Associate Professor, Alabama College of Osteopathic Medicine
It has a head (apex) that provides attachment for the fibular collateral ligament of the knee joint acne tool purchase betnovate now. Lateral malleolus is a projection that articulates with the trochlea of the talus; lies more inferior and posterior than the medial malleolus skin care network barnet ltd purchase 20 gm betnovate otc, It provides attachment for the anterior talofibular skin care after 30 order betnovate overnight delivery, posterior talofibular acne after stopping birth control order betnovate 20 gm without a prescription, and calcaneofibular ligaments. Ossification of fibula: the fibula ossifies from three centres: one primary and two secondary. Law of ossification: Epiphyseal (secondary) centre which appears first unites last with the diaphysis. The explanation to this violation is that epiphyseal centre in the lower end of fibula appears earlier because it is pressure epiphysis and in the upper end later because it is traction epiphysis. Since the growing end fibula is its upper end (as evidenced by the direction of nutrient foramen) it unites with the diaphysis last although its epiphyseal centre also appears last. Patella Patella bone is the largest sesamoid bone and is located within the tendon of the quadriceps femoris, which articulates with the femur but not with the tibia. It attaches to the tibial tuberosity by a continuation of the quadriceps tendon called the patellar ligament. It functions to obviate wear and attrition on the quadriceps tendon as it passes across the trochlear groove and to increase the angle of pull of the quadriceps femoris, thereby magnifying its power. Ossification: Several centres appear during the third to sixth years and these coalesce rapidly. Body weight is transferred from the vertebral column through sacroiliac joints to the pelvic girdle and from pelvic girdle through the hip joints to the femurs. Pelvic girdle connects the lower limb to the axial skeleton via the sacroiliac joint, a plane synovial type of joint, allows effective weight transmission from the trunk to the lower limb. Anteriorly, the pelvic girdle articulates with the contralateral girdle at the pubic symphysis, a secondary cartilaginous joint that may display a slight degree of mobility during hip and sacroiliac movement, and during Body weight is transferred from the knee joint to the ankle joint by the tibia. At the ankle, the weight born by the tibia is transformed to the talus- the keystone of the longitudinal arch of the foot. The longitudinal arch formed by the tarsals and metatarsals, evenly distribute the weight between the heel and foot when standing. Both the knee and ankle are commonly subject to closed injuries, and the relatively superficial location of the knee renders it susceptible to open injury Although the ankle is frequently injured and is a major load-bearing joint, the incidence of clinically significant degenerative arthritis is surprisingly low when compared with that found in the hip and knee joints. Joints Pelvic girdle connects the lower limb to the axial skeleton via the sacroiliac joint, in which mobility has been sacrificed for stability and strength, which allows effective weight transmission from the trunk to the lower limb. Anteriorly, the pelvic girdle articulates with the contralateral girdle at the pubic symphysis, has slight degree of mobility during hip and sacroiliac movement, especially during childbirth. The hip has balanced stability and mobility and allows movement in all three orthogonal planes. The knee joint is a compound joint mainly between the femur and the tibia, and allows flexion, extension and some medial and lateral rotation of the leg. It is not a true hinge joint because its axes of flexion and extension are variable and there is coupled rotation. The tibia and fibula articulate with each other at the superior and inferior tibiofibular joints. The superior joint allows slight gliding movement only, whereas the inferior joint allows a degree of fibular rotation linked to ankle motion. The ankle (talocrural) joint is formed by the distal ends of the tibia and fibula gripping the talus, and allows dorsiflexion and plantar flexion. The multiple joints in the foot allow the complex movements as required for working as a platform for standing and for shock absorption and propulsion in gait. Movement Flexion Muscle Psoas major lliacus Pectineus Rectus femoris Adductor longus Sartorius Extension Gluteus maximus Adductor magnus Semitendinosus, semimembranosus, biceps femoris Medial rotation lliacus Gluteus medius and minimus Tensor fasciae latae Lateral rotation Superior and inferior gemelli Innervation Spinal nn. Nerve to obturator internus and nerve to quadratus femori, srespectively Nerve to quadratus femoris Nerve to piriformis Nerve to obturator internus Obturator n. L1 L2 L3 L4 L5 S1 S2 S3 Note: Blue shading denotes nerve roots from which there is a known dominant contribution. Ligaments of hip joint Capsule attaches to acetabular margin of hip bone, labrum and transverse acetabular ligament. On the femur, it is attached anteriorly to the intertrochanteric line and posteriorly 1 cm in front of (medial to) the intertrochanteric crest). It has two types of fibres-inner circular (zona orbicularis) fibres and outer longitudinal fibres (which are reflected along the neck toward the head to form the retinacula). Note: the synovial membrane lines inner aspect of the fibrous capsule, the intracapsular portion of the femoral neck, glenoid labrum (both surfaces), transverse acetabular ligament, ligamentum teres, and fat in the acetabular fossa. It has inverted Y-shaped, whose apex is attached to the lower half of the anterior inferior iliac spine and acetabular margin and the base to the intertrochanteric line. It has three parts: A lateral thick band of oblique fibres, a medial thick band of vertical fibres, and a large central thin portion. It is the strongest ligament of body and prevents the trunk from falling backward in the standing posture. Pubofemoral ligament reinforces the fibrous capsule inferiorly, extends from the pubis bone to the femoral neck, and limits abduction and extension. Ligamentum teres (round) of the head of femur is actually a flat triangular ligament with apex attached to the fovea of the head, and its base to the transverse acetabular ligament. It carries acetabular branches of the obturator and medial circumflex femoral arteries. Acetabular labrum is a fibrocartilaginous rim attached to the acetabular margin to deepen it.
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This has fostered dramatic increases in patient safety but there is more work ahead acne during pregnancy boy or girl order 20gm betnovate with visa. As we learn more about brain and spinal cord anatomy skin care yg bagus purchase discount betnovate line, we may develop drugs and techniques that allow more specific and targeted anesthetics that further improve patient care and safety acne xylitol purchase betnovate us. A patient presents to the angiography suite for removal of a thrombus in the proximal portion of her right middle cerebral artery acne x lactoferrin buy betnovate with american express. Inability to recognize her left hand Which of the following statement(s) is/are true regarding the brainstem The brainstem houses critical parts that control cardiac, respiratory, sensory, and motor functions in a densely compact arrangement which can lead to clinically devastating deficits with very small lesions. The bilateral locus ceruleus nuclei have norepinephrine-containing neurons that connect to the cortex, hippocampus, thalamus, midbrain, pons, medulla, cerebellum, and spinal cord to regulate the sleep-wake cycle and arousal. The raphe nuclei lie from the middle of the pons extending into the medulla and its neurons also contain norepinephrine and modulate arousal, sleep-wake cycle, and pain sensory input. An expanding cranial mass lesion is causing the medial aspect of the temporal lobe to herniate across the tentorium. Each internal carotid artery divides unevenly into an anterior and middle cerebral artery with the latter receiving the majority of the blood flow. Although the posterior cerebral arteries are usually the terminal branches of the basilar artery, the internal carotid artery supplies a majority of blood to this vessel in one fourth of the population. Most patients have adequate collateral flow in the brain because they have a complete Circle of Willis. Cerebral venous drainage consists of superficial and deep veins that are thin-walled, have no valves or surrounding muscle, and empty into the dural venous sinuses. Which of the following scenarios, if any, is most likely to lead to cortical ischemia Left carotid occlusion in a patient with a hypoplastic anterior communicating artery B. Proximal basilar artery occlusion in a patient with a hypoplastic left posterior communicating artery C. A clip placed on the right anterior cerebral artery just distal to its origin in a patient with hypoplasia of both posterior communicating arteries D. Anterograde perfusion of the right axillary artery when there is no flow through the left carotid or vertebral arteries during aortic arch surgery in a patient with hypoplasia of the anterior communicating and right posterior communicating artery E. Absent patellar tendon reflexes 57 Anatomy of the Brain and Spinal Cord 3 During placement of a carotid stent the patient becomes abruptly bradycardic. Subdural hematomas in children are commonly chronic due to their delicate cerebral veins. Little force is required to damage small bridging veins and cause a subdural hematoma. The continuity of the epidural space from the sacrum to the cranial vault means that medications can be injected into the epidural space at one level to provide analgesia and anesthesia for a broad range of dermatomes. Subdural injection of local anesthesia may lead to spinal cord damage as a result of direct toxicity or compressive effects. Both the spinal epidural and subdural spaces are only potential spaces that are iatrogenically created. Primary activation of a cell in the dorsal root ganglion without a prior synapse B. Ascending pain signals cross in the brainstem to activate the contralateral cortex. The majority of cases involve middle meningeal artery injury and the hematoma crosses cranial suture lines. They commonly present with a lucid interval followed by gradual deterioration as intracranial pressure. Seventy-five to ninety-five percent of epidural hematomas are associated with skull fractures. The middle cerebral artery supplies two-thirds of the lateral surface of the brain and is a common site for ischemic strokes. Because motor and sensory pathways decussate (cross the midline), many symptoms are contralateral to the affected hemisphere. Common findings include contralateral sensory loss and weakness, but each side of the upper portion of the face has motor innervation from both hemispheres. For this reason, an upper motor neuron deficit in the face often spares the forehead. The left hemisphere is dominant for language in 99% of right-handed individuals and roughly 70% of left-handed individuals. It is therefore very unlikely the patient in question would have a language issues with a right-sided lesion. The brainstem is made up of the midbrain, pons, and medulla and is located just ventral to the cerebellum. It contains essential ascending and descending tract and nuclei that are involved with consciousness as well as cardiac, respiratory, sensory, and motor functions. In addition, the brainstem houses these critical parts in a densely compact arrangement that can lead to clinically devastating deficits with very small lesions. The bilateral locus ceruleus nuclei located here have norepinephrine containing neurons that connect to the cortex, hippocampus, thalamus, midbrain, pons, medulla, cerebellum, and spinal cord to regulate the sleep-wake cycle and arousal.
Having the patient lift his or her head off the bed will help define the lateral border of the sternocleidomastoid muscle acne studios sale buy betnovate 20 gm amex. By placing the fingers under the sternocleidomastoid muscle and inferior to the external jugular vein acne keloidalis nuchae surgery 20 gm betnovate fast delivery, sliding them laterally will identify anterior scalene muscle acne regimen betnovate 20 gm generic. This groove sometimes is very obvious during palpation acne treatment during pregnancy purchase generic betnovate on-line, but frequently is subtle and more like a cleft. Once the groove is palpated, several maneuvers can be performed to confirm the groove. During deep inspiration, the groove often is accentuated because the scalenes are accessory muscles of respiration, which tense during inspiration. The groove also can be tracked down toward the first rib and palpate for the subclavian artery, which emerges between the scalenes. Once the interscalene groove is identified the palpating fingers should be gently but firmly pressed between the 6 S. Soliman 1 anterior and middle scalene muscles and should not be moved during the entire block procedure to allow for precise redirection of the needle when necessary. The needle is advanced slowly until stimulation of the brachial plexus is obtained-seen as twitch of the pectoralis, deltoid, arm, forearm, or hand muscles at 0. The latter position is more suitable for in-plane approach from the lateral side, especially when a catheter is placed that needs to be tunneled away from the surgical drapes. Start by identifying the hyperechoic arc of the trachea and moving the probe posterolaterally until sternocleidomastoid muscle is identified. This muscle is triangular shaped and located anteriorly to the carotid artery and internal jugular vein. Once the great vessels are identified, slide the probe more laterally to identify the scalene muscles and the brachial plexus that lies in between them appearing as hypoechoic trunks. Move laterally to identify the subclavian artery and immediately superior and posterior to the artery, the brachial plexus is seen as a grouping of small hyperechoic circles with hypoechoic centers, similar to a cluster of grapes. The plexus is then traced cephalad to the preferred block region at the level of C6. Once the plexus is identified the needle is inserted in-plane- typically in a lateral to medial direction. As the needle passes through the prevertebral fascia, a certain loss of resistance is often felt. Often called the "spinal anesthesia of the upper extremity," the supraclavicular block is a technique of anesthetizing the brachial plexus at distal trunks and origin of the divisions, where the brachial plexus is confined to its smallest surface area. The first percutaneous supraclavicular block was performed by Kulenkampff in Germany in 1911, reportedly on himself [2]. The advantages of a supraclavicular technique over other brachial plexus block approaches are its rapid onset and complete and predictable anesthesia for the entire upper extremity and particularly hand surgery. The introduction of ultrasound guidance to regional anesthesia in the last decade has resulted in significant renewed interest in the clinical application of the supraclavicular block, as well as a greater understanding of its mechanics. Above the mid humerus, the shoulder area, an interscalene block would provide better coverage). Landmark/Nerve Stimulator Technique Classic Approach the most common supraclavicular technique is the subclavian perivascular approach, described by Winnie and Collins [3]. The interscalene groove is palpated and followed distally until the pulsation of the subclavian artery is felt. It is important to note that the dome of the lung is medial to the insertion point of the needle. Entry to the sheath can be identified by a "click" as the needle pierces the tough fascia, by paresthesia, or by an appropriate motor response when a nerve stimulator is used. For vertical supraclavicular block, also called the "plumb bob" technique, identify the lateral border of the sternocleidomastoid as it inserts onto the clavicle by asking the patient to raise the head slightly off the bed. The needle entry site is immediately superior to the clavicle, just lateral to the identified lateral border of the sternocleidomastoid. Ultrasound Technique the patient can be positioned anywhere from supine to sitting upright with their head rotated away from the block site. The probe is placed in the supraclavicular fossa and oriented 7 Peripheral Nerve Block Anesthesia 1 perpendicular to the subclavian artery. Immediately superior and postero-lateral to the artery, the brachial plexus is seen as a grouping of small hyperechoic circles with hypoechoic centers, similar to a bunch of grapes. Alternatively, the plexus can be found in the interscalene space and followed distally to its association with the subclavian artery. Deep to the artery the structures of note are the dome of the lung (identified by its characteristic movement and scatter) and the first rib (identified by its hyperechoic surface with dense posterior shadowing).
Diseases
Scalp defects postaxial polydactyly
Transverse myelitis
Cryptorchidism arachnodactyly mental retardation
Say Carpenter syndrome
Primary malignant lymphoma
Metabolic syndrome X
Soft-tissue sarcoma
Pancreatic cancer
Deafness craniofacial syndrome
Dutta Obs 6th/ed p 532 Female Tubectomy Male Vasectomy Electrocoagulation is using cauterization for the purpose of tubal ligation and clipping is done during laparoscopic tubal ligation acne 25 order discount betnovate line, i acne routine generic betnovate 20 gm line. Friends delex acne 20 gm betnovate sale, here do not get confused by lines of Shaws which says some of these methods are reversible acne upper lip buy cheap betnovate 20 gm line, it does not mean they are not permanent methods. Williams 23/e p698-701 Essure is a permanent intratubal implant inserted transcervically using hysteroscope, not an abdominal technique for tubal ligation. Hysteroscopic tubal occlusion Hysteroscopic tubal occlusion is done by 2 methods and both these methods have high failure rates. Dutta Obs 6th/ed p 553 I have given these 2 questions simultaneously so that you understand how the answer changes as the options of the question change. Sterilization is done at the junction of proximal and middle third-the loop formed consists mainly of isthmus and part of the ampullary region of the tube. Jeffcoate 7th/ed p 825; Novak 14th/ed p 294 Read the following lines "It is important to select the site of tubal ligation carefully which should ideally be done at the tubal isthmus. This is because in the event of the patient desiring a tubal recanalization procedure, the isthmo-isthmic anastomosis carries the best chances of success". Dutta obs 7th/ed p 557 Post ligation syndromeSome patients after tubal ligation can experience post-ligation syndrome characterized by menstrual irregularities like menorrhagia, or irregular periods along with pelvic pain or congestive dysmenorrhea and cystic ovaries. Textbook of Gynae sheila balakrishnan 1st/ed p 373, Dutta obs 7th/ed p 553 Sterility does not occur immediately after vasectomy. So the best thing to do is to repeat the semen analysis and confirm that the male partner has become azoospermic. This is the reason why after vasectomy, 2 separate semen analysis should be done to confirm the absence of sperms in the ejaculate and then additional contraception discontinued. Read below For newly married couples oral contraceptive pill is the method of choice provided there are no contraindications. Chaudhuri 7th/ed p 71 In Breastfeeding Females For lactating mothers, contraceptive should be chosen in such a way that in addition to providing effective contraception, they do not adversely affect the success of lactation or the health of the infant. As a result, while the prolactin level remains high, the ovary produces little estrogen and no progesterone. Shaw 15th/ed p 238 Vasectomy consists of dividing the vas deferens and disrupting the passage of sperms. Dutta Gynae 6th/ed p 248 Tubal reconstruction surgery can be done for a number of reasons including for reversal of sterilisation procedure. The most favourable outcome is seen when it is done for reversal of sterilisation procedures. It is a barrier method of contraception, which is to be used along with spermicidal agent. Mesigyna Ref: Textbook of Gynae sheilabalakrishnan 1st/ed pp 350-351 Non oral hormonal contraceptives are: 1. Multiple chromosomal abnormalities are detected in 50% of all fibroids-most common being translocation between the long arms of chromosomes 12 and 14 followed by deletion of long arm of chromosome Y. Risk of fibroid increases as obesity increases Smoking is protective for fibroids Increasing parity decreases its incidence. Q 222 Self Assessment & Review: Gynecology Sarcomatous Change a fibroid undergoes malignancy, the most common malignancy which is seen is leiomyosarcoma. Subserous fibroids do not affect fertility rates but removing them increases fertility. Intramural fibroid slightly decreases fertility but removal does not increase fertility.
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