MSK Flashcards
(228 cards)
1
Q
what are the bones of the upper limb and pectoral girdle (proximally to distally)?
A
Sternum clavicle, scapula,Humerus, ulnar+ radius, carpals( scaphoid, lunate, triquitum, pisiform, trapizum, trapezioid, capitate, hamate), metacapals (1-5) and phalanges (distal, middle and proximal except in the case of the thumb which only have proximal and distal).
2
Q
what are the joints of the pectoral girdle?
A
sternoclavicular and acromioclavicular.
3
Q
what are the functions of the skeleton?
A
- Movement and mobility;
- Haemopoeisis;
- calcium and fat stores;
- protection and support
4
Q
what are the different types of bone?
A
- long
- short
- sesamoid
- pneumatic
- accessory
- flat
- irregular.
5
Q
Describe bone formation and growth
A
Bone formation can occur via intramembranous or endochondral ossification.
Intramembranous ossification: occurs via mesenchyme differentiating into osteoblasts which then grow out from a set point laying down bone.
Endochondral: occurs via a hyaline template that undergoes ossifcation. This occurs first with the chondrocytes swelling so that the lacunae become confluent and line up. The chondrocytes undergo apoptosis and then secrete alkaline phosphatase and VEGF. This leads to the developement of the periosteal collar and then the formation of the primary ossification centre. There is a massive influx of haemopoetic cells and osteoblasts and clasts. this leads to a breakdown of the the cartillages extracellular matrix and the laying down of boney matrix. Growth continues at the epiphyseal plates after birth, these are the 2nd centres of ossification.
6
Q
describe the pathophysiology of osteogenesis imperfecta
A
This is due to a genetic mutation in the genese coding for type one collagen. There is a mutation that results in a change in the primary sequence of amino acids so a conformational change results. There is a number of different types of varying severity with the most extreme cases being death at child birth and the milder ones being more prone to fracture. Symptoms of include increased risk of fracture, poor muscle tone, blue sclera and hearing loss. Overall height can be also be affected.
7
Q
describe the pathophysiology of osteoporosis
A
Caused by excessive activity of osteoclasts due to loss of inhibition or over proliferation of. It presents with a decreased bone density. Most commonly it arises in post menopausal women and in old age although there is a number of other risk factors (ethnicity, gender, diet etc)
8
Q
describe the pathophysiology of osteomalacia/rickets
A
Deficiency of vitamin D that leads to softening to the bones. This leads to easy fracture, and over curvature of the spine.
9
Q
describe the pathophysiology of paget’s disease.
A
Pagets disease is due to the excessive breakdown and rebuilding of bone that can lead to pain and malformation of bone structure. There is a chaotic structure to the relaid bone that lacks the uniformity of healthy bone.
10
Q
Describe the process of fracture repair in bone.
A
First a haematoma forms that then leads to swelling around the site of injury. Phagocytes then enter into the haemotoma digesting it and then this becomes granulation tissue. This is highly vascularised. Peripheral granulation tissue becomes hyaline cartilage. Then ossification occurs (a combination of both types) this leads to the formation of cancellous bone which then undergoes remodelling to form the normal uniform ostoid structures
11
Q
Describe the classification of joints
A
fibrous (syndesmoses, sutures, gomphoses), cartilagenous (synchondrosis, symphysis), synovial
12
Q
Describe the standard components of a synovial joint.
A
capsule, membrance, fluid, articulating cartilage, articulating bone.
13
Q
what are the 5 common sites for mets in bone cancers
A
lung, breast, prostate, kidney, thyroid
14
Q
what are the terms for bowleddedness and knock knees
A
genu vargus and genu valgus respectively
15
Q
what are the common bone surface landmarks?
A
tuberosity/tubercle, spines, trochanter, epi/condyles, facet, crest, sinus, meatus, fossa, foramen, fissure, notch.
16
Q
what are the 6 types of synovial joints?
A
hinge, saddle, plane, pivot, condyloid, ball and socket.
17
Q
what contributes to joint stability?
A
ligaments, muscle tone, size of articular surface.
18
Q
Name the tarsals an any major boney landmarks
A
Talus, calcaneus, cuboid, navicular, cuneiforms 3, 2, 1
19
Q
What are common traumatic injuries to the bones of the foot?
A
Calcaneus fracture- hard impact onto heel from a high fall, typically disrupts the talocalneal joint where the talus articulates with the calcaneus.
20
Q
Describe the superficial and deep lymph drainage of the lower limb and any common pathological changes and indications of these
A
Superfically they accompany the great/small saphoneus vein, terminating at the superficial inguinal lymph nodes/ popliteal lymph respectively.
Deep lymph drainage is from the popliteal to the deep inguinal which then joins the lumbar thoracic lymph.
If enlarged could be due to micro sepsis or uterine cancer mets.
21
Q
Which veins are autografted in heart bypass surgery and why?
A
The great saphoneous vein due to it being muscular.
22
Q
How do varicose veins occurs? What can they result in?
A
Damage to to valves in superfical veins result in veins remaining engorged. They result in blood pooling and stasis which can lead to the formation of thrombus and as a result Pulmonary embolism.
23
Q
What is a saphoneus cut down?
A
Finding the great saphoneous by cutting down anterior to the medial malleoulus but there is a risk to the saphoneous nerve.
24
Q
Describe the anterior deep venous network of the lower limb
A
Formed from the common illiac proximally. this branches into the internal and external common illiac. Then there is an internal branch of the obturator., below which the great saphoneous vein joins in the femoral triangle to the femoral vein. lateral circumflex gives rise to the perforating branch and descending lateral. This communicates with the genvicular veins of the knee. Then the anterior tibial and the dorsal arch
25
Describe the posterior deep venous network of the lower limb
plantar arch, fibular (with perforating veins) and posterior tibial, popliteal vein and(medial, lateral, superior, inferior), femoral vein and femoral profunda. Also the superior and inferior gluteal.
26
Describe the anterior-medial superficla venous network of the lower limb
dorsal venous arch, great saphonous then passes anterior of the medial malleolus and then medially of the patella. going up the leg until it drains in the femoral vein.
27
Describe the posterior superfical venous network of the lower limb
plantar venous network, lateral margin vein of the foot, drains into popliteal vein.
28
what does DR CUMA stand for?
wrist Drop= radial nerve
ulnar Claw- Ulnar nerve
Ape hand=mediun nerve
29
What does digit ischaimia from cold/stress suggest?
Primary raynaud's syndrome.
30
Describe a common pathology of the tendonous synovial sheath of the fingers and its cause.
Tenosynovitis, from an infected puncture wound.
31
Describe the symptoms of ulnar claw and describe how it originates.
Cant make a fist or fully straighten hand. This is doe to ulnar nerve injury. Only the 4th and 5th digits affected. due to them being supplied by the medial aspect of the flexor digitorum profundus.
32
What common upper limb injury can cyclists get?
Handle bar neuropathy. Characterised by medial sensory loss and atrophy of thenar muscles.
33
What intrinsic hand muscles are innervated by the mediun nerve?
Meat LLOAF: 2 most lateral lumbricals, Oponens pollicis, abductor pollicis brevis, Flexor policis brevis.
34
Describe the role and location of the interossei
3PAD, 4DAB towards/away the midline respectively. also flex and extend with the lumbricals
35
What is the role and location of the lumbricals?
operate over the metocarpalpharengeal joint, flex and extend this.1 and 2 are unipenate, and 3 and 4 are bipenate.
36
Describe the sensory nerve regions on the hand.
ulnar all of 5th and half of 4th digit. This is symetrical on palm and dorsum.
Medium: remainder of palm except most superior region of thumb. finger tops of of medial 2.5 fingers.
Radial: dorsal thumb, medial 2.5 fingers and the hand below them except for the distal region, On palm its the region superior on the thumb (in anatomical position)
37
Describe the aterial supply to the hand.
3 main supplies from the radius, ulnar and interosseous. Interosseous forms a network merging with both radial and ulnar. Radial and ulnar form a deep and superficial palmar arch with the superficial extending most distaly. The superficial gives rise to the common palmar digits and the deep gives rise to the palmar metacarpal. These both merge to form the proper palmar digital arteries. The ulnar has a dorsal branch as does the radial which forms the dorsal arch which is aided by the presence of perforating arties between the digits..
38
What is signigicant about the overlap of dermatomes?
Multiple spinal nerves will be innervating one region so a sensory loss will be due to damage to more than one spinal nerve.
39
Describe the anterior cutaneous nerves from proximal to distal of lower limb.
Genitofemoral, illiguinal, lateral cutaneous, anterior femoral, obturator, lateral sureal, saphoneous, fibular,
40
Describe posterior cutaenous nerve from proximal to distal of lower limb.
Medial, superficial, inferior clunial, Lateral cutaneous, posterior, saphoneous, medial sureal, lateral sureal, medial calcaneal, medial and lateral plantar.
41
Describe the arterial supply to the lower limb. from proximal to distal naming branches lateral to medial
Common illiac, external illiac, internal illiac,
External--> femoral, gives off epigastric laterally, branches into lateral and medial circumflex. Femoris profunda and descencing branch of lateral circumflex run paralle to femoral down leg. Profunda gives off perforating arteries posteriorly. Femoral moves behind knee (travelling through adductor hiatus) becoming popliteal artery. Meshwork of genicular arteries anterior to the knee.
42
Describe the structure of the brachial plexus
has roots from c5-->T1. C5 merges with c6, c7 doesnt merge, c8 and t1 merge. these form the trunks respectively. After the trunks are the divisions. from the inferior is a posterior branch to the middle, from the middle is an anterior branch to the superior. From the superior is a posterior branch to the middle. These then form the cords which are named due to their relative location to the axillery artery. (posterior, medial and lateral). medial gives off 2 branches, one forms the ulnar nerve the other contributes to the mediun nerve along with a branch from the lateral branch. The lateral branch also gives rise to the musculocutaneous nerve. The posterior cord gives rise to the radial artery and the axillery artery.
43
What are the root values of the terminal branches of the brachial plexus?
radial: c5678, T1
ulnar: C8, T1
Mediun:c6,7,8 t1
Musculocutaneous:c5,6,7
Axillery: c5,6
44
What key nerves are given off directly from the brachial plexus?
dorsal scapular (c5) long thoracic (c5,6,7), suprascapular (c5,6) subclavian (c5,6), thoracodorsal (c678) medial pectoral, medial cutaneous of arm/forarm (c8,t1), lateral pectoral (c5.6.7)
45
What can cause an upper brachial plexus injury? what are the symptoms?
rapid force that increases the angle between the neck and shoulder (landing on your head at and angle). Damages the upper roots resulting in likely lesions affecting the axillery and musculotcutaneous and branches off the lateral branch.
46
What can causes a lower brachial plexus injury? what is its symptoms?
klumpke injury is common by having the arm rapidly abducted to above the head. this damages the inferior roots of the brachial plexus. Would manifest as damage to the ulnar nerve and branches off the medial cord. This would result in ulnar claw most probably but also could manifest as weakness in flexion of shoulder and also loss of innervation in the medial cutaneous region of forearm and arm.
47
Describe the path of the radial nerve in the upper limb.
Leaves the brachial plexus via the posterior cord and travels down behind the humerus in the radial groove behind the long head of triceps. It then rotates fully and enters the cubital fossa from the lateral side where it is the most lateral of the contents. It then innervates the extensor compartment which originates from the common extensor origin at the lateral epicondyle. It also has cutaneous innervation the hand (predominantly on the dorsal aspect)
48
Describe the path of the musculocutaenous nerve
from the lateral cord of the brachialplexus, pierces the coracobrachialis, travels deep in the arm passes laterallly to the tendon of biceps brachii where it pierces the deep fascia becoming the lateral cutaneous nerve to the forearm.
49
What is the path of the mediun nerve?
travels in front of the brachial artery moving medially as it approaches the cubital fossa. Innervates the flexors of the forearm with 2 exceptions.
50
What is the path of the ulnar nerve?
originates from the medial cord of the brachial plexus, moves distally passing behind the medial epicondyle. Innervates the flexor carpi ulnaris, and the medial half of flexor digitorum profundus.
51
What should be looked for as indicators of joint injury?
redness, instability, deformity, swelling gait, and systemically a fever, weightloss and raised WBC-count.
52
What is the trendelunberg sign?
patient stands on one leg, if weak abductors of hip then pelvis will drop. namely gluteus medius and minimus.
53
What is valgus and varus?
valgus=knocked knees
| Varus=bowlegged
54
How can a joint be imaged?
MRI, CT, US, Xray, arthroscopy
55
What are the common causes of bone mets?
breast, prostate,lung, kidney, thyroid
56
How can muscles be catagorised based on their movements?
Agonists, antagonists, synergists and fixators
57
How is MND diagnosed?
EMG
58
What are the types of levers used by muscles in the body?
1st- pivot
2nd- force and weight on same side favouring force.
3rd- force and weight on same side favouring weight.
59
What is the role of skeletal muscle?
Thermogenesis, mobility, posture and balance, joint stability.
60
What are the different types of skeletal muscle myocyte?
I- slow twitch, red due to many mitochondria
IIa- pink- intermediate
IIb- white with many glycolytic enzymes like the gastronemius and eye muscles.
61
What is intermittant claudication?
Pain on exertion relieved by rest, the next pain occurs sooner then the first. typically a sign on peripheral vascular disease.
62
What is compartment syndrome?
Where a leakage into a compartment leads to compression of important structures. I.e in the arm if the brachial artery is perforated and expels blood it will compress the nerves of the arm due to being unable to compress the solid structures of bone and muscle present.
63
What is the effect of clostridium tetani on motor neurones?
bacterium produce 2 toxins. Tetanospasmin gets into the blood and enters the neurones where it travels up using dyneins via retrograde axonal transport into the CNS where it inhibits gamma amino butaric acid channels stopping the inhibitory input into the neurone. this results in a fused tetany
64
What is a motor unit?
It is one motor neurone and all the muscle fibres that is innervates and so one impulse results in the contraction of a number of fibres however a motor neurone can innervate anything from 1-1000 mucle fibres depending on the degree of fine motor skills needed.
65
How does recruitment occur?
By spatial summation. By increasing the number of motor neurones and therfore fibres involved in a particular action. This is done through the use of golgi tendon organs, spindle fibres and joint receptors.
66
What is muscle tone? How is muscle tone increased? regulated?
Muslces have high levels of elastin.
Muscles can be made to contract harder by temporal summation. This is where the impulse to contract becomes more frequenct increasing the force of contraction from a fasiculation to an unfused tetany to a fused tetany. This is regulated by the feedback to the brain from the proprioreceptors in the muscles which defom due to stress.
67
What could the possible causes on hypotonia be?
Lesions in any of the nervous pathways.
Motor nerves, sensory afferents, CNS *cerebrellum motor cortex)
Damage/infection in the muscle.
68
How does being innervated prevent muscle hypertrophy?
Loss of innervation removes cross talk between muscle and nerve which can lead to atrophy of both.
69
What are the eneregy stores in skeletal muscle?
ATP, creatine phosphate, Glucose-->pyruvate and then pyruvate to lactate or into the link and TCA cycle.
70
What are the different types of musclular contraction?
Isotonic (concentric, eccentric) , isometric
71
How does rigor mortis occur?
No ATP after death and so the actin and myosin filaments remain attached and so do not allow for movement (contracture) this leads to a stiffening of muscles in the body.
72
Describe the flexors of the hip
Sartorius:flex, abducts and laterally rotates thigh when leg is straight, when knee is bent it medially rotates thigh and flexs at knee. (femoral nerve) (iliac spine to tibia)
Pectineus: adducts and flexors hip (femoral nerve) superior pubic rami to pectineal line
Iliopsoas: composed of the 2 below muscles
-psoas major: lumbar rami
-Iliacus:femoral nerve
Psoas minor: lumbar rami
73
describe the extensors of the knee
Vastas medius: lesser trochanter and medial lip of line of apeara.
Vastas lateralis:greater trochanter and lateral line of apeara
Vastas intermedius: anteriolateral surface of femur
Rectus femoris: anterior infirior illiac spine (also aids in flexing thigh)
All attach to common quadraceps tendon and all by femoral nerve.
74
Describe the muscles of the gluteal region
Tensa of fascia lata: Superior gluteal, superior anterior illiac crest to lateral condyle of tibia.
Piriformis: anterior of sacrum to greater trochanter
Obturator internus: Nerve of obturator, inferior rami of ischium to greater trochanter.
Maximus: Inferior gluteal, above posterior gluteal line to gluteal tuberosity.
Medius: superior gluteal posterior-->anterior gluteal line to greater trochanter
Minimus: superior gluteal anterior-->inferior gluteal line to greater trochanter
Quadrate fermoris: nerve of quadrate femoris ischial tuberosity to quadrate tubercle
superior gemelli: n. of obturator ishial spine --> greater trochanter
Inferior by nerve to quadrate femoris.
75
Describe the adductors of the thigh
adductor longus: inferior Pubis-->
adductor brevis: superior pubis-->
adductor magnus: dorsal pubis-->gluteal tuberosity and linea apeara (most lateral)
gracilis: pubis to tibia
obturator externa: lip of obturator foramen--> intertrochanteric fossa.
Pectineus: superior rami of pubis--> pectineal line
All by obturator nerve except the hamstring part of the adductor magnus which is by the sciatic nerve.
76
Describe the arterial supply to the gluteal region.
Superior and inferior gluteal arteries branch off the internal iliac artery and "flick up" through the greater sciatic notch.
77
Describe the nervous supply to the gluteal region
both the superior and inferior gluteal nerves branch off the sciatic nerve as it passes through the greater sciatic notch.
78
What is carpal tunnel syndrome? causes of? symptoms? diagnosis? treament? epidemiology?
compression of the structures in the carpal tunnel. Causes include hypothroidism, pregnancy, obesity, trauma, infection, arthritis, diabetes acromegaly, bleed, tumour. Diagnosis is a combination of factors and symptoms. symptoms include pain, loss of grip strength (atrophy and thenar weakness). Treatment is carpal tunnel release, and treatment of underlying conditions. Most commonly affects white pregnant women also in the age range of 45-60 is a factor outside of pregnancy.
79
What is contained within the carpal tunnel?
Tendons of the flexor digitorums and flexor policis longus, synovial sheaths covering them. Also the mediun nerve.
80
What is hilton's law?
A nerve that passes across a joint also innervates it.
81
How can the neck of femur be fractured?
Intracapsular: Loss of blood supply leading to necrosis.
| Introchanteric fracture: across the trochanters,
82
What is significant about epiphyseal fractures?
15% of long bone fractures, important to fix quickly, limping gives it away in young children, the shaft moves forwards and upwards in relation to the head. typically caused by acute trauma or repetitive trauma
83
Describe the hip joint
Acettabulum has triradiate cartiladge which forms the joint cavity.
This is deepened by a fibrocartiladge labrum, the base of the acetabulum is formed by the transverse ligamament, behind which is the acetabulum foramen. The head of femurarticulates with this surface and the fovea capitis allows the joining of the ligament of HOF and a branch of the obturator artery.
The capsule extends over the neck of femur and attaches to the acetabulum and transverse ligament.
The Bursae: Ischialgluteal, trochanteric, iliopsoas.
Ligaments: ILF, PF, ISF
84
Describe dislocations of the hip
Posterior: requires huge force i.e car accident can cause damage to sciatic nerve, leg is medially rotated.
85
Describe the osteology of the femur
Anteriorly: fovea of HOF, head of femur, neck of femur, intratrochnateric line, greater and lesser trochanter, adductor tubercle, condyles and epicondyles.
Posterior: interrtrochnateric crest, gluteal tuberosity, pectineal line, quadrate tubercle, spiral line, linea aspera, supraepicondylar lines, intercondylar fossa
86
Describe the osteology of the fibular and tibia
tibia has anterior line and on the back has the soleal line. It has an intercondylar eminence that articulates with the femur.
Fibular and tibia both has malleloui?
87
Describe the osteology of the foot
talus calcaneous, cuboid, navicular, cuniforms (1,2,3)
88
Describe the osteology of the pelvic girdle
illium articulates with the pubis and the ishium in the acetabulum with the triradiate cartiladge and the pubis and the ishium communicate on the obturator foramen. the ishium helps form the greater sciatic notch and also has the ischial tuberosity which is sat on. The illium has anterior-medially the superior and inferior illiac crest and in the centre is the illiac fossa. Posteriorly are the gluteal lines.
89
what % of total height does the spinal cord make up
42%
90
What are the roles of the spinal column?
balance (centre of gravity), muscle attachements, boney attachements, protection of the spinal cord, segmented innervation of the body
91
What movements can the verterbral column undergo?
Flexion, extension, adduction and rotation.
92
What is scoliosis?
Curve moves laterally from the midline
93
What ligaments support the spinal column?
Longitudinal ligaments: posterior (serrated and narrows) and anterior ( strongest and widens inferiorly)
Ligamentum flavum: hold laminae together
Interspinous: hold adjacent boarders
supraspinous: holds tips together
both the inter and supra originate from the ligament nuchae.
94
How many spinal vertabrae are there? how do they fuse?
5-12-7-5-4 the final 9 fuse together.
95
What is cervical spondylosis?
Where there is degeneration of the joints between the vertabra, observed growth of osteophytes.
96
What is IVD herniation? what does it present with?
Where the Nuclus pulposus herniates out of the annulus fibrosis. Typically occurs posteriolaterally where there can be compression of segmental spinal nerves.
97
How does the spine change its curvature in disease and in developement?
in the embryo 4 primary kyphoses. baby lifts head it leads to the superior lordoses, learning to walk leads to the inferior one. Both dissapear in old age. in disease excessive lordoses and kyphoses can occur.
98
What is the structure of the IVD?
Inner part is nucelus polposus. Large fluid component that reduces in volume as the day progresses.
outer part is the tough fibrocartiladge and collagen annulus fibrosus which acts as the shock absorber.
Both contribute to the shock absorbance. Also in the lumbar and thoracic regions they are most large anteriorly.
99
Describe the structure of a spinal vertabrae
Body=largest part usually
Neural arch is attached to body.
Neural arch has transverse processes
and a spinous process
Laminae exist between the 2 processes
pedicles exist between the body are arch.
Pedicles give rise to the interverterbral foramen.
Above and below the junction of the pedicle and laminae are the articulating facets.
100
```
What myotomes... (UPPER LIMB)
-MEDIALLY ROTATE
-LATERALLY ROTATE
-EXTEND SHOULDER
-FLEX SHOULDER
ADDUCT SHOULDER
ABDUCT SHOULDER
-FLEX ELBOW
-EXTEND ELBOW
-WRIST
-DIGITS
PRONATE
SUPINATE
AB/DUCT DIGITS
```
```
SHOULDER
-678
-5
-678
-5
-678
-5
ELBOW
-56
-67
WRIST-67
DIGITS-78 (AD/AB=T1)
-PRONATE-78 SUPINATE-6
```
101
```
What myotomes (LOWER LIMB)
HIP
---LATERAL ROTATION
---MEDIAL ROTATION
---EXTENSION
---FLEXION
---ADDUCTION
---ABDUCTION
KNEE
---FLEXION
---EXTENSION
ANKLE
---DOSIFLEXION
---PLANTAR FLEXION
TOES
---DOSIFLEXION
---PLANTAR FLEXION
```
```
Hip
-L5, S1
-L123
-L45
-L23
L1234
L5S1
Knee
-L5 S1
-L34
Ankle
-L4,5
-S1,2
Toes
-L5 S1
-S1 2
```
102
Describe the lumbar plexus
from L1-L4
Divided into nerves that emerge medially and laterally from psoas major
medially is the obturator
laterally is the femoral
103
Name the Posterior muscles of the forearm
```
Brachioradialis
Extensor carpi radialis
Extensor carpi ulnaris
Extensor digitorum
Extensor indicis
Extensor digiti minimi
Extensor carpi radialis longus
Supinator
APL
EPL
EPB
```
104
Describe the boundaries of the femoral triangle
Sartories, inguinal ligament, adductor longus, pectineous and iliopsoas= floor and roof= fascia lata, and subcutaneous tissue
105
Name the contents of the femoral triangle from lateral to medial
femoral nerve, femoral sheath (containing the femoral artery, vein and also the deep inguinal lymph nodes).
106
What is the signigicance of the saphoneous opening?
Allows the superficial great saphonous vein to drain into the femoral vein.
107
How does a femoral hernia occur?
when a loop of bowel passes into the femoral triangle due to a weakening of the tissue holding it in place. i.e inguinal hernias descend on the same pathway testes use to descend.
108
What can the femoral vein be used for?
insertion of catheter for angiography and for blood samples.
109
Why is the femoral artery vunerable in the femoral triangle?
Very superficial, so laceration could occur. This would lead to bleeding into the space that could cause compression to the nerve.
110
Describe the oestology of the scapula
medial and superior borders, inferior and superior angles,suprascapular notch, subscapular,suprascapular and infrascapular fossa. Spine, acromion and corocoind process, glenoid fossa, infra and supraglenoid tubercles.
111
Describe the osteology of the clavicle
Tubercles=inferior
Widest end=most lateral
Articulates with the acromion and sternum.
112
describe the osteology of the humerus
Head of humerus articulates with the glenoid fossa, greater and lesser tubercle, intertubecular groove, surgical neck, anatomical neck, deltoid tuberosity, radial groove, supracondylar ridge, lateral and medial epicondyles, radial and coronoid fossa, capitulum and trochlea.
113
Describe the osteology of the ulnar and radius
Ulnar: Coronoid process, olcrannon, radial notch, styloid process styloid process, head.
Radius: Head, radial tuberosity, styloid process.
114
What is the most common fracture of the wrist
Colles fracture that results in the hand being placed posteriorly to the radius and ulnar.
115
What is significance of tenderness in the anatomical snuff box?
Indicative of a scaphoid fracture. Scaphoid is supplied blood distal to proximal. so can lead to proximal avascular necrosis of the bone.
116
Where is the most common place to fracture the clavicle? How doe this present?
lateral 1/3, medial 2/3 pulled superiorly by the sternoclidomastoid and lateral 1/3 will drop due to the weight of the arm and will be pulled medially due to the action of the pecs.
117
how can a scapula be fractured?
typically a high impact injury i.e pedestrian Vs car.
118
What structures must be considered when presented with a distal humeral fracture.
Brachial artery, radial nerve if at the supracondylar line, mediun nerve is in the middle and ulna nerve is posterior to the medial epicondyle.
119
How can the radial nerve be damaged?
By a mid shaft humeral fracture.
120
Where is the most common site of humeral fracture? what are the possible complications?
Surgical neck of humerus fracture. Common complications would be damage to the circumflex arteries and also axillery nerve damage.
121
What are the flexors of the forearm?
Pronator teres, flexor carpi radialis, flexor carpi ulnaris, palmaris longus, flexor digitorum superficialis, flexor digitorum profundas, pronator quadratus
122
What are the boarders of the cubital fossa?
Supraepicondylar line, pronator teres, brachiradialis, deep fascia and bicepital aponeurosis, brachialis and supinator.
123
What is the content of the cubital fossa from lateral to medial?
RN BT BA MN also the deep vein that accompany BA.
124
What are the muscles of the upper arm?
Coracobrachialis: corocoid process to mid shaft of humerus, musculocutaneous
Biceps brachii: LH to supraglenoid tuberle, SH to corocoid process, radial tuberosity and bicipital aponeourosis (Musculocutaneus)
Brachialis: mid shaft--> ulna tuberosity Musculocutaneous.
Triceps: radial nerve, LH to infraglenoid tubercle, LH and MH either side of the radial groove, attaches to the olecranon and lateral epicondyle.
anconeous: lateral epicondyle--> olecrannon.
125
Describe the superficial venous drainage of the upper limb.
Hand: superfical palmar arch
Forearm: cephalic of forearm, interosseous, bacillic of forearm
Arm: Cephalic (drains into BV in the axilla) and bacillic vein (drains into BV superior to the medial epicondyle). At the cubital fossa these 2 veins communicate.
126
Describe the deep venous drainage of the upper limb
Deep palmar arch, draining into the ulna and radial veins. IO veins join the ulna. These converge at the cubital fossa forming the BV.
127
What muscles are innervated by the axillery nerve?
Teres minor
| Deltoid
128
Describe the sensory nerves of the upper limb
Forearm: Lateral + medial, posterior,
Arm: medial+ inferior/superior lateral, intercostal branch
129
Describe the borders of the axilla
Medially: seratus anterior and rib cage
Anteriorly: Pec major and minor and subclavius
posteriorly: subclavius, lat dorsi, and teres major
laterally: intertubecular groove
superiorly: upper boarder of 1st rib, posterior of clavicle
Inferiorly: Fascia of armpit
130
Describe the contents of the axilla
```
Axillery artery and Vein (with branches)
Brachial plexus and branches of
Lymph nodes and ducts for upper limb
fat and fascia
short head of biceps and coracobrachialis
```
131
What muscles faciliate pronation
pronator teres, pronator quadratus
132
What muscles facilitate supination
Supinator, biceps brachii
133
What is hiltons law?
The nerve that passes the joint is the one that invervates it.
134
Describe how the bones articulate at the elbow
radius head rotates on the capitulum, radius and ulnar articulate at the radial notch of the ulnar. The olcrannon fossa takes the olcrannon process and anteriorly the coronoid process goes into the fossa on the humerus and the radius has a coresponding fossa laterally.
135
What 3 joints are present involved the ulnar and radius
Proximal radialulnar
interossoseus membrane
distal radioulnar
136
Describe the blood supply to the elbow joint
Lots of recurrents and colaterals that corespond. Ulnar's stem from BA and has both inferior/ superior colateral and anterior posterior recurrents. The mediun and radial colaterals stem from the profunda brachii.
137
Describe the structure of the capsule of the elbow joint
Capsule is weak anterioposteriorly and strong lateralmedially due to collateral ligaments. Proximal radial ulnar joint is contained in the capsule.
138
describe the ligaments of the elbow joint
3 ligaments.
Annular: doesn't attach to the radius but holds it in place. attached to the ulnar.
Radial collateral: it is fan like and blends with the annular.
Ulnar collateral: 3 parts, anterior (strongest) posterior and oblique
139
Describe the bursae of the elbow joint
the 2 major ones are at the olcrannon. One is subtendonous and the other is subcut.
140
Describe subluxation of the radius
Where the head of the radius is pulled below its articulation with the capitulum that results in it slipping down through the annular ligament. This more common in children due to the ligament being less tight around the radius.
141
Describe the ligaments involved in the distal radioulnarcarpal joint.
Collateral ligaments from the radius and ulnar, and palmar/dorsal radiocarpal ligaments that aid in supination and pronation respectively.
142
Describe the role of the articular disk in the wrist
Keeps the ulnar from articulating with the carpals. It also adds to joint stability.
143
Describe the IO
A fibrous syndesmosis. fibres run inferiormedially. Allows absorption of impact efficienctly.
144
What is the role of the inferior sacciform recess?
increases joint stabilty and reduces friction.
145
what is the Treatment for a sprain?
If partial: RICE, tends to heal on it own with the exception of the cruciate ligaments due to the opposition of the other.
If a complete: then surgical repair is needed and also for cruciate of knee.
146
What is the treatment for sepsis in a joint? How can it be detected?
Wash out and IV antibiotics
will cause local swelling, tenderness, loss of function pain, heat, Systemically can result in a fever eleveated wbc count and weight loss.
147
What is the common classification of causes of fractures?
Pathological (infection/tumour)
Stress/trauma
Deficiency
148
Describe the joint classification
Di, ampi syn arthrosis (in levels of movement)
Fibrous (syndesmosis, sutures, gomphoses)
Cartilagenous (sychondrosis, symphysis)
Synovial (hinge, pivot, condyloid, ball and socket, gliding)
149
Describe the structure of a synovial joint
Capsule (fibrous outer and synovium inner)
inner synovial fluid (highly viscous and yellow)
Meniscus
articular cartiladge
bursae
150
Describe the role and composition of synovial fluid
Act as a lubricant and to nourish the articular surface
Made of water, hyuloronic acid, blood ultrafiltrate, glycoproteins
Looks yellow in normal healthy joints
151
What is the role of bursae?
To reduce friction between 2 surface where without it they would be rubbing.
152
Describe the disease RA
Autoimmune condition that is a systemic inflammatory disease. That typically presents with synovial hypertrophy. although there can also be damage to the pericardium and pleura. It is diagnosed by taking in all the information and also on serology (RA factor and Inflammatory markers). Treatment is steroids and NSAIDS for pain and immunotherapy for the inflammation.
153
Describe the disease OA
Presents with joint loss of function due to pain deformity and stiffness. DDX via radiography looking for decreased joint space, osteophytes, subchondro cysts and sclrosis. Mechanism for breakdown is damage to joint=proteolytic breakdown-->fibrillation and erosion--> further inflammation. Treatment is using physio, NSAIDS, surgery (replacement and akylosis).
154
Describe the disease pseudo-gout
due to the build up of calcium pyrophosphate in joint. rhombiod and polarising.
155
Describe Gout
Build of up monosodium urate crystals which are sharp and non polarising.
156
Describe Septic arthritis
Presents with: swelling pain, heat, high WBC and fever
Pathophysiology:due to the build up of a pathogen in the joint (can be fungal but usually staph). The released products of the pathogen leads to the damage in the joint and also the inflammatory response damages the joint. 2 days before joint is completely destroyed.
Treatment:wash out and IV antibiotics
157
Describe the structure of the knee joint ligaments and their role.
Anterior crucitate: stops tibia sliding forwards
Posterior stops opposite
Lateral stops varus
Medial stops valgus
158
What is the typical structure of a lumbar vertabrae
Huge body, vertabral foramen is a small triangle, no costal facets.
159
What is the typical structure of a Thoracic vertabrae
Small circular vertabral foramen, demi facets for ribs, costal facets for rub tubercle.
160
What is the typical structure of a cervical vertabrae
small body, large vertrabral foramen, transverse foramen for artery and nerves.
Bifid spinal process.
161
What is the typical structure of the atlas vertabrae
Widest C vertabrae, no spinous process or body, fused with axis.
162
What is the typical structure of a axis vertabrae
Has a large process called the dens, large spinal process, rugged lateral mass.
163
What is the role of the zone of polarising activity?
Creates the anterior posterior axis
| maintains the Apical endodermal ridge.
164
How does musculature develop in the limbs?
Move in from myotome of a corresponding somite's paraaxial region. Take their nerve supply with them. Coallece into 2 main masses (posterior and anterior compartment precursorts) which then subdivides.
165
Describe common limb and digit defects
Syndactyly
Polydactayly
Acromelia
Meromelia
166
How do the digits form?
By a process of apoptosis between the to be digits.
167
Describe the general developement of a limb.
Lateral plate mesoderm secretes fibroblast growth factor (+) the AER which in tern reciprocates, inducing proliferation of the mesenchyme which causes the growth of the limb bud. As the mesenchmye gets further from the AER it becomes cartilage. The cartilage ossifies by endochondral ossification.
168
How does upper limb developement differ from lower limb?
day 28 for upper limb, rotate laterally
| day 30 for lower limb, rotate medially
169
Describe the trapezius
3 part, superior region elevates scapula, middle=retraction, inferior=depression. spinal accesory nerve and c3 and c5 dorsal rami provide sensory innervation.
170
Describe the rotor cuff muscles
```
Supraspinatus-lat rol,
Infraspinatus-lat rot,
Teres Minor-lat rot,
subscapularis-medial rotation
Collective role to stabilise the glenohumeral joint.
```
171
Describe the latisimus dorsi
from illac crest and spine--> intertubecular groove. innervated by thoraodorsal nerve, adducts arm and extends shoulder joint, also medially rotates arm
172
Disecribe the rhomboids
major and minor. Largst from inferior angle to spine. minor from spine and up. Rotate scapula, tilting the glenoid fossa inferiorly. Innervated by the dorsal scapular nerve
173
Describe teres major
Innervated by lower sub scapular nerve. Attaches into intertubecular groove. Aids in lateral rotation and also in the extension of the shoulder.
174
Describe levator scapulae
Elevates the scapular. i.e in a shrug. Innervated by the dorsal scapular nerve.
175
Describe painful arc syndrome
Arises due to compression of structures in the shoulder joint. Usually due to inflammation of the subacromial bursae due to tendons causing friction in the case of old age or overuse. Will causes weakness in these tendons and calcification. The classical symptoms of subacromial bursistis are pain from 60-120 degrees.
176
What needs to be considered when injecting into the deltoid?
avoiding the major nerurovasculature. i.e suprascapular artery, the humeral circumflex arteries and also the axillary nerve.
177
What is the blood supply for the shoulder?
Humeral circumflex and suprascapular arteries
178
Describe the ligaments of the shoulder joint
CAC, transverse humeral, coracohumeral, inside the capsule anre the superior middle and inferior ligaments.
179
Describe the bursae of the shoulder joint
2 major bursae are the subacromial bursae and the subscapularis bursae
180
What makes the shoulder joint stable?
Combination of a number of factors.
The small area for joint articulation is improved by the presence of the labrum
The ligaments and capsule keep the scapula and humeral articulating surfaces together. The rotor cuff muscles stabilise it further. The key ligament is the CAC due to its incredible strength.
181
What is the most common shoulder disolaction and why? how does it present?
Most common is an inferior due to this being the location of least protection. Humeral head move medially and this can result in impingement of the axillary nerve. this can be tested for with the regimental badge area.
182
Describe muscles in anterior compartment of lower leg
Tibialis anterior- inverts foot
E.Digitorum longus- extends lateral 4 digits
E.Hallucis longus- extends great toe
Fibularis tertius- aids in eversion.
All by (L4 and L5) deep fibular nerve, All dorsiflex ankle.
183
Describe the muscle in the lateral compartment of the lower leg
```
Fibularis longus- base of first MT
Fibularis brevis- Tuberosity of 5th MT
All by ( L5, S1 S2) superficial fibular nerve, all evert and weekly plantarflex ankle.
```
184
Describe the muscles that contribute to the calcaneal tendon
PLantatis-
Gastrocnemius- flexs knee, lateral and medial head.
soleus-
All by tibial nerve and all plantar flex.
185
Describe the deep muscles of the posterior compartment of the lower leg
```
Popliteus- flexs knee and unlocks it.
flexor digitorum longus
flexor hallucis longus
tibialis posterior
All by tibial nerve (all varying routes),
```
186
How can the dorsalis pedis artery be located?
Between the tendon of the extensor hallucis longus and the most medial tendon of the extensor digitorum longus tendon.
187
Describe the blood supply to the lower leg from the knee.
Popliteal artery passes over the popliteal surface and down past the knee joint.
There are 2 main divisions.
First is the division between the posterior and anterior tibial artery.
Then the posterior bifurcates again giving rise to the fibular artery.
All 3 pass down the leg.
Posterior can be palpated posterior to the medial mallilolus.
Anterior gives rise to the Dorsalis pedis pulse on the dorsum of the foot.
188
What is a weakening/absence of the popliteal pulse a sign of? where can it be palpated?
Sign of femoral artery occlusion.
| In the inferior part of the fossa.
189
What are the signs of a popliteal aneurysm?
Abnormal dilatation of the popliteal artery.
Abnormal thrills and bruits.
Can result in nerve compression and occulusion of the venous supply.
Pain is usually referred to the medial aspect of the calf ankle or foor.
Can result in an arteriovenous fistula=BAD
190
What does injury to the tibial nerve result in?
Paralysis of the plantar flexors of the lower leg and intrinsic muscles of the sole of foot.
Results in loss of planter flexion of ankle and toes.
Also loss of sensation in the sole of the foot.
191
What is old age?
by WHO over the age of 65 years
192
What proportion of women will have a fracture due to Osteoporosis?
40%
193
What % of cases to a GP are MSK?
20%
194
What are the associated risks with loss of bone density and sarcopenia?
```
Increased risk of fracture
loss of muscle strength and endurance
Increased risk of falls
Loss of contractility
Loss of neuronal innervation
```
195
Describe the declination in bone density
declines after age of 30
rate of loss is approx 0.75% per annum
Accelerated by menopause
Accerlated by vitamin deficiency and inactivity
Leads to a loss of the normal bone osteons and normal architecture.
196
Describe the pattern of muscle loss in age
30%--> 15% between age 30 to 75
| Men have a higher starting mass but rate of loss is similar across the genders.
197
What factors can contribute to an increased risk of falls?
```
Neuropathy?
Muscle weakness
Synocope
Home environment (stairs etc)
Outside environment (wet/icy etc)
```
198
Define oseoporosis and osteopenia
| How is this tested for?
-2.5 SD below mean
1-->2.5 SD below mean
Using a dexa scan using 2 xrays looking at different angles. Looks at feumr and L-Spine.
199
What are the risk factors for osteoporosis?
Age, low bone mass, not black, low BMI, smoking and poor diet, early menopause.
200
Why do women get type 1 osteoporosis post menopause?
Oestrogen is absent
this has a role in supressing the action of osteoclasts.
When this is absent it leads to an increased burn degradation
This leads to the reduction in the bone density.
201
What is the treatment for osteoporosis?
Bisphophonates: when ingested by osteoclasts cause cell death.
Calcium supplements: ensures that optimum levels of bone synthesis occurs.
HRT: action of oestrogen restored reducing osteoclast activity.
202
Describe a common fracture in the elderly.
| Describe the treatment for this.
NOF fracture.
intracapsular: Hip replacement (total or hemiarthroplasty)
extracapsular: dynamic hip screw.
203
What are the features of OA on a radiograph?
descreased joint space
osteophytes
subchondral scrlosis and cysts.
204
Describe the mechanism of damage in OA.
Trauma--> fibrillation of cariladge surface.
products of degradation trigger the immune systems action to intake these and release cytokinese
These cytokines +ve feedback causing more damage and fibrilliation.
205
What are the complications that can arise from joint replacement?
Sepsis in joint capsule
Reduction in movement
DVT+ PE as a result of surgery
Damage to surrounding neurovascualar structures.
206
What is the function of the retinacula in the ankle?
Prevent muscle tendon bowstringing.
207
Describe the boney articulations of the ankle joint
Talus has 3 articulations
2 with tibia (superior and medial)
and 1 with the fibula (lateral)
208
Describe the articulation of the tibia and the fibular
Proximal: Tibio-fibular articulation, plane synovial
Intermediate: syndesmosis except for gap proximally.
Distal: syndesmosis that is held together by an anterior and a posterior ligament
Posterior distal tibiofibular ligament acts to deepen the joint capsule, part of the posterior ligament is known as the transverse and strengthens the joint.
anterior distal tibiofular ligament also present.
209
What is a mortise tenon joint? How does this relate to the ankle joint?
Mortise-joint space/recess.
tenon-occupant of that joint space.
Tenon=talus
mortise=created by tibia, fibula and its ligaments.
210
Describe the medial arch of the foot.
Formed by the articulations of the calcaneous, the talus, the navicular the 3 cuniforms and
1-->3 MTarsals
211
What common conditions can affect the ankle joint?
Pott fracture. This is a fracture dislocation of the ankle due to forcible eversion. Rips off deltoid ligament and oft part of the medial malleolus. Talus moves laterally sheering off the lateral malleolus and oft breaking the fibular proximal too the tibiofibular syndesmosis.
Sprain: usually an inversion injury due to movement upon plantar flexion. eversion occurs in sports like basketball or running.
Sometimes instead of the ligament being damaged there can be an avulsion fracture with the same mechanisms as mentioned above.
212
Describe the ankle joint.
3 bony articulations between talus, fibula and tibia and 2 with the talus and calcaneus.
Joint capsule: thin anteroposteriorly but strong mediolaterally.
Synovial membrane: synovial membrane is loose and lines the membrane.
The ligaments of the ankle:
Medially is the deltoid ligament that reinforces the capsule (medial malleolous to calcaneous, talus navicular via 4 branches)
Posterioinferiorly of the lateral mallelous is the cancaneofibular ligament. (top if L.malleolous to calcaneous)
Posterior and anterior talofibular ligaments.
213
what plane is the long axis of the talus?
anteromedial plane
214
How does the design of the talus enable it to carry out its function?
How does its design pose any intrinsic weakness?
lateral--> medial concavity
medial and lateral aedges and convex.
This allows the ankle joint to articulate in a manner that stops the fibular and tibia being displaced.
Wider anteriorly--> planter flexion is more unstable as a result.
215
Describe the talar-calcaneal joint
also known as the subtalar joint.
an anterior and posterior articulation are separated by the talocaneal canal.
Mouth of the canal is called the sinus tarsai.
216
What are the signs and symptoms of hip dislocation?
Shortened and medially rotated.
217
Why is the talus at high risk of avascular necrosis if broken?
Due to the high proportion of articular surface resulting in a decreased blood supply to the damaged tissue.
218
Describe the structure of a nerve
epineurium--> peri--> endo--> schwamm--> axon
219
Describe the classification of nerve injury
normal:
neuropraxia: no biochemical lesion, and no wallerian degeneration. caused by concussion/compression. temporary loss of function.
axonotmesis: caused by crush or contusion. Loss of relative continuity of the axon and myelin. Epi and peri neurium preservered. Wallerian degeneration occurs. 1-->3mm/day regrowth.
neurotmesis: Severe damage, continuity preservered, Axon and myelin lose continuity. Perineurium and endoneurium involvement. retrograde and wallerian degeneration.
Transection: complete loss of continuity. Surgery required to even has a chance of regain of function.
220
Describe trauma to the common peroneal nerve
Movements impaired: Anterior lateral compartments of lower leg so loss of eversion and dorsi flexion
Sensation lost:anterior lower leg and dorsum of foot.
221
Describe trauma to the superficial peroneal nerve
Movements impaired: from fibularis longus and brevis which are needed for eversion and weakly planter flexes.
Sensation lost: distal 1/3 of anterior of leg and dorsum of leg except gap between 1 and 2 digit.
222
Describe trauma to the deep peroneal nerve
Movements impaired: supplies anterior muscle of leg so loss of dorsi flesion.
Sensation lost: Skin of first interdigital cleft.
223
Describe the sural nerve
Cutaneous nerve that supplies the posterior of leg and lateral aspects of leg and foot.
originates from both the tibial and common fibular.
224
What are common causes for nerve entrapment in the lower leg
Trauma and external compression
compartment syndrome
piriformus syndrome (radiating pain in buttock)
Meralgia paresthetica (affects lateral cutaneous of thigh, being trapped under inguinal ligament, common in pregnancy and seatbelt overtightening.).
IVD prolaspe
leg lengthening
225
Describe foot drop
Loss of innervation from common fibular nerve.
Leads to the inability to lift the leg upon the swing phase of the gait.
present with a waddling gait/swing out gait/high step.
226
Describe trendelunberg gait
weakness of abductors of hip
| Elicited by making the person stand on one walk and then watch for hip drop WHEN STOOD ON THE AFFECTED LIMB.
227
Describe antalgic gait
Minimize pain upon movement gait.
| Stance phase is shortened. Indicator of pain whilst weight bearing.
228
Describe normal gait components and the main muscles involved in each part.
Heel strike (tibialis anterior, gluteus medius)
Loading phase (quads, hip stabilisers,
Midstance (triceps surae and hip stabilisers)
Terminal stance (triceps surae)
Toe off (hallucis longus)
Swing (Accelerate leg through quads (rectus femoris) and tibialis anterior and hip flexors) -deccelerate leg and extend knee in preparation for heel strike.
