College of Medical and Dental Sciences
M3-CSA-Y18
Clinical Core 2
Clinical Skills Anatomy Handbook
2018-2019
CC2
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
CSA 2 CC2 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
CSA 3 CC2
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.
CSA 4 CC2
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
CSA 7 CC2 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.
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
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.
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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 Heard over the right half of the sternum opposite the fourth lower end of the body of the intercostal space sternum Mitral valve Behind the left half of the Heard over the apex beat – at sternum opposite the fourth the level of the fifth intercostal costal cartilage space in the midclavicular line Pulmonary valve Behind the medial end of the Heard over the medial end of third left costal cartilage and the second intercostal space the adjoining part of the sternum Aortic valve Behind the left half of the Heard over the medial end of sternum opposite the third the second right intercostal intercostal space 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
CSA 16 CC2 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.
CSA 17 CC2 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.
CSA 18 CC2
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 For clinical skills anatomy, students should be able to demonstrate knowledge of the following structures and/or concepts: 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
Students should also have anatomical knowledge of some of the following procedures: Lumbar puncture Spinal and epidural anaesthesia
Radiological anatomy that is relevant for this session may include: Plain imaging MRI spine
CSA 19 CC2 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
CSA 20 CC2 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).
CSA 21 CC2
The Upper Limbs
Upper Limb Knowledge For clinical skills anatomy, students should be able to demonstrate knowledge of the following structures and/or concepts: 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
Students should also have anatomical knowledge of some of the following procedures: Venepuncture Arterial sampling for blood gas analysis Blood pressure measurement
Radiological anatomy that is relevant for this session may include: 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
CSA 22 CC2 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
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 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
CSA 23 CC2 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).
CSA 24 CC2
The Lower Limbs
Lower Limb Knowledge For clinical skills anatomy, students should be able to demonstrate knowledge of the following structures and/or concepts: Hip, knee and ankle joints Foot Peripheral Pulses Venous drainage and superficial veins Femoral triangle Muscles of the legs and reflexes Dermatomes and sensory system Ankle and foot structures
Students should also have anatomical knowledge of some of the following procedures: Venous cut-down Femoral venous and arterial access Gluteal intramuscular injection
Radiological anatomy that is relevant for this session may include: 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
CSA 25 CC2 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)
CSA 26 CC2
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.
CSA 27 CC2
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 For clinical skills anatomy, students should be able to demonstrate knowledge of the following structures and/or concepts: 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
Students should also have anatomical knowledge of some of the following procedures: Fundoscopy EMG Nerve conduction studies
Radiological anatomy that is relevant for this session may include: CT brain imaging MRI brain imaging
CSA 28 CC2
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.
CSA 29 CC2 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.
CSA 30 CC2 Head and Neck Anatomy Knowledge For clinical skills anatomy, students should be able to demonstrate knowledge of the following structures and/or concepts: 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
Students should also have anatomical knowledge of some of the following procedures: Cricothyroidotomy Tracheostomy NG feeding tube Intubation Auroscopy
Radiological anatomy that is relevant for this session may include: Plain Radiography Duplex Ultrasound Barium swallow Sialography Angiography CT/MRI
CSA 31 CC2
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
CSA 32 CC2 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).
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.
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.
CSA 33 CC2 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
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.
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.
CSA 34 CC2
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’. CSA 35 CC2 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.
CSA 36 CC2
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
Students should also have anatomical knowledge of some of the following procedures: Respiratory examination Needle thoracocentesis Intercostal chest drainage
Radiological anatomy that is relevant for this session may include: Plain Chest imaging CT thorax scanning
CSA 37 CC2 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.
CSA 38 CC2
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?
CSA 39 CC2 PBL on Acute Abdominal Pain (Abdomen and Pelvis)
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 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
Students should also have anatomical knowledge of some of the following procedures: Rectal examination
Radiological anatomy that is relevant for this session may include: Plain Abdominal imaging Abdominal ultrasound and it’s different applications CT abdominal imaging
CSA 40 CC2 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.
CSA 41 CC2
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?
CSA 42 CC2
PBL on Wrist Trauma (Upper Limb)
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 students for this PBL include: 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
Students should also have anatomical knowledge of some of the following procedures: Venepuncture Arterial Blood Gas Analysis
Radiological anatomy that is relevant for this session may include: Plain film X-rays (and their varying orientations)
CSA 43 CC2 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.
CSA 44 CC2
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?
CSA 45 CC2
PBL on Knee Trauma (Lower Limb)
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 students for this PBL include: Hip, knee and ankle joints Peripheral Pulses Venous drainage and superficial veins Muscles of the legs and reflexes Dermatomes and sensory system
Students should also have anatomical knowledge of some of the following procedures: Femoral venous and arterial access Doppler USS
Radiological anatomy that is relevant for this session may include: Plain film X-rays (and their varying orientations)
CSA 46 CC2 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.
CSA 47 CC2
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?
CSA 48 CC2
PBL on Neck Pain (Head and Neck)
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: 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
Students should also have anatomical knowledge of some of the following 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
CSA 49 CC2 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.
CSA 50 CC2
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?
CSA 51 CC2
PBL on Facial Palsy (Central Nervous System)
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 students for this PBL include: Dermatomes and Myotomes Cranial nerve testing Visual fields Autonomic nervous system Motor and sensory pathways Blood supply to the brain
Radiological anatomy that is relevant for this session may include: CT brain imaging MRI brain imaging
CSA 52 CC2 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!
CSA 53 CC2
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
CSA 54