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Anatomy Flashcards

1
Q

What are the components of the pectoral region?

A

The pectoral region is the front of the upper part of the trunk

It includes:
-Pectoralis major m.
-Pectoralis minor m.
-Subclavius m.
-Clavipectoral fascia

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2
Q

What are the components of the upper part of the trunk?

A

-Clavipectoral triangle
-Cephalic vein
-Deltoid m.
-Pectoralis major
-Clavicular head
-Sternocoastal part

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3
Q

What is the origin, insertion and nerve supply of the Pectoralis major muscle

A

Origin:
From the front of the trunk

Insertion:
Bicipital groove of humerus

Nerve supply:
Medial and lateral pectoral nerves

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4
Q

What are the actions of Pectoralis major muscle?

A

-Flexion of the shoulder
-Adduction of the shoulder
-Medial rotation
-Elevates the trunk during climbing

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5
Q

What is the importance of the Pectoralis major muscle?

A

-It is important in case of fixation of the humerus
-It acts as an accessory inspiratoria muscle
-It helps in climbing and swimming

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6
Q

What is the origin, insertion, nerve supply and actions of the Pectoralis minor muscle?

A

Origin:
Front of the trunk

Insertion:
Caracoid process of scapula (medial aspect)

Nerve supply:
Medial pectoral nerve

Actions:
-Protraction of the shoulder
-Depression of the shoulder

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7
Q

What is the nerve supply and action of the subclavius muscle?

A

Nerve supply:
Nerve to subclavius

Action:
Steadies the clavicle and fixes it to the first rib during movement of upper limb

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8
Q

What is the nerve supply, attachments and actions of the deltoid muscle?

A

Attachments:
From the lateral part of the clavicle and spine of the scapula (origin) to the deltoid tuberosity (insertion)

Nerve supply:
Axilary nerve (C5, C6)

Action:
-Anterior fibres: flexion and medial rotation of the humerus
-Middle fibres: abduction from 8-90 degrees
-posterior fibres: extension and lateral rotation of the humerus

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9
Q

Give the clinical correlation of the deltoid muscle

A

Injury of the axillary nerve leads to paralysis of the deltoid muscle which leads to flattening of the shoulder

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10
Q

What are the components of the superficial layer of the back muscles?

A

-Trapezius
-Latissimus dori

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11
Q

Describe the trapezius muscle (mention the attachments, insertion, nerve supply and actions)

A

Attachments:
Attached to the Cervical and upper thoracic spines

Insertion:
Lateral part of the clavicle, acrimon and spine of scapula

Nerve supply:
Spinal part of accessory nerve (CN XI)

Action:
The upper fibres elevate the shoulder
The lower fibres depress the scapula
The middle fibres retract the shoulder
It rotates the scapula so that the glenoid cavity faces upwards. This occurs when the arm is raised above the head

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12
Q

Describe the latissimus dorsi muscle (mention the attachments, insertion, nerve supply and actions)

A

Attachments:
Attached to the lower part of the back

Insertion:
Bicipital groove

Nerve supply:
Nerve to latissmus dorsi

Actions:
-Adducts, extends and medially rotates the arm
-Climbing, swimming (when the arms are fixed above the head)

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13
Q

What are the components of the deep layer of the back muscles?

A

-Levator scapulae
-Rhomboideus minor
-Rhomboideus major muscles

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14
Q

Deceive the Levator scapulae and rhomboid muscles (mention the attachments, insertion, nerve supply and actions)

A

Attachments:
They are attached from the middle of the upper part of the back to the medial border of the scapula

Nerve supply:
Dorsal scapulae nerve (nerve to Rhomboids)

Action:
-Levator scapulae elevates the scapula
-The rhomboids retract the scapula
-The rhomboids rotate the scapula so that the glenoid cavity faces downwards (depresses the shoulder)

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15
Q

Mention how paralysis of the trapezius muscle occurs

A

Cause:
The main cause of trapezius palsy is injury to the spinal accessory nerve. The superficial location of the spinal accessory nerve, in the posterior triangle makes it vulnerable to injury.

Paralysis of the trapezius muscle leads to a drop shoulder with rotation of the angle of the scapula towards the midline and restricted abduction of the arm

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16
Q
A
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17
Q
A
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18
Q

What are the scapular muscles?

A

-Supraspinatus
-Infraspinatus
-Subscapularis
-Teres minor
-Teres major

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19
Q

What is the origin and insertion (attachments) of the scapular muscles?

A

Origin:
-All scapular muscles are attached to the back of the scapula except subscapularis which is attached to the front of the scapula
-The supra and infraspinatous muscles are attached on both sides of the spine of the scapula
-Teres minor and major are attached to the lateral border below each other

Insertion:
-Supra, infraspinatous and Teres minor are inserted in the greater tuberosity of the humerus
-Subscapularis is inserted in the lesser tuberosity
-Teres major is inserted in the Bicipital groove.

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20
Q

What are the muscles attached to the Bicipital groove?

A

-Pectoralis major
-Teres major
-Latissimus dorsi

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21
Q

What is the nerve supply of the scapular muscles?

A

-Supra and infraspinatous muscles are supplied by the suprascapular nerve (C5,6)

-Teres minor by axillary nerve (C5,6)

-Teres major by the lower subscapular nerve (C5,6)

-Subscapularis by the upper and lower subscapular nerve (C5,6)

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22
Q

What is the action of the scapular muscles?

A

Supraspinatous: initiation of abduction

Infraspinatous: lateral rotation of the arm

Teres minor: lateral rotation of the arm

Teres major: medial rotation, adduction and extension of the arm

Subscapularis: medial rotation of the arm

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23
Q

What are the rotator cuff muscles?

A

Rotator cuff muscles surround the shoulder joint, they include:

-Subscapularis
-Supraspinatous
-Infraspinatous
-Teres minor

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24
Q

What is the nerve supply and action of the serratus anterior muscle?

A

It is attached from the upper ribs to the front of the medial border of the scapula

Nerve supply:
-Long thoracic nerve (nerve to serratus anterior) (C5,6,7)

Action:
-Protraction of the scapula
-Raising the arm above the head (it lowers fibres and the trapezius

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25
Q

What are the causes of winging of the scapula (clinical correlations)?

A

The long thoracic nerve descends over the serratus anterior and deep to the mammary gland, this explains why the nerve is liable to be injured during mastectomy.

It’s injury leads to projection of the medial border of the scapula (winging of the scapula)

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26
Q

How does abduction of the shoulder occur?

A

Initiation of abduction: (0-18 degrees) Supraspinatous

Completion up to middle fibres of deltoid (90 degrees)

Above 90 degrees: rotational movement of the scapula rather than abduction of the shoulder taken by the trapezius and serratus anterior

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27
Q

Identify the boundaries and contents of the intermuscular quadrangular space

A

Boundaries:
Teres major
Teres minor
Long head of the triceps brachii
Surgical neck of the humerus

Contents:
It transmits the axillary nerve and posterior circumflex humeral artery

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28
Q

What are the boundaries and contents of the medial triangular space?

A

Boundaries:
Teres minor
Teres major
Long head of the triceps

Contents:
It contains the circumflex scapular vessels

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29
Q

What are the boundaries and contents of the lateral triangular space?

A

Boundaries:
Teres major
Long head of the triceps
Humerus

Contents:
Radial nerve and profunda brachii artery

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30
Q

Describe the shoulder joint

A

Type:
Synovial, ball and socket

Articular surface:
Head of humerus
Glenoid cavity of scapula
-each of the articular surfaces is covered by hyaline cartilage
-the glenoid cavity is deepened by a fibro-cartilaginous rim; labrum glenoidale

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31
Q

What are the attachments of the capsule?

A

Medially it is attached to the circumference of glenoid cavity outside labrum glenoidale

Laterally the capsule is attached to the anatomical neck of the humerus

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32
Q

What structures does the synovial membrane line?

A

It lines all structures inside the capsule except for the articular cartilage

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33
Q

What are the ligaments related to the shoulder joint?

A

False ligaments:
-They are the thickening of the capsule of the shoulder joint (glenohumeral ligaments)

True ligaments:
-Coraco- humeral ligament
-Transverse humeral ligament (bridges over the bicepetal groove)

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34
Q

What are the factors that support the capsule?

A

1) Rotator cuff:
-Supraspinatous (superiorly)
-Infraspinatous and Teres minor (posteriorly)
-Subscapularis (anteriorly)

2) Tendon of the long head of the triceps and biceps

3)Ligaments:
-Coracohumeral ligament
-Glenohumeral ligament
-Transverse humeral ligament

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35
Q

What are the movements of the shoulder joint?

A

-Flexion (Pectoralis major, deltoid, coracobrachialis, long head of biceps)
-Extension (deltoid, latissimus dorsi, Teres major)
-Abduction( from 0 -15: Supraspinatous, 15-90: middle fibres of deltoid and 90-180: trapezius and serratus anterior)
-Adduction (muscles inserted into bicipital groove, muscles inserted into lesser and greater tuberosities)
-Medial rotation (anterior fibres of deltoid, muscles inserted into bicipital groove, subscapularis)
-lateral rotation (deltoid, infraspinatous and Teres minor)
-Circumduction

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36
Q

Describe how dislocation occurs

A

The most common site for dislocation of a joint is through the inferior aspect of the capsule which is the least supported part during raising of the arm above the head

The dislocation of the head of the humerus downwards into the quadrangular space may lead to injury of the axillary nerve and the posterior circumflex humeral artery.

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37
Q

Describe the fascia compartments of the arm

A

Medial and lateral borders of the humerus are attached to medial and lateral intermuscular septa which in turn are attached to the deep fascia of the arm, dividing it into anterior and posterior compartments.

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38
Q

What are the muscles of the anterior compartment?

A

-Coracobrachialis
-Biceps
-Brachialis

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39
Q

Identify the origin, insertion, nerve supply and the action of the coracobrachialis

A

Origin:
From the tip of the coracoid process of the scapula (with short head of biceps)

Insertion:
Into the middle of the medial side of the shaft of the humerus

Nerve supply:
Musculotaneous nerve

Action:
Flexion of the shoulder joint

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40
Q

Identify the origin and insertion of the biceps brachii

A

Origin:
Long head: from the supraglenoid tubercle of the scapula

Short head: from the tip of the coracoid process of the scapula

Insertion:
-into radial tuberosity of the radius
-forms the Bicipital aponeurosis which is inserted into the deep fascia of the upper part of the medial side of the forearm

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41
Q

Identify the nerve supply and action of the biceps brachii

A

Nerve supply:
From the musculotaneous nerve

Action:
-supination of the forearm at the radio-ulnar joints
-flexion of the forearm at the elbow joint
-weak flexion of the shoulder joint

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42
Q

Identify the origin, insertion, nerve supply and action of the brachialis muscle

A

Origin:
From the lower half of the anterior surface of the shaft of the humerus

Insertion:
Into the coronoif process of the ulna

Nerve supply:
-mainly from the musculotaneous nerve
-small part by the radial nerve

Action:
Flexion of the elbow joint

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43
Q

What are the veins of the arm?

A

Deep veins: venae comitantes which accompany the arteries and axillary vein

Superficial vein:
-cephalic vein:
Runs on the lateral side of the arm and ends by piercing the Clavipectoral fascia to join the axillary vein

-basilic vein:
Runs on the medial side of the arm till it’s middle then pierced the deep fascia to join the 2 venae comitantes of the brachial artery to form the axillary artery

-median cubital vein:
Connects them

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44
Q

Describe the beginning, end and course of the brachial artery

A

Beginning: at the lower border of Teres major as a continuation of the axillary artery (continuation of subclavian artery at border of the 1st rib)

End: in the cubical fossa at the level of the neck of the radius by dividing into its two terminal branches ; radial and ulnar arteries

Course: the upper part of the artery runs medial to the humerus, while the lower part becomes anterior to the bone

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45
Q

What are the beaches of the brachial artery?

A

-Profunda brachii artery: (The largest and most important)
It passes between the medial and long heads of the triceps to enter the lower triangular space (with the radial nerve). Then it passes in the spiral groove

-Muscular branches

-Nutrient artery: to the humerus

-Superior ulnar collateral artery

-Inferior ulnar collateral artery: which share in anastomosis around the elbow

-Terminal branches:
Radial artery
Ulnar artery

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46
Q

What is the origin and insertion of the triceps muscle?

A

Origin:
-Long head: from the infra glenoid tubercle of the scapula
-lateral head: above the spiral groove
-Medial head: lower half of the posterior surface of the humerus, below the spiral groove (is similar to brachialis but from behind)

Insertion:
The 3 heads unite and are inserted into the posterior part of the upper surface of the olecranon process of the ulna

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47
Q

What is the nerve supply and action of the triceps muscle?

A

Nerve supply:
Radial nerve

Action:
-Main extensor of the elbow
-Long head: supports the shoulder joint during adduction

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48
Q

What are the consequences of paralysis of the biceps and triceps muscles?

A

Biceps:
Biceps is the main supination of the forearm so paralysis of the biceps muscle leads to weak supination

Triceps:
Triceps is the main extensor of the elbow joint so it’s paralysis leads to loss of extension of the elbow

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49
Q

What is the site and boundaries of the cubital fossa?

A

Site: a triangular fascial space in front of the elbow joint

Boundaries:
-Medially: Pronator Teres muscle
-Laterally: Brachioradialis muscle
-Base: Imaginary line between the medial and lateral epicondyles of the humerus

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50
Q

What are the structures on the roof and floor of the cubital fossa and mention it’s contents?

A

Roof:
-Skin
-Superficial fascia (which contains medial, median cubital veins, medial and lateral cutaneous nerves of the forearm and the deep fascia and Bicipital aponeurosis)

Floor:
-Brachialis (medially)
-Supinator (laterally)

Contents (from medial to lateral);
-Median nerve
-End of brachial and beginning of the radial and ulnar arteries
-Biceps brachii tendon
-Radial nerve

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51
Q

How many layers does each forearm compartment have?

A

Flexor compartment: 3 layers
Superficial, middle and deep

Extensor compartment: 2 layers
Superficial and deep

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52
Q

What are the muscles of the superficial layer of the flexor compartment?

A

From the lateral to medial side:
-Pronator Teres
-Flexor carpi radialis
-Palmaris Longus
-Flexor carpi ulnaris

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53
Q

What is the origin and course of the muscles of the superficial layer?

A

Origin: common flexor origin
Front of medial epicondyle of the humerus

Course: the muscles pass deep to the flexor retinaculum except the pronator Teres (ends at the middle of the forearm) and the palmaris Longus

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54
Q
A
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55
Q

What are the bones and joints of the hand?

A

Bones:
-Carpal bones: 8 bones arranged in 2 rows
-Metacarpal bones: 5 bones; one for each finger
-Phalanges: proximal, middle and distal except the thumb that has proximal and distal only

Joints:
-Carpometacarpal
-Metacarpophalangeal
-Proximal and distal interphalangeal

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56
Q

Describe the course of the palmaris Longus muscle

A

Palmaris Longus muscle passes superficial to the flexor retinaculum to be inserted into the palmar aponeurosis. It may be absent

Palmar aponeurosis is a thick triangular fibrous sheet on the palm of the hand deep to the skin for protection of the palm

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57
Q

Identify the muscles of the deep layer

A

It is composed of 3 muscles:
-Flexor pollicis longus (lateral)
-Flexor digitorum profundus (medial)
-Pronator quadratus (deep)

The muscles pass deep to the flexor retinaculum except the Pronator quadratus

They originate from the anterior surfaces of the radius and ulna

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58
Q
A
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59
Q

What is the origin, insertion, nerve supply and action of the middle layer?

A

It is made up of only one muscle:
Flexor digitorum superficialis muscle

Origin:
Common flexor origin
It passes deep to the flexor retinaculum

Insertion:
Middle phalanx of the medial 4 fingers

Nerve supply:
Median nerve

Action:
-Flexion of elbow joint
-Flexion of wrist joint
-Flexion of the metacarpophalangeal and proximal interphalangeal joints of the medial 4 fingers

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60
Q

Describe the flexor digitorum muscles

A

The tendon of the flexor digitorum superficialis is inserted into the middle phalanx and splits to allow the tendon of flexor digitorum profundus to pass to be inserted into the distal phalanx

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61
Q

What are the attachments and the structures passing superficial to the flexor retinaculum muscle?

A

It is a fibrous sheet in front of the wrist joint

Attachments:
-Medially to the pisiform and hamate bones
-Laterally to the scaphoid and trapezium bones

Structures passing superficial to it:
-Tendon of palmaris Longus
-Ulnar artery
-Ulnar nerve
-Superficial palmar branch of radial artery

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62
Q

What is the carpal tunnel?

A

-It is a tunnel connecting the forearm and the hand
-It is bounded by the flexor retinaculum anteriorly and the carpal bones posteriorly
-The tendon of palmaris Longus passes surperficial to the flexor retinaculum

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63
Q

What are the structures that pass through the carpal tunnel?

A

-Median nerve
-Long flexor tendons to the fingers: flexor digitorum superficialis and profundus and the flexor pollicis Longus
-Flexor carpi radialis (in a separate compartment)

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64
Q

What happens when the median nerve in the carpal tunnel is compressed?

A

-Pin and needle sensation in the skin supplied by it
-Wasting of the hand muscles supplied by it

It may be compressed due to:
-Arthritic changes of the bones
-Swelling of the tendons

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65
Q

Describe the elbow joint

A

Type: synovial joint (hinge)

Articulate bones:
-Trochlea and capitulum of the humerus
-Trochlear notch of the ulna
-Head of the radius

Movements:
-Flexion : Biceps brachii, Brachialis and all superficial and deep layers of the flexor muscles of the forearm

-Extension: triceps brachii and anconeus

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66
Q

What are the ligaments of the elbow joint?

A

-Ulnar (medial) collateral ligament:
It is triangular in shape with 3 bands (anterior, posterior and transverse bands)

-Radial (lateral) collateral ligament:
It extends from the lateral epicondyle of the humerus to the annular ligament ( surrounds the head of the radius)

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67
Q

What are the clinical notes of the elbow joint?

A

In normal extended elbow joint:
Medial and lateral epicondyles and top of olecranon process are in one straight line

With flexion: they form a triangle

Tennis elbow: overuse and micro tears of the common extensor tendon and muscles of the forearm cause pain in the lateral side of the elbow

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68
Q

What are the radial and ulnar arteries?

A

They are the terminal branches of the brachial artery in the cubital fossa opposite the neck of the radius

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69
Q

Describe the radial artery

A

It runs in the lateral side of the forearm with the radial nerve on its lateral side deep to the brachioradialis muscle

It winds round the lateral side of the wrist to the dor sun of the hand where it pierced muscles to enter the palm.

Branches:
-Muscular artery
-Articular artery to the elbow joint
-Anterior carpal branch
-Dorsal carpal branch
-Superficial palmar branch that passes superficial to the flexor retinaculum

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70
Q

Where can you feel pulsations of the radial artery

A

In the lower part of the front of the forearm against the lower part of the radius

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71
Q

Describe the ulnar artery

A

It runs in the medial side of the forearm with the ulnar nerve on its medial side deep to the flexor carpi ulnaris muscle

It passes superficial to the flexor retinaculum to enter the palm of the hand where it gives superficial and deep branches

Branches:
-Muscular artery
-Articular to the elbow and wrist joints
-Anterior carpal branch
-Dorsal carpal branch
-Terminal branches (superficial and deep)

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72
Q

Describe the anastomosis around the elbow joint

A

Branches of the brachial and profunda brachii arteries anastomose with branches of the radial and ulnar arteries around the elbow joint

Importance: if the lower part of the brachial artery is occluded, blood will reach the forearm through this anastomosis

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73
Q

Identify the muscles of the superficial layer of the extensor muscles

A

The muscles arranged from the lateral side medially:
-Brachioradialis
-Extensor carpi radialis longus
-Extensor carpi radialis brevis
-Extensor carpi digitorum
-Extensor digiti minimi
-Extensor carpi ulnaris
-Anconeus (small muscle on the back of the elbow)

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74
Q

What is the origin of the brachioradialis and extensor carpi radialis Longus?

A

The 2 most lateral muscles brachioradialis and extensor carpi radialis longus originate from the lateral supracondylar ridge (flex elbow joint)

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75
Q

What is the origin of the muscles of the superficial layer of the extensor muscle?

A

All muscles (except for Brachioradialis and extensor carpi radialis longus and the anconeus) originate from the common extensor origin (front of the epicondyle)

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76
Q

What is the origin of the anconeus muscle?

A

The anconeus arises from the back of the lateral epicondyle

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77
Q
A
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78
Q

What are the muscles of the deep layer of the extensor muscles?

A

-Abductor pollicis Longus
-Extensor pollicis brevis
-Extensor pollicis Longus
-Extensor indicis
-Supinator

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79
Q

What is the origin of the muscles of the deep layer of the extensor muscles?

A

They all originate from the back of the radius and ulna (no action on the elbow joint)

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80
Q
A
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81
Q
A
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82
Q

What are the attachments of the extensor retinaculum?

A

It is a fibrous sheet extending on the back of the wrist. It helps to keep the extensor tendons and prevents them from bowing

Attachments:
-Laterally: anterior border of radius
-Medially: triquetrum and pisiform

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83
Q

What are the structures deep to the extensor reticulum?

A

The space deep to it is divided into 6 compartments:

Compartment 1:
-Extensor pollicis brevis
-Abductor pollicis Longus

Compartment 2:
-Extensor carpi radialis brevis
-Extensor carpi radialis longus

Compartment 3:
-Extensor pollicis longus

Compartment 4:
-Extensor digitorum
-Extensor indicis

Compartment 5:
-Extensor digiti minimi

Compartment 6:
-Extensor carpi ulnaris

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84
Q

Describe the superior radioulnar joint

A

Type: synovial pivot

Articulate bones:
-Head of radius
-Radial notch of ulna
-Annular ligament (attached to the radial notch of ulna and surrounds the head of the radius)

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85
Q

Describe the movements of the superior radioulnar joint

A

Supination:
-biceps brachii
-Supinator

Pronation:
-Pronator Teres
-Pronator quadratus

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86
Q

What is the mobile bone during supination and pronation?

A

The radius

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87
Q

How does the superior radioulnar joint gain its stability?

A

The stability of the superior radioulnar joint depends upon the strength of the annular ligament

Rupture of the ligament leads to dislocation of the joint

Infection of the elbow joint may spread to the superior radioulnar joint as they are continuous

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88
Q

Describe the inferior radioulnar joint

A

Type: Synovial pivot

Articulate bones:
-Head of ulna
-ulnar notch of radius
-Articular disc that lies on the lower surface of the ulnar head

Movements: supination and pronation

The inferior radioulnar joint is not continuous with the wrist notch

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89
Q

What are the carpal bones of the hand?

A

There are 8 carpal bones arranged in 2 rows:
The proximal row:
-Scaphoid
-Lunate
-Teiquetrum
-Pisiform

The distal row:
-Trapezium
-Trapezoid
-Capitate
-Hamate

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90
Q

What are the muscles of the hand?

A

-Thenar muscles
-Hypothenar muscles
-Adductor pollicis
-Lumbrical muscles
-Palmar interosseous muscles
-Dorsal interosseous muscles

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91
Q

Describe the thenar muscles of the hand

A

They form the thenar eminence on the lateral side of the hand
-Abductor pollicis brevis
-Flexor pollicis brevis
-Opponens pollicis(deep to 1,2)

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92
Q

Describe the adductor pollicis muscle of the hand

A

It does not belong to the thenar muscles

Action: adduction of the thumb

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93
Q

Describe the hypothenar muscles of the hand

A

They form the hypothenar eminence on the medial side of the hand

-Abductor digiti minimi
-Flexor digiti minimi
-Opponens digiti minimi (deep to 1,2)

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94
Q

Describe the lumbrical muscles of the hand

A

They are the 4 muscles of the medial 4 fingers

Origin: tendons of flexor digitorum profundus

Action: put the hand in the writing position (flexion of the metacarpal-phalangeal joints and extension of the interphalangeal joints)

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95
Q

Describe the palmar interosseous muscles

A

They are 3 muscles of the index, ring and little fingers

They adduct (PAD) the fingers towards the middle finger and puts the hand in the writing position

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96
Q

Describe the dorsal interosseous muscles of the hand

A

They are the 4 muscles of the middle 3 fingers
The middle finger has 2 muscles
They abduct (DAB) the fingers away from the middle finger and put the hand in the writing position

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97
Q

What is the nerve supply of the muscles of the hand?

A

All the small muscles of the hand are supplied by the deep branch of the ulnar nerve except the thenar muscles (abductor pollicis brevis, flexor pollicis brevis and Opponens pollicis) and the first and second lumbrical muscles which are supplied by the median nerve

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98
Q

Describe the fascial spaces of the palm of the hand

A

The thenar and hypothenar muscles lie in seperate compartments

There are 2 fascial spaces in the palm which lie posterior to the flexor tendons and anterior to the metacarpal bones and interosseous muscles

A lateral space called: thenar space

A medial space called: midpalmar space

The spaces of the palm are filled with loose connective tissue and they are separated by fibrous septa. Thus spread of infection is limited

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99
Q

Describe the superficial palmar arch

A

Site: in the palm of the hand superficial to the flexor tendons

It is formed by:
-Superficial palmar branch of radial artery
-Superficial branch of ulnar artery

it lies distal to the deep palmar arch and it gives branches to the medial 3 and 1/2 fingers

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100
Q

Describe the deep palmar arch

A

Site: in the palm of the hand deep to the flexor tendons

It is formed by:
-Radial artery
-Deep palmar branch of ulnar artery

It lies proximal to the superficial palmar arch

It gives branches to the superficial palmar arch

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101
Q

What is the arterial supply of the fingers?

A

Each finger has 2 palmar digital arteries

The superficial palmar arch supplies the medial 3 and 1/2 fingers

The radial artery supplies the lateral 1 and 1/2 fingers

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102
Q

Describe the anterior carpal arch

A

It lies on the anterior aspect of the carpal bones

It is formed by the anterior carpal branches of the radial and ulnar arteries

It supplies the carpal bones

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103
Q

Describe the dorsal carpal arch

A

It lies on the dorsal aspect of the carpal bones

It is formed by the dorsal carpal branches of the radial and ulnar arteries

It supplies the 2 digital arteries for the dorsal aspect of each finger

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104
Q

Describe the wrist joint

A

Type: synovial ellipsoid

Articular bones:
-Distal end of the radius
-Articular disc that lies on the lower surface of the ulnar head
-Proximal row of the carpal bones

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105
Q

What are the ligaments of the wrist joint?

A

-Ulnar collateral ligament
-Radial collateral ligament
-Palmar radiocarpal ligament
-Dorsal radiocarpal ligament

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106
Q

What are the movements of the wrist joint?

A

-Flexion: flexor muscles of the forearm except Pronator Teres and Pronator quadratus

-Extension: extensor muscles of the forearm except Brachioradialis, anconeus and Supinator

-Abduction: flexor carpi radialis and extensor carpi radialis longus and brevis

-Adduction: flexor and extensor carpi ulnaris

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107
Q

What are the clinical notes of the wrist joint?

A

Wrist sprain: tear of the wrist ligaments that may result from falling in the ground and excessive extension of the wrist

Abduction of the wrist joint is limited than adduction as the styloid process of the radius reaches a lower level than that of the ulna

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108
Q

What are the manifestations of musculotaneous nerve injury?

A

-Weakness of supination (biceps) and flexion (biceps brachialis) of forearm

-loss of sensation on the lateral side of forearm

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109
Q

What are the causes of axillary nerve injury?

A

-Fracture of the surgical neck of the humerus
-Inferior dislocation of the humerus

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110
Q

What are the manifestations of axillary nerve injury?

A

-Weakness of lateral rotation abduction of the arm (the Supraspinatous can abduct the arm but not to a horizontal level)

-Wasting of the deltoid muscle (flat shoulder)

-Loss of sensation over the lower half of the deltoid

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111
Q

What are the causes of median nerve injury?

A

-Above the elbow: supracondylar fracture

-Above the wrist: cut wound

-Carpal tunnel syndrome: due to arthritis or synovitis

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112
Q

What are the manifestations of median nerve compression and carpal tunnel syndrome?

A

-Occupational repetitive movements related to wrist flexion and extension
-Holding the wrist in awkward positions
-Strong gripping of objects

Long term compression:
-Thenar atrophy
-Weakness of the thumb and index fingers

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113
Q

What is the motor and sensory effect of carpal tunnel syndrome (median nerve injury)?

A

Motor effect:
-Absence of abduction and absence of opposition of the thumb
-Long term compression: flattening of the thenar eminence (ape hand)

Sensory effect:
-Lateral 3.5 fingers (parasthesia or anesthesia): sensation on the lateral part of the palm is normal because the palmar cutaneous branch arises in the forearm, so escaping compression in the carpal tunnel

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114
Q

What is the motor effect of median nerve injury above the elbow?

A

Like the manifestations of carpal tunnel syndrome, plus:
-Adduction of the wrist (paralysis of flexor carpi radialis and unopposed action of flexor carpi ulnaris)
-Paresthesia on the lateral part of the palm
-Loss of pronation
-Loss of flexion of interphalangeal joints of 2,3 digits (pointing index)
-Flexion of the distal interphalangeal joints of the 4th and 5th fingers is not affected because the medial part of the FDP, which produces these movements, is supplied by the ulnar nerve. Thus, when the person attempts to make a fist, the 2nd and 3rd fingers remain partially extended

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115
Q

What are the tests that can be done for median nerve function in the hand?

A

Tinel sign
Phalen manoeuvre

-A positive tinel sign refers to distally radiating pain and/or paresthesia elicited by percussing a superficial peripheral nerve, in this case the median

-The phalen manoeuvre is performed by appoint the wrists in 90 degrees of flexion. Parasthesia in the hand within 69 seconds is considered a positive test

116
Q

What are the causes of ulnar nerve injury?

A

-Above the elbow: fracture medial epicondyle
-Above the wrist: cut wounds

117
Q

What are the motor and sensory effects of injury to the ulnar nerve above the wrist?

A

Motor effects(deformity):
-Partial claw hand: due to paralysis of the palmar and dorsal interosseous muscles and the medial two lumbricals; the ring and little fingers are hyperextended at the metacarpophalangeal joints and flexed at the interphalangeal joints

-Loss of adduction and abduction of the fingers
-Loss of adduction of the thumb
-Flattening of the hypothenar eminence

Sensory effects:
Loss of sensation over medial 1/3 of the palm and medial 1.5 fingers

118
Q

What are the motor and sensory effects of injury above the elbow to the ulnar nerve?

A

Motor effects:
-Same as in injury above the wrist except for:
Less apparent clawing (ulnar paradox)
Abduction of the hand

Sensory effects:
Loss of sensation over medial 1/3 of the hand and medial 1 and 1/2 fingers in both surfaces

119
Q

What is the ulnar paradox?

A

Clawing of the hand, particularly of the little and ring fingers, is worse with lesions of the ulnar nerve at the wrist than at the elbow because interruption of the nerve at the elbow paralysed the ulnar half of the flexor digitorum profundus, which leads to lack of flexion at the distal interphalangeal joints in these fingers

120
Q

What is the test used for abduction and adduction of the fingers

A

Paper test

121
Q

What are the causes of radial nerve injury?

A

Radial nerve injury:
-In the axillary, pressure from crutch or back of a a chair
-In the spiral groove, fracture of shaft of the humerus

Posterior interosseous nerve injury:
-Fracture of the head, neck it the upper shaft of the radius

Superficial radial nerve injury:
-Cut wounds

122
Q

What are the motor and sensory effects of radial nerve injury?

A

Motor effects:
-Inability to extend the elbow
-Inability to extend the wrist (wrist drop)
-Inability to extend the fingers (fingers drop)

Sensory effects:
Parasthesia over:
-Lower lateral surface of the arm
-Posterior surface of the arm and forearm
-Lateral 2/3 of the dorsum of the hand and posterior surface of the proximal phalanges of the lateral 3 and 1/2 fingers and on the dorsum of the hand between the 1st and 2nd metacarpal

123
Q

What are the motor effects of posterior interosseous nerve injury?

A

-Inability to extend fingers (fingers drop)
-No wrist drop (intact extensor carpi radialis longus)

-No sensory effects

124
Q

What are the sensory and motor effects of superficial radial nerve injury?

A

No motor effects

Sensory effects:
Parasthesia over the lateral 2/3 of the dorsum of the hand and posterior surface of the proximal phalanges of the lateral 3 and 1/2 fingers and on the dorsum of the hand between the 1st and 2nd metacarpal

125
Q

What are the causes of brachial plexus - upper trunk (C5,6) injury?

A

-Increased angle between the head and the shoulder
-Difficult delivery (shoulder dystocia)

126
Q

What are the motor and sensory effects of upper trunk (C5,6) injury?

A

Effects: Erbs Duchenne palsy

Motor effects: (waiters tip position)
-The shoulder is addicted and medially rotated (arm hangs by the side)
-the elbow is extended
-the forearm is pronated

Sensory effects:
Loss of sensation on the lateral side of the upper limb

127
Q

Describe Erbs Duchenne palsy

A

-Paralysis of the muscles of the shoulder and arm supplied by the C5 and C6 spinal nerves (deltoid, biceps and brachialis)
-The usual appearance is an upper limb with an addicted shoulder, medially rotated arm and extended elbow

128
Q

What are the causes of Brachial plexus- lower trunk (C8,T1) injury (klumpke palsy)?

A

-Excessive abduction of the arm
-Cervical rib

129
Q

What are the motor and sensory effects of Brachial plexus- lower trunk (C8,T1) injury (klumpke palsy)?

A

Motor effects:
-Opposite if writing position: hyper extension of metacarpophalangeal joints and flexion of the interphalangeal joints (complete claw hand = klumpkes palsy)
-Loss of abduction and adduction of the fingers

Sensory effects:
Loss of sensation on the medial side of the upper limb

130
Q

Describe the deep fascia of the thigh (fascia lata)

A

-it encloses the thigh. It’s upper end is attached to the pelvis
-It’s lateral aspect is thickened to form the iliotibial tract

131
Q

What is the saphoneus opening?

A

It is an opening in the deep fascia of the thigh 1 and a half inches (4cm) below and lateral to the pubic tubercle.
It’s upper, lateral and lower margins are sharp (the falciform margin). It is closed by the cribriform fascia which is perforated by the great saphoneus vein, superficial in Guinean arteries and lymph vessels

132
Q

How do varicose veins occur?

A

Frequently, the great saohoneus vein and it’s tributaries become varicose (dilated so that the cusps of their valves do not close)

133
Q

What are the muscles and nerve supply of the anterior (extensor) compartment of the thigh?

A

Muscles:
-Pectineus
-Iliopsoas
-Sartorius
-Quadriceps femoris

Nerve supply:
Femoral nerve

134
Q

What is the origin, insertion, nerve supply and action of the pectineus muscle?

A

Origin: pubic bone

Insertion: upper end of femur

Nerve supply: femoral nerve; sometimes also by obturator nerve

Action: adduction and flexion of the hip; medial rotation of the thigh

135
Q

What is the origin, insertion, nerve supply and action of the psoas major (iliopsoas) muscle?

A

Origin: sides of lumbar vertebrae

Insertion: lesser trochanter of femur

Nerve supply: L1-3

Action: flexion of the hip

136
Q

What is the origin, insertion, nerve supply and action of the iliacus (iliopsoas) muscle?

A

Origin: iliac crest and iliac fossa

Insertion: lesser trochanter of femur

Nerve supply: femoral nerve

Action: flexion of the hip

137
Q

What is the origin, insertion, nerve supply and action of the sartorius muscle?

A

Origin: anterior superior iliac spine

Insertion: superior part of medial surface of tibia

Nerve supply: femoral nerve

Action: flexion and Lateran rotation of thigh and flexion and medial rotation of the knee

138
Q

What is the origin, insertion, nerve supply and action of the quadriceps femoris muscle?

A
139
Q

Describe the manifestations of quadriceps femoris paralysis

A

A person with paralysed quadriceps muscles cannot extend the leg against resistance and usually presses on the distal end of the thigh during walking to prevent inadvertent flexion of the knee joint

140
Q

Where is the femoral triangle located?

A

It is a triangular area I. The anterior aspect of the thigh just below the inguinal ligament

141
Q

What are the boundaries of the femoral triangle?

A

-Superiorly (base): Inguinal ligament
-Laterally: medial border of sartorius
-Medially: medial border of adductor Longus muscle
-Floor: formed of iliopsoas, pectineus and adductor Longus (from lateral to medial)
-Roof: skin and fascia of the thigh

142
Q

What are the contents of the femoral triangle?

A

-Femoral nerve and it’s branches
-Femoral sheath
-Femoral artery and it’s branches
-Femoral vein and it’s tributaries
-Femoral branch of the genitofemoral nerve
-Deep inguinal lymph nodes
-Lateral cutaneous nerve of the thigh

143
Q

Describe what is the femoral sheath

A

It is a downward protrusion into the thigh of the fascial envelope lining the abdominal walls

Anteriorly: it is formed by fascia transversalis

Posteriorly: it is formed by fascia iliaca

It has 3 compartments:
-Lateral compartment: contains the femoral artery and femoral branch of the genitofemoral nerve
-Intermediate compartment: contains the femoral vein
-Medial compartment (femoral canal): contains the lymph node (node of Cloquet). The upper opening of the femoral canal is the femoral ring

144
Q

What are the boundaries of the femoral ring?

A

-Inguinal ligament (anteriorly)
-Superior pubic ramus (posteriorly)
-Lacunar ligament (medially)
-Femoral vein (laterally)

145
Q

What is a femoral hernia?

A

The femoral ring is a site of potential herniation. A femoral hernia is a protrusion of abdominal viscera through the femoral ring into the femoral canal. A femoral hernia may become stangulated due to the sharp edge of the lacunae ligament

146
Q

Describe the femoral artery

A

It is the continuation of the external iliac artery at the mid-inguinal point. The artery descends across the femoral triangle to its apex, where it continues in the subsartorial (adductor canal). It terminates at the end of the adductor canal by passing through the adductor hiatus to continue as the popliteal artery

147
Q

What is the surface anatomy of the femoral artery?

A

It corresponds to the upper two-thirds of a line extending from the mid-inguinal point to the adductor tubercle when the thigh is flexed, abducted and laterally rotated.

148
Q

What are the branches of the femoral artery?

A

-Superficial inguinal arteries
-Deep external pudendal artery: supplies the external genitalia
-Profunda femoris artery(the largest branch) gives:
Lateral circumflex femoral artery
Medial circumflex femoral artery
Perforating arteries
-Descending genicular artery: it anastomoses with the genicular branches of the popliteal artery

149
Q

What is a large femoral arteriography’s fistula and how does it occur?

A

The superficial position of the femoral artery in the femoral triangle makes it vulnerable to traumatic injury, especially laceration.
Commonly both the femoral artery and vein are lacerated in anterior thigh wounds because they lie close together. In some cases, an arteriovenous shunt occurs as a result of communication between the injured vessels

150
Q

What is an adductor canal block?

A

It is a technique for providing analgesia of the knee region without compromising ambulation and disposition

For this block, relatively high volumes of dilute local anesthetic are injected deep to the sartorius muscle in the thigh

151
Q

What are the muscles of the medial compartment of the thigh

A

-Gracilis
-Pectineus
-Adductor Longus
-Adductor brevis
-Adductor magnus
-Obturator externus

152
Q

What is the origin, insertion, nerve supply and action of the muscles of the medial compartment?

A
153
Q

What are the 2 parts of the adductor Magnus muscle of the medial compartment of the thigh?

A

-Pubic part arising from the pubic bone
-Ischial part (hamstring part) arising from the ischium

154
Q

What is the clinical significance of the gracilis muscle of the medial compartment of the thigh?

A

The gracilis is a relatively weak member of the adductor group of muscles, and thus surgeons often transplant this muscle or part of it, with nerve and blood vessels, to replace a damaged muscle in the hand

155
Q

What is the clinical significance of the adductor Longus muscle of the medial compartment of the thigh?

A

Muscle strains of the adductor Longus may occur in horseback riders and produce pain because the riders adduct their thighs to keep from falling from the animal

156
Q

Describe the adductor canal

A

Begins at the apex of the femoral triangle and ends at the adductor hiatus

Adductor hiatus: is the aperatire in the tendon of insertion of the adductor Magnus; it allows the passage of the femoral vessels into the popliteal fossa

Boundaries:
-Anteriorly and laterally: Vastus medialis
-Posteriorly: Adductors longus and magnus
-Medially: Sartorius, which overlies the groove between the above muscles forming the roof of the canal

Contents:
-Femoral vessels
-Saphenous nerve
-Nerve to the vastus medialis
-Descending genicular artery

Clinical relevance:
In addition to functioning as

157
Q

What is the clinical relevance of the adductor canal?

A

Clinical relevance:
In addition to functioning as a key anatomical landmark, the adductor canal is clinically relevant. It can be a site if disease or suffer damage by trauma. It is also an increasingly- common site for the administration of regional anesthetic (nerve block) for knee, ankle and foot surgeries

158
Q

Describe the gluteal region

A

The gluteal region or buttock is bounded superiorly by the iliac crest and inferiority by the fold of the buttock. The region is largely made up of gluteal muscles and a thick layer of superficial fascia

Muscles in the region mainly abduct, extend and laterally rotate the femur relative to the pelvic bone

159
Q

What is the origin, insertion, nerve supply and the action of the gluteus maximus muscle of the posterior compartment of the thigh?

A

Origin: ilium
Insertion: most fibres end in the iliotibial tract; deep fibres insert into the gluteal tuberosity of the femur
Nerve supply: inferior gluteal nerve
Action: extension and lateral rotation of the hip

160
Q

What is the origin, insertion, nerve supply and the action of the gluteus medius and minimus muscles of the posterior compartment of the thigh?

A

Origin: ilium
Insertion: greater trochanter of femur
Nerve supply: superior gluteal nerve
Action: abducts the thigh and steadies the pelvis on leg when opposite leg is raised

161
Q

What is the origin, insertion, nerve supply and the action of the tensor fasciae lata muscle of the posterior compartment of the thigh?

A

Origin: iliac crest
Insertion: iliotibial tract that attaches to the lateral condyle of the tibia
Nerve supply: superior gluteal nerve
Action: stabilises the knee in extension

162
Q

What is the origin, insertion, nerve supply and the action of the small lateral rotators of the thigh?

A
163
Q

What are the manifestations of superior and inferior gluteal nerve injury?

A

Superior gluteal nerve:Trendelenburg gait

Inferior gluteal nerve injury: impairment of hip extension and lateral rotation
Difficulty in raising the body from sitting position

164
Q

Describe the greater sciatic foramen

A

Greater sciatic foramen: provides an exit from the pelvis into the gluteal region
Contents:
-Priformis
-Sciatic nerve
-Posterior cutaneous nerve of the thigh
-Superior and inferior gluteal nerves and vessels
-Nerve to obturator internus and quadratus femoris
-Pudendal nerve and vessels

165
Q

Describe the lesser sciatic foramen

A

Provides an entrance into the perineum from the gluteal region

Contents:
-Tendon of obturator internus muscle
-Nerve to obturator internus
-Internal pudendal vessels
-Pudendal nerve

166
Q

What are the clinical problems related to the back of the thigh?

A

-Hamstring injury
-Hamstring strain: (pulled and/or torn hamstrings) are common in individuals who run or kick hard (sports). The violent muscular exertion required fi excel in these sports may avulse (tear) part of the proximal tendinous attachments of the hamstrings to the ischial tuberosity

167
Q

What are the hamstring muscles?

A

Semiteninosus
Semimembranous
Biceps femoris

168
Q

What is the origin, insertion, nerve supply and the action of the semitendinous muscle of the back of the thigh?

A

Origin: ischial tuberosity
Insertion: medial surface of the superior part of the tibia
Nerve supply: tibial part of the sciatic nerve
Action: extends the hip; flexes the leg and rotates it medially

169
Q

What is the origin, insertion, nerve supply and the action of the semimembranosus muscle of the back of the thigh?

A

Origin: ischial tuberosity
Insertion: medial condyle of the tibia
Nerve supply: tibial part of the sciatic nerve
Action: extends the hip; flexes the leg and rotates it medially

170
Q

What is the origin, insertion, nerve supply and the action of the biceps femoris muscle of the back of the thigh?

A

Origin:
-Long head: ischial tuberosity
-Short head: linea aspera
Insertion: head of tibula
Nerve supply:
-Long head: tibial part of the sciatic nerve
-Short head: common peroneal part of the sciatic nerve
Action: flexes leg and rotates it laterally; it extends the thigh

171
Q
A
172
Q

What type of joint is the hip joint?

A

Synovial, ball and socket

173
Q

What are the articular surfaces of the hip joint?

A

Head of femur
Acetabulum

174
Q

What are the components of the acetabulum?

A

Lunate surface
Acetabular fossa
Acetabular notch- transverse ligament of the acetabulum - Acetabular foramen
Labrum acetabulare

175
Q
A
176
Q
A
177
Q

Describe the capsule to the hip and to the femur

A

To the hip: margins of the acetabulum and the transverse Acetabular ligament

To the femur:
Anteriorly: bases of the greater and lesser trochanters and to the intertrochantric line
Posteriorly: attached to the neck of the femur about one and a half cm medial to the interochantric crest

178
Q

Describe the synovial membrane

A

It lines the capsule and covers the structures inside the hip joint except the articular surfaces

The round ligament of the head of femur is invested with a tube of synovial membrane

179
Q

What are the ligaments of the hip joint?

A

Intracapsular: round ligament
Runs from the acetabular fossa to the fovea of the head of the femur
It enclosed a branch of the obituary or artery, which carries blood supply to the head of the femur

Extracapsular:
There are 3 extracapsular ligaments
They are continuous with the outer surface of the hip joint capsule
-Iliofemoral ligament
-Pubofemoral ligament
-Ischiofemoral ligament

180
Q

Describe the iliofemoral ligament

A

Y- shaped, attached between anterior superior iliac spine and both ends of the intertrochantric line

If prevents hyperextension

181
Q

Describe the pubofemoral ligament

A

Triangular in shape, attached between iliopubic eminence and the capsule

It prevents hyper abduction

182
Q

Describe the isciofemoral ligament

A

From the ischium to the back of the capsule
Weak ligament

183
Q

What are the muscles responsible for flexion and extension?

A

Flexion: Psoas major, iliacus, rectus femoris, sartorius and pectineus

Extension: Gluteus maximus and hamstring

184
Q

What are the muscles responsible for adduction and abduction?

A

Abduction: Gluteus medius, minimus and tensor fascia latae

Adduction: Adductor Longus, brevis, Magnus, gracilis and pectineus

185
Q

What are the muscles responsible for medial and lateral rotation?

A

Medial rotation: gluteus medius and minimus and tensor fascia latae

Lateral rotation: the 6 lateral rotators: obturator internus, 2 gemelli, priformis, obturator extension, quadratus femoris, gluteus maximus and adductors

186
Q

What is the blood supply of the hip joint?

A

-Medial and lateral circumflex arteries (from profunda femoris artery)
-Artery to head of femur (from obturator artery)(passes through round ligament)

187
Q

What does damage to the medial circumflex femoral artery cause?

A

It can result in avascular necrosis of the femoral head

188
Q

What are the factors responsible for stability of the hip joint?

A

-The head of femur fits accurately to the acetabulum and labrum acetabulare
-The three strong ligaments outside the capsule
-the surrounding strong ligaments

189
Q

What are the structures damaged in posterior dislocations?

A

-The affected limb becomes shortened and medially rotated
-The sciatic nerve runs posteriorly to the hip joint, and can be damaged in such an injury

190
Q

Describe what occurs in congenital dislocation

A

-More common in the hip than any other joint of the body
-The head of the femur slips upwards onto the gluteal surface of the ilium because the upper margin of acetabulum is developmentally deficient

191
Q

Describe what happens during femoral neck fracture

A

Fracture neck of femur is a common type of fracture in old age
It can lead to avascular necrosis of head of femur

192
Q

Describe the popliteal fossa

A

It is a diamond shaped intermuscular space present on the back of the knee

193
Q

What are the boundaries of the popliteal fossa?

A

Lateral superior: the biceps femoris
Lateral inferior: gastrocnemius (lateral head) and plantaris muscle
Medial superior: semimembranosus and semitendinosus muscles
Medial inferior: medial head of gastrocnemius muscle inferiorly

Roof: superficial fascia and deep fascia of thigh, posterior cutaneous nerve of the thigh, small saphenous vein and sural nerve
Floor: popliteal surface of the femur, back of knee joint and popliteus muscle

194
Q

What are the contents of the popliteal fossa?

A

Popliteal vessels
Tibial (medial popliteal) nerve
Common perineal (lateral popliteal) nerve
Genicular branch of obturator nerve
Popliteal lymph node
Popliteal fat

195
Q

What is the beginning (origin) of the popliteal artery?

A

It is the continuation of the femoral artery at the adductor hiatus

196
Q

What is the course of the popliteal artery?

A

It is the deepest structure in the popliteal fossa
It descends on the popliteal surface of the femur, back of the knee joint and popliteus muscle
At the lower border of popliteus muscle the artery terminates by dividing into anterior and posterior tibial arteries

197
Q

What are the branches of the popliteal artery?

A

Muscular branches
Cutaneous branch
Articular branches:
-Superior lateral genicular artery
-Superior medial genicular artery
-Middle genicular artery
-Inferior lateral genicular artery
-Inferior medial genicular artery

198
Q

What is the beginning of the popliteal vein?

A

It begins by the union of the vena comitantes of the anterior and posterior tibial veins at the lower border of popliteus

199
Q

What is the course of the popliteal vein?

A

In the lower part of the fossa the vein is medial to the artery. It crosses superficial to the artery and becomes posterolaterak to the artery at the upper part of the fossa

200
Q

What is the termination of the popliteal vein?

A

It terminates by passing through the adductor opening and continues as the femoral vein

201
Q

What are the tributaries of the popliteal vein?

A

Muscular veins
Genicular veins corresponding to the arteries
Short saphenous vein

202
Q

What type of joint is the knee joint?

A

Synovial, modified hinge

203
Q

What are the Articular surfaces of the knee joint?

A

Lower end of femur
Upper end of tibia
Posterior surface of patella

204
Q

What structures are the capsule of the knee joint attached to?

A

Attached to the margins of the Articular surfaces and surrounds the sides and posterior aspect of the joint.

On the front of the joint, the capsule is absent where it is replaced by quadriceps tendon, patellar retinacula and ligamentum patellae

205
Q

What are the extracapsular ligaments of the knee joint?

A

Ligamentum patellae
Lateral collateral ligament
Medial collateral ligament
Oblique popliteal ligament

206
Q

What are the intracapsular ligaments of the knee joint?

A

Anterior cruciate ligament:
-From anterior intercondylar area of tibia to the lateral femoral condyle
-It prevents hyperextension
-It also prevents posterior displacement o the femur on the tibia

Posterior cruciate ligament:
-From posterior intercondylar area of tibia to the medial femoral condyle
-It prevents anterior displacement of femur over tibia

207
Q

Describe the synovial membrane of the knee joint

A

Attached to the margins of the Articular surfaces
It extends up beneath the quadriceps femoris muscle above the patella, forming suprapatellar bursa
It is reflected backwards from the posterior surface of the ligamentum patellae to form infrapatellar fold
At the back of the joint, the synovial membrane is prolonged downward on the deep surface of the tendon of the popliteus forming popliteal bursa
A bursa is interposed between the medial head of the gastrocnemius and the medial femoral consuls and the semimembranosus tendon; this is termed semimembranosus bursa

208
Q

What are the structures inside the knee joint?

A

-Medial meniscus: C-shaped, fixed to the capsule of the knee joint and to the medial collateral ligament (liable to injury)

-Lateral meniscus: circular in shape, more mobile (separated from capsule and lateral collateral ligament by popliteus tendon) so it is more adaptive for twisting movement and less liable to injury

-Anterior cruciate ligament
-Posterior cruciate ligament
-Popliteus tendon

209
Q

What is the function of the menisci?

A

-They increase the concavity of tibial condyles for the better adaptation with femoral condyles

-They maintain a potential joint space for flushing of synovial fluid to provide nutrition to the Articular cartilage

-Menisci act as a shock absorber

210
Q

What is the arterial supply of the knee joint?

A

From the anastomosis around the knee:
-Popliteal artery
-Superior lateral genicular artery
-Inferior lateral genicular artery
-Superior medial genicular artery
-Middle genicular artery
-Inferior medial genicular artery

211
Q

What are the movements of the knee joint?

A

Flexion: By the hamstring muscles, gracilis, gastrocnemius, sartorius, popliteus and plantaris

Extension: By the quadriceps femoris, tensor fascia latae

Locking: medial rotation of the femur on the tibia in full extension
It is done by the anterior cruciate, the collateral and the oblique popliteal ligaments and biceps

Unlocking: lateral rotation of femur on tibia in standing (tibia fixed) or medial rotation of tibia in supine or sitting (tibia free) it is done mainly by popliteus

212
Q

What structures are responsible for stability of the knee joint?

A

Muscles: quadriceps particularly the inferior fibres of the vasti lateralis and medialis

Ligaments: Mainly quadriceps ligament

Menisci: Increase the concavity of tibial condyles

213
Q

What is the triad of injury of the knee joint/ what structures are most affected during knee joint injury?

A

-Medial collateral ligament (tibial)
-Medial meniscus
-Anterior cruciate ligament

The joint becomes swollen because it is filled with blood (hemarthrosis)

The medial meniscus suffers more frequently than the lateral because it is attached to the capsule

214
Q

Describe the difference between anterior cruciate injury and posterior cruciate injury

A

Tear of the anterior cruciate ligament is more common than the posterior
The tibia can be pulled excessively forward on the femur

The tibia can be pulled excessively backwards on the femur in posterior cruciate injury

215
Q

Describe inflammation of bursa and osteoarthritis of the knee joint

A

Inflammation of bursa:
Housemaids knee- subcutaneous pre-patellae bursa

Osteoarthritis of knee joint:
Total knee replacement or knee joint arthroplasty is done in severe destructive arthritis of the joint

216
Q

How many compartments does the leg have?

A

The leg is divided by inter-muscular septa and interosseous membrane into 3 compartments:
-Anterior compartment
-Posterior compartment
-Lateral compartment

217
Q

What are the muscles and nerve supply of the anterior compartment of the leg?

A

Muscles: the tibialis anterior, extensor digitorum longus, peroneus tertius and extensor hallucis longus
Collectively they dorsiflex the foot at the ankle joint

Nerve supply: deep peroneal (fibular) nerve; anterior tibial nerve

218
Q
A
219
Q
A
220
Q

What are the muscles and nerve supply of the lateral compartment of the leg?

A

Muscles: peroneus (fibularis) longus and peroneus (fubularis) brevis
Both pass behind the Lateral Malle plus of fibula
Both every the foot (turn the sole outward)

Nerve supply: Superficial peroneal nerve and the musculotaneous nerve

221
Q
A
222
Q

What are the muscles, blood supply and nerve supply of the posterior compartment of the leg?

A

Muscles: superficial and deep groups

Blood supply: branches from posterior tibial artery

Nerve supply: tibial nerve

223
Q

What are the superficial group of muscles in the posterior compartment of the leg?

A

-Gastrocnemius: Is the most superficial of the muscles in the posterior compartment. It arises by 2 heads (medial and lateral)
In the upper leg, the 2 heads combine to form a single elongate muscle belly, which forms much of the soft tissue bulge identified as the calf

-Plantaris: has a small muscle belly proximally and a long thin tendon

-Soleus: is a large flat muscle under the gastrocnemius muscle

224
Q

What is the origin, insertion and action of the superficial group of muscles in the posterior compartment of the leg?

A

Origin: Gastrocnemius and plantaris originate in the distal end of the femur and can flex the knee joint

Insertion: All of the 3 muscles insert onto the heel (calcaneus) of the foot and plantarflex the foot at the ankle joint

Action: as a unit, these muscles are large and powerful because they;
-Propel the body forward off the planted foot during walking
-Elevate the body upwards onto the toes when standing

225
Q
A
226
Q

What is the clinical correlation of calcaneal (achilles) tendon rupture?

A

Rupture of the calcaneal tendon is often related to sudden or direct trauma

The patient typically complains of being kicked or shot behind the ankle

Clinical examination often reveals a gal in the tendon

227
Q

What are the deep group of muscles of the posterior compartment of the leg?

A

-Popliteus: the smallest and acts on the knee, whereas the other 3 muscles act mainly on the foot
-Flexor hallucis longus
-Flexor digitorum longus
-Tibialis posterior

228
Q
A
229
Q

Describe the arterial supply of the leg

A

The popliteal artery is the major blood supply to the leg

It enters the posterior compartment of the leg from the popliteal fossa

It immediately didvides into the anterior tibial artery and posterior tibial artery at the lower border of the popliteus

230
Q

Describe the anterior tibial artery

A

The anterior tibial artery passes forward through the aperture in the upper part of the interosseous membrane and enters and supplies the anterior compartment of the leg

It passes deep to the superior extensor retinaculum

It continues inferiorly onto the dorsal aspect of the foot as the dorsalis pedis artery

231
Q

What are the branches of the anterior tibial artery?

A
  • Recurrent branch: ascends to share in the anastomosis around the knee joint
    -Muscular branches
    -Anterior malleolar arteries: share in the anastomosis around the ankle
232
Q

Describe the posterior tibial artery

A

The posterior tibial artery supplies the posterior and lateral compartments of the leg and continues into the sole of the foot

It passes through the tarsal tunnel behind the medial malleolus and into the sole of the foot

233
Q

What are the branches of the posterior tibial artery?

A

-Circumflex fibular artery: passes laterally through the soleus muscle and around the neck of the fibula to connect with anastomotic network of vessels surrounding the knee

-Fibular artery: supplies adjacent muscles and bone in the posterior compartment of the leg and also has branches that pass laterally through the intermuscular septum to supply the fibularis muscles in the lateral compartment of the leg

234
Q

What is the artery in the anterior compartment of the leg?

A

Anterior tibial artery which originated from the popliteal artery

235
Q

To what direction/axis does abduction and adduction of the foot occur?

A

Abduction and adduction of the toes are defined with respect to the long axis of the second digit

236
Q

What type of joint is the ankle joint and what are its bones and movements?

A

Type: Synovial, hinge joint (uniaxial)

Bones: Talus of the foot and tibia and fibula of the leg

Movements: dorsiflexion and plantar flexion of the foot on the leg

237
Q

What are the ligaments of the ankle joint?

A

Medial ligament (deltoid):
-large, strong and triangular in shape
-It’s apex is attached above to the medial malleolus (tibia) and it’s broad base is attached below to the navicular bone and the talus

Lateral ligament:
-Talofibular
-Calcaneofibular parts

238
Q

Describe the clinical correlations of ankle sprains

A

-The ankle joint is the most frequently injured joint in the body
-Ankle sprains occur due to torn fibres kf ligaments
-The lateral ligament is most commonly torn

239
Q

Describe the intertarsal joints

A

The major joints at which movements occur include the subtalar, talocalcaneonavicular and calcaneocuboid joints.
The intertarsal joints invert and evert the foot
The spring ligament (plantar calcaneonavicular) is a broad thick ligament
It supports the talus and resists the depression on the medial arch of the foot

240
Q

What are the joints of the foot?

A

-Metatarsophalangeal joints
-Proximal and distal interphalangeal joints

241
Q

What are the clinical correlations of injury to the joints of the foot?

A

Bunion:
-occurs on the medial aspect of the first metatarsophalangeal joint
-Characterized by lateral deviation of the big toe
-This deformity tends to occur among people who wear high-heeled shoes or pointed shoes

242
Q

Describe the superior extensor retinaculum

A

It is attached to the distal ends of the tibia and fibula

Structures that pass beneath it from medial to lateral: (Tom has very nice dogs and pigs)
-Tibialis anterior tendon
-extensor Hallucis longus tendon
-anterior tibial artery with Venae comitantes
-extensor Digitorum longus tendons
-Peroneus tertius

243
Q

What is a retinacula of the ankle?

A

In the region of the ankle joint, the deep fascia is thickened to form a series of retinacula

They serve to keep the long tendons in position

244
Q

Describe the inferior extensor retinaculum

A

It is Y-shaped and attached by its base to the lateral side of the upper surface of the calcaneus

It crosses medially over the foot to attach to the medial malleolus and to the medial side of the plantar aponeurosis

245
Q

Describe the superior peroneal retinaculum

A

It is a thickened band of deep fascia that extends from lateral malleolus to the calcaneus
The tendons of the peroneus longus and brevis pass deep to the retinaculum

246
Q

Describe the inferior peroneal retinaculum

A

It is a thickened band of deep fascia that lies below the lateral malleolus from the stem of the Y of the inferior extensor retinaculum to the calcaneus

247
Q

Describe the flexor retinaculum

A

The flexor retinaculum is a strap-like layer of connective tissue
It spans the bony depression (tarsal tunnel) formed by the medial malleolus and the calcaneus

Structures that pass beneath or through it from medial to lateral: (Tom does very nice hats)
-Tibialis posterior tendon
-flexor Digitorum longus tendons
-posterior tibial artery with Venae comitantes
-flexor Hallucis longus tendon

248
Q

What are the arches of the foot?

A

The bones of the foot do not lie in the same horizontal plane. Instead, they from longitudinal and transverse arches relative to the ground

Longitudinal arch: is formed between the posterior end of the calcaneus and the metatarsals. It is highest on the medial side, where it forms the medial part of the longitudinal arch

Transverse arch: it is highest in a coronal plane that cuts through the foot. Ligaments and muscles support the arches of the foot

249
Q

Describe what is flat foot (des planus)

A

It is the flattening of the medial longitudinal arch

Occurs due to dysfunction of ligaments or muscles of the foot

250
Q

What are the muscles and nerve supply of the dorsum of the foot?

A

2 muscles from the superior surface of the calcaneus:
-Extensor hallucis brevis: to the big toe
-Extensor digitorum brevis: to toes 2,3,4&5

Nerve supply of both muscles: Anterior tibial nerve

251
Q

Describe the arterial supply/ dorsalis pedis artery of the dorsum of the foot

A

The dorsalis pedis artery is the continuation of the anterior tibial artery

It begins as the anterior tibial artery crosses the ankle joint

It ends as the sole of the foot between the big toe and the second toe

Branches:
-Tarsal arteries
-Arcuate artery: arches over metatarsals to give lateral dorsal metatarsal arteries
-1st dorsal metatarsal artery

252
Q

What are the veins of the dorsum of the foot?

A

Dorsal venous arch:
On the dorsal surface of the foot over the metatarsals

Great saphenous vein:
From the medial side of the arch and passes anterior to the medial malleolus and onto the medial side of the leg

Small (short) saphenous vein:
From the lateral side of the arch and passes posterior to the lateral malleolus and onto the back of the leg

253
Q

Describe the plantar aponeurosis of the sole of the foot

A

The most superficial layer of the sole of the foot

It is a thickening of the deep fascia in the sole of the foot

It supports the longitudinal arch of the foot and protects deeper structures in the sole

It is firmly anchored to the calcaneus

The fibres diverge as they pass anteriorly and form digital bands

254
Q

Describe the first layer of muscles in the sole of the foot

A

The most superficial of the 4 layers of muscles of the sole of the foot

Lies immediately deep to the plantar aponeurosis
From medial to lateral these muscles are:
-Abductor hallucis: abducts the big toe
-Flexor digitorum brevis: flexes lateral 4 toes
-Abductor digiti minimi: Abducts the little toe

255
Q

Describe the second layer of muscles of the sole of the foot

A

Is associated with the tendons of the flexor digitorum longus and flexor hallucis longus muscles

Muscles of the foot are:
-Quadratus plantae: helps flexion of lateral 4 toes
-4 Lumbrical muscles: flexion metatarsophalangeal joint and extension interphalangeal joint

256
Q

Describe the third layer of muscles of the sole of the foot

A

-Flexor hallucis brevis: flexes lateral 4 toes
-Adductor hallucis: adducts big toe
-Flexor digiti minimi brevis: flexes little toe

257
Q

Describe the fourth layer of muscles of the sole of the foot

A

There are two muscle groups in the deepest muscle layer in the sole of the foot:
-Dorsal interossei: abduction of toes
-Plantar interossei: adduction of toes

I’m addition to 2 long tendons: Tibialis posterior and peroneus longus

258
Q

Describe the posterior tibial artery course in the dorsum of the foot

A

The posterior tibial artery enters the foot through the tarsal tunnel on the medial side of the ankle and posterior to the medial malleolus

It ends midway between the medial malleolus and the heel, it bifurcates into a small medial plantar artery and a much larger lateral plantar artery

259
Q

Describe the deep plantar arch of the foot

A

The deep plantar arch is formed mainly by the lateral plantar artery which curves in the foot where it is joined medially with the deep plantar branch of the dorsalis pedis artery

It gives the plantar metatarsal and digital arteries

260
Q

Describe the nerve supply of the muscles of the sole of the foot

A

The tibial nerve enters the foot through the tarsal tunnel posterior to the medial malleolus, then it divides into 2 terminal branches : a large lateral plantar nerve and a smaller medial plantar nerve

All intrinsic muscles in the sole are innervated by the lateral plantar nerve except for the muscles supplied by the medial plantar nerve:
-Abductor hallucis
-Flexor digitorum brevis
-Flexor hallucis brevis
-First Lumbrical

261
Q

What is the course of the femoral nerve?

A

It arises from the lumbar plexus then passes lateral to the psoas major muscle

It enters the thigh by passing deep to the inhumanly ligament into the femoral triangle, where it passes lateral to the femoral sheath

262
Q

What are the branches of the femoral nerve?

A

Muscles: quadriceps femoris, iliacus and pectineus

Skin over the anterior aspect of the thigh

Saphenous nerve: a long cutaneous nerve supplying skin of medial side of leg and foot

263
Q

What are the manifestations of femoral nerve injury?

A

Quadriceps femoris paralysis:
A person with paralysed quadriceps muscles cannot extend the leg against resistance

Usually presses on the distal end of the thigh during walking to prevent unwanted flexion of the knee joint

Sensory loss over skin areas supplied by the femoral nerve and its branches

264
Q

Describe the course of the obturator nerve

A

It arises from the lumbar plexus then passes medial to the psoas major muscle

It enters the thigh through the obturator foramen

It divides into anterior and posterior divisions

265
Q

What are the branches of the obturator nerve?

A

Muscles: medial compartment of the thigh except the ischial part of adductor Magnus: adductor longus, adductor brevis, gracilis, pectineus muscles and pubic part of adductor Magnus the obturator externus

Skin of the medial side of the thigh

266
Q

What are the manifestations of obturator nerve injury?

A

Causes a weakness of adduction and lateral swinging of the limb during walking because of the unopposed abductors

Sensory loss over medial side of upper thigh

It may result from pressure on the nerve by the feral head during pregnancy

267
Q

Describe the course of the sciatic nerve

A

It arises from the sacral plexus and is the largest nerve in the body

It emerges from the greater sciatic foramen below the piriformis to lie superficial to structures called the sciatic bed:
-Superior gemellus
-Obturator internus
-Inferior gemellus
-Quadratus femoris

268
Q

What are the branches of the sciatic nerve?

A

Muscles: hamstring muscles (semitendinosus, semimembranosus, biceps femoris and the ischial part of the adductor Magnus)

It divides at the posterior thigh (proximal to the knee and sometimes within the pelvis) into 2 terminal branches:
-Tibial nerve
-Common fibular (peroneal) nerve

The terminal branches supply all the muscles of the leg and foot and the skin to all the leg and foot except the medial aspect

269
Q

What are the manifestations of sciatic nerve injury?

A

Impairment of hip extension and severe impairment of knee flexion

Loss of all movements of the foot (foot drop)

Peculiar gait beachside of increased flexion at the hip to lift the dropped foot off the ground

Sensory loss over all the skin below the knee except the medial aspect of leg and foot

270
Q

Describe what is sciatica (sciatic nerve injury)

A

This is the most common form of back pain that may extend from the buttock down the posterior and lateral aspect of the leg and the lateral aspect of the foot.

It is caused by compression or irritation of the sciatic nerve e.g. due to herniated slipped disc or an improperly administered gluteal inter-muscular injection

271
Q

Describe what is priformis syndrome (sciatic nerve injury)

A

Occurs due to hypertrophy of the piriformis muscle

Causes irritation of the sciatic nerve

272
Q

Describe the characteristics of the common peroneal (fibular) nerve

A

It is the smaller terminal branch of the sciatic nerve

It originates from the sciatic nerve in the posterior compartment of the thigh or in the popliteal fossa

It winds around the neck of fibula (subcutaneous and can be palpable)

The commonest nerve injury in the body

273
Q

What are the branches of the common peroneal nerve?

A

Muscles: all muscles in anterior and lateral compartments of the leg and muscles of the dorsum of the foot

Cutaneous: skin over the lateral aspect of the leg and over the dorsal aspect of the foot and toes

It ends lateral to the neck of fibula by dividing into:
-Superficial peroneal (musculotaneous) nerve
-Deep peroneal (anterior tibial) nerve

274
Q

Describe the characteristics of the anterior tibial nerve (deep peroneal nerve)

A

It is one of the two terminal branches of the common peroneal nerve on the lateral side of the neck of fibula

It pierced the anterior intermuscular septum to reach the anterior compartment of the leg

It ends by dividing into medial and lateral terminal branches at the dorsum of the foot after passing deep to the extensor retinaculum on the lateral side of the dorsalis pedis artery

275
Q

What are the branches of the anterior tibial nerve?

A

Muscular : muscles of the anterior compartment of the leg and dorsum of the foot

Cutaneous: skin of adjacent sides of first and second toes

276
Q

Describe the characteristics of the superficial peroneal nerve (musculotaneous nerve)

A

It is one of the two terminal branches of the common peroneal nerve on the lateral side of the neck of fibula

It emerges between the peroneus longus and brevis and ends by piercing deep fascia and becomes the cutaneous nerve at the lower part of the leg

277
Q

What are the branches of the musculotaneous nerve(

A

Muscles: peroneus longus and brevis

Cutaneous: skin of the dorsum of the foot and all toes except:
-Adjacent sides if first and second rows which supplied by the anterior tibial nerve
-The lateral border supplied by the sural nerve
-The medial border supplied by the saphenous nerve

278
Q

Describe the clinical correlations of a common peroneal nerve injury

A

It usually results from fracture of neck of fibula or entrapment by leg casts

Deformity (equinovaris): foot is plantarflexed and inverted due to unopposed action of planterflexors and invertors

Sensory loss over lateral leg and dorsum of the foot

279
Q

Describe the clinical correlations of injury of the deep peroneal nerve

A

Injury of the deep peroneal nerve (anterior tibial nerve) results in foot drop and characteristic by high steppage gait

Usually results from compression of the nerve by tight fitting ski boots as it passes anterior to the ankle joint (ski boot syndrome)

280
Q

Describe the clinical correlations of injury of the superficial peroneal nerve

A

Injury of the superficial peroneal nerve (musculotaneous nerve) results in no foot drop but causes loss of eversion of the foot

Loss of sensation over most of the dorsum of the foot

281
Q

Describe the course of the tibial nerve

A

It is the larger terminal branch of the sciatic nerve

The tibial nerve descend a through the popliteal fossa, enters the posterior compartment of the leg and continues into the sole of the foot through the tarsal tunnel

Midway between medial malleolus and calcaneus it divides into 2 terminal branches: medial and lateral plantar nerves

282
Q

What are the branches of the tibial nerve?

A

Muscles: all muscles in the posterior compartment of the leg and sole of the foot

Cutaneous:
-Sural nerve: skin in the posterolateral side of the lower half of the leg and lateral side of the foot and the little toe
-Calcaneal branch: skin of the heel

283
Q

What does the lateral plantar nerve supply ?

A

It is the major motor nerve of the sole of the foot

It innervated all intrinsic muscles in the sole, except for the muscles supplied by the medial plantar nerve

284
Q

What does the medial plantar nerve supply?

A

It is the major sensory nerve to the sole of the foot

It gives motor branches to only 4 muscle in the sole:
-Abductor hallucis
-Flexor digitorum brevis
-Flexor hallucis brevis
-First Lumbrical

285
Q

Describe the manifestations of tibial nerve injury

A

Loss of plantarflexion of the foot as well as impaired inversion (calcaneovalgus)

Sensory loss of sole of the foot except for the medial border

It results in abnormality in the posture and locomotion

286
Q

Describe tarsal tunnel syndrome

A

Occurs due to entrapment of the tibial nerve in the tarsal tunnel behind the medial malleolus

Causes numbness in the sole of the foot

Locomotor (4 decks)

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