Case Files Anatomy 3/E, 3rd Edition

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 Contents

Contributors / vii
Preface / ix
Acknowledgments / xi
Introduction / xiii

Section I
Applying the Basic Sciences to Clinical Medicine.................................................... 1
Part 1. Approach to Learning.................................................................................... 2
Part 2. Basic Terminology.......................................................................................... 2
Part 3. Approach to Reading..................................................................................... 3

Section II
Clinical Cases............................................................................................................. 7
Fifty-Eight Case Scenarios......................................................................................... 9

Section III
Listing of Cases...................................................................................................... 381
Listing by Case Number........................................................................................ 383
Listing by Disorder (Alphabetical)........................................................................ 384

Index / 387

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 Contributors

Ashley L. Gunter, MD
Resident Physician in Internal Medicine
University of Texas Medical School at Houston
Houston, Texas
Rotator Cuff Injury

Konrad P. Harms, MD
Associate Program Director
Obstetrics and Gynecology Residency Program
The Methodist Hospital-Houston
Houston, Texas
Clinical Assistant Professor
Weill Cornell School of Medicine
New York, New York
Greater Vestibular Gland Abscess

Krishna B. Shah, MD
Resident in Anesthesiology
Baylor College of Medicine
Houston, Texas
Knee Injury

Shen Song
Medical Resident
Emory University School of Medicine
Atlanta, Georgia
Hydrocephalus
Knee Injury
Rotator Cuff Injury

Allison L. Toy
Senior Nursing Student
Scott & White Nursing School
University of Mary Hardin-Baylor
Belton, Texas
Primary Manuscript Reviewer

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 PREFACE

We appreciate all the kind remarks and suggestions from the many medical students
over the past 5 years. Your positive reception has been an incredible encouragement,
especially in light of the short life of the Case Files® series. In this third edition of
Case Files®: Anatomy, the basic format of the book has been retained. Improvements
were made in updating many of the chapters. New cases include hydrocephalus, knee
injury, peritoneal irritation, rotator cuff injury, and thoracic outlet syndrome. We
reviewed the clinical scenarios with the intent of improving them; however, their
“real-life” presentations patterned after actual clinical experience were accurate and
instructive. The multiple-choice questions have been carefully reviewed and rewrit-
ten to ensure that they comply with the National Board and United States Medical
Licensing Examination (USMLE) format. Through this third edition, we hope that
the reader will continue to enjoy learning diagnosis and management through the
simulated clinical cases. It certainly is a privilege to be teachers for so many students,
and it is with humility that we present this edition.
The Authors

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 Acknowledgments

The inspiration for this basic science series occurred at an educational retreat led by
Dr. Maximillian Buja, who at the time was the dean of the medical school. Dr. Buja
served as Dean of the University of Texas Medical School at Houston from 1995 to
2003 before being appointed Executive Vice President for Academic Affairs. It has
been such a joy to work together with Dr. Lawrence Ross, who is a brilliant anato-
mist and teacher, and my new scientist author Dr. Han Zhang. Sitting side by side
during the writing process as they precisely described the anatomical structures was
academically fulfilling, but more so, made me a better surgeon. It has been a privilege
to work with Dr. Cristo Papasakelariou, a dear friend, scientist, leader, and the fin-
est gynecological laparoscopic surgeon I know. I would like to thank McGraw-Hill
for believing in the concept of teaching by clinical cases. I owe a great debt to
Catherine Johnson, who has been a fantastically encouraging and enthusiastic edi-
tor. It has been amazing to work together with my daughter Allison, who is a senior
nursing student at the Scott and White School of Nursing; she is an astute manu-
script reviewer and already early in her career she has a good clinical acumen and a
clear writing style. Dr. Ross would like to acknowledge the figure drawings from the
University of Texas Medical School at Houston originally published in Philo et al.,
Guide to Human Anatomy, Philadelphia: Saunders, 1985. At Methodist Hospital, I
appreciate and am grateful to Drs. Mark Boom, Alan Kaplan, and Judy Paukert. At
St. Joseph Medical Center, I would like to recognize our outstanding administrators:
Pat Mathews and Paula Efird. I appreciate Linda Bergstrom’s advice and assistance.
Without the help from my colleagues, Drs. Konrad Harms, Priti Schachel, Gizelle
Brooks-Carter, John McBride, and Russell Edwards, this manuscript could not have
been written. Most importantly, I am humbled by the love, affection, and encour-
agement from my lovely wife, Terri, and our children, Andy and his wife Anna,
Michael, Allison, and Christina.
Eugene C. Toy

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 introduction

Mastering the diverse knowledge within a field such as anatomy is a formidable task.
It is even more difficult to draw on that knowledge, relate it to a clinical setting,
and apply it to the context of the individual patient. To gain these skills, the student
learns best with good anatomical models or a well-dissected cadaver, at the labo-
ratory bench, guided and instructed by experienced teachers, and inspired toward
self-directed, diligent reading. Clearly, there is no replacement for education at the
bench. Even with accurate knowledge of the basic science, the application of that
knowledge is not always easy. Thus, this collection of patient cases is designed to
simulate the clinical approach and stress the clinical relevance to the anatomical
sciences.
Most importantly, the explanations for the cases emphasize the mechanisms and
structure–function principles rather than merely rote questions and answers. This
book is organized for versatility to allow the student “in a rush” to go quickly through
the scenarios and check the corresponding answers or to consider the thought-
provoking explanations. The answers are arranged from simple to complex: the bare
answers, a clinical correlation of the case, an approach to the pertinent topic includ-
ing objectives and definitions, a comprehension test at the end, anatomical pearls
for emphasis, and a list of references for further reading. The clinical vignettes are
listed by region to allow for a more synthetic approach to the material. A listing of
cases is included in Section III to aid any students who desire to test their knowledge
of a certain area or to review a topic including basic definitions. We intentionally
used open-ended questions in the case scenarios to encourage the student to think
through relations and mechanisms.

xiii

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 SECTION I: Applying Basic Sciences to Clinical Situations 1

Section I

Applying Basic Sciences

to Clinical Situations

Part 1. Approach to Learning

Part 2. Basic Terminology
Part 3. Approach to Reading

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 2 CASE FILES: Anatomy

Part 1. Approach to Learning

Learning anatomy consists not only in memorization but also in visualization of
the relations between the various structures of the body and understanding their
corresponding functions. Rote memorization will quickly lead to forgetfulness and
boredom. Instead, the student should approach an anatomical structure by trying
to correlate its purpose with its design. Structures that are close together should be
related not only spatially but also functionally. The student should also try to project
clinical significance to the anatomical findings. For example, if two nerves travel
close together down the arm, one could speculate that a tumor, laceration, or isch-
emic injury might affect both nerves; the next step would be to describe the deficits
expected on physical examination.
The student must approach the subject in a systematic manner, by studying the
skeletal relations of a certain region of the body, the joints, the muscular system,
the cardiovascular system (including arterial perfusion and venous drainage), the
nervous system (such as sensory and motor neural innervations), and the skin.
Each bone or muscle is unique and has advantages due to its structure and limi-
tions or perhaps vulnerability to specific injuries. The student is encouraged to read
through the description of the anatomical relation in a certain region, correlate
illustrations of the same structures, and then try to envision the anatomy in three
dimensions. For instance, if the anatomical drawings are in the coronal plane, the
student may want to draw the same region in the sagittal or cross-sectional plane as
an exercise to visualize the anatomy more clearly.

Part 2. Basic Terminology

Anatomical position: The basis of all descriptions in the anatomical sciences, with
the head, eyes, and toes pointing forward; the upper limbs by the side with the palms
facing forward; and the lower limbs together.
Anatomical planes: A section through the body, one of four commonly described
planes. The median plane is a single vertically oriented plane dividing the body
into right and left halves, whereas the sagittal planes are oriented parallel to the
median plane but not necessarily in the midline. Coronal planes are perpendicular
to the median plane and divide the body into anterior (front) and posterior (back)
portions. Transverse, axial, or cross-sectional planes pass through the body per-
pendicular to the median and coronal planes and divide the body into upper and
lower parts.
Directionality: Superior (cranial) is toward the head, whereas inferior (caudal) is
toward the feet; medial is toward the midline, whereas lateral is away from the midline.
Proximal is toward the trunk or attachment, whereas distal is away from the trunk or
attachment. Superficial is near the surface, whereas deep is away from the surface.
Motion: Adduction is movement toward the midline, whereas abduction is move-
ment away from the midline. Extension is straightening a part of the body, whereas
flexion is bending the structure. Pronation is the action of rotating the palmar side

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 SECTION I: Applying Basic Sciences to Clinical Situations 3

of the forearm facing posteriorly, whereas supination is the action of rotating the
palmar side of the forearm anteriorly.

Part 3. Approach to Reading

The student should read with a purpose and not merely to memorize facts. Reading
with the goal of comprehending the relation between structure and function is one
of the keys to understanding anatomy. Also, the ability to relate the anatomical sci-
ences to the clinical picture is critical. The following seven key questions are help-
ful in ensuring the effective application of basic science information to the clinical
setting.
1. Given the importance of a certain required function, which anatomical struc-
ture provides the ability to perform that function?
2. Given the anatomical description of a body part, what is its function?
3. Given a patient’s symptoms, what structure is affected?
4. Which lymph nodes are most likely to be affected by cancer at a particular
location?
5. If an injury occurs to one part of the body, what is the expected clinical
manifestation?
6. Given an anomaly such as weakness or numbness, what other symptoms or
signs would the patient most likely have?
7. What is the male or female homologue to the organ in question?
Let us consider these seven issues in further detail.
1. Given the importance of a certain required function, which anatomical struc-
ture provides the ability to perform that function?
The student should be able to relate the anatomical structure to a function.
When approaching the upper extremity, for instance, the student may begin
with the statement, “The upper extremity must be able to move in many dif-
ferent directions to be able to reach up (flexion), reach backward (extension),
reach to the side (abduction), bring the arm back (adduction), or turn a screw-
driver (pronation/supination).” Because the upper extremity must move in all
these directions, the joint between the trunk and arm must be very versatile.
Thus, the shoulder joint is a ball-and-socket joint to allow movement in the dif-
ferent directions required. Further, the shallower the socket is, the more mobil-
ity the joint has. However, the versatility of the joint makes its dislocation
easier.
2. Given the anatomical description of a body part, what is its function?
This is the counterpart to the previous question regarding the relation between
function and structure. The student should try to be imaginative and not merely
accept the textbook (rote) information. One should be inquisitive, perceptive,

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 4 CASE FILES: Anatomy

and discriminating. For example, a student might speculate as to why bones

contain marrow and are not completely solid and might theorize as follows:
“The main purpose of bones is to support the body and protect various organs.
If the bones were solid, they might be slightly stronger, but they would be much
heavier and be a detriment to the body. Also, production of blood cells is a criti-
cal function of the body. Thus, by having the marrow within the center of the
bone, the process is protected.”
3. Given a patient’s symptoms, what structure is affected?
This is one of the most critical questions of clinical anatomy. It is also one of
the major questions that a clinician must answer when evaluating a patient.
In clinical problem solving, the physician elicits information by asking ques-
tions (taking the history) and performing a physical examination while mak-
ing observations. The history is the single most important tool for making a
diagnosis. A thorough understanding of the anatomy aids the clinician tremen-
dously because most diseases affect body parts under the skin and require “seeing
under the surface.” For example, a clinical observation might be: “a 45-year-old
woman complains of numbness of the perineal area and has difficulty voiding.”
The student might speculate as follows: “The sensory innervation of the peri-
neal area is through sacral nerves S2 through S4, and control of the bladder is
through the parasympathetic nerves, also S2 through S4. Therefore, two pos-
sibilities are a spinal cord problem involving those nerve roots or a peripheral
nerve lesion. The internal pudendal nerve innervates the perineal region and is
involved with micturition.” Further information is supplied: “The patient states
that she has experienced back pain since a fall 2 weeks ago.” Now the lesion can
be isolated to the spine, most likely the cauda equina (“horsetail”), which is a
bundle of spinal nerve roots traversing through the cerebrospinal fluid.
4. Which lymph nodes are most likely to be affected by cancer at a particular
location?
The lymphatic drainage of a particular region of the body is important because
cancer may spread through the lymphatics, and lymph node enlargement may
result from infection. The clinician must be aware of these pathways to know
where to look for metastasis (spread) of cancer. For example, if a cancer is
located on the vulva labia majora (or the scrotum in the male), the most likely
lymph node involved is a superficial inguinal node. The clinician would then be
alert to palpating the inguinal region for lymph node enlargement, which would
indicate an advanced stage of cancer and a worse prognosis.
5. If an injury occurs to one part of the body, what is the expected clinical
manifestation?
If a laceration, tumor, trauma, or bullet causes injury to a specific area of the
body, it is important to know which crucial bones, muscles, joints, vessels, and
nerves might be involved. Also, an experienced clinician is aware of particular
vulnerabilities. For example, the thinnest part of the skull is located in the tem-
poral region, and underneath this is the middle meningeal artery. Thus, a blow
to the temple may be disastrous. A laceration to the middle meningeal artery

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 SECTION I: Applying Basic Sciences to Clinical Situations 5

would lead to an epidural hematoma because this artery is located superficial to

the dura and can cause cerebral damage.
6. Given an anomaly such as weakness or numbness, what other symptoms or
signs would the patient most likely have?
This requires a three-step process in analysis. The student must be able to
(a) deduce the initial injury on the basis of clinical findings, (b) determine
the probable site of injury, and (c) make an educated guess as to which other
structures are in close proximity and, if injured, what the clinical manifestations
would be. To develop skill in discerning these relationships, one can begin from
a clinical finding, propose an anatomical deficit, propose a mechanism or loca-
tion of the injury, identify another nerve or vessel or muscle in that location,
propose the new clinical finding, and so on.
7. What is the male or female homologue to the organ in question?
Knowledge of male–female homologous correlates is important in understand-
ing the embryologic relations and, hence, the resultant anatomical relations
because fewer structures need to be memorized, as homologous relations are
easier to discern than are two separate structures. For example, the vascular
supplies of homologous structures are usually similar. The ovarian arteries arise
from the abdominal aorta below the renal arteries; likewise, the testicular arter-
ies arise from the abdominal aorta.

KEY POINTS
• The student should approach an anatomical structure by visualizing the struc-
ture and understanding its function.
• A standard anatomical position is used as a reference for anatomical planes and
terminology of movement.
• There are seven key questions to consider in ensuring the effective application
of basic science information to the clinical arena.

REFERENCE
Moore KL, Agur AMR, Dalley AF. Clinically Oriented Anatomy, 6th ed. Baltimore, MD: Lippincott
Williams & Wilkins, 2010.

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 SECTION II: Clinical Cases 7

SECTION II

Clinical Cases

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 CASE 1

A 32-year-old woman delivered a large (4800-g) baby vaginally after a somewhat

difficult labor. Her prenatal course was complicated by diabetes, which developed
during pregnancy. At delivery, the infant’s head emerged, but the shoulders were
stuck behind the maternal symphysis pubis, requiring the obstetrician to execute
maneuvers to release the infant’s shoulders and complete the delivery. The infant
was noted to have a good cry and pink color but was not moving its right arm.

CC What is the most likely diagnosis?

CC What is the most likely etiology for this condition?
CC What is the likely anatomical mechanism for this disorder?

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 10 CASE FILES: Anatomy

ANSWERS TO CASE 1:
Brachial Plexus Injury
Summary: A large (4800-g) infant of a diabetic mother is delivered after some dif-
ficulty and cannot move its right arm. There is shoulder dystocia (the infant’s shoul-
ders are stuck after delivery of the head).
• Most likely diagnosis: Brachial plexus injury, probably Erb palsy (Duchenne-
Erb paralysis)
• Most likely etiology for this condition: Stretching of the upper brachial plexus
during delivery
• Likely anatomical mechanism for this disorder: Stretching of nerve roots C5
and C6 by an abnormal increase in the angle between the neck and the shoulder

CLINICAL CORRELATION
During delivery, particularly of a large infant, shoulder dystocia may occur. In this
situation, the fetal head emerges, but the shoulders become wedged behind the
maternal symphysis pubis. An obstetrician will use maneuvers such as flexion of the
maternal hips against the maternal abdomen (McRobert maneuver) or fetal maneu-
vers such as pushing the fetal shoulders into an oblique position. These actions are
designed to allow delivery of the fetal shoulders without excessive traction on the
fetal neck. Despite such carefully executed maneuvers, infants may be born with
stretch injuries to the brachial plexus, resulting in nerve palsies. The most common
of these is an upper brachial plexus stretch injury, in which nerve roots C5 and C6
are affected, resulting in weakness of the infant’s arm. Such injuries usually resolve
spontaneously.

APPROACH TO:
The Brachial Plexus
Objectives
1. Be able to describe the spinal cord segments, named terminal branches, and
motor and sensory deficits of an upper brachial plexus injury
2. Be able to describe the mechanism, spinal cord segments, named terminal
branches, and motor and sensory deficits of a lower brachial plexus injury
3. Be able to describe the mechanism, spinal cord segments, named terminal
branches, and motor and sensory deficits with cord injury of the brachial plexus

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