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The plane between the bladder and rectum is occupied by internal genitalia and a septum formed during embryonic development as the urogenital sinus was partitioned into the urinary bladder and urethra anteriorly and the anorectum posteriorly. The pylorus is normally tonically contracted so that the pyloric orifice is reduced, except when emitting chyme (semifluid mass). If untreated, the disease spreads to other supporting structures, including alveolar bone, producing periodontitis (inflammation and destruction of bone and periodontium). Because their tonic contraction shortens the part of the wall with which they are associated, the colon becomes sacculated or "baggy" between the teniae, forming the haustra. Superiorly, the system communicates with the veins of the scalp and the intracranial venous sinuses via the foramen magnum, the mastoid foramina, and the condylar canals. Small, rapidly recurring changes take place in intracranial pressure owing to the beating heart; slow recurring changes result from unknown causes. At the superior end of the anterior border, a broad, oblong tibial tuberosity provides distal attachment for the patellar ligament, which stretches between the inferior margin of the patella and the tibial tuberosity. Its mainly convex superior surface faces the thoracic cavity, and its concave inferior surface faces the abdominal cavity. Its fibers from the anterior divisions of S2 and S3 supply the skin of the perineum via its perineal branch. Dislocation of Elbow Joint Posterior dislocation of the elbow joint may occur when children fall on their hands with their elbows flexed. Basal ganglia neuronal loops are not limited to the motor cortex but also connect with the posterior parietal, premotor and prefrontal cortex,513 and with the medial and lateral temporal lobes, hippocampus, anterior cingulate and orbitofrontal cortex. In some cases, an arteriovenous shunt occurs as a result of communication between the injured vessels. Ectopic Tubal Pregnancy Tubal pregnancy is the most common type of ectopic gestation (embryonic implantation and initiation of gestational development outside of the body of the uterus); it occurs in approximately 1 of every 250 pregnancies in North America (Moore et al. Motor Innervation of Lower Limb Somatic motor (general somatic efferent) fibers traveling in the same mixed peripheral nerves that convey sensory fibers to the cutaneous nerves transmit impulses to the muscles of the lower limb. The motor nuclei are shown on the left side of the brainstem and the sensory nuclei on the right side. The prominence of the trochanter increases when a dislocated hip causes atrophy of the gluteal muscles and displacement of the trochanter. Lymph from the large intestine flows sequentially to epicolic nodes (on the gut), paracolic nodes (along mesenteric border), intermediate colic nodes (along the colic arteries), and then to the superior or inferior mesenteric nodes and the intestinal trunks. In lacerations of the lip, pressure must be applied on both sides of the cut to stop the bleeding. Diagram adapted from Trollman and Gassmann1021 and redrawn courtesy of Y Yamamoto, Yamaguchi University Graduate School of Medicine, Japan. As the bladder fills, it enters the greater pelvis as it ascends in the extraperitoneal fatty tissue of the anterior abdominal wall. Acquired flat feet ("fallen arches") are likely to be secondary to dysfunction of the tibialis posterior (dynamic arch support) owing to trauma, degeneration with age, or denervation. Anterior and posterior gastric branches of the plexus accompany the esophagus through the esophageal hiatus for distribution to the anterior and posterior aspects of the stomach. Consequently, the axis of the pelvis (a line in the median plane defined by the center point of the pelvic cavity at every level) is curved, pivoting around the pubic symphysis. The median sacral artery represents the caudal end of the embryonic dorsal aorta, which reduced in size as the tail-like caudal eminence of the embryo disappeared. The crest serves as a protective "bumper" and is an important site of aponeurotic attachment for thin, sheet-like muscles and deep fascia. Expansion of a supratentorial mass lesion may therefore be responsible for initiating tentorial herniation and establishing the beginnings of a transtentorial pressure gradient. Arteriolosclerosis tends to be associated with ischaemic white matter disease and vascular dementia rather than lacunar infarcts. The muscles of the tongue do not act in isolation, and some muscles perform multiple actions. Each external carotid artery runs posterosuperiorly to the region between the neck of the mandible and the lobule of the auricle, where it is embedded in the parotid gland, and terminates by dividing into two branches, the maxillary artery and the superficial temporal artery.

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The aim of the dissection is to remove all tissue that bears lymph nodes in one piece. Injury to Laryngeal Nerves Because the inferior laryngeal nerve, the continuation of the recurrent laryngeal nerve, innervates the muscles moving the vocal fold, paralysis of the vocal fold results when injury to laryngeal nerves occurs. Pelvic splanchnic nerves: pathway for parasympathetic innervation of pelvic viscera and descending and sigmoid colon. Nevertheless, dislocation may occur during an automobile accident when the hip is flexed, adducted, and medially rotated, the usual position of the lower limb when a person is riding in a car. They may occur in both deciduous and permanent dentitions, but more commonly occur in the latter. The palmar cutaneous branch of the median nerve arises proximal to , and does not pass through, the carpal tunnel; thus, sensation in the central palm remains unaffected. Apparently, the muscular primordium is established around the whole length of the urethra before development of the prostate. The sympathetic supply is from the lumbar spinal cord, conveyed via lumbar splanchnic nerves and the hypogastric/pelvic plexuses and through the peri-arterial plexus of the inferior mesenteric and superior rectal arteries. Of the three intrinsic ligaments of the joint capsule below, it is the first one that reinforces and strengthens the joint: Anteriorly and superiorly is the strong, Y-shaped iliofemoral ligament, which attaches to the anterior inferior iliac spine and the acetabular rim proximally and the intertrochanteric line distally. Corneal Abrasions and Lacerations Foreign objects such as sand or metal filings (particles) produce corneal abrasions that cause sudden, stabbing pain in the eyeball and tears. It acts with the other two "pes anserinus" muscles to add stability to the medial aspect of the extended knee, much as the gluteus maximus and tensor fasciae latae do via the iliotibial tract on the lateral side. The embryological basis of penile and penoscrotal hypospadias is failure of the urogenital folds to fuse on the ventral surface of the penis, completing the formation of the spongy urethra. The following text provides additional information about the formation of the nerves and their courses. The parotid glands are located lateral and posterior to the rami of the mandible and masseter muscles, within unyielding fibrous sheaths. Because the inferior thyroid arteries provide the primary blood supply to the posterior aspect of the thyroid gland where the parathyroid glands are located, branches of these arteries usually supply these glands. Renal Cysts Cysts in the kidney, multiple or solitary, are common findings during ultrasound examinations and dissection of cadavers. All these stages represent normal anatomy for the particular age and reproductive status of the woman. Vessels of Posterior Abdominal Wall the major neurovascular bundle of the inferior trunk, including the abdominal aorta, the inferior vena cava, and the aortic peri-arterial nerve plexus, courses in the midline of the posterior abdominal wall, anterior to the bodies of the lumbar vertebrae. Medial to the hilum, the lung root is enclosed within the area of continuity between the parietal and the visceral layers of pleura-the pleural sleeve (mesopneumonium). The origins, courses, and distribution of the arteries and the 1340 arterial anastomoses formed are described in Table 6. The ability of the ampulla to relax to accommodate the initial and subsequent arrivals of fecal material is another essential element of maintaining fecal continence. Continued sequential contraction of the inner (apical) spiral elongates the heart, followed by widening as the myocardium briefly relaxes, increasing the volume of the chambers to draw blood from the atria. The perforating veins pass through the deep fascia at an oblique angle so that when muscles contract and the pressure increases inside the deep fascia, the perforating veins are compressed. Abdominal Hernias the anterolateral abdominal wall may be the site of abdominal hernias. The internal occipital crest ends in the internal occipital protuberance formed in relationship to the confluence of the sinuses, a merging of dural venous sinuses. The enlarged posterior part of the bulb of the penis is penetrated superiorly by the urethra, continuing from its intermediate part. Deep to the pectoralis major and its fascia is another layer of deep fascia suspended from the clavicle and investing the pectoralis minor muscle, the clavipectoral fascia.

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They are immediately posterior to the internal carotid artery as they emerge from it. Lateral radiographs allow better viewing of a lesion or anomaly confined to one side of the thorax. It is actively contracted during activities such as forced expiration, coughing, sneezing, vomiting, and fixation of the trunk during strong movements of the upper limbs. This fascia forms a connective tissue matrix or packing material for the pelvic viscera. The right and left livers are subdivided vertically into medial and lateral divisions by the right portal and umbilical fissures, in which the right and left hepatic veins lie. The joint capsule is reinforced medially by the large, strong medial ligament of the ankle (deltoid ligament) that attaches proximally to the medial malleolus. Femur: Through development, our largest bone, the femur, has developed a bend (angle of inclination) and has twisted (medial rotation and torsion so that the knee and all joints inferior to it flex posteriorly) to accommodate our erect posture and to enable bipedal walking and running. The anesthetic should be injected slowly to prevent stripping of the mucosa from the hard palate. The fibers of the aponeuroses interlace in the midline, forming the linea alba, and continue into the aponeuroses of the contralateral muscles. A hydrocele of the testis is confined to the scrotum and distends the tunica vaginalis. To complement these features the brain is endowed with structurally unique protective systems. The inguinal canals in females are narrower than those in males, and the canals in infants of both sexes are shorter and much less oblique than in adults. Skin: thin, except in the occipital region, contains many sweat and sebaceous glands and hair follicles. Traction is applied to the articular disc so that it is not pushed posteriorly ahead of the retracting mandible. It is usually surprising to find how 1263 close the lower abdominal aorta lies to the anterior abdominal wall in lean individuals. At the end of micturition (urination), the bladder of a normal adult contains virtually no urine. The parietal peritoneum is internal to the transversalis fascia and is separated from it by a variable amount of extraperitoneal fat. The artery to the head of the femur, which is a branch of the obturator artery of variable size; it traverses the ligament of the head. Air embolism also plays a role in the neurological damage that can be seen after cardiac bypass surgery. The tibial condyles can be palpated anteriorly at the sides of the patellar ligament, especially when the knee is flexed. Contraction of the muscle fibers that most closely parallel the slope of the ribs at a given point (fibers A and C) will elevate the ribs and sternum; contraction of muscle fibers that are approximately perpendicular to the slope of the ribs (fiber B) will depress the ribs. To understand the actions produced by muscles starting from the primary position, it is necessary to observe the placement and line of pull of the muscle relative to 2039 the axes about which the movements occur. Irritation of the parietal pleura may produce local pain or referred pain projected to dermatomes supplied by the same spinal (posterior root) ganglia and segments of the spinal cord. Smooth and voluntary slips of muscle from the external urethral sphincter, levator ani, and muscular coats of the rectum. While in the pterygopalatine fossa, the maxillary nerve also gives off the two ganglionic branches to the pterygopalatine ganglion (sensory roots of the pterygopalatine ganglion) that suspend the parasympathetic pterygopalatine ganglion in the superior part of the pterygopalatine fossa. Thrombophlebitis of Facial Vein the facial vein makes clinically important connections with the cavernous sinus through the superior ophthalmic vein, and the pterygoid venous plexus through the inferior ophthalmic and deep facial veins. A distal skin incision was made along the transverse wrist crease, crossing the pisiform bone.

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To prevent undesirable heat loss in a cold environment, the arterioles of the hands are capable of reducing blood flow to the surface and to the ends of the fingers. A high-stepping steppage gait, in which extra flexion is employed at the hip and knee to raise the foot as high as necessary to keep the toes from hitting the ground. This section shows that the omental bursa is an isolated part of the peritoneal cavity, lying dorsal to the stomach and extending superiorly to the liver and diaphragm (superior recess) and inferiorly between the layers of the greater omentum (inferior recess). Reduced density in the ischaemic region is usually accompanied by space-occupying effects that depend on the size of infarct. The vestibule of the bony labyrinth is a small oval chamber (approximately 5 mm long) that contains the utricle and saccule. Its superior attachment to the mastoid process is palpable posterior to the lobule 2262 of the auricle. However, even slight movement at the joints of the heads of ribs may produce a relatively large excursion of the distal (sternal or anterior) end of a rib. The fibers of the fundiform ligament are relatively long and loose and lie superficial (anterior) to the suspensory ligament. This standard craniometric reference is the orbitomeatal plane (Frankfort horizontal plane). The fascial compartments of the thigh and leg, containing muscles sharing common functions and innervation, are demonstrated in transverse sections. The major structures in the mediastinum are also surrounded by blood and lymphatic vessels, lymph nodes, nerves, and fat. The articular cavity of the joint is continuous with that of the elbow joint, as demonstrated by the blue latex injected into that space and seen through the thin parts of the fibrous layer of the capsule, including a small area distal to the anular ligament. Several environmental factors have been implicated in the pathogenesis of saccular aneurysms. Lateral sacral arteries: Superior and inferior lateral sacral arteries may arise as independent branches or via a common trunk. Scalp Infections the loose connective tissue layer (layer four) of the scalp is the danger area of the scalp because pus or blood spreads easily in it. Variations in Relationships of Hepatic Arteries In most people, the right hepatic artery crosses anterior to the hepatic portal vein. The greater vestibular glands are round or oval and are partly overlapped posteriorly by the bulbs of the vestibule. They basically resist forces that tend to reduce the longitudinal arch as weight is received at the heel (posterior end of the arch) and then transferred to the ball of the foot and great toe (anterior end of the arch). In all these cases, the peritoneal cavity may be distended with several liters of abnormal fluid, interfering with movements of the viscera. The rib moves (elevates and depresses) around an axis that traverses the head and neck of the rib (arrows). The internal aspect of the abdominal wall is lined with membranous and areolar sheets of varying thickness constituting endoabdominal fascia. The gluteal sulcus, the skin crease inferior to the gluteal fold, delineates the buttocks from the posterior aspect of the thigh. The skin attaches loosely to the subcutaneous tissue, except at the umbilicus, where it adheres firmly. Median nerve injury resulting from a perforating wound in the elbow region results in loss of flexion of the proximal and distal interphalangeal joints of the 2nd and 3rd digits. People experiencing severe chronic anxiety are most prone to the development of peptic ulcers. These movements are important in approximating, tensing, and relaxing the vocal folds. At later stages, the intima is markedly thickened and the internal elastic lamina and the media largely destroyed, and the media and adventitia may become fibrotic and thickened, with blurring of their interface. Developmentally, the fibularis muscles are postaxial muscles, receiving innervation from the posterior divisions of the spinal nerves, which contribute to the sciatic nerve. Its head has two facets for articulation with the bodies of the T1 and T2 vertebrae; its main atypical feature is a rough area on its upper 725 surface, the tuberosity for serratus anterior, from which part of that muscle originates. In infarcts of known cause, the lumen of intracranial large to medium-sized arteries is most commonly occluded by an embolus. Axonal swellings start to develop within hours in the vicinity of the infarct, become more prominent over the following days and persist for several weeks.

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The internal iliac artery is separated from the sacro-iliac joint by the internal iliac vein and the lumbosacral trunk. In current practice, often only the tumor and surrounding tissues are removed-a lumpectomy or quadrantectomy (known as breastconserving surgery, a wide local excision)-followed by radiation therapy (Goroll, 2014). The parathyroid glands are usually embedded in the fibrous capsule on the posterior surface of the thyroid gland. Pampiniform venous plexus: a network formed by up to 12 veins that converge superiorly as right or left testicular veins. These markings provide clues to the relationships of the lungs; however, only the cardiac impressions are evident during surgery or in fresh cadaveric or postmortem specimens. It is located between the optic nerve and the lateral rectus toward the posterior limit of the orbit. The superior lingual gingiva, the part of the gingiva covering the lingual surface of the teeth and the alveolar process, is continuous with the mucosa of the palate. Coronary Angioplasty Cardiologists or interventional radiologists use percutaneous transluminal coronary angioplasty in which they pass a catheter with a small inflatable balloon attached to its tip into the obstructed coronary artery. Muscles: the anterolateral abdominal muscles consist of concentric, flat muscles located anterolaterally and vertical muscles placed anteriorly adjacent 1007 to the midline. The mucosa has been removed on each side of the palatine raphe, demonstrating a branch of the greater palatine nerve on each side and the artery on the lateral side. Note that although they are adjacent on each side, they part company centrally to accommodate intercondylar and infrapatellar structures that are intracapsular (inside the fibrous layer) but extra-articular (excluded from the articular cavity by synovial membrane). In this "bare area" the pericardial sac is accessible for needle puncture with less risk of puncturing the pleural cavity or lung. Trauma may produce a scrotal and/or testicular hematoma (accumulation of blood, usually clotted, in any extravascular location). Right and left hypogastric nerves join the superior hypogastric plexus to the inferior hypogastric plexus. However, attempts to define precise ischaemic thresholds below which damage consistently takes place encounter difficulty because this depends on interacting factors including age, temperature, blood glucose concentration, and duration of ischaemia. The interosseous membrane also provides additional surface area for muscular attachment. Even an experienced mountaineer may lose accrued climbing wisdom, show clear errors of judgement and make poor decisions at high altitudes. In older or nonathletic people, nonsurgical repairs are often adequate, but surgical intervention is usually advised for those with active lifestyles, such as tennis players. Over the 9 months of pregnancy, the gravid uterus expands greatly to accommodate the fetus, becoming larger and increasingly thin walled. Thus, the membrane and ligaments strongly resist the downward pull placed on the fibula by eight of the nine muscles attached to it. Persistent fusiform aneurysmal dilation has been described as a sequel to dissection of the vertebral artery. The needle passes through the thyrohyoid membrane and the anesthetic agent bathes the internal laryngeal nerve, the larger terminal branch of the superior laryngeal nerve. The four parts of the occipital bone are arranged around the foramen magnum, the most conspicuous feature of the 1892 cranial base. The pretracheal layer of fascia includes a thin muscular part, which encloses the infrahyoid muscles, and a visceral part, which encloses the thyroid gland, trachea, and esophagus, and is continuous posteriorly and superiorly with the buccopharyngeal fascia of the pharynx. The thoracic trunks lie against the heads of the ribs in the superior part of the thorax, the costovertebral joints in the midthoracic level, and the sides of the vertebral bodies in the inferior part of the thorax. The occipital sinus communicates inferiorly with the internal vertebral venous plexus. Impaired demarcation between the grey and adjacent white matter within an infarct, and flattening of the ischaemic cerebral sulci are early changes. Each main (primary) bronchus divides into secondary lobar bronchi, two on the left and three on the right, each of which supplies a lobe of the lung. The sacral sympathetic trunks descend posterior to the rectum in the extraperitoneal connective tissue and send communicating branches (gray rami communicantes) to each of the anterior rami of the sacral and coccygeal nerves. This pronation is the result, at least in part, of the medial migration of the distal attachment of the fibularis longus across the sole of the foot. Almost all diseases in neuropathology show selective vulnerability but little is known of the mechanisms. In general, they attach proximally to the antero-inferior external surface of the bony pelvis (pubic bone, ischiopubic ramus, and ischial tuberosity), and adjacent obturator membrane, and distally to the linea aspera of the femur.

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Schematic illustration of the organization of the enteric nervous system within the intestinal wall. This vessel descends in or near the midline anterior to the bodies of the last one or two lumbar vertebrae and the sacrum and coccyx. Nerves of Thoracic Wall the 12 pairs of thoracic spinal nerves supply the thoracic wall. Conversely, the term "valga" or "valgus" describes a bone or joint in a limb that is deformed so that the distal element deviates away from the midline. Damage to one or 1655 more of the listed spinal cord segments, or to the motor nerve roots arising from them, results in paralysis of the muscles concerned. The deep surface of the anular ligament is lined with synovial membrane, which continues distally as a sacciform recess of the proximal radio-ulnar joint on the neck of the radius. The hemi-azygos vein arises on the left side by the junction of the left subcostal and ascending lumbar veins. In addition, pathological changes of vascular smooth muscle and altered release of metabolic factors. Direct adrenergic stimulation from the sympathetic nerve fibers, as well as indirect suprarenal (adrenal) hormone stimulation, increases atrial and ventricular contractility. The seminal colliculus is a rounded eminence in the middle of the urethral crest with a slitlike orifice that opens into a small cul-de-sac, the prostatic utricle. Inferior to the pectinate line, the internal rectal plexus drains into the inferior rectal veins (tributaries of the caval venous system) around the margin of the external anal sphincter. This position makes the lower limb a solid column and more adapted for weight bearing. The right and left frontal sinuses are rarely of equal size, and the septum between them is not usually situated entirely in the median plane. The subcostal nerves (anterior rami of T12) arise in the thorax, pass posterior to the lateral arcuate ligaments into the abdomen, and run inferolaterally on the anterior surface of the quadratus lumborum. Four structures run parallel as they traverse the superior thoracic aperture: trachea, esophagus, left recurrent laryngeal nerve, and thoracic duct. All internal surfaces not covered with or made of articular cartilage (blue or gray in the case of the menisci) are lined with synovial membrane (mostly purple, but transparent and colorless where it is covering nonarticular surfaces of the femur). As a result, the eyeball protrudes (exophthalmos) and the conjunctiva becomes engorged (chemosis). The largest part of the broad ligament, 1422 inferior to the mesosalpinx and mesovarium, which serves as a mesentery for the uterus itself, is the mesometrium. Exposure to any of these three agents causes brain damage, but heart failure always supervenes in sulphide-,8 cyanide-405 and azide-related670 injury. The lateral third of this slightly Sshaped canal is cartilaginous and is lined with skin that is continuous with the auricular skin. The canals have only five openings into the vestibule because the anterior and posterior canals have one limb common to both. Joint Capsule Rbrous layer of joint capsule is attached to margins of articular surfaces L ig am ents Medial, lateral, and posterior talocalcaneal ligaments support capsule; Interosseous talocalcaneal ligament binds bones together. The mesentery is a fan-shaped fold of peritoneum that attaches the jejunum and ileum to the posterior abdominal wall. Fibres degenerate distal to the infarct, a process that continues for months and even years, as macrophages filled with myelin debris mark the pathways of affected tracts. Pus can also reach the psoas fascia by passing from the posterior mediastinum when the thoracic vertebrae are diseased. At sea level, most oxygen delivered in arterial blood consists of the fourth O2 molecule and often the third, leaving two or three O2 molecules in venous blood haemoglobin molecules and an average venous saturation of 70 per cent. The common carotid artery and one of its terminal 2256 branches, the external carotid artery, are the main arterial vessels in the carotid triangle. Nonsurgical treatments include pelvic floor muscle exercises, pessaries (devices placed in the vagina to provide support and resistance), and pharmacotherapy. This injury may be caused by acute trauma or repetitive microtraumas that place increased shearing stress on the epiphysis, especially with abduction and lateral rotation of the thigh. Because the aponeurosis is a layer of the scalp, independent contraction of the occipital belly retracts the scalp and contraction 1927 of the frontal belly protracts it.

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When there is low union, the two ducts may be joined by fibrous tissue, making surgical clamping of the cystic duct difficult without injuring the common hepatic duct. Unilateral and bilateral demonstration of extra-ocular muscle actions, starting from the primary position. The urethra (and vagina in females) and rectum pass through the urogenital hiatus of the pelvic diaphragm. Given the extent of the peritoneal surfaces and the rapid absorption of material, including bacterial toxins, from the peritoneal cavity, when a peritonitis becomes generalized (widespread in the peritoneal cavity), the condition is dangerous and perhaps lethal. A band of connective tissue, often containing accessory thyroid tissue, may continue from the apex of the pyramidal lobe to the hyoid. Both nerve and artery break up into several branches that enter the deep surface of the overlying gluteus maximus muscle. The syndrome may include hematuria or proteinuria (blood or protein in the urine), abdominal (left flank) pain, nausea and vomiting (indicating compression of the duodenum), and left testicular pain in men (related to the left testicular vein draining into the left renal vein proximal to the compression). The superficial veins, usually unaccompanied, course within the subcutaneous tissue; the deep veins are internal to the deep fascia and usually accompany arteries. These symptoms are accompanied by a sense of pressure in the ear, distortion of sounds, and sensitivity to noises (Storper, 2016). Sensory and sympathetic innervation is provided 1498 primarily by the dorsal nerve of the penis, a terminal branch of the pudendal nerve, which arises in the pudendal canal and passes anteriorly into the deep perineal pouch. The glans clitoris is the most highly innervated part of the clitoris and is densely supplied with sensory endings. Inferiorly, the posterior sacro-iliac ligaments are joined by fibers extending from the posterior margin of the ilium (between the posterior superior and posterior inferior iliac spines) and the base of the coccyx to form the massive sacrotuberous ligament. The umbilical (left sagittal) fissure is the continuous groove formed anteriorly by the fissure for the round ligament and posteriorly by the fissure for the ligamentum venosum. Pus from the psoas abscess passes inferiorly along the psoas muscle within this fascial tube over the pelvic brim and deep to the inguinal ligament. Anterior talofibular ligament, a flat, weak band that extends anteromedially from the lateral malleolus to the neck of the talus. Dorsal digital veins continue proximally as dorsal metatarsal veins, which also receive branches from plantar digital veins. Arterial emboli that enter the posterior circulation originate in the vertebral arteries, either in the neck or within the cranial cavity. The lower thoracic splanchnic nerves are the main source of presynaptic sympathetic fibers serving abdominal viscera. It is hidden in the inferior part of the lateral cervical region, posterosuperior to the subclavian vein. Corneal Reflex During a neurological examination, the examiner touches the cornea with a wisp of cotton. Facial artery: arises anteriorly from the external carotid artery, either in common with the lingual artery or immediately superior to it. Saphenous Vein Grafts the great saphenous vein is sometimes used for coronary arterial bypasses because (1) it is readily accessible, (2) a sufficient distance occurs between the tributaries and the perforating veins so that usable lengths can be harvested, and (3) its wall contains a higher percentage of muscular and elastic fibers than do other superficial veins. Breech delivery, with the umbilical cord pressed against the pelvic rim until delivery of the aftercoming head, initially seems a plausible risk factor for cerebral ischaemia, cerebral necrosis and cerebral palsy. The actions of the intrinsic laryngeal muscles are easiest to understand when they are considered as functional groups: adductors and abductors, sphincters, and tensors and relaxers. Distally, the fibrous layer attaches to the femoral neck only anteriorly at the intertrochanteric line and root of the greater trochanter. The inflammation affects primarily the tunica media, causing destruction of the elastic lamellae and inducing the formation of foreign body giant cells, a common finding wherever elastic tissue is destroyed by inflammation. On T2-weighted imaging, ischaemic zones appear as high-signal regions with a reduced diffusion coefficient.

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Anastomoses occur between the portal and systemic veins in the wall of the anal canal. They are invaginated into the roofs of the 3rd and 4th ventricles and on the floors of the bodies and inferior horns of the lateral ventricles. Muscles of face and scalp: the facial muscles play important roles as the dilators and sphincters of the portals of the alimentary (digestive), respiratory, and visual systems (oral and palpebral fissures and nostrils), controlling what enters and some of what exits from our bodies. However, its height on the wall varies considerably, and is lower when abdominal subcutaneous fat is abundant. Terminal lingual branches supply the styloglossus, hyoglossus, genioglossus, and intrinsic muscles of the tongue. Despite its gluteal innervation and shared attachment, this tensor is primarily a flexor of the thigh because of its anterior location; however, it generally does not act independently. With regard to the smooth muscle sphincters, the roles of the sympathetic and parasympathetic systems reverse, with the sympathetic system maintaining tonus and the parasympathetic system inhibiting it. The posterior compartment and the muscles within it are divided into superficial and deep subcompartments/muscle groups by the transverse intermuscular septum. The omental bursa communicates with the greater sac through the omental foramen (epiploic foramen), an opening situated posterior to the free edge of the lesser omentum (hepatoduodenal ligament). Compare this oblique position of the femurs with that of quadrupeds, in which the femurs are vertical and the knees are apart, with the trunk mass suspended between the limbs. The diagonal disposition of the femur recenters support directly inferior to the trunk (body mass) to make bipedal standing more efficient and to enable bipedal walking, in which the full weight is borne alternately by each limb. Vestigial Remnants of Embryonic Genital Ducts When the tunica vaginalis is opened, rudimentary structures may be observed at the superior aspects of the testes and epididymis. Splenectomy and Splenomegaly Repair of a ruptured spleen is difficult; consequently, splenectomy (removal of the spleen) is often performed to prevent the person from bleeding to death. The arytenoid cartilages are paired, three-sided pyramidal cartilages that articulate with the lateral parts of the superior border of the cricoid cartilage lamina. Some of the more superior fibers fan upward, bypassing the pubic tubercle 1012 and crossing the linea alba to blend with the lower fibers of the contralateral external oblique aponeurosis. The laryngeal inlet is bounded (1) anteriorly by the free curved edge of the epiglottis; (2) posteriorly by the arytenoid cartilages, the corniculate cartilages that cap them, and the interarytenoid fold that unites them; and (3) on each side by the aryepiglottic fold that contains the superior end of the cuneiform cartilage. Damage to one or more of the listed spinal cord segments or to the motor nerve roots arising from them results in paralysis of the muscles concerned. During standing, the entire weight of the upper body is transmitted through the hip bones to the heads and necks of the femora. The renal lymphatic vessels follow the renal veins and drain into the right and left lumbar (caval and aortic) lymph nodes. Concurrent enlargement of the frontal and facial regions is associated with the increase in the size of the paranasal sinuses, the air-filled extensions of the nasal cavities in certain cranial bones. The portion of the supracolic compartment of the peritoneal cavity immediately inferior to the liver is the subhepatic space. This view of the female pelvis is the one obstetricians visualize when the patient is on the examining table. The inferior two thirds of its two plate-like laminae fuse anteriorly in the median plane to form the laryngeal prominence. Ectopic pregnancies also occur idiopathically (without demonstrable or understood reason) in women, and there is increased risk in cases of faulty tubal sterilization. Femoral hernias are more common in females because of their wider pelves and smaller inguinal canals and rings. The aponeuroses then interweave with their fellows of the opposite side, forming a midline raphe (G. The left brachiocephalic vein is more than twice as long as the right brachiocephalic vein because it passes from the left to the right side, anterior to the roots of the three major branches of the arch of the aorta. The deep fascia overlying the anterior compartment is dense superiorly, providing part of the proximal attachment of the muscle immediately deep to it.

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Pleurectomy and Pleurodesis Obliteration of a pleural cavity by disease, such as pleuritis (inflammation of pleura), or during surgery. The inferior edge of this large muscle is located just superior to the gluteal fold, which contains a variable amount of subcutaneous fat. Because of the attachment of the ovarian ligaments to the uterus, the ovaries do not relocate to the inguinal region; however, the round ligament passes through the inguinal canal and disperses into the subcutaneous tissue of the anterior labium majus. Olfactory Hallucinations Occasionally olfactory hallucinations (false perceptions of smell) may accompany lesions in the temporal lobe of the cerebral hemisphere. The parasympathetic root of the celiac plexus is a branch of the posterior vagal trunk, which contains fibers from the right and left vagus nerves. Although the rolling movement of the femoral condyles during flexion and extension is limited (converted to spin) by the cruciate ligaments, some rolling does occur, and the point of contact between the femur and the tibia moves posteriorly with flexion and returns anteriorly with extension. The external circular layer of pharyngeal muscles consists of three pharyngeal constrictors: superior, middle, and inferior. The fibrous pericardium protects the heart against sudden overfilling because it is so unyielding and closely related to the great vessels that pierce it superiorly. Sensory fibers from most of the bladder are visceral; reflex afferents follow the course of the parasympathetic fibers, as do those transmitting pain sensations. The reflection of the serous pericardium around the second group of vessels defines the oblique pericardial sinus. The thoracic duct usually empties into the venous system near the union of the left internal jugular and subclavian veins-the left venous angle or origin of the left brachiocephalic vein. Endothelial damage induces aggregation of platelets, which release factors such as thromboxane A2 and adenosine diphosphate. Lymph from the upper lip and lateral parts of the lower lip drains to the submandibular lymph nodes. This selective axon lesion is almost a mirror image of the excitotoxic lesion in selective neuronal death and suggests an entirely different mechanism for pan-necrosis, not an exaggeration of the mechanism of selective neuronal necrosis. To summarize systemically, the order of the major structures in the superior mediastinum, from anterior to posterior, is (1) thymus, (2) veins, (3) arteries, (4) airway, (5) alimentary tract, and (6) lymphatic trunks. The close relationship of the spleen to the ribs that normally protect it can be detrimental when there are rib fractures. They frequently dab their eyes and mouth with a handkerchief to wipe the fluid 1954 (tears and saliva), which runs from the drooping lid and mouth. Intraperitoneal in this case does not mean inside the peritoneal cavity (although the term is used clinically for substances injected into this cavity). A posterior gastric ulcer may erode through the stomach wall into the pancreas, resulting in referred pain to the back. The transverse sinuses pass laterally from the confluence of sinuses, forming a groove in the occipital bones and the postero-inferior angles of the parietal bones. As a person ages, the skin loses its resiliency (elasticity) resulting in ridges and wrinkles in the skin perpendicular to the direction of the facial muscle fibers. A space may develop in the dural border cell layer as the result of trauma, such as a hard blow to the head (Haines, 1993, 2013). Because these are 2193 muscles of the soft palate, equalizing pressure ("popping the eardrums") is commonly associated with activities such as yawning and swallowing. The inguinal canal consists of a series of three musculo-aponeurotic arcades traversed by the spermatic cord or round ligament of the uterus (arrow). In addition to cleansing particles and irritants from the conjunctival sac, lacrimal fluid provides the cornea with nutrients and oxygen. The folds overlie thickened parts of the circular muscle layer of the rectal wall. The posterior vagal trunk supplies branches to the anterior and posterior surfaces of the stomach. Laceration or rupture of the surface of a lung (and its visceral pleura) or penetration of the thoracic wall (and its parietal pleura) results in hemorrhage and the entrance of air into the pleural cavity.

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The veins draining the inferior surface of the diaphragm are the inferior phrenic veins. The left subclavian artery arises from the arch of the aorta, about 1 cm distal to the left common carotid artery. The more the person strains, the more the valve-like prostatic mass obstructs the urethra. Clinically, the internal carotid arteries and their branches are often referred to as the anterior circulation of the brain. The size of the hydrocele depends on how much of the processus vaginalis persists. Lymphatic Drainage of Lower Limb the lower limb has superficial and deep lymphatic vessels. Because of their proximity to the gallbladder, the superior part of the duodenum and the transverse colon are most likely to develop a fistula of this type. While the pattern of segmentation described here is the most common pattern, the segments vary considerably in size and shape as a result of individual variation in the branching of the hepatic and portal vessels. The suprarenal lymphatic vessels arise from a plexus deep to the capsule of the gland and from one in its medulla. Because the ovary is suspended in the peritoneal cavity and its surface is not covered by peritoneum, the oocyte expelled at ovulation passes into the peritoneal cavity. During protrusion and retrusion of the mandible, the head and articular disc slide anteriorly and posteriorly on the articular surface of the temporal bone, with both sides moving together. Increased concentrations of antibodies against phosphatidylserine and ribosomal phosphoproteins have been described but the pathogenesis is unclear. Although early stroke case fatality has decreased in both high-income and low- to middle-income countries, over the past decade early stroke fatality has been 25 per cent greater in the latter than the former group. The bulb of the vestibule and erectile bodies of the clitoris receive parasympathetic fibers via cavernous nerves from the uterovaginal nerve plexus. In both views, the strong perineal membrane is the inferior boundary (floor) of the deep pouch, separating it from the superficial pouch. Moderate and severe traumatic brain injury: epidemiologic, imaging and neuropathologic perpectives. Attempting to approach this "straight line" position as much as possible facilitates passage of a catheter or other transurethral device. The main features of the neurocranial part are the temporal fossa, the external acoustic meatus opening, and the mastoid process of the temporal bone. Care must be taken during high abdominal (laparotomy) incisions, to avoid injuring or cutting the xiphoid process. If the tracheobronchial lymph nodes in the angle between the main bronchi are enlarged because cancer cells have metastasized from a bronchogenic carcinoma, for example, the carina is distorted, widened posteriorly, and immobile. This image at the L1 vertebral level demonstrates an enlarged right kidney 1388 with a dilated intrarenal collecting system (blue arrow). This fluid leaves the ventricular system and enters the subarachnoid space between the arachnoid and pia mater, where it cushions and nourishes the brain. This shock causes cessation of all cardiac movements, and a few seconds later, the heart may begin to beat more normally. The size and appearance of the vaginal orifice vary with the condition of the hymen, a thin anular fold of mucus membrane, which partially or wholly 1517 occludes the vaginal orifice. Other common causes are emboli detaching from thrombi formed on damaged or prosthetic valves (10 per cent) or cardiomyopathy and ventricular aneurysm (7. The bicipitoradial bursa (biceps bursa) separates the biceps tendon from, and reduces abrasion against, the anterior part of the radial tuberosity. Such an abscess may be palpated or observed in the inguinal region, just inferior or superior to the inguinal ligament, and may be mistaken for an indirect inguinal hernia or a femoral hernia, an enlargement of the inguinal lymph nodes, or a saphenous varix. They are also used to stabilize the stance when standing on both feet, to correct a lateral sway of the trunk, or when there is a side-to-side shift of the surface on which one is standing (rocking a boat, standing on a balance board). Whether this part of the muscle compresses or dilates the prostatic urethra is a matter of some controversy. They pass through tiny foramina in the cribriform plate of the ethmoid bone, surrounded by sleeves of dura mater and arachnoid mater, and enter the olfactory bulb in the anterior cranial fossa. The terms pelvis, lesser pelvis, and pelvic cavity are commonly used incorrectly, as if they were synonymous terms. The transverse dimension of the thorax also increases slightly when the intercostal muscles contract, raising the middle (lateralmost parts) of the ribs (especially the lower ones)-the bucket-handle movement.