Clinical surface anatomy - Dafydd Loughran

Dafydd LoughranCST1

*Cover RELEVANT surface anatomy for surgical &

medical procedures & presentations

*Interactive, drawing on each other!

*Scenario based

*Big collision ahead, car vs car, 70mph*1st on scene*23yr male driver*Obvious facial #s. Gross distortion of lower face.*GCS8/15. Stridor then quiet & unable to breath.*Chin lift – no improvement*What are you going to do…?

Cricothyroidotomy – pen, ventflon- Cricothyroid membrane

Tracheostomy – 2/3 tracheal rings

Draw: *Laryngeal prominence of thyroid

cartilage*Cricoid cartilage*Cricothyrotomy placement*Thyroid gland

*It’s your first central line insertion.

*Your boss has asked for a jugular line insertion

*What’s the anatomy?

Draw:

*Anterior triangle – midline, anterior

sternocleidomastoid, mandible

*Posterior triangle – clavicle, post border

sternocleidomastoid, ant border trapezium

Internal Jugular central line:

Done under US guidance.Imagine your pen is the needle.Locate both sternal & clavicular heads of sternocleidomastoid.Choose your spot.

Carotid artery is medial - pulsatile

*Airway now fixed!

*Increasingly SOB.

*Trachea deviated to Left. Reduced Right expansion. Hyper-resonant Right side.

*RR35, SpO2 82%

*Diagnosis?

*What are you going to do?

*What’s the anatomy?

*Sternal angle (of Louis) – lower than often thought

*Intercostal space below

*Mid-clavicular line

Mark out angle & 2nd ribDraw your spot & save a life!

*Definitive management?

*Chest drain anatomy? & in relation to rib?

*Triangle of safety

Draw the triangle & pick a spot!

*18yr Female.

*Fighting in town. Other girl’s protective boyfriend stabs her in the

upper abdomen…

*What’s at risk?

*Where are those organs?

*Draw the 9 regions

*Upper transverse line = Transpyloric plane (L1)

*Hands breadth below xiphoid process.

Draw: pancreas, stomach, duodenum, liver, & spleen

Just below nipples bilaterally!

Base of Rightcostal margin

Hiding under Left 9-11th ribs

At risk especially with blunt trauma

Spleen

Transpyloric plane (L1)

Tail & Body of pancreasPylorus of stomach

2nd part of duodenumSuperior mesenteric artery

*Lumbar puncture, Reg asks you to “crack on”…

*Where are you aiming for?

*What level, why, and how to find it?

*Work your way up & draw the kidneys

*60yr old male. Noticed lump in groin for last few days.

*No obstructive symptoms.

*Cough impulse present

*What will help you get to a diagnosis?

Pubic tubercle Pubic symphysis ASISMid inguinal point = ASIS to PS. Femoral artery

Mid point of inguinal ligament = ASIS to PT. Deep inguinal ring

Identify on yourself:

*Inguinal vs Femoral -

*Direct vs Indirect -

Deep ring- Indirect

Hasselbach’s triangle- Direct (weakness ofabdominal wall)

Superficial ring

Above & Medial to PT = Inguinal

Below & Lateral to PT = Femoral

Controlled at Deep ring (mid-point of inguinal ring)

= Indirect hernia

*90yr female

*Intertrochanteric NOF # overnight

*NOF pathway states Fascia-Iliaca block to be done by F1

*A&E sister kindly reminds you the last one your colleague did punctured the femoral artery. (I was told exactly this!)

*What’s the anatomy? Where will you inject?

1. Point out where you’d perform a needle cricothyrotomy.

2. What are the boundaries of the posterior triangle?

3. What are the boundaries of the triangle of safety?

4. Chest drain – will you go above or below the rib?

5. What nerve is at risk during chest drain insertion?

6. Show the boundaries of the liver.

7. How do you find the position for a lumbar puncture? What

spinal level is this?

8. How to differentiate between a direct or indirect hernia?

9. What lies at the mid-inguinal point?

10. What’s the anatomical landmark for a fascia iliaca block?

Any questions?

Any surgical topics would you like covered before you finish the job?