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.

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.

The size of the foramen ovale regarding to the presence and absence of the emissary sphenoidal foramen: is there any relationship between them?

BACKGROUND: The study investigates the size of the foramen ovale (FO) in relation to the presence and absence of the emissary sphenoidal foramen (ESF). Any possible alteration of the FO size in relation to the ESF (unilateral or bilateral) presence and absence was also examined. MATERIALS AND METHODS: One-hundred and ninety-five (117 male and 78 female) Greek adult dry skulls were investigated. RESULTS: The ESF was present in 40% of the skulls (21.5% bilaterally and 18.5% unilaterally). No statistical significant difference was detected between ESF presence or absence and its unilateral or bilateral occurrence. The ESF existence had no relation to the FO size. CONCLUSIONS: The ESF absence or presence has no effect on FO size. The emissary sphenoidal vein is an additional venous pathway connecting cavernous sinus with the pterygoid venous plexus. These findings enhance that the venous plexus of the FO is a constant trait. The meticulous knowledge of the middle cranial fossa anatomy is of paramount importance during transovale procedures, as the outcome of cannulation may be affected by the existence of ESF, the confluence FO-ESF, the existence of osseous spurs and bridging into the FO. (Folia Morphol 2018; 77, 1: 90-98).

Unilateral asymmetrical anterior bellies of the digastric muscle in coexistence with accessory muscle bundles in the submental triangle: A rare case report.

A three-headed anterior belly of the digastric muscle (ABDM) on the right side of a 54-year old Greek male cadaver coexisted with two accessory muscle bundles (AMB) in the submental region. The left ABDM was typical. Typical ABDM was attached to the digastric fossa, while the accessory right anterior bellies to the lower border of the mandible. A muscle bundle arising from the attachment of the left ABDM to the hyoid bone was also observed fusing with the AMB of the ipsilateral side. It is of extreme importance to be aware of the submental region anatomical variations during surgery, imaging interpretation or differential diagnosis of neck masses.

The accessory tendon of extensor hallucis longus muscle and its correlation to hallux valgus deformity: a cadaveric study.

PURPOSE: The accessory tendon (AT) of the extensor hallucis longus (EHL) is a common anatomic variation, whose clinical significance remains debatable. The purpose of this study was to investigate the incidence and morphology of accessory EHL tendons in cadavers and to examine any possible correlation to the occurrence and severity of hallux valgus (HV) deformity. METHODS: We examined any possible correlation between the AT presence and the cadavers' age and the HV deformity in 98 female adult cadaveric feet. The HV and intermetatarsal (IMA) angles were measured and compared with the relative angle between the primary EHL tendon and AT as well as the length of the AT. RESULTS: AT was present in 26.5% and HV deformity existed in 36.7% of all feet. There was a high prevalence (65.4%) of HV deformity in feet with AT, but the HV angle and IMA were similar in feet with AT and without AT. No significant correlations were found between AT morphological characteristics and the cadavers' age or the HV angle and IMA. CONCLUSIONS: In conclusion, there is a high incidence of HV deformity in cadaveric feet with AT of EHL (almost 2/3), but there is no correlation between the severity of the HV deformity and the presence or characteristics of the AT.

Foramen magnum, occipital condyles and hypoglossal canals morphometry: anatomical study with clinical implications.

BACKGROUND: Current study examines morphometric alterations of the foramen magnum (FM), occipital condyles (OCs) and hypoglossal canals (HCs) and highlights all the morphometric parameters of the FM area that present side asymmetry, gender dimorphism and are affected by the ageing. MATERIALS AND METHODS: One hundred and forty-one (73 male and 68 female) Greek adult dry skulls were examined. RESULTS: Short and long OCs were detected in 27.7% and 26.2%. A combination of short OCs and long HCs was presented in 27.5%. A complete septum was found in 23.6% of the HCs and osseous spurs in 12.9%. Side asymmetry was detected regarding the HCs length (p = 0.046), the maximum extracranial (p = 0.001) and minimum intracranial (p = 0.001) diameters. Mean FM anteroposterior and transverse diameters, FM perimeter and FM surface area were significantly larger in male than in female skulls (p = 0.001 for each parameter). Similarly, the OCs length (right, p = 0.004 and left, p = 0.024) and width (right, p = 0.008 and left, p = 0.006) the left distance HC-OC posterior border (p = 0.048), the anterior (p = 0.011) and posterior (p = 0.001) intercondylar distances and the HCs right length (p = 0.046) were significantly greater in males. A significant decrease was observed with ageing in FM anteroposterior diameter (p = 0.038), FM surface area (p = 0.05), anterior intercondylar distance (p = 0.014) and HC-OC posterior border (p = 0.013). CONCLUSIONS: The study confirmed that only specific HC dimensions showed side asymmetry (HCs maximum extracranial and minimum intracranial diameters and HCs length), gender dimorphism (HCs right length and left distance HC-OC posterior border) and age influence (HC-OC posterior border and HC left extracranial minimum diameter) among young, adults and elderly individuals. FM and OCs dimensions presented gender dimorphism and the age influenced only FM anteroposterior diameter and surface area and the anterior intercondylar distance. The safe zone of OCs drilling in Greeks, calculated by the distance HC-OC posterior border represents the maximum HC depth and is among the lowest values reported in the literature. The significant decrease of this distance with ageing confirms the existence of a drilling safe zone for young, adults and elder individuals. Regarding OCs length, the same probability exists dealing with a short or a long OC during condylectomy. Before planning a transcondylar approach, the coexistence of short OCs and long HCs should be taken into account. These outcomes will be useful for a safe surgery in the craniocervical region in Greeks.

Retro-oesophageal right subclavian artery in association with thyroid ima artery: a case report, clinical impact and review of the literature.

A 37-year-old female Caucasian cadaver with an aberrant right subclavian artery extending from the left side of the aortic arch and following a retro-oesophageal course is presented. A non-recurrent right laryngeal nerve and a thyroid ima artery arising from the lower part of the middle third of the right common carotid artery coexisted. The brachiocephalic trunk was absent, while both common carotid arteries and left subclavian artery followed their normal course. The aim of the current study is to highlight the clinical impact of the above abnormalities providing useful and practically applicable knowledge to interventional clinicians, thoracic and neck surgeons, since the vast majority of documented cases with an arteria lusoria are clinically silent and in most cases discovered incidentally. Clinical manifestations such as dysphagia, chronic cough, and acute ischaemia to the right upper limb may occur, leading to misinterpretation in radiographic examination and complications during neck and thoracic surgery. Review of the literature was also performed and the embryological background of the aberration is highlighted.

Transtendinous course of the infrapatellar branch of saphenous nerve. A contribution to the aetiology of entrapment neuropathy and modification of the existing classification.

BACKGROUND: The course of the infrapatellar branch of saphenous nerve (IPBSN) in relation to the Sartorius muscle has been classified into presartorial, transsartorial and retrosartorial types. Mechanical compression of the IPBSN within the Sartorius tendon has been surgically recognised as a cause of entrapment neuropathy. Purpose of the present study was to differentiate the IPBSNs penetrating the Sartorius tendon from those penetrating the Sartorius muscle, from an anatomical and clinical point of views and thus modifying the existing classification. MATERIALS AND METHODS: The IPBSN was bilaterally dissected in 27 cadavers. The cases of the IPBSNs penetrating the Sartorius tendon were recorded separately from those penetrating the Sartorius muscle belly. RESULTS: In 11 out of 54 limbs (20.4%) the IPBSN ran through the Sartorius muscle belly. In 3 out of 54 (5.6%) limbs, the IPBSN penetrated the Sartorius tendon. CONCLUSIONS: The penetrating type of IPBSN includes two distinct subtypes: the muscle-penetrating type and the tendon-penetrating type. These subtypes are also distinct from a clinical point of view, since only the tendon-penetrating type has been associated with the IPBSN entrapment neuropathy. According to these findings we suggest a modification of the current classification. Further clinical studies are necessary to fully demonstrate whether the tendon-penetrating type should be considered as a predisposing factor for the IPBSN entrapment neuropathy. Distinguishing the two subtypes might be helpful for that purpose.

Foramina of the anterior mandible in dentate and edentulous mandibles.

The study provides a morphometric analysis of the foramina located at the anterior mandible according to dental status. The inner surface from the midline to the distal border of the second premolars of 70 dentate and 27 edentulous Greek adult dry mandibles was investigated. The lingual foramina were divided into medial and lateral foramina. Foramina located at the alveolar process and the midline were subdivided according to their location to genial tubercles. Moreover, the height of the mandible in the genial symphysis and the distances from the foramina to the alveolar crest and the lower border of the mandible were measured. Medial and lateral lingual foramina were presented in 97.9% and 78.4% of the mandibles, respectively. The alveolar medial and lateral lingual foramina were detected in 19.6% and 27.3%, respectively. The mean height of the genial symphysis was 32.06 ± ± 4.88 mm for the dentate and 23.87± 5.37 mm for the edentulous mandibles. The meticulous knowledge of the topography of the lingual foramina and their content is of paramount importance for dentists, oral and maxillofacial surgeons during dental implants placement. Middle and lateral lingual foramina are constant structures, while the alveolar foramina presented only in dentate mandibles. The foramina location is directly affected by dental status. The morphology of edentulous mandibles increases the risk of intraoperative complications at the anterior mandible.

Bilateral Internuclear Ophthalmoplegia as a Presenting Manifestation of Primary Sjögren's Syndrome.

Bilateral internuclear ophthalmoplegia has been linked with various pathological conditions of the central nervous system (CNS), such as multiple sclerosis, stroke, tumours, and brainstem inflammatory processes. Herein the authors report a case of a 45-year-old female patient who presented with diplopia due to bilateral internuclear ophthalmoplegia, with no evidence of brainstem lesion in brain magnetic resonance imaging (MRI) and was diagnosed with primary Sjögren's syndrome.

Bilateral lingual-facial trunk: anatomic and clinical implications.

Common origin of lingual and facial artery is a relatively frequent anatomic varia-tion. Instead, bilateral lingual-facial trunk has been described only sparsely in the literature. In this report authors describe and analyse a case of bilateral common lingual-facial trunk in the context of its anatomical, clinical and embryological implications. We also describe possible consequences in performance of elective and emergent surgical operations and modification in surgical techniques that should be considered. We believe that surgeons should be suspicious for this variation's existence and keep alternative solutions in their armentarium.

Bilateral double testicular arteries: a case report and review of the literature. Potential embryological and surgical considerations.

The aberrancies concerning the number, origin and course of the testicular arteries are found in an incidence of approximately 4.7-20% in the literature and are documented less frequently than the respective variations of the homonymous veins. In the current study, a very rare complex of testicular arteries' variations isdescribed, in which the occurrence of bilateral double testicular arteries is recorded. Particularly, apart from the normal testicular arteries on each side, we observed an additional right testicular artery originated from the ipsilateral renal artery and an additional left testicular artery taking its origin from the abdominal aorta just above the renal artery's origin site; the latter additional testicular artery arched above the left renal vein. Both, the bilateral double testicular arteries accompanied the testicular vein on each side as their satellite arteries. We discuss the potential embryological development of that complex of arterial variants, their likely clinical and surgical applications, as well as we proceed on a brief review of the relevant literature.

A morphometric anatomical and comparative study of the foramen magnum region in a Greek population.

BACKGROUND: The foramen magnum (FM), a complex area in craniocervical surgery, poses a challenge for neurosurgeons. The knowledge of the detailed anatomy of the FM, occipital condyles (OC) and variations of the region is crucial for the safety of vital structures. This study focuses on the FM and OC morphometry, highlights anatomical variability and investigates correlations between the parameters studied. MATERIALS AND METHODS: One hundred and forty-three Greek adult dry skulls were examined using a digital sliding calliper (accuracy, 0.01 mm). RESULTS: Mean FM width and length were found 30.31 ± 2.79 and 35.53 ± 3.06 mm, respectively. The commonest FM shape was two semicircles (25.9 %), whereas the most unusual was irregular (0.7 %). The OC minimum width, maximum width and length were 5.71 ± 1.61, 13.09 ± 1.99 and 25.60 ± 2.91 mm on the right, and 6.25 ± 1.76, 13.01 ± 1.98 and 25.60 ± 2.70 mm on the left side. The commonest OC shape was S-like and the most unusual was ring, bilaterally. The mean anterior and posterior intercondylar distances were 19.30 ± 3.25 and 51.61 ± 5.01 mm, respectively. The OC protruded into the FM in 86.7 % of the skulls. Variations such as a third OC existed in 5.6 % and basilar processes in 2.8 %. Posterior condylar foramina were present in 75.5 %. The gender was correlated with FM width and length, OC length, bilaterally, anterior intercondylar distance (AID) and posterior intercondylar distance (PID). The OC protrusion and existence of posterior condylar foramina were correlated. Bilateral asymmetry for OC shape was statistically significant. CONCLUSION: Our results provide useful information that will enable effective and reliable surgical intervention in the FM region with the maximum safety and widest possible exposure.

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.

A coexisting anatomical variation of median and ulnar nerves in a cadaver palm.

During a routine dissection we observed an anatomical variation of the median nerve and an atypical anastomosis in the palm region of a male cadaver. There were four distinct recurrent motor branches of the left median nerve, and the palmar cutaneous branch of the ulnar nerve communicated directly with the third common palmar digital nerve. The presence of such an anatomical variant in the hand should keep surgeons alert in the management of hand pathology especially in carpal tunnel syndrome, which is a routine operation for many medical centres.

Complicated axillary lymphadenectomy due to a pectoralis quartus muscle.

During lymphadenectomy in the left axilla of a 38-year-old woman with a 1.4 cm invasive ductal breast carcinoma an accessory muscle was found. Due to the presence of the anomalous muscle the lymphadenectomy was carried out with difficulty through a limited field. Based on its anatomical characteristics, the supernumerary muscle was recognized as the pectoralis quartus. To our knowledge this is the first report of a pectoralis quartus muscle as a surgical finding. The surgeon should be aware of the possible presence of this anomaly as well as its anatomical characteristics in order to avoid any complications.

A bicarotid trunk in association with an aberrant right subclavian artery. Report of two cases, clinical impact, and review of the literature.

A combination of an aberrant right subclavian artery (ARSA) and a bicarotid trunk (BCT) appears in up to 2.5% of the population. The aim of this study is to report the higher total and male incidence of this variation in the literature and to summarise its clinical impact, providing useful knowledge to anatomists, radiologists, cardiologists, and vascular and thoracic surgeons in order to avoid diagnostic pitfalls and therapeutic complications. A total of 72 (43 female and 29 male) Greek Caucasian formalin-embalmed cadavers were studied. The international literature was reviewed along with the dissection archives of the Department of Anatomy from 1986 to 2009. Two male cadavers were found to have an ARSA combined with a BCT (incidence: total 2.78%, males 6.9%, females 0%). Both aortic arches consisted of three branches: (1) the BCT, (2) the left subclavian artery, and (3) the ARSA. The common carotids followed a normal route to the neck; the ARSA passed between the trachea and the oesophagus in the first case and behind the oesophagus in the second case, and was accompanied by a non-recurrent laryngeal nerve. In the second cadaver the ARSA formed a sharp angle (kinking/buckling) on its route to the right arm. The ARSA is associated with several congenital cardiovascular anomalies and some chromosomal and other syndromes. It is occasionaly responsible for causing dysphagia, dyspnoea, or acute ischaemia to the right upper limb, and it may present as a superior mediastinal mass in cases of aneurysm formation.