Upper and Lower Limbs Lecture 3, University of Zakho PDF

Lecture 3 The upper and lower limbs. Dr. Hassan H. Hamid M.B.Ch.B., F.I.B.M.S – General Surgeon University of Zakho - College of Medicine First stage. Dec. 9th 2024. Last lecture review How many bones form the skull? The bones of the skull are 22 bones. How many cranial and how many facial? Organ...

Lecture 3 The upper and lower limbs. Dr. Hassan H. Hamid M.B.Ch.B., F.I.B.M.S – General Surgeon University of Zakho - College of Medicine First stage. Dec. 9th 2024. Last lecture review How many bones form the skull? The bones of the skull are 22 bones. How many cranial and how many facial? Organized into a cranial skeleton (8 bones) that surrounds the brain and a facial skeleton (14 bones). Names these skull landmarks. Pterion Vertex Glabella What is the superior border of the neck? External occipital protuberance Mastoid process, tip Inferior border of the mandible What are the boundaries of the anterior triangle of the neck? Lower border of the mandible Midline of the neck Sternocleidomastoid Part 1 Upper limb Outlines of part 1 The regions of the upper limb The bones The joints Bony landmarks The shoulder The axilla The arm The cubital fossa The radius and ulna Anatomical snuffbox The hand Regions of the upper limb The shoulder The arm The forearm The hand The bones of the upper limb The clavicle The scapula The humerus The radius The ulna The carpal bones (8 bones) The metacarpal bones (5 bones) The phalanges (14 bones) The joints The sternoclavicular joint The acromioclavicular joint The glenohumeral joint (shoulder) The elbow joint Proximal radio-ulnar joint Distal radio-ulnar joint The radiocarpal joint (wrist) The Carpometacarpal joints The bony landmarks The clavicle is the subcutaneously palpated throughout its length. Between the two clavicular heads, and the superior edge of the sternum, there is a depression, the jugular notch, can be observed. The lateral end of the clavicle, named the acromial end, can be palpated medial to the later border of the acromion. The coracoid process of the scapula, can be felt deeply below the lateral one third of the clavicle int eh deltopectoral groove, or clavipectoral triangle. The round contour of the shoulder is formed by a wide triangular muscle, the deltoid muscle. The greater tubercle of the humerus, can be felt on deep palpation, inferior to the acromion. The humeral shaft, can be felt in different areas through the muscles surrounding it. The medial and lateral epicondyles of the humerus, are palpated on the medial and lateral aspects of the elbow region. The head of the ulna bone, can be felt as a round subcutaneous prominence that can be easily seen and palpated on the medial side of the dorsal aspect of the wrist. The pointed ulnar styloid process can be felt, distal to the ulnar head when the hand is supinated. Olecranon process lie subcutaneously and can be felt easily when the elbow is extended and flexed. The head of the radius can be palpated in the depression on the posterolateral aspect of the extended elbow, just distal to the lateral epicondyle of the humerus. The radial styloid process can be felt on the lateral side of the wrist, it is approximately 1 cm distal to that of the ulna. Some of the carpal bones, can be felt mainly on the dorsum aspect of the wrist joint. While the metacarpal bones, although being overlapped by the long extensor tendons of the fingers, they can be palpated on the dorsum aspect of the hand. The knuckles, which are more obvious when forming a fist, are the heads of the metacarpals, with the 3rd metacarpal head being the most prominent The dorsal aspect of the phalanges can be palpated easily And the knuckles of the fingers are formed by the heads of the proximal and middle phalanges The axilla Axillary folds. The anterior axillary fold is formed by the lower border of the pectoralis major muscle, which can be palpated between the fingers and the thumb. Is most prominent when the person is pressing the hand on the hip. Posterior axillary fold is formed by the latissimus dorsi tendon, can also be felt between the fingers and the thumb. The axilla Boundaries: superiorly: by the outer border of first rib, superior border of scapula, and posterior border of clavicle. anteriorly: by the pectoralis major, minor, and subclavius posteriorly: by the subscapularis above, and teres major and latissimus dorsi below. medially: serratus anterior and the ribcage. laterally: by the humerus and the surrounding muscles of the arm (coracobrachialis and biceps brachii). floor/base: by the skin (visible surface of axilla). The axilla Contents: Axillary artery and its branches Axillary vein and its tributaries Infraclavicular part of the brachial plexus Long thoracic and intercostobrachial nerves Five groups of axillary lymph nodes and the associated lymphatics Axillary fat and areolar tissue in which the other contents are embedded The arm The borders of the deltoid are visible when the arm is abducted against resistance. Both biceps and triceps muscles for the muscular bulge on both anterior and posterior surfaces of the arm respectively. Those bulges are separated by the medial and lateral grooves. The arm The cephalic vein ascends superiorly in the lateral groove and the basilic vein ascends in the medial groove. The biceps tendon, in the anterior aspect of the elbow joint, can be palpated in the cubital fossa, immediately lateral to the midline, and the triceps tendon is palpated where it is attached on the olecranon process of the ulna. The brachial artery, which is artery supplying the upper limb, can be felt pulsating deep to the medial border of the biceps. The cubital fossa The cubital fossa is a small triangular area located on the anterior surface of the elbow, with the apex of the triangle pointing distally. It contains some important structures, on their passage from the arm to forearm. It is homologous to the popliteal fossa of the lower limb. The cubital fossa The boundaries: Superior (base) - an imaginary line between the medial and lateral epicondyles of the humerus Medial - the lateral boundary of the pronator teres Lateral - the medial border of the brachioradialis The cubital fossa The cubital fossa is a passageway for structures to pass between the upper arm and forearm. Its contents are (lateral to medial): Radial nerve Biceps tendon Brachial artery Median nerve The roof of the cubital fossa also contains several superficial veins. The median cubital vein, which connects the basilic and cephalic veins and can be accessed easily, a common site for venipuncture. The radial and ulnar arteries The radial artery can be drawn by a line extending from the midpoint of the cubital fossa to the base of the styloid process of the radius. And its pulsation can easily be felt on the distal third of the radius. The ulnar artery is best palpated on the anterior medial aspect of the proximal wrist crease when the wrist is hyperextended. The ulnar artery varies in its origin and course in a significant proportion of cases. The anatomical snuff box Also known as the radial fossa, is a triangular depression found on the lateral aspect of the dorsum of the hand. It is located at the level of the carpal bones. and best seen when the thumb is extended. In the past, this depression was used to hold snuff (ground tobacco) before inhaling via the nose – hence it was given the name ‘snuffbox’. The anatomical snuff box Borders: The medial border: Tendon of the extensor pollicis longus. The lateral border: Tendons of the extensor pollicis brevis and abductor pollicis longus. Proximal border: Styloid process of the radius. Floor: Carpal bones; scaphoid and trapezium. Roof: Skin. The anatomical snuff box Contents: Radial artery Superficial branch of the radial nerve Cephalic vein The dorsum of the hand Dorsal venous network: Superficial veins can be seen on the dorsum of the hand, the network drains upward into the cephalic vein laterally and basilic vein medially. The tendons of the extensor digitorum, extensor indicis and extensor digiti minimi can be seen and felt as they pass distally to the bases of the fingers Arterial palmar arches Superficial palmar arterial arch: Located in the central part of the palm, lies on a line drawn across the palm at the level of the distal border of the fully extended thumb. Deep palmar arterial arch: Located in the central part of the palm, lies on a line drawn across the palm at the level of the proximal border of the fully extended thumb.  through way alf e h ’r We Part 2 The lower limb Outlines of part 2 The regions of the lower limb The bones of the lower limb The joints of the lower limb The gluteal region The thigh The femoral triangle The knee joint The popliteal fossa The leg The ankle The posterior tibial artery The foot The dorsalis pedes artery Regions of the lower limb The gluteal region The thigh The knee The leg The ankle The foot The bones of the lower limb The pelvic bones The femur The patella The tibia The fibula The tarsal bones The metatarsal bones The phalanges Joints of the lower limb The hip joint The knee joint The proximal tibiofibular joint The distal tibiofibular joint The ankle joint The tarsometatarsal joint The metatarsophalangeal joint The gluteal region The gluteal region, commonly known as the buttock, lies posterior to the bony pelvis and is defined superiorly by the iliac crest and inferiorly ends at the gluteal fold. Gluteus Maximus is the largest and heaviest muscle in the body. It is the most superficial of all gluteal muscles that are located at the posterior aspect of the hip joint. The gluteal maximus muscle is a common site of IM injection. The buttock region is divided into 4 quarters, the upper outer quarter is where an IM injection is injected. As it is away from the sciatic nerve. The thigh It is the region of the lower limb, between the hip and knee joints. The femur is the single bone in the thigh, which is also the largest bone in the body. It also contains many muscle, that their action decides the movement of the hip and knee joint. The thigh The surface anatomy: Sartorius muscle Quadriceps femoris: rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius Adductor longus muscle Hamstring muscle Femoral triangle. Femoral triangle The femoral triangle is a wedge-shaped area located within the superomedial aspect of the anterior thigh. It acts as a conduit for structures entering and leaving the anterior thigh. Borders of the femoral triangle The femoral triangle consists of three borders, a floor and a roof: Roof – fascia lata. Floor – pectineus, iliopsoas, and adductor longus muscles. Superior border – inguinal ligament (a ligament that runs from the anterior superior iliac spine to the pubic tubercle). Lateral border – medial border of the sartorius muscle. Medial border – medial border of the adductor longus muscle. The rest of this muscle forms part of the floor of the triangle. Contents of the femoral triangle The femoral triangle contains some of the major neurovascular structures of the lower limb. Its contents (lateral to medial) are: Femoral nerve – innervates the anterior compartment of the thigh and provides sensory branches for the leg and foot. Femoral artery – responsible for the majority of the arterial supply to the lower limb. Femoral vein – the great saphenous vein drains into the femoral vein within the triangle. Femoral canal – contains deep lymph nodes and vessels. The knee joint The knee joint connects the thigh to the leg, has a flexion and extension movement (and a small degree of medial and lateral rotation). It is formed by articulations between the patella, femur and tibia. The popliteal fossa It is a diamond shaped area located on the posterior aspect of the knee. It is the main path by which vessels and nerves pass between the thigh and the leg. It contains vital structures passing from the thigh to the leg and vice versa. Borders Superomedial – semimembranosus. Superolateral – biceps femoris. Inferomedial – medial head of the gastrocnemius. Inferolateral – lateral head of the gastrocnemius and plantaris. Contents The popliteal fossa is the main conduit for neurovascular structures entering and leaving the leg. Its contents are (medial to lateral): Popliteal artery Popliteal vein Tibial nerve Common fibular nerve (common peroneal nerve) The leg Is the region of the lower limb, between the knee and the ankle joints Containing the two bones, tibia and fibula Where many of those bones’ landmarks are visible and palpable. Bony landmarks The tibial tuberosity The anterior tibial border, the shin of the leg The medial and lateral tibial condyles Head of the fibula Medial malleolus (tibia) Lateral malleolus (fibula) Main muscles Anterior: Tibialis anterior Extensor digitorum longus Extensor hallucis longus Main muscles Posterior: Plantaris Soleus Gastrocnemius Achilles tendon The ankle joint The ankle joint (or talocrural joint) is a joint located in the lower limb, which connects the leg to the foot. It is formed by the bones of the leg (tibia and fibula) and the foot (talus). Functionally, it permits dorsiflexion and plantarflexion of the foot. The joints has a complex ligamental attachments among different bones. Posterior tibial artery The posterior tibial artery is an artery of the leg. It is a branch of the popliteal artery. It supplies the posterior compartment of the leg and the plantar aspect of the foot. Posterior tibial artery This artery lies just posterior to the medial malleolus. It can be felt most readily by curling the fingers of the examining hand anteriorly around the ankle, indenting the soft tissues in the space between the medial malleolus and the Achilles tendon, above the calcaneus. The foot Bones of the foot are: Metatarsal bone The tarsal bones. The metatarsal bones Proximal phalanges Middle phalanges Distal phalanges The sesamoid bones The dorsalis pedes artery The dorsalis pedis artery is a continuation of the tibialis anterior artery at the ankle level. Can be felt by asking the patient to dorsiflex the big to, and just later to the extensor hallucis longus tendon, on the dorsum of the foot. Any questions Thank you!