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The axillary lymph nodes (12) drain the upper limb erectile dysfunction doctors in pittsburgh buy sildalis overnight, but more importantly in the female erectile dysfunction doctor boca raton buy 120mg sildalis free shipping, they drain much of the breast erectile dysfunction homeopathic drugs purchase sildalis 120mg visa. The anterior, posterior and lateral groups drain to the central group that, along with the infraclavicular group, drains to the apical nodes. Afferents from the latter communicate with the deep cervical nodes and drain to the subclavian lymph trunk. The communication between axillary and deep cervical lymph nodes means that breast tumours may spread to the latter. Distally the fascia specializes as extensor and flexor retinacula (14), and the palmar aponeurosis (15). The deep veins commence as venae comitantes of the arteries, but converge on the axillary vein (16), as do the superficial veins. The veins draining the fingers and hand pass dorsally to form the dorsal carpal plexus, which laterally becomes the cephalic vein (17) and medially the basilic vein. The cephalic vein passes proximally up the radial border of the forearm to the elbow, then lateral to biceps (18) before running in the groove between pectoralis major and deltoid (22). The basilic vein passes proximally on the ulnar border of the forearm to the elbow, and then medial to biceps before piercing the deep fascia half way up the arm to join the venae comitantes of the brachial artery and become the axillary vein. Anterior to the elbow the cephalic and basilic veins are connected by the median cubital vein (23), passing medially and superiorly. It usually receives the median vein of the forearm and lies anterior to the brachial artery (24) and median nerve (25), but separated from them by the bicipital aponeurosis (26). Arteries Arteries are palpable as pulses when they lie superficially, but may also be compressed against bone. Medial to the tendon of biceps the brachial pulse is palpable at the extended elbow. Proximal to the base of the thumb, lateral to flexor carpi radialis (29), the radial pulse (30) is palpable at the wrist. Arterial variation is common and the brachial artery or its branches may take a course superficial to the aponeurosis. Upper limb fascia the upper limb has a thin sleeve of deep fascia (13) that attaches to palpable bony prominences (spine of scapula, acromion, clavicle, humeral epicondyles and subcutaneous border of ulna). The shoulder is a typical synovial, ball and socket joint between the scapular glenoid fossa (2) and the relatively larger humeral head (3). It attaches to the scapula and glenoid labrum, and to the anatomical neck of the humerus. Medially the capsule dips down the shaft of the humerus to provide extra space for the humeral head during abduction. It maybe minimally strengthened by glenohumeral ligaments anteriorly and a coracohumeral ligament superiorly. To provide support and stability, the acromial and coracoid processes overhang the joint, as does the coraco-acromial ligament that connects the two processes. The tendon of the long head of biceps lies within the shoulder joint and attaches to the supraglenoid tubercle of the scapula, immediately above the glenoid fossa. The long head of triceps (6) attaches to the infraglenoid tubercle, immediately inferior to the fossa, and provides some support for the joint inferiorly. But most of the stability is dependent on the musculotendinous, rotator cuff formed by four muscles arising from the scapula and inserting into the humerus, very close to its head, and into the shoulder joint capsule itself. By virtue of their dual insertions they stabilize the shoulder joint, holding the humeral head against the glenoid. Teres minor (9) (axillary nerve (10) (C5,6)) arises from the lateral border of the scapula. Both muscles pass posterior to the joint (to the greater tuberosity) therefore must externally rotate it. It adducts the humerus and as its insertion is in a plane anterior to the shoulder joint it also internally rotates it. Supraspinatus tendon passes in the coraco-acromial bursa, between the upper aspect of the joint capsule and the coraco-acromial ligament. The tendon may become inflamed causing pain during the phase of abduction where it passes beneath the ligament. Subscapularis and infraspinatus also have bursae between their tendons and the joint capsule. All three bursae may communicate with the joint and all three may become painfully inflamed. Excessive, forced abduction may cause the humeral head to dislocate antero-inferiorly, where it may impinge on the axillary nerve (C5,6) as it winds, with the posterior circumflex vessels (14), around the surgical neck of the humerus, immediately inferior to the joint. The axillary nerve is also at risk in fractures of the surgical neck of the humerus. To prevent vascular obstruction during joint movements, the arteries proximal to, and distal to joints send branches that anastomose with each other and provide collateral circulations. At the shoulder, there is a rich scapular anastomosis between branches of the subclavian and axillary arteries. Movements of the joint are flexion and extension, plus pronation and supination as the radius rotates around the ulna. The concave radial head (1) lies against the capitulum of the humerus (2), and is clasped to the ulna (3) by the anular ligament (4). The olecranon and coronoid processes of the ulna form a hook that hangs onto the olecranon fossa, trochlear surface (5) and coronoid fossa of the humerus. The fibrous joint capsule is lax anteriorly and posteriorly to allow flexion and extension, and it attaches at the articular margins of the humerus and ulna. The olecranon, coronoid and radial fossae are included within the capsule so that the equivalent processes of the ulna and radius may enter the fossae during appropriate movements. The lateral collateral ligament runs from the lateral humeral epicondyle to the anular ligament and the medial collateral ligament is a triangular ligament with its apex at the medial epicondyle (6), and diverging to the coronoid and olecranon processes of the ulna. The capsule may be pulled out of the way during elbow flexion by a few fibres of brachialis anteriorly, and during extension by triceps posteriorly.
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Endogenous glucocorticoids decrease the acinar cell sensitivity to erectile dysfunction premature ejaculation treatment purchase 120 mg sildalis with amex apoptosis during cerulein pancreatitis in rats erectile dysfunction 38 years old cheap sildalis online american express. Elaboration of interleukin- 1 receptor antagonist is not attenuated by glucocorticoids after endotoximia yellow 5 impotence cheap sildalis 120 mg overnight delivery. Clinical observation on the effect of dexamethasone and Chinese herbal decoction for purgation in severe acute pancreatitis patients. The therapeutic effects of glucocorticoid on severe acute pancreatitis combined with multiple organ dysfunction syndrome. Effects of dexamethasone and Salvia miltiorrhiza on multiple organs in rats with severe acute pancreatitis. Adjunctive therapy of dexamethasone and composite salvia miltiorrhiza in 45 patients with severe acute pancreatitis. Improving the prognosis of severe acute pancreatitis by using dexamethasone inhibiting inflammatory mediators. The treatment of low-dose glucocorticoid to severe acute pancreatitis: An clinical observation. Role of arachidonic acid metabolism and its inhibition by hydrocortisone in experimental acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. A Continuing Education Course for Radiation Operators Course Directions Completing an X-Ray Lady homestudy course is easy, convenient, and can be done from the comfort of your own couch. To complete this course read the reference corresponding to your posttest and answer the questions. The test questions correspond with the reading and can be answered as you read through the text. Transfer your answers to the blank answer sheet provided and fill out your information. Make a copy of your answer sheet for your records Interactive Testing Center: Get your score and download certificate immediately! Sign up on our website by clicking on the "Online Testing" tab or contact our office. Answer sheets will be graded in-office daily and certificates emailed within 1-2 business days. Fax: If your license expiration date is within 2 weeks of submitting your answers, fax a copy to (502) 327-7921. Certificate Issuance Your certificate will be scored the same day or next business day. The Interactive Testing Center generates your certificate upon successful completion-please print and save your certificate for your records. If you mail, email, or fax your answer sheet certificates will be emailed unless otherwise noted. Reporting Completed Credit Verification of awarded continuing education will be submitted to the radiation control boards of Florida and Kentucky. The following applies if you do not want your course and have no plans of completing it for credit: Returns or exchanges on unused materials may be made up to 30 days from the original order date. Expiring Courses Due to the nature of our courses, no refunds or exchanges are issued for courses expiring within one month of the course approval end date. Customer is responsible for all shipping charges to return or exchange course materials. Refunds and exchanges are issued when the materials are received and determined to be in excellent condition. X-Ray Lady claims no responsibility for any goods lost or stolen in transit or delivery by the U. Customers wishing to return an unwanted eBook will have 30 days from the original order date to receive a credit towards a future purchase minus a $5 processing fee. You cannot order a "test only" at a later date for an eBook that you have received a credit for. If you return your used materials you will not receive a credit and the materials will be discarded. Requests for lost or deleted eBook links after course completion will be fulfilled up to 6 months after the course completion date. Continuing education credit can be awarded only once for the same activity in the same or any subsequent biennium. This course has been evaluated and approved for a specified amount of continuing education by the agencies listed on the course cover. It is the responsibility of the individual completing this course to understand and to comply with state, national, and federal x-ray certification and licensure regulations regarding initial and continuing requirements. Readers are advised to check the most current product information provided by equipment and supply manufacturers. The information contained in this course should not be used for medical diagnosis or treatment. Users of this information are encouraged to contact their physician or health care provider for any health related concerns. Since conventional radiography images contribute to information concerning pathology and trauma, the radiographer must control factors that might otherwise distort the image. Such factors include patient cooperation, correct positioning, photographic and geometric factors, and the proper selection of exposure factors. This course provides the radiographer with a thorough review of the conventional non-contrast radiography imaging of the appendicular skeleton. Basic information about adjunct imaging modalities such as magnetic resonance imaging, computed tomography, ultrasonography, bone densitometry, nuclear medicine, and interventional examinations are also included. Course Objectives: Upon completion of this course, the participant will be able to: 1. Recall technical factors related to conventional radiography positioning protocols of the appendicular skeleton. Select the correct response regarding signs and symptoms of trauma and injury to the appendicular skeleton. The bony skeleton serves a structural function providing mobility, support, and protection for the body. This is evident by the number of imaging examinations performed each day that involve some aspect of the skeletal system. Imaging examinations play a major role in the accurate diagnosis and treatment of disease and trauma of the musculoskeletal anatomy. To produce high quality images, radiographers must have a thorough knowledge of each aspect of the skeletal system. This chapter provides a review of the skeletal system with emphasis on the appendicular skeleton. The Bony Skeleton the bony skeleton serves a structural function providing mobility, support, and protection for the body and acts as a reserve, storing up essential minerals. This assumption is false, however, since bone is living tissue, and from birth to death is in a constant state of flux.
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The lingual artery passes deep to erectile dysfunction needle injection video buy sildalis canada the hyoglossus muscle (resected here) erectile dysfunction treatment dallas texas order 120mg sildalis, close to erectile dysfunction lyrics purchase sildalis 120 mg mastercard the greater horn of the hyoid, and then passes lateral to the middle pharyngeal constrictor muscle, stylohyoid ligament, and genioglossus muscle and turns into the tongue as the deep lingual arteries. In A: the dorsal lingual arteries supply the root of the tongue and palatine tonsil, the deep lingual artery supplies the body of the tongue, and the sublingual branch supplies the floor of the mouth. In B: the inferior (sublingual) surface of the tongue is covered by a mucous membrane through which the underlying deep lingual veins can be seen. The sublingual caruncle, a papilla on each side of the frenulum, marks the location of the opening of the submandibular duct. The suboccipital triangle is bounded by three muscles: obliquus capitis inferior and superior, and rectus capitis posterior major. The suboccipital nerve (posterior ramus of C1) emerges through the suboccipital triangle to innervate the muscles forming the triangle. The sympathetic trunk (including the superior cervical ganglion), which normally lies posterior to the internal carotid artery, has been retracted medially. The pharyngobasilar fascia, between the superior pharyngeal constrictor muscle and the base of the skull, attaches the pharynx to the occipital bone and forms the wall of the noncollapsible pharyngeal recesses. A large wedge of occipital bone (including the foramen magnum) and the articulated cervical vertebrae have been separated from the remainder (anterior portion) of the head and cervical viscera at the retropharyngeal space and removed. The pharynx is a unique portion of the alimentary tract, having a circular layer of muscle externally and a longitudinal layer internally. The circular layer of the pharynx consists of the three pharyngeal constrictor muscles (superior, middle, and inferior), which overlap one another. The stylohyoid muscle passes from the lateral side of the styloid process anterolaterally and splits on its way to the hyoid bone to accommodate passage of the intermediate tendon of the digastric. The glossopharyngeal nerve supplies the sensory component, while the vagus supplies motor innervation. The posterior wall of the pharynx has been split in the midline and the halves retracted laterally to reveal the internal aspect of the anterior wall of the pharynx, occupied by communications that define three parts of the pharynx: (1) the nasal part (nasopharynx), superior to the level of the soft palate, communicates anteriorly through the choanae with the nasal cavities; (2) the oral part (oropharynx), between the soft palate and the epiglottis, communicates anteriorly through the isthmus of the fauces with the oral cavity; and (3) the laryngeal part (laryngopharynx), posterior to the larynx, communicates with the vestibule of the larynx through the inlet of (aditus to) the larynx. The pharynx extends from the cranial base to the inferior border of the cricoid cartilage. The posterior wall of the pharynx has been split in the midline and reflected laterally as in A; then, the mucous membrane was removed to expose the underlying musculature. The muscles of the soft palate, pharynx, and larynx work together during swallowing, elevating the soft palate, narrowing the pharyngeal isthmus (passageway between the nasal and oral parts of the pharynx) and laryngeal inlet, retracting the epiglottis, and closing the glottis, to keep food and drink out of the nasopharynx and larynx as they pass from oral cavity to esophagus. The fauces (throat), the passage from the mouth to the pharynx, is bounded superiorly by the soft palate, inferiorly by the root (base) of the tongue, and laterally by the palatoglossal and palatopharyngeal arches. The palatine tonsils are located between the palatoglossal and palatopharyngeal arches, formed by mucosa overlying the similarly named muscles; the arches form the boundaries, and the superior pharyngeal constrictor the floor, of the tonsillar sinuses. Right side: Palatine mucosa and tonsils removed demonstrating palatine nerves and muscles. The procedure involves removal of the tonsil and the fascial sheet covering the tonsillar sinus. Because of the rich blood supply of the tonsil, bleeding commonly arises from the large external palatine vein or less commonly from the tonsillar artery or other arterial twigs. The glossopharyngeal nerve accompanies the tonsillar artery on the lateral wall of the pharynx and is vulnerable to injury because this wall is thin. The internal carotid artery is especially vulnerable when it is tortuous, as it lies directly lateral to the tonsil. The numerous pinpoint orifices of the ducts of the mucous glands can be seen in the mucosa of the torus. The pharyngeal tonsil lies in the mucous membrane of the roof and posterior wall of the nasopharynx. The palatine tonsil lies in the tonsillar sinus between the palatoglossal and palatopharyngeal arches. Each lingual follicle has the duct of a mucous gland opening onto its surface; collectively, the follicles are known as the lingual tonsil. The pharyngobasilar fascia, which attaches the pharynx to the basilar part of the occipital bone was also removed, except at the superior, arched border of the superior pharyngeal constrictor. In this deeper dissection, the tongue was pulled anteriorly, and the inferior part of the origin of the superior pharyngeal constrictor muscle was cut away. The glossopharyngeal nerve passes to the posterior one third of the tongue and lies anterior to the stylopharyngeus muscle. The tonsillar branch of the facial artery sends a branch (cut short here) to accompany the glossopharyngeal nerve to the tongue; the submandibular gland is seen lateral to the artery and external palatine (paratonsillar) vein. The middle pharyngeal constrictor muscle arises from the angle formed by the greater and lesser horns of the hyoid bone and from the stylohyoid ligament; in this specimen, the styloid process is long and, therefore, a lateral relation of the tonsil. The lingual nerve is joined by the chorda tympani, disappears at the posterior border of the medial pterygoid muscle, and reappears at the anterior border to follow the mandible. The larynx extends vertically from the tip of the epiglottis to the inferior border of the cricoid cartilage. During normal respiration, it is narrow and wedge shaped; during forced respiration, it is wide. Variations in the tension and length of the vocal folds, in the width of the rima glottidis, and in the intensity of the expiratory effort produce changes in the pitch of the voice. Laryngeal fractures may result from blows received in sports such as kickboxing and hockey or from compression by a shoulder strap during an automobile accident. Laryngeal fractures produce submucous hemorrhage and edema, respiratory obstruction, hoarseness, and sometimes a temporary inability to speak. The thyroid, cricoid, and most of the arytenoid cartilages often ossify as age advances, commencing at approximately 25 years of age in the thyroid cartilage. The internal branch of the superior laryngeal nerve innervates the mucous membrane superior to the vocal folds, and the external laryngeal branch supplies the inferior pharyngeal constrictor and cricothyroid muscles. The recurrent laryngeal nerve supplies the esophagus, trachea, and inferior pharyngeal constrictor muscle. It supplies sensory innervation inferior to the vocal folds and motor innervation to the intrinsic muscles of the larynx, except the cricothyroid. A laryngocele (enlarged laryngeal saccule) projects through the thyrohyoid membrane and communicates with the larynx through the ventricle. The inferior laryngeal nerves are vulnerable to injury during operations in the anterior triangles of the neck. The voice is initially poor because the paralyzed fold cannot adduct to meet the normal vocal fold. Injury to the external branch of the superior laryngeal nerve results in a voice that is monotonous in character because the cricothyroid muscle is unable to vary the tension of the vocal fold. On the left side of the specimen, the mucous membrane, which is the innermost coat of the larynx, is intact; on the right side of the specimen, the mucous and submucous coats were peeled off, and the next coat, consisting of cartilages, ligaments, and fibroelastic membrane, was uncovered.
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The carotids can be opened in situ erectile dysfunction doctor kolkata cheap 120mg sildalis visa, or after the laryngo-oesophageal pluck has been removed erectile dysfunction treatment los angeles sildalis 120mg discount. The face is pale erectile dysfunction medication and heart disease buy sildalis discount, indicating a rapid sudden death; much of the skin damaged is directly over the position of the underlying carotid sinus. Later examination revealed facial congestion, fingernail marks on the neck and the impression of her necklace on the skin by strangling hands. In any autopsy, substantial haemorrhage may be seen over the posterior surface of the oesophagus and on the anterior longitudinal ligament of the cervical spine. This is a common post-mortem artefact, described fully by Prinsloo and Gordon (1951) and sometimes known by their name. In the absence of any other neck lesions, especially bleeding in the lateral and anterior parts of the neck, no reliance can be placed on this haemorrhage. It tends to develop more as the post-mortem interval lengthens and even releasing the venous pressure in the neck by removal of the brain, or opening the jugulars early, does not ensure its absence. To avoid the Prinsloo and Gordon artefact, a special technique of dissecting the neck is recommended by Shapiro (1988). These bands are pale areas in the mucosa caused by postmortem hypostasis being prevented from settling by the external pressure of adjacent anatomical structures, including parts of the larynx, trachea and aortic arch. Banding is common in routine non-trauma autopsies, but has been misinterpreted by inexperienced pathologists as evidence of strangulation. There are extensive areas of bleeding in the strap muscles, the lower part of the larynx and on the submandibular gland and jaw margin. Removal of the brain before dissection of the neck reduces the risk of artefactural haemorrhages in this region. The hyoid and thyroid bones fracture either from direct lateral compression, or from traction from the thyrohyoid membrane when it is compressed. This was fully described by Prinsloo and Gordon, and is a reason for draining the blood from the venous system of the head and neck before beginning to dissect. Below this is the smaller cricoid cartilage, which is narrow at the front, but expands posteriorly to occupy the lower part of the space left by the open thyroid cartilage. The hyoid often has natural joints, sometimes even with synovium, which lie at the junction of the body with the greater horns. There are two lesser horns on the upper surface of the body that have no forensic anatomical significance. The hyoid calcifies at variable times: the body is usually calcified, but the horns may calcify irregularly, both in space and time. In teenagers and young adults they are usually cartilaginous and the joints mobile. In middle and later life, the hyoid and thyroid horns calcify and become more brittle. The cricoid cartilage is a modified upper tracheal ring but can also become partly calcified as age increases; no meaningful ages can be placed on any calcification, but traumatic fractures can occur at any time except in children and most teenagers, in whom fractures are rare. Injury to the larynx During manual strangulation the larynx may become damaged in various ways. The cricoid and the main ala of the thyroid cartilage may be cracked, but this is an index of much greater pressure from strangling fingers. The plates may break in a spiral or oblique fashion and the cricoid may crack anteriorly through the narrow bridge rather than at the wider posterior plate. Fractures of these larger areas are also found in direct blunt violence such as punching, kicking or arm-locks, often as part of general severe damage and disruption of the entire larynx. In young persons, the horns are so pliable that they return to their normal position on release of the pressure but, variably beyond the third decade, they may be sufficiently calcified to fracture. As will be discussed later, however, there will be a haemorrhage at the fracture site that will make the lesion obvious. In the case of the hyoid, care must be taken not to misinterpret a natural joint as a fracture. These are more medial than the usual site of fracture, which is likely to be within a centimetre of the tip. The jagged edge of the fracture line may be exposed, especially in an older person with a brittle horn. Radiography before dissection is an excellent way of confirming a fracture, identifying natural joints and detecting any other fractures in the thyroid or cricoid cartilage. Though the hyoid bone has received most attention in publications as being the marker of violence to the larynx, in fact the thyroid horns are far more vulnerable. Simpson (1985) found that, in 25 successive deaths from manual strangulation, there were 22 fractures of thyroid horns but only one fractured hyoid. Though this ratio is not typical of the experience of most pathologists, there is no doubt that the superior horn of the thyroid is much more fragile and more vulnerable than the greater horn of the hyoid bone. Although fractures of the horns are more common with advancing age, they can on rare occasions be found even in teenagers. Care must be taken, however, not to confuse mobility at natural joints with a fracture (Evans and Knight 1982). Conversely, undoubted severe violence to the neck in older persons does not necessarily cause horn fractures. The Significance of laryngeal fractures Laryngeal cornual fractures are, of course, merely indicators of pressure applied to the neck and are not themselves relevant in terms of a threat to life. This is sometimes misunderstood by laymen, especially police and lawyers, who have been misled by the importance that pathologists attach to the finding of a fractured horn into thinking that the injury itself is a significant contribution to the death. Such fractures, if proved to be genuine, are certainly significant in proving the application of violence to the neck, but certain precautions must be observed in their interpretation. The sole finding of a fractured horn, where there is no other injury to the skin, subcutaneous tissues, muscles or rest of the larynx is of little value unless there is firm circumstantial evidence of violence to the throat. When a fracture of a laryngeal horn is found, it must first be proved to be ante-mortem in origin. It is certainly possible to damage the larynx post-mortem by allowing the neck to fall against a hard surface or sharp edge during removal from the place of death, or during handling in the mortuary. Such damage, however, is more likely to occur to the laryngeal plate of the thyroid cartilage or to the cricoid, rather than to the laterally placed horns, though these can be broken. Damage at autopsy is usually caused by an inexperienced pathologist or autopsy-room technician, especially when forensic expertise is lacking. Clumsy removal of the tongue and neck structures can break the thyroid or hyoid cornuae, especially in old persons where they are calcified and brittle and when any natural joints are ankylosed. This may be one justification for radiography before autopsy, but probably the danger of artefactual breakage has been overestimated, especially where a gentle removal technique is employed. Sometimes the bleeding is prominent, with a blood bleb under the periosteum or perichondrium at the fracture line, and the broken end of a calcified horn may be palpable and even slightly crepitant.
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However erectile dysfunction hotline order sildalis toronto, there are well-documented cases of language functions lost from damage to erectile dysfunction nitric oxide discount sildalis online amex the right side of the brain erectile dysfunction 27 order sildalis without prescription. The deficits seen in damage to the left side of the brain are classified as aphasia, a loss of speech function; damage on the right side can affect the use of language. Right-side damage can result in a loss of ability to understand figurative aspects of speech, such as jokes, irony, or metaphors. Nonverbal aspects of speech can be affected by damage to the right side, such as facial expression or body language, and right-side damage can lead to a "flat affect" in speech, or a loss of emotional expression in speech-sounding like a robot when talking. The Diencephalon the diencephalon is the one region of the adult brain that retains its name from embryologic development. The single exception is the system associated with olfaction, or the sense of smell, which connects directly with the cerebrum. In the earliest vertebrate species, the cerebrum was not much more than olfactory bulbs that received peripheral information about the chemical environment (to call it smell in these organisms is imprecise because they lived in the ocean). The diencephalon is deep beneath the cerebrum and constitutes the walls of the third ventricle. The diencephalon can be described as any region of the brain with "thalamus" in its name. The two major regions of the diencephalon are the thalamus itself and the hypothalamus (Figure). There are other structures, such as the epithalamus, which contains the pineal gland, or the subthalamus, which includes the subthalamic nucleus that is part of the basal nuclei. Thalamus the thalamus is a collection of nuclei that relay information between the cerebral cortex and the periphery, spinal cord, or brain stem. All sensory information, except for the sense of smell, passes through the thalamus before processing by the cortex. The thalamus does not just pass the information on, 320 it also processes that information. For example, the portion of the thalamus that receives visual information will influence what visual stimuli are important, or what receives attention. The cerebrum also sends information down to the thalamus, which usually communicates motor commands. Hypothalamus Inferior and slightly anterior to the thalamus is the hypothalamus, the other major region of the diencephalon. The hypothalamus is a collection of nuclei that are largely involved in regulating homeostasis. The hypothalamus is the executive region in charge of the autonomic nervous system and the endocrine system through its regulation of the anterior pituitary gland. Other parts of the hypothalamus are involved in memory and emotion as part of the limbic system. The Diencephalon the diencephalon is composed primarily of the thalamus and hypothalamus, which together define the walls of the third ventricle. The thalami are two elongated, ovoid structures on either side of the midline that make contact in the middle. The hypothalamus is inferior and anterior to the thalamus, culminating in a sharp angle to which the pituitary gland is attached. Brain Stem the midbrain and hindbrain (composed of the pons and the medulla) are collectively referred to as the brain stem (Figure). The structure emerges from the ventral surface of the forebrain as a tapering cone that connects the brain to the spinal cord. Attached to the brain stem, but considered a separate region of the adult brain, is the cerebellum. The midbrain coordinates sensory representations of the visual, auditory, and somatosensory perceptual spaces. The pons and the medulla regulate several crucial functions, including the cardiovascular and respiratory systems and rates. The cranial nerves connect through the brain stem and provide the brain with the sensory input and motor output associated with the head and neck, including most of the special senses. The major ascending and descending pathways between the spinal cord and brain, specifically the cerebrum, pass through the brain stem. The Brain Stem 321 the brain stem comprises three regions: the midbrain, the pons, and the medulla. Midbrain One of the original regions of the embryonic brain, the midbrain is a small region between the thalamus and pons. It is separated into the tectum and tegmentum, from the Latin words for roof and floor, respectively. The cerebral aqueduct passes through the center of the midbrain, such that these regions are the roof and floor of that canal. The tectum is composed of four bumps known as the colliculi (singular = colliculus), which means "little hill" in Latin. The inferior colliculus is the inferior pair of these enlargements and is part of the auditory brain stem pathway. Neurons of the inferior colliculus project to the thalamus, which then sends auditory information to the cerebrum for the conscious perception of sound. The superior colliculus is the superior pair and combines sensory information about visual space, auditory space, and somatosensory space. Activity in the superior colliculus is related to orienting the eyes to a sound or touch stimulus. If you are walking along the sidewalk on campus and you hear chirping, the superior colliculus coordinates that information with your awareness of the visual location of the tree right above you. If you suddenly feel something wet fall on your head, your superior colliculus integrates that with the auditory and visual maps and you know that the chirping bird just relieved itself on you. Throughout the midbrain, pons, and medulla, the tegmentum contains the nuclei that receive and send information through the cranial nerves, as well as regions that regulate important functions such as those of the cardiovascular and respiratory systems. It is visible on the anterior surface of the brain stem as the thick bundle of white matter attached to the cerebellum. The bridge-like white matter is only the anterior surface of the pons; the gray matter beneath that is a continuation of the tegmentum from the midbrain. Gray matter in the tegmentum region of the pons contains neurons receiving descending input from the forebrain that is sent to the cerebellum. Medulla the medulla is the region known as the myelencephalon in the embryonic brain. The initial portion of the name, "myel," refers to the significant white matter found in this region-especially on its exterior, which is continuous with the white matter of the spinal cord. The tegmentum of the midbrain and pons continues into the medulla because this gray matter is responsible for processing cranial nerve information.
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Where there are a number of victims and a large pile of small fragments erectile dysfunction drugs and medicare cheap sildalis generic, this task may be difficult or impossible erectile dysfunction drugs least side effects order 120mg sildalis overnight delivery, but it is naturally of paramount importance to erectile dysfunction doctor washington dc purchase 120mg sildalis with mastercard determine how many victims are involved and to determine the sex of each. This is largely an anatomical exercise, akin to the sorting of multiple skeletal remains. Careful identification of all recognizable structures, such as prostate, uterus, breasts, scalp, eyes, for example, is needed in addition to more gross sorting of limb and trunk fragments. The device probably detonated prematurely, the blast disrupting the head and abdominal region. In spite of the most thorough police search of the scene, considerable proportions of some bodies are never recovered, having been disrupted into tiny fragments and mixed with the masonry and other debris of the bomb site. The collected fragments have to be washed clean from the inevitable dirt that coats them and sorted into groups by anatomical similarity. The completed piles of tissue are then resorted by any apparent similarity, such as racial pigmentation, hair colour and sex. Limbs and large joints are then sorted, allotting them to left and right from anatomical considerations. In one of his incidents, eight victims were accounted for, when a single penile fragment forced the inevitable conclusion that there were in fact nine victims, not eight, though no other recognizable part of this ninth man was ever discovered. Shotgun wounds: multiple probes and shielding effects as adjuncts to determining position of the decreased at time of injury. Wound ballistics; mechanism of production of wounds by small bullets and shell fragments. Frequency of bone lesions: an inadequate criterion for gunshot wound diagnosis in skeletal remains. Minimal velocities necessary for perforation of skin by air gun pellets and bullets. Autopsy findings in head injuries from blunt forces: statistical evaluation of 1367 cases. Assessment of shooting distance on the basis of bloodstain analysis and histological examinations. Brain injury after gunshot wounding: morphometric analysis of cell destruction caused by temporary cavitation. Cranial fracture patterns and estimate of direction from low velocity gunshot wounds. Back spatter of blood from gunshot wound observations and experimental simulation. Computer aided shot reconstructions by means of individualized animated three-dimensional victim models. Body models in forensic ballistics: reconstruction of a gunshot injury to the chest by bullet fragmentation after shooting through a finger. Elemental analysis of bone: proton-induced x-ray emission testing in forensic cases. In developed countries, they are the most common cause of death below the age of 50 years, and in young men this trend is even more marked. The pattern of injury, fatal and otherwise, varies considerably depending upon whether the victim is a vehicle occupant, a motorcyclist, a pedal cyclist or a pedestrian. A constant speed, however rapid, has no effect whatsoever as is evident from space travel or the rotation of the earth. The amount that a human body can tolerate depends greatly on the direction in which the force acts. Deceleration of the order of 300 G can be sustained without injury and even 2000 G can be survived for a short time, if it acts at right angles to the long axis of the body. The frontal bone may resist 800 G without fracture and the mandible 400 G, as can the thoracic cage. During acceleration or deceleration the tissue damage produced will depend upon the force applied per unit area, just as a sharp knife penetrates more easily than a blunt one used with the same force. If a car driver is brought to rest from 80 km/hour by striking 10 cm2 of his head on the windscreen frame, the damage will be vastly more severe than if the same decelerative force was spread over 500 cm2 of a safety belt. Between 60 and 80 per cent of vehicular crashes (either into a fixed structure or into another vehicle) are frontal, causing violent deceleration. Another 6 per cent are rear impacts, which accelerate the vehicle and its occupants. In the common frontal impact, there is never instant arrest of the vehicle, even when it runs into a massive, immovable structure. The vehicle itself deforms from the front so that there is always a deceleration distance and time, albeit small. The object is to extend the stopping distance and time, so that the G value acting on the occupants is reduced. The value of the G forces can be calculated from the formula: G C(V 2)/D, where V is velocity in km/hour, D is the stopping distance in metres after impact, and C is a constant 0. If an occupant was rigidly belted into his seat (a practical impossibility), he would also suffer the same deceleration, which would be survivable. If, however, he was unrestrained, he would continue forwards momentarily at 80 km/hour and suffer massive G forces, the magnitude of which would depend on his deformation stopping distance (a few centimetres of tissue compression) when he struck the internal car structures in front of him. Heavy goods vehicles naturally suffer less than cars and light vans in crashes because of their far greater mass and strength, and also due to their height above the ground. Structural damage from impact with other smaller vehicles is less and often sustained below the level of the driver. Given smaller deceleration forces, however, the cab occupants are vulnerable to the same injury patterns. Light vans are virtually identical to cars with respect to the front-seat occupants. Concentrating on cars, the most common vehicular casualty, the pattern of injury varies according to the position of the occupant. The driver Numerous investigations have been made by road research organizations and car manufacturers using dummies and actual corpses, together with sophisticated recording equipment and high-speed cinematography. These have established a detailed picture of the sequence of events in automobile crashes. The heavy head goes forwards, and there is flexion of the cervical and thoracic spines. The upward and forward component causes the head to strike the windscreen, the upper windscreen rim or the side pillar. Another factor causing injury is the intrusion of structural parts into the passenger compartment.
- Blood clotting defect
- Poorly controlled blood sugar levels in women who have diabetes during pregnancy
- Rapid dehydration
- Blood pressure less than or equal to 140/90 (even lower for patients with diabetes, kidney disease, or heart failure)
- You have abdominal pain, changes in bowel movements, or weight loss
- Antithyroglobulin antibody
- Sometimes the bones on each side of the joint need to be connected (fused) together.
- Exposure to infections, parasites, or toxins
- Did it begin suddenly?
- Injury to the artery
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The halo vest relies on a firm fit of the vest around the torso and is poorly tolerated by elderly patients and patients with pulmonary compromise or thoracic deformities erectile dysfunction caused by fatigue purchase sildalis 120mg online, such as those with ankylosing spondylitis xatral erectile dysfunction purchase sildalis 120mg with mastercard. Anterior pin sites should be placed below the equator of the skull above the supraorbital ridge erectile dysfunction zinc buy cheap sildalis, anterior to the temporalis muscle, and over the lateral two-thirds of the orbit. Posterior sites are variable and are placed to maintain horizontal orientation of the halo. Pin pressure should be 6 to 8 lb in the adult and should be retightened at 24 hours. Prolonged recumbence carries an increased morbidity and mortality risk, and consideration should be given to the use of a RotoRest bed and mechanical as well as pharmacologic thromboprophylaxis. Because of the normally wide spinal canal diameter, decompression of neural elements in upper cervical spine fractures is not commonly required for traumatic conditions. The optimal time to perform surgery, particularly in patients with neurologic deficits, remains unclear. The two most commonly proposed benefits of earlier versus later surgery are improved rates of neurologic recovery and improved ability to mobilize the patient without concern of spinal displacement. However, clinical series have demonstrated that surgery performed as soon as 8 hours after injury does not appear to increase the rate of complications or lead to neurologic decline. Stabilization of the Upper Cervical Spine (Occiput-C2) the mainstay of operative treatment of upper cervical fractures and dislocations remains fusion with instrumentation, most commonly performed from the posterior approach. Anterior Approach There are three main indications for anterior upper cervical spine exposure in trauma. Anterior arthrodesis of the atlantoaxial articulations as a rare salvage procedure for failed posterior atlantoaxial fusion attempts Posterior Approach Most upper cervical fractures are treated through a posterior approach. Modified Brooks or Gallie arthrodesis uses sublaminar wires and a bone graft between the arches of C1 and C2. Flexion control is obtained via the wires, extension via the bone blocks, and rotation via friction between the bone blocks and the posterior arches. Transarticular screws (Magerl) are effective, especially if the posterior elements of C1 and C2 are fractured. Lateral mass screw fixation of C1 and (pedicle) screw fixation of C2 with rods between C1 and C2 (Harms fixation) also provides effective posterior fixation. The posterior approach to the cervical spine is a midline, extensile approach that can be used to access as many spinal levels as necessary, with a variety of instrumentation techniques in use. In the majority of acute, traumatic, subaxial spinal injuries, posterior decompression via laminectomy is not necessary. Canal compromise is most frequently caused by dislocation, translation, or retropulsed vertebral body fragments. In rare cases of anteriorly displaced posterior arch fragments, laminectomy would be indicated to directly remove the offending compressive elements. This is not true, however, in cases of acute spinal cord injury associated with multilevel spondylotic stenosis or ossification of the posterior longitudinal ligament, in which a posterior decompressive procedure may be considered the procedure of choice if cervical lordosis has been maintained. Open reduction of dislocated facet joints is typically performed using a posterior approach. Bilateral lateral mass plating this can be utilized for a variety of fractures including facet fractures, facet dislocations, and "teardrop" (compressive flexion stage V) fractures. Single-level fusions are sufficient for dislocations, although multilevel fusions may be required for more unstable patterns. This can stop fusion at levels with fractured spinous processes or laminae, thus avoiding the fusion of extra levels with consequent loss of motion. Anterior decompression and fusion these are used for vertebral body burst fractures with spinal cord injury and persistent anterior cord compression. The anterior approach to the subaxial spine utilizes the interval plane between the sternocleidomastoid (lateral) and anterior strap (medial) muscles. A simple discectomy or corpectomy in which osseous fragments are removed from the canal and a tricortical iliac or fibular graft placed between the vertebral bodies by a variety of techniques can be performed. In the presence of a herniated cervical disc associated with dislocated facet joints, one may elect to perform an anterior discectomy and decompression before facet reduction. Sixty-five percent of thoracolumbar fractures occur as a result of motor vehicle trauma or fall from a height, with the remainder caused by athletic participation and assault. Most isolated thoracic and lumbar spine fractures are related to osteoporosis and involve minimal or no trauma. Osteoporosis accounts for approximately 750,000 vertebral fractures annually in the United States, and far outnumbers the 15,000 trauma-related thoracic and lumbar spine fractures. Thoracolumbar trauma occurs most frequently in male patients between 15 and 29 years of age. Sixty percent of thoracolumbar fractures occur between T11 and L2 vertebral levels. The thoracic spine is much stiffer than the lumbar spine in flexion-extension and lateral bending, reflecting the restraining effect of the rib cage as well as the thinner intervertebral discs of the thoracic spine. The reason is the orientation of the lumbar facets, which limit the rotation arc to approximately 10 degrees for the lumbar spine versus 75 degrees for the thoracic spine. The cauda equina, which comprises the motor and sensory roots of the lumbosacral myelomeres. The corticospinal tracts demonstrate polarity, with cervical fibers distributed centrally and sacral fibers peripherally. Neurologic deficits secondary to skeletal injury from the first through the tenth thoracic levels are frequently complete deficits, primarily related to spinal cord injury with varying levels of root injury. The proportion of root injury increases with more caudal injuries, with skeletal injuries caudal to L1 causing exclusively root (lower motor neuron) injury. The region between T2 and T10 is a circulatory watershed area, deriving its proximal blood supply from antegrade vessels in the upper thoracic spine and distally from retrograde flow from the purported artery of Adamkiewicz, which can be variably located between T9 and L2. Most thoracic and lumbar injuries occur within the region between T11 and L1, commonly referred to as the thoracolumbar junction. The thoracolumbar junction is a transition zone between the relatively stiff thoracic spine and the more mobile lumbar spine. They may represent a combination of flexion, extension, compression, distraction, torsion, and shear. Evaluate the level of consciousness and neurologic impairment: Glasgow Coma Scale.
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The anatomy that should be demonstrated on the basic radiography images of the knee include the distal femur and the proximal tibia and fibula impotence guilt buy sildalis once a day. The lateral and mediolateral erectile dysfunction hormonal causes 120mg sildalis sale, projection of the knee demonstrates the distal femur erectile dysfunction treatment portland oregon 120 mg sildalis with visa, proximal tibia and fibula, and patella in profile. The tangential, also referred to as the sunrise or skyline projection, is used to demonstrate the intercondylar sulcus and patella of each distal femur, Figures 3-32 and 3-33. Both basic images demonstrate mid and distal femur and are used when trauma is not suspected. Each imaging facility has a particular radiography imaging protocol for the femur, hip, and pelvis whenever trauma is suspected and radiographers are advised to adhere to their imaging protocols. As with all positioning of the lower limb, the radiographer should assure that once the patient is in a supine position that the entire limb is aligned with no evidence of rotation. Immobilization sponge blocks should be used whenever necessary to assist the patient in maintaining the position without discomfort or movement. Radiographers should be aware if there is an orthopedic appliance present in the hip; and, if present, the entire appliance should be included within the image boundaries. For the bilateral "frog-leg" position, the radiographer will ask the patient to flex the knees approximately 90 degrees and then to abduct both femora 40 to 45 degrees from the vertical surface, Figure 3-35. For radiography imaging examinations of the hip(s), the radiographer should ask the patient to suspend respiration during the exposure. The "frog-leg" image provides a lateral view of the acetabulum and femoral head and neck, trochanteric area, and proximal onethird of the femur. There are several alternative methods to acquire substitute images of the hips when trauma to the area is suspected. Radiographers are advised to consult radiographic anatomy and positioning textbooks to become familiar with these alternative methods. Radiographers should be knowledgeable about the trauma radiography imaging guidelines and protocols recommended by their individual medical facility. Bedside Mobile Radiography Patients confined to nursing homes, assisted living facilities and even their own homes often require radiography; however, they cannot be transported to a hospital or radiology clinic. Mobile radiography equipment that is transported via a van to the patient is the solution to such dilemmas. Bedside radiography typically refers to radiography performed while the patient is in a bed confined to a hospital room, intensive or cardiac-care unit. During war and conflict, mobile radiography has served the imaging needs of wounded soldiers. During World War I, the Picker Corporation introduced the first mobile radiography unit for use on the battlefield. Mobile radiography is also used in emergency care and disaster sites, and in other unusual environments. After confirming the status of the 112 patient, the radiographer should complete all routine tasks before attempting to move or position the patient. Patients in critical care units may be able to assume an erect position for only a short period of time because of instability of their blood pressure. The clinical and environmental challenges that confront radiographers in mobile radiography require creative adaptation to routine positioning and selection of technical exposure factors. Because these challenges are unique to mobile radiography, the radiographer must be ever mindful to use all of the recommended radiation protection measures. Also, as a result of the need for unique adaptations in positioning and technical factors, additional projections and retakes are common problems in mobile radiography. Additional projections and retakes result in increased radiation dose to both the patient and the operator. Radiographers should observe all radiation protection measures during mobile radiography, including the use of protective apparel. The radiographer should apply principles of the inverse square law, and stand as far from the patient as possible during the exposure. Most mobile radiography units are equipped with an exposure cord that is six feet long which allows the operator to gain maximum distance. Also, the radiographer should attempt to stand at a right angle (90 degrees) to the x-ray beam scattering object (the patient). This location and direction receives the least amount of scatter radiation during mobile radiography procedures. The following are standard radiation protection guidelines that should be observed during mobile radiography. The radiographer should: Recognize that mobile radiography is performed in surroundings that do not have structurally designed radiation barriers; Not allow others to remain in the room or nearby area during the exposure; Verbally announce, in a loud voice, that the exposure is about to be made; Wear a protective apron and have an extra protective apron available for the patient; Provide gonadal protection for the patient; and, Maintain maximum distance from the patient during the exposure. Surgical Radiography Surgical intervention is often required in the treatment of various diseases and orthopedic conditions affecting musculoskeletal structures. When radiography 113 examinations are required during surgery, the radiographer must adhere to and apply the principles supporting the sterile environment of the surgery suite. Most modern surgery units have designated mobile radiography equipment that is maintained in the sterile environment. Specialized orthopedic surgery suites may have fixed radiography equipment designed with a C-arm x-ray tube. Fluoroscopy equipment is also used during surgical procedures and this may be highly specialized for cardiovascular and orthopedic interventional and diagnostic imaging examinations. The C-arm merely describes the basic design of the unit which forms a large C shape, with the x-ray tube located at one end of the C-arm and the image capture system at the other end. Radiation protection measures are of special concern during radiography examinations in the surgical suite and additional information will be provided later in the Radiation Protection chapter. Technical Overview Conventional radiography of musculoskeletal structures has demonstrated value in the diagnosis and treatment of disease conditions and consequences of trauma. The ultimate goal of any imaging examination is to provide diagnostic quality radiography for prompt and accurate interpretation. The following provides a review of the factors related to optimum image quality that must be considered when evaluating radiography images of the extremities. Evaluation of Conventional Radiography Images the physician is responsible for requesting conventional radiography examinations that are deemed necessary to obtain a diagnosis. For each individual patient, the physician must weigh the benefits versus risks of the each diagnostic procedure ordered and must convey this information to the patient. A qualified physician will interpret the radiography studies and document the findings. The radiographer is responsible for proper care of the patient before, during, and after the radiography study. Prior to beginning any procedure, the radiographer should carefully review the radiographic request and the reason for the examination. If at any time during this preliminary review the radiographer is uncertain about the radiographic request, he or she should not proceed until clarification can be obtained. Also in reviewing the 114 radiographic request the radiographer may be aware of alternate projections or positions that may better demonstrate the particular pathology. In such cases and whenever questions about the request should arise, the radiographer should consult with the supervisor. The radiographer evaluates images based upon the photographic and geometric properties of the image as well as standard requirements such as the complete inclusion of the requested anatomic structures.
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Capitate Carpals There are eight carpal bones erectile dysfunction doctors fort worth best purchase sildalis, which are best remembered by dividing them into two rows consisting of four each erectile dysfunction university of maryland order 120 mg sildalis fast delivery, Figure 1-6 erectile dysfunction female doctor order 120 mg sildalis otc. Hamate A memory mnemonic for the carpal bones is Send Letter (to) Paul to Tell (him to) Come Home. Figure 1-7 provides a chart of the memory aid that may be used to remember the names of the carpal bones. Also called navicular but since there is a navicular bone in the foot, the term scaphoid is used for the wrist. The largest bone in the proximal row and the most frequently fractured carpal bone. Located on the lateral side by thumb and is four sided and has an irregular shape. L Letter P Paul T To T Tell C Come H Home Lunate Pisiform Trapezium Trapezoid Capitate Hamate Proximal row Proximal row Distal row Distal row Distal row Distal row. Ossification begins at the capitate (usually present at one year of age) and proceeds in a counterclockwise direction. The hamate is the second carpus to ossify (by one to two years of age), followed by the triquetrum (by three years of age), lunate (by four to five years of age), scaphoid (by five years of age), trapezium (by six years of age), and trapezoid (by seven years of age). The pisiform is a large sesamoid bone and is the last to ossify (by nine years of age). The radiocarpal articulation is an ellipsoid type joint and is made up of the distal radius, scaphoid, lunate, triquetrum, and ligamentous structures. Carpal Sulcus (Canal or Tunnel) If the carpals were viewed tangentially downward from the wrist and arm from the palm side of a hyperextended wrist, the view would demonstrate the carpal sulcus formed by the concave anterior or palmar aspect of the carpals. The pisiform and hamulus process of the hamate is best visualized on the canal or tunnel projection. The radius and ulna articulate with each other at the proximal radioulnar joint and at the distal radioulnar joint. With the forearm in the true anatomic position, the radius is on the outer or lateral side, and the ulna on the inner or medial side. To remember the position of the radius and ulna is to recall where the radial pulse is counted. Two small conical projections called the styloid processes are located at the extreme distal ends of both the radius and the ulna. The proximal radius is composed of a head, neck, and proximal medial radial tuberosity. The radius and ulna articulate proximally at the elbow joint and distally at the wrist. The ulna is the longer of the two forearm bones and is primarily involved in the formation of the elbow joint. The proximal ulna has two beak-like processes, the olecranon and coronoid process. Blood is supplied to the forearm at the elbow where the brachial artery enters the cubital fossa and branches into the radial artery and ulnar artery. Elbow Joint the humerus, radius, and ulna combine to form the elbow joint, Figure 1-8. The elbow is a type of diarthrodial joint, which allows only flexion and extension. The elbow joint is very stable because it receives support from long ligaments and a tough capsule. The lateral ulnar collateral ligament is an essential elbow stabilizer and runs from the lateral epicondyle to the ulna crista supinatoris. Humerus the humerus is the single bone of the upper arm and it is the largest and longest bone of the upper extremity. The humerus articulates with the scapula on its upper end, forming the glenohumeral joint, and with the radius and ulna on its lower end, forming the elbow joint. The expanded distal end of the humerus is the humeral condyle divided into two parts, the trochlea and the capitulum, Figure 1-9. The surgical neck is lower than the anatomic neck and is frequently involved in fractures. The greater tuberosity, which is situated lateral to the head, serves as the attachment for the supraspinatus, infraspinatus, and teres minor muscles. Distally, the humerus flares into medial and lateral epicondlyes and forms half of the elbow joint with a medial spool-shaped trochlea. There are four major nerves that traverse the arm with the brachial artery and its bifurcations into the radial and ulnar arteries serving the extremity. The scapula spans the second through the seventh ribs and serves as an attachment for seventeen muscles and four ligaments. The scapula forms the posterior part of the shoulder girdle and is a flat triangular bone with three borders, three angles, and two surfaces. The lateral angle is the thickest part and ends laterally in a shallow depression called the glenoid cavity or fossa. The humeral head articulates with the glenoid cavity of the scapula to form the scapulohumeral joint or shoulder joint. The acromion is a long curved process extending laterally over the head of the humerus. The coracoid process is the thick, beak-like process projecting anteriorly beneath the clavicle. The scapula has several processes that include the scapular spine, coracoid, and acromion. Attachments to the coracoid process include the coracoacromial ligament, coracoclavicular ligaments, conjoined tendon, and pectoralis minor. The suprascapular notch has the superior transverse scapular ligament separating the suprascapular artery from the suprascapular nerve. The glenohumeral articulation is a spheroidal (ball-and-socket) joint and has the greatest range of motion of any joint. The shoulder joint motion is at the expense of stability because there are static and dynamic restraints of shoulder motion. The static restraints include the articular anatomy, glenoid labrum, capsule, and ligaments. The dynamic restraints include the rotator cuff, biceps tendon, and scapulothoracic motion. The ligaments of the joint prevent anteroposterior displacement of the distal clavicle. The scapulothoracic joint is not a true joint but allows scapular movement against the posterior rib cage. The muscles connecting the upper limb to the vertebral column include the trapezius, latissimus, both rhomboids, and levator scapulae. The muscles connecting the upper limb to the thoracic wall include the pectoralis muscles, subclavius, and serratus anterior. Muscles acting on the shoulder joint itself are the deltoid, teres major, and four rotator cuff muscles. The rotator cuff muscles depress and stabilize the humeral head against the glenoid.