Ankle and foot

Question 1

Components of ankle joint

Answer 1

inferior surface of tibia - transfers weight
lateral and medial malleolus - stablises
Superior surface of talus - transfer wt to calcaneous and fore foot
Medial and lateral surface concave

Question 2

Describe the movement at the ankle joint

Answer 2

Tibia always in contact
Lateral malleolus changes in positions
Plantiflexion - joint relaxed and lateral malleolus not touch. Slight side movement possible
Dorsiflexion forces movement of fibula due to the talus being wider anteriorly and bigger then morest
Hinge joint = flex and extension only and supported by ligament due to this

Question 3

Describe the ligaments of ankle

Answer 3

Deltoid ligament
- deep part: Posterior tibiotalar ligament
- Superficial part: Tibiocalcaneal ligament
attaches to the sustentaculum tali (Strongest), Anterior tibiotalar ligament, Tibionavicular ligament.
Lateral ligament
Posterior talofibular ligament
Anterior talofibular ligament
Calcaneofibular ligament
Posterior tibiofibular ligament
Anterior tibiofibular ligament

Question 4

Joints of foots

Answer 4

Talocalcaneal joint
Transfers wt
Talocalcanonavicular joint
transfers wt
Inversion and eversion
Ball and socket
head of talus is ball
Socket is form by the navicular, spring ligament and sustentaculum tali (at 2 sites)
Talus articulates with calcaneous in 3 areas

Question 5

Describe the cutaneous nerves of dorsal foot

Answer 5

Superficial nerve - dorsum of foot
pathway - divides above the ankle into medial and lateral branches
Sural - lateral foot and ankle
pieces crura fascia halfway down the calf
Saphenous - medial up to 2 MTP joint
divides into anterior and posterior above the medial malleolus
Deep fibular nerve - lateral of 1st digit and medial of 2rd digit.
cross lateral to dorsals pedis and then arises

Question 6

Veins of dorsal of foot

Answer 6

Dorsal arch to greater and lesser saphenous

Question 7

Describe the fascia of foot

Answer 7

Deep fascia over foot and thickening to produce reticulum

Question 8

Tendons of the dorsal of foot

Answer 8

Tibialis anterior
Extensor hallucus longest
Extensor digitorum longest
Fibularis tertius 
Each have a synovial sheath

Question 9

Muscles of dorsal foot

Answer 9

Extensor hallucus brevis 
N - deep fibular nerve
Extensor digitorum brevis
N - deep fibular nerve
dorsal Interosseos muscle

Question 10

Artery of dorsal foot

Answer 10

Dorsalis pedis - lateral to extensor hallucis longest and then between 1 and 2rd metatarsal and divides deep to anastomosis

Question 11

describe the skin on the plantar surface

Answer 11

Thin in arch and toe
Thick in ball and pad.
Fat for shock absorption
Anchored to plantar aponeurosis to allow grip

Question 12

Describe the cutaneous innervation of plantar surface

Answer 12

Branches of tibial n
Medial calcanea nerve - heel of foot then divides
Medial plantar - Pink - Supplies the first plantar surface and 3 medial toe
Lateral plantar - Yellow. distal lateral surface and 1 and 1/2 toes
Saphenous - blue Medial proximal
Sural - Red. lateral proximal area.

Question 13

Muscles of the 1st layer of plantar surface

Answer 13

Under plantar aponeurosis (o- calcaneous tubosity, inserts at digits, bifurcate to allow tendons through)
Abductor hallucis
Flexor digitoriumbrevis
Abductor digiti minimi

Question 14

Describe the abductor hallucis

Answer 14

O medial tubercle of tuberosity of calcaneous + flexor retinaculum + plantar aponeurosis
I - medial side of base of proximal phalanx of 1st digit
N - Medial plantar nerve
A - Abd and flexes great toe

Question 15

Describe Flexor digitorium brevis

Answer 15

O - Medial tubercle of tuberosity of calcaneous + plantar aponeurosis +intermuscular septa
I - Bother sides of phalanges of later four digits
N - Medial plantar nerve
A - Flexes lateral four digits

Question 16

Describe Abductor digiti minimi

Answer 16

O - Medial and lateral tubercles of tuberosity of calcaneus +plantar aponeurosis + inter muscular septa
I - Lateral side of base of proximal phalanx of 5th digit
N - Lateral plantar nerve
A - Abd and flexes 5th digit

Question 17

Muscles of 2rd layer of plantar aspect

Answer 17

Quadratus plantae
Lumbricals
Flexor Hallucis longus
Flexor digitorum longus

Question 18

Describe Quadratus plantae

Answer 18

O - Medial surface and lateral margin of plantar surface of calcaneous
I - Posterolateral margin of tendon of flexor digitorum longus
N - lateral plantar nerve
A - assists flexor digitorium longus in flexing lateral four digits

Question 19

Describe Lumbricals

Answer 19

O - tendons of flexor digitorum longus
I - medial aspect of expansion over lateral four digits
N - Medial one is medial plantar nerve and lateral three is lateral plantar nerve

Question 20

Describe the muscles of the 3rd layer of plantar surface

Answer 20

Flexor hallucis brevis
Adductor hallucis
Flexor digiti minimi

Question 21

Describe Flexor hallucis brevis

Answer 21

O plantar surfaces of cuboid and lateral cuneiforms
I Both sides of base of proximal phalanx of 1st digit
N- medial plantar
A - flexes great toe’s metatarsophalangeal joint
Description: Covers metatarsal 1, splits into two bellies,

Question 22

Describe Adductor hallucis

Answer 22

O - from bases of metatarsal 2-4 and from fibulas longs tendon sheath (oblique) from a ligament across metatarsophalageal joints
I - Base of proximal phalanx of great toe, lateral side
N - Lateral plantar nerve S2-3
A - Helps maintain the transverse arch of foot weak adductor of great toe
Description: Oblique and transverse heads, deep to lumbricals

Question 23

Describe the flexor digiti minimi

Answer 23

O - Base of metatarsal 5 and tendon sheath of fibulas longs
I - base of proximal phalanx of toe 5
N - lateral plantar nerve
A - Flexes little toe at metatarsophalangeal joint
Description: covers metatarsal 5

Question 24

Describe the contents of the 4th layer

Answer 24

Plantar and dorsal interossei
O - Metatarsal
I - proximal digits
N Lateral plantar nerve
Tendon of fibulas longus
Tendon of tibialis posterior

Question 25

Ligament of plantar foot

Answer 25

``` Long plantar ligament O - Calcanous tubosity I 4 metatarsal Short plantar ligament (Calcaneocuboid) O - same I - Cuboid bone Spring ligament (plantar calcaeonavicular ligament O - sustentaculum tali I Navicular Inmoble form joint ```

Question 26

Innervation of plantar foot

Answer 26

``` Tibia nerve>medial and lateral plantar n Lateral plantar Medical plantar nerve Larger Skin >muscles Medial 3 digit Didgt nerve supplies the great toe ```

Question 27

Arterial and veins supply of plantar foot

Answer 27

Posterior tibia artery > Medial and lateral artery Medial plantar artery Lateral plantar nerve Curve medially to form an arch and joins dorsals pedis and form plantar arch Gives raise to digit branches Vena commatanie Drain to deep veins unlike the dorsum which drain to superficial veins

Question 28

Describe the medial longitudinal arch

Answer 28

Bone: Calcaneous, talus, navicular, 3 cunieform and 3 metatarsal bases Bone not stabilise - shape of bones in arch Ligament - inadequate Plantar aponeurosis Spring ligament - head of talus Interoessuous ligament particular the talus and calcaneous one Muscle Flexor hallucis longus - most important Short muscle of the foot -1st layer Tibialis posterior and anterior - weaker

Question 29

Describe the lateral arch

Answer 29

Calcaneous, talus, cuboid and 2 metatarsal bases - no stability LIagment Plantar aponeurosis - bow spring Long and short plantar ligaments Muscles Fibularis longus Tendon - most important Lateral 2 tendon of flexor digitorum longest 1st layer lateral muscles

Question 30

Describe the Transverse arch

Answer 30

Cuboid and 3 cuneiform and base of all 5 metatarsals - none Ligaments Ligament of metatarsal and cuneiform bone together Transverse metatarsal ligament Muscles Fibularis longus tendon - most important.

Question 31

Components of the thoracic cage

Answer 31

``` Sternum Costal cartilage Ribs Thoracic vertebrae Intervertebrae disc ```

Question 32

describe the sternum

Answer 32

Manubrium Wider laterally Jugular notch Lateral is clavicular notch Lateral to that is the costal cartilage attachment of 1st rib Narrows inferiorly where it forms a synthesis with the body of sternum Hyaline cartilage with fibrocartilage disc between. 2rdary cartilaginous joint. 2rd Rib articulation here Body of stern Flat and made of 4 bone that fuse at 25 yr old lack of fusion of L to R =forament Xiphoid process Fuse to sternum at joint

Question 33

Describe the costal margin

Answer 33

``` 1-7 true 1st is usually fused 2-7 ribs: Synovial joint with fibrocartilagous joint to allow movement. Sternal costal ligament that strengthen the joint. 8-10 false 11-12 floating Function Allow movement during respiration ```

Question 34

Describe the thoracic vertebrae

Answer 34

``` Body - heart shaped Articular facet Demi facet Vertebrae arch pedicle lamina Spinous process Transverse process Facet for tubercle of rib Vertebrae foramen ```

Question 35

Describe Thoracic ribs

Answer 35

Head - widen with superior and inferior facet Neck - narrow between head and tubercle Tubercle Facet and attachment of costotransverse ligament Inferior edge Costal groove - neurvascular bundle. anterior end - cup shaped and costal cartilage here Superior and inferior margin for muscles attachment except the 1st and 12th rib 1st rib = half the length and boarder and curved only articulate with T1 not C7 10-12 ribs only one facet as it only articulates with one vertebrae 11-12 ribs are short and have no neck or tubercle thus no articulation with transverse process

Question 36

Describe the joints of thoracic cage

Answer 36

Costal joint - discussed above Costovertebral joints Head of rib articulates with superior facet of it’s own vertebrae and inferior facet of vertebrae above it. Supported by interarticular ligament to IVD Costotransverse joint (only on ribs 3-9) (1-2, 10-11-12 have larger ROM due to absence of this joint) Transverse process articulates with tubercle of it own rib Supported by costotransverse ligament and lateral costotransverse ligament (tubercle) and superior costotransverse ligament (neck of rib to transverse process of vertebrae above).

Question 37

Muscles of anterior thoracic wall

Answer 37

``` External intercostal Internal intercostal Innermost intercostal Subcostal Transversus thoracis ```

Question 38

Describe the external intercostal

Answer 38

Hands in pocket Elevates ribs during forced inspiration at the costal cartilage the muscle turns into the external intercostal membrane (aponeurosis)

Question 39

Describe Internal intercostal

Answer 39

hands in opposite pockets Interosseous part - depresses rib Interchandral part - elevates ribs Runs from sternum to angle of the rib where it become the internal intercostal membrane

Question 40

Describe the innermost intercostal

Answer 40

same as internal intercostal muscle. Neurovascular bundle travels between.

Question 41

Describe the subcostal

Answer 41

Lay on angle of the rib. Not always present and cross 2-3 ribs

Question 42

Describe the transverses thoracis

Answer 42

4 to 5 splits O - Xphoid process and posterior surface of lower sternum I - internal surface of costal cartilages 2-6. Fan out

Question 43

Describe the neurovascular bundle of the intercostal spaces

Answer 43

Sit in subcostal groove between internal intercostal muscle and innermost Tube insertion position Blocks need to be done and multiple levels due to innervation lap out Intercostal nerve from spinal roots of T1-11, intervertebral foramen then communications of sympathy chain (SNS and PNS) Branches Intercostal nerve - inferior margin of rib Collateral branch - superior margin of rib Lateral cutaneous branches (lateral thoracic wall) piece the external muscle and internal intercostal muscle then branch into posterior and anterior branch to supply lateral wall (not in first space) Anterior cutaneous branches piece the external muscle aponeurosis and internal intercostal muscle then branch into medial and lateral branch to supply anterior and lateral wall. (not in first space)

Question 44

Describe the areas that the nerve 5-12 supply

Answer 44

``` Skin Abdominal muscles Intercostal muscle subcostal Transversus thorscis Serratus posterior ```

Question 45

Describe the dermatomes of the thorax

Answer 45

The thoracic and abdomen wall is supplied by intercostal and subcostal nerve Umbilicus = T10 Nipple level = T4-5 Collar = C3 below collar but above sternal angle is C4 No overlap between C4 and T2

Question 46

Arteries that supply thoracic wall

Answer 46

Branches of subclavian A: Internal thoracic artery and Supreme intercostal arteries Posterior intercostal artery Subcostal artery axillary artery

Question 47

Describe the internal thoracic artery

Answer 47

lays lateral to the sternum running inferiorly supplies anterior intercostal arteries to spaces 1-6 collateral branch - travel superior to rib Larger than the posterior, anastomosis Pericardium Thymus sternum 2-4 intercostal artery supplies breast? Terminal branch - divides into superior epigastric and musculophrenic arteries at the 6th intercostal space

Question 48

Describe the supreme intercostal arteries

Answer 48

supplies the 1st and 2rd intercostal spaces there is no posterior intercostal branch at this level. the supreme branches from this subclavian and then head posterior prior to wrapping anterior to for fill a similar role as the posterior intercostal artery

Question 49

Describe the posterior intercostal artery

Answer 49

travel in costal groove sandwich between the veins and nerve give collateral artery as well close to the angle of the rib the arteries enter the costal grooves, where they lie between the intercostal vein and nerve. At first the arteries run in the endothoracic fascia between the parietal pleura and the internal intercostal membrane then run between the two muscles.

Question 50

Describe subcostal artery

Answer 50

supplies the 12th rib space and muscles of anterolateral abdominal wall travel along the inferior border of 12th rib

Question 51

Describe the venous drainage of thorax

Answer 51

each level has 1 posterior and 2 anterior veins Anterior drains into the muscophrenic and internal thoracic vessels Posterior 1st intercostal vein drains straight into the brachicephelic vein bilaterally Right 2rd and 3rd intercostal vein join to form the superior intercostal vein and drain into the azygos 2-3rd can drain either to brachiocephalic or accessory hemiazygos vein 4-8rd space drains to accessory hemiazygos vein Hemiazygos starts in the abdomen at the L renal vein. Left first rib can do either brachiocephalic or accessory hemiazygos vein Others Superficial vein radiate from umbilicus. if below the umbilicus they drain to great saphenous. If above lateral thoracic then axillary or to portal system

Question 52

Boundaries and contents of superior apertures

Answer 52

Bourdaries: anterior jugular notch, clavicular notches of manlunum, 1st rib and vertebrae body Contents: Trachea, oesophagus, great vessels, nerve.

Question 53

boundaries and contents of inferior apertures

Answer 53

Boudaries: xiphisternal joint anterior, costal margins and 12th rib posterior Closed by diaphragm

Question 54

Position of chest tube

Answer 54

Chest tube: 4th intercostal space in anterior axillary line. Avoids the long thoracic nerve and liver inserted superior to the 5th rib

Question 55

Describe the structure of diaphragm

Answer 55

Muscluar - radiate anterior - horizontal Posterior ventral central Tendon - at level of xiphisternum

Question 56

describe the structures that pass through the diaphragm

Answer 56

T8 = IVC Via the central tendon. When diaphragm contracts the opening is opened and increase venous return to heart. R phrenic n and Lymph vessel pass T10 = Oesophagus Muscular part Anterior and posterior vagal trunks pass as well vein and lymph as well T12 = Aorta Pass behind the median arcuate ligament azygous vein and thorax duct Hemiazygos vein passing through the L crura Splenic nerve piece each crura Sympathic trunk passing behind the medial arcuate ligament subcostal nerve and vessel pass under the lateral arcuate ligament Left phrenic nerve pieces the L dome lateral to pericardium Neurovascular bundles T 7 to T 11 that pass between digitation of of the attachment to costal margins Superior epigastric pass between the xiphisternum and costal margins of the diaphragm

Question 57

Describe the attachment of diaphragm

Answer 57

Crura - attaches to L1-3 on R and L1-2 on L R crura divides to the left to surround the oesophagus and together with L form the median arcuate ligament. Lateral to mid line is the medial and lateral arcuate ligament that anchor the diaphragm to posterior wall. This allows the psoas major and quadrates lumborum muscles to pass.

Question 58

Describe the blood supply of diaphragm

Answer 58

From the lower 5 intercostal and subcostal arteries | Abdominal side is supplied by inferior phrenic arteries from the aorta

Question 59

Innervation of diaphragm

Answer 59

Phrenic nerve (C3,4,5) Descend posteriolateral to internal jugular veins Descend anterior to root of lungs on the surface of pericardium R is associated with venous- descends Posterior to SVC, R artium of heart and then passes through the IVC of diaphragm L is associated with arterial - descends between the carotid and subclavium arteries and lays of aortic arch and then the Left auricle and ventricle and pieces diaphragm lateral to pericardium through the muscles Both divide into anterior, posterior and lateral branches

Question 60

Describe the function of diaphragm

Answer 60

Inspiration Opens IVC increase venous return Sphincter to oesophagus

Question 61

describe the movement of thorax

Answer 61

Increase in diameter in all three planes. Pump- handle movements Direction of movement. A-P. Joint: Manbosternum joint, Costovertebral joints True ribs Muscles: Intercostal Bucket handle movement Direction of movement:Lateral, transverse Joint: 8-12 ribs Muscles: abdominal muscle hold 12th rib Diaphragm Direction of movement: vertical Muscles: Diaphragm Quiet inspiratory: intercostal and scalene Deep inspiratory: Accessory muscles added Expiratory : Abdominal muscle