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By: J. Eduardo Calonje, MD, DipRCPath

  • Director of Diagnostic Dermatopathology, Department of Dermato-Histopathology, St John's Institute of Dermatology, St Thomas' Hospital, London, UK

The proximal attachments of the three palmar interossei are indicated by the letter P; those of the four dorsal interossei are indicated by color only medications causing thrombocytopenia 500 mg secnidazole with visa. At the wrist treatment plant proven 500 mg secnidazole, the radial artery is lateral to symptoms e coli buy secnidazole 500mg with mastercard the flexor carpi radialis tendon medicine quetiapine secnidazole 500 mg, and the ulnar artery is lateral to flexor carpi ulnaris tendon. In the forearm, the radial artery lies between the flexor and extensor compartments. The muscles lateral to the artery are supplied by the radial nerve, and those medial to it by the median and ulnar nerves; thus, no motor nerve crosses the radial artery. The brachioradialis muscle slightly overlaps the radial artery, which is otherwise superficial. The four superficial muscles (pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris) all attach proximally to the medial epicondyle of the humerus (common flexor origin). The palmaris longus muscle, in this specimen, has an anomalous distal belly; this muscle usually has a small belly at the common flexor origin and a long tendon that is continued into the palm as the palmar aponeurosis. The ulnar artery passes obliquely posterior to the flexor digitorum superficialis; at the medial border of the muscle, the ulnar artery joins the ulnar nerve. The ulnar nerve lies between the flexor digitorum profundus and flexor carpi ulnaris. The median nerve descends vertically posterior to the flexor digitorum superficialis and appears distally at its lateral border. The median artery of this specimen is a variation resulting from persistence of an embryologic vessel that usually disappears. The ulnar nerve enters the forearm posterior to the medial epicondyle, then descends between the flexor digitorum profundus and flexor carpi ulnaris and is joined by the ulnar artery. At the wrist the ulnar nerve and artery pass anterior to the flexor retinaculum and lateral to the pisiform to enter the palm. At the elbow, the ulnar nerve supplies the flexor carpi ulnaris and the medial half of the flexor digitorum profundus muscles; superior to the wrist, it gives off the dorsal (cutaneous) branch. The biceps brachii muscle attaches to the medial aspect of the radius; hence, it can supinate the forearm, whereas the pronator teres muscle, by attaching to the lateral surface, can pronate the forearm. The anterior interosseous nerve and artery disappear between the flexor pollicis longus and flexor digitorum profundus muscles to lie on the interosseous membrane. The incision crosses the pisiform, to which the flexor carpi ulnaris muscle attaches, and the tubercle of the scaphoid, to which the tendon of flexor carpi radialis muscle is a guide. The palmaris longus tendon bisects the transverse skin crease; deep to its lateral margin is the median nerve. The radial artery passes deep to the tendon of the abductor pollicis longus muscle. The flexor digitorum superficialis tendons to the 3rd and 4th digits become anterior to those of the 2nd and 5th digits. The recurrent branch of the median nerve to the thenar muscles lies within a circle whose center is 2. Lacerations of the wrist often cause median nerve injury because this nerve is relatively close to the surface. Hence opposition of the thumb is not possible and fine control movements of the 2nd and 3rd digits are impaired. 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. The ability to flex the metacarpophalangeal joints of these digits is also affected because digital branches of the median nerve supply the 1st and 2nd lumbricals. The palmar cutaneous branch of the median nerve does not traverse the carpal tunnel. It supplies the skin of the central palm, which remains sensitive in carpal tunnel syndrome. Dupuytren contracture is a disease of the palmar fascia resulting in progressive shortening, thickening, and fibrosis of the palmar fascia and palmar aponeurosis. The fibrous degeneration of the longitudinal digital bands of the aponeurosis on the medial side of the hand pulls the 4th and 5th fingers into partial flexion at the metacarpophalangeal and proximal interphalangeal joints. Treatment of Dupuytren contracture usually involves surgical excision of all fibrotic parts of the palmar fascia to free the fingers. Transverse section through the middle of the palm showing the fascial compartments for the musculotendinous structures of the hand.

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The perineal branches of S3 and S4 supply levator ani symptoms for bronchitis discount secnidazole 500mg free shipping, along with branches from the pudendal nerve (S2 treatment 5th metatarsal fracture secnidazole 500 mg with mastercard,3 symptoms diarrhea secnidazole 500mg on-line,4) medications on backorder purchase 500 mg secnidazole. Tears may need to be sutured, and pelvic floor exercises become necessary to rebuild supportive muscle tone. Laxity of the pelvic floor may allow the pelvic organs to slip from their normal anatomical positions, possibly compromising urinary control, leading to incontinence. In extreme cases the pelvic organs may prolapse into and even right out of the vagina. Perineum the diamond-shaped perineum is bounded by: the ischial tuberosities (12), covered by obturator internus and obturator fascia; the sacrotuberous ligaments (13); the ischiopubic rami (14); and the inferior end of the pubic symphysis. The ischio-anal fossa (15) is a pyramid with its base covered by skin, its lateral aspect formed by obturator fascia, and its medial aspect formed by levator ani and the anal canal surrounded by its external sphincter. The pudendal neurovascular bundle (16) of internal pudendal artery and vein, and the pudendal nerve (S2,3,4), leaves the pelvis to enter the buttock by passing between piriformis (17) and coccygeus. The inferior rectal neurovascular bundle (18) arises high up in the fossa and runs on levator ani to supply the anal sphincter and sensation to the anal canal. Such an abscess may extend forward into a recess between the pelvic floor and the deep perineal pouch, the anterior recess of the ischio-anal fossa. The external urethral sphincter and the deep transverse perineal muscles that help fix and stabilize the structures within the region, lie above it. The fascia on the superior surface of these muscles forms the deeper, superior layer of the pouch. The superficial perineal pouch is inferior or superficial to the perineal membrane and contains the external genitalia. The scrotum houses both testes, so that they lie outside the body cavity, at a slightly lower temperature. The skin is rugose (2), darker than skin elsewhere and is covered with pubic hair. There is a midline raphe, which stops at the anus (3), but continues with the raphe on the ventral surface of the penis. It contains dartos muscle (4) that contracts during cold or exercise to raise the testes closer to the body (see p. The labia majus (5) are thick folds of skin that meet anteriorly over the pubic symphysis as the mons pubis (6). The thickness of each labium is created by fibro-fatty tissue, into which the round ligament of the uterus inserts. Vascular supply is via the external pudendal arteries and veins anteriorly, and the posterior scrotal or labial branches of the internal pudendal arteries and veins posteriorly. Scrotal and labial nerve supply is also divided into the anterior third and posterior two-thirds. The posterior scrotal or labial branches of the pudendal (S2,3,4) and the perineal branches of the femoral cutaneous nerve of the thigh (S2,3) are posterior. The labia minora are thin, fat-free folds of pink, moist skin that lie within, and hidden by the labia majora. Anteriorly they split into lateral and medial folds, which fuse with those from the opposite side to form the prepuce of the clitoris (8). The vaginal vestibule, between the labia minora, is covered by similar pink, moist skin. The vaginal opening (9) is small in the young and incompletely closed by the hymen. Such closure may only become apparent at puberty with the commencement of menstruation. Once the hymen has been ruptured it is visible only as a few folds of skin, the carunculae hymenales, at the vaginal opening. The slit-like urethral opening (10) is immediately anterior to the vaginal opening. They are attached to the superficial surface of the perineal membrane, meeting only in an anterior commissure in front of the urethra. Hidden under the posterior end of each bulb is a greater vestibular (Bartholin) gland (13) that opens into the vaginal opening or the immediately adjacent vestibule. These secrete lubricating mucus and are aided by para-urethral and lesser vestibular glands, whose secretions reach the vestibule via minute ducts. Branches of the internal pudendal artery and equivalent veins supply the structures between the labia majora.

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Interactions of Skeletal Muscles symptoms 3 days past ovulation discount 500 mg secnidazole, Their Fascicle Arrangement medications prescribed for pain are termed safe 500mg secnidazole, and Their Lever Systems To move the skeleton medications are administered to cheap secnidazole 500 mg free shipping, the tension created by the contraction of the fibers in most skeletal muscles is transferred to medications related to the blood buy generic secnidazole 500mg line the tendons. The tendons are strong bands of dense, regular connective tissue that connect muscles to bones. Interactions of Skeletal Muscles in the Body To pull on a bone, that is, to change the angle at its synovial joint, which essentially moves the skeleton, a skeletal muscle must also be attached to a fixed part of the skeleton. During forearm flexion-bending the elbow-the brachioradialis assists the brachialis. To lift a cup, a muscle called the biceps brachii is actually the prime mover; however, because it can be assisted by the brachialis, the brachialis is called a synergist in this action (Figure). The brachoradialis, in the forearm, and brachialis, located deep to the biceps in the upper arm, are both synergists that aid in this motion. Antagonists play two important roles in muscle function: (1) they maintain body or limb position, such as holding the arm out or standing erect; and (2) they control rapid movement, as in shadow boxing without landing a punch or the ability to check the motion of a limb. Muscle Shapes and Patterns of Fascicle Organization Skeletal muscle is enclosed in connective tissue scaffolding at three levels. Each muscle fiber (cell) is covered by endomysium and the entire muscle is covered by epimysium. When a group of muscle fibers is "bundled" as a unit within the whole muscle by an additional covering of a connective 276 tissue called perimysium, that bundled group of muscle fibers is called a fascicle. Fascicle arrangement by perimysia is correlated to the force generated by a muscle; it also affects the range of motion of the muscle. Based on the patterns of fascicle arrangement, skeletal muscles can be classified in several ways. Parallel muscles have fascicles that are arranged in the same direction as the long axis of the muscle (Figure). Some parallel muscles are flat sheets that expand at the ends to make broad attachments. Muscles that seem to be plump have a large mass of tissue located in the middle of the muscle, between the insertion and the origin, which is known as the central body. When a muscle contracts, the contractile fibers shorten it to an even larger bulge. For example, extend and then flex your biceps brachii muscle; the large, middle section is the belly (Figure). When a parallel muscle has a central, large belly that is spindle-shaped, meaning it tapers as it extends to its origin and insertion, it sometimes is called fusiform. Muscle Shapes and Fiber Alignment the skeletal muscles of the body typically come in seven different general shapes. Tendons emerge from both ends of the belly and connect the muscle to the bones, allowing the skeleton to move. This system reflects the bones of the skeleton system, which are also arranged in this manner. Some of the axial muscles may seem to blur the boundaries because they cross over to the appendicular skeleton. The first grouping of the axial muscles you will review includes the muscles of the head and neck, then you will review the muscles of the vertebral column, and finally you will review the oblique and rectus muscles. There are several small facial muscles, one of which is the corrugator supercilii, which is the prime mover of the eyebrows. Raise your eyebrows as if you were surprised and lower your eyebrows as if you were frowning. The insertions of these muscles have fibers intertwined with connective tissue and the dermis of the skin. Because the muscles insert in the skin rather than on bone, when they contract, the skin moves to create facial expression (Figure). A large portion of the face is composed of the buccinator muscle, which compresses the cheek. This muscle allows you to whistle, blow, and suck; and it contributes to the action of chewing.

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Force transmission across the radiocapitellar articulation takes place at all angles of elbow flexion and is greatest in full extension symptoms 9 dpo 500 mg secnidazole mastercard. Full rotation of the head of the radius requires accurate anatomic positioning in the lesser sigmoid notch medications with acetaminophen purchase 500 mg secnidazole with visa. The radial head plays a role in valgus stability of the elbow symptoms for pregnancy order secnidazole 500 mg overnight delivery, but the degree of conferred stability remains disputed treatment atrial fibrillation cheap secnidazole 500 mg with amex. The radial head is a secondary restraint to valgus forces and seems to function by shifting the center of varus-valgus rotation laterally, so the moment arm and forces on the medial ligaments are smaller. Clinically, the radial head is most important when there is injury to both the ligamentous and muscle-tendon units about the elbow. The radial head acts in concert with the interosseous ligament of the forearm to provide longitudinal stability. Proximal migration of the radius can occur after radial head excision if the interosseous ligament is disrupted. This may occur with a pure axial load, with a posterolateral rotatory force, or as the radial head dislocates posteriorly as part of a posterior Monteggia fracture or posterior olecranon fracture-dislocation. It is frequently associated with injury to the ligamentous structures of the elbow. Well-localized tenderness overlying the radial head may be present, as well as an elbow effusion. Aspiration of the hemarthrosis through a direct lateral approach with injection of lidocaine will decrease acute pain and allow evaluation of passive range of motion. A Greenspan view is taken with the forearm in neutral rotation and the radiographic beam angled 45 degrees cephalad; this view provides visualization of the radiocapitellar articulation. Nondisplaced fractures may not be readily appreciable, but they may be suggested by a positive fat pad sign (posterior more sensitive than anterior) on the lateral radiograph, especially if clinically suspected. Complaints of forearm or wrist pain should be assessed with appropriate radiographic evaluation. Computed tomography of the elbow may be utilized for further fracture definition for preoperative planning, especially in cases of comminution or fragment displacement. Symptomatic management consists of a sling and early range of motion 24 to 48 hours after injury as pain subsides. Aspiration of the radiocapitellar joint with or without injection of local anesthesia has been advocated by some authors for pain relief. Chapter 20 Radial Head 253 Persistent pain, contracture, and inflammation may represent capitellar fracture (possibly osteochondral) that was not appreciated on radiographs and can be assessed by magnetic resonance imaging. A relative indication is displacement of a large fragment 2 mm without a block to motion. A Kocher exposure can be used to approach the radial head; one should take care to protect the uninjured lateral collateral ligament complex. Hardware should be placed only within the 90-degree arc between the radial styloid and Lister tubercle (safe zone). The anterolateral aspect of the radial head is usually involved and is readily exposed through these intervals. After the fragment has been reduced, it is stabilized using one or two small screws. Partial Radial Head Fracture as Part of a Complex Injury Partial head fragments that are part of a complex injury are often displaced and unstable with little or no soft tissue attachments. Open reduction and internal fixation may be performed when stable, reliable fixation can be achieved. In an unstable elbow or forearm injury, it may be preferable to resect the remaining intact radial head and replace it with a metal prosthesis. Fractures Involving the Entire Head of the Radius When treating a fracture-dislocation of the forearm or elbow with an associated fracture involving the entire head of the radius and/or radial neck, open reduction and internal fixation should only be considered a viable option if stable, reliable fixation can be achieved. The optimal fracture for open reduction and internal fixation has three or fewer articular fragments without impaction or deformity, each should be of sufficient size and bone quality to accept screw fixation, and there should be little or no metaphyseal bone loss. Smith and Hotchkiss defined it based on lines bisecting the radial head made in full supination, full pronation, and neutral.

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