Entry 8

Severance of External Jugular Vein

The external jugular vein (EJV) begins with the union of the retromandibular vein and the posterior auricular vein at the inferior angle of the mandible. After crossing the sternocleidomastoid muscle just deep to the platysma and then enters the lateral cervical region. The EJV terminates in the sublavian veins and is responsible for draining most of the scalp and side of the face. The EJV has 8 branches with 5 located in the neck; these include the ascending pharyngeal, superior thyroid, lingual, facial and occipital veins.

Severance of the EJV posterior to the border of the sternocleidomastoid muscle where it pierces the roof of the lateral cervical region where the lumen is held open by the tough investing layer of deep cervical fasica. The negative intrathoracic pressure will suck air into the vein causing a churning noise in the thorax and cyanosis. This could cause a venous air embolism filling the right side of the heart with froth, and nearly stopping blood flow. Application of firm pressure to the severed jugular vein will stop the bleeding and entry of air into the vessel until it can be sutured.
http://www.bartleby.com/107/144.html

Carotid Occlusion and Endarterectomy

The internal carotid arteries (ICA) are major arteries of the head and neck that are the continuations of the external carotid arteries. The distinction between the two vessels occurs at the level of the superior boarder of the thyroid cartilage. The ICA ascends to enter the cranium through the carotid canals in the petrous parts of the temporal bones and become the main blood suppliers of the brain and structures in the orbits.

Atherosclerotic, cholesterol deposits, thickening of the intima of the ICA, which may obstruct blood flow. Symptoms depend on a varying degree of obstruction; a partial occlusion may cause a transient ischemic attack (TIA). TIA is a sudden focal loss of neurological function, e.g. dizziness and vertigo,  that disappear within 24hrs. Arterial occlusion may cause a minor stroke, which is a loss of neurological function such as weakness or sensory loss on one side of the body that exceeds 24hrs. and is gone within 3 weeks. A noninvasive procedure to check for an occlusion is called a Doppler. Once located a procedure called carotid endartercetomy, which is stripping off of the plaque blocking the vessel. After the operation pharmaceutical aids are given to inhibit clot formation until the endothelium has regrown.
http://en.wikipedia.org/wiki/Endarterectomy

Injury to the Suprascapular nerve

The suprascapular nerve originates from the union formed by the 5^th and 6^th cervical nerves. It runs lateral beneath the trapezius and the omohyoideus muscles, and enters the supraspinatous fossa through the suprascapular notch, below the superior transverse scapular ligament. It then passes beneath the supraspinatus muscle and curves around the lateral border of the spine of the scapula to the infraspinatous fossa. The nerve innervates the supraspinatus and infraspinatus muscles.

            Trauma to the suprascapular nerve is usually caused by a fracture of the middle third of the clavicle. Injury of this nerve results in loss of lateral rotation of the humerus at the glenohumeral joint. The ability to initiate abduction of the limb is also affected. Nonsurgical treatment is accomplished by avoiding overhead activities, and the rehab of muscles; unfortunately the overall success is limited and inconclusive. Surgical treatment is the released from the tunnel that has trapped the nerve. Usually performed at the suprascapular notch and/or spinoglenoid notch. This treatment is usually associated with a high rate of pain relief and functional improvement.
http://en.wikipedia.org/wiki/Suprascapular_nerve

Entry 7

Anosmia

  The sense of smell is regulated by cranial nerve I, olfactory n. The cell bodies of olfactory receptor neurons are located in the olfactory organ; located in the roof of the nasal cavity and along the nasal septum and medial wall of the superior nasal concha. These neurons are both receptors and conductors, and the apical surfaces of the neurons are covered in fine olfactory cilia, bathed by a film of watery mucus secreted by the olfactory glands of the epithelium.

Anosmia is simply the loss of smell, just like hearing loss occurs with growing older, so does smell. Sometimes the loss of smell is associated with upper respiratory infections, sinus disease, and head trauma. A severe head trauma the olfactory bulbs may be torn away from the olfactory nerves or some olfactory nerve fibers may be torn as the pass through a fractured cribriform plate. If these bundles are torn a complete loss of smell will occur. Anosmia may also be a clue to a fracture of the cranial base and cerebrospinal fluid rhinorrhea. http://en.wikipedia.org/wiki/Anosmia

Acoustic Neuroma

 Cranial nerve VIII, vestibulocochlear nerve, regulates the special sensations of hearing and equilibrium and motion. CN VIII emerges from the junction of the medulla and pons continuing through the internal acoustic meatus and then separates into the vestibular nerve and cochlear nerves. The peripheral processes of the vestibular neurons extend to the utricle and saccule; to the cristae of the ampullae of the semicircular ducts. The peripheral processes of the cochlear neurons extend to the spiral organ for the sense of hearing.

            Acoustic neuroma is a slow growing benign tumor of the Schwann cells. These cells wrap around neurons creating a myelin shealth, a conductive platform for impulses to travel down. The tumor begins in the vestibular nerve while it is in the internal acoustic meatus. The early symptom is usually hearing loss; Dysequilibrium and tinnitus can also occur but only in 70% of patients. Treatment options range from simple observation to surgery and possibly stereotactic radiosurgery.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001782/

Olfactory Hallucinations

            Cranial nerve I, olfactory nerve, as stated previously in this entry, regulates the sense of smell. CN I emerges from the forebrain, but unlike the other cranial nerves, it consists of a collection of many sensory nerve fibers that extend to the olfactory bulb; passing through the many openings of the Cribriform plate of the Ethmoid bone. These tracts divide into the lateral and medial olfactory striae. The lateral olfactory stria terminates in the piriform cortex of the anterior part of the temporal lobe. The medial stria prjects through the anterior commissure to olfactory structures.

Olfactory hallucinations might be the result of lesions in the temporal lobe of the cerebral hemisphere. These lesions could cause irritation to the lateral olfactory area, which could cause temporal lobe epilepsy, or “uncinate fits”. Characterized by imaginary disagreeable odors and involuntary movements of the lips and tongue. This disorder was one of the symptoms of the patient on the latest House episode. Treatment of these lesions is still in the infancy stages.
http://en.wikipedia.org/wiki/Phantosmia

Entry 6

Foreign Bodies in Laryngopharynx

The laryngopharynx, as called hypopharynx,is one of three sections of the pharynx. The other two are the oropharynx (mesopharynx) and nasopharynx (epipharynx). The laryngopharynx is the section of pharynx that connects the throat to the esophagus; lying inferior to the epiglottis. The superior boundary of the laryngopharynx is the hyoid bone and is the pathway for both air entering the larynx and food & drink entering the esophagus. When the two battle over which one will have the right away, the food & drink wins most of the time. The laryngopharynx is innervated by the pharyngeal plexus and is lined with stratified squamous epithelium.

The laryngopharynx is the location of halting foreign objects in the throat due to the piriform sinus. The piriform sinus is a recess located on either side of the laryngopharynx, and just deep to the mucous membrane of this fossa lie the the internal laryngeal nerve a branch of the superior laryngeal nerve. When objects like chicken bones or fish bones get caught in the piriform sinus there is a risk of puncturing through the mucous membrane and causing damage to the internal and superior laryngeal nerves. Injury to these nerves could cause anesthesia of the laryngeal mucous membrane as far inferiorly as the vocal folds; causing lose of the ability to speak. Until recently this trauma would be permanent but through medical advancements doctors are able to repair the laryngeal nerves.

http://en.wikipedia.org/wiki/Human_pharynx#Laryngopharynx

Enlargement of Thyroid Gland

            The thyroid gland is located in the anterior neck at the same level of C5-T1 vertebrae and the second & third tracheal rings.  The thyroid gland is one of the largest endocrine glands in the body, and controls how quickly the body uses energy, makes proteins and controls how sensitive the body should be to other hormones. The gland produces several hormones: triiodothyronine (T3) and thyroxine (T4) both of these hormones regulate the rate of metabolism, and are synthesized by both iodine and tyrosine. The thyroid also produces calcitonin which plays a role in calcium homeostasis.

            The non-neoplastic and noninflammatory enlargment of the thyroid gland is called a goiter. This is a result of a lack of iodine in the diet. It is common in certain parts of the world where the soil and water are deficient in iodine. The goiter can compress the trachea, esophagus, and recurrent laryngeal nerves. Depending on the size of the goiter determines the treatment. Small goiters are usually monitored but most of the time left alone. Large goiters, compressing the trachea and/or esophagus, need surgical intervention.

http://en.wikipedia.org/wiki/Thyroid

Trauma to the Recurrent Laryngeal Nerves

            The recurrent laryngeal nerves (RLN) branch from cranial nerve X, vagus nerve. The RLN branches into the right and left RLN each following its own distinctive path. The right RLN loops inferior to the right subclavian artery at approximately the T1-T2 level. The left RLN loops inferior to the arch of the aorta at approximately the T4-T5 vertebral level. Both nerves ascend to the thyroid gland, traveling through the tracheo-esophageal groove, innervating the trachea, esophagus, and all the intrinsic muscles of the larynx except the cricothyroid.

Trauma of the recurrent laryngeal nerves can be a result from a surgical procedure, pressure from associated blood vessels, or from blunt force trauma to the neck. The right RLN is intimately related to the inferior thyroid artery and its branches. The nerve can cross this vessel from different directions in different people causing a possible problem during surgery. The left RLN is a little more distinctive during surgical procedures because of its more vertical ascent from the superior mediastinum, and blood vessels. The closer to the inferior aspect of the thyroid gland, the more convoluted the left RLN becomes. Hoarseness is the most common result of trauma; usually pointing toward unilateral RLN injury. Temporary aphonia or disturbance of phonation and laryngeal spasms may also occur. Vocal rest is the usually treatment for unilateral trauma to the RLN.  

http://en.wikipedia.org/wiki/Recurrent_laryngeal_nerve

Entry 5

Coronary Occulsion and Conducting System of Heart

            The normal electrical conduction of the heart allows electrical propagation to be transmitted from the Sinoatrial Node (SA Node), the pace maker of the heart, through both atria to the Atrioventricular Node (AV Node). Baseline physiology allows the further propagation from the AV node to the purkinje fibers and repective bundle branches and fascicles. The SA and AV nodes stimulate the myocardium and proper, time ordered stimulation of the myocardium allows efficient contraction of all four chambers of the heart.

            Damage to the conducting system of the heart, often a result from ischemia, improper blood flow, caused by coronary artery disease. This produces disturbance in the myocardium, and since the anterioter intraventricular branch of the left coronary artery and the right coronary artery supply the AV and/or SA node a heart block could occur. There are several circumstances that could affect the AV and/or SA. When the AV node is affected the ventricles will begin to contract independently at their own rate but allowing the atria to contract at a normal rate. Under these circumstances a cardiac pacemaker would be implanted to control the rate of the ventricles.

http://en.wikipedia.org/wiki/Electrical_conduction_system_of_the_heart

 

Coronary Angioplasty

            Angioplasty is the surgical technique of mechanically widening a narrowed or obstructed blood vessel. An empty and collapsed balloon catheter, guided by a wire, is passed into the narrowed location and then inflated to a fixed size using water pressure normal to blood pressure. The balloon is responsible for crushing the fatty deposits and opening the blood vessel allowing for improved flow. The balloon is then collapsed and withdrawn.

            Percutaneous transluminal coronary angioplasty is a surgical approach for the treatment of stenotic coronary artery disease, and is caused by cholesterol-laden plaques that form due to atherosclerosis. Access to these blood vessels is gained through the femoral artery called percutaneous access. Real time X-ray visualization is used to guide the guiding catheter, which is pushed through the femoral artery ascending until it reaches the coronary artery that is infected. The guide wire is then pushed through the guiding catheter and this serves as the pathway for the balloon. A pharmaceutical aid called Heparin is used to thin the blood and reduce blood clots to help maintain blood flow.

http://en.wikipedia.org/wiki/Percutaneous_coronary_intervention

Fibrillation of Heart

Fibrillation is the rapid, irregular, and unsynchronized contraction of muscle fibers. Two types of cardiac fibrillation exist: artial fibrillation and ventricular fibrillation. During atrial fibrillation the normal rhythmical contractions of the atria are replaced by rapid irregular and uncoordinated twitching of different parts of the atrial walls. During ventricular fibrillation the ventricular contractions are replaced by rapid irregular twitching movements; stop the pumping action of the heart.

Artial fibrillation is usually easily treated with anticoagulation drugs and sometime with a conversion to normal sinus rhythm. The use of drugs are using sufficient in controlling either rate or rhythm, different. Ventricular fibrillation is the most serious condition because it inhibites the proper pumping of blood by the heart. One treatment of V-fib uses an electric defibrillator which can reverse the fibrillation by an electric discharge of direct current to the heart. This method is not always successful. Another treatment method is the implantation of a cardioverter defibrillator, which has been shown to be beneficial. 

http://en.wikipedia.org/wiki/Fibrillation

Entry Four

Mallet/Baseball Finger

            The extensor digitorum tendon at the distal interphalangeal joint is the location of trauma during mallet finger. The extensor digitorum muscle is located in the posterior forearm extending from the lateral epicondyle of the humerus and distally attaching to extensor expansions of medial four digits,. Interphalangeal joints are hinge joints between the phalanges of the hand; the distal interphalangeal joints are those between the second and third phalanges.

            This trauma results from the distal interphalangeal joint suddenly being forced into extreme flexion, for example, while a baseball is miscaught or a finger is jammed into the base pad. Treatment may or may not include a surgical intervention, depending on the severity of the deformity a Mallet splint can be worn for 6 to 8 weeks. The splint allows the tendon to return to normal length on its own. Surgery is used to reattach the tendon and is usually performed within a week of the injury.

 http://orthoinfo.aaos.org/topic.cfm?topic=A00018

Fracture of Olecranon

            The olecranon process of the ulna is a thick curved bony eminence  of the forearm that projects behind the elbow. It is located at the proximal end of the ulna and aids in the hinge joint of the elbow. The olecranon process of the ulna is the distal attachment point for the triceps brachii and the anconeus muscle. Branches of the ulnar nerve are found lying over the olecranon process of the ulna.

            Fracture of the olecranon is called a “fractured elbow”, that’s definitely a proper name for it. Typical trauma is caused by a fall on the elbow combined with sudden powerful contraction of the triceps brachii or an indirect fracture can occur from landing on an outstretched arm. The person lands on the wrist with elbow locked out straight. The triceps muscle on the back of the arm pull the olecranon off the ulna. Surgical intervention is usually always warranted in this type of trauma. Because of the traction produced by the tonus of the triceps on the olecranon fragment, pinning is required.
http://orthoinfo.aaos.org/topic.cfm?topic=A00503

           

Injury of Ulnar Nerve at Elbow

            The Ulnar nerve originates from the medial cord of the brachial plexuses. It runs down the posteromedial aspect of the humerus, over the elbow between the medial epicondyle of the humerus and the olecranon process of the ulna. The nerve continues down the forearm through the two heads of the flexor carpi ulnaris and runs alongside the ulna. The ulnar nerve innervates one and a half muscles in the forearm: the flexor carpi ulnaris and ½ of the flexor digitorum profundus. It also innervates the hypothenar muscles and provides sensory innervation to the 5^th digit and the medial half of the 4^th digit and corresponding part of the palm.

            More than 27% of nerve lesions of the upper limb affect the ulnar nerve. Injuries usually occur in four places: posterior to the medial epicondyle of the humerus, in the cubital tunnel formed by the tendinous arch connecting the humeral and ulnar heads of the FCU, at the wrist, and in the hand. The most common trauma occurs posterior to the medial epicondyle of the humerus. The trauma occurs when the medial part of the elbow hits a hard surface, fracturing the medial epicondyle, commonly know “the funny bone”. Other trauma can result in the extensive motor and sensory loss to the hand. An injury to the nerve in the distal part of the forearm denervates most intrinsic hand muscles. Surgical interventions are, most of the time, unsuccessful in reattaching the ulnar nerve.
http://orthoinfo.aaos.org/topic.cfm?topic=a00069

Entry Three

Rupture Calcaneal Tendon

            The calcaneal tendon, also referred to the Achilles tendon (named after the Greek war hero in Homer’s Iliad). The calcaneal tendon is the strongest, thickest, and most powerful tendon in the body. It is an extension of two leg muscles: the gastrocnemius and soleus; the tendon is approximately 15cm long. The strength of the tendon was proved during a stress test, which showed that the tendon could with stand a load of 3.9 times body weight while walking and about twice that when running. The tendon begins at middle of the triceps surae and distally attaches to the posterior surface of the calcaneal tuberosity.

            The rupturing of the calcaneal tendon is very traumatic and is often seen in poorly conditioned people. The trauma is typically experienced as an audible snap during a forceful plantarflexion with the knee extended followed by sudden triceps surae pain and dorsiflexion of the plantarflexed foot. The rupturing of the calcaneal tendon is the most serve acute muscular problem of the leg. Ambulation is possible but only when the limb is laterally rotated. A hematoma appears in the malleolar region; along with a lump on the calf owing to the shorting of the triceps surae. Surgical intervention is necessary for athletes and people with active lifestyles, but older and non-athletic  people usually are able to rehab without a surgical intervention.

http://en.wikipedia.org/wiki/Achilles_tendon

Hamstring Injuries

            The Hamstring is comprised of three posterior thigh muscles: biceps femoris, semitendinosus, and semimembranosus. The hamstrings cross and act upon two joints: the hip and knee. The semitendinosus and semimembanosus extend the hip when the trunk is fixed; they also flex the knee and medially rotate the lower leg. The biceps femoris extends the hip during walking; short and long heads flex the knee and laterally rotates the lower leg when the knee is bent. The hamstrings play a crucial role in many daily activities like walking, jumping, and controlling some movement in the trunk. The hamstring acts as an antagonist to the quadriceps during most of the activities listed above.

            Hamstring trauma, pulled and/or torn, are common in individuals who run and/or kick hard during athletic activities. This trauma is twice as common as quadriceps strains. The violent muscular exertion required to excel in these sports may avulse part of the proximal tendinous attachments of the hamstrings to the ischial tuberosity. Tearing of the hamstrings is a very painful trauma, and are often caused by inadequate warm up and stretching before physical activity.  Depending on the servarity of the trauma to the hamstrings the rehab regime is straight forward; us cold therapy and compression bandages during the first 48hrs of injury followed by messaging and stretching the muscle. Only under extreme cercumstances is a surgical intervention necessary.

http://en.wikipedia.org/wiki/Hamstring

  

Femoral Hernias

            A hernia occurs when the contents of the abdomen, usually part of the small intestine, push through a weak point or tear the thin muscular wall of the abdomen, which holds the abdominal organs in place. The femoral rings, the base of the femoral canal, is a weak area in the anterior abdominal wall. It’s a long diameter measures about 1.25cm, and its boarder includes the inguinal ligament, pectineus muscle, lacunar ligament, and the medial side of the femoral vein.

            The femoral ring is the usual site for femoral hernias, a protrusion of abdominal viscera through the femoral ring into the femoral canal. The hernia appears as a mass in the femoral triangle, inferolateral to the pubic tubercle. The hernial sac compresses the contents of the femoral canal and distends the wall of the canal. Initially the hernia is small because it is contained within the canal, but it can enlarge by passing inferiorly through the saphenous opening into the subcutaneous tissue of the thigh. Femoral hernias are more common in women because of their wider pelves. Necrosis can occur during strangulation of a femoral hernia because of the sharp, rigid boundaries of the femoral ring, particularly the concave margin of the lacunar ligament. Treatment is usually a surgical intervention, often a piece of plastic mesh is surgically placed to repair the defect in the abdominal wall.

http://en.wikipedia.org/wiki/Femoral_hernia

Entry Two

Chondromalacia Patellae

            The patella, knee cap, is a thick circular-triangular bone which articulates with the femur and protects the anterior articular surface of the knee joint. It provides a bony surface that is able to withstand the compression placed on the quadriceps tendon during  kneeling and friction that occurs during flexion and extention of the knee while running. It also provides additional leverage for the quadriceps in placing the tendon more anteriorly, farther from the joint’s axis, causing it to approach the tibia from a postion of greater mechanical advantage. The patella is the largest sesamoid bone in the human body.

            Chondromalacia patellae is a knee problem that is symptomatic of marathon runners, basketball players, and power lifters.  Chondromalacia is due to an irritation of the undersurface of the patella. The undersurface of the patella is covered with a layer of smooth cartilage and normally this cartilage glides smoothly across the knee during action. Some individuals, the patella tends to rub against one side of the knee joint and the cartilage surface becomes irritated and knee pain follows.
http://en.wikipedia.org/wiki/Chondromalacia_patellae

  

Great Saphenous Vein Graft

            Great saphenous vein is a large subcutaneous vein that spans the length of the thigh and leg. It is formed by the union of the drsal vein of the great toe and dorsal venous arch of the foot. The GSV ascends anterior to the medial malleolus, passes posterior to the medial condyle of the femur, anastomoses freely with the small saphenous vein, transverses the saphenous opening in the fascia lata, and empties into the femoral vein.

            The GSV is sometimes used for coronary arterial bypasses because it is easily accessible, has usable lengths between perforating veins and tribuatries, and the walls of the GSV have a high percentage of muscular and elastic fibers compared to other superficial veins. Saphenous vein grafts are used to bypass obstructions in blood vessels, i.e. intracoronary thrombosis. Since veins have values, which aid in the transport of blood back to the heart, the saphenous vein must be inverted so the values don’t obstruct blood flow.

http://en.wikipedia.org/wiki/Great_saphenous_vein

Transplantation of Gracilis

            The gracilis is a long, strap-like muscle and is the most medial muscle of the thigh. It is part of the adductor group of muscles, and is the weakest and most superficial of the group. The gracilis muscle crosses the hip and knee joint; it joins two other joint muscles (sartorius and semitendinosus). These three muscles have a common distal attachment point, collectively known as the pes anserinus, into the superior part of the medial surface of the tibia. The gracilis’s proximal attachment point is the inferior pubic ramus below the symphysis.

            The gracilis can be removed from the adductor group because of its weak contributions. The gracilis is often transplanted, or part of it, with nerves and blood vessels to replace damaged muscle in the hand. This process has produced good digital flexion and extension. The gracilis can also be dislocated from its distal attachment and repositioned to create a replacement for a nonfunctional external and sphincter.
http://en.wikipedia.org/wiki/Gracilis_muscle