12.3 Flashcards
Name the common flexor origin (forearm muscles)
Medial epicondyle
Name the common extensor origin (forearm muscles)
Lateral epicondyle
The flexor forearm compartment (anterior compartment generally) is composed of 8 muscles. List them all.
2 pronators of forearm (pronator teres + quadrates)
2 long flexors of fingers (flexor digitorum superficialis + flexor digitorum profundus)
1 long flexor of thumb (flexor pollicis longus)
2 flexors of wrist (flexor carpi radialis + flexor carpi ulnaris)
1 long muscle of palm (palmaris longus - vestigial in humans + absent in 10-15% of population)
Most flexor muscles of forearm are innervated by median nerve.
Which are innervated by ulnar nerve?
Flexor carpi ulnaris
Medial part of flexor digitorum profundus
Which is deeper - pronator quadratus or pronator teres?
Pronator quadratus
Which type of forearm muscles are anterior and medial?
Flexor muscles
Which type of forearm muscles are posterior and lateral?
Extensor muscles
How many extensor muscles of the foerarm are there?
12 - all supplied by radial nerve
Which forearm muscle is responsible for supination?
Supinator;
The biceps is also a supinator..
Why is the brachioradialis muscle unusual?
Lies in posterior compartment of forearm but is a weak flexor at elbow but still supplied by radial nerveIt lies on thumb side.
How many tendons pass through the carpal tunnel?
9 flexor tendons
Which nerve passess between the tendons of flexor digitorum profundus and superficialis?
Median nerve
List the main contents of the anatomical snuffbox?
Radial artery
Radial nerve branch
Cephalic vein
What is carpal tunnel syndrome?
o Conditions that cause swelling (e.g. arthritis, pregnancy, oedema) can lead to median nerve compression as it passes through the carpal tunnel
o This leads to loss of sensation in the hand in region supplied by median nerve + reduced movement of the thumb as the median nerve supplies the muscles of the thumb
Name 2 tests for carpal tunnel syndrome.
Tinel’s sign – tapping the nerve in carpal tunnel to elicit pain in median nerve distribution
Phalen’s manoeuvre – holding the wrist in flexion for 60 seconds to elicit numbness/pain in median nerve distribution
What is finger abduction?
When fingers move away from middle finger
Name all the carpal bones in the proximal row from lateral to medial from anterior view.
- Scaphoid – has tubercle on lateral, palmar surface
- Lunate – dislocates uncommonly but have severe morbidity associated with them if the diagnosis is delayed
- Triquetrum
- Pisiform – can be felt
List all the carpal bones in the distal row from lateral to medial from anterior view.
- Trapezium – has tubercle on palmar surface
- Trapezoid
- Capitate – largest carpal bone
- Hamate – has hook on palmar surface
A single synovial sheath surrounds 8 of the 9 flexor tendons. Which tendon is surrounded by its own synovial sheath?
Flexor pollicis longus (flexor digitorum profundus and superficialis have 4 tendons each and around surrounded by the single synovial sheath)
Bennett’s fracture
- Fracture of the 1st metacarpal base
- Extending into the carpometacarpal joint
- Caused by hyperabduction of the thumb
Boxer’s fracture
- Fracture of 5th metacarpal neck
- Usually caused by a clenched fist striking a hard object
- Distal part of fracture is displaced posteriorly, producing shortening of affected finger
Metacarpal I is related to the thumb. What is the 3rd metacarpal related to?
Middle finger
Dorsal venous network of hand is a network of veins in superficial fascia on dorsum of hand formed by dorsal metacarpal veins.
Where are they found and what do they give rise to?
Found on back of the hand and give rise to cephalic and basilic veins
Which digits are affected by an ulnar nerve lesion at the wrist at rest?
Digits 4 and 5
Which digits are affected by a median nerve lesion at wrist or elbow when attempting to make a fist?
Digits 2 and 3.
Only digits 4 and 5 flex
List 4 common fracture sites.
Distal radius
Vertebra
Proximal femur
Proximal humerus
Function of deep fascia
o Covers muscles + helps divide the muscular sections into compartments – which work in functional units
o Fascia prevent the contracting muscles from causing friction in the subcutaneous fat/dermis above as it’s a smooth barrier
o Deep fascia does not stretch –> when muscles work (especially in distal LL) the pressure they cause to increase in size within the compartment helps w/ venous return – muscular venous pump
Which property of deep fascia is what leads to compartment syndrome?
Deep fascia does not stretch –> when muscles work (especially in distal LL) the pressure they cause to increase in size within the compartment helps w/ venous return – muscular venous pump
Muscles that make up quadratus femoris
o Rectus femoris
o Vastus lateralis
o Vastus intermedius
o Vastus medialis
Which compartment are the following muscles a part of?
- Sartorius
- Pectineus
- Iliopsoas
- Quadratus femoris
Anterior thigh compartment
Which compartment do the following muscles belong to?
- Adductor brevis
- Adductor longus
- Adductor magnus*
- Gracilis
- Obturator externus
Medial thigh compartment
Which compartment do the following relate to?
- Obturator nerve (L2-L4 ant)
- Obturator artery
- Adduction of hip
Medial thigh compartment
Which compartment do the following relate to?
- Femoral nerve (L2-L4 post)
- Femoral artery
- Extension of knee + Flexion of hip
Anterior thigh compartment
Which compartment do the following relate to?
- Sciatic nerve (L4-S3)
- Profunda femoris + perforating arteries
- Extension of hip + Flexion of knee
Posterior thigh compartment
Which compartment do the following muscles belong to?
- Biceps femoris
- Semitendinosus
- Semimembranosus
Posterior thigh compartment
Which compartment do the following muscles belong to?
- Tibial anterior
- Extensor digitorum longus
- Extensor hallucis longus
- Fibularis tertinus
Anterior leg compartment
Which compartment do the following relate to?
- Deep fibular nerve
- Anterior tibial artery
- Dorsiflex ankle (L4, L5)
- Bound by extensor retinacula
Anterior leg compartment
Which compartment do the following relate to?
- Superficial fibular nerve
- Fibular artery*
- Evert ankle (L5, S1)
Lateral leg compartment
Which compartment do the following muscles belong to?
- Fibularis longus
- Fibularis brevis
Lateral leg compartment
Which compartment do the following muscles belong to? Superficial group: o Gastrocnemius o Plantaris o Soleus
Deep group: o Popliteus o Tibialis posterior o Flexor digitorum longus o Flexor hallucis longus
Posterior leg compartment
Which compartment do the following relate to?
- Tibial nerve
- Posterior tibial artery
- Plantar flexors (S1, S2)
Posterior leg compartment
The lumbar plexus is formed by the anterior primary rami of which spinal roots?
L1-4
Where does the trunks of the lumbar plexus lie within?
Substance of psoas major
Name the 6 major peripheral nerves which branch from the lumbar plexus.
o Iliohypogastric o Ilioinguinal o Genitofemoral o Lateral cutaneous of thigh o Obturator o Femoral
I, I Get Love On Fridays
What is this a mnemonic for?
Lumbar plexus branches
o Iliohypogastric o Ilioinguinal o Genitofemoral o Lateral cutaneous of thigh o Obturator o Femoral
*H comes before I so ilioHypogastric is before ilioInguinal
Which plexus is formed by the anterior primary rami of S1-4 (with contributions from L4 + 5)?
Sacral plexus
List the 5 major branches of sacral plexus.
o Superior gluteal nerve o Inferior gluteal nerve o Sciatic nerve o Posterior femoral cutaneous o Pudendal nerve
When injecting into the gluteal region, which quadrant should you go for?
Upper lateral quadrant
Medial upper and lower quadrants is bad because of the superior gluteal nerve
Lateral inferior quadrant - there’s a greater chance of hitting sciatic nerve
Name the line on the posterior surface of the femoral shaft
Linea aspera
Where is the pectineal line?
Proximally, on the medial border of linea aspera becomes pectineal line
What can a neck of the femur fracture cause?
Shortened limb
Externally rotated limb (iliopsoas axis of action)
Torn retinacular arteries –> risk of avascular necrosis
Are intra- or extra- capsular fractures more common in elderly people?
Intra
They are result of minor trip or stumble
Facture occurs within capsule of hip joint
Can damage medical femoral artery which causes avascular necrosis of femoral head
Neck of fracture causes external or internal rotation?
External
And leg is shortened
With a dislocation leg is shorted and medially rotated
Where are osteogenic cells located?What do they develop into?
In inner layer of periosteum and endosteum
Develops into an osteoblast
What are bisphosphonates?
o Inhibit mineralisation or bone resorption by inhibiting osteoclasts
o Bisphosphonates are enzyme-resistant analogues of pyrphosphoric acid, which norammly inhibits mineralisation in the bone
MoA of bisphosphonates used in the inhibition of bone resorption.
BPs attach to hydroxyapatite binding sites in bone
They are a prodrug
• Action of osteoclast forming sealing zone releases bisphosphonate, this is taken up by osteoclasts
When osteoclasts resorb bone impregnated w/ BP, BP released during resorption impairs ability of osteoclasts to:
• Form the ruffled border
• Adhere to the bony surface
• Produce the protons for bone resorption
BPs decrease osteoclast activity by decreasing osteoclast progenitor development + recruitment + increasing osteoclast apoptosis
SE of bisphosphonates.
Osteonecrosis of the jaw bone is the widest adverse effect of BP therapy
There is an increased risk of osteonecrosis of jaw bone due to:
• Poor oral hygiene
• Invasive dental procedures
• Prolonged exposure to high doses of IV bisphosphonates
Calcitonin moa
o Another pharmacological approach is trying to modulate the calcitonin/PTH levels to control calcium
o Calcitonin is secreted by thyroid gland when blood calcium level increases:
Decreases blood calcium levels
Stimulates calcium deposition in bones
Reduces calcium uptake in kidneys
PTH is secreted by parathyroid gland when blood calcium level decreases. What does it do?
Increases blood calcium levels
Stimulates calcium release from bones
Increases calcium uptake in kidneys
Increases calcium uptake in intestines
Must be careful about dosage of PTH:
• Low dose – increases osteoblast activity – desired result
• High dose – increases bone reabsorption + thins bone
Why does steroids need to be withdrawn slowly?
• Adrenal gland starts to shrink + reduces steroid production significantly when steroids used long term.
o So steroids need to be withdrawn slowly, so steroid production increases overtime
o If steroid treatment abruptly stopped –> atorpy
What are DMARDs?
Drugs used for other conditions but at low doses help w/ RA.
Disease-modifying antirheumatic drugs
Effects of DMARDs?
- Slow down disease progression
- Reduce damage to the joints
- Usually taken for rest of life
- They suppress body’s overactive immune systems
- Need to have regular blood tests, to see if DMARDs are having any side effects
- But serious side-effects affecting the blood, liver, or kidneys (rare)
What is synovial membrane?
Specialised connective tissue that lines inner surface of capsules of synovial joints + tendon sheath
Function of synovial membrane?
It makes direct contact w/ synovial fluid lubricant
It is primarily responsible for maintaining synovial fluid lubricant
At tissue surface, there are many rounded macrophage-like synovial cells (type A) + fibroblast-like (type B) synovial cells. What are the functions of A and B type cells?
Type A cells – maintain synovial fluid by removing wear-and-tear debris by phagocytosis
Type B cells – secrete hyaluronic acid + protein complex (mucin) of synovial fluid
What is cartilage?
A smooth elastic tissue that covers + protects the ends of long bones at the jointsIt’s a structural component of the rib cage, ear, nose, bronchial tubules, intervertebral discs, other body component
Name 3 types of cartilage.
Elastic – provides strength, elasticity, maintains shape
Hyaline – weakest cartilage found on many joint surfaces, precursor of bone
Fibrous – strongest cartilage, alternating layers of hyaline + collagen
Pick the most appropriate synovial joint.Permits movement in several axis; a rounded head fits into a concavity (glenohumeral joint)
Hinge Saddle Plane Pivot Condyloid Ball and socket
Ball and socket
Pick the most appropriate synovial joint.Permits flexion and extension (elbow joint)
Hinge Saddle Plane Pivot Condyloid Ball and socket
Hinge
Pick the most appropriate synovial joint.Concave and convex joint surfaces unite at this joints (metatarsophalangeal joint)
Hinge Saddle Plane Pivot Condyloid Ball and socket
Saddle
Pick the most appropriate synovial joint.Permit gliding/sliding movements (acromioclavicular joint)
Hinge Saddle Plane Pivot Condyloid Ball and socket
Plane
Pick the most appropriate synovial joint.Allows rotation; a round bony process fits into a bony ligamentous socket (atlantoaxial, proximal radio-ulnar)
Hinge Saddle Plane Pivot Condyloid Ball and socket
Pivot
Pick the most appropriate synovial joint.Permits flexion, extension, adduction, abduction, circumduction (metacarpophalangeal joint)
Hinge Saddle Plane Pivot Condyloid Ball and socket
Condyloid
Other than synovial joints, name 3 types of joints.
Fibrous
Primary cartilaginous (synchondrosis)
Secondary cartilaginous (symphyses)
Define rheumatoid arthritis
Long lasting autoimmune disorder that primarily affects joints
RA = chronic, symmetrical, inflammatory, deforming, polyarthritis
Signs and symptoms of RA
o Insidious onset (gradual)o Joint swelling – inflammatory arthritis
o MCPs, MTPs, wrists commonly affected
o Classically symmetrical in terms of affected joints
o Early morning stiffness – joints stiffen when not used
o Responds well to NSAID
List the 3 stages of progression of RA
Initiation phase – non-specific inflammation
Amplification phase – T-cell activation
Chronic inflammatory phase – tissue injury due to cytokines IL-1, TNF-alpha, IL-6
What can trigger RA?
An external trigger (e.g. infection, trauma, smoking) sets of an autoimmune reaction (perhaps in genetically susceptible individuals)
What does T cell stimulation in RA activate and result in?
- Activates macrophages, fibroblasts, B cells
* Result of this activation = production of whole range of cytokines
What is detected in blood tests for RA?
B cells produce RF and anti-CCP antibody which is detected in blood test
List the 3 main cytokines involved in RA
- TNF-alpha – main cytokine involved
- IL-1
- IL-6
How can inflammation cause joint damage in RA?
o The inflammation happens within the synovial layer
o This gets organised together + starts to invade the adjacent cartilage (this is termed invading mass pannus)
Invading mass pannus – organised synovial cells which are invading + attacking the cartilage + bone
o The cartilage + bone start to break down – this can be seen on an x-ray as joint space narrowing (cartilage degradation)o Bone erosion can be seen as punched out areas on x-ray
List 5 consequences of chronic systemic inflammation in RA
o Early ischaemic heart disease (leading cause of mortality in RA)
o Sarcopenia (damage to muscles w/ inflammation) - muscles become damaged + atrophied (thus not as strong)
o Pain sensation can increase - unusual effects on pain sensitizer + nerve endings –> more susceptible for chronic pain
o Osteoporosis - in patients w/ lots of inflammation
o Insulin resistance + metabolic syndrome
o Dementia
Inflammatory markers are used to predict the prognosis of RA.List some erosion (bone) prognostic factors
Common prognostic factors: smoke status, RF, anti-CCP, ESR, CRP
Inflammatory markers are used to predict the prognosis of RA.List some disability prognostic factors
Specific HLA antigen implicated, RF, anti-CCP
Inflammatory markers are used to predict the prognosis of RA.List some mortality prognostic factors
Specific HLA antigen implicated, RF, anti-CCP
RA summary
Synovial inflammation
Genetic + environmental factors
Articular + extra-articular complications
Morbidity + mortality associated with the disease
Early assessment + diagnosis is essential
Treat inflammation early + aggressively
Established severe RA is bad
MDT approach needed
RA = chronic, symmetrical, inflammatory, deforming, polyarthritis
Action of TNF-alpha
T lymphocyte + macrophage
o Increases pro-inflammatory cytokines + chemokines (IL-1, IL-6, IL-8) -> increased inflammation
o Increased adhesion molecules –> increased cell infiltration (affects vascular lining)
Endothelium
o Increased vascular endothelial growth factor
increased angiogenesis
Hepatocyte
o Increased acute phase response
increased CRP in serum (used in RA blood tests)Epidermis
o Increased keratinocyte hyperproliferation
skin plaques
Synoviocytes
o Increased metalloproteinase syntheses
causes articular cartilage degradation
What is the most common joint disorder/disease that results from breakdown of joint cartilage + underlying bone?
OA (osteoarthritis)
Which joints does OA affect?
Distal interphalangeal joints (DIP)
Proximal interphalangeal joints (PIP)
Carpometacarpal joints
Metatarsophalangeal joints
Axial skeleton
Large weight bearing joints
Symptoms of OA
Tend to come with activity + get better w/ rest
Little inflammation present – repair causes inflammation (wear, tear, repair)
What is anti-CCP?
Anti-cyclic citrullinated peptide (anti-CCP) is an antibody present in most rheumatoid arthritis patients. Levels of anti-CCP can be detected in a patient through a blood test.
A positive anti-CCP test result can be used in conjunction with other blood tests, imaging tests, and physical examinations to reach a rheumatoid arthritis diagnosis.
Bouchard’s nodes
PIP joints – bony outgrowths or gelatinous cysts form
Heberden’s nodes
DIP joints – bony swellings form
List all the causes of pain in OA
o Prostaglandins
o Cytokineso Synovitis
o Subchondral fractures
o Periosteal elevation
o Muscle spasm
o Venous congestion
o Biomechanical effects
Does RA or OA have an earlier onset?
RA (20-40) whereas OA is >50
What is gout?
A form of inflammatory arthritis characterised by recurrent attacks of red, tender, hot, swollen joints
What is the most common type of inflammatory arthritis in young men?
o Gout is the most common type of inflammatory arthritis in young men
o It affects 1-2% of adult population
o Prevalence increases w/ age
Co-morbidities in gout
o Renal impairment typically (cannot excrete uric acid)
o Coronary heart disease
o Metabolic syndrome – obesity, dyslipidaemia, hypertension, type II diabetes
Modifiable risk factors of gout
Hyperuricemia
Diet – seafood, purines (metabolised to uric acid), red meat, beer
Alcohol consumption
Obesity
Certain drugs – low dose aspirin, thiazide diuretics, furosemide, cyclosporine, levodopa, nictonic acid
Which foods/drinks should be avoided in gout?
Products with high purine
Seafood, beer, red meat
Not everyone w/ high levels of uric acid get gout, usually there is a trigger event –> mobilise uric acid in blood. List some triggers.
- Direct trauma
- Intercurrent illness/surgery the triggers an acute phase response
- Dehydration/acidosis – including alcoholic binge
- Rapid weight loss
Summaries gout
o Common metabolic disorder, increasing in incidenceo Associated w/ high-purine diet + high alcohol intake
o Hyperuricemia is the cause of gout
o Attacks caused by deposition of urate crystals in joints, resulting in inflammation
o Gout is a recurrent + progressive condition. Eventually leading to advanced tophaceous gout
o Identification of crystals in joint or tophus aspirate, allows a definitive diagnosis
o Primary care, clinical diagnosis is reasonable accurate for typical presentations (wo/ aspirate)
What is septic arthritis?
Acute swollen joint presentation, think infective arthritis
o Especially if it’s a single joint or there’s a risk factor e.g. IV drug users
o They may be presenting w/ sepsis
How to confirm septic arthritis?
- Aspirate + confirm
- Choose appropriate antibiotic based on gram status + species if it’s septic arthritis
- Septic arthritis can mimic other things like acute gout, treat sepsis w/ broad spec antibiotics if suspicious, wait for results (?gout)
- Duration of antibiotics in confirmed case can be difficult
What is bursitis?
o Inflammation of one or more bursae (small sacs) of synovial fluid in the body
o They are lined w/ synovial membrane that secretes a lubricating synovial fluid
o When bursitis occurs, movement relying on the inflamed bursa becomes difficult + painful
o Moreover, movement of tendons = muscles over the inflamed bursa aggravates its inflammation
What is tenosynovitis?
o Inflammation of the synovium that surrounds a tendon
o Symptoms include pain, swelling + difficulty moving the particular joint where the inflammation occurs
o Tenosynovitis most commonly results from the introduction of bacteria into a sheath through a small penetrating wound such as that made by the point of a needle or thorn
List the 5 big complementary therapies.
Acupuncture:
Fine needles are inserted at certain sites in the body for therapeutic or preventative purposes
Osteopathy:
Moving, stretching and massaging a person’s muscles + joints
Chiropractic:
Spinal manipulation which aims to treat ‘vertebral subluxations’ which are claimed to put pressure on nervesHerbal medicine
Medicines with active ingredients made from plant partsHomeopathy
Based on use of highly diluted substances (H2O) which practitioners claim can cause body to heal itself
List assessment tools for pain.
o Visual analogue score
o Verbal rating score
o Brief pain inventory
o HAD score – Hospital anxiety + depression scale
o McGill pain score – Self-report questionnaire that allows individuals to describe quality + intensity of their pain to S-LANSS score – Aims to identify pain of neuropathic origin, as distinct from nociceptive pain, wo/ clinical examination
List factors that lower pain threshold
- Discomfort
- Insomnia
- Fatigue
- Anxiety
- Fear
- Sadness
- Depression
- Boredom
- Introversion
- Mental isolation
- Social abandonment
List factors that raise pain threshold
- Relief of symptoms
- Sleep
- Rest
- Empathy
- Companionship
- Diversional activity
- Reduction in anxiety
- Elevation of mood
- Analgesics
- Anxiolytics
- Antidepressants
Neurovasculature of knee joint
o Vasculature: genicular anastomoss (supplied by genicular branches of femoral + popliteal arteries)
o Innervation: femoral, tibial, common fibular nerves
Where do collateral ligaments of the knee attach?
Medial and lateral epicondyles
What is the intercondylar fossa?
Depression found on posterior surface of femurLies between 2 condyles and contains 2 facets for attachment of internal knee ligaments (cruciate)
What is the tibial plateau (proximal) formed by?
Formed by the lateral + medial condyles
What does the knee capsule contain?
Patella, ligaments, menisci, bursa
What is menisci?
The medial + lateral menisci are fibrocartilage structures in the knee that serve 2 functions:
o Deepen the articular surface of the tibia, thus increasing stability of joint
o Act as shock absorbers
Hence increase stability + weight distribution
They are avascular
What shape is the medial meniscus?
C (crescent shaped)
What shape is the lateral meniscus?
O (oval shaped)
Which meniscus is attached to MCL?
Medial
Which meniscus is attached to popliteus tendon?
Lateral
Is the medial and lateral menisci fixed of mobile?
Medial = fixed
Lateral = free from LCL hence mobile
What is the function of bursae?
- Synovial filled sac found between moving structures in a joint
- Function = reduce wear + tear on structures
Name the 4 bursa found in knee joint.
o Suprapatellar bursa,
o Prepatellar bursa,
o Infrapatellar bursa,
o Semimembranosus bursa
Ligaments of knee joint
o Tibial collateral ligament resists medial displacement
Assisted by the sartorius, semitendinosus, gracilis
Aided by the quadriceps femoris
o The fibular collateral ligament resists lateral displacement
Assisted by the iliotibial tract
Aided by the quadriceps femoris
o The cruciate ligaments prevent hyperextension by becoming taut
Function of quadratus femoris in knee stabilisation.
The quadriceps femoris prevents anterior dislocation when the knee is flexed
Axial rotation of leg is limited due to what?
o The intercondylar eminence of the tibia lodging in the intercondylar notch of the femur forming the pivot
o The cruciate and collateral ligaments
Which nerve innervates quadriceps muscles?
Femoral nerve (L2-L4)
Function of iliotibial band
Pulls knee into hyperextension
What is the iliotibial band?
o It is a thickening of fascia lata + provides lateral knee support.
Acted on by:
- Tensor fascia latae
- Gluteus maximus
Innervation of hamstrings
Scaiatic nerve
List hamstrings muscles
o Semitendinosus
o Semimembranosus
o Biceps femoris
What is pes anserinus made up of?
3 conjoined tendons of muscles.
One from each thigh compartment.
Name the muscle tendons that conjoin to form pes anserinus
Sartorius – from anterior thigh compartment
Gracilis – from medial thigh compartment
Semitendinosus – from posterior thigh compartment
Contents of popliteal fossa
Popliteal artery
Popliteal vein
Tibial nerve
Common fibular nerve
How to test for posterior cruciate ligament damage?
o Flex knee to 90 degrees
o Look from the side of the knee checking for a poster sag or setback of the tibia
o This would suggest posterior cruciate ligament damage
Describe the anterior draw test (for anterior cruciate ligament)
o Place both hands around upper tibial tuberosity + index finger tucked under the hamstrings to make sure these are relaxed
o Stabilise the lower tibia with your forearm + gently pull the upper tibia forward
o In a relaxed, normal patient there is normally a small degree of movement
o More significant movements suggest anterior cruciate ligament damage
How to test medial + lateral collateral ligament?
o Flex knee to 15 degrees
o Alternatively stress the joint line on each side
o Place hand on opposite side of the joint line of that which you are testing + apply force to lower tibia
What is knock knees aka?
Genus valgus
What is bol-legs aka?
Genu varus
The chief cause of genu varus
Rickets
When does ACL rupture occur?
o Occurs when the biomechanical limits of the ligament are exceeded (over-stretched)
o Frequently occurs in athletes
o Consequence depends on how much knee stability affected + the extent to which other structures have been involved
o If instability is evident then the menisci may get injured, this may lead to progressive, degenerative, arthritis of the knee
PCL rupture
o <20% of knee ligament injuries
o Usually caused by blow to knee whilst flexed
E.g. falling on bent knee, impact from dashboard
What is the terrible triad?
Torn:
Medial (tibial) collateral ligament
Medial meniscus
Anterior cruciate ligament
How to know which collateral ligament is damaged?
Pain on medial rotation indicates damage to the medial ligament.
Pain on lateral rotation indicates damage to the lateral ligament
o If tibial (medial) collateral ligament is damaged, it is likely that medial meniscus is torn, due to their attachment
From proximal to distal, name the 7 tarsals
Talus.
Calcaneus.
Navicular.
Cuboid.
Cuneiforms (there are 3 of these)
Which tarsal bone articulates with ankle joint?
Talus
Name the largest tarsal
Calcaneus.
Achilles tendon attaches to it.
Which compartment does the dorsiflexors lie in?
Anterior leg
Which compartment do ankle evertors belong to?
Lateral leg
Which compartment do plantar flexors belong to?
Posterior leg
Which compartment does the deep fibular nerve supply?
Anterior leg compartment
Which compartment does the superficial fibular nerve supply?
Lateral leg compartment
Which compartment does the tibial nerve supply?
Posterior leg
Which compartment does the anterior tibial artery supply?It continues as dorsalis pedis
Anterior leg
Which compartment does the posterior tibial artery supply? It is a continuation of the popliteal arterty
Posterior leg compartment
Which compartment does the fibular artery supply?
Lateral leg compartment
Name the 3 dorsal foot muscles
Extensor digitorum brevis
Extensor hallucis brevis
Dorsal interossei
Name the 3 superficial plantar foot muscles
- Abductor hallucis
- Flexor digitorum brevis
- Abductor digiti minimi
Name 2 intermediate plantar foot muscles
- Quadratus plantae
* Lumbricals
Name 4 deep plantar foot msucles
- Flexor hallucis brevis
- Adductor hallucis
- Flexor digiti minimi brevis
- Plantar interossei
Short saphenous vein
Found on the lateral side
Runs up the posterior leg + becomes the popliteal vein
Great saphenous vein
Anterior to medial malleolus = where the origin of the great saphenous vein is found.
This is the longest vein in the body.
Runs up until the inguinal ligament where it becomes the femoral vein.
The tarsal tunnel runs from the medial malleolus to the calcaneal tuberosity.
Tendon order only applies here, proximally the tibial artery + flexor digitorum longus swap.
Using the mnemonic - ‘Tom, Dick, ANd Harry’ list tendons, arteryand nerve
T - Tibialis posterior tendon
D - flexor Digitorum
A - posterior tibial Artery
N - tibial Nerve
H - flexor Hallucis longus tendon
What type of joint is the ankle joint (talocrural joint)?
Hinge joint - movements possible in 1 plane (plantarflexion + dorsiflexion)
What is the subtalar joint?
An articulation between 2 of the tarsal bones in the foot (talus + calcaneus)
Ball-and-socket
Which movements occur at the subtalar joint?
It is the chief site within the foot for generation of eversion + inversion movements
- Eversion movement is produced by muscles of the lateral leg compartment
- Inversion movement – tibialis anterior muscles
Which muscles produce plantar flexion and dorsiflexion at the talocrural joint?
- Plantarflexion – produced by muscles in posterior compartment of leg.
- Dorsiflexion – produced by muscles in anterior compartment of leg.
When is the ankle joint most stable?
Dorsiflexion - anterior talus held tightly in mortise.
High heels force plantarflexion which increases injury risk as the joint is least stable in this position.
How many arches does the foot have?
3
Name the arches of the foot.
2 longitudinal (medial + lateral) – formed between the tarsal bones + proximal end of metatarsals
- Medial longitudinal arch - formed by the calcaneus, talus, navicular, 3 cuneiforms, first 3 metatarsal bones
- Lateral longitudinal arch - formed by the calcaneus, cuboid, 4th + 5th metatarsal bones
1 anterior transverse
• Formed by the metatarsal bases, the cuboid + the 3 cuneiform bones
What does pes cavus mean?
High arches
What does pes planus mean?
Low arches (flat footed)
What is hallux vagus?
Hallux is deviated medially, towards the body
Uncommon
What is hallux valgus?
aka bunion.
Hallux deviated laterally.
1st metatarsal bone deviates medially.
What does the following describe?
Foot condition in which the longitudinal arches have been lost
Arches do not develop until about 2-3 years of age so flat feet during infancy is normal causes few, if any, symptoms – may result in ache after prolonged activity
Pes planus
Posture
A. Area demarcated by body’s point of contact with ground (+ any additional walking aids)
B. Theoretical balancing point.
C. A genetic term used to describe the dynamics of body posture to prevent falling.
D. Point location of the body ground reaction foot vector (vGRF) on the floor.
E. The orientation of any body-segment relative to the gravitational vector.
F. Vertical projection of the COM onto the ground
E. The orientation of any body-segment relative to the gravitational vectorIt is an angular measure from the vertical
Centre of mass
A. Area demarcated by body’s point of contact with ground (+ any additional walking aids)
B. Theoretical balancing point.
C. A genetic term used to describe the dynamics of body posture to prevent falling.
D. Point location of the body ground reaction foot vector (vGRF) on the floor.
E. The orientation of any body-segment relative to the gravitational vector.
F. Vertical projection of the COM onto the ground
B. Theoretical balancing point
o Weighted average of the COM of each body segment combined in 3D space
Balance
A. Area demarcated by body’s point of contact with ground (+ any additional walking aids)
B. Theoretical balancing point.
C. A genetic term used to describe the dynamics of body posture to prevent falling.
D. Point location of the body ground reaction foot vector (vGRF) on the floor.
E. The orientation of any body-segment relative to the gravitational vector.
F. Vertical projection of the COM onto the ground
C. A genetic term used to describe the dynamics of body posture to prevent falling
o It is related to the inertial forces acting on the body + the inertial characteristics of body segments
Centre of gravity
A. Area demarcated by body’s point of contact with ground (+ any additional walking aids)
B. Theoretical balancing point.
C. A genetic term used to describe the dynamics of body posture to prevent falling.
D. Point location of the body ground reaction foot vector (vGRF) on the floor.
E. The orientation of any body-segment relative to the gravitational vector.
F. Vertical projection of the COM onto the ground
F. Vertical projection of the COM onto the ground
Centre of pressure
A. Area demarcated by body’s point of contact with ground (+ any additional walking aids)
B. Theoretical balancing point.
C. A genetic term used to describe the dynamics of body posture to prevent falling.
D. Point location of the body ground reaction foot vector (vGRF) on the floor.
E. The orientation of any body-segment relative to the gravitational vector.
F. Vertical projection of the COM onto the ground
D. Point location of the body ground reaction foot vector (vGRF) on the floor
o When standing this is between the 2 feet
Base of support.
A. Area demarcated by body’s point of contact with ground (+ any additional walking aids)
B. Theoretical balancing point.
C. A genetic term used to describe the dynamics of body posture to prevent falling.
D. Point location of the body ground reaction foot vector (vGRF) on the floor.
E. The orientation of any body-segment relative to the gravitational vector.
F. Vertical projection of the COM onto the ground
A. Area demarcated by body’s point of contact with ground (+ any additional walking aids)
o When feet are separate apart, it is easier to maintain balance
o A walking stick + frame will increase base of support –> more like to keep COG within that area –> maintain balance
What does postural control consist of?
- Postural control consists of keeping body’s COG over/within base of support (BOS) during stance + active movements, respectively
- 2/3rd of our body mass is located 2/3rd of body height above the ground
Breakdown the sensory component of balance
Somatosensory – skin receptors:
Motion of the body with respect to support surface.
Proprioceptive – muscle spindles + golgi tendon organs:
Motion of body segments relative to each otherSomatosensory + proprioceptive = 60-70% Visual – eyes (10-20%)
Motion of the body w/ resect to extra-personal space
Vestibular – inner ear (10-20%):
Detects accelerations of the head
What is the postural ankle strategy?
o In response to smaller, slower perturbations
o Shifts COG about the ankle joint w/ minimal contribution from knee or hip
o Distal to proximal muscle activation
o Used on surfaces w/ low resistance to shear forces
What is the postural hip strategy?
o In response to larger, faster perturbations
o Shifts COG about hip joint by flexion/extension
o Ability to generate larger torque, more rapid response
o Produces mostly shear forces
o Transmits horizontal shear force to surface, therefore not suitable for slippery surfaces
o Suitable on surface that have low resistance to torque (narrow bean)
What is the stepping strategy?
o In response to largest, fastest perturbation (or the inability to generate an ankle/hip strategy)
o Shifts COG about hip joint by flexion/extension
o Realigns BOS under the new position of the COG w/ rapid steps, hops or stumbles
o Used when ankle + hip strategies are inadequate
Describe balance in the elderly
o Progressive age-related changes in healthy elderly subjects
o The old were more dependent on proprioceptive input
o They were unable to visually compensate for the disruption if proprioceptive input
o Disruption of proprioceptive input is the most important determinant of quantitative balance performance in >80 years
o The old did not adapt as well to repeated platform perturbations compared with younger elderly
o Deficit in central integration of sensory input or in motor output response
Describe balance in fallers
o No significant difference in functional reach between non-fallers and fallers
o No significant differences were found between non-fallers and fallers for the anterior LOS test
o Significant difference found between non-fallers and fallers for the mean sensory organisation test
o Significant positive correlation for anterior displacement on LOS test and SOT composite score for fallers but not for non-fallers
Main function of fibrous layer of eyeball
To provide shape to eye + support deeper structures
How many layers is the eyeball divided into?
3 main layers:
- FIbrous
- Vascular
- Neural
Name the innermost layer of the eyeball.
Neural layer
Name the 2 main structures in the fibrous layer (they are continuous with each other).
Cornea (anteriorly)
Sclera (posteriorly) - makes up 85% of fibrous layer
Vascular layer consists of 3 main structures which are continuous with one another (anterior to posterior) name them.
Iris
Ciliary body
Choroid
What is the coloured bit of the eye that changes pupil size called?
Iris
Which structure makes up the majority of the fibrous layer?
Sclera
Which structure in the eyeball provides attachment to the extraocular muscles responsible for movement of eye?
Sclera (white part of eye)
Which structure provides 2/3rds of the focusing power of the eye?
Cornea (light entering eye is refracted by cornea)
Which 2 muscles alter pupil size?
Dilatory muscles sympathetic stimulation)
Anterior sphincter muscles
When to dilator muscles relax?
In bright light, pupils smaller
