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The cavity of the superior radioulnar joint is continuous with that of the elbow joint. Flexion and extension are possible, but abduction and adduction or rotation are not possible. As the ulnar artery descends, it passes deep to the deep head of the pronator teres. These separate the gland from the internal carotid artery and the internal jugular vein (37. The iliac fossa and the sacropelvic surface are separated by the medial border of the ilium. The sinus tarsi is cleared of soft tissue to expose the anterior, middle, and posterior facets of the subtalar joints. It is bounded laterally by a ridge raised by the ductus deferens (in the male) or by the round ligament of the uterus (in the female). The inferior thyroid artery runs transversely behind the lower part of the artery (42. Calculate the sensitivity and specificity of the test using the information below. Just below this notch, the border projects backwards and medially as the ischial spine. It appears in the back of the forearm through the lower part of the supinator muscle and gives several branches that supply the muscles of this region. In the female the inferior vesical artery is replaced by the vaginal artery and the uterine artery also gives branches to the bladder. The trapezoid part is attached, below, to the upper surface of the coracoid process; and, above, to the trapezoid line on the inferior surface of the lateral part of the clavicle. In addition to these anterolateral muscles, the anterior abdominal wall has a vertically running muscle, the rectus femoris, which is considered separately. These are the lower end of the humerus and the upper ends of the radius and ulna (7. Bending the elbow so that the front of the forearm tends to touch the front of the arm is flexion. The superior orbital fissure is a prominent cleft that separates the posterior parts of the roof and lateral wall. The lateral margin of the basilar part of the occipital bone is separated from the petrous temporal bone by a fissure that ends below in the jugular foramen. The duct draining the part of the pancreas derived from the dorsal bud at first opens into the duodenum at the minor duodenal papilla. Prophylaxis for deep venous thrombosis is individualized; however, all patients should be started on mechanical compression devices immediately. Small remnants of some embryonic structures are present in the broad ligament near the ovary. Ollier disease, in contrast, is the presence of multiple enchondromas without hemangiomas. Temporal and Infratemporal Regions Temporal Region Infratemporal Fossa Muscles of Mastication the Temporomandibular Joint 39. To prevent this we often add a pubic ramus screw and replace any excised bone back into the osteotomy sites. In a pivot joint, one rod-like (or cylindrical) element fits into a ring formed partly by bone and partly by ligaments. The ala is covered by the psoas major muscle and is crossed by the lumbosacral trunk. Hip Arthrotomy and Dislocation A Z-shaped capsulotomy is then performed, with the longitudinal arm of the Z in line with the anterior neck of the femur. It terminates in front of the ankle joint, midway between the medial and lateral malleoli, by becoming continuous with the dorsalis pedis artery. The artery ends here by dividing into the anterior and middle cerebral arteries that supply the brain. Note that, with the forearm extended at the elbow, the hand can rotate either as a result of rotation of the humerus, or as a result of supination and pronation. The mass is readily seen with an indirect mirror, rigid endoscope or flexible rhinolaryngoscope.

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This is called prolapse of the disc (though it is really prolapse of the nucleus pulposus). Terminal branches of the renal artery enter the kidney at the hilum, and the veins emerge from it. The acetabulum should be concave with a transverse sourcil ("eyebrow" in French) that turns down around the femoral head. At the same time, the surgeon is equally concerned about the integrity of the abdominal wall and plans his incisions in such a way that after healing the abdominal wall returns to as near a condition as it was before the operation. You can draw the lower border in the form of a sharply convex short line as shown in 21. Leukoedema appears grayish white, typically affecting the buccal mucosa bilaterally. Sudden contraction of the quadriceps can sometimes cause evulsion of the ligamentum patellae from the tibial tuberosity. The superior costotransverse ligament is attached to the crest of the neck; the costotransverse ligament to the posterior surface of the neck; and the lateral costotransverse ligament to the rough non-articular part of the tubercle. Incise the periosteum of the outer ilium along the border of the indirect head of the rectus and carefully dissect it off the hip capsule. Slipped capital femoral epiphysis: a prospective study of fixation with a single screw. In the fungal cell membrane synthesis pathway, squalene is converted to lanosterol by squalene epoxidase, which is blocked by allylamines. Each subclavian artery is the initial part of a long channel that supplies the upper limb. The medial part of the posterior surface of the rib gives attachment to the lowest levator costae, and to part of the erector spinae. The dorsal nerve of the penis runs along the lateral edge of the membrane and gives off branches for the bulb, and a branch for the crus of the penis. This is accomplished by predrilling holes in the iliac crest to facilitate passage of heavy, absorbable sutures to reattach the abductor, iliacus, and external oblique musculature. The force of adduction (palmar interossei) can be tested by asking the patient to try and hold a piece of paper forcibly between the fingers, while the examiner tries to pull it off. Various methods have been used for this purpose as follows: External Pelvimetry 1. It ascends behind the lateral malleolus, and runs upwards along the middle of the back of the leg. The deep petrosal nerve consists of sympathetic fibres derived from the plexus around the internal carotid artery. At its lower end the brachial artery terminates by dividing into the radial and ulnar arteries. This study is an essential preparation for the understanding and treatment of disease. The inferior aspect of the bone is distinguished by the presence of a shallow groove on the shaft, and by the presence of a rough area near its medial end. The vein accompanying the middle meningeal artery is called the middle meningeal sinus. The otic ganglion is situated just below the foramen ovale medial to the trunk of the mandibular nerve (43. The liver tissue has considerable reserve and continues to carry out its normal functions even after large amounts of it are damaged. An extreme example is the temporomandibular joint in which the two condyles lie in separate joint cavities (the right and left temporomandibular joints together constituting a condylar joint). Common disorders to affect the thyroid gland include Miscellaneous midline lumps Thyroglossal cysts, midline dermoids and a prominent pyramidal lobe of the thyroid may all be causes of midline neck lumps in adults. The medial rotation of the femur is most marked during the last stages of extension.

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The side to which a given medial cuneiform bone belongs can be determined as follows: a. The inferior surface of the body of the pancreas is lined by peritoneum continuous with the posterior layer of the transverse mesocolon. Lower down, the ligamentum patellae is separated from the synovial membrane by a large (infrapatellar) pad of fat. The 3rd, 4th and 5th cartilages gain attachment to the lateral edge of the sternum at the points of junction of sternebrae; the 6th on the fourth sternebra; and the 7th at the junction of the fourth sternebra and the xiphoid process. CliniCal Correlation Applied Anatomy of the Brachial Plexus and its Branches Causes of disease 1. The largest meningeal artery is the middle meningeal branch of the maxillary artery. The inferior alveolar nerve is a branch of the posterior division of the mandibular nerve. Before surgery, the patient should remain strictly nonweight bearing on the affected leg. Articular processes of vertebrae C4, C5, C6 Occipital bone (medial part of area between superior and inferior nuchal lines) Semispinalis capitus 1. A 5-year-old boy has congenital nail dystrophy with triangular lunulae in all his nails. The sphincter pupillae is a ring of circularly arranged muscle situated just around the pupil. More recently, the endoscopic use of carbon dioxide laser has given good results for laryngeal carcinomas that previously may have been suitable for partial laryngectomy. Fibres responsible for sharp vision arise from an area of the retina called the macula. At times it is not possible to differentiate lacunae and red color of a hemangioma from the milky-red areas that can contain out-offocus reddish globules seen in melanoma. This posterior cut is made first through the medial, then second through the lateral wall of the ischium. Laterally they fan out, the superior ligament passing along the medial side of the tendon of the long head of the biceps to reach the upper part of the lesser tubercle of the humerus. This is a group of small muscles placed in the uppermost part of the back of the neck, deep to the semispinalis capitis. The facial vein begins near the medial angle of the eye by the union of two superficial veins of the forehead, namely, the supratrochlear and the supraorbital veins (42. In the upper part of the femoral triangle, the femoral artery and vein are enclosed in a funnel-like covering of fascia which is called as femoral sheath. Veins of the Front of the Leg Superficial veins over the dorsum of the foot and the front of the leg have been described in Chapter 10. Tumours arising from beta cells of pancreatic islets (beta cell tumours or insulinoma) can produce features of hyperinsulinism. The stem of the artery represents the proximal part of the umbilical artery of the fetus. Descending within the substance of the gland, the vein divides into anterior and posterior branches. The lower part of the pouch is obliterated by fusion of the layers of peritoneum lining it. A 2-day-old, otherwise healthy newborn presents with multiple erythematous papules and pustules. Many autonomic nerve fibres, both sympathetic and parasympathetic, reach viscera after passing through a numberofplexuses. Lower down the artery lies in front of the uncinate process that intervenes between the superior mesenteric artery and the abdominal aorta (28. There are pinpoint/dotted (yellow boxes) and irregular linear (black boxes) vessels plus a general milky-red background color. The dorsal carpal branch passes medially behind the carpus to anastomose with a corresponding branch from the ulnar artery to form the dorsal carpal arch. The highest ligamentum flavum connects the posterior arch of the atlas to the laminae of the axis vertebra (36. The posterior auricular vein begins by union of tributaries present in the posterior part of the scalp.

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Nerves of the Back of Leg and Sole the tibial nerve is the nerve of the back of the leg. The surface of the tooth facing the lip or cheek is the buccal (or labial) surface c. In cases of cancer of the tongue, having intractable pain, the lingual nerve can be cut at this site to relieve pain. If the abscess also bursts into the anal canal an anal fistula (ischiorectal type) is produced. The nerve then enters the pharynx by passing through the interval between the lower border of the superior constrictor of the pharynx and the upper border of the middle constrictor. As this is done, the nerves passing into the muscle from the lateral side come into view and have to be carefully preserved by retracting them up and down. The renal pelves and the ureters are frequently visualised in the living by taking skiagrams after injecting radio-opaque dye into a vein. The abdominal cavity contains all the contents of the abdomen, while the peritoneal cavity is only a potential space. This lies midway between the upper border of the manubrium sterni (suprasternal notch) and the upper border of the symphysis pubis. Proximally, its upward extent is limited by the origin of the flexor digitorum superficialis. Stenosis can also be produced by fibrosis of the wall of the trachea, and this may occur as an after effect of tracheostomy. Keeps medial end of clavicle pressed against articular disc of sternoclavicular joint, and smoothens movements 3. Macrophages are the most important cells for wound healing, releasing numerous growth factors and cytokines. Indirect inguinal hernias are much more common in the male than in the female (the inguinal canal being much narrower in the female as the ovary does not pass through it). While doing so it has to be remembered that although the width of the kidney is actually about 6 cm it appears to be only 4. It has been claimed that macular fibres are more susceptible to damage by pressure than peripheral fibres and are affected first. Pain is elicited with hip flexion, adduction, and internal rotation stress (impingement test). The lesser omentum extends to the bottom of the fissure where its layers are reflected on to the walls of the fissure. The part of the occipital bone lateral to the condyle is called the jugular process. A multicomponent global pattern, symmetry of color and structure, regular network, regular globules and regression C. Fluoroscopic image showing ballpoint pusher (white arrow) and Schanz screw (black arrow). In the carpal tunnel, the radial bursa sometimes communicates with the ulnar bursa. The swallowing tube is best reconstructed using some form of visceral interposition. Just above the notch there is a triangular area bounded posteriorly by the interosseous border. The lateral border of the pronator teres forms the medial boundary of the cubital fossa. The terminal part of the main pancreatic duct is surrounded by the sphincter pancreaticus. The most important of these are the renal arteries,andthearteries to the testes or ovaries. Otherrelationshipsof the nerve in the neck will be considered when we study the head and neck.

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A 60-year-old woman with previously "salt-andpeper" hair comes in to the office complaining that her hair "turned white overnight. We recommend palpation of the posterior edge of the osteotomy after displacement to confirm there is no soft tissue (sciatic nerve) entrapment. Finally, it winds round the inferior edge of the gluteus maximus and supplies the skin over the inferomedial part of the muscle. The 10th nerve runs horizontally towards the umbilicus, but those above it run medially and upwards with increasing degree of obliquity. Medial head from posterior surface of humerus below the radial groove, and from intermuscular septa. These fibres ascend in the sympathetic trunk to reach the cervicothoracic ganglion in which they relay. The upper margin of the radial groove is formed by a roughened ridge that runs obliquely across the shaft. The proper placement of the osteotomy in the coronal plane is at the superior border of the acetabulum, just above the capsule and angled upward 10 to 15 degrees. The importance of muscles of the calf in promoting venous return from the lower limbs has been explained above. The lateral part of the gap is triangular in shape and is called the triangular space. The peritoneal protrusion is the sac of the hernia, and the coils of intestine are the contents of the hernia. The veins draining the iris, the ciliary body and the choroid form a dense plexus deep to the sclera. The next part of the artery passes in front of the horizontal part of the duodenum. The biopsy showed sebaceous differentiation, prominent atypia, with pagetoid spread. The range of movement is increased by movements produced between cervical vertebrae by some of these muscles. This part articulates with the patellar surface on the anterior aspect of the condyles of the femur. Impulses passing along such nerves cause the muscle to contract and thus result in movement. In some cases, the processus vaginalis gets obliterated, but weakness remains in the region of the inguinal canal leading to formation of hernia. On the anterior aspect of the body, they are represented by the right and left lateral lines. Some parts of the great vessels attached to the heart are also encosed by the sac. They are called check ligaments on the assumption that they limit the contraction of these muscles. It is believed that fibres of the accessory nerve supply all the muscles of the soft palate (except the tensor palati). The junction of the upper end of the internal jugular vein with the sigmoid sinus lies in the jugular foramen. The shelf follows the coiling of the cochlea and is, therefore, called the spiral lamina. The muscles supplied are the coracobrachialis, the biceps brachii (both heads) and the brachialis. Dermatofibromas are ubiquitous benign tumors and in most cases dermoscopy is not needed to make the diagnosis. However, on reaching the anterior end of the intercostal space concerned, each nerve passes deep to the costal margin to enter the abdominal wall. The median nerve ends by dividing into a variable number of palmar digital branches that subdivide so that ultimately seven proper palmar digital nerves are formed: two each (one medial and one lateral) for the thumb, the index and the middle fingers, and one for the lateral half of the ring finger. The superficial transversus perinei and the ischiocavernosus arise from the posterior surface of the ramus of the ischium. The kidneys are supplied by the renal arteries and are drained by the renal veins (chapter 31). The amount of true hip flexion and internal and external rotation with the hip extended and hip flexed are noted and compared to the preoperative assessment.

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Near its origin the posterior interosseous artery gives off an interosseous recurrent artery that runs upwards behind the elbow. This leads to a condition that is called paradoxical respiration because the lung expands during expiration and becomes smaller during inspiration. It runs along the radial nerve in the lower lateral part of the arm and ends by anastomosing with the recurrent branch of the radial artery. The anterior aspect of the lower end of the humerus shows two depressions: one just above the capitulum and another above the trochlea. The colon is outlined Chapter 35 Surface and Radiological Anatomy of the Abdomen 709 35. The conoid part is attached, below, to the root of the coracoid process just lateral to the scapular notch. The medial part is occupied only by some lymph nodes and some areolar tissue: and this part is called the femoral canal. The right recurrent laryngeal nerve arises from the right vagus as the latter passes in front of the subclavian artery. The next 5 cm or so is thin walled and has a much larger lumen than the rest of the tube. It passes from the umbilicus to the inferior border of the liver within the ligament. The second part and the upper portion of the third part of the artery lie on the subscapularis muscle. The mountain and valley pattern seen in seborrheic keratosis is in the dermoscopic differential diagnosis. Keratitis-ichthyosis-deafness syndrome and lamellar ichthyosis are the 2 ichthyoses associated with scarring alopecia. Auditory testing is recommended for patients with which of the following palmoplantar keratodermas Which of the following are recommended for treatment of refractory chronic urticaria Lesions preceded by nonspecific respiratory or gastrointestinal tract infection B. The anterior wall is formed by the pectoralis major, the pectoralis minor and the clavipectoral fascia. The lingual artery arises from the front of the external carotid artery opposite the tip of the greater cornu of the hyoid bone. Another group of allergens involved in textile dermatitis are the disperse dyes, of which the Disperse Blue dyes 106 and 124 are the most common allergens. Note that the segments of the middle lobe of the right lung are designated as medial and lateral. Locking is produced by continued action of the same muscles that produce extension, namely the quadriceps femoris. The anterior border of the right lung corresponds to the costomediastinal reflection of the pleura already described. If adequate bone healing is noted on radiography, activity can then be advanced as tolerated. Excessive (or unaccustomed) use of muscles of the anterior compartment can lead to oedema in the compartment and pressure on the deep peroneal nerve. The actual anteroposterior diameter at the inlet of the pelvis (true conjugate) can be estimated from the diagonal conjugate as it is 1. The iliohypogastric nerve (L1) runs a short course within the substance of the psoas major and emerges from the muscle at its lateral margin. From here it passes upwards, forwards and to the right up to the junction of the body of the sternum with the manubrium sterni. Pemphigus vulgaris and pemphigus foliaceus demonstrate deposition of IgG and C3 in a net-like pattern within the epidermis. It causes wrinkling of the skin over the medial side of the palm and may thus help in providing a better grip. In contrast to internal haemorrhoids, external haemorrhoids are formed by dilatation of tributaries of the inferior rectal veins. In its lower part the nerve inclines laterally and passes forwards below the lateral malleolus. Depending upon its size such a clot gets lodged in one of the ramifications of a pulmonary artery. The close relationship of the sigmoid sinus to the middle ear (lying in the petrous temporal bone) and the mastoid process often leads to spread of infection to this sinus. The upper end of the infundibulum is usually continuous with the frontonasal duct which connects the frontal sinus to the nasal cavity.

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The shape of the nose is maintained by the presence of a skeleton made up partly of bone and partly of cartilage. The perforating branches pass through several muscles attached to the femur, at or near the linea aspera. Multiple, longitudinal, creamy-orange, slightly elevated dermal papules on the eyelids of a normolipemic individual. In both these figures, we see the anterior and superior parts of the diaphragmatic surface. A small area on the superomedial part of the anterior surface is in contact with the left suprarenal gland. To the right by continuity of these layers along the superior vena cava, the upper and lower right pulmonary veins and the inferior vena cava. Some words derived from orchis are orchitis (inflammation of testis from any cause), orchidectomy or orchiectomy (surgical removal of testis) and orchidopexy (surgical fixation of testis). Incision and Dissection the skin incision is started 1 cm distal to the tip of the fibula. The lateral process of the malleus can be seen as a white dot where these folds meet. Differences from Interosseous Muscles of the Hand Note the following differences between the interossei of the hand and those of the foot. Dermatitis herepetiformis demonstrates subepidermal vesicuation and an accumulation of neutrophils and fibrin in the papillary dermis. Variability in nomenclature used for nevi with architectural disorder and cytologic atypia (microscopically dysplastic nevi) by dermatologists and dermatopathologists. The superior border passes laterally from the superior angle, but is separated from the glenoid cavity (representing the lateral angle) by the root of the coracoid process. On the medial side the nerve is separated only by a thin plate of bone from the sphenoidal air sinus. The basal turn of the cochlea produces an elevation, the promontory, on the medial wall of the middle ear. However, the patient should understand that abductor weakness may not be improved. They pass through branches of vagus to innervate some of the musculature derived from the branchial arches. During pregnancy, the ligaments of joints of the pelvis are softened by the action of hormones (oestrogen, progesterone, relaxin) produced by the ovaries and the placenta. The nerve ends by joining the nerve of the opposite side to form the optic chiasma (43. The shadow of the scapula is overlapped (in its medial part) by the thoracic cage (made up of ribs). The part of the body adjoining the lateral border is thickened to form a longitudinal bar of bone. The posterior vein of the left ventricle runs backwards on the diaphragmatic surface of the ventricle and ends in the coronary sinus. This includes the muscles of mastication and the musculature of the face, the pharynx and the larynx. The point of the guide pin should be positioned on the anterolateral femoral neck where the entry was estimated above. Carcinoma of the lip Carcinoma of the lip is common in outdoor workers and in regions close to the equator, presumably due to the effects of ultraviolet light. The condition is Kawasaki syndrome (mucocutaneous lymph node syndrome), characterized by coronary artery aneurysms on echocardiogram. The peritoneum lining the posterior aspect of the pylorus is reflected on to the anterior aspect of the neck of the pancreas. They can also reach it from overlying skin of the perineum and, occasionally, by downward rupture of a pelvirectal abscess (through the levator ani). Tendon then runs backwards and laterally to be inserted into the upper lateral quadrant of eyeball behind the equator. This foramen is bounded posteriorly and below by the occipital bone, and opens into the posterior cranial fossa. Above the level of the costal margin, the rectus abdominis lies directly on the costal cartilages and intercostal muscles that separate it from the diaphragm.

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Surgical Approach For operations on the heart, the sternum is split into two by a cut in the midline. In the lower part of the arm, the nerve comes in the anterior compartment, lateral to the humerus. Each epiphysis is united to the diaphysis by a plate of hyaline cartilage called the epiphyseal plate. In relation to the wall of each follicle there is one developing ovum surrounded by supporting follicular cells. When large areas of skin are lost these areas can be covered with skin taken from other parts of the body. In some persons veins over the calf (or sometimes over other regions) become dilated and tortuous. In the intact heart, this border is obscured from view by the parts of the aorta and the pulmonary trunk that lie in front of it. The superficial veins referred to above, therefore, provide channels of communication between the axillary and femoral veins. The superior laryngeal branch is the nerve of the fourth arch, and the recurrent laryngeal branch that of the sixth arch. It then enters the substance of the nerve and runs forwards in its centre to reach the optic disc. They may replace a normal segmental bronchus, may supply an accessory lobe or may be blind. The glossopharyngeal nerve provides the afferent part of the pathway for this reflex. It ascends to anastomose with the radial collateral (anterior descending) branch of the profunda brachii artery. The body has anterior (or costal) and posterior (or dorsal) surfaces which can be distinguished by the fact that the anterior surface is smooth, but the upper part of the posterior surface gives off a large projection called the spine. The nerve runs downwards on the medial side of the axillary artery (between it and the axillary vein) and then enters the arm on the medial side of the brachial artery. The inferior radioulnar joint is formed by articulation of the convex articular surface on the lateral side of the head of the ulna (7. The superior duodenal recess lies to the left of the upper part of the ascending part of the duodenum. The optic tract carries these fibres to the lateral geniculate body of the corresponding side. Part of this layer forms a thickened band extending from the posterior margin of the ramus of the mandible to the styloid process. Maintains longitudinal seous membrane the sustentaculum tali arch of foot (on calcaneus) into the sole 3. In the case of cranial nerves, the neurons are located in somatic efferent nuclei. It passes downward through the gluteal region (deep to the gluteus maximus) to enter the back of the thigh. Along this line, the peritoneum is reflected off from the liver to the diaphragm, and to the upper part of the anterior abdominal wall as the falciform ligament. The thickness and shape of intervertebral discs is different in different parts of the vertebral column. They pierce the sclera a short distance to the corresponding side of the lamina cribrosa (44. The dorsal and ventral roots of spinal nerves pass through the spinal dura mater separately. Draw a line from the lower end of the inferior vena cava to a point a little medial to the midinguinal point. The most important of these are the mylohyoid muscle (in front), the hyoglossus (in the middle) and the wall of the pharynx (posteriorly). Between the middle and lower membranes, there is the superficial perineal space (or pouch). These spaces communicate medially with the anterior chamber, and laterally with the sinus venosus sclerae. Kirschner wire: for dwarves or children up to 4 years of age with bones too small for a plate Custom-made high-angle blade plate: used for older children with bones too large for the Kirschner wire technique Wagner plate: an alternative plate for patients with bones too big for the Kirschner wire technique when a custommade high-angle blade plate is not accessible Positioning the patient is supine on a radiolucent table with a folded blanket beneath the pelvis.