Muscle Groupings (Compartments) of the Upper Limb A. B. Axilla 1. Axillary Nerve 2. Teres Minor and Deltoid Upper Arm 1. Anterior Compartment (Flexors) - pg 374-375 Rohen, 402 Netter a. Musculocutaneous nerve b. Brachial Artery/vein c. Muscles (1) Biceps Brachii (also a supinator) (2) Brachialis (3) Coracobrachialis 2. Posterior Compartment (Extensors) - pgs 370-371 Rohen, 395-398 Netter a. Radial nerve b. Profundus Brachii Artery (Deep artery of the arm) - branch of Brachial artery c. Muscles (1) Triceps brachii (a) Lateral (b) Medial (c) Long d. Exception - Brachioradialis is also innervated by the radial nerve 1 C. Forearm 1. Anterior Compartment (flexors and pronators) - pgs 376-377 Rohen, 412-413, 416 Netter a. Primarily Ulnar Artery b. Median (thumb-side flexors) and ulnar (pinky-side flexors) nerves c. Muscles (1) Superficial: arise primarily from medial epicondyle and its supracondylar ridge. (a) (b) (c) (d) (e) Pronator teres flexor carpi radialis palmaris longus - ends in palmar aponeurosis flexor carpi ulnaris flexor digitorum superficialis - deep to other superficial muscles i) (2) Ulnar nerve Deep: arise from radius and ulna - origin extends to posterior border of ulna; posterior border of ulna separates flexor region from extensor region (a) (b) (c) flexor digitorum profundus (profundus - L. deep) i) Digits 4 and 5 innervated by ulnar nerve ii) Digits 2 and 3 innervated by median nerve flexor pollicis longus pronator quadratus 2 2. Posterior Compartment (extensors and supinators) - pgs 382-383 Rohen, 411 Netter a. Primarily Radial Artery b. Radial Nerve c. Muscles (1) Superficial (a) brachioradialis (b) extensor carpi radialis longus (c) extensor carpi radialis brevis (d) extensor digitorum (e) extensor digiti minimi (f) extensor carpi ulnaris (g) anconeus (2) Deep (a) supinator (deep to anconeus and extensor digitorum) (b) abductor pollicis longus (c) extensor pollicis brevis (d) extensor pollicis longus (e) extensor indicis 3 D. Intrinsic Muscles of the hand - pg 380-381 Rohen, 432-434 Netter 1. Primarily Ulnar nerve a. Superificial branch: innv 5th and ½ of 4th digit b. Deep branch courses below hypothenar muscles c. Exceptions: (1) Thenar muscles innervated by Median Nerve (recurrent branch - very superficial: keep in mind for lacerations to palm) (2) 1st and 2nd Lumbricals innervated by Median Nerve 2. Muscles: (no intrinsic muscles in the back of the hand) a. Palmar Interossei Muscles (3): originate from palmar surfaces of 2 nd, 4 th, and 5 th metacarpals, insert at extensor expansions of digits and bases of proximal phalanges of digits 2, 4, and 5 (Adduction) b. Dorsal Interossei Muscles (4): originate from adjacent sides of two metacarpals, insert at extensor expansions and bases of proximal phalanges of digits 2-4 c. (Abduction) Lumbricals (4): originate from radial side of tendons of flexor digitorum profundus, insert into lateral aspect of extensor (median nerve) Adductor Pollicis Thenar Muscles (median nerve) (1) Abductor Pollicis Brevis (2) Flexor Pollicis Brevis (3) Opponens Pollicis Hypothenar Muscles (1) Abductor Digiti Minimi (2) Flexor Digiti Minimi Brevis (3) Opponens Digiti Minimi expansion of digits 2-5 d. e. f. 4 Blood supply of palm: superficial arch (continuation of ulnar artery) and deep arch (continuation of radial artery) Nerve supply of palm: median and ulnar nerves Note: 8 Muscles Control the Thumb: Adductor Pollicis - intrinsic, ulnar nerve Opponens Pollicis - intrinsic, medial nerve Abductor Pollicis Brevis - intrinsic, medial nerve Abductor Pollicis Longus - extrinsic, radial nerve Flexor Pollicis Brevis - intrinsic, medial nerve Flexor Pollicis Longus - extrinsic, medial nerve Extensor Pollicis Brevis - extrinsic, radial nerve Extensor Pollicis Longus - extrinsic, radial nerve 5 Pull-up harder than a chin-up • Biceps Brachii insert on radial tuberosity • Supine position - straight line for flexion of elbow • Pronated position - insertion rotated, biceps are trying to supinate, have to recruit pronator muscles to compensate • Pull-up also works pronation muscles Compartment Syndrome: • Sudden increases in pressure within a compartment - fluid buildup • When pressures exceed ~40 mm Hg capillaries collapse and do not perfuse • Can lead to tissue death - medical emergency. • Can result from an injury to a leg, broken bone, internal bleeding, or etc. • 3 P’s of compartment syndrome: Pain!!!, Parathesias, and Pulse (lack of a pulse)? Palmar aponeurosis - deep to this are the tendons of the deep and superficial digital flexors (reach the palm via the carpal tunnel) Supinators innervated by radial nerve - supinator Pronators innervated by median nerve - pronator quadratus and pronator teres Pronators/Supinators on pg 378-379 of Rohen 6 Upper Limb Nerve Supply (Brachial Plexus) The Brachial Plexus A. 5 roots: C5, C6, C7, C8, T1 B. 3 trunks: superior, middle, and inferior C. 6 divisions: each trunk has an anterior and posterior division D. 3 cords 1. Lateral: union of anterior superior and anterior middle divisions (C5, 6, 7) 2. Medial: anterior inferior division continues as medial cord (C8, T1) 3. Posterior: union of 3 posterior divisions (C5-T1) E. 5 nerves: each cord has two terminal branches 1. Lateral cord: musculocutaneous nerve and lateral root of the median nerve 2. Medial Nerve: medial root of the median nerve and ulnar nerve 3. Posterior cord: axillary nerve and radial nerve ....................................... 7 Branches of the Brachial Plexus A. Supraclavicular branches 1. Dorsal scapular (C5) supplies rhomboids and levator scapula 2. Long thoracic (C5, 6, 7) supplies serratus anterior 3. Nerve to subclavius (C5, C6) supplies subclavius 4. Suprascapular nerve (C5, C6) through suprascapular notch to supply supra- and infraspinatus muscles B. Lateral cord branches 1. Lateral pectoral nerve (C5, C6, C7) - pectoralis major and pectoralis minor 2. Musculocutaneous nerve (C5, C6, C7) - coracobrachialis, biceps brachii, and brachialis muscles, then becomes lateral cutaneous nerve of forearm 3. Lateral root of median nerve (C5, C6, C7) C. Medial Cord Branches 1. Medial pectoral nerve (C8, T1) - supplies pectoralis major and pectoralis minor 2. Medial cutaneous nerve of forearm (C8, T1) 3. Medial cutaneous nerve of arm (C8, T1) 4. Ulnar nerve (C8, T1) - two forearm muscles (flexor carpi ulnaris and ½ flexor digitorum profundus) plus most muscles of the hand (all but 3 thenar and 1st and 2nd lumbricals) 5. Medial root of median nerve (C8, T1) D. Posterior Cord Branches 1. Upper subscapular nerve (C5, C6) - subscapularis muscle 2. Thoracodorsal nerve (C6, C7, C8) - latisimus dorsi 3. Lower Scapular nerve (C5, C6) - subscapularis and teres major 4. Axillary nerve (C5, C6) - via quadrangular space supplies teres minor and deltoid muscles, then becomes lateral cutaneous nerve of arm 5. Radial nerve (C5-T1) - extensors plus skin of posterior arm and forearm (also the brachioradialis) 8 9 10 11 Be able to discuss the neuromuscular problems associated with: A. Carpal Tunnel Syndrome 1. Compression of the Median nerve 2. Grasp paper in fingers - rule out ulnar vs median a. Median does most of thumb 3. Inflammation/obesity compressing median nerve 4. Also often see atrophy of thenar muscles (loss of median nerve function) B. Winged Scapula (pg 425 of Baby Moore) 1. Serratus anterior paralyzed because of injury to the Long Thoracic Nerve 2. Medial border of the scapula moves laterally and posteriorly and hangs away from the thoracic wall 3. Arm also cannot be abducted above the horizontal position because the serratus anterior is unable to rotate the scapula 4. Note: the long thoracic nerve could potentially be damaged during a mastectomy C. Inability to abduct the arm more than 45 degrees 1. Damage to the Deltoid portion of the Axillary nerve? D. E. F. Claw hand 1. 3rd and 4th Lumbricals (act on digits 4 and 5) flex metacarpophalangeal joints and extend interphalangeal joints (via extensor expansion) 2. Damage to the ulnar nerve prevents the use of the 3rd and 4th Lumbricals, so there is a relative extension of the metacarpophalangeal joints and flexion of the interphalangeal joints 3. Ulnar Nerve (Funny bone) - damage can often occur to the ulnar nerve where it passes posterior to the medial epicondyle of the humerus 4. More proximal damage to the ulnar nerve would also affect the ulnar portion of the flexor digitorum profundus Saturday night palsy 1. Compression of the radial nerve 2. Could result from improper positioning of the upper limb during sleeping (especially in intoxicated persons) Tennis elbow (elbow tendonitis, lateral epicondylitis) 1. Can result from repetitive forceful pronation-supination of the forearm (tennis backhand) 2. Results from premature degeneration of the common extensor attachment (extensor-supinator group of the forearm arises from a common extensor tendon from the lateral epicondyle of the humerus) 3. Overuse, strain, and inflammation 4. Characterized by pain and point tenderness at or just distal to lateral epicondyle of humerus 12 G. H. Wrist drop (pg 448 of Baby Moore) 1. Damage to radial nerve typically more distal than Sat. Night Palsy 2. Damage in radial groove affects only medial head of triceps in arm (weakens triceps) 3. Complete inability to extend wrist and fingers (Posterior compartment of forearm) Erb-Duchenne Palsy - results in Waiter’s Tip Positioning of upper extremity 1. Damage to C5, C6 roots 2. C5-C6 contribute to many nerves a. Cannot abduct shoulder (axillary nerve) b. Teres Minor loses function (axillary nerve) - slight medial rotation of the arm c. Hand relatively pronated (Musculocutaneous nerve and biceps brachii) d. Slight flexion of the wrist (radial loses some function, but it receives roots from C5-T1 so it may still function properly) St. Benedict’s - cannot flex digits 2 and 3 - damage to median nerve -Impairment of 1st and 2nd Lumbricals (and thenar muscles) and radial portion of flexor digitorum profundus Radial Damage - can’t do any extension Radial nerve palsy (?) Nervous injury to arm -start distal and move proximal (sensory) -know cutaneous innervation of arm -adduction of fingers - pure ulnar nerve Synergism of flexors and extensors when making a fist 13 Cutaneous Innervation of Upper Limb Cutaneous innervation of the hand Palmar Median (lateral) Ulnar (M edial) Dorsal Median Ulnar Radial Landmarks: Apex of Shoulder C5 Lateral to Elbow C6 Index Finger C7 Pinky Side C8 Medial Side of Elbow T1 14 Superficial Veins of the Upper Limb 15 Arterial Supply of the Shoulder BRANCHES OF THE SUBCLAVIAN: (Very Important To Come Dressed) Vertebral artery I nternal thoracic artery -m usculophrenic -superior epigastric -pericardiophrenic Th y r o c e r v i c a l t r u n k -SUPRASCAPULAR: supraspinatus & infraspinatus, shoulder joint; anastomoses with the circumflex scapular a. and the dorsal scapular a. to form the scapular anastomosis -TRANSVERSE CERVICAL: trapezius muscle and surrounding tissues -Ascending cervical -Inferior thyroid C o s t o c e r v ic a l - Superior (supreme) intercostal (left) - Deep cervical D o r s a l S c a p u l a r : dorsal scapular a. anastomoses with the suprascapular a. and the subscapular a. to form the scapular anastomosis; dorsal scapular a is a branch of the transverse cervical a. in ~30% of cases BRANCHES OF THE AXILLARY (becomes axillary lateral to 1s t rib, divided by pectoralis minor): 1 st P a r t S u p e r i o r t h o r a c i c : muscles of intercostal space 1 and 2 2 nd P a r t T h o r a c o a c r o m i a l (“CAlifornia P olice Department") - C lavicular (2) - A cromial (1) - P ectoral (3) - D eltoid (4) L a t e r a l t h o r a c i c : serratus anterior, parts of adjacent muscles, skin and fascia of the anterolateral thoracic wall 3 rd P a r t A n t e r i o r h u m e r a l c i r c u m f l e x : deltoid; arm muscles near the surgical neck of the humerus P o s t e r i o r h u m e r a l c i r c u m f l e x : deltoid; arm muscles near the surgical neck of the humerus S u b s c a p u l a r : subscapularis., teres major, teres minor, infraspinatus -Circumflex scapular: teres major m., teres minor m., infraspinatus m. -Thoracodorsal: latissimus dorsi m. Arterial supply of the Arm (Brachium) Brachial Artery Profundus Brachii i. Ascending branch ii. Middle Collateral iii. Radial Collateral Superior Ulnar Collateral Inferior Ulnar Collateral Radial Artery Ulnar Artery 16 17 Arterial Supply of the Forearm and Hand (Antebrachium and Manus) 1. 2. 18 Radial Artery a. Radial Recurrent (to elbow) b. Forms Deep Palmar Arch with deep branch of Ulnar artery Ulnar Artery a. Anterior and Posterior Ulnar Recurrent Arteries (anastomose with ulnar collateral and interosseous recurrent arteries) b. Common Interosseous Artery i. Anterior Interosseous Artery: supplies anterior and posterior compartments in distal forearm ii. Posterior Interosseous Artery: gives rise to recurrent interosseous artery (elbow) c. Deep Palmar Branch to deep arch d. Superficial Palmar Arch Upper Limb: Joints Ligaments and muscles (Not The Syllabus) Shoulder Joint - Glenohumeral A. Synovial - enarthrodial (ball and socket joint) B. Structurally weak, generally supported by the muscles which surround it and not its bony conformation or the presence of any unusually strong ligaments C. Osteology of head and neck of humerus and acromion and coracoid portions of the scapula D. Ligaments 1. Articular (fibrous) capsule from the edge of the glenoid fossa and the glenoidal labrum to the anatomic neck of the humerous. Muscles which strengthen the capsule: a. Subscapular anteriorly b. Infraspinatus and teres minor posteriorly c. Supraspinatus superiorly d. Long head of the triceps brachii inferiorly 2. Glenohumeral ligaments - 3 thickenings of fibrous capsule; stabilize the anterior portion of the joint and insert into the supraglenoid tubercle 3. Coracohumeral: from coracoid to greater tubercle 4. Transverse humeral: from lesser to greater tubercle of humerus; creates intertubercular “canal” and acts as retinaculum for tendon of the long head of the biceps brachii 5. Glenohumeral labrum: fibrocartilagenous rim attached around the margin of the glenoid cavity E. Bursae - note locations 1. Subacromial bursa - between the deltoid muscle and the joint capsule 2. Note that these are potential sites of inflammation F. Review movements of joints and potential injuries Elbow Joint A. B. C. D. E. Compound synovial joint (hinge) Two articulations - together form a uniaxial joint 1. humero-ulnar 2. humeroradial Osteology of distal aspect of humerus and proximal parts of radius and ulna Ligaments 1. articular capsule (fibrous capsule) 2. Ulnar collateral ligament 3. Radial collateral ligament Movements 1. Flexion and extension 2. Review movement and injuries 19 Radio-ulnar joints (2 synovial and one interosseous membrane, often regarded as the nonsynovial middle radio-ulnar joint) A. Proximal radio-ulnar joint (trochoid) 1. Uniaxial pivot joint 2. Between head of radius and radial notch of the ulna ligament: annular ligament B. Middle radio-ulnar joint (interosseous membrane) - weight transmission from radius to ulna via membrane C. Distal radio-ulnar joint (uni-axial pivot joint) 1. Between “head” of ulna and concave ulnar notch of the lower end of the radius 2. Held together by an articular disc 3. Enclosed by an articular capsule Note: supination and pronation occur at the radioulnar joints Radiocarpal Joint A. Synovial (biaxial ellipsoid) B. Formed by distal end of radius and lower surface of articular disc above, and scaphoid, lunate and triquetral bones below C. Ligaments 1. articular capsule 2. palmar radiocarpal ligament 3. palmar ulnocarpal ligament 4. dorsal radiocarpal ligament 5. ulnar collateral ligament 20 Intercarpal Joints - connecting carpal bones; 3 basic joints - all synovial A. Bones of the wrist (X-Ray of wrist on pg 493 of Baby Moore) So Long To Pinky, Here Comes The Thumb 1. Scaphoid (most frequently fractured) 2. Lunate 3. Triquetrum 4. Pisiform 5. Hamate 6. Capitate 7. Trapezoid 8. Trapezium B. Joints between the bones of the proximal row of the carpus (i.e. between pisiform, triquetral, lunate and scaphoid bones) C. Joints between bones of distal row (i.e. between hamate, capitate, trapezoid, and trapezium) D. Extensive joint between 2 rows (midcarpal joint) Carpometacarpal Joints A. Carpometacarpal Joint of thumb (saddle-shaped or seller joint) 1. Review movements of thumb - adduction, abduction, flexion, extension, opposition 2. Briefly review the lateral ligament and palmar and dorsal ligaments B. Review other carpometacarpal joints and intermetacarpal joints 21 Metacarpophalangeal joints (ellipsoid) and interphalangeal joints (uni-axial hinge) are best studied with muscle activity Hilton’s “Law” - the motor nerve to a muscle tends to help supply the joint that muscle moves (especially if this is a prime mover) and also the skin over that joint. Luxation: dislocation Subluxation: sprain; injury to the joint, usually with internal bleeding and/or capsular tear, but without dislocation of the bones from their sockets) Discussion - Joints and Muscle Groups For each joint, know bones involved, blood supply (often collaterals), innervation of muscles, and innervation of Joint (sensory; often same as muscles) Diarthrodial Joints A. Synovial Fluid - lubrication B. Cartilage - articular, nonossifying C. Capsule (bursa) - isolation, makes fluid Shoulder Girdle A. Bones 1. Clavicle 2. Scapula a. Acromion (Greek acros - a point) b. Coracoid (Crow’s beak) 3. Humerus B. Joints 1. Acromioclavicular 2. Sternoclavicular 3. Glenohumeral (gleno = socket) Parts of a long bone A. Diaphysis B. Metaphysis (growth plate) 1. Cartilage, ossifies at one end as it lengthens 2. Synchondrosis - but eventually ossifies with age (synostosis) 3. Appears as a crack on an X-ray 4. Fractures in this region can result in premature ossification C. Epiphysis 22 Motion A. B. C. D. E. F. G. H. I. J. K. L. Flexion 1. Any motion that “makes things smaller” from anatomical position 2. Moore - decreasing the angle between body parts Extension 1. Any motion that takes you back to anatomical position 2. Increasing the angle between body parts Hyperextension - in the extension plane but behind the body Abduction - movement away from the midline (being abducted) Adduction - movement towards the midline (adding-to the midline) Medial rotation - toward the midline Lateral rotation - away from the midline Circumduction - rotation of GH joint Hand 1. Extension/hyperextension 2. Flexion - fist 3. Abduction (think of middle finger as midline; spreading of fingers) a. Dorsal interossei muscles (DAB) 4. Adduction a. Palmar interossei muscles (PAD) 5. Thumb - rotated 90 degrees to other fingers a. Abduction and adduction in different plane b. Apposition - going across the hand; touching thumb to pinky finger c. Reposition d. Thenar and hypothenar muscles of the thumb - equivalent to DAB and PAD 6. “Bye, Bye Motion” a. Done by lumbrical muscles of the hand b. Flexion of metacarpophalangeal joints and extension of interphalangeal joints via extensor expansion Foot 1. Inversion - plantar surface in 2. Eversion - plantar surface out 3. Plantar flexion 4. Dorsiflexion Forearm 1. Supination - anatomical, palm up (carrying a bowl of “soup”) 2. Pronation - palms down Scapula - must rotate scapula (acromion up) to lift the humerus above the head Rotator Cuff Muscles (SITS) 23 A. B. C. D. Supraspinatus (abductor) - not a rotator, most frequently torn Infraspinatus - lateral rotation of humerus Teres minor - lateral rotation of humerus Subscapulais - medial rotation of humerus Movement of the Glenohumeral Joint 0-15 Degrees - Supraspinatus (initiates abduction) Next 45 Degrees - Deltoid 60 Degrees and up - Serratus anterior (rotation of the scapula) **Cannot initiate abduction with injury to supraspinatus Add diagrams from notes taken in class Boundaries and Contents of the Axilla: 437-438 of Baby Moore Cross section of wrist/Flexor Retinaculum: pg 469 of Baby Moore Deep Venous supply General lymphatics Some More good tips courtesy of Anne Stey: The Quadrangular Space The space through which the axillary nerve and posterior circumflex humeral artery pass Borders: superiorly—capsule of shoulder Inferiorly—superior border of teres major Laterally—surgical neck of the humerus Medially—lateral portion of the long head of the triceps The Triangular Interval The space through which the radial nerve and the profunda brachii artery pass. Borders: superiorly—inferior portion of the teres major Laterally—medial border of the lateral head of the triceps Medially—lateral border of the long head of the triceps Note: how the teres major divides the two spaces! The Subacromial Bursa The space between the acromion/deltoid and the supraspinatous portion of the rotator cuff. If have attrition of the supraspinatous tendon see the open communication between the subacromial bursa and the glenohumeral joint---oww! 24 More Notes - Thanks to Anne Collateral circulation around the scapula Subclavianàaxillary @ lateral border of 1st ribà brachial @ inferior border of teres majoràBrachial Artery àulnar & radial arteries Off thyrocervical trunk branch of subclavian arises the transverse cervical and supraclavicular Off subclavian-dorsal scapular just lateral to thyrocervical trunk Off axillary-subscapular artery Off brachial-profunda brachii artery Intercostals anastomose with dorsal scapular which anastomoses in turn with the subscapular, suprascapular and the transverse cervical---this connection allows for the subclavian to be severed without serious consequences! Extremities Terminology: Brachium=arm Antebrachium=forearm Manus = hand Pollux = Thumb Profundus = Deep Triceps=three headed Biceps=two headed Muscle=little mouse The Carpal Tunnel Median nerve Flexor digitorum superficialis and profundus Flexor pollicis longus Flexor carpi radialis NOTE : ulnar nerve and artery aren’t in carpal tunnel ! The Osseofibrous Digital Tunnel The fibrous digital sheath and the phalange bone make up this tunnel The tendons housed in this tunnel have their own synovial sheaths referred to as the digital synovial sheaths within the tunnel and the common synovial sheath in the carpal tunnel 25 Bold terms of Upper Extremities I: Teres minor Quadrangular space Capsule of shoulder joint superiorly Surgical neck of humerus laterally Long head of triceps medially Upper border of teres major inferiorly Long head of the triceps brachii Lateral head of the triceps Triangular interval (between these two heads of Trapezius Latisimus Dorsi Rhomboids Levator Scapulae Scapula Acromion Spine Supraspinous fossa Infraspinous fossa Spinoglenoid notch Glenoid cavity Supraglenoid tubercle Infraglenoid tubercle Coracoid process Scapular notch Humerous Head Greater tubercle (lateral) Lesser tubercle (anterior) Intertubercular sulcus (bicipital groove) Deltoid tuberosity Sulcus for radial nerve or spiral groove Deltoid muscle Axillary nerve Posterior circumflex humeral artery (deltoid the triceps and inferior to the teres major) Floor of the triangular interval Humerus Radial nerve Profunda brachii artery Spiral groove Supraspinatus and infraspinatus muscles Suprascapular ligament Suprascapular nerve (under ligament) Suprascapular artery (over ligament) Posterior belly of the omohyoid Transverse cervical artery (branch of thyrocervical trunk; collateral cervical and middle 1/3 of trapezius) Greater tubercle of humerus supraspinatus infraspinatus teres minor Bursa = synovial sac Subacromial bursa and arm muscles near the surgical neck of the humerus) Cubital Fossa (prominent veins) Forearm region Tendon of the palmaris longus Wrist region Styloid processes or radius and ulna Hand Palmar creases Thenar eminence Hypothenar eminence Superficial veins Cutaneous nerves Bold terms of Upper Extremities II: Shoulder Arm (brachium) Forearm (antebrachium) Hand (manus) Axillary Fossa Anterior Axillary fold Posterior Axillary fold Shoulder Region (Deltoid muscle) Arm Region (biceps brachii) 26 1 st rib and ends at the inferior border of the teres major muscle) Superficial fascia Deep fascia Dorsal venous arch (dorsum of hand) Superficial dorsal veins Basilic vein (ulnar side, pierces deep fascia before reaching the axilla) and Cephalic vein (radial Three parts of Axillary artery 1st - lateral border of 1st rib to superior (medial) border of pectoralis minor 2nd - Deep to the pectoralis minor 3rd - From Inferior (lateral) pectoralis minor to inferior border of teres major 1st part of Axillary artery Superior (supreme) thoracic - 1st and nd 2 intercostal spaces 2nd part of the axillary artery Thoracoacromial artery acromial deltoid pectoral clavicular Lateral thoracic artery - pectoral muscles and lateral mammary gland 3rd part of axillary artery Subscapular artery –> thoracodorsal artery (lat dorsi) Circumflex scapular artery Posterior circumflex humeral artery Anterior circumflex humeral artery Brachial Plexus (infraclavicular portion), three cords: Lateral Musculocutaneous nerve Lateral root of Median nerve Medial Medial root of Median nerve Ulnar nerve Medial cutaneous nerve of forearm Posterior Axillary nerve Subscapular nerves (to side) Superficial nerves Superficial branch of the radial nerve Dorsal branch of the ulnar nerve Median cubital vein (cephalic vein and basilic vein communication in cubital fossa) Perforating veins (perforate deep fascia and drain deeper structures) Medial antebrachial cutaneous nerve ulnar branch anterior branch Lateral antebrachial cutaneous nerve Anterior branch Posterior branch Deep fascia of the arm (brachial fascia) Deep fascia of the forearm (antebrachial fascia) Bicipital aponeurosis (connects biceps brachii to antebrachial fascia) Extensor retinaculum (retains extensor tendons in position) Flexor retinaculum (forms part of tunnel that contains flexor tendons) For walls of the axilla Anterior Wall (Pec Major/Minor?) Posterior Wall (Lat. Dorsi, Teres Major, Subscapularis) Medial (thorax/serratus anterior) Lateral Wall (Intertubercular sulcus of humerous) Contents of axilla axillary sheath lymphatics fat and connective tissue portions of muscles: Long head of biceps brachii Short head of biceps Coracobrachialis Axillary artery (begins at lateral border of subscapularis) Nerve to teres major and deltoid Thoracodorsal nerve (to lat dorsi) Musculocutaneous nerve (most lateral nerve; 27 Subscapularis muscle Brachial artery (distal to axillary) enters coracobrachialis and travels between biceps brachii and brachialis) Tip of the coracoid process Long thoracic nerve Serratus anterior Bold terms of Upper Extremities III: Medial Epicondyle Supracondylar ridge Lateral Epicondyle Supracondylar ridge Capitulum: articulation with radius Trochlea: articulation with ulna Olecranon fossa Brachioradialis muscle (thumb-side) Radial nerve Profunda brachii artery Sulcus for the radial nerve (spiral groove) Three heads of the triceps Long Lateral Medial Cubial Fossa Biceps Brachii Strong tendon of the biceps Bicipital aponeurosis - passes to deep fascia Radius Head: articulation with humerus Neck Tuberosity: for biceps tendon Anterior oblique line: origin of flexor dig. superficialis Styloid process Interosseous border: attachment of covering the flexor muscles of the forearm and protects the: interosseous membrane Median nerve Brachial artery Lateral cutaneous nerve of the forearm Ulna Olecranon: limits hyperextension Head Interosseous border Wrist level, tendons of: Brachioradialis and abductor pollicis longus Flexor carpi radialis Palmaris longus Flexor digitorum superficialis (4 tendons) Flexor carpi ulnaris Ulnar artery Ulnar nerve Radial artery Median nerve Anterior forearm, superficial Flexor digitorum superficialis Pronator teres Flexor carpi radialis Palmaris longus (cutaneous branch of musculocutaneous; emerges between the biceps and the brachialis and reaches cubital fossa lateral to biceps tendon) Arm - Anterior Compartment Coracobrachialis Brachialis Biceps Brachii Musculotaneous nerve (through coracobrachialis and between biceps and brachialis) Median nerve (runs between deep and superficial flexors of forearm) Ulnar nerve Brachial artery (runs with median nerve) Profunda brachii artery Ulnar artery Radial artery Radial recurrent artery (anastamoses around elbow) Humerus 28 Flexor carpi ulnaris Radial nerve Superficial branch Deep branch Brachioradialis Pronator teres Median nerve Ulnar nerve Ulnar artery Common interosseous artery Anterior interosseous artery Posterior interosseous artery Three deep flexors Flexor digitorum profundus Flexor pollicis longus Pronator quadratus Two superficial muscle masses of the hand: Thenar group (ball of thumb) Hypothenar musculature (ball of 5 th Digits 2-5 have three (proximal, middle, and distal) Palmaris longus muscle Palmar aponeurosis Thenar muscles (thenar gr., hand) Abductor pollicis brevis (pollex L., thumb) Opponens pollicis Flexor pollicis brevis (recurrent branch of median nerve passes over it) Hypothenar muscles: Abductor digiti quinti Opponens digiti quinti Flexor digiti quinti Arteries of the superficial palmar arch Ulnar artery Ulnar nerve superficial branch (5 th and medial part of 4 th finger) deep branch (disappears under hypthenar finger) muscles) Eight carpal bones (karpos: gr Wrist) Pisiform bone Triquetrum Hamate Hook of the hamate Capitate Trapezoid Trapezium Tubercle of the trapezium Scaphoid Tubercle of the scaphoid Lunate Flexor retinaculum (transverse carpal ligament) Carpal tunnel (between carpal bones and Median nerve Recurrent branch of median nerve (to thenar muscles) 1 st and 2 nd lumbricals also supplied by median nerve Digital branches Fibrous digital sheaths + phallangeal bones = osseofibrous digital tunnel Common synovial sheath (sac) (lubricating; within carpal tunnel) Digital synovial sheaths (within osseofibrous digital tunnels) Lumbrical muscles (4, small; originate from tendon of flex. dig. profundus) Extensor expansion of digits Adductor Pollicis Arteries of the Deep Palmar Arch Palmar interossei muscles (3; adductors) Dorsal interossei mucles (4; abductors) retinaculum) Five metacarpals Phalanges Thumb has only two (proximal and distal) Bold Terms of Upper Extremities IV: Superficial Extensors 29 Acromion Acromion Coracoacromial ligament Coracoid process Elbow Joint Ulnar Collateral ligament Radial Collateral ligament Anular ligament Synovial Capsule Wrist Joint (Radiocarpal Joint) Radiocarpal ligaments Scaphoid Lunate Triquetrum Articular discs Principle movements (flexion, extension, abduction, adduction) Sternoclavicular Joint Sternum Clavicle Clavicular notch Joint Capsule Articular disc Acromioclavicular Joint Acromion Coracoclavicular ligament Conoid ligament Trapezoid ligament Radioulnar Joints Proximal radioulnar joint Intermediate (middle) Radioulnar Joint Interosseous membrane Distal Radioulnar Joint Sacciform recess Articular disc Small Joint of the hand Intercarpal, Carpome tacarpal, and Intermetacarpal ligaments Midcarpal (Transverse Carpal) Joint Carpometacarpal Joints Joints of the digits Deep transverse metacarpal ligaments Metacarpophalangeal Joints Deep Extensors Anatomical "Snuff Box" Abductor Pollicis Brevis and Extensor Pollicis Brevis (anteriorly) Extensor Pollicis Longus (Posteriory) Radial artery runs in snuff box 1st Dorsal Interosseous muscle Extensor Retinaculum Extensor Carpi Radialis Brevis Extensor digitorum Supinator Posterior interosseous nerve (after supinator, deep branch of radial nerve) Superficial Extensors Brachioradialis Extensor Carpi Radialis longus Extensor carpi radialis brevis Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Anconeus Musclular branches of the radial nerve Deep Extensors Supinator Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis Extensor expansion (flattened sheaths of distal extensor tendons) Shoulder Joint Anatomical and surgical neck of the humerus Fibrous Capsule Synovial Cavity Glenoid Cavity Gle noid Labrum Glenohumeral ligaments Tendon of the long head of the biceps Coracoacromial ligament Coracoacromial arch Coracoid Process Coracoacromial Ligament 30 Interphalangeal Joints Carpal tunnel Lower Limb: Joints, Ligaments, and Muscles I. JOINTS AND LIGAMENTS OF THE LOWER LIMB A. Hip Joint (Acetabulofemoral Joint) 1. Synovial, multi-axial ball and socket 2. Review Osteology of head, neck, and trochanters of femur and acetabulum of hip Note risk for Avascular necrosis: break hip and cut off blood supply going to head of femur 3. Ligaments a. fibrous capsule - surrounds the neck of the femur, and is attached in front to the trochanteric line, above to base of the neck; behind to the neck about 1 cm above trochanteric crest; below to the lower part of the neck close to the lesser trochanter - Contains Intrinsic Ligaments, thickened portions of the capsule: (1) iliofemoral ligament intimately blended with capsule, anterior to capsule. It is of great strength. Termed the Y shaped ligament because of inverted Y shape. Its lateral band is referred to as the iliotrochanteric ligament (2) pubofemoral ligament also triangular - above from iliopectineal eminence, superior ramus of pubis, obturator crest and membrane; below blends with capsule and medial band of 31 iliofemoral ligament b. (3) ischiofemoral ligament - at back of joint. Attaches to ischium below and behind acetabulum and is directed upwards and laterally over back of the neck and femur (4) ligament of the head of the femur (LHF) - recent studies have shown its function is only in fetal life to prevent dislocation of femur from acetabulum acetabular labrum - fibrocartilaginous rim attached to margin of the acetabulum c. 4. transverse ligament of the acetabulum - in reality a portion of acetabular labrum Review Movements at Joint a. Flexion - Extension b. Adduction - Abduction c. Circumduction d. Medial and lateral rotation 32 B. Knee Joint (Genual Joint) - Netter 472-477 1. Synovial, Largest Compound Joint 2. Although it has a single joint cavity in us, it can be described as consisting of two condylar joints between the corresponding condyles of the femur and tibia and a sellar joint between the patella and patellar surface of femur a. No articulation between the fibula and the femur b. Note insertion of patellar tendon insertion on the tibial tuberosity c. Patella: sesamoid bone; accessory-type of bone formed inside a tendon. The patella helps in a biomechanical way, it alters the angle at which the quadriceps pull on the tibia. 3. Review osteology of the distal end of the femur, the patella, and proximal ends of tibia and fibula 4. Ligaments a. fibrous capsule 33 b. 5. ligamentum patellae - is actually the central portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tuberosity of the tibia c. tibial (medial) collateral ligament - broad flat band. One or more bursae may separate it from fibrous capsule. Note its relationship to capsule. Connected to medial meniscus. d. fibular (lateral) collateral ligament: strong, cord like ligament. The ligament is separated from capsule by the tendon of the popliteus muscle. It is not connected to the lateral meniscus. e. oblique popliteal ligament - an expansion from tendon of semimembranosus muscle. Partially blends with fibrous capsule. f. arcuate popliteal ligament. Y -shaped system of capsular fibers g. anterior and posterior cruciate (i.e., they cross each other) ligaments. Powerful posterior ligaments. h. transverse ligament Menisci (medial and lateral). These deepen the surfaces of the upper end of the tibia. a. Menisci attached to tibia by coronary ligaments b. Note: The medial meniscus has its peripheral border attached to the fibrous capsule and is firmly adherent to the deep surface of the tibial collateral ligament.(ACL is also attached to medial meniscus) Realize their importance in relationship to injuries. Note difference between medial and lateral collateral ligaments and their relationship to the menisci. (1) Unhappy Triad = ACL, MCL, and medial meniscus (2) When the ACL is torn, the tibia will displace anteriorly (Clinical Correlate - pg 182 of dissector) 34 C. 6. Bursae a. subcutaneous pre-patellar (no communication with cavity) b. deep infrapatellar (no communication with cavity) c. subcutaneous intrapatellar d. suprapatellar (communicates with the joint and can be regarded as an extension of it. Review clinical importance of fluid buildup). 7. Review Movements at Joint (Flexion-Extension) Tibiofibular articulations 1. superior tibiofibular joint ( synovial, plane) a. review osteology b. fibrous capsule and extensions known ligaments as the anterior and posterior 2. crural interosseous membrane (syndesmosis) 3. inferior tibiofibular joint - fibrous joint, syndesmosis a. anterior tibiofibular ligament b. posterior tibiofibular ligament 35 D. Talocrural or ankle joint (synovial, hinge joint) 1. Review Osteology of the foot 2. E. F. G. H. Ligaments - Pg 394 of Baby Moore a. fibrous capsule b. deltoid ligament c. anterior and posterior talofibular ligaments d. calcaneofibular ligament Intertarsal Joints 1. Subtalar (talocalcanean joint) 2. Talocalcaneonavicular joint 3. Calcaneocuboid joint 4. Cuneonavicular joint 5. Cuboideonavicular joint 6. Intercuneiform joint 7. Cuneocuboid joint Tarsometatarsal articulations 1. Intermetatarsal Joints Metatarsophalangeal articulations Review formation of arch, weakening of arch (“fallen arches”) 1. Plantar ligaments and plantar aponeurosis stretch 2. Calcaneonavicular ligament can no longer support the head of the talus 3. Talar head displaces inferomedially 4. Pgs 400-401 of Baby Moore 36 MORE ON THE FOOT: A. Tarsus - Seven Bones 1. Talus: sits on calcaneus (heal bone), note the position of these two 2. Calcaneus a. Attachment of Achilles tendon b. Talus sits on top c. Sustentaculum tali projects medially 3. Navicular bone 4. Cuneiform bones (3): Medial, Intermediate, and lateral 5. Cuboid Bone B. Metatarsals (heads are proximal) C. Hallux: big toe D. 3 phalanges in digits 2-5, 2 phalanges in hallux E. Osteoligamentous support, not so much muscular 1. From calcaneus: sustentaculum tali (sustains, supports talus) 2. Plantar Calcaneonavicular ligament (Spring Ligament): maintains position of the talus F. Both longitudinal and transverse arches in the foot: allows us to dissipate forces and allow upright walking G. Malleoli (hammers) of Tibia and Fibula - Tendons of foot go under them, they act as pulleys H. Tarsal Tunnel 1. Analogous to carpal tunnel, formed by flexor retinaculum; compression of the medial plantar nerve (or tibial?) a. Medial Plantar Nerve - homologue of median nerve b. Lateral Plantar Nerve - homologue of ulnar nerve 2. Contents from ant. to post.: (Tom Dick ANd Harry) a. Tibialis Posterior Tendon b. Flexor Digitorum Longus tendon c. Posterior Tibial Artery d. Tibial Nerve e. Flexor Hallucis Longus tendon 37 I. MUSCLES OF THE LOWER LIMB A. MUSCLES OF THE GLUTEAL REGION 1. gluteus maximus m. 2. gluteus medius m. 3. gluteus minimus m. 4. tensor fasciae latae lateral rotators of thigh 5. piriformis m. 6. obturator intemus m. 7. superior gemellus m. 8. inferior gemellus m. 9. quadratus femoris m. 10. obturator externus m. B. MUSCLES OF THE THIGH Concept of a "tripod" of muscles 1. Posterior Compartment - posterior leg of tripod; Hamstrings: a. Biceps femoris m. b. Semitendinosus m. c. Semimembranosus m. These are supplied by tibial nerve (except for short head of biceps femoris supplied by peroneal branch of sciatic nerve). These 3 muscles cross 2 joints. 38 2. Medial Compartment - medial leg of tripod a. pectineus m. b. c. d. e. f. adductor longus m. adductor brevis m. adductor magnus m. gracilis m. obturator externus m. (which is really in gluteal region) These are usually supplied by the obturator nerve. Pectineus supplied by both the femoral and obturator nerves. Ischiocondylar (hamstring) part of adductor magnus by tibial nerve. These muscles are adductors and stabilizers during flexion and extension 3. Anterior Compartment - lateral aspect of tripod a. iliopsoas m. b. quadriceps femoris m. (rectus femoris, vastus lateralis, vastus medialis, vastus intennedius) c. sartorius m. iliopsoas supplied by L , L (sometimes by L , L also); others by femoral nerve. review movements of these muscles 39 C. MUSCLES OF THE LEG 1. Anterior compartment of leg (dorsiflexors) - Deep Peroneal Nerve a. Tibialis anterior m. b. Extensor hallucis longus m. c. Extensor digitorum longus m. d. Peroneus tertius m. 2. Lateral compartment of leg (everters of foot) - Superficial Peroneal Nerve a. Peroneus longus m. b. Peroneus brevis m. 3. Posterior compartment of leg (plantar flexors) - Tibial nerve a. Triceps surae m.(gastrocnemius and soleus mm.) b. Plantaris m. c. Popliteus m. d. Tibialis posterior m. e. Flexor digitorium longus m. Tom, Dick, and Harry f. Flexor hallucis longus m. II. Review actions of dorsi-flexion, plantar flexion, eversion and inversion and the respective muscles involved. 40 JOINTS AND THE MUSCLES THAT PRODUCE MOVEMENT MOVEMENT OF THE HIP A. Extension 1. Glut Max 2. Hamstring Group a. Semimembranosus b. Semitendinosus c. Long head of biceps femoris B. Flexion 1. Iliopsoas 2. Rectus Femoris 3. Sartorius 41 C. D. E. F. 4. Tensor Fascia Latae Abduction 1. Gluteus medius 2. Gluteus minimus 3. Tensor Fascia latae Adduction 1. Adductor Magnus (ischiocondylar portion - tibial innervation) 2. Adductor Longus 3. Gracillis 4. Pectineus (Femoral Nerve) Lateral rotation 1. Obturator internus 2. Obterator externus 3. Gamelli 4. Piriformis (supplied by both femoral and obturator nerves) 5. Quadratus femoris 6. Sartorius Medial rotation 1. Medial-most fibers of gluteus medius and minimus MOVEMENT OF THE KNEE: A. Extension - Quadriceps Femoris B. Flexion 1. Popliteus - initiates/unlocks knee for flexion; runs between LCL and capsule of knee 2. Hamstrings and short head of biceps femoris a. Short head gets direct innervation from the common peroneal nerve 3. Sartorius 4. Gastroc 5. Plantaris - vestigial; has its own tendon running separately MOVEMENT OF THE FOOT: A. Dorsiflexion (Extension) 1. Tibialis Anterior 2. Extensor Hallucis longus 3. Extensor digitorum longus 4. Peroneus tertius (5th digit off extensor digitorum longus) 42 B. C. D. Plantar Flexion (true flexion) 1. Gastroc 2. Soleus 3. Plantaris 4. Tibialis Posterior 5. Flexor Hallucis longus 6. Flexor digitorum longus Eversion (plantar surface out) 1. Peroneus longus 2. Peroneus brevis Inversion (plantar surface in) 1. Tibialis posterior 2. Tibialis anterior Note: Talocrural joint is a hinge joint, so only dorsi and plantarflexion are the only movements Inversion and eversion are done primarily at the inferior and anterior surfaces of the talus and these movements are augmented at the joint between the calcaneus and the cuboid (pg 183 of dissector) Sartorius - tailor’s muscle; Hackysack muscle - thanks to Jay Flexes and laterally rotates the thigh Flexes the Knee ***Make note of muscles that cross two joints We will mainly speak of Attachments of muscles; origins and insertions flip-flop depending on what is stabilized. 43 LOWER LIMB: NERVE SUPPLY (LUMBOSACRAL PLEXUS) The lumbosacral plexus is the name given to a collection of nerves fonned by the ventral rami of spinal nerves at the lumbar and sacral levels of the vertebral column. As a general rule, the nerves derived from the lumbar levels form within the psoas major muscle, while those derived from sacral levels are associated with the piriformis muscle and exit the pelvis via the greater sciatic foramen. Below is a list of the nerves of the lumbosacral plexus and their major branches. A diagram is also provided at the end of this section. It is expected that you will be able to identify most of these nerves and understand their functions. Remember that the levels that these nerves are derived from (indicated in parentheses below) are variable. I. Muscular branches (T12, LI, 2, 3,4)- supply quadratus lumborum (T12,LI,2,3,4), psoas minor (LI), psoas major (L2,3,4), and iliacus (L2,3). II. Iliohypogastric nerve (L I) A. Lateral cutaneous branch - supplies the skin of the anterior part of the side of the buttock B. III. Anterior cutaneous branch - supplies the skin of the abdomen above the pubis IV. Ilioinguinal nerve (LI) - supplies internal oblique, the skin of the superomedial area of the thigh, the skin over the root of the penis and upper part of the scrotum in the male, and the skin covering the mons pubis and adjoining labium majus in the female. Genitofemoral nerve (LI,2) A. Genital branch- supplies the cremaster and the skin of scrotum in the male, and the skin of mons pubis and labium majus in the female B. Femoral branch - supplies the skin over the upper part of the femoral triangle V. Lateral (femoral) cutaneous nerve (L2,3) VI. A. Anterior branch - supplies the skin of the anterior and lateral parts of the thigh B. Posterior branch - supplies the skin on the lateral surface of the thigh Obturator nerve (L2,3.4) A. VII. Anterior branch - supplies the skin of the medial side of the thigh, the adductor longus, adductor brevis, gracilis and pectineus B. Posterior branch - supplies the obturator extemus,' adductor magnus, and adductor brevis Femoral nerve (L2,3,4) - prior to branching it supplies the iliacus A. Nerve to the pectineus - supplies the pectineus 44 B. VIII. IX. X. Anterior division 1. Intermediate cutaneous nerve of the thigh - supplies the skin on the front of the thigh 2. Medial cutaneous nerve of the thigh - supplies the skin on the medial side of the thigh C. Posterior division 1. Saphenous nerve - supplies the skin over the medial side of the leg 2. Muscular branches - supply the quadriceps femoris (rectus femoris, vastus lateralis, vastus intermedialis, vastus medialis) Nerve to the quadratus femoris and gemellus inferior (L4,5,S 1) - supplies the quadratus femoris and gemellus inferior Nerve to the obturator intemus and gemellus superior (L5,S 1 ,2) - supplies the obturator intemus and gemellus superior Nerve to the piriformis (S 1 ,2) - supplies the piriformis XI. Superior gluteal nerve (L4,5,S 1) A. Superior branch - supplies the gluteus medius and gluteus minimus B. Inferior branch - supplies the gluteus medius and gluteus minimus XII. Inferior gluteal nerve (L5,S 1 ,2) - supplies the gluteus maximus XIII. Posterior femoral cutaneous nerve (S1, 2, 3) A. Gluteal branches - supplies the skin overlying the lower and lateral parts of the gluteus maximus B. Perineal branch - supplies the skin at the upper and medial side of the thighs, as well as the skin of the scrotum in the male and labium majus in the female C. Branches to the back of the thigh and leg - supplies the skin of the back and medial side of the thigh, and the skin of the upper part of the back of the leg. XIV. Sciatic nerve (Remember: the sciatic nerve is actually two separate nerves, the tibial and common peroneal, contained within one sheath) A. Tibial nerve (L4,5, Sl,2,3) 1. Articular branches - supply the knee joint 2. Muscular branches - supply the semitendinosus, semimembranosus, biceps femoris (long head), gastrocnemius, plantaris, soleus, popliteus, tibalis posterior, flexor digitorum longus and flexor hallucis longus 3. Sural nerve - supplies the skin of the lateral and posterior part of the lower 1/3 of the leg, and he skin of the heel and the medial side of the foot 4. Medial plantar nerve - supplies the skin of the sole of the foot, the undersides of the first 3 1/2 toes, and the abductor hallucis, flexor digitorum brevis, flexor hallucis brevis and the first lumbrical 5. Lateral plantar nerve - supplies the skin over the lateral part of the sole, the 45 underside of the lateral 1 1/2 toes, the flexor digiti minimi brevis, interosseus muscles, 2nd, 3rd and 4th lumbricals, adductor hallucis B. Common Peroneal nerve (L4,5,S 1,2) 1. Prior to branching: a. Articular branches - supply the knee joint b. Cutaneous branches - lateral cutaneous nerve of the calf and sural communicating branch c. Muscular branch - supplies biceps femoris (short head) 2. Deep peroneal (anterior tibial) nerve - supplies the tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius, extensor digitorum brevis, as well as articular branches to the ankle, tarsal and metatarsophalangeal joints, and skin over the dorsal and medial surfaces of the great and 2nd toe. 3. Superficial peroneal (musculocutaneous) nerve - supplies the peroneus longus and brevis, and the skin over the lateral part of the lower leg and the dorsum of the foot XV. Pudendal nerve (S2,3,4) A. Inferior rectal nerve - supplies the sphincter ani externus, the lining of the lower part of the anal canal and the skin around the anus B. Perineal nerve 1. Posterior scrotal (labial) branches - supply the skin of the scrotum (male) or labium majus (female) 2. Muscular branches - supply the transversus perinei superficialis, bulbospongiosus, ischiocavernosus, transversus perinei profundus, sphincter urethrae and the anterior parts of the external sphincter and levator ani C. Dorsal nerve of the penis (clitoris) - supplies the glans penis (male) or clitoris (female) XVI. Visceral branches (pelvic splanchnic nerves; S2,3,4) - preganglionic parasympathetics supplying the bladder, penis, clitoris, testes, ovaries, uterine tubes, uterus, and transverse, descending and sigmoid colon) XVII. Muscular branches (S4) - supply the levator ani, coccygeus and sphincter ani externus XVIII. Coccygeal plexus (S4,5, coccygeal nerves) - supply the skin in the region of the coccyx (anococcygeal nerves) 46 47 48 49 50 51 Discussion: Joints and Muscle Groups NOTES ON THE FEMUR: A. The Iliopsoas (Psoas + Iliacus) is the only muscle to insert onto the Lesser Trochanter B. Greater Trochanter - site for insertion of many lateral rotators C. Linea Aspera - insertion of large adductors; presence of linea aspera gives evidence of an erect hominid D. Condyle - knuckle appearance Thigh = Femur Leg = Crus Foot = Pes Fibula = Peron Pes Cavis = arched foot Pes Planus = flat foot GENERAL NOTES ON JOINTS: A. Wads of Fibrocartilage (labrum) 1. Knee - menisci 2. Hip - labrum B. Synovial Membrane produces synovial fluid 1. Protein-based fluid 2. Gets thicker with use 3. Many sheaths also have synovial fluid 4. Water on the knee - trauma, edeminous situation, breakage of cells and accumulation of fluid C. Joint injuries are often progressive –> One leads to another, body often does not forgive or forget D. Hip Joint vs. Shoulder 1. Hip is much deeper a. More stable - less likely to dislocate b. Less range of motion compared to shoulder joint c. Acetabulum of newborn is very shallow - looks similar to glenohumeral joint 2. Increases in range of motion of a joint are often at the expense of stability and visa versa 52 NERVE DAMAGE: A. Sciatica: term used to describe pain in the area of distribution of the sciatic nerve 1. Could be the result of a radiculopathy 2. Pain and generalized weakness (of the hamstring group) B. Foot Drop - Pg 360 Baby Moore 1. Often due to damage of the common fibular nerve (would result in loss of dorsiflexion and eversion) 2. High stepping gate - so the toes do not hit the ground 3. Foot brought down suddenly, in a distinctive “clop” C. Gluteal Gait (Gluteus Medius Limp or Trendelenburg Gait) - Pg 351 Baby Moore 1. Damage to the Superior Gluteal Nerve 2. Often due to nerve damaage following surgery 3. Weakened abduction of the thigh by the gluteus medius and impairment of medial rotation 4. Without gluteus medius function, when the foot is raised on the normal side, the pelvis falls on that side 5. May also see a “steppage gait” compensation similar to Foot Drop D. Gluteus Maximus Lurch 1. Damage to gluteus maximus 2. Inability to extend the hip E. Problems with the Iliopsoas, Femoral nerve, and Obturator nerve 1. Problem is likely radicular 2. Test both sides - could be central F. Eversion of the foot is easier to loose than inversion 1. Inversion - must knock out tibial and deep peroneal 2. Eversion - mustonly knock out superficial peroneal nerve Bold Terms of Lower Limb I: Greater Trochanter of Femur Intertrochanteric Chrest Trochanteric Fossa (deep depression at the medial Thigh Leg Foot Greater Sciatic Notch Lesser Sciatic Notch Ischial Spine Ischial Tuberosity Sacrotuberous ligament Sacrospinous ligament Greater Sciatic foramen Lesser Sciatic Foramen side of the greater trochanter) Gluteal Tuberosity Gluteus Maximus Posterior Cutaneous nerve of the thigh Gluteus Medius Gluteal tuberosity of the femur Iliotibial tract Greater trochanter of the femur Trochanteric bursa Sciatic nerve Piriformis Muscle 53 Superior Gluteal nerve and Vessels Gluteus Medius Gluteus Minimus Inferior gluteal nerve and vessels Sciatic nerve Pudendal nerve and internal pudendal vessels Greater Sciatic foramen Lesser Sciatic foramen Pudendal Canal Obturator Internus Superior gamellus Inferior gamellus Quadratus femoris Obturator externus tendon (near the greater Bold Terms of Lower Limb II: Cutaneous Branch of the obturator nerve Superficial Inguinal Lymph nodes (horizontal Superficial Veins Superficial Fascia Deep Fascia Deep system of veins Perforating veins (anastamoses between deep and and vertical groups) superficial system of veins) lata) Small Saphenous Vein (pierces deep fascia at popliteal fossa) and associated cutaneous nerves Great Saphenous Vein (venous communications Crural Fascia Great Saphenous Vein –> Femoral Vein Femoral Sheath: Lateral Compartment (Femoral artery) Middle Compartment (Femoral vein) Medial Compartment (Femoral Canal - lymph and areolar tissue) Femoral Ring (mouth of femoral canal) Anterior Superior Iliac Spine Anterior Inferior Iliac Spine Pubic Tubercle Greater Trochanter of Femur Lesser Trochanter of Femur Lateral condyle and Epicondyle of Femur Medial condyle and Epicondyle of Femur Adductor Tubercle Linea Aspera Patella Tuberosity (tubercle) of tibia Femoral Triangle Inguinal ligament Sartorius (laterally) Adductor Longus (medially) trochanter, in the interval between the quadratus femoris and inferior gamellus) Tensor Fasciae latae Deep Inguinal Nodes Deep Fascia Fascia Lata Iliotibial Tract (lateral portion of fascia with small saphenous) Posterior Cutaneous Nerves of the thigh (emerge in popliteal fossa) Sural Nerve (Courses with Sm. Saphenous vein) Lateral Sural Cutaneous Nerve (lateral to sural nerve) Cutaneous Nerves of the Gluteal Region Posterior Cutaneous Nerve of the thigh (inferiorly) Dorsal Rami of L1, L2, L3 (superiorly) Dorsal Venous Arch of the Foot (M ain tributary of great saphenous) Saphenous Opening (Fossa Ovalis) Saphenous Nerve (cutaneous) Superficial Fibular Nerve Dorsal Digital Nerves Femoral cutaneous nerves: Lateral Intermediate Medial 54 Femoral Artery and Vein Profunda Femoris Artery Lateral circumflex femoral artery Medial circumflex femoral artery (lie septum that inserts on the linea aspera) Profunda Femoris Vein Floor of the femoral Triangle Pectineus Adductor Longus Femoral Nerve Intermediate cutaneous nerve of the thigh Medial cutaneous nerve of the thigh Adductor Canal Begins at apex of Femoral Triangle Ends at adductor hiatus Lies deep to sartorius Walls: Vastus Medialis (laterally) Adductor Longus/Magnus (posteromedially) Sartorius (Sartorius) Popliteal Artery Saphenous nerve (accompanies femoral vessels Anterior thigh - Quadriceps Femoris Vastus lateralis Vastus Intermedius Vastus Medialis Rectus Femoris Ligamentum Patellae (Patellar Ligament) Sartorius Pectineus (usually Femoral innervation) Adductors Gracilis Pectineus Adductor Longus Adductor Brevis Adductor Magnus Hiatus Inserts on adductor tubercle on medial epicondyle and linea aspera Obturator Nerve Anterior branch (ant to add. brevis) Posterior branch (post. to add. brevis) Obturator Externus Profunda Femoris Vessels (pass between but does NOT pas through adductor hiatus) pectineus and adductor longus) Tensor Fascia Latae (encased by Fascia Lata) Fascia Lata (continuous with an intermuscular supply adjacent musculature) in the interval between the iliopsoas and pectineus) Perforating arteries (encircle femur and Posterior Cutaneous nerve of thigh Sciatic Nerve Hamstring Muscles (all originate from ischial Bold Terms of Lower Extremities III: Ischial Tuberosity Linea Aspera Lateral Supracondylar line Medial Condyle Lateral Condyle Apex, head, and neck of fibula Medial Condyle of Tibia Posterior Aspect of Tibia Rough area for semimembranosus Popliteal Area Soleal Line tuberosity): Semimembranosus Semitendinosus biceps femoris (long head) Short head of biceps femoris Hamstring Portion of Adductor Magnus (Tibial Nerve) Sciatic Nerve Common Peroneal Nerve Tibial Nerve (passes through gap in 55 Calcaneus Tuber calcanei (achilles) Sustentaculum tali Navicular Cuboid 3 Cuneiforms Metatarsus (tubercle of the 5th metatarsal) Phalanges Tibialis Anterior Superior and Inferior Extensor Retinacula Inferior Peroneal Retinaculum Anterior Compartment Tibialis Anterior Extensor Hallucis Longus Deep Peroneal Nerve/Anterior Tibial Vessels Extensor Digitorum Longus Lower lateral portion is the peroneus tertius Perforating Branch of fibular artery Dorsalis Pedis Artery (continuation of anterior soleus) Most blood supply of thigh is from Perforation branches of the profunda femoris artery Popliteal Fossa Biceps Femoris Semitendinosus/membranosus Gastroc Soleus Popliteus Plantaris Vascular Sheath (envelops popliteal artery and vein) Popliteal artery Superior lateral genicular artery Superior medial genicular artery Inverted Tripod Sartorius Gracilis Semitendinosus Tibia Fibula Interosseous Membrane Anterior and Posterior Crural Septa Three crural compartments Anterior Dorsiflexion, toe extension Deep Peroneal Nerve Anterior Tibial Artery Lateral Plantar Flexion/eversion Superficial Peroneal Nerve Posterior Plantar Flexion Tibial nerve runs between superficial and deep groups Posterior Tibial Artery Medial and lateral condyle of tibia Anterior Border of tibia Head of fibula Medial Malleolus Lateral Malleolus Tarsus Talus tibial) Arcuate Artery Dorsal Metatarsal Arteries Medial Malleolar Artery Lateral Malleolar Artery Tarsal Branches Deep Peroneal Nerve Lateral Compartment Fibularis (peroneus) longus Fibularis (peroneus) brevis Superior Fibular (peroneal) Retinaculum Tendons run posterior to lateral malleolus Inferior fibular retinaculum Holds tendons to calcaneous Superficial peroneal nerve (passes between fibula and fibularis longus) Posterior Crural Compartment Superficial Gastroc (2 heads) Soleus Plantaris Deep 56 Flexor hallucis Longus muscles from deep in posterior crural compartment) Tendo calcaneus (achilles tendon) Flex. Hallucis Long. –> Osseofibrous Tunnel Runs in a groove below the sustentaculum tali Flex. Dig. Longus –> passes on medial border of sustentaculum Sole of the foot (pg. 174-177 of dissector) (fibula) Flexor Digitorum Longus (tibia) Tibialis Posterior (tibia, fibular, and interosseous membrane) Popliteus Tibial Nerve Posterior Tibial Vessels Fibular (Peroneal) artery Intermuscular Septum (separates superficial Calcaneofibular ligament Anterior Talofibular ligament Anterior Inferior tibiofibular ligament Posterior talofibular ligament Articular Capsule Articular Surfaces Deltoid ligament Tibiofibular Joints Proximal tibiofibular joint Joint Capsule Synovial Cavity Middle Tibiofibular Interosseous Membrane Anterior tibial artery pierces Perforating branch of peroneal artery Pierces Distal Tibiofibular Anterior Inferior Tibiofibular ligaments Posterior Inferior Tibiofibular ligaments Cuneonavicular Joint Cubonavicular Joint Intercuneiform Joints Cuneocuboid Joints First Cuneometatarsal Joint Bold Terms from Lower Extremities IV: Hip Joint Fibrous Joint Capsule iliofemoral lig. Ischiofemoral lig. Articular area of head of femur Ligament of the head of the femur Synovial Membrane Acetabulum Lunate articular surface Oburator Externus Knee Joint Tibial collateral ligament (attaches to meniscus) Medial Meniscus (C-shaped; attached to tibia) Lateral Meniscus (O-shaped; mobile) Iliotibial tract Fibular collateral Ligament (does not blend with meniscus) Ligamentum patellae Prepatellar bursa Suprapatellar bura (quadriceps bursa) Anterior Cruciate ligament Posterior Cruciate Ligament Ankle Joint 57 Plantar Ligaments Interphalangeal Joint Intermetatarsal Joints Metatarsophalangeal and Interphalangeal Joints 58