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The tibial tuberosity discount 260mg extra super avana amex impotence after prostatectomy, for attachment of the tibia patellar ligament purchase 260mg extra super avana erectile dysfunction in diabetes, is located on the proximoanterior part of the Tibia body of the tibia. The anterior crest, commonly called the “shin,” is a sharp ridge along the anterior surface of the body. A fibu- lar notch, for articulation with the fibula, is located on the disto- FIGURE 7. In that the tibia is the weight-bearing bone of the leg, it is much larger than the fibula. The patellar surface is located between the condyles on fibula articulates with the proximolateral end of the tibia. Above the condyles on the lateral and medial distal end has a prominent knob called the lateral malleolus. Both processes can be seen as prominent surface features and are easily palpated. Fractures to the fibula above the lateral malleolus are common in Patella skiers. Articular facets on the articular surface of the patella ar- The foot contains 26 bones, grouped into the tarsus, metatarsus, ticulate with the medial and lateral condyles of the femur. Although similar to the bones of the The functions of the patella are to protect the knee joint hand, the bones of the foot have distinct structural differences in and to strengthen the patellar tendon. It also increases the lever- order to support the weight of the body and provide leverage and age of the quadriceps femoris muscle as it extends (straightens) mobility during walking. It usually does Tarsus not fragment, however, because it is confined within the patel- lar tendon. Dislocations of the patella may result from injury or from There are seven tarsal bones. The most superior in position is the underdevelopment of the lateral condyle of the femur. Leg It has a large posterior extension, called the tuberosity of the Technically speaking, leg refers only to that portion of the lower limb between the knee and foot. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 186 Unit 4 Support and Movement Base of patella Articular surface Anterior surface Medial Apex of patella condyle Intercondylar eminence Intercondylar eminence Lateral condyle Articular surface of fibular head Head of fibula Tibial tuberosity Fibular articular Neck of fibula surface Anterior border Body of Body of tibia fibula Patella Tibia Fibula Medial malleolus Lateral malleolus Lateral malleolus (a) (b) FIGURE 7. Anterior to differ in shape, however, because of their load-bearing role. The remaining four The metatarsal bones are numbered I to V, starting with the tarsal bones form a distal series that articulate with the medial (great toe) side of the foot. The proximal bases of the first, second, and third metatarsals ar- Metatarsus ticulate proximally with the cuneiform bones. The heads of the metatarsals articulate distally with the proximal phalanges. The The metatarsal bones and phalanges are similar in name and proximal joints are called tarsometatarsal joints, and the distal number to the metacarpals and phalanges of the hand. The ball of the foot is formed by the heads of the first two calcaneus: L. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 Chapter 7 Skeletal System: The Appendicular Skeleton 187 Sesamoid bone Distal Metatarsal Talus phalanx bones Distal phalanx Cuneiform Tibia Phalanges Proximal bone Middle phalanx Fibula phalanx Navicular Proximal phalanx bone Calcaneus Metatarsal Medial I II cuneiform bone bones III IV V Intermediate cuneiform bone Lateral cuneiform bone Tarsal Navicular bone bones Cuboid bone Talus Calcaneus (a) (b) I II III Distal phalanx IV Phalanges Proximal phalanx V Distal phalanx Middle phalanx Head Proximal phalanx First metatarsal bone Body Metatarsal bones Medial cuneiform Fifth metatarsal bone bone Base Intermediate cuneiform bone Lateral cuneiform bone Navicular bone Cuboid bone Talus Calcaneus Tarsal bones Tuberosity of calcaneus (c) (d) FIGURE 7. Each digit (toe) is indicated by a Roman numeral, the first digit, or great toe, being Roman numeral I. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 188 Unit 4 Support and Movement Phalanges The 14 phalanges are the skeletal elements of the toes. As with the fingers of the hand, the phalanges of the toes are arranged in a proximal row, a middle row, and a distal row. The great toe, or hal- Cuneiform lux (adjective, hallucis) has only a proximal and a distal phalanx. They are formed by the structure and Talus arrangement of the bones and maintained by ligaments and ten- Calcaneus dons (fig. The arches are not rigid; they “give” when Navicular bone weight is placed on the foot, and they spring back as the weight Transverse arch is lifted. Longitudinal arch The longitudinal arch is divided into medial and lateral parts. The talus First metatarsal bone is keystone of the medial part, which originates at the calcaneus, rises at the talus, and descends to the first three metatarsal bones.

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Burns Burns are classified as first degree buy discount extra super avana 260mg on line impotence and age, second degree 260 mg extra super avana visa erectile dysfunction alcohol, or third degree, based on their severity (fig. In first-degree burns, A burn is an epithelial injury caused by contact with a thermal, the epidermal layers of the skin are damaged and symptoms are radioactive, chemical, or electrical agent. Burns generally occur restricted to local effects such as redness, pain, and edema on the skin, but they can involve the linings of the respiratory (swelling). The extent and location of a burn is frequently erally follows in a few days. Second- less important than the degree to which it disrupts body home- degree burns involve both the epidermis and dermis. Burns that have a local effect (local tissue destruction) pear and recovery is usually complete, although slow. Systemic gree burns destroy the entire thickness of the skin and effects directly or indirectly involve the entire body and are a frequently some of the underlying muscle. Possible systemic effects include body dehydration, or charred and is insensitive to touch. As a result, ulcerating shock, reduced circulation and urine production, and bacterial wounds develop, and the body attempts to heal itself by forming infections. Integumentary System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 Chapter 5 Integumentary System 123 (a) Basal cell carcinoma (a) (b) Squamous cell carcinoma (b) (c) Malignant melanoma FIGURE 5. As a way of estimating the extent of damaged skin suffered in burned patients, the rule of nines (fig. An estimation of the percentage of surface area edema—such as with a sunburn; (b) second-degree burns involve damaged is important in treating with intravenous fluid, which the epidermis and dermis and are characterized by intense pain, redness, and blistering; and (c) third-degree burns destroy the entire replaces the fluids lost from tissue damage. As the affected area is warmed, there Frostbite is a local destruction of the skin resulting from freezing. In Like burns, frostbite is classified by its degree of severity: first de- third-degree frostbite, there will be severe edema, some bleed- gree, second degree, and third degree. In first-degree frostbite, ing, and numbness followed by intense throbbing pain and the skin will appear cyanotic (bluish) and swollen. Gangrene will follow untreated mation and hyperemia (engorgement with blood) are symptoms third-degree frostbite. Integumentary System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 124 Unit 4 Support and Movement FIGURE 5. A heterotransplant (xenograph—between two different species) can serve as a tempo- If extensive areas of the stratum basale of the epidermis are de- rary treatment to prevent infection and fluid loss. The process includes seeding the synthetic skin A skin graft is a segment of skin that has been excised with basal skin cells obtained from healthy locations on the from a donor site and transplanted to the recipient site, or graft bed. This treatment eliminates some of the problems of As stated in chapter 4, an autograft is the most successful type of skin grafting—for example, additional trauma, widespread tissue transplant. It involves taking a thin sheet of healthy epi- scarring, and rejection, as in the case of skin obtained from a dermis from a donor site of the burn or frostbite patient and cadaver. Integumentary System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 Chapter 5 Integumentary System 125 (a) (b) (c) FIGURE 5. General body responses include a temporary elevation of wound does occur (fig. Integumentary System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 126 Unit 4 Support and Movement FIGURE 5. The scab that forms from the clot and ingest dead cells and foreign debris. Mechanisms are activated area is repaired and the protective scab is sloughed off. These responses are collectively referred to as develop into scar tissue (fig. The collagenous fibers of inflammation and are characterized by redness, heat, edema, and scar tissue, are more dense than those of normal tissue, and pain. Inflammation is a response that confines the injury and scar tissue has no stratified squamous or epidermal layer. The closer the edges fibroblasts from connective tissue at the wound margins. To- of a wound, the less granulation tissue develops and the less gether with new branches from surrounding blood vessels, granu- obvious a scar. This is one reason for suturing a large break in lation tissue is formed.

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The medial compartment is images are interpreted with an understanding that struc- compressed during varus stress generic extra super avana 260 mg with amex erectile dysfunction youtube, leading to impaction of tures with strong functional or anatomical relationships the medial femoral condyle against the tibia generic extra super avana 260 mg line erectile dysfunction injections treatment. By deducing the traumatic the most common traumatic mechanisms combine valgus mechanism, it is possible to improve diagnostic accuracy force with axial load. Therefore, compression with im- by taking a directed search for subtle, surgically relevant paction injury usually occurs in the lateral compartment, abnormalities that might otherwise go undetected. It may whereas tension with distraction injury occurs in the me- also be possible to communicate more knowledgeably dial compartment. Trauma-re- Acute ligamentous injuries are graded clinically into lated medial meniscal tears tend to be located at the pos- three degrees of severity. In mild sprain (stretch injury), teromedial corner (posterior to the medial collateral liga- the ligament is continuous but lax. The ligament can re- ment) because the capsule is more organized and thick- turn to normal function with appropriate conservative ened in this location, and its meniscal attachment is tight- treatment. MR images show an intact ligament that is the pathophysiological importance of this capsular an- thickened with variable surrounding edema or hemor- chor, which is called the posterior oblique ligament. In moderate sprain (partial tear), some but not all Although the posterior oblique ligament can be dissected fibers are discontinuous. Remaining intact fibers may not free in most cadaver knees, it is only rarely identified on be sufficient to stabilize the joint. Degenerative (attrition) tears of the medial bundles hang loosely, and intact fibers are overstretched meniscus also predominate posteromedially, but they in- with marked edematous swelling and ecchymosis. MR volve the thinner inner margin of the meniscus rather images demonstrate prominent thickening and indistinct than the thicker periphery. In severe sprain (rupture), the liga- a vertical orientation that can extend across the full thick- ment is incompetent. At operation, torn fiber bundles ness of the meniscus (from superior to inferior surface), hang loosely and can be moved easily. MR images show involve a peripheral corner of the meniscus, or redirect it- discontinuity of the ligament, retracted ligamentous mar- self obliquely towards the free margin of the meniscus. Once established, this vertical tear can propagate over time following the normal fiber architecture of the menis- cus. Propagation to the free margin creates a flap, or par- Meniscal Injury rot-beak, configuration. If the tear propagates longitudi- nally into the anterior and posterior meniscal thirds, the Why are most trauma-related medial meniscal tears pe- unstable inner fragment can become displaced into the in- ripheral in location and longitudinally orientated, where- tercondylar notch (bucket handle tear). The degree of lon- as lateral meniscal tears involve the free margin and are gitudinal extension should be specified in the MRI report transverse in orientation? When a distractive force sepa- dists recognize an association between longitudinal tears rates the femorotibial joint, tensile stress is transmitted and mechanical symptoms, and may decide to repair or across the joint capsule to the meniscocapsular junction, resect the inner meniscal fragment before it becomes dis- creating traction and causing peripheral tear. Compressive placed and causes locking or a decreased range of mo- force entraps, splays and splits the free margin of menis- tion. If an unstable fragment detaches anteriorly or pos- cus due to axial load across the joint compartment. Since teriorly, it can pivot around the remaining attachment site the most common traumatic mechanisms in the knee in- and rotate into an intraarticular recess or the weight-bear- volve valgus rather than varus load, the medial femorotib- ing compartment. The identification and localization of a ial compartment is distracted whereas the lateral compart- displaced meniscal fragment can be important in the pre- ment is compressed. Medial distraction means that the operative planning of arthroscopic surgery. Lateral compression means sile stress can avulse the capsule away from the menis- that the lateral meniscus is at risk for entrapment and tear cus (meniscocapsular separation), with or without a along the free margin. Meniscocapsular injury avulsed at sites where they are fixed, but can escape in- may be an important cause of disability that can be jury in regions where they are mobile. Compared to the treated surgically by primary reattachment of the cap- lateral meniscus, the medial meniscus is more firmly at- sule. Since the capsule stabilizes the medial meniscus, tached to the capsule along its peripheral border, and is meniscocapsular separation or peripheral meniscal avul- far less mobile. Normal knee motion involves greater sion can cause persistent pain and lead to posteromedi- translation of the femorotibial contact point in the lateral al instability with eventual degenerative change. In order to shift with the condyle and avoid images, meniscocapsular injury is more difficult to injury, the lateral meniscus requires a looser capsular at- identify than meniscal tear. Since with scarring and apparent reattachment of the capsule the medial meniscus is tightly secured by menis- to meniscus.

The general rule is that breathing activity is in- bral arterial blood and the bicarbonate concentration of versely related to arterial blood PO2 but directly related to cerebrospinal fluid buy 260mg extra super avana visa men's health erectile dysfunction pills. Responses to carbon dioxide and generic 260mg extra super avana mastercard thyroid causes erectile dysfunction, to a lesser Concentration and PCO2 extent, blood pH depend on sensors in the brainstem and Cerebrospinal fluid (CSF) is formed mainly by the sensors in the carotid arteries and aorta. In contrast, re- choroid plexuses of the ventricular cavities of the brain. However, choroidal epithelium actively transports several substances, including ions, and this ac- Respond to Local H tive transport participates in determining the composition Ventilatory drive is exquisitely sensitive to PCO2 of blood of CSF. The source of this chemosensitivity has plexuses is exposed to brain interstitial fluid across the been localized to bilaterally paired groups of cells just be- surface of the brain and spinal cord, with the result that low the surface of the ventrolateral medulla immediately the composition of CSF away from the choroid plexuses is caudal to the pontomedullary junction. Each side contains closer to that of interstitial fluid than it is to CSF as first a rostral and a caudal chemosensitive zone, separated by an formed. Brain interstitial fluid is also separated from blood CHAPTER 22 The Control of Ventilation 369 60 50 PACO2 43 mm Hg 40 30 20 30 10 34 37 38 39 20 40 60 80 100 120 140 Movement of H , HCO , and molecular FIGURE 22. If this had not been done (lower curve), hypocapnia secondary to the hypoxic hyper- In healthy people, the PCO2 of CSF is about 6 mm Hg ventilation would have reduced the ventilatory response. The numbers next to the lower curve are PaO values measured at each higher than that of arterial blood, approximating that of 2 point on the curve. The pH of CSF, normally slightly below that des O2-Druckes in der Einatmungsluft auf die Atemtätigkeit des of blood, is held within narrow limits. Cerebrospinal fluid Menschen, geprüft unter Konstanthaltung des alveolaren CO2- pH changes little in states of metabolic acid-base distur- Druckes. Pflugers Arch Gesamte Physiol Menschen Tiere bances (see Chapter 25)—about 10% of that in plasma. During chronic by the blood-brain barrier (capillary endothelium), acid-base disturbances, the bicarbonate concentration of which has its own transport capability. CSF changes in the same direction as in blood, but the Because of the properties of the limiting membranes, changes may be unequal. In metabolic disturbances, the CSF is essentially protein-free, but it is not just a simple CSF bicarbonate changes are about 40% of those in blood ultrafiltrate of plasma. CSF differs most notably from an but, with respiratory disturbances, CSF and blood bicar- ultrafiltrate by its lower bicarbonate and higher sodium bonate changes are essentially the same. Potassium, magnesium, base disturbances are imposed, CSF bicarbonate changes and calcium ion concentrations also differ somewhat from more slowly than does blood bicarbonate, and it may not plasma; moreover they change little in response to reach a new steady state for hours or days. As already marked changes in plasma concentrations of these noted, the mechanism of bicarbonate regulation is unset- cations. Irrespective of how it occurs, the bicarbonate regula- in CSF, but the mechanism that controls bicarbonate con- tion that occurs with acid-base disturbances is important centration is controversial. Because of the relative imperme- Peripheral Chemoreceptors abilities of the choroidal epithelium and capillary endothe- Respond to PO2, PCO2, and pH lium to H , changes in H concentration of blood are poorly reflected in CSF. By contrast, molecular carbon diox- Peripheral chemoreceptors are located in the carotid and ide diffuses readily; therefore, blood PCO2 can influence the aortic bodies and detect changes in arterial blood PO2, PCO2, pH of CSF. Carotid bodies are small ( 2 mm wide) sensory bicarbonate concentration and PCO2. The relative ease of organs located bilaterally near the bifurcations of the com- movement of molecular carbon dioxide in contrast to hy- mon carotid arteries near the base of the skull. Aortic bodies are located along the as- other poisons of the metabolic respiratory chain. This effect is more within the peripheral chemoreceptors (glomus cells) is the prominent in aortic bodies than in carotid bodies. About 40% of the effect of activity of peripheral chemoreceptors is under some degree PaCO2 on ventilation is brought about by peripheral of efferent control capable of influencing responses by chemoreceptors, while central chemoreceptors bring about mechanisms that are not clear. Unlike the central sensor, peripheral chemorecep- chemoreceptors is also centrally modified in its effects by tors are sensitive to rising arterial blood H and falling PO2. Interactions than aortic chemoreceptors; because of this and their among chemoreflexes, however, are easily demonstrated. The discharge rate of carotid chemoreceptors (and the resulting minute ventilation) is approximately linearly re- Significant Interactions Occur lated to PaCO2. The linear behavior of the receptor is re- Among the Chemoresponses flected in the linear ventilatory response to carbon dioxide The effect of PO on the response to carbon dioxide and 2 illustrated in Figure 22. When expressed using pH, the re- the effect of carbon dioxide on the response to PO have al- 2 sponse curve is no longer linear but shows a progressively ready been noted.

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