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College of Medical and Dental Sciences

M3-CSA-Y18

Clinical Core 2 Clinical Skills Anatomy Handbook 2018-2019

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This course guide has been written to provide outline course content and some

elements of background reading to the clinical skills anatomy course at the beginning

of Year 3. It is intended as a guide only, to supplement learning within a clinical

context at the Teaching Academies as part of Clinical Core 2 component of the

course. It is not intended as a replacement for texts on the subject of anatomy and

provides the main context rather than the whole content of the course.

Any comments about its contents should be directed towards [email protected]

Course Guide Version 1

Prepared by Jamie Coleman, David Morley, and Joanne Wilton

August 2014

Updated August 2017

mailto:[email protected]

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CONTENTS

Introduction .............................................................................................................. 4 Background and Context ........................................................................................ 4 What is the Clinical Skills Anatomy course? ........................................................... 4 The course includes ............................................................................................... 4 Lectures ................................................................................................................. 4 SGT ........................................................................................................................ 4 PBL CSA eCases ................................................................................................... 5 Workbook ............................................................................................................... 5 What this handbook intends to do .......................................................................... 5

Background to Clinical Skills .................................................................................. 6

Basic concepts ......................................................................................................... 7

Thorax ....................................................................................................................... 9 Thorax Knowledge ................................................................................................. 9 Thoracic Anatomy in detail ................................................................................... 10

Abdomen and Pelvis .............................................................................................. 15 Abdomen / Pelvis Knowledge ............................................................................... 15 Abdominal / Pelvis Anatomy in detail .................................................................... 16

The Spine ................................................................................................................ 19 Spine Knowledge ................................................................................................. 19 Spine Knowledge in detail .................................................................................... 20

The Upper Limbs .................................................................................................... 22 Upper Limb Knowledge ........................................................................................ 22 Upper Limb in detail ............................................................................................. 22

The Lower Limbs .................................................................................................... 25 Lower Limb Knowledge ........................................................................................ 25 Lower Limb in detail ............................................................................................. 25

Head and Neck / Central Nervous System ............................................................ 28 Central Nervous System Knowledge .................................................................... 28 Central Nervous System in detail ......................................................................... 29 Head and Neck Anatomy Knowledge ................................................................... 31 Head and Neck Anatomy in detail......................................................................... 32

PBL on Thoracic Trauma (Thorax) ........................................................................ 37

PBL on Acute Abdominal Pain (Abdomen and Pelvis) ........................................ 40

PBL on Wrist Trauma (Upper Limb) ...................................................................... 43

PBL on Knee Trauma (Lower Limb) ...................................................................... 46

PBL on Neck Pain (Head and Neck) ...................................................................... 49

PBL on Facial Palsy (Central Nervous System) ................................................... 52

Bibliography ........................................................................................................... 54

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Introduction

An overview of the Clinical Skills Anatomy course including the course objectives and

general procedure of the sessions.

Background and Context

A course on ‘Clinical Skills Anatomy’ is included in the third year to allow students to

revise information from the first two years and apply this existing knowledge to

clinical skills in medicine and surgery. It will contain elements of regional anatomy but

will provide a new perspective and contextualise the anatomy content of the first two

years of study.

What is the Clinical Skills Anatomy course?

With recent changes to the curriculum you have had lots of regional anatomy taught

alongside systems based anatomy so you have already have an excellent grounding.

The following pages highlight some of the key points that will help you revise the

parts of anatomy that are essential to the clinical skills you will learn over not just the

3rd year, but the rest of the programme.

The course includes

1 hour lecture during your academic in days (September)

2 hour SGT

Series of interactive online cases

A CSA “workbook” to complete before the SGT

This handbook as a supporting resource

Lectures

The lecture slot during your academic in-days will cover the following:

The Anatomy of Procedural Skills

Introduction to the CSA SGT – what to expect and how to get the most out of

the session

SGT

During this 2 hour practical, demonstrators will facilitate your exposure to surface

anatomy and radiological imaging in order to help you learn how to apply the

anatomy you know to clinical examination, procedural skills and the interpretation of

radiological imaging. The intention is that you use this time to focus on moving your

knowledge from the page to the patient. To do this, we have created a number of

brief clinical cases and small exercises for you to work through.

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There will be lots of opportunity to get hands on by using markers and body “painting”

using wash-off pens. Please come prepared to examine and be examined - wearing

shorts and t-shirt if comfortable. Bring your stethoscope please.

Clinical content will be covered; but this will only be at a depth to allow the context of

the subject to be understood. This course does not replace the in depth teaching of

clinical skills that takes place at patients’ bedsides in the teaching Trusts.

PBL CSA eCases

We have prepared a number of online interactive cases for you to work through.

These eCases include a number of carefully chosen links and signposts to additional

materials. They have been developed with student input and also include a few

bonus MCQ format questions too. You get feedback as you go and can also save or

print your completed cases. A version of these cases is also available at the end of

this handbook.

Workbook

As a reference tool to support your clinical skills there are a number of carefully

selected images for you to label and brief exercises to complete. To get the most out

of your SGT we recommend you work though it before your SGT session.

What this handbook intends to do

This course guide has been written to supplement the suggested texts in both

applied anatomy and clinical skills that students will be expected to study. It is not

intended to be a replacement for attending the SGT or studying the relevant texts, it

does however aim to provide:

Further context about the importance of anatomical knowledge for clinical

skills (including diagnoses) and practical procedures

Preparatory material / PBLs to allow students to revise anatomical concepts

from previous anatomy teaching prior to the SGT sessions, and throughout

the academic year.

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Background to Clinical Skills

This CSA course is designed to refresh your knowledge of the essential anatomy

necessary to facilitate your entry into clinical studies. You have already spent two

years of formal anatomy studies and should therefore have a good understanding of

the subject. It is not the intention, nor would it be possible in the time available, to

revisit all of the anatomy curriculum and this course must of necessity, therefore, be

selective and focused. As Stanley Monkhouse puts it in his book Clinical Anatomy, it

covers the anatomy “you need to know” rather than that which is “nice to know”.

Clinical examination and the practice of procedural skills rely heavily on a good

knowledge of surface anatomy including bony landmarks and surface markings, as

well as a sound knowledge of sensory dermatomes and the action of various muscle

groups. It is also important to understand the usefulness of different modes of

radiological imaging and the relevant anatomy.

The underlying philosophy of the course is based on the assumption that the locus of

disease is the body. In order to understand disease it is necessary to know the body.

To this end, the anatomy you most need to know is the anatomy of pathology. The

recognition of the abnormal is only possible by being familiar with the normal.

It is hoped that this very short course will help you to achieve these objectives and

that you enjoy and profit from it. Indeed the more you put into the session and PBLs

yourselves, the more all will benefit from them.

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Basic concepts

Basic concepts Clinical anatomy is the study of the macroscopic structure of the body as it relates to

the practice of medicine. Students will have learnt many of the basic concepts before

they examine patients for the first time. Being able to describe the relationships of

different parts of the body is extremely important. Students should ensure that they

are aware of appropriate terminology (see Table 1).

Terminology Description

Sagittal Plane Vertical plane passing through the centre of the body (top to bottom) dividing it into equal left and right parts

Coronal (Frontal) Plane Plane at right angles to the sagittal plane that divides the standing body into two halves - front and back

Transverse or Axial Plane Horizontal slice through the body

Medial Structure situated nearer to the vertical midline (in sagittal plane) of the body

Lateral Structure lies further from the vertical midline of the body

Ipsilateral On the same side as another structure e.g. the left arm is ipsilateral to the left leg

Contralateral On the opposite from another structure e.g. the left arm is contralateral to the right arm

Proximal A point close to the attachment to the body

Distal A point furthest from the point of attachment to the body

Abduction Movement of the limb away from the midline of the body in the coronal plane

Adduction Movement of a limb toward the body in the coronal plane

Table 1: Basic Anatomical Terminology

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Radiological concepts Diagnostic imaging takes an increasing importance in clinical medicine and surgical

practice. Whilst radiologists are experts in interpreting the images, it is still important

that all clinicians who may request or view the images are aware of the basics of

radiological anatomy (both normal and abnormal). Familiarity will enable clinicians to

be able to quickly recognize serious abnormalities such as fractures and tumours.

Several different imaging modalities are in routine use. You will revisit some of these

types of images during the clinical skills anatomy course.

Clinical examination concepts Some of the basic clinical examination concepts have already been described. Most

effective clinical examination begins as soon as the doctor enters the room and it is

usually the general appearance of the patient that is observed first. Although

examination ‘routines’ often work from the hands upwards, it is usual to initially talk to

your patient and observe their facial expression. Indeed some ‘spot diagnoses’ can

be made just by looking at the patient’s face.

Not all aspects of inspection, percussion, palpation and auscultation are used for

every part of the body – but there are even some instances where a clinician may

wish to listen over someone’s skull!

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Thorax

Knowledge of the anatomy of the thorax is essential in order to understand the

clinical examination of the respiratory and cardiovascular systems. The SGT session

will revise some of the main elements of thoracic anatomy relating to these

examinations and other clinical skills that involve this area of the body.

The PBL based upon thoracic anatomy relates to thoracic trauma.

The thorax is possibly the most important area for revision your knowledge of

anatomy in preparation for your 3rd year. Being able to perform clinical examination

of the cardiovascular and respiratory systems and recognise pathological changes in

these systems relies on such knowledge.

Thorax Knowledge

For clinical skills anatomy, students should be able to demonstrate knowledge of the

following structures and/or concepts:

Thoracic surface anatomy (pleurae, lungs and heart)

Suprasternal notch and notch-cricoid distance

Tracheal position

Axillae, supraclavicular fossae and superficial lymph nodes

Chest wall movements

Cardiac apex beat and intercostal space counting

Position of heart sounds (relative to valves)

Murmurs and their radiation

Respiratory sounds

Breast examination

Students should also have anatomical knowledge of some of the following

procedures:

Needle thoracocentesis

Intercostal chest drainage

Pericardiocentesis

Radiological anatomy that is relevant for this session may include:

Plain Chest imaging

CT pulmonary angiogram

Cardiac MRI

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Thoracic Anatomy in detail

The thorax is divided into the median partition - the mediastinum, and laterally the

pleural cavities containing the lungs. Whilst students are traditionally taught the

examination of the cardiovascular system and respiratory systems separately, as

practising clinicians you will be required to make an assessment of the whole body

and are likely to examine both systems together during a full systematic clinical

examination.

Thoracic surface anatomy (lungs and heart) Clinical examination begins with inspection. When examining from the front or back,

the usually symmetrical nature of the thoracic cage can be appreciated. Anteriorly the

thorax consists of the sternum and costal cartilages, which are continuous laterally

with the ribs. The suprasternal notch forms the superior margin of the manubrium

and the xiphoid process is inferior. The costal margin is the lower boundary of the

thorax and is formed by the cartilages of the 7-10th ribs and the ends of the 11th /12th

ribs.

Posteriorly the thoracic wall is formed by the thoracic part of the vertebral column.

The spinous processes can be appreciated (and palpated) in the midline starting

from the most prominent vertebral spinous process of C7. The scapulae can also be

seen on the upper part of the posterior thoracic surface, usually the medial border

and inferior angle are most discernible. The inferior angle lies on a level with the

spine of T7.

It is important too that you remember the position of the diaphragm, revise the

attachments and position of its domes separating the thoracic cavity from the

abdominal cavity although aspects of both are protected by the bony thorax.

Remember the domes will move substantially during respiration.

Several different imaginary lines are used as landmarks to describe surface locations

on the thorax – see Table 2. It is important that students understand this terminology

and use it when describing examination findings.

Using the model in the ATR and/or diagrams, review the surface landmarks of the

anterior and posterior thoracic walls as well as the surface markings of the lungs

and pleurae.

Try to use the technique of ‘percussion’ on a volunteer or model to appreciate the

underlying resonance and hence borders of the lungs

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Term Description

Midsternal line Lies in the median plane over the sternum

Midclavicular line Runs vertically downwards from the midpoint of the clavicle

Anterior axillary line Runs vertically downwards from the anterior axillary fold (formed by the lower border of pectoralis major)

Midaxillary line Runs vertically downwards from a point midway between the anterior and posterior axillary folds

Posterior axillary line Runs vertically downwards from the posterior axillary fold (formed by the tendon of the latissimus dorsi)

Scapular line Runs vertically downward on the posterior wall of the thorax, passing through the inferior angle of the scapula

Table 2: Lines of orientation on the thorax

Suprasternal notch and notch cricoid distance The suprasternal notch is the dip in the superior part of the manubrium sterni which is

felt between the medial ends of the two clavicles. It lies opposite the body of T2. It is

important to use this to determine the position of the trachea (see below). Some

clinicians use the concept of the notch-cricoid distance to measure the distance

between the suprasternal notch and the cricoid cartilage. The length of the trachea

between these two points is normally three or more finger breadths; shortening of this

distance is usually a sign of hyperinflation of the lungs.

Tracheal position The trachea can normally be felt in the midline (or very slightly deviated to the right)

in the normal patient by placing a finger above the suprasternal notch. By palpating

the space either side of the trachea one can appreciate whether the trachea is

central or not. This procedure is uncomfortable and should be undertaken gently.

Deviation of the trachea usually suggests unilateral upper lobe lung pathology, or in

trauma a potential tension pneumothorax.

Axillae, supraclavicular fossae and superficial lymph nodes Knowledge of the lymph drainage of the upper limb, thorax, and head/neck is

important to be able to identify the possible infectious or malignant causes of

lymphadenopathy identified by clinical examination. When lung disease spreads via

the lymphatics it tends to involve the neck, particularly the supraclavicular nodes.

Other causes of enlarged neck and supraclavicular nodes are lymphoma,

tuberculosis and sarcoidosis. Cancer affecting the stomach or pancreas may cause

an enlarged node in the left supraclavicular region, known eponymously as Virchow’s

node.

The axillary lymph nodes drain the majority of breast tissue (~ 75%) and pleurae.

Larger lymph nodes (>1cm) are nearly always pathological. Examination of a

patient’s axillae is of particular importance in full clinical examination of the breast.

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Chest wall movements By inspection and palpation of chest wall movements, one can appreciate the

respiratory pattern. It is essential to note any inequalities on the two sides and any

change from normal. Expansion is determined by gripping the patient’s ribcage with

the fingers and the thumbs brought together in the midline. Reduced expansion on

one side may indicate underlying abnormalities in that hemithorax.

The techniques will be taught at the bedside, but students are advised to remind

themselves of the basic anatomy and physiology of respiratory movements and

actions from years 1.

Cardiac apex beat and intercostal space counting The apex beat is the cardiac impulse at the most lateral and inferior position at which

it can be felt. The cardiac apex beat is a brisk but light movement felt against the

hand just after the beginning of systole, normally, at the fifth intercostal space in the

mid-clavicular line on the left. It can be felt in the majority of normal patients but be

difficult to distinguish in patients with a ‘barrel-shaped’ chest due to obstructive lung

disease or in very obese patients.

It is important to be able to ‘map out’ the intercostal spaces and describe any

displacement of the cardiac apex which, for example, may occur in the presence of

ventricular dilatation. The sternal angle is the most important landmark as it can be

easily felt and often seen as a transverse ridge between the manubrium and sternal

body. A finger moved to the right or left of this ridge will pass directly onto the second

rib. All other ribs can be counted from this point.

Position of heart sounds (relative to valves) When talking about the heart it is important to remember the terminology that is used

to describe it. The apex of the heart is formed by the left ventricle and it directed

anteroinferolaterally. The base of the heart lies opposite the apex (because the heart

is pyramid shaped). The heart does not rest on its base; it rests on its diaphragmatic

(inferior) border.

Each heart valve is supported at the base of the valve cusps on a fibrous ring. These

fibrous rings form the ‘skeleton’ of the heart and also form the basis of electrical

discontinuity between the atria and the ventricles. The surface position of each of the

heart valves does not necessarily represent where these valve sounds are best

heard at auscultation (see Table 2).

On listening to the heart with a stethoscope, one can hear two heart sounds: S1 and

S2 (lub-dup). The first sound is produced by contraction of the ventricles and blood

hitting the closed tricuspid valves. The second sound is caused by the sharp closure

of the pulmonary and aortic valves. It is important for the clinician to know where to

place the stethoscope on the chest wall so that the heart sounds can be heard within

interference (Table 3).

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Valve Surface Marking Auscultation Position

Tricuspid valve Behind the right half of the sternum opposite the fourth intercostal space

Heard over the right half of the lower end of the body of the sternum

Mitral valve Behind the left half of the sternum opposite the fourth costal cartilage

Heard over the apex beat – at the level of the fifth intercostal space in the midclavicular line

Pulmonary valve Behind the medial end of the third left costal cartilage and the adjoining part of the sternum

Heard over the medial end of the second intercostal space

Aortic valve Behind the left half of the sternum opposite the third intercostal space

Heard over the medial end of the second right intercostal space

Table 3: Surface markings of the cardiac valves and their auscultation positions

Murmurs and their radiation Apart from the sounds of blood hitting the closed valves – S1 and S2 – the blood

passes silently through the normal heart. Turbulence and vibrations that occur when

valve orifices have become narrowed (stenosis) or incompetent (regurgitation) are

heard as heart murmurs. Again these murmurs are not always appreciated at the

same point as the ideal auscultation position of the heart valves. More information

about the position and radiation of heart murmurs is covered in clinical examination

sessions.

Respiratory sounds Auscultation allows clinicians to listen to the breath sounds as the air enters and

leaves the respiratory passages. If the alveoli or bronchi are diseased or contain

fluid, the nature of the respiratory sounds will be altered. It is also sometimes

possible to detect friction sounds produced by the rubbing together of diseased

layers of pleura or pericardium. In order to make these examinations, the clinician

must know the normal structure of the thorax and have a mental image of the normal

position of the lungs and heart in relation to identifiable surface markings as

described above.

The normal soft respiratory sounds heard at the surface of the thorax are described

as ‘vesicular’. If the lung has become consolidated, collapsed or fibrosed, then the

noises heard at the surface are harsher and represent noises from the larger airways

– ‘bronchial’ breathing. Over certain parts of the chest wall that overlie the large

airways, for example the manubrium, the breath sounds heard may be bronchial in

nature. Again this clinical knowledge will be taught at the bedside, but the anatomical

surface representation of the different types of lung sounds is important to be aware

of.

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Breast examination The anatomy of the breast is important in understanding the clinical examination

especially in terms of structure and lymph drainage. This is an area that some

students find embarrassing especially when examining the female breasts.

Examination of the male breasts is necessary to discover whether there is excess

glandular tissue - a condition known as gynaecomastia.

In females the breast is one of the common sites of cancer and also the site of

different types of benign tumours, and is subject to inflammation or abscess

formation. Slight asymmetry is common, but on simple visual inspection swellings

and major degrees of asymmetry may be recognized. Whilst the patient is lying

down, the breasts are usually palpated against the underlying thoracic wall with the

palmar aspect of the fingers of one hand. The breasts are examined systematically

often in a spiral or circular pattern to ensure that no areas are missed. Any lumps

must be characterised and further investigated. The lymph nodes that drain the

breast must also be examined, particularly in the axillae.

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Abdomen and Pelvis

The anatomical knowledge of the abdomen and pelvis can be important in both

medical and surgical practice, as well as later in the course in areas of specialist

surgery (such as urology), and obstetrics and gynaecology.

The abdominal examination is often taught slightly differently by surgical and medical

specialists, as the underlying pathologies that they are looking for are sometimes

different. However, the anatomical knowledge required for an abdominal examination

is fairly standard.

Abdomen / Pelvis Knowledge

For clinical skills anatomy, students should be able to demonstrate knowledge of the following structures and/or concepts:

Abdominal surface anatomy (of viscera)

Abdominal regions / asymmetry of underlying structures

Abdominal distension and its causes

Pyloric plane and its significance

Retroperitoneal structures and kidneys

Right iliac versus left iliac structure and pain (including McBurney’s point)

Inguinal canal and hernias

Anatomy of vaginal and rectal examination

Bowel sounds

Gastrointestinal volvulus Students should also have anatomical knowledge of some of the following procedures:

Ascitic tap Radiological anatomy that is relevant for this session may include:

Plain Abdominal imaging

Abdominal ultrasound and it’s different applications

Dual contrast barium enemas

CT abdominal imaging

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Abdominal / Pelvis Anatomy in detail

The abdominal examination is performed to look for abnormalities in the

gastrointestinal, renal and reproductive systems; however there is often an emphasis

on the gastrointestinal system. Any abdominal examination will begin by examination

of the hands, face, lips and oral cavity, as many of the pathological processes in the

gastrointestinal system may produce abnormalities in these more distant structures.

Here we will concentrate on the abdomen and pelvis only.

Abdominal surface anatomy (of viscera) As with thoracic anatomy, knowledge of the surface anatomy of the abdominal wall,

and abdominal/pelvic viscerae is a prerequisite to competent examination. In

particular, you will need to be familiar with the anatomical landmarks and

relationships of the inguinal canal, in order to understand the different types of hernia

that can occur in this region.

Abdominal regions / asymmetry of underlying structures It is common practice to divide the abdomen into quadrants by using a vertical and

horizontal line that intersect at the umbilicus. Alternatively the abdomen is divided

into 9 regions. The two vertical lines bounding the median regions pass through the

mid-inguinal points – the point midway between the anterior superior iliac spine and

the symphysis pubis. The lower horizontal line is the intertubercular plane and is a

line joining the tubercles on the iliac crests (at the level of L5). The upper horizontal

line is the transpyloric plane (described below).

Visible or palpable masses are best described in relation to the quadrant or region in

which it is seen or felt.

Abdominal distension and its causes There is a range of normal appearances of the abdomen, and it is important to

recognise ‘natural’ variation to avoid offending patients. Any abdomen that

demonstrates true distension requires an explanation. Causes of generalised

abdominal distension can be remembered as the ‘five Fs’: fat, foetus, fluid, flatus,

and faeces. A working knowledge of the underlying markings of the abdomen will aid

the examiner. A distended epigastrium could be due gastric cancer, whereas a

visible distension in the suprapubic region may indicate urine retention in a distended

bladder.

Pyloric plane and its significance The horizontal transpyloric plane passes through the tips of the 9th costal cartilages

on the two sides – that is the point where the lateral margin of the rectus abdominis

crosses the costal margin. The transpyloric plane lies at level of the body of the first

lumbar vertebra. This plane also passes through the pylorus of the stomach, the

duodenojejunal junction, the neck of the pancreas and the hila of the kidneys.

Retroperitoneal structures and kidneys The retroperitoneal space is a relatively hidden space anatomically speaking on the

posterior abdominal wall behind the parietal peritoneum. It extends from the 12th rib

and 12th thoracic vertebra above to the sacrum and iliac crests below. The psoas

muscles and quadratus lumborum muscles lie on the floor of the space, and in

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anterior to them are fascial layers. There is a variable amount of fatty connective

tissue anterior to this fascia which forms a bed for the adrenal (suprarenal) glands,

the kidneys, the ascending and descending parts of the colon, and the duodenum.

The ureters and the renal blood vessels also pass through this area.

Right iliac versus left iliac structure and pain (including McBurney’s point) Pain can be felt within any region of the abdomen, but commonly can occur in either

iliac fossa. The right iliac fossa contains several different structures including the

caecum, the ileocaecal junction, the right ovary, right uterine tube and the appendix.

The left iliac fossa contains the lower part of the descending colon, the upper part of

the sigmoid colon, and the left ovary and left uterine tube.

It is important to recognise localised pain in the right iliac fossa due to possible

appendicitis. The base of the appendix is situated one third of the way up the line

joining the right anterior superior iliac spine to the umbilicus. It is at this point

(McBurney’s point) where the severe, localised pain due to inflammation of the

adjacent parietal peritoneum often occurs in the later stages of acute appendicitis. It

is important to note though that many cases of appendicitis present initially with pain

around the central abdomen, but later at McBurney’s point, (you must revise about

referred pain!).

Inguinal canal and hernias The inguinal canal is an oblique canal that runs from the internal ring (a hole in the

transversalis fascia) to the external ring (a defect in the external oblique

aponeurosis). It allows the passage of the spermatic cord in men and the round

ligament of the uterus in women, together with the ileo-inguinal nerve. The femoral

canal runs beneath the inguinal ligament, under its medial aspect.

The three types of hernia that occur in the groin are the indirect inguinal hernia, the

direct inguinal hernia, and the femoral hernia. Revision of the anatomical basis of

each of these will be useful prior to surgical teaching sessions.

Anatomy of vaginal and rectal examination Both of these examinations can worry students, but both are necessary to learn

about and perform during your studies. The technique will not be covered in detail

here. Suffice to say that like any examination involving palpation, you must have

anatomical and especially spatial knowledge of the adjacent structures. When you

insert a (gloved) finger in the vaginal or rectal orifice, you must be able to imagine the

relationships of the adjacent organs – for example the prostate gland in the PR

examination of a male patient, and the adnexae in the PV examination of females.

Bowel sounds Bowel sounds are normal and instantly recognisable with a stethoscope as gurgling

sounds heard every 10 to 20 seconds. Absence of bowel sounds, only confirmed

after listening for a period of at least 30 seconds to a minute, can occur in a number

of surgical pathologies, such as ileus or peritonitis. Overactive bowel sounds, often in

association with tinkling sounds, may be heard in the presence of bowel obstruction.

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Gastrointestinal volvulus During development the midgut rotates in the abdominal cavity and thereafter should

remain in fixed position. As well as some rare malrotation syndromes which are

congenital, the gut can abnormally rotate during life. The caecum and the sigmoid

colon are the most mobile of the large bowel structures and can rotate around their

mesenteries. When this occurs, it is called a caecal or sigmoid volvulus. Whilst the

condition may correct spontaneously or with conservative treatment, occasionally

surgical intervention is required as the blood supply to these sections of bowel can

be threatened.

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The Spine

The anatomy of the limbs and spine encompasses several different aspects of

clinical examination. The axial skeleton is not high on the list for many student’s

revision priorities, however, knowledge of spinal anatomy and examination is

necessary for musculoskeletal and sometimes general medical conditions, as well as

orthopaedics.

The back extends from the skull base to the tip of the coccyx. The spinal or vertebral

column is the central bony pillar in the posterior midline and supports the skull, upper

limbs, thoracic cage, and by way of the pelvic girdle, transmits body weight to the

legs. It therefore assumes many important functions including being a scaffolding for

the limbs, protection for the spinal cord, and a vibration damper. Disorders of the

spine can affect a person’s function dramatically, as any of you who have had the

misfortune to suffer severe back pain will acknowledge.

Spine Knowledge



Vertebral column and movement

Curves and deformity – kyphosis, lordosis and scoliosis

Spinal cord and peripheral nerve roots

Intervertebral discs and the cauda equina

Dural sac and CSF


procedures:

Lumbar puncture

Spinal and epidural anaesthesia


Plain imaging

MRI spine

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Spine Knowledge in detail

Vertebral column and movement

The spine can be divided into three segments: the neck (cervical spine), the upper

back (thoracic spine), and the lower back (lumbar spine). Examination of the whole of

the spine and its movements requires a comprehensive approach.

The approach to examination should usually follow the schema for musculoskeletal

examination: look, feel, move; although some special tests may also be relevant.

Ideally for a comprehensive examination the patient should be standing, and wearing

nothing more than underwear. The normal range of movement of the different parts

of the vertebral column should be tested. In the cervical region, flexion, extension,

lateral rotation, and lateral flexion are all possible. In the thoracic region the

movements are limited by the presence of the ribs and sternum. In the lumbar region,

flexion, extension, lateral rotation and lateral flexion are possible. Flexion and

extension are fairly free, whereas lateral rotation is limited by the interlocking of

articular processes. Lateral flexion in the thoracic and lumbar region is tested by

asking the patient to slide their hands, in turn, down each lateral side of the leg.

Curves and deformity – kyphosis, lordosis and scoliosis

The spine is naturally curvy. Normally the cervical spine has a lordosis, the thoracic

spine a kyphosis, and the lumbar spine a lordosis. Although there is a degree of

natural variation, one should be aware of abnormal loss or exaggeration of these

curvatures.

Kyphosis is an exaggeration in the sagittal curvature present in the thoracic spine. In

the elderly, severe osteoporosis or degeneration of the intervertebral discs can also

lead to kyphosis affecting the cervical, thoracic or lumbar parts of the spine.

Scoliosis is a lateral deviation of the spinal column and is often a developmental

anomaly. This is most commonly found in the thoracic region and may be caused by

muscular (often nervous) or vertebral defects. Scoliosis may also be due to

compensation for short leg or hip disease especially in the elderly.

Spinal cord and peripheral nerve roots

The spinal cord is a cylindrical, greyish white structure that is continuous above with

the medulla oblongata and terminates below (in the adult) with the level of the lower

border of the L1 vertebra. In the cervical region, the spinal cord gives origin to the

brachial plexus, and in the lower thoracic / lumbar regions it gives origin to the

lumbosacral plexus.

Along the whole of length of the spinal cord are attached 31 pairs of spinal nerves by

the anterior (motor) roots and posterior (sensory) roots. Each spinal nerve roots pass

laterally from each spinal cord segment to the level of their respective intervertebral

foramina, where they unite to form a spinal nerve. Here the spinal nerve is composed

of a mixture of motor and sensory fibres.

Each intervertebral foramen is bounded superiorly and inferiorly by the pedicles,

anteromedially by the intervertebral disc, and posteriorly by the articular processes

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and joints. In this position, the spinal nerve roots are vulnerable and can be pressed

upon and irritated by disease of the surrounding structures. Herniation of the

intervertebral discs, fractures of the vertebral bodies, and osteoarthritis of the

articular joints between vertebrae can all result in pressure or stretching of the

emerging spinal nerve. This causes dermatomal pain – especially when the limb is

moved, muscle weakness, and diminished or absent reflexes.

Intervertebral discs and the cauda equina

The intervertebral discs are responsible for one quarter of the length of the spinal

column. They effectively act as semi-elastic discs, which lie between the rigid bodies

of the adjacent vertebrae therefore allowing movement. They act as shock absorbers

when there is excessive load on the vertebral column, such as when landing

following a jump from a height. With advancing age the water content of the inner

core (nucleus pulposus) of the disc decreases (reducing height) and the resilience of

the discs decreases. Occasionally the disc can rupture under periods of excessive

load and the herniated material can cause pressure on nerve roots, the spinal

nerves, or even the spinal cord.

The spinal roots of the lumbar and sacral nerves below the termination of the cord

(lower border of L1 vertebra in the adult) form a vertical leash of nerves called the

cauda equina. Cauda equina syndrome is a serious neurologic condition in which

there is acute loss of function of the neurologic elements (nerve roots) of the spinal

canal below the termination (conus) of the spinal cord caused by disc herniation,

lumbar vertebra trauma, or metastatic disease.

Dural sac and the CSF

The spinal cord, like the brain, is covered by three meningeal coverings: the dura

mater, the arachnoid mater, and the pia mater. The dural sac is a continuation of the

dura mater of the brain and is a strong fibrous sheet that encloses the spinal cord

terminating below at the cauda equina. The dural sheath lies loosely in the spinal

canal and is separated from the walls of the canal by the extradural space (epidural

space). The arachnoid mater is a delicate impermeable membrane that covers the

spinal cord. It is separated from the pia mater by a wide subarachnoid space which

contains the cerebrospinal fluid. Between the levels of the conus medullaris (the end

of the cord) and the lower end of the subarachnoid space (at the level of S2

vertebra), the nerve roots of the cauda equina lie within the subarachnoid space and

are bathed in cerebrospinal fluid. A needle is passed into this space, usually just

above or below the fourth lumbar vertebra pushing the nerve roots to one side, in

order to obtain CSF for various investigations (the technique of lumbar puncture).

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The Upper Limbs

Upper Limb Knowledge



Shoulder girdle

Brachial plexus – roots and site

Major nerves

Peripheral pulses

Venous system and venepuncture

Antecubital fossa

Muscles of the arms and reflexes

Dermatomes and sensory system

Wrist and hand structures


procedures:

Venepuncture

Arterial sampling for blood gas analysis

Blood pressure measurement


Plain X-rays (and their varying orientations)

Upper Limb in detail

Knowledge of upper limb anatomy is important in many aspects of medicine and

surgery. More detail about musculoskeletal aspects of the upper limb is covered in

the fourth year musculoskeletal rotation; students are however expected to be able to

perform basic examination of joints by the end of the third year. In particular,

examination of the hands is frequently assessed in the end of year clinical OSCEs.

Another area of knowledge that is important is the peripheral vascular system – both

for direct vascular problems (e.g. an acute ischaemic limb) and for clinical skills (e.g.

arterial puncture for blood gas analysis, IV cannulation).

Before considering any joints in the upper or lower limbs, it is important to understand

the basic approach to clinical examination of joints. First of all it is important that you

ask the patient to ensure that you are not going to cause extreme pain. Assuming the

answer is ‘No’, the basic approach is the same for all joints – ‘Look ! Feel ! Move !’

Shoulder and pectoral girdle The shoulder is a very mobile joint, but is consequently less stable than other large

joints. The collection of muscles and tendons that surround the shoulder girdle – the

rotator cuff – provides some stability. Movements at the shoulder include abduction,

adduction, flexion, extension, and internal and external rotation. Students should be

aware about the surface markings of the joints (glenohumeral and acromioclavicular

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joints), as well as how to assess both the active and passive movements of the

shoulder girdle.

Brachial plexus – roots and site The nerves entering the upper limb provide sensory innervations to the skin and

deep structures, motor innervations to the muscles, and sympathetic innervations

providing vasomotor and secretory control. At the root of the neck, the nerves form a

complicated plexus – the brachial plexus. The anterior rami of C5-8 and T1 spinal

nerves contribute to the plexus. Most students don’t know the exact locations of

different parts, but should know about the brachial plexus.

Clinical knowledge about the brachial plexus and major nerves of the upper limb

becomes important in the assessment of traumatic injuries or situations of nerve

entrapment, which both give rise to typical patterns of sensory and motor loss.

Major nerves As well as brachial plexus injuries, students should have an understanding about the

major nerves in the upper limb. Entrapment neuropathies (caused by traction or

pressure) or direct injury can lead to characteristic patterns of disability when major

nerves are affected. The axillary nerve can be compressed in the axilla by direct

pressure or shoulder dislocation. The other major nerves – radial, ulnar and median

nerves – can be affected at different points in their course in the upper limb.

Anatomy of these major nerves should be revised and patterns of disability from

injury should be understood.

Peripheral pulses A clinician must know where the arteries of the upper limb can be felt or compressed

in an emergency. It is easiest to feel a pulse if it crosses a firm structure such as

bone – for example, the subclavian artery can be felt in the root of the posterior

triangle of the neck against the first rib. The brachial artery can be felt in the arm as

in lies on the brachialis and is overlapped from the lateral side by the biceps brachii.

The radial and ulnar arteries can be felt at the anterior wrist lateral and medial to the

major midline flexor tendons respectively. It is important that the radial artery can be

felt, not only because feeling the radial pulse is vital in clinical examination, but also

as this is often the artery that is used to obtain blood via an arterial stab for

measurement of arterial blood gases. Remember the potential for damage the

median nerve during this procedure.

Venous system and venepuncture The superficial veins are clinically important, and many junior doctors worry about

these vessels as they are needed for phlebotomy and intravenous cannulation.

There are common variations in the superficial venous network. Review the common

patterns of the venous system of the upper limb. It is important to be able to

Review the structure of the brachial plexus, consider what patterns of abnormality

may be present in injuries to the upper and lower parts of the plexus respectively.

Hint: Look up Erb-Duchenne Palsy and Klumpke Palsy

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recognise the cephalic vein at the wrist – often called the ‘Houseman’s friend’, as it

runs fairly constantly in a straight line superficial to the radial styloid and is often a

fairly reliable place for an intravenous cannula.

Antecubital fossa The antecubital fossa contains many of the important structures that have already

been mentioned. It is important to understand the anatomical relationships of the

venous network, median nerve, brachial artery, biceps tendon, and the radial nerve

at the elbow.

The supratrochlear lymph node also lies in the superficial fascia in the upper part of

the antecubital fossa. It drains lymph from the 3rd - 5th fingers and medial hand

/forearm, therefore becoming enlarged if there is infection or inflammation in these

regions.

Muscles of the arms and reflexes An outline understanding of the types and range of movement of joints in the upper

limb, as well as the major muscle groups is required for clinical medicine. A physician

must know about the segmental innervation of the muscle reflexes in the arm:

Biceps brachii tendon reflex: (C5 and) C6 (flexion of the elbow joint by tapping

the biceps tendon)

Triceps tendon reflex: C6, C7 and C8 (extension of the elbow joint by tapping

the triceps tendon)

Brachioradialis tendon reflex: (C5), C6 and C7 (supination of the radioulnar

joints by tapping the insertion of the brachioradialis tendon)

Dermatomes and sensory system The dermatomes have already been mentioned in the session on the central nervous

system. The dermatomes of the upper cervical segments C3 to C6 are located along

the lateral margin of the upper limb; the C7 dermatome is situated on the middle

finger; and the dermatomes for C8, T1 and T2 are along the medial margin of the

limb (think about this when you are in the shower). Despite the fact that the nerve

fibres from a specific segment of the spinal cord exit from the cord in a spinal nerve

of the same segment, they pass to the skin in two or more different cutaneous

nerves. It is not necessary to remember all of the different names – but a few

concepts can be important such as referred pain, and the consequences of nerve

entrapment on sensation.

The skin over the point of the shoulder and halfway down the lateral part of the

deltoid is supplied by the supraclavicular nerves (C3 and C4). Pain can be referred to

this region from inflammation of the diaphragmatic pleura or peritoneum. The afferent

stimuli reach the spinal cord via the phrenic nerves (C3-5) and therefore pain from

pleurisy, peritonitis, or gallbladder disease can all be experienced as shoulder pain.

Wrist and hand structures Knowledge of the wrist and hand should relate to the bones (especially carpal bones)

and patterns of injury; the carpal tunnel and structures that become compressed in

carpal tunnel syndrome; the innervation of the intrinsic muscles (including which

muscles are supplied by the median rather than the ulnar nerve); and the basic

structures of the other soft tissues (e.g. tendon sheaths).

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The Lower Limbs

Lower Limb Knowledge



Hip, knee and ankle joints

Foot

Peripheral Pulses

Venous drainage and superficial veins

Femoral triangle

Muscles of the legs and reflexes


Ankle and foot structures


procedures:

Venous cut-down

Femoral venous and arterial access

Gluteal intramuscular injection


Plain imaging

Venography

Lower Limb in detail

Knowledge of lower limb anatomy is also covered in more detail in the fourth year

Musculoskeletal rotation; students should understand the basic joint examination by

the end of the third year. In the lower limb students are most likely to be asked to be

able to perform an examination of a knee joint in the end of year clinical OSCE.

Similar to the upper limb, knowledge of the peripheral vascular system is also

necessary.

Hip, knee and ankle joints The lower limbs support the weight of the body and provide a stable foundation for

activity. The hip is a more stable joint compared to the shoulder, but has a slightly

more limited range of movement. The knee joint has many vital functions in

locomotion. It is also prone to various injuries, especially in sport. As with the upper

limb, students will need to be aware of the normal range of movement of each of the

joints and understand common musculoskeletal problems of the lower limbs.

Foot The foot, like the hand, is a complex anatomical structure. The foot supports the body

weight and serves as a spring to absorb shocks and ensure normal gait. The arches

of the foot allow for this function. Although it has lots of small intrinsic muscles, most

of these are used to maintain the shape and arches of the feet, compared to the

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delicate and precise movements seen in the hand which allow dextrous movements

of the fingers.

Peripheral Pulses Students most often learn about the peripheral pulses in the lower limbs from

vascular surgeons. The underlying anatomical knowledge of the precise positions of

the major arteries in the lower limb is necessary to be able to determine whether

there is an evidence of arterial occlusion in patients with arteriosclerosis. You should

revise how and where to palpate the femoral, popliteal, dorsalis pedis and posterior

tibial arterial pulses.

Venous drainage and superficial veins The veins in the lower limb are used rarely for venepuncture or intravenous

cannulation, although both of these may be used in certain clinical situations. The

femoral vein can be catheterised in situations when rapid access to a large vein is

required. The femoral vein has a constant relationship to the medial side of the

femoral artery just below the inguinal ligament.

Superficial veins, especially in the thigh and lower leg, may become dilated and

tortuous in situations where the vein walls have become weak or the valves have

become incompetent. This gives rise to varicose veins – a condition which is often

surgically treated if the patient has associated pain, discomfort or oedema and

resulting ischaemic skin.

As well as superficial veins, the deep venous system is important due to the

problems of venous thromboembolism. The anatomy of the deep veins is perhaps

less important in this regard than the physiology of the venous circulation and the

‘calf muscle pump’. Immobility can lead to thrombosis in the deep venous system in

the legs, which is problematic if the thrombosis spreads proximally and/or becomes

dislodged, passing to the lungs to cause pulmonary embolism.

Femoral triangle The femoral triangle is a triangular depressed area situated in the upper part of the

medical aspect of the thigh just below the inguinal ligament. It contains the terminal

part of the femoral nerve, the femoral sheath, the femoral artery, the femoral vein,

and the deep inguinal lymph nodes.

An understanding of the relationships of these structures is important for various

reasons including the identification of femoral hernia, the puncture of the femoral

artery for blood gas analysis (instead of the radial artery), and for the placement of

femoral venous catheters.

Muscles of the legs and reflexes Students should have an outline understanding of the types and range of movement

of joints in the lower limb, as well as the major muscle groups. As per the upper limb,

a physician must also know about the segmental innervation of the muscle reflexes in

the leg:

Patellar tendon reflex (knee jerk): (L2), L3 and L4 (extension of the knee joint

on tapping the patellar tendon)

Achilles tendon reflex (ankle jerk): S1 (and S2) (plantar flexion of the ankle

joint on tapping the Achilles tendon)

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Dermatomes and sensory system The dermatomes have already been mentioned in the session on the central nervous

system. The dermatomes of the lower leg are again dependent on embryonic

development and consequently are slightly irregularly placed around the leg. Being

able to localise the ‘level’ of sensory impairment is helpful in patients with spinal

injury or those who are receiving spinal anaesthesia.

As well as cutaneous nerves, there are a number of major nerves that supply motor

and sensory functions to the lower limb. As in the upper limb, these major nerves are

subject to entrapment syndromes or direct injury. One of the commonest problems is

common fibular (peroneal) nerve injury, as this nerve is extremely vulnerable to injury

as it winds around the neck of the fibula. It can be damaged directly or secondary to

upper fibula fractures and this can lead to a characteristic foot drop gait. Direct injury

to the sciatic nerve in the buttock can also result from incorrect intramuscular

injection in the gluteus maximus muscle. As part of the clinical skills passport you will

be taught correct techniques for intramuscular injections and therefore you must be

aware of the relevant anatomy.

Ankle and foot structures Knowledge of the ankle and foot should relate to the bones and other soft tissues, in

particular to patterns of musculoskeletal injury. Detailed anatomical knowledge of the

intrinsic muscles of the foot is not routinely required in clinical practice; however

sprains and ligamentous injuries as well as fractures are not uncommon.

The ankle is more complex comprised of two joints, and usually poorly understood by

students and junior doctors alike. Ankle fractures are relatively common, so

knowledge (even if basic) is important. Students should revise the two different joints

that make up the ankle, the major bones of these joints and the associated

ligamentous support.

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Head and Neck / Central Nervous System

The central nervous system examination may involve many different aspects,

including an assessment of conscious level, cognitive testing, evaluation of speech,

and cranial nerve testing. A few anatomical pointers may be helpful in making

neurological diagnoses.

Neurological diseases and the examination of the neurological system may seem

daunting at first sight. For many practising doctors examination of the central and

peripheral nervous systems is practised much less frequently than other

examinations and therefore becomes less ‘routine’. A comprehensive examination of

the central nervous system requires a cooperative (and preferably communicative)

patient.

The neurologists at the University of Birmingham Medical School have a separate

lecture series that aims to reduce the complexity and fear that our medical students

have of neurological diseases and examination.

Central Nervous System Knowledge



Dermatomes and Myotomes

Cranial nerve testing

Visual fields

Autonomic nervous system

Key reflexes

Motor and sensory pathways

Blood supply to the brain

Cerebellum and coordination


procedures:

Fundoscopy

EMG Nerve conduction studies


CT brain imaging

MRI brain imaging

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Central Nervous System in detail

Dermatomes and Myotomes Areas of skin and the skeletal muscles receive segmental innervations from spinal

nerves which are called dermatomes and myotomes respectively. The area of skin

supplied by a single spinal nerve (and therefore a single segment of the spinal cord)

comprises a single dermatome. The arrangement of the dermatomes is complicated

and reflects the embryonic changes that occur as the limbs grow out from the body

wall. Clinicians need to have a working knowledge of the dermatomal innervations in

order to determine whether a particular spinal nerve or segment of the spinal cord is

functioning correctly.

Most skeletal muscles are innervated by nerves arising from between 2 and 4 spinal

segments. It is impossible to memorise all myotomes, but the segmental innervations

of muscles responsible for the major reflexes should be known (see below).

Cranial nerve testing The twelve cranial nerves arise from the brainstem provide important motor and

sensory functions to the head and neck, including the eyes, ears and some internal

organs. Lesions of the cranial nerves can cause motor or sensory loss to the areas

supplied or will affect the special senses of sight, hearing, smell or taste.

Visual fields Assessment of the visual fields is part of the examination of the optic nerve (cranial

nerve II), but can be a bit haphazard at the bedside (using the confrontation

technique). Students should revise the visual pathways and the field defects that can

arise from lesions along these paths.

Autonomic nervous system The autonomic nervous system regulates physiologic processes. Regulation occurs

without conscious control - autonomously. The 2 major divisions are the sympathetic

and parasympathetic systems. An understanding of the effector functions of the

autonomic nervous system, for example pupillary function, heart rate variability,

postural responses, and glandular function, can help the understanding and

diagnosis of autonomic dysfunction.

Key reflexes There are short pathways that do not travel up to the motor cortex of the brain but

form a local reflex arc between the muscle and the spinal cord. These are the spinal

reflexes that allow us to perform swift protective movements and do not require

conscious thought. These reflexes are commonly tested in the neurological

examination to assess whether particular spinal nerves or segment(s) of the spinal

cord are functioning correctly. By remembering the root values of the reflexes tested

you can help localize neurological lesions.

Motor and sensory pathways An idea of how nerve impulses travel down from the motor cortex and up to the

sensory cortex via the corticospinal tract and dorsal column / spinothalamic tracts

respectively can aid the localisation of various neurological diseases or lesions.

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Blood supply to the brain The brain is supplied by the two internal carotid and the two vertebral arteries. The

four arteries anastomose on the inferior surface of the brain and form the circle of

Willis. The internal carotid artery divides into the anterior and middle cerebral

arteries. The two vertebral arteries adjoin at the lower border of the pons (anterior to

the brainstem) to form the basilar artery. The basilar artery gives off branches to the

cerebellum, and the internal ear; and finally divides into the two posterior cerebral

arteries. An understanding of the contribution of the arteries and their courses can

help explain the symptoms and signs seen in various stroke syndromes. Stroke

physicians classify strokes as partial or total, and anterior or posterior circulation in

origin depending on the disability caused.

Cerebellum and coordination The cerebellum is located posterior and inferior to the cerebral hemispheres. It also

consists of two hemispheres which are linked by a midline structure called the

vermis. The cerebellum plays an important role in the control of muscle tone and the

coordination of muscle movement on the same side of the body, whilst the vermis is

involved with the maintenance of posture. A number of specialised tests are used to

examine for the presence of cerebellar dysfunction. These again will be taught at the

bedside and/or during neurology demonstrations at the medical school.

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Head and Neck Anatomy Knowledge



Skull

Scalp

Facial bones

Muscles of facial expression

TMJ

Eyes including ptosis

Oral cavity

Salivary glands

Triangles of the neck

Sternocleidomastoid

Carotids and Jugular Venous Pulse

Larynx and trachea

Thyroid gland and goitre

Head and Neck pain


procedures:

Cricothyroidotomy

Tracheostomy

NG feeding tube

Intubation

Auroscopy


Plain Radiography

Duplex Ultrasound

Barium swallow

Sialography

Angiography

CT/MRI

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Head and Neck Anatomy in detail

Skull The skull is composed of the cranium and facial bones. The vault of the skull is made

up of various parts (frontal, parietal, sphenoid, occipital and temporal bones) joined

together by immobile joints called sutures. The bones appear ‘stitched together’ by

these joints and this can make interpretation of fractures or discontinuities in the

bone difficult. Fractures are one of the main clinical concerns about the skull – both

obvious fractures of the vault and also of the base of the skull (underneath the brain).

The type of fracture that is seen depends on the age of the patient, the severity of the

trauma, and to which area the blow occurs. The main concerns relate to possible

damage to the delicate brain tissue or related vasculature, as well as the introduction

of infection to the brain and meninges (in open fractures).

Scalp The scalp covers the cranium in layers, three of which are tightly bound together –

the skin, the subcutaneous connective tissue and the aponeurosis of occipito-

frontalis (epicranium). The next two layers – the loose areolar tissue and the

pericranium (skull vault periosteum) lie deeper. The scalp has a very rich superficial

blood supply and little dense connective tissue – this has important implications as

scalp lacerations often form large flaps of skin (with its associated layers) which can

bleed extensively.

Facial bones The facial bones and the mandible make up the rest of the skull. Whilst detailed

knowledge of every facial bone is not absolutely necessary, it is important to know

the major structures and understand which bony features can be felt in a normal

person.

Fractures of the delicate facial bones are fairly common in road traffic collisions, falls,

and other trauma. In adults many of the facial bones are adjacent to air-filled sinuses

or cavities and therefore most facial fractures are considered to be open fractures

and require antibiotic treatment as they are susceptible to infection.

Muscles of facial expression The muscles of the face mostly arise from the bones of the face and are inserted into

the skin. The eye, nostrils and mouth are surrounded by muscles that open or close

these structures. Of course the other function of these muscles is to allow us to smile

(or grimace). All of the muscles of the face are supplied by the facial nerve (CN VII)

and testing for upper and lower cranial nerve abnormalities is an important skill (refer

to texts on cranial nerve section for details).

TMJ The TMJ is the only mobile joint in the skull (apart from those between the ossicles),

allowing the mandible to articulate with the temporal bone of the skull. It is a synovial

joint with an articular disc, and the condyle or head of the mandibule sits in the

temporomandibular fossa. The mandible moves forward (anteriorly) onto the articular

tubercle when the jaw opens. If this action goes too far, or the jaw receives a sudden

movement, the articular disc can move too far forward over the summit of the

articular tubercle and dislocation of the TMJ occurs. TMJ dysfunction and/or ‘jaw

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clicking’ occur when the articular disc becomes partially detached from the joint

capsule.

Movements of the jaw rely on the temporalis, masseter and pterygoid muscles all of

which are supplied by the mandibular division of the trigeminal nerve (CN Vc). These

are collectively known as the muscles of mastication.

Eyes including ptosis The eye is surrounded by the orbicularis oculi muscle which has a palpebral part

which is responsible for closing the upper eyelid, and an orbital part, a sphincteric

muscle with pulls the skin around the orbit to protect the eyeball. The eyelids are

extremely important for protecting the eye from injury and from excessive light

exposure. The position of each eyelid is also partially controlled by a small muscle

called the levator palpebrae superioris. The overall position of the eyelid at rest is

controlled by the two muscles – being closed by contraction of the orbicularis oculi

and the relaxation of the levator palpebrae superioris, and vice versa.

Ptosis – refers to the unilateral or bilateral drooping of the upper eyelid, usually due

to neurogenic or myogenic causes (i.e. caused by neurological or muscle disorders).

The eye is an important structure in the clinical examination and there are many

abnormalities that can be picked up from visual inspection of the eyes and pupils,

e.g. jaundice or anaemia (not just ptosis).

Oral cavity Examination of the tongue, dentition, mucosa, and palate can reveal important

abnormalities which give clues to pathology. The clinician must therefore at least

recognize all of the structures visible in the mouth and normal variations in the

mucosa.

Examination of the mouth is often seen as part of the gastrointestinal exam, although

many other factors can relate to the mouth such as respiratory cyanosis or nutritional

deficiencies.

The oral mucosa may reveal clinical clues such as ulceration (a break in the

epithelium) which can be seen in inflammatory bowel diseases; petechial

haemorrhages (red or purple spots) due to minor bleeding seen in several different

conditions; or superficial white coating due to infection from oral candidiasis.

The tongue is a muscular tissue consisting of striated muscle controlled by the

hypoglossal nerve (CN XII). Sensory fibres of taste are carried by the chorda tympani

branch of the facial nerve (VII) and glossopharyngeal nerve (CN IX) for the anterior

two thirds and posterior one third respectively, with general sensation carried by the

mandibular branch of the trigeminal nerve (CN Vc) for the anterior two thirds of the

tongue.

Ptosis can be either complete or partial. Using your anatomical knowledge (or

reference books) revise the neurological basis of each of these and look up some of

the clinical causes of each.

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Salivary glands There are three main salivary glands: the parotid, the submandibular, and the

sublingual glands. A number of diseases and other conditions can cause the glands

to enlarge (sialadenitis). Acute bacterial or viral infections and stone disease may

cause painful enlargement of the glands. Tumours may also cause painless

enlargement. The parotid gland lying just behind the ramus of the mandible is

relatively superficial and can be damaged in patients sustaining facial injuries. The

submandibular gland lies beneath the lower border of the body of the mandible, and

when examining the neck pathological swelling of this gland is easily mistaken for

enlarged submandibular lymph nodes.

Triangles of the neck Examination of the neck is an important aspect of clinical examination for many

reasons. It is important to identify the position of structures in the neck which is done

by dividing the neck anatomically into two triangles by the sternocleidomastoid. The

anterior and posterior triangles can be used to describe any abnormal features or

masses. It is therefore important for students to have a working map of where the

major organs are situated in each of these triangles.

Sternocleidomastoid The sternocleidomastoid is the large straplike muscle that appears as an oblique

band crossing the side of the neck from the sternoclavicular joint to the mastoid

process of the skull. It divides the neck into the anterior and posterior triangles. The

anterior border of the muscle covers the carotid arteries, the internal jugular vein and

the deep cervical lymph nodes. The sternocleidomastoid is covered by skin, fascia,

the platysma muscle and the external jugular vein. It is innervated by part of the

accessory nerve (CN XI) and therefore testing its action is also part of the cranial

nerve examination. Each muscle rotates the head to the opposite side and therefore

the action is tested by preventing rotation of the head away from the side of muscle

action.

Carotid Arteries and Jugular Venous Pulse

Inspection, palpation and auscultation of the blood vessels in the neck is a key part of

the cardiovascular exam. Students must be well practiced in being able to visualise

the jugular venous pulse, and feel / listen over the carotid pulse.

Common carotid arteries – the carotid arteries are paired vessels but have different

origins. The right common carotid artery arises from the brachiocephalic artery

posterior to the right sternoclavicular joint whereas the left common carotid artery

arises from the arch of the aorta in the superior mediastinum. The common carotids

run upward through the neck under the cover of the sternocleidomastoid muscle from

the sternoclavicular joint to the upper border of the thyroid cartilage.

Try to palpate your own and a partner’s carotid pulsation. You should use one or

two fingers to feel just beneath the anterior border of sternocleidomastoid at the

level of the superior border of the thyroid cartilage. Take the pulse rate (in beats per

minute) and become familiar with the character (pressure waveform) of the normal

pulse.

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CSA 35

Carotid sinus – the common carotid arteries divide into external and internal carotid

arteries at a localised dilatation called the carotid sinus. This structure contains

numerous nerve endings and serves as a reflex pressure receptor mechanism as

well as a chemoreceptor: rises in blood pressure stimulate the carotid sinus and

cause a slowing of the heart rate and arteriolar vasodilatation.

External and Internal Carotid Arteries – the external carotid artery provides arterial

blood supply to the structures of the neck, face and scalp. The internal carotid artery

continues upward in the neck in the carotid sheath with the internal jugular vein and

the vagus nerve to provide arterial blood supply principally to the eye and the

forebrain. It is worth briefly revisiting the numerous branches of both these arteries.

External Jugular Vein – the external jugular vein varies in size but is visible in most

people especially when straining (forced Valsalva manoeuvre). It begins behind the

angle of the mandible and crosses the neck obliquely (criss-crossing and superficial

to sternocleidomastoid) and disappears behind the clavicle in the posterior triangle to

drain into the subclavian vein. You should be able to visualise the vein in other

people. This vein can be quite tortuous and therefore is not usually used for venous

catheterisation; occasionally it is used in extreme emergency situations (e.g. cardiac

arrest) to obtain quick venous access.

Internal Jugular Vein – the internal jugular vein is a large vein that receives blood

from the brain, face and neck. It descends from the jugular foramen in the skull in the

carotid sheath lateral to the vagus nerve and the internal / common carotid arteries.

This vein is fairly constant in position and follows a path from a point midway

between the tip of the mastoid process and the angle of the jaw (superiorly) to the

sternoclavicular joint (inferiorly). The internal jugular vein is one of the veins of choice

for central venous cannulation.

JUGULAR VENOUS PRESSURE, JVP

Evaluation of the jugular venous pressure is one of important skills in clinical

examination, and one that students often find difficult. Understanding the anatomy

and physiology, as well as the correct positioning of patients, is key in being able to

demonstrate this skill.

The right atrial pressure can indicate the presence of pulmonary or cardiac disease;

however it is the internal jugular vein that is used as a ‘manometer’ of right atrial

pressure as these structures are in direct communication.

As the normal maximal right atrial pressure is about 7cm of water, the internal

jugular vein is collapsed and the venous pulsations are too deep in the chest to

visualise. Conversely when a patient is lying flat the vein is not fully distended and

there is again no visible pulsation.

Patients are usually examined reclining at 45° when the pulsations are normally at

the level of the clavicle between the heads of sternocleidomastoid. They may or

may not be visible here, but if the JVP is elevated the pulsations will usually be

visible higher up the neck.

Try to visualise the JVP in a friend and see what happens if the angle of recline is

changed (you should be able to visualise the pulsation if the angle is changed to

30°). If you can’t see the venous pulsation make sure that the person is fully

relaxed by asking them to ‘sink backwards into the bed’.

CC2

CSA 36

Larynx and trachea The larynx lies at the level of the 4-5th cervical vertebrae and is an organ that

provides protection of the upper airway and is responsible for voice production. It

opens above into the laryngeal pharynx and below is continuous with the trachea.

Detailed knowledge is not necessary for third year clinical skills anatomy, but clearly

is important for ENT surgery and anaesthetics. Students need to understand the

anatomical basis for techniques such as endoscopic bronchoscopy and endotracheal

intubation. he intrinsic muscles of the larynx are responsible for phonation, and

damage to the nerves which supply these (especially the recurrent laryngeal nerves)

can lead to changes in voice production and sometimes breathing difficulties. Lastly

an understanding of the surface anatomy of the larynx (thyroid and cricoid cartilages)

is important in other clinical interventions such as cricothyroidotomy.

The trachea can be readily felt below the larynx. As it descends it becomes more

deeply placed and can be as much as 4 cm from the surface at the suprasternal

notch. The trachea is a mobile elastic tube and is easily displaced by tumours or

enlargement of adjacent organs (e.g. goitre). The cervical section of the trachea is

also easily ‘pushed’ or ‘pulled’ to one side by pathology in the thorax (e.g. tension

pneumothorax or oesophageal cancer). Again knowledge of the surface anatomy of

the trachea is important for clinical examination and some procedural skills (e.g.

tracheostomy).

Thyroid gland and goitre The thyroid gland is attached to the larynx and therefore follows the movements of

the larynx in swallowing. This is important as any pathological swelling of the thyroid

gland will move up on swallowing. The gland consists of right and left lobes

connected by a narrow isthmus, situated anterior to the 3rd tracheal ring. The lobes

extend up to the thyroid cartilage and extend down to the fourth or fifth tracheal ring.

Clinical examination of anterior neck swellings including goitres is an essential skill in

medicine and surgery.

Head and Neck pain

Headaches and neck pain are both common symptoms. Discerning the cause of

certain types of pathology may require knowledge of the neuroanatomical basis of

pain. Direct and referred pain are both possible, and a basic understanding of the

nervous supply of the organs and tissues that have been discussed is required.

CC2

CSA 37

PBL on Thoracic Trauma (Thorax)

You are presented with a clinical scenario in this PBL. Use the resources available to

you and some of the recommended reading to work through the case and consider

the anatomical implications in clinical practice.

Learning outcomes relevant to this PBL include knowledge of the following:

Thoracic surface anatomy (lungs and heart)

Tracheal position

Jugular venous pulse

Chest wall movements

Cardiac apex beat and intercostal space counting

Respiratory sounds

Intercostal space structures

Parietal and visceral pleurae


procedures:

Respiratory examination

Needle thoracocentesis

Intercostal chest drainage


Plain Chest imaging

CT thorax scanning

CC2

CSA 38

A building site blunder

A 45 year-old builder is admitted to the emergency department following a building

site injury. He was working with some steel erectors to put up a frame of a new

building when a piece of steelwork fell and hit him on the right hand side of his chest.

He was not entrapped and his colleagues were able to get him to the emergency

department within 10 minutes. The patient had no other injuries other than those to

the chest, and there is no obvious external bleeding although the area is very tender.

On examination of the patient, he is haemodynamically stable, his airway is clear, his

respiratory rate is slightly raised (18 breaths per minute) and his oxygen saturations

on air are 98%. His pulse rate is 86 beats/min and his blood pressure is 132/76

mmHg. An ECG trace shows normal sinus rhythm. He is fully alert; his pupils are

equal in size and react to light. Inspection of the chest reveals some early bruising

and redness over the 6th, 7th and 8th ribs over the lateral right side of the thoracic

cage. There is extreme tenderness over these ribs. Auscultation of the chest is

normal.

Question 1 – How can the emergency doctor determine the correct position

and numbering of the ribs from his assessment of the patient?

Hint: you will need to revise the surface anatomy of the chest and there may be two

ways to determine which ribs are which.

The emergency doctor suspects that there may be some underlying injury and being

satisfied that there are no immediate life threatening injuries organises a plain chest

radiograph. This initial Chest X-ray and a normal X-ray for comparison are available

to view on Canvas.

Question 2 – Describe the abnormalities that you can see on this X-ray? What

underlying structures may be damaged by injuries to the ribs and why is the

patient in so much pain?

Hint: The anatomy of the intercostal space and parietal pleura may be important

here.

The patient is put onto oxygen (8 litres/min via a standard face mask) and given

some analgesia in the form of intravenous morphine. The emergency doctor

conducts a secondary survey to look for other injuries but doesn’t find any. Within 20

minutes and despite the oxygen the patient starts to complain of increasing

breathlessness. His respiratory rate now is 24 breaths per minute and his oxygen

saturations are 96% on oxygen at a flow rate of 8 litres per minute. The doctor

immediately reassesses the patient particularly looking at the position of the trachea

and apex beat of the heart, the jugular venous pressure, and percussion/

auscultation of the lungs to look for hyper-resonance and reduced breath sounds or

crackles respectively.

CC2

CSA 39

Question 3 – From an anatomical point of view, why are each of these

examinations important in this patient?

(The physical examinations which require explanation are:

Position of the trachea

The position of the apex beat of the heart

The jugular venous pulse in the neck

The pulmonary examination – percussion for resonance and

auscultation for breath sounds and crackles)

Hint: The doctor wishes to exclude the dangerous pulmonary complications of

thoracic trauma.

Findings from the examination and subsequent imaging suggest that the patient has

a suspected pneumothorax on the right hand side. The emergency doctor decides to

perform a tube thoracostomy (intercostal chest drain insertion) on the patient. Under

supervision he prepares to insert the chest tube into the fourth intercostal space in

the anterior axillary line aiming to insert the tube just above the fifth rib.

Question 4 – What is the rationale for inserting a chest tube in this location?

What structures will the needle and tube have to pass through to get into the

thoracic cavity?

Hint: The location is important both in terms of the positioning on the chest and the

relationship with the ribs.

The chest tube is inserted successfully into the right side of the chest and a

subsequent chest X-ray confirms the correct position. However, after a few hours the

patient complains of some swelling his right chest going up into the neck. On

examination there is some definite swelling of the area and on palpation of the area

there is a popping sensation underneath the skin which the doctor describes like

‘popping bubblewrap’.

Question 5 – What condition has the patient got and what are the possible

explanations for this?

The patient subsequently improves and after 48 hours his chest tube is removed and

he is discharged the day later.

That is the end of this case, but if you have time think about the following

questions:

Why do children tend to suffer from different patterns of thoracic trauma

injuries as compared to adults?

If the patient had become suddenly short of breath and a needle

thoracocentesis was indicated, how and where anatomically would this be

performed?

If the patient had broken several ribs in several places, what condition may

have been present? What can this lead to?

CC2

CSA 40

PBL on Acute Abdominal Pain (Abdomen and Pelvis)




.

Learning outcomes relevant to students for this PBL include:

Abdominal surface anatomy (of viscera)

Abdominal regions / asymmetry of underlying structures

Retroperitoneal structures and kidneys

Right iliac versus left iliac structure and pain (including McBurney’s point)

Inguinal canal and hernias

Bowel sounds


procedures:

Rectal examination


Plain Abdominal imaging

Abdominal ultrasound and it’s different applications

CT abdominal imaging

CC2

CSA 41

Abdominal pain the day after the night before

A 28-year-old woman goes to see her GP after being sent home from work ill one

Thursday afternoon. She is complaining of worsening abdominal pain throughout the

day, with associated nausea and vomiting (2 episodes in the afternoon). She admits

to the GP that she went out the night before to an Aussie bar on Broad Street and

ended up having one too many gin and tonics. Despite the GP’s initial reservations

he examines the patient and feels that despite the dubious history she is exhibiting

central abdominal tenderness not in keeping with a hangover. Her pulse rate (100

bpm) and blood pressure (136/80 mmHg) are also elevated. She was previously fit

and well, with no known health problems and her only medications are the combined

oral contraceptive pill and as required analgesia for ‘migraines’.

The GP decides that the patient requires further investigation immediately and refers

her to the RSO at the local hospital, who begrudgingly accepts the patient.

While waiting in the SAU at hospital she has further vomiting, and her pain worsens

and changes character. The FY1 doctor on call takes the history from the patient

which offers no further information than that given to the GP.

Question 1 – What clinical examinations of the patient should the FY1/RSO do

and why? What are the anatomical considerations they should be thinking

about regarding the abdominal component?

Hint: After hearing the history a good clinician should already be deciding their

differential diagnosis, the examination should be confirming their suspicions.

The examination reveals the patient is exhibiting tenderness in the epigastric central,

suprapubic and RIF regions of the abdomen. PR revealed an empty rectum. She also

looks rather pale and sweaty, her HR is elevated (120 bpm) but her BP is dropping,

but normal (now 110/68 mmHg).

Question 2 – What investigations should be carried out as soon as possible?

Are there any contraindications to certain investigations you’d like, and if so,

are there any other questions you’d like to ask the patient that the FY1 may

have forgotten about?

Hint: Consider what diagnoses you’re looking for and what you want to rule out.

Whilst waiting for the results of her investigations, she is given some analgesia and

an antiemetic. Her radiological investigations show no abnormalities and the blood

work reveals elevated inflammatory markers, slightly low haemoglobin and a mildly

raised alanine aminotransferase (ALT). Urinalysis is normal.

The nursing staff bleep you to inform you that despite the analgesia she is still

vomiting and is doubled over in pain.

She is looking worse from the edge of the bed, she is hot and clammy, and

examination now reveals grossly generalized tenderness of the abdomen with

rebound tenderness in the central and lower regions and guarding throughout the

entire central and right abdomen.

Question 3 – Why has the nature of her abdominal pain changed? Is there any

anatomical basis for this? What are your top 3 differential diagnoses?

Hint – consider the seriousness of her condition and the anatomy of where the major

of her signs are elicited from.

CC2

CSA 42

The registrar informs the Consultant surgeon who decides she needs to go to

emergency theatre for a diagnostic laparoscopy. During this it is noted that there is a

large amount of free pus in the abdomen and the bowel is heavily stuck down, there

is omentum covering the caecum. He says that the laparoscopy needs to be

converted to an open procedure. He is considering a Gridiron or Lanz incision.

Question 4 – What are the layers of the abdomen one would have to dissect in

a Gridiron/Lanz incision in order to access the peritoneum? What and where is

McBurney’s point, and why is this essential to know?

Hint: The ‘McBurney-Gridiron’ is a classical right lower abdominal incision

The surgery successfully removed a nasty looking appendix that had perforated with

a localized abscess cavity. She was discharged from hospital well 3 days later.

Consider the following questions too:

If the patient was pregnant, would any of your management have changed?

What differences in treatment/investigation would you consider if the patient

was male and of older age, with a lump in the right groin?

Where would the majority of the free pus have collected in this patient? Would

that differ in males?

If there was blood in the abdominal cavity rather than pus, where may it have

come from?

CC2

CSA 43

PBL on Wrist Trauma (Upper Limb)




.


Brachial plexus – roots and site

Major nerves

Peripheral pulses

Venous system and venepuncture

Antecubital fossa

Muscles of the arms and reflexes


Wrist and hand structures


procedures:

Venepuncture

Arterial Blood Gas Analysis


Plain film X-rays (and their varying orientations)

CC2

CSA 44

A helping hand

A 24-year-old male rugby-playing student attends the A&E department late one

evening after tripping over a vacuum cleaner whilst playing air guitar with the hose.

He put his right hand out to break the fall but unfortunately put his hand straight

through a table of glasses, lacerating the medial aspect of his right wrist. Blood

started squirting immediately and the ambulance was called.

In A&E his blood pressure and heart rate were mildly elevated but otherwise he was

haemodynamically stable. He was also complaining of numbness in certain areas of

his right hand, despite the fact that he’s in a serious amount of pain. He also says the

pain is stopping him from moving his fingers.

Question 1 – Which artery and nerve have been ligated? What symptoms

would you expect the patient to be suffering from, and where?

Hint: Think about other structures that may have been damaged to.

The patient needs to be admitted under the Trauma & Orthopaedic team for

emergency exploration of the wound and re-attachment of ligated structures. As the

FY1 on the T&O firm (and the SHO says he’s far too busy) you’ve been asked to take

some pre-op blood test and cannulate the patient.

Question 2 – Where precisely would you take the venous blood from, the

arterial blood gas sample (if you wanted one!) and insert the cannula

(anatomically speaking)? What are the risks?

Hint: Consider where the patient’s injury is.

Before the patient goes down to the theatre you have to mark the side of the

operation. The nursing staff take down the dressings and you notice that there is

another stab wound from the glass further up the medial aspect of his right forearm.

Question 3 – What layers/structures would this injury have penetrated

assuming it went through to the bone? What symptoms could this injury

contribute to?

Hint: Consider the musculature.

The surgery repaired all damage done and dressings were applied to the wrist and

forearm. The next day post-op he starts complaining of severe pain in his forearm.

He was given adequate analgesia but was still in agony.

Question 4 – What condition is the patient now suffering from? How would you

treat it? And what are the anatomical reasons for the condition?

Hint: How do you relieve pressure?

Fortunately there was quick and adequate treatment and so the patient was

discharged well. He was followed up in the clinic and received outpatient

physiotherapy. During the physiotherapy it was noted that there was some muscle

wasting in his hand and he was still suffering from pain.

CC2

CSA 45

Question 5 – Which muscles are most likely to be wasting and why? If the pain

is bony, which bone(s) may be affected?

Hint: Revise the carpal bones

Also consider the following questions:

If the injury to the nerve laceration occurred more proximally, i.e. around the

elbow joint, would there be any differing symptoms?

If the laceration was on the lateral side of his forearm, what different symptoms

would be suffer from?

What other symptoms would you get from any other major nerve injuries in the

upper limb?

CC2

CSA 46

PBL on Knee Trauma (Lower Limb)





Hip, knee and ankle joints

Peripheral Pulses

Venous drainage and superficial veins

Muscles of the legs and reflexes



procedures:

Femoral venous and arterial access

Doppler USS


Plain film X-rays (and their varying orientations)

CC2

CSA 47

Look out when crossing the road!

A 19-year-old female student is admitted to A&E after being hit by a car when

attempting to cross the road. The car was a large saloon but only travelling at

approximately 20-30 mph along the busy Bristol Road. A passer-by called an

ambulance. The ambulance crew found that apart from shock and a few grazes she

seemed unharmed but was a little unsteady on her feet. There were no obvious head

injuries.

Whilst in A&E her observations were recorded as HR 98 bpm, BP 130/78 mmHg, RR

22 breaths per min and O2 saturations of 98% on air. She is previous fit and well,

taking no regular medications except for the combined oral contraceptive pill. She

then started to complain of very sharp and increasingly severe pain in her right knee,

where she felt the car actually hit her. The SHO in A&E examined her thoroughly,

especially her lower limbs, including her neurology and peripheral vasculature

system

Question 1 – Where would the SHO have felt for her peripheral pulses

(exactly)? If he/she could not feel any of them, what else may they do in order

to help their examination? What neurology would they be looking for?

Hint: Consider the position of the femoral pulse; how may you see/hear pulses?

Finding that all pulses were present and that her neurology was grossly intact

(despite a difficult examination of her right knee due to the pain), the SHO continued

on to examine the musculoskeletal system by way of “look, feel, move”. There was

swelling on the inferior aspect of her right knee and some cuts and bruises.

Question 2 – What bony areas/landmarks/prominences would the SHO feel for

(anatomically speaking)? And what movements would they perform on the

knee joint? Are there any special tests they could do, and if so, what do they

test for?

Hint: Revise ligaments!

The SHO orders some plain radiography investigations of the knee joint and hip joint.

This shows that the patient has suffered a fracture of her tibial plateau. The SHO re-

checks their neurology examination and then refers to the Trauma & Orthopaedic

team for further management.

Question 3 – Why would the SHO re-check the neurology? Are there any

injuries that could occur to the nervous system during an injury like this? If so,

what symptoms could you expect to see?

Hint: Think about the position of a car bumper!

She is put into a ‘back-slab’ leg cast and kept nil by mouth ready for surgery to fix the

fracture. Post-operatively she is prescribed regular analgesia and told to mobilise

with crutches as soon as possible.

Despite doing all she is asked, 24 hours post-op she develops swelling and pain in

her right calf. The calf looks red and is quite warm to touch. She says the pain is

getting progressively worse.

CC2

CSA 48

Question 4 – What are your top 3 differential diagnoses for the calf pain, taking

into account her history and the anatomy of the leg? And why could she be

suffering from any of these three?

Hint: What structures are in the leg?

She is treated with the relevant medications for her calf pain and this settles

accordingly. She begins mobilizing again after 7 days but during her sessions with

the physiotherapist, she struggles with elevating her toes and lifting her foot off the

ground. The physiotherapist says that this kind of weakness is normal after an

operation, due to muscle atrophy due to disuse. With time and regular physio, she

says, the strength will return.

Question 5 – Is the physiotherapist correct in her diagnosis? If not, why might

she be struggling to elevate her feet/toes? Could there be a problem with her

ankle that was missed during her initial management?

Thankfully the patient makes a full recovery, although it took some intensive

physiotherapy and more time that would have originally been expected!

Consider also these questions:

If the car struck her on the back of the knee/leg instead of the front, what

symptoms may have been different?

What must all surgical patients receive as part of their medical and

conservative management unless there is a specific contraindication, to avoid

complications like those above?

If along with her post-op calf pain there was a painful lump felt in her groin,

what would your preferred diagnosis have been? What could the lump be and

why?

CC2

CSA 49

PBL on Neck Pain (Head and Neck)




.

Learning outcomes relevant to this PBL include knowledge of the following:

Cervical spinal osteology and contents of foraminae

Arrangement and compartmentalisation of neck musculature

Arrangement of cranial and spinal nerves

Structure and situation of cervical vertebral discs

Arrangement of spinal ligaments

Fascia of the neck; investing, prevertebral and pretracheal fascial planes

Retropharyngeal space

Deep and superficial cervical lymph nodes

Laryngeal, oesophageal and tracheal positions

Carotid sheath and contents

Surface anatomy of the neck; triangles of the neck, pulses, thyroid gland,

lymph nodes, thyroid cartilage, spinous processes, hyoid bone, sub-

mandibular gland

Sectional anatomy of the neck


procedures:

Principles of neurological examination

Principles of lymph node examination

Radiological anatomy that is relevant for this session:

Plain cervical spine radiology

Sagittal and coronal spinal MRI

CC2

CSA 50

A pain in the neck

A 50-year-old teacher attended at the emergency department of his local District

General Hospital reporting acute severe neck pain of several hours duration with

radiation into the left shoulder and arm, along with a cold, tingling numbness in his

left thumb and index finger. He had been working on a DIY project that involved

some heavy lifting and thought that this might have been the cause of the problem.

He had taken paracetamol and ibuprofen for the pain but with no relief.

There was no diabetes or significant medical history apart from a surgical repair of a

meniscal tear on his right knee 25 years earlier (he had been a keen footballer and

was still involved in the sport through coaching the local junior league) and removal

of a melanoma from his forehead last year. On examination, there was tenderness

over the suprascapular muscles and medial border of the scapula on the left. His

temperature was 36.8°C, BP was 137/72 mmHg, and O2 saturations of 97% on air.

Auscultation of the chest was normal as was the 12-lead ECG trace. Neurological

examination revealed no gross abnormality and there was no obvious

lymphadenopathy in the neck, axillae, or groin.

Question 1 – Discuss the significance of the investigations in this case. What

neurological examinations would the doctor have performed and why? What

was the purpose of the lymph node examination?

Hint: you will need to think about the past medical history and possible differential

diagnoses.

The emergency doctor suspected some underlying problem in the cervical spine and

organised a plain chest and lateral cervical spine radiographs and some routine

blood tests. Intravenous morphine was given for the patient’s pain and plans were

made to make an urgent orthopaedic referral.

Question 2 – Why did the doctor suspect a problem in the cervical spine?

Hint: revise the distribution of dermatomes and think about their relationship to this

patient’s symptoms.

The chest X-ray appeared normal but the lateral cervical spine X-ray showed

evidence of degenerative disease with reduced disc space and osteophytic spurs at

C5 / 6. The doctor decided that an urgent MR scan was needed. In the interim period

the patient was transferred to the emergency assessment unit where a few hours

later he complained that he could not move his legs properly and was having

problems urinating. A repeat neurological examination demonstrated normal cranial

nerve function but weakness in both lower limbs. Look at the image of the cervical

MR scan on web-CT.

Question 3 – Why did the Doctor request an urgent MR scan? Identify the

pertinent anatomical features on the MR scan and describe any abnormality

you can identify. What underlying structures may be damaged by the

abnormality? Explain why is the patient having difficulty moving his legs while

in so much pain in his arm and shoulder?

Hint: The anatomy of the vertebral and intervertebral foramina are important here.

CC2

CSA 51

The results of the scan indicated central and left lateral disc herniation effacing the

anterior aspect of the thecal sac and causing foraminal stenosis. A working diagnosis

of traumatic cervical disc herniation was made and the case was discussed with the

neurosurgeons.

Question 4 – What is the significance of these developments and why was the

neurosurgical team contacted?

Hint: The doctor wishes to minimise any damage to important neurological structures.

(Which ones and why?)

The neurosurgical team decided that an urgent discectomy was needed. The patient

was transferred to the neurosurgical unit where anterior discectomy and fusion of C5

/ C6 vertebrae was undertaken. At the same time some osteophytic spurs were

removed. The neck was immobilised postoperatively for several weeks.

Question 5 – Why was urgent surgical intervention required? What was the

rationale for undertaking the discectomy? Suggest the likely surgical approach

for this procedure. What anatomical structures needed to be divided to access

the disc? Which important fascial “space” lies immediately anterior to the

cervical vertebral discs and bodies and what is the significance of this space?

Hint: An understanding of the cross sectional anatomy and anterior / posterior

compartmentalisation of cervical musculature together with arrangement of cervical

fascial planes will help here.

Despite a slow post-operative recovery, hindered by development of a sacral

pressure ulcer, full mobility was eventually regained following appropriate

rehabilitation.

That is the end of this case, but you should also think about the following

questions:

What might have been the consequences for the patient had the admitting

emergency doctor not responded so quickly to the patients complaints of pain

/ sensory and motor disturbances?

How would the patients symptoms have differed had the problem been at C3/4

disc rather than C5/6?

Why might the patient have developed a pressure ulcer and how would this

have delayed his recovery? How could the ulcer have been prevented? Why is

the sacral area susceptible to pressure ulceration? What other anatomical sites

are at risk of pressure ulceration and why?

How would discovery of lymphadenopathy have influenced the possible

differential diagnosis?

CC2

CSA 52

PBL on Facial Palsy (Central Nervous System)





Dermatomes and Myotomes

Cranial nerve testing

Visual fields

Autonomic nervous system

Motor and sensory pathways

Blood supply to the brain


CT brain imaging

MRI brain imaging

CC2

CSA 53

Keeping an eye on other things?

A 42 year-old estate agent is admitted to the Medical Assessment Unit after waking

up in the morning and noticing in the mirror that his left eyelid is dropping. He also

says his skin feels a little dry. He has never experienced these symptoms before and

his right eye is normal. He takes regular medication for hypertension, diagnosed one

year ago, and has recently taken amoxicillin for a chest infection. Otherwise he is

slightly overweight, drinks about 21 units of alcohol a week and currently smokes

about 10 cigarettes a day. His observations show a heart rate of 88 bpm, blood

pressure of 146/90 mmHg, temperature of 37.5°C and oxygen saturations of 92% on

air.

Question 1 – Which clinical examinations would you like to perform? What

results of these would you expect?

Hint: Do you just want to examine his eye?

He has a drooping left eyelid and a large left pupil. Otherwise his facial neurology is

normal. He has some crackles in his chest, but then again, he is a smoker. You

diagnose Horner’s syndrome.

Question 2 – What is the anatomical basis for the symptoms of Horner’s

syndrome? Why is it unilateral?

Hint: Consider the autonomic nervous system

You decide to admit the patient for further investigations.

Question 3 – Which investigation is vital?

Hint: Consider the causes of Horner’s syndrome that you want to rule out

Whilst waiting for the investigations to be performed, you notice that the JVP on his

left side of the neck is slightly raised and he has a productive cough with a small

amount of blood in the sputum. He is pleased to announce that he is smoking much

less now than a few years ago, when he used to smoke at least 30-40 cigarettes a

day and that he has lost some weight recently.

Question 4 – Why might his JVP be raised? And why are you now 99% sure of

the diagnosis without needing the results of your earlier investigation?

Hint: Put all the information given so far together, and consider your cardiothoracic

anatomy

He is, unfortunately, diagnosed with an apical lung tumour on the left, which is what

you were expecting (!).

Question 5 – Where else may a tumour be if the first presentation is a facial

droop?

Hint: Think outside the box!

CC2

CSA 54

Bibliography

There are a number of specific texts which may be useful for reference however your

basic anatomy texts will contain the majority of the important information covered in

this course. It is not suggested that you purchase any of the following texts, but they

are included for reference.

Clinical Anatomy by Harold Ellis. Blackwell Publishing

Clinical Anatomy by Stanley Monkhouse. Churchill Livingstone

Gray’s Anatomy for Students by Drake, Vogl and Mitchell. Churchill Livingstone

Clinical Anatomy for your pocket by Douglas J. Gould. Lippincott Williams &

Wilkins – this may be worth buying.

Clinically Orientated Anatomy by Keith Moore Arthur Dalley and Anne Agur.

Lippincott Williams & Wilkins

Essential Clinical Anatomy by Keith Moore and Anne Agur. Lippincott Williams &

Wilkins

Illustrated Clinical Anatomy by P. Abrahams, J. Craven and J. Lumley. Hodder

Arnold

Netter’s Clinical Anatomy by John Hansan and David Lambert. Icon Learning

Systems

General Surgical Anatomy and Examination by Alastair Thompson. Churchill

Livingstone

Surface Anatomy by John Lumley. Elsevier Churchill Livingstone

Atlas of Clinical Gross Anatomy by Moses, Banks, Nava and Petersen, Elsevier

Mosby

Anatomy - A Regional Atlas of the Human Body by Carmine Clemente. Lippincott

Williams & Wilkins

clinical skills anatomy handbook - thewhea.co.uk · thoracic surface anatomy (lungs and heart)...

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