Bone And Joint Anatomy Flashcards
1
Q
What movements can the spine permit
A
Flex
Extend
Laterally flex
Rotate
2
Q
What are the primary curves of the spine
A
Concave anteriorly - thoracic and sacral
3
Q
What are the secondary curves of the spine
A
Concave posteriorly - cervical and lumbar
4
Q
How is a babies spine shaped at birth
A
Single primary curvature concave anteriorly, the secondary curves develop with age and muscle strength and are postural
5
Q
What are the components of the vertebral arch
A
Laminae posteriorly
Pedicles anteriorly
6
Q
What are the processes attached to each vertebral arch?
A
1 Spinous process projecting posteriorly from between the laminae
2 transverse processes projecting laterally from where laminae meet pedicles
4 articular processes - bilateral superior and inferior originating from the lamina
7
Q
How are the vertebral fascet joints formed
What is the significance of their variable orientation at different levels
A
Articulation of the inferior articular processes with the corresponding superior articular process of the vertebra below.
Variability at different levels determines extent and direction of movement permitted
8
Q
What are the boundaries of the intervertebral foramene
A
Superior - inferior vertebral notch of pedicle
Inferior - superior vertebral notch of pedicle
Anterior - posterior lateral aspect of veterbral bodies and disc
Posterior - superior and inferior articular processes forming the facet joint
9
Q
What are the features of C3-7 and why
A
- Small wide oval body as not carrying much weight
- Oval flat facet joints for movement
- Transverse processes pieced by foramen transversarium for artery+ anterior/posterior tubercles for scalene attachment.
- short bifid spinous processes c3-6, larger singular at c7 forming attachment point for ligamentum nuchae
10
Q
What makes the bodies of cervical vertebra unique
A
Raised superior edges forming uncinate processes for extra articulation - only found in mammals that can rotate head
11
Q
How are cervical vertebra facet joints directed
What movement does this allow
A
Superior directed posteriormedially
Inferior directed anteriolaterally
Flexion, extension, lateral flexion
12
Q
What variant may exist to the anterior tubercles of the transverse process on c7
A
Cervical rib
13
Q
What is the ligamentum nuchae
Function
A
Tough ligament from occipital protuberance to spinous process of c7
Limits flexion of cspine
14
Q
Features of atlas c1
A
No body or spinous process
Had an anterior and posterior arch
2 lateral masses with upper and lower facets
Contains the transverse Atlantal ligament
15
Q
What forms the lateral masses of c1
How are its facet joints shaped?/atriculates
A
Transverse processes
Superior articulate with occipital condyles shaped to allow head to nod
Inferior facets articulate with axis
16
Q
Features of axis C2
A
Bifid spinous process Thick pedicles and lamina Ordontoid peg Horizontal superior facets Small transverse process
17
Q
Where does the ordontoid peg sit?
A
Anterior to transverse ligament of c1 articulating with anterior arch
18
Q
What are the characteristics of the thoracic veterbra?
A
Laminae overlap adjacent vertebra
Bodies have costal facets laterally for articulation with ribs
Transverse processes directed posteriolaterally
Articular processes are orientated nearly vertically with superior facing posteriorly and inferior facing anteriorly
Spinous processes are long and angled steeply causally
19
Q
How do the ribs articulate with the thoracic vertebra?
A
1 - articulates directly with one facet on T1
2-9 articulate with demifacets on two adjacent vertebra (the corresponding and the one above).
10-12 - same as one
20
Q
What is the structure of the thoracic transverse processes
A
Long, strong, directed posteriorlaterally to behind articular processes
T1-10 have anterior facets for articulation with respective ribs
21
Q
What is the positioning of the thoracic articular facets
What does this allow
A
Nearly A-P
Rotation but limited flexion
22
Q
Why are thoracic epidurals challenging? How to overcome this?
A
Steep caudally angulated spinous processes obscure intervertebral space
Approach paramedially
23
Q
Features of lumbar vertebra
A
No foramen transversarium (c) or costal facets (t)
Large triangular vertebral foramen
Large vertebral bodies
Long slender transverse processes l1-3 becoming shorter and fatter l4-5
Articular processes s - posteriormedial, I- anteriolateral
Short broad spinous processes
Non-overlapping laminae
24
Q
What is the lumbosacral angle
Significance?
A
Angle between sacrum and l5
Formed due to wedge shaped l5 body. Increases with lordosis reaching 70o
This can lead to obstruction of local anaesthetic flow after caudal anaesthesia
25
Layout and permitted movement of lumbar articular processes
Superior posteriomedially
Inferior anteriolaterally
Allows flex, extend and lateral flexion but not much rotation
26
What is the significance of the lumbar laminae compared to other levels
Non-overlapping so easier to access spine for injection
27
What is the hole down the middle of the vertebra called (formed by the body pedicles and lamina)
What about those laterally formed by two adjacent vertebra
Vertebral foramen
| Intervertebral foramen
28
How much of hight do intervertebral discs contribute?
25%
29
What is the general shape of the sacrum
Irregular triangle
| Concave anteriorly convex posteriorly
30
What happens to the spinous processes in the sacrum
Fuse to form median sacral crest
31
What happens to the articular processes in the sacrum
Fuse to create the intermediate/articular crests (4 pairs). The superior S1 processes still articulate with L5 then inferior S5 processes form rounded tubercles - the sacral cornua
32
Where do the sacral nerves emerge? Made from what?
Dorsal and ventral sacral foramina respectively for the dorsal and ventral rami
33
What do the transverse processes form in the sacrum
Lateral sacral crests
34
What is the term for the lateral aspects of the sacrum lateral to the sacral foramina
Lateral mass
35
What do the vertebral bodies form in the sacrum
Transverse ridges
36
Where does the ilium articulate with the sacrum
Upper part of lateral edge of lateral mass
37
What forms the base of the sacrum
S1 (it is the superior aspect!).
| The anterior edge projects forward to form a sacral promontory
38
What sits either side of S1 body on the base of the sacrum - why are they grooved?
The ala
| Grooved by the passage of the lumbosacral trunk of the sacral plexus
39
What happens to the vertebral canal in the sacrum
Becomes the sacral canal
40
What is the anatomy of the sacral canal
Bounded anteriorly by fused s1-4 bodies and posteriorly by fused laminae and spinous processes
Upper opening at base of sacrum
Ends inferior at sacral hiatus
Opens via dorsal and ventral sacral foramen
41
What is the sacral hiatus
| Borders?
End of sacral canal beneath median crest
Failure of fusion of laminae of S5
Superiorly - lower borders of fused S4 laminae
Laterally - medial borders of unfused S5 laminae
Posteriorly - skin and soft tissue inc sacrococcygeal ligament
Inferiorly- coccyx and posterior body of S5
42
Relevance of sacral hiatus
| How is it located
Caudle epidural injection
Locate posterior superior iliac spines (underling skin dimples)
Connect them and draw an equilateral triangle pointing down - sacral hiatus at the apex felt as a depression
43
How many vertebra from the coccyx
| How are they connected
Usually 4 but 3-5
Disc and lateral synovial joints between coccyx and sacrum
Usually c1 separate then subsequent fused
44
Parts of intervertebral disc
Annulus fibrosis - outside, dense fibrocartilage ring
| Nucleus pulposus - inside, avascular semi fluid gelatinous core
45
What sits between each disc and veterbral body
Hyaline cartilage
46
What are the ligamentous attachments of the intervertebral discs?
Anterior and posterior longitudinal ligaments
47
How do discs contribute to the vertebral column
Shape - wedge shaped in cervical and lumbar (thick anteriorly) contributing to lordosis
Height - around 25% in youth - getting less with age
Flexibility
Cushioning
48
Features of posterior longitudinal ligament
Runs over posterior bodies and discs - widens over discs and narrows over bodies
49
Location of anterior longitudinal ligament
2nd cervical vertebra to sacrum
50
What ligament connects adjacent lamina in the spine - in what direction does it pass
Ligamentum flavum
| From lower inner surface of superior lamina to upper outer of inferior
51
What ligament lies between spinous processes
| What ligament lies posterior to the spinous processes (between which vertebra - what is it contiguous with)
Interspinous
| Supraspinous - c7 to sacrum becoming ligamentum nuchae superiorly
52
What ligaments link transverse processes
Intertransverse ligaments
53
What vertebral level is the larynx
C4-6
54
What is the vertebral level of the xiphisternum and umbilicus
T10
| L3/4
55
What vertebral level is the tip of the scapula when arms by side
T7
56
What vertebral level are the top of the iliac crests? What can change this?
L4
Elderly, vertebral body #s, drop of spine into pelvis
Obesity can make top of hips seem more cephalad due to fat
57
What vertebral level are the skin dimples at top of buttocks
| What do they overly
S2
| Posterior superior iliac spines
58
What are the types of spina bifida with description
Occulta - failure of fusion of vertebral arch but all nervous tissue/meninges in normal place
Meningocele - posterior protrusion of meningeal sac
Myelomeningocele - nervous tissue (spine and or nerve roots in menigeal sac)
Myelocele - failure of neural tube to fuse so open to surface - fatal
59
Bones that make up the face
```
Frontal
Zygomatic
Maxillary
Mandible
Nasal
```
60
Where does the mandible articulate
Glenoid fossa of temporal bone
61
What are the 3 main sutures of the bones of the cranium
Sagittal (interparietal)
Coronal (frontoparietal)
Lambdoid (parietoccipital)
62
What is the area of the frontal bone found between the two orbits called
Glabella
63
What is the junction between the frontal nbone and the nasal bones called
Nasion
64
What is the opening in the skull for the nose called
Piriform apateur
65
What foramen is located in the middle of the body of the maxilla
What passes through it
Infraorbital foramen
| Infraorbital nerve and vessels
66
What are the two parts of the mandible
| How are they separated
Body
Ramus
Angle of the jaw and oblique line
67
What is the swelling at the front of the mandible in the midline? What sits either side? What passes through?
Mental protruberance
Mental foramen
Mental nerve and vessels
68
What foramen is found on the medial surface of the jaw? What passes through it to where?
Mandibular foramen
Inferior alveolar nerve supplying sensation to lower teeth and jaw
Passes through mandibular canal
69
What are the upward projections on the superior border of the mandibular rami. What are their functions
Anterior coronoid process - attachment of temporalis muscle
| Posterior condylar process - articulation at TMJ
70
What ligaments anchor the tmj and where do they go?
Sphenomandibular ligament - lingua of medial ramus to sphenoid bone
Lateral - articular tubercle to ramus
Stylomandibular - styloid process of temporal bone to posterior ramus
71
Movements possible at tmj?
Opening and closing of mouth
Side to side
Anterior subluxation of jaw (protrusion
72
What muscles are involved in mandibular opening
Digasteic
Geniohyoid
Mylohyoid
73
What muscles are involved in mouth closure?
Masseter
Temporalis
Medial pterygoid
74
What muscle causes mandibular protrusion
Lateral pterygoid
75
What are the classifications of facial #
Le Fort I - across maxilla under nose
Le Fort 2 - along superior border of maxilla (over nose)
Le Fort 3 - over frontal bone and through eye sockets
76
How many tarsals, metatarsals and phalanges per leg
8 tarsal bones
5 metatarsals
14 phalanges
77
Movements possible at hip
Flex, extend, adduct, abduct, internal rotate, external rotate
78
Bones that make up the acetabulum
Ilium
Pubis
Ischium
79
What muscles stabilise the hip when the opposite leg is lifted?
Sign of deficient?
Relevance to anaesthesia?
Gluteus medius and minimus
Trendelenburg sign
When lifting legs into lithotomy do both together as no stabilisation thus can strain SI or lumbar joints.
80
What is the path of the inguinal ligament
ASIS to pubic tubicle
81
Where is the asis
Anterior end of iliac crest
82
What ligaments span the back exit of the pelvis? What do they help form?
Sacrotuberous - from ischial tuberosity on posterior of ischium to the posterior iliac spines and margins of sacrum/coccyx
Sacrospinous - from the ischial spine on the posterior of ischium to coccyx
Form the greater and lesser sciatic foramen
83
How much blood can be lost into the pelvis in trauma
What blood vessels are often involved?
How can it be controlled
All of it
Internal iliac arteries and veins at back
External iliac arteries and veins passing over pubic rami
Control with pelvic binder and tying feet together into internal rotation
84
Proximal route of sciatic nerve
Exits pelvis though greater sciatic foramen
| Moves down and out crossing slightly medial to a line between ischial tuberosity and great trochanter
85
Name for protuberances at distal end of femur
Med and lat epicondyle
86
Potential blood loss from a femur fracture
1-2 litres
87
Main muscle group of anterior thigh
| Contents?
```
Quadriceps muscles
Rectus femoris
Vastus lateralis
Vastus medialis
Vastus intermedius
```
88
Muscles of the medial thigh
```
Adductor muscles:
Gracilis
Pectineus
Adductor longus
Adductor brevis
Adductor Magnus
Obturator externus
```
89
Muscle group in the posterior compartment of thigh
Hamstrings
90
Nerves that supply the knee joint
Obturator
Femoral
Tibial
Common fibular
91
Main ligaments of the knee
Med and lat collateral
| Ant and pot cruciate
92
Boundaries of the popliteal fossa
Superior medial - semitendinosus
Superior lateral - semimembranosus
Inferior med and lat - heads of the gastrocnemius
93
Contents of popliteal fossa medial to lateral
Popliteal artery, popliteal vein, tibial nerve
94
Significance of superficial route of common peroneal nerve around neck of fibula
Vulnerable to injury causing foot drop
| Can be used for nerve stimulation causing foot dorsiflexion
95
What is contained in the anterior and lateral compartments of the lower limb
Foot dorsiflexors, everters and abductors
Common peroneal nerve
Popliteal artery
96
What is contained in the posterior compartment of the lower leg
Muscles that plantar flex, adductor and invert the foot
Tibial nerve
Posterior tibial artery
97
Causes of compartment syndrome in lower leg
| Main symptom? Subsequent symptoms
```
High energy injuries
Fractures to long bones
Tight dressings
Burns
Vascular damage
Prolonged unconsiousness (eg midazolam od)
```
Main symptom pain, then pulse less, pale, paraesthesia, cold, paralysis
98
What tissue pressure leads to compartment syndrome
>35 mmhg
99
What articulation is present at the distal end of the tib/fib with the foot. Type of joint and movement allowed
Mortis joint with talus
| Allows ankle plantar and dorsiflexion
100
Where do foot ab/aducution and in/eversion occur? What movements are paired?
At the subtalar joint between talar and navicular and other joints of the forefoot.
Abduction paired with eversion and adduction with inversion.
101
What important structures pass anterior and posterior to the medial malleolus?
Anterior - long saphenous vein, saphenous nerve
| Posterior - posterior tibial artery, tibial nerve
102
What important structures pass anterior and posterior to the lateral malleolus?
Anterior - superficial peroneal nerve
| Posterior - Sural nerve
103
Names of the tarsal bones
```
Talus - superior proximal
Calcanious - inferior proximal
Navicular - medial midlayer
Cuboidal - lateral midlayer/distal layer
Medial, internediate and lateral cuneiforms - distal layer
```
104
Arterial supply to the foot
Dorsalis pedis artery
| Posterior tibial artery
105
Main nerves of the foot
Medial and lateral planters (from tibial)
Deep and superficial fibular
Sural
Saphenous
106
How do the sensory nerves approach the toes?
| Clinical significance?
Terminal sensory branches run between the metatarsals of each toe
Can be blocked at the distal end of the metatarsal space or at the digits by injection into the web space.
107
What is at the distal end of the spine of the scapula?
The acromion process
108
What is the anterior projection of the scapula superiomedial to the glenoid cavity
Coracoid processs
109
Where does the suprascapular nerve run on the scapula?
A groove superior to the spine of the scapula
110
Where does the clavicle articulate?
Manubrium of sternum at sternoclavicular joint
| Acromion of scapula at acromioclavicular joint
111
What are the protuberances at the neck of the humerous termed
What muscles attach to them?
Greater and lesser tubercles
| The rotator cuff - supraspinatous, infraspinatous, teres minor, subscapularis)
112
What structures are at risk on fracture of the neck of humerus
Axillary nerve and posterior circumflex artery
113
What are the structures at the distal end of the humerous
Medial and lateral epicondyles either side of the condyle
114
What enlarges the glenoid cavity to accommodate the head of humerus
Glenoid labrum
115
Origin and insertion of the trapezius
Origin - occipital protuberance, superior nuchal line, ligamentum nuchae, spinous processes of c7-t12
Inserts - spine and acromion of scapula and lateral third of clavicle
116
Actions of trapezius
Upper fibres lift scapula rotating it to allow humerous to abduct beyond midline
Lower fibres depress scapula
Middle fibres retract scapula
117
Origin and insertion of deltoid
| Action
Scapula spine and acromion and distal clavicle to insert on deltoid tuberosity of humerous
Abducts the arm
118
What muscles run from the midline to the posterior scapula causing elevation (from superior to inferior)
Levator scapulae
Rhomboid minor
Rhomboid major
119
Origin and insertion of coracobrachialis
| Action
Coracoid process to midshaft humerous
| Shoulder flexion
120
Muscular walls of the axilla?
Anterior - pec major and minor, subclavious
Medial - serratous anterior,
Lateral - no muscles, just humerous
Posterior - subscapularis, latissimus dorsi, teres major, long head of triceps
121
Which nerves are vulnerable to injury on abduction of the arm more than 90o?
How can this be reduced
Median and ulnar
| Pronation of hand
122
How is the radial nerve most commonly injured
Pressure in axilla, eg crutch or Saturday night palsy
123
How does the radius articulate with the humerus
Radial head articulates with capitellum (lateral part of condyle of humerus)
124
What nerve is vulnerable on fracture or dilation of radial head
Posterior interosseous
125
Where do the biceps muscle insert
On the radial tuberosity at upper end of radius
126
Which wrist bones does the radius articulate with
Scaphoid and lunate
127
Anatomy of proximal ulnar
Posterior olecronon
Anterior Coronoid process
In between trochlear notch
Lateral radial notch
128
Processes on distal radius and ulnar palpable through skin
Styloid processes
129
Articulations and movements of the elbow joint
Trochlear notch of ulnar to humeral condyle - hinge joint for flex and extend
Radial head with capitellum of humerous - pivots to allow pronation and supination
Proximal radioulnar joint - also permitting pronation and supination
130
Where are the radial and median nerve vulnerable to tourniquet damage
Distally on the humerus where they are superficial
131
What are the anterior flexors of the upper arm and their route and action
Coracobrachialis - coronoid process to radius - flex’s arm at shoulder
Brachialis - shaft of humerus to ulna - elbow flexion and supination of forearm
Biceps brachialis - scapula to radial tuberosity of ulna - elbow and shoulder flexion
132
What muscles are In the posterior upper arm, route, action
Triceps brachii
Long head from scapula, medial and lateral from humerus, inserts onto olecronon process
Long head extends and adducts arm at shoulder and all extends arm at humorous
133
Pronators of the forearm and route
Pronator teres - medial epicondyle and lateral radius
| Pronator quadratus- distal radius to ulnar
134
Supinatiors of the forearm
Biceps brachii
| Supinator
135
Muscles of anterior compartment forearm
Deep - pronator quadratus, flexor digitorum profundus, flexor pollicis longus
Middle - flexor digitorum superficialis,
Superficial - flexor carpi ulnaris, palmar is longus, flexor carpi radialis, promimally pronator teres
136
Muscles of posterior forearm
Deep - abductor pollicis longus, extensor pollicis brevis and longus, extensor indicis, supinator
Superficial - brachioradialis, extensor carpi radialis longus and brevis, extensor digitorum, extensor digitorum minimise, extensor carpi ulnaris, aconeus
137
What are the carpel bones
Lateral to medial proximal row first
Scaphoid, lunate, triquetrum, pisiform
Trapezium, trapezoid, capitate, hamate
138
How does the ulnar nerve enter the wrist
| What does stimulation of it activate
Posterior to ulnar styloid process then radial to pisiform the across hook of hamate
Contraction of adductor pollicis and hypothenar muscles
139
Route of radial nerve into hand
Through anatomical snuff box
140
What forms the carpel tunnel
The flexor retinaculum spanning between pisiform and trapezium
141
What is within the carpel tunnel
Tendons of flexor muscles
| Median nerve
142
What muscles of the hand perform fine movments of the fingers
Main actions
Anterior and posterior interosseous muscles - ab and adduction of fingers
143
What nerves supply the small muscles of the hand
Ulnar nerve - interosseous muscles and hypothenar eminance, medial 2 lumbericles, adductor pollicis
Median nerve - thenar eminence
144
What is the nerve supply to the fingers
Digital nerve either side which divide into dorsal and ventral branches mid way down the first phalanx
145
Where is the p6 point, what it is used for?
```
2 cun (width of patients thumb) above transfers skin crese on palmer side of wrist between palmaris longus and flexor carpi radialis
Antiemetic on aquapuncture!
```
146
Risk factors for patient positioning injury
Patient - DM, RA, male, age, atherosclerosis, obesity, cachexia
Anaesthetic - prone, lateral or lithotomy positioning, long operation time, hypovolaemia, hypotension, hypoxia, hypothermia
Surgical - tourniquet use, neck or axillary surgery (many vulnerable nerves)
147
How can nerves become damaged interop?
```
Direct trauma
Ischaemia
Compression,
Angulation
Traction or strain
```
148
Why is the ulnar nerve particularly vulnerable to interop damage
Superficial over bone so vulnerable to compression injury
| Transverses elbow leaving open to angulation injury
149
Manifestation of ulnar nerve injury
Motor - weak flexion of medial fingers, weak finger abduction and adduction, weak thumb adduction
Sensory impairment over medial third of hand and 1.5 fingers
150
What can reduce interop injury / pressure sores
```
Appropriate padding (not just a blanket role but specially designed materials)
Automatic or manual repositioning, redistribution of padding or movement
Avoidance of hypotension, hypovolaemia, hypothermia
```
151
Risks to eyes interop
Corneal abrasions from direct trauma
Pressure injuries
Chemical injury from cleaning fluids
152
Ideal padding materials interop
```
Take a variety of loads
Adequate thickness
Prevent bottoming out
Fire and infection resistant
Antiallergenic
```
153
What is the ideal supine position
Supine with arms semi abducted around 45o, mid pronation
Padded under elbows and heels
Head on standard hospital pillow
154
What should be the non-compressible thickness of a surgical table mattress
11cm
155
What is the risk of arm flexion interop
| Where needs to be padded
Ulnar nerve under great traction and potential pressure
| Ensure padded under elbow
156
What are the risks of lithotomy positioning
Damage to sciatic and obturator form positional traction
Damage to common peroneal and saphenous nerves from direct pressure
Compartment syndrome due to pressure related muscle ischaemia with reduced arterial inflow.
157
Definition of neuropraxia
Mild insult with loss of impulse conduction across effected segment of nerve - heals rapidly
158
Definition of axonotmesis
More severe axonal disruption - requires neuronal regeneration - 1-4mm per day
159
Definition of neurotmesis
Total section of nerve following direct trauma and laceration, rarely fully heals, may need surgical apposition for recovery
160
How long after surgery does an ulnar nerve injury tend to present
48 hrs
