Y2 LCRS Anatomy of the Limbs

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The bony pelvis is formed by:

The bony pelvis is formed by the a) Sacrum b) Coccyx c) 3 pelvic bones: Ilium, ischium and pubis. All of the hip, buttock and thigh muscles relating to hip movement are proximally attached to the pelvic bone

Where is the tubercle of the base of the metacarpal of the thumb?

Tubercle of the base of the metacarpal of the thumb in the snuff box

Distal carpals

Lateral to Medial: 1) Trapezium (has a tubercle and is next to the thumb) 2) Trapezoid 3) Capitate (largest of all carpal bones) 4) Hamate (has a hook on palmar surface)

Innervation and function of levator scapulae

o attach to superior angle of scapula and also transverse processes of C1 to C4. o Supplied by the dorsal scapular nerve (+ C3,4). (same as rhomboids) o Elevates and rotates the scapula

Segmental nerve supply: dermatomes

o fields of cutaneous surface whose sensation supplied by particular spinal root. o gets distorted in lower limb due to twisting in development. o L3 to knee, L4 to floor.

anterior thigh compartment muscles proximal attachments

attach to the anterior ilium. 1) Iliac fossa: Iliacus Forms the iliopsoas muscle. 2) Anterior superior iliac spine (red): Sartorius, Tensor fascia lata 2) Anterior inferior iliac spine (green): Rectus femoris

sartorius attachment

attachment at ASIS, as it crosses the thigh inferomedially crossing the knee to attach to the proximal medial shaft of the tibia.

Safe Area For Gluteal Injection

avoid hitting the sciatic nerve (and superior gluteal nerve and vessels) during i.m. injection. o usually goes into gluteus medius muscle.

Quadriceps at the Knee

at knee fibres of quadriceps fuse to form a tendon that attaches to ligament that covers patella, and the ligament continues as patellar ligament to tibial tuberosity (anterior of tibia and below knee). o all muscles are converging across knee joint via patella (extensors); in sports where a lot of knee bending and kicking use these muscles alot. o have bursae as well.

Flexor digitorum superficialis innervation

median nerve

Pubis and Ischiopubic Ramus - what attaches here?

The adductor compartment muscles attach to the pubis and ischiopubic ramus a)Pectineus b)Adductor longus c)Adductor brevis d)Adductor magnus - also has attachment to ischial tuberosity e)Gracilis

What is one of the major branches of the brachial artery?

The brachial artery supplies the upper arm, and one of its major branches in the upper arm is the profunda brachii artery.

What occur at adductor hiatus?

The canal ends at the adductor hiatus of adductor magnus: a) The femoral artery becomes the popliteal artery b) The popliteal vein becomes the femoral vein

Osseo-fibrous Tunnels

The osseo-fibrous tunnels are present on the palmar aspect of the hand They are tunnels which are formed by the fibrous digital sheaths and the underlying bone. Within the tunnels run the: a) Long flexor tendons b) And their digital synovial sheaths The picture on the bottom right shows the fibrous digital sheath and its annular (A) and cruciate (C) condensations

What are the two fascia of the palm?

The palmar fascia is the deep fascia of the palm. It condenses into the: 1) Palmar aponeurosis: Overlies the long flexor tendons of the hand, which are contained in a common synovial sheath Proximally continuous with the flexor retinaculum Distally continuous with the fibrous digital sheaths. 2) Fibrous digital sheaths: This fascia further condenses into annular and cruciate ligaments

What is venae comitantes formed from?

The palmar venous arches form the venae comitantes of the radial and ulnar arteries These flow to the "brachial veins" (venae comitantes of the brachial artery)

The appendicular and axial skeleton

The skeleton is made of the axial (ribcage and spine) and appendicular (limbs) skeleton.

Bone development - when does skeleton start to form?

The skeleton starts to form at 6 weeks of fetal life and growth continues in some bones until 25 years of age.

Proximal Radio-Ulnar Joint

This is a pivot joint which allows pronation and supination of the forearm The radius is held over the ulna by the annular ligament but is allowed free rotation Commonly dislocated in children

Injuries to the Upper Roots appearance

o "Waiter's Tip" Position with Upper Root Injury - flexion of wrist. Many muscles affected (shoulder, anterior arm). Forearm pronated by lack of biceps supination. o A devastating injury to limb mobility

Anterior Knee

o ACL and PCL. named for their attachment to tibia (cross over. ACL attaches anteriorly to intercondylar tibia and goes back and attaches to femur; PCL attaches posteriorly to intercondylar tibia and goes forward and attaches to femur). o fibular (lateral) collateral ligament and medial collateral ligament prevent adduction and abduction. v strong that is undue pressure, head of fibula breaks before tendon.

Posterior Knee

Brachialis attachments and innervations

o Anterior arm compartment * Proximal attachment: Anterior humeral shaft. *Distal attachment: Ulnar tuberosity * Function: Flexion at the elbow joint (main flexor) * Innervation: Musculocutaneous

Tom, Dick and very nervous Harry

tibialis posterior, flexor digitorum longus, tibial artery, tibial vein, tibial nerve, flexor hallucis longus. used to describe structures posterior to medial malleolus

Motor Segmental Supply of knee, leg, ankle and foot

•Hip Flexors -L23 •Hip Extensors -L45 •Knee Extensors -L34 •Knee Flexors -L5S1 •Ankle Dorsiflexors -L45 •Ankle Plantarflexors -S12

Opponens pollicis in pic

(underneath abductor pollicis brevis)

The Carrying Angle: Sex differences at the elbow

* arm between males and females: male = 10-15; female = >15

Which spinal nerves supply the trunk?

T2-L1

Sural communicating branch

The sural communicating branch of common peroneal nerve is a nerve which gives rise to the sural nerve.

Ventrogluteal site

Use your left hand for the right hip and your right hand on the left hip. Place palm on greater trochanter and place index finger on the ASIS and spread the rest of your fingers so the middle finger runs back along the iliac crest. Site of injection: gluteus medius, in between the index and middle finger

Which is more flexible: woven or lamellar bone?

Woven bone - this is immature bone, found either in the growing skeleton or after a fracture. It is more RANDOM than lamellar bone, and is WEAKER but MORE FLEXIBLE than its more mature counterpart. Woven bone is NOT stress-oriented.

What are osteoclasts derived from?

also called giant cells, are the cells that remove bone matrix. They are derived from MONOCYTES and thus of a different lineage from the other bone cells.

Thenar fascia

covers thumb muscles and forms the thenar compartment

Supraclavicular Branches of the Brachial Plexus

dorsal scapular, long thoracic, suprascapular, nerve to subclavius

Popliteal artery branches

its terminal branches: the anterior and posterior tibial arteries in the leg and foot.

Scapula - Posterior pic

learn labels. The scapula lies on the posterior and lateral aspect of the chest, overlying the 2nd to 7th ribs. It has 3 angles (superior, inferior, lateral), 3 borders, 3 processes and 2 surfaces.

common flexor origin

medial epicondyle of humerus

Posterior tibial artery palpation

o behind medial malleolus

Blood supply to bones

o major part of blood supply is by nutrient vessels that passes through nutrient foramen o also get epiphyseal arteries and veins

olecranon process

projection at the upper end of the ulna that forms the bony point of the elbow

What does distal wrist crease present?

represents the proximal extent of flexor retinaculum **snuff box: EPL medially, EPB and APL laterally. scaphoid forms part of floor and radial artery runs within it.

What is posterior to medial epicondyle

ulnar nerve

Which is more ulnar or radial deviation?

ulnar. radial styloid process is more distal to ulnar styloid process.

Arteries of the Foot

§ posterior tibial artery --> medial and lateral plantar arteries. § anterior tibial artery --> dorsalis pedis artery.

•Anterior compartment of the arm

•three muscles: a) Brachialis b) biceps c) coraco-brachialis •C5,6,7 segmental supply • gets there Musculocutaneous nerve •Deep brachial artery •Flexes the elbow •Biceps is also a strong supinator of the forearm through its attachment to the radius bone

Dorsiflexion

Backward flexion, as in bending backward either a hand or foot. aka extension

Which plexus supplies the upper limb?

Brachial plexus. nerves merge, swap fibres, merge again and supply. starts in neck, passes under clavicle into axilla and biggest nerves formed at distal end of axilla.

Which spinal nerves supply the neck?

C1-4

Game Keeper's (Skier's ) Thumb

Damage to medial collateral ligament of the first metacarpophalangeal joint by violent abduction. Thumb becomes unstable for eg: you can't hold a pinch grip with the index finger.

Which hand muscles does radial nerve supply?

Does not supply any hand muscles - Cutaneous supply only!! Superficial radial nerve (sensory) at elbow continues into hand: ØLateral 2/3 of hand dorsum ØThumb dorsum ØProximal portion of dorsal index + middle fingers

Function of lumbricals

Flexion of MCP and extension of IP joints

Formation of achilles tendon

Gastrocnemius (2 heads) and Soleus (1 head) together form Triceps Surae whose distal tendon is tendocalcaneus (Achilles tendon).

Which veins does great saphenous vein anastomoses with?

In the leg it anastomoses freely with: Short saphenous vein and also has connections Deep system elsewhere via perforating veins

What is elbow joint an articulation between?

It is the articulation between the distal humerus with the radius and ulna.

Outcome of lower root injury?

Lower root injury: Klumpke's Palsy: o T1 mainly supplies the small muscles of the hand via the ulnar and median nerves. o Loss of their activity results in clawed hand. o Try to work out why this claw is presented.

Radial and ulnar styloid process

Radial styloid process is distal to the ulnar styloid process

Which vein does great saphenous vein drain into?

femoral

gluteal tuberosity of femur

insertion of gluteus maximus

Colles' Fracture

ØA fracture of the distal radius bone just above the wrist ØCommon following a fall onto the outstretched hand ØSymptoms: a) Wrist pain b) Wrist swelling c) Dinner fork deformity § Common cause: Falling on the outstretched hand, females, over 50 yrs. Fracture of distal radius (within one inch of wrist joint) and ulnar styloid. Distal fragment with hand shows dorsal displacment and dorsal angulation (Dinner fork deformity). Proximal impaction and radial deviation. In severe cases distal radio-ulnar joint may be dislocated. § Treatment: Non-surgical reduction and plaster cast for 4 weeks. Follow up with x-rays.

Segmental motor supply to the limbs summary

•Groups of motor nerve cell bodies in the spinal cord •C5-T1 = upper limb •L2-S3 = lower limb •Plexi for each limb •Anterior divisions = flexor muscles •Posterior divisions = extensor muscles

Lymphatic Drainage of the hip, buttock and thigh

•Lymph flows with the superficial and deep veins •Superficial inguinal lymph nodes •Deep inguinal lymph nodes •External iliac lymph nodes o The superficial system runs with the long and short saphenous veins and has lymph nodes in the groin called the superficial inguinal lymph nodes. These drain to both the deep inguinal lymph nodes and the external iliac lymph nodes. o The deep system of lymphatic drainage drains alongside the deep veins to the deep inguinal lymph nodes. These subsequently drain into the external iliac lymph nodes

When can blood Supply of the Head of the Femur be damaged?

•Medial and lateral circumflex arteries •The artery of the head of the femur (more important in children) •Damaged in INTRACAPSULAR fractures of the femoral neck •Avascular necrosis of the femoral head

Blood Supply of the Head of the Femur

•Medial and lateral circumflex arteries (distal). • little bit from obturator artery •The artery of the head of the femur (more important in children) •Damaged in INTRACAPSULAR fractures of the femoral neck •Avascular necrosis of the femoral head

Main Nerves of the Upper Limb

•Musculocutaneous nerve (C5,6,7). •Ulnar nerve (C8,T1). •Median nerve (C6,7,8,T1). •Radial nerve (C5,6,7,8,T1).

Arrangement of lamellar (mature) bone

•Outer hard layer of compact lamellar bone (cortical bone) •Inner layer of interlacing struts/spikes of lamellar bone: cancellous bone (= spongy or trabecular bone) *(be careful not to confuse cancellous bone with woven (immature) bone)* o have this cavity cos otherwise would be very heavy and gives space for marrow

Tibial Nerve

•Posterior Compartment of the Leg •Passes behind medial malleolus to divide into: -Medial plantar nerve -Lateral plantar nerve •All intrinsics except extensor digitorum brevis

What kind of nerves are digital nerves?

•Purely sensory •Often damaged --> can cause disability

1)How can we subdivide the muscles of the posterior compartment of the leg?

•Superficial (gastrocnemius, soleus and plantaris) and deep (popliteus, tibialis posterior, flexor digitorum longus, flexor hallucis longus)

Lymphatic Drainage of the elbow, forearm and wrist

•Superficial and deep systems, run with veins •Cubital lymph nodes •Axillary nodes are also draining nodes for the distal parts of the upper limb

The Bones of the Wrist and Hand

•The Radius •The Ulna •The Carpus (carpal bones); -Proximal row - scaphoid, lunate, triquetrum, pisiform -Distal row - trapezium, trapezoid, capitate, hamate •The metacarpal bones •The phalanges

What does axilla contain?

•The gateway for nerves and blood vessels to enter/ leave the upper limb •Shaped like a pyramid •Contains: 1) Arteries - axillary artery and its branches 2) Veins - axillary vein and its tributaries 3) Lymphatic vessels and lymph nodes - axillary lymph nodes (important!) 4) Nerves - the infraclavicular part of the brachial plexus, long thoracic and intercostobrachial nerves. o It is shaped like a truncated pyramid and consequently has a base, apex and four walls; 1) base - skin, subcutaneous tissue and fascia extending from the arm to the chest. 2) apex - between the first rib, the clavicle and the superior border of the subscapularis muscle. 3) anterior wall - pectoralis major and pectoralis minor. 4) posterior wall - scapula and subscapularis (superiorly) and the teres major and latissimus dorsi (inferiorly). 5) medial wall - the chest wall (1st to 4th ribs) and the serratus anterior. 6) lateral wall -intertubercular groove of the humerus.

Forearm muscles position of extensors and flexors

•The hand and wrist are operated by 'remote control' by these muscles •The forearm muscles actually take origin from the distal humerus as well as the radius and ulna •Flexors (and pronators) anteriorly •Extensors (and supinators) posteriorly

Bones of hip and thigh

•The pelvis (the "hip bone"): -Ischium -Ilium -pubis •The femur

The names of the thumb and digits

•Thumb •Index finger •Middle finger •Ring finger •Little finger

How to find dorsal radial tubercle?

(Extensor pollicis longus tendon of extended thumb leads toward the tubercle)

Bones of wrist

* Proximal row: a) scaphoid b) lunate c) triquetrum d) pisiform (not involved in articulation though - sesamoid bone (embedded in a muscle/ tendon; patella is also sesamoid) *Distal row: a) trapezium b) trapezoid c) capitate d) hamate

Dermatome Regions of the Upper Limb

** C4 - Shoulder ** C5 - Lateral side of arm **C6 - Lateral side of forearm & thumb ** C7 - Middle and ring finger ** C8 - Medial side of hand, forearm & little finger ** T1 - Medial side of upper forearm and arm ** T2 - Axilla. (Note: On the anterior and posterior surfaces of the upper limb draw the anterior and posterior axial lines as shown in the adjacent diagram. Dermatomes don't cross the axial lines.)

Palmaris Brevis

**Origin: Palmar aponeurosis Flexor retinaculum **Insertion: Medial dermis of the hand **Innervation: Ulnar nerve

Thumb movements

**Thumb (Carpo-metacarpal Joint)- Important to keep anatomical position - supinated wrist Movements: Abduction - "With palm facing up, lift thumb upwards" Adduction - "With palm facing up, move thumb downwards" Flexion - "With palm facing up, bring thumb toward you" Extension - "With palm facing up, bring thumb away from you" Opposition - "Touch your thumb and your middle finger tightly"

Triangular Shaped Articular Disc

**What is an articular disc? Articular discs separate synovial joints allowing them to have independent movements O The wrist has a triangular-shaped articular disc which separates the distal radio-ulnar joint from the radio-carpal joint.

Plantar flexion of foot

**these tendons all go behind middle malleolus and head into foot. tibialis posterior attaches on tarsal region, all others go to digits and distal phalanges. **involved in plantar flexion of foot. **two sesamoid bones highlighted; flexor pollicus longus - important in pushing off when starting. tendon runs between these bones which protect it.

Dermatomes of the Upper Limb

*C6*: Pad of thumb *C7*: Pad of middle finger *C8*: Pad of small finger

CRITOE

*appearance of epiphyses around elbow 1) C - capitulum - 2 years age 2) R - radial head - 4 years age 3) I - internal/medial epicondyle - 6 years age 4) T - trochlea - 8 years age 5) O - olecranon - 10 years age 6) E - external/lateral epicondyle - 12 years age

Bones of the elbow

*capitulum is rounded condyle * trochlea more spool-like shape *epicondyles above * olecranon fossa posteriorly *radial and coronoid fossa

Principles of segmental nerve supply

*muscles are supplied by two adjacent segments. o Same action on joint = same nerve supply o Opposing muscles nerves (flex vs. extend) are 1-2 segments above or below each other. o Muscles more distal in the limb have nerves originating more caudal in the spine (closer to tail).

Muscles in hypothenar and thenar region

*note how lumbricals start anteriorly. o the thenar muscles: abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, adductor pollicis. o hypothenar muscles: abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi. o lumbricals attached to the tendons of flexor digitorum profundus and inserting into the extensor expansions of the digit sheaths at the lateral side in digits 2-5. o palmar interossei (1-3) and the dorsal interossei (1-4) and note their attachments in relation to the axial line of the hand (the middle finger).

upper arm compartments in cross-section

- can see how deltodi decreases along - how biceps goes from small and in two divisions to big

How to test for palmaris longus?

- cup hand without bending digits.

Deep veins of hand

- run with the arteries - veins are venae comitantes that run close to surface of artery . *Most of the venous drainage of the hand is via the superficial system but some is via the deep system.*

Bone development - what are the two types of ossification?

1) Intramembranous (directly from mesenchyme): •In existing vascular connective tissue •Bone matrix (ostein) deposited around collagen •Mineralises to form woven bone •Remodels to lamellar bone 2) Endochondral (mesenchyme differentiates to cartilage before forming bone)" •Within existing fetal cartilage models •Cartilage calcifies and chondrocytes die •Periosteal osteoclasts cut channels for sprouting vessels •Osteoblasts enter with vessels to build bone round them

Rotator cuff muscles

1) Supraspinatus o Proximal: Supraspinous fossa o Function: Abduction up to 15⁰ o Nerve*: Suprascapular 2) Infraspinatus o Proximal: Infraspinous fossa o Function: Lateral rotation o Nerve*: Suprascapular 3) Teres minor o Proximal: Infraspinous fossa o Function: Lateral rotation o Nerve: Axillary 4) Subscapularis o Proximal: Medial border of scapula o Distal: Lesser tubercule o Function: Medial rotation o Nerve*: Upper and lower subscapular nerves **Distal attachments: They ALL insert onto the GREATER tubercle EXCEPT for subscapularis, which inserts onto the lesser tubercle And hence causes medial rotation

Scapular attachments label

1) Supraspinatus origin 2) Infraspinatus origin 3) Teres Major origin 4) Teres minor origin 5) Subscapularis origin 6) Short head of biceps, coracobrachialis, pectoralis minor 7) Long head of biceps origin 8) Long head of triceps origin

True leg length vs apparent (functional) leg length

1) True leg length: § distance between the medial malleolus of the ankle and a fixed bony part of the pelvis like the ASIS using a tape measure. Measure the length on both right and left sides and note down the readings. If the difference is >1.5 cm then there is discrepancy in true leg length. 2) Apparent (functional) leg length: § distance between the medial malleolus of the ankle and a non-fixed landmark such as xiphisternum. Measure the length on both right and left sides and note down the readings. If the difference is >1.5 cm then there is discrepancy in apparent (functional) leg length. Pelvic tilt/rotation, hip joint or sacroiliac joint abnormalities are the main causes of apparent (functional) leg length discrepancy. ***(Please note that the true or apparent leg length measurements are not absolute values. The absolute leg length can be measured only by radiographic imaging.)

Injuries to the Axillary Nerve (Derived from Posterior Cord)

1) Wasting of Deltoid Muscle (loss of smoothness of shoulder) The axillary nerve also supplies teres minor (rotator cuff muscle). 2) there's also a branch of axillary nerve - superior lateral cutaneous nerve of arm which supplies skin in that area. get lost sensation in that area (regimental badge area).

Adductor longus muscle Netters

1) adductor longus muscle 2) greater trochanter 3) pubic tubercle § Origin (proximal): Adductor longus muscle arises from the body of the pubic bone, just beneath the pubic tubercle. § Insertion (distal): Adductor longus muscle inserts onto the linea aspera of the femur. § Action: Adductor longus muscle adducts the thigh and can flex and medially rotate the thigh. § Innervation: Obturator nerve via its anterior branch (L2, L3, and L4). § Comment: The adductor longus is the most anterior of the 3 adductors. It lies within the same plane as the pectineus muscle. § Clinical: The adductor muscles may be tested collectively by asking a patient in the supine position (lying on the back) whose lower limb is extended to adduct the limb while the examiner holds the ankle to provide resistance to this movement. The adductor muscle bellies can be seen and palpated as the patient adducts the limb.Groin injuries are common in athletes and usually involve a pulling or tearing of the proximal attachment (origin) of the anteromedial thigh muscles, especially the adductor group.

Exceptions to innervations in thigh

1) anterior compartment supplied by femoral nerve EXCEPT pectineus muscle which is supplied by obturator too 2) middle compartment supplied by obturator nerve EXCEPT adductor magnus, which has a ischial head and hence has innervation of tibial nerve 3) posterior compartment supplied by tibial nerve EXCEPT short head of biceps femoris which has an attachment to the femur and is supplied by the common peroneal nerve (is the ONLY structure that common peroneal nerve supplies as then divides into superficial and deep division).

Label humerus

1) attachment for lateral head of triceps brachii 2) radial groove 3) deltoid tuberosity 4) attachment for coracobrachialis

Extensor carpi ulnaris muscle Netters

1) extensor carpi ulnaris muscle 2) abductor pollicis longus tendon 3) extensor pollicis brevis tendon 4) extensor pollicis longus tendon § Origin (proximal): Extensor carpi ulnaris muscle has 2 heads. One head arises from the lateral epicondyle of the humerus, and the other arises from the posterior border of the ulna. § Insertion (distal): Attaches to the medial side of the base of the 5th metacarpal. § Action: Extends and adducts the hand at the wrist joint. § Innervation: Radial nerve (posterior interosseous branch) (C7 and C8). § Comment: Similar to the extensor carpi radialis longus and brevis muscles, the extensor carpi ulnaris acts as a synergist to the finger flexors because it keeps the wrist extended to give additional strength when the hand grasps an object. This action is essential for a power grip. § Clinical: Clinically, the extensor carpi ulnaris muscle is tested by having the patient extend and adduct the wrist against resistance. The examiner can hold the patient's pronated fist and provide resistance against wrist extension and adduction (movement toward the little finger side of the wrist). The bulging contracted muscle belly will be evident along the medial forearm and its tendon at the wrist.

Humerus Proximal End label

1) greater tubercle - faces lateral 2) intertubercular sulcus 3) lesser tubercle (subscapularis) - faces anterior 4) intertubercular groove 5) deltoid tuberosity (deltoid) 6) attachment for coracobrachialis 7) anatomical neck; surgical neck 8) attachment for pectoralis major 9) deltoid tuberosity (deltoid) 10) greater tubercle; superior facet (supraspinatus); middle facet (infraspinatus); inferior facet (teres minor) 11) anatomical neck; surgical neck

Bones of Forearm Netter

1) head 2) neck 3) radial tuberosity 4) interosseous membrane 5) styloid process of ulna 6) oblique cord 7) ulnar tuberosity 8) trochlear notch 9) olecranon 10) styloid process of radius 11) dorsal (lister's) tubercle 12) posterior border of radius **Comment: The bones of the forearm include the medially placed and longer ulna and the laterally placed radius.Along the length of the forearm, the radius and ulna are connected by the interosseous membrane, which contributes to the radioulnar joint, a fibrous (syndesmosis) joint. The interosseous membrane divides the forearm into anterior and posterior muscular compartments. The anterior compartment muscles are largely flexors of the wrist and fingers and pronators; the posterior compartment muscles are extensors of the wrist and fingers and one is a supinator.Distally, the radius and the ulna display styloid processes. **Clinical: A Colles' fracture is a fracture of the distal radius, commonly occurring from a fall on an outstretched hand. In such fractures, the distal fragment of the radius is forced proximally and dorsally, resulting in a "dinner fork" deformity.

Humerus labels (JAS)

1) head 2) neck 3) radial tuberosity 4) lateral epicondyle 5) capitulum (lateral) articulates with radius in elbow flexion 6) head of radius 7) medial epicondyle 8) trochlea (medial) articulates with ulna 9) ulna 10) radius **Ensure you can identify: Deltoid tuberosity, Radial groove, Medial and lateral epicondyles, Olecranon fossae, Trochlea & capitulum.

Hip Joint: Lateral View Netters

1) lunate (articular) surface of acetabulum 2) articular cartilage 3) head of femur 4) ligament of head of femur (cut) 5) lesser trochanter of femur 6) ischial tuberosity 7) transverse acetabular ligament 8) obturator foramen 9) acetabular labrum (fibrocartilagnous) 10) AIIS 11) ASIS § Comment: The hip joint is a multiaxial ball-and-socket synovial joint between the acetabulum and the head of the femur. The acetabular labrum deepens the acetabular cavity even farther, and the fibrous joint capsule is reinforced by 3 ligaments. Within the acetabulum, the ligament of the head of the femur attaches to the femoral head and provides a pathway for a small artery derived from the obturator artery.The hip participates in abduction and adduction, flexion and extension, and rotation and circumduction.The ligament of the head of the femur contains the acetabular branch (artery of the round ligament of the femoral head) that arises from the obturator artery.Blood is supplied to the hip by branches of the medial and lateral femoral circumflex arteries, the gluteal arteries, and the obturator artery. § Clinical: About 1.5 in 1000 infants are born with a congenital hip dislocation; girls are affected more than boys.

Label this femur

1) neck 2) greater trochanter 3) femoral head 4) intertrochanteric line 5) lesser trochanter 6) greater trochanter 7) neck 8) lesser trochanter **Important parts to recognise: Greater trochanter Lesser trochanter Intertrochanteric line Head of the femur Neck of the femur

palmar interossei muscles Netters

1) palmar interosseus muscles 2) trapezoid bone 3) capitate bone 4) radius 5) ulna 6) pisiform bone 7) hook of hamate bone § Origin (proximal): The 3 palmar interossei muscles arise from the palmar surfaces of the metacarpal bones of digits 2, 4, and 5. § Insertion (distal): Tendons of the palmar interossei insert into the extensor expansions of the digits and bases of the proximal phalanges of digits 2, 4, and 5. § Action: The palmar interossei adduct the fingers at the metacarpophalangeal joint, moving them toward an imaginary line through the axis of the middle finger (arrows). They also assist in flexing the proximal phalanx at the metacarpophalangeal joint and aid in extension of the 2 distal phalanges at the interphalangeal joints. § Innervation: Deep branch of the ulnar nerve (C8 and T1). § Comment: The 3 unipennate palmar interossei are smaller than the 4 dorsal interossei. § Clinical: The palmar interossei are tested clinically by asking the patient to hold a sheet of paper between 2 adjacent adducted fingers. As the patient holds the paper, the examiner tries to pull the paper away. With weakened adduction, the patient will have difficulty holding the sheet of paper between the fingers.

Muscles of Foot - plantar interossei

1) plantar interossei muscles 2) distal phalanx of great toe 3) sesamoid bones 4) cuneiform bones (lateral; intermediate; medial) 5) navicular bone 6) cuboid bone § Origin (proximal): These 3 plantar interossei muscles arise from the bases and medial sides of the bodies of the 3rd, 4th, and 5th metatarsal bones. § Insertion (distal): The plantar interossei insert into the medial sides of the bases of the proximal phalanges of the same toes and into the dorsal digital aponeurosis of the tendons of the extensor digitorum longus. § Action: Plantar interossei adduct the 3rd, 4th, and 5th toes toward the axis of the foot, an imaginary longitudinal line extending through the 2nd toe. They also flex the proximal phalanx at the metatarsophalangeal joint and extend the distal phalanges. § Innervation: Lateral plantar nerve (S2 and S3). § Comment: Similar to the interossei of the hand, the plantar interossei muscles adduct the digits (toes) and flex the proximal phalanges while extending the distal phalanges. § Clinical: One can test the plantar interossei muscles by placing a finger between the toes and asking the patient to adduct the toes and feel the resistance (muscle strength) against the finger.

Muscles of Back Netters

1) splenius capitis muscle 2) splenius cervicis muscle 3) rhomboid minor muscle (cut) 4) serratus posterior superior muscle 5) rhomboid major muscle 6) serratus posterior inferior muscle 7) erector spinae muscles (covered with investing fascia) 8) thoracolumbar fascia 9) latissimus dorsi muscle 10) trapezius muscle § Comment: Extrinsic muscles of the back are really concerned with movements of the upper limb or of the rib cage and are not true "intrinsic" back muscles. The trapezius, latissimus dorsi, levator scapulae, rhomboid major and minor, and serratus posterior superior and inferior muscles are extrinsic muscles. All of these muscles are concerned with movements of the upper limb except the serratus muscles, which move the rib cage. They are shown in detail in the Upper Limb flash cards. The erector spinae muscles are true intrinsic back muscles. § Clinical: The extrinsic muscles can be strained with excessive movements of the neck, upper limbs, or rib cage. Chronic back pain, most common in the lumbar region, is a major health issue. The pain may be due to disorders of the vertebral ligaments, joints, or intervertebral discs; disorders of the dura mater covering the spinal cord; nerve root compression; or cramping of muscles.

Humerus and scapula: anterior view label

1) superior angle, superior border, suprascapular notch, neck, medial border, subscapular fossa, infragelnoid tubercle, inferior angle 2) clavicle (cut) 3) coracoid process 4) acromion 5) acromial angle, supragenoid tubercle, anatomical neck, greater tubercle, lesser tubercle, surgical neck 6) deltoid tuberosity 7) glenoid cavity of scapula 8) head of humerus 9) humerus

Arteries of Leg: Anterior View Netters

1) superior lateral genicular artery 2) anterior tibial artery 3) anterior lateral malleolar artery 4) dorsal digital arteries 5) arcuate artery 6) medial tarsal artery 7) dorsalis pedis artery 8) fibular artery (perforating branch) 9) anterior tibial artery 10) inferior medial genicular artery § Comment: The anterior tibial artery, a branch of the popliteal, supplies the anterior compartment of the leg and the dorsum of the foot. It is accompanied by the deep fibular nerve, which supplies the muscles of the anterior compartment.At the ankle, there is a rich anastomosis from malleolar, tarsal, and arcuate arteries. § Clinical: Two pulses are commonly taken on the distal lower limb. The posterior tibial pulse is felt between the medial malleolus and the calcaneal tendon. The dorsalis pedis artery is a continuation of the anterior tibial artery, and its pulse may be palpated on the dorsum of the foot just lateral to the tendon of the extensor hallucis longus as it emerges from the extensor retinaculum.

Teres minor muscle Netters

1) teres minor muscle 2) teres major muscle **Origin (proximal): The teres minor originates from the lateral border of the scapula. The teres major arises from the dorsal surface of the inferior angle of the scapula. **Insertion (distal): The teres minor inserts into the inferior facet on the greater tubercle of the humerus. The teres major inserts into the medial lip of the intertubercular groove of the humerus. **Action: The teres minor rotates the arm laterally and weakly adducts the arm at the shoulder. Similar to the other 3 rotator cuff muscles, it draws the humerus toward the glenoid fossa, strengthening the shoulder joint. The teres major helps extend the arm from the flexed position, and it adducts and medially rotates the arm at the shoulder. **Innervation: The teres minor is supplied by the axillary nerve (C5 and C6), whereas the teres major is innervated by the lower subscapular nerve (C6 and C7). **Comment: The teres minor is 1 of the 4 rotator cuff muscles, and it helps stabilize the shoulder joint. Often, it is inseparable from the infraspinatus muscle. **Clinical: The teres major is tested clinically by having the patient adduct the horizontally elevated arm against resistance while viewing the contraction of the muscle as it passes from the scapula to the humerus. The integrity of the subscapular nerve is also tested by this action.

Summary of Upper Limb Arteries Netters

1) thoracoacromial artery 2) axillary artery 3) brachial artery 4) profunda brachii (deep brachial) artery 5) radial artery 6) superficial palmar branch of radial artery 7) superficial palmar arch 8) common palmar digital arteries 9) deep palmar arch of ulnar artery 10) ulnar artery 11) anterior interosseus artery 12) common interosseus artery 13) subscapular artery

Leg: Cross Section just above middle of leg

1) tibialis anterior muscle 2) extensor digitorum longus muscle 3) fibularis brevis muscle 4) gastrocnemius muscle (lateral head) 5) flexor hallucis longus muscle 6) flexor digitorum longus muscle 7) tibialis posterior muscle 8) great saphenous 9) tibia 10) anterior tibial artery and veins and deep fibular nerve

Thenar and Hypothenar Functions

1)Abductor pollicis brevis and abductor digiti minimi: Abduction at MCP of the thumb and little finger respectively. 2)Flexor pollicis brevis and flexor digiti minimi: Flexion at MCP of the thumb and little finger. 3)Opponens pollicis and opponens digiti minimi: Opposition (flexion and rotation) of the carpo-metacarpal joint of the thumb and little finger respectively.

Derivation and innervation of femoral nerve

1)Femoral Nerve (L234, posterior fibres): (Iliopsoas (+L1) and anterior thigh). 2)Obturator Nerve (L234, anterior fibres): (Medial (adductor) compartment of thigh). 3)Sciatic Nerve (L345S123, ant. & post. fibres): (Post. thigh; leg; foot) 4)Superior Gluteal Nerve (L45S1): (Gluteus medius and minimus, Tensor fascia lata) 5)Inferior Gluteal Nerve (L5S12): (Gluteus maximus)

Derivation and innervation of sciatic nerve

Pronation and Supination

1)Supination: a)Supinator b)Biceps - tendon attaches to radial tuberosity. so when pronation, biceps tendon is stretched and pulled so radial tuberosity is pulled round. c)(EPL, ECRL) 2)Pronation: a)Pronator quadratus b)Pronator teres (FCR, PL, brachioradialis)

Arteries of the Hand

1)Ulnar Artery: a)Beside FCU at the wrist b) Interosseous arteries in the forearm (anterior and posterior (beneath interosseus membrane) c) Superficial palmar arch - palmar digital arteries as cross wrist joint d) Deep palmar branch *many connections between palmar and dorsal arteries, useful so there's always supply even when arteries compressed from certain angles* **The ulnar artery runs in the anterior compartment of the forearm and passes on the ulnar side of the palmar surface of the wrist (just lateral to FCU). The ulnar nerve lies medial to it at the wrist joint. i.e. from medial to lateral, the relationships are FCU, ulnar nerve, ulnar artery. On its course in the forearm the ulnar artery supplies the medial muscles of the forearm, with branches which include the common interosseous artery, the anterior interosseous artery and the posterior interosseous artery. o The ulnar artery runs into the hand over the flexor retinaculum, lateral to the pisiform and through the semi-rigid ulnar (Guyon's) canal with the ulnar nerve. It divides just beyond this into: 1) the superficial palmar arch, which receives a contribution from the superficial palmar branch of the radial artery 2) the deep palmar branch of the ulnar artery. o The superficial palmar arch gives off three common palmar digital arteries. These arteries subsequently divide into palmar digital arteries. 2)Radial Artery: a)Under brachioradialis and beside FCR at the wrist b)Anatomical snuff box c)Deep palmar arch d)Palmar metacarpal arteries **The radial artery passes down the lateral aspect of the forearm under the cover of the brachioradialis muscle. It is easily palpable at the wrist where it lies superficially on the palmar aspect of the radial side of the wrist. o It subsequently crosses the floor of the anatomical snuff box and enters the palm of the hand between the two heads of the first dorsal interosseous muscle. It then also passes between the two heads of the adductor pollicis muscle. o The radial artery then anastomoses with the deep palmar branch of the ulnar artery to form the deep palmar arch. The deep palmar arch gives origin to the palmar metacarpal arteries.

Testing muscles and tendons in arms and forearm

1. Biceps - flex the forearm against resistance (Nerve - musculocutaneous C5,6,7). 2. Triceps - extend the flexed forearm against resistance (Nerve-Radial C6,7,8). 3. Brachioradialis- elbow flexed against resistance with forearm in midprone position (Nerve - Radial C5,6,7). 4. Flexor carpi ulnaris (FCU)- wrist flexed against resistance (Nerve - Ulnar C7,8). 5. Palmaris longus (PL)- wrist flexed against resistance (Nerve - Median C 6,7). 6. Flexor carpi radialis (FCR)- wrist flexed against resistance (Nerve - Median C 6,7)

Parts of metatarsal bones

1. Body (shaft) 2. Base (at the proximal end, for cuneiforms & cuboid) 3. Head (distal end,for phalanges) § There is a single row of five metatarsal bones lying in the foot which are numbered 1 to 5 (from the great toe to the little toe).

Ramus of ischium

1. Body of the ischium 2. Ramus of the ischium 3. Ischio-pubic ramus 4. Obturator foramen 5. Greater sciatic notch 6. Lesser sciatic notch 7. Ischial spine 8. Ischial tuberosity 9. Ischial portion of the acetabulum

Pubic crest

1. Body of the pubis 2. Superior pubic ramus 3. Inferior pubic ramus (only the medial half). The lateral half belongs to the ischium) 4. Pubic crest 5. Pubic tubercle 6. Pubic portion of the acetabulum

Surface mark sciatic nerve.

1. Palpate three bony landmarks - (PSIS), ischial tuberosity and greater trochanter. 2. The nerve leaves the greater sciatic notch 3. It enters the gluteal region at the midpoint between the PSIS and the ischial tubersoity. 4. It forms a downward curve to pass into the thigh around the midpoint between the greater trochanter and the ischial tubersoity 5. It reaches the popliteal fossa (behind the knee) 6. It splits into tibial and common peroneal.

There are two layers of fascia in the lower limb...

1. Superficial fascia - subcutaneous tissue. 2. Deep fascia - in the thigh it is called the fascia lata. o The fascia lata extends from the pelvis down the leg underneath the skin like a stocking. A thickened area of it laterally is called the ilio-tibial tract.

Talus labelled

1. Talus (ankle bone -L): 1.1 Trochlea (dome) of talus (superior surface) . 1.2 Body of talus (sits on calcaneum). 1.3 Neck of talus. 1.4 Head of talus.

Ulnar and radial arterial pulses

1. The brachial artery, against humerus in the medial bicipital groove shaft - palpate pulse. 2. The brachial artery, in the cubital fossa, medial to biceps tendon - palpate pulse. 3. The radial artery at the wrist (anterior surface of distal radius)- palpate pulse.

Flexors and extensors of elbow joint

1. The main flexors of the elbow are brachialis, biceps and brachioradialis, with some assistance by pronator teres. 2. The extensors of the elbow are triceps and anconeus.

What muscles make up the intrinsic shoulder muscles?

1.Deltoid 2.Teres Major 3.The Rotator Cuff Muscles: a.supraspinatus b.infraspinatus c.teres minor d.subscapularis

The Joints of the elbow, forearm and wrist

1.Elbow joint 2.Proximal radio-ulnar joint 3.Distal radio-ulnar joint 4.Wrist joint

gastrocnemius arterial supply

2 sural arteries arise from the popliteal artery. § It supplies which muscles? = Gastrocnemius, soleus, plantaris muscles **At inferior limit of popliteal fossa, popliteal artery bifurcates into: a) Anterior tibial: Enters and descends in the anterior compartment of leg b) Posterior tibial: Descends in posterior compartment of leg, behind medial malleolus. Gives off another important branch - peroneal artery **Peroneal artery: Descends on the lateral side of the posterior compartment. It supplies: i) Adjacent muscle/bone in the Posterior Compartment ii) Branches penetrate intermuscular septum to supply Lateral Compartment

How many bones form the proximal row of tarsal bones?

2: talus and calcaneus

how many phalanges in big too?

3 Groups compose the foot 1) 7 Tarsal Bones: a) Proximal: •Talus •Calcaneus b) Intermediate: •Navicular c) Distal: •3x cuneiforms •Cuboid 2) 5 Metatarsal Bones 3) Phalanges: a) Great Toe: 2 b) Toes 2-5: 3

Ligaments of the hip joint (4)

4 ligaments reinforce this capsule: 1.Ligament of the femoral head - attaches the femoral head to the acetabulum 2.Ilio-femoral ligament 3.Pubo-femoral ligament 4.Ischio-femoral ligament

Mallet finger

Avulsion of extensor digitorum longus tendon at the base of distal phalanx

Capsule of The Glenohumeral Joint

Ball and socket synovial joint The cartilaginous glenoid labrum deepens the socket of the glenoid The joint has a fibrous capsule which "cups" the head of the humerus to hold it in place (not shown): a) Subacromial bursa: The capsule extends above the humeral head to form a bursa b) The glenoid is extended to the neck of the humerus below the humeral head* The tendon of the long head of the biceps passes through the joint. The acromion, coracoid and acromio-coracoid ligament form an arch above the joint: a) Common site of pathology for impingement at the shoulder b) This is trapping of a tendon (usually supraspinatus) when raising the arm resulting in pain The capsule surrounds the joint. A number of clinically important ligaments make up the capsule: a) Gleno-humeral (x3) b) Coraco-humeral c) Transverse-humeral Inflammation of the joint: Results in frozen shoulder

Which nerves supply the shoulder girdle muscles?

C3-C7

Which nerves supply shoulder joint muscles and elbow flexors?

C5-6

Nerve supply to upper limb

C5-T1

Which spinal nerves supply the upper limb?

C5-T1

What occurs when blood Ca2+ levels high?

Calcitonin released by parafollicular thyroid cells: a) breakdown of bone matrix by osteoclasts inhibited b) uptake of Ca2+ into bone matrix is promoted. When blood Ca2+ levels low: o Parathyroid Hormone (PTH) released by chief cells of parathyroid gland: a) osteoclast bone resorption activity promoted b) increases Ca2+ re-absorption by the kidneys.

Radial Artery

Crosses the floor of the anatomical snuff box to enter the hand. Here, it forms the palmar arches. Radial artery also gives off a dorsal carpal branch which will anastomose with the dorsal carpal branch of the ulnar artery and the interosseous arteries to form the dorsal carpal arch*

Foot drop

Deep peroneal nerve innervates tibialis anterior When this is damaged, the ability to dorsiflex the foot is lost

All intrinsic foot muscles supplied by tibial nerve apart from which muscle?

EDB. EDB innervated by? Deep peroneal nerve

elbow and forearm

Elbow is made up of three bones: Ulna, Radius, Humerus - largest and longest bone of the upper extremity

Effects of lesion to median nerve

Elbow: supracondylar humeral fractures Wrist laceration Loss of sensation lateral 3½ fingers Loss of: Wrist flexion, elbow pronation AND flexion of radial ½ of digits Presence of "benediction sign" Presence of ape hand deformity Tinel's sign*

Posterior view of femur

Examine the external surface of the ilium, iliac crest, anterior superior iliac spine (ASIS), the trochanters of the femur, the gluteal tuberosity of the femur, ischium (ischial tuberosity, ischial spine), sacrum, pubic bone, obturator foramen.

Posterior view of pelvis

Examine the pelvic skeletons showing the major ligaments of the hip and buttock (the iliofemoral, ischiofemoral and pubofemoral spiral ligaments at the hip joint; and the sacrospinous and sacrotuberous ligaments that divide the greater and lesser sciatic notches into the greater and lesser sciatic foramena).

Perforating veins in leg

Examine the venae comitantes and the long and short saphenous veins

Extension of the thumb

Extensor pollicis brevis Extensor pollicis longus Abductor pollicis longus: mostly thumb abduction

Diagram showing motor and sensory innervation by femoral nerve

Femoral Nerve (L2,3,4)

What is the long bone in the body?

Femur: o shaft = diaphysis o head = epiphysis § Metaphysis is in between these. o Spongy bone in head and compact bone o Medullary cavity - majority of shaft has holy centre for marrow o articular cartilage at ends of bone o little holes for vessels to enter and leave (nutrient foramen) § Outer hard layer of compact bone (cortical bone). § Inner layer of interlacing struts (cancellous/spongy/trabecular bone).

Anterior and posterior views of forearm

Flexors (anterior) and Extensors (posterior)

Scapulo-thoracic joint movement

For each: ACT it out (for the patient) + SAY it out (for the examiner) = Slick and easy to understand Scapulo-thoracic: A FALSE joint between the scapula and thorax **Movements: Elevation - A shrug - "Could you shrug your shoulders for me please?" Depression - Relax shoulders - "Could you drop your shoulders for me please?" Protraction - Forward lateralisation - "Could you hug (this pillow) please?" Retraction - Backward medialisation - "Could you put your arms out like a chicken, and push back?"

Intercarpal Joints

Gliding movement Augment other movements of the hand. A) Joints between the proximal row: Scaphoid, lunate, triquetrum, pisiform B) Joints between the distal row: Trapezium, trapezoid, capitate, hamate C) Joints between the proximal and distal rows: the midcarpal joint

Bones articulating to form the Elbow Joint

Humerus Radius Ulna

Collateral Ligaments of the Interphalangeal Joints

IPJs not that stable on own, but collateral ligaments prevent abduction and adduction, only allow flexion and extension. increase stability. *One of the collateral ligaments of the thumb is important clinically - this is the ulnar collateral ligament of the thumb. It is frequently injured in skiing, by falling onto the outstretched thumb.

What happens if all roots of brachial plexus damaged?

If all roots (C5- T1) are damaged the whole limb will be paralysed, with complete sensory loss. There will also be Horner's syndrome due to loss of sympathetic supply to the head which comes via the T1 segment. **Damage of C5 & C6 nerve roots - Erb's lesion This is a lesion of the upper roots (C5 & C6) of the brachial plexus. ** Damage to C8 & T1 nerve roots - Klumpke's lesion This is a lesion of the lower roots (C8 & T1) of the brachial plexus. (Note: In ulnar nerve damage, the C8 & T1 supply to all intrinsic muscles other than the thenar and the lateral two lumbricals are affected. The median nerve carries the C8, T1 fibres to the thenar and the lateral two lumbrical muscles. In a lower roots lesion of the brachial plexus, involving C8 & T1, all intrinsic muscles (without exception) are affected because both median and ulnar nerves are deficient in C8 & T1 components.

Femoral Triangle vessels

Important anatomical space in the superior, anterior thigh. The borders of the triangle labels highlighted in red outline: superiorly by inguinal ligament; laterally by sartorius; medially by adductor longus. Contains the femoral nerve, artery and vein. Large vessels used for access to the heart.

Ulna distal structures

Important bony landmarks: Olecranon and coronoid processes Trochlear notch Ulnar tuberosity Distally: Ulnar head Ulnar styloid process

Bursitis

Inflammation of a bursa is bursitis - very painful. *handsmaid bursitis* a) Repetitive injury/pressure/friction b) Infection c) Inflammatory conditions Typical signs of inflammation § Sometimes restricted joint movement

Injury to the Lower Roots aka

Klumpke's Palsy. o Common cause is over-abduction due to gripping overhead to break a fall. affects T1 (and sometimes C8).

Knee joint movements

Knee Joint Position: Knee must have free movement Sitting off the side of the bed Flexion - Backward - "Could you bring your foot backward?" Extension - Forward - "Could you bring your foot forward?" Rotation: Plant foot on ground, and without moving, turn your knee left/right.

Nerve supply to lower limb

L2- S3

Which spinal nerves supply the lower limb?

L2-S3

Function of ligaments at elbow joint

Ligaments at the elbow joint are arranged to stabilise the joint, but allow pronation/supination movements.

Glenohumeral joint dislocation

Most occur anteroinferiorly Labrum may tear Once capsule has weakened there is a greater risk of repeated dislocation. Axillary nerve compression by humeral head Radial nerve paralysis can occur due to stretching Posterior dislocation caused by vigorous muscle contractions associated with epilepsy caused by electrocutions*** If associated with a fracture may require surgical resection otherwise needs relocation, a sling and analgesia*

Extensors that move the digits

Muscles that move the digits: a)Extensor digitorum (ED) b)Extensor indicis (EI) c)Extensor digit minimi (EDM)

What does musculocutaneous nerve supply?

Musculocutaneous Nerve (C5,6): •Supplies all the anterior compartment of the upper arm •Sensory to the lateral forearm (as the lateral cutaneous nerve of the forearm)

Anconeus Origin and insertion

O: lateral epicondyle of humerus I: olecranon process of ulna

Which is the unlocking muscle of knee?

Popliteus (attach lateral side of femoral epicondyle - fans out and attaches to upper shaft of tibia), unlocks knee joint when it is locked. § popliteus muscle whose tendon attaches to the lateral femoral condylar surface, passes within the capsule of the knee joint, and its fibres fanning out to attach to the posterior surface of the proximal tibia; this is the "unlocking" muscle.

Proximal Attachments of posterior compartment of thigh

Posterior compartment muscles ---> Ischial tuberosity: 3 hamstrings of the posterior compartment and the hamstring component of the adductor magnus all attach to the ischial tuberosity

Damage to the long thoracic nerve

Pressing against a wall will lead to "winging" of the scapula resulting from the loss of activity of serratus anterior (holds scapula down). o damaged in car accident/stabbing.

What is the function of the ACL?

Prevent anterior displacement of tibia

Dorsogluteal site

Superior lateral quadrant of gluteal area. Purpose: For gluteal injections. Avoids nerve path of sciatic nerve and vessels. Recently some debate if this is the safest option for gluteal IM injection - inconsistent depth of adipose tissue, so few injections administered this area are injected to the correct depth.

what type of movement occurs at hip joint?

Synovial ball and socket joint between the head of the femur and the acetabulum. Similar to the glenohumeral joint it allows all types of movement: Flexion, extension, abduction, adduction, lateral rotation, internal rotation, circumduction

Radiocarpal (wrist) Joint

Synovial joint between the distal end of radius, the scaphoid and lunate **Numerous fibrous ligaments*: A) Palmar and dorsal radio-carpal ligaments B) Ulnar and Radial collateral ligaments (of the wrist) **Movements: Flexion, Extension Abduction and adduction Circumduction

The tendons of which muscles form the rotator cuff? Why is the rotator cuff important?

Tendons of the infraspinatus, supraspinatus, teres minor, and the subscapularis form the rotator cuff, which forms a foundation on which the arms and shoulders can be stabilized and move.

Ligaments at the ankle and foot

The ankle joint is a hinge synovial joint between the tibia (medial malleolus), fibula (lateral malleolus) and the talus (talar dome). § It again, like the knee joint, is very important, and required study in depth. § In particular study the ligaments around the ankle: a. The lateral ligament complex b. The medial or deltoid ligament of the ankle

Iliac tubercle

The anterior portion of outer lip of this landmark is the origin for the tensor fasciae latae.

Why is there less movement at the pelvic girdle than pectoral?

The appendicular muscles of the lower body position and stabilize the pelvic girdle, which serves as a foundation for the lower limbs. Comparatively, there is much more movement at the pectoral girdle than at the pelvic girdle. There is very little movement of the pelvic girdle because of its connection with the sacrum at the base of the axial skeleton. The pelvic girdle is less range of motion because it was designed to stabilize and support the body.

Which is lateral - basilic or cephalic vein?

The basilic vein runs superficially on the medial (ulnar) aspect of the forearm and passes deep halfway up the arm to become the axillary vein. The cephalic vein runs superficially on the lateral (radial) aspect of the forearm and upper arm. It passes deep at the level of the shoulder to drain into the axillary vein.

Brachial artery pulse

The brachial artery pulse - palpate (extend the elbow, medial to biceps tendon in the cubital fossa)

Ulnar Artery

The common interosseous artery branches off the ulnar artery, this splits into the: 1) Anterior interosseous artery Supplies anterior compartment of the forearm 2) Posterior interosseous artery Supplies posterior compartment of the forearm **These anastomose on the posterior of the hand with the dorsal carpal branches of the radial and ulnar arteries to form the dorsal carpal arch* Ulnar artery runs into hand over flexor retinaculum

The cords of the brachial plexus are named according to their relationship to the....

The cords of the brachial plexus are named according to their relationship to the axillary artery. e.g. The posterior cord is posterior to the artery etc.

Summary of attachments of the deep anterior compartment of the forearm

The deep anterior compartment produces flexion and bends fingers to make a fist. These are the flexor pollicis longus and the flexor digitorum profundus.

Lumbo-sacral plexus

The details of this plexus not required to the same degree at the brachial plexus, but the general organisation should be understood. o L2-S3.

Digital creases

The digital creases on the palmar surface of the fingers (proximal, middle & distal)

The Bones of the Wrist

The distal ends of the radius and ulna articulate with the proximal row of carpal bones, with the exception of pisiform (a sesamoid bone). *tubercle of trapezium and hook of hamate are attachments for flexor retinaculum * shape of bones important for carpal tunnel

The Wrist and Distal Radio-Ulnar Joints grooves for tendons

The distal ulna does not articulate directly with the triquetrum carpal bone. An articular disc intervenes. Disc is attached to styloid process of ulnar, so when radius is turning over it gets dragged over.

The structure of the endosteum

The endosteum is an incomplete cellular layer lining the marrow cavity. It is also very active during bone growth and repair.

Dorsal Tendinous Anatomy

The extensor tendons will pass under the extensor retinaculum They are connected by intertendinous bands Covered by synovial sheaths

Gluteal Region muscles

The extensors, ABductors and external rotators of the hip. 1) Gluteal muscles: i.Gluteus maximus ii.Gluteus medius iii.Gluteus minimus iv. (Tensor fasciae latae) 2) Short external (lateral) rotators of the hip: (HOLD HEAD OF FEMUR TO STABILISE HIP JOINT) i. Piriformis ii. Obturator internus iii. The gemelli (sup. and inf.) iv. Quadratus femoris

Cannulation of the femoral artery and vein

The femoral artery and vein can be easily exposed and cannulated at the groin e.g. for cardiac arteriography (artery) or for resuscitation (vein).

The femoral artery and vein pass from the anterior compartment to the posterior of the knee (the popliteal fossa) through...

How do femoral artery and vein pass through leg?

The femoral artery and vein pass from the anterior compartment to the posterior of the knee (the popliteal fossa) through the hiatus of adductor magnus muscle. After passing posteriorly, they are named the popliteal artery and vein. **artery and vein passing through adductor hiatus (from adductor magnus) and go from anterior to posterior.

What do you press against in palpation of femoral artery pulse?

The femoral artery can be palpated at the mid-inguinal point: Halfway between the ASIS and Pubic symphysis. §It lies on the Psoas tendon and can be "easily" palpated

Region of adductor canal in relation to femoral triangle

The femoral triangle is continuous with the adductor canal. Inferior end of femoral triangle forms apex of adductor canal. Sartorius curves around medially to become the anterior border of the adductor canal. Hence the adductor canal is sometimes referred to at the "subsartorial" canal.

Femoral vein and nerve in relation to femoral artery

The femoral vein veins can't be palpated but surface mark it on the medial side of the femoral artery. The femoral nerve Surface mark on the lateral side of the femoral artery.

hip bone (innominate bone), is formed by the fusion of

The hip bone (innominate bone), is formed by the fusion of three primary bones- the ilium, ischium and pubis. The fusion lines are not visible in the adult skeleton. The hip bones are connected to the sacrum, posteriorly, at the sacro-iliac joints, and anteriorly to themselves at the symphysis pubis.

Purpose of interosseus membrane

The interosseous membrane separates the anterior and posterior compartments, and is a site of attachment for muscles in the forearm. *distal ends of ulna and radius articulate with articular disc and lunate and scaphoid.

What do long saphenous and short saphenous vein arise from?

The long saphenous vein arises from the MEDIAL aspect of the DORSAL VENOUS ARCH. It ascends very constantly just anterior to the medial malleolus of the ankle and continues up the medial side of the limb to join the femoral vein (passing to the deep system) in the groin. The short saphenous vein arises from the LATERAL aspect of the DORSAL VENOUS ARCH. It ascends the posterior compartment the leg to join the popliteal vein of deep system at the back of the knee.

Radial artery

The major artery in posterior forearm; it is palpable at the wrist on the thumb side.

How many phalanges does thumb have?

The majority of the function of the upper limb is devoted to the hand. Bones involved (Lateral to Medial): 1) Carpal Bones: a) Proximal row: Scaphoid, Lunate, Triquetrum, Pisiform b) Distal row: Trapezium, Trapezoid, Capitate, Hamate 2) Metacarpals (I to V) 3) Phalanges (Thumb only has 2) carpal mnemonic: Some Lovers Try Positions That They Can't Handle

Pic of muscles along dorsal and plantar side of foot

The muscles along the dorsal side of the foot (a) generally extend the toes while the muscles of the plantar side of the foot (b, c, d) generally flex the toes.

Summary of attachments of the deep posterior compartment of the forearm

The muscles of the deep posterior compartment of the forearm (deep posterior extensor compartment of the forearm) originate on the radius and ulna. These include the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis

Injury to the obturator nerve

The obturator nerve is rarely damaged. Beware pain in the distribution of the obturator nerve as it can be indicative of malignant disease in the pelvis.

Forearm - Deep Venous Drainage

The venae comitantes of the radial and ulnar arteries flow to the "brachial veins" (venae comitantes of the brachial artery)

interphalangeal joints

There are proximal and distal IPJs for all digits except thumb Allow flexion and extension only Reinforced by medial and lateral collaterals

Why test femoral and sciatic nerve reflexes?

They are the biggest ones in the leg.

How spinal roots recombine to form peripheral nerves

This diagram shows the way that fibres of spinal roots recombine to form peripheral nerves

The Interosseous Membrane of the Forearm

This is a fibrous sheet that connects the radius and the ulna forming a fibrous joint (syndesmosis) between the two bones. It divides the forearm into anterior and posterior compartments, gives rise to muscle attachments and transfers forces from the raius to the ulna to the humerus and vice versa.

Lower limb pulse points

This will likely be tested as 'take the patient's pulse' Know at least 3 sites CONFIDENTLY a) Femoral artery Mid-inguinal Point (between ASIS and Pubic Symphysis) b) Popliteal artery Inferior aspect of Popliteal Fossa (with knee flexed) c) Tibialis posterior artery Posterior to medial malleolus d) Dorsalis pedis artery Between 1st and 2nd metatarsals Bones compressed against?

Nerves to the foot

Tibial nerve and common peroneal (fibular) nerve: Formed as the terminal branches of the sciatic nerve, which divide just superiorly to the apex of the popliteal fossa (though this can be variable, i.e. can happen more proximally). a) Follow the TIBIAL nerve as it passes distally through the popliteal fossa and into the posterior leg. Trace the nerve as it runs on the surface of tibialis posterior, then posterior to the medial malleolus, passing under the plantar aponeurosis where it divides to form the medial and lateral plantar nerves that supply the small muscles of the foot. b) Trace the COMMON PERONEAL nerve as it leaves the popliteal fossa laterally to wind around the head of fibula. Attempt to find the terminal branches: the superficial peroneal nerve supplying the peroneal (lateral) muscles of the leg, and the deep peroneal nerve supplying the anterior muscles of the leg. A branch of the superficial peroneal nerve emerges just superior to the ankle joint to provide cutaneous innervation to the dorsum of the foot.

Types of innervation (2)

a) Segmental (dermatomes) - sensory and motor b) Peripheral (nerves to muscles, cutaneous nerves). Peripheral nerves to the limbs emerge from nerve plexuses

The posterior compartment superficial and deep flexors

a) The posterior compartment - superficial: brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, anconeus. (The 1st two muscles are sometimes classed as the lateral compartment of the forearm. The muscles underlined have a common tendon attachment to the lateral epicondyle of the humerus.) b) The posterior compartment - deep: supinator, abductor pollicus longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis.

bones of pectoral girdle

a) •The Scapula b) •The Clavicle c) •The Humerus

Talus bone

ankle bone; the bone with which the tibia and fibula connect to form the ankle joint

AIIS

anterior inferior iliac spine.. origin of rectus femoris

Transverse section of anterior hand

anteriorly, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis, flexor policis longus, flexor digitorum profundus. *(Note the relationship between the tendons and distal attachments of flexor digitorum superficialis and flexor digitorum profundus)

arm vs forearm

arm is shoulder to elbow. forearm is elbow to hand

pectineus muscle attachments

attaching to the pubic bone and the superior part of the pectineal line of the femur

Terminal Branches of the Brachial Plexus

axillary nerve, radial nerve, median nerve, ulnar nerve, musculocutaneous nerve

What is the largest muscle in the lower leg? a) soleus b) gastrocnemius c) tibialis anterior d) tibialis posterior

b) gastrocnemius

The vastus intermedius muscle is deep to which of the following muscles? a) biceps femoris b) rectus femoris c) vastus medialis d) vastus lateralis

b) rectus femoris

Path of the Ulnar Nerve (Derived from Medial Cord)

biggest branch from medial cord. emerges in axilla, goes down medial aspect of arm, behind medial epicondyle of humerus, only supplies to flexor carpi ulnaris and medial half of FDP in forearm and lots in hand (hypothenar, two medial lumbricals, all of interossei and adductor pollicis).

metacarpal parts

body (shaft), head (at distal end), base (at proximal end). **same applies for phalanges **"Note: Secondary ossification (growth) center of the thumb metacarpal develops at its base whilst the growth centers of the other 4 MCs develop at their heads. **Note: Secondary ossification (growth) centers of the phalanges develop at their bases (not heads).

Leg - Lateral Compartment

fibularis longus. fibularis brevis

Brachioradialis

flexes forearm

Gluteal muscles

gluteus maximus, gluteus medius (underneath) , gluteus minimus (further underneath) o medius and minimus cross laterally over hip joint and attach to greater trochanter of femur (abductors) - important in normal gait for stabilisation. o piriformis - comes off sacrum, attaches to greater trochanter

capitulum articulates with

head of radius

Hip bones

ilium (flat), ischium (posteriorly), pubis (anteriorly). ischial tuberosity important for attachment. flat bit of ilium articulates with sacral bone. all bones come together --> socket of hip joint (acetabulum).

Scapula - Anterior pic

learn labels. The scapula lies on the posterior and lateral aspect of the chest, overlying the 2nd to 7th ribs. It has 3 angles, 3 borders, 3 processes and 2 surfaces.

ulnar, median and musculocutaneous arrangment

medial - ulnar, middle - median, lateral - musculocutaneous.

Which superficial vein in the arm is usually used for phlebotomy or insertion of a venous line?

median cubital vein (red arrow pointing it in pic), linking the basilic and cephalic veins. (not always present)

Innervation of FDP?

median nerve and ulnar nerve

Fracture of femoral neck

more common than intertrochanteric. more common with aging population.

Segmental sensory nerve supply: dermatomes

more twisted in lower limbs

Circumduction movement

moving the joint in a circular manner. The wrist joint is not the only joint that allows flexion and extension at the wrist region - the midcarpal joint and the carpo-metacarpal joints also allow these movements.

Bennett's Fracture and Boxer's Fracture

o Bennett's- caused by punching with thumb exposed o Boxer's- poor punching form

Peripheral nerve damage implication

o Peripheral nerves carry nerve components from several spinal segments (or roots) to muscles and skin areas. o Therefore, damage to a peripheral nerve may result in a WIDE RANGING effect on more than one dermatomal area or myotomes which may include large areas of skin and several muscles.

How to feel for hook of hamate?

o The pisiform (distal end of flexor carpi ulnaris tendon). o The tubercle of scaphoid (fully extend the wrist and it is along the line of FCR). o The hook of the hamate (palpate deep to the hypothenar muscles 1 cm distal and lateral to pisiform). o The ridge of trapezium (palpate deep to the middle of the root of the thenar muscles, distal to scaphoid

How to feel for pisiform?

position of ulnar nerve, median, musculocutaneous and radial nerve

o branches of the musculocutaneous nerve supplying biceps and brachialis o radial nerve supplying brachioradialis

Femur (thigh bone)

o long bone ** proximal end: o head covered in hyaline cartilage which articulates with acetabulum --> hip joint o greater and lesser trochanters o intertrochanteric line **At distal end: o two condyles (articular surface) o intercondylar region - patella articulates here o two epicondyles *patella = sesamoid bone (within tendon of a muscle), when muscle moves over surface of bone to minimise friction or damage to muscle or bone.

Leg arteries angiogram

o popliteal --> anterior and posterior tibial o posterior tibial --> gives off peroneal

Dorsalis pedis artery palpation

o press against tarsals/metatarsals . Palpable between the first and second metatarsals o just lateral to extensor hallucis longus tendon

Humerus labels

o proximal and distal ends are widened and articulate with other structures o anatomical neck - true neck o The surgical neck is more commonly damaged than the anatomical neck. o deltoid tuberosity - where proximal part of deltoid muscle attaches o tubercles are more rounded; tuberosity more irregular o capitulum and trochlea are condyles; epicondyles above condyles

Subclavius action

o proximal attachment - 1st rib close to costochondral joint o distal attachment - inferior part of clavicle. *anchors the clavicle and stabilises the sternoclavicular joint. * The innervation is carried by the subclavian nerve (C5-6), a branch of the brachial plexus.

Cutaneous Innervation of the Foot

o saphenous nerve o superficial fibural nerve o dorsal lateral cutaneous nerve of foot

The Sciatic Nerve path and what it innervates

o sciatic nerve is two nerves (tibial and common fibular) joined together. •Passes from pelvis to buttock via GREATER sciatic notch/foramen •In the buttock, lies in the INFERIOR and MEDIAL quadrant. o The sciatic nerve normally enters the gluteal region INFERIORLY to piriformis muscle, but can be superior or pierce the muscle itself. •Passes along POSTERIOR aspect of the thigh •Divides into the TIBIAL and the COMMON PERONEAL nerve (inconstant level) •Supplies all the HAMSTRING muscles and all the muscles BELOW the level of the knee •If injecting in the buttock, use the SUPERIOR and LATERAL quadrant

Popliteal artery in relation to sciatic nerve

popliteal artery is deeper.

adductor tubercle of femur

projection on the medial surface of the medial epicondyle - for attachment of adductor magnus.

Pelvic bone pics

§ (A): Anteromedial view (R) pelvic bone § (B): Posterolateral view (R) pelvic bone

Which is more dangeorus: proximal DVT or distal?

§ A proximal DVT is more dangerous than a distal DVT There is a high risk of a pulmonary embolism. **Immobility (e.g. a long plane journey) means less efficient venous return from the foot and leg, as the muscles are not contracting as frequently. Sluggish deep venous return can lead to Deep Vein Thrombosis (DVT). Elastic SURGICAL SOCKS compress the superficial veins promoting more vigorous deep venous return.

What type of joint is ankle joint?

§ A synovial Joint § Movement: Dorsi or plantar flexion § Tibia/Fibula forms a 'mortice' for Talus of the Foot §'Mortice' Faces: Roof - Inferior Surface of Distal Tibia; Medial Side - Medial Malleolus of Tibia; Lateral Side - Lateral Malleolus of Fibula.

Proximal Attachments of medial compartment of thigh

§ Adductor compartment muscles --> body of the pubis and the ischiopubic ramus § All of the adductor compartment muscles (including pectineus) attach to either the pubis or the ischiopubic ramus *Except obturator externus

Boundaries of snuff box

§ Anatomical 'Snuff' box. § Named as it is easily broken= Commonly(?) used for snorting cocaine **Clinical significance? a) Trauma/Fracture common b) Damages scaphoid bone c) Damages branch of radial artery

Assessing ACL/PCL Integrity

§ Anterior / posterior draw test - °. in anterior - lower leg pulled up to check laxity of knee joint(if moves more than 5mm and is more than uninjured leg --> = positive for injury). in posterior - lower leg is pushed down to see laxity: PCL rupture with +ve Sag Sign § Can also do a Lachman's test (not pictured) - doctor bends knee to a 20-degree angle. They may also rotate your leg so your knee points outward. one hand is on your lower thigh and one hand on lower leg just below where your leg bends. pulls lower leg up towards them, keeping your thigh stable with their other hand. Assess: a) Endpoint. How much shin bone and knee move during the test. b) And also Laxity (How firm ACL feels when it moves within its normal range of motion during the test),

Sartorius attachments

§ Anterior compartment of the thigh § Proximal: ASIS § Distal: Pes anserinus ligament* on medial tibia inferior to the tibial tuberosity § Function: Hip and knee flexion

Tensor Fascia Lata attachments

§ Anterior compartment of the thigh § Proximal: ASIS. § Distal: Iliotibial tract - Attaches to the lateral condyle of the tibia. § Function: Stabilise the knee in extension § Innervation: Superior gluteal nerve

Palpation of body of pubis, pubic tubercle, ischial tuberosity, inferior pubic ramus

§ Body of pubis - A hand's width below umbilicus, below pubic hair line. § Pubic tubercle - 2 cm lateral to the pubic symphysis. § Ischial tuberosity - On the inferior part of the buttock when thigh is flexed - feel it on yourself while seated. § Inferior pubic ramus - follow the body of pubis inferiorly and then continue infero-laterally.

Superficial Thrombophlebitis

§ Clot of the superficial veins and inflammation of this clot § Not as dangerous as a DVT but painful § Treatment Symptom guided

When is common peroneal nerve susceptible to injury?

§ Descends around the neck of the fibula § Susceptible to injury: Fibular Fracture and Knee Joint Dislocation § Presentation of Common Peroneal Nerve Palsy? Foot Drop (High Stepping Gait) § Divides into: a) Deep Peroneal Nerve - anterior compartment b) Superficial Nerve - lateral compartment

Fibularis Tertius

§ Dorsiflexion, Eversion of Foot § Proximal: Distal, Medial Fibula § Distal: Dorsal surface of Base of 5th Metatarsal

Flexor Hallucis Longus

§ Flexion of Great Toe § Proximal: Posterior interosseous membrane; Fibula. § Distal: Plantar surface of Base of Distal Phalanx of Great Toe

Where to put hands for gluteal injections?

§ Inject in the superolateral quadrant to avoid damaging the sciatic nerve and other important structures (vasculature)

What is the torsion angle of femoral neck?

§ It is the angular difference between the axis of femoral neck and the transcondylar axis of the knee. § In the adults it is around 12 degrees. § At birth, it is around 30- 40 degrees which reduces by a degree each year until 20+. § A higher anteversion angle results in intoed feet (feet turned towards the midline). Intoeing is normal in young children.

Lymphatic Drainage of ankle, knee and leg

§ Lymph flows with the superficial and deep venous systems. § In the popliteal fossa are popliteal lymph nodes, superficial and deep.

Clinical importance of perforating veins

§ Perforating veins are veins that connect superficial and deep veins and these have a valve that only allow flow from superficial --> deep. o If the valve is compromised --> blood pushed from deep to superficial --> varicose veins. § Elastic surgical socks promote more vigorous deep venous return as patients are often immobilised for long periods of time in surgery. This is to prevent DVT.

What does tibial nerve divide into?

§ Posterior Compartment § All Intrinsic Foot Muscles (except extensor digitorum brevis) § At the ankle passes through tarsal tunnel behind medial malleolus § Divides into: Medial plantar nerve and Lateral plantar nerve.

Where are the sesamoid bones of the foot most commonly located?

§ Sesamoid bones within Flexor Hallucis Brevis (Flexor Hallucis Longus traverses through these) Head of 1st Metatarsal ('Ball of the Foot')

Venous Grafts

§ Superficial veins are used as grafts in elective surgery: a) CABG (coronary artery bypass graft) b) Arterial by-pass surgery § Due to the dual system in the limb, and the extensive anastomosis in the leg, removal of a vein is fine Valves! (only allow flow in one direction)

Synovium and Ligament of the Femoral Head

§ Synovial membrane surrounding the head § The ligament of the head of the femur attaches the femoral head to the acetabulum

The Femoral nerve

§ The Femoral Nerve (L2L3L4, posterior divisions) The femoral nerve is formed from the lumbar plexus. It supplies ilio-psoas and the anterior thigh muscles. It is also sensory to the front of the thigh. § Its terminal branch is the saphenous nerve, which is sensory to the medial aspect of the leg

Gluteal fold and sulcus

§ The gluteal fold - the inferior border of gluteus maximus. Extend the thigh at hip joint and feel the muscle contracting and producing the rounded contour of the buttock. § The gluteal sulcus - visible skin crease separating the buttock and thigh which crosses the true gluteal fold obliquely

Summary of attachments of lateral compartment of leg

§ The lateral compartment of the leg includes two muscles: the fibularis longus (peroneus longus) and the fibularis brevis (peroneus brevis).

Sacral plexus and gluteal compartmen t

§ The sacral plexus supplies the roots of the sciatic nerve: Sciatic nerve (L4-S3) is a combination of two nerves: a) Peroneal (fibular) nerve b) Tibial nerve **Other nerves in the plexus: § Supply to the gluteal compartment: a) The nerve to piriformis (S1,2) b) The nerve to nerve to obturator internus (L5 + S1,2) c) The superior gluteal nerve (L4,5 + S1) - Gluteus medius, minimus and tensor fascia lata d) The inferior gluteal nerve (L5 + S1,2) - Gluteus maximus § Other nerves a)The posterior cutaneous nerve of the thigh (S1-3) b) The pelvic splanchnic nerves (S2-4) - parasympathetic* c) The pudendal nerve (S2-4)*

Piriformis and Obturator Internus

§ They are both part of deep gluteal compartment: short, lateral rotators of the hip 1) Piriformis: Proximal: Anterior Sacrum Distal: Medial aspect of greater trochanter Splits the greater sciatic foramen into two parts 2) Obturator internus: Proximal: Internal obturator membrane Distal: Medial aspect of Greater trochanter Tendon makes a 90⁰ turn to go through the lesser sciatic foramen

Tibial nerve damage

§ Tibial nerve leaves the popliteal fossa deep to gastrocnemius and soleus muscles. § Tibial nerve (L4-S3) § would lead to motor loss in all the muscles of the posterior leg; the foot would be dorsiflexed and everted (no inversion/plantarflexion forces to check the everters and dorsiflexors)

Plantaris

§ in superficial posterior (flexor) compartment of leg § plantaris with its small muscle belly arising from the lateral supracondylar area of the femur, lying medial to the proximal lateral head of gastrocnemius, and trace its long slender tendon to the heel bone (calcaneus), just medial to the calcaneal tendon § Plantarflexion, Knee Flexion § Proximal: Inferior part of lateral supracondylar line of femur § Distal: Calcaneal tendon

Label collateral ligaments

§ notice pes anserinus: gracilis, sartorius, semitendinous 1) lateral (fibular) collateral ligament 2) medial (tibial) collateral ligament § one on each side of the joint - stabilise the hinge-like motion of the knee

Extensor Hallucis Longus

§Extension of Great Toe, Dorsiflexion §Proximal: Medial Fibula; Anterior Interosseous Membrane §Distal: Dorsal surface of Base of Distal Phalanx of Great Toe

Extensor Digitorum Longus

§Extension of Lateral 4 Toes, Dorsiflexion §Proximal: Medial Fibula; Lateral Tibial Condyle §Distal: Dorsal surface of Bases of Distal & Middle Phalanges of Lateral 4 Toes (via Dorsal Digital Expansions)

Flexor Digitorum Longus

§Flexion of Lateral 4 Toes §Proximal: Medial Tibia §Distal: Plantar surfaces of Base of Distal Phalanx of Lateral 4 Toes

Arterial embolism implications

Ø Sudden occlusion Ø Acute ischaemia Ø Intermittent claudication (muscle pain commonly in calf during activity, associated with arterial disease)

Movements of the Elbow Joint

1)Flexion: a)Brachialis b)Biceps c)(Brachioradialis) d)(Pronator teres) 2)Extension: a)Triceps b)(Anconeus)

Bones of forearm

* radius and ulna * parallel *The interosseous membrane separates the anterior and posterior compartments, and is a site of attachment for muscles in the forearm

What goes through the tarsal tunne;

1) "Tom" - tendon of tibialis posterior 2) "Dick" - tendon of flexor digitorum longus 3) "And" - posterior tibial artery 4) " Very" - posterior tibial vein 5) "Naughty" - tibial nerve 6) "Harrow" - tendon of flexor hallucis longus § Gateway into foot: Behind medial malleolus § What goes through the tarsal tunnel? Tom Dick And Very Naughty Harry

Acetabular notch

1. Acetabular notch 2. Acetabular fossa 3. Lunate fossa 4. The acetabulum is directed inferiorly, laterally and anteriorly

Lunate fossa

1. Acetabular notch 2. Acetabular fossa 3. Lunate fossa 4. The acetabulum is directed inferiorly, laterally and anteriorly

Patella labelled

1. Anterior surface (slightly convex). 2. Posterior surface (Inclined medial and lateral articular surfaces. Lateral surface larger. 3. Pointed apex (inferiorly). 4. Broad base (superiorly) 5. Is it a right or a left patella? (clue: The bone lies down on its lateral surface)

Tenosynovitis

Flexor tendons enclosed in sheath for lubrication and as a pulley Bacterial infection here can cause spread to the hand and wrist: a) FD tendon sheath to ulnar bursa b) FP tendon sheath to radial bursa 4 signs of infection (Previous history of infection/trauma): a) Finger held in flexion b) Swelling c) Tenderness along the flexor tendon sheath d) Pain with passive extension of the digit

What sort of movement occurs at the subtalar joint?

Gliding and rotation

Lateral Rotators of hip function

Lateral Rotators: i.Piriformis ii.Obturator internus - comes from obturator foramen iii.The gemelli (sup. and inf.) iv.Quadratus femoris **One of this group's main functions is to stabilise the hip joint.

Gemelli (superior and inferior)

Origin: Ischial spine and tuberosity Insertion: Medial surface of greater trochanter with tendon of obturator internus Action: Lateral rotation at hip

Distal Radio-ulnar Joint

Pivot type joint. Pronation and supination

Muscles involved in radial and ulnar deviation of the wrist joint

Radial deviation of wrist: 1. APL 2. FCR 3. ECRL 4. ECRB Ulnar deviation of wrist: 1. ECU 2. FCU

Talo-Calcaneo-Navicular Joint movement

Site of inversion and aversion of foot These movements are commonly mistaken as ankle movements a) Inversion - Medialisation - "Could you bend your foot inward?" b) eversion - Laterialisation - "Could you bend your foot outward?" *1st MetaTarso-Phalangeal Joint (MPJ) Enables movement of the big toe Unlikely to be tested

How many muscles below knee does sciatic nerve supply?

Supplies ALL muscles below the knee Divides into tibial and common peroneal nerve

Upper limb pulse points

This will likely be tested as 'take the patient's pulse' Know at least 3 sites CONFIDENTLY 1) Subclavian artery Just above and behind the medial end of the clavicle 2) Brachial artery - palpable in two positions Arm: brachial artery can be compressed against medial side of humerus Cubital fossa - medial to biceps tendon 3) Radial artery - distal, lateral side of the wrist 4) Ulnar artery - distal, medial side of the wrist Difficult as it passes under the flexor carpi ulnaris tendon 5) Axillary not included as it is rarely taught or practised 6) know Bones compressed against for each pulse

femoral triangle

Upside down 3 sided pyramid: a) Base of the triangle (superior border of triangle) Inguinal ligament. b) Medial border of triangle: Adductor longus. c) Lateral border of triangle: Sartorius. d) Apex of the triangle (inferior end) Continuous with the adductor canal.

Muscles that move the thumb

abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus

Adductor pollicis

adducts thumb

The hip joint - What type of joint is this?

ball and socket

1. The rhomboid major and minor muscles are deep to the ________. a) rectus abdominis b) scalene muscles c) trapezius d) ligamentum nuchae

c) trapezius

With respect to injuries to the brachial plexus, which of the following is true? a.Klumpke's paralysis is caused by injury to the upper roots b.Erb's palsy is commonly associated with falling onto an abducted arm c. Erb's palsy is commonly associated with shoulder dystocia d.Erb's palsy causes a typical claw-like hand e.Klumpke's palsy affects the axillary nerve

c. Erb's palsy is commonly associated with shoulder dystocia

Which is more commonly damaged: surgical neck or anatomical neck?

surgical neck

leg vs thigh

leg is bit only between knee and ankle; thigh is between hip and knee

Innervation of pronator teres?

median nerve

Where to palpate for femoral artery pulse

midinguinal point.

supination and pronation

palm up vs. palm down

Twisting of the lower limb during development

permanent pronation at the mid-thigh level makes the terminology in the lower limb confusing. hence anterior and posterior switch round.

Transverse section of posterior hand

posteriorly, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, abductor pollicus longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis. *(Note the anatomical snuffbox between the tendons of extensor policis longus (medially) and extensor pollicis brevis / adductor pollicis longus (laterally).

Subtalar Joint

§ A joint between the large posterior calcaneal facet and the inferior surface of the talus § Allow gliding and rotation: Thus, enables foot Inversion/Eversion § Lateral, Medial, Posterior & Interosseous talocalcaneal ligaments stabilise the joint

Leg - Posterior Compartment

§ Gastrocnemius + Soleus = Triceps Surae

Tendon Anatomy of the Hand

•Anterior tendons •Posterior tendons

Four layers of muscles in the sole of the foot

A) FIRST layer: 1. Abductor hallucis longus 2. Flexor digitorum brevis 3. Abductor digiti minimi. B) SECOND layer: 1. Quadratus plantae 2. The tendons of flexor hallucis longus and flexor digitorum longus (the long toe flexors) 3. The lumbricals C) THIRD layer: 1. Flexor hallucis brevis 2. Adductor hallucis 3. Flexor digiti minimi brevis D) FOURTH layer: 1. The plantar interossei 2. The dorsal interossei **On the dorsum of the foot are two muscles; 1. Extensor digitorum brevis 2. Extensor hallucis brevis

Peripheral Distribution - Leg and Foot

A) Femoral nerve (Saphenous Branch) 1.medial leg 2.Saphenous nerve (as in goes through popliteal fossa) B) Sural nerve 1.Calf region (posterior leg) and lateral foot 2.From tibial and common peroneal C) Superficial Peroneal 1.Anterio-lateral leg and dorsal foot D) Deep Peroneal 1.First toe web E) Tibial nerve 1.Sole of foot **FOR THIGH: A) Femoral nerve: 1.Anterior thigh and medial leg 2.Medial and intermediate femoral cutaneous nerve 3.Saphenous nerve (as in goes through popliteal fossa) B) Posterior femoral cutaneous: 1.Posterior thigh 2.From sacral plexus C) Lateral femoral cutaneous: 1.Lateral thigh 2.From lumbar plexus D) Obturator: 1.Medial thigh 2.Cutaneous branch of obturator

Transverse Acetabular Ligament

Around the rim of the bony acetabulum is an incomplete rim of tissue called the acetabular labrum. This is completed by the transverse acetabular ligament

What's So Special About The Thumb?

Capable of a very wide range of movements and can be opposed to the other digits The trapezium (carpal bone of thumb) and metacarpal I are exceptionally mobile compared to the other metacarpals which function as a unit Phalanges (Thumb has 2; remainder have 3)

Lower limb: CT

High density tissue (such as bone) absorbs the radiation to a greater degree, and a reduced amount is detected by the scanner on the opposite side of the body - looks white. Low density tissue (such as the lungs), absorbs the radiation to a lesser degree, and there is a greater signal detected by the scanner - looks dark. A contrast can be added to view details such as vasculature.

Remembering The Main Reflex Arcs

In both limbs: Ankle (S1,2) Knee (L3,4) Biceps (C5,6) Triceps (C7,8) Just count to 8, and remember the area of the spinal cord

4 bony points of flexor retinactulum

Ligament which forms the roof of the carpal tunnel. Anchors to 4 bony points: 1.Laterally a.Tubercle of scaphoid b.Tubercle of trapezium 2.Medially a.Pisiform b.Hook of hamate

Ligaments of the Hip Joint

Ligaments of the Hip Joint named in relation to the pelvic bone to which they attach proximally. •Ilio-femoral ligament (ilium --> femoral intertrochanteric line) •Pubo-femoral ligament (pubis -->intertrochanteric line) •Ischio-femoral ligament (posteriorly from ischium to intertrochanteric line) •The ligament of the head of the femur **are spirally arranged, so when extend hip, tighten up and draw two parts closer together (pull head of femur towards pelvis --> help stabilisation)

venae comitantes

Literally means accompany veins, refers to two (occasionally more) veins closely accompanying an artery in such a manner that the pulsations of the artery aid venous return. They are usually present with the deep arteries of the extremities and branch between one another.

Foot arches

Medial and Lateral Longitudinal Arches & Transverse Arch. Absorb and distribute downward forces when standing/different surface types. Long tendons and Intrinsic muscles support arches. **angle of the longitudinal arch 150-170°

Muscles that position the pectoral girdle

Muscles that position the pectoral girdle are located either on the anterior thorax or on the posterior thorax. The anterior muscles include the subclavius, pectoralis minor, and serratus anterior. The posterior muscles include the trapezius, rhomboid major, and rhomboid minor. When the rhomboids are contracted, your scapula moves medially, which can pull the shoulder and upper limb posteriorly.

Summary of attachments of muscles that position the pectoral girdle

The ulna directly articulates with which carpal bone? A. Hamate B. Trapezium C. Scaphoid D. None

None. articulates with articular disc. "The radius and its triangular fibrocartilage articulates with the scaphoid, lunate and triquetrum (the ulna does not itself articulate with the carpus. o The scaphoid has an unusual blood supply which is clinically important. Its blood vessels tend to pass from distal to proximal. They can be interrupted by fracture of the waist of the bone, which can cut off the blood supply to its proximal portion causing a condition termed avascular necrosis.

Nerves of the buttock and posterior thigh

Piriformis muscle is one of the lateral rotator group of gluteal muscles. It is an important landmark in relation to the nerves and vessels of the gluteal region. o superior gluteal - emerge above piriformis. o inferior gluteal - emerge below piriformis o sciatic also beneath piriformis (biggest nerve). divides to give tibial and common peroneal. o posterior cutaneous nerve of thigh - biggest cutaneous nerve

What does radial nerve supply?

Radial Nerve (C5,6,7,8,T1): •Supplies all the muscles of the posterior compartments of the upper arm and forearm. doesn't supply any muscles of hand but does have some cutaneous innervation •Passes around the body of the humerus at its mid-shaft in the radial groove (easily damaged!) •Supplies triceps in the arm •Courses via the anterior compartment of the upper arm more distally •Divides just above the level of the elbow into; •Deep branch - the posterior interosseous nerve (motor) •Superficial branch - the superficial radial nerve (sensory)

Some of the major structures maintaining the arches of the foot:

Some of the major structures maintaining the arches of the foot: Ligaments and long tendons are both involved. o Long tendons and intrinsic muscles help support the arches of the foot. o plantar aponeurosis from calcaneus. o spring ligament (calcaneonavicular) - important for holding arches together. o flexor hallucis longus runs between two sesamoid bones. o muscles also contribute to arches.

The Common Peroneal Nerve

The Common Peroneal Nerve (L4L5S1S2): § This is one of the two terminal branches of the sciatic nerve. The nerve passes around the neck of the fibula, where it is easily damaged. § It supplies the anterior and lateral compartments of the leg, and is sensory to the anterior and lateral aspects of the leg and the dorsum of the foot. Its two terminal branches are the superficial peroneal nerve and the deep peroneal nerve. An important sensory branch is the sural nerve

The Proximal and Distal Radio-Ulnar Joints pic

The distal radio-ulnar joint (DRUJ) is a pivot-type synovial joint that allows the radius to rotate around the ulna. Within the DRUJ is an triangular fibrocartilage articular disc called the triangular ligament. The muscles moving the DRUJ are identical to those of the proximal radio-ulnar joint.

Summary of attachments of extensor digitorum brevis in feet

The foot also has intrinsic muscles, which originate and insert within it (similar to the intrinsic muscles of the hand). These muscles primarily provide support for the foot and its arch, and contribute to movements of the toes ([link] and [link]). The principal support for the longitudinal arch of the foot is a deep fascia called plantar aponeurosis, which runs from the calcaneus bone to the toes (inflammation of this tissue is the cause of "plantar fasciitis," which can affect runners. The intrinsic muscles of the foot consist of two groups. 1) The dorsal group includes only one muscle, the extensor digitorum brevis. 2) The second group is the plantar group, which consists of four layers, starting with the most superficial. § The muscles along the dorsal side of the foot generally extend the toes while the muscles of the plantar side of the foot generally flex the toes.

How many supinators?

The forearm flexors include the biceps brachii, brachialis, and brachioradialis. The extensors are the triceps brachii and anconeus. The pronators are the pronator teres and the pronator quadratus. The supinator is the only one that turns the forearm anteriorly.

Two major regions

The gluteal region (part of the trunk) and the "free lower limb" (thigh, leg and foot). Flexion and extension switch round for knee and hip. Lateral external and medial internal rotation.

Pic of Muscles That Move the Forearm.

The muscles originating in the upper arm flex, extend, pronate, and supinate the forearm. The muscles originating in the forearm move the wrists, hands, and fingers.

Two functions of rotation cuff? What can anterior dislocation of the humerus result in?

The rotator cuff has two functions: 1) Hold the humerus in the glenoid cavity 2) Compressing the joint during abduction to minimise risk of dislocation *Anterior dislocation of the humerus can result in: a) Tearing of the glenoid labrum b) Compression of the axillary nerve, which will result in: limited ABDUCTION due to reduced function of the DELTOID muscle. **Pic: Top to bottom: - supraspinatous - infraspinatous - teres minor - subscapularis

Variations of the emergence of the sciatic nerve from the pelvis interior to the gluteal region

The sciatic nerve normally enters the gluteal region inferiorly to piriformis muscle, but can be superior or pierce the muscle itself. *For this reason, care must be taken to avoid the nerve during intramuscular injection.

Which muscles does the sciatic nerve supply?

The sciatic nerve supplies the posterior compartment of the thigh. In detail it supplies: a. biceps femoris b. semimembranosus c. semitendinosus d. part of adductor magnus

Nerves of the leg and foot

Upper limb anterior compartments

Upper limb anterior compartments: anterior shoulder (pectoral) girdle, anterior (flexor) arm, anterior (flexor) forearm, palmar compartment of the hand.

Upper limb posterior compartments

Upper limb posterior compartments: posterior part of the shoulder (pectoral girdle), posterior (extensor) arm, posterior (extensor) forearm, posterior (dorsum) of the hand. o humerus, radius, ulna, carpus, metacarpals, phalanges

Acromioclavicular joint damage

Usually sports injuries where fall onto point of shoulder Scapula forced downward Clavicle looks very prominent Various grades of injury Management* a) Acute: sling or surgical reduction and fixation b) Follow up: PT or surgical stabilisation

What occurs when blood Ca2+ levels low?

When blood Ca2+ levels low: o Parathyroid Hormone (PTH) released by chief cells of parathyroid gland: a) osteoclast bone resorption activity promoted b) increases Ca2+ re-absorption by the kidneys. * When blood Ca2+ levels high: Calcitonin released by parafollicular thyroid cells: a) breakdown of bone matrix by osteoclasts inhibited b) uptake of Ca2+ into bone matrix is promoted.

The large muscle group that attaches the leg to the pelvic girdle and produces extension of the hip joint is the ________ group. a) gluteal b) obturator c) adductor d) abductor

a) gluteal

Sensory Peripheral Supply

a)Subcostal nerve (T12) b)Ilio-hypogastric nerve (L1) c)Ilio-inguinal nerve (L1) d)Genito-femoral nerve (L12) e)Lateral cutaneous nerve of the thigh (L23) f)Sensory branches of the femoral nerve (L234) g)Sensory branches of the obturator nerve (L234) h)Posterior cutaneous nerve of the thigh (S23) i)Saphenous nerve (L234) j)Buttock nerves from the scaral plexus (L1-S3)

Sternoclavicular Joint

The SCJ is a synovial joint composed of two portions separated by a fibrocartilage articular disc. - The clavicle and sternum are separated by an articular disk It is stabilised by the sterno-clavicular and costoclavicular ligaments - It is a very strong joint and this strength arises from the very strong sterno-clavicular ligaments. However these are sometimes injured, resulting in sterno-clavicular subluxation and dislocation. - The sternal end of the clavicle not only articulates with the sternum (manubrium); it also articulates with the first costal cartilage. - The SCJ is the only connection of the pectoral girdle to the the axial skeleton and it allows movement of the CLAVICLE (and therefore the PECTORAL GIRDLE) in 3 planes). ** pic: 1) articular disc 2) costoclavicular ligament 3) anterior sternoclavicular ligament

The peripheral innervation of the upper and lower limb is derived from where?

"The peripheral innervation of the upper limb is derived from the BRACHIAL PLEXUS, which is derived from the anterior rami of the C5-T1 spinal nerves. The peripheral innervation of the lower limbs is derived from the LUMBO-SACRAL PLEXUS, which is derived from the anterior rami of the lumbar and sacral spinal nerves. "The peripheral nerve supply, distributing the segmental supply, comprises motor, sensory and autonomic components. Reflex arcs are mediated by some peripheral nerves. Most peripheral nerves are "mixed" i.e. contain both motor and sensory fibres. However, are purely motor whilst others are purely sensory.

Which is lateral, radius or ulnar?

"The radial artery supplies the lateral (radial) aspect of the forearm and hand. The ulnar artery supplies the medial (ulnar) aspect of the forearm and hand. It has a main branch, the common interosseous artery, which then itself divides into the anterior interosseous artery and the posterior interosseous artery.

Elbow joint

(Modified*) synovial hinge joint which allows Flexion and extension only The trochlea articulates with ulna The capitulum articulates with the radius. In addition to the elbow joint there is a proximal radio-ulnar joint which allows supination. *There are 3 ligaments which stabilise the elbow joint: 1) Radial collateral ligament (lateral) 2) Ulnar collateral ligament (medial) 3) Annular ligament (Strictly part of the proximal radio-ulnar joint)

What is distal limit of deep palmar arch and what is the main artery?

(The main artery is the radial. The arch lies 1 cm proximal to the superficial palmar arch at the distal edge of the flexor retinaculum)

What is distal limit of superficial palmar arch and what is the main artery?

(The main artery is the ulnar. The distal limit of the arch is at the level of the distal border of the fully extended thumb, just proximal to the proximal palmar crease)

The collateral ligaments of the ankle joint

(sprained ankles)!! o The broader and tougher tibiocalcaneal ligament is less often damaged. This ligament is also called the deltoid ligament (medial). o The lateral ligaments (3 parts) are commonly damaged by over-inversion. all are related to fibula and lateral malleolus. posterior and anterior talofibular ligaments (attaching to talus) and calcaneofibular ligament (attaching to calcaneus). often calcaneofibular damaged.

Biceps attachments

* Biceps : o The biceps muscle has two heads, the short head and the long head, distinguished according to their origin at the coracoid process and supraglenoid tubercle of the scapula after passing through bicipital groove, respectively. o distal biceps tendon. attaches to a part of the radius bone called the radial tuberosity.

What nerve does biceps tendon reflex test?

* Biceps tendon reflex (musculocutaneous nerve - C5, 6). o Ask the subject to rest comfortably (sitting or lying supine), with elbow semi flexed and hand pronated. Place the examiner's thumb on the biceps tendon and tap briskly with a knee hammer on the nail bed of the thumb. o If the reflex arc is intact there will be a brisk contraction of the biceps causing flexion of the forearm at the elbow joint. Compare with that of the contralateral limb.

musculocutaneous and median nerves

* Musculocutaneous nerve (lateral cord C5-7) The musculocutaneous nerve supplies the flexors of the elbow joint (biceps and brachialis). This nerve is rarely damaged. *Median nerve (medial and lateral cords C5-T1) The median nerve leaves the axilla and runs in front of the brachial artery. In the elbow, it lies medial to the brachial artery beneath the bicipital aponeurosis. It descends between the two heads of pronator teres and passes beneath the flexor digitorum superficialis (FDS). At the wrist it emerges between the tendons of FDS and palmaris longus and enters the carpal tunnel and into the hand.

How are radius and ulna connected?

* S(o)upination: palms up (as in the anatomical position) (Imagine holding a bowl of soup) * Pronation: palms down Radius and Ulna are connected... a) Proximally: proximal radio-ulnar joint b) Interosseous membrane (2 apertures, one superiorly, one inferiorly*) c) Distally: distal radio-ulnar joint **Responsible muscles: 1) Pronation: Pronator teres, pronator quadratus 2) Supination: Supinator, biceps brachii (in pronated position)

When does basilic join brachial vein

* Superficial: Basilic - draining medial part Cephalic - draining lateral part * Deep The venae comitantes of the brachial artery (brachial vein) - The palmar venous arches form the venae comitantes of the radial and ulnar arteries These flow to the "brachial veins" (venae comitantes of the brachial artery) o Basilic pierces deep fascia midway up arm to become deep and joins the brachial vein to form the axillary vein at the inferior border of the teres major. Cephalic dives in to join the axillary vein At the delto-pectoral triangle*

The Proximal and Distal Radio-Ulnar Joints

* The Proximal Radio-Ulnar Joint o between proximal heads of radius and ulna there's a synovial joint. o head of radius held in place by anular ligament of radius o the proximal radio-ulnar joint (PRUJ) is a uni-axial pivot-type synovial joint that allows the head of the radius to rotate within the annular ligament that attaches it to the margins of the radial notch of the ulna. o In young children (typically under 5 years of age) the radial head may harmlessly sublux out of position ('pulled elbow') when the child's forearm is pulled suddenly. It can be manipulated back in to place on supination. *The Distal Radio-Ulnar Joint o muscles are pronator teres wraps which around lateral side of radius and pronator quadratus, when contracts it pulls wrist round (pronation) o The distal radio-ulnar joint (DRUJ) is a pivot-type synovial joint that allows the radius to rotate around the distal ulna and the articular surfaces are held together by a fibrocartilage articular disc. o Supination and pronation are the movements that take place at the proximal and distal radio-ulnar joints. Supination is the movement that directs the palm anteriorly whilst pronation is the movement that directs the palm posteriorly. o The muscles producing these movements are: 1) Supination - supinator, biceps brachii. 2) Pronation - pronator quadratus, pronator teres.

Triceps tendon reflex tests which nerve?

* Triceps tendon reflex (radial nerve - C7, 8). o Ask the subject to rest comfortably (sitting or lying supine), with elbow semi-flexed and hand pronated. The examiner should support the elbow with one hand. Tap the triceps tendon directly with the tendon hammer. o If the reflex arc is intact there will be a brisk contraction of the triceps causing extension of the forearm. Compare with that of the contralateral limb.

Function of palmar interossei and innervation

** Origin: Sides of metacarpals 3-4 of them **Insertion: Extensor hoods **Function: Adduction at the MCP joint **Innervation: Ulnar nerve

divisions of brachial plexus

** Roots: formed from anterior rami of spinal nerves. **Trunks: a) upper : C5-6 b) middle : C7 c) lower : C8- T1 **Divisions: anterior and posterior which recombine to form cords **Cords: a) Lateral - from top 2 anterior b) Posterior - all 3 posterior divisions c) Medial - lower anterior *branches come off at different parts, e.g. dorsal scapular from C5 and long thoracic; also subscapular, medial pectoral etc. *purple is supraclavicular, blue is infraclavicular.

Which muscles of the medial compartment of thigh act across the knee joint?

***•Gracilis (acts across the knee joint) (comes from inferior ramus of pubis down across knee joint). Rest of muscles in compartment: •Adductor longus •Adductor brevis •Adductor magnus •Obturator internus

What is innervation for extensor digitorum? How is it tested?

**1. Flexor pollicis longus (Nerve-Median via anterior interosseus br C8,T1) (The examiner holds the proximal phalanx of the thumb whilst the distal phalanx is flexed against resistance. The muscle or tendon is deep for palpation. **2. Extensor pollicis longus (Nerve-Radial via posterior interosseus br C7,8) (Thumb is extended against resistance at the interphalangeal joint. Tendon visible at the medial border of the snuff box and medial to dorsal tubercle of radius.) **3. Flexor digitorum profundus (Nerve-Ulnar C8,T1 for 4th & 5th digit & Median C8,T1 for 2nd & 3rd digits). (The examiner holds the proximal interphalangeal (IP) joint in extended position while the distal IP joint is flexed against resistance.) Using this test how would you assess the integrity of median and ulnar nerves? **4. Flexor digitorum superficialis (Nerve-Median C7,8,T1) (Each digit is tested separately. Non test fingers are held in full extension by the examiner while the proximal IP joint of the test finger is flexed against resistance.) **5. Extensor digitorum (Nerve-Radial C7,8) (The forearm is pronated and the digits extended at MCP joints. Examiner applies resistance on the proximal phalanges. The tendons become visible and palpable on the dorsum of the hand, and the muscle belly is palpable on the forearm. What is a mallet finger? - Avulsion of extensor digitorum longus tendon at the base of distal phalanx **6. a) Dorsal interossei (ulnar C8, T1) (The examiner holds the adjacent extended and adducted fingers of the subject between his thumb and index finger while the subject attempts to abduct them. b) Palmar interossei (ulnar C8, T1) (The subject holds a slip of paper between adjacent fingers that are extended and adducted. The subject is asked to close the fingers tightly on the paper while the examiner attempts to withdraw it.)

What is innervation for flexor digitorum profundus ? How is it tested?

What is innervation for flexor pollicis longus ? How is it tested?

**1. Flexor pollicis longus (Nerve-Median via anterior interosseus br C8,T1) (The examiner holds the proximal phalanx of the thumb whilst the distal phalanx is flexed against resistance. The muscle or tendon is deep for palpation. **2. Extensor pollicis longus (Nerve-Radial via posterior interosseus br C7,8) (Thumb is extended against resistance at the interphalangeal joint. Tendon visible at the medial border of the snuff box and medial to dorsal tubercle of radius.) **3. Flexor digitorum profundus (Nerve-Ulnar C8,T1 for 4th & 5th digit & Median C8,T1 for 2nd & 3rd digits). (The examiner holds the proximal interphalangeal (IP) joint in extended position while the distal IP joint is flexed against resistance.) Using this test how would you assess the integrity of median and ulnar nerves? **4. Flexor digitorum superficialis (Nerve-Median C7,8,T1) (Each digit is tested separately. Non test fingers are held in full extension by the examiner while the proximal IP joint of the test finger is flexed against resistance.) **5. Extensor digitorum (Nerve-Radial C7,8) (The forearm is pronated and the digits extended at MCP joints. Examiner applies resistance on the proximal phalanges. The tendons become visible and palpable on the dorsum of the hand, and the muscle belly is palpable on the forearm. What is a mallet finger? - Avulsion of extensor digitorum longus tendon at the base of distal phalanx. **6. a) Dorsal interossei (ulnar C8, T1) (The examiner holds the adjacent extended and adducted fingers of the subject between his thumb and index finger while the subject attempts to abduct them. b) Palmar interossei (ulnar C8, T1) (The subject holds a slip of paper between adjacent fingers that are extended and adducted. The subject is asked to close the fingers tightly on the paper while the examiner attempts to withdraw it.)

What is innervation for extensor pollicis longus ? How is it tested?

What is innervation for flexor digitorum superficialis ? How is it tested?

What is innervation for interossei ? How are they tested?

The Anterior Compartment of the Thigh

**Hip Flexors and Knee Extensors: *(Mostly) supplied by the femoral nerve 1) Pectineus - also supplied by obturator in addition to femoral. Hence is also an adductor. 2) Ilio-psoas (from pelvis) - Only the ilacus is suppled by the femoral nerve. The psoas has other innervation. 3) (Tensor fasciae latae) - Innervated by the superior gluteal nerve 4) Sartorius 5) Quadriceps femoris ( 4 heads): a) Rectus femoris (straight) b) Vastus medialis c) Vastus intermedius d) Vastus lateralis

What is the basic unit of cancellous bone?

**In cancellous bone the lamellae are NOT arranged into osteons. o The matrix develops into an interlacing network of rods called TRABECULAE. This is much LESS heavy than compact bone, and also provides an ideal environment for the cells of the bone MARROW. ** compact bone: the basic unit = OSTEON or HAVERSIAN SYSTEM. o The osteocytes are arranged in layers around a central Haversian canal. o Each canal carries a blood and nerve supply to the osteon. The Haversian canals run parallel to the bone surface. o The osteons are arranged into lamellae. Most are arranged in a cylindrical fashion in the longitudinal axis of the bone and are called CONCENTRIC LAMELLAE. o There are also INTERSTITIAL lamellae filling in the spaces. o CIRCUMFERENTIAL lamellae are adjacent to either the periosteum or the endosteum and are produced during the growth of bone.

Posterior Compartment of the Thigh

**Knee Flexors and Hip Extensors "The Hamstrings": * Supplied by the sciatic nerve. 1) Semimembranosus 2) Semitendinosus 3) Biceps femoris **come off ischial tuberosity except for biceps femoris. (long head comes from ischial tuberosity and short head comes from posterior of femur; attaches to head of fibula). o Semimembranosus and semitendinosus stay medial and attaches across knee to medial side of tibia. tendinosus forms more tendon rope-like structure, but membranous is more flat like membrane.

The Femoral Triangle

**Outlined by: -Superiorly - the inguinal ligament -Medially - adductor longus -Laterally - sartorius **Contains: -Femoral nerve -Femoral artery -Femoral vein **deficiency on fascia lata in the anteriorsuperior region: the saphenous opening. saphenous opening where great saphenous vein pierces and joins femoral vein. lymph nodes in green. nerve is most lateral, then artery then vein.

The Femoral Triangle borders and contents

**Outlined by: -Superiorly - the inguinal ligament -Medially - adductor longus lateral edge -Laterally - sartorius medial edge **Contains: -Femoral nerve -Femoral artery -Femoral vein **The femoral sheath encloses the femoral artery and vein (but not the femoral nerve). A portion of it medially forms the femoral canal. **usually covered by fascia lata.

Innervation and attachment of teres major

**Proximal: a) Inferior angle of the scapula. ** Distal: a) Medial lip of intertubercular groove **Function (GHJ) a) Medial rotation b) Adduction c) Extension (tiny bit) **Innervation* Inferior (lower) subscapular nerve o attachment of latissimus dorsi (cut) and teres major to floor and medial lip of intertubercular sulcus of humerus. oTeres major is not rotator cuff.

Labels on tibia and fibula

**Tibia: 1. Medial and lateral condyles. 2. Medial and lateral tibial plateaus 3. Intercondylar eminence 4. Medial and lateral intercondylar tubercles (spines by radiologists). 5. Anterior and posterior intercondylar areas (cruciate ligaments and menisci attached. 6. Tibial tubersosity (anteriorly). 7. Body (shaft) of the tibia (medial, lateral & posterior surfaces). 8. Medial malleolus (inferior and medial). 9. Distal articular surface (for the talus) **Fibula: 1. Head (superior end. oval or round articular facet and styloid process.). 2. Neck. 3. Body (medial, lateral & posterior surfaces). 4. Lateral malleolus (distal end is spear shaped). 5. Articular facet on lateral malleolus (triangular facet for talus, on the medial side of lateral malleolus). 6 Malleolar fossa (located behind the triangular articular facet for talus which is found on its left for the left fibula, and on the right for the right fibula).

intercondylar eminence of tibia

Elbow joint movements

*Elbow Joint Movements: Flexion - "Could you flex your arm for me?" Extension - "Could you relax your arms please?" *Radio-Ulnar Joints (proximal and distal) Movements: Pronation - "Could you have your palms face the floor?" Supination - "Could you have your palms face the ceiling please?"

Muscles involved in flexion and extension of wrist

*Flexion of wrist: 1. FCR - important 2. FCU- important3. Long flexors of the thumb & fingers 4. Palmaris longus *Extension of wrist 1. APL 2. ECRL - important 3. ECRB - important 4. ECU - important 5. Long extensors of the thumb & fingers Abbreviations : (FCR-flexor carpi radialis; FCU-flexor carpi ulnaris; APL-abductor pollicis longus; ECRL-extensor carpi radialis longus; ECRBextensor carpi radialis brevis; ECU-extensor carpi ulnaris)

What view is this?

*Important bony features •Greater trochanter of femur •Proximal head of fibula •lateral and medial malleoli at ankle •Sesamoid bones at the 1st MPJ •General organisation of the foot arches *View: axial view from bottom. Note that kneecap i.e. patella is a separate bone to the femur

Shoulder joint movements

*Movements: ØAbduction - Lateral raise - "Could you raise your arms to your side please?" ØAdduction - Lateral drop - "Could you put your arms by your side please?" ØFlexion - Forward raise - "Could you put your arms in front of you please?" ØExtension - Forward drop - "Could you bring your arms to your back?" ØCircumduction - Conical movement - "Could you draw a circle with your elbow straight?" ØPut hand on shoulder to stop incorrect thoraco-scapular movement

Proximal and distal row of carpal bones

*Proximal row of carpal bones: 1) Scaphoid (boat -Greek) 2) Lunate (moon - Latin) 3) Triquetrum (three cornered -L) 4) Pisiform (pea) *Distal row of carpal bones : 5) Trapezium 6) Trapezoid (wedge shaped) 7) Capitate (head ) 8) Hamate (hook)

Radial Collateral Ligament

*There are 3 ligaments which stabilise the elbow joint: 1) Radial collateral ligament (lateral) 2) Ulnar collateral ligament (medial) 3) Annular ligament (Strictly part of the proximal radio-ulnar joint)

Ulnar Collateral Ligament:

What 3 ligaments which stabilise the elbow joint?

Cross-sectional view of compartments in the thigh and leg

*Thigh: o anterior quadriceps o adductors are medial muscles o hamstrings *Leg: o anterior, middle and posterior compartments o soleus and gastrocnemius are big leg muscles

Triceps attachments

*Triceps Brachii Attachments: a) Long head - originates from the infraglenoid tubercle. b) Lateral head - originates from the humerus, superior to the radial groove. c) Medial head - originates from the humerus, inferior to the radial groove. *Distally, the heads converge onto one tendon and insertinto the olecranon of the ulna.

Wrist joint movements

*Wrist Joint Movements (from anatomical position): Flexion - "Could you bend your wrist upwards?" Extension - "Could you bend your wrist downwards?" Radial Deviation - "Could you bend your wrist sideways away from you?" Ulnar Deviation - "Could you bend your wrist sideways towards you?"

What does proximal wrist crease present?

*or middle wrist crease is present - marks position of wrist (radio-carpal) joint line.

Fascia of the elbow, forearm and wrist

*palmaris longus is small muscle and has long tendon that goes over wrist region and there's a palmar aponeurosis that covers the underlying tendons, vessels, nerves. * flexor retinaculum - band of connective tissue found at/near joints that binds tendons, so when flex and extend don't get bowing. covers median nerve and other structures. *palmaris longus not always present, but will still get aponeurosis, not simply an extension of the tendon. * can test if have tendon: opposing thumb and pinky and flexing wrist and tendon should pop out if have it.

Peripheral nerve injury: Lesion of Common Peroneal Nerve at Fibular Neck

*susceptible as it winds round fibula. ØMotor - foot drop (supplied by lateral and anterior muscles of leg which do eversion and dorsiflexion respectively). get a high stepping gait to avoid catching foot as walk; or get swinging gait. overtime can get devices (spring) to help dorsiflex flex. ØSensory - dorsum of foot at least ØReflex - none ØAutonomic - minimal

Dorsum and plantar aspect of foot

*tarsals, metatarsals and phalanges. ** hallicus (refers to toe) **of tarsal bones: talus articulates with leg bones. also have navicular, cuboid and three cuneiforms. Together they form transverse joint (--> flexibility of foot). ** toe has two phalanges, rest have three. **beneath the talus is calcaneus (heel bone but also forms substantial part of proximal foot). where calcaneal tendon (achilles tendon) attaches. **sesamoid bones - will see in X-rays, where bones formed within muscle or tendon, important in tip toeing and prevent crushing tendon that runs through them to distal phalynx.

The anatomical snuff box borders

- APL, EPB anteriorly and EPL posteriorly -(contents: scaphoid and radial artery)

Nerves of pectoral girdle

- the Brachial Plexus. Largest nerves of brachial plexus: 1.Axillary nerve (C5 and C6) 2.Musculocutaneous nerve (C5, 6 and 7) 3.Ulnar nerve (C8 and T1) 4.Median nerve (C6, 7,8, and T1) 5.Radial nerve (C5, 6, 7, 8, and T1) **plexus: spinal nerves mingling, forming mixed peripheral nerves containing nerves from more that one spinal root. o The brachial plexus is the plexus of the nerves that serves the upper limb. It is formed from the anterior primary rami of C5-T1 spinal nerves.

What is Allen's test?

-A visual test for relative contribution of radial & ulnar arteries to the hand Subject is asked to raise the hand and make a clenched fist. Examiner compresses both radial and ulnar arteries. When the fist is released the palmar skin appears pale. The examiner releases either one of the arteries and notes the ulnar artery is dominant in hand. but use radial artery for cannulation. § Used to test the competence of ulnar artery § Included here to better understand anastomoses § Normally, either artery should adequately fill palm § Inadequate filling by ulnar (smaller) artery indicates it is incompetent ***Clinical relevance - when using artery as a graft for a bypass, test to see if perfuses hand. ulnar artery is dominant (80%) to radial (20%).

Infraclavicular Branches of the Brachial Plexus (Not including the terminal branches of the cords or Cut. Ns)

-medial pectoral nerve (Pec. minor, clavicular and sternal heads pec. major)). - lateral pectoral nerve (Clavicular head pec. major). - upper subscapular nerve (subscapularis). - lower subscapular nerve (lower subscapularis, teres major, branches from posterior cord). - thoracodorsal (latissimus dorsi)

Intrinsic muscles of the hand compartments

-thenar compartment -adductor compartment -hypothenar compartment -interossei and lumbricals

Claw-like hand in ulnar and median nerve lesion

. Claw-like hand: Clawing is hyperextension at MCP joints and flexion at IP joints. ** Clawing of the fingers due to a lesion in ULNAR nerve is better demonstrated when the subject is asked to straighten all the fingers. The IP joints of little and ring fingers cannot straighten completely like the other three fingers which gives a claw-like hand. It is worth remembering that in a lesion of this nerve, if the subject attempts to make a fist, the little and ring fingers cannot flex completely (to form a tight fist) while the other three fingers form a tight fist. This gives a claw-like hand. **Clawing of fingers due to a MEDIAN nerve lesion is better demonstrated when the subject is asked to form a tight fist with all fingers. This results in partially extended index and middle fingers ("hand of Benediction"). Here, MCP joints of index & middle fingers are hyperextended (1st & 2nd lumbricals) and loss of flexion in the proximal IP joints (flexor digitorum superficialis) and in the distal IP joints (FDP). Also the loss of thenar muscles function the thumb cannot oppose. ((Ulnar paradox: Clawing is more pronounced with an ulnar nerve lesion near the wrist than a lesion at or near the elbow. In a lesion near the wrist, the ulnar supply to the FDP is intact which causes more flexion of the IP joints which results in increased clawing.))

How to see head of ulna

. The head of ulna on the dorsum of the wrist (flex the wrist to see) *The radial styloid and scaphoid in the anatomical snuff box.

Lumbricals Netters

1) 1st and 2nd lumbrical muscles 2) lumbrical muscles 3 and 4 3) flexor digitorum profundus tendons 4) flexor digitorum superficialis tendons (cut) 5) flexor digitorum profundus tendons 6) scaphoid bone 7) lunate bone 8) triquetrum bone 9) pisiform bone § Origin (proximal): Lumbrical muscles 1 and 2 arise from the 2 lateral tendons of the flexor digitorum profundus. Lumbrical muscles 3 and 4 arise from the 3 medial tendons of the flexor digitorum profundus. § Insertion (distal): Attach to the lateral sides of the extensor expansions of digits 2 through 5 (index finger to little finger). § Action: Flex the metacarpophalangeal joints and extend the interphalangeal joints. § Innervation: Lumbricals 1 and 2 are innervated by the median nerve (C8 and T1). Lumbricals 3 and 4 are innervated by a deep branch of the ulnar nerve (C8 and T1). § Comment: Because of the way the lumbricals pass by the proximal interphalangeal joint, they prevent the extensor digitorum from hyperextending the joint.The lumbrical muscles may exhibit considerable variation in their attachments. § Clinical: The lumbricals can be tested clinically by having the patient flex the 4 medial metacarpophalangeal joints against resistance while keeping the interphalangeal joints extended.

Thenar and Hypothenar Innervation

1) 3 Thenar Muscles: Abductor pollicis brevis Flexor pollicis brevis Opponens pollicis Innervated by MEDIAN Nerve (recurrent branch*) 2) 3 Hypothenar Muscles: Abductor digiti minimi Flexor digiti minimi Opponens digiti minimi Innervated by ULNAR Nerve (deep branch*)

Label the pelvic bones (JAS)

1) ASIS (anterior superior iliac spine) 2) AIIS (anterior inferior iliac spine) 3) linea terminalis 4) pubic tubercle 5) articular surface for pubic symphysis 6) Obturator foramen 7) ischial tuberosity 8) lesser sciatic notch 9) greater sciatic notch 10) greater sciatic notch 11) ischial spine 12) lesser sciatic notch 13) ischial tuberosity 14) obturator membrane 15) obturator canal 16) pubic tubercle 17) acetabulum 18) AIIS 19) ASIS

Movements of the Thumb

1) Abduction: -APL, APB 2) Adduction: -Adductor pollicis, first dorsal interosseous 3) Extension: -EPL, EPB, APL 4) Flexion: -FPL, FPB 5) Opposition: -Opponens pollicis

Muscles responsible for thumb movements

1) Abduction: -APL, APB 2) Adduction: -Adductor pollicis, first dorsal interosseous 3) Extension: -EPL, EPB, APL 4) Flexion: -FPL, FPB 5) Opposition: -Opponens pollicis (underneath abductor pollicis brevis) *palmaris brevis present too.

Ligaments and Tendons of Ankle: Lateral View Netters

1) Anterior and posterior tibiofibular ligaments 2) superior fibular (peroneal) retinaculum 3) inferior fibular (peroneal) retinaculum 4) fibular (peroneus) brevis tendon 5) bifurcate ligament (calcaneonavicular ligament; calcaneocuboid ligament) 6) components of lateral (collateral) ligament of ankle (posterior talofibular ligament; calcaneofibular ligament; anterior talofibular ligament) § Comment: The ankle (talocrural) joint is a hinge-type (ginglymus) uniaxial synovial joint between the tibia and fibula and the trochlea of the talus. This joint permits dorsiflexion (extension) and plantarflexion. Its thin, fibrous capsule is reinforced by the medial (deltoid) ligament, which has 4 parts, and the lateral collateral ligament, which has 3 parts.Of the tarsal joints, the talocalcaneal (subtalar) joint is a plane synovial joint between the talus and calcaneus. It permits inversion and eversion of the foot.The talocalcaneonavicular joint is a partial ball-and-socket synovial joint between the head of the talus and the calcaneus and navicular bones (along with the calcaneocuboid joint, it forms the transverse tarsal joint). It is supported by the spring ligament and is important in gliding and rotational movements of the foot. § Clinical: The lateral collateral ligament is weak and often is sprained. It resists inversion of the foot. One or more of its parts may tear in the common inversion ankle injury; when this happens, the ligaments usually tear from anterior to posterior, with the anterior talofibular ligament being torn first.

Knee: Cruciate and Collateral Ligaments Netters

1) Anterior cruciate ligament 2) popliteus tendon 3) (lateral) fibular collateral ligament 4) lateral meniscus 5) transverse ligament of knee 6) (medial) tibial collateral ligament 7) lateral meniscus 8) Anterior cruciate ligament 9) Posterior cruciate ligament 10) Posterior cruciate ligament § Comment: The knee is the largest and most complicated joint in the body. It is a biaxial condylar synovial joint between the condyles of the femur and tibia. It also includes a saddle joint between the femur and patella.The knee participates in flexion and extension. When flexed, it also participates in some gliding and rotation movements. When the knee extends fully, the femur rotates slightly and medially on the tibia, pulling each of the ligaments taut and stabilizing the joint.The menisci, the cruciate ligaments, and the transverse ligament are intracapsular ligaments. The transverse ligament binds and stabilizes the menisci.Most of the blood supply to the knee is from genicular branches of the popliteal artery. § Clinical: The posterior cruciate ligament is shorter and stronger than the anterior cruciate; consequently, it is not torn nearly as often as the anterior cruciate ligament.

Vertebral Ligaments: Lumbar Region Netters

1) Anterior longitudinal ligament 2) intervertebral disc 3) posterior longitudinal ligament 4) pedicle (cut surface) 5) ligamentum flavum 6) supraspinous ligament 7) interspinous ligament 8) ligamentum flavum 9) capsule of zygapophysial joint (partially opened) § Comment: Intervertebral discs form secondary cartilaginous joints (symphyses) between the bodies of adjacent vertebrae. They are secured by the anterior and posterior longitudinal ligaments. There is no intervertebral disc between the atlas and axis.Ligaments of the vertebral column include the anterior and posterior longitudinal ligaments. The former run along the anterior surfaces of the vertebral bodies. The latter run along the posterior surfaces. The ligamentum flavum connects adjacent laminae and limits flexion. Supraspinous ligaments (which limit flexion) and interspinous ligaments (which are weak ligaments) run between adjacent spinous processes.The anterior longitudinal ligaments limit extension of the vertebral column; the posterior longitudinal ligaments limit flexion. The anterior longitudinal ligament is stronger than the posterior longitudinal ligament. The ligamenta flava help support an upright posture. § Clinical: Excessive flexion, especially extension, of the vertebral column can place the longitudinally running ligaments at risk for tearing when they are stretched.

Proximal Tibia - Shaft features

1) Anterior: a) Tibial Tuberosity Patellar Ligament. b) Pes Anserinus Sartoris, Gracilis, Semitendinosus. 2) Posterior: Soleal Line **Pes anserinus ("goose foot") refers to the conjoined tendons of three muscles that insert onto the anteromedial (front and inside) surface of the proximal extremity of the tibia. The muscles are the sartorius, gracilis and semitendinosus sometimes referred to as the guy ropes.

Vertebral Column Netters

1) Atlas (C1) 2) T1 3) L1 4) Coccyx 5) sacrum (S1-S5) 6) Lumbar vertebrae 7) Thoracic vertebrae 8) Cervical vertebrae 9) axis C2 § Comment: Typically, the vertebral column comprises 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused), and 4 coccygeal (last 3 fused) vertebrae.Primary curvatures of the vertebral column include the thoracic curvature and sacral curvature. Secondary curvatures include the cervical curvature and lumbar curvature. Secondary curvatures develop during infancy as children begin to bear the weight of the head, sit up, stand, and support their own weight.The cervical and lumbar spine allow for greater movement than the other regions of the vertebral column.Note from the illustration that intervertebral discs separate individual bodies of adjacent vertebrae (except the first 2 cervical vertebrae, called the atlas and axis, and the fused vertebrae of the sacrum and coccyx). § Clinical: An accentuated lateral and rotational curvature of the thoracic or lumbar spine is called scoliosis. An accentuated flexion of the thoracic spine is kyphosis (hunchback), and an accentuated extension of the lumbar spine is lordosis (swayback).

biceps femoris muscle Netters

1) Biceps femoris muscle (short head) 2) Biceps femoris ( long head) 3) quadratus femoris muscle 4) piriformis muscle § Origin (proximal): The long head of the biceps femoris muscle arises from the ischial tuberosity. The short head of the biceps femoris muscle arises from the linea aspera and lateral supracondylar line of the femur. § Insertion (distal): The 2 heads of the biceps femoris muscle unite, and their common tendon inserts on the lateral side of the head of the fibula. Just before this attachment, the tendon is split by the fibular collateral ligament of the knee. § Action: The biceps femoris flexes the leg at the knee, and, after the knee is flexed, the muscle rotates the tibia laterally from the femur. The long head (but not the short head) also extends the thigh at the hip. § Innervation: The long head is innervated by the sciatic nerve, tibial division (L5, S1, and S2). The short head is innervated by the sciatic nerve, common fibular (peroneal) division (L5, S1, and S2). § Comment: The long head of the biceps femoris is 1 of the 3 muscles making up the hamstrings. Similar to the other 2 hamstring muscles, the long head of the biceps femoris extends the thigh at the hip and flexes the leg at the knee. The long head also laterally rotates the leg at the knee.The short head of the biceps femoris does not cross 2 joints and is not innervated by the tibial division of the sciatic nerve. § Clinical: The hamstrings are collectively tested by having the supine patient flex the limb 90° at the hip and knee and then further flex the knee against resistance.

The Carpal Tunnel attachments, and contents

1) Bony attachments -Scaphoid, trapezoid, pisiform, hamate -Form a gutter 2) Roof is the flexor retinaculum (aka transverse carpal ligament) 3) Contains a) Median nerve b) FPL tendon c) 4 tendons of FDP d) 4 tendons of FDS **o The carpal tunnel gives passage for the median nerve, the tendon of flexor pollicis longus, the four tendons of flexor digitorum profundus and the four tendons of flexor digitorum superficialis from the forearm into the hand. o Its base is formed by the bony arch of the carpal bones, the palpable bony margins of the carpal tunnel are, laterally the scaphoid and trapezoid bones, and medially the pisiform and hamate bones. The roof of the carpal tunnel is formed by the flexor retinaculum. o Carpal tunnel syndrome results from compression of the median nerve in the carpal tunnel, resulting in tingling, loss of sensation and pain in the hand.

Knee joint ligaments and muscles

1) Briefly review the distal attachments of the thigh muscles that act across the knee: a) quadriceps - attach across patella to form patellar tendon b) gracilis - medial shaft of tibia c) hamstrings - semimembranosus and semitendinosus attachments at the superior MEDIAL EPICONDYLAR region of the TIBIA. long head of biceps femoris runs laterally to be joined by fibres arising from the inferior linea aspera and supracondylar ridge of the femur (the short head) forming a common tendon that crosses the knee joint to insert into the HEAD OF FIBULA 2) Examine and compare the lateral (fibular) and medial (tibial) collateral ligaments, and also the anterior and posterior cruciate ligaments in the intercondylar region. 3) Compare the articular surfaces of the femoral and tibial condyles, in particular, examine the lateral and medial menisci (the Cshaped cartilages of the tibial plateau). 4) Examine popliteus muscle whose tendon attaches to the lateral femoral condylar surface, passes within the capsule of the knee joint, and its fibres fanning out to attach to the posterior surface of the proximal tibia; this is the "unlocking" muscle. **Note how the patella articulates with the intercondylar and distal anterior region of the femur

Spinal Cord and Ventral Rami in Situ Netters

1) C1 spinal nerve 2) conus medullaris 3) cauda equina 4) filum terminale internum 5) sacral plexus 6) lumbar plexus 7) brachial plexus 8) cervical plexus § Comment: The spinal cord is the inferior extension of the brainstem; the cord and the brain make up the central nervous system. Thirty-one pairs of spinal nerves (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal) course from the spinal cord.The spinal cord, similar to the brain, is surrounded by 3 meningeal layers. The innermost layer is the pia mater, which is closely applied to the spinal cord. The middle layer is the arachnoid mater. The tough, outer fibrous meningeal layer is the dura mater.Posterior and anterior roots of the lumbar and sacral spinal nerves form the cauda equina (horse's tail).The terminal filum is an extension of pia mater from the tip (conus medullaris) of the spinal cord. It blends with dura at the apex of the dural sac and attaches to the dorsum of the coccyx. It helps anchor the distal spinal cord. § Clinical: A spinal needle may be used to sample the cerebrospinal fluid in the subarachnoid space, and this procedure is done in the lower lumbar region where the needle will not penetrate the spinal cord (the cord ends at about the L1 vertebral level in adults). The roots of the cauda equina, bathed and floating in cerebrospinal fluid, will part and allow the needle to enter the subarachnoid space without puncturing a root.

1.Which spinal levels supply the musculocutaneous nerve? (1) 2.Which nerve supplies the following muscles? (5) a.Deltoid b.Triceps Brachii c.Biceps Brachii d.Flexor Carpi Ulnaris e.Pectoralis minor 3.Which spinal levels contribute to the brachial plexus? (1) 4.Which cord supplies the following? (3) a.Radial nerve b.Musculocutaneous nerve c.Ulnar nerve

1) C5- 7 2) a.Deltoid - axillary b.Triceps Brachii - radial c.Biceps Brachii - musculocutaneous d.Flexor Carpi Ulnaris - ulnar e.Pectoralis minor - medial pectoral nerve 3) C5- T1 4) a.Radial nerve - posterior b.Musculocutaneous nerve - lateral c.Ulnar nerve - medial

Bone Mechanical Properties

1) Cable-like flexibility and resistance to tension because framework is collagen + other bone proteins (= osteoid). 2) Pillar-like stiffness and resistance to compression conferred by impregnation of collagen with crystalline mineral (hydroxyapatite - a complex calcium hydroxyphosphate)

2 UL fractures to know about

1) Colles' fracture: Fall onto outstretched arm with wrist extended Distal radial fracture with dorsal displacement of the distal radial fragment Dinner fork deformity Opposite of Smith's fracture* 2) Scaphoid bone fracture: Scaphoid bone supplied by radial artery branches alone in 10% of patients Fracture in proximal 1/3 leads to avascular necrosis of proximal fragment Blood supply runs from distalàproximal X-ray changes very late!* MRI better Any snuff box tenderness, put a case for 10 days and redo x-ray*

Deltoid Muscle Netters

1) Deltoid muscle **Origin (proximal): Arises from the lateral third of the clavicle, the superior surface of the acromion, and the spine of the scapula. **Insertion (distal): The fibers converge in a thick tendon that is attached to the deltoid tuberosity on the lateral aspect of the shaft of the humerus. **Action: The principal function is abduction of the arm at the shoulder in a movement initiated together with the supraspinatus muscle. The clavicular portion of the muscle rotates the arm medially and helps the pectoralis major flex the arm at the shoulder. The spinous portion rotates the arm laterally and helps the latissimus dorsi extend the arm at the shoulder. **Innervation: Axillary nerve (C5 and C6). **Comment: The deltoid is a thick, triangular muscle with coarse fibers. It covers the shoulder joint anteriorly, posteriorly, and laterally. The multipennate central portion of the muscle is most active in abduction.The blood supply is largely via the thoracoacromial artery and also via the anterior and posterior humeral circumflex arteries, which arise from the axillary artery. **Clinical: To test the deltoid muscle strength and the integrity of the axillary nerve, have the patient abduct the upper limb against resistance (the middle fibers of the muscle should be seen to contract). The posterior fibers can be seen to contract if the patient tries to retract the abducted upper limb against resistance.

Joints of wrist and hand

1) Distal radio-ulnar joint 2) Wrist joint 3) Intercarpal joints 4) Carpo-metacarpal and inter-metacarpal joints 5) Metacarpo-phalangeal joints 6) Interphalangeal joints

Erector spinae muscles Netters

1) Erector spinae muscles § Origin (Inferior Attachment): The erector spinae muscle comprises the iliocostalis, longissimus, and spinalis muscles. They arise by a broad tendon (deep to the thoracolumbar fascia) from the posterior aspect of the iliac crest, the posterior aspect of the sacrum, the sacral and inferior lumbar spinous processes, and the supraspinous ligament. § Insertion (Superior Attachment): The iliocostalis muscles attach to the angles of lower ribs and the cervical transverse processes.The longissimus muscles attach to the ribs between the tubercles and angles, to the transverse processes in the thoracic and cervical vertebral regions, and to the mastoid process of the temporal bone.The spinalis muscles attach to the spinous processes in the upper thoracic region and midcervical region and to the skull. § Action: Together, these muscles extend the vertebral column and head. Unilaterally, they bend the vertebral column laterally. Specifically, the erector spinae are powerful extensors of the thoracic and lumbar spine. Their action on the cervical spine is weak and overshadowed by the actions of the semispinalis and splenius muscles. Innervation: Posterior rami of the respective spinal nerves in each region. § Comment: Because of their locations, the iliocostalis muscles are classified into lumborum, thoracis, and cervicis groups; the longissimus muscles into thoracis, cervicis, and capitis groups; and the spinalis muscles into thoracis, cervicis, and capitis groups. § Clinical: These strong extensors of the spine can come under extreme stress when one is lifting heavy objects, especially when one lifts with the back instead of keeping the spine straight and lifting with the powerful leg muscles.

Muscles moving the Hip Joint

1) Hip Flexors: i.Ilio-psoas ii.Sartorius iii.Tensor fascia lata iv.Rectus femoris v.Adductor longus vi.Adductor brevis vii.Adductor portion of adductor magnus viii.gracilis 2) Hip Adductors: i.Adductor longus ii.Adductor brevis iii.Adductor magnus iv.Gracilis v.Pectineus vi.Obturator externus 3) Hip Extensors: i. The hamstrings - semimembranosus, semitendinosus, biceps femoris ii.Posterior part of adductor magnus iii.Gluteus maximus 4) Hip Abductors: i.Gluteus medius ii.Gluteus minimus iii.Tensor fascia lata 5) Hip External Rotators: i. Obturator internus and obturator externus ii.The Gemelli iii.Piriformis iv.Quadratus femoris v.Gluteus maximus 6) Hip Internal Rotators: i.Anterior portion of gluteus medius ii.Anterior portion of gluteus minimus iii.Tensor fascia lata

Extensor carpi radialis brevis muscle Netters

1) Extensor carpi radialis brevis muscle 2) tendon of extensor carpi radialis brevis muscle § Origin (proximal): Extensor carpi radialis brevis muscle arises from lateral epicondyle of the humerus. § Insertion (distal): Extensor carpi radialis brevis muscle inserts on the base of the 3rd metacarpal bone. § Action: Extends and abducts the hand at the wrist joint. § Innervation: Radial nerve (deep branch) (C7 and C8). § Comment: The extensor carpi radialis brevis muscle is shorter and thicker than the extensor carpi radialis longus, which partially covers it. Occasionally, both muscles form a single belly that gives rise to 2 tendons. This muscle is important for a power grip (a power grip requires wrist extension). § Clinical: The extensor carpi radialis brevis muscle acts with the extensor carpi radialis longus and is tested clinically along with that muscle. The patient is asked to extend and abduct the hand at the wrist against resistance. This action not only tests these 2 muscles but also tests the integrity of the radial nerve (its deep branch).

Extensor digitorum muscle Netters

1) Extensor digitorum muscle 2) abductor pollicis longus muscle 3) extensor pollicis brevis muscle 4) extensor pollicis longus tendon § Origin (proximal): Extensor digitorum muscle arises from lateral epicondyle of the humerus. § Insertion (distal): Extensor digitorum muscles insert as extensor expansions of the medial 4 digits (index finger to little finger). § Action: Extensor digitorum muscle performs extension at the metacarpophalangeal and interphalangeal joints. This muscle also participates in wrist extension when the fingers are extended. § Innervation: Radial nerve (posterior interosseous branch) (C7 and C8). § Comment: The tendons of the extensor digitorum pass through the extensor retinaculum and to the extensor expansions of the medial 4 digits. Occasionally, this muscle has only 3 tendons instead of 4. Often, the extensor digiti minimi is attached to the extensor digitorum. § Clinical: The extensor digitorum muscle is tested clinically by having the patient extend the fingers against resistance. This is best done as one supports the patient's pronated hand with one hand and provides resistance to the fingers across the metacarpophalangeal joints with the other hand. The contracting muscle belly will bulge out along the lateral forearm (little finger side in the pronated position).

Testing movement of teres minor/infraspinitus

1) Flexion: a) clavicular head of pectoralis major b) anterior fibres of deltoid c) coracobrachialis d) biceps 2) Extension: a) latissimus dorsi 3) Abduction: a) supraspinatus (first 15 degrees) b) central fibres of deltoid (after 15 degrees) 4) Adduction: a) pectoralis major b) latissimus dorsi 5) Internal rotation: a) subscapularis 6) External rotation: a) infraspinatus b) teres minor

Flexor digitorum profundus Netters

1) Flexor digitorum profundus muscle 2) Tendons of flexor digitorum superficialis 3) Tendons of flexor digitorum profundus § Origin (proximal): Flexor digitorum profundus muscle arises from the proximal three-fourths of the medial and anterior aspects of the ulna and from the interosseous membrane. § Insertion (distal): Four tendons of the flexor digitorum profundus attach to the bases of the distal phalanges of the medial 4 digits (index finger to little finger). § Action: The primary action of the flexor digitorum profundus muscle is flexion of the distal interphalangeal joints. The muscle also produces some flexion at the proximal interphalangeal joints, the metacarpophalangeal joints, and the wrist because its tendons cross those joints. § Innervation: Proximal to the wrist, the flexor digitorum profundus muscle divides into 2 parts. The medial part is innervated by the ulnar nerve (C8 and T1). The lateral portion of the muscle is innervated by the anterior interosseous branch of the median nerve (C8 and T1). § Comment: The tendons of the flexor digitorum profundus, similar to those of the superficialis, cross the carpal canal and the palm of the hand. The 4 tendons pass through the slits of the superficialis tendons before attaching to the distal phalanges. § Clinical: The flexor digitorum profundus muscle is tested clinically by having the patient flex the distal interphalangeal joint against resistance as one places the thumb and index finger on the proximal interphalangeal joint of the tested finger to keep it in extension and then holds the tip of the finger to provide resistance to flexion of the distal interphalangeal joint.

Shoulder Pathology

1) Frozen Shoulder: "Adhesive capsulitis" Seen in trauma Chronic pain and cramps, worse on moving NSAIDs and steroids can help* Physiotherapy or manipulation under anaesthetic can help break up the adhesions* Surgery only if very severe* 2) Shoulder Impingement: Tendons of rotator cuff become inflamed as they pass under the acromion Weakness, pain and reduced movement Can be due to trauma or age-related degeneration (tendinopathy) Hawkins-Kennedy test* Treatment* Conservative (PT and pain relief) Steroid or local anaesthetic injection Surgery if severe

Muscular Anatomy of the hips buttock and thigh

1) Gluteal compartment: a) Gluteal muscles - superficial i.Gluteus maximus ii.Gluteus medius iii.Gluteus minimus iv.(Tensor fasciae latae) b) Short external (lateral) rotators of the hip - deep: i.Piriformis ii.Obturator internus iii.The gemelli (sup. and inf.) iv.Quadratus femoris 2) Anterior compartment of the thigh: **Hip Flexors and Knee Extensors: •Pectineus •Ilio-psoas (from pelvis) •(Tensor fasciae latae) •Sartorius •Quadriceps femoris ( 4 heads): a) Rectus femoris (straight) b) Vastus medialis c) Vastus intermedius d) Vastus lateralis 3) Medial compartment of the thigh: Hip ADductors: •Adductor longus •Adductor brevis •Adductor magnus •Gracilis •Obturator externus 4) Posterior compartment of the thigh: **Knee Flexors and Hip Extensors "The Hamstrings": •Semimembranosus •Semitendinosus •Biceps femoris

Origin of small and long saphenous veins

1) Great Saphenous Veins: § Origin Medial Side of Dorsal Venous Arch. § Ascent Anterior to Medial Malleolus; Medial side of leg, knee and thigh. § Drainage into Femoral vein inferior to inguinal ligament Sapheno-femoral junction 2) Small Saphenous Veins: § Origin Lateral Side of Dorsal Venous Arch. § Ascent Posterior to lateral malleolus; Posterior surface of leg. § Drainage into Penetrates deep fascia --> Popliteal Vein; Popliteal vein proximal to knee become femoral vein

Segmental motor supply to the lower limb (hip, knee, ankle)

1) HIP: a) Flex - L2L3 b) Extend - L4L5 2) KNEE: a) Extend - L3L4 b) Flex - L5S1 3) ANKLE: a) Dorsiflex (ext) - L4L5 b) Plantarflex (flex) -S1S2 4) BIG TOE: Dorsi-flexion: L5, S1 Plantar flexion: S1,S2 (notice exception to rule: starts at S1 not S2).

Quadriceps Femoris attachments

1) Rectus femoris: § Proximal AIIS. § Distal Quadriceps femoris tendon. § Function Hip flexion and knee extension. 2) Vastus medialis, intermedius and lateralis: § Proximal Medial, anterior and lateral femoral shaft respectively; lateralis has other proximal attachments*. § Distal Quadriceps femoris tendon. § Function Knee extension.

Hip Joint: Anterior and Posterior Views Netters

1) Iliofemoral ligament (Y ligament of bigelow) 2) iliopectineal bursa 3) pubofemoral ligament 4) Iliofemoral ligament 5) ischiofemoral ligament 6) ischial spine 7) ischial tuberosity 8) lesser trochanter of femur § Comment: The hip joint is a multiaxial ball-and-socket synovial joint between the acetabulum and the head of the femur. The acetabular labrum deepens the acetabular cavity even farther, and the fibrous joint capsule is reinforced by 3 ligaments.The iliofemoral ligament is the most important ligament reinforcing the hip joint. This ligament forms an inverted Y ligament (of Bigelow) that limits hyperextension and lateral rotation. The pubofemoral ligament limits extension and abduction, whereas the ischiofemoral ligament limits extension and medial rotation. If one notices where these ligaments attach, one can understand how they limit movement in a certain direction.The hip participates in abduction and adduction, flexion and extension, and rotation and circumduction. § Clinical: The iliofemoral ligament is the strongest of the hip ligaments, and the ischiofemoral is the weakest of the 3 ligaments.

What movement occurs at intercarpal Joints

1) Joints between the proximal row -scaphoid, lunate, triquetral, pisiform 2) Joints between the distal row -trapezium, trapezoid, capitate, hamate 3) Joints between the proximal and distal rows -the midcarpal joint **"gliding occurs at these joints"

Ligaments, menisci, bursae and extensor mechanism in knee joint

1) Ligaments: a. Anterior cruciate ligament b. Posterior cruciate ligament c. Medial collateral ligament d. Lateral collateral ligament 2) Meniscsi:(cartilaginous C-shapes on surface of condyles of tibia) a. Medial meniscus b. Lateral meniscus 3) Extensor mechanism: a. Quadriceps b. Quadriceps tendon c. Patella (isn't part of knee joint; has articulation in supracondylar region of femur but doesn't articulate with tibia). d. Patellar ligament e Tibial tuberosity 4) Bursae (synovial sac - prevent friction between tendons and muscles): a. Pre-patellar bursa b. Pre-patellar tendon bursa c. Popliteal bursa (Baker's cyst)

Surface mark the following veins: •Long saphenous vein •Short saphenous vein with respect to the malleoli

1) Long Saphenous Vein: Anterior to medial malleolus of ankle Medial side of leg Posterior border of medial epicondyle of femur Into femoral vein at femoral triangle Clinically important: vein cut down (IV access)* 2) Short Saphenous Vein: Posterior to lateral malleolus of ankle Runs up posterior leg Drains into popliteal vein in popliteal fossa (knee)

What is mallet finger?

1) Mallet Finger: oExtensor tendon at finger tip is stretched/torn > unable to straighten finger tip. Avulsion of extensor digitorum longus tendon at the base of distal phalanx 2) Trigger Finger (Stenosing Tenosynovitis): oInflammation of tendon or tenosynovium > formation of nodules oDifficult for tendons to move through pulleys 3) Skier's thumb (acute) /Gamekeeper's thumb (chronic): o UCL torn or stretched causing an instability of the MCP joint. o UCL usually helps in grasping + pinching- helps maintain thumb strength

Stabilisation of the Ankle

1) Medial (deltoid) ligament: 4 components: a) Tibiocalcaneal b) Tibionavicular c) Anterior tibiotalar d) Posterior tibiotalar 2) Lateral ligament: 3 components a)Anterior talofibular b)Posterior talofibular c)Calcaneofibular

Hip (Coxal) Bone: Lateral View Netters

1) PSIS (posterior superior iliac spine) 2) PIIS (posterior inferior iliac spine) 3) greater sciatic notch 4) body of ilium 5) body of ischium 6) ischial tuberosity 7) pubic tubercle 8) acetabulum 9) iliac crest § Comment: The hip bone consists of 3 bones: the ilium, ischium, and pubis. Before puberty, these bones are joined by cartilage, but they begin to fuse by midadolescence and are completely fused in adulthood. All 3 fused bones contribute to the acetabulum, the cup-like cavity for articulation of the head of the femur.The fused hip bone articulates with the femur (thigh bone) and with the vertebral column (spine). Specifically, the ilium articulates with the sacrum in a plane synovial joint that allows for little movement, in contrast to the shoulder joint, and provides great stability. This stability is important for standing, walking, and running on 2 legs (bipedalism).The acetabulum forms a C-shaped articular area that is lined with hyaline cartilage. The cartilage has a labrum, or lip, of fibrocartilage around its edge that deepens the hip socket. § Clinical: Bruising over the iliac crest, often from an athletic injury or direct trauma, is commonly referred to as a hip pointer.

Fascia of the Palm

1) Palmar fascia - dense 2) Palmar aponeurosis - said to be extension of palmaris longus tendon; but even if palmaris longus is absent, aponeurosis still present. -overlies the long flexor tendons of the hand -proximally continuous with the flexor retinaculum -distally continuous with the fibrous digital sheaths 3) Fibrous digital sheaths -contain the flexor tendons and their synovial sheaths **skin of palm is thick skin/plantar-palmar skin and has no hair compared to rest of body. **underneath skin is fascia

Thoracic Spinal Nerve and Connections to Sympathetic Trunk Netters

1) Posterior root 2) spinal ganglion 3) sympathetic trunk 4) ganglion of sympathetic trunk 5) spinal nerve 6) white ramus communicantes 7) gray ramus communicantes 8) anterior root 9) splanchnic nerve 10) celiac ganglion 11) vagus nerve (CN X) 12) intermediolateral cell column 13) superior mesenteric ganglion 14) enteric nerve plexuses of gut § Comment: Afferent (sensory) nerve fibers (shown in black) return to the spinal cord via the splanchnic nerve (pain sensation from viscera) and via the spinal nerve. The cell bodies of these sensory nerve fibers reside in the spinal (dorsal root) ganglion.Preganglionic sympathetic efferent (motor) nerve fibers (shown in red) originate from neurons in the intermediolateral cell column of the thoracic spinal cord, leave the cord via the anterior root, and enter the sympathetic chain via a white ramus communicans. Here the nerve may continue via a splanchnic nerve to the celiac ganglion to synapse, pass up or down the sympathetic chain to synapse at a higher-level or lower-level chain ganglion, or synapse in the chain ganglion at the spinal cord level where it exited the cord.When the preganglionic fiber has synapsed on the postganglionic neuron (in a chain ganglion or the celiac ganglion), postganglionic fibers course to innervate viscera, smooth muscle, glands, or arrector pili muscles of the skin (attached to hair follicles).Parasympathetic efferent fibers in this schematic illustration course to the viscera via the vagus nerve. Reflex afferents from the viscera return to the brainstem also via the vagus nerve. Visceral afferents also convey pain from distention, inflammation, or ischemia and return to the spinal cord via the splanchnic nerve and posterior root (cell bodies in the spinal ganglion).

Vasculature of the Knee

1) Predominantly Descending and Genicular Branches of: a)Femoral b)Popliteal c)Lateral circumflex femoral artery d)Circumflex peroneal artery 2) Recurrent branch: a) Anterior tibial artery **ALL FORMS an Anastomotic Network

Summary of venous supply to lower limbs

1) SUPERFICIAL VEINS: § The superficial veins lie in the subcutaneous tissue, and have valves to prevent the backflow of blood. § The dorsal venous arch receives most of the blood from the foot. § The long saphenous vein starts as the continuation of the medial portion of the dorsal venous arch of the foot. It lies 2cm anterior and 2cm proximal to the medial malleolus. § The vein runs proximally along the medial aspect of the leg, passing behind the medial femoral condyle of the knee. As the long saphenous vein passes up the leg, there are a number of very important tributaries to the deep venous system. These tributaries are called perforating veins. Physiologically blood should flow from the superficial to deep system, and there are valves ensuring that there is no back-flow from the deep to superficial venous systems. If these valves do not exist or are incompetent, then blood can flow from the deep to superficial systems, resulting in varicose veins. The perforating veins as well as the main spahenous veins have valves. § The vein then runs along the medial thigh to merge with the femoral vein, passing through the cribriform fascia (the saphenous opening), 3cm below and lateral to the pubic tubercle. § The long saphenous vein has many valves, about 20, throughout its length, mostly below the knee although some are present above the knee. § At the saphenous opening a number of venous tributaries join the vein as it merges with the femoral vein. § The short saphenous vein drains the lateral aspect of the dorsal venous arch. It passes with the sural nerve at the back of the leg in the midline and passes into the popliteal vein at the popliteal fossa. It communicates at several levels with the long saphenous vein. § Note that the normal physiological blood flow is from the superficial to deep venous systems. 2) DEEP VEINS: § The deep veins lie within the deep fascia, and in general run alongside the arteries. The deep veins have valves to prevent backflow of blood. Usually two veins run alongside each artery. § The venae comintantes of the anterior and posterior tibial arteries and the popliteal artery form the popliteal vein. The deep veins are mainly within muscle, and the "muscle pump" contributes towards the venous return from the lower limb to the abdomen. § The popliteal vein also receives the short saphenous vein at the level of the popliteal fossa. § The popliteal vein passes into the popliteal fossa, at all times lying between the popliteal artery and the tibial nerve. § The femoral vein passes behind the femoral artery and lies medial to it at the level of the inguinal ligament. § Just proximal to the inguinal ligament it is joined by the profunda femoris vein(s) and then by the long saphenous vein. Once passed beneath the inguinal ligament it forms the external iliac vein

Proximal carpals

1) Scaphoid Most lateral Boat shaped Articulates with radius Has an anteriorly projecting tubercle 2) Lunate Crescent shaped, also articulates with radius 3) Triquetrum 3 sided bone 4) Pisiform Sesamoid bone existing in the tendon of the flexor carpi ulnaris

What are the two types of innervation? Rules of segmental innervation?

1) Segmental - The spinal roots where the motor neurones originate (ie. L2-4). a) muscles are supplied by two adjacent segments. b) Opposing muscles nerves (flex vs. extend) are 1-2 segments above or below each other. I.e. If knee extension is L3,4. Then, knee flexion will be L5,S1. c) Muscles more distal in the limb have nerves originating more caudal in the spine (closer to tail). 2) Peripheral - The nerve leaving the spine that actually synapses with the muscle (ie. obturator nerve) Example with vastus intermedius: § What does it do? Knee extension (quadriceps) § Which spinal roots do that? L3/L4 § Segmental supply = L3/L4 § Which nerve innervates it? Femoral § Peripheral = femoral nerve **Femoral nerve is formed by L2/3/4 --> So you might think L2 is in the segmental supply. BUT L2 is involved in hip flexion. Vastus intermedius is not involved in hip flexion. Hence L2 does not supply vastus intermedius. **Note: There are not two different nerves going to the muscle; SEGMENTAL and PERIPHERAL innervation is simply two ways of looking at the same thing.

Compartments of the Hand

1) Septa - medial and lateral •Septa ; from palmar aponeurosis to... a) medially : to little finger metacarpal b) laterally : to middle finger metacarpal 2) Hypothenar compartment (little finger) 3) Central compartment 4) Thenar compartment (thumb) 5) Adductor compartment *there is midpalmar and thenar space (closest to thumb and prominence made by muscles there) **The space between the palmar apponeurosis and the bones of the hand is separated into compartments by extensions of fascia called septa. A medial septum (to the little finger metacarpal) and a lateral septum (to the middle finger metacarpal) divides the space into a hypothenar compartment, a central compartment and a thenar compartment. Deep to the thenar compartment is a fourth compartment - the adductor compartment, which contains the adductor pollicis muscle.

Label this clavicle

1) Shaft 2) Conoid tubercle 3) acromial facet (articular surface) 4) trapezoid line 5) subclavian groove 6) impression for costoclavicular ligament 7) sternal facet (articular surface)

What joints make up the pectoral girdle?

1) Sterno-clavicular joint 2) Acromio-clavicular joint 3) Gleno-Humeral joint (Shoulder joint) 4) Scapulo-thoracic joint (sometimes referred to as a "virtual" or "physiological" joint) 5) Elbow joint **The pectoral girdle = SCJ + ACJ + GHJ + STJ

Deep venous Drainage of knee, leg ankle and foot

1) Superficial veins: i.Dorsal venous arch which gives off two saphenous veins ii.Long saphenous vein (anterior to middle malleolus; comes up medial thigh --> anterior --> pierces saphenous opening, draining into femoral vein) iii.Short saphenous vein (posterior to lateral malleolus, pierces fascia at popliteal fascia and drains into popliteal vein) iv.Perforating veins to the deep system (mainly in the calf) v.Valves! 2) Deep veins: i.Deep calf veins - venae comitantes of arteries ii.Popliteal vein iii.Femoral vein iv.External iliac vein v.Sapheno-femoral junction vi.Venae comitantes of the profunda femoris artery **FROM COURSEGUIDE: Deep system: 1. Dorsal digital veins 2. Posterior tibial veins 3. Popliteal vein 4. Perforating veins whereby normally blood passes from the superficial to the deep systems. **Note that the deep system forms a powerful "muscle pump" whereby the muscles of the calf pump blood back towards the heart.

Superficial venous Drainage of knee, leg ankle and foot

Pic of origin and attachment of serratus anterior, pec major, pec minor and subclavius

1) pec major: o Proximal attachments: on the medial 1/3rd of the clavicle, the sternum and costal cartilages. o Distal attachment: lateral lip of the intertubercular sulcus (groove). *Action: Adducts and medially rotates the humerus. Lesser actions on the scapula. developed well in boxers. 2) Pec minor: o underneath pec major o proximal attachment to coracoid process of scapula o distal attachment to 2, 3, 4, and 5th ribs. *acts on scapula to pull forward and down 3) serratus anterior: o Long thoracic nerve (C5, C6, C7) o Runs from medial border of scapula to the anterior attachments on the ribs. attaches to medial part of scapula at back, then runs anteriorly over surface of thoracic cage to attach to ribs 1-9 (can vary). *holds scapula down along with other muscles. 4) Subclavius: o proximal attachment - 1st rib close to costochondral joint o distal attachment - inferior part of clavicle. *stabilises and anchors the clavicle.

Veins of the hip, buttock and thigh

1) Superficial veins: ØLong saphenous vein ØJoins the femoral artery at the sapheno-femoral junction ØValve! 2) Deep veins: ØPopliteal vein ØFemoral vein ØExternal iliac vein ØSapheno-femoral junction ØVenae comitantes of the profunda femoris artery o o As in the upper limb, the lower limb also has a system of superficial and deep veins. o In the thigh the main superficial vein is the long saphenous vein (also known as the great saphenous vein). It runs from the medial border of the foot, passes the knee on its medial aspect, passes up the medial aspect of the thigh to join the deep system at the sapheno-femoral junction. The long saphenous vein pierces the fascia of the thigh to join the deep system at the femoral triangle. There is an important valve at the sapheno-femoral junction that prevents blood passing from the deep to the superficial system. This valve is often faulty or incompetent in varicose veins. o The deep veins of the thigh flow into the popliteal vein at the level of the knee. The popliteal vein runs along side the popliteal and femoral arteries to form the femoral vein. The femoral vein lies medial to the femoral artery in the groin, and then passes beneath the inguinal ligament to form the external iliac vein. The femoral vein receives the long saphenous vein at the saphenofemoral junction in the groin. Proximal to this it also receives the venae comitantes of the profunda femoris artery. **Arteries: ØExternal iliac artery ØFemoral artery - midinguinal point ØFemoral artery lies between the femoral vein (medial) and the femoral nerve (lateral) ØProfunda femoris artery ØCircumflex vessels ØFemoral artery continues as the superficial femoral artery and subsequently as the popliteal artery. o The external iliac artery passes from the pelvis beneath the inguinal ligament and proceeds as the femoral artery. At the level of the inguinal ligament the artery lies at the mid-inguinal point i.e. half-way between the ASIS and the pubic symphysis. It is easily palpable here. It is lateral to the femoral vein and medial to the femoral nerve. o The femoral artery then gives of the main branch to the thigh called the profunda femoris artery. At this level the femoral artery and its profunda branch give off the circumflex vessels, which supply the hip joint. o The femoral artery continues after giving off the profunda femoris artery as the superifical femoral artery. At the level of the knee the superficial femoral artery becomes the popliteal artery.

Superior gemellus muscle Netters

1) Superior gemellus muscle 2) Inferior gemellus muscle 3) greater trochanter of femur 4) gluteus maximus (cut) 5) iliotibial tract 6) biceps femoris (short head) § Origin (proximal): The superior gemellus muscle arises from the spine of the ischium. The inferior gemellus muscle arises from the ischial tuberosity. § Insertion (distal): Both gemellus muscle tendons blend with the tendon of the obturator internus to insert on the medial aspect of the greater trochanter of the femur. § Action: Both gemellus muscles laterally rotate the extended thigh and abduct the flexed thigh at the hip. They also steady the femoral head in the acetabulum. § Innervation: The superior gemellus is supplied by the nerve to the obturator internus (L5 and S1). The inferior gemellus is innervated by a branch of the nerve to the quadratus femoris (L5 and S1). § Comment: The 2 small gemelli lie parallel to the obturator internus tendon in the gluteal region. Although each muscle varies in size, the superior gemellus is usually smaller. § Clinical: The 2 gemelli and the obturator internus really form a "3-headed" muscle (triceps coxae) that fills the space between the piriformis above and the quadratus femoris below. These 3 muscles act as a functional unit.

Supinator and brachioradialis

1) Supinator: a)Proximal: Lateral epicondyle of humerus* b)Distal: Proximal 1/3 of radius* c)Function: Wrist supination 2)Brachioradialis: a)Proximal: Distal humerus* b)Distal: Lateral distal radius* c)Function: Elbow flexion **Innervation: a)The entire posterior forearm is innervated by the posterior interosseous nerve, which is a continuation of the deep motor branch of the radial nerve.

The Bones of the Elbow, Forearm and Wrist

1) The Humerus 2) The Radius 3) The Ulna 4) The carpal bones: a) Proximal row: scaphoid, lunate, triquetrum, pisiform b) Distal row: trapezium, trapezoid, capitate, hamate *in pic: epicondyles of humerus important for attachment for forearm muscles; condyles (capitulum and trochlea) for role in elbow joint) *radius is lateral and ulna is medial. *distal end of these bones form proximal part of wrist.

What is sole and dorsum of foot innervated by?

1) The Sole: -4 layers -Intrinsic Muscles -Tibial nerve 2) Dorsum of the Foot: -EDB, EHB -EDB by Common peroneal nerve

1. Which muscles form the hamstrings? How do they function together? 2. Which muscles form the quadriceps? How do they function together?

1) The biceps femoris, semimembranosus, and semitendinosus form the hamstrings. The hamstrings flex the leg at the knee joint. 2) The rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius form the quadriceps. The quadriceps muscles extend the leg at the knee joint

Intrinsic Muscles of the Hand

1) Thenar muscles: a) abductor pollicis brevis b) flexor pollicis brevis -opponens pollicis 2) Adductor muscle a) adductor pollicis 3) Hypothenar muscles a) abductor digiti minimi b) flexor digiti minimi c) opponens digiti minimi 4) Interossei and lumbricals: a) lumbricals - flex the MCP's, extend the IPJs b) palmar interossei - adduct the digits ("PAD") c) dorsal interossei - abduct the digits ("DAB")

Brachial Artery and Anastomoses Netters

1) Thoracoacromial artery 2) axillary artery 3) posterior circumflex humeral artery 4) brachial artery 5) profunda brachii (deep brachial) artery 6) radial collateral artery 7) radial recurrent artery 8) radial artery 9) ulnar artery 10) common interosseus artery 11) superior ulnar collateral artery 12) circumflex scapular artery 13) subscapular artery § Comment: The brachial artery is a continuation of the axillary artery; it begins at the lower margin of the teres major muscle. The brachial artery provides a deep branch to the muscles of the posterior compartment of the arm. In the cubital fossa, the brachial artery divides into the radial and ulnar arteries.The elbow joint is surrounded by a rich anastomosis of radial and ulnar recurrent and collateral arteries.The radial nerve courses with the deep branch of the brachial artery in the arm. The ulnar nerve courses with the superior ulnar collateral artery. The median nerve courses with the brachial artery. § Clinical: Like the shoulder joint, the elbow joint possesses a rich vascular anastomosis, providing blood to the muscles acting on the elbow joint and supplying the joint itself.

Cutaneous innervation of the hand

1) ULNAR NERVE: medial 1.5 digits on the palmar surface; 2.5 digits on the dorsal side. 2) RADIAL NERVE: dorsal side of the lateral 2.5 digits ; EXCEPT the tips of these fingers. 3) MEDIAN NERVE: palmar side of the lateral 3.5 digits; fingertips of these 3.5 fingers.

Abductor pollicis brevis muscle Netters

1) abductor pollicis brevis muscle (cut) 2) flexor retinaculum (transverse carpal ligament) (reflected) 3) median nerve 4) ulnar nerve and artery 5) deep palmar (arterial) arch § Origin (proximal): Abductor pollicis brevis muscle arises from the flexor retinaculum and the tubercles of the scaphoid and trapezium bones. § Insertion (distal): Inserts into the lateral side of the base of the proximal phalanx of the thumb. § Action: Abducts the thumb at the carpometacarpal and metacarpophalangeal joints. § Innervation: Recurrent branch of the median nerve (C8 and T1). § Comment: The abductor pollicis brevis muscle is 1 of the 3 muscles that make up the thenar muscles at the base of the thumb. The thenar muscles are all innervated by the recurrent branch of the median nerve. § Clinical: The abductor pollicis brevis muscle is tested clinically by having the patient abduct the thumb against resistance. Abduction of the thumb involves moving it at right angles to the palm toward the elbow in the supinated position. Look for the bulging of the muscle belly in the thenar eminence.

Arteries of the elbow, forearm and wrist

1) Ulnar and Radial arteries formed from division of brachial artery at elbow joint (usually at the level of the radial neck): Ulnar artery gives off common interosseous branch which immediately branches to give the anterior and posterior interosseous atreries 2) Arches of the hand - anastomosis of the radial and ulnar arteries as cross wrist. **o The brachial artery, the artery of the arm, divides at the elbow (usually at the level of the radial neck) into the ulnar artery and the radial artery. o The ulnar artery descends in the anterior compartment of the forearm and passes into the hand anteriorly, on the ulnar side of the wrist (just lateral to FCU). The ulnar nerve lies medial to it at the wrist joint, i.e. from medial to lateral, the relationships are FCU, ulnar nerve, ulnar artery. o In the forearm, the ulnar artery supplies the medial muscles of the forearm, via branches including the common interosseous artery, the anterior interosseous artery and the posterior interosseous artery. o The ulnar artery terminates in the hand to form the palmar arches (to be covered in the next session) with the radial artery. o The radial artery descends the lateral aspect of the forearm under the cover of the brachioradialis muscle. It is easily palpable at the wrist where it lies anteriorly on its radial aspect. It subsequently crosses the floor of the anatomical snuff box and ultimately anastomosis with branches of the ulnar artery to form the palmar arches.

What is a reflex? Why does it occur? Why is it tested?

1) What is a reflex? Spine-induced contraction of a muscle, tested by hitting the tendon of a muscle 2) Why does it occur?* Prevent overstretch injury Eliciting reflexes involves simulating tendons by overstretching them Normally, this extent of tendon stretch only occurs with forces capable of tearing muscle 3) Why are reflexes tested? To test nerve function

Deep muscles of the posterior (flexor compartment of the leg)

1) You will have examined popliteus when investigating the knee joint . The remaining deep muscles have their proximal attachments on the posterior leg bones and the interosseous membrane. 2) Flexor digitorum longus attaches to the distal ½ of the posterior tibial surface, its tendon passes posterior to the medial malleolus and under the plantar aponeurois, where the tendon divides to insert into each of the distal phalanges of digits 2-4. 3) Flexor hallucis longus attaches to the distal ½ of the posterior surface of the fibula and the lower part of the interosseous membrane; its tendon passes posterior to the medial malleolus, running medially in the foot to attach to the distal phalanx of hallux (big toe). 4) Tibialis posterior attaches to the posterior aspect of interosseous membrane, superior 2/3 of medial posterior surface of fibula and the superior aspect of posterior surface of tibia; its tendon passes posterior to the medial malleolus, under the plantar calcaneal ligament in then splits to attach to the navicular tuberosity and the bases of the 2nd to 4th metatarsals.

Muscles of Sole of Foot: First Layer- Abductor digiti minimi muscle

1) abductor digiti minimi muscle 2) lumbrical muscles 3) medial plantar nerve 4) plantar aponeurosis (cut) § Origin (proximal): Abductor digiti minimi muscle arises from the medial and lateral tubercles of the tuberosity of the calcaneus, the plantar aponeurosis, and the intermuscular septa. § Insertion (distal): The tendon of the abductor digiti minimi muscle and the tendon of the flexor digiti minimi brevis muscle insert together into the lateral side of the base of the proximal phalanx of the 5th, or little, toe. § Action: Abductor digiti minimi muscle abducts and helps flex the little toe at the metatarsophalangeal joint. § Innervation: Lateral plantar nerve (S2 and S3). § Comment: Some fibers of the abductor digiti minimi muscle often insert onto the tuberosity at the base of the 5th metatarsal as well. These fibers can constitute a separate muscle named the abductor ossis metatarsi quinti. §Clinical: The abductor digiti minimi muscle, a small toe abductor, works as a unit with some of the other muscles of the sole to push the foot off the ground and to assist in maintaining balance. Clinically, it is difficult to isolate the specific actions of a single small foot muscle.

abductor digiti minimi muscle Netters

1) abductor digiti minimi muscle 2) opponens digiti minimi longus muscle 3) adductor pollicis muscle (both heads) 4) flexor retinaculum 5) palmar carpal ligament (reflected) 6) flexor carpi radialis tendon 7) radial artery 8) palmaris longus tendon § Origin (proximal): Abductor digiti minimi muscle arises from the pisiform bone and the tendon of the flexor carpi ulnaris muscle § .Insertion (distal): Attaches to the medial side of the base of the proximal phalanx of the 5th digit. § Action: Abducts the 5th digit. § Innervation: Deep branch of the ulnar nerve (C8 and T1). § Comment: The abductor digiti minimi muscle is 1 of the 3 muscles that make up the hypothenar muscles, which constitute the intrinsic muscles of the little finger. All are innervated by deep branches of the ulnar nerve and supplied by deep branches of the ulnar artery. § Clinical: The abductor digiti minimi muscle is tested clinically by having the patient abduct the little finger against resistance. With the palm supinated and fingers extended and together, ask the patient to abduct the little finger (move it medially away from the palm and other fingers) while providing resistance.

Muscles of Sole of Foot: First Layer Netters - Abductor hallucis muscle

1) abductor hallucis muscle and tendon 2) flexor sheaths of flexor tendons 3) flexor hallucis longus tendon 4) superficial branches of medial plantar artery and nerve 5) abductor digiti minimi muscle 6) tuberosity of calcaneus § Origin (proximal): Abductor hallucis muscle arises from the medial process of the tuberosity of the calcaneus and from the flexor retinaculum and plantar aponeurosis. § Insertion (distal): Abductor hallucis muscle inserts into the medial aspect of the base of the proximal phalanx of the big toe. § Action: Abductor hallucis muscle abducts the big toe at the metatarsophalangeal joint and can flex the toe. § Innervation: Medial plantar nerve (S2 and S3). § Comment: The tendon of the abductor hallucis muscle and the medial tendon of the flexor hallucis brevis muscle insert together.The 1st layer of foot muscles are covered by medial and lateral plantar fascia and a central thickened plantar aponeurosis (fascia). § Clinical: Plantar fasciitis (heel spur syndrome) is a common cause of heel pain, especially in joggers, and results from inflammation of the plantar aponeurosis at its attachment point to the calcaneus (cut in this figure).

Label the femoral triangle

1) inguinal ligament 2) sartorius 3) adductor longus **The femoral triangle contains within the femoral sheath: §Femoral artery §Femoral vein §Lymphatics **Outside of the femoral sheath: §Femoral nerve §Psoas major tendon* §Pectineus* §Lateral femoral cutaneous nerve*

Abductor pollicis longus muscle Netters

1) abductor pollicis longus muscle 2) extensor pollicis brevis muscle 3) extensor pollicis longus tendon 4) 1st dorsal interosseus muscle 5) extensor indicis tendon 6) extensor digitorum tendons 7) abductor digiti minimi muscle 8) extensor digiti minimi muscle 9) extensor carpi ulnaris muscle § Origin (proximal): Abductor pollicis longus muscle arises from posterior aspect of the ulna, radius, and interosseous membrane. § Insertion (distal): Attaches to the base of the 1st metacarpal bone. § Action: Abducts, extends, and laterally rotates the thumb at the carpometacarpal joint. It also may contribute to abduction of the wrist. § Innervation: Radial nerve (posterior interosseous branch) (C7 and C8). § Comment: When the thumb is abducted, the tendon of the abductor pollicis longus becomes prominent and forms the lateral boundary of the "anatomical snuffbox." § Clinical: The abductor pollicis longus muscle is tested clinically by having the patient supinate the hand (palm up) and extend the forearm at the elbow. The examiner places a finger on the lateral aspect of the patient's extended thumb for resistance and asks the patient to try to move the thumb toward the elbow (abduct). While the patient does this, the examiner looks for the tendon of the muscle running to the base of the thumb's metacarpal bone.

Shoulder (Glenohumeral) Joint: Anterior View Netters

1) acromioclavicular joint capsule (incorporating acromioclavicular ligament) 2) coracoacromial ligament 3) supraspinatus tendon (cut) 4) subscapularis tendon (cut) 5) biceps brachii tendon (lond head) 6) capsular ligaments 7) superior transverse scapular ligament and suprascapular notch 8) coracoclavicular ligament (trapzeoid ligament; conoid ligament) **Comment: The shoulder is a multiaxial synovial ball-and-socket (spheroidal) joint. Movements include abduction and adduction, flexion and extension, and rotation and circumduction. The shallow glenoid cavity of the scapula permits extensive movement at the shoulder but also makes this joint vulnerable to dislocation. The 4 tendons of the rotator cuff muscles help stabilize the joint.Also shown is the acromioclavicular joint, a synovial plane joint between the acromion and clavicle. This joint permits gliding movement as the arm is raised and the scapula rotates. **Clinical: Because of the wide range of motion at the shoulder and its rather shallow glenoid cavity, this joint is one of the most frequently dislocated joints in the body. This glenohumeral joint usually dislocates in an anterior or anteroinferior direction (subcoracoid dislocation) and can place the axillary and musculocutaneous nerves of the brachial plexus at risk for injury. Upper Limb / Skeletal

Humerus and Scapula: Anterior View Netters

1) acromion 2) greater tubercle 3) lesser tubercle 4) intertubercular sulcus 5) medial and lateral epicondyles 6) capitulum 7) coronoid fossa 8) glenoid cavity of scapula 9) inferior angle 10) subscapular fossa **Comment: The clavicle and scapula form the pectoral girdle, or shoulder, which connects the upper extremity to the trunk. The clavicle serves as a strut, keeping the upper limb away from the trunk and free for movement. It is vulnerable to fracture.The scapula, or shoulder blade, articulates with the clavicle and the head of the humerus (glenohumeral joint). Seventeen different muscles attach to the scapula. Fractures of the scapula are uncommon.The humerus is a long bone. Its proximal end forms part of the shoulder joint, and its distal end contributes to the elbow joint. The surgical neck of the humerus (the region just below the lesser tubercle) is a common fracture site. Fractures at this site may injure the axillary nerve of the brachial plexus. ** Clinical: Fractures of the clavicle are common, especially in children. The fracture usually results from a fall on an outstretched hand or from direct trauma and commonly occurs in the middle third of the clavicle.

Adductor brevis muscle Netters

1) adductor brevis muscle 2) adductor magnus muscle 3) femoral artery and vein (cut) 4) adductor magnus tendon 5) medial patellar retinaculum 6) rectus femoris muscle (cut) 7) femoral nerve § Origin (proximal): Adductor brevis muscle arises from the body and inferior ramus of the pubis. § Insertion (distal): Adductor brevis muscle inserts into the pectineal line and proximal portion of the linea aspera of the femur. § Action: Adductor brevis muscle adducts the thigh at the hip joint and can flex and medially rotate the thigh. § Innervation: Obturator nerve (L2, L3, and L4). § Comment: The adductor brevis, longus, and magnus muscles are the main adductors of the hip. They are helped to a small extent by the gracilis and pectineus muscles.Branches of the femoral and obturator arteries supply blood to these adductors. § Clinical: The adductor muscles may be tested collectively by asking a patient in the supine position (lying on the back) whose lower limb is extended to adduct the limb while the examiner holds the ankle to provide resistance to this movement. The adductor muscle bellies can be seen and palpated as the patient adducts the limb.Groin injuries are common in athletes and usually involve a pulling or tearing of the proximal attachment (origin) of the anteromedial thigh muscles, especially the adductor group.

Muscles of Sole of Foot: Third Layer- adductor hallucis muscle

1) adductor hallucis muscle (transverse and oblique heads) 2) common plantar digital nerves 3) plantar metatarsal arteries 4) fibularis longus tendon 5) fibularis brevis tendon 6) lateral plantar artery and nerve 7) medial plantar artery and nerve 8) flexor hallucis longus tendon (cut) § Origin (proximal): The oblique head of the adductor hallucis muscle arises from the bases of the 2nd to 4th metatarsal bones and the long plantar ligament. The transverse head of the adductor hallucis muscle arises from the plantar metatarsophalangeal ligaments of the 3rd, 4th, and 5th toes. § Insertion (distal): The 2 heads of the adductor hallucis muscle converge, and their central tendon blends with that of the flexor hallucis brevis and shares the lateral sesamoid bone with that muscle. The common tendon inserts on the lateral side of the base of the proximal phalanx of the big toe. § Action: Adducts the big toe and flexes the proximal phalanx at the metatarsophalangeal joint. It also helps to maintain the transverse metatarsal arch of the foot. § Innervation: Deep branch of lateral plantar nerve (S2 and S3). § Comment: The transverse head of the adductor hallucis muscle does not arise from a bone but from plantar ligaments. § Clinical: A bunion (hallux valgus) often occurs in those who wear shoes that are too narrow. In this deformity, the 1st metatarsal bone is displaced medially (varus) and the proximal phalanx is partially dislocated and displaced laterally (valgus). The lateral sesamoid bone also is displaced laterally.

adductor magnus Netters

1) adductor magnus muscle § Origin (proximal): This large, triangular muscle arises from the inferior ramus of the pubis, the ramus of the ischium, and the ischial tuberosity. § Insertion (distal): Inserts into the gluteal tuberosity, linea aspera, medial supracondylar line, and adductor tubercle of the femur. The portion inserting on the supracondylar line is called the adductor portion. The portion inserting on the adductor tubercle of the femur is called the hamstring portion. § Action: This muscle is a powerful adductor of the thigh at the hip. Its superior portion weakly flexes and medially rotates the thigh. Its lower portion helps extend and laterally rotate the thigh. § Innervation: The adductor portion is innervated by the obturator nerve (L2, L3, and L4). The hamstring portion is innervated by the tibial portion of the sciatic nerve (L4). § Comment: The most superior portion of the adductor magnus is called the adductor minimus if it forms a distinct muscle, as seen in this plate.The lowest portion of the muscle contains an opening called the adductor hiatus, which allows the femoral vessels to pass into the popliteal fossa. § Clinical: The adductor magnus, or 1 or more of the other adductors, helps to keep the lower limb positioned under the body's center of gravity (prevents one from doing the "splits") and may be easily stretched or torn when forcefully contracted, leading to a groin injury.

adductor pollicis muscle Netters

1) adductor pollicis muscle 2) superficial palmar branch of radial artery 3) pronator quadratus muscle 4) deep branch of ulnar nerve § Origin (proximal): The proximal fibers of the adductor pollicis muscle make up the oblique head and arise from the bases of the 2nd and 3rd metacarpals and the capitate bone. The transverse head arises from the anterior surface of the body of the 3rd metacarpal bone. § Insertion (distal): Both heads of the adductor pollicis muscle converge on a sesamoid bone on the medial or ulnar side of the metacarpophalangeal joint. They attach to the base of the proximal phalanx of the thumb. § Action: Adducts the proximal phalanx of the thumb toward the middle digit. § Innervation: Deep branch of the ulnar nerve (C8 and T1). § Comment: The adductor pollicis muscle is not considered a thenar muscle. Although it acts on the thumb, it is innervated by the ulnar nerve. § Clinical: The adductor pollicis muscle is tested clinically by asking the patient to adduct the thumb against resistance. This is done by having the patient place the thumb in a fully abducted position (at right angles to the supinated palm, sticking straight up in the air) and then by providing resistance as the patient tries to move the thumb back into an adducted position (flat in the palm just lateral to the index finger).

Hip (Coxal) Bone: Medial View Netters

1) ala of ilium (iliac fossa) 2) arcuate line 3) pecten pubis (pectineal line) 4) symphyseal tubercle 5) ramus of ischium 6) ischial tuberosity 7) lesser sciatic notch 8) ischial spine 9) articular surface (for sacrum) 10) iliac tuberosity § Comment: The hip bone consists of 3 bones: the ilium, ischium, and pubis. Before puberty, these bones are joined by cartilage, but they begin to fuse by midadolescence and are completely fused in adulthood.Anteriorly, the 2 pubic bones articulate with one another at the pubic symphysis. A fibrocartilage disc separates the 2 bones, and this joint allows some movement. § Clinical: Forensic scientists can identify the pelvic bones of females and males by the structural adaptations observed in the pelvis for childbirth. The female pelvis is usually smaller, lighter, and thinner than its male counterpart. In females the pelvic inlet is oval and the outlet is larger, the pelvic cavity is wider and shallower, and the pubic arch is wider. The obturator foramen is usually oval or triangular in the female and round in the male.

Lumbar vertebrae Netters

1) annulus fibrosus 2) nucleus pulposus 3) superior articular process 4) pedicle 5) intervertebral disc 6) mammillary process 7) inferior articular process 8) inferior vertebral notch 9) intervertebral (neural) notch 10) superior vertebral notch 11) transverse process 12) lamina 13) articular facet for sacrum § Comment: Intervertebral discs form secondary cartilaginous joints (symphyses) between the bodies of 2 adjacent vertebrae. They are present from the axis to the sacrum, but there are no discs between the atlas and axis (C1 and C2). The discs serve as shock absorbers. A disc consists of a central nucleus pulposus surrounded by a fibrocartilaginous anulus fibrosus.Adjacent inferior and superior vertebral notches form an intervertebral foramen that allows a spinal nerve to exit.The joints of the vertebral arches are plane synovial joints between the superior and inferior articular processes (facets) that allow for some gliding or sliding movement. § Clinical: An accentuated lumbar lordosis is an abnormal extension of the lumbar spine (swayback) and is common in women during the third trimester of pregnancy when the weight of the fetus places stress on the lower lumbar region.Disc herniation also is common in the lumbar spine, especially between the L4-L5 and L5-S1 intervertebral discs.

Veins of Vertebral Venous Plexus and Spinal Cord Netters

1) basivertebral vein 2) internal vertebral (epidural) venous plexus 3) intervertebral vein 4) internal vertebral (epidural) venous plexus 5) external vertebral venous plexus 6) basivertebral vein 7) anterior segmental medullary/radicular vein 8) pial venous plexus 9) posterior spinal vein 10) anterior spinal vein §Comment: Usually, there are 3 anterior and 3 posterior spinal veins (although veins are often variable). These veins communicate freely with one another and drain into segmental radicular veins.Veins of the spinal cord and vertebrae form an internal vertebral plexus of veins. These veins communicate with an external vertebral venous plexus surrounding the bony vertebrae. This vertebral venous plexus ultimately drains into intervertebral veins and then into the vertebral veins, ascending lumbar veins, azygos venous system, and inferior vena cava.Most of the veins of the vertebral venous plexus do not possess valves, but recent evidence suggests that some do; because of the large region that they drain (entire spine), they provide a conduit for the spread of cancer cells (metastasis) from one region (e.g., the pelvic region) to distant sites (e.g., the lungs, brain). § Clinical: The vertebral venous plexus (of Batson) is a network of veins that course along the spine and provide a route for venous metastases of cancer cells from distal locations (e.g., the pelvis) to seed the spine and other organs located more proximally (e.g., the lungs, brain).

Posterior Forearm muscles

1)Extension of the wrist: a)Extensor carpi radialis longus b)Extensor carpi radialis brevis c)Extensor carpi ulnaris 2)Extension of the digits: a)Extensor digitorum (all 4 digits) b)Extensor indicis (index digit) c)Extensor digiti minimi (little finger) 4) Extension of the thumb: a) Extensor pollicis brevis b) Extensor pollicis longus c) Abductor pollicis longus: Mostly thumb abduction. 5) Supinator: a)Proximal: Lateral epicondyle of humerus* b)Distal: Proximal 1/3 of radius* c)Function: Wrist supination 6)Brachioradialis: a)Proximal: Distal humerus* b)Distal: Lateral distal radius* c)Function: Elbow flexion **Innervation: a)The entire posterior forearm is innervated by the posterior interosseous nerve, which is a continuation of the deep motor branch of the radial nerve.

Biceps brachii muscle Netters

1) biceps brachii muscle 2) deltoid muscle (reflected) 3) subscapularis muscle 4) teres major muscle 5) latissimus dorsi muscle 6) bicipital aponeurosis 7) biceps brachii tendon **Origin (proximal): The short head of the biceps brachii muscle arises from the apex of the coracoid process of the scapula. The long head of the biceps brachii muscle arises from the supraglenoid tubercle of the scapula. **Insertion (distal): Both muscle bellies of the biceps brachii muscle join to form a flattened tendon that is inserted into the radial tuberosity. Opposite the elbow, the tendon gives off a broad aponeurosis from its medial side. This bicipital aponeurosis descends medially to fuse with the deep fascia of the forearm. **Action: With the forearm partially flexed, the biceps brachii is a powerful supinator of the forearm. It also is an important flexor of the supinated forearm. It assists other muscles, although weakly, as a flexor of the arm at the shoulder. **Innervation: Musculocutaneous nerve (C5 and C6). **Comment: As its name implies, the biceps is a fusiform muscle that has 2 heads. Its insertion by the bicipital aponeurosis allows it to flex the elbow.The brachial artery supplies blood to this muscle. **Clinical: Tapping the biceps tendon elicits the biceps tendon reflex, testing spinal cord segments C5 and C6. The biceps is tested clinically by having a patient flex the supinated forearm against resistance and watching for the distinct contraction of the biceps in the anterior arm. This action also tests the integrity of the musculocutaneous nerve.

Arm: serial cross section Netters

1) biceps brachii muscle (short and long heads) 2) coracobrachialis muscle 3) deltoid muscle 4) brachialis muscle 5) radial nerve 6) triceps brachii muscle (medial, lateral and long heads) 7) brachioradialis muscle 8) musculocutaneous nerve **Comment: Functionally, the arm is divided into an anterior compartment and a posterior compartment. Simplistically, the anterior compartment contains the flexors of the elbow and the posterior compartment contains the extensors of the elbow.The musculocutaneous nerve innervates the muscles of the anterior, or flexor, compartment. The radial nerve innervates the muscles of the posterior, or extensor, compartment.The anterior compartment is supplied largely by the brachial artery and its branches. The posterior compartment is supplied largely by the deep brachial (profunda brachii) artery and its branches.The median and ulnar nerves pass through the arm in a medial neurovascular bundle compartment as they course to the forearm. These 2 nerves do not innervate muscles of the arm. **Clinical: The radial nerve passes around the shaft of the humerus to gain access to the posterior compartment of the arm. Fractures of the shaft of the humerus can place the radial nerve in jeopardy of being stretched or torn as it wraps around the humerus, affecting wrist and finger extensors.

Cervical Vertebrae Netters

1) body 2) transverse process 3) foramen transversarium 4) pedicle 5) lamina 6) dens 7) spinous processes § Comment: The first 2 cervical vertebrae are the atlas and axis (see Section 1, Head and Neck, for a description).The cervical spine allows for considerable movement.A typical cervical vertebra has a body, pedicle, lamina, and spinous process.The transverse processes of the cervical vertebrae contain the foramen transversarium (transverse foramen), which allows for passage of the vertebral vessels.The lower illustration shows the articulated cervical vertebrae from C2 to C7 and the 1st thoracic vertebra. The 7th cervical vertebra is called the vertebra prominens because of its long spinous process, usually the 1st spinous process one can visualize and easily palpate. The intervertebral discs between adjacent vertebrae have been removed in this illustration. § Clinical: Cervical disc herniation (a herniation of the nucleus pulposus) usually occurs in the absence of trauma and is often related to dehydration of the nucleus pulposus. Motor and sensory loss may occur if the herniation compresses a nerve root or the spinal nerve. Common cervical sites of herniation include the C5-C6 or C6-C7 intervertebral discs.

Brachialis muscle Netters

1) brachialis muscle 2) coracoid process 3) acromion process 4) biceps brachii tendons (cut) (long and short heads) 5) lateral antebrachial cutaneous nerve **Origin (proximal): Brachialis muscle arises from the distal half of the anterior humerus. **Insertion (distal): Inserts into the tuberosity and the anterior surface of the coronoid process of the ulna. **Action: The brachialis is a powerful flexor of the forearm at the elbow. **Innervation: Musculocutaneous nerve (C5 and C6). Also, the radial nerve sends a minor branch to the brachialis (C7). **Comment: Because the brachialis is covered superficially by the biceps, it is often not appreciated as the most important and powerful flexor of the forearm at the elbow. Although the muscle can participate in quick flexion, its isometric contraction maintains the flexed position, especially when a weight is applied to the forearm.The brachial artery supplies the brachialis with blood. **Clinical: Damage to the musculocutaneous nerve proximal to the brachialis (compression injury as it passes through the coracobrachialis muscle) can lead to weakness in the brachialis and biceps brachii muscles, thus affecting elbow flexion.

Brachioradiallis muscle Netters

1) brachioradiallis muscle 2) radial artery 3) median nerve 4) ulnar artery 5) ulnar nerve 6) palmaris longus tendon 7) flexor digitorum superficialis muscle 8) flexor carpi radialis muscle 9) pronator teres muscle 10) bicipital aponeurosis (dense connective tissue) § Origin (proximal): Brachioradialis muscle arises from proximal two-thirds of the lateral supracondylar ridge of the distal humerus and intermuscular septum. § Insertion (distal): Brachioradialis muscle inserts on the lateral aspect of the distal radius just proximal to the styloid process. § Action: Brachioradialis muscle is an accessory flexor of the forearm at the elbow. § Innervation: Radial nerve (C5 and C6), before it divides into its superficial and deep branches. § Comment: The brachioradialis is a unique muscle in that it is a muscle of the posterior compartment of the forearm (innervated by the radial nerve) but is not an extensor or supinator. It is a weak flexor of the forearm at the elbow and is most efficient as a flexor when the forearm is in midpronation. § Clinical: If one tests forearm flexion against resistance in the midpronated position, the brachioradialis is easily seen as a muscle bulge over the lateral epicondyle of the elbow. Pain over the lateral epicondyle is often referred to as "tennis elbow," but this muscle pain, usually from overexertion, can be caused by a number of actions, including playing tennis or golf or lifting heavy objects (e.g., a suitcase) by a handle.

Derivation and innervation of inferior gluteal nerve

Nerves of Hand Netters

1) branches of median nerve to thenar muscles and to 1st and 2nd lumbrical muscles 2) branches from deep branch of ulnar nerve to 3rd and 4th lumbrical muscles, all interosseus muscles, the hypothenar muscles and the adductor pollicis muscle 3) deep palmar branch of ulnar artery and deep branch of ulnar nerve 4) median nerve (cut) 5) ulnar nerve § Comment: The median and ulnar nerves innervate intrinsic muscles on the anterior (palmar) side of the hand. The median nerve innervates muscles that act on the thumb; these muscles form the thenar eminence and lumbricals of digits 2 and 3. All the other intrinsic muscles of the palmar hand are innervated by the deep branches of the ulnar nerve. § Clinical: Sensation of the skin over the surface of the hand can vary depending on the branching of the radial, median, and ulnar sensory branches. Testing of radial sensation can only be done reliably over the dorsal web space between the thumb and index finger. Median sensation is tested reliably on the palmar (volar) aspect of the tip of the index finger. Ulnar sensation is tested reliably on the palmar aspect of the tip of the little finger.The rich blood supply to the hand via the palmar arches means that lacerations of the palm often bleed profusely and may be difficult to control.

Humerus and Scapula: Posterior View Netters

1) clavicle (cut) 2) suprascapular notch 3) superior angle 4) supraspinous fossa 5) spine 6) infraspinous fossa 7) medial epicondyle) 8) trochlea of humerus 9) olecranon fossa 10) deltoid tuberosity 11) head of humerus **Comment: Posteriorly, the scapula displays a prominent spine that separates the supraspinous and infraspinous fossae.The clavicle is the 1st bone to ossify but the last bone to fuse and is formed by both endochondral and intramembranous ossification. It is one of the most commonly fractured bones.Midshaft on the humerus is the deltoid tuberosity, the insertion point for the deltoid muscle.Distally, the depression above the trochlea is called the olecranon fossa, which accommodates the olecranon of the ulna when the elbow is extended fully. **Clinical: Fractures of the scapula are relatively uncommon. Fractures of the surgical neck of the humerus are common and may injure the axillary nerve from the brachial plexus. A midshaft fracture of the humerus may injure the radial nerve.

Common Fibular Nerve Netters

1) common fibular nerve (L4-S2) 2) superficial fibular nerve 3) medial dorsal cutaneous nerve 4) intermediate dorsal cutaneous nerve 5) lateral dorsal cutaneous nerve (branch of sural nerve) 6) dorsal digital nerves 7) inferior extensor retinaculum (partially cut) 8) tibialis anterior muscle 9) tibia 10) deep fibular nerve § Comment: The common fibular nerve is a direct extension of the sciatic nerve. It wraps superficially around the head of the fibula and divides into a superficial branch and a deep branch.The superficial fibular nerve innervates muscles of the lateral compartment of the leg, which are essentially involved in eversion of the foot. The deep fibular nerve innervates muscles of the anterior compartment of the leg and muscles on the dorsum of the foot. These muscles are essentially dorsiflexors of the foot at the ankle and extensors of the toes. § Clinical: The common fibular nerve is the most commonly injured nerve of the lower limb. This nerve is vulnerable to compression injury, usually from direct trauma, where it wraps around the head of the fibula. When injured, the patient may present with footdrop (inability to dorsiflex at the ankle) and an inability to evert the foot. The corresponding nerve of the upper limb would be the ulnar nerve, which passes posterior to the medial epicondyle of the humerus and is vulnerable to injury.

Coracobrachialis muscle Netters

1) coracobrachialis muscle 2) subscapularis muscle 3) musculocutaneous nerve 4) teres major muscle 5) latissimus dorsi muscle **Origin (proximal): Coracobrachialis muscle arises from the apex of the coracoid process of the scapula along with the short head of the biceps brachii. **Insertion (distal): Inserts into the middle of the medial surface and border of the humerus. **Action: Flexes and adducts the arm at the shoulder. **Innervation: Musculocutaneous nerve (C6 and C7). **Comment: The coracobrachialis is the smallest of the 3 anterior compartment muscles of the arm.The brachial artery supplies the coracobrachialis with blood.As the musculocutaneous nerve leaves the brachial plexus, it usually dives into the proximal portion of the coracobrachialis muscle. **Clinical: Since the musculocutaneous nerve runs through the coracobrachialis muscle, it is vulnerable to nerve compression within the muscle, and this can lead to weakness of elbow flexion (loss of some brachialis and biceps function) and hypesthesia of the lateral forearm.

Ligaments and Tendons of Foot: Plantar View Netters

1) deep transverse metatarsal ligaments 2) plantar ligaments (plates) 3) plantar metatarsal ligaments 4) fibularis (peroneus) longus tendon 5) long plantar ligament 6) plantar calcaneonavicular (spring) ligament 7) sesamoid bones 8) interphalangeal (IP) joint § Comment: The tarsometatarsal joints are plane synovial joints. They consist of articular capsules and are strengthened by plantar, dorsal, and interosseous ligaments. They permit gliding and sliding movements.The metatarsophalangeal joints are multiaxial condyloid synovial joints surrounded by articular capsules and strengthened by plantar and collateral ligaments. They permit flexion and extension, some abduction and adduction, and circumduction. The plantar (plate) ligaments are part of the weight-bearing surface of the foot.The interphalangeal joints are uniaxial hinge-type (ginglymus) synovial joints that also are enclosed by capsules and strengthened by plantar and collateral ligaments. They permit flexion and extension. § Clinical: Direct trauma to the foot can result in fracture of the metatarsals and phalanges. These are usually treated by immobilization because the extensive ligament attachments that stabilize these joints prevent the fragments from becoming displaced.

Muscles of Foot - interossei Netters

1) dorsal interossei muscles 2) cuboid bone 3) navicular bone 4) 1st metatarsal bone 5) proximal phalanx of great toe 6) distal phalanx of 4th toe 7) middle phalanx of 4th toe 8) proximal phalanx of 4th toe § Origin (proximal): These 4 bipennate muscles arise by 2 heads from adjacent sides of the metatarsal bones. § Insertion (distal): The 1st interosseous inserts into the medial aspect of the proximal phalanx of the 2nd toe. The 2nd through 4th interossei insert into the lateral sides of the 2nd to 4th toes. § Action: The dorsal interossei abduct the toes in relation to an imaginary longitudinal axis of the foot drawn through the 2nd toe. They also flex the proximal phalanx at the metatarsophalangeal joint and extend the distal phalanges. § Innervation: Lateral plantar nerve (S2 and S3). § Comment: Plantar and dorsal interosseous muscles form the 4th muscle layer of the foot. Similar to the interossei of the hand, the dorsal interossei abduct the digits (toes) and extend the distal phalanges. § Clinical: One can test the dorsal interossei muscles by asking the patient to spread the toes against resistance.

Dorsal interosseous muscles Netters

1) dorsal interosseus muscles 2) radial artery 3) radius 4) abductor digiti minimi muscle § Origin (proximal): The 4 dorsal interosseous muscles are bipennate. They arise by 2 heads from adjacent sides of the metacarpal bones. § Insertion (distal): Each interosseous muscle inserts into the base of the proximal phalanx and into the aponeurosis that forms the extensor expansion of digits 2 through 4. § Action: Abducts the fingers from an imaginary longitudinal line through the middle finger (arrows). Also, the dorsal interossei flex the fingers at the metacarpophalangeal joints and aid in extension of the 2 distal phalanges at the interphalangeal joints. § Innervation: Deep palmar branch of the ulnar nerve (C8 and T1). § Comment: The 1st dorsal interosseous is the largest. It fills the space between the metacarpal bones of the thumb and index finger and is sometimes referred to as the "pinch" muscle. The 1st dorsal interosseous also is used with the adductor pollicis muscle during a precision grip.Dorsal interosseous muscles are not associated with the thumb or little finger; these digits possess their own abductors. § Clinical: The dorsal interossei are clinically tested by holding the adducted extended fingers together and asking the patient to spread the fingers (abduct them) against this resistance.

Arteries Around Scapula Netters

1) dorsal scapular artery 2) supraspinatus muscle (cut) 3) superior transverse scapular ligament and suprascapular notch 4) infraspinatus muscle (cut) 5) circumflex scapular artery 6) posterior humeral circumflex artery (in quadrangular space) and ascending and descending branches 7) infraspinous branch of suprascapular artery 8) acromial branch of thoracoacromial artery 9) suprascapular artery § omment: Around the shoulder joint, a rich vascular anastomosis forms from branches of the thyrocervical trunk, thoracoacromial artery, subscapular artery, and posterior and anterior humeral circumflex arteries. This anastomosis not only supplies the 17 muscles attaching to the scapula and some of the shoulder muscles but also provides collateral circulation to the upper limb should the proximal part of the axillary artery become occluded.The dorsal scapular artery (from the thyrocervical trunk) anastomoses freely across the supraspinous and infraspinous fossae with branches from the suprascapular, posterior humeral circumflex, and circumflex scapular branches of the subscapular arteries. § Clinical: Joints tend to have rich vascular anastomoses around them to supply the muscles working on each joint and to supply the joint itself. Clinically, these anastomoses can be critical if a proximal artery is lacerated, because adjacent arteries can still supply distal tissues with blood.

Radial Nerve in Arm and Nerves of Posterior Shoulder Netters

1) dorsal scapular nerve (C5) 2) lower subscapular nerve (C5-6) 3) triceps brachii muscle (lateral head) (cut) 4) triceps brachii tendon 5) anconeus muscle 6) extensor carpi radialis longus muscle 7) brachioradialis muscle 8) posterior antebrachial cutaneous nerve 9) radial nerve (C5-C8, T1) 10) axillary nerve (C5-C6) 11) suprascapular nerve (C5-C6) § Comment: Branches of the brachial plexus innervate the shoulder and arm muscles. Prominent among these branches are the dorsal scapular nerve, the suprascapular nerve, the lower subscapular nerve, and 2 of the 5 terminal branches of the brachial plexus, the axillary nerve and the radial nerve.The radial nerve innervates the extensor compartment of the arm and courses posteriorly to the shaft of the humerus, running with the deep brachial artery. In the arm, this nerve innervates the triceps and anconeus muscles. § Clinical: The radial nerve is vulnerable to stretching or tearing in fractures of the shaft of the humerus and can be compressed by tourniquets that are too tight or by direct compression (Saturday night palsy) leading to weakened elbow, wrist, and finger extension and supination. Wristdrop is a common clinical sign if the forearm extensor muscles are affected.

Extensor carpi radialis longus muscle Netters

1) extensor carpi radialis longus muscle 2) tendon of extensor carpi radialis longus muscle 3) tendon of extensor carpi radialis brevis muscle 4) abductor pollicis longus 5) extensor pollicis brevis § Origin (proximal): Extensor carpi radialis longus muscle arises from lateral supracondylar ridge of the humerus. § Insertion (distal): Attaches to the base of the 2nd metacarpal § Action: Extends and abducts the hand at the wrist joint. § Innervation: Radial nerve (C6 and C7). § Comment: The extensor carpi radialis longus muscle arises just distal to the brachioradialis muscle. Its belly ends in the proximal third of the forearm. Its flat tendon continues distally along the lateral border of the radius beneath the abductor pollicis longus and extensor pollicis brevis muscles.This muscle also acts synergistically during flexion of the fingers by extending the hand at the wrist to give additional strength when the hand grasps an object. This action is essential for a power grip. § Clinical: The extensor carpi radialis longus muscle is tested clinically by having the patient extend and abduct the hand at the wrist against resistance. This requires that the examiner hold the patient's fist and apply resistance to the lateral aspect of the wrist while the patient tries to bend the fist laterally (abduct or move it toward the thumb side of the wrist) and extend the wrist simultaneously.

Extensor digiti minimi muscle Netters

1) extensor digiti minimi muscle 2) common extensor tendon 3) lateral epicondyle of humerus 4) ulna 5) extensor digiti minimi tendon 6) extensor indicus tendon § Origin (proximal): Extensor digiti minimi muscle arises from lateral epicondyle of the humerus. § Insertion (distal): Extensor digiti minimi muscle inserts as an extensor expansion of the 5th digit. § Action: Extends the 5th digit at the metacarpophalangeal and interphalangeal joints. This muscle also participates in wrist extension when the fingers are extended. § Innervation: Radial nerve (posterior interosseous branch) (C7 and C8). § Comment: The slender extensor digiti minimi muscle is often connected to the larger extensor digitorum. § Clinical: The small extensor digiti minimi muscle acts with many of the other finger and wrist extensors and usually will not be tested clinically as an individual muscle, because its isolated action is difficult to ascertain.

1.Give 2 causes of injury to the ulnar nerve (2) 2.What are the typical motor and sensory symptoms of ulnar nerve damage (3) 3.Why is an ulnar lesion at the elbow less severe than a lesion at the wrist? (2) 4.What is the innervation and action of serratus anterior? (2) 5.Explain why paralysis of serratus anterior causes winging of the scapula (1)

1) self-harm and elbow fracture and funny bone trauma 2) Ulnar claw: a)Hyper-extended 4th and 5th digits at MCP b)Hyper-flexed 4th and 5th digits at IPJs c)Inability to abduct/adduct fingers against resistance d)Weak thumb adduction "Froment's sign" e)Claw worse on extension (unlike median nerve) sensory loss to medial 1.5 digits (palmar and dorsal). 3) ulnar paradox - because the ulnar nerve also innervates the ulnar half of FDP, flexion of the IP joints is weakened, therefore less claw-like appearance. 4) innervated by long thoracic nerve; acts to protract and stabilise the scapula 5) When patient tries to push forward or throw a punch, it normally moves the scapula around the ribs (anteriorly)

Extensor digitorum longus muscle netters

1) extensor digitorum longus muscle 2) fibula 3) superior extensor retinaculum 4) inferior extensor retinaculum 5) extensor hallucis brevis muscle § Origin (proximal): Extensor digitorum longus muscle arises from the lateral condyle of the tibia, most of the upper anterior surface of the body of the fibula, and the interosseous membrane. § Insertion (distal): After passing beneath the superior and inferior extensor retinacula, the extensor digitorum longus tendon divides into 4 slips that insert into the middle and distal phalanges of toes 2 through 5. § Action: Extensor digitorum longus muscle extends the proximal phalanges of the lateral 4 toes and is a dorsiflexor of the foot at the ankle. § Innervation: Deep fibular nerve (L5 and S1). § Comment: The penniform extensor digitorum longus muscle lies in the lateral part of the anterior compartment of the leg. Variations are frequent. Although described as dividing into 4 slips, or small tendons, it may send multiple slips to the toes.There is also an extensor digitorum brevis muscle on the dorsum of the foot. It sends 3 small muscle slips to toes 2, 3, and 4. This muscle helps the extensor digitorum longus extend the toes. It is also innervated by the deep fibular nerve. § Clinical: The extensor digitorum longus muscle is tested clinically by having the patient dorsiflex (extend) the 4 lateral toes against resistance.Anterior (tibial) compartment syndrome (known as an anterior or a lateral "shin splint") occurs from excessive contraction of anterior compartment muscles. Pain radiates down the ankle and dorsum of the foot overlying the extensor tendons of these muscles.

extensor hallucis longus muscle Netters

1) extensor hallucis longus muscle § Origin (proximal): Arises from the middle portion of the anterior surface of the fibula and the interosseous membrane. § Insertion (distal): Inserts on the dorsal aspect of the base of the distal phalanx of the big toe. § Action: Extends the big toe, assists in dorsiflexion of the foot at the ankle, and is a weak invertor. § Innervation: Deep fibular nerve (L5 and S1). § Comment: Most of the muscular belly of the extensor hallucis longus is covered by the tibialis anterior and the extensor digitorum longus.There is also a small extensor hallucis brevis muscle on the dorsum of the foot (see Card 7-43). It sends its tendon to the proximal phalanx of the big toe. This muscle is innervated by the deep fibular nerve and extends the proximal phalanx of the big toe. § Clinical: The extensor hallucis longus muscle is clinically tested by having the patient dorsiflex (extend) the big toe against resistance. The tendon is seen passing to the great toe.Anterior (tibial) compartment syndrome (known as an anterior or a lateral "shin splint") occurs from excessive contraction of anterior compartment muscles. Pain radiates down the ankle and dorsum of the foot overlying the extensor tendons of these muscles.On the dorsum of the foot, just lateral to the tendon of the extensor hallucis longus muscle, one can find the dorsalis pedis (artery) pulse.

Extensor indicis muscle Netters

1) extensor inidicis muscle 2) ulna 3) olecranon 4) medial epicondyle of humerus 5) radius 6) extensor pollicis brevis muscle § Origin (proximal): Extensor indicis muscle arises from posterior surface of the ulna and the interosseous membrane. § Insertion (distal): Extensor indicis muscle is an extensor expansion of the 2nd digit. § Action: Extends all the joints of the index finger. It can help other extensors extend the wrist. § Innervation: Radial nerve (posterior interosseous branch) (C7 and C8). § Comment: The extensor indicis muscle, a narrow, elongated muscle, lies medial and parallel to the extensor pollicis longus muscle. It permits the index finger to extend independently of the other fingers. § Clinical: Along with the extensor digitorum muscle, the extensor indicis muscle provides independent extension of the index finger, such that the other digits may be flexed while still extending the index finger (pointing at someone). This maneuver is more difficult to do with any of the other fingers.

Extensor pollicis brevis muscle Netters

1) extensor pollicis brevis muscle 2) abductor pollicis longus muscle 3) radius 4) supinator muscle 5) anconeus muscle 6) ulna 7) extensor indicis muscle 8) extensor retinaculum 9) radial artery (in anatomical snuff box) § Origin (proximal): Extensor pollicis brevis muscle arises from the posterior surface of the radius and the interosseous membrane. § Insertion (distal): Attaches to the base of the proximal phalanx of the thumb. § Action: Extends the proximal phalanx of the thumb at the metacarpophalangeal joint. By its continued action, it also can extend the 1st metacarpal bone at the carpometacarpal joint. § Innervation: Radial nerve (posterior interosseous branch) (C7 and C8). § Comment: The extensor pollicis brevis muscle, a short extensor of the thumb, courses with the abductor pollicis longus muscle. The tendons of the 2 muscles form part of the lateral boundary of the "anatomical snuffbox." § Clinical: One can test the extensor pollicis brevis muscle clinically by having the patient supinate the extended hand and then attempt to extend the thumb (the hitchhiking thumb position) against resistance. Not only will the strength of the muscle be tested, but the tendon of the muscle should be visible and palpable over the dorsal surface of the thumb's metacarpophalangeal joint.

Extensor pollicis longus muscle Netters

1) extensor pollicis longus muscle 2) extensor carpi ulnaris muscle (retracted) 3) lateral epicondyle of humerus 4) extensor radialis longus muscle 5) extensor radialis brevis muscle 6) interosseus membrane 7) abductor pollicis longus muscle 8) extensor indicis muscle tendon § Origin (proximal): Extensor pollicis longus muscle arises from posterior surface of the middle third of the ulna and the interosseous membrane. § Insertion (distal): Attaches to the base of the proximal phalanx of the thumb. § Action: Extends the distal phalanx of the thumb at the metacarpophalangeal and interphalangeal joints. Because it runs in an oblique fashion, it can contribute to abduction of the thumb. § Innervation: Radial nerve (posterior interosseous branch) (C7 and C8). § Comment: The tendon of the extensor pollicis longus forms the medial or ulnar border of the "anatomical snuffbox." § Clinical: The radial artery can be found within the anatomical snuffbox, and its pulse may be palpated at that point. The anatomical snuffbox is bounded laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis muscles and medially by the extensor pollicis longus tendon. The scaphoid carpal bone lies in the floor of the snuffbox; fracture from a fall on the outstretched hand will present as pain and swelling in the snuffbox (the scaphoid is the most commonly fractured carpal bone).

Derivation and innervation of obturator nerve

Spinal Nerve Origin: Cross Section Netters

1) fat in epidural space 2) sympathetic ganglion 3) anterior root 4) white and grey rami communicantes 5) spinal nerve 6) posterior ramus 7) spinal ganglion 8) subarachnoid space 9) dura mater § Comment: The spinal cord connects to the sympathetic chain ganglia by rami communicantes. White and gray rami communicantes are found between the T1 and L2 spinal cord levels, but only gray rami communicantes are found at the other spinal cord levels.Anterior and posterior roots join to form the spinal nerve in the intervertebral foramen. The spinal nerve immediately divides into a small posterior ramus, which supplies the skin and underlying intrinsic back muscles, and a much larger anterior ramus.The epidural space (between the dura mater and the bony vertebral canal) is filled with fat and a rich vertebral venous plexus. The subarachnoid space (between the arachnoid and pia mater) contains cerebrospinal fluid. § Clinical: Any pathology that narrows the size of the intervertebral foramen (excessive growth of adjacent bone, a tumor, an abscess) can impinge on the posterior or anterior roots or the spinal nerve and cause symptoms related to the nerve fibers carried in those roots or the nerve.

Arteries of Thigh and Knee: Schema Netters

1) femoral artery 2) deep artery of thigh 3) superior lateral genicular artery 4) anterior tibial artery 5) fibular artery (phantom) 6) posterior tibial artery (phantom) 7) inferior medial genicular artery (partially in phantom) 8) popliteal artery (phantom) 9) medial circumflex femoral artery 10) obturator artery § Comment: The femoral artery is a continuation of the external iliac artery. Its deep branch provides blood to the deep muscles of the thigh.Medial and lateral circumflex femoral branches provide a rich anastomosis around the hip joint. Similarly, a rich anastomosis around the knee joint is provided by medial and lateral pairs of genicular arteries.When the femoral artery passes through the adductor hiatus of the adductor magnus muscle, it assumes a position behind the knee (popliteal fossa), becoming the popliteal artery. Inferior to the knee, the popliteal artery divides into anterior and posterior tibial branches. § Clinical: Arterial pulses in the thigh and about the knee may be taken over the proximal femoral artery in the femoral triangle or posterior to the knee in the popliteal fossa over the popliteal artery (more difficult to feel because of its deep location).

Summary of Lower Limb Arteries Netters

1) femoral artery 2) deep femoral (profunda femoris) artery 3) superior medial and lateral genicular arteries 4) posterior tibial artery (phantom) 5) anterior tibial artery 6) fibular artery 7) dorsal digital arteries 8) arcuate artery 9) dorsalis pedis artery (dorsal artery of foot) 10) popliteal artery 11) femoral artery § Comment: The femoral artery is a direct continuation of the external iliac artery. The medial and lateral circumflex femoral arteries form an anastomosis around the hip joint, with a contribution from the obturator artery. Genicular branches of the popliteal artery form a rich anastomosis around the knee. The posterior tibial artery continues into the sole and divides into medial and lateral plantar arteries. § Clinical: The major pulse points of the lower limb include: a) Femoral pulse, just inferior to the inguinal ligament b) Popliteal pulse, deep behind the knee (difficult to find) c) Posterior tibial pulse, on the medial aspect of the ankle posterior to the medial malleolus d) Dorsalis pedis pulse, felt just lateral to the flexor hallucis longus muscle tendon

Fibularis brevis muscle Netters

1) fibuaris brevis muscle and tendon 2) biceps femoris (long and short heads) 3) tibialis anterior muscle 4) superficial fibular nerve 5) superior extensor retinaculum 6) inferior extensor retinaculum 7) fibularis brevis tendon § Origin (proximal): Fibularis brevis muscle arises from the distal two-thirds of the lateral surface of the fibula. § Insertion (distal): Fibers of the fibularis brevis muscle course downward, ending as a tendon that passes behind the lateral malleolus and runs forward to insert into the tuberosity on the lateral side of the base of the 5th metatarsal. § Action: Fibularis brevis muscle everts the foot and acts as a weak plantarflexor of the foot at the ankle joint. § Innervation: Superficial fibular nerve (L5, S1, and S2). § Comment: During walking, the fibularis brevis muscle helps balance the foot and support weight by compensating for inversion. § Clinical: The fibularis brevis muscle is tested clinically by having the patient evert the foot against resistance. In some individuals with excessively mobile ankle joints, hypereversion can irritate the lateral compartment muscles (fibularis longus and fibularis brevis), causing pain, swelling, and compression of the neurovascular bundle.

Fibularis longus muscle Netters

1) fibularis longus muscle and tendon 2) gastrocnemius muscle (lateral head) 3) head of fibula 4) common fibular nerve 5) iliotibial tract 6) patellar ligament 7) tibialis anterior muscle 8) extensor digitorum longus muscle § Origin (proximal): Fibularis longus muscle arises from the head and upper two-thirds of the lateral surface of the fibula. § Insertion (distal): Fibularis longus muscle ends in a long tendon that runs behind the lateral malleolus and crosses obliquely on the plantar surface of the foot to insert at the base of the 1st metatarsal and medial cuneiform bone. § Action: Fibularis longus everts the foot and is a weak plantarflexor of the foot at the ankle. § Innervation: Superficial fibular (peroneal) nerve (L5, S1, and S2). § Comment: The oblique course of the tendon across the plantar aspect of the foot helps maintain the foot's lateral longitudinal and transverse arches. § Clinical: The fibularis (peroneus) longus muscle is tested clinically by having the patient evert the foot against resistance. In some individuals with excessively mobile ankle joints, hypereversion can irritate the lateral compartment muscles (fibularis longus and fibularis brevis), causing pain, swelling, and compression of the neurovascular bundle.

Flexor carpi radialis muscle Netters

1) flexor carpi radialis muscle 2) head of radius 3) lateral epicondyle of humerus 4) tendon of flexor carpi ulnaris muscle **Origin (proximal): Flexor carpi radialis muscle arises from the medial epicondyle of the humerus and the antebrachial (forearm) fascia. **Insertion (distal): Inserts into the base of the 2nd metacarpal bone and sends a slip to the base of the 3rd metacarpal bone. **Action: Flexes the hand at the wrist joint and aids in wrist abduction. **Innervation: Median nerve (C6 and C7). **Comment: The radial extensors help the flexor carpi radialis abduct the wrist.Distally at the wrist, the radial artery pulse may be palpated just lateral to the tendon of this muscle. Simply rest your index and middle fingers on this tendon and press to feel the radial pulse. **Clinical: One can clinically test the flexor carpi radialis by grasping the patient's hand and having the patient flex the wrist against resistance. As the patient does this, look for the tendon of the muscle to tighten in the wrist.

flexor carpi ulnaris muscle Netters

1) flexor carpi ulnaris muscle 2) tendon of flexor carpi radialis muscle 3) medial epicondyle of humerus 4) common flexor tendon 5) 5th metacarpal **Origin (proximal): Flexor carpi ulnaris muscle has 2 heads. The humeral head arises from the medial epicondyle of the humerus by the common flexor tendon. The ulnar head arises from the medial margin of the olecranon and posterior border of the ulna. **Insertion (distal): Inserts into the pisiform bone, but an extension of its ligament attaches to the hook of the hamate and base of the 5th metacarpal. Several of its fibers also attach to the flexor retinaculum. **Action: Flexes and adducts the hand at the wrist. **Innervation: Ulnar nerve (C7 and C8). **Comment: The 2 heads of this muscle join just below the medial epicondyle; the ulnar nerve runs between the heads as it courses toward the wrist. The ulnar extensor helps the flexor carpi ulnaris adduct the hand at the wrist. **Clinical: As the ulnar nerve passes between the 2 heads of the flexor carpi ulnaris, the nerve can become compressed, leading to a cubital tunnel syndrome. This syndrome is 2nd only to carpal tunnel syndrome among compression neuropathies. Compression may be especially acute as the elbow is flexed because this narrows the space between the 2 muscle heads.

Muscles of Sole of Foot: Second Layer - Flexor digiti minimi brevis muscle

1) flexor digiti minimi brevis muscle 2) sesamoid bones 3) abductor hallucis muscle (cut) 4) flexor hallucis longus tendon § Origin (proximal): Flexor digiti minimi brevis muscle arises from the base of the 5th metatarsal bone and the long plantar ligament. § Insertion (distal): Inserts onto the base of the proximal phalanx of the little toe. § Action: Flexes the proximal phalanx of the little toe at the metatarsophalangeal joint. § Innervation: Superficial branch of lateral plantar nerve (S2 and S3). § Comment: The flexor digiti minimi brevis muscle often resembles one of the interossei. Its tendon of insertion may blend laterally with that of the abductor digiti minimi. § Clinical: The flexor digiti minimi brevis muscle, a small toe flexor, is difficult to test independent of the other toe flexors. These muscles often act as a flexor unit of the toes in general.

flexor digiti minimi brevis muscle Netters

1) flexor digiti minimi brevis muscle 2) ulnar artery 3) ulnar nerve 4) median nerve 5) trapezium bone 6) 1st metacarpal bone 7) common flexor sheath 8) lumbrical muscle 9) superficial palmar (arterial) arch § Origin (proximal): Flexor digiti minimi brevis muscle arises from the hook of the hamate bone and the flexor retinaculum. § Insertion (distal): Inserts into the medial aspect of the base of the proximal phalanx of the little finger, as does the abductor digiti minimi. § Action: Flexes the proximal phalanx of the 5th digit at the metacarpophalangeal joint. § Innervation: Deep branch of the ulnar nerve (C8 and T1). § Comment: The flexor digiti minimi brevis muscle is 1 of the 3 muscles that make up the hypothenar muscles, which constitute the intrinsic muscles of the little finger. All are innervated by deep branches of the ulnar nerve and supplied by deep branches of the ulnar artery. § Clinical: The flexor digiti minimi brevis muscle is tested clinically by asking the patient to flex the little finger at the metacarpophalangeal joint against resistance. It helps to hold the middle 3 fingers in an extended position while the patient tries to flex the 5th digit, which should be extended at the interphalangeal joints.

Muscles of Sole of Foot: First Layer - Flexor digitorum brevis muscle Netters

1) flexor digitorum brevis muscle 2) flexor digitorum brevis tendons overlying flexor digitorum longus tendons 3) flexor digiti minimi brevis muscle 4) medial calcaneal branches of tibial nerve and posterior tibial artery § Origin (proximal): Flexor digitorum brevis muscle arises from the medial tubercle of the tuberosity of the calcaneus and from the plantar aponeurosis and intermuscular septa. § Insertion (distal): The flexor digitorum brevis muscle gives rise to 4 tendons that are superficial to the tendons of the flexor digitorum longus. Within their digital tendon sheaths, the tendons of the brevis split to allow the long flexor tendons to pass to the distal phalanges. The brevis tendons insert on both sides of the middle phalanges of the 4 lateral toes. § Action: Flexor digitorum brevis muscle flexes the 2nd (middle) phalanx of the 4 lateral toes. § Innervation: Medial plantar nerve (S2 and S3). § Comment: The arrangement of the flexor digitorum longus and brevis tendons in the foot is similar to that of the superficial and deep digital flexors in the hand. § Clinical: Generally, unlike the muscles of the hand, the muscles of the sole of the foot act as a unit to maintain balance, maintain the arches of the foot (along with the supporting ligaments), and act in pushing the foot off the ground.

Flexor digitorum longus muscle netters

1) flexor digitorum longus muscle 2) posterior tibial artery 3) tibialis posterior tendon 4) flexor digitorum longus tendon 5) flexor hallucis longus tendon 6) tibialis posterior muscle § Origin (proximal): Flexor digitorum longus muscle arises from the middle portion of the posterior surface of the tibia inferior to the soleal line and from the fascia covering the tibialis posterior. § Insertion (distal): In the sole of the foot, the tendon of the flexor digitorum longus muscle divides into 4 slips that insert on the bases of the distal phalanges of the 4 lateral toes. § Action: Flexor digitorum longus muscle flexes the 4 lateral digits, especially the distal phalanges, allowing them to grip the ground during walking. This muscle also plantarflexes the foot at the ankle, aids with inversion, and helps support the foot's longitudinal arches. § Innervation: Tibial nerve (S2 and S3). § Comment: The flexor digitorum longus muscle is situated on the tibial side of the leg. Along with the flexor hallucis longus tendon and tibialis posterior tendon, the tendon of the flexor digitorum longus courses posteriorly to the medial malleolus, passing deep to the flexor retinaculum. § Clinical: The flexor digitorum longus muscle is tested by having the patient plantarflex the toes against resistance. As this is done, one can palpate the tendons to the 4 lateral toes on the plantar aspect of the distal foot.

Cross section of palm Netters

1) lumbrical muscle in its fascial sheath 2) flexor tendons to 5th digit in common flexor sheath (ulnar bursa) 3) hypothenar muscles 4) dorsal interosseus muscles 5) palmar interosseus muscles 6) adductor pollicis muscle 7) flexor digitorum superficialis and profundus tendons to 3rd digit 8) palmar aponeurosis 9) common palmar digital artery and nerve § Comment: Muscles at the base of the thumb compose the thenar cone, or eminence.Intrinsic muscles at the base of the 5th digit make up the hypothenar eminence.The palmar interosseous muscles adduct the middle 3 fingers, whereas the dorsal interosseous muscles abduct the middle 3 fingers. Together, the interossei also flex the metacarpophalangeal joint and, because of their insertion into the extensor expansion, extend the proximal and distal interphalangeal joints. § Clinical: Several potential spaces exist in the palm and can become sites of infection. The thenar space exists just anterior to the adductor pollicis muscle. The midpalmar space exists posterior (deep) to the central compartment that contains the long flexor tendons and lumbrical muscles.

Arteries of Sole of Foot Netters

1) flexor digitorum longus tendon (cut) 2) common plantar nerves and arteries 3) plantar metatarsal arteries 4) deep plantar arterial arch and deep branches of lateral plantar nerve 5) lateral plantar artery and nerve 6) medial plantar artery and nerve 7) deep branches of medial plantar artery and nerve 8) superficial branches of medial plantar artery and nerve 9) proper plantar digital branch of superficial branch of medial plantar artery 10) flexor digitorum longus tendon (cut) §Comment: The medial and lateral plantar arteries are continuations of the posterior tibial artery.The lateral plantar artery is much larger than the medial branch. It forms the major portion of the plantar arch, which anastomoses with other plantar branches and the dorsalis pedis artery.Plantar metatarsal arteries arise from this plantar arch and give rise to proper plantar digital branches. § Clinical: Puncture wounds or lacerations to the sole of the foot may bleed profusely because of the rich vascular anastomoses of the plantar arches. Moreover, because of the tight, deep compartments containing tendons, muscles, and ligaments in the sole, controlling the bleeding from a laceration may be problematic.

Muscles of Sole of Foot: Second Layer- Flexor hallucis brevis muscle

1) flexor hallucis brevis muscle 2) superficial branch of lateral plantar nerve 3) flexor digitorum longus tendon 4) flexor digitorum brevis muscle (cut) § Origin (proximal): Flexor hallucis brevis muscle arises from the plantar surfaces of the cuboid and lateral cuneiform bones. § Insertion (distal): The muscle belly of the flexor hallucis brevis muscle divides into 2 parts. The medial portion blends with the abductor hallucis and shares a medial sesamoid bone of the big toe to insert on the medial aspect of the base of the proximal phalanx. The lateral portion blends with the 2 heads of the adductor hallucis, sharing a lateral sesamoid bone and inserting on the lateral side of the base of the proximal phalanx. § Action: Flexor hallucis brevis muscle flexes the proximal phalanx of the big toe at the metatarsophalangeal joint. § Innervation: Medial plantar nerve (S2 and S3). § Comment: The tendons of insertion of the flexor hallucis brevis muscle are associated with the 2 sesamoid bones of the big toe. § Clinical: The flexor hallucis brevis muscle, a large toe flexor, works as a unit with some of the other muscles of the sole to push the foot off the ground and to assist in maintaining balance. Pushing off the "ball of the foot" is especially important, as this is the last portion of the foot to leave the ground. Clinically, it is difficult to isolate the specific actions of single small foot muscles.

Flexor hallucis longus muscle Netters

1) flexor hallucis longus muscle (retracted) 2) posterior tibial artery 3) fibular artery 4) tibial nerve 5) fibular artery 6) flexor hallucis longus tendon § Origin (proximal): Flexor hallucis longus muscle arises from the inferior two-thirds of the posterior surface of the fibula and from the inferior portion of the interosseous membrane. § Insertion (distal): The tendon of the flexor hallucis longus muscle enters the foot with the tendons of the flexor digitorum longus and tibialis posterior. It inserts on the base of the distal phalanx of the big toe. § Action: Flexor hallucis longus muscle flexes the distal phalanx of the big toe, plantarflexes the foot at the ankle, and helps propel the foot during walking or running. § Innervation: Tibial nerve (S2 and S3). § Comment: The flexor hallucis longus muscle helps support the medial longitudinal arch of the foot. § Clinical: The flexor hallucis longus muscle is tested clinically by having the patient flex the big toe, especially against resistance. As this is done, one can palpate the tendon of the muscle on the plantar aspect of the base of the big toe.

Flexor pollicis brevis muscle Netters

1) flexor pollicis brevis muscle 2) recurrent branch of median nerve 3) radial artery 4) ulnar artery 5) ulnar nerve § Origin (proximal): Flexor pollicis brevis muscle has 2 heads. The superficial head arises from the flexor retinaculum and the trapezium bone. The deep head arises from the floor of the carpal canal, which overlies the trapezoid and capitate bones. § Insertion (distal): The 2 heads of the flexor pollicis brevis muscle join in a common tendon that inserts on the lateral side of the 1st metacarpal bone and base of the proximal phalanx. The tendon of insertion contains the radial sesamoid bone of the metacarpophalangeal joint. § Action: Flexes the proximal phalanx of the thumb at the metacarpophalangeal joint and indirectly rotates the metacarpal bone of the thumb medially at the carpometacarpal joint. § Innervation: Recurrent branch of median nerve (C8 and T1). § Comment: The flexor pollicis brevis muscle is 1 of the 3 muscles that make up the thenar muscles at the base of the thumb. The thenar muscles are all innervated by the recurrent branch of the median nerve. § Clinical: The recurrent branch of the median nerve lies somewhat superficial in the palm before diving into the belly of the flexor pollicis brevis muscle. Lacerations across the palm and thenar eminence may sever this important branch, as it innervates all 3 of the thenar muscles. Therefore, one must carefully test the integrity of these muscles in hand lacerations.

flexor digitorum superficialis Netters

1) flexor pollicis longus muscle 2) flexor digitorum superficialis muscle 3) flexor digitorum superficialis tendons **Origin (proximal): Flexor digitorum superficialis muscle arises by 2 heads and inserts by 4 tendons. The humeroulnar head arises from the medial epicondyle of the humerus, the ulnar collateral ligament, and the coronoid process of the ulna. The radial head arises from the superior half of the anterior aspect of the radius. **Insertion (distal): Four tendons of insertion of the flexor digitorum superficialis attach to the bodies of the middle phalanges of the medial 4 digits (index finger to little finger). **Action: This muscle acts primarily as a flexor of the proximal interphalangeal joints. It also contributes to flexion of all the joints it crosses, including the elbow, wrist, and metacarpophalangeal joints. **Innervation: Median nerve (C7, C8, and T1). **Comment: Opposite the bases of the 1st phalanges, each tendon divides to allow the corresponding tendon of the deep flexor (flexor digitorum profundus) to reach each finger. A common synovial tendon sheath, or bursa, wraps around both sets of tendons, facilitating the sliding of the tendons over one another. **Clinical: Testing this muscle is done by asking the patient to flex the index or middle finger while one holds it between the thumb and index finger in a flexed position at the proximal interphalangeal joint, thus providing resistance. As the patient tries to flex the joint and move the finger toward the palm, the muscle's strength can be assessed.

Derivation and innervation of superior gluteal nerve

Flexor pollicis longus muscle Netters

1) flexor pollicis longus muscle 2) interosseus membrane 3) flexor digitorum profundus muscle § Origin (proximal): Flexor pollicis longus muscle arises from anterior aspect of the radius and adjacent interosseous membrane. § Insertion (distal): Flexor pollicis longus muscle inserts on the base of the distal phalanx of the thumb. § Action: The primary action of the flexor pollicis longus muscle is flexion of the distal phalanx of the thumb. The muscle also can flex the proximal phalanx because its tendon crosses that joint. § Innervation: Median nerve (anterior interosseous branch) (C7, C8, and T1). § Comment: The tendon of the unipennate belly of the flexor pollicis longus muscle crosses the carpal canal on the lateral or radial side of the digital flexor tendons and passes to the distal phalanx of the thumb. The tendon has its own synovial sheath. § Clinical: The flexor pollicis longus muscle is tested clinically by asking the patient to flex the tip of the thumb against resistance while the examiner holds the proximal phalanx fixed between the thumb and fingers. This action not only tests the strength of muscle contraction but also tests the integrity of the median nerve, which innervates this muscle.

Gastrocnemius muscle Netters

1) gastrocnemius muscle 2) tibial nerve 3) common fibular nerve 4) small saphenous vein 5) soleus muscle 6) Calcaneal (achilles) tendon § Origin (proximal): Gastrocnemius muscle has 2 heads. The lateral head arises from the lateral aspect of the lateral condyle of the femur. The medial head arises from the posterior part of the medial condyle and the popliteal surface of the femur above the medial condyle. § Insertion (distal): The fibers of the gastrocnemius muscle unite to form a tendinous raphe. The raphe expands into a broad aponeurosis that unites with the tendon of the soleus and forms the calcaneal tendon. The tendon attaches to the posterior surface of the calcaneus. § Action: Gastrocnemius muscle plantarflexes the foot at the ankle, flexes the leg at the knee, and raises the heel during walking. § Innervation: Tibial nerve (S1 and S2). § Comment: The gastrocnemius tendon blends with that of the soleus muscle to form the calcaneal (Achilles) tendon. § Clinical: One tests the gastrocnemius muscle clinically by having a supine patient extend the leg and plantarflex the foot against resistance. The muscle bellies in the calf should be obvious.Tendinitis of the calcaneal tendon is a painful inflammation that often occurs in runners who run on hills or uneven surfaces. Repetitive stress on the tendon occurs as the heel strikes the ground and when plantarflexion lifts the foot. Rupture of the tendon is a serious injury.

gluteus maximus muscle Netters

1) gluteus maximus muscle 2) adductor magnus muscle 3) semitendinous muscle 4) semimembranosus muscle 5) gastrocnemius muscle (both heads) § Origin (proximal): The large gluteus maximus muscle arises from the posterior gluteal line of the ilium, the dorsal surfaces of the sacrum and coccyx, and the sacrotuberous ligament. § Insertion (distal): Most of the gluteus maximus muscle's fibers insert in the iliotibial tract, but some fibers from its lower half attach to the gluteal tuberosity of the femur. § Action: The gluteus maximus muscle is a powerful extensor and lateral rotator of the thigh at the hip joint. Its upper fibers may assist in abduction of the thigh, whereas the lower fibers adduct the thigh. § Innervation: Inferior gluteal nerve (L5, S1, and S2). § Comment: The gluteus maximus is the largest muscle in the body and the most powerful extensor of the hip. Although it is used in standing and walking, this muscle is most important as a powerful extensor at the hip when the trunk is being raised from the flexed position. The gluteus maximus is most important in hip extension when a person is rising from a sitting position or climbing stairs. § Clinical: One tests the gluteus maximus muscle with the patient in a supine position with the leg extended at the knee. The underside of the ankle is held, and the patient is asked to extend the slightly raised limb at the hip against this resistance.

Gluteus medius muscle Netters

1) gluteus medius muscle (covered by gluteal aponeurosis) 2) biceps femoris (long head) 3) biceps femoris (short head) 4) popliteal vessels and tibial nerve 5) gracilis muscle § Origin (proximal): Gluteus medius muscle arises from the external surface of the ilium between the anterior and posterior gluteal lines. § Insertion (distal): Gluteus medius muscle inserts into the greater trochanter of the femur. § Action: The gluteus medius muscle is a strong abductor and medial rotator of the thigh at the hip joint. It also steadies the pelvis on the leg when the opposite leg is raised off the ground. § Innervation: Superior gluteal nerve (L5 and S1). § Comment: The gluteus medius is a broad, thick, fan-shaped muscle that, along with the gluteus minimus, is the chief abductor of the hip and medial rotator. § Clinical: The gluteus medius and minimus are tested clinically with the patient in the supine position and the lower limb extended (straight). The examiner holds the ankle laterally and asks the patient to abduct (move laterally) the limb against this resistance. Medial rotation is tested in the supine position by having the patient internally (medially) rotate the thigh against resistance with the lower limb flexed at the hip and knee.

Gluteus minimus muscle Netters

1) gluteus minimus muscle 2) gluteus medius muscle (cut) 3) quadratus femoris muscle 4) iliotibial tract 5) adductor minimus part of adductor magnus muscle 6) adductor magnus muscle 7) semimembranosus muscle § Origin (proximal): Gluteus minimus muscle arises from the external surface of the ilium between the anterior and inferior gluteal lines. § Insertion (distal): Gluteus minimus muscle inserts on the greater trochanter of the femur. § Action: The gluteus minimus abducts and medially rotates the thigh at the hip. Along with the gluteus medius, it steadies the pelvis on the leg when the opposite leg is raised from the ground. § Innervation: Superior gluteal nerve (L5 and S1). § Comment: The gluteus minimus lies deeper than the gluteus medius. The 2 muscles are separated by deep branches of the superior gluteal neurovascular bundle.These muscles are important in stabilizing the hip during walking. § Clinical: The gluteus medius and minimus are tested clinically with the patient in the supine position and the lower limb extended (straight). The examiner holds the ankle laterally and asks the patient to abduct (move laterally) the limb against this resistance. Medial rotation is tested in the supine position by having the patient internally (medially) rotate the thigh against resistance with the lower limb flexed at the hip and knee.

Nerves of the Lower Limb

Gracilis muscle Netters

1) gracilis muscle 2) vastus intermedius muscle § Origin (proximal): Gracilis muscle arises from the body and inferior ramus of the pubis. § Insertion (distal): Gracilis muscle inserts into the medial aspect of the upper portion of the tibia, just below the medial condyle. § Action: Gracilis muscle adducts the thigh, flexes the leg at the knee, and, when the knee is flexed, is a medial rotator. § Innervation: Obturator nerve (L2 and L3). § Comment: The gracilis is a long, thin, flat muscle. It crosses the hip and the knee, acting on both joints. Below the knee, its tendon of insertion curves forward and expands, lying in close approximation to the insertions of the sartorius and semitendinosus muscles. The expanded insertion of the tendons of these 3 muscles is called the "pes anserinus" because the insertion resembles the foot of a goose. § Clinical: The gracilis muscle, along with the sartorius and semitendinosus muscles, helps stabilize the medial aspect of the extended knee (while the tensor fasciae latae muscle and the iliotibial tract do this on the lateral side of the extended knee). The gracilis is the weakest of the medial adductor group of muscles.

Deep Veins of the Leg Netters

1) great saphenous vein 2) perforating vein (Sherman's vein) 3) posterior tibial artery and vein 4) perforating veins (Cockett's veins) 5) dorsal venous arch 6) posterior tibial artery and vein and tibial nerve 7) perforating vein 8) small saphenous vein 9) superficial posterior venous arch 10) small saphenous vein 11) popliteal artery and vein § Clinical: Virtually everywhere in the body, humans possess a superficial and deep set of veins. This is especially evident in the limbs. The veins of the limbs contain valves, which assist in venous return to the heart. Venous stasis (stagnation) can result in thrombus formation, often at the site of venous valves, and especially in the lower limb (deep venous thrombosis). Deep venous thrombosis can occur elsewhere as well, but the veins of the lower limb are most often involved. Perforating veins can shunt venous blood around a thrombus or may themselves become blocked by venous stasis and clot formation. Clinical risk factors for deep venous thrombosis include postsurgical immobility, muscular inactivity, vessel trauma, infection, paralysis, malignancy, and pregnancy.

Suboccipital Triangle Netters

1) greater occipital nerve (posterior ramus of C2 spinal nerve) 2) great auricular nerve (Cervical plexus C2 and C3) 3) lessor occipital nerve (Cervical plexus C2 and C3) 4) third occipital nerve (posterior ramus of C3 spinal nerve) 5) greater occipital nerve (posterior ramus of C2 spinal nerve) 6) obliquus capitis inferior muscle 7) obliquus capitis superior muscle 8) suboccipital nerve (posterior ramus of C1 spinal nerve) 9) rectus capitis posterior major muscle 10) rectus capitis posterior minor muscle § Comment: The suboccipital region comprises muscles in the deep, posterior aspect of the neck, and these muscles are associated with the atlas and axis (C1 and C2 vertebrae).These muscles are largely postural, but they also assist with head movements. The muscles of the suboccipital region are innervated by the posterior ramus of C1, the suboccipital nerve.The first 3 pairs of cervical spinal nerves (posterior rami) are found in this region. Generally, the suboccipital nerve (posterior ramus of C1) does not possess cutaneous sensory nerve fibers, so dermatome charts showing the back and top of the head begin with C2, rather than depicting a C1 dermatome. It does possess proprioceptive (position sense) fibers in addition to its somatic efferents and postganglionic sympathetic fibers. Note the presence of the vertebral artery (from the subclavian artery) passing into the foramen magnum. § Clinical: The vertebral arteries supply blood to the brain, along with the internal carotid arteries, and atherosclerosis of these arteries can compromise the blood supply to the brain

Femur netters

1) greater trochanter 2) body (shaft) 3) lateral epicondyle 4) lateral condyle 5) medial condyle 6) medial epicondyle 7) adductor tubercle 8) linea aspera (medial lip; lateral lip) 9) lesser trochanter 10) intertrochanteric crest 11) neck of femur 12) head of femur § Comment: The femur, or thigh bone, is the longest bone in the body. When a person is standing, the femur transmits the weight of the body from the hip to the tibia.The head of the femur articulates with the coxal (hip) bone at the acetabulum. The femoral neck is a common fracture site. The greater trochanter is the point of the hip and an attachment site for several of the gluteal muscles (abductors of the thigh at the hip). The lesser trochanter is an attachment site for the iliopsoas tendon, a strong flexor of the thigh at the hip. § Clinical: Femoral neck fractures are common and often occur in the young from trauma and in the elderly from osteoporosis and an associated fall. Complications are related to nonunion of the bone, especially with intracapsular fractures, and avascular necrosis of the femoral head may occur as a result.

iliacus muscle Netters

1) iliacus muscle 2) genitofemoral nerve (L1-L2) 3) transverse abdominis muscle (cut) 4) femoral nerve (L2-L4) 5) superior and inferior pubic rami § Origin (proximal): The fan-shaped iliacus muscle arises from the inner surface of the wing of the ilium (iliac fossa). § Insertion (distal): The iliacus fibers blend with those of the psoas major and insert on the lesser trochanter of the femur. § Action: The iliacus acts in unison with the psoas major muscle. The 2 muscles are often called the iliopsoas muscle. The iliopsoas flexes the thigh at the hip and is an important flexor of the trunk ipsilaterally. § Innervation: Femoral nerve (L2, L3, and L4). § Comment: The iliacus is innervated by branches derived from the femoral nerve as this larger nerve descends to pass into the thigh. § Clinical: The iliacus muscle (iliopsoas complex) is tested clinically by having the patient flex the thigh at the hip joint against resistance (with the leg also flexed at the knee).

Label these nerves in the leg

1) ilioinguinal nerve 2) femoral 3) internal saphenous nerve 4) obturator nerve 5) sciatic nerve 6) tibial nerve 7) common peroneal nerve 8) deep peroneal nerve 9) superficial peroneal nerve 10) lateral femoral cutaneous nerve

Nerves of Gluteal Region and Thigh: Posterior View Netters

1) inferior gluteal artery and nerve 2) pudendal nerve (S2, S3, S4) 3) posterior cutaneous nerve of thigh 4) sciatic nerve (L4-S3) 5) tibial nerve (L4-S3) 6) common fibular nerve (L4-S2) 7) semimembranosus muscle 8) biceps femoris muscle (long head retracted) 9) piriformis muscle 10) superior gluteal artery and nerve § Comment: Nerves to the gluteal region and posterior thigh arise from the sacral plexus. They come largely from the anterior rami of L4-S4.The major nerves of the gluteal region are the superior and inferior gluteal nerves. The largest nerve of the sacral plexus is the sciatic nerve, made up of anterior rami of L4-S3. The sciatic nerve innervates all muscles of the posterior compartment of the thigh. Through its 2 terminal branches, the tibial and common fibular nerves, it also innervates all muscles below the knee. § Clinical: Intramuscular gluteal injections are given in the upper outer quadrant of the buttock to avoid injuring the sciatic nerve, which passes just inferior to or through the piriformis muscle in the middle of the gluteal region.

Metacarpophalangeal and Interphalangeal Ligaments:Anterior View Netters

1) joint capsule 2) flexor digitorum superfi cialis tendons (cut) 3) flexor digitorum profundus tendons 4) palmar ligaments (palmar plates) 5) deep transverse metacarpal ligaments 6) palmar metacarpal ligaments 7) palmar carpometacarpal ligaments **Comment: The metacarpophalangeal joints are biaxial condyloid synovial joints that participate in flexion and extension, abduction and adduction, and circumduction. These joints are reinforced by the palmar (volar) ligaments and 2 collateral ligaments on either side.The interphalangeal joints for digits 2 through 5 include a proximal interphalangeal joint and a distal interphalangeal joint. These joints are uniaxial synovial hinge joints that are reinforced by palmar ligaments and 2 collateral ligaments. They permit flexion and extension. The palmar ligaments prevent hyperextension. **Clinical: Fractures of the metacarpals can occur from direct blows (boxer fractures). They may not only disrupt the bones and ligaments but may also affect the pull of the muscle tendons that attach to the metacarpals. These fractures need to be carefully set so that optimal finger function can be achieved after the injury heals and the patient undergoes physical therapy.

Ligaments of Elbow Netters

1) joint capsule 2) radial collateral ligament 3) synovial membrane 4) articular cartilage 5) biceps brachii tendon 6) anular ligament of radius 7) ulnar collateral ligament 8) triceps brachii tendon **Comment: The elbow joint forms a uniaxial synovial hinge (ginglymus) joint that includes the humeroradial joint (between the capitulum of the humerus and the head of the radius) and the humeroulnar joint (between the trochlea of the humerus and the trochlear notch of the ulna). The joint also includes a proximal uniaxial radioulnar synovial (pivot) joint that participates in supination and pronation (rotation). Movements about the elbow include flexion and extension.The joint is stabilized by the laterally placed radial collateral ligament and medially placed triangular ulnar collateral ligament. The anular ligament holds the head of the radius in place.Blood is supplied to the elbow by branches of the brachial artery and recurrent collateral branches of the radial and ulnar arteries. **Clinical: A strong pull on the forearm, especially in children, can pull the head of the radius out of the anular ligament, resulting in a dislocation of the proximal radioulnar joint. Elbow dislocations occur 3rd in frequency after shoulder and finger dislocations.

Cutaneous Nerves and Superficial Veins of Forearm Netters

1) lateral antebrachial cutaneous nerve (from musculocutaneous nerve) 2) cephalic vein 3) median antebrachial vein 4) proper palmar digital nerves and palmar digital veins 5) perforating veins 6) basilic vein 7) anterior branch and posterior branch of medial antebrachial cutaneous nerve 8) basilic vein § Comment: Cutaneous nerves of the forearm arise from the musculocutaneous nerve, from the radial nerve, from the ulnar nerve, or directly from the brachial plexus.The principal superficial veins of the forearm are the cephalic vein and the basilic vein. These veins communicate in the cubital fossa via the median cubital vein (this card, 6-62, shows a common variation in which the median antebrachial vein drains into the cephalic and basilic veins proximally).Superficial veins communicate with deeper veins via perforating branches. The deeper veins accompany the radial and ulnar arteries and their major branches. The superficial and deep veins of the upper limb possess valves to assist in returning blood to the heart. § Clinical: The cephalic and basilic veins begin on the dorsum of the hand; because the hand is largely used for grasping objects, the arterial blood from the palmar arches is squeezed from the palm and drains into the dorsal venous plexus and thence into the cephalic and basilic veins. If the veins were on the palm, they would be squeezed shut every time we grasped something!

Tibia and fibula Netters

1) lateral condyle 2) apex, head and neck of fibula 3) fibula 4) lateral malleolus 5) medial malleolus 6) tibia 7) tibial tuberosity 8) medial condyle 9) superior articular surfaces (medial and lateral facets) 10) malleolar fossa of lateral malleolus § Comment: The tibia articulates with the condyles of the femur and is the weight-bearing bone of the leg.The smaller fibula lies posterolateral to the tibia. It exists largely for muscle attachment.The tibial tuberosity is the insertion site for the patellar ligament. The tendon of attachment for the quadriceps muscles of the anterior thigh that extend the leg at the knee joint inserts into the patella, which then attaches to the tibia via the patellar ligament.The proximal tibiofibular joint is a plane synovial joint that permits limited gliding movement. The distal tibiofibular joint is a fibrous joint (syndesmosis), which allows almost no movement. § Clinical: Fractures of the tibial shaft are the most common fractures of a long bone. Because the tibia lies just beneath the skin along the medial border of the leg, tibial shaft fractures often are open injuries (in which the skin is perforated).

Bones of Elbow: In 90° Flexion Netters

1) lateral epicondyle of humerus 2) capitulum 3) neck of radius 4) radius 5) ulna (radial notch, coronoid process, trochlear notch, olecranon) 6) humerus 7) head of radius 8) tuberosity 9) trochlear notch 10) groove for ulnar nerve on humerus 11) medial epicondyle of humerus **Comment: The bones of the elbow include the humerus and the 2 bones of the forearm: the radius and ulna. The ulna lies more medially in the forearm and is the longer of the 2 bones. The point of the elbow that can be easily felt is the olecranon, located posteriorly and proximally on the ulna. **Clinical: Dislocations of the elbow may be accompanied by fractures of the humeral epicondyle, olecranon (ulna), radial head, or coronoid process of the ulna. The median or ulnar nerve of the brachial plexus, or both, may be injured in elbow dislocations or fractures.Fractures of the proximal radius usually involve the head or neck of the radius.Ulnar fractures often occur from a direct blow to or forced pronation of the forearm and involve the ulnar shaft.

Palmaris longus muscle Netters

1) palmaris longus muscle 2) radius 3) palmar aponeurosis 4) hook of hamate 5) pisiform bone 6) ulna **Origin (proximal): Palmaris longus muscle arises from the medial epicondyle of the humerus by the common flexor tendon and the antebrachial (forearm) fascia. **Insertion (distal): Inserts into the anterior aspect of the distal flexor retinaculum and into the palmar aponeurosis. **Action: Flexes the hand at the wrist and tightens the palmar aponeurosis. **Innervation: Median nerve (C6 and C7). **Comment: The palmaris longus is vestigial in humans and is absent in 10% to 15% of the population. In other species, this muscle retracts the claws. In humans, it acts primarily at the wrist. **Clinical: By having the patient make a tight fist, one can determine if the patient possesses the palmaris longus muscle, as its tendon will appear in the midwrist. The median nerve lies just lateral to the tendon of this muscle before entering the carpal tunnel.

Superficial Nerves and Veins of Lower Limb: Anterior View Netters

1) lateral femoral cutaneous nerve 2) saphenous opening (fossa ovalis) 3) anterior femoral cutaneous nerves (from femoral nerve) 4) branches of lateral sural cutaneous nerve (from common fibular nerve) 5) dorsal metatarsal veins 6) dorsla venous arch 7) great saphenous vein 8) saphenous nerve (terminal branch of femoral nerve) 9) cutaneous branches of obturator nerve 10) great saphenous vein 11) femoral vein § Comment: The cutaneous nerves of the thigh and leg are branches of the femoral, obturator, and sciatic nerves. The lateral cutaneous nerve of the thigh arises directly from the lumbar plexus.The great saphenous vein arises from a plexus of dorsal veins over the foot. It ascends along the medial aspect of the leg, knee, and thigh to drain into the femoral vein. Numerous superficial tributaries drain into the great saphenous. Perforating branches from the saphenous vein and its tributaries communicate with deep veins accompanying the femoral and tibial arteries (see Card 7-68).The superficial and deep veins of the lower limb, similar to the veins of the upper limb, possess venous valves to aid in venous return to the heart against gravity. §Clinical: The great saphenous vein may be harvested and used as a vessel graft (e.g., in coronary bypass).The superficial veins of the lower limb may become varicose (dilated), usually because their valves become incompetent and allow venous blood to back up and reverse flow in the veins.

Knee: Interior (Superior View) Netters

1) lateral meniscus 2) iliotibial tract blended into capsule 3) patellar ligament (tendon) 4) ACL 5) synovial membrane 6) medial meniscus 7) oblique popliteal ligament 8) semimembranous tendon 9) PCL 10) popliteus tendon 11) lateral (fibular) collateral ligament § Comment: The knee is surrounded by a thin, fibrous capsule that is stabilized by the surrounding muscle attachments and intracapsular and extracapsular ligaments. Intracapsular ligaments include the anterior and posterior cruciate ligaments, medial and lateral menisci, and transverse ligament. Extracapsular ligaments include the medial and lateral collateral ligaments, patellar ligament, and arcuate and oblique popliteal ligaments.Of the 2 cruciate ligaments, the anterior is the weaker and is most taut when the knee is fully extended, preventing hyperextension. It is usually torn in hyperextension with the tibia medially (internally) rotated. The posterior cruciate tightens most during flexion of the knee, preventing excessive anterior displacement of the femur on the tibia or excessive posterior displacement of the tibia on the femur. Both cruciate ligaments maintain some level of tautness during movements of the knee.The tibial collateral ligament limits extension and abduction of the leg and is attached to the medial meniscus. The fibular collateral ligament limits extension and adduction of the leg. § Clinical: Rupture of the tibial collateral ligament, which is attached to the medial meniscus, may tear the medial meniscus. The medial meniscus is larger than the lateral meniscus.

Latissimus Dorsi Netters

1) latissimus dorsi muscle 2) teres major muscle 3) thoracolumbar fascia **Origin (proximal): Latissimus dorsi muscle arises from a broad aponeurosis of the posterior layer of the thoracolumbar fascia, from the spinous processes of the lower 6 thoracic vertebrae, and by fleshy digitations of the caudal-most 3 or 4 ribs. The muscle also may attach to the iliac crest. **Insertion (distal): The fibers of the latissimus dorsi muscle converge as the muscle curves around the lower border of the teres major and twists on itself. They end as a tendon that inserts into the intertubercular groove of the humerus. **Action: Extends, adducts, and medially rotates the humerus (arm). **Innervation: Thoracodorsal nerve (C6-C8). **Comment: With the upper extremity fixed, the latissimus dorsi elevates the trunk when the arms are stretched above the head, as when reaching up while climbing.The origin of the muscle from the thoracic vertebrae and lower ribs may vary.The blood supply is by the thoracodorsal artery, a branch of the subscapular artery (which arises from the axillary artery). **Clinical: The latissimus dorsi is tested clinically by having the patient raise the arm horizontal to the body with the elbow flexed, as if signaling someone to "stop." Then the patient is asked to adduct the arm against resistance to test the muscle's strength and the integrity of the thoracodorsal nerve. The muscle can also be felt to contract over the patient's back when the patient is asked to cough.

Ligaments of Wrist: Palmar View Netters

1) long radiolunate ligament 2) radioscaphocapitate ligament 3) short radiolunate ligament 4) lunate bone 5) scaphocapitate ligament 6) trapezium bone 7) ulnolunate ligament 8) ulnocapitate ligament 9) ulnotriquetral ligament 10) pisiform bone 11) triquetrocapitate ligament 12) capitate bone **Comment: The wrist, or radiocarpal joint, is an ellipsoid biaxial synovial joint formed by the distal end of the radius (an articular disc) and the scaphoid, lunate, and triquetrum carpal bones. This joint is reinforced by radial and ulnar collateral ligaments and by dorsal and palmar (volar) radiocarpal ligaments. The joint permits flexion, extension, abduction, adduction, and circumduction.Anatomists often simply lump these ligaments into a palmar radiocarpal ligament (long and short radiolunate and radioscaphocapitate ligaments [1-3 in the list above]), a palmar ulnocarpal ligament (ulnolunate, ulnocapitate, and ulnotriquetral ligaments), and various intercarpal and metacarpal ligaments.The carpometacarpal joint of the thumb is a biaxial saddle (sellar) joint (with trapezium). It provides flexion and extension, abduction and adduction, and circumduction. The other 4 carpometacarpal joints are plane synovial joints that permit gliding movements. **Clinical: Hand surgeons classify these ligaments more precisely based on their attachments, but anatomists lump them together (see the second paragraph above in the Comment section).

Sacrum and Coccyx Netters

1) lumbosacral articular surface 2) ala (lateral part) 3) coccyx 4) superior articular process 5) promontory 6) anterior (pelvix) sacral foramina 7) transverse process of coccyx 8) auricular surface 9) lateral sacral crest 10) median sacral crest 11) sacral hiatus 12) coccygeal cornu (horn) 13) sacral cornu (horn) 14) posterior sacral foramina § Comment: The wedge-shaped sacrum represents the 5 fused sacral vertebrae. Because it forms the posterior aspect of the pelvis, it provides stability and strength to the pelvic architecture. The articulation between the sacrum and pelvis is the strong sacroiliac joint; the description of this joint may be viewed on Card 5-1.Four pairs of anterior and posterior sacral foramina provide exits for the ventral and dorsal rami of spinal nerves.The coccyx is also a wedge-shaped bone; the 1st coccygeal segment is not fused, but the remaining 3 vertebrae are fused. § Clinical: Falling on your "tail bone" can actually fracture the coccyx or cause a fracture-dislocation of the sacrococcygeal joint. The coccyx is a remnant of our embryonic tail, which is present in early development but is largely absorbed, leaving no indication of our tail except for the small subcutaneous coccyx. If the remnant persists, it can be cosmetically corrected.

Brachioradialis jerk nerve roots

Brachioradialis jerk: C 5, 6

Muscles of Sole of Foot: Second Layer- Lumbrical muscles

1) lumbrical muscles 2) flexor digiti minimi brevis muscle 3) abductor digiti minimi muscle (cut) § Origin (proximal): Lumbrical muscles arise from the tendons of the flexor digitorum longus. The 1st, or most medial, lumbrical arises from the medial side of the tendon to the 2nd toe. The 2nd lumbrical arises from the 2 tendons that flank it, and the other 2 lumbricals arise from their flanking tendons. § Insertion (distal): The tendons of the lumbrical muscles pass below the deep transverse metatarsal ligaments. They are inserted into the extensor expansions of the extensor digitorum longus on the dorsal surface of the proximal phalanges. § Action: Similar to the lumbricals in the hand, the lumbricals in the foot flex the proximal phalanges at the metatarsophalangeal joints and extend the 2 distal phalanges of the 4 lateral digits. § Innervation: The 1st lumbrical is innervated by the medial plantar nerve (S2 and S3). The 3 lateral lumbricals are innervated by the lateral plantar nerve (S2 and S3). § Comment: The lumbrical muscles in the foot act in a manner similar to the lumbricals in the hand, which arise from the flexor digitorum profundus muscle tendons. § Clinical: It is difficult to isolate the action of the lumbrical muscles clinically. Three of the four lumbricals are innervated by the lateral plantar nerve.

Ligaments and Tendons of Ankle: Medial View Netters

1) medial collateral (deltoid) ligament of ankle (posterior tibiotalar part; tibiocalcaneal part; tibionavicular part; anterior tibiotalar part) 2) dorsal talonavicular ligament 3) navicular bone 4) tuberosity of 1st metatarsal bone 5) medial cuneiform bone 6) plantar calcaneonavicular (spring) ligament 7) long plantar ligament 8) calcaneal (achilles) tendon (cut) 9) tibia § Comment: The ankle (talocrural) joint is a hinge-type (ginglymus) uniaxial synovial joint between the tibia and fibula and the trochlea of the talus. This joint permits dorsiflexion (extension) and plantarflexion. Its thin, fibrous capsule is reinforced by the medial (deltoid) ligament, which has 4 parts, and the lateral collateral ligament, which has 3 parts.The medial (deltoid) ligament has 4 parts and limits eversion of the foot. This ligament helps maintain the medial long arch of the foot, whereas the plantar calcaneonavicular (spring) ligament provides strong plantar support for the head of the talus (which maintains the arch of the foot). § Clinical: Many ankle injuries are caused by twisting, so that the talus rotates in a frontal plane and impinges on either the lateral or medial malleolus. This movement causes a fracture of the malleolus and places tension on the supporting ligaments of the opposite side.

Metacarpophalangeal and Interphalangeal Ligaments: Medial Views Netters

1) metacarpal bone 2) joint capsule 3) Metacarpophalangeal (MP) joint 4) Proximal interphalangeal (PIP) joint 5) Distal interphalangeal (DIP) joint 6) phalangeal bones (proximal, middle, distal) 7) palmar ligament (palmar plate) 8) collateral ligament **Comment: The metacarpophalangeal joints are biaxial condyloid synovial joints that participate in flexion and extension, abduction and adduction, and circumduction. The capsule is supported by the collateral and palmar (volar) ligaments. The collateral ligaments are tight in flexion and loose in extension.The interphalangeal joints (proximal interphalangeal and distal interphalangeal) are uniaxial synovial hinge joints that participate in flexion and extension. Ligaments similar to the metacarpophalangeal joints reinforce these joints. The palmar ligaments prevent hyperextension. **Clinical: Dorsal dislocation of the proximal interphalangeal joint is fairly common. Palmar and rotational dislocations are uncommon but can occur. Distal dislocations or fractures of the distal interphalangeal joint may occur from a direct blow to the fingertip (mallet finger), as from a blow by a baseball or volleyball, often resulting in extensor tendon damage.

Superficial Nerves and Veins of Lower Limb: Posterior View Netters

1) middle cluneal nerves (from posterior rami of S1, S2, S3) 2) branches of posterior femoral cutaneous nerve 3) great saphenous vein 4) small saphenous vein 5) sural nerve 6) lateral sural cutaneous nerve (from common fibular nerve) 7) inferior cluneal nerves (from posterior cutaneous nerve of thigh) 8) superior cluneal nerves (from posterior rami of L1, L2, L3) § Comment: The sural nerve is formed by the union of cutaneous nerves from the tibial and common fibular nerves. It courses with the small saphenous vein.The small saphenous vein receives numerous superficial tributaries. Perforating branches from the small saphenous vein and its tributaries communicate with deep veins accompanying the tibial artery and its branches. The small saphenous vein drains into the popliteal vein behind the knee.The superficial and deep veins of the lower limb, similar to the veins of the upper limb, possess venous valves to aid in venous return to the heart against gravity (see Card 7-68). § Clinical: Inactivity and venous stasis can have grave consequences for the veins of the lower limb. Deep venous thrombosis can result and a thromboembolus can pass toward the heart and become lodged in the small capillary networks of the lung, obstructing a pulmonary artery.

Nerves of Upper Limb Netters

1) musculocutaneous nerve 2) radial nerve (deep branch; superficial branch) 3) median nerve 4) recurrent (motor) branch of median nerve to thenar muscles 5) common palmar digital branches of median nerve 6) superficial branch of ulnar nerve 7) median nerve 8) ulnar nerve 9) radial nerve § Comment: Nerves of the arm, forearm, and hand are derived from the 5 terminal branches of the brachial plexus. The musculocutaneous nerve innervates the flexors of the elbow, which are contained in the arm's anterior compartment. The radial nerve innervates the arm's posterior compartment, which contains muscles that extend the elbow.In the forearm, the radial nerve also innervates the extensors of the wrists and digits, and the median nerve innervates most of the flexors of the wrist and digits (although the ulnar nerve innervates 1 ½ muscles).The median and ulnar nerves innervate the intrinsic muscles of the hand, although the ulnar nerve predominates (innervates the hypothenar muscles, 2 lumbricals, the adductor pollicis muscle, and all the interossei). § Clinical: Median nerve injury can affect wrist and finger flexion and, in particular, the ability to effectively use the thumb and index and middle fingers. Ulnar nerve injury can present as a clawhand and an inability to effectively use the ring and little fingers, as well as a loss of abduction and adduction of the 2nd to 5th digits.

Movements of the Wrist Joint muscles

1)Flexion a)FCR and FCU - important b)Long flexors of thumb and fingers c)(PL, APL) 2)Extension a)ECRL, ECRB, ECU - important b)Long extensors of the thumb and fingers 3)Radial deviation a)APL, FCR, ECRL, ECRB 4)Ulnar deviation a)ECU, FCU

Movements of the Wrist Joint Inferior view

1)Flexion: a)FCR - important b) FCU - important c)Long flexors of thumb and fingers d) PL -Palmaris longus e) APL 2)Extension: a)ECRL- important b) ECRB- important c) ECU - important b)Long extensors of the thumb and fingers 3)Radial deviation (abduction): a)APL b) FCR c) ECRL d) ECRB e) Extensor pollicis brevis 4)Ulnar deviation (adduction): a)ECU b) FCU *need muscles acting together to get movements.

Brachial Plexus: Schema Netters

1) musculocutaneous nerves (C5-7) 2) axillary nerve (C5-C6) 3) radial nerve (C5-C8, T1) 4) Median nerve (C6-C8, T1) 5) Ulnar nerve (C7-C8, T1) 6) Thoracodorsal (middle subscapular) nerve (C6-8) 7) long thoracic nerve (C5-C7) 8) dorsal scapular nerve (C5) § Comment: The brachial plexus is formed by the anterior rami of C5-T1 spinal nerves. Its branches supply muscles of the shoulder, including superficial muscles on the back and anterior thoracic wall and all the muscles of the upper extremity.The 5 roots of the brachial plexus give rise to 3 trunks and to 3 anterior and 3 posterior divisions, which coalesce into 3 cords: the lateral, posterior, and medial cords (named for their relationships to the axillary artery). The 3 cords give rise to 5 terminal branches.The anterior rami of the spinal nerves that contribute fibers to each of the previously listed branches may vary from individual to individual, so it is wise to use caution in assigning absolute nerve components to each branch. This accounts for the variability seen in textbook descriptions of these nerves. §Clinical: Upper plexus injuries (C5-C6) (Erb's palsy) affect largely the muscles of the shoulder and arm and present as an extended elbow and flexed wrist (wristdrop) but a normal grasp. Lower plexus injuries (C7-T1) (Klumpke's palsy) affect primarily muscles of the forearm and hand; the patient has a weak grasp owing to the loss of flexion.

obturator externus muscle Netters

1) obturator externus muscle 2) adductor longus muscle (cut and reflected) 3) pectineus muscle (cut and reflected) 4) quadratus femoris muscle 5) pectineus muscle (cut and reflected) 6) adductor brevis muscle (cut and reflected) 7) adductor longus muscle (cut and reflected) 8) tendon of adductor magnus muscle. § Origin (proximal): The flat, triangular obturator externus muscle covers the outer surface of the pelvis. It arises from the margins of the obturator foramen and obturator membrane. § Insertion (distal): The fibers of the broad obturator externus muscle converge and course behind the neck of the femur to insert on the intertrochanteric fossa. § Action: Obturator externus muscle laterally rotates the thigh at the hip and helps steady the head of the femur in the acetabulum of the pelvis. § Innervation: Obturator nerve (L3 and L4). § Comment: The gluteus maximus and medius muscles help the obturator externus rotate the hip laterally.The obturator externus muscle lies deep in the medial compartment of the thigh and is visible only when the pectineus muscle is reflected. § Clinical: Although it is combined with the medial adductor groups of muscles, the obturator externus is really a lateral rotator of the thigh at the hip. During a clinical examination, this lone muscle is difficult to separate from other muscles that are lateral rotators (some gluteal muscles).

Obturator internus muscle Netters

1) obturator internus muscle 2) pirformis muscle 3) superior gluteal nerve 4) inferior gluteal nerve (passing to gluteus maximus muscle) 5) pudendal nerve (to perineum) 6) ischial tuberosity 7) sciatic nerve (cut) 8) greater trochanter of femur § Origin (proximal): Obturator internus muscle arises from the pelvic aspect of the obturator membrane and the pelvic bones surrounding the obturator foramen. § Insertion (distal): Obturator internus muscle inserts on the medial surface of the greater trochanter of the femur. § Action: Obturator internus muscle laterally rotates the extended thigh at the hip joint and abducts the flexed thigh at the hip. The muscle also steadies the femoral head in the acetabulum. § Innervation: Nerve to the obturator internus (L5 and S1). § Comment: The obturator internus has an extensive area of origin from within the pelvis, but it quickly tapers into a narrow muscle belly and tendon. The muscle leaves the pelvis through the lesser sciatic foramen and courses to its insertion. Its sides are bounded by the 2 gemelli. § Clinical: Along with the 2 gemelli, the obturator internus forms the "triceps of the hip" (triceps coxae). These 3 muscles act as a functional unit. A bursa exists over the posterior border of the ischium and allows the tendon of the muscle to glide easily over this bony region.

Label this ulna

1) olecranon 2) radial notch 3) coronoid process 4) trochlear notch 5) coronoid process 6) tuberosity of ulna (brachialis inserts here)

Opponens digiti minimi muscle Netters

1) opponens digiti minimi muscle 2) abductor digiti minimi muscle (cut) 3) radial artery 4) superficial palmar branch of radial artery 5) opponens pollicis muscle 6) adductor pollicis muscle 7) common palmar digital arteries § Origin (proximal): Opponens digiti minimi muscle arises from the hook of the hamate bone and the flexor retinaculum. § Insertion (distal): Inserts on the palmar surface of the body of the 5th metacarpal. § Action: Abducts, flexes, and laterally rotates the 5th metacarpal, enhancing the cupping of the hand, increasing the power of the grip, and opposing the little finger to the thumb. § Innervation: Deep branch of the ulnar nerve (C8 and T1). § Comment: The opponens digiti minimi muscle is 1 of the 3 muscles that make up the hypothenar muscles, which constitute the intrinsic muscles of the little finger. All of these muscles are innervated by deep branches of the ulnar nerve and supplied by deep branches of the ulnar artery. § Clinical: To clinically test opposition, have the patient touch the tips of the thumb and little finger together and then, with a finger on the patient's thenar and hypothenar eminence, try to pull the opposed fingers apart to test the strength of the opponens muscles.

Opponens pollicis muscle Netters

1) opponens pollicis muscle 2) 1st dorsal interosseus muscle 3) first 2 lumbrical muscles (reflected) § Origin (proximal): Opponens pollicis muscle arises from the flexor retinaculum and the trapezium bone. § Insertion (distal): Attaches to the lateral side of the 1st metacarpal bone. § Action: Pulls and rotates the 1st metacarpal in a medial fashion across the palm, opposing the thumb against the fingers. § Innervation: Recurrent branch of the median nerve (C8 and T1). § Comment: The opponens pollicis muscle is 1 of the 3 muscles that make up the thenar muscles at the base of the thumb. The thenar muscles are all innervated by the recurrent branch of the median nerve. § Clinical: The opponens pollicis muscle is tested clinically by asking the patient to touch the base of the little finger with the thumb while resistance is provided to the palmar side of the base of the thumb.As with all of the thenar muscles, injury in the palm before the origin of the recurrent branch of the median nerve will denervate these muscles. If the median nerve injury is confined to the wrist and/or hand, then all the forearm muscles innervated by the median nerve should still be functional.

Movements of the Wrist Joint

1)Flexion: a)FCR and FCU - important b)Long flexors of thumb and fingers c)(PL, APL) 2)Extension: a)ECRL, ECRB, ECU - important b)Long extensors of the thumb and fingers 3)Radial deviation (abduction): a)APL, FCR, ECRL, ECRB 4)Ulnar deviation (adduction): a)ECU, FCU *need muscles acting together to get movements.

Pectineus muscle Netters

1) pectineus muscle 2) iliopsoas muscle (cut) 3) vastus lateralis muscle 4) vastus medialis muscle § Origin (proximal): Pectineus muscle arises from the pecten of the pubic bone. § Insertion (distal): Pectineus muscle inserts on the pectineal line of the shaft of the femur just inferior to the lesser trochanter. § Action: Pectineus muscle adducts and flexes the thigh at the hip joint and assists with medial rotation of the thigh. § Innervation: Femoral nerve (L2 and L3) and occasionally a branch from the obturator nerve. § Comment: The pectineus muscle is medial to the iliopsoas and forms a portion of the floor of the femoral triangle. The muscle is usually flat and quadrangular.The pectineus is unusual in that it is a muscle of the medial compartment of the thigh (adductor muscles) but is innervated largely by the femoral nerve, a nerve more often associated with the anterior compartment of the thigh (extensors of the leg at the knee). § Clinical: Because the pectineus muscle may have a dual innervation (femoral and obturator), it really is a muscle that is "caught" between 2 compartments of the thigh (the anterior extensor and medial adductor compartments). The femoral canal lies just superficial to this muscle.

Piriformis muscle Netters

1) piriformis muscle 2) biceps femoris (long head cut) 3) biceps femoris (short head cut) 4) popliteus muscle § Origin (proximal): Piriformis muscle arises from the anterior surface of the 2nd, 3rd, and 4th sacral segments and the sacrotuberous ligament. § Insertion (distal): Piriformis muscle inserts by a round tendon into the greater trochanter of the femur. § Action: The piriformis abducts the flexed thigh at the hip and helps stabilize the hip joint. It also laterally rotates the extended thigh. § Innervation: Anterior rami of S1 and S2. § Comment: The piriformis muscle is a pyramid-shaped muscle that arises within the pelvis and passes through the greater sciatic foramen as it courses to its insertion. The sacral nerve plexus is formed largely on the surface of the piriformis muscle within the pelvis. In the gluteal region, the sciatic nerve may pass through the piriformis muscle; more often, it emerges just inferior to the muscle's belly. § Clinical: Because of the close relationship of the piriformis muscle to the large sciatic nerve, hypertrophy or spasm of this muscle can compress the sciatic nerve, causing significant pain. This is most common in athletes who use these muscles frequently (e.g., ice hockey players, figure skaters, rock climbers, cyclists)

Plantaris muscle Netters

1) plantaris muscle 2) common fibular nerve (cut) 3) plantaris muscle tendon 4) fibularis longus tendon 5) fibularis brevis tendon 6) superior fibular retinaculum 7) flexor retinaculum § Origin (proximal): Plantaris muscle arises from the inferior end of the lateral supracondylar line of the femur and oblique popliteal ligament. § Insertion (distal): Plantaris muscle's long, slender tendon crosses obliquely between the gastrocnemius and soleus and inserts into the posterior part of the calcaneus, often fusing with the calcaneal tendon. § Action: Plantaris muscle weakly assists the gastrocnemius in plantarflexion of the foot at the ankle and flexion of the leg at the knee. § Innervation: Tibial nerve (S1 and S2). § Comment: The gastrocnemius, soleus, and plantaris muscles form the superficial group of muscles in the posterior compartment of the leg. The tibial nerve and posterior tibial vessels run just deep to these 3 muscles. § Clinical: The plantaris muscle is absent in a small proportion of the population (5% to 10%) and is vestigial in humans. The small tendon may be used for grafting, especially in reconstructive surgery of the hand where tendons may have been damaged beyond repair.

Popliteus muscle Netters

1) poplietus muscle 2) plantaris muscle 3) calcaneal tuberosity § Origin (proximal): Popliteus muscle arises from the lateral surface of the lateral condyle of the femur and the capsule of the knee joint. This muscle has a tendinous attachment to the lateral meniscus of the knee. § Insertion (distal): Popliteus muscle inserts on the posterior surface of the tibia, superior to the soleal line. § Action: Popliteus muscle flexes and medially rotates the leg at the knee. When the limb is supporting weight, the popliteus rotates the femur laterally on the tibia to "unlock" the knee joint. § Innervation: Tibial nerve (L4, L5, and S1). § Comment: The thin, flat, triangular popliteus muscle forms the distal part of the floor of the popliteal fossa. § Clinical: A small bursa lies between the tendon of the popliteus muscle and the lateral tibial condyle. The popliteus tendon runs over this bursa and lies just deep to the fibular collateral ligament of the knee joint. Once the knee is unlocked, the popliteus assists the hamstrings in flexion of the leg at the knee.

Arteries of Leg: Posterior View Netters

1) popliteal artery and tibial nerve 2) posterior tibial artery 3) medial plantar artery and nerve 4) lateral plantar artery and nerve 5) fibular artery (perforating branch and communicating branch) 6) fibular artery 7) fibular artery 8) anterior tibial artery 9) inferior lateral genicular artery 10) superior lateral genicular artery § Comment: The posterior tibial artery is a continuation of the popliteal artery. Below the knee, it gives rise to the fibular artery, which courses deep to the flexor hallucis longus muscle.As the posterior tibial artery passes inferiorly to the medial malleolus and enters the sole of the foot, it divides into medial and lateral plantar arteries.The tibial nerve accompanies the posterior tibial artery along most of its course. § Clinical: The tibial artery pulse can be felt midway between the medial malleolus and the calcaneal tendon. This artery passes beneath the sustentaculum tali of the calcaneus with the tibial nerve and long flexor tendons.Atherosclerosis also can affect the arteries of the lower limb, causing arterial stenosis or occlusion (peripheral vascular disease).

Knee: Interior (Inferior View) Netters

1) popliteus tendon 2) fibular collateral ligament 3) ACL 4) arcuate popliteal ligament 5) tibial collateral ligament (superficial and deep parts) 6) PCL 7) suprapatellar synovial bursa 8) patellar ligament § Comment: The knee is surrounded by a thin, fibrous capsule that is stabilized by the surrounding muscle attachments and intracapsular and extracapsular ligaments. Intracapsular ligaments include the anterior and posterior cruciate ligaments, medial and lateral menisci, and transverse ligament. Extracapsular ligaments include the medial and lateral collateral ligaments, patellar ligament, and arcuate and oblique popliteal ligaments.Of the 2 cruciate ligaments, the anterior is the weaker and is most taut when the knee is fully extended, preventing hyperextension. The posterior cruciate tightens most during flexion of the knee, preventing excessive anterior displacement of the femur on the tibia or excessive posterior displacement of the tibia on the femur. § Clinical: Rupture of the anterior cruciate ligament is a common athletic injury, usually associated with a sharp turn when the knee is twisted medially while in extension and the foot is firmly on the ground. The anterior drawer test assesses this injury. If the anterior cruciate ligament has been injured, the tibia will move anteriorly more than 5 mm, indicating a positive test result. The anterior cruciate ligament normally limits knee hyperextension. The posterior cruciate ligament is most taut during knee hyperflexion.

Meninges and Nerve Roots Netters

1) posterior root of spinal nerve 2) spinal ganglion 3) anterior ramus of spinal nerve 4) dura mater 5) arachnoid mater 6) subarachnoid space 7) pia mater overlying spinal cord 8) denticulate ligament § Comment: Posterior (dorsal) and anterior (ventral) nerve filaments combine in the intervertebral foramen to form the posterior and anterior roots of the spinal nerve. Just distal to this point lies the spinal sensory, or posterior root, ganglion. The spinal ganglion contains the sensory nerve cell bodies. Each spinal nerve divides into a very large anterior ramus and a much smaller posterior ramus.About 20 pairs of denticulate ligaments anchor the spinal cord to the dura. Denticulate ligaments are pial extensions that pass laterally between the posterior and anterior roots of spinal nerves to attach to the dura.The spinal cord is surrounded by 3 meningeal layers: the fibrous, tough outer dura mater, the middle arachnoid mater, and the investing pia mater. Cerebrospinal fluid is found in the space between the arachnoid mater and pia mater (subarachnoid space). § Clinical: The subarachnoid space (brain and spinal cord) contains about 150 mL of cerebrospinal fluid. The pressure of this fluid can be measured or sampled for laboratory analysis to determine if an infection is present somewhere in the central nervous system.

Arteries of Spinal Cord: Intrinsic Distribution Netters

1) posterior spinal arteries 2) anterior spinal artery 3) anterior radicular artery 4) dorsal branch of posterior intercostal artery 5) posterior intercostal artery 6) thoracic (descending) aorta 7) anterior segmental medullary artery 8) anterior spinal artery 9) pial arterial plexus 10) right posterior spinal artery § Comment: Arteries supplying the spinal cord are derived from branches of the vertebral, ascending cervical, posterior intercostal, lateral sacral, and lumbar arteries. Generally, a single longitudinal anterior spinal artery and 2 longitudinal posterior spinal arteries course the length of the spinal cord.Segmental radicular arteries accompany the posterior and anterior roots of the spinal nerves. Anastomoses between the anterior and posterior spinal arteries and the segmental medullary branches form a pial arterial plexus. § Clinical: The anterior spinal artery and paired dorsal spinal arteries provide the main blood supply to the spinal cord. However, this supply is supplemented by radicular arteries from the aorta. If the blood flow through these radicular arteries is impaired (e.g., during surgery or if a fracture, dislocation, or other injury has occurred), the spinal cord may become ischemic and a spinal infarct can result.

Pronator teres Netters

1) pronator teres muscle 2) pronator quadratus muscle **Origin (proximal): The pronator teres has 2 heads. The humeral head arises immediately above the medial epicondyle from the common flexor tendon, intermuscular septum, and antebrachial fascia. The ulnar head arises from the medial side of the coronoid process of the ulna.The pronator quadratus arises from the medial aspect of the anterior surface of the distal one-fourth of the ulna. **Insertion (distal): The pronator teres inserts about midway along the lateral surface of the radius.The pronator quadratus inserts into the distal fourth of the lateral border and anterior surface of the shaft of the radius. **Action: The pronator teres rotates the radius on the ulna (pronation) and helps flex the forearm at the elbow.The pronator quadratus pronates the hand. It is assisted by the pronator teres when additional power is required. **Innervation: Both muscles are innervated by the median nerve (pronator teres—C6 and C7; pronator quadratus—C8 and T1). **Comment: The pronator teres is well suited for quick, powerful pronation. The pronator quadratus is the deepest muscle in the forearm, and its contraction is difficult to show. **Clinical: One clinically tests the pronator teres by grasping the patient's hand with the forearm extended and asking the patient to pronate against resistance (turn the hand downward) while watching the medial epicondyle of the humerus to see if the muscle contracts.

Muscles in Cross Section of Forearm Netters

1) pronator teres muscle 2) supinator muscle 3) flexor carpi radialis muscle 4) flexor pollicis longus muscle 5) extensor digitorum muscle 6) pronator quadratus muscle 7) flexor digitorum profundus muscle 8) flexor carpi ulnaris muscle 9) flexor digitorum superficialis muscle 10) ulna ?? (what the card says although points at muscle) 11) interosseus membrane § Comment: Muscles of the forearm are divided into an anterior compartment and a posterior compartment. Muscles in the anterior compartment are largely flexors at the wrist and of the fingers (and 2 are pronators). Muscles in the posterior compartment generally are extensors at the wrist and of the fingers (and 1 is a supinator muscle).Muscles of the anterior, or flexor, compartment of the forearm are innervated largely by the median nerve and its branches. Only the flexor carpi ulnaris and the medial half of the flexor digitorum profundus are innervated by the ulnar nerve and its branches.Muscles of the posterior compartment of the forearm are innervated by the radial nerve and its branches. § Clinical: Rarely do muscles act alone, but rather they contract and function on a joint by acting together. Therefore, it is important to think of them in compartments based on their function (e.g., extensors or flexors) and know which nerve and vessels supply the muscles of that compartment.

Psoas Major Muscle Netters

1) psoas major muscle 2) quadratus lumborum muscle 3) iliopectineal bursa 4) iliofemoral ligament (Y ligament of bigelow) 5) greater trochanter of femur § Origin (proximal): Psoas major muscle arises from the transverse processes of all 5 lumbar vertebrae and from the sides of the T12-L5 vertebrae and the intervertebral discs between them. § Insertion (distal): Psoas major muscle tapers inferiorly, crossing in front of the sacrum and sacroiliac joint to join with the iliacus muscle and to insert on the lesser trochanter of the femur. § Action: With the iliacus, the psoas major flexes the thigh at the hip and is an important flexor of the trunk at the hip. Acting alone, it laterally flexes the trunk ipsilaterally. It is also used to balance the trunk when a person is in a sitting position. § Innervation: Anterior rami of lumbar nerves L1-L3. § Comment: The psoas major and iliacus muscles are commonly referred to as the iliopsoas muscle because they act in unison. Their action is especially important in flexing the trunk against gravity, as when a person does sit-ups with the legs straight (hips extended).About half the population has a smaller muscle, the psoas minor, on the anterior surface of the psoas major. § Clinical: The psoas major (iliopsoas complex) is tested clinically by having the patient flex the thigh at the hip joint against resistance (with the leg also flexed at the knee).

Quadratus femoris muscle Netters

1) quadratus femoris muscle 2) gluteus medius muscle (cut) 3) gluteus minimus muscle 4) gluteus maximus muscle (cut) 5) sacrospinous ligament 6) sacrotuberous ligament 7) biceps femoris (long head) § Origin (proximal): Quadratus femoris muscle arises from the lateral border of the ischial tuberosity. § Insertion (distal): Quadratus femoris muscle inserts on the quadrate tubercle on the intertrochanteric crest of the femur and inferior to it. § Action: Quadratus femoris muscle rotates the thigh laterally. § Innervation: Nerve to the quadratus femoris (L5 and S1). § Comment: As its name implies, the small, flat quadratus femoris muscle is quadrilateral in shape.The piriformis, obturator internus, superior and inferior gemelli, and quadratus femoris function as short lateral rotators at the hip. All of these muscles insert near the trochanteric fossa and help rotate the extended femur laterally. They also stabilize the hip joint by steadying the head of the femur in the acetabulum. § Clinical: A trochanteric bursa protects the muscles that insert at or near the greater trochanter, and inflammation of this bursa (bursitis) is common. The pain is especially acute when the patient abducts and laterally rotates the thigh at the hip against resistance.

Muscles of Sole of Foot: Second Layer- Quadratus plantae muscle

1) quadratus plantae muscle 2) flexor hallucis longus tendon 3) superficial branches of medial plantar artery and nerve 4) lateral plantar artery and nerve 5) tibialis posterior tendon 6) flexor hallucis longus tendon § Origin (proximal): Quadratus plantae muscle has 2 heads. The larger medial head arises from the medial surface of the calcaneus; the lateral head arises from the lateral border of the calcaneus. § Insertion (distal): The 2 portions of the quadratus plantae muscle join into a flattened muscular band that inserts into the posterolateral margin of the tendon of the flexor digitorum longus. § Action: Quadratus plantae muscle helps the flexor digitorum longus flex the terminal phalanges of the 4 lateral toes. § Innervation: Lateral plantar nerve (S2 and S3). § Comment: The quadratus plantae is unique, having no equivalent in the hand. Its primary role is to modify the effect of the flexor digitorum longus, which tends to pull obliquely across the foot. The quadratus plantae corrects this oblique motion. § Clinical: Like many of the muscles of the sole of the foot, the quadratus plantae muscle helps with flexion of the toes and helps to maintain the arches of the foot and balance.

Arteries of Hand: Palmar View Netters

1) radial artery 2) superficial palmar branch of radial artery 3) proper palmar digital nerves and arteries 4) common palmar digital nerves and arteries 5) superficial palmar (arterial) arch 6) deep palmar branch of ulnar artery and deep branch of ulnar nerve 7) ulnar artery and nerve § Comment: The superficial palmar arch is a continuation of the ulnar artery. It anastomoses with the superficial palmar branch of the radial artery. From this superficial arch arise common palmar digital arteries, which divide into proper palmar digital arteries.A deep palmar arch exists deeper within the palm. It is the terminal part of the radial artery, and it anastomoses with the deep palmar branch of the ulnar artery. Perforating branches join the superficial and deep palmar arches. § Clinical: Allen's test is used to test the vascular perfusion distal to the wrist. The examiner's thumbs are placed lightly on the patient's ulnar and radial arteries as the patient makes a tight fist to "blanch" the palmar skin. Then, compressing the radial artery with the thumb, the examiner releases the pressure on the ulnar artery and asks the patient to open the clenched fist. Normally, the skin should turn pink immediately, indicating normal ulnar artery blood flow through the anastomotic palmar arches. Then, the test is repeated by occluding the ulnar artery to assess radial artery flow.

Bones of Elbow: In Extension Netters

1) radial fossa 2) capitulum 3) head 4) tuberosity (radius) 5) coronoid fossa 6) medial epicondyle 7) trochlea of humerus 8) tuberosity (ulna) 9) olecranon fossa 10) groove for ulnar nerve on humerus 11) lateral epicondyle 12) olecranon 13) head 14) neck **Comment: The elbow bones include the humerus and the 2 bones of the forearm: the radius and ulna. The ulna lies more medially in the forearm and is the longer of the 2 bones. The point of the elbow that can be easily felt is the olecranon, located posteriorly and proximally on the ulna. ** Clinical: Dislocations of the elbow joint are 3rd in frequency after shoulder and finger dislocations and usually result from a fall on an outstretched hand. Posterior dislocations are the most common type.

Rectus femoris muscle Netters

1) rectus femoris muscle 2) pectineus muscle 3) inguinal ligament § Origin (proximal): Rectus femoris muscle arises by 2 separate heads, a straight head from the anterior inferior iliac spine and a reflected head from the ilium just superior to the acetabulum. § Insertion (distal): The tendons of origin of the rectus femoris muscle combine to form a fusiform muscle belly that inserts into the quadriceps tendon. This tendon inserts into the base of the patella and, by extension of the patellar ligament, into the tibial tuberosity. § Action: The rectus femoris muscle acts on the knee through the patellar ligament and is an extensor of the leg at the knee joint. Because it also crosses the hip joint, it helps the iliopsoas flex the thigh at the hip. § Innervation: Femoral nerve (L2, L3, and L4). § Comment: The rectus femoris and the 3 vastus muscles form the quadriceps femoris complex. These muscles are powerful extensors of the knee. Of the 4 quadriceps muscles, only the rectus femoris crosses the hip and the knee joints. § Clinical: The rectus femoris muscle acts in concert with the other 3 muscles of the quadriceps femoris. It is tested clinically by having the patient extend the leg, flexed at the knee, against resistance. When the thigh is also flexed at the hip during this test, one can see the contraction of the rectus femoris muscle. This muscle may be injured in sporting events where active kicking is required; it is susceptible to injury at its origin (especially the anterior inferior iliac spine).

Thoracic vertebrae Netters

1) vertebral foramen 2) lamina 3) pedicle 4) body 5) inferior articular process and facet 6) spinous process 7) inferior vertebral notch 8) inferior costal facet 9) transverse costal facet 10) superior costal facet § Comment: Typical thoracic vertebrae have costal facets. The superior costal facet articulates with the head of the corresponding rib, the inferior facet articulates with the rib below, and the transverse costal facet articulates with the tubercle of the corresponding rib.The body, pedicle, and lamina enclose the vertebral foramen, which houses the spinal cord and its meningeal coverings.The spinous processes of the thoracic vertebrae are long and oriented posteriorly.The thoracic region of the spine allows for some movement but is constrained by the articulation of the ribs to the vertebrae posteriorly and the sternum anteriorly. § Clinical: The thoracic vertebrae articulate with the ribs and provide a stout "thoracic cage" that protects the thoracic viscera. Movement of the thoracic spine is limited compared with the lumbar and cervical spine. Osteoporosis, a metabolic bone disease, occurs when the bones lose calcium. The bodies of the vertebrae are the most susceptible to osteoporosis and may fracture.

Extrinsic Muscles of Back Netters

1) rhomboid major muscle 2) rhomboid minor muscle 3) accessory nerve (CNXI) innervating trapezius muscle 4) trapezius muscle (reflected) 5) posterior cutaneous branches (from medial branches of dorsal rami of C4-T6 spinal nerves) 6) latissimus dorsi muscle 7) posterior cutaneous branches (from lateral branches of dorsal rami of T7-T12 spinal nerves). § Origin: The rhomboid minor muscle arises from the ligamentum nuchae and the spinous processes of the C7 and T1 vertebrae. The rhomboid major muscle arises from the supraspinous ligaments and the spinous processes of the T2-T5 vertebrae. § Insertion: The fibers of these 2 muscles often blend together and attach to the medial border of the scapula from about the level of the spine to the inferior angle. The rhomboid minor also attaches to the smooth triangular surface at the medial end of the spine of the scapula. § Action: These muscles retract the scapula and rotate it to depress the glenoid cavity. They also fix the scapula to the thoracic wall. They assist in forcibly lowering the raised upper limb. § Innervation: Dorsal scapular nerve (C4 and C5). § Comment: The rhomboid minor and rhomboid major muscles are superficial back muscles. Most superficial back muscles have attachments to the scapula and are involved with movements of the upper limb. The rhomboid major is about 2 times wider than the rhomboid minor. § Clinical: Damage to the dorsal scapular nerve can weaken the rhomboid muscles, resulting in an ipsilateral shift of the scapula as the pull of the other scapular muscles draws the bone toward the shoulder (winged scapula). The rhomboids may be tested clinically by having the patient place the hands posteriorly on the hips and then push the elbows posteriorly against resistance.

Intrinsic Muscles of Back: Deep Layers Netters

1) rotatores cervicis muscle (longus; brevis) 2) rotatores thoracis muscle (longus; brevis) 3) Levatores costarum muscle (longus; brevis) 4) multifidus lumborum muscles 5) multifius thoracis muscles 6) semispinalis thoracis muscle 7) semispinalis capitis muscle § Comment: This plate shows the deepest layer of back muscles, which includes the transversospinal, or paravertebral, muscles. The transversospinal muscles include the semispinalis, multifidi, and rotatores. Most of these muscles arise from the transverse processes of adjacent vertebrae. They pass superiorly to attach to spinous or transverse processes of vertebrae above.The transversospinal muscles are important for stabilizing the vertebrae during movements of the vertebral column, and they can assist in extension and rotary movements of the vertebrae. All are innervated by posterior rami of the respective spinal nerves in each region. § Clinical: Clinicians often refer to the transversospinal muscles simply as the paravertebral muscles because they form a solid mass of muscle tissue interposed between the transverse and spinous processes.Myofascial back pain is a syndrome that is common but poorly understood. It involves localized musculoskeletal pain (deep aching or burning pain) associated with specific trigger points, usually over the erector spinae muscles that maintain posture, especially in the neck and lower back.

Thigh Muscles cross section Netters

1) sartorius muscle 2) tensor fascia latae muscle 3) vastus lateralis muscle 4) Biceps femoris (short head; long head) 5) adductor magnus muscle 6) gracilis muscle 7) semitendinous muscle 8) gracilis muscle § Comment: The thigh muscles are divided into 3 compartments. The anterior compartment contains the quadriceps femoris group, which extend the knee. The medial compartment contains the adductors of the thigh at the hip. The posterior compartment contains the hamstring muscles, which flex the knee and extend the hip.In general, muscles of the anterior compartment are innervated by the femoral nerve; muscles of the medial compartment, by the obturator nerve; and muscles of the posterior compartment, by the sciatic nerve (mostly the tibial portion of the sciatic nerve). These generalizations are a good way to categorize these thigh muscles and remember their innervations, but exceptions to each of these generalizations exist for each compartment. § Clinical: Sensory changes to the femoral nerve can be detected over the anterior thigh, medial knee, and medial aspect of the leg. Obturator sensory changes are detected over the medial thigh and sciatic nerve changes over the midposterior thigh, knee, posterolateral leg, and entire sole of the foot.

Sartorius muscle Netters

1) sartorius muscle 2) tensor fasciae lata muscle 3) vastus medialis muscle 4) rectus femoris tendon (becoming part of quadriceps femoris tendon) 5) patellar ligament § Origin (proximal): Sartorius muscle arises from the anterior superior iliac spine. § Insertion (distal): Sartorius muscle inserts on the superior portion of the medial surface of the tibial shaft, close to the insertions of the gracilis and semitendinosus muscles. § Action: The sartorius muscle crosses the hip and knee joints. Consequently, it is a flexor, abductor, and lateral rotator of the thigh at the hip joint. It is also a flexor of the leg at the knee joint. Along with other muscles originating from the pelvis, it helps to balance the pelvis. § Innervation: Femoral nerve (usually anterior rami of L2 and L3). § Comment: Sartorius is Latin for "tailor." By sitting cross-legged in a tailor's position, one can appreciate the function of the sartorius muscle. § Clinical: The sartorius muscle is the longest muscle in the human body. Because it crosses 2 joints, it acts on both of them (hip and knee). However, despite its length, the sartorius is not a particularly strong muscle.

Bones of Wrist and Hand Netters

1) scaphoid and its tubercle 2) trapezium and its tubercle 3) trapezoid bone 4) metacarpal ones 5) proximal phalanges bones 6) middle phalanges bones 7) distal phalanges bones 8) capitate bone 9) lunate bone **Comment: Bones of the wrist and hand include the 8 carpal bones; 5 metacarpal bones (1 for each digit); and, for digits 2 through 5, proximal, middle, and distal phalanges. The 1st digit, or thumb, has only a proximal phalanx and a distal phalanx.The scaphoid, lunate, and triquetrum articulate with the distal radius to form the radiocarpal wrist joint. **Clinical: The scaphoid is the most commonly fractured carpal. The scaphoid lies just below the "anatomical snuffbox" (dorsal region at the base of the thumb), so pain and swelling are common over this area. The 5th metacarpal is the most commonly fractured metacarpal, and the distal phalanx of the middle finger is the most commonly fractured digit of the hand.

Motor Peripheral Supply to hip, buttock and thigh

1)Anterior Compartment of the Thigh: a)Femoral Nerve b) Derived from posterior divisions of lumbar plexus (L234) 2)Medial Compartment of the Thigh: a)Obturator Nerve b)Derived from anterior divisions of the lumbar plexus (L234) 3)Posterior Compartment of the Thigh: a)Sciatic nerve ( from lumbosacral plexus: L3,4, 5, and S1,2) 4)Gluteal Compartment of the Thigh: a)Superior gluteal nerve (L45S1) - gluteus medius and minimus b)Inferior gluteal nerve (L5S12) - gluteus maximus

Semimembranosus muscle Netters

1) semimembranosus muscle 2) semitendinous muscle (retracted) 3) gracilis muscle 4) ischial tuberosity 5) obturator internus muscle 6) vastus lateralis muscle deep to iliotibial tract 7) common fibular nerve 8) plantaris muscle § Origin (proximal): Semimembranosus muscle arises by a thick tendon from the ischial tuberosity. § Insertion (distal): The tendon of the semimembranosus muscle inserts on the posteromedial aspect of the medial condyle of the tibia. The tendon of insertion also gives rise to a lateral expansion into the knee joint capsule, forming much of the oblique popliteal ligament. A few fascial expansions may reinforce the medial patellar retinaculum. § Action: The muscle flexes the leg at the knee and rotates the flexed leg medially. It also extends the thigh at the hip joint. With the hip and knee flexed, it extends the trunk. § Innervation: Sciatic nerve, tibial division (L5, S1, and S2). § Comment: The semimembranosus is 1 of the 3 muscles making up the hamstrings. Although the muscle is tendinous at its origin and its insertion, the middle portion is long and flat, resembling a membrane. § Clinical: The hamstrings are collectively tested by having the supine patient flex the limb 90° at the hip and knee and then further flex the knee against resistance. Hamstring muscle pulls or tears are common athletic injuries. They occur especially commonly just as the heel of the foot hits the ground and the muscles are maximally stretched (knee extension and hip flexion).

Intrinsic Muscles of Back Netters - semispinalis capitis

1) semispinalis capitis muscle 2) splenius capitis and cervicis muscle 3) rectus capitis posterior minor muscle 4) obliquus capitis superior muscle 5) rectus capitis posterior major muscle 6) obliquus capitis inferior muscle § Origin (Inferior Attachment): The semispinalis capitis muscle arises by a series of tendons from the transverse processes of the first 6 or 7 thoracic vertebrae and the lower cervical vertebra. § Insertion (Superior Attachment): This broad muscle inserts between the superior and inferior nuchal lines of the occipital bone. § Action: Extends the head and cervical spine, and rotates the head so that the face turns toward the opposite side. § Innervation: Posterior rami of cervical spinal nerves. § Comment: The semispinalis capitis is 1 of 3 groups of semispinalis muscles. The other 2 are the cervicis and thoracis groups. The semispinalis capitis muscle covers the semispinalis cervicis muscle. Muscles numbered 3 to 6 in the list are suboccipital muscles, innervated by the suboccipital nerve (C1 posterior ramus).The semispinalis muscles (capitis, cervicis, and thoracis components) are part of the transversospinal muscle group, which is situated deep to the erector spinae and fills the concave region between the transverse and spinous processes of the vertebrae. This group of muscles sometimes is referred to clinically as the paravertebral muscles. § Clinical: These deep intrinsic muscles of the neck may become strained with excessive movements of the neck or when the neck is kept fixed in one position for a long time.Intrinsic Muscles of Bac

Semitendinosus muscle Netters

1) semitendinous muscle 2) gluteus maximus muscle 3) adductor magnus muscle 4) semimembranosus muscle 5) popliteal vessels and tibial nerve 6) gastrocnemius muscle (medial and lateral heads) § Origin (proximal): Semitendinosus muscle arises from the ischial tuberosity of the pelvis. § Insertion (distal): The prominent tendon of the semitendinosus muscle inserts on the medial surface of the superior portion of the tibia. § Action: Semitendinosus muscle flexes the leg at the knee and, when the knee is flexed, medially rotates the tibia. It also is an extensor of the thigh at the hip joint. When the hip and knee both are flexed, the semitendinosus muscle can extend the trunk. § Innervation: Sciatic nerve, tibial division (L5, S1, and S2). § Comment: The semitendinosus is 1 of the 3 muscles making up the hamstrings. This slender muscle has a long tendon of insertion.The tendon of insertion combines with the tendons of the gracilis and sartorius to form the pes anserinus (goose's foot) on the medial aspect of the knee joint. § Clinical: The hamstrings are collectively tested by having the supine patient flex the limb 90° at the hip and knee and then further flex the knee against resistance. Hamstring muscle pulls or tears are common athletic injuries because these muscles stretch across 2 joints. Stretching these muscles before vigorous exercise is recommended.

Extrinsic Muscles of Back: Intermediate Layers Netters

1) serratus posterior superior muscle 2) serratus posterior inferior muscle 3) iliocostalis lumborum muscle 4) longissimus thoracis muscle 5) spinalis thoracis muscle 6) iliocostalis thoracis muscle (retracted) 7) longissimus cervicis muscle 8) spinalis cervicis muscle § Origin: The serratus posterior superior muscle attaches to the lower extent of the ligamentum nuchae and the spinous processes of the C7-T3 vertebrae. The serratus posterior inferior muscle attaches to the spinous processes of the T11-L2 vertebrae and their supraspinous ligaments. § Insertion: Four fleshy digitations attach the serratus posterior superior to the 2nd to 5th ribs just lateral to their angles. The serratus posterior inferior divides into 4 flat digitations that insert into the inferior borders of the last 4 ribs just lateral to their angles. § Action: The serratus posterior superior elevates the ribs, whereas the serratus posterior inferior pulls the ribs outward and downward, counteracting the inward pull of the diaphragm. § Innervation: The serratus posterior superior is innervated by the anterior rami of the T1-T4 spinal nerves. The serratus posterior inferior is supplied by the anterior rami of the T9-T12 spinal nerves. § Comment: These 2 muscles have attachments to the ribs, are considered muscles of the thoracic wall (can be lumped into extrinsic back muscles), and act on the ribs during respiration. These 2 muscles are often thin and may be fused to overlying musculature. Muscles numbered 3 to 8 in the list are intrinsic back muscles (erector spinae muscles) innervated by posterior rami of spinal nerves. § Clinical: These 2 sets of muscles are accessory muscles of respiration and may be well developed in athletes. In the elderly, however, they are often thin and even difficult to discern. Rarely, the serratus posterior inferior may be entirely absent.

Borders of cubital fossa

1)Borders: a)Line between the medial and lateral epicondyles b)Brachioradialis (lateral) c)Pronator teres (medial) 2)Roof*: a)Aponeurosis of the biceps brachii and deep fascia of the forearm 3)Contains: a)Median cubital vein b)Medial and lateral cutaneous nerves of the forearm *Most things passing from arm to forearm go through the cubital fossa: a) Median nerve b) Radial nerve Passes anterior to lateral epicondyle* c) Brachial artery (divides in the cubital fossa into radial and ulnar) d) Biceps tendon IMPORTANT EXCEPTION: Ulnar nerve, passes posteriorly to medial epicondyle

Soleus muscle Netters

1) soleus muscle 2) popliteal vessels and tibial nerve 3) plantaris muscle tendon 4) soleus muscle inserting into calcaneal tendon 5) posterior tibial artery and vein and tibial nerve § Origin (proximal): Soleus muscle arises from the posterior aspect of the head of the fibula, the proximal third of the posterior body of the fibula, the soleal line, and the medial border of the tibia. § Insertion (distal): The soleus muscle fibers end in an aponeurosis that thickens and then narrows where it joins the gastrocnemius. The resulting calcaneal tendon inserts on the posterior surface of the calcaneus. § Action: Soleus muscle plantarflexes the foot at the ankle and is an important postural muscle. Apparently, it is constantly active, even during quiet standing, and it aids in maintaining balance. § Innervation: Tibial nerve (S1 and S2). § Comment: The upper portion of the soleus is covered largely by the gastrocnemius muscle. § Clinical: The soleus muscle is tested clinically by having the supine patient flex the limb at the hip and knee and then plantarflex the foot against resistance.Tendinitis of the calcaneal tendon is a painful inflammation that often occurs in runners who run on hills or uneven surfaces. Repetitive stress on the tendon occurs as the heel strikes the ground and when plantarflexion lifts the foot. Rupture of the tendon is a serious injury.

Levator scapulae muscle Netters

1) splenius capitis muscle 2) levator scapulae muscle **Origin (proximal): Levator scapulae muscle arises from the transverse processes of the first 4 cervical vertebrae. **Insertion (distal): Inserts into the superior portion of the medial (vertebral) border of the scapula. **Action: Elevates the superior angle of the scapula and tends to draw it medially. Also rotates the scapula so that the glenoid cavity is tilted inferioly. When the scapula is held in a fixed position, the levator scapulae bends the neck laterally and rotates it slightly toward the same side. **Innervation: By the 3rd and 4th cervical nerves from the cervical plexus and by a branch from the dorsal scapular nerve (C5) to the muscle's lower fibers. **Comment: Contraction of the levator scapulae helps shrug the shoulders. The blood supply to the muscle comes largely from the transverse cervical artery of the thyrocervical trunk. **Clinical: One can easily test the levator scapulae muscle by asking the patient to shrug his or her shoulders against resistance. Weakness in this action would require a more specific examination to determine to what degree the trapezius may also be affected or compensating, since both muscles elevate the scapula.

Intrinsic Muscles of Back: Superficial Layers Netters

1) splenius capitis muscle 2) splenius cervicis muscle 3) semispinalis capitis muscle 4) supraspinatus muscle 5) teres minor and major muscle 6) erector spinae muscle § Origin: The splenius capitis and splenius cervicis muscles blend together and arise from the ligamentum nuchae and the spinous processes of the C7-T6 vertebrae (capitis from C7-T3 and cervicis from T3-T6). § Insertion: Capitis fibers insert into the mastoid process of the temporal bone and the lateral third of the superior nuchal line of the occipital bone. The cervicis fibers ascend to attach to the transverse processes of the C1-C3 vertebrae and the posterior tubercle of C3. § Action: Acting with their opposite partners, the splenius capitis and splenius cervicis extend the head and neck. Acting unilaterally, they laterally bend the head and neck to the side of the contraction. § Innervation: The capitis is innervated by the posterior rami of the middle cervical spinal nerves. The cervicis is innervated by the posterior rami of the lower cervical spinal nerves. § Comment: The splenius capitis and splenius cervicis form the superficial layer of intrinsic back muscles. Generally, intrinsic back muscles are innervated by posterior rami of spinal nerves. The semispinalis capitis and erector spinae muscles also are deep intrinsic muscles. The teres minor and major muscles and the supraspinatus muscle are scapular muscles associated with movements of the upper limb. § Clinical: As intrinsic muscles that extend the neck, these muscles can be involved in neck pain. This pain may be a result of simple muscle tension, holding one's neck in an unusual fixed position for a long period of time (when awake or asleep), or hyperextension. Spasm (a reflexive cramping) of the muscle may eventually produce ischemia in the muscle, adding to the pain.

Lumbar Plexus Netters

1) subcostal nerve (T12) 2) iliohypogastric nerve 3) ilioinguinal nerve 4) lateral femoral cutaneous nerve 5) femoral nerve 6) obturator nerve 7) lumbosacral trunks § Comment: Nerves of the lumbar plexus arise from the anterior rami of L1-L4. These nerves, along with the subcostal nerve (T12), innervate the muscles of the lower trunk and send branches to muscles of the anterior and medial compartments of the thigh (femoral and obturator nerves, respectively).The femoral nerve arises from L2, L3, and L4 and innervates the extensors of the knee. Likewise, the obturator nerve arises from L2, L3, and L4. In the thigh, it innervates the medial compartment muscles, which are adductors of the hip.Similar to the cervical plexus (C1-C4) and the brachial plexus (C5-T1), the lumbar plexus is a somatic nerve plexus that innervates skeletal muscles and conveys sensation from the skin, muscles, and joints. Similar to all somatic nerves, postganglionic sympathetic fibers of the autonomic nervous system also travel within these nerves and innervate vasomotor smooth muscle and the arrector pili smooth muscle associated with the hair follicles in the skin and sweat glands. § Clinical: Muscles of the lower limb, like those of the upper limb, are derived from multiple segmental myotomes and therefore receive their innervation from several spinal cord levels. They are all derived from anterior r

Shoulder (Glenohumeral) Joint: Lateral View Netters

1) subdeltoid bursa 2) glenoid fossa (cavity) (articular cartilage) 3) inferior glenohumeral ligament 4) middle glenohumeral ligament 5) subscapularis tendon (fused to capsule) 6) biceps brachii tendon (long head) 7) coracohumeral ligament 8) coracoid process 9) coracoacromial ligament **Comment: The glenoid cavity is deepened by the presence of the glenoid labrum (lip). The joint is stabilized by a capsule, ligaments, and the 4 tendons of the rotator cuff muscles. The 4 tendons of the rotator cuff muscles reinforce the joint posteriorly, superiorly, and midanteriorly (subscapularis tendon). Most shoulder dislocations occur anteriorly or anteroinferiorly, where there is less support.Blood is supplied to the shoulder by branches of the suprascapular, humeral circumflex, and scapular circumflex arteries. **Clinical: Bursae are synovial-lined, fluid-filled enclosed cushions that protect tendons and ligaments from injury related to frictional movement over adjacent bony projections or other rough surfaces. They may become infected, fill with fluid, and become quite painful.

Scapulohumeral Dissection Netters

1) subscapularis muscle **Origin (proximal): Arises from the medial two-thirds of the subscapular fossa and from the lower two-thirds of the lateral border of the scapula. **Insertion (distal): The fibers converge in a tendon that is inserted into the lesser tubercle of the humerus and the anterior portion of the shoulder joint capsule. **Action: As a rotator cuff muscle, the subscapularis helps stabilize the shoulder joint and prevents anterior displacement of the humerus. It also medially rotates and adducts the humerus (arm) at the shoulder. **Innervation: Upper and lower subscapular nerves (C5 and C6). **Comment: The tendon of the muscle is separated from the neck of the scapula by the subscapular bursa.Along with the supraspinatus, infraspinatus, and teres minor muscles, the subscapularis is the 4th muscle of the rotator cuff group.The subscapularis and serratus anterior muscles together form a functional (physiological) articulation of the shoulder called the scapulothoracic joint. The joint is between the muscles, the scapula, and the loose connective tissue trapped between these 2 muscles, which permits a gliding movement of the scapula on the chest wall. Scapular movements at this joint include elevation, depression, protraction, retraction, and rotation.The blood supply to the muscle is by the subscapular artery, a branch of the axillary artery. **Clinical: Weakness of the serratus anterior leads to "winging" of the scapula.

Supinator muscle Netters

1) supinator muscle 2) pronator teres muscle 3) ulna 4) pronator quadratus muscle 5) radius 6) lateral epicondyle of humerus § Origin (proximal): Supinator muscle arises from the lateral epicondyle of the humerus, the radial collateral ligament of the elbow joint, the anular ligament of the proximal radioulnar joint, the supinator fossa, and the crest of the ulna. § Insertion (distal): Inserts into the lateral, posterior, and anterior surfaces of the proximal third of the radius. § Action: The supinator rotates the radius to supinate the forearm and hand. Supination occurs whether the forearm is flexed or extended. § Innervation: Deep branch of the radial nerve (C5 and C6). § Comment: The most powerful supinator of the forearm is the biceps brachii, which acts primarily when the forearm is flexed. In contrast, the supinator can supinate a forearm that is flexed or extended.The posterior interosseous artery passes through the supinator, serving as its major blood supply. § Clinical: The deep branch of the radial nerve (the radial nerve's motor component) can become compressed as it passes through the supinator, leading to a posterior compartment neuropathy, resulting in weakened extension of the wrist and fingers. The supinator is tested clinically by having the patient supinate the extended forearm against resistance.

Cutaneous Nerves and Superficial Veins of Shoulder and Arm Netters

1) supraclavicular nerves (from cervical plexus) (medial; intermediate; lateral) 2) medial brachial cutaneous nerve 3) superior lateral brachial cutaneous nerve (from axillary nerve) 4) cephalic vein 5) cephalic vein 6) basilic vein 7) median cubital vein 8) lateral antebrachial cutaneous nerve (terminal part of musculocutaneous nerve) 9) basilic vein § Comment: Cutaneous nerves of the shoulder arise from the supraclavicular nerves of the cervical plexus. Cutaneous nerves of the arm arise from the axillary nerve, from the radial nerve, or directly from the brachial plexus.The largest superficial veins of the arm are the cephalic vein and the basilic vein. The cephalic vein is joined to the basilic vein by the median cubital vein, which passes anteriorly across the cubital fossa (variations in this pattern are common).Via perforating veins, the superficial veins communicate with deep veins accompanying the brachial artery and its branches. The superficial and deep veins of the upper limb possess valves to assist in returning blood to the heart.The cephalic vein drains proximally into the axillary vein, and the basilic vein drains proximally into, or becomes continuous with, the axillary vein. § Clinical: The median cubital vein is often used for venipuncture to withdraw a blood sample.

label this posterior aspect of scapula

1) suprascapular notch 2) superior border 3) superior angle; supraspinous fossa, spine, neck, infraspinous fossa, medial border, lateral border, inferior angle 4) clavicle (cut) 5) coracoid process 6) acromion process 7) acromial angle 8) greater tubercle, head of humerus, anatomical neck, surgical neck, infraglenoid tubercle, deltoid tubersoity, radial groove 9) humerus

Supraspinatus muscle Netters

1) supraspinatus muscle 2) infraspinatus muscle 3) rhomboid minor muscle 4) rhomboid major muscle 5) teres major muscle **Origin (proximal): The supraspinatus muscle occupies the supraspinous fossa, originating from the medial two-thirds and arising from the strong supraspinatus fascia. The infraspinatus muscle occupies most of the infraspinous fossa; it arises from the medial two-thirds and from the infraspinatus fascia. **Insertion (distal): Fibers of the supraspinatus converge to form a tendon that inserts into the superior facet on the greater tubercle of the humerus. The infraspinatus fibers also converge to form a tendon, which inserts into the middle facet on the greater tubercle of the humerus. The tendons of the 2 muscles adhere to each other. **Action: The supraspinatus strengthens the shoulder joint by drawing the humerus toward the glenoid fossa. With help from the deltoid, it initiates abduction at the shoulder and is a lateral rotator of the humerus (arm). The infraspinatus strengthens the shoulder joint by bracing the head of the humerus in the glenoid fossa. It is also a lateral rotator of the humerus. **Innervation: Both by the suprascapular nerve (C5 and C6). **Clinical: Repeated abduction and flexion of the shoulder (as in the throwing motion) may cause wear and tear on the tendons as they rub on the acromion and coracoacromial ligament. This action can lead to rotator cuff tears or ruptures. The tendon of the supraspinatus is the most vulnerable to injury.

Bones of Foot Netters

1) talus (head; trochlea) 2) calcaneus (body; tuberosity) 3) cuboid bone 4) navicular bone 5) cuneiform bones 6) sesamoid bone 7) calcaneus (tuberosity; sustentaculum tail) 8) phalangeal bones 9) metatarsal bones 10) navicular bone § Comment: The bones of the foot include the 7 tarsal bones, of which only the talus articulates with the leg bones. Five metatarsal bones articulate proximally with the tarsals and distally with the phalanges. Similar to the thumb, the 1st toe (big toe) has only 2 phalanges. Toes 2 through 5 have a proximal, middle, and distal phalanx.The trochlea of the talus (ankle bone) articulates with the tibia and fibula, and the head of the talus articulates with the navicular bone. The calcaneus (heel bone) articulates with the talus superiorly and the cuboid anteriorly. § Clinical: The calcaneus is the most commonly fractured tarsal bone. Most calcaneal fractures occur from a forceful landing on a heel, in which the talus is driven down into the calcaneus. The bone density of the calcaneus is less than that of the talus, which also contributes to its being fractured more often.

Tensor fasciae latae muscle Netters

1) tensor fasciae latae muscle 2) gluteus maximus muscle 3) iliotibial tract 4) vastus lateralis muscle 5) biceps femoris muscle (long and short heads) 6) head of fibula 7) patella 8) rectus femoris muscle § Origin (proximal): Tensor fasciae latae muscle arises from the anterior superior iliac spine and the anterior portion of the iliac crest. § Insertion (distal): As its name suggests, the tensor fasciae latae muscle inserts into the iliotibial tract. This strong tendinous tract inserts on the lateral condyle of the tibia. § Action: The tensor fasciae latae muscle flexes, abducts, and medially rotates the thigh at the hip. With the assistance of the gluteus maximus, this muscle stabilizes the hip joint. The tensor fasciae latae also stabilizes the extended knee. § Innervation: Superior gluteal nerve (L4 and L5). § Comment: The chief action of the tensor fasciae latae is hip flexion. The muscle also acts with the gluteus maximus to control anteroposterior tilting of the pelvis when 1 leg supports all of the body's weight. Stabilization of the hip occurs because the muscle holds the femoral head in the acetabulum. The tensor fasciae latae also stabilizes the knee in extension. § Clinical: This muscle helps flex the thigh at the hip, assisting the iliopsoas complex and rectus femoris muscle. If the iliopsoas complex is paralyzed, the tensor fasciae latae can hypertrophy to compensate.The iliotibial tract (called "band" by most physicians) can become inflamed in runners where it crosses the lateral femoral condyle.

Tibial nerve - Netters

1) tibial nerve (L4-S3) 2) medial sural cutaneous nerve (cut) 3) common fibular nerve 4) lateral sural cutaneous nerve (cut) 5) tibial nerve 6) medial plantar nerve 7) lateral plantar nerve 8) superficial branch of lateral plantar nerve 9) common plantar digital nerves § Comment: The tibial nerve is a direct extension of the sciatic nerve. It innervates muscles of the posterior compartment of the leg and the intrinsic muscles on the plantar surface of the foot. The muscles of the posterior compartment of the leg are essentially plantarflexors at the ankle and flexors of the toes. These muscles also can participate in inversion. § Clinical: Because of its deep location in the posterior compartment of the leg, the tibial nerve is relatively protected from direct trauma. It can be injured during inflammation of the muscles of the posterior compartment (compartment syndrome) when swelling occurs sufficient to compress the tibial nerve.A lesion to the tibial nerve may result in loss of plantarflexion and weakened inversion of the foot, leading to a shuffling gait.Lacerations on the sole of the foot may damage the terminal branches of the tibial nerve, the medial and lateral plantar nerves, which innervate the intrinsic muscles

Tibialis anterior muscle Netters

1) tibialis anterior muscle 2) superficial fibular nerve 3) fibularis brevis muscle 4) tibia § Origin (proximal): Tibialis anterior muscle arises from the lateral condyle and superior half of the lateral surface of the tibia and from the interosseous membrane. § Insertion (distal): Tibialis anterior muscle inserts into the medial and inferior surfaces of the medial cuneiform tarsal and the base of the 1st metatarsal. § Action: Tibialis anterior muscle dorsiflexes the foot at the ankle and inverts the foot at the subtalar and midtarsal joints. § Innervation: Deep fibular nerve (L4 and L5). § Comment: The tibialis anterior is the largest muscle in the anterior compartment of the leg. In general, muscles of this compartment dorsiflex (extend) the foot at the ankle and extend the toes. Their blood supply comes largely from the anterior tibial artery and its branches. § Clinical: The tibialis anterior muscle is clinically tested by having the patient dorsiflex the foot against resistance. The muscle tendon and belly will be evident over the anterior leg. Anterior (tibial) compartment syndrome (known as an anterior or a lateral "shin splint") occurs from excessive contraction of anterior compartment muscles. Pain radiates down the ankle and dorsum of the foot overlying the extensor tendons of these muscles.

Tibialis posterior muscle Netters

1) tibialis posterior muscle 2) flexor digitorum longus muscle 3) popliteus muscle 4) fibularis brevis tendon 5) fibularis longus tendon § Origin (proximal): Tibialis posterior muscle arises from the posterior surface of the interosseous membrane, the posterior aspect of the tibia inferior to the soleal line, and the posterior surface of the fibula. § Insertion (distal): Tibialis posterior muscle inserts on the tuberosity of the navicular bone; the plantar surfaces of the cuboid and cuneiform bones; and the bases of the 2nd, 3rd, and 4th metatarsals. § Action: Tibialis posterior muscle plantarflexes the foot at the ankle and inverts the foot when the foot is not bearing weight. § Innervation: Tibial nerve (L4 and L5). § Comment: When the foot is bearing weight, the tibialis posterior, along with several other muscles, helps distribute the weight on the foot and helps maintain balance. § Clinical: One can test the tibialis posterior muscle by having the patient invert the foot against resistance.The term "shin splints" refers to pain along the inner distal two-thirds of the tibial shaft and is a common syndrome in athletes. The primary cause is repetitive pulling of the tibialis posterior tendon as one pushes off the foot during running. Stress on the muscle occurs at its attachment proximally to the tibia and interosseous membrane.

Trapezius muscle Netters

1) trapezius muscle 2) deltoid muscle 3) latissimus dorsi muscle **Origin (proximal): Trapezius muscle arises from external occipital protuberance and medial third of the superior nuchal line of the occipital bone, ligamentum nuchae, and spinous processes of the 7th cervical vertebra and all 12 thoracic vertebrae. **Insertion (distal): Superior fibers of the trapezius muscle insert into the posterior border of the lateral third of the clavicle. Middle fibers insert into the medial margin of the acromion and posterior border of the scapular spine. Inferior fibers converge to end in an aponeurosis inserted into the scapular spine. **Action: The upper and lower fibers of the trapezius muscle act primarily to rotate the scapula for full abduction of the upper extremity. The upper fibers, acting alone, elevate the shoulder and brace the shoulder girdle when a weight is being carried by the shoulder or hand. Central fibers run horizontally and retract the shoulder. Lower fibers draw the scapula downward. When both muscles act together, the scapula can be adducted and the head drawn directly backward. **Innervation: Motor supply is from the accessory nerve (CN XI). Proprioceptive fibers are from the 3rd and 4th cervical nerves. **Comment: The trapezius, in contrast to the other shoulder muscles, does not receive nerve fibers from the brachial plexus. **Clinical: The trapezius can be tested by having a patient elevate the shoulder against resistance (the upper portion of the contracting muscle can be felt). This tests the integrity of the accessory nerve (CN XI) innervating this muscle.

Triceps brachii muscle Netters

1) triceps brachii muscle 2) anconeus muscle **Origin (proximal): The long head of the triceps arises from the infraglenoid tubercle of the scapula. The lateral head arises from the posterior surface of the humerus. The medial head arises from the posterior surface of the humerus inferior to the radial groove.The anconeus arises from the lateral epicondyle of the humerus. **Insertion (distal): All 3 heads of the triceps insert by a common tendon into the posterior portion of the proximal olecranon of the ulna. A band of fibers continues distally on the lateral side over the anconeus to blend with the deep fascia of the forearm.The anconeus inserts into the lateral aspect of the olecranon and into the upper dorsal surface of the body of the ulna. **Action: The anconeus muscle and all 3 heads of the triceps extend the forearm at the elbow. The anconeus also abducts the ulna during pronation. The long head of the triceps, arising from the scapula, also can extend the humerus (arm) at the shoulder joint. **Innervation: The triceps and anconeus are supplied by the radial nerve (C7 and C8). **Comment: The medial head of the triceps is the functional counterpart of the chief flexor of the elbow, the brachialis. The medial head is misnamed; it really lies deep, not medial.The triceps receives its blood supply from the deep brachial artery. **Clinical: Tapping the triceps tendon elicits the triceps reflex, testing spinal cord segments C7 and C8.

Ligaments of Wrist: Posterior View Netters

1) ulna bone 2) dorsal radioulnar ligament 3) triquetrum bone 4) hamate bone 5) capitate bone 6) trapezoid bone 7) trapeziotrapezoid ligament 8) trapezium bone 9) scaphoid bone 10) scapholunate ligament 11) dorsal radiocarpal ligament 12) radius bone **Comment: Proximal to the wrist lies the distal radioulnar joint, which is a uniaxial synovial pivot (trochoid) joint between the ulna and the ulnar notch of the radius. It allows for pronation and supination (rotation).The wrist, or radiocarpal joint, is an ellipsoidal biaxial synovial joint formed by the distal end of the radius (an articular disc) and the scaphoid, lunate, and triquetrum carpal bones. Movements at the wrist include flexion, extension, abduction, adduction, and circumduction.Anatomists often simplify the designation of these ligaments into a dorsal radiocarpal ligament, dorsal carpometacarpal ligaments, and intercarpal ligaments.Between the proximal and distal rows of carpal bones lies the midcarpal (intercarpal) joints, synovial plane joints. These joints permit some gliding and sliding movements. **Clinical: Hand surgeons classify these ligaments more precisely based on their attachments.

Vastus intermedius muscle Netters

1) vastus intermedius muscle 2) vastus lateralis muscle 3) vastus medialis muscle 4) rectus femoris tendon (cut) 5) patella 6) sartorius tendon 7) patellar ligament 8) anteromedial intermuscular septum 9) gracilis muscle § Origin (proximal): Vastus intermedius muscle arises from the anterior and lateral aspects of the femoral shaft and the lateral intermuscular septum. § Insertion (distal): Vastus intermedius muscle inserts into the posterior surface of the upper border of the patella and forms part of the quadriceps tendon. The patellar ligament inserts into the tibial tuberosity. § Action: Vastus intermedius muscle extends the leg at the knee joint. § Innervation: Femoral nerve (L2, L3, and L4). § Comment: The vastus intermedius is 1 of the 4 muscles of the quadriceps femoris group that makes up the extensor complex of the knee. Tapping the patellar ligament of this extensor complex elicits the knee jerk reflex and tests spinal cord segments L3 and L4. § Clinical: The vastus intermedius muscle acts in concert with the other 3 muscles of the quadriceps femoris and is tested clinically by having the patient extend the leg, flexed at the knee, against resistance.

Vastus lateralis muscle Netters

1) vastus lateralis muscle 2) gracilis muscle 3) adductor longus muscle 4) pubic tubercle 5) iliopsoas muscle § Origin (proximal): Vastus lateralis muscle arises from the posterior aspect of the femur, beginning at the greater trochanter and continuing inferiorly along the lateral lip of the linea aspera of the femur. § Insertion (distal): Most of the vastus lateralis muscle inserts into the lateral patella and the tendon of the rectus femoris to form the quadriceps tendon. The patellar ligament inserts into the tibial tuberosity. § Action: Vastus lateralis muscle extends the leg at the knee. § Innervation: Femoral nerve (L2, L3, and L4). § Comment: The vastus lateralis is 1 of the 4 muscles making up the quadriceps femoris extensor complex of the knee. It covers essentially the entire lateral portion of the thigh. § Clinical: The vastus lateralis muscle acts in concert with the other 3 muscles of the quadriceps femoris and is tested clinically by having the patient extend the leg, flexed at the knee, against resistance. The vastus lateralis is the largest of the quadriceps muscles.

Vastus medialis muscle Netters

1) vastus medialis muscle 2) iliotibial tract § Origin (proximal): Vastus medialis muscle arises from the intertrochanteric line and medial lip of the linea aspera of the femur and from the medial intermuscular septum. § Insertion (distal): Vastus medialis muscle inserts into the medial border of the quadriceps tendon, but some of its inferior fibers insert directly into the medial side of the patella. The patellar ligament inserts into the tibial tuberosity. § Action: Vastus medialis muscle extends the leg at the knee joint. § Innervation: Femoral nerve (L2, L3, and L4). § Comment: The vastus medialis is 1 of the 4 muscles of the quadriceps femoris complex that extends the knee. Similar to the vastus lateralis, the vastus medialis contributes some aponeurotic fibers to the knee joint capsule. § Clinical: The vastus medialis muscle acts in concert with the other 3 muscles of the quadriceps femoris. It is tested clinically by having the patient extend the leg, flexed at the knee, against resistance. As with the other 2 vastus muscles of the quadriceps group, it is difficult to isolate the individual movements of these muscles.

Lumbar Vertebra Netters

1) vertebral body 2) vertebral foramen 3) pedicle 4) transverse process 5) superior articular process 6) lamina 7) spinous process 8) mammillary process 9) accessory process § Comment: Typical lumbar vertebrae have large bodies and massive transverse processes. They support the weight of the trunk and provide attachment sites for muscles of the trunk and back.The lumbar region of the spine allows for considerable movement (flexion, extension, lateral bending, and rotation). Although lumbar vertebrae have long transverse processes for muscle attachment, they do not articulate with ribs. § Clinical: The lumbar spine is designed for both support and movement. Lumbar spinal pain (lower back pain) is common and is often due to a disorder of the muscles (especially extensor muscles), ligaments, or discs, which frequently affects a spinal nerve. Herniated intervertebral discs are most common in the lumbar region, especially the discs between L4 and L5 and between L5 and S1. An L4-L5 herniation may compress the L5 spinal nerve root, while herniation between L5 and S1 may compress the S1 spinal nerve root. Spinal stenosis is a narrowing of the vertebral foramen, which may cause compression of the spinal nerve roots (cauda equina, see Card 2-16). Lumbar stenosis commonly occurs at the level of the intervertebral discs but also may occur in the vertebral foramen.

Movement at metacarpophalangeal and interphalangeal joints

1)MCPs (knuckles): o are condylar synovial joints between the metacarpal heads and the proximal phalange. These joints allow the following movements: a) flexion and extension b) abduction and adduction c) ulnar collateral ligament of the thumb 2) Interphalangeal (IP) joints: a)Flexion and extension ONLY b)Proximal Interphalangeal PIP c)Distal Interphalangeal DIP d)IP (thumb) e)volar plate o The interphalangeal joints (IP's) are hinge synovial joints which allow for flexion and extension. There is a proximal IP joint and a distal IP joint in each digit. The thumb only has one IP joint. o There are a number of important ligaments holding the MCP and IP joints together. These include the collateral ligaments, both radial and ulnar. o One of the collateral ligaments of the thumb is important clinically - this is the ulnar collateral ligament of the thumb. It is frequently injured in skiing, by falling onto the outstretched thumb. o The volar plate is a very important structure on the anterior surface of the proximal interphalangeal joint. It is a dense condensation of fibrous tissue formed by the collateral ligaments at the front of the proximal IP joint and is frequently damaged.

Nerves in the Hand

1)Median nerve (C8, T1): a)Main nerve of the anterior compartment of forearm b)Some supply to hand intrinsic muscles 2)Ulnar nerve (C6 - T1) a)MAIN nerve of the hand b)Some of anterior compartment (FCU, half of FDP). *gives some contribution to the more medial muscles of the anterior compartment of the forearm, but most of its fibres passes into the hand to supply most of its intrinsic muscles.* 3)Radial nerve (C5-T1): a)Posterior compartment of the forearm b)Some sensory component to the hand, NO MOTOR. **In the hand all three of these nerves contribute to its sensory supply. They do so in the digits by the digital nerves which are purely sensory. Division of one of these nerves causes anaesthesia in part of the digit.**

Extensor Compartment of the Forearm

1)Muscles that move the wrist joint: a)Extensor carpi radialis longus (ECRL) b)Extensor carpi radialis brevis (ECRB) c)Extensor carpi ulnaris (ECU) 2)Muscles that move the digits: a)Extensor digitorum (ED) b)Extensor indicis (EI) c)Extensor digit minimi (EDM) 3)Muscles that move the thumb: a)Abductor pollicis longus (APL) b)Extensor pollicis brevis (EPB) c)Extensor pollicis longus (EPL) 4)Other muscles of forearm: a)Brachioradialis b)Supinator

Pectoralis major Netters

1)Pectoralis major muscle **Origin (proximal): Arises from the sternal half of the clavicle, the upper half of the sternum, and the aponeurosis of the external abdominal oblique muscle. **Insertion (distal): The fibers converge toward the anterior wall of the axilla. All 3 parts of the muscle (clavicular, sternal, and abdominal) end as a flat tendon inserted into the intertubercular groove of the humerus. **Action: The primary action is adduction of the arm at the shoulder. The pectoralis major is also a medial rotator of the humerus, and its clavicular portion helps flex the shoulder and adduct the humerus medially across the midline. The sternocostal portion, along with the latissimus dorsi and teres major muscles, can extend—against resistance—the flexed humerus to the side of the trunk. **Innervation: Medial and lateral pectoral nerves (C5-C8 and T1). **Comment: The converging fibers of this fan-shaped muscle course toward the insertion on the humerus, forming the anterior boundary of the axilla.The thoracoacromial and lateral thoracic arteries supply the pectoralis major. **Clinical: The pectoralis major (sternocostal portion) is tested clinically by having the patient adduct (move toward the body) the arm from a position of 45 ° lateral to the body wall with the elbow flexed. One can place a hand on the elbow and provide resistance against this adduction to test the muscle's strength and the integrity of the pectoral nerves.

Types of Grip

1)Power Grip a) The grip is formed by the long forearm flexors of the digits + intrinsic muscles of the palm b) The grip is stabilised by the extensors of the wrist joint *the fingers are flexed around and object with counter pressure from the thumb e.g. grasping a rod. 2)Precision Grip a)the wrist and fingers are held rigidly by the long flexors and extensors (don't want wrist to be floppy so forearm muscles also work) b)the intrinsic muscles of the hand carry out the fine movements needed *the object is gripped between the tips of the fingers and the thumb, with the intrinsic muscles of the hand carry out the fine movements needed. Typically, the wrist and fingers are held rigidly by the long flexors and extensors. e.g. unbuttoning a shirt. 3)Hook Grip a)consumes little energy, mainly involves long flexors of digits; e.g. carrying shopping bag or briefcase

Anterior Forearm - Superficial (From lateral to medial):

1)Pronator teres: a)Distal: Radius b)Function: Wrist pronation + flexion c)Innervation: Median 2)Flexor carpi radialis: a)Distal: metacarpals (II & III) b)Function: Wrist abduction* + flexion c)Innervation: Median 3)Palmaris longus: a)Distal: Palmar aponeurosis of the hand b)Function: Wrist flexion c)Innervation: Median 4)Flexor carpi ulnaris: a)Distal: Carpal and metacarpals b)Function: Wrist adduction* + flexion c)Innervation: Ulnar

Movements of the Radio-Ulnar Joints

1)Supination: a)Supinator b)Biceps - tendon attaches to radial tuberosity. so when pronation, biceps tendon is stretched and pulled so radial tuberosity is pulled round posteriorly. c)(EPL, ECRL) 2)Pronation: a)Pronator quadratus b)Pronator teres (FCR, PL, brachioradialis)

Fractures in arm and forearm to know

1)Supracondylar fractures a)Common in children due to unformed elbow b)Can cause medial nerve injury c)Volkmann's ischaemic contracture* 2)Humeral mid-shaft (Radial) 3)Surgical neck of humerus (Axillary) 4)Medial epicondyle and elbow fractures (Ulnar)

How do radial and ulnar artery pass into hand?

1)Ulnar artery: a)Passes into the hand medially (Guyon's Canal) b)Superficial palmar arch and deep palmar branch 2)Radial artery: a)Passes into the hand through the dorsolateral aspect of the wrist after crossing the anatomical snuffbox b)Deep palmar arch and superficial palmar branch

Radial and ulnar artery in forearm path

1)Ulnar artery: a)Runs in the anterior compartment of the forearm b)Common interosseous artery branches off the ulnar artery this splits into the anterior and posterior interosseous c)Ulnar artery runs into hand over flexor retinaculum 2)Radial artery: a)Crosses the floor of the anatomical snuff box and enter the hand

What are the three main sources of blood supply to a long bone?

1. Arteries enter bone mainly via the periosteum. These PERIOSTEAL arteries enter the bone at a NUMBER OF POINTS, and thus stripping of the periosteum (which occurs in fractures and with surgery) can result in the deprivation of the blood supply from the bone, and in some cases this can result in bone death (bone infarction) and bone infection (osteomyelitis). 2. A second source of blood supply to a bone is via its NUTRIENT ARTERY. This enters near the MIDDLE of the bone, passing obliquely through the compact bone, and supplies the MEDULLA (spongy bone and any bone marrow within). 3. A third source of blood supply is via the METAPHYSEAL and EPIPHYSEAL arteries, which supply the ENDS of bones. (These are only present in the GROWING skeleton and a particular feature of these arteries is that blood can "sludge" within them. This is thought to be the reason why haematogenous bone infection (osteomyelitis) occurs in children but rarely in adults.

How to palpate the brachial artery

1. Brachial artery pulse along middle third of humerus - palpate (palpate in the medial bicipital groove behind the medial border of biceps). 2. Brachial artery pulse at cubital fossa- palpate (on the m

The two muscles of the dorsum of the foot?

1. Extensor digitorum brevis 2. Extensor hallucis brevis

How to palpate flexor carpi ulnaris, radialis and palmaris longus

1. Flexor carpi ulnaris (FCU) tendon (flex wrist against resistance) 2. Palmaris longus (PL) tendon (cup the hand without bending digits) 3. Flexor carpi radialis (FCR) tendon (flex wrist against resistance)

How to see head of metacarpals from palmar and dorsal view?

1. Heads of metacarpals on the dorsum of the hand (make a fist and palpate) 2. Heads of metacarpals on the palm of the hand (palpate along the distal palmar crease)

Landmarks at elbow

1. Olecranon 2. Medial epicondyle - the ulnar nerve is posterior to it 3. Lateral epicondyle 4. Biceps tendon (anteriorly) 5. Bicipital aponeurosis - palpate (overlies the median nerve and the brachial artery) 6. The brachial artery pulse - palpate (extend the elbow, medial to biceps tendon in the cubital fossa) 7. The cubital fossa - boundaries 8. Triceps tendon (posteriorly

With knowledge of the palmar fascia, describe the path of the flexor digitorum tendons from the wrist to their phalangeal attachments. (4 marks)

1. Pass into the hand under the flexor retinaculum And enters a common synovial sheath... 2. Passes through an osseo-fibrous tunnel Within a digital synovial sheath 3. The FDS splits around the FDP 4. The FDS attaches to the middle phalanx and FDP attaches to the distal phalanx

Lymphatics of the lower limb

1. Popliteal lymph nodes- palpate (around popliteal fossa along small saphenous vein). 2. Superficial inguinal lymph nodes - palpate (on yourself) (near the termination of long saphenous vein. 3. Deep inguinal nodes along the proximal part of femoral vein) (Note: Lymph nodes are palpable only when they enlarge significantly)

Arteries of pectoral girdle?

1. Subclavian artery: a) passes over the first rib to become... 2.Axillary artery: a) at the lower border of teres major becomes the... 3.Brachial artery: a) Gives off a large branch in the arm - profunda brachii b) Divides as the level of the elbow into... 4.Ulnar and Radial arteries o the axillary artery is divided into three parts according to its relation to the pectoralis minor muscle (superior, deep, inferior) and gives off a number of branches in the axilla. There is an extensive collateral circulation in this region around the scapula. o The brachial artery is the main artery to the arm. It ends by dividing at the elbow into the radial and ulnar arteries. In the distal part of the arm it runs alongside lateral to the median nerve. o as brachial artery goes through the arm, it gives off a number of muscular branches, the largest of which is the profunda brachii artery, which follows the radial nerve. o profunda brachii - supplies blood to the posterior compartment of the arm. It enters the posterior compartment of the arm o There is an extensive arterial anastomosis at the elbow.

Which muscles in radio-ulnar joint contract during supination and pronation?

1. Supination - supinator, biceps 2. Pronation - pronator quadratus, pronator teres. *Supination and pronation occur at the proximal radio-ulnar joint and the distal radio-ulnar). Supination is the movement to direct the palm anteriorly whilst pronation is the movement to direct the palm posteriorly. *The muscles moving the The Distal Radio-Ulnar Joint (DRUJ) are identical to those moving the proximal radio-ulnar joint.

Three main nerves in the forearm?

1. The ulnar nerve - supplies only FCU and the Ulnar half of FDP. 2. The median nerve -supplies all of the remaining anterior compartment muscles. 3. The radial nerve - supplies all posterior compartment muscles. 1) The Ulnar Nerve: o The ulnar nerve (C8 T1) has no branches in the arm and initially descends in its anterior compartment, but distally passes into the posterior compartment to lie superficially, posterior to the medial epicondyle of the elbow, where it is at risk of damage. The ulnar nerve enters the forearm passing between the heads of flexor carpi ulnaris, it then descends on the medial side of the forearm, where it supplies the more medial muscles in the anterior compartment. In the forearm it supplies: a) flexor carpi ulnaris (FCU) b) medial portion of flexor digitorum profundus (FDP) i.e. to the ring and little fingers. o The ulnar nerve also gives a sensory supply to the medial aspect of the ventral forearm. o At the wrist, the ulnar nerve lies between the FCU (medially) and the ulnar artery (laterally) and then passes into the hand where is supplies most of the intrinsic muscles. 2) The Median Nerve: o The median nerve (C6,7,8 T1) descends in the anterior compartment of the arm, within which it does not give any branches. Anterior to the elbow, it lies medial to the brachial artery, where it is at risk of damage by supracondylar fractures of the humerus. The median nerve then descends into the forearm between the heads of pronator teres to become the principal motor nerve of the anterior compartment. In the forearm it supplies: a) pronator teres b) FDS c) lateral portion of FDP (to the index and middle fingers) d) FCR e) Pronator quadratus f) Palmaris longus o At the anterior wrist, the median nerve lies quite superficially between the tendons of FDS and FDP and deep to palmaris longus (if present), prior to entering the hand through the carpal tunnel. 3) The Radial Nerve: o The radial nerve (C5,6,7,8 T1) supplies the posterior (extensor) compartment of the arm. It lies on the humerus in the radial (spiral) groove where it is at risk in humeral shaft fractures. Just superior to the elbow it divides into the superficial radial nerve (cutaneous sensory) and the deep branch of the radial nerve (motor), which descends into the forearm between the heads of supinator, to be come the posterior interosseous nerve and to supply all of the muscles of the posterior (extensor) compartment of the forearm and it ends as a pseudoganglion below the extensor retinaculum. o In the forearm: 1) The radial nerve supplies: a) Brachioradialis b) ECL 2) The deep branch of the radial nerve supplies: a) ECRB b) Supinator 3) The posterior interosseous nerve supplies: a)ED b) ED minimi c) ECU d) APL e) EPB f) EPB g) E indicis

Fracture repair process

1. Torn vessels bleed to produce a fracture HEMATOMA. 2. Osteoprogenitor cells and relatively inactive osteoblasts from the periosteum and endosteum differentiate into active OSTEOBLASTS and migrate towards the fracture. 3. These migrating osteoblasts form a provisional type of bone and cartilage called EXTERNAL CALLUS. This external callus bridges the end of the bones. INTERNAL CALLUS also forms between the bone ends. Chondrocytes produce cartilage, which then is replaced by bone. The initial bone formed is WOVEN bone, which then re-structures to form CANCELLOUS bone. 4. Osteoblasts and osteoclasts remodel the cancellous bone over time, to give rise to CORTICAL bone.

Digital injuries

1.Mallet finger - Avulsion of extensor digitorum longus tendon at the base of distal phalanx 2.Trigger finger (Stenosing Tenosynovitis) 3.Skier's/Gamekeeper's thumb 4.De Quervain's syndrome* (Tendinopathy due to tenosynovitis) - De Quervain's often occurs due to overuse of the thumb leading to reduced thumb flexion, abduction and extension.

Assessment of Nerve Function

1.Motor Function 2.Sensory Function 3.Reflex Function 4.Autonomic Function

Bones of the Upper Limb

1.Pectoral girdle a) Clavicle b) Scapula 2.Arm - Humerus 3.Forearm a) Radius b) Ulna 4.Wrist - Some lovers try positions that they can't handle a) Scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate 5.Metacarpals - 5 in each hand 6.Phalanges - all digits have 3 except for thumb which has 2

What are the anterior pectoral girdle muscles?

1.Pectoralis major 2.Pectoralis minor 3.Subclavius 4.Serratus anterior* *runs between anterior and posterior

Superficial Anterior Compartment of the Forearm (flexors)

1.Pronator teres (PT) 2.Flexor carpi radialis (FCR) 3.Palmaris longus (PL) 4.Flexor digitorum superficialis (FDS) 5.Flexor carpi ulnaris (FCU) *common flexor tendon attaches to medial epicondyle of humerus where PT, FCR, PL and FCU all originate. Part of FDS originates here too. * may of muscles also have attachments on shafts of bone and interosseus membrane. * Flexor Digitorum Superficialis (FDS), Flexor Digitorum Profundus (FDP) which is deeper, and Flexor pollicus Longus (FPL) which is for thumb. * have pronator teres (straight muscle) and pronator quadratus (square shaped muscle)

Muscles of the elbow, forearm and wrist

1.Anterior compartment of the arm (except coracobrachialis) 2.Posterior compartment of the arm: triceps, anconeus (supplied by radial nerve C7,8) 3.Anterior compartment of the forearm a.Superficial compartment b. Deep compartment 4.Posterior compartment of the forearm

What are the muscular compartments in the pectoral girdle?

1.Anterior pectoral girdle muscles: a) Pectoralis major b) Pectoralis minor c) Subclavius d) Serratus anterior 2.Posterior pectoral girdle muscles: a) Trapezius b) Latissimus dorsi c) Levator scapulae d) The rhomboids 3.Intrinsic shoulder muscles: a) Deltoid b) Teres major c) The rotator cuff muscles: i) Supraspinatus ii) Infraspinatus iii) Teres minor iv) Subscapularis 4.Anterior compartment of the upper arm: a) Biceps b) Brachialis c) Coraco-brachialis 5.Posterior compartment of the upper arm: a) Triceps b) Anconeus

Deep Anterior Compartment of the Forearm

1.Flexor digitorum profundus (FDP) 2.Flexor pollicis longus (FPL) 3.Pronator quadratus (PQ)

Axillary Nerve path (Derived from Posterior Cord)

Commonly damaged through dislocations of shoulder and fracture of the surgical neck of the humerus. - smaller than radial. passes under shoulder joint then goes lateral.

Function of dorsal interossei and innervation

4 of them **Origin: Sides of two metacarpals All of them are bi-pennate muscles* ** Insertion: Sides of extensor hoods **Function: Abduction at MCP joint **Innervation: Ulnar nerve o Radial artery passes through the heads of first DI*

Deep tendon reflexes (spinal myotactic or stretch reflex)

A muscle is supplied by one or more spinal cord segments or nerve roots. When the tendon of the muscle is tapped (thus causing stretch of muscle spindles) it results in an involuntary contraction (or a jerk) in the muscle. Presence of reflex activity indicates the integrity of the nerve pathway (lower motor neuron) of the particular spinal cord segment.

what is a nerve plexus?

A nerve plexus is formed when peripheral spinal nerve roots merge (and swap) and split to produce a network of nerves from which new multi-segmental peripheral nerves emerge. Both upper and lower limbs are supplied by plexuses (brachial and lumbosacral)

Peripheral Distribution - thigh

A) Femoral nerve: 1.Anterior thigh and medial leg 2.Medial and intermediate femoral cutaneous nerve 3.Saphenous nerve (as in goes through popliteal fossa) B) Posterior femoral cutaneous: 1.Posterior thigh 2.From sacral plexus C) Lateral femoral cutaneous: 1.Lateral thigh 2.From lumbar plexus D) Obturator: 1.Medial thigh 2.Cutaneous branch of obturator **FOR leg and foot: A) Femoral nerve (Saphenous Branch) 1.medial leg 2.Saphenous nerve (as in goes through popliteal fossa) B) Sural nerve 1.Calf region (posterior leg) and lateral foot 2.From tibial and common peroneal C) Superficial Peroneal 1.Anterio-lateral leg and dorsal foot D) Deep Peroneal 1.First toe web E) Tibial nerve 1.Sole of foot

Arteries of the hip, buttock and thigh

Abdominal aorta --> at L4 becomes common iliac: internal and external at pelvic brim/ Ø External iliac artery passes under inguinal ligament and enters femoral triangle --> Femoral artery - midinguinal point Ø The femoral artery is lateral to the femoral vein and medial to the femoral nerve (NAVY from lateral to medial). ØBranches in the triangle --> Profunda femoris artery (deep) --> Circumflex vessels Ø Femoral artery continues as the superficial femoral artery and subsequently as the popliteal artery at the adductor hiatus in knee. o branch of internal artery is obturator artery --> supplies in buttock and medial thigh (e.g. little branch to head of femur is from obturator). o The external iliac artery passes from the pelvis beneath the inguinal ligament and proceeds as the femoral artery. At the level of the inguinal ligament the artery lies at the mid-inguinal point i.e. half-way between the ASIS and the pubic symphysis. It is easily palpable here. It is lateral to the femoral vein and medial to the femoral nerve. o The femoral artery then gives of the main branch to the thigh called the profunda femoris artery. At this level the femoral artery and its profunda branch give off the circumflex vessels, which supply the hip joint. o The femoral artery continues after giving off the profunda femoris artery as the superifical femoral artery. At the level of the knee the superficial femoral artery becomes the popliteal artery. **Veins: 1) Superficial veins: ØLong saphenous vein ØJoins the femoral artery at the sapheno-femoral junction ØValve! 2) Deep veins: ØPopliteal vein ØFemoral vein ØExternal iliac vein ØSapheno-femoral junction ØVenae comitantes of the profunda femoris artery o As in the upper limb, the lower limb also has a system of superficial and deep veins. o In the thigh the main superficial vein is the long saphenous vein (also known as the great saphenous vein). It runs from the medial border of the foot, passes the knee on its medial aspect, passes up the medial aspect of the thigh to join the deep system at the sapheno-femoral junction. The long saphenous vein pierces the fascia of the thigh to join the deep system at the femoral triangle. There is an important valve at the sapheno-femoral junction that prevents blood passing from the deep to the superficial system. This valve is often faulty or incompetent in varicose veins. o The deep veins of the thigh flow into the popliteal vein at the level of the knee. The popliteal vein runs along side the popliteal and femoral arteries to form the femoral vein. The femoral vein lies medial to the femoral artery in the groin, and then passes beneath the inguinal ligament to form the external iliac vein. The femoral vein receives the long saphenous vein at the saphenofemoral junction in the groin. Proximal to this it also receives the venae comitantes of the profunda femoris artery.

Attachments of the adductor muscles

Adductor longus, brevis and magnus (adductor component). § Proximal Pubis and ischiopubic ramus. § Distal Femoral shaft. § Function Adduction and medial rotation of hip joint.

Anterior forearm - Deep muscles

All innervated by median nerve except for FDP to ring and little fingers (ulnar nerve) 1) Flexor digitorum profundus: a)Proximal: Ulna and interosseous membrane* b)Distal: Anterior aspect of distal phalanges c)Function: Flexion of interphalangeal joints and wrist d)Innervation - ulnar nerve 2)Flexor pollicus longus: a)Proximal: Radius* b)Distal: Distal phalanx of thumb* c)Function: Flexes interphalangeal joints of thumb 3)Pronator quadratus: a)Proximal: Distal ulna* b)Distal: Distal radius* c)Function: Pronation

Ankle joint movement

Ankle Joint Position: Ankle must have free movement Sitting off the side of the bed DorsiFlexion - Upward - "Could you bend your foot up?" PlantarFlexion - Downward - "Could you bend your foot down?" DorsiExtension and PlantarExtension are moot terms*

Coracobrachialis attachments and innervations

Anterior arm compartment 1.Proximal attachment: Coracoid process 2.Distal attachment: - Humeral shaft 3.Function: - Flexion at the gleno-humeral joint 4.Innervation: - Musculocutaneous

Obturator nerve innervation

Anterior divisions of L2-4 Innervates all of the muscles in the adductor compartment except? a) The hamstring half of the adductor magnus b) Pectineus *Has an anterior and posterior branch (relative to the adductor longus)

Sciatic nerve branches

At The Popliteal Fossa: § The sciatic nerve continues into the popliteal fossa where it divides into the tibial and common peroneal nerves: a) Common peroneal: winds around the fibular head where it can be easily damaged. Divides into: i) Superficial peroneal: lateral compartment of leg ii) Deep peroneal: anterior compartment of leg + extensor digitorum brevis (EDB) b) Tibial: innervates posterior compartment of leg and continues into the foot. i) Divides into medial and lateral plantar nerves to innervate all foot muscles (except EDB)

Gleno-humeral Joint is what kind of joint?

Ball and socket synovial joint between the glenoid cavity of the scapula and the head of the humerus. The cartilaginous glenoid labrum deepens the socket of the glenoid The joint has a fibrous capsule which "cups" the head of the humerus to hold it in place (not shown): a) Subacromial bursa: The capsule extends above the humeral head to form a bursa b) The glenoid is extended to the neck of the humerus below the humeral head* The tendon of the long head of the biceps passes through the joint **"It allows for great mobility, but at the expense of stability. The stability of the joint derives not from the shape of the bony articulation itself, but rather from the muscles, ligaments and capsular attachments around it. The glenoid cavity forms a very shallow socket. It is deepened by the glenoid labrum, which is clinically important. The humeral head lies within the glenoid and its labrum. To a significant extent the head stays within the socket not because of the shape of the bony articulation, but because of the active tone of the rotator cuff muscles (subscapularis, suprasinatus, infraspinatus and teres minor. The capsule of the shoulder joint has a very important clinical arrangement. As well as extending from the glenoid to the humeral head, it has two other extensions: 1) The subacromial bursa - the capsule extends above the humeral head to form a bursa between the humeral head and the overlying acromial process - this is often the site of pathology in impingement of the gleno-humeral joint. 2) An extension around the long head of biceps as it lies within the inter-tubercular grove of the humerus. o The coraco-acromial arch lies above the gleno-humeral joint - it consists of the acromion, the coracoid process and a strong ligament running between the two, the coraco-acromial ligament. This arch prevents the humerus from rising superiorly against the acromion. Beneath the arch is the subacromial bursa and the supraspinatus tendon (part of the rotator cuff). This is typically he site of the pathology of impingement of the shoulder, probably the commonest shoulder problem in clinical practice. o clinically important ligaments which blend in with the capsule of the gleno-humeral joint: 1) The gleno-humeral ligaments : these strengthen the anterior portion of the shoulder capsule 2) The coraco-humeral ligament : strengthens the capsule superiorly 3) The transverse humeral ligament - holds the tendon of the long head of biceps in the inter-tubercular groove.

Metacarpals

Base, body and Head Heads form knuckles NOTE: Metacarpal I is not connected to the others ; this contributes to thumb's mobility

Dermatome vs cutaneous nerve patterns

Because of all the fibre recombination that takes place in a plexus, the pattern of cutaneous nerve distribution is very different from the dermatome pattern. fibres supplying dermatomes might come from more than one peripheral nerve.

Metacarpo-phalangeal (MCP) Joints are reinforced by what?

Between the metacarpal heads and the bases of the proximal phalanges. Allow flexion, extension, adduction, abduction Reinforced by... a) Palmar ligament b) Medial and lateral MCP collateral ligaments

Brachioradialis reflex tests what nerves

Biceps jerk: C5/6 Triceps jerk: C6/7 Brachioradialis reflex: C6/7

Biceps and triceps tendon

Biceps tendon (anteriorly), Triceps tendon (posteriorly). *Triceps Brachii Attachments: a) Long head - originates from the infraglenoid tubercle. b) Lateral head - originates from the humerus, superior to the radial groove. c) Medial head - originates from the humerus, inferior to the radial groove. *Distally, the heads converge onto one tendon and insertinto the olecranon of the ulna. * Biceps : o The biceps muscle has two heads, the short head and the long head, distinguished according to their origin at the coracoid process and supraglenoid tubercle of the scapula, respectively. o distal biceps tendon. attaches to a part of the radius bone called the radial tuberosity.

How much of adult skeleton is remodelled each year?

Bone remodelling is affected by the physical stresses placed upon the bone as well as metabolic and hormonal factors. The turnover rate is relatively high - 20% of the adult skeleton is remodelled each year.

What does profunda brachii run alongside?

Brachial artery has many branches: It is lateral to the median nerve Most important branch: the profunda brachii The profunda brachii runs alongside the RADIAL nerve Gives off the nutrient artery to the humerus Divides at the elbow into the radial and ulnar arteries

What muscles cause flexion and extension of the elbow joint?

Brachialis, Brachioradialis & Biceps Brachii. Triceps

Brachial plexus

C5-T1. plexus is structure of spinal nerves mixing up --> peripheral nerves (fibres from more than one spinal root). roots formed from anterior rami of spinal nerves.

Which nerves supply wrist and coarse hand muscles?

C6-8

Which nerves supply elbow joint extensors?

C7-8

Which nerves supply small hand muscles?

C8-T1

Trigger Finger

Cause: Flexor profundus longus tendon causes friction to the tendon sheath and results in swelling of the tendon which in turn irritates the sheath, causing it narrow. When the finger is flexed it gets stuck in the sheath in a flexed position because the extensors are not strong enough to straighten the finger.

What vein passes through snuffbox?

Cephalic vein

When is common fibular nerve vulnerable to damage?

Common fibular nerve leaves the popliteal fossa and winds around the head of fibula where it is vulnerable to damage.

Gluteal Compartment Innervation

Derived from the sacral plexus. § The superior gluteal nerve (L4-S1): Gluteus medius, minimus and tensor fascia lata § The inferior gluteal nerve (L5-S2): Gluteus maximus §The nerve to piriformis (S1,S2) § The nerve to obturator internus (L5-S2): Obturator internus and gamellus superior § The nerve to the quadratus femoris (L4-S1): Quadratus femoris and gamellus inferior

Segmental vs cutaneous sensory innervation

Dermatomes are supplied by specific/discrete spinal nerves but these recombine to form cutaneous (peripheral) nerve patches - determine lesion position. segmental fibres may get to that area via different nerves, don't all arrive as a single nerve.

Distributions of sensory innervation can be classified in two ways

Distributions of sensory innervation can be classified in two ways: 1) Dermatomal Innervation - The strip of skin supplied by a pair of spinal nerves is referred to as a dermatome (e.g. L2 to anterior thigh) 2) Peripheral Innervation - The area of skin supplied by a single peripheral nerve (e.g. femoral nerves cutaneous branches to anterior thigh) **Why are the distributions different? Spinal nerves mix to form the peripheral nerves; same explanation for brachial plexus.

Sole of the Foot

Do not need to know in as much detail as hands, but fundamentally similar § Organised into 4 Layers (Superficial --> Deep): 1) 1st Layer Abductor hallucis, Abductor digiti minimi, FDB. 2) 2nd Layer Quadratus plantae, Lumbrical. 3) 3rd Layer Adductor halluces, FHB, FDMB. 4) 4th Layer 4 Dorsal / 3 Plantar interossei. **Quadratus plantae - It acts to aid in flexing the 2nd to 5th toes (offsetting the oblique pull of the flexor digitorum longus) and is one of the few muscles in the foot with no homolog in the hand

Draw the course of the sciatic nerve

Draw the course of the sciatic nerve in the buttock and thigh. § First, palpate three bony landmarks - posterior superior iliac spine (PSIS), ischial tubersoity and greater trochanter. § The nerve leaves the greater sciatic notch and enters the gluteal region at the midpoint between the PSIS and the ischial tubersoity. § It forms a downward curve to pass into the thigh around the midpoint between the greater trochanter and the ischial tubersoity before reaching the popliteal fossa (behind the knee).

Effects of lesion to ulnar nerve

Elbow fractures Funny bone trauma Wrist trauma **effects: Sensory loss in medial 1½ fingers (palmar and dorsal) Ulnar claw: a)Hyper-extended 4th and 5th digits at MCP b)Hyper-flexed 4th and 5th digits at IPJs c)Inability to abduct/adduct fingers against resistance d)Weak thumb adduction "Froment's sign" e)Claw worse on extension (unlike median nerve)

Acute compartment syndrome treatment

Emergency fasciotomy required to prevent the death of muscles in the affected compartment.

How does posterior tibial artery enter foot?

Enters sole of foot through the tarsal tunnel. Divides into medial and lateral plantar arteries to supply the foot

spiral ligaments in hip joint

Examine the hip joint, particularly noting: a) • the cartilaginous labrum that deepens the socket b) • the ligament of the head of femur c) • the spiral ligaments o The hip joint capsule is formed by three major ligaments: the iliofemoral, pubofemoral, and ischiofemoral ligaments. The capsular ligaments run in a spiral fashion preventing hip extension and are surrounded by thick longitudinal fibers that provide additional stability in the lateral plane.

Anterior Tendinous Anatomy of the Digits

Fibrous digital sheath: A = annular parts, C = cruciate parts **thickened plates (palmar ligaments (plates)) at joints. **As explained above the fibrous digital sheaths are a continuation of the palmar fascia. These sheaths extend from the level of the metacarpal head to the base of the distal phalanx in each digit. Together with the underlying bone they form osseo-fibrous tunnels through which the long flexor tendons and their synovial sheaths run. Parts of the fibrous digital sheath form condensations called pulleys, which allow for more functional use of the long flexor tendons. These are called the annular and cruciform pulleys. o Just after passing the wrist joint, the tendons of FDP and FDS pass deep to the flexor retinaculum and enter a common synovial sheath. The tendons then pass to their respective digit via a digital synovial sheath, which is contained within the fibrous digital sheath. The digital synovial sheaths of the index, middle and ring fingers are separate from the common synovial sheath. Those of the little finger and the thumb are usually continuous with the common sheath. o At the base of the proximal phalanx the FDS tendon splits around the FDP. The FDS attaches to the anterior surface of the middle phalanx whilst the FDP attaches to the distal phalanx. o The long tendon of the thumb, flexor pollicis longus, has its own synovial sheath at the flexor retinaculum. It then runs to the distal phalanx of the thumb.

Anterior Forearm - Intermediate muscles

Flexor digitorum superficialis: a)Large muscle inferior to the common wrist flexors 1)Proximal*: a)Radial and ulnar heads b)Partial attachment to the humerus 2)Distal: a)Middle phalanx 3)Functions: a)Flexion at the proximal interphalangeal, MCP and wrist joints 4)Innervation: a)Median nerve

Anterior Thigh muscles

Flexors of the hip and extensors of the knee. -psoas major - has attachments on lumbar vertebrae - psoas major fuses with iliacus muscle that has attachments on internal surface of iliac fossa --> iliopsoas muscle - iliopsoas attaches to lesser trochanter of femur - iliacus and psoas pass under the inguinal ligmanet (ASIS to pubic tubercle) - are FLEXORS. - psoas major = fillet for meat eaters - pectineus is also flexor of hip joint, attaches to superior ramus of pubic bone and lateral thigh - sartorius attaches to shaft of tibia (goes inferior and medially).

Presentation of Common Peroneal Nerve Palsy?

Foot Drop (High Stepping Gait)

Fibrous Membrane of the Knee Joint

Formed by extensions from tendons of the surrounding muscles. Encloses the articular cavity and intercondylar region.

Medial and lateral supracondylar ridges

Found just superior the respective epicondyles.They are felt as somewhat prominent lines and the lateral is more prominent that the medial.

What are the anterior superficial forearm muscles?

Four of these have the same proximal attachment, the common flexor origin a)Pronator teres b)Flexor carpi radialis c)Palmaris longus d)Flexor carpi ulnaris

Gateways

Gateways facilitate passage of nerves, vessels and tendons from the abdomen to the lower limb (and perineum) 1) Greater sciatic foramen: Links gluteal region of lower limb to pelvis a) Above piriformis: Superior Gluteal artery, vein and nerve b) Below piriformis: i) inferior gluteal artery, vein and nerve ii) Internal pudendal artery and vein and pudendal nerve iii) Sciatic nerve iv) Nerves to Obturator Internus and Quadratus Femoris v) Posterior femoral cutaneous nerve 2) Lesser sciatic foramen: Connects gluteal region of lower limb to perineum. Contents: a) Pudendal Nerve and Pudendal Vessels (going into the perineum) b) Tendon of obturator internus 3) Obturator Foramen: Connects medial compartment of lower limb to pelvis. Contains obturator nerve and vessels.

Lower limb posterior compartments

Gluteal, posterior thigh, posterior leg (sup. and deep), plantar (sole) surface of the foot. Also medial (adductor) compartment of thigh, and lateral (peroneal (UK) or fibular (USA)) compartment of the leg.

Medial Compartment of the Thigh

Hip ADductors: *(Mostly) supplied by the obturator nerve 1)Adductor longus 2) Adductor brevis 3) Adductor magnus - is attached to the ischial tuberosity and is supplied by the sciatic nerve. 4) Gracilis 5) Obturator externus **tend to have attachments around pubic bone and distal attachments on posterior of femoral shaft. o adductor magnus is tricky as has part that is medial adductor and a part that is posterior (has broad attachment) - has an adductor hiatus before attaching to medial epicondyle. hiatus important for structures passing between anterior and posterior structures of thigh. o gracilis is long strap muscle going from inferior ramus across knee and attach to tibia. o obturatur externus is smaller muscle.

Hip joint movements

Hip Joint Movements (from standing): a) Abduction - Lateral Upward - "Could you raise your leg to the side please?" b) Adduction - Lateral Downward - "Could you cross your leg behind the other leg?" To avoid gravity-assist, test movement against resistance. c) Flexion - Forward - "Could you raise your knee please?" d) Extension - Backward - "Could you bring your knee as far back as you can?" To avoid gravity-assist, test movement against resistance. Alternatively, raise knee while bending over. e) Circumduction - Conical movement - "Could you draw a circle with your foot please?" Give support to avoid falling Internal rotation* External rotation*

Injury to the Ulnar Nerve (Derived from Medial Cord)

Injuries to medial epicondyle of humerus cause injury to the ulnar nerve at the elbow. **Ulnar nerve injury: CLAW deformity. Loss of lumbrical contraction means loss of flexion of the MPJs and weakened extension of the IPJs. What other motor deficits will be evident? - Many small muscles of hand affected but thumb, index and middle finger movements largely spared. Sensory problems inconvenient - not as bad due to median nerve because that affects the middle and index etc.

Pattern of Innervation in the Hand palmar aspect

Intrinsic hand muscle innervation: a) Median supplies thenar muscles and the lateral 2 lumbricals b) Ulnar supplies all of the other intrinsic hand muscles

Brachial plexus summary with lesions

JAS slide 5 brachial plexus pp. o dorsal scapular n. - rhomboids maj and minor, levator scapular o subclavius n. o suprascapular n.- supraspinatus and infraspinatus. shoulder dislocation risk and pain. o lateral pectoral n. - pec major o musculocutaenous - ant. compartment of arm, lateral cutaneous nerve of forearm. weak elbow flexion and supinator, absent biceps reflex, lateral forearm sensory loss. o axillary - deltoid, teres minor, upper lateral cutaneous nerve of arm. loss of abudction (>15), regimental patch, weak rotation. o radial - post. compartment of arm and forearm, lower lateral cutaneous n. of arm, posterior cutaneous nerve of arm and forearm superficial branch (dorsum). weak extension of elbow, wrist and fingers; decreased power grip, dorsal sensory loss. o median - LOAF muscles, ant. compartment of arm (except FCU and medial half of FDP), lateral 3.5 digits and palm. weak wrist flexion, pronation, 'benediction sign' and 'ape hand'; sensory loss lateral 3.5 digits. o ulnar - Non-LOAF muscles of hand, medial 1.5 of FDP, FCU; medial 1.5 of digits. Ulnar claw hand, froment's sign, loss of finger ab/adduction, worse on extension, sensory loss medial 1.5 digits, ulnar paradox. o lower subscap. n. - subscapularis and teres major - risk of shoulder dislocation and pain o middle subscapular --> thoracodorsal --> latissimus dorsi o upper subscapularis n. - subscapularis o medial cut. nerve of arm and forearm o medial pectoral - pec major and minor o long thoracic - serratus anterior. winging of scapulae.

Brachial plexus summary with lesions JAS

Ecofreindly knee joint design

Knee is designed to save energy when fully extended. 1)Shape of the femoral condyles - flatter/broader anteriorly 2)Medial rotation of the femur on the tibia - tightens ligaments ('Locking' mechanism). Unlocked by - popliteus. 3)Body's line of centre of gravity is ANTERIOR o the knee joint.

What type is knee joint?

Largest synovial joint in body; superficial; primarily a hinge-type synovial joint with some gliding, rolling and rotation. principle movements are flexion and extension. § The knee joint is a hinge synovial joint between the femur and proximal tibia, and it involves the patella ( 3 bones) § Ligaments & Menisci § Popliteal Fossa

Deep View of the Gluteal Region

Lateral Rotators: One of this group's main functions is to stabilise the hip joint.

What is the serratus anterior innervated by?

Long thoracic nerve (C5, C6, C7). a) Long Thoracic Nerve - supplies serratus anterior b) Suprascapular Nerve - supplies supraspinatus and infraspinatus c) Medial and Lateral pectoral nerves - supply pectoralis major d) Thoracodorsal nerve - latissimus dorsi e) The axillary nerve - supplies teres minor and then deltoid as well as an area of skin over the deltoid. f) The musculocutaneous nerve (C5,6,7) - nerve of the anterior compartment of the arm (coracobrachialis, brachialis and biceps). It continues as the lateral cutaneous nerve of the forearm. It lies close to the subscapularis tendon anterior to the shoulder and is at risk during surgery to the anterior gleno-humeral joint. g) The ulnar nerve (C8, T1) - one of the nerves that supplies the anterior compartment of the forearm but is mainly the nerve of the hand. It has no branches in the arm and passes though the arm in the anterior compartment initially but more distally in the posterior compartment. It lies posterior to the medial epicondyle of the elbow and is at risk there. h) The median nerve (C6,7,8 T1) - one of the nerves that supplies the anterior compartment of the forearm and hand. It has no branches in the arm. It passes through the arm in the anterior compartment. At the level of the elbow it lies alongside the brachial artery and is at risk in supracondylar fractures of the humerus. i) The radial nerve (C5,6,7,8T1) -supplies the posterior compartment of the arm as well as the posterior compartment of the forearm. It lies on the humerus in the radial groove and is at risk in humeral shaft fractures. Just proximal to the elbow, it divides into the superficial radial nerve (sensory) and the posterior interosseous nerve (motor). o The last four nerves (musculocutaneous, ulnar, radial and median nerves) are the principal nerves of the upper limb.

Extensor Posterior Compartment of the Forearm

Lots of muscles in the forearm, but you can begin to make some sense of them by exploiting the terminology. * Forearm muscles can be classified into functional groups: a) Flexors (anterior) and Extensors (posterior) b) Movers of the wrist (the "carpi" muscles) act on the radial (radialis) or ulnar (ulnaris) aspects of the forearm. c) Movers of the digits:- act on groups of digits (digitorum muscles) or on individual digits (pollicis (thumb), indicis (index finger) digiti minimi (little finger)) (these muscles also contribute to wrist movements). d) Also note that if there's a longus, there's a brevis; if there's a superficialis, there's a profundus. e) The main complications are the muscles involved in pronation (anterior) and supination (posterior).

Nerves to the Lower Limb emerge from which plexus?

Lumbosacral Plexus. o Femoral n. supplies anterior compartment of thigh. passes underneath inguinal ligament - enters femoral triangle and sprays out a lot of terminal branches. posterior division but supplies anterior compartment due to pronation in birth o Obturator n. supplies medial (adductor) compartment of thigh. passes through obturator foramen. anterior division of plexus. o Sciatic n. (or its terminal branches Tibial and Common Peroneal ns.) supply the remaining compartments (i.e. post. thigh, ant. and post. leg, foot). both anterior and posterior divisions. **anterior and posterior divisions shown in pic.

Inter-Metacarpal Joints

Made of deep transverse metacarpal ligaments Bind together the 2nd and 5th metacarpals No attachment to metacarpal I, allowing the thumb to act more independently

Antecubital veins

Major superficial veins in antecubital fossa. *(NOTE: To demonstrate superficial veins of the upper limb, you will apply pressure around the middle of the arm of the subject by encircling with your hands. This will cause venous congestion and distention of the veins distally.)

Innervation of lumbricals

Medial two: Ulnar Nerve (deep branch*) Lateral two: Median Nerve. SPECIAL muscles because they link flexor and extensor tendons and allow small intricate movements. *Origin: Sides of FDP tendons * Insertion: Lateral side of extensor hoods * Function: Flexion of MCP and extension of IP joints

What does median nerve supply?

Median Nerve (C6,7,8,T1): •Courses through the anterior compartment of the arm (no significant branches) and lies anterior to the elbow, with the brachial artery (easily damaged!) •Main nerve to the muscles of the forearm

Nerves of forearm

Median nerve, Ulnar nerve, Radial nerve (including the superficial and deep / interosseous branches)

MCP joint movements

Metacarpo-phalangeal (MCP) Joint Movements: Abduction - "Could you open your palms wide?" Adduction - "Could you bring your fingers together" Flexion - "Could you bring your fingers towards you?" Extension - "Could you bring your fingers away from you?"

Scaphoid Fracture

Most common carpal injury In most people, the bone receives 80% blood from the radial artery Retrograde blood supply A fracture of the scaphoid can therefore, result in... Avascular necrosis of the scaphoid

Summary of attachments of iliopsoas region

Most muscles that insert on the femur (the thigh bone) and move it, originate on the pelvic girdle. The psoas major and iliacus make up the iliopsoas group. Some of the largest and most powerful muscles in the body are the gluteal muscles or gluteal group. The gluteus maximus is the largest; deep to the gluteus maximus is the gluteus medius, and deep to the gluteus medius is the gluteus minimus, the smallest of the trio

Which nerve does not pass through cubital fossa

Most things passing from arm to forearm go through the cubital fossa: a) Median nerve b) Radial nerve Passes anterior to lateral epicondyle* c) Brachial artery (divides in the cubital fossa into radial and ulnar) d) Biceps tendon IMPORTANT EXCEPTION: Ulnar nerve, passes posteriorly to medial epicondyle

Assessment of nerve function different methods

Nerve function can be assessed via the following modalities (SMART): A. Motor function; B.Sensory function; C.Reflex function ; D.Autonomic function; E. Trophic function. § When there has been an injury or disorder to a nerve, always describe the functional deficit in terms of the above five functions. § For example, if there is a prolapsed intervertebral disc at L5/S1, causing pressure on the right S1 nerve root, this will cause a segmental loss as follows in the right limb: A) Motor - loss of eversion of the foot (and weakness elsewhere). B) Sensory - loss of sensation along the lateral border of the foot. C) Loss of the right ankle jerk (S1). D) Abnormalities of sweating in the S1 cutaneous nerve distribution (not normally noticed by the patient in the lower limb, but quite a feature in the upper limb). E) Trophic - in long-standing lesions, there may be trophic changes on the lateral aspect of the foot. Effects on surrounding tissues due to chronic loss of innervation. Remember, LMN lesion causes muscle wasting § However, if there is damage to the common peroneal nerve at the level of the fibular neck (e.g. due to pressure of the leg against an operating table), there will be a peripheral loss as follows: § A. Motor - foot drop i.e. paralysis of the anterior and lateral compartments of the leg. § B.Sensory - loss of sensation in the distribution of the common peroneal nerve i.e. the dorsum of the foot at least. § C.Reflex - no loss of reflexes as the ankle jerk is provided mainly by the tibial nerve. § D.Autonomic - abnormalities of sweating in the cutaneous distribution of the common peroneal nerve. § E. Trophic - in chronic cases there may be damage to the sole of the foot due to the pressure effects of the foot drop. Effects on surrounding tissues due to chronic loss of innervation. Remember, LMN lesion causes muscle wasting

Nerves to the Lower Limb emerge from the [...]

Nerves to the Lower Limb emerge from the Lumbosacral Plexus. o Femoral n. supplies anterior compartment of thigh. o Obturator n. supplies medial (adductor) compartment of thigh (coming through obturator foramen). o Sciatic n. (or its terminal branches Tibial and Common Peroneal ns.) supply the remaining compartments (i.e. post. thigh, ant. and post. leg, foot)

Which nerve supplies anterior compartment of thigh?

Nerves to the Lower Limb emerge from the Lumbosacral Plexus. o Femoral n. supplies anterior compartment of thigh. o Obturator n. supplies medial (adductor) compartment of thigh. o Sciatic n. (or its terminal branches Tibial and Common Peroneal ns.) supply the remaining compartments (i.e. post. thigh, ant. and post. leg, foot)

Which nerve supplies medial compartment of thigh?

Nerves to the Lower Limb emerge from the Lumbosacral Plexus. o Femoral n. supplies anterior compartment of thigh. o Obturator n. supplies medial (adductor) compartment of thigh. o Sciatic n. (or its terminal branches Tibial and Common Peroneal ns.) supply the remaining compartments (i.e. post. thigh, ant. and post. leg, foot)

Which nerve supplies posterior compartment of thigh?

Nerves to the Lower Limb emerge from the Lumbosacral Plexus. o Femoral n. supplies anterior compartment of thigh. o Obturator n. supplies medial (adductor) compartment of thigh. o Sciatic n. (or its terminal branches Tibial and Common Peroneal ns.) supply the remaining compartments (i.e. post. thigh, ant. and post. leg, foot)

Lateral and medial view of feet

Note the sesamoid bones in flexor hallucis brevis. (similar bones in the thumb). **on lateral: talus, which forms part of ankle joint, calcaneus underneath, cuboid, navicular and 2/3 cuneiforms. ** on medial: talus, calcaneus, navicular, first cuneiform and couple metatarsals. medial sesamoid (ball of foot where lots of weight). **medial arch is higher than lateral arch. also transverse arch.

Musculocutaneous Nerve

O C5, C6 Supplies the anterior compartment of the arm Continues as the lateral cutaneous nerve **It is important to remember the roots and the peripheral nerves they supply: Musculoskeletal (C5, C6) Axillary nerve (C5, C6) Ulnar nerve (C8, T1) Radial nerve (C5 - T1) - Median nerve (C6 - T1

Axillary Nerve

O C5, C6 Supplies the deltoid and teres minor muscles Emerges from the posterior cord of the brachial plexus alongside the radial nerve **It is important to remember the roots and the peripheral nerves they supply: Musculoskeletal (C5, C6) Axillary nerve (C5, C6) Ulnar nerve (C8, T1) Radial nerve (C5 - T1) - Median nerve (C6 - T1

Radial Nerve

O C5-T1 Supplies the posterior compartments of the arm and forearm It lies on the humerus in the radial groove and can be damaged there by fractures It descends between the medial and lateral heads of the triceps brachii* Above the elbow it divides into: Superficial radial nerve Posterior interosseous nerve. **It is important to remember the roots and the peripheral nerves they supply: Musculoskeletal (C5, C6) Axillary nerve (C5, C6) Ulnar nerve (C8, T1) Radial nerve (C5 - T1) - Median nerve (C6 - T1

Median Nerve

O C6 - T1 Supplies most the anterior compartment of the forearm and some intrinsic hand muscles It passes through the upper arm via the anterior compartment. It originates anteriorly to the brachial artery*. At the level of the elbow it lies medial to the brachial artery and can be damaged there during a supracondylar fracture. **It is important to remember the roots and the peripheral nerves they supply: Musculoskeletal (C5, C6) Axillary nerve (C5, C6) Ulnar nerve (C8, T1) Radial nerve (C5 - T1) - Median nerve (C6 - T1

Ulnar Nerve

O C8, T1 No branches in the upper arm Upper arm in the anterior compartment initially but pierces the intermuscular septum and distally runs in the posterior compartment Lies posterior to the medial epicondyle and can be damaged Supplies the hand and some muscles in the anterior compartment of the forearm **It is important to remember the roots and the peripheral nerves they supply: Musculoskeletal (C5, C6) Axillary nerve (C5, C6) Ulnar nerve (C8, T1) Radial nerve (C5 - T1) - Median nerve (C6 - T1

What do osteoblasts eventually become?

Osteoblasts produce new bone matrix. The matrix is initially called osteoid before it is calcified. Ultimately the osteoblasts become osteocytes.

Biceps Tendon Reflex

Palpate biceps tendon in cubital fossa, place thumb on tendon Tap thumb briskly with a tendon hammer Observe for? Tests C5, C6 reflex arc - Musculocutaneous nerve

Parts of the dorsal venous arch drain into the ____. The plantar venous arch drains into the _____

Parts of the dorsal venous arch drain into the anterior tibial vein. The plantar venous arch drains into the posterior tibial veins

Median nerve palsy

Patient presents with sensory and motor loss to the radial 3 1/2 fingers, paralysis of thenar muscles with inability to oppose the thumb. There is no sensory loss in the central palmar region

Erb's palsy sensory loss

Patient presents with sensory loss to the lateral aspect of the arm and forearm, with arm adducted, medially rotated and forearm pronated at the elbow. There is also paralysis of supraspinatus, infraspinatus, deltoid, biceps, brachialis and brachioradialis.

Klumpke's palsy sensory loss

Patient presents with sensory loss to the ulnar side of the hand and forearm, with paralysis of all intrinsic muscles of the hand with clawing of all fingers. In addition the patient has Horner's syndrome due to symapathetic loss in C8 & T1 (drooping eye lid, constricted pupil and dry facial skin on the same side of the face as the upper limb lesion).

Lower Limb Veins: varicose veins

Perforating veins connecting superficial and deep veins contain a valve that will allow flow only from superficial to deep. If such a valve is compromised, blood is pushed from deep to superficial veins leading to varicose veins. o swelling of superficial veins; can get ulcers and pains consequently. ØValves in superficial, deep and perforating veins ØSapheno-femoral junction valve most important ØVenous "insufficiency" ØLipodermatosclerosis (skin thickening) (chronic inflammatory cause?) ØVenous ulcers- important in diabetics and older people

Peripheral vs Segmental Motor Supply

Peripheral - The final nerve leaving the plexus that actually goes to the muscle (ie. femoral nerve for hip flexion). Segmental - The spinal roots where the motor neurones originate (ie. L2-3 for hip flexion)

Distal Radio-Ulnar Joint

Pivot type joint which allows the radius to move around the ulna in rotation: Pronation and supination. * The articular surfaces are connected together by the following ligaments: a) Palmar radio-ulnar ligament b) Dorsal radio-ulnar ligament c) Articular disk (triangular fibrocartilage) There is an articular disc called the triangular fibro-cartilage. *Articular discs separate synovial joints allowing them to have independent movements *In the case of the triangular fibro-cartilate, this will be the distal radio-ulnar and radiocarpal (wrist) joint.

profunda femoris artery

Posterior and lateral to the superficial femoral artery. o external iliac artery as is passes under the inguinal ligament to continue as the femoral artery. o deep artery of the thigh (PROFUNDA FEMORIS artery) which branches from the femoral artery in the femoral triangle and immediately gives of the lateral and medial CIRCUMFLEX arteries (providing the distal supply to the head of femur), while the artery passes inferiorly, medial to the femoral shaft, giving off PERFORATING branches.

Femoral nerve innervation

Posterior divisions of L2-4. Innervates all muscles in anterior compartment of thigh. Also innervates the pectineus of the adductor compartment. Has some important sensory cutaneous branches: a) Medial femoral cutaneous nerve: Medial part of anterior thigh* b) Intermediate femoral cutaneous nerve: Middle part of anterior thigh* c) Saphenous nerve: anteromedial knee, medial leg and foot

Which spinal nerves supply the perineum?

S2-Cx2

When is sciatic nerve likely to be damaged?

Sciatic nerve leaves the pelvis through the greater sciatic foramen to enter the gluteal region. It contains the tibial and the common fibular components. The nerve is likely to be damaged in hip fractures, dislocation of the hip joint, or wrongly administered intramuscular injections in the gluteal region.

Hamstrings attachments

Semimembranosus, semitendinosus, biceps femoris and hamstring component of adductor magnus § Proximal Ischial tuberosity. § Distal Biceps femoris: Fibula; Semi-M and semi-T: Tibia; Adductor magnus*: Hamstring part attaches to adductor tubercle. § Functions Knee flexion and thigh extension

Thenar and Hypothenar contain what muscles?

Sets of 3 muscles dedicated entirely to little finger and thumb Contain an abductor, a flexor and an opponens muscle 1)Thenar compartment: a)Abductor pollicis brevis b)Flexor pollicis brevis c)Opponens pollicis 2)Hypothenar compartment: a)Opponens digiti minimi b)Flexor digiti minimi brevis c)Abductor digiti minimi **Thenar muscles originate from: Tubercle of scaphoid, trapezium and adjacent flexor retinaculum **Hypothenar muscles originate from: Hook of hamate, pisiform bone and adjacent flexor retinaculum **The abductor and the flexor insert on the outside of the extensor hood and base of proximal phalanx respectively The opponens insert on the outside of the respective metacarpal.

What is the subacromial bursa?

Subacromial bursa: The capsule extends above the humeral head to form a bursa **In glenohumeral joint: Ball and socket synovial joint The cartilaginous glenoid labrum deepens the socket of the glenoid The joint has a fibrous capsule which "cups" the head of the humerus to hold it in place (not shown): a) Subacromial bursa: The capsule extends above the humeral head to form a bursa b) The glenoid is extended to the neck of the humerus below the humeral head* The tendon of the long head of the biceps passes through the joint

The Lymphatic Drainage of pectoral girdle

Superficial and deep systems, run with veins: 1.Cubital lymph nodes 2.Delto-pectoral lymph nodes 3.Axillary lymph nodes - important! 4.Subclavian lymph trunk 5.Long thoracic nerve and thoraco-dorsal nerve! o Lymph drains from the hand via superficial lymphatics which run alongside the cephalic and basilic veins. Some lymphatics pass directly and superficially up the arm but there are also some cubital lymph nodes at the elbow. Similarly there are some delto-pectoral lymph nodes alongside the cephalic vein. Ultimately lymph from the superficial system drains to the AXILLARY lymph nodes. o There are also deep lymphatics which run alongside the deep veins and which also terminate in the axillary lymph nodes. o The axilla contains a large number of axillary lymph nodes, and these are of significant importance clinically in relation to carcinoma of the breast, as the lymphatic drainage of the breast includes these lymph nodes. o There are five groups of axillary lymph nodes - apical, pectoral, subscapular, humeral and central. All the groups drain via the apical lymph nodes, which drain into the subclavian lymphatic trunk and then ultimately the right lymphatic duct (right side) or the thoracic duct (left side). o The axillary lymph nodes are frequently dissected and "sampled" in patients with carcinoma of the breast. There are two nerves in close relation to the axillary lymph node region. These are: a) the long thoracic nerve - supplies the serratus anterior muscle. b) The thoracodorsal nerve - supplies the latissimus dorsi muscle. o These nerves may be are at risk during axillary lymph node dissections. Section of the thoracodorsal nerve surprisingly does not produce too much disability but section of the long thoracic nerve causes paralysis of the serratus anterior muscle and as a result, winging of the scapula.

Forearm - Superficial Venous Drainage

Superficial drainage is via the cephalic and basilic veins The dorsal venous arch forms the cephalic vein laterally and the basilic vein medially. The median cubital vein connects the cephalic and basilic vein at the level of the elbow This is a common site for venepuncture

Superficial veins of hand

Superficial veins in the region of the Cubital Fossa are commonly used for phlebotomy or insertion of a venous line. The median cubital vein, linking the basilic and cephalic veins, is not always present. o dorsal digital veins --> superficial dorsal venous network --> basilic (medial) and cephalic (lateral) *Most of the venous drainage of the hand is via the superficial system but some is via the deep system.*

Scapular anastomosis

Suprascapular artery (subclavian), Dorsal scapular artery, Circumflex scapular artery (subscapular artery from axillary), Possibly intercostal arteries (aorta). *much of the arterial supply to the scapular region arises from the suprascapular and transverse cervical arteries (branches of the thyrocervical trunk from the first part of the subclavian artery). *axillary artery as it enters the axilla as the continuation of the subclavian artery. Attempt to find some of the smaller branches (thoracoacromial and superior thoracic arteries) arising in its most proximal part. In the arm, the axillary artery becomes the brachial artery distal to the inferior border of teres major muscle. Look for the anterior and posterior circumflex humeral branches and the subscapular artery at the level of the neck of humerus, and also the deep brachial artery more distally.

Acromio-clavicular joint is what kind of joint?

Synovial joint between the clavicle, acromion and coracoid process of scapula. Three important ligaments: a) Acromioclavicular b) Coracoclavicular: Composed of the conoid and trapezoid ligaments. runs from the coracoid process of the scapula to the clavicle. c) Coracoacromial (not shown) - this is not particularly strong, but it is clinically important in that it is often a cause of impingement of the gleno-humeral joint. **Dislocation: Commonly injured by falls onto outstretched hand and can tear the ligaments (red line). a) Minor dislocations: Acromio-clavicular ligament tear b) Major dislocations: Coraco-clavicular ligament tear **pic: 1) coracoclavicular ligament 2) acromioclavicular ligament 3) coronoid ligament 4) trapezoid ligament

The Obturator Nerve

The Obturator Nerve (L2L3L4, anterior divisions): § The obturator nerve is formed from the lumbar plexus. It supplies the adductor (medial) compartment of the thigh and is also sensory to parts of the pelvis and the medial aspect of the thigh.

The Sural nerve is formed from...

The Sural nerve is formed from a branch of the tibial nerve and a smaller branch from the common peroneal nerve. Runs distally close to the short saphenous vein, towards the lateral foot. Can be used in nerve repair.

The Tibial Nerve

The Tibial Nerve (L4L5S1S2S3): § This is the other terminal branch of the sciatic nerve. It supplies the posterior compartment of the leg and most of the intrinsic muscles of the foot. It is sensory to the back of the leg and the sole of the foot.

Blood Supply to the Femoral Head

The blood is supplied by 2 branches of the profunda femoris: a) Lateral circumflex artery b) Medial circumflex artery Also, by Acetabular branch of the obturator artery*

posterior forearm is innervated by what?

The entire posterior forearm is innervated by the posterior interosseous nerve, which is a continuation of the deep motor branch of the radial nerve. 1) Extension of the wrist a)Extensor carpi radialis longus b)Extensor carpi radialis brevis c)Extensor carpi ulnaris 2) Extension of the digits: a)Extensor digitorum (all 4 digits) b)Extensor indicis (index digit) c)Extensor digiti minimi (little finger) 3) Extension of the thumb: a)Extensor pollicis brevis b)Extensor pollicis longus c)Abductor pollicis longus -mostly thumb abduction

Which four nerves in humerus in contact with?

The humeral head articulates with the glenoid cavity of scapula. At the distal humerus the capitulum and the trochlea articulates with the radius (in full flexion) and ulna respectively. The humerus is in contact with four nerves, which can be damaged by fractures or dislocation of the humerus: 1) The axillary nerve - winds around the surgical neck of the humerus and can be damaged by shoulder dislocation. 2) The radial nerve - runs in the radial (spiral) groove and can be damaged in humeral shaft fractures. 3) The ulnar nerve - runs posterior to the medial epicondyle (funny bone) and is very superficial. It can be damaged in fractures and dislocations of the elbow joint. 4) The median nerve - runs anterior to the distal humerus and can be damaged in supracondylar fractures of the humerus and dislocation of the elbow joint.

Lumbar and Sacral Plexi

The lumbar plexus is formed by the ventral rami of L1-4. The sacral plexus is formed by the: a) Lumbosacral trunk (L4,5): This is a branch of the lumbar plexus. b) Ventral rami of S1-S4.

Movements of gleno-humeral joint

The movements of the gleno-humeral joint and the muscles producing these movements are: 1) Flexion: a) clavicular head of pectoralis major b) anterior fibres of deltoid c) coracobrachialis d) biceps 2) Extension: a) latissimus dorsi 3) Abduction: a) supraspinatus (first 15 degrees) b) central fibres of deltoid (after 15 degrees) 4) Adduction: a) pectoralis major b) latissimus dorsi 5) Internal rotation: a) subscapularis 6) External rotation: a) infraspinatus b) teres minor 7) Circumduction i.e. a combination of movements. **know this for testing muscles in OSPE as well!!** **"The following muscles are also involved in resisting dislocation at the joint: 1) Rotator cuff muscles - hold the humeral head against the glenoid cavity 2) deltoid 3) coracobrachialis 4) short head of biceps 5) long head of biceps

Summary of attachments of the superficial posterior compartment of the forearm

The muscles in the superficial posterior compartment of the forearm (superficial posterior extensor compartment of the forearm) originate on the humerus. These are the extensor radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and the extensor carpi ulnaris.

List the general muscle groups of the shoulders and upper limbs as well as their subgroups.

The muscles that make up the shoulders and upper limbs include the muscles that position the pelvic girdle, the muscles that move the humerus, the muscles that move the forearm, and the muscles that move the wrists, hands, and fingers

Topographical vs functional division of nervous system

The nervous system can be divided topographically into A. The Central Nervous System - brain and spinal cord B.The Peripheral Nervous System - cranial and spinal nerves. § However, the nervous system can also be divided functionally into: A. The Somatic Nervous System: i. A1 : Somatic Motor (Efferent)- to skeletal muscle ii.A2 : Somatic Sensory (Afferent) - sensory information from skin and muscle B.The Autonomic Nervous System, to and from cardiac muscle, smooth muscle, glands, gut etc. i. B1 : Autonomic Motor ii.B2 : Autonomic Sensory § There are 31 pairs of spinal nerves: 8 Cervical, 12 Thoracic, 5 Lumbar, 5 Sacral, 1 Coccygeal. § Each spinal nerve is formed from the union between an anterior root (motor) and a dorsal root (sensory). § The roots merge at the intervertebral foramen to form a spinal nerve. Autonomic fibres pass between T1-L2 and S2-4.

Compartment syndrome - what is it?

The neuromuscular compartments of the limbs are enclosed in fibrous sheaths which confine them. Ø Ischaemia caused by trauma-induced increased pressure in a confined limb compartment Ø Commonly the anterior, posterior and lateral compartments of the leg. can occur in arm too. Ø Normal pressure = 25mmHg; only need 50-60mmHg to collapse vessels, so arterial pulse still PRESENT Ø Acute compartment syndrome (trauma associated). Treatment- Emergency fasciotomy Ø Chronic compartment syndrome (exercise-induced) e.g. swelling due to (and only during) exercise in athletes. Treatment: Elective fasciotomy

Vasculature of the Leg - Arterial

The popliteal artery passes into the posterior compartment of the leg between the gastrocnemius and popliteus muscles. As it continues inferiorly it passes under the tendinous arch formed between the fibular and tibial heads of the soleus muscle and enters the deep region of the posterior compartment of the leg where it immediately divides into an anterior tibial artery and a posterior tibial artery

Summary of attachments of hamstrings

The posterior compartment of the thigh includes muscles that flex the leg and extend the thigh. The three long muscles on the back of the knee are the hamstring group, which flexes the knee. These are the biceps femoris, semitendinosus, and semimembranosus. The tendons of these muscles form the popliteal fossa, the diamond-shaped space at the back of the knee.

Arteries of the knee leg ankle and foot

The superficial femoral artery runs through the adductor hiatus in the thigh. As it winds around to gain access to the back of the knee it becomes the popliteal artery. Just distal to the knee joint, the popliteal artery divides into three arteries at the popliteal trifurcation. 1) Popliteal artery- genicular (knee) branches 2) Popliteal "Trifurcation" a) Anterior tibial artery : which runs in the anterior compartment of the leg, and which passes over the front of the ankle to form the dorsalis pedis artery. b) Posterior tibial artery : in the posterior compartment of the calf, to pass behind the medial malleolus. c) Peroneal artery : runs in lateral compartment of leg 3) At the ankle a) Posterior Tibial Artery : sole of the foot via the medial and lateral plantar arteries b) Dorsalis pedis artery (continuation of the anterior tibial artery) and supplies the dorsum of the foot and the digits. Is the main artery to the toes of the foot.

Capsule in hip joint

The synovial membrane is surrounded by a capsule which extends down the neck of the femur. Runs further anteriorly than posteriorly. Fractures of the hip are intracapsular or extracapsular.

Venous Drainage of knee, leg ankle and foot

There are superficial and deep systems in the leg. 1) Superficial veins: a) Dorsal venous arch which gives off two saphenous veins - on the dorsum of the foot. b) Long saphenous vein - From the medial aspect of the dorsal venous arch runs the long saphenous vein. (anterior to middle malleolus; comes up medial thigh --> anterior --> pierces saphenous opening, draining into femoral vein). This lies very constantly 2cm above and 2cm medial to the medial malleolus. It runs up the medial aspect of the leg, behind the knee and empties into the femoral vein in the groin at the sapheno-femoral junction. In the leg it anastomoses freely with the short saphenous vein and also has connections (perforating veins), via valves, with the deep veins of the calf. c) Short saphenous vein (posterior to lateral malleolus, pierces fascia at popliteal fascia and drains into popliteal vein) From the lateral aspect of the dorsal venous arch of the foot runs the short saphenous vein. This runs posterior to the lateral malleolus and up the back of the calf to join the deep venous system in the popliteal fossa to drain into the popliteal vein. It connects freely with the long saphenous vein and via perforating veins and valves to the deep veins of the calf. d) Perforating veins to the deep system (mainly in the calf) e) Valves! 2) Deep veins: a) Deep calf veins - venae comitantes of arteries b) Popliteal vein c) Femoral vein d) External iliac vein e) Sapheno-femoral junction g) Venae comitantes of the profunda femoris artery **FROM COURSEGUIDE: Deep system: 1. Dorsal digital veins 2. Posterior tibial veins 3. Popliteal vein 4. Perforating veins whereby normally blood passes from the superficial to the deep systems. **Note that the deep system forms a powerful "muscle pump" whereby the muscles of the calf pump blood back towards the heart.

Arches of the Foot

There are three important arches in the foot: 1. Medial longitudinal arch (higher than lateral) 2. Lateral longitudinal arch 3. Transverse metatarsal arch **The shape of the foot bones, and how they fit together, contributes to the formation and stability of the arches of the foot. o Some of the major structures maintaining the arches of the foot: Ligaments and long tendons are both involved.

Injruy to the Lateral Cutaneous Nerve of the thigh

This superficial nerve passes 2cm medial to the anterior superior iliac spine at the level of the inguinal ligament. It can be compressed at this level causing MERALGIA PARAESTHETICA.

Triceps tendon reflex

Triceps Tendon Reflex Support patient elbow with 1 hand, locate triceps tendon proximal to elbow Tap tendon briskly with a tendon hammer Observe for? C7,8 spinal nerves - Radial nerve

supinator muscle

Turns the forearm and hand outward so the palm faces upward

Intracapsular and Extracapsular Fractures:

Two important fractures to be aware of in the proximal femur 1) Extracapsular : Fracture at the intertrochanteric line These are less common. (2 types: Intertrochanteric and subtrochanteric*) 2) Intracapsular: Fracture of the femoral head or neck Risk of avascular necrosis of the femoral head due to damage to the circumflex arteries

What is superficial fascia in thigh made up off?

Two layers: 1. Superficial fascia § Similar to fascia throughout the body. Made up of subcutaneous tissue 2 Deep fascia: § Area of the thigh called the fascia lata § Extends like a stocking beneath the skin § Lateral thickened area is the iliotibial tract

What are the two main types of bone tissue?

Two main types of bone tissue: 1) Woven (immature) bone - only found in repairing fractures or in disease of the bone (i.e. Paget's disease). 2) Lamellar (mature) bone - shows concentric rings of cells as opposed to woven bone that does not. § Outer hard layer of compact bone (cortical bone). § Inner layer of interlacing struts (cancellous/spongy/trabecular bone).

What does ulnar nerve supply?

Ulnar Nerve (C8,T1): •Courses via the posterior compartment of the upper arm •No significant branches in the upper arm •Lies behind the medial epicondyle at the elbow (easily damaged when bang elbow) o supplies flexor carpi ulnaris and medial half of flexor digitarum profundus •The main nerve of the hand

The calf pump

Valves in the veins allow flow only up towards the heart. In the leg, the deep vessels are sandwiched between layers of calf muscles. During walking and running, contractions of these muscles squeeze the thin-walled veins and push blood up the veins: the calf pump. Immobility (e.g. a long plane journey) means less efficient venous return from the foot and leg. Sluggish deep venous return can lead to Deep Vein Thrombosis (DVT). Elastic surgical socks compress the superficial veins promoting more vigorous deep venous return.

What are venae comitantes?

Venae comitantes (VC) = accompanying veins •Multiple veins form a network of smaller veins with arteries which they accompany •Connections between the VC •Allow heat exchange (so blood that's cooled by going to extremity is warmed by central blood) •Artery pulse promotes venous flow

Bursa

a fibrous sac between certain tendons and bones that is lined with a synovial membrane that secretes synovial fluid. fluid-filled sac that allows for easy movement of one part of a joint over another.

Quadriceps

a muscle group consisting of four muscles that is located along the front of the thigh. -rectus femoris is only quadricep that attaches across the hip joint, the others don't and stay within thigh (vastus medialis, intermedius and lateralis)

Upper limb compartments include

a) - pectoral (chest) girdle muscles b) intrinsic shoulder muscles, c) anterior (upper) arm muscles - flexors d) posterior (upper) arm muscles - extensors e) anterior forearm muscles - flexors, f) posterior forearm muscles - extensors g) intrinsic hand muscles.

What muscles make up the anterior compartment of the arm? Innervation?

a) Biceps (aka biceps brachii): o short (medial) and long head (lateral). o short head has proximal attachment on coracoid process; o tendon of long head of biceps goes through INTERTUBERCULAR GROOVE, goes through transverse humeral ligament, crosses shoulder joint and attaches to supraglenoid tubercle. o two head join distally to form tendon to attach to radial tuberosity. o also forms a biceps aponeurosis which fans out to merge with fascia of the region. b) Brachialis: o underneath biceps o flexion of elbow joint o proximally attaches to middle part of shaft of humerus o attaches to coronoid process of ulna distally after crossing elbow joint. c) Coracobrachialis: o broadens distally and attaches to humerus o attaches proximally to coracoid process of scapula o acts across shoulder joint and adducts arm **All supplied by the musculocutaneous nerve.

Superficial Posterior Compartment of the Leg

a) Gastrocnemius (2 heads (medial and lateral) converge to form part of calcaneal tendon). attaches across knee joint. b) Soleus (underneath, flat, also contributes to calcaneal tendon). attach on tibia and fibula c) Plantaris - gives long tendon that inserts into calcaneus bone, near achilles tendon, doesn't do much but can be harvested for repair in plastics e.g. in knee construction. if damaged = painful. **triceps surae: gastrocnemius and soleus

Motor Segmental Supply to hip, buttock and thigh

a) Hip Flexors: -L2,3 b) Hip Extensors: -L4,5 c) Knee Extensors: -L3,4 d) Knee Flexors: -L5,S1 §Skeletal muscles are innervated by groups of motor nerve cell bodies within the spinal cord, allowing an efficiency of action. § In the fetus the limb buds grow out from the trunk and take the nerves destined to supply those parts with them (arms, C5-T1, legs L2-S2). The nerves form plexi, and the anterior divisions supply the flexor muscles, whilst the posterior divisions supply the extensor muscles. § In the upper limb, which is relatively straightforward, the flexor muscles are anterior and the extensor muscles are posterior. § However in the lower limb, the muscle compartments are complicated by the fact that the limb undergoes extension and internal rotation. As a consequence the extensor muscles are anterior and the flexor muscles are posterior. § There are some basic principles to the segmental spinal innervation of muscles: a) Most muscles are supplied by two adjacent segments of the spinal cord. b) Muscles with the same primary action on a joint share the same spinal segmental nerve supply. c) The opposing muscles also share a common segmental supply, either two above or two segments below. e.g. knee extensors - L3,L4 e.g. knee flexors - L5,S1. d) The more distal a joint in the limb, the more caudal are the spinal segments controlling the muscles acting upon that joint

Deep Posterior Compartment of the Leg

a) Popliteus (attach lateral side of femoral epicondyle - fans out and attaches to upper shaft of tibia), unlocks knee joint when it is locked. b) Flexor Digitorum Longus c) Flexor Hallucis Longus (underneath) d) Tibialis Posterior **these tendons all go behind middle malleolus and head into foot. tibialis posterior attaches on tarsal region, all others go to digits and distal phalanges. **involved in plantar flexion of foot.

Sacrospinous and sacrotuberous ligaments

a) Sacrospinous: Between sacrum and ischial spinous process b) Sacrotuberous Between sacrum and ischial tuberosity Prevents upward tilting of the sacrum § Cross each other and form the lesser and greater sciatic foramen. 1) Greater sciatic foramen: Formed by the greater sciatic notch and the ligaments Transmits structures leaving the pelvis to the LOWER LIMB Important: Sciatic nerve 2) Lesser sciatic foramen Formed by the lesser sciatic notch and the ligaments Transmits structures passing from the pelvis to the PERINEUM.

Nerves of the anterior and medial thigh

a) The FEMORAL nerve (L2-4) is formed in the lumbar plexus, descends through the pelvis (supplying iliacus) and passes under the inguinal ligament into the femoral triangle laterally to the femoral vessels. After entering the triangle, the nerve divides to give a number of muscular (anterior compartment of the thigh) and cutaneous branches. Trace the terminal cutaneous branch, the saphenous nerve, as is passes inferiorly in the adductor canal, then superficially to supply the anteromedial aspects of the knee, leg and foot. b) The OBTURATOR nerve (L2-4) is formed in the lumbar plexus, emerges on the medial border of psoas muscle, runs inferiorly and anteriorly in the pelvis, and passes through the superior part of the obturator foramen to supply the adductor muscles of the medial compartment. (Note that adductor magnus has a hamstring part with origin on the ischial tuberosity, and this is supplied by the tibial part of the sciatic nerve)

The anterior compartment superficial and deep flexors

a) The anterior compartment superficial flexors: pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis. (FDS may be referred to as being in either the superficial or the intermediate compartment.) (Note their common proximal attachment at the medial epicondyle of the humerus: the common flexor origin). b) The anterior compartment deep flexors: flexor policis longus, flexor digitorum profundus, pronator quadratus. (Note their proximal attachments on the flexor surfaces of the radius, ulna and interosseous membrane.)

Implication of internal rotation of developing lower limb

a) The lower limb internally rotates during its development meaning that, in the thigh and leg, the extensors are anterior and the flexors are posterior. b) In addition, the dermatomes have twisted, oblique fields, as opposed to the straighter fields in the upper limb.

What are the posterior pectoral girdle muscles?

a) Trapezius b) Latissimus dorsi c) Levator scapulae d) the Rhomboids

What muscles make up the posterior compartment of the arm? Innervation?

a) Triceps (aka triceps brachii): o three heads o lateral and medial head attached to posterior shaft of humerus o long head which crosses shoulder joint and attaches to infraglenoid tubercle of scapula. o triceps converge distally to form triceps tendon and attach to olecranon process of ulna. o major extensor of elbow joint b) Anconeus: o attaches to lateral epicondyle of humerus proximally o then broadens and attaches to posterior ulna shaft o stabilise ulnar joint mainly (with pronation and supranation) and also help with extension. **Supplied by the RADIAL nerve

Movements of the Shoulder (GH) Joint

a) abduction b) adduction c) flexion d) extension e) lateral rotation f) medial rotation o Circumduction (combination of movements). **Muscles involved: 1) Flexion: a) clavicular head of pectoralis major b) anterior fibres of deltoid c) coracobrachialis d) biceps 2) Extension: a) latissimus dorsi 3) Abduction: a) supraspinatus (first 15 degrees) b) central fibres of deltoid (after 15 degrees) 4) Adduction: a) pectoralis major b) latissimus dorsi c) teres major 5) Internal rotation: a) subscapularis 6) External rotation: a) infraspinatus b) teres minor **Resisting dislocation - Deltoid, Rotator Cuff, tendon of long head of biceps, short head of biceps, coracobrachialis

4. Which muscles stabilize the pectoral girdle? a) axial and scapular b) axial c) appendicular d) axial and appendicular

a) axial and scapular

Sensory Peripheral Supply of knee, leg, ankle and foot

a)Sensory branches of the femoral nerve (L2,3,4) supply the front of the thigh b)Saphenous nerve - a branch of the femoral nerve, supplies a strip of skin along the inner border of the leg and ankle. This nerve accompanies the long saphenous vein. c)Sural nerve - a branch of the tibial nerve in the popliteal fossa, supplies the lateral aspect of the leg and foot. This nerves accompanies the short saphenous vein. d)Superficial Peroneal nerve -most of the dorsum of the foot. e)Deep Peroneal nerve - a patch of skin on the dorsum of the foot at the base of the great and second toes. f)Tibial nerve g)Medial and lateral plantar nerves - the sole of the foot

Adductor hiatus

adductor muscles, adductor longus, brevis and magnus, spanning between the pubic bone and the linea aspera of the shaft of the femur. Obturator externus attaches to the external surface of the obturator foramen and the greater trachanter of the femur. Gracilis spans between the pubic bone and the superior medial surface of the shaft of the tibia. You may be able to find branches of the obturator nerve supplying the adductor muscles. Examine the gap in the attachment of adductor magnus at its distal end: the hiatus of adductor magnus.

The Adductor Canal borders and contents

aka (Hunter's Canal, Subsartorial Canal). **•Extends along the medial aspect of the thigh from the apex of the femoral triangle and transmits the superficial femoral artery and vein and the saphenous nerve. It is formed by the vastus medialis (anteriorly), the adductor longus and magnus (posteriorly) and sartorius (medially). •Formed by: a) Vastus medialis (anteriorly) b) Adductor longus and adductor magnus (posteriorly) c) Sartorius (medially) d) terminates at adductor hiatus **Contains: a) Femoral artery b) Femoral vein c) Saphenous nerve (one of terminal branches of femoral nerve) **femoral artery and vein continue travelling under sartorius muscle after passing femoral canal (hence adductor canal is sometimes referred to at the "subsartorial" canal). Sartorius curves around medially to become the anterior border of the adductor canal. **muscle-lined gutter starting at the inferior apex of the femoral triangle and ending at the hiatus of adductor magnus. The femoral triangle is continuous with the adductor canal. The vessels pass through the hiatus of adductor magnus into the popliteal fossa.

The main peripheral nerves arising from the brachial plexus are... (5)

axillary, musculocutaneous, radial, ulnar and median. * The axillary nerve (posterior cord c5-6) winds around the neck of the humerus to supply C5 & C6 fibres to the deltoid, the main abductor of the shoulder. * The radial nerve ((posterior cord C5-T1) enters the arm as a continuation of the posterior cord and winds around behind the humerus in the radial groove in the posterior compartment. At the lateral border of the humerus, about 1/3 way above the elbow, the nerve enters the anterior compartment of the arm. Anterior to the lateral epicondyle it divides into deep (muscular) and superficial (cutaneous) branches. It supplies all the muscles of the posterior compartment of the arm and forearm. *Ulnar nerve (medial cord C7-T1) The ulnar nerve is a continuation of the medial cord from the axilla, running medial to the brachial artery, in front of the insertion of the long head of triceps. It then runs posterior to the brachial artery, pierces the medial intermuscular septum to enter the posterior compartment and lies in the groove for the ulnar nerve between the medial epicondyle and olecranon. Here it is easily palpable. It then passes between the two heads for flexor carpi ulnaris and enters the flexor compartment of the forearm, descends on the flexor digitorum profundus to the wrist and runs on the flexor retinaculum along the pisiform. * Musculocutaneous nerve (lateral cord C5-7) The musculocutaneous nerve supplies the flexors of the elbow joint (biceps and brachialis). This nerve is rarely damaged. *Median nerve (medial and lateral cords C5-T1) The median nerve leaves the axilla and runs in front of the brachial artery. In the elbow, it lies medial to the brachial artery beneath the bicipital aponeurosis. It descends between the two heads of pronator teres and passes beneath the flexor digitorum superficialis (FDS). At the wrist it emerges between the tendons of FDS and palmaris longus and enters the carpal tunnel and into the hand.

3. What is the origin of the wrist flexors? a) the lateral epicondyle of the humerus b) the medial epicondyle of the humerus c) the carpal bones of the wrist d) the deltoid tuberosity of the humerus

b) the medial epicondyle of the humerus

2. Which muscle extends the forearm? a) biceps brachii b) triceps brachii c) brachialis d) deltoid

b) triceps brachii

Leg aka

between knee and ankle. thigh is between hip and knee

Popliteal Fossa pic

borders: medial and lateral heads of gastrocnemius. superomedially: semimembranous. superolaterally: biceps femoris. § contains popliteal artery, popliteal vein and short saphenous vein which drains into it, popliteal lymph nodes. § common peroneal and tibial nerves.

The Elbow Joint

capitulum and trochlea condyles of humerus; head of radius and ulna and coronoid process of ulna. *trochlea fits into ulnar articulation *radius spins around and moves relative to elbow joint. o The elbow is a synovial hinge joint between the humerus proximally and the ulna and radius distally. In addition to the elbow joint, there is a proximal radio-ulnar joint between those two bones - it is not part of the elbow joint itself. o The distal humerus articulates with the ulna via the trochlea whilst the radius articulates with the radius via the capitulum, but only in full flexion. o There are a number of important ligaments at the elbow which contribute to the stability of the joint: 1) The medial (ulnar) collateral ligaments 2) The lateral (radial) collateral ligaments 3) The annular ligament (part of the proximal radio-ulnar joint) o The movements of the elbow joint itself are flexion and extension: 1) the main flexors of the elbow are :brachialis, biceps and brachioradialis, with some assistance from pronator teres. 2) the extensors of the elbow are triceps and anconeus. o The carrying angle is the deviation of the long axis of the radius and ulna from that of the humerus (in extension). It is greater in women than men and averages 7 degrees o There is a large bursa over the olecranon at the posterior of the elbow - the olecranon bursa, which frequently becomes inflamed.

palmar arterial arches in the hand

courses of the radial and ulnar arteries at the wrist and the formation of the palmar arterial arches in the hand.

Which muscle produces movement that allows you to cross your legs? a) the gluteus maximus b) the piriformis c) the gracilis d) the sartorius

d) the sartorius

The Veins of the elbow, forearm and wrist: deep drainage

deep drainage follows the arteries.

lateral malleolus

distal end of fibula

Head of ulna is at which side of ulna?

distal end of ulna

medial malleolus

distal process on medial tibial surface

The dorsal surface of the foot

extensor hallucis brevis, extensor digitorum brevis. act on groups of digits.

Dorsum of the Foot

extensor hallucis brevis; extensor digitorum brevis and longus

The main peripheral nerves arising from the lumbo-sacral plexus are

femoral, obturator, and sciatic (tibial and common fibular components), 1) Femoral Nerve (L2,3,4) 2) Obturator nerve (L2, 3 & 4) 3) Sciatic nerve (L4-S3): a) Common fibular nerve (L4-S3) b) Tibial nerve (L4-S3)

Bones of the Knee Joint

femur, tibia, patella. o lateral femorotibial articulation and medial femorotibial articulation. o fibula does not articulate with knee joint. o femoral condyles posteriorly that have long curved surface important for flexion and extension of knee.

Which is more lateral - tibia or fibula?

fibula.

How to test for Flexor carpi ulnaris and radialis?

flex wrist against resistance *Note: To demonstrate superficial veins, apply pressure around the middle of the arm of the subject by encircling with your hands. This will cause venous congestion and distention of the veins distal to the compression.

Which is thicker extensor retinaculum or flexor?

flexor

delto-pectoral groove

formed between pectoralis major and deltoid, allows passage for the cephalic vein

Where does fibular artery come from?

from posterior tibial artery. o Note that the femoral artery passes through the hiatus of adductor magnus to become the popliteal artery which will give off genicular (knee) branches as it progresses in the fossa. o As it passes inferiorly in the popliteal fossa, note the division of the artery to form the anterior tibial artery that pierces the superior part of the interosseous membrane to pass into the anterior compartment of the leg. o The other division is the posterior tibial artery that immediately gives off the peroneal artery supplying the lateral posterior and peroneal compartments. o Trace the posterior tibial artery as it passes into the foot posteriorly to the medial malleolus to divide into the medial and lateral plantar arteries, which form a plantar arterial arch. o Trace the anterior tibial artery as it runs inferiorly supplying the anterior compartment to cross the ankle and continue as the dorsalis pedis artery passing anteromedially to turn laterally as the arcuate artery giving off the digital branches. Note that perforating arteries communicate between the plantar arch and the arcuate artery.

Tibial and common peroneal nerve in dissection

from sciatic nerve. common peroneal nerve exits the fossa laterally. Going deeper into the fossa, is the popliteal artery

triceps surae

gastrocnemius and soleus

The most superficial muscle of the gluteal region....

gluteus maximus. o proximal attachments - posterior ilium, sacrum and adjacent connective tissues, and define its distal attachments on the gluteal tuberosity of the femur and the iliotibial tract of the fascia lata of the thigh. Examine the upper and lower borders. (Note that gluteus maximus is course-grained, indicating large-calibre muscle fibres associated with gross (i.e. not fine) movements.) o gluteus medius and minimus - attachments to the external surface of the ilium bone of the pelvis and the greater trochanter of the femur. o tensor fasciae latae at the anterior superior iliac spine, and note its insertion into the ilio-tibial tract. o Deep to gluteus maximus and inferior to the attachments of medius and minimus are the external (lateral) rotators of the hip (piriformis, obturator internus, superior gemellus, inferior gemellus and quadratus femoris). Have distal attachments to the greater trochanter. o In particular, piriformis, is a useful anatomical landmark of the deep gluteal region. o Examine the superior gluteal nerve and vessels passing between the pelvis and the buttock superior to piriformis, and the inferior gluteal nerve and vessels passing inferiorly to piriformis. o Trace the sciatic nerve from its emergence inferior to piriformis (typically, but not always) to its entry into the posterior thigh. The posterior cutaneous nerve of the thigh often emerges with, and runs on the surface of, the sciatic nerve.

insertion of quadriceps (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)

insertion into the tibial tuberosity via the patella and the patellar ligament.

Segmental reflexes

involve neurons in a single cord segment. o There are two (main) reflex arcs in the upper limbs; 1) The biceps jerk -C6 2) The triceps jerk- C7 o There are two reflex arcs in the lower limbs; 1) The Knee Jerk- (L3,4) - Tap Patellar Tendon. Efferent Muscles - Anterior compartment of thigh: Quadriceps femoris. 2) The Ankle Jerk- (S1,S2) - Tap Calcaneal Tendon. Efferent Muscles - Posterior compartment of leg: (Gastrocnemeus, Soleus, Plantaris). ***The reflexes are stretch reflexes or deep tendon reflexes and are monosynaptic. The sequence, for example for the knee jerk, is as follows: o Tap o Stretch the patellar tendon o Detected by proprioceptive sensory receptors --> Stimulation of afferent (1a) fibres in quadriceps o Passes to spinal cord via posterior (dorsal) nerve root o Synapse with alpha-motor neurone in anterior (ventral) horn of spinal cord o Efferent signal to quadriceps (effector muscle) o Quadriceps extends the knee joint (efferent action)

Where do we inject into but? Why?

lateral and superior region as sciatic nerve is in the medial inferior region. •Passes from pelvis to buttock via GREATER sciatic notch/foramen •In the buttock, lies in the INFERIOR and MEDIAL quadrant •Passes along POSTERIOR aspect of the thigh •Divides into the TIBIAL and the COMMON PERONEAL nerve (inconstant level) •Supplies all the HAMSTRING muscles and all the muscles BELOW the level of the knee •If injecting in the buttock, use the SUPERIOR and LATERAL quadrant

Posterior tendonous Anatomy of the Digits

lumbrical underneath interossei. **tendinous hood over proximal interphalangeal joint and metacarpophalangeal joint = extensor expansion. lumbrical muscle pulls on this (goes from anterior to posterior - allows you to straighten fingers) for each finger except thumb there is proximal and distal IPJs. o FDS attaches to base of middle phalanx o FDP attaches to distal phalanx and pierces superficial as it does this.

Which nerve passes through the carpal tunnel?

median nerve. passes with lots of tendons. o Carpal Tunnel Syndrome - The commonest nerve entrapment problem o ulnar nerve more medial. o when median nerve goes through carpal tunnel, gives of recurrent branch that supplies the thenar muscles. o sensory branches to thumb, index, middle and half of ring finger. o ulnar sensory - half of ring finger, pinky. o median nerve also gives a branch before going through carpal tunnel that passes superficially to flexor retinaculum that supplies part of palm, so even if damage wrist there's part of palm that's still supplied.

Why are gluteal muscles a common site of injection?

muscles have large blood supply

Biceps Brachii attachments and innervations

o Anterior arm compartment * Proximal attachments(two heads): a) Short: Coracoid process b) Long: Supraglenoid tubercle * Distal attachments: a) Radial tuberosity b)Bicipital aponeurosis *Functions: a) Flexion at the gleno-humeral joint b) Flexion at the elbow joint c) Supination of the forearm at the proximal radio-ulnar joint. * Innervation: Musculocutaneous

Arterial supply of the lower limb

o Arterial supply - aorta --> common iliac arteries (int. & ext.) --> external iliac artery passes under inguinal ligament (runs between ASIS and pubic tubercle)--> femoral artery (pulse point) goes posteriorly--> Popliteal artery (pulse point): Posterior tibial (pulse point), anterior tibial, fibular/peroneal (pulse point) (these go behind the lateral malleolus to give plantar arches) & anteriorly get dorsalis pedis (pulse point) arteries (important to see integrity of blood supply). § The femoral artery is more anterior whilst the popliteal artery is more posterior. Femoral artery can be used to access a large artery to get into coronary repair e.g. for stenting § lower limb more pulse points as often arteries more affected due to gravity and distance § The majority of arterial supply to limb comes from external iliac, but some does come from internal iliac (medial compartment of thigh) ooo Venous drainage - superficial and deep systems: § DEEP - Ant. & Post. Tibial Venae Comitantes --> popliteal vein --> femoral vein --> external iliac. § SUPERFICIAL - Venous arches --> long saphenous vein --> short saphenous vein. o The great saphenous vein --> femoral vein at the groin. o The small saphenous vein --> popliteal vein at the popliteal fossa. o The saphenous veins are consistent (other veins vary).

Arterial supply to the upper limb

o Arterial supply - aorta --> subclavian artery --> axillary artery --> brachial arteries (pulse point) --> ulnar and radial arteries (pulse point) --> hand palmar arches (deep and superficial) --> metacarpal and digital arteries. *there are also branches at various points supplying locally e.g. circumflex around neck of humerus. o Venous drainage - superficial and deep systems - o dorsal venous arch (sup.) --> cephalic (lateral, sup.) vein and basilic (medial, sup.) vein --> basilic merges with Venae comitantes (deep); cephalic goes straight up arm and joins --> Axillary vein (deep) --> subclavian vein --> superior vena cava. § NOTE - cubital fossa superficial veins are often used for phlebotomy - MEDIAN CUBITAL VEIN · This vein links the basilic and cephalic veins (but it's not always present). § venae comitantes - deep veins of limbs that run as multiple veins esp. more distally *Lymphatic system - cubital lymph nodes can drain to the axillary pectoral lymph nodes.*

Neurovascular contents of the axilla

o Arteries - axillary artery and its branches o Veins - axillary vein and its tributaries o Lymphatic vessels and lymph nodes (important!) o Nerves - the brachial plexus

Radio-ulnar joint

o Articulating bones: head of radius and radial notch of ulna o Structural classification: synovial o Synovial type: pivot o Actions: pronation/supination of forearm

What type of joint is the shoulder (gleno-humeral) joint?

o Ball-and-socket synovial joint. o The glenoid fossa (the socket) is shallow, but slightly deepened by a cartilaginous labrum (glenoid lebrum) o However, muscles required for joint stability. (eg. Rotator cuff group) - anteriorly, posteriorly and superiorly. o prone to dislocate shoulder joint, normally, inferiorly.

Lower limb: Magnetic Resonance Imaging principles

o Best option for visualizing soft tissue. o Two main contrast settings: T1 (for injuries) and T2 (for diseases). o Remember: T tWo weighted image shows Water as White.

Carpo-metacarpal Joints

o Between the distal row of carpal bones and the bases of metacarpals I to V 1st carpo-metacarpal joint" a) The joint between the metacarpal I and the trapezium b) It is a saddle joint which permits all movements of the thumb c) Often becomes osteoarthritic o 2nd-5th carpo-metacarpal joints: Less mobile than the joint for the thumb

Superficial veins of the lower limb

o Both the great and small saphenous veins arise from the venous network of the dorsum of the foot. o The great (long) saphenous vein drains into the femoral vein at the groin. o The small (short) saphenous vein drains into the popliteal vein at the popliteal fossa. § Venous arches of foot crosses --> long/great saphenous vein or short/small saphenous vein. o Great saphenous vein: venous arch of foot on medial side crosses anterior to medial malleolus --> up leg --> behind knee and comes medially to drain into opening in inguinal region. The great saphenous vein --> femoral vein at the groin. o small saphenous vein: venous arch of foot goes posterior to lateral malleolus --> comes up posterior of calf superficially --> pierces fascia over popliteal fossa and drains into popliteal vein. The small saphenous vein --> popliteal vein at the popliteal fossa. o The saphenous veins are consistent (other superificial veins vary).

Organisation of spinal nerves - anterior rami

o C1-C4 are for the neck o C5-T1 are for the upper limbs (brachial plexus) o T2-L1 are for the trunk o L2-S2 are for the lower limbs (lumbosacral plexus) o S2-C2 is for the perineum.

Assessment of Nerve Function: Lesion of Common Peroneal Nerve at Fibular Neck

o CPN is a peripheral nerve. it is one of branches of sciatic nerve just above knee (CPN and tibial nerve). CPN leaves popliteal fossa and head round head of fibula bone and gives off superficial and deep nerves. nerve supplies anterior muscles of leg and these raise ankle and toes. o pic shows device used to raise toes •Motor - foot drop (can't raise toes - hence need to have high-stepping or swinging gait) •Sensory - dorsum of foot at least •Reflex - none •Autonomic - minimal

Injury to median nerve (derived from medial and lateral cords)

o Carpal Tunnel Syndrome - The commonest nerve entrapment problem. o Get wasting of the thenar eminence and loss of both sensation and fine movement in the lateral digits is a significant disability. o get little bulge instead more medial which is adductor pollicis that is not affected because its supplied by the ulnar nerve. o loss of sensation of thumb to half of ring finger.

What type of injury can damage the lower roots (C8, T1)

o Common cause is over-abduction due to gripping overhead to break a fall. affects T1 (and sometimes C8). o Lower root injury during birth, pulling arm.

Does cortical or cancellous bone have a higher turnover rate?

o Cortical or compact bone: makes up 80% of the skeleton, and has a SLOW turnover rate and a HIGH resistance to torsion and bending. o Cancellous bone (spongy or trabecular bone): this is LESS dense, consists of SPICULES with marrow in between, and has a HIGHER turnover rate than compact bone.

Venous drainage of the lower limb

o DEEP SYSTEM that mirrors the arterial supply: •Ant & Post Tibial Venae Comitantes •Popliteal Vein •Femoral Vein •External iliac vein *SUPERFICIAL SYSTEM: •Venous arches •Long saphenous vein •Short saphenous vein

Sensory Segmental Supply to hip, buttock and thigh

o Dermatomal distribution: are twisted due to pronation in development). •Front of the thigh : T12, L123 •Back of the thigh : S123 •Buttock: S2-4. * ØL3 to the Knee ØL4 to the Floor ØL5 - Great Toe ØS1 - Lateral Dorsum of Foot/Sole ØS2 - Most of the Posterior Leg/Thigh

dorsal venous network --> basilic and cephalic vein

o Digital veins drain into the dorsal venous network of the hand. formation of the 2 main superficial veins: laterally, the cephalic vein and medially, the basilic vein. o often there's a communicating branch just distal to the elbow region: median cubital vein. o The cephalic vein passes between the deltoid and pectoralis major muscles (the delto-pectoral groove) to pierce the clavipectoral fascia to drain into the proximal axillary vein. o The basilic vein passes deeply approximately mid-arm, runs with the brachial artery and joins with its venae comitantes to form the axillary vein . o The deep veins of the hand and forearm and arm are the venae comitantes of the arteries. venae comitantes increase in calibre as they pass proximally. *(There are numerous perforating branches connecting the superficial and deep veins

Do most bones ossify by endochondral or intramembranous ossification?

o Endochondral (mesenchyme differentiates to cartilage before forming bone): *In long bones; 1. Mesenchymal cells differentiate into CHONDROBLASTS (cartilage forming cells), which form cartilage models of the bones. 2. The cartilage bone model GROWS by both expansion of the cartilage matrix (INTERSTITIAL growth) and also by new growth of cartilage at the outer surface of the bone (APPOSITIONAL growth). 3. In the middle of the bone model, the cartilage CALCIFIES and the CHONDROCYTES DIE. At the same time the PERIOSTEUM (the sheath lining the bone model) delivers periosteal CAPILLARIES into the calcified centre to form the PERIOSTEAL BUD. 4. The periosteal bud differentiates to form OSTEOBLASTS (bone forming cells), and as a consequence a PRIMARY OSSIFICATION CENTRE forms in the middle of the cartilage model. This primary ossification centre then grows in both directions to replace the cartilage model by bone. The body of a bone formed from a primary ossification centre is called the DIAPHYSIS. The diaphysis increases in diameter by appositional growth. 5. SECONDARY OSSIFICATION CENTRE also form in other parts of the bone, and the parts of bone formed from these centres are called EPIPHYSES. The time of appearance of these secondary ossification centres varies from bone to bone and between individuals. The first centre to form is at the distal femur and at birth, most babies have ossification centres at the distal femur, proximal humerus and proximal and distal tibia. 6. The EPIPHYSEAL PLATE is the cartilaginous area between the diaphysis and the epiphysis, and persists until growth is complete. 7. A bone grows by the laying down of bone at each epiphysis, and the bone continues to grow until the epiphysis FUSES with the diaphysis.

Injuries to the Upper Roots aka

o Erb-Duchenne Palsy. o "Waiter's Tip" Position with Upper Root Injury - Many muscles affected (shoulder, anterior arm). Forearm pronated by lack of biceps supination.

Where does FDS and FDP attach?

o FDP and FDS tendons pass in the carpal tunnel beneath the flexor retinaculum •...enter a common synovial sheath •...enter a digital synovial sheath, within its own fibrous digital sheath •Little finger and thumb sheaths continuous •FDS splits around FDP •FDS to middle phalanx, FDP to distal phalanx

Function of intrinsic muscles of foot

o For most people, the intrinsic muscles of the foot function generally act as shock absorbers, adjusting the foot to uneven surfaces. o Feet can be "trained" for carrying out fine movements, such as writing and drawing. Individuals lacking upper limbs are able to use their feet to carry out a variety of fine activities.

Which arteries comes from internal iliac artery?

o In the buttock, examine the superior and inferior gluteal arteries (branches of the internal iliac artery) as they emerge superiorly and inferiorly to piriformis, to supply the muscles of the gluteal compartment. o Find the obturator artery as it passes from the internal iliac artery in the pelvis, through the obturator foramen, and into the medial compartment to supply medial muscles. o flowchart in pic

Common sites of injury to the Ulnar Nerve (Derived from Medial Cord)

o Injuries to medial epicondyle of humerus cause injury to the ulnar nerve at the elbow. o What situation commonly encountered by clinicians could cause injury at the wrist? - self-harm

Which muscles of the posterior compartment of thigh act across the knee joint?

o Knee Flexors and Hip Extensors "The Hamstrings". ALL act across the knee joint: •Semimembranosus •Semitendinosus •Biceps femoris **hamstrings come off ischial tuberosity, have attachments across knee in tibia and fibula. short head of biceps femoris doesn't come off ischial tuberosity.

Segmental Sensory Supply of the lower limb pic

o L3 to knee, L4 to floor. o axial line of limb seen posteriorly o segmental says S1 supplies most of posterior thigh; but when see cutaneous innervation, have posterior cutaneous for thigh and other nerves supply rest of leg. o from which roots do the fibres from posterior cutaneous nerve originate - S1 and S2. o shows peripheral nerves from more than one spinal root and often different spinal nerves.

Trapezius innervation and major actions

o Left and right trapezius which meet in midline. ** superior proximal attachment - a) nuchal line of skull and then spines of cervical b) thoracic vertebrae till T12. (superior part is descending part of trapezius, middle is middle part, inferior part is ascending part). **distal attachment: a) acromion b) lateral 1/3 clavicle anteriorly c) scapular spine. **Innervation: The motor supply is by the spinal accessory nerve (CNXI). (N.B. a muscle of the upper limb is supplied by a cranial nerve.) o Major actions on the scapula - stabilise. Multiple movements of the STJ (elevation, rotation, retraction, depression)

Median nerve

o Proximal to the wrist, the median nerve gives off the palmar cutaneous branch - Supplies the part of the lateral skin of the palm o Travels through the carpal tunnel along with the 9 flexor tendons: Supplies the thenar compartment (Recurrent branch*) Supplies the lumbricals Supplies sensation to the palmar skin and dorsal nail beds of lateral 3 ½ digits

What is the innervation of serratus anterior? Attachments? Action? What happens when injured?

o Long thoracic nerve (C5, C6, C7) o Posterior attachment: medial border of scapula o Anterior attachments on the ribs 1-9 (can vary). attaches to medial part of scapula at back, then runs anteriorly over surface of thoracic cage to attach to ribs. *ACTION: holds scapula down along with other muscles. protraction at STJ, and rotation (can elevate the glenoid fossa) **Injury: Lymph node exploration during mastectomies: This procedure can also damage the thoracodorsal nerve Serratus Anterior is responsible for centring the scapula on the thoracic wall If the nerve is damaged, scapular WINGING occurs

Lower limb compartments include

o Lower limb compartments include : a) hip abductors/extensors/flexors b) anterior/medial/posterior thigh muscles, c) anterior/lateral/posterior leg muscles d) intrinsic foot muscles.

Which cords is median nerve derived from?

o Medial and Lateral Cords o runs in medial part of arm, doesn't supply anything here, supplies most muscles in forearm and goes through carpal tunnel and supplies some of hand muscles.

When/where does intramembranous ossification occur?

o Mesenchymal models of the bones form during the EMBRYONIC period of development. This mesenchyme then directly ossifies into bone during the FETAL life. o At a cellular level, the osteoblasts differentiate within the mesenchymal tissue. o Intramembranous ossification is typical of bones just beneath the surface of the skin (it is also sometimes termed DERMAL ossification) and is the mechanism of ossification for the SKULL bones, the MANDIBLE and the CLAVICLE.

Pectoral/shoulder girdle

o Movements of the shoulder involve both movements of the arm relative to the scapula at the shoulder joint, and movements of the scapula relative to the chest wall. o Muscles acting on the shoulder joint have attachments in the neck, anterior chest, back and arm. o trapezius, deltoid, pec major (fans out towards sternum), serratus anterior o latissimus dorsi, rotator cuff muscles, trapezius

courses of the large nerves running in the arm and into the forearm (median, ulnar and radial nerves)

o Musculocutaneous n. supplying anterior arm muscles. o Ulnar and Median ns. pass through the arm without supplying muscles. **It is important to remember the roots and the peripheral nerves they supply: Musculoskeletal (C5, C6) Axillary nerve (C5, C6) Ulnar nerve (C8, T1) Radial nerve (C5 - T1) - Median nerve (C6 - T1

Trabecular/spongy/cancellous bone

o Not to be confused with Woven Bone. o Trabecular bone is lamellar/mature (still organised structure but smaller and orientation is bit more random). § Inner trabecular bone is arranged in same way as outer lamellar bone but the concentric rings are found in structures called trabeculae. o osteocytes within lamellae

obturator externus attachments

o Obturator externus attaches to the external surface of the obturator foramen and the greater trachanter of the femur. o Gracilis spans between the pubic bone and the superior medial surface of the shaft of the tibia.

What do osteocytes lie within?

o Osteocytes are mature bone cells and lie within LACUNAE, which are pockets within the bone matrix. o Each lacuna contains only ONE osteocyte, and these osteocytes NEVER divide. o Lacunae are connected by CANALICULI. The canals contain cytoplasmic extensions of the osteocytes and provide for metabolic exchange. o Osteocytes maintain the bone matrix (protein and minerals) and are also involved in the repair of bone. Simplistically, if a bone is damaged, the osteocytes are FREED from their lacunae and DIFFERENTIATE into osteoblasts or osteoprogenitor cells.

Carpal Tunnel transverse section

o Passage between the forearm and the hand 1) Anterior wall: Flexor retinaculum 2) Posterior wall: Carpal arch formed by 6 carpal bones **Contents - 9 tendons, 1 nerve a) 4 FDS tendons b) 4 FDP tendons c) Flexor pollicis longus tendon d) Median nerve Palmaris longus, ulnar nerve and ulnar artery pass SUPERFICIALLY to flexor retinaculum Ulnar nerve is MEDIAL to ulnar artery They both pass through Guyon's canal* Radial artery curls around to enter the hand through posterolateral aspect of wrist

Carpometacarpal and Intermetacarpal Joints

o Plane type of synovial joint, except the carpometacarpal joint of the thumb (trapezium and 1st metacarpal) which is a saddle joint •CMC of the thumb - clinically important (trapezium to thumb metacarpal)- as often becomse osteoarthirtic. It is a synovial joint of the saddle variety. o The other carpo-metacarpal joints (CMC) are synovial elipsoid joints between the trapezoid, capitate and hamate with the metacarpals of the digits. The CMC's of the index and middle finger are very rigid, that of the ring finger less rigid and that of the little finger very mobile. •CMC of digits. o There are also plane synovial intermetacarpal joints (IMC) between the metacarpals at their bases. The movements that occur at the C-MC and IMC joints are: a) flexion and extension b) radial deviation and ulnar deviation c) circumduction •Intermetacarpal joints

Triceps attachment and innervations

o Posterior arm compartment *Proximal attachments (3 heads): a) LonPosterior arm compartment Proximal attachments (3 heads): Long: Infraglenoid tubercle Medial and lateral: Posterior humeral shaft Distal attachments: Olecranon Functions: Extension of the elbow joint Long head extends the gleno-humeral joint Innervation: Radialg: Infraglenoid tubercle b) Medial and lateral: Posterior humeral shaft * Distal attachments: Olecranon * Functions: a) Extension of the elbow joint b) Long head extends the gleno-humeral joint * Innervation: Radial

What type of joint is distal Tibiofibular Joint?

o Proximal Tibiofibular Joint: is plane type synovial, but capsular ligaments limit movement. o Distal Tibiofibular Joint: is a fibrous joint. **Slight movement of both of these joints during dorsiflexion/plantarflexion of the foot.

What type of joint is proximal Tibiofibular Joint?

Pectoralis Major attachments and actions

o Proximal attachments: a) medial 1/3rd of the clavicle b) the sternum c) costal cartilages (1-7) o Distal attachment: lateral lip of the intertubercular sulcus (groove). *Action: a) flexion b) adduction c) medially rotates the humerus (all 3 actions at GHJ) d) Lesser actions on the scapula. developed well in boxers. *Innervation: Lateral and medial pectoral nerves

Ulnar Nerve position to ulnar artery

o Proximal to the wrist, the ulnar nerve gives off the palmar and dorsal cutaneous branches*: Supplies the medial skin of the palm and 1 ½ digits o At the wrist: The FCU is MEDIAL to the nerve The ulnar artery is lateral to the nerve. o It then passes over the flexor retinaculum (in Guyon's canal*) with the ulnar artery. **Divides into the 1) Superficial branch - Sensory ØPalmar surface of little finger + medial side of ring finger 2) Deep branch - motor: ØHypothenar muscles ØAdductor pollicis ØMedial 3rd + 4th lumbricals ØAll interossei **The ulnar nerve controls most of the fine movement of the hand

Bursae of the Knee

o Sacs of fibrous tissue lined with synovial membrane and filled with fluid (synovia) o little sacs of synovium; if inflamed bursitis --> painful. o Occur where parts move over one another E.g. Around joints, where ligaments/tendons pass over bone: Prepatellar, Anserine, Semimembranosus, others include popliteus, gastrocnemius, subcutaneous infrapatellar, deep infrapatellar. o Minimise friction generated.

Segmental motor supply to the upper limb

o Shoulder: •abduction C5, adduction C678 •external rotation C5, internal rotation C678 o Elbow: •flexion C56, extension C78 o Forearm: •supination C6, pronation C78 o Wrist: •flexion C67, extension C67 o Long tendons to hand: •flexion C78, extension C78 o Intrinsic hand: •T1

Arm - Venous Drainage

o Superficial: a) Basilic - draining medial part b) Cephalic - draining lateral part o Deep: The venae comitantes of the brachial artery o Basilic pierces deep fascia midway up arm to become deep and joins the VCBA to form the axillary vein at the inferior border of the teres major - This is the same landmark as when axillary artery becomes brachial. o Cephalic dives in to join the axillary vein at the delto-pectoral triangle

Supinator and pronator muscles

o Supinator: *origin - lateral epicondyle of humerus, supinator crest of ulna *insertion - lateral surface and posterior border of radius *action - supinates forearm *innervation - radial nerve o Pronator teres: *origin - medial epicondyle of humerus, medial border of coronoid process of ulna *insertion - lateral aspect of shaft of radius *action - pronates forearm *innervation - median nerve

Comparison of Segmental and Peripheral Nerve Supplies to a Limb

o Take for example the anterior compartment of the (upper) arm. It is occupied by the biceps, coraco-brachialis and brachialis muscles. The biceps and brachialis muscles flex the elbow. o The segmental nerve supply to these muscles is C5,6. o The nerve of the anterior compartment of the arm is the musculocutaneous nerve. Any of the muscles that therefore flex the elbow are supplied by the musculocutaneous nerve. The musculocutaneous nerve is derived from the C5 and C6 spinal nerve segments. o Therefore, biceps has a segmental motor nerve supply of C5,6 and a peripheral nerve supply of the musculocutaneous nerve. This is frequently written as a supply from the musculocutaneous nerve (C5,6). Of course the segmental and peripheral nerve supply are in fact the same nerves. The segmental nerves pass from the spinal cord, via the brachial plexus to the musculocutaneous nerve and then to the muscle. It is the organization and the distribution of the segmental and peripheral nerve supplies that are important to understand. o As well as a motor segmental and peripheral nerve organization, there is of course a sensory pattern of organisation. The skin over the arm is a little complicated and so consider the thumb. o The thumb has a segmental sensory nerve supply from C6. However, the anterior aspect of the thumb has a peripheral nerve supply via the median nerve, but its posterior surface it is supplied by the radial nerve. The sensory nerves fibres pass from the skin in both the median and radial nerves, via the brachial plexus to the C6 spinal segment. .

Testing the integrity of sensory innervation of upper limb

o Test the integrity of sensory innervation of the dermatomes of upper limb using 'crude' or 'light' touch o First, demonstrate to the subject on a normal area of the skin by touching with blunt end of a pencil or cotton wool. Then ask the subject to close the eyes while you examine individual dermatome areas methodically. Ask whether the subject could feel the touch sensation as normal, dull or none at all. Repeat the test on the opposite limb and compare the results from corresponding dermatomes. In clinical practice you will use a sharp pin for crude touch but for today's practical you are not allowed to use a pin for health and safety reasons. For light touch you will use cotton wool.

Nerves: motor supply in the forearm

o The Radial Nerve supplies all posterior muscles. o The Ulnar Nerve supplies only FCU and the Ulnar half of FDP . o The Median Nerve supplies all of the remaining anterior muscles.

What are the five groups of axillary lymph nodes?

o The axilla contains a large number of axillary lymph nodes, and these are of significant importance clinically in relation to carcinoma of the breast, as the lymphatic drainage of the breast includes these lymph nodes. o There are five groups of axillary lymph nodes - apical, pectoral, subscapular, humeral and central (CHAPS). All the groups drain via the apical lymph nodes, which drain into the subclavian lymphatic trunk and then ultimately the right lymphatic duct (right side) or the thoracic duct (left side). o The axillary lymph nodes are frequently dissected and "sampled" in patients with carcinoma of the breast. There are two nerves in close relation to the axillary lymph node region. These are: a) the long thoracic nerve - supplies the serratus anterior muscle. b) The thoracodorsal nerve - supplies the latissimus dorsi muscle. o These nerves may be are at risk during axillary lymph node dissections. Section of the thoracodorsal nerve surprisingly does not produce too much disability but section of the long thoracic nerve causes paralysis of the serratus anterior muscle and as a result, winging of the scapula.

Segmental innervation of upper limb

o The body wall muscles and skin are supplied segmentally by the spinal nerves. This is true for the limbs as well. o An area of skin supplied by a single spinal nerve root or spinal cord level is called a dermatome and a similarly innervated region of a skeletal muscle is called a myotome. o On the skin the adjacent dermatomes overlap considerably. Therefore, loss of a single spinal nerve root will not produce any detectable sensory loss in that dermatome. o Most of the muscles are supplied by more than one spinal nerve root. Integrity of the nerve supply of myotomes can be evaluated by testing the joint movement or the muscle action.

How to feel for ridge of trapezium?

What does bone matrix contain?

o The bone matrix consists of extracellular protein fibres, ground substance and a great deal of inorganic irons ( calcium phosphate, calcium hydroxyapatite and calcium hydroxide.) o These inorganic salts account for 2/3 of the weight of bone. o The collagen fibres laid down in bone provide a supporting lattice for the hydroxyapatite crystals. Collagen is strong, flexible, good at resisting tension twisting and bending, BUT poor at resisting compression. o Calcium phosphate crystals are hard but inflexible and brittle, but are GOOD at withstanding compression. *The combination of the two (collagen and calcium phosphate crystals) allows for the excellent biomechanical properties of bone.*

Nerves of the brachial plexus

o The brachial plexus is the plexus of the nerves that serves the upper limb. It is formed from the anterior primary rami of C5-T1 spinal nerves. o Largest nerves of brachial plexus: 1.Axillary nerve (C5 and C6) 2.Musculocutaneous nerve (C5, 6 and 7) 3.Ulnar nerve (C8 and T1) 4.Median nerve (C6, 7,8, and T1) 5.Radial nerve (C5, 6, 7, 8, and T1) o have roots C5-T1 they pass under clavicle --> trunks --> divisions --> cords --> ultimately forming terminal branches (peripheral nerves). * roots formed in the neck from the spinal nerve roots. *trunks formed from the roots in the posterior triangle of the neck. *divisions formed from the trunks behind the clavicle. *cords formed from the divisions in the axilla in close proximity to the axillary artery. *branches the peripheral nerves supplying the upper limb itself. o some terminal branches that come off earlier e.g. suprascapular nerve, lateral pectoral and long thoracic nerve *ROMAN TOGAS DON'T COVER BALLS

Compartments of the Forearm are separated by what?

o The compartments of the forearm are separated by the interosseous membrane, which lies between the radius and ulna. 1)Anterior forearm compartment: a)Superficial b)Intermediate c)Deep 2)Posterior (extensor) forearm compartment: o Can be more easily remembered through function: a)Wrist extensors b)Digit extensors c)Thumb extensors (and more) * Also supinator and brachioradialis

Boundaries of popliteal fossa

o The diamond-shaped space posterior to the knee-joint **•Boundaries: 1. Superolaterally by the biceps femoris 2. Superomedially by the Semimembranosus 3. Inferolaterally by the lateral head of gastrocnemius 4. Inferomedially by the medial head of gastrocnemius 5. Posteriorly by skin and fascia 6. Anteriorly by femur **Contains: 1. Popliteal artery 2. Popliteal vein 3. The tibial and common peroneal nerves (two terminal branches of sciatic nerve that forms above knee joint) 4. Short saphenous vein (superficial, pierces fascia and drains into popliteal vein) 5. Popliteal lymph nodes

Contents of popliteal fossa

Popliteal Fossa

What is found at the base of the neck of the femur?

o The femur consists of a head, neck and two trochanters proximally. o The head and neck continue to form the long shaft of the femur. o The head of the femur is directed superiorly, medially and slightly anteriorly with respect to the shaft of the femur via the neck of the femur. o It articulates with the acetabulum of the hip bone. o At the base of the neck of the femur are the greater trochanter and the lesser trochanter. o The two trochanters are joined by the intertrochanteric line anteriorly and the intertrochanteric crest posteriorly. o On the posterior surface of the shaft (the body) of the femur is a long ridge called the linea aspera. **Note: 1. Body (shaft) of the femur 5. Intercondylar fossa (posteriorly) 2. Linea aspera (on the posterior side) 6. Femoral trochlea (patellar surface) 3. Medial and lateral femoral condyles 7. Medial and lateral epicondyles 4. Medial and lateral supracondylar lines (on the posterior side) 8. Adductor tubercle (above medial epicondyle)

What is the function of the brachial plexus?

o The function of the brachial plexus is to rearrange the nerve fibres from C5-T1 into bundles travelling to appropriate parts of the limb. o All nerves supplying extensor muscles pass though a bundle in the plexus named the posterior cord. o All nerves supplying flexor muscles pass through bundles in the plexus named the lateral and medial cords.

nerve supply of bones

o The nerve supply of bones accompanies the ARTERIES supplying that bone. o The PERIOSTEUM surrounding a bone is very richly innervated with nerve fibres. o Most of these periosteal nerves are SENSORY in function, for both pain and also proprioception. o The blood vessels in most bones also have a strong SYMPATHETIC supply, regulating bone blood flow.

The pattern of deep venous return in legs follows...

o The pattern of deep venous return follows that of the arteries, as venae comitantes, defined veins, or both. You will have examined these as you explored the arteries. Review the deep veins. o The superficial venous return is extensive and variable, but two major veins are consistent. They arise from the dorsal venous network of the foot to give the long saphenous vein medially and the short saphenous vein laterally. o Examine the long vein as it passes anterior to the medial malleolus at the ankle and continues superiorly and medially in the leg, more posteriorly at the knee, then medial in the thigh until the vein passes anterior to the femoral triangle to drain into the femoral vein through the saphenous opening in fascia lata. o The short saphenous vein passes posteriorly to the lateral malleolus at the ankle, runs superiorly on the posterior leg to drain into the popliteal vein after piercing the fascia over the popliteal fossa. **Note that there are numerous perforating branches connecting the superficial and deep veins.

How to feel for tubercle of scaphoid?

What are the two projections of the ulna

o The proximal end of the ulna has two projections (the olecranon and coronoid processes), connected by a long body (shaft) to the distal end which has a head, and a styloid process (on the medial aspect). The main function of the ulna is to stabilise the forearm. The main movements are flexion and extension at the elbow joint. In the forearm, the ulna lies medially whilst the radius lies laterally. *lateral border is the interosseus border. * at proximal end of ulna: a) olecranon process - projection at the upper end of the ulna that forms the bony point of the elbow. on top of trochlear notch. b) coronoid process c) trochlear notch - articulates with trochlea of humerus d) radial notch - articulates with head of radius e) ulnar tuberosity - brachialis muscle inserts here * at distal end of ulna: a) ulnar head b) styloid process

The proximal, distal and radial longitudinal palmar skin crease

o The proximal palmar skin crease o The distal palmar skin crease (marks the position of the metacarpophalangeal (MP) joints) o The radial longitudinal crease (partly encircles thenar eminence)

Radial nerve of hand

o The radial nerve (C5,6,7,8 T1) supplies the posterior compartment of the upper arm as well as the posterior compartment of the forearm. It lies on the humerus in the radial (spiral) groove and is at risk from mid humeral shaft fractures. Just superior to the elbow it divides into the superficial radial nerve (sensory) and the deep radial nerve (motor). o The superficial branch of the radial nerve is cutaneous only. It is sensory to the lateral two-thirds of the dorsum of the hand, the dorsum of the thumb and the proximal portions of the dorsal index and middle fingers. o The posterior interosseous nerve is the direct continuation of the deep radial nerve as it passes between the heads of supinator. The radial nerve and its continuations, the deep radial nerve and the posterior interosseous nerve, supply all the extensor compartment muscles of the arm and forearm. It does not supply any muscles in the hand. Ø Divides just above the level of the elbow into: 1) Deep branch - the posterior interosseous nerve (motor) 2) Superficial branch - the superficial radial nerve (sensory) Ø NO motor supply in the hand Ø Sensory supply to the dorsum of the hand

Radius bone anatomy

o The radius has a cylindrical head at the proximal end, a long body (shaft) in the middle, connecting a broad distal end with a laterally projecting styloid process. The radius rotates around the ulna in supination/pronation, involving the proximal and distal radio-ulnar joints (both of which are of pivot type synovial joints). **At the proximal end and the body of a radius: 1. Head of the radius 2. Neck of the radius 3. Radial tuberosity 4. Medial (interosseous) border 5. Articular surface for capitulum of humerus 6. Articular surface for the radial notch of the ulna 7. Body (shaft) of radius ** At the distal end of a radius: 1. Ulna notch - accommodates the ulnar head 2. Radial styloid process (lateral) 3. Dorsal tubercle

Muscles involved in movements of scapulo-thoracic joint

o The scapula has the following movements upon the chest wall as part of the physiological "scapulo-thoracic joint" (for reference the "prime movers" are also given): 1) Elevation-superior trapezius, levator scapulae, rhomboids. 2) Depression - inferior trapezius, pectoralis minor, serratus anterior. 3) Protraction - pectoralis minor, serratus anterior. 4) Retraction - rhomboids, middle trapezius, latissimus dorsi. 5) Rotation -glenoid fossa faces upwards or downwards as scapula rotates. 6) Rotation-up: superior trapezius, inferior trapezius, serratus anterior. 7) Rotation down: pectoralis minor, latissimus dorsi, rhomboids and levator scapulae.

Structure and function of periosteum

o The superficial layer of compact bone is covered by the periosteum. o This consists of a FIBROUS OUTER layer and an INNER CELLULAR layer. o The periosteum functions by PROTECTING the bone from the surrounding tissues, provides a route for BVs and NERVES and very importantly is actively involved in bone GROWTH AND REPAIR.

Where does the long and short saphenous vein travel?

o The superficial venous return is extensive and variable, but two major veins are consistent. They arise from the dorsal venous network of the foot to give the long saphenous vein medially and the short saphenous vein laterally. o Examine the long vein as it passes anterior to the medial malleolus at the ankle and continues superiorly and medially in the leg, more posteriorly at the knee, then medial in the thigh until the vein passes anterior to the femoral triangle to drain into the femoral vein through the saphenous opening in fascia lata. o The short saphenous vein passes posteriorly to the lateral malleolus at the ankle, runs superiorly on the posterior leg to drain into the popliteal vein after piercing the fascia over the popliteal fossa. **Note that there are numerous perforating branches connecting the superficial and deep veins.

Ulnar nerve of hand

o The ulnar nerve (C8 T1) initially descends the arm in the anterior compartment, but more distally it moves to the posterior compartment, to lie superficially posterior to the medial epicondyle of the humerus, where it is at risk of damage. It does not give off any branches in the arm o The ulnar nerve enters the anterior compartment of the forearm passing between the heads of flexor carpi ulnaris and it descends on the medial side of the forearm. In the forearm it supplies. o flexor carpi ulnaris (FCU) medial portion of flexor digitorum profundus (FDP) i.e. to the ring and little fingers. o Proximal to the wrist, the nerve gives off two cutaneous branches to the hand; o Palmar cutaneous branch - supplies the medial palm of the hand. o Dorsal cutaneous branch - supplies the medial half of the dorsum of the hand, including the little and ring fingers o At the wrist it lies anteriorly, between the FCU (medially) and the ulnar artery (laterally) and then passes into the hand. Ø At the wrist lies by FCU Ø Runs OVER (not under) the flexor retinaculum, lateral to the pisiform Ø Divides into; 1) Superficial branch, sensory to: palmar surfaces of LF and half of RF 2) Deep branch, motor to: a) hypothenar muscles b) adductor pollicis c) lumbricals III and IV d) all the interossei

Path of the long saphenous vein

path of the long saphenous vein in the thigh and examine where it empties into the femoral vein after passing through the saphenous opening in fascia lata.

The Wrist Joint

o The wrist joint is an elipsoid synovial joint between the distal radius and its associated triangular fibrocartilage articular disc, with the proximal row of the carpal bones (scaphoid, lunate and triquetrum). o There are a number of strong ligaments stabilising the wrist joint. These include: 1) The ulnar collateral ligament 2) The radial collateral ligament 3) The palmar radio-carpal ligament 4) The palmar ulnocarpal ligament 5) The dorsal radio-carpal ligament 6) The inter-carpal ligaments o The radio-carpal and inter-carpal ligaments were previously thought to be relatively unimportant but they are now known to be very important clinically and are frequently injured. The movements of the wrist joint are: 1) Flexion/extension 2) Radial deviation and ulnar deviation (abduction and adduction) 3) Circumduction o The wrist joint is not the only joint that allows flexion and extension at the wrist region - the midcarpal joint (between the proximal and distal row of carpal bones) and the carpo-metacarpal joints also allow these movements.

The Veins of the elbow, forearm and wrist: superficial drainage

o There are superficial and deep venous systems in the upper limb. o The major superficial veins are the cephalic vein and the basilic vein. The cephalic vein ascends the upper limb on its lateral side, whilst the basilic vein runs medially. They arise from the lateral and medial sides, respectively, of the dorsal venous arch on the posterior surface of the hand. o The median cubital vein connects the cephalic and basilic veins at the level of the elbow - this is a common site for venepuncture and is variable in its anatomy. o Deep veins (venae comitantes) accompany the radial and ulnar arteries. They eventually flow to the brachial vein in the arm. o The superficial and deep veins have numerous connections with valves allowing one-way flow from the superficial to the deep system.

Lateral Compartment of the Leg

o This compartment consists chiefly of the ankle evertors •Superficial Peroneal Nerve •Peroneal Artery o Muscles: •Peroneus Longus •Peroneus brevis **also a peroneus tertius. o two tendons (long and short) go behind lateral malleolus; one attaches to base of 5th metatarsal and other takes a turn and goes along opposite side of foot (Everter). ** Anterior compartment muscles extend (dorsiflex) the foot at the ankle joint and extend the digits. Supplied by the deep branch of the peroneal nerve. Lateral compartment muscles evert the foot and can contribute to dorsiflexion.

Posterior Compartment of the Leg

o This compartment consists of ankle plantarflexors (tip toeing), and has superficial and deep divisions •Supplied by tibial nerve •Posterior Tibial Artery o Muscles: 1) Superficial: a) Gastrocnemius b) Soleus c) Plantaris 2) Deep: a) Popliteus b) Flexor Digitorum Longus c) Flexor Hallucis Longus d) Tibialis Posterior

The ulnar paradox

o Ulnar injury at the wrist results in a more severe deformity (clawing) than injury at the elbow, though you might normally expect a more proximal, and thus more debilitating, injury to result in a more deformed appearance. o This is because the ulnar nerve also innervates the ulnar half of FDP, flexion of the IP joints is weakened, therefore less claw-like appearance. *'the closer to the paw, the worse the claw'

Polarizing Microscopy of Bone

o Woven (immature) bone - only found in repairing fractures or in disease of the bone (i.e. Paget's disease). more irregular. o Lamellar (mature) bone - shows concentric rings of cells as opposed to woven bone that does not. § Outer hard layer of compact bone (cortical bone). § Inner layer of interlacing struts (cancellous/spongy/trabecular bone).

What is adductor pollicis supplied by?

o a "pollicis" muscle supplied by the ULNAR nerve. o attaches to base of proximal phalynx of thumb (only has proximal and distal pharanges) and middle metacarpal. o (the thenar muscles are supplied by the median nerve).

Detail pathway of abdominal aorta --> arteries in feet.

o abdominal aorta --> common iliac artery --> external iliac artery --> common femoral artery. o common femoral artery divides into: a) profunda femoris (deep branch) which forms medial and lateral circumflex arteries b) superficial femoral artery carries on o superficial femoral artery --> popliteal artery once passes through hiatus of adductor magnus --> 'trifurcation': tibioperoneal trunk --> anterior tibial and peroneal; other branch is posterior tibial. o posterior tibial --> plantar arteries o anterior tibial --> dorsalis pedis. o peroneal --> lateral compartment

Scapula labels

o acromion at end of spine on posterior surface

Layers 3 and 4 of the sole of the foot

o adductor hallucis, flexor hallucis brevis, flexor digit minimi brevis. o plantar and dorsal interossei.

Pelvic bones

o ala of ilium is the wing. fossa is internal bit. o ischium- tubercle and spine. o pubis - body (cetnre) and two rami (superior and inferior)

How is arm divided into two compartments?

o arm is region of upper limb between shoulder and elbow. o Arm is divided into two compartments (*by medial and lateral intermuscular septa which connect the humerus to the deep fascia of the arm)

Palpating cubital lymph nodes

o around the medial epicondyle, medial to basilic vein. **Note: The lymph nodes are normally palpable only when they are enlarged due to any pathology. Therefore in a healthy subject you may not palpate any lymph nodes.

Innervation and actions of rhomboids

o attach to medial border of scapula and spinous process of lower part of neck (C7) and upper thorax (till T5). o rhomboid minor and major) o Supplied by the dorsal scapular nerve. o Retracts, rotates and fixes the scapula.

Attachment of the three hamstring muscles

o attachment of the three hamstring muscles at the ischial tuberosity: semimembranosis (flat distal tendon), semitendonisis (rope-like distal tendon) and the long head of biceps femoris. o semimembranosus and semitendinosus attachments at the superior medial epicondylar region of the tibia. o long head of biceps femoris runs laterally to be joined by fibres arising from the inferior linea aspera and supracondylar ridge of the femur (the short head) forming a common tendon that crosses the knee joint to insert into the head of fibula.

What does ulnar artery give off?

o bifurcation of the brachial artery to form the ulnar and radial arteries. The ulnar artery gives off the short common interosseous branch that divides to give the anterior, posterior and recurrent interosseous arteries. as ulnar artery goes through forearm and crosses the wrist to form the superficial palmar arch (and contribute to the deep palmar arch). o radial artery passes distally in the forearm and crosses the wrist entering the thenar eminence and forming the deep palmar arch (also contributes to the superficial palmar arch). o At the wrist, a branch of the radial artery passes dorsally to anastomose with the distal end of the anterior and posterior interosseous arteries to form the dorsal carpal arch.

The control of calcium ion levels in the body involves the control of the balance of bone absorption/resorption

o bones are Ca2+ stores When blood Ca2+ levels high: Calcitonin released by parafollicular thyroid cells: a) breakdown of bone matrix by osteoclasts inhibited b) uptake of Ca2+ into bone matrix is promoted. When blood Ca2+ levels low: o Parathyroid Hormone (PTH) released by chief cells of parathyroid gland: a) osteoclast bone resorption activity promoted b) increases Ca2+ re-absorption by the kidneys.

Nerves of the Upper Limb common sites of damage anterior view

o brachial plexus o can see musculocutaenous nerve but can't see terminal branch that becomes lateral cutaneous nerve of forearm o median nerve only starts to supply at forearm and some in hand. *common damanged in elbow joint and wrist.

Brachial plexus is responsible fro innervation of entire upper limb EXCEPT which muscle?

o brachial plexus is a somatic plexus formed from the anterior rami of spinal nerve C5-T1. Responsible for the innervation of the entire upper limb EXCEPT for Trapezius

Boundaries of cubital fossa

o brachioradialis muscle (lateral), o pronator teres muscle (medial), o the line between the medial and lateral humeral epicondyles (superior) *"the floor: brachialis and supinator muscles and contents: biceps tendon, the brachial artery which bifurcates to the radial and ulnar arteries, the median nerve and the radial nerve and its deep branch. The roof of the fossa is formed from skin and superficial fascia containing the median cubital vein, the lateral and medial cutaneous nerves of the forearm and deep fascia reinforced by the bicipital aponeurosis.

What do the capitulum and trochlea of the humerus articulate with?

o capitulum (lateral) articulates with radius o trochlea (medial) articulates with ulna

Ligamentous Anatomy of the Pelvis

o come from sacrum to ischial tuberosity and spine (sacrotuberous and sacrospinous) o have foramina (from buttock to pelvis) o form greater and lesser sciatic foramina

Peripheral Cutaneous Nerves

o common peroneal branch can get damaged quite easily in knee o deep fibular nerve goes right to toes. o different to dermatomes due to mixing of fibres in dermatomes

Cross-section of lamellar bone

o compact bone in cortical areas. is made up of units called osteon (central canal containing nerves and vessels, surrounded by concentric lamellae with cells) o trabecular bone is still strong due to interlacing spikes. but doesn't resist same amount of compression as compact bone o many blood vessels running through

What is the basic unit of compact bone?

o compact bone: the basic unit = OSTEON or HAVERSIAN SYSTEM. o The osteocytes are arranged in layers around a central Haversian canal. o Each canal carries a blood and nerve supply to the osteon. The Haversian canals run parallel to the bone surface. o The osteons are arranged into lamellae. Most are arranged in a cylindrical fashion in the longitudinal axis of the bone and are called CONCENTRIC LAMELLAE. o There are also INTERSTITIAL lamellae filling in the spaces. o CIRCUMFERENTIAL lamellae are adjacent to either the periosteum or the endosteum and are produced during the growth of bone. **In cancellous bone the lamellae are NOT arranged into osteons. o The matrix develops into an interlacing network of rods called TRABECULAE. This is much LESS heavy than compact bone, and also provides an ideal environment for the cells of the bone MARROW.

What is the biggest muscle in the body?

o deep 1/4 inserts to gluteal tuberosity of femur. o superficial 3/4 of gluteus maximus attaches to iliotibial tract. o extensor of hip joint and little bit of adduction. o tensor fascia latae - tenses fascia and helps stabilise knee as it crosses

Osteoprogenitor cells

o effectively stem cells, which can differentiate into osteoblasts. o Although there are only a small number present in bone, they are actively involved in FRACTURE REPAIR. o Most osteoprogenitor cells are located in the PERIOSTEUM, the ENDOSTEUM and in the VASCULAR CANALS in the bone matrix.

treatment of acute compartment syndrome

o emergency fasciotomy - required to prevent the death of muscles, and other tissues, in the affected compartment. o completely opens up the compartment to relieve pressure

How do most short bones ossify?

o endochondral ossification, but only via one primary ossification centre. However the CALCANEUM (heel) has a secondary ossification centre. o A useful rule of thumb is that primary centres appear at about 2 MONTHS IN UTERO and secondary centres about 2 YEARS after birth (often earlier in the largest bones).

Bone elongation: epiphyseal growth

o epiphyseal plate o cells arranged in columns o proliferation near head then calcification

Tendons of the digits

o extensor digitorum tendon --> extensor expansion (hood), which lumbrical is attached to. expansion narrows and goes distally (allows complete extension of digit) o interossei attached mostly to bone but also hood

Posterior cord of brachial plexus generally supplies what...

o extensors Axillary and Radial nerves

What type of injury can damage the upper roots (C5, C6

o fall onto neck o pulling head and stretching neck during birth

The femoral artery in the groin palpation

o feel between ASIS and pubic tubercle (is in midinguinal point) o pressing femoral artery against pubic ramus and can feel pulse there

movement terminology: flexion, extension, abduction, adduction, rotation, circumduction, protraction, retraction, pronation, supination

o flexion - Bending or decreasing the angle between bones or parts of the body. o extension - Straightening or increasing the angle between bones or parts of the body. o abduction - Moving the distal part away from the midline in the coronal plane.) NB: the "midline" of the hand is the middle finger, and in the foot is the second toe. o adduction - Moving the distal part towards the midline in the coronal plane. o rotation -Revolving a body part along its longitudinal axis o internal (medial) rotation - Bringing the anterior surface of a body part closer to the midline. o external (lateral) rotation - taking the anterior surface of a body part away from the midline. o circumduction - A combination of flexion/extension and abduction/adduction so that the distal part of the upper limb moves in a circle. e.g. upper limb at shoulder joint o opposition - Bringing the pad of the thumb towards the pad of another digit. o protraction - an anterior movement of a body part o retraction - a posterior movement of a body part e.g. scapula on thoracic wall o elevation - movement of a body part superiorly o depression - movement of a body part inferiorly o pronation - Rotation of the forearm along its long axis so that the palm faces posteriorly (palm down) o supination - Rotation of the forearm along its long axis so that the palm faces anteriorly

Long tendons and intrinsic muscles help support the arches of the foot.

o flexor hallucis longus that holds arch in place. o palmar aponeurosis o can see difference in footprints for different arches. o arches can affect skin of foot (--> hard).

Position of long thoracic nerve in plexus

o formed from roots of C5,6 and 7. o Supplies serratus anterior (medial edge of scapula to ribs 1-9) (holds scapula down) o Long thoracic nerve is relatively superficial, therefore easily damaged.

How many dorsal and palmar interossei are there?

o four dorsal (attach towards centre of metacarpals (axial line), cause ABduction). o three palmar. (attach outwards of metacarpals (axial line), cause ADduction) o lumbricals are little worm-like muscles that have proximal attachments at tendons of flexor digitorum profundus. muscles have distal attachment after converge to form tendon and attach to posterior of finger that forms a hood (extensor expansion)

The Wrist and Distal Radio-Ulnar Joints

o gap between distal end of radius and proximal row < gap between distal end of ulnar and proximal row. o this is because there is an intervening fibrous disc between ulnar and proximal row. *so radius articulates directly and ulnar articulates via the fibrous disc.

Muscles and nerves of the lower limb arise in the abdominal and pelvic cavities.

o iliopsoas (psoas has attachment on lumbar vertebra and its fibres converge with iliacus muscle which is on inner surface of iliac bone; they attach onto inferior tubercle)

Where to feel for subclavian artery pulse

o just above and behind the medial end of clavicle. o can also feel the trunks of brachial plexus in the supraclavicular fossa

Nerves of the Leg and Foot

o just above knee, sciatic knee divides to give tibial and common peroneal nerve. o tibial nerve stays posterior and runs down to ankle o common peroneal leave popliteal fossa and runs around neck of fibula and is susceptible to damage here. when it goes round it divides into deep (anterior muscles) and superficial (lateral muscles). o saphenous nerve - major branch of femoral nerve that makes it below knee. cutaneous nerve fo medial leg and foot. o sural nerve - formed by branches of tibial and common peroneal nerve (communicating branches) - important cutaneous nerve of lateral leg and foot. sometimes removed for nerve reconstruction.

Consequences of injury to the Radial Nerve (Derived from Posterior Cord)

o larger than axillary nerve. travels out from axillary region into posterior arm and forearm. divides at elbow to give cutaneous superficial branch and deep muscular branch. o The radial nerve runs closely apposed to the shaft of the humerus, so can be damaged in humeral fractures. o Radial Nerve damage: Wrist drop and anaesthesia of the dorsal hand. Loss of muscle mass evident in the arm and forearm. As posterior forearm extensors innervated by radial nerve. also get sensory deficit in lateral dorsal part of hand. **Loss of the "Power Grip" is the most important outcome - when grip, extension of wrist is necessary for most efficient grip.

Injuries to the Radial Nerve (Derived from Posterior Cord)

Radial Nerve path (Derived from Posterior Cord)

Superior view of the tibial plateau, showing the menisci

o menisci - C-shaped cartilaginous o underneath is hyaline cartilage on top of bone o collateral ligaments o meniscus cartilage is attached to collateral ligament, so if collateral ligament is stretched it will pull on meniscus; hence medial meniscus commonly damaged. o tendon of popliteus muscle, passing through joint capsule and unlocks knee. o patellar tendon acting at tibial tuberosity via patella; quadriceps will extend knee. o ACL and PCL cut.

The Lymphatic Drainage of the Arm

o most of lymph nodes follow deep veins. o cubital lymph nodes in elbow region. o Axillary lymph nodes also very important in draining the breast; removing axillary lymph nodes in breast cancer treatment can lead to lymphedema of the arm, forearm and hand. (Already considered in Thorax anatomy)

How to palate axillary artery

o on the medial side of humerus, posterior to the tendon of short head of bicep

Clavicle labels

o one of first bones to start calcify; and last to stop calcify. o The clavicle connects the upper limb to the axial skeleton. The clavicle is unusual in that it is the first long bone to ossify (5th week of intra uterine life) humans. It does so by intramembranous ossification rather than endochondral ossification that is common to most long bones. o flattened at acromial end (lateral) o broad sternal (medial) end articulates with manubrium and first costal cartilage o superior surface is smooth o inferior surface is rough o medial 2/3 convex anteriorly o lateral 1/3 concave anteriorly o has conoid tubercle laterally o subclavian groove for subclavius muscle.

Bone cells

o osteogenic cells (stem cells) --> osteoblast (forms bone matrix) --> osteocyte (maintains bone tissue) o osteoclast- modified immune cells (similar lineage), dissolves calcium in bone

Microscopy of lamellar bone osteon

o osteon has central canal carrying nerves and vessels, with concentric layers of osteocytes with calcium salt deposits o lots of black streaks - shows connections between cells o gap junctions allow cells to transfer things (e..g nutrients/waste) between them; hence substances from central blood vessels can reach cells at the outside by passing through other cells as the extracellular space is filled by solid material.

Nerves of the upper limb

o pectoral nerves supplying pec major and minor o muscocutaneous - anterior compartment of arm o median nerve doesn't supply till passes elbow then innervates forearm muscles o ulnar nerve - passes through arm and only starts supplying in forearm and mostly in hand. o axillary and radial nerve - posterior part of brachial plexus forms axillary nerve and radial nerve. axillary nerve supplies deltoid muscle. radial nerve supplies all posterior muscles of arm and forearm.

Common sites of damage in nerves of the upper limb

Which is the biggest cutaneous nerve in body?

o posterior cutaneous nerve of thigh - biggest cutaneous nerve

Arteries of the Ankle

o posterior tibial passes behind medial malleolus (PULSE POINT) o anterior tibial artery - runs deep in anterior compartent of legs --> dorsalis pedis as it passes ankle. o dorsal pedilis is pulse point.

Deltoid innervation and action

o proximal attachments (same as distal attachments of trapezius): a) spine of scapula b) acromion c) anteriorly attached to lateral 1/3 of clavicle. o distal attachment: Deltoid tuberosity of the humerus o 3 parts: clavicular (anterior), middle and spinal (posterior) part. o **Innervation: Supplied by the axillary nerve. o **Function: Deltoid abducts arm beyond first 15⁰ (GHJ)

Rotator cuff innervation and action

o proximal attachments on scapula, all attach to head of humerus. o Rotator cuff group acts to fix the head of humerus in the glenoid fossa. o Supraspinatus important in initiating abduction of arm for first 15°, then deltoid takes over. o Teres major (not rotator cuff) adducts and medially rotates arm.

Innervation and actions of latissimus dorsi

o proximal: attaches inferiorly to iliac crest and sacrum through thoraco-lumbar fascia and also up till T8 superiorly. o distal: fibres converge distally to form tendon that attaches to floor of intertubercular groove of humerus. *o Function: a) Extension (opposite to pec major) b) adducts (same as pec major) c) medially rotates the humerus (same as pec major); pulls the body up to the arms during climbing. Also important in ROWING. *o Supplied by the thoracodorsal nerve (can be injured during mastectomy)

Injuries to the Musculocutaneous Nerve (Derived from Lateral Cord)

o stays within axilla and into the arm it pierces coracobrachialis and continues supplying rest of anterior arm; then gives off lateral cutaneous nerve of forearm (doesn't supply any muscles below elbow). o Musculocutaneous nerve is not often injured in trauma as it is well protected by muscles. May be damaged during surgery for breast cancer (as near lots of lymph nodes)

Testing actions of sterno-cleido-mastoid, trapezius, pec major, serratus anterior, teres major, latissimus dorsi, anterior axillary fold, posterior axillary fold, deltoid.

o subscapularis does internal rotation. o teres minor does external rotation. o ulnar deviation is adduction. o radial deviation is abduction and we have less movement here. *Note: To test muscle action, ask the subject to bring about movement that causes contraction of muscle whilst the examiner resists the movement which makes the muscle belly to stand out and readily palpable. e.g. to test the biceps, the subject is asked to flex the elbow whilst the examiner applies an opposing force against the flexion.

Levels of angles of scapula

o superior angle - T2 o medial end of scapular spine - T3 o inferior angle - T7

Anatomical snuff-box

o tendons that define it are extensor pollicis longus (EPL) and extensor pollicis brevis (EPB). Abductor pollicis longus is a tendon nearby. o when extend thumb see the two tendons and the snuff-box, there's a branch of RADIAL ARTERY in that area and SCAPHOID BONE (commonly damaged - issue as blood supply is recurrent so can potentially cause disability of wrist joint) **Important in determining if the scaphoid might be fractured: a common injury.

The Cubital Fossa

o the space anterior to the elbow joint. o can see brachial artery and median nerve and other veins.

Wrist: flexor retinaculum

o thick band of CT that connects bony features on either side of wrist of carpal region. o protects all things going through from anterior forearm into palmar region o median nerve and numerous tendons here.

Nerves of the Leg and Foot pic

o tibial - supplies posterior compartment ; at ankle divides to give plantar nerves. o just above knee, sciatic knee divides to give tibial and common peroneal nerve. o tibial nerve stays posterior and runs down to ankle o common peroneal leave popliteal fossa and runs around neck of fibula and is susceptible to damage here. when it goes round it divides into deep (anterior muscles) and superficial (lateral muscles). o saphenous nerve - major branch of femoral nerve that makes it below knee. cutaneous nerve fo medial leg and foot. o sural nerve - formed by branches of tibial and common peroneal nerve (communicating branches) - important cutaneous nerve of lateral leg and foot. sometimes removed for nerve reconstruction.

Proximal Tibia

o tibial plateau with intercondylar eminence. o head of fibula does not articulate with knee joint.

Nerves of the Upper Limb common sites of damage posterior view

o ulnar nerve behind medial epicondyle, wrist and just below shoulder joint for axillary nerve. radial nerve can be damaged by fractures to shaft of humerus, because it runs along humerus with radial artery.

Pectoralis Minor labels

o underneath pec major * distal attachment to coracoid process of scapula * proximal attachment to 2, 3, 4, and 5th ribs. *ACTION: acts on scapula to pull forward and down (protraction of the STJ) *Innervation: Medial pectoral nerve ONLY

Lower limb anterior compartments

o upper limb is attached to trunk by sacro-iliac joint o femur big bone, tibia and fibula, tarsus, metatarsus, phalanges o anterior thigh, anterior leg, dorsal surface of the foot. Also medial (adductor) compartment of thigh, and lateral (peroneal (UK) or fibular (USA)) compartment of the leg.

Movements of the Scapulo-Thoracic Joint

o virtual joint o When describing movements of the pectoral girdle, it is crucial to realise that movement is not only occurring at the sterno-clavicular joint, movement also occurs at the scapulo-thoracic 'joint'. o The scapulo-thoracic 'joint' is essentially a theoretical concept, but represents the 'articulation' between the scapula and the chest wall. The main movements of the scapula at the scapulo-thoracic 'joint' are: 1) Elevation and depression of the scapula 2) Protraction of the scapula i.e. forward and lateral movement of the scapula against the chest wall AND Retraction of the scapula i.e. backward and medial movement of the scapula against the chest wall 3) Rotation of the scapula. **Important: These movements are separate and independent of movements at the gleno-humeral joint

Segmental Sensory Supply of the lower limb- Autonomous sensory zones

o zones where, if have abnormal sensation in these areas are indicative of spinal root damage for that particular dermatome. o can see confined region for L3, L4, L5 (lateral patch under L4) and S1),

Extensor Hoods

oThe extensor tendons will expand over the proximal phalanges to form complex extensor hoods: The interosseous muscles attach to the extensor hoods The distal attachment of the lumbricals is the extensor hood. This is why they cause MCP flexion and IP extension

Summary of attachments of lateral rotators of hip

obturator externus, gemelli, piriformis, quadratus femoris. § Deep to the gluteus maximus, the piriformis, obturator internus, obturator externus, superior gemellus, inferior gemellus, and quadratus femoris laterally rotate the femur at the hip.

What muscle separates superior and inferior gemelli?

obturator internus muscle

How to show long extensor tendons of hand?

on dorsum of hand - (extend the wrist against resistance). *can also see the dorsal venous arch and origin of the basilic and cephalic veins

Terminology for muscle attachments

origins and insertions = Now considered inaccurate. For Limbs, the correct terminology is: o proximal attachment and distal attachment. The proximal attachment is at, or CLOSER to, the TRUNK.

Obturator nerve where would feel abnormal sensation if damaged?

peripheral nerve area where would get abnormal sensation if obturator damaged

The sacro-iliac joint - What type of joint is this?

plane synovial joint

PSIS

posterior superior iliac spine

Flexor carpi radialis and ulnaris

powerful wrist flexor, hand abductor and adductor. **Flexor carpi radialis: o originates on the medial epicondyle of the humerus. It runs just laterally of flexor digitorum superficialis and inserts on the anterior aspect of the base of the second metacarpal, and has small slips to both the third metacarpal and trapezium tuberosity. **Flexor carpi radialis: o arises from the medial epicondyle of the humerus. o But the flexor carpi ulnaris muscle has an additional attachment point on the head of the ulna. o It inserts at two wrist bones: the pisiform bone and the hook of the hamate. It also inserts at the base of the pinky finger

Which large branch comes off the femoral artery?

profunda femoris artery, which supplies the posterior compartment of the thigh and continues as the superficial femoral artery. § Course guide: o external iliac artery as is passes under the inguinal ligament to continue as the femoral artery. o deep artery of the thigh (PROFUNDA FEMORIS artery) which branches from the femoral artery in the femoral triangle and immediately gives of the lateral and medial CIRCUMFLEX arteries (providing the distal supply to the head of femur), while the artery passes inferiorly, medial to the femoral shaft, giving off PERFORATING branches. o Follow the major part of the femoral artery as it leaves the femoral triangle at the inferior apex and progresses inferiorly in the adductor canal. o Note that the artery passes through the hiatus of adductor magnus to become the popliteal artery which will give off genicular (knee) branches as it progresses in the fossa. As it passes inferiorly in the popliteal fossa, note the division of the artery to form the anterior tibial artery that pierces the superior part of the interosseous membrane to pass into the anterior compartment of the leg. The other division is the posterior tibial artery that immediately gives off the peroneal artery supplying the lateral posterior and peroneal compartments. o Trace the posterior tibial artery as it passes into the foot posteriorly to the medial malleolus to divide into the medial and lateral plantar arteries, which form a plantar arterial arch. o Trace the anterior tibial artery as it runs inferiorly supplying the anterior compartment to cross the ankle and continue as the dorsalis pedis artery passing anteromedially to turn laterally as the arcuate artery giving off the digital branches. Note that perforating arteries communicate between the plantar arch and the arcuate artery. o In the buttock, examine the superior and inferior gluteal arteries (branches of the internal iliac artery) as they emerge superiorly and inferiorly to piriformis, to supply the muscles of the gluteal compartment. o Find the obturator artery as it passes from the internal iliac artery in the pelvis, through the obturator foramen, and into the medial compartment to supply medial muscles.

The pubic symphysis - What type of joint is this?

secondary cartilaginous

hip joint

see transverse acetabular ligament

Pattern of Sensory Nerve Distribution

sensory different to dermatome innervation as fibres supplying dermatomes might come from more than one peripheral nerve.

Layers 1 and 2 of the sole of the foot

sesamoid bones, digits. o abductor digiti minimi, lumbricals, abductor hallucis, quadratus plantae (pulls on tendons of flexor digitorum longus). **here these don't mirror hand muscles.

Palmar cutaneous branch of median nerve

skin of central palm

ala of ilium

spread of the fan

Venous drainage of the upper limb

superficial and deep veins. deep veins parallel arteries o dorsal venous arch (sup.) --> cephalic (lateral, sup.) vein and basilic (medial, sup.) vein --> basilic merges with Venae comitantes (deep); cephalic goes straight up arm and joins --> Axillary vein (deep) --> subclavian vein --> superior vena cava. § NOTE - cubital fossa superficial veins are often used for phlebotomy - MEDIAN CUBITAL VEIN · This vein links the basilic and cephalic veins (but it's not always present). § venae comitantes - deep veins of limbs that run as multiple veins esp. more distally *Lymphatic system - cubital lymph nodes can drain to the axillary pectoral lymph nodes.*

Bicipital aponeurosis

superficial to brachial artery and median nerve; fuses with deep fascia covering the origin of the wrist and finger flexors. A broad aponeurosis of the biceps brachii which is located in the cubital fossa of the elbow and separates superficial from deep structures in much of the fossa. (overlies the median nerve and the brachial artery)

Fascia of the Buttock and Thigh

tensor fascia lata and gluteus maximus tend to act through ilio-tibial tract (thickened fascia lata that fuses below knee joint)

Which muscles of the anterior compartment of thigh act across the knee joint?

tensor fasciae lata, sartorius and quadriceps.

Summary of attachments of intermediate hand muscles

the intermediate muscles act on all the fingers and include the lumbrical, the palmar interossei, and the dorsal interossei. The lumbrical muscles, with the help of the interosseous muscles, simultaneously flex the metacarpophalangeal joints while extending both interphalangeal joints of the digit on which it inserts.

malleolus

the rounded bony protuberance on each side of the ankle

deficiency on fascia lata in the anteriorsuperior region is the...

the saphenous opening. Find the long (great) saphenous vein draining into the femoral vein via the saphenous opening. is 2-3 inches inferolateral to the pubic tubercle

Table of dermatomal regions of lower limbs

touch with blunt end of a pencil (for crude touch) or a cotton wool pellet (for light touch)

Draw and outline the flexor retinaculum (connect the above 4 bony landmarks)

trapezium, pisiform, scaphoid, hamate. Flexor retinaculum forms the roof of the carpal tunnel.

eversion

turning the sole of the foot outward (little toe up) Eversion: Moving the sole of foot away from the median plane, ie facing laterally. Inversion: Moving the sole of foot away from the median plane, ie facing laterally. Moving the sole of foot towards the median plane, ie facing medially

Connective tissue septae in the hand

walls separate vessels and tendons

The weight-bearing at the ankle joint is by...

weight-bearing at the ankle joint is by talus via it's superior articulation with tibia. Fibula is not weight-bearing, but it's distal lateral malleolus, with tibia's medial malleolus, forms the square socket of the ankle joint. o talus fits into square-shaped socket (mortise) and sits on top of calcaneus. o square-shaped socket formed from distal ends of tibia and fibula. o tibia and fibula attached helps maintain stability.

Median Nerve Claw Hand

§ Hand of Benediction. § Cause: Median nerve damage § Muscles involved: FD profundus (radial half), lumbricals of (radial side § Presentation: When trying to make a fist, 2nd 3rd fingers fail to flex completely with thumb unable to oppose. Difficulty in making a fist= because flexion of 2 nd & 3rd digits incomplete at distal interphalageal jts. The MCP joints hyperextended due to unopposed action of extensor digitorum. Thumb unable to oppose due to paralysis of opponens pollicis, FP brevis, (thenar muscles)

The sympathetic supply to the lower limbs is derived from ...?

§ "The sympathetic supply to the upper limbs is derived from the T2-6. § The sympathetic supply to the lower limbs is derived from T11-L2. (from the lower thoracic and lumbar region). Blood flow & sweating are principal markers of SNS function § There is NO parasympathetic outflow to the limbs.

What nerve roots are tested in knee and ankle jerk reflex

§ A muscle is supplied by one or more spinal cord segments or nerve roots. When the tendon of the muscle is tapped (thus causing stretch of muscle spindles) it results in an involuntary contraction (or a jerk) in the muscle. Presence of reflex activity indicates the integrity of the nerve pathway of the particular spinal cord segment. 1) Patellar tendon reflex (knee jerk) (femoral nerve L2-4) o If the reflex arc is intact a brisk extension of the knee joint will be seen. Simultaneous contraction of the quadriceps should be palpated (by the examiner) on the anterior surface of thigh. o Repeat the test on the opposite side and compare the responses. 2) Calcaneal (Achilles) tendon reflex (Ankle Jerk) (S1-2) o If the reflex arc is intact, a plantar flexion of the ankle joint will occur. Repeat the test on the opposite side and compare the responses. o The ankle jerk may be absent or diminished if the S1 spinal nerve root is affected (for e.g in a prolapse of L5/S1 lumbar intervertebral disc) or in tibial nerve damage.

The concept of arterial embolism

§ Acute arterial embolism can be caused by sudden occlusion of an atheroclerotic vessel or by thrombus from atrial fibrillation. If a vessel is suddenly occluded with no time for a collateral circulation to develop, the consequences can be severe. For example if an arterial clot forms in the popliteal artery, there may be no time for a collateral circulation to develop and the leg may become ischaemic and require amputation if the lesion is no cleared within a few hours. § Intermittent claudication is a condition where there is a gradual occlusion of arteries within the limb, usually atherosclerotic. The muscles supplied distal to the occlusion become deprived of blood on exercise so that there is a limited walking distance before pain occurs, most commonly in the calf, but sometimes in the thigh or buttock.

Distal attachment of ilio-psoas

§ Anterior compartment of the thigh § Ilio-psoas (Iliacus and psoas major) § Proximal: a) Iliacus attaches to: Iliac fossa of anterior ilium b) Psoas major attaches to the posterior abdominal wall § Distal: Lesser trochanter § Function: Hip flexion

Cutaneous branch of obturator nerve

§ Anterior divisions of L2-4 § Innervates all of the muscles in the adductor compartment except? a) The hamstring half of the adductor magnus b) Pectineus § Cutaneous branch to medial thigh *Has an anterior and posterior branch (relative to the adductor brevis)

Boundaries of axilla

§ Apex: cervico-axillary canal (passageway between neck and axilla § Base: skin forming the axillary fossa § Anterior wall: pectoralis major and minor (pectoralis major forms anterior axillary fold) § Posterior wall: subscapularis and scapula (lat. dorsi, teres major form posterior axillary fold) § Medial wall: thoracic cage and serratus anterior § Lateral wall: intertubercular sulcus of humerus

Injury to the common peroneal nerve

§ As well as being damaged at the level of the hip, ALSO the common peroneal nerve is highly vulnerable to damage at the level of the fibular neck, around which the nerve winds. § Causes of damage are trauma, knee replacement and external pressure e.g. from plasters or during surgical procedures.

The Anatomy of the Femoral Sheath

§ At the level of the inguinal ligament, the femoral artery lies between the femoral vein and the femoral nerve. § The femoral artery crosses the inguinal ligament at the midinguinal point i.e. half way between the pubic symphysis and the anterior superior iliac spine. § The femoral vein lies just medial to the femoral artery. § The femoral nerve lies just lateral to the femoral artery. § The femoral canal lies to the medial side of the femoral vein, and within it lies a lymph node. This is the canal through which a femoral hernia passes.

Fracture healing

§ Bleeding is an important part of the process. The haematoma becomes infiltrated by fibrous matrix and invaded by cartilage/bone progenitors. a) Initially a haematoma forms and then a fibrocartilaginous callus forms. b) The fibrocartilaginous callus --> bony callus which is then remodelled into new bone. c) The fracture repair phase involves woven bone formation. d) this will eventually remodel into mature lamellar bone

What are the two main consequences of DVT?

§ Blood can clot (thrombose) in the superficial and deep veins of the lower limb - when t occurs in the deep veins, this is termed deep venous thrombosis (DVT). § DVT is often "silent" but may present with pain and swelling in the calf or the proximal thigh. § A distal DVT occurs in the calf whilst a proximal DVT extends into the thigh and pelvis. § A proximal DVT is very dangerous, as there is a high risk of propagation of the clot into the LUNGS. § DVT is very important clinically. It can occur idiopathically (i.e. without an obvious cause) but is often associated with immobility, trauma, surgery within the abdomen, pelvis or limbs, obesity, malignancy, pregnancy or with the use of the oral contrceptive pill. § DVT has TWO MAIN consequences: 1) the clot may propagate into the pulmonary circulation, causing a pulmonary embolus (PE). A PE may be fatal and for this reason DVT's are usually treated by anticoagulation to prevent this complication occurring. 2) The clot in the deep veins may cause increased back pressure in the deep veins, causing venous insufficiency and leg ulcers (the POST-PHLEBITIC SYNDROME). § The superficial veins may also clot or become inflamed/infected. This causes SUPERFICIAL THROMBOPHLEBITIS. This is not so dangerous as DVT but can be very painful. The treatment is usually symptomatic (analgesia, rest, ice etc) rather than with anticoagulation. § The superficial veins as grafts in elective surgery: o The saphenous veins are often used in cardiac and vascular surgery as grafts to replace arteries. o Obviously the veins need to be orientated correctly due to the valves present within them. o As there is such an excellent anastomosis in the leg, the removal of the superficial veins rarely causes a problem.

Supraclavicular Lesion-Erb's Palsy

§ C5 & C6 roots or upper trunk § Cause: Damage to upper trunk or (C5 & C6 roots) of the brachial plexus. Damage during birth, or motorcycle falls when abduction of head and neck occurs. § Muscles involved: Supra & infraspinatus (lateral rotators of shoulder), deloid (abductor), biceps, brachialis, brachioradialis (elbow flexors), supinator and wrist extensors (weak) § Presentation: Arm adducted, medially rotated, pronated forearm with flexed wrist known as Waiter's tip position.

Acute limb ischaemia causes and effects

§ Cause: Sudden occlusion of blood supply a) 85% due to thrombosis § Due to atherosclerosis § Or aneurysm (e.g. of the popliteal artery) b) 15% due to embolism E.g. thrombus of the heart due to atrial fibrillation. § Effect: 6 P's - Pain, Pallor, Pulseless, Paraesthesia, Paralysis, Perishingly cold

True Claw Hand

§ Cause: Ulnar & Median nerve damage (or C5-T1 roots damage) § Presentation: clawing will be present in all 4 fingers with the thumb assuming abducted position.

Is arterial pulse lost in acute compartment syndrome?

§ Compartment syndromes can occur anywhere in the leg but are most common in the true leg itself. § There are three compartments in the leg, the anterior, posterior and lateral compartments. § Each compartment is bound by a very tight fascia, which only let the enclosed muscles swell to a certain degree before resisting any further expansion and then increase the pressure in the muscle itself. § If the pressure in the muscle increases too far, the arterial supply and venous return of the muscle in that compartment is cut off, resulting in muscle death, with resulting loss of movement and contractures in the limb. § There are clinical syndromes where muscle swelling causes such damage, and these are termed compartment syndromes. § Acute compartment syndrome occurs after trauma to a limb, e.g. fractures, muscle damage. Unless the fascia is released urgently by a FASCIOTOMY the muscle will die with disastrous consequences. **NOTE: that the arterial pulse is NOT lost in acute compartment syndromes. The tissue pressure is only 25mmHg and pressure need only to rise to 50-60mmHg to cause a compartment syndrome. The diastolic blood pressure is 80mmHg and the systolic 120mmHg! Chronic compartment syndrome occurs in athletes where the muscles swells during exercise and causes activity-related pain. Elective fasciotomy can relieve the pain of this condition

Proximal Attachments of Each Compartment of thigh

§ Conveniently, each compartment pretty much entirely attaches to the same part of the pelvic bone. § The exceptions to this rule are* a) The obturator muscles b) The deep gluteal compartment muscles These muscles all attach to different parts of the pelvis 1) Anterior compartment hip flexors --> Anterior ilium: a) Iliacus, rectus femoris, sartorius and tensor fascia lata (The 3 "vastus" muscles of the quadratus femoris do not attach to the pelvis at all) 2) Superficial gluteal compartment --> Posterior ilium Gluteus maximus, medius and minimus

Proximal attachments of deep gluteal compartment and obturators

§ Deep gluteal compartment: 1.Piriformis: Anterior sacrum 2.Obturator internus: Obturator membrane 3.Superior and inferior gamelli: Ischium 4.Quadratus femoris: Ischium § Adductor compartment 1. Obturator externus: Obturator membrane

Why are all the patients in a surgical ward wearing the same socks?

§ Elastic surgical socks promote more vigorous deep venous return as patients are often immobilised for long periods of time in surgery. This is to prevent DVT. o Valves in the veins allow flow only up towards the heart. In the leg, the deep vessels are sandwiched between layers of calf muscles. p During walking and running, contractions of these muscles squeeze the thin-walled veins and push blood up the veins: THE CALF PUMP o Immobility (e.g. a long plane journey) means less efficient venous return from the foot and leg. o Sluggish deep venous return can lead to Deep Vein Thrombosis (DVT). o Elastic surgical socks compress the superficial veins so more blood goes deep promoting more vigorous deep venous return.

tibiocalcaneal ligament

§ Examine the fibrous distal tibio-fibular joint, and the articular surfaces of the dome of talus and the distal ends of tibia and fibula. § Examine the lateral and medial collateral ligaments of the ankle, noting the differences in their arrangement. § The lateral ligaments are three distinct parts: the anterior and posterior talofibular ligaments and the calcaneofibular ligament. § The medial (Deltoid) ligament has a broader triangular organisation. § If possible, examine the anterior and posterior tibiofibular ligaments at the distal tibiofibular joint. Examine the flexor and extensor retinaculae at the ankle.

Flexor hallucis longus and brevis in foot

§ Examine the plantar aponeurosis. § there are many similarities to the intrinsic muscles of the hand (e.g. lumbricals and interossei). § One muscle to take note of is Flexor hallucis brevis; its distal attachment to the lateral and medial sides of the proximal phalanx of hallux via two tendons, each of which contain a sesamoid bone. § This arrangement a$llows the long tendon of flexor hallucis longus to run in the groove between the sesamoid bones, protecting it during walking and running. Observe the sesamoid bones in X-rays of the foot.

identify the major bony features of the knee joint: the condyles of the distal femur and the proximal tibia, the tibial tuberosity and the patella.

§ Examine the relationship between the proximal head of the fibula and the tibia (proximal tibio-fibular joint). § Explore the distal ends of the leg bones (the distal tibio-fibular joint, the lateral and medial malleoli) and their relationship to the tarsal bone, talus, at the ankle joint. § Examine the tarsal, metatarsal and phalangeal bones of the foot

Fibularis Brevis

§ Foot Eversion § Proximal Lower 2/3 of lateral surface of fibula. § Distal Base of 5th Metatarsal

Summary of attachments of the superficial anterior compartment of the forearm

§ From lateral to medial, the superficial anterior compartment of the forearm includes the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis. § The flexor digitorum superficialis flexes the hand as well as the digits at the knuckles, which allows for rapid finger movements, as in typing or playing a musical instrument . § However, poor ergonomics can irritate the tendons of these muscles as they slide back and forth with the carpal tunnel of the anterior wrist and pinch the median nerve, which also travels through the tunnel, causing Carpal Tunnel Syndrome.

The Gait Cycle

§ Gait can be divided into swing phase and stance phase. Ask your colleague to walk normally several steps and follow the movements of one of the lower limbs very carefully; for example the right lower limb. The activity of one limb is sub divided into eight sub-phases. (In the diagram below two of the sub phases are combined into one as seen in (F)). § The stance phase of the right limb starts with heel strike (A) and ends with heels off (D). The swing phase starts with preswing (E) and ends with terminal swing (G).

Cutaneous branches of tibial nerve

§L4-S3 §In the leg: §Exits the Popliteal Fossa §Enters and innervates all muscles of posterior compartment §Important Cutaneous branches are: a) Sural (posterior leg)- Supplies the lateral cutaneous aspect of the leg b) Medial calcaneal*

Innervation and testing of gluteal muscles

§ Gluteus maximus - (Nerve-Inferior gluteal L5,S1,2) Subject lies prone with the knee flexed. Ask the subject to extend the thigh at the hip joint while applying resistance at the distal end of thigh. Examiner palpates the rounded contour of the buttock for the muscle contraction. § Gluteus medius and minimus (Nerve-Superior gluteal L5,S1) - Subject lies on the side with the lower limb fully extended. Ask the subject to ABduct the limb at the hip joint while applying resistance at the distal end of thigh. Examiner palpates the contraction of the gluteus medius just inferior to ilac crest. § Tensor fascia lata - (Nerve-Superior gluteal L5,S1) - Same as for gluteus medius but this time the subject is rolled slightly toward supine (not fully) and examiner's finger tip on the Tensor fascia lata muscle and the ilio-tibial band (which may become visible).

Intermittent Claudication

§ Impaired blood flow to leg, causing pain when demands are greater than supply § "Muscle pain during activity, usually associated with arterial disease" § Cause: Atherosclerosis § However, whilst in acute limb ischaemia there is sudden occlusion, in intermittent claudication there is gradual occlusion § Distal muscles are deprived of oxygen: a) Causes pain - relieved by rest b) Limits walking distance § Consequently, distal muscles like the calf are more commonly effected than thigh or gluteal muscles

Cut-down at the medial malleolus of the long saphenous vein.

§ In the shocked patient, venous cannulation may not be easy or possible. § The anatomical surface marking of the long saphenous vein at the ankle (2cm above and proximal to the tip of the medial malleolus) makes it an excellent site to perform a "cut-down". § A small incision can be made at the ankle and a venous cannula placed under direct vision into the vein for resuscitation.

Injury to the tibial nerve

§ Injury to the tibial nerve is uncommon because of its deep and protected position in the popliteal fossa; however, the nerve may be injured by deep lacerations in the fossa. Posterior dislocation of the knee joint may also damage the tibial nerve. § Severance of the tibial nerve produces paralysis of the flexor muscles in the leg and the intrinsic muscles in the sole of the foot. § People with a tibial nerve injury are unable to plantarflex their ankle or flex their toes. § Loss of sensation also occurs on the sole of the foot.

Anteversion (torsion angle) of the femoral neck

Injury to the saphenous nerve

§ Its terminal branch is the saphenous nerve, which is sensory to the medial aspect of the leg. § Injury to this nerve is surprisingly common. § The nerve can be damaged at the medial malleolus (e.g. after varicose vein surgery or cut down) or at the level of the knee (e.g. ACL surgery).

Label distal femur

§ Linea aspera widens to form floor of popliteal fossa § Two muscles orginate here: Gastrocnemius and Plantaris. § Medial supracondylar line ends at the ADDUCTOR TUBERCLE. Insertion of HAMSTRING part of A.MAGNUS. 1) medial epicondyle 1a) medial condyle 2) patellar surface 3) lateral epicondyle 3a) lateral condyle 4) intercondylar fossa 5) medial supracondylar line 6) lateral supracondylar line

What connects lumbar and sacral plexus?

§ Lumbosacral Plexus: Made up of: a) Lumbar plexus - formed by the ventral rami of L1-4 b) Sacral plexus - The sacral plexus is formed by the: i) Ventral rami of S1-S4 ii) Lumbosacral trunk (L4,5) This is a branch of the lumbar plexus c) Lumbosacral trunk connecting the two

Where do deep inguinal nodes drain into?

§ Lymph flows into inguinal nodes: a) Superficial inguinal --> Deep inguinal b) Deep inguinal --> External iliac

Gracilis attachments

§ Medial compartment of the thigh § Proximal Pubis. § Distal Medial-proximal tibial shaft. § Function Hip adduction and knee flexion.

Motor and sensory deficits in distribution of segmental supply (spinal roots) are .... to peripheral supply

§ Motor and sensory deficits in distribution of segmental supply (spinal roots) are different to peripheral supply § The exact pattern of deficits can tell us where the lesion is

Compartment syndrome

§ Muscle groups are in confined compartments separated by fascia (have anterior, medial and posterior). § Compartment syndrome - ischaemia caused by trauma-induced increased pressure in a confined compartment. o Commonly affects - anterior, posterior and lateral compartments of the leg. can also see in arm tho. o Normal pressure = 25mmHg, but you only need 50-60mmHg to collapse the small vessels (and cause ischaemia) but the pulse is still present (120/80). o Acute = trauma associated. o Chronic = exercise-induced. o Treatment - emergency fasciotomy. ***Symptoms and Signs of Ischaemic Limb: •Pain, greater than expected •Pallor of the limb, patchy •The limb is cool •Pulses absent •Movement, passive extension is very painful

Anaesthetic Nerve Blocks

§ Nerve blocks can be utilised by anaesthetists to aid or substitute general anaesthesia during surgery. § Examples include femoral nerve blocks, sciatic nerve blocks, ankle blocks or blocks of the lateral cutaneous nerve of the thigh. Knowledge of peripheral anatomy allows the anaesthetist to localise the best place to insert local anaesthetic and also to predict the level and extent of anaesthesia provided.

Development of spine

§ Nerve supply: o The upper limbs are supplied by the brachial plexus (C5-->T1). o The lower limbs are supplied by L2-->S3. § Flexion/extension: o Upper limbs - flexors are anterior (e.g. biceps brachii), extensors are posterior (e.g. triceps brachii). o Lower limbs - flexors are posterior, extensors are anterior (limbs rotate internally, hence other way around).

On which bone are the menisci?

§ On Proximal Tibia - Tibial Plateau § Dispersion of weight: Medial Condyle --> medial meniscus Lateral Condyle --> lateral meniscus - Intercondylar Region (in between): Anterior/Posterior Horns of both Meniscus and ACL/PCL Inferior Attachment.

Growth in bone diameter aka

•Apposition - addition to exterior at periosteum •Osteoblasts and osteoclasts create ridges and grooves on bone surface that blood vessels align in; these periosteal ridges fuse to form endosteum-lined tunnels for BVs to sit in. •Osteoblasts build new osteons around vessels •Osteoclasts remove bone from endosteal surface

How many bones does tarsus consist of?

§ PROXIMAL row: 1. Talus (ankle bone -L): 1.1 Trochlea (dome) of talus (superior surface) . 1.2 Body of talus (sits on calcaneum). 1.3 Neck of talus. 1.4 Head of talus. 2. Calcaneus (heel bone - L): 2.1 Calcaneal tuberosity 2.2 Sustentaculum tali (medial side) § INTERMEDIATE row: 3. Navicular (little ship - L) 3.1 Navicular tuberosity (inferiorly) § DISTAL row: 4. Medial cuneiform. 5. Intermediate cuneiform. 6. Lateral cuneiform. 7. Cuboid (most lateral) .

Leg nervous supply

§ Posterior Compartment + Foot Intrinsic Muscles (apart from EBD) Tibial Nerve § Anterior Compartment Common Peroneal Nerve (Deep Branch) § Lateral Compartment Common Peroneal (Superficial Branch) **Knee extensors (Quadriceps - Femoral Nerve); Knee flexors (Hamstrings - Sciatic Nerve).

Cutaneous branches of femoral nerve

§ Posterior divisions of anterior rami of L2,3,4 § Innervates all muscles in anterior compartment of thigh §And one in adductor compartment? pectineus §Has some important cutaneous branches: a) Medial femoral cutaneous nerve: Medial part of anterior thigh* b) Intermediate femoral cutaneous nerve: Middle part of anterior thigh* c) Saphenous Nerve: anteromedial knee, medial leg and foot

What type of joint is proximal tibiofibular and distal tibifibular?

§ Proximal Tibiofibular Joint Synovial Joint. § Distal Tibiofibular Joint Fibrous Joint.

Gluteus maximus innervation

§ Proximal attachment: posterior ilium. (between PSIS and posterior gluteal line) § Distal attachment : a) Deep fibres: Gluteal tuberosity b) Superficial fibres: Iliotibial tract § Function: Hip Extension Some lateral rotation and abduction § Innervation: Inferior gluteal nerve

Gluteus medius and medius innervation

§ Proximal: posterior ilium § Distal: Greater trochanter § Function: Hip abduction § Innervation: Superior gluteal nerve

Ankle Sprain Injuries

§ Refers to a tearing of the ankle ligaments § Most common is of lateral ligaments: Occur during over-inversion injuries § Patient will present with: Pain on outside of ankle, Swelling, Ecchymosis § Treatment: RICE (Rest, ice, compression, elevate), Physical Therapy

What type of bone is patella?

§ Sesamoid bone - formed in quadriceps tendon § Posterior surface articulates with femur (PFJ) § Naturally lies supero-medially

Intra-articular menisci

§ Shock absorber § Convert round bone ends to flat shape § Medial meniscus attached to: a) Tibial Collateral Ligament b) Joint Capsule Hence, more susceptible to injury compared to lateral meniscus

Distal attachment of deep gluteal compartment

§ Short external rotators of the hip: 1.Piriformis 2.Obturator internus 3.Superior gamellus 4.Inferior gamellus 5.Quadratus femoris § Function: Lateral rotation of hip § Distal: ALL attach to greater trochanter *Quadratus femoris is technically distally attached to the intertrochanteric crest *Proximal: Complex (differs for each one) *Innervation: Complex (differs for each one)

Pic of muscles That Move the Humerus

§ Similar to the muscles that position the pectoral girdle, muscles that cross the shoulder joint and move the humerus bone of the arm include both axial and scapular muscles. The two axial muscles are the pectoralis major and the latissimus dorsi. The pectoralis major is thick and fan-shaped, covering much of the superior portion of the anterior thorax. The broad, triangular latissimus dorsi is located on the inferior part of the back, where it inserts into a thick connective tissue shealth called an aponeurosis. Muscles That Move the Humerus: § (a, c) The muscles that move the humerus anteriorly are generally located on the anterior side of the body and originate from the sternum (e.g., pectoralis major) or the anterior side of the scapula (e.g., subscapularis). § (b) The muscles that move the humerus superiorly generally originate from the superior surfaces of the scapula and/or the clavicle (e.g., deltoids). The muscles that move the humerus inferiorly generally originate from middle or lower back (e.g., latissiumus dorsi). § (d) The muscles that move the humerus posteriorly are generally located on the posterior side of the body and insert into the scapula (e.g., infraspinatus).

Summary of attachments of gluteal maximus, medius and minimus and tensor fascia lata

§ Some of the largest and most powerful muscles in the body are the gluteal muscles or gluteal group. The gluteus maximus is the largest; deep to the gluteus maximus is the gluteus medius, and deep to the gluteus medius is the gluteus minimus, the smallest of the trio § The tensor fascia latae is a thick, squarish muscle in the superior aspect of the lateral thigh. It acts as a synergist of the gluteus medius and iliopsoas in flexing and abducting the thigh. It also helps stabilize the lateral aspect of the knee by pulling on the iliotibial tract (band), making it taut. § The large and powerful muscles of the hip that move the femur generally originate on the pelvic girdle and insert into the femur. The muscles that move the lower leg typically originate on the femur and insert into the bones of the knee joint. The anterior muscles of the femur extend the lower leg but also aid in flexing the thigh. The posterior muscles of the femur flex the lower leg but also aid in extending the thigh. A combination of gluteal and thigh muscles also adduct, abduct, and rotate the thigh and lower leg.

What does popliteal vein become?

§ Superficial: Popliteal vein becomes the femoral vein at the knee. § Deep: The superficial femoral vein receives the venae comitantes of the profunda femoris artery. § Saphenofemoral junction occurs in the femoral triangle **Venous Drainage of the Leg: 1) Deep Veins: Follow the arteries and have similar names a) Venae comitantes of arteries: Calf and Profunda femoris b) Popliteal c) Femoral 2) Superficial Veins: Great/Small Saphenous Veins. § In subcutaneous connective tissue § Interconnect with deep system using perforating veins

Summary of attachments of hip adductors

§ The adductor longus, adductor brevis, and adductor magnus can both medially and laterally rotate the thigh depending on the placement of the foot. The adductor longus flexes the thigh, whereas the adductor magnus extends it. The pectineus adducts and flexes the femur at the hip as well. The pectineus is located in the femoral triangle, which is formed at the junction between the hip and the leg and also includes the femoral nerve, the femoral artery, the femoral vein, and the deep inguinal lymph nodes.

Blood Supply of the Limbs in general

•Arterial Supply •Venous Drainage •Lymphatic drainage and lymph nodes * why is it important? - DVT, diabetes, vascular disease, age-related changes

The Anterior (Extensor) Compartment of the Leg

§ The anterior muscles have their proximal attachments on the anterior surfaces of the leg bones and the interosseus membrane. 1) Tibialis anterior attaches to the proximal ½ of the anterolateral tibial surface and the interosseous membrane; its tendon runs inferomedially to cross the ankle joint and attach to the medial cuneiform and base of the 1st metatarsal. 2) Extensor digitorum longus attaches to the lateral head fibula, upper 2/3 of medial fibular shaft surface and upper part of interosseous membrane; its tendon crosses the ankle medially and splits into 4 tendon slips, each of which insert on dorsum of middle and distal phalanges as part of extensor expansion. 3) Extensor hallucis longus attaches to the mid and distal anterior surface of the fibula and the adjacent interosseous membrane; its tendon crosses the ankle centrally to insert into the distal phalanx of hallux. Attempt to find branches of the deep peroneal nerve supplying the anterior leg muscles

Summary of aorta course to lower limbs

§ The aorta splits into the common iliac arteries. § The common iliac arteries bifurcate at the pelvic brim into the internal iliac artery and the external iliac artery. § The external iliac artery becomes the femoral artery at the inguinal ligament. § The femoral artery passes beneath the inguinal ligament at the mid-inguinal point i.e. half way between the symphysis pubis and the anterior superior iliac spine. At this point it lies upon the psoas tendon and can be easily palpated. This is also the site where the artery can be cannulated. § The femoral artery has four branches in the thigh just below the inguinal ligament: a. the superficial circumflex iliac artery b. the superficial epigastric artery c. the superficial external pudendal artery d. the deep external pudendal artery. § The femoral artery descends and gives off a large branch, the profunda femoris artery, and then itself passes into the adductor canal. § The profunda femoris artery is the artery of the thigh. It arises about 4cm distal to the inguinal ligament from the femoral artery. Its major branches are the perforating arteries and the medial and lateral femoral circumflex arteries. § The femoral artery (superficial femoral artery) passes in the adductor canal and becomes the popliteal artery. The popliteal artery may be easily palpated at the level of the popliteal fossa. § At the distal portion of the popliteal fossa, the popliteal artery forms the bifurcation into; a. the posterior tibial artery b. the anterior tibial artery. § The anterior tibial artery passes into the anterior compartment of the leg, running on the interosseous membrane. At the level of the foot it becomes the dorsalis pedis artery which is palpable between the first and second metatarsals. § The posterior tibial artery passes into the posterior compartment of the leg alongside tibialis posterior. It passes behind the medial malleolus, where it may be easily palpated. It divides in the foot into the medial and lateral plantar arteries. The peroneal artery is a branch of the posterior tibial artery which runs in the lateral compartment of the leg, and is usually smaller than the anterior or posterior tibial arteries. It is not usually palpable at the level of the ankle.

Periosteum - the outer surface of bone, function and layers

§ The bones are covered by an outer periosteum. § There is a fibrous and cellular layer. •Key roles in: a) bone growth and repair (as houses cells that can form osteoblasts) b) •Vascular supply c) Good sensory nerve supply (how we get bony pain)

Which muscles originate from the scapula?

§ The clavicle and scapula make up the pectoral girdle, which provides a stable origin for the muscles that move the humerus. The muscles that position and stabilize the pectoral girdle are located on the thorax. § The anterior thoracic muscles are the subclavius, pectoralis minor, and the serratus anterior. § The posterior thoracic muscles are the trapezius, levator scapulae, rhomboid major, and rhomboid minor. § Nine muscles cross the shoulder joint to move the humerus. § The ones that originate on the axial skeleton are the pectoralis major and the latissimus dorsi. § The deltoid, subscapularis, supraspinatus, infraspinatus, teres major, teres minor, and coracobrachialis originate on the scapula.

Injury to the sciatic nerve

§ The commonest cause today of injury to the sciatic nerve is after hip replacement. The common peroneal division is far more vulnerable than the tibial division. § To avoid damage to the sciatic nerve, always give an intramuscular injection in the upper outer quadrant of the buttock. § Keep away from the lower inner quadrant, which is where the nerve is most likely to be situated. Other causes of damage are trauma (e.g. hip dislocations or acetabular fractures) and pelvic disease.

Summary of compartments of forearm

§ The extrinsic muscles of the hands originate along the forearm and insert into the hand in order to facilitate crude movements of the wrists, hands, and fingers. 1) The superficial anterior compartment of the forearm produces flexion. These muscles are the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and the flexor digitorum superficialis (underneath the others) 2) The deep anterior compartment produces flexion as well. These are the flexor pollicis longus and the flexor digitorum profundus. The rest of the compartments produce extension. 3) The extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris are the muscles found in the superficial posterior compartment. 4) The deep posterior compartment includes the abductor longus, extensor pollicis brevis, extensor pollicis longus, and the extensor indicis.

Cannulation of The Femoral Vessels

§ The femoral artery and vein can be easily exposed and cannulated at the femoral triangle § Femoral artery use: Arteriography. § Femoral vein use Resuscitation

Injury to the femoral nerve

§ The femoral nerve is relatively superficial in the groin but is rarely damaged except by doctors (IATROGENIC injuries). § The commonest injury today is via traction injuries during HIP REPLACEMENTS, and also at laparoscopic repair of INGUINAL HERNIAS. § It can also be damaged during erroneous attempted cannulations of the femoral artery or femoral vein. inability to extend the leg and loss of sensation in the skin over anteromedial aspect of the thigh.

Clinical importance of femoral triangle

§ The femoral triangle is the region where the femoral artery can be accessed - e.g. to access cardiac vessels to carry out angiograms and angioplasties. o The pulse can be felt here as well. § Perforating veins are veins that connect superficial and deep veins and these have a valve that only allow flow from superficial --> deep. o If the valve is compromised = varicose veins. § Elastic surgical socks promote more vigorous deep venous return as patients are often immobilised for long periods of time in surgery. This is to prevent DVT.

Joints of the foot

§ The foot is divided into the hind-foot, mid-foot and the fore-foot. § The subtalar joint consists of: 1. The talo-calcaneal joint 2. The talo-navicular joint 3. The calcaneo-cuboid joint § The talo-calcaneonavicular joint is part of the transverse tarsal joint or the mid-tarsal joint. Movement at this joint contributes to inversion and eversion of the foot together with movement of the subtalar joint. § The midtarsal joint consists of the joints between the midtasral bones and the metatarsals. Plantarflexion and dorsiflexion occur at the ankle joint. Inversion and eversion occur at the subtalar joint. o subtalar joint (between talus and calcaneus) o joint between head of talus and navicular bone.

Keys to bone growth and remodelling

•Bone has a large blood supply - cells are never far from nutrients and O2 •Osteocytes maintain matrix but can activate osteoblasts for new bone building •Osteoclasts are giant cells specialised for destruction of bone matrix.

Organisation of the spinal nerves

•C1-4 : neck •C5-T1 : upper limb •T2-L1 : trunk •L2-S3 : lower limb •S2-C1 : perineum

Summary of attachments of posterior muscles of arm

Summary of attachments of pronators and supinators

Summary of attachments of anterior muscles of arm

§ The forearm, made of the radius and ulna bones, has four main types of action at the hinge of the elbow joint: flexion, extension, pronation, and supination. The forearm flexors include the biceps brachii, brachialis, and brachioradialis. The extensors are the triceps brachii and anconeus. The pronators are the pronator teres and the pronator quadratus, and the supinator is the only one that turns the forearm anteriorly. When the forearm faces anteriorly, it is supinated. When the forearm faces posteriorly, it is pronated. § The biceps brachii, brachialis, and brachioradialis flex the forearm. The two-headed biceps brachii crosses the shoulder and elbow joints to flex the forearm, also taking part in supinating the forearm at the radioulnar joints and flexing the arm at the shoulder joint. Deep to the biceps brachii, the brachialis provides additional power in flexing the forearm. Finally, the brachioradialis can flex the forearm quickly or help lift a load slowly. These muscles and their associated blood vessels and nerves form the anterior compartment of the arm (anterior flexor compartment of the arm)

Innervation and testing hamstrings and quadricpes

§ The hamstrings - (Nerve-Tibial division. of sciatic L5, S1,2, except for biceps short head, which is common fibular division L5, S1,2). Subject lies prone with the knee flexed to 30 degrees. The examiner applies an opposing force just above the posterior side of the ankle while the subject attempts to flex the knee further. The hamstring tendons will be seen around the popliteal region and the muscle contraction is palpable on the posterior side of the mid-thigh. (Hamstrings = Biceps femoris, semitendinosus, semimembranosus). § Quadriceps -(Nerve-Femoral L2,3,4) Subject sits on the couch with knees bent to 90 degrees over the edge. The examiner applies pressure at the distal part of the leg while the subject attempts to extend it. The contracting quadriceps can be palpated on the anterior thigh. (Quadriceps femoris= rectus femoris, vastus medialis, intermedius & lateralis)

Summary of attachments of hypothenar muscles

§ The hypothenar muscles include the abductor digiti minimi, flexor digiti minimi brevis, and the opponens digiti minimi. These muscles form the hypothenar eminence, the rounded contour of the little finger, and as such, they all act on the little finger.

Pic of intrinsic muscles of hand

§ The intrinsic muscles of the hand both originate and insert within it. § These muscles are divided into three groups: a) The thenar muscles are on the radial aspect of the palm. b) The hypothenar muscles are on the medial aspect of the palm c) intermediate muscles are midpalmar. § The thenar muscles include the abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and the adductor pollicis. These muscles form the thenar eminence, the rounded contour of the base of the thumb, and all act on the thumb. The movements of the thumb play an integral role in most precise movements of the hand. § The hypothenar muscles include the abductor digiti minimi, flexor digiti minimi brevis, and the opponens digiti minimi. These muscles form the hypothenar eminence, the rounded contour of the little finger, and as such, they all act on the little finger. § Finally, the intermediate muscles act on all the fingers and include the lumbrical, the palmar interossei, and the dorsal interossei. The lumbrical muscles, with the help of the interosseous muscles, simultaneously flex the metacarpophalangeal joints while extending both interphalangeal joints of the digit on which it inserts.

Sciatic Nerve innervation

§ The longest and widest nerve in the human body (Posterior divisions of L4-S3) = Absolute beast* § Composed of two nerves: a) Tibial b) Common Peroneal § It supplies the entire posterior compartment of the thigh: 4 hamstring muscles In the posterior compartment: a) Tibial nerve (almost all): Semitendinosus, Semimembranosus, Long head of biceps femoris, Hamstring component of adductor magnus. b) Common peroneal: Short head of biceps femoris **Everything from the knee onwards is supplied by the sciatic nerve. It enters the limb, usually below the piriformis muscle

Summary of attachments of anterior compartment of leg

§ The muscles of the anterior compartment of the lower leg are generally responsible for dorsiflexion, and the muscles of the posterior compartment of the lower leg are generally responsible for plantar flexion. The lateral and medial muscles in both compartments invert, evert, and rotate the foot. § The muscles in the anterior compartment of the leg: the tibialis anterior, a long and thick muscle on the lateral surface of the tibia, the extensor hallucis longus, deep under it, and the extensor digitorum longus, lateral to it, all contribute to raising the front of the foot when they contract. § The fibularis tertius, a small muscle that originates on the anterior surface of the fibula, is associated with the extensor digitorum longus and sometimes fused to it, but is not present in all people. T § hick bands of connective tissue called the superior extensor retinaculum (transverse ligament of the ankle) and the inferior extensor retinaculum, hold the tendons of these muscles in place during dorsiflexion.

The Lateral Peroneal (Fibular (USA)) Compartment of the Leg

§ The two lateral muscles have their proximal attachments on the fibula. 1) Peroneus longus attaches to the head of fibula and the upper 1/2 - 2/3 of lateral fibular shaft surface. 2) peroneus brevis to the inferior 2/3 of lateral fibular surface. § Both tendons pass behind the lateral malleolus and run laterally in the foot. The tendon of longus turns medially to attach at the plantar posterolateral aspect of medial cuneiform and lateral side of 1st metatarsal base. The tendon of brevis attaches to the lateral surface of styloid process of 5th metatarsal base. Attempt to find branches of the superficial peroneal nerve supplying the lateral leg muscles.

Summary of attachments of quadriceps femoris and gracilis

§ The muscles of the anterior compartment of the thigh flex the thigh and extend the leg. This compartment contains the quadriceps femoris group, which actually comprises four muscles that extend and stabilize the knee. § The rectus femoris is on the anterior aspect of the thigh, the vastus lateralis is on the lateral aspect of the thigh, the vastus medialis is on the medial aspect of the thigh, and the vastus intermedius is between the vastus lateralis and vastus medialis and DEEP to the rectus femoris. § The tendon common to all four is the quadriceps tendon (PATELLAR TENDON), which inserts into the patella and continues below it as the patellar ligament. The patellar ligament attaches to the tibial tuberosity. § In addition to the quadriceps femoris, the sartorius is a band-like muscle that extends from the anterior superior iliac spine to the medial side of the proximal tibia. This versatile muscle flexes the leg at the knee and flexes, abducts, and laterally rotates the leg at the hip. This muscle allows us to sit cross-legged.

Tracing nerves in the buttock and posterior thigh

§ The nerves of the lower limb are formed in the lumbo-sacral plexus (L1-S4). One of the central prosections shows the plexus. § Nerves the buttock and posterior thigh: a) Sciatic: (L4-S3) Typically enters the gluteal region from the pelvis inferior to piriformis (be aware of possible variation). Trace the nerve to the posterior thigh and note its division to its terminal branches, the tibial and common peroneal nerves. b) Superior Gluteal: (L4-S1) Passes into the gluteal region via the greater sciatic foramen superior to piriformis. Attempt to trace branches to gluteus medius and minimus and tensor fascia lata. c) Inferior Gluteal: (L5-S2) Passes into the gluteal region via the greater sciatic foramen inferior to piriformis. This nerve supplies gluteus maximus only. d)Nerves to the external (lateral) rotators: nerve to quadratus femoris (also supplies inferior gemellus) and nerve to obturator internus (also supplies superior gemellus)

The peripheral nerve supply to the lower limb

§ The peripheral innervation of the lower limbs is derived from the lumbo-sacral plexus, which is derived from the anterior rami of the lumbar and sacral spinal nerves. The lumbar plexus is derived from L1-4 anterior rami. § It has the following branches seen in pic.

Ischial Tuberosity what attaches here?

§ The posterior compartment muscles attach to the ischial tuberosity: a) Semimembranosus b) Semitendinosis c) Biceps femoris d) adductor magnus has a hamstring component which also attaches to the ischial tuberosity

Summary of attachments of scapular muscles

§ The rest of the shoulder muscles originate on the scapula. The anatomical and ligamental structure of the shoulder joint and the arrangements of the muscles covering it, allows the arm to carry out different types of movements. § The deltoid, the thick muscle that creates the rounded lines of the shoulder is the major abductor of the arm, but it also facilitates flexing and medial rotation, as well as extension and lateral rotation. § The subscapularis originates on the anterior scapula and medially rotates the arm. Named for their locations, the supraspinatus (superior to the spine of the scapula) and the infraspinatus (inferior to the spine of the scapula) abduct the arm, and laterally rotate the arm, respectively. The thick and flat teres major is inferior to the teres minor and extends the arm, and assists in adduction and medial rotation of it. The long teres minor laterally rotates and extends the arm. Finally, the coracobrachialis flexes and adducts the arm. § The tendons of the deep subscapularis, supraspinatus, infraspinatus, and teres minor connect the scapula to the humerus, forming the rotator cuff (musculotendinous cuff), the circle of tendons around the shoulder joint. When baseball pitchers undergo shoulder surgery it is usually on the rotator cuff, which becomes pinched and inflamed, and may tear away from the bone due to the repetitive motion of bring the arm overhead to throw a fast pitch.

Summary of attachments of posterior compartment of leg: superficial muscles

§ The superficial muscles in the posterior compartment of the leg all insert onto the calcaneal tendon (Achilles tendon), a strong tendon that inserts into the calcaneal bone of the ankle. The muscles in this compartment are large and strong and keep humans upright. The most superficial and visible muscle of the calf is the gastrocnemius. Deep to the gastrocnemius is the wide, flat soleus. The plantaris runs obliquely between the two; some people may have two of these muscles, whereas no plantaris is observed in about seven percent of other cadaver dissections. The plantaris tendon is a desirable substitute for the fascia lata in hernia repair, tendon transplants, and repair of ligaments. § There are four deep muscles in the posterior compartment of the leg as well: the popliteus, flexor digitorum longus, flexor hallucis longus, and tibialis posterior.

Varicose veins and deep venous insufficiency

§ The superficial veins in the limb have valves which prevent backflow of blood. § However, as well as this, the deep veins and the perforating veins also have valves. § Probably the most important valve is at the SAPHENO-FEMORAL junction in the groin. § If this valve is incompetent, then blood can easily flow back into the superficial venous system, causing varicose veins. § Most operations for varicose veins involve tying off the saphenofemoral junction. § Varicose veins are DILATED and TORTUROUS SUPERFICIAL veins. § They can be painful, causing an aching discomfort on standing. However, they are also pathological in that the increased pressure within the superficial venous system can cause increased pressure in the superficial circulation, causing skin changes (LIPODERMATOSCLEROSIS) and often SKIN ULCERS. Most skin ulcers are due to venous insufficiency of this type.

Injury to the superior gluteal nerve

§ The superior gluteal nerve supplies the gluteus medius and gluteus minimus muscles. § If this nerve is damaged, the result is a Tredelenberg gait, where the pelvis lurches during gait. § The commonest injury today to the superior gluteal nerve is at hip replacement. The nerve lies approximately 5cm proximal to the tip of the greater trochanter, and approaches to the hip joint should not extend more than 5cm from the tip of the greater trochanter.

Summary of attachments of thenar muscles

§ The thenar muscles include the abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and the adductor pollicis. These muscles form the thenar eminence, the rounded contour of the base of the thumb, and all act on the thumb. The movements of the thumb play an integral role in most precise movements of the hand.

Fibularis Longus

§Foot Eversion, Plantarflexion, Support arches of foot § Proximal Upper lateral surface/Head of fibula. § Distal Base of 1st Metatarsal; Medial cuneiform.

how many spinal nerves

§ There are 31 pairs of spinal nerves: 8 Cervical, 12 Thoracic, 5 Lumbar, 5 Sacral, 1 Coccygeal. § Each spinal nerve is formed from the union between an anterior root (motor) and a dorsal root (sensory). § The roots merge at the intervertebral foramen to form a spinal nerve. Autonomic fibres pass between T1-L2 and S2-4. § Each spinal nerve, immediately after it passes through the intervertebral foramen, splits into an anterior ramus and a posterior ramus. § The anterior rami merge to form the major plexi of the limbs (C5-T1 for the upper limb, L2-S2 for the lower limb). § The posterior rami are smaller and less important, and are mainly cutaneous and for the back muscles: o C1-C4 are for the neck o C5-T1 are for the upper limbs (brachial plexus) o T2-L1 are for the trunk o L2-S2 are for the lower limbs (lumbosacral plexus) o S2-C2 is for the perineum.

Summary of attachments of posterior compartment of leg: deep muscles

§ There are four deep muscles in the posterior compartment of the leg: the popliteus, flexor digitorum longus, flexor hallucis longus, and tibialis posterior.

Parts of toe phalanges

§ There are three phalanges (proximal, middle and distal) on each digit except the great toe which has two. 1. Body (shaft) 2. Base (at the proximal end) 3. Head (at the distal end)

When does thigh become leg? When does leg become foot?

§ Transition Points 1) Thigh --> Leg: via Popliteal fossa 2) Leg --> Foot: a) Plantar Aspect via Tarsal Tunnel (Posteromedial to the ankle). b) Dorsal Aspect Enter directly, anterior to the ankle. ** Names for neurovasculature often change here

Trendelenberg test

§ Trendelenberg Test for the integrity of abductors of the Hip Joint. § This test is done to evaluate the motor loss of the abductors (gluteus medius and minimus) of the hip joint. Patients with a positive Trendelenberg test tend to "waddle" when they walk. § the abductors of the thigh prevent tilting of the pelvis when a limb is raised. **TEST: § First, the subject is asked to stand on both legs. Both right and left side of the pelvis should remain at same level without any tilt. Examiner should stand behind the subject and feel the pelvis. § Then ask the subject to raise one leg off the ground. The pelvis should remain horizontal on one leg. § If the pelvis on the raised leg side drops downward then the Trendelenberg test is said to be positive. A positive test indicates a loss or weakness of the motor function of the abductor muscles (gluteus medius and minimus) in the leg the subject is standing on (supported side). § so weakness is on the side OPPOSITE to the drooping side.

Lumbar Plexus

§ Ventral rami of L1-4 supply the nerves to the gluteal, anterior and adductor compartments: a) Femoral Nerve (L2,3,4) Derived from the posterior divisions. b) Obturator Nerve (L2,3,4) Derived from the anterior divisions. **Note the lumbosacral trunk (L4,5) which comes off the lumbar plexus, to form the sacral plexus § Nerves to the abdomen and perineum only: a) Iliohypogastric (L1). § Nerves to abdomen and perineum, also with cutaneous branches to the lower limb: a) lioinguinal nerves (L1) b) Genitofemoral nerve (L1, L2). § Cutaneous nerve to the lower limb: a) Lateral femoral cutaneous (L2, L3).

Proximal attachments of gluteal muscles

§ You just need to know that the gluteus muscles attach the posterior ilium § Between the posterior iliac spine and the posterior gluteal line*: Gluteus maximus § Between posterior and anterior gluteal lines*: Gluteus medius § Between anterior and inferior gluteal lines*: Gluteus minimus

Level of iliac crest, tubercle, femoral head, PSIS and greater trochanter of femur

§ iliac crest - where you place hands on the hip. Top of crest at L4/5 § Iliac tubercle - L5 level § Femoral head - At the midpoint between ASIS and pubic symphysis/ site of femoral artery pulsation. § Posterior superior iliac spine (PSIS) - indicated by a skin dimple at the back - at the level of S2 § Greater trochanter of the femur - Bony prominence on the lateral side of the upper thigh about 10 cm below iliac crest.

Safe Area for intramuscular injection in the buttock. Into what muscle are such injections normally made, and why?

§ injection made into gluteus medius muscle (superolateral quadrant of butt - avoid injury to underlying sciatic nerve) § Muscles have a greater blood supply and thus uptake of the drug is often faster than from SC and sub-dermal injections. Allows large amount of drug to be induced at once, but absorbed gradually. also fewer pain receptors. § The buttock is often contraindicated due to proximity to major vessels and nerves and the variation in adipose tissue over the muscles. Process: o find the trochanter. it is the knobbly top portion of the femur (size of golf ball). o find Posterior iliac crest - many people have dimples over this bone. o draw an imaginary line between the two bones o after locating the centre of the imaginary line, find a point one inch towards the head. this is where the needle needs to be inserted. o stretch the skin tight. o hold the syringe like a pencil or dart. insert the needle at a right angle to the skin. o up to 3 ml of fluid can be given in this site.

origin of quadriceps group

§ rectus femoris is only which attaches to AIIS and iliac bone.

When does profunda femoris form? Why is it important?

§Arises 4cm distal to the inguinal ligament §Gives off two important branches: a) Lateral femoral circumflex b) Medial femoral circumflex §Why are these arteries important - Avascular necrosis of the femoral head. §Also gives off multiple perforating arteries

Ulnar Claw Hand

§Causes: Ulnar nerve damage §Muscles involved: FC ulnaris, FD profundus (little and ring finger), lumbricals of (little and ring finger), and all interossei. §Presentation: Hand will show clawing 4th & 5th digit when at rest or extending all fingers §Difficulty in straightening all fingers= 4th & 5th fingers are over extended at MCP. But at distal interphalageal jts, due to the paralysis of the lumbricals and the interossei they can't be straightend. Assumes semi flexed position due to action FD superficialis §Difficulty in making a fist= because flexion of 4th & 5th digits incomplete at distal interphalangeal jts. The MCP joints hyperextended due to unopposed action of extensor digitorum.

Tibialis Anterior

§Dorsiflexion, Foot Inversion, Support of medial arch of foot §Proximal: Lateral Tibia; Anterior interosseous membrane. §Distal: Medial Cuneiform; Base of 1st Metatarsal.

Great Saphenous Vein Cut-down

§Emergency procedure, where venous cannulation is not possible - For example, in a shocked patient. §Incision made 2cm anterior and proximal to the medial malleolus to gain direct access to the great saphenous vein under direct vision §Cannula inserted into vein to resuscitate patient

Where is name for cruciate ligaments derived?

§Name derived from attachment position on Tibial Plateau. Stops tibial movement in that direction 1) ACL: lateral --> anterior a) Superior: Lateral Wall of Femoral Intercondylar Fossa b) Inferior: Anterior Tibial Intercondylar region 2) PCL: medial --> posterior a) Superior: Medial Wall of Femoral Intercondylar Fossa b) Inferior: Posterior Tibial Intercondylar region **PMAL. § Extra-synovial BUT Intra-articular § They are termed "cruciate" (Latin for "shaped like a cross") because they cross each other in the sagittal plane between their femoral and tibial attachments

Is proximal fibula weight bearing?

§Not involved in the formation of the knee-joint §Not weight bearing §Supero-medial surface articulates with the tibia (proximal TFJ - synovial) §Lateral surface of head ---> Attachment of Biceps Femoris

Which nerve does short saphenous vein run with?

§Originates from the lateral aspect of the dorsal venous arch of the foot §Runs posterior to the lateral malleolus §Continues up the back of the calf along with the sural nerve - Drains into popliteal vein (deep system) at popliteal fossa §It connects freely with: a) long saphenous vein b) Deep system elsewhere via perforating veins §Valves ensure blood moves in the proper direction

Where does sural nerve originate?

§Originates high in the leg between two heads of gastrocnemius §Formed from branch of Tibial Nerve + Common Peroneal §Supplies skin on: a) Lower Posterolateral Leg b) Lateral Foot/Little Toe §Harvested for Nerve Repair

Tibialis Posterior

§Plantarflexion, Foot Inversion §Also support of Medial Arch §Proximal: Posterior interosseous membrane; Tibia/Fibula §Distal: Navicular Tuberosity; Medial Cuneiform

Popliteus

§Stabilises knee joint and limits lateral rotation of tibio-femoral joint §"Unlocks" the knee joint § Proximal: Lateral femoral condyle §Distal: Posterior surface of tibia

Soleus muscle

§Superficial muscle in the Posterior (Flexor) Compartment of the Leg. § Deep to gastrocnemius, explore the proximal attachments of soleus at the posterior aspect of fibular head, the upper 1/4 - 1/3 of posterior surface of fibula and the middle 1/3 of medial border of tibial shaft. Soleus unites with the gastrocnemius aponeurosis to form the calcaneal tendon, inserting on the middle 1/3 of the posterior calcaneal surface. §Plantarflexion §Proximal: Soleal line and medial border of tibia; Posterior fibular head. §Distal: Calcaneal tendon

Gastrocnemius

§Superficial muscle in the Posterior (Flexor) Compartment of the Leg. § lateral and medial heads of gastrocnemius muscle from their attachments to the posterior non-articular surfaces of the femoral condyles to their merging at the calcaneal (Achilles) tendon §Plantarflexion, Knee Flexion. §Proximal: Medial Head - Superior to medial femoral condyle; Lateral Head - Superior to lateral femoral condyle. §Distal: Calcaneal tendon.

Which side sags in trendelenburg test?

§Tests for a paralysed or weak hip abductor §Raise the opposite leg (the "good" leg) §If the hip drops on the side of the leg which is being raised, then the patient is Tendelenberg positive; they have a loss or weakness of the gluteus medius and minimus of the bad leg §"Sound side sags" **Positive findings can be associated with various hip abnormalities such as congenital hip dislocation, rheumatic arthritis, osteoarthritis

"Muscle pump"

§The arterial system has the heart to push blood §The pressure generated by the heart is largely lost in the capillaries and so the venous system can't depend on the heart §Surrounding muscles squeeze veins to push blood §Valves ensure blood only moves forward **Remember: ØSuperficial flows to deep ØPerforating arteries assist in this flow ØValves are present to stop flow from deep to superficial. ØMuscle pump helps push blood back to the heart

Cutaneous innervation of thigh (JAS)

§lioinguinal nerves (L1) §Genitofemoral nerve (L1,2) §Lateral cutanenous nerve §Medial femoral cutaneous nerve: Medial part of anterior thigh §Intermediate femoral cutaneous nerve: Middle part of anterior thigh §Saphenous Nerve: anteromedial knee, medial leg and foot §The posterior cutaneous nerve of the thigh (S1-3)

Acute vs chronic compartment syndrome

Ø Acute compartment syndrome (trauma associated) Ø Chronic compartment syndrome (exercise-induced)

Venous grafts

Ø CABG (coronary artery bypass graft) Ø Arterial by-pass surgery Ø Valves! (only allow flow in one direction, so graft must be oriented in the correct direction)

Deep venous thrombosis

Ø Clot in deep veins Ø Clinical diagnosis Ø Risk factors - e.g. immobility, long haul flights Ø Proximal and distal DVT Ø Relationship to pulmonary embolism (PE) - DVT becomes dislodged and gets lodged in lungs Ø Post-phlebitic syndrome Ø Superficial thrombophlebitis o Valves in the veins allow flow only up towards the heart. In the leg, the deep vessels are sandwiched between layers of calf muscles. During walking and running, contractions of these muscles squeeze the thin-walled veins and push blood up the veins: the calf pump. Immobility (e.g. a long plane journey) means less efficient venous return from the foot and leg. Sluggish deep venous return can lead to Deep Vein Thrombosis (DVT). Elastic surgical socks compress the superficial veins promoting more vigorous deep venous return.

Deep veins of lower limb

Ø Run alongside arteries, may follow them as venae comitantes Ø"Muscle pump" in the calf ØAnterior and posterior tibial veins ØPopliteal vein (receives SSV) ØProfunda femoris vein ØFemoral vein (receives LSV) ØExternal iliac vein

Segmental Sensory Nerve Supply to the Upper Limb

•C4 - infraclavicular region. •C5 - lateral arm. •C6 -lateral forearm and thumb. •C7 -middle finger. •C8 -little finger and medial forearm. •T1 -medial arm. •T2- axilla and trunk. •T4 -nipple. •T10 -umbilicus. •T12 -lower abdomen.

Adaptability of bone

•Can grow without compromising its support functions •Increases or decreases bulk and density in response to pattern of use e.g. if don't use, decrease density •Can alter its external and internal shape in response to pattern of use - remodelling •Can repair when fractured

Which muscles of the anterior compartment of the arm does not act across the elbow joint?

•Coracobrachialis. *but biceps (unite to form biceps tendon) attach to radial tuberosity and aponeurosis that attaches to fascia) and brachialis (attaches to shaft of humerus and coronoid process of ulna and is flexor of elbow) . *all supplied by musculocutaneous nerve (c5, c6)

Median nerve in hand

Ø descends through the anterior compartment of the arm, where it has no branches. in the cubital fossa, it lies medial to the brachial artery and can be damaged there by supracondylar fractures of the humerus fractures or dislocations. The median nerve then passes between the heads of pronator teres. Ø At the wrist lies between FDS and FDP, deep to PL. crosses under flexor retinaculum Ø Enters the carpal tunnel with FDP, FDS and FPL Ø Motor to: a) Thenar muscles (APB, FPB, OP) b) lumbricals I and II (lateral) Ø Sensory to: a) Palmar surface of thumb, IF, MF and half of RF b) Some of the dorsal surface of those digits **in forearm it supplies: 1) pronator teres 2) FDS 3) lateral portion of FDP (to the index and middle fingers) 4) FCR 5) Pronator quadratus 6) Palmaris longus i.e. all the anterior compartment other than the FCU and the ulnar portion of FDP. o At the level of the wrist it lies quite superficially between the tendons of FDS and FDP, and deep to palmaris longus, prior to entering the carpal tunnel. Within the carpal tunnel it is accompanied by the nine flexor tendons. o The recurrent branch of the median nerve usually leaves the main trunk within the carpal tunnel and supplies the three thenar muscles is the. o The median nerve provides the sensory supply to the palmar surface of the thumb, index and middle fingers as well as the lateral half of the ring finger. It also supplies some of the dorsal surface of these digits.

Radial Nerve (JAS)

ØAnterior to the lateral epicondyle it divides into ØSensory: Superficial radial nerve ØMotor: Posterior interosseous nerve (deep branch) ØPosterior interosseous passes through head of supinator to supply the extensor compartment ØNOTE: The "deep branch of the radial nerve" is the true division, it is this nerve which becomes the posterior interosseous nerve*.

Overview of arterial anatomy of lower limb

ØAorta ØCommon iliac arteries ØExternal iliac / internal iliac arteries, passes uner inguinal ligament... ØFemoral artery ØProfunda femoris artery (deep branch) ØCircumflex femoral arteries ØFemoral artery passes through hiatus of adductor magnus... ØPopliteal artery Ø"Trifurcation": a) Anterior tibial artery --> dorsalis pedis artery b) Posterior tibial artery --> plantar arteries c) Peroneal artery ** o Aorta o Common iliac arteries: Internal iliac artery and External iliac artery (main supply) o External iliac artery o Femoral artery (pulse): Deep femoral artery that goes through adductor hiatus to go posteriorly and form... o Popliteal artery (pulse): •Posterior tibial artery (pulse) •Anterior tibial artery •Peroneal artery •Dorsalis pedis (pulse). **pulse: to assess vascular health; lower limb is further away so more issues. important for diabetics, aging, if being perfused properly. **femoral and popliteal - important for cannulation.

Superficial veins of lower limb

ØDorsal venous arch ØLong saphenous vein (formed from dorsal venous arch of foot, merges anterior and superior to medial malleolus, travels up medially, goes behind knee, comes up thigh more anteriorly and medially, passes through saphenous opening to drain into femoral vein). ØShort saphenous vein (from dorsal venous arch, goes posterior to lateral malleolus, goes up posterior of leg, pierces fascia of popliteal fossa and drains into popliteal vein). ØPerforating veins ØSapheno-femoral junction ØBlood flow is from superficial to deep

Ulnar nerve (JAS)

ØEnters forearm below head of flexor carpi ulnaris ØSupplies FCU and medial FDP ØProximal to the wrist it gives off the ØPalmar cutaneous branch ØDorsal cutaneous branch ØAt the wrist, it is medial to the FCU and lateral to the ulnar artery

Supracondylar Fracture

ØFracture of the humerus above the epicondyles ØCaused by hyperextension of the humerus due to a fall ØCan tear, entrap or compress the brachial artery ØResults in compartment syndrome ØWill be covered in later sessions ØCan compress the median nerve

Median nerve (JAS)

ØMedial to the brachial artery at the level of the elbow ØCan be damaged by supracondylar elbow fractures or dislocations ØEnters forearm below head of pronator teres ØIt gives off the anterior interosseous nerve* which supplies the anterior compartment, except for? ØFlexor carpi ulnaris ØMedial flexor digitorum profundi ØAlso gives off a palmar cutaneous branch prior to the wrist ØEnters wrist through carpal tunnel

Root injury example: prolapsed intervertebral disc prolapse at L5/S1

ØMotor - loss of eversion ØSensory - loss of sensation outer border of foot ØReflex - loss of ankle jerk (S1) ØAutonomic - minimal

The Veins of the elbow, forearm and wrist

ØSuperficial and deep systems. ØCephalic vein (superficial) runs up lateral border of arm. ØBasilic vein (superficial) runs up the medial border of arm. ØBasilic veins joins venae comitantes to form the axillary vein in the arm. ØCephalic vein joins axillary vein in the axilla. ØAxillary vein becomes the subclavian vein at the level of the first rib. ØCephalic and Basilic veins arise from the dorsal venous arch of the hand. ØCommonly connected at the cubital fossa by the median cubital vein (not always present or prominent). ØMedian cubital vein is commonly used in phlebotomy. ØWhen median cubital vein is absent, cephalic or basilic in the region are used to take blood.

Varicose veins

ØValves in superficial, deep and perforating veins ØSapheno-femoral junction valve most important ØVenous "insufficiency" ØLipodermatosclerosis (skin thickening) (chronic inflammatory cause?) ØVenous ulcers - important in diabetics and older people

Anterior Compartment of the Leg

•Ankle Dorsiflexors (extensors - toes upwards) •supplied by Deep Peroneal Nerve. •Anterior Tibial Artery o Muscles: 1) Tibialis Anterior (acts acts across ankle joint and medial side of tarsals) 2) Extensor Digitorum Longus (acts on 4 digits) 3) Extensor hallucis Longus (acts on large toe) ** Anterior compartment muscles extend (dorsiflex) the foot at the ankle joint and extend the digits. Supplied by the deep branch of the peroneal nerve. Lateral compartment muscles evert the foot and can contribute to dorsiflexion (two muscles: peroneus/fibularis longus and brevis; attached on fibularis and tibia and tendons go behind lateral malleolus and down into foot); can also evert the foot.

Compartments of the knee, leg, ankle and foot

•Anterior compartment of the leg •Lateral compartment of the leg •Posterior compartment of the leg •Intrinsic muscles of the foot: -Sole - 4 layers -Dorsum - 2 muscles

Deep Venous Drainage - Anterior

•Anterior drainage of the hand is deep. •The superficial and deep palmar arches have venae comitantes. •These drain into the venae comitantes of the radial and ulnar arteries

Sensory Segmental Supply of knee, leg, ankle and foot

•Dermatomal distribution •"L3 to the knee and L4 to the floor" •L5 to the great toe •S1 to the lateral side of the foot •S1 to the sole of the foot § Each segment of skin supplied by a single spinal nerve is termed a dermatome. Each dermatome overlaps considerably, and thus mostly the loss of one spinal nerve is not appreciably noticed by the patient. However there are areas, termed axial lines, where the dermatomes are not linked at the spinal level e.g. S2 and L2 lie side by side in the posterior thigh.

Summary of limbs 1 lecture

•Embryological difference between upper limb and lower limb •Compartmentalised nature of the limbs •Arterial and venous supplies and drainage •Segmental innervation patterns •Peripheral innervation patterns •Nerve lesions

Posterior Tendinous Anatomy of the Hand

•Extensor retinaculum (at wrist; prevents bow stringing during exension, not quite as tough as flexor retinaculum). •Synovial tendon sheaths •Inter-tendinous bands •Extensor expansions •Lumbricals and interossei attach to the expansions •Extensor digitorum, EI, EDM **All the extensor tendons of the hand are held to the dorsum of the wrist region by the extensor retinaculum. o As on the palmar surface of the wrist, there are synovial tendon sheaths that surround the tendons that facilitate free movement of the tendons. Some of the synovial tendon sheaths are connected, some are individual. o On the dorsum of the hand, the long extensor tendons to the digits are joined by inter-tendinous bands. To some extent, these bands prevent free movement of one extensor tendon independently of the others. o At the level of the metacarpals the long extensor tendons flatten to form extensor expansions. These expansions form a hood on the back of the digit. The lumbricals and the interossei attach to this extensor expansion. The extensor expansions are intricately involved in the movements of the digits. o The extensor digitorum extends the MCP joint as well as the IP joints. It also plays some part in extending the wrist joint after maximal extension of the digits. The index finger and the little finger have their own individual long extensors.

Motor Peripheral Supply of knee, leg, ankle and foot

•Femoral nerve : Knee Extensors •Sciatic Nerve : Hamstrings (knee flexors) •Tibial nerve : Posterior Compartment and Foot intrinsics •Common Peroneal Nerve : Anterior and Lateral Compartments § The sciatic nerve runs down the back of the thigh and divides inconstantly into the tibial nerve and the common peroneal nerve. The sciatic nerve "proper" supplies the hamstrings. § The tibial nerve supplies all the muscles of the posterior compartment of the leg. After passing behind the medial malleolus it divides into the medial plantar nerve and the lateral plantar nerve. The plantar nerves supply all the intrinsic muscles of the foot except extensor digitorum brevis. § The common peroneal nerve winds around the neck of the fibula where it may be easily damaged. It supplies the anterior and lateral compartments of the leg. The common peroneal nerve divides into the deep peroneal nerve (supplies the anterior compartment) and the superficial peroneal nerve (supplies the lateral compartment).

Anterior Tendinous Anatomy of the Hand

•Fibrous digital sheath •Osseo-fibrous tunnels •In the tunnels run the long flexor tendons and their synovial sheaths •Annular and cruciform pulleys ** •FDP and FDS tendons pass in the carpal tunnel beneath the flexor retinaculum •...enter a common synovial sheath •...enter a digital synovial sheath, within its own fibrous digital sheath (synovial sheath help lubricate and prevent friction) •Little finger and thumb sheaths continuous •FDS splits around FDP •FDS to MIDDLE phalanx, FDP to DISTAL phalanx **In pic - purple is synovial sheath. FDP and FDS and flexor pollicus longus go through carpal tunnel ** little fingers digital sheath is continuous with one going through carpal tunnel. ** in synovial sheath of digit have synovial lining tunnel and lining of tendon that is joined by mesotendon. **As explained above the fibrous digital sheaths are a continuation of the palmar fascia. These sheaths extend from the level of the metacarpal head to the base of the distal phalanx in each digit. Together with the underlying bone they form osseo-fibrous tunnels through which the long flexor tendons and their synovial sheaths run. Parts of the fibrous digital sheath form condensations called pulleys, which allow for more functional use of the long flexor tendons. These are called the annular and cruciform pulleys. o Just after passing the wrist joint, the tendons of FDP and FDS pass deep to the flexor retinaculum and enter a common synovial sheath. The tendons then pass to their respective digit via a digital synovial sheath, which is contained within the fibrous digital sheath. The digital synovial sheaths of the index, middle and ring fingers are separate from the common synovial sheath. Those of the little finger and the thumb are usually continuous with the common sheath. o At the base of the proximal phalanx the FDS tendon splits around the FDP. The FDS attaches to the anterior surface of the middle phalanx whilst the FDP attaches to the distal phalanx. o The long tendon of the thumb, flexor pollicis longus, has its own synovial sheath at the flexor retinaculum. It then runs to the distal phalanx of the thumb.

Visualising adductor canal

•Formed by: a) Vastus medialis (anteriorly) b) Adductor longus and adductor magnus (posteriorly) c) Sartorius (medially). Sartorius curves around medially to become the anterior border of the adductor canal. d) terminates at adductor hiatus

Greater and Lesser Sciatic Foramina contents

•Greater sciatic foramen: structures passing from the pelvis to the THIGH. •Lesser sciatic foramen: structures passing from the pelvis to the PERINEUM. •The Sciatic Nerve!

Foramens, notches and ligaments in gluteal region

•Greater sciatic notch •Lesser sciatic notch •Greater sciatic foramen and lesser sciatic foramen •Sacrotuberous ligament •Sacrospinous ligament o Important ligaments are present in the gluteal region connecting the bones of the region and providing passageway from nerves and vessels. o The greater sciatic notch and the lesser sciatic notch (parts of the ischial bone) are converted to the greater sciatic foramen and the lesser sciatic foramen by the sacrotuberous ligament and the sacro-spinous ligament. o The greater sciatic notch transmits the structures leaving the pelvis to the lower limb and this includes the sciatic nerve. o The lesser sciatic notch transmits the structures passing from the pelvis to the perineum. o It is important to appreciate the course of the sciatic nerve in the buttock and thigh. It passes through the greater sciatic notch to pass from the pelvis into the buttock. The nerve passes through the buttock and on the posterior aspect of the thigh to divide at a very inconstant level into the tibial nerve and the common peroneal nerve. The sciatic nerve itself supplies the hamstring muscles whereas its divisions supply all the muscles below the level of the knee. If the buttock area is divided into quadrants, the nerve lies in the inferior and medial quadrant. If giving an injection into the buttock always give the injection in the superior and lateral quadrant to minimise the risk of damaging the sciatic nerve.

Segmental motor supply to the limbs

•Groups of motor nerve cell bodies in the spinal cord •C5-T1 = upper limb •L2-S3 = lower limb •Plexi for each limb •Anterior divisions of anterior rami supply FLEXOR muscles •Posterior divisions of anterior rami spinal nerves supply EXTENSOR muscles *muscles are supplied by two adjacent segments. o Same action on joint = same nerve supply o Opposing muscles nerves (flex vs. extend) are 1-2 segments above or below each other. o Muscles more distal in the limb have nerves originating more caudal in the spine (closer to tail).

Segmental motor supply to the lower limb

•HIP: a) Flex= L2, L3 b) Extend= L4, L5 •KNEE: a) Extend = L3, L4 b) Flex = L5, S1 •ANKLE: a) Dorsiflex= L4, L5 b) Plantarflex = S1, S2

Identify on a skeleton: •Bones •Femur •Patella •Tibia/fibula •Tarsal bones •Metatarsals •Phalanges

•Important bony features •Greater trochanter of femur •Proximal head of fibula •lateral and medial malleoli at ankle •Sesamoid bones at the 1st MPJ •General organisation of the foot arches

intramembranous ossification

•In existing vascular connective tissue •Bone matrix (ostein) deposited around collagen •Mineralises to form woven bone •Remodels to lamellar bone e.g. flat bones and mandible

Deep veins of pectoral girdle

Veins of the pectoral girdle?

•In limbs, venous return is via superficial and deep vessels: 1.Cephalic vein (superficial) runs up lateral border of arm 2.Basilic vein (superficial) runs up the medial border of arm 3.Basilic veins joins venae comitantes to form the axillary vein in the arm 4.Cephalic vein joins axillary vein in the axilla 5.Axillary vein becomes the subclavian vein at the level of the first rib **Superficial - originated from dorsal venous network at the back of the hand: a) Basilic - draining medial part b) Cephalic - draining lateral part ** Deep: The venae comitantes of the brachial artery (brachial veins). Basilic pierces the deep fascia midway up arm to join the brachial veins forming the axillary vein at the inferior border of teres major This is the same landmark as when axillary artery becomes brachial. Cephalic dives in to join the axillary vein

Superficial veins of pectoral girdle

•In limbs, venous return is via superficial and deep vessels: o dorsal venous network in head that forms cephalic and basilic vein. 1.Cephalic vein (superficial) runs up lateral border of arm 2.Basilic vein (superficial) runs up the medial border of arm 3.Basilic veins joins venae comitantes to form the axillary vein in the arm 4.Cephalic vein goes up and passes through dectopectoral groove and joins axillary vein in the axilla 5.Axillary vein becomes the subclavian vein at the level of the first rib **sometimes have median cubital vein between cephalic and basilic useful for taking bloods. **The axillary vein receives a large number of tributaries, including the cephalic vein (the other superficial vein of the arm) and the lateral thoracic vein. The thoracoepigastric vein connects the superficial epigastric vein to the lateral thoracic vein and can act as a shunt for blood if the portal system develops hypertension or blockage, e.g. by tumour. o The cephalic vein and the basilic vein are the superficial veins of the forearm and arm. The cephalic vein ascends on the lateral aspect of the forearm and arm and terminates by passing deep in the delto-pectoral groove to join the axillary vein. The basilic vein asends on the medial side of the forearm and arm and passes deep halfway to form the axillary vein with the venae comitantes of the brachial artery as described above.

Main function of rotator cuff and shoulder joint?

•Main function is to hold the humeral head within the glenoid •The rotator cuff depresses the humeral head (hold it in).

Endochondral ossification and growth in bone length

•Most long bones must support large forces while growing •These would disrupt terminal appositional growth (growing at ends) Solution? •Shaft ossifies first, followed by epiphyses •Growth continues by ossification at growing cartilage plate between them •Growth cessation when cartilage growth ceases and plate is over-run by ossification. *diagram: 1. Cartilage model forms 2. Cartilage model grows (calcification and cells dying) 3. Primary ossification centre forms - start to get BVs and osteoclasts remodelling calcified bone 4. Medullary cavity forms and develops. 5. Secondary ossification centre forms - more BVs 6. Epiphyseal plate forms which is a cartilage plate that enables bone elongation growth. a. Note that in young children, they will have what appears to be breaks in the bones on X-ray but these are just epiphyseal plates. b. These epiphyseal plates ossify in the 2nd year but remain cartilaginous until after puberty. § Bone can do all this due to - large blood supply, osteocyte/osteoblast interactions and bone creation, osteoclast destruction.

Assessment of Nerve Function with Root Injury e.g. from Prolapsed intervertebral disc at L5/S1.

•Motor - loss of eversion (can't turn sole of foot outwards) •Sensory - loss of sensation outer border of foot •Reflex - loss of ankle jerk (S1) •Autonomic - minimal (n/a)

The Nerve Supples of the knee, leg, ankle and foot

•Motor Segmental Supply •Motor Peripheral Supply •Sensory Segmental Supply •Sensory Peripheral Supply

The Nerve Supplies of the hip, buttock and thigh

•Motor Segmental Supply •Motor Peripheral Supply •Sensory Segmental Supply •Sensory Peripheral Supply

Principles of the segmental supplies

•Muscles supplied by two adjacent segments •Same action on joint = means generally same nerve supply •Opposing muscles are generally 1-2 segments above or below in spinal cord •More distal in limb = more caudal in spine are the roots

Age-related changes in the appearance of normal bones

•Note that in young children, they will have what appears to be breaks in the bones on X-ray but these are just epiphyseal plates. o In child's wrist (lower) epiphyses ossify in 2nd year. •Epiphyseal plates (dark) remain cartilaginous until growth ceases after puberty o cartilage appears dark o wrist bones look really far apart in child but there's lots of cartilage surrounding which hasn't fully ossiffied yet. o if child breaks bone and damages epiphyseal plate, can affect growth so can put special scaffold to elongate artificially and achieve more even growth

What does sciatic nerve divide into?

•Passes from pelvis to buttock via GREATER sciatic notch/foramen •In the buttock, lies in the INFERIOR and MEDIAL quadrant •Passes along POSTERIOR aspect of the thigh •Divides into the TIBIAL and the COMMON PERONEAL nerve (inconstant level) •Supplies all the HAMSTRING muscles and all the muscles BELOW the level of the knee •If injecting in the buttock, use the SUPERIOR and LATERAL quadrant

The Sciatic Nerve

•Passes from pelvis to buttock via greater sciatic notch/foramen •In the buttock lies in the inferior and medial quadrant •Passes along posterior aspect of the thigh •Divides into the tibial nerve and the common peroneal nerve inconstantly •Supplies all the hamstring muscles and all the muscles below the level of the knee •If injecting in the buttock, use the superior and lateral quadrant § (L4L5S1S2S3) § The sciatic nerve is the formation of two separate nerves, the tibial nerve and the common peroneal nerve. It is very important clinically. § The nerve passes through the greater sciatic foramen, behind the hip joint in the buttock. It then passes in the posterior compartment of the thigh and divides (variably), usually just above the knee joint, into the tibial nerve and the common peroneal nerve. § The sciatic nerve proper supplies the hamstring muscles in the posterior compartment of the thigh. It also has some sensory branches to the back of the thigh.

Superficial Venous Drainage - Posterior

•Posterior drainage of the hand is superficial. •Dorsal digital veins drain into the dorsal venous arch •Then form the veins of the forearm: ØCephalic vein (laterally, through the anatomical snuffbox) ØBasilic vein (medially)

Ankle and foot joints

•Proximal and Distal Tibio-Fibular Joints •Ankle Joint •Subtalar Joint •Midtarsal Joint •Metatarso-phalangeal joints •Interphalangeal Joints

Cut-down of the LSV at medial malleolus

•Shocked patient, ATLS •2cm lateral and proximal to medial malleolus. Not used as much today. Has been superseded by intraosseous administration of fluids. (A needle is inserted into a bones marrow space and fluid infused into the circulation by this route) In well-equipped facilities, ultrasound can be used to find a patent vein.

Functions of Bone

•Support of the body shape •System of levers for muscle action •Protection of internal organs (e.g. thoracic cage for heart and lungs) •Site of blood cell formation (bone marrow) •Mineral storage pool (esp. calcium)

What are hip fractures classified as?

•Synovial ball and socket joint •Head of the femur and the acetabulum •Acetabular labrum •Transverse acetabular ligament •Capsule of the hip joint -Extends further anteriorly than posteriorly -Within capsule runs the blood supply of the femur head -Hip fractures are classified intracapsular and extracapsular

What type of joint is hip joint?

•Synovial ball and socket joint •between the head of the femur and the acetabulum •Acetabular labrum (deepens the socket) •Transverse acetabular ligament •Capsule of the hip joint: -Extends further anteriorly than posteriorly -Within capsule runs the blood supply of the femur head -Hip fractures are classified intracapsular and extracapsular. **This is a synovial ball and socket joint between the head of the femur and the acetabulum. Around the rim of the bony acetabulum is a rim of tissue called the acetabular labrum. There is also a transverse acetabular ligament within the acetabulum. The capsule of the hip joint extends down the neck of the femur. Anteriorly it extends further than posteriorly. Within the capsule runs an important blood supply to the head of the femur. Hip fractures are described as intracapsular and extracapsular to reflect this differential blood supply disruption. There are a number of important ligaments at the hip joint; 1. The ilio-femoral ligament; 2. The pubo-femoral ligament; 3. The ischio-femoral ligament; 4. The ligament of the had of the femur. The blood supply of the hip joint is derived from the medial and lateral circumflex arteries plus, insignificantly in the adult but significant in the child, the artery of the head of the femur. The circumflex vessels are the main blood supply in the adult and are easily damaged in intracapsular fractures of the proximal femur.

Intrinsic Muscles of the Hand - Innervation

•The deep branch* of the ulnar nerve supplies almost all of the muscles of the hand •The median nerve supplies the thenar eminence and the lateral two lumbricals •This can be remembered by LOAF: •Lateral 2 lumbricals •Opponens pollicis •Abductor pollicis brevis •Flexor pollicis brevis

Bones of the knee, leg, ankle and foot

•The femur •The tibia (more substantial; articulates with fibula, separated by interosseus membrane) •The fibula •The patella •The bones of the foot **tibial condyles (medial and lateral), intercondylar area, tibial plateau. tibial tuberosity (attachment for patellar tendon) **malleoli at distal end that forms part of ankle joint.

Compartments in Limb Anatomy

•The limbs are divided into compartments: a) Compartments tend to have a distinct function b) Compartments tend to have the same nerve supply c)Compartments tend to have the same blood supply o Upper limb compartments include a) - pectoral (chest) girdle muscles b) intrinsic shoulder muscles, c) anterior (upper) arm muscles - flexors d) posterior (upper) arm muscles - extensors e) anterior forearm muscles - flexors, f) posterior forearm muscles - extensors g) intrinsic hand muscles. o Lower limb compartments include - a) hip abductors/extensors/flexors b), anterior/medial/posterior thigh muscles, c) anterior/lateral/posterior leg muscles d) intrinsic foot muscles.

Fascia of the hips, buttock and thigh

•There are two layers of fascia -Superficial fascia - i.e. subcutaneous tissue -Deep fascia - in the thigh called fascia lata •Fascia lata extends like a stocking beneath the skin - holds muscle compartments within them. •A lateral thickened area of it is called the ILIO-TIBIAL tract - runs inferiorly to merge with fascia just below the kneep

Common Peroneal Nerve

•Winds around the neck of the fibula § L4-S2 § Division of the sciatic nerve § Innervates short head of the biceps femoris § Exits the popliteal fossa laterally **Divides into: a) Superficial peroneal: ØSupplies the lateral compartment of the leg ØSensory cutaneous innervation of lateral leg to the dorsum of the foot b) Deep peroneal: ØInnervates the anterior compartment of the leg ØPasses into the dorsum of foot under the extensor retinaculum (with the dorsalis pedis and deep peroneal vein) ØInnervates one muscle in the dorsum of foot: ØExtensor Digitorum Brevis ØSmall patch of cutaneous innervation in the 1st dorsal web space

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