Moore’s Blue Boxes (Key Points)

Thorax:

Flail chest broken ribs move paradoxically (opposite of supposed action, i.e. inspiration going inwards)

Thoracotomy posterolateral 5th-7th intercostal spaces

Sternal fractures usually at angle. If in body, comminuted fracture results, high mortality

Rib dislocation rib/cartilage displaced from sternum

Rib separation rib separated from costal cartilage

Intercostal nerve block need to do ribs above and below

Breast cancer peau d’Orange (blocked lymphatics), inverted nipple (pulling on lactiferous ducts), dimpling (pull on suspensory

ligaments), movement with pec major (attachment to muscular fascia)

o Most common in superolateral quadrant, spread to anterior (pectoral) nodes

Atelectasis collapse of lung

Thoracentesis 9th intercostal space at midaxillary line

Chest tube 5th/6th intercostal space at midaxillary line

Aspiration of foreign bodies most common in right inferior lobe (right bronchus is straighter)

Pulmonary embolism blocks pulmonary arteries, can be caused by air, blood, or fat (commonly from leg vein)

Pleural pain from intercostal and phrenic nns.

Cardiac tamponade Beck’s triad (jugular vein distension, aortic hypotension, muffled heart sounds)

Pericardiocentesis 5th/6th intercostal space near sternum

VSDs most common heart defect (25%), commonly occur in membranous portion

Valvular insufficiency regurgitation backwards into last chamber

Valvular stenosis narrowed opening of valve

Myocardial infarction (MI, Heart Attack) LAD (40-50%), RCA (30-40%), Circumflex (15-20%). Most pain is in the

Angina pectoris alleviate by use of nitroglycerin (vasodilator)

CABG use the great saphenous vein (occasionally radial artery)

Cardiac referred pain to chest, arm, upper shoulder

Coarctation of aorta postductal (closed ductus arteriosus), preductal (patent ductus arteriosus)

Constriction of esophagus from enlargement of left atrium

Abdomen:

Abdominal hernias umbilical (near umbilicus), epigastric (through linea alba)

Appendix incision at McBurney’s point (1/3 of way from ASIS to umbilicus), Gridiron (muscle splitting) incision

o Iliohypogastric nerve at risk for iatrogenic injury

Cryptorchidism undescended testis

Umbilical vein well-oxygenated, nutrient-rich

Inguinal hernias

o Direct Result of weakening of abdominal wall muscles. Medial to inferior epigastric, does not go into scrotum, acquired

o Indirect Result of patent processus vaginalis. Lateral to inferior epigastric, goes into scrotum, congenital

Hydrocele fluid in processus vaginalis. Occurs due to patency of middle portion of processus vaginalis. Detected by transillumination of

scrotum

Testicular torsion obstructs venous drainage, can result in varicocele

Vestigial structures (males) appendix testis (mullerian/paramesonephric duct), appendix epididymis (wolffian/mesonephric duct)

Varicocele “bag of worms”, caused by pampiniform plexus enlargement

Hysterosalpingography check patency of uterine tubes (find any leaks to peritoneum, etc.)

Ascites excess fluid in peritoneal cavity

Abdominal paracentesis needle through anterolateral abdominal wall (in linea alba)

Greater omentum cushioning, insulation

Flow of ascitic fluid through paracolic gutters

Fluid in omental bursa located posterior to stomach. Thus, posterior ulcers can create fluid in the sac

Cholecystectomy ligate cystic artery (also need to compress hepatic artery through hepatoduodenal ligament)

Portal hypertension signs visible at portal-caval anastomoses

o Esophageal varices left gastric and esophageal veins

o Caput medusae paraumbilical and inferior epigastric

o Internal hemorrhoids superior rectal and inferior/middle rectal

Hiatal hernia

o Paraesophageal hiatal hernia less serious, only fundus herniates. Patient has no regurgitation while lying down

o Sliding hiatal hernia more serious, cardia and fundus herniate. Patient has regurgitation while lying down

Congenital hypertrophic pyloric stenosis projectile, non-bilious vomiting

Gastric cancer spread to celiac nodes, then right gastric

Gastric ulcers helicobacter pylori is common cause. Treatment is vagotomy (parasympathetic, reduces gastric acid secretion)

o Posterior ulcer can erode into pancreas, splenic artery (referred pain on back)

Visceral referred pain

o Stomach mid upper back

o Gall bladder under scapula

o Kidney loin to groin

o Spleen exact location of organ

o Pancreas back, exact location of organ

o Liver location of organ, radiating on back

o Appendix T10 to RLQ

o Colon exact location of organ

Duodenal ulcers

o Anterior peritonitis

o Posterior gastroduodenal artery affected

Upper GI rotation 90° clockwise

Midgut rotation 270° counterclockwise around SMA

o Malrotation = volvulus. Can result in necrotic intestine

Ischemia of intestine vasa recta occluded. Results in colicky pain, abdominal distension, vomiting

Meckel diverticulum in ileum. Rule of 2’s (2 feet proximal, 2% of people, twice as often in males, 2 in. long). Remnant of vitelline

(omphaloenteric duct)

Appendicitis T10 to RLQ

o Old people fecalith

o Young people hyperplasia of lymphatics

Ulcerative colitis (Crohn’s disease) treated by colostomy

Spleen rupture 9th/10th ribs, left side

Blockage of hepatopancreatic ampulla pancreatitis, enlarged pancreas, jaundice

Pancreatic cancer head or neck can compress hepatic portal, IVC. Head is posterior to SMA

Aberrant hepatic arteries right hepatic from SMA, left hepatic from left gastric

Gallstones in duodenum Hartmann pouch ruptures, allows passage

Portosystemic shunt splenic to left renal vein

Renal vein entrapment (Nutcracker) syndrome compression of renal vein under SMA

Congenital kidney anomalies early splitting of ureteric bud cause bifid ureter, renal pelvis, etc. Complete division is a supernumerary

kidney

Kidney stones (calculi) 3 common locations

o At base of renal pelvis

o Crossing external iliac/pelvic brim

o Entering bladder

Congenital diaphragmatic hernia defect in foramen of Bochdaler (posterolateral). Abdominal organs go into thoracic cavity, can hear

bowel sounds

Psoas sign extension of thigh against resistance elicits pain (sign of appendicitis)

Abdominal aortic aneurysm pulsating mass in midline, easily moved side-to-side

Pelvis and Perineum:

Pelvic shapes males have “heart-shaped”, females have “oval-shaped”

o Wider pelvic brim in females

o Platypelloid is dangerous (small distance from sacral promontory to pubic symphysis)

Pelvic diameters measure diagonal conjugate (through posterior fornix to sacral promontory), true diameter is ~1.5cm less

Pelvic fractures usually comminuted

Injury to pelvic floor damage to levator ani (pubococcygeus, puborectalis)

Iatrogenic injury of ureters during ligation of uterine artery (artery passes over ureter), during ligation of ovarian vessels (structures

close to each other near pelvic brim)

Injury to pelvic nerves can injure obturator nerve, causing spasm in adductor region

Cystocele tear of pubocervical fascia allows herniation

Vasectomy ligation of vas deferens through superior scrotum

BPH benign, caused by medial lobe hyperplasia. Carcinomous hyperplasia from posterior lobe

Ectopic pregnancy usually in ampulla of uterine tube

Remnants of embryonic ducts (Female) epoophoron, Gartner’s ducts

Bicornate uterus incomplete fusion of paramesonephric ducts

Uterus/Uterine prolapse usually anteflexed (90°, at external os) and anteverted (170°, at internal os).

o Prolapse caused by severance of transverse cervical (Cardinal) ligament and/or uterosacral ligament

Digital pelvic examination palpation of structures (cervix, ischial spine, sacral promontory) palpated through vaginal or rectal

examination

Vaginal fistulae vesicovaginal, rectovaginal varieties

Culdoscopy/culdocentesis aspirate fluid from rectouterine pouch by going through posterior fornix

Anesthesia for childbirth

o General anesthesia patient asleep

o Spinal block L3-L4 level, anesthetize waist down

o Caudal block popular choice, administered through sacral canal, anesthetizes subperitoneal region. Entire birth canal is

anesthetized

o Pudendal block anesthetizes S2-S4 dermatomes, inferior quarter of vagina. Does NOT block pain from birth canal

Pelvic pain line

o Above pain travels with sympathetics

o Below pain travels with parasympathetics (pelvic splanchnics)

Episiotomy

o Median incises perineal body, further tearing can affect levator ani

o Mediolateral tears perineal body, bulbospongiosus, superficial transverse perineal muscle

Urine extravasation (males) NEVER goes to thigh

o Rupture of superior wall (dome) of urinary bladder goes to peritoneal cavity

o Rupture of side wall (anterior) aspect of bladder goes to retropubic space (Subperitoneal)

o Rupture of urethra on way to UG diaphragm goes to retropubic space (Subperitoneal)

o Inferior to UG diaphragm (crush bulb of penis) goes to superficial perineal space (Extends to anterior abdominal wall from

penis and scrotum)

o Rupture in penile urethra confined to penis

Hemorrhoids

o Internal non-painful (visceral afferent)

o External painful (somatic afferent)

Hypospadia urethra opens on ventral side of penis. Failure of urogenital folds to close

Epispadia urethra opens on dorsal side of penis

Infection of greater vestibular glands (Bartholin) occlusion of duct results in a cyst

Pudendal nerve block needle inserted near ischial spine

Vaginismus involuntary spasms, of perivaginal (bulbospongiosus, transverse perineal) and levator ani muscles

Lower Limb:

Coxa vara/valga Coxa vara (decreased angle between neck and shaft of femur), Coxa valga (increased angle between neck and shaft)

o Coxa vara results in mild shortening of limb, limits passive abduction

Femoral fractures

o Neck can injure medial circumflex femoral artery

o Intracapsular

o Greater trochanter/shaft can be comminuted, spiral fracture

Tibial fractures usually occur at middle/inferior thirds, often a compound fracture

Osgood-Schlatter disease inflammation of tibial tuberosity

Fibular fractures at neck, can injure common fibular nerve

Compartment syndromes compress structures in specific region. For example, anterior tibial artery, deep fibular nerve in anterior

compartment

Varicose veins valves in veins do not function properly

Saphenous vein graft used for CABG

Saphenous vein injury numbness on medial edge of leg/foot

Chondromalecia patella (runner’s knee) pain deep to patella, common in runners and basketball players

Patellar reflex tests femoral nerve (L2-L4)

Palpation/compression/cannulation of femoral artery palpated in femoral triangle, compression against psoas major and femoral head

Laceration/ligation of femoral artery lacerated due to superficial location. Ligation is acceptable due to cruciate anastomoses

(medial/lateral circumflex, inferior gluteal, 1st perforating artery)

Saphenous varix edema, specific type of varicose vein

Femoral hernia bounded by femoral vein laterally, lacunar ligament medially

o More common in females

Aberrant obturator artery in 20% of people, runs close to femoral ring to reach obturator foramen

Trochanteric bursitis gluteus maximus rubbing on bursa of greater trochanter

Ischial bursitis ischial tuberosity rubbing on ischial bursa

Injury to superior gluteal nerve gluteus medius gait, positive Trendelenburg test, swing-out gait, steppage gait

o Unaffected hip droops during Trendelenburg test

Anesthetic block of sciatic nerve midpoint of PSIS and greater trochanter

Injury to sciatic nerve

o Piriformis syndrome (compression of sciatic nerve)

o Safe zone for gluteal injections is superolateral quadrant

Popliteal pulse deep in popliteal fossa, easier when leg is flexed

Injury to tibial nerve foot remains dorsiflexed, toes are extended

Shin splints tibialis anterior strain

Foot drop injury to common/deep fibular nerve

o Waddling gait

o Swing-out gait

o Steppage gait

Deep fibular nerve entrapment foot drop, can still evert foot

Superficial fibular nerve entrapment numbness and paresthesia

Calcaneal tendon reflex S1/S2, foot should plantar flex

Posterior tibial pulse between posterior surface of medial malleolus and calcaneal tendon

Plantar fasciitis inflammation of plantar fascia, often from overuse

Plantar reflex L4-S2, should result in flexion of toes.

o Fanning of toes is normal in infants (Babinksi sign)

Palpation of dorsalis pedis lateral to extensor hallucis longus

Posterior dislocation of hip joint can injure sciatic nerve

Genu valgum/varum valgum (knock knee knee is adducted), varum (bow-leg, knee is abducted)

Patelofemoral syndrome abnormal tracking of patella on femur. Fixed by strengthening vastus medialis

Knee joint injuries

o ACL positive anterior drawer test (tibia can be displaced anteriorly with respect to femur)

o PCL positive posterior drawer test (tibia can be displaced posteriorly with respect to femur)

o Unhappy Triad (O’Donoghue’s Triad) medial meniscus, MCL, ACL

Knee Bursitis

o Housemaid’s knee prepatellar bursitis (inflammation on anterior surface of knee)

o Infrapatellar bursitis excessive friction between skin and tibial tuberosity

o Suprapatellar bursitis abrasions or penetrating wounds

Ankle injuries

o Inversion most often injures anterior talofibular ligament

o Eversion Pott’s fracture, injures deltoid ligament

Hallux valgus lateral deviation of great toe

Hammer toe MTP joint extended, IP joints lie straight

Claw toe extension of MTP joints, flexion of all others

Pes Planus (flat foot) disruption of spring ligament

Clubfoot (talipes equinovarus) entire foot lies in inverted position