L01- Introduction to MJM: Overview of The MSK System

Apparatus of movement

Also known as the Musculoskeletal System

 Its tissues are divisible into Two Groups
o Hard Tissues
 Cartilage
 Bones
o Soft Tissues
 Fascial envelopes
 Periosteum
 Endosteum
 Muscles
 Ligaments
 Tendons
 Nerves
 Vasculature

The hard tissues of the apparatus of movement

 Taken together, they constitute the skeletal apparatus of the body

 The skeleton is made up of
o Cartilage
o Bones
 The skeleton is divisible broadly into
o Axial Skeleton
o Appendicular Skeleton

The classification of bones

 The human foetus has at least 300 bones

 At birth, there the body has 270 bones
 In the adult, there are 206 bones
o Potential for inter-individual variation exists
 The bones are classifiable into 5 anatomical classes as follows:
o Short
o Long
o Flat
o Sesamoid
o Irregular

Gross Anatomy of Bones

 They constitute the hard tissues of the body

 They are classified as connective tissue of the body
 They constitute an avascular plane of the body
 They do not have lymphatic drainage
 They are lined by Endosteum & Periosteum

THE NERVE, ITS BRANCHES & TISSUE ENVELOPES

Membranous Envelopes of Cranial & Spinal Nerves

 Epineurium
o Ensheaths the entire nerve
o Interfascicular bands attach adjacent nerve fascicle
 Perineurium
o Ensheaths a nerve fascicle
o a fascicle is a collection of axons
 Endoneurium
o Ensheaths a single cell’s axon

Anatomy of The Neuro-muscular Junction

 It is confined to a specific area of the muscle known as the ‘nerve entry point’ or
neurovascular hilum
 The nerve entry point is the:
o Geographical centre of any given muscle
o Site of entry of a moto neurone into the substance of the muscle
o Site of entry of arterial supply to a muscle
o Site of exit of venous drainage of the muscle
o Site of aggregation of nicotinic receptors of healthy muscles

L02- History taking

Aims of history taking

Identify possible causes of the problem(s)

 Which structures are likely to be involved?
 What is the time course?
 Are other systems involved?
 Was there a precipitant?
 What is the impact of the problem on the patient / what are their expectations?

Screening questions (only 3)

1. Do you have any pain or stiffness in your muscles, joints or back?
2. Can you dress yourself completely without any difficulty?
3. Can you walk up and down stairs without any difficulty?

General approach
 History of presenting complaint
o Joints
o Muscle
o Supporting tissues
o Bone
 Systems review
 Past medical history
 Family history
 Social history
 Treatment history

How do MSK problems present?

Pain+ stiffness/swelling+ loss of function

Asking about MSK pain

 Site
 Distribution
 Onset – timing and precipitating factors
 Nature of pain (quality, severity, associated features, relieving factors)

Anatomical site of pain

 Joint=arthritis
 Tendon=tendonitis
 Bursa=bursaitis

Distribution of pain
 How many joints?
 Symmetrical?
1 = mono–articular
2-4 = oligo–articular
>4 = poly-articular

Which joints are affected?

 Hot, red, tender, reduced movement
 Gout > septic arthritis
 Septic arthritis > gout

Onset, timing and precipitating factors

Can help in identifying underling pathology
Faster
 Trauma (ACL rupture)
 Infection (septic arthritis)
 Inflammation (rheumatoid)
 Degenerative (osteoarthritis)
Slower

Nature of pain 1
Inflammatory or degenerative?
Inflammatory Degenerative
Pain At rest (better with moving) Moving (better with rest)
Stiffness (Morning) Long> 45 min Short <20 min
Swelling Softer/ “boggy” Hard/bony
Tenderness +++ +
Redness ++ -
Warmth ++ -

Specific pain types

bone Peri-articular
Severe Diffuse
Localised Not well-localised
Disturbs sleep Around joint
Radiation
 Starts in 1 place and travels to another
 Usually along the path of a nerve
 Eg. Sciatica
 Neck pain radiating to fingers
 Hip pain radiating to knee

Other things to think about

 Muscle pain? (myalgia)
 Instability of joint (degenerative/trauma)
 Worse against resistance (tendinitis)
 Weakness? (due to pain? independent?)
 Neurological symptoms?
o Neuropathic pain – shooting/electric shock/burning
o Paraesthesia (tingling)
o Numbness

Specific questions for trauma

 When and how did the incident occur?
 What happened exactly?
 How much force?
 Has the bone/joint been damaged before?
 (History of other trauma/fractures)
 Is there peripheral circulation intact?
 Is the peripheral nervous system intact?
 Is the central nervous system intact?
 Fit for anaesthetic?

Deeper organs
Example questions
Cardiovascular Raynaud’s phenomenon?
Kidneys Blood in urine?
GI tract Change in bowels?
Respiratory Chest pain?
Nervous system Tingling/numbness?

Past medical history

 History of infections / travel?
 Bowel symptoms? Skin disease?
 MSK problems in childhood?

Social history
 Smoking / alcohol / other drugs?
 Occupation? – if you don’t know what it entails it’s OK to ask (!)
 Home situation
o Who?
o Dependents?
o Adaptations?
Family history
 1st degree relatives with similar conditions?
 Autoimmune diseases “hunt in packs”
  Monogenic: some rare inflammatory syndromes (arthritis)
 Polygenic: e.g. rheumatoid arthritis concordance
o Monozygotic: 15%
o Dizygotic: 4%

Impact of problem
 Limitation of activities?
 Time off work?
 Personal hygiene?
 Needing to use walking aids/other devices?
 Psychological impact

Treatment history
 What has been tried already?
 If previous treatments have failed – why?
o Inefficacy
o Adverse effects
 Could this be related to other drugs?
o e.g. statins and myalgia
 Non-medical treatments

Classifying MSK disorders

Problems occurring in joints/bones/periarticular
(i.e. no or very little systemic involvement)
 Osteoarthritis
 Crystal arthritis (gout)
 Tendonitis or bursitis
 Bone tumours
Systemic conditions with prominent joint features
(aetiology often unclear)
 e.g Rheumatoid arthritis

Non-rheumatological conditions which can affect the MSK system

 Sickle cell disease
 Cancer metastasis to bone
 Vitamin D deficiency

L03- bone, cartilage, tendon and muscle

Tendons and ligaments

 Tendons
o Connect muscle to bone (collagen)
o Connect bone to bone (collagen and elastin)

Muscle tendons
 Many tendons from a single muscle enables movement of several bones
Tendinitis (Tendon Swelling)
 Tendinitis in the digits
 The tendons enter a tube (the tendon sheath) that runs the length of the finger. Helps
protect the tendon from wear and tear
 Problem area: at the entrance, where the restraint is the most snug.
 Typically where the worst inflammation and irritation occurs.
 Swelling at the palms and stiffness around the digits
 Tendons can be damaged and repaired

Ligaments
 Tough bands of white, fibrous slightly elastic tissue.
 An essential part of skeletal joints: binding bones together
 Also support many internal organs (uterus, liver, bladder)
 In joints with wide ranging movements, ligaments can be torn.
 “Double Jointed” is a result of longer ligaments, allowing joints to move beyond their normal
range.

The Knee: The Anterior Cruciate Ligament (ACL)

 Links the upper leg bone (femur) with one of the tibia by running crosswise inside the center
of the knee joint.
 The ACL stabilizes knee movement in a forward and backward direction.
 Commonly damaged in sporting injuries
 Excessive force leads to tearing
 Bone-tendon-bone transplant for repair

Cartilage
 Composed of collagen and elastin fibres, chondrocytes and extracellular matrix
 Avascular: nutrients diffuse through ECM
 3 types:
o Hyaline - most common, provides a framework for bone deposition. Also supplies
smooth surfaces for articulation.
o Fibrocartilage - found in areas requiring tough Support. Eg pubic symphisis.
o Elastic - walls of the auditory canals and larynx. Present to keep tubes open.

Bone
 Osseous tissue: hard, lightweight, formed mostly from calcium phosphate
 Many fibres - collagen gives elasticity
  NB: Very well vascularised good wound repair

Five Functions of Bone

 Support: framework for muscle and soft tissue attachment
 Protection: of internal organs
 Movement: contraction of SKELETAL muscles moves the skeleton
 Mineral Storage: calcium and phosphorous
 Haemopoiesis: blood cell production in bone marrow

General bone structure

 Compact bone
 Cancellous (Spongy bone)
o Contains an organised network of trabeculae, arranged to give maximum strength at
sites of weight bearing
 Compact and cancellous bone are distributed at different sites in a typical bone

Bone membranes
 Endosteum
o A single layer of cells lining the inner surface of bone
 Periosteum
o Several cell layers lining the outer surface of bone

Bone formation: endochondral ossification

1. Embryonic mesenchyme forms a mesenchymal model
2. Intermediate cartilaginous model
3. Replaced by bone via endochondral ossification

 Cartilage is destroyed and replaced by bone

 Primary ossification centres appear in bone shafts, most are present by birth
 Secondary ossification centres appear at bone end after birth
 Between the ends and the shaft is the growing area: epiphyseal growth plate

Epiphyseal growth plates grow during adolescence

Types of bone
 Long
o Tubular shaft and an articular surface at each end
 o Arms and legs
o Femur (unpaired)
o Tibia and fibula (paired)
o Humerus (unpaired)
o Radius and ulna (paired)
 Short
o Same as long bone but shorter
o Hands and feet
o Metacarpals and metatarsals
o Phalanges
o Clavicles
 Flat
o Thin with broad surfaces
o Innominate bone (hip bone)
o Scapula
o All ribs
o Sternum
 Irregular
o Vertebral column
o 8 carpal bones
o 7 tarsal bones
o Patella (knee cap)

L04- muscle groups and movements

Skeletal muscle
 Voluntary control
 Moves skeleton
 600 skeletal muscles in the body
 50% of body weight
 Produce movements by contracting (shortening of muscle fibres)

Movement of muscles
Flexion: decreasing the angle between two bones (bending).

Extension: increasing the angle between two bones (straightening a bend).

Abduction: moving away from the body’s midline.

Adduction: moving toward the body’s midline.

Pronation and supination

Describing the rotation of the forearm back and forth requires special terms. Spread
your fingers out and look at the palms of your hands and the fingers and then rotate
your palms to look at your nails. Now look at your palms again. That’s forearm
supination and pronation.

Pronation: rotating the forearm so the palm is facing backward or down.

Supination: rotating the forearm so the palm is facing forward or up.

Elevation and depression are up-and-down movements, such as chewing or
shrugging your shoulders. When you move the mandible down to open the mouth,
that’s mandible depression. Move the mandible back up, that’s mandible elevation.

Elevation: moving a body part up.

Depression: moving a body part down.

Protraction and retraction

By moving your jaw back and forth in a jutting motion, you are protracting and
retracting your mandible.

Protraction: moving a bone forward without changing the angle.

Retraction: moving a bone backward without changing the angle.

Inversion and eversion

You invert your foot when you turn it inward to see what is stuck under your shoe.
You evert your foot to put the sole of your shoe back on the floor.

Inversion: turning the sole of the foot inward.

Eversion: turning the sole of the foot outward.

Dorsiflexion and plantar flexion You dorsiflex your feet to walk on your heels,
and plantar flex them to tiptoe.

Dorsiflexion: bringing your foot upward toward your shin.

Plantar flexion: depressing your foot.

Each muscle has

 Origin
 Insertion
 Innervation
 Function

Eg. Biceps Brachii

 Origin · Long head from Supraglenoid tubercle · Short head from Coracoid process
 Insertion: Radial tuberosity, and Bicipital aponeurosis Innervation: Musculocutaneous Nerve
 Function: Flexion of the elbow

Muscle nomenclature
Most names describe some anatomical feature of the muscle:
 Size: vastus (huge); maximus (large); longus (long); minimus (small); brevis (short).
 Shape: deltoid (triangular); latissimus (wide); teres (round).
 Direction of fibres: rectus (straight); transverse (across); oblique (diagonally); orbicularis
(circular). Location: pectoralis (chest); gluteus (buttock or rump); brachii (arm)

Categorisation Of Muscles: Function

 FLEXORS: eg. Biceps Brachii
 EXTENSORS: eg. Triceps Brachii
 ABDUCTORS: eg. Deltoid
 ADDUCTORS: eg. Pectoralis Major
 SPHINCTERS, DILATORS: eg. Orbicularis Oculi
  LEVATOR: to lift or elevate a structure eg. levator scapulae
 MASSETER: a chewer.

Muscular agonism and antagonism

 Wrist flexion involves two muscle groups:
o Flexors on anterior forearm
o agonist
o prime movers
o Extensors on posterior forearm
o Antagonist
o No elongation but change in muscle tone

Muscle Tone:
 Muscles are in a constant state Of partial contraction.
 Only part of skeletal muscle activity that is under involuntary control
 Loss of muscle tone, eg by paralysis means muscles become FLACCID

Pennate structure
 Arrangement of muscle fibres allows categorisation
 Pennate muscles can be
o Unipennate- flexor pollicus longus
o Bipennate- rectus femoris
o Multipennate- deltoid
 Multi-pennate muscles allow packing of more muscle fibres, makes for powerful muscles:
 The more pennate the muscle, the more powerful it is
Insertion of muscles
 Where tendons are prone to compression, sesamoid bones may develop. Largest sesamoid
bone is the patella in quadriceps femoris tendon.
 Muscles can insert via a flattened tendon (APONEUROSIS)
 Aponeurosis of Occipitofrontalis
o Strong sheet-like tendon
o Provides attachment over a large area, to increase strength of muscle attachment
o If the aponeurotic layer is cut, scalp wounds gape widely

Dupuytren’s contracture
 Cause is unknown.
 Thickening and shortening of the palmar aponeurosis so that the tendons connected to the
fingers cannot move freely.
 Fingers bend toward the palm and cannot be straightened.
 The little and ring fingers are most commonly affected.
 Progresses slowly and is usually painless.

Fascia:
 Sheet of fibrous tissue allowing attachment of muscle
 Most facial muscles attach to bone or to fascia.
 Eg. Muscles of facial expression, which move the facial skin
 As skin ages, it becomes less elastic.
 Wrinkles in the skin appear at right angles to muscle fibres in muscles of facial expression
 Botox (Botulism Toxin type A) acts to paralyse muscles, so wrinkles disappear

L05- Joints- Stability, support and movement

Classification of Joints
 Fibrous Joints
 Skull sutures
 Syndesmosis: bones united by a sheet of fibrous tissue, or a ligament, or a
membrane (eg. Interosseus membrane between radius and ulna)
 Gomphosis: Joint between tooth and socket. Movement here is pathological
 Cartilaginous joints
 Primary cartilaginous joints: united by hyaline cartilage.
Usually a temporary joint during growth of a long bone.
  Secondary cartilaginous joint: articular surface coated with Hyaline cartilage. Bones
united by strong fibrocartilage.
Strong joints allowing only slight movements eg. between vertebrae
 Synovial joints:
Allows locomotion
Provide free movements. Very common, multiple types
Many have specialised features:
o Articular discs (fibrocartilage pads) which act as
Shock absorbers
 eg in Temporomandibular joint
o Fibrocartilage ring (labrum) to help deepen the joint
 Eg glenoid labrum at shoulder
o Tendons passing through joint capsule
 eg biceps Brachii at shoulder

Synovial Joints: 6 common features

 Bone ends covered by articular cartilage
 Joint has a connective tissue capsule
 Joint cavity
 Inner surface of capsule lined by synovial membrane
 Commonly reinforced by ligaments
o Allow a wide range of movements

 Hip joints/ knee joints

o Hip dislocations are rare due to strong cartilage

The Shoulder Joint: Synovial Ball and Socket Joint

 Articulation between humeral head, and the glenoid cavity of the scapula
 Bony stability at the shoulder is sacrificed to enable a wide range of movements of the upper
limb

Shoulder joint ligaments

 Acromioclavicular ligament
 Coracoacromial ligament
 Coracoclavicular ligaments

The glenoid labrum

 Fibrocartilaginous lip around the glenoid cavity
 Acts to deepen the cavity for better articulation
Superficial Muscles of the Shoulder Region
Pectoralis Major (Lateral and Medial Pectoral Nerves)
 Attached to clavicle, sternum and upper ribs, tendon runs in
 Intertubercular groove of humerus.
Deltoid (Axillary Nerve)
 From clavicle, acromion and spine of scapula to deltoid tuberosity.
 Facilitates flexion, extension, abduction and medial and lateral rotation.
Trapezius (Accessory Nerve)
 From vertebral column and external occipital protruberance to clavicle, acromion and spine
of scapula.
 Facilitates bracing and shrugging shoulders
Latissimus Dorsi (Thoracodorsal Nerve)
 From thoracolumbar fascia, iliac crest, lower 6 thoracic vertebrae and lower 3 or 4 ribs.
Tendon lies in intertubercular groove.
 Facilitates extension, adduction, medial rotation.

 As well as the superficial back and chest muscles…..

 The shoulder region contains the ROTATOR CUFF, a specialised muscle group which FIXES
the head of the humerus into the glenoid cavity

The Rotator Cuff Muscles

INNERVATION:
 Subscapularis: Upper and Lower Subscapular N.
 Supraspinatus: Suprascapular N.
 Infraspinatus: Suprascapular N.
 Teres Minor: Axillary N.

Attachment and Movements of Rotator Cuff Muscles

Subscapularis
 From subscapular fossa to lesser tuberosity of humerus.
 Faciliates medial rotation and adduction
Supraspinatus
 From supraspinous fossa to greater tuberosity of humerus.
 Facilitates abduction.
Infraspinatus
 From infraspinous fossa to greater tuberosity of humerus.
 Facilitates lateral rotation.
Teres Minor
 From lateral border of scapula to greater tuberosity of humerus.
 Facilitates lateral rotation

Shoulder Joint Dislocation

 Articulation between humerus and glenoid cavity is poor, so shoulder is a commonly
dislocated large joint
 Humeral head rarely moves upwards during dislocation due To the presence of the coracoid
process
 So, dislocation of humeral head usually occurs inferiorly, with head lying in a subcoracoid
position
 Tears joint capsule, and can damage Axillary Nerve
  Axillary Nerve is susceptible to damage because of positioning –winds around upper aspect
of humerus
 Damage to Axillary Nerve results in loss of sensation to skin over deltoid: ‘Regimental Badge’
sign.

The elbow joint

 A synovial hinge joint
 Articulation between the distal end of the humerus and proximal ends of the radius and ulna
Ligaments for stability:
 Medial Ligament holds Ulna in place
 Lateral Ligament holds Radius in place
 Annular Ligament holds Radius in place

Pulled Elbow: Subluxation Of The Head of The Radius

 Radial Head held in place by ring like Annular Ligament
 Ligament is softer in children, hence more prone to dislocation

Muscles of the elbow

Elbow Flexors
1. Biceps Brachii
Arises from 2 heads:
 long head from supraglenoid tubercle
 short head from coracoid process
 Inserts into
o a) radial tuberosity
o b) bicipital aponeurosis
2. Brachialis
Arises from humeral shaft
 Inserts into tuberosity of ulna
 Musculocutaneous Nerve

Elbow extensors
3. Triceps Brachii
Arises from 3 heads:
 lateral head: superior, lateral margin of humerus
 long head: infraglenoid tubercle of scapula
 medial head: posterior surface of humerus
 Inserts into Olecranon of Ulna
 Radial Nerve

Summary
 Fibrous, cartilaginous: no/little movement
 Synovial: free moving, danger of damage
o Stability enhanced by muscles and ligaments
 Rotator cuff
o Shoulder: muscular specialisation enhances stability
 L06- Distribution of nerves and vessels in the upper limb

Osteology
The Upper Limb is divided into:
 The Pectoral Girdle (Clavicle & Scapula)
 The Arm (or Brachium)
 The Forearm (or Antebrachium)
 The Wrist (i.e. a Joint)
 The Hand

Ascending Limb & Arch of Aorta

 Supplies arterial blood to the:
o Heart (aortic sinus of the aorta)
o Head
o Neck
o Upper Limbs
 There is Left‐Right asymmetry in blood supply to the:
o Head
o Neck
o Upper limbs

Aortic Supply of The Head & Neck

 Derived from the arch of the aorta as follows:
 First branch is the Innominate brachiocephalic artery supplying the right side of body
 Brachiocephalic artery then divides into
o Right subclavian artery
o Right common carotid artery
o At level of sternoclavicular articulation
 Right Subclavian Artery
o Supplies the right Upper Limb
 Third branch is the Left Subclavian Artery
o Supplies the left Upper Limb

Anatomy of Segmentation of Arterial Tree of Upper limb

  Arterial supply to the upper limb is derived from a continuous but also branching arterial
tube
 The arterial tube is segmented by anatomical key landmarks along its journey
 As the arterial tube encounters key anatomical landmarks along its course, its segments are
named accordingly
 We are required to know each the key anatomical landmarks in sequential order
o Subclavian Artery
 Aortic Arch (Left) or Sternoclavicular Joint (R)
o Axillary Artery
 Lateral border of the first Brachial Artery
o Profunda Brachii
 Inferior Border of Teres Minor Muscle
o Ulnar & Radial Arteries
 Radial tuberosity
o Deep & Superficial Palmer Arches

Clinical Usefulness of The Arterial Tree of Upper limb

 Estimation of systemic arterial blood pressure
 Assessment of integrity of perfusion using distal limb pulses
o Staging of limb pulses from proximal to distal in investigations
 Some pulses are used routinely
 Axillary Artery Pulse
o Difficult to palpate
o Palpated in investigations of occlusion
 Brachial Artery Pulse
o Position approximates height of the heart in situ
o Used for estimation of systemic Blood Pressure
 Its height is important for accuracy of BP estimation
 Radial Artery Pulse
o Used routinely in clinical assessment
o Used also for arterial samples for Blood‐Gas Analyses
 Ulnar Artery Pulse
o Relatively difficult to palpate though it is possible

Venous Drainage of Blood From The Upper Limb

 Organised as two parallel systems
 Superficial Venous Drainage
 Deep Venous Drainage
 Deep veins drain Superficial veins via Perforators
 Deep veins use the musculo‐venous pump to energise their drainage to the superior vena
cava
Axial Lines of Limbs
• The boundary line between two dermatomes supplied from discontinuous spinal levels is
known as the axial line
• The limbs have anterior and posterior axial lines (pre & post axial borders)
• The axial lines also mark boundaries between the flexor and extensor compartments of the
limb
• These borders are conveniently marked out by superficial veins
o Cephalic & Basilic (Upper Limb)
o Great saphenous & Small saphenous veins (Lower Limb)

Clinical Importance of Venous Drainage of Upper Limb

 Lymphoedema
 Venae puncture
 Sites for:
o Harvesting blood for analysis
o Administration of IV drugs
o Fluid replacement for hydration status of body
o Blood transfusion (route for)

Lymphatic Drainage of The Upper Limb

 This system is designed in much the same way as that of venous drainage
 It begins at the tips of the fingers and drains into clavicular lymph vessels
 It deploys lymph nodes as follows:
o Supratrochlear Lymph Nodes
o Axillary Lymph Nodes
o Infraclavicular Lymph Nodes
 Drainage is through two parallel systems
o Superficial Lymphatic Channels
 o Deep Lymphatic Channels
 Lymphatic drainage is often disturbed in axillary clearance of lymph nodes
o Leading to lymphoedema

The Dermatomyotome
 Embryonic precursors of the adult dermis and muscle units are known as dermatomyotomes
 Each dermatomyotome eventually differentiates into dermis (dermatome) and muscle
(myotome) in the adult
 Dermatomyotomes develop in association with a specific neural level of the embryonic
neural tube tissue
 The neural tube is the precursor of what will eventually become the adult spinal cord
 Dermatomyotomal tissue takes its neural supply with it irrespective of where it ends up in
the adult body
 Differentiated skin & muscle units of a dermatomyotome always have a common source of
nervous supply
 The adult nervous supply to the dermis and muscle of a dermatomyotome is a spinal
segmental nerve

What is a Segmental Nerve?

 At Each Vertebral Level the spinal cord gives out a pair of nerves
 One to the Left
 One to the Right
 The nerves exit the vertebral column through inter‐vertebral foramina
 Each of these nerves is known as a Spinal Segmental Nerve
 A vertebral level and a neuronal spinal level are two different entities (never to be mixed
up!)

The Segmental Neurovascular Bundle

 Segmental Nerves always travel with their equivalent segmental arteries
 Segmental Nerves always travel with their equivalent segmental veins

Composition of a Segmental Nerve

 Segmental Nerves are known as Mixed Spinal Nerves
 Each Spinal Segmental Nerve comprises of:
o Dorsal Roots (Sensory or afferent)
o Ventral Roots (Efferent)
o Motor
 skeletal muscle
o Autonomic
 Smooth muscle
 Glands

Branching order of a segmental nerve

 As the mixed spinal nerve emerges through the intervertebral foramen it divides into 2
branches
 Posterior or Dorsal Ramus (small)
o The Posterior Ramus Divides further into Medial & Lateral Branches
 Anterior or Ventral Ramus (Large)
 All Rami contain all functional modalities for that segmental level
Nerve Supply to The Upper Limb
• It Receives all its Nerve Supply from The Spinal Cord
• Most of Its Supply is derived from Cervical Spinal Segments (C5‐T1)
• The rest comes from T2 Roots
• Spinal Nerves (except T2) to the Upper Limb form a Network of nerves
• The Brachial Plexus
o Roots
o From Anterior Rami C5‐T1 Unite & Divide to give
 UpperTrunk (C5,C6)
 Middle Trunk (C7)
 Lower Trunk (C8,T1)
o All Trunks Divide into Divisions:
 Anterior
 Posterior
o Divisions give rise to Cords (Axillary Artery):
 Medial Cord
 Lateral Cord
 Posterior Cord
Other Nerves of the Upper Limb
• Lateral Pectoral
• Upper Subscapular
• Lower Subscapular
• Dorsal Scapular
• Suprascapular Nerve
• Long thoracic
• Axillary

What is a Dermatome?
• translates to: – skin (derma‐) segment (‐tome)
• It is an area of skin supplied by sensory nerve fibres from a single spinal nerve (Neural
Level)
• Dermatomes are arranged as highly ordered slices of the skin
• A spinal nerve root supplies 1 slice of skin (or dermatome)
• 1 Dermatome receives sensory supply from 1 spinal nerve root

Sensory Nerve Territories of The Upper Limb

• Sensory Divisions of Terminal Nerves of the Brachial Plexus Supply the Skin in Territorial
Domains
• These are known as Sensory Nerve Territories
• Sensory Nerve Territories are Not Dermatomes
 L07/8- upper limb

 Arm - from shoulder to elbow

 Forearm - from elbow to wrist

Scapula
 Shallow socket
 Mobility
 Always a pay-off in joints between mobility and stability
 Easy to dislocate due to mobility
 Subscapularis attaches to scapular fossa
 Coracoid process attachment site for biceps

Clavicle
 First bone of ossification

Humerus
 Proximal end nearest to axial skeleton
 Epiphysis
 Shaft
 Greater and lesser tubercle
o Rotator cuff muscles attach
 Intertubercular sulcus
o Biceps
 Condyle

L09- common joint pathologies

Synovial joints
• Articular surfaces of the bones are covered by a thin layer of hyaline cartilage
• There is a joint cavity
• The cavity is lined by synovial membrane
• Viscous synovial fluid
• Lubrication
• Shock absorption
• Nutrient distribution

Synovial joints: accessory structures 1

• Surrounded by a fibrous capsule.
• Capsule reinforced externally or internally (or both) by fibrous ligaments.
• Bursae are fluid-filled sacs that facilitate smooth movement between articulating
structures.
• Muscles acting over the joint move it through its normal range
• Tendons anchor muscle to bone
• Muscles, ligaments & capsule provide stability
Infective (septic) arthritis
• Inflammation of a joint caused by infection (usually bacterial)
• Can affect any age group, but more common in children & elderly
• Risk factors
o Breach of the skin barrier
o Immunosuppression for any cause
o Extremes of age
o Underlying inflammatory arthritis
o Joint replacement
 Loss of joint space
 Erosions
 New bone formation
Routes of infection
• Blood stream (haematogenous route)
• Directly into joint (wound, needle)
• From a skin/tissue infection
• From a bone infection

Consequence of untreated infection

• Rapid joint destruction often with infection of surrounding bone (osteomyelitis)
• May drain to skin surface (sinus)
• Bacterial spread to blood stream (sepsis)
• Stimulation of excess bone formation leading to fusion of the joint → loss of function

Gout
Definition:
• Crystal induced arthritis in which the deposition of uric acid (monosodium urate) crystals
in joints leads to inflammation.
• Monoarticular or pauciarticular (asymmetrical at first)
• May become polyarticular and symmetrical later
Incidence:
• More common in men (middle age onwards)
• Post-menopausal women

Aetiology:
Primary (idiopathic)
• Usually due to impaired excretion of uric acid by kidney; may be family tendency
Secondary
 • Increased production of uric acid: e.g. alcohol consumption or high purine intake in diet
or high turnover of cells e.g. treatment of leukaemia
• Impaired excretion by kidney; disease or drugs e.g. diuretics)
Pathological changes:
• Cartilage degeneration
• Synovial hyperplasia and erosion of bone
• Secondary degenerative change (osteoarthritis)
• Soft tissue swelling
• Tophaceous deposits in skin

Osteoarthritis
Definition:
• Predominantly degenerative disease
• Dysregulation of normal tissue turnover & repair
Incidence:
• Extremely common age-related disorder
• Major cause of disability & inability to work >50yrs
• Increasingly common above 60 years of age
• 80% of the elderly population show radiographic evidence of OA not all are symptomatic

Osteoarthritis Aetiology:
• Primary
• Secondary (e.g. complication of other joint disorders, mainly inflammatory joint disease,
trauma to joints, congenital joint deformities) Pathological changes:
• Involve cartilage, bone, synovium, and joint capsule with secondary effects on muscle
(due to disuse)

Pathological features of OA
• Focal areas of destruction of articular cartilage (fibrillation and erosion)
• Hypertrophy of subchondral bone, joint margin (osteophyte formation) & capsule
(synovial metaplasia)
• Pseudocysts

Radiological features of OA
• Joint space narrowing
• Subchondral bone sclerosis and cysts
• Marginal osteophyte formation

Rheumatoid Arthritis Aetiology:

• Autoimmune (exact aetiology uncertain)
Clinical manifestation:
• Symmetrical deforming polyarthritis
• Widespread small joint involvement (hands and feet)
• Medium and large joints also involved
• May be associated with non-articular disease
Pathological changes:
• Synovial hyperplasia and inflammatory infiltration resulting in pannus formation
• Invasion and destruction of articular cartilage
• Focal destruction of bone (erosions)
• Soft tissue swelling
• Joint space narrowing
 • Osteopenia (reduced bone density)
• Erosions

L10- osteology of the skull and TMJ

The skull
• It is made from 22 discrete bones
• Most bones are joined by fibrous joints called sutures – Fibrous Joints are also known as
Symphises (pl)
• It also has a very special bilateral moveable joint – The Temporomandibular Joint (TMJ)

The cranium
It is divisible into three further components:
• The Calvaria
– It is the upper box-like bony construct
– It houses the brain and attendant anatomical structures
– neurocranium
• Facial Skeleton
– It is the lower & anterior part
– It is made up from the rest of the cranial skeleton that is not part of the
neurocranium
– Membranous viscerocranium
• Skull Base
– Articulates with the vertebral column
– Chondrocranium
– Forms inferior margins of the cranium
– Articulates with the vertebral columbones

Bones of the skull

• Frontal
• Parietal
• Temporal
• Sphenoid
• Occipital
• Facial bones
• Mandible
• Teeth

Sutures
• Allow bones to interlock firmly

Basic functions of the skull

• Encloses and protects:
o The brain
 Flat bones, dense and strong
 2 plates of compact bone
 Resilience
 1 middle layer of spongy bone
 Diploe
 Reduce weight of the cranium
o Special sense organs
  Eyes, ears, vestibular organs, taste, olfaction
• Creates a specialised environment in which the brain thrives
o The cranial cavity
• Site for attachments of:
o Muscles
o Meninges

Thickness of the cranium

• Variable thickness:
o Thick: occipital & frontal bones
o Thin: pterion
The calvaria
• Cap & base
• Frontal
• Parietal
• Occipital
• Temporal
• Suture lines
o Coronal
o Longitudinal
o Lambdoid
o Bregma
o Lambda
• Foramina
o Emissary veins
o Lessen the weight of the skull
o Allow for passage of anatomical structures between extra- and intra- cranial
compartment
o Large number make the cranium floor weak
o Cranial base is liable to fracture in high energy impacts to the head

Cranial floor
• Anterior fossa
• Middle fossa
• Posterior fossa

Mandible
• 2 separate bones
• Bilateral bony structure
• Union of L & R mandibles
o Joined by midline fibrous joint
 Mental symphysis
• Temporomandibular joint
o Articulation of mandible with cranium
o Anterior to- and vertical level with the tragus of the ear
o Surfaces:
 Superior (bone of the cranium)
 Mandibular fossa (posterior and concave)
 Articular tubercle (anterior& convex)
 Inferior (process of mandible)
 Condyles of the mandible
Articulatory surfaces of TMJ
• 2 on the squamous temporal under surface
• 1 on each side of the mandible
TMJ
• Most complex joint in the body
• Modified synovial variety
• A gliding joint
• A modified hinge joint
TMJ capsule
• Fibrous capsule
o Strong
o Thin and loose to permit movements of the joint
• Direct bone-to-bone articulation does not occur
• Fibrous disc known as the articular disc or meniscus separates bony surfaces from making
direct contact
o Upper cavity & lower cavity
• Synovial cavity is compartmentalised
Incongruity between articulatory surfaces of the TMJ
• Superior surface
o Convexo-concave (antero-posteriorly)
• Inferior surface
o Condyloid with an oblique trajectory superiorly
• Articular disc/ meniscus between bony articular surfaces improves fir and makes them more
congruent

L11- spine

Function of the spine

• Support the trunk
• Protect the spinal cord
• Provide muscle attachment
• Haemopoiesis

Spinal curvature
• Cervical curvature (secondary)
• Thoracic curvature (primary)
• Lumbar curvature (secondary)
• Sacral/ coccygeal curvature (primary)
Early embryo
• Concave of primary curvature

Abnormal spinal curvatures

• Kyphosis
o hunchback
• Scoliosis
o s/c shape curvature
• lordosis
o excessive inward curvature

Movement of the spine

• extension, flexion
• lateral flexion
• rotation
Vertebral ligaments
• posterior longitudinal ligament
• anterior longitudinal ligament
• ligamenta flava
• ligamentum nunchae
• supraspinous ligament
 • infraspinous ligament

Muscles of the spine: extrinsic muscles- superficial layer

• trapezius
• latissimus dorsi
• rhomboids
• levator scapulae
o all supplied by ventral rami of cervical spinal nerves

Muscles of the spine: extrinsic muscles - Deep layer

• serratus posterior superior & inferior
o supplied by intercostal nerves

Muscles of the spine: intrinsic muscles- superficial layer

• splenius
• erector spinae: spinalis, longissimus, iliocostalis
o supplied by dorsa rami of spinal nerves

Muscles of the spine: intrinsic muscles- deep layer

• semispinalis
• multifidus
• rotatores
• interspinales & intertransverse (even deeper)

L12- upper limb injuries

See RA L21

L13- Lower limb 1- osteology & radiology

Four major sub-divisions:

 the hip
o between the iliac crest and greater trochanter of femur
 the thigh
o between the greater trochanter and the knee
 the knee joint
 the patellar
 the leg
o below the knee and above the foot
 the foot

The hip bone

 Innominate bone
 Union of 3 bones
o Ilium
o Ischium
o Pubis
 Before puberty bones are separated by cartilage
 Begin to fuse at the acetabulum at 15-17 years to form 1 hip bone
 Fusion of hip bones usually complete at 23
The ilium
 Has an ala (wing) & body
 Iliac fossa is a concavity in the Ala and forms part of the pelvic wall
 Has an auricular surface for articulation with the sacrum
 Forms superior 2/3 of the hip bone
 Forms 2/5 of the acetabulum
 Hand on hips rests on the iliac crest
 Iliac crest can be palpated
o Used as surface landmark in lumbar punctures
o Separates anterior and posterior iliac spines

Ischium
 Posterior 1/3 of hip bone
 Posterior 2/5 of acetabulum
 Body and ramus
 Body
o Superior portion fused with ilium and pubis at the acetabulum
o Inferior end has ragged blunt projection (ischial tuberosity)
 Bears weight of the body where we sit

Pubis
 L-shaped inferior part of hip bone and anteromedial 1/5 of acetabulum
 Body and 2 rami
 Superior ramus passes superolaterally to acetabulum
 Inferior ramus passes posteriorly, inferiorly and laterally to join ischium ramus
o Forms half of pubic arch (ischiopubic ramus)
 Body of pubis joins body of opposite pubis at fibrocartilaginous joint (pubic symphysis)

Femur
 Thigh bone
 Longest, strongest and heaviest bone in the body
 Extends from hip joint to knee joint
 Consists of:
o Body (shaft)
o Proximal extremity
 Head
 Neck
 Greater & lesser trochanters
o Distal extremity
 Medial condyle
 Lateral condyle
 Articulates with:
o Acetabulum (superiorly)
o Tibia (inferiorly)

Greater trochanter
 Large rectangular projection from the junction of body & neck
 Provides for attachments of several muscles of the gluteal region
 Lies laterally to skin (palpable)
Body (shaft)
 Slightly bowed anteriorly, narrowest at midpoint
  Inferior to the neck: smooth body, Linea aspera
o Medial and lateral lips of Linea aspera
 Form medial and lateral supracondylar lines
Distal ends of femur
 Broadened for articulation with femur
 Medial and lateral condyles
 Broad posteriorly
 Blend anteriorly with each other
 Blend superiorly with body of the femur
 Separated by deep intercondylar notch
 Subcutaneous, palpable
Head of femur
 Smooth, forms 2/3 of a sphere
 Directed medially, superiorly and slightly anteriorly as to fit in the acetabulum
 Fovea capitus at the centre (Pit in the head)
 Teres attached at fovea ligamentum
Neck of femur
 Connects head to body at 125°
 Laterally limited y greater trochanter
 Narrowest in the middle
 Broad, rough interotrochanteric line runs inferomedially from greatest trochanter
 Interotrochanteric line is continuous with Linea aspera
o Produced by attachments of massice iliofemoral igament
o Interotrochanteric crest unites the two trochonters posteriorly
 Neck has several prominent pits (esp posteriorly) for entranceof blood vessels

The Leg
 Inferior part of lower limb between knee & ankle joints
 Tibia
o Shin bone
o Supports most of body weight
o Broad proximal end and flattened at the surface
 Give rise to medial and lateral tibial plateaus
 Articulates with condyles of femur superiorly
 Distal end articulates with talus of foot inferiorly
 & fibula
o Posterolateral to tibia
o Slender shaft has to weight bearing functions
o Provide sites for muscle attachments
o Allows tibia to withstand twisting & bending actions
o Neck : slightly constricted part of the body near the head
o Distal end: knob like appearance, constitutes lateral malleolus
o Medial surface of distal end
 Articulates with lateral side of tibia and talus

Bones of the foot

 Talus
 Calcaneous
 Navicular
 Cubid
 Cuneiform
  Metatarsals
o 5 bones
 Phalanges
o 14 bones

Arches of the foot

 Transverse arch
 Lateral part of longitudinal arch
 Medial part of longitudinal arch

L14- lower limb 2- musculofascial compartments

Function of the lower limb

 Rhythmical motor act
 Limb 1
o Extended to support weight of body
 Limb 2
o Flexed as the body is thrown forwards, taking a step
o Extended to take weight of the body, as it lands
 Repetition of cycle of limb extension and flexion

Functional classes of joints

 Articulation between bones at etiher
o Immovable joints
o Slightly movable joints
o Freely movable joints

Structural classes of joints

 Some bones articulate at either
o Fibrous joints
 Sutures
 Symphysis
 Syndesmosis
o Cartilaginous joints
 Primary (or synchondroses)
 Transitional cartilage stage followed by complete union
 Secondary (or symphyses)
 Retain fibrous tissue or fibrocartilage without ossification at the
joint
o Synovial joints
 6 varieties

Lower limb during standing:

 Hip + knee joints extended
 Both limbs undergo extension and there is no propulsion
 Knee and hip joints most stable when in full extension

Regions of the lower limb

 Hip
o Between iliac crest and greater trochanter of femur
 Thigh
 o Between the greater trochanter and knee
 Knee joint
o Between medial &lateral palpable landmarks
 Patellar
 Leg
o Below the knee and above the foot

Tissue layers of the Thigh are:

 The skin
 Superficial Fascia
 Deep Fascia (Fascia Lata vs Iliotibial Tract)
 Muscles (and membrane coverings)
 Femur (covered in periosteum)
 Intermuscular Septa
 Neurovascular bundle
 Lymph nodes

Muscular fascial compartments of the thigh

 Anterior
o Knee extensors
 Quadriceps
o Femoral nerve (L2, 3, 4)
o Femoral artery
 medial
o knee flexors & hip extensors
 hamstrings
o obturator nerve (L2, 3, 4)
o obturator artery
 posterior
o thigh adductors
 adductors
o sciatic nerve (L4, 5, S1, 2, 3)
o branches of profunda femoris

Knee joint
 femur, tibia and patella

Muscular compartments of the leg

 anterior
o muscles
 tibialis anterior
 extensor digitorum longus
 extensor hallucis longus
o actions
 dorsiflexion
 inversion
o nerve supply
 deep peroneal nerve
 lateral
o muscles
  peroneus (fibularis) longus
 peroneus (fibularis) brevis
 both supplied by superficial peroneal (fibular) nerve
o functions
 evert the foot
 plantar flexion
 posterior
o muscles
 superficial
 gastrocnemius (triceps surae)
 soleus (triceps surae)
 plantaris (triceps surae)
o share tendon of insertion: tendo alcaneous (archilles
tendon), strongest tendon in the body
 function
o plantar flex
 & deep group
 Popliteus
 Flexor halucis longus
 Tibialis posterior
 Flexor digitorum longus

Bones of the foot & arches

 Talus
 Calcaneous
 Navicular
 Cuboid
 Cuneiform
 Metatarsals (5 bones)
 Phalanges (14 bones)

Dorsiflexion of the foot

 Fibula division of sciatic nerve (L4-5)
 Muscles
o Tibialis anterior
 Extensor digitorum longus
 Extensor hallucis longus

Plantarflexion of the foot

 Tibial division of the sciatic nerve (S1-2)
 Muscles
o Gastrocnemius and soleus
 Tibialis posterior
 Flexor hallucis longus
 Flexor digitorum longus

Compartment syndrome
 Limb, life threating condition
 Perfusion pressure falls below tissue pressure in closed anatomical compartment
 Untreated= necrosis & death
  Can be found in any compartment
 Cause:
o Pressure in anatomical compartment is too high, exceeds capillary perfusion
pressure
o Due to :
 Decreased compartment size
 Increased fluid content
 Burns
 Haemorrhage
 Intra-arterial injection
 Treatment: fasciotomy

Pathophysiology of compartment syndrome

 Similar to ischaemic injury
 Pressure rises when volume decreases
 Compartments have fixed volume
 Excess fluid or extraneous constriction increases pressure
o Decreases tissue perfusion until no O2 is left for cellular metabolism
 Ischaemic muscle=toxic metabolites=pain

L15- Clinical application of spinal anatomy

The composition of spine

 Bone strength
Increased by Decreased by
Calcium intake Ageing
Exercise Tobacco
Sunshine Tippling
Moderate alcohol steroids

Intervertebral discs
 Shock absorber
 Nucleus pulposus
 Annulus fibrosus
 High osmotic pressure
 Dehydration and degeneration universal

Implications of Level of Neural Compression

 L5 and below - Impaired sphincter and sexual function Foot and ankle weakness
 L5- L2 - Progressively less likely to walk
 L1/2 - T1 – Can’t walk
 T1 - C5 - Lower the injury the better
o upper limb function
 Above C4 – Can’t Breathe

Myelopathy -Usually Cervical

 Consequence of pressure on spinal cord
 Weakness and sensory changes affecting Upper Limb>Lower Limb
 Broad based shuffling Gait
 Often accompanied by Upper Limb radiculopathy
 Increased Reflexes Extensor Plantars
  Rarely Urinary symptoms

Radiculitis and Radiculopathy

 Radiculitis - Root Pain (Sclerotomal)and tension
 Radiculopathy - Root dysfunction
 Subjective /Objective
 Sensory (Dermatomal)
 Motor ( Myotomal)
 Sphincter

Aspects of Spinal Vascular supply- Neural Principal Cord Blood Supply

1. Anterior spinal artery
2. 2 Posterior spinal arteries
3. Supplemented by segmental vessels
Vulnerable regions
 Upper thoracic T1-4
 Thoraco- Lumbar Junction

Spine disorders
Congenital Acquired
Deformity Infection
Degenerative Trauma
Neoplastic (tumour) inflammatory

Spinal balance
 Short term=muscle fatigue-> postural pain
 Long term= degenerative change-> mechanical pain

Origin of spine deformity

 Column buckling
 Kyphosis
 Lordosis with scoliosis

Physical signs of scoliosis

 Shoulder asymmetry
 Scapula prominence
 Waist asymmetry
 Hip prominence
 Visible curve
 Rib or lumbar hump becomes more prominent

Component abnormality
 Failure of formation
 Failure of segmentation

Neurally mediated spinal deformity

Upper motor neurone Lower motor neurone
Pulled over Fall over
 CPU abnormality Viral myelitis- polio
Cerebral palsy Spinal muscular atrophy
Cord abnormality trauma

‘Normal’ spinal degeneration

 Affects everyone
 Age on onset determined genetically and environmentally
 Analogous to hair greying
 All imaging modalities reflect this, particularly MRI
 Variably symptomatic

Root tension
 Sciatic nerve (L4-S2) straight leg raise
o back pain= Dural tension
o leg pain= root tension
 Femoral nerve (L2-4) femoral stretch test (FST)
o Lie prone flex knee and extend hip
o Back pain=Dural tension
o Leg pain= root tension

Characteristics of stenosis
 Insidious onset
 Age> 50yr
 Numb aching dysaethetic leg pain
 Pain by standing/ walking
 Relief by sitting, leaning forward
 Back pain
 Weakness and sphincter symptoms if severe

Spondylolysis
 Spondyl=vertebra
 Lysis= break
 Uni or bi lateral defect in the pars interarticularis
 Usually L3-L5, most common L5
 Fatigue fracture

Spondylolisthesis
 ‘slip of the vertebra’
1. Dysplastic
2. Isthmic
3. Degenerative
o Reduced AP diameter of central and lateral canal
o Traction and compression of root
4. Traumatic
5. Pathological

Neoplastic disease in the spine

 Primary and secondary tumours- anterior
 Weakness and alteration of pain and temp often precede loss of fine touch and
proprioception
 o Dissociated sensory loss

Spinal metastases neural compression

 Tumour compression- may respond to DXR (test for bone density) or chemo
 Pathological requires decompression and stabilisation
 Disc spaces normally preserved

Infection of the spine

 Child- discitis
o Immature circulation pattern of disc
 Adult- vertebral osteomyelitis or spondylodiscitis
o Usually involves 2 bodies adjacent to disc
 Disc often involved in pyogenic and TB infection

Rheumatoid arthritis of the spine

Cervical spine Lumbar spine
Atlanto-axial joint subluxation Relatively immune
Subaxial cervical spine- anaesthetic implications Ankylosing spondylitis
Whole spine involvement

L16- Nerves & Vessels of the Lower limb

The descending aorta

 Commences at the end of the aortic arch
 Continues down into the abdomen
 Biruficates into L/R common iliac arteries
 Two parts:
o Thoracic aorta
o Abdominal aorta

Thoracic aorta
 Commences at the eternal angle of Louis
o Thoracic plane
 Supplies arterial blood to:
o Muscles of the chest wall
o Spinal cord

Abdominal aorta
 Continues from the aortic hiatus of the diaphragm
 T12
 Biruficates into L/R common iliac arteries
o L4/5 intervertebral disc
o Supracistal plane of pelvis
o Vertebral level of umbilicus
o T19 dermatomal level
Anatomical landmarks for staging of Lower limb arterial tube
 Common iliac artery
o L3-4 intervertebral disc
o Umbilicus
o Supracristal plane
o Bifurcated into external iliac & internal iliac artery
 External iliac artery
o L5-S1 intervertebral disc
 Femoral artery
o Inguinal ligament
o Begins at the lower border of the inguinal ligament
o Passes inguinal ligament at its mid-point
o Ends at the apex of the femoral triangle
o Ends by entering the adductor canal
o Pulse palpated at mid-inguinal line
 Popliteal artery
o Adductor canal
o Starts at the opening of adductor canal and ends at the adductor hiatus
 Tibial artery
o Adductor hiatus
 Anterior tibial arteries
o Lower border of polipteus
o Pulse palpated at dorsalis pedis (above the navicular bone or medial to the
tendon of extensor hallucis longus)
  posterior tibial arteries
o Larger of the terminal branches
o Descends deep to soleus, becomes superficial in the lower third of the leg
o Passes behind the medial malleolus between tendons of the FDL & FHL
o Divides into medial & lateral plantar arteries
 Principle blood supply to the foot
 Dorsalis pedis (anterior tibial artery)

Classes of veins
 Superficial veins
 Deep veins
 Perforating veins
 Accompanying veins
o Vaso vasorum
 Accompany veins
o Venue commitante
 Accompany arteries
 Venous blood flows from superficial to deep veins via perforating veins

Great vs short saphenous vein

Great saphenous vein Small saphenous vein

 Longest vein in the body

 Drains medial part of the venous plexus  Drains the lateral side of the venous
of the foot plexus of the foot

 Begins in medial marginal vein of the  Begins behind lateral malleolus

foot

 Ends in femoral vein  Perforates the deep fascia in the

popliteal fossa to End in popliteal vein
between heads of Gastrocnemius
 Ascends in front of medial malleolus  First ascends along lateral margin of
 Ascends along medial side of leg tendo clacaneous
 Ascend sin relation to the saphenous  Then crosses it obliquely to reach
nerve middle back of leg

 Has 10-20 valves  Before piercing deep fascia, it gives a

 Has more valves in leg that in thigh branch that runs upwards and forwards
to join the Great Saphenous Vein

Nerve Supply to The Lower Limb

• The Lower Limb Also Receives all its Nerve Supply from The Spinal Cord
• It is supplied from the Lumbar and Sacral Spinal Segments (L1-S4)
• Spinal Nerves to the Lower Limb originate from two separate Networks of nerves
o The Lumbar Plexus (L1-L4)
o Sacral Plexus (L4-S4)

The Lumbar Plexus

• It forms behind within the psoas major muscle
 • Nerves emerge either medial or lateral to the borders of the psoas
• Nerves emerging lateral to psoas
o The femoral
o liohypogastric
o Ilioinguinal
o Lateral cutaneous nerve of the thigh
• Nerves emerging medial to psoas
o The obturator nerve
o The lumbosacral trunk

The Sacral Plexus Composed of:

• Lumbosacral trunk
• Sacral spinal segmental outflow
• Plexus forms within the pelvic cavity
• Plexus lies in relation to piriformis
• It supplies nerves to:
o Pelvic region
o Gluteal region
o Perineal region
o The lower limb (via the sciatic nerve)

The Sciatic Nerve

• It is the principal nerve of the sacral plexus
• Enters the thigh between the ischial tuberosity and greater trochanter
• Intramuscular Injections in RUQ to avoid sciatic nerve
• It is composed of
o A pre-axial nerve (Tibial)
o A post-axial nerve (Common Peroneal)
• These nerves are covered in the same sheath
• Its root values are L4-S4
• Emerges through the greater foramen together with
o Inferior gluteal artery
 o Inferior gluteal nerve
• Always emerges in relation to piriformis muscle
Piriformis syndrome
• results from compression of the sciatic nerve around the piriformis muscle
• If the sciatic nerve undergoes a spasm= nerve compression
• a variant of pyriformis syndrome
• Symptoms: pain and numbness in the buttocks and down the leg.
o Often symptoms are worsened with sitting or running
• Causes: trauma to the gluteal muscle, spasms of the piriformis muscle, anatomical variation,
or an overuse injury

L17- lower limb trauma

Energy+anatomy=injury=consequences
Anatomical
• Fracture
• Dislocation
• Soft tissue injury

Physiological
• Bleeding+shock
• Coagulopathy
• Multiple organ failure

Pelvic fractures
• High energy=strong bone+ligament injury
• Anatomical
o Pubic rami fractures
o Sacro-iliac dislocation
o Urethral injury
• Physiological
o As above

Polo mint theory

• In hip fractures, likely to have posterior AND anterior fractures
o Difficult to only fracture 1 site
o Bones dependent on each other

Ligaments of the pelvis

• Anterior ligaments
o Pubic symphysis
 Superior pubic ligament
 Arcuate ligament
• Secondary ligaments
o Iliolumbar
o sacrospinous
o Sacrotuberous
 Main function=control sagittal tilt of spine
 Stabilise the pelvis
• Posterior ligaments
o Sacroiliac joint
  Anterior sacroiliac ligament
 Interosseous sacroiliac ligament
 Posterior sacroiliac ligament

Antero-posterior compression (APC)

• ‘open book pelvis injury’
• Haemorrhage
o Pelvic floor under tension
 Pelvic floor torn
o Arterial, venous and broke bone surfaces
o Major vascular structures
o Fragile vesical plexus of veins

Embolization
• Without replacement, bleeding 20ml/min for 2hrs is lethal

Hip fractures
• Fractured neck of the femur
o Intrascapular (majority), trochanteric, subtrochanteric
o NOT acetabular / femoral head fractures
• Cause
o Low fall <2m, weak bone due to osteoporosis
o Older age
• Anatomical Consequences
o Fracture
o Need surgery to restore mobility
• Physiological consequences
o Typical frail patients
o Multiple comorbidities
o What caused the fall?
 Heart conditions, arrythmia, stroke, hypothermia, pressure sores
• High mortality
• Presentation
o Shortened and externally rotated limb
o Axis of rotation changes
o Profile of lesser trochanter is an important clue
 lesser trochanter looks more prominent in external rotation

Femoral head blood supply

• lateral circumflex femoral artery (anterior)
• medial circumflex femoral artery (posterior)
• retinacular vessels (posterior)
o blood vessels would be damaged in fracture
o avascular necrosis occurs
 SCLEROTIC FEMORAL HEAD, subchondral collapse, acetabulum damage
 Bone healing depends of stability+blood supply

Treatment of displaced fractures

• Hemiarthroplasty=half hip replacement
• Trochanteric fractures
o Most likely will heal
 o Usually fixed internally
o Blood supply rarely an issue
• Subtrochanteric fractures
o High energy mechanism
o Blood supply rarely an issue
o Surgery: intramedullary nailing of femur

Joint stability
• Hip is the most stable synovial joint relative to its motion
• Knee has relative lack of intrinsic bony stability
o No socket->unstable->made up by ligaments (anterior+posterior cruciate
ligaments)
o Popliteal artery is vulnerable is knee dislocation
 Integral tear of artery
 Vascular repair

L18-Control of muscle length

There are three types of movement:

• Involuntary or Reflex (simplest)
• Voluntary (most complex)
• Rhythmic (a combination of reflex and voluntary) All require muscle contraction - eg
diaphragm.

Centre of gravity
• Our centre of gravity moves with unconscious (reflex) change in posture or with
voluntary, goal-directed, movement - but must remain within the area bounded by our
feet - if we are to avoid falling.

Our postural muscles need:

• to maintain tone in order to stay in a constant state of partial contraction - and thus
counteract gravity:
• corrective reflexes to maintain stability and position
• A role for receptors and somatic reflexes

Sensory input
• Visual system + Vestibular system
 o Vestibulo-ocular reflex and optokinetic reflex
• Skin receptors + proprioceptors
o Somatic sensation ‘somesthesia’

Muscle spindles
• in parallel with muscle fibres. Undergo same length change as muscle
• and Golgi Tendon Organs - in series with muscle fibres
• Proprioceptors are sensory receptors found in muscle that are important for reflex control of
muscle length and tension

Somatic Motor Reflexes

• are stereotypic movements elicited by specific sensory stimuli
• Characteristic somatotopic organisation and large dendritic tree

The Muscle Spindle

• Intrafusal fibres lying in parallel within the extrafusal muscle fibres.
• Greatest density in small muscles serving fine movement and also in deep muscles of the
neck.
• Innervated by sensory and motor nerves
• Muscle spindles detect dynamic and static changes in muscle length
o essential for detection of muscle length and rate of change of length
• central region:
o Specialised non-contractile fibres Primary and secondary sensory afferent (sensory)
endings
• polar regions:
o Innervated by Gamma γ motor neurones Does not contribute to overall force
Adjusts sensitivity of spindle

Afferent innervation of the muscle spindle

• Secondary afferents:
o Innervate ends of central region and respond to static length
• Primary afferents:
o Innervate central region and respond primarily to velocity of lengthening
Role of gamma (γ) efferents
• passive stretch activates gamma efferents and can initiate corrective reflex
• If alpha motor axons activated (without firing of gamma efferents ) the spindle loses activity
when the muscle contracts

Alpha-gamma co-activation
• maintains spindle function when muscle contracts Alpha- gamma co-activation
• In mammals alpha and gamma motor neurons are activated independently.
o Even dynamic and static gamma neurons are innervated separately and
independently.
Golgi tendon organs (GTO)
• are sensory stretch receptors that are found in tendons near junctions with muscle fibres
and respond to tension changes in the muscle.
• They are innervated by myelinated, Ib fibres
• Ib fibres go to ventral horn and activate interneurons which inhibit (glycinergic) alpha motor
neurons (ie opposite of muscle spindle effect) but with a higher threshold than for muscle
spindle
• Stimulation of Golgi sensory neuron fibres thus causes a reflex inhibition in the efferent
signal to skeletal muscle and thus there is a loss in contraction strength.

Golgi Tendon Organ:

• response to load and overload Initially believed to prevent overstretching of muscle (‘clasp-
knife’ reflex)
• but now believed to assist in the fine control of muscle length playing a role in the
maintenance of posture.
o eg fatigue reduces force in muscle
 GTO inhibition reduced
 force in muscle increased
 L19- Musculoskeletal Embryology

1. implantation of blastocyst (6 days)

2. bilaminar germ disc
3. gastrulation
4. trilaminar germ disc
a. ectoderm, mesoderm, endoderm
b. On each side, mesoderm divides into:
i. Paraxial mesoderm
ii. Intermediate mesoderm
iii. Lateral plate mesoderm
5. Formation of notochord
a. Notochord forms in midline
b. Earliest axial support (later replaced by vertebrae)
6. Neurulation
7. Bones and muscles of the trunk develop from somites

8. Development of spine
9. Vertebrae replace notochord
a. HOX genes control vertebral differentiation
10. Development of trunk muscles
11. Development of limb muscles
a. Muscle primordia may fuse and split - but retain original nerve supply
b. On the inside:
i. Limb ‘bones’ appear as branching rod of mesenchyme
ii. Cartilage models form
iii. Ossification begins in embryo (week 8)
iv. Epiphyseal/growth plate stays open until bone is fully grown
c. On the outside:
 i. Limb bud forms: mesoderm core inside ectoderm
ii. Hand and foot plates appear
iii. Digits separate
12. Development of skull
a. Derives from mesoderm and neural crest
b. Ossifies by both intramembranous and endochondral ossification
c. Fusion of sutures overtime

Congenital malformations
• Neural Tube Defects
o Abnormal neural tube closure causes defects such as spina bifida & anencephaly
o Neural tube defects vary in severity and region affected
o Folic acid taken during pregnancy significantly reduces risks of NTDs

Limb defects
• Phocomelia - thalidomide prescribed as anti-nausea drug during pregnancy in 1950s and 60s
- over 10,000 babies born with limb defects
• Syndactyly - fused fingers or toes
• Polydactyly - extra digits
• Clinodactyly - bent digit - especially little finger
• Club foot - inverted feet

L20- Spinal trauma

Terminology
 Radiculopathy- root injury
 Myelopathy- cord injury
 Quadriplegia- loss of function in upper and lower limbs
 Paraplegia- loss of function of lower limbs
 Paraparesis- weakness due to cord or root compression

Implications of neural compression

 Above C4- loss of ventilation
 C5- quadriplegia
 C5-T1- decreasing arm function
 T1-L1- paraplegia
 L2-L5- decreasing leg function
 L5 and below- impaired sphincter and sexual function
o Foot and ankle weakness

Cervical & thoracic cord compression

 Spastic paresis/ paralysis
 Increased tone and clonus
 Brisk reflexes
 Extensor plantar response
 Retention, overflow and automatic bladder

Conus compression (T12-L1)

 Flaccid paresis/paralysis
 Absent reflexes
 Absent plantar response
  Autonomous neurogenic bladder
 Impotence

Cauda equina & compression below L1

 Radicular weakness
 Muscle wasting & fasciculation
 Decreased tone & loss of reflexes
 Autonomous dribbling bladder
 Impotence

Initial assessment of spinal trauma

 ATLS protocol
 Airway and C-spine control
 Breathing
 Circulation (hypovolaemic vs neurogenic shock)

Increased suspicion
 Mechanism of injury
 Blunt trauma above the clavicle
 Facial fractures
 Altered consiousness
 Ankylosing spondylitis

Suspect SCI
 Flaccid areflexia
 Loss of anal tone
 Priapism
 Spinal shock and the bulbo cavernosus reflex

Clearing the C spine

 Alert patient
o No tenderness, full ROM- no x-rays needed
o Pain & reduced ROM- C spine series
 Normal x-ray, low index of suspicion- observe
 Normal x-ray, high energy, focal pain, loss of movement- CT/ MRI
 Non-cooperative patient
o All have C spine series
o If normal- retain collar until cooperative or MRI

Systematic appraoch
 Adequacy and alignment
 Body abnomality
 Contours and cartilage
 Disc spaces

Mechanism and type of injury

 Wedge compression
o Usually stable
o Anterior column fails
o Potentially unstable
 50% loss of height
  30 degree kyphosis
 Flexion/distraction
o Chance/ seatbelt fracture
o Unstable injury
o Facet joint dislocation
o Reduction and surgical fusion
 Burst
o Unstable
o Anterior and middle column involvement
o Need to assess poserior ligamentous complex
o Usually requires surgery
 Fracture/ dislocation
o Very unstable
o Needs surgical stabilisation
o Can have rotation/ rotation+sheer

Spinal cord injury

 Primary injury
o Contusion
o Compression
o Traction
o Shear
 Secondary injury
o Hypotension
o Hypoxia
o Oedema
o Ischaemia

Resuscitation
 50% polytrauma
 Often hypovolarmic
 May have neurogenic shock
o Not volume depleted, vasodilated
o Treat with vasopressors
o Bradycardic due to unopposed vagal activity
 Use of steroids in controversial
o Need to use huge doses
o No proven benefit

Treatment
 Primary immobilizaion
 Assessment of stability
 Assessment of neurologial compromise
 Long-term rehabilitation

Surgical aims
 Provide stability
 Decompress the spinal cord
 Optimize the spinal cord for potential novel therapies
Timing of surgery
  Options
o Immediate
o Within a few hours
o Within 24 hours
 Considerations
o Deteriorating neurology
o Stable neurology
o Mechanical stability

Prognosis
 Highest mortality in first two weeks
 Complete lesions may recoer one to two levels
o No motor or sensory function in the anal and perineal region
 80-90% patients with incomplete lesion recover to grade 4/5 power if they have some power
in the root post injury

L21- Gait

Structured clinical observation of gait

 Overall gait dynamics- the gait cycle
 Ankle and foot position and motion
o Pronation
o Neutral
o Supination
 Knee position and motion
 Hip position and motion
 Pelvic position and rotation
 Head and trunk position and movement
 Arm swing

Gait patterns
Normal: age related, +FH Abnormal
Bowleg: toddler (1-2yr) Antalgic: pain
Toe walking: 1-3 yr Circumduction: LLD
Pes planus: 1-6 yr Stiff hip
Spasticity/ scissoring:
neurological

Development of gait
Gross motor Fine motor Speech Social
6 months Roll Hand transfer Babble Laugh
9 months Sit Pincer grip Dada, mama Stranger aware
12 months Walk Stacking Expressive Waves bye
18 months Walk & pick up Tower: 3 blocks Names body Interactive
parts games
2 years Jump Tower: 6 blocks 3 word phrase Temper tantrums
3 years Hop Block bridge Questions Interactive play

The gait laboratory

 1. Computer-assisted gait analysis
2. Force platforms
3. Pressure sensors

Rapid clinical gait analysis

1. Is there pain?
2. Is there symmetry?
a. Which side takes the most weight
b. Is there compensation?
3. Is there scissoring or waddling (muscle tone/ strength)
4. Is there a wide base? (Imbalance)
5. Is it bizzare? (Psychosomatic)
6. Is there a wheelchair/ walking aids?

Age related bone and joint diagnosis

Infant and toddler Child Adolescent
DDH Reactive arthritis SUFE
Congenital limb disorders Perthes Osteochondritis dissecans
Non-accidental injury Osgood-Schalatters (knee) Stress fractures
Septic arthriti Severs (heel) Kohler (navic) Overuse syndromes
Foreign body Tarsal coalition Bony tumours

Physical examination to assess limping

 Muscoloskeletal system
o Gentle explanation, pain enquiry
o Inspection: symmetry
o Begin at feet
 Interphalangeal joints
 Metatarsophalangeal joints
 Midtarsal joints
 Subtalar joints
 Ankle joints
 Entheses
o Knees: tenderness, range, stability
o Hips internal rotation at 90 degrees flexion
o Upper limbs
 Extra-articular sytemic exam
o Growth
o Vital signs (Bp and urinalysis)
o Skin
o Muscle strength
o Tremor and dyspraxia
o Peripheral neurology
o Peripheral pulses
o Abdominal examination
 Appendicitis
 Intusseception
 Psoas abscess