Methods and outcomes of teaching functional anatomy of the musculoskeletal system: A scoping review

PURPOSE

Although musculoskeletal anatomy is inherently related to motion, there is a lack of evidence review about the best teaching practices for the locomotor apparatus functional anatomy. We aimed to detect the strategies that have been implemented for functional musculoskeletal anatomy education, and their outcomes, with the ultimate purpose of suggesting the most effective teaching methods.

METHODS

The databases PubMed, Scopus, ERIC, and Cochrane Library were searched for papers with the purpose of exploring the outcomes (participants' perceptions and/or examination performance) of teaching functional musculoskeletal anatomy. From each study, the following information was extracted: author(s), number of participants, implementation method, participants' perceptions and/or examination performance after the educational intervention, and classification of the outcomes according to the Kirkpatrick hierarchy.

RESULTS

Seven papers were included. Six of them involved active learning strategies (other than seeing, listening, and taking notes). Several specific teaching methods were implemented, including physical activities, lectures, textbooks, atlases, prosected specimens, near-peer teaching, and digital and physical models. Overall, methods that involved active learning, especially some form of physical activity, had the best educational outcomes, while passive learning was not found to be significantly more effective in any case. The role of modern anatomy education technologies has been inadequately explored.

CONCLUSIONS

It appears that teaching functional musculoskeletal anatomy is more successful when using active learning methods, especially involving some form of physical activity. More research is necessary to determine the best environment for these methods and investigate the role of modern technologies in functional musculoskeletal anatomy education.

Thyroidea ima artery multiple branching pattern over the trachea

PURPOSE

The current cadaveric report describes a rare case of a thyroidea ima artery (TIA) with multiple branching pattern over the trachea.

METHODS

A cadaver dissection of the neck and thorax region of a formalin-embalmed 90-year-old male cadaver of a body donor took place. The body donation was made after a signed informed consent.

RESULTS

The TIA variant originated from the brachiocephalic artery before its bifurcation into the right common carotid artery (CCA) and right subclavian artery (SCA). TIA further divided into three anterior and two posterior branches, with subsequent multiple division into smaller branches. All branches were located anterior and right side to the trachea. The anterior branches supplied the infrahyoid muscles and the posterior ones supplied the thyroid gland inferior lobes and the inferior parathyroid glands. The TIA coexisted with a brachiocephalico-carotid trunk, derived after the left CCA and brachiocephalic artery fusion.

CONCLUSION

The presence of multiple arterial branches over the trachea creates a high risk for excessive bleeding during tracheotomy or cricothyroidotomy.

Extensor digitorum muscle tendon to the index finger from the extensor carpi radialis brevis: a cadaveric case report

The forearm extensor compartment is known for its wide variability in terms of muscle origin, number of tendons and their distal insertion. The index finger on its dorsal aspect is the typical place of insertion of the two tendons of the extensor digitorum (ED-index) and of the extensor indicis. Being acquainted with their anatomy is of immense importance to orthopaedic surgeons in the treatment of e.g., de Quervain's syndrome. The current report presents a rare finding of the ED-index tendon arising from the extensor carpi radialis brevis (ECRB). A routine dissection revealed their fused course from the lateral epicondyle of humerus, though separate from the extensor carpi radialis longus. The ED-index muscle belly separated from the ECRB, 119 mm distal to the lateral epicondyle. The distal insertion point of the ED-index was located radially to that of the extensor indicis. The deep branch of the radial nerve and the recurrent interosseous artery supplied the ED-index. No other musculotendinous variations were encountered neither on the ipsilateral nor the contralateral upper limb of the cadaver. This study presents in detail a tendon of the ED-index arising from the ECRB, a knowledge that can be applied namely in the lateral epicondylitis treatment or approach to the ulnar nerve at the level of the elbow. Extensive depiction of both the proximal and distal attachment points of the muscles, their course and dimensions is indispensable to attain the best patient outcomes and avoid iatrogenic injuries.

Outcomes of the implementation of game-based anatomy teaching approaches: An overview

OBJECTIVE

We aimed to investigate to what extent the literature supports that game-based learning (gamification) could play a significant role in anatomy education.

MATERIALS AND METHODS

PubMed, Education Resources Information Center and Cochrane Databases were searched for papers with purpose to investigate the educational outcomes of game-based anatomy learning. We extracted from each paper the number of participants, type of study (comparative or not), level of evidence according to Kirkpatrick hierarchy, possible evaluation of statistical significance, method which was implemented, academic performance of participants after the educational intervention, perceptions about the effectiveness of game-based approach and its impact on motivation to learn.

RESULTS

Eight papers were included. Six of them were comparative, comprised assessment of students' examinations results and showed that those results were generally improved after exposure to game-based methods, in comparison with non-game-based ones. There is lack of evidence that the intensity of competition is correlated with the educational outcomes and that game-based approaches motivate students to a greater extent in comparison with other teaching methods.

CONCLUSION

Game-based methods could obtain a remarkable supplemental role in the blended learning approach, which is applied by anatomy educators. Further research is needed to shed light on the characteristics of game-based methods which are more useful and should be adopted.

A systematic classification of the left-sided aortic arch variants based on cadaveric studies' prevalence

INTRODUCTION

Typical branching pattern of the left-sided aortic arch consists of the brachiocephalic trunk (BCT), the left common carotid artery (LCCA) and the left subclavian artery (LSA). Variant patterns have been associated with a broad spectrum of pathologies. The meticulous knowledge of potential aortic arch variants is of utmost importance to radiologists, interventional cardiologists, vascular and thoracic surgeons. The current systematic review collects all aortic arch branching patterns and their frequency as published by various cadaveric studies, calculates prevalence taking into account the gender and the different people background, as well. All extracted variant patterns are classified into types and subtypes according to the number of emerging (major and minor) branches (1, 2, 3, 4 and 5) and to the prevalence they appear. In cases of similar prevalence, total cases were taken into consideration; otherwise the variants were classified under the title "other rare variants".

METHODS

A systematic online search of PubMed and Google books databases was performed only in cadaveric studies.

RESULTS

Twenty studies with typical (78% prevalence) and variable (22%) branching patterns were included. Types 3b, 2b, 4b, 1b and 5b had a prevalence of 81%, of 13%, of 5%, 0% and of 0%, respectively. Common variants were the brachiocephalico-carotid trunk (BCCT, 49% prevalence), the aberrant left vertebral artery (LVA, 41%) and the aberrant right subclavian artery (ARSA, 8%). LVA of aortic origin was detected in 32%, the bicarotid trunk (biCT) in 5% and the bi-BCT trunk in 3%. Thyroidea ima artery, a minor branch emerging from the aortic arch was found in 2%. Coexisted variants were detected in 4% (ARSA with a distinct RCCA and LCCA origin), in 3% (BCCT with a LVA of aortic origin), in 2% (ARSA with a biCT and a vertebrosubclavian trunk).

CONCLUSION

No significant gender or ethnic differences exist among the 5 branching types. The proposed classification scheme aims to become a valuable and easy to use tool in the hands of all physicians involved in diagnosis and treatment of aortic arch pathology. It could be also useful in anatomical education, as well.

Pterional variable topography and morphology. An anatomical study and its clinical significance

BACKGROUND

Pterion is the junction of the frontal, parietal, greater wing of the sphenoid and the squamous part of the temporal bone. The sphenoparietal, frontotemporal, stellate and epipteric pteria were described. The current study determines pterion topography, morphology (variant types' frequency) and morphometry, as well as epipteric bones presence in dried skulls. Gender impact is underlined as well.

MATERIALS AND METHODS

Ninety Greek adult dried skulls were observed. The distances in between pterion and the zygomatic arch midpoint and in between pterion and the frontozygomatic suture were measured.

RESULTS

The sphenoparietal pterion was the commonest (58.3%), following by the stellate (25%), epipteric (15.5%) and by the frontotemporal pterion (1.1%). Twenty-eight (15.5%) skulls had epipteric bones, further categorised as quadrisutural (35.7%), trisutural (57.1%), bisutural and multiple (3.57%). The mean distances between pterion and the midpoint of zygomatic arch were 4.13 ± 0.45 cm on the right and 4.09 ± 0.47 cm on the left side and between pterion and the frontozygomatic suture were 3.47 ± 0.61 cm on the right and 3.52 ± 0.65 cm on the left side. Both distances were symmetrical. Male skulls showed slightly higher values on the left side for the distance (pterion-midpoint of zygomatic arch).

CONCLUSIONS

Pterion is a commonly used neurosurgical landmark and thus in depth knowledge of the pteric area and its variants could be valuable. Recognition of the possible variability in pterion location, morphology and morphometry, as well as possible occurrence of epipteric bones may render pterional craniotomy safer among different population groups.

Surgical anatomy of the lateral circumflex femoral artery branches: Contribution to the blood loss control during hip arthroplasty

BACKGROUND

The lateral circumflex femoral artery (LCFA) branches encountered during anterior and lateral hip approaches; although vessels' haemostasis is suggested in surgical textbooks, literature is scarce regarding their topography. The current study defines the exact location of the LCFA and its branches, based on osseous landmarks, as well as their size and possible variants, providing helpful information for intraoperative identification and demonstrating the magnitude of potential haemorrhage during hip surgery.

METHODS

Twenty-three human cadavers (46 lower limbs) were dissected. The LCFA branching pattern was recorded. The distances of the LCFA origin and its first branch from the anterior superior iliac spine (ASIS) were measured. Length and width of the LFCA, LCFA ascending and transverse branches (LCFAab and LCFAtb) were calculated and compared to the ipsilateral ulnar artery (UA) width, which was served as a comparative guide.

RESULTS

The LFCA origin was located 106.9 ± 17.5 mm distal and 65.6 ± 14.7 mm medial to the ASIS, while the LFCA first branch origin was 115.1 ± 24.3 mm distal and 48.2 ± 14.3 mm medial to the ASIS. The mean lengths of the LCFA, LCFAab and LCFAtb were 23.2 ± 12.6 mm, 44.8 ± 14.9 mm and 42.3 ± 13.6 mm, respectively. Their mean widths were 4.3 ± 1.0 mm, 2.9 ± 0.9 mm and 2.7 ± 0.7 mm, respectively, while the mean UA width was 2.7 ± 0.4 mm.

CONCLUSION

The surgeon may detect the LCFA and its branching, at a mean distance of 110 mm (range 100-126 mm), distal to the ASIS. The LCFAab and LCFAtb widths are similar to the UA width. Meticulous knowledge of the branching pattern topography and vessels' size may contribute to a successful management of the intraoperative blood loss.

Vertebral artery variations revised: origin, course, branches and embryonic development

BACKGROUND

The vertebral artery originates from the subclavian artery and is divided into four segments. The aim of this study is to investigate the anatomical variations in the course and branches of the vertebral artery.

MATERIALS AND METHODS

A research was performed via PubMed database, using the terms: "variations of vertebral artery AND cadaveric study", "variations of vertebral artery AND cadavers" and "anomalies of vertebral artery AND cadavers".

RESULTS

A total of 24 articles met the inclusion criteria, 13 of them referring to variations of the origin of the vertebral artery, 9 to variations of the course and 3 to variations of its branches. On a total sample of 1192 cadavers of different populations, origin of the left vertebral artery directly from the aortic arch was observed at 6.7%. In addition, among 311 cadavers, 17.4% were found with partially or fully ossified foramen of the atlas for the passage of the vertebral artery, while the bibliographic review also showed variants at the exit site of the artery from the transverse foramen of the axis.

CONCLUSIONS

Despite the fact that variations of both the course and the branches of vertebral artery are in most cases asymptomatic, good knowledge of anatomy and its variants is of particular importance for the prevention of vascular complications during surgical and radiological procedures in the cervix area.

A prefix brachial plexus with two trunks and one anterior cord

The brachial plexus presents a great variability in formation, division and branching pattern. Its variants are of immense importance during axillary and arm surgery and nerve blockade. The current case highlights a unilateral atypical formation of brachial plexus, the so called prefix, in which the C4 root contributed a large branch to the superior trunk and further anastomosis with the inferior trunk. Thus, the prefix or high brachial plexus consisted of a superior and inferior trunk and one anterior cord. Coexisting neural and arterial variations are also discussed in relation to the data literature.

An aperture in the sagittal plane of the dorsal wall of the sacrum

The dorsal wall of the sacrum presents various anatomical variations, while the dorsal bony wall of the sacral canal suffers more. We report a case of a sacrum with a series of variants in the midline due to abnormal ossification and a bizarre aperture on the sagittal plane between the 1st and the 2nd sacral spinous processes. A failure of the ossification patter during embryological life, or an ossification of the supraspinous ligament may result in such an aperture. Sacrum variety is of great importance for the daily proper medical practice.

An unusual case of asymmetrical combined variations of the subclavian and axillary artery with clinical significance

In a Greek Caucasian male cadaver, a combination of the following arterial variations were observed: an aberrant right subclavian artery originating as a last branch of the aortic arch and coursed posterior to the oesophagus, a right non-recurrent laryngeal nerve, an atypical origin of the left suprascapular artery from the axillary artery, an unusual emersion of the lateral thoracic artery from the subscapular artery and a separate origin of the left thoracodorsal artery from the axillary artery. According to the available literature the corresponding incidences of the referred variants are: 0.7% for the aberrant right subclavian artery, 1.6-3.8% for the origin of the suprascapular artery from the axillary artery, 3% for the origin of the left thoracodorsal artery from the axillary artery and 30% for the origin of the lateral thoracic artery from the subscapular artery. Such unusual coexistence of arterial variations may developmentally be explained and has important clinical significance.

Body donation for research and teaching purposes: the contribution of blood donation units in the progress of anatomical science

BACKGROUND

Cadaver's dissection has a fundamental role in teaching and understanding the anatomy. Postmortem body donation (PMBD) is an important source of cadavers and provides an opportunity to carry out research or educational activities in medicine and surgery. The objective of the current study is to determine the perspectives and attitudes toward PMBD among blood donors (BLD) and elderly people. These data are fundamental to highlight the PMBD extent and individual factors that might influence PMBD.

MATERIALS AND METHODS

Six hundred and fifty questionnaires were distributed to 500 (327 male and 173 female, mean age 39.9 ± 9.6 years) blood donors (BLD) and 150 elderly people (62 males and 88 females, mean age 74 ± 9.4 years). A specially designed self-administered questionnaire covering demographic data, knowledge and attitude of the participants concerning body donation (BD) was used.

RESULTS

Concerning the perception of BD among BLD and elderly people, the most common reason for BD in both study groups was the contribution in research, while the commonest reason for hesitating about BD was the lack of information, following by personal reasons. The BLD were more likely to be interested in BD for contribution in research and personal reasons. Additionally, BLD were less likely than the elderly to hesitate about BD for religious and personal reasons and more likely to hesitate about BD for not being informed. BLD who were interested in BD for contribution in research were significantly older. Elderly people who hesitated about BD for personal reasons were significantly older. In the BLD group, those who responded that blood and body donation are the same were significantly younger, while in the elderly group - significantly older. The proportion of BLD who declared that blood and body donation is the same was significantly higher in more educated people.

CONCLUSIONS

A need for well-organised and informative BD programmes is evident. Orientating the public towards this practice is of high moral and medical value, since with this important promotion the altruistic act of BD will expand globally.

Investigation of the styloid process length in a Greek population

BACKGROUND

The styloid process (SP) is a slender cylindrical bony projection of the temporal bone with 2 ligaments and 3 muscles attached to it. Symptomatic SP elongation is also referred to, as Eagle's syndrome. The aim of the present study is to investigate the distribution of the SP length in a young adult Greek population.

MATERIALS AND METHODS

Moreover, we provide a comparison of the results by using two different methods for assessing SP elongation, as described in the lite- rature. Finally, we explore the possibility of using orthopantomograms (OPGs), as a diagnostic aid by investigating inter-examiner, intra-examiner and inter-exami- nation variability and we propose a limit for SP elongation measurable in OPGs.

RESULTS

The sample comprised 805 digital OPGs, taken from student pilots and engineers entering the Hellenic Air Force Academy, from 2008 onwards. Two measuring approaches were selected, one using the temporal bone, as a cranial landmark and the other, using the external auditory meatus. The end tip of the process was always the caudal landmark. The mean SP length was 28.42 ± ± 8.48 mm in males and 26.04 ± 7.69 mm in females, when measured from the temporal bone. The mean SP length was 38.35 ± 8.90 mm in males and 34.24 ± ± 8.63 mm in females, when measured from the external auditory meatus. The length of 30 mm is most commonly used as a starting point for SP elongation. In the total sample, 30.6% of the measured SPs exceeded the length of 30 mm. In males, 33.12% of the SPs were elongated; while in females the corresponding incidence was 20%. One hundred and nineteen (14.8%) SPs were not traceable.

CONCLUSIONS

The SP is typically detectable and measurable in OPGs. An elonga- ted SP should be kept in mind, since symptoms of elongation may overlap with clinical manifestations of temporomandibular joint disorders.

An atypical biceps brachii and coracobrachialis muscles associated with multiple neurovascular aberrations: a case report with clinical significance

Neural and vascular variations in the axilla and upper limb area are usually paired, but coexistence of muscular aberration on top of this is uncommon. The current case report emphasizes on the unilateral coexistence of a three-headed (tricipital) biceps brachii muscle, a two-headed coracobrachialis with an accessory muscle bundle joining the superficial and deep heads of coracobrachialis muscle. On the ipsilateral side of the 72-year-old male cadaver, a connecting branch originated from the musculocutaneous nerve and joined the median nerve after surpassing the accessory muscle bundle. A large diameter subscapular trunk originated from the 2nd part of the axillary artery and after giving off the 1st lateral thoracic artery trifurcated into a common stem which gave off the 2nd and 3rd lateral thoracic arteries, the circumflex scapular artery and a common branch that gave off the 4th and 5th lateral thoracic arteries and the thoracodorsal artery, as the ultimate branch. All lateral thoracic arteries were accompanied by multiple intercostobra- chial nerves. Documentation of such muscular and neurovascular variants and their embryologic origin increases awareness of their potential impact on diagnosis and treatment of upper limb pathology. To the best of our knowledge, the currently reported cadaveric observations seem to constitute a unique finding.

From thyroid cartilage to thyroid gland

The ancient Greek physicians skipped the description of thyroid gland probablydue to their difficultly to understand the anatomy and the existence of this organ.Although the ancient physicians had described the disease bronchocele (Greek:Βρογχοκήλη), this disease did not correspond exactly to goitre. The first officialdescription of this gland was made by Andreas Vesalius (1514-1564). Thomas Wharton (1614-1673) in his work Adenographia was the one who coined the term 'Glandulae thyreoidea'.

The position of the mental foramen in dentate and edentulous mandibles: clinical and surgical relevance

BACKGROUND

The knowledge of the exact location of the mental foramen (MF) in dentate and edentulous mandibles is clinically important when constructing complete dentures, performing anaesthetic block of the lower-anterior teeth area and intervening in the MF nearby area. In edentulous mandibles, the bone resorption after teeth loss makes the mental nerve (MN) prone to damage due to the extreme location of the MF very close to the alveolar crest (AC). Chronic compression on the MN may result in pain in the area of MN distribution (ipsilateral face and cheek area) and numbness at the lower lip. The purpose of the current study is to evaluate the exact position of the MF, calculating the distances MF-superior border of the AC and MF-inferior border of the mandible (IBM) in dentate and edentulous mandibles.

MATERIALS AND METHODS

One hundred and two (36 edentulous and 66 dentate) adult dry Greek mandibles were studied.

RESULTS

In 9 out of 36 edentulous mandibles (25%), the MF was found nearby the AC, while in 27 edentulous mandibles (75%), the MF was located at an average distance 6.4 mm from the AC and 12.6 mm from the IBM. In 38 out of 66 dentate mandibles (57.6%), the MF was located at an average distance 13.6 mm from the AC and 15.2 mm from the IBM. The dental status significantly affected (p = 0.001) the distances MF-AC and MF-IBM. Side symmetry was observed for both dentate and edentulous mandibles (p = 0.39 and p = 0.45).

CONCLUSIONS

The MF is an important landmark and its location needs to be considered prior to dental implants placement in order to avoid the MN injury and related complications. The position of MF is altered in edentulous mandibles compared with the dentate ones. The MF is a symmetric structure in Greeks.

Giacomini vein: thigh extension of the small saphenous vein - report of two cases and review of the literature

BACKGROUND

Varicose vein surgery is very commonly performed. Also, it is very frequently employed for recurrent disease. The recognition of the normal or variant veins, inducing incompetency, is a prerequisite for effective treatment. The thigh extension of the small saphenous vein, the so-called Giacomini vein, was extensively described in 1873 by Carlo Giacomini in an incidence of 72%. However, such a vein is usually underestimated in classic surgical textbooks.

DESCRIPTION OF CASES

We present two cases of Giacomini vein found in two cadavers, dissected for academic purposes in the Department of Anatomy, where the small saphenous vein displayed a thigh extension without terminating into the popliteal vein. In one case Giacomini vein drained into the large saphenous vein, while in the other case the vein divided into two branches, separately draining into the large saphenous vein and the subcutaneous tissue of the gluteal region.

CONCLUSION

Due to the fact that Giacomini vein could be incompetent, associated with or without varicose saphenous vein trunks, the vascular surgeon should keep in mind that anatomical entity, to include it in preoperative ultrasound scanning control. Moreover, this vein could be utilized as an autologous graft, when the large saphenous is not available. Hippokratia 2015; 19 (3): 263-265.

Anatomic variability in the relation between the retromandibular vein and the facial nerve: a case report, literature review and classification

Knowledge of anatomic variations concerning head and neck veins is important to surgeons performing interventions in these regions, as well as to radiologists. The retromandibular vein is used as a guide to expose the facial nerve branches inside the parotid gland, during parotid surgery and open reduction of mandibular condyle fractures. It is also used as a landmark for localisation of the nerve and compartmentalisation of parotid gland lesions preoperatively, during computed tomography, magnetic resonance imaging and sonography. In this paper, the anomalous retromandibular vein's course on the left side of a male cadaver is described. The vein was formed around the nerve, while the maxillary vein travelled medial to the facial nerve branches and superficial to the superficial temporal vein. Interestingly, the facial nerve temporofacial division crossed again the superficial temporal vein upwards, forming a "nerve fork". The incidence of the reported variability of the relationship between the retromandibular vein and the facial nerve are discussed with a detailed literature review. Accordingly, the typical deep position of the retromandibular vein in relation to the facial nerve is estimated to 88.17% to all sides. Furthermore, an updated classification system is proposed, including 4 types and subtypes.

The great surgeon Jean-Louis Faure (1863-1944) and his contribution in the treatment of uterine cancer

At the beginning of the 20th century, Professor Jean-Louis Faure, one of the leading surgeons of the innovative Parisian Medical School, published an exhaustive work on uterine cancer. He was the first to perform in France the procedure of total abdominal hysterectomy by median section of the uterus contributing to the evolution of cancer surgery.

Joseph Gensoul's operation for sarcoma of the maxillary antrum, one century before Moore

Joseph Gensoul is considered an important figure of the 19th century Lyonnais Medical School. His contribution to maxillofacial surgery and his legendary abilities secured him a place in the history of Medicine.

Median to ulnar nerve anastomosis: a review of the literature

Median to Ulnar nerve anastomosis in the forearm has been shown to be of clinical significance leading to "anomalous" innervation and is correlated with misdiagnosis during the assessment of nerve lesions, injuries and Carpal Tunnel Syndrome (CTS). In 1763, Martin first described the anastomosis and Gruber next mentioning it, in 1870 thus referred to as Martin--Gruber anastomosis. Despite its long history, its nature remains unclear. Many anatomical, electrophysiological, histological and genetic studies have been published, reporting the anastomosis' frequency, citing its clinical importance and classifying it into various classes and types. Diagnosis is made mostly with electrophysiological studies whereby researchers have cited certain clues taking into consideration the asymptomatic nature of the anastomosis. The current literature on median to ulnar nerve anastomosis is reviewed, highlighting its frequency and clinical significance making an excellent tool for correct diagnosis in many clinicians.

Uterine cancer through the works of the eccentric Auguste Joseph Lutaud (1847- 1925), famous gynaecologist, publisher and intellectual of the 19th century

Auguste Lutaud was standing for almost half century in front of the French and International stage for his controversy and eccentric personality, his undisputed authority in gynecology, his writings and his publishing success. Thanks to his writings, he is considered as the main propagator of the prevailing ideas on uterine cancer diagnosis and treatment.

The father of hematologic oncology Jean Bernard (1907-2006) and his contribution to the research and treatment of leukemia

Through his medical research and scientific work Jean Bernard dominated for half century in medicine and literature and he was honored as no other scientist. He excelled in different medical fields and is rightly considered as the founder of hematology, oncology and bioethics.