MSK Exam 5

Why does α2 agonism cause gut SMC relaxation?

(Gi which decreases cAMP) The α subunit inhibits adenyl cyclase but this cant explain A conformation change also blocks the Ca2+ channels and inhibits Ca2+ from flowing in. This therefore inhibits the gut SMC from contracting and results in relaxation The ßγ sunbunit stimulates K+ channel to allow K+ to flow out. As K+ flows out, the SMC will also become hyperpolarized and further prevents contraction

What is the role of α2 in pancreatic ß cell insulin secretion

(Gi) Inhibits pancreatic ß cell insulin secretion

α2 activation in the gut

(Gi) SMC relaxation (atony, ileus, constipation) Decreased intestinal secretion (reduces cAMP which is needed for exocytosis)

M3 effect on the Gut

(Gq) SMC contraction (peristalsis, flatulence, borborygmi, diarrhea) Increased gastric secretion (H+/K+- ATPase insertion) Increased pancreatic exocrine secretion NO release (by interacting with an interneuron)- Sphincter relaxation

α1 activation in the gut

(Gq) Sphincter contraction

What is the role of M3 in pancreatic ß cell insulin secretion

(Gq) Stimulates pancreatic ß cell insulin secretion

What is the role of ß2 in glucose metabolism in liver and skeletal muscle?

(Gs) Stimulates Hepatocyte glycogenolysis and gluconeogenesis Stimulates rhabdomyocyte glycogenolysis Insulin-dependent GLUT4 (leads to uptake of glucose)

What is the role of ß3 in lipolysis

(Gs) Stimulates adipocyte lipolysis Insulin-dependent GLUT4 (leads to uptake of glucose)

What is the role of ß2 in pancreatic ß cell insulin secretion

(Gs) Stimulates pancreatic ß cell insulin secretion

PFK1

*RATE LIMITING ENZYME OF GLYCOLYSIS* fructose 6 phosphate --> fructose 1,6 phosphate

Portions of the quadriceps femoris

- rectus femoris - vastus lateralis - vastus medialis - vastus intermedius

prevertebral sympathetic ganglia

-Celiac ganglia -Superior mesenteric ganglia -Aorticorenal ganglia -Inferior mesenteric ganglion -Superior Hypogastric -Inferior Hypogastric Note: these mediate sympathetic visceromotor control of the gut and enteric organs

Rectouterine pouch (Douglas)

-lowest point of female abdominal cavity, space between the uterus and rectum -accumulates blood/ascites -drained from posterior fornix of vagina Note: this is within the peritoneum

Types of Evidence synthesis

Systematic reviews Metanalysis Individual patient-level data (IPD) meta-analysis Other secondary data reuse opportunities

Lesser Splanchnic nerve

T10-T11 Goes mostly to the superior mesenteric ganglion which controls the head of the pancreas, distal part of the duodenum, the jejunum, ileum, and cecum, the ascending colon, and the transverse colon Note: few go to the celiac ganglion and aorticorenal ganglion

Least Splanchnic nerve

T12 Goes to the aorticorenal ganglion which controls the adrenal glands, kidneys, and the proximal part of the ureters

Greater Splanchnic nerve

T5-T9 Goes mostly to the celiac ganglion which controls the liver, gallbladder, stomach, spleen, pancreas, and proximal part of the duodenum Note: few go to the superior mesenteric ganglion

Unhappy/Terrible triad

Tear of the medial collateral, anterior cruciate, and medial meniscus or lateral meniscus(depending on the severity of the injury)

Anterior Drawer Test

Test for Anterior cruciate ligament With a ruptured ACL, the tibia moves anterior until PCL prevents further movement

Posterior Drawer Test

Test for Posterior cruciate ligament With a ruptured PCL, the tibia moves posterior until ACL prevents further movement

Lachman's Test

Test fro Anterior Cruciate Ligament tear Brace femur, With a tear of the ACL, the tibia can be moved anteriorly an inch or more

iliopsoas

The Psoas muscle originates form lumbar vertebrae and the iliac muscle originates from the ilium, the iliopsoas will then insert on the lesser trochanter of femur Innervated by Lumbar spinal nerves Hip flexion (femur)

Tibial Nerve Damage

The Tibial nerve supply to posterior compartment: Inverts and Plantar Flexors These Inverters are assisted by inverted of anterior compartment These plantar flexors are assisted by plantar flexors in lateral compartment Therefore with tibial nerve damage: -Only weakness in plantar flexion (lifting the heel off the ground) -Only weakness in inversion (supination)

Pelvis arteries posterior

The common iliac branches into the external and internal iliac External iliac- Lower Extremity Internal Iliac- Pelvic Organs, Gluteal Region, Perineum, Note: it has an Anterior Division and Posterior division

Femoral Nerve compression

The femoral nerve can become compressed against the inguinal ligament if the hip is flexed for a prolonged period of time during surgery or child delivery Often compressed by the inguinal ligament

Internal anal sphincter

The layer of inner circular smooth muscle at the terminal end of the anus Involuntary control impacted by the autonomic nervous system

Systematic reveiews

The most common type of evidence synthesis Features a set of clearly specified, rigorous, reproducible, and transparent methods. These reviews provide answers to specific clinical questions by analyzing published and unpublished results from all relevant studies on a given topic They identify, select, and summarize findings of available research to make clear what is known about a topic and what is still not known

Why has the enteric nervous system been separated from the autonomic nervous system?

The number of neurons in the submucosal and myenteric plexuses across the whole gut is equal to the number of neurons in the whole spinal cord So anatomically it is distinct Also, if you cut out autonomics, the enteric nervous system will maintain many of the functions of the gut

Fibularis (peroneus) brevis

The only everts of the ankle and assists with plantar flexion Innervated by the Superficial Peroneal (Fibular) n. Originates from the Proximal part of lateral surface of shaft of fibula and Inserts on the First metatarsal, medial cuneiform

Fibularis (peroneus) longus

The only everts of the ankle and assists with plantar flexion Innervated by the Superficial Peroneal (Fibular) n. Originates from the Proximal part of lateral surface of shaft of fibula and Inserts on the First metatarsal, medial cuneiform

Sympathetic efferent control of enteric nervous system

The preganglionic neuron synapses with the postganglionic neuron in prevertebral ganglia, and the postganglionic will then enter the wall of the gut where it finds another neuron, secretes α1, that neuron will produces NE This stimulates α2 Note: unlike the parasympathetic, this extra neuron belongs to the enteric nervous system and isn't shared

Parasympathetic (vagal) efferent control of enteric nervous system

The preganglionic neuron will travel down and synapse with postganglionic neuron in the parasympathetic intramural vagal ganglia within the myenteric plexus (this postganglionic neuron is shared between the parasympathetic and enteric nervous system) The postganglionic neurons will then release ACh and M3 will then be activated Note: it serves as a modulator of the enteric nervous system!

Sympathetic innervation of sweat glands

The preganglionic neurons resides T1-L2 The postganglionic neuron will release Ach and therefore stimulate the M3 on sweat glands

Sciatic nerve high division

The sciatic nerve typically comes inferior to the piriformis m. Sometimes it will divide into its two terminal nerves while in the greater sciatic Forman. If so, the common perineal nerve generally pierces the piriformis m. and become entrapped. One could also travel above while the other travels below the piriformis

sustentaculum tali of calcaneus

The superior surface is concave and articulates with the middle calcaneal surface of the talus. The inferior surface has a groove for the tendon of flexor hallucis longus. Several ligamentous structures attach to the sustentaculum tali: -plantar calcaneonavicular ligament (anterior surface) -deltoid ligament (medial surface) -medial talocalcaneal ligament

Injury to the Navicular bone

The talonavicular joint allows for hindfoot motion in all planes. Loss of TN motion results in loss of complex hindfoot circumduction. It is therefore extremely important to retain TN function as it has a protective function for the adjacent joints. Loss of TN motion leads to adjacent joint degeneration. Retaining even a small amount of motion is thought to be protective for the adjacent joint function. Medial column length is crucial in maintaining the shape of the medial arch. If the navicular injury has resulted in comminution with loss of length, reconstruction needs to restore the length and normal geometry. Bridging the hardware distally and using bone graft will assure proper length of the medial column, overall shape and alignment of the foot. The navicular has an oval shape on cross-section. Small branches of the posterior tibial and dorsalis pedis arteries comprise the blood supply of the navicular. The medial and lateral areas are more or less well supplied while the central section has the most marginal blood supply. Therefore if not repaired quickly it can cause avascular necrosis

Arteries of the uterus

The uterine artery comes over the top of the ureter just lateral to the cervix and provides a very rich blood supply to the uterus The uterine artery will anastomose with the ovarian artery which came off the aorta There is also the vaginal and perineal artery (branch of the internal pudendal artery) which all anastomose with the uterine artery

retroverted and retroflexed uterus

The uterus is in an abnormal position different from anteflexed or anteverted Seems to be an issue if the woman is having fertility issues

Hip Anastomosis

The vessels of the anastomosis between the internal and external iliac arteries will begin to delete if plaque impedes blood flow through the external iliac or femoral artery The vessels of the cruciate anastomosis include: Inferior gluteal artery and Superior Gluteal artery Lateral Circumflex Femoral artery Medial Circumflex Femoral artery 1st perforating artery

50-year-old male was delayed at work in a five-o'clock meeting and headed home disregarding an urgent need to urinate. His car is rear-ended at a red light and he is taken to the ED. Below is the axial CT cystogram obtained from this patient.

There is a rupture of membranous urethra. Above the perineal membrane, usually at the base of the prostate can tear. Therefore urine and blood will be going into the pelvis as apposed to the superficial pouch

Straddle Injury

There is essentially a rupture to the bulb of the penis and the penile urethra coming through Therefore, blood and urine will spill out into the superficial pouch Will only spread to the posterior border of the perineum (won't go into thigh or past inguinal ligament). However it can travel up anteriorly into the abdomen and form a butterfly hemotoma note: this can happen in females, but the urethra is less likely to rupture

Autonomic Nerves ot Pelvic Viscera

There is the sympathetic trunk and superior hypogastric plexus (caudal portion of aortic plexus) which divides into a left hypogastric and inferior hypogastric plexus which is near the rectum and is a mix both sympathetic and parasympathetic innervation The sympathetics are the lumbar splanchnics (L1-L2 lateral horn) and sacral splanchnic (L1-L2 lateral horn). The parasympathetics are coming from pelvic splanchnic (S2-S4 lateral horn)

T5-L2 sympathetics

They pass though the sympathetic paravertebral ganglia and then branch out and enter the prevertebral ganglia where the body of the postganglionic neuron are located and will synapse and spread out to supply different portions of the GI

Plantar Fascia

Thick wide band of fibrous tissue that supports the foot against downward forces wide, nonelastic ligamentous tissue that extends from the anterior portion of the calcaneus to the heads of the metatarsals

Morton's Neuroma (Intermetartasal neuroma)

Thickening of the connective tissue around the nerve. Usually the common plantar n. between the 3rd and 4th metatarsal Swelling in a nerve sheath between the 3rd and 4th metatarsal bones is most common

Individual patient-level data (IPD) meta-analysis

This approach obtains and synthesizes all of the relevant measured characteristics of each participant in multiple related studies. It is a powerful method to identify the ways in which treatments may have varying benefits and risks for people with different characteristics. It isa way to see whether treatments should be targeted for use in specific groups of individuals. It is also an important method to reconcile differences between studies examining the same treatments that have found conflicting results.

meta-analysis

This approach uses statistical methods to combine published or unpublished study findings to produce estimates of an intervention's effect and to illustrate how consistent and strong the effect is across the research. Meta-analyses typically summarizes the average treatment effect for the entire study population

Shin Splints (tendonitis, periostitis, stress fractures)

Tibalis posterior muscle origins at posterior surface of tibia, interosseous membrane, and fibula and inserts into the undersurface of the navicular, all 3 cuneiforms, and 2nd, 3rd, and 4th metatarsals Blue arrow indicates excessive traction of tendon on tibial periosteum and interousseius membrane caused by hyperpronation Can be caused by small tears in muscle or small fractures in bones

What is the attachment of the patellar tendon

Tibial Tuberosity

Innervation to posterior compartment of thigh

Tibial nerve Except for the short head of biceps (common peroneal)

Anterior compartment of the leg Muscles

Tibialis anterior Extensor hallucis longus Extensor digitorum longus

Perineal artery

To all muscles of the superficial pouch and to posterior area of scrotum and labia majora

Tibial plateau fracture

To bend outward with compressive forces to knee with knee in flexion. This is region with menisci

Deep artery

To corpora cavernosa

Dorsal artery

To glans penis and clitoris

Inferior rectal artery

To the anal area

Job of Pelvis

Transfers weight of body to lower limbs Supports internal organs

Ductus (Vas) Deferens

Transports sperm from testes

Visceral pain of intraperitoneal pelvic viscera

Travel with Lumbar and sacral splanchnic nerve (L1-2) Referred to L1-2 Include: Fundus and body of uterus Uterine tube Ovary Bladder (superior)

Superficial muscles of the Posterior compartment of leg

Triceps Surae -Medial Head of Gastrocnemius -Lateral Head of Gastrocnemius -Soleus Plantaris (doesn't do much, good for tendon transplants, however, you will know if it tears because it forms a bulge behind the knee) Innervated by the Tibial n. Action: Flexion at the knee joint and Plantar Flexion (heel off the ground)

Uterine postions

Typically the uterus is believed to be in the anteflexed which is 170 degrees between the fundus and cervix It may also be in the anteverted position which is 90 degrees between the vagina and cervix

Apparent Leg length

Umbilicus to medial malleolus Discrepancy in apparent leg lengths may be due to pelvic tilt caused by adductor spams

Loss of innervation to the medial compartment of the thigh can lead to:

Unstable gait Wide stance Waddling gait Excessive Abduction

External structures of the female genitalia

Urethra Paraurethral Glands (Skene's) Vestibule Greater Vestibular Gland opening (Bartholin's) Labia Majora Labia Minora Glans Clitoris Mons Pubis

Vestibule of the vagina contains opening for:

Vagina Urethra Paraurethral glands (skene's) Greater Vestibular Glands

Valgus vs Varus

Valgus has more letters than varas: therefore more angle past normal Varus is less angle than normal

Incompetent valves may cause

Varicose veins

______ Compensate for the lateral pull on the patella by the vastus lateralis

Vastus Medialis with oblique fibers

Sphincter urethrae in males

Voluntary control

primary lymphatic drainage of female perineum

Vulva: Skin, Horizontal Superficial inguinal nodes Clitoris: cavernous bodies, Horizontal Superficial inguinal nodes Glans: Deep inguinal node Uterus: Internal and External Iliac, Horizontal Superficial inguinal nodes Anal canal: -Upper= Internal iliac node -Lower= Horizontal Superficial inguinal nodes

Cervix

Where the uterus intersects with the vagina, this is the neck of the uterus

Utricle

Within the prostatic urethra On top of the seminal colliculus, this is the male homolog of the vagina

seminal colliculus

Within the prostatic urethra This is the mound which is the male homolog of the hymen

Opening of the Ejaculatory duct

Within the prostatic urethra, these come from the vas deferens and seminal vesicles Just below the utricle

Is there Very little energy required to stand at attention if using the tensor fascia late, as compared to the quadriceps for extended periods of knee extension?

YES

Is renin produced via sympathetic stimulation?

YES This is long term regulation of BP (increases)

Might a femoral hernia repair sometimes involve suturing a mesh into the pectineal ligament?

Yes Don't suture into the femoral vein!

Does the pirirformis muscle exit out of the greater sciatic Formen?

Yes It travels out and attaches to the femur

Does the pressure of the deep veins fluctuate?

Yes, with leg muscle contraction This allows the blood to flow from the superficial to the deep in little pulsations

Anesthesia for childbirth

You can identify the ischial spine and perform a pudendal nerve block (you go in from the vagina and feel for the ischial spine and inject anterior medially) (would do this in an emergency delivery) You can do an epidural higher which eliminates the need for a pudendal nerve block and numbs the uterus, birth canal, and perineum

iliopectineal line

a bony ridge on the inner surface of the ilium and pubic bones that divides the true and false pelvis

Bursa

a fibrous sac between certain tendons and bones that is lined with a synovial membrane that secretes synovial fluid to assist in preventing friction

subtalar joint

a joint in the ankle found between the talus and calcaneus

Mons pubis

a mound of fatty tissue covering the pubic area in women

Achilles Tendon

a tendon in the back of the ankle and foot that attaches the gastrocnemius and soleus muscles to the calcaneus

Evidence synthesis can yield useful information within____

a year or two, instead of the 3-5 years typically required for a new research study

Dorsal Interossei

abducts toes 4 of them Innervated by Tibial n.

Gs receptors

adenylate cyclase activation, increase in cAMP D1 D5 ß1 ß2 ß3

What cells make leptin

adipose (fat) cells

plantar fasciitis

an inflammation of the plantar fascia on the sole of the foot Often caused by a calcaneal spur (which can often get lengthy and can fracture) at the attachment of the plantar aponeurosis or knots in muscles Can help by wearing firm, well fitting heel counter, and a stretcher to prevent it being injured (note: steroids can destroy fat pad) Worse in the morning when they first step on the floor

Peroneus tertius

ankle dorsiflexion and foot eversion innervated by Deep peroneal n.

If the hip joint is weakest during flexion, what mechanism would produce a dislocation in this position?

anterior force

The contents of the femoral sheath cross the pectineal ligament ____

anteriorly

nucleus of the tractus solitarius (NTS)

area in the medulla that receives input from parasympathetics

Pes Anserine bursa

between pes anserine tendon and MCL on the proximal medial side of tibia Can get pin point here

subcutaneous prepatellar bursa

between skin and patella Associated with prepatellar bursitis (nurse maid's knee)

Subcutaneous infrapatellar bursa

between skin and patellar ligament

ACL injuries occur when ___

bones of the leg twist in opposite directions under full body weight

Lateral meniscus

cartilage in the knee between the lateral femoral condyle and the lateral tibial plateau

Sacroiliac ligament

connects sacrum to ilium and includes one that connects anteriorly and posteriorly

sacrotuberous ligament

connects sacrum to ischial tuberosity

interosseous membrane

connects the tibia and fibula

Deep pouch In males

contains: Sphincter Urethra Deep Transverse Perineal muscle Bulbourethral (Cowper's) Gland Note: Cowpers glands are in the deep pouch, but their secretions go through the superficial pouch and into the urethra

Medial Malleolus

distal process on medial tibial surface

The femoral sheath is formed by ___

endoabdominal fascia

ampulla of vas deferens

expanded portion at end next to ejaculatory duct that serves as a sperm reservoir

Extensor hallucis brevis

extends big toe innervated by Deep peroneal n.

Extensor digitorum brevis

extends toes 2-4 innervated by Deep peroneal n.

Posterior fornix of vagina

extension of vagina behind the cervix toward the rectouterine pouch

Anterior fornix of vagina

extension of vagina in front of the cervix toward the vesicouterine pouch

Transverse rectal folds

extensions of rectal wall. hold feces up so it isn't all resting on sphincters

Ischioanal fossa

fat-filled wedge shaped space located lateral to the anal canal and inferior to the pelvic diaphragm. It is somewhat prismatic in shape, with its base directed to the surface of the perineum, and its apex at the line of meeting of the obturator and anal fasciae.

Femoral sheath contents

femoral artery, femoral vein, femoral canal Note: they are the external and internal iliac artery and vein before they pass the inguinal ligament

Mallet toe

flexion of the DIP joint Associated with DIP

anterior ischioanal fossa

formed by the reflection of the fossa, anteriorly, with the urogenital diaphragm. This recess is between the pelvic diaphragm (superior border) and UG diaphragm (inferior border)

Contents of the Femoral Triangle

from lateral to medial Femoral nerve Femoral artery Femoral vein Femoral Canal/ Empty Space

Adductor Hiatus

gap between the hamstring portion of the adductor magnus and were it attaches to the adductor tubercle on the medial epicondyle of the femur Note: this is in the medial compartment of the thigh

dorsiflexion

heel on ground, elevate toes off the ground

Claw toe

hyperextension of the MTP and flexion of the PIP and DIP (2-5 PIP Joint) Associated with PIP joint of the 4 toes

Most Achilles tendons tears is caused by_____

hyperpronation

Achilles Tendonitis

inflammation of the Achilles tendon causing severe pain (can often get a lot of small tears, etc) Will present as tenderness over the joint (pushing against tendon will show pain)

Osgood-Schlatter disease

inflammation or irritation of the tibia at its point of attachment with the patellar tendon (tibial tuberosity)

The prepuce of the clitoris is derived from the ____

labia minora

Obturator Internus

laterally rotates thigh Innervated by the nerve to the Obturator inernus (L5, S1-2)

Pubovesical ligament (pubocervical)

ligament that extends from the neck of the bladder to the inferior aspect of the pubis bones

Acetabular labrum

lip of fibrocartilage that surrounds outer margin of the acetabulum on the hip bone This adds depth to the fossa

Where does gluconeogenesis occur?

liver and kidney

Where does glycogenolysis occur?

liver and skeletal muscle Note: skeletal muscle is stingy and keeps the glucose for itself

Parts of the broad ligament

mesovarium (next to the ovary) mesosalpinx (goes to the uterine tube) mesometrium (associated with ureter) These are a double layer of mesentery

Dermatomes of the lower limbs

most of the anterior thigh comes from branches of the femoral n Area in medial part of thigh that is covered by the obturator n. most of the lateral thigh comes form the lateral femoral cutaneous n. Posterior thigh is mostly covered by the posterior femoral cutaneous n.

inferior rectal nerve

motor to external anal sphincter and sensory to the anal area

Bethanechol

muscarinic agonist (acts on M3 in the detrusor muscle) used for Ileus and atonic bladder

Oxybutynin

muscarinic antagonist (blocks the M3 receptors on the detrusor muscle) Used for overactive bladder

Propantheline Bromide

muscarinic antagonist (blocks the M3 receptors on the detrusor muscle) Used for overactive bladder

Peroneal tubercle

on the lateral side of the calcaneus with the peroneus brevis superior and the peroneus longus inferior (it separates the tendons of peroneus brevis and the peroneus longus)

Sciatica

pain, numbness, tingling that follows the pathway of the sciatic nerve, caused by compression or trauma of the nerve or its roots

What innervation causes contraction of the urethra

parasympathetic

Jumpers knee

patellar tendonitis (inflammation of the patellar tendon) Dont confuse with runner's knee (pain around the patella). Although both are overuse syndromes and can occur at any age Press on tendon to diagnosis

Greater Sciatic foramen

pelvic opening formed by the greater sciatic notch of the hip bone, the sacrum, and the sacrospinous ligament Exit to Gluteal region: Priformis m. Sciatic n. Superior gluteal n. Inferior gluteal n. Pudendal n. Nerve to obturator internus Internal Pudendal a. Superior gluteal a. Inferior gluteal a.

Lesser sciatic foramen

pelvic opening formed by the lesser sciatic notch of the hip bone, the sacrospinous ligament, and the sacrotuberous ligament Exit to gluteal region: Obturator Internus Enter to perineum: Pudendal n. Internal pudendal a. Nervel to Obturator Internus

PFK2

phosphofrunctokinase 2 activated by *insulin* inhibited by *glucagon* fructose 6 phosphate --> fructose 2,6 phosphate fructose 2,6 phosphate activates PFK1 and then blocks F1,6- phosphatase

Injury and inflammation fo the ______ can entrap the entire sciatic nerve

piriformis muscle Leads to sciatica

The femoral artier pass though the adductor hiatus and becomes the ____, behind the knee joint

popliteal artery

posterior cruciate ligament

prevents backward displacement of the tibia or forward sliding of the femur Attaches to the posterior tibia in the intercondylar area and on the anterior femur on the medial condyle.

Cystocele

prolapsed bladder Bulges into the anterior wall fo the vagina Can be caused by loss of support by the floor of the pelvis, in part which is provided by the fascias

Kegel exercises

repetitious contraction and relaxation of the pubococcygeal muscle to improve vaginal tone and urinary continence

What spaces are in the male pelvis?

retrovesical space

Pain over the lateral epicondyle of the femur would be due to ____

rubbing of the IT band

sacrospinous ligament

sacrum to ischial spine

uterosacral ligament

secures the uterus to the sacrum

Uterosacral ligament

secures the uterus to the sacrum just medial to the ureter

Sphincter Vesicae

smooth muscle sphincter that is near the exit of the bladder Parasympathetic= Relaxes Sympathetic= Contracts

Subphrenic space

space located between the diaphragm and the superior border of the liver

Cortisol

stress hormone released by the adrenal cortex It is a glucocorticoid therefore it has a nuclear receptor so its primary action is through gene activation It also causes activation of PLA2

Ischial Tuberosities

strongest part of hip bone. These are your sitting bones Can be seen from inferior view

Coccygeus

supports pelvic viscera Innervated by S4 Along the sacrospinous ligament. It runs from the coccyx to the Ischial Spine

The capsule of the knee joint is not completely anterior, so the bursa is exposed under the _____

tendon of the gastrocnemius

Urogenital Hiatus

the anterior gap of the levator ani where the passage of the urogenital organs

pubic symphysis

the cartilaginous joint known that allows some movement to facilitate childbirth

trigone of bladder

triangular region at the base of the urinary bladder between the openings of the two ureters and the urethra

Structure of the bladder

trigone shaped arrangement with 3 openings, 2 ureters and the urethra; lining contains transitional epithelium which changes shape and allows the bladder to distend. Has: anterior, apex, superior, and base sides to it

Prostatic venous plexus

venous drainage of prostate, connects to the vertebral plexus Therefore, if you do have prostate cancer, it is common to see metastasis up the spinal column

Glycogenolysis in skeletal muscle is stimulated by ___

ß2 --> ATP production

Glycogenolysis and Gluconeogenesis in the liver is stimulated by __

ß2 --> hyperglycemia

Lipolysis for gluconeogenesis in adipocytes is stimulated by

ß3

Omental adipose tissue leptin is stimulated by __

ß3

Mirabegron

ß3 agonist used for overactive bladder

Glucagon comes from which cells

α cells

Doxazosin

α1 blocker used for BPH SE: Orthostatic hypotension

Prazosin

α1 blocker used for BPH SE: Orthostatic hypotension

Terazosin

α1 blocker used for BPH SE: Orthostatic hypotension

What are the autonomic receptors that control the internal urethral sphincters

α1 receptors (sympathetic from T12-L2 this causes contraction of the internal urethral sphincter and prevents urinary incontinence)

NE acts on what receptors?

α1, α2, ß1

Epi acts on what receptors

α1, α2, ß1, ß2, ß3

Pancreatic ß Cell insulin secretion is inhibited by ____

α2

Compartments of the thigh

1. Anterior (comes from dorsal limb bud) 2. Medial (comes from ventral limb bud) 3. Posterior (comes from ventral limb bud) Note: These each have their own nerve supply, blood supply, and muscle action

Posterior Hip dislocation

1. Force applied to a flexed knee, extremity appears shortened 2. Tx = closed reduction under conscious sedation 3. Complications = sciatic nerve injury, avascular necrosis

Branches of the pudendal nerve

1. Inferior rectal nerve 2. Perineal nerve 3. dorsal nerve

The 2 triangles in the perineum

1. Urogenital triangle 2. Anal triangle

Branches of the internal pudendal artery

1. inferior rectal artery 2. perineal artery 3. dorsal artery 4. deep artery 5. artery to bulb

Knee joint in Adult Q angle is ___

10 degrees

Sinding-Larsen-Johansson Disease

10-14 year old active adolescent Immature osteotendinous junction not completed. Inflammation with small tears inflammation of the bone at the bottom of the patella, where the tendon from the tibia attaches. It is an overuse knee injury rather than a traumatic injury.

Hip joint in an adult angle is ____

125 degrees

Prostate gland

20% of ejaculate; contains PGs, citric acid (pH 6.4), phosphatase, proteases (liquefaction of semen)

Plantar Interossei

3 of them Innervated by the Lateral plantar n. Adducts digits 3,4,5 ; Flexes MP joints & Extends IP joints of digits 3-5 Note: adducts to the 2nd digit

Dorasal Interossei

4 of them Innervated by the Lateral plantar n. Abducts digits 2,3,4 ; Flexes MP joints & Extends IP joints of digits 2-4

Seminal vesicle

50% of ejaculate; gelatinous, contains fructose; an alkaline pH (7.4)

Normal glucose levels

70-110 mg/dL If you have high sugar intake, levels should return to normal by 2 hours

Slipped Capital Femoral Epiphysis (SCFE)

A dislocation of the epiphyseal end of the femur, usually found in children and adolescents.

Salter-Harris Fracture

A fracture through the Metaphysis (shaft of long bone) Physis (growth plate) Epiphysis (rounded end of long bone) Where ossification is occurring This can affect growth!

Broad ligament

A peritoneum that surrounds the uterus, uterine tubes, and ovaries (all of which are mesenteric)

Sympathetic innervation of the adrenal medulla

A preganglionic neurone passes though both the prevertebral and paravertebral ganglia and synapses in the adrenal medulla cells (basically postganglionic neurons without axons) which release Epi and NE

Knee sprain

A tear in any of the 4 ligaments

A deep laceration in the lateral plantar region of the foot has severed a nerve. Motor function to which of the following most likely would be lost? A. Adductor hallucis B. Abductor hallucis C. Flexor hallucis brevis D. 1st lumbrical E. Flexor digitorum brevis

A. Adductor hallucis (supplied by the lateral plantar n.; the rest are supplied by the medial plantar n.)

Which of the following nerves causes vasodilation of blood vessels that fill the corpus cavernosus and corpus spongiosus, and produces erection? A. Cavernous nerve B. Dorsal nerve C. Perineal nerve D. Pudendal nerve E. Sacral splanchnic nerve

A. Cavernous nerve

What direction is the probe marker pointed when scanning the hepatorenal recess? A. Celphalad B. Caudal C. Patients right side D. Patients Left side

A. Celphalad

Which of the following probes would be the best choice for obtaining FAST exam ultrasound images of abdominal organs or spaces? A. Low Frequency Phased Array B. Low Frequency curved C. High Frequency linear

A. Low Frequency Phased Array

A 30-year-old male comes to the family clinic for an annual physical exam. You ask him to stand on his right lower limb and his hip dips to the left and he leans his body to the right. He reports that he has had a limp since a childhood illness. Which of the following nerves is most likely damaged in this patient? A. Right superior gluteal B. Left superior gluteal C. Right inferior gluteal D. Left inferior gluteal E. Obturator

A. Right superior gluteal This is involved in paralysis for the Gluteus medius

Which of the following is a boundary of the adductor canal? A. Sartorius B. Vastus lateralis C. Pectineus D. Iliopsoas E. Inguinal ligament

A. Sartorius (roof)

The pes anserine inserts on the: A. medial tibial condyle B. head of the fibula C. Gerdy's tubercle D. patella E. adductor tubercle

A. medial tibial condyle

Referred pain from inflammation of which of the following pelvic structures would be felt most likely in the L1 dermatome region? A.Uterine tube B.Cervix C.Prostate gland D.Seminal vesicle E.Vagina

A.Uterine tube

True leg length

ASIS to medial malleolus

Sympathetic upregulation of leptin

Abdominal fat cells, ß2 and ß3 stimulate HSL which lead to the breakdown of TG into FFA. This also stimulates the release of leptin from these cells Leptin increases central sympathetic outflow and therefore increases the production of ß1,ß2, ß3 increasing levels of leptin and renin

What is the first layer of plantar muscles

Abductor Digiti Minimi Flexor Digitorum Brevis Abductor Hallucis All intrinsic

tensor fasciae latae

Abducts and medially rotates at the hip. Assists in extension at the knee joint Innervated by the Superior Gluteal n. (L4,L5,S1) Originates from the anterior superior iliac spine (iliac tubercle) and inserts into the fascia late (Iliotibial band) of the thing and acts as an extensor at the knee joint.

gluteus medius

Abducts and medially rotates thigh (very important in walking and standing) Innervated by the Superior Gluteal n. (L4, L5, S1) Originates from the lateral surface of ilium and inserts on the greater trochanter of femur

Piriformis

Abducts the flexed thigh and laterally rotates thigh at the hip Innervated by the Nerve to Piriformis (S1-2) Originates from the anterior surface of sacrum and inserts on the greater trochanter of femur

suprapatellar bursa

Above the patella, allow anterior thigh muscles to move over the distal end of the femur Synovial sac of the knee joint

Superficial layer of muscles of the medial compartment of the thigh

Adductor Longus Gracilis

Knee arterial anastomosis

All the branches of the popliteal artery anastomose The descending branch of the lateral femoral circumflex will then anastomose with the superior lateral genicular artery There is a lot of the genicular arteries (superior medial, inferior medial, superior lateral, inferior lateral)

Where is the site to feel the dorsals pedis a.

Ankle joint

Superficial peroneal nerve damage

Antagonist muscles will have foot inverted

If the deep peroneal nerve is cut, _____

Antagonist muscles will have the foot plantar flexed and there will be no dorsiflexion(foot drop/Slap gait) There will also be sensory loss between the 1st and 2nd toes

The dorsal compartment of the limb bud of the lower limb become ___

Anterior The limb bud rotates medially! This includes the nerves!

branches of the popliteal artery

Anterior Tibial and Posterior Tibial Note: The Fibular artery branches off the Posterior Tibial artery Note: this was the femoral artery and changed name has it went posterior

Portions of the prostate

Anterior lobe Median Lobe (BPH) Posterior lobe (Cancer, near the rectum)

What is a major point of access to the great saphenous vein?

Anterior to the Medial Malleolus It begins here, travels up the leg, posterior at the knee joint, and then up the medial side of the thigh were it empties into the femoral vein

Anal Triangle boundaries

Anterior: Perineal Body (draw line from the ichciotuberosities) Lateral: Obturator Internus Medial: Levator Ani Posterior: Coccyx

Boundaries of the Urogenital triangle

Anterior: Pubic Symphysis Lateral: Ischiopubic Ramus Posterior: Perineal Body

Pubalgia

Any strain or tear of the muscles of the groin (attach to pubis). AKA Hockey Hernia, Gilmore's Groin, Sports hernia (It is not a hernia!) Symptoms: Sharp pain in the groin which is alleviated by rest. Stiffness or tenderness in the groin Treatment: RICE, anti-inflammatory medications, physical therapy. If these conservative treatment fails, surgery

talonavicular joint

Articulation between the talus and the navicular bones; part of the midtarsal joint. Allows for hindfoot motion in all planes

Acetabulum

Articulation site for head of femur Composed of all three pelvic bones

Iliotibial Band Friction Syndrome

As the knee flexes and extends, the iliotibial tract glides back and forth over the lateral femoral epicondyle causing friction and pain Will present as diffuse pain and tenderness on the lateral side of the knee (not pin point pain like popliteus)

Background Questions

Ask for general information about a condition or thing A question root (who, what, when, etc. ) combined with a verb Ex. What are the spectrum of symptoms in migraine with aura These are typically best answered by textbooks

Foreground questions

Ask for specific knowledge about a specific patient with a specific condition ex. In patients with migraine headaches without aura, is depakote more effective than inderal for prophylaxis of headaches These are typically answered by databases that access the research literature

Structures Within the superior and inferior extensor retinaculum

At the ankle joint From Medial to Lateral: Tibialis Anterior Extensor Hallucis longus Dorsalis Pedis Artery (can feel pulse here) Deep Peroneal nerve Extensor Digitorum Longus "T-HanD"

fibular (lateral) collateral ligament

Attaches fibula to femur Prevents lateral movement of leg Stops leg extension

Anterior Cruciate ligament (ACL)

Attaches the anterior of intercondylar area of the tibia to the medial side of the lateral condyle of the femur. Prevents forward sliding of the tibia.

tibial (medial) collateral ligament

Attaches tibia to femur Also attaches to medial meniscus Prevents medial movement of leg Stops leg extension

Lesser Trochanter of femur

Attachment for illipsoas

Intertrochanter crest of femur

Attachment for the Short lateral rotators of the femur

Greater Trochanter of femur

Attachment for the gluteus medius and gluteus minimus

Bone infarction

Avascular necrosis due to the loss of nutrient arterial supply to the bone. Injury of the arteries around the knee can have devastating effect!

Which function is totally lost due to lesion of the superficial peroneal nerve? A. Inversion at the ankle B. Eversion at the ankle C. Knee flexion D. Plantar flexion E. Dorsiflexion

B. Eversion at the ankle

There is a sensory loss to the plantar surface of the foot. Which intervertebral disc most likely has ruptured? A. L3 B. L4 C. L5 D. S1 E. S2

B. L4 (impinges on the nerve below)

A positive Trendelenburg sign raises the right foot and stands on the left lower limb indicates potential damage to the: A. Right superior gluteal n. B. Left superior gluteal n. C. Right inferior gluteal n. D. Left inferior gluteal n.

B. Left superior gluteal n.

If the best choice probe is not available for the abdominal FAST views, which probe would be a reasonable second choice? A. Low Frequency Phased Array B. Low Frequency curved C. High Frequency linear

B. Low Frequency curved

Which of the following forms the roof of the superficial perineal pouch? A. Levator ani m. B. Perineal membrane C. Sphincter urethra m. D. Superior fascia of the UG diaphragm

B. Perineal membrane

Which muscle tendon inserts on the 5th metatarsal? A. Peroneus longus B. Peroneus brevis C. Extensor hallucis brevis D. Tibialis posterior E. Plantaris

B. Peroneus brevis (also the peroneus tertius)

Which of the following statements is true? A. Urine in the bladder blocks ultrasound signals returning from posterior structures B. Urine in the bladder enhances ultrasound signals returning from posterior structures C. Urine in the bladder is not visible with ultrasound D. Urine sappers as a hyperechoic area with ultrasound

B. Urine in the bladder enhances ultrasound signals returning from posterior structures

A positive lachman's test reveals: A. exessive posterior movement of the tibia B. excessive anterior movement of the tibia C. hyperextension of the hip joint D. hyperextension of the knee joint E. genu valgus

B. excessive anterior movement of the tibia

The lateral meniscus is separated from the fibular collateral ligament by the: A. plantaris muscle B. popliteus muscle C. lateral head of the gastrocnemius muscle D. biceps femoris tendon E. articularis genus muscle

B. popliteus muscle

Which structure provides a landmark for the pudendal nerve during a pudendal nerve block procedure? A.Coccygeus m. B.Ischial spine C.Ischial tuberosity D.Sacrospinous ligament E.Sacrotuberous ligament

B.Ischial spine

retro-pubic space (cave of retzius)

Below the peritoneal cavity, down in the pelvis and anterior to the bladder

Other secondary data reuse opportunities

Besides IPD meta-analyses, a statistical approach called predictive analytics can be applied to previous trialsor other research data to provide more personalized results that can optimize the use of specific treatments. This approach can be helpful in studies with a diverse group of people and a wide range in individual responses to an intervention.

Where does the Inferior Gluteal artery typically exit?

Between S1-2 or S2-3

Where does the Superior Gluteal artery typically exit?

Between the Lumbosacral Trunk and S1

Where can you have an out pocketing of hip joint synovial bursa?

Between the pubofemoral and Iliofemoral ligament

Symptoms of abdominopelvic autonomic dysfunction

Bloating, nausea, vomiting of old food (gastroparesis) Constipation, absent bowel sounds (intestinal paresis=ileus) Borborygmi (overactive bowels) Urinary frequency, hesitancy, or incontinence (bladder tonicity ±) Impotence

Superficial Peroneal nerve

Branch of the common peroneal (common fibular nerve) Motor nerve of the lateral compartment Sensory to dorsum of the foot except for the dorsum of the foot between the 1st and 2nd toes

Deep Peroneal nerve

Branch of the common peroneal (common fibular nerve) Motor to anterior compartment Sensory to dorsum of the foot between the 1st and 2nd toes

Skeletal muscle in the urogenital triangle in males

Bulbospongious muscle Ischiocavernosus muscle Superficial Transverse Perineal muscle

Skeletal muscle present in the superficial pouch in females

Bulbospongious muscle (covering the bulb of vestibule) Ischiocavernosus muscle (covering the crus of clitoris) Superficial Transverse Perineal muscle

Prolapsed uterus

Bulges into the vestibule of the vagina Can be caused by loss of support by the floor of the pelvis, in part which is provided by the fascias The levator ani is the main support and this is lost Can be caused by: -Multiparous female -Repeated stretching and micro tears in the pubococcygeous which can be strengthened with kegal exercises

A 45-year-old man was evaluated in the Family Medicine clinic for an annual physical exam. He had an unusual gait where his right knee remained partially flexed following heal strike. He compensated by stabilizing his knee with his right hand during the stance phase. Upon further testing he was unable to extend his knee. The diagnosis was most likely damage to the: A. Superior gluteal nerve B. Tibial nerve C. Femoral nerve D. Deep fibular (peroneal) nerve E. Superficial fibular (peroneal) nerve

C. Femoral nerve

Which of the following would enter or exit the femoral triangle outside the femoral sheath? A. Femoral artery B. Femoral vein C. Femoral nerve D. Deep inguinal lymph node E. Femoral hernia

C. Femoral nerve

Weakness in a patient's right hip extension may indicate a problem with the ______________ muscle. A. Piriformis B. Gluteus medius C. Gluteus maximus D. Gluteus minimus E. Obturator internus

C. Gluteus maximus

The neck and head of the femur are supplied by the _____ arteries. A. Obturator B. Perforating C. Retinacular D. Genicular E. Deep circumflex iliac

C. Retinacular

A male patient comes to the ER with a chainsaw laceration that has cut through the attachment of his pen anserine. When considering repair to these tendons, what is the proper orientation of the tendons from anterior to posterior? A. Gracilis, Sartiorius, Semitendinosus B. Semitendinosus, Gracilis, Semimembranosus C. Sartorius, Gracilis, Semitendinosus D. Semimembranosus, Gracilis, Sartorius E. Sartorius, Gracilis, Semimembranosus

C. Sartorius, Gracilis, Semitendinosus

A lesion of the common peroneal nerve will result in motor loss to the: A. Plantaris B. Gastrocnemius C. Short head of the biceps femoris D. Soleus E. Popliteus

C. Short head of the biceps femoris

The cell bodies of sacral splanchnic nerves are located in the ________. A.Dorsal root ganglion of S2-S4 B.Lateral horn of the spinal cord at T5-L2 C.Lateral horn of the spinal cord at L1-L2 D.Lateral horn of the spinal cord at S2-S4 E.Paravertebral ganglion

C.Lateral horn of the spinal cord at L1-L2

Which lobe of the prostate gland is found between the prostatic urethra and the ejaculatory duct? A.Anterior B.Posterior C.Median

C.Median

What molecules are needed for exocytosis?

Ca2+ or cAMP

Bones of the foot

Calcaneus Talus Cuboid (lateral) Navicular (medial) Cuneiform (medial, intermediate, lateral) (hare articulations with individual metatarsals) Metatarsals Phalanges (proximal, middle, distal) Note: there are sharp edges of articulation between the bones

Layers of superficial fascia

Camper's fascia (fatty) Scarpa's fascia (membranous)

medial meniscus

Cartilage in the knee between the femoral condyle and the medial tibial plateau Attached to the tibial collateral ligament

Pump bump

Caused by inflammation of bursa beneath Achilles tendon Tender slightly red nodule just lateral to calcaneal attachment of Achilies tendon

Retroperitoneal pelvis organs in the female

Cervix Lower portion of bladder Vagina Lower 1/2 of rectum These are below the peritoneal cavity

Coccydynia

Coccygeus pain

Somatic innervation of the pelvis

Comes from the Pudendal which serves as motor and sensory (pain) This is in the perineum

Parasympathetics to the Gut

Comes mostly from the Vagus, also comes from the pelvic splanchnic nerves

Calcium Pyrophospahte Dihydrate Disease (CPPD disease)

Common in the elderly Associated with hyperparathyroidism Associated with Vitamin D deficiency Associated with cortical thinning of the femur (subperiosteal resorption and osteopenia) Characterized by the deposition of calcium pyrophosphate in soft tissues and cartilages This is also called pseudogout! (calcium is depleted from bones and deposited in the tissue)

sciatic nerve divides into

Common peroneal and tibial nerves

Anterior and Lateral Compartment Syndrome

Compression of muscles within the fascial sheath before they have time to warm up allowing the sheath to expand compressing the arteries in this area and can cause avascular areas with pain This is more evident in cold weather Note: anterior will have pain on lateral calf area Note: Lateral will have pain on lateral ankle area

Patella Alta

Congenital Patellar pain caused by the patella lying above the tracheal of femur instead of being between the condyles of the femur due to an abnormally long patellar ligament Pin point pain

Perforating veins

Connect the superficial and deep venous system Although the other veins all have valves, these especially have valves and prevent the back flow from deep to superficial

Tarsometatarsal joint

Connects the tarsal bones to the metatarsal bones

Sacral Plexus

Contains anterior and posterior divisions Sciatic nerve Tibial n. (L4, L5, S1, S2, S3) anterior divisions Common Peroneal n. (L4, L5, S1, S2) posterior divisions Nerve to Piriformis (S1-S2) posterior divisions Inferior Gluteal n. (L5, S1, S2) posterior divisions Superior Gluteal n. (L4, L5, S1) posterior divisions Lumbosacral Trunk (L4, L5) Nerve to Obturator Internus (L5, S1, S2) anterior divisions Posterior Femoral Cutaneous n. (S1-3) anterior divisions Nerve to Levator Ani & Coccygeaus (S3-4) anterior divisions; found on the deep surface of the levator ani Pudendal n. (S2-4) Supplies perineum; anterior divisions

Deep pouch in females

Contains the Sphincter Urethra and Deep transverse perineal Floor: Inferior fascia of the urogenital diaphragm (perineal membrane) Roof: superior fascia of the urogenital diaphragm

Posterior Knee

Contains: Gastrocnemius muscle medial and lateral heads their associated and bursa Joint capsule (discontinuous anterior) Semimembranosus tendon Oblique popliteal ligament Popliteus muscle (penetrates the joint capsule, no bursa) Plantaris muscle

Structure of penis

Corpus Cavernosa (starts as a bulb and the end forms the glans) Corpus Spongiosum (contains the urethra and is formed by the two crus on each side) Note: all of this is kind of glued by the perineal membrane Note: The cure are anchored in the ischiopubic ramus Note: this forms over the urogenital hiatus

The lateral femoral condyle extends more ___ than the medial femoral condyle

Cranial

The lateral rotators of the hip joint insert along the: A. Greater trochanter B. Lesser trochanter C. Intertrochanteric line D. Intertrochanteric crest E. Ischial tuberosity

D. Intertrochanteric crest

The dermatome for the area over the patella is: A. L1 B. L2 C. L3 D. L4 E. L5

D. L4

Which of the following structures supports the medial longitudinal arch of the foot? A. Long plantar ligament B. Peroneus brevis C. Abductor digiti minimi D. Plantar calcaneonavicular ligament E. Short plantar ligament

D. Plantar calcaneonavicular ligament Everything else supports the lateral arch

While conducting a routine physical of a patients lower extremity, you detect a swelling at the back of the knee joint in the patient's right lower extremity which is not present in the patient's left lower extremity. You suspect enlarged lymph nodes. Where would you look for a potential melanoma that would cause these lymph nodes to be enlarged. A. Anterior lateral thigh B. Medial dorsum of the foot C. Anterior medial leg D. Posterior lateral leg E. Posterior medial leg

D. Posterior lateral leg

A 13-year-old male is a member of his high school cross country running team. His parents take him to their family doctor because the boy has a lot of knee pain and cannot run. The physician orders an MRI. What is the diagnosis? A. Calcium Pyrophosphate Dihydrate Disease B. Bone infarct C. Osgood/Slatter's Disease D. Sinding-Larsen-Johansson Syndrome E. Patella alta

D. Sinding-Larsen-Johansson Syndrome

A 50-year-old male cuts the medial side of his thigh while crossing a barbwire fence. A week later the wound has become infected. To which lymph nodes would this infected wound first drain? A. Popliteal B. External iliac C. Deep inguinal D. Superficial inguinal

D. Superficial inguinal

The articularis genus inserts on the: A. subcutaneous prepatellar bursa B. deep infrapatellar bursa C. tibial tuberosity D. suprapatellar bursa E. Gerdy's tubercle

D. suprapatellar bursa

Genu Vara/ Bow Legged

Decrease Q angle- tilt tibia inward

Coxa Vara/ Knocked Knee

Decreased angle or tilt femur inward

What are the two pouches in the Urogenital triangle

Deep pouch: provides the foundation for the external genitalia Superficial pouch: where all the external genitalia is located

Articular Genus

Deep to the vastus intermedius Inserts on the suprapatellar bursa. Contracts to pull bursa out of joint during knee extension so that it doesn't get entrapped

Where does the deep thigh drain?

Directly to the deep inguinal nodes From here, they will travel to the iliac nodes--> Lumbar trunk --> Cysterna chyli-->Thoracic duct

Neck of femur fracture

Disrupts the blood supply to the head of the femur, which undergoes avascular necrosis

Lateral Malleolus

Distal process on the lateral fibial surface

4th layer of plantar muscles

Dorsal interossei (4) Plantar Interossei (3) Mix of Intrinsic and Extrinsic (Peroneus Longus and Tibialis posterior)

Anterior Tibial artery changes name to _____

Dorsalis Pedis Artery once it is below the malleoli

Talipes Calcaneovalgus

Dorsiflexion and eversion at the ankle joint. Happens with oligohydramnios (too little amnionic fluid and is pushed against uterus) Can be stretched to correct

Internal iliac nodes

Drainage from: Uterus Oviduct Bladder Seminal Vesicle Prostate Superior Vagina Cervix lower rectum upper anal canal

External iliac nodes

Drainage from: bladder seminal vesicle Vas Deferens Prostate Uterus Cervix Superior Vagina These will eventually drain into the lumbar trunk

Deep Plantar Arch

Drains the plantar surface of the foot. Continues to form the posterior tibial vein.

A 25-year-old male is bowlegged. Which of the following most likely will cause this condition? A. Coxa valga B. Coxa vara C. Genu valga D. Genu vara E. Both A & D F. Both B & C

E. Both A & D

Which function is totally lost due to lesion of the tibial nerve? A. Inversion at the ankle B. Knee flexion C. Plantar flexion D. Dorsiflexion E. Flexion of the metatarsal phalangeal joints

E. Flexion of the metatarsal phalangeal joints (loss of flexor digitorium longus and flexor hollicis longus)

Which of the following muscles would still function after a lesion of the tibial nerve? A. Semimembranosus B. Semitendinosus C. Hamstring portion of the adductor magnus D. Long head of the biceps femoris E. Gracilis F. Popliteus G. Plantaris H. Gastrocnemius I. Soleus

E. Gracilis (obturator n.)

The smooth muscle of which of the following structures relaxes with parasympathetic stimulation? A. Detrusor muscle B. Circular muscular layer of colon C. Longitudinal muscular layer of colon D. External anal sphincter E. Helicine arteries

E. Helicine arteries

A 25-year-old man lays carpet for a living. He began having pain in the area indicated by the red arrow. What is a possible cause for the pain? (pointing to medial side of the upper portion of the tibia) A. Inflammation of the suprapatellar bursa B. Inflammation of the IT band C. Inflammation of the deep infrapatellar bursa D. Inflammation of the medial gastrocnemius bursa E. Inflammation of the pes anserine bursa

E. Inflammation of the pes anserine bursa

Which of the following structures is found in the deep perineal pouch? A. Bulb of the penis B. Bulbospongiosus m. C. Crus of the clitorus D. Labia majora E. Membranous urethra F. Scrotum

E. Membranous urethra

The major arterial supply to the hamstring muscles is by direct branches of the ______________ artery. A. External iliac B. Femoral C. Lateral and medial femoral circumflex D. Superficial external pudendal E. Profunda femoris

E. Profunda femoris Note: there is no major artery in the posterior

Lymphatic drainage of which of the following structures is initially to the para-aortic lymph nodes. A. Anus B. Lower 1/3 of the vagina C. Penis D. Scrotum E. Testicle

E. Testicle

During gynecological surgery to remove the uterus (hysterectomy) it is critical to identify and not damage the ureters. The best anatomical description of the pelvic path of the ureters would be: A.Posterior to internal iliac and uterine arteries B.Posterior to internal iliac artery and anterior to uterine artery C.Running along ovarian artery and uterine tube D.Anterior to internal iliac and uterine arteries E.Anterior to internal iliac artery and posterior to uterine artery

E.Anterior to internal iliac artery and posterior to uterine artery

Which of the following structures forms the posterior wall of the true pelvis? A.Coccygeus m. B.Ischiopubic ramus C.Levator ani m. D.Obturator internus m. E.Piriformis m.

E.Piriformis m.

Evidence synthesis

Evaluates all relevant completed studies on a particular clinical question or topic to clarify what is known and what evidence gaps still exists. It builds on previous research, reusing already gathered data, to provide results quickly and efficiently

Hallux Valgus

Excessive Lateral Deviation of the big toe at the MP joint Often with women wearing those tight shoes

Inguinal hernia

Exits the superficial inguinal ring medial and superior to the pubic tubercle

gluteus maximus

Extension at the Hip Joint, Climbing, Arising from chair Innervated by the Inferior Gluteal nerve (L5, S1, S2) Originates from the iliac crest, sacrum, coccyx and inserts on the gluteal tuberosity of femur, in part, into the fascia late of the thigh

What dorsal muscles are involved in medial and lateral longitudinal arch support

Extensor Digitorum Longus (lateral) Tibialis Anterior (medial) Extensor Hallucis Longus (medial) Medial is more extensive

Muscles of the dorsal of foot

Extensor digitorum brevis Extensor hallucis brevis Peroneus tertius 4 Dorsal Interossei

Anal Triangle contents

External Anal Sphincter m. Anus Inferior rectal artery Inferior rectal vein Inferior rectal nerve

Contents of the Urogenital triangle

External Genitalia Deep pouch Superficial pouch

Iliofemoral ligament (Y- ligament of Bigelow)

External and reinforce the hip joint capsule; located anterior Limits extension

Pubofemoral ligament

External and reinforce the hip joint capsule; located anterior Limits extension and abduction

Ischiofemoral ligament

External and reinforce the hip joint capsule; located posterior Limits extension

Contents of the superficial pouch in males

External genitalia Perineal nerve Perineal arteries

Are the cruciate ligaments intrasynovial or extrasynovial?

Extrasynovial They are also vascular (bleeding)

Which of the following paired structures does not represent homologous structures between the male and female? A. Bulb of the penis/bulb of the vestibule B. Bulbourethral gland/greater vestibular gland C. Glans penis/clitorus D. Perineal membrane/inferior fascia of the UG diaphragm. E. Prostate gland/paraurethral glands F. Scrotum/labia minora

F. Scrotum/labia minora

What 3 things are used in gluconeogenesis

Fat Carbohydrate Protein (especially Ala)

Layers of Perineal Superficial fascia in males

Fatty Membranous (colles) -Dartos (in scrotum) -Superficial fascia of penis (in penis) Note: these are all continuous with the colles

Nerves in dorsal (posterior) limb bud,

Femoral Common Fibular (Anterior; Anterior and Lateral)

Contents passing through the Adductor hiatus

Femoral Artery (anterior) Femoral Vein (posterior) Branch of the obturator nerve to knee joint

Deep veins of lower extremities

Femoral Vein Popliteal Vein

Blood supply to the anterior compartment of thigh

Femoral artery and Vein

Innervation to the anterior compartment of thigh

Femoral nerve (L2-L4) Except for the Iliopsoas

Muscles of the Lateral Compartment of the Leg

Fibularis (peroneus) longus (more superficial with a flat tendon) Fibularis (peroneus) brevis Note: these tendons go behind the lateral malleolus

obturator foramen

Filled mostly with Obturator membrane except for an obturator canal

Femoral Canal

Filled with fat and lymphatics (deep inguinal lymph nodes), this is the site of a femoral hernia

Pes Planus

Flat foot

The Hip joint is weakest in which position?

Flexion

What Plantar muscles are involved in medial and lateral longitudinal arch support

Flexor Digiti Minimi (lateral) Abductor Digiti Minimi (lateral) Abductor Hallucis (medial) Flexor Hallucis Brevis (medial) Flexor Hallucis Longus (medial)

The Lateral plantar n. innervates:

Flexor Digiti Minimi Brevis Abductor Digiti Minimi 2,3,4th Lumbricals Adductor Hallucis Quadratus Plantae All Dorsal and Plantar Interossei Note: it is a branch of the tibial n.

3rd layer of plantar muscles

Flexor Digiti Minimi Brevis Adductor Hallucis Flexor Hallucis Brevis All Intrinsic

Posterior Compartment of the leg Deep muscles

Flexor Digitorum Longus (insertion on lateral aspect of foot) Tibialis Posterior (insertion on medial aspect of foot) Flexor Hallucius Longus (insertion on medial aspect of foot)

The Medial plantar n. innervates:

Flexor Hallucis Brevis Abductor Hallucis 1st Lumbrical Flexor Digitorum Brevis Note: it is a branch of the tibial n.

Tarsal tunnel

Flexor Retinaculum which holds these tendon down Area where you can feel tibial a. pulse

Anal Valves

Formed by the connections at the base of the anal columns

Pectinate line

Formed where endoderm (hindgut) meets the ectoderm. It divides the upper 2/3 and lower 1/3 of the anal canal. Located at the bottom of the anal valves

Butterfly hematoma

Forms as a result of a straddle injury

Relationship of structures from posterior compartment at the medial malleolus within the tarsal tunnel

From anterior to posterior: Tibialis Posterior Flexor Digitorum Longus Posterior Tibial Artery (this has a pulse you can feel) Tibial nerve Flexor Hallucis Longus "Tom Dick an Harry"

Pelvic diaphragm

Funnel shaped floor of the pelvis

Contents of superficial pouch in females

Gland Clitoris (formed by the bulb of vestibule) Crus of clitoris Greater Vestibular gland (like the cowper's gland)

How do glucagon and cortisol regulate glycolysis

Glucagon (Gs) inhibits the kinase function of PFK-2, This reduces the production of F26BP and therefore allows for the stop of the inhibition of F1,6- phosphatase (blocking gluconeogenesis) Therefore glycolysis is inhibited

How do glucagon and cortisol regulate gluconeogenesis

Glucagon (Gs) inhibits the kinase function of PFK-2, This reduces the production of F26BP and therefore allows for the stop of the inhibition of F1,6- phosphatase (blocking gluconeogenesis). Therefore glycolysis is inhibited and gluconeogensis is promoted Cortisol increases the expression of HSL and there will be more gluconeogenesis. It also helps with the proteins which degrade proteins to make Ala and increase glucoeneogeneis further. Finally, it increases activity of PEPCK and increases glucoeneogeneis further.

How do glucagon and cortisol regulate glycogenolysis

Glucagon binds and stimulates glucagon receptors (Gs) found on the liver which will activates PKA leading to the phosphorylation and activation of Glycogen phosphorylase kinase This activates glycogen phosphorylase This produces G6P from the glycogen chain and therefore promotes glycogenolysis in the liver and therefore the release of glucose in the bloodstream

Gq receptors

Gq receptor ->Phospholipase C, incr Ca2+, PKC α1 M1 M3 M5

The______ is one of the vessels harvested for coronary bypasses

Great Saphenous vein Others include: Internal throacic artery Radial arteries

Superficial veins of the lower extremity

Greater Saphenous Small Saphenous

Bony Pelvis Landmarks

Greater Sciatic notch Superior ramus of pubis Inferior ramus of pubis Ischial Ramus Lesser sciatic notch Ischial Spine Iliac Crest

Posterior Compartment of Thigh muscles

Hamstring Muscles -Hamstring portion of Adductor Magnus -Semimembranosus -Semitendinosus -Long head of biceps femoris Short head of Biceps Femoris

Posterior compartment of leg

Has its own nerve and ateriral supply Action at the ankle: plantar flexors left the heel off the ground. Inverters raise the medial side of the foot off the ground Innervation: Tibial n. Artery: Posterior Tibial

Test for gluteus medius

Have the patient lie flat on an examine table. Apply resistance to the outside fo the limb and have them attempt to abduct the thigh

Where is a site of damage to the common peroneal nerve

Head of Fibula

Posterior side of bladder in a males

Here you will see most of the male reproductive portions: Vas Deferens (comes from deep ring) Ampulla of Vas Deferens Seminal Vesicle Prostate Gland Ejaculatory duct

Potential swellings in the femoral triangle

Hernias are mobile and soft Lymph nodes are tethered to the fascia and harder Femoral artery aneurism Femoral vein thrombosis

Popliteal Cyst (Baker's Cyst)

Herniation of the knee joint synovial membrane into the popliteal fossa; excess synovial fluid due to a knee injury (arthritis, cartilage tears) Associated with the gastrocnemius bursa of the medial head that communicates (continuous) with the synovial membrane of the knee joint

Some causes of Sciatica

High Sciatic nerve division A tumor in any of the pelvis can compress the ventral rami of the lumbosacral plexus Compression of spinal nerve roots

Pes Cavus

High medial longitudinal arch

Are the deep veins high or low pressure

High, however, the superficial veins flow here

Tamsulosin

Highly selective for α1A in the prostate There is less orthostatic hypotension

Rectus Femoris

Hip Flexion Innervated by Femoral n. Only one to cross the hip join and therefore assists in flexion of that joint

What does the lymphatics of the Upper rectum drain

IMA nodes

Bladder Trauma

If a penetrating wound goes to the superior portion of the bladder (intraperitoneal), urine can pass into the peritoneal cavity Often the lower portion of the bladder (retroperitoneal) is injured in crushed pelvis injuries, urine will travel to the true pelvis in the cave of retzius, around the prostate, etc

Nerves in the scrotum

Ilioinguinal Genitofemoral Pudendal Posterior Cutaneous of Thigh

Branches off the posterior division of the internal iliac

Iliolumbar Lateral Sacral Superior gluteal Note: these are common in both sexes

Parts of the hip bone

Ilium Ischium Pubis

Deep Pouch

In both sexes, contains the Sphincter Urethra and Deep Transverse Perineal muscle

prevertebral ganglia vs paravertebral ganglia

In the prevertebral ganglia, the preganglionic neuron passes through the prevertebral ganglia and synapses with the postganglionic neuron in a distant paravertebral ganglia In paravertebral ganglia, the preganglionic neuron synapse with the postganglionic neurons in the nearby parabertebal ganglia

Pelvis Organs in Females

Include: Bladder Urethra Vagina Cervix Uterus Ovary Rectum Sigmoid Colon Ureter Note: Ovarian Vessels come over the psoas muscle Note: top half is covered with peritoneum so there is visceral pain refereed along the sympathetics

Tibial nerve dermatomes of leg

Includes S1, S2, and L5 Lateral posterior leg and lateral side of digit 5 is mostly S1 by the sural n. (branch of tibial n.) Medial posterior leg is mostly S2 L5 is the posterior heel and most plantar surface of the foot

Anterior knee

Includes: Articulates Genus Quadriceps Tendon and muscles Patella Patellar tendon

Lateral Knee

Includes: Lateral Epicondyle of femur Iliotibial Tract Biceps Femoris Tendon Bursa of the biceps femoris (might also have pin point pain) Bursa of the lateral collateral ligament Bursa of iliotibial tract (associated with over protonation)

Genu Valga/ Knocked knee

Increase Q angle- title tibia outward

Coxa Valga/ Bow Legged

Increase angle or tilt femur outward

VSMC, BSMC, and USMC relaxation by ß2 (Gs)

Increases cAMP --> PKA-- > MLCK phosphorylation --> decreased binding of calcium-calmodulin --> relaxation

Ischioanal fossa absess

Infection can track up here If you have tears in the lateral wall of the vagina, it can open into this recess

Contents below the Pectinate Line

Inferior Rectal Artery Inferior Rectal Vein (external hemorrhoids; covered by skin) Pudenal Nerve (Somatic S2-S4) Lymphatics: Superficial Inguinal Nodes

What is the floor of the deep pouch

Inferior fascia of the urogenital diaphragm (perineal membrane)

What is the roof of the superficial pouch?

Inferior fascia of the urogenital diaphragm (perineal membrane)

Superficial pouch in males

Inferior fascia of the urogenital diaphragm is the roof of the superficial pouch

Ischial Bursa

Inflammation caused by repetitive hip extension while seated (ex. cycling, rowing) Point tenderness over ischial tuberosity (ex. sitting) Between the Gluteus maximus and the ischial tuberosity

Trachanteric bursa

Inflammation caused by repetitive motion (ex. climbing) Point tenderness over greater trochanter Between the greater trochanter and gluteus maximus

Retrocalcaneal Bursitis

Inflammation of the bursa between the Achilles tendon and the calcaneus. Will present as tenderness in front of the tendon (pinching it will show pain)

Popliteus Tendonitis

Inflammation of the popliteus tendon Will present as point tenderness at the attachment of the popliteus tendon on the femur

Gi receptors

Inhibits adenylate cyclase activation, and therefore decreases cAMP levels α2 M2 M4 D2 D3 D4

High Ankle Sprain

Injury to the Tibiofibular ligament Comes from driving the fibula toward the ground Might often have a fibula fracture

Muscle layers of the rectum

Inner Circular Smooth Longitudinal Muscle layer Circular Muscle layer

Adductor Hallucis

Innervated by Lateral plantar n. Adducts big toe

flexor digiti minimi brevis action

Innervated by Lateral plantar n. Flex MP joint of digit 5

Quadratus Plantae

Innervated by Lateral plantar n. Straightens the pull of the FDL tendons (flexor digitorium longus tendons)

Flexor Hallucis Brevis

Innervated by Medial plantar n. Flex MP joint of the big toe

Lateral Compartment of the Leg

Innervated by Superficial Peroneal n. Artery: Fibular Action at ankle: Assists with Plantar Flexion and is the only everters (pronators)

Abductor Hallucis

Innervated by the Medial plantar n. (branch of tibial n.) Abducts 1st digit

Flexor Digitorum Brevis

Innervated by the Medial plantar n. (branch of tibial n.) Flexes MP joints and Flexes proximal IP joint of digits 2-5 originates form the calcaneus and inserts on toes

Abductor Digiti Minimi

Innervated by the lateral plantar n. (branch of tibial n.) Abducts the 5th digit

Anterior Compartment of the Leg

Innervation: Deep Peroneal n. (branch of common peroneal) Artery: Anterior Tibial Action at the ankle: The only dorsiflexors; assist in Inversion (supination)

Vastus Lateralis

Inserts in the common quadriceps tendon, through the patella through the patellar ligament, and eventually onto the tibia Knee Extension Innervated by Femoral n.

Vastus Intermedius

Inserts in the common quadriceps tendon, through the patella through the patellar ligament, and eventually onto the tibia Knee Extension Innervated by Femoral n. Deep to the rectus femoris

Vastus Medialis

Inserts in the common quadriceps tendon, through the patella through the patellar ligament, and eventually onto the tibia Knee Extension Innervated by Femoral n. The oblique fibers are involved in holding the patella medially for proper tracking over the trochlea of the femur

Iliotibial tract

Inserts on Gerdy's Tubercle of Tibia Located on the lateral side of the knee

Biceps Femoris Tendon

Inserts on the head of the Fibula Located on the lateral side of the knee

What is the last action of extension at the knee joint?

Internal (medial) rotation of the femur; locking of the femur on the tibia The tibia is now immovable because of body weight

Blood supply to the Urogenital triangle

Internal pudendal artery with its many branches

Where does the fibular artery disappear?

Into the flexor hallucis longus

Are the menisci intrasynovial or extrasynovial?

Intrasynovial They are also avascular (no bleeding), it is a fibrocartilage Note: they are on the posterior portions forming a C shaped) Note: there can be inflammation though

metatarsal phalangeal joint

Joint between the Metatarsal and the proximal phalange

DIP Joint

Joint between the middle phalange and distal phalange

PIP Joint

Joint between the proximal phalange and middle phalange

Calcaneocuboidal joint

Joint located in the foot between the calcaneus bone and the cuboid bone; part of the midtarsal joint.

Calcaneonavicular joint

Joint located in the foot between the calcaneus bone and the navicular bone

Lumbar Splanchnic nerves

L1-2 lateral horn Sympathetic trunk and L1-5 paravertebral ganglia Cell bodies in lateral horn of L1-2. Preganglionic fibers travel down the sympathetic trunk, trough the paravertebral ganglia, enter the inferior hypogastric plexus and synapse with postganglionic neurons in ganglia in the plexus.

Lumbar Splanchnic nerve

L1-L2 Goes to the Inferior mesenteric ganglion which controls the descending colon, sigmoid colon, upper portion of rectum, and distal ureter

Sacral Splanchnic nerves

L1-L2 lateral horn Sympathetic trunk and S1-5 paravertebral ganglia Cell bodies in lateral horn of L1-2. Preganglionic fibers travel down the sympathetic trunk, trough the paravertebral ganglia, enter the inferior hypogastric plexus and synapse with postganglionic neurons in ganglia in the plexus.

Hip Flexion is due to which ventral rami of the somatic spinal nerves?

L2, L3

Knee Extension is due to which ventral rami of the somatic spinal nerves?

L3, L4

Ankle Extension and Inversion is due to which ventral rami of the somatic spinal nerves?

L4, L5

Ankle Eversion is due to which ventral rami of the somatic spinal nerves?

L5, S1

Hip extension is due to which ventral rami of the somatic spinal nerves?

L5, S1

Knee Flexion is due to which ventral rami of the somatic spinal nerves?

L5, S1

Femoral Hernia

Lateral and inferior to the pubic tubercle

Sensory portion of the common peroneal n.

Lateral posterior leg (upper 1/2) Lateral anterior leg Dorsal of foot Knee joint

Peroneal nerve dermatome

Lateral sural cutaneous n. (branch of common peroneal L5) supplies the medial portion of the superior leg Superficial Peroneal n. L5 supplies most of the medial portion of the lower leg and the dorsum of foot above toes 2-4 and lateral side of toe 1 Deep peroneal n. L5 supplies between Toe 1-2

Deep infrapatellar Bursa

Lies between the patellar tendon and the tibia

The Lower limbs, in embryological development, grow out as a____

Limb bud, which has a dorsal and ventral compartment

Small saphenous vein

Lit posterior to the lateral malleolus and drains into the popliteal vein

Where is glucose-6-phosphatase found?

Liver

costodiaphragmatic recess

Located In the Upper Right Quadrant or Upper Left Quadrant

Hepatorenal Recess

Located in the Upper Right Quadrant

Groove in cuboid

Located on the plantar surface of the foot This if for the peroneus longus tendon where it will insert on the first metatarsal

Anal Columns (Morgagni's)

Longitudinal folds and will contain the plexus of superior rectal veins Portal Hypertension can cause varicosities here

Is the superficial veins high or low pressure?

Low

What does the lymphatics of the ovary drain?

Lumbar nodes

2nd Layer of Plantar muscles

Lumbricals (1-4) Quadratus Plantae Mix of Extrinsic (flexor hallucinate longus and flexor digitiorum longus) and Intrinsic

Lumbricals

Lumbricals 2-4: innervated by Lateral plantar n. Lumbrical 1: innervated by Medial plantar n. These flex MP joints & extend IP joints of digits 2-5

Gastric and pancreatic exocrine secretion is simulates by ____

M3

Gastric emptying and intestinal peristalsis is stimulated by __

M3 Note: causes smooth muscle contraction

What are the autonomic receptors that control the detrusor

M3 (parasympathetic from S2-S4 causes contraction of the detrusor muscle) ß3 (sympathetic from T12-L2 causes the relaxation of the detrusor smooth muscle)

Pancreatic ß Cell insulin secretion is stimulated by ____

M3 and ß2

Disease Oriented Evidence (DOE)

Measures outcomes that are markers for the disease Refers to the outcomes of studies that measure physiologic or surrogate markers of health

Patient orientated evident that matters (poem)

Measures outcomes that patients care about and have the potential to change practice Refers to outcomes of studies that measure things a patient would care about, such as improvement in symptoms, morbidity, QOL, cost, etc.

Adductor canal boundaries

Medial Wall: Adductor Longus Roof: Sartorius Lateral Wall: Vastus Medialis

The ventral compartment of the limb bud of the lower limb become ___

Medial and eventually posterior The limb bud rotates medially! This includes the nerves!

Lower limb arteries

Medial femoral Circumflex a. Femoral artery Profunda Femoris (branch of the femoral a.) Lateral Femoral Circumflex a.

What nerve runs over the plantar fascia?

Medial plantar n. (branch of the tibial n.)

Sensory portion of the tibial n.

Medial posterior leg Lateral posterior leg (lower 1/2) Plantar surface of foot Knee joint

gluteus minimus

Medially rotates thigh (very important in walking and standing) Innervated by the Superior Gluteal n. (L4, L5, S1) Originates from the lateral surface of ilium and inserts on the greater trochanter of femur

Perineal nerve

Motor to all muscles of the UG triangle (both pouches) and sensory to posterior area of scrotum and labia majora Note: this is typically in the pudendal canal

Pelvis Organs in males

Much the same as in females, the top of the bladder is covered with a visceral peritoneum The bladder has an anterior, apex, superior, and base There is a urogenital diaphragm There is a Retro-pubic space

Layers of the Gut

Mucosa Tunica Muscularis mucosae Submucosal plexus (Meissner's plexus) Circular muscle Myenteric plexus (Auerbach plexus) Longitudinal muscle

Extensor digitorum longus

Muscle of the anterior compartment of the leg The only dorsiflexors of ankle (digits raised off the ground) Innervated by the Deep Peroneal n.

Tibialis anterior

Muscle of the anterior compartment of the leg The only dorsiflexors of ankle (digits raised off the ground), and assist in Inversion Innervated by the Deep Peroneal n.

extensor hallucis longus

Muscle of the anterior compartment of the leg The only dorsiflexors of ankle (digits raised off the ground), and assist in Inversion Innervated by the Deep Peroneal n.

__________ can create an abscess that tracks into the poses fascia and presents as a swelling in the femoral triangle

Mycobacterium Tuberculosis and Staphylococcus Aureus Note: Osteomyelitis of the iliac crest can create a similar abscess

Is there a spongy urethra in females?

NO

Can you palpate the deep inguinal nodes?

NO! You can palpate the superficial inguinal nodes though

sural nerve

Nerve of the lower leg that supplies impulses to the skin on the outer side and back of the foot and leg.

Contents of the Adductor canal

Nerve to Vastus Medialis (femoral n.) Saphenous Nerve (femoral n.) Femoral Artery Femoral Vein

What are the autonomic receptors that control the external urethral sphincters

Nm receptors (Somatic from S2-S4 allows for voluntary control of the external urethral sphincters)

In the male, camper's fascia essentially disappears and is replaced in the scrotum by the dartos muscle with not much fat, is this similar in females?

No, in the female with the labia majora, there is abundant layer of fat

Erectile Dysfunction

Normally NO stimulates guanylyl cyclase causing production of cGMP. This reduces concentration of Ca2+ --> smooth muscle relaxation --> Increased inflow of blood into penis --> erection ---> reduced concentration of cGMP by degradation by PDE5 --> no erection Erectile Dysfunction results in reduced concentration of cGMP and therefore no erection Sildenafil blocks the the PDE5 activity and therefore increases the levels of cGMP and therefore erections

Perineum

Not in the pelvis! This is the region below the floor of the pelvis

Nerves in ventral (anterior) limb bud,

Obturator Tibial (Posterior and Medial; Posterior)

Branches off the anterior division of the internal iliac in males

Obturator Umbilical Inferior Gluteal (variable) Internal Pudendal (perineum) Superior Vesicular Inferior vesicular Prostatic (usually off the inferior vesicular) Middle Rectal

Branches off the anterior division of the internal iliac in females

Obturator Umbilical Uterine Superior Vesicular (often off the umbilical) Vaginal (usually off the uterine) Inferior Vesicular Middle Rectal Internal Pudendal (perineum) Inferior Gluteal (variable)

Deep layer of muscle of the medial compartment of the thigh

Obturator Externus Adductor Brevis Adductor Magnus Adductor portion Adductor Magus Hamstring portion

Innervation of the Medial compartment of the thigh

Obturator nerve Except the Hamstring part of the Adductor Magnus

What exits out of the obturator canal?

Obturator nerve (L2-4) Obturator artery Obturator Vein

Patellar sleeve fracture (Osgood/Slatter's Disease)

Occurs in 10-14 year old active adolescent Growth plates are not fully formed Fracture of the tibial tuberosity (shear off the tibia) because Haven't gotten complete ossification yet

Obturator canal

Opening in the obturator membrane where the obturator nerve comes through Note: this is a site where this nerve can be compressed

Flexor Digitorum Longus

Originates at the Posterior surface of the body of the tibia and Inserts on the Plantar surface; base of the distal phalanges of the four lesser toes Innervated by the Tibial n. Action: Plantar Flexion and flexes digits 2-5

Plantaris muscle

Originates form the Posterior lateral condyle of femur and inserts on the posterior calcaneus Innervated by the Tibial n. Knee Flexion

Tibialis Posterior

Originates from the Tibia and fibula and inserts on the Navicular and medial cuneiform bone Innervated by the Tibial n. Action: Plantar Flexion and Inversion (medial side of the foot raised off the ground)

Sartorius

Originates from the anterior superior iliac spine and inserts on the medial aspect of proximal tibia Innervated by the femoral nerve Flex, laterally rotate and abduct the femur Flex and medially rotate the leg (tibia)

Obturator Externus

Originates from the external surface of obturator membrane and inserts on the trochanteric fossa of femur Innervated by the Obturator n. posterior division Involved in Adduction of the thigh (brings it to midline)

Short head of Biceps femoris

Originates from the femur and inserts on the head of fibula and lateral condyle of tibia innervated by the Common peroneal (fibular) n. Knee flexion Note: this is not a hamstring muscle!

Soleus

Originates from the fibula, medial border of tibia (soleal line) and Insertis on the tendo calcaneus Innervated by the Tibial n. Action: Plantar flexion

Flexor Hallucius Longus

Originates from the fibula, posterior aspect of middle 1/3 and inserts on the plantar surface; base of distal phalanx of big toe Innervated by the Tibial n. Action: Plantar Flexion and Inversion (medial side of the foot raised off the ground) and flexes all joints of the big toe

Long head of biceps femoris

Originates from the ischial tuberosity and inserts on the head of fibula and lateral condyle of tibia Innervated by the Tibial n. Hip extension and knee flexion

Semimembranosus

Originates from the ischial tuberosity and inserts on the medial condyle of the tibia Innervated by the Tibial n. Hip extension and knee flexion

Semitendinosus

Originates from the ischial tuberosity and inserts on the medial surface of the proximal tibia Innervated by the Tibial n. Hip extension and knee flexion

Adductor Magnus Hamstring portion

Originates from the ischiopubic ramus and inserts adductor tubercle on the medial epicondyle of the femur Innervated by the Tibial n. Involved in Adduction of the thigh (brings it to midline)

Adductor Magnus Adductor portion

Originates from the ischiopubic ramus and inserts on the linea aspera of femur Innervated by the Obturator n. posterior division Involved in Adduction of the thigh (brings it to midline)

Adductor Longus

Originates from the pubis and inserts on the line aspera of the femur Lies between the adductor longus and adductor brevis Innervated by the Anterior division of the obturator nerve Involved in Adduction of the thigh (brings it to midline)

Adductor Brevis

Originates from the pubis and inserts on the linea aspera of femur Innervated by the Anterior division of the obturator nerve Involved in Adduction of the thigh (brings it to midline)

Gracilis

Originates from the pubis and inserts onto the medial tibia Innervated by the Anterior division of the obturator nerve Involved in Adduction of the thigh (brings it to midline)

Pectineus

Originates from the superior ramus of pubis and inserts on the pectineal line of femur Innervated by the Femoral nerve Hip flexion (femur)

Poplitues muscle

Originates on the tibia, penetrates the joint capsule, inserts on the lateral femoral epicondyle Innervated by the Tibial nerve Unlocks knee joint prior to flexion (this involves external rotation (lateral) of the femur on the tibia)

Parasympathetic outflow to the pelvis

Outflow form vagus and pelvic splanchnics (come from the inferior hypogastric plexus) follow mesenteric vessels

Sympathetic Outflow to the Pelvis

Outflow from pre-vertebral ganglia Leads to decreased muscle and secretory activity but contraction of sphincters

Subtrochanteric fracture

Outside the capsule. Does not disrupt the blood supply to the head of the femur

Hammer toe

PIP flexed and DIP extended Associated with PIP joint

Erection innervation

Parasympathetic (coming from the pelvic splanchnics) traveling along the cavernous n. Closes AV bypass (normally shuts blood around the cavernous sinus to keep it flaccid) Opens the Helicine arteries (within the corpus cavernous and results in erections) Note: during erection, the veins are compressed between tunica albuginea of cavernous sinus and Buck's fascia which helps maintain erection in the penis

Detrusor muscle in males

Parasympathetic = contract

Sphincter Vessicae in males

Parasympathetic= relax Sympathetic= contracts, ejaculation

Patellofemoral stress syndrome

Patellar pain due to a misshaped patella or weak medial head of the quadracepts muscle that allows lateral tracking of the patella out of the femoral trochlea

PICO question

Patient population Intervention Comparison (may or may not be there) Outcome

Pelvis Components

Pelvic bones and ligaments= bowl with bottom cut out, essentially a ring Pelvic bones= Sacrum + Coccyx, Hip bone (Ilium, Ischium, Pubis) Pelvic Ligaments =Sacroiliac, Sacrotuberous, Sacrospinous, Pubic Symphysis

Which nerve supplies all skeletal muscle in the deep and superficial pouch?

Perineal nerve

What Plantar ligaments and tendons are involved in Medial and Lateral Longitudinal arch support

Peroneus Longus Tibialis Posterior Long Plantar Ligament Short Plantar Ligament Spring Ligament

The 5th metatarsal is the site of insertion of which 2 muscles?

Peroneus Tertius Peroneus Brevis

Lateral Rotators in the Gluteal region

Piriformis Superior gamellus (innervated by nerve to obturator internus) Obturator internus (innervated by nerve to obturator internus) Inferior gamellus (innervated by nerve to quadratus femoris) Quadratus femoris (innervated by nerve to quadratus femoris) Note: these insert on the intertrochanteric crest

What ligaments are involved in medial longitudinal arch support

Plantar Calcaneonavicular ligament (spring ligament) This is attached to the sustentaculum tali of calcaneum and navicular Helps to flatten out the medial arch

Talipes Equinovarus

Plantar flexion at ankle and inversion at midtarsal joint Happens with oligohydramnios (too little amnionic fluid and is pushed against uterus) Can be stretched to correct

Popliteal Fossa Contents

Popliteal Lymph nodes Tibial Nerve Popliteal Vein Popliteal Artery Popliteus Muscle Note: popliteal artery is deep and medial Note: popliteal vein is most superficial and lateral to the artery Note: Tibial nerve is lateral to the vein

Where can you palpate the Popliteal Lymph nodes

Popliteal fossa

What forms the floor of the popliteal fossa?

Popliteus muscle

Perineal superficial fascia attachments in males

Posterior perineal membrane Fascia lata of thigh Inguinal Ligament

Cave of Retizus (retropubic space)

Posterior to the pubic symphysis and anterior to the bladder The space is extraperitoneal and separated from the anterior abdominal wall by transversalis fascia; it extends as high as the umbilicus

Boundaries of Pelvis

Posterior: Sacrum Anterior: Pubic Symphysis Floor: Pelvic Diaphragm There is not a border superior, but more of an opening with the pelvic inlet

Popliteus tendon

Prevents the attachment of the lateral meniscus to the lateral collateral ligament

Blood supply fo the medial compartment of the thigh

Profunda Femoris

Blood supply of the posterior compartment of thigh

Profunda femoris via perforating arteries

Rectocele

Prolapsed rectum Bulges into the posterior wall of the vagina Can be caused by loss of support by the floor of the pelvis, in part which is provided by the fascias

portions of male urethra

Prostatic (goes through prostate) Membranous (goes through sphincter urethrae) Spongy/penile (goes through penis)

Muscles of the Levator ani in females

Puborectalis (blends with the external anal sphincter) Pubococcygeus (pubovaginalis) (help support the vagina) Ilioccoygeus (arises from tendinous arch) Coccygeus

Muscles of the Levator ani in males

Puborectalis (wrap around rectum) Pubococcygeus (puboprostaticus) Ilioccoygeus (arises from tendinous arch) Coccygeus

What can be found below the piriformis muscle?

Pudendal nerve (S2-4) Internal Pudendal artery Nerve to Obturator internus m. Inferior Gluteal nerve (goes to the gluteus maximus) Sciatic nerve (very large!)

Innervation of the Urogenital triangle

Pudendal nerve (S2-S4) (ventral rami)

The Ischial Spine is an important landmark for____

Pudendal nerve blocks

Dorsal nerve

Pure sensory to glans penis and clitoris

Muscles of the anterior compartment of thigh

Quadriceps femoris - rectus femoris - vastus lateralis - vastus medialis - vastus intermedius Iliopsoas Pectineus Sartorius

Pes Anserine (goose foot)

Refers to the conjoined tendons of three muscles that insert onto the anteromedial surface of the proximal extremity of the tibia From anterior to posterior Sartorius Gracilis Semitendinosus "Say Grace before Tea"

Visceral afferents in pelvis

Reflex sensations- travel with parasympathetic fibers Pain- travel with sympathetic fibers through splanchnic nerves (except: lower 1/2 of rectum which runs with parasympathetic fibers in the pelvic splanchnic nerves)

Bilateral Quadriceps tendon tear indicates potential underlying conditions such as:

Renal failure Hyperparathhyroidism Gout Systemic lupus erythematosus Long term statin use Anabolic steroids

Lateral Ankle Sprains

Results from driving the fibula toward the ground Laterally, it can result in injury (torn) to the Posterior Talofibular Ligament, Anterior Talofibular Ligament, or Calcaneofibular ligament

Medial Ankle Sprain

Results from driving the tibia toward the ground involves injury to the Deltoid Ligament A sprain to this ligament may shear the Tibial styloid (medial malleolus) process from the tibia

What is the only blood supply to the head and neck of the femur in adults?

Retinacular arteries These come off from the lateral circumflex femoral artery and the medial circumflex femoral artery Note: there is a minor supply coming from the acetabular branch coming off the obturator artery

Boundaries of the femoral triangle

Roof: Skin and Fascia Floor- Lateral: Iliopsoas Floor-Medial: Pectineus Lateral Wall: Sartorius Medial Wall: Adductor Longus Superior Vorder: Inguinal Ligament Note: femoral hernias can occur here

Popliteal fossa boundaries

Roof: Skin and Fasica Medial Wall: Semimembranosus and Medial head of the Gastronemius Floor: Poplitus muscle is deep to the planters and gastrocnemius muscle Lateral Wall: Biceps Femoris, Plantaris, and Lateral head of Gastrocnemius Note: if the knee is flexed, if you go through the posterior wall of the joint capsule the first thing you would hit would be the popliteal artery and vein

Lateral cervical ligaments (Mackerodt's or Cardinal)

Runs transverse and contains the uterine artery

Visceral pain of retroperitoneal pelvic viscera

Runs with pelvic splanchnic nerves (S2-S4) Referred to S2-4 Include: Lower 1/2 of rectum Bladder (inferior) Cervix Vagina Prostate Seminal Vesicle

Ankle Flexion is due to which ventral rami of the somatic spinal nerves?

S1, S2

pelvic splanchnic nerves

S2-4 Lateral horn Parasympathetic Cell bodies in lateral horn of S2-4. Preganglionic through the pelvic splanchnic nerves, through the inferior hypogastric plexus and synapse with postganglionic neurons in ganglia in the organs.

Pelvis GVE innervation

SMA -sympathetic; Thoracic Splanchnics (T10-11, 12) -parasympathetic; vagus IMA -sympathetic; Lumbar splanchnics (L1-2) -parasympathetic; pelvic splanchnics (S2-4) Inferior Hypogastric plexus (lower 1/2 rectum) -sympathetic; sacral splanchnics (L1-L2) -parasympathetic; Pelvic splanchnics (S2-4) Somatic; Pudendal Nerve (S2-4) (external sphincter and those organs below the urogenital diaphragm) Somatic; Nerve to Levator Ani (S3-4) (external sphincter and those organs below the urogenital diaphragm)

Pelvis GI pain

SMA visceral pain -Lesser Thoracic Splanchnics (T10,11,12) IMA visceral pain -Lumbar splanchnics (L1-L2) (descending colon, upper 1/2 of rectum) Inferior Hypogastric plexus visceral pain -Pelvic splanchnics (S2-S4) (lower 1/2 of rectum) Pudendal Nerve (S2-4) This is somatic pain and not referred Inferior Rectal Nerve

The sacral plexus can possibly be damaged with:

Sacral fracture Cancer Surgery

Which muscle is referred to as the tailor's muscle

Sartorius, it is responsible for crossing ones leg while sitting

If an anterior force is applied to the hip in flexion, what structure would most likely be damaged?

Sciatic nerve

primary lymphatic drainage of male perineum

Scrotum: Skin, Horizontal Superficial inguinal nodes Penis: Skin and cavernous bodies, Horizontal Superficial inguinal nodes Glans and Spongy urethra: Deep inguinal node Testis: Lumbar Anal canal: -Upper= Internal iliac node -Lower= Horizontal Superficial inguinal nodes

Retroperitoneal organs in male pelvis

Seminal vesicle Prostate gland Lower portion of bladder Lower 1/2 of rectum These are all below the peritoneum (those above like the top of the bladder, upper 1/2 of rectum are intraperitoneal)

Vertical Superficial lymph nodes

Sentinel nodes for the Superficial regions of -All thigh -Medial leg -Medial foot Note: these travel along the great saphenous vein From here, they will travel to the deep inguinal nodes -> iliac nodes--> Lumbar trunk --> Cysterna chyli-->Thoracic duct

Popliteal Lymph nodes

Sentinel nodes for the Superficial regions of: Lateral leg Lateral foot Also all deep leg and foot Note: these run along the small saphenous veins and then along the popliteal artery then along the femoral artery From here, they will travel to the deep inguinal nodes -> iliac nodes--> Lumbar trunk --> Cysterna chyli-->Thoracic duct

Medial Intermuscular Septum

Separates the anterior and medial compartment of the thigh (deep fascia)

Posterior Intermuscular Septum

Separates the medial and posterior thigh compartments (deep fascia)

Lateral Intermuscular septum

Separates the posterior and anterior thigh compartments (deep fascia)

What is the only flexor at the knee joint that is not innervated by the tibial nerve?

Short head of Biceps femoris

Hip Injection

Should be performed in the superior lateral quadrant (between the tubercle of the iliac crest and ASIS) An injection directly into the sciatic nerve can cause temporary or permeant damage to the nerve!

Bulbospongious muscle

Skeletal muscle which covers the bulb of the penis

Ischiocavernosus muscle

Skeletal muscle which covers the crus of the penis

Dartos muscle

Smooth muscle in the wall of the scrotum Under sympathetic control Involved in thermoregulation and has sweat glands

Detrusor Muscle

Smooth muscle that compresses the urinary bladder and expels urine into the urethra. Parasympathetic= Contracts

Expulsion innervation

Somatic traveling along the Pudendal n Relaxes UG diaphragm Causes rhythmic contraction of bulbosponhiousus m. and others Note: parasympathetic causes contraction of urethra!

Uterovesicular pouch

Space between the bladder and uterus Note: this is within the peritoneum

External Anal Sphincter

Striated muscle which can be divided into a deep, superficial, and subcutaneous portion; though it functions as one Voluntary control, controlled by the Pudendal nerve (S2-S4)

Sphincter urethrae

Striated muscle which opens and closes urethra Voluntary control, innervated by branches of the Pudenal Nerves (Somatic S2-S4)

Babinksi Sign

Stroke the plantar surface of the foot A normal response is plantar flexion of the toes An abnormal response is dorsi flexion of the toes Central nervous lesion

Bunion

Subcutaneous bursa over the head of the 1st metatarsal, result of hallux valgus

Common peroneal nerve damage

Superficial Peroneal n.- Lateral compartment with only everters (motor deficits) Deep Peroneal n. - Anterior compartment with only Dorsi Flexors (motor deficits) Therefore antagonist will have the foot: Plantar flexed and Inverted

What neurovascular bundle is above the piriformis muscle?

Superior Gluteal nerve Superior Gluteal artery These go to the gluteus medius and minimus

Contents above the Pectinate Line

Superior Rectal Artery Superior Rectal Vein (internal hemorrhoids; coved by mucosa) Parasympathetics; Pelvic splanchnics S2-4 Sympathetic (upper= IMA plexus; Lower= Inferior hypogastric plexus L1-2) Lymphatics: upper= pararectal then inferior mesenteric nodes; Lower Rectum and upper anal canal= Internal iliac nodes

What is the roof to the deep pouch?

Superior fascia of the urogenital diaphragm

Trendelenburg sign

Superior gluteal nerve, upper medial gluteal injection Gluteus medius/minimus injured, contralateral hip drops when he lifts his left foot off the floor

Levator Ani

Supports pelvic viscera and provides sphincter-like action in anal canal and vagina Innervated by S3-4 Originates from the pubic bone and then along the tendinous arch on the obturator internus fascia then to the Ischial Spine

Abdominal fat innervation

Sympathetic innervation acts on the visceral adipocyte It stimulates the ß3 (Gs) which will then go on to activate the HSL. This goes on to cleave TG and form FFA This process also causes the release of Leptin

Epi effect on metabolism

Sympathetic stimulation results in the adrenal medulla releasing EPI which simulates ß2 and ß3 receptors (Gs) which will activates PKA leading to the phosphorylation and activation of Glycogen phosphorylase kinase This activates glycogen phosphorylase This produces G6P from the glycogen chain and therefore promotes glycogenolysis in the liver and muscle G6P is kept in the skeletal muscle and used there, in the Liver it is converted to glucose and released in the blood stream

Emission innervation

Sympathetics Closes internal urethral sphincter (to prevent retrograde ejaculation) Contracts epididymis, vas deferent, seminal vesicles, and prostate