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Professor, Sidney Kimmel Medical College at Thomas Jefferson University
Dissection of Axillary Lymph Nodes Excision and pathologic analysis of axillary lymph nodes are often necessary for staging and determining the appropriate treatment of cancer antibiotic used for acne cheap azitrix generic, such as breast cancer systemic antibiotics for acne vulgaris buy 100 mg azitrix overnight delivery. Because the axillary lymph nodes are arranged and receive lymph (and therefore metastatic breast cancer cells) in a specific order bacteria meaning order azitrix 250mg mastercard, removing and examining the lymph nodes in that order is important in determining the degree to which the cancer has developed and is likely to have metastasized. Lymphatic drainage of the upper limb may be impeded after removal or radiation of the axillary nodes, resulting in lymphedema, swelling as a result of accumulated lymph, especially in the subcutaneous tissue. During surgery, the long thoracic nerve to the serratus anterior is identified and maintained against the thoracic wall. As discussed earlier in this chapter, cutting the long thoracic nerve results in a winged scapula. If the nodes around this nerve are obviously malignant, sometimes the nerve has to be sacrificed as the nodes are resected to increase the likelihood of complete removal of all malignant cells. Variations of Brachial Plexus Variations in the formation of the brachial plexus are common (Illustrated Encyclopedia of Anatomical Variation). When the superiormost root (anterior ramus) of the plexus is C4 and the inferiormost root is C8, it is a prefixed brachial plexus. Alternately, when the superior root is C6 and the inferior root is T2, it is a postfixed brachial plexus. In the latter type, the inferior trunk of the plexus may be compressed by the 1st rib, producing neurovascular symptoms in the upper limb. Variations may also occur in the formation of trunks, divisions, and cords; in the origin and/or combination of branches; and in the relationship to the axillary artery and scalene muscles. For example, the lateral or medial cords may receive fibers from anterior rami inferior or superior to the usual levels, respectively. In some individuals, trunk divisions or cord formations may be absent in one or other parts of the plexus; however, the makeup of the terminal branches is unchanged. Because each peripheral nerve is a collection of nerve fibers bound together by connective tissue, it is understandable that the median nerve, for instance, may have two medial roots instead of one. This results from the fibers of the medial cord of the brachial plexus dividing into three branches, two forming the median nerve and the third forming the ulnar nerve. Sometimes it may be more confusing when the two medial roots are completely separate; however, understand that although the median nerve may have two medial roots, the components of the nerve are the same. Brachial Plexus Injuries Injuries to the brachial plexus affect movements and cutaneous sensations in the upper limb. Disease, stretching, and wounds in the lateral cervical region (posterior triangle) of the neck (see Chapter 9) or in the axilla may produce brachial plexus injuries. With incomplete paralysis, not all muscles are paralyzed; therefore, the person can move, but the movements are weak compared with those on the normal side. Injuries to superior parts of the brachial plexus (C5 and C6) usually result from an excessive increase in the angle between the neck and shoulder. These injuries can occur in a person who is thrown from a motorcycle or a horse and lands on the shoulder in a way that widely separates the neck and shoulder. This stretches or ruptures superior parts of the brachial plexus or avulses (tears) the roots of the plexus from the spinal cord. Observe the excessive increase in the angle between the head and left shoulder during delivery of the fetus.
At a deeper level antibiotics to treat staph buy discount azitrix 500 mg online, the flexor retinaculum extends between the anterior prominences of the outer carpal bones bacteria 3d safe azitrix 100mg, converting the anterior concavity of the carpus into an osseofibrous carpal tunnel antibiotic abbreviation order genuine azitrix. In the forearm, similar fascial compartments are surrounded by the antebrachial fascia and are separated by the interosseous membrane connecting the radius and ulna. The antebrachial fascia thickens posteriorly over the distal ends of the radius and ulna to form a transverse band, the extensor retinaculum, which retains the extensor tendons in position. The antebrachial fascia also forms an anterior thickening, which is continuous with the extensor retinaculum but is officially unnamed; some authors identify it as the palmar carpal ligament. Immediately distal and at a deeper level to the latter, the antebrachial fascia is also continued as the flexor retinaculum (transverse carpal ligament). The deep fascia of the upper limb continues beyond the extensor and flexor retinacula as the palmar fascia. The central part of the palmar fascia, the palmar aponeurosis, is thick, tendinous, and triangular and overlies the central compartment of the palm. Its apex, located proximally, is continuous with the tendon of the palmaris longus (when it is present). The aponeurosis forms four distinct thickenings that radiate to the bases of the fingers and become continuous with the fibrous tendon sheaths of the digits. The bands are traversed distally by the superficial transverse metacarpal ligament, which forms the base of the palmar aponeurosis. These ligaments hold the palmar skin close to the aponeurosis, allowing little sliding movement of the skin. Perforating veins form communications between the superficial and deep veins. Like the dermatomal pattern, the logic for naming the main superficial veins of the upper limb cephalic (toward the head) and basilic (toward the base) becomes apparent when the limb is placed in its initial embryonic position. Arrows indicate the flow of lymph within lymphatic vessels, which converge toward the vein and drain into the cubital and axillary lymph nodes. Anterior to the elbow, the cephalic vein communicates with the median cubital vein, which passes obliquely across the anterior aspect of the elbow in the cubital fossa (depression in front of the elbow), and joins the basilic vein. The cephalic vein courses superiorly between the deltoid and pectoralis major muscles along the deltopectoral groove and then enters the clavipectoral triangle. It then pierces the costocoracoid membrane and part of the clavipectoral fascia, joining the terminal part of the axillary vein. The basilic vein ascends in the subcutaneous tissue from the medial end of the dorsal venous network along the medial side of the forearm and inferior part of the arm; it is often visible through the skin. It then passes deeply near the junction of the middle and inferior thirds of the arm, piercing the brachial fascia and running superiorly parallel to the brachial artery and medial cutaneous nerve of the forearm to the axilla, where it merges with the accompanying veins (L. It begins at the base of the dorsum of the thumb, curves around the lateral side of the wrist, and ascends in the middle of the anterior aspect of the forearm between the cephalic and basilic veins. The median antebrachial vein sometimes divides into a median basilic vein, which joins the basilic vein, and a median cephalic vein, which joins the cephalic vein. Lymphatic Drainage of Upper Limb Superficial lymphatic vessels arise from lymphatic plexuses in the skin of the fingers, palm, and dorsum of the hand and ascend mostly with the superficial veins, such as the cephalic and basilic veins. Some vessels accompanying the basilic vein enter the cubital lymph nodes, located proximal to the medial epicondyle and medial to the basilic vein. Efferent vessels from these lymph nodes ascend in the arm and terminate in the humeral (lateral) axillary lymph nodes (see Chapter 4). Superficial lymphatic vessels originate from the digital lymphatic vessels of the digits and lymphatic plexus of the palm.
In a healthy vein antibiotics to treat bronchitis order azitrix overnight, the valves allow blood to flow toward the heart (B) while keeping blood from flowing away from the heart (C) infection without elevated wbc generic 250mg azitrix overnight delivery. Valves in varicose veins (D) are incompetent due to dilation or rotation and no longer function properly antibiotics for uti urinary tract infection buy 250mg azitrix fast delivery. Venous stasis can be caused by incompetent, loose fascia that fails to resist muscle expansion, diminishing the effectiveness of the musculovenous pump. A large thrombus that breaks free from a lower limb vein may travel to a lung, forming a pulmonary thromboembolism (obstruction of a pulmonary artery). 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. When part of the great saphenous vein is removed for a bypass, the vein is inverted so that the valves do not obstruct blood flow in the venous graft. Because there are so many other leg veins, removal of the great saphenous vein rarely produces a significant problem in the lower limb or seriously affects circulation, provided the deep veins are intact. In fact, removal of this vein may facilitate the superficial to deep drainage pattern to take advantage of the musculovenous pump. Saphenous Saphenous Nerve Injury Cutdown and Even when it is not visible in infants, in obese people, or in patients in shock whose veins are collapsed, the great saphenous vein can always be located by making a skin incision anterior to the medial malleolus. This procedure, called a saphenous cutdown, is used to insert a cannula for 1602 prolonged administration of blood, plasma expanders, electrolytes, or drugs. The saphenous nerve accompanies the great saphenous vein anterior to the medial malleolus. Should this nerve be cut during a saphenous cutdown or caught by a ligature during closure of a surgical wound, the patient may complain of pain or numbness along the medial border of the foot. Abrasions and minor sepsis, caused by pathogenic microorganisms or their toxins in the blood or other tissues, may produce moderate enlargement of the superficial inguinal lymph nodes (lymphadenopathy) in otherwise healthy people. Because these enlarged nodes are located in subcutaneous tissue, they are usually easy to palpate. When inguinal lymph nodes are enlarged, their entire field of drainage-the trunk inferior to the umbilicus, including the perineum, as well as the entire lower limb-should be examined to determine the cause of their enlargement. In female patients, the relatively remote possibility of metastasis of cancer from the uterus should also be considered because some lymphatic drainage from the uterine fundus may flow along lymphatics accompanying the round ligament of the uterus through the inguinal canal to reach the superficial inguinal lymph nodes. Regional Nerve Blocks of Lower Limbs Interruption of the conduction of impulses in peripheral nerves (nerve block) may be achieved by making perineural injections of anesthetics close to the nerves whose conductivity is to be blocked. Paresthesia (tingling, burning, tickling) radiates to the knee and over the medial side of the leg if the saphenous nerve (terminal branch of femoral) is affected. Therefore, to interpret abnormalities of peripheral sensory function, peripheral nerve distribution of the major cutaneous nerves must be interpreted as anatomically different from dermatome distribution of the spinal cord segments. Pain sensation is tested by using a sharp object and asking the patient if pain is felt. Veins: the veins of the lower limb include both superficial (in the subcutaneous tissue) and deep (internal to the deep fascia) veins. Lymphatic vessels: Most lymph from the lower limb drains via 1604 lymphatics that follow the superficial veins. Lymph drainage from the lower limb then passes deep to the external and common iliac nodes of the trunk. Cutaneous nerves: the cutaneous innervation of the lower limb reflects both the original segmental innervation of the skin via separate spinal nerves in its dermatomal pattern and the result of plexus formation in the distribution of multisegmental peripheral nerves. Typically, the actions of lower limb muscles are described as if the muscle were acting in isolation, which rarely occurs.
They terminate on the arteriovenous anastomoses and helicine arteries of the erectile bodies antibiotics every 6 hours azitrix 500mg discount, which infection xbox 360 discount 500mg azitrix, when stimulated antibiotic interactions purchase genuine azitrix line, produce erection of the penis or engorgement of the clitoris and vestibular bulb in females. Reflective of their abdominal origins, lymph from the testes follow a route, independent of the scrotal drainage, along the testicular veins to the intermesenteric portion of the lumbar (caval/aortic) and pre-aortic lymph nodes. Lymphatic drainage from the intermediate and proximal parts of the urethra and cavernous bodies drains into the internal iliac lymph nodes, whereas most vessels from the distal spongy urethra and glans penis pass to the deep inguinal nodes, but some lymph passes to the external inguinal nodes. Details about the attachments, innervation, and actions of these muscles are provided in Tables 6. Lymphatic drainage of male urogenital triangle-penis, spongy urethra, scrotum, and testis. They cross the pelvic outlet like intersecting beams, supporting the perineal body to aid the pelvic diaphragm in supporting the pelvic viscera. Simultaneous contraction of the superficial perineal muscles (plus the deep transverse perineal muscle) during penile erection provides a firmer base for the penis. The bulbospongiosus muscles form a constrictor that compresses the bulb of the penis and the corpus spongiosum, thereby aiding in emptying the spongy urethra of residual urine and/or semen. The anterior fibers of the bulbospongiosus, encircling the most proximal part of the body of the penis, also assist erection by increasing the pressure on the erectile tissue in the root of the penis. At the same time, they also compress the deep dorsal vein of the penis, impeding venous drainage of the cavernous spaces and helping promote enlargement and turgidity of the penis. They force blood from the cavernous spaces in the crura into the distal parts of the corpora cavernosa, which increases the turgidity (firm distension) of the penis during erection. Contraction of the ischiocavernosus muscles also 1503 compresses the tributaries of deep dorsal vein of the penis leaving the crus of the penis, thereby restricting venous outflow from the penis and helping maintain the erection. Because of their function during erection and the activity of the bulbospongiosus subsequent to urination and ejaculation to expel the last drops of urine and semen, the perineal muscles are generally more developed in males than in females. Consequently, the helicine arteries straighten, enlarging their lumina and allowing blood to flow into and dilate the cavernous spaces in the corpora of the penis. The bulbospongiosus and ischiocavernosus muscles compress veins egressing from the corpora cavernosa, impeding the return of venous blood. As a result, the corpora cavernosa and corpus spongiosum become engorged with blood near arterial pressure, causing the erectile bodies to become turgid (enlarged and rigid), and an erection occurs. During emission, semen (sperms and glandular secretions) is delivered to the prostatic urethra through the ejaculatory ducts after peristalsis of the ductus deferentes and seminal glands. Prostatic fluid is added to the seminal fluid as the smooth muscle in the prostate contracts. During ejaculation, semen is expelled from the urethra through the external urethral orifice. After ejaculation, the penis gradually returns to a flaccid state (remission), resulting from sympathetic stimulation, which causes constriction of the smooth muscle in the coiled helicine arteries. The bulbospongiosus and ischiocavernosus muscles relax, allowing more blood to be drained from the cavernous spaces in the corpora cavernosa into the deep dorsal vein. It is also performed to irrigate the bladder and to obtain an uncontaminated sample of urine. When inserting catheters and urethral sounds (slightly conical instruments for exploring and dilating a constricted urethra), the curves of the male urethra must be considered. Just distal to the perineal membrane, the spongy urethra is well covered inferiorly and posteriorly by erectile tissue of the bulb of the penis; however, a short segment of the intermediate part of the urethra is unprotected.
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