Stuart Kessler, M.D.

• Vice Chairman, Department of Emergency
• Medicine
• Mount Sinai School of Medicine
• New York, NY
• Director, Department of Emergency Medicine
• Elmhurst Hospital Center
• Elmhurst, NY

Individually medicine ball buy cheapest trecator sc, each plantar interosseus moves either the third medicine education order trecator sc 250mg online, fourth medications kidney failure discount trecator sc generic, or fifth digit toward the second digit medicine 3x a day cheap trecator sc 250 mg online, which is the midline of the foot medicine jobs purchase cheapest trecator sc. Medial side of proximal phalanges 3 medicine youth lyrics generic trecator sc 250 mg line,4 and 5 Explanation of Actions One plantar interosseus muscle originates on the medial side of the third metatarsal. This interosseus muscle inserts on the medial side of the proximal phalanx of the third digit. When the muscle shortens, it pulls the proximal phalanx of the second digit medially. The plantar interosseus muscle that originates on the medial side of the fourth metatarsal inserts on the medial side of the proximal phalanx of the fourth digit. Thus, when it shortens, it pulls the proximal phalanx of the fourth digit medially. The plantar interosseus muscle that originates on the medial side of the fifth metacarpal inserts on the medial side of the proximal phalanx of the fifth digit, and thus pulls the fifth digit medially when it shortens. The combined movements of the three interossei muscles is to bring digits 3, 4, and 5 closer to digit 2, which is the same as adducting the toes. Antagonists Dorsal interossei (abducts the toes) Implications of Shortened and/or Lengthened/ Weak Muscle Shortened: Limited ability to abduct the toes is noted. The word brevis informs us that this muscle is shorter than flexor hallucis longus. Location Flexor hallucis brevis is a third-layer intrinsic foot muscle, located on the plantar surface of the foot and covering the first metatarsal. Palpation and Massage this muscle can be palpated on the plantar side of the first metatarsal. Extensor hallucis longus and brevis (extend the big toe) Innervation and Arterial Supply Innervation: medial plantar nerve Arterial supply: medial plantar artery Notable Muscle Facts There are two tendons of insertion of flexor hallucis brevis, each of which contains a sesamoid bone. Notable Muscle Facts Adductor hallucis helps to support the transverse arch of the foot. Adductor hallucis is similar to adductor pollicis in that both muscles have a transverse head and an oblique head. Location Adductor hallucis is a third-layer intrinsic foot muscle, located on the plantar surface of the foot. Implications of Shortened and/or Lengthened/ Weak Muscle Shortened: Inability to abduct the great toe is noted. Because the origin is proximal to the insertion, and the muscle crosses the plantar surface of the big toe, adductor hallucis also flexes the big toe. Brevis indicates that the digiti minimi of the foot is smaller than that of the hand. Location Flexor digiti minimi brevis is a third-layer intrinsic foot muscle, located on the plantar surface of the foot. Palpation and Massage Flexor digiti minimi brevis can be palpated and massaged by applying direct pressure or friction to the muscle on the plantar surface of the fifth digit. Origin and Insertion Origin: base of the fifth metatarsal Insertion: base of the proximal phalanx of the fifth digit How to Stretch this Muscle Extend the fifth digit of the foot. Thus, the plantar surface of the proximal phalanx is pulled toward the fifth metatarsal. Location Lumbricals are located quite centrally on the plantar surface of the foot. Plantae refers to the fact that this muscle is located on the plantar surface of the foot. Location Quadratus plantae is located on the proximal or posterior third of the plantar surface of the foot. Implications of Shortened and/or Lengthened/ Weak Muscle Shortened: Tension is felt in the heel area. Lengthened: Reduced ability to flex the four lateral toes is noted, particularly when the ankle is dorsiflexed. Origin and Insertion Origin: calcaneus Insertion: tendon of insertion of flexor digitorum longus Palpation and Massage Quadratus plantae can be palpated and massaged by applying friction and direct pressure to the plantar surface of the calcaneus. Explanation of Actions By anchoring on the calcaneus and by pulling the tendon of flexor digitorum longus directly toward the calcaneus, quadratus plantae helps to flex the toes. Implications of Shortened and/or Lengthened/ Weak Muscle Shortened: Limited ability to adduct and/or extend the big toe is noted. Lengthened: When abductor hallucis is weak or overlengthened, one can experience difficulty abducting the big toe fully. Location Abductor hallucis is located on the medial side of the plantar surface of the foot. Palpation and Massage Abductor hallucis can be palpated and massaged by applying friction and direct pressure to the medial side of the calcaneus. Origin and Insertion Origin: tuberosity of the calcaneus Insertion: medial side of the base of the proximal phalanx of the big toe How to Stretch this Muscle Adduct and extend digit one of the foot. Actions Abducts and flexes the big toe Synergists There is no other major abductor of the great toe. Explanation of Actions Because abductor hallucis attaches to the medial side of the proximal phalanx of the big toe and because the origin is proximal to the insertion, the muscle has the leverage to pull the proximal phalanx of the big toe medially, thus causing abduction. Antagonists Adductor hallucis (adducts the big toe) Innervation and Arterial Supply Innervation: medial plantar nerve Arterial supply: medial and plantar artery Notable Muscle Facts Abductor hallucis supports the medial longitudinal arch. Digitorum tells us that this muscle acts upon the four digits, in this case the four lateral toes. Also, brevis tells us that the flexor digitorum brevis is shorter than the flexor digitorum longus. Implications of Shortened and/or Lengthened/ Weak Muscle Shortened: Limited ability to adduct the fifth digit is noted. Palpation and Massage Abductor digiti minimi can be palpated and massaged by applying direct pressure and friction to the lateral plantar aspect of the foot. Origin and Insertion Origin: tuberosity of the calcaneus Insertion: lateral side of the base of the proximal phalanx of the fifth digit of the foot How to Stretch this Muscle Actions Abducts the fifth digit of the foot Adduct the fifth digit of the foot. Explanation of Actions Because abductor digiti minimi inserts on the lateral aspect of the proximal phalanx of the fifth digit, and because the origin is proximal to this insertion, the muscle pulls the proximal phalanx of the fifth digit laterally, thus causing abduction of the smallest toe. Antagonists Plantar interossei Notable Muscle Facts Abductor digiti minimi helps stabilize the lateral portion of the longitudinal arch. It runs down the thigh before branching into the common peroneal and tibial nerves at the popliteal fossa. First perforating artery Second and third perforating artery Vastus lateralis muscle Semitendinosis muscle the popliteal artery and vein lie within the popliteal fossa, along with the tibial nerve. Tibial nerve Medial sural cutaneous nerve Small saphenous vein Fourth perforating artery Superior lateral genicular artery Biceps femoris muscle (long head cut) the common peroneal nerve lies lateral to the head of the fibula. The common peroneal nerve, also called the fibular nerve, runs through the popliteal fossa inferiorly and near the neck of the fibula before branching in superficial and deep divisions in the lower leg. Superficial branch of peroneal nerve Medial plantar nerve Lateral plantar nerve C the superficial peroneal nerve runs inferiorly between peroneus longus and extensor digitorum longus. The deep peroneal nerve follows the anterior tibial artery around the fibular head to the anterior lower leg. Medial dorsal cutaneous branch of superficial peroneal Sural nerve the anterior tibial artery runs laterally to the tibia and down to the ankle. However, a true understanding of how these muscles affect our posture and our ability to move is essential to use this information to guide our massage therapy treatments to best assist our clients. Palpation Exercise #1 this palpation exercise will require you to palpate the six deep lateral rotators of the hip and the hip adductors. You can tell that you have found piriformis when you feel a thin strip of dense tissue, deep to gluteus maximus. The other lateral rotators in the group of the six all run from the ischium and obturator foramen toward the greater trochanter. Their names are the gemellus inferior and superior, obturator internus and externus, and quadratus femoris. Ask your partner to adduct the thigh against resistance by placing your hand on the medial thigh just proximal to the knee and asking your partner to press his or her thigh into your hand. Remind yourself of the names of all five adductors, and note their basic locations, beginning with adductor magnus, the deepest and largest thigh adductor, which inserts quite distally on the linea aspera of the femur. Recall that pectineus is located within the femoral triangle and that this is an endangerment site. Finally, end by reviewing gracilis, the slender, most medial and superficial muscle of the thigh. The proximal attachments of the hip adductor muscles are in a sensitive area, as they are so close to the genitals. It is possible to instruct your client to perform friction to the tendons of origin of the adductors (near the pubis) as homework, rather than working in that area yourself, as it may not be appropriate for you to address this area. Gluteus medius is a triangular-shaped muscle that lies between the iliac crest and the greater trochanter. Pressing right into the external surface of the ilium allows us to apply friction and direct pressure to these muscles with ease. All of gluteus minimus is deep to gluteus medius, and much of gluteus medius is deep to gluteus maximus. Find the small section of gluteus medius (just inferior to the anterior iliac crest) that is superficial. You can ask your partner to abduct his or her thigh to feel for contraction of gluteus medius and gluteus minimis. It is a thick, strong muscle and other than the quadriceps group, is the largest muscle in the body. Palpation Exercise #3 this palpation exercise will require you to palpate the hamstrings and their related bone markings. Head of fibula: Find this rounded bone marking on the most proximal aspect of the fibula. Proximal, posterior, medial tibia: Look for the insertion spot of semimembranosus. Make sure you check in with your partner, so you do not stretch the muscles too far. Palpation Exercise #4 this palpation exercise will require you to palpate the iliopsoas, the quads, and related bone markings. Lesser trochanter: Note the location of the lesser trochanter on the proximal, medial femur. But note the location of this bone marking, even though you cannot actually feel it. Linea aspera: Recall the rough line that runs almost the entire length of the posterior femur. This bone marking is impossible to palpate, as it is covered by the hamstring muscles, most notably biceps femoris. Tibial tuberosity: Find the patella and move directly distal about an inch or an inch and a half. Pes anserinus: Revisit this flat area on the proximal, anterior, medial tibia once more. Look at the colored illustration of origin and insertion sites earlier in this chapter. The psoas major originates on the transverse processes and bodies of the lumbar vertebrae and T12. You may have to adjust the angle of your pressure or direction of your fingers to move through digestive organs as you work your way to the psoas major muscle. When you feel you have reached the depth required to contact psoas major, ask your partner to flex his or her hip to see if you can feel fibers contract. Note: Palpation/massage of psoas major must be done with great care and clear communication with the client. Iliacus fills the iliac fossa on the anterior aspect of the ilium and inserts at the lesser trochanter. Curl your fingers around the anterior iliac spine, pressing gently and medially into the iliac fossa. It is possible to distinguish vastus medialis from the hip adductor muscles by isometrically contracting the quadriceps group. Then, position your hand on the anterior distal leg and have your partner press his or her anterior leg into your hand. You should be able to feel the distinction between the contracted quadriceps and relaxed adductor muscles. The medial portion of vastus lateralis is deep to rectus femoris, but the lateral aspect is easily palpable. Palpation Exercise #5 this palpation exercise will require you to palpate the posterior leg muscles and relevant bone markings that are attachment sites. Continue to move posteriorly, and palpate gently into the edges of the popliteal fossa to feel for the attachment sites of gastrocnemius. Calcaneus and Achilles tendon: Find the thick Achilles tendon on the posterior, distal leg. Deep to gastrocnemius is soleus, a flat muscle whose inferior aspect is more distal than gastrocnemius. This tendon is long and extends distally to join the Achilles tendon and attach to the calcaneus. Gastrocnemius and soleus: Have your partner lie prone with feet hanging off the end of the table. Feel distal to gastrocnemius to find soleus, which creates the contour of the distal leg.

Classification of exocrine glands They are classified by their structure and shape of the secretary portion symptoms 5 days past ovulation cheap trecator sc 250 mg without a prescription. According to structural classification they are grouped into: 32 Human Anatomy and Physiology a) Unicellular gland: Single celled medicine lake california purchase trecator sc australia. The best examples are goblet cell in Respiratory medicine ball buy trecator sc amex, Gastrointestinal & Genitourinary system medicine park cabins buy trecator sc american express. By combining the shape of the secretary portion with the degree of branching of the duct of exocrine glands are classified in to Unicellular Multi-cellular Simple tubular Branched tubular Coiled tubular Acinar Branched Acinar If the secretary portion of a gland is 33 Human Anatomy and Physiology - Compound Tubular Acinar Tubulo-acinar 3 medicine 4839 buy trecator sc 250mg with amex. Embryonic connective tissue Embrayonic connective tissue contains mesenchyme & mucous connective tissue treatment authorization request purchase trecator sc 250 mg on line. Mesenchyme is the tissue from which all other connective tissue eventually arises. Adult connective tissue It is differentiated from mesenchyme and does not change after birth. Adult connective tissue composes connective tissue proper, cartilage, osseous (bone) & vascular (blood) tissue 34 Human Anatomy and Physiology a) Connective tissue proper, connective tissue proper has a more or less fluid intercellular martial and fibroblast. Adipose tissue: It is the subcutaneous layer below the skin, specialized for fat storage. It is common around the kidney, at the base and on the surface of the heart, in the marrow of long bone, as a padding around joints and behind the eye ball. In areas where fibers are interwoven with out regular orientation the forces exerted are in many directions. This occurs in most fascia like deeper region of dermis, periosteum of bone and membrane capsules. In other areas dense connective tissue adapted tension in one direction and fibers have parallel arrangement. It helps to form a delicate supporting storma for many organs including liver, spleen and lymph nodes. It consists of a dense network of collagenous fibers and elastic fibers firmly embedded in chondriotin sulfate. The surface of a cartilage is surrounded by irregularly arranged dense connective tissue called perichondrium. Found at joints over long bones as articlar cartilage and forms costal cartilage (at ventral end of ribs). It forms embryonic skeleton, reinforce respiration, aids in free movement of joints and assists rib cage to move during breathing. Fibro cartilage: they are found at the symphysis pubis, in the inter-vertebral discs and knee. Elastic cartilage: in elastic cartilage the chondrocyte are located in thread like network of elastic fibers. Elastic cartilage provides strength and elasticity and maintains the shape of certain organs like epiglottis, larynx, external part of the ear and Eustachian tube. The osseous tissue together with cartilage and joints it comprises the skeletal system. Skeletal muscle tissue are attached to bones, it is voluntary, cylindrical, multinucleated & striated Cardiac muscle tissue: It forms the wall of the heart; it is involuntary, uni-nucleated and striated. Smooth muscle tissue: located in the wall of hallow internal structure like Blood vessels, stomach, intestine, and urinary bladder. Clinically they are important because they are potential to replicate and produce cancerous growths. They line body cavities, cover surfaces, connect, or separate regions, structures and organs of the body. Mucous membranes line the entire gastro intestine, respiratory excretory and reproductive tracts and constitute a lining layer of epithelium. To 39 Human Anatomy and Physiology prevent dry out and to trap particles mucous membranes secret mucous. Serosa is composed of parietal layer (pertaining to be outer) and visceral layer (pertaining to be near to the organ). Pleura and pericardium are serous membrane that line thoracic and heart cavity respectively. The epithelial layer of a serious membrane secret a lubricating fluid called serious fluid. Synovial membranes secret synovial fluid that lubricate articular cartilage at the ends of bones as they move at joints. Unicellular glands composed of columnar cells that secrete mucous are known as:a) Cilia b) Microvilli c) Goblet cell d) Endocrine glands e) Basal cell 2. A group of similar cell that has a similar embryological origin and operates together to perform a specialized activity is called:a) Organ b) Tissue c) System d) Organ system e) Organism 3. Mucous membranes a) Lines cavities of the body that are not open to the outside b) Secret thin watery serous fluid c) Cover the outside of such organs as the kidney and stomach d) Are found lining the respiratory & urinary passages e) Are described by none of the above. Which tissue is characterized by the presence of cell bodies, dendrites and axons The system functions in protection, in the regulation of body temperature, in the excretion of waste materials, in the synthesis of vitamin D3 with the help of sunrays, and in the reception of various stimuli perceived as pain, pressure and temperature. Epidermis is the outer layer of the skin that is made of stratified squamous epithelium. These are stratum cornium, lucidium, granulosum, spinosum and basale, Stratum cornium is the outer, dead, flat, Keratinized and thicker layer. The cells in this stratum have a poly-hydral shape and they are in the process of protein synthesis. Stratum basale rests on the basement membrane, and it is the last layer of epidermis next to stratum spinosum. Dermis / true skin/ a strong, flexible, connective tissue mesh work of collagen, reticular and elastic fibers. Indentations of papillary layer in the palms and soles reflected over the epidermis to create ridges. It is made of dense connective tissue with course of collagenous fiber bundles that crisscross to form a storma of elastic network. In the reticular layer many blood and lymphatic vessels, nerves, fat cell, sebaceous (oil) glands and hair roots are embedded. Hypodermis is composed of loose, fibrous connective tissue, which is richly supplied with lymphatic and blood vessels and nerves. With in it coils of ducts of sudoriferous (sweat) glands, and the base of hair follicles. Protection: against harmful microorganisms, foreign material and it prevents excessive loss of body fluid. Sensory reception: it contains sensory receptors of heat, cold, touch, pressure, and pain. The presence of melanin a dark pigment produced by specialized cell called melanocyte 2. The color of blood reflected through the epidermis * * the main function of melanin is to screen out excessive ultraviolet rays. All races have some melanin in their skins although the darker races have slightly more melanocyte. The person 47 Human Anatomy and Physiology who is genetically unable to produce any melanin is an albino. Sudoriferous /sweat/ glands Types: Eccrine and Apocrine glands Eccrine glands are small, simple coiled tubular glands distributed over nearly the entire body, and they are absent over nail beds, margins of lips of vulva, tips of penis. The sweat they secret is colorless, aqueous fluid containing neutral fats, albumin, urea, lactic acid and sodium chloride. Apocrine glands are odiferous, found at the armpits, in the dark region around nipples, the outer lips of the vulva, and the anal and genital regions. The female breasts are apocrine glands that have 48 Human Anatomy and Physiology become adapted to secret and release milk instead of sweat. It functions as a permeability barrier, an emollient (skin softening) and a protective a gent against bacteria and fungi. Acne vulgaris is a condition when there is over secretion of sebum, which may enlarge the gland and plug the pore. It covers the entire body except the palms, soles, lips, tip of penis, inner lips of vulva and nipples. Hair consist epithelial cell arranged in three layers from the inside out medulla, cortex and cuticle. The bulb pushes in ward along its bottom to form a papilla of blood rich connective tissue. Part of the hair follicle is attached with the bundle of smooth muscle about halfway down the follicle. When it contracts in pulls the follicles and its hair to an erect position producing goose bump. The fastest growth rate occurs over 51 Human Anatomy and Physiology the scalp of women aged 16 to 24 years. Just before a hair is to be shed, the matrix cell gradually become inactive and eventually dies. Nails are composed of flat, cornified plates on the dorsal surface of the distal segment of the fingers and toe. The proximal part of nail is lunula, which is white in its color because of the capillaries underneath are covered by thick epithelium. The thicker layer of skin beneath the nail root is the matrix, where new cells are generated. Skin gets its color from a) Carotene b) Underlying blood vessels c) Melanin d) a and b only e) a, b and c 54 Human Anatomy and Physiology 4. Sudoriferous glands secret their secretion in response to: a) Physiological process b) Heat c) Stress d) Sexual experience e) In all of the above condition 5. Hair covers all of the following parts of the body except: a) Sole b) Face c) Neck d) Trunk. But from structural point of view, the human skeletal system consists of two main types of supportive connective tissue, bone and cartilage. Support: it forms the internal framework that supports and anchors all soft organs. Movement: skeletal muscles attached to the skeletal system use the bone to levers to move the body and its part. It is a moist changing, productive tissue that is continually resorbed, reformed and remodeled. Short bones are about equal in length, width and thickness, which are shaped with regular orientation. Typical sesamoid bones are patella and pisiform carpal bone, which are in the tendon of quadriceps femuris and flexor carp ulnaris muscle respectively. Gross anatomy of a typical long bone You can take Tibia (in the leg) one of the longest bones in the body. Flat and irregular bones of the trunk and limbs have many epiphysis and the long bones of the finger and toe have only one epiphysis. It is made up of epiphyseal plate and adjacent bony trabeculae of cancellous bone tissue. The red marrow also known as myeloid tissue Endosteum is the lining the medullary cavity of compact bone tissue and covering the trabeculae of spongy bone tissue. It is more rigid than other tissues because it contains inorganic salts mainly calcium phosphate & calcium carbonate. A network of collagenous fibers in the matrix gives bone tissue its strength and flexibility. Most bones have an outer sheet of compact bone tissue enclosing an interior spongy bone tissue. Compact bone tissue contains cylinders of calcified bone known as osteons (Haversion system). Osteons are made up of concentric layers called lamellae, which are arranged seemingly in wider and wider drinking straws. In the center of the osteons are central canals (haversion canal), which are longitudinal canals that contains blood vessels, nerves and lymphatic vessels. Lacunae (Little spaces) that houses osteocytes (bone cells) are contained in lamella. Radiating from each lacuna are tiny canaliculi containing the slender extensions of the osteocytes where nutrients and wastes can pass to and from central canal. Spongy (cancellous) Bone tissue Is in the form of an open interlaced pattern that withstands maximum stress and supports in shifting stress. Trabeculae are tiny spikes of bone tissue surrounded by bone matrix that has calcified. They have high mitotic potential and can be transformed into bone forming cells (osteoblasts). They are able to synthesize and 63 Human Anatomy and Physiology secrete un-mineralized ground substance, act as pump cell to move calcium and phosphate in and out of bone tissue. They together with osteoclasts play an important role of homeostasis by helping to release calcium. They are believed to be derived from osteoblast that ceases their physiological activity. Bone in embryo develops in two ways: Intra-membranous ossification, If bone develops directly from mesenchymal tissue. Endochondrial Ossification, When bone tissue develops by replacing hyaline cartilage. The 64 Human Anatomy and Physiology cartilage it self do not converted into bone but the cartilage is replaced by bone through the process. Endochondrial ossification produces long bones and all other bones not formed by intra-membranous ossification. These are surface markings where muscles, tendons and ligaments attached, blood & lymph vessels and nerves pass.

Selective oestrogen receptor modulators-These synthetic agents act as oestrogen agonists on bone and lipids symptoms diagnosis cheap trecator sc 250mg amex, but without oestrogenlike stimulation of breast and endometrial tissues medicine 6469 discount 250mg trecator sc overnight delivery. Raloxifene reduces the risk of vertebral fracture but has not been shown to decrease the risk of non-vertebral fractures symptoms hypoglycemia buy trecator sc paypal. Like hormone replacement therapy medicine queen mary buy online trecator sc, raloxifene is associated with small increases in the Formation-stimulating agents Teriparatide and parathyroid hormone-These agents have good evidence for their abilities to increase bone formation (and later bone resorption) with an improvement in bone mass and structure medicine 5443 trusted trecator sc 250 mg, particularly in trabecular bone such as the vertebrae medicine organizer box buy cheap trecator sc 250 mg on line, with reductions in spine fracture risk. They are expensive agents and their use is limited to patients with severe, progressive osteoporosis despite exposure to antiresorptive therapy. Teriparatide is licensed for use in men and women, whereas recombinant parathyroid hormone 1-84 is only licensed for postmenopausal women. Alternative agents Strontium ranelate-Strontium ranelate been shown to significantly reduce vertebral and non-vertebral fracture risk in postmenopausal women. Pain relief Pain relief is frequently adequately achieved with analgesics, but physical measures-such as hydrotherapy or transcutaneous nerve stimulators-may be useful adjuncts to treatment. The pain associated with fractures usually resolves within 6 months, but patients with vertebral fractures may need to be given longterm analgesia because of secondary degenerative disease. Monitoring of treatment the rationale for monitoring treatment response is that a proportion of patients fail to respond to treatment, commonly due to non-persistence with therapy, poor dosing compliance or, less commonly, due to underlying disease. The decrease in bone turnover in response to antiresorptive agents may be a superior predictor of the decrease in fracture risk. Falls prevention Predisposing factors, such as postural hypotension or drowsiness due to drugs, should be eliminated where possible. Patients may benefit from physiotherapy to improve their balance and saving reflexes. Patients should be provided with appropriate walking aids, and an environmental assessment should be made of their accommodation to eliminate hazards such as loose rugs and cables. Assessment via specialized falls clinics may be appropriate, particularly in those individuals with features suggesting a medical cause for falls, such as palpitations or blackouts. Education An important part of the management of osteoporosis is education and support of the patient, their carers and their family. Progressive joint destruction and extraarticular manifestations account for the disability and increased mortality. Early recognition and intervention with diseasemodifying therapy is key to preventing the progressive disability. Geographical variations in disease pattern have been reported and attributed to lifestyle differences in populations; however, genetic differences have also been implicated in the severity of the disease. Usually the disease is insidious in nature, rarely occurring in men younger than 30 years, with gradually rising incidence with advancing age. In women the incidence steadily increases from the mid-20s to peak incidence between 45 and 75 years. In the classical presentation, which remains the more common variant, the disease affects the small joints of the hands and feet in a more symmetrical pattern. Less common forms of presentation are acute monoarticular, palindromic rheumatism and asymmetrical large joint arthritis. They can affect almost any system of the body and are mediated by various mechanisms. Immune responses such as immune complex deposition, cytokine production and direct endothelial injury can produce distant and local effects. Also, mechanical causes such as synovial hypertrophy and subluxation of joints may cause entrapments of the nerves or vessels. The disability leads to disuse and abnormal mechanics, which leads to degenerative changes and osteoporosis. The response has crossreactivity with host tissue, initiating an autoimmune synovitis and subsequent hypertrophy. Synovial hypertrophy is the key factor that leads to cartilage and bone destruction, causing progressive joint damage and disability. Other tissues are affected through different mechanisms, accounting for the extra-articular manifestations. Atlanto-axial subluxation-This results from involvement of the atlanto-axial joint, which may be clinically asymptomatic until the subluxation develops. Development of pain around the occiput, radiating arm pain, numbness or weakness of the limbs and vertigo on neck movement are warning signs; if not picked up this may lead to sudden death, especially if patients undergo neck manipulation for endotracheal entubation during surgical procedures. Drug-related causes such as gold- or penicillamine-induced proteinuria need to be ruled out. History A detailed history of the problem, its onset and progression with time, relieving and aggravating factors and the distribution of the symptoms are all important elements in the history. A progressive pattern of joint involvement, stiffness and increased pain after a period of inactivity and a history of joint swellings are indicative of inflammatory joint disorders. The distribution of joint involvement helps in distinguishing other forms of arthritides such as spondyloarthritis and psoriatic arthritis. Clinical examination the objective of the clinical assessment is to identify signs of inflammatory arthritis, such as swelling, tenderness and restriction of movement of the joints. Clinical evaluation may also pick up extra-articular findings that can support the diagnosis or refute it-for example, the presence of rheumatoid nodules and psoriatic skin patches, respectively. Acute-phase responses such as a high erythrocyte sedimentation rate or C-reactive protein, a high platelet count and high serum Pericarditis-Onset of central chest pain worsened by lying flat, accompanied by a pericardial rub, merits urgent echocardiogram to confirm and urgent initiation of steroid therapy. Infective causes such as tuberculosis need to be ruled out by aspiration and analysis when suspected. It is prudent to initiate treatment for possible septic arthritis until the results of the joint aspirate rule it out. Called scleromalacia perforans, this sinister condition is thankfully rare but needs to be looked out for. Arthritis of hand joints (wrist, metacarpophalangeal joints or proximal interphalangeal joints) 4. Symmetric arthritis* (bilateral involvement of metacarpophalangeal, proximal interphalangeal or metatarsophalangeal joints is acceptable without absolute symmetry) 5. Serum rheumatoid factor, as assessed by a method positive in less than 5% of control subjects 7. Radiographic changes, as seen on anteroposterior radiographs of wrists and hands *Possible areas: proximal interphalangeal joint, metacarpophalangeal joint, wrist, elbow, knee, ankle and metatarsophalangeal joint (observed by a physician). Anaemia of chronic disease may be present in many patients with chronic conditions. A very high leucocyte response is uncommon and usually indicative of an infection, which should be looked for in such situations. A number of conditions are associated with the presence of rheumatoid factor in serum (Box 12. Conventional radiology can still be useful in monitoring progression of the disease in established diagnosis and to plan corrective surgeries when there is significant disability. Newer modalities such as magnetic resonance imaging are now increasingly employed to detect early synovitis and bone oedema and can be utilized effectively in picking up early disease. High-resolution computed tomography is the modality of choice in picking up interstitial lung disease and pulmonary fibrosis. Synovial fluid analysis this test is rarely required to establish diagnosis in a typical presentation; however, in atypical presentations with large joint involvement, especially monoarticular, it is vital to rule out infective aetiology and crystal arthropathy. The fluid would typically show a high protein and leucocyte count and the absence of crystals and organisms on Gram stain. Malignant conditions such as leukaemias and lymphomas should be sought, especially in acute presentations in younger patients. No laboratory tests are diagnostic, and ultimately the diagnosis relies on a clinical evaluation by the practitioner. However, the usefulness of small molecules such as methotrexate has not been overshadowed by the current interest in biological-response modification. While symptomatic control and reduction of the clinical signs of synovitis have been the foremost considerations in the past, modern pharmacotherapy has emphasized the need to slow down, if not halt, disease progression as well as to prevent the development of potential complications. It is now recognized that significant documented radiological damage can occur in this disease much earlier than previously thought, certainly within the first 2 years of disease onset. Disease-modifying therapy is therefore introduced early following confirmation of diagnosis, particularly in those with poor prognostic indicators, such as severe disease activity, radiological damage or anti-cyclic citrullinated peptide positivity. Expression of cyclooxygenase-2 is induced at sites of inflammation, particularly on polymorphonuclear cells and macrophages. Furthermore, multiple routes of administration, including depot injections (methylprednisolone and triamcinolone acetonide) and local intra-articular injections offer a variety of therapeutic options. An intramuscular drug of proven efficacy, radiological improvement with decrease in radiological damage bore evidence of its disease-modifying capacity. However, weekly injections may be cumbersome, and an oral form proved inefficacious. This, together with the fact that over half of drug discontinuations were reported to be the result of toxicity (such as severe skin rash and nephrotoxicity), heralded a decline in its popularity over the years. An oral drug administered on a weekly basis, its anti-inflammatory mechanisms of action are thought to differ from its anti-malignant effects, and are largely related to its induction of adenosine release to the inflammatory environment. Compared with gold it has an excellent side-effect profile, the only frequent problem being post-dosage nausea, which frequently responds to folic acid (Box 13. It is composed of sulfapyridine and 5-aminosalicylic acid moieties and should be avoided in patients allergic to sulfa medications. Plasma half-life is greatly influenced by acetylation status, and slow acetylators are more likely to develop serious toxicities. It may be useful in patients who have failed to respond to methotrexate, but can also be administered together with methotrexate to improve response. As a long washout period of up to 2 years is suggested prior to conception, careful planning is needed in premenopausal women. It has been suggested that using these medications with different but complementary mechanisms of action in combination not only allows for greater efficacy, but also limits effective required dosage and hence toxicity. Various combinations, including step-up and step-down regimens have been tried, often with the inclusion of methotrexate. Understanding of the molecular and cellular mechanisms that contribute to the generation and maintenance of the inflammatory processes that culminate in synovial inflammation and joint destruction has escalated astronomically in recent decades. These fundamental elements of the inflammatory cascade, whether it be a cytokine or an inflammatory cell subset, have become the targets of new treatment modalities. Life expectancy may be shortened by as much as 7 years in men and 3 years in women. Its short half-life means that subcutaneous injections have to be given on a daily basis. Radiological improvement, including rates of progression of joint-space narrowing and erosion, have been more striking, however. Rituximab the B-lymphocyte is not only the source of inflammatory cytokines and antibodies important to the pathogenesis of the disease such as rheumatoid factor and anti-cyclic citrullinated peptide; B-cell help is a vital contributor to T-cell activation and antigen presentation. While the risk of infection remains a concern with B-cell depletion, this has not been a problem based on available clinical trial data. Abatacept T-lymphocyte activation and proliferation requires a dual stimulatory signal that involves both the T-cell and the antigen-presenting cell. In this respect, the roles of physiotherapy and occupational therapy and meticulous foot care cannot be overlooked. Advances in orthopaedic surgery have also benefited situations such as atlanto-axial subluxation, arthroplasties and tendon transfer and repair surgeries. Management of established rheumatoid arthritis with an emphasis on pharmacotherapy. Comparison of the efficacy of biologic therapy for rheumatoid arthritis: can the clinical trials be accurately compared The spondyloarthritides (SpA) comprise a group of syndromes that are distinct from rheumatoid arthritis and are characterized by inflammation of the spine in many, but not all, cases. Other key features include asymmetric oligoarthritis, enthesitis, psoriatic skin and mucous membrane lesions, and eye and bowel inflammation. Spondyloarthritides occur in both adults and children, although spinal involvement is rare in children. A working definition has been provided by the European Spondyloarthritis Study Group (Box 14. The classical forms of spondyloarthritis (also called "spondyloarthropathies") and the key physical features are listed in Table 14. Up to 15% of children with juvenile idiopathic arthritis are classified as having juvenile-onset spondyloarthritis. Such children present with pauciarticular peripheral arthritis with a predilection for the tarsal joints; axial complaints, with the development of radiographic sacroiliitis, tend only to develop in late teenage years or later. Fatigue often accompanies inflammatory back pain, although it may also be present in fibromyalgia and other conditions. Inadequately controlled inflammation leads to persistent stiffness and progressive loss of spinal mobility. Low back pain and stiffness >3 months with improvement on exercise, not relieved by rest b.

Orchiopexy chapter 7 medications and older adults buy trecator sc line, Orchidopexy symptoms 39 weeks pregnant discount 250mg trecator sc with mastercard, Orchiorrhaphy suturing of an undescended testicle in the scrotum medicine river order 250mg trecator sc mastercard. Example of destruction procedures: Phrenic nerve operation when the phrenic nerves are divided symptoms cervical cancer purchase trecator sc no prescription, crushed treatment ulcer cheap trecator sc 250mg otc, or injected paralysis of the corresponding side of the diaphragm is produced medications in pregnancy order trecator sc 250 mg on-line. Bones: Parietal Occipital Frontal Temporal Mandible Cervical vertebrae Thoracic vertebrae Lumbar vertebrae Sacrum Ilium Ischium Scapula Clavicle Humerus Radius Ulna Carpus Metacarpus Patella Tibia Fibula Tarsus Calcaneus Because all physicans rely heavily on accuracy and baseline data, a sound knowledge of radiological terminology is essential. Clitoriditis Metrorrhagia Oophorectomy Orchidectomy Salpingectomy Spermicide Uteropexy Definition I 80 Medical Terminology Course Reproductive system medical terminology Dictionary homework Word abortion amenorrhoea amitosis areola atrophicus bulbouretral cavernous cervix uteri clitoris corpora cavernosa corpus luteum dysmenorrhoea ectopic pregnancy endometrium epididymis estrogen fertilization fimbria foreskin gamete gonad Graafian follicle hymen hyperplastic inguinal labia lactation menorrhagia menopause menstruation metrorrhagia mons pubis myometrium nulliparous ostium abdominale ovary oviduct ovulation ovum parainetrium penis perineum prepuce progesterone prostate Meaning Medical Terminology Course 81 Word puberty scrotum semen seminal vesical spermatozoa testis tunica vaginalis uterus vagina vas deferens vestibule vulva zygote Meaning Endocrine system assignment Root Carotis Gone Pinea Pituita Thymos Thyreos Galact Mamma Mastos Thel Meaning Carotid Gonad Pineal Pituitory Thymus Thyroid Milk Breast Breast Nipple Example Carotid gland Gonadotrophic Pmealopathy Pituitrin Thymectomy Thyroadenitis Galactemia Mammary gland Mastitis Thelalgia Definition Endocrine system medical terminology Dictionary Homework Word androgen cachexia cell rests chromaffin cortex diabetes endocrinology estrogen exophthahnos gastrin. Prefix Ab Apo De Ad Arnbi Amphi Meaning))From, away from) Example Abduction Apoplexy Detract Adrenal Ambidextrous Arnpitheatre Meaning of example 2. To, near, toward Both)) On) both Ainphogenic Anabolism Antenatal Precancerous Prognosis Antispasmodic Contraindication Counterbalance Catabolism Circumference Pericardium Co-ordination Compound Congenital Symbiosis Synarthrosis Diaphoresis Percutaneous Transhepatic Diarthrosis Disarticulation Enucleate Eczema Exhale Ectopic Exogenous Extravasation Empyema Encapsulated Impacted Inspiration sides 5. Ampho Ana Ante Pre Pro Anti Contra Counter Cata Circum Peri Co Corn Con Sym Syn Dia Per Trans Di Dis E Ec Ex Ect Exo Extra Em En 1m In Up, apart, across))Before)) 7. Epi Infra Hypo Sub inter Intro Meta Para Post Re Retro Re Super Upon)) Under) Between into Change Beside After Again) Endocardium Entopic Intravenous Epicondyle Inframamary Hypodermic Subelavian Intercostal Introduction Metaplasia Paranasal Postoperative Recurrence Retroflexion Relapse Superimpose Backward 26. Prefix Sept Hept(a) Octa Nonagen Novem Meaning) Example Septan Heptose Octogenarian Nonan Novemiobate Meaning of example Seven) 8. Cent Hect(o)) Centimetre Hundred Hectogram Millimetre Thousand Kilogram Demilune Semicircular Hemiplegia Multinodular Polycythaemia Supernumerary Pertussis))))))) 12. Hyperaemia Extrasystole Subnormal Less Hypocrinism Hypo Prefixes denoting colour Albumin 1. Polio Chlor Glauc Verdin Cirr Lutein Xanth)))) White)) Albuminuria Albinism Leucitis Leukaemia Auriginous Cinerea Golden) Grey 4. Yellow Poliomyelitis Chlorophyll Glaucoma Verdohaemoglobin Cirrhosis Corpus luteum Xanthopsis 88 Medical Terminology Course 6. Rube Erythr Cyan Indigo Purpur) Rubella Red Erythrocyte Cyanosis Blue Indigouria Purpura) 7. Blast Brachy Brady Cry Crypt(o) Cyt Fibr Gyn Hetero Hydr Leio Lith Micr Morph Myc Neo 011g Onc Pachy Pan Pseudo Py Sciirh Scoho Meaning Unequal Imperfect Germobe Short Slow Cold Hidden Cell Ropelike Woman Different Water Smooth Stone Small Form Fungus New Few Tumour Thick All False Pus Hard Crooked. Example Anisocytosis Atelectasis Blastomycosis Brachygnathia Bradyeardia Cryosurgery Cryptorchidism Cytology Fibroma Gynaecology Heterogeneous Hydronephrosis Leiomyoma Cholelithiasis Microscope Morphology Mycoplasm Neoplasm Oliguiia Oncology Pachyderm Pan hysterectomy Pseudocyesis Pyorrhoea Scirrhous Scoliosis Meaning of example Medical Terminology Course 89 Prefix Sten Tachy Toxi Troph Vas Suffixes Suffix orna algia atresia blast cele dde cleisis clysis cyst cyte dynia ectasis emesis Meaning Contracted Fast Poison Example Stenosis Tachycardia Meaning of example Toxicology Thyrotropic Nourishmen4Vasospasm Vessel Meaning New growth Pain Without opening Germ Swelling Killer Closure Injection Sac of fluid Cell Pain Expansion Vomiting Example Carcinoma Neuralgia Proctatresia Myeloblast Hydrocele Germicide Enterocleisis Hypodermoclysis Dacrocyst Leukocyte Pleurodynia Atelectasis Haematernesis Meaning of Example Suffix aemia iris lith ogy malacia orexia pathy penia plasia pnoea ptosis orrhagia rrhoea spasm stasis uria Example Meaning Anaemia Blood Inflammation Iritis Fecolith Stone Biology Study of Osteomalacia Softening Anorexia Appetite Adenopathy Disease Thrombopenia Poor Aplasia Formation Dyspnoea Breathing Nephroptosis A falling Bursting forth Metrorrhagia Diarrhoea Flow Pylorospasm Contraction Metastasis Position In the urine I Haematuria Meaning of example. Appendices, found at the end of the text, provide medical abbreviations, word parts and their meanings, and answers to self-check questions. Following the appendices are a bibliography and photo credits, as well as an index. The lessons emphasize the important material discussed in the text and provide additional tips or examples to help you grasp the material. Note the chapters for each assignment in the textbook and read the assignment in the textbook to get a general idea of its content. Study the assignment, paying attention to all details, especially the main concepts. After answering the suggested questions, check your answers with those given in the back of the study guide. If you miss any questions, review the pages of the textbook covering those questions. At any time, you can contact your instructor for information regarding the materials. These numbers are for reference only if you have reason to contact Student Services. A compound word may consist of two word roots, such as in the case of collarbone (collar + bone). To facilitate the pronunciation of words, a combining vowel is placed in between word roots. Aprefix is attached before the word, while a suffix is placed at the end of a word root. Guidelines Linking combining forms Linking combining formsandsuffixes Linking combining formsandsuffixes with initial vowels Linking other word partsandprefixes In most instances, the combining vowel is retained amid combining forms. For instance, appendectomy may be written as append + ectomy to highlight its component parts. Inthemedicalfield,diseases,organs,procedures,or body functions can be eponyms; hence, they are frequently capitalized. Note: Abbreviations and symbols should be used cautiously, especially when medications are involved. The branch of science that deals with the preparation, properties, uses, and actions of drugs is known as pharmacology. Drugs, most commonly referred to as medicines, are used in the prevention and treatment of diseases. Writing the answers to these questions will help you review what you have learned so far. The suffix-istmeans"onewho";hence,ananesthetist is one who administers anesthesia. An anesthetist can be a physician or a nurse, while an anesthesiologist is a medical doctor orphysician. Polypectomy and adrenalectomy refer to the excision or removal of polyps and adrenal glands, respectively. Colonoscopy is a means of visualizing thecolonwiththeuseofafiber-optic instrument. Colostomy is a surgical procedure that creates an opening for the colon or large intestine through the abdomen. Encephalopathy is a general term that refers to a disorder or disease of the brain. Osteoporosis is a disease that weakens the bones, thereby increasing the risk for fractures. Asymptom indicates a disorder or disease in which changes in health status are perceived by the client. Omphalocele is an abdominal wall defect in which the abdominal organs protrude through an opening at the base of the umbilical cord. Angioedema involves the precipitous swelling of the tissues under the skin, usually due to an allergic reaction. Lymphoma refers to a group of blood cancers originating from the lymphatic system. Neutropenia refers to abnormally low levels of neutrophils, a type of white blood cell. The word microscope (word part= micro), for example, is used not only by healthcare professionals but in customary language as well. A 78-year-old man who had a blood vessel removed during surgery is likely to have which term documented in his chart During a physical examination, a physician can visualize the eardrum using a tool called an a. The centigrade or Celsius scale is a unit of measurement for temperature, which is divided into 100 degrees. Superior vena cava is a large-diameter blood vessel that drains blood from the upper parts of the body. Malabsorption results from the inability of the gastrointestinal tract to properly absorb food nutrients. Unlike the combining forms discussed in the earlier chapters, these forms are not generally used in everyday conversations. The following table lists the most common combining forms for colors and their meanings. Lack of oxygen in the blood can cause a bluish discoloration of the skin and mucous membranes known as cyanosis. For example, phagocytes (withthesuffix-cyte) refer to cells that ingest foreign matter. Phagocytic (withthesuffix-tic), on the other hand, refers to a cell capable of functioning as a phagocyte. Combiningformssuchastherm/o (in thermometer) and carcin/o (in carcinogenic) are usual examples. Cryosurgery utilizes extreme cold temperature to destroy or remove diseased tissue. Electrocardiography is a test that detects problems with the electrical activity of the heart. Histology is the study of the microanatomy of cells and tissues of plants and animals. Optometry is concerned with the diagnosis, treatment, and prevention of eye and vision problems. Phototherapy or light therapy pertains to treatment using a special kind of light. A tracheostomy is a surgical procedure that creates an opening in the trachea (windpipe) to facilitate breathing. A term for a large cell, usually restricted to mean an extremely large red blood cell, is a. These tests may include clinical studies, laboratory tests, and radiologic (radio + logic) studies. Apart from these tests, the healthcare practitioner also needs to check for signs and symptoms of a disease. Signs are observable characteristics that have been gathered through the use of the senses. Technique Inspection Palpation Sense Involved sight touch Skill Eyes are used to observe. Handsareusedtofeel for the texture, size, consistency, and location of body parts. Thefistorfingertipsare used to tap the body part to determine the size, borders, and consistency of body organs. It makes use of an endoscope (endo + scope) to view the internal body cavities or organs. Diagnostic Radiology the domain of medicine related to the diagnosis of diseases with the use of x-rays, radioactive substances, and radiant energy is known as radiology. Combining Form ech/o, son/o electr/o fluor/o radi/o tom/o ultra- (prefix) sound electricity emittingorreflectinglight radiant energy to cut excessive Meaning Example echocardiogram, sonography electroconvulsive fluoroscopy radiography tomography ultrasonography Diagnostic imaging modalities include: a. The procedure in which the image is digitized and immediately displayed on a monitororrecordedonfilmis a. Lisa visits her obstetrician, who uses a stethoscope to listen to the heart rate of her 38-week developing fetus. A term that means pertaining to a procedure that uses an illuminated instrument for the visualization of the interior of a body cavity or organ is a. These structures start from the smallest unit, which is an atom, to the largest, most complex unit, the human organism. The body is made up of many levels of structural organization: cells make up tissues, tissues form organs, organs form body systems, and the body systems make up an organism. There are four types of tissues according to function: connective, epithelial, muscular, and nervous. Organs are formed when two or more tissue types work together to accomplish a particular function. Theprefixana- and suffix-plasia are commonly used to describe these abnormalities. Ana- means upward, excessive, or again, while -plasia refers to development or formation of tissue. The following word parts are frequently used to describe abnormal tissue development. The underdevelopment of organ or tissue is known as hypoplasia (a less severe form of aplasia). Directional Terms Directional terms denote the position of a structure in relation to another structure. The two major body cavities are the dorsal (located near the posterior part of the body) and ventral (located near the anterior part of the body) cavities. The dorsal cavity is subdivided into the cranial and spinal cavities, while the ventral cavity is subdivided into the thoracic and abdominopelvic cavities. Mostbodyfluidisintracellular (found within the cell), but some is extracellular (outsidethecell). Thebodyhastwodefense mechanisms, nonspecific resistance and specific (selective) resistance, otherwise known as immunity. Microorganisms are used as weapons of mass destruction because they can easily be transmitted, have high chances of causing death, may lead to panic, and lastly, would require extraordinary attention. This section will discuss medical terminologies related to the musculoskeletal, circulatory, and respiratory systems. Chapters 6, 7, and 8 of your textbook will provide comprehensive discussion on these systems. The musculoskeletal system protects, supports, and aids in the movement of body parts. Apart from these functions, the musculoskeletal system, particularly the bones, are essential in hematopoiesis or blood production (hemat/o = blood, -poiesis = production). The bones also function to store fat in the bone marrow and to store and release minerals. The branch of medicine that aims to prevent and correct problems concerning the bones and the muscles is known as orthopedics (orth/o = straight, ped/o = child, -ic = pertaining to). As one matures, the cartilage is replaced with bones, except for some structures such as the external ear and the nasal septum. Articulations that have cavities between adjoining bones are known as synovial joints.

The volunteer should use his or her opposite hand to grasp the wrist of the arm from which the signal is being recorded treatment as prevention trecator sc 250mg discount. Add the comment: "biceps contraction" and ask the volunteer to moderately contract the biceps muscle treatment tracker discount trecator sc 250mg free shipping, by trying to bend the arm further and resisting this movement with the other arm medications and breastfeeding purchase 250mg trecator sc overnight delivery. Add the comment: "triceps contraction" and ask the volunteer to moderately contract the triceps muscle by trying to straighten out the arm and resisting this movement with the other arm symptoms xxy best buy trecator sc. In the data panel there are four channels: two for the biceps and two for the triceps symptoms 32 weeks pregnant generic 250 mg trecator sc otc. The mathematical "trick" to deal with this is to square all the values medicine 524 buy trecator sc 250mg online, for the square of a negative value gives you a positive one. Based on the data you collected, what can you infer is happening to the muscles as weight is added Lesson 19: Axial Skeleton Created by Aimee Williams Introduction the axial skeleton forms the vertical, central axis of the body and includes all bones of the head, neck, chest, and back and serves to protect the brain, spinal cord, heart, and lungs. The axial skeleton also serves as the attachment site for muscles that move the head, neck, and back, and for muscles that act across the shoulder and hip joints to move their corresponding limbs. Distinguish among vertebrae located in different regions of the vertebral column 3. Identify and describe unique features of a fetal skull, including fontanels, and describe their function in the fetus the axial skeleton of the adult consists of 80 bones, including the skull, the vertebral column, and the thoracic cage. The skull is formed by 22 bones and the vertebral column consists of 24 bones, each called a vertebra, plus the sacrum and coccyx. The thoracic cage includes 12 pairs of ribs in addition to the sternum, the flattened bone of the anterior chest. The rounded brain case surrounds and protects the brain and houses the middle and inner ear structures. The facial bones underlie the facial structures, form the nasal cavity, enclose the eyeballs, and support the teeth of the upper and lower jaws. In the adult, the skull consists of 22 individual bones, 21 of which are immobile and united into a single unit. The 22nd bone is the mandible (lower jaw), which is the only moveable bone of the skull. The interior space that is almost completely occupied by the brain is called the cranial cavity. The bones that form the top and sides of the brain case are usually referred to as the "flat" bones of the skull. This is a complex area that varies in depth and has numerous openings for the passage of cranial nerves, blood vessels, and the spinal cord. The frontal bone is the single bone that forms the forehead supraorbital margin of the orbit, forming rounded ridges under the eyebrows. It extends into the eye socket to form the roof of the orbit below and the floor of the anterior cranial cavity above. These are paired bones, with the right and left parietal bones joining together at the top of the skull. Each parietal bone is also bounded anteriorly by the frontal bone, posteriorly by the occipital bone, and inferiorly by the temporal bone. The occipital bone is the single bone that forms the posterior skull and posterior base of the cranial cavity. On the base of the skull, the occipital bone contains the large opening of the foramen magnum, which allows for passage of the spinal cord as it exits the skull. On either side of the foramen magnum is an ovalshaped occipital condyle, which form joints with the first cervical vertebra and thus support the skull on top of the vertebral column. The temporal bone forms the lower lateral side of the skull and is possibly named because this area of the head (the temple) is where hair typically first turns gray, indicating the passage of time (temporal = "time"). Below this area and projecting anteriorly is the zygomatic process of the temporal bone, which forms the posterior portion of the zygomatic arch when joined with the temporal process of the zygomatic bone. Projecting inferiorly from this region is a large prominence, the mastoid process, which serves as a muscle attachment site. The mastoid process can easily be felt on the side of the head just behind your earlobe. Anterior to the mastoid process is an elongated, downward bony projection called the styloid process, so named because of its resemblance to a stylus (a pen or writing tool). On the interior of the skull, the temporal bone forms a prominent, diagonally oriented ridge in the floor of the cranial cavity (figure 19. Located inside each ridge are small cavities that house the structures of the middle and inner ears. The external acoustic meatus, a large opening that house the ear canal, can be seen on the lateral side of the skull. It serves as a "keystone" bone, because it joins with almost every other bone of the skull. Inside the cranial cavity, the right and left lesser wings of the sphenoid bone, which resemble the wings of a flying bird, form the lip of a prominent ridge and the sella turcica ("Turkish saddle") is located in between the lesser wings. The sella turcica is named for its resemblance to the horse saddles used by the Ottoman Turks, with a high back and a tall front. The rounded depression in the floor of the sella turcica is the hypophyseal (pituitary) fossa, which houses the pea-sized pituitary (hypophyseal) gland. The greater wings of the sphenoid bone extend laterally to either side away from the sella turcica, where they form the anterior floor of the middle cranial fossa. At the posterior apex of the orbit is the opening of the optic canal, which allows for passage of the optic nerve from the eyeball to the brain. Lateral to this are the elongated and irregularly shaped superior orbital fissure and inferior orbital fissure, which provides passage for the blood supply to the eyeball, sensory nerves, and the nerves that control the muscles involved in eye movements. Within the nasal cavity, the perpendicular plate of the ethmoid bone forms the upper portion of the nasal septum. This portion of the ethmoid bone consists of two parts, the crista galli and cribriform plates. It functions as an anterior attachment point for one of the covering layers of the brain. To either side of the crista galli is the cribriform plate, a small, flattened area with numerous small openings termed olfactory foramina. Small nerve branches from the olfactory areas of the nasal cavity pass through these openings to enter the brain. Facial Bones the anterior skull consists of the facial bones and provides the bony support for the eyes and structures of the face. The facial bones of the skull form the upper and lower jaws, the nose, nasal cavity and nasal septum, and the orbit. Although classified with the brain-case bones, the ethmoid bone also contributes to the nasal cavity and orbit and the sphenoid and frontal bones make up part of the orbit. The orbit is the bony socket that houses the eyeball and contains the muscles that move the eyeball and the upper eyelid. On the anterior maxilla, just below the orbit, is the infraorbital foramen, which is the point of exit for a sensory nerve that supplies the nose, upper lip, and anterior cheek. The plates from the right and left palatine bones join together at the midline to form the posterior quarter of the hard palate. In a lateral view of the skull, the large, rounded brain case and the upper and lower jaws are separated by the bridge of bone known as the zygomatic arch. The zygomatic arch is the bony arch on the side of skull that spans from the area of the cheek to just above the ear canal. It is formed by the junction of two bony processes: a short anterior component, the temporal process of the zygomatic bone and a longer posterior portion, the zygomatic process of the temporal bone, extending forward from the temporal bone. Thus the temporal process (anteriorly) and the zygomatic process (posteriorly) join together, like the two ends of a drawbridge, to form the zygomatic arch. One of the major muscles that pull the mandible upward during biting and chewing arises from the zygomatic arch. The lacrimal fluid (tears of the eye) drains at the medial corner of the eye, which extends downward to open into the nasal cavity. In the nasal cavity, the lacrimal fluid normally drains posteriorly, but with an increased flow of tears due to crying or eye irritation, some fluid will also drain anteriorly, thus causing a runny nose. In an anterior view of the skull, the vomer can be seen articulating to the perpendicular plate of the ethmoid bone, which forms the superior portion of the nasal septum. At the time of birth, the mandible consists of paired right and left bones, but these fuse together during the first year to form the single U-shaped mandible of the adult skull. Each side of the mandible consists of a horizontal body and posteriorly, a vertically oriented ramus of the mandible (ramus = "branch"). The more anterior projection is the flattened coronoid process of the mandible, which provides attachment for one of the biting muscles. The posterior projection is the mandibular condyle, also known as the condylar process of the mandible, which is topped by the ovalshaped condyle. The mandiblular condyle articulates (joins) with the mandibular fossa and articular tubercle of the temporal bone. Together these articulations form the temporomandibular joint, which allows for opening and closing of the mouth. Additionally, the outside margin of the mandible, where the body and ramus come together is called the angle of the mandible. Located on each side of the anterior-lateral mandible, the mental foramen is an opening that allows passage of a sensory nerve supplying a chin. Sutures of the Skull A suture is an immobile fibrous joint between adjacent bones of the skull. The narrow gap between the bones is filled with dense, fibrous connective tissue that unites the bones. The long sutures located between the bones of the brain case are not straight, but instead follow irregular, tightly twisting paths. The two suture lines seen on the top of the skull are the coronal and sagittal sutures. The coronal suture runs from side to side across the skull, within the coronal plane of section. The sagittal suture extends posteriorly from the coronal suture, running along the midline at the top of the skull in the sagittal plane of section to unite the right and left parietal bones. On the posterior skull, the sagittal suture terminates by joining the lambdoid suture. The lambdoid suture extends downward and laterally to either side away from its junction with the sagittal suture. The lambdoid suture joins the occipital bone to the right and left parietal and temporal bones. This suture is named for its upsidedown "V" shape, which resembles the capital letter version of the Greek letter lambda. After birth, the fontanelles allow for continued growth and expansion of the skull as the brain enlarges. The largest fontanelle that most people are familiar with is the anterior fontanelle, at the junction of the frontal and parietal bones. Additionally, there are posterior, mastoid, and sphenoid fontanelles, which decrease in size and disappear by age 2. However, the skull bones remain separated from each other at the sutures, which contain dense fibrous connective tissue that unites the adjacent bones. The connective tissue of the sutures allows for continued growth of the skull bones as the brain enlarges during childhood growth. The second mechanism for bone development in the skull produces the facial bones and floor of the brain case. A hyaline cartilage model of the future bone is produced and as this cartilage model grows, it is gradually converted into bone. This is a slow process and the cartilage is not completely converted to bone until the skull achieves its full adult size. At birth, the brain case and orbits of the skull are disproportionally large compared to the bones of the jaws and lower face. This reflects the relative underdevelopment of the maxilla and mandible, which lack teeth, and the small sizes of the paranasal sinuses and nasal cavity. During early childhood, the mastoid process enlarges, the two halves of the mandible and frontal bone fuse together to form single bones, and the paranasal sinuses enlarge. These changes all contribute to the rapid growth and enlargement of the face during childhood. In the neck, there are usually seven cervical vertebrae, each designated with the letter "C" followed by its number. The single sacrum, which is also part of the pelvis, is formed by the fusion of five sacral vertebrae. Similarly, the coccyx, or tailbone, results from the fusion of four small coccygeal vertebrae. However, the sacral and coccygeal fusions do not start until age 20 and are not completed until middle age. Interestingly, almost all mammals have seven cervical vertebrae, regardless of body size. This means that there are large variations in the size of cervical vertebrae, ranging from the very small cervical vertebrae of a shrew to the greatly elongated vertebrae in the neck of a giraffe. General Structure of a Vertebra Within the different regions of the vertebral column, vertebrae vary in size and shape, but they all follow a similar structural pattern. The body is the anterior portion of each vertebra and is the part that supports the body weight. Because of this, the vertebral bodies progressively increase in size and thickness going down the vertebral column.

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