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AANNAATTOOMMYY
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ANATOMY REVISION
OF THE
UPPER LIMB,
LOWER LIMB
& BACK
Second Edition
This book is sponsored by the Medical Protection Soci...
1
p r e f a c e
Fellow Medic,
The first edition of Anatomy Revision of the Upper Limb, Lower Limb & Back was compiled in
2...
2
i n t r o d u c t i o n
The study of anatomy can seem daunting, as the human body is a complex system in
terms of both s...
3
c o n t e n t s
page
ANATOMY OF THE UPPER LIMB 4
Upper Limb Osteology 5 – 7
Cross Sectional Anatomy of the Upper Limb 8
...
4
ANATOMY
OF THE
UPPER LIMB
FUNDAMENTAL MOVEMENTS OF THE UPPER LIMB
Retraction
Flexion
Extension
Pronation
Supination
Palm...
5
UPPER LIMB OSTEOLOGY – SCAPULA
LEFT SCAPULA – POSTERIOR VIEW
LEFT SCAPULA – ANTERIOR VIEW
(Suprascapular nerve passes th...
6
UPPER LIMB OSTEOLOGY – SHOULDER
UPPER LIMB OSTEOLOGY – WRIST
RIGHT PROXIMAL
HUMERUS – ANTERIOR &
POSTERIOR VIEWS
Triquet...
7
UPPER LIMB OSTEOLOGY – ELBOW
RIGHT DISTAL HUMERUS – ANTERIOR, POSTERIOR & LATERAL VIEWS
RIGHT PROXIMAL ULNA – ANTERIOR, ...
8
CROSS-SECTIONAL ANATOMY OF THE ARM & FOREARM
Cephalic vein
Biceps brachii
Brachialis
Musculocutaneous nerve
Median nerve...
MUSCULATURE OF THE AXILLA, ARM & FOREARM
ORIGIN INSERTION INNERVATION ACTION
TRAPEZIUS Ligamentum Nuchae;
Spinous processe...
ORIGIN INSERTION INNERVATION ACTION
TERES MAJOR
Posterior surface of
inferior angle of scapula
Intertubercular groove on
a...
ANTERIOR COMPARTMENT OF FOREARM – Comprises flexors & pronators
ORIGIN INSERTION INNERVATION ACTION
FLEXOR DIGITORUM
SUPER...
POSTERIOR COMPARTMENT OF FOREARM – Comprises extensors & supinator, innervated by RADIAL NERVE
ORIGIN INSERTION ACTION
BRA...
UPPER LIMB MUSCLES ANTERIOR VIEW POSTERIOR VIEW
RIGHT UPPER LIMB LEFT UPPER LIMB
Flexor carpi ulnaris
Hypothenar muscles :...
14
NEUROLOGY OF THE UPPER LIMB
C 4
C 3
T 2
C 5
T 1
C 7
C 6
C 8
POSTERIOR VIEW
C 4
C 6
C 5
T 2
T 1
C 7
C 8
DERMATOMES OF TH...
15
MAJOR NERVES OF THE UPPER LIMB (ANTERIOR VIEW OF RIGHT UPPER LIMB)
Brachial
plexus
Musculocutaneous nerve
Axillary nerv...
16
VASCULATURE OF THE UPPER LIMB
AXILLARY ARTERY passes medial to head of the humerus and becomes BRACHIAL ARTERY.
PROFUND...
17
MAJOR VESSELS OF THE UPPER LIMB (ANTERIOR VIEW OF LEFT UPPER LIMB)
Brachial
artery
Brachial
vein
Profunda
brachii
arter...
18
ANATOMY
OF THE
LOWER LIMB
FUNDAMENTAL MOVEMENTS OF THE LOWER LIMB
Extension Flexion
Adduction
Abduction
Medial (interna...
19
LOWER LIMB OSTEOLOGY – PELVIS
ANTERIOR VIEW
POSTERIOR VIEW
Iliacus
Sartorius
Quadratus
femoris
(Connected to pubic tube...
20
LOWER LIMB OSTEOLOGY – FEMUR & PATELLA
LEFT FEMUR – ANTERIOR & POSTERIOR VIEWS
LEFT PATELLA – POSTERIOR VIEW
LEFT PATEL...
21
LOWER LIMB OSTEOLOGY – TIBIA & FIBULA
LEFT TIBIA – ANTERIOR, POSTERIOR & LATERAL VIEWS
LEFT
FIBULA
Interosseous
membran...
22
OSTEOLOGY OF THE FOOT
LIGAMENTS OF THE KNEE JOINT
LEFT FOOT –
DORSAL
SURFACE
MEDIAL
VIEW
LATERAL VIEW
RIGHT KNEE (FLEXE...
23
CROSS-SECTIONAL ANATOMY OF THE THIGH & LEG
Vastus lateralis
Rectus femoris
Vastus intermedius
Femur
Vastus medialis
Pro...
MUSCULATURE OF THE GLUTEAL REGION, THIGH & LEG
ORIGIN INSERTION INNERVATION ACTION
TENSOR FASCIAE LATAE Lateral aspect of ...
QUADRICEPS
FEMORIS
ANTERIOR COMPARTMENT OF THIGH – Innervated by FEMORAL NERVE
ORIGIN INSERTION ACTION
PSOAS MAJOR Transve...
POSTERIOR COMPARTMENT OF THIGH – Innervated by SCIATIC NERVE
ORIGIN INSERTION ACTION
HAMSTRINGS
SEMIMEMBRANOSUS
Ischial tu...
POSTERIOR COMPARTMENT OF LEG – Comprises superficial & deep groups, innervated by TIBIAL NERVE
DORSAL FOOT MUSCLES – Exten...
LOWER LIMB MUSCLES ANTERIOR VIEW POSTERIOR VIEW
SUPERFICIAL MUSCLES DEEP MUSCLES DEEP MUSCLES
Extensor
hallucis
longus
Ten...
29
NEUROLOGY OF THE LOWER LIMB
L 1
L 2
L 3
S 3
L 4
L 5
S 1
S 4L 2
S 3
S 2 L 3
L 4
L 5
S 1
L 5
L 4
DERMATOMES OF
THE LOWER ...
30
MAJOR NERVES OF THE LOWER LIMB (POSTERIOR VIEW OF RIGHT LOWER LIMB)
Obturator
nerve
Sciatic
nerve
Common fibular
(peron...
31
VASCULATURE OF THE LOWER LIMB
COMMON ILIAC ARTERY bifurcates in front of the sacrum to form EXTERNAL & INTERNAL ILIAC
A...
32
SMALL SAPHENOUS VEIN runs up posterior aspect of leg, before passing between the heads of
gastrocnemius and draining in...
33
ANATOMY
OF THE
BACK
FUNDAMENTAL MOVEMENTS OF THE BACK
Extension
Flexion
Lateral
flexion Rotation
34
STRUCTURAL ANATOMY OF THE VERTEBRAL COLUMN
Vertebral column comprises 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, ...
35
LUMBAR
VERTEBRA
SPINAL
LIGAMENTS
Anterior and posterior longitudinal ligaments run along anterior
and posterior surface...
36
STRUCTURES OF THE VERTEBRAL CANAL
The spinal cord is part of the central nervous system situated in the superior two-th...
37
Between the arachnoid mater and pia mater is the subarachnoid space, which contains
cerebrospinal fluid (CSF). Spinal a...
MUSCULATURE OF THE BACK – EXTRINSIC MUSCLES
Extrinsic muscles of the back are comprised of: – SUPERFICIAL GROUP (Related t...
INTRINSIC MUSCLES
ORIGIN INSERTION INNERVATION ACTION
ERECTOR SPINAE
MUSCLES
Spinous processes of
lower thoracic vertebrae...
40
CLINICAL ANATOMY
Studying anatomy from a clinical perspective involves a fundamental approach that considers
both struc...
41
Anatomical snuff box (radial fossa): The scaphoid and trapezium form the floor of the
anatomical snuff box, located bet...
42
CROSS-SECTIONAL ANATOMY – EXAMINATION TIPS
Before identifying any individual structures on a cross-section, it is impor...
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Anatomy Revision of the Upper Limb, Lower Limb & Back

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Anatomy Revision of the Upper Limb, Lower Limb & Back

  1. 1. sseeccoonndd eeddiittiioonn AANNAATTOOMMYY RREEVVIISSIIOONN OOFF TTHHEE UUPPPPEERR LLIIMMBB,, LLOOWWEERR LLIIMMBB && BBAACCKK NN II MM AA RR AA ZZ II II
  2. 2. ANATOMY REVISION OF THE UPPER LIMB, LOWER LIMB & BACK Second Edition This book is sponsored by the Medical Protection Society and Wesleyan Medical Sickness: medicalprotection.org/uk/students insight.wesleyan.co.uk/juniordoctors www.mps.org.uk www.wesleyan.co.uk Copyright © 2012 by Nima Razii All rights reserved
  3. 3. 1 p r e f a c e Fellow Medic, The first edition of Anatomy Revision of the Upper Limb, Lower Limb & Back was compiled in 2009, intended as a study aid for medical students. I hoped it would prove to be of some benefit during those challenging times of revising - that I remember all too well from my own first year in medicine - when an examination or viva was impending, and the 1000 + pages of Gray’s Anatomy for Students seemed somewhat overwhelming to browse through! I could not have imagined at the time, that what started out as a series of diagrams and annotations, would develop into something that has been so well received. I am incredibly grateful to have obtained so much constructive feedback from students and staff alike throughout the process, and I have attempted to incorporate as many of the practical suggestions I received as possible into this second edition of the publication. Naturally, this guide does not, by any means, intend to be a replacement for comprehensive anatomy textbooks and atlases – such as Gray’s or McMinn’s – but is rather designed to complement them as a lighter way of revising and/ or reminding yourself of some of the more fundamental anatomical features of the upper limb, lower limb and back that you are likely to be tested on. Looking beyond exams and assessments, I hope you also develop an enjoyment of anatomy and an appreciation of the marvel of nature that is the human body. Finally, the very best of luck in all your medical studies, now and in the future. Sincerely, Many thanks to the staff of the Department of Anatomy at the School of Biosciences, Cardiff University, without whom the writing of this guide would have been impossible, and for promoting the study of anatomy in a practical & engaging manner.
  4. 4. 2 i n t r o d u c t i o n The study of anatomy can seem daunting, as the human body is a complex system in terms of both structure and function. However, the fact remains that a sound grasp of anatomy is essential in any branch of medicine. Fortunately, there are ways to familiarize oneself with the way in which the body’s structures are organized and also to develop the propensity for viewing the human body from a clinical perspective. For the purposes of this revision guide, we will introduce the anatomy to each body section with an overview of the fundamental movements of that area. Learning these early on will prove useful, not only in further studies, but also in a clinical context, where terms relating to anatomical movements are frequently used. Following this, the osteology of each region is considered, with the important features and prominences of bones being labelled in highlighted black text, and sites of muscle attachments in blue. Cross-sections of the upper and lower limbs give an indication of the positioning of various structures in relation to each other. Prosections are often used in anatomy examinations, with questions asking for specified structures (e.g. muscles or nerves) to be correctly identified. In the final section, a structured strategy is developed for orientating oneself before going on to identify various individual structures on a cross- section, useful for when under the time constraints of a spotter examination or viva. Muscles of the upper limb, lower limb and back are arranged into tabulated groups, and the origin, insertion, action, and nervous innervation for each is given. The major nerves & plexi supplying the upper and lower limbs are illustrated, along with the dermatomes of these regions. Dermatomes are used in neurological examination, as they can indicate the location of damage to spinal nerves, although it is noteworthy that they do overlap, and that there is variation between individuals. The organization of various structures within the vertebral canal is depicted after a section on the anatomy of the vertebral column itself. Vasculature is a fundamental part of human anatomy, and the distribution of major blood vessels throughout the upper limb, lower limb and back is described and illustrated in turn for each region. In terms of studying anatomy from a clinical perspective, it is worth adopting a mindset that encourages one to think about the possible consequences arising from certain dysfunctions; accordingly, a section is dedicated to some notable clinical scenarios and commonly associated anatomical causes.
  5. 5. 3 c o n t e n t s page ANATOMY OF THE UPPER LIMB 4 Upper Limb Osteology 5 – 7 Cross Sectional Anatomy of the Upper Limb 8 Musculature of the Upper Limb 9 – 13 Neurology of the Upper Limb 14 – 15 Vasculature of the Upper Limb 16 – 17 ANATOMY OF THE LOWER LIMB 18 Lower Limb Osteology 19 – 22 Ligaments of the Knee 22 Cross Sectional Anatomy of the Lower Limb 23 Musculature of the Lower Limb 24 – 28 Neurology of the Lower Limb 29 – 30 Vasculature of the Lower Limb 31 – 32 ANATOMY OF THE BACK 33 Structural Anatomy of the Vertebral Column 34 – 35 Structures of the Vertebral Canal 36 – 37 Musculature of the Back 38 – 39 CLINICAL ANATOMY 40 – 41 CROSS SECTIONAL ANATOMY – EXAMINATION TIPS 42
  6. 6. 4 ANATOMY OF THE UPPER LIMB FUNDAMENTAL MOVEMENTS OF THE UPPER LIMB Retraction Flexion Extension Pronation Supination Palm posterior Palm anterior Lateral rotation Medial rotation Adduction Abduction Protraction Extension Flexion
  7. 7. 5 UPPER LIMB OSTEOLOGY – SCAPULA LEFT SCAPULA – POSTERIOR VIEW LEFT SCAPULA – ANTERIOR VIEW (Suprascapular nerve passes through suprascapular notch) Coracobrachialis, Pectoralis minor & Short head of biceps Long head of triceps Subscapularis Serratus Anterior Levator Scapulae Supraspinatus Trapezius Rhomboid minor Rhomboid major Infraspinatus Latissimus dorsi Teres major Teres minor Long head of triceps Deltoid Coracobrachialis, Pectoralis minor & Short head of biceps Long head of biceps
  8. 8. 6 UPPER LIMB OSTEOLOGY – SHOULDER UPPER LIMB OSTEOLOGY – WRIST RIGHT PROXIMAL HUMERUS – ANTERIOR & POSTERIOR VIEWS Triquetrum and styloid process of ulna lie posterior to pisiform, which in turn cannot be seen when hand is pronated. CARPAL BONES RIGHT HAND RIGHT DISTAL ULNA & RADIUS – ANTERIOR VIEW SUPINATED POSITIONBrachioradialis Pronator quadratus Subscapularis Supraspinatus Supraspinatus Infraspinatus Teres Minor Lateral head of triceps Medial head of triceps Brachialis Teres major Latissimus dorsi Deltoid Pectoralis major
  9. 9. 7 UPPER LIMB OSTEOLOGY – ELBOW RIGHT DISTAL HUMERUS – ANTERIOR, POSTERIOR & LATERAL VIEWS RIGHT PROXIMAL ULNA – ANTERIOR, POSTERIOR & LATERAL VIEWS RIGHT PROXIMAL RADIUS – ANTERIOR, POSTERIOR & MEDIAL VIEWS Flexors Extensors Brachialis Brachialis Supinator Biceps brachii Triceps brachii Brachialis Supinator Brachialis Trochlea articulates with ulna. Capitulum articulates with head of radius. Biceps brachii Flexor pollicis longus Brachioradialis Extensors Annular ligament Supinator
  10. 10. 8 CROSS-SECTIONAL ANATOMY OF THE ARM & FOREARM Cephalic vein Biceps brachii Brachialis Musculocutaneous nerve Median nerve Brachial artery & veins Basilic vein Ulnar nerve Superior ulnar collateral artery Humerus Radial nerve Profunda brachii artery Triceps brachii Posterior cutaneous nerve Brachioradialis Cephalic vein Radial nerve, artery & veins Lateral cutaneous nerve Flexor carpi radialis Palmaris longus Medial cutaneous nerve Flexor digitorum superficialis Flexor pollicis longus Median nerve Flexor carpi ulnaris Ulnar nerve, artery & veins Radius Anterior interosseous nerve & artery Basilic vein Interosseous membrane Extensor pollicis longus Ulna Flexor digitorum profundus Extensor carpi ulnaris Posterior interosseous artery Extensor digiti minimi Abductor pollicis longus Extensor digitorum Extensores carpi radiales (longus & brevis)
  11. 11. MUSCULATURE OF THE AXILLA, ARM & FOREARM ORIGIN INSERTION INNERVATION ACTION TRAPEZIUS Ligamentum Nuchae; Spinous processes of C7-T12 Lateral third of clavicle; Acromion; Spine of scapula Accessory nerve Elevates shoulder & rotates scapula during abduction of humerus above horizontal; middle fibres retract scapula; lower fibres depress scapula DELTOID Lateral third of clavicle ; Acromion ; Spine of scapula Deltoid tuberosity of humerus Axillary nerve Abducts arm beyond initial 15° (accomplished by supraspinatus) LEVATOR SCAPULAE Transverse processes of C1-C4 Upper medial border of scapula C3 & C4 anterior rami; Dorsal scapular nerve Elevates scapula RHOMBOID MAJOR Spinous processes of T2-T5 Lower medial border of scapula Dorsal scapular nerve Retracts (adducts) & elevates scapula RHOMBOID MINOR Ligamentum Nuchae; Spinous processes of C7 & T1 Medial border at spine of scapula ROTATOR CUFF MUSCLES are designed to stabilize the shoulder (glenohumeral joint) by attaching the humerus to their respective scapular fossae: SUPRASPINATUS Supraspinous fossa Greater tubercle of humerus Suprascapular nerve Abducts arm up to 15° INFRASPINATUS Infraspinous fossa Laterally (externally) rotates arm TERES MINOR Lateral border of scapula Axillary nerve SUBSCAPULARIS Subscapular fossa Lesser tubercle of humerus Subscapular nerve Medially (internally) rotates arm 9
  12. 12. ORIGIN INSERTION INNERVATION ACTION TERES MAJOR Posterior surface of inferior angle of scapula Intertubercular groove on anterior surface of humerus Subscapular nerve Medially (internally) rotates & extends arm at glenohumeral joint PECTORALIS MAJOR Clavicular head : Anterior surface of clavicle Sternocostal head : Sternum ; costal cartilages 1-7 ; aponeurosis of external oblique Lateral edge of intertubercular groove of humerus Medial & lateral pectoral nerves Flexes, adducts & medially (internally) rotates arm at glenohumeral joint PECTORALIS MINOR Ribs 3-5 Coracoid process of scapula Medial pectoral nerve Depresses shoulder & protracts scapula SUBCLAVIUS Medial aspect of rib 1 Inferior surface of clavicle Nerve to subclavius Depresses clavicle SERRATUS ANTERIOR Lateral surfaces of ribs 1-9 Medial border of scapula Long thoracic nerve Protracts, stabilizes & rotates scapula ANTERIOR COMPARTMENT OF ARM BICEPS BRACHII Long head : Supraglenoid tubercle of scapula Short head : Apex of coracoid process Tuberosity of radius Musculocutaneous nerve Flexes & supinates forearm CORACOBRACHIALIS Apex of coracoid process Medial aspect of humerus Flexes & adducts arm BRACHIALIS Anterior aspect of humerus Tuberosity of ulna Flexes forearm TRICEPS BRACHII Long head : Infraglenoid tubercle of scapula Medial & lateral heads : Posterior surface of humerus Olecranon process of ulna Radial nerve Extends forearm POSTERIOR COMPARTMENT OF ARM 10
  13. 13. ANTERIOR COMPARTMENT OF FOREARM – Comprises flexors & pronators ORIGIN INSERTION INNERVATION ACTION FLEXOR DIGITORUM SUPERFICIALIS Medial epicondyle of humerus (Common flexor tendon) Middle phalanges of fingers (except thumb) Median nerve Flexes proximal IP joints of fingers (except thumb) FLEXOR POLLICIS LONGUS Anterior surface of body of radius; interosseous membrane Distal phalanx of thumb Flexes MCP & IP joints of thumb PRONATOR QUADRATUS Distal anteromedial surface of ulna Distal anterior surface of radius Pronates forearm PRONATOR TERES Medial epicondyle of humerus; medial aspect of coronoid process Body of radius PALMARIS LONGUS Medial epicondyle of humerus _ (Common flexor tendon) Palmar aponeurosis of hand Flexes wrist FLEXOR CARPI RADIALIS 2nd & 3rd metacarpals Flexes & abducts wrist FLEXOR CARPI ULNARIS Pisiform ; ligaments into hamate & 5th metacarpal Ulnar nerve Flexes & adducts wrist FLEXOR DIGITORUM PROFUNDUS Anteromedial surface of body of ulna; interosseous membrane Distal phalanges of fingers (except thumb) Flexes wrist, MCP & distal IP joints of fingers (except thumb) Distal interphalangeal joints (DIJ) IP: Interphalangeal joints Proximal interphalangeal joints (PIJ) MCP: Metacarpophalangeal joints CMC: Carpometacarpal joints Midcarpal joint Distal phalanges Intermediate phalanges Proximal phalanges Metacarpals Carpal bones JOINTS OF THE HAND 11
  14. 14. POSTERIOR COMPARTMENT OF FOREARM – Comprises extensors & supinator, innervated by RADIAL NERVE ORIGIN INSERTION ACTION BRACHIORADIALIS * Lateral supracondylar ridge of humerus Distal aspect of radius Flexes forearm at elbow EXTENSOR CARPI RADIALIS LONGUS Base of 2nd metacarpal Extends & abducts wrist EXTENSOR CARPI RADIALIS BREVIS Lateral epicondyle of humerus (Common extensor tendon) Base of 2nd & 3nd metacarpals EXTENSOR CARPI ULNARIS Base of 5th metacarpal Extends & adducts wrist EXTENSOR DIGITORUM Extensor expansion of middle & distal phalanges of all fingers (except thumb) Extends all fingers (except thumb) & wrist EXTENSOR DIGITI MINIMI Extensor expansion of proximal phalanx of little finger Extends joints of little fingers ABDUCTOR POLLICIS LONGUS Posterior surfaces of distal radius & ulna ; Interosseous membrane Lateral aspect of base of 1st metacarpal Abducts CMC joint of thumb ; assists in extension of thumb EXTENSOR POLLICIS BREVIS Posterior surface of radius Base of proximal phalanx of thumb Extends MCP joint of thumb EXTENSOR POLLICIS LONGUS Posterior surface of ulna Base of distal phalanx of thumb Extends IP joint of thumb EXTENSOR INDICIS Posterior surface of distal ulna Extensor expansion of index finger Extends index finger SUPINATOR Lateral epicondyle of humerus ; Supinator crest of ulna ; Radial collateral & annular ligaments Lateral aspect of proximal radius Supinates forearm (* Although categorized in the posterior compartment, Brachioradialis flexes the elbow joint.) 12
  15. 15. UPPER LIMB MUSCLES ANTERIOR VIEW POSTERIOR VIEW RIGHT UPPER LIMB LEFT UPPER LIMB Flexor carpi ulnaris Hypothenar muscles : Abductor digiti minimi Flexor digiti minimi brevis Opponens digiti minimi Palmaris brevis Flexor carpi radialis Pronator teres Pectoralis major Deltoid Biceps brachii Serratus anterior Brachioradialis Extensor digitorum Extensor carpi ulnaris Latissimus dorsi Triceps brachii Deltoid Trapezius Infraspinatus Thenar muscles: Abductor pollicis brevis Flexor pollicis brevis Opponens pollicis Adductor pollicis Extensores carpi radialis longus & brevis
  16. 16. 14 NEUROLOGY OF THE UPPER LIMB C 4 C 3 T 2 C 5 T 1 C 7 C 6 C 8 POSTERIOR VIEW C 4 C 6 C 5 T 2 T 1 C 7 C 8 DERMATOMES OF THE UPPER LIMB ANTERIOR VIEW C 3 RIGHT UPPER LIMB LEFT UPPER LIMB MUSCULOCUTANEOUS NERVE AXILLARY NERVE MEDIAN NERVE RADIAL NERVE ULNAR NERVE BRACHIAL PLEXUS Long thoracic nerve Medial pectoral nerve Medial cutaneous nerve of arm Medial cutaneous nerve of forearm Suprascapular nerve Lateral pectoral nerve Thoracodorsal nerve Nerve to subclavius Superior subscapular nerve Inferior subscapular nerve
  17. 17. 15 MAJOR NERVES OF THE UPPER LIMB (ANTERIOR VIEW OF RIGHT UPPER LIMB) Brachial plexus Musculocutaneous nerve Axillary nerve Radial nerve Median nerve Interosseous nerve Ulnar nerve
  18. 18. 16 VASCULATURE OF THE UPPER LIMB AXILLARY ARTERY passes medial to head of the humerus and becomes BRACHIAL ARTERY. PROFUNDA BRACHII ARTERY branches off posterior aspect of BRACHIAL ARTERY, passes through radial groove and down lateral side of humerus. BRACHIAL ARTERY passes between lateral and medial epicondyles of humerus and bifurcates in the cubital fossa, giving rise to the RADIAL ARTERY & ULNAR ARTERY. RADIAL ARTERY runs down the anterolateral part of the forearm, between flexor pollicis longus & brachioradialis, and forms the DEEP PALMAR ARCH of the hand. RADIAL ARTERY is accompanied by the RADIAL NERVE. ULNAR ARTERY runs down the anteromedial part of the forearm, between flexor digitorum profundus & superficialis, and forms the SUPERFICIAL PALMAR ARCH of the hand. ULNAR ARTERY is accompanied by ULNAR NERVE. DORSAL VENOUS NETWORK OF THE HAND gives rise to BASILIC & CEPHALIC VEINS. BASILIC VEIN runs up medial aspect of upper limb; CEPHALIC VEIN runs up anterolateral aspect of upper limb. Both are subcutaneous. BASILIC VEIN becomes AXILLARY VEIN, and CEPHALIC VEIN drains into AXILLARY VEIN at the deltopectoral triangle. BASILIC & CEPHALIC VEINS communicate via MEDIAN CUBITAL VEIN, a superficial vein located in the cubital fossa (from where blood is often taken). DEEP VEINS accompany arteries of the upper limb & share their names (e.g. ulnar & radial veins).
  19. 19. 17 MAJOR VESSELS OF THE UPPER LIMB (ANTERIOR VIEW OF LEFT UPPER LIMB) Brachial artery Brachial vein Profunda brachii artery Basilic vein Axillary artery Ulnar artery Cephalic vein Radial artery Superficial palmar arch Anterior interosseous artery Deep palmar arch Axillary vein Ulnar vein Median cubital vein Radial vein Median antebrachial vein Dorsal venous network of the hand
  20. 20. 18 ANATOMY OF THE LOWER LIMB FUNDAMENTAL MOVEMENTS OF THE LOWER LIMB Extension Flexion Adduction Abduction Medial (internal) rotation Dorsiflexion PlantarflexionExtension Flexion Eversion Inversion Lateral (external) rotation
  21. 21. 19 LOWER LIMB OSTEOLOGY – PELVIS ANTERIOR VIEW POSTERIOR VIEW Iliacus Sartorius Quadratus femoris (Connected to pubic tubercle by inguinal ligament) Obturator internus Gluteus medius Gluteus maximusGluteus minimus External oblique Tensor fasciae latae Semimembranosus Semitendinosus & Long head of biceps femoris Quadratus femoris Adductors brevis, longus & magnus Quadratus externus Adductor magnus Piriformis
  22. 22. 20 LOWER LIMB OSTEOLOGY – FEMUR & PATELLA LEFT FEMUR – ANTERIOR & POSTERIOR VIEWS LEFT PATELLA – POSTERIOR VIEW LEFT PATELLA ANTERIOR VIEW Piriformis Gluteus minimus Vastus lateralis Gluteus maximus Vastus intermedius Vastus medialis Psoas major & Iliacus Quadratus femoris Obturator externus Gluteus medius Obturator internus Psoas major & Iliacus Pectineus Vastus medialis Adductor magnus Adductor brevis Biceps femoris (Short head) Vastus intermedius Lateral head of gastrocnemius Plantaris Popliteus Adductor magnus Medial head of gastrocnemius Adductor Magnus Vastus intermedius Rectus femoris Vastus lateralis Vastus medialis
  23. 23. 21 LOWER LIMB OSTEOLOGY – TIBIA & FIBULA LEFT TIBIA – ANTERIOR, POSTERIOR & LATERAL VIEWS LEFT FIBULA Interosseous membrane Soleus Biceps femoris Fibularis longus Fibular collateral ligament Biceps femoris Soleus Tibialis posterior Fibular collateral ligament Biceps femoris Extensor digitorum longus Fibularis longus Tibialis posterior Soleus Popliteus Tibialis posterior Tibialis anterior Semitendinosus Gracilis Sartorius Tibialis anterior Semimembranosus Vastus medialis Iliotibial tract Posterior cruciate ligament Semimembranosus Iliotibial tract Extensor digitorum longus Fibularis longus Fibularis tertius
  24. 24. 22 OSTEOLOGY OF THE FOOT LIGAMENTS OF THE KNEE JOINT LEFT FOOT – DORSAL SURFACE MEDIAL VIEW LATERAL VIEW RIGHT KNEE (FLEXED) – ANTERIOR VIEW Fibularis brevis Extensor digitorum brevis Achilles tendon (Calcaneal tendon) Plantaris Femur Posterior cruciate ligament Medial (tibial) collateral ligament Medial meniscus Tibia Fibula Lateral (fibular) collateral ligament Lateral meniscus Anterior cruciate ligament Fibula Lateral (fibular) collateral ligament Lateral meniscus Femur Anterior cruciate ligament Medial (tibial) collateral ligament Tibia Posterior cruciate ligament Posterior meniscofemoral ligament Medial meniscus RIGHT KNEE (EXTENDED) – POSTERIOR VIEW
  25. 25. 23 CROSS-SECTIONAL ANATOMY OF THE THIGH & LEG Vastus lateralis Rectus femoris Vastus intermedius Femur Vastus medialis Profunda femoris artery & vein Adductor longus Sartorius Saphenous nerve Femoral artery & vein Great saphenous vein Adductor magnus Gracilis Perforating artery & vein Adductor magnus Semimembranosus Semitendinosus Sciatic nerve Biceps femoris (long head) Biceps femoris (short head) Iliotibial tract of fascia lata Extensores digitorum longus & hallucis Tibialis anterior Deep fibular nerve Anterior tibial artery & vein Interosseous membrane Tibia Flexor digitorum longus Great saphenous vein Saphenous nerve Tibialis posterior Posterior tibial artery & vein Tibial nerve Tendon of plantaris Gastrocnemius Soleus Fibular artery & vein Gastrocnemius Medial cutaneous nerve Small saphenous vein Lateral cutaneous nerve Gastrocnemius Fibula Superficial fibular nerve Fibularis longus & brevis
  26. 26. MUSCULATURE OF THE GLUTEAL REGION, THIGH & LEG ORIGIN INSERTION INNERVATION ACTION TENSOR FASCIAE LATAE Lateral aspect of iliac crest Iliotibial tract of fascia lata Superior gluteal nerve Stabilizes knee during extension GLUTEUS MAXIMUS Posteromedial aspect of ilium & sacrum Gluteal tuberosity on posterior aspect of femur & iliotibial tract Inferior gluteal nerve Extends hip joint ; laterally (externally) rotates & abducts thigh GLUTEUS MEDIUS External surface of ilium (under gluteus maximus) Lateral aspect of greater trochanter of femur Superior gluteal nerve Medially (internally) rotates & abducts thigh GLUTEUS MINIMUS External surface of ilium (under gluteus medius) Anterolateral aspect of greater trochanter of femur PIRIFORMIS Anterior surface of sacrum Medial aspect of greater trochanter of femur Nerve to piriformis Laterally (externally) rotates thigh during hip extension ; abducts thigh during hip flexion OBTURATOR INTERNUS Ischiopubic ramus & obturator membrane Medial aspect of greater trochanter of femur Nerve to obturator internus SUPERIOR GEMELLUS Muscular fasciculi associated with the upper & lower margins of the obturator internus tendonINFERIOR GEMELLUS Nerve to quadratus femorisQUADRATUS FEMORIS Ischial tuberosity Intertrochanteric crest of femur Laterally (externally) rotates thigh Piriformis is the landmark muscle of the gluteal region and passes through the greater sciatic foramen. Piriformis syndrome can occur when the sciatic nerve passes through piriformis in 15% of the population, predisposing them to referred pain known as sciatica. Piriformis, obturator internus, quadratus femoris & gemelli lie deep to the gluteus muscles. Tensor fasciae latae is the most lateral of the thigh muscles. 24
  27. 27. QUADRICEPS FEMORIS ANTERIOR COMPARTMENT OF THIGH – Innervated by FEMORAL NERVE ORIGIN INSERTION ACTION PSOAS MAJOR Transverse processes of T12 – L5 Lesser trochanter of femur Flexes thigh at hip joint ILIACUS Iliac fossa VASTUS MEDIALIS, INTERMEDIUS & LATERALIS Proximal aspect of femur Patella via quadriceps femoris tendon Extends leg at knee joint RECTUS FEMORIS Anterior inferior iliac spine & iliac boundary of acetabulum Extends leg at knee joint & flexes thigh at hip joint SARTORIUS Anterior superior iliac spine Anteromedial surface of proximal tibia PECTINEUS Pectineal line of pubis Posterior aspect of femur (linea aspera) Flexes & adducts thigh MEDIAL COMPARTMENT OF THIGH – Innervated by OBTURATOR NERVE GRACILIS Ischiopubic ramus Anteromedial surface of proximal tibia Adducts thigh & flexes leg ADDUCTOR LONGUS Body of pubis Posterior aspect of femur (linea aspera) Adducts & medially (internally) rotates thighADDUCTOR MAGNUS Adductor part: Ischiopubic ramus Posterior aspect of femur Hamstring part: Ischial tuberosity Adductor tubercle & supracondylar line of femur ADDUCTOR BREVIS Body of pubis & inferior pubic ramus Posterior aspect of proximal femur (linea aspera) Adducts thigh OBTURATOR EXTERNUS Obturator membrane Trochanteric fossa on greater trochanter of femur Adducts thigh & laterally (externally) rotates thigh 25
  28. 28. POSTERIOR COMPARTMENT OF THIGH – Innervated by SCIATIC NERVE ORIGIN INSERTION ACTION HAMSTRINGS SEMIMEMBRANOSUS Ischial tuberosity Medial tibial condyle Extends & medially rotates thigh at hip joint ; flexes & medially rotates leg at knee jointSEMITENDINOSUS Anteromedial surface of proximal tibia BICEPS FEMORIS Long head : Ischial tuberosity Short head : Linea aspera of femur Head of fibula Extends & medially rotates thigh ; flexes & laterally rotates leg ANTERIOR COMPARTMENT OF LEG – Innervated by DEEP FIBULAR NERVE LATERAL COMPARTMENT OF LEG – Innervated by SUPERFICIAL FIBULAR NERVE TIBIALIS ANTERIOR Lateral aspect of tibia & interosseous membrane Medial cuneiform & 1st metatarsal Dorsiflexes & inverts foot EXTENSOR HALLUCIS LONGUS Medial aspect of fibula & interosseous membrane Dorsal surface on base of distal phalanx of hallux (big toe) Extends hallux (big toe) & dorsiflexes foot EXTENSOR DIGITORUM LONGUS Medial aspect of proximal fibula & lateral tibial condyle Dorsal surface of middle & distal phalanges of lateral 4 digits Extends lateral 4 digits & dorsiflexes foot FIBULARIS TERTIUS Anteromedial aspect of distal fibula Dorsal surface of 5th metatarsal Dorsiflexes & everts foot FIBULARIS LONGUS Anterolateral aspect of proximal fibula & lateral tibial condyle Lateral surface of medial cuneiform & 1st metatarsal Plantarflexes & everts foot FIBULARIS BREVIS Lateral aspect of fibula Lateral tuberosity of 5th metatarsal Everts foot 26
  29. 29. POSTERIOR COMPARTMENT OF LEG – Comprises superficial & deep groups, innervated by TIBIAL NERVE DORSAL FOOT MUSCLES – Extensor hallucis brevis , Extensor digitorum brevis PLANTAR FOOT MUSCLES – Abductor hallucis , Flexor digitorum brevis , Abductor digiti minimi ; Quadratus plantae , Lumbricals ; Flexor hallucis brevis , Adductor hallucis , Flexor digiti minimi brevis ; Dorsal interossei , Plantar interossei SUPERFICIAL GROUP ORIGIN INSERTION ACTION GASTROCNEMIUS Medial head : Distal femur, immediately superior to medial femoral condyle Lateral head : Lateral femoral condyle Posterior aspect of calcaneus (via calcaneal tendon) Plantarflexes foot & flexes knee PLANTARIS Lateral surface of lateral femoral condyle SOLEUS Posterior aspect of proximal fibula; medial border & soleal line of tibia Plantarflexes foot DEEP GROUP TIBIALIS POSTERIOR Posterior aspect of interosseous membrane ; inner posterior borders of tibia & fibula Navicular & medial cuneiform Inverts & plantarflexes foot POPLITEUS Lateral femoral condyle Posterior aspect of proximal tibia Plantarflexes foot & flexes knee FLEXOR HALLUCIS LONGUS Posterior aspect of fibula & interosseous membrane Plantar surface of distal phalanx of hallux (big toe) Flexes hallux (big toe) FLEXOR DIGITORUM LONGUS Posteromedial aspect of tibia Plantar surfaces on bases of distal phalanges of lateral 4 digits Flexes lateral 4 digits 27
  30. 30. LOWER LIMB MUSCLES ANTERIOR VIEW POSTERIOR VIEW SUPERFICIAL MUSCLES DEEP MUSCLES DEEP MUSCLES Extensor hallucis longus Tensor fasciae latae Extensor retinaculum Soleus Gastrocnemius Vastus medialis Adductor magnus Psoas major & Iliacus Pectineus Adductor longus Gracilis Sartorius Rectus femoris Vastus lateralis Iliotibial tract Fibularis longus, brevis & tertius Tibialis Anterior Gastrocnemius Semitendinosus Semimembranosus Biceps femoris Iliotibial tract Gluteus maximus Gluteus medius Gluteus medius Piriformis Obturator internus Quadratus femoris Adductor magnus Semimembranosus Popliteus Soleus Soleus Flexor hallucis longus Flexor digitorum longus Calcaneal tendon (Achilles tendon)SUPERFICIAL MUSCLES
  31. 31. 29 NEUROLOGY OF THE LOWER LIMB L 1 L 2 L 3 S 3 L 4 L 5 S 1 S 4L 2 S 3 S 2 L 3 L 4 L 5 S 1 L 5 L 4 DERMATOMES OF THE LOWER LIMB ANTERIOR VIEW POSTERIOR VIEW Common fibular part Tibial part SCIATIC NERVE Pudendal nerve To levator ani, coccygeus & external anal sphincter Posterior femoral cutaneous nerve To quadratus femoris To obturator internus SACRAL PLEXUS LUMBAR PLEXUS Dorsal divisions Ventral divisions Iliohypogastric nerve Ilio-inguinal nerve Genitofemoral nerve Lateral cutaneous nerve of thigh To iliacus & psoas FEMORAL NERVE OBTURATOR NERVE To piriformis Inferior gluteal nerve Superior gluteal nerve
  32. 32. 30 MAJOR NERVES OF THE LOWER LIMB (POSTERIOR VIEW OF RIGHT LOWER LIMB) Obturator nerve Sciatic nerve Common fibular (peroneal) nerve Superficial fibular (peroneal) nerve Tibial nerve Saphenous nerve Femoral nerve Deep fibular (peroneal) nerve
  33. 33. 31 VASCULATURE OF THE LOWER LIMB COMMON ILIAC ARTERY bifurcates in front of the sacrum to form EXTERNAL & INTERNAL ILIAC ARTERIES. SUPERIOR & INFERIOR GLUTEAL ARTERIES branch off INTERNAL ILIAC ARTERY in the pelvic cavity, and supply gluteal region via greater sciatic foramen. OBTURATOR ARTERY supplies medial compartment of the thigh via obturator foramen after branching off INTERNAL ILIAC ARTERY. FEMORAL ARTERY begins where EXTERNAL ILIAC ARTERY passes under the inguinal ligament to enter anterior aspect of upper thigh. PROFUNDA FEMORIS ARTERY (DEEP ARTERY OF THE THIGH) branches off in femoral triangle on lateral side & travels down posteriorly adjacent to femur; from it originate LATERAL & MEDIAL CIRCUMFLEX ARTERIES and 3 PERFORATING BRANCHES which pass through adductor magnus to supply posterior compartment of thigh. FEMORAL ARTERY passes through adductor hiatus in adductor magnus, becoming POPLITEAL ARTERY, which in turn bifurcates, giving rise to POSTERIOR & ANTERIOR TIBIAL ARTERIES (the latter of which passes through aperture in interosseous membrane to supply anterior leg compartment). FIBULAR ARTERY branches off POSTERIOR TIBIAL ARTERY, running laterally adjacent to it. It has a PERFORATING BRANCH to the POSTERIOR TIBIAL ARTERY, and a COMMUNICATING BRANCH to the ANTERIOR TIBIAL ARTERY. LATERAL & MEDIAL PLANTAR ARTERIES supply the sole of the foot, arising from the POSTERIOR TIBIAL ARTERY. DORASLIS PAEDIS ARTERY supplies dorsal aspect of the foot, arising from the ANTERIOR TIBIAL ARTERY. DORSAL VENOUS ARCH OF THE FOOT gives rise to SMALL & GREAT SAPHENOUS VEINS (superficial veins of the lower limb). GREAT SAPHENOUS VEIN runs up medial side of leg, passing over medial epicondyle of femur before tending toward anterior aspect of thigh, joining FEMORAL VEIN at the saphenofemoral junction in the femoral triangle.
  34. 34. 32 SMALL SAPHENOUS VEIN runs up posterior aspect of leg, before passing between the heads of gastrocnemius and draining into the POPLITEAL VEIN at the knee. FIBULAR VEIN drains into POSTERIOR TIBIAL VEIN, which joins with ANTERIOR TIBIAL VEIN before contributing to the POPLITEAL VEIN. POPLITEAL VEIN becomes FEMORAL VEIN at the adductor canal. FEMORAL VEIN drains into EXTERNAL ILIAC VEIN, which in turn joins INTERNAL ILIAC VEIN at the level of the pelvic brim to form the COMMON ILIAC VEIN. INTERNAL ILIAC VEIN initially receives OBTURATOR & GLUTEAL VEINS, amongst others from the pelvis & perineum. MAJOR VESSELS OF THE LOWER LIMB (ANTERIOR VIEW OF LEFT LOWER LIMB) Common iliac artery External iliac artery Internal iliac artery Profunda femoris artery Profunda femoris vein Femoral artery Popliteal artery Anterior tibial artery Posterior tibial artery Fibular artery Dorsalis paedis artery Lateral plantar artery External iliac vein Common iliac vein Femoral vein Great saphenous vein Popliteal vein Posterior tibial vein Anterior tibial vein Dorsal venous arch Small saphenous vein
  35. 35. 33 ANATOMY OF THE BACK FUNDAMENTAL MOVEMENTS OF THE BACK Extension Flexion Lateral flexion Rotation
  36. 36. 34 STRUCTURAL ANATOMY OF THE VERTEBRAL COLUMN Vertebral column comprises 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused), 4 coccygeal (fused). Each vertebra (with the exception of C1 & C2) consists of a vertebral body, located anteriorly, and a vertebral arch (where most of the prominences and features are to be found), situated posterior to the body and surrounding the vertebral canal. Cervical vertebrae are distinguished by foramen transversarium, through which vertebral arteries pass, and also bifid spinous processes. Atlas (C1) and axis (C2) are atypical and have special distinguishing features (see diagram). Thoracic vertebrae are distinguished by the presence of facets on the sides of vertebral bodies for articulation with the heads of ribs, and long spinous processes directed obliquely downwards. Lumbar vertebrae are distinguished by their large vertebral bodies and mammillary processes. The joint between the superior articular process of a vertebrae and the inferior articular process of the vertebrae directly above it is called a zygapophyseal joint. Articular processes emerge from the junctions of the pedicles and laminae. ATLAS (C1) AXIS (C2) THORACIC VERTEBRA CERVICAL VERTEBRA
  37. 37. 35 LUMBAR VERTEBRA SPINAL LIGAMENTS Anterior and posterior longitudinal ligaments run along anterior and posterior surfaces of vertebral bodies respectively. (Posterior longitudinal ligament situated in vertebral foramen). Ligamenta flava connect adjacent laminae. Interspinous ligaments pass between adjacent spinous processes. Supraspinous ligament passes along tips of spinous processes from C7 to sacrum. Above C7, supraspinous ligament becomes the much thicker ligamentum nuchae. AXIAL CROSS SECTION Intervertebral discs lie between adjacent vertebral bodies. They consist of an outer, fibrocartilaginous anulus fibrosus, surrounding the inner, jelly-like nucleus pulposus. The disc nucleus acts as a shock absorber for the spine, and has a certain degree of movement in relation to its surrounding disc anulus. SAGITTAL CROSS SECTION SPINAL LIGAMENTS
  38. 38. 36 STRUCTURES OF THE VERTEBRAL CANAL The spinal cord is part of the central nervous system situated in the superior two-thirds of the vertebral canal. It extends from the foramen magnum (an opening at the base of the skull) to between L1 & L2 (around L3 in newborn infants). The distal end is called the conus medullaris. The pial part of the filum terminae continues inferiorly from the apex of the conus medullaris, along with spinal nerves arranged in a bundle, collectively referred to as the cauda equina. The spinal cord has a cervical enlargement and a lumbosacral enlargement which correspond to spinal nerves C5 - T1 and L1 - S3 respectively. Anterior spinal artery & anterior spinal vein follow the course of the anterior median fissure. Posterior spinal arteries run along each posterolateral sulci. Posterior spinal vein runs along posterior median sulcus. Internal vertebral plexus of veins occurs in extradural space, surrounding the dura mater (which in turn wraps around the spinal cord / cauda equina). Dura mater extends to envelop spinal nerve roots, becoming the epineurium (outer covering) of these nerves. Within the spinal dura mater lies the arachnoid mater, a thin delicate membrane which ends at the level of S2. Pia mater is a membrane firmly attached to the surface of the spinal cord. It extends into the anterior median fissure and bilaterally outwards (denticulate ligaments). CROSS SECTION SPINAL CORD
  39. 39. 37 Between the arachnoid mater and pia mater is the subarachnoid space, which contains cerebrospinal fluid (CSF). Spinal anaesthesia involves injection of a local anaesthetic into the CSF. The various maters are collectively referred to as meninges, a system of membranes enveloping the central nervous system. There are 31 pairs of spinal nerves, formed from the merging of the dorsal and ventral roots which emerge from the spinal cord. The name of each spinal nerve corresponds to the vertebra above it, with the exception of spinal nerves C1 – C8 in the cervical region, which emerge above their respective vertebrae C1 – T1. It is also noteworthy that the coccygeal nerve is the only spinal nerve of the coccygeal region. CROSS SECTION OF STRUCTURES WITHIN THE VERTEBRAL CANAL
  40. 40. MUSCULATURE OF THE BACK – EXTRINSIC MUSCLES Extrinsic muscles of the back are comprised of: – SUPERFICIAL GROUP (Related to movements of the upper limb) – INTERMEDIATE GROUP (Attached to ribs, serving a respiratory function) ORIGIN INSERTION INNERVATION ACTION TRAPEZIUS Ligamentum Nuchae; Spinous processes of C7-T12 Lateral third of clavicle; Acromion; Spine of scapula Accessory nerve Rotates, elevates, adducts & depresses scapula LATISSIMUS DORSI Spinous processes of T9-L5 & sacrum; Iliac Crest; Ribs 10-12 Floor of intertubercular groove of humerus Thoracodorsal nerve Extends, adducts & medially (internally) rotates humerus LEVATOR SCAPULAE Transverse processes of C1-C4 Upper medial border of scapula C3 & C4 anterior rami; Dorsal scapular nerve Elevates scapula RHOMBOID MAJOR Spinous processes of T2-T5 Lower medial border of scapula Dorsal scapular nerve Retracts (adducts) & elevates scapulaRHOMBOID MINOR Ligamentum nuchae ; Spinous processes of C7 & T1 Medial border at spine of scapula SERRATUS POSTERIOR SUPERIOR Ligamentum nuchae; Spinous processes of C7-T3; Supraspinous ligament Upper border of ribs 2-5 Anterior rami of upper thoracic nerves (T2-T5) Elevates ribs 2 – 5 SERRATUS POSTERIOR INFERIOR Spinous processes of T11-L3; Supraspinous ligament Lower border of ribs 9-12 Anterior rami of lower thoracic nerves (T9-T12) Depresses ribs 9 -12 & prevents elevation of lower ribs during diaphragm contraction 38
  41. 41. INTRINSIC MUSCLES ORIGIN INSERTION INNERVATION ACTION ERECTOR SPINAE MUSCLES Spinous processes of lower thoracic vertebrae Spinous / transverse processes of higher thoracic vertebrae & cervical vertebrae Posterior rami of spinal nerves Extension, flexion & lateral flexion of vertebral column (and certain movements of the head) INTERMEDIATE GROUP OF EXTRINSIC MUSCLES SUPERFICIAL GROUP OF EXTRINSIC MUSCLES Levator scapulae Supraspinatus Infraspinatus Teres minor Teres major Rhomboid minor Rhomboid major External oblique Latissimus dorsi Deltoid Trapezius Serratus posterior superior Thoracolumbar fascia Serratus posterior inferior Erector spinae muscles are comprised of: iliocostalis (lateral column) ; longissimus (intermediate column) ; spinalis (medial column) 39
  42. 42. 40 CLINICAL ANATOMY Studying anatomy from a clinical perspective involves a fundamental approach that considers both structure & function. An awareness of this cause & effect relationship enables the practical application of anatomical knowledge to clinical scenarios, and the essence of this is to be able to make the necessary association between the two. In this section, a number of important clinical manifestations and their commonly associated anatomical causes are listed. Rotator cuff: Either trauma or prolonged degeneration can cause irritation or damage to the tendons (or, in some cases, muscles) of the rotator cuff. Most commonly affected is the supraspinatus tendon, which passes inferolaterally to the acromion process and inserts onto the greater tubercle of the humerus. Rotator cuff tears or tendonitis can cause inflammation within the shoulder capsule, impairing the shoulder’s normal range of movement, with the gradual onset of pain and/or weakness. Radial nerve palsy: The most common cause is damage to the radial nerve as it passes through the radial groove on the posterior aspect of a fractured humeral shaft, between the medial and lateral heads of triceps brachii. This presents with wrist drop (inability to extend the muscles of the forearm & hand) and can cause sensory changes across the dorsal aspect of the hand. Median nerve palsy: Trauma to the upper limb or neuropathy can damage the median nerve. Depending upon the level of the injury, these are categorized into high and low median nerve palsies. Paralysis of the thenar muscles (innervated by the median nerve) causes an inability to oppose or abduct the thumb, referred to as ‘ape hand deformity’. Weakness in forearm pronation, wrist and finger flexion can also potentially manifest. Compression of the median nerve can occur at various levels, such as between the shaft of the humerus and its medial epicondyle (if Struthers' ligament has calcified), but by far the most common example is median nerve entrapment in carpal tunnel syndrome: Pressure upon the median nerve as it passes through the carpal tunnel causes pain and paraesthesia across the distribution. Atrophy of the thenar eminence and associated muscle weakness is also possible. Surgical decompression of the flexor retinaculum may be necessary to alleviate this condition. Ulnar nerve palsy: Compression or injury of the ulnar nerve as it passes posterior to the medial epicondyle of the humerus (either due to degenerative changes of the surrounding retinaculum or direct trauma) manifests as cubital tunnel syndrome, which presents with paraesthesia of the little finger and the medial aspect of the ring finger, and can be followed by weakness in the corresponding muscles of the hand. Entrapment of the ulnar nerve as it passes through the wrist is termed Guyon’s canal syndrome, resulting in sensory and/or motor impairment. In more severe cases of ulnar nerve lesions, an ulnar claw can develop, where hyperextension in the MCP joints and flexion in the proximal & distal IP joints of the 4th and 5th digits sets in. Ulnar claw can be distinguished from the similar claw appearance of Dupuytren’s contracture (thickening &_ fibrosis of the palmar aponeurosis), in that the MCP joints are hyperextended in the former, but flexed in the latter.
  43. 43. 41 Anatomical snuff box (radial fossa): The scaphoid and trapezium form the floor of the anatomical snuff box, located between the radial styloid process and the base of the thumb. The extensor pollicis longus tendon is the posterior border, whilst the anterior border comprises the extensor pollicis brevis and abductor pollicis longus tendons. The radial artery passes through the anatomical snuff box, and the wrist articulation between the radius and scaphoid tends to bear the brunt of force during a fall on an outstretched hand. A scaphoid fracture tends not to present with any significant wrist deformity, but rather swelling and tenderness, and must be diagnosed correctly since the proximal scaphoid is at risk of avascular necrosis. Long thoracic nerve: The long thoracic nerve is susceptible to injury, either due to trauma, (direct, stretching or compressive forces), neuritis, or iatrogenic damage – for instance, during breast surgery. Such damage results in paralysis of the serratus anterior, and presents with a winged scapula. Pain (often described as a burning sensation) can occur in the scapular region. Piriformis syndrome: In approximately 15% of the population, the sciatic nerve passes through piriformis, and thus can become compressed or irritated at this position. This condition presents with pain and paraesthesia radiating down the affected leg, called sciatica, which in turn can be caused by (and therefore should be distinguished from) an intervertebral disc herniation – most commonly occurring in the lumbar region, impinging upon the cauda equina. Gluteal intramuscular injections should be given on the upper, outer quadrant of the gluteal region in order to avoid injury to the sciatic nerve and resultant neuropathic complications. Knee ligaments & menisci: Since the anterior cruciate and medial (tibial) collateral ligaments are attached to the medial meniscus, an ACL or MCL tear (often due to sports injuries and direct knee trauma) can also damage the medial meniscus. Conversely, the lateral meniscus is less commonly injured as there is no attachment to the lateral collateral ligament or joint capsule. It is important to note that either meniscus can rupture alone, either due to trauma or age-related degeneration. Either the Lachman or drawer test can be used to examine the integrity of the cruciate ligaments; excessive anterior displacement of the tibia in relation to a stabilized femur is indicative of a torn ACL, whereas excessive posterior displacement suggests a PCL tear. Fibular (peroneal) nerve palsy: Traumatic injury involving abnormal forces applied to the knee or below, chronic compression (at the head of the fibula), or peripheral neuropathy can cause damage to the common (or deep) fibular nerve, which typically manifests as foot drop. The muscles in the anterior compartment of the leg are unable to dorsiflex the foot, causing it to drag during walking, with toes pointing downwards. In turn, this may be accompanied by sensory loss upon the dorsal surface of the foot and lateral aspect of the distal leg. Tarsal tunnel syndrome – tibial nerve entrapment: This is a compression neuropathy where compression of the tibial nerve by the flexor retinaculum posterior to the medial malleolus causes paraesthesia across the heel and plantar aspect of the foot, radiating to the hallux (big toe) and adjacent two digits.
  44. 44. 42 CROSS-SECTIONAL ANATOMY – EXAMINATION TIPS Before identifying any individual structures on a cross-section, it is important to orientate oneself and recognize which part of the body is being observed. Under the time constraints of a spotter examination or viva, a structured strategy, such as follows, can be beneficial: ARM: Find neurovascular bundle, comprising brachial artery & veins, median nerve, ulnar nerve and basilic vein – MEDIAL ASPECT Find remaining prominent superficial vein (Cephalic vein) – ANTEROLATERAL FOREARM: Ulna (POSTEROMEDIAL) is more subcutaneous and triangular in cross-section than radius (LATERAL). Basilic & cephalic veins similarly positioned as in arm. Flexors positioned anteriorly to bones (and their connecting interosseous membrane); extensors positioned posteriorly & laterally. THIGH: Find prominent superficial vein (Great saphenous vein) – MEDIAL ASPECT Find largest, most prominent nerve (Sciatic nerve) – POSTERIOR ASPECT Rectus femoris most anteriorly positioned muscle in thigh. Vastus muscles surround femur. Hamstrings immediately posterior to sciatic nerve. LEG: Find prominent superficial vein (Great saphenous vein) – MEDIAL ASPECT Subcutaneous surface of tibia – ANTEROMEDIAL Interosseous membrane connects tibia to much smaller (& more posterolaterally positioned) fibula; separates tibialis anterior & posterior muscles. Small saphenous vein positioned posteriorly. How many bones? Arm / Thigh Forearm / Leg 1 2 ? Are the bones (a) similar in size or (b) is one considerably larger than the other with a subcutaneous border? a b Forearm Leg ? The thigh has a much greater muscle mass (comprising 3 compartments) than the arm (which has only 2 muscle compartments). The humerus is almost circular in cross-section; the femur is slightly more triangular.

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