Anatomy Exam 1

Lateral herniation of the lumbar disc

- Can press on nerve roots posterior to the discs exiting the lower intervertebral foramen (EX: herniation of the L4-L5 nucleus pulposus into the vertebral canal compresses the L5 root) Local back bone - Pain along associated dermatome - Weakening if the motor part of the spinal nerve is affected

Spina bifida

- Due to a failure of development and/or fusion of the *vertebral arches of L5 or S1 vertebrae*

Third layer of the plantar region muscles

- Flexor hallucis brevis - Adductor hallucis - Flexor digiti minimi brevis - Opponeus digit minimi

Interspinalis, intertransversarii, and levatores costarum

- Found in deeper layers between vertebrae and adjacent ribs - smaller - Involved in the movements of the vertebral column and assisting in respiration

Coccyx

- Four rudimentary vertebrae that are fused together (some people may have 3) Co1 (first cocygeal vertebrae) may have some similarities (like transverse process) and may remain separated from the rest! - Superior surface of the bone faces the sacrum and has two *Cornua (horns)* that articulate with the sacral horns - Other coccyx bones are small and round

Most common injuries of the cervical spine

- Fractures of the dens of the axis - Traumatic spondylolisthesis (anterior slippage of the vertebral body) - Atlas fractures

Serratus posterior inferior

- Originates from the thoracolumbar fascia and inserts into the lower ribs ACTION: Depresses the ribs INNERVATION: intercostal nerves (T9-T12)

Popliteal fossa contents

- Popliteal arteyr and vein - Tibial nerve - Common peroneal nerve - Genicular artery and vein

THe obturator foramen contents

- The obturator membrane (covers it) - Obturator nerve and vessels - THe acetabular notch - the acetabular notch of the obturator artery through the teres to supply the femur with blood

What is the *true* (obstetric) conjugate?

11.5cm - The distance between the posterosuperior aspect of the symphysis and the middle of the promontory - The *narrowest fixed diameter of the pelvic inlet* - Calculated by substracting approximately 1.5cm from the diagonal conjugate

The vertebral foramen contains the...

1) Spinal cord 2) Meninges 3) Nerve Roots 4) Vessels 5) Fat tissue

The vertebral column contains the..

1) Spinal cord and its nerve roots 2) Vessels 3) Meninges 4) Cerebrospinal Fluid 5) Other fluids 6) LIgaments/supporting tissues

What are the regions of the back?

1) Suprascapular region 2) Part of deltoid region 3) Vertebral region 4) Scapular region 5) Interscapular region 6) Infrascapular region 7) Lumbar region

What are the contents of the suboccipital triangle?

1) Third part of the vertebral artery (Turns medially on the posterior arch of the atlas) 2) Suboccipital nerve (dorsal ramus of C1) that innverates all four muscles of the suboccipital triangle 3) Suboccipital plexus of veins

Anterior leg muscles

1) Tibialis anterior 2) Extensor hallucis longus 3) Extensor digitorum longus

What are the extrinsic muscles of the back?

1) Trapezius 2) Latissimus dorsi 3) Levator scapulae 4) Rhomboideus minor and major "Intermediate extrinsic back muscles" - Serratus posterior superior and inferior

Posterior leg muscles

1) Triceps surae

The hip joint has ___ ligaments

5 Four are *extracapsular*: 1) *Iliofemoral ligament* = lateral part that prevents lateral rotation and adduction of the femur, and medial part that prevents medial rotation of femur 2) *Ischiofemoral ligament* = prevents medial rotation of the femur 3) *Pubofemoral ligament* = prevents femur abduction 4) *Orbicular zone (zona orbicularis)* = maintains contact between the head and the socket Intracapsular ligament: 5) *Teres (round) ligament* = ligament at head of femur that extends between the acetabulum and the head of the femur, and *contains the acetabular artery (branch of obturator artery)

Metatarsal bones

5 'long bone' Base articulates with the tarsal bones Head articulates with the phalangeal bones

How many cervical spinal segments are there?

8, but only 7 cervical vertebra

Symphysis pubis

A *fibrocartilage* tissue between the symphysial surface of the pubic bones (of the two sides) and is *reinforced by the superior and inferior pubic ligaments*

The *intrinsic and extrinsic* muscles of the back are separated by...

A superficial layer of thoracolumbar fascia

Osteophytes and uncinate process

Bony outgrowths (osteophytes) on the uncinate process resulting from uncovertebral arthorsis (degeneration) may compress both the nerve and artery leading to chronic pain

No dorsalis pedis pulse can indicate

Buerger's disease or DM

Rupture of the ligaments securing the dens...

ESP the transverse ligament - Can cause paralysis or death due to compression of the spinal cord or brainstem

Anterior and posterior atlanto-occipital membranes

Extend between the occipital bone and the anterior and posterior arches of the C1, respectively

Sacrospinous ligament

Extends between the *ischial spine and the sacrum* - *Encloses the greater sciatic notch* and converts it to the *greater sciatic foramen*

Sacrotuberous ligament

Extends between the *ischial tuberosity and the sacrum*

Adductor longus

Extends in a mediolateral direction - deeper to the sartorious and lies on the adductor magnus ORIGIN: superior ramus of the pubis INSERTION: middle part of linea aspera ACTION: adduction of thigh: hip flexion INNERVATION: obturator nerve (L2-L4)

The muscles in the anterior region of the leg are ____ of the foot

Extensors (dorsiflexors) and aid in the inversion of the foot

Intramembranous ossification is from cartilage

False; endochondral is (mainly hyaline cartilage)

The short head biceps femoris is a hamstring muscle

False; the long head

There is an intervertebral disc between C1 and C2

False; there is not

You cannot palpate the iliac crest beneath the skin

False; you can - can be used for *bone marrow biopsy* due to the *accessible red bone marrow)

Skin innervation of the back

Innervated by the *cutaneous branches of the intercostal and other spinal nerves* Around midline: - Innervated by *posterior branches of the spinal nerve* (2" from midline) Laterally: - skin is innervated by *anterior cutaneous branches* Scapular line can be used as the border for each innervation

Semispinalis thoracis, cervicis, and capitis

Innervated by the primary dorsal rami and are involved in extesnion of the head and vertebral column, and rotation

Other diameters outside the pelvis

Intercristal distance = 29cm between the lateral aspects of the two iliac crests External conjugate = 20cm between the superior border of the symphysis pubis and L5 spinous process

Vertebral bodies are connected by...

Intervertebral discs (symphyses) and secured by the *posterior and anterior longitudinal ligaments*

The spinal nerve and the vertebral artery pass through the ____ and ____, respectively

Intervertebral foramen and transverse foramen

The cruciate ligaments in the knee are...

Intracpasular but extraarticular (NOT inside the joint cavity)

Rotator brevis and longus

Invovled in stabilizing the vertebrae and aid in rotation and extension of the vertebrae

Branches of the external iliac artery

It continues as the *femoral artery* when it passes beneath the *inguinal ligament and through the *LACUNA VASORUM* - Proximally, the femoral artery gives off some superficial branches including the *superifical epigastric artery, superficial circumflex iliac artery, and the external pudendal artery* that supply the addominal wall - *Deep femoral artery* - found in the FEMORAL TRIANGLE is the largest branch of the femoral artery in the anterior region of the thigh - *Medial and lateral circumflex femoral arteries* originate from the deep femoral artery or direclty from teh femoral artery - Femoral arteyr gives off to *3-5 perforating branches* that pierce and supply the adductor and dorsal muslces

What is the lumbar cistern?

It lies beneath the termination of the spinal cord as the *medullary cone* around L2 - Contains the *CAUDA EQUINA* that consists of *nerve roots and the filum terminale* floating in the CSF

The iliac crest is level with ___

L4

What are the roots of the sciatic nerve?

L4 L5 S1 S2 S3

The lumbosacral trunk is and includes

L4 and L5 - Sciatic nerve - Common peroneal nerve - Tibial nerve - Posterior femoral cutaneous nerve - PUdendal nerve - Superior gluteal nerve

The sacral plexus is from ___ to ___

L4 to S3

The lowest functional intervertebral disc is between

L5 and S1 vertebrae

Meningocele and Meningomyelocele

May be associated with *spina bifica cystica* - Meningocele = It is a herniation of the meninges - Meningomyelocele = herniation of the meninges AND roots/spinal cord Can lead to sensory, motor, autonomic (paralysis of limbs) problems

Central disc herniation

May compress the whole cauda equina causing *paraplegia*

The tibial nerve divides into the ..., which innervates the

Medial and lateral Plantar nerve; the plantar aspect of the foot (sole)

Adductor magnus

Medial aspect of anterior thigh - Part is found deep in posterior aspect of thigh and works with the hamstrings ORIGIN: inferior ramus of pubis, ramus of ischium, and the ischial tuberosity INSERTION: medial lip of linea aspera (adductor part) and the adductor tubercle above the medial femoral epicondyle (hamstring part) - forming the *hiatus tendineus between the two insertion points* ACTION: extensor of the hip and strong adductor of the leg at the hip joint; the part that inserts into the linea aspera is a lateral rotator of the thigh; the adductor part flexes the thgih also; part of the adductor magnus that inserts to the adductor tubercle is a medial rotator of the leg INNERVATION: tibial nerve innervates the part that inserts to the adductor tubercle (hamstring part) and the obturator nerve innervates the adductor part

Gracilis

Medial thigh - Long and thin from pubic bone to tibia ORIGIN: inferior ramus of pubis INSERTION: medial tibial condyle (part of the *pes anserinus superificialis) ACTION: adductor of thigh; flexor of hip and knee joints INNERVATION: obturator nerve (L2-L4)

Rhomboid Minor and Major

Minor: - Origin: spinous process of C6,C7,and T1 - Insertion: Medial margin of the scapula Major (inferior to rhomboid minor): - Origin: spinous process of T2-T5 - Insertion: medial margin of the scapula, inferior to attachment of rhomboid minor ACTIONS OF BOTH: - Press scapulae to thoracic wall and in medial rotation and retraction of scapula INNERVATION: - Dorsal scapular nerve (C4 and C5) to both rhomboids

Osteoporosis

More bone material gets reabsorbed than built up, resulting in decreased bone mass SX: compression fractures and back bone

Spina bifida cystica

More severe form of spina bifida that result when *one or more vertebral arches fail to develop*

Semitendinosus

More superficial, medial ORIGIN: ischial tuberosity INSERTION: proximal part of shaft of the tibia medially, where it joins the tendons of other muscles (gracilis and sartorius) ACTION: extension of the hip joint, as well as strong flexion and medial rotation at the knee joint INNERVATION: tibial nerve (L5-S2)

Tibialis anterior

Most medially located muscle ORIGIN: tibia and interossesous membrane INSERTION: medial cuneiform and the first metatarsal bone ACTION: dorsiflexion and inversion of the foot at the ankle joint

Flexor Digitorum longus

Most medially located muscle, deep posteriorly ORIGIN: tibia (below soleal line) INSERTION: via four tendons to the base of the terminal phalanx of the second to fifth digits

Gastrocnemius

Most superficial of the triceps surae ORIGIN: origiantes by the medial and lateral heads, proximal to the medial and lateral femoral condyles INSERTION: calcaneal tuberosity via Achilles tendon ACTION: plantar flexion at ankle and assists in walking. Active for *Fast* movements (white fiber types) and also flexes the leg at the knee joint

Trendelenberg's sign

Negative - patient can abduct the pelvis on the left side Positive - patient can't abduct pelvis on the left femur - the right buttock droops

*Transverse foramen* =

Present in *CERVICAL VERTEBRAE* - transmits the *vertebral artery on each side* - Develop due to an incomplete fusion of the vertebral and costal elements of the transverse process of the cervical vertebrae during the development - Transverse process of the cervical vertebrae has an *ANTERIOR AND POSTERIOR TUBERCLE* and a *sulcus* between these to allow *spinal nerves to pass through*

ACL in the knee does

Prevents *backward* slipping of the femur, produces medial rotation, and locks the knee in extension

PCL in the knee does

Prevents the femur from *forward slipping*

Plantaris

Relatively small and thin with a long tendon (may be missing in some peole) ORIGIN: lateral femoral condyle INSERTION: tuberosity of the calcaneus

The dura mater ends at the level of ___

S2

"False vertebrae"

Sacral and coccygeal Sacral bones fuse to form the sacrum and coccygeal form the coccyx

Epidural anesthesia is given through ____ to block ___

Sacral hiatus to block the pelvic nerve

Sacralization and Lumbariztion

Sacralization = fusion of the L5 vertebrae with the sacrum Lumbarization = when S1 separates from the sacrum Has pain and other symptoms

Spinal block

Same as LP but input drugs

T3

Scapular spine spinous process

The thickest nerve in the body is the

Sciatic nerve (L4 and S3) branching off the sacral plexus of the lumbosacral plexus

What passes through the greater sciatic foramen?

Several structures including the *piriformis muscle and the sciatic nerve*

Biceps femoris is innervated by

Short head - common peroneal nerve Long head - tibial nerve

Interspinous ligament

Short ligaments between the spinous processes of the vertebrae

Intertransverse ligaments

Short ligaments located between transverse processes of the vertebrae

Congenital Brevicollis (Klippel-Feil syndrome)

Shortness of the neck due to the reduction of cervical vertebrae or fusion of multiple hemivertebrae into one osseous mass with limited neck motion and low hairline

Lumbosacral plexus syndrome

Since the plexus passes close to the abdominal and pelvic structures, it is more prone to damage - Trauma following the surgery like a hysterectomy or during labor may injure the plexus - Compression from abdominal/pelvic tumors, aortic aneurysm, or radiotherapy may also damage the plexus

Where is the lower extension of the spinal cord in adults and newborns?

Spinal cord in adults ends at the *lower level of the L1 vertebra* Newborns it ends in the *L3 vertebra*

Splenius cervicis and capitus

Splenius cervicis: - Originates from spinous process of the mid to upper thoracic vertebrae and runs upward to the C1-C2 transverse process Splenius captius: - Originates from the spinous processes of upper thoracic and lower cervical vertebrae and inserts into the mastoid process ACTION: rotate (when one side contracts) or extend the head and the neck when BOTH contract

Superior gemellus and inferior gemellus

Superior arises from ischial spine, and inferior gemellus originates from the ischial tuberosity INSERTION: both insert to the trochanteric fossa INNERVATION: superior gemellus is supplied via nerve to obturator internus while the inferior gemellus is supplied by the nerve to the quadratus femoris

The ____ nerve can be used for a graft for nerve damage

Sural nerve

The hips join at the ____

Symphysis pubis

The intervertebral discs with their supporting ligaments are considered "___"

Syphyses (secondary cartilaginous joints) between the vertebrae

The Lumbar Plexus is from ____ to ___

T12 to L4

What are the hybrid muscles?

THe *pectineus* (femoral and obturator nerve) Adductor magnus (tibial and obturator nerves)

What are the borders of the femoral triangle?

The *Sartorius muscle* laterally, the *adductor longus* medially (also part of the floor of the triangle) and the *inguinal ligament* is the upper border - The floor of the triangle is formed by the *iliopsoas muscle laterally* and the *pectineus and adductor longus muscles medially*

Site of attachment of the teres ligament on the femur

The *fovea* = a depression on the head of the femur

A fibular fracture can damage..

The common peroneal nerve which causes foot drop/no dorsiflexion (deep peroneal nerve on the anterior muscles of the leg) NO eversion (superior peroneal nerve - peroneus longus and brevis)

What makes intervertebral discs more prone to rupture with age

The gelatinous part of the intervertebral disc (in nucleus pulposus) distributes the pressure and will shrink with age causing the tension on the annulus fibrosus to decrease ALSO Annulus of intervertebral discs is *thinner in its posterolateral parts* and is prone to tearing/herniation of the nucleus pulposus at these sites - Might tear radial and concentrically or may be displaced

The chief extensor of the hip joint

The gluteus maximus

The chief flexor of the hip joint

The iliopsoas muscle

Calcaneus

The largest tarsal bone and has the large bony posterior *calcaneal tuberosity* - There are three articular surfaces on the superior aspect of the calcaneus for articulation with the talus - *Sustentaculum tali* = middle talar articular subsurface is on this bonyprocess - *Calcaneal groove* = the depressed portion of the calcaneus between teh anterior and posterior articular surfaces that appears as a cavity (tarsal sinus) when teh talus is on top of the calcaneus - *Navicular bone* = lies in fron of the talus and articulates with teh three *cuneform bones* anteriorly and the talus posteriorly The cuboid articulates with the calcaneus posterirly; anterirly, it articualtes with the base of the 4th and 5th metatarsal bones, and medially the cuboid articualtes primarily with the lateral ceneiform bone

What are the contents of the femoral triangle?

The main contents

The intervertebral foramen has...

Transmits the: - *Nerve roots* - Vessels of the spinal cord - *Dorsal root ganglion*

"Hangman's fracture"

Traumatic spondylolisthesis of C2 (axis) and tearing of the ligaments between C2 and C3

The lower limb needs to be stronger and larger than the upper limb

True; due to locomotion and movement functions as well as weight bearing - Stronger joints that are more stable, as well

The deep intrinsic muscles of the back?

Two groups *Transversospinalis muscles* 1) Semispinalis 2) Multifidus 3) Rotators *Deep segmental back muscles: 1) Interspinales 2) Intertransversarii 3) Levatores costarium

Dorsal interossei muscles

Two heads each and originate from the opposing surface of all the metatarsal bones INSERTION: base of 2-4th digits AcTION: abductors of the digits

Peronaeal (lateral) group muscles

Two muscles: - Peroneus longus - PEroneus brevis Responsible for teh eversion of the foot at the subtalar and talo-calcane-navicular joints (eversion corresponds to standing on the medial margin of the foot while the lateral margin is up)

Biceps femoris

Typically has two bellies or heads (long and short heads) and lies laterally in the posterior aspect of the thigh LONG head origin: ischial tuberosity of the hip bone Short head origin: linea aspera (lateral lip) of the femur INSERTION: by one tendon to the head of the fibula, encircles the lateral collateral ligament ACTION: long head is involved in extension of the hip, muscle is a flexor and lateral rotator at the knee joint INNERVATION: long head by *tibial nerve (L5-S2)* and short head by *common peroneal nerve (S1-S2)*

Uncovertebral joints

Uncinate processes that are usually flat, but start to elevate during childhood (5-10 years) - These joints can lead to tearing of the intervertebral discs in the cervical region

Osteoarthritis of the vertebra causes ...

Uncovertebral joints to form causing tears/herniation in the disc

Ilium

Upper part = *ala (wing)* Lower part = body *Iliac crest* = curved superior border on the ala - which has medial and lateral lips and an intermediate zone *Anterior superior iliac spine* - the anterior pole of the iliac crest ends into this ' *Anterior inferior iliac spine* = below above *Posterior superior iliac spine* = iliac crest ends here posteriorly *Posterior inferior iliac spine*

Measuring the pressure of CSF

Using a *manometer*

Tibial nerve is composed of ___ rami

Ventral rami

Vertebral ligaments summary:

Vertebral body ligaments: 1) *Anterior longitudinal ligaments* = along anterior surface of the vertebral body 2) *Posterior longitudinal ligaments* = along posterior surface of the vertebral body Vertebral arch ligaments: - *Ligamentum flavum* = between laminae - *Interspinous ligaments* = between spinous processes - *Supraspinous lig.* = along posterior ridge of spinous processes - *Intertransverse lig.* = between the transverse processes *Nuchal lig* = between external occipital protruberance and spinous process of C7 (broadened superiorly)

Obturator nerve injury causes ___

Weakened adduction of the leg

Femoral nerve injury causes ..

Weakened flexion at the hip and extension of the leg (due to the quadriceps femoris and sartorius)

Hemivertebrae

Wedge-shaped vertebrae and can cause angle in the spine (kyphosis, scolisosi, and lordosis) - Results from a lack of formation of one half of a vertebral body - *common cause of congenital scoliosis* Congential - can cause neurologic problems

Cervical rib

When the costal element is preserved independently - usually bilateral but can be one sided (left mostly) CAN CAUSE: - Ischemic muscle pain due to compression of subclavian artery - Pain in the *ulnar* side of the forearm and hand - Palpable mass over the clavicle

Semimembranosus

Wider, deeper than teh semitendonosus on medial aspect ORIGIN: ischial tuberosity INSERTION: divides into three parts (inserts to the medial tibial condyle and neighboring tissues, deep to the pes anserinus superficialis ACTION: extension of the hip joint, strong flexion and medial rotation of the knee INNERVATION: the tibial nerve

Vertebrae are connected by ___ joints, and...

Zygapophysial (intervertebral) And intervertebral discs between the bodies and several reinforcing ligaments

Spina bifida occulta

occulta = "Hidden" Milder form of spina bifida in which some of the vertebrae do not close completely, but the malformation is covered by the skin

Apical ligament

of dens extends from the head of the odontoid process to the anterior border of the foramen magnum

In the transverse foramen of C6, the vertebral artery (from subclavian) will join the other vertebral artery at the ____ to form the ___-

foramen magnus to form the basilar artery

Peroneus longus

has a long tendon and is the most superficial muscle in the lateral aspect of the leg that runs behind the lateral malleolus and passes through the tendon groove of the cuboid bone in the plantar aspect of the foot ORIGIN: head and proximal part of the fibula laterally INSERTION: plantar surface of the base of the first metatarsal and medial cuneiform bones INNERvATION is via the *superficial peroneal nerve (L5-S1) and S2*

Multifidus

innervated by the primary dorsal rami and involved in the stabilization of the vertebrae with the movement of the vertebral column

What is the pelvic inlet?

("Brim") - Extends posteriorly from the middle of the *first* sacral bone (promontory) laterally to the terminal line of both sides - to the pectinate line and the symphysis pubis anteriorly - A heart-shaped border between the upper and lower pelvis that extends from the promontory of the sacrum onto the ala of the sacrum, passing at the arcuate line on theilium, the iliopubic eminence, the pectineal line (pecten pubis), the pubic crest, and the upper border of the pubic symphysis

What is the oblique diameter II of the pelvic inlet?

*11.5-12cm* - Lies between the left sacroiliac joint and the iliopubic eminence on the oppoiste side

What is the oblique diameter I of the pelvic inlet?

*12-12.5 cm* - Distance between the right sacroiliac joint and the opposite iliopubic eminence

What is the transverse diameter of the pelvic inlet?

*13.5 to 14cm* - Measured across the middle of the pelvic inlets

Layers of the intervertebral discs

*Annulus fibrosus* = outer layer - Composed of *collagen and fibrocartilage* tissues arranged in concentric rings *Nucleus pulposus* = central layer - jellylike structural remnant of the embronic notochord - AVASCULAR - gets nutrition via *diffusion* from surrounding blood vessels (like vertebrae and annulus fibrosus)

The spinal cord termiate at ___ in adults (becomes the ___) and at the ___ in newborns

*Conus medullaris* at L1 (adults) where it becomes the cauda equina - nerves and meninges; and the L3

What are the superficial intrinsic muscles of the back?

*Splenius muscles*: Splenius capitis and splenius cervicis

Sacrum

- "Wedge-shaped bone" formed as result of fusion of five sacral vertebrae with their intervertebral discs - Part of the bony pelvis and located between the two hip bones - Base lies superior and faces L5 and apex is inferior and joins the coccyx - Has a *concave (pelvic) surface and convex dorsal surface* Anterior surface (base -top to apex at bottom): - *Sacral promontory* = anterior edge of the S1 vertebra - Two lateral parts that continue with the *ala* of the hip bone - Four pairs of *anterior sacral foraminae* through which the anterior branches of the spinal nerves leave the sacral canal to their destinations - Transverse ridges between the foraminae Dorsal surface: - *superior articular processes* - articulate with L5 - *Opening of the sacral canal* where the cauda equina and surrounding meninges continue downward - *Median, intermediate, and lateral sacral crests* - * Four pairs of posterior sacral foraminae* - *Sacral hiatus* in lowe rpart - *Two sacral horns (cornua) flanking the sacral hiatus Auricular surfaces seen on lateral aspect that are covered by hyaline cartialge to help form the *sacroiliac joint*

What are the contents of the intervertebral foramen?

- *Dorsal root ganglion* lies at the foramen on both sides - The *spinal roots and vessels*

Diameters of the pelvic outlet

- *Interspinous diameter (10cm)* is between the two ischial spines (CRUCIAL) - *Median conjugate (11.5cm)* is the distance between the inferior border of the symphysis pubis to the inferior border of the sacrum - *Straight conjugate (9.5-10cm)* extends from the inferior border of the symphysis pubis to the tip of the coccyx - *distance is variable* due to flexibility/slight movement of coccyx

Posterior aspect of the femur...

- *Linea aspera* can be seen: sharp edge - with a medial lip and lateral lip (that extends to the gluteal tuberosity below the trochanters) - *Condyles* = articular (curvatures are not equal and can be seen on the posterior view - which is why there is an *obligatory medial rotation of the leg at the knee joint when teh knee is fully extended* - *Epicondyles* = nonarticular - *Patellar surface* = the central articular part of the distal end - *Adductor tubercle* = prominence on the superomedial aspect of the medial epicondyle - *indercondylar fossa* lies posteriorly between the medial and lateral epicondyles and provides the base for the triangular popliteal surface above it

Lateral view of the hip:

- *gluteal surface* can be distinguished on the posterior aspect of the ala of the ilium - *Three gluteal lines* (inferior, anterior, and posterior) can be seen on the gluteal surface - and these areas between them give *origin to the gluteal muscles*

Minor differences of the C3-C7 vertebrae

- Anterior tubercle of C6 is *more prominent* = *carotid tubercle* - *Uncinate processes* project upward from the superolateral borders of the body of these vertebrae (including C7) - these are usually flat, but can begin to elevate at 5-10 years old to develop into *uncovertebral joints* - *Vertebra prominence* at the C7 with long palpable spinous process - *C7 is missing an anterior tubercle on its transverse process*

The Hip Joint

- Ball-and-socket synovial joint between the head of the femur and the acetabulum of the hip bone - There is an *articular lip* at the edge of the acetabulum MOVEMENTS: flexion, extension, abduction, adduction, rotation, and circumduction

Ischium

- Body and a ramus and joins the ilium and pubic bone at the *acetabulum* and joins the pubic bone at the *inferior ramus of the pubis* - *Ischial spine and ischial tuberosity* are parts where several muscles attach to - *Lesser sciatic notch* lies between them

What is in the popliteal region?

- Greater saphenous vein (medially) - Saphenous nerve (medially) - Small saphenous vein - Medial sural cutaneous nerve - Branhces of hte posterior femoral cutaneous nerve

Tibia

- Has a *body* (shaft), a *proximal end* and a *distal end* - Articulates with the femur in the knee joint, and the lateral aspect articulates with the fibula at *3 sites* - Proximal end is thick with lateral and medial condyles - *Intercondylar eminence* = the two bony processes that consist of the lateral and medial intercondylar tubercles - *Anteroior and posterior intercondylar areas* lies anterior and posterior to the intercondylar eminences - *Small articular surface is located on the posterolateral aspect of the lateral tibial condyle for articulartion with the head of the fibula* - *Tibial tuberosity* = prominent bony process on the upper limit of the anterior border and is the *site of attachment for the patellar ligament* - *Soleal line* = oblique bony ridge on posterior aspect of upper part of shaft is *site of origin for soleus muscle* - *Interosseous membrane* = tough fibrous tissue (continuous fibrous joint) between tibia and fibula - Distal end is elongated medially and forms the *medial malleolus* - *Fibular notch* = site of articulation with fibula is found on the lateral aspect - INferior articular surface on teh distal end of tibia articulates with the talus in the ankle joint

The ankle joint

- Hinge-type synovial with articular surfaces provided by the tibia, fibula, and talus SUPPORTING LIGAMENTS: - Deltoid ligament - Anterior and posterior talofibular ligaments - Calcaneofibular ligaments

Contents of the lesser sciatic foramen

- Internal pudendal vessels - Pudendal nerve - Obturator internus with tendon

Symptoms of the cervical rib

- Ischemic pain due to subclavian artery compression - Pain due to compression of brachial plexus - Palpable mass in root of neck

Female pelvis characteristics

- Larger - Shallower with wider lesser pelvis - Lighter - Softer - Wider pelvic angle - Less vertically located obturator foramen

The Lumbar Vertebrae

- Larger "kidney-shaped bodies" - *Triangular* vertebral foramen - Vertebral arch consists of a short lamina and a thick pedicle - *Transverse (costal) process is long and slender with an accessory process in the back - Superior articular processes have medial-facing facets - Inferior articular processes have lateral-facing facets - A mammillary process on the posterior surface of the superior articular process - Spinous process is short, thick, and FLAT, and extend in the sagittal direction

Patella

- Largest *sesamoid* bone (bone develops in the tendon of the muscles - Develops in the tendon of the quadriceps femoris muscle and its tendon inserts into the patella in adults - *patellar ligament* is the tissue between the patella and the tibial tuberosity - Has *anterior and posterior (mainly articular) surfaces* with its *apex facing downward* and *base upward*

Cervical disc herniation

- Lateral protrusions compress the *spinal nerve* (EX: disc herniation between C5-C6 or C6-C7 compresses the spinal root C6 or C7) - Can cause pain in the lower neck area and the shoulders - Central disc protrusions press on the spinal cord and affect various tracts as well as vessels (anterior spinal artery)

Trapezius muscle

- Most superficial muscle in the posterior back - Belongs to cranial muscle group inserted on the shoulder girdle - Triangular muscle with *extended midline attachments* and both muscles from both sides produce a trapezium-shaped broad muscle that extends from *external occipital protuberance down to the T12 spinous process* - Covers width of trunk between shoulders Three parts: 1) Descending 2) Transverse 3) Ascending

Sciatica

- Occurs in *lumbar disc herniation* - Referred pain down back/lateral side of leg and foot - in distribution of L5 and S1 - Motor deficits: *dorsiflexion (L5)* and/or *plantar flexion* (S1)

Spondylolisthesis

- One bone in your back slides forward over the one below it - Common in L-spine - Pain/numbess/weakness/incontinence CAN be due to: - Congenital defect - Trauma - Stress fracture - INfection/arthritis affecting joint

Serratus posterior superior

- Originates from spinous process of lower cervical and upper thoracic vertebrae, inserts into upper ribs ACTION: elevates ribs and is involved in respiration INNERVATION: Intercostal nerves (T1-T4)

Ligamentum nuchae

- Originates from the occipital bone and extends to the spinous process of the cervical vertebrae, where it *becomes continuous with the supraspinous ligaments* - SOME BACK MUSCLES ATTACH TO THIS LIGAMENT

Medial view of the ilium

- Smooth lateral part = *iliac fossa* on the ala - Rough medial part on the back = *iliac tuberosity* that faces the sacrum in the pelvis - *Auricular surface* = smooth part of bone between the iliac fossa and the iliac tuberosity - *site of articulation with sacrum at the sacroiliac joint* - *Arcuate line* = lower limit of the ala that extends from the anterior aspect of the auricular surface to the *ilipubic eminence* - Body of the ilium is located *below the arcuate line* and extends posteromedially to the *greater sciatic notch*

What are the contents of the transverse foramen?

- Vertebral artery and vein in the *C1-C6 vertebrae* - *C7*'s contains the *accessory vertebral vessels*

Metatarsal stress fractures

- repetitive stress - 2nd and 3rd metatarsals most affected

General structure of the vertebrae:

1) *Body* = anterior 2) *Vertebral arches* = connects the body posteriorly and fuse together to form the *vertebral foramen* 3) *Spinous process* = bone process posterior to point of fusion 4) *Pedicle and lamina* = on the arch itself - Pedicle = adjacent to the body - Lamina = continues posteriorly 5) *Transverse process* = bony extension on the vertebral arch 6) *Superior articular process* = at the junction between the pedicle and the lamina on each side = PROJECTS UPWARD -contains a *facet covered by hyaline cartilage* 7) *Inferior articular process* = PROJECTS DOWNWARD = at junction of pedicle & lamina - contains a *facet covered by hyaline cartilage* -- THE SITES OF ARTICULATION 8) *Vertebral notch* = a depression on the superior and inferior surfaces of the pedicle, between the articular process and the vertebral body 9) *Intervertebral foramen* = where vertebrae join each other in the vertebral column, formed by the vertebral notch

What are the differences between the male and female pelvis?

1) *Pelvic inlet (brim)* = wider and oval shaped from side to side in female; more narrow and heart-shaped in males 2) *Pelvic outlet* = F: wider, ischial tuberosities are shorter and farther part and everted; M: more narrow; ischial tuberosities are longer, sharper, and point more medially 3) *Iliac fossa* = F: shallower; M: deeper 4) *Pubic arch* = F: >90degrees; M: <90 degrees 5) *Acetabulum* = F: faces anteriorly; M: diverted laterally 6) Ischial spine = F: points posteriorly; M: points medially 7) Obturator foramen = F: oval; M: round

The branches of the *internal iliac artery* to the lower limb

1) *Superior and inferior gluteal arteries* - originate indirectly from the internal iliac artery and leave the pelvis posteriorly toward the glutes through the *superpiriformis hiatus and infrapiriformis hiatus of the GREATER SCIATIC FORAMEN*, respectively 2)*Internal pudendal artery* - leaves through the infrapiriformis hiatus and enters the lesser sciatic foramen, then *supplies the perineum by passing through ALCOCK"S CANAL* (fascia of the obturator internus muscle) 3) *Obturator artery* - indirect branch of the internal iliac artery - passes through the *obturator canal and supplies the lower limb (adductor) muscles and other structures by an anterior branch* - also supplies the *external muscles of the hip via a posterior branch* 4) *Acetabular branch of the obturatory artery* - etners the ligament of the head of the femur (round/teres ligament) and is very imoprtant esp in children - other branches, such as the iliolumbar artery , supply the *psoas muscle and other structures*;

What are the adductors of the thigh?

1) Adductor longus 2) Adductor brevis 3) Adductor magnus 4) Gracilis 5) Pectineus

Functions of the intervertebral discs

1) Bearing weight 2) Facilitating movement between adjacent vertebrae 3) Absorbing shock to the vertebral column and spinal cord - Compressible and contribute *20-25%* of the length of the vertebral column - Has a thin plate of hylaine cartilage on top and bottom (derived from epiphysis of the vertebral body)

Posterior (dorsal) hip muscles

1) Gluteus maximus, medius, and minimus

What are the bones of the lower limb?

1) Hip bone 2) Femur 3) Patella 4) Tibia/fibula 5) Tarsal bones (calcaneus, talus, navicular bone, cuboid, and three cuneiform bones) 5) 5 metatarsal bones 6) 5 proximal phalanges 7) 5 distal phalanges 8) 4 intermediate phalanges (big toe has two phalangeal bones)

What are the intermediate intrinsic muscles of the back?

1) Iliocostalis 2) Longissimus dorsi 3) Spinalis AKA The *ERECTOR SPINAE* muscles

Three parts of the hip bone

1) Ilium (upper part) 2) Ischium (posteroinferior part) 3) Pubis (anteroinferior part)

What are the articulations between the C1 and C2

1) Lateral atlanto-axial articulation 2) Median atlanto-axial articulation

Hamstring muscles

1) Long head of the biceps 2) Semitendinosus 3) Semimembranosus 4) Ischial portion of the adductor magnus

Contents of the intervertebral foramen

1) Nerve roots 2) Dorsal root ganglia 3) Vessels

What is the content of the popliteal fossa?

1) Popliteal artery 2) Popliteal vein 3) Tibial nerve 4) Common peroneal nerve 5) Genicular arteries and veins

The deep muscles of the posterior leg

1) Popliteus - flexes the knee 2) Flexor digitorum longus - active in plantar flexion at ankle joint/inversion of foot 3) Tibialis posterior - active in plantar flexion at ankle joint/inversion of foot 4) Flexor hallucis longus - active in plantar flexion at ankle joint/inversion of foot The tendons of (2-4) pass beneath the flexor retinaculum that extends transversely between the medial malleolus and calcaneus VARIOUS roots of the tibial nerve (L4-S3) are responsible for innervation

What are the functions of the vertebral column?

1) Protect spinal cord 2) Points of origin/insertion for muscles 3) Movement of trunk and body posture 4) Supports weight/movement of head and trunk/pelvis Movements of the vertebral column: - Flexion - Extension - Lateral flexion - Rotation

The muscles that build the borders of the SUBOCCIPITAL TRIANGLE

1) Rectus capitus posterior major 2) Obliquus capitis superior 3) Obliquus capitis inferior The rectus capitus posterior minor is close to the MIDLINE of this region

The anterior thigh muscles

1) Sartorious 2) Quadriceps femoris 3) Iliopsoas 4) Pectineus 5) Gracilis 6) Adductor muscles

What are the major differences between the cervical and other vertebrae?

1) Smaller vertebral body 2) Larger vertebral foramen 3) Transverse foramen 4) Most have a *bifid spinous process*

Thoracic vertebrae

12 - "Heart-shaped body" with an arch on the posterolateral aspect on each side - Pedicle is the anterior part of the arch followed by the lamina (posterior part of arch) toward the back - Arches join and form a vertebral foramen (*Smaller usually than C or L vertebral foramen) - *long and posterioinferior sloping* of the spinous process! (Distinguishing) (Except for the last 3 or 4 T spines) - *Long and strong transverse processes and extend posterolaterally from the arch near the junction between pedicle & lamina - Two superior and inferior *articular processes* close to the lamina/pedicle junction and have *articular facets* for articulation with other vertebrae - *Superior vertebral notch* - shallow depression on superior margin of the pedicle and on its inferior margin, the deeper *inferior veretebral notch* is visible - FOrms the *intervertebral foramen on each side* when two vertebrae articulate

What is the anatomical conjugate of the pelvic inlet?

12 cm Between the upper border of the symphysis pubis to the middle of the promontory

The neck of the femur connects the body (shaft) at a ____ angle

126 degree angle in adults = *angle of inclination* Angle is usually wider (145) in small children, and *smaller* in older people (120)

Diagonal conjugate

13cm - Distance between the inferior border of the symphysis pubis and the middle of the promontory - Measured via *vaginal examination* - Two fingers: index and middle - middle finger will touch the promontory and the glove is marked (with the other hand) close to the thumb at the orifice of the vagina while still touching the promontory, and the distance from the tip to the middle finger is measured

____ of the vertebral column is the vetebral disk

20-25%

Intermeningeal spaces and their contents

3 spaces can be identified with relation to the meninges: 1) *Epidural space* = between the bone (periosteum) and the dura mater - Contains fat, vertebral veins, and nerve roots - Wider in lower parts of the vertebral canal (below L2) 2) *Subdural space* = between the dura mater and the arachnoid mater 3) *Subarachnoid space* = between the arachnoid and pia maters - Contains the CSF - Larger in specific areas of the vertebral column = *Cisterns* These vessels also contain vessels and nerve roots

Vertebrae in the human body..

33-34 7 Cervical 12 Thoracic 5 Lumbar 4-5 Soccygeal Vertebral column extends from the head (skull) down to the apex of the coccyx

Action and innervation of the Trapezius

ACTION: - Supports scapula and shoulder, *elevation of scapula (shrug)* using the descending fibers producing slight elevation of arm in conjunction with the serratus anterior muscle - All parts work to pull scapula toward vertebrae to allow *retraction* and some fibers pull the clavicle - *Acending and descending* fibers rotate the scapula and adduct the arm INNERVATION: - Spinal root of the *accessory nerve (Cranial nerve XI)* is involved in MOTOR innervation - *C3-C4* are involved in SENSORY (proprioception and pain)

ACTIONS and sensory innervation of the suboccipital triangle

ACTION: bilateral contractions turns the head backward, unilateral contracts turn the head to the side SENSORY: greater occipital nerve (C2)

Extensor hallucis brevis

ACTION: dorsiflexion of the big toe Innervation: deep peroneal nerve (L5-S1)

*Anterior longitudinal ligament*

ALL - Strong and broad band that *prevents hyperextension of the vertebral column* - Attached on the anterior aspect of the vertebral bodies and extends from *atlas down to sacrum* - In uppermost portion: Between the *occipital and C1* = called the *anterior atlanto-occipital membrane* , and between *C1 and C2* = the ALL is called the *anterior atlanto-axial membrane*

Fourth layer of the plantar regions muscle

ALl innervated by the *lateral plantar nerve*

The largest and most powerful tendon in the body

Achilles (calcaneal)

The subsartorious canal

Adductor, Hunter's canal Starts distal to the femoral triangle Contains: - Femoral artery and vein - Saphenous nerve - Nerve to vastus medialis - Small branch of the obturator nerve - Great saphenous vein

How and where is the lumbar puncture performed?

After the spinal cord ends (around L1 in adults) the dura mater continues downward to S2, where a *dural sac or lumbar cistern is formed and is used for an LP* - Needle is passed between the spinous processes and the interlaminar space between L3-L4 or L4-L5 - through the skin into the *subarachnoid space* by piercing *through the dura and arachnoid mater* - A line drawn between teh iliac crests is at the approximate level of the L4 spinous process - LP for newborns is better at L4-L5 to prevent spinal cord injury - Anesthetics, drugs, and contrast medium for myelography can be given through an LP

Pelvic outlet

Almost diamond-shaped border between the *coccyx* (posterior), ischial tuberosities laterally, inferior rami of the pubic bones (on both sides), to the inferior border of the symphysis pubis (anterior)

Transverse ligament of the atlas

Articulates with the articular facet of dens posteriorly

Talus

Articulates with the lower leg bones to transmit the body weight to the foot (primarily to the underlying calcaneus) as well as to other tarsal bones - Has a body, neck, and head with few articular surfaces on the talus that connect with other bones - Superior part is the *trochlea* that bears articular facets for the distal fibula/tibia - Navicular surface = articulates with the nvicular bone on the articular surface o fthe head - 3 articular facets can be distinguished (posterio facet) on the inferior surface of the talus - for *articulation with teh calcaneus* - *Talar sinus* = groove on the inferior surface of the talus between the middle and mposterior calcaneal facets

Zygapophysial joints

Articulations between the *Vertebral arches* - Plane-type synovial joints - Articulations between the *facets of the vertebral articular processes* - Have tense capsule that is lax in the cervical joints and *permits meniscoid infoldigns*

Tibial nerve innervates everything in the ___ leg except the

Back of leg; except the short head biceps femoris

Atlanto-occipital articulation (upper head joint)

Between the *superior articular facets of the atlas (C1) on the lateral masses* and the *occipital condyles* FORWARD (flexion) and BACKWARD (extension) movement of the head are permitted by this joint

Buerger's disease

Blood vessels become inflamed, swell, and can become blocked with thrombi and can lead to infection/gangrene

Atlas

C1 vertebrae 1) NO BODY in the atlas 2) Two lateral masses connected by a small *anterior arch* and a large *posterior arch* with their superior and inferior surfaces being covered by cartilage forming the *articular surfaces* that join the *occipital bone superiorly* and with the *axis at the LATERAL ATLANTO-AXIAL ARTICULATION* inferiorly 3) Large vertebral foramen with the anterior part providing a space for the *dens (odontoid process)* of the axis 4) Has the *fovea dentis* = an articular facet on the Inner aspect of the anterior arch for one of the articulations between C1 and C2 (*MEDIAN ATLANTO-AXIAL ARTICULATION) 5) NO spinous process but has a *posterior TUBERCLE and anterior TUBERCLE on its two arches* 6) Has transverse process to bear the transverse foramen each side laterally

Axis

C2 1) *Dens/"odontoid"* process on the body with an *apex and two articular facets: anterior for articulation with the atlas and posterior for connection with the transverse ligament of the atlas* 2) Relatively large vertebral foramen 3) Bifid spinous process (usually) 4) Transverse process with transverse foramen 5) *OBLIQUE ARTICULAR SURFACES* and articulate with the atlas at the superior articular surfaces and join with C3 at the inferior articular surfaces

The trapezius is innervated by the ___-

CN XI (accessory nerve) C3 and C4

Sacrum

COnsists of *five* sacral vertebrae fused with one another with the *intervertebral discs between them* followed by 4-5 coccygeal vertebrae - It articulates with the hip bones on *both sides of the sacroiliac joints* that is reinforced by several ligaments including the dorsal, ventral, and interosseous sacroiliac ligaments

Bacterial meningitis

CSF from subarachnoid space has decreased glucose and increased protein

What is vertebrobasilar syndrome?

Caused by *artherosclerosis* of the vertebral arteries in and around the suboccipital triangle - Due to insufficient blood supply to the hindbrain - BLood supply to brain can be lessened by turning the head up and back for a period of time - leading to dizziness and light-headedness

Distinguishing factors for the cervical, thoracic, and lumbar vertebrae

Cervical = transverse foramen, bifid spinous processes, larger vertebral foramen and smaller bodies Thoracic = long spinous processes with a postoinferior slope; costal facet Lumbar = large kidney shaped body, small vertebral bodies and short spinous processes

Order of the size of vertebral foramens

Cervical > Lumbar > Thoracic

Orientations of the facets on the articular processes

Change as we move caudally Supero-inferior orientation facing upward and downward in the *cervical region* Facets face medially on the superior articular process and laterally on the inferior articular process for *lumbar region*

The common peroneal nerve is composed of ___ rami

Dorsal rami

If the head of the fibula is damaged, the ___ nerve is damaged

Common peroneal

If the fibrous ring of the anulus ruptures completely (stress resistance decreases with age), the herniated material may..

Compress the contents of the intervertebral foramen (nerve roots and blood vessels)

Longissimus

Comprised of longissimus thoracis, cervicis, and capitus - All are innervated by the primary dorsal rami of the spinal nerves

Spinalis

Comprised of spinalis thoracis, cervicis, and capitis - Spinalis capitis is often absent

Iliocostalis

Comprised of the iliocostalis lumborum, thoracis, and cervicis - All innervated by the dorsal rami of various spinal nerves

Quadriceps femoris

Consist of *four heads*: 1) Rectus femoris 2) Vastus lateralis 3) Vastus intermedius 4) Vastus medialis ORIGIN: rectus femoris is from anterior inferior iliac spine, vastus muscles from shaft of the femur INSERTION: come together in one common tendon, insert into the patella , and continue below thepatella as the patellar ligament that inserts to the tibial tuberosity ACTION: Extesnor of the knee joint, and the rectus femoris can also flex the hip joint INNERVATION: *Femoral nerve (l2-L4)*

Iliopsoas

Consists of the iliacus and psoas major muscles - Psoas major is deep abdominal muscle and the iliacus is a muscle of the pelvic wall - they join to form iliopsoas ORIGIN: Psoas originates from the body and transverse process of the *five lumbar vertebrae* and iliacus originates from the iliac fossa of the ala of the ilium INSERTION: lesser trochanter of the femur ACTION: Strong flexor of the hip and psoas major can flex body laterally INNERVATION: lumbar plexus for psoas and femoral nerve for iliacus muscle

Atlanto-axial articulation (lower head joint)

Consists of the median and lateral atlanto-axial articulations between teh *C1 and C2 vertebrae* - Lateral joints are found between the *inferior articulate facets of the atlas* and the *superior articular facets of the axis* - Median atlanto-axial joint is located between the *anterior articular facet of the odontoid process (dens) of the axis* and the *posterior surface of the anterior arch of the atlas - an articular site for the dens* ALLOWS ROTATION (side to-side movement of head) - During rotation of the head, the cranium and C1 move as *one unit* on C2

Filum terminale

Cordlike extension of the pia mater originating at the medullary cone

Obturator membrane

Covers the obturator foramen, but leaves a small opening called the *"Obturator canal"* on the superomedial part - which the *obturator nerve and vssels pass thro

The Joints of the vertebral column

Craniovertebral joints: 1) *Atlanto-occipital joints* - occiput and C1 2) *Atlantoaxial joints* - C1 & C2 Joints of the vertebral bodies: 3) Uncovertebral joints - C3-C7 4) Intervertebral joints - C2-S1 Joints of the vertebral arch: 5) Zygapophyseal joints - C2-S1

Trendelenbug sign/waddling gait is caused by..

Damage to the superior gluteal nerve (gluteus medius and minimus that keeps the pelvis level)

The _____ innervates the anterior lower leg and the dorsum of the foot

Deep peroneal nerve

____ can help determine whether or not vaginal delivery will be difficult

Diagonal conjugate

The popliteal fossa

Diamond shaped Inferior: *Gastrocnemius (medial and lateral heads* muscle Superior: *Semitendinosus and semimembranosus (medial)* and biceps femoris (lateral) FLoor: - Popliteal surface of femur, knee joint, and upper - Tibial bone, oblique popliteal ligament, and popliteal muscle

Adductor hallucis

Features an oblique head and transverse head ORIGIN: oblique head from cuboid, lateral cuneiform and the base of the 2-4 metatarsal bones; transverse head from deep tissues on the metacarpophalangeal joints INSERTION: both into the lateral sesamoid bone, beneath head of 1st metatarsal bone INNERVATION: lateral plantar nerve (S2-S3)

Femoral hernia is more painfula nd present in

Females Below and lateral to pubic tubercle

Sacrum males vs females

Females: sacrum is wider, shorter, and more concave Males: sacrum is longer and less wide

The lower limb is supplied mainly by the ___ artery, coming from...

Femoral artery, coming from the *external iliac artery* and by bracnhes of the *internal iliac artery*

Pectineus muscle is innervated by the

Femoral nerve and obturator nerve

Among the cervical vertebrae, the ____ are different among the other vertebrae

First, second, and seventh

Cruciate ligament

Formed by the superior and inferior longitudinal bands, and the transverse ligament of the atlas

Lumbricals

Four tiny muslces originating from the medial side of the tendons of the flexor digitorum longus INSERTION: dorsal aponeurosis of the 2-5 digits ACTION: plantar flexion of the 2-5 digits INNERVATION: medial plnatar nerve (S2-S3) to the medial lumbrical, and the lateral plantar nerve (S2-S3) to the other lumbricals

The ____ innervates the posterior aspect of the leg, except

Tibial nerve; except the short head of biceps femoris

Vertebral artery

Goes through the transverse foramen - Originates from the *subclavian arteries* on both sides - Provide the major blood supply to the *spinal cord and brain stem, and partially the brain* - Has three parts: 1) Extends from point of origin to the transverse foramen 2) Ascending in the transverse foraminae 3) Turns medially on the posterior arch of the atlas and is found in the *suboccipital triangle*

The ___ vein can be used for coronary bypass surgery

Greater saphenous vein

Piriformis

Greater sciatic foramen and may be paritally or totally absent ORIGIN: arises with several slips from teh anterior surface of the sacrum and the sacrotuberous ligament INSERTION: greater trochanter of the femur ACTION: lateral rotator of the extended thigh and abductor of the flexed thigh, keeps the femur head in teh acetabulum INNERVARTION: nerve to the piriformis (sacarl plexus S1-S2)

The trochanteric fossa lies behind the ____

Greater trochanter

Pubis

Has a *body* - Inferior and superior *ramus* as well - *Obturator foramen* is between the rami of the pubis and the ischium - *Pectin pubis (pectinate line)* extends from the iliopubic eminence to the pubic tubercle on the body and superior ramus of the pubis (medial view) - *Pubic crest* follows the *pubic tubercle* toward the *symphysial surface of the pubis* where it articulates with teh pubic bone on the other side *in the symphysis pubis*

Flexor hallucis brevis

Has two heads (medial/lateral) extending to the medial and lateral sesamoid bones on the plantar surface of the head of the first metatarsal bone ORIGIN: medial cuneiform bone INSERTION: proximal phalanx of the big toe INNERVATION: medial plantar nerve (S2-S3)

Herniation of a disc is more common...and less common...

Herniation of the disc (*nucleus pulposus*) is more common in the lower lumbar (betwee L4-L5, L5-S1) Less common in the lower cervical (between C5-C6; C6-C7)

Extensor digitorum brevis

INSERTION: by three tendons to the dorsal aponeurosis ACTION: involved in the dorsifflexion of the digits Innervation: deep peroneal nerve (L5-S1)

The sciatic nerve injury can cause

If complete: - Causes complete loss of the function of the leg beacuse the hip is impaired - Flexion of the leg is lost - All foot/ankle movements are lost Damages to the medial side of the butt can cause damage to the branches of the sciatic nerve that innervate the hamstrings which would impair thigh extension and leg flexion

Bone grafting is from the ___-

Iliac crest

Bone marrow can be taken from the

Iliac crest of the inonimate bone

Iliopsoas is innervated by the...

Iliacus - femoral nerve Psoas - lumbar plexus

Action and innervation of the intermediate intrinsic back muscles (iliocostalis, longissimus, and spinalis)

Iliocostalis and longissimus muscles keep the body in an *erect position* Erector spinae act as *extensors* of the vertebral column when both sides contract and they flex the spines laterally to the same side if contracted unilaterally Spinalis muscles have similar actions but on their corresponding spines INNERVATION: all by primary spinal dorsal rami

Iliolumbar ligament

Important - Srong that lies between the *Transverse process of the lumbar vertebra and the iliac crest* to support connection of hip bone to vertebrae

Spina bifida can result from a neural tube defect...

In which the caudal neuropore fails to close in the *4th intrauterine week* MAY decrease chance with *folic acid supplement*

The tarsal bones

Include the - Talus - Calcaneus - Cuboid - Navicular bones - Three cuneiform bones

Muscles of the dorsum of the foot:

Include the *extensor hallucis brevis* and the *extensor digitorum brevis* - The tendons of the long extensors of the foot lie superficially to these muslces, and form a *dorsal aponeurosiss* into which the tendons of the short extensors of the digits (and the plantar/dorsal interosseus muscles) ORIGIN: calcaneus bone INNERVATION: deep peroneal nerve (L5-S1)

The second layer of the plantar muscles

Include the quadratus plantae and the lumbricals

Gluteus medius

LIes partially beneath the gluteus maximus, it is fully revealed when teh gluteus maxius has been removed or sectioned ORIGIN: iliac crest and external surface of the ilium (ala), between the anterior and posterior gluteal lines INSERTION: greater trochanter of the femur ACTION: abduction and medial rotation of the thigh; it also helps in lateral rotation and flexion of the hip. gluteus medius keeps *the pelvis level when the opposite leg is raised* INNERVATION: superior gluteal nerve (L5-S1)

Fibula

Lateral - same lenght as tibia - Proximal: has a sharp *apex* followed by the head with an articular facet on the medial aspect of the proximal end for tibial articulation - Distal end forms the lateral malleolus - Fibula connects to the tibia at the distal end via the *tibiofibular syndesmosis* and bears the anterior and posterior tibiofibular ligaments

Due to the incongruity between the articular surfaces, the -____ facilitate the movement of the knee joint

Lateral and medial menisci

Together the ____ and ____ make the arcuate artery that gives rise to

Lateral tarsal and dorsalis pedis make the arcuate artery giving rise to metatarsals and dorsal digital arteries

L4

Level of iliac crest

S2

Level of the posterior superior iliac spine

Adductor brevis

Lies partially beneath the adductor longus ORIGIN: inferior ramus of pubis INSERTION: upper part of linea aspera ACTION: adduction of thigh and flexor of hip joint INNERVATION: obturator nerve (L2-L4)

How to differentially diagnose a winged scapula

Lift arm greater than 90 degrees = damage to the *dorsal scapular nerve (rhomboid major/minor)* IF you can't lift the arm greater than 90 degrees there is damage to the *long thoracic nerve (serratus anterior)* - from bad mastectomy common

Ligamentum flavum vs the Longitdudinal ligaments

Ligament inside vertebral foramen (posterior) Longitudinal is anterior (near body of vertebrae)

Adductor magnus is innervated by the

Linea aspera - tibial nerve Adductor tubercle by the obturator nerve

Ligamentum flavum

Located between the *vertebral arches* and is considered a *continuous joint* between them - Contains *elastic fibers* and is yellowish - Brings the *flexed vertebral column back into its erect position* - An "active" ligament with peculiar structure/innervation

Sartorius

Long and narrow muscle ORIGIN: anterior superior iliac spine INSERTION: medial aspect of proximal tibia together with tendon of gracilis and semitendinosus to form the *pes anserinus superficialis* ACTION: acts on two joints - a flexor at both the hip and knee joints INNERVATION: femoral nerve (L2-L4)

The Lumbosacral plexus

Lumbar part (*Lumbar plexus (T12-L4)*): - Lies on the psoas muscle - Innervates anterior regions mostly and structures of abdominal wall, pelvis, and perineum - Major nerves include: *femoral nerve (L2-L4)* and *obturator nerve (L2-L4)* - Other nerves: subcostal (T12), iliohypogastric (T12-L1), ilioinguinal (L1), and genitofemoral (L1-L2) and the lateral cutaneous nerve of the thigh (L2-L3) Sacral part (*Sacral plexus (L4-S3)*): - Innervates the posterior regions mostly and parts of the abdominal wall, pelvis, and perineum - Formed by the anterior/posterior rami of L4-S3 and lies on the *piriformis muscle* - Nerves branching: *Sciatic nerve (L4-S3)* that is found in the infrapiriformis hiatus of the greater sciatic foramen deep in the gluteal region - Sciatic nerve consist of the *common peroneal* and *tibial branches (nerves)* that separate in mid/lower thigh region close to the popliteal fossa - Common peroneal nerve is formed by the *dorsal rami of L4-S2* - Tibial nerve consists of the *ventral rami of L4-S3* - OTHER NERVES: *inferior and superior gluteal nerves* and *posterior femoral cutaneousn nerve* - *Pudendal nerve* is formed by the S2,3, and S4 roots and innervates the perineal structures - L4 and L5 form the *lumbosacral trunk*

The nerves to the skin, muscles, and deep tissues of the lower limb are derived from the ______

Lumbosacral plexus

Opponens digiti minimi

MOst often found beneath the flexor digiti minimi brevis

Gluteus minimus

ORIGIN: ala of the ilium, between teh anterior and inferior gluteal lines INSERTION: greater trochanter of the femur ACTION: gluteus medius's actions too abduction and medial rotation of the thigh; it also helps in lateral rotation and flexion of the hip. gluteus medius keeps *the pelvis level when the opposite leg is raised* INNERVATION: superior gluteal nerve (L5-S1)

Tensor Fasciae Latae

ORIGIN: anterior superior iliac spine, extending distally to the greater trochanter where the main belly of the muscle is located, then merging into the IT tract INSERTION: lateral tibial condyle (through IT tract) ACTION: abduction, medial rotation, and flexion of the (hip) thigh, and supports the knee joint INNERVATION: superior gluteal nerve (L4-L5)

Flexor digiti minimi brevis

ORIGIN: base of 5th metatarsal INSERTION: base of proximal phalanx of the 5th digit Innervation: lateral plantar nerve (S2-S3)

Flexor digitorum brevis

ORIGIN: calcaneal tuberosity and plantar aponeurosi INSERTION - middle phalanx of the second through fourth digits

Abductor hallucis

ORIGIN: calcaneal tuberosity and plantar aponeurosis INSERTION: medial sesamoid bone and the base of the proximal phalanx of the big toe

Abductor digiti minimi

ORIGIN: calcaneus and plantar aponeurosis, as well as the fifth metacarpal bone INSERTION: base of hte proximal phalanx of the fifrth digit

Flexor hallucis longus

ORIGIN: fibula and interosseous membrane INSERTION: base of the termianl phalanx of the big toes ACTION: flexes the big toe and helps in plantar flexion

Extensor Hallucis longus

ORIGIN: fibula and interosseous membrane INSERTION: terminal phalanx of the big toe ACTION: dorsiflexion of the big toe and the ankle

Soleus

ORIGIN: head and proximal parts of the fibula; soleal line and middle part of the tibia INSERTION: tuberosity of calcaneus via the Achilles tendon ACITON: active in *hard and sustained motion* (red fiber type)

Characteristics of Hamstring muscles

ORIGIN: ischial tuberosity INSERTION: around the bones of the knee joint ACTION: flexors (Strong) of the knee joint; extensors (Weak) of the hip joint INNERVATION: the tibial nerve

Quadratus femoris

ORIGIN: ischial tuberosity INSERTION: intertrochanteric crest ACTION: lateral rotation and adduction of the hip, lateral rotators of the thigh are stronger than the medial rotators, and control balance INNERVATION: supplied via the nerve to the quadratus femoris

Popliteus

ORIGIN: lateral femoral epicondyle INSERTION: the tibia, above the soleal line ACTION: flexion of the knee, unlcoking of the knee joint (rotates the femur) and medial roation of the leg

Obturator Internus

ORIGIN: obturator internus originates at the inner surface of the hip bone, near the obturator foramen, before passing posteriorly through teh lesser sciatic foramen INSERTION: trochanteric fossae (2) INNERVATION: nerve to the oburator internus (L5-S1)

Pectineus muscle

ORIGIN: pectin of pubis from iliopubic eminence down to the pubic tubercle INSERTION: pectineal line on the posterior aspect of the femur ACTION: adductor of thigh and flexor of hip joint INNERVATION: femoral (L2-L3) and obturator nerve

Extesnor digitorum longus

ORIGIN: tibial condyle, fibula, and interosseous membrane INSERTION: base of the distal phalanx of hte second through fifth digit ACTION: dorsiflexion of the foot at the ankle, and the corresponding digits

The adductor muscles are innervated by the ____ nerve, with the exception of the

Obturator; except part of the adductor magnus

*Uncovertebral joints*

Occur *between the uncinate processes of C3-C7 and the inferolateral surfaces of the vertebral bodies superior to them* in the cervical region "secondary joints" that develop during childhood (around 10 yo) as the uncinate processes elongate and elevate - May result from fissures in the cartilage of the discs that assume an articular character - If the fissures become complete tears, the risk of nucleus pulposus herniation is increased - May induce gaps in intervertebral discs - increasing chance of patholgoic cleft or split/tear in disc (common in C5)

Peroneus tertius

Often present and is sometimes part of the extensor digitorum longus and extends to the base of hte fifth metatarsal bone Helps in eversion of the foot

Supraspinous ligaments

On the spinous processes, that provide a *continuous connection* from C7 to sacrum

Uncovertebral arthrosis

One of the major degenerative disorders of the cervical spine

Hamstring muscles: Origin: ____ Innervation: ____ Function (strong): ___ Function (weak): ____ Insertion: ____

Origin ischial tuberosity Innervation: tibial nerve Function: strong flexors of the knee Function: weak extensors of the hip Insertion: around the knee joint

Transverse part of trapezius

Origin: Spinous process of C7-T3 and the supraspinous ligaments Insertion: Clavicle and spine of scapula, including the acromion process

Acending part of trapezius

Origin: Spinous process of T3-T12 and supraspinous ligaments INsertion: Spine of scapula

Lattisimus dorsi

Origin: Spinous process of T7-T12, the thoracolumbar fascia, the lower ribs (10-12), iliac crest, and inferior angle ofscapula Insertion: Crest of lesser tubercle of the humerus ACTION: adduction and lowering the arm, and raise the body toward the shoulder; Medial rotation and extension of the arm by acting on the humerus; COUGHING and forced expiration INNERVATION: *Thoracodorsal nerve (C6,7,8) - branch of posterior cord coming from the BRACHIAL PLEXUS*

Levator scapulae

Origin: Transverse process of C1-C4 Insertion: Superior angle of the scapula ACTIONS: elevates the scapula, rotates the inferior angle of the scapula medially, rotates the glenoid of the scapula downward INNERVATION: Dorsal scapular nerve (C4-C5)

Quadratus plantae

Origin: by two heads from teh calcaneus Insertion: lateral border of the tendon of the flexor digitorum longus Innervation: lateral plantar nerve (S2-S3)

Descending part of trapezius

Origin: external occipital protuberance, superior nuchal line, and ligamentum nuchae INsertion: lateral third of the clavicle

Alar ligaments

Originate from both sides of the dens to the lateral borders of the foramen magnum

Peroneus brevis

Originates from teh lateral surface of the fibula, has a shorter tendon, and inserts to the tuberosity (base) of the 5th metatarsal bone INNERvATION is via the *superficial peroneal nerve (L5-S1) and S2*

Ligaments supporting the knee joint

Outside the joint capsule: - *Medial (tibial) collateral ligaments* - *Lateral collateral ligaments* - *Iliotibial tract* (laterally) - *Lateral and medial patellar retinaculae* (anterior) - *patellar ligament* (anterior) - *Oblique popliteal ligament* (posterior) - *Arcuate popliteal ligament* (posterior) Intrinsic (beneath the fibrous capsule) : - *Anterior and posterior cruciate ligaments* - *Meniscofemoral ligaments* - *Transverse ligament*

Posterior longitudinal ligament

PLL - Narrow band - Consisting of a *superficial and deep layer* - Runs along the posterior aspect of the vertebral bodies *within the vertebral canal* and is firmly attached to the *intervertebral discs (esp in T and L regions)* - Superficial layer on body of C2 is the continuation of the tectorial membrane originating from inner aspect of the foramen magnum - Deep layer continues from the cruciate ligament of the atlas and extends down into the sacral canal - PREVENTS hyperflexion of the vertebral column and helps protect against *posterior disc (nucleus pulposus) herniation* Disc herniation occurs posterolaterally in part due to a narrower PLL

Coccydyna

Pain in coccyx can be due to falling on buttocks especially in famels Can cause pain during delivery or intercourse if doesn't heal correctly

Tibial nerve injury causess

Paralysis of the flexors of the leg and intrinsic muscle of the foot (so loss of plantar flexion and toe flexion)

Osgoodschlatter's disease

Periostitis and sometimes avulsion of the tibial tuberosity Caused by the overextension of the quadriceps femoris

The greater sciatic foramen is divided into two parts by the ___; the contents inside it are

Piriformis muscle 1) Suprapiriformis hiatus - Superior gluteal vessels 2) Infrapiriformis hiatus - Inferior gluteal vessels - Internal pudendal artery and vein - PUdendal nerve - Posterior cutaneous nerve of the thigh - Sciatic nerve - Nerve to the obturator internus

Deep gluteal muscles

Piriformis, obturator internus, superior and inferior gemellus, and quadratus femoris

The ___ muscle and/or tendon can be used for tendon resconstruction

Plantaris muscle/tendon

Adductor hiatus contents

Popliteal artery and vein (from the femoral artery and vein)

Gluteus maximus

The most superficial in the gluteal region, though it has deep fibers ORIGIN: gluteus maximus origiantes primarily from the thoracolumbar faschia, iliac crest, posterior superior iliac spine, sacrum, and coccyx; deep fibers originate from the ilium and the sacrotuberous ligament INSERTION: primarily into the iliotibial tract (fascia of the tensor fasciae latae) with only about 25% of muscle fiers inserting to the gluteal tuberosity of the femur ACTION: powerful extensor of the hip joint and lateral rotator and abductor of the hip; also helps adduction of the hip (via fibers inserting into the gluteal tuberosity) and is active in rising, sitting, and climbing INNERVATION: inferior gluteal nerve (L5-S2)

Triceps surae

The muscles of the superficial layer of the posterior compartment of the leg COnsist of: 1) Gastrocnemius 2) Plantaris 3) Soleus muscles Have a common *Achilles (calcaneal) tendon* that inserts tot he posterior aspect of the calcaneal tuberosity ACTION: strong plantar flexion, walking/running INNERVATION: gastrocnemius, plantaris, and soleus muscles are all supplied by the *tibial nerve (S1-S2)*

Adductors of the thigh are innervated by

The obturator nerve (L2-L4) EXCEPT the pectineus and adductor magnus that are supplied by more nerves

Patellar tendon

The patella grows in the tendon of the quadriceps femoris so below patella

What makes the diaphgram and posterior abdominal wall

The psoas major and minor muscle Quadratus lumborum Lumbar plexus and its related nerves

What forms the lesser sciatic foramen? What goes through this?

The sacrospinous and sacrotuberous ligament crossing each other - through which the *obturator internus muscle and pudendal nerve and vessels (internal pudendal artery and vein* pass

The _____ innervates the lateral aspect of the lower leg

The superficial peroneal nerve (fibular nerve) Innervates the peroneus muscle

Prominent distinctions of the thoracic vertebrae?

The two *costal facets* that are each about 1/2 of an articular facet ("demifacet") that will articulate with the head of the rib to form *costovertebral joints* 1,10, 11, and 12 T vertebrae typically have *one articular facet for articulation with the head of the rib* The transverse processes of the T1-T10 thoracic vertebrae each have a costal facet for articulation with the *tubercle of the ribs* to make *Costotransverse joints*

What are the *denticulate ligaments*?

They are extensions of the *pia mater* from the surface of the spinal cord to the arachnoid mater (DAP from outside to in) They support the spinal cord in the vertebral canal and *separate the ventral and dorsal roots of the spinal nerves*

Why are L5 and S1 nerves more likely to be damaged?

They are thicker than other nerves and the intervertebral foramen they come out of are more narrow

Curvatures of the adult vertebral column

Thoracic and sacrum = kyphoses (concave anteriorly) = *primary curvatures* that develop during fetal life (flexed position of fetus) Cervical and lumbar = lordoses (convex anteriorly) = *secondary curvatures*(after birth - head erect at 3 mo.; and standing at 9-10 mo)

Plantar interossei muscles

Three muscles in the plnatar side with a single head ORIGIN: medial side of the 3-5th metatarsal bones INSERTION: medial side of 3-5 digits ACTION: adductors of the digits

The superficial layer of the plantar muscles

Three muscles: - INNERVATED by the *medial and lateral plantar nerves* (S2-S3) 1) Abductor hallucis 2) flexor digitorum brevis 3) abductor digit minimi

Caudal epidural anesthesia for childbirth

Through sacral hiatus because only anesthetizes up to S2

Tibialis posterior

between the flexor digitorum longus and flexor hallucis longus - Its tendon cross beneath that of the flexor digitorum longus on the medial aspect of hte ankle area, and is therefore the first tendon in an anteroposterior direection to the medial malleolar area SEcond tendon belongs to the flexor digitorum longus (in the middle) and the third tendon is that of the flexor hallucis longus and is the most posteriorly located one ORIGIN: tibia, fibula, and interosseous membrane INSERTION: navicular bone and three cuneiform bones, may extend to metatarsal bones

Muscles of the anterior region of the leg are all innervated by

different roots of the deep peroneal nerve (L4-L5)

The femoral ring contents

in the femoral sheath - Femoral artery and vein - Genitofemoral nerve - Lymph nodes and aerolar tissue (*Femoral canal*) - Rosenmuller node (drains glans penis and clitoris) Femoral nerve