Muscoskeletal System Flashcards
0
Q
What is the appendicular skeleton?
A
Upper limb (shoulder, pectoral girdle, arms, forearm, hands) Lower limb (pelvic girdle, legs, lower leg, feet) 126 bones (64 upper limb and 62 lower limb) Mobility
1
Q
What is the axial skeleton?
A
Skull (protects brain) Vertebral column (protects the spinal cord) Rib cage (protects heart and lungs) 80 bones (8 cranial, 6 auditory ossicles, 14 facial, 26 vertebral, 26 thoracic)
Protection and support
2
Q
What are the five types of bone?
A
Long Flat Short (cuboidal) Irregular Sesamoid
3
Q
What is an example of the long bone?
A
Femur
4
Q
What is an example of a flat bone?
A
Parietal bone of skull
5
Q
What is an example of a short bone?
A
Calcaneus (heel bone)
6
Q
What is an example of an irregular bone?
A
Sphenoid of skull
7
Q
What is an example of a sesamoid bone?
A
Patella
8
Q
What is a tuberosity?
A
Roughened rounded elevation
Ischial tuberosity
9
Q
What is a tubercle?
A
Smaller elevation than tuberosity
Greater and lesser tubercle of humerus
10
Q
What is a spine?
A
Slender projection
Spine of scapula (posterior)
11
Q
What is a trochanter?
A
Large blunt projection
Gated trochanter of the femur
12
Q
What is a condyle?
A
Large prominence or rounded surface
Lateral and medial femoral condyles
13
Q
What is an epicondyle?
A
Smaller prominence than the condyles above a condyle
Lateral and medial epicondyle of humerus
14
Q
What is a facet?
A
Flattened surface for joint, muscle attachments
Superior costal facet on the body of the vertebra for articulation with a rib
15
Q
What is a crest?
A
Ridge
Iliac crest
16
Q
What is a sinus?
A
Hollow space
17
Q
What is a meatus?
A
Tunnel / canal
18
Q
What is a fossa?
A
Depression
Infra spinous and supra spinous fossa of scapula
19
Q
What is a foramen?
A
Hole, opening
Obturator foramen
20
Q
What is a fissure?
A
Cleft or narrow slit
21
Q
What is a notch?
A
Large groove
Greater sciatic notch
22
Q
Where are bone markings and formations found?
A
Found where fascia, ligaments, tendons or aponeuroses are attached to bone
23
Q
Are bone markings and formations found at birth?
A
Not present at birth
Appear after puberty
24
How do bone markings and formations form?
1. Pulling of fibrous structures causes periosteum to be raised and new bone to be deposited beneath- tuberosity, condyles etc.
2. Pressure on the bone surface may cause a groove, fossa, notch etc.
25
What is a joint?
An articulation between two or more bones
26
What is a fibrous joint?
Fibrous tissue
- syndesmoses (interosseous membrane in forearm- joins radius and ulnar)
- sutures (cranium)
- gomphosis (between root of tooth and alveolar process of jaw)
27
What is a cartilaginous joint?
Synchondroses- primary cartilage
- hyaline cartilage, growth plates
Sympheses- secondary cartilage
- fibrocartilage, pelvis and pubic symphysis
28
What is a synovial membrane?
```
Articular capsule (outer fibrous layer, lined by an articular cartilage at articulating surfaces of bone and a serous synovial membrane at all other surfaces)
Synovial fluid
```
Erosion of the articulating surface = osteoarthritis
Secondary erosion = rheumatoid arthritis
29
What movements can synovial joints do?
```
Extension and flexion
Adduction and abduction
Internal (medial) rotation and external (lateral) rotation
Circumduction
Gliding
```
30
What are the 6 types of synovial joints?
```
Hinge
Saddle
Condyloid
Pivot
Ball and socket
Plane
```
31
What movements does a hinge do?
Flexion and extension
| E.g. Elbow joint
32
What movements does a saddle do?
Concave and convex joint surfaces
| E.g. 1st MPJ
33
What movements does a plane do?
Gliding, sliding movements
| E.g. Acromioclavicular joint
34
What movements does a pivot do?
Rotation (round bony process fits into a bony ligamentous socket)
E.g. Atlantoaxial joint and proximal radio ulnar joint
35
What movements does a candyloid do?
```
Flexion
Extension
Adduction
Abduction
Circumduction
E.g. MCPJ
```
36
What movements does a ball and socket do?
Movements in several axes (rounded head fits into a concavity)
E.g. Shoulder and hip joints
37
What are joints stabilised by?
Articulation (shape size and surfaces)
Ligaments and capsules
Muscles and muscle tone
38
What is the Sagittal plane?
Plane that separates left from right
39
What is the coronal plane?
Separates anterior from posterior
40
What is the transverse plane?
Separates superior and inferior
41
What are the two surfaces of the hand?
Dorsal- back of hand
| Palmar- palm of hand
42
What are the two surfaces of the foot?
Dorsal - top of foot
| Plantar - sole of foot
43
What does flexion mean?
Decreasing the angle between joints/ bending
44
What does extension mean?
Increasing the angle between joints/ straightening
45
What does abduction mean?
Limb movement away from the midline
46
What does adduction mean?
Limb movement towards the midline
47
What does internal (medial) rotation mean?
Towards the midline
48
What does external (lateral) rotation mean?
Away from the midline
49
What does circumduction mean?
Combining flexion, extension, abduction and adduction
50
What does pronation of the hands mean?
Hands face down
| Towards the midline
51
What does supination of the hands mean?
Hands face up
| Away from the midline
52
What does retraction of the shoulder mean?
Posterior movement of scapula
53
What does protraction of the shoulder mean?
Anterior movement of the scapula
54
What does flexion of the wrist mean?
Bending the wrist forward
55
What does extension of the wrist mean?
Bending the wrist back
56
Describe the following movements of the thumb: extension, flexion, abduction, adduction, opposition, reposition
Act them out
57
Describe the following movements of the fingers: extension, flexion, adduction, abduction, circumduction
Act them out
58
What does flexion of the hip mean?
Movement of lower limb forwards
59
What does extension of the hip mean?
Movement of leg backwards
60
What does dorsiflexion of the foot mean?
Decreasing angle between dorsal surface of foot and lower leg
61
What does plantar flexion mean?
Decreasing angle between plantar surface of foot and lower leg
62
What bones make up the upper limb and pectoral girdle?
```
Sternum
Ribs
Clavicle
Scapula
Humerus
Radius
Ulnar
Carpals- trapezium, trapezoid, capate, hook of hamate, pisiform, triquestrum, lunate, scaphoid
Metacarpals,
Phalanges
```
63
What are the four main muscles in the pectoral region of the body?
Pectoralis major
Pectoralis minor
Subclavius
Serratus anterior
64
What is the proximal and distal attachment of the pectoralis major?
Proximal- clavicular head (anterior surface of medial half of clavicle) and sternocostal head (anterior surface of sternum, costal cartilages of 1-6; aponeurosis of external oblique muscle)
Distal- lateral lip of intertubercular sulcus of proximal humerus
65
What nerves innervate the pectoralis major?
Lateral and medial pectoral nerves
66
What movements can the pectoralis major control?
Adduction of the humerus
Medial rotation of the humerus (draws scapula inferiorly and anteriorly) (BOTH sternocostal head and clavicular head)
Flexion of humerus (clavicular head)
Extension of humerus (sternocostal head)
67
What are the proximal and distal attachments of the pectoralis minor?
Proximal- 3rd to 5th ribs near bathe costal cartilages
| Distal- coracoid process of the scapula
68
What nerve innervates the pectoralis minor?
Medial pectoral nerve
69
What movements can the pectoralis minor control?
Stabilises scapula
| Draws scapula inferiorly and inferiorly against the thoracic wall
70
What are the proximal and distal attachments of the subclavius?
Proximal- junction of the first ring and its costal cartilage
Distal- inferior surface of middle surface of the clavicle
71
What nerve innervates the subclavius?
Nerve to the subclavius
72
What movements does the subclavius control?
Anchors the clavicle
| Depresses the clavicle
73
What are the proximal and distal attachments of the serratus anterior?
Proximal- external surfaces of the lateral parts of the 1st to 8th rib
Distal- anterior surface of medial border of scapula
74
What nerve innervates the serratus anterior?
Long thoracic nerve
75
What movement does the serratus anterior control?
Protracts the scapula (holds it agains the thoracic wall)
| Rotates the scapula
76
What are the main features of the clavicle bone?
S shaped
Convex medially
Concave laterally
Acromioclavicular articulating surface (circular)
Sternoclavicular articulating surface (triangular)
Conoid tubercle (more lateral)
Costal tuberosity (more medial)
Inferior surface is rougher due to the attachments of ligaments
77
What are the main features of the scapula?
Anterior- subscapular fossa, scapula notch, coracoid process, glenoid cavity
Posterior- spine, supraspinous fossa, infraspinous fossa, acromion
78
What are the main features of the humerus bone?
Anterior, superior to inferior- head, anatomical and surgical neck, greater tubercle (lateral), lesser tubercle (medial), intertubercular sulcus/ groove, deltoid tuberosity, radial fossa, coronoid fossa, capitulum (lateral-radius) and trochlea (medial-ulnar) articulating surfaces
Posterior, superior to inferior- head, radial groove, olecranon fossa, medial epicondyle (larger) and lateral epicondyle
79
What are the main features of the radius?
Radial tuberosity
Radial styloid process
Ulnar notch
80
What are the main features of the ulnar?
```
Trochlear notch
Coronoid process
Radial notch
Ulnar tuberosity
Ulnar styloid process
Olecranon process
```
81
What is the clinical relevance of the surgical neck of the humerus?
It's the most commonest site of fractures
82
What is the clinical relevance of cutting the long thoracic nerve?
Winged scapula
| Protraction can no longer occur
83
Describe some fractures of the clavicle
One of the most frequently fractured bones
Weakest region is junction of its middle and lateral thirds
Common in children (most often incomplete- greenstick fractures one side of bone is broken and other is bent), babies with broad shoulders in delivery,
Caused by indirect force transmitted from an outstretched hand though the bones of the forearm and arm during a fall, or direct fall on shoulder
After a fracture the sternocleidomastoid muscle elevates the medial fragment of bone- readily palpable
After a fracture- Trapezius muscle is unable to hold the lateral fragment of the clavicle up (due to the weight of the upper limb)- so shoulder drops
Pectoralis major may pull the arterial fragment of the clavicle medially (adduction)
84
Describe some fractures of the scapula
Usually result of severe trauma (RTA/ PTA)
Common with fractured ribs
Require little treatment- as scapula is covered in muscles on both sides
Most fractures include the protruding subcutaneous acromion process
85
Describe some fractures of the humerus
Surgical neck- (axillary nerve) Common in old people with osteoporosis; most commonly occurs due to minor fall on the hand with the force being transmitted up the forearm bones of the extended limb
Avulsion fracture of greater tubercle of humerus- common in middle aged and elderly people; small part of tubercle is avulsed (torn away); commonly occurs due to fall on acromion; in younger people usually occurs due to a fall on the hand when the armies in abduction; subscapularis muscle (still attached to humerus) plus limb into medial rotation
Transverse fracture of shaft of humerus- commonly occurs due to direct blow to arm; pull of deltoid muscle carries proximal fragment laterally
Spiral fracture of humeral shaft- commonly occurs due to fall on outstretched hand
Intercondylar fracture of the humerus- commonly occurs due to sever fall on flexed elbow; ole random of ulna is driven like a wedge between medial and lateral parts of the condyle of the humerus
Because the humerus is surrounded in muscle and had a well developed periosteum the bone fragments in fractures usually unite well
86
What nerves are at risk in a fracture of the humerus?
Surgical neck- axillary nerve
Radial groove- radial nerve
Distal end of humerus- median nerve
Medial epicondyle- ulnar nerve
87
What firmly binds the ulnar and radius?
Shafts of the bone are bound by the interosseous membrane- fracture of the bone is likely to be associated with the dislocation of the nearest joint
88
Describe some fractures of the radius and ulna?
Commonly occur due to severe injury
Fracture of distal end of radius- common in >50 yo; women with osteoporosis
Colles fracture- complete transverse fracture of distal 2 cm of the radius; most common fracture of forearm; distal fragment displaced dorsally and is often broken into pieces, ulna styloid process is broken off (avulsed); radial styloid process projects farther dismally than ulnar styloid process; commonly occurs when individual slips or trip and tries to break fall with the forearm and hand pronated; rich blood supply means good recovery
89
Describe some fractures of the carpals
Scaphoid- most frequent; fall on palm when hand is abducted (can be confused with severely sprained wrist)
Hamate- hook fracture; risk of damage to ulnar nerve and ulnar artery = decreased grip strength
90
How can the pectoral muscles be invaded by a breast tumour (fixed mass)?
Find out
91
What are the various arrangements of skeletal muscle?
```
Circular- orbicularis oris
Convergent- pectoralis major
Parallel- sartorius
Unipennate- extensor digitorum longus
Bipennate- rectus femur is
Fusiform- biceps brachii
Multipennate- deltoid
```
92
What are some functions of skeletal muscle?
Movement
Posture
Stability
Heat generation
93
What is the mechanical efficiency of skeletal muscle?
About 20%
| So 80% lost as heat
94
What is the gross anatomy of skeletal muscle?
Epimysium surrounds whole muscle/ bundles of fascicles
Perimysium surrounds individual fascicles/ bundles of muscle fibres
Endomysium surrounds individual muscle fibres/ bundles of myofilaments
95
What is fasisculation?
Muscle twitching
Occurs when tires
Occurs in motor neurone disease (when motor neurones degenerate)
96
What are the three classes of levers of skeletal muscle?
First class lever (skull balanced on top of vertebrae), second class lever (gastronemeus and calcaneus bone) and third class lever (biceps brachii)
97
Which class of lever is the least efficient?
Third class
98
What is an agonist?
Prime movers- main muscles responsible for a particular movement
99
What is an antagonist?
Oppose prime movers
100
What is a synergist?
Assist prime movers
| Neutralise extra motion
101
What is a fixator?
Stabilises the action of prime movers
| E.g. Fixes a non moving joint when prime movers act over two joints
102
What are the compartments of skeletal muscle?
In a transverse section compartments are the anterior and posterior regions
Each compartment has its own fascia
103
What is the compartment syndrome?
When blood vessels burst
Pressure builds up and is exerted on the nerve
Paraesthesia, numbness, pain
104
How does muscle contraction occur?
You know this- refer to esa1
105
How does muscle relaxation occur?
Calcium is pumped back int the sarcoplasmic reticulum via calcium pumps (SERCA)
*some calcium can bind to calmodulin
106
What is isotonic contraction?
Constant tension
Variable muscle length
Can be: concentric (muscle shortens - lifting a load with the arm) or eccentric (muscle exerts a force while being extended- walking down hill) - result in DOMS (delayed onset muscle soreness a few days after)
107
What are the muscle fibre types?
Red (slow, oxidative) - darker, aerobic, high myoglobin levels, many mitochondria, rich capillary supply, fatigue resistant, endurance activities, posture
Pink (fast, oxidative) - medium, aerobic, high myoglobin levels, many mitochondria, rich capillary supply, moderate fatigues resistance, walking and sprinting
White (fast, glycolytic) - lighter, anaerobic, low myoglobin levels, few mitochondria, poorer capillary supply, rapidly fatigable, short intense movements
108
What is spatial summation?
Lots of neurones are activated to recruit a single skeletal muscle
109
What is temporal summation?
Increased frequency of action potential to muscle fibres causes summation, tetanus (unfused- twitch/ fused- contract)
110
What is clostridium tetanii?
When a toxin interferes with the feedback control of a motor neurone - tetanus- twitching and contractures
111
What is a motor unit?
Motor neurone and the muscle fibre it innervates
| 2-2000 muscle fibres (dependent on necessity)
112
How does a motor neurone and a muscle fibre communicate in a motor unit?
Via cross talk
Signalling molecules communicate between the nerve and muscle (neurotrophins- neurotrophin3, cytokinesis cardiotrophin1, insulin like growth factors- IGF1)
113
What us the clinical relevance of atrophy of a nerve or muscle fibre in a motor unit?
Can lead to atrophy of the corresponding nerve or muscle fibre
114
What is muscle tone?
Baseline tone present in muscles at rest due to: motor neurone activity and muscle elasticity
115
How is muscle tone controlled?
Via motor control centres in the brain
| Via afferent fibre signals originating in the muscle
116
What is hypotonia?
Decreased muscle tone due to:
Damage to motor cortex/cerebellum (involved with feedback)
Shock/ damage to spinal cord
Lesion of sensory afferents from muscle spindles
Primary degeneration of muscle- myopathies
Lesion of lower motor neurones- poly neuritis
117
How is the force of contraction controlled?
```
Proprioception
Feedback control of movement
Proprioreceptors- muscle spindles
Associated with nerve endings
Tells the brain how much force the muscle is exerting
```
118
What are the sources of energy for contraction?
1 short term stores of ATP in muscle fibre (few seconds)
2 phosphorylation of ATP fro. Creatine phosphate using creatine kinase (15 seconds)
3 anaerobic glycolysis and lactate formation (20-40 seconds) (glycolysis of blood glucose or glucose 6 phosphate from muscle glycogen)
4 aerobic respiration (ox phos)- prolonged aerobic muscular events
119
What is muscle and peripheral fatigue?
Depletion of muscle glycogen stores
| Within one minute if blood flow is interrupted
120
What is a contracture?
State of continuous contraction
| E.g. No ATP - rigor mortis
121
What are the 6 surfaces of the axilla?
Apex, lateral wall, medial wall, posterior wall, anterior wall, base
122
What does the apex of the axilla interact with?
First rib, clavicle, superior edge of clavicle
123
What does the lateral wall of the axilla interact with?
Narrow bony wall formed by intertubercular sulcus in the humerus
124
What does the medial wall of the axilla interact with?
Formed by thoracic wall (1st to 4th ribs and intercostal muscles) and overlying serratus anterior
125
What does the base of the axilla interact with?
Skin, subcutaneous tissue and axillary (deep) fascia extending from arm to thoracic wall (at 4th rib level) forming the axilla fossa- armpit
126
What does the anterior wall of the axilla interact with?
Pectoralis major and minor and pectoral and claviopectoral fascia associated with them
127
What does the posterior wall of the axilla interact with?
Anterior surface- scapula, subscapularis muscle
| Posterior surface- there's major and latissimus dorsi
128
How are the arteries of the upper limb arranged?
Brachiocephalic trunk- subclavian- axillary- brachial artery
Axillary-
1st part- between lateral border of 1st rib and medial border of pectoralis minor, enclosed by a sheath, 1 branch- superior thoracic artery
2nd part- posterior to pectoralis minor, 2 branches- thoracoacromial artery (medial to pecmin) and lateral thoracic artery (lateral to pecmin)
3rd part- between inferior border of pectoralis minor to inferior border of teres major, 3 branches- subscapularis artery (LARGEST) , anterior circumflex humeral and posterior circumflex humeral artery (share a common trunk)
129
What are the branches of the axillary artery?
```
Superior thoracic artery
Thoracoacromial artery
Lateral thoracic artery
Subscapularis artery
Posterior circumflex humeral artery
Anterior circumflex humeral artery
```
130
How are the veins of the upper limb arranged?
Brachial and basilic vein- axillary vein (or cephalic vein which enters axillary vein superior to the pec minor, close to its transition into the subclavian vein) - subclavian vein
131
What are the five main groups of axillary lymph nodes and their arrangement?
```
Pectoral
Subscapular
Humeral
ALL FEED INTO
Central
WHICH FEED INTO
Apical
WHICH FEEDS INTO
Subclavian lymphatic trunk
```
132
What are the five regions of the brachial plexus?
```
Roots
Trunks
Division
Cords
Terminal branches
```
133
Describe the brachial plexus
Roots - C5,6,7,8 T1
Trunks- C5 & 6 join to form superior, C7 forms middle, C8 & T1 form inferior
Divisions- anterior and posterior
Cords- lateral, posterior and medial
Terminal branches- musculocutaneous, median, radial, ulnar, axillary
134
What does each terminal branch of the brachial plexus supply?
Find out
135
What is axillary clearance (removal of lymph nodes) and the clinical relevance of this?
Removal of the axillary lymph nodes
In breast cancer- important to determine the degree to which the cancer has metastasised, lymph collects in axilla region (pectoral lymph odes drain to apical and central lymph nodes), remove any cancer cells which may have metastasised to axillary lymph nodes
In removal, you must be careful of damaging long thoracic nerve (winged scapula) and thoracodorsal nerve (Weakened medial rotation and adduction of the arm)
136
What is lymphangitis in the upper limb?
An infection in the upper limb can cause the axillary nodes to enlarge and become tender and inflamed
Usually involves the humeral group of nodes
Lymphangitis is characterised by the development of warm, red, tender streaks in the skin of the limb
137
What are some clinically significant injuries of the brachial plexus?
Erbs palsy UBP injury
| Klumpke palsy LBP injury
138
What are the anterior muscles of the arm?
Biceps brachialis
Brachialis
Coracobrachialis
139
What are the posterior muscles of the arms?
Triceps brachii
Deltoid
Anconeus
140
Describe the structure, location, origin, insertion, innervation and main actions of the biceps brachii
Structure: 2 headed muscle
Location: anterior of humerus, but not attached to humerus
Origin: short head- coracoid process/ long head- supraglenoid cavity of scapula
Insertion: radial tuberosity
Innervation: musculocutaneous nerve
Main action: supination of forearm, flexion of arm at elbow and shoulder (when forearm is supinated)
2 headed muscle
Anterior of humerus
141
Describe the structure, location, origin, insertion, innervation and main actions of the coracobrachialis
Structure: strap like
Location: lies deep to biceps brachii in the arm
Origin: coracoid process
Insertion: medial side of humeral shaft at the level of the deltoid tubercle
Innervation: musculocutaneous nerve
Main action: flexion of arm at shoulder
142
Describe the structure, location, origin, insertion, innervation and main actions of the brachialis
Structure:
Location: lies deep to biceps brachii, found more distally than other muscles of the arm, forms base of cubital fossa
Origin: medial and lateral surfaces of humeral shaft
Insertion: tuberosity of ulna- distal to elbow joint
Innervation: musculocutaneous nerve and radial nerve (small portion)
Main action: main flexion at elbow (in all positions)
143
Describe the structure, location, origin, insertion, innervation and main actions of the triceps brachii
Structure: 3 headed muscle, medial head of triceps lies deeper than the other two, which cover it (so not visible unless the other two heads are dissected away)
Location: posterior compartment
Origin: lateral head- humerus, superior to radial groove/ long head- infraglenoid cavity/ medial head- humerus, inferior to radial groove
Insertion: three heads converge to form one muscle and one tendon which attaches to the olecranon of the ulna
Innervation: radial nerve
Main action: extension of the arm at the elbow
144
Describe the structure, location, origin, insertion, innervation and main actions of the anconeus
Structure:
Location:
Origin: posterior aspect of lateral epicondyle
Insertion: lateral olecranon
Innervation: radial nerve
Main action: weak elbow extension, abducts ulna during forearm pronation
145
Describe the structure, location, origin, insertion, innervation and main actions of the deltoid
Structure:
Location:
Origin: outer 1/3 of anterior clavicle, outer border of acromion and lower border of spine of scapula
Insertion: deltoid tuberosity
Innervation: axillary nerve
Main action: abduction of humerus, anterior fibres flex arms, posterior fibres extend arms
146
What muscles of the back are there?
```
Trapezius
Latissimus dorsi
Levator scapulae
Rhomboid major and minor
Deltoid
Teres major
Rotator cuff muscles- supraspinatus, infraspinatus, subscapularis, teres minor
```
147
Describe the structure, location, origin, insertion, innervation and main actions of the trapezius
Structure:
Location: superficial
Origin: occipital bone, ligamentum nuchae (links cervical vertebrae together, spine of 7th cervical, spines of all thoracic vertebrae
Insertion: upper fibres- lateral third of clavicle/ middle and lower fibres- acromion and spine of scapula
Innervation: spinal part of accessory nerve (motor)
Main action: elevates scapula, retracts scapula, depresses scapula
148
Describe the structure, location, origin, insertion, innervation and main actions of the latissimus dorsi
Structure:
Location: superficial
Origin: iliac crest, lumbar fascia, spines of lower 6 thoracic vertebrae, lower 3 or 4 ribs, inferior angle of scapula
Insertion: floor of bicipital groove of humerus (intertubercular)
Innervation: thoracodorsal nerve
Main action: extends arm at shoulder joint, powerfully adducts arm at shoulder joint, medially rotates arm at shoulder joint
149
Describe the structure, location, origin, insertion, innervation and main actions of the levator scapulae
Structure:
Location: deep
Origin: transverse processes of 1st 4 cervical vertebrae
Insertion: medial border of scapula
Innervation: C3 C4 dorsal scapula nerve
Main action: raises medial border of scapula- elevates scapula, rotates scapula
150
Describe the structure, location, origin, insertion, innervation and main actions of the rhomboid minor
Structure:
Location: deep
Origin: ligamentum nuchae and spines of 7th cervical and 1st thoracic vertebrae
Insertion: medial border of scapula
Innervation: dorsal scapular nerve
Main action: raises medial border of scapula upwards and medially- retracts and rotates scapula
151
Describe the structure, location, origin, insertion, innervation and main actions of the rhomboid major
```
Structure:
Location: deep
Origin: 2nd-5th thoracic spines
Insertion: medial border of scapula
Innervation: dorsal scapular nerve
Main action: raises medial border of scapula upwards and medially, retracts and rotates scapula
```
152
Describe the structure, location, origin, insertion, innervation and main actions of the teres major
Structure:
Location: scapulo-humeral
Origin: lower third of lateral border of scapula
Insertion: medial lip of bicipital groove of humerus (intertubercular)
Innervation: lower subscapular nerve
Main action: medially rotates and adducts arms, stabilises shoulder joint
153
Describe the structure, location, origin, insertion, innervation and main actions of the supraspinatus
Structure:
Location: scapulo-humeral
Origin: supraspinous fossa of scapula
Insertion: greater tuberosity of humerus, capsule of shoulder joint
Innervation: suprascapular nerve
Main action: abducts arms, stabilises shoulder joint
154
Describe the structure, location, origin, insertion, innervation and main actions of the infraspinatus
Structure:
Location: scapulo-humeral
Origin: infraspinous fossa of scapula
Insertion: greater tuberosity of humerus, capsule of shoulder joint
Innervation: suprascapular nerve
Main action: laterally rotates arm, stabilises shoulder joint
155
Describe the structure, location, origin, insertion, innervation and main actions of the teres minor
Structure:
Location: scapulo- humeral
Origin: upper 2/3s of lateral border of scapula
Insertion: greater tuberosity of humerus, capsule of shoulder joint
Innervation: axillary nerve
Main action: laterally rotates arm, stabilises shoulder joint
156
Describe the structure, location, origin, insertion, innervation and main actions of the subscapularis
Structure:
Location: scapulo- humeral
Origin: subscapular fossa of scapula
Insertion: lesser tuberosity of humerus
Innervation:upper and lower subscapular nerves
Main action: medially rotates arm, stabilises shoulder joint
157
What are the 4 rotator cuff muscles?
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
158
What are three main features of the shoulder joint?
Relatively unstable: most commonly dislocated joint
Very mobile
Greatest range of movement
159
What is the glenohumeral joint?
Shoulder joint, synovial joint, ball and socket
160
What are the articular surfaces of the glenohumeral joint?
Head of humerus and glenoid cavity of scapula
Lined by hyaline cartilage
Glenoid labrum (fibrocartilage rim)- which deepens glenoid cavity and makes it more stable
161
How does the articulating surface appear in an X ray?
Articular hyaline cartilage is radioluscent and so appears as a clear black space
162
What is the capsule of the glenohumeral joint?
Capsule is attached to- glenoid labrum, margins of glenoid cavity of scapula, anatomical neck of humerus
Capsule bridges intertubercular (bicipital) groove and dips down medially to the surgical neck- provides laxity of full abduction
Capsule has a small opening anteriorly where the synovial membrane of the shoulder joint communicates with the subscapular bursa
Synovial membrane lines capsule and bone upto the edge of articular surfaces
Tendon of long head of biceps lies within the joint cavity (attached to supra glenoid cavity of scapula)
Tubular sleeve of synovium reflected back around the biceps tendon like a tube
Synovium and joint cavity is continuous with subscapular bursa through a gap in the capsule
163
What are the intrascapular ligaments?
3 glenohumeral ligaments (superior, middle and inferior)
There are three fibrous bands extending between glenoid labrum and humerus
Form part of the fibrous capsule and reinforce it anteriorly (can only be seen from the inside) of the capsule
164
What four extra capsular ligaments are there?
Coracoacromial ligament
Coracohumeral ligament
Transverse humeral ligament
Coracoclavicular (trapezoid and conoid)
165
What is the extra capsular coracoacromial ligament?
```
Coracoacromial ligament (CAL)
Between acromion and coracoid process
Coracoacromial arch consists of the ligament, acromion and coracoid process
Strong osseoligamentous structure
Overties humeral head
Prevents upper displacement of humerus
```
166
What muscles are involved in flexion of the shoulder joint?
```
Pectoralis major (clavicular head)
Anterior fibres of deltoid
Coracobrachialis and biceps brachii
```
167
What is the extra capsular coracohumeral ligament?
Ligament which lies between the coracoid process and greater tubercle of the humerus
168
What is the extra capsular transverse humeral ligament?
Bridges the greater and lesser tubercle
| Holds the long head of the biceps brachii in place during shoulder movements
169
What muscles are involved in extension of the shoulder joint?
Posterior fibres of deltoid
Latissimus dorsi
Teres major
170
What muscles are involved in abduction of the shoulder joint?
0-20 supraspinatus (initiator of abduction)
20-90 deltoid (central fibres)
Above 90 by rotation of scapula- trapezius, serratus anterior
171
What muscles are involved in adduction of the shoulder joint?
Pectoralis major
Latissimus dorsi
Teres major
172
What muscles are involved in medial rotation of the shoulder joint?
Subscapularis
Teres major
Pectoralis major
Latissimus dorsi
173
What muscles are involved in lateral rotation of the shoulder joint?
Infraspinatus
| Teres major
174
What muscles are associated with the shoulder joint?
```
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Deltoid
Long head of biceps
Long head of triceps
```
175
What is a bursa?
Small sacs filled with synovial fluid and lined by synovial membrane which facilitate movement of tendons and muscles on one another and bone by reducing friction
176
What does the subscapular bursa do?
Facilitates movement of the tendon of the subscapularis muscle over the scapula
Communicates with the joint cavity
177
What does the subacromial bursa do?
Facilitates movement of supraspinatus tendon under the CAA and the deltoid muscle over the shoulder joint capsule and the greater tubercle of the humerus
178
What is the blood supply of the shoulder joint?
Anterior and posterior circumflex humeral arteries
| Suprascapular artery
179
What is the nerve supply of the shoulder joint?
Suprascapular nerves
Axillary nerves
Lateral pectoral nerves
(From the brachial plexus C5,C6)
180
What provides the stability of the shoulder joint?
1. Tendons of the rotator cuff muscles (posterior, anterior, superior)
2. Coracoacromial arch (superior)
3. Glenohumeral ligaments (anterior, inferior)
4. Coracohumeral ligament (superior)
5. Deepening glenoid cavity by labrum (all around)
6. Splinting effect of : long heads of biceps (above) and long head of triceps (below)
181
Which border of the shoulder joint is least supported?
Inferiorly
182
How do muscle tendons associated with the shoulder joint increase its stability?
Tendons blend with each other as they approach the humeral head to form a cuff
Tendinous cuff also fuses with the capsule (and strengthens it)
Tone in muscles holds the head of the humerus close to the glenoid cavity
Supraspinatus tendon separated from the CAA by subacromial bursa
183
What do somites consist of?
Sclerotome
Myotome
Dermotome
Surrounding the neural tube
184
In an adult, what is the remnant of the dermomyotome?
Dermis and muscle
185
How is a somite associated with the neural tube?
Dermomyotome develops in association with a specific neural level of the embryonic neural tube tissue
Dermomyotome takes its nerve supply with it irrespective of where it ends up in the adult body
186
What is the adult nervous supply to the dermis and muscle of a dermomyotome?
Spinal segmental nerve
187
What is the structure of the spinal cord?
Long cylindrical column
Consists of millions of nerve cell bodies (grey) and neurone axons (white)
4 regions: cervical, thoracic, lumbar, sacral
Starts where medulla of brain ends
Ends at conus medullaris (membrane tapers into a ligament - film terminale)
188
What is the name of the ligament at the end of the spinal cord?
Filum terminale
189
What is the vertebral foramen?
Hole in which the spinal cord runs through the vertebrae (some of the vertebral column ends above 2/3)
190
What is the intervertebral foramina?
Holes on either side of each vertebra through which the spinal nerves leave the spinal canal
191
Describe the structure of the mixed spinal nerve
```
Dorsal RAMUS of spinal nerve
Dorsal root ganglion
Afferent dorsal root of spinal nerve
Efferent ventral root of spinal nerve
Ventral ramus of spinal nerve
Sympathetic chain
Roots of splanchnic nerve
```
192
What is segmentation?
Sensory nerves serve discrete territories of skin (sensations of the segment are fed through this route)
Motor nerves sever myotomial territories (motor instructions of the segment are mediated through this route)
193
What is the difference between the neural (spinal) and vertebral level?
Neural level is the neural tissue given off by the spinal cord
Vertebral level is the bone tissue at which the spinal cord gives off a pair of nerves - neural level exists)
194
As the mixed spinal nerve emerges through the intervertebral foramen what two branches does it divide into?
```
Dorsal RAMUS medial and lateral (small)
Ventral RAMUS (large)
```
195
What is the nerve supply to the upper limb?
```
Spinal cord
Cervical spinal segment (C5-T2)
BRACHIAL plexus (C5-T1) and T2 roots
Radial nerve
Musculocutaneous nerve
Ulnar nerve
Median nerve
Lateral pectoral, upper subscapular, lower subscapular, dorsal scapular, suprascapular, long thoracic, axillary
```
196
What is the nerve supply to the lower limb?
Spinal cord
```
Lumbar spinal segments (L1-1/2 of L4)- posterior to psoas major muscle (nerves arise medially and laterally to psoas major)
Illiohypogastric nerve
Illoinguial nerve
Lateral cutaneous of thigh
Femoral
Genitofemoral
Obturator
Lumbosacral trunk
```
```
Sacral spinal segments (1/2 of L4 - S4) - anterior primary rami, within pelvic cavity, near to piriformis, supplies gluteal and perineal region and the lower limb via the sciatic nerve
Gluteal nerve
Common peroneal nerve
Tibial nerve
Sciatic nerve
Pudendal nerve
Perforating cutaneous nerve
Posterior cutaneous nerve of the thigh
Nerve to obturator internus
Nerve to quadratus femoris
```
197
Why are limb dermatomes important?
Enable organised examination of integrity and sensory function of skin
Pinpoints regions of skin with disturbed function
Predicts what nerves and spinal segments may be affected by injury
When disturbed its important to anaesthetise segments of nerves and associated skin with accuracy
198
Define a dermatome
Area of skin supplied by sensory nerve fibres from a single spinal level (neural level)
199
What does it mean (in reality) that there is a functional overlap between adjacent dermatomes?
There is a functional overlap between adjacent dermatomes
So some regions are served by 2 successive spinal nerve
So a dermatome sandwiched between 2 others will have 3 successory sensory nerves
200
Why is it advantageous for adjacent dermatomes to have a functional overlap?
Ensures there is no skin without a nerve supply
If you have a lesion, there I backup by two adjacent nerve supplies
Therefore for damage to occur, large amounts of the spinal cord would need to be damaged!
201
Describe what the axial lines of limbs are
Axial lines of limbs- line of junction between 2 dermatomes supplied by discontinuous spinal levels
Boundaries between flexor and extensor compartments of the limbs
Cephalic and basilic vein in upper limb
Great and small saphenous vein in lower limb
202
What are the anterior superficial muscles of the forearm?
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor carpi ulnaris
203
What is the anterior intermediate muscle of the forearm?
Flexor digitorum superficialis
204
What are the anterior deep muscles of the forearm?
Flexor digitorum profundus
Flexor pollicis longus
Pronator quadratus
205
What forms the roof of the carpal tunnel?
Flexor retinaculum
206
What forms the base of the carpal tunnel?
Extensor retinaculum
207
What 10 things run through the carpal tunnel on the anterior surface of the arm?
4 tendons of flexor digitorum superficialis
4 tendons of flexor digitorum profundus
1 tendon of flexor pollicis longus
Median nerve
208
What muscles does the median nerve supply of the anterior forearm?
Flexor carpi radialis
Pronator teres
Palmaris longus
Flexor digitorum superficialis
Flexor digitorum profundus (anterior interosseous nerve from median)
Flexor pollicis longus (anterior interosseous nerve from median)
Pronator quadratus (anterior interosseous nerve from median)
209
What muscles does the ulnar nerve supply of the anterior forearm?
Flexor carpi ulnaris
| Flexor digitorum profundus
210
What are the common fractures of the forearm and which structures are damaged?
Mid shaft humeral fracture- Radial nerve injury
Fracture half way up forearm- Median nerve injury
Cubital tunnel / wrist / hand fracture - Ulnar nerve injury
211
What are the consequences of a mid shaft humeral fracture?
Common in younger and more active people
Injury to radial nerve (humeral radial groove on posterior surface of humerus)
WRIST FUNCTION TEST- paralysis of posterior compartments of forearm- no longer can extend arm- wrist drop
212
What are the consequences of median nerve injury?
Mostly due to fractures higher up the forearm, not the wrist
TEST- flexion of proximal interphalangeal joints of 1st and 3rd fingers are lost and flexion of distal interphalangeal joints of fingers are reduced- so impossible to make a fist- hand of Benedicts(2nd and 3rd finger remain partially extended
Cutaneous branch of median nerve -loses sensation in forearm
213
What are the consequences of ulnar nerve injury?
Posterior to medial epicondyle of humerus
Cubital tunnel, wrist, Hand
Numbness and tingling in 5th and 1/2 of 4th digit
TEST- MCPJoints become hyperextended- cannot extend 4th and 5th DIJ which are supplied by the ulnar
Denervation of intrinsic muscles in the hand/ wrist
Adduction is impaired- hand is drawn to the lateral side
214
Describe the structure, location, origin, insertion, innervation and main actions of the brachioradialis
Structure: border muscle
Location: superficial anterior forearm
Origin: proximal 2/3s of the supra epicondyle ridge of humerus
Insertion: lateral surface of distal end of radius, proximal to styloid process
Innervation: radial nerve
Main action: weak flexion of the arm
215
Describe the structure, location, origin, insertion, innervation and main actions of the pronator teres
Structure:
Location: superficial anterior forearm
Origin: medial epicondyle of humerus, coronoid process of ulna
Insertion: middle of convexity of lateral surface of radius
Innervation: median nerve
Main action: pronation of forearm at elbow, flexion of forearm at elbow
216
Describe the structure, location, origin, insertion, innervation and main actions of the flexor carpi radialis
```
Structure:
Location:superficial anterior forearm
Origin: medial epicondyle of humerus
Insertion: base of 2nd metacarpal
Innervation: median nerve
Main action: flexion of hand a wrist, abduction of hand at wrist
```
217
Describe the structure, location, origin, insertion, innervation and main actions of the palmaris longus
Structure:
Location: superficial anterior forearm
Origin: medial epicondyle of humerus
Insertion: distal half of flexor retinaculum and apex of palmar aponeurosis
Innervation: median nerve
Main action: flexion of hand at wrist, tenses palmar aponeurosis
218
Describe the structure, location, origin, insertion, innervation and main actions of the flexor carpi ulnaris
Structure:
Location: superficial anterior forearm
Origin: medial epicondyle of humerus, olecranon and posterior border of ulna (via aponeurosis)
Insertion: pisiform, hook of hamate, 5th metacarpal
Innervation: ulnar nerve
Main action: flexion of hand at wrist, adducts hand at wrist
219
Describe the structure, location, origin, insertion, innervation and main actions of the flexor digitorum superficialis
Structure:
Location: intermediate anterior forearm
Origin: medial epicondyle of humerus, radius (superior half of anterior border)
Insertion: shafts of middle phalanges of medial 4 digits
Innervation: median nerve
Main action: flexes middle phalanges at proximal interphalangeal joint of middle 4 digits, acting more strongly it flexes proximal phalanges at metacarpalphalangeal joints
220
Describe the structure, location, origin, insertion, innervation and main actions of the flexor digitorum profundus
Structure:
Location: deep anterior forearm
Origin: proximal 3/4 of medial and anterior surfaces of ulna and interosseous membrane
Insertion: base of distal phalanges of 2nd, 3rd, 4th and 5th digits
Innervation: ulnar nerve and anterior interosseous nerve (from median)
Main action: flexes distal phalanges 2,3, 4 and 5 at distal interphalangeal joints
221
Describe the structure, location, origin, insertion, innervation and main actions of the flexor pollicis longus
Structure:
Location:
Origin: anterior surface of radius and adjacent interosseous membrane
Insertion: base of distal phalanx of thumb
Innervation: anterior interosseous nerve (of median nerve)
Main action: flexes phalanges of thumb
222
Describe the structure, location, origin, insertion, innervation and main actions of the pronator quadratus
Structure: square shaped
Location: deep anterior forearm
Origin: distal quarter of anterior surface of ulna
Insertion: distal quarter of anterior surface of radius
Innervation: anterior interosseous nerve (from median nerve)
Main action: pronates forearm
223
Describe the structure, location, origin, insertion, innervation and main actions of the extensor carpi radialis longus
Structure:
Location: superficial posterior forearm
Origin:lateral supraepicondylar ridge of humerus
Insertion: dorsal aspect of base of 2nd metacarpal
Innervation: radial nerve
Main action: extends and abducts hand at the wrist joint, active during fist clenching
224
Describe the structure, location, origin, insertion, innervation and main actions of the extensor digitorum
Structure:
Location: superficial posterior forearm
Origin: lateral epicondyle of humerus
Insertion: extensor expansions of medial 4 digits
Innervation: deep branch of radial nerve
Main action: extends medial 4 digits primarily at metacarpalphalangeal joints, secondarily at interphalangeal joints
225
Describe the structure, location, origin, insertion, innervation and main actions of the supinator
Structure:
Location: deep posterior forearm
Origin: lateral epicondyle of humerus, radial collateral and anular ligaments, supinator fossa, crest of ulna
Insertion: lateral posterior and anterior surfaces of proximal 1/3 of radius
Innervation: deep branch of radial nerve
Main action: supinated forearm, rotates radius to turn palm anteriorly or superiorly (if elbow is flexed)
226
Describe the structure, location, origin, insertion, innervation and main actions of the extensor carpi radialis brevis
Structure:
Location: deep posterior forearm
Origin: lateral epicondyle of humerus
Insertion: dorsal aspect of base of 3rd metacarpal
Innervation: deep branch of radial nerve
Main action: extends and abducts hand at wrist joint, active during fist clenching
227
Describe the structure, location, origin, insertion, innervation and main actions of the extensor digit minimi
Structure:
Location: deep posterior forearm
Origin: lateral epicondyle of humerus
Insertion: extensor expansion of 5th digit
Innervation: deep branch of radial nerve
Main action: extends 5th digit primarily at metacarpalphalangeal joint, secondarily at interphalangeal joint
228
Describe the structure, location, origin, insertion, innervation and main actions of the extensor carpi ulnaris
Structure:
Location: deep posterior forearm
Origin: lateral epicondyle of humerus
Insertion: posterior border of ulna via a shared aponeurosis
Innervation: deep branch of radial nerve
Main action: extends and adducts hand at wrist joint, active in fist clenching
229
Describe the structure, location, origin, insertion, innervation and main actions of the extensor indicis
Structure:
Location:
Origin: posterior surface of distal third of ulna and interosseous membrane
Insertion: extensor expansion of 2nd digit
Innervation: posterior interosseous nerve, continuation of deep branch of radial nerve
Main action: extends 2nd digit enabling its independent extension
230
Describe the structure, location, origin, insertion, innervation and main actions of the abductor pollicis longus
Structure:
Location: outcropping deep posterior forearm
Origin: posterior surface of proximal halves of ulna, radius and interosseous membrane
Insertion: base of thumb
Innervation: posterior interosseous nerve, continuation of deep radial nerve
Main action: abducts and extends (at carpometacarpal joint) thumb
231
Describe the structure, location, origin, insertion, innervation and main actions of the extensor pollicis longus
Structure:
Location:
Origin: posterior surface of middle 1/3 of ulna and interosseous membrane
Insertion: dorsal aspect of base, distal phalanx of thumb
Innervation: posterior interosseous nerve, continuation of deep branch of radial nerve
Main action: extends distal phalanx of thumb at interphalangeal joint, extends metacarpalphalangeal and carpometacarpal joint
232
Describe the structure, location, origin, insertion, innervation and main actions of the extensor pollicis brevis
Structure:
Location:
Origin: posterior surface of distal third of radius and interosseous membrane
Insertion: dorsal aspect of base of proximal phalanx of the thumb
Innervation: posterior interosseous nerve, continuation of deep branch of radial nerve
Main action: extends proximal phalanx of thumb at metacarpophalangeal joint
233
Describe the carpal tunnel
Between forearm and hand
Roof - flexor retinaculum (pisiform to trapezium), anterior
Base - extensor retinaculum, posterior
Nerves- ulnar (posterior), median (anterior) and radial (dorsum of hand)
Tendons- anterior-
4 tendons of flexor digitorum superficialis
4 tendons of flexor digitorum profundus
1 tendon of flexor pollicis longus
Tendons- posterior-
234
What is the carpal tunnel syndrome?
Increase in pressure in carpal tunnel area
TEST- tinnels test (tap over carpal tunnel), fahlens test (back of hands together) --> reproduces symptoms
235
In the upper limb what is the dermatome for C4?
Skin over the shoulder tip
236
In the upper limb what is the dermatome for C5?
Radial side of upper arm
237
In the upper limb what is the dermatome for C6?
Radial side of forearm
238
In the upper limb what is the dermatome for C7?
Skin of hand
239
In the upper limb what is the dermatome for C8?
Ulnar side of forearm
240
In the upper limb what is the dermatome for T1?
Ulnar side of upper arm
241
In the upper limb what is the dermatome for T2?
Skin of the axilla
242
In the lower limb, what dermatome is largely supplied by lumbar segments?
Front of limb
243
In the lower limb what dermatome is largely supplied by the sacral segments?
Back of limb
244
In the lower limb what dermatomes are completely supplied by the sacral segments?
Saddle and perineal area
245
What are limb nerve territories?
Regions of skin supplied by nerves and their peripheral nerves
Not dermatomes
246
Describe the boundaries of the anatomical snuff box
Sde
247
Scaphoid snuff box
X
248
What 5 things are found in the axilla?
Axillary artery – It is the main artery supplying the upper limb. It is commonly refered as having three parts, one medial to the pectoralis minor, one posterior to pectoralis minor, and one lateral to pectoralis minor. The medial and posterior parts travel in the axilla.
Axillary vein – The main vein draining the upper limb, its two largest tributaries are the cephalic and basilic veins.
Brachial plexus – A collection of spinal nerves that form the peripheral nerves of the upper limb.
Biceps brachii and corocobrachialis – These muscle tendons move through the axilla, where they attach to the coracoid process of the scapula.
Axillary Lymph nodes - The axillary lymph nodes filter lymph that has drained from the upper limb and pectoral region. In women, axillary lymph node enlargement is a non-specific indicator of breast cancer.
249
What 6 things are found in the cubital fossa?
Radial nerve - This is not always strictly considered part of the cubital fossa, but is in the vicinity, passing underneath the brachioradialis muscle. As it does so, the radial nerve divides into its deep and superficial branches.
Biceps tendon - It runs through the cubital fossa, attaching to the radial tuberosity, just distal to the neck of the radius.
Brachial artery - The brachial artery supplies oxygenated blood the forearm. It bifurcates into the radial and ulnar arteries at the apex of the cubital fossa.
Median nerve - Leaves the cubital between the two heads of the pronator teres. It supplies the majority of the flexor muscles in the forearm.
Median cubital vein- in roof of cubital fossa
Bicipital aponeurosis- posterior to median cubital vein but anterior in median nerve and brachial artery- for protection
250
What are the borders of the carpal tunnel?
Carpal Arch
Concave on the palmar side
Formed laterally by the scaphoid and trapezium tubercles
Formed medially by the hook of the hamate and the pisiform
Flexor Retinaculum
Thick connective tissue
Turns the carpal arch into the carpal tunnel by bridging the space between the medial and lateral parts of the arch.
Originates on the lateral side and inserts on the medial side of the carpal arch.
251
What is another name for the anatomical snuff box?
Radial fossa
252
When is the anatomical snuff box most vividly seen?
When the thumb is abducted
253
What are the borders of the anatomical snuff box?
Medial border: Tendon of the extensor pollicis longus.
Lateral border: Tendons of the abductor pollicis longus and extensor pollicis brevis.
Proximal border: Styloid process of the radius.
Floor: Carpal bones; scaphoid and trapezium.
Roof: Skin.
254
What three things are found in the anatomical snuff box?
Radial artery, a branch of the radial nerve, and the cephalic vein
The radial artery crosses the floor of the anatomical snuffbox in an oblique manner. It runs deep to the extensor tendons. Subcutaneously, terminal branches of the superficial branch of the radial nerve run across the roof of the anatomical snuffbox, providing innervation to the skin of the lateral 3 1/2 digits on the dorsum of the hand, and the associated palm area.
Also subcutaneously, the cephalic vein crosses the anatomical snuffbox, having just arisen from the dorsal venous network of the hand.
255
What are the main functions of the clavicle?
Attaches the upper limb to the trunk.
Protects the underlying neurovascular structures supplying the upper limb.
Transmits force from the upper limb to the axial skeleton.
256
What are the main bony landmarks of the clavicle?
On the inferior surface of the bone there are enlarged ugh ended areas of the bone acting as attachments for ligaments
(Acromial end) Conoid tubercle is where the Conoid ligament attaches (= medial part of coracoclavicular ligament)
Trapezoid line is where the Trapezoid ligament attaches
(Sternal end) rough oval depression-for costoclavicular ligament
257
What are the articulating surfaces of the elbow joint?
HUMERUS -
Trochlea (articulates with ulna)
Capitulum (articulates with the radius)
Olecranon fossa (articulates with olecranon process of ulna)
Coronoid fossa (articulates with coronoid process of ulna)
Radial fossa (articulates with head of radius)
ULNA-
Coronoid process
Trochlear notch
Olecranon process
RADIUS-
Head
258
What are the main movements of the elbow joint?
Extension- at full extension the ulna makes an angle of 170 with the humerus
259
What type of joint is the elbow joint?
Hinge type synovial joint
260
What muscles are involved in making the hinge movement of the elbow joint?
Biceps brachii
Triceps brachii
Brachioradialis
261
What is difference between the carrying angle of the elbow joint in a male and female?
Forearm is angled further away from the trunk in females
262
Describe the capsule of the elbow joint
Weak anteriorly and posteriorly - allowing flexibility
It is strengthened by collateral ligaments (medially and laterally)
Elbow and proximal radio ulnar joint share a capsule
Synovial membrane lines the fibrous capsule and the humerus is enclosed by the capsule
263
What three main ligaments are found in the elbow joint?
Ulnar collateral ligament
Radial collateral ligament
Annular ligament
264
Describe the ulnar collateral ligament
Triangle shape
3 bands- anterior (strongest), posterior (fan like arrangement) and oblique (deepens the socket of the trochlear notch- further enhances the stability to the elbow joint)
Connects medial epicondyle of humerus to coronoid process and olecranon of ulna
265
Describe the radial collateral ligament
Broad fan like ligament
Attaches to the lateral epicondyle of the humerus, the radial notch of the ulna and the annular ligament
Anterior and posterior bands
266
Describe the annular ligament
Surrounds the radial head and radial notch of ulna to keep it in place
Also allows for pronation and supination movements of the arm
267
What bursae are found in the elbow joint?
There are many bursae found in the elbow joint
They relieve pressure and friction of muscles moving at the joints
Most don't have any associated problems except:
Subcutaneous olecranon bursa - very superficial
Subtendinous olecranon bursa - under the biceps brachii tendon
268
Describe the subcutaneous olecranon bursa
Located between the olecranon process of ulna and the skin
| Release from pressure and friction of muscles moving at the joint
269
What nerves are associated with the elbow joint?
Radial nerve passes anterior to the lateral epicondyle
| Ulnar nerve passes posterior to the medial epicondyle
270
What is hiltons law?
Muscles extending directly across and acting at a given joint also innervate the joint
271
What is the vascular supply of the elbow joint?
Arterial anastomoses formed by collateral arteries and the recurrent branches of the ulnar, radial and interosseous arteries
Brachial archery runs through the elbow joint
272
What are the three radioulnar joints?
1- proximal radioulnar
2- interosseous membrane (muscle attachment)
3- distal attachment
273
What movements are the radioulnar joints involved in?
Increases manual dexterity allowing pronation and supination
Head of radius pivots on the capitulum of humerus (ball and socket joint)
Supination- radius and ulnar lie parallel to one another
Pronation- radius moves over the ulna
274
What type of the joint is the proximal radioulnar joint?
Pivot
275
What are the articulating surfaces of the proximal radioulnar joint?
Radius- head
| Ulna- radial notch
276
What ligaments are found in the proximal radioulnar joint?
Annular ligament
- ligament pus collar attached to the ulna, anteriorly and posteriorly to its radial notch
- ring ligament supports the head of the radius from below and the end of the humerus
277
What injury involves the annular ligament which is common n children?
Pulled elbow- where a force causes the radial head to subluxation from the annular ligament
This causes a lump due to the muscles pulling the radial head superiorly
278
What type of joint is the interosseous membrane?
Fibrous joint
279
Describe some features of the interosseous membrane?
Fibrous joint
Fibres run inferiomedially
Allows distribution of force from radius to ulna- Aims to prevent fractures of the bone
280
What are the articulating surfaces of the distal radioulnar joint?
ULNA- rounded head
RADIUS- ulnar notch on medial border
ARTICULAR DISK- main structure of affording joint integrity; separates cavity of distal radioulnar joint from the wrist cavity (from carpal bones)
281
What movements are the distal radioulnar joint involved in?
Pronation (pronator quadratus and pronator teres) and supination (supinator an e biceps brachii)
- articular disc ensures joint integrity is maintained
- sacciform recess superior extension of synovial capsule allows the twisting of the capsule
282
Where are the (wrist) radiocarpal joints found?
Between the radius and the carpals only, not the ulna
283
What are the articulating surfaces of the (wrist) radiocarpal joints?
Distal radius and articular disk with proximal carpal bones
RADIUS- distal radius
CARPALS- proximal row of carpal bones (not pisiform) = scaphoid, triquestrum and lunate
284
What ligaments are associated with the (wrist) radiocarpal bones?
```
Collateral ligaments (radial and ulnar)
Palmar radiocarpal (ensure hand follows radius during supination)
Dorsal radiocarpal (ensures hand follows radius during pronation)
```
285
What movements are the (wrist) radiocarpal joints involved in?
Flexion and extension- radius extends more than the ulnar
| Abduction and adduction- radial/ ulnar deviation; abduction limited by radial styloid process
286
What is a Colles fracture?
Falling on an outstretched hand - posterior displacement of distal 2cm fragment of the radius
Results in the dinner fork deformity
287
What is a scaphoid fracture?
Scaphoid carpal bone is fractured
Tenderness over the anatomical snuffbox
Avascular necrosis may occur due to potential damage to the radial artery
288
What are the three main functions of joints?
Allows motion
Absorbs shock
Allows growth
289
What are the 4 most common injuries to synovial joints?
Dislocation
Fractures (intra-articular)
Fracture- dislocation
Sprains
290
What are some obvious signs of joint injury upon examination?
Look- Swelling, Bruising, Obvious deformity, Puncture or skin wounds, joint fluid
Feel- Painful anatomical sites, Laxity, Crepitus
Move- range of movements, pulses difficult to feel
291
What investigations can be carried out when assessing joint injuries?
```
X rays
Stress views
MRI
CT scan
Aspiration
Rule of twos- 2 bones, 2 joints, 2 sides, 2 views (polo mint analogy)
```
292
What is a fracture?
It is a soft tissue injury with an underlying break in the bony cortex
293
What are some causes of fractures?
Trauma
Pathological (infection/ tumour)
Stress (marathon runners/ soldiers)
Insufficiency (osteoporosis/ osteopenia)
294
What local factors affect fracture healing?
Disruption of vascular supply (delays healing)
Degree of the immobilisation of fracture (motion at site delays healing)
Abnormal bone (infection, tumour, irradiated; slower to heal)
Degree of local trauma/bone loss (a comminuted fracture with more soft tissue injury is more difficult to heal)
Area of bone affected (metaphyseal fractures heal faster than diaphyseal fractures)
295
What systemic factors affect fracture healing?
```
Smoking
Drugs
Age
Nutrition (diabetes)
General health
Generalised atherosclerosis
Hormonal factors
```
296
How do fractures heal?
There are three phases
1. inflammatory (1-5 days)
2. Reparative (4-40 days)
3. remodelling (25- 200 days)
Immediately: haematoma/ clot formation
Within 48 hours: inflammation- cells; Organisation/ resorption clot
2 to 12 days: granulation – mesenchymal cells, fibroblasts, new capillaries
One week to 12 days: soft callus – bridges fracture site – cartilage and trabecular bone; hard callus – trabecular bone
Months: remodelling
297
How would you assess a fracture?
```
Using OLD ACID
Open versus cold
Location
Degree of fracture
Articular extension/ involvement
Comminution/ pattern
Displacement/ angulation/ rotation
```
298
What is meant by an open fracture?
Fracture in which bone penetrates the skin and is exposed to air - OPEN
299
How would you describe the location of fracture?
Divide the bone into thirds – proximal, middle and distal
Anatomic orientation- posterior, anterior, lateral, medial, proximal and distal)
Anatomic landmarks
300
How would you describe the degree of a fracture?
Complete – whole cortical circumference; fragments are completely separated
Incomplete – not fractured all the way through; only one cortex involved
301
How would you describe pattern of a fracture?
```
Transverse
Oblique
Longitudinal/ linear
Spiral
Segmental
Comminuted
Compression impacted
```
302
What are the three angulations of bone fractures?
Valgus/ apex medial
Parallel/ no angulation
Vagus/ apex lateral
303
What is meant by the rotation of bone in a fracture?
The extent to which fracture fragments are rotated relative to each other
Convention to describe which direction the distal fragment is rotated relative to the proximal position of the bone
304
What are the goals of fracture treatment?
Reduce
Hold
Rehabilitate
305
What are some local early fracture complications?
```
Nerve injury
Vascular injury
Compartment syndrome
Avascular necrosis
Infection
Surgical
```
306
What are some systemic early fracture complications?
```
Hypovolaemia/shock
Fat embolism
Thromboembolisms
Acute respiratory distress syndrome
Disseminated intravascular coagulation
```
307
What are some local late fracture complications?
```
Delayed union
Non-union
Malunion
Myositic ossificans
Refracture
```
308
What are some regional late fracture complications?
```
Osteoporosis
Joint stiffness
Chronic regional pain syndrome
Abnormal biomechanics
Osteoarthritis
```
309
What is someone at risk of if healing goes wrong?
Infection
Malunions– deformity; late arthrosis
Non-union – hypertrophic/atrophic
310
What is a sprain?
Damage to a ligament
311
What are the three severities of a sprain?
Complete
Partial
Damaged by this with continua tea in traffic
312
How do sprains arise?
By forces which stress the ligaments
313
Where are the three most common sites of a sprain?
Ankle – anterior talofibular ligament
Knee
Joints of the hand – usually the farm3
314
What are the treatments of a sprain?
```
Rest
Ice
Compression
Elevation
RICE
Ottawa ankle rules – tells a whether an X ray is required or not
```
315
What is a dislocation?
Complete loss of the continuity of the articulating surfaces of a joint
316
What are three examples of a dislocation?
Finger dislocation
Anterior shoulder dislocation – axillary nerve
Posterior shoulder dislocation – lightbulb sign
317
What is subluxation?
The partial loss of continuity of the articulating surfaces of the joint
318
What are five examples of subluxation?
```
Subluxed shoulder joint
Hip dislocation – sciatic nerve
T R H dislocation
Knee dislocation – popliteal artery; common peroneal nerve
Patella dislocation
```
319
What are the main consequences of joint injury?
```
Pain
Stiffness
Deformity
Loss of function
Cosmetically poor
Lots of love
```
320
What is the palmar aponeurosis?
Thick strong fascia
Covers the soft tissue of palmar surface of hand
Overlies long flexor tendons- Longitudinal fibres/tendons = fibrous digital sheaths; Transverse fibres
Continuous with apex of palmar longus
321
What is the clinical relevance of the palmar aponeurosis?
– Shortening, thickening and fibrosis of palmer fascia and aponeurosis
– 4th and 5th fingers can become flexed
– Management: Surgical release
322
What is the fibrous digital sheath of the hand?
Ligamentous tube/ encloses flexor tendons and synovial sheaths
Prevents tendons bow stringing
Osteofibrous tunnels
Pulleys - 5x annular and 4x cruciform
323
What is the clinical relevance of the fibrous digital sheath?
Trigger finger- fibrous narrowing of tunnel, difficult for tendons to move over, snap on extension of the finger
324
What are the synovial sheaths of the hand?
Produce synovial fluid to keep the tendons lubricated and decrease function
325
What is the clinical relevance of the synovial sheaths?
Tenosynovitis = infection of digital sheath
2nd, 3rd, 4th usually confined
1st and 5th spread
326
How are the tendons arranged on the fingers?
Superficialis splits in two to permit profundus passing through
327
Where do extrinsic muscles of the hand originate?
In the forearm
328
Where do intrinsic muscles of the hand originate?
In the hand
329
What grip are extrinsic muscles of the hand responsible for?
Power grip
330
What grip are intrinsic muscles of the hand responsible for?
Precision grip
331
What are the two major muscle groups beneath the palmar aponeurosis?
Thenar and hypothenar muscle groups / eminences
332
What intrinsic muscles are found in the hand?
Thenar eminence- opponens pollicis, abductor pollicis brevis, flexor pollicis brevis
Hypothenar eminence- opponens digiti minimi, abductor digiti minimi, flexor digiti minimi brevis
Lumbricals
Palmaris brevis
Adductor pollicis
Interossei muscle
333
Describe the Thenar eminence
Thumbside muscles responsible for thumb movement
opponens pollicis (opposes thumb)
abductor pollicis brevis (abducts thumb)
flexor pollicis brevis (flexes thumb)
All innervated by the median nerve
334
Describe the hypothenar muscles
Little finger side- responsible for little finger movements
opponens digiti minimi (opposes little finger)
abductor digiti minimi (abductor little finger at MCP joint)
flexor digiti minimi brevis (flexes little finger at MCP joint)
All innervated by deep branch of ulnar nerve
335
Describe palmaris brevis
Originates at flexor retinaculum
Inserts medially int the dermis of the skin
Overlies hypothenar muscles
Action- tenses ulnar/ medial side of palm and hollows palm in gripping action
Innervated by ulnar nerve
336
Describe the lumbricals
There are 4- medial (4- pinky) to lateral (1- index)
Originate on TENDONS of flexor digitorum profundum and insert at extensor portions (don't attach to bones)
Action- Flexion at be MCP joint and extension at IP Joints
Medial two lumbricals - 3 and 4 innervated by ulnar nerve
Lateral two lumbricals - 1 and 2 innervated by median nerve
337
Describe adductor pollicis
Originates from 3rd metacarpal and inserts onto base of proximal phalynx and extensor hood of thumb
2 heads (transverse and oblique- direction of fibres)
Action- adducts thumb
Innervated by deep branch of ulnar nerve
338
Describe the interossei muscles
2 groups- dorsal and palmar
Muscles in between MC Bones and insert onto the extensor hood
Dorsal - abduction
Palmar - adduction at MCP joints of index, middle and ring fingers
339
Which 7 arteries are found in the hand?
```
Superficial palmar arch
Deep palmar arch
Common palmar digital
Proper palmar digital
Princess pollicis
Radialis indicis
Dorsal carpal arch
```
340
Where does the superficial palmar arch artery originate from and what is its course?
Origin: direct continuation of ulnar archery; arch is completed on lateral side by superficial branch of radial artery or another of its branches
Course: curves laterally deep to the Palmer aponeurosis and superficial to long flexor tendons; curve of arch lies across palm at level of distal border of extended thumb
341
Where does the deep palmar arch artery originate from and what is its course?
Origin: direct continuation of radial artery ; arch is completed on medial side by deep branch of ulnar artery
Course: curves medially, deep to long flexor tendons; is in contact with base of metacarpals
342
Where does the common palmar digital originate from and what is its course?
Origin: superficial palmar arch
Course: pass distally on lumbricals to webbing of digits
343
Where does the proper palmar digital originate from and what is its course?
Origin: common palmar digital arteries
Course: run along sides of second to fifth digits
344
Where does the princess pollicis originate from and what is its course?
Origin: radio artery as it turns into the palm
Course: descends on palmar aspect of first metacarpal; divides at base of proximal phalanx into two branches that run along sides of thumb
345
Where does the radialis indicis originate from and what is its course?
Origin: radial artery that may arise from princeps pollicis artery
Course: passes along the lateral side of index finger to its distal end
346
Where does the dorsal carpal arch originate from and what is its course?
Origin: radial and ulnar arteries
Course: Arches within fascia on dorsum of hand
347
Describe the veins of the hand
Superficial and deep venous palmar arches, associated with the superficial and deep palmar arterial arches, drain into deep veins of the forearm. The dorsal digital veins drain into three dorsal metacarpal veins, which unite to form a dorsal venous network. Superficial to the metacarpus, this network is prolonged Proximally on the lateral side of the cephalic vein. The basilic vein arises from the medial side of the dorsal venous network.
348
What is raynauds syndrome?
Pain, Paraesthesia
Abnormal vasoconstriction – no blood supply/ pale fingers, hypoxia, blue fingers, blood supply returns = reactive hyperaemia (Metabolites)
Cold weather and extreme emotion
349
What muscles of the hand are innervated by the median nerve?
Thenar side
Lumbricals 1 and 2
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
350
What sensory areas are supplied by the median nerve?
Palmar cutaneous branch comes off before the carpal tunnel- supplies the skin of the palm (not affected in CTS)
Supplies 3 1/2 fingers (1,2,3 and half of 4) and finger tips and nails of dorsal surface
351
What muscles of the hand are innervated by the ulnar nerve?
Hypothenar little finger side
```
Lumbricals 3 and 4
Opponens digiti minimi
Abductor digiti minimi
Flexor digiti minimi
Interossei muscles
```
352
What sensory areas are supplied by the ulnar nerve?
Aupplies medial 1 and a half digits front and back
| 3 branches = superficial (fingers), palmar (palms) and dorsal (back of hand)
353
What muscles of the hand are innervated by the radial nerve?
None
354
What sensory areas are supplied by the radial nerve?
ONLY SENSORY SUPPLY TO THE HAND
NO MOTOR SUPPLY TO INTRINSIC HAND MUSCLES
skin covering Thenar region (anterior)
Posterior surface of 1st, 2nd and 3rd fingers
355
What are the main features of the hip bone?
Consists of Ilium, pubis, ischium
Pubis- pubic symphysis (where 2 hip bones fuse), superior pubic ramus, ischiopubic ramus, pubic tubercle (inguinal ligament)
Ischium- ramus of ischium, ischiopubic ramus, ischial tuberosity (rough, muscle attachement), ischial spine
Ilium- wing of ilium (ala) iliac fossa, iliac crest, tubercle of iliac crest, anterior/posterior inferior iliac spine, anterior/posterior superior iliac spine
Other features- greater sciatic notch, lesser sciatic notch, obturator foramen (canal), gluteal lines
356
What does the pelvic girdle consist of?
2 hip bones
Pubic symphysis
Sacrum
357
Before puberty, what separates the ilium, pubis and ischium in the hip bones?
Triradiate cartilage separates the ilium, pubis and ischium prior to puberty
358
At what age does the ilium, ischium and pubis fuse?
Fuse at age 15-17
359
What does fusion of the pubis, ilium and ischium form?
Forms the acetabulum- where all three sections of bone meet, where head of femur articulates
360
What is the clinical importance of the inguinal ligament?
We can palpate the ASIS and pubic tubercle to find the mid point of the inguinal ligament to locate the femoral artery
Forms the superior medial border of the femoral triangle
361
What are the attachments of the inguinal ligament?
Pubic tubercle
| ASIS
362
What two bones does the hip bone articulate with?
Femur
| Sacrum
363
What are the main features of the femur?
Proximal- head, neck, greater trochanter, lesser trochanter, intertrochanteric line, pectineal line, gluteal tuberosity
Shaft- linea aspera, medial supraepicondylar line, lateral supraepicondylar line
Distal- intercondylar fossa, lateral epicondyle, medial epicondyle, adductor tubercle, lateral condyle, medial condyle, popliteal fossa
364
What are the main features of the tibia?
Lateral condyle, medial condyle, intercondylar eminence/tubercle, facet for articulation with fibula, tibial tuberosity, soleal line, groove for tibialis posterior tendon, medial malleolus, fibular notch
366
What are the main features of the fibula?
Facet for articulation with tibia, lateral malleolus
367
What are the 7 tarsal bones?
```
Calcaneus
Talus
Cuboid
Navicular
Lateral cuneiform
Intermediate cuneiform
Medial cuneiform
```
368
What are the foot bones?
7 tarsals
5 metatarsals
14 phalanges
369
What bone of the foot articulates with the tibia bone?
Talus
370
What tarsal bone articulates with the 4th and 5th digit of the foot?
Cuboid
371
What tarsal bone articulates with the 3rd digit of the foot?
Lateral cuneiform
372
What tarsal bone articulates with the 2nd digit of the foot?
Intermediate cuneiform
373
What tarsal bone articulates with the 1st digit of the foot?
Medial cuneiform
374
Describe the structure, location, origin, insertion, innervation and main actions of the psoas major
Origin: lumbar vertebrae
Insertion: lesser trochanter of femur (coverages with iliacus)
Nerve: femoral
Action: flexion and lateral rotation at hip joint
375
Describe the structure, location, origin, insertion, innervation and main actions of the iliacus
Origin: iliac fossa of pelvis
Insertion: lesser trochanter of femur (coverages with psoas major)
Nerve: femoral
Action: flexion and lateral rotation at hip joint
376
What three muscles form iliopsoas?
Iliacus
Psoas major
Psoas minor
377
Describe the structure, location, origin, insertion, innervation and main actions of the vastus medalis
```
Location: anterior thigh
Origin: medial lip of line of aspera of femur and intertrochanteric line
Insertion: patella
Nerve: femoral
Action: extensor at knee joint
```
378
Describe the structure, location, origin, insertion, innervation and main actions of the vastus intermediatus
```
Location: anterior thigh
Origin: anterior and lateral surface of femur
Insertion: patella
Nerve: femoral
Action: extensor at knee joint
```
379
Describe the structure, location, origin, insertion, innervation and main actions of the vastus lateralis
```
Location: anterior thigh
Origin: greater trochanter of femur
Insertion: patella
Nerve: femoral
Action: extensor at knee joint
```
380
Describe the structure, location, origin, insertion, innervation and main actions of the rectus femoris
Location: anterior thigh, crosses both knee and hip joints
Origin: anterior inferior iliac spine and part of acetabulum
Insertion: patella
Nerve: femoral
Action: extensor at knee joint, flexion at hip joint
381
What 4 muscles make up the quadratus femoris?
Vastus medialis
Vastus intermediatus
Vastus lateralis
Rectus femoris
382
Describe the structure, location, origin, insertion, innervation and main actions of the sartorius
Structure: longest muscle in the body
Location: anterior thigh, runs across thigh inferiomedially, superficial, inferior border of femoral triangle
Origin: anterior superior iliac spine
Insertion: superior medial surface of tibia
Nerve: femoral
Actions: flexion, abduction and lateral rotation at hip joint, flexion at knee joint
383
Describe the structure, location, origin, insertion, innervation and main actions of the pectineus
Location: anterior, medial thigh
Origin: pectineal line on anterior surface of the pelvis
Insertion: pectineal line on posterior side of femur (inferior to lesser trochanter)
Nerve: femoral nerve
Action: adduction and flexion at the hip joint
*innervation by femoral nerve is characteristic of the anterior compartment but its actions are typical of a muscle from the medial compartment
384
Describe the structure, location, origin, insertion, innervation and main actions of the adductor Magnus
Structure: largest muscle in medial compartment of thigh; has 2 parts- adductor and hamstring part
Location: medial thigh
Adductor part-
Origin: inferior rami of pubis and rami of ischium
Insertion: linea aspera of femur
Nerve: obturator nerve
Action: adduction of thigh (w/hamstring part), flexion of thigh
Hamstring part-
Origin: ischial tuberosity
Insertion: adductor tubercle on distal and medial side of femur
Nerve: tibial
Action: adduction of thigh (with adductor part), extension of thigh
385
Describe the structure, location, origin, insertion, innervation and main actions of the adductor longus
Structure: long flat muscle
Location: medial thigh, partially covers adductor brevis and magnus, medial border and floor of femoral triangle
Origin: pubis- fan shaped
Insertion: broad attachment to linea aspera of femur
Nerve: obturator
Action: adduction of thigh, medial rotation of thigh
386
Describe the structure, location, origin, insertion, innervation and main actions of the adductor brevis
Structure: short muscle
Location: medial thigh, beneath adductor longus, lies between anterior and posterior divisions of obturator nerve
Origin: body of pubis and inferior pubic rami
Insertion: linea aspera of posterior surface of femur- proximal to adductor longus
Nerve: obturator
Action: adduction of thigh
387
Describe the structure, location, origin, insertion, innervation and main actions of the obturator externus
Structure: smallest muscle of medial thigh
Location: media thigh, most superior, passes under neck of femur
Origin: membrane of obturator foramen and adjacent bone
Insertion: posterior aspect of greater trochanter
Action: laterally rotates thigh
388
Describe the structure, location, origin, insertion, innervation and main actions of the gracilis
Location: medial thigh, most superficial and medial of muscles, crosses hip and knee joints
Origin: inferior rami of pubis and its body
Insertion: medial surface of tibia in between tendons of sartorius and semitendinous (posterior)
Nerve: obturator
Action- adducts thigh at hip joint, flexion of leg at knee
389
What is the medial border of the femoral triangle?
Medial border of adductor longus muscle
390
What is the superior border of the femoral triangle?
Inguinal ligament
391
What is the lateral border of the femoral triangle?
Medial border of the sartorius muscle
392
What makes up the floor of the femoral triangle?
Rest of the adductor longus muscle, pectineus and iliopsoas
393
What is the roof of the femoral triangle?
Fascia lata
394
What is the contents of the femoral triangle? (4)
Femoral nerve
Femoral artery
Femoral vein
Femoral canal
395
Where does the femoral nerve supply?
Innervates anterior compartment of thigh and provides sensory branches for the leg and foot
396
Where does the femoral artery supply?
Majority of arterial supply of lower limb
397
What vein drains into the femoral vein within the femoral triangle?
Great saphenous vein
398
What does the femoral canal contain?
Deep lymph nodes and vessels
399
What are the femoral artery, vein and canal contained within?
Femoral sheath (fascial compartment)
400
Describe the course of the femoral artery to the adductors canal
After leaving the femoral triangle, the femoral artery continues down the anterior surface of the thigh, via a tunnel - adductor canal
During its descent the artery supplies anterior thigh muscles
The adductor canal ends at an opening in the adductor Magnus- adductor hiatus- femoral artery goes through this opening and enters the posterior compartment of the thigh, becoming the popliteal artery.
401
Describe the structure, location, origin, insertion, innervation and main actions of the tensor of fascia latae
Structure: has a thick iliotibial ligament that can be palpated along the lateral surface of the thigh
Origin: anterior superior iliac spine and anterior part of iliac crest
Insertion: iliotibial tract
Nerve: superior gluteal nerve
Action: tenses fascia Latae, abduction at hip joint, flexion at hip joint, internal rotation at hip joint
402
What is the fascia Latae?
The deep fascia that forms a complete sheath for the thigh and has an opening in front just below the inguinal ligament for the passage of the great saphenous vein
403
What 8 muscles re found in the gluteal region of the body?
```
Gluteus maximus
Gluteus medius
Gluteus minimus
Piriformis
Obturator internus
Superior gemellus
Inferior gemellus
Quadratus femoris
```
404
What 3 muscles make up the superficial layer of the gluteal region?
Gluteus maximus, medius and minimus
405
What 5 muscles make up the deep layer of the gluteal region?
```
Piriformis
Obturator internus
Superior gemellus
Inferior gemellus
Quadratus femoris
```
406
What are some features of superficial gluteal muscles?
Abductors and extenders of the femur
| Group of larger muscles (compared to deep gluteal)
408
Describe the structure, location, origin, insertion, innervation and main actions of the gluteus minimus
Location: deepest of superficial
Structure: smallest of the gluts, similar in shape and function to glut medius
Origin: ilium
Insertion: tendon- anterior side of greater trochanter
Nerve: superior gluteal nerve
Action: abducts and medially rotates lower limb; during locomotion, it secures the pelvis, preventing pelvic drop of the opposite limb- walking stability
409
Describe the structure, location, origin, insertion, innervation and main actions of the gluteus medius
Location: superficial, lies between glut max and min
Structure: fan shaped, similar to glut minimus in structure and function
Origin: gluteal surface of ilium
Insertion: lateral surface of greater trochanter
Nerve: superior gluteal nerve
Action: abducts and medially rotates lower limb; during locomotion it secures the pelvis, preventing pelvic drop of opposite limb- walking stability
410
Describe the structure, location, origin, insertion, innervation and main actions of the piriformis
```
Location: deep gluteals, most superior of deep muscles, key landmark in gluteal region, runs inferiorlaterally through greater sciatic foramen
Structure:
Origin: anterior surface of sacrum
Insertion: greater trochanter of femur
Nerve: nerve to piriform
Action: lateral rotation, abduction
```
411
What are some key features of the deep gluteal muscles?
Lateral rotators
Group of smaller muscles (compared to superficial gluteal)
Stabilise hip joint by pulling femoral head into acetabulum of pelvis
412
Describe the structure, location, origin, insertion, innervation and main actions of the superior gemellus
Location: deep gluteals, separated by obturator internus tendon
Structure: two narrow, triangular muscles
Origin: ischial spine
Insertion: greater trochanter of femur
Nerve: nerve to obturator internus
Action: lateral rotation, abduction
413
Describe the structure, location, origin, insertion, innervation and main actions of the obturator internus
Location: deep gluteals, lateral walls of pelvic cavity, runs through lesser sciatic foramen
Structure:
Origin: pubis and ischium at obturator foramen
Insertion: greater trochanter of femur
Nerve: nerve to obturator internus
Action: lateral rotation, abduction
414
Describe the structure, location, origin, insertion, innervation and main actions of the quadratus femoris
Location: deep gluteals, most inferior of deep muscles of gluteal region, below gemelli and obturator internus
Structure: flat square shaped muscle
Origin: lateral side of ischial tuberosity
Insertion: quadrate tuberosity on intertrochanteric crest
Nerve: nerve to quadratus femoris
Action: lateral rotation
415
Describe the structure, location, origin, insertion, innervation and main actions of the inferior gemellus
Location: deep gluteals, separated by obturator internus tendon
Structure: two narrow, triangular muscles
Origin: ischial tuberosity
Insertion: greater trochanter of femur
Nerve: nerve to quadratus femoris
Action: lateral rotation, adduction
416
What is the main function of the hip joint?
Stable weight-bearing joint
417
What type of joint is the hip joint?
Ball and socket synovial type
418
What is the acetabulum and some of its features?
Acetabulum is the cup like depression on the lateral side of the pelvis – much deeper than the glenoid fossa of the scapula (decreases probability of head slipping out of the acetabulum)
In the acetabulum, the ilium, ischium and pubis fuse (15-17--> 20-25 yo) replacing the triradiate cartilage
The depth of the acetabulum is increased by the fibrocartilaginous collar around it- acetabular labrum
The margin of the acetabulum is incomplete inferiorly- acetabular notch
419
What are the articular surfaces of the hip joint?
Head of the femur and the acetabulum of pelvis
Joins lower limb to pelvic girdle
Articulating cartilage is thicker at places of weight bearing
(Acetabular labrum and notch)
420
What is the capsule of the hip joint?
Fibrous envelope containing synovial fluid that surrounds the hip joint
Connects anterior and posterior periphery of the acetabulum to the head of the femur
Iliofemoral, pubofemoral and ischiofemoral ligaments all cross the capsule of the hip joint providing it with reinforcement and support
Allows movement of hip joint in three planes: sagittal frontal and transverse
Anteriorly attaches at intertrochanteric line
Posteriorly attaches at extracapsular region- covers more of the anterior region
421
What are three functions of the acetabular labrum?
Increases the depth of the acetabulum
Provides a large articulating surface
Improves stability of the joint
422
What is the ligament of the femoral head of the hip joint?
Small ligament that attaches from acetabular fossa to the fovea of the femur
It encloses a branch of the obturator arteries (small supply of blood to the hip joint and head of femur)
423
What 5 ligaments are involved in hip joint?
```
Ligament of the femoral head
Iliofemoral
Pubofemoral
Ischiofemoral
Transverse acetabular ligament
```
424
What is the iliofemoral ligament of the hip joint?
Protects superior and anterior
Found anteriorly on the hip joint, body's strongest ligament
Originates from Ilium (inferior to the anterior inferior iliac spine) Attaches to intertrochanteric line, thickening in two places (Y-shaped appearance)
Prevents hyper extension of hip joint
425
What is the pubofemoral ligament of the hip joint?
Protects the anterior and inferior
Found anteriorly and inferiorly on hip joint
Attaches to the pelvis of the iliopubic eminence and obturator membrane and then blends with the articular capsule
Prevents excessive abduction and medial rotation
426
What is the transverse acetabular ligament of the hip joint?
Main inferior ligament of the hip joint – at acetabular notch
Strengthens the inferior portion of the acetabulum
427
What is the ischiofemoral ligament of the hip joint?
Protects posterior
Main posterior ligament of the hip joint, weakest of the ligaments
Attaches to ischium of pelvis and greater trochanter of femur
Prevents excessive medial rotation of femur at hip joint
428
What six movements can the hip joint do?
Flexion-Degree to which flexion can occur depends on whether the knee is the flexed, which relaxes the hamstrings and increases the range of flexion
Extension-Limited by joint capsule and in particular by the iliofemoral ligament/ structures become taut during extension limiting further movement
Abduction
Adduction
Lateral rotation
Medial rotation
429
Which three ligaments stabilise the hip joint greatly and how?
Iliofemoral ligament
Pubofemoral ligament
Ischiofemoral ligament
Unique spiral orientation
Causes them to become tighter when the joint is extended
Less energy is needed to maintain a standing position
430
What muscles are involved in extension at the hip joint?
Gluteus maximus, semimembranosus, semitendinosus, biceps femoris (long head)
431
What muscles are involved in flexion at the hip joint?
Iliopsoas
Rectus femoris
Sartorius
432
What muscles are involved in adduction at the hip joint?
Adductor longus, brevis and Magnus
Pectineus
Gracious
Obturator externus
433
What muscles are involved in abduction at the hip joint?
Gluteus medius
Gluteus minimus
Deep gluteals- piformis, gemellus
Tensor fascia Latae
434
What muscles are involved in medial rotation at the hip joint?
Gluteus medius
Gluteus minimus
Semitendinosus
Semimembranosus
435
What muscles are involved in lateral rotation at the hip joint?
Biceps femoris
Gluteus maximus
Deep gluteals- piriformis, gemelli
Obturator internus
436
Where is the iliopsoas bursa found in the hip joint?
Anterior external surface of joint capsule of hip
| Deep to iliopsoas
437
What are the four main bursae in the hip joint?
Iliopectineal / iliopsoas bursa
Superficial trochanteric bursa
Deep trochanteric bursa
Ischiogluteal bursa
438
Where is the superficial trochanteric bursa found in the hip joint?
Lateral on trochanter of femur, beneath tensor fascia Latae
439
Where is the deep trochanteric bursa found in the hip joint?
Lateral and superior to trochanter of femur between it and gluteus medius muscle
440
What are bursae and their function?
Fluid filled sacs
| Guiding surfaces that reduce friction between bones at joints
441
Where is the ischiogluteal bursa found in the hip joint?
Base of pelvis on ischial tuberosity of pelvic bone
442
When can there be inflammation of the superficial and deep trochanteric bursae in the hip joint?
Arthritis
443
Which two hip joint bursae are found between the gluteus maximus muscle and the greater trochanter of the femur?
Superficial trochanteric bursa
| Deep trochanteric bursa
444
What can cause inflammation of ischiogluteal bursa of the hip joint?
Inflamed by sitting down, cycling, horse riding
445
How will an inflamed iliopsoas bursa of the hip joint present?
Swelling below the inguinal ligament
| Must be distinguished between herniae
446
What can cause bursitis?
Asceptic- injury, strain
| Sceptic- infected by bacteria
447
What is inflammation of a bursa called?
Bursitis
448
What is the blood supply of the hip joint?
Medial and lateral circumflex femoral arteries (usually a deep artery of the thigh ) and from the artery to the ligament of the femoral head (branch of the obturator arteries)
Large proportion – medial circumflex femoral artery (avascular necrosis upon damage)
Lateral circumflex femoral artery has to penetrate through the iliofemoral ligament to reach the hip joint and so supplies less blood
449
How does bursitis present generally?
Pain on movement and direct pressure
450
H
.
451
What is the nerve supply to the hip joint?
Using Hilton's law – the nerves supplying the muscles extending directly across and acting at a given joint also innervate the joint
Femoral nerve – anterior – innervates flexors of hip joint
Obturator nerve – inferior – innervates lateral rotators of hip joint
Nerve to quadratus femoris – posterior – innervates lateral rotators of the hip joint
Superior gluteal nerve – superior – Innervates adductor muscles
452
Describe the structure of the cervical vertebra
Typical cervical vertebrae consist of a vertebral body, a vertebral arch, a transverse process, a spinous process and articular processes
Cervical vertebrae have small bodies and are most easily distinguished by the presence of foramina in their transverse processes.
Features:
- 7
- spinous process bifurcates into 2- bifid spinous process
- foramen transversium in each spinous process- through which vertebral arteries pass as they ascend to supply the brain
- vertebral foramen is triangle in shape
- the upper two cervical vertebrae serve to support the weight of the head and permit movement- C1, the atlas, lacks a body whilst C2, the axis, has an extension of its body called the dens or odontoid process, which articulates with the vertebral arch of the axis
- C7 has a much longer spinous process that does not bifurcate
453
What is the vertebral column composed of?
The vertebral column is formed from seven cervical, twelve thoracic, five lumbar, five fused sacral and three to five rudimentary coccygeal vertebrae which are usually in two or three separate parts.
454
Describe the structure of the lumbar vertebrae
Typical lumbar vertebrae consist of a body, a vertebral arch, a transverse process, a spinous process and articular processes. Lumbar vertebrae have large bodies, their articular processes approximate to the sagittal plane and hence permit a large degree of flexion and extension but little rotation.
Features:
- 5 largest
- very large vertebral bodies which are kidney shaped
- no foramen transversium
- no costal facets
- no bifid spinous processes
- triangle shaped vertebral foramen
455
Describe the structure of the thoracic vertebrae
Typical thoracic vertebrae consist of a body, a vertebral arch, a transverse process, a spinous process and articular processes. . Typical thoracic vertebrae are characterised by articular processes for the ribs; on the bodies these articulate with the head of the rib and on the transverse process with the tubercle of the rib.
Features:
- 12 medium sized (increase in descent)
- each thoracic vertebrae has 2 Demi facets on each side of the body- articulates with head of respective ribs
- on transverse processes there is a costal facet for articulation with the respective rib
- spinous processes slanted anteriorly and inferiorly (increased protection of spinal cord preventing object like a knife entering spinal canal through intervertebral discs
- vertebral foramen is circular in shape
456
Describe the intervertebral discs of the vertebral column and the movements they permit
Secondary cartilaginous joints- symphyses
Symphyses between adjacent vertebrae= the intervertebral disc. Each disc consists of an outer annulus fibrosus (annular bands, outer bands are collagenous, inner bands are fibro-cartilaginous, stronger than vertebral body- real shock absorbers)
The nucleus pulposus (jelly like, high osmotic pressure, water reserve for disc, changes size in day dependent on water distribution in disc, changes size with age, centrally located in faint, posterior in adult) is a central mucoid portion which is enclosed in the annulus fibrosus.
The discs permit tilting movements between adjacent vertebrae and act as shock absorbers.
• IVDs are not of uniform size (same as the vertebrae)
• They increase in size from Superior to Inferior
• They are wedge shaped in the lumbar and thoracic levels
• Thickest anteriorly (in the lumbar and thoracic levels)
• Thinnest posteriorly (in the lumbar and thoracic levels)
457
Describe the joints of the vertebral column and the movements these joints permit
The atlanto-occipital joint is formed by the condyles of the occiput and the superior articular facets of the axis; it permits flexion and extension of the head. The atlanto-axial joint between the atlas and axis permits rotation of the head by allowing rotation between the atlas and axis. The remaining cervical, thoracic and lumbar vertebrae have facet (zygopophyseal) joints between adjacent superior and inferior articular facets. These permit varying degrees of flexion, extension, lateral flexion and rotation
458
What is the Ligamentum Flava of the Vertebral Column?
* High content of elastic fibres
* They join laminae of adjacent vertebrae
* They are attached to the front of the upper lamina and to the back of the lower lamina
* They are stretched by flexion of the spine (leaning forwards)
459
What are the two main longitudinal ligaments of the vertebral column?
The whole assembly of vertebra and intervertebral discs are strapped together by two major longitudinal ligaments
Anterior longitudinal Ligament:
• It is a flat band that broadens as it passes downwards
• Extends from the anterior tubercle of the atlas to the front of the upper part of the sacrum
• It is firmly united to the periosteum of the vertebral bodies
• It is free over the intervetebral discs
• It is the stronger of the two longitudinal ligaments of the vertebral column
Posterior longitudinal Ligament:
• Extends from the back of the body the axis (2nd Cervical Vertebra) to the canal of the sacrum
• It is continued above the body of the axis as the “Membrana Tectoria”
• It narrows gradually as it passes downwards
• It has serrated margins
• The serrations are broadest over the intervertebral discs to which they are firmly united
• The ligament narrows over vertebral bodies
• They are separated from vertebral bodies by the emerging basivertebral veins
460
What is the Interspinous Ligament of the Vertebral Column?
* They are relatively weak sheets of fibrous tissue
* They unite spinous processes along their adjacent borders
* They are well developed only in the lumbar region
* They fuse with supraspinous ligaments
461
What is the Supraspinous Ligament of the Vertebral Column?
* Joins the tips of adjacent spinous processes
* They are strong bands of white fibrous tissue
* They are lax in the extended spine
* Full flexion effectively prevents erector spinae muscles from extending the spine
* In flexion of the vertebral column, they are drawn taut to mechanically support the vertebral column
462
Describe the sacrum
5 fused vertebrae
Upside down triangle
Apex points inferiorly
Distinguishing factors- facets on lateral walls of sacrum for articulation with pelvis at sacroiliac joints
463
What are the attachments of the ligament nuchae and its function?
* Also known as the nuchal ligament
* Proximal attachment: Occiput (back of skull)– occiptal protuberence
* Distal attachments: Thoracic spinal ligaments- Interspinous and supraspinous ligament
* Intermediate Attachments: All cervical vertebrae- spinous processes
Functions of Ligament Nuchae
• It maintains the secondary curvature of the cervical spine
• Helps the cervical spine support the head
• Acts as a major site of attachment of neck and trunk muscles (e.g. Trapezius, Rhomboids)
464
Describe the joints of the vertebral column
5 articulations for each vertebra
Articular surfaces:
-cartilaginous joints, articulating surfaces covered by hyaline cartilage, connected by a fibrocartilage intervertebral disc
-joints are strengthened by anterior and posterior longitudinal ligaments (A thicker and prevents hyper extension/ P thinner and prevents hyper flexion)
Articular facets:
-facet joints- allows for gliding between vertebrae
- strengthened by ligamentum flava, infra/supra spinous ligaments, intertransverse ligament
465
Describe the coccyx
Small bone which articulates with the apex of the sacrum
| Distinguishing factors: lack of vertebral arches, no vertebral canal, coccyx does not transmit spinal cord
467
Describe the structure of the vertebral body
Found anteriorly
Main weight bearing part of vertebra
Main site of contact between adjacent vertebrae
Lined with hyaline cartilage
Linked to adjacent vertebral bodies by way of intervertebral discs
Size of body of vertebrae increases from top-downwards
468
Describe the structure of the vertebral/neural arch
Found posteriorly
-Spinous Process (n=1)
• Midline, Posterior
-Transverse Processes (n=2)
• Found laterally, 1 on each side of midline
-Articular Processes
• At the junction of the lamina and pedicle are found articular facets
• 1 above and 1 below on each side (n=2)
• They are found on both sides (total n=4)
• Cartilage-lined
• Allow for synovial joints to be formed between neural arches of adjacent vertebrae
• Strengthened by Ligamentum Flavum
-The Pedicle
• Is the part of the neural arch between the body
and the transverse process
-The Lamina
• Is the part of the neural arch between the transverse process and the spinous process
-Joints formed between adjacent neural arches
• Synovial
• Prevent anterior displacements of the vertebrae
• Allow for limited movements
• Can bear weight when upright
* Each pedicle (n=2) has 2 notches that reduce its height- vertebral notches - superior and inferior
* Superior and Inferior Vertebral Notches (on each side) of adjacent vertebrae form an intervertebral foramen
* Segmental nerves pass from cord to periphery through the intervertebral foramen
* Dorsal Root Ganglia found here
469
What are the gross functions of the vertebral column?
1) Center of gravity of the body
2) Attachments for Bones
3) Attachments for Trunk muscles
4) Protection & Passage of the Spinal Cord
5) Segmental innervation of the body
470
How does the vertebral column provide the centre of gravity of the body?
* The weight of the body is projected into lower limbs about a line that passes centrally through the natural curvatures of the vertebral column
* This line is the center of gravity of the body
471
How does the vertebral column provide attachments for bones?
```
Above:
• It bears/supports the head
Centrally:
• Supports the ribs
• Indirectly supports the upper limbs
Below:
• Articulates with the hip bones
• Together with the hip bones, they bear most of the body weight.
```
472
How does the vertebral column provide attachments for muscles?
* Attachment of the upper limbs
* Trunk muscles are largely attached to the vertebral column
* The upright posture is determined by continuous low- level contraction of trunk muscles to support body weight
473
How does the vertebral column act as protection and allow passage of the spinal cord?
• It acts as a conduit through which an assembly of nerve fibres pass:
– a) from the brain to the rest of the body (efferents) – and
– b) from all levels of the body to the brain (afferents)
• This neuronal assembly is called the spinal cord
• The vertebral column protects the spinal cord on its journey
• It allows segmental nerves to leave or join the cord at specified points along the continuum of the vertebral column to supply their targets
474
Describe the vertebral column in a foetus
* It lies flexed in a single curvature throughout its entire extent
* The curvature approximates the shape of ‘figure of C’
* The curvature faces anteriorly
* It is concave anteriorly (or an anterior flexion)
* This curvature is known as the “Primary Curvature”
* The primary curvature is retained throughout life in the Thoracic, Sacral and Coccygeal parts
475
Describe how the foetal vertebral column changes into the vertebral column of a young adult
* During development from the fetus to young adult
* The primary concave curvature is remodelled in parts
* The C-shaped column opens up to elongate
* The cervical spine develops the first posterior concavity when a young child begins to lift its head
* This posterior concavity becomes the first secondary curvature
* The lumbar spine also opens up during crawling until the child begins to stand-up and walk.
* A second posterior concavity then appears.
* This second concavity becomes the second secondary curvature
476
Describe the vertebral column in a young adult
* Viewed from the side
* It has a more complex presentation
* It has 4 distinct curvatures
* Its approximates the figure of “s”
* It has a sinusoidal profile
* Sinuous bends give the column great resilience
* 2 anterior flexions (anterior concavities)
* 2 Posterior flexions (posterior concavities)
* Anterior Concavities are continuations of the primary curvature of the foetus
* Posterior Concavities are secondary curvatures
477
Describe the natural curvatures of the vertebral column
* 4 Curvatures of Note:
* 2 Primary
* 2 Secondary
* Sequentially (top-bottom)
* Cervical (Secondary)
* Thoracic (Primary)
* Lumbar (Secondary)
* Sacral (Primary)
478
Describe the vertebral column in an old person
* The secondary curvatures start to disappear
* The vertebral column seems to return to its original shape in the foetus
* A fully continuous primary curvature re- establishes
* The vertebral column closes up again (as if, in the foetus)
481
Describe the structure, location, origin, insertion, innervation and main actions of the gluteus maximus
Location: Superficial, slopes across buttocks at 45 degrees
Structure: largest of the gluts, shape of buttocks
Origin: gluteal (posterior) surface of ilium, sacrum and coccyx
Insertion: iliotibial tract and gluteal trochanter of femur (gluteal tuberosity and greater trochanter)
Nerve: inferior gluteal nerve
Action: main extensor of thigh, lateral rotation, only used when foce is required (running and climbing), stabilised knee
482
What is the femoral canal?
In human anatomy of the leg, the femoral sheath has three compartments. The lateral compartment contains the femoral artery, the intermediate compartment contains the femoral vein, and the medial and smallest compartment is called the femoral canal. The femoral canal contains efferent lymphatic vessels and a lymph node embedded in a small amount of areolar tissue. It is conical in shape and is about 2 cm long.
An 'empty' space into which the femoral vein can expand into, during exercise when venous return is increased
483
What are the borders of the femoral canal?
The femoral canal is bordered:
anterosuperiorly by the inguinal ligament
posteriorly by the pectineal ligament lying anterior to the superior pubic ramus
medially by the lacunar ligament
laterally by the femoral vein
It contains the lymph node of Cloquet. It should not be confused with the nearby adductor canal.
484
What is the clinical significance of the femoral canal?
The entrance to the femoral canal is the femoral ring, through which bowel can sometimes enter, causing a femoral hernia.
485
What is the physiological significance of the femoral canal?
The position of the femoral canal medially to the femoral vein is of physiologic importance. The space of the canal allows for the expansion of the femoral vein when venous return from the lower limbs is increased or when increased intrabodominal pressure (valsalva maneuver) causes a temporary stasis in the venous flow.
486
What is the adductor canal?
The adductor canal (subsartorial or Hunter’s canal) is an aponeurotic tunnel in the middle third of the thigh, extending from the apex of the femoral triangle to the opening in the adductor magnus, the adductor hiatus.
487
What are the boundaries of the adductor canal?
It courses between the anterior compartment of thigh and the medial compartment of thigh, and has the following boundaries:
Anteriorly - sartorius.
Postermedially - adductor longus and adductor magnus.
Laterally - vastus medialis.
It is covered in by a strong aponeurosis which extends from the vastus medialis, across the femoral vessels to the adductor longus and magnus.
Lying on the aponeurosis is the sartorius (tailor's) muscle.
488
What are the contents of the adductors canal?
The canal contains the femoral artery, femoral vein, and branches of the femoral nerve (specifically, the saphenous nerve, and the nerve to the vastus medialis). It consists of three foramina: superior, anterior and inferior. The femoral artery with its vein and the saphenous nerve enter this canal through the superior foramen. Then, the saphenous nerve and artery and vein of genus descendens exit through the anterior foramen, piercing the vastoadductor intermuscular septum. Finally, the femoral artery and vein exit via the inferior foramen (usually called the hiatus) through the inferior space between the oblique and medial heads of adductor magnus.
489
What is the adductors hiatus/ Hunters canal?
Hole in the adductor Magnus muscle through which the femoral artery dmd vein lass through from the anterior compartment into the medial/ posterior compartment and become the popliteal artery and vein
490
What are the main actions that the knee joint is involved in?
Flexion, extension, (and some medial and lateral rotation)
491
What are the two articulating surfaces within the knee joint?
Tibiofemoral- medial and lateral condyles of the femur articulate with the tibia; weight bearing joint of the knee
Patellofemoral- anterior and distal part of femur articulate with the patella - allows the tendon of the quadriceps femoris (main extensor of the knee) to be inserted directly over the knee, increasing the efficiency of the muscle
Both joint surfaces are lined with hyaline cartilage and enclosed within a single joint cavity
492
Where is the patella found and what is the significance of its presence?
Patella is formed inside the tendon of quadriceps femoris anterior to the Tibiofemoral articulation and its presence minimises wear and tear on the tendon
493
What are the menisci of the knee and their 2 functions?
C shaped medial and lateral fibrocartilage structures in the knee
Functions- deepen the articular surface of the tibia and thus increase stability of the joint AND act as shock absorbers
494
What are the attachments of the menisci?
Attached at both ends to intercondylar area of tibia
Medial meniscus also fixed to the tibial (medial) collateral ligament and joint capsule
Lateral meniscus is smaller and does not have any extra attachments rendering it fairly mobile
495
How can damage to the menisci occur?
Damage to tibial (medial) collateral ligament can result in tearing of medial menisci
Lateral menisci is smaller and rarely undergoes damage
496
Describe the capsule of the knee joint
Sac containing tibiofemoral and patellofemoral articulating surfaces in the knee joint
Outer fibrous layer
Inner synovial membrane- secretes synovial fluid and is composed of loose CT with smooth muscle that lines the joint cavity
497
What are the main ligaments of the knee joint?
```
Tibia collateral ligament
Fibular collateral ligament
Anterior cruciate ligament
Posterior cruciate ligament
Patellar ligament
Oblique popliteal ligament (extension of semimembranosus tendon) and arcuate popliteal ligament- (posteriorly) - strengthen capsule
```
498
Describe the patellar ligament of the knee joint
Continuation of the quadriceps femoris tendon distal to the patellar
Attaches to the tibial tuberosity
Transmits the draw of the quadriceps femoris, using the patella as a hypomochlion (angle) that increases the leverage.
499
Describe the extracapsular collateral ligaments of the knee joint
2 strap like ligaments, stabilise hinge motion, prevent medial and lateral movement
TIBIAL
-wide, flat ligament, on medial side of joint
-proximally attaches to medial epicondyle of the femur
-distally attaches to medial surface of the tibia
-medial meniscus is attached to it
-stabilises knee
-less flexible than fibular as it's attached to the medial meniscus and is hence more susceptible to injury
FIBULAR
-thinner and rounder
-proximally attaches to lateral epicondyle of femur
-distally attaches to depression on lateral surface of fibular head
-stabilises knee
-more flexible- less susceptible to injury
500
Describe the intrascapular cruciate ligaments of the knee joint
2 ligaments that connect the femur and tibia and cross each other in doing so
ANTERIOR CRUCIATE- Anterior passes Posterior and inserts Laterally
-attaches to anterior intercondylar region of the tibia and ascends posteriorly to attach to the femur in the intercondylar fossa
-prevents anterior dislocation of tibia onto the femur
-weaker, relatively poor blood supply
-limits hyper extension
POSTERIOR CRUCIATE- Posterior passes Anterior and inserts Medially
-attaches at posterior intercondylar region of tibia nd ascends anteriorly to attach to the femur in the intercondylar fossa
-prevents posterior dislocation of tibia onto the femur
-limits hyper flexion
-main stabiliser in weight bearing with a flexed knee
501
What are the 4 main movements of the knee joint?
Extension
Flexion
Lateral rotation
Medial rotation
502
What muscle is involved in extension at the knee joint?
Quadriceps femoris- inserts into tibial tuberosity- main extensor of the knee
503
What muscle is involved in flexion at the knee joint?
Hamstrings
Gracilis
Sartorius
Popliteus
504
What muscle is involved in lateral rotation at the knee joint?
Biceps femoris
505
What muscle is involved in medial rotation at the knee joint?
```
Semimembranosus
Semitendinosus
Gracilis
Sartorius
Popliteus
```
506
When can medial and lateral rotation at the knee joint occur?
Only when the knee is flexed- otherwise rotation will be at HIP JOINT not KNEE JOINT
507
What bursae are found on the knee joint?
```
Suprapatellar bursa
Prepatellar bursa
Subcutaneous infrapatellar bursa
(Infrapatellar bursa
Semimembranosus bursa)
```
508
What is the unhappy triad of knee joint injuries?
Medial collateral ligament is firmly attached to medial meniscus
Injury of one is likely to result in damage to the other
Blows to the side of the knee-/ lateral twisting of flexed knee
ACL is also taut during flexion- can also be damaged
509
When can ACL be damaged and how can this be tested for?
In hyper extension of the knee joint
| Anterior draw sign test
510
How can PCL be damaged and how can this be tested for?
Falling onto the tibial tuberosity with a flexed knee
Tibia being used back against the femur
Posterior draw sign test
511
Which two bursae are most likely to become inflamed upon kneeling?
Pre-patellar bursa
| Subcutaneous infra patellar bursa
512
What is the common name of bursitis of the prepatellar bursa?
Housemaids knee
513
What is the common name of bursitis of the subcutaneous infrapatellar bursa?
Clergyman's knee
514
What is the main blood supply to the knee joint?
Popliteal artery and vein
515
What is the main nervous supply to the knee joint?
Common fibular nerve
| Tibial nerve
517
Describe the structure, location, origin, insertion, innervation and main actions of the biceps femoris
Location: most lateral of posterior thigh muscles
Structure: 2 proximal heads- 1 long and 1 short
Origin: long head- ischial tuberosity of pelvis AND short head- linea aspera on posterior femur
Insertion: tendon inserts into head of fibula
Nerve: long- tibial division of sciatic nerve AND short- common fibular division of sciatic nerve
Action: lateral rotation at hip and flexed knee
518
Describe the structure, location, origin, insertion, innervation and main actions of the semitendinosus
Location: posterior compartment of thigh, lies medially to biceps femoris, covers most of semimembranosus
Structure: largely tendinous muscle
Origin: ischial tuberosity of pelvis
Insertion: medial surface of tibia
Nerve: tibial division of sciatic nerve
Action: medially rotates hip and flexed knee
519
Describe the structure, location, origin, insertion, innervation and main actions of the semimembranosus
Location: posterior compartment of thigh, underneath semitendinosus
Structure: flattened and broad
Origin: ischial tuberosity
Insertion: medial tibial condyle
Nerve: tibial division of sciatic nerve
Action: medially rotates hip and flexed knee
520
Where is the popliteal fossa found?
Posterior side of knee
521
What is the popliteal fossa?
Diamond shaped region on posterior surface of knee through which structures move from the thigh into the leg
522
What are the borders of the popliteal fossa?
Superiomedially- semimembranosus
Superiolaterally- biceps femoris
Inferiomedially- medial head of gastrocnemius
Inferiolaterally- lateral head of gastrocnemius (and plantaris)
Floor- posterior surface of knee joint capsule Nd posterior surface of femur
Roof- 2 layers- popliteal fascia and skin- continuous with fascia latae of leg
523
What is the contents of the popliteal fossa? Deepest to superficial
```
Popliteal artery (continuation of femoral artery)
Popliteal vein (small saphenous vein pierces the popliteal fascia of popliteal fossa and empties into popliteal vein)
Tibial nerve and common fibular nerve (most superficial branches of sciatic nerve) (cfn follows the biceps femoris tendon running along lateral margin of popliteal fossa)
```
549
Describe the muscles of the posterior compartment of the thigh
Collectively known as the hamstrings
Extension at the hip and flexion at the knee
Innervated by the sciatic nerve
Hamstrings from prominent tendons medially and laterally to back of the knee
Biceps femoris, semitendinosus and semimembranosus
550
What two structures are found in the radial groove of the humerus?
Profunda brachii artery
| Radial nerve
551
What muscles make up the anterior compartment of the leg (below knee)?
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Fibularis tertius
552
What nerve supplies all the muscles of the anterior compartment of the leg (below knee)?
Deep fibular nerve
553
Collectively what actions do the muscles of the anterior leg (below the knee) carry out?
Dorsi flexion and inversion of foot at ankle joint
| EDL and EHL also act to extend the toes
554
What artery supplies the muscles of the anterior compartment of the leg (below the knee)?
Anterior tibial artery
555
Describe the structure, location, origin, insertion, innervation and main actions of the tibialis anterior
Location: anterior, along lateral surface of tibia
Structure: STRONGEST DORSIFLEXORS OF FOOT
Origin: lateral surface of tibia
Insertion: medial cuneiform and base of MT1
Nerve: deep fibular nerve
Action: dorsi flexion of foot; inversion of foot
556
Describe the structure, location, origin, insertion, innervation and main actions of the extensor digitorum longus
Location: anterior, lateral and deep to tibialis anterior
Structure: tendons of EDL can be palpated on dorsal surface of foot
Origin: lateral condyle of tibia and medial surface of fibula
Fibres converge to a tendon which travels to the dorsal surface of the foot- tendon splits into four and inserts into...
Insertion: each into a toe (2-5)
Nerve: deep fibular nerve
Action: extension of toes 2-5; dorsi flexion of foot
557
Describe the structure, location, origin, insertion, innervation and main actions of the extensor hallucis longus
Location: anterior, deep to EDL and TA
Structure:
Origin: median surface of fibular shaft- it crosses the anterior ankle joint
Insertion: base of distal phalanx of big toe
Nerve: deep fibular nerve
Action: extension of big toe; dorsi flexion of foot
558
Describe the structure, location, origin, insertion, innervation and main actions of the fibularis tertius
Location: anterior, arises from most inferior part of EDL, not present in all individuals
Structure: can be considered as part of the EDL
Origin: within EDL from medial surface of fibula, tendon descends with EDL to the dorsal surface of the foot
Insertion: diverges and attached to MT 5
Nerve: deep fibular nerve
Action: eversion of foot, dorsi flexion of foot
559
What are some features of the posterior compartment of the leg (below the knee)?
Organised into a superficial and deep layer, separated by a band of fascia.
Posterior compartment is the largest of the three in the leg
Collectively the muscles act to plantar flex and invert the foot at the ankle joint
Muscles are innervated by the tibial nerve (terminal branch of the sciatic nerve)
560
What muscles make up the posterior compartment of the leg (below the knee)?
Superficial-
Gastrocnemius
Plantaris
Soleus
```
Deep-
Popliteus
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
```
561
Describe the structure, location, origin, insertion, innervation and main actions of the gastrocnemius
Location: posterior, superficial, most superficial of all muscles in posterior leg
Structure: 2 heads (medial and lateral) which converge to form a single muscle belly; comprised mainly of fast twitch muscle fibres - forceful movements- running and jumping
Origin: lateral head- lateral femoral condyle; medial head- medial femoral condyle
Single muscle belly, combines with soleus, calcaneal tendon
Insertion: calcaneus
Nerve: tibial nerve
Action: plantar flexes the foot; flexes at knee (as it crosses the knee joints
562
Describe the structure, location, origin, insertion, innervation and main actions of the plantaris
Location: posterior, superficial
Structure: small muscle with a long tendon- can be mistake for a nerve as it descends the leg
Origin: lateral supra condylar line of femur
Descends medially condensing into a tendon that runs down the leg, between gastrocnemius and soleus, tendon blends with calcaneal tendon
Insertion: calcaneus
Nerve: tibial nerve
Action: plantar flexes foot, flexes at knee
563
Describe the structure, location, origin, insertion, innervation and main actions of the soleus
Location: posterior, superficial, deep to gastrocnemius
Structure: large and flat, resembles a sole/flat fish
Origin: soleal line of tibia and proximal fibular area
Muscle narrows in lower part of leg, joins calcaneal tendon
Insertion: calcaneus
Nerve: tibial nerve
Action: plantar flexion of foot
564
Describe the structure, location, origin, insertion, innervation and main actions of the popliteus
Location: posterior, deep; located superiorly in leg, behind knee joint forming base of popliteal fossa
Structure: popliteus bursa lies between popliteal tendon and posterior surface of the knee joint
Origin: posterior surface of tibia
Insertion: lateral condyle of femur
Nerve: tibial nerve
Action: laterally rotates femur on tibia UNLOCKING the joint so that flexion at the knee can occur
565
Describe the structure, location, origin, insertion, innervation and main actions of the tibialis posterior
Location: posterior, deep, deepest of the muscles in posterior compartment, lies between FDL and FHL
Structure:
Origin: interosseous membrane between tibia and fibula and posterior surfaces of two bones
Tendon enters foot posterior to medial malleolus
Insertion: plantar surface of medial tarsal bones
Nerve: tibial nerve
Action: inversion of foot, plantar flexes foot, maintains medial arch of foot
566
Describe the structure, location, origin, insertion, innervation and main actions of the flexor digitorum longus
Location: posterior, deep, located medially in posterior leg
Structure: surprisingly smaller muscle than FHL
Origin: medial surface of tibia
Insertion: plantar surfaces of toes (2-5)
Nerve: tibial nerve
Action: flexes toes (2-5)
567
Describe the structure, location, origin, insertion, innervation and main actions of the flexor hallucis longus
Location: posterior, deep, lateral side of leg, slightly counterintuitive as it originates on opposite side to big toes which it acts on
Structure: larger than FDL
Origin: posterior surface of fibula
Insertion: plantar surface of phalanx of big toe
Nerve: tibial nerve
Action: flexes big toe
568
What are the collective actions of the lateral compartment of the leg muscles?
Eversion (turning the sole of the foot outwards)
| Fix medial margin of foot during running and preventing excessive inversion
570
Describe the structure, location, origin, insertion, innervation and main actions of the fibularis longus
Location: lateral, more superficial than FB
Structure: longer than FB
Origin: superior and lateral surface of fibula and lateral tibial condyle
Fibres converge to a tendon that descends into the foot posterior to the lateral malleolus
Tendon crosses under the foot
Insertion: medial side of medial cuneiform base of MT1
Nerve: superficial fibular nerve
Action: eversion of foot, plantar flexes foot, supports lateral and transverse arches of the foot
571
Describe the structure, location, origin, insertion, innervation and main actions of the fibularis brevis
```
Location: lateral, more deep than FL
Structure: shorter than FL
Origin: inferior and lateral surface of fibular shaft
Muscle belly forms a tendon which descends with the fibularis longus tendon and travels into the foot posterior to the lateral malleolus
Passes over calcaneus and cuboidal bones
Insertion: tubercle on MT5
Nerve: superficial fibular nerve
Action: eversion of foot
```
572
Describe the structure, location, origin, insertion, innervation and main actions of the
```
Location:
Structure:
Origin:
Insertion:
Nerve:
Action:
```
573
What type of joint is the ankle joint?
Hinge type synovial joint
| Formed by tibia, fibula and talus
574
What main actions does the ankle joint permit?
Plantarflexion and dorsiflexion of foot
575
What are the articulating surfaces of the ankle joint?
Tibia and fibula are bound together by strong anterior and posterior tibiofibular ligaments producing a bracket shaped socket which is covered in hyaline cartilage- malleolar mortise
Body of the talus (trochlear- wedged shaped- wider anteriorly and thinner posteriorly) fits nicely into the mortise
576
Describe the state of the ankle joint when dorsi flexed
Grip of malleolar mortise on trochlear is strongest
Movement forces wider anterior part of trochlear posteriorly between the malleoli, spreading the tibia and fibular slightly apart (limited by strong interosseous tibiofibular ligament)
Joint more stable when dorsi flexed
577
Describe the state of the ankle joint when plantar flexed
Grip of malleolar mortise on trochlear is the weakest
Movement does not cause spreading of tibia and fibula - brings them closer
Trochlear is narrower posteriorly and so lies relatively loosely in the malleolar mortise
Joint more unstable when plantar flexed
578
Describe the capsule of the ankle joint
Thin anteriorly and posteriorly but supported on each side by strong lateral and medial ligaments (collateral)
Fibrous layer attached superiorly to borders of the articular surfaces of the tibia and malleoli and inferiorly to the talus
Synovial membrane is loose and lines the fibrous layer of the capsule
Synovial cavity often extends superiorly between the tibia and fibula as far as the interosseous talofibular ligament
579
Describe the ligaments of the ankle joint
There are two main sets of ligaments which originate from each malleolus
- Medial (deltoid) ligament
* attached to medial malleolus
* 4 separate ligaments- posterior tibiotalar part, tibia calcaneal part, tibionavicular part, anterior tibiotalar part
* resists over eversion of foot
- Lateral ligament
* attached to lateral malleolus
* 3 separate ligaments- anterior talofibular (lateral aspect of talus), posterior talofibular (posterior aspect of talus), calcaneofibular (calcaneus)
* resists over inversion of foot
580
What movements and muscles occur at the ankle joint?
Plantar flexion- muscles in posterior compartment of leg - gastrocnemius, soleus, plantaris and posterior tibialis
Dorsi flexion- muscles in anterior compartment of leg - tibialis anterior, extensor hallucis longus and extensor digitorum longus
581
What is the blood supply to the ankle joint?
Arteries derived from the malleolar branched of fibular and anterior and posterior tibial arteries
582
What is the innervation of the ankle joint?
Derived from the tibial nerve and the deep fibular nerve division of the common fibular nerve
583
What muscles are found on the plantar surface of the foot?
1st layer- abductor hallucis, flexor digitorum brevis, abductor digiti minimi
2nd layer- quadratus plantae, lumbricals (1st to 4th)
3rd layer- flexor hallucis brevis abductor hallucis, flexor digit minimi brevis
4th layer- plantar interossei (3), dorsal interossei (4)
584
What muscles are found on the dorsal surface of the foot?
Extensor digitorum brevis, extensor hallucis brevis
585
What nerves supply the muscles on the plantar surface of the foot?
Medial and lateral plantar nerves
586
What nerve supplies the muscles on the dorsal surface of the foot?
Deep fibular nerve
587
Walking and gaits
..
588
What two muscles make up the lateral compartment of the leg (below the knee)?
2 muscles- fibular is brevis and longus
