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122 Cards in this Set

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What is removed in a radical mastectomy? What nerves can be injuried?
Breast, pectoralis major and minor, axillary lymph nodes and fascia, and part of the thoracic wall.

Long thoracic n. and thoracodorsal n.
What is a modified radical mastectomy?
Removal of breast and axillary lymph nodes but preservation of pectoralis major and minor (the pectoralis m. is usually severed near its insertion into the coracoid process)
Tennis elbow
Caused by chronic inflammation or irritation of the tendo of the extensor muscles of the forearm from the lateral epicondyle to the humerus.
Golfers elbow
Painful condition, same as tennis elbow, except it happens on the other side of the elbow (medial epicondyle). It does not compress the ulnar nerve.
Dupuytren's contracture
A progressive thickening, shortening, and fibrosis of the palmar fascia producing a flexion deformity of fingers - esp third and fourth fingers
Carpel tunnel syndrome
Caused by compression of the median nerve in the carpal tunnel leading to pain and paresthesia in the area of the hand supplied by the median nerve.
Injury to the long thoracic nerve:
Caused by a stab wound or during radical mastectomy or thoracic surgery. It causes paralysis of serratus anterior m. and inability to elevate the arm above the horizontal. = winged scapula
Injury to posterior cord?
Caused by pressure from cross piece of a crutch resulting in paralysis of arm --> loss of function of extensors of the arm, forarm, and hand and produces a wrist drop.
Injury to axillary n?
Axillary (C5-C6)
Caused by fracture to the surgical neck of the humerus or anterior shoulder dislocation. --> loss of deltoid action --> weak lateral rotation and abduction (supraspinatus can abduct but not up to horizontal)
Injury to radial n?
Radial nerve (C5-T1)
Caused by fracture of the shaft of the humerus. Radial n. is known as the "great extensor n". It provides innervation of the Brachioradialis, Extensors of the wrist and fingers, Supinator, and Triceps (BEST)

--> loss of wrist extension (wrist drop) and weakness of abd/adduction of hand
What movement does the supinator make?
Makes you carry a bowl of soup.
Injury to musculocutaneous n.
MC: C5-C7
Loss of function of the coracobrachialis, biceps, and brachialis m. (biceps reflex). So: weak supination (biceps) and forearm flexion (brachialis and biceps)

It passes through the coracobrachialis.
Injury to the median nerve?
Median: C5-T1
Caused by a supracondylar fracture of the humerous or compression of the carpal tunnel.

No loss of power in any of the arm muscles; loss of forearm pronation, wrist flexion, finger flexion, and several thumb movements --> eventually thenar atrophy

Loss of sensation over the lateral palm and thumb and the radial 2 1/2 fingers.

Nerve passes through pronator teres
Injury to ulnar nerve?
Ulnar nerve: C7-T1
Fracture of the medial epicondyle causing impaired wrist flexion and adduction, and impaired adduction of the thumb and the ulnar two fingers (claw hand).

Loss of sensation over the medial palm and ulnar 1 1/2 fingers. Passes through flexor carpi ulnaris.
Why does a clavicular fracture not injury the brachial plexus?
It is protected by the subclavius muscle
Upper trunk injury?
Erb-Duchenne palsy (C5-C6)
Traction or tear of the upper trunk of the brachial plexus (C5-C6 roots).
Comes from blow to shoulder or trauma during delivery

Findings: limb hangs by side (paralysis of abductors), medially rotated (paralysis of lateral rotators), forearm is pronated (loss of biceps).

Waiters tip
What is thoracic outlet syndrome?
An embryologic defect; can compress subclavian artery and inferior trunk of brachial plexus (C8, T1), resulting in thoracic outlet syndrome:
1. atrophy of the thenar and hypothenar eminences
2. atrophy of the interosseous muscles
3. sensory deficits on the medial side of the forearm and hand
4. dissapearance of the radial pulse upon moving the head toward the opposite side.
If the brachial artery is tied off distal to the inferior ulnar collateral artery will blood get to the ulnar and radial arteries?
Yes, via the anastomoses around the elbow.
Where do you feel for a brachial artery?
On the brachialis against the humerus but medial to the biceps and its tendon.
What phlebotic error can cause gangrene and loss of all or part of hand?
When the ulnar artery is mistaken for a vein and injected with drugs.
What forms the rotator cuff?
Tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor .

The quadrangular space is bounded by the teres minor with subscapularis, teres majory, triceps (long head), and the humerus and transmits the axillary nerve and the posterior humeral circumflex vessels.
What forms the carpal tunnel?
The flexor reticulum through which the median n and tendons of the long flexor muscles are transmitted.
What are the branches of the subclavian artery?
Internal thoracic (divides into superior epigastric and musculophrenic), vertebral a, thyrocervical trunk (divides into suprascapular, transverse cervical, and inferior thryoid), costocervical trunk (intercostals)
What are the branches of the brachial artery?
Brachial: continuation of the axillary a branching into the deep brachial (runs with radial n), superior ulnar collateral (runs with ulnar n), inferior ulnar collateral branches, then the brachial divides into ulnar and radial arteries.
What is the superior palmar arch a continuation of?
Ulnar artery
Muscles supplied by musculocutaneous n? (3)
Anterior compartment of arm
Biceps brachii
Coracobrachialis
Brachialis
Muscles supplied by radial n? (2)
Posterior compartment of arm
Triceps
Anconeus
Muscles supplied by radial nerve? (?)
Posterior compartment of the radial n:
superfical layer: brachioradialis, extensor carpi's, extensor digitorum, extensor digiti

Deep layer: supinator, abductor pollicis longus, extensor pollicis', extensor indices
Muscles of median n?
Median n:
Pronator teres, palmaris longus, and flexor everything
Describe a rotator cuff injury:
Rotator cuff stabilizes the shoulder jt and is a common site of tendonitis. A rupture of the supraspinatous tendon after middle age by attrition causes inflammatory changes (tendonitis) of the rotator cuff and can lead to subacromial bursitis and a painful shoulder.

Abduction of arm is very painful
What can a fracture of the scaphoid damage?
Radial artery and can cause avascular necrosis of the bone and degenerative joint disease of the wrist
What can a fracture of the hamate bone injure?
The ulnar n. and artery
What vein is used in central venous catheterization? (2)
Axillary vein and internal jugular
What vein can a venupuncture and blood transfusion be performed on?
Cephalic vein (posterior to the styloid process of the radius) and median cubital vein (in the cubital fossa)
Boutonniere deformity?
Refers to abnormaly flexed middle phalanx with an extended distal phalanx due to an avulsion of the central band of the extensor tendo from the middle phalanx or rheumatoid arthritis
What are the rotator cuff muscles?
SItS
Supraspinatus-helps deltoid abduct the arm
Infraspinatus: laterally rotates the arm
Teres minor: adducts and laterally rotates arm
Subscapularis: medially rotates and adducts the arm
What is the dislocation of the femoral head associated with?
osteoporosis
Goljan HY

What runs along the radial artery?
Median nerve
Goljan HY

What artery is affected in femoral neck fracture?
Medial femoral circumflex artery - damage leads to aspetic necrosis of the femoral head. (posterior dislocations are most dangerous)
Goljan HY

What causes weakness of the quadriceps m and an absent knee jerk reflex?
Herniated L3-L4 disk
Goljan HY

Pain in the hip and lateral quadriceps, numbness of the anterolateral leg and the webbed space between the great toe, weakness of dorsiflexion of the foot, and nL knee and ankle jerk reflexes?
Herniated L4-L5 (note nL DTRs)
Goljan HY

Numbness along the lateral and posterior aspect of the calf and plantar aspect of the foot, and absent knee jerk reflex:
Herniated L5-S1 (thus damaged 1sr sacral nerve root)
p.156 Netter
Netter

Numbness in lateral leg (front) and first 3 toes; foot drop
Herniated L4-L5
5th lumbar root
Goljan HY

Young child falls on his outstretched arm and has pain in the middle and lateral portion of his clavicle; upper extremity remains in abduction, extension, and internal rotation: Nerve injured?
C5-C6 (erb-ducheene syndrome, or superior brachial plexus injury due to a clavicular fraction; these are the most common fractures in newborns)
Goljan

Numbness over thenar eminence of hand?
Median nerve (carpal tunnel)
Anterior drawer sign?
forward sliding of the tibia on the femur due to rupture of the anterior cruciate ligament (posterior drawer: rupture of posterior cruciate ligament)
Which is more easily torn:
Medial or lateral meniscus?
Medial meniscus because of its strong attachement to the tibial collateral ligament
What vein is used for coronary artery bypass?
great saphenous vein
What muscles are controlled by the tibial n?
Gastrocnemius, soleus, plantaris, popliteus, tibialis posterior, flexor digitorum longus, flexor hallucis longus
What nerve is vulnarable to injury when doing a coronary artery bypass?
Saphenous n.
Why is femoral a. vulnerable to injury?
Because of its superficial position in the femoral triangle
FA

Common peroneal n injury
L4-S2
Loss of dorsiflexion (foot drop). Deep peroneal nerve innervates anterior compartment; superficial innervates lateral compartment)

PED: Peroneal Everts and Dorsiflexes; if injured, foot dropPED
FA

Tibial n. injury
L4-S3
Loss of plantar flexion. Tibial nerve innervates posterior compartment

TIP: Tibial Inverts and Plantarflexes; if injured can't stand on TIPtoes
FA

Femoral n injury
L2-L4
Loss of knee extension/knee jerk
FA

Obturator n injury
Loss of hip adduction
Describe the ankle jerk reflex?
Reflex twitch of the triceps surae. Its reflex center is in the L5 and S1 spinal n. Rupture of the achilles tendon disables the gastrocnemius and soleus muscles, causing an impaired plantar flexion of the foot.
FA

Patient presents with decreased pain and temp sensation over the lateral aspects of both arms: Dx
Syringomyelia
FA p.344

What are the seven functions of the hypothalamus?
TAN HATS

Thrist and water balance
Adenohypophosis controls releasing factors
Neurohypophysis and median eminence release hormones synthesized in the hypothalamic nuclei

Hunger
Autonomic reg (anterior hypothal = parasymp; posterior = symp); circadian rhythms
Temperature regulation
Sexual urges and emotions
FA p.344

What does the lateral and ventromedial nucleus of the hypothalamus control?
Lateral: hunger (lesion=anorexia)

Ventrolateral: satiety
(lesion=grow VENTRALLY and MEDIALLY)
FA p.344

What nucleus of the hypothalamus controls thirst and water balence?
Supraoptic nucleus
FA p.344

What part of the hypothalamus regulates circadian rhythms?
Suprachiasmatic nucleus
FA p.344

What part of the hypothalamus cools you when you are hot?
Anterior hypothalamus (A/C)

Posterior hypothalamus regulates heat conservation and heat production when cold -- or when you ignite your sympathetics)
FA p.344

What area of the hypothalamus controls sexual urges and emotions?
Septal nucleus

if this area is lesioned patient will be in a rage.
FA p.344

The posterior pituitary releases oxytocin and ADH - where does it get it from?
Axonal projections from the hypothalamus' supraoptic (ADH) and paraventricular (oxytocin) nuclei.
FA p.344

What are the seven parts of the thalamus?
Lateral geniculate nuc (visual/light)
Medial geniculate nuc (medial/music)

Lateral ventral posterior nuc: body sensation, spinothalamic, dorsal column
Medial ventral posterior nuc: facial sensation (CN V)

Lateral ventral anterior nuclei: relays motor information
FA p.345

What are the five F's of the limbic system?
Feeding
Fighting
Feeling
Flight
sex
FA p.346

What are the functions of the frontal lobe?
Frontal lobe:
"executive functions" - planning, inhibition, concentration, orientation, language, abstraction, judgement, motor regulation, mood.
FA p.346

What lesion causes lack of social judgement/change of personality?
Frontal lobe
FA p.346

What lesioned artery would be involved if a patient presented with lower extremity sensory and motor deficits?
Anterior cerebral
FA p.346

What arterial lesion may be involved if a patient presented with sensory and motor deficits everywhere (or somewhere) but lower extremities?
Middle cerebral a.
FA p.346

What arterial lesion could be if patient could not see?
Anterior chorodial artery
FA p.347

Describe the location of the dural venous sinus'?
Venous sinuses run in the dura mater where its meningeal and periosteal layers separate.
FA p.346

What is the venous blood flow pathway in the brain?
Cerebral veins --> venous sinus --> internal jugular singus
FA p.346

What is so freakin special about the superior saggital sinus?
It not only receives venous blood from the bridging veins, it receives CSF through arachnoid villi
FA p.346

Describe the pathway from the superior sagittal sinus to the internal jugular vein?
Superior sagittal --> confluence of sinuses --> transverse sinus --> sigmoid --> IJV
FA p.347

Describe the pathway from the great cerebral v to the internal jugular vein?

Inferior saggital sinus?
Great cerebral vein --> straight sinus --> confluence --> transverse --> sigmoid sinus --> int jugular v.

Inferior sagittal sinus also drains into the straight sinus --> same
FA p.348

Describe drainage of the lateral, 3rd, and 4th ventricles:
Lateral drains to the 3rd via the foramen of monroe

3rd --> 4th via aqueduct of sylvius

4th --> subarachnoid space via: lateral - foramina of Luschka; medial - foramina of magendie
FA p.348

How many spinal nerves do we have?
Spinal nerves: 31 total

8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal
FA p.348

Where is the most common location of disc herniation?
between L5 and S1
FA p.346

Where does the subarachnoid space extend to in adults? Spinal cord? Lumbar puncture performed?
Subarachnoid space extends to lower border of S2
SC: L1-L2
LP: L3-L4 or L4-L5 interspaces (to keep the cord alive, keep the spinal needle between L3 and L5)
FA p.348

While performing a lumbar puncture what structures are being permiated?
1. skin/superficial fascia
2. ligaments (supraspinous, interspinous, ligamentus flavum)
3. epidural space
4. dura mater
5. subdural space
6. arachnoid
7. subarachnoid space (where CSF is)

PIA is not PIERced
FA p.352

Landmark dermatomes?
C2: posterior half of the skill cap
C3: is a high turtleneck shirt
C4: is a low-collar shirt
T4: is at the nipple
T7: is at the xiphoid process
T10: is at the umbilicus (important for early appendicitis pain referral)
L1: is at the inguinal ligament
L4: includes the kneecaps
S2, S3, S4: erection and sensation of the penila and anal zones!! VIP

Notes: gallbladder pain is referred to the right shoulder via the phrenic n. T4 at the TEAT PORE. T10 at the belly butTEN. L1 is IL (Inguinal Ligament). Down on L 4's (all fours).
"S2, 3, 4 - keep the penis off the floor"
FA p.353

Clinical reflexes of biceps, triceps, patella, achilles?
Count up in order:
S1,2 = achilles (S1 root); ankle reflex
L3,4 = patella (L4 root); knee reflex
C5,6 = biceps (C5 root); bicep reflex
C7,8 = triceps (C7 root): tricep reflex
FA p.359

Lesion of the right parietal lobe
spacial neglect syndrome (agnosia of the contralateral side of the world)
FA p.359

Lesion of the reticular activating system
Coma
FA p.359

Lesion of the mamillary bodies
bilateral: Wernicke-Korsakoff syndrome - a manifestation of thiamine deficiency, or beri-beri. In the United States, this is usually secondary to alcohol abuse.
FA p.359

Lesion of the basal ganglia
May result in a tremor at rest, chorea, or athetosis
FA p.359

Lesion of the cerebellar hemisphere
Intention tremor, limb ataxia

Cerebellar hemispheres are LATERALLY located - affect the lateral limbs. Vermis is CENTRALLY located and affects the CENTRAL body.
FA p.359

Chorea
Sudden, jerky, purposeless movements. Characterisitic of basal ganglial lesions (eg Huntingtons disease)
FA p.359

Athetosis
Slow, writing movements, especially for fingers.
Characteristic of basal ganglion lesion
FA p.359

Hemiballismus
Sudden, wild flailing of 1 arm. Characteristic of contralateral subthalamic nucleus lesion. Loss of inhibition of thalamus through globus pallidus
FA p.359

Lesion of the cerebellar vermis
Truncal ataxia, dyarthria
FA p.359

Lesion of the subthalamic nucleus
Contralateral hemiballismus
FA p.361

What are the two types of partial seizures?
Partial seizures: in one area of the brain

1. simple partial (consciousness intact)-motor, sensory, autonomic, psychic

2. complex seizures (impaired consciousness)
FA p.361

Are febrile seizures epilepsy?
NO
FA p.361

What are the five types of generalized seizures?
Generalized: diffuse brain involvement

1. Absence (petit mal): blank stare
2. Myoclonic: quick, repetitive jerks
3. Tonic-clonic: grandmal-alternating stiffening and movement
4. Tonic: stiffening
5. Atonic: "drop" seizures
FA p.361

Can partial seizures become generalized?
Yes
FA p.361

Causes of seizures in children?
Genetic, infection, trauma, congenital, metabolic
FA p.361

Causes of seizures in adults?
Tumors, trauma, stroke, infection
FA p.361

Causes of seizures in elderly?
Stroke, tumor, trauma, metabolic, infection
Goljan HY!!!

Eye closed cannot open and eye deviated down and out:
Oculomotor nerve palsy; trochlear n. palsy (down and out)
Goljan HY!!!

Child with a popsicle stick in his mouth falls down causing the popsicle stick to hit the back of his throat and he develops ptosis and meiosis of the right eye. Dx:
Dx: injury to the cervical sympathetic ganglion
Goljan HY!!!

What CN is vertical diplopia assoc with?
CN IV palsy
Goljan HY!!!

Pt with headache and physical findings of mydrasis in the right eye in associations with mild lid lag, and deviation of the eye down and out. Dx?
Dx: aneurysm compressing CN III (headache = aneurysm)
Goljan HY!!!

Pt with recent hx of meningitis has horizontal diplopia in the left eye which is much worse on gaze to the left. Dx?
CN VI palsy
Goljan HY!!!

Pt with bilateral lateral rectus muscle weakness. Dx?
Increase in intracranial pressure (classic sign) and papilledema is usually present
Goljan HY!!!

Paralysis of upward gaze in an infant?
Dx: hydrocephalus secondary to stenosis of the aqueduct of Sylvius (Parinauds syndrome)
Goljan HY!!!

Multiple oculomotor n. disorders in an adult. MCC?
Diabetes (common cranial n. palsies from osmotic damage to nerves)
Goljan HY!!!

Patient has paralysis of oculomotor n. after a head injury. Dx?
Uncal herniation with compression of the 3rd n. (ptosis of eye, mydriasis-dilation)
Goljan HY!!!

Bitemporal heminopsia; MCC
Lesion at the optic chiasm; commonly caused by craniopharngioma (derived from Rathke's pouch)
Goljan HY!!!

Defect causing inferior quadrantanopia?
Defect in superior fibers in the parietal lobe.
Goljan HY!!!

CN III and UMN signs on opposite sides?
midline midbrain lesion (near superior colliculus, red nucleus, substantia nigra)
Goljan HY!!!

Loss of pain and temp and UMN signs on same sides?
mid pons lesion
(corticospinal (UMN) decussates in medulla and the lateral spinothalamic tract decussates immediately) -- since they run in opposite directions, a right pons lesion could cause a left sided loss of pain and temp and right sided UMN lesion
Goljan HY!!!

Weber syndrome
Lesion of oculomotor nerve and UMN signs with a midline midbrain lesion.
Goljan HY!!

A schwannoma in the jugular foramen causes (3 CN's are affected and what do they cause)?
CN IX: loss of taste sensation posterior 1/3 of tongue

CN X: weakness of palate/loss of gag reflex and laryngeal paralysis

CN XI: trapezius and sternocledomastoid
Goljan HY!!!

Lesion of the carotids with occlusion of the anterior cerebral artery:
would effect contralateral leg
FA p.358

What test tests the CN X?
Kuh-kuh-kuh tests palate elevation (CN 10)
FA p.358

What test tests the hypoglossal n (CN 12)?
La-La-La: tongue
FA p.358

What test tests CN VII-facial?
Mi-mi-mi: tests lips
FA p.362

What is a subarachnoid hemorrhage? Findings?
Rupture of an aneurysm (usually berry) or an AVM. Patients complain of "worst headache of my life"

Will see bloody or xanthochromic spinal tap.
FA p.362

What is a parenchymal hematoma?
A hematoma caused by hypertension, amyloid angiopathy, DM, and tumors.
FA pp.362

What are the features of berry aneurysms?
They occur at the bifurcation