Anatomy 2 (after S18) Flashcards
Where do the testicles form and end up
- form in the retroperitoneum
- migrates through the abdominal wall into the scrotum
Where is a common site for hernias
-the inguinal canal
What is the superficial inguinal ring
- basically the triangular space produced by how the external oblique aponeurosis are attached
- only external oblique aponeurosis in lower 3rd of abdomen
- some fibres attach to the pubic tubercle and some to the pubic tubercle on the other side
Where does the inguinal ligament attach to and actually is it
- the pubic tubercle
- an opening in the transversalis fascia
Which abdominal muscle forms the starts in front of the inguinal canal and travels behind it and what does it do to the inguinal canal when it contracts
- the internal oblique muscle
- it forms the front wall (superiorly), roof and back wall (inferiorly) of the inguinal canal
- it closes the inguinal canal and stops any bowel in the abdomen coming down the inguinal canal and causing a hernia
Which artery is the deep inguinal ring just lateral to
-the inferior epigastric artery
Where do the internal oblique muscle and transversus abdominis muscle attach and insert on in the lower 1/3 of the abdomen
Internal oblique muscle - arise from the lateral 2/3 of the inguinal ligament and attach on the conjoint tendon
Transversus abdominis - arise from lateral 1/3 of the inguinal ligament and attach to the pubic tubercle
What is the cremesteric muscle
- as the spermatic cord descends through the inguinal canal
- it is surrounded first by deep spermatic fascia derived from the transversalis fascia layer
- the next muscle layer that surrounds the spermatic cord derived from the internal oblique muscle is the cremesteric muscle
- the next muscle layer that surrounds the spermatic cord derived form the external oblique layer is the external spermatic fascia
-the ilioinguinal nerve runs on its surface
Why is the pampiniform plexus of veins important?
-spermatogenesis needs a body temperature lower than our core temparature so men have multiple veins surrounding the testis are cooled by the high surface area of the scrotum which cools the testis to the right temperature for spermatogenesis
What does the vas deferens do and how is different from other vessels in the spermatic cord
- carry sperm from the testis to the penis for ejaculation
- bigger than other vessels
- it is hard and thick
What is the tunica vaginalis
- peritoneal sac covering the testis
- travels down with the testis from retroperitoneum during development
- sometimes has a connection still remaining to the abdomen called the processus vaginalis
- the sac covers only the testis not the epididymis
What is a congenital indirect inguinal hernia and what causes it
- this is when bowel is pushed into the inguinal canal when a baby cries
- occurs because the processus vaginalis from the tunica vaginalis remains as a tube instead of degenerating
What makes up the spermatic cord
Rule of 3s
3 coverings - external spermatic fascia, cremesteric muscle and internal spermatic fascia
3 arteries - testicular artery, cremesteric artery and the artery of the vas
3 veins - testicular veins, cresmesteric vein and the vein from the vas
3 nerves - genital branch of the genitofemoral nerve (nerve to the cremester muscle), inguinal branch of the ileoinguinal nerve (supplies sensation to the anterior 1/3 of the scrotum) and sympathetic nerves to the vas and testis
3 structures - vas deferens, lymphatics and processus vaginalis (connects peritoneal sac around testis to the peritoneal sac in abdomen)
Which nerves supplies sensation to the anterior 1/3 of the scrotum
-the inguinal branch of the ileoinguinal nerve
What is the epidydimus of the testis and what does it do
- runs from the top of the testis to the bottom
- connection to the testis are the ducti efferentis
What is the tunica albuginia of the testes
-the white coating layer on the testis deep to the tunica vaginalis
What is Buck’s fascia and what does it do
- thick fascia surrounding the penis
- limits the amount of blood that flows into the penis during an erection
Name the 3 cylinders that form the erectile tissue of the penis
- 2 corpora cavernousus (end just before the glans penis and is responsible for penis being hard)
- 1 corpora spongiosus (forms the glans penis entirely and is responsible for penis being erect)
In which erectile compartment in a male does the urethra lie
-the corpora spongiosum
What is the navicular fossa
-the wider aspect of the urethra in the glans penis of a male
What does the inguinal canal convey in women and how long is it
- the round ligament of the uterus
- the ilio-inguinal nerve (in men and women)
- about 5cm (in men and women)
Describe the skin and superficial fascia deep to the skin
- skin is thin, wrinkled and darkly pigmented
- superficial fascia has no fat but contains fibres of involuntary muscles called dartos
What are hernias referred to in relation to the inferior epigastric artery
- a hernia medial to the inferior epigastric artery is called a direct inguinal hernia
- a hernia lateral to the inferior epigastric artery is called an indirect inguinal hernia
What is another name for a prepuce
-a foreskin
What is a direct hernia
If it passes through the tranversus fascia of the posterior wall, directly through the internal oblique layer and directly through the external ring
What is an indirect hernia
If the hernia passes along the length of the inguinal canal through each of the 3 layers of abdominal wall in different positions
Where would gonadal lymph node metastasis be found
- lymph node metastasis located around the aorta in the upper abdomen
- gonads form on the posterior abdominal wall in the embryo and migrate from the level of the kidney down to their adult position
What is hydrocoel
- the testis is partially surrounded by the tunica vaginalis
- disease of the testis or scrotum can cause fluid to collect in the tunica vaginalis
- the tunica vaginalis swells and fees fluid, it transmits light so when a torch can be shown through it
Give the borders of the urogenital triangle (the peroneum)
- along both inferior pubic rami to the ischial tuberosities
- a line from one ischial tuberosity to the other
Give the borders of the ano-rectal triangle
- a line from one ischial tuberosity to the other
- the coccyx as the head of the triangle
What membrane covers the urogenital triangle and is the attachment point for the external genitalia
The peroneal membrane
What do the deep peroneal pouch form
- these muscles form part of the sphincters for the vagina and urethra in a female
- just the urethra in a male
What is the crura cavernosus and where does it arise
- it forms the foot of the column of erectile tissue (the corpora cavernosus)
- arise in the groove between the peroneal membrane and the inferior pubic ramus
What is ischio-cavernosus and where is it
- skeletal muscle
- over the top of the crura caverosus
What forms the foot of the corpora spongiosus in men and what muscle overlies that
- the crura spongiosus
- bulbospongiosus muscle
Describe the spongiosus in females
-2 bodies seperated by the interoitus
2 labia majora (hair bearing and sweat glands)
2 labia minora (no hair follicles)
These 4 erectile tissue meet to form the clitoris
-the hood of the clitoris is a bit of anterior labia minora
Which nerves supply the female genitalia above and below the line just below the clitoris
- the skin above the line is L1 ilioinguinal nerve
- the skin below the line is the S2 sacral nerve
- S2 supply a ring around the anal canal
- S3 a smaller ring around the anal canal
- S4 a smaller ring around the anal canal
- S5 a tiny ring including the distal part of the anal canal itself
Where does the peudendal nerve pass out of and what is its clinical significance
- the greater sciatic foramina
- sends a superficial and a deep branch to supply the peroneum
- useful to inject anaesthetic during childbirth
- it numbs the posterior 2/3 of the peroneum which includes the vaginal orifice where the baby comes through
Which nerve supplies the peroneum and where does it arise
- the peudendal nerve
- a branch of the sacral 2, 3 and 4
What does the peudendal nerve supply
- exits the greater sciatic foramina (with sciatic nerve and piriformis muscle) and enters the lesser sciatic foramina
- supply the posterior 2/3 of the external genitalia
- supplies the area of skin of the central buttocks
- supplies the lower 2/3 of the anal canal
Give the origin, insertion, innervation and function of the gluteus maximus muscle
Origin = external surface of the ilium, coccyx and (sacrotuberous ligament, sacrum and iliac crest)
Insertion =iliotiial tract of fascia lata and gluteal tuberosity of proximal femur
Innervation = inferior gluteal nerve L5, S1, S2 (and superior gluteal nerves)
Function = extensor of flexed femur at hip joint, laterally rotates and adducts thigh
Give the origin, insertion, innervation and function of the levator ani muscle
Origin = pubic bone, ischial spine Insertion = perineal membrane, anal canal Innervation = anterior ramus of S4, inferior rectal branch of the pudendal nerve S2 to S4 Function = forms the part of the pelvic floor (closes off the pelvic outlet), reinforces external and anal sphincter
What does the sacrotuberous ligament do
Tbc
- the peudendal nerve passes deep to the sacrotuberous ligament to enter the ischio-rectal fossa
- the sacrotuberous ligament lies on top of the sacrospinous ligament
Which ligament does the peudendal nerve run superficial to and what does this ligament do
- the sacospinous ligament
- tbc
Give the origin, insertion, innervation and function of the obturator internus muscle
Origin = wall of true pelvis Insertion = medial surface of greater trochanter of femur Innervation = nerve to obturator interns L5, S1 Function = lateral rotation of extended hip joint, abduction of flexed hip
The inguinal canal is a potential weakness in the anterior abdominal wall. What factors normally prevent herniation of the abdominal contents through the inguinal canal?
- the deep inguinal ring and the superficial inguinal ring are in different positions
- the lower fibres of tranversalis and internal oblique arch over the canal and close it off during contraction of the abdominal wall
Where would you palpate the ductus deferens? And how would you identify it by palpation alone
- it is easy to feel between the upper pole of the testis and superficial inguinal ring (in the spermatic cord)
- feels like a hard cord but flexible
- it arises at the lower pole of the testis but it is hard to feel there
What is a varicocele
- high pressure of venous blood in the pampiniform plexus of veins in the scrotum causes the veins to enlarge
- basically dilated veins in the pampiniform plexus
Some indirect inguinal hernias are congenital (means present at birth) even though they may not appear until later in life. Explain the embryology of these hernias
- the testis develops in the posterior part of the abdomen and migrate down through the inguinal canal to lie in the scrotum
- as it migrates it pulls a covering of peritoneum with it (tunica vaginalis)
- normally the connection between the peritoneal cavity and the tunica vaginalis obliterates but in some cases it remains a tube (processus vaginalis
- the processus vaginalis might stretch and become a hernia
Where would you try to palpate lymph nodes to assess the spread of testicular cancer?
-in the epigastrium
- the lymph drainage of any organ follows the arteries (but flow in the opposite direction)
- cancer of the testis will spread to lymph nodes around the aorta where the testicular arteries arise
Where might you look for an undescended testis? Is it worth surgically correcting this anomaly?
- testis develop just below the kidney and travel down the posterior abdominal wall through the inguinal canal and into the scrotum during inter-uterine development
- spermatogenesis does not occur correctly at body temperature so the testis migrates into the scrotum where the temperature is lower
- in undescended testis, correction is essential to ensure future fertility
What anatomical structure in the glans penis might impede the progress of a catheter?
-the navicular fossa
Which nerves provide sensory innervation to the scrotal skin
- the ilio-inguinal nerve (L1) supplies the anterior 1/3 of the scrotal skin
- the pudendal nerve (S2, 3 and 4) supplies the posterior 2/3 of the scrotal skin
Which 3 veins form the left renal veins and which structures do they drain
- left suprarenal -drains the adrenal glands
- left renal vein (smaller one)
- testicular vein - drains deep inguinal ring
Why are tumours of the left kidney important in relation to the testicular vein
- tumours of the left kidney can compress the testicular vein
- causing a swelling of the left testicle
- may cause swelling of the veins around the testis (varicoceole)
Which veins drain into the right side of the inferior vena cava independently in the abdomen (as opposed to the left side which join into one before draining into the inferior vena cava)
- right suprarenal vein
- right renal vein
- right testicular vein
What are the 3 main structures within the hilum of the kidney
- renal vein
- renal artery
- ureter
- also some lymphatics and sympathetic nerves
Which 2 places do the ureter run under major vessels
- under the testicular artery and vein (gonadal artery and vein in women)
- under the vas deferens (also called ductus deferens) (in men)
Name the layers surrounding the kidney and their significance
- peritoneum
- paranephric fat
- renal fascia
- perinephric fat
- renal capsule
- kidney
- tumours tend to grow along the veins of the kidneys
- it is clinically significant because it means tumours and infections of the kidney rarely spread into other tissues because there are too many layers to get through
What would be a precautious action to take if a patient presents with unilateral swelling of the left scrotum
-an ultrasound scan of the kidney to enter it is not a tumour that is blocking the testicular vein
Which nerve roots form a plexus between the psoas muscle and the iliacus muscle
-L2, L3 and L4 nerve forming the femoral nerve running into the anterior thigh
Which nerve runs superficial to the psoas muscle
-the genitofemoral nerve
Give the origin, insertion, innervation and function of the psoas muscle
Origin = fascia on the sides of the lumbar vertebra and intervertebral discs Insertion = lesser trochanter of the femur Innervation = anterior rami of L1 to L3 Function = flexion of the thigh at hip joint
Give the origin, insertion, innervation and function of the iliacus muscle
Origin = upper 2/3 of the iliac fossa, sacrum Insertion = lesser trochanter of the femur Innervation = femoral nerve L2 to L4 Function = flexion of the thigh at the hip joint
Which muscle runs runs from the lower border of the 12th rib to the upper part of the pelvis
-quadratus lumborum
Give the origin, insertion, innervation and function of the quadratus lumborum muscle
Origin = iliac crest, iliolumbar ligament, tranverse process of L5 Insertion = inferior border of 12th rib, transverse process of L1 to L5 vertebra Innervation = anterior rami of T12 and L1 to L4 Function = depresses and stabilises rib 12, lateral bending of the trunk
Where are the lateral, medial and median arcuate ligaments (lines) and what are their significance
Later arcuate ligament = back wall of retroperitoneum
Medial arcuate ligament = medial side of the spine in the retroperitoneum
Median arcuate ligament = just in front of the aorta
- the lateral ligament is where the quadratus lumborum meets the diaphragm in the retroperitoneum
- the medial arcuate ligament shows where the diaphragm meets the psoas muscle
- the median arcuate line is where the diaphragm passes in front of the aorta
Which nerve does L1 divide to create
- the iliohypogastric nerve
- the ilio-inguinal nerve
-supply the area above the pubis
Which nerve rises from the lateral border of the psoas muscle, the nerve passes underneath the inguinal ligament. What does the nerve do
- lateral cutaneous nerve of the thigh
- supplies the lateral part of the thigh with sensation
Where can the obturator nerve be found
-on the medial side of psoas
Describe the bifrucation of the aorta to the level of the femoral artery
- aorta bifurcation at the level of the umbillicus
- common iliac arteries
- internal and external iliac arteries
- external iliac artery runs on the medial side of psoas major msucle
- external iliac artery passes underneath the inguinal ligament to become the femoral artery
- external iliac artery gives off the inferior epigastric artery before it becomes the femoral artery
- the internal iliac artery becomes the anterior internal iliac artery and the posterior internal iliac artery
- anterior internal iliac artery supplies the bladder and the uterus in the female and the placenta in the foetus
- posterior internal iliac artery passes out into the buttocks to form the superior gluteal arteries and inferior gluteal arteries
- the superior and inferior gluteal arteries supply blood to the buttocks and anastomose with the profuno-femoral artery at the back of the thigh
Where do umbilical arteries (medial umbilical ligaments arise) from
-the anterior branch of the internal iliac arteries
What does the obturator nerve do
- supplies sensation to the medial part of the thigh down to the knee
- motor supply to the medial compartment of the thigh
What are the dimensions of the kidney (length, width and thick)
11cm long
7cm wide
4cm thick
What does extraperitoneal and retro-peritoneal mean and how do these relate to the kidneys
- extraperitoneal means outside the peritoneum
- retro-perioneal means behind the peritoneal cavity
-the kidneys are extra-peritoneal and retroperioneal
How many arteries and veins supply the suprarenal glands (adrenal glands)
3 arteries
- inferior phrenic artery gives off the superior suprarenal artery
- middle suprarenal artery
- inferior suprarenal artery
1 vein
-suprarenal vein
What do the genital and femoral branches of the genitofemoral nerve do
- the genital branch passes through the deep inguinal ring and supplies the cremester muscle (when the inside of the thigh is tickled, the testis retract)
- the femoral branch passes under the inguinal ligament and is sensory to the inside of the thigh
Give the 3 points where renal calculi (stones) might get stuck in the ureter
- where the pelvis of the kidney becomes the ureter
- at the pelvic brim
- where the ureter passes into the bladder wall
What is the function of the psoas muscle
-flexor of the hip
How can inflammation of the appendix affect the psoas muscle
- the appendix might lie on the psoas muscle and can be inflammed causing the psoas muscle to spasm
- the psoas muscle is a hip flexor
- so the patient will have a flexed hip and trying to extend the hip will cause pain
What is a duplex ureter and how does it contribute to recurrent urinary tract infections
- in duplex ureters, the valve the bottom of he ureter does not function
- so during micturition, urine passes back up the ureter into the kidney
- during a urinary tract infection, it is easy for urine to pass up to the kidney
- urine is also never completely expelled as there is always infected urine passing up the ureter which continually re-infects the bladder
Renal tumours can become very large before they invade adjacent structures, which anatomical features explain this
- thick and resilient capsule
- surrounded by renal fibrous capsule, perinephric fat (or perirenal fat) then the renal (perinephri fascia which encloses the kidney and adrenal glands together)
Describe two common variations in the anatomy of the renal pelvis and ureter
- duplex system
- pelvoureteric junction obstruction
- two ureters can arise from the same kidney, they can join and enter the bladder together or can separately enter the bladder
- if there are two ureters there may be two separate kidneys on that side
- the upper kidney would drain normally at the trigone of the bladder but he lower kidney would drain higher up on the bladder
- so the ureter of the lower kidney would not valve mechanism so urine would pass back up into the kidney when the bladder contracts
What veins do the right and left gonadal veins drain into
- left gonadal vein drains into the renal vein
- right gonadal vein drains directly into the inferior vena cava
What is a polar artery and why do they exist
- a polar artery is an accessory renal artery usualy supplying the lower pole of the kidney
- the kidney develops as lots of kidneys with their individual arteries
- these kindeys fuse and their arteries join to form a single renal artery
- about 1/4 of people have two renal arteries to one kidney, a large renal artery and a smaller one to the inferior pole of the kidney
What is clinical complication that could arise with a polar artery
-a polar artery can compress the ureter and stop urine flow
Where would you palpate an abdominal aortic aneurysm?
-the aorta finishes just above the umbilicus so can only be felt in the upper abdomen
Describe the relationship of the ureter to bony landmarks of the abdomen and pelvis (useful for finding the ureter on an x-ray)
- pelvis of the right kidney is at L3
- pelvis of the left kidney is L2/3
- the ureter starts at the lower part of the pelvis and run down the tips of the transverse processes of the lumbar vertebra
- the ureter runs medial to the sacroiliac joint or directly over it
- the ureter runs across the spinous process of the pelvis and medially to the bladder
How many ossification centres is the hemi-pelvis (innominate bone) made from and where are they connected
- 3 separate ossification centres that fuse at the end of puberty
- connected at the midline (pubis symphysis -secondary cartiliginous joint)
- connected posteriorly at the 2 sacro-iliac joints (fibrocartilage and synovial cavity)
Give the different parts of the pubic bone
- superior pubic ramus
- pubic tubercle
- body of the pubis
- 1st 1/3 of the inferior pubic ramus
Which bone contains the 2/3 of the inferior pubic ramus
-the ischium
How many bones make up the hemi-pelvis
3
- ilium
- pubic bone
- ischium
At what intervertebal level does the intercristal plane lie and what is the clinical significance
- between L4 and L5
- allows us to know where to put needles for epidurals
What cartilage lies in the sacoiliac joints of the pelvis and what is the clinical significance
- fibrocartilage
- synovial joint
- prone to rheumatoid arthritis which is a disease of the synovium
Where do the ischiosacral ligament and spinosacral ligament extend to and from
- from the ischial tuberosity to the sacrum - ischiosacral ligament
- from the spinous process to the sacrum - spinosacral ligament
Which ligament creates the greater sciatic foramina
-the sacrotuberous ligament (ischiosacral ligament)
Which ligaments create the lesser sciatic formina
- the sacrotuberous ligament (ischiosacral ligament)
- the sacrospinous ligament (spinosacral ligament)
Why is the angle between the inferior pubic rami of a male a “V” shape
- so the crura of the penis (ischiocavernosus) attached along the “V” passes into the shaft of the penis
- the angle needs to be as straight a line as possible to avoid damage to the penis and its attachments during intercourse
Give the differences between the male and female pelvis
- the male pelvis has a straight V shape of the inferior pubic rami
- the spine of the ischium points to the sacrum and is a short distance between them (for strength- allows greater amount of weight to pass through the ligaments supporting the upper body mass of the male)
- prominent lumbo-sacral junction (supporting the weight of the vertebral column unto the sacrum)
- in women both are the opposite to allow easier delivery of babies
- no prominence to the lumbo-sacral junction giving a round/oval pelvic outlet
Why is there a space anteriorly in the levator ani muscle
- in men and women for the passage of the urethra
- in women for the passage of the vagina
Which structures support the urogenital triangle
- the levator ani muscles
- the perineal membrane
- the deep and superficial peroneal pouches
What structures does the posterior of the bladder lie against in males and females
In males - front of the rectum
In females - upper 1/3 of the vagina and part of the cervix
Is there any structure between bladder and rectus abdominis muscle and what is the clinical significance
- there is no structure between the bladder and rectus abdominis muscle
- so when the bladder is full they are directly touching
- it is clinically significant because in children, urine samples can be obtained by passing a needle through the lower abdominal wall
- or if a catheter cannot be put into the urethra, it can be passed directly through the lower abdominal wall into the bladder
What are rugae and which structures have them
- rugae is when there is more lining than the size of the organ so the lining is thrown into folds
- the bladder and stomach
Which nerve passes medially to the psoas
- obturator nerve
- deep to the obturator nerve is the lumbosacral trunk
Name the pouches between the bladder and the structures behind it in males and females
Males
- recto-vesical pouch
Female
- utero-vesical pouch anterior to the uterus
- recto-uterine pouch (pouch of Douglas) posterior to the uterus
Explain what occurs in benign prostatic hypertrophy, does it require catheterisation
- the prostate gland completely encircles the urethra
- with progressing age, the prostate tissue enlarges (hypertrophy) and can completely block the urethra and cause an inability to pass urine
-require emergency catheterisation
Give a possible way prostate cancer metastasis can occur
- venous drainage of the prostate passes into a plexus of veins which lie anterior to the sacrum and communicate with veins which run up to the azygous veins in the chest
- these veins communicate with veins in the vertebral bodies and do not have valves so blood can flow in either direction
- during inspiration, the negative pressure in the chest sucks blood up the veins but during expiration gravity pulls it back down again
- tumour cells travel up the veins and then pass down into the vertebral bodies where they may attach and cause a metasis
What are the 3 components of micturition (passing urine)
- control of the brain
- control from the spinal cord
- sensory input from the bladder
How does loss of the brain control aspect in micturition present and why, is there a risk of renal failure
- bladder fills
- spinal cord knows bladder is full and asks brain permission to empty
- brain does not reply
- spinal causes the bladder to empty
- patient suddenly and unexpectantly passes urine with no control
- there is low pressure in the bladder so no risk of renal failure
How does loss of the sensation aspect in micturition present and why, is there a risk of renal failure
- spinal cord and brain cannot know that bladder is full as no sensation so cannot tell it to empty
- bladder fills up
- patient continually dribbles urine
- high pressure in the bladder and kidney which rapidly progresses to kidney damage and failure
How does loss of the spinal control aspect in micturition present and why, is there a risk of renal failure
- patient knows bladder is full but cannot empty it
- high pressure in bladder and kidney so causes renal failure
How is a prostate examination carried out and why is possible
- through the anal canal
- the prostate lies immediately anterior to the rectum
Where do the femoral, obturator and sciatic nerves pass from the abdomen into the thigh
Femoral - under the inguinal ligament halfway between the pubic tubercle and anterior superior iliac spine
Obturator - through the obturator foramina (canal)
Sciatic - through the greater sciatic foramen into the buttock and then thigh
Why is the ureter in danger of damage during a hysterectomy (removal of the uterus)
-the uterus runs immediately under the uterine artery which needs to be ligated and divided to complete the hysterectomy
What stops urine passing from the bladder back up the ureter
- the ureter enters the bladder at an oblique angle forming a flap valve
- as pressure increases in the bladder, the angle presses on the part of the ureter which is in the bladder wall and stops urine passing back up to the kidney
Where does the bladder lie when full
- the fundus of the bladder lies immediately above the pubis symphysis and there is no peritoneum between the abdominal wall and bladder
- against the lower abdominal wall with no peritoneum between the bladder and the abdominal wall
A 25 year old woman involved in a car crash suffered complete transection of her spinal cord at the level of T6.
Is she able to tell when her bladder is full?
Does her bladder empty via muscle contraction or does it simply overflow?
Will her bladder completely empty?
She cannot tell when her bladder is full as the signals cannot reach her brain (no sensation)
Her bladder empties by muscle contraction controlled by a spinal micturition reflex in the sacral part of the spinal cord (S2 to S4)
Her bladder will completely empty because it empties by contraction
- the spinal micturition reflex process
- as the bladder fills it is detected by the sensory nerves entering the cord at S2-4
- once the bladder is sufficiently full these sensory nerves stimulate the motor nerve to contract the detrusor muscle and relax the sphincters
- same reflex is found in pre-potty trained children
- once micturition is initiated, it cannot be suppresed
What is the action of psoas muscle
-flexion of the hip joint
Give the origin, insertion, innervation and function of psoas minor
Origin = bodies of T12 and L1 vertebra Insertion = pelvic brim and iliopubic eminence Innervation = anterior rami of L1 Function = weak flexion of lumbar vertebral column
Where are the internal and external bladder sphincter
- the internal bladder is at the bladder neck at its base, just on top of the prostate gland, at the start of the urethra
- the external bladder sphincter is just below the prostate gland and is part of the peroneum
Which part of the prostate gland is prone to malignancy
-the peripheral part
Which part of the prostate gland is prone to hypertrophy
-the central part of the prostate gland
If the uterus is bent forwards compared to the vagina, it is called
Anteverted
If the uterus is bent backwards compared to the vagina, it is called
Retroverted
If the uterus itself is bending forward but its body is straight with the vagina, it is called
Anteflexed
If the uterus itself is bending backwards while its body is straight with the vagina, it is called
Retroflexed
What is the narrowing at the outlet of the cervix called
-the external os
Which structure marks the start of the uterine cavity
-the internal os
What is the space slightly behind, lateral and in front of the cervix called
- the posterior fornix
- the anterior fornix
- the lateral fornix
Why is the posterior fornix clinically important
- the posterior fornix is close to the peritoneal cavity
- so a needle can be inserted into the vagina through the posterior fornix and into the peritoneal cavity to harvest eggs from the ovaries at the back of the uterus by the ligament of the ovary and covered in mesovarium (broad ligament)
What does the Pouch of Douglas contain
-the sigmoid colon or small bowel
Where and what is the broad ligament
- lateral side of the uterus
- double fold of peritoneum
Which structure runs along the upper limits of the broad ligament
-the fallopian tube
Where are the ovaries found
-attached to the back of the uterus by the ligament of the ovary and covered in mesovarium (broad ligament)
Where does the round ligament of the uterus run
-from the uterus into the inguinal canal and through the deep inguinal ring to the labia majora
If a tumour of the ovary metasises via lympahtics where would it be found
- the lymphatics follow the ovarian artery to the aorta (just like with the testicular artery)
- the metastases will occur around the aorta at the level of the kidneys
Which structures make up the ovarian fossa and what is the clinical significance of on of these sturctures
- between the internal iliac (artery/vein) and external iliac (artery/vein) with the obturator nerve in the middle
- the ovary will lie in front of this fossa
- diseases of the ovary can irritate the obturator nerve which supplies the inside of the lower thigh
- so the patient will feel pain on the inside of the lower thigh even though they have a disease within the ovarian fossa
Which artery does the uterine artery come off
-the internal iliac artery
Which vessel does the uterine artery anastomose with and why is this neccessary
- ovarian arteries
- neccessary during preganancy as the uterine arteries cannot supply all the blood supply for full development of the foetus on their own
Which ligament holds the uterus in a midline position
-the broad ligament (runs from the lateral wall of the pelvis to the lateral wall of the uterus)
Which ligaments support the cervix and where do they attach to
- cardinal ligaments (also called pelvic fascia)
- run from the lateral wall of the cervix to the lateral pelvic side at the base of the broad ligament
- pelvic floor, bones of the sacrum and pelvic ring
Can the urethra and rectum prolapse into the vagina, which other structure can prolapse into the vagina and why
- yes
- the cervix can prolapse into the vagina especially in women who have had multiple vagina delivery and are old
By manual examination through the vagina, which structures can be examined
- the wall of the bladder
- the urethra
- the wall of the rectum
- anal canal
- Pouch of Douglas
- bimanual examination might allow the palpation of a particularly large ovarian cyst
Testicular pain may radiate to the loin why?
- the nociceptive nerve fibres (pain sensation) to the testis are sympathetic and follow the testicular artery from the aortic sympathetic plexus
- nerve fibres to the testis are from the T11 and T12 nerve roots
- pain is felt in the distribution of the cutaneous nerve of these segments as referred pain
Which muscle maintains the angle between the anal canal and rectum
- levator ani is the whole sheet of muscle
- the anterior fibres of the levator ani called puborectalis maintain the angle
What are the parts of the uterus
- fundus
- body
- cervix
How long is the uterus
-8cm long
What is the normal position of the uterus
-anteflexed and anteverted
What are the structures between the cervical canal and the vagina and the uterus
- internal os is between the cervix and the uterus
- external os is between the cervix and vagina
How long are the uterine tubes (fallopian tube)
10cm
Which ligament keeps the ovary in the right position near the fimbriae of the fallopian tubes
Suspensory ligament of the ovary
Where does the vagina terminate
-the introitus (vaginal orifice)
Where does the upper 2/3 of the vagina lie
-pelvic cavity
Where does the lower 1/3 of the vagina lie
-in the perineum
What is the mons pubis
-rounded hair bearing area of skin covering the front of the pubic symphysis
What is the vestibule of the vagina
-the area between the labia minora
How many bundles of erectile tissue make up the clitoris
-3 just like penis
At the back of the bladder, the ductus deferens joins the duct of which vessel to form the ejaculatory duct
-the seminal vesicles
Where is the ampulla of the ductus deferens found
-on the posterior aspect of the bladder
In urinary retention, the emergency treatment is catheterisation. Give 3 places where it may be difficult to pass a catheter
- the navicular fossa of the glans of the penis
- the perineal membrane (which is fixed while the distal urethra is flexible), the urethra has to be pulled out to length to make it taught to allow a catheter to pass
- the bladder neck with the internal sphincter
What can cause urinary incontinence (inability to store urine)
- neurological control of micturition
- muscle weakness
- vaginal hernias
Which structures can herniate through the vagina
- uterus (uterine prolapse)
- bladder (cystocele)
- urethra (urethrocele)
- rectum (rectocele)
How can sexually acquired infection cause pelvic inflammatory disease
- sexually acquired infection can spread from the vagina into the uterus to the fallopian tube
- the fallopian tube open directly into the peritoneal cavity so the infection can spread to the pelvic part of the cavity
- causing pelvic inflammatory disease
Why may inflammation of the ovary cause pain along the medial aspect of the thigh
-the ovary sits alongside the lateral pelvic side wall where the obturator nerve runs, irritation of the nerve leads to medial thigh pain as referred pain
What is a retroverted uterus
- the uterus usually lies tilted forwards over the bladder
- retroversion is when it lies further away from the bladder and may impinge on the anterior wall of the rectum or sacrum
What maintains the normal position of the uterus
- tone in the levator ani muscles
- transverse cervical ligaments (cardinal)
- pubocervical ligaments
- sacrocervical ligaments
- broad ligaments
To which lymph nodes would cervical cancer spread
- the blood supply to the cervix is from the internal iliac arteries
- the main lymph nodes along these arteries would be involved in the spread of cervical malignancy
What structures may be palpable during a vaginal examination
Anteriorly
- base of bladder
- urethra
- lower ureters (if they contain a stone)
Laterally
- ureter
- levator ani muscles
- ovary (by bimanual palpitation)
Posteriorly
- rectum
- pouch of Douglas
- perineal body
What is the superficial perineal pouch
-area of the perineum superficial to the urogenital diaphragm
What is the perineal membrane
-superficial layer of fascia covering the urogenital diaphragm
What is the urogenital diaphragm
-tissues forming a triangle of tissue closing the anterior pelvic outlet
If there was a rupture of the penile urethra where would the urine collect
-superficial perineal pouch
Give the difference between the muscles of the forearm closer to the wrist and closer to the elbow
-closer to the elbow, the muscle becomes more adherent to the surface of the deep fascia and the bone
How many muscles layers are there of the flexor compartment of the forearm
Superficial tendon
- palmaris longus (middle tendon - superficial to the flexor retinaculum)
- flexor carpi radialis (on radial side - attached to wrist bone)
- flexor carpi ulnaris (on ulna side - also attached to wrist bone)
- pronator teres
Middle compartment
-flexor digitorum superficialis (group of 4 tendons in one, flexes the proximal interphalangeal joint in the fingers)
Deep compartment
- flexor digitorum profundus (group of 4 tendons in one, deep to the superfiscialis one, flexes the distal interphalangeal joint)
- flexor pollicis longus (flexes the thumb)
- pronator quadratus (quadraletral muscle)
Give the origin, insertion, innervation and function of the pronator teres muscles
Origin = medial epicondyle of the humerus
Insertion = halfway down the radius
Innervation =
Function = pronates the forearm
Give the origin, insertion, innervation and function of the palmaris longus muscles
Origin = medial epicondyle of the humerus
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the palmaris brevis muscles
Origin =
Insertion =
Innervation =
Function =
Small muscle on side of the palm
Give the origin, insertion, innervation and function of the flexor carpi radialis muscles
Origin = medial epicondyle of the humerus
Insertion =
Innervation =
Function = flex the wrist
Give the origin, insertion, innervation and function of the flexor carpi ulnaris muscles
Origin = medial epicondyle of the humerus
Insertion =
Innervation =
Function = flex the wrist
Give the origin, insertion, innervation and function of the flexor digitorum superficialis muscles
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the flexor digitorum profundus muscles
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the flexor pollicis longus muscles
Origin =
Insertion = base of the terminal phalanx of the thumb
Innervation =
Function =
Give the origin, insertion, innervation and function of the pronator quadratus muscles
Origin =
Insertion =
Innervation =
Function = pronate the forearm
Describe the journey of the median nerve in the wrist
-runs through the carpal tunnel
Describe the journey of the ulna artery and nerve at the wrist, is there a risk of damage and compression
-ulna artery and nerve runs on the side of the ulna and do not go through the carpal tunnel
-less risk of damage and compression
Lies lateral to the pisiform
Describe the journey of the radial artery at the wrist, is there a risk of damage and compression
- radial artery run on the radial side
- sit on bone
- lies lateral to the flexor carpi radialis
Which veins make up the dorsal venous arch on the back of the hand
- cephalic vein
- basilar vein
Which nerve supplies the anterior part of the arm
-the musculocutaneous nerve
Which nerve supplies the posterior aspect of the arm and forearm
-radial nerve
Which nerve supplies the anterior compartment of the forearm
- majorly supplied by the median nerve
- two muscles supplied by the ulna nerve (flexor carpi ulnaris and medial half of flexor digitorum profundus)
-the ulna nerve only supplies the flexor digitorum profundus to the little finger and ring finger
Give the origin, insertion, innervation and function of the brachioradialis muscle
Origin = lateral supracondylar ridge of the humerus Insertion = distal end of the radius just above its styloid process Innervation = radial nerve Function = flexor of the elbow
Where can the ulna nerve be damaged
- at the elbow where it passes behind the medial epicondyle of the humerus
- at the wrist where it lies superficially lateral to the pisiform bone
Which nerve is not affected by carpal tunnel syndrome
-the ulna nerve
Which structures form the carpal tunnel
- flexor retinaculum
- carpal bones of the wrist
Which structures pass through the carpal tunnel
- median nerve
- 8 flexor tendons for the fingers (from flexor digitorum superficialis and flexor digitorum profundus)
- flexor pollicis longus
Explain carpal tunnel sydrome
- swelling of the 8 tendons or arthritis affecting the joints of the carpal bones can increase pressure in the tunnel which will compress the median nerve
- manifests as pain and diminished sensation on the skin along the distribution of the median nerve
- may also be weakness of the hand muscles supplied by the median nerve
Explain Colles fracture
- to break their fall, many people put their hand out
- this leads to a fracture of the distal end of the radius
- falls are common in elderly people
- elderly women are more at risk as a reduction in oestrogen after menopause leads to weaker bones (osteoporosis)
- can lead to carpal tunnel syndrome
Explain De Quervain’s syndrome (repetitive strain injury)
- the synovial sheath of the tendons of the wrist become inflamed and painful
- common in those repeating the same movements over and over e.g typing on a keyboard
What is a “ganglion” in terms of the wrist
- when synovium undergoes hypertrophy and the excess synovium and excess liquid present as a soft squidgy bulge
- often near the dorsal aspect of the wrist
What are the 3 superficial veins of the forearm and where do they run
- cephalic vein
- basilic vein
- antecubital vein
- cephalic vein runs from the lateral side of the dorsal venous arch over the radius up to the antecubital fossa to give off the antecubital vein
- continues in the groove between the triceps and the biceps on the lateral side of the arm till it reaches the deltoid
- runs in the deltopectoral groove to below the clavicle where it passes into the axillary vein
- basilar vein runs from the medial side of the dorsal venous arch and runs over the ulna till the antecubital fossa
- joins the antecubital vein and passes on the medial side between the triceps and biceps to become the brachial vein
What are three major nerves entering the forearm and what do they supply
- radial nerve
- median nerve
- ulna nerve
radial
-motor to posterior compartment of forearm and skin on the lateral part of the back of the hand
median
- motor to all flexors of the forearm except flexor carpi ulnaris and the medial fingers of the flexor digitorum profundus
- motor to the LLOAF muscles of the hand which are opponense pollicis, abductor pollicis brevis, flexor pollicis brevis
- skin on the lateral 3.5 digits on the palm of the hand
Ulna
- motor to flexor carpi ulnaris and medial fingers of flexor digitorum profundus
- motor to all muslces in hand except LLOAF
- skin on the medial 1.5 digits on palm of the hand
Where is the common flexor origin
-medial epicondyle of the humerus
How do you test the muscles supplied by the median nerve
- flexion of the thumb and lateral two fingers
- movement of the thenar muscles
Where can you palpate the brachial, radial and ulna arteries
Which is easier to palpate and why
Brachial - medial to the biceps aponeurosis
Ulna - lateral to the pisiform or just proximal to this position
Radial -lateral to the most lateral tendon at the wrist
-the radial artery is the easiest to palpate because it s superficial and has bone directly behind it
Where does the brachial artery and median nerve pass into the forearm
-median to the biceps aponeurosis
How many carpal bones from the wrist and what are they
8
From the radius
- scaphoid
- lunate
- triquetrum
- pisiform
- hamate
- capitate
- trapezoid
- trapezium
Why is the blood supply of the scaphoid important (explain the avascular necrosis of the scaphoid)
- scaphoid started embryologically as two separate bones but fused together to form a single bone
- the artery supply to the medial (proximal)side of the scaphoid disappeared leaving only one blood supply to the bone
- if you fall on the bone and fracture it down its midline, the medial (proximal) aspect might die
- this will cause dysfunction at the wrist joint
Does the palmaris longus lie on top or through the flexor retinaculum
-on top of flexor retinaculum
What allows the lack of movement of the skin of the palm of the hand
- the palmar fascia (palmar aponeurosis)
- makes it easy to grip things
What is the hypothenar eminence
- abductor digiti minimi
- flexor digiti minimi brevis
- opponens digiti minimi
What does the thenar eminence consist of
3 of them
- abductor pollicis brevis
- flexor pollicis brevis
- opponense pollicis
Which artery form the superficial palmar arch and what does the superficial palmar arch supply
- ulna artery
- supplies majority of the hand
- superficial palmar arch supply blood to the fingers
Which artery passes through the anatomical snuff box
-the radial artery
Where is the 1st web space and which artery passes through it
- between the 1st and 2nd metacarpal through the muscle
- the radial artery
Which artery forms the deep palmar arch and where is the deep palmar arch
- the radial artery
- between the tendon and bones
Where is the venous drainage of the hand
-on the back of the hand
Where do the lumbricals attach and insert ad what do they do
Origin = flexor digitorum profundus of each phalanx
Insertion = dorsal digital expansion on posterior of the finger
Innervation = two lateral lumbericals supplied by the median nerve and two medial lumbricals supplied by the ulnar nerve
Function = used to simultaneously flex the metacarpophalangeal joit while extending the interphalangeal joints
-so making an upstroke while writing
- starts in the palm and travels across the metacarpalphalangeal joint
- they attach to the profundus tendon on the finger
- travel round the finger to insert on the extensor on the posterior (dorsal) aspect
- when they contract they pull the profundus tendon superiorly (check this line)
- bends the metacarpalphalangeal joint and straighten the 2 higher interphalangeal joints
What allows the tendons in the fingers to freely slide
-synovial membrane producing synovial fluid
What is a retinaculum and what does it do
- also called fibrous flexor sheath
- it is a sheath that covers the tendons of the fingers at a joint to prevent them pulling away from the bone when the finger is flexed
Which flexor of the digits(fingers) divides into two and passes round the other tendon to insert on the middle phalanx
-the flexor digitorum superficialis
What are the vincula and what are their purpose
- loose connections between the tendons of the flexor digitorum superficialis and profundus
- it is how the tendons get their blood supply
- they are lined with synovium
Give the origin, insertion, innervation and function of the abductor pollicis brevis muscle
Origin = flexor retinaculum Insertion = lateral aspect of the first phalanx of the thumb Innervation = median nerve Function = pulls the thumb away from the palm of the hand
Give the origin, insertion, innervation and function of the flexor pollicis brevis muscle
Origin =
Insertion = lateral aspect of the first phalanx of the thumb
Innervation = median nerve
Function = flex the thumb joint
Give the origin, insertion, innervation and function of the opponens pollicis muscle
Origin = shaft of the metacarpal Insertion = carpus Innervation = median nerve Function = rotates the thumb so it can pinch the tips of fingers (opposition)
Give the origin, insertion, innervation and function of the adductor pollicis muscle
Origin =
Origin =
Insertion =medial aspect of the first phalanx
Innervation = ulnar nerve
Function = pull the thumb towards the palm of the hand
Give the origin, insertion, innervation and function of the abductor digiti minimi muscle
Origin = pisiform bone
Insertion = proximal phalanx
Innervation =
Function = pulls little finger away from the ring finger
Give the origin, insertion, innervation and function of the flexor digiti minimi muscle
Origin =
Insertion = proximal phalanx
Innervation =
Function = flex the metrcarpophalangeal joint
Give the origin, insertion, innervation and function of the opponens digiti minimi muscle
Origin = carpal bone
Insertion = whole shaft of metacarpal
Innervation =
Function = rotates the metacarpal so tip of the little finger faces the thumb (opposition)
Give the origin, insertion, innervation and function of the dorsal interosseus muscle
Origin =
Insertion = proximal phalanx of the finger
Innervation =
Function = pulls the index finger away from the middle finger
What are the web spaces of the hand
-basically the bottom of the space between the fingers
How many dorsal interosseus muscles are there
4
Attached to lateral aspects of fingers
Give the actions of the four dorsal interosseous muscles
1- moves index finger away from middle finger
2 -moves middle finger towards index finger
3 - moves middle finger towards ring finger
4 - moves ring finger away from middle finger
DAB
Dorsal interosseus ABduct
How many interossues muscle are there on the palm of the hand
3
-attached to medial aspect of finger
What are the actions of the 3 ventral interosseus muscles
1- pull index finger towards the middle finger
2- pull rings finger towards the middle finger
3- pulls little finger towards the middle finger
PAD
Palmar interossei ADDuct
What does LLOAF stand for
L - lateral two lumbricals (near the thumb)
O - Opponens pollicis
A - Abductor pollicis brevis
F - Flexor pollicis brevis
-these are all supplied by the median nerve
In the hand what does the ulna nerve supply (motor)
- all motor except LLOAF
- so all the dorsal and ventral interossei
- the median lumbricals (the one close to the little finger)
- the hypothenar eminence muscles
In the hand, what does the ulna nerve supply (sensory)
- all the little finger
- later half of anterior and posterior of the ring finger
In the hand, what does the median nerve supply (sensory)
- anterior of the thumb, index, middle and medial half ring finger and the according part of the palm
- the posterior tip of the thumb, index, middle and medial half of ring finger (above the distal phalangeal joints)
In the hand, what does the radial nerve supply
-the posterior of the thumb, index, middle and the medial half of the ring finger except their tips (below the distal phalangeal joints)
What can cause tenosynovitis of the hand and how
- penetrating injuries (like thorns) of the fingers
- introduces infection to the retinaculum (fibrous sheath and synovial sheath) of the finger
How is the precision grip (also called pincer’s grip) f holding a pen is produced and which muscles are involved
- abductor pollicis brevis
- flexor pollicis brevis
- opponens pollicis
- adductor pollicis
- the thumb is first abducted and flexed
- then medially rotated at the carpometacarpal joint (so it is opposed)
- the adductor pollicis is used to exert pressure on the object
Will injuries to nerves at the wrist result in total palmar sensory loss
- sensation of the palm of the fingers will be affected
- may not result in total sensory loss because the cutaneous branches of the median and ulnar nerves are given off in the foream
Explain Dupuytren’s contracture
- when the palmar fascia progressively scars and leads to shortening of the fascia
- pulls affected fingers into flexion until fingers are tightly held against the palm
- rendering the hand totally useless
- common in manual workers
- the palmar fascia arises from the flexor retinaculum and attaches to the flexor sheath of each finger
Where does the palmar fascia arise and attach to
- arises from the flexor retinaculum
- attaches to the flexor sheath of each finger
Explain trigger fingers syndrome
- when the tendon sheaths holding the tendons of each finger to the bone becomes narrowed, damaged or swollen
- the tendon cannot slide freely
- the tendon will catch and suddenly pull through like the trigger of a gun
- this is because of the steady increase of pressure of the muscle
Explain the gameskeeper’s thumb (also called skier’s thumb)
- when the thumb is rapidly forced away from the hand
- this may rupture the medial ligament of the thumb
- causes instability of the joint and any grip using the thumb is weaker eg picking up a saucepan
- called gameskeeper because the movement is like breaking a rabbits neck
- called skier’s thumb because the movement is like falling when skiing
Which carpal bone is prone to injury
- the scaphoid
- it is in direct contact with the radius so putting ur hand out to stop yourself falling will put all the force directly through the scaphoid
What is the cutaneous distribution of the median and ulnar nerves in the hand
Median - palmar lateral 3.5 digits and extends over the fingertips to posterior side up to the distal interphalangeal joint
Ulnar - palmar medial 1.5 digits and extends over the fingertips to teh posterior side up to the distal interphalangeal joint
What are the thenar muscles?
What is their nerve supply
- muscles at the base of the thumb (abductor pollicis brevis, flexor pollicis brevis and opponens pollicis)
- the median nerve
If infection occurs in the synovial flexor tendon sheath, how far will it spread in the
- middle finger
- thumb
- little finger
Middle finger - to the distal skin crease on the palm of the hand
Thumb - into the forearm
Little finger - into the forearm
Where do the synovial flexor tendon extend to for the
Thumb and little finger?
Index, middle and ring finger?
Thumb and little finger - into the forearm
Index, middle and ring finger - the distal crease on the palm of the hand
How do you test the interossei muscles
-test abduction and adduction of the fingers
What are the differences in the motor and sensory loss due to injury of the median nerve at the elbow and at the wrist?
- sensory loss will be the same for injury at the elbow and writ
- motor loss at the wrist - will paralyse the LLOAF muscles (lateral two lumbricals, opponens pollicis, abductor pollicis brevis and flexor pollicis brevis)
- motor at the elbow will paralyse the long flexor to the thumb
- both flexors to the index and middle fingers
- superficial flexors to the ring and little finger
- and LLOAF muscles
Where is a common point of origin for the superficial extensor muscles
-the lateral epicondyle of the humerus
What are the muscles of the forearm extensor compartment
Superficial compartment
- extensor carpi ulnaris
- extensor digiti minimi
- extensor digitorum (group of 4 tendons in one)
- extensor carpi radialis longus
- extensor carpi radialis brevis
Deep compartment
- extensor indicis (pulls on index finger)
- extensor pollicis longus (pulls on the thumb)
- extensor pollicis brevis (pulls on the thumb, wraps over both the extensor carpi radialis muscles)
- abductor pollicis longus (pulls the thumb away from the hand, and wraps over both extensor carpi radialis muscles too)
- supinator muscle (wraps around the radius and causes it to twist)
- all supplied by the radial nerve
- all run under the extensor retinaculum (on the back of the hand)
Give the origin, insertion, innervation and function of the extensor carpi ulnaris muscle
Origin = lateral epicondyle of the humerus
Insertion = carpal bone just beyond the wrist joint
Innervation =
Function = extends the wrist
-extends beyond the wrist joint
Give the origin, insertion, innervation and function of the extensor digiti minimi muscle
Origin = lateral epicondyle of the humerus
Insertion =
Innervation =
Function = extends the little finger
Give the origin, insertion, innervation and function of the extensor digitorum muscle
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the extensor carpi radialis brevis muscle
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the extensor carpi radialis longus muscle
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the extensor indicis muscle
Origin =
Insertion =
Innervation = radial nerve
Function = extends index finger
Give the origin, insertion, innervation and function of the extensor pollicis longus muscle
Origin =
Insertion =
Innervation = radial nerve
Function = extends the thumb
Give the origin, insertion, innervation and function of the extensor pollicis brevis muscle
Origin =
Insertion =
Innervation = radial nerve
Function = extends the thumb
Give the origin, insertion, innervation and function of the abductor pollicis longus muscle
Origin =
Insertion =
Innervation = radial nerve
Function = abducts the thumb away from the hand
Give the origin, insertion, innervation and function of the suppinator muscle
Origin =
Insertion =
Innervation = radial nerve
Function = causes the radius to twist over the ulna
Give the origin, insertion, innervation and function of the brachioradialis muscle
Origin =
Insertion =
Innervation =
Function =
Why is it possible to straighten the index finger and the little finger independently while the middle and ring finger tend to extend together
- the index, middle, ring and little finger all have the tendons of the extensor digitorum connected to them and these tendons are joined together
- the index finger also has the extensor indicis allowing straightening
- the little finger also has the extensor digiti minimi allowing straightening
Describe the division and attachment of the extensor digitorum on the dorsum of the hand
- extensor digitorum divides into 3
- the middle part attaches to the proximal phalanx
- the two lateral parts attach to the distal phalanx
Under which tendons does the radial artery pass to enter the anatomical snuff box
- the abductor pollicis longus
- the extensor pollicis brevis
Where does the subclavian artery change its name to the axillary artery-
-outer border of the first rib
Where is the 1st, 2nd and 3rd part of the axillary artery
1st - outer border of the 1st rib to the start of pectoralis minor
2nd - behind pectoralis minor
3rd - end of pectoralis minor and the lower border of pectoralis major
If the brachial artery was damaged in the antecubital fossa, which vessels would continue blood supply of the forearm
- the ulnar collateral artery
- the radial collateral artery
Between which bones does flexion and extension of the elbow occur
-humerus and ulna
Which movements occur between the humerus and the ulna
- flexion of the elbow
- extension of the elbow
Which movements occur at the elbow joint
- flexion and extension
- pronation and supination
Between which bones does pronation and supination occur
-the ulna and radius
Which movements occur between the radius and ulna
-pronation and supination
In the anatomical position the biceps does what to the elbow joint
-flexion
At a 90 degree angle to the elbow, the biceps does what to the elbow joint
-supination
What is the point of articulation of the ulna on the humerus
-the trochlear of the humerus
What is the point of articulation for the radius on the humerus
-the capitulum
How is the pad on the arm deep to the brachialis muscle useful in xrays of the elbow joint
- this fat pad does not absorb xrays as effectively so actually can be seen on an xray
- if there if damage to the elbow joint it will widen or come away from the bone
Which ligament holds the head of the radius against the ulna
- the annular ligmanent
- not actually attached to the radius
- lined by synovium and articular cartilage
What kind of joint is the wrist joint
- a condyloid joint
What kind of joint is between the trapezium and metacarpal of the thumb
-a saddle joint
What kind of joint are the metacarpophlangeal joints
-condyloid joints (has a curvature and a lesser curvature)
Give two examples of condyloid joints
- metacarpophalangeal joints
- wrist joint between the scaphoid, lunate bone and radius
What kind of joints are the interphalangeal joints
-hinge joints
What forms the extensor expansion on the posterior aspect of the fingers
-the extensor digitiorum
Which structures form the anterior border of the anatomical snuff box
- abductor pollicis longus
- extensor pollicis brevis
Which structure form the posterior border of the anatomical snuff box
-extensor pollicis longus tendon
Which muscle can be connected to the tendon of the extensor pollicis longus to repair a hammer thumb
-extensor indicis
Apart from allowing the index finger to straighten independently, what else is the extensor indicis clinically important for
-the muscle of the extensor indicis can be connected to the tendon of the extensor pollicis longus to repair a hammer thumb
What structures border the anatomical snuff box
Medially bound by the extensor pollicus longus
Laterally bound by the extensor pollicis brevis and abductor pollicis longus
Scaphoid bone forms the floor of the anatomical snuff box
What structures lie in the anatomical snuff box
- radial artery
- cephalic vein
Where are the interossei and lumbricals inserted to
-the proximal part of the extensor expansion
Explain tennis elbow
-this is damage to the lateral epicondyle of the humerus
What is golfer’s elbow
-this is damage to the medial epicondyle of the humerus
What is mallet finger
- this is when the insertion of the an extensor tendon to the distal phalanx ruptures
- the distal interphalangeal joint is held in flexion
- when examined it can be fully extended manually quite easily
-an acute injury version of mallet finger
What is swan neck finger
- when the insertion of the extensor tendon on the distal interphalageal joint ruptures
- the tip of the finger is held in flexion
- the middle slip of the extensor tendon overcompensates
- so the proximal interphalangeal joint is held in extension
- finger looks like swan neck
-this is a chronic injury version of the mallet finger
Explain a boutonniere deformity
- if the insertion of an extensor tendon to the proximal interphalangeal joint ruptures
- the distal interphalangeal joint (marginal side slips) overcompensate so the distal joint is held in extension
- the proximal interphalangeal joint pokes through the gap in the extensor tendon like a button giving the name
Muscles that produce pronation
- pronator teres
- pronator quadratus
Muscles that produce supination
- supinator
- biceps
Is the annular ligament attached to the radius
-no it is wrapped around the head (and neck) of the radius
What is the nerve supply of the extensor compartment of the forearm and what are of the skin does this nerve also supply
- radial nerve
- posterior aspect of 3.5 lateral digits up to the distal interphalangeal joint
Which bone lies in the base of the anatomical snuff box
-scaphoid
Which nerve and vein cross the anatomical snuff box superficially
- radial artery
- cephalic vein
If the thoracic 1 nerve root is damaged which group muscles will be paralysed and which area of skin will be anaesthetic
- all the muscles in the hand will be paralysed
- the skin over the medial arm is anaesthetic
Which muscle is the most powerful supinator and which position does the elbow need to be in to maximise its force
- biceps
- elbow flexed to a 90 degrees
Which fingers have two extensors and tendons
-index finger and little finger
Describe how the radius moves during pronation and supination
- the proximal radius rotates on its own axis
- the distal radius rotates round the ulna
On the lateral aspect of the knee, which structure can you feel subcutaneously
-the tibial plateau
What sits just underneath the skin of the thigh
- the fascia lata
- thinner going posteriorly and anteriorly of the thigh
Give the origin, insertion, innervation and function of the sartorius muscle
Origin = anterior superior iliac spine
Insertion = tibia
Innervation =
Function =
Give the origin, insertion, innervation and function of the tensor fascia lata muscle
Origin = deep surface of the fascia lata
Insertion =
Innervation =
Function =
Name the muscles in the anterior compartment of the thigh
quadriceps
- rectus femoralis
- vastus lateralis
- vastus medialis
- vastus intermedius
Give the origin, insertion, innervation and function of the quadriceps muscle
5 origins Origin of straight head of rectus femoris = on the hip joint on the lip of the acetabulum Origin of reflected head of rectus femoris = Origin of vastus lateralis = femur Origin of vastus medialis = femur Origin of vastus intermedius = femur Insertion = Innervation = Function =
Give the origin, insertion, innervation and function of the rectus femoris muscle
Origin = lip of the acetabulum
Origin = lateral to the lip of the acetabulum
Insertion =
Innervation =
Function = flex the hip and straighten the knee
Runs straight down the thigh
What type of muscle is the rectus femoris
-bipennate muscle
Give the origin, insertion, innervation and function of the vastus lateralis muscle
Origin = femur
Insertion =
Innervation =
Function = extend the knee
Give the origin, insertion, innervation and function of the vastus medialis muscle
Origin = femur
Insertion =
Innervation =
Function = extend the knee
Give the origin, insertion, innervation and function of the vastus intermedius muscle
Origin = femur
Insertion =
Innervation =
Function = extend the knee
Which direction is knee bent
-inwards (a valgus direction)
Are the hip, knee and ankle all on a straight line, which other structure is on this line
Yes
-the tibia
In which direction is the patella most likely to dislocate during strong contraction of the quadriceps
-laterally
Which two mechanisms counteract the lateral dislocation of the patella
- the inferior fibres of the vastus medialis muscles (they are horizontal to patella and pull it medially) (active)
- the lateral part of the groove on the femur is much more prominent than the medial part so greater mechanical resistance to patella moving laterally (passive)
Give an example of an active mechanism use to counteract the lateral dislocation of the patella
-the inferior fibres of the vastus medialis muscles (they are horizontal to patella and pull it medially)
Give an example of a passive mechanism used to counteract the lateral dislocation of the patella
-the lateral part of the groove on the femur is much more prominent than the medial part so greater mechanical resistance to patella moving laterally
Where does the long sapheanous vein run
- medial aspect of the thigh
- posterior to the sartorious muscle
Name the muscles on the medial aspect of the thigh
Adductor muscles
- adductor longus
- adductor brevis
- adductor magnus
- adductor gracilis
What structures border the femoral triangle
- the inguinal ligament
- sartorious
- adductor longus
- the floor of the femoral triangle is the pectoneus muscle
- lateral part of the floor of the triangle are iliopsoas muscle from the iliacus muscle
What vein does the long saphenous vein join
-the common femoral vein
What structures lie in the femoral triangle
- common femoral vein
- common femoral artery
- femoral nerve
- lymphatics
Where is the saphenofemoral junction
-where the long spahenous vein join the common femoral vein
Where does the neurovascular bundle of the femoral triangle lead to
- travels along sartorious
- as far as the adductor canal and through the adductor hiatus into the popliteal fossa
Which muscle divides the anterior and medial compartment of the thigh
-the sartorius muscle
Give the origin, insertion, innervation and function of the adductor magnus muscle
Origin = pubis bone
Origin = ischial tuberosity
Insertion of pubic component = shaft of the femur
Insertion of hamstring component = adductor tubercle on the medial condyle of the femur
Innervation =
Function =
Give the origin, insertion, innervation and function of the adductor gracilis muscle
Origin = pubis bone
Insertion = tibia
Innervation =
Function =
Give the origin, insertion, innervation and function of the adductor brevis muscle
Origin = pubis bone
Insertion = femur
Innervation =
Function =
Give the origin, insertion, innervation and function of the adductor longus muscle
Origin = pubis bone
Insertion = femur
Innervation =
Function =
Which nerve can be found between adductor longus and adductor brevis
-obturator nerve
What creates the adductor hiatus
-the v space between the two insertion points of the adductor magnus muscle
Which superficial vein is a primary site for varicose veins?
- long saphenous vein
- it can be used in cardiac and limb bypass surgery
Give the origin, insertion, innervation and function of the ilio-psoas muscle
Origin =
Insertion = lesser trochanter of the femur
Innervation =
Function=
What is the ligamentum patellae and where does it attach
- also called the patella ligament
- lies on top of the patella
- attached to the tibial tuberosity
What is femoral hernia
- where bowel passes in the space between the inguinal ligament and superior pubic ramus
- this is where the femoral vessels and nerve pass from the back of the abdomen into the thigh
How and where is a femoral blood sample taken from
- in front of the hip
- where the external iliac artery becomes the femoral artery
- a needle can be passed into the femoral artery to take an arterial sample
- a needle can be passed medial to the femoral artery to obtain a sample from the femoral vein
What can cause paralysis of the quadriceps
- damage or disease of the femoral nerve
- the femoral nerve supplies all the muscles in the anterior compartment of the thigh
What is the surface marking of the femoral artery and saphenous opening
Femoral artery - (within 1.5cm of) the point halfway between the pubic tubercle and the anterior superior iliac spine
Saphenous opening - 3cm below and lateral to the pubic tubercle, medial to the femoral artery (which is 3cm below the inguinal cancal)
What is the order of the femoral artery, vein and nerve in the groin
Lateral to medial
Nerve, artery and vein
Which vein becomes the superficial femoral vein? Going up the leg
The popliteal vein as it passes through the adductor canal
What is supplied by the femoral nerve? Motor and sensory
Motor - anterior compartment of the thigh
Sensory -anterior thigh skin, hip and knee joint
What are the attachments of the adductor muscles
- all take origin from the pubis bone
- all insert into the femur
Which nerve supplies the adductor muscles
-obturator nerve
What passes through the adductor canal
- superficial femoral artery
- popliteal vein
The muscles of the thigh, leg, arm and forearm are contained within a facsia so the fat is not directly on the muscles, which musces are not contained in a fascia
- pectoralis
- gluteus region
Name the muscles on the posterior aspect of the thigh
Hamstring muscles
-all originate on the ischial tuberosity
Give the origin, insertion, innervation and function of the gluteus medius muscle
Origin = posterior 2/3 of the outer wing of the ilium
Insertion = greater trochanter of the femur
Innervation =
Function =
Give the origin, insertion, innervation and function of the quadratus femoris muscle
Origin =
Insertion =
Innervation =
Function =
Which tendon runs in between the gemellus superior and gemellus inferior muscle
-the tendon of the obturator internus muscle
Give the origin, insertion, innervation and function of the gemellus superior muscle
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the gemellus inferior muscle
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the gluteus minimus muscle
Origin =
Insertion = greater trochanter of the femur
Innervation =
Function = abduction of the hip joint (pull femur outwards and greater trochanter upwards) needed for walking
Where would be advised to do an intramuscular injection in the buttocks
- the upper outer quadrant of the buttocks
- if injected in the lower medial, there is risk of the sciatic nerve damage
Describe the spread of the hamstring around the popliteal fossa
-1 muscle passes laterally to it
biceps femoris
-3 muscles pass medially to it semi membranosus, semi tendonosus
Where does the sciatic nerve supply
-posterior compartment of the thigh
Give the origin, insertion, innervation and function of the biceps femoris muscle
Origin = ischial tuberosity
Insertion = head of the fibula
Innervation =
Function = long head will extend the hip and flex the knee, the short head will only flex the knee
Give the origin, insertion, innervation and function of the semi tendinosus muscle
Origin = ischial tuberosity
Insertion =
Innervation = sciaitic nerve
Function = extend the hip, flex the knee (as cross the hip joint)
Give the origin, insertion, innervation and function of the semi membranosus muscle
Origin =
Insertion =
Innervation =
Function = flex the knee, extends the hip (as cross the hip)
What does the sciatic nerve split into
- the tibial nerve runs between the two heads of gastronemius to enter the posterior calf
- the common peroneal nerve (also called the common fibula nerve) runs laterally round the head of the fibula
Which structures form the popliteal fossa
Above laterally - biceps femoris
Above medially - semimembranosus muscle and semitendonosus muscle
Below medially - medial head of the gastronemius muscle
Below laterally - lateral head of the gastronemius muscle
Floor -plantaris muscle
What structures are present in the popliteal fossa
-the sciatic nerve dividing into the tibial nerve (running in between the two heads of gastronemius) and the common peroneal nerve (running laterally round the head of the fibula)
- popliteal artery
- popliteal vein
How many compartments does the leg have
3
Lateral, posterior and anterior
- each is supplied by a single nerve and a single artery so
- popliteal artery divides into anterior, posterior and peroneal artery
- common peroneal divides into deep peroneal and superficial peroneal nerve
Anterior
- anterior tibial artery (supplies anterior)
- deep peroneal nerve
Posterior
- posterior tibial artery (supplies posterior and the foot)
- tibial nerve
Lateral
- peroneal artery (supplies lateral)
- Superficial peroneal nerve
Where does the short saphenous vein travel
- runs up the posterior aspect of the calf
- pierces the fascia and enters the popliteal vein in the popliteal fossa
Which nerve runs alongside the short saphenous vein and what does it supply
- the sural nerve
- it supplies sensation to the back of the calf and part of the foot
Which nerve does the sural nerve branch off
-the tibial nerve
Which bone do we sit on
- the ischium
- the ischial tuberosity
Give the origin, insertion, innervation and function of the plantaris muscle
Origin = femure
Insertion = calcanium
Innervation =
Function =
Has tendon that runs on the deep surface of the gastrocnemius till the calcanium
What is sciatica and give the common anatomical cause
- compression of the sciatic nerve in the intervertebral foramina
- causing pain in the skin of the lateral thigh and leg into the foot
- prolapse of the intervertebral disc between L5 and S1 is a common cause
- the sciatic nerve arises from the L5 to S4
Explain a popliteal aneurysm
- the popliteal artery wall can be disease and the pressure of the blood can cause swelling (an aneurysm)
- high risk of clot within aneurysm or a rupture
What does the trendelenburg test do
- tests the gluteaus medius and minimus muscles
- during normal walking, when one leg is lifted off the ground, the opposite gluteus medius and minimus contract to support the pelvis in a horizontal position
- if contraction of the gluteus medius and minimus is insufficient then the pelvis will tilts so walking is difficult and looks abnormal
-the gluteus medius and minimus abduct the hip joint
What do the gluteus medius and minimus do
-abduct the hip joint
What is the function of the hip extensors and which is the most powerful
- gluteus maximus
- used for climbing up hill and up stairs
Which muscles abduct the hip and when is abduction vital to normal function
- gluteus minimus and medius
- they hold the pelvis horizontal during walking when one leg is off the ground
What structures pass through the greater sciatic foramen
- sciatic nerve
- piriformis muscle
- superior and inferior gluteal vessels
- pudendal nerves (to perineum)
Is the ischial spine palpable in the living, if so how do you palpate it
-yes through the vagina or rectum
Where is the surface marking of the sciatic nerve and why is this important
- lower inner quadrant of the buttock
- drug injection into the buttock is common so need to be aware to avoid the nerve
If the sciatic nerve is completely cut which parts of the lower limb will still have a nerve supply
- sensation from the anterior and medial thigh (femoral and obturator nerves)
- sensation from the medial dorsum of the foot up the anteromedial calf (saphenous nerve, branch of femoral)
- motor to the anterior and medial compartments of the thigh
Which major vessels supply the buttock with blood
- the superior and inferior gluteal arteries
- both branches of the posterior internal iliac artery
What is the leg
-from the knee joint to the ankle joint
Name the muscles of the anterior compartment of the leg and the dorsum of the foot
Superficial compartment
- tibialis anterior
- extensor digitorum longus
- peroneus tertius
Deep compartment
- extensor hallucis longus
- extensor hallucis brevis
- extensor digitorum brevis
Which artery and nerve supplies the anterior compartment of the leg
- anterior tibial artery
- deep peroneal nerve
Which artery and nerve supplies the posterior compartment of the leg
- posterior tibial artery
- tibial nerve
Which artery and nerve supplies the lateral compartment of the leg
- peroneal artery
- superficial peroneal nerve
What is the name of the fascia on the anterior aspect of the ankle
-the extensor retinaculum
What is the name of the fascia covering the anterior compartment of the leg
- deep fascia of the leg
- attaches to tibia medially and fibula laterally and completely surrounds the anterior compartment of the foot
Name the muscles in the lateral compartment of the leg and foot
Superficial compartment
-peroneus longus (also called fibularis longus)
Deep compartment
-peroneus brevis (also called fibularis brevis)
Give the origin, insertion, innervation and function of the peroneus longus (fibularis longus) muscle
Origin =
Insertion = base of the first metatarsal (big toe)
Innervation = superficial branch of the peroneal nerve
Function = flex the ankle joint (plantar flexion) causing toes to be pointed, pulls medial side of the foot more (dorsiflexion)
Give the origin, insertion, innervation and function of the peroneus brevis (fibularis brevis) muscle
Origin =
Insertion = base of the fifth metatarsus
Innervation = superficial branch of the peroneal nerve
Function = flex the ankle joint (plantar flexion) causing toes to be pointed, pulls lateral side of the foot more
What does the superficial branch of the peroneal nerve do
- motor to the peroneus longus (fibularis longus) and peroneus brevis (fibularis brevis) muscles
- sensation to the lateral aspect of the foot
Which nerve runs deep to the peroneus longus muscle
-the common peroneal nerve (common fibulla nerve)
Why is the common peroneal nerve (common fibula nerve) at risk
- runs behind the fibula
- so can be damaged by direct pressure or if the fibula becomes broken
Which nerve is at risk if the head or neck of the fibula is broken
-the common peroneal nerve (common fibula nerve)
What is the foot drop and indicator of and why
- damage to the common peroneal nerve
- the common peroneal nerve supplies all the muscles lift the foot up and lift the toes up
- this is a problem for walking because we need to lift the foot up to swing the leg over when we take the next step
- the patient will need to lift the knee higher to top the toes hitting the floor causing an abnormal gait (pattern of walking)
Which nerve supplies all the muscles of the anterior compartment of the leg
-the deep peroneal nerve
What forms the medial malleolus
-the lower end of the tibia
What forms the lateral malleolus
-the lower end of the fibula
Give the origin, insertion, innervation and function of the tibialis anterior muscle
Origin =
Insertion = base of the first metatarsus (big toe)
Innervation =
Function =
Give the origin, insertion, innervation and function of the extensor hallucis longus muscle
Origin =
Insertion = base of the first metatarsus (big toe)
Innervation =
Function = extend the big toe
Give the origin, insertion, innervation and function of the extensor digitorum longus muscle
Origin =
Insertion = to the base of the lateral four metatarsus
Innervation =
Function = extend the digits
Give the origin, insertion, innervation and function of the peroneus tertius muscle
Origin =
Insertion = base of fifth metatarsus (little toe)
Innervation =
Function = extend the digits
Give the origin, insertion, innervation and function of the extensor digitorum brevis muscle
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the extensor hallucis brevis muscle
Origin =
Insertion =
Innervation = deep peroneal nerve
Function =
Which artery on the dorsal aspect of the foot is a continuation of the anterior tibial artery
- dorsalis pedis pulse
- it goes between the 1st and 2nd metatarsus to enter the sole of the foot
Through which membrane does the anterior tibial artery pass to enter the anterior compartment of the leg
-through the interosseus membrane between the fibula and tibia
Which branch of the popliteal artery finished before it gets to the ankle
-the peroneal artery
Why does a fractured tibia have difficulty healing
- the lower 1/3 of the tibia has no muscle attachements so has difficulty healing
- bone receive blood supply from the muscle attached to them
- tibia is quite superficial so a fracture could pierce the skin and allw introduction of infection
- bone infection is difficult to treat because antibiotics do not penetrate mineral bone effectively
Where would ankle pulse be felt
- the dorsal pedis pulse between the first and second metatarsus on the dorsal aspect of the foot
- the posterior tibial pulse can be felt behind the medial malleous
What is a bursa
- a pocket of synovium which produces synovial fluid
- they allow tissue to slide around freely
Explain the clergyman’ syndrome
- this is when the bursa over the infra-patella tendon become damaged and inflammed
- the bursa swells restricting bending of the knee and makes kneeling painful
- clerygymen kneel regularly giving it the name
Explain compartment syndrome in relation to the lower limb
- a compartment is completely enclosed by strong fascia
- damage to structures within the compartment will lead to swelling
- swelling increases the pressure in the compartment until it exceeds the capillary perfusion pressure
- this stops blood flow and the compartment dies
- can be treated by cutting open the fascia to relieve pressure
Which nerve supplies the anterior and lateral compartments of the leg
Anterior compartment - deep branch of the common peroneal nerve (deep peroneal nerve)
Lateral compartment - superficia branch of the common peroneal nerve (superficial peroneal nerve)
Where is the deep peroneal nerve and superficial peroneal nerve at risk of damage
-where they run against the neck of the fibula just under the skin
Which artery supplies the anterior compartment of the leg
-anterior tibial artery
How many extensor tendons are there to each of the toes
Where do they originate?
Two tendons to each of the toes
Big toe - extensor hallucis longus and extensor hallucis brevis
2nd to little toe - extensor digitorum longus and extensor digitorum brevis
- the longus tendon is attached to the fibula and interosseus membrane
- the brevis tendon is attached to the dorsum calcanium and surrounding ligaments in the lateral foot
Where are the palpable pulses in the leg
- behind the knee in the popliteal fossa (between the heads of gastrocnemius muscles)
- the posterior tibial pulse (posterior to the medial malleolus)
- the dorsalis pedis (between the extensor tendons of the hallux and the second toe)
What do the nutrient arteries in bone do?
-they supply the bone marrow
Describe the movements at the ankle joint
- dorsiflexion
- plantar flexion
-the ankle joint is between the tibia and fibula mortice and the talus
Name the muscles of the posterior compartment of the leg
Superficial compartment
- gastrocnemius
- soleus
Deep compartment (flexors for the toes)
- flexor hallucis longus
- flexor digitorum longus
- tibialis posterior
Give the origin, insertion, innervation and function of the gastrocnemius muscle
Origin of lateral head =
Origin of medial head = above the condyles of the femur
Insertion = superficial aspect of the achilles tendon
Innervation =
Function = flex the knee and plantar flex the ankle
Why is the tendon of the plantaris muscle important
-the tendon can be removed and used as a graft for repairing other tissues such as cut tendons and ligaments
Give the origin, insertion, innervation and function of the soleus muscle
Origin = fibula
Insertion = calcanius
Innervation =
Function = flexing the ankle
Give the origin, insertion, innervation and function of the popliteus muscle
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the flexor hallucis longus muscle
Origin =
Insertion = 1st metatarsus (big toe)
Innervation =
Function = flex the big toe
-has a tendon that goes behind the medial malleolus to the big toe
Give the origin, insertion, innervation and function of the flexor digitorum longus muscle
Origin =
Insertion =
Innervation =
Function = flex the toes
Give the origin, insertion, innervation and function of the tibialis posterior muscle
Origin =
Insertion = base of the 5th metatarsus (little toe)
Innervation =
Function = flex the ankle and invert the foot
What is the rhyme Tom, Dick and very naughty Harry used to remember
Tom = tibialis posterior muscle Dick = flexor digitorum longus And = artery Very = vein Naughty = posterior tibial Nerve Harry = flexore hallucis longus
Describe the 4 layers of the sole of the foot
Fascia from the calcanium to the base of the toes
Superficial muscles (1)
- abductor hallucis brevis (move big toe out)
- abductor digiti minimi (move little toe out)
- flexor digitorum brevis (flex the 4 lateral toes)
Deep muscles (2)
- flexor hallucis longus (flex big toe)
- flexor digitorum longus (flex other toes)
- lumbricles (attached to the flexor longus tendons and travel to the dorsal aspect of the toe to attach to the extensor tendons)
- quadratus plantae
Deeper muscles (3)
- flexor hallucis brevis (flex big toe)
- adductor hallucis (move big toe in)
- adductor digiti minimi (move little toe)
- flexor digiti minimi brevis (flexes the metatarsophalangeal joint of the little toe)
Deepest muscles (4)
-interossei muscles (plantar and dorsal)
-interossei muscles (similar to the hand but the center digit for the foot is the 2nd toe instead of the middle finger in the hand)
the dorsal interossei (top of the foot)
-move the second toe side to side
-moves other toes away from the 2nd toe
the plantar interossei (sole of the foot)
-moves the other toes towards the 2nd toe
Which structure holds up the arch of the foot
-the fascia running from the calcanium to the base of the toes
Name the bones of the foot
- calcanium
- talus
- cuboid
- naviculum (navicular)
- medial cuniforms
- intermediate cuniforms
- lateral cuniforms
Another name of the achilles tendon
-tendo-calcaneus (calcaneal tendon)
What can cause an achilles tendon rupture?
- playing sport which requires rapid change of direction like squash
- healing is prolonged
How can long distance travel lead to deep vein thrombosis
- dehydration can lead to altered blood constituents
- prolonged inactivity reduces flow of blood
- pressure on calves can alter the endothelium of the blood vessels
- all these can lead to a deep vein thrombosis
- if the clot breaks free and travels to the right ventricle
- it can cause cardiac arrest and death
What would be the effect of damage to the common peroneal (fibular) nerve
- paralysis of the muscles in the anterior and lateral compartments
- loss of sensation down the lateral leg from the knee to the ankle and onto the dorsum of the foot including the dorsum of the medial four toes
Which muscles are attached to the achilles tendon
- gastrocnemius
- soleus
- plantaris
What is the nerve supply of the posterior compartment
-tibial nerve (branch of the sciatic nerve)
Where does the long saphenous vein start and what is its route up the limb
- starts on the medial end of the dorsal venous arch on the dorsum of the foot
- runs up anterior to the medial malleolus, just lateral to the tibialis anterior tendon
- runs up the anteromedial calf and pass posteriorly to lie over the sartorius muscle
- into the upper thigh to the apex of the femoral triangle
- joins the femoral vein 3cm below the inguinal ligament
What is the action of the peroneal muscles
- peroneal longus = ankle flexion and eversion at the subtalar joint
- peroneal brevis = ankle flexion and eversion at the subtalar joint
- tertius =ankle dorsiflexion (extension) and eversion at the subtalar joint
How many flexor tendons does each toe have and what are their origins
Big toe - one =flexor hallucis
Other toes -2 = flexor digitorum longus, flexor digitorum brevis
Longus is attached to the tibia
Brevis is attached to the calcaneum
What is the importance of the deep veins and their valves
- the deep veins transmit blood back to the heart and work using muscle pumps
- the valves only allow blood up the vein and from outside of the leg to the inside
- when a muscle is relaxed, the deep veins fill
- when the muscle contracts the blood is pumped further up the vein
What are the 3 ligaments that attach the pelvis to the femur and state from which pelvic bone they come from
- ilio-femoral (ilium)
- pubo-femoral (pubis)
- ischio-femoral (ischium)
Which two ligaments restrict extension of the hip
- ilio-femoral ligament
- pubo-femoral ligament
Femoral dislocation is more common posteriorly than anteriorly because
-there is a weakness in the hip joint as the ischio-femoral ligament does not restrict flexion of the hip
What structure travels in the gap in the acetabulum rim
-the nutrient artery feeding the femoral head in children before its fusion to the femoral neck during skeletal maturation
What feature of the acetabulum socket helps to resist dislocation of the femur
-fibrocartilagenous labrum over the hemisphere of the head of the femur
What is the risk if the neck of the femur is broken
- the blood supply to the mature head of the femur is through the arteries running in the periosteum of the neck of the femur
- so if the neck of the femur is broken, the blood supply is interrupted and the head of the femur will undergo necrosis
- so might need to be replaced
What are the four ligaments that hold the knee in place, how and where are they?
- medial collateral ligament (can also be called the tibial collateral ligament) which stops the tibia moving laterally from a straight position (runs from the medial epicondyle of the femur to the tibia)
- lateral collateral ligament (can also be called the fibula collacteral ligament) which stops the tibia moving medially from a straight position (runs from lateral epicondyle of the femur to the fibula)
- anterior cruciate ligament which stops the tibia moving forwards relative to the femur (runs from the front of the tibia to the posterior of the femur)
- posterior cruciate ligament stops the tibia moving backwards relative to the femur (runs from the posterior of the tibia to the front of the femur)
With the knee flexed at 90 degrees, all 4 of the knee ligaments are lax so the tibia can move. As the leg is brought back up in extension of the knee, at about 30 degrees which ligament is tight and at risk of rupture?
- the anterior cruciate ligament is tight
- while all the other 3 ligaments are still lax
- so it is at risk of rupture if a twisting force was introduced to the joint
-at full extension, all the knee ligaments are tight so all can share any force so less risk of damage
Which muscle is used to unlock the knee before flexion
- the popliteus muscle
- on the posterior aspect of the knee
What shape is the medial and lateral menisci
The medial is a C shape
The lateral is an O shape
Why is a medial meniscus tear more common than a lateral meniscus tear
- the lateral meniscus can move with the femur when the knee twists because it is attached at two ends
- the medial meniscus cannot move because it is attached to the capsule all the way around its perimeter so it tears
Which ligament is attached to the talus and calcanium in a D shape
- the deltoid ligament of the ankle
- on the medial side of the ankle
Which ligament travels from the fibula to the talus and from the fibula to the calcanium
- the anterior talo-fibula ligament
- the posterior talo-fibula ligament
- the fibulo-calcaneal ligament
Name the ligaments of the ankle
- the deltoid ligament (on the medial side)
- the anterior talo-fibula ligament
- the posterior talo-fibula ligament
- the fibulo-calcaneal ligament (calcaneofibular ligament)
What is osteoporosis
- a common condition in the elderly especially elderly women
- causes brittle bones
- elderly people who fall and land on their hips often fracture the neck of their femur which then needs to be surgically removed and replaced
Which structures connect the tibia and fibula bones
- superior tibiofibular joint
- inferior tibiofibular joint
- interosseus membrane
Which ligaments are commonly damaged in a sprained ankle
- the deltoid ligament (on the medial side)
- the anterior talo-fibula ligament
- the posterior talo-fibula ligament
- the fibulo-calcaneal ligament (calcaneofibular ligament)
What does the long plantar ligament on the sole of the foot do
-converts the groove on the cuboid bone into a tunnel which the tendon of the peroneus longus lies
What does the plantar calcaneonavicular ligament (also called spring ligament) do
- extends from the sustentaculum tali to the navicular bone
- its upper surface forms part of the capsule of the subtalar joint
- the head of the talus rests on the spring ligament
What structures does the interosseus talocalcaneal ligament attach
-the talus bone to the calcanium bone on the posterior aspect
Which movements of the foot allow one to walk on uneven ground
- inversion and eversion
- they take place at the subtalar joint
When the lateral border of the foot is slightly raised making the sole of the foot face laterally, the foot is
Eversed
-in eversion
- the midtarsal joint abducts
- when the foot is flat on the ground, there is medial rotation of the leg
When the medial border of the foot is slightly raised making the sole of the foot face medially, the foot is
Inversed
-inversion
- the midtarsal joint adducts
- when the foot is flat on the groun, there is lateral rotation of the leg
Which muscles invert the foot
- tibialis anterior
- tibialis posterior
Which muscles evert the foot
- peroneus longus
- peroneus brevis
At which joints does flexion, extension, inversion and eversion of the ‘ankle’ take place
- flexion and extension occur at the ankle joint (between the tibia, fibula and talus bone)
- eversion and inversion occur at the subtalar joint (between the talus and calcanium)
Which anatomical features maintain the arches of the foot
- shape of the bones (wedge shaped)
- tendons coming from the leg pulling the arch upwards
- strong ligaments running between the bones on the plantar surface
- the plantar fascia/ligament hold the front and back of the foot close together
Which nerves supply the hip joint
- the rule for nerve supply to a joint
- the nerve supplying the joint with sensation is the same as the nerve supplying the muscles that move the joint
So
- femoral (e.g rectus femoris)
- obturator (e.g adductors)
- tibial component of the sciatic (hamstrings)
What are the functions of the cruciate ligaments and how would you test them
anterior cruciate ligament
- stops the tibia moving forwards relative to the femur
- tested by the Lachman test
- put knee at 20-30 degrees of flexion (so ligament is tight) and try pulling the tibia forwards
- the tibia should not move
Posterior cruciate ligament
- stops the tibia moving backwards relative to the femur
- placing the knee at a 90 degree flexion and pushing the tibia backwards
- there should be a little movement
What is the normal angle between the femur and tibia
-about 175 degrees
