|
Copy of First Block
|
|
Below is a navigation bar... Use it to find the lab instruction lecture number
TITLE: Superficial Structures of Back PAGES: Groups (A, B, C, D) Dissector: l-6; 115-120. NOTE: You will ALL be responsible for ALL clinical correlations in ALL assigned readings throughout the course.
GENERAL OBJECTIVES: (A) Gain experience in procedures for dissecting a human body. (B) Gain experience in identifying and reflecting skin, superficial fascia, and deep fascia. (C) Learn how to find cutaneous nerves. (D) Learn how to clean muscle. SPECIFIC OBJECTIVES: (l) Identify and where possible palpate the following bony landmarks on yourselves, a cadaver, and on available skeletal and radiographic material: spinous process of seventh cervical vertebrae (C7; vertebra prominens). Iliac crest. On scapula: borders, angles, spine, acromion (cf. dissector, p. 115-116). (2) Also be able to define midaxillary line. This is an imaginary vertical line drawn down either lateral surface of a body. It is located midway between an anterior axillary fold (a muscular fold forming the anterior border of the "armpit") and a posterior axillary fold (a muscular fold composed largely of latissimus dorsi muscle). Palpate these axillary folds and note the position of the midaxillary line. DISSECTOR MODIFICATIONS: Although we will refer to material in your dissector during this laboratory , you will follow instructions in this manual for your first dissection period. You will begin to use the dissector as you and your laboratory partner begin your assigned dissections for presentation to the other students at your table. A review of the material you are dissecting now will be incorporated into appropriate student presentations as the course proceeds.
Plan for Dissection Incisions will be made on the back and four large flaps of skin will be reflected laterally, exposing an underlying fatty layer known as superficial fascia. Flaps of superficial fascia will then be reflected laterally, permitting identification of some of the segmentally arranged cutaneous nerves and vessels and the investing layer of deep fascia (fascia overlying the muscles of the body). You will then begin the tedious task of removing the investing layer of deep fascia from exposed portions of two extensive superficial muscles of the back, trapezius and latissimus dorsi. In subsequent laboratories, some students will begin their first assigned dissections while the remaining students will complete the cleaning of the superficial back.
Skin Incisions You will make some, but not all incisions shown in figure 4-8 of the dissector. Be sure and cut only through skin. On both sides of the body cut:
(2) From point R down midline to a point about 2-5cm (l-2 inches) above the top of the
(3) From point S laterally along iliac crests as far as midaxillary lines (point T). (4) From middle of incision RS (point U) laterally to midaxillary lines (point V).
Dissection You have now made four large skin flaps. Each flap has two corners. Each dissector should begin reflecting skin at one of these corners. Some will have to wait a few minutes until reflection of an adjacent flap has begun. Pick up a corner with your large, blunt forceps and begin to separate skin from the underlying, yellowish fat of the superficial fascia. Keep the skin taut and work your scalpel blade along the underside of the skin. You will recognize the underside of skin by its tougher consistency and pebblegrain appearance; rather like the surface of a football. Once you have identified the underside of the skin, pull the flap back, hold it taut, and separate skin from fascia by cutting at the base of the flap. It is easier to distinguish between skin and fascia if you use the back of the scalpel tip at this time, rather than the cutting edge. The sharp edge of your blade will cut skin, fascia and fat with equal ease, whereas the back of the tip will allow you to feel the differences in toughness. The back of the scalpel tip will tear fascial fibers as you scrape across them, but it will not penetrate the skin so easily. Remember that this is your only chance to gain experience removing skin before beginning an assigned dissection. Try to do a good job, not a fast one. As you proceed, notice that skin in the middle of the back is quite thick, but it becomes much thinner laterally. Removal of skin dulls scalpel blades quickly. As you change blades, put used blades only in containers provided at sides of the laboratory. Be very careful when you first start to use a new blade. You usually forget how sharp it is. Do NOT cut the skin flaps away from the body. Leave them attached laterally (at midaxillary line) so they can be placed back over the dissected area. In death as in life, skin is the best protection against drying, but only as long as the skin itself does not dry out. Make a practice of keeping reflected skin flaps rolled in moist cloths. The next objective is to remove the superficial fascia and expose cutaneous nerves and blood vessels. In most cases, you will be able to see locations of many cutaneous nerves with superficial fascia intact. Your cadaver was embalmed on its back and blood tended to pool in cutaneous veins that accompany nerves. Each nerve is accompanied by a small artery and vein, these three structures constituting a so-called neurovascular bundle. This arrangement is a commonly observed one throughout the body, often involving very large vessels and nerves as well as smaller ones. Note that cutaneous nerves (see Atlas fig. 4-47) emerge close to midline in the upper back, but are located more laterally in the lower back. About halfway between midline and midaxillary line, make a longitudinal incision through the superficial fascia. Ideally, you will know when you are through this layer when you come to a thin, whitish membrane, which is the investing layer of deep fascia. In the lower back, you will encounter a membrane which is much thicker and glistening white. It is a flattened sheet of tendon called an aponeurosis. This is the lumbar aponeurosis shown but not labelled in Atlas 4-47A. If you cut through deep fascia, or the lumbar aponeurosis, you will see muscle, which is reddish or brownish in color. No great harm done, just back up and identify fascia. Leave the deep fascia in place and reflect superficial fascia by blunt dissection; use your fingers, or when necessary, forceps, scalpel handle, or the back of a scalpel blade. When you encounter cutaneous neurovascular bundles, you will be able to feel them as they enter superficial fascia; they feel like slippery threads or strings. Cut them free as you find them, leaving visible stumps attached to the body. As you proceed with reflection of superficial fascia, notice that it varies greatly in thickness, not only from body to body but in different parts of the same body. It is much thicker laterally on the lower back than on the upper back. As flaps of superficial fascia are loosened, cut them free. Discard these, and all other human remains, only into containers for human remains. These are containers located along side walls of the laboratory. You will often find paper towels handy for removing fat from muscle surfaces, etc. Discard such towels in the containers for human remains also. Your next objective is to clean superficial back muscles and related structures. Cleaning of muscles involves removal of deep fascia, usually by sharp dissection, to determine muscle boundaries and attachments as well as directions in which muscle fibers run. This is a particularly tedious process on the large expanses of superficial back muscles. Clean exposed portions of trapezius and latissimus dorsi muscles (Atlas 4-47; Dissector 4-11); do not split trapezius to find the accessory nerve. Keep deep fascia moist and pick it up, bit by bit, with blunt forceps. In some cases it may come off in strips if you cut in the direction of muscle fibers with a sharp scalpel. Remove only deep fascia. These muscles are very thin where you are working and it is very easy to slice right though them. Clean muscles all the way to their (exposed) attachments. The greatest trouble students have later, when they try to reflect muscles out of the way of underlying structures, is that they have not cleaned the muscle well enough and are working blind on attachments still buried in fat or connective tissue. In a similar fashion clean exposed portions of the lumbar aponeurosis. You may not be able to get as neat an appearance as the Atlas suggests because lobules of fat are often buried between the connective tissue sheets that make up this aponeurosis. Clean one or two of the larger neurovascular bundles to determine that each contains three structures. If the vein contains blood, it is easy to identify. The (thinner) artery may be difficult to distinguish from the (tougher, flatter, shiny) nerve. Identification will be easier later, when you are working at deeper levels where the structures are larger.
AT THE END OF LAB: For this laboratory, no muscles have been reflected, so simply wet exposed muscles and fasciae, and undersurface of skin with preservative solution. Replace the skin flaps. In later laboratories, you will also be replacing muscles in their original positions. Cover the skin, particularly over incisions, with cloth and spray preservative on the cloth. Keep wrappings on head and extremities moist with preservative solution.
NOTE: When you are not working on the body, your dissection table should always be kept closed, with stools stacked on top of it. You are encouraged to examine dissections other than your own. However, you have no right to use or examine any other body without the knowledge and permission of the dissectors of that body. Treat other cadavers as your own. Keep them moist, and see that they are properly covered when you are finished studying them. LABORATORY DEMONSTRATIONS: Throughout this course, special laboratory demonstrations consisting of models and/or predissected material will be set up to aid in your understanding of particular regions of the body. There are no special demonstrations for today's laboratory, but subsequent sessions will often include models and demonstrations. These will be placed on the counters in the back of the lab. Such material provides important information that you might not encounter in your dissections. It should be examined by all. Note that, in some instances, these demonstrations will be available only during class hours and not during study hours. Radiographs for study of Bony Landmarks are also provided. These are in boxes on the walls next to the view boxes. They are available to you at all times. PREPARATION FOR THE NEXT LABORATORY PERIOD: In this manual, instructions for dissecting each region are found on the pages for the day on which that region is introduced. Dissectors of a particular region are expected to be familiar with those instructions before they come to the laboratory. Come prepared with any questions about the region when you are given a prosection in the laboratory. All students should look over objectives for a laboratory before it is presented by the dissectors and bring any questions to the presentors. Furthermore, all students are responsible for completing all assigned readings (for all groups) prior to the laboratory period when the material is presented.
TITLE: Continue Superficial Back (Groups C, D); Introduction to Posterior Neck (left side),
PAGES: Group (A) Dissector: 120-122 (deep Moore: 351-359 muscle group up to spinal cord) 115-117 and 123-124 (bony landmarks) Group (B) 206-208 783-796 Groups (C, D) 1-6; 530-533 115-120 GENERAL OBJECTIVES:
SPECIFIC OBJECTIVES:
Group A should begin dissection of back of neck, deep back, spinal column (left side only) in order to demonstrate the following: (l) Superficial muscles of posterior neck. (2) Greater occipital nerve and occipital artery. (3) Splenius capitis and cervicis and semispinalis capitis and cervicis muscles.
Group B should begin their dissection of posterior triangle of neck (only on right side). Your specific objectives are as follows:
Groups C, D: At the end of this laboratory, Groups C, D should have completed the following:
DISSECTOR MODIFICATIONS:
Group A (Posterior neck, deep back, spinal column): Extend midline incision R--X (fig. 4-8) somewhat more cranially than the dissector indicates to about 2.5 cm above external occipital protuberance. Likewise, keep transverse incision X--M higher, but curving down to the mastoid process, M, only at the lateral extent of the incision. Do this only on the left side. [Note: In anatomy, left and right refer to the cadaver’s left and right.] Expose greater occipital nerve and occipital artery on the left side as directed by the dissector (p. 118). Then comlete the cleaning and reflection of trapezius that was begun by groups C and D. Upon reflection of trapezius and the rhomboids, identify underlying splenius and semispinalis as indicated in your dissector (p. 120). Reflect splenius laterally, and try to trace the course of the occipital artery toward the skull. Trace longissimus capitis m. to the skull. Identify greater occipital nerve piercing semispinalis capitis. If not already done, carefully clean the internal oblique muscle in the lumbar triangle to demonstrate that, in the lumbar region, the internal oblique m. takes origin from the lumbar aponeurosis. Identify serratus posterior superior and inferior mm. on both sides. Cut the thoracolumbar fascia free from the vertebral spines along its entire exposed length, then cut the lumbar aponeurosis transversely at skin incision S-T and reflect the flaps laterally. On the left side of the body, cut across erector spinae (sacrospinalis) through its entire thickness and identify the three columns of muscle: spinalis, longissimus, and iliocostalis. Reflect the muscles laterally, using blunt dissection whenever possible, to reveal their lateral attachments. Try to preserve some of the posterior primary rami as they enter the deep surface of the muscles (Atlas 4-49). On the right side, examine multifidus of the transversospinalis group, in the lumbar region. To do this, make a shallow longitudinal incision through the aponeurotic lumbar portion of sacrospinalis next to the vertebral spines and reflect the muscle mass laterally. Multifidus (Atlas 4-53) can then be readily exposed by blunt dissection (fingers). Back on the left side, observe the depth of multifidus and the rest of the deep muscles by using a scalpel to cut a segment of the entire, intact deep muscle mass free of the vertebral spines and laminae. Again try to preserve posterior primary rami as they enter the deep surface of the muscles. Clearly expose the laminae and spines of one or two vertebrae.
Group B (Posterior triangle of the neck): Skin Incisions in figure 4-8 in your dissector should be modified as follows: Posterior triangle will be dissected only on the right side. [Note: In anatomy, left and right refer to the cadaver’s left and right.] Begin incision X-M about 2.5cm superior to the external occipital protuberance and extend it laterally to just inferior to the right ear. Next, make an incision from tip of acromion medially along the clavicle to about 2cm from midline of the body (you may have to turn the cadaver on its side). This will allow you to reflect this flap of skin anteriorally to the border of sternocleidomastoid m. DO NOT MAKE INCISION E-F IN FIGURE 7.29!! You will dissect this region in two stages. Stage l will be a dissection of superficial structures (p. 206-208 in dissector). Do not resect the clavicle (Note: Because you will not resect the clavicle, you will not expose the subclavius m.). Stage 2 will begin two labs hence with dissection of structures deep to the fascial floor of the triangle. Now continue your dissection as described in the dissector p. 207 with the following change:
Although your dissector does not instruct you to do so, you should examine a clavicle and first rib before examining structures deep to the floor of the triangle. In particular note the scalene tubercle, and grooves for subclavian artery and vein on a first rib. In regard to clavicle, examine its blunt proximal end for articulation with manubrium of sternum and its flattened distal end that articulates with scapula. Also note that the clavicle is bowed anteriorly to provide space for important structures that pass over the first rib to reach the upper limb.
LABORATORY DEMONSTRATIONS (Predissected material to be examined): Course of the vertebral artery through the neck and into the skull. Atlantooccipital and atlantoaxial joints. Transverse sections: cervical and thoracolumbar regions
TITLE: Introduction to Scapular/Deltoid Region (Group C); Introduction to Gluteal
PAGES: Group (A) same as lab 2 same as lab 2 Group (B) same as lab 2 same as lab 2 Group (C) Dissector: 161-164 Moore: 533-539; Case 6-2 Group (D) 135-138 Cases 5-1, 5-5, 5-6
GENERAL OBJECTIVES: (A) Group A should continue posterior neck, deep back and spinal column. (B) Group B should continue posterior cervical triangle. (C) Group C should complete the dissection of superficial back muscles. They should be
(D) Group D will receive instructions for dissecting the gluteal region. (E) Groups A and B should also study spinal cord and spinal column demonstrations (see
SPECIFIC OBJECTIVES: GROUP C (SCAPULAR/DELTOID): In addition to the "Bony Landmarks" listed in your dissector, Group C should identify the following structures either on a skeleton or on a radiograph:
You will also be responsible for presenting the following: (l) Deltoid muscle and its nerve and blood supply. What is its action? (2) Quadrangular space and its contents. (3) Triangular interval and its contents. (4) Identify three of the muscles (SIT) comprising the rotator cuff and understand
(5) Examine triceps brachii muscle and its nerve and blood supply. (6) Examine teres major muscle. What is its action? (7) Identify the inferior belly of the omohyoid muscle. (8) Understand collateral circulation around the shoulder. (9) Trapezius, levator scapulae, latissimus dorsi, rhomboideus major and minor muscles, along with serratus anterior muscle (Atlas 6-28), all influence movements at the shoulder joint. Understand which movements are produced by each of these muscles.
GROUP D (Gluteal) (1) In demonstrating bony landmarks, note that the sacroiliac joint (Atlas 4-28) acts as
(2) Emphasize relations of the nerves and vessels to piriformis m. (3) Emphasize that the inferior border of gluteus maximus approximates a straight line. How
(4) Injections in which quadrants would endanger the superior or inferior gluteal nerves?
(5) What structures pass through the greater and lesser sciatic foramina? (6) Note how the sciatic nerve is related to: piriformis m., ischial tuberosity, posterior
(7) Put traction on gluteus maximus to demonstrate its insertion upon the iliotibial tract.
DISSECTOR MODIFICATIONS: GROUP C (Scapular/Deltoid) Superficial vessels and cutaneous nerves need not be dissected. Do not dissect the origins of the axillary nerve and posterior humeral circumflex artery as directed by your dissector. This will be done later. Simply expose these structures and their relationship to the deltoid muscle. NOTE: Skin Incisions for this dissection should be done as follows: make a longitudinal incision from the acromion, down the lateral aspect of the arm as far as the elbow. From the distal end of this, make a transverse incision medially, across the posterior surface of the elbow. Reflect skin and superficial fascia medially in one flap. This exposes the extensor compartment of the arm. Identify the deep surface of the serratus anterior muscle at its insertion along the vertebral border of the scapula. Clean the first 5 or 6 cm of its thickened inferior border (Atlas 4-48) to permit a clearer view of its deep surface and attachment at the inferior angle of the scapula. The course of the radial nerve and profunda brachii artery through the posterior compartment will be traced. First, clean the triceps brachii muscle by incising the investing layer of deep fascia (Brachial Fascia) longitudinally down the middle of the back of the arm. Try to peel the fascia free as two flaps, a lateral and medial, to expose the muscle (Atlas 6- 40B). Use blunt dissection (fingers) as much as possible. Use no sharp dissection at all near the medial aspect of the elbow, to avoid damage to the ulnar nerve (Atlas 6-40B), which will be studied later. As you reach the borders of the muscle, identify the extensions of deep fascia that go deep to attach to the humerus. These are the medial and lateral intermuscular septa (dissector 6.13) which separate the extensor compartment from the flexor compartment. Now pass a probe downward along the course of the radial nerve and profunda brachii artery, through the narrow tunnel formed by the medial and lateral heads of the triceps and the spiral groove of the humerus. Cut down to the probe (through the lateral head of the triceps) to expose the course of the artery and nerve through the extensor compartment. Use the directions in your dissector to complete your study of this region. One further comment should be made. Work with the dissectors of the posterior triangle of the neck in finding and tracing the courses of the transverse cervical artery, accessory nerve, suprascapular nerve and vessels, dorsal scapular nerve and vessels, and the omohyoid muscle. Whoever finds a structure first can make it easier for everyone else to trace. Group D (Gluteal): Dissect the gluteal region on the right side only. Make a midline incision through the skin covering the lower lumbar region and sacrum as far inferiorly as the (palpable) tip of the coccyx. From that point, continue the incision laterally and inferiorly, at an angle of about 46 degrees, as far as the lateral border of the thigh. Beginning at midline, use sharp dissection to remove skin and superficial fascia in one flap from the muscle fibers of gluteus maximus. As you do this, you will notice that the investing layer of deep fascia (gluteal fascia) you are removing from the muscle is very thin. As you define the superior border of the muscle, this fascia will suddenly become very thick, where it covers gluteus medius. Sharp dissection will also be necessary to expose gluteus medius. As you define the inferior border of gluteus maximus medially, it will end upon a thick pad of fat, which should be left undisturbed. More laterally, the gluteal fascia will blend with the thicker, investing fascia of the thigh (fascia lata). Try not to cut into the fascia lata; the posterior cutaneous nerve of the thigh lies just deep to it. On the lateral aspect of the thigh, the fascia lata will be seen to become still thicker, where it forms the iliotibial tract (Atlas 5-34) containing the tensor fascia lata muscle. You will probably do better at finding the posterior cutaneous nerve deep to gluteus maximus after you reflect it, rather than going deep to the fascia lata as your dissector directs. (The nerve will be found just medial to the sciatic, and is considerably larger at its commencement than it is in the thigh).
LABORATORY DEMONSTRATIONS: Spinal column and meninges. Spinal cord and spinal nerves.
In addition to those structures listed in your dissector under "spinal cord" pp. 86-87, identify the following with the aid of lab demos, skeleton and your atlas:
GROUP C As an aid, dissections will be available for each of the following:
TITLE: Complete Posterior Neck, Deep Back and Vertebral Column (Group A); Continue Gluteal Region, right side (Group D); Continue Scapular and Deltoid Regions, right side (Group C); Introduction to Deep Posterior Triangle of Neck (Group B). Groups C and D should study spinal cord and spinal column demonstrations. PAGES: Group (A) Dissector: same as lab 2 Moore: same as lab 2
Group (B) same as lab 2 same as lab 2
Group (C) same as lab 3 same as lab 3 Group (D) same as lab 3 same as lab 3
GENERAL OBJECTIVES: (A) Group A should complete posterior neck, deep back and vertebral column for presentation in the next laboratory. (B) Group B will receive further instructions for posterior triangle of neck (right side). (C) Group C should continue scapular and deltoid dissection (right side). (D) Group D should continue gluteal region dissection (right side). (E) Groups C and D should also study spinal cord and vertebral column demonstrations (see LABORATORY DEMONSTRATIONS, LABORATORY: #3). SPECIFIC OBJECTIVES: NONE DISSECTOR MODIFICATIONS: NONE LABORATORY DEMONSTRATIONS (NEW): NONE
TITLE: Present Posterior Neck (left side), Deep Back, Spinal Column, Begin Pectoral Region (Group A); Complete Gluteal Region, right side (Group D); Complete Scapular and Deltoid Regions, right side (Group C); Continue Posterior Cervical Triangle, right side (Group B). PAGES: Group (A) Dissector: 7-14;164-165 Moore: 501-510; 45-48
Group (B) same as lab 2 same as lab 2 Group (C) same as lab 3 same as lab 3 Group (D) same as lab 3 same as lab 3
GENERAL OBJECTIVES: (A) Group A will present posterior neck, deep back, spinal column. You will receive instructions for dissecting the pectoral region. (B) Group B should continue dissecting the posterior cervical triangle. (C) Group C should complete dissecting the scapular and deltoid regions. (D) Group D should complete dissection of the gluteal region. You will receive instructions for dissecting the pectoral region. SPECIFIC OBJECTIVES: Upon completion of this dissection, Group A should: (l) Understand the structure of the breast as it relates to function, emphasizing factors involved in mammary carcinoma in particular. (2) Review cutaneous branches of a spinal nerve paying particular attention to the ventral ramus and its branches. (3) Identify pectoralis major and minor, and subclavius muscles. Know their nerve supply, vasculature, and actions. (4) Also identify and clean serratus anterior muscle. Isolate its nerve and blood supply. Understand its action. (5) Note the clavipectoral fascia. It is a deep layer of fascia that invests subclavius and pectoralis minor muscles. In early stages of breast carcinoma it helps arrest its spread to deeper structures. (6) Besides using skeletal material, identify on the available radiographs those structures listed under "Bony Landmarks".
DISSECTOR MODIFICATIONS: Group A (PECTORAL REGION): Omit the exercise on identifying intercostal spaces (I.C.S.) and dissection of platysma. They will be dissected in a later laboratory. Furthermore, do not make incision E-C in figure l.6 of the dissector. Once the remaining incisions are made however, reflect the skin flap laterally, but do not join with incisions on the back. NOTE: When you uncover the clavipectoral fascia, show it to your table before removing it as per the directions in your dissector. In addition to muscles you are asked to identify in the dissector, also clean serratus anterior muscle. It should be cleaned as far superiorly as floor of the axilla. As you clean the muscle, identify its nerve, which runs on its surface (Atlas 6-28). Work together with dissectors of the axilla in tracing the nerve through the axilla and to its origins in the posterior triangle. Finally, unlike the directions in your dissector, do not trace the cephalic vein and thoracoacromial artery into the axilla. LABORATORY DEMONSTRATION On a female breast, identify nipple, areola, and suspensory ligaments (Cooper's ligaments). Note compartments containing lobules of fat. Finally, identify lactiferous ducts passing from gland tissue to nipple.
TITLE: Continue Pectoral Region (right side) (Group A); Present Gluteal Region (right side), Introduction to Axilla (right side) (Group D); Present Scapular and Deltoid Regions (right side), Introduction to Arm, Flexor Region of Forearm (right side) (Group C); Continue Posterior Triangle (right side) (Group B). PAGES: Group (A) Dissector: 7-14 Moore: same as lab 5
Group (B) 206-208 same as lab 2 Group (C) 168-174 539 (arm)-581 Case 6-1, 6-3 Group (B) 164-168 510-530
GENERAL OBJECTIVES: (A) Group A should continue dissecting the pectoral region. (B) Group B should continue dissecting the posterior cervical triangle. (C) Group C will present the scapular and deltoid regions and will receive instructions for dissecting arm and flexor region of the forearm (right side). (D) Group D will present the gluteal region and will receive instructions for dissecting the axilla. SPECIFIC OBJECTIVES: Group C:
(2) Identify the muscles in the flexor compartment of the arm and forearm.
(5) Make some general comparisons between the upper and lower limb circulation. (6) On a skeleton, observe the following joints: elbow, radioulnar, wrist.
Group D: At the completion of this laboratory dissection, Group D should present the following:
(2) Examine the axillary vessels and their branches.
(4) Examine superficial and cutaneous nerves of the limb. (5) Understand, in a general way, lymphatic drainage through the axillary nodes. (6) Compare major blood vessels supplying upper and lower limbs. (7) Review collateral circulation to the arm (Atlas figure 6.7). DISSECTOR MODIFICATIONS: Group C: When dissecting the forearm, Group C should make a skin incision down the lateral border of the forearm and then another encircling the wrist (dissector fig. 6.1). Use blunt dissection to remove skin and superficial fascia as one flap. Optionally, you may wish to retain the cephalic, basilic and median cubital veins (Atlas 6-4). Once the skin is reflected, proceed as directed by your dissector, only omitting the sections on the triceps brachii which have been previously done. You should however, demonstrate the continuity of the radial nerve from the axilla to the cubital fossa, and trace the profunda brachii artery from the brachial artery into the radial groove. Furthermore, you do not have to dissect the anastomoses around the elbow. Simply present this using either your dissector (fig. 6.15) or Atlas (fig. 6-63). Reflect muscles after cutting palmaris longus and flexor carpi radialis tendons. Pass a probe from the cubital fossa distally through pronator teres muscle along the course of the median nerve (between the two heads of pronator teres). Complete the division of pronator teres close to the radius and be sure you can see the median nerve passing deep to the flexor digitorum superficialis before detaching that muscle from the radius. When examining the various joints, note the following:
Group D (AXILLA): In exposing the axilla, do not be overly concerned with damaging superficial structures of the upper limb (except for the cephalic vein, which should be retained). To gain access to the axilla, use blunt dissection on the right side of the body to peel the flap of skin and attached superficial fascia from the pectoral region away from the floor of the axilla and the anterior and medial aspects of the arm. Work together with dissectors of the pectoral region in tracing the cephalic vein into the axillary vein. Sever the axillary vein distal to the entrance of the cephalic vein and remove it, and its branches from the axilla as you proceed. The axillary artery, vein and parts of the brachial plexus lie within a delicate, fibrous axillary sheath which you should carefully remove. Also work together with the dissectors of the pectoral region in exposing the origins of the thoracoacromial artery and tracing the long thoracic nerve (to serratus anterior) into the posterior triangle of the neck. Finally, when you have identified the cords of the brachial plexus, follow them proximally toward the posterior triangle. Try to identify and clean the anterior and posterior divisions (dissector fig. 6.11) which connect the trunks to the cords. LABORATORY DEMONSTRATIONS: Examine the ligaments associated with the joints.
Again, observe the special prosections of the lower extremity. Note the similarity between the upper and lower limbs.
TITLE: Contiune Axilla, Introduction to Posterior thigh (Group D); Complete Pectoral Region (Group A); Continue Posterior Triangle (Group B); Continue Arm & Flexor Region of Forearm, Introduction to Anterior and Medial Thigh (Group C). PAGES: Group (A) Dissector: 7-14 Moore: same as lab 5 Group (B) 206-208 same as lab 2 Group (C) 161-164, 131-135 377 (thigh)-407 Group (D) 164-168 510-530
GENERAL OBJECTIVES: (A) Group A will complete dissecting the pectoral region. You will present this dissection in the next laboratory period. (B) Group B will continue posterior triangle. (C) Group C will continue arm amd flexor region of forearm, and receive instructions for anterior and medial thigh. (D) Group D will continue axilla and receive instructions for the posterior thigh. ALL BEGIN LOWER EXTREMITIES SPECIFIC OBJECTIVES: Group C (ANTERIOR AND MEDIAL THIGH): In laboratory #10 you will present to your tablemates certain structures on the anterior and medial portions of the thigh using the predissected lower extremity. You will be responsible for presenting the following:
Group D (POSTERIOR THIGH): In laboratory #10 you will present to your tablemates certain structures on the posterior thigh using the predissected lower extremity. You will be responsible for presenting the following: (1) Identify the posterior cutaneous nerve of the thigh (posterior femural curaneous nerve) and its dermatome distribution.(Atlas 5.7) (2) Identify the "hamstring" muscles. (semitendinosus, semimembranosus, long head of biceps femoris) Differentiate between the long and short head of biceps femoris. What is their nerve supply? (Atlas 5.8D, 5.31, 5.32, 5.34) (3) Identify the adductor magnus. (Atlas 5.34) (4) Identify the sciatic nerve. (5) Isolate a few perforating branches from the profunda femoris artery. (6) What are the boundaries of the popliteal fossa? (Atlas 5.53) (7) Demonstrate the popliteal artery and vein. (Atlas 5.54, 5.55, 5.57) (8) Identify the common peroneal and tibial nerve as they approach the fossa. DISSECTOR MODIFICATIONS: NONE
TITLE: Continue Anterior Part of Arm and Flexor Region of Forearm & Anterior and medial Thigh (Group C); Complete Posterior Triangle (Group B); Present Pectoral Region, Begin Superficial Palm (Group A); Continue Axilla & Posterior Thigh (Group D). PAGES: Group (C) Dissector: 168-174; Moore: 539(arm) - 581 Case 6-1, 6-3 131-135 377(thigh) - 407 Group (B) 206-208 same as lab 2 Group (A) 174-178 591-607 Case 6-5,6-6,6-7 Group (D) 164-168 same as lab 6 GENERAL OBJECTIVES: (A) Group A present the pectoral region. You will then be given instructions for dissecting the superficial palm (right side). (B) Group B should complete the posterior triangle. You are scheduled to present this region in the next laboratory. (C) Group C should continue to dissect the anterior compartment of the arm, flexor region of the forearm on the right side, and anterior and medial thigh. (D) Group D continue dissecting the axilla on the right side and the posterior thigh. SPECIFIC OBJECTIVES:
DISSECTOR MODIFICATIONS: Group A: Follow the directions in your dissector for examining the superficial palm. Include however, the following: Try to leave the palmar aponeurosis attached between the ring and little fingers, so that it can be put back for demonstration. Try to keep palmaris brevis m. attached to the aponeurosis, not the hypothenar fascia. Do not try to inject the synovial sheaths to demonstrate their extent. Use the atlas instead. On one finger, leave the fibrous digital sheaths and synovial sheaths intact. On another finger, make a midline longitudinal incision through the digital sheaths and synovial sheath to demonstrate the insertions of the long flexor tendons. Identify and clean the lumbricals as well as you can (Atlas 6-90, 91). They will be better exposed in the next dissection; do not cut flexor digitorum superficialis or profundus muscles or disturb the anatomy of the rest of the superficial palm just to show the origins of the lumbricals from flexor digitorum profundus tendons (they arise from the radial sides of their respective tendons). Expose and clean the tendon of flexor pollicis longus. LABORATORY DEMONSTRATIONS: NONE
TITLE: Present Posterior Triangle -- Begin Deep Palm and Extensor Region of Forearm (Group B); Continue Superficial Palm, Introduction to Anterior and Lateral Leg (Group A); Complete Axilla, Continue Posterior Thigh. Posterior Thigh (Group D); Continue Arm and Flexor Region of Forearm & Anterior and Medial Thigh (Group C). PAGES: Group (B) Dissector: 178-181 Moore: 596-606 631 (Case 6-3) 631 (Case 6-4) 632 (Case 6-5) Group (D) 164-168 same as lab 6 Group (C) 168-174 same as lab 7 Group (A) 174-178 same as lab 7 GENERAL OBJECTIVES: (A) Group A continue superficial palm and receive introduction to anterior and lateral leg. (B) Group B will present posterior triangle. You will then be given instructions to dissect the deep palm and extensor region of forearm. (C) Group C will complete the arm, flexor region of the forearm for presentation in the next laboratory. Continue dissecting the anterior and medial thigh (for presentation in laboratory #10). (D) Group D will cmplete dissecting the axilla and posterior thigh. You will present these regions in the next laboratory. SPECIFIC OBJECTIVES:
Group B:
DISSECTOR MODIFICATIONS: Group B (Deep Palm and Extensor Region of Forearm): These regions will be dissected on the left upper limb. Remove the limb at the middle of the arm by cutting around the integument and muscles and sawing through the humerus. Remove the skin and superficial fascia as one flap. Make your initial skin incisions on the lateral side of the arm and forearm and across the front of the wrist. Once the skin and superficial fascia have been reflected from the front of the forearm, proceed to reflect the skin of the hand and examine the deep palm as follows: Identify the palmaris longus and transect it about halfway up the forearm. Identify the ulnar artery and nerve and preserve them. Use the distal end of the palmaris longus to put traction on the palmar aponeurosis. Work a probe or your finger deep to the aponeurosis and cut it free, along with the overlying skin, on each side. Reflect the flap distally to the bases of the fingers. Make incisions along the sides of the fingers past the PIP joints and reflect the skin flap that far distally. Next, identify the tendons of the flexor digitorum superficialis muscle and follow them proximally to the fleshy belly of the muscle. Transect this fleshy belly. Reflect the tendons distally to the bases of the fingers, cutting through any structures which interfere (e.g., superficial palmar arch). Slit the fibrous flexor sheaths so that the tendons can be retracted past the proximal interphalangeal joint. Identify the fleshy belly of the flexor digitorum profundus and transect it. Pull the tendons distally as far as you can without disturbing the origins of the lumbrical muscles from these tendons. Now identify the deep branch of the ulnar artery and ulnar nerve at the wrist. You can now proceed with the rest of the dissection as directed by your dissector to isolate the deep muscles of the palm. Remove the rest of the skin of the limb. LABORATORY DEMONSTRATION: Cutaneous veins of the extremities.
TITLE: Continue Deep Palm and Extensor Region Forearm (Group B); Present Axilla, Continue Posterior Thigh (Group D); Present Arm, Flexor Region of Forearm, Continue Anterior and Medial Thigh (Group C); Continue Superficial Palm & Anterior and Lateral Leg (Group A).
PAGES: Group (B) Dissector: 178-181 Moore: same as lab 8 Group (D) 164-168 same as lab 6 Group (C) 168-174 same as lab 7 Group (A) 174-178 same as lab 7 GENERAL OBJECTIVES: (A) Group A will continue the superficial palm and anterior and lateral leg dissections. (B) Group B will continue deep palm and extensor region of forearm. (C) Group C will present their dissection of the arm and flexor region of the forearm. They should then complete their dissection of anterior and medial thigh for presentation in the next laboratory. (D) Group D will present axilla. They should then complete their dissection of posterior thigh for presentation in the next laboratory.
SPECIFIC OBJECTIVES: NONE
DISSECTOR MODIFICATIONS: NONE
LABORATORY DEMONSTRATION: NONE
TITLE: Present Anterior and Medial Thigh, Introduction to Anterior Abdominal Wall (Group C); Present Posterior Thigh, Introduction to Anterior Thoracic Wall (Group D); Continue the Superficial Palm & Anterior and Lateral Leg (Group A); Continue the Deep Palm and Extensor Region of the Forearm, Introduction to Posterior Leg (Group B). PAGES: Group (A) Dissector: 174-178 Moore: same as lab 7 Group (B) 178-181 same as lab 8 Group (C) 43-47 (omit "Inguinal 127-138 Region"), 48-51 beginning with "Muscles of Anterior Wall" (omit "Deep Inguinal Ring and Transversalis Fascia" and "Reflection of the Abdominal Wall") Group (D) 7-14 (omit "Removal of 33-45 Anterior Thoracic Wall")
GENERAL OBJECTIVES: (A) Group A should continue dissecting the superficial palm and anterior and lateral leg. (B) Group B will receive instructions for the posterior leg, and should continue dissecting the deep palm and extensor region of the forearm. (C) Group C will present the anterior and medial thigh, and will receive instructions on dissecting anterior abdominal wall. (D) Group D will present posterior thigh, and will receive instructions on dissecting anterior thoracic wall.
SPECIFIC OBJECTIVES: Group C:
Group D:
(5) Know the extent of the projections of the heart and lungs onto the rib cage (Figure 1.5).
DISSECTOR MODIFICATIONS: Group C: This dissection will emphasize the muscles and fascial layers of the abdomen, along with a few superficial nerves and vessels. The very important structures of the inguinal region will be dissected later in the course. In order for the inguinal canal and its contents to be preserved until that time, you will follow only a selected subset of the instructions in the Dissector. In addition, the following instructions must be followed:
Group D: Do not reflect the rib cage at this time. Simply examine the structures composing the thoracic wall in preparation for reflecting it in a later laboratory.
TITLE: Complete Superficial Palm, Continue Anterior and Lateral Leg (Group A); Complete Deep Palm and Extensor Region of Forearm, Complete Posterior Leg (Group B); Continue Anterior Abdominal Wall (Group C); Continue Anterior Thoracic Wall (Group D). PAGES: Group (A) Dissector: 174-178 Moore: same as lab 7 Group (B) 178-181 same as lab 8 Group (C) 43-47 (omit "Inguinal 127-138 Region"), 48-51 beginning with "Muscles of Anterior Wall" (omit "Deep Inguinal Ring and Transversalis Fascia" and "Reflection of the Abdominal Wall") Group (D) 7-14 (omit "Removal of 33-45 Anterior Thoracic Wall")
GENERAL OBJECTIVES: (A) Group A should complete the superficial palm dissection for presentation in the next laboratory, and continue the anterior and lateral leg dissection. (B) Group B should complete dissection of the deep palm and extensor region of the forearm for presentation in the next laboratory period, and continue dissection of the posterior leg. (C) Group C should continue dissecting the anterior abdominal wall. (D) Group D should continue dissecting the anterior thoracic wall.
TITLE: Present Superficial Palm, Complete Anterior and Lateral Leg (Group A); Present Deep Palm, Extensor Region of Forearm, Complete Posterior Leg (Group B); Complete Anterior Abdominal Wall (Group C); Complete Anterior Thoracic Wall (Group D). PAGES: Group (A) Dissector: 174-178 Moore: same as lab 7 Group (B) 178-181 same as lab 8 Group (C) 43-47 (omit "Inguinal 127-138 Region"), 48-51 beginning with "Muscles of Anterior Wall" (omit "Deep Inguinal Ring and Transversalis Fascia" and "Reflection of the Abdominal Wall") Group (D) 7-14 (omit "Removal of 33-45 Anterior Thoracic Wall")
GENERAL OBJECTIVES: (A) Group A will present the superficial palm. They should complete dissection of the anterior and lateral leg for presentation in the next laboratory. (B) Group B will present deep palm and extensor region of forearm. They should complete dissection of the posterior leg for presentation in the next laboratory. (C) Group C should complete their dissection of the anterior abdominal wall for presentation in the next laboratory. (D) Group D should complete their dissection of the anterior thoracic wall for presentation in the next laboratory.
TITLE: Present Anterior and Lateral Leg (Group A); Present Posterior Leg (Group B); Present Anterior Abodminal Wall (Group C); Present Anterior Thoracic Wall (Group D) GENERAL OBJECTIVES: (A) Group A will present the the anterior and lateral leg. (B) Group B will present the posterior leg. (C) Group C will present the anterior abdominal wall. (D) Group D will present the anterior thoracic wall.
LABORATORY ALL: Review |