Thursday, November 20, 2008

median nerve:-motor innervation.

Motor innervation

The nerve innervates most of the flexor muscles of the forearm with the exception of the flexor carpi ulnaris and the medial two digits of the flexor digitorum profundus, which are supplied by the ulnar nerve

Unbranched, the median nerve supplies the following muscles:

  • Pronator teres
  • Flexor carpi radialis
  • Palmaris longus
  • Flexor digitorum superficialis

The anterior interosseus branch supplies the following muscles:

  • Lateral (radial) half of the Flexor digitorum profundus
  • Flexor pollicis longus
  • Pronator quadratus

In the hand, the median nerve provides innervation to:

  • 1st and 2nd lumbricals
  • Thenar muscles: Abductor pollicis brevis, Flexor pollicis brevis, Opponens pollicis

Contributing spinal nerve roots

C5, C6, C7, C8, T1

sesamoid bones :-

Sesamoid bones are small more or less rounded masses embedded in certain tendons and usually related to joint surfaces. Their functions probably are to modify pressure, to diminish friction, and occasionally to alter the direction of a muscle pull.
They are not covered by periosteum & begin to ossify after birth & are partly ossified.
They may be articular or non-articular.
In the lower extremity the largest sesamoid bone of the joints is the patella, developed in the tendon of the Quadriceps femoris.

Monday, June 16, 2008

Vascular supply and venous drainage of the chest wall

the intercostal space receives its blood supply from anterior & posterior intercostal arteries.
the anterior intercostal arteries are branches of internal thoracic artery & its terminal branch musculophrenic artery.
lowest 2-spaces has no anterior intercostal supply.
The posterior intercostal arteries are much longer & the first 2-3 arises from superior intercostal branch of costocervical trunk which itself is a branch of 2nd part of subclavian artery.
The lower 9 are the branches of thoracic aorta.
The anterior intercostal veins drain in to the internal thoracic vein & posterior intercostal veins in to azygous & hemiazygous system.

The intercostal space

Each intercostal space contains 3 muscles:-external intercostal,internal intercostal & innermost intercostal.
fibers of external intercostal runs forward & downwards while that of internal intercostal runs backwards & downwards.
innermost intercostals:-this group comprises the subcostal muscles
posteriorly, the intercostales intimi laterally and the transversus thoracis
anteriorly. The fibres of these muscles span more than one intercostal
space.
The neurovascular space lies between internal intercostal & innermost intercostal muscle layers.
pleural aspiration should be performed close to the upper border of rib to minimise injury to this neurovascular bundle.

ANATOMY:-

The thoracic cage:-

The thoracic cage is formed by the sternum and costal cartilages in
front, the vertebral column behind and the ribs and intercostal spaces
laterally.
It is separated from the abdominal cavity by the diaphragm and communicates
superiorly with the root of the neck through the thoracic
inlet .
The ribs :-
• Of the 12 pairs of ribs the first seven articulate with the vertebrae posteriorly
and with the sternum anteriorly by way of the costal cartilages
(true ribs).
• The cartilages of the 8th, 9th and 10th ribs articulate with the cartilages
of the ribs above ( false ribs).
• The 11th and 12th ribs are termed ‘floating’ because they do not articulate
anteriorly ( false ribs).
Typical ribs (3rd–9th)
These comprise the following features :
• A head which bears two demifacets for articulation with the bodies
of: the numerically corresponding vertebra, and the vertebra above.

• A tubercle which comprises a rough non-articulating lateral facet as
well as a smooth medial facet. The latter articulates with the transverse
process of the corresponding vertebra .
• A subcostal groove: the hollow on the inferior inner aspect of the
shaft which accommodates the intercostal neurovascular structures.
Atypical ribs (1st, 2nd, 10th, 11th, 12th)
• The 1st rib is short, flat and sharply curved. The head
bears a single facet for articulation. A prominent tubercle (scalene
tubercle) on the inner border of the upper surface represents the insertion
site for scalenus anterior. The subclavian vein passes over the 1st
rib anterior to this tubercle whereas the subclavian artery and lowest
trunk of the brachial plexus pass posteriorly.
A cervical rib is a rare ‘extra’ rib which articulates with C7 posteriorly
and the 1st rib anteriorly. A neurological deficit as well as vascular
insufficiency arise as a result of pressure from the rib on the lowest
trunk of the brachial plexus (T1) and subclavian artery, respectively.

• The 2nd rib is less curved and longer than the 1st rib.
• The 10th rib has only one articular facet on the head.
• The 11th and 12th ribs are short and do not articulate anteriorly.
They articulate posteriorly with the vertebrae by way of a single facet
on the head. They are devoid of both a tubercle and a subcostal groove.
The sternum :-
The sternum comprises a manubrium, body and xiphoid process.
• The manubrium has facets for articulation with the clavicles, 1st
costal cartilage and upper part of the 2nd costal cartilage. It articulates
inferiorly with the body of the sternum at the manubriosternal joint.
• The body is composed of four parts or sternebrae which fuse between
15 and 25 years of age. It has facets for articulation with the lower part
of the 2nd and the 3rd to 7th costal cartilages.
• The xiphoid articulates above with the body at the xiphisternal joint.
The xiphoid usually remains cartilaginous well into adult life.
Costal cartilages
These are bars of hyaline cartilage which connect the upper seven ribs
directly to the sternum and the 8th, 9th and 10th ribs to the cartilage
immediately above.
Joints of the thoracic cage :-
• The manubriosternal joint is a symphysis. It usually ossifies after the
age of 30.
• The xiphisternal joint is also a symphysis.
• The 1st sternocostal joint is a primary cartilaginous joint. The rest
(2nd to 7th) are synovial joints. All have a single synovial joint except
for the 2nd which is double.
• The costochondral joints (between ribs and costal cartilages) are primary
cartilaginous joints.
• The interchondral joints (between the costal cartilages of the 8th, 9th
and 10th ribs) are synovial joints.
• The costovertebral joints comprise two synovial joints formed by the
articulations of the demifacets on the head of each rib with the bodies of
its corresponding vertebra together with that of the vertebra above. The
1st and 10th–12th ribs have a single synovial joint with their corresponding
vertebral bodies.
• The costotransverse joints are synovial joints formed by the articulations
between the facets on the rib tubercle and the transverse process
of its corresponding vertebra.

embryology:-important facts

Brachial arches:-
Brachial arches also known as pharyngeal arches are mesodermal thickenings in the wall of cranial most part of foregut,the first arch is called mandibular arch, and second arch is the hyoid arch,the rest of the arches third,forth & sixth arches do not have special names,i don't mention 5th arch here because it disappers soon after formation,so the only 1st and 2nd arches have special names.
let us talk about the first arch,it is the only arch in the human embryo having double innervation,that is the 1st arch got dual nerve supply,firstly Chorda tympani that is a branch of the facial nerve is the pretrematic nerve,&,the mandibular nerve is the post-trematic nerve,i think you don't have problem to remember this,now lets talk about arterial supply of first arch,artery that supply the first arch is Maxillary artery,here is little introduction for maxillary artery,The maxillary artery,which is the larger of the two terminal branches of the external carotid artery, arises behind the neck of the mandible, and is at first imbedded in the substance of the parotid gland; it passes forward between the ramus of the mandible and the sphenomandibular ligament, and then runs, either superficial or deep to the lateral pterygoid muscle, to the pterygopalatine fossa.
It supplies the deep structures of the face, and may be divided into mandibular, pterygoid, and pterygopalatine portions,lets come back to our topic,now m talking about the muscles derived from 1st arch,these are the muscles of mastication which include masseter,temporalis,medial & lateral pteryoids,along with the muscles of mastication some other muscles like mylohyoid,anterior belly of digastric,tensor tympani & tensor palati also derived from the first arch.
Cartilage of the first arch is known as Meckel's cartilage,it got dorsal and ventral part,dorsal part gives rise to incus and malleus; while the ventral part gives rise to sphenomandibular ligament and anterior ligament of malleus.
2nd arch:-
nerve of second arch is facial nerve , while the artery is stapedial artery.
muscles derived from 2nd arch are:-stapedius,stylohyoid,posterior belly of digastric muscle,platysma,muscles of face,auricular muscles and occipitofrontalis.
cartilae of second arch is Reichter's cartilage while that of 1st arch is meckel's cartilage.Reichter's cartilage gives rise to 5s:-stapes,stylohyoid ligament,styloid process,smaller cornu of hyoid and superior part of body of hyoid.
3rd arch:-
nerve of third arch is glossopharyngeal nerve.
muscle derived from third arch is stylopharyngeus muscle.
cartilage of third arch forms greater cornu & lower part of body of hyoid bone.
4th arch:-4th arch got its nerve supply from superior laryngeal nerve.
6th arch:-the nerve of 6th arch is recurrent laryngeal nerve.
4th & 6th arches together gives rise to muscles of larynx,pharynx and soft palate.
After the formation of pharyngeal arches the region of the neck is marked on the outside by a series of groove or ectodermal clefts.
Dorsal part of first cleft gives rise to epithelial lining of external auditory meatus while ventral part of 1st cleft obliterates.
2nd arch grows much faster then the 3rd, 4th and 6th arches,so overhangs them creating a space in between called the cervical sinus.Persistence of this sinus may give rise to brachial cyst.
Lastly the endodermal pouches form the following organs:-
Ventral part of 1st pouch forms tongue.
Dorsal part of 1st and 2nd pouch forma the tubotympanic recess,which forms the eustachian tube & middle ear cavity.
Ventral part of 2nd pouch forms the tonsils.
3rd pouch forms the thymus & inferior parathyroid gland.
4th pouch forms superior parathyroid glands & parafollicular C-cells of thyroid.


embryology of diaphragm:-it is form by the fusion of septum transversum (forming the central tendon),dorsal oesophageal mesentry,the pleuroperitoneal membrane & body wall.


embryology of thyroid gland:-it develops from thyroglossal diverticulum,which pushes out from the tongue at the foramen caecum.it descends to its definitive position in the neck & losses all connections with its origin.
this development accounts for the occasional occurence of lingual thyroid,thyroglossal cyst or sinus along the path of descent.


aortic arches & their derivatives:-
common arterial trunk gives rise to "Truncus arteriosus" which forms six pairs of aortic arches out of which first,second & fifth arch disappears.
third arch gives rise to carotid arteries.
right fourth arch forms brachiocephalic & right subclavian arteries.
left fourth arch forms aortic arch & left subclavian artery.
sixth arch gives rise to riht &left pulmonary arteries & ductus arteriosus.


Derivatives of foregut , midgut & hindgut:-
Foregut:-supplied by coeliac artery.
*part of floor of mouth , including the tongue.
*pharynx.
*Derivatives of phayngeal pouches & thyroid.
*oesophagus & stomach.
*Duodenum:ascending (2nd) part up to major duodenal papilla.
*Liver , pancreas,biliary channels.
&* respiratory system.
Midgut:-supplied by superior mesenteric artery.
*from descending (2nd) part of duodenum distal to major papilla to the right two-third of transverse colon.
Hindgut:-supplied by inferior mesenteric artery.
*from left one-third of transverse colon to upper part of anal-canal.
*parts of the urogenital system derived from the primitive urogenital sinus.
derivatives of dorsal mesogastrium:-greater omentum,gastrosplenic ligament , gastrophrenic ligament & lienorenal ligament.
derivatives of ventral mesogastrium:-lesser omentum,falciform ligament,coronary ligament,right & left triangular ligament.