Finals Tables - Anatomy (1) PDF

a 1) to support the body weight Foot has two important functions: 2) to serve as a lever to propel the body forward in walking and running...

a 1) to support the body weight Foot has two important functions: 2) to serve as a lever to propel the body forward in walking and running Three anatomical and functional zones Arches Of The Foot Sole Muscles HIP JOINT abductor hallucis Hindfoot Midfoot Forefoot Medial longitudinal Lateral longitudinal Transverse arches 2 Groups LIGAMENTS Origin Insertion Orientation Description 1st LAYER Flexor digitorum brevis Talus & calcaneus navicular, cuboid, cuneiforms metatarsals and phalanges Keystone: rounded head of Talus Cuboid Cuneiforms (intermediate) Transverse acetabular ligament... acetabulum notch... INTRACAPSULAR abductor digiti minimi Staples at inferior edge: Plantar ligaments Long & short plantar ligaments Deep transverse ligament Ligamentum teres femoral head to acetabulum Quadratus Differences!!! HIP JOINT KNEE JOINT Plantar aponeurosis, medial part of Plantar aponeurosis, aBd DM, Peroneus longus Iliofemoral ligament AIIS Intertrochanteric line Inverted “Y”-shaped Strongest; Prevents overextension during standing Tie beam: EXTRACAPSULAR Lumbricals Type of Joint: Synovial ball & socket Hinge Joint (Hyaline cart.) FDB & FDL, aBductor H, FHL, FHB lateral half of FDL & FDB Pubofemoral ligament Superior pubic rami Intertrochanteric line Triangular shaped Prevents excessive abduction and extension 2nd LAYER "IPIS" Flexor digitorum longus tendon 1) Femoral condyle TIbialis anterior & posterior, Peroneus longus & brevis Peroneus longus & brevis Ischiofemoral ligament Body of the ischium Greater trochanter Spiral orientation prevents hyperextension Suspension from Above: Flexor hallucis longus tendon Composition: 2) Patella medial ligament of ankle Talus, calcaneus, navicular, 3 cuneiform, 1st 3 bases of metatarsal & cuboid and 3 cuneiform Flexor hallucis brevis 3) Tibial plateau Examples Calcaneus, cuboid, 4th & 5th metatarsal metatarsal bones bones 3rd LAYER aDDuctor hallucis 1) Iliofemoral ligament Medial Collateral Ligament Clinical correlation largest, most impt. Flexor digiti minimi Ligaments: 2) Pubofemoral ligament Lateral Collateral Ligament Interossei 3) Ischiofemoral ligament Dorsal (4) 4th LAYER Plantar (3) Note!! Anatomy Lab!!! Quadriceps tendon → Patella → Patellar tendon Qualitative Assessment of Shortening Fibularis longus tendon Nelaton's Line Schoemaker's line Chiene's line / test Morris's bitrochanteric Tibialis posterior tendon IT → ASIS→ pass over near top G.t Troch tip → ASIS → ant. umbilicus ASIS → ASIS ; GT → GT Troch → px dislocated hip/ fract. fem neck Greater troch (elevated) → cross midline to examine the hip and pelvis. distance from tip of troch to pubic symph Tibialis Posterior troch above line = femur is displaced prox Flexor Digitorum longus Arteries of the Foot Tibial Artery "Toms Dick And Nervous Harry" Tibial Nerve Flexor Hallucis Longus HIP JOINT Synovial ball & socket Articulation: b/n head of femur & acetabulum deepened by presence of fibrocartilaginous rim cavity of acetabulum called acetabular labrum 2 Groups (ligament) Ligamentum teres → attach: apex head of femur base: transverse ligament margin: acetabular notch INTRACAPSULAR Transverse acetabular ligament Iliofemoral ligament → strong ; prevents overextension during standing EXTRACAPSULAR Pubofemoral ligament → triangular; limits extension & aBduction "IPIS" Ischiofemoral ligament → spiral; limits extension Femoral Nerve (front&medial) + supply skin → Pain: front & medial of thigh Obturator Nerve (both hip & bone) → Pain: knee join Sciatic Nerve Medial circumflex femoral Artery MAJOR ; Damage = avascular necrosis Lateral circumflex femoral Artery Primary function: to weight-bear Movements: Iliopsoas Rectus femoris Flexion Sartorius Pectineus G. maximus semimembranosus Extension semitendinosus biceps femoris (the hamstrings) G. medius G. minimus Abduction Sartorius Piriformis Tensor fascia latae ADDuctors Longus, Brevis, Magnus Abduction Pectineus Biceps femoris G. maximus Lateral rotation Piriformis Assisted by the Obturators, Gemilli and Quadratus femoris Anterior fibres of gluteus medius and minimus Medial rotation Tensor fascia latae Trendelenburg sign Clinical correlation: - G. medius & G. minimus = aBductors KNEE JOINT Hinge Joint (Hyaline cart.) 1) Femoral condyle Composition: 2) Patella 3) Tibial plateau (flat plate) Patellar tendon (4) Quadriceps Patella (knee cap) for bone extension !!!! INTRA-ARTICULAR STRUCTURES !!!! (side to side motion) Medial Meniscus Gracilis Lateral Meniscus Medial Collateral Ligament → medial condyle of femur ; TIBIA Lateral Collateral Ligament → Lateral condyle of femur ; FIBULA Cruciate Ligaments → prevents posterior displacement Anterior Cruciate Ligament → attaches to Ant. Intercondylar of tibia → attach to Lateral Femoral condyle → prevents anterior displacement Posterior Cruciate Ligament → attaches to Post. Intercondylar of tibia → attach to Medial Femoral condyle "LAMP" LFC = ACL ; MFC = PCL Force aBd = Medial CL Clinical correlation: Force aDD = Lateral CL MCL forced ABD of the knee will tear? Proximal Tibio-fibular joint →articulation b/n Lat condyle of Tibia & head of Fib → small amt of gliding mvt Distal Tibio-fibular joint →art. b/n fibular notch @ lower end tibia & fibula → small amt of mvt SHAPES Acetabulum → horseshoe shaped Medial Meniscus / Menisci (n.) → C shaped Iliofemoral ligament → Y shaped Pubofemoral → triangular shaped Surface Anatomy Gluteal region Thigh Four Regions Leg Foot Talus Tarsal Joints Calcaneous b/n talus & calcaneum Subtalar joint Navicular Interosseous lig (talocalcaneal) → strong & main bond union b/n 2 bones Tarsal Bones Medial Cuneiform (1) Talocalcaneonavicular joint b/n rounded head of talus, upper surface of sustentaculum tali, & post. concave surface of navi "Tiger Cub Needs MILC" Intermediate Cuneiform (2) Calcaneocuboid joint b/n ant. end of calcaneum & post surface of cuboid Lateral Cuneiform (3) Cuboid Clinical Correlation Hallux valgus Lat. dev. of great toe @ meta Puncture of Bone Marrow Metatarsophalangeal Joint of Big Toe by pull of flexor hallucis longus & extensor hallucis longus muscle Natal / Gluteal cleft --> crack Hallux rigidus stiff & painful Gluteal folds --> bottom of cheek L4 lumbar puncture Coxa vara Decreased angle inclination Coxa valga Increased angle of inclination Hip join injection or Aspiration Synovium Inguinal Region Gluteal Region are easily palpable along their entire inguinal ligament beneath the skin fold in the groin length cartilaginous joint that lies in the midline Each crest ends in front at the ASIS and symphysis pubis between the bodies of the pubic bones iliac crests behind at the PSIS lies beneath a skin dimple at the level of pubic tubercle can be felt on the upper border of the pubis the second sacral vertebra and the middle of the sacroiliac joint ridge of bone on the upper surface of the body prominence felt on the outer surface of the pubic crest iliac tubercle of the pubis, medial to the pubic tubercle iliac crest about 2 in. posterior to the ASIS. can be palpated in the lower part of the Mid inguinal point ASIS to PS. Femoral artery ischial tuberosity buttock lateral surface of the thigh and moves Mid point of inguinal ligament ASIS to PT. Deep inguinal ring greater trochanter of the femur beneath the examining finger as the hip joint is flexed and extended fused with each other to form the median femoral hernia spinous processes of the sacrum sacral crest can be palpated beneath the skin in the Inguinal Above & Medial to PT tip of the coccyx cleft between the buttocks about 1 in. behind the anus can be palpated with a gloved finger in Femoral hernia Below & Lateral to PT anterior surface of the coccyx the anal canal collected at Deep ring Indirect hernia fold of the buttocks (mid-point of inguinal ring) most prominent in the standing position Direct buttock lies under of the gluteus m. Hasselbach's triangle sciatic nerve (weakness of abdominal wall) muscle Femoral artery palpation cardiac angiography (femoral a-ext iliac - Cannulation common iliac - aorta) Inguinal Region Selding technique inguinal ligament beneath the skin fold in the groin cartilaginous joint that lies in the midline Femoral catheterization 1 cm medial to the artery symphysis pubis between the bodies of the pubic bones can be felt on the upper border of the 2-3 cm inferior to the inguinal ligament pubic tubercle pubis ridge of bone on the upper surface of the pubic crest body of the pubis, medial to the pubic tubercle Types of Bursitis of the Knee Suprapatellar housemaid's knee ; knee injection Femoral Triangle Prepatellar most common / popeye knee Sartorius (lateral) Infrapatellar carpenters knee (parson's knee to pray) Adductor longus (medial) Pes anserine Inguinal ligament (superior) Femoral a +v, lymph nodes horizontal group of superficial inguinal Menisci palpated in the superficial fascia just below and parallel to the inguinal ligament lymph nodes enters the thigh deep to the inguinal ligament at the midpoint of a line joining the The artery is easily palpated here because It can be pressed backward against the pectineus muscle and the superior ramus of the Feel for Clicks, Listen for Crepitus femoral artery Femoral artery symphysis pubis to the anterosuperior iliac spine, where its pulsations are easily felt pubis. McMurrays test - medial + lateral leaves the thigh by passing deep to the inguinal ligament medial to the pulsating can be felt by gentle palpation In the depths of the popliteal space provided that the deep fascia is fully relaxed by passively flexing femoral vein Popliteal artery menisci femoral artery the knee joint enters the thigh behind the midpoint of the inguinal ligament, that is lateral to the palpable between the tendons of extensor hallucis longus and extensor digitorum longus, midway between the medial and lateral Medial McMurray's leg flexed, foot EXTERNALLY rotated femoral nerve Dorsalis pedis artery pulsating femoral artery malleoli on the front of the ankle pierces the saphenous opening in the deep fascia (fascia lata) of the thigh and joins the passes behind the medial malleolus and beneath the flexor retinaculum. It lies between the tendons of flexor digitorum longus and Lateral McMurray's leg flexed, foot INTERNALLY rotated great saphenous vein posterlor tiblal artery femoral vein 1.5 in. flexor hallucls longus. The pulsations of the artery can be felt midway between the medial malleolus and the heel meniscal tears in young adult, Note that the dorsalis pedis artery Is sometimes absent and Is replaced by a large perforating branch of the fibular artery.Also,the Menisci injuries degenerative lesions in middle age fibular artery may be larger than normal and replace the posterior tibial artery ln the lower part of the leg. firm on palpation joint line, tender on deep Meniscal cysts Adductor Canal pressure - usually lateral side Meniscal Cartilage located between the femur and tibia lies in the middle third of the thigh, immediately distal to apex of femoral triangle adductor (subsartorial) canal cruciate ligament 4th and 5th level It contains the femoral vessels and the saphenous nerve damaged more often torn or ruptured during hyperextension, Knee Region ACL particularly if combined with rotation anterior drawer test ( +ve if ant. cruciate torn) patella and the ligamentum patellae can be easily palpated in front of the knee or Lachman test tuberosity of the tibia The ligamentum patellae can be traced downward to its attachment to the ______ thicker, stronger condyles of the femur and tibia can be recognized on sides of knee, and joint line can be identified between them bandlike medial collateral ligament & can be palpated on the sides of the joint line; they can be followed above and below to PCL damaged by dashboards rounded lateral collateral ligament their bony attachments posterior drawer test ( +ve if post. cruciate torn) menisci located in the interval between the femoral and tibial condyles Move - instability tendon of the biceps femoris Valgus Stress test (+ve if medial lig torn) Varus Stress test (+ve if lat lig torn) inflammation of a tendon Patellar tendinitis poor blood supply, slow to repair Wear of the gliding articular cartilage (OA) Roughens increasing gliding friction Knee Arthritis Pain, inflammation, sweling Pain with weather change, load bearing Improves with rest, anti-inflammatory medicines, low impact exercise Remove worn cartilage surface Replace with metal, plastic bearing surface Larger incision Knee Replacement Longer hospital stay Higher risks 10-15 year longevity Arterial Palpation Collateral Circulation Femoral artery palpated within the femoral triangle lf arterial supply to leg is occluded, necrosis or gangrene will follow unless an adequate bypass to the obstruction is present that is, a collateral circulation. Sudden occlusion of femoral artery by ligature or embolism, for example, Is usually followed by gangrene. Popliteal artery palpated within the popliteal fossa However, gradual occlusion such as occurs in atherosclerosis Is less likely to be followed by necrosis because the collateral blood Posterior tibial artery best palpated post. to the medial malleolus vessels have time to dilate fully. The collateral circulation for the proximal part of the femoral artery is through the cruciate and trochanteric anastomoses. For the femoral artery In the adductor canal, lt ls through the perforating branches of the profunda Dorsalis pedals artery best palpated on the dorsum of the foot femoris artery and the articular and muscular branches of the femoral and popliteal arteries. medial malleolus Posterior tibial pulse posterior tibial artery calcaneal tendon Extensor hallucis longus Palpation of Dorsalis Pedis Pulse Dorsalis pedis artery Tibialis anterior tendon Traumatic Injury Injury to the large femoral artery can cause rapid exsanguination of the patient. Unlike In the upper extremity, arterial Injuries of the lower limb do not have a good prognosis. The collateral circulations around the hlp and knee Joints, although Compartment Syndrome present, are not as adequate as those around the shoulder and elbow. Damage to a neighboring large vein can further complicate the situation and causes further Impairment of the circulation to the distal part of the limb. Pain Arterial Ocdusive Leg Disease Pallor Arterial occlusive disease of the leg Is common In men. Ischemia of the muscles produces a crampllke pain with exercise. If the femoral artery is obstructed, the supply of blood to the calf muscles is inadequate, and the patient is forced to stop walking after a 5 P signs of acute arterial occlusion Paresthesia Jimlted distance because of the Intensity of the pain. With rest, the oxygen depletion Is corrected and the pain disappears. However, on resumption of walldng, the pain recurs. This condition is known as lntermltlent clalullcation. Paralysis Pulselessness Sympathetic Innervation of Arteries Sympathetic Innervation of the arteries to the leg is derived from the lower three thoracic and upper two or three lumbar segments of the spinal cord. The preganglionic fibers pass to the lower thoracic and upper lumbar ganglia via white rami. The fibers synapse In the lumbar and sacral ganglia, and the postganglionic fibers reach the blood vessels via branches of the lumbar and sacral Tendon Reflexes plexuses. The femoral artery receives Its sympathetic fibers from the femoral and obturator nerves. The more distal arteries receive their postganglionic fibers via the common fibular and tibial nerves. L2, 3, 4 extension of knee jt on tapping patellar tendon Lumbar Sympathectomy and Occlusive Arterial Disease Patellar tendon reflex (knee jerk): Lumbar sympathectomy may be advocated as a form of treatment for occlusive arterial disease of the lower limb to Increase blood Hand on quadriceps should feel muscle flow through the collateral drculatlon. Preganglionic sympathectomy Is performed by removing the upper three lumbar ganglia and contract the intervening parts of the sympathetic trunk. S1, 2 Tendon Reflexes Achilles tendon reflex (ankle jerk): Most skeletal muscles receive a multlsegmental Innervation from two to four segments of the spinal cord. Eliciting simple tendon plantar flexion by tapping Achilles tendon reDexes In the patient can test the condition of the following spinal segments. aka: Calcaneal Tendon Reflex Plantarflexion of the ankle joint Patellar tendon reflex (knee jerk): L2, 3, and 4 (extension of the knee joint on tapping the patellar tendon) Adillles tendon reftex (ankle Jerk): Sl and 2 (plantar flexion of the ankle joint on tapping the Achllles tendon) aka: Triceps surae reflex Tests S1, S2 Femoral Nerve Injury The femoral nerve (L2, 3, and 4) enters the thigh deep to the inguinal ligament, at a point midway between the anterosuperlor lilac medial long. arch is depressed / collapsed spine and the pubic tubercle; it lles about a fingerbreadth lateral to the femoral pulse. About 2 ln. (5 em) below the ingulnalligament. Pes Planus (Flat foot) the nerve spllts into its terminal branches. - forefoot is displaced laterally & everted The femoral nerve can be injured in stab or gunshot wounds, but a complete division of the nerve is rare. The foJiowlng clinical features are present when the nerve Is completely dlvlded: medial long. arch is unduly high Motor: The quadriceps femoris muscle is paralyzed, and the knee cannot extend. In walking, this is compensated for to some Pes cavus (claw foot) extent by use of the adductor muscles. - caused by muscle imbalance = poliomyelitis Seuory: Skin sensation is lost over the anterior and medial sides of the thigh, over the medial side of the lower part of the leg, and along the medial border of the foot as far as the ball of the big toe; the saphenous nerve normally supplies this area. Sclatlc Nerve Injury The sciatic nerve (L4 and 5 and Sl, 2, and 3) curves laterally and downward through the gluteal region, situated at first midway between the posterosuperior lilac spine and the ischial tuberosity, and lower down, midway between the tip of the greater trochanter and the ischial tuberosity. The nerve then passes downward in the mtdltne on the posterior aspect of the thigh and dlvldes Into the common fibular (peroneal) and tibial nerves, at a variable site above the popliteal fossa. Trauma Penetrating wounds, fractures of the pelvls, or dislocations ofthehipjointsometimesInJurethesciaticnerve.ItIsmost frequently Injured by badly placed intramuscular Injections in the gluteal region. To avoid this injury, injections into the gluteus maximus or the gluteus medius should be made well forward in the upper outer quadrant of the buttock. Most nerve lesions are incomplete, and ln 90% of injuries, the common fibular part of the nerve Is the most affected. Thiscanprobablybeexplainedbythefactthatthecommon fibular nerve fibers lie most superficial in the sciatic nerve. The following clinical features are present: Motor. The hamstring muscles are paralyzed, but weak flexion of the knee Is possible because of the action of the sartorius (femoral nerve) and gracllls (obturator nerve). All the muscles below the knee are paralyzed, and the weight of the foot causes it to assume the plantar flexed position,orfootdrop. Senaory: Sensation Is lost below the knee, except for a narrow area down the medlal side of the lower part of the leg and along the medial border of the foot as far as the ball of the big toe. which is supplied by the saphenous nerve (femoral nerve). The result of operative repair of a sciatic nerve injury Is poor. It Is rare for active movement to return to the small muscles of the foot, and sensory recovery Is rarely complete.Lossofsensationinthesoleofthefoot makesthe development of trophic ulcers inevitable. Sciatica Sciatica describes theconditioninwhichpatientshavepain along the sensory distribution of the sciatic nerve. Thus, the pain Is experienced in the posterior aspect of the thigh, the posterior and lateral sides of the leg, and the lateral part of the foot. Sciatica can be caused by prolapse of an intervertebral disc, with pressure on one or more roots of the lower lumbar and sacral spinal nerves, pressure on the sacral plexus or sclatlc nerve by an Intrapelvic tumor, or lnflammatlon of the sdatic nerve or Its terminal branches. Common Fibular Nerve Injury The common fibular nerve Is in an exposed posltton as it leaves the popllteal fossa and winds around the neck of the fibula to enter the fibularls longus muscle. It is commonly injured in fractures of the neck of the fibula andbypressurefromcastsorsplints. Thefollowingclinical features are present: Motor: The muscles of the anterior and lateral compartments of the leg are paralyzed, namely, the tlblalls anterior, the extensor digltorum longus and brevis, the fibularls tertius, the extensor hallucls longus (supplied by the deep fibular nerve), and the fibularts longus and brevis (supplledbythesuperficialfibularnerve).Asaresult,the opposingmuscles,theplantarflexorsoftheanklejointand the lnvertors of the subtalar and transverse tarsal Jolnts, causethetoottobeplantarOexed(footdrop)andinverted, an attitude referred to as eqaJDoftrus (see Flg. 11.88). Sell80ry: Loss of sensation occurs down the anterior and lateral sides of the leg and dorsum of the foot and toes, including the medial side of the big toe. The lateral border of the toot and the lateral side of the llttle toe are virtually unaffected (sural nerve, mainly formed from the tibial nerve). The medial border of the foot as far as the ball of the big toe Is completely unaffected (saphenous nerve, a branch of the femoral nerve). Footdrop. With this condition, the Tibial Nerve Injury The tibial nerve leaves the popliteal fossa by passing deep to the gastrocnemius and soleus muscles. Because of its deep and protected position, it is rarely injured. Complete division results in the following clinical features: Motor: All the muscles in the back of the leg and the sole of the foot are paralyzed. The opposing muscles dorsiflex the foot at the ankle joint and evert the foot at the subtalar and transverse tarsal joints, an attitude referred to as calcaneovalgus. Sensory: Sensation Is lost on the sole of the foot; later, trophic ulcers develop. Obturator Nerve Injury The obturator nerve (L2, 3, and 4) enters the thigh as anterior and posterior divisions through the upper part of the obturator foramen. The anterior division descends in front of the obturator externus and the adductor brevis, deep to the floor of the femoral triangle. The posterior division descends behind the adductor brevis and in front of the adductor magnus. It Is Injured (rarely) In penetrating wounds, In anterior dislocations of the hip joint, or in abdominal herniae through the obturator foramen. The fetal head may press it on during parturition. The following clinical features occur: Motor: All the adductor muscles are paralyzed except the hamstring part of the adductor magnus, which Is supplied by the sciatic nerve. Sensory: The cutaneous sensory loss is minimal on the medial aspect of the thigh.