Anatomy Lecture Exam 2 PDF

FOOT - Plantar Fasciitis may result from a bone spur coming o8 the medial tubercle of the calcaneus. This bone spur may also create a bursa that can become inflamed and tender. Plantar Muscles of the Foot 1st Layer (abductors and short flexor tendons)...

FOOT - Plantar Fasciitis may result from a bone spur coming o8 the medial tubercle of the calcaneus. This bone spur may also create a bursa that can become inflamed and tender. Plantar Muscles of the Foot 1st Layer (abductors and short flexor tendons) O I N A Abductor Calcaneal Medial side of Medial plantar Abducts & hallucis tuberosity proximal s2 & s3 flexes 1st digit (medial); phalanx of 1st plantar digit aponeurosis Flexor Calcaneal Both sides of Medial plantar Flexes lateral digitorum tuberosity middle s2 & s3 4 digits brevis (medial); phalanges of Plantar digits 2-5 aponeurosis (lateral 4) Abductor digiti Calcaneal Lateral side of Lateral plantar Abducts & minimi tuberosity base of s2 & s3 flexes 5th digit (medial & proximal lateral); Plantar phalanx of 5th aponeurosis digit 2nd Layer (long flexor tendons) O I N A Quadratus Medial and Lateral border Lateral plantar Assists flexor plantae lateral surface of flexor nerve s2 &s3 digitorum of plantar digitorum longus in surface pf tendon flexing lateral calcaneus 4 digits Lumbricals Tendons of Proximal Medial: medial Flex proximal flexor phalanges of plantar nerve phalanges; digitorum digits 2-5 s2 & s3 extend middle longus & distal Lateral: lateral phalanges of plantar nerve lateral 4 digits s2 & s3 3rd Layer O I N A Flexor hallucis Plantar Both sides of Medial plantar Flexes brevis surfaces of proximal s2 & s3 proximal cuboid and phalanx of 1st phalanx of 1st cuneiforms digit digit Adductor Oblique head: Both heads Deep branch of Adducts 1st hallucis (7 bases of 2nd- 4th attach to lateral plantar digit; helps muscle) metatarsals lateral side of s2 & s3 maintain base of 1st digit transverse arch of foot  Transverse head: plantar ligaments of MTP joints Flexor digiti Flexor digiti Proximal Superficial Flexes minimi brevis minimi brevis phalanx of 5th branch of proximal digit lateral plantar phalanx of 5th nerve s2 & s3 digit 4th Layer O I N A Plantar Plantar aspect Medial sides of Lateral plantar Adducts digits interossei of medial sides bases of nerve s2 & s3 3-5 and flex of shafts of 3rd- phalanges 3-5 MTP joints 5th metatarsals Dorsal Adjacent sides 1st : medial side Lateral plantar Abducts digits interossei of shafts of 1st – of proximal nerve s2 & s3 2-4 and flex 4th metatarsals phalanx of 2nd MTP joints digit 2nd-4th : lateral sides of digits 2-4  ¨ DAB: dorsal interossei muscles abduct toes (bipennate) ¨ PAD: plantar interossei muscles adduct toes (unipennate) Dorsal Muscles of Foot O I N A Extensor Calcaneus; Long extensor Deep fibular Aids extensor digitorum interosseus tendon of digits nerve L5/S1 digitorum brevis talocalcaneal 2-4 longus in ligament extending digits 2-4 Extensor Calcaneus; Dorsal aspect Deep fibular Aids extensor hallucis brevis interosseus of proximal nerve L5/S1 hallucis longus talocalcaneal phalanx of 1st in extending 1st ligament digit digit Tarsal Tunnel - Medial plantar nerve (MPN) is larger and more anterior than lateral plantar nerve (LPN) - Both plantar nerves enter through porta pedis, a space between the abductor hallucis and the calcaneus - Tarsal tunnel syndrome: entrapment of tibial nerve that creates insidious onset of burning/aching pain from posterior aspect of heel to midtarsal zone. It is aggravated by WB and flat feet. There is decreased sensation in the plantar foot, arch, and heel. Plantar Cutaneous Innervation - Deep peroneal innervates space between 1st and 2nd toes - Lateral plantar nerve innervates plantar surface of 5th digit and half of 4th digit along with tips of corresponding toes (like ulnar nerve in hand) - Medial plantar nerve innervates 1st – 3rd digit and half of 4th digit along with tips of corresponding toes - Sural nerve innervates lateral portion of foot - Saphenous nerve innervates medial portion of foot Blood Supply of Foot - Anterior and posterior tibial arteries - Dorsalis pedis supply dorsal aspect of foot - Medial (small) and lateral (large) arteries supply plantar aspect of foot - Anastomoses between dorsalis pedis and plantar arteries are important for foot health Foot Arches - Tibialis anterior & posterior and fibularis longus tendon support medial arch - Tibialis posterior and fibularis longus support transverse arch - Tibialis posterior tendon dysfunction = flat foot Talocrural Joint - Hinge joint - Deltoid (medial) ligament and lateral ligament Plantar Ligaments - Spring ligament supports head of talus and plays major role in weight transfer - Long plantar ligament important in maintaining longitudinal arch of foot - Plantar calcaneocuboid (short plantar) ligament important in maintaining longitudinal arch of foot DELTOSCAPULAR REGION - FOOSH most common fracture in children - Greenstick Fracture is when the clavicle bends and cracks but does not fully separate into 2 di8erent pieces Humeral Fractures - Anatomical neck fracture can cause avascular necrosis of humeral head - Surgical neck fracture can damage axillary nerve and humeral circumflex artery & vein via the quadrangular space - Midshaft fracture damages radial nerve - Supracondylar region fracture damages brachial artery and median nerve - Medial epicondyle fracture damages ulnar nerve ¨ Long thoracic nerve palsy due to axillary dissection in mastectomy presents as winged scapula. Subacromial Bursitis - Often due to supraspinatus tendinitis Dorsal Scapular Spaces - Quadrangular space is made of teres major & minor + long head & lateral head of triceps. The axillary nerve and posterior circumflex artery & vein pass through this space. - Triangular space is made of teres major & minor + long head of triceps. The circumflex scapular artery and vein pass through this space. - Triangular interval is made of teres major + long head & lateral head of triceps. The radial nerve and deep artery of the arm pass through this space. AXILLA AND BRACHIAL PLEXUS  DELTOSCAPULAR REGION Bony landmarks of the scapula, humerus, clavicle - Scapula: acromion, coracoid process, spine of scapula - Humerus: greater & lesser tubercles, medial & lateral epicondyles, olecranon - Clavicle: sternal end, shaft, acromial end Shoulder joints: SC, AC, GH, ST joints Clavicular fractures - FOOSH (fall on outstretched hand) - Greenstick Fracture- clavicle bends and cracks but does not fully separate into 2 di8erent places Suprascapular notch with transverse scapular ligament-artery over, nerve under. Possible impingement site. Suprascapular C5-C6 - Since suprascapular nerve runs underneath the notch, it can be compressed with inflammation. Humeral Fractures and Implications - Proximal humeral fractures at risk of necrosis at anatomical neck, surgical neck fractures risk of axillary nerve via quadrangular space. - Fractures at greater/lesser tubercles aMect rotator cuM - Radial nerve most aMected by mid shaft fractures - Brachial artery and median n. Most a8ected by supracondylar region Ulnar nerve most a8ected at medial epicondyle AC joint seperation typically ruptures coracoclavicular ligaments. Movements of ST joint: elevation/depression, pro/retraction, upwards/downwards rotation Serratus anterior- long thoracic nerve (C5-C7)* innervated superficially Pec minor - Innervated my medial pectoral w/ a small communication branch from lateral pectoral Long head biceps brachii attaches to supraglenoid tubercle and becomes part of the labrum. - Intracapsular but extra synovial due to transverse ligament - Can be problematic in SLAP tears Deltoid, Pec major, Lat, teres major. At Intertubercular groove: Pec major lateral to groove, Lat inside groove, Teres major medial to groove. LH Biceps lays overtop Lat in groove. Dorsal scapular spaces: know borders and contents - Quadrangular space is made of teres major & minor + long head & lateral head of triceps. The axillary nerve and posterior circumflex artery & vein pass through this space. - Triangular space is made of teres major & minor + long head of triceps. The circumflex scapular artery and vein pass through this space. - Triangular interval is made of teres major + long head & lateral head of triceps. The radial nerve and deep artery of the arm pass through this space. AXILLA AND BRACHIAL PLEXUS Roots, Trunks, Divisions, Chords, Branches: understand the pathways and makeup. Long thoracic breaks o8 roots (C5, 6, 7) to go to serratus. Dorsal scapular and n to subclavius branch o8 C5. Upper/lower subscapular and Thoracodorsal (C6, 7, 8) branch o8 posterior cord. Erb-Duchenne palsy: Upper brachial plexus injury to C5-C6 - Waiter’s tip resting arm position due to damage of C5-C6  - Arm in IR and wrist in flexion Klumpke palsy: Lower roots and trunk injury to C8-T1 (median nerve a8ected slightly) - Usually occurs when upper limb is suddenly pulled superiorly - Combination of claw hand (ulnar nerve) and ape hand (median nerve) Cords named relative to axillary artery Medial and Lateral pectoral n named from their cords they branch o8 Posterior cord made from all three posterior divisions, so C5-T1 all represented here. - Since posterior cord is made of upper, middle, and lower trunks, every nerve of plexus (C5-T1) is represented. Roots, Trunks, Divisions, Cords, Branches (“Ready To Drink Cold Beer”) Terminal branches: MARMU. Know innervations to understand injuries. - Musculocutaneous - Axillary - Radial - Median - Ulnar Musculocutaneous branch: Biceps, Coracobrachialis, Brachialis Axillary: Deltoid and teres minor. Also has small sensory patch over lateral shoulder. Radial: Posterior arm, posterior forearm, dorsum of hand/wrist. Plus brachioradialis, supinator, abductor pollucis longus. Radial branch is most frequently injured branch! Sensory distribution of hand (median, ulnar, radial) Median n: *C5-T1* no arm muscles, superficial flexors except FCU, pronators, thenar, FDS, two lateral lumbricals and lateral tendons for FDP. “Hand of benediction” will present when asked to make a fist if injured. Carpal tunnel contents: 9 tendons, 1 nerve - Median nerve runs through carpal tunnel - If median nerve is injured, patient will not be able to flex index and middle fingers. Ulnar n: no arm, FCU, medial FDP, medial lumbricals, intrinsic hand including adductor pollucis. PADS/DABS, Hypothenar. “Ulnar claw” will present TOS: a8ects brachial plexus and vasculature of upper extremity at scalene, rib 1, and subclavicular, coracopectoral ARM, CUBITAL FOSSA, AND FOREARM Bony landmarks of humerus, radius, ulna Radial head held in place by annular ligament to allow pronation/supination, subluxed during dislocations often in children. UCL tears in pitching athletes Lateral epicondylitis (Tennis elbow) involves common extensor tendon Medial epicondylitis (Golfers elbow) involves common flexor tendon Biceps: know di8erence in LH vs SH Coracobrachialis, brachialis, triceps (only long head is 2 joint), anconeus Veins: Cephalic, Basilic, connected at median cubital. Axillary artery to become brachial artery below teres major border. Has profunda brachii branch that splits into radial and ulnar. Superficial flexors: pronator teres, FCR, palmaris longus, FCU Intermediate flexors: FDS Deep: FDP, FPL, Pronator quadratus Contents of carpal tunnel: - FPL tendon - FDS tendons (4) - FDP tendons (4) Extensors: Brachioradialis, ECRL/ECRB, ED, ECU, Indicis, Minimi, (supinator also incl here) Borders for anatomical snu8box: - Extensor pollicis longus (EPL) - Extensor pollicis brevis (EPB) - Abductor pollicis longus (APL) HAND AND WRIST Di8erence in FDS and FDP at finger joints (PIP vs DIP attachments) - Flexor digitorum profundus inserts at DIP - Flexor digitorum superficialis inserts at sides of PIP Carpals and bones of the hand - Scaphoid - Lunate - Triquetrum - Pisiform - Trapezium - Trapezoid - Capitate - Hamate Thumb movement - Flexion - Extension - Abduction - Adduction Mallet finger, boutonniere deformity, OA/RA characteristics, Dupuytrens a8ecting palmar aponeurosis - Mallet Finger: extensor digitorum tendon avulsed from base of distal phalanx (inability to extend DIP) - Boutonniere Deformity: extensor mechanism is torn which causes a constant state of flexion by FDP and FDS; DIP joints are forced into hyperextension - Osteoarthritis: fingertip swelling = Heberden’s nodes middle joint swelling = Bouchard’s nodes - Rheumatoid arthritis: inflammatory arthritis that erodes bones Fractures - Scaphoid fracture: may not present on x-ray but there will be deep pain in anatomical snu8box - Hamate fracture: ulnar nerve may be damaged which decreases grip strength of hand - Boxer’s fracture: necks of metacarpal bones are fractured Thenar and Hypothenar m: Abd, flex, opponens Adductor pollucis, PADs/DABs Lumbricals branch o8 FDP Sensory distribution in the hand LUNGS AND THORAX Bony landmarks of the sternum, clavicle, and thoracic cage (rib organization, etc) Sternal angle/manubriosternal junction/Angle of Louis= Rib 2, Carina, Aorta, Superior Mediastinum - Sternal angle of Louis: 2nd rib articulates to manubrium here; trachea bifurcates at carina, aortic arch begins and ends here, inferior border of mediastinum Border of superior thoracic aperture - Posteriorly by T1 vertebral body - Laterally by 1st rib - Anteriorly by manubrium Intercostal muscles, neurovasculature of intercostal spaces  - External, internal, and innermost intercostal muscles help support expansion/contraction of ribs during respiration cycle - Superior à inferior is VAN (vein, artery, nerve) - Intercostal nerve and posterior intercostal artery are most vulnerable structures because they are not covered by ribs Breathing mechanics Mammary gland - Suspensory ligaments of Cooper - 15-20 lobes each drained by lactiferous ducts open into nipple Signs of breast cancer (skin dimpling, “peau-d’orange” sign (suspensory ligaments involved), inversion of nipple. Retromammary space - Separates mammary gland from pectoral fascia to allow the breast to move freely over pec major Internal thoracic artery = internal mammary Basics of lymphatic drainage - Lymphatic fluid- excess interstitial fluid collected by lymphatic capillaries - Cisterna chyli- large collection of lymph nodes located in aortic hiatus - Thoracic duct- drains lymph from every region of body except right side of head, neck, thorax, and upper limb - 75% drains to axillary lymph nodes - Lymphatic nodes above umbilicus drain to axillary nodes, below umbilicus drain to inguinal nodes Phrenic nerve (C3-5) - Arises from anterior branches - Runs anterior to root of lungs - A8erent cell bodies in DRG - Pain is perceived in neck/shoulder region - C3 C4 C5 keeps the diaphragm alive! Parietal vs visceral pleura - Visceral pleura lines organs - Parietal pleura lines cavity Conditions: Pneumothorax, Pleural e8usion, aspiration, asthma, copd - Pneumothorax: “free air” outside the lungs enters lungs due to less resistance within the cavity - Pleural eMusion: fluid buildup in lung cavity - Asthma: sympathetic (vasoconstriction), parasympathetic (vasodilation) Anatomy of the lungs: Lobes, fissures, Right vs left, Lingula (left) - Right lung has 3 lobes: superior, middle, and inferior lobe à oblique fissure à horizontal fissure - Left lung has 2 lobes: superior and inferior lobe à oblique fissure à lingula Hilum of the lungs: Artery, Bronchus, Veins - Are Brides Vain? Right! Bride Are Vain! (pulmonary Artery, Bronchus, pulmonary Vein) Right vs left bronchi - Right bronchi more vertical so aspirated objects get stuck here Phrenic vs Vagus pathways - ? Triangle of auscultation and stethoscope positioning for lungs Breath sounds of superior lobe: - Anterior chest wall above 4th rib for R lung - Anterior chest wall above 6th for L lung Breath sounds of middle lobe of R lung:  - Anterior chest wall between 4th and 6th ribs Breath sounds - Posterior chest wall HEART Pericardium, layers, and positioning of the heart Visceral pericardium = epicardium Conditions: Cardiac tamponade, Hypertrophy, MI, Congential defects (ASD, VSD, PDA) - Cardiac tamponade requires about 150-250cc. Compresses heart and causes low cardiac output. - Arterial Septal Defect (ASD) results from failure to close forwent oval after birth. Postnatally, ASDs result in left to right shunting and are non-cyanotic conditions. - Ventricular Septal Defects (VSD) is the most common congenital heart condition. It results from failure to fuse membranous portion with muscular portion of ventricular septum. Left to right shunting. - Patent Ductus Arteriosus (PDA) results from failure of ductus arterioles, common in premature infants. Know all great vessels and chambers Circulation pathways (systemic and pulmonary) - Look in notebook! Distinguishing characteristics of each chamber: - Right atrium à pectinate muscle, fossa ovalis  - Right ventricle à chordae tendineae, papillary muscles, trabeculae carneae, moderator band - Left atrium à fewer pectinate muscle, receives oxygenated blood from pulmonary veins - Left ventricle à papillary muscle, trabeculae carneae Veins of the heart: coronary sinus, great, small, middle Valves: Pulmonary, Aortic, Tricuspid, Mitral Fetal circulation pathway - Blood in fetus partially diverted from pulmonary circulation by foramen ovale and ductus arteriosus - Ductus venosus shunts blood from umbilical vein to inferior vena cava Heart dominance - Right dominant (65%): right coronary artery supplies inferior left ventricular wall through posterior descending artery - Left dominant (25%): left coronary circumflex artery supplies the posterior descending artery - Codominant 10%