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Diathrodial joint with a fibrocartilaginous disk.  The disk has a great variation in size and shape and eventually undergoes rapid degeneration until it is essentially non-functional by the fourth decade.
The posterior and superior AC ligaments should be preserved during distal clavicle resection to prevent posterior instability. Based on available anatomic studies obvious oversimplifications can be made:  the AC ligaments control anteroposterior stability, the CC ligaments control superoinferior stability.
Consider stess views with patient holding 5-10lb weights or comparison veiws of the uninjured side.
Type III: acromioclavicular and coracoclavicular ligaments disrupted, deltoid and trapezius insertions disrupted. Type VI: acromioclavicular and coracoclavicular ligaments disrupted with inferior dislocation of the distal clavicle inferior to the coracoid process and posterior to the biceps and coracobrachialis tendons.
The information on this website is intended for orthopaedic surgeons.  It is not intended for the general public.
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The Importance of Venous and Renal Anomalies for Surgical Repair of Abdominal Aortic AneurysmsRoberto Jimenez 1 and Francisco Morant1[1] Hospital General Universitario de Alicante, Spain1. The greatest increase in PR interval duration is typically between the first and second beats of the cycle. Malfunctioning AV node cells tend to progressively fatigue until they fail to conduct an impulse. Mobitz I is usually a benign rhythm, causing minimal haemodynamic disturbance and with low risk of progression to third degree heart block.
The Wenckebach pattern here is repeating in cycles of 5 P waves to 4 QRS complexes (5:4 conduction ratio).
However, there is a single 3:2 Wenckebach cycle visible in the middle of the rhythm strip (QRS complexes 5 + 6).
Continuous rhythm strip recording revealed that this patient was indeed in Mobitz I AV block. The interval between the pacing spikes increases progressively until there is a non-conducted pacing spike. Lateral clavicle palpable posteriorly, may tent skin, usually very painful, pain with any ROM. Embryologic derivation of the inferior vena cava from 6-8 weeks of gestation (A) to the adult (B).
Introduction The presence of venous and renal anomalies can create technical difficulties during aortoiliac surgery, and the patients are most likely to suffer severe bleeding, thus the surgeon must be alert to detect these anomalies and to treat them correctly to avoid severe injuries.2. Crossed renal ectopia is an uncommon genitourinary anomaly, detected in 1 of 7000 autopsies. This is different to cells of the His-Purkinje system which tend to fail suddenly and unexpectedly (i.e. However, the difference is more obvious if you compare the first PR interval in the cycle to the last. If you look hard, you can see a non-conducted P wave deforming the downslope of the T wave in complex 6. Our Team, headed by Mike Cadogan & Chris Nickson, consists (mostly) of emergency physicians and intensivists based in Australia and New Zealand.
Xray-lateral clavicle may be elevated, AC joint widened, coracoclavicular interspace maintained.
Anatomy and etiologyIVC results of a complex embryological process between the sixth and tenth weeks of gestation.
Major venous anomalies Congenital venous abnormalities in the retroperitoneal space are relatively infrequent and, under normal circumstances, asymptomatic, but have clinical importance in aortoiliac surgery. The prevalence of marsupial cava in humans cannot be predicted, but it is probably very rare because only sporadic cases are described in literature, and studies of inferior cava anomalies do not even cite. The right subcardinal vein remains to form the suprarenal inferior vena cava, while the left subcardinal vein completely regresses. Genitourinary anomalies Horseshoe kidney is a renal fusion anomaly estimated to be present in 0,25-0,6% of the population. It is twice as common in males as in females, while abdominal aortic aneurysm (AAA) occurs in 2% of the elderly. Retroaortic left renal vein The vein crosses the aorta in posterior face instead of the anterior face like normally.


2A).In the retroaortic LRV type II the dorsal limb is detected in a lower position, at L4–L5, behind the aorta, and joins the IVC, gonadal or ascending lumbar veins (Fig.
The left-sided infrarenal IVC typically joins the LRV, before it crosses the aorta to form a normal right-sided suprarenal IVC. Probably it could be subclassified in complete left-sided IVC, if there is a preaortic trunk lying in front of the aorta and connected to the normal right suprarenal IVC (Fig.
A complete transposition of the IVC to the left with hemiazygous continuation is extremely rare (Guray et al., 2004). Double inferior vena cavaIn the double IVC, both left and right supracardinal veins persist. The renal segment of the IVC develops from the right suprasubcardinal and postsubcardinal anastomoses, and the infrarenal segment develops from the right supracardinal vein. The left iliac vein ascends as duplicated left IVC and usually drains into the left renal vein, which then crosses anterior to the aorta and joins the right IVC in a normal fashion, incomplete double IVC (Fig. In the right-sided double IVC it is speculated that both of them are derived from the right supracardinal and subcardinal veins. Embryologically, the ventral vessel originates from the right subcardinal vein, whereas the dorsal vessel originates from the right supracardinal vein.
The right gonadal vein drains into the ventral vessel in majority of cases and into the IVC between the renal venous confluence and the confluence of the two vessels in other cases. Marsupial cava or preaortic venous confluence At fifth week embryo, three paired veins are roughly symmetrical (posterocardinal, supracardinal and sucardinal). At eighth week, a complex venous plexus appears in the lumbar region, with consolidation of various anastomoses between posterocardinal and supracardinal veins and with further development of circumumbilicous venous rings, which surround the future common iliac arteries on each side.
Retrocaval ureter or circumcaval ureterThe embryological significance of the retrocaval ureter is, strictly speaking, an anomaly affecting the IVC and not the ureter. The posterior cardinal and subcardinal veins lie ventrally, and the supracardinal veins lie dorsally. The left supracardinal veins and the lumbar portion of the right posterior cardinal vein atrophy and the subcardinal veins become the internal gonadal veins. If the postcardinal vein in the lumbar portion fails to atrophy and becomes the right-side IVC, the ureter is trapped dorsally to it.
This occurs because the right postcardinal vein is positioned ventral to ureter in the definitive inferior vena cava, so the developing right ureter courses behind to the IVC.Retrocaval ureter almost invariably involves the right side. In this uncommon venous anomaly the right ureter courses posterior to the IVC and partially encircles it. Marked hydronephrosis is seen in over 50% of patients.In type II (high loop), the renal pelvis and upper ureter lie horizontally, and the retrocaval segment of the ureter is at the same level as the renal pelvis.
The retrograde pyelogram shows a “sickle shape” of the involved ureter, generally with mild hydronephrosis.
Occasionally exits the transcaval ureter or periureteral venous ring and may cause ureteral obstruction (Fig. Inferior vena cava malposition, anterior or posterior There has been described malposition of the inferior vena cava, anteriorly to an AAA or posterior at it.
The hepatic segment drains directly into the right atrium, and the blood from the infrarenal IVC returns to the heart through the azygos and hemiazygos veins.
Absence of the infrarenal IVC with preservation of the suprarenal segment implies a failure of the development of the right supracardinal vein (Fig. 4D).Absence of the entire IVC, suggests that all three paired vein systems failed to develop properly.
Horseshoe kidney The renal system is developed from three structures that follow in time: pronephros, mesonephros and metanephros. The embryologic kidneys ascend cranially and receive blood from multiple arteries of common iliac arteries and media sacra artery; the renal artery is formed later in the third month.
If the migration does not happen it gives the pelvic kidney, and if a fusion occurs, gives the horseshoe kidney.The normally separate left and right metanephric blastemas fuse prior to migration and rotation, resulting in a fused mass.
During the development of the kidney, if the metannephric masses come into contact or fuse and their normal medial rotation is interrupted, the anomalous horseshoe kidney come about. The isthmus connecting the lower poles contains usually functional parenchyma but may be a fibrous band and is located anterior to the aorta and IVC and posterior to the inferior mesenteric artery.
The renal pelvis is usually rotated anteriorly and ureters arise anteriorly or laterally, because the horseshoe kidney, similarly to the pelvic kidney cannot rotate (Fig. C, Pancake kidney.The blood supply to the horseshoe kidney can be quite variable, especially in the isthmus and lower poles.


The abnormalities of blood supply have been reported in 60% to 74% of patients with horseshoe kidneys and frequently the isthmus and lower poles frequently have their own accessory renal artery from the aorta or iliac arteries.
The occurrence of the renal ischemia was as high as 74% and is recommended reconstructing the accessory artery whenever its diameter is 2 mm or more. The renal vein anatomy is normal, with two renal veins each from left and right portions of the horseshoe kidney draining into the cava in a standard position. Pancake kidney or fused pelvic kidney Although the embryologic development of pancake kidney has not been fully elucidated, it is thought that it arrests in the early stages of rotation and migration. The renal blastemas are completely fused at 4-8 week embryos, and consequently fails to migrate in a cephalic direction, leaving it in a pelvic location that is usually at or below the aortic bifurcation. The kidney is normally located at the level of the aortic bifurcation and gives rise to two collecting systems from his anterior surface that join the bladder in the normal anatomic position. Various cases from literature report two, three or four renal arteries that supply the kidney from the aorta, the right or the left common iliac arteries.
The only assumption one should make is that the renal blood supply will be variable in number and position of renal arteries and can often involve the distal aorta and iliac arteries.
The venous drainage systems could be variable to the iliac vein and proximal vena cava (Fig.
Congenital pelvic kidney A pelvic kidney occurs when the blastema in the 5 to 7 week embryo inexplicably fails to ascend normally. Adding variety to the anatomy is the fact that the pelvic kidney does not rotate medially, so its hilium is ventrally located. Whenever is a single renal artery (49% of cases), it origins systematically from the aortic bifurcation.
When the renal arteries are double, in 40% cases, a branch is originated from aortic bifurcation, and the second branch can emanate from the ipsilateral or the contralateral common iliac artery or from internal iliac artery. In case of three or four arteries (11% of cases), a branch comes from aortic bifurcation and the others branches from iliac axis ipsi and contralateral. Rarely, blood supply is guaranteed by feeding arteries originating from inferior mesenteric arteries. In definitive, if there are multiple renal arteries (in more than 50% of cases), one of the branches origin systematically from aortic bifurcation, and the other branches comes from ipsilateral iliac axis and more rare from contralateral iliac axis.
Acquired pelvis kidney (renal transplant) The corpse kidney is situated in the pelvis, with anastomosis in iliac arteries and veins (Fig.
Crossed renal ectopia Causes may involve faulty development of the ureteric buds, vascular obstruction to the ascent of the kidneys, and environmental factors.The ectopic kidney crosses the midline and lies contralateral to its normal position, and usually is fused to the normal kidney, so is called crossed fused ectopia. The ureter of the ectopic kidney crosses the midline to enter the bladder at its normal position.
This type of kidney is most often malrotated (ventral helium) and situated below the normal kidney. The anomaly is more common in male patients, and frequently involves the left kidney.The blood supply to the kidneys is from the aorta or the iliac arteries, and the number of renal arteries varies. Venous drainage may also be abnormal, but because venous structures are not involved in aortic surgery, there have been no reports regarding this. In this anomaly, the kidneys, including the nonectopic kidney, have an anomalous blood supply.
Multiple renal arteries or renal veins Renal arteries are derived from the embryonic mesonephric arteries.
Regression of these arteries results in persistence of single mesonephric artery and formation of a single renal artery.
Multiple renal veins can occur, but is less important because are not directly implied in aortic surgery.5.
An increased incidence of thrombosis formation in double IVC has been seen, but the exact cause is unknown; some authors suggested than this may be related to the degree of narrowing of the vessel as it crosses the aorta. An inadequate blood return through collaterals may increase the venous blood pressure in the veins of the legs, favoring venous stasis and subsequent deep venous thrombosis. The presence of a pancake kidney may predispose to recurrent urinary tract infection due to the short anomalous ureter that is prone to obstruction, but most of the reported cases are asymptomatic.
Major venous anomalies Since computed tomography (CT) is routinely performed for the elective repair of AAA, usually these anatomical anomalies like retroaortic LRV (Fig.




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