Anatomy Flashcards
(286 cards)
1
Q
What are the components of the pectoral region?
A
The pectoral region is the front of the upper part of the trunk
It includes:
-Pectoralis major m.
-Pectoralis minor m.
-Subclavius m.
-Clavipectoral fascia
2
Q
What are the components of the upper part of the trunk?
A
-Clavipectoral triangle
-Cephalic vein
-Deltoid m.
-Pectoralis major
-Clavicular head
-Sternocoastal part
3
Q
What is the origin, insertion and nerve supply of the Pectoralis major muscle
A
Origin:
From the front of the trunk
Insertion:
Bicipital groove of humerus
Nerve supply:
Medial and lateral pectoral nerves
4
Q
What are the actions of Pectoralis major muscle?
A
-Flexion of the shoulder
-Adduction of the shoulder
-Medial rotation
-Elevates the trunk during climbing
5
Q
What is the importance of the Pectoralis major muscle?
A
-It is important in case of fixation of the humerus
-It acts as an accessory inspiratoria muscle
-It helps in climbing and swimming
6
Q
What is the origin, insertion, nerve supply and actions of the Pectoralis minor muscle?
A
Origin:
Front of the trunk
Insertion:
Caracoid process of scapula (medial aspect)
Nerve supply:
Medial pectoral nerve
Actions:
-Protraction of the shoulder
-Depression of the shoulder
7
Q
What is the nerve supply and action of the subclavius muscle?
A
Nerve supply:
Nerve to subclavius
Action:
Steadies the clavicle and fixes it to the first rib during movement of upper limb
8
Q
What is the nerve supply, attachments and actions of the deltoid muscle?
A
Attachments:
From the lateral part of the clavicle and spine of the scapula (origin) to the deltoid tuberosity (insertion)
Nerve supply:
Axilary nerve (C5, C6)
Action:
-Anterior fibres: flexion and medial rotation of the humerus
-Middle fibres: abduction from 8-90 degrees
-posterior fibres: extension and lateral rotation of the humerus
9
Q
Give the clinical correlation of the deltoid muscle
A
Injury of the axillary nerve leads to paralysis of the deltoid muscle which leads to flattening of the shoulder
10
Q
What are the components of the superficial layer of the back muscles?
A
-Trapezius
-Latissimus dori
11
Q
Describe the trapezius muscle (mention the attachments, insertion, nerve supply and actions)
A
Attachments:
Attached to the Cervical and upper thoracic spines
Insertion:
Lateral part of the clavicle, acrimon and spine of scapula
Nerve supply:
Spinal part of accessory nerve (CN XI)
Action:
The upper fibres elevate the shoulder
The lower fibres depress the scapula
The middle fibres retract the shoulder
It rotates the scapula so that the glenoid cavity faces upwards. This occurs when the arm is raised above the head
12
Q
Describe the latissimus dorsi muscle (mention the attachments, insertion, nerve supply and actions)
A
Attachments:
Attached to the lower part of the back
Insertion:
Bicipital groove
Nerve supply:
Nerve to latissmus dorsi
Actions:
-Adducts, extends and medially rotates the arm
-Climbing, swimming (when the arms are fixed above the head)
13
Q
What are the components of the deep layer of the back muscles?
A
-Levator scapulae
-Rhomboideus minor
-Rhomboideus major muscles
14
Q
Deceive the Levator scapulae and rhomboid muscles (mention the attachments, insertion, nerve supply and actions)
A
Attachments:
They are attached from the middle of the upper part of the back to the medial border of the scapula
Nerve supply:
Dorsal scapulae nerve (nerve to Rhomboids)
Action:
-Levator scapulae elevates the scapula
-The rhomboids retract the scapula
-The rhomboids rotate the scapula so that the glenoid cavity faces downwards (depresses the shoulder)
15
Q
Mention how paralysis of the trapezius muscle occurs
A
Cause:
The main cause of trapezius palsy is injury to the spinal accessory nerve. The superficial location of the spinal accessory nerve, in the posterior triangle makes it vulnerable to injury.
Paralysis of the trapezius muscle leads to a drop shoulder with rotation of the angle of the scapula towards the midline and restricted abduction of the arm
16
Q
A
17
Q
A
18
Q
What are the scapular muscles?
A
-Supraspinatus
-Infraspinatus
-Subscapularis
-Teres minor
-Teres major
19
Q
What is the origin and insertion (attachments) of the scapular muscles?
A
Origin:
-All scapular muscles are attached to the back of the scapula except subscapularis which is attached to the front of the scapula
-The supra and infraspinatous muscles are attached on both sides of the spine of the scapula
-Teres minor and major are attached to the lateral border below each other
Insertion:
-Supra, infraspinatous and Teres minor are inserted in the greater tuberosity of the humerus
-Subscapularis is inserted in the lesser tuberosity
-Teres major is inserted in the Bicipital groove.
20
Q
What are the muscles attached to the Bicipital groove?
A
-Pectoralis major
-Teres major
-Latissimus dorsi
21
Q
What is the nerve supply of the scapular muscles?
A
-Supra and infraspinatous muscles are supplied by the suprascapular nerve (C5,6)
-Teres minor by axillary nerve (C5,6)
-Teres major by the lower subscapular nerve (C5,6)
-Subscapularis by the upper and lower subscapular nerve (C5,6)
22
Q
What is the action of the scapular muscles?
A
Supraspinatous: initiation of abduction
Infraspinatous: lateral rotation of the arm
Teres minor: lateral rotation of the arm
Teres major: medial rotation, adduction and extension of the arm
Subscapularis: medial rotation of the arm
23
Q
What are the rotator cuff muscles?
A
Rotator cuff muscles surround the shoulder joint, they include:
-Subscapularis
-Supraspinatous
-Infraspinatous
-Teres minor
24
Q
What is the nerve supply and action of the serratus anterior muscle?
A
It is attached from the upper ribs to the front of the medial border of the scapula
Nerve supply:
-Long thoracic nerve (nerve to serratus anterior) (C5,6,7)
Action:
-Protraction of the scapula
-Raising the arm above the head (it lowers fibres and the trapezius
25
What are the causes of winging of the scapula (clinical correlations)?
The long thoracic nerve descends over the serratus anterior and deep to the mammary gland, this explains why the nerve is liable to be injured during mastectomy.
It’s injury leads to projection of the medial border of the scapula (winging of the scapula)
26
How does abduction of the shoulder occur?
Initiation of abduction: (0-18 degrees) Supraspinatous
Completion up to middle fibres of deltoid (90 degrees)
Above 90 degrees: rotational movement of the scapula rather than abduction of the shoulder taken by the trapezius and serratus anterior
27
Identify the boundaries and contents of the intermuscular quadrangular space
Boundaries:
Teres major
Teres minor
Long head of the triceps brachii
Surgical neck of the humerus
Contents:
It transmits the axillary nerve and posterior circumflex humeral artery
28
What are the boundaries and contents of the medial triangular space?
Boundaries:
Teres minor
Teres major
Long head of the triceps
Contents:
It contains the circumflex scapular vessels
29
What are the boundaries and contents of the lateral triangular space?
Boundaries:
Teres major
Long head of the triceps
Humerus
Contents:
Radial nerve and profunda brachii artery
30
Describe the shoulder joint
Type:
Synovial, ball and socket
Articular surface:
Head of humerus
Glenoid cavity of scapula
-each of the articular surfaces is covered by hyaline cartilage
-the glenoid cavity is deepened by a fibro-cartilaginous rim; labrum glenoidale
31
What are the attachments of the capsule?
Medially it is attached to the circumference of glenoid cavity outside labrum glenoidale
Laterally the capsule is attached to the anatomical neck of the humerus
32
What structures does the synovial membrane line?
It lines all structures inside the capsule except for the articular cartilage
33
What are the ligaments related to the shoulder joint?
False ligaments:
-They are the thickening of the capsule of the shoulder joint (glenohumeral ligaments)
True ligaments:
-Coraco- humeral ligament
-Transverse humeral ligament (bridges over the bicepetal groove)
34
What are the factors that support the capsule?
1) Rotator cuff:
-Supraspinatous (superiorly)
-Infraspinatous and Teres minor (posteriorly)
-Subscapularis (anteriorly)
2) Tendon of the long head of the triceps and biceps
3)Ligaments:
-Coracohumeral ligament
-Glenohumeral ligament
-Transverse humeral ligament
35
What are the movements of the shoulder joint?
-Flexion (Pectoralis major, deltoid, coracobrachialis, long head of biceps)
-Extension (deltoid, latissimus dorsi, Teres major)
-Abduction( from 0 -15: Supraspinatous, 15-90: middle fibres of deltoid and 90-180: trapezius and serratus anterior)
-Adduction (muscles inserted into bicipital groove, muscles inserted into lesser and greater tuberosities)
-Medial rotation (anterior fibres of deltoid, muscles inserted into bicipital groove, subscapularis)
-lateral rotation (deltoid, infraspinatous and Teres minor)
-Circumduction
36
Describe how dislocation occurs
The most common site for dislocation of a joint is through the inferior aspect of the capsule which is the least supported part during raising of the arm above the head
The dislocation of the head of the humerus downwards into the quadrangular space may lead to injury of the axillary nerve and the posterior circumflex humeral artery.
37
Describe the fascia compartments of the arm
Medial and lateral borders of the humerus are attached to medial and lateral intermuscular septa which in turn are attached to the deep fascia of the arm, dividing it into anterior and posterior compartments.
38
What are the muscles of the anterior compartment?
-Coracobrachialis
-Biceps
-Brachialis
39
Identify the origin, insertion, nerve supply and the action of the coracobrachialis
Origin:
From the tip of the coracoid process of the scapula (with short head of biceps)
Insertion:
Into the middle of the medial side of the shaft of the humerus
Nerve supply:
Musculotaneous nerve
Action:
Flexion of the shoulder joint
40
Identify the origin and insertion of the biceps brachii
Origin:
Long head: from the supraglenoid tubercle of the scapula
Short head: from the tip of the coracoid process of the scapula
Insertion:
-into radial tuberosity of the radius
-forms the Bicipital aponeurosis which is inserted into the deep fascia of the upper part of the medial side of the forearm
41
Identify the nerve supply and action of the biceps brachii
Nerve supply:
From the musculotaneous nerve
Action:
-supination of the forearm at the radio-ulnar joints
-flexion of the forearm at the elbow joint
-weak flexion of the shoulder joint
42
Identify the origin, insertion, nerve supply and action of the brachialis muscle
Origin:
From the lower half of the anterior surface of the shaft of the humerus
Insertion:
Into the coronoif process of the ulna
Nerve supply:
-mainly from the musculotaneous nerve
-small part by the radial nerve
Action:
Flexion of the elbow joint
43
What are the veins of the arm?
Deep veins: venae comitantes which accompany the arteries and axillary vein
Superficial vein:
-cephalic vein:
Runs on the lateral side of the arm and ends by piercing the Clavipectoral fascia to join the axillary vein
-basilic vein:
Runs on the medial side of the arm till it’s middle then pierced the deep fascia to join the 2 venae comitantes of the brachial artery to form the axillary artery
-median cubital vein:
Connects them
44
Describe the beginning, end and course of the brachial artery
Beginning: at the lower border of Teres major as a continuation of the axillary artery (continuation of subclavian artery at border of the 1st rib)
End: in the cubical fossa at the level of the neck of the radius by dividing into its two terminal branches ; radial and ulnar arteries
Course: the upper part of the artery runs medial to the humerus, while the lower part becomes anterior to the bone
45
What are the beaches of the brachial artery?
-Profunda brachii artery: (The largest and most important)
It passes between the medial and long heads of the triceps to enter the lower triangular space (with the radial nerve). Then it passes in the spiral groove
-Muscular branches
-Nutrient artery: to the humerus
-Superior ulnar collateral artery
-Inferior ulnar collateral artery: which share in anastomosis around the elbow
-Terminal branches:
Radial artery
Ulnar artery
46
What is the origin and insertion of the triceps muscle?
Origin:
-Long head: from the infra glenoid tubercle of the scapula
-lateral head: above the spiral groove
-Medial head: lower half of the posterior surface of the humerus, below the spiral groove (is similar to brachialis but from behind)
Insertion:
The 3 heads unite and are inserted into the posterior part of the upper surface of the olecranon process of the ulna
47
What is the nerve supply and action of the triceps muscle?
Nerve supply:
Radial nerve
Action:
-Main extensor of the elbow
-Long head: supports the shoulder joint during adduction
48
What are the consequences of paralysis of the biceps and triceps muscles?
Biceps:
Biceps is the main supination of the forearm so paralysis of the biceps muscle leads to weak supination
Triceps:
Triceps is the main extensor of the elbow joint so it’s paralysis leads to loss of extension of the elbow
49
What is the site and boundaries of the cubital fossa?
Site: a triangular fascial space in front of the elbow joint
Boundaries:
-Medially: Pronator Teres muscle
-Laterally: Brachioradialis muscle
-Base: Imaginary line between the medial and lateral epicondyles of the humerus
50
What are the structures on the roof and floor of the cubital fossa and mention it’s contents?
Roof:
-Skin
-Superficial fascia (which contains medial, median cubital veins, medial and lateral cutaneous nerves of the forearm and the deep fascia and Bicipital aponeurosis)
Floor:
-Brachialis (medially)
-Supinator (laterally)
Contents (from medial to lateral);
-Median nerve
-End of brachial and beginning of the radial and ulnar arteries
-Biceps brachii tendon
-Radial nerve
51
How many layers does each forearm compartment have?
Flexor compartment: 3 layers
Superficial, middle and deep
Extensor compartment: 2 layers
Superficial and deep
52
What are the muscles of the superficial layer of the flexor compartment?
From the lateral to medial side:
-Pronator Teres
-Flexor carpi radialis
-Palmaris Longus
-Flexor carpi ulnaris
53
What is the origin and course of the muscles of the superficial layer?
Origin: common flexor origin
Front of medial epicondyle of the humerus
Course: the muscles pass deep to the flexor retinaculum except the pronator Teres (ends at the middle of the forearm) and the palmaris Longus
54
55
What are the bones and joints of the hand?
Bones:
-Carpal bones: 8 bones arranged in 2 rows
-Metacarpal bones: 5 bones; one for each finger
-Phalanges: proximal, middle and distal except the thumb that has proximal and distal only
Joints:
-Carpometacarpal
-Metacarpophalangeal
-Proximal and distal interphalangeal
56
Describe the course of the palmaris Longus muscle
Palmaris Longus muscle passes superficial to the flexor retinaculum to be inserted into the palmar aponeurosis. It may be absent
Palmar aponeurosis is a thick triangular fibrous sheet on the palm of the hand deep to the skin for protection of the palm
57
Identify the muscles of the deep layer
It is composed of 3 muscles:
-Flexor pollicis longus (lateral)
-Flexor digitorum profundus (medial)
-Pronator quadratus (deep)
The muscles pass deep to the flexor retinaculum except the Pronator quadratus
They originate from the anterior surfaces of the radius and ulna
58
59
What is the origin, insertion, nerve supply and action of the middle layer?
It is made up of only one muscle:
Flexor digitorum superficialis muscle
Origin:
Common flexor origin
It passes deep to the flexor retinaculum
Insertion:
Middle phalanx of the medial 4 fingers
Nerve supply:
Median nerve
Action:
-Flexion of elbow joint
-Flexion of wrist joint
-Flexion of the metacarpophalangeal and proximal interphalangeal joints of the medial 4 fingers
60
Describe the flexor digitorum muscles
The tendon of the flexor digitorum superficialis is inserted into the middle phalanx and splits to allow the tendon of flexor digitorum profundus to pass to be inserted into the distal phalanx
61
What are the attachments and the structures passing superficial to the flexor retinaculum muscle?
It is a fibrous sheet in front of the wrist joint
Attachments:
-Medially to the pisiform and hamate bones
-Laterally to the scaphoid and trapezium bones
Structures passing superficial to it:
-Tendon of palmaris Longus
-Ulnar artery
-Ulnar nerve
-Superficial palmar branch of radial artery
62
What is the carpal tunnel?
-It is a tunnel connecting the forearm and the hand
-It is bounded by the flexor retinaculum anteriorly and the carpal bones posteriorly
-The tendon of palmaris Longus passes surperficial to the flexor retinaculum
63
What are the structures that pass through the carpal tunnel?
-Median nerve
-Long flexor tendons to the fingers: flexor digitorum superficialis and profundus and the flexor pollicis Longus
-Flexor carpi radialis (in a separate compartment)
64
What happens when the median nerve in the carpal tunnel is compressed?
-Pin and needle sensation in the skin supplied by it
-Wasting of the hand muscles supplied by it
It may be compressed due to:
-Arthritic changes of the bones
-Swelling of the tendons
65
Describe the elbow joint
Type: synovial joint (hinge)
Articulate bones:
-Trochlea and capitulum of the humerus
-Trochlear notch of the ulna
-Head of the radius
Movements:
-Flexion : Biceps brachii, Brachialis and all superficial and deep layers of the flexor muscles of the forearm
-Extension: triceps brachii and anconeus
66
What are the ligaments of the elbow joint?
-Ulnar (medial) collateral ligament:
It is triangular in shape with 3 bands (anterior, posterior and transverse bands)
-Radial (lateral) collateral ligament:
It extends from the lateral epicondyle of the humerus to the annular ligament ( surrounds the head of the radius)
67
What are the clinical notes of the elbow joint?
In normal extended elbow joint:
Medial and lateral epicondyles and top of olecranon process are in one straight line
With flexion: they form a triangle
Tennis elbow: overuse and micro tears of the common extensor tendon and muscles of the forearm cause pain in the lateral side of the elbow
68
What are the radial and ulnar arteries?
They are the terminal branches of the brachial artery in the cubital fossa opposite the neck of the radius
69
Describe the radial artery
It runs in the lateral side of the forearm with the radial nerve on its lateral side deep to the brachioradialis muscle
It winds round the lateral side of the wrist to the dor sun of the hand where it pierced muscles to enter the palm.
Branches:
-Muscular artery
-Articular artery to the elbow joint
-Anterior carpal branch
-Dorsal carpal branch
-Superficial palmar branch that passes superficial to the flexor retinaculum
70
Where can you feel pulsations of the radial artery
In the lower part of the front of the forearm against the lower part of the radius
71
Describe the ulnar artery
It runs in the medial side of the forearm with the ulnar nerve on its medial side deep to the flexor carpi ulnaris muscle
It passes superficial to the flexor retinaculum to enter the palm of the hand where it gives superficial and deep branches
Branches:
-Muscular artery
-Articular to the elbow and wrist joints
-Anterior carpal branch
-Dorsal carpal branch
-Terminal branches (superficial and deep)
72
Describe the anastomosis around the elbow joint
Branches of the brachial and profunda brachii arteries anastomose with branches of the radial and ulnar arteries around the elbow joint
Importance: if the lower part of the brachial artery is occluded, blood will reach the forearm through this anastomosis
73
Identify the muscles of the superficial layer of the extensor muscles
The muscles arranged from the lateral side medially:
-Brachioradialis
-Extensor carpi radialis longus
-Extensor carpi radialis brevis
-Extensor carpi digitorum
-Extensor digiti minimi
-Extensor carpi ulnaris
-Anconeus (small muscle on the back of the elbow)
74
What is the origin of the brachioradialis and extensor carpi radialis Longus?
The 2 most lateral muscles brachioradialis and extensor carpi radialis longus originate from the lateral supracondylar ridge (flex elbow joint)
75
What is the origin of the muscles of the superficial layer of the extensor muscle?
All muscles (except for Brachioradialis and extensor carpi radialis longus and the anconeus) originate from the common extensor origin (front of the epicondyle)
76
What is the origin of the anconeus muscle?
The anconeus arises from the back of the lateral epicondyle
77
78
What are the muscles of the deep layer of the extensor muscles?
-Abductor pollicis Longus
-Extensor pollicis brevis
-Extensor pollicis Longus
-Extensor indicis
-Supinator
79
What is the origin of the muscles of the deep layer of the extensor muscles?
They all originate from the back of the radius and ulna (no action on the elbow joint)
80
81
82
What are the attachments of the extensor retinaculum?
It is a fibrous sheet extending on the back of the wrist. It helps to keep the extensor tendons and prevents them from bowing
Attachments:
-Laterally: anterior border of radius
-Medially: triquetrum and pisiform
83
What are the structures deep to the extensor reticulum?
The space deep to it is divided into 6 compartments:
Compartment 1:
-Extensor pollicis brevis
-Abductor pollicis Longus
Compartment 2:
-Extensor carpi radialis brevis
-Extensor carpi radialis longus
Compartment 3:
-Extensor pollicis longus
Compartment 4:
-Extensor digitorum
-Extensor indicis
Compartment 5:
-Extensor digiti minimi
Compartment 6:
-Extensor carpi ulnaris
84
Describe the superior radioulnar joint
Type: synovial pivot
Articulate bones:
-Head of radius
-Radial notch of ulna
-Annular ligament (attached to the radial notch of ulna and surrounds the head of the radius)
85
Describe the movements of the superior radioulnar joint
Supination:
-biceps brachii
-Supinator
Pronation:
-Pronator Teres
-Pronator quadratus
86
What is the mobile bone during supination and pronation?
The radius
87
How does the superior radioulnar joint gain its stability?
The stability of the superior radioulnar joint depends upon the strength of the annular ligament
Rupture of the ligament leads to dislocation of the joint
Infection of the elbow joint may spread to the superior radioulnar joint as they are continuous
88
Describe the inferior radioulnar joint
Type: Synovial pivot
Articulate bones:
-Head of ulna
-ulnar notch of radius
-Articular disc that lies on the lower surface of the ulnar head
Movements: supination and pronation
The inferior radioulnar joint is not continuous with the wrist notch
89
What are the carpal bones of the hand?
There are 8 carpal bones arranged in 2 rows:
The proximal row:
-Scaphoid
-Lunate
-Teiquetrum
-Pisiform
The distal row:
-Trapezium
-Trapezoid
-Capitate
-Hamate
90
What are the muscles of the hand?
-Thenar muscles
-Hypothenar muscles
-Adductor pollicis
-Lumbrical muscles
-Palmar interosseous muscles
-Dorsal interosseous muscles
91
Describe the thenar muscles of the hand
They form the thenar eminence on the lateral side of the hand
-Abductor pollicis brevis
-Flexor pollicis brevis
-Opponens pollicis(deep to 1,2)
92
Describe the adductor pollicis muscle of the hand
It does not belong to the thenar muscles
Action: adduction of the thumb
93
Describe the hypothenar muscles of the hand
They form the hypothenar eminence on the medial side of the hand
-Abductor digiti minimi
-Flexor digiti minimi
-Opponens digiti minimi (deep to 1,2)
94
Describe the lumbrical muscles of the hand
They are the 4 muscles of the medial 4 fingers
Origin: tendons of flexor digitorum profundus
Action: put the hand in the writing position (flexion of the metacarpal-phalangeal joints and extension of the interphalangeal joints)
95
Describe the palmar interosseous muscles
They are 3 muscles of the index, ring and little fingers
They adduct (PAD) the fingers towards the middle finger and puts the hand in the writing position
96
Describe the dorsal interosseous muscles of the hand
They are the 4 muscles of the middle 3 fingers
The middle finger has 2 muscles
They abduct (DAB) the fingers away from the middle finger and put the hand in the writing position
97
What is the nerve supply of the muscles of the hand?
All the small muscles of the hand are supplied by the deep branch of the ulnar nerve except the thenar muscles (abductor pollicis brevis, flexor pollicis brevis and Opponens pollicis) and the first and second lumbrical muscles which are supplied by the median nerve
98
Describe the fascial spaces of the palm of the hand
The thenar and hypothenar muscles lie in seperate compartments
There are 2 fascial spaces in the palm which lie posterior to the flexor tendons and anterior to the metacarpal bones and interosseous muscles
A lateral space called: thenar space
A medial space called: midpalmar space
The spaces of the palm are filled with loose connective tissue and they are separated by fibrous septa. Thus spread of infection is limited
99
Describe the superficial palmar arch
Site: in the palm of the hand superficial to the flexor tendons
It is formed by:
-Superficial palmar branch of radial artery
-Superficial branch of ulnar artery
it lies distal to the deep palmar arch and it gives branches to the medial 3 and 1/2 fingers
100
Describe the deep palmar arch
Site: in the palm of the hand deep to the flexor tendons
It is formed by:
-Radial artery
-Deep palmar branch of ulnar artery
It lies proximal to the superficial palmar arch
It gives branches to the superficial palmar arch
101
What is the arterial supply of the fingers?
Each finger has 2 palmar digital arteries
The superficial palmar arch supplies the medial 3 and 1/2 fingers
The radial artery supplies the lateral 1 and 1/2 fingers
102
Describe the anterior carpal arch
It lies on the anterior aspect of the carpal bones
It is formed by the anterior carpal branches of the radial and ulnar arteries
It supplies the carpal bones
103
Describe the dorsal carpal arch
It lies on the dorsal aspect of the carpal bones
It is formed by the dorsal carpal branches of the radial and ulnar arteries
It supplies the 2 digital arteries for the dorsal aspect of each finger
104
Describe the wrist joint
Type: synovial ellipsoid
Articular bones:
-Distal end of the radius
-Articular disc that lies on the lower surface of the ulnar head
-Proximal row of the carpal bones
105
What are the ligaments of the wrist joint?
-Ulnar collateral ligament
-Radial collateral ligament
-Palmar radiocarpal ligament
-Dorsal radiocarpal ligament
106
What are the movements of the wrist joint?
-Flexion: flexor muscles of the forearm except Pronator Teres and Pronator quadratus
-Extension: extensor muscles of the forearm except Brachioradialis, anconeus and Supinator
-Abduction: flexor carpi radialis and extensor carpi radialis longus and brevis
-Adduction: flexor and extensor carpi ulnaris
107
What are the clinical notes of the wrist joint?
Wrist sprain: tear of the wrist ligaments that may result from falling in the ground and excessive extension of the wrist
Abduction of the wrist joint is limited than adduction as the styloid process of the radius reaches a lower level than that of the ulna
108
What are the manifestations of musculotaneous nerve injury?
-Weakness of supination (biceps) and flexion (biceps brachialis) of forearm
-loss of sensation on the lateral side of forearm
109
What are the causes of axillary nerve injury?
-Fracture of the surgical neck of the humerus
-Inferior dislocation of the humerus
110
What are the manifestations of axillary nerve injury?
-Weakness of lateral rotation abduction of the arm (the Supraspinatous can abduct the arm but not to a horizontal level)
-Wasting of the deltoid muscle (flat shoulder)
-Loss of sensation over the lower half of the deltoid
111
What are the causes of median nerve injury?
-Above the elbow: supracondylar fracture
-Above the wrist: cut wound
-Carpal tunnel syndrome: due to arthritis or synovitis
112
What are the manifestations of median nerve compression and carpal tunnel syndrome?
-Occupational repetitive movements related to wrist flexion and extension
-Holding the wrist in awkward positions
-Strong gripping of objects
Long term compression:
-Thenar atrophy
-Weakness of the thumb and index fingers
113
What is the motor and sensory effect of carpal tunnel syndrome (median nerve injury)?
Motor effect:
-Absence of abduction and absence of opposition of the thumb
-Long term compression: flattening of the thenar eminence (ape hand)
Sensory effect:
-Lateral 3.5 fingers (parasthesia or anesthesia): sensation on the lateral part of the palm is normal because the palmar cutaneous branch arises in the forearm, so escaping compression in the carpal tunnel
114
What is the motor effect of median nerve injury above the elbow?
Like the manifestations of carpal tunnel syndrome, plus:
-Adduction of the wrist (paralysis of flexor carpi radialis and unopposed action of flexor carpi ulnaris)
-Paresthesia on the lateral part of the palm
-Loss of pronation
-Loss of flexion of interphalangeal joints of 2,3 digits (pointing index)
-Flexion of the distal interphalangeal joints of the 4th and 5th fingers is not affected because the medial part of the FDP, which produces these movements, is supplied by the ulnar nerve. Thus, when the person attempts to make a fist, the 2nd and 3rd fingers remain partially extended
115
What are the tests that can be done for median nerve function in the hand?
Tinel sign
Phalen manoeuvre
-A positive tinel sign refers to distally radiating pain and/or paresthesia elicited by percussing a superficial peripheral nerve, in this case the median
-The phalen manoeuvre is performed by appoint the wrists in 90 degrees of flexion. Parasthesia in the hand within 69 seconds is considered a positive test
116
What are the causes of ulnar nerve injury?
-Above the elbow: fracture medial epicondyle
-Above the wrist: cut wounds
117
What are the motor and sensory effects of injury to the ulnar nerve above the wrist?
Motor effects(deformity):
-Partial claw hand: due to paralysis of the palmar and dorsal interosseous muscles and the medial two lumbricals; the ring and little fingers are hyperextended at the metacarpophalangeal joints and flexed at the interphalangeal joints
-Loss of adduction and abduction of the fingers
-Loss of adduction of the thumb
-Flattening of the hypothenar eminence
Sensory effects:
Loss of sensation over medial 1/3 of the palm and medial 1.5 fingers
118
What are the motor and sensory effects of injury above the elbow to the ulnar nerve?
Motor effects:
-Same as in injury above the wrist except for:
Less apparent clawing (ulnar paradox)
Abduction of the hand
Sensory effects:
Loss of sensation over medial 1/3 of the hand and medial 1 and 1/2 fingers in both surfaces
119
What is the ulnar paradox?
Clawing of the hand, particularly of the little and ring fingers, is worse with lesions of the ulnar nerve at the wrist than at the elbow because interruption of the nerve at the elbow paralysed the ulnar half of the flexor digitorum profundus, which leads to lack of flexion at the distal interphalangeal joints in these fingers
120
What is the test used for abduction and adduction of the fingers
Paper test
121
What are the causes of radial nerve injury?
Radial nerve injury:
-In the axillary, pressure from crutch or back of a a chair
-In the spiral groove, fracture of shaft of the humerus
Posterior interosseous nerve injury:
-Fracture of the head, neck it the upper shaft of the radius
Superficial radial nerve injury:
-Cut wounds
122
What are the motor and sensory effects of radial nerve injury?
Motor effects:
-Inability to extend the elbow
-Inability to extend the wrist (wrist drop)
-Inability to extend the fingers (fingers drop)
Sensory effects:
Parasthesia over:
-Lower lateral surface of the arm
-Posterior surface of the arm and forearm
-Lateral 2/3 of the dorsum of the hand and posterior surface of the proximal phalanges of the lateral 3 and 1/2 fingers and on the dorsum of the hand between the 1st and 2nd metacarpal
123
What are the motor effects of posterior interosseous nerve injury?
-Inability to extend fingers (fingers drop)
-No wrist drop (intact extensor carpi radialis longus)
-No sensory effects
124
What are the sensory and motor effects of superficial radial nerve injury?
No motor effects
Sensory effects:
Parasthesia over the lateral 2/3 of the dorsum of the hand and posterior surface of the proximal phalanges of the lateral 3 and 1/2 fingers and on the dorsum of the hand between the 1st and 2nd metacarpal
125
What are the causes of brachial plexus - upper trunk (C5,6) injury?
-Increased angle between the head and the shoulder
-Difficult delivery (shoulder dystocia)
126
What are the motor and sensory effects of upper trunk (C5,6) injury?
Effects: Erbs Duchenne palsy
Motor effects: (waiters tip position)
-The shoulder is addicted and medially rotated (arm hangs by the side)
-the elbow is extended
-the forearm is pronated
Sensory effects:
Loss of sensation on the lateral side of the upper limb
127
Describe Erbs Duchenne palsy
-Paralysis of the muscles of the shoulder and arm supplied by the C5 and C6 spinal nerves (deltoid, biceps and brachialis)
-The usual appearance is an upper limb with an addicted shoulder, medially rotated arm and extended elbow
128
What are the causes of Brachial plexus- lower trunk (C8,T1) injury (klumpke palsy)?
-Excessive abduction of the arm
-Cervical rib
129
What are the motor and sensory effects of Brachial plexus- lower trunk (C8,T1) injury (klumpke palsy)?
Motor effects:
-Opposite if writing position: hyper extension of metacarpophalangeal joints and flexion of the interphalangeal joints (complete claw hand = klumpkes palsy)
-Loss of abduction and adduction of the fingers
Sensory effects:
Loss of sensation on the medial side of the upper limb
130
Describe the deep fascia of the thigh (fascia lata)
-it encloses the thigh. It’s upper end is attached to the pelvis
-It’s lateral aspect is thickened to form the iliotibial tract
131
What is the saphoneus opening?
It is an opening in the deep fascia of the thigh 1 and a half inches (4cm) below and lateral to the pubic tubercle.
It’s upper, lateral and lower margins are sharp (the falciform margin). It is closed by the cribriform fascia which is perforated by the great saphoneus vein, superficial in Guinean arteries and lymph vessels
132
How do varicose veins occur?
Frequently, the great saohoneus vein and it’s tributaries become varicose (dilated so that the cusps of their valves do not close)
133
What are the muscles and nerve supply of the anterior (extensor) compartment of the thigh?
Muscles:
-Pectineus
-Iliopsoas
-Sartorius
-Quadriceps femoris
Nerve supply:
Femoral nerve
134
What is the origin, insertion, nerve supply and action of the pectineus muscle?
Origin: pubic bone
Insertion: upper end of femur
Nerve supply: femoral nerve; sometimes also by obturator nerve
Action: adduction and flexion of the hip; medial rotation of the thigh
135
What is the origin, insertion, nerve supply and action of the psoas major (iliopsoas) muscle?
Origin: sides of lumbar vertebrae
Insertion: lesser trochanter of femur
Nerve supply: L1-3
Action: flexion of the hip
136
What is the origin, insertion, nerve supply and action of the iliacus (iliopsoas) muscle?
Origin: iliac crest and iliac fossa
Insertion: lesser trochanter of femur
Nerve supply: femoral nerve
Action: flexion of the hip
137
What is the origin, insertion, nerve supply and action of the sartorius muscle?
Origin: anterior superior iliac spine
Insertion: superior part of medial surface of tibia
Nerve supply: femoral nerve
Action: flexion and Lateran rotation of thigh and flexion and medial rotation of the knee
138
What is the origin, insertion, nerve supply and action of the quadriceps femoris muscle?
139
Describe the manifestations of quadriceps femoris paralysis
A person with paralysed quadriceps muscles cannot extend the leg against resistance and usually presses on the distal end of the thigh during walking to prevent inadvertent flexion of the knee joint
140
Where is the femoral triangle located?
It is a triangular area I. The anterior aspect of the thigh just below the inguinal ligament
141
What are the boundaries of the femoral triangle?
-Superiorly (base): Inguinal ligament
-Laterally: medial border of sartorius
-Medially: medial border of adductor Longus muscle
-Floor: formed of iliopsoas, pectineus and adductor Longus (from lateral to medial)
-Roof: skin and fascia of the thigh
142
What are the contents of the femoral triangle?
-Femoral nerve and it’s branches
-Femoral sheath
-Femoral artery and it’s branches
-Femoral vein and it’s tributaries
-Femoral branch of the genitofemoral nerve
-Deep inguinal lymph nodes
-Lateral cutaneous nerve of the thigh
143
Describe what is the femoral sheath
It is a downward protrusion into the thigh of the fascial envelope lining the abdominal walls
Anteriorly: it is formed by fascia transversalis
Posteriorly: it is formed by fascia iliaca
It has 3 compartments:
-Lateral compartment: contains the femoral artery and femoral branch of the genitofemoral nerve
-Intermediate compartment: contains the femoral vein
-Medial compartment (femoral canal): contains the lymph node (node of Cloquet). The upper opening of the femoral canal is the femoral ring
144
What are the boundaries of the femoral ring?
-Inguinal ligament (anteriorly)
-Superior pubic ramus (posteriorly)
-Lacunar ligament (medially)
-Femoral vein (laterally)
145
What is a femoral hernia?
The femoral ring is a site of potential herniation. A femoral hernia is a protrusion of abdominal viscera through the femoral ring into the femoral canal. A femoral hernia may become stangulated due to the sharp edge of the lacunae ligament
146
Describe the femoral artery
It is the continuation of the external iliac artery at the mid-inguinal point. The artery descends across the femoral triangle to its apex, where it continues in the subsartorial (adductor canal). It terminates at the end of the adductor canal by passing through the adductor hiatus to continue as the popliteal artery
147
What is the surface anatomy of the femoral artery?
It corresponds to the upper two-thirds of a line extending from the mid-inguinal point to the adductor tubercle when the thigh is flexed, abducted and laterally rotated.
148
What are the branches of the femoral artery?
-Superficial inguinal arteries
-Deep external pudendal artery: supplies the external genitalia
-Profunda femoris artery(the largest branch) gives:
Lateral circumflex femoral artery
Medial circumflex femoral artery
Perforating arteries
-Descending genicular artery: it anastomoses with the genicular branches of the popliteal artery
149
What is a large femoral arteriography’s fistula and how does it occur?
The superficial position of the femoral artery in the femoral triangle makes it vulnerable to traumatic injury, especially laceration.
Commonly both the femoral artery and vein are lacerated in anterior thigh wounds because they lie close together. In some cases, an arteriovenous shunt occurs as a result of communication between the injured vessels
150
What is an adductor canal block?
It is a technique for providing analgesia of the knee region without compromising ambulation and disposition
For this block, relatively high volumes of dilute local anesthetic are injected deep to the sartorius muscle in the thigh
151
What are the muscles of the medial compartment of the thigh
-Gracilis
-Pectineus
-Adductor Longus
-Adductor brevis
-Adductor magnus
-Obturator externus
152
What is the origin, insertion, nerve supply and action of the muscles of the medial compartment?
153
What are the 2 parts of the adductor Magnus muscle of the medial compartment of the thigh?
-Pubic part arising from the pubic bone
-Ischial part (hamstring part) arising from the ischium
154
What is the clinical significance of the gracilis muscle of the medial compartment of the thigh?
The gracilis is a relatively weak member of the adductor group of muscles, and thus surgeons often transplant this muscle or part of it, with nerve and blood vessels, to replace a damaged muscle in the hand
155
What is the clinical significance of the adductor Longus muscle of the medial compartment of the thigh?
Muscle strains of the adductor Longus may occur in horseback riders and produce pain because the riders adduct their thighs to keep from falling from the animal
156
Describe the adductor canal
Begins at the apex of the femoral triangle and ends at the adductor hiatus
Adductor hiatus: is the aperatire in the tendon of insertion of the adductor Magnus; it allows the passage of the femoral vessels into the popliteal fossa
Boundaries:
-Anteriorly and laterally: Vastus medialis
-Posteriorly: Adductors longus and magnus
-Medially: Sartorius, which overlies the groove between the above muscles forming the roof of the canal
Contents:
-Femoral vessels
-Saphenous nerve
-Nerve to the vastus medialis
-Descending genicular artery
Clinical relevance:
In addition to functioning as
157
What is the clinical relevance of the adductor canal?
Clinical relevance:
In addition to functioning as a key anatomical landmark, the adductor canal is clinically relevant. It can be a site if disease or suffer damage by trauma. It is also an increasingly- common site for the administration of regional anesthetic (nerve block) for knee, ankle and foot surgeries
158
Describe the gluteal region
The gluteal region or buttock is bounded superiorly by the iliac crest and inferiority by the fold of the buttock. The region is largely made up of gluteal muscles and a thick layer of superficial fascia
Muscles in the region mainly abduct, extend and laterally rotate the femur relative to the pelvic bone
159
What is the origin, insertion, nerve supply and the action of the gluteus maximus muscle of the posterior compartment of the thigh?
Origin: ilium
Insertion: most fibres end in the iliotibial tract; deep fibres insert into the gluteal tuberosity of the femur
Nerve supply: inferior gluteal nerve
Action: extension and lateral rotation of the hip
160
What is the origin, insertion, nerve supply and the action of the gluteus medius and minimus muscles of the posterior compartment of the thigh?
Origin: ilium
Insertion: greater trochanter of femur
Nerve supply: superior gluteal nerve
Action: abducts the thigh and steadies the pelvis on leg when opposite leg is raised
161
What is the origin, insertion, nerve supply and the action of the tensor fasciae lata muscle of the posterior compartment of the thigh?
Origin: iliac crest
Insertion: iliotibial tract that attaches to the lateral condyle of the tibia
Nerve supply: superior gluteal nerve
Action: stabilises the knee in extension
162
What is the origin, insertion, nerve supply and the action of the small lateral rotators of the thigh?
163
What are the manifestations of superior and inferior gluteal nerve injury?
Superior gluteal nerve:Trendelenburg gait
Inferior gluteal nerve injury: impairment of hip extension and lateral rotation
Difficulty in raising the body from sitting position
164
Describe the greater sciatic foramen
Greater sciatic foramen: provides an exit from the pelvis into the gluteal region
Contents:
-Priformis
-Sciatic nerve
-Posterior cutaneous nerve of the thigh
-Superior and inferior gluteal nerves and vessels
-Nerve to obturator internus and quadratus femoris
-Pudendal nerve and vessels
165
Describe the lesser sciatic foramen
Provides an entrance into the perineum from the gluteal region
Contents:
-Tendon of obturator internus muscle
-Nerve to obturator internus
-Internal pudendal vessels
-Pudendal nerve
166
What are the clinical problems related to the back of the thigh?
-Hamstring injury
-Hamstring strain: (pulled and/or torn hamstrings) are common in individuals who run or kick hard (sports). The violent muscular exertion required fi excel in these sports may avulse (tear) part of the proximal tendinous attachments of the hamstrings to the ischial tuberosity
167
What are the hamstring muscles?
Semiteninosus
Semimembranous
Biceps femoris
168
What is the origin, insertion, nerve supply and the action of the semitendinous muscle of the back of the thigh?
Origin: ischial tuberosity
Insertion: medial surface of the superior part of the tibia
Nerve supply: tibial part of the sciatic nerve
Action: extends the hip; flexes the leg and rotates it medially
169
What is the origin, insertion, nerve supply and the action of the semimembranosus muscle of the back of the thigh?
Origin: ischial tuberosity
Insertion: medial condyle of the tibia
Nerve supply: tibial part of the sciatic nerve
Action: extends the hip; flexes the leg and rotates it medially
170
What is the origin, insertion, nerve supply and the action of the biceps femoris muscle of the back of the thigh?
Origin:
-Long head: ischial tuberosity
-Short head: linea aspera
Insertion: head of tibula
Nerve supply:
-Long head: tibial part of the sciatic nerve
-Short head: common peroneal part of the sciatic nerve
Action: flexes leg and rotates it laterally; it extends the thigh
171
172
What type of joint is the hip joint?
Synovial, ball and socket
173
What are the articular surfaces of the hip joint?
Head of femur
Acetabulum
174
What are the components of the acetabulum?
Lunate surface
Acetabular fossa
Acetabular notch- transverse ligament of the acetabulum - Acetabular foramen
Labrum acetabulare
175
176
177
Describe the capsule to the hip and to the femur
To the hip: margins of the acetabulum and the transverse Acetabular ligament
To the femur:
Anteriorly: bases of the greater and lesser trochanters and to the intertrochantric line
Posteriorly: attached to the neck of the femur about one and a half cm medial to the interochantric crest
178
Describe the synovial membrane
It lines the capsule and covers the structures inside the hip joint except the articular surfaces
The round ligament of the head of femur is invested with a tube of synovial membrane
179
What are the ligaments of the hip joint?
Intracapsular: round ligament
Runs from the acetabular fossa to the fovea of the head of the femur
It enclosed a branch of the obituary or artery, which carries blood supply to the head of the femur
Extracapsular:
There are 3 extracapsular ligaments
They are continuous with the outer surface of the hip joint capsule
-Iliofemoral ligament
-Pubofemoral ligament
-Ischiofemoral ligament
180
Describe the iliofemoral ligament
Y- shaped, attached between anterior superior iliac spine and both ends of the intertrochantric line
If prevents hyperextension
181
Describe the pubofemoral ligament
Triangular in shape, attached between iliopubic eminence and the capsule
It prevents hyper abduction
182
Describe the isciofemoral ligament
From the ischium to the back of the capsule
Weak ligament
183
What are the muscles responsible for flexion and extension?
Flexion: Psoas major, iliacus, rectus femoris, sartorius and pectineus
Extension: Gluteus maximus and hamstring
184
What are the muscles responsible for adduction and abduction?
Abduction: Gluteus medius, minimus and tensor fascia latae
Adduction: Adductor Longus, brevis, Magnus, gracilis and pectineus
185
What are the muscles responsible for medial and lateral rotation?
Medial rotation: gluteus medius and minimus and tensor fascia latae
Lateral rotation: the 6 lateral rotators: obturator internus, 2 gemelli, priformis, obturator extension, quadratus femoris, gluteus maximus and adductors
186
What is the blood supply of the hip joint?
-Medial and lateral circumflex arteries (from profunda femoris artery)
-Artery to head of femur (from obturator artery)(passes through round ligament)
187
What does damage to the medial circumflex femoral artery cause?
It can result in avascular necrosis of the femoral head
188
What are the factors responsible for stability of the hip joint?
-The head of femur fits accurately to the acetabulum and labrum acetabulare
-The three strong ligaments outside the capsule
-the surrounding strong ligaments
189
What are the structures damaged in posterior dislocations?
-The affected limb becomes shortened and medially rotated
-The sciatic nerve runs posteriorly to the hip joint, and can be damaged in such an injury
190
Describe what occurs in congenital dislocation
-More common in the hip than any other joint of the body
-The head of the femur slips upwards onto the gluteal surface of the ilium because the upper margin of acetabulum is developmentally deficient
191
Describe what happens during femoral neck fracture
Fracture neck of femur is a common type of fracture in old age
It can lead to avascular necrosis of head of femur
192
Describe the popliteal fossa
It is a diamond shaped intermuscular space present on the back of the knee
193
What are the boundaries of the popliteal fossa?
Lateral superior: the biceps femoris
Lateral inferior: gastrocnemius (lateral head) and plantaris muscle
Medial superior: semimembranosus and semitendinosus muscles
Medial inferior: medial head of gastrocnemius muscle inferiorly
Roof: superficial fascia and deep fascia of thigh, posterior cutaneous nerve of the thigh, small saphenous vein and sural nerve
Floor: popliteal surface of the femur, back of knee joint and popliteus muscle
194
What are the contents of the popliteal fossa?
Popliteal vessels
Tibial (medial popliteal) nerve
Common perineal (lateral popliteal) nerve
Genicular branch of obturator nerve
Popliteal lymph node
Popliteal fat
195
What is the beginning (origin) of the popliteal artery?
It is the continuation of the femoral artery at the adductor hiatus
196
What is the course of the popliteal artery?
It is the deepest structure in the popliteal fossa
It descends on the popliteal surface of the femur, back of the knee joint and popliteus muscle
At the lower border of popliteus muscle the artery terminates by dividing into anterior and posterior tibial arteries
197
What are the branches of the popliteal artery?
Muscular branches
Cutaneous branch
Articular branches:
-Superior lateral genicular artery
-Superior medial genicular artery
-Middle genicular artery
-Inferior lateral genicular artery
-Inferior medial genicular artery
198
What is the beginning of the popliteal vein?
It begins by the union of the vena comitantes of the anterior and posterior tibial veins at the lower border of popliteus
199
What is the course of the popliteal vein?
In the lower part of the fossa the vein is medial to the artery. It crosses superficial to the artery and becomes posterolaterak to the artery at the upper part of the fossa
200
What is the termination of the popliteal vein?
It terminates by passing through the adductor opening and continues as the femoral vein
201
What are the tributaries of the popliteal vein?
Muscular veins
Genicular veins corresponding to the arteries
Short saphenous vein
202
What type of joint is the knee joint?
Synovial, modified hinge
203
What are the Articular surfaces of the knee joint?
Lower end of femur
Upper end of tibia
Posterior surface of patella
204
What structures are the capsule of the knee joint attached to?
Attached to the margins of the Articular surfaces and surrounds the sides and posterior aspect of the joint.
On the front of the joint, the capsule is absent where it is replaced by quadriceps tendon, patellar retinacula and ligamentum patellae
205
What are the extracapsular ligaments of the knee joint?
Ligamentum patellae
Lateral collateral ligament
Medial collateral ligament
Oblique popliteal ligament
206
What are the intracapsular ligaments of the knee joint?
Anterior cruciate ligament:
-From anterior intercondylar area of tibia to the lateral femoral condyle
-It prevents hyperextension
-It also prevents posterior displacement o the femur on the tibia
Posterior cruciate ligament:
-From posterior intercondylar area of tibia to the medial femoral condyle
-It prevents anterior displacement of femur over tibia
207
Describe the synovial membrane of the knee joint
Attached to the margins of the Articular surfaces
It extends up beneath the quadriceps femoris muscle above the patella, forming suprapatellar bursa
It is reflected backwards from the posterior surface of the ligamentum patellae to form infrapatellar fold
At the back of the joint, the synovial membrane is prolonged downward on the deep surface of the tendon of the popliteus forming popliteal bursa
A bursa is interposed between the medial head of the gastrocnemius and the medial femoral consuls and the semimembranosus tendon; this is termed semimembranosus bursa
208
What are the structures inside the knee joint?
-Medial meniscus: C-shaped, fixed to the capsule of the knee joint and to the medial collateral ligament (liable to injury)
-Lateral meniscus: circular in shape, more mobile (separated from capsule and lateral collateral ligament by popliteus tendon) so it is more adaptive for twisting movement and less liable to injury
-Anterior cruciate ligament
-Posterior cruciate ligament
-Popliteus tendon
209
What is the function of the menisci?
-They increase the concavity of tibial condyles for the better adaptation with femoral condyles
-They maintain a potential joint space for flushing of synovial fluid to provide nutrition to the Articular cartilage
-Menisci act as a shock absorber
210
What is the arterial supply of the knee joint?
From the anastomosis around the knee:
-Popliteal artery
-Superior lateral genicular artery
-Inferior lateral genicular artery
-Superior medial genicular artery
-Middle genicular artery
-Inferior medial genicular artery
211
What are the movements of the knee joint?
Flexion: By the hamstring muscles, gracilis, gastrocnemius, sartorius, popliteus and plantaris
Extension: By the quadriceps femoris, tensor fascia latae
Locking: medial rotation of the femur on the tibia in full extension
It is done by the anterior cruciate, the collateral and the oblique popliteal ligaments and biceps
Unlocking: lateral rotation of femur on tibia in standing (tibia fixed) or medial rotation of tibia in supine or sitting (tibia free) it is done mainly by popliteus
212
What structures are responsible for stability of the knee joint?
Muscles: quadriceps particularly the inferior fibres of the vasti lateralis and medialis
Ligaments: Mainly quadriceps ligament
Menisci: Increase the concavity of tibial condyles
213
What is the triad of injury of the knee joint/ what structures are most affected during knee joint injury?
-Medial collateral ligament (tibial)
-Medial meniscus
-Anterior cruciate ligament
The joint becomes swollen because it is filled with blood (hemarthrosis)
The medial meniscus suffers more frequently than the lateral because it is attached to the capsule
214
Describe the difference between anterior cruciate injury and posterior cruciate injury
Tear of the anterior cruciate ligament is more common than the posterior
The tibia can be pulled excessively forward on the femur
The tibia can be pulled excessively backwards on the femur in posterior cruciate injury
215
Describe inflammation of bursa and osteoarthritis of the knee joint
Inflammation of bursa:
Housemaids knee- subcutaneous pre-patellae bursa
Osteoarthritis of knee joint:
Total knee replacement or knee joint arthroplasty is done in severe destructive arthritis of the joint
216
How many compartments does the leg have?
The leg is divided by inter-muscular septa and interosseous membrane into 3 compartments:
-Anterior compartment
-Posterior compartment
-Lateral compartment
217
What are the muscles and nerve supply of the anterior compartment of the leg?
Muscles: the tibialis anterior, extensor digitorum longus, peroneus tertius and extensor hallucis longus
Collectively they dorsiflex the foot at the ankle joint
Nerve supply: deep peroneal (fibular) nerve; anterior tibial nerve
218
219
220
What are the muscles and nerve supply of the lateral compartment of the leg?
Muscles: peroneus (fibularis) longus and peroneus (fubularis) brevis
Both pass behind the Lateral Malle plus of fibula
Both every the foot (turn the sole outward)
Nerve supply: Superficial peroneal nerve and the musculotaneous nerve
221
222
What are the muscles, blood supply and nerve supply of the posterior compartment of the leg?
Muscles: superficial and deep groups
Blood supply: branches from posterior tibial artery
Nerve supply: tibial nerve
223
What are the superficial group of muscles in the posterior compartment of the leg?
-Gastrocnemius: Is the most superficial of the muscles in the posterior compartment. It arises by 2 heads (medial and lateral)
In the upper leg, the 2 heads combine to form a single elongate muscle belly, which forms much of the soft tissue bulge identified as the calf
-Plantaris: has a small muscle belly proximally and a long thin tendon
-Soleus: is a large flat muscle under the gastrocnemius muscle
224
What is the origin, insertion and action of the superficial group of muscles in the posterior compartment of the leg?
Origin: Gastrocnemius and plantaris originate in the distal end of the femur and can flex the knee joint
Insertion: All of the 3 muscles insert onto the heel (calcaneus) of the foot and plantarflex the foot at the ankle joint
Action: as a unit, these muscles are large and powerful because they;
-Propel the body forward off the planted foot during walking
-Elevate the body upwards onto the toes when standing
225
226
What is the clinical correlation of calcaneal (achilles) tendon rupture?
Rupture of the calcaneal tendon is often related to sudden or direct trauma
The patient typically complains of being kicked or shot behind the ankle
Clinical examination often reveals a gal in the tendon
227
What are the deep group of muscles of the posterior compartment of the leg?
-Popliteus: the smallest and acts on the knee, whereas the other 3 muscles act mainly on the foot
-Flexor hallucis longus
-Flexor digitorum longus
-Tibialis posterior
228
229
Describe the arterial supply of the leg
The popliteal artery is the major blood supply to the leg
It enters the posterior compartment of the leg from the popliteal fossa
It immediately didvides into the anterior tibial artery and posterior tibial artery at the lower border of the popliteus
230
Describe the anterior tibial artery
The anterior tibial artery passes forward through the aperture in the upper part of the interosseous membrane and enters and supplies the anterior compartment of the leg
It passes deep to the superior extensor retinaculum
It continues inferiorly onto the dorsal aspect of the foot as the dorsalis pedis artery
231
What are the branches of the anterior tibial artery?
- Recurrent branch: ascends to share in the anastomosis around the knee joint
-Muscular branches
-Anterior malleolar arteries: share in the anastomosis around the ankle
232
Describe the posterior tibial artery
The posterior tibial artery supplies the posterior and lateral compartments of the leg and continues into the sole of the foot
It passes through the tarsal tunnel behind the medial malleolus and into the sole of the foot
233
What are the branches of the posterior tibial artery?
-Circumflex fibular artery: passes laterally through the soleus muscle and around the neck of the fibula to connect with anastomotic network of vessels surrounding the knee
-Fibular artery: supplies adjacent muscles and bone in the posterior compartment of the leg and also has branches that pass laterally through the intermuscular septum to supply the fibularis muscles in the lateral compartment of the leg
234
What is the artery in the anterior compartment of the leg?
Anterior tibial artery which originated from the popliteal artery
235
To what direction/axis does abduction and adduction of the foot occur?
Abduction and adduction of the toes are defined with respect to the long axis of the second digit
236
What type of joint is the ankle joint and what are its bones and movements?
Type: Synovial, hinge joint (uniaxial)
Bones: Talus of the foot and tibia and fibula of the leg
Movements: dorsiflexion and plantar flexion of the foot on the leg
237
What are the ligaments of the ankle joint?
Medial ligament (deltoid):
-large, strong and triangular in shape
-It’s apex is attached above to the medial malleolus (tibia) and it’s broad base is attached below to the navicular bone and the talus
Lateral ligament:
-Talofibular
-Calcaneofibular parts
238
Describe the clinical correlations of ankle sprains
-The ankle joint is the most frequently injured joint in the body
-Ankle sprains occur due to torn fibres kf ligaments
-The lateral ligament is most commonly torn
239
Describe the intertarsal joints
The major joints at which movements occur include the subtalar, talocalcaneonavicular and calcaneocuboid joints.
The intertarsal joints invert and evert the foot
The spring ligament (plantar calcaneonavicular) is a broad thick ligament
It supports the talus and resists the depression on the medial arch of the foot
240
What are the joints of the foot?
-Metatarsophalangeal joints
-Proximal and distal interphalangeal joints
241
What are the clinical correlations of injury to the joints of the foot?
Bunion:
-occurs on the medial aspect of the first metatarsophalangeal joint
-Characterized by lateral deviation of the big toe
-This deformity tends to occur among people who wear high-heeled shoes or pointed shoes
242
Describe the superior extensor retinaculum
It is attached to the distal ends of the tibia and fibula
Structures that pass beneath it from medial to lateral: (Tom has very nice dogs and pigs)
-Tibialis anterior tendon
-extensor Hallucis longus tendon
-anterior tibial artery with Venae comitantes
-extensor Digitorum longus tendons
-Peroneus tertius
243
What is a retinacula of the ankle?
In the region of the ankle joint, the deep fascia is thickened to form a series of retinacula
They serve to keep the long tendons in position
244
Describe the inferior extensor retinaculum
It is Y-shaped and attached by its base to the lateral side of the upper surface of the calcaneus
It crosses medially over the foot to attach to the medial malleolus and to the medial side of the plantar aponeurosis
245
Describe the superior peroneal retinaculum
It is a thickened band of deep fascia that extends from lateral malleolus to the calcaneus
The tendons of the peroneus longus and brevis pass deep to the retinaculum
246
Describe the inferior peroneal retinaculum
It is a thickened band of deep fascia that lies below the lateral malleolus from the stem of the Y of the inferior extensor retinaculum to the calcaneus
247
Describe the flexor retinaculum
The flexor retinaculum is a strap-like layer of connective tissue
It spans the bony depression (tarsal tunnel) formed by the medial malleolus and the calcaneus
Structures that pass beneath or through it from medial to lateral: (Tom does very nice hats)
-Tibialis posterior tendon
-flexor Digitorum longus tendons
-posterior tibial artery with Venae comitantes
-flexor Hallucis longus tendon
248
What are the arches of the foot?
The bones of the foot do not lie in the same horizontal plane. Instead, they from longitudinal and transverse arches relative to the ground
Longitudinal arch: is formed between the posterior end of the calcaneus and the metatarsals. It is highest on the medial side, where it forms the medial part of the longitudinal arch
Transverse arch: it is highest in a coronal plane that cuts through the foot. Ligaments and muscles support the arches of the foot
249
Describe what is flat foot (des planus)
It is the flattening of the medial longitudinal arch
Occurs due to dysfunction of ligaments or muscles of the foot
250
What are the muscles and nerve supply of the dorsum of the foot?
2 muscles from the superior surface of the calcaneus:
-Extensor hallucis brevis: to the big toe
-Extensor digitorum brevis: to toes 2,3,4&5
Nerve supply of both muscles: Anterior tibial nerve
251
Describe the arterial supply/ dorsalis pedis artery of the dorsum of the foot
The dorsalis pedis artery is the continuation of the anterior tibial artery
It begins as the anterior tibial artery crosses the ankle joint
It ends as the sole of the foot between the big toe and the second toe
Branches:
-Tarsal arteries
-Arcuate artery: arches over metatarsals to give lateral dorsal metatarsal arteries
-1st dorsal metatarsal artery
252
What are the veins of the dorsum of the foot?
Dorsal venous arch:
On the dorsal surface of the foot over the metatarsals
Great saphenous vein:
From the medial side of the arch and passes anterior to the medial malleolus and onto the medial side of the leg
Small (short) saphenous vein:
From the lateral side of the arch and passes posterior to the lateral malleolus and onto the back of the leg
253
Describe the plantar aponeurosis of the sole of the foot
The most superficial layer of the sole of the foot
It is a thickening of the deep fascia in the sole of the foot
It supports the longitudinal arch of the foot and protects deeper structures in the sole
It is firmly anchored to the calcaneus
The fibres diverge as they pass anteriorly and form digital bands
254
Describe the first layer of muscles in the sole of the foot
The most superficial of the 4 layers of muscles of the sole of the foot
Lies immediately deep to the plantar aponeurosis
From medial to lateral these muscles are:
-Abductor hallucis: abducts the big toe
-Flexor digitorum brevis: flexes lateral 4 toes
-Abductor digiti minimi: Abducts the little toe
255
Describe the second layer of muscles of the sole of the foot
Is associated with the tendons of the flexor digitorum longus and flexor hallucis longus muscles
Muscles of the foot are:
-Quadratus plantae: helps flexion of lateral 4 toes
-4 Lumbrical muscles: flexion metatarsophalangeal joint and extension interphalangeal joint
256
Describe the third layer of muscles of the sole of the foot
-Flexor hallucis brevis: flexes lateral 4 toes
-Adductor hallucis: adducts big toe
-Flexor digiti minimi brevis: flexes little toe
257
Describe the fourth layer of muscles of the sole of the foot
There are two muscle groups in the deepest muscle layer in the sole of the foot:
-Dorsal interossei: abduction of toes
-Plantar interossei: adduction of toes
I’m addition to 2 long tendons: Tibialis posterior and peroneus longus
258
Describe the posterior tibial artery course in the dorsum of the foot
The posterior tibial artery enters the foot through the tarsal tunnel on the medial side of the ankle and posterior to the medial malleolus
It ends midway between the medial malleolus and the heel, it bifurcates into a small medial plantar artery and a much larger lateral plantar artery
259
Describe the deep plantar arch of the foot
The deep plantar arch is formed mainly by the lateral plantar artery which curves in the foot where it is joined medially with the deep plantar branch of the dorsalis pedis artery
It gives the plantar metatarsal and digital arteries
260
Describe the nerve supply of the muscles of the sole of the foot
The tibial nerve enters the foot through the tarsal tunnel posterior to the medial malleolus, then it divides into 2 terminal branches : a large lateral plantar nerve and a smaller medial plantar nerve
All intrinsic muscles in the sole are innervated by the lateral plantar nerve except for the muscles supplied by the medial plantar nerve:
-Abductor hallucis
-Flexor digitorum brevis
-Flexor hallucis brevis
-First Lumbrical
261
What is the course of the femoral nerve?
It arises from the lumbar plexus then passes lateral to the psoas major muscle
It enters the thigh by passing deep to the inhumanly ligament into the femoral triangle, where it passes lateral to the femoral sheath
262
What are the branches of the femoral nerve?
Muscles: quadriceps femoris, iliacus and pectineus
Skin over the anterior aspect of the thigh
Saphenous nerve: a long cutaneous nerve supplying skin of medial side of leg and foot
263
What are the manifestations of femoral nerve injury?
Quadriceps femoris paralysis:
A person with paralysed quadriceps muscles cannot extend the leg against resistance
Usually presses on the distal end of the thigh during walking to prevent unwanted flexion of the knee joint
Sensory loss over skin areas supplied by the femoral nerve and its branches
264
Describe the course of the obturator nerve
It arises from the lumbar plexus then passes medial to the psoas major muscle
It enters the thigh through the obturator foramen
It divides into anterior and posterior divisions
265
What are the branches of the obturator nerve?
Muscles: medial compartment of the thigh except the ischial part of adductor Magnus: adductor longus, adductor brevis, gracilis, pectineus muscles and pubic part of adductor Magnus the obturator externus
Skin of the medial side of the thigh
266
What are the manifestations of obturator nerve injury?
Causes a weakness of adduction and lateral swinging of the limb during walking because of the unopposed abductors
Sensory loss over medial side of upper thigh
It may result from pressure on the nerve by the feral head during pregnancy
267
Describe the course of the sciatic nerve
It arises from the sacral plexus and is the largest nerve in the body
It emerges from the greater sciatic foramen below the piriformis to lie superficial to structures called the sciatic bed:
-Superior gemellus
-Obturator internus
-Inferior gemellus
-Quadratus femoris
268
What are the branches of the sciatic nerve?
Muscles: hamstring muscles (semitendinosus, semimembranosus, biceps femoris and the ischial part of the adductor Magnus)
It divides at the posterior thigh (proximal to the knee and sometimes within the pelvis) into 2 terminal branches:
-Tibial nerve
-Common fibular (peroneal) nerve
The terminal branches supply all the muscles of the leg and foot and the skin to all the leg and foot except the medial aspect
269
What are the manifestations of sciatic nerve injury?
Impairment of hip extension and severe impairment of knee flexion
Loss of all movements of the foot (foot drop)
Peculiar gait beachside of increased flexion at the hip to lift the dropped foot off the ground
Sensory loss over all the skin below the knee except the medial aspect of leg and foot
270
Describe what is sciatica (sciatic nerve injury)
This is the most common form of back pain that may extend from the buttock down the posterior and lateral aspect of the leg and the lateral aspect of the foot.
It is caused by compression or irritation of the sciatic nerve e.g. due to herniated slipped disc or an improperly administered gluteal inter-muscular injection
271
Describe what is priformis syndrome (sciatic nerve injury)
Occurs due to hypertrophy of the piriformis muscle
Causes irritation of the sciatic nerve
272
Describe the characteristics of the common peroneal (fibular) nerve
It is the smaller terminal branch of the sciatic nerve
It originates from the sciatic nerve in the posterior compartment of the thigh or in the popliteal fossa
It winds around the neck of fibula (subcutaneous and can be palpable)
The commonest nerve injury in the body
273
What are the branches of the common peroneal nerve?
Muscles: all muscles in anterior and lateral compartments of the leg and muscles of the dorsum of the foot
Cutaneous: skin over the lateral aspect of the leg and over the dorsal aspect of the foot and toes
It ends lateral to the neck of fibula by dividing into:
-Superficial peroneal (musculotaneous) nerve
-Deep peroneal (anterior tibial) nerve
274
Describe the characteristics of the anterior tibial nerve (deep peroneal nerve)
It is one of the two terminal branches of the common peroneal nerve on the lateral side of the neck of fibula
It pierced the anterior intermuscular septum to reach the anterior compartment of the leg
It ends by dividing into medial and lateral terminal branches at the dorsum of the foot after passing deep to the extensor retinaculum on the lateral side of the dorsalis pedis artery
275
What are the branches of the anterior tibial nerve?
Muscular : muscles of the anterior compartment of the leg and dorsum of the foot
Cutaneous: skin of adjacent sides of first and second toes
276
Describe the characteristics of the superficial peroneal nerve (musculotaneous nerve)
It is one of the two terminal branches of the common peroneal nerve on the lateral side of the neck of fibula
It emerges between the peroneus longus and brevis and ends by piercing deep fascia and becomes the cutaneous nerve at the lower part of the leg
277
What are the branches of the musculotaneous nerve(
Muscles: peroneus longus and brevis
Cutaneous: skin of the dorsum of the foot and all toes except:
-Adjacent sides if first and second rows which supplied by the anterior tibial nerve
-The lateral border supplied by the sural nerve
-The medial border supplied by the saphenous nerve
278
Describe the clinical correlations of a common peroneal nerve injury
It usually results from fracture of neck of fibula or entrapment by leg casts
Deformity (equinovaris): foot is plantarflexed and inverted due to unopposed action of planterflexors and invertors
Sensory loss over lateral leg and dorsum of the foot
279
Describe the clinical correlations of injury of the deep peroneal nerve
Injury of the deep peroneal nerve (anterior tibial nerve) results in foot drop and characteristic by high steppage gait
Usually results from compression of the nerve by tight fitting ski boots as it passes anterior to the ankle joint (ski boot syndrome)
280
Describe the clinical correlations of injury of the superficial peroneal nerve
Injury of the superficial peroneal nerve (musculotaneous nerve) results in no foot drop but causes loss of eversion of the foot
Loss of sensation over most of the dorsum of the foot
281
Describe the course of the tibial nerve
It is the larger terminal branch of the sciatic nerve
The tibial nerve descend a through the popliteal fossa, enters the posterior compartment of the leg and continues into the sole of the foot through the tarsal tunnel
Midway between medial malleolus and calcaneus it divides into 2 terminal branches: medial and lateral plantar nerves
282
What are the branches of the tibial nerve?
Muscles: all muscles in the posterior compartment of the leg and sole of the foot
Cutaneous:
-Sural nerve: skin in the posterolateral side of the lower half of the leg and lateral side of the foot and the little toe
-Calcaneal branch: skin of the heel
283
What does the lateral plantar nerve supply ?
It is the major motor nerve of the sole of the foot
It innervated all intrinsic muscles in the sole, except for the muscles supplied by the medial plantar nerve
284
What does the medial plantar nerve supply?
It is the major sensory nerve to the sole of the foot
It gives motor branches to only 4 muscle in the sole:
-Abductor hallucis
-Flexor digitorum brevis
-Flexor hallucis brevis
-First Lumbrical
285
Describe the manifestations of tibial nerve injury
Loss of plantarflexion of the foot as well as impaired inversion (calcaneovalgus)
Sensory loss of sole of the foot except for the medial border
It results in abnormality in the posture and locomotion
286
Describe tarsal tunnel syndrome
Occurs due to entrapment of the tibial nerve in the tarsal tunnel behind the medial malleolus
Causes numbness in the sole of the foot
