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Year 2 > Block 12 > Flashcards

Block 12 Flashcards

1
Q

Pronator teres

A
  • Medial epicondyle of humerus + coronoid process of ulnar
  • Passes obliquely across the forearm
  • Lateral surface of radius – at its midpoint
  • Median nerve (C7)
  • Inf ulnar collateral, common interosseous, ulnar, radial (proximal to distal)
  • Pronate forearm and flexes elbow joint
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2
Q

Flexor carpi radialis

A
  • Medial epicondyle of humerus
  • Base of 2nd and 3rd metacarpals
  • Median merve (C7)
  • Perforating branch from the ulnar recurrent arteries
  • Flexes and abducts wrist joint
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3
Q

Palmaris longus

A
  • Medial epicondyle of humerus
  • Distal half of reticulum and palmar aponeurosis
  • Median nerve (C8)
  • Anterior ulnar recurrent artery
  • Flexes the wrist joint and tightens palmar aponeurosis
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4
Q

Flexor carpi ulnaris

A
  • Medial epicondyle of humerus and olecranon and post border of humerus
  • Pisiform, hoof of hamate and 5th metacarpal
  • Ulnar nerve (C8)
  • Ulnar recurrent, ulnar, inf ulnar collateral
  • Flexes and adducts wrist joint
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5
Q

Flexor digitorum superficialis

A

• 1) Medial epicondyle of humerus, ulnar collateral ligament, coronoid process of ulnar,
2) Superior-anterior border of radius
• Bodies of middle plalanges of middle four digits
• Median nerve (C8)
• Ulnar recurrent, ulnar, radial, median arteries
• Flexion of proximal PIPs, metacarpals and wrist joint.

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6
Q

Flexor digitorum profundus

A
  • Proximal ¾ of medial and anterior surface of ulnar and interosseous membrane
  • Bases of distal phalanges of medial 4 digits
  • Medial = ulnar nerve (C8) & Lateral = median (C8)
  • Ulnar collateral and recurrent, ulnar, interosseous, median arteries
  • Flexes DIPs of medial 4 digits. Assists with flexion of wrist
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7
Q

Flexor pollicis longus

A
  • Anterior surface of radius and adjacent interosseous membrane
  • Base of distal phalanx of thumb
  • Anterior interosseous nerve from median nerve (C8)
  • Ant interosseous, radial
  • Flexes IP joints of thumb (1st digit) and assists in flexion of wrist joint.
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8
Q

Pronator quadratus

A
  • Distal ¼ of anterior surface of ulnar
  • Distal ¼ of anterior surface of radius
  • Anterior interosseous nerve from median nerve (C8)
  • Ant interosseous artery
  • Main pronator of the forearm
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9
Q

Bracheoradalis

A
  • Proximal 2/3 of humerus
  • Styloid process of radius
  • Radial nerve (C6)
  • Radial recurrent, radial collateral, radial
  • Flexion of elbow joint
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10
Q

Extensor carpi radialis longus

A
  • Lateral supra-epycondylar ridge of humerus
  • Base of 2nd metacarpal bone
  • Radial nerve (C6 and C7)
  • Radial recurrent artery
  • Extension and abduction of wrist joint
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11
Q

Extensor carpi radialis brevis

A
  • Lateral epicondyle of humerus
  • Base of 3rd metacarpal bone
  • Deep branch of radial nerve (C7)
  • Radial recurrent, radial
  • Extension and abduction of wrist joint
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12
Q

Extensor digitorum

A
  • Lateral epicondyle of humerus
  • Extensor expansions of medial 4 digits
  • Posterior interossus nerve (from radial nerve)
  • Radial recurrent, post interosseous arteries
  • Extends medial 4 metacarpal joints and wrist
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13
Q

Extensor digiti minimi

A
  • Lateral epicondyle of humerus
  • Extensor expansion of 5th digit
  • Posterior interossus nerve (from radial nerve)
  • Radial recurrent, post interosseous arteries
  • Extends metacarpophalygeal joints of 5th digit
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14
Q

Extensor carpi ulnaris

A
  • Lateral epicondyle of humerus and post border of ulnar
  • Base of 5th metacarpal
  • Posterior interossus nerve (from radial nerve)
  • Radial recurrent artery
  • Extends and adducts wrist joint
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15
Q

Anconeus

A
  • Lateral epicondyle of humerus
  • Olecranon and sup post ulnar
  • Radial nerve
  • Post interosseous recurrent
  • Assists in extension of elbow, stabilization of elbow, abducts ulnar in pronation
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16
Q

Supinator

A
  • Lateral epicondyle of humerus, collateral and anular ligaments, crest of ulnar
  • Proximal 1/3 of radius
  • Deep branch of radial nerve
  • Radial recurrent and post interosseous arteries
  • Supinates forearm
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17
Q

Abductor pollicis longus

A
  • Post surface or ulnar, radius and interosseous membrane
  • Base of 1st metacarpal
  • Post interosseous nerve
  • Post interosseous artery
  • Abducts and extends carpometacarpal joint of thumb
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18
Q

Extensor pollicis brevis

A
  • Posterior surface of radius and interosseous membrane
  • Base of proximal phalanx of thumb
  • Post interosseous nerve
  • Post interosseous artery
  • Extends metacarpophalangeal joint of thumb
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19
Q

Extensor pollicis longus

A
  • Posterior surface of middle 1/3 of ulnar and interosseous membrane
  • Base of distal phalanx of thumb
  • Post interosseous nerve
  • Post interosseous artery
  • Extends metacarpophalangeal and interphalangeal joints of thumb
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20
Q

Extensor indicis

A
  • Posterior surface of ulnar and interosseous membrane
  • Extensor expansion of 2nd digit
  • Post interosseous nerve
  • Post interosseous artery
  • Extends MCP and IP joints of 2nd digit and extends wrist joint.
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21
Q

What is the cutaneous innervation of the forearm?

A
  • Anterior = anterior branches of cutaneous nerves of forearm
  • Posterior = posterior branches of cutaneous nerve of forearm
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22
Q

Describe the interosseous membrane

A
  • Connect radius and ulna
  • Attachments for deep muscles of forearm
  • Transmit forces from hand and radius to the ulna and rest of forearm
  • Fully relaxes when hand is in either pronation or supination. Only tense when somewhere in between

Runs dorsomedially

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23
Q

What are the 3 compartments of the forearm? What do they contain and what is compartment syndrome?

A
  • The deep fascia, Interosseous membrane and muscular septa divide the forearm into 3 compartments.
  • Anterior superficial and deep flexor compartement (all flexors)
  • Extensor compartment (all extensors)
  • Mobile wad (bracheoradalis, extensor carpi radialis longus & brevis)
  • Fascia becomes thickened in the wrist (flexor and extensor retinacua) which hold the digital tendons in place
  • Compartment syndrome where accumulation of fluid (haemorrhage, trauma, burns) can lead to increased pressure = loss of function and possible necrosis of the muscles in that compartment.
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24
Q

What is the common flexor origin?

A

The medial epicondyle of the humerus.

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25
Q

What are the 7 characteristics of rheumatoid arthritis? How do they differ from osteoarthritis?

A

May begin at any time (40-70yrs)
Rapid disease progression (weeks-months)
Joints are painful, swollen and stiff
Begins in the small joints and progresses to the larger ones. Hips and spine normally spared
Usually symmetrical
Morning stiffness that last longer than 1h.
Frequent feelings of fatigue and being ill.

Usually begins later in life
Slow progression over years
Joints ache and may be tender but have little or no swelling
Usually in the large joints (hips, knees, spine). The joints that have greatest strain.
Usually asymmetrical
Morning stiffness that lasts <1h and returns later in the day.
Systemic symptoms are not present

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26
Q

What would you LOOK for in a hand exam?

A
  • Scars, swellings, muscle wasting, deformity
  • Skin for thinning or bruising
  • Nails for pitting, onycholysis, vasculitis
  • Symmetrical or asymmetrical
  • What joints do the changes involve
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27
Q

What would you FEEL for in a hand exam?

A
  • Peripheral pulses
  • Bulk of thenar and hypo-thenar eminences for tendon thickening
  • Median nerve sensation = thenar eminence
  • Ulnar nerve sensation = hypo-thenar eminence
  • Radial nerve sensation = 1st-2nd finger web space
  • Skin temperature
  • Tenderness in MCP joints by squeezing across the joints
  • Bimanually palpate any abnormal MCP joints
  • Bimanually palpate the wrists
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28
Q

What would you MOVE in a hand exam?

A
  • Straighten fingers fully against gravity (extensor damage)
  • Make a fist (tendon or small joint damage)
  • Wrist flexion and extension active and passive
  • Phalen’s test (forced wrist flexion for 60s) to reproduce symptoms
  • Abduction of the thumb (median nerve)
  • Finger spreading (ulnar nerve)
  • Pick a small object out of hand (pincer grip function)
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29
Q

How would you test FDS?

A

Inserts into MP of each digit. Tested by isolating MPC joint and active flexion of PIP joints.

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30
Q

How would you test FDP?

A

Inserts into DP of each digit. Tested by isolating PIP and active flexion of DIP joints.

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31
Q

How would you test FPL?

A

1˚ flexor of the thumb. Tested by isolating MCP joint and active flexion of IP joint.

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32
Q

How do you test wrist flexors?

A

FCU, FCR, PL

Should be able to feel the tendons under the skin during wrist flexion.

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33
Q

How do you test EPL?

A

1˚ extensor of thumb. Test extension of thumb IP joint by isolating MCP joint.

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34
Q

How do you test wrist extensors?

A

ECR, ECU

Function tested by extension of the wrist.

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35
Q

What are the branches of the median nerve and what do they innervate?

A

Median = All forearm extensors (-FCU and medial FDP) and elbow joint

Anterior interosseous = deep flexor muscles of forearm (-medial FDP)

Palmar cutaneous nerve = Skin of the hand

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36
Q

Describe the skin of the hand.

A

thin, thick on tip of fingers, hairless, defined stratum lucidum, high density of nerve endings and sweat glands, no sebaceous glands

The proximal crease line of the hand-forearm (there are 2) marks the proximal end of the flexor synovial sheaths.

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37
Q

What is the cutaneous vascular supply of the hand?

A

Superficial palmar branches of radial and ulnar arteries. Thenar and hypo-thenar respectively.

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38
Q

What is the cutaneous innervation of the hand?

A

Radial nerve = posterior thumb and 2-3 digits
Median nerve = Anterior thumb, 2-3 digits and ½ 4th digit
Ulnar nerve = Anterior and posterior 4-5 digits

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39
Q

What are the longitudinal ligaments of the hand?

A

All from palmar aponeurosis

1) skin attachments just before the fingers
2) = Pass into the fingers where continuous with Cleland’s ligaments
3) = wrap around the extensor tendon and insert into metacarpal.

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40
Q

What are the transverse ligaments of the hand?

A

Natatory ligament (superficial transverse metacarpal)
Deep transverse metacarpal (x3)
Transverse fivers of palmar aponeurosis

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41
Q

What are the carpal bones in order?

A

Scaphoid
Lunate
Triquetrum
Pisiform

Trapezium
Trapezoid
Capitate
Hamate

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42
Q

Describe the radioulnar joint.

A

Head of ulnar and ulnar notch of radius
Pivot type synovial joint (same with proximal R-U joint)
Articular disk
Interosseous innervation and arterial supply

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43
Q

What muscles pronate and supinate the radioulnar joint?

A

Pronation:
Pronator teres, pronator quadratus

Supination:
Supinator, biceps

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44
Q

Describe the radio carpal joint.

A

Synovial biaxial and ellipsoid joit
Radius with: lunate and scaphoid + triquetrum (T only in contact in full adduction)
Interosseous nerves and arteries
Extrinsic ligaments = carpals –> radius/ulnar
Intrinsic ligaments = carpals –> carpals

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45
Q 
What muscles provide:
Flexion of the wrist?
Extension of the wrist?
Adduction of the wrist?
Abduction of the wrist?
A

Flexion:
FCR, FCU, FDS, FDP, PL, FPL

Extension:
ECRL, ECRB, ECU, ED, EDM, EI, EPL

Adduction:
FCU, ECU

Abduction:
ECRL, ECRB, FCR, APL, EPB

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46
Q

Describe the carpometacarpal joint of the thumb.

A 
Synovial saddle joint 
1st metacarpal base and trapezium
Lateral, posterior, anterior ligaments
Radial artery
Post interosseous nerve
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47
Q 
Of the caropmetacarpal joint of thumb, what muscles provide:
Flexion
Extension
Adduction
Abduction
A

Flexion: FPB and FPL (flexion entails medial rotation)
Extension: APL, EPL, EPB
Abduction: APB, APL,
Adduction: Adductor pollicis

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48
Q

Describe the 2nd - 5th carpometacarpal joints

A 
Synovial ellipsoid joints
Strong palmar and dorsal ligaments
Interosseous ligaments
Post carpal branches of radial and ulnar arteries
Innervation = Ulnar, IO, radial, median
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49
Q

Describe the metacarpal pharyngeal joints.

A

Synovial ellipsoid joints
Each has 1 palmar and 2 collateral ligaments
Deep transverse metacarpal ligaments
Vascular = dorsal and palmar metacarpal arteries
Innervation = Median, ulnar, IO nerves

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50
Q 
Of the metacarpalphalyngeal joint of thumb, what muscles provide:
Flexion
Extension
Adduction
Abduction
A

Flexion: FDS, FDP, L, IO, FDM, FPL, FPB
Extension: ED, EI, EDM, EPL, EPB
Adduction: IO, AP
Abduction: IO, ED, ADM, APB,

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51
Q

Describe the interphalyngeal joints

A 
Synovial uniaxial hinge joints
•	Palmar ligament (volar plate)
•	Collateral ligaments (x2)
Vascular = palmar digital arteries
Innervation = palmar digital branches of median nerve
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52
Q

What muscles flex and extend the interphalangeal joints?

A

Flexion: FDS, FDP, FPL
Extension: ED, EDM, EPL, APL, EPB

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53
Q

Describe the flexor retinaculum and the contents of the carpal tunnel.

A

Medial attachment = pisiform + hook of hamate
Lateral attachment = scaphoid and trapezium.
Forms the carpal tunnel with the carpal arch underneath
• Flexor digitorum superficialis and profundus
• Median nerve
• Flexor pollicis longus
• Flexor carpi radialis
Crossed superficially by ulnar vessels and nerves. But another band crosses this neurovascular bundle forming Guyon’s canal that can be a site of ulnar nerve entrapment.

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54
Q

Flexor pollicis brevis

A
  • Tubercle of trapezium and flexor retinaculum
  • Proximal phalanx of thumb
  • Lateral terminal branch of median nerve
  • Sup palmar branch of radial artery
  • Flexes thumb at metacarpophalangeal joint
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55
Q

Abductor pollicis brevis

A
  • Flexor retinaculum
  • Radial side of proximal phalanx of thumb
  • Lateral terminal branch of median nerve
  • Sup palmar branch of radial artery
  • Abducts the thumb
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56
Q

Opponens pollicis

A
  • Tubercle of trapezium and flexor retinaculum
  • Lateral margin of metacarpal of thumb
  • Lateral terminal branch of median nerve
  • Sup palmar branch of radial artery
  • Flexes metacarpal of thumb
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57
Q

Adductor pollicis

A
  • Oblique head (capitate, base of 1+2) and transverse head (metacarpal 3)
  • Base of proximal phalanx and extensor hood of thumb
  • Deep branch of ulnar nerve
  • 1st palmar metacarpal artery
  • Adduction of the thumb
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58
Q

Flexor digiti minimi brevis

A
  • Hook of hamate, flexor retinaculum
  • Base of proximal phalanx of 5
  • Deep branch of ulnar nerve
  • Deep palmar branch of ulnar artery
  • Flexion of little finger
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59
Q

Opponens digiti minimi

A
  • Hook of hamate, flexor retinaculum
  • Ulnar margin of 5th
  • Deep branch of ulnar nerve
  • Deep palmar branch of ulnar artery
  • Flexes 5th = forward and lateral rotation
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60
Q

Abductor digiti minimi

A
  • Pisiform and tendon of FCU
  • Proximal phalanx of 5th
  • Deep branch of ulnar nerve
  • Deep palmar branch of ulnar artery
  • Abducts little finger
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61
Q

Palmar interossei

A
  • x3 for 2nd, 4th and 5th
  • Whole length of metacarpal
  • Middle finger facing side of corresponding proximal phlange.
  • Deep branch of ulnar nerve
  • Deep palmar arch and perforating arteries
  • Adduct the fingers
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62
Q

Dorsal interossei

A
  • Four bipennate muscles (2 for the middle finger)
  • Arise from metacarpal and adjoining metacarpal
  • Insert into proximal phalanx above the muscle
  • Deep branch of ulnar nerve
  • Dorsal metacarpal arteries, palmar metacarpal arteries
  • Abduct the fingers
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63
Q

Palmaris brevis

A
  • Flexor retinaculum
  • Dermis on ulnar border of hand
  • Superficial branch of ulnar nerve
  • Ulnar end of superficial palmar arch
  • Hollows the palm, wrinkles skin and secures palmar grip
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64
Q

Lumbricals

A
  • x4
  • From the tendons of the flexor digitorum profundus (first 2 are unipennate. 3rd and 4th are bipennate from opposite sides of adjacent tendons)
  • Radial side of corresponding finger
  • 1+2 = median nerve, 3+4 = deep branch of ulnar nerve
  • Corresponding palmar digital arteries
  • Both flexion and extension of the fingers
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65
Q

What are the 3 grades of soft tissue injury?

A
  • 1st = minor contusion with bleeding | minimal pain | minimal impairment
  • 2nd = moderate contusion and structural tearing. Overall structure intact | bruising, pain, spasm | joint stable but painful, may be some loss of power
  • 3rd = totally torn, considerable loss of function and strength, Require surgical repair.
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66
Q

What is the immediate management strategy for soft tissue injury?

A

PRICE

Protection, rest, ice, compression, elevation

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67
Q

When might surgical intervention be needed in wounding?

A
  • Heavily contaminated
  • Nerve damage (suspected?)
  • Vascular damage (suspected?)
  • Loss of tendon function
  • Communicates with joint cavity – high possibility for infection
  • When there is underlying fracture
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68
Q

What are the different ways of naming fractures? describe them.

A 
Simple/closed = skin intact
Open/compound = breach in skin and soft tissue
Undisplaced = <2mm fracture with no movement
Displaced = large movement of bone shards
Oblique = diagonal fracture
Comminuted/fragmentary = lots of shards
Spiral = twisting force to form spiral damage
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69
Q

What is osteitis deoformans?

A

-

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70
Q

What are some factors that can cause bone weakening?

A

degenerative (osteoporosis), congenital, tumor, cysts

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71
Q

What is the difference between an avulsion fracture and a stress fracture?

A

Avulsion = occur at point of tendon/ligament attachment = failure of bone in tension = abnormal bone

Stress = repeated abnormal stress to bone. Could be normal stress in abnormal bone of extensive stress on normal bone.

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72
Q

What are the main aims of good fracture management?

A
  • Heals in a good position
  • Joints to have full range of movement
  • Limb regains normal strength and function (as quickly as possible)
  • Person able to take up pervious role in society
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73
Q

What is the algorithm of ATLS?

A
  • 1˚ survey = ABCDEE (disability & exposure/environment)
  • Resuscitation = O2, ventilation, fluids, vitals
  • 2˚ survey = complete evaluation (top to toe) and diagnostic tests
  • Definitive care = final treatment

If something changes to the patient and they start to get worse, start again from the beginning. Their airway may have occluded while you are working on them.

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74
Q

What are the main signs of fracture?

A
  • Local tenderness
  • Crepitus = ends of fracture running over each other
  • Deformity (may be ±)
  • Swelling
  • Loss of function and movement
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75
Q

What are the methods of fracture treatment?

A
  • Reduction
  • External fixation
  • Casts
  • Internal fixation
  • Physiotherapy
  • Look at psychological impact (PTSD etc.)
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76
Q

What are the 2 types of pain. Each of these types can be either chronic (>3m) or acute

A

• Nociceptive pain (acute tissue damage).
Somatic = localized and easily described.
Visceral pain = poorly localized and associated w/ autonomic changes. Responds well to conventional analgesics.

• Neuropathic pain (structural neural damage). Peripheral or central.
Usually associated with altered sensation.
Burning, shooting, lancinating.
Responds POORLY to conventional analgesics.

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77
Q

What is the gate theory of pain?

A

Nociceptor and touch fibers both synapse onto the same inter-neuron. A-delta fiber stimuli can inhibit the 2˚ central nociceptor by activating the inhibitory inter-neuron.

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78
Q

What are hyperalgesia and allodynia?

A

Both are increased sensitisation to pain.

Hyperalgesia = increased sensitivity to NOXIOUS stimuli. Mainly due to cell damage and released chemicals.

Allodynia = intense hyperalgesia to something that does not normally produce pain.

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79
Q

What are some individual behavioural factors which can influence perception of pain?

A
  • Fear avoidance
  • Somatization = manifestation of mental health issues as physical pain
  • Catastrophising = excess worry associated with development of pain (pain→no job→no mortgage→no house→no wife→no children→ etc…)
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80
Q

What are the positive and negative aspects of pain?

A
  • Positive = sympathy, support, attention
  • Negative = loss of income, altered family role, discomfort
  • (Depending on the person these will be different and individual +ve could be –ve etc.)
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81
Q

What is the biopsychosocial model of pain?

A
  • Bio = physiological dysfunction or neurological pain
  • Psycho = illness behavior, beliefs, coping, emotions, distress
  • Social = culture, social interactions, sick role
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82
Q

What are the main different treatments for pain?

A
  • Physical therapy: exercise, hydrotherapy, TENS, yoga, accupuncture
  • Psychological approach: education, coping, CBT, management programmes
  • Non-drug interventions
  • Drugs
  • Self help programms
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83
Q

What is TENS?

A

–

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84
Q

What is mindfulness therapy?

A

–

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85
Q

What are the classical features of osteoarthritis?

A
  • Most common joint disorder
  • Not symmetrical
  • DIP, PIP, large weight bearing joints
  • Less inflammation
  • Symptoms increase with activity
  • Short <1h morning stiffness.
  • Increases with age
  • Women more likely
  • Some genetic component
  • Obesity = increased stress on joints (also manual labor etc.)
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86
Q

What are the treatment options for osteoarthritis?

A
  • Patient education
  • Pain relief
  • Exercise and strengthening
  • Surgical options
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87
Q

Describe in brief, gout.

A
  • Most painful joint disorder
  • Acute onset
  • Big toe MTP joint commonly
  • 1-2% prevalence in UK
  • Most common inflammatory arthritis in men
  • Male:female 5:1
  • Prevalence increases with age
  • Co-morbidities are common (renal impairment, CVD, metabolic syndrome, renal stones)
  • Non-modifiable: age, gender, race, genetics,
  • Modifiable: hyperuricaemia, high-purine diet, alcohol, obesity, diuretics
  • Almost linear relationship between gout levels and recurrence of gout attacks
  • Steak, seafood, alcohol (particularly beer+spirits) are very high in purines = increased gout risk
  • Obesity = risk increase with BMI

Caused by crystallisation of uric acid in the joints
Causes irritation + inflammatory reaction

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88
Q

Describe in brief, septic acthritis.

A
  • Sudden onset
  • Fever
  • Sweats
  • Rigors
  • Temperature
  • Steroids, immunosuppression, antibiotic treatment?
  • Trauma
  • Recent infection/septicemia
  • IV drug user

Joint is: swollen, red, hot, fixed, only one.

Treatment/Dx: aspiration, FBC, LFT, renal function, blood culture, imaging

S. aureus is most common organism

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89
Q

Describe the hip joint.

A

Multiaxial ball and socket joint
It has high stability at the expense of movement
Flexion, extension, abduction, adduction, lateral rotation and medial rotation
Head of femur with lunate surface of acetabulum
High levels of joint congruity with bony surfaces and acetabular labrum

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90
Q

What are the ligaments of the hip joint?

A

Transverse acetabular ligament = bridges the lower part of teh acetabular notch and convertes it into a fossa

Ligament of head of femur = fovea of femur to acetabulum. Carries a branch of the obturator artery which is important during bone development

Iliofemoral ligament = inverse Y, ilium and intertrochanteric notch of femur

Pubofemoral ligament = Anterioinferior to hip joint
iliopubic emenence to inferior surface of iliofemoral ligament

Ischiofemoral ligament = posterior to hip, ischium to greater trochanter. Deep to other ligaments

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91
Q

What are the major passageways through the pelvis?

A

Obturator canal
Greater sciatic foramen
Lesser sciatic foramen
Gap between inguinal ligament and pelvic bones

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92
Q

What is carried in the obturator canal?

A

The obturator nerve and vessles

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93
Q

What is carried in the greater sciatic foramen?

A

Divided into 2 by the piriformis muscle.

Superior = sup. gluteal nerves and vessels

Inferior = sciatic nerve, inferior gluteal nerve and vessels, pudendal nerve (out), nerve to obturator internus, nerve to quadratus femoris

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94
Q

What forms the lesser sciatic foramen and what is carried though it?

A

Sacrospinous ligament
Sacrotuberous ligament

Tendon of obturator internus
Internal pudendal nerve and vessels (in) to enter below levator ani muscles

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95
Q

What is carried in the gap between the inguinal ligament and the pelvic bones?

A

Psoas major and minor, iliacus

Femoral nerve and vessels

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96
Q

Describe the deep fascia of the thigh.

A

Fascia lata
A stocking like covering of the thigh, just below the superficial fat and fascia.
Continuous with the deep (Scarpa’s) fasica of the abdomen
Thickened laterally into the iliotibial tract which is a major point of attachment for muscles
Has a saphenous opening for the superficial saphenous vein.

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97
Q

What is the femoral triangle? Describe its borders and what is carried in it.

A

Depression between the muscles of the upper thigh
Base = inguinal ligament
Medial = adductor longus
Lateral = sartorius
Floor = pectineus, adductor longus, iliopsoas
Apex = contiunues into the adductor canal which lies deep to the sartorius

Carries the femoral vein –> artery –> nerve
(medial to lateral)

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98
Q

What are the 7 pelvic ligaments? (not incluiding ligaments of the hip joint).

A 
Obturator membrane
Inguinal ligament
Iliolumbar ligament
Anterior sacroiliac ligament
Posterior sacroiliac ligament
Sacrotuberous ligament
Sacrospinouis ligament
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99
Q

Piriformis

A

Anterior surface of sacrum (L1-L4)
Greater trochanter of femur
L5-S2
Superior gluteal artery (from post int iliac)
Laterally rotates and extends hip. Adductor of flexed hip

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100
Q

Obturator internus

A 
Internal surface of obturator foramen
Greater trochanter of femur
Nerve to obturator internus
Obturator artery
Laterally rotates thigh. Abducts flexed thigh
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101
Q

Obturator externus

A 
External surface of obturator foramen
Intertrochanteric fossa of femur
Posterior branch of obturator nerve
Obturator and circumflex femoral arteries
Laterally rotates thigh. Abducts flexed
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102
Q

Gemellus inferior

A 
Upper ischial tuberosity
Greater trochanter
Nerve to quadratus femoris
Medial circumflex femoral artery
Lateral rotator of thigh
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103
Q

Gemellus superior

A 
Dorsal ischial spine
Greater trochanter
Nerve to obturator internus
Internal pudendal artery
Laterally rotates thigh
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104
Q

Quadratus femoris

A

Upper ischial tuberosity
Quadrate tuberosity in the intertrochanteric fossa of femur
Nerve to quadratus femoris
Inferior gluteal and circumflex femoral arteries
Laterally rotates thigh

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105
Q

Tensor fascia latae

A

Anterior 5cm of iliac crest
Iliotibial tract of fascia latae
Superior gluteal nerve
Superior gluteal and circumflex femoral arteries
Extends knee with lateral rotation. Mainly a postural muscle

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106
Q

Gluteus maximus

A

Posterior gluteal line of ilium, iliac crest and sacrum
Gluteal tuberosity and iliotibial tract
Inferior gluteal nerve
Inferior gluteal artery
Extension of flexed thigh. Raising trunk after stooping

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107
Q

Gluteus medius

A 
Just below external iliac crest
Greater trochater of femur
Superior gluteal nerve
Superior gluteal artery
Abducts thigh and raises contralateral pelvis during swing phase of walking. Prevents hip drop = Trendelenburg's sign
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108
Q

What is Trendelenburg’s sign?

A

A hip drop when walking. Suggests damage/paralysis of the gluteus medius and minimus of the contralateral side.

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109
Q

Gluteus minimus

A

Outer ilium between anterior and inferior gluteal lines
Greater trochanter
Superior gluteal nerve
Superior gluteal artery
Abducts thigh and raises contralateral pelvis during swing phase of walking. Prevents hip drop = Trendelenburg’s sign

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110
Q

Psoas major

A

Anteriolateral surfaces of all 5 lumbar vertebrae
Lesser trochanter of femur
L1-L3
Iliolumbar artery
Acts with iliacus (as iliopsoas) to flex the thigh and raise the trunk when the pelvis is fixed (sit-up)

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111
Q

Psoas minor

A 
Anteriolateral surfaces of T12-L1
Superior pubic ramus 
L1
Lumbar arteries
Weak flexion of the trunk

Only present in 60% of the population

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112
Q

Iliacus

A 
Superior interior 2/3 of iliac fossa
Lesser trochanter of femur
Femoral nerve
Iliolumbar arteries
Acts with psoas major (as iliopsoas) to flex the thigh and raise the trunk when the pelvis is fixed (sit-up)
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113
Q

Sartorius

A 
ASIS
Medial, proximal tibia
Femoral nerve
Femoral and profunda femoris arteries
Flexion of leg and thigh. Slight abduction and lateral rotation of thigh
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114
Q

Rectus femoris

A 
ASIS, supracetabular groove and hip capsule
Posteior border of patella
Femoral nerve
Profunda femoris artery
Extension of leg and flexion of thigh.
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115
Q

Vastus medialis

A 
Intertrochanteric line of femur
Medial border of patella
Femoral nerve
Profunda femoris artery
Extension of leg and flexion of thigh.
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116
Q

Vastus lateralis

A 
Intertrchanteric line of femur
Lateral border and base of patella
Femoral nerve
Profunda femoris artery
Extension of leg and flexion of thigh.
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117
Q

Vastus intermedius

A 
Anteriolateral upper 2/3 of femur
Laterla border of patella
Femoral nerve
Profunda femoris artery
Extension of leg and flexion of thigh.
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118
Q

Gracilis

A

Medial margin of lower 1/2 of body of pubis
Superior medial tibia
Obturator nerve
Profunda femoris artery
Adduction of the thigh with flexion and slight medial rotation of the leg

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119
Q

Adductor longus

A 
Front of body of pubis
Linea aspera in middle of femur
Obturator nerve
Profunda femoris artery
Adduction of the thigh with flexion and slight medial rotation of the leg
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120
Q

Adductor brevis

A

Front of body of pubis, posterior to adductor longus
Medial border of linea aspera. Above longus
Obturator nerve
Profunda femoris artery
Adduction of the thigh with flexion and slight medial rotation of the leg

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121
Q

Adductor magnus

A 
Ischiopubic ramus and ischial tuberosity
Linea aspera on mid femur
Obturator nerve
Profunda femoris artery
Adduction of the thigh with flexion and slight medial rotation of the leg
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122
Q

Pectineus

A 
Superior pubic ramus
Superiomedial humerus
Femoral nerve
Medial circumflex femoral artery
Adducts thigh and flexes it on pelvis
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123
Q

Semitendinosus

A

Inferiomedial, posterior ischial tuberosity
Upper surface of tibia
Sciatic nerve
Medial circumflex femoral artery
Flexes leg + extends thigh with slight medial rotation.

124
Q

Semimenbranosus

A

Superomedial posterior ischial tuberosity
Upper surface of tibia
Sciatic nerve
Perforating femoral arteries
Flexes leg + extends thigh with slight medial rotation.

125
Q

Biceps femoris

A

Long head = inferiomedial posteior ischial tuberosity
Short head = lateral line aspera of femur
Head of fibula
Sciatic nerve
Medial circumflex femoral artery
Flexes leg + extends thigh with slight medial rotation.

126
Q

Describe the arachiodonic metabolism pathway.

A

–(Phospholipase A2) –> Arachidonic acid –(COX)–> Cyclic endoperoxides –(lots of enzymes)–> Prostaglandins

Arachidonic acid –(5-lipoxygenase)–> leukotrienes

127
Q

What are the 3 types of prostanoid?

A

Classic prostaglandins (PGE2, PGD2, PGF2)

Thromboxane A2

Prostacycline

128
Q

What is the function of ‘classic prostaglandins’?

A

Vasodilation
Vasopermeability
Inflammatory reaction
Nociceptive sensitisation

129
Q

What is the function of thromboxane A2

A

Platelet aggregation and vasoconstriction

130
Q

What is the function of prostacycline (PGI2)?

A

Inhibition of platelet aggregation and vasoconstriction

131
Q

What is the function of leukotrienes?

A

Increase vascular permeability
Promote leukocyte chemotaxis
Contraction of bronchial smooth muscle

132
Q

What are the 2 isoforms of COX and their function?

A

COX-1 = GI protective, platelet aggregation, systemic

COX-2 = Induced at sites of inflammation and promotes production of prostanoids and leukotrienes

133
Q

What are the statistics of falls?
Chance
Result in fracture
Ecocnomics

A

30% of over 65s have a fall every year
10% of falls result in serious injury
1-2% of falls result in hip fracture
Around 2 billion is spent every year on falls and their consequences.

134
Q

What is the morbidity and mortality of hip fractures resulting from falls?

A

Because of age and other diseases.
20% die within 1 year
50% no longer live independently

135
Q

What are the methods of bone protection in the elderly?

A
  • Hip protectors don’t work and people don’t wear them. No benefit and some possibility of harm. DONT USE THEM
  • Bisphosphonates = reduces hip fractures by around 30%
  • Calcium and vitamin D = together has reduction of around 10-15% (vitamin D alone has no effect)
  • HRT reduces hip fractures by around 20-30% lots of side effects for opposed oestrogens but can take unopposed oestrogens with hysterectomy.
136
Q

What are the risk factors for fracture resulting from falls?

A
  • Bone mineral density (important but other factors outweigh it)
  • Age = every 5yrs doubles your risk
  • Women (menopause and living longer)
  • Family history
  • Lower body weight (fat tissue producing oestrogens and physical padding)
  • Prior history
  • Smoking
  • Ethnicity (quite high risk is Caucasian)
  • Corticosteroid use
137
Q

What are the risk factors for alls?

A
  • Muscle weakness
  • History of falling
  • Eyesight problems
  • Balance defects
  • Gait defects
  • Medical conditions (arthritis, depression, cognitive impairment, neuropathy)
  • Age
  • Drugs (psychotropic, anti-arrhythmics, diuretics, polypharma)
138
Q

What are the methods of fall prevention?

A
  • Reducing medication
  • Occupational therapist assessing home environment
  • Podiatry = footwear, ankle supports, exercises
  • Strength and balance training
  • Education and information
139
Q

How are patients assessed when they have fallen?

A
  • Risk factors
  • Coping strategies
  • Psychological consequences
  • Osteoporotic risk
  • Rehabilitation (overcome fear of falling and depression)
140
Q

Why is supporting the decision making of vulnerable patients important?

A
  • Difficult to make decisions for themselves
  • Vulnerable to abuse and exploitation
  • Patients can be stigmatised, disempowered, ‘stripped of personhood’
  • Happier if can make decisions for themselves
  • Respecting autonomy
  • Positive and stronger patient-doctor interaction
  • Professional and legal requirement.
141
Q

What are the 5 main principles of the Mental Capacity Act (2005)

A
  • A person is assumed to have capacity unless presumed otherwise.
  • Patients are not treated as unable to make a decision unless all steps to help understanding have been taken
  1. Different forms of communication (pictures, signs etc.)
  2. Initially treating condition which may affect capacity
  3. Attempts to improve capacity
  • A patient is not treated as incompetent merely because he makes unwise decision
  • An act done on behalf of a patient that lacks capacity must be done ‘in his best interest’
  • Before an act is done, a decision must be made as to whether the purpose can be achieved in a less damaging and restrictive way.
142
Q

What are the main criteria for assessing capacity?

A
  • Understand relevant information
  • Retain information
  • Use information to weigh decision making process
  • Communicate their decision by some means
143
Q

What are advance directives and advance wish statements. What is the difference between them?

A

Advance directives are legally binding and are made when a patient has capacity as to what they wish to happen in the case of lacking capacity (e.g. DNR). Only give the patient the power to REFUSE a treatment, not to request. Requests can be part of advance wish statements but these are not legally binding.

144
Q

What are the nerve roots that control action of the hip and knee?

A
  • Flexion of hip (L2-L3)
  • Extension of hip (L4-L5)
  • Flexion of knee (L3-L4)
  • Extension of knee (L5-S1)

Similar to the arm. Each action is supplied by two nerve roots. The opposite action is supplied 2 segments lower down. Going down 1 joint moves the nerve roots down 1 segment.

145
Q

What is the order of corticosteroid potency?

A 
Cortisone (0.8)
Hydrocortisone (1)
Prednisolone (4)
Dexamethasone (30)
Betamethasone (30)
146
Q

Describe the components of the knee.

A

Articular surfaces of the femur (medial and lateral epicondyles ) and the tibia (medial and lateral condyles)

Articulation between the femur and patella

2x collateral ligaments
Anterior and lateral cruciate ligaments
Ligament of the popliteus muscle entering the capsule
2x meniscus within the joint

147
Q

Describe the two menisci within the knee joint.

A

Lateral = attached to popliteus but not lateral collateral ligament
Medial = attached to the medial collateral ligament.
Both are connected anteriorly by transverse meniscal ligament

Function:
• Increase joint congruity
• Increase stability
• Increase distribution (without a meniscus, loading is 3x greater)
• Decrease loading stress
• Increase synovial fluid distribution to the entirety of the joint

148
Q

Describe the attachment of the popliteus within the knee joint/

A

Lateral meniscus, femoral condyle, and posterior capsule. This means it pulls the meniscus and capsule out of the way when it laterally rotates the femur.

149
Q

What anatomical structures prevent the patella rising with a slight angle, towards the ASIS when the knee is flexed?

A

Large lateral femoral condyle

Medial attachment of the vastus mediais to the patella.

150
Q

What ligament is the axis for knee locking?

A

Anterior cruciate ligament

151
Q

What are the boundaries of the popliteal fossa?

A
  • Sup = biceps femoris and semimembranosus/semitendinosus
  • Inf = heads of the gastrocnemius
  • Roof = fascia lata
  • Floor = knee joint
  • Superficial to deep = nerve → vein → artery
152
Q

What is the difference between a valgus deformity and a varus deformity.

A

Valgus = lateral (outward) deformity e.g. knock knees

Varus = medial (inward) deformity

153
Q

What is the triple tendon that attaches to the proximal shaft of the femur?

A

Pes anseuresis = formed from the medial muscles of the popliteal fossa

Sartorius
Gracilis
Semitendinosus

154
Q

What are the 3 main bursas of the knee joint?

A

Subcutaneous patella = superficial to patella ligament
Deep infra patella = deep to patella ligament
Prepatella = superficial to patella

155
Q

What is the function of the collateral ligaments of the knee?

A

Stabilisation of rotation of the hinge joint. Prevent lateral and medial movement.

Lateral collateral ligament is a thin cylinder that is not attached to any joint structures
Medial collateral ligament is a thick, flat band that attaches to the meniscus within the joint

156
Q

What is the function of the cruciate ligaments within the knee joint?

A

Anterior = prevents anterior displacement of tibia on a fixed femur.

Posterior = prevents posterior displacement of tibia on a fixed femur.

157
Q

Describe the locking mechanism of the knee.

A

When the knee is fully extended, there is a slight medial rotation of the femur to move the two broad, flat articulating surfaces into contact.
This tightens all of the ligaments to hold the knee in that position.
The knee is back slightly to place the centre of gravity in front of the knee to prevent unlocking.

The popliteus is a lateral rotator of the knee joint and functions to unlock it.

158
Q

What are the notable structures on the tibia bone?

A 
Tibial tuberosity
Anterior border
Interosseous border
Medial maleolus 
Soleal line
Groove for tibialis posterior
159
Q

Gastrocnemius

A

• Medial head = upper medial epicondyle of femur
Lateral head = lateral surface of lateral epicondyle
• Aponeurosis that forms calcaneal tendon and inserts into calcaneal tuberosity
• Tibial nerve
• Perforating sural arteries from popliteal artery
• Action with soleus (plantarflexion of the foot and flexion of the knee)

160
Q

Plantaris

A
  • Lateral supracondylar line of humerus
  • Calcaneus, medial to calcaneal tendon
  • Branches of tibial nerve
  • Popliteal artery
  • Vestigial muscle, week plantarflexor of the foot
161
Q

Soleus

A
  • Posterior surface of head and upper ¼ of shaft of femur (soleal line)
  • Joins with gastrocnemius to form calcaneal tendon and insert into calcaneal tuberosity
  • Tibial nerve
  • Superior = popliteal artery & inferior = fibular artery
  • Action with gastrocnemius (plantarflexion of the foot and flexion of the knee)
162
Q

Flexor digitorum longus

A
  • Medial side of posterior tibia
  • Plantar surfaces of distal phalanges of 2nd to 5th metatarsals
  • Tibial nerve
  • Posterior tibial artery
  • Flexion of 2nd to 5th metatarsals
163
Q

Flexor hallucis longus

A
  • Posterior surface of fibular and IO membrane
  • Plantar surface of distal phalanx of 1st metatarsal
  • Tibial nerve
  • Fibular artery
  • Flexion of great toe
164
Q

Tibialis posterior

A
  • Posterior surface of IO membrane and adjacent tibia and fibula
  • Tuberosity of navicular and medial cuneiform
  • Tibial nerve
  • Posterior tibial artery
  • Inversion and plantarflexion of foot. Also supports the arch during walking
165
Q

Popliteus

A
  • Lateral femoral condyle
  • Posterior and medial surface of proximal tibia
  • Tibial nerve
  • Posterior tibial artery
  • Stabilisation of knee and lateral rotation of femur = unlocking
166
Q

Fibularis longus

A
  • Head and upper lateral surface of fibula
  • Plantar surface of medial cuneiform and base of metatarsal 1
  • Superficial fibular nerve
  • Superficial tibial and fibular arteries
  • Eversion and plantarflexion of the foot. Also supports the arch during walking.
167
Q

Fibularis brevis

A
  • Distal 2/3 of the fibular shaft
  • Lateral tubercle of metatarsal 5
  • Superficial fibular nerve
  • Superficial tibial and fibular arteries
  • Eversion of the foot
168
Q

Tibialis anterior

A
  • Lateral, anterior tibia and adjacent IO membrane
  • Medial cuneiform and metatarsal 1
  • Deep fibular nerve
  • Anterior tibial artery
  • Dorsiflexion and the foot and ankle. Inversion of the foot and dynamic support of medial arch.
169
Q

Extensor hallucis longus

A
  • Middle ½ of medial tibia and adjacent IO membrane
  • Dorsal surface of distal phalanx of great toe
  • Deep fibular nerve
  • Anterior tibial artery
  • Extension of great toe and dorsiflexion of foot
170
Q

Extensor digitorum longus

A
  • Proximal 1/2 of medial tibia and fibula
  • Bases of distal and middle phalanges of 2nd to 5th metatarsals
  • Deep fibular nerve
  • Anterior tibial artery
  • Extension of lateral 4 toes and dorsiflexion of foot
171
Q

Flexor tertius

A
  • Distal, medial surface of fibula
  • Dorsomedial surface of metatarsal 5
  • Deep fibular nerve
  • Anterior tibial artery
  • Dorsiflexion and eversion of foot
172
Q

What are the tarsal bones?

A 
Talus
Calcaneus
Navicular
Cuboid
3x cuneiforms (medial, intermediate, lateral)
173
Q

What is the ankle joint proper? Describe it.

A

Talocrural joint
Articulation between the talus and the tibia/fibula
Synovial joint
Allows dorsiflexion and plantar flexion of the foot

Roof = inferior surface of distal tibia
Medial side = medial malleolus of tibia
Lateral side = lateral malleolus of fibula

Stabilised by:
Deltoid ligament medially
Lateral ligaments

174
Q

What are the 4 components of the medial deltoid ligament of the ankle?

A

Tibionavicular
Tibiocalcaneal
Posterior tibiotalar
Anterior tibiotalar

175
Q

What are the 3 lateral ligaments of the ankle?

A

Anterior talofibular
Posterior talofibular
Calcaneofubular

176
Q

Name all of the inter tarsal joints.

A 
Subtalar joint
Talocalcaneonavicular joint
Calcaneocuboidal joint
Calcaneonavicular joint
Cuneiform/cuneiform/navicular joints
177
Q

Describe the subtler joint of the ankle.

A

Synovial
Allows gliding and rotational movement
Inversion and eversion of the foot
Stabilised by talocalcaneal ligaments

178
Q

Describe the tarsometatarsal joints.

A

Synovial plane joints
Allow limited sliding movement
Greatest movement is between the medial cuneiform and 1st metatarsal

179
Q

Describe the metatarsophalangeal joints.

A 
Ellipsoid synovial joints
Mainly extension and flexion (limited sideways movement)
Medial and lateral collateral ligaments
Plantar ligaments
Deep transverse metatarsal ligaments
180
Q

Describe the interphalangeal joints of the foot.

A

Synovial hinge joints
Allow flexion and extension
Medial and lateral collateral ligaments

181
Q

What is the flexor retinaculum of the ankle? What is contained within the tarsal tunnel?

A

A fibrous covering between the medial malleolus and the medial talus/calcaneus
It is the roof of the tarsal tunnel

FDL tendon
TP tendon
Tibial artery and vein
Tibial nerve
FHL tendon
(medial --> lateral)
182
Q

What is the extensor retinaculum of the ankle? What is contained within it?

A

Two ligaments:
Sup. = anterior tibia and fibular
Inf. = ‘Y’ calcaneus and medial malleolus and plantar aponeurosis

TA tendon
EHL tendon
Dorsalis pedis artery
FT tendon
EDL tendon
(medial --> lateral)
183
Q

What is the extensor retinaculum of the ankle? What is contained within it?

A

Two ligaments:
Sup. = lateral calcaneus and lateral malleolus
Inf. = lateral calcaneus and inf. extensor retinaculum

FL tendon
FB tendon

184
Q

What is the muscle on the dorsum of the foot?

A

Extensor digitorm brevis

• Superiolateral surface of calcaneus
• Base of proximal phalanx of great toe
Lateral sides of tendons from EDL toes 2-5
• Deep fibular nerve
•
• Extension of MTP and IP joints of all toes.

185
Q

What is confounding?

A

Happens when a relationship between an exposure and an outcome is distorted by their shared relationship with something else.

186
Q

Describe an ‘observational study’. Name the two types.

A
  • No intervention by investigator
  • ‘Looking in through the window’
  • An analysis of spontaneously occurring events
  • Group assignments are not random
  • Often used to explore aetiology
  • Cohort study = start with exposure and look for outcome
  • Case-control study = start with outcome and look for exposure
187
Q

What is the triangle that a factor must be a part of to be classified as a ‘confounding factor’?

A

Exposure → confounder → outcome

Exposure → outcome

188
Q

What are the 4 methods for addressing confounding?

A
  • Restriction
  • Matching
  • Stratification
  • Multiple variable regression
189
Q

Describe restriction in addressing confounding.

A

exclusion, limitation of groups, less data, difficult when >1 confounder.

190
Q

Describe matching in addressing confounding.

A

case-control, create comparison group ‘matched’ on possible confounders, actively create balanced groups. Used for ‘strong confounders’ (sex and age). Has to be used with analytical approaches.

191
Q

Describe stratification in addressing confounding.

A

analytical approach; analyze exposure:outcome association in different sub-groups of the confounder. Take the confounders out of both groups and compare their association with the group without the confounding factor. Final step is adjusting to create a weighted average.
Doesn’t work with multiple confounding factors as for 4 factors 32 strata are needed. Run out of data!

192
Q

Describe multiple variable regression in addressing confounding.

A

COMPLEX :(

193
Q

What is the function of the optic nerve?

A

Purely special sensory - vision

194
Q

Describe the path of the optic nerve.

A

Common tendinous ring –> optic canal –> optic chiasma –> optic tract –> 1, 2, 3

1 = internal capsule --> visual cortex
2 = pre-tectal nucleus = pupil reflexes
3 = superior colliculus = body reflexes
195
Q

What is the function of the olfactory nerve?

A

Purely special sensory - smell

196
Q

Describe the path of the olfactory nerve.

A

cribiform plate –> olfactory bulb –> olfactory tract –> brainstem and hypothalamic nuclei

197
Q

What is the function of the occulomotor nerve?

A

Somatic motor = sup, inf, mid rectus and inf oblique and levator palpebrea superior

Autonomic motor = ciliary muscles

198
Q

Describe the path of the occulomotor nerve.

A

midbrain –> cavernous sinus –> sup. orbital fissure –> sup + inf divisions

sup = common tendinous ring –> S. rectus and LPS

Inf = common tendinous ring –> M. rectus, I. rectus, I. oblique, ciliary muscles

199
Q

What is the function of the trochlear nerve?

A

Purely somatic motor to the superior oblique eye muscle

200
Q

Describe the path of the trochlear nerve.

A

dorsal aspect of midbrain –> around cerebellar peduncles –> cavernous sinus –> Sup. orbital fissure –> common tendinous ring –> S. oblique

201
Q

What is the function of the trigeminal nerve?

A

-

202
Q

Describe the path of the trigeminal nerve.

A

-

203
Q

What is the function of the abducent nerve?

A

-

204
Q

Describe the path of the abducent nerve.

A

-

205
Q

What is the function of the facial nerve?

A

-

206
Q

Describe the path of the facial nerve.

A

-

207
Q

What is the function of the vestibulocochlear nerve?

A

-

208
Q

Describe the path of the vestibulocochlear nerve.

A

-

209
Q

What is the function of the glossopharyngeal nerve?

A

-

210
Q

Describe the path of the glossopharyngeal nerve.

A

-

211
Q

What is the function of the vagus nerve?

A

-

212
Q

Describe the path of the vagus nerve.

A

-

213
Q

What is the function of the accessory nerve?

A

-

214
Q

Describe the path of the accessory nerve.

A

-

215
Q

What is the function of the hypoglossal nerve?

A

-

216
Q

Describe the path of the hypoglossal nerve.

A

-

217
Q

What are the two parts of the membranous labyrinth contained within the vestibule of the inner ear?

A

Saccule
Utricle

Both contain endolymph and are surrounded by perilymph.

218
Q

What are the 3 components of the vestibular apparatus?

A

Semicircular canals
Saccule
Utricle

219
Q

What are the functional organs within the saccule and utricle?

A

Macula

In the saccule positioned vertically for position when lying down

In the utricle positioned horizontally for position when standing up.

220
Q

Describe the micro-anatomy of the hair cells that cover the macules in the vestibular apparatus.

A

Lots of microfillaments (stereocilia) and one larger cilia (Kinocilum). The stereocilia are oriented towards the kinocilum and attached by filamentous attachments.

Bending of the micro cilia towards the kinocilum opens ion channels in the hair cell causing depolarisation and increased nervous impulses. Away = closing of the channels and reduced firing.

Lots of hair cells in each macula, al oriented in different directions = some are activated in every axis of movement for full proprioception.

221
Q

What is the substance enclosing the vestibular maculae and its function?

A

STRATOCONIA.

Contains lots of calcium carbonate crystals and has a very high specific gravity so it pulls the cilia in the direction of strongest gravitational pull

222
Q

What is the function of the semicircular canals? How does it differ from that of the saccule and utricle?

A

The canals are used to measure an acceleration of change in acceleration of the head within space. The saccule and utricle are useful for positioning within space when the head is still but with movement - the stratoconia falls onto the cilia which the body falsely interprets as a backwards falling motion.

223
Q

Describe the functional part of the semicircular canals and how they measure movement?

A

Ampulla at the end of each canal.
Contains endolymph and a CUPULA.

Cupula is very similar to that of the macula with hair cells (and micro cilia) however, all face in the same direction so only measure movement in one axis. (Reason for 3 canals)

Fluid movement pushes the cupula and causes firing of the hair cells. Allows for measurement of change in movement and rate of change.

224
Q

What are the 3 compartments within the cochlea? Draw a diagram.

A

Scala vestubuli
Scala media
Scala tympani

225
Q

Describe the micro-anatomy of the organ of corrti within the cochlear.

A

looks like a wave.

Top = tectorial membrane
Inner hair cells
Outer hair cells
Resting on the basilar membrane
Rods of corti attach the membrane to the organ.
Cochlear nerve (mainly attached to the inner hair cells)
Basilar fibres attached to the bony modiolus of the cochelar.

226
Q

Describe the anteriolateral pathway.

A

Ascending nervous pathway for: pain, temperature, crude touch, sexual sensations, itch.

1st order neurone: periphery, decussation in spinal cord after rising 1-2 levels. Synapse in the dorsal grey horns

2nd order neurone: Travels contralaterally to the thalamus (some synapses in the medulla)

3rd order neurone: From the thalamus to the post-central gyrus (3,2) via the internal capsule

Paleospinothalamic = slow pain (C type with substance P)
Neospinothalamic = fast pain (a delta with glutamate)
227
Q

Describe the dorsal column medial lemniscus pathway.

A

Ascending sensory pathway for: fine touch, proprioception, vibration and fine pressure

1st order neurones: periphery to the medulla. Travels ipsilaterally in the cuneate and gracile fasiculae. Cuneate and gracile nuclei in the medulla.

2nd order neurone: Decussates in the medulla and travels ipsilaterally to the thalamus in the medial lemniscus pathway.

3rd order neurone: From the thalamus to the somatosensory cortex (post-central gyrus 3+2) via the internal capsule.

228
Q

Describe the cortocospinal pathway.

A

Part of the dorsolateral system of motor neurones. Controls fine movement of the periphery.

1st order neurone: Form the pre-frontal gyrus (1), down the internal capsule and into the medulla.
90% decussation in the medulla (lateral corticospinal tract)
10% dont decussate and do in the spinal cord (anterior corticospinal tract)

2nd order neurone: From the spinal cord to the periphery.

With damage to this tract, a pianist could walk to a piano but couldn’t play.

229
Q

What are the two components of the dorsolateral tract?

A

Corticospinal

Rubrospinal

230
Q

What are the main components of the ventromedial tracts?

A

Pontine reticulospinal
Tectospinal
Vestibulospinal

Control gross movements of the trunk and major limb movements.
Also balance and movement against gravity.

231
Q

What is the difference between dysarthria and dysphasia.

A

Dysarthria = a physical disorder of speech caused by a failure of the muscles of articulation and speech.

Dysphagia = a disorder of language and/or the understanding of language. Caused by upper motor neurone lesions within the CNS.

Either expressive = Broca’s area where the individual not fluent in language and can’t form proper words or sentences but can understand.
Or receptive = Wernike’s area where the individual can speak fluently but has meaningless articulation and no comprehension (FOREIGN LANGUAGE)

232
Q

What are the main primary, secondary and tertiary methods of stroke prevention?

A

Primary = advertising, eat healthy, exercise, education

Secondary = minimising the progression of risk factors = high BP, diabetes, AF, smoking, obesity.

Tertiary = medication, stent, thrombolytics, etc…

233
Q

What is amaurosis fugax?

A

A painless, transient, monocular loss of vision. Described as a ‘curtain of darkness’.

Caused by some form of blockage of the opthalmic artery, a large division of the internal carotid as it enters the skull.

234
Q

What are the major causes of raised ICP?

A

Haemorrhage
Mass (tumor, object)
A failure of the CSF (increased production, flow blockage or decreased drainage)

235
Q

What are the consequences of raised ICP?

A 
Depends on the area of the brain that is compressed. 
Major problems are of herniation:
- Subfalcine
- Transtentorial
- Tonsillar (coning)

Tonsillar herniation is the worst form as it compresses the brainstem and can cause fatal respiratory depression.

236
Q

What are the two forms of damage caused by traumatic brain injury?

A

Primary = initial damage occurring at the moment of impact.

Secondary = delayed, non-mechanical damage = Diffuse axonal injury and brain swelling

Secondary damage due to ischaemia (ischaemic cascade) increased anaerobic respiration and cerebral oedema.
Failure of the membrane ion pumps and increased depolarisation with Ca2+ influx. Calcium leads to membrane damage and cellular death.

237
Q

What are the muscles of the eye and the directions in which they cause movement?

A

Superior rectus = Moves eye upwards - (elevation with internal rotation)

Inferior rectus = Moves eye downwards - (depression with internal rotation)

Lateral rectus = Moves eye outwards - (abduction)

Medial rectus = Moves eye inward - (adduction)

Superior oblique = Rotates eye towards nose and moves it downwards

Inferior oblique = Rotates eye away from nose and moves it upwards

238
Q

What is the difference between nociceptive and neuropathic pain?

A

Nociceptive = acute tissue damage. Visceral and somatic pain. Responds well to conventional analgesics.

Neuropathic = Structural neural damage. Usually associated with altered sensation. Responds poorly to conventional analgesics.

239
Q

What is the gate theory of pain?

A

Nociceptors and sensory fibres both synapse onto the same interneurone and by activating the sensory fibres, pain can be controlled.

240
Q

How an individual psychology influence pain?

A

Fear avoidance
Somatization = manifestation of mental health issues as physical pain
Catastrophising = excess and unnecessary worry associated with the development of pain.
pain –> no job –> no mortgage –> no house –> no family

241
Q

What is the incidence of chronic pain within the general population?

A

Between 7 and 8 percent.

242
Q

What can happen with damage to the axillary nerve?

A

Loose abduction to 90 degrees and loose the majority of external rotation.

243
Q

What can happen with damage to the radial nerve?

A

Wrist drop as damage to the forearm extensors

Loose power grip as it requires extension of the forearm.

244
Q

What can happen with damage to the musculocutaneous nerve?

A

Loss of forearm flexion (at the elbow) and strong supination (biceps brachii)

245
Q

What can happen with damage to the median nerve?

A

Loss of flexion of the wrist and ulnar deviation (flexor carpi ulnaris is supplied by the ulner nerve)

246
Q

What can happen with damage to then ulnar nerve?

A

Claw hand.
Only nerve damage when a proximal lesion is better than a distal one. This is because with a distal lesion, 1/2 of FDP can act on the fingers to cause a worse claw hand.

247
Q

What can happen with damage to the long thoracic nerve?

A

Supplies the serratus anterior and causes a ‘winged scapula’ and loss of abduction of the shoulder greater than 90 degrees.

248
Q

How is a TIA differentiated from a stroke?

A

A stroke is an episode of focal cerebral function lasting longer than 24h.
Usually a TIA last less than 90 minutes.

249
Q

What are the modifiable and non-modifiable risk factors for stroke?

A

Non-modifiable:
Age, male gender, race, FHx

Modifiable:
CHADS2
Congestive heart failure, hypertension, (age), diabetes, prior stroke
Atrial fibrillation, smoking, hyperlipidemia, obesity

250
Q

What are the major causes of atrial fibrillation?

A

RITA

R = rheumatic heart disease
I = ischaemic heart disease
T = thyrotoxicosis
A = Alcohol
251
Q

What is the most common nerve damaged through increased intracranial pressure?

A

Occulomotor nerve - has a very long and tortuous path through the skull and is easily compressed. The first things to go are the outer sympathetic nerves which supply the pupil.

252
Q

How would a extradural haematoma and subdural haematoma look on a CT scan?

A

Extradural = meningeal arteries = arterial bleed externally to dura so smooth oval edges.

Subdural = dural sinuses and veins = venous bleed within the dura os slow expansion with irregular edges.

253
Q

What are the common symptoms post - traumatic brain injury?

A 
Nausea and vomiting
Post-traumatic amnesia
Pain
Dizziness
Alteration of consciousness
254
Q

What is the monroe-kelly doctrine?

A

The components within the cranium (arterial blood, venous blood, CSF, brain) are able to compensate for an increase in one of the components through movement into another compartment. However, this only compensates for an increase in ICP up to a point.

255
Q

What are the areas in the frontal lobe of the brain that could be damaged if a stroke occurred in that area? What would the damage be if these areas were destroyed?

A

Precentral gyrus = primary motor cortex so ataxia of contralateral movements
Brocas area = motor coordination of speech so expressive aphasia
Prefrontal areas = personality, initiative and drive damage.
Bladder and bowel controls. = neurogenic bladder

256
Q

What are the areas in the parietal lobe of the brain that could be damaged if a stroke occurred in that area? What would the damage be if these areas were destroyed?

A

Post-central gyrus = primary somatosensory cortex so contralateral abnormal sensation
Wernike’s area = understanding of speech so receptive aphasia
Visual pathways
Handeling of: numbers, calculation, body image, awareness of environment.

257
Q

What are the areas in the temporal lobe of the brain that could be damaged if a stroke occurred in that area? What would the damage be if these areas were destroyed?

A

Auditory cortex
Learning and memory
Visual pathways

258
Q

What are the main causes of stroke and their relative incidences?

A

Occlusion 50%
Haemorrhage = 20%
Embolisation = 25%
Other (demyelination, tumour) = 5%

259
Q

What are the main forms of dementia?

A 
Alzheimers
Vascular
Frontotemporal dementia
Dementia with Lewy bodies
Parkinsonian dementia

(Parkinsonian dementia is very similar to dementia with lewy bodies, however, in DLB the parkinsonian symptoms appear after the dementia rather than before)

260
Q

What is the pathology of alzheimers dementia.

A

All of the damage is caused by beta amyloid plaque deposits within the brain.

Amyloid precursor proteins is broken down by: alpha, beta and gamma secretase enzymes. In alzheimers disease, the alpha secretase enzyme doesn’t work and the B, G enzymes form an insoluble beta amyloid protein that lodges within the brain.

261
Q

What are the main symptoms of dementia?

A

Loss of orientation in: person, place and time
Memory loss (not all forms but most)
Loss of personality
Loss of functional ability
Difficulty with language
Possible psychiatric features (dementia, etc.)

262
Q

What is the incidence of dementia within the general population?

A

Varies with age.
4% under 65yrs
20% over 85rys

263
Q

What are the main risk factors for developing dementia?

A 
Age
Genetics and family history
Repeated head trauma
High cholesterol (risk factors for atheroma)
AF (risk factors for arterial embolus)
264
Q

What are the main foramina of the skull base?

A 
Optic canal
Superior orbital fissure
Inferior orbital fissure
Cribiform plate
Foramen rotundum
Foramen ovale
Foramen spinosum
Foramen lacerum 
Internal acoustic meatus
Jugular foramen
Hypoglossal canal
Foramen magnum
265
Q

What is the incidence of epilepsy within the general population?

A

50-70/100,000

The chance of an individual having some form of seizure in their lifetime is 1/10

266
Q

What are the two main forms of epilepsy?

A

Focal (confined to one specific area of the brain)

Generalised (beginning in one area but spreading to the rest of the brain - total involvement)

267
Q

What are the main triggers for epilepsy?

A 
Fatigue (mental and physical)
Sleep deprivation
Flashing lights
Missed doses of anti-epileptic drugs
Concurrent infection
268
Q

What is the perceived pathology of epilepsy?

A

An imbalance in the levels of inhibitory GABA and excitatory glutamate within the brain. Leading to generalised neuronal hyperactivity

269
Q

What is status epilepticus?

A

A medical emergency. Occurs when a seizure goes on longer than 30mins. Patients can die of exhaustion.

Treated by rectal diazepam to halt the seizure.

270
Q

What are the main types of generalised seizures?

A 
Tonic-clonic
Absence
Tonic
Myoclonic 
Atonic
271
Q

What are the two forms of focal seizure?

A

With involvement of consciousness

  • affecting the temporal lobe
  • Smacking lips and picking at clothes

Without involvement of consciousness
-Motor or sensory impairment

272
Q

How would a generalised absence seizure be distinguished from a focal seizure?

A

Generalised absence = childhood, brief, can occur 20-30pd, no warning, no post-ictal state

Focal = later in life, last longer, post-ictal state, possible preceding aura.

273
Q

Describe a tonic-clonic seizure.

A

Warning (aura)
Tonic phase (stiffness, falling, tongue biting, incontinence)
Clonic phase (irregular jerking of muscles, frothing at the mouth)
Recovery (post-ictal state)

274
Q

Describe an absence seizure

A

Always occurs in childhood (juvenile absence epilepsy). Is a short, loss of consciousness with no preceding factors or sequelae.

20-30pd
May be mistaken for day-dreaming.

275
Q

Describe a myoclonic seizure.

A

Brief jerking movements of the limbs
Mainly the arms
Mostly occurring in the morning and provoked by fatigue / lack of sleep

276
Q

Describe a tonic seizure.

A

Increase in muscle tone (+- loss of consciousness)

Usually seen as part of a epileptic syndrome and not on its own.

277
Q

Describe an atonic seizure.

A

Brief loss of muscle tone accompanied by heavy falls.

+- loss of consciousness

278
Q

What are the main skull foramina?

A 
Optic canal
Superior orbital fissure
Inferior orbital fissure
Foramen rotundum
Foramen ovale
Foramen lacerum
Foramen spinosum
Internal auditory meatus
Jugular foramen
Hypoglossal canal
Foramen magnum
279
Q

Where in the skull is the cavernous sinus?

What is contained within it?

A

Two large venous plexuses that lie within the body of the sphenoid bone, on either side of the sella turcica.

4 cranial nerves pass through the cavernous sinus in their course through the skull. + the jugular artery

Occulomotor nerve (II)
Trochlear nerve (III)
Trigeminal nerve (IV)
Abducent nerve (V)

A lesion within the cavernous sinus can, therefore, damage these nerves with the corresponding signs:
3, 4, 6 = nystagmus, ptosis, mydriasis,
5 = loss of sensation, anhidrosis, reduced power to muscles of mastication.

280
Q

What is the danger triangle of the face?

A

An area - from the corners of the mouth to the bridge of the nose that (due to the blood supply) when infected, the infection can spread retrograde into the brain/meninges and cause encephalitis and meningitis.

Mainly due to the vein from the superior sagital sinus passing through the skull and into the frontal compartment of the cranium. Through the foramen cecum (anterior to the cribiform plate).

281
Q

Where is the orbital canal and what is carried within it?

A

In the anterior cranial fossa. The 3rd most anterior skull foramen, posterior to the foramen cecum and the cribiform plate.

Carries the optic nerve to the retina and the opthalmic artery.

282
Q

Where is the superior orbital fissure and what is carried within it?

A

Just posterior to the optic canal, in the lesser wing of the sphenoid bone.

Carries cranial nerves: 3, 4, 5(1)
Superior and inferior devisions of the opthalmic veins.

283
Q

Where is the inferior orbital fissure and what is carried within it?

A

A foramen in the inferior wall of the orbit.

Transmits the infraorbital vessels and zygomatic branch of the maxillary nerve.

284
Q

Where is the foramen rotundum and what is carried within it?

A

Posterior to the superior orbital fissure, in the middle cranial fossa.

Transmits the maxillary branch of the trigeminal nerve. (5(2)).

285
Q

Where is the foramen ovale and what is carried within it?

A

A large foramen in the posterior - middle cranial fossa. Middle of the group of 3 foramina.

Transmits the mandibular division of the trigeminal nerve (5(3)).

286
Q

Where is the foramen spinosum and what is carried within it?

A

In the posterior - middle cranial fossa. Lateral of the group of 3 foramina.

Transmits the middle meningeal artery

287
Q

Where is the foramen lacerum and what is carried within it?

A

In the posterior - middle cranial fossa. Medial of the 3 foramina.

Largely filled with fibrocartilage at the base but the carotid artery passes through it laterally after entering the skull via the carotid canal

288
Q

What is transmitted through the foramen magnum?

A

Spinal cord, meninges, spinal accessory nerve entering the skull, vertebral arteries, brainstem.

289
Q

Where is the internal acoustic meatus and what is carried within it?

A

Located in the anterior - posterior cranial fossa.

Transmits the facial nerve, vestibulocochlear nerve and the labyrinthine artery.

290
Q

Where is the jugular foramen and what is carried within it?

A

A large foramen in the posterior cranial fossa.

Transmits the Jugular vein, glossopharyngeal nerve, vagus nerve and spinal accessory nerve

291
Q

Where is the hypoglossal canal and what is carried within it?

A

A very small foramen in the circumference of the foramen magnum.

Transmits the hypoglossal nerve.

292
Q

Describe the path of the facial nerve.

A

Cranial nerve 7.
Arises from the pons (between the pons and medulla). The most anterior of the cranial nerves arising from the side of the brainstem between the pons and medulla.
7, 8, 9 and 10.

Enters the internal acoustic meatus (with the vestibulocochlear nerve). Innervates the stapedius and chorda tympani before exiting the skull through the stylomastoid foramen.

Wraps round the outside of the mastoid process to innervate the muscles of facial expression.

293
Q

What are the two branches to the occulomotor nerve?

A

Superior branch = innervates sup. rectus and LPS

Inferior branch = innervates: MR, IF, IO

294
Q

What would the findings be on a patient with occulomotor nerve damage?

A 
Diplopia
Dilated pupil
Ptosis
"down and out eye" action of LR and SO
Loss of pupil reflexes (only on the side of the lesion)
295
Q

What direction does the super oblique move the eye?

A

Down and in

296
Q

What direction does the inferior oblique move the eye?

A

Up and out

297
Q

What is the action of the trigeminal nerve?

A 
V1 = opthalmic = sensory from upper face and cornea
V2 = maxillary = sensory from cheeks and upper teeth
V3 = mandibular = sensory from lower face and anterior 2/3 of tongue, motor to the muscles of mastication
298
Q

What is the action of the facial nerve?

A

motor to the muscles of the face and the scalp, parasympathetic innervation to the sublingual and submandibular glands.
Sensory = sense of taste

299
Q

What are the two forms of damage to the facial nerve?

A

Bells palsy = peripheral nerve inflammation = ipsilateral face drop = non-permenant

Central nerve palsy = contralateral face drop with forehead sparing.

300
Q

What would occur with damage to the vestibulocochlear nerve.

A

Loss of hearing
Spinning and dizziness
Rotatory nystagmus

301
Q

What is the function of the glossopharyngeal nerve?

What would happen if it was damaged?

A

Motor to the stylopharyngus
Sensory to the pharynx, posterior 1/3 of tongue and external ear

Impaired swallowing, loss of taste, uvula deviates towards healthy side

302
Q

What is the function of the vagus nerve?

What would happen if it was damaged?

A

Motor for larynx and upper oesophagus voluntary
Involuntary (parasympathetic) innervation to most of the chest and abdominal viscera.

Impaired swallowing, hoarse voice.
Loss of ability to swallow LIQUID is indicative of nervous damage.
Solid swallowing impairment is muscular damage.

303
Q

What is the function of the hypoglossal nerve?

A

Motor innervation to the tongue muscles (-palatoglossus, innervated by the glossopharyngeal).

Fasiculation and deviation of the tongue towards the damaged side.

304
Q

What are the risk factors for stroke?

A

Non-modifiable: age, male, previous MI, FHx

Modifiable: hypertension, diabetes, hyperlipidemia, smoking, AF (AF is a MAJOR risk factor)

305
Q

What are the medications that can minimise the risk factors from stroke?

A

Aspirin
Warfarin
Clopidogrel (g2b3a inhibitor)
Dipyrimadole (ADP inhibitor)

306
Q

What is the CHADS2 score?

A 
Risk factors for development of AF
Congestive heart failure = 1 point
Hypertension = 1 point
Atrial fibrillation = 1 point
D = Diabetes = 1 point
S = stroke or TIA history = 2 points.
307
Q

What are the major symptoms of stroke?

A

Contralateral hemiplegia/hemisensory disturbance.
Hemianopia
Decreased GCS (only major stroke)
Receptive or expressive aphasia (or global)
Severe dysarthria

If haemorrhage, also symptoms of raised ICP = headache, N+V, decreased GCS, pupillary changes, 3rd and 6th nerve palsy, ptosis (superior branch of occulomotor)

Year 2 (7 decks)

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