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1) A 46 yr. old male is admitted to the ER after a motorcycle accident. A ruptured spleen is suspected.  Where might abdominal imaging reveal pooled fluid from this rupture?
Spleen is embedded in foregut mesentery.  Hemmorhage can pool along gastrosplenic ligament, splenorenal (leinorenal) ligament, lesser omentum, and can distend subphrenic space. CT imaging modality of choice Plain film radiographs may show:
      1. Displaced gastric bubble
      2. Elevated hemi-diaphram
2) This same patient also sustained severe lacerations to the left kidney with hemorrhage.  Surgical technicians are prepping the patient for a left renal nephrectomy. 1) Where would blood pool from this injury? 2) What approach will most likely be used by the surgeon? 3) What structures will be incised or reflected during the procedure?
1) Where would blood pool from this injury? Retroperitoneal area– kidney capsule 2) What approach will most likely be used by the surgeon? Loin (flank) approach, table flexed, with kidney bar raised under 12 rib if necessary 3) What structures will be incised or reflected during the procedure? Obliques incised from lateral rectus to under 12th rib. Subcutaneous and fascial layers cut, including “Gerota’s fascia”. Laproscopic (intraperitoneal) approach used less frequently.
3) CLINICALLY IMPORTANT RELATIONS/ Psoas major muscle and sheath related to vertebral bodies and intervertebral discs.  Psoas absess can form along entire sheath from invasion of vertebral pathogens.
Psoas absess are often caused by micobacterium teberculoses which love to live in the blood of vertebrae (low The body in response will sometimes block off the bacterial with calcium walls blocking it from the body.  However, you can trigger the release or breakdown of that calcium wall which leads to a bacterial infection that spreads into the aponeurosis of the Psoas major muscle. The infection will spred down into the femoral area and create an absesses
4) A 54 yr. old male is admitted to the ER with lower back pain 6/10. Routine lateral abdominal radiograph to assess for disc space narrowing in this patient reveals pronounced scalloping of anterior lumbar vertebral bodies.  What is the next logical step?
Aortic aneurysm can cause resorptive changes on abdominal and thoracic vertebral bodies, due to the direct relationship of these structures.  Intervertebral discs are not subject to this; therefore, the appearance is “scalloped” in lateral view.
5) A 29 year old female intravenous drug user, HIV positive, presents with severe right lumbar pain 8/10.  A hard mass 2 x 3 cm is present in the right inguinal area.  Antibody and blood culture are positive for Mycobacterium tuberculosis infection.
  • What might be the proximal cause of these symptoms?
  • What fascial plane and mm. are in communication with sub-inguinal area?
  • Which of these are also present in the lumbar area?
Psoas absess, where pus and infectious material moves along psoas sheath.  This is communicated from the vertebral reservior of Mycobacterium tuberculosis  in spinal TB.
6) A 28 year old female presents with severe abdominal pain 8/10 and vaginal spotting.  A urine screening for HCG reveals she is pregnant but has not sought prior prenatal care.  Ultrasound reveals conceptus in fallopian tubes. What is the prognosis?
Iliac fossa abdominal pain, positive pregnancy test & lack of ultrasound evidence of conceptus in uterus indicate tubal pregnancy. Pain may indicate tubal rupture.  Surgery will address repair or excise unterine tube and remove conceptus.
  • Extrauterine (ectopic) pregnancy can occur when the fertilized oocyte is not swept into uterine tube.  Capillary beds of peritoneal cavity, particularly the posterior greater omentum and intestinal mesenteries can be co-opted by developing embryo, which can persist and develop outside the uterus for several months.
  • Tubal pregnancy is when implantation occurs in the uterine tube.  This is a life-threatening condition, as rupture of the tube can cause hemorrhage and maternal death.
  • As a result of the uterine tube opening into peritoneal cavity, infection and inflammation can spread from uterus and uterine tubes into pelvic peritoneal cavity.  This can be the route for disseminated pelvic inflammatory disease, a chronic condition.
7) Uterine fibroids (myomas, leiomyoma) – benign tumors
Endometriosis – “escaped” endometrial tissue (Peritoneal Endometriosis)
8) Routine ultrasound of abdomen of 35 year old female at 14 weeks gestation reveals a bicornate uterus, with the embryo implanted in one cornua.  What causes this malformation and what are the prospects for a normal gestation & birth?
Developmental incomplete union of the paramesonephic (Mullerian) ducts causes a bicornate uterus.
  • Incidence of congenital uterine anomalies: difficult to determine since many are, asymptomatic & undiagnosed.
  • Uterine anomalies occur in 2 to 4 percent of fertile women with normal reproductive outcomes.
  • The prevalence is higher among women with adverse reproductive outcomes (5-25%).
  • Pregnancy outcomes have been reported to be close to those of the general population. However, some women do develop complications, such as pregnancy loss, preterm labor, or malpresentations Surgical treatment requires uterine reunification through a laparotomy.
9) Loss of IHP means loss of continence and bladder control
10) A 77 year old female patient presents with visibly enlarged irregular veins running cranial to caudal on the abdomen to chest. These include enlarged branches of the superficial inferior epigastric vv.   No venous radiation is seen surrounding the umbilicus.  What could be the cause of this phenomenon?
No umbilical radiation lowers the likelihood of portal v. obstruction.  However, a blocked IVC – as with thrombosis – will cause hypertrophy in collateral pathways, like in this case.
11) A 74 year old male presents with diffuse lower back pain and sacroiliac pain of several months duration.  Initial onset of symptoms was “several” years ago, but pain has become more intense with time. PE shows lumbar mobility is greatly reduced.  Radiographs shows ankylosis of both SI joints. What is your diagnosis?
Fusion of the Sacroiliac joints is an early stage of the disease Ankylosing spondylitis.  The ligaments crossing spinal joints, particulary the sacro-iliac joing and the anterior longitudinal ligament in the lumbar, are particulary susceptable.  The cause is unknown, although thought to be immune-related, as it is assocIated with HLA B27 major histocompatability complex antigen.  It is most prevalent in men of Northwest European origin and is frequently subclinical. SI biopsies/autopsies reveal subchondral granulation tissue, scattered areas of new cartilage formation, and osteitis [as well as synovitis and enthesitis, including pannus formation, myxoid marrow, superficial cartilage destruction, intra-articular fibrous strands, new bone formation, and bony ankylosis.  Biopsies have also been obtained using computed tomographic (CT) guidance and magnetic resonance imaging. They reveal dense cellular infiltrates with approximately 50 percent T lymphocytes, consisting of both CD4+ and CD8+ cells
12) A 32 year old female, 4 weeks post-partum with normal labor and delivery, presents with extreme pain and soreness of the right “hip”.  She states that she cannot get up off the floor because of the pain on her rt. anterior thigh.  She points to an area overlying tensor fascia lata and over the right sacroiliac joints as being the most painful.  What is the likely cause of these symptoms?  What is a possible treatment?
Skeletal examination revealed a sacral torsion, a mal-alignment of the right sacro-iliac joint.  Relaxin is secreted late in pregnancy to allow pelvic ligaments to stretch during birth.  As the sacro-iliac joint  returns to its pre-oartum state, malalignment can occur.  This torsion caused abnormal stresses across the anterior pelvis, and the tensor fascia lata muscle was stretched and painful.
13) A 23 year old female with her 1st pregnancy at 32 weeks, is concerned that she is too “small-boned” to have her baby vaginally.  What can be done to check that her pelvic dimensions will suffice?
Manual determination by examination is typically sufficient to determine whether adequate skeletal room exists for the fetal head to pass.
14) The ilio-inguinal nerve is commonly encountered in open inguinal hernia operations, and should be carefully preserved.
Division of the nerve results in numbness in the area of cutaneous supply. Entrapment with fibrous tissue or prosthetic mesh sometimes leads to inguinal post-operative pain.
15) A 29 year old female presents with the complaint of “wetting herself” when she coughs or lifts her baby, causing her obvious distress.  Hx reveals that she is 5 months post-partum, having a normal vaginal delivery of a 9 lb 2 ounce boy.  She wonders if something is wrong with her urethra, and whether the drugs she saw advertised on television might help.
The diagnosis is most likely urinary stress incontinence, secondary to birth trauma.  The drugs she saw advertised on TV are likely those targeting “Urge incontinence” -- an overactive detrusor muscle of the bladder.  The patient’s problem may stem from neuromuscular damage to pelvic diaphram and perhaps urethral sphincter due to the vaginal birth.  Time, “Kegel” exercises and potentially surgery are treatment options. SUI is associated with post-partum neuromuscular  damage
  • Levator ani and coccygeus muscles major role.
  • EMG recordings of rt. /lft. pubococcygeus muscles (N=8) with stress incontinence and ten controls found that childbirth was associated with asymmetric muscle injury resulting in both qualitative and quantitative changes.
  • Some muscle function was lost and the remaining muscle did not function normally.
  • Contraction strength of the levator ani muscles is related to their cross sectional area.
  • Nerve damage associated with vaginal delivery can cause atrophy of the levators with a decrease in their cross sectional area. (Kegel exercises)
  • Urethral sphinchter not implicated.  EMG studies have not shown that denervation or reinnervation of the urethral sphincter correlates with changes in post-partum SUI.
  • The position of the bladder neck is significantly lower at rest in women who have had a vaginal delivery compared to those who had an elective cesarean delivery or in nulligravid controls
  • Bladder neck mobility with coughing and Valsalva may also be affected due to pregnancy and delivery related changes to the pelvic floor, such as connective tissue defects or neuromuscular changes. One study of 169 nulliparous women examined by ultrasound in the first/early second trimester, late third trimester, and then two to five months postpartum found a correlation between delivery characteristics and mobility of the urethra, bladder neck, posterior bladder wall, cervix, and rectal ampulla/anterior rectal wall on Valsalva.
  • Vaginal delivery resulted in significant prolongation of the mean pudendal nerve terminal motor latencies (PNTML) and an increase in perineal descent during straining. PNTML were not altered after elective cesarean delivery. Labor, large birth weight, and a longer second stage of labor were also associated with significant prolongation of PNTML. However, eight of 12 women with a prolonged PNTML at six weeks postpartum had normal measurements when restudied six months after delivery
16)  A 34 year old male is brought to the ER after a bicycling accident with pain of 7/10.  Hx reveals he fell forcefully onto the bar of his bike.  His scrotum, base of penis and anterior abdominal wall are warm and appear distended.  What structure has likely been damaged?
The urethra has likely been ruptured.  Extravasation of urine and blood into the deep perineal space can occur from an injury to the membranous urethra.  Lacerating the bulb of the penis can leak these fluids into the superficial perineal space.  This is known as a straddle injury.  It can also occur from improper catheterization.
17)  A 29 year old male, 6’1” 225 lb presents with severe hip pain and loss of mobility.  Patient Hx reveals that he suffered a hip injury while being tackled during the Raiders' playoff victory over the Cincinnati Bengals six months previous.    MRI reveals distinct signs of necrosis on the anterior superior portion of the femoral head.  What is the likely scientific mechanism underlying the finding of necrosis?
Bo Jackson, Heisman trophy winner (injured 1991). Trauma to hip most likely damaged medial circumflex femoral vessels. Hip replacement surgery followed and precipitated end of football and baseball careers.
18)  A 42 year old male, 5’10”, 280 lbs presents with lower back pain 7/10 and sciatica.  PH unremarkable.  PE reveals negative Pace’s sign.  Radiograph is suggestive of both L3/L4 and L4/L5 disc space narrowing.  What simple physical exam can you perform to further determine if spinal root impingement is behind the symptoms?
Nerve roots impinged by these discs could include L4 and L5.
  • Inversion of foot will test L4
  • Extension of big toe will test L5.
19) A 34 year old female presents in the ER from minor motocross accident with rt. knee pain and difficulty walking.  You observe foot slap when she walks into the examining room.  Radiographs reveal broken right proximal fibula.  What might account for her locomotor symptoms?
Foot slap – forced plantar flexion -- is controlled by the tibialis anterior m.  If the deep peroneal nerve is damaged, it impairs this muscle and “foot slap” can result.
20) Unfortunate MS-II finds himself on crutches after skateboarding accident. He reveals that he experienced a severe inversion sprain of the left ankle and that a bone was fractured by the force of muscle tendon’s pull.  What is the muscle and where is the fracture?
Inversion IS limited in most people by the length of peroneus brevis; therefore, evulsion fracture of 5th metatarsal common in cases of forcible inversion
21) A 52 year old male presents with left posterior hip & leg pain of three days duration.  The pain is described as “shooting” down the back of the thigh.  Patient Hx reveals a fall prior to onset of symptoms.  Radiograph reveals no hip fractures or narrowing of intervertebral disc spaces in lumbar region.  Forced internal (medial) rotation results in exacerbation (increase) in pain.  What is the most likely cause for the patient’s symptoms?
? Piriformis Syndrome ?
  • Evolving compression of the sciatic nerve by the piriformis muscle.
  • Associated with acute trauma to the buttock
  • Sitting difficult and participation in activities where hip flexion or internal rotation is required, almost impossible.
  • Pain in sciatic nerve distribution can be provoked by forced internal rotation of the extended thigh (Pace’s sign)
  • Physical examination: tenderness directly over the piriformis tendinous or in the gluteal area, and the pain can be listed by forced internal rotation of the extended thigh – this is sometimes called ‘Pace’s sign’.  There is sometimes weak abduction against resistance or external rotation against resistance, and the pain may also be reproduced by rectal or vaginal examination.
  • Treatment involves rest and oral anti-inflammatory drugs.  The diagnosis can also be confirmed by the injection of local anesthetic under fluoroscopy into the area of injury.  Steroid injection may occasionally be necessary.  In refractory cases, surgical exploration of the piriformis and/or division of the piriformis muscle and/or mobilization of the sciatic nerve may be necessary.
The piriformis syndrome is thought to be due to irritation of the sciatic nerve as it passes over the piriformis tendon.  This causes buttock pain and sciatica.  The pain can be reproduced by applying pressure to the piriformis fossa on the posterior aspect of the greater trochanter and by stressing the piriformis muscle.
22) A 17 year old female is brought to the ER with left knee pain 6/10 and edema.  Hx reveals that she had been injured in a soccer game 3 hours previous, when an opposing player slide into her extended supporting leg from the front.  Patient heard a “pop” and fell.  She is able to walk, but with considerable discomfort.  Radiograph is unremarkable except for edema.  What structure(s) are most likely to be damaged?
The anterior cruciate ligament is most likely to be damaged in this scenerio, as the blow descibed would have cause posterior tranlation of the femur on a fixed tibia.  Along with an ACL tear, the medial meniscus and the medial collateral ligament are commonly injured.
23) A fashionable 14 year old girl is admitted to the ER with ankle pain 10/10.  Hx reveals that she “fell” off her platform shoes while dancing, EVERTING her foot.  What structures were most likely compromised?
More unusual than an inversion injury, this eversion could result in a tear of the deltoid ligament, especially posterior tibiotalar and tibiocalcaneal portions.  In this instance, the distal fibula is often broken transversely as well.
24) A 63 year old female presents with a greatly enlarged bump on the medial aspect of her 1st metatarsal/phalangeal joint.  Colloquially, this is termed a bunion, and prevents the patient from wearing most of her closed-toe shoes.  What is the basic scientific mechanism for its etiology?
Hallux varus, due to forced adduction of great toe and /or weakness of transverse ligaments of metatarsal heads. As distal phalanx pushes in, it forces the MTP joint “out”.
25) PE of a 34 year old male patient complaining of lower back pain reveals “fallen arches” in the feet.  What structure is compromised and what action cann be taken to improve the situation?
EXTRAS: Testicles and the ovaries both drain into the lumboaortic and pelvic lymph nodes.  This is why metastisizing testicular cancer is so dangerous- it travels all the way up near the celiac plexus and the thoracic duct—this is right near the nerve plexus of the body
CLINICAL NOTES: Fertilization occurs immediately after ovulation, high in uterine tube at or near fimbriae.  Extra-uterine (ectopic) pregnancy can occur when the fertilized oocyte is not swept into uterine tube.  Capillary beds of peritoneal cavity, particularly the posterior greater omentum and intestinal mesenteries can be co-opted by developing embryo, which can persist and develop outside the uterus for several months.  Tubal pregnancy is when implantation occurs in the uterine tube.  This is a life-threatening condition, as rupture of the tube can cause hemorrhage and maternal death.   As a result of the uterine tube opening into peritoneal cavity, infection and inflammation can spread from uterus and uterine tubes into pelvic peritoneal cavity.  This can be the route for disseminated pelvic inflammatory disease, a chronic condition.
The vagina does not extend into the uterus.  Notice that the pink area of the cervix projects down into the vagina.  The cervix runs from the External Os to the Internal Os ~3-5 cm long normally.  As labor progresses the uterus will contract and the cervix will stretch out.  You will messure efacement-the shortening of the cervix length.  The dialation of the Os will tell you how close to birth you are.
SEE SLIDE 23 from Thursday 9/20à  Peritoneal Pouches in genitalia area In this area we have all of the peritoneal reflections-if you have peritoneal bleeding in men it will pool in the rectovesical pouch which is the deepest area The wall between the vaginal fornix and the rectouterine pouch is very thin.  This is why home abortions are so dangerous-if you poke through the vaginal wall at that angle you will not penetrate the uterus you would instead go through into the rectum through the rectouterin pouch this can allow the spread of infection throughout the peritoneum and between the uterus an dthe rectum and vagina.  Not good
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