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CHAPTER 2 The Abdomen, Pelvis and Perineum
61
OSCE Scenario 2.3
A 40-year-old female has had two attacks of acute cholecystitis and has recently had an attack of biliary colic. She has
been admitted for laparoscopic cholecystectomy.
1. Describe biliary colic. What causes it?
2. What is Calot’s triangle?
1. Describe your initial management of this patient?
2. What are the potential options for treating bleeding
duodenal ulcers?
3. Which vessel is most commonly involved in bleeding
duodenal ulcers—describe its anatomy?
4. Name three other causes of upper GI bleeding.
3. Why is a knowledge of the structures in the free edge
of the lesser omentum important while performing gall
bladder surgery?
4. What may result from the close relationship between
the fundus of the gall bladder and the duodenum?
5. Gangrene of the gall bladder with perforation is rare,
even if the cystic artery has thrombosed. Why?
OSCE 2.5
A 62-year-old male presents to his GP with weight loss,
abdominal pain, jaundice and a palpable gallbladder. He
has dark urine and pale stools.
1. What are three potential causes for his jaundice?
2. What is Courvoisier’s Law?
3. What would you expect to see on the liver function
OSCE 2.4
tests?
A 78-year-old male is brought into the Accident and
Emergency department with a history of a sizeable fresh
Answers in Appendix pages 433–436
blood haematemesis. He has a history of peptic ulcer disease. He is hypotensive and tachycardic.
Please check your eBook at https://studentconsult.inkling.com/ for more self-assessment questions. See inside cover for
registration details.
3
Coracoid process
Acromion
Supraspinous
Superior angle
Acromion
Glenoid
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The Upper Limb and Breast
THE PECTORAL GIRDLE
e pectoral girdle consists of two bones:
• Clavicle.
• Scapula.
ese are joined to:
• e axial skeleton at the sternoclavicular joint.
• Each other at the acromioclavicular joint.
THE BONES OF THE UPPER LIMB
Scapula (Fig. 3.1)
• Extends from the second to the seventh ribs posteriorly
(when arm is by the side).
• Spine, acromion and coracoid process are easily
palpable.
• e glenoid fossa laterally contributes to the shoulder
joint.
• Rotation of the scapula is required in full abduction of
the limb.
Scapular notch
Superior
angle
fossa
Spine of
scapula
• Strong muscular coverings protect the scapula and
fracture is rare, requiring direct and severe violence.
Clavicle
• Medial two-thirds convex anteriorly and circular in
cross section.
• Lateral third convex posteriorly and attened in cross
section.
• Articulates medially at the sternoclavicular joint (articular disc in joint).
• Attached to the rst costal cartilage by the costoclavicular ligament.
• Articulates laterally with acromion at the acromioclavicular joint (incomplete articular disc in joint).
• Attached to the coracoid process by tough coracoclavicular ligament.
• It has no medullary cavity.
• It is the rst bone to ossify in the fetus.
• It is the only long bone to develop in membrane.
• It may be pierced by the supraclavicular nerves.
Coracoid process
Glenoid
cavity
cavity
Fig. 3.1 The scapula. (A) Posterior view. (B) Anterior view.
Infraspinous
A
fossa
Anterior surface
Lateral border
Inferior angle
B
62
Medial
border
Inferior
angle
CHAPTER 3 The Upper Limb and Breast
Anatomical neck
epicondyle
epicondyle
63
• It transmits forces from the upper limb to the axial skeleton.
• It acts as a strut to hold the arm free from the trunk.
• It is the most commonly fractured bone in the body, the
fracture usually occurring at the junction of the middle
and outer thirds.
Humerus (Fig. 3.2)
• e head is third of a sphere and faces medially, upwards
and backwards.
• e head is separated from the greater and lesser tubercles by the anatomical neck.
• e tubercles are separated from one another by the
bicipital groove (containing the tendon of the long head
of the biceps).
• e upper end and sha meet at the surgical neck,
humeral vessels.
• e sha is circular in the section above and attened
lower down.
• e spiral groove lies posteriorly on the sha and
is related to the radial nerve, which winds round it
between the medial and lateral head of triceps.
Head
Greater
tuberosity
(tubercle)
Surgical
neck
Lesser
tuberosity
(tubercle)
Bicipital groove
(intertubercular
sulcus)
• e lower end bears the rounded capitulum laterally for
articulation with the radial head, and the trochlea medially for articulation with the trochlear notch of the ulna.
• Medial and lateral epicondyles are extracapsular. e
ulnar nerve lies in a groove on the posterior aspect of
the medial epicondyle.
• Fractures of the humerus are common and important in
view of the close relationship of the axillary, radial and
ulnar nerves.
Radius and Ulna (Fig. 3.3)
• Considered together as they are complementary in the
makeup of the forearm.
• Radius consists of head, neck, sha and expanded distal
end.
• Ulna consists of the olecranon, trochlear fossa, coronoid
process with its radial notch (for articulation with the
radial head), sha and small distal head (for articulation
with the medial aspect of the distal radius).
The Carpus (Figs. 3.4 and 3.7)
• Made up of two rows of four bones.
Deltoid
tuberosity
Shaft
Lateral
supracondylar
ridge
Coronoid
Trochlea
fossa
Medial
epicondyle
Medial
epicondyle
B
Lateral
Capitulum
Radial
fossa
A
Fig. 3.2 The humerus. (A) Anterior view. (B) Posterior view.
Spiral groove
for radial
nerve
Lateral
Trochlea
Olecranon
fossa
64
Dorsal tubercle
Head of
phalanx
Head of fourth
Proximal phalanx
Middle phalanx
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SECTION I Anatomy
Radial notch of ulna
Head of
radius
Radial
tuberosity
Styloid process
Trochlear
notch
Coronoid
process
Head of ulna
Styloid process
A
Fig. 3.3 The radius and ulna. (A) Anterior view. (B) Posterior view.
Distal phalanx
Styloid
process
B
Olecranon
Styloid process
Distal phalanx
Middle phalanx
Base of
phalanx
metacarpal
A
Hamate
Pisiform
Triquetral
Lunate
Capitate
Second
metacarpal
Sesamoid
bone
Trapezoid
Trapezium
Scaphoid
Fig. 3.4 The carpals, metacarpals and phalanges. (A) Anterior view. (B) Posterior view.
• Proximally, lateral to medial—scaphoid, lunate, triquetral (plus attached pisiform).
• Distally, lateral to medial—trapezium, trapezoid, capitate, hamate.
Second
metacarpal
First
metacarpal
Trapezoid
Trapezium
Scaphoid
Lunate
B
• Carpus is arched transversely, the palmar aspect being
concave.
• Arch is maintained by individual bones, which are
broader posteriorly than anteriorly (except the lunate).
Pisiform
Hamate
Triquetral
Head of fourth
metacarpal
Base of
phalanx
Capitate
Proximal
phalanx
Head of
phalanx
CHAPTER 3 The Upper Limb and Breast
Glenoid labrum
Greater tuberosity
65
• Arch is also maintained by the exor retinaculum passing from the scaphoid and trapezium laterally to the
pisiform and hook of the hamate medially.
Metacarpals and Phalanges
• First metacarpal is important because of the mobility
of its carpometacarpal joint, which is responsible for
opposition of the thumb.
• Second metacarpal articulates with three carpal bones:
trapezium, trapezoid and capitate.
• Capitate articulates with three metacarpals: second,
third and fourth.
JOINTS OF THE UPPER LIMB
Shoulder Joint (Fig. 3.5)
• Ball-and-socket joint.
• Articular surfaces: head of humerus with shallow glenoid fossa of scapula (deepened somewhat by the
labrum glenoidale—a cartilaginous ring).
• Capsule: lax and attached around epiphyseal line of glenoid and humeral head. Extends down to diaphysis on the
medial aspect of the neck of the humerus. Capsule lined by
synovial membrane along tendon of long head of biceps,
which passes through joint. Synovium communicates
with subcapsular bursa beneath tendon of subscapularis.
• Stability depends largely on strength of surrounding
muscles:
• rotator cu
• long head of biceps
• deltoid, pectoralis major, latissimus dorsi, teres
major, long head of biceps.
Muscles Acting on Shoulder Joint
• Abductors: supraspinatus, deltoid.
• Adductors: pectoralis major, latissimus dorsi.
• Flexors: anterior bres of deltoid, pectoralis major,
coracobrachialis.
• Extensors: latissimus dorsi, teres major, posterior bres
of deltoid.
• Medial rotators: pectoralis major, latissimus dorsi, teres
major, subscapularis, anterior bres of deltoid.
• Lateral rotators: infraspinatus, teres minor, posterior
bres of deltoid.
The Shoulder Girdle
Movements of the shoulder joint itself cannot be separated
from those of the shoulder girdle as a whole.
Sternoclavicular Joint
• Articular surfaces: medial end of clavicle and sternum,
intra-articular disc.
• Ligaments: costoclavicular ligament passes from clavicle to rst costal cartilage. is forms a fulcrum so that
when the outer end of the clavicle is raised, e.g. shrugging the shoulders, the medial end is depressed.
Acromion
Humeral head
of humerus
Deltoid
Fig. 3.5 Coronal MRI right shoulder joint.
Clavicle
Supraspinatus
Glenoid fossa
66
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SECTION I Anatomy
Acromioclavicular Joint
• Articular surfaces: lateral end of clavicle and the acromion, incomplete articular disc.
• Ligaments: coracoclavicular (conoid and trapezoid
ligaments).
• Movements: induced passively by scapular movement.
• Dislocation of the outer end of the clavicle at the joint
is easily reduced; maintenance of reduction is dicult,
owing to inclination of joint surfaces.
Rotator Cuff
• Sheath of tendons of short muscles of the shoulder
which surround and blend with all but the inferior
aspect of the joint.
• Consists of supraspinatus, infraspinatus and teres
minor, which are inserted from above down into the
greater tuberosity of the humerus, and subscapularis,
which is inserted into the lesser tuberosity.
• All the above muscles originate from the scapula.
• Supraspinatus is important in initiation of abduction of
the shoulder joint.
• Supraspinatus passes over the apex of the shoulder
beneath the acromion and coracoacromial ligament,
from which it is separated by the subacromial bursa.
Movements of Shoulder Girdle
• All but very slight glenohumeral movements are always
accompanied by movements of the scapula on the clavicle and of the clavicle on the manubrium.
• Abduction is initiated by supraspinatus (15°).
• Deltoid then abducts to 90°.
• Further movement to 180° is brought about by rotation
of the scapula by trapezius and serratus anterior.
• As soon as abduction commences at the shoulder joint,
rotation of the scapula begins.
• Movements of the scapula occur with reciprocal movements of the sternoclavicular joint, i.e. elevate the
shoulder and the joint is depressed; move the shoulder
forwards and the joint moves backwards.
• e scapula can be elevated (shrugging the shoulders)
and depressed. Trapezius and levator scapulae elevate;
gravity, pectoralis major and pectoralis minor depress.
• e scapula can be protracted (moved forwards round
the chest wall) and retracted. Serratus anterior and pectoralis minor protract; rhomboids and middle bres of
trapezius retract.
• Rotation of the scapula upwards is carried out by trapezius and serratus anterior.
Clinical Points
• In fractures of the clavicle, trapezius is unable to support
the weight of the arm. e patient therefore supports the
upper limb with the opposite hand. e lateral fragment
is depressed and drawn medially by the shoulder adductors and the broken ends overlap. Slight elevation of the
medial fragment occurs due to sternocleidomastoid.
• Rupture of the tendon of supraspinatus results in inability to actively initiate abduction of the shoulder. e
patient develops a trick movement of tilting the body to
the injured side so gravity allows the limb to swing away
from the trunk. Deltoid then comes into action.
• Supraspinatus tendinitis results in a painful arc of shoulder movement between 60° and 120°. It is during this
range of movement that the tendon impinges against
the overlying acromion and coracoacromial ligament.
• Serratus anterior, which protracts the scapula and keeps
it applied to the chest wall, is supplied by the long thoracic nerve of Bell, C5, C6 and C7. Damage to this nerve
(neck, breast or axillary surgery) results in winging of
the scapula.
Elbow Joint (Fig. 3.6)
Consists of three articulations and one synovial cavity.
• Humeroulnar: trochlea of humerus and trochlear notch
of ulna (hinge joint).
• Humeroradial: capitulum and radial head (ball-andsocket joint).
• Proximal radioulnar: head of radius and radial notch of
ulna (pivot joint).
• Capsule: thin and lax anteriorly and posteriorly; thickened at sides to form medial and lateral collateral
ligaments. e lateral ligament is attached to annular
ligament, which holds the head of the radius in place.
e medial and lateral epicondyles are extracapsular.
• Movement: exion and extension. Pronation and supination occur at proximal radioulnar joint (with distal
radioulnar joint).
• Muscles acting on joint are:
• exors: biceps, brachialis, brachioradialis, forearm
exors
• extensors: triceps, anconeus
• pronators: pronator teres, pronator quadratus
• supinators: biceps, supinator.
Wrist Joint (Fig. 3.7)
• Articular surfaces: distal radius and head of ulna,
the latter separated from the carpus by an articular
disc. Proximal articular surfaces of scaphoid, lunate,
triquetral.
• Condyloid joint: allows exion, extension, adduction,
abduction and circumduction.
• Movements are:
• exion: all muscles crossing the anterior aspect of
the joint
CHAPTER 3 The Upper Limb and Breast
Trochlea of humeru
s
d
Pronator quadratus
Base of metacarpal bones
Shaft of humerus
Olecranon fossa
of humerus
s
67
Coronoid process
of ulna
Fig. 3.6 Coronal MRI left elbow joint.
Hamate
Capitulum of humeru
Head of radius
Radial tuberosity
Trapezium
Trapezoid
Capitate
Triquetral
Lunate
Head of ulna
Fig. 3.7 Coronal MRI left wrist joint.
Scaphoid
Radial styloi
68
Distal phalanx Middle phalanx
Proximal phalanx
Interosseous
profundus
superficialis
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SECTION I Anatomy
• extension: all muscles crossing the posterior aspect
of the joint
• adduction: exor carpi ulnaris, extensor carpi ulnaris
• abduction: exor carpi radialis, extensor carpi radialis longus, abductor pollicis longus, extensor pollicis
longus.
Joints of the Hand
Carpometacarpal Joint
Thumb
• Saddle joint.
• Flexion, extension, abduction, adduction, opposition.
• Flexion/extension in plane parallel to palm.
• Abduction/adduction in plane at right angle to palm.
• Opposition: thumb opposes to little nger.
• Other carpometacarpal joints have limited gliding
movement only.
Metacarpophalangeal Joints
• 60° range of exion/extension at metacarpophalangeal
joint of thumb.
• 90° at other metacarpophalangeal joints, together with
abduction, adduction and circumduction.
• Abduction and adduction are impossible with the metacarpophalangeal joints exed.
• Metacarpophalangeal joints of ngers (not thumb)
are joined by deep transverse ligaments which prevent
them spreading during a rm grip.
Interphalangeal Joints
• Hinge joints.
• Flexion/extension only.
• Collateral ligaments lax in extension and taut in
exion.
Muscles Controlling the Hand
Long Flexors
• Flexor digitorum profundus: inserted into base of distal
phalanx.
• Flexor digitorum supercialis: inserted into sides of
middle phalanx.
• Profundus tendon pierces supercialis tendon over
proximal phalanx.
• Profundus exes the distal phalanx.
• Supercialis exes the middle phalanx.
• Both muscles ex the ngers and the wrist.
Long Extensors
• Extensor digitorum longus inserted into the extensor
expansion.
• Extensor indicis inserted into the medial side of the
extensor digitorum longus to index nger.
• Extensor digiti minimi inserted into the medial side of
extensor digitorum longus to the little nger.
• ey extend the ngers and wrist.
Extensor Expansion (Fig. 3.8)
• Covers the dorsum of the proximal phalanx and sides of
its base.
• Attaches by central slip into the base of the middle
phalanx and two lateral slips into the base of the distal
phalanx.
• Receives the insertion of the interossei and lumbricals.
Fig. 3.8 The extensor expansion and tendons of a finger. (A) Dorsal view. (B) Lateral view.
A
B
Extensor expansion
Flexor digitorum
Flexor digitorum
Extensor
digitorum
Lumbrical
Extensor
digitorum
Interosseous
Lumbrical
CHAPTER 3 The Upper Limb and Breast
69
Small Muscles of the Hand
Interossei
• Arise from the sides and front of metacarpals.
• Abduct and adduct the ngers.
• Insert into the extensor expansion.
• Flex the metacarpophalangeal joints.
• Extend the interphalangeal joints.
Lumbricals
• Arise from the four profundus tendons.
• Insert into the extensor expansion.
• Flex the metacarpophalangeal joints.
• Extend the interphalangeal joints.
Muscles of the Thumb
Long muscles
• Flexor pollicis longus: inserted into distal phalanx.
• Extensor pollicis longus: inserted into the distal
phalanx.
• Extensor pollicis brevis: inserted into proximal
phalanx.
• Abductor pollicis longus: inserted into the rst
metacarpal.
Short muscles (thenar eminence)
• Adductor pollicis: inserted into base of proximal
phalanx.
• Flexor pollicis brevis: inserted into base of proximal
phalanx.
• Abductor pollicis brevis: inserted into base of proximal
phalanx.
• Opponens pollicis: inserted along the rst metacarpal.
Muscles of the Little Finger (Hypothenar Eminence)
• Abductor digiti minimi.
• Opponens digiti minimi.
• Flexor digiti minimi.
Muscle Actions
• Flexor digitorum profundus exes the distal phalanx.
• Flexor digitorum supercialis exes the middle
phalanx.
• Profundus and supercialis acting together ex the ngers and wrist.
• e interossei and lumbricals ex the metacarpophalangeal joints and extend the interphalangeal joints.
• e interossei plus abductor digiti minimi abduct and
adduct the ngers.
• Extensor digitorum has a weak abduction action.
• e long exors have a weak adduction action.
• e abductor/adductor actions of extensor digitorum
and the long exors are eliminated by placing the hand
at on a table. Abduction/adduction then become the
actions of the intrinsic muscles only.
• e above can be tested by gripping a card between the
ngers (tests T1 and partly ulnar nerve integrity).
VEINS OF THE UPPER LIMB
• Important in cannulation.
• Important in creation of arteriovenous stula for
dialysis.
Superficial Veins
• Commence as dorsal venous network on dorsum of
hand.
• Dorsal venous network drains into lateral cephalic vein
and dorsal basilic vein.
Cephalic Vein
• Lies subcutaneously just behind the radial styloid,
where it is very constant in position.
• Runs up the anterior aspect of the forearm.
• Lies in groove along the lateral border of biceps in the
upper arm.
• Passes to the deltopectoral triangle.
• Pierces the clavipectoral fascia to enter the axillary
vein.
• Is supercial until it reaches the deltopectoral triangle.
Basilic Vein
• Runs along the posteromedial aspect of the forearm.
• Passes to the anterior aspect of the elbow on the medial
side.
• Runs in the groove along the medial border of biceps.
• Pierces the deep fascia at the middle of the upper arm.
• Joins venae comitantes of brachial artery, eventually
forming the axillary vein.
Veins at the Elbow
• Variable pattern.
• Median cubital vein connects the cephalic and basilic
veins.
• e veins are separated from the underlying brachial
artery by the tough bicipital aponeurosis.
Clinical Points
• e cephalic vein at the wrist is very constant and available for cannulation and for the formation of radiocephalic (Cimino–Brescia) stulae for dialysis (the radial
artery is in close proximity).
• Avoid injection of irritant drugs into the veins at the
elbow. ere is a risk of accidentally entering the brachial artery or a supercially placed aberrant ulnar
artery. Drug addicts are not aware of these anatomical
relations!
70
A
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SECTION I Anatomy
Deep Veins
• Venae comitantes (accompanying the arteries).
• Usually in pairs or multiple.
• Nuisance value when exposing deep arteries, to which
they are closely applied.
ARTERIES OF THE UPPER LIMB (Fig. 3.9)
• Axillary.
• Brachial.
• Radial.
• Ulnar.
Axillary
• Commences at the lateral border of the rst rib as the
continuation of the subclavian artery.
• Ends at the lower border of teres major to become the
brachial artery.
• Divided into three parts by pectoralis minor:
• First part gives o one branch:
• superior thoracic artery.
• Second part gives o two branches:
• acromiothoracic artery
• lateral thoracic artery.
• ird part gives o three branches:
• subscapular artery
• anterior circumex humeral artery
• posterior circumex humeral artery.
• Relations: brachial plexus cords surround the artery, i.e.
the lateral, medial and posterior cords.
Brachial Artery
• Commences at the lower border of teres major as a continuation of the axillary artery.
• Terminates at the level of the neck of the radius where it
divides into the radial and ulnar artery.
• It lies immediately below the deep fascia in most of its
course where it is readily accessible, e.g. for brachial
embolectomy.
• It is crossed supercially from the lateral to medial side
by the median nerve at the level of the midhumerus.
• High bifurcation of the artery is not unusual.
Radial Artery
• Commences at the level of the radial neck lying on
the tendon of biceps (frequently bifurcation may be
higher).
• Overlapped by brachioradialis in its upper half.
• In the distal forearm it lies between brachioradialis
and exor carpi radialis where it can be palpated at the
wrist.
• It is closely related to the radial nerve in the middle of
the forearm.
• Distal to the wrist the branches given o contribute to
the supercial palmar arch.
• Passes deep to tendons of abductor pollicis longus and
extensor pollicis brevis to enter the anatomical snuox
where it is palpable.
• Pierces rst dorsal interosseous and adductor pollicis to
contribute to deep palmar arch.
Ulnar Artery
• Commences at level of neck of radius (frequently bifurcation may be higher).
• Passes deep to muscles from common exor origin.
• Lies on exor digitorum profundus, overlapped by
exor carpi ulnaris.
• Crossed supercially by the median nerve separated
from it by the deep head of pronator teres.
• Distally in the forearm it becomes supercial between
the tendons of the exor carpi ulnaris and exor digitorum profundus.
Radial artery
nterior interosseous
Fig. 3.9 MRA left forearm and hand. (© University of Michigan Medical School, with kind permission of
Thomas R. Gest PhD.)
artery
Ulnar artery
Deep palmar arch
Proper palmar
digital artery
Common palmar
digital artery
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