Anatomy

quadratus femoris

originates from the ischial tuberosity and inserts on the deep surface of the greater trochanters

zona orbicularis

orbicular zone and helps the other ligaments surround the neck of the femur, circular fibers deep to other ligaments, helps hold the femoral head in place

Lumbar plexus

ordered intermingling of the vental primary rami of spinal nerves that come together to form a biger nerve Lateral femoral cutaneous nerve (L2, L3)- sensory cutaneous fibers Femoral nerve (L2-L4) obturator nerve (L2-l4)

sartorius

originates at the ASIS and connects to the medial condyle tibia

Inversion Ankle Sprain

inversion ankle sprain that involves the anteriotalofibular ligament between the talus and the fibula of the leg

Central Nervous System

the brain an spinal cord, covered by the meninges and has three layers that form the boundary between CNS and PNS

Nerve supply to the knee

1. Anterior - proximal- femoral n. -distal- common (deep) fibular nerve 2. Posterior -tibial n 3. Lateral -common (superficial) fibular n 4. Medial -obturator n -saphenous n

transverso-spinalis

three layers: semispinalis- it runs about half of the spine multifidius- becomes thicker as you go down into the pelvis rotatores All: originate on the transverse processes insert on spines of vertebrae above Action: extend trunk in a bilateral action, rotate unilaterally, stabilize vertebral column Note: orientation of muscle fibers: ransversospinalis are angled up and towards spines; erector spinae are parallel to vertebral column innervated by dorsal primary rami

Posterior Sag Sign

tibia is posteriorly displaced, if quadriceps are compensating and this cannot be see, perform a postertio drawer test

epimere

true muscles of the back, innervated by dorsal primary rami

hypomere

ventral muscles, innervated by ventral primary rami

Typical Spinal Nerve

*Grey matter* contains neuron cell bodies, dendrites and axons and is divided into: -posterior dorsal horns -anterior ventral horns -lateral horns (only found in the thoracis and lumbar regions *White matter* contains myelinated axons, three columns of funiculi: ventral, dorsal and lateral and each of these are divided into sensory or motor tracts The ventral and dorsal roots join to form a short spinal nerve -the spinal nerve then immediately divides into: small dorsal primary ramus ( supplies the true back muscles as well as sensation along the skin of the back) and a larger ventral primary ramus (supplies everything else and forms the plexuses and the thoracic/ inner costal nerves in the thorax) *dorsal and ventral primary rami are mixed nerves, containing motor and sensory fibers* Dorsal root ganglia: where the cell bodies of the sensory nerves reside in the PNS right before the dorsal roots insert into the horn, this is before the short section that is the spinal nerve cluneal nerves are derived from dorsal primary rami

Anterior Compartment of the Leg

*Muscle:* 1. Tibialis Anterior 2. Extensor Digitorum Longus 3. Extensor Hallicus Longus 4. Peroneus Tertius *Origin:* Tibialis Anterior: Lateral condyle and superior lateral tibia and interosseous membrane extensor digitorum longus: lateral tibial condyle, superior medial fibula, interosseous membrane extensor hallucis longus: fibula and interosseous membrane peroneus tertius: distal fibula and interosseous membrane, muscle belly usually combines with the flexor digitorum longus, usually just see a fifth tendon coming from the digitorum that inserts ont he shaft of the fifth metatarsal *Insertion:* Tibialis Anterior: Medial cuneiform and 1st metatarsal Extensor Digitorum Longus: Middle and distal phalanges (2-5) Extensor Hallucis Longus: Distal phalanx of great toe Peroneus Tertius: 5th metatarsal *Innervation:* Deep Peroneal Nerve (L4/L5) *Main Action* Tibialis Anterior: Dorsiflexes ankle, inverts foot Extensor Digitorum Longus: Extends lateral four digits; dorsiflexes ankle Extensor Hallucis longus: extends great toes; dorsiflex ankle peroneus tertius: dorsiflex ankle, everts foot all cross the ankle joint anteriorly, so they participate in dorsiflexion *all of these muscles and tendons are held down by a superior and inferior extensor retinaculum Blood Supply: Anterior Tibial Artery *perforating branch of fibular artery: provides anastomosis around the ankle joint Deep peroneal and anterior tibial artery pass under the extensor retinaculum and run parallel to the extensor halliculs longus tendon, once the anterior tibial artery crosses into the foot, it beceomes the *dorsalis pedis artery* *leg is drained by great and small saphenous vein

Deep Posterior Compartment

*Muscles:* 1. Popliteus 2. Flexor Hallicus 3. Flexor digitorum longus 4. Tibialis Posterior *Origin:* popliteus: lateral surface of later condyle of femus and lateral meniscus flexor hallucis: inferior 2/3 of posterior fibula; inferior posterior interosseous membrane flexor digitorum: medial part of posterior tibia inferior soleal line tibialis posterior: interosseous membrane; posterior tibia inferior to soleal line; posterior fibula *Insertion:* popliteus: posterior tibia, superior to soleal line flexor hallicus: plantar surface base of distal phalanx of great toe (1, hallux) flexor digitorum: base of distal phalanges 2-5 tibialis posterior: tuberosity of navicular, cuneiform, cuboid and sustentaculum tail; bases of 2, 3, 4 metatarsals, crosses down to our medial malleolus to go into the foot *Innervation:* popliteus: tibial nerve (L4, L5, S1) flexors: tibial nerve (S2, S3) Tibialis posterior (L4, L5) *Main Action* Popliteus: weakly flexes knee and unlocks it by rotating it 5 degrees on fixed tibia when in the extended position flexor hallucis: flexes great toe; week plantarflex; supports longitudinal arch flexor digitorum: flexes lateral four digits of toes; plantarflex foot; supports longitudinal arch tibialis posterior: plantar flex ankle; inverts foot all the muscles are innervated by the tibial nerve Tom, Dick ANd, Harry went around the medial malleolus tibial nerve: gets to the foot and bifrucates into the lateral (last two toes) and medial (first three toes) plantar nerves

Lateral Compartment of the Leg

*Muscles:* 1. Peroneus Longus 2. Peroneus Brevis *Origin* Longus: superior 2/3 of the lateral fibula Brevis: inferior 2/3 of the lateral fibula *Insertion* longus: 1st metatarsal and medial (first) cuneiform by wrapping down below the long plantar ligament on the base of the foot brevis: 5th metatarsal tuberosity *Innervation* superficial peroneal nerve (L5, S1, S2) - does sensory of 2-5 *Main Action* Everts foot (lifting lateral part of the foot off of the floor or pronation); weak plantarflexion common peroneal wraps around the head of the fibula, it is very exposed and is a common site of injury during blows to the side of the knee and can cause peristesia (foot drop if the deep peroneal is damaged)

Functional Division of the Nervous System

*Somatic*: voluntary, monitor and regulate skeletal muscle and skin sensation -General somatic afferent (GSA or sensory), General somatic efferent (GSE or motor) *Autonomic*: involuntary, monitors and controls visceral function and is subdivided into: sympathetic (fight or flight) and parasympathetic (rest and digest) -General visceral afferent (GVA or sensory) dorsal root ganglion -General visceral efferent (GVE) brain nuclei, intermediolateral cell column (sympathetic nervous system preganglionic cell bodies located from T1- L2/L3)

serratus posterior

*muscle have very thin aponeurosis* superior: originates on vertebrae (cervical and upper thoracic spines) inserts onto ribs raises ribs in inspiration (?) inferior: originates on vertebrae lumbar and lower thoracic spines; inserts onto ribs lowers ribs in expiration (?) Innervation: both muscels by Intercostal nerves (T1, T2, T10/11) *shown in picture is inferior

patella (knee cap)

- 6-sided bone that is relatively smooth on its anterior surface and on the posterior surface is rougher. It sits in the middle of the medial and lateral condyles on the anterior portion of the knee joint and helps to protect the knee joint. The quadriceps tendon passes over it, becomes the patellar ligament, and extends downward past the knee joint and attaches to a boney prominence on the tibia called the tibial tuberosity -puts the action of the quadriceps tendon and the patellar ligament (which is a continuation of the quadriceps tendon) farther away from the axis of rotation of the knee joint increasing its ability to extend the leg at the knee joint

Sacral Spine

- five sacral vertebrae are fused together, anteior surface is smooth and have transverse ridges that represent fusion sites, there are also, foramena that give rise to the ventral primary rami that will form plexuses that give rise to femoral or sciatic sacral promontory- this to the pubic symphysis is the shortest fixed distance in the pelvis, this distance is measured to see if a babies head will fit during childbirth POSTERIOR: median sacral crest: represents the fusion of the spinous processes lateral sacral crest: represents the fusion of the transverse sacral processes sacral hiatus: represents a defect in the fusion of the sacral hiatus cornua of sacral hiatus: seen as horns but are palpable structures that can be used to locate the sacral hiatus, through which you can administer an epidural to block the sacral nerves (caudal epidural nerve block)

Thoracic Vertebrae

- have little facets on the vertebral body and on the transverse processes that are not on the lumbar vertebrae for the attachement of the ribs superior costal facet of verbral body: attaches to head of the rib transverse costal facet- connects to tubercle of the rib intervertebral facets: orienteed in coronal plane that facilitates movement from side to side along an arch that is centered on the vertebral body--- rotation of vertebrate, but no flexion or extension *ligaments support the ribs and bind them together to the vertebrate

anterior cruciate ligament (ACL)

- runs from anterior interarticular area of the tibia to medial surface of the lateral femoral condyle *in extension (weight-bearing position), the ACL prevents posterior movement of femoral condyles on tibial plateau *in flexion (non-weight bearing), the ACL prevents anterior movement of the tibia *ACL rupture is 10 times more common than PCL rupture- ACL is the only thing supporting during flexion (weight and force centered on the knee with a rotation) * Commonly occurs from rotation of femur with the leg fixed or a lateral blow to the knee in extension -Females are 2-8 times more likely than males to sustain an ACL injury

Knee dislocation

- whole knee is dislocated and becase the popliteal artery is tethered at both the adductor hiatus and the soleus, the artery is sheared and there is blood flowing into the compartments -if it is not fixed withing 6 hours, the leg will begin necrosis.

Vertebral Column

-30-33 Vertebrae -7 cervical -12 thoracis -5 lumbar -5 sacral -a few coccygeal Axial skeleton- vertebral column, skull and ribcage appendicular skeleton- represents the bones of the freely moving upper and lower limbs

Routes of Ingress

-Cells that ingress come from specific parts of the epiblast- fate map -Cells that ingress follow stereotyped routes anterio-lateral cells to the node: become the definitive ectoderm near node AND groove form definitive endoderm further back and laterally form the mesoderm. For the mesoderm, there are different routes of ingress throught the primative streak complex: 1. midline: axial mesoderm (notochordal process) 2. side of midline: para-axial mesoderm 3. semi-lateral: intermediate mesoderm 4. lateral: lateral plate mesoderm will migrate around the amnionic cavity and also around the yolk sac and the extra-embryonic mesoderm; these will become part of the linings the viscera and the body wall cavity *eventually you have the neural plate forming on top

Hip Joint Summary

-Connection between lower limb and pelvic girdle -strong and stable multi-axial ball and socket synovial joint -2nd most mobile joint inthe body, but also designed for stability over a wide range of motion have both flexion and extension, abbuction and adduction, medial and lateral rotation, circumduction with is a combination of all of the movements triradiate cartilage- y-shaped cartilage in between the acetabulum, fusion occurs in puberty, and ossification occurs when we are 25 Lunate surface- smooth acetabular fossa- no articulation with femur but covered with a fat pad acetabular notch has articular cartilage and acetabular labrum on the side which helps to increase the size of the acetabulum by 10% and enclose 2/3 of the head of the femor inside of the socket, at the bottom is a transverse acetabular ligament that runs between the articular cartilage on the inferior part and coming from this is the ligament of the head of the femur. On the outside are the fibrous joint capsules fovea of the head of the femur has a ligament that attaches tot he transverse acetabular ligament.

Formation and Migration of Neural Crest

-Neural crest forms by the delamination of neuroectoderm at lateral margins of neural plate -Crest forms along the length of the neural tube up tothe rostral end of the brainstem -at the point where you been to elaborate the the forebrain or cerebral corteces of the neural tube neural crest: cells begining the migrate between the somite and ectoderm, they then have the ability to move throughout the body. This process is akin to metastases of a cancer (same genes and epithelial to mesachymal transfer) can migrate laterally (form the melanocytes of the skin), or ventrally between the somite and the neural tube (dorsal root ganglia or sympathetic chain ganglion, chromafin cells of adrenal medella, and the enteric ganglia in the gut) -these cells receive signals based on the location that they migrate

Early Development of the NS

-Neurulation: formation of the nueral tube -Regionalization: of the tube, specializaiton ofthe tube (cranial and caudal part) -Neurogenesis: generation of neuron and glial cell elements -nerural crest migration and differention: only found in vertebrates, forms the head (cephalization) -axon outgrowth and targeting: establishment of axon function

Paraxial Mesoderm

-Situated just lateral to notochord -will give rise to axial skeleton and ribs, its voluntary musculature and dermis -sits as a bar, then starts to break up to become a really tight ball of cells that are also attached to the intermediate mesoderm -formation of somitomeres (musclulature of the face, jaw and throat and then somites (compact balls bones, ve) from the solid rod of paraxial mesoderm that extends up through the head area; somite begin at the eventual location of the posterior skull and their formation proceeds caudally 7 somitomeres form and contribute the musculature of the head and neck area, coelesque at the head and neck region and never form into an epithelial somite somites (head and neck region): contribute to the base of the skull and can contribute to the musculature of the tung and the extra-occular muscles inferior somitomeres will eventually form into epithelial somite

Hip Joint Capsule

-Synovial membrane: head of femur at margin of articular cartilage at the margin of acetabulum; folds down and around itself so it does not stretcha as well move, has retinacular folds for the blood supply for the head and neck of the femur, on the inside Fibrous capsule: acetabulum (superficial to synovial membrane) and intertrochanteric line and greater trochanter, reinforces and strengthens the joint weak spots: anterior just between the iliofemoral and pubofemoral there is a weak spor and posteriorly just above the ischiofemoral ligament posterior is most common hip displacement when the femur is flexed and adducted usually in a car accident situation, most common nerve affected is the sciatic nerve, when this happens we can also damage the medial circumflex artery (acetabular artery stemming from the obturator artery in developing children) *obturator artery passes through the ligamentum capitus femoris while the medial and lateral circumflex ONLY supply blood

Intervertebral Joints

-The intervertebral joints are 3- part joints- between the 2 pairs of facets and between the vertebral bodies and IV disks *joints are synovial and can become inflammed* -foramena can be narrowed by the formation of bone on the facet joints and can impinge on the nerve roots coming out into the periphery IV disk: fulcrum for motion

Gluteal Region

-area lateral and posterior to hip (buttocks) -contains muscles which extend, laterally rotate, medially rotate, abduct and stabilize femur at hip -supplied by branches of lumbo-sarcal plexus of nerves -originates on the boney pelvis and inserts in the femur

Tarsometatarsal Joint

-articulations between cuneiforms and metatarsals 1-3 -cuboid and metatarsals 4 and 5 -when metatarsals are displaced, this causes the Lisfranc injury

Hip Joint Fractures

-at femoral neck or intertrochanteric line in individuals over 60 and females or from high impact events in younger individuals replacements can cause damage to medial circumflex leading to avascular necrosis which is also associated with neurovascular disease

Hip Joint

-ball and socket joint, there is a depression called the acetabulum where the illium, ischium and pubis come together and the ball is the head of the femur, which is the longest bone in the body, a single bone of the thigh - head of femur rotates freely inside of the acetabulum allowing for flexion/extension, abduction /abduction and around the long axis of the femur calling for lateral and medial rotation -hip bone: not a complete socket and is deficient in the bottom and have a space for an artery to supply the head of the femur with blood and nutrient; in early life the three bone (ischium, illium and pubis) are not fused together, they form a tri-radiate cartilage (y-shaped epiphyseal plate), at the age ot 12/14, the cartilage begins to become osefied and at the age of 24/25 it becomes solid bone -obturator foramen is the circular cavity located under the acetabulum

Posterior Thigh

-contains hamstrings that extend thigh and flex leg at knee -supplied by tibial division of the sciatic nerve -originates bony pelvis and inserts in the leg (tibia or fibula)

cervical spine

-distinguished by openings or foramena in their transverse processes which transmit the vertebral arteries from the root of the neck all the way to the base of the skull. Invertebral facets are relatively flat and oriented horizontally, allowing rotation, flexion, extension and lateral bending of the cervical vertebral column Atlas (C1): large ring shaped bone without a vertebral body. This space is present so that the dens of the C2 can project and provide a pivot point around which the atlas and the skull together can rotate as a unit Axis (C2):

Gastrulation

-establishes 3 definitive germ layers (ectoderm, mesoderm and endoderm) in the trilaminar germ disc -all tissues of the body will derive from the three germ layers -Establishes the body plan and the 3 axes: cranial caudal, dorsal-ventral, right-left

Spinal cord

-extends from foramen magnum to second lumbar vertebra -segmented: -8 cervical -12 thoracic -5 lumbar -5 sacral -1 coccygeal 31 nerves in total Connected to 31 pairs of spinal nerves: all are mixed nerves and contain both sensory and motor fibers -they are not uniform in diameter throughout the length of the spinal cord *cervical enlargement*: supplies upper limbs, nerves coming over the ventral rami form plexuses such as the brachial plexus that supplies structures in the upper limb, cervical plexus supplies things in our head *lumbar enlargement*: supplies lower limbs, femoral nerve and sciatic nerve plexuses from the ventral primary rami -conus medullaris: tapered inferior end, at L1/L2 -the dural sac extends down to the S2 vertebral level: the meninges enclosing the spinal cord -cauda equina: origins of spinal nerves extending inferiorly from lumbosacral enlargement and conus medullaris after it has ended, these nerves come down because during development, the spinal cord did not lengthen as long as the body itself, so the lower nerves have to descend some distance before the exit through the lower foramena Covered by meninges: 1. dura mater- outside 2. arachnoid mater- middle 3. pia mater- inside Spaces: 1. epidural 2. subdural- between the dura and arachnoid *3. subarachnoid (containing CSF)* Lumbarcistern- the fusion of the arachnoid and dura mater; contains CSF starts around L3, subarachnoid space within the dural sac in the lower lumbar Filum terminale: runs from the conus medullaris through the cistern all the way toe the coccyx, vestige of the primative spinal cord, inside of lumbar cistern the filum terminale is covered in pia mater, as it leaves its covered by dura mater. It serves the anchor the lower part of the spinal cord.

Medial and Lateral Meniscus

-fibrocartilage disks that sit on the tibeal plateau -thicker on their lateral sides where they're attached to joint capsul -medial is "c-shaped" -lateral is almost circular MOI- sudden extension or rotation of the femur while the tibia is fixed *usually occurs in Medial meniscus because the MCL is more fixed to the capsule and can pull at the meniscus 1. bucket handle tear 2. Radial tear poor vascularization so hard to heal

Potts Fracture

-forced eversion causes the strong deltoid ligament to avulse the medial malleolus -the talus then moves laterally shearing off the lateral melleolus -trimalleolar fracture can also occur if the posterior margin of the tibia is sheared off *bimalleolar fracture due to forced eversion of the foot

lumbosacral angle

-formed at the L5 vertebrate and forms a see-saw for the weight of the body, controlling the direction of movement sacrum

Neural Crest Derivatives

-head and neck (cranial): ears up -trunk - what is formed is generally determined by where it is coming from in the body, somethings form specficially from the cranial neural crest which is anterior to the otic placode otic placode (gives rise to structures in the inner ear): key landmark for neural crest cell fate trunk neural crest: dorsal root ganglia and autonomic ganglia at the level of the trunk certain derivatives in common between cranial and trunk neural crest: schwann cells, glial cells, melanocytes, meninges, enteric ganglia, found in all levels and formed by all levels of the neural crest

Ilium Structure

-iliac crest- maker from the L4 lumbar vertebrae -iliac fossa- attached to the illiacus muscle that is one of the thigh muscles that helps to flex the muscle at the hip joint -anterior superior iliac spine, bone prominence on the iliac crest and is connected to the pubic tubercle by the *inguinal ligament* that connects two or more bones- forms of the roof of the passage from inside of the pelvis to the outside of the thigh region (femoral nerve, artery and vein passes underneath the inguinal ligament from the lower abdomen to the upper thigh), also attaches to the sartorious muscle -iliac tubercle- located posterior to the ASIS inguinal ligament is the lower free edge of the aponeurosis (the flat, broad tendon) of the external oblique muscle where the oblique muscle meets tendon anterior inferior iliac spine- connects to the rectus femoris of the quadriceps and extends down to the anterior thigh, extends and the hip and also at the knee posterior superios iliac spine- posterior inferior iliac spine- greater sciatic notch- the dip formed anterior to the PIIS ischial spine- superior spine of the ischium lesser sciatic notch- the dip formed inferior to the ischial spine i

Primitive steak complex

-key hole like structure in the middle of the buccopharyngeal membrane (mouth) and the cloacal membrane (anus) - primitive pit, node and groove *groove is where invagination occurs for streak to move between the epi- and hypoblast *forms at beginning of 3rd week in epiblast and is the portal for ingressing cells of epiblast* epiblast are cells that are isolated to form embryonic stem cells

Lumbar vertebrae

-largests of the vertebrae because they have to support more weight than the other vertebrae In the lumbar region, articular processes are oriented in a sagittal plane- facilitating flexion/ extension and lateral bending, but not rotation because they are locked together 1. vertebral body is massive 2. posterior arch connected to spinous process 3. vertebral body to posterior arch are connected by pedicles 4. Flat portions between the articular processes and the spinous processes are the lamina 5. Vertebral canal has spinal cord and meninges 6. transverse processes are points of attachment for muscles that act on the vertebrate and allow motion (extension, lateral bending or rotation) 7. Vertebral foramena are where the spinal nerve pass to go out into the periphery 8. Spaces are intervertebral disks made of cartilage so they do not show up on a radiograph

Femur

-longest bone in the body that consists of (from top to bottom) a rounded head, a neck, a long shaft, and two condyles (knuckle-like projections), on top of the medial condyles are the adductor tubercles -between the neck and shaft there is the greater trochanter (projects upward and attaches the abductor muscle and gluteal region) and a lower trochanter (projects medially/posteriorly and connects to the illiopsoas tendon the main muscle tendon involved in flexing the thigh), the greater and lesser trochanter are connected by the intertrochanteric line -anterior surface is smooth, but the posterior side has a rough line of bone called *linea aspera* and divides the posterior bone the medial and lateral lip and is the connector for the medial muscles that are coming from the pubis and is responsible for adduction main blood supplies is the medial femoral circumflex

Neurogenesis

-neural tube after it is formed is lined by a neural epithelium which is a pseudostratified epithelium, cells then begin to take residence outside as time proceed and become the post mitotic neurons of the spinal cord *ventral level becomes: lateral motor neurons, motor complex, ventral horn of the spinal cord -neurons from glia of PNS and CNS come from different sources: CNS from neural tube, much of PNS from neural crest (dorsal root ganglia) radioglia (neuroepithelial cells)- span the width of the tube and nucleus bobs up and down in a process called interkinetic nuclear migration, mitosis occurs inte inside of the tube near the neural canal, after these cells cease mitosis will begin to migrate out to take residence as neurons or glial cells -process ends with the formation of the lining ofthe neural canal, and the creation of other nearby cells

Disorders of Neural Crest Development

-neurocristopathies *diGeorge syndron (velocardofacial syndrome): thymic hypoplasia, great cardial vessel abnormalities (thoracic aorta), thyroid and parathyroid abnormalities, facial dysmorphogenesis, -Due to deletion and haploinsufficiency of chromosomal region 22q11.2 Sipple syndrome- multiple endocrine neoplasia type IIa

Pubofemoral ligament

-orginates athe the pubic bone and inserts in the iliofemoral ligament and prevents overabduction

iliofemoral ligament

-originates from the anterior inferior iliac spine and goes to the intertrochanteric line and is the bodies strongest ligament, it prevents hyperextension and anterior displacement, it is the strongest because the anterior muscles are weaker

Rotators- Walking

-pelvis gets advanced by rotating it slightly laterally to the left side, calling for a medial rotation of the femur and foot to move the foot forward, but to keep the foot straight, there is a need for muscles that laterally rotate the femur at the hip joint medial- tensor of fascia lata, gluteus minimus, gluteus medius (anterior fibers) lateral- quadratus femoris, gluteus maximus, piriformis , triceps coxae, obturator internus, obturator externus, sartorius *smaller muscles (all excluding gluteus maximus) attach at the greater trochanter

Level of origin and crest cell fate

-pre-otic: ectomesenchyme of head and neck; sensory and parasympathetic ganglia of head and neck -vagal (post-otic)- sensory and parasympathetic of head and neck; enteric ganglia, ectomesenchyme of head and neck, great vessels -cervical and thoracic- sympathetic ganglia and DRGs; adrenal medual at thoracic levels -lumbosacral- sympathetic ganglia and DRGs, parasympathetic ganglia, enteric NS in distal colong - all levels: glia of PNS, meninges, pigment cells

Meninges

-primary function to protect the CNS end right at a point where the dorsal root ganglia or sitting surgeons should cut distally to the dorsal root ganglion to avoid spillage of CSF Layers Deep- Superficial: 1. Cord 2. Pia Mater CT 3. Subarachnoid space- CSF is in this space 4. arachnoid mater CT 5. Subdural space- usually does not exist because the CSF pushes the arachnoid space to the dura mater 6. Dura mater CT- very tough 7. Epidural space- where you inject anesthesia, it would bathe the nerve roots as they come out 8. Vertabra

Regionalization

-process of specifying the distinct AP identify (shape, etc.) of the parts of the body -Hox genes: DNA-binding transcription factors; 4 clusters, anterio-posterior expression reflection position in gene cluster (genes at 3' end are for anterior embryo), overlapping and shifting patters of expression (originally discovered in fruit fly, antennapedia) -every one single section of the body has a single set of genes

Roles of the Spine

-protects the spinal cord -supports weight of the head -provides a partially rigid and flexible axis for the body -plays a role in posture and locomotion ROM of Spine Cervical -flexion -extension -lateral bending -rotation Lumbar -flexion -extension -lateral bending Thoracic -rotation Limitations -Thickness, elasticity and compressibility of IV disks -shape of facet joints between adjacent vertebrae -resistance of back muscle and ligaments -bulk of surrounding tissue * normal posture depends on balance of forces between back and abdominal muscles

Early axon outgrowth and branching

-rootlets extend continously along cord. -funneled into roots by rostral sclerotome- a permissive substrate for axon growth *dosral vs. ventral primary rami- when myotome splits into epimere and hypomere, the rami go with it

Midline or Axial Mesoderm

-signals produced by the primitive noder and other structures regulate the differentiation of surrounding tissue -cells migrating through the primitive pit remain in the midline. The first ones migrate cranially to form the prechordal plate and later ones form the notochord as the streak regresses caudally. prechordal plate: remain somewhat disorganized in the midline for the induction of the structures of the head and neck nodochordal process: forms everything else * these layers will release factors that change the overlying ectoderm and change it to the neuro-ectoderm

Surface Anatomy

-skin covers the quadriceps muscle and the sartorious palpable structures: -ASIS, pubic tubercle, patella, condyles of femur and tibia, and tibial tuberosity -vasti and satorius muscles and abductors -will see the great saphonous vein that runs up the medial thigh and disappears through an opening in the fascia lata ( deep fascia that surrounds all the muscle in the thigh region) -see some cutaneous nerves that are branches from the femoral nerve that provide sensation in the skin of the femoral thigh -removing the fascia lata and the superficial structures there are the quadriceps muscles and the strap-like sartorius

Enteric ganglia

-submucosal ganglia, a plexus -myenteric plexus *both work to coordinate movement *has many millions of neurons in it IBS, excessive bowel movements are problems with control of the bowel systems Hirshsprungs, the distal parts lack the neurons

Tensor Fascia Lata

-supplied by the superior gluteal nerve *tenses the fascia lata and the illiotibial tract* originate from the most anterior part of the illiac crest and its aponeurosis will insert onto the illiotibioal tract with attaches tot he anterolateral tubercle (Gerdy's Tubercle on the tibia) -Medially rotates thigh, along with anterior fibers of gluteus medius and minimus and also helps to flex the thigh at the hip (helping the illiopsoas and pectinius muscle).

adductor canal

-the superficial femoral artery, femoral vein and saphenous nerve travel downward in this space formed by the medial edge of the vastus medialis, adductor longus and sartorius. -superficial femoral artery and femoral vein then pass through the adductor hiatus into posterior chanber of the thigh the popliteal fossa to become the popliteal vessels. The saphenous nerve does not pass through the adductor hiatus which is located int he adductor magnus muscle. It continues down the medial side of the leg to the ankle providing sensation from these area *the artery will be deeper than the vein* -groove between the vastus medialis, adductor longus and sartorius

Bones of Leg and Knee Joint

-tibia bares the weight from femur across the knee joint -tibia also has medial and lateral condyles and upper flat surfaces that will articulate with the cartilage covering the medial and lateral femoral condyles forming the knee joint -crossing inbetween medial and lateral condyle cartilage are the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) that help to reinforce the knee joint and the menisci inferior to the femur and superior to the tibia -tibia has a very superficial shaft and in end is the medial malleolus and forms the medial part of the ankle joint -fibula: long thin bone that does not bare any weight but has a lot of muscles that extend from the ankle that extend from the tibia to the fibula **structure has a head, neck, interosseous border that connects to the interosseous membrane, fibula, and lateral malleolus and forms the lateral part of the ankle joint - it attaches to the tibia vial the tibiofibula syndesmosis, is a very tight ligamentous joint that does not move both malleolus and formed inferiorly for articulationwith the talus 4 compartments: anterior, lateral, superficial posterior, and deep posterior osteology: between the medial and lateral condyles are the medial and lateral intercondylar tubercles gerdy's tubercle, superior to the tibial tuberosity, which connects to the IT band

Saphenous cutdown

-used to obtain rapid access for the purpose of infusing IV fluids, blood products or medications at the medial mellalous of the tibia -great saphenous also used for coronary bypass preceduces and catheters can be inserted through there

spinal arteries

1 anterior, 2 posterior they come from the vertebral artery that comes off of the subclavean artery in the root of the neck lower part supply: thoracic aortic will give the posterior inner costal arteries (between your ribcage) blood as well as anterior and posterior segmental meduallary arteries that combine to form the one anterior and 2 posterior spinal arteries anterior segmental medullary Radicular artery (Adamkiewicz): major blood supply to the lumbar and sacral region of the spinal cord lumbar arteries- coming from the abdominal part of the aorta

Superficial Gluteal Muscles

1. *Gluteus Maximus*- 2. *Gluteus Medius* 3. Gluteus Minimus 4. Tensor Fascia Lata

Lower Extremity Arterial Supply

1. External Illiac 2. Superficial Femorla 3. Popliteal Arterry 4. Anterior and posterior tibial 5. Posterior and fibular artery Blood Supply to the Knee: Popliteal artery gives off genicular artery branches that will supply the knee joint 1. Superior Lateral 2. Superior medial 3. Inferior lateral 4. inferior medial 5. middle - all form an anastomosis around the knee joint *middle genicular artery branches off anterior side of popliteal artery and supplies the cruciate ligaments, synovium and peripheral menisci

Process of Gastrulation

1. Invation of epiblast through primitive pit and groove 2. The first cells displace hypoblast to form the definitive endoderm (will form gut and viscera) 3. Others spread between epiblast and the definitive endoderm to form intraembryonic mesoderm (will form GU system, muscle, bone and CT) 4. Once cells have ingressed, epiblast becomes ectoderm

Sensory Innervation of the Leg

1. Laterally: lateral sural nerve (from the common fibular) 2. Inferior Laterally and Digits 2-5 on dorsum of foot: Superficial fibular nerve 3. Lateral side of foot: sural nerve (derived from the recombination of the lateral and medial (from the tibial nerve) sural nerves 4. Webbing between toes 1-2: deep fibular nerve 5. Medial (anterior and posterior) side: medial crural branches from the saphenous nerve 5. posterior lateral: sural nerve (medial sural nerve and sural communicating nerve from the common peroneal); this runs right down the posterior part of the leg, runs right next to the small saphenous vein 6. Middle Lateral side: superficial fibular nerve

Nervous tissue

1. Neurons 2. Neuroglia Neurons -Biopolar (interneuron) -*Unipolar (Senory neuron)* -*multipolar (motorneuron)* -pyrimidal cell *both have cell bodies and long axons with nerve fibers

Deep Gluteal Muscle

1. Obturator Internus 2. Piriformis 3. Superior and Inferior Gemelli 4. Quadratus Femoris

Hamstring Muscles

1. Semimembranosus- has a flat membranous tendon that comes of the ischial tuberosity 2. Semitendinosus- medial side, has very long skinny tendon (about half of the length) 3. Bicep femoris- long (superficial), short (deep) *everything but short head of biceps originates on the ischial tuberosity, short head orginates on the shaft -tendons will cross the knee joint posteriorly (semimembranosis and -tendinosis attach on the upper medial side of the tibia (*pes anserinus*) forming the upper medial border of the popliteal fossa) and combined biceps attach on the head of the fibula on the lateral side and form the upper lateral border of the popliteal fossa Action: extend high (except for short head of biceps) and flex leg at knee (muscles cross both hip and knee joint) Innervation: everything but short head of biceps femoris- tibial division of sciatic; short head of biceps branch of the sciatic nerve called the common peroneal avulsion: occurs when there is flexion at the hip and extension at the knee and the hamstrings are pulled out of the ischial tuberosity treating injured hamstring- 1. rest 2. ice 3. compression 4. elevation

Superficial Posterior Compartment

1. Soleus 2. Plantaris (tendon) 3. Gastrocnemius (two heads medial and lateral) *Origin* Gastrocnemius- lateral and medial condyle of femur soleus: posterior superior fibular and soleal line of tibia plantaris: lateral superacondylar line of femur Insertion: Posterior surface of calcaneous (calcaneal tuberosity) via the calcaneal tendon innervation: tibial nerve (S1, S2) *Main Action:* gastroc: plantarflex foot (knee extended); raises heel when walking; flex leg at knee joint ( crosses the knee joint) soleus: plantarflex foot, has a tendonous arch on the medial side that has a space for neurovasculature (tibial nerve and popliteal artery as they traverses the popliteal fossa to enter into the deeper part of the leg) plantaris: weakly assists gastrocs in plantarflexion (crosses over the knee to the leg)

Deep Back Muscles

1. Splenius- flat, surrounds the muscle structures in the neck 2. Erector spinae- help to extend the back 3. transverso-spinalis- deep to erector spinae ALL: 1. Act to exten trunck when act bilaterally 2. located doral to vertebral column 3. Inntervated by dorsal primary rami of spinal nerves

Gait cycle

1. Stance phase -heel strike: heel impacts the ground and the toes are off the ground -foot flat: -mid-stance: -heel off: -toe off: start of the swing phase 2. Not weight-bearing: foot is picked up off of the ground and knee is flexed and it ends with heel strike *consists of alternate cycles of stance and swing phases *utilizes the hip the knee and the ankle joint

Muscles of the Back

1. Superficial layer: move upper extremity (attach to humerus or scalpula) 2. Intermediate layer: respiratory muscles attach to ribs 3. Deep layer: move trunk and back (attach to verterae and ribs), erector spinae

Classifications of Neurons

1. Unipolar (psuedounipolar): Have one process which divides into a central branch that functions as an axon and a peripheral branch that serves as a dendrite. They are called pseudounipolar because they were originally bipolar. The two processes fuse during development to form a single process that bifurcates at a distance from the cell body. They are the sensory neurons of the PNS and found in spinal and cranial nerve ganglia 2. Bipolar Neurons:Have two processes (one dendrite and one axon); are sensory and are found in the olfactory epithelium, the retina and the inner ear 3. Multipolar neurons: Have several dendrites and one axon and are most common in the CNS (e.g., motor neurons in anterior and lateral horns of the spinal cord and autonomic ganglion cells.

Characteristics of the Vertebrae

1. Vertebral body 2. Vertebral Arch 3. Spinous process 4. Transverse processes running laterally 5. 2 superior and 2 inferior articular processes (articulate with adjacent vertebrae and allow some motion across those vertebrae) Aging: decrease in bone density occurs particularly in the central part of the vertebral body resulting in the superior and inferior surfaces of the vertebrae to become increasingly concave and for the IV to become increasingly convex. This can lead to shrinking in old age *lose .25 to .5 and inch per decade after 40

Middle Thigh Cross Section

1. fat layer- superficial facial with saphenous vein 2. facial lata 3. muscles divided by three septa each connecting to the femur - medial, lateral and posterior 4. anterior compartment is demarcated by the medial and lateral septa; has the quadriceps and is innervated by the femoral nerve *(muscle will flex the thigh at the hip and extend the leg at the knee)* 5. posterior compartment is demarcated by the lateral and posterior septa has the hamstrings as is innervated by the tibial division of the sciatic nerve *(can extend the thigh at the him and flex the leg at the knee)* 6. the medical compartment is demarcated by the medial and posterior septa and has the adductors and is innervated by the obturator nerve *(will pull the femur towards the midline and will adduct)*

Lateral Ligaments

1. posterior talofibiular 2. calcaneofibular ligament 3. Anterior talofibular ligament- most commonly sprained ligament

Ligaments of Spinal Column

1. sacrospinous ligament 2. sacrotuberous ligament 3. illiolumbar ligament 4. anterior sacoiliac ligament all are joint that can become inflammend 5. anterior longitudinal ligament: runs from the base of the skull on the anterior aspect of the intervertebral bodies , it is narrow in the cervical region then becomes much broader as you go down into the lumbar and sacral region - prevents hyperextension of the spine, prevents the bodies from separating and prevents anterior protrusion of the intervertebral disk 6. supraspinous ligament: attached to the edge of the spinous processes and descends down the spine 7. Interspinous ligament: between each spinous process, prevent hyperflexion 8. Posterior longitudinal ligament: that runs on the inside of the vertebral canal on the posterior aspect of the vertebral bodies and disks to prevent hyperflexion of spine and posterior protrusion of IV disks into canal and posterior displacement, much narrowered than the anterior one 9. Ligamentum flavum: yellow ligaments that are posterior and run from between the lamina of the vertebrae and stop that from separating and prevent excess flexion in the spine

Transverse tarsal joint (Chopart's Joint)

1. talonavicular part of the talocalcaneonavicular joint 2. Calcaneocuboid joint

Position of the Spinal Cord in the Adult

1. the cord initially extends the full length ofthe embryo, but be cause of differential tissue growth, the caudal end seems to regress; as a consequence: if an intervertebral disk would bulge out, it can impact the nerve below it (L4/S1 affects the S1 nerve) 2. Advantages of L2 termination of spinal cord: it leaves a pool of CSF that can be tapped into without damaging the spinal cord

Functional Components in Peripheral Nerves

1.General somatic afferent (GSA) fibers: Transmit pain, temperature, touch and proprioception from the body to the CNS 2.General somatic efferent (GSE): Carry motor impulses to skeletal muscles of the body 3. General visceral afferent (GVA) fibers: Convey sensory impulses from visceral organs to the CNS 4. General visceral efferent (GVE) fibers (autonomic nerves):Transmit motor impulses to smooth muscle, cardiac muscle and glands 5. Special somatic afferent (SSA) fibers: Convey special sensory impulses of vision, hearing and balance to the CNS 6. Special visceral afferent (SVA): Transmit smell and taste sensations to the CNS 7.Special visceral efferent (SVE) fibers: Conduct motor impulses to the muscles of the head and neck, such as muscles for mastication, facial expression and elevation and movement of the pharynx and larynx

Curvatures of spine

2 primary (curvatures present during embryonic development): 1. Thoracic 2. Sacral (kyphosis- concave anteriors) 2 Secondary curvatures : 1. Cervical- developed as we lift our heads 2. Lumbar - developed as we begin to walk (lordosis concave posteriorly) Curvatures are determines by shape of vertebrae and IV disks Hyperlordosis: Excessive lumbar lordosis can be a result of weak hamstring which allow tight hip flexors to tilt pelvis anteriorly and the back muscles to hyperextend the spine, increasing the lumbar lordosis Hypo-lordosis: a posterior pelvic tilt may be caused by tight hamstrings and resulting in a straigtening of the lumbar spine, or "flatback" women in advance stages of pregnancy develop lower back back because their center of gravity is shifted anterior and they have to re-center themselves by using their erector spinae muscles Kyphosis: excessive in the throacic region where there is a hump. This can either be congenital (failure of formation or failure of segmentation) or mechanical (caused by slouching, associated with muscle weakness and can be caused by age-related osteoporosis causing the anterior part of the vertebral body to be compressed)

tri-copmartmental join

2 tibiofemoral joints: articulation betweent he medial and lateral femoral condyle and tibial condyles 1 patellofemoral joint: articulation between the patella and femoral condyle (trochlea)

osteology of the foot

28 Bones: 7 tarsals, 5 metatarsals, 14 phalanges, 2 sesamoids Dorsum of foot (top): Plantar surface (sole): 4 layers of muscles anterior to posterior: 1. phalanges (toe 1, has only distal and proximal bones, others have 2 2. Metatarsals 3. Cuneiforoms (m, i, l) 4.navicular (medial) 4. Cuboid (lateral 5. Talus- what articulates between the medial and lateral malleoli (mortise and tenon joint)- provides a lot of support and restricts movement 6. Calcaneous

Quadriceps Muscles

Actions: togehter, the quadriceps extends the leg at the knee. Rectus can also help the illiopsoas to flex the thigh at the hip because it crosses the hip joint anteriorly Muscles: rectus femoris m (inserts at AIIS), vastus lateralis m (inserts at greater trochanter), vastus medialis m, vastus intermedius (inserts at femur) Innervation: Femoral Nerve all four muscles combine into the quadriceps tendon that passes over the patella , becomes the patellar ligament and inserts on the tibial tuberosity Vastus lateralis and medialis serve to keep the patella in place between the condyles. If one of the vasti overexerts force, there could be a misplacemet leading to runners knee

Epithelial Somite Tissue Types

All mesoderm 1. Sclerotome- bone: migrate medially and take residence around the neural tube and notachord and become the verterbal column 2. Myotome- muscle, will stay close to the vertebral column to form the musclulature 3. Dermatome- CT of skin (dermomytome) take residence deep and form the dermis (ectoderm forms the epidermis) somite numbers 4 occipital , 8 cervical , 12 thoracic, 5 lumbar, 5 sacral and 8-10 coccygeal after the third week of fertilization

Nerve Supply to Hip Joint

Arise from nerves supply the muscles located across an acting on the hip joint *Hilton's Law* -Anterior- femoral n. -Posterior/Superior- Superior gluteal -Posterior/ Inferior- Nerve to quadratus femoris and obturaotr internus/obturator nerve

Popliteus m.

Attachments: lateral femoral condyle and meniscus and inserts in posterior tibia Action: fixed tibia- laterally rotates femur to unlock knee unfixed- medially rotates tibia

Popliteal Fossa

Boundaries: -semimebrinanosus -biceps femoris -medial and later heads of gastrocnemius -superficial border is the skin and popliteal fascia -deep border is the popliteal surface of the femus, the joint capsule, and the popliteus muscle/fascia Contents: -Popliteal artery and vein -tibial division of sciatic nerve -common fibular (peroneal) div. of sciatic n. and will follow the biceps femoris to the lateral part of the leg where -popliteal lymph nodes -small saphenous vein dumps into the popliteal vein *popliteal artery and tibial nerve run through the tendinous arch of the soleous muscle, after this the will run in the fascia in between the posterior deep and superficial compartments -diamond shaped space at the posterior knee

Segmentatin of the Vertebrae

Cervial: C1- C7 (only 7 vertebrae, but has 8 nerves) Thoracic: T1-T12 Lumbar: L1-L5 Sacral: S1- S5 30 vertebrae but 31 spinal nerves * C1 spinal nerve emerges before the C1 vertebrae -above C7, the vertebra the spinal nerve leaves above the corresponding vertebra, below the T1, the spinal nerve exits below each spinal nerve will exit the vertebral canal through the intervertebral foramen bilaterally -formed by the inferior and superior vertebral notch Coccygeal: 2-5 (fused into tail bone) *spinal cord is protected by vertebral column

Intra-articular ligaments

Cruciate Ligaments -keep articular surfaces of tibia and femur opposed while stabilizing the knee joint -within the fibrous joint capsule, but outside the synovial membrane -synovial FOLD creates lateral and medial compartments of the knee joint anterior cruciate ligament and posterior cruciate ligaments :

Ski Boot Syndrome

Deep Fibular Nerve Entrapment, because it has to run underneath the extensor hallicus longus, in ski boots it can get entrapped resulting in pain and potential numbness in webbing between the first and second toe

Lower Limb Regions

Gluteal region Thigh Leg Foot Separations Hip Knee Ankle Function: weight bearing and balance and locomotion creating mobility and at the same time stability center of gravity is located posterior to the hip joint, anterior to the knee and even more anterior to the ankle and is centered in between the feet.

Intervertebral Disks

Healthy- vertebrate provide body support, discs act as shock absorbers, vertebra protects spinal cord and nerves, nerves have space and are not pinched Stenotic: as we age, ligaments and bone can thicken, there is narrowing (stenosis) that impinges on nerves in spinal canal and nerve roots exiting to spine to legs, this results in pain and numbness in back and legs have an inner nucleus pulposus ( gel-like) and an outer annulus fibrosis herniation: nucleus pulposus moving into the annulus fibrosis and into the spinal canal where there can pincha nd compress nerve roots ( cauda equina) and can cause sciatica like pain narrowing of disks can lead to bone formations or bone spurs

Unhappy Triad

Lateral force on the knee leading to tear in MCL, bucket handle tear in medial meniscus and tear in ACL

Back Pain

Lumbago -common cause for office visits Common Causes 1. lumbar "strain/sprain" of muscles and or ligaments- 70% 2. Degenerative changes in vertebrae/ disks- 10% 3. Herniated disk- 4% 4. Osteoporosis compression fractures-4% 5. Spinal Stenosis-3%

Postero-lateral protrusion of Disk

Lumbar disck protrusion usually does not affect nerve exiting above disc. Lateral protustions at disk level L4-5 affects L5 spinal nerve, not L4 spinal nerve. Protrusion at L5-S1 affects S1 spinal nerve

Postero-medial protustion of Disk

Medial protrusion at dis level L4-5 and rarely affects L4 spinal nerve buy may affect L5 and sometimes S1-S4 spinal nerves

Efferent

Motor impulses away from CNS reside in the CNS and extend to the periphery to synapse on muscle CNS to periphery motor potentials leave from the ventral horn SA*ME* DA*VE* multipolar moter neurons: cell bodies in ventral horn of spinal cord gray matter and are efferent

Concept of Compartments

Muscles in the extremities (upper and lower limbs) are packeaged in compartments. The contents of one compartment are contains in a tough connective tissue called the deep fascia. Within a compartment there is: 1. One major artery supplying blood to the compartment 2. One major nerve -Muscles in a compartment have similar function e.g. to flex the same joint

Nerves

One axon is wrapped in a myelin sheath and is wrapped in an endoneurium (loose CT). Each axon with endoneurium is held in a bundle with others and is wrappend with perinerium (loose CT) that creates a fascicle. Multiple fascicles going to a same part fo the body along with blood vessels and wrapped within an epineurinum (dense, tough fibrous CT) * the are mixed nerves that carry both motor and sensory fibers * myelin sheath keeps action potentials from intermingling between the two types of neurons of opposing directions

Levator Costarum

Origin: Transver processes of C7 to T11 Insertion: superior border and external surface of the subjacent rib between its tubercle and angle Bends thoracic spine to same side; rotates to opposite side innervated by dorsal primary rami

Latissimus Dorsi

Originates on Vertebrae T6-T12 (spines) Fascia- Thoracolumbar fascia and inserts on the pelvic bone Pelvic bone- illiac crest Inserts onto Humerus-Intertubercular (bicipital) groove Actions: adduction, extension, and medial rotation of the arm Innervation: thoracodorsal nerve (brachial plexus)

Developmental Innervatio of Embryonic Muscles and Dermis

Relationship between nerves and the skin and muscle they innervate is established during embryonic development motor neurons derive from the primitive neural tube, lateral and to the side are the sensory neurons *Muscles and dermis are formed by cells dervied from somites* Somites are bilateral biscuit- like clumps of cells that segmentally flank the primative spinal cord and then migrate out with the motor and sensory nerves to their appropriate locations Nerves develop in bilateral pairs and serve the skin and muscles forming tissue of the adjacent somite As dermomomyotome cells migrate of the somites, motor and sensory fibers innervating them are organized into nerves *In the thoracic region segmental organization is preservers. Intercostal muscles are derived form only one somite* Muscles in the limbs can be derived form somites from multiple adjacent segments. So in segments adjacent to limb buds (e.g L2-L4 from muscle of the anterior thigh) nerves form plexi

cauda equina

S2-S5 which are sensory nerves

Pes Anseritus

Sartorius, gracilis and semitendinosus that form a tendon that inserts in the tibia AKA Goose foot

Surface Anatomy of the Back

Skin and Fascia Superficial Muscles: trapezius, latissimus dorsi; not true back muscles because they are not invervated by the dorsal primary rami and are actually muscles of the upper limb -erector spinae muscle are the true palpable muscles of the back dimples in the lower back overly the PSIS which are landmarks for the S2 vertebral level -lower part of the sacrum lies right above the intergluteal cleft of sacral canal -line across illiac crest is important for L4 vertebrae vertebral column with spinal cord ( can be palpated), the meniniges and the nerve roots rib cage

piriformis syndrome

The sciatic nerve runs through the piriformis, this causes compression of the nerve and pain similar to sciatica -starts in the buttocks, extends along the course of the sciatic nerve, down back of thigh and calf, and sometimes into the foot and worsens when sitting.

Superficial Plantar Surface

There is a large plantar fascia that covers over the plantar surface of the foot. Can be inflammed and is called plantar fasciaitis. * there are both medial and lateral plantar nerves and arteries

common peroneal

divides into the deep and superficial peroneal and innervates the lateral and anterior compartments of the leg

Sacrospinous ligament

Tip of the spine of the ischium over to the side of the sacrum. Work to create the greater and lesser sciatic foramen

Varicose Veins

Valves in perforating veins become incompetent or tortuous leading to retrograde venous blood flow into superficial veins. Varicose veins may be associated with: -Venous stasis ulcers -fungal and bacterial infections -phlebitis -deep venous thrombosis: blood clots that occur within the deeper lying veins, blocking the valves

Thoracic Region of Spinal Cord

Ventral primary rami gives rise to an intercostal nerve at each vertebral level. Dorsal primary rami innervates muscle and skin of the true back ventral primary rami will innervate the intercostal muscles and it will extend cutaneous branches that will innervate skin at every level and will make stripes, there is overlapped, but the intercostal sensory nerves can be see in Shingles or Herpes Zoster (segmental innervation) Both ventral and dorsal primary rami will carry GSA, GSE and GVE

Plexus Formation

Ventral primary rami in the cervical lumbar and sacral regions from plexi for innervation Cervical plexus- head brachial plexus- arms lumbosacral plexus- innevation of the legs

Segmentation

a fundamental organizing principle for the vertebrate body and somites are responsible

Saphenous Nerve

a sensoy nerve to the medial side of the thigh and leg down to the ankle that branches from the femoral nerve terminally

Caudal eminence

after primiteve streak regresses, the caudal eminence forms at the posterior edge. it is *responsible for inducing tissue at the caudal end to form the structures corresponding to lower limb and sacral area*. Sirenomelia (not compatible with extra-uterine life) and caudal dysplasia are a result of if there is a problem with the posterior ridge

internal pudendal artery

also a branch of the internal illiac artery and travels with the pudendal nerve through the greater and less sciatic foramen and supplies blood to the structures in the perineum including the lower part of the rectum

dermatome

an area of skin that is mainly supplied with sensation by a single spinal nerve

obturator foramen

an opening formed by the pubis and the ischium, mostly covered by a membrane, but has an opening for the obturator nerve that comes from inside of the pelvis to the medial part of the thigh that will innervate the muscle in the medial portion

subtalar joint

anatomical- posterior articular facets of talus and calcaneus, where the talus and calcaneus meet clinical- anatomical subtalar joint plus the talocancaneal part of the talocalcaneonavicular joint

Extracapsular ligaments

anterior patellar ligament, medial collateral ligament ( continuous with joint capsule), fibular collateral ligament (is outside of the joint capsule), posterior: oblique popliteal ligament (extension of the semimembranosus tendon and crosses the knee joing from medial to lateral in a superior direction to help) and arcuate popliteal ligament (attaches the head of the fibula and the lateral condyle and forms a sheath for the popliteus tendon and inserts on the inside of the joint capsule *superior portion of capsule is formed by the sheath created by the quadriceps tendon Lateral order of CT (superior to deep): 1. tendon of biceps 2. LCL 3. APL 4. Popliteus tendon 5. Joint Capsule

Anterior Drawer Test

done when the ACL is ruptured: 1. knee is flexed at 90 degrees 2. Lax hamstring tendons 3. pull tibia anterior from neutral position

dermatomes and sensory innervation

area of the skin that is innervated by a single spinal nerve -as dermatomal cells migrate to form hypodermis and dermis, the sensory fibers go with -As a consequence, the cutaneous sensory innervation of the adult reflects segmental origin, but if a single nerve is knocked out, because someof the cutaneous nerves lie in the regions above and below the dermatome, the region will not be anesthetized *there can be recognized differences in sensitivity however

inferior gluteal nerve

arise from belowe the piriformis and go into the deep surface of the gluteus maximus also a branch of the internal iliac artery

superior gluteal nerve

arises above the piriformis and resides anterior to the gluteus minimus and posterior to the gluteus medius a branch of the interal iliac artery accompanied by a superior gluteal artery

Dermatome

band-like strip of skin from the posterior midline to the anterior midline supplied by the dorsal and ventral primary rami of a single spinal nerve sensory innervation ofthe skin corresponds to the segmental levels of the spinal nerves Important reference dermatomes: T4- nipple line T10- umbilicus, where pain from appendix will first refer to Lateral femoral cutaneous nerve (L2, L3) Anterior cutaneous femoral nerves (L2, L3) Medial crural cutaneous nerves (terminal branches of saphenous nerve from the femoral nerve) (L3, L4)

Pubis structure

body which is a straight part connected to the pubic tubercle and the superior ramus and the inferior ramus that are both branches connected to the body of the pubis pubic tubercle

Femoral Triangle

boundaries are the sartorius and the medial edge of the adductor longus, floor formed by pectineus and illiopsoas, roof formed by fascia lata and skin NAVL - Nerve, Artery, Vein, Lymphatic -Femoral artery comes from the abdominal aortic artery the external and interal illiac artery, that pass the inguinal ligament and become the femoral artery and vein, same structures different location and name femoral sheath- extension of fascia which lines the abdomen, surrounds the femoral arter, femoral vein and lymphatic channel (femoral canal) *femoral nerve lies deep to the canal* can palpate the pulse of the femoral artery around the inguinal ligament

sciatic nerve

comes from underneath the periformis through the gluteal region and down the posterior thigh and underneath the muscle and is the largest nerve in the body runs superficial to the gemelli, obturator internus and the quadratus femoris L4-S3 and is divided into the common peroneal (posterior and goes laterally) and the tibial nerve (anterior) the course of the sciatic nerve can be found by bisecting the between the greater truchanger and teh ischia tuberosity if gluteal region is divided into quadrants, the safer area is the upper lateral quadrant of the gluteus maximus *supplies knee flexors and all muscles below the knee *supplies sensation to all of leg except medial side (saphenous nerve-branch of femoral) *does not supply the gluteal muscles even though it passes though this region*

Hisrchsprung's disease

congenital megacolon, the area of the gut tube remains shrunken because is lack the neurons of the enteric ganglia *babies cannot be discharged until the poop first -like DiGeorge syndrome, caused by faulty crest migration, in this case vagal crest into distal gut

Thoracolumbar (Lumbar) Fascia

covers the deep muscles of back attaches medially to spines of vertebrae -inferiorly to ilium (pelvic bone), provides for muscle attachments - dorsal rami of spinal nerves exit from this fascia muscles are located in the region between the transverse processes and the spinous processes

Peripheral Nervous System

cranial nerves: 12 pairs arrising from the brain, CN I ... etc CN III occular motor nerve spinal nerves: 31 pairs arising from the spinal cord, arise bilaterally ganglia: groups of nerve cell bodies outside the CNS

Articularis Genu

deep to the vastus intermedius and medialis -attached superiorly to femor and inferiorly to the synovial membrane of the knee joint so it does not get crushed by the patella -pull synovial membrane superiorly during extension of leg preventing it from being compressed between femur and patella -supplied by femoral nerve

Rotatores

deepest layer of transversospinalis Originates on transverse processes of the cervical, thoracic and lumbar vertebra (usually on fully developed in the thoracic region) Inserts on: Long rotatores: spinous processes of the vertebra on level above origin short rotatores: spinous processes on adjacent vertebra innervated by dorsal primary rami

sensory innervation

dorsal rami innervate the true back muscles BUT, they have sensory neurons that come down and supply the intervertebral facet joints -The dorsal primary rami from the spinal nerves supply sensation from the facet joints -Each facet joint receives sensory fibers from two adjacent spinal nerves

ankle joint actions

dorsiflexion- toes up plantarflexion- toes down *inversion (supination) *eversion (pronation) *these movements occur at the subtalar and transverse tarsal joint

Ocult spinal dyraphism

dysraphism- failure to form an arch 1. associated with a leakage of CSF, hypertrichosis (hairy patch) at base of spine, cyst, but no functional deficit 2. Arrowhead- syringomyelia, arros- bony spurs due to failure of vertebral arch closure plus tethering of conus medullaris 3. Arrow- split cord (diastematomyelia), as a consequence of the bony spurs Rx: drain syrinx, release cord, remove bony spurs, correct CSF leak

denticulate ligamnents

extensions of the pia matter (from cervical to T12) on each side (around 21 total) *which anchor it to the arachnoid and dura mater*

Lumbar puncture

find the L4 level at the illiac crest

Ischium

forms the more posterior, inferior part of the hip bone, has a rounded boney prominence called the ischial tuberosity which is the origin of the hamstring muscles and the quadratus femoris and an ischial spine

sclerotomme

gives rise the vertebra, intervertebral discs and ribs -each vertebra is assembled from two somites: the caudal half of one somite and the rostral half of the next posterior one -in comparison with somite, vertebrae are intersegmental Ex: somite O4 and C1 give rise to the base of the occipital bone which is not a true spinal bone, also the intersementation and numbering (8 cervical somites) is what gives rise to the nerves which emerged and are aligned with the original somites intervertebral disk is in the middle of the somite and is formed from sclerotome cells surrounding it; it is also thought the remnant of the notochord sits within the IV disk cordoma are tumors that lie withing the midline of the IV disk

intermediate mesoderm

gives rise to the genito-urinary system, kidney and urinary

Inguinal region Lymph Nodes

great saphenous vein goes through a saphenous opening directly inferior to the inguinal ligament and will empty into the deeper lying femoral veing superficial inguinal lymph nodes arranged in the horizontal group underneath the inguinal ligament and in a vertical (inferior) group that ends just as the great saphenous vein permeates the fascia lata through the saphenous opening -lymph nodes are palpable nodes and are right below the skin, can grow with infection below the lower limb as the lymphatic channels of the lower limb congregate around the superficial inguinal lymph nodes *area of drainage is anywhere below the umbillicus* -from superficial inguinal lymph nodes that are lymphatics that drain deeper into the abdomen and pelvis and then all the way up *above the umbillicus, channels drain upwards to the axillary lymph nodes in the arm pit

Knee joint basics

hinge synovial joint- flexion extension with gliding and roation, pretty week joint that is dependent on surrounding muscles, tendons and ligaments for stability Rotation: 10 degrees medial 30-40 in lateral to unlock to the knee from extension, the popliteus m. contracts an laterally rotates femur 5 degrees ontibial plateus, pulling the condyle of the femur posteriorly, allowing the knee to roll

Neural Induction

induced by Noggin and Chordin which bind to and block actions of Bone Morphogenetic Proteins (come from the rest of the embryo) that suppress neural induction Things that happen: -primitive streak begins to regress, and then structure forms that is responsible for secondary neural induction called the *caudal eminence* -neural plate begins to expand -neural groove begins to form -two sides of the neural plate rise up to touch each other to form a complete tube that forms the CNS

Gemelli

inferior (originates from the ischial tuberosity and superior (originates from the ischial spine) short small muscles that originate on the pelvis and insert inferiorly on a fossa on the deep surface of the greater trochanter, they surround the *obturator internus* which originates on the inside of the obturator foramen on the membrane the closes it off obturator externus- outside of the obturator foramen and goes around the femor and inserts slightly anterior to the obturator internus

cruciate anastomosis

inferior gluteal artery, lateral femoral circumflex artery, medial femoral circumflex and first perforating artery from the deep femoral artery that has an ascending branch that completes the cross blood supply to thigh is mostly from deep femoral this system makes it so that if one artery is blocked, blood supply is not lost

osteology of posterior leg

inferior othe medial condyle is the groos for semimembranosus tendon and on the back of the tibia there is a diagonal line called the soleal line that attaches to the soleal muscle, distally and medial there a groove for tibialis posterior and flexor digitorum longus tendon, medial to that is the medial malleolus and lateral to that at the bottom of the fibula is the lateral malleolus. biceps femoris tendon bifrucates and attaches to the lateral head of the fibula

Spondylitis

inflammation of the spine Ex. Ankylosing Spondylitis - chronic inflammatory arthritis and is autoimmue. It mainly affects joints in the spine and the sacroiliac joint in the pelvis and can cause eventual fusion of the spine spine becomes stiff and inflexible cause is unknown but individuals with the HLA-B27 genotype are at significantly increased risk *no known cure Procession of Disease: 1. Normal spine 2. Inflammation of ligaments and joints 3. Formation of syndesmophytes (boney growth inside of a ligament) in bones 4. Fusion of discs- *Bamboo spine*

Compartmentalization of the Leg

injuries cause compartment syndyrom because the leg is so tight 1. Anterior compartment 2. Lateral compartment 3. Superficial posterior Compartment 4. Deep Posterior compartment

Autonomic nervous system

innervate smooth muscle -2 neuron chain 1. efferent motor neuron that lives in the inner medial spinal column 2. projects into ventral root 3. enters into the sympathetic chain through a white ramus communicans (white because it is myelinated) 4. synapses there with a sympathetic chain ganglion 5. post ganglionic neurons travel out into the periphery to innervate smooth muscles (intestines, or irector pillae muscles for the hairs of our skin) *autonomic and somatic happen on both sides of the body

tibial division of sciatic nerve

innervates the posterior compartments of thigh and leg and plant surface of the foot

Sartorius

inserts in the ASIS and crosses the thigh from lateral to medial and then runs along side of the knee joint and inserts in the upper anterior medial part of the tibia helps to flex the thigh and the hip and can put the thigh laterally and can rotate the thigh laterally. Can also help other muscle flex and the knee joint Summary of Actions: flexion, abduction and lateral rotation of the thigh flexion of the leg innervation: femoral nerve

spinal venus

internal epidural venous plexus, located inside of the vertebral canal but outside of the dura, and will drain blood from the vertebrae themselves and will connect to an external plexus on the outside and the spinal veins themselves. -anterior and posterior 3 venous plexus: 1. Posterior internal vertebral vnous plexus 2. Anterior interanal vertebral venous plexus 3. Anterior external vertebral plexus starts in the pelvis and connects all the way up to the veins in the skull *way to spread prostate or pelvic cancer, goes to bones, spine and brain*

Femoral artery

it is a continuatio of the external iliac after once it passes underneath the inguinal ligament, it divides into two main branches: 1. Deep femoral artery- lateral and medial and lateral femoral and circumflex branches, goes around the neck of the femur providing collateral circulation or an anastomosis and to the head of the femur; breaking the head of the femur will lead to avascular necrosis in this region of the hip -also have perforating branches that go down through the adductor magnus and supply the posterior compartment of the thigh 2. Superficial femoral artery-medial; not really superficial as it is underneath the fascia will go down through the adductor canal and will pass through a space called the adductor hiatus between the adductor part of the magnus and the hamstring part and then go to the back of the knee and it is called the popliteal artery

Scoliosis

lateral bending of the spine that occurs in 2-3% of Americans and is 2 times more common in females. It is measured by the Cobb Angle. Causes: 1. congenital: malformation of the vertebrae or fused ribes during development 2. Functional: spine is normal, problem elsewhere in the body causes curvature i.e. shorter leg 2. Neuromuscular scoliosis: poor muscle control, weakness, or paralysis caused by cerebral palsy, muscular dystrophy, spina bifida and polio 3. Idiopathic: appears in a previously straight spine Kyphoscoliosis is possible

gluteus medius and minimus

lie a little anterior to the gluteus maximus and originate from the side fo the illium and send there tendon to the greater trochanter -gluteal lines: posterior, anterior and inferior, between the lines are the muscles, gluteus medius and minimus when these fibers contract they will pull the femur laterally and will cause abduction of the thigh at the hip -they are supplied by the *superior gluteal nerve* anterior fibers can also pull femur anteriorly and can cause medial rotation of the femur - they stabilize the pelvis when we are walking; the gluteus medius and minimus on the opposite side of the extended leg contract and pull the pelvis on the unsupported side so the foot can clear the ground; when walking, gluteus medius and minimus pull pelvis down on side that supports weights *trendelenburg test- hip sags on unsupported side (trendelenberg sign)- to compensate for a positive trendelenburg sign, the person can lurch towards affects side, using other muscle in the back, to keep center of gravity over that foot or hold a cane in the hand on the unaffected side (hip lurch)

sacrotuberous ligament

ligament that moves from the sacum to the ischial tuberosity, word to create the greater and lesser sciatic foramen. -the weight of the body is transferred from the lumbar spine to the sacrum, the ligaments (sacrotuberous and sacrospinous) are needed to prevent the sacrum from moving up when the weight of the body presses down

Splenius Capitus and Cervicis

located deep to trapezius, both muscles have same origin and different insertions -attach to lateral part of the skull and help to extend the skull or laterally bend or rotate if you only contract one side originates on T1-T4 vertebrae Capitus- inserts onto skull cervicis- inserts on the transverse processes of C2, C3 These muscles extend head and neck and rotate in a unilateral direction

sciatica

lower back pain combined with a pain throught hte buttock and down one leg, usually on one side due to impingement of roots of sciatic nerve -pain usually extends past the knee and may go farther to the foot. Sometimes, weeknes in the leg muscles Some Causes: -herniated intervertebral disc -spinal stenosis- narrowing of the space between your spine -piriformis syndrome -hematoma following trauma in gluteal region L5 root compression: weekness in dosiflexion of foot, and big toe, difficulty walking on heels S1 nerve root compression: weekness in plantarflexion of foot, big toe, difficulty walking on toes

Rhomboids

minor: originate on lower cervical and upper thoracic processes (C7, T1 spines) Insert onto scapula (medial border) major: originates on vertebrate T2-T5 spines inserts onto scapula (medial border) to inferior angle Actions: retracts scapula and rotates it inferiorly and bring it torwards the midline Innervation: All by dorsal scapular nerve (brachial plexus) *not from the dorsal rami*

Neural tube defects

minor: spina bifida- delay of closure causing the sclerotome to be unable to enclose it giving you a gap in the vertebral arch, also causes an unsual tuft of hair intermediate: (even greater delay of closure) do not get the sclerotome, and membranes form but create a cystic structure called a *meningocele* serious: (very great delay), have spinal cord tissue in the cyst causing a *meningomyocele*, there will be damage to spinal cord resulting in paralysis to the lower limbs, but is not incompatible with life no closure: myelochisis, fail to form sclerotome, and spinal tissue is exposed to amniotic fluid which is devastating the formation of neural and glial cells anterior- anencephaly posterior- spina bifida frequency- 1:1000 pregnancies causation: numerous genetic (40 genes) contributors, FOLIC ACID

piriformis

originates on the inside lateral part of the sacrum and goes through the greater sciatic foramen and inserts on the upper medial part of the greater trochanter is a lateral rotator and pulls the femur posterior to the axis created by the neck of the femor -important because the names of the nerves in th gluteal region are named based on their orientation to the piriformis as they come out

trapezius

originates on the skull- external occipital protuberance, spine of C7, T1-T12 Inserts on clavicle- laterarl 1/3; scapula- acromion and spine Actions 1. Elevates (upper fibers) and depresses (lower fibers) shoulder 2. Retracts scapula 3. Extends head Innervation: spinal accessory nerve (cranial nerve XI)

pudendal nerve

originates out of the greater sciatic foramen, runs lateral to the sacrospinous ligament, then passes under the lesser sciatic foramen and is a great sensory and motor nerve to the perineum area and supplies innervation to external genitilia S2-S4 spinal regions

illiacus

originates: illiac fossa inserts: lesser trochanter of femur innervation: femoral nerve L2-L4 action: flexes thigh at hip * is supplied by the femoral nerve as it come up from under the inguinal ligament

pectineus

originates: superior ramus of pubis inserts: inferior to lesser trochanter innervation: femoral nerve and may receive a branch from obturator L2-L4 action: adducts and flexes thigh at hip

psoas major

originates: transverse processes of T12-L5 Inserts: lesser trochanter of femur innervation: ventral primary rami or branches of spinal nerves from L1- L3 Actions: flexes thigh at hip

Illiotibial Band (tract) syndrome

pain above the lateral knee or along the lateral thigh caused by inflammation of the IT tract and when it becomes tight it rubs agains the lateral condyle of the femur during flexion/extension of knee

spondylolysis

pars interarticularis- region between the superior and inferior articular processes, can cause the upper section of the vertebral column to slip forward leading to spondylolysthesis scotty dog sign in normal vertebral column, this is disrupted when there is a fracture *this region is fractures of malformed may be caused by repetitive trauma to lumbar spine or stenuous sports such as football or gymnastics or as the result of facet arthritis

Femoral hernia

passes through the remoral ring (opening in the femoral canal), medial tothe femorval vein below the inguinal ligament, inferior and lateral to the pubic tubercle. It can enlarge by passing through the daphenous opening where strangulation of the loop of small intestines interferes with its blood supply

Adductor Muscles

pectineus, adductor longus, adductor brevis and adductor magnus (hamstrig part and adductor part), gracillis innervation: the obturator nerve from the obturator foramen, all except the adducts magnus hamstring portion that is innervated by the tibial division of the sciatic nerve Insertions and origins: the superior, body and inferior ramus of the pubis and insert on the linea aspera, pulling the femur towards the midline obturator nerve: arising from lumbar spine nerve roots L2, L3 and L4 and is divded into anterior and posterior branches -anterior branch, lies betweenand supplied both the adductor longus and brevis muscles and innervates the gracilis - posterior branch, lies deep to the fascia of the adductor magnus and supplies the adductor portion of the muscle *adductor brevis is the dividing plane between the anterior and posterior divisions* blood is supplied via the obturator artery

Lumbosacral plexus

plexus is an ordered intermingling of the ventral primary rami ventral rootlets carry motor innervation that are going to innervate the muscles going back to the dorsal are sensory neurons that is cutaneous innervation from the skin the ventral and dorsal nerves combine and have two branchlets: the ventral and dorsal primary rami ventral primary rami- in the cervix, lumbar and sacral region will form plexus, each having an anterior and posterior division creates plexuses between L4 and S5

neurulation

process by which neural plate rolls up into neural tube 1. neural groove stage shortly after the induction of the neural plate 2. edges of groove begin to elevate and form neural fold 3. Edges meet each other forming the neural tube Components of Process: - at the level of the cells you see constriction of the apex and expansion of the base (fan shaped) -differential growth of the cells surround the plate will produce tension which results in eleveation -cortical tractor where the cells crawl up along side of each other, allowing the folds to elevate even further *tube first forms in the middle as somites are beginning to form then zips up and down simultaneously -anterior (cranial) neuropore closes first - posterior neuropore closes afer *failure of closure of first is fatal, caudal is compatible with extra-uterine life

lesser sciatic foramen

provides a passage from the gluteal region to the perineum (the area that contains the external genetilia and the anus) pudendal that comes out the greater sciatic foramen to the lesser sciatic foramen and into the perineum that provides sensation and motor inervation to the muscles in that region

great sciatic foramen

provides a passage from the inside of the pelvis to the gluteal region and vice versa

Knee alignment

q-angle: made by the intersection oa line drawn from the ASIS to center of the patella, and one fromt he center of the patella to the tibial tuberosity normal: males- 14 degree, females- 17 degrees genu varum (bow leg)- decrease in Q angle genu valgum (knock knees)- increasein Q angle * both call for decreased joint space can cause erosion in the articular cartilage of the knee

Dermatome and Myotome

remain segmental -dermomyotome breaks ups: dermatomal tissue migrate to dermis and hypodermis and myotome is ply by transverse process of vertebrae to form epimere (back musculature ) and hypomere (ventral body wall and limb musculature) -myotome doesn't shift craniocaudal, so as vertebrae and ribs form intersegmentally, myotome bridges between them, muscle spans betweent he space where the intervertebral disk is. The nerve leaves and innervates its appropriate segmental muslce -artery also does not shift and fills the space between the original somites

Pott's Disease

results forom hematogenous spread of *tuberculosis* from other sites, ofter pulmonary, to the spine May lead to a *psoas abscess, formed under the fascial sheath of the psoas major muscle* - this abscess can go down the inguinal ligament and into the upper thigh

ischiofemoral ligaments

runs from the ischium to the greater trochanter and is the weakest of the three ligaments and prevents posterior displacement, this is because the muscles are stronger

Posterior cruciate ligament

runs from the posterior intercondylar area to the later surface of the medial femoral condyle -prevent anterior displacemen of the femur on the tibia and posterior displacement of the tibia on the femur *PCL aslo prevents hyperflexion of the knee* -in weight-beering flexion, the PCL stabilizes the femur over the tibia *Dashboard injury* -knee in flexion -body motion forward, anterior force on tibia *Fall on Flexed Knee* -knee in flexion -anterior force on tibia

posterior cutaneous nerve of thigh

runs medial to the sciatic nerve as it emerges from under the piriformis and is the sensory nerve for the skin so it runs superficial to the posterior thigh muscle runs superficial to the gemelli, obturator internus and the quadratus femoris emerges from S1-S3

Afferent

sensory information to the CNS: Touch, temperature, pain, proprioception *at the periphery there are nerve endings to detect these things and generate action potentials and bypass the cell body periphery to CNS *SA*ME *DA*VE sensory axons come in to the dorsal horn unipolar sensory neurons: cell bodies are in the dorsal root ganglion, no synapses, roots project into dorsal horn of spinal cord gray matter ie. pancinian corpuscles or free nerve endings for pain can move through the dorsal or ventral primary ramus

bursa

small fluid-filld sacs lined by a synovial membrane with an inner capillary layer of viscous fluid. It provides a cushion between bones and tendons and/or muscles around a joint. This helps to reduce friction between the bones and allows free movement bursittis is inflammation of the bursae, resulting in repetitive actions which use the gluteus maximus resulting in point tenderness over the ischial tuberosity or greater trochanter of from calcificaion of the bursae -there are three that lie deep to the gluteus maximus 1. ischial bursa- over the ischial tuberosity 2. Trochanteric bursa- greater trochanter 3. Gluteofemoral

Direction of Fibers

spiral fibers unwind during flexion and wind tighter during extension limiting extension to 10-20 degrees beyond vertical

lateral plate mesoderm

split into somatopleuric (dorsal) and splanchnopleuric (ventral) somatopleure: inner body wall, limbs and their dermis splanchnopleure: CT covering abdominal and thoracic organs

popliteal artery

splits into anterior and posterior tibial arteries which supply leg and foot (plantar and dorsal pedal a.s. ) anterior artery will pass through the interosseous membrane and will supply blood to the anterior portion of our leg posterior tibial artery will branch into posterior and fibular (runs laterally). posterior will continue to run with the tibial nerve and will go down to the medial malleolus to get into the foot

great saphenous vein

starts at the dorsal venus network at the dorsum of the foot (big toe), lies superficial to the fascia lata, and assends up the medial side of the leg and goes a little behind the knee joint and then the medial side of the thigh and then goes through and opening of the fascia lata and enters into the femoral veins -there are also superficial veins that empty into the fascia lata small/lesser saphenous vein: starts at the ankle and drains blood from the posterior lateral part of the calf and ends at the popliteal fossa, the region behind the knee joint -can also see cutaneous branchs of femoral nerve that bring sensation from the skin in the anterior thigh region (cluneal nerves are cutaneous nerves of the buttocks) -veins deep to the fascia lata are still connected to the saphenous vein via perforating veins, these veings have one way valves that prevent blood from refluxing back towards the foot. The blood flows from the saphenous vein to the deep vein and is stopped from flowing back by a valve. Blood is propelled upwards using the gastrocnemius muscles

illiopsoas tendon

tendon resides in the posterior abdomenal wall and has something called the false pelvis created from the illiacus muscle connected to the illiac fossa and the psoas major muscle connected to the lumbare vertebrae that cross the hip joint anteriorly and connect to the lesser trochanter on the femur and projects posterio-medially -when they contract the pull the femur and elevate the femor into the flexion position *main flexor of the thigh at the hip joint* femoral nerve give branch to illiacus muscle, but has the main job to innervate muscles in the anterior thigh (quadraceps and satorius muscle) pectineus- originates on the superior ramus of the pubis on the pectinial line and extends just below the lesser trochanter and crosses the hip joint anteriorly and helps the illiopsoas muscle and tendon to flex the thigh at the hip joint, but because it is located about 45 degrees when it pulls it will also help the main adductor muscle to pull the femor into the midline into adduction

Spondylolisthesis

the anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below Causes: -congenital -*isthmic (spondylolysis or fracture)* -degenerative (arthitis) -traumatic -pathological (osteoporosis, infection or tumor) -post-surgical Symptoms -lower back pain -muscle tightness (tight hamstring muscles) -pain in thighs and buttocks -stiffness -tenderness in the area of the slipped disc *nerve damage (leg weakness or changes in sensation) may result from pressure on nerve roots and may cause pain radiating down the legs

Medial Ligament of the Ankle Joint

the deltoid ligament

Gluteus Maximus

the largest, thickest, coarsest muscle in the body. Originates off of the side of the sacrum through the sacrotuberous ligament and the lower part attach to the upper lateral end of the femur linea aspera called the *gluteal tuberosity*. The space between the gluteus maximus is called the *intergluteal cleft*. The inferior edge of the gluteus maximus is called the *gluteal fold and sulcus* -upper fibers of the gluteus maximus, generally its aponeurosis, will insert in the illiotibial tract (It band) and reinforce it along with fibers from the tensor fascia lata and crosses the leg laterally and insert in a tubercle in the knee -action: contraction pulls femur around laterally and extends at the hip (it is is the power extender) -innervated by the inferior gluteal nerve - gluteus maximus is covered in gluteal fascia -on top of the fascia are the cluneal nerves: superior cluneal nerves arise from the L1-L3 dorsal primary rami inferior cluneal nerves come from the brs. of Post. cutaneous. n. thigh (S2- S3) posterior cutaneous of n. thigh come from S1- S3 and branches and resides under the gluteus fold and supplies the lower part of the skin of the gluteus, and Middle cluneal n.s from S1-S3 of dorsal p.r innervate the lower medial part of the gluteus *these are sensory nerves - the gluteus maximus is supplied with motor innervation by the inferior gluteal nerve) *

Myotome

the muscles innervated by a single segmental spinal nerve, motor loss is usualsy resultant of Spinal pathology tested using isometric resisted muscle testing can also test using the somatic reflex arch (i.e a stretch receptor- sensory)

Sutentalculum tali

the pertuberance on the calcaneous bone, tendon to the flexor hallicus will run under this bone

Arches of the foot

there is active and passive stabiliztion of the arches - talus will act as the keystone within the arch and will place force anteriorly and posteriorly Pes planus "flat foot" (adult acquired flatfoot deformity) arch is formed by the medial longitudinal arch, transverse arch, and lateral longitudinal arch

illiotibial tract

thickening of the fascia lata which helps to support the knee joint when extended and inserts on gerdy's tubercle on the upper lateral tibia helps to brace the knee -it is supported by the aponeurosis of the gluteus maximus and the fascia from the tensor fascia lata

Erector spinae

three colums of muscles lying in parallel: spinalis-most medial, attach to the spinous processes longissiumus- intermediate, longest one and attach to the skull along the mastoid process, it is behind the ear, these muscles can extend the skull on the cervical column illiocostalis- lateral and attach to the ribs originate in thick tendon that attaches to illiac crest, sacrum and sacrotuberus ligament, sacral and spinous processes innervated by the dorsal primary rami