Block 12 - Musculoskeletal and nervous system (anatomy) Flashcards
What are the 4 phases of gait?
Heel-strike, Foot flat, Midstance/Swing phase, Push off
What happens to the pelvis during swing phase?
Rotation
What causes a trendelenberg gait?
Weak hip abductors
Define GALS
Global Assessment of the Locomotor System
What is adhesive scaularitis?
Frozen shoulder
Movement only at scapula so abduction is decreased
How do you test finger flexor power?
What injury prevents you from doing this?
Hold the patients fingertips with yours and get them to pull
Elbow injury of the dorsal interosseus nerve
How do you test abduction of the fingers?
Get them to push against yours
How do you test adduction of the fingers?
Pull a piece of paper from between the patients fingers
What nerve supplies the pincer grip?
Radial
What nerve supplies the power grip?
Ulnar
2 causes of fixed flexion deformity
How would you test the right leg?
Osteoarthritis, Severe lumbar lordosis
To test the right leg you would flex the left leg off the couch
Define version, antiversion and retroversion
Version: Angle of the femoral neck relative to the vertical plane
Antiversion: Foot inwards
Reteroversion: Foot outwards
Who is anteversion commonly seen in?
How can this cause problems?
Commonly seen in babies and can cause problems in adolescence if it does not rectify itself
When may the true and apparant leg length differ?
Scoliosis or Lumbar spine disease
What causes genu varum and valgum?
Varum: Arthritis in the medial knee
Valgum: Arthritis in the lateral knee
Define genu recurvarum
1 possible cause
Knee is hyperextended
Neurovascular
2 movements in the ventral portion of the arm
Where do they arise from?
Flexion and adduction
From coracoid
2 movements in the dorsal portion of the arm
Where do they arise from?
Extension and abduction
From scapula
What passes through the intertubular groove?
Biceps tendon
What is the anatomical neck of the humerus?
Epiphysis
What are the 2 (+2) ligaments surrounding the shoulder joint?
What do they do
Coracoacromial ligament: Allows shoulder to move relative to clavicle Coracoclavicular ligements (Trapezoid and Conoid): Maintain stability of the scapula relative to the clavicle
What happens if the intraarticular disc between the clavicle and the sternum tears?
Dislocation
Which muscles’ tendon increases stability of the glenohumeral joint?
Biceps brachii
Where does the teres minor muscle arise?
Arises from the bottom of the scapula blade
Where does the subscapularis muscle arise?
Arises from the subscapular fossa
What are the two painful arcs and what degrees are they felt at?
Acromioclavicular painful arc (170-180 degrees)
Glenohumeral painful arc (60-120 degrees)
What are the 2 bursa’s found around the shoulder?
Under scapula (subscapular bursa) Between the acromion and supraspinatus muscle
What needs to happen for you to fully abduct the arm?
Scapula and humerus need to rotate fully
What vessel does the subclavian artery form and what vessel forms the subclavian vein?
Axillary artery and vein
What are the medial, posterior and anterior borders of the axillary fossa?
Medial: Serratus anterior
Posterior: Subscapular muscles
Anterior: Pectoral muscles
What order do the nerves, arteries and veins enter the axillary fossa?
Subclavian vein directly above clavicle
Behind the vein is the artery
Behind the artery is the nerve
What makes up the roots of the brachial plexus?
Ventral primary rami of cervical spinal nerves
ANTERIOR DIVISIONS OF BRACHIAL PLEXUS:
Nerves
Movements
Skin
Nerves:
- Musculocutaneous (upper arm)
- Median, Ulnar (forearm and hand)
Flexors and Adductors (median is an abductor)
Muscles and skin at the FRONT of the armPOSTERIOR DIVISIONS OF BRACHIAL PLEXUS:
Nerves
Movements
Skin
Nerves: Axillary, Radial
Extensors and Abductors
Muscles and skin at the BACK of the arm
What area of the hand is supplied by the median, ulnar and radial nerve?
Google it babs i can’t draw on here
Another name for a radial nerve injury
Crutch palsy (can be caused by being on crutches)
How do you test the myotome of T1?
Test the intrinsic hand muscles
Explain what happens in Erb’s palsy
Tight birth causes tension on the brachial plexus and the 5th cervical nerve root to tear
Sensation in the lateral part of the arm and shoulder muscles is lost so the arm hangs loosely by the side
Explain what happens in Klumpke’s paresis
Birth or motorbike injury
Damage to T1 so all intrinsic hand movements lost
Lost sensation to the medial side of the forearm
What are the borders of the cubital fossa?
Line between the lateral and medial epicondyles
Brachioradialis on the lateral border
Pronator teres on the medial border
What makes up the floor and the roof of the cubital fossa?
Floor: Brachialis
Roof: Skin and superficial fascia
POSTERIOR COMPARTMENT OF THE FOREARM: Ventral or dorsal Movements Nerve Where do they arise?
Dorsal aspect
Extensors of the wrist and digits
Radial nerve
Arises at the lateral epicondyle
ANTERIOR COMPARTMENT OF THE FOREARM: Ventral or dorsal Movements Nerve Where do they arise?
Ventral aspect
Flexors of the wrist and digits
Median and ulnar nerve
Arises at the medial epicondyle
How does the extensor digitorum insert
Ends in 4 tendons which pass over the MCP joint and insert into the middle phalanx
Tendon splits into lateral and medial slip which pass around the MCP joint and insert into the distal phalanx
Where is the anatomical snuffbox?
Between the extensor pollices brevis/longus and the abductor pollices longus
What does the anatomical snuffbox contain?
Pulse of the radial artery
What causes tenderness in the snuffbox?
FOOSH
Fractures the neck of the scaphoid
What is the mneumonic to remember the ulnar and median nerve supply of the forearm?
LOAF
Median nerve supplies the Lateral 2 lumbricals, Opponens pollices, Abductor pollices brevis, Flexor pollices brevis
All the other are ulnar
What branches off the deep and superficial palmar arch?
Deep:
Principes pollicis artery (thumb)
Radial artery of the index finger
Superficial:
Common palmar digital arteries
Proper palmar digital arteries
What passes through the carpal tunnel (2)
Tendons and the median nerve
2 things which can cause compression of the median nerve
Arthritis or swelling in the wrist
How do you test the flexor digitorum profundus?
Hold the wrist and digits in expansion and flex the dip joint
How do you test the flexor digitorum superficialis?
Pull the digits into extension to stop the produnfus then flex the finger
What do the tests of the flexor digitorum profundus and superficialis also flex?
They also flex the wrisp, mcp and the profundus the pip as the tendon passes over all of these joints
What movement do the long flexors and extensors of the wrist allow?
Flexors flex the wrist
Extensors extend the wrist
What is another name for adduction and abduction of the wrist?
Which muscles allow these movements
Abduction = radial deviation (radial flexors and extensors) Adduction = ulnar deviation (ulnar flexors and extensors)
Explain what happens in a pulled elbow
Annular ligaments usually hold the radius against the ulnar head but in a child they are less stable
Swinging/pulling a child’s hand dislocated the radius within the annular ligament
What is the role of the lumbrical muscles? (3)
Balance tension between the flexor and extensor tendons
Also control fine movement and independent control of joints
What is the role of the palmar aponeurosis?
Palmaris longus tendon binds to the flexor retinaculum and skin of the palm allowing the skin of the palm to cup
What are the muscles of the hypothenar eminence?
Where are they found?
Abductor, flexor and opponens digiti minimi
Base of the little finger
What are the muscles of the thenar eminence?
Where are they found?
Abductor, flexor and opponens pollicis brevis
Base of the thumb
How many DORSAL interosseus muscles are there?
Where are they found?
4
Dorsal space between the metacarpals
Explain how the muscles of the finger are abducted
Little finger abducted by abductor digiti minimi
Ring abducted by muscle arising on radial side of 5th metacarpal and ulnar side of 4th metacarpal inserting into the ulnar side of the 4th digit
Middle abducted in both directions. Muscle from radial 4th and ulnar 3rd inserting to 3rd. Muscle from radial 3rd and ulnar 2nd inserting to 3rd.
Index finger abducted by muscle from radial 2nd and ulnar thumb inserting to 2nd digit
How many PALMAR interosseus muscles are there?
Where are they found?
3
Palmar space between the metacarpals
Explain how the muscles of the finger are adducted
2 muscles from the radial side of the 4th and 5th metacarpal adduct the little and ring finger towards the middle
Muscle from the ulnar side of the 2nd metacarpal adducts the index finger towards the middle finger
What does variable nerve supply mean?
Opponens pollicis and flexor pollicis brevis can be supplied by the median or ulnar nerve (should be median)
Abduction is always median
What is lost in an injury to the median nerve?
How do you test for it?
Sensory loss to the thumb, index, middle and half of ring finger and the radial side of the palm
Motor loss of aBduction
Test sensation on the thenar eminence
Test motor by thumb abduction (your hand above theirs, touch my hand with your thumb)
What is lost in an injury to the ulnar nerve?
How do you test for it?
Sensory loss in the little, half of ring finger, ulnar side of palm and back of hand
Motor loss of aDduction
Test sensation in the hypothenar eminence
Test motor by getting the patient to hold a piece of paper between their fingers and not let you pull it away
What is lost in an injury to the radial nerve?
How do you test for it?
Sensory loss of the radial side of the back of the hand and thumb
Motor loss of wrist extension
Test sensation in the dorsal web space
Test motor by wrist drop
How many digital nerves are there per digit?
4 (2 palmar and 2 dorsal)
Where is the cribiform fascia?
What is its role?
At the superior end of the femoral triangle
Allows passage of the great saphenous vein
What does the fascia lata thicken to form?
Iliotibial band/tract
What joint does the fascia lata support?
The knee
Define paresis
What syndrome would you find it in?
Foot drop
Compartment syndrome
What are the 3 compartments in the thigh?
What muscle groups do they contain? (movements)
Anterior (quadriceps): Hip flexor and knee extensor
Medial (adductors): Hip adductors
Posterior (hamstrings): Hip extensor and knee flexor
What are the 3 compartments in the leg?
What muscle groups do they contain? (movements)
Anterior: Ankle extensors and dorsiflexors
Lateral: Ankle evertors
Posterior: Ankle flexors and plantarflexors
What are the 2 compartments in the foot?
What muscle groups do they contain? (movements)
Anterior: Extensors
Posterior: Flexors
What is the name of the anterior and posterior region of the pelvis?
What muscle groups do they contain? (movements)
Anterior: Iliac region: Hip flexors
Posterior: Gluteal region: Abductors, rotators and extensors
What is the blood supply and innervation to the anterior compartment of the thigh?
Femoral artery
Femoral nerve (posterior roots)
- L3 and L4 (vastus = extend knee)
- L2 and L3 (rest = flex hip)What is special about the pectineus muscle?
It has the same nerve supply as the anterior compartment but acts as a medial compartment muscle
What is the blood supply and innervation to the medial compartment of the thigh?
Obturator artery
Obturator nerve (anterior roots)
- L2, L3, L4
What is the clinical significance of the femoral triangle? (3)
Femoral venopuncture
Femoral catheter
Femoral hernia
Where does the saphenous vein exit the adductor canal?
Medially between the sartorius and gracilis
What 2 nerves does the lumbar plexus give rise to?
Where do they exit?
Femoral nerve (inguinal ligament --> femoral triangle) Obturator nerve (through obturator foramen)
What is the blood supply and innervation to the posterior compartment of the thigh?
Profundus femoris (branch of the femoral artery)
Tibial branch of the sciatic nerve
- L4 and L5 (extend hip)
- L5 and S1 (flex knee)
(Short head of biceps = fibular branch of sciatic)
What is the main structure which comes off the sacral plexus?
Sciatica
What are the 2 nerves which make up the sciatica?
Tibial and Common fibula
What are 3 exceptions to the common naming rules of muscles?
Tibialis = invertor
Fibularis = evertor
Palmaris longus = short
What is the blood supply and innervation to the anterior compartment of the leg?
Anterior tibial artery
Deep fibular nerve (splitting of common fibula from sciatic)
- L4 and L5 (dorsiflex ankle)
What is special about the fibularis muscles?
Fibularis tertius is in the anterior compartment
Fibularis longus is in the lateral compartment
Thy share the muscle belly of the extensor digitorum longus but have their own tendon
Which muscle supports the arches of the foot?
How?
Fibularis longus
Scoops under foot and inserts onto the 1st metatarsal
(passes under the tendon of the fibularis brevis)
What is the blood supply and innervation to the lateral compartment of the leg?
Fibular artery (artery in posterior compartment and sends smaller arteries across)
Superficial fibular nerve
- L5 and S1 (evert ankle)
What is the blood supply and innervation to the posterior compartment of the leg?
Posterior tibial artery
Tibial nerve
- S1 and S2 (plantarflex)
How do you test plantarflexion?
Get the patient to stand on their tiptoes
What is the motor and sensory deficit in a femoral nerve neuropathy?
Motor: Anterior thigh compartment (knee extension and hip flexion)
Sensory: Medial thigh, anterior and medial leg
What is the motor and sensory deficit in a sciatic nerve neuropathy?
Motor: Posterior thigh compartment, leg and foot (knee flexion, hip extension and distal limb movements)
Sensory: Posterior thigh and distal lower limb
What bone makes the acetabulum?
What is it made from?
Innominate bone
Ilium, ischium and pubis
What ligament stabilises the anterior and inferior third of the hip bone?
Transverse acetabular ligament
What are the 3 ligaments of the hip joint?
Where are they?
What movement do they limit?
Which is the strongest and weakest?
Iliofemoral: Anterior hip joint –> NOF (limits extension)
Pubofemoral: Pubis –> Proximal femur (limits abduction)
Ischiofemoral: Ischium –> Greater trochanter (limits rotation)
(Iliofemoral strongest and ischiofemoral weakest)
What does the obturator artery branch to form?
Branches to form the artery of the head of the femur
What is the position of the limb like in a NOF fracture?
What movement is lost and why?
Limb is externally rotated as the femur is laterally rotated
Lesser trochanter is now anterior so flexion is lost
Which muscle is out of action in a NOF fracture?
Why?
Iliopsoas is out of action
It inserts onto the lesser trochanter which was on the posterior femur but is now at the midline
What are the 2 parts of the body where bone displacement tears arteries from their anastamoses?
NOF
Schaphoid
What are the 2 anastamoses in the femur?
Where are they?
Trochanteric anastamoses on the greater trochanter
Cruciate anastamoses posterior and inferior to trochanteric
What is the blood supply to the NOF in children and adults?
Children: Artery of the head of the femur
Adults: Femoral artery, profundus femoris and small circumflex
What causes a trendelenberg gait?
Superior gluteal nerve lesion Weak abductors (weak gluteus medius and minimus)
Step on the affected leg, the hip will drop on the contralateral side
Where does the pudendal nerve exit?
Underneath the piriformis
Where does the sciatica usually exit the pelvis?
3 other places it can exit
Underneath the piriformis
7% Fibula through piriformis and tibial underneath
2% Fibula over the top of piriformis and tibial underneath
1% Both through the piriformis
Where does the sacrotuberus ligament run from and to?
What is its role?
How do structures from the piriformis pass it?
Sacrum to ischial tuberosity
Maintains pelvis stability
Structures from the piriformis loop under
When does the knee NOT have slight flexion and extension?
When it is locked
What are the 2 joints at the knee?
Patellofemoral and Tibiofemoral
Where is the adductor canal?
How does it transport the femoral vessels?
Between the attachments of the adductor magnus
Transports them from anterior thigh to posterior thigh
Where does the common fibula and medial tibial nerve run?
Common fibula under the fibula head
Medial tibial directly against the skin (no protection)
What are the 2 knee deformities
valgus and varus
OR
valgum and varum
What is the difference in appearance between the medial and lateral collateral ligament?
Medial = broad and flat (thinner so increased injury)
Part of the capsule and attached to medial meniscus
Lateral = cord like
Not part of the joint capsule so has no attachments
Which forces are resisted by the medial and lateral collateral ligaments?
Medial = resists valGUS Lateral = resists vaRUS
Where does the anterior and posterior cruciate ligament attach and insert?
Anterior: Anterior tibial plateau > Lateral femoral condyle
Posterior: Posterior tibial plateau > Medial femoral condyle
When is the anterior and posterior cruciate ligament taut?
Anterior: Taut in extension
Posterior: Taut in flexion
What increases the risk of a posterior cruciate ligament injury?
Falling onto the tibia (when the knee is flexed)
Are the cruciate ligaments inside or outside of the joint capsule?
Inside the joint capsule but outside the synovial fluid
Which ligament provides the axis for the knee locking mechanism?
Anterior cruciate
What 3 things rupture in a terrible triad injury?
How does the injury occur?
Anterior cruciate ligament
Medial meniscus
Medial collateral ligament
Tibia is flexed but forced back whilst the body moves forward
What are menisci?
2 roles of them?
How are they connected anteriorly?
Fibrocartilage structures which circle around the tibial condyles (stop them moving)
They increase stability and weight distribution
Connected anteriorly by the transverse ligament
Draw the diagram of how the menisci help weight distribution
See image saved in revision folder
Explain how the knee is locked (4)
Medial rotation of the femur on the tibia
ACL, MCL and oblique popliteal ligament tighten
Flat surface of femoral condyles in contact with tibia
CoG anterior to the knee joint so extension maintained
Explain how the knee is unlocked
Popliteus muscle laterally rotates the femur on the tibia and simultaneously retracts the lateral meniscus to prevent impactation
What does the popliteus muscle insert into?
Deep half inserts onto the lateral meniscus
Superficial half inserts onto the lateral femoral condyle
What stops the knee unlocking?
A lesion in the tibial nerve
popliteus is innervated by the tibial nerve
What is the iliotibial band?
A thickening of the fascia lata which inserts onto the tensor fascia lata and gluteus maximus and lateral tibial condyle
It hyperextends the knee allowing locking and provides lateral knee support
Which ligament has been recently discovered?
Where does it run from and to?
What does it do?
Anterolateral ligament
Femur > Tibia (lateral)
Resists lateral rotation of the femur on the tibia
What are the 3 muscles which make the goose foot?
Where do they insert?
What do they do?
Anterior = Sartorius Medial = Gracilis Posterior = Semitendinous
Attach to the proximal medial tibial surface
Superficial to the MCL > dynamic knee support
What is the role of a bursa?
To reduce friction
fluid filled sack between areas which move against each other
What are the 2 bursas found in the knee?
Where do they run?
How do they cause inflammation?
Suprapatellar bursa: Anterior femur and quadriceps
(inflammation through sudden overuse/damage)
Prepatellar bursa: Between skin and patella
(inflammation through compression e.g. kneeling)
How is the sural nerve formed?
The sciatica splits into the tibial and common fibula nerves which then re-combine to form the sural nerve
Where is the sural nerve found?
Sural nerve found in mid-fascia until the gastrocnemius tendon then penetrates the deep fascia becoming a cutaneous innovator
What does the sural nerve run alongside?
What can these 2 things be used for?
Runs alongside the short saphenous vein
Both used for grafts
What nerve does the saphenous nerve branch from?
Branches off the femoral nerve
Which bone forms the roof of the ankle joint? (and mortise)
Tibia
How do you x-ray a foot?
Why?
Medial rotation
To view the mortise
Where is the anterior tibial artery found?
What does it become?
Deep to the tibialis anterior muscle
Crosses the ankle joint to become the dorsalis pedis artery
What are the 2 types of extensor retinaculum in the foot?
Superior: Forms a sheet on the ankle
Inferior: Y shaped from tibia to cuneiforms
Which muscle has proprioceptors which give information about where the leg is in space?
What does this allow?
Plantatis
Allows postural adjustment
What forms the calcaneal tendon?
What does it allow you to do?
Gastrocnemius and soleus
Allows you to bring the calcaneus bone up –> walk and stand on tiptoes
How do the tendons and vessels cross into the foot?
Cross posteriorly behind the medial malleolus
From anterior to posterior = Tom Dick ANd Harry
tendon of Tibialis posterior tendon of flexor Digitorum longus posterior tibial Artery tibial Nerve tendon of flexor Hallucis longus
This ONLY works at the medial malleolus
Where do the saphenous veins arise from?
What are they both called?
Arise from the dorsal venous arch at the top of the foot
Great saphenous vein and Small saphenous vein
What is the path of the great saphenous vein?
Anterior to the medial malleolous
Enters the femoral triangle becoming the femoral vein
What is the path of the small saphenous vein?
Posterior to the lateral malleolus (with sural nerve)
Enters the popliteal fossa becoming the popliteal vein
What is the ankle joint called?
Talocrural joint
What happens to the talus in dorsiflexion and plantarflexion?
What causes injury?
Dorsi: Anterior talus held tightly in mortise (stable)
Plantar:Reduced bone contact (unstable)
High heels force plantar = injury
What is another name for the lateral and medial collateral ligament at the ankle?
Lateral = Fibular Medial = Deltoid
What are the 3 ligaments which make up the fibular collateral ligament?
Where do they attach?
What forces do they resist?
Anterior talofibular
Posterior talofibular
Calcaneofibular
Attach to the lateral malleolus and talus/calcaneus
Resists inversion of the foot
What are the 4 ligaments which make up the deltoid collateral ligament?
Where do they attach?
What forces do they resist?
Anterior tibiotalar
Posterior tibiotalar
Tibiocalcaneal
Tibionavicular
Attach to the medial malleolus
Resists eversion of the foot
How are the fibular and deltoid ligaments torn?
What other damage can occur?
Fibular: Over inverting causes the ligament to tear (or the fibula to fracture)
Deltoid: Over everting causes the ligament to tear (or the medial malleolus to fracture)
In severe causes the mortise slides and fractures the lateral malleolus
In super severe cases the joint slides and fractures the tibia
What causes a sprained ankle?
One of the ligaments are ‘pulled’
Another name for the calcaneonavicular ligament
Where is it?
Spring ligament
Between the ledge on the medial calcaneous which the talus balances on
What are the 2 subtalar joints?
Talocalcaneal joint: Inversion and eversion
Talocalcaneonavicular joint: Inversion, eversion, rotation
What makes the floor of the talocalcaneonavicular joint?
Navicular, Calcaneous and Spring ligament
If the foot arches are destroyed, where will the weight be?
How are the foot arches destroyed?
On the talus
Maintained by ligaments so ligaments tearing will destroy the arch
What are the 3 points of weight distribution on the foot in order?
Heel (most) > Big toe mound > Little toe mound (least)
What is the smallest arch?
Transverse
Holds the centre of the foot across the metatarsals
Does the plantar aponeurosis move?
2 roles
No
Allows grip and stops skin sliding
Define pes cavus and pes planus
Pes cavus: Overarching of the feet (calcaneus arches)
Pes planus: Underarching (flat feet)
How do you test for flat feet?
Get the patient to stand on their tiptoes
What does the quadratus plantae muscle allow you to do?
Where does it run from and to?
Scrunch the feet up and pull the arches closer
Calcaneous > flexor digitorum longus tendon
Define hallux varus and valgus
Which causes a bunion?
What shoes cause each problem?
Varus: Medial deviation of phalanx (flip flops)
Valgus: Phalanx deviates laterally but 1st metatarsal protrudes medially –> bunion (tight pointed shoes)
