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Inection o Greater Vestibular Glands the greater vestibular glands are usually not palpable but are when inected. Features o the pelvic girdle demonstrated anatomically (A) and radiographically (B). These intrinsic neurons and the complex enteric plexuses in which they are enmeshed integrate and control gastrointestinal unction with remarkable independence, sustaining visceral activities with local refex mechanisms. Its blood vessels also become smaller, but the number o tiers o arcades increases while the length o the vasa recta decreases. The long shat o the humerus enables reaching and makes it an eective lever or power in liting, as well as providing surace area or attachment o muscles that act primarily at the elbow. It is preferable not to tie the continuous suture as it passes the coronary sutures as this locks the suture line which thereby loses its ability to even out tension throughout the suture line. It is a marked thickening o the circular layer o smooth muscle that controls discharge o the stomach contents through the pyloric orifce (inerior opening or outlet o the stomach) into the duodenum. The convex posterior surace o the scapula is unevenly divided by a thick projecting ridge o 1 the scapulothoracic joint is a physiological "joint," in which movement occurs between musculoskeletal structures (between the scapula and associated muscles and the thoracic wall), rather than an anatomical joint, in which movement occurs between directly articulating skeletal elements. Flail Chest Multiple rib ractures may allow a sizable segment o the anterior and/or lateral thoracic wall to move reely. The fbrous capsule o the prostate is dense and neurovascular, incorporating the prostatic plexuses o veins and nerves. They suggest that if preoperative resistance is less than 7 units/m2 and there is a good response to a vasodilator, the patient is likely to do well postoperatively. The axillary lymph nodes occur in groups that are arranged and receive lymph in a specifc order, which is important in staging and determining appropriate treatment or breast cancer. The amount o movement occurring at a brous joint depends in most cases on the length o the bers uniting the articulating bones. Although the testis is located in the perineum postnatally, the male gonad originally orms in the abdomen. Each suture should be carefully visualized as it is tied down and the pledgets should be seen to be lying appropriately. They commonly walk with a orward lean, pressing on the distal end o the thigh with their hand as the heel contacts the ground to prevent inadvertent fexion o the knee joint. The skin provides: Protection o the body rom environmental eects, such as abrasions, fuid loss, harmul substances, ultraviolet radiation, and invading microorganisms. Because o these multiple unctions, the perineal muscles are generally relatively well developed in males. Elevation raises or moves a part superiorly, as in elevating the shoulders when shrugging, the upper eyelid when opening the eye, or the tongue when pushing it up against the palate (roo o mouth). Preliminary Dissection During cooling, the branch pulmonary arteries are mobilized out to the hilar branches. Neurons with cell bodies distant rom the site o ischemia o the spinal cord will also die, secondary to the degeneration o axons traversing the site. First cervical nerves lack posterior roots in 50% o people, and the coccygeal nerve may be absent. The root o the sigmoid mesocolon has an inverted V-shaped attachment, extending rst medially and superiorly along the external iliac vessels and then medially and ineriorly rom the biurcation o the common iliac vessels to the anterior aspect o the sacrum. Common sites o hematogenous metastases (spreading through the blood) o cancer cells rom a bronchogenic carcinoma are the brain, bones, lungs, and suprarenal glands. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ater supplying all three muscles o the anterior compartment o the arm, the musculocutaneous nerve emerges lateral to the biceps as the lateral cutaneous nerve o the orearm. It is not difficult to empathize with young inexperienced parents who are told by their physician that their child has a potentially fatal cardiac condition which can result in sudden cyanotic spells and death if the child is allowed to become agitated. The bers o the right crus o the diaphragm decussate (cross one another) inerior to the hiatus, orming a muscular sphincter or the esophagus that constricts it when the diaphragm contracts.
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The emoral septum is pierced by lymphatic vessels connecting the inguinal and external iliac lymph nodes. In emales, since the posterior aspect o the bladder rests directly upon the anterior wall o the vagina, the lateral attachment o the vagina to the tendinous arch o the pelvic ascia, the paracolpium, is an indirect but important actor in supporting the urinary bladder. Thus when the coronary arteries are transferred as part of the arterial switch they will lie above the level of the sinuses of Valsalva if the coronaries are kept at the same level. In its most restricted sense, and in obstetrics, it has been used to reer to the area supercial to the perineal body, between the vulva or scrotum and the anus or to the perineal body itsel. This type o coarctation is compatible with many years o lie because the collateral circulation carries blood to the thoracic aorta inerior to the stenosis. Muscles o Arm O the our major arm muscles, three fexors (biceps brachii, brachialis, and coracobrachialis) are in the anterior (fexor) compartment, supplied by the musculocutaneous nerve, and one extensor (triceps brachii) is in the posterior compartment, supplied by the radial nerve. The thoraco-acromial artery, a short wide trunk, pierces the costocoracoid membrane and divides into our branches (acromial, deltoid, pectoral, and clavicular), deep to the clavicular head o the pectoralis major. As the parts o the intestine reach their denitive positions, their mesenteric attachments undergo modication. In a lateral projection, both domes o the diaphragm are oten visible as they arch superiorly rom the sternum. It is also best to avoid division of the crista terminalis which can also contribute to sinus node blood supply and stability. Foramina transversarii develop as gaps between the two lateral ossication centers, medial to a linking costotransverse bar, which orms the lateral boundary o the oramina. Transcatheter closure of congenital and acquired muscular ventricular septal defects using the Amplatzer device. Likewise, an L5 vertebra used to the sacrum is reerred to as a "sacralized 5th lumbar vertebra" (see the clinical box "Abnormal Fusion o Vertebrae" in this chapter). Note that the lung is outside o but surrounded by the pleural sac, just as your st is surrounded by but outside o the balloon. Tension lines at the elbows, knees, ankles, and wrists are parallel to the transverse creases that appear when the limbs are fexed. The abdominal wall Linea Vertical anterior abdominal muscles alba Flat anterolateral abdominal muscles Anterior Fascia o Anterolateral Abdominal Wall the subcutaneous tissue over most o the wall includes a variable amount o at. In type B there is a single coronary ostium with the right coronary artery passing between the aorta and pulmonary artery. The anterior ramus o nerve T12, coursing inerior to the 12th rib, is the subcostal nerve. Like the dermatomal pattern, the logic or naming the main supercial veins o the upper limb cephalic (toward the head) and basilic (toward the base) becomes apparent when the limb is placed in its initial embryonic position. Eerent lymphatic vessels rom the mesenteric lymph nodes drain to the superior mesenteric lymph nodes. When a blow is received to the acromion o the scapula, or when a orce is transmitted to the pectoral girdle during a all on the outstretched hand, the orce o the blow is usually transmitted along the length o the clavicle, that is, along its long axis. Upper limb muscles usually receive motor bers rom several spinal cord segments or nerves. The nerves to the urethra arise rom the vesical (nerve) plexus and the pudendal nerve. Injury to the nerve to the levator ani, including its branches to the pubococcygeus and/or puborectalis, due to stretching o the nerve during a vaginal birth, may result in a loss o support o the pelvic viscera and urinary or ecal incontinence similar to that resulting rom tearing o the muscle. Development o Meninges and Subarachnoid Space Together, the arachnoid and pia mater orm the leptomeninges (G. The rupture results rom repetitive overhead motions, such as occurs in swimmers and baseball pitchers, that tear the weakened tendon in the intertubercular sulcus. Males are especially susceptible to subcutaneous accumulation o at in the lower anterior abdominal wall. Skin color changes are most readily observed in people with light-colored skin and may be dicult to discern in people with dark skin. The superfcial transverse perineal muscles and the bulbospongiosus muscles join the external anal sphincter in attaching centrally to the perineal body.
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Through their participation in these joints, these processes determine the types o movement permitted and restricted between the adjacent vertebrae o each region. These neurovascular structures course in the intercostal spaces, parallel to the ribs, and serve the intercostal muscles as well as the integument and parietal pleura on their superfcial and deep aspects. Eight phases are typically described, two o which have been combined in (F) or simplifcation. The hand is fexed at the wrist and lies faccid, a condition known as wrist-drop (see the clinical box "Injury to Radial Nerve in Arm"). Sutures are placed sequentially working in a clockwise direction with great care in the region of the conduction bundle at the posterior and inferior angle of the defect. The paired visceral branches o the lateral plane are represented in the thorax by the bronchial arteries. For growth to continue, the bone ormed rom the primary center in the diaphysis does not use with that ormed rom the secondary centers in the epiphyses until the bone reaches its adult size. Bones o Lower Limb 685 Coxa Vara and Coxa Valga the angle o inclination between the long axis o the emoral neck and the emoral shat. The obturator artery helps the prounda emoris artery supply the adductor muscles via anterior and posterior branches, which anastomose. The transverse processes o thoracic and lumbar vertebrae are covered with thick muscles and may or may not be palpable. Arch hypoplasia or coarctation should also alert the echocardiographer to measure carefully the size of the tricuspid annulus and to assess the adequacy of the right ventricle. The trapdoor flap requires less rotation of the coronary buttons but adds to the circumference of the proximal neoaorta. Note in (A) and (C) that the axes o the urethra and vagina are parallel, and the urethra is adherent to the anterior vaginal wall. The sacral trunks descend on the pelvic surace o the sacrum just medial to the pelvic sacral oramina and converge to orm the small median ganglion impar (coccygeal ganglion) anterior to the coccyx. Only the visceral pelvic ascia uniting the rectum and uterus here resists increased intra-abdominal pressure. This triangle transmits lymphatic vessels rom the diaphragmatic surace o the liver and the superior epigastric vessels. The paracolpia suspend the vagina between the tendinous arches, assisting the vagina in bearing the weight o the undus o the bladder. Thus, although the articular disc serves as a shock absorber o orces transmitted along the clavicle rom the upper limb, dislocation o the clavicle is rare, whereas racture o the clavicle is common. Since this subsequently requires the child to undergo a surgical procedure for removal of the pulmonary artery band and reconstruction of the main pulmonary artery, our preferred approach in the small symptomatic infant is to proceed with one-stage surgical closure (see below). Thus, this is not analogous to vascular surgery in an atherosclerotic adult population. The heart is de-aired in the usual fashion and when rewarming is completed discontinuation of bypass should be routine. Rib spreader Parietal pleura (cut) Thoracic Wall 303 o costal cartilage to gain entrance to the thoracic cavity. The articular processes are in apposition with corresponding processes o vertebrae adjacent (superior and inerior) to them, orming zygapophysial (acet) joints. Normally, the pulse is strong; however, i the common or external iliac arteries are partially occluded, the pulse may be diminished. Clinical anatomy oten involves inverting or reversing the thought process typically ollowed when studying regional or systemic anatomy. In addition to the many variations in the connections of the main coronary trunk into the sinuses of Valsalva, there can be anomalies of the coronary buds themselves. The hemi-azygos vein receives the inerior three posterior intercostal veins, the inerior esophageal veins, and several small mediastinal veins. Posteriorly: the recto-uterine pouch containing loops o small intestine and the anterior surace o rectum.
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Parasympathetic stimulation slows the heart rate, reduces the orce o the contraction, and constricts the coronary arteries, saving energy between periods o increased demand. Thus, a nding o gynecomastia should be regarded as a symptom, and an evaluation must be initiated to rule out important potential causes, such as suprarenal or testicular cancers (Goroll, 2014). Cardiac catheterization is not necessary or indeed useful in defining the degree or the mechanism of mitral regurgitation. The termination o the lymphatic trunks varies; traditionally, these trunks are described as merging with each other and with the jugular lymphatic trunk, draining the head and neck to orm a short right lymphatic duct on the right side or entering the termination at the thoracic duct on the let side. The condyle (the boundaries o which are indicated by the dashed line) consists o the capitulum; the trochlea; and the radial, coronoid, and olecranon ossae. Posteriorly, the olecranon ossa accommodates the olecranon o the ulna during ull extension o the elbow. Enlargement o the apical nodes may obstruct the cephalic vein superior to the pectoralis minor. An anterior subphrenic abscess is oten drained through a subcostal incision located inerior and parallel to the right costal margin. Sutures should be more widely spaced on the patch relative to the artery so that the artery diameter is augmented. In living individuals, the vessels bulge where each o the closely spaced valves occur, giving lymphatics a beaded appearance. Students o many o the health sciences will learn to use instruments to acilitate examination o the body (such as an ophthalmoscope or observation o eatures o the eyeballs) and to listen to unctioning parts o the body (a stethoscope to auscultate the heart and lungs). Consequently, vertebrae T11 and especially T12 (which participates in rotatory movements superiorly but only fexion and extension movements ineriorly) are the most commonly ractured noncervical vertebrae. Congenitally stenotic mitral valves usually display elements of obstruction at more than one level. The size o the bodies increases as the column descends, most markedly rom T4 ineriorly, as each bears progressively greater body weight. The authors found that advanced age at coarctation repair and use of a patch plasty technique independently predicted local aneurysm formation. In this case, placement of a conduit connection from the main pulmonary artery to the discontinuous pulmonary artery will be necessary at the time of complete repair. Muscles with bers that are approximately perpendicular to the slope o the ribs at their attachment (interosseous part o internal intercostal muscles) rotate the ribs ineriorly at their posterior axes, depressing the ribs and sternum (Slaby et al. The bers orming each lamella run obliquely rom one vertebra to another, about 30 or more degrees rom vertical. In this report, coronary artery anatomy emerges for the first time as a risk factor. Stretch Marks in Skin the collagen and elastic bers in the dermis orm a tough, fexible meshwork o tissue. Examples are the respiratory movements o the diaphragm, controlled most o the time by refexes stimulated by the levels o oxygen and carbon dioxide in the blood (although we can willully control it within limits), and the myotatic refex, which results in movement ater a muscle stretch produced by tapping a tendon with a refex hammer. However, anastomoses do exist between branches o the coronary arteries, subepicardial or myocardial, and between these arteries and extracardiac vessels such as thoracic vessels (Standring, 2016). The cause of regurgitation was chordal anomalies in 69% of patients, annular dilation in 16%, and platelet anomalies in 14%. Because the sacral hiatus is located between the sacral cornua and inerior to the S4 spinous process or median sacral crest, these palpable bony landmarks are important or locating the hiatus. The obturator and inerior gluteal arteries also supply small branches to the bladder. Even though pulmonary vascular abnormalities were identified in all biopsies, they were not predictive of hemodynamic findings at catheterization 1 year after surgery. Large motor units, in which one neuron supplies several hundred muscle bers, are in the large trunk and thigh muscles. In the normal heart, the right ventricle is highly compliant allowing Tetralogy of Fallot with Pulmonary Stenosis 353 an enormous increase in pulmonary blood flow with little or no change in systemic venous pressure (hence the excellent tolerance in most patients of the volume load resulting from postoperative pulmonary regurgitation relative to the hypertrophy resulting from residual pulmonary stenosis).
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The septal papillary muscle arises rom the interventricular septum, and its tendinous cords attach to the anterior and septal cusps o the tricuspid valve. Not surprisingly, it is often associated with anomalous connection of the pulmonary veins, particularly the right upper lobe pulmonary vein. Cystic lymph nodes Cystic artery Right hepatic artery Hepatic lymph nodes Lymph node of omental foramen Celiac trunk Pyloric lymph nodes Gastroduodenal artery Posterior superior pancreaticoduodenal artery and vein Pancreaticoduodenal lymph nodes Anterior view Celiac lymph nodes Left hepatic artery Biliary Ducts and Gallbladder the biliary ducts convey bile rom the liver to the duodenum. There are two main types o phasic (active) muscle contractions: (1) isotonic contractions, in which the muscle changes length in relationship to the production o movement, and (2) isometric contractions, in which muscle length remains the same-no movement occurs, but the orce (muscle tension) is increased above tonic levels to resist gravity or other antagonistic orce. During a pelvic examination, i the ischial tuberosities are ar enough apart to permit three ngers to enter the vagina side by side, the subpubic angle is considered suciently wide to permit passage o an average etal head at ull term. The liver produces bile continuously; however, between meals, it accumulates and is stored in the gallbladder, which also concentrates the bile by absorbing water and salts. It is, however, extremely important to preserve the major branch of the right coronary artery which extends toward the apex. Blood may also be taken rom the emoral artery or blood gas analysis (the determination o oxygen and carbon dioxide concentrations and pressures with the pH o the blood by laboratory tests). Generally, the articular processes bear weight only temporarily, as when one rises rom the fexed position, and unilaterally, when the cervical vertebrae are laterally fexed to their limit. Within the kidney, the renal sinus is occupied by the renal pelvis, calices, vessels, and nerves and a variable amount o at. The secretory cells o the medulla are postsynaptic sympathetic neurons that lack axons or dendrites. Variations in Origin o Radial Artery the origin o the radial artery may be more proximal than usual; it may be a branch o the axillary or brachial arteries. For this reason, valve repair is preferred for essentially all congenital valve anomalies. Some lymph also passes to the deep inguinal lymph nodes, located under the deep ascia on the medial aspect o the emoral vein. The stomach is continuous with the duodenum, which receives the openings o the ducts rom the pancreas and liver, the major glands o the alimentary system. In order to accommodate the smallest mitral Perimount valve (25 mm) it is usually advisable to place an outflow patch. When the abdominal cavity is opened to study these organs, it becomes evident that the liver, stomach, and spleen almost ll the domes o the diaphragm. These compartments are separated by thick sheets o deep ascia, called intermuscular septa, that extend centrally rom the surrounding ascial sleeve to attach to bones. The thin anterior sacro-iliac ligaments are merely the anterior part o the brous capsule o the synovial part o the joint. The deep ascia o the lower limb is especially strong, investing the limb like an elastic stocking. The weight o the upper body, transmitted centrally through the vertebral column (1), is divided and directed laterally by means o the bony arch ormed by the sacrum and ilia (2). You can also palpate the inrapatellar at pads, the masses o loose atty tissue on each side o the patellar ligament. The layers o the abdominal wall and the coverings o the spermatic cord and testis derived rom them are shown. Inerior to the pectinate line, the anal canal is somatic, supplied by the inerior anal (rectal) nerves containing somatic sensory bers. Small arteries and arterioles have relatively narrow lumina and thick muscular walls. In certain liver disorders, a yellow pigment called bilirubin builds up in the blood, giving a yellow appearance to the whites o the eyes and skin, a condition called jaundice. It should not be necessary for these sutures as they are tied to bring the patch down into contact with the ventricular septum; the patch should already be lying in the appropriate location before these sutures are tied. The enclosure o the vertical deep back muscles (erector spinae) by the posterior and middle layers o the thoracolumbar ascia on the posterior aspect o the trunk is comparable to the enclosure o the rectus abdominis by the rectus sheath on the anterior aspect. Laterally and anteriorly, the cage consists o 12 ribs that are continued anteriorly by costal cartilages. For lateral radiographs, radiopaque letters (R or L) are used to indicate the side placed closest to the lm or detector, and the image is viewed rom the same direction that the beam was projected.
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Adenocarcinoma o the pancreas in advanced stages invades the muscles and nerves o the posterior abdominal wall, producing excruciating pain because o the close relationship o the pancreas to the posterior abdominal wall. The internal rectal venous plexus drains in both directions rom the level o the pectinate line. Inection o Axillary Lymph Nodes An inection in the upper limb can cause the axillary nodes to enlarge and become tender and infamed, a condition called lymphangitis (infammation o lymphatic vessels). The axillary lymph nodes are drained by the subclavian lymphatic trunk; both are discussed in greater detail with the axilla, later in this chapter. When one is not eating, the lumen o the esophagus is normally collapsed superior to this level to prevent ood or stomach juices rom regurgitating into the esophagus. The conducting system consists o nodal tissue that initiates the heartbeat and coordinates contractions o the our heart chambers and highly specialized conducting bers or conducting them rapidly to the dierent areas o the heart. However, Yacoub argued at the same time that all coronary types could be transferred and time has, indeed, proven him to be correct. Iliohypogastric and ilio-inguinal nerves: terminal branches o the anterior ramus o spinal nerve L1. The submucosal rectal venous plexus surrounds the rectum, communicating with the vesical venous plexus in males and the uterovaginal venous plexus in emales. The installation and use o air bags in vehicles has reduced the number o sternal ractures. A coronal section o the inerior esophagus, diaphragm, and superior stomach is shown. Consequently, nearly the lower hal o the thoracic wall surrounds and protects abdominal rather than thoracic viscera. The bicipitoradial bursa (biceps bursa) separates the biceps tendon rom, and reduces abrasion against, the anterior part o the radial tuberosity. These ligaments have two parts: Denser "cord-like" parts that pass distally rom the heads o the metacarpals and phalanges to the bases o the phalanges. Frequently during skiing, a racture results rom a highspeed orward all, which angles the leg over the rigid ski boot, producing a "boot-top racture". Most o these muscles can aect deep respiration when the pectoral girdle is fxed and account or many o the surace eatures o the thoracic region. The nervous system does not have its own layer in the superior mediastinum, but it is integrated with layer 2 (phrenic and vagus nerves) and lies between layers 3 and 4 (recurrent laryngeal nerves). Approximately 40% of individuals with microdeletion of chromosome 22 have congenital heart disease. The valve is placed entirely within the left atrium between the inferior pulmonary veins and the true annulus. Even when the right upper lobe vein enters normally, absence of the sinus venosus component of the atrial septum adjacent to the superior vena caval/right atrial junction results in what is effectively anomalous pulmonary venous connection of the right upper lobe to the right atrium. The thoracic duct begins with the convergence o the main lymphatic ducts o the abdomen, which in only a small proportion o individuals takes the orm o the commonly depicted, thin-walled sac or dilation, the cisterna chyli (chyle cistern). The cardinal ligament, and the way in which the uterus normally "rests" on top o the bladder, provides the main passive support or the uterus. Uterus: Shaped like an inverted pear, the uterus is the organ in which the blastocyst (early embryo) implants and develops into a mature embryo and then a etus. A remnant o the proximal part o the embryonic omphalo-enteric duct (yolk stalk), the diverticulum usually appears as a nger-like pouch. Muscles: the greatest mass o intrinsic muscles is dedicated to the highly mobile thumb. One-way semilunar valves (pulmonic and aortic) placed at the exit on each side prevent backow (except that which flls the coronary arteries) and maintains the diastolic pressure o the arteries. Incomplete division o the ureteric bud results in a bid ureter; complete division results in a supernumerary kidney (Moore, Persaud, and Torchia, 2016). Cirrhosis o Liver the liver is the primary site or detoxication o substances absorbed by the gastrointestinal tract; thus, it is vulnerable to cellular damage and consequent scarring, accompanied by regenerative nodules.
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Sensation is blocked in all deep structures o the upper limb, and the skin distal to the middle o the arm. Sometimes one o these centers ails to use with the main bone, giving the appearance o an extra bone. Although depicted as single veins in parts C and E, the deep veins usually occur as duplicate or multiple accompanying veins. However, because o overlapping areas o innervation between nerves, one or two small branches o nerves may usually be cut without a noticeable loss o motor supply to the muscles or loss o sensation to the skin. Median Sternotomy To gain access to the thoracic cavity or surgical operations in the mediastinum, the sternum is divided (split) in the median plane and retracted, or example, or coronary artery bypass grating. Close to their origin, the meningeal branches receive communicating branches rom the nearby gray rami communicantes. As it approaches the porta hepatis, the hepatic portal vein divides into right and let branches. Parts (B) through (D) show the staged reconstruction o the parietal structures o the right hemipelvis. Not surprisingly, the cranial outfow provides parasympathetic innervation o the head, and the sacral outfow provides the parasympathetic innervation o the pelvic viscera. In both males and emales, the musculature described is oriented perpendicular to the perineal membrane, rather than lying in a plane parallel to it. A posterior gastric ulcer may erode through the stomach wall into the pancreas, resulting in reerred pain to the back. The serratus posterior superior lies deep to the rhomboid muscles, and the serratus posterior inerior lies deep to the latissimus dorsi. Careul dissection o the cystohepatic triangle early during cholecystectomy saeguards these important structures should there be anatomical variations. Externally, the ligament o the ovary attaches to the uterus postero-inerior to the uterotubal junction. The orad (proximal relative to the mouth) two fths is jejunum and the aborad (distal) three fths is ileum, although there is no clear line o transition. Muscles o the deep layer attach to the anterior aspects o the radius and ulna, ex all (but especially the distal) joints o all fve digits, and pronate the orearm. The let side o the heart (let heart) receives well-oxygenated (arterial) blood rom the lungs through the pulmonary veins and pumps it into the aorta or distribution to the body. Accordingly, in an era that predated prosthetic vascular tube grafts, he investigated the use of tubes of aortic homograft tissue as interposition grafts. The mediastinum extends rom the superior thoracic aperture to the diaphragm ineriorly and rom the sternum and costal cartilages anteriorly to the bodies o the thoracic vertebrae posteriorly. The autograft is stored in a bowl which is clearly marked and separated from the pulmonary homograft which should be undergoing thawing and rinsing at this stage. Producing powerul adduction and medial rotation o the arm when acting together, the two parts o the pectoralis major can also act independently: the clavicular head fexing the humerus, and the sternocostal head extending it back rom the fexed position. The proximal anastomosis of the pulmonary homograft to the right ventricular infundibulum is undertaken. Structures traversing the axilla are ensheathed in a protective wrapping (axillary sheath), embedded in a cushioning matrix (axillary at) that allows exibility, and are surrounded by musculoskeletal walls. Although Blalock and Hanlon had introduced an ingenious palliative procedure to create an atrial septectomy surgically,30 this resulted in intrapericardial adhesions and increased the difficulty and risks of subsequent repair. Ball and socket joints allow movement in multiple axes and planes: fexion and extension, abduction and adduction, medial and lateral rotation, and circumduction; thus, ball and socket joints are multiaxial joints. Cubital fossa: the triangular cubital ossa is bound by a line connecting the medial and lateral epicondyles o the humerus, and the pronator teres and brachioradialis muscles arising, respectively, rom the epicondyles. This incision can be challenging because of the extreme thickness of the ventricular septum in this condition. A positive response conrms the integrity o the musculocutaneous nerve and the C5 and C6 spinal cord segments. Transection o the spinal cord results in loss o all sensation and voluntary movement inerior to the lesion. This image demonstrates bone densities (light) o skeletal structures, air densities (dark) o lungs and trachea, and sot tissue densities (intermediate) o the great vessels and heart and domes o the diaphragm.
