HUBIO 553 MUSCULOSKELETAL SYSTEM Introduction

UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE 2008

Not to be reproduced without authors permission

Wk 1 Thurs Jan 3

wk2 Thurs Jan 10

wk3 Thurs Jan 17

wk4 Thurs Jan 24

wk5 wk6 MONDAY Thurs Feb 7 Jan 28 12-12:20 Living anatomy for instructors: Hip and thigh Midterm!! Lecture: Clinical 12:30 Correlations 1:20pm Growth & Devel Hip (Schmale) Anat Lecture VI Sacral Plexus, Gluteal & Posterior Thigh (Goldstein) Hogness Auditorium Anat Lecture VIII - Anat Lecture Knee Joint, VII Ant & Lat Comp Post. Comp. Leg, Leg, and Foot sole of foot (Goldstein) (Goldstein) 12-12:20 Living anatomy for instructors: Knee, ankle, foot

wk7 Thurs Feb 14

wk8 Thurs Feb 21

wk9 Thurs Feb 28

wk10 - Monday March 3

12:00

12-12:20 Intro to living anatomy for instructors: 12-12:20 Living anatomy for instructors: Elbow and hand Lecture: Arthritis I (Schmale) Anat Lecture IV Hand (Goldstein)

12:30 Intro 10 min Anat Lect I Arm, Elbow, and Brachial Plexus

Anat Lect II Shoulder (Goldstein)

1:00 Lecture: Clinical Corr - Hand (Goldstein/Schmale) No class Thursday this week Anat Lect III Cubital Fossa and Forearm Anat Lecture V Lumbar Plexus/ Thigh Lab III - Cubital Lab IV - Hand Fossa & Forearm Lab V - Lumbar Plexus and Thigh Living Anatomy Elbow and Hand (Small groups) Introduction to radiographic interpretation (Schmale) Living anatomy Hip and Thigh (Small groups) Lecture: Trauma (Schmale) Lecture: Clin. Correlations - Hip (Schmale/ Goldstein)

1:30

Lecture - Spine Lecture: Clinical Lecture: (Goldstein) Corr-Shoulder Arthritis II (Goldstein/Schmale) (Schmale)

Lecture: Clinical Correlations Knee, Foot, and Ankle (Goldstein/ (Schmale/ Goldstein)

Living Anatomy - Knee Ankle, and Foot (Small groups)

2:00

2:30

Lecture: Living Anatomy Neck and Back C-spine and shoulder Pain (Small groups) (Schmale)

Lab - VII Post. Comp Leg, Sole of Foot (starts at 2:30) Lecture: Spinal segments, lower extremities Lab VIII -Knee Joint, Lab VI - Sacral Leg, and Foot Plexus, Gluteal and (starts at 3:30 pm) Posterior Thigh

Final Exam: Monday March 3 Hogness

3:00

3:30

Lab I - Brachial Lab II - Shoulder Plexus

4:00

Please turn in all bone boxes

5:30

5:30 Optional review session -

5:30 Optional review session -

INTRODUCTORY MATERIAL Also available on website: http://courses.washington.edu/hubio553/index.html A. Syllabus

This syllabus was developed by M.S. Core faculty and has been refined over the years. It is intended to assist you as you plan and direct your learning and to guide you to resources. It is essential that you use the syllabus constantly and prepare for each class as suggested. Objectives are included for each section. Reading the appropriate sections in a text such as Hollinshead and Rosse, Moore, Netter, or Bernstein will help you meet each objective. In many cases, this material can be found within the syllabus as well. Descrepencies between these sources are commonly seen. This is frequently the case among well-respected texts in the medical literature. The realm of musculoskeletal medicine is no exception. This syllabus and our course handouts do include information that does not entirely match that seen in our recommended texts; however, we have chosen to include what we have because we feel it is to the point and appropriate for this level of training. Additional details, though perhaps interesting, are likely beyond the scope of this course.

The information in the syllabus is reasonably correct to the best of our knowledge and should be used in concert with course handouts - ahead of other sources- for the purposes of testing in this course. We welcome your signaling any errors or inconsistencies within the sylIn the anatomy lectures and laboratory notes there will be references to clinical problems. These are chosen to aid in your understanding of normal structure and function. However, do not interpret this as anecdotal material; it is objective clinical information and will be included on the examinations. Know the cases listed in the syllabus; they reflect the most common musculoskeletal problems. B. Objectives At the end of this course, the student should be able to: 1. 2. 3. 4. 5. 6. describe the origins, insertions, actions and innervations of the major muscles of the upper and lower limbs. make the distinction between testing of the central and peripheral nervous systems. describe the major vascular supply to the upper and lower limbs.

labus or course handouts, as we are continually striving to provide our students a better course guide.

understand anatomical, physiological, and pathological bases of normal and abnormal physical signs in the musculoskeletal system. correlate normal and abnormal anatomic and radiographic findings. demonstrate proficiency in finding key musculoskeletal anatomic landmarks on the living human subject.

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recognize how the musculoskeletal system is affected by: Aging Diseases of the Nervous System Infection Inflammation Neoplasia Trauma

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use your understanding of the above to effectively approach clinical problems in musculoskeletal medicine.

C.

Organization The course includes anatomy and clinical lectures, gross anatomy labs, and living anatomy/ clinical correlation small groups. In addition, there is required work in radiology on the internet. All in-class activities rely heavily on the independent study you are expected to do in preparation for each class. There will be a quiz at the start of class each day, on that day's material. Prepare for class to be an asset to your group. "Failing to prepare is preparing to fail," John Wooden, former UCLA basketball coach.

D.

General Instructional Methods and Philosophy The lectures are designed to elucidate and add to the material in the textbooks, syllabus, and living anatomy small groups. The anatomy lectures will highlight the core of anatomical information and provide a format to discuss this information within the context of functional or applied clinical anatomy. They will not provide infinite anatomical details. You may wish to refer to a textbook of anatomy to explore in more detail the information provided in the syllabus. Everything you will be tested on will originate from the syllabus and course handouts and the required radiology self-study on the internet, though we may expect you to do some independent thinking and build on the facts listed herein. The radiology component of the course will be learned through self study. Radiology resources on the internet will give you the opportunity to correlate your knowledge of bony anatomy with radiographic findings (normal and abnormal). You are expected to complete Totally Rad, which can be found at: http://courses.washington.edu/hubio553/totrad/index.html ** Before working on Totally Rad, go through

http://courses.washington.edu/hubio553/totrad/SCAR/index.html An Introduction to Interpreting Musculoskeletal Images (linked to the Totally Rad website) would also be useful to work through. If you would like to practice identifying the bones, additional labeled and unlabeled radiographs of normal anatomy can be found at: http://www.rad.washington.edu/radanatomy.html Radiographs of musculoskeletal disorders are found in Son of Rad at:

http://courses.washington.edu/hubio553/totrad/RadReference/index.html You will find Son of Rad useful during PBL as well. iv

In the gross labs you will explore the musculoskeletal system by dissection. This allows you to understand anatomical spatial relationships. This presumes you have facts to relate. The dissecting laboratory is not a place for anatomical discovery by medical students. It is a means of confirming and interrelating anatomical facts, i.e. never incise the skin as though it were the lid of a black box, because if the contents are unfamiliar objects, your only gain is to multiply your unknowns. The living anatomy small groups will provide a transition from learning the anatomy on a cadaver to using your anatomic knowledge clinically. E. Prerequisites Basic knowledge of histology, physiology, and pathology is necessary. F. Evaluation & Grading You will be graded on the basis of 2 examinations (upper and lower limb, 45 and 47 points respectively), eight weekly quizzes worth one point each (eight points total), for a total of 100 points. Quizzes are given at the start of each class. Be on-time or take a zero for the quiz. The upper limb exam will be given during the course. The lower limb exam will be given during finals week. If you fail the upper limb exam, you will be re-examined on this material at the time of the other exam and the score on your first exam will be thrown out. We are willing to tutor you if necessary so that you will pass these exams and the course. We are much more interested in and able to provide you help during the course, as opposed to during Spring or Summer quarters, so do respond to our offers of assistance and let us know if you would like some tutoring. Please notify Dr. Goldstein ([email protected]), Dr. Graney ([email protected]), or Dr. Schmale ([email protected]) if you need help. Exams will primarily be in the multiple choice or matching format, samples of which are provided in the syllabus. There will also be one long-answer clinical case-related question on each exam, worth three points on the first exam and five points on the second. A pass/fail grading system will be utilized. Honors will be awarded to students whose points total 91 or greater and who demonstrate leadership and excellence in all aspects of the course. You are not eligible for honors if you fail the initial upper limb exam, even if you get a perfect score on the retake and have 91 or greater total points. A pass grade is at or above 70 points. Your performance in the lab and small groups may be used to help you in borderline pass/fail situations. This would be at the discretion of the Course Chair. In the gross lab, you are expected to complete the required dissection and be able to demonstrate it. In the living anatomy small groups, you should be able to find, draw, and demonstrate the assigned structures. You are expected to be prepared for these small group sessions. Attendance is mandatory for all small group sessions. We are fortunate to have many community physicians assisting us with these small groups. It should go without saying that as representatives of the University of Washington School of Medicine, it is expected that you will be professional and respectful in your dealings with small group leaders, lab assistants, and your classmates. All of the material in the syllabus and all lecture handouts (also available off of the web) are fair game for testing. The clinical case-related question on each exam will include a radiograph. Be sure to complete at least the upper limb half of Totally Rad prior to the exam, so that you have some familiarity with upper limb radiographs. As one of the objectives of the v

trauma lecture is to be able to describe fractures, there will be a few radiographs on the lower limb exam with multiple choice answers concerning fractures. Completion of Totally Rad will help you prepare for questions that include radiographs. You can also practice looking at and describing fractures at Son of Rad (see our home page for the direct link). Weekly Quizzes: Each week there will be a short one-point quiz at the start of class on a simple question related to that day's topic(s). For example, there will be a quiz on the first day of class related to back pain, and on the second day of class on the brachial plexus. There is no make-up for missing these quizzes. After the first two weeks, quizzes will focus on material related to that day's dissection. G. Instructional Materials and Resources You are expected to have an anatomy text and atlas. A suggested atlas is Netters Concise Atlas of Orthopaedic Anatomy by Jon Thompson. Please be aware that despite suggesting this Thompson text as your atlas, there are conflicts with the syllabus regarding muscular innervations. When that is the case, the syllabus and course handouts are the final word for the purposes of this course. The required radiology component can be found at

http://courses.washington.edu/hubio553/totrad/index.html However, prior to beginning this section, be sure to spend time working through
http://courses.washington.edu/hubio553/totrad/SCAR/index.html This site will give you direction in approaching radiographs and provide a method for handling totally rad in the most effective way. A highly recommended textbook is "Musculoskeletal Medicine," edited by Joseph Bernstein. It will be helpful in both this course and your PBL (Problem Based Learning) course. Additional radiographs are on the internet at http://www.rad.washington.edu/radanatomy.html Also see our course web site: http://courses.washington.edu/hubio553/index.html Additional resources on reserve in the library include: Books Adams, J. Adams, J. Bernstein, J. Outline of Orthopdics Outline of Fractures, Including Joint Injuries Musculoskeletal Medicine vi

Brooke, M.H. CIBA Clinical Symposia

A Clinicians View of Neuromuscular Diseases Congenital Dislocation of the Hip Running Injuries Skiing Injuries

Dandy, D.J. & Edwards, D.J. DeLisa, J. Downey, J.A. & Darling, R.C. Drake et al Gates, S.J. & Mooar, P.A. Harrison, T. Hoppenfeld, S. Iverson, L. Klippel, J. Kotke, F. & Lehmann, J. Licht, S. Lippert, F. & Teitz, C. McCarty, D. Moore, K. Moore and Dalley

Essential Orthopaedics and Trauma Rehabilitation Medicine, Principles and Practice Physiological Basis of Rehabilitation Medicine Grays Anatomy for Students 2006 Musculoskeletal Primary Care Principles of Internal Medicine Physical Examination of the Spine and Extremities Manual of Acute Orthopaedic Therapeutics Primer on the Rheumatic Diseases Handbook of Physical Medicine and Rehabilitation Stroke and its Rehabilitation Diagnosing Musculoskeletal Problems: A Practical Guide Arthritis and Allied Conditions The Developing Human Clinically Oriented Anatomy, 5th ed, 2006

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Netter Post, M. Rockwood, C. Shurtleff, D.

Atlas of Anatomy, 5th ed, 2003 Physical Examination of the Musculoskeletal System Fractures in Adults Myelodysplasias and Extrophies: Significance, Prevention and Treatment Exercises in Diagnostic Radiology: Bone Practice of Pediatric Orthopaedics Scientific Foundations of Sports Medicine Netters Concise Atlas of Orthopaedic Anatomy Diagnostic Imaging in Clinical Medicine

Squire, Lucy F. Staheli, L. Teitz, Carol C. Thompson, Jon C. Troupin, R. H. Software & CDs: Netter, F. H. Study Strategies 1. Gross Anatomy

Interactive Atlas of Human Anatomy

You should find musculoskeletal anatomy the easiest material to organize compared to previous trunk or head and neck anatomy. This region is truly an ordered system of bones, muscles, and neurovascular bundles. The course begins proximally on the trunk and progresses distally in a logical sequence. Regardless of the particular region of the limb you are studying at the time, the approach is always the same: bones, muscles, nerves and blood supply. If there is a study prescription it is as follows: a. b. Study a diagram of the skeleton and note the bony landmarks. Study the muscles noting their origins and insertions using diagrams of the skeleton to supplement your reading. You can usually visualize the origin and insertion more rapidly by studying the diagrams than by reading exhaustive descriptions. Learn the action of the musclenote the different effects depending on which end is fixed or mobile. Devise a test for the muscle. Most clinical testing is intuitive if you reason it out. We have provided flash cards of this information on the web at www.rad.washington.edu/atlas/ and www.rad.washington.edu/atlas2/ .

c.

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Learn the name of the peripheral nerve supplying the muscle, the course of the nerve through the entire limb, and which spinal segments contribute to the nerve. Learn the basic pattern of arteries and veins in each limb. Learn the peripheral cutaneous nerve maps and compare to segmental maps of dermatomes. (see pages xiii - xxiv in syllabus) Note: the syllabus is our source for all tests in this course. Put it all together by drawing the brachial or lumbosacral plexuses over a lightly drawn outline of the upper or lower extremity, including the peripheral nerves, the muscles they innervate, and the spinal segments that contributed to the nerves.

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2.

Living Anatomy / Clinical Correlation

You are expected to find the assigned structures and outline (draw) them on a fellow student in your small group. The faculty tutor in your group will help you determine how knowledge of these anatomic landmarks in combination with certain clinical tests/exam maneuvers may help you differentiate one possible diagnosis from another. Preparation will help you to be most efficient and to gain maximal benefit from your contact time with faculty members. Time spent in class will be of little benefit to you unless you come to each class well prepared. Though living anatomy is not dedicated to teaching the musculoskeletal physical exam, which you will see instead in ICM II this same quarter, undoubtedly you will be introduced to many elements of the musculoskeletal clinical exam during these sessions. This instruction should help clarify your diagnostic thinking as you sort through differential diagnoses. Though somewhat less structured than other activities in this course, these are the most important sessions for putting it all together! a. b. c. Know the location of each assigned structure. Think about what findings you might expect for each diagnosis listed. Use your small group tutor to clarify the location and clinical use of these anatomic landmarks.

3.

Radiology

Some of you may feel perfectly confident when someone gives you a film to interpret. The rest of you may feel a bit like a pig with a wristwatch. The purpose of this tutorial is to help you evolve past this stage. You should be able to identify common bony landmarks on radiographs of normal bones, and

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to describe findings associated with common fractures, tumors, infections, and arthritis. Using our internet-based resources: a. Learn landmarks by looking at the labeled radiographs of normal anatomy. Then test yourself on the unlabeled radiographs at http://www.rad.washington.edu/radanatomy.html Check out An Introduction to Interpreting Musculoskeletal Images at http://courses.washington.edu/hubio553/totrad/SCAR/index.html Proceed through the Interactive Radiology Tutorial - Totally Rad at http://courses.washington.edu/hubio553/totrad/index.html Additional examples of musculoskeletal radiographs and clinical scenarios can be found on Son of Rad at

b. c. d.

http://courses.washington.edu/hubio553/totrad/RadReference/index.html

Specific inStructional MethodS for radiology

Radiology of the musculoskeletal system is learned in this course by independent study. We expect you to be able to identify bony landmarks on radiographs and to describe findings associated with common fractures, tumors, infections, and arthritis. Learn to use words like distal, proximal, medial, lateral, epiphyseal, metaphyseal, diaphyseal, sclerotic, osteopenic as well as the terms used to describe fractures (see the trauma lecture). Though the trauma lecture may occur after the midterm, we will have seen numerous radiographs during the clinical correlations and arthritis lectures by the half-way point in this course. The material covered in Totally Rad will be included on the two exams and is fair game for the quizzes. The pages that follow itemize the bony landmarks you should be able to identify. Use these pages as you look at the radiographs of normal bones on our web site at http://www.rad.washington.edu/radanatomy.html Learn the landmarks by looking at the labeled radiographs of normal anatomy. Then test yourself on the unlabeled radiographs. You will be expected to complete the radiology component of the course by proceeding through Totally Rad which can be found at http://courses.washington.edu/hubio553/totrad/index.html Before working on Totally Rad, look at An Introduction to Interpreting Musculoskeletal Images at http://courses.washington.edu/hubio553/totrad/SCAR/index.html If you want to look at radiographs of musculoskeletal disorders for PBL or for fun, go to Son of Rad at http://courses.washington.edu/hubio553/totrad/RadReference/index.html You will need your own code or ID to enter Totally Rad. For simplicity sake, use your name and your mothers maiden name as the password every time you log-in to Totally Rad. If you log-in, do some work, and log-out, only to find at the next log-in that the program does not remember your previous work, not to worry. You will not be graded on completing this self-study (though you will be tested on it.) x

Schedule and preparation for claSS

Please Note: The radiology component of the course is self study. Work at your own pace. See syllabus, pages x and 279-284. Lecture: Prepare: Anatomy 1 Lecture: Prepare: Lecture: Prepare: Gross Lab: Prepare: Arm, Elbow, Axilla and Brachial Plexus/Dr. Goldstein Introduction.....................................................................................ii-x, 1-2 3-25 The Spine/Dr. Goldstein Anatomy and Development of the Vertebral Column ........................26-28 Neck and Back Pain/Dr. Schmale Neck and Back Pain ...........................................................................29-34 Axilla and Brachial Plexus Anatomy 1/Lab Dissection.................................................................35-38

Thursday January 3, 2008

12:30-1:20 p.m.

1:30-2:20 p.m. 2:30-3:20 p.m. 3:30-5:20 p.m.

Thursday January 10, 2008

12:30-1:20 p.m. 1:30-2:20 p.m. Lecture: Prepare: Lecture: Prepare: 2:30-3:20 p.m. Small Group: Prepare: Gross Lab: Prepare: Lecture: Prepare: Lecture: Prepare: Lecture: Prepare: Gross Lab: Prepare: The Shoulder/Dr. Goldstein Anatomy 2 ..........................................................................................39-50 Clinical Correlations in the Shoulder Drs. Goldstein and Schmale Clinical Correlations ..........................................................................51-60 Review Anatomy 2 .............................................................................39-50 Living Anatomy: Cervical Spine and Upper Limb Living Anatomy Instructions .............................................................61-64 Cervical Spine and Upper Limb.........................................................65-72 Muscles of the Superficial Back, Shoulder and Arm Anatomy 2/Lab Dissection.................................................................73-76 Arthritis I/Dr. Schmale Arthritis: An Overview.......................................................................77-86 Arthritis II/Dr. Schmale Arthritis (continued)...........................................................................77-86 Cubital Fossa and Forearm Muscles/Dr. Goldstein Anatomy 3 ........................................................................................87-104 Cubital Fossa and Forearm Muscles .............................................. 105-110 Anatomy 3/Lab Dissection...............................................................87-104

3:30-5:20 p.m.

Thursday January 17, 2007

12:30-1:20 p.m. 1:30-2:20 p.m. 2:30-3:20 p.m. 3:30-5:20 p.m.

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Thursday January 24, 2008

12:30-1:20 p.m. 1:30-2:20 p.m. Lecture: Prepare: Lecture: Prepare: 2:30-3:20 p.m. 3:30-5:20 p.m. 5:30-6:20 p.m. Small Group: Prepare: Gross Lab: Prepare: Review: Prepare: Hand/Dr. Goldstein Anatomy 4 ...................................................................................... 111-120 Clinical Correlations in the Hand Drs. Goldstein and Schmale Clinical Correlations ......................................................................121-128 Review Anatomy 4 ......................................................................... 111-120 Living Anatomy: Elbow & Hand Elbow and Hand .............................................................................129-136 Hand Anatomy 4/Lab Dissection.............................................................137-142 Optional Review Session Upper Limb Review & Cases ........................................................143-146

Monday January 28, 2008 Midterm today!

12:30-1:20 p.m.

Examination: Upper Limb (in Hogness A 420) Prepare: Upper Limb Review & Cases ........................................................143-146 Know Objectives through January 26, 2005 See Sample Exam .....................................................289-290, 293-294 No class today

Thursday January 31, 2008 Thursday February 7, 2008 12:30-1:20 p.m. 1:30-2:20 p.m. 2:30-2:50 p.m. 3:00-3:50 p.m. Lecture: Prepare: Lecture: Prepare: Lecture Prepare Lecture: Prepare: 4:00-5:20 p.m. Gross Lab: Prepare:

Growth and Development of the Hip/Dr. Schmale Growth and Development of the Hip .............................................147-154 Musculoskeletal Trauma /Dr. Schmale Musculoskeletal Trauma ...............................................................155-164 Introduction to radiographic interpretation Introduction to radiographic interpretation ....................................165-168 Introduction to the Lower Limb Lumbar Plexus and Muscles of the Thigh/Dr. Goldstein Anatomy 5 ......................................................................................169-184 Lumbar Plexus and Muscles of the Thigh Anatomy 5/Lab Dissection.............................................................185-188

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Thursday February 14, 2008 12:30-1:20 p.m. 1:30-2:20 p.m. Lecture: Prepare: Lecture: Prepare: 2:30-3:50p.m. 4:00-5:20 Small Group: Prepare: Gross Lab: Sacral Plexus: Gluteal and Posterior Thigh/Dr. Goldstein Anatomy 6 ......................................................................................189-202 Clinical Correlations in the Hip Drs. Schmale and Goldstein Clinical Correlations ......................................................................203-206 Review Anatomy 5 & 6,..................................................184-187, 189-202 Living Anatomy: Lumbar Spine, Hip, and Thigh Lumbar Spine, Hip and Thigh........................................................207-212 Sacral Plexus: Gluteal and Posterior Thigh Muscles .....................213-216

Thursday February 21, 2008

12:30-1:20 p.m. 1:30-2:50 p.m. Lecture: Prepare: Lecture: Prepare: 3:00 - 3:20 3:30-5:20 p.m. Lecture Prepare: Gross Lab: Prepare:

Knee Joint, Anterolateral Compartments of the Leg and Ankle Joint Dr. Goldstein Anatomy 7 ......................................................................................217-228 Clinical Correlations in the Knee, Ankle & Foot Drs. Goldstein and Schmale Clinical Correlations ......................................................................229-237 Review Anatomy 7 ........................................................................217-228 Spinal Segments/ Dr. Goldstein Spinal Segments .............................................................................238-242 Knee Joint, Anterolateral Compartments of the Leg, & Ankle Joint Anatomy 7/Lab Dissection.............................................................243-248

Thursday February 28, 2008

12:30-1:20 p.m. 1:30-2:20 p.m. 2:30-4:20 p.m. 5:30-6:20 p.m. Lecture: Prepare: Small Group: Prepare: Gross Lab: Prepare: Review: Prepare: Posterior Compartment of Leg and Sole of Foot/Dr. Graney Anatomy 8 ......................................................................................249-266 Living Anatomy: Lumbar Spine, Knee, Leg, Ankle, & Foot Lumbar Spine, Knee, Leg, Ankle, & Foot .....................................267-274 Posterior Compartment of Leg and Sole of Foot Anatomy 8/Lab Dissection.............................................................275-278 Optional Review Session Lower Limb Review & Cases .......................................................285-288

Monday March 3, 2008

2:30am-5:50 p.m. Examination: Lower Limb (in Hogness A 420) Prepare: Lower Limb Review & Cases ........................................................285-288 Know Objectives for classes February 7 through 28, 2008 See Sample Exam ....................................................................289-304 xiii

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Key Sensory Points

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Key Sensory Points

Images reproduced with permission in their entirety from the American Spinal Injury Association.

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introduction to anatoMy
The Approach As noted in the study strategies, you need to start your study of the musculoskeletal system by learning the joints and muscles. This requires a knowledge of bones, their specific landmarks and of the joint or joints which the muscles moves. In this way you can define actions of each muscle. It is important throughout the study of the musculoskeletal system to note the design and movements of the each joint encountered. For example, the shoulder joint is designed as a ball that fits into a rounded socket. Movements at the shoulder include flexion-extension, abductionadduction, and internal-external rotation. You need to know the muscles which perform each action. The novice student begins by memorizing the origins, insertions, innervation, and actions listed on a flash card and parroting it for each muscle. This may help to build a data base, but it is more important for a student to be able to use this information in assessing a patients functional loss. The raison dtre of muscles is to move joints. A patient does not point to a muscle and say, This muscle does not work anymore. The usual complaint is, Doctor, I can not bend my arm anymore! Incidentally, before you begin pulling on the patients arm and beating her tendons with a reflex hammer, remember, history first. It might be important for you to know that she cannot move it because it hurts too much. As you will learn in your small groups, one does not test a patients musculo-skeletal function by alphabetically testing the muscles of the upper limb. Also, if the patient is unable to flex his or her elbow, you do not limit your exam to the elbow. One will perform a complete musculo-skeletal screening exam testing all of the joints and muscles of the limb as well as the cutaneous sensory function. In general, there are four essential functions of a joint: movement, strength, stability, and smoothness. Anything that interferes with one or more of these functions will result in a musculoskeletal problem. If a patient is unable to completely flex the elbow, for example, you need to determine if this limited range of active motion is also present if you (the examiner) take the patients forearm and passively bend the elbow. If a patent has neuromuscular weakness, you would expect that the patient is unable to move the joint through the full range of motion but the examiner is able to do this passively. There are other possible explanations for limited movement including tightness, joint changes that occur as a result of diseases such as arthritis, and loose bodies within the joint. To return to our patient who can not bend her arm, let us suppose she is unable to flex her elbow and the elbow is extended at the patients side at all times. There is no swelling or pain and you have determined there is a normal passive flexion. There are two muscles (the brachialis and the biceps) responsible for elbow flexion and both are supplied by the musculocutaneous nerve. Even without testing either of the muscles, it may seem reasonable to assume the musculocutaneous nerve is the problem. But how do you know it is not a problem of the ventral horn cells in the spinal cord at the level of C5 and C6 which are the levels that motor cells send fibers into the musculocutaneous nerve? For example, there are viral infections that affect the ventral horn cells (e.g., polio). If the C5 and C6 ventral horn cells are affected by polio, all nerves that carry these fibers will be affected. Similarly degenerative diseases of the descending tracts in the brain and spinal cord, which innervate these motor cells could also affect the biceps and brachialis at the level of C5 and C6. You must determine if this is the case by testing other muscles supplied by these segments, e.g. deltoid, supraspinatus. You will learn approaches to figure out exactly how to locate the problem. If the pathology results in a biomechanical problem, the patient will manifest problems that interfere with movement (e.g. 1

producing stiffness), strength, stability, and/or smoothness. Yet functions of the nervous system (such as sensation) should be normal. On the other hand, if the problem is in the nervous system, a careful evaluation of both motor and sensory function must be evaluated. Has the patient complained of numbness or tingling of the skin? If not, have you tested for it? In the case of the patient who cannot bend her arm, if the problem is in the musculocutaneous nerve she will also have deficits of sensation in the distribution of the nerve (i.e., on the lateral side of the forearm).

Sensory nerve problems People have alterations in sensation with both central and peripheral nervous system problems. In this course, we will only discuss peripheral problems. There are three patterns of sensory loss that are common: 1) generalized peripheral neuropathies, 2) peripheral nerve problems, and 3) segmental nerve problems. There are many different types of generalized peripheral neuropathies. A typical example is a dying-back neuropathy from a metabolic disease such as diabetes mellitus. As the disease progresses, it is very common that the nerves die back from their most distal point. So first affected are the longest nerves (in the feet), then shorter nerves (in the hands), and so on. The nerves die back farther and farther and the sensory deficits advance proximally in a stocking-glove distribution. 2) There are many types and locations of peripheral nerve problems. The most common are entrapment problems such as carpal tunnel syndrome. In such disorders, the peripheral nerve is mechanically entrapped and functions beyond that point (e.g., sensory and motor) are affected. To understand these types of problems, it is important that you know the anatomy of peripheral nerves. Therefore, you will learn peripheral nerve maps. The distribution of a peripheral nerve is relatively straight-forward to learn. You need to know the muscles (motor) and skin (sensory) innervated by the nerve. 3) Segmental nerve problems arise when there is a proximal nerve problem at the nerve root level. Since nerve roots are typically distributed to several peripheral nerves, root problems typically result in several nerves affected. In addition, the way roots are organized is quite different than peripheral nerves. You will learn how roots are organized into myotomes (for muscles) and dermatomes (for sensation). To help summarize the difference between peripheral nerve and nerve root innervations, peripheral nerve maps and segmental nerve maps are included in this syllabus. Since there is considerable variation in textbooks:

the definitiVe reference for theSe nerVeS for eXaMination purpoSeS iS thiS SyllaBuS. not grant, not netter, not Moore, or any other reference.
There is no escape from learning origins, insertions, innervation, and actions of muscles. There is also no short-cuts in learning the design of joints and how they move. If flash cards help, use them. If tables help, use them. However, always think of the information in the context of a clinical problem. You will be given many during the progress of the course. Before the course is over, one of you or the faculty will have a musculoskeletal problem. It never fails. Having a story or personality to link to the musculoskeletal facts, concepts, and diagnoses will help you remember them in the years to come.

anatoMy 1: elBow and arM; aXilla and Brachial pleXuS

Objectives
1. Describe the origin, insertion, action and innervation for each muscle listed in this exercise. (Most of these muscles will be reconsidered in later laboratories and you will have ample time to reinforce this information). (See Summary Tables) 2. Describe the boundaries and contents of the AXILLA. 3. Draw the brachial plexus in two steps: first, from roots to terminal branches, omitting peripheral branches arising from roots, trunks, and cords. Label the spinal segments composing all of the parts; second, add all branches given off from the roots, trunks, and cords and similarly label each branch with the spinal segments composing it. At this point in time you should learn all of the muscles innervated by the different branches of the brachial plexus except for the radial, median and ulnar nerves. You should also begin learning the cutaneous distribution of these branches with the exception of the radial, median and ulnar. You will learn these branches with the forearm and hand. 4. Describe the compartments of the arm. 5. Describe the anatomy and movements of the elbow joint.

OSTEOLOGY
Review the following bones of the pectoral girdle and their anatomical landmarks on the skeleton. This can be done exclusively with illustrations but a better appreciation of relationships and dimensions can be gained if the exercise is done with the bone in hand or with an articulated skeleton in the laboratory. Scapula: Angles: identify the superior and inferior angles Fossae: there are three fossae, supraspinatus, infraspinatus and subscapular each occupied by a muscle of the same name Coracoid process: site of attachment of three muscles (coracobrachialis, short head of biceps and pectoralis minor. At the medial base of the coracoid many scapulae display a distinct notch, the suprascapular notch. On some bones the notch may be shallow or even imperceptible. However, the notch is occupied by the suprascapular nerve, a branch of the brachial plexus. This relationship has clinical significance and will be discussed later in this exercise. Spine and acromion: the spine forms an obvious keel-like structure on the posterior surface of the scapula, its expanded end is the acromion or point of the shoulder. The acromion articulates with the acromial end of the clavicle forming the acromioclavicular joint which is the site of shoulder separation when the acromioclavicular ligaments are stretched or torn. Glenoid cavity: the concavity fits the convexity of the humeral head forming the glenohumeral joint or shoulder joint. Even though the glenoid cavity is surrounded by a lip 3

of fibrocartilage, the glenoid labrum, the shallowness of the joint creates an inherent instability of the shoulder joint resulting in dislocation of the humeral head when the joint capsule is stretched or torn. Clavicle The clavicle is somewhat S shaped with a sternal and acromial end. The sternal end articulating with the manubrium of the sternum forms the sternoclavicular joint, the sole joint with which the upper limb articulates with the axial skeleton. Five muscles attach to the clavicle; pectoralis major, trapezius, deltoid, sternocleidomastoid, and subclavius. The clavicle is frequently fractured by a fall on the outstretched hand or, as noted above, the acromioclavicular joint capsule is injured producing variable degrees of shoulder separation. (Not to be confused with shoulder dislocation at the glenohumeral joint.) The parts of the proximal humerus are the head, neck, shaft, tuberosities, bicipital groove, and articular surface of the head. The distal part of the humerus may be noted in passing, but will be studied in detail with the forearm and elbow joint. The greater and lesser tuberosities define the intertubercular groove, more commonly known as the bicipital groove because it is the site of the tendon from the long head of the biceps muscle. Identify the deltoid tuberosity, the attachment of the deltoid muscle on the lateral aspect of the shaft. Also note the spiral groove on the upper shaft which is the path of the radial nerve. The proximity of the radial nerve to bone can cause compression of the nerve when pressure is applied to the arm. Fractures of the mid shaft may trap or lacerate the radial nerve producing significant disability of the extensors of the wrist and fingers.

Humerus

MUSCLE ATTACHMENTS: (Fig. 1.1-1.6; See Tables pgs. 36-38 of syllabus)

Muscles of the scapula:*

As you study the bones of the pectoral girdle, note the attachment sites of various muscles to the scapula, clavicle, and humerus. Of the following muscles, all either originate or insert on the scapula, and with two or three exceptions, have their other attachment on either the clavicle or humerus. Using the syllabus figures and your atlas, describe the action of the muscles before looking it up in the tables. It will not be until the completion of the second laboratory that you will complete all of the muscles of the pectoral girdle. Do not let the mass of material overwhelm you. The Living Anatomy and ICM II Physical exam sessions will also review muscle function and testing. I suggest you start with the muscles attaching to the posterior aspect of the scapula (Fig. 1.1) and then build to the more superficial muscles. e.g. trapezius. Do the muscles of the posterior and anterior compartments of the arm last. supraspinatus infraspinatus subscapularis trapezius long head of triceps teres major teres minor levator scapulae rhomboid major and minor long head of biceps deltoid serratus anterior pectoralis minor coracobrachialis short head of biceps

* For the sake of simplicity the attachments of the omohyoid and latissimus dorsi muscles are omitted. For the quantitatively inclined, there are 18 muscles, counting major, minor, long and short heads attaching to the scapula.

Posterior view

Levator scapulae Rhomboid minor Rhomboid major Teres major

Figure 1.1

Muscle attachments of the proximal humerus. The greater and lesser tuberosities of the humeral head serve as attachment sites for four muscles called the rotator cuff. The subscapularis attaches to the lesser tuberosity and is primarily an internal rotator of the humerus. (Fig. 1.2)

Anterior View Acromio-clavicular joint Greater tuberosity Coracoid process Subscapularis

Figure 1.2

The greater tuberosity has three facets (flat spots) for the attachment of the supraspinatus (an abductor), infraspinatus (external rotator) and teres minor (external rotator) muscles. (Fig. 1.3) The above four muscles that form the rotator cuff contribute to the capsule of the shoulder joint (glenohumeral). Mechanical (sports) injuries and degenerative problems frequently affect the rotator cuff and capsule and will be discussed at length in lecture and the small groups. Other sites of muscle attachments include the deltoid tuberosity and medial and lateral lips of the intertubercular groove. The pectoralis major attaches to the lateral lip and the medial lip has two muscle attachments, the latissimus dorsi anteriorly and teres major, posteriorly. The majority of the muscles described above are concerned with movements of the shoulder complex, i.e. scapula, clavicle and glenohumeral joint.

Supraspinatus Infraspinatus Teres minor

Figure 1.3

There are other muscles originating on the humerus and scapula that are described as primary arm muscles that occupy the anterior or posterior compartments. The triceps is the sole muscle in the posterior compartment, having two heads (lateral and medial) from the humerus and one, the long head, from the infraglenoid tubercle of the scapula. It inserts on the olecranon process of the ulna and is the dominant extensor of the elbow joint. (Fig. 1.4) The triceps is supplied by the radial nerve from the posterior cord of the brachial plexus.

Infraglenoid tubercle Long head of triceps m. Lateral head of triceps m.

Medial head of triceps m.

Olecranon process
Figure 1.4

The anterior compartment of the arm contains three muscles, two of which are important for you to learn. The biceps brachii is a strong elbow flexor and supinator of the forearm; it also is a relatively weak shoulder flexor. (Fig. 1.5) Brachialis is a prime flexor of the elbow. (Fig. 1.6) Coracobrachialis is a relatively unimportant and weak shoulder flexor and adductor. All three muscles of the anterior compartment of the arm are innervated by the musculocutaneous nerve.

Figure 1.5

Long head of biceps m. from supraglenoid tubercle Short head of biceps m. from coracoid process

Bicipital aponeurosis Biceps tendon to radial tuberosity Coracobrachialis m. Brachialis m. Brachialis insertion onto coronoid process of ulna
Figure 1.6

Osteology of the Distal Arm and Elbow:

Before beginning a study of the joints of the spine, you should be familiar with some of the major landmarks and shapes of the joints at the distal humerus. Humerus: medial and lateral epicondyles olecranon fossa coronoid fossa trochlea capitulum Radius: head pronator ridge neck styloid process tuberosity dorsal tubercle (of Lister) Ulna: olecranon process coronoid process tuberosity trochlear notch styloid process

Elbow: anterior Figure 1.6B

Coronoid fossa Lateral epicondyle Capitulum Trochlea Radial head Coronoid process Radial tuberosity

Synovium

Medial epicondyle

Annular ligament Ulnar tuberosity

10

Elbow: posterior Figure 1.6B

Olecranon fossa

Synovium

Medial epicondyle Olecranon process Annular ligament

Elbow: lateral Figure 1.6C Capitulum Annular ligament Radial head

Lateral collateral ligament Triceps tendon

11

Elbow: medial Figure 1.6D Trochlea Coronoid process

Triceps tendon Medial collateral ligament

Classification of Joints
Joints of the musculoskeletal system may be fibrous (a syndesmosis), cartilaginous (an amphiarthrosis), or synovial (a diarthrosis). Examples of a syndesmosis include the sutures of the skull or the interosseus membrane connecting the radius to the ulna of the forearm. An example of a cartilaginous joint would be the cartilage that connects the ribs to the sternum. Most of the joints of interest in this course will be synovial joints - though not all of them. Synovial joints have a capsule and a synovial membrane, and have articular cartilage capping the ends of the bones at the joints. By definition, synovial joints are made up of two or more bones, have a synovial lining of cells that make synovial fluid, have a capsule with supporting ligaments for stability, and muscles and tendons that move the joint. There are many types of joints. The elbow joint is a complex arrangement of three different joints, the most obvious of which is an example of one of the most simple joints: a hinge or uniaxial joint at the ulno-humeral joint. (The elbow also contains two pivot joints, the radiocapitellar and proximal radial-ulnar joints.) The glenohumeral joint of the shoulder is a ball and socket joint. This allows for movement in almost any direction. The hip is another ball and socket joint. Very mobile joints are often less stable. For example, in comparing ball and socket joints, the glenohumeral joint of the shoulder is very mobile while the hip is very stable. The glenoid socket is much shallower than that of the hip, thus increasing shoulder mobility. But as there is less bony support of the socket for the shoulder, the risk of dislocation of the glenohumeral joint is much greater for a given force or energy of trauma than the risk of dislocation of the hip.

12

Axilla: The axilla is the space between the trunk and limb containing the neurovascular bundle of the upper limb (the axillary vessels and the brachial plexus with most of its major branches). The concentration of neurovascular structures makes it an important anatomical area, but more importantly there are a number of clinical and surgical problems which require thorough knowledge of this area. Boundaries: In a cross sectional view the axilla appears as a triangular space with the following boundaries: (Fig. 1.7-1.8) 1. Anterior: pectoralis major, minor and clavipectoral fascia 2. Medial: thoracic cage and serratus anterior muscle 3. Posterior: scapula and subscapularis muscle, teres major and latissimus dorsi 4. Lateral: head of humerus and intertubercular groove 5. Floor: axillary fascia 6. Roof: trapezius and cervical fascia

Subscapularis m. attaching to the lesser tuberosity Serratus anterior m. Axillary sheath Posterior cord Axillary a. Lateral cord Medial cord Axillary vein

Biceps long head in the intertubercular groove

Pectoralis minor m. Pectoralis major m.

Figure 1.7

13

Figure 1.8

Anterior View

Pectoralis minor m. (in phantom view deep to major) Pectoralis major m. Deltoid m. attaching to deltoid tuberosity of the humerus

14

Contents: axillary artery, brachial plexus, axillary vein, fat and lymph nodes The key to understanding the axilla is knowing its boundaries and the course of the axillary artery. The axillary artery begins at the lateral border of the first rib and ends at the lower border of teres major muscle. (Fig. 1.9) It is useful to divide the artery into three parts, the first part is located from the lateral border of the first rib to the upper border of the pectoralis minor, the second part lies posterior to the pectoralis minor, and the third part lies inferior to the pectoralis minor. Each part has a respective number of branches. First part: superior thoracic artery (not important) Second part: (two branches) Thoracoacromial trunk, (This includes several named branches for which you are not responsible, although they may be listed in your reading. It is the dominant artery supplying the pectoralis major.) Lateral thoracic artery. It contributes to the supply of the pectoralis minor and serratus anterior muscles.

Axillary Artery Superior thoracic a. Thoracoacromial trunk Lateral thoracic a. Posterior humeral circumflex a. Anterior humeral circumflex a. Subscapular a. Teres major tendon

Pectoralis minor tendon

Figure 1.9 15

These two branches of the 2nd part have particular significance in the female, because they contribute to the blood supply of the lateral hemisphere of the breast. The medial hemisphere is supplied by anterior intercostal arteries. Because the watershed of the lymphatic drainage of the breast follows these vessels, metastasis of a breast carcinoma in the medial hemisphere will be directed along lymphatics into mediastinal nodes, whereas metastasis from the lateral hemisphere (the more frequent site) will be carried by lymphatics to axillary nodes. Third part: (three branches) Anterior humeral circumflex artery: It is usually the smaller of the two circumflex arteries. Posterior humeral circumflex artery: This artery accompanies the axillary nerve passing through the quadrangular space and supplies the deltoid muscle. (Fig. 1.10). Because the artery lies next to the humeral neck, fractures of the neck may compromise the vessel causing avascular necrosis of the humeral head. Subscapular artery: This artery ultimately becomes the artery of the latissimus dorsi muscle. It courses inferiorly along the posterior axillary wall accompanied by the nerve of the latissimus dorsi, the thoracodorsal nerve.

Axillary n. Posterior humeral circumflex a. Quadrangular space Teres minor m. Teres major m. Triangular interval

Triangular space

deep brachial artery

Fig. 1.10

16

AXILLARY VEIN
The axillary vein parallels the artery and for the most part has the same named branches. You should note that it begins at the teres major and ends at the first rib as a tributary of the subclavian vein (axillary artery begins here). However, the subclavian vein lies anterior to the scalenus anterior muscle, thus it does not accompany the artery and brachial plexus lying in the interval between the scalenus anterior and scalenus medius muscles. For this reason, the vein in not enclosed in the axillary sheath, which is a sleeve or extension of the prevertebral fascia (Fig. 1.7). This fascial sleeve is of use to anesthesiologists performing brachial plexus blocks. By introducing a needle just deep to the fascial sheath, an anesthetic agent such as lidocaine can be injected inside the sheath , so that it will track along the nerves for maximum effect. The axillary vein is part of the deep system of limb veins and lies in the anterior compartment of the arm. It is fed by the brachial vein which in turn receives blood from veins located in the muscular compartments of the forearm and hand. The superficial veins lie superficial to the deep fascia of the limb in the subcutaneous plane. The two principal vessels are the cephalic vein on the radial side and the basilic vein on the ulnar side. The cephalic is a direct tributary of the axillary vein whereas the basilic drains first into the brachial vein (G. 6.4). At the anterior surface of the elbow joint (the cubital fossa) there is an anastomotic connection between the cephalic and basilic termed the median cubital vein. These three vessels are the ones commonly used for venipuncture.

BRACHIAL PLEXUS
The complexity and rigor of detail in the study of the brachial plexus along with student folklore usually presents an intimidating and daunting task for students. But in the spirit of a trite expression this isnt rocket science, it is more like learning the multiplication tables, it requires repetition. The tried and true technique is to draw the plexus building a basic and organized framework, and then to embellish it with finer detail. The drawing begins with the roots, trunks, divisions, cords and terminal branches and includes the spinal segments contained in each part or branch of the plexus. (Fig. 1.11) Basic framework implies the drawing without the branches of the roots, trunks, or cords. Table 1 presents all the information needed to construct such a diagram which can be modeled after Grants 6.20 or Netters 405. The finer detail involves going back to the roots, trunks, divisions and cords detailing each of the branches. One needs to note the distribution of each branch to muscle and or skin and the segments contained in each branch. (See Table 1. at the end of this section)

17

Cords Divisions Trunks Roots

Musculocutaneous n. Radial n. Ulnar n. Median n.

Figure 1.11

18

A synopsis of the branches of the plexus is as follows. Fig. 1.11-13 Roots: Only C5, 6, and 7 have branches: n. rhomboid C5 (dorsal scapular), n. subclavius C5, C6 n. serratus anterior C5, 6, 7 (long thoracic) Trunks: Suprascapular n. from upper trunk (Fig 1.12). The middle and lower have none. Divisions: There are no branches from the anterior and posterior divisions. Cords: lateral: lateral pectoral n., musculocutaneous n. and lateral root of median nerve. medial: medial pectoral n., ulnar n., medial root of median nerve, medial cutaneous nn. of arm and forearm. posterior: axillary n., upper and lower subscapular nn., and n. latissimus dorsi (thoracodorsal) radial n. (Fig. 1.13) Figure 1.12

Suprascapular n. Suprascapular a.

Thyrocervical trunk Transverse scapular ligament Transverse cervical a.

Does it make any difference if you know where a particular nerve branches from the brachial plexus? It does, because you will localize injuries by using your knowledge of brachial plexus anatomy. For example, the nerve to the rhomboid arises from the C5 root. If there is a brachial plexus injury and the nerve to the rhomboid is not working (meaning that the rhomboid muscles are unable to contract), this is evidence that the C5 nerve root is injured so proximally (i.e., close to the spinal cord) that it is probably ripped out (avulsed) from the spinal cord. The prognosis for recovery is very poor if nerve roots are avulsed. If one looks carefully at the point where small rootlets enter and exit the spinal cord, it is apparent that the dorsal and ventral roots for a segmental spinal nerve are formed by a series of small rootlets, not a single root like most diagrams of the spinal nerve might suggest. Sudden

19

forceful traction on the plexus may pull all or part of the rootlets out of the cord, resulting in permanent loss of function. Similarly, anatomical knowledge of which branches arise from which roots, trunks or cords assists in understanding brachial plexopathy and differentiating it from central nervous system lesions. With this background and further study, you will be able to perform a peripheral nerve examination to assess a patient presenting with motor and sensory deficits of the upper limb. If you look at a drawing of the brachial plexus, you will note that the three trunks each give off an anterior and posterior division. The anterior divisions form the medial and lateral cords (Fig. 1.11) which subsequently give off musculocutaneous, median, and ulnar nerves. These

Lateral and medial cords -cut ends Posterior divisions forming the Posterior cord

Axillary n. Radial n. Lower subscapular n. Thoracodorsal n. Upper Subscapular n.

Figure 1.13 20

TABLE 1: SUMMARY OF BRACHIAL PLEXUS SEGMENTS 5, 6 5 5, 6, 7 5, 6 supraspinatus, infraspinatus subclavius rhomboid maj. & minor serratus anterior MUSCLES SUPPLIED CUTANEOUS AREA

NERVE

Roots n. subclavius dorsal scapular n. long thoracic

Trunks upper: suprascapular middle: none lower: none

Divisions none

Cords subscapularis subscapularis, teres major latissimus dorsi deltoid, teres minor

1. Posterior a) upper subscapular b) lower subscapular c) thoraco-dorsal d) axillary e) radial 1) cutaneous 7, 8 5 6 6 6, 7 6, 7 6 6, 7 7, 8 7, 8 7, 8 7, 8 7, 8 7, 8 7, 8 triceps, long, med. lateral heads anconeus

5, 6, 7, 8 5, 6 5, 6 6, 7, 8 5, 6 5, 6, 7, 8 5

upper lateral cutaneous nerve of the arm (C5) lower lateral cutaneous nerve of the arm post cutaneous n. of arm post cutaneous n. of forearm

21
brachioradialis ext. carpi radialis longus brachialis (minor contribution) supinator ext. carpi radialis brevis ext. carpi ulnaris ext. digiti V ext. digitorum communis ext. indicis proprius ext. pollicis longus ext. pollicis brevis abd. pollicis longus

2) muscular br. 3) cutaneous

4) muscular br.

5) superficial radial

3-1/2 digits on dorsum of hand

6) post. interosseous

TABLE 1: SUMMARY OF BRACHIAL PLEXUS SEGMENTS 5, 6, 7 5, 6, 7 5, 6 pect. major coracobrachialis biceps brachialis lat. cutaneous n. forearm MUSCLES SUPPLIED CUTANEOUS AREA

NERVE

2. Lat. cord a) lateral pectoral b) musculocutaneous

c) lat. root median n. (see under 4) 8, T1 8, T1 pect. maj. & min. medial cutaneous n. of arm and forearm flex. dig. prof. (2 tend) flex. carpi ulnaris intrinsics of hand: add pollicis, interossei, ulnar lumbricals hypothenar: (palm brevis, abd. dig. V, opponens V, flex dig. brevis V) pronator teres flex carpi radialis palmaris longus flex dig. superficialis flex. dig. prof. (2 tend) flex pollicis longus pronator quad. abd. pollicis brevis, flex pollicis brevis opponens pollicis, lumbricals (radial) 8, T1 8, T1

6, 7

3. Medial cord a) medial pectoral b) medial root of median n. (see under 4) c) cutaneous

d) ulnar muscular

cutaneous 8, T1

8, T1 8, T1 8, T1 8

22
(5), 6, 7, 8, T1 6, 7 6, 7 7, 8 7, 8 8, T1 8, T1 7, 8 8, T1 6, 7, 8

deep ulnar

1-1/2 digits in hand palmar and dorsal

4. Median nerve (From both med and lat cords) a) muscular

b) anterior interosseous

c) cutaneous d) recurrent

palmar br. 3-1/2 digits - radial side of palm

e) cutaneous

Draw your brachial plexus here:

23

Draw your brachial plexus here:

24

In less than 3 minutes, draw your brachial plexus here:

25

anatoMy and deVelopMent of the VerteBral coluMn

(Lecture notes and self study no laboratory)

Background Expectations - know this prior to lecture

1. List the parts of a typical vertebra and the specific features characterizing each of the five regions of the vertebral column 2. Sketch the development of the vertebral column . 3. Draw a cross-section of the vertebral column at T1, include spinal cord, spinal roots, spinal nerves, and all meningeal layers in the drawing. 4. Draw the termination of the spinal cord, the course and composition of fibers composing the cauda equina. 5. Describe the blood supply of the spinal cord

Objectives
1. Name the ligaments and joints of the vertebral column and describe the types of motion permitted in each region. 2. In particular, describe the intervertebral and zygapophyseal joints, their locations, smiliarities and differences. 3. Describe the mechanism of compression of spinal nerve roots in the vertebral canal and intervertebral foramen.

I. Outline of lecture
I. Overview and epidemiology of neck and back problems a. Common problems regardless of age, occupation, education, culture, or income b. Which health care professionals see people with neck and back pain? c. Causes of neck and back pain II. The vertebral column a. Functions b. Structure, support, and movement c. Spinal cord and spinal nerves d. Curvatures: normal and abnormal III. Vertebrae: the bones a. Location and number; regional differences b. Anatomy i. Body ii. Neural arch 26

1. Named parts: pedicle, lamina 2. Processes a. Spinous b. Transverse c. Articular i. Superior ii. Inferior iii. Trabeculae 1. Clinical application: compression fractures iv. Pars interarticularis 1. Between the superior and inferior articular processes 2. Clinical application: spondylolysis IV. The joints a. Intervertebral disk: movements allowed i. NOT a synovial joint 1. Symphysis ii. Annulus fibrosis 1. Direction of collagen fibers iii. Nucleus pulposus 1. Function 2. Movement during flexion and extension iv. Disk troubles 1. Clinical application: herniated nucleus pulposus b. Facet joint (zygapophyseal joints, neural arch joints) i. Synovial joints surrounded by a capsule ii. Joint is between the superior articular process and the inferior articular process (of vertebra above) iii. As with all moveable joints, the movements allowed at the joint are dictated by the architectural design of the joint iv. Examine the differences between the facet joints in the cervical, thoracic, and lumbar regions of the spine. What movements (and how much) are allowed in each of these regions? V. Ligaments a. Ligaments act as check reins to movement. When a ligament is pulled taut, it restricts further movement. Several structures may restrict movement other than ligaments that are taut (e.g., capsule, muscle-tendon unit).

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b. Longitudinal ligaments i. Anterior longitudinal ligament ii. Posterior longitudinal ligament iii. Supraspinous ligament c. Segmental ligaments i. Interspinous ii. Intertransverse fibers) iii. Ligamentum flavum (this is an elastic ligament composed primarily of elastic

d. Clinical application: instability may result of ligaments are torn or stretched VI. Muscles and movements a. Movements in each region of the spine i. What is considered normal range of movement? ii. What is considered stiff? b. Muscles that act on the spine i. Flexor group (anterior) ii. Lateral group iii. Extensor group (posterior) c. Review the prime movers of the cervical spine d. Review the prime movers of the lumbar spine e. Erector spinae i. Function ii. Layers iii. Innervation VII. Review spinal cord anatomy and meninges a. Where does the spinal cord terminate? b.What is the cauda equina? What is the conus medullaris? VIII. Spinal nerves a. Neuroforamina b. Spinal nerve: where are cell bodies of the sensory fibers located? Motor fibers? c. Clinical application: radiculopathy

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neck and Back pain

Objectives:
1. Describe the epidemiology of neck and back pain. 2. Describe the major structures found in the spine, their relative positions and how local pathologic processes may result in neck and back pain. 3. Describe the segmental innervation of the upper and lower extremitiesmyotomes and dermatomes, including where named nerve roots exit relative to each vertebral level of the spine. 4. Define the following terms: spondylosis, spondylolysis, spondylolisthesis, spinal stenosis, scoliosis, herniated nucleus pulposis. 5. Describe the mechanical and non-mechanical causes of neck and back pain. 6. List the extra spinal causes of neck and back pain. 7. Describe a multidisciplinary approach for the treatment of neck and low back pain.

There is an epidemic of neck and back pain. 80% of adults will have severe neck or low back pain at one time or another. Most is mechanical and resolves by 6 weeks. More than 30% of children have back pain, most of unclear etiology. It may be due to heavy backpacks, increased activity, better reporting, or adult back pain role models. Low back pain is the most frequent cause of lost work time and disability in adults under age 45. Most is of limited duration: 85% return to work within one month, though 4% have symptoms lasting longer than 6 months. This 4% generate 85-90% of the costs to society for treating low back pain. Second only to low back pain in frequency of musculoskeletal complaints seen by primary care physicans is neck pain. As many as 10% of North Americans report neck pain on at least 7 days per month, with an annual incidence of acute neck pain of 20-30%. There is a high association between neck pain and psychosocial factors including the presence of stressors such as major life events, depression, poor general health, obesity, and high numbers of children. Children with back pain have higher non-mechanical diagnosis rates than in adults and generally deserve an early work-up. The exception: pain of many years duration is probably benign, though late diagnoses of malignancy of the pediatric spine do occur and have been reported. Because it can be difficult to determine a cause for back pain in children, when plain radiographs are negative, technecium 99 bone scans are quite sensitive for the production of new bone, and are often employed as the first additional imaging study for the child with undiagnosed back pain. Why would new bone be forming? It could be healing fracture, tumor or infection, to name the most common reasons. Because of reports of cold bone scans and missed diagnoses with benign appearing bone scans in children with malignancy, MRI is now recommended by many as the first next-test after radiographs for the child with undiagnosed back pain and negative radiographs.

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Keep it simple: Why do necks and backs hurt?

There may be soft tissue structural problems, such as muscle aches/spasm, or bony problems (periosteum is well innervated), such as fracture; or something eating at the bone, such as tumor or infection. Curvature (scoliosis) of the spine with abnormal load bearing may also cause pain (usually in adults, not children or adolescents). Disc problems are a potential source of pain, from the squeeze of a nerve root via a herniated disc (producing radicular pain or a radiculopathy - pain down the course of a nerve or along a nerves distribution), to simple pain from release of inflammatory factors from a sick disc (so-called discogenic pain). Many believe that discogenic pain is an unusual occurrence, as there are many more people with no neck or back pain who have discs looking on MRI exactly like those diagnosed with discogenic pain. Besides the numerous diagnoses described below, dont neglect the possible extra-spinal causes of neck and back pain, such as cardiac ischemia, shoulder pathology, ovarian cyst, nephrolithiasis, pancreatitis, abdominal aortic aneurysm, ulcer disease, and drug seeking behavior, among others.

Strain of Paraspinous Muscles

The most common cause of neck and low back pain is strain of the paraspinal muscles, often caused by or associated with repeat lifting and twisting, operating vibrating equipment, poor fitness, smoking, poor work satisfaction, hypochondriasis, and simple overuse. In the neck, whiplash syndrome or neck pain without identifyable structural injury after a motor vehical collision is a common occurrence. The work-up includes a careful history and physical, with the physical exam revealing paraspinous spasm and a normal neurological exam. In general, no x-rays are indicated for this diagnosis if the onset is recent, and there is no midline tenderness, no focal neurological deficit, normal alertness, no intoxication, and no additional painful distracting injury. Treatment goals include minimizing bed rest, and directed and focused efforts towards return to activity. An act as usual approach has been shown to work better than many specific treatments. Daily walking and minimizing narcotics, while utilizing non-steroidal anti-inflammatories (NSAIDs), +/- muscle relaxants can be effective in minimizing time away from work. In general, when act as usual does not bring a return to prior activity levels, Employ a multidisciplinary approach early. Such an approach may include physical and occupational therapy sessions, regular home exercise, job counseling, and life-skills assistance. Paraspinous strain and resulting muscle spasm are the most common causes of low back pain. A graduated return to activity is the recommended treatment as opposed to bed rest. For long-standing back pain interfering with return to work, work hardening programs, i.e. programs designed to help patients deal with their discomfort and perform tasks required at their jobs, in combination with multidisciplinary therapy including back-school, counseling, and pain management have been shown to be best to get people back to work.

High Energy Spine Trauma

High energy spine trauma resulting in fracture is an obvious cause of neck and back pain. These patients typically have the appropriate history, require immobilization and careful serial neurological exams during work-up, and appropriate and timely imaging studies to optimize patient outcomes. However, some fractures are subtle and require additional detective work and attention to detail. Routinely going through the following steps: stabilizing the spine, performing the ABCs and the primary and secondary surveys, followed by trauma spine imaging studies, is the best way to insure that fractures are not missed. Soft-tissue injury to the cervical spine may not be obvious on initial imaging studies in the face of high energy truama. Cervical spine stabilization with a rigid collar followed in a delayed fashion by physician assisted flexion-extension views may be indicated

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Low Energy Spine Trauma

Low energy spine fractures are probably more common and are perhaps more easily missed than the high energy variety. Having a healthy dose of suspicion when confronted with an elderly or merely post-menopausal patient who would be susceptible to osteoporotic fracture will you help make the diagnosis. These fractures are often simple compression type fractures. Type I fractures are postmenopausal, are seen mostly in women 50-65 years of age, are related to estrogen deficiency and to decreased trabecular bone mass, and are osteoclast mediated. Type II fractures are of the senile type. Type II fractures are a result of decreased osteoblastic activity and decreased cortical bone mass. Overall, women are twice as commonly affected as men, and the age of patients with these fractures is generally older.

Cervical and Lumbar Disc Disease

Degenerative disc disease is usually seen in adults. Discs lose height with aging as the water content of the disc tends to decrease. Tears in the annulus fibrosis, the region of stiffer disc material which encircles the softer nucleus pulposis, allows the soft nucleus pulposis to squirt out and potentially push on structures that arent supposed to be pushed on (i.e. nerve roots). When nerve roots are under pressure, radicular signs may be present, i.e. abnormal motor or sensory function in the distribution of that nerve root. Treatment includes NSAIDs, activity modification, and walking. Cervical disc herniations may place pressure on the spinal cord, producing a myelopathy. Myelopathic symptoms and signs might include easy fatigue, weakness, clumbsyness, and an altered gait, as well as upper motor neuron tract signs, such as hyperreflexia. Herniated Discs are seen in adults (commonly) and teens (uncommonly). The intervertebral disc consists of an annulus fibrosis that surrounds a gel-like nucleus pulposis. A herniated disc occurs when the relatively weak posterolateral region of the annulus fibrosis fails. L4-L5 and L5-S1 are the most common sites of a lumbar herniated nucleus pulposis (HNP). In the cervical spine, a C5-6 HNP is the most common.

Disc compression of nerve root through herniation

Know the dermatomes and major muscles innervated by C5, C6, C7, C8, T1, and L4, L5, and S1 (See Living Anatomy sections.) Disc herniations at what level(s) may push on the C5 and L5 nerve roots? Be sure to go through these questions in your living anatomy sessions. Recall the numbering of the nerve roots at the various levels. It is easiest to start with the C8 nerve root. Between which two vertebrae must it exit? (draw in the margin...) It must exit between C7 and T1, because there is no C8 vertebra. So, C5 must exit between C4 and C5. And, that means the T1 nerve root exits between the T1 and T2 vertebrae. Therefore, the L5 nerve root must exit between L5 and S1. Where does it go when it exits? It must go below the pedicle, otherwise it would be passing between the L5 and L4 vertebrae, and we know from above that it cant do that, by counting back to C7 and the path of the C8 nerve root. Can the L5 nerve root be compressed by a herniated disc at L5-S1? Not unless it is a far lateral disc. In most cases, the central disc herniations at L5-S1 will miss the L5 nerve root compressing instead the S1 nerve root, which is heading lateral but must first curl under the S1 pedicle. Radicular pain is pain that follows the distribution of a nerve root. Radicular pain may be caused by compression of the nerve root by a nearby disc.

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Spondylolysis is a stress fracture of the pars interarticularis. It rarely occurs before age 5 years and is usually associated with sports in which hyperextension of the back is common, such as gymnastics, cheerleading, diving, weight lifting, and football. Symptoms and signs of spondylolysis include focal tenderness of the lower lumbar region just off the midline, and painful hyperextension. Though the classic x-ray view to identify a spondylolysis is the oblique view of the lumbar spine, revealing the fracture as the collar of the Scotty-dog, the radiation dose from such imaging is quite high. Most cases will be seen on the lateral lumbar film. If the stress fracture is healing, it will be hot on bone scan. Cold lesions on bone scan suggest little potential for osseus union, though any bony gap certainly fills with scar tissue which should become asymptomatic with time. Symptoms are best treated with a wrap-around TLSO that prevents hyperextension. If not improved with bracing, surgery to fuse the affected segments may be indicated. Spondylolisthesis is the slip of upper vertebrae on lower because of pars insufficiency. It is rarely painful unless progressive or already severe. It is best seen on lateral lumbar films. Spondylolisthesis has 6 causes: congenital due to deficiency of the S1 superior facet; isthmic - due to stress fracture or fractures resulting in elongation of the pars; degenerative due to facet arthrosis leading to L4/5 subluxation; traumatic - from acute fracture NOT through the pars; pathologic - where tumor or other pathologic condition results in incompetence of the bony elements; and iatrogenic induced by surgery. Severe slip can cause neurologic symptoms. On physical exam one can see loss of lumbar lordosis, flattening of buttock, palpable step off, tenderness limited forward flexion, and tight hamstrings. Neurological changes may also be present. Treatment for spondylolisthesis is primarily activity modification until symptoms subside. For severe or progressive cases in children and adolescents, bracing may provide relief. In adults, spondylolisthesis is often a result of spondylosis or arthrosis of the spine. Limited fusion may be the best solution if activity modification and therapy are not successful in reducing symptoms. Spinal stenosis, or narrowing of the spinal canal, may be due to spondylolisthesis or acquired via osteophyte encroachment of osteoarthritis (spondylosis). Pain often radiates down the thighs and is usually relieved with forward bending. Treatment begins with physical therapy, to include hamstring and paraspinus muscle stretching. If unsuccessful, decompression of the narrowed segments may be required. Such a procedure may destabilize the spine, thus requiring a limited fusion.

Metastatic disease
Metastatic disease is MUCH more common than primary tumors of the spine. 50% of all patients with solid tumors will have spine metastases at some time. The most common metastatic cancers to spine include breast, lung, prostate, and renal. Multiple myeloma and lymphoma of bone may also involve the spine. Mets through hematogenous spread may present as an incidental finding in an asymptomatic patient, in patients with known primary tumors, as localized spinal pain, and by focal neurological findings in a patient with or without known tumor. Symptoms/signs may include PAIN, night pain, pain after trivial trauma, constant or worsening pain, with or without a radicular component with nerve root compression, motor and sensory change with severe nerve compression, and loss of normal bowel and bladder function that may be irreversible. Pathologic fracture may lead to paraplegia. Benign tumors of the spine include osteoid osteoma, osteoblastoma, eosinophilic granuloma, aneurysmal bone cyst, and hemangioma.

Infection
Infection of the vertebrae is a well-recognized cause of back pain, though it is no longer as common in adults because of the decreased incidence of TB. TB of the spine is known as Potts disease. These systemic signs of infection may be delayed and unimpressive: anorexia, weight loss, decreased energy, elevated inflammatory factors, night pain, constant or increasing pain. Immune compromised patients are at the greatest risk for infection of the spine. Infections of the spinal column probably lie on a 32

continuum, from involving only the disc spaces to including the whole vertebral body. Spine infections in children are not uncommon. Radiographic changes may take 2-3 weeks to appear, but bone scan is usually hot early-on. Staph. aureus is the most common organism involved in a childhood spinal infection, so biopsy is rarely indicated. Antibiotics (with or without bracing) are the usual treatment.

Scoliosis
Idiopathic scoliosis is not painful in children and young adults. Painful scoliosis may suggest splinting from a painful spinal or peri-spinal process. Adult scoliosis may be painful because of nerve root compression with asymmetric facet joint hypertrophy, asymmetric disc degeneration, and mild rotary subluxation of the spine. The unstable spine may need a fusion. Progressive neurologic deterioration needs emergent management.

Acute back pain in children

Most acute back pain in children, i.e. < 3 months duration, is felt to likely be the result of some objective pathology. Thus, careful work-up is indicated. The more common causes of acute back pain in children may be post-traumatic, such as from a stress fracture or spondylolysis, from a disc herniation, Scheuermanns kyphosis, spondylolisthesis, infection, or tumor. Chronic/intermittent back pain in children is now common - up to 30% of children have chronic back pain with no identifiable cause. The pain is most commonly activity related, may be accompanied by paraspinous spasm or hamstring contractures. Treatment is symptomatic and typically includes stretching and NSAIDs (non-steroidal anti-inflammatory medications).

Evaluation History
It is important to determine the duration of symptoms, their onset - acute vs. insidious, whether the pain is activity related, occurs at night or at rest, is accompanied by a limp or refusal to walk or any change in bowel or bladder function.

Physical exam
On exam, observe the patients gait is their a list or limp? Is the spine symmetric with forward bending, or is there a prominent rib hump on one side suggesting a scoliosis? Are there cutaneous changes - hair patches, dimples, nevi suggesting intraspinal pathology? Is there muscle spasm present? Are there focal neurogical differences comparing one side to the other?

Diagnosis
For suspected bony lesions obtain a bone scan or CT; use MRI for suspected tumors with neurologic changes, a soft-tissue component, or spinal cord involvement.

Summary
Beware the patient with persistent pain unrelieved by rest or bracing, increasing pain, unexplained pain - especially with neurologic signs, or back pain accompanied by systemic signs such as malaise, weight-loss, or fever.

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References: Ferrari R and AS Russell: Neck Pain. Best Practice & Research Clinical Rheumatology, 17 (1): 57-70, 2003. Ginsburg GM, and GS BAssett: Back Pain in Children and Adolescents: Evaluation and Differential Diagnosis. Journal of the American Academy of Orthopaedics, 5:67-78, 1997. Harrop JS, Hanna A, Silva MT, and A Sharan: Neurological Manifestations of Cervical Spondylosis: An Overview of Signs, Symptoms, and Pathophysiology. Neurosurgery, 60;S1-14-S1-20, 2007. Hazard, RG: The Multidisciplinary Approach to Low Back Pain and Disability. Journal of the American Academy of Orthopaedics, 2(3)May/June:157-163, 1994.

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laBoratory diSSection
Goals
1. Identify the boundaries of the axillary space. 2. Osteologyidentify the major clavicular, scapular, proximal humeral landmarks. 3. Identify branches of the axillary artery. 4. Identify the course of the nerves of the brachial plexus, including the roots, trunks, divisions, cords, and branches along the way.

I. Pectoral Region:
Depending upon previous use, this area may or may not have been dissected already. If the area has been dissected proceed to I, A. If not, make the following incisions: Incise the skin in the midline over the chest, from the manubrium to xiphoid. From the superior end of your incision, make a transverse cut following the line of the clavicle to the point of the shoulder. From the inferior end of your midline incision, cut laterally following the line of the costal margin as far as the midaxillary line. Reflect the skin and superficial fascia as a unit and clean the pectoralis major. Detach the pectoralis major from its clavicular, sternal and costal origin and reflect it laterally. Be careful as the pectoralis is elevated from the ribs to look for the medial and lateral pectoral nerves. A. Review the origins and insertions of the pectoralis major and minor and give their innervation, including segments. (See Tables) 1. The medial pectoral nerve. It is a slender fiber emerging from the pectoralis minor, entering the pectoralis major on its undersurface. It supplies both muscles. 2. The lateral pectoral nerve. To locate it, put your finger on the superior border of the pectoralis minor and trace it superiorly towards the coracoid process. Your finger should intersect the nerve where it crosses the upper border of the pectoralis minor if you did not cut it reflecting the pectoralis major. The lateral pectoral nerve is accompanied by a branch of the thoracoacromial artery which has several branches supplying the adjacent areas. B. Axillary Artery: The purpose of the following dissection is to open the axillary space to expose the axillary artery and brachial plexus. Be sure you understand the concept of the axillary space as you work through it to identify its various contents. To locate the axillary artery and its branches, detach the pectoralis minor muscle from the chest wall and reflect it laterally. Identify: 1. superior thoracic artery (Do not spend time on this branch as it is unimportant). 2. thoracoacromial trunk and the lateral thoracic artery 3. subscapular artery and the anterior and posterior humeral circumflex aa. (These branches will be better identified after the parts of the brachial plexus have been cleaned later in the dissection)

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II. Brachial Plexus:

The major function of the brachial plexus is to innervate the upper limb musculature and skin. Although there are occasional variations in its anatomical pattern and segmental composition, in general, it is a relatively constant structure being formed by the anterior primary rami of spinal segments C5-8 and T1. You should first memorize its anatomical pattern which is a prerequisite to providing you with a basic framework for understanding the subsequent branches. A. Mobilize the clavicle by incising the capsule of the sternoclavicular joint. Identify the subclavius muscle. Detach the subclavius muscle from the clavicle by subperiosteal dissection, leaving the sternocleido-mastoid muscle attached to the superior surface of the clavicle. Make a transverse cut through the clavicle with a Stryker saw at the anterior border of the deltoid, or open the AC joint and detach the AC and CC ligaments. Reflect the medial two-thirds of clavicle and its attached skin and muscle superiorly. Clean the fascia from the muscles covering the floor of the posterior triangle of the neck and identify the scalenus anterior and medius muscles. Identify the subclavian vessels at the lateral border of the first rib and their transition to axillary vessels. Note the origin of the brachial plexus emerging between the scalenus anterior and medius muscles. What other structure traverses this space? Q1.1 B. Review the branches of the subclavian artery and vein in the root of the neck. After identifying the venous branches, clear the vein from the dissection. (Meticulous dissection of veins is not a productive effort in this course. It is generally recommended that you remove all veins after identifying them in order to simplify and clarify the pattern of arteries and nerves.) C. Clean the fascia (axillary) from the roots, trunks and divisions of the brachial plexus. Note the suprascapular nerve arising from the upper trunk. Identify the cords and the medial and lateral pectoral nerves as they arise from medial and lateral cords. Identify the major branches of these cords, musculocutaneous nerve from the lateral cord, median nerve from both cords, and ulnar nerve from the medial cord. D. Summary of Brachial Plexus dissection: By this point in your dissection, you should have elevated the skin over the posterior triangle, resected the middle third of the clavicle, and cleaned the fascia (axillary sheath) from the axillary artery. E. Dissection of the Serratus Anterior: Clean the fat and fascia on the anterior border of the latissimus dorsi muscle from its insertion on the humerus to its origin on the back. Be careful of the subscapular artery and the thoracodorsal nerve which are located on the medial and more posterior aspect of the axilla and latissimus dorsi. If you palpate the anterior and posterior folds of the axilla on a patient, which muscles are you palpating? Continue cleaning the fat from the medial aspect of the latissimus, until you encounter the serratus anterior on the medial aspect of the axilla. Identify the nerve to serratus anterior. What are its segments? If you did not detach the pectoralis minor muscle earlier, do so now by separating the fleshy fibers from the costal margin. Reflect the muscle superiorly to expose the axillary artery.

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III. Branches of the Brachial Plexus:

A. Be sure you are thoroughly familiar with the basic framework of the brachial plexus. Identify the roots, trunks, divisions and cords. Using TABLE I, A Summary Chart of the Brachial Plexus, return to the level of the roots and identify those branches arising from the roots. Next, briefly identify the divisions, and then note the formation of the medial and lateral cords. Omit the posterior cord for the moment. Identify all branches of the medial and lateral cords. Grasp the medial and lateral cords, and the axillary artery in the fingers of one hand and retract them anteriorly and lateral i.e. towards the point of the shoulder or the acromion. This should help expose the posterior cord and make it easier to identify its branches. B. Identification of the branches of the posterior cord will require further cleaning of the posterior part of the axilla. If you work your dissecting instruments in the vertical plane, rather than transversely, you will be less likely to damage the branches of the posterior cord. Identify the three subscapular nerves: 1. Upper subscapular n. (C5, 6) to subscapularis muscle 2. Thoracodorsal n. (C6, 7, 8) to latissimus dorsi muscle. The nerve is sometimes referred to as the middle subscapular n. 3. Lower subscapular nerve (C5, 6) to subscapularis and teres major muscles. Identify the axillary nerve and the radial nerve which is the continuation of the posterior cord after the axillary nerve is given off. Which spinal segments are contained in these nerves? Name the muscles supplied by the nerves. Can you identify any cutaneous branches of the posterior cord? (See TABLE I) C. The axillary nerve and the posterior humeral circumflex artery exit from the axilla via the quadrangular space. What is the triangular space and what structure traverses it? D. You should now be ready to identify the parts of the brachial plexus beginning with the roots. Do not proceed beyond the musculocutaneous, median, ulnar and radial nerves. The specific branches of these nerves will be considered in subsequent laboratory sessions. E. It will be advantageous to detach the deltoid muscle at this time as it will demonstrate the terminal part of the axillary nerve and expose the capsule of the shoulder joint expediting dissection in the next laboratory. Incise the deltoid along its origin from clavicle and scapular spine. Reflect it inferiorly and observe the axillary nerve and the posterior humeral circumflex artery. F. Reflect the skin down to the elbow. Then turn the cadaver prone for the next laboratory session. (Please try to keep the plastic sheeting and cotton blanket clean when repositioning the cadaver. Do not leave the covers heaped on the floor.) ANSWER TO ANATOMY QUESTION 1.1 The brachial plexus and subclavian artery course between the scalenus anterior and medius muscle. The subclavian vein courses anterior to the muscle.

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38

anatoMy 2: MuScleS of the Superficial Back MuScleS of the Shoulder and arM
Objectives
1. Describe the classification of back muscles. Understand the arrangement and general nomenclature of the deep muscles, but do not memorize. The superficial back muscles are part of the pectoral group and will be studied today in detail with the shoulder region. 2. This laboratory completes the shoulder and arm regions. After today, you should be able to describe the origin, insertion, action and innervation of the following muscles. Trapezius Latissimus Dorsi Levator Scapulae Rhomboid Major Rhomboid Minor Serratus Anterior Teres Major Teres Minor Deltoid Supraspinatus Infraspinatus Subscapularis Pectoralis Major Pectoralis Minor Biceps Brachii Coraco Brachialis Brachialis Triceps

3. Describe the muscles producing the following motions of the pectoral girdle. (Table 2) a. Elevation - depression b. Protraction - retraction c. Rotation of scapula 4. Describe the muscles producing the following motion of the glenohumeral joint. (Table 3) a. Flexion - extension b. Abduction - adduction c. Internal and external rotation 5. Describe the joints and biomechanical events necessary for full range of abduction of the upper limb. (From lecture material) 6. Describe the course and intermuscular planes for the radial, musculocutaneous, median and ulnar nerves in the arm. 7. Describe the innervation of the skin of the arm.

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I. MUSCLES OF THE BACK

The muscles of the back are those which are topographically located on the posterior aspect of the trunk. They are usually described in three layers: 1) Superficial layer: the upper limb musculature 2) Intermediate layer: accessory muscles of respiration 3) Deep layer: extensors and rotators of the spine (erector spinae). Only the latter group, the erector spinae, are true back muscles and therefore, innervated by posterior primary rami of spinal nerves. You will not dissect the erector spinae group. You should learn the names and innervation of the superficial back muscles because they are important muscles of the pectoral girdle and prime movers in shoulder function. 1. Superficial layer (upper limb musculature) (G6.25; M: 467-470) a) Trapezius (spinal-accessory nerve, XI) (Fig 2.1) b) Latissimus dorsi (thoraco-dorsal n. C6, 7, 8) (Fig 2.1) c) Serratus anterior (long thoracic n. C5, 6, 7) (Fig 2.2) d) Levator scapulae (cervical plexus C3, 4) (Fig. 2.3) e) Rhomboids (dorsal scapular n. C5) (Fig. 2.3)

Trapezius Serratus anterior

Latissimus dorsi

Figure 2.1
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Figure 2.2

Figure 2.3

Levator scapulae m.

Rhomboid minor m.

Rhomboid major m.

Note that the levator scapulae is supplied by the cervical plexus and the trapezius is supplied by the spinal accessory nerve. The others are supplied by nerves from the brachial plexus. As it will become apparent following the discussion of shoulder biomechanics, all of the above muscles are critical to a full range of shoulder motion. When a patient is unable to move his or her arm approximately 180 degrees to reach above the head, basic activities of daily living, e.g. combing ones hair, placing an object on or retrieving it from a high shelf are compromised significantly. Similarly, sports activities involving an overhead motion such as tennis serve, golf swing, or any throwing motions (ball, javelin, etc.) are also affected. If you think about going through a day where you are unable to raise your hand above eye level, you can appreciate these patients plight. In the small group sessions you will learn to test these muscles and determine ranges of motion. It may be

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helpful to scan the sessions that relate to the current anatomy that you are studying, as it gives you an added perspective to the anatomy. 2. Intermediate layer (respiratory muscles) a) Serratus posterior superior and inferior (anterior rami of segmental spinal nerves.) (Do not memorize.) 3. Deep layer (true back muscles) (For general information only. Although you will not dissect the deep back muscles you should understand their nomenclature and function.) a) Splenius cervicis and capitis b) Longitudinal muscle groups Erector Spinae Lateral group - Iliocostalis Intermediate group - Longissimus Medial group - Spinalis Movements of the vertebral column: The primary function of the muscles of the back (i.e., true back muscles) is to effect movement of the vertebral column. In fact they are only part of the total muscles which act on the vertebral column. Muscles of the neck and abdomen (not included in this course) also play an important role in the posture of the vertebral column. Essentially all intervertebral motion is the same, that is, between two vertebrae it is possible to flex or extend, laterally bend, or rotate. The degrees of each motion may vary from cervical to lumbar regions, however these are the primary motions. A summary of all muscles (back, neck, trunk) acting on the vertebral column according to their functional grouping is as follows: Extension: erector spinae Flexion: scalenes, longus coli, longus capitis, sternomastoid, rectus abdominis, internal and external oblique Lateral flexors (side bending): quadratus lumborum, erector spinae (back, neck, trunk) Rotators: sternomastoid, erector spinae, external and internal obliques (back, neck, trunk)

II. MUSCLES OF THE POSTERIOR SCAPULAR REGION: These muscles are included in the list of muscles under objective two of this exercise. Some are important in moving the scapula and clavicle as a part of pectoral girdle motion and others act primarily at the glenohumeral joint. Use your figures and Tables 2 & 3 to understand their functions and innervation. Medial border of the scapula and spine: These you have studied as the superficial back muscles, Trapezius, latissimus dorsi, rhomboids and levator scapulae. Figs 2.1 and 2.3

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Figure 2.4

Supraspinatus m. Infraspinatus m. Teres minor m.

Rotator Cuff Group: Supraspinatus, Infraspinatus, Teres minor and Subscapularis (Fig 2.4-2.5) During the dissection of the brachial plexus, only the subscapularis muscle could be readily identified because the cadaver was supine. At this time the remaining three muscles of the rotator cuff can be identified in the laboratory after the trapezius is cleared from the scapula. Remember these four muscles attach to the tuberosities of the humerus. The subscapularis attaches to the lesser tuberosity and the others to the greater. If you study the anatomical figures and note the tendons carefully during your dissection you will see that the tendons attach not only to bone but blend in to the glenohumeral capsule. In this manner, the tendons contribute a continuous cuff of dense connective tissue to the shoulder capsule. A tear in the capsule can be exacerbated during heavy exercise since the tendons also transmit tension to the capsule. Shoulder biomechanics and the

43

Figure 2.5

Subscapularis m.

44

rotator cuff will be discussed in the session on applied anatomy and clinical correlations of the shoulder.

III. MUSCLES OF THE ARM:

The muscles of the arm, forearm and to some extent the hand, are located in fascial compartments. In most cases a single nerve supplies the muscles of each compartment. This is a fundamental concept for all limbs in all vertebrates. When reviewing the muscles of the limbs, you should do so in the context of compartments. It will not only help you in organizing the information and understanding functional muscle groups but will facilitate your understanding of some clinical problems as well, e.g. compartment syndrome of the leg. Posterior Compartment of the arm: Fig 2.6 The triceps brachii is the muscle of the posterior compartment. Note only one head, the long head, attaches to the infraglenoid tubercle and thus has an extensor action at the glenohumeral joint. The remaining heads act only at the elbow joint. The triceps is the principal extensor of the elbow joint. It is supplied by the radial nerve quite proximally, prior to its path in the spiral groove of the humerus. For this reason, the triceps is usually spared when the radial nerve is injured by spiral fractures of the humerus. Proximal pressure on the radial nerve branches

Radial n.

Triceps brachii m. long head

lateral head medial head

Figure 2.6

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in the floor of the axilla because of improper use of crutches can cause triceps weakness. How would you test triceps strength? Is there a reflex test for the triceps? Anterior Compartment of the arm: Fig 2.7-2.8 There are three muscles, the coracobrachialis, biceps brachii and brachialis in the anterior compartment of the arm. All of them are supplied by the musculocutaneous nerve. Their attachments and functions should be familiar to you at this time after your study in the first laboratory exercise. At this point you should note the course of the musculocutaneous nerve branching from the lateral cord, piercing the coracobrachialis muscle and coursing in the plane between the brachialis and biceps. The musculocutaneous nerve subsequently emerges in the cubital fossa at the lateral border of the biceps tendon. Here the nerve courses anteriorly piercing the fascial roof of the cubital fossa to lie in the subcutaneous space of the forearm. From the cubital fossa to the wrist, the musculocutaneous nerve is termed the lateral cutaneous nerve of the forearm. It has no motor branches after leaving the anterior compartment of the arm and its cutaneous distribution to skin ends at the wrist crease.

Long head of biceps m. Short head of biceps m.

Figure 2.7

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Figure 2.8

Coracobrachialis m.

Brachialis m.

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TABLE 2: MUSCLE SUMMARY: SCAPULAR MOTION ORIGIN ligamentum nuchae transverse processes of upper cervical vertebrae spinous processes C7 thru T5 ribs 3 thru 5 spinous process T4 thru T12 ribs 4 thru 8 inferior angle of scapula (ventral surface) humerus (lateral lip of bicipital groove) humerus (medial lip of bicipital groove) see above humerus - see above med & lat pect dorsal scapular spinous processes acromion spinal accessory C5, 6, 7, 8, T1 C5 long thoracic spine of scapula (medial portion) CN XI coracoid process medial pectoral medial border of scapula dorsal scapular C5 superior angle of scapula spinal accessory C3, 4 acromion & lateral third of clavicle spinal accessory C3, 4 INSERTION PERIPH. NERVE SPINAL SEGMENTS

MOVEMENT

PRIMARY MUSCLES

Elevate scapula

1. upper trapezius

2. levator scapulae

3. rhomboids major & minor

Depress scapula

Directly 1. pectoralis minor

C8, T1 C5, 6, 7

2. lower trapezius

3. lower fibers of serratus anterior sternum & costal cartilages 3 thru 6 sacrum, lumbar spinous processes ribs 1 thru 8 clavicle & upper sternum

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Indirectly 4. pectoralis major

lat. pectoral med. pectoral thoracodorsal

C5, 6, 7, C8, T1 C6, 7, 8

5. latissimus dorsi

Protract scapula

pectoralis minor serratus anterior

pectoralis major

Retract scapula

Directly 1. rhomboids

2. middle trapezius

Rotate scapula upward

1. upper trapezius

2. lower trapezius

3. serratus anterior

TABLE 3: MUSCLE SUMMARY: GLENOHUMERAL MOTION ORIGIN clavicle (lateral portion) SEE TABLE 2 coracoid process long head: supraglenoid tubercle of scapula Short head: coracoid process spine of scapula SEE TABLE 2 scapula-lateral border infraglenoid tubercle of scapula clavicle, acromion, spine of scapula supraspinous fossa SEE TABLE 2 SEE TABLE 2 SEE ABOVE infraspinous fossa lateral border of scapula subscapular fossa suprascapular axillary subscapular C5, 6 C5, 6 C5, 6 humerus - deltoid tuberosity humerus-greater tuberosity (superior facet) ulna - olecranon process humerus - medial lip of bicipital groove subscapular radial axillary suprascapular C5, 6 C7, 8 C5, 6 C5, 6 humerus - deltoid tubercle axillary radius-radial tuberosity and lacertus fibrosus musculocutaneous humerus musculocutaneous C5, 6 C5, 6 humerus - deltoid tubercle axillary C5, 6 INSERTION PERIPH. NERVE SPINAL SEGMENTS

MOVEMENT

PRIMARY MUSCLES

Flex arm

1. anterior deltoid

2. pectoralis major (clavicular head)

3. coraco-brachialis

4. biceps brachii

Extend arm

1. posterior deltoid

C5, 6

2. latissimus dorsi

3. teres major

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humerus-greater tuberosity (middle facet) humerus-greater tuberosity (lowest facet) humerus-lesser tuberosity

4. triceps (long head)

Abduct arm

1. deltoid

2. supraspinatus

Adduct arm

1. latissimus dorsi

2. pectoralis major

3. teres major

Laterally rotate arm

1. infraspinatus

2. teres minor

Medially rotate arm

1. subscapularis

TABLE 4: MUSCLE SUMMARY: ELBOW FLEXORS & EXTENSORS ORIGIN SEE TABLE 3 humerus-anterior surface humerus (distal lateral) 1. long head: infraglenoid tuberosity of scapula 2. lateral head: humerus-superior & lat. to radial groove 3. medial head: humerus - medial and inferior to radial groove olecranon radial C7, 8 radius - distal, lateral aspect radial C6 ulna-tuberosity musculocutaneous C5, 6 INSERTION PERIPH. NERVE SPINAL SEGMENTS

MOVEMENT

PRIMARY MUSCLE

Flex Elbow

1. biceps brachii

2. brachialis

3. brachioradialis

Extend elbow

1. triceps

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clinical correlationS in the Shoulder

Objectives and Preparation:
1. Describe the joints and biomechanical events necessary for full range of abduction of the upper limb. (From lecture material) 2. Review tables 2 (scapular motion) and 3 (glenohumeral motion) which summarize muscle action about the shoulder. 3. Understand the presentation and treatment of common clinical problems in the shoulder including: impingement syndrome, rotator cuff tendinitis and tears, acromioclavicular joint separations, and glenohumeral joint dislocations. (Syllabus reading below)

Applied Anatomy
The following information is provided to highlight some of the anatomy you need to know in regard to shoulder function. Review this material prior to the lecture. The lecture will expand on this material and clarify any confusion you may have concerning this subject matter.

A. Arthrology: Joints of the Shoulder Complex

The colloquial expression shoulder movement usually implies motion at the glenohumeral joint and therefore movement of the humerus. In actuality, glenohumeral motion seldom occurs as an isolated movement but rather occurs in concert with other joints and movement interfaces that together compose the shoulder complex. Because these joints form a biomechanically linked unit, disability or limitation of any part impairs the whole. Even in the absence of specific glenohumeral pathology, significant shoulder dysfunction may occur if there is injury or disease of the pectoral girdle. Full range of humeral motion, particularly abduction and forward flexion, requires a concert of motion at all joints and movement interfaces, in what has been termed scapulohumeral rhythm. The shoulder complex consists of three synovial joints (glenohumeral, sternoclavicular, acromioclavicular) and two movement interfaces (scapulothoracic, humeroacromial). The interfaces are

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not truly synovial joints in that they do not have an intervening synovial membrane and other components of a true joint. 1. Glenohumeral Joint The glenoid fossa of the scapula is a shallow articular surface for the head of the humerus. It provides minimal bony stabilization for the joint compared to the hip joint, which has a deep acetabular cup. The depth of the glenoid is augmented by a fibrocartilaginous labrum or lip, which attaches to the rim of the glenoid. (Figure 1) Since the bony design of the joint is inherently unstable, the strong capsule and ligaments stabilize the

Acromion

Clavicle

Coracoid process Glenoid fossa Glenoid labrum

Scapula

Figure 1

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glenohumeral joint at end-range. There are three main ligaments that are thickenings of the capsule, that help to stabilize the glenohumeral joint: the superior, middle, and inferior glenohumeral ligaments. In the mid-ranges, the capsule and ligaments of the joint are lax so other ways to stabilize the joint are needed. Two mechanisms that are important for joint stability in the mid-ranges are concavity compression and glenohumeral orientation. Concavity compression is where short muscles, particularly the rotator cuff, compress the humeral head into the glenoid cavity. Glenohumeral orientation, also called glenohumeral balance, is where the glenoid cavity is positioned to give the glenohumeral joint the greatest stability.

Figure 2 Acromion Synovial membrane Clavicle Sternoclavicular joint

Humerus

Scapula

Using your skeletal set or the laboratory skeleton, examine the smooth articular surfaces of the glenoid and humerus and note that these areas are covered by articular cartilage (hyaline) in life. It is important to understand that injury to the articular cartilage may result in permanent damage to the joint, since regeneration of articular cartilage is limited. The lubrication of all freely movable joints or synovial joints is a function of the synovial fluid secreted by the synovial membrane (Figure 2). The synovial membrane forms a seal for the joint cavity by attaching to bone at the interface with the peripheral edge of articular cartilage (osteochondral junction). Articular cartilage is never covered by synovial membrane since it is the bearing surface of the joint and the delicate membrane could not withstand such pressure. 53

Acromioclavicular joint & ligamentous capsule

Coracoacromial ligament

trapezoid conoid Coracoclavicular ligament

Joint capsule

Figure 3

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A capsule composed of dense connective tissue attaches to the adjacent bone covers the outside surface of the synovial membrane (Figure 3). In addition certain areas of the capsule are thickened to form capsular ligaments, the glenohumeral ligaments, which are the basis for capsular and ligamentous restraint of the joint. It is important to understand that in all joints, some part of the capsule must be lax to permit movement; a tight capsule will hinder motion. In the glenohumeral joint, the greatest laxity of the capsule is found at the inferior portion of the joint so when the arm is raised overhead, there is additional space for the humeral head. The disadvantage of this arrangement is when a force on the arm results in pressure of the humeral head against the lax capsule, the humeral head can dislocate. Capsular stretching or tears accompany most dislocations. 2. Sternoclavicular joint The sternoclavicular joint is a synovial joint and the only synovial joint attaching the upper limb to the axial skeleton (Figure 2). It contains articular cartilage, a synovial membrane, and an articular fibrocartilaginous disc. Movement of the clavicle occurs at the sternoclavicular joint in concert with the cardinal movements of the pectoral girdle: protraction and retraction, elevation and depression, and rotation of the pectoral girdle during abduction and adduction of the arm. The major stabilizing ligament of the sternoclavicular joint is the costoclavicular ligament. 3. Acromioclavicular joint The AC joint is the articulation between the scapular acromion and the acromial end of the clavicle and is a synovial joint. (Figure 3) The joint has a synovial membrane, a capsule, and articular surfaces covered by cartilage. The very strong coracoclavicular ligament is the most important stabilizing structure of the joint. Motion at the AC joint is important during most movements of the clavicle and scapula. However, forced motion through the joint, (e.g., a fall onto the shoulder), may tear the capsule resulting in shoulder separation or more precisely, acromioclavicular separation. The topic is discussed in detail later in this section. 4. Scapulothoracic interface This articulation is not a joint as there is no defined joint space between bones. It is rather a bursal space lying between the subscapularis muscle and the serratus anterior. A bursa is a closed synovial sac containing synovial fluid and is usually found between tendon and bone as a lubricating mechanism. In this case it allows the scapula to slide on the thoracic musculature when the scapula glides against the thoracic wall. Roughness, such as a snapping sensation may develop in the scapulothoracic interface. 5. Humeroacromial interface The humeroacromial interface is between the humeral head below and the acromion and coracoacromial arch above. Particularly in the setting of rotator cuff disease, the humeral head may rise and articulate with the undersurface of the coracoacromial arch.

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6. Ligaments of the Pectoral Girdle: a. Acromioclavicular ligament (Figure 3) The capsule of the acromioclavicular joint is also called the acromioclavicular ligament. The joint contains an articular disc. b. Coracoacromial ligament (Figure 3) The coracoacromial ligament is a broad flat band of collagenous tissue between the coracoid process and the acromion. It has no defined function per se, since it lies between two fixed points of the scapula. It can restrict shoulder motion during pathologic conditions of the glenohumeral joint. c. Coracoclavicular ligament. (Figure 3) This ligament lies between the coracoid process and the clavicle and consists of two parts: a medial conoid ligament and a lateral trapezoid ligament. These ligaments provide restraint during shoulder motion and can be torn when excessive force is applied to the shoulder. B. Biomechanics: As noted previously, the full range of shoulder movement is achieved only by a concerted movement occurring at all of the joints and interfaces. The motion of abduction is an ideal model to explain shoulder movement. The full range of abduction of the upper limb is 180 degrees. However, the glenohumeral joint is capable of only 120 degrees of motion. The remaining 60 degrees is contributed by movements of the pectoral girdle as follows: For 180 degrees of abduction: 120 degrees occur at the glenohumeral joint: the remaining 60 degrees of motion are accomplished by scapular rotation: (Think of the scapula as a wheel attached to the posterior chest wall. If you rotated it towards the vertebral column, the glenoid would move upward, i.e, upward rotation.) Be sure you understand that glenohumeral motion and scapular rotation are not serial, they occur synchronously. Another way of expressing this is to state that for every 15 degrees of abduction, 10 degrees are glenohumeral motion, and 5 degrees are scapular rotation. How does scapular rotation occur? The serratus anterior and the upper and lower fibers of the trapezius muscles are the prime movers that rotate the scapula upward. Along with the scapule, the clavicle moves as described below. The first 30 degrees of scapular rotation occur synchronously with elevation of the clavicle a corresponding number of degrees. This motion occurs at the sternoclavicular joint. The second 30 degrees of scapular rotation accompany motion at the acromioclavicular joint. This is described as a hinge action of the acromion with the acromial end of the clavicle. However, in order for hinging or AC motion to occur, the clavicle must rotate on its long axis. The necessity of rotation relates to a tethering effect by the coracoclavicular ligament. An upward rotation of the clavicle releases tension in the ligament, and permits hinging at the AC joint. It follows, therefore, that abduction of the arm will be impeded when movement at any of the joints is altered because of disease or trauma. For example, arthritis of the sternoclavicular joint will impede clavicular elevation, thus restricting the first 30 degrees of scapular rotation and resulting in 90 degrees or less of abduction. Fusion or stabilization of the acromioclavicular joint will similarly limit abduction, since the last 30 degrees of scapular rotation are depen56

dent upon AC hinging. Congenital fixation of the scapula (Sprengels shoulder) will obviously prevent scapular rotation at the scapulothoracic joint and result in shoulder disability. Since the major muscles rotating the scapula are the trapezius and serratus anterior, a nerve palsy affecting either the XI cranial nerve or the long thoracic nerve will result in limited abduction of the arm. Would paralysis of any of the following nerves affect shoulder motion? Q 2A musculocutaneous nerve? radial nerve? axillary nerve? suprascapular nerve? C: BURSAE Identify in your atlas the subdeltoid or subacromial bursa and the subscapularis bursa. Which of these communicates with the synovial space of the glenohumeral joint?

CLINICAL CORRELATION Many disease processes affect the shoulder such as inflammatory arthritis, infectious arthritis, and degenerative soft tissue problems such as rotator cuff tears. Traumatic injuries may result in a variety of soft tissue, bony, or joint injuries. In thinking about shoulder problems, it is also useful to think of the types of mechanical impairments that manifest as a result of the disease process or traumatic injury. Mechanical impairments include stiffness, weakness, instability, and roughness. Both the underlying disease process and the mechanical impairment must be treated in order to have a good outcome. For example, if someone has gout which has resulted in glenohumeral stiffness and pain, treatment of the underlying disease process will treat gout but it will not treat stiffness. Conversely, physical therapy and range of motion will treat stiffness but will not treat gout. Two common shoulder problems will be reviewed: rotator cuff problems and traumatic dislocations.
A. Rotator cuff tendinitis/tears/ impingement syndrome The rotator cuff is made up of 4 muscles: the supraspinatus, the infraspinatus, the teres minor, and the subscapularis. Together, they are responsible not only for active movement of the glenohumeral joint, but also for stabilizing the glenohumeral joint in mid-range positions. The blood supply to the supraspinatus tendon is tenuous particularly within 1 cm of its insertion into the greater tuberosity. This limited vascularity is further compromised by overhead use of the arm. Microtears of the supraspinatus tendon occur, with an ensuing inflammatory response producing a clinical condition known as rotator cuff tendinitis. In patients over 35, this inflammation can lead to degenerative macroscopic rotator cuff tears. In younger patients, cuff tears usually occur due to trauma, such as a fall on the outstretched arm. People who use their arms overhead such as swimmers, throwers, tennis players, as well as painters, carpenters, and some musicians are especially subject to cuff tendinitis.

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Cuff tendinitis typically presents as lateral shoulder pain, often felt in the region of the deltoid. The pain is aggravated by overhead use of the arm and lying on the involved side. On physical exam, one often finds tenderness close to the site of the supraspinatus insertion on the humerus. There may be weakness or pain during external rotation against resistance, or while initiating abduction against resistance (the painful arc).When a macroscopic tear is present, the patient may be unable to initiate abduction. When the rotator cuff is dysfunctional, secondary impingement can occur. When the patient tries to initiate abduction, the supraspinatus is unable to hold the humeral head against the glenoid and the deltoid pulls it directly upward against the underside of the acromion. This produces pain, by pinching both the inflamed supraspinatus tendon and the subacromial bursa. Impingement can be reproduced by the examiner flexing the arm while holding the scapula down with the other hand. This is especially effective if the arm being flexed is also held in an internally rotated position thus bringing the greater tuberosity under the acromion. Treatment for cuff tendinitis with or without impingement includes avoiding overhead use of the arm temporarily. One then works on strengthening the rotator cuff, particularly the supraspinatus. In addition, it is important for the muscles stabilizing the scapula to be strengthened so that the cuff has a stable target in which to place the humeral head. Therefore emphasis is placed on strengthening the rhomboids, serratus anterior, trapezius and latissimus muscles, the peri-scapular stabilizers. When a macroscopic rotator cuff tear is suspected, or the patients symptoms do not resolve with strengthening exercise, imaging studies are recommended to assess the degree of cuff damage. Some rotator cuff tears require operative repair. B. Shoulder separation/ dislocation Shoulder separation usually refers to injury to the acromioclavicular joint (AC), whereas shoulder dislocation refers to dislocation of the glenohumeral joint. AC separations typically occur secondary to a fall on the point of the shoulder which depresses the acromion (and the rest of the scapula) relative to the clavicle. A Grade I sprain of this joint consists of injury to the AC ligament only and produces no instability of the joint. This patient will have tenderness only over the AC joint. A Grade II sprain consists of an AC ligament tear in addition to a tear of one of the coracoclavicular (CC) ligaments (conoid and trapezoid). This produces some instability of the clavicle on the acromion and may be associated with a tear of the intra-articular disc in the AC joint. The patient will be tender over the AC joint and over the CC ligaments. The lateral end of the clavicle may be more prominent on the involved side.

Figure 5
58

In a Grade III sprain, both coracoclavicular ligaments are torn in addition to the AC ligament, and the lateral clavicle dislocates superiorly. This patient appears to have a squared off shoulder. When the lateral end of the clavicle dislocates through the trapezius and deltoid musculature, a Grade IV separation has occurred. (Figure 5) Typically only Grade IVs are repaired acutely. Grade Is quickly become asymptomatic and are usually treated with a sling for a few days to one week, followed by shoulder muscle rehabilitation to avoid disuse atrophy. Grade III sprains are treated in a similar fashion although for comforts sake, the sling may be required for a longer period of time, perhaps up to 3 weeks. However, all efforts are made to wean the patient from the sling as soon as possible. Some physicians try to hold the AC joint reduced by using a special sling that pulls up on the arm (and scapula) while pushing down on the clavicle. Patients wearing these types of slings must be followed very closely as skin ulcers develop from the excessive pressure on the clavicle. When the AC joint is not reduced, the patient is left with a bump on the top of the shoulder. For some this is a cosmetic consideration, however, this injury will usually not produce pain in the long term. The grade II injuries are the most likely to produce long term problems. This is because the joint is not totally separated but subluxates up and down, irritating the intra-articular disc. These patients have little cosmetic deformity but often have pain. The pain is aggravated by lying on the involved side or using the arm across the chest. They often have tenderness over the AC joint, and pain during adduction of the arm. If symptoms persist despite strengthening of the muscles that suspend the scapula, the AC joint can be internally fixed, the ligaments reconstructed, or the distal clavicle excised. The most common type of glenohumeral dislocation is the anterior/inferior dislocation which typically occurs when the involved arm is abducted and externally rotated and the humeral head is levered anteriorly where it remains. In patients who are innately lax, the humerus can dislocate without causing much secondary injury. On the other hand, in most patients suffering from an acute glenohumeral dislocation, the anterior capsule and glenohumeral ligaments that make up the capsule are torn; in many, the glenoid labrum is torn as well (Bankart lesion). In some patients, a defect is also created in the back of the humeral head (Hill-Sachs lesion) where it has been levered on the glenoid rim. The brachial plexus also can be stretched during dislocation. Most commonly the axillary nerve is involved in this type of injury. The patient with an anteriorly dislocated shoulder appears to have a square shoulder. S/he will usually be supporting the injured arm with the other hand and will not allow much if any range of motion, resisting in particular internal rotation. The examiner will note a space underneath the acromion where the humeral head should be, and a mass (the humeral head) anteriorly. One should be sure to check for sensation in the distribution of the axillary, musculocutaneous, median, radial, and ulnar nerves as well as checking the radial and ulnar pulses prior to instituting treatment. There are many techniques for relocating the humeral head, some less traumatic than others. In a hospital setting, the shoulder is x-rayed to rule out a humeral head fracture. Then IV sedation is administered, and the shoulder is reduced with slow, steady pressure. In young patients, the incidence of redislocation is high... up to 80% in military populations. In older patients, stiffness occurs after a dislocation and recurrence is less likely than is seen in younger populations. But, anyone who has had a prior shoulder dislocation is at an increased risk of re-dislocation. Because of the high recurrence rates in young populations, and with the advent of the arthroscope, many orthopaedists now recommend initial arthroscopic evaluation and if needed, stabilization procedures such as arthroscopic repair of the torn glenoid labrum. For nonoperative treatment of dislocations, often occurring in concert with a labral tear, the patients arm is now recommended to be held in neutral to slight external rotation in a sling for three weeks in hopes that the anterior capsular tear and labral detachment will both heal. (Tension of the capsule 59

on the torn labrum theoretically pulls the labrum back to the edge of the glenoid rim when the shoulder is in this position) One then proceeds with shoulder muscle rehabilitation. The treatment of recurrent dislocations depends on many factors including the age of the patient, inherent ligamentous laxity, direction of instability, and the structures damaged. Bilateral shoulder instability is often atraumatic in origin, occurs in multiple directions, and responds best to a rehabilitation program without a surgical intervention. ANSWER TO APPLIED ANATOMY QUESTION 2A Injury to the axillary nerve impairs the deltoid and prevents abduction of the shoulder. Injury to the suprascapular nerve will result in significant deficits of abduction (supraspinatus) and external rotation of the humeral head (infraspinatus). Injury to the musculocutaneous nerve does not significantly affect function of the shoulder joint. One should note, however, that some stability of the head of the humerus is provided by the course of the tendon of the long head of the biceps. That is, the tendons position prevents upper dislocation of the humeral head during abduction. In cases of the loss of this tendon, either due to injury to the musculocutaneous nerve or avulsion of the tendon, there may be impingement of the humeral head on the acromion. In the case of an injury to the radial nerve, shoulder function is not primarily affected.

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Specific inStructional MethodS for liVing anatoMy

The Concept
The Living Anatomy small groups will give you the opportunity to reinforce and apply what you have learned in lecture, gross lab and reading. In coordination with ICM II, these living anatomy sessions are designed to teach surface anatomy of many of the structures revealed during dissection, whose function and clinical significance is revealed during the clinical correlations. They may also provide an introduction to basic musculoskeletal exam techniques. Though each Living Anatomy session precedes one of the two related gross labs, preparation for the gross lab that follows is key for efficient work in these living anatomy sessions. Having the living anatomy session before gross lab will also hopefully raise questions that may be answered in the dissection. Once you can locate the anatomy on a living subject, you are ready to learn additional physical exam tests (both here and in ICM II). We want you to think about anatomy in a clinical context.

The Game Plan

We will have four sessions for living anatomy, two for the upper extremity and two for the lower extremity. During each session you will be given 2-3 presenting complaints and a differential diagnosis for each. We wont give you much information regarding age, gender, or a great deal of history as having these would narrow the possibilities. We want you to be thinking anatomically, and be able to identify all pertinent structures that might help you differentiate one diagnosis from another. Because of the vagueness of the clinical scenarios, more than one answer/diagnosis may be appropriate. Try to determine what additional information might be useful in support of each of the diagnoses listed on the differential. On your partner, draw each of the structures listed. You only need to draw the structure on one side (i.e. right or left, not both) and you should take turns. If you think some of your drawings will be superimposed on others, feel free to draw some on the right extremity and others on the left. In some cases, we have asked you to indicate a structure with an x or an o rather than outlining the entire structure. Your tutor will check to see if you found everything and will help you if you have problems. You may or may not have time to discuss the differential and other useful clinical tests, depending on how well prepared your group is and therefore, how quickly you find and demonstrate the landmarks.

Preparation
Please come prepared to draw and to be drawn on. In order to outline a structure on your partner, you must know approximately where it is and be able to palpate it. Bring washable color markers and wear clothing (tank top, shorts, bathing suit, or underwear) that reveals the structures you are assigned to find. Also bring a reflex hammer. Your cooperation and participation in these classes is essential so that everyone can learn.

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About Deep Tendon Reflexes (DTRs)

The monosynaptic muscle stretch reflex can be tested in almost any muscle that can be stretched rapidly. It is used to test the integrity and symmetry of peripheral nerves, nerve roots and lower motor neurons.The best method for obtaining a rapid brief stretch is tapping the tendon with a hammer. To do this the muscle must be in a slightly stretched position but fully relaxed. Briskly tap the tendon and look and feel for the desired contraction. If no response is elicited, attempt to augment the response by slightly increasing the muscle tone. This can be most consistently achieved by vigorous contraction of distant muscle groups (i.e., clamping the jaws to augment UE reflexes and clenching the fists to augment LE reflexes). Reflexes are somewhat difficult to quantify and measure but in clinical practice the attempt should be made to do so for diagnosis and recording for future comparison. The usual grading scale is from 0-4 with grade 0no response; grade 1minimal response; grade 2mid-range normal response; grade 3slightly hyperactive response; and grade 4hyperactive response with clonus. Many people will have grade 1 or grade 3 responses depending on their state of relaxation, drug use (e.g. alcohol), or nervousness. The best evaluation, therefore, is made by comparing sides or upper and lower extremities for symmetrical responses.

Muscle Strength Grading System

Grade 0 Grade 1 Complete paralysis; no visible or palpable contraction. (Trace strength) Muscle contraction can be seen or palpated but strength is insufficient to produce motion, even when gravity is eliminated. (Poor strength) The muscle can move the joint it crosses through a full range of motion only if the part is positioned so that the force of gravity is eliminated. (Fair strength) The muscle can move the joint it crosses through a full range of motion against gravity but not against any additional resistance. (Good strength) The muscle can move the joint it crosses through a full range of motion against gravity and against moderate resistance applied by the examiner. (Normal strength) The muscle can move the joint it crosses through a full range of motion against gravity and against full resistance applied by the examiner.

Grade 2

Grade 3

Grade 4

Grade 5

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nerVe Supply of the upper and lower liMB

I. Nerve supply of the upper and lower limb a. Spinal cord and spinal nerves organization: dermatomes and myotomes b. Peripheral organization: peripheral nerves and branches c. Clinical relevance: sensory or motor changes may come from the spinal cord, spinal nerves, or peripheral nerves Movement a. Spinal centers and myotomes i. Movements are organized as follows: 1. Each movement is typically represented by two segments 2. For a particular joint, agonists and antagonists (e.g., flexion and extension) are located in spinal segments that are close together a. For most movements, agonists and antagonists are located in contiguous segments. For example, flexors at the shoulder are located at C5,6 while extensors are in the next two continguous segments at C7,8. b. Exceptions to this rule are found in the more distal upper limb (wrist and hand). b. Peripheral nerves i. Innervate muscles found in compartments ii.Examples: 1. The radial nerve innervates the posterior compartment of the arm (triceps) which controls elbow extension. 2. The musculocutaneous nerve innervates the anterior compartment of the arm (biceps and brachialis) which controls elbow flexion c. Clinical relevance i. If a patient presents with weakness, how do you know if the problem is at a spinal cord, myotome, or peripheral nerve level? Sensation a. Sensory problems are typically caused by problems at the spinal nerve (root) level (dermatome), the peripheral nerve, or by generalized problems that affect peripheral nerves (peripheral neuropathy). b. Clinical relevance: i. The pattern of sensory loss will point to the anatomical site of injury or disease. 1. Spinal nerve (root) level (dermatome) a. Pattern: the area innervated by the spinal nerve is affected typically, this will not correspond to a specific peripheral nerve i. Example: numbness of the medial hand may indicate a C8 nerve root compression. However, how do you know that it is not from ulnar nerve compression? Ulnar nerve compression causes numbness of the medial hand, BUT THE SENSORY CHANGES DO NOT CROSS THE WRIST INTO THE FOREARM. The C8 dermatome affects the medial hand and the medial forearm. 2. Peripheral nerve entrapment

II.

III.

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a. Pattern: the area innervated by the peripheral nerve is the only area that will demonstrate sensory changes. i. Example: carpal tunnel syndrome. 3. Generalized peripheral neuropathy a. Pattern: stocking (lower limb) or glove (upper limb) distribution i. As the disease process progresses, the nerve is affected more and more proximally (the area of sensory loss moves up the lower and upper limb ii.Example: diabetic neuropathy

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liVing anatoMy /clinical correlation cerVical Spine and upper eXtreMity

Wear proper clothes, everyone needs to be drawn on, attendance required Objective:
Be able to find, outline, and demonstrate key musculoskeletal landmarks. Preparation for Class: 1. Review the pertinent anatomy. 2. Bring washable color markers. 3. Wear clothing that allows visualization of the structures you are assigned to find. 4. Bring a reflex hammer. 5. Consider what findings you might expect for each of the diagnoses listed. 6. What additional information would support the possible diagnoses below? Draw the outline of the following on your partner: the clavicle, the coracoid process the lateral edge of the acromion the acromioclavicular joint (AC joint) the sternoclavicular joint (SC joint) the long head of the biceps tendon the spine of the scapula ( the spine of the scapula generally lines up with which vertebral level?) the inferior angle of the scapula ( the inferior angle of the scapula generally lines up with which vertebral level?) C-7 spinous process (vertebra prominens) dermatomes for C-5, C-6, C-7 (using the maps in the syllabus and not an atlas) the sensory distribution of the axillary and musculocutaneous nerves. Draw an x where you would stick a needle if you wanted to inject the AC joint. Draw an x where you would stick a needle if you wanted to inject the subacromial bursa. Demonstrate deep tendon reflexes of the biceps, brachioradialis, and triceps. Which nerve root (segmental level) is tested by each?

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Case 1:
After a fall, your patient complains of neck and shoulder pain with shooting pains down the arm. Exam reveals painful neck movement that is decreased in all planes. Left is decreased more than the right. Possible causes of the problem (differential diagnosis) include: cervical spine arthritis herniated disk and radiculopathy (nerve root compression) rotator cuff tear injury to upper trunk of the brachial plexus

Questions:
A. How well do each of the above diagnoses match the history? B. What additional information would support or reject each possible diagnosis? C. What motions can be tested for the neck and shoulder? If you decide that the history is most consistent with a cervical spine problem, and find numbness on exam on the lateral arm, which dermatome would be involved? Which nerve root might be pinched? Where would the cervical prolbem most likely originate?

Case 2:
Your patient complains of shoulder pain and inability to lift the involved arm overhead. No trauma preceded this problem. Possible causes of the problem (differential diagnosis) include: rotator cuff tear bicipital tendinitis adhesive capsulitis (frozen shoulder) glenohumeral arthritis shoulder instability

Question:
A. What additional information/findings would support or reject each of the five diagnoses? B. If additional examination revealed crepitus with passive and active motion of the shoulder, and a much greater range of passive motion than active, what would this suggest? C. How would you assess muscle strength of each of the rotator cuff muscles and the biceps? D. What position of the shoulder would produce apprehension for a patient with anterior instability? for a patient with posterior instability?

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laBoratory diSSection
BE EFFICIENT DISSECT SAFELY DONT DAWDLE Goals: 1. Identify and reflect the trapezius and latissimus dorsi to reveal the rhomboids. 2. Dissect the supraspinatus, infraspinatus, teres minor, and three heads of the triceps to reveal the radial nerve posteriorly. 3. See the intervals and spaces about the tricipes and teres minor including the nerves and vessels passing through each. 4. Identify the radial, median, ulnar and musculcutaneous nerves as they exit the axilla and enter the arm. 5. Detach the deltoid to find the axillary nerve; follow the long head of the biceps tendon into the glenohumeral joint and dislocate the shoulder.

I. Muscles of the Back:

A. Superficial Back Muscles Incise the skin vertically in the midline of the back from C7 to the sacrum. Make transverse incisions extending from C7 to the point of each shoulder. From the inferior point of your midline incision, incise the skin laterally and superiorly following the curve of the iliac crest to the midaxillary line. Reflect both skin flaps to expose the superficial muscles, being careful near the midline to avoid lifting the muscles which are quite thin in this area. (G 6.25) Clean the surfaces of the trapezius and latissimus dorsi of all fascia. On the trapezius over the posterior scapula, you will encounter considerable fascia which tends to slow you down. There are no important structures between the skin and the trapezius. Cut down to the surface of the trapezius to locate your plane of dissection and then you should be able to reflect the fascia with some speed. Reflection of trapezius: Incise the trapezius approximately one inch from the midline in a vertical fashion along the entire length of the muscle. Reflect it laterally leaving it attached to the spine of the scapula. Identify its innervation by the accessory nerve as it enters the deep surface of the superior part of the muscle. Reflection of the trapezius exposes three other superficial muscles, the levator scapulae and the rhomboid major and minor. Clean the area sufficiently to identify each muscle. You will probably not see their nerves as they are small and difficult to locate. Incise the rhomboids vertically near the midline and mobilize the scapula. This will allow you to see the origin of the serratus anterior and one of the intermediate muscles the serratus posterior superior. It is not necessary to divide the rhomboids on both sides. Reflection of latissimus dorsi: Incise the latissimus along its lumbar attachment and reflect it laterally. Identify the serratus posterior inferior. Review the anatomy of the spinal nerve and its division into anterior and posterior primary rami. How is this related to the brachial plexus and the supply of the deep back muscles? What is the distribution of primary rami; distinguish rami from spinal roots. What type of nerve fibers are 73

contained in the spinal roots? Following these considerations, what type of clinical deficit would you expect from an injury to the dorsal roots? Ventral roots? Anterior or posterior primary rami? Any anatomy text can be used as a resource for this information.

II. Muscles of Posterior Scapular Region:

While the cadaver is prone, there are several muscles attaching to the scapula which should be identified. Four of these muscles form a group known as the Rotator Cuff Group or Musculo Tendinous Cuff Muscles; these include the supraspinatus, infraspinatus, and teres minor on the posterior aspect of the scapula and subscapularis on the anterior aspect. Review insertions of these muscles. Identify the supraspinatus muscle and incise the muscle vertically at the base of the coracoid process. Reflect the muscle and identify the suprascapular nerve on the posterior aspect of the scapula. Where does the suprascapular nerve arise from the brachial plexus? Trace the suprascapular nerve and artery to the superior border of the scapula. What is the course of the nerve and artery in relationship to the suprascapular notch and transverse scapular ligament? Do you think the nerve could be pinched at this point? If so, describe the clinical signs and symptoms of the patient with this problem. Divide the infraspinatus muscle vertically, medial to the acromion and reflect the muscle. Identify the terminal part of the suprascapular nerve.

III. Arm Muscles:

From previous dissection most of the skin in the shoulder region should be mobilized. If, not reflect the shoulder skin and all skin of the arm inferiorly to two inches below the elbow joint. This is best done by making an incision from the point of the shoulder inferiorly along the posterior aspect of the arm. Be careful to preserve the subcutaneous veins and nerves. A. Posterior Muscles of the Arm: Open the fascia surrounding the triceps and clean the long and lateral heads of the triceps. Much of this fascia is loose and can be stripped with your finger. Note the origin of each of the three heads of the triceps. Follow the common muscle mass noting its insertion on the olecranon process of the ulna. Review the triangular and quadrangular spaces as observed from the posterior aspect of the scapula. (G6.30) Note another triangular region termed the triangular interval bounded by teres major and the long and lateral head of triceps. It contains the radial nerve and the deep brachial artery. Follow the radial nerve into the spiral groove. In order to visualize more of the radial nerve, use a scalpel to separate the long and lateral heads of the triceps where they fuse together. What are some of the clinical consequences of the relationship of the radial nerve to the humerus? (Q2.1)

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B. Anterior Muscles of the Arm: In order to continue with the anterior muscles it will be necessary to turn the cadaver back to the supine position. Strip away the fascia overlying the anterior compartment muscles. 1. Identify the coracobrachialis, biceps (long and short heads) and the brachialis. Note their origins and insertions. 2. Note the coracobrachialis is split by the course of the musculocutaneous nerve. Clean the fascia from the biceps and explore the plane between the biceps and brachialis. Follow the continuation of the musculocutaneous nerve. Where does it leave this plane, distally? (Q2.2) IV. Vasculature of Axilla and Arm: Locate the beginning of the brachial artery in the axillary fascia. Clean the fascia, and follow the vessel and the adjacent median nerve inferiorly into the cubital fossa. Periodically you should review the subclavian, axillary and brachial arteries, naming their boundaries and branches in order to understand the continuity of the vascular pattern. Describe the anastomoses of vessels from the subclavian and axillary arteries about the scapula. What is the collateral blood flow to the arm if 1) the axillary artery is occluded at the level of the teres major; or 2) the subclavian artery is occluded at the lateral border of the first rib? (Q2.3) V. Dislocation of the shoulder Identify the two heads of the biceps tendon. Follow the long head back to its origin on the glenoid. Open the joint to see the glenoid labrum, the glenoid, and the humeral head. Release the long head of the biceps and the anterior capsule to reveal the full articular surfaces of the glenohumeral joint. Were the thickenings of the capsule, the glenohumeral ligaments, obvious? ANSWERS TO ANATOMY QUESTIONS 2.1 The course of the radial nerve in the spiral groove of the humerus results primarily in compromise of the nerve either by compression against the bone or direct trauma to the nerve when the humerus is fractured. Note that in most cases the fibers of the radial nerve supply the triceps rather high on the arm so that injury to the radial nerve at midshaft does not normally affect the function of the triceps. The musculocutaneous nerve leaves the anterior compartment of the arm by piercing the deep fascia overlying the cubital fossa. This occurs at the lateral edge of the biceps tendon in the midportion of the fossa. The musculocutaneous nerve as well as the medial cutaneous nerve of the forearm lie in the superficial fascia of the forearm adjacent to the superficial veins of the forearm. During IV procedures, it is possible to contact one of these nerves with the needle, causing the patient to experience the feeling of an electric shock shooting down his or her forearm. The collateral blood flow for the axillary artery distal to the teres major muscle is minimal. The branches of the axillary artery from its first, second, and third parts, particularly the subscapular artery, have anastomoses with the vessels of the chest wall and about the scapula. These are abundant connections for collateral flow. At the level of the subclavian artery, all of those branches from its origin to the lateral border of the first rib may contribute blood in a retrograde flow in the case where the proximal part of the subclavian artery is narrowed. This may even occur to the detriment of the individual such as in the case of Subclavian Steal Syndrome. In this disease, the subclavian artery is narrowed at its origin from the aortic arch. The low pressure resulting in the downstream portion of the subclavian artery will actually siphon blood from

2.2

2.3

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arthritiS: an oVerView
Objectives:
1. Develop an organizational framework in which to place patients presenting with joint pain. 2. Describe and contrast the general clinical, laboratory, and radiographic features of Osteoarthritis (Degenerative Joint Disease), Rheumatoid Arthritis, Crystalline Arthritis, Infectious Arthritis, and the Spondyloarthropathies.

Preparation:
Arthritis: An Overview (in syllabus) The term arthritis describes a large family of disorders that occur in synovial joints. One must first understand that these joints consist of bones covered in articular hyaline cartilage surrounded by a synovial lining which in turn is covered by a fibrous capsule. Some joints have intra-articular ligaments (knee), and fibrocartilaginous structures (labrum in the hip or shoulder, menisci in the knee). All have thickenings in the capsule called capsular ligaments. The synovial lining (also known as synovium) is responsible for the production of joint fluid. Normally the amount of fluid produced is just enough to provide a thin lubricating layer between the articular surfaces of the bones. However the synovium will increase its production of fluid rather non-specifically in response to infection, inflammation, crystals in the joint, increased blood flow near the joint, increased friction in the joint, and sometimes for reasons we dont understand. An increased amount of joint fluid is called an effusion. Synovial fluid is normally viscous, transparent and straw colored. It contains less than 2,000 white blood cells, the majority of which are mononuclear. When the fluid contains more than 100,000 white cells, the joint is infected. Similarly when greater than 95% of the white cells are polymorphonuclear, the joint is infected. Cell counts between 50,000 and 100,000 are problematic as they may represent inflammation or infection. One must take into account the clinical situation as well as the white cell count and differential cell count. Inflammatory fluid is translucent or opaque and also tends to be more watery than normal or non-inflammatory fluid, but this finding is not particularly reliable. Excessively viscous fluid is found in effusions from patients with systemic lupus erythematosus or hypothyroidism.

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Osteoarthritis
Although the ending itis implies inflammation, the most prevalent form of arthritis, osteoarthritis, is distinguished by its lack of inflammatory cells in the synovium and synovial fluid and is also called degenerative joint disease (DJD) or osteoarthrosis (OA). OA is associated with aging and with abnormalities in the joint surfaces caused by previous trauma. OA most commonly occurs in a weight bearing joint and in distal finger joints. It generally produces an aching type of pain that is better after rest and gets worse as the day goes on. When the joint surface is examined microscopically, one sees fibrillation, fissures, and chondrocyte clones in the articular cartilage as well as debris in the joint cavity. On a biochemical level one finds a decrease in glycosaminoglycan content as well as increased water content in the cartilage. Functionally the articular cartilage loses its weight-bearing ability and the joint loses its range of motion. Radiographically these changes are manifested as narrowing of the"joint space", sclerosis of subchondral bone, osteophyte formation, and subchondral cysts. Treatment is symptomatic using acetaminophen or non-steroidal-anti-inflammatory drugs. Two new treatment approaches include oral glucosamine and intra-articular hyaluronan. Although data are limited at this time, glucosamine theoretically stimulates chondrocyte production of collagen and proteoglycans. Hyaluronan is thought to inhibit proteases in the joint fluid thereby decreasing matrix catabolism. Hyaluronan may also stimulate synovial cells to produce hyaluronate. When the patient has symptoms that are not relieved medically, surgery may be helpful.

Rheumatoid Arthritis
Rheumatoid Arthritis is an inflammatory, autoimmune arthritis of uncertain etiology. Changes in the HLA-DRB1gene are thought to produce a genetic predisposition to the disease. It is characterized by the development of a profuse and erosive synovitis that destroys joints. Multiple organ systems may be affected by this autoimmune disease. Early disease is thought to produce injury to synovial microvasculature, resulting in larger regions of synovial tissue injury and exacerbation of the inflammatory response. Though T-cells may initiate the immune actions in the rheumatoid joint, neutrophil activation results in the release of multiple enzymatic factors and proteases which begin the degradation of the joint surfaces and the surrounding ligaments and tendons. The synovium becomes hypertrophic and edematous or engorged, with numerous villi protruding into the joint. Activated fibroblasts make up the majority of cells present within the synovium. These fibroblasts form an aggressive granulation tissue known as pannus which erodes the surrounding cartilage surfaces and subchondral bone within joints. As the joint surfaces are eroded irregularly, the subchondral bone is eroded by pannus and resorbed by osteoclasts, and the surrounding soft tissues are attenuated by the erosive and infiltrative nature of the disease process, pain and progressive disability typically result. Clinical features of the disease include persistent poylarthritis, symmetric involvement, morning stiffness, painful joint motion, and muscle wasting. Later, the patient may have subcutaneous nodules, joint deformity, and the involvement of additional systems as listed below. Laboratory abnormalities include: positive rheumatoid factor in the serum (autoantibody to IgG) in about 80% of adult patients,

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anemia of chronic disease, elevated erythrocyte sedimentation rate (ESR), and positive tests for antinuclear antibody (ANA) in about 25% of patients. Synovial fluid is inflammatory having from 2,000 to 50,000 white cells per cubic millimeter, of which greater than 25% are neutrophils. In contrast to osteoarthritis, rheumatoid joints display symmetric marginal erosions, subchondral or periarticular osteopenia, soft tissue swelling, and in severe disease, subluxation or dislocation of joints on radiographs. Typical regions and joints involved include the cervical spine, shoulders, elbow, hand, hip, knee, foot and ankle. Soft tissue involvement about the c-spine can lead to life-threatening instability, placing pressure on the spinal cord. Symmetric involvement of joints is commonly seen. Skin involvement typically includes rheumatoid nodules, soft tissue swellings that are subcutaneous and arise along tendon sheaths, in bursae, and about bony prominences. Ocular manifestations are common, and may include forms of conjunctivitis or scleritis. In children with Juvenile Rheumatoid Arthritis, untreated iridiocyclitis may result in blindness. Respiratory, cardiac, renal, gastrointestinal, and neurologic system involvement are also commonly seen late in disease. Current treatment principles include relief of pain by reduction or suppression of inflammation, and preservation of muscle and joint function. These principles are usually carried out using a combination of drug therapy, physical therapy, and surgery when necessary. Treatment focuses on reducing synovitic symptoms, which in turn may reduce the severity of resulting structural damage. Nonsteroidal anti-inflammatory drugs are the mainstay of initial treatment of the synovitis of RA. Corticosteroids and disease-modifying antirheumatic drugs (DMARDs) are also commonly used. DMARDs have included gold, methotrexate, hydroxychloroquine, and azothioprine. Etanercept (Enbrel) and infliximab (Remicade) are new drugs that block tumor necrosis factor.

Septic Arthritis
This group of arthritic disorders includes arthritis caused by bacteria, viruses, spirochetes, mycobacteria, and fungi. As a group, they tend to be mono- or pauciarticular with the exception of arthritis due to parvovirus which is usually polyarticular and resembles rheumatoid arthritis. Acute bacterial arthritis, septic or pyogenic arthritis, is a significant source of morbidity, particularly in the growing child. Not only may cartilage be destroyed by release of harmful enzymes, but increased pressure from the inflammatory response can lead to occlusion of local blood vessels and complications such as avascular necrosis of the proximal femur. The potential sources of infectious agents are multiple. Bacteria may be inoculated through trauma, iatrogenically introduced from surgery, spread from contiguous osteomyelitis, or hematogenously spread from pulmonary, cardiac, GI or GU sources. Pathogens include aerobes, polymicrobial or anaerobes or mycobacteria. Staphylococcus aureus is the most common organism in adults and children. Common sites of infection are the larger joints, particularly the hip, knee, elbow, shoulder, ankle, and wrist. Joints with large capsules that extend to the metaphysis on either side of the joint (hip, ankle, elbow) allow for eruption of pus from metaphyseal osteomyelitis into the joint. Susceptibility to pyogenic arthritis is increased by co-morbidities, particularly immune compromised states, such as prematurity, diabetes, HIV disease, chronic liver failure or renal disease, rheumatoid arthritis and conditions treated with sytemic steroids. Newborns are especially susceptible, often presenting with unimpressive signs and symptoms despite severe involvement. Septic arthritis of the hip is more common in children than adults. The elderly are also at a greater risk of a pyogenic arthritis, particularly at those joints where they may have undergone a joint replacement surgery. Any prosthetic implant increases the risk of infection. IV drug users are at significant risk of developing endocarditis and bacterial vegetations on heart valves. These vegetations may lead to septic emboli and thrombi, increasing the risk of pyogenic arthritis as well.

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The diagnosis requires a careful history and physical. In the child, a history of fever, refusal to walk or move the affected limb (called pseudoparalysis), generalized irritability, loss of appetite and an inconsolable disposition are all important symptoms of disease. On exam, resistance to passive motion of the affected limb, even when performed by a parent well coached by the physician, without involvement of joints above and below the suspected infected joint is a key finding. Tenderness over the joints is commonly seen. If it is the hip joint in question, it is often held flexed and externally rotated (why would that be?) Elevated temperature at the time of the exam, and an elevated white blood count and erythrocyte sedimentation rate are also helpful clues. Kocher has reported a greater than 90% incidence of septic arthritis of the hip in children who, upon presentation, had an irritable hip, were febrile (>38.5), had an elevated white blood cell count and erythrocyte sedimentation rate, and refused to ambulate. The C-reactive protein is an even more sensitive measure of acute phase reactants than ESR, often becoming elevated days before elevations in ESR are seen. A CRP should be obtained with blood draws in all suspected infectious conditions. Blood cultures should also be drawn routinely in the case of suspected infection. Other diagnostic tools include radiographs of the affected joint, including joints above and below as well. Widening of joint spaces suggests fluid collection and possible pus under pressure. Ultrasound is a very useful tool for imaging joints. It is non-invasive and is quite sensitive at detecting fluid collections. CT scans are best reserved for suspected bony involvement, and MRI scans are difficult to obtain on short notice, are unnecessarily long and quite expensive, typically requiring sedation for the younger child. Bone scans are useful adjunct studies if no fluid is suspected at the joint in question, but a question of bony involvement remains. The treatment for suspected septic arthritis is aspiration of the joint(s) in question with open or arthroscopic washout for confirmed purulent collections of fluid. Determining the number of white cells in the synovial fluid and establishing cultures for aerobes, anaerobes, fungi and acid fast bacteria are key to making the diagnosis. Fluid from most septic joints will typically have white blood cell counts of greater than 50,000, and greater than 90% of cells will be polymorphonuclear leukocyctes. Other factors, such as the presence or absence of bacteria on gram stain, and the glucose and protein levels of the fluid are less useful to making a diagnosis from a joint aspiration. Negative gram stain may be followed by growth of organisms on culture, though growth occurs in only about 50% of cases. When a septic arthritis is suspected but the initial arthrocentesis (withdrawal of fluid from the joint) is not diagnostic, open or arthroscopic drainage or decompression and lavage of the joint is essential. Antibiotic therapy should not be initiated until specimens are obtained from the arthrocentesis. Treating suspected joint infections with oral or intravenous antibiotics without arthrocentesis or decompression of the joint can lead to a delay in diagnoses and selection for resistant organisms. Cultures are less likely to grow following pre-aspiration antibiotics making tailored antibiotic therapy impossible. Serial aspirations have been documented as a means to treat septic arthritis of the knees in goats. Following each aspiration with immediate flushing of the joint with sterile saline may decrease the infectious load adequately enough to avoid a surgical procedure, however aspirations and irrigations with large bore needles are uncomfortable and difficult to perform outside of the operating room. They are perhaps only appropriate for those patients who have contraindications to surgical irrigation and debridement of the infected joints. Gonococcal arthritis due to Neisseria gonorrhea may affect the knees, elbows and ankles, as well as the small joints of the hand and wrist, and the sternoclavicular joints. This is a sexually transmitted disease, first presenting with fever, shakes, chills, rashes and bullous eruptions, polyarthralgias and tenosynovitis. Associated genitourinary symptoms such as urethritis or cervicitis may or may not be present. The initial presentation evolves into an arthritis of one or few joints. Treatment with high 80

dose antibiotics after a joint aspiration is adequate treatment in this form of arthritis. For persistent re-accumulations of fluid, serial aspirations may be performed. Unlike infections with other bacterial organisms, surgical debridement of the joint is not routinely necessary with gonococcal arthritis. Viral Arthritis. The hepatitis virus and rubella virus (or vaccine) may cause an immune-complex mediated arthritis which is usually self-limited and not destructive. This arthritis is usually pauciarticular and migratory. Parvovirus, on the other hand, produces a polyarticular arthritis very similar to rheumatoid arthritis in up to 10% of children with Fifth disease (known for a slapped cheeks appearance) and in almost 80% of infected adults. The opportunity for viral isolation or acute-phase serology is often missed because patients typically present late in the disease course and because viral arthritis is not often in the differential diagnosis. Lyme Disease. Lyme disease is caused by Borrelia burgdorferi which is a tick-borne spirochete. Classically, it begins with erythema migrans, then progresses to disseminated disease with neurologic and cardiac manifestations, and only in its late stages presents with intermittent migratory polyarthritis in about 50% of patients who have not been treated earlier in the disease process. 10% of patients may develop chronic monoarticular arthritis. In many patients, arthritis is the only manifestation of the disease. Serologic testing may confirm the diagnosis. Antibiotic treatment often does not affect the arthritis which is treated using corticosteroid injections, hydroxychloroquine, or synovectomy. Mycobacterial and Fungal Arthritis. Joints are infrequently affected by these organisms except in immunosuppressed individuals. Monoarticular arthritis, especially in hips and knees, is most common and insidious in its onset. The joint is usually only mildly inflamed and destruction, if any, occurs slowly. Treatment with appropriate antibiotics is usually sufficient. Occasionally, synovectomy may be necessary.

Mycobacterial infection of bone. Extra-pulmonary tubercular infection most commonly occurs in the
spine, and is known as Potts disease. TB abscesses destroy bone and disc spaces, potentially leading to psoas abscesses that may drain into the hip joint or through the skin in the groin region. Abscesses may also form fistulas that drain throught the skin of the back. Collapse of the spine may lead to gross deformity and paralysis. TB is the number two infectious disease killer world-wide, after HIV.

Crystalline Arthritis
The most common type of crystals are urate, calcium pyrophosphate, and apatite. The arthritis is an inflammatory response to crystals in the joint. Urate crystals produce various chemotactic factors that attract neutrophils. They also stimulate the release of numerous inflammatory mediators from both the neutrophils and from synovial cells. Clinically this is represented by an acutely painful swollen joint which is often erythematous, resembling cellulitis. Uric acid crystals may also accumulate slowly over time in soft tissues, forming a nodule called a tophus. An attack of crystalline arthritis is often precipitated by stress such as trauma or surgery. In order to make a definitive diagnosis of crystalline arthritis, urate or pyrophosphate crystals must be found in the joint fluid when it is examined microscopically using polarizing lenses. Radiographs reveal sharply marginated periarticular erosions (mouse nibbles).

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In gout (monosodium urate crystalline arthritis), the initial attack is monoarticular and involves the first metatarsal phalangeal joint in over 50% of patients. Over 90% will ultimately have involvement of this joint. Other common sites of involvement include the midfoot, ankles, and knees. The upper extremity joints are less commonly affected. In pseudogout (calcium pyrophosphate dihydrate crystalline arthritis) the knees are involved in more than 50% of cases, though any joint may be affected, including the first MTP joint. Treatment of acute crystalline arthritis involves decreasing the inflammatory process using indomethacin or other nonsteroidal anti-inflammatory agents. Sometimes colchicine is added to inhibit the motility and phagocytosis of the neutrophils. In the case of gout, one may wish to decrease the serum urate levels using either a uricosuric drug or a drug which inhibits the production of urate. Such agents, however, are indicated only for the control of chronic hyperuricemia and never for the treatment of acute gouty arthritis.

Spondyloarthropathies
The spondyloarthropathies are a collection of arthritic disorders that tend to present with asymmetrical arthritis, involvement of the sacroiliac joints and spine, and enthesitis (inflammation where a tendon attaches to a bone). They also have in common the absence of rheumatoid factor in the serum (hence the term seronegative), and an association with HLA-B27. Ankylosing spondylitis: Clinical features include the insidious onset of low back pain, usually before 40 years of age, associated with morning stiffness, and improving with exercise. Although sacroilitis is virtually always seen, the amount of spinal arthritis varies. Peripheral arthritis occurs in approximately 1/3 of patients. Eye disease and cardiac disease are also seen. Approximately 90% of patients are HLA-B27 positive. Pathologically there is inflammation where ligaments attach to bone (enthesitis) and cartilaginous erosions secondary to subchondral granulation tissue. Radiographs late in the disease reveal a bamboo spine due to ossification of the annulus fibrosus and intervertebral ligaments, and ultimately obliteration of the sacroiliac joints. Reiter's Syndrome: Classic features include urethritis, arthritis, conjunctivitis or iritis often occurring as a "reaction" in susceptible individuals (HLA-B27 positive) to Chlamydial urethritis or dysentery caused by Yersinia, Salmonella, or Shigella. Other features may include a skin rash (keratoderma blenorrhagica), balanitis, nail changes, mucous membrane lesions, and aortic insufficiency. Arthritis is asymmetrical, usually in the lower extremities, and may produce "sausage digits" of the toes. Although usually episodic, arthritis may become chronic. Enthesitis (inflammation at the insertions of a tendon) is common at the plantar fascial origin and the Achilles tendon insertion (lovers heel). Sacroilitis (often unilateral) tends to occur in those patients with recurring arthritis and is eventually present in 25% - 50% of these patients. Radiographs may reveal changes of unilateral sacroiliitis. In patients with heel pain, fluffy periosteal reaction at entheses may be seen. Psoriatic Arthritis: Arthritis occurs in approximately 7% of patients with psoriasis. Three main forms include: l) asymmetrical oligo-arthritis involving any joint but especially DIP and PIP joints of hands and feet; nails often are dystrophic. 2) symmetrical arthritis including DIP and PIP joints of hands and feet; "RA-like".

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3) spondyloarthritis with sacroiliitis and often spondylitis; may be associated with peripheral arthritis as well; 60% are HLA-B27 positive. Enteropathic Arthritis: This type of arthritis occurs in 10-20% of patients with ulcerative colitis, or Crohns disease, but can also follow bacterial dysentery. Two main forms include: 1) peripheral arthritis, especially knees and ankles but also hips, usually associated with active bowel disease; may be associated with erythema nodosum, oral ulcers or uveitis. 2) ankylosing spondylitis tends to be independent of activity of bowel disease and may precede bowel disease. Current treatment principles for the seronegative spondyloarthropathies include relief of pain by reduction or suppression of inflammation, and preservation of mobility and joint function. These principles are usually carried out using a combination of drug therapy, exercises, and surgery when necessary. The types of drugs used include non-steroidal-anti-inflammatory drugs (NSAIDS), and Sulfasalazine. Two studies published in 2002 demonstrated efficacy of anti-TNF-alpha agents in decreasing symptoms and improving function. Education of patients is particularly important so that they follow exercise protocols meant to prevent permanent stiffness and deformity. When Chlamydial infection has been diagnosed, it should be treated with Doxycycline. Further evaluation is also mandatory for any cardiac or ocular symptoms.

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OVERVIEW OF ARTHRITIS/SUMMARY Joints Involved: Large weight-bearing Peripheral Spine Miscellaneous Patterns: Polyarticular Monoarticular Pauciarticular Symmetric Asymmetric Time Course: Acute Chronic Progressive Paroxysmal Chronic Remittent Time of Day: Morning Stiffness Worse toward end of day No pattern Deformities: Fingers Spine Nodules Tophi rheumatoid, osteo, psoriatic seronegative rheumatoid crystalline rheumatoid, seronegative osteo septic, crystalline crystalline, septic osteo, seronegative crystalline, septic rheumatoid rheumatoid osteo, seronegative, septic, crystalline juvenile rheumatoid rheumatoid any except rheumatoid Type of Arthritis: osteo, seronegative rheumatoid, crystalline seronegative septic

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Overview of Arthritis (contd) Systemic Involvement: Pulmonary Cardiac Vascular Ocular Renal Skin Radiographic Findings: Symmetry Erosions Well circumscribed erosions Sclerosis Osteophytes Sacroiliitis Enthesopathic Lesions Osteopenia rheumatoid rheumatoid, crystalline crystalline osteo osteo seronegative seronegative rheumatoid Type of Arthritis: rheumatoid seronegative rheumatoid seronegative/juvenile rheumatoid crystalline, seronegative psoriatic, seronegative

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Types of Arthritis Compared Rheumatoid Arthritis Patterns Symmetrical Polyarticular Chronic/remittent Morning > 30 minutes Swan-neck, Boutonniere deformities, Bouchards nodes, Rheumatoid nodules Pulmonary, Vasculitis, Sjogrens Symmetry, Subchondral Osteopenia, Marginal Erosions, Progressive Destruction with joint space narrowing Osteoarthritis Weight bearing Spondylitis Gout 1st MTP and Peripheral Joints Paroxysmal ------Tophi

Joints, Assymetrical Spine, SI Joints, Sausage Digits Chronic/ progressive 5-10 minutes Heberdens nodes (DIP joint), Bouchards nodes (PIP joint) ------Chronic Morning Kyphosis

Time Course Stiffness Deformity

Systemic Involvement X-R

Cardiac (AI), Ocular Enthesopathic Lesions, Bamboo Spine, Sacroilitis

Renal stones

Subchondral Sclerosis, Marginal Osteophytes, Joint Space Narrowing, Cysts

Well defined erosions, Progressive destruction

Synovial Fluid Analysis Normal or Non-inflammatory Gross Appearance WBC transparent < 2,000 Inflammatory translucent or opaque 20-50,000 (or >) Septic translucent or opaque > 100,000 (typical) > 50,000 & < 100,000 (not uncommon) < 50,000 (uncommon) > 90% pmns

Differential WBC

> 50% pmns

> 50% <90%

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anatoMy 3: cuBital foSSa and forearM MuScleS

Objectives
1. Describe the boundaries and contents of the cubital fossa. 2. Describe the bones of the forearm, wrist and hand. 3. Describe the origin, insertion, action and innervation of all muscles in the flexor compartment of the forearm. Describe which of these muscles are supplied by the anterior interosseous branch of the median nerve. Describe a test for anterior interosseous nerve palsy. 4. Describe the muscles of the extensor compartment of the forearm. 5. Describe the branching of the radial nerve at the elbow and muscles supplied by each part. 6. Describe the synovial sheaths for the extensor tendons at the wrist. Describe the anatomical snuff box, including boundaries and contents. 7. Describe the anatomy and movements of the wrist.

Osteology of the Forearm:

Before beginning a study of the forearm muscles you should be familiar with some of the major landmarks for the origins and insertions of these muscles. Humerus: medial and lateral epicondyles olecranon fossa coronoid fossa trochlea capitulum Radius: (G 6.54, 6.8; N: 420-421) head pronator ridge neck styloid process tuberosity dorsal tubercle (of Lister) Ulna: olecranon process coronoid process tuberosity trochlear notch styloid process

Carpal bones: proximal row: scaphoid, lunate, triquetrum, pisiform distal row: trapezium, trapezoid, capitate, hamate

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Elbow: anterior Figure 3.1B

Coronoid fossa Lateral epicondyle Capitulum Trochlea Radial head Coronoid process Radial tuberosity Elbow: posterior Figure 3.1B

Synovium

Medial epicondyle

Annular ligament Ulnar tuberosity

Olecranon fossa

Synovium

Medial epicondyle Olecranon process Annular ligament

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Elbow: lateral Figure 3.2A Capitulum Annular ligament Radial head

Lateral collateral ligament Triceps tendon

Elbow: medial Figure 3.2B Trochlea Coronoid process

Triceps tendon Medial collateral ligament

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Triquetrum Radial styloid process Dorsal tubercle Ulnar styloid process

Figure 3.3 Capitate

Hamate Pisiform Lunate Pronator ridge Figure 3.4

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Trapezoid Trapezium Scaphoid

Cubital Fossa
The cubital fossa is the transition from arm to forearm. It includes muscles of both arm and forearm and major nerves and vessels of the flexor compartment of the forearm. The anatomical relationships of the cubital fossa are important in several clinical and surgical situations. For example, intravenous procedures utilize the superficial veins, and the brachial artery may be used in catheterization procedures or to obtain an arterial blood gas. Surgical access to the lower humerus, elbow joint, upper radius and ulna utilize the muscle planes of this area. Boundaries: The cubital fossa is defined as an inverted triangle, the three sides described as follows: Base: transverse line through supracondylar ridge Lateral side: brachioradialis muscle and wrist extensor group Medial side: pronator teres and flexor group Floor: brachialis, biceps, supinator, anterior capsule of elbow joint Roof: bicipital aponeurosis and deep fascia of forearm The contents of the fossa include: (Fig 3.5) the brachial artery, vein and median nerve -lying medial to the biceps tendon. the lateral cutaneous nerve of the forearm - lying lateral to the biceps tendon the radial nerve dividing into deep and superficial radial nerves - lying deep to the brachioradialis. Lying in contact with the roof of the cubital fossa, but technically not within the fossa, are the cephalic, median cubital and basilic veins. On the medial aspect of the roof of the fossa, the medial cutaneous nerve of the forearm continues its subcutaneous path from the arm to the forearm.

Brachial a. Median n. Lateral cutaneous nerve of the forearm Medial cutaneous n. of the forearm

Figure 3.5
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Motion at the Wrist and Fingers:

In order to make sense of the functions of forearm muscles one needs to know the points of insertion of all of them and the joints at which they act (See Tables 5&6). This implies you know the defined motions of the joints of the wrist, fingers and thumb. From the anatomic postition, the wrist can be flexed (palm facing up with hand moved anteriorly) or extended (palm facing down with hand moved posteriorly). From the anatomic postition, the wrist can be deviated to the ulnar side (adduction) by the flexor carpi ulnaris or to the radial side (abduction) by the flexor carpi radialis. Because the terms abduction and adduction require a knowledge of the anatomical position (palm facing anterior), the terms radial and ulnar deviation are more frequently used in clinical conversation. The latter terms are more intuitive than having to figure out which way the palm is facing.

Superficial Flexor Group

Motion at the Phalangeal Joints:

Making a fist requires flexion at all of the phalangeal joints: metacarpophalangeal joint

Pronator teres m. Flexor carpi radialis

Palmaris longus Flexor carpi ulnaris

Figure 3.6

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(MCP), proximal phalangeal joint (PIP) and distal interphalangeal joint (DIP). Extension of these joints occurs when the fingers are straight. Adduction occurs when the fingers are brought close Intermediate Flexor Group: Flexor digitorum superficialis

Intermediate Flexor Group Median n.

Flexor digitorum superficialis m.

Ulnar n.

Figure 3.7

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together and abduction when they are spread apart. These motions occur about an imaginary line through the long or middle finger, thus movement away from the line is abduction and movement toward the line is adduction.

Deep Flexor Group

Median n. (cut) Anterior interosseus n. Flexor pollicis longus m. Flexor digitorum profundus m. Pronator quadratus m.

Figure 3.8

Having defined these functions it is possible to assign some of them to the above muscles. One will not understand all of these functions until the study of the hand has been completed. DIP and PIP Joints Flexion of the DIP joint is by the flexor digitorum profundus Flexion of the PIP joint is by the flexor digitorum superficialis.

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Without consulting a table of insertions, it should be intuitive to you that if it flexes the end of your finger, the flexor digitorum profundus must attach to the distal phalanx. Similarly the flexor digitorum superficialis must attach to the middle phalanx if it is to flex the PIP joint. Which of these muscles flex the MCP joints? One might say you need both of them to continue their action and complete the making of a fist. This is true, but suppose you want to keep the fingers straight, (not flexed at the DIP and PIP) but flexed at the MCP joints, similar to holding a pencil in your hand for writing. The fingers are straight but flexed at the MCP joints, look at your hand. Therefore, there must be other muscles to flex the MCP joints independently when the interphalangeal joints are extended. These muscles are the interossei and lumbrical muscles which you will study in the next session. These muscles are also in part responsible for abduction and adduction of the fingers.

Motion of the Thumb:

Place your palms together as in prayer, not crossing your thumbs, but keeping them parallel. Notice the thumb nail and fingernails are at right angles to each other. (You can see the tops of your thumbnails but not your fingernails.) Thus the action of the thumb is at right angles to the motions defined for the fingers. Keeping one hand in the prayer position, bend the thumb down so that it touches the base of the fifth finger. You will note motion at the interphalangeal joint and metacarpophalangeal joint which is defined as flexion. Pulling the thumb back or straightening it is extension. Compare the axis of flexion and extension of the thumb with that of the fingers. Return your hand to the prayer position, and move the thumb toward the mid line, do not lift it, keep the thumbnail parallel to the floor. The movement of the thumb away from the palm as above is abduction and returning the thumb to the side of the first finger is adduction. Compare the plane of abduction-adduction for the fingers to the plane for the thumb. You should note that they are also at right angles to each other. Opposition is a movement by which the pulp surface of the thumb is placed squarely in contact with or the terminal pads of one or all of the remaining digits. Touch the pads of the thumb and ring finger together; note that the plane of the thumb nail is now in the same plane of the other fingers.

Muscles of the Forearm:

The forearm muscles contained in the flexor and extensor compartments are primarily related to the function of the wrist and hand. Except for the muscles producing the actions of pronation and supination, which are true movements of the forearm, most of the other forearm muscles serve to flex or extend the wrist and the digits of the hand. The muscles that move the fingers are referred to as the extrinsic hand muscles in contrast to the small muscles that arise and insert in the hand (referred to as intrinsic muscles). The extrinsic muscles are designed for power (e.g., grip) while the intrinsic muscles are designed for precise, fine movements. The Naming Game: in general, each muscle of the forearm has a name that describes: 1) action; 2) joint or moving part; 3) relative position. For example, the flexor carpi ulnaris is a flexor of the wrist (carpus) that is located on the ulnar side of the forearm. There is also a flexor carpi radialis; it is also a flexor of the wrist but is on the radial side of the forearm. In the extensor compartment, there is an extensor carpi ulnaris which is an extensor of the wrist, found on the ulnar side.

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Flexor Compartment of the Forearm: To memorize the flexor muscles of the forearm, remember that there are eight muscles and the memorization pattern is 2-2-2-2. Two muscles flex the wrist. Two muscles flex the fingers. Two muscles are pronators. And two muscles are long muscles.
Using a more anatomical scheme to organize the muscles, the flexor group consists of superficial, intermediate and deep muscles. The first two groups originate from the supracondylar ridge of the medial epicondyle of the humerus and cross the forearm in a consistent order. From radial to ulnar the sequence is as follows: (Fig. 3.6) Superficial Flexor Group: Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris The flexor digitorum superficialis has a common origin with the other long flexors but as it enters the forearm its tendons lie in a deeper plane to create an intermediate layer of tendons. (Fig. 3.7) Three muscles comprise the deep group: Fig. 3.8 Flexor digitorum profundus Flexor pollicis longus Pronator quadratus

Innervation of the Flexor Group:

Instead of making a list of all of the above muscles with their innervations, use the rule of exclusion. All of the above muscles in the flexor compartment are supplied by the median nerve, except those supplied by the ulnar nerve, namely the flexor carpi ulnaris, and the ulnar two tendons of the flexor digitorum profundus (tendons to the ring and small finger). There is an important branch of the median nerve, the anterior interosseus nerve, that supplies most of the deep muscles of the forearm flexors. In fact, all of the muscles in the deep compartment of the forearm are supplied by the anterior interosseus branch (Fig 3.8), except the ulnar two tendons of the flexor digitorum profundus which are supplied by the ulnar nerve as noted above. (The other way of saying the above is, the anterior interosseus nerve supplies pronator quadratus, flexor pollicis longus and the radial two tendons of the flexor digitorum profundus.) Entrapment of the anterior interosseus nerve results in weakness of these muscles. How would you test these muscles if you suspected an anterior interosseus nerve palsy?

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Extensor Compartment of the Forearm: Brachioradialis To memorize the extensor muscles of the forearm, remember that Extensor carpi radialis longus there are twelve muscles and the memorization pattern is 3-3-3-3. Three muscles extend the wrist. Three muscles extend the fingers. Three muscles move the thumb. Extensor carpi radialis brevis And three muscles are left over (the BAS muscles).
All of the long extensor group of forearm muscles arise from Extensor digitorum communis a common tendon at the lateral condyle of the humerus (Fig 3.9). Similar to the flexor arrangement, these form an ordered array of tendons across the posterior aspect Extensor digiti minimi of the forearm. Their function is to extend the wrist, fingers, and Extensor carpi ulnaris thumb. In the proximal part of the flexor compartment there was a short muscle, the pronator teres, responsible for rotating the forearm. An antagonist muscle is found in the extensor compartment, namely the supinator muscle (Fig. 3.10). Remember to make brief sumFigure 3.9 maries of functional groups, e.g. two supinator muscles, biceps and the supinator, and two pronator muscles, the pronator quadratus and pronator teres. Review their innervation. The following is a schematic way of organizing the extensor compartment muscles: *Mobile Wad: (Fig. 3.9) Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis *Long Extensors: (Fig. 3.9) Extensor digitorum communis Extensor digiti minimi (quinti) Extensor carpi ulnaris Anconeus (Listed for the sake of completeness, but you can ignore it for the purposes of this course.)

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A second set of muscles, the short extensors, do not arise from the common tendon at the elbow but rather from the radius, ulna, and interosseus membrane of the forearm. Hence these muscles have no action at the elbow but serve the thumb and forefinger. *Short Extensors (Fig 3.10) Three for the thumb: Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus One for the forefinger Extensor indicis proprius

Function of the Extensor Muscles:

Instead of making an individual list of the insertions and functions of these muscles, study them in terms of the action of the muscles at wrist, finger and thumb joints. . The extensors of the wrist are the extensor carpi ulnaris, extensor carpi radialis brevis and longus. Extension of the fingers at the MCP joints is a function of the extensor digiti minimi (little finger), extensor digitorum communis (digits 2-5), and the extensor indicis proprius (forefinger).

Supinator

Extensor pollicis longus Extensor pollicis brevis Abductor pollicis longus Extensor indicis proprius

Figure 3.10

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Deep Radial (Posterior Interosseus) n. (splitting supinator)

Radial n. branches to: Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis

Extensor carpi ulnaris Extensor digiti minimi Extensor digitorum communis Superficial radial n. Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus

Extensor indicis proprius

Figure 3.11
Extension of the thumb at the IP joint is the function of the EPL, and extension at the MCP is the function of the EPB. Some movements of the wrist use muscles that are in both the flexor and extensor compartments. What about ulnar deviation? It involves both the flexor and extensor of the wrist on the ulnar side of the wrist, e.g. FCU and the ECU. Similarly, radial deviation involves the FCR and the ECRL and ECRB.

Innervation of the Extensor Muscles:

The rule of exclusion also applies to the extensor muscles. All of the extensor muscles will be supplied by the deep radial (also known as the posterior interosseus nerve) as it emerges from between the heads of the supinator muscle, except the mobile wad muscles (BR, ECRL and ECRB) which are supplied by the radial nerve before it divides into the deep and superficial radial nerves. Because the ECRB borders muscles that are supplied by the radial nerve (proximal) and muscles that are supplied by the deep radial nerve (distal), its innervation is variable. ECRB can be innervated by either nerve or the superficial branch of the radial nerve. The superficial radial nerve normally does not innervate any muscle, but supplies cutaneous innervation to much of the radial side of the dorsum of the hand. (Fig 3.11) Occasionally, it may be the motor nerve to the ECRB.

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TABLE 5: FIVE SUPERFICIAL MUSCLES OF ANTERIOR COMPARTMENT OF FOREARM THAT ORIGINATE FROM MEDIAL EPICONDYLE OF HUMERUS ORIGIN INSERTION MOVEMENTS NERVE

MUSCLES

Pronator teres of humerus ulnar head: coronoid process of the ulna

humeral head: medial epicondyle

middle of lateral surface of radius

pronates forearm

median n. (C6, 7)

Flexor carpi radialis forearm)

medial epicondyle (fascia of

base of 2nd metacarpal

flexes wrist; assists in pronation, abducts hand, flexes elbow

median n. (C6, 7)

Palmaris longus transverse carpal ligament

medial epicondyle

palmar aponeurosis

flexes wrist, assists in pronation

median n. (C7, 8)

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humeral head: medial epicondyle metacarpal ulnar head: olecranon of ulna humeral head: medial epicondyle ulnar head: proximal ulna radial head: diagonal line between supinator & FPL base of middle phalanx of all but thumb pisiform, hamate, 5th

Flexor carpi ulnaris

flexes wrist, assists in adducting hand

ulnar n. (C8- T1)

Flexor digitorum superficialis

flexes middle phalanx of all but thumb, aids in flexing wrist and elbow

median (C7, 8)

(sublimis)

TABLE 6: THREE DEEP MUSCLES IN ANTERIOR COMPARTMENT OF FOREARM ORIGIN INSERTION MOVEMENTS NERVE

MUSCLES

Flexor digitorum profundus interosseous membrane 4 digits 4 digits

anterior surface of ulna,

distal phalanges of medial

flexes distal phalanges of medial

ulnar (C8, T1), and anterior interosseous (median) (C8, T1)

Flexor pollicis longus interosseous membrane

anterior surface of radius,

base of distal phalanx of thumb

flexes thumb

anterior interosseous (median) (C8, T1)

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distal l/4 of ulna distal l/4 of radius pronates forearm anterior interosseous (median) (C8, T1)

Pronator quadratus

TABLE 7: POSTERIOR COMPARTMENT OF FOREARM EIGHT SUPERFICIAL MUSCLES FROM LATERAL EPICONDYLE INSERTION styloid process of radius base of 2nd metacarpal base of 3rd metacarpal base of proximal phalanx and extensor expansion extends M-P joint, Extends PIP & DIP with interossei & lumbricals assists in extension of wrist extends 5th as above extends wrist, adducts hand assists triceps in extending forearm supinates forearm extends wrist, abducts hand extends wrist and abducts hand radial (C6, 7) deep radial* (C6, 7) deep radial (C7, 8) assists in flexion of elbow after biceps and brachialis radial (C6) MOVEMENTS NERVE

MUSCLES

ORIGIN

Brachioradialis

lateral supracondylar ridge of humerus

Extensor carpi radialis longus

lateral supracondylar ridge of humerus

Extensor carpi radialis brevis

lateral epicondyle of humerus radial collateral ligament

Extensor digitorum communis

lateral epicondyle of humerus

Extensor digiti minimi base of 5th metacarpal post. surface of ulna and olecranon lat. and ant. surface of radius

lateral epicondyle of humerus

proximal phalanx of 5th digit

deep radial (C7, 8) deep radial (C7, 8) radial (C7, 8) deep radial (C6)

Extensor carpi ulnaris

lateral epicondyle of humerus

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Anconeus

lateral epicondyle of humerus

Supinator

lat. epicondyle & supinator crest of ulna

* a.k.a. posterior interosseous n. Note that innervation is variable (sometimes proper radial or superficial radial)

TABLE 8: POSTERIOR COMPARTMENT OF FOREARM - FOUR DEEP MUSCLES ORIGIN middle l/3 of ulna, radius and interosseous membrane posterior surface of radius and interosseous membrane middle l/3 of ulna and interosseous membrane posterior lower l/3 of ulna; interosseous membrane proximal phalanx of index finger extends proximal phalanx of index finger base of distal phalanx of thumb extends distal phalanx of thumb base of proximal phalanx of thumb extends proximal phalanx of thumb deep Radial (C7, 8) deep Radial (C7, 8) deep Radial (C7, 8) base of lst metacarpal abducts thumb and wrist deep Radial * (C7, 8) INSERTION MOVEMENTS NERVE

MUSCLES

Abductor pollicis longus

Extensor pollicis brevis

Extensor pollicis longus

Extensor indicis

* a.k.a. posterior interosseus nerve

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laBoratory diSSection
Goals:
1. Expose and explore the cubital fossa. 2. Reveal the contents of the flexor compartmment of the forearm. 3. Expose and explore the dorsal forearm - the mobile wad and remaining extensors.

I. Cubital Fossa
A. Review the boundaries of the cubital fossa before beginning the dissection B. Extend your midline incision of the skin from the area of the cubital fossa to the wrist crease. Remove skin preserving veins and cutaneous nerves. Identify the following superficial to the roof of the fossa, i.e., within the superficial fascia: 1. Lateral cutaneous n. of forearm: emerging between biceps and brachioradialis at the lateral margin of cubital fossa 2. Medial cutaneous n. of forearm continuing from arm 3. Cephalic, basilic and median cubital veins 4. What are the segments of the above cutaneous nerves and what is their distribution? See Syllabus Maps C. Contents of fossa: Incise the superficial fascia of the fossa, clean and identify the following: 1. Locate the radial nerve as it enters the fossa between brachioradialis and brachialis muscles. The radial nerve divides into a deep radial (posterior interosseous) nerve supplying wrist and digital extensors and a superficial radial nerve which provides cutaneous innervation to the skin on the dorsum of the hand. Note the deep radial nerve divides the supinator muscle into superficial (oblique) and deep (transverse) fibers. 2. Locate the median nerve and brachial artery entering the medial aspect of the fossa between biceps tendon and pronator teres. The latter is also divided into superficial and deep parts by the median nerve. 3. Follow the brachial artery as it divides into radial, ulnar, common interosseous, and anterior and posterior interosseous arteries.

II.

Flexor compartment of forearm:

The forearm is divided into an anterior and posterior compartment with each compartment supplied by a specific nerve. The muscles of the anterior compartment or flexor group are supplied by the median and ulnar nerves, whereas the posterior compartment or extensor group is supplied by the radial nerve. The flexor group can be further divided into three muscle layers. Clean the fascia and fat from the flexor compartment and identify the muscles in the respective layers. A. Superficial layer: (Median nerve innervated, except the flex. carpi ulnaris)

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1. Pronator teres 2. Flexor carpi radialis 3. Palmaris longus (frequently absent) 4. Flexor carpi ulnaris (ulnar n. innervated) B. Intermediate layer: (Median nerve innervated) 1. Flexor digitorum superficialis (sublimis) a) Clean the superficialis muscle near its origin. Then detach the insertion of the pronator teres from the radius. Preserve the median nerve and note it splits the fibers of the pronator before coursing deep to the origin of the superficialis. Note this region well as it is frequently the site of median nerve entrapment. C. Deep layer (anterior interosseous nerve innervation) 1. Flexor digitorum profundus (the ulnar two tendons supplied by the ulnar nerve) 2. Flexor pollicis longus 3. Pronator quadratus D. Review the origins and insertions of the above muscles listed in A-C. Which are primary wrist flexors and which act on the digits? E. It is convenient to think of the neurovascular bundles as occupying planes between the muscles. In effect the three muscle layers lie between the skin and a base consisting of interosseus membrane attached to the radius and ulna. This establishes four neuro-vascular planes: 1. Anterior to superficial flexors: Identify superficial radial nerve, medial and lateral cutaneous nn. of forearm, cephalic and basilic veins 2. Anterior to intermediate group: Identify radial artery 3. Anterior to deep group: Identify median and ulnar nerves and ulnar artery 4. Anterior to interosseous membrane: anterior interosseus nerve and artery.

III.

Clinical applications:
In surgical procedures, access and visibility of structures is always limited by the incision. Identification of muscles, tendons, blood vessels and nerves is based on relationships, rather than visualizing the entire course of the structure. The relationships at the wrist crease and in the cubital fossa are classic examples. Practice identifying these relationships by wrapping your fingers about the arm and forearm exposing only the cubital fossa and identifying the structures. Similarly, repeat the

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exercise at the wrist crease. If you had to perform a median or ulnar nerve block at the wrist for local hand surgery, where would you inject the xylocaine? A. What are the differences in the patient presenting with median nerve palsy due to entrapment above the elbow compared to entrapment at the pronator teres? at the wrist? (Q3.1)

IV. The Extensor Compartment of the Forearm.

The muscles in the extensor compartment primarily extend the wrist or digits. Motion of the forearm itself is mostly flexion and extension, accomplished by the biceps, brachialis, and triceps, respectively. Pronation and supination are actions intrinsic to forearm musculature. The biceps is considered to provide the power of supination while the supinator muscle provides the speed. With the exception of the muscles involved in pronation and supination, the long extensors arise from the supracondylar ridge or common extensor tendon attached to the lateral epicondyle. By now you should have removed all skin on the forearm down to the hand. Clean and identify the following muscles: Extensor muscle group: A. Originating from supracondylar ridge: 1. Brachioradialis 2. Extensor carpi radialis longus B. Arising from common tendon on lateral epicondyle: 1. Anconeus 2. Extensor carpi radialis brevis 3. Extensor digitorum communis 4. Extensor digiti quinti 5. Extensor carpi ulnaris C. Single muscle: 1. Supinator D. Short muscles acting on thumb and forefinger: 1. Abductor pollicis longus 2. Extensor pollicis brevis

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3. Extensor pollicis longus 4. Extensor indicis proprius

V. Dorsum of Hand:

Radial artery
Extensor pollicis longus Abductor pollicis longus

Extensor pollicis brevis

Figure 3.12

In order to follow the extensor tendons into the hand, clean the skin of the hand as far distally as the metacarpo-phalangeal joints. Do not remove palmar skin at this time. A. Define the anatomical snuff box. What are the boundaries of this space? Contents? (Fig 3.12) B. As the extensor tendons cross the dorsum of the wrist joint they are encased in synovial sheaths. How are the tendons grouped within these sheaths? Define DeQuervains Syndrome. (Q3.2)

VI. Dissection about the elbow joint

A. Release the roof of the cubital tunnel (the head of the flexor carpi ulnaris), to allow for transposition of the ulnar nerve into the anterior forearm (should you so desire). B. Release the ulnar collateral ligament of the ulno-humeral joint, to allow entrance into the joint. Open the joint with a valgus stress.

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C. On the lateral side of the elbow, palpate the radial head. Identify the orbicular ligament. Transect it to allow for better examination of the radio-capitellar joint. Where does the radial nerve pass relative to the proximal radius? (Q 3.3) Follow its course into the forearm.

VII.

Clinical applications:

List the physical signs you would expect after laceration of the radial nerve at the following sites: 1) midhumeral shaft 2) at the supinator (deep radial)? At the wrist (superficial radial)? Does a radial nerve palsy affect flexor strength? (Q3.3) ANSWERS TO ANATOMY QUESTIONS 3.1 This is basically a question of the branching pattern of the median nerve. Entrapment of the median nerve above the elbow produces a complete paresis of the median nerve. Entrapment at the pronator teres spares the superficial flexor group (i.e., pronator teres, flex carpi radialis, palmaris longus) and the flexor digitorum sublimis (middle layer) but results in loss of motor supply to the deep group, (flexor pollicis longus, flexor digitorum profundus (two tendons) and pronator quadratus) thenar muscles, and the first and second lumbrical. In addition there is a cutaneous deficit of the palmar skin from the base of the thenar mass distally over the radial three and one half digits. Entrapment at the level of the wrist spares the forearm muscles and the palmar cutaneous branch of the median nerve, but produces a function loss in the thenar muscles, radial two lumbricals, and palmar skin of the radial three and one half digits. (See Anatomy 4: Hand) As you can see from Grants Atlas, the tendons occupy six synovial sheaths. In the case of De Quervains Syndrome there is an inflammation involving the synovial sheath of the abductor pollicis longus and the extensor pollicis brevis. Whenever the thumb is adducted and the hand deviated ulnarly, the patient usually experiences acute pain over the radial side of the base of the thumb. (Finkelstein Test) This is initially treated by bracing, though it is usually cured by injections of anti-inflammatory drugs into the sheath or in cases of chronic problems, removal of the synovial sheath (synovectomy). The radial nerve enters the supinator just distal to the elbow joint, anterior and lateral to the radial head. Injury of the radial nerve at the midhumeral shaft usually spares the triceps but results in paralysis of all distal muscles including loss of sensation of the skin on the dorsum of the hand. At the level of the supinator one should recognize that the nerve divides into a superficial and deep branch. The superficial radial nerve will supply only the skin over the dorsum of the first web-space in the hand and infrequently also the extensor carpi radialis brevis (The ECRB is variably innervated, sometimes by the superficial radial, deep radial, or the proper radial before it divides). The deep radial/posterior interosseus nerve will supply the supinator muscle and all extensors in the forearm. At the level of the wrist only the superficial radial nerve persists supplying the first web-space of the dorsum of the hand. Radial nerve palsy involving the extensors of the forearm will significantly affect flexor strength. This may seem paradoxical, but if one makes a fist, it is necessary to have the extensors stabilize the wrist. Without this the flexors will continue flexing the fingers, moving the wrist into flexion and weakening the grip of the hand. In combat sports, flexion of the wrist is a standard defense technique to weaken an opponents grip particularly in the case where the hand contains a weapon.

3.2

3.3 3.4

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anatoMy 4: hand
Objectives
1. Describe the three groups of hand muscles, thenar, hypothenar and intrinsics. (Origin, insertion, action and innervation) 2. Describe all movements of the thumb and little finger. 3. Describe all movements of the fingers at the DIP, PIP and MCP joints. Name the prime movers at each joint. 4. Describe the blood supply of the hand. 5. Describe the innervation of the skin of the hand.

Carpal Tunnel: Transition from Forearm to Hand (Fig. 4.1)

In the previous exercise, you studied the flexor muscles of the forearm. Some flexed the wrist joint and others the finger joints. The wrist flexors (and extensors) usually attach to the proximal part of the metacarpals and do not extend into the distal hand. All of the digital flexors must cross the palm to reach the fingers and thus traverse a fibro-osseous tunnel, the carpal tunnel. The tunnel is formed by the volar concavity of the proximal and distal rows of carpal bones. The concavity is roofed by the flexor retinaculum to form a closed tunnel. The attachment of the retinaculum rests on four piers: the pisiform and hook of the hamate on the ulnar side and the tubercles of the scaphoid and trapezium on the radial side. Nine tendons and a nerve pass through the space of tunnel: Four tendons of the flexor digitorum superficialis Four tendons of the flexor digitorum profundus The tendon of the flexor pollicis longus The median nerve. The flexor carpi radialis appears to be in the carpal tunnel, but is actually in a separate fibrous compartment. Swelling of the tendons due to a variety of causes may compromise the median nerve resulting in muscle weakness of the thumb and tingling or numbness of the skin of the thumb and first two and one-half fingers. (Is the ulnar nerve affected?) (Q4.1)

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Flexor digitorum profundus insertion

Flexor digitorum superficialis chiasm Flexor pollicis longus

Flexor digitorum superficialis Flexor digitorum profndus Ulnar nerve

Flexor carpi radialis Transverse carpal ligament Median nerve

Figure 4.1

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Intrinsic Muscles of the Hand

The muscles of the hand are composed of three groups, thenar, hypothenar and central.
Figure 4.2

Sesamoids

Figure 4.3

Hypothenar mm.

Abductor digiti minimi Flexor digiti minimi brevis

Thenar muscles Abductor pollicis brevis Flexor pollis brevis

Opponens digiti minimi Opponens pollicis

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Thenar and Hypothenar Groups: Fig. 4.2-4.3 These two groups are considered together because the three muscles in each group have the same action, namely, abduction (at the MCP joint), flexion (at the MCP joint) and opposition (at the carpometacarpal joint). Note the insertions of 2 of the 3 thenar muscles to the proximal phalanx at the base of thumb (Fig. 4.2). The third thenar muscle, the opponens pollicis, inserts into the first metacarpal (Fig. 4.3). The flexor pollicis brevis splits into two heads each containing a sesamoid bone. The attachment of these heads is shared with the abductor tendon on the radial side and the adductor tendon on the ulnar side of the proximal phalanx. The central group of hand muscles includes: Four dorsal interossei, which abduct the fingers (Fig. 4.4)* Three palmar interossei, which adduct the fingers (Fig. 4.5)* Four lumbricals which, in conjunction with the interossei, extend the DIP and PIP joints and flex the MCP joints Adductor pollicis whose name describes its function.
Figure 4.4

Figure 4.5

Dorsal interossei

D1

D2

D3 D4 P2 P1

Palmar interossei Hypothenar motor branch Deep branch of ulnar n. Adductor pollicis m. Superficial ulnar n. (cut)

P3

Ulnar nerve
*Abduction is movement away from the midline, adduction is movement toward the midline. The midline of the hand is the third ray. 114

Innervation of the Hand Muscles: (Fig 4.5-4.6)

All of the hand muscles are supplied by the ulnar nerve, except the thenar group and the first two lumbricals (forefinger and long finger). The latter are supplied by the recurrent branch of the median nerve (thenar) or motor branches of the digital nerves (lumbricals). Another exception within the thenar group is the deep head of the flexor pollicis brevis, which is supplied by the ulnar nerve. The ulnar nerve divides into a deep branch which supplies the hypothenar muscles, the interossei, the

Figure 4.6

Proper digital n. and Common digital n.

Superficial ulnar n. Deep ulnar n. n. Deep ulnar

Recurrent branch of median n. for thenar muscle mass

Median nerve Ulnar nerve

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Motion at the Joints of the Fingers and Hand

The following chart may help to sort out the action of the muscles of the hand in terms of finger motion. In order to test the patient for a hand disability you must understand which muscle moves each joint of the hand and fingers. Test yourself. Look at your finger joints and name the muscle flexing, extending, etc. each joint and the bone on which it inserts. (For example: the DIP is flexed by the FDP inserting on the terminal phalanx)

MOTION OF THE FINGER JOINTS ACTION Flexion Extension MCP Joint Lumbricals and interossei Extensor digitorum communis Dorsal interossei Palmar interossei PIP Joint Flexor digitorum superficialis Lumbricals and interossei (Central Slip) DIP Joint Flexor digitorum profundus Lumbricals and interossei (Terminal Slip)

Abduction Adduction

MOTION OF THE THUMB JOINTS ACTION Flexion Extension Adduction Abduction Opposition Abductor pollicis longus Opponens pollicis CMC Joint MCP Joint Flexor pollicis brevis Extensor pollicis brevis Adductor pollicis Abductor pollicis brevis IP Joint Flexor pollicis longus Extensor pollicis longus

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IV. Extensor hood. (Fig. 4.9)

The extensor hood receives the insertion of three muscles, long extensor, lumbrical, and interosseous. A. Long extensor tendon: This inserts principally on the base of the proximal phalanx and serves to extend the MCP joint. B. Lumbricals and interossei act on the remaining parts of the hood which are the central slip and the lateral bands. The central slip inserts on the base of the middle phalanx and serves to extend the PIP joint. The lateral bands combine over the dorsum of the middle phalanx to form the terminal slip which inserts on the base of the terminal phalanx and serves to extend the DIP joint. The lumbricals and superficial parts of the interossei therefore are extensors of the interphalangeal joints. Note that the position of the lateral bands and the central slip is dorsal to the axis of flexion and extension of these joints. The deep part of the interossei attach on the base of the proximal phalanx and act either to abduct or adduct the phalanx and digit. The attachments of the dorsal interossei provide abduction and the palmar interossei adduction. At the MCP joint the lumbricals and interossei are volar to the axis of flexion and extension and therefore also act to flex this joint when the interphalangeal joints are extended. The long flexors can also flex the MCP joints, but only after they have wound up their laxity and flexed the DIP and PIP joints.

Terminal slip Lateral bands

Central slip

Extensor hood merging with the tendon of the interosseus Interosseus Interosseus

Figure 4.9

Most anatomy texts and atlases do not use the terms central slip, lateral bands and terminal slip. This is regrettable because the terms are used by clinicians in discussing the mechanism of action of the DIP and PIP joints. Furthermore, these are the sites of injury in Mallet Finger and Boutonniere Deformity. You are responsible for knowing these anatomic terms and understanding the pathophysiology of these finger injuries. Define Boutonniere Deformity and Mallet Finger. (Q4.5)

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TABLE 9: FOUR SHORT MUSCLES OF THE THUMB ORIGIN trapezium and transverse carpal ligament trapezium and transverse carpal ligament (deep to the above) superficial head: trapezium and transverse carpal ligament deep head: trapezoid and capitate transverse head: third metacarpal oblique head: capsules of carpal joints ulnar base of proximal phalanx adducts thumb base of proximal phalanx of thumb flexes thumb, aids in opposition anterior surface of radial side of first metacarpal oppose thumb to each of the other digits lateral side of base of proximal phalanx of thumb abducts thumb (draws thumb forward at right angles to palm) median (C8, Tl) median (C8, Tl) median, (C8, Tl) ulnar (C8, T1) ulnar (Tl) INSERTION MOVEMENTS NERVE

MUSCLES

Abductor pollicis brevis

Opponens pollicis

Flexor pollicis brevis

Adductor pollicis

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Table 10: HYPOTHENAR GROUP OF INTRINSIC HAND MUSCLES ORIGIN pisiform (tendon of flex. carpi ulnaris) hook of hamate (transverse carpal lig.) hook of hamate (transverse carpal lig.) palmar aponeurosis and transverse carpal ligament skin over base of 5th metacarpal corrugates skin over 5th metacarpal, deepens hollow of hand ulnar side of 5th metacarpal draws 5th metacarpal forward base of proximal phalanx of 5th digit flexes proximal phalanx of 5th digit ulnar (C8, T1) ulnar (C8, T1) ulnar (C8, T1) base of proximal phalanx of 5th digit abducts 5th digit (see dorsal interossei ulnar (C8, T1) INSERTION MOVEMENTS NERVE

MUSCLES

Abductor digiti minimi

Flexor digiti minimi brevis

Opponens digiti minimi

Palmaris brevis

TABLE 11: CENTRAL GROUP OF INTRINSIC HAND MUSCLES ORIGIN radial side of flex. digit. profundus tendon on 2nd to 5th digits dorsal extensor expansion over M-P joint to base of distal phalanx of 2nd-5th digits INSERTION MOVEMENTS flex at M-P joint, extend at PIP (via central slip) and DIP (via lateral bands) joints NERVE median (C8, T1) to lateral two ulnar (C8, T1) to medial two middle finger as reference, abducts 2nd, 3rd, and 4th digits ulnar (C8, T1)

MUSCLES

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by two heads from adjacent sides of metacarpals base of proximal phalanx, 1st to radial side of index, 2nd & 3rd to 3rd digit, 4th to ulnar side of 4th digit, and extensor expansion base of proximal phalanx ulnar side of 2nd digit radial side of 4th digit radial side of 5th digit and extensor expansion ulnar side of 2nd metacarpal radial side of 4th radial side of 5th

4 lumbricals

4 dorsal interossei

3 volar interossei

adducts 2nd, 4th, & 5th digits, also aids lumbricals

ulnar (C8, T1)

*NOTE: The effective insertion of the lumbricals and interossei is as follows: 1: into the central slip of the hood inserting into the base of the middle phalanx. Tension on the central slip results in extension of the PIP joint; and 2: via the lateral bands of the hood which fuse into the terminal slip inserting into the base of the distal phalanx. Tension on the lateral bands results in extension of the DIP joint.

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clinical correlationS in the wriSt and hand

Objectives:
1. Describe the pathophysiology and clinical features of boutonniere deformity, swan neck deformity, mallet finger, trigger finger, and intrinsic and extrinsic muscle contractures. (Syllabus material below) 2. Understand the presentation and treatment of common fractures about the wrist: Colles fracture and scaphoid fracture. (Syllabus material below) 3. Describe the pathophysiology and clinical features of gamekeepers (skiers) thumb. (Syllabus material below) 4. Describe the pathophysiology and clinical features of carpal tunnel syndrome. (Syllabus material below)

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Applied Anatomy
1. Finger pathologies A. Boutonniere Deformity A boutonniere deformity (Figs 1 & 2) is recognized as flexion at the proximal phalangeal joint and extension of the distal interphalangeal joint. Any injury or disease that disrupts the insertion of the central slip of the extensor aponeurosis at the base of the middle phalanx can cause this deformity. The remaining lateral bands sublux and slip volar to the axis of the proximal interphalangeal joint. Often, this deformity does not appear immediately after injury, but develops later,

Fig. 1

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as the lateral bands tear, stretch and eventually sublux and become flexors of the the proximal interphalangeal joints. B. Swan Neck Deformity The swan neck deformity (Figs 3 & 4) is maintained by a hyperextension of the proximal interphalangeal joint and flexion at the distal interphalangeal joint. This muscle imbalance may be the

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result of volar plate injury, flexor digitorum superficialis weakness, or synovitis in the rheumatoid hand. C. Mallet Finger A mallet finger deformity (Figs 5 & 6), or baseball finger, occurs from traumatic hyperflexion of the distal interphalangeal joint. This causes avulsion of the terminal slip of the extensor aponeurosis from its insertion on the distal phalanx or an avulsion fracture of the distal phalanx in which a

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piece of the bone remains attached to the terminal slip. Loss of extension at the distal interphalangeal joint occurs. A laceration at the distal joint that severs the extensor aponeurosis also results in this deformity. D. Trigger Finger Trigger finger usually results from a nodule or fusiform swelling of the superficial flexor tendon just proximal to its bifurcation. When the finger is flexed, the nodule is usually just proximal to the first annular pulley at the distal palmar crease. The nodule is usually secondary to chronic trauma from repeatedly grasping an object (such as a barbell in serious weight lifters) or from a partially lacerated tendon which heals leaving a nodule sufficiently large to cause triggering.The nodule can be palpated in the palm by the examiners fingertip and will move with the tendon. (Fig 7)

nodule A1 pulley

Figure 7

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2. Common Fractures
A. Colles fractures Colles fractures are the most common fracture of the distal radius and ulna. They occur in osteoporotic bone and were described by Abraham Colles in 1814 (prior to x-ray) as a fracture occurring due to a fall on the outstretched arm, and producing a deformity which has come to be known as a silver fork deformity. The deformity is due to dorsal displacement or angulation (apex volar) of the distal radial fragment. The ulnar styloid is typically avulsed as well. The examiner should document median nerve function as well as function of the extensor pollicis longus both before and after reduction. The median nerve is occasionally stretched by the apex of the fracture. The blood supply to the EPL may be damaged by the dorsal displacement of the radius and delayed rupture of the EPL can occur. The physician also needs to be alert for compartmental syndrome and subacute median nerve compression. The classic Colles fracture unites well using immobilization after reduction, although various degrees of malunion are common. More comminuted fractures and other fractures in the same part of the forearm may require external or internal fixation depending on the fracture pattern and degree of comminution. Take care NOT to call all distal radius fractures Colles fractures. B. Scaphoid fractures Fractures of the scaphoid occur commonly in young people due to a fall on the outstretched arm. They present with pain and tenderness in the anatomic snuffbox. Initial radiographs are often normal. Therefore if the history and physical exam support the diagnosis, the patients wrist should be immobilized and an x-ray repeated between 10 days and 2 weeks. At this time, initial resorption of the fracture ends will have occurred and the fracture will be more obvious. These fractures require immobilization of the wrist for 6-20 weeks. Because the scaphoid traverses both carpal rows, it is difficult to immobilize. Orthopaedists debate the necessity for immobilization of the elbow and/or thumb as well. When the fracture fragments are not well aligned, internal screw fixation is recommended. Because the scaphoids blood supply enters from its distal pole, fractures through the waist of the scaphoid can produce avascular necrosis of the proximal fragment as well as non-union of the fracture. These potential complications should be discussed with the patient in advanc

C. Skiers or Gamekeepers Thumb This condition originally derived its name because it was an occupational hazard of gamekeepers who stretched out the ulnar collateral ligament (UCL) of the first MCP joint in the process of wringing rabbits necks. Nowadays the UCL tears typically when a skier falls on his/her hand with the thumb stretched (abducted) around the ski pole or strap or both. (Fig 8) The patient presents with swelling, pain and tenderness over the ulnar aspect of the MCP joint of the thumb. X-rays should be taken before stressing the joint to prevent possible displacement of an undisplaced fracture. Pain is increased by abducting (radially deviating) the thumb. The examiner must compare the amount of deviation to that on the opposite hand. If the ligament is only partially torn, it will heal if the thumb is held slightly adducted for 3-6 weeks. This can be done using a cast, a splint, or adhesive strapping. If the ligament is completely torn (and there is no end point on stress testing), surgical repair is recommended for an optimal result that will restore pinch strength and stability.

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C. Skiers or Gamekeepers Thumb This condition originally derived its name because it was an occupational hazard of gamekeepers who stretched out the ulnar collateral ligament (UCL) of the first MCP joint in the process of wringing rabbits necks. Nowadays the UCL tears typically when a skier falls on his/her hand with the thumb stretched (abducted) around the ski pole or strap or both. (Fig 8) The patient presents with swelling, pain and tenderness over the ulnar aspect of the MCP joint of the thumb. X-rays should be taken before stressing the joint to prevent possible displacement of an undisplaced fracture. Pain is increased by abducting (radially deviating) the thumb. The examiner must compare the amount of deviation to that on the opposite hand. If the ligament is only partially torn, it will heal if the thumb is held slightly adducted for 3-6 weeks. This can be done using a cast, a splint, or adhesive strapping. If the ligament is completely torn (and there is no end point on stress testing), surgical repair is recommended for an optimal result that will restore pinch strength and stability.

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D. Carpal tunnel syndrome Carpal tunnel syndrome is a common clinical problem caused by compression of the median nerve in the carpal tunnel. Conditions that increase the size of the contents of the tunnel may initiate symptoms. These include ganglions, and swelling caused by injury, synovitis, hypothyroidism, pregnancy, or repetitive wrist or finger motion. Conditions that decrease the size of the bony tunnel, such as fractures, spurs, or arthritic changes, may also initiate symptoms. The primary symptom of carpal tunnel syndrome is numbness / tingling in the distribution of the median nerve (volar thumb, index, long, and radial side of ring fingers). This may occur at night, causing waking, or may occur during daytime from prolonged grip or pinch. Pain may be an associated symptom and may extend proximally into the forearm, arm, or shoulder. Clinical exam varies depending on the severity and longevity of the problem. Tinels sign may be demonstrated by percussing the median nerve at the carpal tunnel; Phalens test (prolonged wrist volar flexion) may reproduce the tingling. One may find decreased two-point discrimination in the involved finger tips, and weakness of the opponens pollicis muscle. Electromyograms (EMG) and Nerve Conduction Velocity testing can document the presence of median nerve entrapment in the carpal tunnel. If the underlying cause can be treated early, often the symptoms will resolve spontaneously. Injection of cortisone into the tunnel (but not into the nerve) may relieve symptoms when synovitis is the etiology. When symptoms persist, or neurologic deficit progresses, the carpal tunnel is released surgically. Care must be taken to avoid injuring the palmar sensory and recurrent branches of the median nerve. Although recovery of the nerve depends upon the length of time and severity of the nerve compression, results are good in greater than 85% of cases. (FYI: Nice reference NOT REQUIRED: DArcy CA & McGee S, Does This Patient Have Carpal Tunnel Syndrome. JAMA 283(23): 3110-3117, 2000.) (See Figure 4.1 for anatomical drawing of carpal tunnel)

Numbness/ tingling

Numbness/tingling are in the median distribution, as shown above. Pain may extend proximally, even up to the shoulder.

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liVing anatoMy /clinical correlation cerVical Spine, elBow & hand

Objective:
Be able to find, outline, and demonstrate key musculoskeletal landmarks.

Preparation for Class:

1. Review the pertinent anatomy. 2. Bring washable color markers. 3. Wear clothing that allows visualization of the structures you are assigned to find. 4. Bring a reflex hammer. 5. Consider what findings you might expect for each of the diagnoses listed.

Draw the following on your partner:

C-7 spinous process (vertebra prominens) The autonomous zones (for the dermatomes) for C-5, C-6, C-7, C-8, T-1 The autonomous zones of the median, radial, and ulnar nerves in the hand (the autonomous zone refers to an area where there is unlikely to be overlap between two nerves. For example, half of the ring finger is supplied by the ulnar nerve and half by the median nerve. Therefore, the ring finger does not have an autonomous zone for either of these nerves and using the ring finger to test sensation supplied by either of these nerves is unreliable.) Review and practice the deep tendon reflexes of the biceps, brachioradialis, and triceps. Which nerve root (segmental level) is tested by each? Outline the snuff box, the radial styloid, the ulnar styloid, the hook of the hamate, the volar mcp joints. the olecranon (mark with a circle) the medial epicondyle of the humerus (mark with a circle) the lateral epicondyle of the humerus (mark with a circle) the radial head the ulnar nerve (from an inch above to an inch below the elbow) Draw an x where you would stick a needle if you wanted to aspirate the elbow joint. Draw an x where you would stick a needle if you wanted to aspirate the olecranon bursa. Draw an x where you would stick a needle if you wanted to inject a tennis elbow.

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Case 1:
Your patient complains of lateral elbow pain after pruning bushes in the garden. Your differential diagnosis includes: lateral epicondylitis elbow joint arthritis olecranon bursitis radial head dislocation Referring to the pertinent anatomic structures drawn on you and your partner, answer the following question: A. Which of the above diagnoses best support the clinical scenario? B. What additional findings might further support or reject each of the diagnoses? C. What is the typical range of motion of the elbow? for forearm pronation and supination? D. What is a functional range of motion for the elbow? for the forearm?

Case 2:
Your patient complains of right wrist pain and hand weakness of gradual onset. There was a remote fall 3 months ago onto the outstretched hand. The right hand is a bit cooler than the left. Your differential diagnosis includes: DeQuervains tenosynovitis Carpal Tunnel syndrome Radiocarpal arthritis Median nerve entrapment at the elbow Ulnar nerve entrapment at the wrist Radial artery thrombosis Scaphoid fracture In order to sort out the possibilities, you must be able to identify certain anatomic structures. Draw the following on your partner: median nerve at the cubital fossa median nerve at the wrist ulnar nerve at the wrist radial and ulnar arteries at the wrist boundaries of the anatomical snuff box (extensor pollicis longus; extensor pollicis brevis and abductor pollicis longus) Which carpal bone lies in the snuff box? radial and ulnar arteries at the wrist (perform an Allens test. The examiner compresses the patients radial and ulnar arteries at the wrist. The patient is then asked to rapidly open and close the hand until the palm appears white. The examiner releases either the radial or the ulnar artery and looks for return of pink color and circulation to the hand. The test is then repeated releasing the other

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artery. The hand should return to its pink color within six seconds if circulation through that artery is adequate.) (see also the glossary on our web page for an example of a positive Allens test.) the carpal tunnel (which bones are the anchoring pillars of the carpal tunnel ? what structures are in the carpal tunnel?) Draw a circle where you would tap on the median nerve to look for Tinels sign. (see also the glossary on our web page) Draw an x where you would stick a needle if you wanted to inject the carpal tunnel (or do a median nerve block). Draw an x where you would stick a needle if you wanted to aspirate or inject the wrist joint.

Questions:
A. Which of the above diagnoses best supports the clinical scenario? B. What additional findings might further support or reject each diagnosis? C. What is the typical range of motion of the wrist? of the fingers? D. What examinations allow for testing of the peripheral nerve function of the upper limb?

Case 3:
Your patient complains of neck pain, small finger numbness, and weak index finger abduction. Your differential diagnosis includes: cervical radiculopathy (which nerve root?) radial nerve entrapment ulnar nerve entrapment injury to upper trunk of the brachial plexus injury to the lower trunk of the brachial plexus

Questions:
A. How is each of the diagnoses on the differential supported or refuted by the clinical scenario? B. What might be the full complement of signs and symptoms supporting each of the diagnoses? C. How would yhou differentiate between a lower trunk and ulnar nerve injury?

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laBoratory diSSection
Goals:
1. Remove the skin and palmar fascia expiditiously! 2. See the intrinsic, thenar, and hypothenar muscles of the hand. 3. Explore the flexor tendons and the lumbricals. 4. Dislocate an MCP joint, a PIP joint, a DIP joint. 5. Do a carpal tunnel release without injuring the median nerve or its recurrent branch.

I. Dissection: Skin and Palmar Fascia (15 minutes MAX! Be efficient, dissect safely, move on.)
A. Remove all skin from the palmar surface of the hand. Be careful to reflect only the skin, leaving the palmar aponeurosis intact. Note also at the radial and ulnar margins of the palmar aponeurosis, the digital branches of the ulnar and median nerves. These branches of the median and ulnar nerves are vulnerable to superficial lacerations of the hand since they are unprotected by the palmar aponeurosis. Aside from their cutaneous distribution, would you expect any motor loss from laceration of these nerves? B. Remove the palmar aponeurosis and the fascia of the thenar and hypothenar masses. Identify the digital branches of the median and ulnar nerves, the digital arteries arising from the superficial volar arch, and the long flexor tendons with the four lumbrical muscles arising from the radial side of the profundus tendons.

II. Intrinsic Muscles of the Hand:

The muscles of the hand are composed of three groups 1) thenar 2) hypothenar and 3) central. The thenar and hypothenar groups arise in part from the flexor retinaculum or transverse carpal ligament of older terminology. Consider the flexor retinaculum a bridge over the concavity of the carpal bones, anchored by four piers, two on the medial side and two on the lateral side of the wrist. Ulnarly: pisiform and hook of hamate Radially: tubercles from scaphoid and trapezium A. Identify the thenar muscles: these arise in part from the radial aspect of the flexor retinaculum 1. Abductor pollicis brevis (inserts on base of proximal phalanx)

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MOTION OF THE THUMB JOINTS ACTION Flexion Extension Adduction Abduction Opposition Abductor pollicis longus Opponens pollicis CMC Joint MCP Joint Flexor pollicis brevis Extensor pollicis brevis Adductor pollicis Abductor pollicis brevis IP Joint Flexor pollicis longus Extensor pollicis longus

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2. Flexor pollicis brevis (usually two heads: one inserting on the radial aspect of the proximal phalanx and the other inserting on ulnar side). Where are the sesamoid bones of the thumb? (Q 4.2) 3. Opponens pollicis (inserts on first metacarpal) Locate the recurrent branch of the median nerve supplying these muscles. Describe the motion occurring at the interphalangeal joint, metacarpophalangeal joint and the carpo-metacarpal joint of the thumb. Which muscles are responsible for each action? Note that the thumb is supplied by three motor nerves, the radial, median, and ulnar. Devise a clinical test for each of these nerves using only thumb motions. (Q 4.3) B. Hypothenar muscles: note that the names of these muscles are essentially the same as the thenar group and that their insertions are similarly patterned. Identify: 1. Abductor digiti V 2. Flexor digiti V brevis 3. Opponens digiti V Note the ulnar nerve divides into a deep branch and a superficial branch which accompanies the ulnar artery and crosses superficially to the hypothenar mass. The superficial ulnar nerve supplies the palmaris brevis muscle (insignificant) and then supplies the skin of the fifth and ulnar half of the fourth fingers. The deep ulnar nerve supplies the hypothenar mass then courses ulnar to the hook of the hamate bone and supplies the interossei and adductor pollicis. The ulnar two lumbricals are also supplied by the deep ulnar nerve. \ C. Identify the central intrinsic muscles of the hand 1. Lumbricals Each arises from a flexor profundus tendon and inserts on the radial side of the extensor hood. (Innervation of the radial pair is by motor branches from the digital branches of the median nerve and the ulnar pair by the deep ulnar nerve.) What is their chief function? 2. Interossei a) Four dorsal interossei abduct the fingers b) Three palmar interossei adduct the fingers How do you test these clinically? Which spinal segment or segments supply these muscles? 3. Adductor pollicis Two heads of this muscle are described; the oblique and transverse. Both are supplied by ulnar nerve. Note that the insertion is on the ulnar side of the proximal phalanx with the deep part of the flexor pollicis brevis. It is common for the deep head of the flexor pollicis brevis to be innervated by the ulnar nerve.

III.

Middle Compartment of the Hand

A. DISSECTION: Long Flexor Tendons: Incise the flexor retinaculum longitudinally in the midpalmar plane. In the lower third of the forearm cut the sublimis tendons transversely and reflect the flexor sublimis distally, as far as the metacarpal-phalangeal joint. The latter will usually require some sacrifice of the superficial volar arch. If not done previously, remove the skin from one or two fingers on both palmar and dorsal aspects. Be careful to 139

preserve the digital arteries and nerves. If the fingers on your cadaver are too dry to dissect, please find these structures on another cadaver. B. Tendon and synovial sheaths: in the fingers, the long flexor tendons are contained within a connective tissue sheath composed of two parts; a fibrous sheath and a synovial lining. The fibrous sheath forms annular and cruciform ligaments which act as pulleys for the flexor tendons (Fig. 4.7). The first annular ligament is located palmar to the metacarpophalangeal joint (MCP), and is involved in producing the phenomenon of Trigger Finger. As the patient flexes the DIP and PIP, the flexor tendons slide in the tendon sheath, moving palmarward as the muscle shortens. If the tendon is thickened at the base of the proximal phalanx and, or A1 (1st annular ligament) is narrowed, then there is resistance as the patient extends the finger, which is abruptly released after the thickened part of the tendon passes A1, hence Trigger Finger. [Note: the swelling in the tendon below would not cause triggering; why not?] Incise the tendon sheaths longitudinally from the MCP joint to the tip of the finger. Study the attachments of the flexor tendons to the distal and middle phalanges. C. Palmar Ligaments or Volar Plate Ligament. (Fig. 4.7)

A5 A4 Palmar plate A3

C3 C2 C1

A2 Palmar plate A1 Transverse metacarpal lig.

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The anterior or volar capsule of the PIP and DIP joints is thickened to form a strong fibrous band termed the palmar plate. Besides serving as a capsule for the joint, the ligament also serves to limit hyperextension of the joints. Define Swan Neck deformity. At the MCP joint the capsular ligament is termed the transverse metacarpal ligament. Note how it is possible to hyperextend the MCP joints, but not the PIP or DIP joints.

Collateral ligaments

Central slip Terminal slip

Lateral band

Flexor digitgorum profundus

Lumbrical Interosseus Flexor digitorum superficialis

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D. Collateral ligaments. (Fig. 4.8) All three joints of the digits MCP, PIP and DIP have collateral ligaments located along the medial and lateral margins of the joints. These ligaments are slack during extension and tense during flexion. If it were necessary to cast the hand for six weeks, what position of the fingers is best to avoid contraction of the collateral ligaments? (Q4.4) ANSWERS TO ANATOMY QUESTIONS 4.1 4.2 4.3 A Carpal Tunnel Syndrome affects only the median nerve. The ulnar nerve is not affected since it courses superficial to the flexor retinaculum. The tendons of the flexor pollicis brevis muscle contain the sesamoid bones of the thumb. These may easily be seen on plain films of the hand. The thumb may be used as a rapid test of the intactness of the radial, median, and ulnar nerves. The radial nerve is tested by asking a patient to extend the thumb. Median nerve is tested by opposition of the thumb to the little finger, and the ulnar nerve is tested by adducting the thumb. Obviously, if the collateral ligaments are slack in extension it will be unwise to cast the hand with the MCP joints extended. The contraction of these ligaments during the period of immobilization would result in their shortening and subsequent loss of motion of the MCP joints. The hand is usually placed in a cast with the MCP joints in 90 degrees of flexion and the IP joints in extension. Mallet Finger is the result of an avulsion of the terminal slip of the extensor aponeurosis. The effect of this is an inability to extend the DIP joint. Restoration of function usually requires stabilization of the DIP joint in extension for a period of 6 weeks. The Boutonniere deformity is a result of injury to the central slip of the extensor expansion with an ultimate drift of the lateral bands volar to the axis of flexion and extension of the PIP joint. The eventual characteristic deformity is hyperextension of the DIP joint and hyperflexion of the PIP joint. The PIP joint can not be actively extended but can be straightened with the opposing hand. This swelling in the flexor tendon would not cause triggering because with the PIP and DIP joints in full extension the swelling is lying on the proximal side of the pulleys. Any flexion of the finger would pull it more proximally. Triggering requires that the Nodas Node or swelling in the tendon lie distal to at least one pulley (usually the A1 pulley) with the finger in extension, as shown in figure 7, Clinical Correlations of the Hand, p.117.)

4.4

4.5

4.6

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upper liMB reView

The following clinical problems have been designed to aid in your preparation for the upper limb exam. They present the anatomy in an applied way, which is, after all, how you will use your anatomic knowledge in practice. First, you should: 1. Review upper limb anatomy: basic and applied (functional). 2. Review syllabus section on living anatomy of the cervical spine and upper extremity. Then, carefully study the upper limb cases presented. (This may be more fun in a group.) First try to come up with a differential diagnosis after reading only the presenting complaint. Then, after reading the physical findings, try to rule in or out the diagnoses on your list and come up with a final single diagnosis. You should understand and be able to describe the following clinical problems: 1. Cervical nerve root impingements 2. Brachial plexus lesions 3. Peripheral nerve injuries: a. Radial nerve, high.. Saturday night paralysis low..supinator entrapment b. Median nerve high, low (carpal tunnel syndrome) c. Ulnar nerve injury, high, low (claw hand) 4. Common hand injuries a. mallet finger b. boutonniere deformity c. swan neck deformity d. gamekeepers thumb e. DeQuervains Syndrome f. laceration of extensor tendons A few of the questions on the exam will be in the form of a similar clinical case presentation followed by multiple choices for the diagnosis (see sample exam at end of syllabus).

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Upper Limb Cases

These are also available with links to the pertinent anatomy and physical exam tests on our course web site at http://eduserv.hscer.washington.edu/hubio553/cases/index.html Case #l: G.S. is a 39-year-old right-handed woman complaining of left wrist pain present for two months since the birth of her child. The pain is located on the radial aspect of the wrist and is aggravated by movement of her thumb. Physical exam reveals redness and swelling over the radial aspect of the forearm, distally. The area just proximal to the snuffbox is tender to palpation. She has pain when trying to actively extend her thumb and when her thumb is flexed into her fist and the fist ulnarly deviated. Case #2: D.G. is a 46-year-old man complaining of right arm weakness and thumb numbness. He first noticed this 3 years ago. Since then, the problem has been intermittent usually occurring for 2-3 weeks annually. On physical exam, there is tenderness to palpation at the base of the neck posteriorly. Sensory and motor examination of the shoulder is normal. There is slight weakness of forearm supination and of wrist flexion and extension. The remainder of the motor exam in the upper limb is normal. The patient has decreased sensation to pinprick on the dorsolateral aspect of the forearm and on all of the thumb. The remainder of the sensory exam is normal. Deep tendon reflexes at the elbow are normal. Brachioradialis reflex is decreased. Case #3: C.F. is a 30-year-old female typist with a 3 month history of aching and numbness in both hands. The numbness is worse at night and often wakes her from sleep. The nocturnal numbness is relieved somewhat by shaking her hands out. Physical exam reveals slight wasting of the thenar eminence on the left hand. There is decreased sensation to pinprick and two-point discrimination on the tips of the thumb and index finger on the left hand, decreased two-point discrimination only on the tips of the thumb and index finger on the right hand. Opposition strength is decreased on the left, normal on the right. Other motor tests in the hand are normal. Forced volar flexion of the wrist produces bilateral hand pain and tingling in the thumb and index fingers. Case #4: G.O. is a 19-year-old male member of the U.W. crew team complaining of weakness in grasping the oar. This has progressed over the last two months since the onset of more intensive weight training. Physical exam reveals a well-muscled individual. There is slight tenderness to palpation on the ventral surface of the forearm about 3 inches distal to the cubital fossa in the midline. Tapping in this area produces no numbness in the hand. Weakness is present on attempted flexion of the interphalangeal joint of the thumb and the DIP joints of the index and long fingers. All other motor tests reveal normal strength. Sensation in the forearm and hand is normal.

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Case #5: S.C. is a 39-year-old, right-handed, male tennis player complaining of right elbow pain that has lasted 5 months. The pain began after he continued to use a tennis racket that had cracked. The pain is present on the lateral aspect of the elbow and is aggravated by playing tennis, particularly during the backhand. Physical exam reveals no swelling, redness or deformity of the right elbow. The lateral epicondyle of the elbow is tender to palpation. Passive rotation of the radial head is painless. Wrist dorsiflexion against resistance is painful as is finger extension against resistance, particularly extension of the long finger. Motor and sensory examinations are normal. Case #6: A.I. is a 24-year-old male brought into the Harborview E.R. by the Seattle Police. He is holding his dominant right arm in front of him close to his chest, supporting his elbow. He is complaining of severe pain in his arm. Physical exam reveals marked shortening of the right arm with deformity and swelling posteriorly. Though the patient is not particularly cooperative, it is obvious that he is unable to extend (dorsiflex) his right wrist. He can straighten his fingers but cannot extend them beyond a 90 degree angle to the metacarpals. He refuses to move his elbow or to let you test sensation in the arm. Sensation in the forearm is decreased dorsally in a strip down the center extending almost to the wrist. Sensation in the hand is decreased dorsally over the thumb and the first two fingers. The patient is markedly tender to palpation in the midthird of the humerus.

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Upper Limb Cases- Discussion

1. De Quervains syndrome Tenosynovitis of the first extensor compartment i.e. extensor pollicis brevis and abductor pollicis longus. Commonly occurs during or after pregnancy during which times the synovium tends to be thickened. 2. C-6 radiculopathy A classic presentation. The key to differentiating this from more peripheral nerve problems (e.g. median or radial nerve) is that the entire thumb has decreased sensation. 3. Carpal tunnel syndrome A classic presentation. All findings are consistent with a distal median nerve problem. 4. Entrapment of the anterior interosseous nerve as it leaves the pronator teres muscle and enters the deep anterior compartment of the forearm. Occurs due to hypertrophy of the pronator teres muscle. Key to differentiating this from a more proximal median nerve problem is that losses are motor losses only. 5. Tennis elbow (aka Lateral epicondylitis, aka tendonitis of the common extensor origin) Use of the involved muscles against resistance is painful. The extensor carpi radialis brevis is usually most involved and since it inserts into the base of the third metacarpal, extension of this finger against resistance is usually particularly uncomfortable. 6. Fracture of the humerus and injury of the radial nerve in the spiral groove of the humerus. The patient can straighten his fingers because it is the interossei and the lumbricals that do this via the extensor hood (aka extensor expansion). In order to extend the fingers at the MCP joints, the radial nerve (extensor digitorum communis) must be functioning.

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growth and deVelopMent of the eXtreMitieS

Objectives:
1. Describe the major periods of embryonic and fetal development in terms of spine and limb development relative to other organ systems. 2. Describe the causes and types of hip dysplasia. 3. List the clinical tests for hip dysplasia and describe how they are performed. 4. Describe the diagnostic studies employed to detect DDH. 5. Understand the risks of untreated hip dysplasia including the possible adult sequelae. 6. Terms to know: dysplasia, subluxation, dislocation, teratologic.

Recall the stages of growth and differentiation of cells of the human embryo. During each week, new structures and organ systems develop. Having a rough idea of when major systems begin formation can help one predict co-incident pathologies. At the time of fertilization, the gametes form a zygote, which differentiates into first a morula, then a blastocyst at the time of implantation. During the second week, the trilaminar embryonic disc is formed. Cells have differentiated into endoderm, ectoderm, and mesoderm. During the third week, the neural tube forms, and the somites develop, consisting of mesoderm that will become dermatome, sclerotome, and myotome during the fourth week. The fourth through eight weeks are known as the embryonic period. Most organ systems form early in this period, and by the eighth week the basic human form is present. During the fourth week, the limb buds begin to form. It is during this week that the heart begins to beat, the primitive gut forms, the somites appear - to soon be rearranged as the primitive vertebral column develops, and the primitive urogenital system forms. Insult to the embryo during this period may thus lead not only to significant limb deformities, but deformities of the heart, vertebral column, digestive and genitourinary systems as well. Syndromes of congenital malformations frequently include many of these systems because of the timing of their development. Some of these congenital malformations are obvious (tracheo-esophageal fistula or imperforate anus, for example) while some are subtle (horseshoe kidney, congenital scoliosis). Studying the urogenital, cardiac, and musculoskeletal systems in apparently asymptomatic infants having one or more of these malformations is important, as finding an anomaly would allow it to be followed and potentially treated before becoming a significant problem. One such pairing of congenital malformations is found in the TAR syndrome Thrombocytopenia (not obvious), Absent Radius (obvious). Why would it be useful to know that a child has thrombocytopenia? During the fifth week, the hand plate begins to develop. Rays of the digits appear during the sixth week, and the cartilage model for future bones begins to appear at this time. The lower limb development lags slightly behind that of the upper limb. The seventh week marks the separation of the rays into individual digits. Failure of this separation leads to a process known as syndactylism. At this time, the upper limb begins to rotate externally, from an elbows-up and palms-on-belly position to elbows-down at the side and palms-out facing147

forward, or palms away from the midline. The lower extremity rotates in the opposite direction, from knees pointing out to the side with big toes up towards the head, to knees in line with the spine and feet flat with great toes toward the midline (Figure 5.12). It is this rotation that results in the twisting of the ligaments about the hip as well as the twists seen in the dermatomes of the upper and lower extremities (Figure 5.13). Eighth week: The fingers are now distinct, the limbs long and the elbows and knees bent. The hip joint begins to form as a cleft develops within the primitive mesynchemal tissue that will become acetabulum and femoral head. Acetabulum means vinegar cup, so think of the hip as a ball and socket joint with the acetabulum as the cup or socket. The ninth week marks the beginning of the fetal period. The hip joint is completely developed by approximately 11 weeks gestation. The early fetal period is the earliest time at which the hip is at risk for dislocation, during the completion of rotation of the lower limb.

Clinical Correlation:

Developmental Dysplasia of the Hip Developmental dysplasia of the hip, or DDH, refers to a condition in which the femoral head does not have a normal relationship with the acetabulum. It includes dislocated hips, where the femoral head is not in contact with the acetabulum, subluxated hips (note: subluxed is not a word), where the femoral head only partially articulates with the acetabulum, and the largest subgroup of all: hips with acetabular dysplasia, where the socket of the ball and socket joint is incompletely developed. DDH also includes hips with instability, where provocation subluxates the joint. The term developmental has been adopted over congenital, because the findings of DDH may not be present at birth, occurring as the child grows during the first year of life. DDH is rare but well recognized. The incidence of hip dislocation at birth is as high as 1:100 in Native Americans, 1: 1000 in Caucasians, and as low as 1:10,000 or less in those of African descent. The incidence of hip

Figure 5.12 Rotation of the extremities

Figure 5.13 Early embryonic dermatomes

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dysplasia without dislocation is approximately ten times as great. Routine screening of newborns and infants during the first year of life can detect this condition when it is most easily treated. Dysplasia means abnormal growth and development. Thus developmental dysplasia of the hip, or DDH, is a redundant term. Nonetheless, it is used to distinguish the hip dysplasia of the otherwise typically normal child from the hip dysplasia of children with spasticity or neuromuscular hip dysplasia, or the child with multiple joint contractures and teratologic hip dislocations. Teratologic dislocations occur before approximately the 20th week of gestation, and are associated with incompetent rotation of the lower limb early in the fetal period, or abnormal muscle growth and development about the hip joint, at about the 18th week. During the final four weeks of gestation, mechanical forces play a role in the development of hip dysplasia. Breech positioning extends the knees which puts stretch on the hamstrings and pushes the femoral head against the lip of the acetabulum, known as the labrum. The position of the hip is also relatively adducted, where the head of the femur is not well covered by the acetabulum. This may lead to dislocation in-utero, or dysplasia in the newborn. Other conditions thought to be in part due to packaging, i.e inadequate space for normal development, have an association with DDH. Calcaneovalgus and metatarsus adductus are foot deformities of a multifactorial nature, but in part are thought to be due to inadequate space for the fetus. The risk of DDH in patients with foot deformities such as these is higher than that of the general population. Torticollis, or congenital wry neck may also have an association with DDH, though recent studies suggest that this association is weak at best. Firstborns have a greater risk of DDH, presumably because the mothers uterus is tighter for them than for children born later in the birth order. The left hip is more commonly affected than the right, probably because the most common in-utero position, inverted and facing posteriorly and slightly to the right relative to the mother, positions the left thigh of the fetus adducted against the mothers sacrum. After delivery, swaddling habits may increase the risk of dysplasia. Holding hips adducted and extended is sub-optimal, producing some of the stresses described above in the breech positioning. Infants with hips held widely separated and flexed are less likely to develop hip dysplasia, because the abducted and flexed position tends to push the head of the femur into the deepest part of the acetabulum, encouraging further deepening of the acetabulum with time. [However, there is no evidence that double or triple diapering (with the intent of holding hips more flexed and abducted) has any impact on the growth and development of the hips.] All newborns should be checked for hip dysplasia. A newborn nursery exam by a trained healthcare provider is standard practice in this country. It includes an assessment of relative thigh lengths (the Galeazzi test, Fig 5.14), a gentle maneuver to try and reduce what may be a perched or barely dislocated hip (the Ortolani maneuver, Fig 5.15), and a gentle posterior stress on the adducted hips to test for any instability (the Barlow maneuver, Fig 5.16). The relative range of abduction of each hip is also determined. Asymmetry in any of these exams suggests the possibility of dislocation or subluxation, and further evaluation would be necessary. Upset infants can not be reliably examined, at any age. As the child ages, these exams are routinely repeated, though the likelihood of making a diagnosis from perceived instability drops with each month. The hip joint tightens with growth and development; dislocated but reducible hips tend to become irreducible, and dislocatable hips tend to stabilize despite dysplasia of the acetabulum (incomplete coverage of the femoral head). Methods for confirming a diagnosis of hip dysplasia include ultrasound and radiography, though clinical exam is adequate to make a diagnosis in the obvious case. Ultrasound is a preferable study for younger children, radiography for those over 3-4 months of age. What are the late effects of hip dysplasia or dislocation? The natural history of these conditions in adults is well known. A unilateral dislocated hip produces a shortened limb, with a shorter moment

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arm for the abductor muscles. This produces a characteristic limp, called a Trendelenburg gait. The outer table of the ilium may become a false acetabulum, but will not take the shape and perform the function of the normal acetabulum. Stiffness compared to the unaffected side may contribute to the limp, and spine problems due to compensation for the differences in leg lengths may ensue. Unilateral hip dislocations are not hard to diagnose in the early ambulator, and so are not usually seen in adults. Bilateral developmental hip dislocations are certainly harder to identify. (Q1: Why would that be?) If untreated by about age 6 years, most pediatric orthopaedists will chose not to try to relocate the hips, as the complication rates are high and the adult function with bilateral dislocated hips is fair. The gait of a patient with both hips dislocated is a bilateral Trendelenberg gait, as the abductors are weak on each side. Hyperlordosis of the spine is typically seen, and relatively reduced range of motions of the hips are seen when compared to population norms. False acetabulae are commonly present. It is

Figure 5.14 The Galeazzi test

Hip out

Hip in

Hip relocates with abduction - examiner feels clunk Figure 5.15 The Ortolani testreveals a dislocated hip

Hip pushed to rim - examiner feels clunk with relocation Figure 5.16 The Barlow testreveals an unstable hip

obvious why treatment of the dislocated hip is desired by all parents - no one wants to have a child that limps. When there is dysplasia without dislocation, what are the risks? Early degenerative arthritis is the number one concern. Abnormal load bearing across the dysplastic hip is caused by a deficient roof over a frequently malpositioned femoral head. This increases the pressure on the articular cartilage 150

of both the femoral head and the acetabulum, leading to early breakdown and arthritis. Though the patient may be asymptomatic as a pre-teen or teen (Fig. 5.17) (while the cartilage is still present), pain and stiffness early in adult life commonly follow (Fig 5.18). Q2: What are the signs of dysplasia in these two figures? Q3: What are the signs of arthritis in figure 5.18? Q4: What kind of arthritis would this be?

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Figure 5.17 Left greater than right hip dysplasia in a young adolescent

Figure 5.18 Bilateral hip dysplasia with signs of early degenerative arthritis in a teenager 152

Answers to questions Q1: Bilateral hip dislocations may be difficult to diagnose on exam because asymmetry may be absent. The hips may be Galeazzi negative, and if the child is older, Ortalani and Barlow negative as well. Decreased abduction of the hips, and, if walking, an abnormal (Trendelenberg) gait may be the only clues. Q2: The signs of hip dysplasia in figure 5.17 are hip subluxation (left greater than right), and abnormal development of the acetabulum (the roof is not as broad nor as down-going on the lateral edge as one would expect, and is seen on both sides). In figure 5.18, the roof of the acetabulum does not extend much beyond the midpoint of the femoral heads (should extend about 90% across the femoral heads), there is sclerosis and joint space narrowing, and the femoral heads appear small and dysplastic. Q3: Signs of early arthritis in figure 5.18 include bilateral joint space narrowing and sclerosis of the acetabular roof. Q4: This is not an inflammatory, infectious, crystalline, or seronegative arthritis, so it must be early osteoarthritis.

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MuSculoSkeletal trauMa
Objectives and Preparation:
1. Understand the physiology of normal bone turnover and fracture healing. 2. Be able to describe a fracture and anticipate its possible complications. 3. Understand the physiology and expected findings in compartmental syndrome.

Clinical Perspective:
You are an emergency room doctor. You are told that there are 3 patients waiting to be seen: Behind door 1: 16 year old female athlete with shin pain for two weeks since starting track season at high school Behind door 2: 16 year old skier with shin pain for two hours following a ski accident in which her bindings didnt release Behind door 3: 16 year old male with shin pain for maybe about a month Which patient should you see first?

Fracture Definitions:
Fracture : broken bone: normal bone, abnormal loads Pathologic fracture: broken bone: abnormal bone, normal loads Stress fracture: crack : normal bone, normal loads, abnormal frequency of loading Bone turnover Bone is made up of a mineralized organic matrix on a collagen framework. Bone is a dynamic tissue, constantly remodeling itself. Osteoclasts remove old bone and osteoblasts deposit new bone. During normal bone turnover, resorption and deposition are coupled in a cellular construct called a cutting cone. The osteoclasts at the head of the cone decrease the pH of the tissue, making hydroxapatite soluble. Osteoblasts follow, laying down osteoid which is soon mineralized. This process is regulated by systemic and local factors and by physical loading. As originally described by Wolff in 1892, bone adapts to stress by altering its shape, its inner structure, and the distribution of matrix within the bone. Remodeling can be initiated by stresses (load or force) and strains (elasticity or displacement) within the bone generated by gravitational forces, impact, muscle pull or muscle fatigue. Remodeling depends not only on the biophysical environment, but also on the local and systemic environments. Exercise produces distortions in bone cell membranes which may change their electrical potentials. It also affects circulation and hormone production. All are involved in signaling the bone with regard to its rate of remodeling. Remodeling is faster in young and recently fractured bone because they are more elastic. Bone is anisotropic (not homogeneous). Therefore, strength and elastic properties differ depending on the direction in which the bone is loaded. The anisotropic nature of bone causes the strains to be

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variable in different parts of the bone in conformance with its varying microstructure. The adaptation (remodeling) of bone to a change in its stress/strain pattern often neutralizes the change so that the new configuration of bone is more capable of withstanding the stress applied. Adaptation is a function of the number of loading cycles, the frequency of cycling, and the amount of strain, strain rate, and strain duration per cycle. When bone is loaded excessively, it fractures. However, when smaller loads are applied, bone mass will increase as long as the frequency of stress/strain cycles is low. Because living bone is able to undergo cyclical loading and unloading indefinitely, stress fractures occur only when the remodeling of bone is outpaced by the fatigue process, i.e. when the rate of osteoblastic bone deposition is exceeded by the rate of osteoclastic bone resorption. Although the terms stress fracture and pathologic fracture are sometimes used interchangeably, they really shouldnt be. In stress fractures the bone is normal and the body is usually making an attempt to adapt but isnt given enough time. In pathologic fractures the bone is abnormal and there may be little if any remodeling occurring. Stress fractures Stress fractures occur most commonly in the lower extremity especially in the tibia, fibula and metatarsals. Stress fractures typically hurt during impact exercise and are tender to touch over a discrete area. Because stress fractures are cracks, they are visible radiographically in only 50 % of cases (fewer when symptoms are less than 10 days old). Technetium diphosphonate bone scans will show a stress fracture after 24 hours of symptoms. Bone scans depend on the bones uptake of radioactive phosphorous following an intravenous injection. If an area of bone is turning over at a faster than normal rate, that bone will take up more of the phosphorous. Special cameras pick up emissions from the phosphorous isotope and one sees a skeleton with a hot spot (more emissions) at the site of the lesion. Bone scans are extremely nonspecific but very sensitive. The increased turnover/uptake can be due to infection, tumor, fracture, or blood flow and one must use clinical information to differentiate them in ones patient. (Some tumors are cold on bone scan, i.e. they induce no reaction in the bone and therefore no increased uptake, e.g. multiple myeloma or lymphoma of bone). Magnetic Resonance Imaging (MRI) will also show a stress fracture in its early stages, but is significantly more expensive. However, MRI is helpful when trying to distinguish a stress fracture from a tumor and also in the pediatric setting where normal physeal uptake makes visualization of stress fractures difficult. When a patient has had a series of stress fractures or when a female patient with a stress fracture has irregular menses, consider the possibility of underlying decreased bone mineral density. Bone mass is laid down before the age of 30. Therefore the teenage and early adult years are critical for lifelong bone health. Even when an abnormal hormonal milieu is recognized and treated, further bone loss may be curtailed, but the patient will never recover the amount of bone lost. Pathologic fractures Pathologic fractures present as the sudden onset of pain, perhaps with a previous history of lowgrade aching. Usually there is no history of trauma or change in activities. When there is a history of trauma, usually the energy of injury is low. Pathologic fractures occur in the following settings: osteopenia- metabolic (eg- osteomalacia, Cushings disease), osteoporosis (hormonal, disuse, neuropathic), primary tumor (eg-multiple myeloma), metastatic tumor (most common: lung, prostate, breast, renal), cysts, and infection. The tumor most commonly found in bone is a metastatic tumor. The tumor most commonly originating in bone is multiple myeloma. The most common skeletal sites for metastatic tumors are the vertebrae, pelvis, femur, and humerus.

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Fracture healing Fracture healing is dependent on the vascularity of the fractured bone and its surrounding soft tissues as well as on the biomechanical environment. If there is enough oxygen (vascularity) present but the ends of the bone are moving, fibrous tissue will form. If there is enough oxygen and the ends of the bone are held still and approximated, bone will form. If there is movement and insufficient oxygen, cartilage will form (no blood, no bone). The interaction between these factors determines whether the outcome will be union, malunion, delayed or non-union. In the first 7 days after fracture an inflammatory response occurs. From day 14 to day 17 the reparative process begins with synthesis of collagen, proteoglycan, and differentiation of pluripotential mesenchymal cells to osteoblasts. When a bone fractures completely, the hematoma which forms is gradually replaced first by fibrous tissue, then by fibrocartilage. This mass of fibrocartilaginous tissue is known as callus. As it starts to ossify, it becomes visible radiographically as a fluff of bone around the fractured bone ends. Callus acts as a scaffolding for the deposition of new bone. Over time (usually a year) the callus remodels to conform to the bones original shape. This remodeling is due to the strains seen by the bone from loads applied by muscle pull, weight-bearing, and gravity, all of which determine the shape the bone will take. The message from the physical loads to the bone cells is transmitted via a combination of electrical and chemical signals. When a fracture is rigidly fixed internally, no external callus occurs and the fracture ends are bridged directly by a process that strongly resembles remodeling. Osteoclasts remove bone and osteoblasts lay down new bone without the intermediary stage of fibrocartilage formation. Fracture patterns One must be able to accurately analyze and describe a fracture in order to understand how it occurred and in order to communicate with a consultant when necessary. Understanding the mechanism of injury leads to proper reduction maneuvers when the fracture is not ideally aligned, and anticipation of expected outcome including possible complications. The following are the key factors in this analysis and description: 1. location: intra-articular, epiphyseal, diaphyseal, metaphyseal Intra-articular fractures require anatomic reduction or early motion to lessen the chances of secondary osteoarthritis. For pediatric fractures that cross the growth plate (physis), Salter described a classification system which is extremely helpful in determining treatment based on usual outcome for each class. Physeal fractures may lead to cessation of growth, either partially or completely, or to overgrowth. 2. patterns: transverse (bending), spiral (rotation), oblique (a combination of bending and rotation), compression (axial). The pattern tells you how the fracture occurred and therefore how to reduce the fracture when it is not aligned properly. 3. comminution: pieces Comminution reflects the energy of injury. The greater the force (energy) (think explosion) the more comminution and the higher the potential for complications. One complication is delayed union due to interrupted blood flow and/or less control of the fracture by surrounding muscles. Others are various sequelae of swelling such as fibrosis or compartmental syndrome. 4. open vs closed An open fracture is more likely to become infected. Even a tiny puncture wound communicating with a broken bone is considered an open fracture.

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5. alignment- displaced, angulated The alignment determines whether any reduction maneuver will be required before the fracture is immobilized either externally or internally. Varus or valgus, flexed or extended always refer to the position of the distal fragment relative to the proximal fragment. Valgus: distal fragment is angulated away from the midline.

*********************************************************** Compartmental syndrome The pathophysiology of compartmental syndrome begins with an increase in local tissue pressure within the fixed space of a fascial compartment. This in turn increases the intracompartmental venous pressure, leading to a decreased arteriovenous gradient, and to decreased capillary flow to the tissues such that they become ischemic. The ischemia can affect nerves as well as muscles. Arteries (and therefore distal pulses) are usually intact. The key problem is insufficient capillary flow to meet metabolic demands. Ischemic tissues are usually painful. Treatment requires decreasing venous pressure. This might be initiated by loosening dressings (including splints or casts), or elevation of the involved limb, but not above heart level. (Why?) In most cases, one must operatively release the fascia of the involved compartment. [More on compartment syndrome in the trauma section that follows.]

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Lets return to the emergency room and our three patients: Behind door 1: 16 year old female athlete with shin pain for two weeks since starting track season at high school; Behind door 2: 16 year old skier with shin pain for two hours following a ski accident in which her bindings didnt release; Behind door 3: 16 year old male with shin pain for maybe about a month; Which one should you see first and why?

Answers: Who is in need of emergent care? One patient had a recent trauma and may have an acute fracture that could be complicated by a compartment syndrome, one may have a stress fracture or shin splints with a new activity, and the third isnt even sure how ling they have been having pain -- though that doesnt mean they woudnt benefit from careful evaluation.

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160

putting it all in perSpectiVe tipS on reading radiographS

Objectives and Preparation:

More trauMa

1. Understand the musculoskeletal aspects of trauma. 2. Be able to list five musculoskeletal emergencies 3. Be able to explain the fracture pattern seen on trauma radiographs.

Clinical Perspective:
You are (still) an emergency room doctor. You are told that there are 3 (more) patients waiting to be seen: Behind door 1: 36 year old female front seat passenger extricated from a vehicle involved in a high speed collision. She has facial trauma, difficult respirations, and gross deformity of the lower extremity. Behind door 2: 36 year old truck driver yelling in pain with a flexed, shortened, and internally rotated thigh following the same motor vehicle collision. Behind door 3: 36 year old inebriated male lying on a back board moaning about tingling toes. Which patient should you see first? What should you do for them?

Definitions:

I. Musculoskeletal Aspects of Trauma Trauma is one of the leading causes of death and disability worldwide. In the US, it has been the number one cause of death for people ages 1 to 44 years of all races and socioeconomic levels. This disease costs the US nearly $50 billion per year, with 100,000 fatalities per year and 500,000 permanent disabilities. Trauma related admissions constitute the majority of emergency department visits at acute care hospitals.1 70-80% of those admitted for trauma have musculoskeletal injuries. These may be due either to blunt trauma or penetrating trauma. Worldwide, 20 million people per year are injured or disabled by road-traffic injuries. On average, there are 55,000 serious injuries per day, 90% of which occur in low and middle income countries. 2 Musculoskeletal injuries have impacts on the patient, their family, and society as a whole. There are the physical and psychological effects of pain, limitations in activities of daily living and loss of independence with loss of quality of life; societal costs for diagnosis, treatment, and rehabilitation from injuries; and the indirect costs associated with lost income for a family and loss of productivity for society.3 Worldwide, where societal safety net programs often do not exist, these indirect costs can push a family beyond their means and leave them destitute. Establishing rapid and effective treatments for potentially debilitating musculoskeletal trauma are major global challenges. (For more information, see http://www.sign-post.org for more information on one organizations approach to this near-epidemic).

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Motor vehicle accidents are the second most common cause of nonfatal accidental injury at all ages.5 Velocity of a motor vehicle accident and the involvement of drugs or alcohol are the major factors associated with increased risk of fatality. Falls are the leading cause of nonfatal hospital visits. Younger patients are less likely to be admitted (under age 5) while for older patients (over age 65 yrs), falls are the leading cause of accidental death. The most common fractures in the older age group are hip fractures (femoral neck and intertrochanteric femur fractures) and distal radius or Colles fractures. II. Musculoskeletal Emergencies Compartmental syndrome: The pathophysiology of compartmental syndrome begins with an increase in local tissue pressure within the fixed space of a fascial compartment. This in turn increases the intracompartmental venous pressure, leading to a decreased arteriovenous gradient, and to decreased capillary flow to the tissues such that they become ischemic. The ischemia can affect nerves as well as muscles. Arteries (and therefore distal pulses) are usually intact. The key problem is insufficient capillary flow to meet metabolic demands. Ischemic tissues are usually painful. In acute compartmental syndrome, the earliest clinical finding is significant swelling and tightness to palpation of the compartment and pain out of proportion to the injury or pain that does not respond to analgesic medication. The ischemic muscles will be especially painful when they are passively stretched. Later one finds hypesthesia in the distribution of the nerve supplying that compartment (NOT necesarily in the skin overlying the compartment) and weakness of the muscles in the involved compartment. One must have a high index of suspicion (based on the energy of injury) and consider the diagnosis early. If you are not thinking of this diagnosis, you will miss it. Although compartmental pressures can be measured, this need not be done when the clinical setting and picture is characteristic. When a patient has an untreated acute compartmental syndrome for more than 12 hours, permanent damage is highly likely. This damage takes the form of fibrosis and contracture of the involved muscles leading to loss of function. Early diagnosis and treatment are critical. One needs to relieve venous pressure. This might be initiated by loosening dressings (including splints or casts), or elevation of the involved limb, but not above heart level. (Q1: Why?) In most cases, one must operatively release the fascia of the involved compartment. In chronic compartmental syndrome (also called exertional compartmental syndrome) the swelling does not occur acutely, nor is it as dramatic. Chronic compartmental syndrome is due to swelling in the muscles secondary to exercise. MRI has shown that muscles generally swell about 10% of their original volume secondary to exercise. Usually this is not problematic. However some patients either swell more (idiopathic or drug-related) or have less compliant fascia and end up with compartmental syndrome that occurs only during exercise. These patients have leg pain that comes on after exercising for a certain amount of time or running a certain distance. Usually the time period before symptoms is very consistent for that particular patient. The patient may or may not notice swelling, tightness, or numbness. Pain resolves after a few hours. (Q2: Why?) Unless you examine the patient at the time s/he is exercising, you will find nothing on exam. Sometimes you will find a muscle hernia. (Q3: Should you repair it?) The diagnosis of chronic compartmental syndrome can be made by measuring intracompartmental pressures before, during, and after exercise. Once the diagnosis is made, one can treat the problem by

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suggesting that the patient exercise below the symptomatic threshold or change any medication that might be playing a role. Alternatively, one can do an operative fascial release. Spinal injuries: Falls from a height with calcaneus fracture(s) are often accompanied by a fracture of the spine. These may be a mild vertebral compression fracture with no neurologic compromise, to fracture dislocation with paraplegia. Immobilizing the spine during evaluation may prevent progressive neurologic injury after destabilization from a trauma. Motor vehicle accidents are again the most common cause of spinal injury. The cervical spine is the most commonly injured, followed by the lumbar spine. Evaluation of spinal function follows establishment of the Glascow Coma score and includes a survey of the sensory dermatomes and motor levels from C4-T4, L1 to S1, and a determination of the basic reflexes. Crush Injuries: Prolonged compression of a limb may lead to tissue necrosis from ischemia with myoglobinemia, hyperkalemia, metabolic acidosis, and hyperphosphatemia. This may lead to hyovolemic shock, renal failure, and a 20-40% mortality rate. Open fractures: Any fracture that is associated with a connection to a disruption of the overlying skin is an open fracture at risk for infection. Early aggressive irrigation and debridement of grossly infected tissues is essential to forming a non-infected early union of the fracture fragments. A fight bite - a punch to the mouth resulting in a tooth lacerating the skin overlying the fractured knuckle of the puncher - is an open fracture that needs irrigation and debridement. If the metacarpal is not fractured by the tooth, the extensor tendon may be lacerated and at risk for an infectious tenosynovitis or tendon sheath infection. Pelvic Fracture: Often associated with high-energy trauma, pelvic fracture may result in significant blood loss and morbidity. Early stabilization may prevent death from hemorrhagic shock. Because of the high-energy required for these injuries, additional extremity fractures, as well as injuries to the chest and abdomen, should be suspected. Bilateral Femur Fractures: Bilateral femur fractures have a high mortality rate, as each thigh may accept up to a liter or more of blood without an open wound. Early stabilization prevents further injury to the soft tissues and may limit further blood loss. Traumatic Knee Dislocation: High energy trauma to the knee may result in multiple ligament injuries and dislocation of the tibiofemoral joint. The trauma may result in popliteal artery disruption or injury, putting the leg and foot at risk. Ankle-brachial indices or ABIs should be routinely performed after reduction of a knee dislocation to assess vascularity of the extremity below the knee.

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Bone and Joint Infections Pus under pressure, for example as seen in septic arthritis of the hip, may inhibit the blood supply to the femoral head. Also, the enzymes released from lysis of neutrophyls and other cells may erode articular cartilage, thus pus in joints is typically a relative orthopaedic emergency. The best treatment is drainage, dilution, and then specific antibiotics. When the infection is within the bone, often it occurs in the metaphysis. Eruption into the joint may occur, bringing with oit the risks noted above.

Answers to Questions Above: Q1: Why not elevate a limb when there is a question of compatmental syndrome? Elevation of the limb would potentially increase ischemia by decreasing capillary blood flow, as pressure in the terminal arterioles would be decreased. Q2: Why does pain resolve a few hours after stopping exercise in chronic exertional compartmental syndrome? Pain in this case is from a mild or relative ischemia. Intracompartmental swelling, here likely triggered by increased blood flow in the exercising muscle within the compartment, would be expected to slowly drop as muscle size decreases with rest. In contrast, an acute traumatic compartmental syndrome is often accompanied by bleeding within the tissues that slowly increases the pressure within the compartment. Q3: Should one repair a muscle hernia when concerned about chronic compartmental syndrome? Pain from a bit of muscle squeezing through a rent in the fascia would be best prevented from recurring by opening the fascia, i.e. compartment release. Closing the rent in the fasica would increase pressures withinin the compartment during exercise, risking recurrence of a chronic compartmental syndrome or resplitting of a portion of the fascia and repeat muscle herniation.

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Interpreting radiographs of fractures and deformities

Consider the following radiographs: Questions to ask 1. What bone (or bones) are fractured? (Q1) 2. Where in the bone is the fracture? (proximal, distal; medial, lateral; metaphyseal, diaphyseal, epiphyseal) (Q2) 3. What is the fracture pattern? (transverse, oblique, comminuted, etc.)(Q3) 4. What is (are) the displacement(s)? a. For example, the displacement may be apex anterior or posterior, apex medial or lateral. The apex is the bend. The angle made by the bend looks a bit like the head of an arrow. The direction that arrowhead points is the apex. Rotational deformities may also occur. What are the deformities in the fracture above? (Q4) b. Near a joint, use the terms varus or valgus, flexion or extension. When a deformity moves a limb away from the midline, it is in valgus; towards the midline, varus. For example, what is the deformity at the knees in this patient? (Q5)

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Practice questions: describe these fractures or deformities. A. B. C.

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Answers to above questions on interpreting radiographs: Q1. What bone or bones are fractured? These forearm radiographs show a definite fracture of the radius, that is already showing signs of healing with the presence of fracture callous, and a probable fracture of the ulna. Q2. Where in the bone is the fracture? The fractures are distal metaphyseal. Review the parts of bones - diaphysis (shaft), metaphysis (where the cortex is towards the joints in adults, on the diaphysial side of the physis in skeletally immature patients), physis (growth plate in skeletally immature patients), epiphysis (between the physis and the joint in skeletally immature patients.) Q3. What is the fracture pattern? Tough to say here, as the radius fracture is already healing. Q4. What is (are) the displacement(s)? The radius is most obvious displaced. It is angulated and not translated. The displacements of the radius are apex ulnar and volar, or - considering the anatomic position, apex medial and anterior. Q5. For example, what is the deformity at the knees in this patient? This patient has valgus of the knees (genu valgum), as the legs (the distal side of the joint) point away from the midline.

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References: 1. Skinner, HB et al. Musculoskeletal Trauma Surgery. In Current Diagnosis and Treatment in Orthopedics, edited by Skiner, HB. Appleton and Lange, East Norwalk, 1995, p. 51. 2. Yegge, John. Questions & Answers About the Kiwanis/SIGN Initiative to Save Families by Working to Achieve Equality of Fracture Care Worldwide, http://www.tcfn.org/kiwanis-sign/resourceg.pdf. 3. Skinner, HB et al. Musculoskeletal Trauma Surgery. In Current Diagnosis and Treatment in Orthopedics, edited by Skiner, HB. Appleton and Lange, East Norwalk, 1995, p. 51. 4. Committee on Trauma, American College of Surgeons: Advanced Trauma Life Support. American College of Surgeons, Chicago, 1993. 5. Bernstein, J. Musculoskeletal Medicine. AAOS, Rosemont, 2003, p. 153.

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anatoMy 5: introduction to the lower liMB: luMBar pleXuS and MuScleS of the thigh
Objectives
1. Describe the compartmentalization of muscles in the lower limb. (Lecture topic and to be developed in future labs)

2. Describe the developmental rotation of the limb in relation to innervation by the lumbar and sacral plexuses. (Most of this will be in lecture) 3. Describe the lumbar plexus. 4. Describe all bony landmarks of pelvis and femur in relation to the origin and insertion of muscles located in the anterior and medial compartments of the thigh. Describe the actions and innervations of these muscles. 5. Describe the femoral triangle including boundaries and contents. 6. Describe the branches of the lumbar plexus which provide cutaneous distribution to the lower limb. ) 7. Describe the femoral artery and its branches in the anterior compartment of the thigh. I. Osteology:
You should begin your study of the lower limb by learning the following bony landmarks. A. Innominate bone: Note the innominate consists of three fused elements: ilium, ischium and pubis. Identify the following on the skeleton: iliac crest ant. sup. iliac spine ant. inf. iliac spine ilio-pubic eminence acetabulum acetabular notch B. Femur: Identify the following: head neck greater trochanter lesser trochanter intertrochanteric line linea aspera condyles adductor tubercle intercondylar notch pubic tubercle obturator foramen ischial tuberosity post. sup. iliac spine post. inf. spine gr. sciatic notch

II. Muscles of the Buttock and Thigh - Introductory Comments: )

An effective means of studying the muscles of the buttock and thigh is to compartmentalize them on an anatomical and functional basis. In this manner, the buttock and thigh may be divided into four 169

muscular compartments each having an action on the hip. This concept is facilitated by the fact that the muscles in each compartment are supplied by a single nerve. FLEXORS: Anterior compartment of the thigh: Femoral nerve EXTENSORS: Posterior compartment of the thigh: Tibial branch of sciatic ADDUCTORS: Medial compartment of the thigh: Obturator ABDUCTORS: Lateral or gluteal compartment: Superior gluteal nerve The muscles in the anterior group also act at the knee as extensors of the knee joint, and conversely, posterior thigh muscles flex the knee joint. Two of the four compartments are supplied by the lumbar plexus (femoral and obturator nerves) and two by the lumbosacral plexus, (superior gluteal and tibial branch of sciatic.) Regrettably, teaching strategies often employ half truths for the purposes of simplifying concepts and the above is no exception. The prime extensor of the hip is the gluteus maximus supplied by the inferior gluteal nerve, whereas the posterior compartment muscles, the hamstrings, are only secondary hip extensors. The gluteal muscles and the posterior compartment will be studied in the next laboratory session. A. Muscles of the Anterior Compartment: Using your figures, atlas, and tables, identify the attachments of all muscles in the anterior compartment. Quadriceps femoris: Rectus Femoris Vastus medialis Vastus intermedius Vastus lateralis Sartorius Pectineus Tensor fascia lata

The primary role of the quadriceps femoris (Fig 5.1 and 5.2) is extension of the knee via the patellar ligaments attachment on the tibial tuberosity. Do not confuse the quadriceps tendon which can be identified proximal to the patella and the patellar ligament (tendon) distal to the patella. A variety of trauma occurs in this region including quadriceps tendon tear, tendonitis, patellar fractures, and avulsion of the patellar ligament either proximally (patellar end) or distally

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(tibial end). An inflammatory condition of the tibial tuberosity, tibial apophysitis (Osgood-Schlatter Disease), is common in 12-14 year old adolescents. Note the rectus femoris is the only muscle of the quadriceps group to act at the hip and then only as a weak flexor. The primary flexor of the hip is the iliopsoas, (Fig 5.3) originating from the lumbar vertebrae and the iliac fossa inserting on the lesser trochanter of the femur. As the psoas tendon crosses the hip joint, it is enveloped in a bursa, which if inflamed, can produce hip pain during flexion.

Quadriceps Femoris Rectus Femoris Vastus lateralis Vastus intermedius Vastus medialis

Figure 5.1 171

Figure 5.2

The sartorius is a long slender muscle crossing both the hip (which it can flex and externally rotate) and the knee (which it can flex) (Fig 5.4). It inserts into the medial tibia at the gooses foot, the pes anserinus, in conjunction with the gracilis and semitendinosus muscles. The tensor fascia lata inserts on the lateral side of the tibia via the iliotibial tract (Fig 5.4). Its most important role is probably in postural control of the pelvis during standing. Although most

Psoas major m.

Iliacus m.

Insertion of Iliopsoas on lesser trochanter

Figure 5.3 172

texts include it as a muscle of the anterior thigh, it is innervated by the superior gluteal nerve and shares its attachment to the iliotibial tract with the gluteus maximus, the principal extensor of the hip. The pectineus is a small muscle, but is innervated by both femoral and obturator nerves. It may act in flexion and adduction and is usually considered to be part of both the anterior and medial compartments of the thigh (Fig 5.5). B. Muscles of the medial compartment (adductor compartment) of the thigh.

Tensor fascia lata m.

Sartorius m.

Figure 5.4 173

Using your figures, atlas, and tables, identify the attachments of all muscles in the medial compartment.

Pectineus m. Adductor brevis m. Gracilis m.

Figure 5.5 174

Gracilis Pectineus

Adductor brevis Adductor longus Adductor magnus

The gracilis muscle is the only muscle of this group which crosses both the hip and the knee (Fig 5.5). It inserts into the pes anserinus along with the sartorius and the semitendinosus. All of the muscles in this compartment serve to adduct the hip joint. For anyone who has been on snow or water skis, the abduction force on the legs while one is in motion is well appreciated. The adductors resist this force to keep the skier on track. When the leg is forcibly abducted, whether on skis or having a person fall on your outstretched leg (football or soccer), there is a substantial traction on the adductors which can result in an adductor tear (groin pull) or avulsion of the pubic bone from which the adductors originate. This is essentially the same event as the more well known hamstring pull off the ischial tuberosity and results frequently in such spasm and pain that the patient requires medication. In reviewing the insertion of the adductor magnus (Fig 5.6), note that the distal part attaches not only to the linea aspera but also to the adductor tubercle on the medial epicondyle of the femur. This creates a tunnel or hiatus (adductor hiatus) for the femoral artery and vein to pass from the anterior compartment of the thigh to the popliteal space. It is also the point where the femoral artery changes its name to popliteal artery.

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All of the adductors are supplied by the obturator nerve from the lumbar plexus.

You should note that the obturator nerve has two divisions, an anterior and posterior which supply muscle and skin as follows:
Anterior division: pectineus, gracilis, adductor brevis, adductor longus, and medial cutaneous nerve of the thigh. Figure 5.6

Adductor longus m.

Adductor magnus m.

Adductor hiatus

Posterior division: obturator externus, adductor magnus. (Fig 5.6 and 5.7)

The adductor brevis separates the anterior and posterior divisions of the obturator nerve, with the anterior division lying directly on the muscle.

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Figure 5.7

Obturator externus m.

Anterior division of the obturator n. Posterior division of the obturator n.

III. LUMBAR PLEXUS: (Fig 5.8)

A. One might expect the five lumbar spinal nerves to be distributed over the lumbar portion of the abdominal trunk and the sacral nerves to be distributed to the lower extremities. In fact, only L1 supplies the skin of the abdomen; the remaining lumbar nerves are distributed to the skin and muscles of the lower limb. Some texts consider the spinal nerves L1-S5 to compose a single large plexus, the lumbosacral plexus. Others divide the nerves into separate lumbar and sacral plexuses. In this course they will be considered separate plexuses. The lumbar plexus will be studied in this exercise and the sacral plexus in the next laboratory with the gluteal region. B. The nerves of the lumbar plexus are formed by the division of spinal segments T12-L4 which subsequently reform a series of six peripheral nerves plus unnamed muscular branches (Fig 5.8). With the exception of L1, all of the nerves forming the lumbar plexus will subsequently divide into anterior and posterior divisions. These are not to be confused with the anterior and posterior primary rami of the spinal nerves. Each anterior primary ramus from L2-S5 forms an anterior and posterior division which may unite in a plexus form to establish a peripheral nerve, thereby consisting of more than one segment. During your study of the anatomy of the abdomen, you were introduced to the lumbar plexus in relation to the posterior abdominal wall.

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Figure 5.8

Lateral cutaneous n. of thigh Obturator n. Femoral n.

C. Lumbar Plexus: The lumbar plexus essentially forms six nerves. Three supply the skin of the trunk and three contribute to the innervation of the lower limb. The first three nerves should have been studied previously during the first year anatomy course because they relate to the skin of the lower abdominal wall and perineum. The latter three nerves are important sensory and motor nerves to the thigh. 1. 2. 3. 4. 5. 6. Iliohypogastric: (T12), L1 Ilioinguinal: L1 Genitofemoral: L1, L2 Obturator: L2, 3, 4 Lateral femoral cutaneous: L2, 3 Femoral: L2, 3, 4

IV. THE FEMORAL TRIANGLE (Fig 5.9)

The femoral triangle includes muscles from both anterior and medial compartments. It is bounded by the inguinal ligament, sartorius and adductor longus muscles. It is not a plane triangle, but has depth (as in solid geometry), so that there is also a roof and floor. The roof is formed by the fascia lata and the floor by the iliopsoas tendon and pectineus muscle (Fig 5.9).

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Figure 5.9

Femoral Triangle Inguinal ligament Sartorius m. Adductor longus

The triangle contains the femoral nerve, artery, and vein and their branches as well as a femoral hernia when present (Fig 5.10). It is the site where a catheter is placed in the femoral artery for angiography or in the femoral vein for venograms of the trunk. In the femoral triangle the femoral nerve supplies all of the anterior thigh muscles. In addition it sends cutaneous branches to the skin of the anterior thigh. The terminal branch of the nerve is named the saphenous nerve. It continues past the medial side of the knee, giving off an infrapatellar branch to the skin of the patellar region, and supplies the skin of the medial leg and foot.

Femoral n. Femoral artery Femoral vein

Fig. 5.10 179

Both femoral artery and vein give off deep femoral branches which in turn give off perforating branches into the posterior compartment. Although the pattern varies to some degree, in general, the deep femoral vessel sends medial and lateral femoral circumflex vessels around the neck of the femur (Fig 5.11). The arteries are particularly important because the medial femoral circumflex supplies the head of the femur and the lateral femoral circumflex the greater trochanter. Injury to these arteries in children may cause dysplasia (abnormal growth and development) of these growth centers. Injury of the medial femoral circumflex artery in particular may cause avascular necrosis of the femoral head in both children and adults.

Lateral femoral circumflex a. Medial femoral circumflex a.

Femoral artery Deep Femoral a.

Femoral artery traversing adductor hiatus to become popliteal a.

Figure 5.11 180

V. Lumbar Plexus: Distribution of Nerves in the Limb

A. Developmental rotation of the limb The distribution of the lumbar and lumbosacral plexuses to the lower limb may be confusing until the development of the lower limb is considered. During development the plantar surfaces (soles) of the feet face medially, i.e. towards each other. The upper limb develops in a similar manner and can be used to model lower limb development. Place your hand at your side with the palm facing forward. All of the muscles on the anterior aspect of the arm, forearm and hand are supplied by anterior divisions of the brachial plexus, while posterior muscles are supplied by posterior divisions. If you could similarly position your lower limb you would find the same parallel for the divisions of the lumbar and lumbosacral plexuses. Because of our plantigrade posture, there is a medial rotation of the lower limb to place the sole of the foot on the ground. Place both hands at your side in the anatomical position, then rotate your thumbs medially and place the palms of your hands on a table at about waist level. This is the rotation of the lower limb. Note how the muscles which were originally facing forward are now facing posteriorly, i.e. your forearm is now facing your body. Thus, the muscles which are located on the anterior aspect of the adult thigh or leg were located posteriorly in the embryo and are therefore supplied by posterior divisions. This accounts for the fact that the femoral nerves are made up from posterior divisions, although they supply muscles located on the anterior aspect of thigh and leg in the adult. (see page 186 for further details)

181

TABLE 12: MUSCLES ACTING ON THE HIP JOINT ORIGIN pubic crest inf. ramus of pubis pubic symphysis & arch pectineal line inf. pubic ramus & ischium ischial tuberosity outer ilium outer ilium front of sacrum inner surface of pelvis ant. sup. iliac spine gluteal tuberosity & iliotibial tract post tibia upper medial tibia lateral side of head of fibula linea aspera & adductor tubercle lesser trochanter lesser trochanter base of patella linea aspera upper medial tibia ilio-tibial tract inferior gluteal sciatic-tibial portion sciatic-tibial portion sciatic-tibial & fibular portions obturator & sciatic direct: lumbar plexus femoral nerve femoral femoral & obturator femoral superior gluteal lateral greater trochanter ant. greater trochanter upper greater trochanter medial greater trochanter iliotibial tract sup. gluteal sup. gluteal first & second sacral sacral plexus nerve superior gluteal linea aspera upper linea aspera upper medial tibia linea aspera linea aspera & adductor tubercle intertrochanteric line obturator obturator obturator femoral, obturator obturator & sciatic N. to QF and gem. inf. INSERTION PERIPH. NERVE SPINAL SEG. L2, 3 L2, 3 L2, 3, 4 L2, 3 L3, 4 L4, 5, S1 L4, 5, S1 L4, 5, S1 S1, 2 L5, S1, 2 L4, 5, S1 L5, S1, 2 L5, S1 L5, S1, 2 L4, L5, S1, 2 L3, 4) L2, 3 L2, 3 L2, 3, 4 L2, 3 L2, 3 L4, 5, S1

MOVEMENT

MUSCLES

Adduction

adductor longus adductor brevis gracilis pectineus adductor magnus quadratus femoris

Abduction

gluteus medius gluteus minimus piriformis obturator internus tensor fascia lata

Extension

gluteus maximus

semimembranosus semitendinosus biceps femoris (adductor magnus lumbar vertebrae iliac fossa inf. Iliac spine, acetabulum pectineal line; pubis anterior superior iliac spine anterior superior iliac spine

post. gluteal line, sacrum & coccyx ischial tuberosity ischial tuberosity ischial tuberosity & femur inf. pubic ramus & ischium

182
SEE ABOVE ischial spine ischial tuberosity ischial tuberosity area of obturator foramen medial greater trochanter medial greater trochanter intertrochanteric line trochanteric fossa

Flexion

psoas major iliacus rectus femoris pectineus sartorius

Rotation medial

TFL gluteus minimus semitendinosus semimembranosus

Rotation lateral

sartorius gluteus maximus gluteus medius

pirformis obturator internus gemellus sup. gemellus inf. quadratus femoris obturator externus

nerve to obturator internus nerve to quadratus femoris special branch from sacral plexus obturator nerve

L5, S1, 2 L4, 5, S1 L4, 5, S1 L3, 4

TABLE 13: MUSCLES ACTING ON KNEE JOINT

MOVEMENT quadriceps femur (vasti) & anterior inferior (3 vasti and rectus femoris) iliac spine (rectus) semimembranosus semitendinosus biceps femoris gastrocnemius (plantaris) sartorius semitendinosus gracilis popliteus tensor fascia lata gluteus maximus iliac crest sacrum gluteal tuberosity of femur iliotibial tract SEE TABLE 12 SEE TABLE 12 SEE TABLE 12 posterior aspect; upper tibia SEE TABLE 12 SEE TABLE 12 SEE TABLE 12 lateral condyle of femur femoral sciatic obturator tibial sup. gluteal inf. gluteal calcaneus (via Achilles tendon) ischial tuberosity ischial tuberosity ischial tuberosity (long head) linea aspera (short head) posterior aspect of lower end of femur post. aspect of medial tibial condyle pes anserina (med. tibia) head of fibula sciatic sciatic sciatic (tibial) (common fibular ) tibial quadriceps tendon to patellar ligament and tibial tubercle femoral

MUSCLES

ORIGIN

INSERTION

PERIPH.NERVE

SPINAL SEG. L3, 4 L5, S1 L5, Sl, 2 L4, 5, S1, 2 L5, S1, 2 S1, 2

Knee extension

Knee flexion

Flexion and medial rotation of tibia

L2, 3 L5, S1, 2 L2, 3, 4 L4, 5, S1 L4, 5, S1 L5, S1, 2

Extension and lateral rotation of tibia

183

184

laBoratory diSSection
Goals:
1. Dissect and identify the femoral triangle, its margins and contents. 2. Explore the medial compartment of the thigh, identify the branches of the obturator nerve, and ultimately open the medial hip joint.

I. Lumbar Plexus
As noted previously you should already be familiar with three nerves of the lumbar plexus. The iliohypogastric, ilioinguinal, and genitofemoral nerves. Go back to the posterior abdominal wall of the cadaver and identify these nerves. Little dissection should be required. In the region of the iliac fossa identify the lateral femoral cutaneous nerve and the femoral nerve in the gutter between the iliacus and psoas. Next, look on the lateral wall of the true pelvis and identify the obturator nerve. You may find a pad of fat and fascia following it into the obturator hiatus. This is an obturator hernia. If it were a large hernia, do you think it might compromise the nerve? What might the patients symptoms be? You will see the continuation of these nerves in the anterior and medial compartments of the thigh.

II. Anterior Compartment Muscles

A. Incise the skin over the inguinal ligament from anterior superior iliac spine to the pubic tubercle. Next make a vertical incision from the middle of the inguinal ligament extending inferiorly in the midline of the thigh as far as the insertion of the patellar ligament. At the patellar ligament extend transversely half way around the knee on both the medial and lateral sides. Reflect your skin flap and superficial fascia to expose the fascia lata. Note the saphenous vein as it enters the fossa ovalis of the fascia lata. Preserve the inguinal ligament by incising the fascia lata one half inch inferior to the ligament, beginning at the superficial inguinal ring extending to the anterior superior iliac spine. Be careful to preserve the lateral cutaneous nerve which is piercing the inguinal ligament at the anterior superior iliac spine. B. Identify and clean the femoral nerve, artery and vein. When cleaning the femoral nerve, stay on the medial side of the nerve as this makes it easier to save the branches which leave the lateral side of the nerve.

185

C. Identify the following anterior compartment muscles. 1. Quadriceps Femoris rectus femoris vastus medialis vastus lateralis vastus intermedius 2. Iliopsoas 3. Pectineus 4. Tensor fascia lata (because of its innervation and action it should be included in the gluteal group) 5. Sartorius What is the innervation of these muscles? (Q5.1) D. Femoral triangle: 1. Boundaries: Inguinal ligament, sartorius, and adductor longus 2. Floor: Iliopsoas and pectineus 3. Roof: Fascia lata 4. Contents: Femoral nerve, femoral artery and vein and their major branches. What are the major branches of the femoral artery? What is the major arterial anastomosis about the hip? (Q5.2) Identify any cutaneous branches of the femoral nerve. What is the terminal branch of the femoral nerve? Where is it distributed? Q5.3

III.

Muscles of the Medial Compartment

These muscles compose the adductor group of the hip joint. They are innervated by the obturator nerve of the lumbar plexus formed from anterior primary rami of segments L2, 3, 4. After the obturator nerve travels on the medial surface of the obturator internus muscle, it traverses the obturator canal and divides into anterior and posterior divisions which supply the following muscles: A. Anterior division of the obturator nerve: Clean fascia and identify the following: Pectineus Adductor longus Adductor brevis Gracilis Release the adductor longus from its origin and reflect the muscle laterally. B. Posterior division of the obturator nerve: Adductor magnus Obturator externus

186

C. The two branches of the obturator nerve may be located by using the adductor brevis. Locate the anterior division between the brevis and adductor longus. Separate the adductor brevis from the magnus and locate the posterior division of the obturator nerve in the fascia anterior to the adductor magnus. Does the obturator nerve have any cutaneous distribution? (Q5.4) D. Develop the interval between the adductor brevis and the pectineus muscles, following the anterior branch of the obturator nerve. This may require partial release of both of these muscles from their origin (which is?) Palpate the lesser trochanter deep in the dissection field. Identify the iliopsoas tendon and release it from the lesser trochanter. Open the hip joint capsule to expose the femoral head. Palpate the structures of the inferior acetabulum and femoral head. The hip is best dislocated at the end of the next lab. E. Turn the cadaver prone for the next laboratory session. ANSWERS TO ANATOMY QUESTIONS 5.1 All of the muscles in the anterior compartment of the thigh are supplied by the femoral nerve. The exceptions are the pectineus which receives additional innervation from the anterior branch of the obturator nerve, and the iliopsoas which is sometimes described as receiving direct branches from the lumbar plexus. The third exception is the tensor fascia lata muscle which receives innervation from the superior gluteal nerve. The branching of femoral artery is important with respect to the profunda femoris artery and the medial and lateral femoral circumflex arteries. The circumflex arteries provide important blood supply to the hip region, particularly during infancy and prepubertal growth. The medial femoral circumflex artery supplies the head of the femur and the lateral femoral circumflex supplies the region of the greater trochanter. The interference of these blood supplies for whatever reason, can result in a dysplastic hip. Although a cruciate anastomosis is sometimes described between the branches of the femoral and gluteal arteries, it is only functional when there is a gradual occlusion. The terminal branch of the femoral nerve is the saphenous nerve. Note its distribution on the medial side of the leg and medial aspect of the foot. It should also be noted that the saphenous nerve has an infrapatellar branch at the knee which is frequently cut during medial knee surgery. This results in an area of hypesthesia and/or anesthesia in the infrapatellar region. Since the advent of arthroscopic knee surgery, the frequency of medial arthrotomy has decreased significantly, except in cases of severe medial ligament injury. The obturator nerve supplies skin in the medial region of the knee. This is an important consideration with respect to the possibility of projected pain. For example, a metastatic mass in the lateral wall of the pelvic cavity or a hip joint ailment in an adolescent might stimulate the obturator nerve resulting in the patients perceiving medial knee pain.

5.2

5.3

5.4

187

188

anatoMy 6: Sacral pleXuS: gluteal and poSterior thigh MuScleS

Objectives
1. Describe the sacral plexus and distribution of nerves to the muscles of the pelvis, gluteal region and thigh. 2. Describe the greater and lesser sciatic foramina and the structures traversing each foramen. 3. Describe the origin, insertion, action and innervation of the following muscles. gluteus maximus gluteus medius gluteus minimus piriformis obturator internus obturator externus quadratus femoris superior and inferior gemelli

Hamstrings: biceps femoris, semimembranosus, semitendinosus 4. Describe the boundaries and contents of the popliteal fossa.

I. The Sacral Plexus (L4, 5, S1, 2, 3)

Unlike the brachial plexus, you are not expected to know the details of the merging roots of the sacral plexus but rather the names and distribution of the peripheral nerves that emerge from the plexus. You should note that half of L4 joins with L5 to form the lumbosacral trunk crossing the ala of the sacrum and enters the pelvis to merge with the sacral rami. The nerves that pass through the anterior sacral foramina are not spinal nerves but anterior primary rami of spinal nerves. The posterior primary rami exit the spinal canal via the posterior sacral foramina. Remember that all plexuses, cervical, brachial, lumbar and lumbosacral are formed by anterior primary rami. The posterior primary rami never form plexuses. They remain as segmental nerves to muscle and skin. The essential points to remember in regard to the sacral plexus are that it supplies two of the functional groups of the hip: abductors and extensors, and all muscles below the knee. The chief abductor muscles are the gluteus medius and minimus; the chief extensors are the gluteus maximus assisted by the hamstring group. Both of these muscle groups, as well as all of the remaining muscles of the leg and foot, are innervated by branches of the sacral plexus. With the exception of the saphenous distribution to the medial leg and foot, the sacral plexus supplies the skin of the posterior thigh and all of the remaining leg and foot. As in the case of the lumbar plexus, the anterior primary rami of spinal nerves L4, 5, S1, 2, 3 divide into anterior and posterior divisions, each supplying embryologically anterior or posterior muscle groups. Review the developmental rotation of the lower limb and work out which muscles are supplied by anterior divisions and which are supplied by posterior divisions.

189

A. Distribution of the sacral plexus: (Fig 6.1) Some branches of the sacral plexus are simply named for the muscles they innervate, whereas others are named more topographically. Of the nerves listed below, those marked with an asterisk (*) will be difficult to locate on the cadaver. 1. 2. 3. 4. 5. 6. 7. 8. *N. to quadratus femoris and gemellus inferior L4, 5 S1 *N. to obturator internus and gemellus superior L5 S1, 2 Pudendal S2, 3, 4 Posterior cutaneous nerve of thigh S2, 3 *N. to piriformis S1, 2 Superior gluteal L4, 5 S1 Inferior gluteal L5 S1, 2 Sciatic (includes) Tibial part (anterior portion) L4, 5 S1, 2, 3 Common fibular (peroneal) (posterior portion) L4, 5 S1, 2

Superior gluteal n. Inferior gluteal n. N. to obturator internus Pudendal n. Posterior cutaneous n. of thigh Sciatic n. Tibial part Common fibular part

Figure 6.1 190

II. Gluteal Region

A. Osteology: (Fig 6.2) Review the innominate bone and sacrum, identifying the following landmarks: Posterior superior iliac spine Posterior inferior iliac spine Greater sciatic notch Lesser sciatic notch Ischial spine Attachments of sacrotuberous ligament Attachments of sacrospinous ligament

Greater sciatic notch and foramen Sacrospinous ligament attaching to ischial spine Lesser sciatic notch and foramen Sacrotuberous ligament

Figure 6.2 191

B. Hip Joint: The bony architecture differs markedly from the glenohumeral joint of the shoulder. Observe the deep acetabulum of the innominate bone. During childhood and adolescence the acetabulum contains the triradiate cartilage, the site of union of the three parts of the innominate bone: pubis, ischium and ilium. The articular surface of the acetabulum is covered by a horseshoe shaped articular cartilage. The open part of the articulation is occupied by the round ligament (Ligamentum teres) of the femur (Fig 6.3)

Site of capsular attachment Articular cartilage

Ligamentum teres

Figure 6.3

192

The joint is closed by a synovium and thick capsule which is subdivided into three parts, iliofemoral, pubofemoral and ischiofemoral ligaments. (Fig 6.4, 6.5). These thickenings of the capsule provide exceptional restraint for the joint, so that massive forces are required in order to dislocate the hip joint.

Iliofemoral ligament

Figure 6.4 (Anterior) Iliofemoral ligament Ischiofemoral ligament

Figure 6.5 (Posterior)

193

C. Muscles of the Gluteal Region: You should study the attachments of all of the muscles included in the gluteal region as listed in Objective 3. Functionally these can be grouped as follows: Hip extensor: Gluteus maximus. Note that the majority of its origin is from the sacrum and not the posterior ilium (Fig 6.6). Approximately two-thirds of the muscle insert on the posterior femur and the remaining contributes to the iliotibial tract (Fig 6.7). It is supplied by the inferior gluteal nerve.

Gluteus maximus muscle

Tensor fascia lata m.

Iliotibial band

Posterior view

Lateral view
Figure 6.6 194 Figure 6.7

Hip abductors: Gluteus medius (Fig 6.8A) and Gluteus minimus. (Fig 6.8B). From their origins on the posterior ilium, they insert onto the dome of the greater trochanter. Although they can abduct the hip, for example if you are lying on your side, this is not the primary function of these muscles. If you are in a standing position and raise one leg (flexing the hip and knee) what keeps you standing? In other words, why doesnt your pelvis drop down letting you fall towards the side on which your leg is in the air? When you lift your right leg, your pelvis doesnt drop on the right because your left hip abductors (gluteus medius and minimus) contract and stabilize your pelvis. However, if these muscles are paralyzed from an injury to the superior gluteal nerve, you may fall to the side on which you lift your foot. This is in fact a clinical test for abductor function. When the pelvis drops opposite the weak leg (on which the patient is standing), the patient has a Trendelenburg sign. (Sometimes this is called a positive Trendelenburg sign. Technically this is not the correct usage, because if you perform a physical diagnostic maneuver, a patient either displays the sign or does not.)

Gluteus medius m. Gluteus minimus m.

Figure 6.8A

Figure 6.8B

195

Hip rotators (external): (Fig 6.9) Piriformis, obturator internus, obturator externus, gemelli, quadratus femoris. The most significant function of these muscles as described in the texts is lateral rotation of the hip (toe points out). However, if the foot is fixed on the ground they can rotate the trunk. For instance if the two feet are together ( as in attention) and the left leg is lifted, externally rotated, as though to turn left, the pelvis is rotated backwards to initiate the turn of the trunk. The backward rotation or pivot is accomplished over the right hip by the lateral rotators because the right leg is fixed (left leg is in the air so that pivot must occur over the right hip).

Short rotator muscles of hip Piriformis m Superior gemellus m. Obturator internus m. Inferior gemellus m. Quadratus femoris m.

Figure 6.9 196

Organization of the Blood Vessels and Nerves of the Gluteal Region

The arteries of the gluteal region derive from the internal iliac artery within the pelvis and enter the gluteal region through the greater sciatic notch. They are accompanied by veins which are tributaries of the internal iliac vein. The nerves also pass through the greater sciatic notch as branches of the sacral plexus. While many of the smaller nerves supply the muscles of the region, two of them, the sciatic and posterior cutaneous nerve of the thigh, travel further to supply skin and muscles of the thigh, leg and foot. An injury to the sciatic nerve in the gluteal region is a devastating injury, because it destroys all motor function of the muscles of the posterior thigh and all muscles of the leg and foot. The only sensory innervation preserved below the knee is the medial leg supplied by the saphenous branch of the femoral nerve. The organization of the neurovascular bundles is keyed to the piriformis muscle. (Fig 6.1). At its superior edge are the superior gluteal nerve, artery and vein. The superior gluteal nerve supplies gluteus medius, gluteus minimus and tensor fascia lata. Note the course of the nerve is between the g. medius and g. minimus. At the inferior margin of the piriformis is the inferior gluteal neurovascular bundle, sciatic nerve, posterior cutaneous nerve of thigh (always medial to sciatic), nerve to the obturator internus with a branch to the superior gemellus muscle, and the pudendal neurovascular bundle. The inferior gluteal nerve supplies the gluteus maximus muscle.

Superior gluteal n. Inferior gluteal n. N. to obturator internus Pudendal n. Posterior cutaneous n. of thigh Sciatic n. Tibial part Common fibular part

197 Figure 6.1

Label this reprint of figure 6.1 with the piriformis muscle and the arteries referred to above. Although you have studied the pudendal nerve as a part of your pelvic anatomy, this is a chance to review its branches and path through the pudendal canal. Note that an aggressive pudendal nerve block (the needle is pushed too far superiorly) ends in the gluteal space and provides a sciatic nerve block along with anesthesia of the most of the nerves inferior to the piriformis.

III. The Muscles of the Posterior Compartment of the ThighThe Hamstrings (Figs 6.10
and 6.11) The hamstrings are three muscles in the posterior compartment of the thigh which originate on the ischial tuberosity and insert on the tibia medially or the fibula laterally. They extend the hip and flex the knee. The biceps femoris on the lateral side has a second or short head originating on the distal third of the femur. The biceps tendon inserts onto the head of the fibula (Fig 6.10).

Biceps femoris m. long head short head

Figure 6.10
198

Figure 6.11A

Figure 6.11B

Semimembranosus m. Semitendinosus m.

The medial group includes the semitendinosus (Fig 6.11A), which joins the pes anserinus, and the semimembranosus, which inserts on the medial tibia (Fig 6.11B). All of the hamstrings are supplied by the tibial branch of the sciatic nerve (medial part) and the short head of the biceps femoris is innervated by a branch of the common fibular (peroneal) part (lateral) of the sciatic nerve. At this point you will have studied all three of the muscles inserting into the pes anserinus. A mnemonic acronym for the pes is SGT FOS (like Sergeant Foss). Sartorius, gracilis, semitendinosus, supplied by femoral, obturator and sciatic nerves.

IV. The Popliteal Fossa (Fig 6.12)

The popliteal fossa is a diamond shaped space located posterior to the knee, homologous to the cubital fossa of the upper limb. (Fig 6. 12 ). Although it is a four-sided figure, it is another example of anatomical solid geometry. Namely it has depth, such that there is a floor, roof and contents. Boundaries: Identify the following: 199

a. b. c. d. e.

Superior: semimembranosus and biceps femoris Inferior: medial and lateral heads of gastrocnemius (Define: fabella) Roof: fascia lata Floor: posterior capsule of knee joint, popliteal surface of femur and popliteus muscle Contents: popliteal artery and vein. The vessels enter the space through the adductor hiatus. As the vessels cross the plane of the knee joint and come into contact with the interosseus

Semimembranosus m. Semitendinosus m. Sciatic n. Common fibular branch Tibial branch Gastrocnemius m. medial head lateral head

Biceps femoris m.

Sural n.

Figure 6.12 membrane between the tibia and fibula, they give off anterior interosseus branches and then become the posterior tibial artery and vein. The popliteal vein receives the short saphenous vein as it pierces the fascial roof of the fossa. Within the fossa the sciatic nerve has divided into its two branches: the tibial nerve and the common fibular (peroneal) nerve. The tibial nerve: sends motor branches to gastrocnemius, plantaris and popliteus muscles. It also sends a medial sural cutaneous n. to the skin of the posterior knee. At the inferior apex of the popliteal fossa, the tibial nerve passes deep to the origin of the soleus muscle and enters the deep posterior compartment of the leg as the posterior tibial nerve. (Fig 6.13A) Here, it innervates the flexor digitorum longus, flexor hallucis longus and the tibialis posterior muscles. The common fibular (peroneal) nerve: gives off the lateral sural cutaneous nerve to the skin of the posterior lateral knee, but has no motor branches in the popliteal fossa.The lateral sural cutaneous nerve joins the medial sural cutaneous nerve (branch of the tibial) to form a new nerve, the sural nerve, which passes inferiorly beyond the popliteal fossa and pierces the fascia of the distal leg to end in the skin of the dorso-lateral foot.

200

Figure 6.13A Posterior

Common fibular (peroneal) nerve Common fibular (peroneal) nerve

Figure 6.13B Anterior

Tibial nerve

Superficial fibular (peroneal) nerve

Deep fibular (peroneal) nerve

After the lateral sural nerve has been given off, the common fibular (peroneal) nerve crosses the lateral head of the gastrocnemius muscle and enters a groove on the fibular neck. The nerve then gives off the superficial fibular (peroneal) nerve which enters the lateral compartment of the leg. The remaining nerve fibers become the deep peroneal nerve of the anterior compartment of the leg. (Fig 6.13B)

201

202

clinical correlationS in the adult and childS hip

Objectives and Preparation:
1. Review table 12 on muscle actions about the hip. 2. Describe the innervation and blood supply of the hip. 3. Understand the presentation and treatment of common clinical problems around the hip including: slipped capital femoral epiphysis, hip fractures, and iliotibial tendinitis/greater trochanteric bursitis .

Slipped Capital Femoral Epiphysis

The capital femoral epiphysis refers to the epiphysis at the proximal end of the femur. In adults it will become the femoral head. Slipped Capital Femoral Epiphysis (SCFE) is a condition in which the physis (growth plate) weakens and the epiphysis slips off the femoral neck, usually posterior and medial. SCFEs usually occur early in the adolescent growth spurt. Although no one is certain about the etiology of this condition, it seems to have something to do with an imbalance between growth hormone and sex hormones. Growth hormone decreases the shear strength of the physis whereas sex hormones increase the physeal shear strength. Classically the patient is prepubescent but large and obese, though this picture is seen in only about one-half to two-thirds of patients, i.e. one-third to one-half of patients with a SCFE are of normal body habitus. SCFE is twice as common in boys than girls. SCFE is bilateral in 20-40 percent of cases (2/3 of which will be simultaneous, the other third will have occurred within 18 months). The patient usually presents with the insidious onset of groin pain, but some patients will complain only of medial knee pain. This is a type of referred pain that we have called projected pain. (Which nerve is conveying the message?) Pain will increase with weight bearing. The patient may or may not be limping. Further physical exam frequently reveals limited abduction and internal rotation, and mild discomfort during range of motion, When putting the affected hip through a range of motion, flexion is simultaneously accompanied by abduction and external rotation. Affected hips typically have no internal or medial rotation, and the extreme in this direction of attempted motion is usually painful. If still ambulating, the patient typically has a marked external rotation foot progression angle, i.e. when walking north, a patient with a SCFE on the right will have his right foot pointing east while the left foot points north. Radiographs taken early will reveal only widening of the proximal femoral physis. This is a preslip. As the epiphysis actually starts to slip, one will see that the femoral epiphysis is no longer centered on the femoral neck. It looks like ice cream sliding off the top of a cone. The displacement is best seen on a frog-leg lateral radiograph. The goal of treatment is to prevent slippage. A complete slip may lead to avascular necrosis of the femoral head. A partial slip may produce incongruity between the femoral head and the acetabulum. Because closed manipulation can also lead to avascular necrosis, the usual treatment is to pin the epiphysis in situ and hold it in place until skeletal maturity. One must also be vigilant for any symptoms/signs in the contralateral hip.

203

Hip Fractures
Hip fractures are the most common fractures in adults over 60 and occur more frequently in women than men. Most are secondary to falls. Hip fractures in younger people are usually due to significant trauma. Hip fractures are classified as either intertrochanteric or femoral neck fractures. Intertrochanteric fractures are extracapsular whereas femoral neck fractures are intracapsular. Because intracapsular fractures may disrupt or compress the blood supply to the femoral head, these fractures are associated with a high incidence of avascular necrosis of the femoral head and non-union of fracture fragments. (Compression of the blood supply is due to high intracapsular pressures secondary to bleeding. What is the blood supply to the femoral head?) The elderly patient presenting with a hip fracture typically reports a fall. She complains of groin or thigh pain which increases with attempts to move the hip. She is unable to bear weight on the affected limb (unless the fracture is impacted- 5% of these fractures). The limb typically appears short and externally rotated. Radiographs will reveal the fracture location, position (displacement, angulation), and number of fragments (comminution). These factors are all important in determining the appropriate treatment. Intertrochanteric fractures are internally fixed, usually with a sliding screw and side plate. Femoral neck fractures may be internally fixed with a group of screws when the fracture is at the base of the neck and it is not significantly displaced. When the fracture is just distal to the femoral head ( subcapital), avascular necrosis is extremely likely, especially if treatment is delayed. Therefore, the femoral head will be replaced with a metallic femoral head (endoprosthesis). The aim of treatment is to get the patient ambulating as soon as possible. Bed rest following hip fracture is associated with pneumonia, deep venous thrombosis and pulmonary emboli.

Iliotibial tendonitis
Iliotibial tendonitis can present as pain about the lateral aspect of the upper thigh or at the lateral aspect of the knee. In both areas, the iliotibial band must ride over a bony prominence (the greater trochanter proximally, and the lateral epicondyle of the femur distally). At the upper thigh, iliotibial tendonitis can present as a snapping hip. Some patients think the hip is dislocating when they sense the iliotibial band snapping over the greater trochanter. (It isnt!) Iliotibial tendonitis is most common in runners and cyclists due to the frequent flexion and extension of the hip in these activities and the consequent motion of the iliotibial band (ITB) over the greater trochanter. Anatomic factors that place the ITB on stretch, and therefore make it tighter during motion, will cause it to rub as it passes over the greater trochanter. These include bow-leggedness (genu varum), a leg length discrepancy or functional short leg (running on a canted surfacethe down leg), or a cross over running style. These patients present with pain (and sometimes a snap) over the greater trochanter. It is sometimes difficult to distinguish iliotibial tendonitis from greater trochanteric bursitis. Furthermore, a tight ITB can cause greater trochanteric bursitis by rubbing over the bursa. The onset of pain is typically insidious and unilateral. The patient will be tender to palpation over the greater trochanter when tendonitis is present, or behind it when bursitis is present. In either case, there may be pain when the leg is adducted across the midline. Bursitis is usually painful to lie on whereas iliotibial tendonitis is not. Tendonitis may produce pain when the involved limb is abducted against resistance. This will not aggravate bursitis. An Obers test (see following page) will reveal ITB tightness.

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The initial treatment for either diagnosis is the same. Nonsteroidal anti-inflammatory drugs are useful as is ice-friction massage. Iliotibial stretches are helpful, but may aggravate bursitis initially. One must also look for any biomechanical/anatomic factors that may have contributed to the problem, and correct them. If the patient has bursitis, and it does not respond to the treatment mentioned above, the bursa can be injected with corticosteroid. If tendonitis does not respond, the patient may undergo an operative lengthening of the ITB. This is rarely done. Obers test: (See figure) A test for iliotibial tract contracture. The patient lies on his/her unaffected side with the unaffected hip and knee flexed enough to eliminate lumbar lordosis. The extremity to be tested is held by the examiner with the knee flexed. The examiners other hand stabilizes the patients pelvis. The limb being tested is then flexed (A), abducted (B), and hyperextended (C), to catch the iliotibial band on the greater trochanter. The limb is then adducted (D). If the IT tract is tight, the limb cannot be adducted back down to the examining table or opposite limb, but will remain passively abducted.

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ICE AND FRICTION MASSAGE Theory:

Ice and friction massage is used to decrease inflammation and promote healing of inflamed tendons and bursae. Ice constricts surface blood vessels whereas friction dilates these vessels. Alternating ice and friction massage therefore stimulates circulation in the injured area, theoretically improving the removal of waste products and introducing new cells and substances required for healing. Cross-fiber friction massage has also been shown in the laboratory to send an electrical message to newly forming collagen fibers informing them of the desired direction of growth. (All musculoskeletal tissues contain collagen. In particular, tendons and ligaments contain collagen fibers which line up in a single direction. When a microscopic tear has occurred in one of these structures, the new collagen that is produced as part of the healing response is laid down initially in a multidirectional mesh. Normally, tension on these structures determines the ultimate direction in which the collagen fibers will line up during the later stages of healing. Cross-fiber massage may aid this process.)

Technique:
Ice Massage Use water frozen in dixie cups or on popsicle sticks, or use a frozen juice can as your source of ice. The juice can has the advantage of being less messy and is reusable. Do not use blue ice or other chemical coolants as they will burn the skin. Rub the ice in a circular motion all around the sore area. The initial cold feeling will soon be followed by burning, achiness, and then numbness. Numbness usually occurs within 3 to 4 minutes. As soon as numbness occurs, switch to friction massage. Friction Massage Using the pad of your thumb or index finger, rub back and forth over the sore area in the direction indicated by your physician or therapist. Start with fairly light pressure and gradually increase the pressure so that by the end of the massage you are pressing quite firmly. Continue the friction massage until the feeling has returned to the skin. This will take 3 to 5 minutes. Repeat the ice massage, friction massage, and ice massage in that order. Always end with ice so that you do not leave the affected area inflamed. This procedure should take approximately 15-20 minutes and should be repeated 2-3 times per day.

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liVing anatoMy /clinical correlation luMBar Spine and lower liMB

Objective:
Be able to find, outline, and demonstrate key musculoskeletal landmarks.

Preparation for Class:

1. Review the pertinent anatomy. 2. Bring washable color markers. 3. Wear clothing that allows visualization of the structures you are assigned to find. 4. Bring a reflex hammer and tape measure. 5. Consider what findings you might expect for each of the diagnoses listed. How do the symptoms support or conflict with each diagnosis in your differential? What signs on physical exam would support each diagnosis differential? Draw the following on your partner: the anterior superior iliac spine (mark with a circle) the posterior superior iliac spine (mark with a circle) (the iliac crests generally line up with which vertebral level?) the greater trochanter Draw an x where you would stick a needle if you wanted to inject the greater trochanteric bursa. the sacroiliac joint (Perform a Patrick or FABER test. Place the heel on the opposite knee and force external rotation by pushing down on the flexed knee while stabilizing the opposite iliac crest. Pain elicited in the SI joint may be indicative of disease of that joint.) (See also the glossary on our web page for a demonstration of this test.) Measure the true leg lengths (right AND left) of your partner. True leg length is measured on a supine patient from the anterior-superior spine to the medial malleolus of the ipsilateral limb. When a standing patients iliac crests appear to be at different levels, the examiner assumes that their lower extremities are of different lengths. This is not always true. Some patients will have scoliosis, pelvic obliquity, or hip adduction or abduction contractures that account for their apparent leg length discrepancy. Other patients will have a true leg length discrepancy. dermatomes for L-2, L-3, L4, L5, S1, S2 the origin of the gluteus medius Test for a positive Trendelenburg sign. Ask your partner to stand on the involved leg and raise the uninvolved leg off the ground. When the sign is present , the pelvis will drop on the uninvolved side. The Trendelenburg sign is a sign of gluteus medius weakness or inhibition. (see also the glossary on our web page for an example of a positive Trendelenburg sign) Demonstrate deep tendon reflexes of the patellar and Achilles tendons. Which nerve root (segmental level) is tested by each? 207

The origin and insertion of the iliotibial band. Contracture of the IT band is demonstrated with Obers test. (See the diagram in the preceding chapter.) Demonstrate the Thomas test to evaluate if there is a hip flexion contracture.

Case 1:
Your patient complains of hip pain. (The patient points to the lateral hip. The word hip, as it is used by the general public, often refers to the upper outer buttock or iliac crest. Where is the anatomic hip joint? Where does pain originating in the hip joint present?) Your differential diagnosis includes: sacroiliitis greater trochanteric bursitis gluteus medius tendinitis iliotibial band syndrome lumbar radiculopathy (L2 or L3)

Answer the following questions:

A. What additional findings might further support or reject each of the diagnose(s)? B. What is the typical range of motion of the spine? of the hips? C. How would you test strength of the muscles responsible for these active motions?

Case 2:
Your adolescent patient complains of anterior thigh and groin pain. It has come on slowly over the last two weeks. Your differential diagnosis includes: inflammatory arthritis of the hip septic arthritis of the hip undiagnosed hip dysplasia slipped capital femoral epiphysis groin pull/adductor strain And non-musculoskeletal causes such as... Answer the following:

Questions:
A. Which of the above diagnoses best support the clinical scenario? B. What additional findings might further support the diagnose(s)?

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Case 3:
A patient presents to your office after a surgery near one of her hips. Shes limping and complains of a numb spot on her medial thigh. Your differential diagnosis should include: Lateral femoral cutaneous nerve injury Femoral nerve injury Obturator nerve injury Herniated disk and radiculopathy (which level?)

Mark the sensory distributions of: Lateral femoral cutaneous nerve Obturator nerve Saphenous nerve Femoral nerve Dermatomes for L4/L5/S1

Questions:
A. Which of the above diagnoses best support the clinical scenario? B. What additional findings might further support or reject each diagnosis?

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laBoratory diSSection
Goals:
1. Expose the gluteus maximus and carefully reflect it laterally to view the medius and underlying stuctures. Identify the piriformis and surrounding neurovascular structures. 2. Expose the muscles of the posterior thigh and the margins and contents of the popliteal fossa. 3. Dislocate the hip and examine the femoral head, acetabulum, and acetabular labrum.

I. Gluteal Region:
Dissection of the gluteal region: With the cadaver prone, identify the posterior superior iliac spine, and incise the skin from this point, curving inferiorly to the anus. From the anus, continue your incision, curving laterally and inferiorly until you intersect the greater trochanter. Reflect the skin and fat and study the gluteus maximus muscle. Identify the inferior gluteal nerve and vessels supplying the gluteus maximus by carefully detaching the muscle at its origin from the sacrum and reflecting it laterally (use careful sharp dissection to elevate the muscle from the sacrum, but avoid aggressive sharp dissection when elevating the maximus off of the medius). Be careful to save the sacrotuberous ligament as you reflect the muscle. The most superior muscle you will encounter is the gluteus medius; detach it from its origin on the upper ilium and reflect it inferiorly to expose the gluteus minimus muscle which lies deep to the medius. A. Greater sciatic foramen: After identifying the gluteal muscles the remaining structures are best studied by noting their relationships to the greater and lesser sciatic foramina. The key to the greater sciatic foramen is the piriformis muscle. Identify: 1. Structures lying superior to the piriformis Superior gluteal nerve, artery and vein 2. Structures lying inferior to the piriformis Inferior gluteal nerve, artery and vein Sciatic nerve Posterior cutaneous n. of thigh Pudendal nerve, artery and vein Nerve to obturator internus B. Lesser sciatic foramen: Within the foramen note the following: 1. Obturator internus and superior and inferior gemelli 2. Pudendal nerve, artery and vein entering ischiorectal fossa within the pudendal canal (of Alcock) C. Quadratus femoris muscle: Note the origin and insertion of this muscle which is an external rotator of the femur. Detach the quadratus at its insertion and identify the obturator externus tendon located deep in the plane between the quadratus and inferior gemellus.

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II. Posterior compartment of the thigh:

The muscles of the posterior compartment are the hamstrings, innervated by the tibial branch of the sciatic nerve, except for the short head of the biceps femoris innervated by the common fibular (peroneal) branch of sciatic. A. Dissection: Incise the skin of the posterior thigh in the midline from the gluteal fold to the popliteal fossa and reflect the skin flaps. Save all nerves and the short saphenous vein in the popliteal fossa. 1. Identify the individual hamstring muscles. a. biceps femoris b. semimembranosus c. semitendinosus 2. Where do the hamstrings insert? What are the tendons composing the pes anserinus? (Q 6.1) B. Popliteal fossa: Diamond shaped space located posterior to the knee, homologous to cubital fossa of upper limb. 1. Boundaries: Identify the following: a. Superior: semimembranosus and biceps femoris b. Inferior: medial and lateral heads of gastrocnemius (Define: fabella) c. Roof: fascia lata d. Floor: posterior capsule of knee joint, popliteal surface of femur and popliteus muscle e. Contents: popliteal artery and vein. (Check the figure in your atlas and note the boundaries of these vessels, as distinct from femoral or tibial.) Also note the course of the short saphenous vein as it pierces the fascia to enter the popliteal vein. Tibial nerve: motor branches to gastrocnemius, plantaris and popliteus; medial sural cutaneous n. Common fibular (peroneal) nerve: lateral sural cutaneous nerve 2. What is the cutaneous distribution of the sural nerves?

III. Hip Joint

A. On one side of your cadaver, prepare to dislocate the hip. Identify the insertions of the short external rotators and release them from the femur, beginning inferiorly with the quadratus femoris and working superiorly. Identify the hip joint capsule and open it just lateral to the presumed location of the labrum of the acetabulum, releasing the capsule as circumferentially as you are able. Rotate the hip joint internally. This may be aided by flexing the knee (if possible). If resistant to dislocation, before fracturing the femur, first reexamine the soft tissue attachments extending across the joint and be sure they are adequately released. If still resistant to dislocation, take an osteotome or chisel to the posterior wall of the acetabulum to fracture it and relieve the bony posterior restraint to hip dislocation. B. Once dislocated, examine the surfaces of the femoral head and acetabulum. Is there evidence of arthritis? Note the horseshoe shape of the acetabular weight-bearing surface. Is there a ligamentum teres present?

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ANSWER TO ANATOMY QUESTION 6.1 The tendons composing the pes anserinus are the following: 1) Sartorius 2) Gracilis and 3) semiTendinosus. The insertion of these tendons at the medial side of the knee forms a triradiate tendon which resembles the appearance of the rays of a gooses foot. The importance of the pes structure is that it provides support for the medial side of the knee. In earlier times, transfer of the pes was used to reinforce the medial knee after ligament injury. This technique was called the Slocum procedure. It is no longer done. The innervation of these structures is by the Femoral, Obturator, and Sciatic nerves. Think Sgt. FOS when thinking of muscles of the PES.

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anatoMy 7: knee Joint, antero-lateral coMpartMentS of the leg, and ankle Joint
Objectives
1. Describe the knee joint: include articular surfaces, capsule, synovium, menisci, intra and extracapsular ligaments. 2. Describe the muscles in the anterior and lateral compartments of the leg including origin, insertion, action and innervation. 3. Describe the ankle joint; articular surfaces, synovium, ligaments and motion. 4. Describe the common fibular (peroneal) nerve and its distribution in the leg.

The Knee Joint:

The knee joint is fundamentally a hinge joint with a single horizontal axis of motion consisting of flexion and extension. Unlike a simple door hinge where the axis of motion is isocentric, (stays at the same point) the axis of knee motion follows a short arc. This provides for additional complexity in the construction of prosthetic knees and orthotic devices. The anatomy of the joint and its capsular and ligamentous restraints permits only a few degrees of axial rotation at the knee. Injuries of these restraints however, will result in rotatory instability. A prototypical synovial joint consists of two bones whose articular surfaces are covered by cartilage, a synovial membrane attached at the osteochondral junction, and a fibrous capsule which may be thickened in certain regions to form capsular ligaments. The knee joint differs from this model, in that it also has intra-articular ligaments (cruciates), intraarticular menisci, and a redundancy of the synovial membrane (suprapatellar pouch).

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Anterior and posterior cruciate ligaments: (Fig. 7.1 - 7.2) The cruciate ligaments are located within the intercondylar notch and are attached superiorly to the femoral condyles and inferiorly to the tibial plateau. The course of the anterior cruciate ligament (ACL) is from the medial aspect of the lateral femoral condyle to the anterior tibial plateau.

Anterior cruciate ligament

Posterior cruciate ligament

Lateral collateral ligament

Medial collateral ligament

Lateral meniscus

Medial meniscus

Figure 7.1

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The course of the posterior cruciate ligament (PCL) is from the lateral aspect of the medial femoral condyle to the posterior tibial plateau. The crossed arrangement provides a distinct function for each. When the femur is fixed, an anterior pull on the tibia is resisted by the anterior cruciate and conversely, a posterior displacement of the tibia is resisted by the posterior cruciate ligament. Although there is more complexity to the previous statement, in general, a rupture of the ACL results in an excessive anterior drawer sign or Lachmans test when tested clinically. Conversely, rupture of the PCL produces an excessive posterior drawer sign.

Posterior cruciate ligament Posterior meniscofemoral ligament Deep medial collateral ligament Superficial medial collateral ligament

Popliteus

Figure 7.2

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Medial (tibial) and lateral (fibular) collateral ligaments of the knee: The medial collateral ligament (MCL) is represented by a thickening of the medial knee capsule. It begins proximally at the center of the medial femoral condyle and has two distal attachments, a deep part attaching to the medial meniscus and medial tibia at the joint line and a superficial part attaching to the proximal medial tibia posterior to the pes anserinus. It stabilizes the medial side of the knee against valgus angulation. A forced abduction of the leg at the knee joint (valgus stress) can result in a stretch or tear of the ligament. The lateral collateral ligament (LCL) is not part of the capsule, but lies outside it (Fig. 7.3). It is a rounded band attached to the lateral femoral condyle proximally and the head of the fibula distally. It stabilizes the lateral side of the knee against varus angulation. Forced adduction of the leg (varus stress) can strain or tear the LCL. When the knee is in extension, additional support for the lateral side is provided by the iliotibial band, the tendon of the biceps femoris, and the popliteus.

Iliotibial band

Lateral collateral ligament Popliteus tendon

Figure 7.3
Menisci of the Knee joint (Fig. 7.4) The knee joint contains two wedge shaped semilunar fibrocartilages located between the femoral condyles and tibial plateau. The medial meniscus is an open C with each end attached to the tibia by an anterior and posterior horn. The lateral meniscus is more of a closed C so that its anterior and posterior horns are attached more centrally to the tibial plateau. Both are attached at their peripheries to the capsule with the exception of a small opening in the attachment of the posterior aspect of the lateral meniscus for the passage of the popliteal tendon on its way to insert on the femur. The medial 220

meniscus is also attached to the deep MCL (medial collateral ligament). The LCL (lateral collateral ligament) has no attachments to the lateral meniscus. The superior surfaces of the menisci have a concavity which mates to the convexity of the femoral condyles and aids in dissipating the force of the condyles more evenly over the surface of the tibia. Anterior cruciate ligament Medial meniscus Lateral meniscus

Figure 7.4

Posterior cruciate ligament

Meniscofemoral ligament

Suprapatellar pouch The suprapatellar pouch is an extension of the synovial membrane under the posterior part of the quadriceps tendon and the anterior surface of the supracondylar region of the femur, providing lubrication of these surfaces during knee motion. Distension of the soft tissue around the patella (i.e. in the pouch) is evidence of excessive fluid in the joint space. During physical exam, the examiner can squeeze the suprapatellar pouch towards the patella and force any fluid in the pouch into the main synovial space. Bursae There are a number of bursae about the knee. The prepatellar bursa lies anterior to the patella and the infrapatellar bursa lies posterior to the patellar tendon. These can become inflamed and swollen by pressure or blunt trauma resulting in prepatellar bursitis (housemaids knee) or infrapatellar bursitis (parsons knee). The semimembranosus bursa lies posteromedially and can fill when there is excessive fluid in the knee joint (Bakers cyst). Knee-lock or screw-home mechanism As the knee moves from flexion towards maximum extension, the femur rotates medially on the tibia, ultimately locking the knee in full extension. This rotation into full extension is called the screwhome mechanism. At full extension, the anterior cruciate ligament and the collateral ligaments are taut. To initiate flexion the popliteus muscle laterally rotates the femur and thus unlocks the knee joint. (This assumes the tibia is fixed. When it is free, the popliteus can medially rotate the tibia). The locked position of the knee is also the position of close pack a term used to describe the state of a joint when there is maximal congruency of the mated surfaces, tautness of all ligaments, and thus the maximal stable position of the joint. Loose pack is the reciprocal state: least congruency of surfaces, lax ligaments and an unstable state. These terms can be used to describe any joint.

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Anterior Compartment of the Leg (Figs 7.5-7.8)

The fascia lata of the thigh is continued as a fascial stocking about the leg. The interosseus membrane and intermuscular septae divide the leg into anterior, lateral and posterior compartments. The posterior compartment is further subdivided into a superficial and deep space. Because fascia is a tough inelastic material, swelling occurring in the leg in response to trauma (e.g. tibial fractures) may decrease the arteriovenous pressure difference at the capillary level such that muscles and nerves become ischemic. The clinical picture that results is called a compartmental syndrome. Acute compartmental syndromes are surgical emergencies, as they reflect jeopardized viability of the muscles of the leg. The anterior compartment of the leg contains four muscles that can extend (dorsiflex) the ankle joint. Two of them also extend the joints of the toes. All of the muscles in the anterior compartment are supplied by the deep fibular (peroneal) branch of the common fibular (peroneal) nerve. Tibialis Anterior: (Fig 7.5) The tibialis anterior originates from the proximal tibia and fibula and inserts on the medial aspect of the first metatarsal and the medial cuneiform of the foot. The tibialis anterior is an invertor of the foot and a dorsiflexor of the ankle.

Tibialis Anterior m.

Insertion on medial cuneiform and first metatarsal

Figure 7.5 222

Extensor hallucis longus: (Fig. 7.6) The extensor hallucis longus muscle originates from the midportion of the fibula and inserts on the base of the distal phalanx of the great toe extending the interphalangeal joint. Peroneus Tertius: (Fig 7.6) The peroneus tertius originates from the distal fibula and inserts into the base of the fifth metatarsal. It is a weak everter of the foot and assists in dorsiflexion of the ankle joint.

Extensor hallucis longus m. Peroneus tertius m.

Figure 7.6 223

Extensor digitorum longus: (Fig. 7.7) The extensor digitorum longus originates from the fibula forming four tendons for the 2nd through the 5th toes, inserting into the extensor aponeurosis of each.

Extensor digitorum longus

Figure 7.7 224

The Lateral Compartment of the Leg (Fig 7.8)

There are two muscles in the lateral compartment of the leg whose principal action is eversion of the foot. Both muscles are supplied by the superficial fibular (peroneal) branch of the common fibular (peroneal) nerve. Peroneus longus: (Fig. 7.8) The peroneus longus originates from the fibula, courses posterior to the lateral malleolus, crosses the lateral calcaneus, enters a groove on the plantar surface of the cuboid and inserts into the plantar surface of the first metatarsal and medial cuneiform. (Its insertion parallels that of the tibialis anterior.) The peroneus longus is also a plantar flexor of the first metatarsal. Peroneus brevis: (Fig. 7.8) The peroneus brevis originates from the fibula, courses posterior to the lateral malleolus, crosses the lateral calcaneus and cuboid and inserts on the tubercle on the base of the fifth metatarsal. When the peroneus longus and brevis are paralyzed by injury to the superficial fibular (peroneal) nerve, the unopposed action of the inverters causes the foot to strike the ground on the lateral side during the gait cycle, predisposing the patient to roll the ankle unless an orthosis is used.

Peroneus longus m. Peroneus brevis m.

brevis tendon
Figure 7.8

longus tendon

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Muscles on the Dorsum of the Foot (Fig 7.9)

Unlike the hand, the dorsum of the foot has two muscles, the extensor hallucis brevis and the extensor digitorum brevis (Fig. 7.5). In some books these are considered one muscle, the extensor digitorum. The muscles are supplied by a continuation of the deep fibular (peroneal) nerve. Figure 7.9

Dorsalis pedis a. Extensor hallucis brevis m. Extensor digitorum brevis m. Deep fibular (peroneal) n.

Extensor hallucis brevis: it originates from the calcaneus and inserts on the base of the proximal phalanx, thus extending the metatarsal phalangeal joint of the great toe. Extensor digitorum brevis: it originates from the calcaneus forming three tendons which insert into the extensor aponeurosis of the second, third and fourth toes. The first four toes all have a long and short extensor; the fifth has only a long extensor.

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TABLE 19: FOUR MUSCLES IN THE ANTERIOR COMPARTMENT OF LEG

MOVEMENT prox. tibia upper anterior surface of fibula base of proximal phalanx and extensor expansion distal phalanx of big toe deep fibular medial cuneiform, 1st metatarsal deep fibular

MUSCLES

ORIGIN

INSERTION

PERIPH. NERVE

SPINAL SEG. L4, 5, S1 L4, 5, S1

Dorsiflexes and inverts foot tibialis anterior extensor digitorum longus extensor hallucis longus anterior surface of fibula

Extends phalanges (continued action dorsiflexes foot)

Extends big toe (continued action dorsiflexes foot) peroneus tertius lower anterior surface of fibula dorsal surface 5th metatarsal

deep fibular

L5, S1

Dorsiflexes and everts foot

deep fibular

L5, S1

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extensor hallucis brevis extensor digitorum brevis forepart of upper surface of calcaneus forepart of upper surface of calcaneus

TWO MUSCLES ON DORSUM OF FOOT proximal phalanx of big toe lateral side of ext. dig. longus tendons deep fibular deep fibular L5, S1 L5, S1

Extends proximal phalanx of big toe

Extends phalanges of the 2nd, 3rd & 4th toes

TABLE 20: TWO MUSCLES IN THE LATERAL COMPARTMENT OF LEG MUSCLES peroneus longus peroneus brevis lower lateral surface of fibula lateral side of 5th metatarsal superficial fibular upper lateral surface of fibula plantar surface of med. cuneiform and first metatarsal superficial fibular ORIGIN INSERTION PERIPH. NERVE SPINAL SEG. L5, S1 L5, S1

MOVEMENT

Everts and plantar flexes

Everts and plantar flexes

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clinical correlationS in the knee, ankle, and foot

Objectives and Preparation:
1. Review the anatomy of the knee joint including capsule, synovium, menisci, intra- and extracapsular ligaments. 2. Review the muscles acting on the knee joint (Table 13). 3. Describe the joints responsible for motion of the ankle and foot. 4. Review Tables 14, 15, 19, 20 which summarize muscles around the ankle. 5. Review the ankle ligaments 6. Understand the presentation and treatment of common clinical problems in the knee, foot and ankle including patellofemoral pain, meniscal and anterior cruciate ligament tears, ankle sprains, and forefoot pain. (Syllabus materials below)

Applied Anatomy
The following is provided to highlight some of the anatomy you need to know in regard to ankle function. Review this material prior to the lecture. The lecture will expand on this material. Ankle Joint: The ankle joint classically is defined as the talocrural joint, comprising talus, tibia and fibula. It is basically a hinge joint about a horizontal axis allowing for flexion (plantar flexion) and extension (dorsiflexion) of the foot on the leg. The motion is essentially a sliding action between the dorsum of the talus and the flat (plafond) distal portion of the tibia. Total joint motion around the foot and ankle actually includes three other joints which are as follows (B & C below are actually one joint although for ease of understanding they are described separately): Study these on the skeleton.

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The Foot The foot can be divided into the hindfoot, consisting of the talus and calcaneus; the midfoot, including the navicular, cuneiforms, and the cuboid, and the forefoot, including the metatarsals and phalanges. A. Posterior Talocalcaneal Joint (subtalar) The articulation between the posterior portions of the talus and calcaneus form a distinct synovial joint with separate capsule. Study the facets in the atlas and on the disarticulated skeleton. B. Anterior Talocalcaneal Joint: (talo-calcaneo-navicular) This joint consists of the middle and anterior facets of the calcaneus articulating with a complimentary surface on the plantar portion of the talus. Although this joint has a capsule separate from the posterior talocalcaneal joint, the two are sometimes classified together as the subtalar joint. C. Talonavicular Joint: (pretalar joint) This is the articulation between the anterior surface of the talus and posterior surface of the navicular. The synovial space of the pretalar joint is shared with that of the anterior talocalcaneal joint and hence these joints are sometimes collectively known as the talocalcaneo-navicular joint. D. Calcaneocuboid Joint: This joint consists of the anterior surface of the calcaneus and the posterior surface of the cuboid. When this joint is considered together with the pretalar joint, it composes a transverse joint across the foot, i.e., the transverse tarsal joint. Because its components have separate capsules, the transverse tarsal joint is probably better thought of as an anatomical or surgical plane than as a functioning joint. E. Using the nomenclature at the top of the page, the joint between the hindfoot and midfoot is also called Choparts joint. The joint between the midfoot and forefoot (the tarsometatarsal joint) is also known as Lisfrancs joint.

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Motion at the foot and ankle Motion at the foot and ankle includes not only talocrural motion, but also motion at the above listed joints. If one considers the standard three axes of motion, it is clear that flexion and extension are motions about an horizontal axis. Because this axis is not true but slightly inclined, extension (dorsiflexion) also includes some lifting of the lateral side of the foot (pronation) and plantar flexion includes some lifting of the medial side of the foot (supination). Similarly, there is no pure internal or external rotation of the foot about a vertical axis because there are no joint planes aligned in a way to provide such motion. Lastly, there is no true motion of the foot about a longitudinal axis (heel-toe) because of the absence of joints permitting such motion. However, due to the plane of the articular facets in the subtalar and pretalar joints, motion at these joints provides a composite movement about a complex axis that has both a vertical and a longitudinal component. Understanding the actions of muscles at the ankle joint is complicated because tendon attachments are not always immediately adjacent to the talocrural, subtalar or pretalar joints. Instead the attachments are more distal at the navicular-medial cuneiform joint and the medial cuneiform-first metatarsal joints as well. In other words, ankle function has an antecedent forefoot motion, because before any motion can occur at the talocrural joint, e.g. dorsiflexion, the muscle mainly responsible for that motion, the tibialis anterior muscle, must first wind up the laxity in the distal joints before it can act at the talocrural joint. Similar comments can be made regarding the functions of the tibialis posterior and the peroneus longus. Forefoot motion about a theoretical longitudinal plane is termed pronation or supination but always occurs in conjunction with some abduction or adduction of the forefoot, because there are no facets which permit pure movement of either type. The term inversion or eversion therefore, is inclusive of forefoot motion, hindfoot motion, and ankle motion and can be summarized as follows: INVERSION Plantar Flexion (talocrural) Adduction (internal rotation) Supination EVERSION Dorsiflexion (talocrural) Abduction (external rotation) Pronation

To assist in your understanding of ankle function, complete the table provided below (note that you may not need all of the blanks). DORSIFLEXORS 1._______________ 2._______________ 3._______________ 4._______________ PLANTAR FLEXORS 1.__________________ 2.__________________ 3.__________________ 4.__________________ INVERTERS EVERTERS

1.__________________ 1.___________________ 2.__________________ 2. ___________________ 3.__________________ 3.___________________ 4.__________________ 4.___________________

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Despite the complexities and interrelatedness of foot and ankle motions, there are ways to isolate their motions to better understand whether or not the structures are normal or pathologic. Tight heelcords (tendoachilles, Achilles tendon, or triceps surae they all mean the same thing) are commonly seen in children and adults, alike. Tight heelcords can lead to many different ailments, including calf pain, heel pain, anterior or lateral ankle pain, sole of foot pain, medial or lateral foot pain, and toe walking, to name just a few! So, how to tell if the tendoachilles is tight, especially when dorsiflexion of the ankle is usually accompanied by eversion of the subtalar joint? The trick is to lock the subtalar joint by maximally inverting it. This can be done by supinating the forefoot, i.e. turning the sole of the foot medially and dorsally, or away from the floor and toward the ceiling in the upright patient. Grabbing the sole of the foot and twisting it so that the big toe is elevated dorsally above the lesser toes will accomplish this. Inverting the subtalar joint effectively locks it, preventing eversion during ankle dorsiflexion. So, any dorsiflexion with the foot in this position results in pure ankle motion. If the tendoachilles is tight, the ankle will not be able to dorsiflex much beyond the neutral position. Will flexing the knee allow for an increase in ankle dorsiflexion? (Q1) Why? (What muscles make up the Achilles tendon, and which cross the knee joint?) Normal ankle dorsiflexion with the knee extended should be about 10 degrees. Patients who cant dorsiflex to 10 degrees above neutral with the knee extended have tight heelcords and are at risk for all of the problems described above. Why might tight heelcords lead to each of these pathologies? (Q2) CLINICAL CORRELATIONS

The Knee
Patellofemoral pain Patellofemoral pain is often associated with lower extremity malalignment. The most common form of lower extremity malalignment is a triad of excessive femoral anteversion, and external tibial torsion and flat feet with valgus heels. Femoral anteversion describes the angle of the femoral neck relative to the plane of the femoral condyles at the knee. In most individuals this angle is ten degrees. In individuals with excessive femoral anteversion, the angle between the neck of the femur and its shaft may equal as much as 20 degrees. This is reflected clinically by an excessive amount of internal rotation of the hip. The tibia compensates for this excessive internal rotation at the hip by rotating externally in relation to the femur. As femoral anteversion and external or lateral tibial torsion increase, so does the Q-angle (line of quadriceps pull) and the lateral vector tending to pull the patella laterally. (Figure 1) Subsequent abnormal patellar tracking with wear of the articular surfaces, patellar subluxation, or excessive pressure on the lateral facet of the patella result. The first has been called chondromalacia of the patella. Pain originating in the patellofemoral joint presents as a poorly localized aching in the anterior aspect of the knee aggravated by going down hills or stairs or by squatting. Sitting with the knee flexed for any length of time will produce discomfort and is known as a positive theatre sign. Giving way is common and is due to reflex quadriceps inhibition. Treatment is based on the principle of trying to gain optimal position of the patella in the trochlear groove. This can be achieved by overstrengthening medial attachments to the patella, (especially the vastus medialis obliquus component of the quadriceps muscle-VMO) and stretching lateral attachments ( the iliotibial band- ITB). VMO strengthening includes isometric contractions, straight leg raises with the leg externally rotated, and mini squats. Full arc isotonic exercises are discouraged due to the high patellofemoral compression forces produced.

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Figure 1: Q-Angle (Quadriceps Line of Pull)

Q-Angle

Approximately 10% of patients with patellofemoral pain due to malalignment will require surgery to release the lateral retinacular structures, or to move the tibial tubercle to change the Q angle. Meniscal tears The menisci provide stability to the knee by acting as spacers and by increasing the congruence between the femur and the tibia. They also distribute load in the knee, act as shock absorbers, and help distribute synovial fluid. Only the outer one fourth of the meniscus has a vascular supply. The medial meniscus is most commonly injured by a twisting mechanism; the lateral meniscus is most commonly injured by hyperflexion of the knee. Using the plane of the tibial plateau as a reference, meniscal tears can either be vertical, radial, or horizontal. (Figure 2)

Figure 2: Types of Meniscal Tears

Vertical

Radial 233

Horizontal

A patient with a meniscal tear presents with knee pain and tenderness localized to the joint line on the affected side. An effusion is often present. The patient may have experienced locking of the knee. McMurrays maneuver often produces pain. The treatment for torn menisci is to either remove the torn fragment, leaving a stable, functional meniscal remnant, or to repair the meniscus when the tear is in the vascular zone. Anterior Cruciate Ligament Tears The anterior cruciate ligament (ACL) is responsible for rotational and anteroposterior stability in the knee. Its primary function is to resist anterior translation of the tibia on the femur. The ACL is most commonly torn from sudden flexion with rotation, with or without a valgus stress, on a planted foot. It can also tear during hyperextension of the knee. ACL tears are often associated with meniscal tears and with bone bruises seen on MRI, most commonly in the lateral femoral condyle and lateral tibial plateau. When the ACL tears, the patient sometimes hears or feels a pop. The knee will swell within 12 hours of the injury due to a hemarthrosis. The examiner should look for increased laxity on Lachmans test. Sometimes because of swelling or because a fragment of meniscus is locked in the knee, the Lachmans test. The anterior drawer exam may also reveal laxity in the case of a torn ACL. The treatment of ACL tears is dependent on the degree of instability in the knee, and on the functional requirements of the patient. Non-operative treatment includes hamstring strengthening (to hold the tibia back), proprioceptive training, and derotational braces. Operative treatment reconstructs the ACL using part of the patellar tendon, the quadriceps tendon, or the semitendinosus and gracilis tendons as autografts. Allograft tissue (from a cadaver at the bone bank) may also be used for ACL reconstruction. Other Knee Ligament Sprains MCL Sprains The medial collateral ligament works in concert with the ACL to prevent medial compartment opening with a valgus stress to the knee. The triad of ACL, MCL, and medial meniscal tears is a not uncommon injury complex seen with high energy valgus force to a knee. As the medial meniscus has attachments to the deep fibers of the MCL, tearing of the MCL often results in injury to the medial meniscus as well. Unlike the ACL, which is essentially an intra articular ligament bathed in synovium with injury, the MCL has superficial and deep bands that are extra articular and may heal with rest and appropriate relief from valgus deforming forces. PCL Sprains and Posterolateral Corner Injuries Posterior cruciate ligament (PCL) injuries are much less common than ACL injuries. An isolated PCL deficient knee is often not symptomatic for patients, as the PCL performs its major task during 90 of knee flexion, unlike the ACL, which acts primarily in 30 of knee flexion. (How many dynamic activities do we do in 90 of knee flexion?) Isolated lateral collateral ligament (LCL) injuries are rare, as the lateral collateral ligament is part of a larger complex known as the posterolateral corner, consisting of the lateral capsule, the LCL,

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the popliteus and popliteo- fibular ligaments and arcuate ligament. Injuries to the posterolateral corner may lead to rotatory instability of the knee, making cutting and jumping sports difficult. Traumatic Knee Dislocations High energy trauma to the knee may result in multiple ligament injuries and dislocation of the tibio-femoral joint. This is an orthopaedic emergency. The trauma may result in popliteal artery disruption or injury, putting the leg and foot at risk. Peroneal or fibular nerve and tibial nerve injuries with knee dislocation have also been described. Such a knee joint, once reduced, would also likely be grossly unstable.

The Ankle
Ankle Sprains A sprain is a torn ligament. Ankle sprains most commonly occur on the lateral side of the ankle due to inversion of the foot and ankle which stretches components of the lateral ligament complex (anterior talofibular, calcaneofibular, posterior talofibular ligaments). The examiner should palpate these ligaments as well as the anterior tibiofibular ligament and the medial ligament complex. The anterior drawer test will be positive when the anterior talofibular ligament is completely torn. The talar tilt will be positive when the calcaneofibular ligament is completely torn. Squeezing the calf will produce ankle pain when the anterior tibiofibular ligament is torn. Immediate care includes ice, compression, and elevation (ICE). Crutches may be necessary. Early treatment should include a compressioin wrap to decrease swelling, and range of motion exercises. Subsequent treatment depends on the number of ligaments torn and the degree to which they are torn. Various classification systems exist to describe the degree of ankle sprains and to determine treatment. A tear of only the anterior talofibular ligament can be treated symptomatically with strengthening and proprioception exercises. There is considerable debate concerning treatment of more significant injuries. The treatment recommendations include rehabilitation only, immobilization for 3 weeks followed by rehabilitation, and primary operative repair. Ankles with residual instability are often braced for participation in sports. Ankles with a torn anterior tibio-fibular ligament should be immobilized and kept non-weight bearing for six weeks.

The Foot
Forefoot pain The differential diagnosis for a patient with forefoot pain includes a metatarsal stress fracture, metatarsalgia, or Mortons neuroma. Stress Fractures Stress fractures occur in people with normal bone who have increased their activity faster than their bones can remodel to compensate for the increased mechanical stress. They also occur in people with osteopenic bone. Patients with stress fractures will be tender to palpation right over the fracture. Their foot MAY be swollen and red. Weight bearing is often pain-free, but impact is not. Stress fractures do not always show up on the initial x-ray, but will produce increased uptake on bone scan with technetium diphosphonate (an isotope of phosphorus).

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Metatarsal stress fractures are usually treated by stopping impact activities for 4-6 weeks. Immobilization is not typically necessary. Metatarsalgia Metatarsalgia is due to the second and third metatarsal heads taking more weight than they should. Usually, weight on the forefoot is borne by metatarsal heads 1-5. The first metatarsal head (through its two sesamoid bones) should take twice as much weight as any one of the other metatarsal heads. If the first metatarsal head is shorter than the second, is hypermobile and elevated, or is medially deviated, the second and third will take more weight and produce painful calluses on the ball of the foot. Other causes for metatarsalgia include claw toes which drive the metatarsal heads downward, a cavus foot (high arch), or loss of the normal fat pad (due to aging or rheumatoid arthritis). Patients with metatarsalgia usually have tenderness and callus distribution isolated to the plantar surface of the second or second and third metatarsal heads. The examiner should look for the etiologic factors noted above. The treatment depends on which etiologic factors are present. Generally, one tries to equalize the weight distribution across all metatarsal heads. This can usually be done with padding under the first metatarsal head, or by elevating the second and third metatarsal heads using padding under the metatarsal shafts. Sometimes operative treatment is required to address the etiologic factors. Mortons Neuroma Morton described a swelling of the common digital nerve between the 3rd and 4th metatarsals which produced lateral forefoot pain. Sometimes patients with this type of neuroma will also describe a burning or shooting pain radiating into the 3rd and 4th toes. Initially the swelling is only edema. Over time, however, perineural fibrosis occurs. These neuromata develop due to low grade trauma such as running or dancing on the balls of ones feet, or wearing high-heeled shoes. The examiner will find tenderness BETWEEN the metatarsal heads on both the plantar and dorsal surfaces of the foot.(Figure 3) Pain may also be produced by compressing the metatarsal heads from medial and lateral and by applying axial pressure in the 3rd web space. Toe numbness is an inconsistent finding. When symptoms are recent, Mortons neuromata are treated by shifting weight away from the lateral part of the foot using shoe pads, and by making certain that shoes are not too tight. A corticosteroid injection into the area of the neuroma may decrease early swelling. When these treatments fail to relieve symptoms, the neuroma is excised. Figure 3: Sites of Tenderness with Forefoot Problems

Mortons neuroma metatarsalgia stress fracture

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Answers to questions:
Q1. Will flexing the knee allow for an increase in ankle dorsiflexion? Why? Yes, flexing the knee will relax posterior muscles that cross the knee joint, which include the gastrocnemius. As the gastrocnemius contributes to the Achilles tendon, relaxing it at the knee will provide greater ankle dorsiflexion than when the ankle is dorsiflexed and the knee is extended. Q2. Why might tight heelcords lead to each of these pathologies? As we spend a good deal of time during the gait cycle with the knee extended, having a smooth gait requires full extension of the knee. Therefore, having a flexible gastrocnemius is essential for normal gait. When tight, increased tension will stress the muscle, the musculotendinous junction, the tendonous attachment, and the bone to which the tendon attaches (the calcaneus). In young people who are skeletally immature, tendons are often stronger than bones. Tension in the Achilles can lead to microfractures in the calcaneus, also known as Severs apophysitis (inflammation of the bone at the tendinous attachment of a muscle). On the other side of the calcaneus, on the plantar surface, attaches the plantar fascia. A tight heelcord (Achilles tendon) can even lead to plantar fasciitis, as the calcaneus is pulled away from the un-stretchable plantar fascia.

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nerVe Supply to the upper and lower liMB

I. Nerve supply of the upper and lower limb a. Spinal cord and spinal nerves organization: dermatomes and myotomes b. Peripheral organization: peripheral nerves and branches c. Clinical relevance: sensory or motor changes may come from the spinal cord, spinal nerves, or peripheral nerves Movement a. Spinal centers and myotomes i. Movements are organized as follows: 1. Each movement is typically represented by two segments 2. For a particular joint, agonists and antagonists (e.g., flexion and extension) are located in spinal segments that are close together a. For most movements, agonists and antagonists are located in contiguous segments. For example, flexors at the shoulder are located at C5,6 while extensors are in the next two continguous segments at C7,8. b. Exceptions to this rule are found in the more distal upper limb (wrist and hand). b. Peripheral nerves i. Innervate muscles found in compartments ii. Examples: 1. The radial nerve innervates the posterior compartment of the arm (triceps) which controls elbow extension. 2. The musculocutaneous nerve innervates the anterior compartment of the arm (biceps and brachialis) which controls elbow flexion c. Clinical relevance i. If a patient presents with weakness, how do you know if the problem is at a spinal cord, myotome, or peripheral nerve level? Sensation a. Sensory problems are typically caused by problems at the spinal nerve (root) level (dermatome), the peripheral nerve, or by generalized problems that affect peripheral nerves (peripheral neuropathy). b. Clinical relevance: i. The pattern of sensory loss will point to the anatomical site of injury or disease. 1. Spinal nerve (root) level (dermatome) a. Pattern: the area innervated by the spinal nerve is affected typically, this will not correspond to a specific peripheral nerve

II.

III.

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i. Example: numbness of the medial hand may indicate a C8 nerve root compression. However, how do you know that it is not from ulnar nerve compression? Ulnar nerve compression causes numbness of the medial hand, BUT THE SENSORY CHANGES DO NOT CROSS THE WRIST INTO THE FOREARM. The C8 dermatome affects the medial hand and the medial forearm. 2. Peripheral nerve entrapment a. Pattern: the area innervated by the peripheral nerve is the only area that will demonstrate sensory changes. i. Example: carpal tunnel syndrome. 3. Generalized peripheral neuropathy a. Pattern: stocking (lower limb) or glove (upper limb) distribution i. As the disease process progresses, the nerve is affected more and more proximally (the area of sensory loss moves up the lower and upper limb ii. Example: diabetic neuropathy

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Myotomes: organization in spinal cord

Nerve supply of the lower limb

Barry Goldstein, MD, PhD [email protected]

Myotomes of the lower limb

hip L2

Lower limb myotomes

Flexors
knee
L3

ankle

L4

Extensors

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Which goes first: flexors or extensors?

flexion extension L2,3 dorsiflexion L3,4 hip L4,5 +S1 L4,5 knee L5,S1 ankle S1,2

L5 radiculopathy
flexion extension L2,3 dorsiflexion L3,4 hip L4,5 +S1 L4,5 knee L5,S1 ankle S1,2 hip L4,5 +S1 L3,4 L2,3 flexion

S1 radiculopathy

extension dorsiflexion

L4,5 knee L5,S1 ankle S1,2

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Dermatomes

Common presentations of nerve problems in the lower limb

3 common patterns
Peripheral neuropathy (generalized) Entrapment neuropathy

L2: mid-anterior thigh L3: medial knee L4: medial malleolus L5: 3rd ray, dorsum of foot S1: lateral heel S2: popliteal fossa

Segmental

Examples
3 common patterns
Peripheral neuropathy (generalized) Entrapment neuropathy

3 examples
Diabetic or alcoholic neuropathy Fibular nerve at femoral neck Radiculopathy

Segmental

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laBoratory diSSection
Goals:
1. Systematically destabilize the knee joint by sequential disruption of ligaments. 2. Examine the articular surfaces of distal femur, patella, and proximal tibia at the knee. 3. Expose the contents of the anterior and lateral compartments of the leg, following the branches of the peroneal nerve. 4. Systematically destabilize the ankle by sequential disruption of ligaments.

I. Knee Joint:
A. Osteology: On the skeleton identify the following bony parts of the skeleton: 1. Articular surfaces of femur and tibia, intercondylar notch of femur, tibial plateau. ) B. Dissection 1. Cruciate ligaments: Open the knee joint by making an inverted U shaped incision in the quadriceps tendon with the patella centered in the U. Reflect the patella and the patellar tendon inferiorly, and identify the infrapatellar fold and fat-pad. Only the anterior attachments of the cruciate ligaments will be visible from this dissection. Are the cruciates located within the synovial space? When are the cruciates taut? Which ligament restricts anterior displacement of the tibia on the femur? (Q 7.1) 2. Menisci - shapes and attachments: Note that the medial meniscus is attached to the medial collateral ligament or joint capsule. Would you expect tears of the medial collateral ligament to affect the medial meniscus? During extension and flexion of the knee there is slight anterior or posterior movement of the menisci, respectively. When the leg is fixed (weight bearing on the ground) and the femur is rotated medially or laterally, the menisci move with the femoral condyles. The rotatory movement of the menisci is also slight but important, otherwise the femoral condyle would over-run the thin edge of the meniscus and damage it. 3. Collateral ligaments and stabilizing tendons: Medial collateral, attachments? Lateral collateral, attachments? Iliotibial tract, attachments? Which muscles act on the tract? Pes anserinus; name the three tendons. Popliteus tendon, attachments?

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C. Sequential release of ligaments 1. Section (incise) the MCL (medial collateral ligament). What happens to the stability of the knee? Test with varus/valgus/anterior/ posterior stresses. 2. Now section the ACL (anterior cruciate ligament) and repeat tests of stability. 3. Now section the PCL (posterior cruciate ligament) and repeat the tests of stability. 4. Now section the LCL (lateral collateral ligament) and repeat the tests of stability.

II. Anterior Compartment of the Leg:

A. Strip the skin and fascia from the anterior aspect of the leg and separate the tendons of the following muscles. Identify: 1. Tibialis anterior 2. Extensor hallucis longus 3. Extensor digitorum longus 4. Peroneus tertius B. What are the insertions of these muscles? All are innervated by the deep fibular (peroneal) nerve. Does the deep fibular (peroneal) nerve supply skin? (Q 7.2) C. Study the retinacula and synovial sheaths at the ankle. Inflammation of the synovial sheaths (tenosynovitis) may involve these sheaths at the ankle in a manner similar to that described for the extensors of the wrist joint.

III. Lateral Compartment of the Leg:

Remove any remaining skin of the leg and also the skin overlying the dorsum of the foot as far distally as the metatarsal-phalangeal joints. Try to preserve, as much as possible, the cutaneous nerves i.e., sural, saphenous, and the superficial fibular (peroneal). A. Muscles: Identify: 1. Peroneus longus - note its insertion on the base of the 1st metatarsal and medial cuneiform. 2. Peroneus brevis - note its insertion on the base of the fifth metatarsal. To be precise, the insertion is on the tubercle of the fifth metatarsal. When one suddenly turns an ankle or falls suddenly in such a manner that the foot is inverted, the peroneus brevis attempts to stabilize the foot by everting. The pull of the brevis on the tubercle of the fifth metatarsal may be sufficient to fracture the tubercle or avulse it from the base. 3. Identify the superficial branch of the common fibular (peroneal) nerve which supplies the lateral compartment. Where does it become cutaneous? What area of skin does it supply? (Q 7.3)

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IV. Dorsum of Foot: (Fig. 7.5)

Identify: extensor hallucis brevis extensor digitorum brevis Clean the dorsum of one or two toes and note the insertion of both long and short extensor tendons. Compare with the extensor arrangement in the hand.

Anterior tibiofibular ligament Posterior talofibular ligament Anterior talofibular ligament

Figure 7.10

Calcaneofibular ligament

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Both of these muscles on the dorsum of the foot are supplied by the deep fibular (peroneal) nerve.

V. Ligaments of the Ankle: (Fig 7.10)

Identify: A. Lateral aspect of the ankle 1. Anterior talofibular ligament 2. Calcaneofibular ligament 3. Posterior talofibular ligament

Interosseus membrane

Posterior tibiofibular ligament

Posterior talofibular ligament

Calcaneofibular ligament Figure 7.11

B. Medial aspect of the Ankle: 1. Deltoid ligament (This can be subdivided into several subsets of ligaments, but they are not important for this course.) C. Anterior aspect of the ankle: 1. tibio-fibular ligament (Fig 7.10)

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D. Posterior aspect of the ankle (Fig 7.11): 1. tibio-fibular ligament E. Ligament Injury: Which ligaments are commonly injured in inversion type injuries? Eversion type? (Q 7.4)

VI. Sequential injury to the ankle ligaments.

A. On one ankle, place an inversion stress on the ankle and see what ligaments appear to be under the most tension. Incise these. Continue to stress the ankle, incising or releasing the ligaments off the fibula and then the tibia as you work around the posterior of the ankle. See the talus. Where does its blood supply come from? B. On the other ankle, repeat the stress test with an eversion stress. Serially release those ligaments that are tight as you work around the ankle. This should expose the other side of the ankle joint. Where does the blood supply of the talus enter? (Q 7.5) ANSWERS TO ANATOMY QUESTIONS 7.1 The anterior cruciate ligament prevents anterior displacement of the tibia in relation to the femur. Conversely, the posterior cruciate ligament prevents posterior displacement of the tibia on the femur. Although both cruciates are intraarticular they are not bathed by synovial fluid because they are not actually within the synovial membrane. The deep fibular (peroneal) nerve supplies a small area of skin in the web space between the great toe and the second toe. Although this is a small area, it can be tested clinically for hypesthesia or anesthesia. The superficial fibular (peroneal) nerve emerges from the fascia of the lower leg just above the lateral malleolus. It crosses onto the dorsum of the foot where it supplies most of the skin of the dorsum except for the web space supplied by the deep fibular (peroneal) nerve. Remember that the medial side of the foot is supplied by the terminal part of the saphenous nerve and the lateral surface by the distal part of the sural nerve. In inversion injuries, the most commonly injured ligaments are the anterior talofibular and calcaneofibular ligaments. The deltoid ligament is injured in eversion injuries. 60% of the surface of the talus is covered by articular cartilage. The talus has no muscular or tendonous attachments. Because of these few soft tissue attachments, the talus has a limited blood supply. This results in slow healing of fractures and a high incidence of avascular necrosis following talus fractures.

7.2

7.3

7.4 7.5

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248

anatoMy 8: coMpartMentS of leg and Sole of foot

Objectives:
1. Describe the compartmentalization of muscles in the posterior leg. 2. Describe origin, insertion, action and innervation of all muscles in the leg compartments. 3. Describe the distal tibia and fibula noting in particular the medial and lateral malleoli and their areas of articular cartilage which articulate with the talus. Understand the role of the sustentaculum tali (medial projection of the calcaneus) as a fulcrum for the flexor hallucis longus. 4. Describe bones of the foot. 5. Describe the muscle layers of the foot; describe the origin, insertion, action and innervation of the muscles of the foot. (See Summary Tables) 6. Describe the innervation of the skin of the foot. ) 7. Describe the anatomy and movements of the ankle

The Posterior Compartment of the Leg: (Figs 8.1-8.5)

The posterior compartment of the leg is divided into a superficial and deep space. All of the muscles in the posterior compartment of the leg act to flex (plantar) the ankle and or the toes. The ability to lift the heel off the ground, (stand on tip toes) is the function of the two strong muscles (gastrocnemius and soleus) inserting into the Achilles tendon (tendocalcaneus). Deep calf muscles are able to plantarflex the ankle as well but are not as strong as the two large superficial muscles.

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The superficial space of the posterior compartment Gastrocnemius (Fig. 8.1) The medial and lateral heads of gastrocnemius originate from the posterior aspect of the respective femoral condyles. The heads unite to form a single muscle mass joining the tendocalcaneus or Achilles tendon.

Plantaris m. Gastrocnemius m medial head lateral head

Achilles tendon

Figure 8.1 250

Soleus (Fig. 8.2) The soleus originates along a diagonal line from the head of the fibula to the popliteal line on the tibia. It inserts into the Achilles tendon. Branches from the tibial nerve innervate the muscles of the superficial posterior compartment. Plantaris (Fig. 8.2) The plantaris is a homologue of the palmaris longus of the forearm. As such, it is absent in a significant number of individuals. When present, it originates from the posterior aspect of the lateral femoral condyle as a short bellied muscle that becomes a long tendon inserting into the medial aspect of the Achilles tendon just proximal to the calcaneus.

Plantaris m.

Soleus m.

Figure 8.2 251

The deep space of the posterior compartment There are four muscles in this space, the popliteus acts at the knee joint; the three remaining muscles act at the ankle to flex the toes or plantar flex the ankle joint.

Popliteus m.

Flexor hallucis longus m.

Figure 8.3

Popliteus (Fig. 8.3) The popliteus originates from a triangular area on the posterior medial aspect of the tibia and inserts onto the lateral aspect of the lateral femoral condyle. In the locked-knee position, the femur is slightly medially rotated. With the foot on the floor, the tibias position is fixed. With bending of the knee, the popliteus unlocks the femur and laterally rotates it while the knee is flexing. Flexor hallucis longus (Fig 8.3) The flexor hallucis longus originates on the fibula with its tendon crossing the medial side of the ankle inferior to the sustentaculum tali of the calcaneus where it is housed in a fibro-osseus tunnel. It inserts into the terminal phalanx of the great toe and flexes the interphalangeal joint.

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Tibialis posterior (Fig. 8.4) The tibialis posterior originates from the posterior tibia, upper fibula, and the interosseus membrane and inserts primarily on the navicular and medial cuneiform bones of the foot. It is a plantar flexor and inverter of the ankle joint. It has a major role in supporting the arch of the foot as seen in patients who have a flat foot after rupture of this tendon .

Tibialis posterior m.

Figure 8.4 253

Flexor digitorum longus (Fig. 8.5) The flexor digitorum longus originates from the tibia and inserts into the distal phalanges of the second through the fifth toes. It flexes the distal interphalangeal joints.

Flexor digitorum longus m.

Figure 8.5 254

All of the muscles of the deep posterior compartment are supplied by the posterior tibial nerve, the terminal branch of the sciatic nerve. They receive blood supply from the posterior tibial artery, the continuation of the popliteal artery (Fig. 8.6)

Popliteal artery Anterior tibial a. entering anterior compartment Posterior tibial a. Fibular (Peroneal) a.

Figure 8.6 255

At the medial side of the ankle, there is a regular arrangement of the tendons and neurovascular bundle which is important in surgery of this area and in providing a posterior tibial nerve block at the ankle (Fig 7.7). The mnemonic is Tom, Dick, and a very nervous Harry, for the sequence of: tibialis posterior flexor digitorum longus posterior tibial artery posterior tibial vein posterior tibial nerve flexor hallucis longus

Tibialis posterior Flexor digitorum longus Posterior tibial a. Posterior tibial n. Medial calcaneal n. Medial plantar n. Lateral plantar n. Flexor hallucis longus

Figure 8.7 256

Muscles of the Sole of the Foot (Figs 8.8-8.12)

The muscles of the foot can be organized in a manner similar to those of the hand: a thenar equivalent, hypothenar equivalent and central group. With the exception of two unique muscles found only in the foot, (quadratus plantae and flexor digitorum brevis) they are as follows : Thenar: equivalents: Abductor hallucis Flexor hallucis brevis Hypothenar equivalents Abductor digiti minimi Flexor digiti minimi brevis Central Group Lumbricals Interossei Adductor hallucis

Notice there are no opponens muscles in the foot of human primates. The above is a functional organization which is useful in organizing the functions of the foot and comparing them to the hand. The following organization by layer is useful in dissection or surgery as it is the sequence in which the muscles and other structures are encountered. Layer One: (Three short muscles) (Fig 8.8) Abductor hallucis: originates from the medial calcaneus and inserts onto the medial aspect of the proximal phalanx of the great toe (Innervated by the medial plantar nerve) Flexor digitorum brevis: originates from the central portion of the calcaneus and inserts onto the base of the middle phalanges of the second through the fifth toe. (Innervated by the medial plantar nerve) Abductor digiti V: originates from the calcaneus and inserts on the lateral aspect of the proximal phalanx of the fifth toe. (Innervated by the lateral plantar nerve)

Abductor hallucis Flexor digitorum brevis Abductor digiti minimi

Figure 8.8 257

Layer Two: (Two long tendons and two short muscles) (Fig 8.9) Flexor hallucis longus: the tendon is continuing from the medial side of the ankle to insert on the distal phalanx of the great toe, flexing the interphalangeal joint. (innervated by the tibial nerve) Flexor digitorum longus: the tendons insert on the distal phalanges where they will flex the DIP joints of the second through the fifth toes. (Innervated by the tibial nerve) Quadratus plantae: originates from the calcaneus and inserts into the FDL tendon to redirect the force vector on the toes to a more central point in the foot. (Innervated by the lateral plantar nerve) Lumbricals: as in the hand, each lumbrical originates from the long flexor tendon and inserts on the medial aspect of the extensor mechanism of the toes. (*1st lumbrical to second digit is innervated by medial plantar nerve; great toe has no lumbrical)

Flexor hallucis longus Flexor digitorum longus with attached Lumbricals Quadratus plantae Flexor digitorum longus

Fig. 8.9

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Layer Three: (Three short muscles) (Fig 8.10) Flexor hallucis brevis: originates from the cuboid and the lateral cuneiform as two heads and inserts via two tendons, each containing a sesamoid, into the base of the proximal phalanx of the great toe, flexing the MTP joint (The muscle is innervated by the medial plantar nerve.) Adductor hallucis: the muscle has two heads, an oblique from the bases of 2nd - 4th metatarsals and a transverse from the capsules of the 2nd - 5th MTP joints. Both insert into the lateral side of the proximal phalanx of the great toe. Flexor digiti V: the muscle originates from the fifth metatarsal and the sheath of the peroneus longus tendon and inserts into the proximal phalanx of the fifth toe. Layer three also includes the muscular branches of the medial and lateral plantar nerves.

Flexor hallucis brevis with sesamoids Adductor hallucis m. transverse head oblique head Flexor digiti minimi brevis

Fig. 8.10 259

Layer Four: (Two long tendons and two short muscles) (Fig 8.11) Tibialis posterior: the terminal part of the tendon and its insertion is observed Peroneus longus: the terminal part of the tendon and its insertion is observed Interossei. As in the hand these muscles are important for abduction and adduction of the toes. In the foot the second ray defines the plane of ab- and adduction.

P3 Interossei Peroneus longus Tibialis posterior

P2

P1

D1

D2

D3 D4

Figure 8.11A

Figure 8.11B

A. Attachment of the four dorsal interossei of the foot that serve as abductors of the toes. B. Attachment of the three plantar interossei of the foot that serve as adductors of the toes. The midline of the foot is the second ray (dashed line). Abduction is movement away from the midline and adduction is movement toward the midline.

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In the foot almost all of the muscles are supplied by the lateral plantar branch of the tibial nerve. Only four muscles are supplied by the medial plantar nerve: the flexor hallucis brevis, abductor hallucis , flexor digitorum brevis and the first lumbrical. (Fig 8.12). The pattern of cutaneous innervation is also similar to the hand with the medial plantar nerve supplying three and a half digits and the lateral plantar nerve one and a half digits. Thus the medial plantar nerve can be thought of as a median nerve and the lateral plantar nerve as an ulnar nerve.

Lateral plantar n Medial plantar n.

Medial plantar n. supplies: Abductor hallucis Flexor hallucis brevis Flexor digitorum brevis First lumbrical all others by Lateral plantar n.

Figure 8.12 261

TABLE 14: MUSCLES IN THE SUPERFICIAL POSTERIOR COMPARTMENT OF THE LEG AND PLANTARIS MUSCLE MUSCLES gastrocnemius medial head: medial femoral condyle lateral head: lateral femoral condyle post. surface - of upper tibia and fibula lateral condyle of femur medial and posterior surface of calcaneus tibial n. calcaneus via Achilles tendon tibial n. S1, 2 L5, S1 calcaneus via Achilles tendon tibial n. S1, 2 ORIGIN INSERTION PERIPH. NERVE SPINAL SEG.

MOVEMENT

Plantar flexes foot, flexes femur on tibia

Plantar flexes foot, steadies (extends) leg on foot plantaris

soleus

Plantar flexes foot (Weak or absent muscle)

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TABLE 15: FOUR MUSCLES IN THE DEEP POSTERIOR COMPARTMENT OF THE LEG

MOVEMENT tibialis posterior flexor digitorum longus flexor hallucis longus inferior post. surface of fibula distal phalanx of big toe posterior tibial posterior surface of tibia distal phalanx of 4 lateral toes posterior tibial posterior tibia, upper fibula and interosseous membrane Navicular and medial cuneiform posterior tibial

MUSCLES

ORIGIN

INSERTION

PERIPH. NERVE

SPINAL SEG. L5, S1 L5, S1

Plantar flexes and inverts foot

Flexes toes (phalanges), continued action, plantar flexes foot

Flexes great toe, continued action aids in plantar flexion of foot popliteus SEE TABLE 13 SEE TABLE 13

L5, S1

Flexes leg, rotates tibia medially at beginning of flexion

posterior tibial

L4, 5, S1

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TABLE 16: TWO PLANTAR MUSCLES OF BIG TOE (THENAR EQUIVALENTS)

MUSCLES calcaneous cuboid and lateral cuneiform medial and lateral surface of proximal phalanx of big toe flexes big toe proximal phalanx of big toe abducts big toe medial plantar medial plantar

ORIGIN

INSERTION

MOVEMENT

PERIPH. NERVE

SPINAL SEG. L5, S1 L5, S1

Abductor hallucis

Flexor hallucis brevis

TABLE 17: TWO MUSCLES OF THE SMALL TOE (HYPOTHENAR EQUIVALENTS)

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ORIGIN base of calcaneus fifth metatarsal & sheath of peroneus longus base of proximal phalanx lateral side proximal phalanx INSERTION

MUSCLES

MOVEMENT abducts little toe flexor of little toe

PERIPH. NERVE lateral plantar lateral plantar

SPINAL SEG. L5, S1 L5, S1

Abductor digiti V

Flexor digiti V

TABLE 18: PLANTAR MUSCLES FOR THE LATERAL 4 TOES

MUSCLES calcaneus base of middle phalanx of 4 lateral toes tendon of flexor digitorum longus dorsal expansion of extensor digitorum longus tendon flexes M-P joint, extends interphalangeal joints straightens oblique pull of flexor digitorum longus tendon. Flexes 4 lateral toes lateral plantar flexes middle phalanx (continued action, flexes proximal toes) medial plantar

ORIGIN

INSERTION

MOVEMENT

PERIPH. NERVE

SPINAL SEG. L5, S1

Flexor digitorum brevis

Quadratus plantae

calcaneus

S1, 2

Four lumbricals

tendon of flexor digitorum longus

medial plantar, (1st lumb.) lateral plantar (lumb 2-4)

L5, S1 S1, 2 S1, 2 S1, 2

Four dorsal interossei

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3rd, 4th, & 5th metatarsals 3rd, 4th, 5th proximal phalanges. Also to dorsal expansion of extensor tendons proximal phalanx of big toe 2nd-5th metatarsals

by two heads from adjacent base of proximal phalanges 2-4 abducts toes (use 2nd toe lateral plantar sides of metatarsals and extensor expansion as reference) Flexes M-P joint and extends I-P joints adducts 3rd, 4th, and 5th toes. Flexes M-P joint and extends interphalangeal joints adducts big toe lateral plantar

Three plantar interossei

S1, 2

Adductor hallucis (two heads)

lateral plantar

S1, 2

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liVing anatoMy /clinical correlation luMBar Spine, knee, ankle, & foot
Objective:
Be able to find, outline, and demonstrate key musculoskeletal landmarks. Preparation for Class: 1. Review the pertinent anatomy. 2. Bring washable color markers. 3. Wear clothing that allows visualization of the structures you are assigned to find. 4. Bring a reflex hammer and tape measure. 5. Consider what findings you might expect for each of the diagnoses listed.

Draw the following on your partner:

the suprapatellar pouch the patella the medial and lateral femoral epicondyles (mark with a circle for each) the medial and lateral joint lines of the knee the tibial tubercle the patellar tendon the fibular head the pes anserinus Gurdys tubercle (where the iliotibial band inserts) the medial collateral ligament the lateral collateral ligament Draw an x where you would stick a needle if you wanted to aspirate the knee joint.

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Case 1:
Your patient complains of knee pain and swelling. It came on suddenly with a fall on the soccer field. Your differential diagnosis includes: arthritis patellofemoral syndrome torn meniscus torn collateral ligament torn cruciate ligament Osgood-Schlatter disease (adolescents) In order to sort out the possibilities, you must be able to identify the anatomic structures above. Which of these diagnoses would NOT produce an effusion? What additional history (symptoms) and physical exam findings (signs) would accompany each of these diagnoses?

Questions:
A. Which of the above diagnoses best support the clinical scenario? B. What additional findings might further support or reject each diagnosis? C. What is the normal range of motion of the knee? How do you examine the stability of the knee? What provacative tests are useful in evaluating knee function?

Case 2:
Your spouses divorce lawyer limps into your office with a chief complaint of thigh and knee pain after slipping on the walkway in front of your new office. It is snowing outside, and you forgot to hire an environmental services firm to manage the problems of inclement weather... Your differential includes: femur fracture hip fracture patella fracture knee dislocation patella dislocation anterior knee pain

Questions:
A. Which of the above diagnoses best support the clinical scenario? B. What additional findings might further support the diagnose(s)?

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Draw the following on your partner:

the lateral malleolus the medial malleolus the dome of the talus in the mortise the anterior talofibular ligament the calcaneofibular ligament the posterior talofibular ligament the anterior tibiofibular ligament the deltoid ligament the posterior tibial tendon ( from just above the tarsal tunnel to its insertion) Draw an x where you would stick a needle if you wanted to aspirate the ankle joint.

Case 3:
Your patient complains of ankle pain and swelling. It has come and gone over the past five years, but now it as severe as it has ever been. Your differential diagnosis includes: sprained ankle ankle (talocrural) arthritis malleolar fracture syndesmosis sprain osteochondritis dissecans of talar dome In order to sort out the possibilities, you must be able to identify the anatomic structures listed above. What constitutes the syndesmosis?

Questions:
A. Which of the above diagnoses best support the clinical scenario? B. What additional findings might further support or refute each diagnosis? C. What is the normal range of motion of the ankle? Does it matter if the knee is flexed or extended? The subtalar joint inverted or everted? D. How do you examine the stability of the ankle? E. Subtalar joint arthritis was not on the above differential. How would having it on your differential change your exam, and if present, what might the exam finding(s) be? F. Be sure you are clear on the peripheral nerve exam for the lower extremity. What are the motor and sensory tests for each of the major peripheral nerves of the lower limb?

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laBoratory diSSection
I. The Posterior Compartment of the Leg:
A. Superficial space of posterior compartment: Continue midline incision from popliteal fossa to point of heel, and reflect skin flaps. Identify and note the origin and insertions of the following: 1. Gastrocnemius, medial and lateral heads 2. Soleus 3. Plantaris B. Deep space of Posterior Compartment: Before identifying the muscles of this space, cut the insertion of the gastrocnemius muscle as it joins the soleus. Reflect the gastrocnemius superiorly. Next, detach the soleus from its origin on the tibia and fibula and reflect it inferiorly. Identify: 1. Popliteus 2. Flexor digitorum longus 3. Tibialis posterior 4. Flexor hallucis longus C. The tibial nerve supplies all posterior compartment muscles. The posterior tibial artery and the peroneal artery supply all muscles in the posterior compartment. Contrary to its name the peroneal artery is not located in the lateral (or peroneal) compartment of the leg. What is the cutaneous distribution of the sural nerves on the leg? (Q 8.1) D. Refer to summary charts at end of anatomy section to review muscles, actions, innervations, and segments. SOLE OF THE FOOT I. Osteology: Review the bones of the foot and familiarize yourself with the origin and insertion of the various muscles. Some of the insertions represent the tendons of muscles from the leg.

II. Layers of the Foot: There are 2 approaches to the foot described below. Two members of the team should work on one limb following the directions in II.1, and two on the other limb followoing the directions in II.2 below. II.1. On the limb that has not been dislocated at the hip, remove the skin over the sole of the foot and as far distally as the distal phalanx of 2-3 toes. If the toes on your cadaver are too dry to dissect, please find the digital insertions on another cadaver. Be careful to initially preserve the plantar aponeurosis. Most textbooks consider the layers of the foot to be composed of muscles and thus exclude the plantar aponeurosis as a layer of the foot. After noting the distribution of the plantar aponeurosis remove it and begin to study the muscle layers. Be careful to preserve the neurovascular bundle at the medial side of the foot (post.

275

tibial artery, and tibial nerve). Note the relationship of the neurovascular bundle to the three long tendons of the posterior compartment. What is their order of sequence? The medial side of the ankle is comparable to the area of the anterior wrist, in the sense that the tibial nerve is like a combined median and ulnar nerve. After the tibial nerve divides into its medial and lateral plantar branches, each supplies an area of skin and muscle mass equivalent to that supplied by the median and ulnar nerves respectively. Using this parallel you can reason out most of the innervation of the foot. With the exception of the four muscles noted with asterisks that are supplied by the medial plantar nerve, all of the remaining intrinsic muscles of the foot are supplied by the lateral plantar nerve. What is the cutaneous distribution of the plantar nerves? Identify: A. Layer One: (Three short muscles) 1. Abductor hallucis* (Medial plantar nerve) 2. Flexor digitorum brevis* (Medial plantar nerve) 3. Abductor digiti V Layer one also includes the digital branches of the medial and lateral plantar nerves and the digital vessels. B. Layer Two: (Two long tendons and two short muscles) 1. Flexor hallucis longus tendon 2. Flexor digitorum longus tendon 3. Quadratus plantae 4. Lumbricals (*1st lumbrical to second digit is innervated by medial plantar nerve; great toe has no lumbrical) C. Layer Three: (Three short muscles) 1. Flexor hallucis brevis* (medial plantar nerve) 2. Adductor hallucis 3. Flexor digiti V Layer three also includes the muscular branches of the medial and lateral plantar nerves. D. Layer Four: (Two long tendons and two short muscles) 1. Tibialis posterior tendon 2. Peroneus longus tendon 3. Interossei. How is abduction and adduction defined in the foot? How does this affect the pattern of innervation of the lumbricals and functional pattern of the interossei compared with the hand?

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The insertions of these muscles can be determined on a logical basis once plane of abduction-adduction is defined. E. Trace the tendons of the flexor digitorum longus and brevis to their insertions on the phalanges. Which flexes the DIP? PIP? Compare MTP flexion and extension to the MCP joints. Similarly work out flexion and extension of the DIP and PIP. Use the table below to work out the muscles flexing and extending each joint. MTP FLEXORS EXTENSORS _________________ __ ___________________ PIP __________________ __________________ DIP _____________________ _____________________

II.2. On the limb that has been dislocated at the hip, identify the posterior tibial nerve as it winds down the posterior calf, posterior to the medial malleolus. Identify its divisions; the calcaneal and medial and lateral plantar nerves. Follow the plantar nerves into the sole of the foot. This may require reflecting the abductor hallucis medially. There may be three slips of origin of the abductor hallucis, separated by the medial and lateral plantar nerves. Carefully release these slips of abductor hallucis muscle off of the calcaneus, preserving the nerves. Identify the lateral plantar nerves path across the sole of the foot. Develop a tunnel around this nerve. This will result in the more superficial side of the tunnel being Layer I in the foot and the deep side of the tunnel being Layer II. Make the tunnel larger by releasing Layer Is attachment to the calcaneus. Reflect Layer I off of Layer II more distally in the foot to improve visualization. Incise the skin across the sole in the region where Layer I was reflected off of the calcaneus for even more exposure. Continue to reflect deeper structures and layers as described above. The advantages to this approach are that it enters the foot between natural tissue planes and does not require exposure and reflection of the plantar fascia. III. Blood Supply in the Foot: Follow the posterior tibial artery from the medial side of the ankle into the sole of the foot. Note its branching pattern and its anastomosis with the dorsalis pedis artery on the dorsum of the foot. ANSWER TO ANATOMY QUESTION 8.1 The distribution of the sural nerves is best studied on the peripheral nerve map provided in the syllabus. Briefly, the medial and lateral sural nerves supply the respective areas of the calf skin. The medial and lateral sural nerves usually fuse to form the sural nerve just above the lateral aspect of the ankle. The nerve subsequently supplies the lateral surface of the foot and ankle. Because of their superficial course in the skin, they are vulnerable to lacerations or incisions.

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Radiology of the Cervical Spine

Objectives:
Be able to identify the following structures on cervical spine radiographs: Odontoid (Dens) Vertebral body Disc space Superior articular facet Inferior articular facet Facet joint Pedicle Lamina Spinous process The set of radiographs includes AP, lateral, odontoid and oblique views. On the lateral view, note the importance of the relationship of the odontoid process (dens) to the anterior arch of C-1. This distance normally measures 2-3mm. The opening of the spinal canal at that level (the distance between the posterior margin of the dens and the anterior margin of the posterior arch of C-1) measures 8mm. The spinal cord takes up 4mm of this width. Therefore, 4mm remain as the free space in the spinal canal at this level. C-1 can sublux on C-2 by a distance of 4mm without impinging on the spinal cord. The lateral view is also useful for assessing alignment. The posterior borders of the vertebral bodies should lie in a relatively straight line that gently curves in a lordotic direction. When normal cervical lordosis is present, lines drawn through the horizontal axis of each spinous process should converge on a point well posterior to the cervical spine. In addition, there should be no step off in the normal adult cervical spine. A step off may indicate either a fracture in the posterior elements or a facet subluxation or dislocation. The disc spaces should be approximately equal width. All 7 cervical vertebrae should be visualized, particularly in a trauma case. The oblique view gives the best picture of the neural foramen. The highest neural foramen visible is that for the C-3 nerve root which is superior to the C-3 vertebral body. Arthritic changes in the facet joints or the uncinate processes can encroach upon the nerve root as it emerges from the neural foramen. The open mouth view demonstrates the odontoid in the AP projection and the relationship of C-1 to C-2. The distances between the odontoid and the lateral masses of C-1 on each side should be equal. If these distances are not equal, a rotatory subluxation may exist. Most fractures of the odontoid occur at its base. Any apparent fractures above this level may represent a congenital anomaly called an os odontoideum.

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Radiology of the Shoulder

Objectives:
Be able to identify the following structures on radiographs of the shoulder: Humeral head Glenoid Coracoid process Acromioclavicular joint Greater and lesser tuberosities On the AP views, notice that internal rotation reveals the greater tuberosity of the humerus. On the axillary view note how the humeral head is centered at the glenoid fossa. The coracoid process is apparent anteriorly, and the acromion is apparent posteriorly. The relationship of the humeral head to these structures changes when the humeral head dislocates.

Radiology of the Elbow, Forearm, Wrist, and Hand

Objectives:
Be able to identify the following structures: Elbow: Capitulum (capitellum) Trochlea Radial head Coronoid process Olecranon process Wrist: Scaphoid Lunate Trapezium Capitate Hand: Metacarpals Phalanges

Radiography of the Elbow

The AP and lateral views show the normal anatomical alignment of the humerus, radius and ulna. Note the alignment of the radial head with the capitellum of the humerus. Any alteration in this alignment represents a dislocation of the radial head or fracture. On the lateral view note the coronoid process and the olecranon process of the ulna.

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Radiography of the Wrist and Hand

On the AP view of the wrist note that the lunate has four sides and there is very little space between the lunate and the scaphoid. The lunate appears moon shaped on the lateral view. If the lunate appears wedge or pie shaped on the AP view, or if there is an increased distance between the scaphoid and the lunate there has been a disruption of the ligamentous structures and a dislocation has occurred. This may be either a lunate or a perilunate dislocation. This dislocation can be confirmed on a lateral view on which the radius, lunate, capitate and metacarpals usually lie in a relatively straight line. The normal angle between the long axis of the scaphoid and the long axis of the lunate should be between 35 and 70 degrees. Also note on the lateral view that the distal margins of the radius and ulna overlap. if the ulna appears to be in a more dorsal position, either there is an ulnar dislocation or the film is not a true lateral.

Radiology of the Spine Objectives:

Be able to identify the following structures on spine radiographs: Vertebral body Disc space Superior articular facet Inferior articular facet Facet joint Pars interarticularis Pedicle Lamina Transverse process Spinous process AP film of the lower thoracic and the upper lumbar spine shows the normal alignment of the vertebral segments and the articulation of the posterior portion of the ribs with the vertebrae near the transverse processes. AP and lateral films of the lumbar spine show the normal anatomic structures. The paired oval densities noted on the AP film at each vertebral level are the pedicles which extend posteriorly from the body to the area of the articular processes. The tear-shaped structure centrally at each segment is the spinous process. On the lateral view note the disc spaces, the facet joints, and the position of the lumbar vertebrae in relation to the sacrum. The oblique views allow evaluation of the facet joints and the intervening portion of the vertebra which is referred to as the pars interarticularis. The shape of this region has been called a scottie dog with the eye of the dog being formed by the pedicle, the ear by the superior articular facet, and the front leg by the inferior articular facet. The neck of the scottie dog is the pars interarticularis. A developmental defect or a fracture running transversely through the pars interarticularis is known as spondylolysis. (The dog is wearing a collar.) Note the articulation of the sacrum with the pelvis at the sacroiliac joints. These show best on an oblique view.

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Radiology of the Pelvis and Hip Objectives:

Be able to identify the following structures on radiographs of the pelvis and hips: Sacroiliac joints Pubic symphysis Obturator foramen Acetabulum Femoral head Greater and lesser trochanters On the AP view of the adult pelvis note the pubic symphysis and the sacroiliac joints. The pubic bones should appear symmetric on a true AP view. Alterations in appearance between the right and left sides may indicate a fracture of the pubic ring or a disruption of the pubic symphysis. A fracture on one side of the pelvic ring may be accompanied by a fracture on the contralateral side or by sacroiliac joint separation. Note the normal position of the femoral head in relationship to the acetabulum.

Radiology of the Knee, Leg, Ankle, and Foot Objectives:

Be able to identify the following structures on radiographs of the knee, leg, ankle, and foot: Knee and Leg: Patella Femur Tibia Fibula Ankle: Tibia (medial malleolus) Fibula (lateral malleolus) Talus (Mortise) Foot: Calcaneus Cuboid Talus Navicular Cuneiforms Metatarsals Phalanges

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The Knee
The AP view shows superimposition of the patella on the distal femur. Alignment of the knee joint (bow leg or knock knee) can be evaluated on the AP view especially if the film was obtained with the patient bearing weight. The tibiofibular joint can be better visualized in a slightly internally rotated projection. This is important in cases of suspected tibiofibular dislocation. Sometimes, a small circular bone is seen posterior to the femoral condyle. This bone is called the fabella and is a sesamoid, as is the patella. The fabella is located in the lateral head of the gastrocnemius. It is a common normal finding. Note that the term fibular head refers to the proximal end of the fibula in the same way that radial head refers to the proximal end of the radius.

The Ankle and Foot

The most distal part of the fibula is called the lateral malleolus and the distal medial aspect of the tibia, the medial malleolus. The radiolucent cartilage space between the tibia, fibula and talus is referred to as the ankle mortise because of its shape. The mortise is best visualized on a view in which the leg has been internally rotated approximately 15 degrees. There should be an equal amount of radiolucency on all sides of the mortise, i.e. between the talus and the fibula, the talus and the horizontal articular surface of the distal tibia (the plafond) and the talus and the medial malleolus. If these distances are not equal, there is either instability or subluxation of the ankle joint. On the lateral view notice the tuberosity of the calcaneus. Spurs are commonly seen in this area secondary to traction by the plantar fascia. Sometimes the posterior process of the talus, which has its own center of ossification separate from the center of ossification for the body of the talus, fails to fuse with the body of the talus. It then forms a separate bone called an os trigonum. This is not a fracture of the talus. The talus and calcaneus compose the hindfoot. The midfoot is made up of the remaining tarsal bones. The joint between the hindfoot and the midfoot is called Choparts joint. The forefoot includes the metatarsals and phalanges. The joint between the midfoot and forefoot (tarsometatarsal joint) is called Lisfrancs joint. Injury to Lisfrancs joints can be subtle. Careful radiographic analysis is important to identify displacements across this joint that may require surgical treatment.

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lower liMB reView

The following clinical problems have been designed to aid in your preparation for the lower limb exam. They present the anatomy in an applied way, which is, after all, how you will use your anatomic knowledge in practice. First, you should: 1. Review lower limb anatomy: basic and applied (functional). 2. Review syllabus section on physical exam of the lumbar spine, hip, knee, ankle and foot. Then carefully study the lower limb cases presented. (This may be more fun in a group.) First try to come up with a differential diagnosis after reading only the presenting complaint. Then, after reading the physical findings, try to rule in or out the diagnoses on your list and come up with a final single diagnosis. You should be able to describe and understand the following clinical problems: 1. Lumbosacral nerve root impingements 2. Peripheral nerve injuries: a. sciatic b. posterior tibial c. peroneal 3. Common lower limb problems a. hip abductor lurch (Trendelenburg gait) b. knee instability c. ankle instability d. claw toes A few of the questions on the exam will be in the form of a similar clinical case presentation followed by multiple choices for the diagnosis (as on the upper limb exam)

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Lower Limb Cases

These are also available with links to the pertinent anatomy and sample tests on our course web site at http://eduserv.hscer.washington.edu/hubio553/cases/index.html. Case #1: H.D.S. is a 21-year-old male skier presenting with a painful swollen right leg. Six hours ago he jumped over a mogul and fell. His bindings did not release and his right ski twisted up behind him. He felt a cracking sensation in his right leg and was brought down the hill by the ski patrol. His right leg was splinted and he was sent to you. On physical examination, he has a swollen right leg from the mid-third tibia down through the toes. There is marked tenderness to palpation at the junction of the mid and distal thirds of the tibia as well as in the mid-third of the fibula. He has decreased sensation in the first web space on the foot and has pain when you try to flex his toes. He is able to extend his toes and his ankle with considerable pain. Case #2: I.B. is a 28-year-old dancer complaining of medial arch pain present for one month. One month ago in addition to her usual class work, she began rehearsing 4 to 5 hours per day for an upcoming performance. On physical examination, swelling and slight tenderness are noted posterior to the medial malleolus extending distally to the level of the tarsometatarsal joint. Inversion and plantar flexion of the foot against resistance cause medial arch pain. Crepitus is noted behind the medial malleolus during ankle motion. Case #3: J.K. is a 35-year-old martial arts participant complaining of lateral knee pain present for 6 weeks. He did not have any specific injury. He has noted intermittent swelling in his knee. There has been no instability. On physical examination, a 30 cc effusion is present. He has tenderness to palpation along the lateral joint line. Full range of motion is present although there is pain at terminal flexion. Tests for ligamentous laxity are negative. Pain is increased on the lateral side of the knee when the knee is flexed and the tibia rotated (McMurrays test). There is no pain with active extension of the knee to terminal extension. Case #4: H.D. is a 42-year-old flight attendant complaining of right foot pain. The pain is present under the metatarsal heads particularly toward the lateral aspect of the foot. The pain is made worse when the patient is on her feet all day, particularly when she wears high-heeled shoes. She has noted slight numbness in the adjoining surfaces of the 3rd and 4th toes. On physical examination, she has tenderness to palpation between the 3rd and 4th metatarsal heads. There is also pain in this region produced by squeezing her foot from medial and lateral simultaneously. In addition, pain is also elicited by applying axial pressure in the 3rd web space. Case #5: R.S. is a 39-year-old physician presenting with a one year history of low back pain. One week ago he sneezed and produced pain radiating down the anterior aspect of the left leg to the medial malleolus. This pain has not resolved. The leg pain becomes worse during Valsalva maneuvers. He has had no associated numbness, weakness or change in bowel or bladder habits.

286

On physical examination, he lists forward and to the right. Back flexion and extension are marked by dysrhythmia. Tests of motor strength show grade 4 strength of the tibialis anterior on the left but otherwise are normal. Sensation is intact. Deep tendon reflexes are 1+ at the left knee, 2+ at the right knee and 2+ at both ankles. The straight leg raising test is negative. However, the reverse straight leg raising test is markedly positive on the left. Case #6: B.H. is a 50-year-old female runner complaining of left posterior thigh pain. The pain has been present for about a year following a fall onto her left buttock. The pain is intermittent in nature and occasionally is associated with cramping in the left calf. When she sits for a long time, she develops numbness in the posterior aspect of the leg and the bottom of the foot. Physical exam of her back reveals normal range of motion and no tenderness. Physical exam of her hips reveals 60 of external rotation and 10 of internal rotation on the left compared to 45 in each direction on the right. Forced internal rotation of the left hip is associated with pain. There is slight tenderness to palpation in the left sciatic notch. The neurological exam of the lower extremities is normal. Straight leg raising is associated with pain on the left side only when the left leg is flexed beyond 90. There is no weakness in the lower extremities and the deep tendon reflexes are normal.

287

Lower Limb Cases-Discussion

1. Fracture of the tibia and fibula with developing deep anterior compartmental syndrome The site of tenderness on the bone usually is indicative of the site of fracture. The compartmental syndrome has not yet progressed to the point of loss of extensor muscle strength. 2. Tendonitis of the posterior tibial tendon This is an overuse problem. Pain with use against resistance of the involved muscle-tendon unit is a classic finding when tendonitis is present . 3. Torn lateral meniscus Common as a result of martial arts due to the repeated hyperflexion and rotation of the knee during kicking maneuvers. The site of tenderness is usually the site of the tear. Typically if the tear is posterior to the middle of the meniscus, terminal flexion will be painful. Similarly if the tear is anterior to the middle of the meniscus, terminal extension may be painful. 4. Mortons neuroma (neuroma of the common plantar digital nerve between the third and fourth metatarsals) This can occur due to trauma or to excessive pressure on the ball of the foot (as a result of shoe wear, cavus foot, or running-dancing on the ball of the foot). 5. L-4 nerve root impingement due to a herniated nucleus pulposus (disc) A classic presentation. Leaning to the right can relieve the impingement of the disc on the nerve root (on the left) when the disc protrusion is lateral to the nerve root. 6. Piriformis syndrome (irritation of the sciatic nerve as it emerges below the piriformis muscle) Nerve impingements do not always produce neurologic deficits, and may only produce radicular pain. The key to differentiating this from nerve root impingement with sciatica (a term describing radicular pain in the distribution of the sciatic nerve) is the loss of internal rotation of the hip on the involved side. This implies a tight external rotator, in this case the piriformis muscle.

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HuBio 553 Musculoskeletal System

SAMPLE EXAM

This exam is intended to be a learning experience for you. The questions include all the types that you will find on the real thing. Questions 1-23 are single answer multiple choice. 1. Which of the following does not produce numbness of the tip of the index finger (2nd digit)? a. b. c. d. e. 2. median nerve lesion lesion of the lower trunk of the brachial plexus lesion of the lateral root of the median nerve carpal tunnel syndrome lesion of the lateral cord of the brachial plexus

Which of the following would be seen in a patient with a lower trunk brachial plexus palsy (Klumpke-Dejerine Syndrome)? a. b. c. d. e. thenar muscle wasting numbness of the tip of the long finger loss of elbow flexion loss of shoulder abduction loss of sensation on the lateral forearm

3.

The first 30 degrees of scapular rotation during shoulder abduction a. b. c. d. e. requires hinging at the acromioclavicular joint requires elevation of the clavicle requires axial rotation of the clavicle is accompanied by 30 degrees of glenohumeral motion is accomplished by action of the rhomboids

4.

In regard to the synovial membrane of the glenohumeral joint: a. b. c. d. e. there are no extensions of the membrane to provide bursae for adjacent tendons there is usually an opening connecting it with the subacromial bursa it surrounds the pectoralis major tendon it is continuous with the synovial space of the acromioclavicular joint it forms a bursa for the subscapularis tendon

5.

Which of the following muscles does not attach to the clavicle? a. b. c. d. e. pectoralis major supraspinatus trapezius deltoid subclavius

289

6.

With respect to the quadrangular space: a. b. c. d. e. no nerves pass through the space only the radial nerve traverses it only the suprascapular nerve traverses it injury to the nerve traversing it results in loss of scapular rotation injury to the nerve traversing it causes loss of sensation on the upper lateral surface of the arm

7.

Which of the following statements is true in regard to the cutaneous distribution of C-7? a. b. c. d. e. it supplies the ulnar side of the hand it is distributed in the median nerve it supplies the ring finger it is distributed by the lateral cutaneous nerve of the forearm it is distributed by the deep radial nerve

8.

Which of the following arteries is a branch of the second part of the axillary artery? a. b. c. d. e. lateral thoracic artery anterior humeral circumflex posterior humeral circumflex subscapular thyrocervical trunk

9.

Which of the following is a clinical test of T-1? a. b. c. d. e. have the patient extend the thumb against resistance have the patient extend the MCP joint of the index finger against resistance have the patient spread the fingers against resistance have the patient extend the wrist against resistance have the patient flex the wrist against resistance

10.

The most important stabilizer of the glenohumeral joint is a. b. c. d. e. the synovial membrane the fibrous capsule the glenoid fossa the glenoid labrum the rotator cuff

11.

The lumbar plexus is composed of nerves one of which supplies: a. b. c. d. e. muscles in the posterior compartment of the thigh skin on the lateral aspect of the leg (not thigh) skin on the lateral aspect of the foot an extensor of the hip the extensors of the knee

290

12.

Which of the following muscles attaches to the anterior superior iliac spine? a. b. c. d. e. pectineus sartorius rectus femoris vastus intermedius gracilis

13.

Which of the following muscles traverses the greater sciatic foramen? a. b. c. d. e. gluteus medius gluteus minimus gluteus maximus quadratus femoris piriformis

14.

The only innervation of the femoral nerve below the level of the knee is: a. b. c. d. e. the gracilis muscle the tibialis anterior muscle the skin of the lateral foot the adductor longus the skin of the medial leg

15.

The muscle attaching to the lesser trochanter of the femur is the: a. b. c. d. e. pectineus iliopsoas gluteus maximus piriformis obturator externus

16.

The posterior division of the obturator nerve supplies the: a. b. c. d. e. obturator externus muscle skin of the anterior thigh gracilis muscle semitendinosus muscle adductor longus muscle

17.

The muscles of the lateral compartment of the leg include: a. b. c. d. e. an evertor of the foot an invertor of the foot a dorsiflexor of the ankle an extensor of the fifth digit (toe) one which attaches to the sustentaculum tali

291

18.

The muscle of the foot which is equivalent to the flexor digitorum superficialis (sublimis) of the hand is the: a. b. c. d. e. quadratus plantae (flexor accessorius) flexor digitorum brevis flexor digitorum longus plantaris tibialis posterior

19.

The dermatomal distribution of spinal segment L-4 is over the a. b. c. d. e. lateral surface of the thigh medial surface of the thigh medial surface of the leg lateral surface of the leg lateral surface of the foot

20.

In the foot the extensor digitorum longus is: a. b. c. d. e. an extensor of the MTP joint an extensor of the PIP joint an extensor of the DIP joint attached to the metatarsal an invertor of the foot.

21.

Your physical exam of a patient shows no active or passive dorsiflexion of the ankle when his knee is extended, whereas there is near normal range of dorsiflexion when his knee is flexed. The anatomical explanation for this physical finding is: a. b. c. d. e. paralysis of the gastrocnemius and soleus muscles contracture of the gastrocnemius contracture of the soleus paralysis of the tibialis anterior paralysis of the peroneus tertius

22.

A 23 year old man presents in the ER with a stab wound in the groin. Physical exam reveals a one inch long wound between the scrotum and left thigh with moderate bleeding. You find the man cannot adduct his left leg and that he has an area of cutaneous sensory deficit on the medial aspect of his left thigh. You conclude that: a. b. c. d. e. the left femoral nerve was cut roots L-2, L-3, and L-4 were cut on the left the left lumbosacral trunk was cut the left obturator nerve was cut the left lateral femoral cutaneous nerve was cut

292

23.

The integrity of C6 spinal cord segment is best tested by: a. b. b. d. e. brachioradialis tendon reflex biceps tendon reflex triceps tendon reflex cutaneous sensation on the middle finger cutaneous sensation on the fifth finger

The remaining questions are matching questions. For questions 24-32 identify upper and lower limb homologues. Choose the homologous upper limb structure labeled A to D for each of the lower limb structures listed. Choose E if no upper limb homologue is listed. 24. 25 26. 27. 28. 29. 30 31. 32. Fibula Femur Obturator nerve Tibia Sciatic nerve Tibial nerve Medial plantar nerve Deep peroneal nerve Femoral nerve A. B. C. D. E. radius ulna median nerve posterior interosseous nerve none

Match the numbered muscles listed in column A with the areas of the scapula to which they attach listed in column B. A 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. infraspinatus serratus anterior trapezius rhomboid major subscapularis teres major supraspinatus pectoralis major latissimus dorsi coracobrachialis A. B. C. D. E. B medial border of the scapula scapular spine coracoid process posterior surface of the scapula none of the above

293

Match the numbered nerves listed in column A with the parts of the brachial plexus from which they are given off listed in column B. 43. 44. 45. 46 . 47. 48. 49. 50. 51. 52. A thoracodorsal nerve dorsal scapular nerve lateral pectoral nerve ulnar nerve lower subscapular nerve axillary nerve musculocutaneous nerve lateral cutaneous nerve of the forearm anterior interosseous nerve suprascapular nerve A. B. C. D. E. B lateral cord medial cord posterior cord upper trunk none of the above

Match the numbered muscles listed in column A with the actions listed in column B. A B 53. 54. 55. 56. 57. brachioradialis biceps brachialis pronator teres triceps A. B. C. D. E. flexion of the elbow pronation supination extension of the elbow at least 2 of the above

Match the numbered muscles listed in column A with the nerves listed in column B. 58. 59. 60. 61. 62. 63. 64. 65. A brachioradialis pronator teres pronator quadratus flexor pollicis longus flexor digitorum superficialis flexor carpi ulnaris extensor pollicis longus supinator A. B. C. D. E. B median nerve anterior interosseous nerve deep radial nerve (a.k.a. posterior interosseous nerve) radial nerve ulnar nerve

294

Answers to sample exam 1. b. The index finger receives innervation from C-6 through the median nerve. 2. a. Thenar muscles are supplied by C-8, T-1 . 3. b. See Dr. Graneys discussion of shoulder mechanics in Anatomy 2 section in syllabus. 4. e. 5. b. 6. e. The axillary nerve traverses the quadrangular space. 7. b. 8. a. 9. c. 10. e. There is very limited stability provided by the anatomic shape of the glenoid even with the labrum. Although the capsule is quite strong and important in stabilization, patients with redundant capsules (after shoulder dislocation) can often further stabilize their shoulders by strengthening their rotator cuff muscles. 11. e. The quadriceps muscle is supplied by the femoral nerve. 12. b. 13. e. 14. e. via the saphenous nerve, the terminal branch of the femoral nerve 15. b. 16. a. The skin of the anterior thigh is supplied by the femoral nerve, the gracilis and adductor longus muscles are supplied by the anterior branch of the obturator nerve, and the semitendinosus is supplied by the sciatic nerve. 17. a. 18. b. The flexor digitorum brevis flexes the middle phalanx of the toe as the FDS flexes the middle phalanx of the finger. 19. c. 20. a. Extension of the PIP and DIP joints is accomplished by the intrinsic muscles via the extensor expansion (hood) 21. b. Paralysis would not account for lack of passive motion. Since the gastroc originates above the knee, straightening the knee puts increased tension on the Achilles tendon, which, if tight, will prevent active or passive dorsiflexion of the ankle.

295

22. d. 23. a. 24. B. 25. E. (none) humerus 26. E. (none) (musculocutaneous) 27. A. 28. E. (none) (equivalent to radial, median and ulnar) 29. E. (none) (equivalent to median and ulnar together) 30. C. 31. D. 32. E. (none) (equivalent to radial to the triceps) 33. D. 34. A. 35. B. 36. A. 37. E. 38. D. 39. D. 40. E. 41. E. 42. C. 43. C. 44. E. 45. A. 46. B. 47. C. 48. C.

296

49. A. 50. E. 51. E. 52. D. 53. A. 54. E. (flexes and supinates) 55. A. 56. E. (flexes and pronates) 57. D. 58. D. 59. A. 60. B 61. B. 62. A. 63. E. 64. C. 65. C.

297

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HuBio 553 Musculoskeletal System 1.

SAMPLE CLINICAL EXAM QUESTIONS

A 14 year old boy falls off his bike and injures his forearm. Which of the following best describes the radiograph shown below? a. displaced physeal fractures of the radial head and the distal ulna b. displaced, transverse, metaphyseal fractures of the distal radius and ulna c. displaced intraarticular fractures of the distal radius and ulna d. displaced transverse fractures of the radial head and ulna e. displaced transverse epiphyseal fractures of the distal radius and ulna

2.

This fracture is/is not likely to produce abnormal growth in the radius because the fracture line crosses the a. the epiphysis b. the physis c. the metaphysis d. the diaphysis e. part of the physis and the epiphysis

299

3.

Noah sustains this injury when he is hit by a car while crossing the street. Which of the following best describes the fractures shown below? a. segmental fracture of the proximal to mid-third tibia and a short oblique fracture of the proximal fibula b. segmental fracture of the proximal to mid-third tibia and a short oblique fracture of the proximal fibula with comminution at both ends of the fractured tibial segment c. segmental fracture of the proximal to mid-third tibia and a short oblique fracture of the proximal fibula with comminution at both ends of the fractured tibial segment and slight varus angulation of the distal end of the tibial segment d. segmental intraarticular fracture of the proximal to mid-third tibia and a short oblique fracture of the proximal fibula e. segmental fracture of the proximal to mid-third tibia and a short oblique fracture of the proximal fibula with comminution at both ends of the fractured tibial segment and displacement of the tibial segment

300

4.

An hour later Noah is seen in the emergency room. His anterior leg is ecchymotic and swollen. His dorsalis pedis and posterior tibial pulses are full. The sensation in his toes is normal. You put his leg in a splint and admit him for overnight observation because you are worried about which of the following? a. infection b. arterial injury c. displacement of the fracture d. compartmental syndrome e. all of the above

5.

Six hours later the nurse calls you to tell you that Noah is complaining of pain despite a fair amount of IM Demerol. You stop in to check Noah. Which of the following would confirm your suspicions? a. absent pulses b. fever c. blueness of the digits d. loss of sensation in the foot e. the splint is too loose For the following questions, choose an answer from the following 6 options. Each option can be used once, more than once, or not at all. a. osteoarthritis b. rheumatoid arthritis c. seronegative spondyloarthropathy d. crystalline arthritis e. fungal arthritis f. septic arthritis

6. 7.

A radiograph of an affected joint will show narrowed cartilage space, sclerosis, and osteophytes. A 30 year old man with a warm, swollen, knee joint and conjunctivitis is most likely to have _____________. In this form of arthritis, inflammation is found where ligaments attach to bone. This form of arthritis is associated with Crohns disease. Joint fluid from an affected joint is likely to contain 110,000 WBCs, 95% of which will be polymorphonuclear leukocytes.

8. 9. 10.

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11.

A 78 year old woman presents with right groin pain which has been present for 3 days. Three days ago she slipped on a throw rug. However she managed to catch herself and did not fall to the ground. Since that time, however, she has noted groin pain and has been limping slightly. She has a history of vertebral compression fracture three years ago after a fall in the bathroom. Physical exam reveals a frail, elderly woman who is limping with a lurch over the right side. She has a positive Trendelenberg sign on the right. Range of motion of her hips is symmetrical. However, the patient guards and has slight pain with medial rotation of her right hip. X-rays reveal a dense line across the femoral neck. The most likely diagnosis is: a. b. c. d. e. metastatic tumor impacted femoral neck fracture degenerative joint disease muscle strain neuromuscular disorder

12.

Which one of the following is not generally associated with delayed unions or non-unions? a. b. c. d. e. infection osteoporosis open fracture interposition of muscle between the fracture fragments inadequate immobilization of the fracture

13.

Fracture healing always requires which of the following: a. b. c. d. e. blood supply to the fractured bone casting internal fixation callus formation calcium supplements

302

Answers to Sample Clinical Exam Questions**

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

b c c d d a c c c f b b a

303

304

indeX
Allens Test ................................................................................................................................................130 Anatomy Lectures Ankle .................................................................................................................224, 254 Arm .............................................................................................................................39 Axilla ...........................................................................................................................14 Brachial Plexus......................................................................................................18, 20 Cubital Fossa ...............................................................................................................92 Foot anterior.............................................................................................................224 posterior ...........................................................................................................257 Forearm .......................................................................................................................93 Gluteal Muscles .........................................................................................................186 Hand .......................................................................................................................... 111 Hip anterior.............................................................................................................191 posterior ...........................................................................................................192 Knee ..........................................................................................................................217 Leg Anterior Compartment ....................................................................................217 Lateral Compartment .......................................................................................225 Posterior Compartment....................................................................................249 Lumbar Plexus ..........................................................................................................176 Sacral Plexus .............................................................................................................188 Shoulder ......................................................................................................................40 Spine ...........................................................................................................................26 Thigh Muscles anterior.............................................................................................................169 posterior ...........................................................................................................197 Vertebral Column ........................................................................................................26 See Gross Labs anatomy lecture .........................................................................................................217 clinical correlations in ...............................................................................................229 gross lab ....................................................................................................................243 living anatomy ...........................................................................................................267 motion of ...................................................................................................................229 pain ............................................................................................................................235 radiology ...................................................................................................................283 sprains .......................................................................................................................233 305

Anatomy Labs Ankle

Anterior Cruciate Ligament Tears................................................................................ .........................234 Arm anatomy lecture ...........................................................................................................39 gross lab ......................................................................................................................73 ankylosing spondylitis .................................................................................................82 comparison of ..............................................................................................................86 crystalline ....................................................................................................................82 enteropathic .................................................................................................................83 fungal...........................................................................................................................81 infectious .....................................................................................................................80 osteo ............................................................................................................................78 overview ......................................................................................................................77 psoriatic .......................................................................................................................83 Reiters syndrome .......................................................................................................82 rheumatoid...................................................................................................................79 septic ...........................................................................................................................79 spondyloarthropathy ....................................................................................................82 viral .............................................................................................................................81

Arthritis

Assignments .................................................................................................................................................ix Axilla anatomy lecture .............................................................................................................3 gross lab ......................................................................................................................35 see Bone Turnover

Bone Metabolism

Bone Turnover ..........................................................................................................................................155 Boutonniere Deformity ............................................................................................................................122 Brachial Plexus anatomy lecture ...........................................................................................................13 gross lab ......................................................................................................................35

Carpal Tunnel Syndrome ........................................................................................................................128 Cases lower limb ................................................................................................................285 upper limb .................................................................................................................143 Clinical Assessment of Nerve Roots cervical .................................................................................................................. 63-65 lumbar ......................................................................................................................238

Clinical Correlations

306

Ankle and Foot ..........................................................................................................229 Hand ..........................................................................................................................121 Hip .............................................................................................................................203 Knee ..........................................................................................................................229 Shoulder ......................................................................................................................51 Clinical Lectures arthritis ........................................................................................................................77 trauma ................................................................................................................155, 161

Colles Fracture .........................................................................................................................................126 Compartmental syndrome ..............................................................................................................158, 162 Cubital Fossa anatomy lecture ...........................................................................................................87 gross lab ....................................................................................................................105

Deep tendon reflexes ..................................................................................................................................62 DeQuervains Tenosynovitis ....................................................................................................................144 Dermatomes anterior ................................................................................................................ xv, xxv lateral ........................................................................................................................xxix posterior............................................................................................................. xvii, xxi shoulder .......................................................................................................................59

Dislocation

Dissection Instructions see Gross Labs Elbow Pain ................................................................................................................................................131 Exams about ..............................................................................................................................v sample .......................................................................................................................289 capital, slip of ............................................................................................................203 mallet .........................................................................................................................124 trigger ........................................................................................................................125 anterior anatomy lecture ...............................................................................................224 gross lab ...........................................................................................................243 clinical correlations in ....................................................................................229 forefoot pain ..............................................................................................................235

Femoral Epiphysis Finger

Foot

307

joints of......................................................................................................................230 metatarsalgia .............................................................................................................235 Mortons neuroma .....................................................................................................236 posterior anatomy lecture ...............................................................................................257 gross lab ...........................................................................................................275 radiology ..................................................................................................................241 stress fractures of.......................................................................................................225 Forearm anatomy lecture ...........................................................................................................93 gross lab ....................................................................................................................105 radiology ...................................................................................................................279 Colles.........................................................................................................................126 healing .......................................................................................................................152 hip ..............................................................................................................................203 patterns ......................................................................................................................157 pathologic ..................................................................................................................154 scaphoid.....................................................................................................................129 stress ..........................................................................................................................156 tibia and fibula ...........................................................................................................163

Fracture

Gamekeepers Thumb .............................................................................................................................128 Gluteal Muscles anatomy lecture .........................................................................................................189 gross lab ....................................................................................................................213

Grading .........................................................................................................................................................v Gross labs

Ankle .........................................................................................................................243 Arm ............................................................................................................................74 Axilla ...........................................................................................................................36 Brachial Plexus............................................................................................................36 Cubital Fossa .............................................................................................................105 Dissection Instructions .............................................................................................. viii Foot anterior.............................................................................................................243 posterior ...........................................................................................................275 Forearm .....................................................................................................................105 Gluteal Muscles .........................................................................................................213

308

Hand ..........................................................................................................................137 Hip anterior.............................................................................................................185 posterior ...........................................................................................................213 Knee .........................................................................................................................243 Leg Anterior Compartment ....................................................................................243 Lateral Compartment .......................................................................................243 Posterior Compartment....................................................................................275 Lumbar Plexus ..........................................................................................................185 Sacral Plexus ............................................................................................................189 Shoulder ......................................................................................................................73 Thigh Muscles anterior.............................................................................................................169 posterior ...........................................................................................................213 Hand anatomy lecture ......................................................................................................... 111 clinical correlations in ..............................................................................................121 gross lab ....................................................................................................................137 living anatomy ...........................................................................................................129 radiology ...................................................................................................................268 weakness ..................................................................................................................130

Heel Pain ...................................................................................................................................................232 Hip anatomy lecture .........................................................................................................168 clinical correlations in ...............................................................................................202 fractures of ...............................................................................................................203 gross lab ...................................................................................................................214 living anatomy ..........................................................................................................208 pain ............................................................................................................................208 radiology ...................................................................................................................282

Ice and Friction Massage.........................................................................................................................205 Iliotibial tendinitis ....................................................................................................................................204 Impingement Syndrome, Shoulder...........................................................................................................58 Intrinsic muscles, Hand ...........................................................................................................................113 Knee anatomy lecture .........................................................................................................217 anterior cruciate ligament tears .................................................................................234

309

clinical correlations in ...............................................................................................229 gross lab ....................................................................................................................243 living anatomy ...........................................................................................................267 meniscal tears ............................................................................................................233 patellofemoral pain....................................................................................................232 pain ............................................................................................................................238 radiology ...................................................................................................................282 Labs Lectures see Gross Labs see Anatomy Lectures see Clinical Correlations see Clinical Lectures Anterior Compartment anatomy lecture ......................................................................... .....................217 gross lab ...........................................................................................................243 Length Discrepancy ..................................................................................................208 Lateral Compartment anatomy lecture ...............................................................................................217 gross lab .......................................................................................................... 243 Posterior Compartment anatomy lecture ...............................................................................................249 gross lab ...........................................................................................................275 Radiology ..................................................................................................................282 Cervical Spine Elbow and Hand ...............................................................................129 Cervical Spine and Upper Limb ..................................................................................65 instructions ..................................................................................................................61 Lumbar Spine, Knee, Ankle, and Foot ......................................................................267 Lumbar Spine and Lower Limb ................................................................................207 anatomy lecture .........................................................................................................169 gross lab ....................................................................................................................185

Leg

Living Anatomy

Lumbar Plexus

Mallet Finger ............................................................................................................................................124 Massage, Ice and Friction........................................................................................................................205 Meniscal Tears ..........................................................................................................................................233 Mortons neuroma ...................................................................................................................................236 Multiple Myeloma ..............................................................................................................................33, 156

310

Muscle

strength, grading of .....................................................................................................63

Neck pain ............................................................................................................................................29, 129 Nerve autonomous zones ..................................................................................xv, xvii, iv, 129 maps anterior....................................................................................................... xv, xxv lateral ..............................................................................................................xxix posterior .................................................................................................. xvii, xxi anterior interosseous .................................................................................................144 radial ..........................................................................................................................145 clinical assessment of cervical ..............................................................................................................63 lumbar ..............................................................................................................238 maps of see Dermatomes

Nerve Entrapment Nerve Injury Nerve Roots

Obers Test ................................................................................................................................................205 Objectives, course ...................................................................................................................................... iii Organization, course .................................................................................................................................. iii Osteopenia ................................................................................................................................................156 Osteophytes.................................................................................................................................................79 Patellofemoral Pain..................................................................................................................................232 Patrick Test ...............................................................................................................................................208 Peripheral Nerve Maps see Dermatomes Phalens test ..............................................................................................................................................128 Piriformis syndrome ................................................................................................................................288 Q-angle ......................................................................................................................................................239 Radiculopathy C-6 .......................................................................................................................31, 132 lumbar .........................................................................................................................31 Ankle .........................................................................................................................283 Cervical Spine ...........................................................................................................279 Elbow ........................................................................................................................280 311

Radiology

Foot ...........................................................................................................................282 Forearm .....................................................................................................................280 Hand ..........................................................................................................................281 Hip .............................................................................................................................282 Instructions ...................................................................................................................X Knee ..........................................................................................................................282 Leg.............................................................................................................................282 Pelvis .........................................................................................................................282 Shoulder ....................................................................................................................280 Spine ..........................................................................................................................281 Wrist ..........................................................................................................................281 Reflexes see Deep tendon reflexes

Resources ......................................................................................................................................................v Reviews lower limb .................................................................................................................285 upper limb .................................................................................................................143

Rotator Cuff Tear/Tendinitis.....................................................................................................................57 Sacral Plexus anatomy lecture .........................................................................................................189 gross lab ....................................................................................................................213

Sample Exams ..........................................................................................................................................289 Scaphoid Fracture ....................................................................................................................................136 Schedule ........................................................................................................................................................x Shoulder

anatomy lecture ...........................................................................................................39 arthrology ....................................................................................................................52 biomechanics ...............................................................................................................57 bursae ..........................................................................................................................57 clinical correlations in .................................................................................................52 dislocation ...................................................................................................................58 gross lab ......................................................................................................................73 impingement syndrome ...............................................................................................57 living anatomy .............................................................................................................65 pain ..............................................................................................................................57 radiology ...................................................................................................................280 rotator cuff tear/tendinitis ............................................................................................57 separation ....................................................................................................................58

312

Snuff box, anatomical ..............................................................................................................................126 Spine anatomy lecture ...........................................................................................................26 radiology ...................................................................................................................281 ankle ..........................................................................................................................241

Sprains

Study Strategies........................................................................................................................................ viii Swan Neck Deformity ..............................................................................................................................123 Synovial Fluid Analysis..............................................................................................................................86 Tables Brachial Plexus .................................................................................................... 21-22 Elbow Flexors and Extensors ............................................................................. 48-50 Finger Joints, Motion of..........................................................................................116 Foot, Two Dorsal Muscles of ..................................................................................227 Forearm, Anterior Compartment of (Deep) .........................................................101 Forearm, Anterior Compartment of ( Superficial)...............................................100 Forearm, Posterior Compartment of (Deep) ........................................................103 Forearm, Posterior Compartment of (Superficial) ..............................................102 Glenohumeral Motion ...............................................................................................49 Hallux, Two Plantar Muscles of .............................................................................264 Hand, Central Intrinsic Muscles of .......................................................................119 Hip Joint, Muscles Acting on..................................................................................181 Hypothenar Muscles ...............................................................................................119 Knee Joint, Muscles Acting on ...............................................................................182 Leg, Anterior Compartment of ..............................................................................227 Leg, Lateral Compartment of ................................................................................228 Leg, Posterior Compartment of (Deep) .................................................................263 Leg, Posterior Compartment of (Superficial) .......................................................262 Scapular Motion ........................................................................................................49 Thumb, Four Short Muscles of ...................................................................... 116, 118 Thumb, Motion of ...................................................................................................139 Toe, fifth, Two Muscles of .......................................................................................264 Toes, Lateral 4 Plantar Muscles of.........................................................................265 anterior cruciate ligament ..........................................................................................234 meniscus ....................................................................................................................233 Iliotibial .....................................................................................................................146

Tears

Tendinitis

313

Tennis Elbow ............................................................................................................................................146 Thigh Muscles anterior anatomy lecture ...............................................................................................169 gross lab ...........................................................................................................185 posterior anatomy lecture ...............................................................................................189 gross lab ...........................................................................................................213 numbness ...................................................................................................................128 muscles of..................................................................................................................113

Thumb

Tinels sign ................................................................................................................................................128 Trauma see Compartmental syndrome see Fracture

Trendelenburg Sign..................................................................................................................................209 Trigger Finger ..........................................................................................................................................125 Vertebral Column anatomy lecture ...........................................................................................................26 arthrology ....................................................................................................................26 ligaments of .................................................................................................................27 osteology .....................................................................................................................26

Wrist pain .................................................................................................................................................126

314