can prevent proper speech. Genioglossus is a life-saving muscle, since if it is paralyzed, the tongue can fall back into the mouth blocking the airway, due to unopposed action of retractors Gag reflex: Post 1/3 affererent: Glossopharyngeal. Efferent: Vagus nervesupplies muscles of pharynx. So to test CN IX, and CN X, can try gag reflex To test the hypoglossal nerve, have patient protrude tongue. If there is any nerve damage/muscle paralysis, the tongue will deviate to the side that is damaged/paralyzed (if right side is paralyzed, tongue will deviate to the right) To access pituitary gland, do not need to open cranial cavity, can access by going through nose, then through body sphenoid bone to the hypophyseal fossa If there is too much of a difference (will be some) in the division of the nose, is called deviated nasal septum, can be surgically corrected (can result in snoring, difficulty breathing) Fracture of nose is common in automobile accidents and sports. Can result in deformation of nose, epistaxis (nose bleeding) or possibly fracture of cribiriform plate of ethmoid bone Dangerous area of face: Around nose, venous drainage can take blood from face to cavernous sinus (in cranial cavity). In this way, infection can spread. Two pathways: o Directly from face through opthalmic vein, to cavernous sinus o From faceFacial veinDeep facial veinPterygoid venous plexus (around lateral pterygoid)Emissary veinsCavernous sinus Epistaxis is common due to rich blood supply to nasal mucosa. Most often, bleeding if from kiesselbach area, the region of anastomosis of the 5 arteries

Rhinitis: Severe upper RTI and allergic rxns. Mucosa becomes swollen and inflamed. Infection can spread to o Anterior cranial fossa through cribriform plate of ethmoid bone o Nasopharynx through chonae (posterior nasal apertures) o Middle ear through auditory tube o Paranasal sinuses (through their openings/ducts) o Lacrimal apparatus and conjunctiva CSF Rhinorrhea: Results from fracture of (relatively weak) cribriform plate, tearing of cranial meninges. Results in leakage of CSF (clear fluid) through noseSend for x-ray/MRI Dentists must be careful when removing first two maxillary molars, since it can result in communication b/t oral cavity and maxillary sinus Maxillary sinus is most commonly infected due to its suboptimal drainage. Can be identified easily by X-ray Infection of ethmoid sinuses may occur if nasal drainage is blocked, since ethmoidal sinuses might break through fragile medial wall of orbit. Severe infections may cause blindness since some posterior ethmoidal sinuses lie close to optic canal (which gives passage to optic nerve and ophthalmic artery (and end artery supplying the retina)). Can also affect dural sheath of optic nerve causing optic neuritis Fracture to neck of mandible most likely will result in damage to auriculotemporal nerve, can possibly damage facial nerve as well. Fracture to facial nerveBells palsy (paralysis facial nerves on one side) When extracting last molar, must be careful, since lingual nerve (with chordae tympani contribution) is nearby. Damage to the nerve by improper extraction of (say an impacted last molar) causes loss of general and special sense from anterior 2/3 of tongue (no taste loss from circumvallate papillae), as well as loss of salivation from submandibular and sublingual glands Paralysis of stapedius (through damage to facial nerve) results in hyperacusis (small noises are painful/irritating) Bells Palsy: Paralysis of muscles of facial expression. Transverse wrinkles in forehead disappears, eyebrow droops, palpebral fissure will be wider, drooping of lower eyelid (ectropion), angle of mouth on affected remains motionless while smiling, spilling of tears (epiphora), accumulation of food in vestibule of mouth (paralysis of buccinators), food can dribble out of paralyzed lips. May be caused by sudden exposure to cold, middle ear infections, fractures, tumours Corneal reflex: Afferentophthalmic nerve, EfferentFacial nerve (acts on orbicularis oculi) When scalp is cut, the dense connective tissue can hold the blood vessels open resulting in profuse bleeding, must compress against cranial bones to stop bleeding Swelling in dense connective tissue layer is localized Swelling in loose areolar tissue layer is general (so wont be apparent until whole layer is full Loose areolar layer is where communication with the valve-less emissary veins occurs Trigeminal Neuralgia (Tic douloureux): Sensory disorder of sensory root of CN V, sudden attacks of excruciating lightning-like jabs of facial pain. Paroxysm (sudden pain) can last of 15 minutes or more. V2 most frequently involved, then V3, least likely is V1. Often triggered by touching sensitive trigger

zone in skin. Origin is unknown, but thought to be due to anomalous blood vessel compressing sensory root of CN V (others believe it to be caused by pathological processes affecting neruons of trigeminal ganglion). Sometimes must resection sensory root for relief of pain from CN V neuralgia Lesions of CN V: Widespread analgesia (anterior half of scalp, face [except for area overlying angle of mandible], cornea and conjuctivy, mucus membranes of nose and paranasal sinuses, mouth and ant. part of tongue. Paralysis of muscles of mastication. In a fracture to the orbit, medial wall most likely to break due to weaker ethmoid bone, medial wall involves ethmoidal and sphenoidal sinuses Damage to maxillary part of orbit could damage infraorbital nerve (which runs through infraorbital fossa), resulting in loss of sensation over lower eyelid, ala, upper lip Orbital fractures often cause intraorbital bleeding , pressure on eyeballExophthalmos Superior wall is strongest (frontal bone), but is thin and translucent enough to be penetrated by a sharp object, which can penetrate through to the frontal lobe of the brain Stye: Inflammation of sebaceous glands (ciliary glands) for the eyelashes, found on margin of eyelid Chalazion: Block or inflammation of tarsal gland, results in swelling on inner aspect of lid To test superior and inferior rectus: Have patient follow finger laterally (cover the other eye). This lateral movement brings the sup and inf recti in line with axis of eye. Sup rectus will elevate eye, inf rectus will depress itInability to do one of those movements means damage to muscle or its nerve To test sup and inf obliques: Have patient follow finger medially (cover other eye). This medial movement brings the sup and inf obliques in line with axis of eye. Sup oblique will depress eye, inf oblique will elevate it. Inability to do one of those movements means damage to muscle or its nerve Test lateral rectus: Have patient move eye laterally Test medial rectus: Have patient move eye medially Damage to occulomotor nerve will result in the eye being depressed and laterally rotated (lateral squint)Just in terms of muscles, there is also loss of direct light reflex in affected eye, dilation of eye, loss of accommodation reflex Tumour of pituitary gland can compress optic chiasm resulting in being able to see only medial side, not lateral (temporal) side. Called bitemporal hemianopsia Loss of innervation of orbicularis occuli (by CN VII): Cannot close eyelids tightly, lower eyelid droops (spillage of tears), loss of tears allows drying of conjunctivy Loss of innervation of lps by sup branch of CN III: Ptosis, damage can be caused by head injury Loss of innervation of superior tarsal muscle by symp fibers: Partial ptosis (think apical pulmonary tumourHorners syndrome) Oculomotor palsy: If complete, affects most ocular muscles (including lps, sphincter pupillae,) will see ptosis, dilated pupil, lateral squint, double vision Abducent palsy: Paralysis of later rectus, pt. cannot abduct eye on affected sidemedial squint, diplodpodia (double vision) Block central retinal artery: Terminal branches are end arteries, obstruction by embolus results in instant, total blindness

Blockage of central retinal vein: Enters cavernous sinus, thrombophlebitis of this sinus can result in passage of thrombus to central retinal vein producing a blockage in one of the small retinal veins, which h can result in slow, painless loss of vision Increased secretion or defective removal of aqueous humour can increase intraocular pressure, resulting in glaucoma which can lead to blindness resulting from compression of retina and its blood supply Myopic eye: A-P diameter increased to ~29mm Hypermetropia: A-P diameter reduced to ~20mm Loss of elasticity of lens (due to age) in the lens can give rise to cataracts Fundoscopy: Can see posterior part of eye (optic disc, optic nerve, central retinal artery (CRA) and its 4 terminal branches). Can also see fovea (only densely packed cones for increased visual acuity). If it looks all red, its okay, if there appear to be streaks of white, it could be blockage of CRA Pupillary light reflex: Direct; constriction of same pupil, consensual; constriction of opposite pupil. Damage to CN III will result in loss of direct light reflex, but consensual light reflex will remain Accomodation reflex: Convergence of eyeballs (adduction), constriction of pupil, ant. curvature of lens (parasympathetic) Argyll Robertson Pupil: Lesion in pretectal nucleus, accommodation present, light reflex absent Detachment of retina: Split between nervous and pigment layers (not pigment layer from choroid) If depressions are seen in groove for sup. sag sinus, then it could be an older skull, since arachnoid granulations can form these depressions, but they take a while to form. Thrombosis of SSS due to spread of infection from nose, scalp, diploic veins, manifested by venous tension, resulting from defective absorption of CSF Abucent nerve lies just by ICA in middle of CavS. Aneurysm/dilation of ICA at that point will compress CN VIAbducent palsy (medial squint, blurring of vision) Cavernous sinus thrombosis: Due to formation of thrombus in CavS, most common cause is spread of infection by squeezing pimple or boil from danger zone (upper lip, around nose). Can produce papilledema, exophthalmos, diplopia, loss of vision, ophthalmoplegia, edema of eyelids, chemosis, sluggish pupillary response, ptosis of upper eyelids. Can be associated with significant morbidity/mortality because of formation of meningitis. Tx via high doses of antibiotics, sometimes need surgical draining. Corticosteriods may reduce edema and inflammation as adjunctive therapy Epidural hematoma: Usually following blow to head that produces a loss of consciousness (trauma near pterion) or fracture of greater wing of sphenoid, torn dural venous sinus Subdural hematoma: Venous bleeding, usually from torn cerebral veins where they enter SSS, can cause displacement of brain Subarachnoid hemorrhage/hematoma: Due to rupture of cerebral arteries and veins crossing subarachnoid space. Results from a ruptured intracerebral aneurysm arising from vessels supplying and around the arterial circle (of Willis) Hydrocephalus: Excess CSF in ventricles, due to secretion, absorption, or blocked absorption of CSF, results in increased intracranial pressure Tumours to hypophysis can o Produce enlargement of sella turcicaheadache

Compression of optic nerve or optic chiasm (temporal vision problems) Pressure on hypothalamusObesity (Frohlichs syndrome) Pressure on cavernous sinusExophthalmos, opthalmoplegia (due to compression of nerves associated with cavernous sinus) Since EAM is S-shaped, to see through it to get to tympanic membrane, pull ear superiorly, posteriorly, and a little laterally to straighten it If cleaning ear with sharp object, can irritate CN X, which is parasympathetic supply to heartDecrease heart rateCan even result in death Hyperacusis: Normal sounds appear very loud, due to damage of middle ear muscles or their nerve supply (tensor tympani tenses tympanic membrane to protect vs loud noises, stapedius helps) Otitis media: Must drain puss through tympanic membrane, but should only pierce the tympanic membrane at the posterior inferior quadrant, since the anterior inferior quadrant is the cone of light, and the rest has underlying bone or nerve Meringotomy: Puncture of tympanic membrane (to drain fluid from middle ear) Hearing pathways are on both sides, so even if right cochlear nerve is damaged, hearing will not be lost (there may be a decrease). If both right and left cochlear nerves are damaged, then cortical deafness will occur Conductive deafness: Hearing impairment caused by defect in sound-conducting apparatus (auditory meatus, eardrum, ossicles) Otosclerosis: Abnormal bone formation around stapes and oval window, limiting movement of stapes, thus resulting in progressive conduction deafness

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