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62nd Sem: Movement Science > Exam 2 > Flashcards

Flashcards in Exam 2 Deck (109):
1

Below are flashcards on 2.1 - Whole Spine

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2

How many specific vertebrae do you have at each level of the spine:

Cervical: 7
Thoracic: 12
Lumbar: 5
Sacral: 5 (sometimes 6 in some)
Coccyx: 4 (sometimes 3 if some fuze together)

33 total ... some count sacrum as 1, and coccyx as 1

3

Review the spinal curves of the back:

REMEMBER: Lordosis is LUMBAR ... so if Lumbar is Lordosis, so much cervical area. The other two must be opposite = kyphosis.

Cervical: Lordosis
Thoracic: Kyphosis
Lumbar: Lordosis
Sacral: Kyphosis

4

What is the line of gravity in "Zero" standing position:

From external auditory meatus (lateral side) ...
Come down through C2 dens ....
Then down the posterior side of cervical vertebrae (since it is Lordosis going forward) ...
Then anterior side of the thoracic vertebrae (since they are kyphosis) ...

*** Goes through C2, then C7/T1, then T12/L1, Then L5/S1

5

What are the main bony features of a typical vertebrae (all vertebrae):

Body
Pedicle
Lamina
Arch
Sup / Inf Articular processes
Transverse processes
Spinous process
Intervertebral foramen (for spinal nerve)
Vertebral foramen (vertebral foramina for spinal cord)
Superior / inferior vertebral notch

6

A typical vertebral BODY has 2 main parts, explain each:


Which of those two areas is cortical and which is cancellous bone?

1) Epiphyseal end plate: This is the OUTER growth plate of a vertebrae (body). So in an adult skeleton this outer area will be fuzed, but in an immature skeleton you'd see some hyaline cartilage suggesting growth.

2) Cartilaginous end plate: The INNER portion which remains as hyaline cartilage throughout adulthood. It has many holes / perforations in the hyaline cartilage where blood vessels can go through and feed IV discs above/below.

OUTER epiphyseal end plate is hard CORTICAL. INNER cartilaginous end plate is CANCELLOUS bone.

7

1) What are 2 reasons that having cancellous bone is important in the body of a vertebrae:

2) Can weight / stress placed on a superior articular process, for example, be redistributed to the body of the vertebrae?

3) Can forces on vertebral body be transferred into vertebral arch?

4) Do these cancellous bony parts intersect? Why?

1)
- It helps distribute the stress / weight / forces on spinal column.
- It allows blood vessels (and bone marrow ... create new blood cells) to go up/down to IV discs to nourish and supply IV discs.

2) Yes. The cancellous bone has both vertical and horizontal cancellous bone to help distribute weight across the vertebrae.

3) Yes.

4) Yes - the intersection creates the winding/binding together, thus the strength.

8

1) About what age do blood vessels STOP passing through IV discs and cancellous bone?

What does that mean about injury and aging?

1) After age 8, blood vessels stop passing through vertebrae. The older one gets, the fewer blood vessels pass blood through. So injury at young age gets blood so can heal quicker, but older a person gets they lose blood to those areas so bone can't heal.

SO, movement makes IV Discs pass fluid through IV discs. So movement is KEY to help spine stay healthy and be able to move. More you move, the more your joints get nourished / lubricated.

9

What area of a vertebrae is area of WEAKNESS. Why?

An area of weakness in body of vertebrae is ANTERIOR since there are fewer intersections of cancellous bone. Most likely area of a crush or WEDGE or injury is the ANTERIOR part of vertebral body (collapses down).

10

1) Explain the 2 main structures of an IV disc

1A) Describe the orientation of fibers of the annulus fibrosus ... and why

2) What are these 2 composed of

3) What are Sharpey's fibers?












4) Describe the movement of the 2 parts of the IV disc










5) Does the annulus fibrosus have ability to resist compression forces (from weight above)? Is it as good at resisting compression as nucleus pulposus?


6) You know what a herniated disc is, but where typically does breakdown of an annulus fibrosus take place?

7) If you FLEX back, what part of disc is compressed? If you EXTEND back, what part of disc is compressed?

8) So if you do FLEXION, what happens to the POSTERIOR part of the disc? Does it go on tension or compression?

1) Has an annulus fibrosus on the outside, and nucleus pulposus on inside.

1A) The annulus fibrosus is like a tree - it has rings or layers / lamina. The fibers of the outer ring go in a perpendicular orientation to the next layer down. And it keeps going alternating like this down to the nucleus pulposus. Why? So if you do TORSION, one layer goes on stretch (to RESIST torsion), the other layer just deep goes on slack. The layers rubbing against each other help create grip / friction / resistance to weight pushing IV disc out.

2)
Nucleus Pulposus: Primarily WATER (glyco cymetoglycan) Fibers (gel / squishy, absorbs weight).

Annulus Fibrosus: Fibrocartilaginous rings (layers)

3) Sharpey's fibers are what anchor the IV disc to the Vertebral body. Otherwise, how do they stay connected together (lots of ligaments hold vertebrae together, but sharpey's fibers hold IV disc to vertebral body)? They need to be anchored together - that is what Sharpey's fibers are.

4) 1A above talks about how the fiber orientation of the annulus fibrosus layers go in diff directions to help with torsion. But also, when force/weight is placed DOWN VERTICALLY onto a IV disc, naturally the nuceus pulposus will get pressed down and squeezed out in all directions. The annulus fibrosus layers will contain it from popping or being compressed too much, and these annulus fibrosus layers will SHEAR during that expansion/tension. As annulus fibrosus resists the expansion, it naturally expands, and the layers of fibers will SHEAR as they act against each other as they expand.

5) Annulus fibrosus can take some compession, but when weight is placed on back, the nucleus pulposus takes most of the compression force.

6) Postero-LATERAL corner of the IV disc.

7) Flexion will make ANTERIOR disc compressed/bulge. Extension will make POSTERIOR disc compressed/bulge.

8) It goes on TENSION

11

1) If you do back flexion, what happens to the INFERIOR articular process?

2) If you do back FLEXION, will the anterior annulus fibrosus be on compression or tension

3) During flexion, which way does nucleus pulposus want to go (to pop out)?

4) If you do EXTENSION, will anterior annulus go on compression or tension?

5) During back extension, which way does nucleus pulposus want to go (pop out)?

6) Are the intervetebral joints (sup/inf articular processes) being opened or closed during extension?

1) It goes UP ... opening that joint.

2) Compression

3) Posterior

4) Tension

5) Anterior

6) Closed

12

1) If you do back FLEXION, what limits that motion?

2) T or F: All diarthrodial (synovial) joints have a capsule

3) If you do back EXTENSION, what limits that motion?

4) Pushing / pressing two joint surfaces together is called? Is this the same as opposition?

1) CAPSULE and LOTS of Ligaments (supraspinous lig, interspinous lig, ligamentum flavum, somewhat the post. longitudinal lig). So flexion is limited by soft tissues / ligament tissues.

2) True

3) Primarily bony prominences running into each other ... Sup and Inf. articular processes limit this movement. Plus, a little from the ant. longitudinal lig.

4) Apposition. Apposition is when two surfaces are pressed together. OPPOSITION is when two surfaces oppose each other.

13

How does a IV disc and vertebral body get nourished?

Is it active or passive?

Nourishment comes from MOVEMENT. As you move, nucleus pulposus/annulus fibrosus nourishes vertebral bodies.

NUTRITION OF IV DISC IS PASSIVE.

14

1) Are ligaments innervated and have a nerve supply?

2) Is fibrocartilage innervated with a nerve and blood supply?

2A) Can hyaline cartilage repair itself after an injury?

2B) Is articular cartilage hyaline cartilage

3) Is Annulus fibrosus fibrocartilage?

4) Is annulus fibrosus innervated with nerve and blood supply?

1) YES

2) NO

2A) Cartilage has limited repair capabilities: Because chondrocytes are bound in lacunae, they cannot migrate to damaged areas. ... Also, because hyaline cartilage does not have a blood supply, the deposition of new matrix is slow. Damaged hyaline cartilage is usually replaced by fibrocartilage scar tissue.

2B) YES

3) YES

4) Well ... no. But since the outer layers are right next to all those lig's which do get blood and nerve supply, so the few outer layers of the annulus fibrosus do get some nerve and blood supply as a result.

15

1) Remember he talked about the Nachemson and Wilke study. What was it?

2) What is normal upright standing position =

3) Will IV disc pressure increase or decrease in a slightly FLEXED back position?

4) Will IV disc pressure increase or decrease in a slightly EXTENDED back position?

5) Why is EXTENDED LESS pressure?

5A) Why is FLEXED MORE pressure

6) What will laying sideline or lazy-boy with back inclined do to IV disc pressure

7) What about supine position?

1) They put needles from skin all the way into IV discs AT LUMBAR SPINE AREA of people in varying postures. They measured different changes in IV disc pressure in various posture positions.

2) Normal upright = 100% pressure on IV disc holding weight of body.

3) Flexed position will INCREASE IV disc pressure

4) Extended position will DECREASE IV disc pressure

5) Because instead of the IV disc taking all the weight, the extended position puts the SUP and INF articular processes touching, so bone on bone helps take off pressure from the IV disc.

5A) Because no bony prominences to help distribute weight, so much more of the weight / pressure falls on IV disc.

6) These will decrease IV disc pressure.

7) Supine will take off LOTS of pressure.

16

For the ligaments below ... explain where they start, where they end, and their function:

- Anterior Longitudinal Lig:
- Posterior Longitudinal Lig:
- Supraspinous Lig:
- Interspinous Lig:
- Ligamentum Flavum:
- Intertransverse Lig's:

- Anterior Longitudinal Lig: From occiput to anterior body of vertebrae (and IV discs) down to sacrum. Purpose is to hold vertebrae together and prevent too much EXTENSION.

- Posterior Longitudinal Lig: TECHNICALLY it begins at C2. From Occiput or foramen magnum down to C2 it is the TECTORIAL MEMBRANE. But then goes from posterior bodies (and IV discs) of vertebrae down to coccyx. It's purpose is to hold vertebrae in place, and prevent too much FLEXION.

- Supraspinous Lig: From ext. occipital protuberance down (is the nuchal lig in cervical area) to posterior part of spinous processes down to L5/S1. It prevents too much movement of spinous processes / holds them together. First to go on stretch during flexion. Becomes slack during extension.

- Interspinous Lig: Between adjacent spinous processes from C2 to L5/Sacrum. Same purpose as supraspinous lig.

- Ligamentum Flavum: Lig between adjacent lamina. From C2 to Sacrum (above C2 they are the ant/post occipital membrane/lig). Attach to the joint capsules of the facets and between lamina's. High elastic fiber content to assist in upright posture, and pull joint capsule out of the way when capsule placed on slack.

- Intertransverse Lig's: Lig's between adjacent transverse processes. Small role in restraining side bending, and place for muscle attachment.

(*** These all thicken as you descend inferiorly).

17

1) Facet joints in Vertebrae are what type of joint:

2) IV discs are what type of joint:

3) Would posterior long. ligament be placed on compression or tension during back flexion?

4) Would a compression stress, tension stress, or shearing stress be strongest, or be able to resist the most amount of stess/force? Rank them.

1) Diarthrodial (synovial) - Plane synovial

2) Fibrocartilaginous

3) Tension

4) Compression is strongest/most, then tension, and shearing is weakest.

18

1) Which spine region allows greatest amount of movement, and why?

2) Which back area has very limited ROTATION movement, and why?

3) Which back area has very limited FLEXION/EXTENSION movement, and why?

1) Cervical. Specifically upper cervical. Because sup/inf articular processes are basically flat (facing up) on top of each other, allowing flexion/extension, rotation, side bending. Angle changes as you go caudally down cervical vertebrae.

2) LUMBAR, because sup /inf articular processes are angled postero-medially. So you can do some flexion/extension, but little rotation.

3) THORAX area, because the sup articular processes is angled posteriorly and sup/inferiorly, and inf. articular process (facet) is angled anteriorly (and up/down). And giraffe spinous process beaks run into each other. So flexion/extension is limited.

19

1) What provides STABILITY to Back


2) What do muscles specifically do to help with stability?


3) T or F: The amount of movement of the back is limited by all the things listed in point #1?

4) T or F: The amount of movement of the back is not impacted by the thickness of the IV disc?

5) T or F: The facet joint orientation impacts the back's stability and mobility?

1)
- Intact nucleus pulposus and annulus fibrosus (IV discs)
- Orientation of facet joints (with associated capsules)
- Muscles
- Lig's
- Ribs and sternum
- Inter-abdominal and inter-thoracic pressure

2) Muscles help create a compressive force to counter any tension or shearing stress movement.

3) True

4) FALSE. A thicker disc would naturally allow more movement (more flexion/extension, side bending). One of the other reasons you can do more flexion/extension in lumbar region.

5) True. If sup/inf. facet joints are apposed, they help create stability during movement or weight bearing. Plus, they ultimately determine how much / little movement can take place based on their orientation.

20

What is the term for creating Inter-abdominal and inter-thoracic pressure?

What is it and why would you do it (and how)?

Valsalva maneuver

Take huge breath in, fill up lungs, close off your glottis and anus, and just hold pressure in, it will create inner abdominal pressure area that creates stiffness, helping support the spine.

21

1) T or F: If you imagine a ligament around a joint, the further out the ligament fiber is from the AOR, the less it will be stretched?

2) So during back flexion, which lig is going to be stretched the most?

3) Which lig will go on stretch first during back extension?

4) What lig is placed on SLACK during flexion?

5) Rotation of the spine is based primarily on what?

1) FALSE. The point or fibers furthest from the AOR will experience the most stretch, pull, tension.

2) Supraspinous lig. (It's the farthest away from AOR during flexion movement)

3) Anterior longitudinal ligament

4) Anterior longitudinal ligament

5) Orientation of the facet joints

22

Remember the diagrams that show where the instantaneous AOR is in cervical, thoracic, and lumbar vertebrae during movement. For those listed below, describe where AOR is:

Cervical:
- Flexion/Extension:
- Lateral Side bending:
- Rotation:

Thoracic:
- Flexion/Extension:
- Lateral Side bending:
- Rotation:

Lumbar:
- Flexion/Extension:
- Lateral Side bending:
- Rotation:

Cervical:
- Flexion/Extension: Anterior vertebral body
- Lateral Side bending: ?
- Rotation: Middle vertebral body

Thoracic:
- Flexion/Extension: Middle vertebral body
- Lateral Side bending: R/L side of vertebral body
- Rotation: Middle vertebral body

Lumbar:
- Flexion/Extension: **** Flexion in front vertebral body, extension in back of vertebral body
- Lateral Side bending: R/L side of vertebral body
- Rotation: Middle vertebral body

23

COUPLING:

1) What is a coupling pattern?

2) Generally, if you go from erect spinal position and laterally bend left, the RIGHT side of the facet joints will _______, and the LEFT side of the facet joints will ________

3) So with coupling though, if you side bend to the left, what happens in each area of the spine:

1) When you do one motion, what other motions secondarily occur as a result?

2)
RIGHT: Pull apart (open)
LEFT: Go together (close)

3)

C2-T1:
- Vertebral body will also rotate left, and so spinous process will go right. ****
- Rotation and side bending (coupling) goes to SAME side

T1-T4:
- Same as above.

T4-T8 and T8-L1:
- There is no predictable pattern. You can't predict it in Thoracic spine because of the rib cage attached.

Lumbar Spine:
- In left side bending, spinous process moves same direction (LEFT), but that means the vertebral body is moving to the RIGHT.
- Rotation and coupling goes to OPPOSITE side

24

1) What is 'lower cervical spine'

1A) Most of the cervical motion occurs where?

2) T or F: In lower cervical spine, vertebral body rotation and side bending occur to same side

2A) In cervical area, if I rotate or side bend to the left, what happens to spinous process?

3) T or F: Upper thoracic spine behaves the same as lower cervical spine?

4) T or F: The upper thoracic spine (T1-T4) act as a "unit" together with lower cervical spine (C2-T1)

5) T or F: In middle to lower thoracic spine, there is NO predictable pattern for movement to right or left with side bending and rotation

6) In lumbar spine, if you do left side bending, which way will spinous process go?

7) In lumbar spine, if you do left side bending, which way will vertebral body go?

8) In cervical spine, rotation and side bending are coupled to _______ side.

9) In lumbar spine, rotation and side bending are coupled to _______ sides?

1) C2-T1

1A) C1 and C2 (O/A joint and A/A joint)

2) True. If I side bend to the left, rotation of vertebral body to the left also naturally occurs.

2A) Goes to the RIGHT

3) True

4) True

5) True

6) Spinous process goes LEFT

7) Vertebral body goes RIGHT

8) SAME

9) Opposite

25

1) Is Dura tough and resiliant, or soft and elastic?

2) Dura starts where and ends where?

3) Would Dura get stretched during flexion or extension? WHY?

4) Is dura innervated?

5) If dura gets impinged (in IV foramina), how do you relive pressure?

1) Dura is a tough covering, non-compliant, or resiliently elastic.

2) Dura goes from foramen magnum down to sacrum ... and goes out to periosteum around IV foramen.

3) Dura gets stretched during FLEXION, but shortens during extension. Why? Because spinal cord is POSTERIOR to the AOR during Flexion. AOR is vertebral bodies, which are ANTERIOR to spinal cord. Thus, it compresses during extension.

4) Yes. Dura is well innervated (Pia and arachnoid mater have little nerve supply).

5) STRAIGHT LEG RAISE / CHIN TUCK. If dura gets pinched, you'd need to relieved pressure. How? Raise patients leg (keeping knee extended and hip flexed) to stretch out those nerves, and put chin to their chest. This stretches out entire. NERVE FLOSSING. So pt raises leg and that hurts in back. Then separately they do a chin tuck and that hurts same place in back ... probably a dura impingement.

26

1) Borders of IV foramina where spinal nerves come out?

2) Of the borders of the IV foramina, what parts are innervated.

3) As spinal nerve exits the IV foramina, what covers or surrounds it?

4) Is IV foramen longer or shorter in cervical spine?

4A) What is found in IV foramina, or what's its contents?

5) After the dorsal and ventral roots get to the IV foramen, they join to become a "spinal nerve" ... but there is a part that loops back around and back into IV foramen and then back into spinal cord. What is that called (two names)?

6) Does the nerve from #5 carry somatic (muscle) or autonomic nerve fibers? And why?

7) Do ligaments have blood vessels?

8) Do joint capsules have blood vessels?

9) How does posterior longitudinal ligament get innervated?

1) IV foramina (canal) is formed by: pedicles (above and below), lamina (above and below posteriorly), facet joints, and IV discs anteriorly with the post. long. Lig.

2) Bone (periosteum) is innervated, IV disc is not too much, but post. Long. Lig and ligamentum flavum are very innervated. Facet capsules are innervated. So IV foramina is very well innervated.

3) Dura mater

4) Longer in cervical, shorter in thoracic and lumbar spine.

4A) The nerve roots take up only 20 - 25% of the total available space in the IV foramen. The remaining space is filled with fat, blood vessels, connective tissue and lymph
vessels which form a protective envelope. The sinu-vertebral nerve is also found in the IV Foramen

5) The recurrent spinal meningeal nerve (also called SINU vertebral nerve).

6) Autonomic ... so has sensory (not motor) fibers. Ligaments and joint capsules all have vessels and nerves - so the recurrent spinal meningeal nerve goes BACK into spinal column to give nervous innervation to meningies, ligaments, periosteum in spinal column.

7) YES

8) YES ... all diarthrodial (synovial) joints have blood vessels.

9) The recurrent spinal meningeal nerve (also called SINU vertebral nerve).

27

1) So as spinal nerve (combined dorsal and ventral roots) joins and exits IV foramina, it branches into how many - and what nerve branches?

2) Explain details and function of each of the nerves from #1


3) What is special about recurrent spinal meningeal nerves C1-C3:







3A) This special nerve is called: ****

4) Why is injuring the nerve from #3A bad?

1 ) 4 total. Dorsal primary ramus, ventral primary ramus, ramus communicans, recurrent spinal meningeal nerve.

2)
- Dorsal Primary Ramus: gives sensory innervation to back and skin in back. And gives Motor innervation to back muscles

- Ventral Primary Ramus: Sensory and motor innervation to front

- Ramus Communicans: Innervation to sympathetic trunk/chain

- Recurrrent Spinal Meningeal Nerve: See flashcard above, but primarily innervates inside spinal canal: lig's, meningies, blood vessels, periosteum, external lamella of IV disc.

3) The recurrent spinal meningeal nerves of C1, C2 and C3 join inside the spinal canal to ASCEND UP into the skull via the foramen magnum and supply the dura of the posterior cranial fossa.

3A) The joined nerve is called the Posterior Meningeal Nerve.

4) Since the Posterior Meningeal nerve innervates dura and periosteum of cerebellum area, you injure that nerve and you'll get dizzyness and vision problems since the cerebellum has those functions.

28

Internal spinal pain (meningies) is specific or general?

Why?

It is general, but specific by region. So you know it is in lumbar or cervical region, but can not pin point pain specifically to a certain area.

Why? Cause the recurrent spinal meningeal nerve innervates the area with it's friends a few levels up/down ... pain radiates between 3-6 levels.

29

1) What is the straight leg raise test (with chin tuck)?

2) What is the slump test?

3) Why are these tests used?

1) Patient will lift leg out with knee extended. Do a chin tuck too for added measure. This stretches spinal cord (dura mater) and sciatic nerve all the way up to spinal cord to brain to tips of toes.

2) Patient slumps over flexing (to elongate spinal cord and dura mater). Then lifts leg out with knee extended, and dorsiflexes foot. Basically elongate the entire spinal cord down through sciatic nerve from head to toe.

3) Why? To detect and hopefully relieve nerve impingement (or dura impingement) at a spinal root / IV foramina. Nerve flossing.

30

Another name for the Recurrent Spinal Meningeal nerve?

Sinu-vertebral nerve

31

Below are flashcards for 2.2 Cervical Spine

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32

1) Why do vertebral bodies get larger as you move down the spinal column?

2) Is a cervical vertebrae body wider from side to side, or from front to back?

3) What is the small upward bony prominence on lateral sides of cervical vertebrae body? What is it and why?

4) What is the Lushka joint? Is it an actual joint?
(**** how to remember)

5) What are the "typical" cervical vertebrae?

6) Many cervical vertebrae's spinous process is unique. What is it and what is it called?

6A) Why do cervical vertebrae have bifid spinous processes?

7) What passes through the transverse foramen / foramina in cervical vertebrae?

8) Cervical transverse processes function is primarily for what?

9) Is the angle of facet joints different in C1 to C3 to C7? How?

10) The "average" angle of facet joints in cervical vertebrae is what?

11) What is the type of articulation of these facet joints?

12) Which way does the Superior articular process face in the 'typical' cervical vertebrae?

13) Which way does the Inferior articular process face in cervical vertebrae?

14) What is unique about C1, C2, C6, and C7 vertebrae:

1) Because the body holds the weight of everything above, so the lower you go, the more weight it needs to carry.

2) Side to side is wider.

3) Uncinate process. It essentially is a bumper that holds the upper vertebral body above in place during movement. So it is primarily for SIDE BENDING block.

4) It is where the uncinate processes come up ... but it is not a joint with a joint cavity with blood supply. Just a bumper.
(The 'luge' is a narrow track with big bumpers on the side so you don't fly off track)

5) C3-C6. C1 and C2 are unique, and even C7 has unique spinous process and looks like a thoracic vertebrae.

6) Bifid spinous process projection at end of spinous process.

6A) For the nuchal ligament to run through.

7) Vertebral artery

8) Muscle attachment for scalenes, splenius cervicis, levator scapulae, and longissimus muscles.

9) YES. The angle goes from very flat in C1 to almost straight up and down in C7 (like in thoracic vertebrae).

10) 45 degrees

11) They are diarthrodial (synovial) ... but PLANE joints. A plane joint is a flat surface on another flat surface. Apposition.

12) Posterior and superiorly (at increasing angle as you descend)

13) Anterior and inferiorly

14)
C1: atlas, holds skull, does "yes" nodding
C2: dens, does "no" rotation
C6: Palpable tubercle of C6 = carotid tubercle (then you can't palpate transverse processes after this point)
C7: Vertebral prominence (palpable spinous process)

33

Know in general how many degrees of movement C-spine allows in Flexion, Extension, Side Bending, and Rotation.

And specifically how much of that total movement is made at AO and AA joints compared to lower C3-C7 spine.


Total Upper Lower
C-spine C-spine
(OA and AA)

Flexion: 60 - 75 5 and 5 50 - 65
Extension 50 - 75 10 and 5 35 - 60
Side Bending (one side) 40 - 65 2 and 5 33 - 58
Rotation (one side) 80 - 95 2 and 45 33 - 48

34

1) Why is cervical spine Lordosis?

2) T or F: The annulus fibrosus forms the majority of the IV disc in cervical spine?
(*** how to remember)

1) Because the annulus fibrosus or IV disc is bulged anteriorly naturally in c-spine.

2) False. The nucleus pulposus forms the majority of IV disc in cervical spine area.
(You need more annulus fibrosus down lower to help constrict the increasing weight placed on nuclues pulposus down lower in spine)

35

C1:

1) Another name for C1

2) Does C1 have a vertebral body?

3) Is there a disc between C1 and skull?

4) Is there a disc between C1 and C2?

4A) Is there a disc between C2 and C3

5) Can you palpate posterior tubercle of C1?

6) How many synovial joints are on C1

6A)
- The joint of the dens with C1 is what type of joint?
- The joint with condyles of occipital bone are what type of joints?
- The joint between C1 and C2 is what type of joint?

7) The peanut shaped joints of C1 are what:

8) Explain the route of the vertebral artery

9) What happens if you injure vertebral artery?

10) Are condyles of skull the concave or convex members in that AO joint? So where does AOR go through?

11) Does AO joint allow more flexion or extension?

1) Atlas

2) NO

3) NO

4) NO

4A) YES

5) Not usually ... very hard to palpate in most people

6) 5 TOTAL: 1 on posterior side of anterior arch for articulation with dens, 2 lateral masses / sup. articular processes to hold up skull (articulate with condyles of foramen magnum), 2 below for A/A joint

6A)
- Pivot joint
- Condylar joints
- Plane joint

7) They are the superior articular processes of C1 that articulate with condyles of skull.

8) The vertebral artery runs up the transverse foramina of cervical vertebrae, but above C1, it actually then goes posterior and medial (through groove for vertebral artery) to go to vertebral foramen to then ascend up into foramen magnum (to supply blood to posterior cranial fossa).

9) If cervical spine gets injured or twisted you can ruin vertebral artery (and nerves). So a lot of PT's avoid doing neck manipulations to avoid doing injury of cervical spine. It is so dangerous. If you are not careful, you can impinge the vertebral artery, which can cause major issues / headaches / head pain / dizziness / vision problems. Be so careful.

10) Convex ... AOR goes through the Convex member.

11) Extension.

36

C2:

1) Another name for C2

2) Does C2 have a body?

3) Unique feature of C2 (and another name for this is:)

4)
- How many facets are part of C2 - what are they?
- Type of joint with Dens and C1
- Type of joint with sup. articular processes
- Type of joint with inf. articular processes

5) Is Dens articulation with Atlas a synovial joint?

6) Describe uniqueness of C2's body

7)
- Can you palpate spinous process of C1?
- Can you palpate transverse process of C1?
- Can you palpate spinous process of C2?
- When can you NOT palpate transverse processes?

8) Where is AOR for C2?

1) Axis

2) Yes (although it's not a typical one like all others below)

3) Dens (Odontoid process)

4)
6 total
- 1 is the anterior facet at anterior tip of dens to allow rotation with C1. 1 posterior on the dens to articulate with the transverse/cruciform ligament. 2 superior articular processes / facets to articulate with C1. 2 inferior articular processes / facets.
- Pivot joint
- Plate / Plane joint
- Plane

5) Yes

6) Not a typical body, and the bottom part protrudes / projects down like a beak (probably to hold IV disc of C3 in place).

7)
- No
- Yes
- Usually yes you can.
- About C6

8) Tip of the dens

37

1) Describe the joint and interaction of C1 and C2 at the sup. articular surface of C2 with the inferior articular surface of C1.

2) T or F: Whether rotating to the Right or Left, the AA joint will experience the Atlas descending down onto Axis during both movements? Explain.

3) Is joint capsule on stretch or slack during normal position (for AA joint)

4) So if someone hurts their neck at AA joint, what will they naturally do?

1) Remember the AA joint is unique where the inf. articular processes of C1 are convex, and sup. articular process of C2 are also convex. SO in neutral position, the sit on the high points of the facet (like a dinner plate on a shoulder)

2) True. Because it is a "plate on a shoulder" it will slide DOWN whether you look left or right.

3) Stretch.

4) They will go to a LEAST packed position and put capsule on slack, by slightly bending or TURNING head to the side to give relief.

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LIGAMENTS BETWEEN C1 and C2:

1) Are there IV discs for the AO and AA joints? Why is that important to know?

2) So what gives STABILITY to the Upper c-spine (C1 and C2)?

3) Explain extrinsic and intrinsic lig's of upper c-spine ... and explain each's function/purpose.

1) NO. So IV discs (like in lower spine) help provide stability during compressive forces, and OA and AA don't have those, so they have to get their stability elsewhere ...

2) Ligaments

3)
Extrinsic Lig's:
- Anterior longitudinal lig
- Capsular Ligaments
- Anterior atlanto-occipital membrane (A/O lig)
- Anterior atlanto-axial lig
- Posterior atlanto-occipital membrane (A/O lig)
- Posterior atlanto-axial ligament
- Lateral atlanto-occipital membrane (ligament) which joins the anterior and posterior a/o ligaments like a shower curtain.

Intrinsic Ligaments (inside spinal canal)
- Tectorial membrane (becomes post. long. lig)
- Alar ligaments (odontoid ligaments -or- check ligaments)
- Transverse lig
- Longitudinal lig
- Cruciform lig
- Apical lig (Suspensory ligament)

- Alar lig: goes from each side of dens to condyles of occipital bone (foramen magnum). Stability for dens, and limits flexion and rotation. Depending on which way you rotate, one will go on stretch.
- Transverse lig: goes across the posterior side of dens to hold it in place
- Cruciform lig: Has 2 bands, the transverse lig and longitudinal lig. Both hold dens in place.
- Tectorial membrane: Comes off occipital bone down into spinal column to hold dens and vertebrae in place ... become posterior longitudinal lig. at around C3
- Capsular lig's of FACET joints between Atlas and Axis
- Apical lig: goes from tip of dens up to ant. part of foramen magnum. Most say there is no real function ... but maybe to help stabilize dens.

39

1) Do the anterior and posterior (and thus lateral) atlanto-occipital membrane/ligaments attach to C1?

2) Explain how the name of the lig in #1 changes as you descend down cervical spine

3) The layer of ligaments closest to the actual spinal cord in the spinal column on the anterior side (but posterior the vertebral bodies) is called what in the upper c-spine, and what in lower c-spine?

4) SO what is deep to the ligament from #3 above?

5) T or F: transverse lig. is part of the cruciform lig

6) Explain why the Alar and Cruciform lig's are SO important

7) Is their an articular disc between the dens and posterior part of the anterior arch of C1?

8) Is the posterior part of dens and the cruciate lig articulation a synovial joint?

9) If you look / rotate head to the left, which Alar ligament will get placed on stretch, which will be on slack?

1) They actually go from Occipital bone to C2, and C1 acts as a WASHER between.

2) It comes off skull as ant/post atlanto occipital membrane, then between C1 and C2 is ant/post atlanto axial ligament. Then after C2 it is essentially the ligamentum flavum (continuing down spinal column).

3) Upper c-spine it is tectorial membrane, then becomes post. longitudinal lig. (AT C3) in lower c-spine. But it is the SAME ligament, just a name change.

4) Cruciform lig (transverse lig and longitudinal lig), and Alar lig from dens to condyles, and also Apical lig.

5) True (so is longitudinal lig)

6) They hold the dens in place with ant. arch of C1. If they are broken, C1 can drift forward, and impinge the spinal cord. That would be paralysis or death!

7) Yes. It is a synovial joint.

8) NO. But it does have a bursa to reduce friction between the dens/bone and ligaments holding it in place.

9) Right Alar lig on stretch, Left Alar lig on slack.

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What nerve keeps you breathing? How do you remember


First place an IV disc shows up?

Phrenic nerve ... it innervates diaphragm ... comes off of C3, C4, C5 ... keeps you alive.

Between C2 and C3

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1) Explain the rythm or the movement of CERVICAL FLEXION. What happens in succession?

2) What will stretch first during flexion, the ligamentum flavum or the posterior longitudinal lig?

3) What happens to the inferior facets as you do flexion in c-spine?

4) So how does the return from flexion happen?

1) First thing to move is skull on C1 (chin to chest). First 10 degrees is O/A/A joint (5 degress from O/A). When posterior atlanto-occipital lig stretches, then lower c-spine movement occurs. So now C2 moves, and joint capsule and cruciate lig restricts it. So C3 moves. Then ligamentum flavum and supraspinous lig restricts it. Then C4, etc. The farther you flex, the more these tighten.

2) Tightening happens from outer to inner / superficial to deep. And movement happens cranially to caudally. So because post. long. lig. is more interior, it will get stretched LAST.

3) The inferior facets of the lower c-spine glide symmetrically UPWARD on the superior facets during flexion.

4) The return from full flexion to neutral is the reverse of this process.

42

1) Explain the rhythm or movement of CERVICAL EXTENSION. What happens in succession?



2) So what primarily limits cervical flexion? What primarily limits cervical extension?

1) The first 10 to 15 degrees of motion is due to movement at the O/A/A joint complex. This movement is blocked when the posterior edges of the superior facets of C1 lock into the condylar fossa of the occipital bone. The A/A joint then moves and locks when further tipping of the atlas on the dens is blocked. The sup/inf articular processes bump into each other as you move down, and ant. long. lig gets stretched.

A cephalo-caudal progression of extension is carried out from C2 through C7. The inferior facets of the lower c-spine glide symmetrically DOWNWARD over the superior facets. As movement of the cranial segment is checked by approximation of the joint surfaces, tightening of the ANTERIOR LONGITUDINAL LIGAMENT and progressive compression of the nucleus pulposus, the next most caudal segment begins to move.

The return from hyperextension to neutral is the reverse of this process.

2) Flexion is limited by soft tissues - lig's stretched. Extension is limited by ant. long. lig yes, but mainly sup/inf articular processes blocking each others' further movement (bone on bone).

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1) For rotation of c-spine, explain steps of movement








2) In lower cervical spine, do side bending and rotation happen on same side, or opposite sides?

3) Return from rotation is what process?

1)
-There is little rotation allowed at the A/O joint thus the skull and C1 essentially function as a single unit during most of the cycle of rotation.
- The first ~40 degrees comes from C1/C2 (AA joint). Around 40 ish degrees, the Alar lig and facet joint capsules prevent more movement.
- Then from C2-C7 ... it goes cephalo to caudal.
- In the lower c-spine, the inferior facet ON THE SIDE TO WHICH ROTATION IS OCCURRING glides downward on the superior facet below it. The inferior facet ON THE SIDE OPPOSITE TO THAT WHICH ROTATION IS OCCURRING glides upward on the superior facet below it.


2) SIDE BENDING AND ROTATION OCCUR TO THE SAME SIDE.

3) The return to neutral is the reverse of this process.

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1) For side bending of cervical spine, does O/A joint allow much side bending?

2) Does A/A joint allow much side bending

3) So sidebending progression of movement =

1) Practically none

2) Practically none

3) Starts between C2 and C3, goes cephalo to caudal. If you side bend to the right, then right sided facet joint bump into each other (cephalo to caudal), and LEFT sided ligamentum flavum is stretched, LEFT sided intertransverse lig's are stretched, etc.

45

Below are a few flashcards on the cervical spine muscles

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46

MAKE SURE you review all the muscles of:

- Back
- Thorax
- Abdomen
- Cervical/neck
- Shoulder
- Arm
- Forearm

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47

Make sure you know NERVE innervation of all those muscles ... know dermatomes ... know brachial plexus

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1) Usually, what nerve gives you headaches?

2) Are multifidus or rotaters bigger / larger lever arm?

3) One of the most frequently injured m's during whiplash is the __________

4) Levator scapulae muscle has a twist in it?

5) Where would you find the longus colli and longus capitis m's

1) Greater occipital nerve

2) Multifidus

3) Levator scapulae during extreme flexion, and SCM during extreme extension

4) True

5) Behind esophogus on anterior part of vertebral bodies

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Explain function and details of Scalene m's:




What is danger if the scalenes get inflamed or injured.

Scalene m’s: you can palpate (except
The posterior is behind SCM and trap …
And anterior is somewhat behind the
Clavicle).

They attach to the tubercles of the
Cervical spine, and ribs 1 and 2. They help elevate ribs during forced breathing.

The ant. and middle help flex cervical spine
(posterior is a side bender and synergist)

*** If these muscles get inflammed or injured, they could squeeze the subclavian artery (so you check for pulse in radial/brachial artery areas to check). Or it could send tingles down arm as it pinches brachial plexus.

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Below are flashcards for THORACIC vertebrae / area

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51

1) Remember the coupling motions and how cervical and lumbar are predicatable. Why is the lower thorax area movement not predictable?

2) Which direction do the sup/inf articular processes go in thoracic spine area. What motion does this limit?

3) How can you tell a thoracic vertebrae from other regions of the back?

4) How many total joints, and how many synovial joints are on a thoracic vertebrae?

5) Is thoracic vertebral body thicker anteriorly or posteriorly?

6) Would you fracture a thoracic vertebral body easier anteriorly or posteriorly? Why?

7) Would you have more torque in cervical or thoracic spine, and why?

8) What are "kissing spinous processes" in thoracic vertebrae?

9) Limitation to flexion in thoracic spine is ________, and limitation of extension in thoracic spine is __________

10) What happens to facets during a RIGHT side bend in thoracic spine?

11) What limits side bending in thorax?

12) If you turn to the right, will the transverse process on the right move anterior or posterior?

13) T or F: Ribs act as a resistance to rotation in thorax?

1) Because the ribs are attached to them, and that throws movement off since so many moving factors change the movement of thoracic vertebrae.

2) They are straight up and down, limiting flexion and extension (sup articular process faces posterior and superior)

3) Spinous process is giraffe beak, and MANY facets for ribs.

4) 12 total, 10 synovial

5) Thinner anteriorly, thicker posteriorly (thus why there is kyphosis)

6) Anteriorly ... because remember cancellous bone is LESS anteriorly in a vertebral body, so less support anteriorly.

7) More in thoracic because the actual vertebral bodies are further from the line of gravity, creating a bigger moment arm, thus more torque.

8) Because thoracic vertebrae have long spinous processes projecting down, they hit (kiss) each other during extension, which also significantly limits thoracic area to do extension.

9) Flexion = soft tissue (lig's)
Extension = bone (facet joints and spinous processes)

10) Right facets (sup and inf) hit each other, and the left facets pull away from each other / open.

11) Primarily ribs and sternum, but on side you bend it would be bone on bone of facet joints, and on other side it would be intertransverse lig, ligamentum flavum, costotransverse lig.

12) Posterior. , and the LEFT transverse process moves ANTERIOR.

13) True. Otherwise, we'd be able to rotate more in thorax.

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RIBS:

1) What are the main bony landmarks of a rib:

2) The last directly attached rib on a typical person is:

3) Ribs 8-10 are attached to the sternum via:

4) Floating ribs are:

5) What kind of cartilage is the costal cartilage?

6) Does Costal cartilage move?

7) Are transverse processes and spinous processes at same level (for palpation) in thoracic spine?

1) Head, neck, tubercle, angle, body

2) 6 / 7 ... just depends on the person.

3) Costal cartilage / costal arch

4) 11-12

5) Hyaline cartilage

6) Yes, it helps to absorb movement and distortion more than bone. As we age, the hyaline cartilage ages and becomes more bone-like (ossified).

7) IN THORAX area, remember the transverse processes are ABOVE the SPINOUS process if you are palpating **** And visa versa. If you get an "ouch" at a transverse process, the spinous process for that vertebrae is 1-2 fingers width below that point.

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LIGAMENTS For Ribs .... Explain each and where they are and what they do:

- Radiate Lig of head of rib:
- Costotransverse lig:
- Lateral costotransverse lig:
- Superior costotransverse lig:
- Intra-articular lig
- Ant. long. lig:
- Ligament of the Neck:


What is a L.A.A.D.

- Radiate Lig: Joints neck and head of rib to vertebral body

- Costotransverse lig: From neck of rib over to transverse process by it.

- Lateral costo-transverse lig: joints transverse process to tubercle of rib

- Superior costo-transverse lig: From neck of rib up to ABOVE transverse process.

- Intra-articular lig: Between head of rib and vertebral body
(on inside)

- Ant. long. lig: Front part of vertebral bodies

- Ligament of the neck: This is technically the posterior costotransverse lig.


L.A.A.D. = Ligament at a distance

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STERNUM:

1) Ligament that joins rib (costal cartilage part of it) to sternum:

2) What is the typical manubrio-sternal angle?

3) If sternum (or manubrio-sternal angle) is too far anterior, it is called __________, if it is too far posteriorly, it is called _________

1) Radiate ligament

2) 160 degrees

3) Pectus Caranatum (angle protrudes sternum out)
Pectus Excavatum (angle is too shallow)

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RESPIRATION:

1) What is pump handle movement during respiration

2) What is bucket handle movement during respiration?

3) Do these 2 act together / happen at the same time?

4) Where is AOR during Respiration for rib cage movement?

5) Will slight flexion open rib cage or close it? Will full flexion open or close rib cage?

6) If someone had an issue with LEFT lung, and you wanted to help them breathe better, what would you instruct them to do?



7) Will full flexion and full extention increase or decrease volume of thoracic cavity?

8) If you side bend to the RIGHT, which side will open and which side of thorax will close?

9) If you rotate to the LEFT, which side of thorax will open and which side will close (more/less volume)?

1) Pump handle movement: sagittal plane and ribs move anterior/superior with air going in, and then posterior/inferior during exhale.

2) Bucket Handle movement: This is LATERAL (and superior) movement up during inspiration (ribs more horizontal), and then ribs go laterally down during expiration (ribs move more vertical)

3) These two movements occur TOGETHER at the same time during breathing.

4) AOR is back at costovertebral joint (and some little movement at sternocostal joint). But most is at costovertebral joint (although both move).

5) *** SLIGHT flexion actually brings ribs out and up a bit and INCREASES lung volume. But FULL flexion of thorax decreases volume of ribs as abdomen organs compress and limit lung expansion.

6) If someone has left lung issues and you want to help increase lung capacity to help them breathe better … you would: have them slightly flex, side bend to OPPOSITE side, then rotate towards involved side. Slight flexion opens up thorax, side bend AWAY opens the rib cage, and rotate towards opens that side too.

*** To open up ribs: Slight flexion, bend away, rotate towards ***

7) BOTH will DECREASE

8) Side bending to the RIGHT will cause LEFT side to open, and RIGHT side to close / push together.

9) Rotating to left will OPEN left, and CLOSE right side.

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Let's compare cervical to thoracic to lumbar ...

1) Does thorax do more flexion/extension or rotation?

2) Does lumbar area do more flexion/extension or rotation?

3) Which area has the MOST flexion/extension

4) Which area has most rotation

1) Rotation

2) Flexion/Extension

3) Cervical

4) Cervical

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1) If you inspire a lot of air, will the ribs become more vertical or horizontal?

2) Would lungs collapse if they came out of rib cage? Why

3) If alveoli get injured (COPD), would it make lungs collapse or expand?

1) Horizontal

2) Yes. The lungs would collapse if they came out of rib cage. The parietal layer (inner rib cage) has an adhesive element with visceral layer (on lungs) to keep them together and thus keep the lungs inflated.

3) If the alveoli gets injured (COPD), this will make lungs less elastic, so inward pressure is diminished = lungs EXPAND. So someone with COPD actually has a large inflated chest (you'd think the opposite) because air is getting into pleural cavity, but air can not get OUT of this cavity.

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1) What is Scoliosis

1A) How could you measure / diagnosis it?

1B) Can we as PT's treat scoliosis?


2) What is Osteoporosis

1) Abnormal lateral curvature of the spine (s shape).


1A) Have pt bend forward, and if one side of rib cage is more posterior than the other, and you place a level on back to confirm = scoliosis.

1B) We as PT's can improve the motion of the ribcage, try to strengthen weak muscles, etc. ... but we can't treat or limit or cure the curvature of the spine as this is an osteo disease that we can't treat. We also can't make nerves re-grow (they can, it just takes a long long time). Strengthening m's / posture is great, but won't limit the progression of the scoliosis from an osteoporosis standpoint. *** Patient would need a surgical intervention to put rods in back to straighten back.

2) A condition where bones become weak and brittle, so can't hold weight as well. As you age and develop more kyphosis, then the greater the moment arm is (spine will bend out more) … so more torque with head pulling down, and that creates more pressure or wedge fractures on spinal column. Anterior vertebral body gets thinner as weight of body bears down on it over time.

*** The more forward flexed you are - the more torque and force pushing down on those vertebrae. It just gets progressively worse and worse.

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1) What is the innervation for the traps

2) What is innervation of rhomboids

3) If both these muscles contract bilaterally, what is their function?

4) If you could stabilize the scapula, and contract trap or rhomboid, what would happen?

5) Latissimus dorsi is innervated by

6) What is action of latissimus dorsi on thoracic vertebrae (and lumbar)

7) What is unique about the erector spinae m's compared to latissimus dorsi for example

1) CN XI (Accessory)

2) Dorsal Scapular N.

3) To stabilize thoracic spine

4) Spinous processes would move toward scapula.

5) Thoracodorsal n

6) Basically stabilizes it during bilateral contraction

7) The erector spinae m's are innervated (by dorsal spinal rami) SEGMENTALLY. Meaning if you lose innervation to a segment, the entire muscle isn't lost (like other muscles who just have one nerve innervating it).

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Explain the motion of bending forward and touching the ground. From cranial to caudal, explain what is happening:

- First you'd do flexion of O/A joint, then A/A joint, then lower cervical vertebrae, down through thorax, to lumbar, then to HIP.
- At first, you have lig's in spine preventing too much flexion, and erector spinae m's eccentrically limiting flexion.
- At the point where spine can't flex any more, hips then rotate.
- At around 45 degrees, erector spinae m's shut down and spinal lig's are pulling / on stretch / holding the weight.
- After 45 degrees, hip extensor m's (one joint and two joint) take over. Hamstrings get stretched as ischial tuberosity rotates UP. So hamstrings limit ability to continue moving forward.
- Keep going till hamstrings are stretched to their limit.

- THEN AS YOU GO BACK and extend, the hips work, and then half way up the back muscles kick back in. But now erector spinae m's are working concentrically.

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1) What are the 3 transversospinalis m's:

2) What is their innervation?

3) What is their function?

4) T or F: Multifidus are same size throughout spinal column?

5) Which ones are loaded with PROPRIOCEPTORS?

6) Damaging the transversospinalis m's leads to:

1) Semispinalis, Multifidus, Rotatores

2) Dorsal spinal rami (segmentally innervated)

3) Bilateral extendors / stabilizers, and unilaterally they contrallaterally rotate

4) False. They get bigger in lumbar area.

5) Mutifidus ... but really all of them

6) Idea is if you damage these muscles or nerve innervation to them, it can lead to damage of PROPRIOCEPTORS, and thus leads to SCOLIOSIS.

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1) Supposedly, there are more small deep muscles in the back between spinous processes and transverse processes. What are they:

2) What do they do?

3) Why 'supposedly'

1) Interspinales and Intertransversarii

2) Interspinales pull spinous processes together so they cause extension, and Intertransversarii would pull transverse processes together so as to create side bending.

3) Because they are so small, so spotty, and not found in everyone.

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1) If you increase the internal dimensions of the rib cage, would it increase or decrease the internal pressure

2) Review the m's (a,i,o and innervation) of respiratory m's

3) External intercostal muscle will elevate or depress ribs? Can that change?

4 Explain the levator costorum muscle's attachments and action

5) Explain transversus thoracis

6) Diaphragm goes up or down during inspriation?

7) What innervates diaphragm?

8) Is it possible to have one side of the diaphragm innervated and one not?

9) Explain morphology of diaphragm

10) So as central tendon of diaphragm gets innervated, it will do what:

1) Decrease (expanding volume causes pressure to drop)

2) ok

3) Elevate. Well if you hold lower rib in place and stabalize it, then it would move upper rib down. Remember that with muscles, the more mobile end moves.

4) Levator Costorum: From transverse process to the rib below (with transverse process as the stable member). As the name suggests, it elevates the rib.

5) Transversus Thoracis: Sternum is stable member, and this helps depress the rib cage

6) DOWN

7) Phrenic nerve (you have 2 phrenic nerves. Root levels are 3,4,5 ... keep you alive … for phrenic nerve).

8) Yes. If one of your 2 phrenic nerves gets injured, then one side of diaphragm will not work.

9) Has a central tendon below which attaches to anterior vertebral bodies in lower thoracic / lumbar area, then sides of diaphragm are up and attach to and around lower ribs.

10) Pull down diaphragm and thus push the abdomen out ... leading to the lungs expanding, which pulls air INTO the trachea/lungs.

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1) What are the secondary m's involved in respiration:

2) Would rectus abdominis and obliques be inspiratory or expiratory m's

3) Would scalene m's be expiratory or inspiratory?

1)
- Rectus abdominis / obliques contracting will pull ribs down (to help during expiration)
- Scalene m's: Help elevate upper ribs (go from cervical spine to upper ribs) - help with inspiration
- Others: SCM, Traps, Peck Major/Minor, Serratus Anterior, Serratus Posterior Sup/Inf, Latissimus Dorsi

2) Expiratory. Tightening them forces abdomen in and up, pushing up lungs and air out.

3) Inspiratory (pull ribs up)

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1) 70% of QUIET (not forced) INSPIRATION comes from what muscle?

2) Other 30% comes from what primary inspiratory m's

3) With Expiration (quiet / not forced) that comes from what?

1) Diaphragm.

2) Ext. intercostal m's, serratus posterior superior, and a little from scalene m's. RIB cage motion (pump handle / bucket handle) is primarily diaphragm and few muscles that help.

3) Mostly passive or gravity and lungs collapsing ... but internal/innermost intercostal m's, diaphragm going back up, serratus posterior inferior, transversus thoracis, scalenes do work eccentrically to help lower down rib cage.

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1) Hardest working muscle in the body is:

2) Hardest working skeletal / striated muscle in the body is:

1) Heart

2) Diaphragm

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Explain the process of FORCED inspiration and FORCED expiration:

Forced Inspiration: Usually you slightly flex forward and extend the rib cage fully, plus you kick in the other respiration accessory muscles to help open up rib cage. You often see the professorial position (arms out to stabilize) which helps open up airways. Upper throat m's: scalenes, SCM, platysma, suprahyoid, serratus anterior, serratus posterior superior, peck minor, external intercostals, diaphragm, etc. all work much harder during forced inspiration.

Forced Expiration: Rather than passive motion, you can contract the secondary m's: rectus abdominis, oblique's, and transversus abdominis. These all pull rib cage down powerfully and push abdominal contents in, which pushes diaphragm (and thus lungs) up to force air out. Plus the quadratus lumborum and erector spinae help depress the rib cage. If you bring arms in and compress rib cage, this also helps maximally force air out.

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1) Define Paradoxical

2) What are 2 ways you can have Pathomechanics or paradoxical breathing

3) Do intercostal m's (when working properly) make the ribs stiff or less stiff if contracted?

4) Explain each

1) Paradoxical means it is doing something different than you think it should be doing.

2) Dysfunctional intercostal m's, and Dysfunctional diaphragm

3) Stiff

4) Dysfunctional intercostal m's: if diaphragm contracts, and the intercostal m's are NOT innervated, they will NOT be stiff, so ribs will collapse IN and that pushes abdominal contents OUT.

Dysfunctional diaphragm: If phrenic nerve gets damaged and you lose diaphragm contraction, then you have to do upperchest breathing and the ribs protrude OUT and abdomen goes IN.

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Below are flashcards for 2.4 on SHOULDER

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1) The shoulder girdle is composed of 4 joints. What are they:

2) Are each of these a synovial joint?

3) What TYPE of joint is each:
- Sternoclavicular joint
- Acromioclavicular joint
- Glenohumeral joint
- Scapulothoracic joint

4) The stability of the shoulder girdle is where? And why?

5) How many ... and what are the ligaments of the S/C joint:

6) Which of the 4 S/C lig's is a L.A.A.D. What is that?












7) Does S/C joint have articular cartilage and articular disc?

8) The sternal end of the clavicle is what type of joint, and the acromion end of clavicle is what type of joint?

9) Why is clavicle shaped in a strange S type shape?

1)
- Sternoclavicular joint (S/C)
- Acromioclavicular joint (A/C)
- Glenohumeral joint (G/H)
- Scapulothoracic joint

2) Sternoclavicular and Glenohumeral are for sure, but Acromioclavicular is sort of a pseudo synovial / plane joint, and Scapulothoracic joint is not at all (there is no joint aspect to scapulothoracic).

3)
- Sternoclavicular joint: Saddle
- Acromioclavicular joint: ?? plane
- Glenohumeral joint: Ball and Socket
- Scapulothoracic joint: not a joint

4) S/C joint. Because it is the only place it is connected (by lig's) to a stable bony surface.

5) 4 total.
- Interclavicular lig: connects the two clavicals across the top of sternum (jugular notch).
- Anterior sternoclavicular lig
- Posterior sternoclavicular lig
- Costoclavicular lig: (L.A.A.D.)

6) Costoclavicular lig. It is a ligament at a distance (L.A.A.D.) which is a lig that is part of a joint, but not at the joint capsule. This is important because it connects 1st rib to clavicle, and creates a MOMENT ARM to resist TORQUE's on the clavicle.

7) Yes, like all synovial joints, it has articular cartilage and a disc. The Articular Disc is between end of clavicle and clavicular notch of the manubrium. It helps with compression of shoulder girdle down/in towards sternum (like me sleeping at night)

8) Sternal end is a true synovial joint (SADDLE jt), so it has a disc, articular cartilage, capsular lig's, etc. The acromion end of clavicle is covered in fibrocartilage and joint capsule (acromioclavicular lig), but it is not a real synovial joint (sort of a pseudo plane joint).

9) It allows the muscles attached to it (like the trapezius) to have a greater moment arm = more torque. And allow some rotation as you elevate/depress clavicle.

71

ROM of S/C Joint:

1) How far UP can S/C joint ELEVATE from rest position up (in frontal plane)

2) How about depression

3) Protraction?

4) Retraction?

5) Upward Rotation and downward rotation ... and explain how this movement works?

1) 40-50 degrees

2) 10 degrees

3) 15-30 degrees

4) 15-30 degrees

5) Upward = 25-55 degrees. Downward = less than 10 degrees. It is as you do elevation or depression, the clavicle actually rotates.

72

1) Do injuries at the S/C joint happen often

2) If an injury does happen, how would it happen. Explain

3) 3 ways / directions a clavicle can go during a S/C injury are what? Explain how each would happen?

4) T or F: If you injure or disrupt the S/C joint, the entire shoulder girdle and upper extremity are effected?





5) If clavicle gets broken (from a front on collision, thus a transverse / shear) type break so not from a strong compression force from the side (as described above), then clavicle will break easily rather than have S/C joint get dislocated. What will this result in?

6) T or F: Bones are strong along their long axis. Why?

1) Rarely.

2) Someone hits you from side of shoulder and so clavicle compresses into sternum, or you fall on shoulder and clavicle gets compressed into sternum. This would probably not break clavicle (since it is strong with compression), but it would dislocate the S/C joint and all 4 of those S/C joint lig's could be torn as the clavicle gets dislocated.

3) Up. Anterior. Posterior. Up, is it is forced up out of capsule away from disc superior. Anterior, so you'd see it poking out anteriorly (PT could pop it back into place). Or posterior dislocation, and this is very hard to treat, and pt will feel pressure in throat because of displaced clavicle.

4) True. The S/C joint is critical to shoulder girdle. It is the jt. that provides stability, mobility, and is rarely injured.

5) The break won't necessarily dislocate the S/C joint, but now you have no stability or mobility for shoulder girdle and UE. And you may tear muscle that attaches to clavicle (trap and deltoid laterally, subclavius in middle of clavicle, SCM proximally/medially).

6) True. The long axis has good compressive force resistance, so it is strong. But a break from transverse section / shear angle is much weaker.

73

1) T or F: The clavicle and scapula act as a surrounding protection for the upper thorax?

2) T or F: The clavicle and scapula are parallel to each other and to the frontal axis?

3) What is the angle of the scapula compared to the frontal plane straight line?

1) True

2) False. Both the clavicle and scapula are at an angle to the frontal plane.

3) 40 degrees

74

1) The A/C joint ... what is it's purpose?

2) What type of joint is it?

3) It has many ligaments, how many, and explain each's purpose:














4) Does the A/C joint have a capsule over the joint?

5)
- If you abduct your arm (glenohumeral joint) about the shoulder up to 90 degrees, where is the instantaneous AOR?
- After 90 degrees, where is AOR?

6) Does the A/C joint have any ROM?

1) For stability within pectoral girdle. And to attach the clavicle to the scapula, to thus distribute forces from scapula / shoulder to clavicle. And it helps to raise the UE up past the head.

2) A/C joint is not really a synovial joint, but it is close to a plane / gliding synovial joint.

3)
3 total (technically 4)
- Coracoclavicular lig: Connects clavicle to coracoid process (scapula). It has 2 lig's (conoid and trapezoid lig's). It is a L.A.A.D. so it is not really part of the joint area, but very important stabilizer and distributor of forces.
- Capsule: Cover / protect joint surface (this capsule / jt. starts as fibrocartilage, but as we age and need mobility, it breaks down and deteriorates). THIS STARTS AS FIBROCARTILAGE .... THEN BECOMES CAPSULE / ACROMIOCLAVICULAR LIG.
- Coracoacromial lig: This one is interesting because it passes from one part of the bone to the other. Why? It is to share and distribute stress/strain/force. So, any muscle that attaches to acromion (deltiod and traps) or any muscle that attaches to coracoid (biceps, peck minor, coracobrachialis) will help share / distribute load to other part of bone to reduce tension on that area. And, this ligaments is somewhat a "cap" or ROOF over the G/H joint so head of humerus can't come up superiorly.

4) Yes. It is the acromioclavicular lig.

5)
- Up to 90 degrees it is head of humerus (because that is the CONVEX member).
- But past there it would be middle of scapula as the scapula does upward rotation.

6) Yes, but very little. As you move S/C joint during movement of clavicle, a little of the movement is attributed to the A/C joint.
- Up/Downward rotation: 5 degrees
- Winging: 10 degrees
- Scapular tipping: 5 degrees

75

1) What are the motions / movements the scapula can do?

2) Can the A/C joint get dislocated?

3) If clavicle gets dislocated at the A/C joint, what direction would it go?

4) Why is A/C joint so important?

5) If you had a huge break and had to remove part of the lateral clavicle, what are the ramifications of that?

6) Is the S/C or A/C joint more mobile? Which one is more stable?

1) Elevation / Depression, Ab/Adduction, Up/Downward rotation

2) Yes. You'd see clavicle sticking up and an area/space between two bones.

3) Typically it would go UP

4) Well, even though most the movement of the scapula / shoulder / UE comes from the S/C joint, the A/C jt. getting dislocated disrupts the movement and stability coming from the S/C joint. So it is the connection point. (And remember it helps at very top part of arm abduction movement, and to help distribute forces).

5) You could remove the lateral clavicle (claviculictomy) … it makes the arm very mobile, but much less stable. You can't go back to sports or major lifting of weights. You disrupt the mechanics of UE, but it removes pain. OR, you can wire the A/C joint back, and this will look better, but reduce a lot of movement.

6) S/C joint is more mobile. They both provide a lot of stability.

76

For the GlenoHumeral Joint:

1) Know bony landmarks of humerus

2) Is the anatomic neck or the surgical neck of humerus more proximal?

3) Does the Greater Tubercle of humerus have it's own bony landmarks? Explain

4) The G/H joint has a capsule. Where are the proximal and distal attachment points of the capsule for the G/H joint?

5) What is the angle of inclination of the head of humerus compared to the long axis / shaft of the humerus?

6) Is humeral head anteversion or retroversion? Is femur head anteversion or retroversion? Explain

7) So explain direction of humeral head in relation to the long axis of the shaft of humerus?

8) So, humeral head inclination is at what angle? And humeral retroversion / torsion is at what angle?

1) ok

2) Anatomic is higher ... it is the neck of the head (anatomy) of humerus.

3) Yes, it has a superior facet, middle, and inferior facet. For Supraspinatus, Infraspinatus, then Teres Minor muscle attachments.

4) Proximally, above the rim of glenoid fossa/cavity. And then distally, to the head of humerus where articular cartilage stops (just distal to anatomic neck).

5) 130-150 degrees.

6) Humeral head is RETROversion, and Femur is ANTEversion. RETROversion for humerus means the head of humerus has slight rotation or torsion posteriorly (it's opposite for femur head).

7) Superior, Medial, Posteriorly

8) Inclination is 130-150 degrees. Retroversion / torsion is 16 degrees.

77

LIGAMENTS of GlenoHumeral Joint:

1) What type of joint is the G/H joint? It main purpose is __________

2) Is the G/H very stable?

3) Where does G/H joint get it's stability?

4) How many lig's are at the G/H joint? List them and describe their purpose:

5) What is a ligament that is NOT part of the G/H joint, but plays an important role?

1) Ball and Socket ... it's main purpose is MOBILITY

2) No not really.

3) Capsule, ligs (rotator cuff), and muscles

4) 6 total
- Coracohumeral lig: Lig from lateral coracoid process down to greater tubercle of the humerus, and a small band to the lesser tubercle. It is NOT a L.A.A.D.
- Glenohumeral lig: Has 5 sub parts ... see notes below

5) Coracoacromial lig: Not really part of the G/H joint, but helps tie two parts of scapula together to help distribute forces. Forms a "roof" over the G/H joint.

78

1) Main ligament for shoulder is:

2) Explain G/H lig in detail (each part):

3) What else will you find within the G/H joint capsule

4) Where is weakest part of the G/H capsule?

5) What muscle overlies that weak part of the anterior capsule?

6) The capsule has an INFERIOR lig. with an anterior and posterior band, and what sits between those?

7) What is the TOP portion of the capsule?






8) What is the posterior portion of the G/H capsule?

9) The posterior / inferior part of capsule is what?

10) What is the ring around the external border of glenoid fossa?

11) Review:
- how many m's involved in G/H capsule/joint?
- how many EXTERNAL lig's involved in the G/H joint:
- how many INTERNAL G/H capsule lig's (not muscles, but actual lig's):
- Where does capsule attach on both ends?

12) Of the 5 lig's of the INNER G/H joint, let's forget IGHLC for a second .... if you do lateral rotation, which lig's go on stretch?

13) If you do internal rotation, which ligs go on stretch?

14)
- Where are most of the ligament reinforcements / stability of the G/H capsule?
- So because of this, what motion is thus limited most and what motion is limited least?

15) What limits ABduction of arm / GH joint?

1) G/H lig

2) Has a superior, middle, and inferior band (lig). The superior is obviously superior part of capsule, middle is middle, and then the inferior has both an anterior and posterior band.

3)
- The biceps tendon going up to supraglenoid tubercle
- Rotator cuff muscle tendons
- And IGHLC (see below)

4) Space between the superior and middle bands of the anterior capsule.

5) Subscapularis

6) The Axillary pouch or inferior part of capsule. This "Axillary Pouch" is the IGHLC = Inferior GlenoHumeral Ligament Complex.

7) Suprispinatus m.

8) Infraspinatus m.

9) Teres Minor m.

10) Labrum

11)
- 5 (rotator cuff and biceps)
- 2 (coracoacromial, coracohumeral)
- 5 total: Sup, Middle, Inferior band (Inf has an anterior and posterior band), and between Ant and Post band is the IGHLC.
- Up around labrum and glenoid fossa, and down around humeral ANATOMIC neck (and greater/lesser tubercle for m's attachments).

12) The sup, middle, and inf (anterior band) are all anterior - so they all go on stretch during ER. So if you do external rotation, those 3 will go on stretch. BUT, the posterior band of the inferior lig goes on slack at first, but then does actually get stretched as you keep going. SO ALL OF THEM.

13) During internal / medial rotation, the post. band of the inf. G/H lig goes on stretch. *** SO POST band of inf. lig goes on stretch during ext/int rotation of shoulder.

14)
- ANTERIORLY with the sup, mid, and ant inf band.
- So lateral rotation (ER) would thus be most limited, and internal rotation is LEAST limited.

15)
- IGHLC (or axillary pouch) gets pulled
- Supraspinatus can't pull further (past 90 degrees)
- Greater tubercle hits glenoid cavity / acromion
- Bursitis or tendinitus

79

1) What is the loose (open) packed position with the G/H joint?

1A) Is open pack, loose pack, and least packed synonymous?

1B) Is close pack and closed packed synonymous?

2) When your arm hangs down to the side, what is happening with the superior and the inferior G/H lig?

3) Which part of the G/H joint or capsule is weakest?

4) There are two predictable openings in the G/H capsule. What are they?

4A) Why is knowing about these two openings important?

5) What holds the biceps brachii tendon into the intertubercular groove?

1) Arm out at 30 degrees flexion and 60 degrees abduction.

1A) YES

1B) YES

2) Superior G/H lig will be stretched as arm is relaxed, but the inf. G/H lig would be lax.

3) Anteriorly between superior and middle G/H lig where subscapularis m tendon is.

4)
- Opening in anterior part where there is weakness for the subscapularis bursa which is under subscapularis muscle and above capsule.
- The other part is where the biceps tendon is in intertubercular groove. It is an opening to allow biceps tendon to come in, so it is a hole with bursa and synovium around it to reduce friction of that tendon moving.

4A) Because there are holes in the capsule. So if you get injured, the inflammation in capsule may leak out into the bursa and cause pain when you flex bicep or subscapularis muscles.

5) Transverse humeral lig.

80

1) Why doesn't the humerus just fall off ... what 2 main PASSIVE STABILITIES that keep humerus suspended in zero (resting) position?

2) What are a few ACTIVE STABILITIES that help keep humerus suspended in zero (resting) position?











3) Is the Deltoid muscle part of the rotator cuff?

4) But is the Deltoid a SYNERGIST with the rotator cuff m's?

1)
- The capsule is very helpful with all the lig's helping suspend the arm up. The CORACOHUMERAL LIGAMENT is MOST important to keep arm suspended. (Obviously rotator cuff m's help, when contracted, but you can't walk around contracting those all day long every day).

- AND ... second, remember the glenoid fossa is positioned in a way to act as a SHELF to allow humeral head to sit in/on it's LIP.

*** So the humerus will stay resting on the shelf of glenoid fossa so long as the coracohumeral lig helps pull it in close (as it should / does).

2)
- Supraspinatus pulls up while gravity pulls down, and the resultant (net) vector thus pushes it into the lip of the glenoid fossa.
- Deltoid muscle pulls from deltoid tuberosity to help pull it up.
- Biceps and triceps also work to help pull/keep it up
- You could argue the infraspinatus and teres minor, and subscapularis m's (when contracted) help pull humerus in to help sit on the glenoid fossa lip.
- And the other G/H ligaments in the capsule (sup, middle, inf, IGHLC)

3) NO

4) Absolutely yes

81

For ROM of G/H Joint:

1) How many degrees of active ABduction can you do (specifically from the G/H joint)? Why ... explain? What about passive?

2) How many degrees of ADduction can you get at G/H joint?

3) What about flexion (actively and passively) of G/H joint?

4) What about extension? DEFINE extension ...

5) What about External Rotation? Explain 2 ways you can do this, and WHY?

6) What about Internal Rotation

1) Active is 90 degrees (from just G/H joint). Supraspinatus pulls greater tubercle up until the greater tubercle hits glenoid fossa. This is about 90 degrees. After that you could get passive (from someone else) ABduction up to about 120 degrees. But past 90 degrees, it is now the scapula (thus glenoid fossa rotating from scapula rotation) rotating that allows you MORE than 90 degrees of abduction.

2) About 8 degrees

3) Flexion is 65 degrees active (of just G/H joint), 120 degrees passive

4) Extension is not from top of the flexion point (arm raised/flexed up) and then down ... that is "RETURN FROM FLEXION." Once arm is back at resting/neutral position, then you proceed to bring arm back, and that is EXTENSION. So extension is about 35 degrees.

5) ER is arm in mid prone position and ER out. You can do about 45-50 degrees. But greater tubercle bumps into the glenoid fossa. So, if you abduct arm, you'll ensure the greater tubercle does NOT hit glenoid fossa, so now you can ER 80-95 degrees.

6) IR is about 50-70 degrees.

82

*** Anterior capsule ligaments of G/H joint goes on stretch during __________ (what motion/movement)

*** Posterior capsule / ligs of G/H joint go on stretch during ____________ (what motion/movement)

Lateral / External rotation (they limit lat. rotation)

Internal (medial) rotation

83

SCAPULAR-HUMEROL MOVEMENT

1) What is the ratio of humeral to scapular motion during abduction, and what does that mean?

2) What is the "setting phase" during scapular/humeral abduction?

3) What is the A/C joint stress during this movement?

4) So beginning of ROM for scapula/humeral abduction is __________ and end of ROM is _________

5) What position would you need to put your arm to get maximum closed pack compression on G/H joint?

6) What position would you need to put your arm to get most loose packed position of G/H joint?

7) So the best position to test joint play in a patient for G/H joint is:

1) 2:1 ... so humerus moves 2x more than scapula moves during abduction of arm.

2) If you ABDUCT arm out, first the "setting phase" will be from the scapula. First 20 degrees of humerus Abducting, the scapula going between AB then ADduction, then AB back to ADduction. This is the "setting phase" ... it is paradoxical movement or unpredictable.

3) At very end of ROM, last 5 degrees, the A/C joint goes on stress.

4) Setting phase .... A/C joint stress.

5) Maximum abduction, and maximum external rotation

6) 30 degrees of flexion, and 60 degrees of abduction

7) Laying supine to minimize scapular movement, with arm 30 degrees flexed and 60 degrees abducted.

84

1) What is the purpose of Bursa?

2) Where would you find bursa around the G/H joint:

1) Friction reducing device

2)
- You have the subacromial (or subdeltoid is another name), it is below acromion and above suprasinatus tendon.
- Subscapularis bursa
- You have the bursa over the biceps tendon.
- Often you'll find a subcoracoid bursa as well.

85

Explain what the 2 "Painful Arcs" are with lifting arm in abduction:

FIRST: A "Painful Arc" is when a person lifts hand up (abduction), the greater tubercle goes right under acromion, and if there is any inflammation, the greater tubercle will impinge that area ... the supraspinatis tendon, or bursa. It happens between 60-120 degrees.

Next one is the "Terminal A/C Painful Arc" ... it happens at end of the ROM between 160-180 degrees. It is where the A/C joint experiences tension and pain.

86

The Subacromial space ... where is it LEAST packed?

Where is it closed packed?

Least: With arm at 90 degrees abduction combined with internal rotation

Arm straight down

87

Below are flashcards on 2.5 - ELBOW

ok

88

1) What is the purpose of the elbow?

2) How many joints are part of the elbow joint ... list them each, what type of joint, and what it does:

3) Are the 3 joints at the elbow all within the same capsule / synovial fluid?

1) Shorten and lengthen the UE (as well as to pronate and supinate the hand)

2) 4 total (3 at the elbow within the capsule, 1 distally)
- Ulnohumeral: hinge joint, does flexion/extension
- Radiohumeral: mix between hinge and ball and socket ... helps with flexion/extension and pronation/supination
- Proximal Radioulnar: pivot jt, pronation/supination
- Distal Radioulnar: pivot jt, pronation/supination

3) Yes

89

Check out the skeleton, or get anatomy flashcards out, and just review the bony landmarks of ALL bones for this exam:

- Vertebrae
- Ribs
- Sternum
- Clavicle
- Scapula
- Humerus
- Radius
- Ulna

1) The indentation at the top of the head of the radius is called:

2) Head of radius articulates with what on the humerus

3) The olecranon swivels around what of the humerus?

4) The outside border of the head of the radius is called the:

5) T or F: There is articular cartilage around the articular circumference of head of radius, the radial notch on ulna, and capitulum / trochlea on humerus for those radiohumeral and proximal radioulnar joints?

6) Where does the Brachialis attach (distally)?

7) **** T or F: The biceps is a more powerful flexor of the forearm than the brachialis? Why?

ok












1) Fovea of head of radius

2) Capitulum


3) Trochlea of the humerus (trochlear notch of ulna)

4) Articular circumference


5) True




6) Tuberosity of the ulna and corocoid process.

7) False. The brachialis is more of a powerful flexor, because it attaches to the bone that does NOT rotate. And plus, the biceps helps with shoulder flexion and pronation/supination.

90

1) Explain the boundaries of where the capsule is for the elbow joint (all 3 joints together)

2) What is the annular ligament?

3) Is the annular ligament deep within elbow joint capsule, or external? Why is this important to know?

1) On posterior side, it goes around rim of olecranon fossa and down around neck of radius. Anteriorly, it then wraps around neck of radius to anterior side and up under the coronoid process, then up around tip of the coronoid and radial fossa's above on humerus.

2) Ligament that holds the head of the radius snug up into the radial notch of the ulna.

3) External. The ANNULAR LIGAMENT rubs against the capsule / articular cartilage … so it is easy to get inflamed.

91

ELBOW CAPSULAR LIGAMENTS:

1) How many ligaments are there at the elbow:

2) What are those ligaments:

3) The medial collateral lig (Ulnar collateral lig) has a few bands / parts to it. How many, what are they called, and where do they run:

4) Why is the transverse band so unique with the MCL?







5) Overall, the MCL's function or purpose is what?

6) For the lateral collateral ligament (radial collateral lig), it also has sub-bands. How many, what are they called, and where do they run:

7) What is the purpose of the lateral (or radial) collateral lig of the elbow:

8) What is the oblique cord? Where does it run .. and what is it's purpose?

9) Is the oblique cord part of the collateral ligament system?

10) So the elbow joint (all 3) have a strong medial and lateral ligament for support, but is there an anterior and posterior portion? Are they as strong?

11) If you flex arm, wouldn't the capsule get caught? How does it NOT get caught?

12) Same as above ... what happens during extension with the posterior capsule?

13) During flexion, would the posterior or anterior capsule be on slack?

1) 6

2)
- Medial collateral (ulnar collateral) lig
- Lateral collateral (radial collateral) lig
- Oblique cord
- Anterior capsule (lig)
- Posterior capsule (lig)
- Interosseous membrane (lig)

3)
- 3 total
- Anterior, posterior, transverse bands
Anterior band: from medial epicondyle to coronoid
process
Posterior band: from medial epicondyle to ulna
Transverse band: from olecranon post. to coronoid

4) It goes from one part of a bone (olecranon) to same bone (to coronoid process). It SHARES STRESS between those two parts as they have load placed on them.

5) Restrain lateral (VALGUS) movement of forearm on arm.

6) 3 total (not including annular lig for head of radius):
- Lateral ulnar collateral band: Lat. epicondyle down to ulna (yes, ulna)
- Radial collateral band: Lat. epicondyle to the annular lig.
- Accessory lateral collateral band: Helps stiffen annular lig (from ulna up to head of radius)

7) Restrain medial (VARUS) movement of forearm on arm.

8) From proximal ulna down to radius (around radial tuberosity) ... It helps RESTRAIN SUPINATION.

9) NO

10) There is an anterior and posterior part of the capsule, which technically is a ligament yes, but is very very weak (compared to MCL and LCL of elbow joint).

11) The brachialis and biceps send small tendons into capsule to pull it out of the way during flexion so it doesn't get caught or poked by coronoid process coming up during flexion.

12) The triceps will pull the post. capsule out of the way during extension so the olecranon doesn't come up and get it.

13) Anterior

92

1) Explain 4 main functions of the interosseous membrane / lig:

2) Explain the orientation of the fibers within interosseous membrane





3) If I did a push up, explain how the force is transferred up the arm.

4) Where is "neutral" position for interosseous membrane, and what happens to it if you move out of this position?

1)
- Keeps radius and ulna bound, so they don't spread apart.
- It shares stress between radius and ulna.
- Site for muscular attachment of forearm m's.
- Prevents too much supination/pronation

2) There are two layers between/connecting the radius and ulna, and they are obliquely oriented (perpendicular) to each other so one goes on stretch while the other goes on slack during pronation/supination.

3) The force goes up the radius. But then the head of radius is NOT directly connected to the humerus, so the force is transferred through interosseous membrane to the ulna, then up through humerus, etc. *** The head of the radius (fovea) does articulate with the capitulum of the humerus, and if you have enough pressure/compression, it does help distribute some weight through joint to humerus, but a lot is transferred from radius to interosseous membrane to ulna up through humerus.

4) Neutral position is mid prone elbow flexion with thumb up. If you supinate, one side of interosseous membrane goes on stretch and the other goes on slack. Then to pronation it is opposite.

93

1) With the ulnohumeral joint, the actual 'cup' of the fossa between the olecranon and coronoid process ... is that cup parallel to or not parallel to the long axis of the ulna? Why is this important?

2) SO related to point 1, if normal angle is 45 degrees, and now the cup is MORE than 45 degrees, what motion would you expect at the elbow?
- If angle is LESS than 45 degrees, what will that result in?

1) NOT parallel. If the cup is tipped/angled too far forward or back, it will effect how the elbow can move.

2)
- MORE than 45 degrees = places cup forward, allowing you to do MORE hyperextension, less flexion
- LESS than 45 degrees = places cup back more, so you get limited extension and it would appear as a contracture (but it is bone on bone end feel).

94

1) Normal valgus or carrying angle is about what:

2) Is valgus more in males or females ... why?

3) What is a "gunstock" deformity? How/why does it happen?

1) 5-15 degrees

2) Women (hips)

3) Varus. When forearm is medially rotated with respect to the humerus. Happens from a distal humerus fracture, so muscles pull arm in.

95

1) How much (degrees / ROM) can you get with elbow flexion

2) How much can you get with extension?

2A) How can you actually get hyperextension?

3)
- End feel for elbow flexion is:
- End feel for elbow extension is:

4) If you hang arm down into neutral position and then move it up to full elbow flexion ... which area will have the greatest amount of force (torque)

5) Main m's involved in Elbow Flexion

6) If you get a musculocutaneous nerve legion, could you flex your elbow?

1) 0-150 degrees

2) 0-5 degrees (remember that extension starts from arm at neutral anatomical position

2A) Hyperextension comes if olecranon fossa is really deep, or olecranon tip is too short, or you overstretch anterior arm muscles.

3)
- Flexion: soft (soft tissue)
- Extension: hard (bone on bone)

4) Around 80-90 degrees (mid-way) of elbow flexion. It is much less when you are fully extended or fully flexed. Then as you pass 90 degrees and keep flexing, your force weakens again. The peak is about at 80 degrees. This is where moment arm / lever arm is greatest.

5) Biceps brachii and Brachialis ... but you also have brachioradialis, coracobrachialis, part of deltoid, and all the forearm flexor muscles.

6) Well you'd lose biceps, brachialis, and coracobrachialis, but you'd still have the others listed above - so you probably still could weakly yes. AND ... remember motor points. So depending on where the legion is will determine what or where you still have innervation

96

For ulnohumeral joint:

1) What is least packed position

2) What is close packed position

3)
- What nerve root is for elbow flexion
- Which is for elbow extension

4) *** With the ulnohumeral capsule flexing and extending ... if you lost flexion or extension, which loss has greater consequences?

1) Mid flexed position

2) Full extension

3)
- Flexion: C6
- Extension: C7

4) Losing some FLEXION has much greater consequences. Remember that extension (or hyperextension) is past neutral. If we can't do that, no big deal. But if we can't "return from flexion" back to neutral, or a loss of flexion, that has big consequences on our functioning.

97

1) Which of the 4 joints of the elbow is a "cooperative" joint, and why?

2) T or F: During flexion, the head of radius becomes less congruent with capitulum?

3) T or F: There is more distraction when you move into flexion for the head of radius with capitulum

4) If the radiohumeral joint does have space and distraction between two bony surfaces, can it get osteoarthritis?

5) If an injury happened to the proximal radius and it needed to be removed to relieve pain, what would that do to elbow / forearm functioning?

1) The radiohumeral joint. Because it assists with flexion/extension, and with pronation/supination.

2) False. The fovea of head of radius gets more tight (congruent) in capitulum as you move more through flexion.

3) False. The distraction happens as you move into extension and head of radius pulls apart more from capitulum (distraction)

4) Osteoarthritis is when articular cartilage gets broken down and weak. This happens between head of radius (fovea) and capitulum of humerus if someone does a lot of pronation / supination (work with tools twisting).

5) You could still flex weakly, and can still extend, and pronate and supinate (weakly), it just might allow more VALGUS movement of forearm since head of radius won't get stopped by capitulum.

98

1) Explain where the Annular lig is, and it's function

2) Explain where the Quadrate lig is, and it's function

1) Annular Lig: it wraps around head of radius to bind it to ulna, and help support it head of radius during pronation/supination. The ulna has the 'radial fossa/notch' where there is articular cartilage, and then as head of radius rotates around, you have annular lig holding the head of radius in place taut to ulna.

2) Quadrate Lig: Just distal to where head of radius articulates with ulna at the radial notch of ulna, is a ligament band under there = quadrate lig. It is a capsular thickening … it connects the radius to ulna, and so it RESTRAINS or limits radius from too much supination/pronation movement.

99

What is the "Nursemaid's Elbow"

When mom (or maid) is walking kid, and kid wants to go one way, but Mom yanks their arm. Well that dislocates head of radius out of place from annular lig.

Or you spin your child around and around, but instead of holding on proximal to elbow (which you should), you hold down by the wrist. This could not only pull brachial plexus, but dislocate head of radius out as well.

100

1) Now for the 4th Elbow joint ... what is the 4th joint not really associated with elbow joint capsule?

2) What does "volar" mean

3) Are there any ligaments associated with this joint?

3A) Is this joint synovial?

4) What is the TFCC ... and it's many functions

5) What is the ROM for the distal radioulnar joint.

1) Distal radio-ulnar jt.

2) Volar is another term for anterior or palmar

3) Yes. The volar radioulnar lig, and posterior radioulnar lig. Think of these as the ant. and post. capsular lig's.

3A) Yes. It has a capsule, synovial fluid, etc.

4) TFCC: Triangular Fibro Cartilage Complex
It is fibrocartilage down at the distal area past the head of ulna between ulna and carpal bones, and between radius and ulna. Its purpose is to:
- Connect head (pole) of ulna to the radius
- Prevent anterior or posterior or even medial/adduction of ulna away from radius.
- Give cushion / protection so ulna doesn't rub up against carpal bones.
- A cushion or hammack for the triquetrum carpal bone
- MAINLY, a stabilizer for the distal radio-ulnar joint.

5) Pronation is 0-80 degrees. Supination is 0-90 degrees.

101

1) What is the "mobile wad of 3"

1A) What nerve goes into "wad of 3"

2) Review the picture with all the m's and nerves from forearm

1) 3 extensor m's that you can grab and they are quite mobile.

1A) Radial nerve

2) ok

102

What is "Tennis Elbow"

Usually, what muscle is most effected?

So what is "Golfers Elbow"

It is TENDONITIS (inflammation of the tendon) of the fleshy muscle attachments into LATERAL epicondyle of the elbow (extensor m's)

Extensor carpi radialis brevis

Same thing as tennis elbow, but on the FLEXOR side / MEDIAL epicondyle (flexor m's)

103

Is there bursa around the elbow? Where

Explain bursa (where it is and what it does) in elbow

Yes. Main one is around olecranon of the elbow.

It has parts, one is between skin and triceps tendon, one between triceps tendon and bony olecranon processes. It reduces friction of muscle attachments rubbing against bone.

104

Explain the cutaneous nerve innervation around the elbow:

- Medial Cutaneous Nerve of the arm = branch of MEDIAL cord of brachial plexus

- Medial Cutaneous Nerve of the Forearm = branch of MEDIAL cord of brachial plexus

- Lateral Cutaneous Nerve of the Forearm = branch of the MUSCULOCUTANEOUS nerve

- Posterior Cutaneous Nerve of the Forearm = branch of the RADIAL nerve

105

Distinguish between open (loose) and close packed position:

Open-packed Position ... or LOOSE / LEAST:
•Position with the LEAST amount joint surface congruency
•Capsule and support ligaments are LAX
•Accessory motion or joint play is maximized

Close-packed Position
•Position with the MOST amount of joint congruency
•Capsule and supporting ligaments are maximally tight / taut
•Accessory motion is minimized​​

106

**** I asked him about the difference between a dermatome, a cutaneous nerve, and a peripheral nerve. Here is my explanation:

DERMATOME: This is an area of SKIN innervated by a specific spinal nerve root level. So the C5 spinal nerve descends through brachial plexus and has lots of nerves outshoot from it, but during embryo, as the C5 nerve descended into the arm, the area of skin it descends into is that dermatome area.

CUTANEOUS NERVES: These also supply an area of skin, but supply a certain area. So, think of the brachial plexus, for example. The medial brachial cutaneous and medial antebrachial cutaneous nerves come OFF of the brachial plexus to go and supply an area of skin.

PERIPHERAL NERVES: These nerves typically have origination from MUILTIPLE spinal nerves (C6-C7 for long thoracic nerve, for example, or C7-C8 for radial nerve). They carry both sensory and motor fibers and typically go deep to supply muscles and deeper tissues.

107

1) T or F: Most dermatomes do not overlap with another dermatome?

2) Does C6 and C7 overlap each other in the distal dorsal hand?

1) FALSE. Most dermatomes have about a 20-30% overlap with the adjacent dermatome next to it. There IS overlap. That is why dermatomes are messy.

2) YES. C6 does dorsal thumb, index, and most times middle finger ... C7 does all the medial fingers (not thumb or pinky). So there is overlap yes.

108

What is a MOTOR POINT?

Define innervate vs. denervate

Motor Point: The site in the muscle where the motor neuron passes in to reach the muscle fibers. It is the point where all the actions (action potential) initiates / stimulates the muscle.

Innervate is give nerve supply (action potential). Denervation: remove or cut off the nerve supply so there is no nerve innervation to that area.

109

What does Trabecular bone mean?

It is cancellous bone. It is the spongy cancellous bone NOT the cortical bone).