Test 2 Memorizables Flashcards
Cutaneous Nerves:
Anterior Thigh
Branches from Femoral Nerve
Cutaneous Nerves:
Lateral Thigh
Lateral Femoral Cutaneous Nerve of Thigh
Cutaneous Nerves:
Medial Thigh
Branches from Obturator Nerve
Cutaneous Nerves:
Medial Leg
Saphenous Nerve
Cutaneous Nerves:
Lateral Leg
Lateral Sural Cutaneous Nerve
Cutaneous Nerves:
Posterior Leg
Sural Nerve
Cutaneous Nerves:
Dorsal Foot
Superficial Peroneal Nerve
Cutaneous Nerves:
Sole of Foot
Medial and Lateral Plantar Nerves (from Tibial Nerve)
Drains Lymph from Gluteal Region and Posterior Thigh
Horizontal Group (Superficial Inguinal Nodes)
Located below inguinal ligament
Drains Lymph from most of lower extremity
Vertical Group (Superficial Inguinal Node)
Located along terminations of Great Saphenous Veins
Drains lymph from vessels that accompany Small Saphenous Vein
Popliteal Nodes
Drain lymph from deep structures of leg through Femoral Canal
Deep Inguinal Nodes
Located Medial to Femoral Vein
Inguinal Ligament Dermatome
L1
Anterior Knee Dermatomes
L3, L4
Medial Side of Foot and Big Toe Dermatome
L4
Lateral Side of Foot, Little Toe Dermatome
S1
Posterior Side of Leg and Thigh Dermatome
S1, S2
Pes Anserinus
Convergence of Sartorius, Gracilis, and Semitendinosus at the Tibia
Hip Pointer
Contusion at Anterior superior iliac spine or over iliac crest
Pulled Groin
Tear or stretch of adductor muscles at Pubis
Borders of the Femoral Triangle
Superior: Inguinal ligament
Medial: Adductor Longus
Lateral: Sartorius
Floor: Adductor longus and pectineus
Course of arterial supply to Lower Extremity
LV, CIAs, EIA, FA (ant. then post.) –> PA, Ant.&Post. TAs
Attachments of the inguinal ligament
ant. sup. iliac spine
pubic tubercle
Cruciate anastomosis
sup: inferior gluteal artery
inf: first perforating artery
med: medial femoral circumflex
lat: lateral femoral circumflex
Positive Trendelenburg Sign
When lifting a leg, pelvis tilts on that (non-paralyzed) side
Muscle deep to superior gluteal artery and nerve
Gluteus minimus
Weaver’s Bottom
Ischial Bursitis
Site of Gluteal Region Intramuscular Injection
Upper lateral quadrant
Piriformis Syndrome
Early branching of sciatic nerve that penetrates the piriformis; compression becomes painful
Pulled Hamstring
Tear or avulse from part of origin of muscle from Ischial Tuberosity
Boundaries of the Popliteal Fossa
sup med: semimembranosus and semitendinosus
sup lat: biceps femoris
inf: gastrocnemius
Branch of the Tibial Nerve
Sural Nerve
accompanies small saphenous vein
Branch of the Common Peroneal Nerve
Lateral Sural Cutaneous Nerve
Damage to the common peroneal nerve can lead to
Foot Drop
Genicular Anastomosis:
SMG, SLG, IMG, ILG
What do they anastomose with?
SMG: Descending genicular artery
SLG: Descending branch of lateral femoral circumflex
IMG&ILG: Recurrent branch of Anterior tibial artery
Middle Genicular Artery:
Where does it arise from? What does it anastomose with?
Popliteal Artery
Sup. or Inf. lateral genicular arteries
Ligation point in femoral aneurysm
Femoral Artery–above knee, deep to sartorius in subsartorial canal
Sprained Ankle
Excessive Inversion
Anterior talofibular or calcaneofibular ligaments stretched or partially torn
Fabella
Sesamoid bone in lateral head of gastrocnemius
Achilles Tendon Tap Reflex Tests what nerves?
S1, S2
Orientation of deep muscle group bellies in the posterior compartment of the leg
Muscle bellies are backwards: flexor for great toe is lateral, flexor of other toes is medial
Where do the tibial nerve and posterior tibial artery lie in the posterior compartment of the leg?
Between superficial and deep groups
Sustentaculum tali
Projection from the calcaneus
Acts as pulley for flexor hallucis longus tendon
Tarsal Tunnel Syndrome
Swelling of synovial sheaths covering tendons of deep posterior leg muscles.
Symptoms: numbness of sole, and toes, weakened flexion of toes
Anterior leg syndrome leads to compression of what nerve? What condition can this lead to?
Deep peroneal nerve
Foot Drop
Muscles that end on the Extensor Expansions of the toes
Extensor Hallucis Longus
Extensor digitorum longus
Peroneus Tertius
Part of Extensor Digitorum Longus that ends on 5th metatarsal
Intermittent Claudication
Narrowing of the posterior tibial artery due to arteriosclerosis
Produces ischemia, painful cramps when walking, but subsides after rest
Blount’s Disease
Severe genu varum
Black children
Progressive
Rickets
Cause of genu varum
Lack of vit. D
Intrinsic Ligaments of the Hip Joint:
Attachments, function
Iliofemoral: ilium / intertrochanteric line
prevents overextension
Pubofemoral: superior ramus of pubis / lower part of intertrochanteric line
limits extension and abduction
Ischiofemoral: (spiral shaped) ischium / greater trochanter
limits extension
Function of the Ligament of the head of Femur
Transmit artery of ligament of head of femur (branch of obturator artery)
Common cause of hip dislocation
Presentation?
Congenital: upper lip of acetabulum fails to form
Leg rotated medially, appears shorter
Visible presentation of a fracture in the neck of the Femur
Leg rotated laterally
Bursae of the Knee
Locations?
Suprapatellar: posterior to quadriceps tendon
Prepatellar: between skin and patella
Superficial infrapatellar: between skin and patellar ligament
Housemaid’s Knee
Prepatellar bursitis
Clergyman’s Knee
Superficial infrapatellar bursitis
Attachments of the LCL
lateral condyle of femur / head of fibula
Attachments of the MCL
medial condyle of femur / medial side of tibia
ACL function
prevents movement of tibia anteriorly
PCL function
prevents movement of tibia posteriorly
Menisci of the knee attachments to collateral ligaments
Medial meniscus attached to MCL
Lateral meniscus NOT attached to LCL
Terrible Triad of the Knee
MCL, ACL, Medial Meniscus
Caused by lateral blow to the flexed knee
Medial ligament of the ankle:
Attachments? What motion does it limit?
Medial malleolus / Medial surface of talus and calcaneus
Limits eversion
Anterior and Posterior talofibular ligaments
Attachments? Limits what motion?
lateral malleolus of fibula / talus
limit inversion
Calcaneofibular ligament
Attachments? Limits what motion?
lateral malleolus of fibula / calcaneus
limit inversion
Inversion/Eversion movements occur at what two foot joints?
Subtalar joint (talus / calcaneus)
Transverse tarsal joint (med: talus / navicular & lat: calcaneus / cuboid bones)
Pott’s Fracture
What is damaged? (2)
Excessive Eversion
Medial malleolus is fractured,
Break in shaft of fibula
Muscles involved in generating forces in the foot for walking and running (3)
Gastrocnemius
Soleus
Flexor Hallucis Longus
Pes Planus:
Which ligament is affected?
Flat Feet
Stretching of the plantar calcaneonavicular ligament
The axis of abduction/adduction for the toes is
The middle of the second toe
Plantar Aponeurosis Functions (2)
Protects underlying structures
Helps support arch (lateral)
Quadratus Plantae
Pulls flexor digitorum longus tendon laterally to straighten out toe flexion
Function of the two sesamoid bones under head of the first metatarsal
Prevents weight of the body from resting on great toe tendon
Adductor Hallucis Structure
Two heads of origin: oblique and transverse
One common tendon
Layer 4 Deep Tendons (2)
Tendon of Peroneus Longus
Tendon of Tibialis Posterior
Branches of Posterior Tibial Artery in the Foot
Lateral Plantar Artery
Medial Plantar Artery
Lateral Plantar Artery gives rise to what?
Planter Arterial Arch
which gives rise to plantar digital arteries
Which foot ligament is known as the ‘spring’ ligament?
Plantar calcaneonavicular ligament
*Also most important ligament in foot, apparently.
What is the lateral arch of the foot supported by?
Long plantar ligament
Plantar aponeurosis
Peroneal tendons
What is the transverse arch supported by?
Interosseus muscles
Peroneus longus tendon
Growth Disturbance (varus)
Cause of genu varum
epiphyseal dysplasia
Post-trauma (varus)
Cause of genu varum
Injury to growth plate near knee
Foot muscles innervated by medial plantar nerve
flexor hallucis brevis
1st lumbrical
abductor hallucis
flexor digitorum brevis
Which kinds of cartilage lack perichondrium?
Hyaline cartilage on articular surfaces of bone,
Fibrocartilage
Which type of cartilage growth is associated with the formation of isogenous groups?
Interstitial growth
Fibrocartilage features what kinds of collagen in a regular pattern?
Type 2 and Type 1
Proton-ATPases are utilized by what type of bone cell?
Osteoclasts
What resides in Howship’s Lacuna?
Osteoclasts
What orientation do Volkmann’s canals have in relation to the long bone?
Transverse
Osteopetrosis
Reduced osteoclast activity resulting in too much bone
High Ankle Sprain
Tear or stretch of the anterior inferior tibio-fibular ligaments
Pathway of Blood
RA - tricuspid valve - RV - pulmonary valve - pulmonary arteries - lungs - lung capillary beds - pulmonary veins - LA - mitral valve/bicuspid - LV - aortic valve - systemic arteries - systemic capillary beds - systemic veins - RA
Layers of Arteries and Veins
Tunica Adventitia - outer connective tissue
Tunica Media - middle smooth muscle layer (controls arterial vasomotor tone)
Tunica Intima - inner lining - endothelial cells (diffusion)
Features that distinguish veins from arteries
Veins….
- thin walls
- large luminal diameters
- do not pulsate when cut
- occur as multiple vessels in a common vascular sheath
- valves
- ability to expand (have 80% of blood volume)
What are capillaries comprised of?
Simple endothelial cell tubes
Capillary Beds
Networks of capillaries that connect arterioles and venules. Hydrostatic pressure at arteriole end forces fluid (o2) out of blood and osmotic pressure at the venule end allows waste and co2 into blood.
At the arteriole end of capillary beds, what force pushes nutrient-rich fluid into the tissues?
Hydrostatic pressure
The portal venous systems
Hepatic: drains blood from capillary beds of digestive tract to (eventually) the liver for metabolism and detox before hitting the heart
Hypophyseal: drains from capillary beds at base of hypothalamus to capillary plexus around anterior pituitary gland. Hypothalamic-anterior pituitary communication (neurosecretory hormones)
At the venule end of capillary beds, what force allows waste products to enter the blood?
Osmotic pressure
Locations without lymphatic capillaries
Teeth, Bone, Marrow, CNS
Regions supplied by each: Subclavian Arteries Common Carotid Aortic Arch Brachiocephalic Trunk Pulmonary Veins Pulmonary Trunk Sup and Inf Vena Cava
Upper limb
Head and neck
From LV it descends to abdomen, pelvis, and lower limb
Branches to rt subclavian and rt carotid
LA from lungs
RV to lungs
RA from upper and lower body
Name of heart valves: RV --> lungs LA --> LV LV --> systemic RA --> RV
pulmonary valve
mitral valve
aortic valve
tricuspid valve
What do lymphatic capillaries lack that allows the entry of material into the lymph?
Basement membrane
What does the right lymphatic duct drain?
Upper right quadrant of the body
What does the thoracic duct begin with?
Cisterna chyli (merger of the lymphatic trunks draining the lower half of the body)
Where does the thoracic duct join the venous system?
Left venous angle
Thrombus
Embolus
Embolism
Blood clot in place of origin
Blood clot that has moved
Obstructed vessel due to embolus
Infarct
Stenosis
Necrosis due to total occlusion of an artery
Damage due to partial occlusion
Varicose Veins
Abnormally swollen and dilated veins, usually occurring in the legs. Walls of veins lose their elasticity and damaged valves allow blood to pool in their veins instead of returning to the heart.
Edema
Swelling of tissue due to excess amt of interstitial fluid
Hypertension
High blood pressure because of abnormally high smooth muscle tonus
Ateriovenous anastamoses
Where blood passes from arterial to venous circulation without passing through capillaries
Found in skin (esp. fingers) for thermal regulation
A-delta mechanosensitive nociceptors are activated by what stimulus?
Noxious mechanical stimulation
C fibers are activated by which stimuli?
Variety of chemical stimuli in addition to noxious mechanical and thermal stimulation
*polymodal nociceptors
What is the difference between activators and sensitizers?
Activators directly activate nociceptors while sensitizers lower the threshold for nociceptor activation.
(Types of substances released into extracellular fluid compartment due to local tissue damage)
Stepwise process of pain
- Lesion occurs
- Substance released into extracellular fluid from cells around lesion
- Free nerve endings respond to the stimuli present
- Orthodromic action takes signal toward DRG and spinal cord
A-delta mechanothermal nociceptors are activated by which types of stimulation?
Noxious Mechanical and Thermal stimulation
Chemical activators released in response to damage (4)
serotonin
bradykinin
potassium
histamine
Chemical sensitizers released in response to injury
substance P
prostoglandins
Which substance is both an activator and sensitizer in pain response?
serotonin
Axon Reflex
Activation of one nociceptor ending initiates action potentials which conduct orthodromically towards CNS. These action potentials also propagate antidromically to invade nociceptor endings which were not activated by the noxious stimulus.
Which pain response substance is released through axon reflex?
substance P (by C-fibers)
Functions of Substance P in peripheral tissues
Sensitizer
Vasodilator
Induces histamine release from mast cells
Source of potassium in pain response
Damaged cells
Source of serotonin in pain response
Platelets
Source of bradykinin in pain response
Plasma kininogen
Source of Histamine in pain response
Mast cells
Source of Prostaglandins in pain response
Damaged cells (arachidonic acid)
Source of Substance P in pain response
Nociceptors
Hyperalgesia
An exaggerated response to a noxious stimulus which signifies increased sensitivity of nociceptive afferent fibers
Primary Hyperalgesia
Occurs in tissues surrounding the site of injury and is caused by the peripheral release of chemical activators and sensitizers during axon reflex.
*extent of this correlates with redness due to substance P induced vasodilation
Secondary Hyperalgesia
Surrounds area of primary hyperlgesia and is mediated centrally through multiple processes. Results in lowered thresholds for nociceptors which innervate the surrounding area.
Allodynia
Typically accompanies hyperalgesia and is pain sensation resulting from stimuli which are not capable of evoking pain.
The excitatory influence by the ascending spinothalamics can be countered by what descending fibers? (2)
- Serotonergic
- Noradrenergic
*originate in medulla and pons of brainstem
Gate Control Theory
Interneurons act as the gate keeper and are naturally inhibitory within the dorsal horns. C fibers “hold the gate open” by inhibiting the interneuron AND exciting the projection neuron (to spinothalamics). A-alpha or A-beta (non-nociceptive fibers) close the gate by exciting the interneuron to inhibit the projection neuron (to spinothalamics) thereby inducing analgesia.
3 classes of endogenous opioid peptides
- Enkephalins
- Dynorphins
- Endorphins
3 classes of opioid receptors
- MU (enkephalins and endorphins)
- Delta (enkephalins and endorphins)
- Kappa (only dynorphins)
*all metabotrophic (g-coupled!)
What is the principal opioid and its receptor in the dorsal horn of the spinal cord?
enkephalin; mu receptors
How do opioids work?
They exert powerful pre- and post-synaptic inhibition at the synapses between nociceptor afferents and projection neuron and also in the periaqueductal gray to regulate descending noradrenergic and sergonergic fibers.
Postsynaptic Inhibition by opioids
Caused by the opening of K channels, hyperpolarizing the projection neurons and decreasing their ability to fire action potentials.
Presynaptic inhibition by opioids
Reduces neurotransmitter release through a combination of effects:
- opening K channels
- inhibiting Ca channels
- inhibiting adenylyl Cyclase and therefore reducing cAMP levels
How can the periaqueductal gray be activated in pain modulation?
Exciting projection neuron by disinhibition by opioids: GABA inhibiting interneurons deactivated
Excitation from lateral spinothalamic tract collaterals (also stress, emotion)
The PAG contains a high concentration of what? (3)
MU receptors, enkephalin producing neurons, and dynorphin producing neurons.
Opiate drugs (like morphine - binds MU receptors) produce analgesia in what 2 ways?
- Excitation of PAG projection neurons which then activate the descending serotonergic and noradrenergic pathways from the brain stem.
- Inhibition of neurotransmission from nociceptors to dorsal horn projection neurons.
Other Analgesics (5)
- Cyclo-oxygenase Inhibitors (aspirin) - inhibit formation of prostaglandins
- Capsaicin - induces long term desensitization to painful stimuli
- Antidepressants - inhibit reuptake of serotonin/norepinephrine; enhance effectiveness of descending pain control system
- NMDA receptor antagonist - ketamine
- Anticonvulsants - reduce abnormal excitability in pain system
Neuropathic Pain
Chronic pain resulting from a disease or injury which affects neurons.
Many causes: diabetes, shingles, chronic trauma, tumors….may be idiopathic (no cause)
Channelopathies
Chronic pain linked to a genetic mutation. Specific mutations in genes that code for the Na-v subunits expressed in periphery sensory neurons are implicated in some pain disorders.
Congenital insensitivity to pain due to issues with voltage gated sodium channel subunits.
What ligament completes the cup of the acetabulum?
Transverse acetabular ligament
