- Hello, my name is Rachel Rose and I'm an attorney in Houston, Texas, where I've had my own law firm, Rachel V. Rose, Attorney at Law, PLLC, for over a decade. My practice primarily focuses on healthcare, cybersecurity, securities law, False Claims Act, and Dodd-Frank matters in relation to compliance, transactional and litigation. I also teach bioethics at Baylor College of Medicine, something that I have done for the past nine years, and I'm fortunate to be extensively published and sought after, as both an expert and a presenter. Today, I am delighted to join Quimbee in bringing you Anatomy for Lawyers: Anatomy, Injuries, and Common Procedures. So no presentation is complete without a disclaimer, and the information presented here today is not meant to constitute legal advice. So you should consult your attorney for advice on a specific situation. Additionally, the information presented is current as of the initial date of this presentation and participants are encouraged to check relevant government and other relevant websites for the most up-to-date information. So today, I'm going to begin with some legal aspects related to procedural and evidentiary considerations. From there, I'll delve into medical positioning terminology and general terms which every lawyer should know. I'll then transition into anatomy, and specifically, the framework of orthopedic anatomy and neuroanatomy, because a lot of common injuries, whether they come about in terms of medical malpractice or car or other types of accidents, or some of the class actions that are typically seen around the medical device and pharmaceutical industry typically have a neurologic or an orthopedic component to them, I'll then wrap up and provide a conclusion. So what are some of the critical evidence and procedure considerations? Well, first and foremost, for those of you who practice in federal court, discovery in any case is absolutely paramount and the key discovery rule of civil procedure is 26, specifically certain information is required to be provided to the opposing side without a discovery request. Certain items such as the name, address, telephone number of known persons with discoverable information. Additionally, initial disclosures must be made at or within 14 days after the party's Rule 26 conference. And in terms of expert testimony disclosure, in addition to the disclosures required by Rule 26 , a party must disclose to the other parties, the identity of any witness it may use at trial to present evidence under Federal Rule of Evidence 702, 703 or 705. Importantly for new lawyers, there are two types of expert witnesses. There's one which is a consultative expert and another which is a testifying expert. So it's important to appreciate that distinction because the consultative expert does not need to be disclosed, but the testifying expert absolutely has to be disclosed. So what about expert testimony and reports? Well, Federal Rule Of Evidence 702 is the fundamental rule which governs this. And here a witness who was qualified as an expert by knowledge, skill, experience, training or education may testify in the form of an opinion or otherwise if the following conditions are met. The expert scientific, technical or other specialized knowledge will help the trier of fact, which is typically the jury, unless there is a bench trial, then you have the judge who is also the trier of fact, to understand the evidence or to determine a fact in issue. The testimony is based on sufficient facts or data. The testimony is the product of reliable principles and methods. And the expert has reliably applied the principles and methods to the facts of the case. Now, if we lived in a vacuum and it was only the text of 702, then that would be easy. As many people know, who are seasoned lawyers, and if you've been through law school, there are typically evidentiary rules at the state level as well, which correlate to Rule 702 under the federal rules. Now there have been two key standards based on expert opinions. The first is Frye and that actually stems back to the DC Circuit in 1923. So almost a century ago. And in essence, the takeaway from that case is an expert opinion is admissible if the scientific technique on which the opinion is based is generally accepted as reliable in the relevant scientific community. Now fast forward 70 years, from 1923 to 1993, and the Supreme Court hears the Daubert vs Merrell Dow Pharmaceuticals case. The takeaway here is that the Supreme Court effectively overruled Frye in federal courts and that's imperative to appreciate, holding that the case law was inconsistent with the applicable evidentiary rules, namely Rule 702 of the Federal Rules Of Evidence. Now in Daubert, the court held that the twin standards of Rule 702, relevance and reliability are incompatible with the stricter general acceptance test. Now in 1997, the court emphasized the importance of expert methodology as opposed to focusing solely on the conclusory opinion, finding that conclusions and methodology are not entirely distinct from each other. So while the federal court system exclusively follows Daubert, some state courts are divided between applying Daubert and Frye. One item of particular note is that an update to the text of Federal of Evidence 702 is forthcoming, and could become effective December, 2023, specifically December 1st, 2023. Here, what the conference has indicated, as we all know, is that the judge has the role of gatekeeper in terms of what to admit and what to keep out. And the two items to focus on are one, the proponent of the expert testimony must show admissibility by a preponderance of the evidence. And the expert's opinion must be reliable in light of the facts and applicable principles or methodology. So what are some of the key items related to Daubert? And the next slide will absolutely bring it home for us, but it requires a reliability of proof or relevance. And the Daubert test, in order for an expert to be qualified, all four factors must be met. And this typically occurs after voir dire, where the opposing counsel and the judge may ask questions of the expert as well, may ask a series of questions and then move to disqualify an expert. So first, when an attorney is employing an expert, it's imperative to consider the Daubert factors. So first whether a theory or technique can be and has been tested. Secondly, whether the theory or technique has been subjected to peer review and publication. Third, in respect to a particular technique, there is a high known or potential rate of error. And whether there are standards controlling the technique's operation, and whether the theory or technique enjoys general acceptance within a relevant scientific community. Now in 1999, the Supreme Court also held that these four Daubert factors also apply to non-scientists or non-medical, if you may, types of experts. So the result for not meeting the four factors is not being qualified as an expert. Now, the procedural considerations that relate to expert reports, as we know, some cases involving anatomy are brought in state court and others involving anatomy are brought in federal court. The ones that we see in federal court are either diversity jurisdiction, which meet the standards under 1332 for diversity jurisdiction of the parties, as well as a mountain controversy or more of a class action or multi-district litigation scenario. Versus state court is where we typically see a lot more of certain accident cases or medical negligence cases. So I have two examples. The first comes from Texas and the second comes from Tennessee. And regarding an expert report. So in a healthcare liability claim in Texas, a claimant shall no later than the 120th day after the date each defendant's original answer is filed, serve on that party, or the party's attorney, one or more expert reports with a CV of each expert listed in the report for each physician or healthcare provider against whom a liability claim is asserted. The date for serving the report may be extended by written agreement of the affected parties. So it's imperative to meet and confirm, and then submit that to the court. Each defendant, physician, or healthcare provider whose conduct is implicated in a report, must file and serve any objection to the sufficiency of the report no later than the 21st day after the date the report is served or the 21st day after the date the defendant's answer is filed, failing which all objections are waived. So again, that's analogous to raising an affirmative defense. If you don't raise it within the prescribed period, you lose it. So what about some procedural considerations that relate to expert testimony? Well, in Tennessee, there is a unique role and oftentimes it is referred to as the contiguous state rule. So under the Tennessee Healthcare Liability Act, it's requirement is that healthcare professionals testifying as experts, in addition to other requirements, be either licensed in Tennessee or a bordering state. Now a recent decision, which was promulgated by the Tennessee Supreme Court found that a trial court's refusal to waive this requirement was not so far removed from the usual course of judicial proceedings so as to qualify for a Rule 10 appeal. Now, an item of note is that if there is an instance where there is a conflict or an expert cannot be found either within Tennessee or within the contiguous states, then it is permissible to go throughout the country, but that needs to be substantiated and proved by the court. So what about fundamental medical terminology? Specifically, I'm going to focus on positioning and references. A great resource to use is the Merck Manual because it's been around for quite some time and oftentimes courts will take judicial notice of it. So if we look at two terms, which many people learn in ninth grade biology, physiology is how the body functions and then anatomy is how the body is structured. So anatomy is organized by levels from the smallest components of cells to the largest organs in their relationship to other organs. And as a fun fact, the skin is in fact, the largest organ in the body. Human gross anatomy is the study of the body's organs as seen with the naked eye during visual inspection and when the body is cut open for examination. This is also known as dissection. Cellular anatomy is the study of cells and their components, which can be observed only with the use of special techniques and special instruments, such as microscopes. An example of where you might use cellular anatomy in a case is by employing a pathologist as an expert. Typically, this would come up in cancer types of cases, or you might see it in class actions where a certain substance, whether it is tobacco or asbestos, which there have been a lot of cases on have been shown to cause cancer. And so typically again, a gross anatomy would be a biopsy and then the cellular level is the pathology slide. And what the pathologist reads on that sliver which is then confirmed the cancer or some other type of condition, or maybe ruled out a cancer. Molecular anatomy is often called molecular biology. And it is the study of the smallest components of cells at the biochemical level. So again, hearkening back to ninth grade biology, you have the mitochondria, you have the nucleus, you have all of the different components of a cell. So moving on from the basic anatomy and pathology into positioning terminology. So first and foremost, we have the anatomical planes and this comes up a lot whenever you begin reading radiology reports, whether it is a plain film, also known as a common x-ray or you get into more sophisticated types of imaging, such as an MRI, a CT scan, or a PET scan. So the axial plane, as you can see here, is the horizontal plane, which is in green and it divides the body into the upper part and the lower part. It's also known as the transverse plane. Next, the red portion is known as the sagittal or the lateral plane. It is a vertical plane which divides the body into left and right. And oftentimes when you start to read different x-ray reports that are done by radiologists, you'll see a sagittal view for example, or an axial view being used in that write up. Lastly, we have the coronal plane also known as the frontal plane, and that is the purple division here. Again, that is a vertical plane and it divides the body into the front and the back. The front of the body is referred to as the anterior portion and the back of the body is referred to as the posterior portion. So when we talk about directional terms, distal means away from a reference point and proximal means towards a reference point. And a good example would be in the humerus, which is the long bone in the upper part of your body, between the shoulder and the elbow. So here, the distal portion of the humerus is the lower portion of the humerus. And the proximal portion of the humerus is the upper portion of the humerus. Now cauda or caudad, that's actually Latin and it means tail or tail end. And the cauda equina is actually the base of the spinal cord where the individual neurons or nerves come together and as a horse's tail. So cauda equina is what it's called. And the English for cauda equina is horse's tail. Now you have cephalad or cranial, and that means the head. So caudad or cauda is the tail, and cephalad or cranial is the head. Lateral means away from the midline. And for anyone who goes to a gym and uses those painful machines that do your abductors and your adductors, lateral is away, so it's the side of your body. And the midline, you can think of it as the line between your legs here, that space between your legs or the interior part of your legs is your midline. Ventral is anterior, and I like to think of a fish. So again, anterior being the front, posterior being the back. And oftentimes with fish, you have ventral fins, which are located on the front of a fish's body. And then you have dorsal fins. And ironically, because this is typically being viewed by lawyers, you can think of a shark and the dorsal fin being on the shark's back. Superior means above and inferior means below. So what about orthopedic anatomy specifically? Well, one should think of the musculoskeletal and the spine as really the framework. And I like to think of this part of anatomy as a house. Just as you see a house being built from the ground up, you have the foundation and then you have the infrastructure, which is put up first. The scaffolding and the different beams for support. That is your musculoskeletal system. There are 206 bones that comprise the adult skeleton. Now in general, there are five categories of bones. You have long bones, and those are cylindrical in shape being longer than they are wide. And they are rigid bars that move when muscles contract. So some very common ones are the humerus again, that is the long bone, the upper part of your arm. And below you have your radius, which is the long bone which runs along your thumb side. And then you have the ulna which is also a long bone in your lower arm, which then runs along your pinky finger side. In terms of the femur that is in your thigh, that is the long, large bone in your thigh. Metacarpals, carpals always think hands. Metatarsals, tarsals, always think feet. Phalanges mean your fingers. Flat bones, you have thin and curve service points of attachment for muscles and to protect internal organs. So your sternum is an example of that. Scapula, which is that triangular bone at the top of your back that you feel if you were to put your hand on your shoulder and just tap the upper part of your back. That ridge that you feel if you were to run your finger across it is called the scapular spine. And then you have the cranial flat bones. And the cranial flat bones really come together and look like a puzzle in your head. And just like a puzzle has lines in between it to show the different shapes, those are called sutures and there are different types of "sutures" that we find in the cranial flat bones. Irregular bones are those which come in complex shapes and the vertebrae, which you see in the anterior portion of your spine, the vertebral bodies constitute irregular bone. Short bones are cube like and fairly equal in length. These are typically known as the cuneiform bones in the carpals and tarsals. You might be thinking, well, Rachel, there are carpals up there and tarsals up there. Yes, there are, but they are different because meta means middle. So you have carpals in tarsals in one portion, and then you have metacarpals and metatarsals, which are a different shape in another portion of your hand and your foot, and then you have the phalanges or your fingers and toes. So that's the easiest way to remember that. Carpals go to metacarpals, go to phalanges or fingers. Sesamoid bone, you only have two of these in your body and they have one job, and that is to protect the tendons. And the patella, also known as the kneecap, is the sesamoid bones in your body. You have two because... Typically you have two, unless an amputation has occurred or there is a congenital defect where the patella did not form. So what about connective structures? Well, you have tendons which are dense connective tissue that connect bones to muscles. And sesamoid bones form where a great deal of pressure is generated in a joint. So again, if we think about all of our joints and their specific functions, the knee absolutely meets that criteria and that's why we only have sesamoid bones at our knee, and that's our knee cap. Ligaments are connective tissue that is typically more pliable than a tendon. We then have fascia, which is a web-like connective tissue. And finally cartilage, which acts as a shock absorber. And oftentimes one will hear cartilage referred to in terms of the knee, again, not surprising. So what about the musculoskeletal system in general? And again, it is the body scaffolding so that's the way I like to think about it. I normally start with the bones because to me that is very similar to when I drive past a construction site and then I see all of the framework of the house being put up. It is the supporting portion of your body. Anatomy in general, just to give you a bit of orientation before we delve into where all of the bones and then the muscles and so forth are. So the brain is obviously in our head and then there is our mouth, there are tonsils in the back,\ there's our nose. There are two main pipes that go down the throat and they are the trachea and the esophagus. Next, we have the thyroid, which is part of the endocrine system. And that is a critical gland because it regulates so very much of our body's functions from temperature to metabolism. It really plays a vital role from there, we have the lungs, here's the heart right here. And then there's this wall, if you may, called the diaphragm. From there, we get into the liver, the gall bladder, the pancreas, which is involved in insulin production and glucagon as well. And then we have the stomach, importantly, the large part of the stomach is called the fundus. So you may hear that term fundus used in other parts of anatomy as well, including the eye and the uterus. The spleen is to the left side. And then from the stomach, we get into the small intestine, which has three parts, which then goes into the ileocecal sphincter. Your large intestine is also referred to as your cecum and it has the descending and then the ascending and then the traverse and then it goes out again through the anal sphincter and out through the rectum. Now you also have the kidneys which are found posterior, and then you have the relay system so to speak from the kidneys to the bladder, and those are known as the ureters. From there, you also have the female or male gonads or reproductive organs. So that's pretty much how that works. Now, in terms of the skeleton, the parietal bones here again, when I mentioned the cranial bones, that's one. The lines that I mentioned, those sutures you can see here in a very pronounced way. So you have the parietal bones on either side. You have the occiput, you have the temporal bone, which is on the side. And then you start getting into the cervical vertebrae. And I'm going to delve into the vertebrae itself, but you really have four sections of the spine, the cervical, the thoracic, the lumbar, and the sacrum. On the front side or anterior side, we have the frontal bone, we have the nasal bone, we have the sphenoid bones. And inside, if you were to take that axial view, you would see the greater and lesser wing of sphenoid, which is where the frontal lobe portion of your brain sits. So some of your boney anatomy is more interior in terms of your head. And some of it is more exterior like we're seeing now. The zygomatic process, that's your cheekbone. The maxilla is your upper jaw, mandible is your lower jaw. Then as you can see, you have the anterior portion of your spine. Clavicles are also known as your collarbone. And then that scapula that I mentioned is the posterior portion, which is known as your shoulder blade. The scapular spine or that ridge that you could probably feel when I told you to pat yourself on the back is found right here, where my pointer is. Now the sternum is also known as the breast bone and it has different components to it as well. Here you have the body, and then you have the xiphoid process at the end. This notch at the top is sometimes referred to as your sternoclavicular notch. And that's because there is a muscle that comes down called your sternocleidomastoid, and it attaches there. And then clavicle clavicular is right there as well. Another name for it is the jugular notch, and that's because your jugular vein, you have your internal and your external as we'll see on another slide, also connects right there. Ribs, you have 12 pairs of ribs. Ribs are also called your costals. And the term costal is important because there are parts of the thoracic spine which also use that specific term. The humerus is right here. And then we have the ulna, which is that long bone which you can run your finger down, if you go pinky finger all the way down to your elbow, that is known as your ulna. And then your radius, the easiest way to remember the distinction is that you make a radius with your thumb, so that is exceptionally important. Another item to consider is the way the skeleton is positioned here is the anterior view. And this is important because if you are positioning a patient on the table, see how the hand is turned out. That's known as the anatomical position. And the easiest way for me to relate this to a jury is to use yoga terminology. So the anatomical position, it's also called the corpse position, but I would suggest refrain using that for a couple of reasons, A, it might mislead the jury and B, it's rather macabre, but Savasana is the term for those of you who do yoga, which is used where you're laying on the mat, literally in anatomical position with your hands out so your radius is turned outwards along that particular position. So here we have, as I mentioned, those carpals, and they begin here. As you can see, the metacarpals are the long bones, and that's why the metacarpals are considered long bones versus the short bones being your carpals and your tarsals. Phalanges are the fingers in the hand. If you go to what's known as the pelvic girdle, you have your ileum, and this portion here is your iliac crest, which if you feel your hip bone, that's exactly what you are feeling. Then you get into the ischium, which is posterior right here. And you get on into your ischial spines, your sacrum, I mentioned. And if you were to sit down and feel the bony part of your backside, not the sacrum, but the portions that are right here, those are known as your ischial spines. So the pubis is in the front, that portion which looks like a gap is actually your pubic symphysis and that's what expands and contracts during a woman's pregnancy as well. The femur is the long bone, and here you have the femoral head and the femoral neck right there. And then you have the greater trochanter and lesser trochanter. And then you have rough portions called tuberosities and that's where the various connective tissues attach. Again, your patella is the sesamoid bone. And we only have typically two of those, tibia is the big bone, which is typically your weight bearing bone. And then fibula is the non-weight bearing bone. Phalanges of the toes, the metatarsals, and the tarsals pretty much round that out. Now I've given you the framework for the skeletal system and that's important, but before I move on to the muscular system, what I want to do is show you the difference between these two types of bone. Inside you have what's known as cancellous bone, and that's important because as you can see here, it looks spongier. It has a sponge-like texture, almost like coral. And that's where a lot of nutrients and blood and processes are occurring. The external part of your bone is known as cortical bone. And that is really a hard shell which encompasses the cancellous bone. Now, why is that important? It's important because, A, whenever I describe this to clients, what I do is think of a Whopper candy. The Whopper candy, the chocolate is the cortical bone and inside you have that same almost look with the cancellous bone that you do inside the bone. So cut a Whopper in half and you'll be able to visualize more readily, what the distinction is and how it works. So if we look at all the muscles, a lot of times this may seem daunting, but it's really not as daunting if you learn the skeletal anatomy first, because oftentimes there are correlations, whether it's the nerve or the vessels or the muscles to the underlying term in the bone. Now, if we were to step away from that for a moment and get into for example, a lot of people work out. So on your chest, you have your pecs, your pectoralis major and your pectoralis minor. If you go into your shoulder, you have your deltoid muscle. If you go into your muscles in your upper arm, you have your biceps, which are the two front muscles, bi meaning two. And then you have your triceps. So you have three muscles in the back of your arm. And for those of you who work out, I'm sure you have a nice ridge across the back. The anatomy for muscles in the legs is slightly different and does not use the same terms. And in the lower legs, it doesn't, just as in the upper arm it does not either. But again, you want to think of where things are positioned in terms of the bones first, and then begin to layer. So a more detailed picture here. As I mentioned, we have the deltoids and then you have your biceps and triceps are on the posterior there. You have your thoracolumbar or fascia, and for those of who are unfamiliar with fascia, if you've ever cooked a chicken, that web-like substance between the skin and the meat, that's fascia. And so we have that in our own bodies as well. In terms of the brachioradialis and the flexor carpi radialis as well as the flexor digitorum superficialis, the muscles are a little more complex than the bone sometimes, but again, it's appreciating carpi, again, carpi carpal, where is it going to attach to? Digiti, oftentimes your fingers, are also referred to as a number of digits. So if you can start to synthesize all these different terms, it'll absolutely be very helpful. Now, in terms of your leg muscles, you have the gluteus medias, you have the tensor fasciae latae on the outside, you have the rectus femoris, you have the pectineus and you have the sartorius as well as the adductor longus in the middle. You also have the gracilis muscle, which is the superficial muscle on your inner thigh. On the backside, you have the semimembranosus, semitendinosus, and down the middle, you have the biceps femoris. There, you have the gastrocnemius at the top for your calf muscle, and then the soleus down the back there. The tibialis anterior, again, the tibia is this very large weight bearing bone in the lower part of your leg. Tibialis, tibia, again, begin to make that association. The circulatory system, again, think of it as layering, even though a lot of times the vessels are below the muscles, think of it as layering on top of your skeletal system. So I mentioned the external jugular and the internal jugular, and on this particular image, veins are typically designated as blue and arteries are designated as red. Arteries are responsible for carrying oxygenated blood away from the heart to the various parts of the body, while veins bring back the deoxygenated blood to the heart so that it can then be processed and more fresh oxygenated blood can be released. So the subclavian vein really comes across your clavicle, clavicle, clavicular, subclavian. Again, we're in that same area. The internal carotid artery, the external carotid artery also run along your neck. If you start to move, pulmonary is lungs. So anything with pulmonary, pulmonary artery, pulmonary vein, those are critical. The superior vena cava and the inferior vena cava, that is what's known as a major vessel. It is the largest vein in the body. As you see here, the aorta is the corollary to that on the arterial side, which is helpful to know. And that really is within our abdomen. Renal is kidney, so that's important to make that correlation. You have the radial artery. Again, our radius, and it runs right down the line of the radius long bone. And then you have the ulnar artery. Again, located running along the ulna long bone. The iliac artery is important to note too, because, and I'm gonna sidestep for a minute, as well as the iliac vein. So I mentioned as part of the pelvic girdle, your ilium, you also have an ileum in your small intestine, one spelled with one L one spelled with two Ls. So your ileocecal sphincter, the ileum is the distal portion of your small intestine. It's also your hip bone, which is more specifically designated as your iliac crest. So again, the femoral vein and the femoral artery, and then you get anterior tibial artery, posterior tibial artery, again, correlating to the bones and small saphenous vein and great... I've heard it's pronounced saphenous or saphenous vein. So pick your poison on that. The spine, the central nervous system and the peripheral nervous system. So here, the nervous system is broken down into the central nervous system, which is basically the brain and the spinal cord, and then the peripheral nervous system, which is the relay system throughout the entire rest of the body. So it's a network of nerve cells and fibers that transmit nerve impulses between portions of the body. Now within the nervous system, as I mentioned, we have the central and the peripheral nervous systems, as you can see, there are a lot of other branches which stem from the peripheral nervous system. So I like to think of this as an algorithm. So from the PNS, we have sensory neurons and we have motor neurons, sensory neurons are referred to as afferent neurons and motor neurons are referred to as efferent neurons. From there, the motor neurons further break down into the somatic nervous system, which is voluntary. Typically, that is your breathing versus the autonomic nervous system, which is involuntary. And that would be when we intentionally contract and release one of our muscles that we just saw on the skeletal system. From there, we have sympathetic and we have the parasympathetic. So somatic, the voluntary side of the equation, again, is the skeletal muscles. And autonomic is our involuntary and that's our cardiac muscles, our smooth muscles and our glands. Our sympathetic nervous system is known as fight or flight. So whenever we feel a threat, the increased heart rate, the pupil dilation, a lot of sweating sometimes occurs in people, that would be the sympathetic nervous system being triggered versus the parasympathetic nervous system which is rest and digestion. So again, a way to calm the fight or flight is through deep breathing, meditation or yoga. Those have all been found to help calm that fight or flight. Exercise is also good. But specifically, if you can't go out and run, it's also beneficial to lower one's heart rate and that heightened state first, before engaging in any strenuous cardiac activity. So yoga is a great way in particular, as well as the deep breathing and meditation to impact the parasympathetic nervous system and kick that into gear in order to balance the fight or flight. Now, as you can see here, we have the parasympathetic and the sympathetic nervous system, and I'm not gonna spend a lot of time on this, but I wanted to make it available so that one can see where the parasympathetic, which is our autonomic system, again, going back to this one, autonomic is involuntary and somatic is voluntary, and we have the sympathetic nervous system. So again, here we have the fight or flight on the sympathetic and the parasympathetic is rest and digestion. So fight or flight is going on here and rest and digestion is going on over here. So there is absolutely a lot in play in terms of our biofeedback system and a lot of different systems as they're called, whether it's our circulatory system, in our nervous system, in our endocrine system within our body being affected. So this breaks it down even more, and really just brings together what I set forth on the previous slides. The sympathetic branch is predominant during alarm or distress. It stimulates heartbeat, it raises blood pressure, dilates pupils, dilates the trachea and bronchia, your bronchia found in your lungs, shunts blood from the skin in the sural to skeletal muscles, brain, and heart. And it helps conserve energy for necessary organs. It inhibits peristalsis in the gastrointestinal tract, and peristalsis is the movement of the small intestine and large intestine, which enables us to flush out our waste. Now, the parasympathetic branch normative action, it slows heartbeat, normalizes blood flow, lowers blood pressure, constricts pupils, normalizes the trachea and bronchia and normalizes blood flow to all areas of the body. Finally, it normalizes peristalsis in the gastrointestinal track. Moving on to the spine. As I mentioned, there are four main regions in the spine, the cervical, which has seven vertebrae, the thoracic, which has 12 vertebrae and the lumbar, which has five vertebrae. As you can see, the sacrum is more fused right here and the base of the sacrum, that part that's extending is known as the coccyx, also typically referred to as the tailbone. So here, if we look at the sagittal view, this right here is the posterior view, but this is our sagittal view. Again, going back to that plane that divides the body into left and right, or if you have a side view of something. So if we were to look here, we have the vertebral body and in between the vertebral bodies and most of your spine, you have what are known as discs. There are two parts of the disc. There is the outside annulus, annulus fibrosus is the complete term, and then inside that shock-like absorption is the nucleus pulposus. So that's what you're seeing here. Here you see the spinous process, and those are the bony parts right here, all along your spine. So if you were to run your finger down the middle of your back, that is in fact what you would be feeling are your spinous processes. Now, depending on the region of the spine that we're in, there are anatomical differences. So first and foremost, the cervical spine is unique in that it has two cylindrical type of vertebrae. You have the axis at C1, and then you have the atlas at C2. The atlas in particular is unique because it has a portion that extends up on the anterior portion of the vertebral body. And it's known as the dens or the odontoid. And that's important because that is how our head articulates from right to left along those lines. Here on the cervical, as you can see, you have openings. Openings are known as foramen, and the two here that I'm pointing to are known as your vertebral foramen, and that's where the vertebral arteries run up the spine through the cervical vertebrae and into the brain. So the opening here is where your spinal cord goes down the major foramen. And then unlike where you have the spinal processes in the thoracic and the lumbar spine, here what you find is that the protrusion out the back is actually bifurcated. And as you can see here, it has an indentation. And that's because of the supraspinous ligament which runs down across the back of our entire spine, across the back of these spinous processes. Why is it important that the head has A, the cervical vertebrae has a bifurcated portion in this part of its anatomy? It's because the supraspinous ligament is known as the nuchal ligament. It's a lot thicker, and that's because of the need to keep our neck stabilized and give us the ability to move our neck. So, as we moved into the thoracic area here, you have again, the vertebrae. Here you have the transverse process, and at the end you have the costal facets. And that is the facet joint where the rib, the costal, articulates from. So that's why we have some of the micro movement that we do in order for our lungs to expand and to contract. Again, you have the transverse process here. Now, if you start going into the lumbar, you can see that the size of the vertebral bodies as we move down the spine, get larger, and that's because there's more load bearing on the anterior column of our spine. Now, the posterior portions, you have pedicles, you have laminas and you have the transverse process here. And oftentimes what you'll find in spinal surgery is a pedicle screw, which is placed through the pedicle and it fixates into the vertebral body. Typically, they'll have it go through to the end of the vertebral body so that it has a more secure fixation, because as I mentioned in the middle, we have all of this cancellous bone or that spongy bone. So here we have some views of the spine, and we have the anterior view again, the sagittal view and then we have the posterior view as well. The cervical spine, as I mentioned, you have the atlas on top that dens or the odontoid is in fact, this protrusion that you see right here, typically it's referred to as an odontoid fracture. And since the summer and voting season are upon us, that is a common fracture to have. It's a complex screw that has to be put in, and oftentimes, unfortunately, people can be rendered either a quadriplegic or a paraplegic, depending on the level of the break. When you're dealing with spinal anatomy, the cervical spine designates C1, C2, C3 C4, C5, C6 C7. From there, you have two curves in your body, you have a lordotic curve, which is what we find in the cervical spine and in the lumbar spine. And then in our thoracic spine and in the sacrum, we find a kyphotic curve, which makes sense. So that just means that the apex or the top of the curve in the cervical and the lumbar faces forward and in the thoracic and the sacral, it is more concave, and in fact, faces backwards. So all of the anatomy has some nuances to it, depending on the region of the spine that we're in, unlike the cervical vertebrae, which use C1, thoracic not surprisingly uses T1 through T12 to designate the level of the thoracic vertebrae that a person's on. These protrusions here form what are known as facet joints and that's what enables us to move forward and backward. So the lumbosacral spine here you can see nerve roots exiting very nicely. And again, that's the disc space, that's the vertebral body here. And then that's the spinous process. We also have the lamina and the pedicles and the facets. So what are some common injuries and procedures? Well in orthopedics, oftentimes you find fractures being described, and there are open fractures, which are also known as a compound fracture, where the bone breaks through the skin and here one needs to use, typically, you'll see what's known as a fixateur externe, and that's when the halo or that plastic round device is external. It's not internal fixation, it's external fixation along with the various pins and screws protruding from the bone or the leg typically, or the arm, but typically the leg itself. And that is a very complex type of surgery and it's also very painful and it can take a while to heal. Now, closed fractures are known as a simple fracture. The bone does not break through the skin. A partial fracture is an incomplete break of the bone. A complete fracture is when there is a complete break of the bone causing it to be separated into two or more pieces. Typically when you have a complete fracture, one needs to have, for example, the bone reset or realign so that it can heal appropriately. A stable fracture occurs when broken ends of the bone line up and have not been moved out of place, versus a complete fracture is typically an unstable fracture. And again, it may require either a resetting and/or an IM rod, for example, in either the femur or the tibia or the fibula, an IM rod is known as an inter medullary rod. And it actually goes up the hollow portion, so to speak, of the long bones. Displaced fracture is the gap between the broken ends of the bone, and it may require surgery. So what are some types of bone fractures? While there's a transverse fracture, which is a break that is straight across the bone, it's typically caused by traumatic events like falls or automobile accidents. A spiral fracture is literally a spiral, and if you think about a spiral ham, that's exactly what it would look like on an x-ray. A greenstick fracture is very common in children and for anyone who's ever taken a young tree branch and tried to break it, it breaks in part, but it's still so soft that it does not break all the way. Typically in a real tree, that would be the green branch, which really does not break and create a clean break. Axial compression fracture. This occurs in the top of the cervical spine. Oftentimes it occurs with a diving accident. And this is where, as I mentioned earlier, you can break the odontoid or the dens, or even end up with a paralysis, whether it's a quad or a para type situation, a comminuted fracture is when the bone... Typically it shatters, but it breaks into three or more pieces and there is also a lot of bone fragments present at the fracture site. This is typically due to high impact trauma. And avulsion fracture is when a fragment is pulled off the bone by tendon or a ligament. This is typically more common in children, and it can cause a growth plate fracture, typically growth plate fractures occur in the wrist. So what are some common procedures? You have reduction or repair of a long bone fracture using a fixateur externe, which I mentioned, or the fixateur interne, which is typically an IM rod or an angle blade plate could used for a typical plateau fracture, for example. Reduction of a spondylolisthesis in the spine. Typically in spine, you have trauma, you have degeneration, you have deformity and you have cancer. So those are typically the types of reasons why people have surgery in the spine and some common terminology or some common types of spinal surgery are ACDF, Anterior Cervical Discectomy Fusion. You can have a lumbar laminectomy, where a surgeon goes in and removes the lamina and to release pressure that's on the spine. You can have an ALIF, which is an Anterior Lumbar Inner Body Fusion. You can have a PLIF, which is a Posterior Lumbar Inner Body Fusion. You can have a TLIF, which is a Transverse Lumbar Inner Body Fusion. So it just depends on the region of the spine. It depends on the pathology that the surgeon, which is typically an orthopedic surgeon or a neurosurgeon will go in and fix. Most orthopedic surgeries are performed, other than the spine, they are performed by an orthopedic surgeon. Sometimes you'll see a general surgeon in there or a vascular surgeon, depending on the issues associated with other organs or the vessels themselves. In hand surgery, a neurosurgeon may be present if there are a lot of issues with the nerves as well. So in ACL reconstruction, if you think of the knee, that's your anterior cruciate ligament. The knee itself has the anterior cruciate ligament, the posterior cruciate ligament, the medial collateral ligament, and the lateral collateral ligament. You also have the patella tendon and ACL reconstruction is actually more common in women than in men. And it's because of two things, a during a woman's cycle, the hormone release has an impact on the pelvic girdle, and in turn has an impact on the ACL. Oftentimes you see soccer players and skiers, and a lot of athletes undergoing this type of reconstruction. Freddie Fu, who unfortunately passed away, was a renowned orthopedic sports surgeon at the University Of Pittsburgh who authored a lot of books on this. So if you're interested, his works are a great resource. Labrum and rotator cuff tear occur in the shoulder, carpal tunnel repair, again, that's typically in our carpals, right? The bones in the lower portion of our hand which then extend into the wrist, and total joint replacements whereby it's typically the hip or the knee. And oftentimes these are performed in Medicare patients, not all the time, but often times. So in terms of a wrap up, it's important to appreciate that anatomy should be considered in a holistic manner. You need to choose the right expert who can survive a Daubert inquiry, And also the four Daubert factors should be considered from the outset. And lastly, understanding the nuances of anatomy and being able to ask witnesses, whether on direct or cross meaningful questions is critical as well as being able to relate to the judge and the jury. So with that, I wanna thank you for your time and attention here today. And I hope that you have enjoyed this program.