Module 2.3 Flashcards by Mary Rose Carvajal

The Vertebral Column is composed of:

7 Cervical 
12 Thoracic
5 Lumbar
5 Fused Sacral
4 Fused Coccygeal
2 Primary Curves
2 Secondary Curves

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Curves

Infant: 1 primary convex curve

Adult: 2 secondary concave curves
Cervical – as the baby hold its head up
Lumbar – as the child starts to walk upright

3rd or 4th month: concave curve develops
As the child walks: lumbar concave curve develops

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is an exaggeration of the thoracic curvature, which may occur in the aged due to osteoporosis or disc degeneration

KYPHOSIS

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is an exaggeration of the lumbar curvature, which may occur as a result of pregnancy, spondylolisthesis, or “pot belly.”

LORDOSIS

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is a complex lateral deviation/torsion, which may occur due to poliomyelitis, a short leg, or hip disease.

SCOLIOSIS

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True or False

There is a physiologic Kyphosis and Lordosis, but Scoliosis is ALWAYS pathologic

True

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Parts Of A Typical Vertebrae

Body – Anteriorly
Vertebral Canal
Lamina – “roofs”
Pedicles – “walls”

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Typical Vertebrae: 7 Projections

o (1) SPINOUS PROCESS- posteriorly
o (2) TRANSVERSE PROCESSES- laterally
o (2) SUPERIOR FACETS-facing dorsally
o (2) INFERIOR FACETS-facing ventrally

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MOTION SEGMENT: 3 Joints

Intervertebral Disc
• Synarthroses (bone – connective tissue – bone)
• Cartilage joint

2 Facet joints
• Diarthroses (bone – joint capsule – joint)
• Synovial joint

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o Half the height of corresponding body forming a superior and inferior notch
o Adjacent inferior and superior notches form the intervertebral foramen thru neural and vascular structures pass

Pedicles

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“Circular life preserver with a beach ball at the center”

INTERVERTEBRAL DISC

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FACET JOINT ORIENTATION

Cervical facets are more on the transverse plane-allowing more head rotation

Thoracic facets are on the coronal plane-allowing more trunk lateral flexion

Lumbar facets are more on the sagittal plane- allowing more trunk flexion/extension

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Motion Segment: 6 LIGAMENTS

Anterior longitudinal ligament
Posterior longitudinal ligament
Ligamentum flavum
Intertransverse ligament
Interspinous ligament
Supraspinous ligament

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Strong, dense anterolateral band from sacrum to C2 and atlanto-occipital ligament (from C2 to the head)
Twice stronger than PLL
Function: limits extension

ANTERIOR LONGITUDINAL LIGAMENT (ALL)

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Narrow posterior band from sacrum to C2 and tectorial membrane (from C2 to the head)
Allows posterolateral disc herniation
Function: limits flexion

POSTERIOR LONGITUDINAL LIGAMENT (PLL)

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Paired yellow elastic bands from ventral surface of upper lamina to upper lip of lower one
Bridges spaces between adjacent laminae (superior and inferior laminae)
Central gap facilitates anesthetic needle passage in lumbar punctures
In constant tension even when spine in neutral

LIGAMENTUM FLAVUM

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Small, but well developed in lumbar area

INTRATRANSVERSE / INTERSPINOUS LIGAMENTS

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From sacrum to C7, ligamentum nuchae

- Among earliest to fail in hyperflexion

SUPRASPINOUS LIGAMENT

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High water & proteoglycan contents
o Proteoglycan = glycosaminoglycans (GAGs) + water

GAGs:
o Chondroitin-4-sulfate
o Chondroitin-6-sulfate
o Hyaluronate
o Keratan sulfate

Lower collagen (type II-better for compression) content

Central nucleus

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higher collagen (type I-higher resistance to tension) content; arranged in concentric lamellae
attached to the vertebral cartilaginous endplates, epiphyseal ring (Sharpey’s fibers), vertebral body periosteum, longitudinal ligaments

Peripheral annulus

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Peripheral “life preserver”
Low water
Higher collagen fibers in concentric lamellae
Type I collagen (for tension)

ANNULUS FIBROSUS/ PERIPHERAL ANNULUS

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Central “beach ball”
Higher water and proteoglycans
Lower collagen
Type II collagen (for compression)

NUCLEUS POLPOSUS/ CENTRAL NUCLEOUS

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CHANGES WITH AGE (Degenerative Changes)

DISC- “circular life preserver with beach ball at the center”
loss of water content
loss of proteoglycans which maintain disc hydration

FACET JOINTS
Osteophyte formation
Joint capsule thickening

LIGAMENTUM FLAVUM
thickening

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Narrowing of the neural foramen and spinal canal
Compression of neural elements
Instability of the motion segment
Diagnosis is RAYUMA.
o Spinal stenosis
o Degenerative osteoarthritis
o Spondylosis

END RESULT = BACK PAIN +/- NUMBNESS/PARESTHESIAS OF LEGS

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- Improper back use exceeding tensile strength of fibers - Tears=back pain - Healing of tear=symptom relief but weaker disc - Continued improper back use - Tears getting bigger - Unable to hold beach ball in the middle - Strong PLL posteriorly - Ball “slips” posterolaterally

DISC HERNIATION

DISC HERNIATION: Clinical Tests | - bent leg

Kernig’s sign

DISC HERNIATION: Clinical Tests | - flexing head, coughing, sneezing, shock-like sensation down extremities

Lhermitte’s

DISC HERNIATION: Clinical Tests | - flexing head, px adducts and flexes knee

Brudzinski’s

DISC HERNIATION: Clinical Tests | - straight-leg

Laseague’s sign

DISC HERNIATION: Clinical Tests | -crossed straight-leg raising

Fajerstajn’s

- Transverse diameter > AP diameter - Has transverse foramina in the transverse process where vertebral artery passes - Transverse process has anterior and posterior tubercles (attach cervical muscles) - Uncinate processes on the supero-lateral body to add stability

CERVICAL VERTEBRAE

- Bifid spinous process for muscle attachments - Facets oriented in an up-down direction (transverse plane) - Superior facing upward and posteriorly - Inferior facing downward and anteriorly - Allows high degree of mobility (rotation and flexion/extension)

CERVICAL VERTEBRAE

- means carries the globe (head) alone - No body, no spinous process (ring), - Has 2 lateral masses - All facet joint surfaces are concave

ATLAS (C1)

- Has a dens (or odontoid process) – “projects like an axis” | - Has large thick laminae since the weight of the head is transmitted directly from the atlas

AXIS (C2)

- Synovial joint composed of 2 concave superior facets of the atlas and 2 convex occipital condyles of the skull - Allows head nodding - “O-O”

AtlantO-Occipital joint

- Synovial joint that allows head turning side-to-side – “Ah-Ah” - Large free space for cord to lessen impingement during cervical motion - Ligaments and joint capsules are lax - Muscles provide most of the stability

Atlanto-Axial (AA) joint

- Vertebra Prominens (because it has the most prominent spinous process) - Has the longest spinous process - Spinous process is not bifid

- Articulates with paired ribs - Demifacets – facets on transverse process and body - Rib cage limits motion - is the most stable because it has rib cage - Facets oriented in the coronal plane allowing lateral rotation - Spinous process is long and oriented inferiorly limiting extension.

THORACIC VERTEBRAE

- Has massive body to support weight of upper body | - Facets oriented along sagittal plane

LUMBAR VERTEBRAE

BODY: small SUPERIOR FACET ORIENTATION: superiorly and medially INFERIOR FACET ORIENTATION: inferiorly and laterally TRANSVERSE PROCESS: foramen for vertebral artery SPINOUS PROCESS: bifid

Cervical

BODY: equal transverse and AP diameter; demifacet for ribs SUPERIOR FACET ORIENTATION: supero-posteriorly and laterally INFERIOR FACET ORIENTATION: anteriorly and medially TRANSVERSE PROCESS: demifacet for ribs SPINOUS PROCESS: slopes inferiorly and overlaps with adjacent process

Thoracic

BODY: massive SUPERIOR FACET ORIENTATION: concave; medially and posteriorly INFERIOR FACET ORIENTATION: anteriorly and laterally TRANSVERSE PROCESS: long and slender SPINOUS PROCESS: broad and thick

Lumbar

- 5 fused vertebrae - Triangular complex supporting the spine and posterior wall of the pelvis - Concave and very smooth anteriorly and tilted towards the back (sacro-vertebral angle) - Laterally projecting alae are the fused anterior costal and posterior transverse processes of S1 to S3 and articulate with the iliac bone of either side (sacro-iliac joints)

Sacrum

- 4 ligaments-strong and taut; prevents separation of the ilium from the sacrum on erect posture - ½ bodyweight passes thru from L5 and S1 then down each extremity during bipedal stance - Ligaments soften during pregnancy to allow childbirth

Sacro-iliac joint

- 4 vertebral rudiments - Contributes no supportive function to the spine - Serves as an origin for the gluteus maximus posteriorly and the pelvic diaphragm anteriorly

COCCYX

- Bilateral muscles located anterior and lateral to the spine - Attach to the ribs, sternum and pelvis - Will flex structures forward if acting bilaterally - Will flex laterally if acting unilaterally - Act indirectly on the vertebral column by pulling on adjacent structures (e.g. pulling pelvis to the ribs as in a sit up flexes the lumbar spine) - Not active during normal erect standing - Will contract isometrically to stabilize the ribs and pelvis during pushing, pulling or lifting

SPINE FLEXORS

CERVICAL AND HEAD FLEXORS

- Scalenus anterior - Scalenus medius - Scalenus posterior - Longus capitis - Longus colli

HEAD FLEXORS

- Rectus capitis anterior | - Rectus capitis lateralis

LUMBAR FLEXORS

- Psoas major and minor - Iliacus - Quadratus lumborum ``` Anterior Abdominal wall muscles (attach ribs to pelvis) o Rectus abdominis o External oblique o Internal oblique ```

- Bilateral muscles located posteriorly and laterally in several layers - Extends when acting bilaterally - Laterally flexes or rotates when acting unilaterally - Eccentric contraction controls extent and rate of forward flexion - At a disadvantage if lifting in a forward flexion due to greater moment by gravity, requires more forceful contractions, increasing intradiscal pressure

SPINE EXTENSORS

Erector Spinae (S-I-LO): Spinalis (upper 80%, interspine connection) , Iliocostalis (lower 80%, transverse process, rib to rib, or ilium), LOngisimus (connects trans processes) Transversospinalis (SMR)-Semispinalis (superficial & extends), Multifidus (intermediate), Rotatores (deepest and rotates)

SPINE EXTENSORS (DEEPEST LAYER)

- Interspinalis | - Intertransvarii

- Very strong - Transfers weight from the axial skeleton to the lower extremity during stance - Supports body weight while standing - Serves as attachment of powerful trunk and lower extremity muscles

BONY PELVIS

Pelvis: 4 Bones

1. paired hip, hemipelvic or inominate bones- from 3 separate (infant) and eventually fused (puberty) bones: ilium, ischium and pubis 2. sacrum- from 5 fused sacral vertebrae 3. coccyx- from 4 fused rudimentary coccygeal vertebrae

INNOMINATE BONE

1. Ilium Crest 2. Pubis 3. Ischium

Joints of the pelvis

Symphyses - lumbosacral joint - sacrococcygeal joint pubic symphysis - Synovial joint - sacro-iliac joint

- Paired plane synovial joints that unite the hemipelvis to the sacrum posteriorly on either side - Very strong slightly movable weight-bearing joints reinforced by interlocking bone ends; interosseous ligaments and anterior and posterior sacro-iliac ligaments

Sacro-iliac joints

- joins the 2 innominate bones in front | - symphysis (secondary cartilaginous joint)- slightly movable midline joint whose bone ends are united by fibrocartilage

Symphysis pubis

Ligaments are relaxed by increase in sex hormones and the peptide hormone __ from the corpus luteum during menstruation and pregnancy.

relaxin

Joints become less bound resulting in more motion causing a 10-15 degree increase in the transverse diameter of the pelvis commonly causing __

back pain

- pelvic brim (edge of the inlet) which has a 55 degree angle with horizontal - coincides with a line from the superior pubis to the sacral promontory, conjugate diameter (AP) of the pelvis

Pelvic inlet

Pelvic inlet: Borders

- pubic symphysis, pubic crest, pecten pubis - arcuate line of ilium - sacral ala, sacral promontory

Pelvic Outlet: Borders

- inferior margin of pubic symphysis, inferior ramus of pubis - ischial tuberosity - sacrotuberous ligament - tip of the coccyx

- superior to the inlet, inferior abdomen - contains ileum and sigmoid colon - anterior abdominal wall in front, iliac fossa at the sides, L5-S1 vertebrae at the back

Greater pelvis

- pelvic inlet separates it from greater pelvis - between pelvic inlet and outlet - contains bladder, uterus and ovaries - enclosed by the innominate bones, sacrum and coccyx

Lesser pelvis

``` General structure: Thick and heavy Greater pelvis: Deep Lesser pelvis: Narrow and deep Pelvic inlet: Heart-shaped (android) Pelvic outlet: Smaller Pubic arch and subpubic angle: Narrow Obturator foramen: Round Acetabulum: Larger ```

Male Pelvis

``` General structure: Thin and light Greater pelvis: Shallow Lesser pelvis: Wide and shallow Pelvic inlet: Oval and rounded (gynecoid) Pelvic outlet: Larger Pubic arch and subpubic angle: Wide Obturator foramen: Oval Acetabulum: Smaller ```

Female Pelvis

- forms the contour of the buttocks, crosses 1 joint main hip extensor (with the hamstrings), superior portion abducts the hip, inferior portion adducts the hip, laterally rotates hip - very active (with the hamstrings) during walking by slowing hip flexion at the end of swing and in pulling the trunk over the stance limb at early stance

Gluteus maximus

well-developed Gluteus maximus in athletes cause tightness and may force the trunk to hyperflex in squatting and tying shoes leading to __

low back pain

- main hip abductor - keeps pelvis level in a unilateral stance anterior and middle portions medially rotate the hip - posterior portion laterally rotate the hip

Gluteus medius

- Anteroposterior compression of the pelvis occurs during crush accidents (when a heavy object falls on the pelvis) - Commonly produces fractures on the pubic rami - When the pelvis is compressed laterally, the acetabula and ilia are squeezed toward each other and may be broken - Below 17 years old: Acetabulum may fracture through the triradiate cartilage into its 3 developmental parts or the bony acetabular margins may be torn away.

Pelvic Fractures

Weak areas of the pelvis (where fractures often occur):

o Acetabulum o Pubic ramus o Region of sacroiliac joints o Alae of ilium

Powerful rotators and joint surface compressors because of their almost perpendicular line of action to shaft of femur

Six short lateral rotators

Nerve Innervation of Gluteus medius and Gluteus minimus

superior gluteal nerve

Nerve innervation of Gluteus Maximus

inferior gluteal nerve

(Short hip lateral rotators) Nerve innervation of Obturator internus and externus, Superior and inferior gemilli and Quadratus femoris

spinal nerves L5 and S1

(Short hip lateral rotators) Nerve innervation of Piriformis

spinal nerves S1 and S2

- Hip extensors, knee flexors, leg rotators - Innervated by the Sciatic nerve (tibial division) except short head of biceps femoris which is supplied by the common fibular division - Muscles: o Biceps femoris (long and short head) o Semimembranosus o Semitendinosus

Posterior thigh muscles

- attaches to fibular head, lateral leg rotator

Biceps femoris

- attaches to medial tibia, medial leg rotator

Semimembranosus and Semitendinosus

- Ventral rami of L4-S3 - Actually 2 nerves loosely joined by common connective tissue: Tibial and Common fibular nerves - Largest nerve in the body - With its own artery from the Inferior gluteal artery - Supplies the skin and muscles of the foot, leg, and posterior thigh - Variations occur as to how it passes the piriformis muscle

Sciatic Nerve

- May result from repetitive actions such as climbing stairs while carrying heavy objects, or running on a steeply elevated treadmill o These movements involve the gluteus maximus and move the superior tendinous fibers repeatedly back and forth over the bursae of the greater trochanter - Causes deep diffuse pain in the lateral thigh region - Characterized by point tenderness over the great trochanter - The pain radiates long the iliotibial tract that extends from the iliac tubercle to the tibia

Trochanteric Bursitis

- Recurrent microtrauma resulting from repeated stress>>inflammation of the ischial bursa - A friction bursitis resulting from excessive friction between the ischial bursae and the ischial tuberosities - Localized pain occurs over the bursa - The pain increases with movement of the gluteus maximus - Calcification may occur in the bursa with chronic bursitis - May lead to pressure sores in debilitated people because the ischial tuberosities bear the body’s weight during sitting

Ischial Bursitis

-  Common in individuals who run and/or kick hard - The violent muscular exertion required to excel in these sports may avulse/tear part of the proximal tendinous attachments of the hamstrings to the ischial tuberosity - often so painful when the athlete moves or stretches the leg that the person falls and writhes in pain - often result from inadequate warming up before practice or competition - Avulsion of the ischial tuberosity at the proximal attachment of the biceps femoris and semitendinosus may result from forcible flexion of the hip with the knee extended

Hamstring Strains

- Injection site: a few centimeters inferior to the midpoint of the line joining the posterior superior iliac spine (PSIS) and the superior border of the greater trochanter - Paresthesia radiates to the foot because of anesthesia of the plantar nerves (terminal branches of the tibial nerve derived from the sciatic nerve)

Anesthetic Block of Sciatic Nerve

- is a common injection site because the muscles are thick and large, and they also provide a substantial volume for absorption of injected substances by intramuscular veins

 Gluteal region

Injections into the buttock are safe only in the:

- Superolateral quadrant of the buttock - Superior to a line extending from the PSIS to the superior border of the greater trochanter - Anterolateral part of the thigh (the needle enters the tensor fasciae latae) as it extends distally from the iliac crest and ASIS

(hip) - Congruence of 3 bones - Directed laterally, inferiorly, and anteriorly - Birth: bones are separated and joined by a Y-shaped tri-radiate hyaline cartilage - 15-17 y/o: bones start to fuse - 20-25 y/o: fusion is completed

Acetabulum

(hip) - Acetabular region lined with hyaline cartilage - Covers a peripheral horseshoe-shape articular surface with the femoral head

Articular Surface (Lunate Surface)

(hip) Notch – inferiorly located  Fossa o Non-articular and contains fibroelastic fat covered with synovial membrane o Deepens the socket to provide some “vacuum effect”

Non-articular Surface

(hip) - Ring of wedge-shaped fibrocartilage which deepens the socket - Increases the concavity of the acetabulum - Triangular in cross-section - Grasps the femoral head to maintain articular contact

Labrum

(hip) - Measure of acetabular development - Range: 22-42 degrees o Average in male: 38 degrees o Average in female: 35 degrees - More vertical orientation of the acetabulum, the smaller the angle, diminished head coverage - Angle increases with age from childhood

Center Edge Angle of Wiberg

``` (hip) Infancy: 150 degrees Adult: 115-140 degrees Decreased angle  Coxa vara Increased angle  Coxa valga ```

Neck-Shaft Angle (Angle of Inclination)

(hip) - Circular hyaline cartilage – covered surface - Fovea – devoid of cartilage; where the ligamentum attaches - Attached to the shaft via the neck and trochanters

Femoral Head

Hip Development

- Normal hip development requires the normal relationship of the femoral head with the acetabulum - Intervention is done to maintain the “ball in the socket”

- Synovial ball and socket joint - Femoral head and acetabulum - Most mobile joint of the lower extremity - Allows squatting and standing - Stable enough to support weight of head, trunk, upper extremities and in single-legged stance including that of the opposite leg - 3 degrees of freedom

HIP JOINT

Hip Joint: Stability

- Bony configuration - Strong capsule - Strong reinforcing ligaments with fibers arranged in a special orientation

Hip Joint: Position of least stability

Flexion – where the ligaments are unwound Adduction – where the femoral head is uncovered and outside the acetabulum

- Strong and dense capsule from entire acetabular periphery to the base of the femoral neck - Longitudinal fibers along its neck - Circular fibers within its substance around the femoral neck, zona orbicular - Thickened anterosuperiorly, loose posteroinferiorly - Encloses entire femoral head and most of the neck

Hip Joint Capsule

Capsule is reinforced outside anteriorly by the: o Iliofemoral ligament / Y-ligament of Bigelow (strongest) o Pubofemoral ligament Capsule is reinforced posteriorly by the: o Ischiofemoral ligament - Prevent excessive hip extension

HIP LIGAMENTS

Anterior ligaments – also prevent excessive abduction  Posterior ligament – also prevents excessive adduction and medial rotation  Make hip extension (standing) a position of stability by pulling the joint surfaces together and tightening

HIP LIGAMENTS

- From the acetabular notch to the femoral head | - Carries the artery of ligamentum teres – major blood supply to most of the head before closure of epiphysis

Ligamentum Teres

Main blood supply before maturity

Artery of the Ligamentum Teres

– main blood supply in adult

Medial Circumflex Arteries

NERVE SUPPLY TO THE HIP

Mainly from branches of the lumbosacral plexus ``` Anteriorly: o Femoral nerve o Accessory obturator nerve  Inferiorly: Obturator nerve  Superiorly and posteriorly: o Superior gluteal nerve o Nerve to quadratus femoris ```

- Aka Intracapsular fractures - Disruption of the blood supply to the femoral head - Problems with healing and avascular necrosis of the femoral head - In the physiologically active patient, open reduction internal fixation is performed. - In the elderly, joint replacement is done.

Femoral Neck Fractures

- Abnormal development of either the acetabulum or femoral head - Abnormal measurements in the center angle or the neck-shaft angle may be noted

Hip Dysplasia

- Fractures of the hip bone - Avulsion fractures of hip bone may occur during sports that require sudden acceleration or deceleration forces, such as sprinting or kicking in football, soccer, hurdle jumping, basketball, and martial arts - These fractures occur at apophyses (bony projections that lack secondary ossification centers) - Avulsion fractures occur where muscles are attached: ASIS, AIIS, ischial tuberosities, ischiopubic rami

Pelvic Fractures

causes a mild shortening of the lower limb and limits passive abduction of the hip

Coxa vara

Dashboard injury in a vehicular accident

Hip dislocation

HIP VS. SHOULDER STABILITY

The shoulder is more mobile. Stability is from integrity of the capsule, ligaments and rotator cuff muscle activity. Strengthening the rotator cuff has a role in improving stability.  The hip’s stability is more from the bony articulation and integrity of the capsule and ligaments than muscle contractions. Surgical interventions have a bigger role in addressing stability issues for the hip

- Hip flexors and knee extensors - Nerve supply: o Spinal nerves L1-L3 o Superior gluteal nerve o Femoral nerve

ANTERIOR THIGH MUSCLES

``` Pectineus Iliopsoas Tensor of fascia lata Sartorius Quadriceps femoris ```

major hip flexor; activity affects lumbar curvature

Iliopsoas muscle

only one of quadriceps group that crosses both hip and knee; knee position affects its action on the hip; stronger hip flexor when knee is flexed

Rectus femoris

maintains tension on the iliotibial band which relieves tensile stresses on the femur during weight-bearing; may be excised and used as a graft without altering hip and knee function

Tensor fascia lata

- Mainly adducts thigh, stabilizes thigh during flexion and extension - Hip adductors - Innervation: obturator nerve

Medial thigh muscles

Adductor brevis Adductor longus Adductor magnus Gracilis

largest adductor with adductor and hamstring parts, dual nerve supply

Adductor magnus

- most superficial and weakest - strap-like muscle on the medial thigh and knee - crosses the knee joint (flexes knee, medially rotates leg) - used in tendon grafts in ACL reconstruction

Gracilis

FEMORAL TRIANGLE: Borders

- Inguinal ligament - Sartorius - Adductor longus

Femoral Triangle: Contents

- Femoral nerve - Femoral sheath - Allows gliding of vessels in hip motion - Femoral artery – lateral compartment - Femoral vein – middle compartment - Lymph vessels – medial femoral ring and canal

Continuation of external iliac artery - Deep artery or profunda femoris artery - Medial and lateral circumflex arteries Thru femoral triangle and adductor canal becoming the popliteal artery

Femoral artery

From the internal iliac or as an accesory obturator artery of the inferior epigastric artery - Artery of the ligamentum teres

Obturator artery

Intermuscular passage for the femoral vessels to the popliteal fossa.

Adductor canal (Hunter’s canal)

Adductor canal (Hunter’s canal): Borders

anterior and lateral- vastus medialis medially-sartorius posteriorly- adductor longus and magnus

Adductor canal (Hunter’s canal): Contents

femoral artery and vein saphenous nerve nerve to the vastus medialis

(femoral fracture)  – most frequently fractured because it is the narrowest and weakest part of the bone and it lies at a marked angle to the line of weight-bearing

Neck of femur

(femoral fracture) - Usually at the transcervical (middle of neck) and intertrochanteric - Usually occur as a result of indirect trauma (stumbling or stepping down hard, as off a curb or step) - Due to angle of inclination, these fractures are inherently unstable and impaction occurs  Impaction – over-riding of fragments resulting in foreshortening of the limb

Fractures of the proximal femur

(femoral fracture) o Usually result from direct trauma o Most common during the more active years o Frequently occur during motor vehicle accidents and sports such as skiing and climbing

Fractures of the greater trochanter and femoral shaft

(femoral fracture) o May be complicated by separation of the condyles, resulting in misalignment of the articular surfaces of the knee joint, or by hemorrhage from the large popliteal artery o Compromises the blood supply to the leg

Fractures of the distal femur

- The great saphenous vein and its tributaries become varicose (dilated so that the cusps of their valves do not close). - are common in the posteromedial parts of the lower limb and may cause discomfort

Varicose Veins

- Characterized by swelling, warmth, and erythema | - Venous stasis (stagnation) is an important cause of thrombus formation

Deep Venous Thrombosis (DVT)

- A contusion of the iliac crest that usually occurs at its anterior part - One of the most common injuries to the hip region - Usually occurring in association with collision sports, such as the various forms of football, ice hockey, and volleyball - May also refer to avulsion of bony muscle attachments

Hip pointer

- Cause bleeding from ruptured capillaries and infiltration of blood into the muscles, tendons, and other soft tissues

Contusions

o May refer either to cramping of an individual thigh muscle because of ischemia or to contusion and rupture of blood vessels sufficient enough to form a hematoma o Injury is usually the consequence of tearing of fibers of the rectus femoris o most common site of a thigh hematoma: QUADRICEPS o Associated with localized pain and/or muscle stiffness and commonly follows direct trauma

Charley horse

A retroperitoneal pyogenic infection (pus-forming) in the abdomen or greater pelvis, characteristically occurring in association with TB of the vertebral column, or secondary to regional enteritis of the ileum (Crohn diseases) may result in the formation of a __

psoas abscess

- The person cannot extend the leg against resistance - The person usually presses on the distal end of the thigh during walking to prevent inadvertent flexion of the knee joint - Arthritis or trauma to the knee joint  weakness of vastus medialis or vastus lateralis  abnormal patellar movement and loss of joint stability

Paralysis of Quadriceps

- Muscle strains of the adductor longus may occur in horseback riders and produce pain  rider’s strain - Ossification sometimes occurs in the tendons of these muscles because the horseback riders actively adduct their thighs to keep from falling from their animals - The areas of the ossified tendons are sometimes called “rider’s bones”

Injury to the Adductor Longus

- A f-way common meeting of the medial and lateral circumflex femoral arteries with the inferior gluteal artery superiorly and the first perforating artery posterior to the femur

Cruciate anastomosis

- Composed of the bones of the tibia and fibula, joined at the Proximal and distal tibia-fibular joints and Interosseous membrane

Leg

- Medial leg bone, 2nd largest in the body - Articulates proximally via the large tibial plateau with the femoral condyles, central intercondylar eminences fit in the intercondylar notch of the femur - Triangular cross-section with a prominent subcutaneous anterior border - Articulates distally with the talus via the tibial plafond - Distal medial projection, medial malleolus with a lateral facet for the talus - Accepts at least five-sixths of the bodyweight passing thru that leg

Tibia

- Posterolateral to the tibia - Mainly for muscle attachments, accepts at most one-sixth of the bodyweight passing thru that leg - Head articulates with the lateral condyle of the tibia - Serves as attachment of the biceps femoris muscle - Around the neck winds the common peroneal nerve - Has a distal lateral projection, lateral malleolus, which is posterior to the medial malleolus and 1 cm more distal - Has a medial articulation with the talus

Fibula

3 joints which allow some motion to accommodate movement of the talus in and out of the ankle in dorsiflexion and plantarflexion

- Proximal tibio-fibular joint (synovial plane) - Interosseous membrane (syndesmosis) - Distal tibio-fibular joint (syndesmosis)

- In adults, there is a normal 20-40 degree external or lateral angulation between the transverse axes of the malleoli and that of the tibial condyles, lateral tibial torsion - In children, medial tibial torsion is the most common cause of in-toeing. Surgery not often done unless to correct after age 8-10 if with functional deformity.

Lateral tibial torsion

Syndesmosis (fibrous joint)- between concave facet of tibia and convex facet of fibula, supported by ligaments Stabilized by: Strong superior interosseous ligament Strong inferior anterior and posterior tibio-fibular ligs Serves as fulcrum of fibular motion, small motions cause big motions proximally

Tibio-fibular joints

- Extensors (dorsiflexors) of the ankle, hallux and lesser toes. All pass in front of the medial malleolus. 1. Tibialis anterior- 2. Extensor digitorum longus 3. Extensor hallucis longus 4. Peroneus tertius- also a weak foot evertor

The anterior compartment (deep peroneal n)

main ankle dorsiflexor, also a foot invertor, attaches to the base of 1st mt, medial cuneiform

Tibialis anterior

- Evertors of the foot, weak ankle plantar flexors. All pass behind the lateral malleolus. 1. Peroneus longus- attaches to the base of the 1st mt and medial cuneiform 2. Peroneus brevis- attaches to the base of 5th mt

The lateral compartment (superficial peroneal n)

- Plantarflexors of the ankle. Attached to the calcaneus via the Achilles tendon.

The superficial posterior compartment (tibial n)

Plantarflexors of the ankle

1. Gastrocnemius- crosses the knee joint, strong when knee extended, very active in walking and running 2. Soleus- very powerful, acts mainly alone when knee flexed 3. Plantaris - very weak, minimal activity, may be harvested for tendon grafting

- All pass behind the medial malleolus except Popliteus muscle. 1. Tibialis posterior 2. Flexors of the hallux and lesser toes, weak plantar flexors - Flexor digitorum longus - Flexor hallucis longus 3. Popliteus- weak knee flexor, externally rotates femur during knee flexion (unlocking)

The deep posterior compartment (tibial n)

main invertor of the foot, weak plantar flexor

Tibialis posterior

Structures behind medial malleolus | Tom, Dick ANd Harry

1. Tibialis posterior 2. Flexor Digitorum longus 3. Posterior tibial artery 4. Tibial nerve 5. Flexor hallucis longus

- tendinous extension of gastrocnemius, soleus, and plantaris. - thickest and strongest tendon in the body - about 15 cm long, and begins near the middle of the calf inserted into the middle part of the posterior surface of the calcaneus - a bursa is present between the tendon and the calcaneus

Achilles tendon

- inflammation from overuse | - Clinically, pain posteriorly on walking, tiptoeing

Achilles tendonitis

- usually occurs in sports requiring sudden eccentric stretching, such as sprinting - Clinically, weak plantar flexion. Not absent due to other plantar flexors - Thompson’s test- to test integrity of tendon

Achilles tendon rupture

- (continuation of the femoral artery), has geniculate branches to the knee

Popliteal artery

- supplies the muscles of the anterior compartment and sends perforating branches to muscles of lateral compartment

Anterior tibial artery

- (larger br. of popliteal artery), supplies the posterior compartment, main blood supply to the foot

Posterior tibial artery

A nerve bifurcates at apex of popliteal fossa into the 1. Common peroneal (fibular) nerve 2. Tibial nerve 3. Saphenous nerve 4. Sural nerve (short saphenous nerve)

Sciatic

Nerve that passes behind the head of the fibula and winds around the neck, deep to the peroneus longus where it divides into the 1. Superficial peroneal nerve- supplies the lateral compartment 2. Deep peroneal nerve- supplies the anterior compartment

Common peroneal (fibular) nerve

- larger br., supplies all muscles in the posterior compartment, distal to the medial malleolus, it divides into the Medial and lateral plantar nerve

Tibial nerve

Cutaneous branch from the femoral nerve, passes medial side of thigh and leg, supplies the skin on the medial leg and foot

Saphenous nerve

Cutaneous branch from common peroneal and tibial nerves, supplies the skin on the postero-lateral leg and foot

Sural nerve (short saphenous nerve)

(lateral foot) palpable anterolateral depression formed by the union of the sulcus tali and sulcus calcanei, contains the talar neck, anterior talo-fibular ligament and a venous plexus

Sinus tarsi

- Between the talus and calcaneus - Dampens bodyweight rotation while foot in contact with the ground - Where pronation and supination occurs - Stabilized by the medial and lateral ankle collateral ligaments and an interosseous talo-calcaneal ligament

Subtalar joint

- Talo-navicular and calcaneo-cuboid joints - Synovial plane joints - The navicular and cuboid do not move in wt-bearing. - Motion is by the talus and calcaneus on the navicular and cuboid bones, mainly pronation and supination - Allows the forefoot to remain flat on the ground while the hindfoot pronates and supinates when traversing uneven ground

Transverse tarsal joint

- Synovial plane joints - Function is to adjust the forefoot if compensation from the more proximal joints (transverse tarsal and subtalar) are not enough in more extreme hindfoot position.

Tarso-metatarsal joint

- Synovial condyloid joints that allow flexion and extension and abduction and adduction - Extension of the phalanges allow the body to pass over the foot in gait, allows the hindfoot to rise (metatarsal break) - Flexion allows balancing of the bodyweight as the toes press down on the ground

Metatarso-phalangeal joint

Arches of the foot

1. Medial longitudinal arch- calcaneus-talus-navicular-medial cuneiform-1st to 3rd metatarsals 2. Lateral longitudinal arch- lower, flatter, calcaneus-cuboid-4th and 5th metatarsals 3. Transverse arch-cuneiforms-cuboid and bases of metatarsals

- Not so important individually, unlike in the hand since fine foot motion commonly not needed - Helps the ligaments to maintain the arches - Facilitate standing on uneven ground

Muscles of the foot

The talar dome receives all the weight from the leg,

1. 50% goes to the (hindfoot) calcaneus 2. 50% thru the talo-navicular and calcaneo-cuboid joints to the (forefoot) metatarsal heads - 1st MT head- 50% - 2nd-5th MT head-12.5% each

Stability Mechanism (foot)

1. Mobile strut-tie-rod mechanism- dependent on plantar restraints to prevent separation 2. Static arch-beam- compression of top portion, tension of bottom portion

- Bodyweight tends to flatten the medial longitudinal arch as it passes thru the anterior and posterior struts. - The tie-rod below allow some flattening but pulls on the ends of the struts toward the center maintaining the arch. - The plantar ligaments make-up the tie-rod. - Non-weight bearing, tie-rod pulls ends toward the center.

Strut-tierod mechanism

Arch mechanism

1. Navicular/talar head- serves as the keystone for the medial arch 2. Cuboid- lateral arch 3. Middle cuneiform- transverse arch 4. Plantar ligaments make sure arches do not separate

- Excessive elevation of the longitudinal arch - Excessive forces on the metatarsal heads - Contracture of the plantar structures - Orthotic arch supports to distribute forces

Cavus deformity

- Collapse of longitudinal arch Depression of navicular Antero-infero-medial displacement of talus Eversion of calcaneus - Stretching of ligaments, muscle action required in simple standing - Orthotic arch supports to normalize weight bearing forces

Pes planus

Hindfoot equinus Hindfoot varus Forefoot adduction

Talipes equinovarus/Congenital clubfoot

- Positive Trendelenburg test - Pelvis tilts to opposite side in single leg stance - To compensate during gait, the trunk is tilted or lurched toward weak side to prevent falling

Gluteus medius weakness

- Footdrop, unable to clear ground during swing phase - Much more hip and knee flexion like soldiers marching in high step - Steppage gait

Weakness of foot dorsiflexors

- is primarily a hinge type of synovial joint, allowing flexion and extension; however, the hinge movements are combined with gliding and rolling and with rotation about a vertical axis.

knee

Although the knee joint is well constructed, its function is commonly impaired when it is __ (e.g., in body-contact sports such as hockey).

hyperextended

- the distal part of the quadriceps tendon, is a strong, thick fibrous band passing from the apex and adjoining margins of the patella to the tibial tuberosity

patellar ligament

- rounded and cord-like, is strong | - It extends inferiorly from the lateral

fibular collateral ligament (FCL)

- is a strong flat band that extends from the medial epicondyle of the femur to the medial condyle and superior part of the medial surface of the tibia - At its midpoint, the deep fibers are firmly attached to the medial meniscus.

tibial collateral ligament (TCL)

- is a reflected expansion of the tendon of the semimembranosus that strengthens the joint capsule posteriorly - arises posterior to the medial tibial condyle and passes superolaterally to attach to the central part of the posterior aspect of the joint capsule

oblique popliteal ligament

- arises from the posterior aspect of the fibular head, passes superomedially over the tendon of the popliteus, and spreads over the posterior surface of the knee joint.

arcuate popliteal ligament

- join the femur and tibia, criss-crossing within the joint capsule but outside the articular cavity - cross each other obliquely like the letter X.

cruciate ligaments

- the weaker of the two cruciate ligaments, arises from the anterior intercondylar area of the tibia, just posterior to the attachment of the medial meniscus - extends superiorly, posteriorly, and laterally to attach to the posterior part of the medial side of the lateral condyle of the femur - prevents posterior displacement of the femur on the tibia and hyperextension of the knee joint - When the joint is flexed at a right angle, the tibia cannot be pulled anteriorly because it is held by this ligament

anterior cruciate ligament (ACL)

- the stronger of the two cruciate ligaments, arises from the posterior intercondylar area of the tibia - passes superiorly and anteriorly on the medial side of the ACL to attach to the anterior part of the lateral surface of the medial condyle of the femur - limits anterior rolling of the femur on the tibial plateau during extension, converting it to spin - prevents anterior displacement of the femur on the tibia or posterior displacement of the tibia on the femur and helps prevent hyperflexion of the knee joint

posterior cruciate ligament (PCL)

In the weight-bearing flexed knee, the __ is the main stabilizing factor for the femur (e.g., when walking downhill).

posterior cruciate ligament (PCL)

- are crescentic plates of fibrocartilage on the articular surface of the tibia that deepen the surface and play a role in shock absorption

menisci of the knee joint

o From medial femoral condyle to medial aspect of proximal tibia o Posterior fibers attach medially to joint capsule and medial meniscus o Weaker than lateral collateral o Resists valgus stress

Medial collateral ligament (MCL)

o Stronger o No attachment to meniscus o From lateral femoral condyle to lateral fibular head o Resists varus stress

Lateral collateral ligament (LCL)

- Distal part of extensor mechanism - Attaches inferior pole of patella with tibial tuberosity - Blends with the retinacula on either side

Patellar Tendon

- Formed proximally from fascia of tensor fascia late - Gluteal muscles insert distally into lateral tibial tubercle - Consistently taut regardless of knee position - Reinforcing anterolateral capsule

Iliotibial Band

o Medial tibio-femoral angle greater than 190 degrees

Genu Valgus

o Medial tibio-femoral angle less than 190 degrees

 Genu varum

- A common knee problem for marathon runners, also in basketball players - The soreness and aching around or deep to the patella results from quadriceps imbalance - May also result from a blow to the patella or extreme flexion of knee

Chondromalacia Patellae / Runner’s Knee

- Patella ossifies during 3rd-6th years, frequently from more than one ossification center - Patella may remain separate on one or both sides  bipartite or tripartite patella

Abnormal Ossification of Patella

- Tapping the patellar ligament with a reflex hammer normally elicits the patellar reflex / knee jerk - The person is test while sitting with dangling legs. - Strike on the ligament  extension of leg - Tests the integrity of the femoral nerve and L2-L4 spinal cord segments

Patellar Tendon Reflex

o ACL tear o Medial meniscal tear o Medial collateral tear

Unhappy Triad of O’Donahue

Module 2.3 Flashcards

(203 cards)