Y2: MSK Flashcards
Upper Limb 1: Shoulder, Arm and Elbow
Regions of the Upper Limb
and their joints
Shoulder
Shoulder girdle (Clavicle and Scapula)
Acromioclavicular & glenohumeral joints
Arm
Humerus
Elbow
Humeroulnar, humeroradial & proximal radioulnar joints
Forearm
Radius and Ulna
Wrist
Carpal bones
Distal radioulnar, radiocarpal & intercarpal joints
Hand
Metacarpals and phalanges
Carpometacarpal, intercarpal, metacarpophalangeal & interphalangeal joints
Upper Limb 1: Shoulder, Arm and Elbow
Features of the Clavicle
“Key, hook”
Connection of UL to axial skeleton
Common fracture site
Acts as a strut, increasing UL ROM
S shaped
Medial 2/3 convex anteriorly
Lateral 1/3 concave anteriorly
Flat lateral and quadrangular medial end.
Sternal end (Sternoclavicular joint)
Acromial end (Acromioclavicular joint)
Upper Limb 1: Shoulder, Arm and Elbow
Features of the Shoulder Girdle- the Scapula
Triangular
3 border
2 angles
Lies on posterior thoracic wall
Ribs 2-7
Highly mobile
Numerous muscle attachments.
Posterior axioappendicular muscles
Scapulohumeral muscles
Upper Limb 1: Shoulder, Arm and Elbow
Features of the Proximal Humerus
Largest bone of UL
Joints
Glenohumeral proximally
Elbow joint distally
2 necks
Anatomical
Surgical
Fractures of surgical neck
2 tubercles
Greater
Lesser
Upper Limb 1: Shoulder, Arm and Elbow
Features of the Distal Humerus
Elbow joint
Trochlear with ulna
Capitulum with radius
Epicondyles and supracondylar ridges
Important site for muscle attachment
Fossa
To accommodate radius and ulna in flexion and extension.
Upper Limb 1: Shoulder, Arm and Elbow
Proximal Radius and Ulna
“staff/rod- radius”
CLINICAL
Clinical: Fractures of Humerus
Surgical neck
Axillary nerve
Deltoid muscle weakness/ paralysis
Reduced sensation over regimental badge area
Mid-shaft
Radial nerve
Wrist extensor weakness/ paralysis
Reduced sensation in skin supplied by radial nerve
Distal Humerus
Median nerve
Medial epicondyle
Ulnar nerve
Upper Limb 1: Shoulder, Arm and Elbow
Sternoclavicular Joint
Only articulation of UL to axial skeleton.
Manubrium, medial end of clavicle, and 1st costal cartilage.
Synovial saddle joint
Reinforced by ligaments
Sternoclavicular
Interclavicular
Costoclavicular
Acromioclavicular Joint
“highest shoulder - acromion” “Clavicle little key”
Acromial end of clavicle with acromion process
Plane type synovial joint
Reinforced by ligaments
Acromioclavicular
Coracoacromial
Coracoclavicular
Conoid
Trapezoid
Glenohumeral Joint
“glene- socket”
Synovial Ball and Socket joint.
Glenoid cavity
Head of humerus
High mobility, low stability
Reinforced by labrum, ligaments and muscles
Clinical:
Anterior (anteroinferior) dislocations
Bursitis
Elbow
Elbow joint
Synovial hinge – Flexion/Extension
Humeroulnar
Humeroradial
Proximal radioulnar joint
Synovial pivot – Pronation/Supination
Reinforced by ligaments
Ulnar collateral – 3 bands
Radial collateral – Blends with
Anular ligament
Movements: Scapula
Movements: Glenohumeral Joint
Flexion/Extension
Abduction/Adduction
Lateral/Medial Rotation
Circumduction
Movements: Elbow
Flexion/Extension
Pronation/Supination
Axioappendicular
Anterior axioappendicular: Pectoralis Major, Pectoralis Minor, Subclavius, Serratus Anterior
Posterior axioappendicular: Trapezius, Latissimus dorsi, Levator scapulae, Rhomboid Minor and Major.
Scapulohumeral
Rotator Cuff:
Supraspinatus,
Infraspinatus,
Teres minor,
Subscapularis
Teres Major,
Deltoid
Arm muscles
Anterior: Biceps Brachii, Coracobrachialis, Brachialis
Posterior: Triceps Brachii, Anconeus
Pectoralis Major
“pectus- breast”
Origin: Medial half of clavicle (clavicular head), sternum, superior six costal cartilages, aponeurosis of external oblique (sternocostal head).
Insertion: Lateral lip of intertubercular sulcus
Actions: Adduction and medial rotation of shoulder joint. Acting alone the clavicular head flexes the shoulder joint and sternocostal head extends it.
Innervation: Lateral and medial pectoral nerves
Pectoralis Minor
Origin: Anterior surface of 3rd to 5th ribs
Insertion: Coracoid process of scapula
Actions: Stabilises the scapula by drawing it anteroinferiorly
Innervation: Medial pectoral nerve
Subclavius
“below clavicle”
Origin: Junction of 1st rib and its costal cartilage
Insertion: Subclavian groove of clavicle
Actions: Stabilises and depresses clavicle
Innervation: Nerve to subclavius
Serratus Anterior
“serrated- shape”
Origin: Anterior surfaces of ribs 1 to 8/9
Insertion: Medial border of scapula
Actions: Protracts scapula and holds it against thoracic wall
Innervation: Long thoracic nerve
Trapezius
named for shape
Origin: Superior nuchal line, external occipital protuberance, nuchal ligament & spinous processes of C7-T12
Insertion: Lateral third of clavicle, acromion and spine of scapula
Actions: Retraction of the scapula. Acting alone the descending part elevates the scapula and the ascending part depresses the scapula
Innervation: Spinal accessory nerve & C3 and 4 spinal nerves
Latissimus Dorsi
“broadest (latissimus) back (dorsi)”
Origin: Spinous processes of T7-T12, thoracolumbar fascia, iliac crest & inferior 3-4 ribs
Insertion: Floor of intertubercular sulcus
Actions: Extend, adduct and medially rotate the shoulder joint
Innervation: Thoracodorsal nerve
Levator Scapulae
“lift scapula”
Origin: Transverse processes of C1-C4
Insertion: Medial border of scapula superior to spine
Actions: Elevation & downwards rotation of scapula
Innervation: Dorsal scapula nerve & C3 & 4 spinal nerves
Rhomboids
shape
Origin: Minor: Nuchal ligament & spinous processes of C7-T1.
Major: Spinous processes of T2-T5
Insertion: Minor: Medial border of scapula level with spine of scapula. Major: Medial border of scapula from spine to inferior angle
Actions: Retraction & downwards rotation of scapula
Innervation: Dorsal scapula nerve
Rotator Cuff
Supraspinatus
“above spine (of scapula)”
Origin: Supraspinous fossa of scapula
Insertion: Greater tubercle of humerus (superior facet)
Actions: Initiates abduction of shoulder joint (first 15deg)
Innervation: Suprascapular nerve
Rotator Cuff
Infraspinatus
“below spine (of scapula)”
Origin: Infraspinous fossa of scapula
Insertion: Greater tubercle of humerus (middle facet)
Actions: Lateral rotation of shoulder joint
Innervation: Suprascapular nerve
Rotator Cuff
Teres minor
“Small round”
Origin: Middle part of lateral border of scapula
Insertion: Greater tubercle of humerus (inferior facet)
Actions: Lateral rotation of shoulder joint
Innervation: Axillary nerve
Rotator cuff
Subscapularis
“beneath scapula”
Origin: Subscapular fossa of scapula
Insertion: Lesser tubercle of humerus
Actions: Medial rotation of shoulder joint
Innervation: Upper and lower subscapular nerves
Teres Major
“big round”
Origin: Inferior part of lateral border of scapula and inferior angle
Insertion: Medial lip of intertubercular sulcus
Actions: Adduction and medial rotation of shoulder joint
Innervation: Lower subscapular nerve
Deltoid
“D shape”
Origin: Lateral third of clavicle (anterior), acromion (middle), and spine of scapula (posterior)
Insertion: Deltoid tuberosity of humerus
Actions: Abduction of shoulder joint. Acting alone the anterior part flexes & medially rotates the shoulder joint and the posterior part extends & laterally rotates the shoulder joint
Innervation: Axillary nerve
Brachial Fascia
Deep fascia that encloses muscles of the arm
Continuous with deep fascia of the forearm
Intermuscular septa divide the arm into:
Anterior (flexor) compartment
Musculocutaneous nerve
Posterior (extensor) compartment
Radial nerve
Clinically important for spread of infection and haemorrhage
Arm Muscles (Anterior Compartment)
Biceps Brachii
“2 head muscle of arm”
Origin: Long head: Supraglenoid tubercle of scapula
Short head: Coracoid process of scapula
Insertion: Radial tuberosity and fascia of forearm via bicipital aponeurosis
Actions: At shoulder: Flexion of shoulder joint
At elbow: Supinates forearm. When already supinated it flexes the elbow joint
Innervation: Musculocutaneous nerve
Arm Muscles (Anterior Compartment)
Coracobrachialis
“from coracoid to arm”
Origin: Coracoid process of scapula
Insertion: Middle third of medial humerus
Actions: Flexion and adduction of shoulder joint
Innervation: Musculocutaneous nerve
Arm Muscles (Anterior Compartment)
Brachialis
“arm”
Origin: Distal half of anterior humerus
Insertion: Ulnar tuberosity and coronoid process
Actions: Flexion of elbow joint (whether pronated or supinated)
Innervation: Musculocutaneous nerve
Arm Muscles (Posterior Compartment)
Triceps Brachii
“3 headed muscle of arm”
Origin: Long head: Infraglenoid tubercle of scapula
Lateral head: Posterior humerus, superior to radial groove
Medial head: Posterior humerus, inferior to radial groove
Insertion: Olecranon process of ulna
Actions: At shoulder: Long head extends shoulder joint
At elbow: Extension of elbow joint
Innervation: Radial nerve
Anconeus
“bend of the elbow”
Origin: Lateral epicondyle of humerus
Insertion: Lateral olecranon and proximal humerus
Actions: Stabilises elbow joint & assists with elbow extension
Innervation: Radial nerve
How does the scapula move?
Clinical: Rotator cuff injuries
Impingement
Supraspinatus under acromion process
Causes
Inflamed bursa
Swollen supraspinatus muscle/tendon
Subacromial bony spurs
Pain during abduction
Tendinopathy
Disorganisation of normal tendon
Causes
Overuse
Age related degeneration
Repeated trauma
Poor blood supply
Tears
Partial or full thickness tears
Causes
Trauma
Degenerative changes
Overuse
Most common in older adults
Subcalvian artery
Branches that supply upper limb:
Thyrocervical Trunk
Transverse Cervical
Suprascapular
Dorsal Scapular
Forms anastomosis with 3rd part of axillary via subscapular a.
Axillary artery
Screw The Lawyer Save A Patient
1st part
Superior thoracic
2nd part
Thoracoacromial trunk
Branches: Clavicular, Pectoral, Deltoid, Acromial
Lateral thoracic
3rd part
Subscapular
Anterior circumflex humeral
Posterior circumflex humeral
Brachial artery
Course
Medial arm in groove between biceps brachii and brachialis.
Medial to median nerve in proximal half
Lateral to median nerve in distal half
At elbow lies medial to biceps tendon and deep to bicipital aponeurosis
Branches
Deep brachial artery (Profunda brachii)
Termination:
Bifurcation into radial and ulnar arteries
Brachial plexus
Nerve plexus that supplies the UL
Formed by:
Anterior rami C5-T1 (emerge between anterior and middle scalenes)
Component parts:
ROOTS – C5-T1
TRUNKS – Superior, Middle, and Inferior
DIVISIONS – 3 Anterior, 3 Posterior
CORDS – Lateral, Medial and Posterior
BRANCHES – 5 Terminal
Read That Damn Cadaver Book
Terminal Branches of Brachial Plexus
5 terminal branches
Musculocutaneous C5,6,7
Median C5-T1
Ulnar C8-T1
AxillaryC5,6
RadialC5-T1
Find the M!
Draw the brachial plexus
Musculocutaneous Nerve
Origin
Lateral cord – C5-7
Course
Pierces coracobrachialis
Descends between biceps brachii and brachialis
Continues as the lateral cutaneous nerve of forearm
Structures innervated
Anterior compartment of arm (coracobrachialis, biceps brachii,and brachialis)
Skin of lateral aspect of forearm
Median Nerve
Origin
Lateral and medial cords – C5/6-T1
Course
Descends through arm, lateral to brachial artery
The crosses to lie medial at cubital fossa
Structures innervated
Anterior/flexor compartment (except for flexor carpi ulnaris and ulnar half of flexor digitorum profundus
Thenar eminence and first 2 lumbricals
Skin of lateral half of palm and lateral three and a half fingers
Ulnar Nerve
Origin
Medial cord – C8-T1
Course
Descends medially and passes posterior to medial epicondyle
Descends along ulnar aspect of forearm to hand
Structures innervated
Flexor carpi ulnaris and medial half of flexor digitorum profundus
Rest of the hand muscles
skin of medial half of dorsal and palmar aspect of palm and medial one and a half fingers
Axillary Nerve
Origin
Posterior cord – C5, C6
Course
Passes through QUADRANGULAR SPACE with posterior circumflex humeral artery
Winds around surgical neck of humerus
Structures innervated
Deltoid and teres minor
Skin of lower half of deltoid (Admirals badge)
Radial Nerve
Origin
Posterior cord – C5-T1
Course
Passes Inferior to teres major with deep brachial artery in the radial groove
Runs between lateral and medial heads of triceps brachii
Passes anterior to the lateral epicondyle to enter the cubital fossa where it divides into a superficial and deep branch
Structures innervated
All muscles of posterior arm and forearm
Skin of posterior and inferolateral arm, posterior forearm, and lateral side of dorsum of hand and dorsal surface of lateral three and a half fingers
Minor Branches
of Brachial Plexus
Brachial Plexus Injuries
Erb’s Palsy (Upper Brachial Plexus Injury)
Forced separation of head from shoulder
E.g. During birth or a fall onto the shoulder
Affects C5, 6 nerve roots
Waiters tip position: Arm by side, medial rotation, pronated forearm
Klumpke’s Palsy (Lower Brachial Plexus Injury)
Forced separation of arm from head
E.g. During birth or grabbing something above during fall
Affects C8, T1 nerve roots
Claw hand: Flexed medial fingers (paralysis of the lumbrical muscles)
Label the bones of the forearm
What is the Ulna?
Main stabilising bone of forearm
Narrows distally
Doesn’t articulate at wrist joint
What is the radius?
Rotates over stationary ulna
Broader distally
Articulates at radiocarpal (wrist) joint and distal radioulnar joint
Which is broader distally and which is narrower distally?
Ulna Narrows distally
Radius Broader distally
Which articulates at the wrist? Ulna or radius?
Ulna Doesn’t articulate at wrist joint
Radius Articulates at radiocarpal (wrist) joint and distal radioulnar joint
How may Carpal bones are there?
8 bones
How are the carpal bones organised?
Proximal row
Scaphoid
Lunate
Triquetrum
Pisiform (sesamoid bone)
Distal row
Hamate (Hook of hamate)
Capitate
Trapezoid
Trapezium
Straight Line to Pinky
Here Comes The Thumb
Label the carpal bones
Scaphoid- “Boat”
Luneate- “crescent/moon”
Triquetium
Pisiform- “pea shaped”
Hamate - “hooked”
Capitate- “head”
Trapezoid- “like a trapezium”
Trapezium- “big trapezium” (THUMB)
Scaphoid Fracture
Most common carpal injury
Mechanism: Fall on Outstretched hand (FOOSH)
Location: Most common at waist of scaphoid
10% receive blood supply from distal source
Can result in avascular necrosis to proximal scaphoid
Often missed by X-rays leading to delayed diagnosis and greater risk of osteoarthritis of the wrist in later life
What is the radiocarpal joint?
Condyloid synovial joint
Articulation
Distal radius and articular disc with proximal row of carpal bones (except pisiform)
Ligaments
Ulnar collateral ligament, Radial collateral ligament & Palmar and dorsal radiocarpal ligaments
Identify the carpal joints
What joints are present in the wrist?
Radiocarpal joint (Wrist joint)
Distal radioulnar joint
Midcarpal joint
Intercarpal joints
Carpometacarpal joints
How many bones in the hand?
19
Metacarpals
Proximal, middle and distal phalanges
Thumb only has proximal and distal
What is the Metacarpophalangeal joint (MCP) type?
Condyloid synovial joint
What is the Proximal (PIP), and distal (DIP) interphalangeal joints
joint type?
Hinge synovial joint
Identify the joints
What are the palmar ligaments?
Join head to base of adjacent bone
Firmly attached to deep transverse metacarpal ligament
Stabilises joints
What are the Deep transverse metacarpal
ligaments?
2nd to 5th metacarpal
Resist separation of metacarpals
What are the collateral ligaments?
Stabilise MCP and IP joints
Taught in flexion
Label the ligaments of the hand
What movements can the wrist do?
Flexion
Extension
Ulnar deviation
Adduction
Radial deviation and** ab**duction
What movements can the fingers achieve?
Flexion Extenion
Abduction
Adduction
What movements can the thumb achieve?
Flexion Extenion
Abduction
Adduction
Opposition and Reposition
What mucles are present in the anterior of the forearm?
The flexor muscles
Superficial layer (4): Pronator Teres, Flexor Carpi Radialis, Palmaris Longus, Flexor Carpi Ulnaris
ENGLISH: a round pronator muscle, flexor to radius wrist, long palm muscle, flexor to ulnar wrist
Intermediate layer (1): Flexor Digitorum Superficialis
ENGLISH: superficial finger flexor (to Mid Phalanx)
Deep layer (3): Flexor Digitorum Profundus, Flexor Pollicis Longus, Pronator Quadratus
ENGLISH: Deep finger flexor (to Distal Phalanx), Long Thumb flexor, Square pronator at wrist
What muscles are present in the posterior compartment of the forearm?
The extensor muscles
Superficial layer (6): Brachioradialis, Extensor Carpi Radialis Longus, Extensor Carpi Radialis Brevis, Extensor Digitorum, Extensor Digiti Minimi, Extensor Carpi Ulnaris
ENGLISH: arm muscle, extensor to radius at wrist, short extensor to radius at wrist, extend fingers (1-3), extend pinky, extensor to wrist at ulna
Deep layer (5): Supinator, Extensor Indicis, Abductor Pollicis Longus, Extensor Pollicis Brevis, Extensor Pollicis Longus
ENGLISH: Supinator (at elbow, 2 heads), Extend pointer, abduct thumb, extend thumb short, extend thumb long.
Pronator Teres
Origin:
Humeral head: Common flexor tendon (medial epicondyle)
Ulnar head: Coronoid process of ulna
Insertion: Lateral mid-shaft of radius
Actions: Pronation
Innervation: Median nerve
Round pronator
The flexor carpi radialis
Origin: Common flexor tendon (medial epicondyle)
Insertion: Base of 2nd and 3rd metacarpals
Actions: Wrist flexion and radial deviation (abduction)
Innervation: Median nerve
Palmaris longus
Origin: Common flexor tendon (medial epicondyle)
Insertion: Palmar aponeurosis of hand
Actions: Flexes wrist and tenses palmar aponeurosis
Innervation: Median nerve
Flexor carpi ulnaris
Origin: Common flexor tendon (medial epicondyle)
Insertion: Pisiform, hook of hamate, 5th metacarpal
Actions: Wrist flexion and ulnar deviation (adduction)
Innervation: Ulnar nerve
Flexor Digitorum Superficialis
Origin:
Humero-ulnar head: Common flexor tendon (medial epicondyle) and coronoid process
Radial head: Oblique line of radius (anterior proximal half)
Insertion: Middle phalanx of medial 4 digits
Actions: Wrist flexion, flexion of PIP joints of medial 4 digits
Innervation: Median nerve
Flexor Pollicis
Longus
Origin: Anterior radius & interosseous membrane
Insertion: Base of distal phalanx of thumb
Actions: Flexion of MCP and IP joint of thumb
Innervation: Median nerve
Flexor Digitorum
Profundus
Origin: Proximal ¾ of medial and anterior surfaces of ulna and interosseous membrane
Insertion: Base of distal phalanx of medial 4 digits
Actions: Wrist flexion & flexion of DIP joints of medial 4 digits
Innervation: Ulnar nerve (medial half) and median nerve (lateral half)
Pronator Quadratus
Origin: Distal anterior ulna
Insertion: Distal anterior radius
Actions: Pronation
Innervation: Median nerve
Brachioradialis
Origin: Lateral supracondylar ridge
Insertion: Lateral distal radius
Actions: Flexion of elbow in midpronation
Innervation: Radial nerve
Extensor Carpi
Radialis Longus
Origin: Lateral supracondylar ridge (distal to brachioradialis)
Insertion: Base of 2nd metacarpal
Actions: Wrist extension and radial deviation (abduction)
Innervation: Radial nerve
Extensor Carpi
Radialis Brevis
Origin: Common extensor tendon (lateral epicondyle)
Insertion: Base of 3rd metacarpal
Actions: Wrist extension and radial deviation (abduction)
Innervation: Radial nerve
Extensor
Digitorum
Origin: Common extensor tendon (lateral epicondyle)
Insertion: Base of middle and distal phalanx of medial 4 digits via the extensor expansion
Actions: Extension of wrist, MCP, PIP and DIP joints of medial 4 digits
Innervation: Radial nerve
Extensor Digiti
Minimi
Origin: Common extensor tendon (lateral epicondyle)
Insertion: Extensor expansion of 5th digit
Actions: Extension of wrist and little finger
Innervation: Radial nerve
Extensor Carpi
Ulnaris
Origin: Lateral epicondyle of humerus and posterior ulna
Insertion: Base of 5th metacarpal
Actions: Wrist extension and ulnar deviation (adduction)
Innervation: Radial nerve
Supinator
Origin: Lateral epicondyle, radial collateral and annular ligaments & supinator crest of ulna.
Insertion: Lateral proximal 1/3 of radius
Actions: Supination
Innervation: Radial nerve
Extensor Indicis
Origin: Posterior distal 1/3 of ulna and interosseous membrane
Insertion: Extensor expansion of 2nd digit
Actions: Extension of wrist and index finger
Innervation: Radial nerve
Abductor Pollicis
Longus
Origin: Middle 1/3 of radius, ulna & interosseous membrane
Insertion: Base of 1st metacarpal
Actions: Abducts thumb, extends wrist and CMC joint
Innervation: Radial nerve
Extensor Pollicis
Brevis
Origin: Posterior radius and interosseous membrane
Insertion: Base of proximal phalanx of thumb
Actions: Extends proximal phalanx of thumb at 1st MCP joint. Extends wrist and CMC joint
Innervation: Radial nerve
Extensor Pollicis Longus
Origin: Posterior ulna and interosseous membrane
Insertion: Base of distal phalanx of thumb
Actions: Extends distal phalanx of thumb at 1st IP joint. Also extends wrist and CMC and MCP joint
Innervation: Radial nerve
Muscle groups of the hand
Thenar
Hypothenar
Adductor
Central
Interosseous
Muscles in the hand
Thenar (at the thumb)
Abductor pollicis brevis, Flexor pollicis brevis, opponens pollicis
alphabetical: A, F, O (superficial to deep) Remember thenar is brevis
Hypothenar (at the pinky)
Abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi
*alphabetical: A, F, O (superficial to deep)
Adductor
Adductor pollicis
Central
Long flexor tendons, lumbrical muscles
Interosseous
interossei
Abductor Pollicis
Brevis (cut)
Insertion: Base of proximal phalanx of the thumb
Actions: Abduction of thumb
Flexor Digiti
Minimi (cut)
Insertion: Base of proximal phalanx of 5th digit
Actions: Flexion of 5th digit
Opponens Digiti Minimi
Insertion: 5th metacarpal
Actions: Opposition of 5th digit
The deep branch of the ulnar nerve innervates
The hypothenar group
Adductor Pollicis
Transverse head
Oblique head
Insertion: Base of proximal phalanx of thumb
Actions: Adduction of Thumb
Innervation: Deep branch of ulnar nerve
Lumbricals
Origin: Flexor digitorum profundus tendons
Insertion: Extensor expansion
Actions: Flexion of MCP and extension of IP joints
Innervation: Median nerve (1st and 2nd ), deep branch of ulnar nerve (3rd and 4th)
Interossei
PAD (Palmar ADDuct)
DAB (Dorsal ABduct)
Origin: In-between metacarpals
Insertion: Base of proximal phalanx and extensor expansion
Actions: Palmar adduct, dorsal abduct from 3rd digit. Assist lumbricals actions.
Innervation: Deep palmar branch of the ulnar nerve
Cephalic Vein
Originates from lateral dorsal venous arch
Run medially up forearm and arm
Runs in deltopectoral groove then drains into axillary vein at clavipectoral triangle
Basillic vein
Originates from medial dorsal venous arch
Runs laterally up forearm and arm
Becomes axillary vein at lower border of teres major
Median cubital vein
Unites basilic and cephalic veins at elbow
Common venepuncture site
Deep veins
Accompany arteries and drain into paired brachial veins
Brachial veins drain into basilic/axillary vein
Label the veins
The Ulnar Artery Course
Forearm
Deep to pronator teres
Medial forearm between FCU and FDP
Branches
Common interosseous
Anterior and posterior interosseous
The radial artery
Forearm
Radial artery
Course
Deep to brachioradialis
Lateral forearm, lateral to FCR
Ulnar Artery
Hand
Course
Lateral to FCU tendon
Superficial to flexor retinaculum in Guyons canal
Branches
Superficial palmar arch
Common palmar digital
Proper palmar digital
Deep palmar branch of ulnar artery
Anastomoses with deep palmar arch
Radial Artery
Hand
Course
Lateral to FCR tendon
Posterior through anatomical snuffbox and then anterior through 1st dorsal interossei
Branches
Deep palmar arch
Palmar metacarpal arteries
Anastomose with proper palmar digital
Superficial palmar branch of radial artery
Anastomoses with superficial palmar arch
Label the arterial supply of the hand
The radial NERVE
Origin
Posterior cord – C5-T1
Course
Passes anterior to the lateral epicondyle where it splits into a superficial and deep branch
Deep branch: Pierces supinator to reach posterior forearm and continues as posterior interosseous nerve which runs between superficial and deep layer.
Superficial branch: Descends lateral forearm deep to brachioradialis and passes through superficial anatomical snuff box to reach the dorsum of the hand.
Structures innervated
All muscles of posterior arm and forearm
Skin of posterior and inferolateral arm, posterior forearm, and lateral side of dorsum of hand and dorsal surface of lateral three and a half fingers
The median nerve
Origin
Lateral and medial cords – C5/6-T1
Course
Medial to brachial artery at cubital fossa
Passes deep to pronator teres
Passes between Flexor Digitorum Superficialis (FDS) and Profundus (FDP)
Passes through carpal tunnel
Gives off recurrent branch to thenar eminence
Structures innervated
Anterior compartment (except for flexor carpi ulnaris and ulnar half of flexor digitorum profundus
Thenar eminence and first 2 lumbricals
Skin of lateral half of palm and lateral three and a half fingers
The Ulnar Nerve
Origin
Medial cord – C8-T1
Course
Passes posterior to medial epicondyle and between 2 heads of Flexor Carpi Ulnaris (FCU)
Descends between FCU and FDP
Passes superficial to flexor retinaculum and divides into superficial and deep branches
Structures innervated
FCU & medial half of FDP
Rest of the intrinsic hand muscles
Skin of medial half of dorsal (dorsal branch) and palmar aspect of palm and medial one and a half fingers
The carpal tunnel
Carpal tunnel
Roof: Flexor retinaculum
Floor: Carpal bones (carpal arch)
Contents:
Flexor pollicis longus
4 Flexor digitorum superficialis
4 Flexor digitorum profundus
MEDIAN NERVE.
Clinical: Carpal tunnel syndrome
Why does the flexor policis brevis not enter the carpal tunnel?
It originates from the trapezium, capitate, trapezoid and flexor retinaculum.
These are proximal to the carpal ligament
The ulnar cubital tunnel
Ulnar (Cubital) tunnel:
Medial wall: Medial epicondyle
Lateral wall: Olecranon
Floor: Joint capsule & ulnar collateral lig.
Roof: Cubital tunnel retinaculum
Contents: ULNAR NERVE
Clinical: Cubital tunnel syndrome
Lower Limb 1- Hip, Thigh and Knee
What ____ bones is the pelvic girdle made from?
Sacrum
Coccyx
Right hip / pelvis bones
Left hip / pelvic bones
Lower Limb 1- Hip, Thigh and Knee
What are the functions of the bony pelvis?
- Transmits the body’s weight from the vertebral column to the femur
- Contains, protects, & supports the pelvic organs (bladder, rectum, anal canal, & reproductive tracts)
- Provides attachment for the lower limbs & trunk
- Anchors the roots of external genitalia
What is the sacroiliac joint?
Transfers weight from
sacrum to hip bones
Lower Limb 1- Hip, Thigh and Knee
What is the pubic symphysis?
Secondary cartilaginous joint
During pregnancy can soften
& stretch causing pain
Lower Limb 1- Hip, Thigh and Knee
What is the lumbrosacral joint?
Lower Limb 1- Hip, Thigh and Knee
What is the sacrococcygeal joint?
Lower Limb 1- Hip, Thigh and Knee
What is the subpubic angle?
Angle between two pubic arches (Left & right ischiopubic rami)
Lower Limb 1- Hip, Thigh and Knee
Annotate the landmarks of the hip bones
Angle between two pubic arches (Left & right ischiopubic rami)
Lower Limb 1- Hip, Thigh and Knee
The hip is formed of ____ bones which fuse at the ______
Composed of 3 bones which fuse at acetabulum
Ilium
Ischium
Pubis
Lower Limb 1- Hip, Thigh and Knee
Annotate the ligaments of the pelvic girdle
Lower Limb 1- Hip, Thigh and Knee
What are the ligaments of the pelvic girlde?
- Obturator membrane
- Sarcoiliac ligament (weight bearing)
- Sacrospinous (Runs between ischial spine & sacrum & coccyx)
- Sacrotuberous ligament (Runs between sacrum & ischial tuberosity)
Lower Limb 1- Hip, Thigh and Knee
What are the pelvic foramina?
- Obturator Canal
- Greater Sciatic Foramen
- Obturator membrane
- Lesser Sciatic Foramen
Lower Limb 1- Hip, Thigh and Knee
What is the greater sciatic foramen?
Route of communication between
he pelvic cavity & lower limb
Lower Limb 1- Hip, Thigh and Knee
What is the lesser sciatic foramen?
Route of communication between the pelvic cavity & the perineum & gluteal region
Lower Limb 1- Hip, Thigh and Knee
What is the obturator canal?
Passage of obturator nerve
& vessels: supply thigh
Lower Limb 1- Hip, Thigh and Knee
Label the Proximal Femur
Lower Limb 1- Hip, Thigh and Knee
Label the Distal Femur
Lower Limb 1- Hip, Thigh and Knee
Label the proximal tibia
- Intercondylar Eminence
- Medial and Lateral Articular surfaces
- Lateral and Medial Condyle
- Tibial Tuberosity
Lower Limb 1- Hip, Thigh and Knee
Label the Patella
Largest sesamoid bone in the body
Base and Apex- Base IS NOT AT THE BOTTOM
Lower Limb 1- Hip, Thigh and Knee
Which tendon is superior to the patella?
Quadriceps
Tendon
Sits at the base of the patella
Lower Limb 1- Hip, Thigh and Knee
Which tendon is inferior to the patella?
Patella Ligament
Lower Limb 1- Hip, Thigh and Knee
The Anterior Femur is supported to the hip by ____ ligaments
ANTERIOR
Iliofemoral Ligament
Intertrochanteric line.
Strongest ligament in the body
Triangular capsular ligament
resists hyperextension
Pubofemoral Ligament
Intertrochanteric line
resists hyper-abduction of the hip joint
Lower Limb 1- Hip, Thigh and Knee
The Posterior Femur is supported to the hip by ____ ligaments
POSTERIOR
Ischiofemoral Ligament
Greater trochanter
limits the internal rotation and adduction of the hip when it is in a flexed position
Lower Limb 1- Hip, Thigh and Knee
The Acetabulum is supported by…..
- Acetabulum Labrum (lip)
- Transverse Acetabular Ligament
- Ligament of the head of femur (contains artery of head of femur)
Lower Limb 1- Hip, Thigh and Knee
The Acetabulum is supported by…..
- Acetabulum Labrum (lip)
- Transverse Acetabular Ligament
- Ligament of the head of femur (contains artery of head of femur)
Lower Limb 1- Hip, Thigh and Knee
What is present in the knee joint?
MODIFIED HINGE JOINT
* Tibiofemoral and patellofemoral components
* Ligaments:
* Anterior Cruciate Ligament (ACL)
* Posterior Cruciate Ligament (PCL)
* Medial Collateral Ligament (MCL)
* Lateral Collateral Ligament (LCL)
* Meniscus
* Medial meniscus attached to MCL
* Popliteus “unlocks” knee joint
*
Lower Limb 1- Hip, Thigh and Knee
Label the knee joint
Lower Limb 1- Hip, Thigh and Knee
CLINICAL: Bursa of Knee
Lower Limb 1- Hip, Thigh and Knee
What movements can the hip do?
Flexion/Extension
Abduction/Adduction
Medial /Lateral Rotation
Lower Limb 1- Hip, Thigh and Knee
What is the Gluteal muscle group?
Superficial layer (4): Gluteus maximus, gluteus medius, gluteus minimus, tensor fascia lata
Deep layer (5): Piriformis, gemellus superior, obturator internus, gemmelus inferior, quadratus femoris
Remember as: start with Glutes and a coffee
Lower Limb 1- Hip, Thigh and Knee
What is the Thigh muscle group?
Anterior compartment (7): Pectineus, iliopsoas, sartorius, rectus femoris, vastus lateralis, vastus intermedius, vastus medialis
Medial compartment (5): Adductor magnus, adductor longus, adductor brevis, gracilis, obturator externus
Posterior compartment (3): Semitendinosus, semimembranosus, biceps femoris
Lower Limb 1-Hip Thigh and Knee
The thigh is compartmented:
Deep fascia Separates muscles into compartments
Lateral intermuscular septum
Medial intermuscular septum
Posterior intermuscular septum
Increases contraction efficiency
Aids venous return
Lower Limb 1- Hip thigh and knee
What is the Illiotibial band?
Lateral thickening in fascia lata
Runs from iliac tubercle to Gerdy’s tubercle (lateral tibia)
Stabilises knee & hip
Indirect actions via gluteus maximus & tensor fascia lata
Lower Limb 1- Hip thigh and knee
Obturator Internus
Origin: Obturator membrane & adjacent bone
Passes through lesser sciatic foramen
Insertion: Trochanteric fossa
Actions: Hip lateral rotation & abduction (when flexed)
Innervation: Nerve to obturator
internus
Lower Limb 1- Hip thigh and knee
Quadratus Femoris
Origin: Ischial tuberosity
Insertion: Quadrate tubercle of femur
Actions: Hip lateral rotation
Innervation: Nerve to quadratus femoris
Lower Limb 1- Hip thigh and knee
Piriformus
Origin: Anterior sacrum
Passes out greater sciatic foramen
Insertion: Greater trochanter of femur
Actions: Hip lateral rotation & abduction (when flexed)
Innervation: anterior rami of S1, S2
Lower Limb 1- Hip thigh and knee
Gemelli
Origin:
Superior: Ischial spine
Inferior: Ischial tuberosity
Insertion: Trochanteric fossa (via tendon of obturator internus)
Actions: Hip lateral rotation & abduction (when flexed)
Innervation: Same as muscle directly inferior
Lower Limb 1- Hip thigh and knee
Gluteus Maximus
Origin: Posterior Ilium, sacrum, coccyx, & sacrotuberous ligament
Insertion: Iliotibial tract & gluteal tuberosity of femur
Actions: Hip extension & lateral rotation
Innervation: Inferior gluteal nerve
Lower Limb 1- Hip thigh and knee
Gluteus Medius
Origin: Posterior ilium between
anterior & posterior gluteal lines
Insertion: Greater trochanter of femur
Actions: Hip abduction & medial rotation (anterior fibres)
Innervation: Superior gluteal nerve
Lower Limb 1- Hip thigh and knee
Gluteus Minimus
Origin: Posterior ilium between
anterior & inferior gluteal lines
Insertion: Greater trochanter of femur
Actions: Hip abduction & medial rotation (anterior fibres)
Innervation: Superior gluteal nerve
Lower Limb 1- Hip thigh and knee
Tensor Fascia Lata
Origin: Anterior superior iliac spine, iliac crest
Insertion: Iliotibial tract (Lateral tibia)
Actions: Stabilises hip & knee joints
Innervation: Superior gluteal nerve
Lower Limb 1- Hip thigh and knee
What is the Trendelenburg Sign?
Clinical: Medius & Minimus keep pelvis level when opposite leg is elevated. With paralysis to these muscles, patients present with a Trendelenburg sign (pelvic drop)
Lower Limb 1- Hip thigh and knee
Pectineus
Origin: Superior pubic ramus
Insertion: Posterior proximal femur
Actions: Hip flexion, adduction & medial rotation
Common innervation to anterior compartment: Femoral nerve
Lower Limb 1- Hip thigh and knee
Ioliopsoas
Origin:
Iliacus: Iliac fossa
Psoas major: Transverse processes L1-5. Intervertebral discs & Vertebral bodies T12 - L5
Insertion: Common tendon on lesser trochanter of femur
Actions: Hip flexion
Innervation: Psoas major: Anterior rami L1-3
Lower Limb 1- Hip thigh and knee
Rectus Femoris
Origin:
Straight head: Anterior inferior iliac spine
Reflected head: Superior acetabulum
Insertion: Patella (via quadriceps femoris tendon)
Actions: Hip flexion, knee extension
Common innervation to anterior compartment: Femoral nerve
Lower Limb 1- Hip thigh and knee
Sartorius
Origin: Anterior superior iliac spine
Insertion: Medial tibia (Pes anserinus)
Actions: Hip flexion, abduction, lateral rotation. Knee flexion (Think crossing legs)
Lower Limb 1- Hip thigh and knee
Vastus Lateralis
Origin: Greater trochanter & lateral lip of linea aspera
Common insertion: Patella (via quadriceps femoris tendon). Vastus medialis & lateralis also insert directly onto patella & tibia via medial & lateral patellar retinaculum
Common Action: Knee extension
Common innervation: Femoral nerve
Lower Limb 1- Hip thigh and knee
Vastus Medialis
Origin: Medial lip of linea aspera
Common insertion: Patella (via quadriceps femoris tendon). Vastus medialis & lateralis also insert directly onto patella & tibia via medial & lateral patellar retinaculum
Common Action: Knee extension
Common innervation: Femoral nerve
Lower Limb 1- Hip thigh and knee
Vastus Intermedius
Origin: Anterolateral femur
Common insertion: Patella (via quadriceps femoris tendon). Vastus medialis & lateralis also insert directly onto patella & tibia via medial & lateral patellar retinaculum
Common Action: Knee extension
Common innervation: Femoral nerve
Lower Limb 1- Hip thigh and knee
Gracilis
Origin:
Body of pubis & inferior pubic ramus
Insertion: Medial tibia (Pes anserinus)
Actions: Hip adduction, knee flexion
Common innervation to medial compartment: Obturator nerve
Lower Limb 1- Hip thigh and knee
Obturator Externus
Origin: Obturator membrane & adjacent bone
Insertion: Trochanteric fossa
Actions: Hip lateral rotation
Common innervation to medial compartment: Obturator nerve
Lower Limb 1- Hip thigh and knee
Adductor Brevis
Origin: Body of pubis & inferior
pubic ramus
Insertion: Linea Aspera (upper 1/3)
Common actions: Hip adduction, weak hip flexion. Hamstring part of adductor magnus: Hip extension
Common innervation: Obturator nerve. Hamstring part of adductor magnus: tibial part of sciatic nerve
Lower Limb 1- Hip thigh and knee
Adductor Magnus
Origin:
Adductor part: Ischiopubic ramus
Hamstring part: Ischial tuberosity
Insertion:
Adductor part: Linea aspera & medial supracondylar line
Hamstring part: Adductor tubercle
Common actions: Hip adduction, weak hip flexion. Hamstring part of adductor magnus: Hip extension
Common innervation: Obturator nerve. Hamstring part of adductor magnus: tibial part of sciatic nerve
Lower Limb 1- Hip thigh and knee
Adductor Longus
Origin: Body of pubis
Insertion: Linea Aspera (middle 1/3)
Common actions: Hip adduction, weak hip flexion. Hamstring part of adductor magnus: Hip extension
Common innervation: Obturator nerve. Hamstring part of adductor magnus: tibial part of sciatic nerve
Upper Limb 1- Hip Thigh and Knee
What are the Hamstrings?
Upper Limb 1- Thigh Hip and Knee
Demonstrate the branches and divisions from the comon illiac to the femoral artery via the external
- Common Illiac
- External Illiac
- Femoral
Upper Limb 1- Thigh Hip and Knee
Demonstrate the branches and divisions from the comon illiac to the femoral artery via the internal
- Common Illiac
- Internal Illiac
- Superior Gluteal, Obturator, Inferior Gluteal
Upper Limb 1- Thigh Hip and Knee
What are the Nerve origins of the Hip?
- Lumbar Plexus: L1-L4
- Sacral Plexus: L4 to S3
- Lumbrosacral trunk
- Femoral (L2-4)
- Obturator (L2-4)
- Sciatic (L4 to S3)
*
Upper Limb 1- Thigh Hip and Knee
What are the boundaries of the Femoral Triangle?
Boundaries (SAILL)
Lateral: Sartorius
Medial: Adductor longus
Superior: Inguinal Ligament
Roof: Fascia lata
Floor: Iliopsoas & pectineus
Upper Limb 1- Thigh Hip and Knee
What are the contents of the Femoral Triangle?
Contents (NAVEL- from lateral to medial)
Femoral Nerve
Femoral Artery
Femoral Vein
Empty space
Deep inguinal Lymph nodes
Upper Limb 1- Thigh Hip and Knee
What is the adductor canal?
Passageway for structures moving between the anterior thigh and posterior leg
Femoral triangle to adductor hiatus
CLINICAL: Adductor Canal Block
Upper Limb 1- Thigh Hip and Knee
What does the adductor canal contain?
Femoral artery
Femoral vein
Nerve to the vastus medialis
Saphenous nerve
Upper Limb 1- Thigh Hip and Knee
What are the boundaries of the Adductor Canal?
Boundaries
Anteromedially: Sartorius
Laterally: Vastus medialis
Posteriorly: Adductor longus & magnus
Upper Limb 1- Thigh Hip and Knee
What is the Profunda Femoris Artery?
Supplies hip joint, A, P, M Thigh
Branches
**Lateral circumflex femoral
**Muscles of anterolateral thigh
**Medial circumflex femoral
**Head and neck of femur, muscles of the medial thigh
Anastomosis with lateral circumflex femoral
**Perforating arteries (3-4)
**Muscles of posterior thigh
Upper Limb 1- Thigh Hip and Knee
Label the branches of the Profunda femoris artery?
Upper Limb 1- Thigh Hip and Knee
What is the clinical significance of the profunda femoris artery?
Cruciate anastomosis
Allows alternative route when femoral artery is blocked
Upper Limb 1- Thigh Hip and Knee
CLINICAL: Neck of Femur Fracture
High mortality rate (30% at one year)
Retrograde arterial supply
Via retinacular arteries
Negligible supply from artery to head of femur in adults
Intracapsular NOF fracture can disrupt blood supply
Often causes avascular necrosis of the head
Requires joint replacement rather than fixation
Intertrochanteric fractures preserve the blood supply
Upper Limb 1- Thigh Hip and Knee
Obturator Nerve
Medial Thigh
Route: Lumbar pexus- through psoas major - obturator canal
Branches – surround adductor brevis
Anterior division
Posterior division
Supplies muscles of the medial compartment of the thigh
except hamstring part of adductor magnus (tibial part of sciatic)
Upper Limb 1- Thigh Hip and Knee
Sciatic Nerve
Posterior Thigh
Origin: lumbosacral plexus (L4-S3)
Tibial and common fibular components encased in fibrous sheath
Tibial component supplies Hamstrings and hamstring part of adductor magnus
Common fibular component supplies short head of biceps femoris
Divides at popliteal fossa
Tibial nerve
Common fibular nerve
Lateral towards neck of fibula
Upper Limb 1- Thigh Hip and Knee
The gluteal Nerves
All enter gluteal region via greater sciatic foramen
Superior Gluteal Nerve
Innervates gluteus medius, gluteus minimus, and tensor fasciae latae muscles.
Inferior Gluteal Nerve
Innervates gluteus maximus muscle.
Posterior Femoral Cutaneous nerve
Skin to posterior thigh, knee, & proximal leg
Nerve to quadratus femoris
Quadratus femoris & Gemellus inferior
Nerve to obturator internus
Obturator internus & Gemellus superior
Lower Limb 2: Leg, Ankle and Foot
Label the Tibia & Fibula
Lower Limb 2: Leg, Ankle and Foot
What are the key features of the Tibia?
Main weight-bearing leg bone
Articulates at knee and ankle joints
Lower Limb 2: Leg, Ankle and Foot
What are the key features of the fibula?
Non-weight bearing
Mainly a site for muscle attachment
Lower Limb 2: Leg, Ankle and Foot
There are X joints between tibia and fibula:
Proximal tibiofibular joint
Plane synovial joint
Distal tibiofibular joint
Syndesmosis (fibrous joint)
Interosseous membrane
Syndesmosis (fibrous joint)
Lower Limb 2: Leg, Ankle and Foot
The foot is divided into X sections
3 sections
Hindfoot 2 bones
Midfoot 5
Forefoot 3
Lower Limb 2: Leg, Ankle and Foot
Label the bones of foot
Tiger Cubs Need** MILC**
Talus (“‘ankle”)
Calcaneus (“heel, chalk”)
Navicular (“Boat”)
Medial cuneiform (“wedge”)
Intermediate cuneiform
Lateral cuneiform
Cuboid (“cube like”)
Lower Limb 2: Leg, Ankle and Foot
Label the bones of foot
Tiger Cubs Need** MILC**
Talus (“‘ankle”)
Calcaneus (“heel, chalk”)
Navicular (“Boat”)
Medial cuneiform (“wedge”)
Intermediate cuneiform
Lateral cuneiform
Cuboid (“cube like”)
Lower limb 2: leg, ankle, foot
Ankle Joint
Hinge synovial joint
Dorsiflexion/plantarflexion
Trochlear of talus with medial and lateral malleoli
Most stable in dorsiflexion
Talus wider anteriorly
Lower limb 2: leg, ankle, foot
Ligaments present in the ankle joint
Lateral
Anterior talofibular ligament (ATFL
Posterior talofibular ligament (PTFL)
Calcaneofibular ligament (CFL)
Medial
Deltoid ligament
4 parts which attach to talus, calcaneus and navicular bones
Anterior and posterior
Anterior tibiofibular
Posterior tibiofibular
Lower Limb 2: Leg, Ankle, Foot
Label the ankle
What are the Intertarsal joints?
Subtalar
Talus & calcaneus
Inversion and eversion
Talocalcaneonavicular (TCN)
Talus, calcaneus & navicular
Ball & socket type synovial joint
Gliding & rotation movements
Calcaneocuboid
Calcaneus & cuboid
Inversion and eversion
What are the Tarsometatarsal joint?
Cuboid, cuneiforms & metatarsals
There are X joints of the foot
Intertarsal 3
Tarsometatarsal 3
Metatarsophalangeal
Interphalangeal
There are X arches of the foot
3 arches
Medial longitudinal
Lateral longitudinal
Transverse
Supported by bones, ligaments and muscles.
**Acts as **shock absorbers & springs & increase flexibility
What is the support of the Longitudinal Arches
Dynamic support: Tibialis anterior, tibialis posterior, fibularis longus, flexor digitorum longus, flexor hallucis longus and the intrinsic foot muscles.
Passive support: Mainly by long and short plantar ligaments, spring ligament, plantar aponeurosis, and the shape of the bones.
What is the support of the Transverse Arch
Dynamic support: Fibularis longus, tibialis posterior
Passive support Wedge shaped metatarsals, cuneiform and cuboid bones, ligaments above & transverse metatarsal ligament
Lower limb 2: Foot, ankle, leg
Pes Planus
Flat footed
Loss of longitudinal arches
Normal under 2-3 years old
Causes: Hereditary, acquired or idiopathic. E.g. Trauma, ligament laxity, tibialis posterior dysfunction.
Lower limb 2: Foot, ankle, leg
Pes Cavus
High medial longitudinal arch
Reduced ability to absorb shock
Causes: Hereditary, acquired, or idiopathic. e.g. Charcot-Marie-Tooth disease
Lower limb 2: Foot, ankle, leg
Movements: Ankle
Dorsiflexion/Plantarflexion
Inversion /Eversion
Flexion/Extension (think toes)
Abduction /Adduction (think toes)
Lower Limb 2: foot, ankle, leg
Muscle groups of the lower Leg
Posterior compartment (7)
Anterior compartment (4)
Lateral compartment (2)
Lower Limb 2: Leg, foot, ankle
The posterior compartment of the leg contains
7 muscles
Superficial layer (3):Gastrocnemius, soleus, plantaris
Deep layer (4):Popliteus, tibialis posterior, flexor digitorum longus, flexor hallucis longus
Tibial nerve
Lower Limb 2: Leg, foot, ankle
The anterior compartment of the leg contains
4 muscles
Tibialis anterior, extensor digitorum longus, extensor hallucis longus, fibularis (peroneus) tertius
Deep fibular nerve
Lower Limb 2: Leg, foot, ankle
The lateral compartment of the leg contains
2 muscles
Fibularis Longus & fibularis brevis
Superficial fibular nerve
Lower Limb 2: Leg, foot, ankle
Muscle groups: Foot
Plantar aspect (10)
* 1st layer (3):
* 2nd layer (2):
* 3rd layer (3):
* 4th layer (2):
Dorsal aspect (2)
Lower Limb 2: Leg, foot, ankle
Plantar aspect of the foot contains
10 Muscles
1st layer (3): Abductor hallucis, flexor digitorum brevis, abductor digiti minimi
2nd layer (2): Quadratus plantae, lumbricals
3rd layer (3): Flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis
4th layer (2): Plantar interossei. dorsal interossei
Dorsal aspect of the foot contains
Extensor digitorum brevis & extensor hallucis brevis
Deep Fascia (Crural Fascia) of the Leg
Continuous with fascia lata
Interosseous membrane
Separates Anterior from posterior compartment
Anterior intermuscular septum
Separates anterior from lateral compartment
Posterior intermuscular septum
Separates lateral from posterior compartment
Transverse intermuscular septum
Separates superficial posterior from deep posterior compartment
Lower limb 2: leg, foot, ankle
Retinacula of the Ankle
Lower limb 2: leg, foot, ankle
Gastrocnemius
Superficial Posterior Compartment
Medial head: Medial femoral codyle
Lateral head: Lateral femoral condyle
Actions: Knee flexion & ankle plantarflexion (when knee is extended
Common Insertion: Calcaneus via calcaneal tendon
Common innervation: Tibial nerve
Lower limb 2: leg, foot, ankle
Plantaris
Superficial Posterior Compartment
Origin: Lateral supracondylar line of femur
Actions: Weak knee flexion & ankle plantarflexion
Common Insertion: Calcaneus via calcaneal tendon
Common innervation: Tibial nerve
Lower limb 2: leg, foot, ankle
Soleus
Superficial Posterior Compartment
Origin: Head of fibula & posterior tibial & fibula
Actions: Ankle plantarflexion in any position
Common Insertion: Calcaneus via calcaneal tendon
Common innervation: Tibial nerve
Lower limb 2: leg, foot, ankle
Popliteus
Deep Posterior Compartment
Origin: Lateral femoral condyle
Insertion: Posterior proximal tibia
Action: Laterally rotates femur & weakly flexes knee (unlocks locked knee)
Common innervation: Tibial nerve
Lower limb 2: leg, foot, ankle
Tibialis Posterior
Deep Posterior Compartment
Origin: Posterior tibia, fibula & interosseous membrane
Insertion: Mainly to the navicular & medial cuneiform
Action: Foot inversion, ankle plantarflexion & supports medial longitudinal arch
Common innervation: Tibial nerve
Lower limb 2: leg, foot, ankle
Flexor Digitorum Longus
Deep Posterior Compartment
Origin: Posterior tibia
Insertion: Distal phalanx of lateral 4 toes
Action: Weak ankle plantarflexion & flexion of lateral 4 toes
Common innervation: Tibial nerve
Lower limb 2: leg, foot, ankle
Flexor Hallucis Longus
Deep Posterior Compartment
Origin: Posterior fibula & interosseous membrane
Insertion: Distal phalanx of great toe
Action: Weak ankle plantarflexion & flexion of great toe
Common innervation: Tibial nerve
Lower Limb 2: Leg, ankle, foot
Tarsal Tunnel
Passage for structures to pass from posterior leg to the foot
Tunnel created by flexor retinaculum forming the roof
Contents: (From anterior to posterior)
Tom: Tibialis posterior
Dick: Flexor Digitorum longus
And: Posterior tibial Artery
Very: Posterior tibial Vein
Nervous: Tibial Nerve
Harry: Flexor Hallucis longus
Clinical: Tarsal tunnel syndrome
Lower Limb 2: Leg, ankle, foot
Extensor Digitorum Longus
Anterior Compartment
Origin: Fibula & lateral tibial condyle
Insertion: Middle & distal phalanges of lateral four toes (Via dorsal expansion)
Action: Ankle dorsiflexion & extension of lateral 4 toes
Common innervation: Deep fibular nerve
Lower Limb 2: Leg, ankle, foot
Tibialis Anterior
Anterior Compartment
Origin: Tibia & interosseous membrane
Insertion: Medial cuneiform & base of 1st metatarsal
Action: Ankle dorsiflexion & foot inversion
Common innervation: Deep fibular nerve
Lower Limb 2: Leg, ankle, foot
Fibularis Tertius
Anterior Compartment
Origin: Distal fibula
Insertion: Base of 5th metatarsal
Action: Ankle dorsiflexion & foot eversion
Common innervation: Deep fibular nerve
Lower Limb 2: Leg, ankle, foot
Extensor Hallucis Longus
Anterior Compartment
Origin: Fibula & interosseous membrane
Insertion: Distal phalanx of great toe
Action: Ankle dorsiflexion & extension of great toe
Common innervation: Deep fibular nerve
Lower Limb 2: Leg, ankle, foot
Fibularis Longus
Lateral Compartment
Origin: Fibular head and superior 2/3 of fibula
Insertion: Base of 1st metatarsal & medial cuneiform
Common Action: Foot eversion, weak ankle plantarflexion, & help support arches of foot
Common innervation: Superficial fibular nerve
Lower Limb 2: Leg, ankle, foot
Fibularis Brevis
Lateral Compartment
Origin: Inferior 2/3 of fibula
Insertion: Base of 5th metatarsal
Common Action: Foot eversion, weak ankle plantarflexion, & help support arches of foot
Common innervation: Superficial fibular nerve
Lower Limb 2: Leg, foot, ankle
Abductor Digiti Minimi
Plantar – 1st Layer
Insertion: Base of proximal phalanx of little toe
Action: Abduction and flexion of little toe
Innervation: Lateral plantar nerve
Lower Limb 2: Leg, foot, ankle
Flexor Digitorum Brevis
Plantar – 1st Layer
Insertion: Middle phalanges of lateral four toes
Action: Flexion of lateral four toes PIP joint
Innervation: Medial plantar nerve
Lower Limb 2: Leg, foot, ankle
Abductor Hallucis
Plantar – 1st Layer
Insertion: Base of proximal phalanx of great toe
Action: Abduction & flexion of great toe
Innervation: Medial plantar nerve
Lower Limb 2: Leg, foot, ankle
Lumricals
Plantar – 2nd Layer
Origin: Tendons of flexor digitorum longus
Insertion: Extensor hoods of lateral 4 toes
Action: Flexion of MTP joint & extension of IP joints
Innervation: Medial (1st) & Lateral (2nd, 3rd, 4th) plantar nerves
Lower Limb 2: Leg, foot, ankle
Quadratus Plantae
Plantar – 2nd Layer
Insertion: Lateral aspect of tendon of flexor digitorum longus (FDL)
Action: Assists FDL in flexion of lateral 4 toes
Innervation: Lateral plantar nerve
Lower Limb 2: Leg, foot, ankle
Flexor Digiti Minimi Brevis
Plantar – 3rd Layer
Insertion: Base of proximal phalanx of little toe
Action: Flexion of little toe
Innervation: Lateral plantar nerve
Lower Limb 2: Leg, foot, ankle
Adductor Hallucis
Platar- 3rd Layer
Insertion: Base of proximal phalanx of great toe
Action: Adduction of great toe
Innervation: Lateral plantar nerve
Transverse above oblique head
Lower Limb 2: Leg, foot, ankle
Flexor Hallucis Brevis
Plantar- 3rd layer
Insertion: Base of proximal phalanx of great toe (Sesamoid bones within tendons)
Action: Flexion of great toe
Innervation: Medial plantar nerve
Lower Limb 2: Leg, foot, ankle
Interossei
Plantar – 4th Layer
Origin: Metatarsals
Insertion: Base of proximal phalanx & extensor expansion
Actions: Plantar adduct, dorsal abduct from 2nd digit
Innervation: Lateral plantar nerve
3 plantar, 4 dorsal
Lower Limb 2: Leg, foot, ankle
Extensor Hallucis Brevis
Insertion: Base of proximal phalanx of great toe
Action: Extension of great toe
Common innervation: Deep fibular nerve
Lower Limb 2: Leg, foot, ankle
Extensor Digitorum Brevis
Insertion: Tendons of extensor digitorum longus (EDL)
Action: Assists EDL in extension of digits 2 to 4
Common innervation: Deep fibular nerve
Lower Limb 2: Leg, ankle, foot
Popliteal Fossa
Boundaries
Roof: Fascia and skin
Floor: Joint capsule, popliteus & posterior femur
Superomedial: Semimembranosus and semitendinosus
Superolateral: Biceps femoris
Inferomedial: Medial head of the gastrocnemius
Inferolateral: Lateral head of the gastrocnemius and plantaris
Lower Limb 2: Leg, ankle, foot
Popliteal Fossa Contents
Popliteal artery (pulse point)
Popliteal vein
Tibial nerve
Common fibular nerve
Lower Limb 2: Leg, ankle, foot
Venous drainage of LL: Deep veins
- Beneath the deep fascia.
- Accompany arteries and named the same
- Anterior tibial, posterior tibial and fibular veins unite to form the popliteal vein
Lower Limb 2: Leg, ankle, foot
Venous drainage of LL: Superficial veins
Great Saphenous
Originates medially from dorsal venous arch
Ascends medially - anterior to medial malleolus & posterior to medial femoral condyle
Pierces deep fascia at saphenous opening to drain into femoral vein
Short saphenous
Originates laterally from dorsal venous arch
Ascends posterior to lateral malleolus, lateral to calcaneal tendon, & in between the two heads of gastrocnemius
Pierces deep fascia to drain into popliteal vein
Lower Limb 2: Leg, ankle, foot
Popliteal Artery
- Begins as femoral artery passes through adductor hiatus
- Runs deep within popliteal fossa
- Passes between heads of gastrocnemius & through the tendinous arch of soleus
- Branches: Geniculate arteries supply the knee. Terminates as anterior and posterior tibial arteries
Lower Limb 2: Leg, ankle, foot
Posterior tibial Artery
- Give off fibular artery early in its course
- Descends inferomedially with tibial nerve through deep posterior compartment
- Passes through tarsal tunnel to reach the plantar aspect of the foot (pulse point)
- Branches: Fibular artery & Medial & lateral plantar arteries
*
Lower Limb 2: Leg, ankle, foot
Fibular Artery
- Branch of posterior tibial artery
- Descends inferiorly within posterior compartment on medial surface of the fibula
- Branches: Perforating branches to lateral compartment
*
Lower Limb 2: Leg, ankle, foot
Anterior tibial Artery
- Passes through aperture in interosseous membrane to reach anterior compartment of leg
- Runs inferiorly down the leg deep with deep fibular nerve
- Branches: Perforating branches to lateral compartment. Terminates as dorsalis pedis artery
*
Arteries of the Ankle & Foot
Dorsalis Pedis (4)
Medial Plantar (2)
Lateral plantar artery (3)
Lower Limb2 : leg, foot, ankle
Tibial Nerve
Same path as posterior tibial artery through deep posterior compartment
Supplies all posterior compartment muscles
Gives off calcaneal branches to skin of heel
Passes through tarsal tunnel and divides into:
Medial plantar
Runs medially with medial plantar artery
Motor innervation to abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, & the 1st lumbrical
Cutaneous innervation to medial sole, and medial 3 ½ digits
Lateral plantar
Runs laterally with lateral plantar artery
Divides into superficial and deep branches
Motor innervation to the rest of the intrinsic muscles of the foot
Cutaneous innervation to lateral sole, and later 1 ½ digits
Lower Limb2: leg, foot, ankle
Common Fibula Nerve
Runs deep to fibularis longus and divides at the neck of fibula into:
Superficial fibular
Runs deep to fibularis longus within lateral compartment
Pierces deep fascia to become cutaneous
Motor innervation to lateral compartment
Cutaneous innervation to distal anterolateral leg and most of dorsum of foot
Deep fibular
Wraps around neck of fibula to reach anterior compartment
Runs inferiorly with anterior tibial artery
Passes under extensor retinaculum
Motor innervation to anterior compartment and dorsal foot muscles
Cutaneous innervation to first interdigital cleft
Lower Limb2: leg, foot, ankle
Other Cutaneous Nerves
Back and Vertebral Column
Osteology of spine
33 vertebrae – Base of cranium to apex of coccyx
Bony framework of trunk
5 regions
Cervical (7)
Thoracic (12)
Lumbar (5)
Sacral (5 fused)
Coccygeal (4 fused)
Back and Vertebral Column
Functions of the vertebral column
Protection
Support
Movement
Flexibility
Site of muscle attachment
Haematopoiesis
Back and Vertebral Column
There are X curvatures in the adult spine
FOUR
Cervical lordosis
Thoracic kyphosis (primary)
Lumbar lordosis
Sacrococcygeal kyphosis (primary)
The primary curvatures are retained from the C shaped fetal curvature
The others develop after birth whe lifting head and walkig
Back and Vertebral column
Label the following
Back and Vertebral column
Label the cervical veretbrae
Back and Vertebral Column
Label the thoracic vertebrae
Back and Vertebral Column
Label the lumbar vertebrae
Back and Vertebral column
Compare the vertebrae
Back and Vertebral Column
What is Atlas and Axis?
No vertebral body or spinous process
Back and vertebral column
What is the sacrum?
Back and Vertebral column
What is the coccyx?
Back and Vertebral column
Hyperkyphosis
Common cause: Osteoporosis and subsequent fractures
Reduce load through anterior body
Ant. wedge fractures
Hyperlordosis
Common causes: Muscle weakness, poor posture, Obesity and pregnancy
Scoliosis
Occurs in 3% of people
4:1 F:M ratio
Most prevalent between 10-20 years
Cause usually unknown (65% idiopathic)
Adductor Magnus Innervation
AM SO!
Adductor Magnus is innervated by Sciatic and Obturator
Popliteal Fossa Muscle Arrangement
The two semi’s go together
M for Medial
Tendonous on Top
SO:
Semi membranous and semi tendonous are medial
Biceps Femoris is latera.
Psoas Major Innervation
l2,3,4
Psoas Major gets Sore
Obturator Canal
Whos at the top?
Obviously Not A Vein
Obturator
Nerve
Artery
Vein
Femoral Artery Deep Branches
Put My Leg Down PLease
Profundus femoris
Medial circumflex
Lateral circumfles
Descending genicular
Perforating
Femoral Triangle
NAVEL
Nerve, Artery, Vein, Empty, Lymphatics
Hip Lateral Rotator
Piece Goods Often Go On Quilts
Piriformis
Gemellus superior
Obturator internus
Gemellus inferior
Obturator externus
Quadratus femoris
Branches of Internal Illiac Artery
I Love Going Places In My Very Own Underwear
Illeolumbar
Lateral sacral
Gluteal
Pudendal
Inferior vesicle (uterine in female)
Middle rectal
Obturator
Umbilical
Cruicate Ligament
PAMs APpLes
Posterior [passes] Anterior [inserts] Medially
Anterior [passes] Posterior [inserts] Laterally
Femoral Triangle
NAVY
Nerve Artery Vein Y of Groin
Femoral Triangle Boundaries
So I May Always Love Sally
Superior: Inguinal lig
Medial: Adduct longus
Lateral: Sartorius
Lumbar plexus roots
2:1
2:2
2:3
I Have Got Less Opportunities For Learning
Illioinguinal, Illiohypogastric (L1)
Genitofemoral (L1,L2), Lateral femoral (L2,L3£
Obturator (2,3,4) Femoral (2,3,4)
L= Lumbar Plexus
Medial Malleolus
Tom Dick And Nervous Harry
Tibialis, Digitorum, Artery, Nerve, Hallicus
Internal Illiac Artery
PILS
Posterior Branch
Iliolumbar
Lateral Sacral
Superior gluteal
Muscle function of soles and gastrocnemius
Stand on Sole. Explosive Gas
Soleus for posture
Explosive movements for Gastrocnemius
Potentially Absent Muscles
5 P
Palmer’s Longus
Plantaris
Peroneus tertius
Pyramidalis
Psoas minor
Inversion vs Eversion
E for Eversion
Perineus longue, brevis, terrils
I for Inversion
Tibialis anterior, posterior
Anterior muscles of the leg
The Hospitals Are Not Dirty Places
Tibialis anterior
Hallucis longus (extensor)
anterior tibial Artery
deep fibular Nerve
Digitorum longus (extensor)
Petronius tertius
Innervation of Thigh
MAP OF SCIATIC
M Obturator
A Femoral
P SCIATIC
Medial Tibial muscle
Girl between Two Strangers
Gracilus between Sartotius and Semitendonous
Popliteal Fossa Arrangement
Serve And Volley Next Ball
Semimembranous/ tendinour
Artery
Vein
Nerve
Biceps Femoris
Tarsal Tunnel
Tiny Dogs Are Not Hunters
Tibialis posterior
flex Digitorum longus
Artery
Nerve
flex Hallucis longus
Walls of the Inguinal Canal
2MALT
Muscles (Superior:) : internal oblique, transverse abdominius
Anterior: 2 Aponeuroses
Lower: 2 Ligaments
Posterior : Transversalis fascia and Tendon
Rotator Cuff
SItS
Supraspinatus
Infraspinatus
teres minor
Suprascapular
Thenar and Hypothenar
Hypothenar - digits minimise
Thenar- Pollicis (brevics)
OAF
Opponens
Adductor
Flexor
What innervates serrates anterior?
SALT
Serratus Anterior
Long Thoracic
Median Nerve Supply of Hand
LOAF
Lumbricals
Opponens
Abductor Pol brev
Flexor Pol
Upper Limb: Arm Muscle
‘Rule of 3s’ and ‘Busy Bees CollaBorate well’
3 in flexor compartment of arm: biceps, brachialis, coracobrachialis
3 in extensor compartment of arm: 3 heads of triceps (long, medial, lateral)
