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HAD Unit III Review. Tom Eck [email protected] Unit III Exam. A ton of material, but questions tend to be a bit more targeted—be sure to use the TBL as a guide Lab: review the prosections, especially the pelvis ones. Abdominal Wall Perineum Gastrointestinal Tract Genitourinary

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unit iii exam
Unit III Exam
  • A ton of material, but questions tend to be a bit more targeted—be sure to use the TBL as a guide
  • Lab: review the prosections, especially the pelvis ones
slide3

Abdominal Wall

  • Perineum
  • Gastrointestinal Tract
  • Genitourinary
  • Lower Limb
  • Lymphatics
  • Embryology
  • Shelf
abdominal wall
Abdominal Wall
  • Fascia Layers
  • Innervation – intercostals, iliohypogastric, ilioinguinal
  • Musculature – rectus abd., obliques, quad. lumborum
  • Vessels – inferior and superior epigastric
  • Hernias – inguinal, femoral, congenital
  • Abdominal folds
    • Median = urachus
    • Medial = umbilical arteries (deoxygenated)
    • Lateral = inferior epigastric vessels
slide5
1. When surgeons cut through the anterior abdominal wall below the arcuate line, which of the following do they NOT encounter?
  • Camper’s fascia
  • Scarpa’s fascia
  • Anterior layer of rectus sheath
  • Posterior layer of rectus sheath
  • Transversalis fascia
layers of anterior abdominal wall
Layers of Anterior Abdominal Wall
  • Skin
  • Camper (fatty)
  • Scarpa (fibrous)
  • Muscles

-External Oblique

-Internal Oblique

-TransversusAbdominus

  • Transversalis Fascia (fibrous)
  • Extraperitoneal Fat
  • Parietal Peritoneum
  • Above the arcuate line, the aponeuroses of the abdominal muscles ensheath the rectus abdominus
  • Below the arcuate line, they pass in front of it
slide7
2. What would likely result from a vertical incision through the right semilunar line superior to the umbilicus?
  • Paralysis of the right rectus abdominis
  • Ischemia of the right rectus abdominis
  • Paralysis of the right external oblique
  • Ischemia of the right external oblique
innervation and blood supply to rectus abdominus
Innervation and Blood Supply to Rectus Abdominus

Blood Supply via Superior Epigastric

Semilunar Line

Innervation via Intercostals

Blood Supply via Inferior Epigastric

slide9
3. You palpate a mass lateral to the inferior epigastric artery and superior to the inguinal ligament. What is true of this hernia?
  • It always passes through the superficial inguinal ring
  • It is encased in spermatic fascia
  • It does not pass through the deep inguinal ring
  • It passes medial to femoral vein
hernias of the myopectineal orifice
Hernias of the Myopectineal Orifice
  • Superior to Inguinal Ligament = Inguinal
    • Direct: between medial and lateral umbilical folds (in Hesselbach’s Triangle)
      • medial fold = obliterated umbilical artery
      • lateral fold = inferior epigastric vessels
    • Indirect: lateral to lateral umbilical fold; may be congenital, due to failure of processus vaginalis to close
  • Inferior to the Inguinal Ligament = Femoral
    • Passes through the femoral canal medial to the femoral veins
4 which nerve supplies the efferent limb of the cremasteric reflex
4. Which nerve supplies the efferent limb of the cremasteric reflex?
  • Iliohypogastric nerve
  • anterior scrotal nerve
  • Ilioinguinal nerve
  • genital branch of genitofemoral nerve
  • femoral branch of genitofemoral nerve
cremasteric reflex
Cremasteric Reflex
  • Afferent Limb: femoral branch of genitofemoral nerve and ilioinguinal nerve
  • Efferent Limb: genital branch of genitofemoral nerve
  • Iliohypogastric Nerve (L1): skin above inguinal ligament
  • Ilioinguinal Nerve (L1): skin of anterior scrotum and adjacent thigh
  • Genitofemoral (L1, L2): skin below inguinal ligament, motor to cremaster
  • Note: both the ilioinguinal nerve and the genital branch of the genitofemoral nerve pass through the inguinal canal
slide13

Perineum

  • Fascia Layers
  • Muscles – external urethral sphincter, external anal sphincter, bulbospongiosus, ischiocavernosus
  • Innervation – Pudendal Nerve, primarily
  • Autonomics (i.e. point and shoot)
slide14
5. When fluid deep to Scarpa’s fascia in the abdominal wall reaches the perineum, where does it accumulate?
  • just under the skin
  • the superficial perineal pouch
  • the deep perineal pouch
  • the ischioanalfossa
perineal spaces of urogenital triangle
Perineal Spaces (of Urogenital Triangle)

Skin

Subcutaneous Fat  Camper Fascia on Abdomen

Colles Fascia*  Scarpa’s Fascia of Abdomen  Dartos Fascia of Scrotum

Deep Superficial

Superficial Perineal Compartment (Ischiocavernosus, Bulbospongiosus, etc.)

Perineal Membrane

Deep Perineal Compartment (External Sphincter, etc.)

LevatorAni (Encased in Fascia)

*Note: also continuous with the fascia lata of the thigh, though fluid will not pass laterally

6 when anesthetic is injected near the ischial spine which of the following areas retains sensation
6. When anesthetic is injected near the ischial spine, which of the following areas retains sensation?
  • anal region
  • anterior labium majora
  • posterior labium majora
  • anterior labium minora
  • posterior labium minora
pudendal nerve
Pudendal Nerve
  • S2, S3, S4
  • the pudendal nerve supplies ALL of the perineal muscles and ALL of the overlying skin…
  • EXCEPT for the anterior scrotum/labium majora, which are supplied by the ilioinguinal nerve
  • Path: exits greater sciatic foramen and wraps around the ischial spine to enter the lesser sciatic foramen, extending anteriorly to the perineum
pudendal nerve block
Pudendal Nerve Block

Block here

  • anesthetized it as it wraps around the ischial spine
  • Pudendal Nerve Branches
    • Inferior Anal Nerves: external anal sphincter, perianal skin
    • Perineal Nerve: perineal muscles, perineal skin
    • Dorsal Nerve of the Penis/Clitoris: external urethral sphincter
slide19

GI Tract

  • Arterial Supply
    • Foregut = Celiac Truck
    • Midgut = Superior Mesenteric Artery
    • Hindgut = Inferior Mesenteric Artery
  • Portal Circulation
  • Biliary Flow
  • Innervation (Sympathetic and Parasympathetic)
  • major relationships (i.e. superior mesenteric artery passes over the third part of the duodenum)
7 which artery is in direct danger from an ulcer eroding the posterior wall of the stomach s body
7. Which artery is in direct danger from an ulcer eroding the posterior wall of the stomach’s body?
  • common hepatic
  • left gastric
  • right gastric
  • gastroduodenal
  • splenic
the celiac trunk
The Celiac Trunk

Splenic Artery

  • artery of the foregut
  • Three branches:
    • Splenic
    • Common hepatic
    • Left gastric
  • Artery endangered by ulcer in posterior wall of first part of the duodenum?
    • Gastroduodenal artery

Celiac Trunk

slide22
8. Which vessel(s) have reversed flow to permit a collateral circulation in this patient with chronic hepatitis?
  • periumbilical veins
  • left umbilical vein
  • gastric veins
  • middle rectal veins
  • Inferior rectal veins
porto caval anastamoses
Porto-Caval Anastamoses
  • Paraumbilical veins  superficial veins of abdominal wall Caput medusae
  • Superior rectal veins  Middle and Inferior Rectal Veins (Inferior Iliac Vein) Internal hemorrhoids
  • Gastric veins  Veins of Lower Esophagus ( Azygous System) Esophageal varices

1,2,3

9 if the left renal vein becomes occluded near its termination which of the following will result
9. If the left renal vein becomes occluded near its termination, which of the following will result?
  • caput medusae
  • esophageal varices
  • internal hemorrhoids
  • left varicocele
  • right varicocele
slide26

Memorize major branches/tributaries of the abdominal aorta and IVC as well as how they relate to each other. Be able to draw this out.

slide27

10. When the pain of acute appendicitis moves into the right lower quadrant from the periumbilical region, which nerves carry this sensation?

  • visceral afferents from the foregut
  • visceral afferents from the midgut
  • visceral afferents from the hindgut
  • intercostal nerves
referred pain in appendicitis
Referred Pain in Appendicitis
  • Initial pain = periumbilical; visceral afferents from inflamed appendix refer to the T10 dermatome
  • Later pain = LRQ; as the parietal peritoneum is irritated, somatic afferents from intercostal nerves (subcostal, iliohypogastric, etc.) transmit well-localized pain
slide29

Genitourinary

  • Arterial Supply
  • Follow the Urinary Tract
  • Female Reproductive Tract
  • Male Reproductive Tract
    • SEVEN UP (Seminiferous Tubules, Epididymus, Vas Deferens, Ejaculatory Duct, (Nothing), Urethra and Penis)
  • Innervation (Sympathetic and Parasympathetic)
slide30
11. If a surgeon were to accidentally lacerate one of the following, which would involve the least risk of hemorrhage?
  • suspensory ligament
  • mesovarium
  • mesosalpinx
  • mesometrium
  • round ligament
  • cardinal ligament
ligaments of the female reproductive tract
Ligaments of the Female Reproductive Tract
  • Broad ligament
    • Mesovarium
    • Mesosalpinx
    • Mesometrium
  • Suspensory Ligament: carries ovarian neurovascular bundle
  • Cardinal Ligament: carries the uterine artery, situated below the broad ligament
  • Round Ligament (and Ovarian ligament): remnant of gubernaculum
12 what does this hysterosalpingogram demonstrate
12. What does this hysterosalpingogram demonstrate?
  • uterine fistula
  • endometriosus
  • fallopian tube obstruction
  • congenital ovarian agenesis
  • normal anatomy
slide33
the female reproductive tract communicates with the peritoneal cavity via the fallopian tubes
  • a major route for spread of infection
  • basis for abdominal pregnancy
13 which of the following is at greatest risk in a hysterectomy
13. Which of the following is at greatest risk in a hysterectomy?
  • uterine artery
  • ureter
  • urinary bladder
  • urethra
  • rectum
the ureter
The Ureter
  • Know the path of the ureter
  • At risk for damage when the uterine artery is ligated
  • Passes along the posterior abdominal cavity
  • Crosses the external iliac artery lateral to the internal iliac artery below the pelvic brim
  • “water under the bridge” - passes under the uterine artery, lateral to the lateral fornix of the vagina before entering the urinary bladder
14 along which nerve s do fibers carrying pain from the prostate travel
14. Along which nerve(s) do fibers carrying pain from the prostate travel?
  • hypogastric nerve
  • sacral splanchnic nerves
  • pelvic splanchnic nerves
  • thoracoabdominalsplanchnic nerves
visceral pain
Visceral Pain
  • pain line = lower limit of peritoneum
  • above the pelvic pain line, visceral afferents follow sympathetic fibers
  • below the pain line, visceral afferents follow parasympathetic fibers
  • Pelvic splanchnic nerves carry Parasympathetic fibers
  • Sacral splanchnic nerves carry Sympathetic fibers (as do all other splanchnic nerves)
  • Don’t get hung up on pathways for autonomics (i.e. greater splanchnic celiac ganglion, etc.; straight from Dr. Vasan); symptoms are more important
15 which branch of the internal iliac artery supplies the superior portion of the bladder
15. Which branch of the internal iliac artery supplies the superior portion of the bladder?
  • obturator
  • umbilical
  • uterine
  • vaginal
  • superior vesicle
the internal iliac artery
The Internal Iliac Artery
  • posterior division: superior gluteal, iliolumbar, lateral sacral
  • anterior division: supplies the viscera of the pelvis from anterosuperior to posteroinferior
the anterior division
The Anterior Division

Obturator Foramen

Obturator

Umbilical ( S. vesicle)

Uterine

Greater Sciatic Foramen

Vaginal

Inferior Vesicle (in males)

Middle Rectal

Internal Pudendal

Inferior Gluteal

slide41

Lower Limb

  • Muscles, Actions, and Innervations
  • Same kinds of things as upper limb, except…
    • ligaments are stressed a bit more
    • the foot matters <<< the hand
    • In general, somewhat less detail required—knowing muscle compartment often enough to define action and innervation
    • know all major nerve deficits, how to recognize them, and what structures are involved
slide42
16. What action at the hip might be lost if the nerve that passes through the obturator foramen were damaged?
  • flexion
  • extension
  • adduction
  • abduction
  • medial rotation
  • lateral rotation
medial compartment of thigh
Medial Compartment of Thigh
  • Innervation: obturator nerve
  • Receives blood supply, in part, from the obturator artery
  • Muscles: adductors longus, brevis, and magnus; gracilis, obturatorexternis*
  • For most muscles, simply knowing the compartment will tell you its primary action

*The pectineus is the only muscle that contributes to adduction, but is not innervated by the obturator nerve.

slide44

17. If a tumor were to compress the structures that exit the greater sciatic foramen superior to the piriformis, which of the following might be lost?

  • thigh extension
  • hip abduction
  • foot eversion
  • posterior thigh sensation
  • urinary continence
greater sciatic foramen
Greater Sciatic Foramen
  • formed from greater sciatic notch, closed off inferiorly by the sacrospinous ligament and posteromedially by the sacrotuberous ligament
  • the superior gluteal nerve innervates the gluteus medius, gluteus minimus, and tensor of the fascia lata all three provide hip abduction (and medial rotation); loss = “hip drop”
  • thigh extension = tibial, inferior gluteal;
  • foot eversion = peroneal (superficial);
  • posterior thigh sensation = post. femoral cutaneous
  • urinary continence = pudendal (external urethral sphincter)
18 what action at the hip would be most weakened by avulsion of the lesser trochanter of the femur
18. What action at the hip would be most weakened by avulsion of the lesser trochanter of the femur?
  • extension
  • flexion
  • abduction
  • adduction
  • elevation
iliopsoas
Iliopsoas

Psoas Major

Iliacus

  • The most powerful flexor of the hip
  • Three muscles: psoas major, psoas minor, iliacus
  • Psoas major and iliacus are the only muscles that insert at the lesser trochanter
  • Psoas major significant for signaling apendicitis, route for spread of infection to/from thigh
  • Greater trochanter: most of the gluteal muscles; gluteus medius, minimus, gemelli, obturatorinternis, piriformis

Greater Trochanter

Lesser Trochanter

important attachment sites
Important Attachment Sites
  • Greater trochanter
  • Lesser trochanter
  • Tibialtuberosity = quadriceps femoris
  • Ischialtuberosity = hamstrings (except short head of biceps femoris)
  • Base of 5th metatarsal = fibularisbrevis
  • Base of 1st metatarsal = fibularislongus
  • For most of the rest, simply knowing the bone (or general region) should suffice
slide49

19. Following injury, if you note ease in abducting the tibia, causing visual deformity (genu valgum), which ligament may have been damaged?

  • anterior cruciate
  • posterior cruciate
  • fibular collateral
  • tibial collateral
  • patellar
ligaments of the knee
Ligaments of the Knee
  • The knee is the largest and least stable joint of the body; know the deficits
  • ACL = laxity in anterior displacement of tibia; connects lateral femoral condyle to anterior tibia
  • PCL = laxity in posterior displacement of tibia; connects medial femoral condyle to posterior tibia
  • FCL (lateral) = genuvarum
  • TCL (medial) = genuvalgum
  • vaLgum = Lateral displacement of distal component
  • varum = medial displacement of distal component
  • Coxa = hip; genu = knee; hallux = big toe
20 id this ligament
20. ID this ligament:
  • anterior cruciate
  • posterior cruciate
  • fibular collateral
  • tibial collateral
  • patellar
the acl and pcl
The ACL and PCL
  • The attachments of the ACL and PCL are important to know; they also explain why lateral rotation of the tibia—when the knee is bent—is greater than medial rotation

ACL

MEDIAL FEMORAL CONDYLE

LATERAL FEMORAL CONDYLE

PCL

TIBIAL PLATEAU

RIGHT KNEE JOINT FROM ABOVE

The ligaments become lax upon lateral rotation and taut on medial rotation

LATERAL ROTATION

the acl and pcl1
The ACL and PCL

ACL

MEDIAL FEMORAL CONDYLE

LATERAL FEMORAL CONDYLE

PCL

TIBIAL PLATEAU

RIGHT KNEE JOINT FROM ABOVE

Only the ACL resists anterior displacement. Likewise, only the PCL resists posterior displacement.

ANTERIOR DISPLACEMENT

slide55

21. In an individual complaining of “foot drop,” foot inversion is also weakened, but not abolished. Which muscle permits continued functionality?

  • flexor digitorumlongus
  • flexor hallucislongus
  • tibialis posterior
  • soleus
  • gastrocnemius
ankle joint movements
Ankle Joint Movements
  • “foot drop”: loss of deep fibular nerve, specifically, but most common injury occurs to the common fibular nerve as it winds around the neck of the fibula
  • Inversion: tibialis anterior and posterior
  • Eversion: lateral compartment muscles
  • Plantar flexion: posterior compartment muscles
  • Dorsiflexion: anterior compartment muscles
22 which nerve when damaged leads to anesthesia over the plantar surface of the foot
22. Which nerve, when damaged, leads to anesthesia over the plantar surface of the foot?
  • tibial
  • deep fibular
  • superficial fibular
  • femoral
  • obturator
cutaneous nerves of the lower limbs
Cutaneous Nerves of the Lower Limbs
  • Fairly important to know
  • Generally, knowing the name of the cutaneous nerve is less important than knowing the major nerve it is derived from
  • Tibial medial/lateral plantar
  • Femoral  saphenous
  • Know cutaneous distribution of obturator, superficial peroneal, deep peroneal
slide59

Lymphatics

  • Memorize the lymph chart!!
  • Also study lower limb drainage
  • When in doubt—which there shouldn’t be any—guess superficial inguinal!
23 to which group of nodes does lymph from the 5 th toe reach first
23. To which group of nodes does lymph from the 5th toe reach first?
  • popliteal
  • superficial inguinal
  • deep inguinal
  • external iliac
  • internal iliac
lymphatics of the lower limbs
Lymphatics of the Lower Limbs
  • Lymph following the drainage of the small saphenous vein  popliteal ( deep inguinal)
  • Lymph following the drainage of the great saphenous vein  superficial inguinal
  • Lymph following the deep veins of the legs  deep inguinal
slide62

Embryology

  • Gastrointestinal – know foregut, midgut, hindgut derivatives; rotation
  • Urinary – three stages of kidney development
  • Reproductive – know the precursors to each adult structure; know the male/female homologs
  • congenital abnormalities
24 which of the following is derived from the ventral mesentery of the stomach
24. Which of the following is derived from the ventral mesentery of the stomach?
  • Greater omentum
  • Lesser omentum
  • Splenorenal ligament
  • Gastrosplenic ligament
  • Gastrocolic ligament
stomach rotation
Stomach Rotation
  • The stomach rotates clockwise 90° during development
  • Ventral mesentery  lesser omentum
  • Dorsal mesentery  greater omentum
  • The greateromentum can be divided into gastrocolic, gastrosplenic, gastrophrenic, and occasionally, splenorenal ligaments

DORSAL

VENTRAL

25 which of the following is derived from an embryo kidney structure
25. Which of the following is derived from an embryo kidney structure?
  • uterine tube
  • prostatic utricle
  • suspensory ligament
  • ductus deferens
  • round ligament
urogenital development
Urogenital Development
  • The urinary tract and reproductive tract develop in close association with each other
  • Much of the male reproductive tract is derived from the mesonephric duct of the second set of kidneys (mesonephros), including the ductus deferens
  • Remember: Male = Mesonephric duct = Medulla-Derived Testis
  • Female = Paramesonephric duct = Cortex-Derived Ovary
26 what restricts the normal ascent of a horseshoe kidney
26. What restricts the normal ascent of a horseshoe kidney?
  • inferior mesenteric vein
  • inferior mesenteric artery
  • fused bladder
  • shortened ureters
horseshoe kidney
Horseshoe Kidney
  • Because the IMA is the inferiormost vessel that branches off the aorta anteriorly, it will block the ascent of a horseshoe kidney
  • This condition is asymptomatic
slide69

Shelf Exam

  • The Bad News: cumulative final; limited study time
  • The Good News: you’ve been preparing all along! The clinical approach the course directors employ is a good representation of what you’ll see. Also, questions tend to be less detail-oriented on the Shelf.
slide70

27. A 45-year-old woman has a uterine leiomyoma that is 5 cm in diameter and is pressing on the urinary bladder, causing urinary frequency. Which of the following is the most likely location of the leiomyoma?

  • cervical canal
  • lateral margin of uterine cavity
  • subendrometrially in the uterine cavity
  • subperitoneally on the anterior surface of the uterine corpus
  • subperitoneally on the posterior surface of the uterine fundus
slide71
First, don’t let the details of the clinical scenario intimidate you
  • Who knows what a leiomyoma is?! Who cares!
  • All we need to know is that its pushing on the bladder and causing increased urinary frequency
  • You are well equipped to handle most questions; don’t assume anything is over your head
slide72
The question is really just a convoluted way to test our understanding of how the uterus relates to the bladder
  • Process of elimination 
  • Cervical canal and subendometrial are both inside the uterus
  • Lateral margin – too far away
  • Subperitoneally – good – on surface of uterus; anterior or posterior? anterior – uterus lies behind the bladder (this is what they were testing!)
what s on the test
What’s on the Test?
  • Go to nbme.org and look for “Basic Science Subject Examinations” “Content Outline”
  • You will find a breakdown of the topics and their representation; 20 sample questions – do them
  • Last year’s exam
    • A ton of GI questions
    • Very little head and neck – if you dissect the content outline, this is plausible
    • From asking around about previous years, I found this to be a common observation
study suggestions
Study Suggestions
  • My number one suggestion: make learning this unit your number one priority, since GI and pelvis tend to be strongly represented
  • If you do that, you will leave yourself a day and a half to go over the first two units (especially unit I)
  • Review Books:
    • BRS Gross Anatomy: detail can be a bit overwhelming; focus on the pink boxes; comprehensive exam at end is fairly representative; chapter exams are somewhat detail-oriented (also try RoadMap, PreTest)
    • High-Yield Embryology: embryo is 25 of 150 questions; high-yield has a reasonable level of detail, no questions
study suggestions1
Study Suggestions
  • Another good approach: review your TBL’s; the questions tend to cover the most clinically relevant material
  • If you’re really ambitious, you might even consider reading through the Big Moore Blue Boxes (depending on how comfortable you are with the basic anatomy)
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