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It extends from the apex of the femoral triangle virus apparel cheap 250 mg sumycin free shipping, where the sartorius crosses over the adductor longus virus that causes cervical cancer sumycin 250mg otc, to the adductor hiatus in the tendon of the adductor magnus. The adductor canal provides an intermuscular passage for the femoral artery and vein, the saphenous nerve, and the slightly larger nerve to vastus medialis, delivering the femoral vessels to the popliteal fossa where they become popliteal vessels. In the inferior third to half of the canal, a tough subsartorial or vastoadductor fascia spans between the adductor longus and the vastus medialis muscles, forming the anterior wall of the canal deep to the sartorius. Because this fascia has a distinct superior margin, novices dissecting in this area commonly assume when they see the femoral vessels pass deep to this fascia that they are traversing the adductor hiatus. The adductor hiatus, however, is located at a more inferior level, just proximal to the medial supracondylar ridge. This hiatus is a gap between the aponeurotic adductor and the tendinous hamstrings attachments of the adductor magnus. Surface Anatomy of Anterior and Medial Regions of Thigh 1636 In fairly muscular individuals, some of the bulky anterior thigh muscles can be observed. The prominent muscles are the quadriceps and sartorius, whereas laterally, the tensor fasciae latae is palpable as is the iliotibial tract to which this muscle attaches. The fourth part (vastus intermedius) is deep and almost hidden by the other muscles and cannot be palpated. The rectus femoris may be easily observed as a ridge passing down the thigh when the lower limb is raised from the floor while sitting. The patellar ligament is easily observed, especially in thin people, as a thick band running from the patella to the tibial tuberosity. You can also palpate the infrapatellar fat pads, the masses of loose fatty tissue on each side of the patellar ligament. On the medial aspect of the inferior part of the thigh, the gracilis and sartorius muscles form a well-marked prominence, which is separated by a depression from the large bulge formed by the vastus medialis. To make these measurements, compare the affected limb with the corresponding limb. Keep in mind that small differences between the two sides-such as a difference of 1. The proximal two thirds of a line drawn from the midpoint of the inguinal ligament to the adductor tubercle when the thigh is flexed, abducted, and rotated laterally represents the course of the femoral artery. The proximal third of the line represents this artery as it passes through the femoral triangle, whereas the middle third represents the artery while it is in the adductor canal. The femoral triangle, in the supero-anterior aspect of the thigh, is not a prominent surface feature in most people. When some people sit cross-legged, the sartorius and adductor longus stand out, delineating the femoral triangle. The surface anatomy of the femoral triangle is clinically important because of its contents. The femoral artery runs a 5-cm superficial course through the femoral triangle before it is covered by the sartorius in the adductor canal. The great saphenous vein enters the thigh posterior to the medial femoral 1638 condyle and passes superiorly along a line from the adductor tubercle to the saphenous opening. The central point of this opening, where the great saphenous vein enters the femoral vein, is located 3. This is one of the most common injuries to the hip region, usually occurring in association with collision sports, such as the various forms of football, ice hockey, and volleyball. Contusions cause bleeding from ruptured capillaries and infiltration of blood into the muscles, tendons, and other soft tissues. The term hip pointer may also refer to avulsion of bony muscle attachments, for example, of the sartorius or rectus femoris to the anterior superior and inferior iliac spines, respectively, of the hamstrings from the ischium. Another term commonly used is "charley horse," which may refer either to the cramping of an individual thigh muscle because of ischemia or to contusion and rupture of blood vessels sufficient enough to form a hematoma. The injury is usually the consequence of tearing of fibers of the rectus femoris; sometimes, the quadriceps tendon is also partially torn.

In turn antibiotic resistance warning buy 500mg sumycin amex, their function and efficiency in the other movements they produce are affected by elbow position antibiotic spectrum chart buy sumycin 500mg otc. The brachioradialis can produce rapid flexion in the absence of resistance (even when the chief flexors are paralyzed). Normally, in the presence of resistance, the brachioradialis and pronator teres assist the chief flexors in producing slower flexion. The chief extensor of the elbow joint is the triceps brachii, especially the medial head, weakly assisted by the anconeus. Of the several bursae around the elbow joint, the olecranon bursae are most important clinically. Intratendinous olecranon bursa, which is sometimes present in the tendon of triceps brachii. The bicipitoradial bursa (biceps bursa) separates the biceps tendon from, and reduces abrasion against, the anterior part of the radial tuberosity. The anular ligament attaches to the radial notch of the ulna, forming a collar around the head of the radius. 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. The synovial membrane lines the deep surface of the fibrous layer and nonarticulating aspects of the bones. The synovial membrane is an inferior prolongation of the synovial membrane of the elbow joint. 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. This arrangement allows the radius to rotate within the anular ligament without binding, stretching, or tearing the synovial membrane. The head of the radius rotates in the "socket" formed by the anular ligament and radial notch of the ulna. Supination is the movement of the forearm that rotates the radius laterally around its longitudinal axis, so that the dorsum of the hand faces posteriorly and the palm faces anteriorly. Pronation is the movement of the forearm, produced by pronators teres and quadratus, that rotates the radius medially around its longitudinal axis, so that the palm of the hand faces posteriorly and its dorsum faces anteriorly. The actions of the biceps brachii and supinator in producing supination from the pronated position at the radio-ulnar joints. The interosseous membrane connects the interosseous margins of the radius and ulna, forming the radioulnar syndesmosis. The general direction of the fibers of the interosseous membrane is such that a superior thrust to the hand is received by the radius and is transmitted to the ulna. The axis for these movements passes proximally through the center of the head of the radius, and distally through the site of attachment of the apex of the articular disc to the head (styloid process) of the ulna. During pronation and supination, it is the radius that rotates; its head rotates within the cup-shaped collar formed by the anular ligament and the radial notch on the ulna. Almost always, supination and pronation are accompanied by synergistic movements of the glenohumeral and elbow joints that produce simultaneous movement of the ulna, except when the elbow is flexed. The distal radio-ulnar joint is the pivot type of synovial joint between the head of the ulna and the ulnar notch of the radius. The inferior end of the radius moves around the relatively fixed end of the ulna during supination and pronation of the hand. The two bones are firmly united distally by the articular disc, referred to clinically as the 678 triangular ligament of the distal radio-ulnar joint. It has a broad attachment to the radius but a narrow attachment to the styloid process of the ulna, which serves as the pivot point for the rotary movement. During pronation, the inferior end of the radius moves anteriorly and medially around the inferior end of the ulna, carrying the hand with it. Pronation is produced by the pronator quadratus (primarily) and pronator teres (secondarily).

The inner part of the balloon wall (adjacent to your fist liquid antibiotics for sinus infection generic 500 mg sumycin visa, which represents the lung) is comparable to the visceral pleura; the remaining outer wall of the balloon represents the parietal pleura antibiotic and yeast infection 250 mg sumycin mastercard. The cavity between the layers of the balloon, here filled with air, is analogous to the pleural cavity, although the pleural cavity contains only a thin film of fluid. At your wrist (representing the root of the lung), the inner and outer walls of the balloon are continuous, as are the visceral and parietal layers of pleura, together forming a pleural sac. Note that the lung is outside of but surrounded by the pleural sac, just as your fist is surrounded by but outside of the balloon. During the embryonic period, the developing lungs 796 invaginate (grow into) the pericardioperitoneal canals, the precursors of the pleural cavities. The invaginated celomic epithelium covers the primordia of the lungs and becomes the visceral pleura in the same way that the balloon covers your fist. The epithelium lining the walls of the pericardioperitoneal canals forms the parietal pleura. During embryogenesis, the pleural cavities become separated from the pericardial and peritoneal cavities. The pleural cavity-the potential space between the layers of pleura- contains a capillary layer of serous pleural fluid, which lubricates the pleural surfaces and allows the layers of pleura to slide smoothly over each other during respiration. The surface tension of the pleural fluid provides the cohesion that keeps the lung surface in contact with the thoracic wall; consequently, the lung expands and fills with air when the thorax expands while still allowing sliding to occur, much like a film of water between two glass plates. The visceral pleura (pulmonary pleura) closely covers the lung and adheres to all its surfaces, including those within the horizontal and oblique fissures. In cadaver dissection, the visceral pleura cannot usually be dissected from the surface of the lung. It provides the lung with a smooth slippery surface, enabling it to move freely on the parietal pleura. The visceral pleura is continuous with the parietal pleura at the hilum of the lung, where structures making up the root of the lung. The left sternal reflection of parietal pleura and anterior border of the left lung deviate from the median plane, circumventing the area where the heart is, lies adjacent to the anterior thoracic wall. In this "bare area" the pericardial sac is accessible for needle puncture with less risk of puncturing the pleural cavity or lung. The shapes of the lungs and the larger pleural sacs that surround them during quiet respiration are demonstrated. The costodiaphragmatic recesses, not 798 occupied by lung, are where pleural exudate accumulates when the body is erect. The outline of the horizontal fissure of the right lung clearly parallels the 4th rib. The parietal pleura lines the pulmonary cavities, thereby adhering to the thoracic wall, mediastinum, and diaphragm. It is thicker than the visceral pleura, and during surgery and cadaver dissections, it may be separated from the surfaces it covers. The parietal pleura consists of three parts-costal, mediastinal, and diaphragmatic-and the cervical pleura. The costal part of the parietal pleura (costovertebral or costal pleura) covers the internal surfaces of the thoracic wall. It is separated from the internal surface of the thoracic wall (sternum, ribs and costal cartilages, intercostal muscles and membranes, and sides of thoracic vertebrae) by endothoracic fascia. This thin, extrapleural layer of loose connective tissue forms a natural cleavage plane for surgical separation of the costal pleura from the thoracic wall (see the Clinical Box "Extrapleural Intrathoracic Surgical Access"). At this level, the 799 mediastinum consists of the pericardial sac (middle mediastinum) and the posterior mediastinum, mainly containing the esophagus and aorta. The deep groove surrounding the convexity of the diaphragm is the costodiaphragmatic recess, lined with parietal pleura. Anteriorly at this level, the pericardium and costomediastinal recesses and, between the sternal reflections of pleura, an area of pericardium only (the bare area) lie between the heart and the thoracic wall. The mediastinal part of the parietal pleura (mediastinal pleura) covers the lateral aspects of the mediastinum, the partition of tissues and organs separating the pulmonary cavities and their pleural sacs. It is continuous with costal pleura anteriorly and posteriorly and with the diaphragmatic pleura inferiorly. Superior to the root of the lung, the mediastinal pleura is a continuous sheet passing anteroposteriorly between the sternum and the vertebral column. At the hilum of the lung, it is the mediastinal pleura that reflects laterally onto the root of the lung to become continuous with the visceral pleura the diaphragmatic part of the parietal pleura (diaphragmatic pleura) covers the superior (thoracic) surface of the diaphragm on each side of the mediastinum, except along its costal attachments (origins) and where the diaphragm is fused to the pericardium, the fibroserous membrane surrounding the heart.

The renal lymphatic vessels follow the renal veins and drain into the right and left lumbar (caval and aortic) lymph nodes antibiotics for staph acne buy discount sumycin 500mg line. Lymphatic vessels from the superior part of the ureter may join those from the kidney or pass directly to the lumbar nodes antibiotics for sinus infection or not buy 250 mg sumycin mastercard. Lymphatic vessels from the middle part of the ureter usually drain into the common iliac lymph nodes, whereas vessels from its inferior part drain into the common, external, or internal iliac lymph nodes. The lymphatic vessels of the kidneys form three plexuses: one in the substance of the kidney, one under the fibrous capsule, and one in the perirenal fat. Four or five lymphatic trunks leave the renal hilum and are joined by vessels from the capsule (arrows). The lymphatic vessels follow the renal vein to the lumbar (caval and aortic) lymph nodes. The lumbar lymph nodes drain through the lumbar lymphatic trunks to the cisterna chyli. The suprarenal lymphatic vessels arise from a plexus deep to the capsule of the gland and from one in its medulla. The nerves to the kidneys arise from the renal nerve plexus and consist of sympathetic and parasympathetic fibers. The renal nerve plexus is supplied by fibers from the abdominopelvic (especially the least) splanchnic nerves. The nerves of the abdominal part of the ureters derive from the renal, abdominal aortic, and superior hypogastric plexuses. Ureteric pain is usually referred to the ipsilateral lower quadrant of the anterior abdominal wall and especially to the groin (see the Clinical Box "Renal and Ureteric Calculi," p. The nerves of the kidneys and suprarenal glands are derived from the celiac plexus, abdominopelvic (lesser and least) splanchnic nerves, and the aorticorenal ganglion. The main efferent innervation of the kidney is vasomotor, autonomic nerves supplying the afferent and efferent arterioles. Exclusively in the case of the suprarenal medulla, the presynaptic sympathetic fibers pass through both the paravertebral and prevertebral ganglia without synapsing to end directly on the secretory cells of the suprarenal medulla. The rich nerve supply of the suprarenal glands is from the celiac plexus and abdominopelvic (greater, lesser, and least) splanchnic nerves. In lean adults, the inferior pole of the right kidney is palpable by bimanual examination as a firm, smooth, somewhat rounded mass that descends during inspiration. To palpate the kidneys, 1230 press the flank (side of the trunk between the 11th and 12th ribs and the iliac crest) anteriorly with one hand while palpating deeply at the costal margin with the other. The left kidney is usually not palpable unless it is enlarged or a retroperitoneal mass has displaced it inferiorly. For example, fascia at the renal hilum attaches to the renal vessels and ureter, usually preventing the spread of pus to the contralateral side. However, pus from an abscess (or blood from an injured kidney) may force its way into the pelvis between the loosely attached anterior and posterior layers of the renal fascia. When kidneys descend, the suprarenal glands remain in place because they lie in a separate fascial compartment and are firmly attached to the diaphragm. Nephroptosis (dropped kidney) is distinguished from an ectopic kidney (congenital misplaced kidney) by a ureter of normal length that has loose coiling or kinks because the distance to the bladder has been reduced. Symptoms of intermittent pain in the renal region, relieved by lying down, appear to result from traction on the renal vessels. The lack of inferior support for the kidneys in the lumbar region is one of the reasons transplanted kidneys are placed in the iliac fossa of the greater pelvis. Other reasons for this placement are the availability of major blood vessels and convenient access to the nearby bladder. Renal Transplantation Renal transplantation is the preferred treatment for selected cases of chronic renal failure. The kidney can be removed from the donor without damaging the suprarenal gland because of the weak septum of renal fascia that separates the kidney from this gland. The renal artery and vein are joined to the external iliac artery and vein, respectively, and the ureter is sutured into the urinary bladder. Renal Cysts Cysts in the kidney, multiple or solitary, are common findings during ultrasound examinations and dissection of cadavers. Adult polycystic disease of the kidneys 1232 is an important cause of renal failure; it is inherited as an autosomal dominant trait.