Block 2: foot, deltoscapular region, axilla, brachial plexus, UE, thoracic wall & lungs, heart

hindfoot

talus & calcaneus

midfoot

tarsal bones (navicular, cuboid, cuneiforms)

forefoot

metatarsals & pahalanges

skin on the ___ surface of the foot is thin & less sensitive; subcutaneous tissue is ___ (especially around med malleolus)

dorsal; loose

skin on the ___ surface of the foot is thick; subcutaneous tissue has ___ & ___ ___ (shock absorption)

plantar; ligaments; fat pads

plantar aponeurosis

thick, longitudinal, central part of plantar fascia; strong bundles of dence fibrous CT; spans from calcaneus to digits; protects central compartment of foot from compression by maintaining longitudinal arch

plantar fascitis

inflammation of plantar fascia/aponeurosis due to overuse, running & high-impact aerobics; common in runners; point tenderness at med tubercle of calcaneus (origin) → med foot pain & bursa development

1st layer of plantar of food

abd hallucis, flex digitorum brevis, abd digiti minimi

2nd layer of plantar of foot

lumbricals (under MTP joints), quadratus plantae, tendon of flex digitorum longus

3rd layer of plantar of foot

flex hallucis brevis, add hallucis, flex digiti minimi

4th layer of plantar of foot

dorsal & plantar interossei, tendons of fibularis longus & tibialis post

the two (transverse & oblique) heads of ___ ___ & ___ ___ form a “7” shape

add hallucis & add pollux

PADs & DABs rule

interossei muscles in the foot & hands act to add (plantar/palmar) or abd (dorsal) digits 2-4 to/away from the 2nd digit

DABs interossei of the foot are ___ & PADs are ___

bipennate; unipennate

tarsal tunnel borders

sup: talar tubercles

med: flexor retinaculum

lat: med calcaneus

inf: abd hallucis

tarsal tunnel contents

tibialis post, flex digitorum longus, post tibial a., post tibial v., & tibial n.

tibial n. bifurcates into the larger ___ plantar n. & post ___ plantar n. in the tarsal tunnel

med; lat

porta pedis

space b/n abd hallucis & calcaneus thwere med & lat plantar nerves enter the foot from the tarsal tunnel

tarsal tunnel syndrome

entrapment of tibial n.; insidious onset of burning, aching pain from post heel to mid-tarsal zone → decr sensation of plantar foot, arch, heel; worse at night & aggravated by WB

med plantar n.

branch of tibial n.

motor: abd hallucis, flex hallucis brevis, flex digitorum brevis, 1st lumbrical

cutaneous: skin, nail beds, & tips of med 3.5 digits

lat plantar n.

branch of tibial n.

motor: all intrinsic plantar muscles not innervated by med plantar n.

cutaneous: skin, nail bed, & tips of lat 1.5 digits

med calcaneal n.

branch of tibial n.

cutaneous: skin of calcaneal region

deep fibular n.

motor: dorsal muscles of the foot

cutaneous: web of skin b/n digits 1-2

superf fibular n.

cutaneous: skin of dorsum of foot except web b/n digits 1-2

dorsalis pedis a.

from ant tibial a. → arcuate a. → dorsum of foot & toes → deep plantar a. → formation of deep plantar arch

plantar arteries

from post tibial a. → smaller med & larger lat plantar arteries → plantar of foot

pulsations of ant tibial a. can be felt b/n the tendons of ___ ___ ___ & ___ ___

ext hallucis longus; ext digitorum

pulsations of post tibial a. can be felt behind ___ ___, post to tendon of ___ ___ ___

med malleolus; flex digitorum longus

pulsations of dorsalis pedis a. can be felt w/ slightly DF feet along a long from the ___ ___ to just lat to tendon of __ ___ ___

ext retinaculum; ext hallucis longus

5 signs of acute arterial occlusion/arterial disease

pain, pallor, parasthesia, paralysis, pulselessness

keystone of med longitudinal arch

talar head

transverse arch curvature is maintained by the crossing of tendons ___ ___ & ___ ___ under the sole of the foot

tibialis post; fibularis longus

transmission of BW in the foot as the elastic arches flatten

tibia → talus → calcaneus → ball of foot/sesamoids of 1st digit & metatarsal head of 2nd digit

med longitudinal arch is supported by ___ ___ as it PF & foot IV

tibialis post (tendon dysfunction → arch collapse, pain, swelling, difficult to stand on toes)

talocrural joint

hinge joint from distal tibia & fibula against talus body→ DF/PF; WB on trochlear surfaces of tibia & talus, stabilized by lat & med malleoli

med/deltoid ligament of talocrural joint

tibionavicular, tibiocalcaneal, ant & post tibiotalar ligaments; prevent over-EV of foot & help maintain med longitudinal arch

lat ligaments of talocrural joint

calcaneofibular, ant & post talofibular ligaments; resist foot IV; common torn during IV injury/akle sprain bc not as strong as deltoid ligament

Pott’s fracture

distal fracture of fibula common w/ severe ankle sprains

subtalar joint

saddle joint from talus to calcaneus; allows foot IV/EV

spring/calcaneonavicular ligament

supports talar head & helps transfer weight; helps maintain longitudinal arch

long plantar ligament

from plantar surface of calcaneus to groove on the cuboid & bases of metatarsals; form tunnel for tendon of fibularis longus; maintain longitudinal arch

short plantar/calcaneocuboid ligament

from ant-inf surface of calcaneus to inf of cuboid; b/n spring/calcaneonavicular & long plantar ligaments; maintains longitudinal arch

quadrangular space contents

axillary n, post circumflex humeral a. & v.

triangular space contents

circumflex scapular a. & v.

triangular interval contents

radial n., deep a. of arm

ant compartment of brachium/arm

flexor muscles: biceps brachii, coracobrachialis, brachialis

motor innervated by musculocutaneous n.

the ___ is the most mobile joint in the body → unstable, great ROM, many accompanying muscles, tendons, ligaments, labrum, capsule

shoulder

clavicle

collarbone; 1st bone to begin ossification during 7th week of development; absorbs force from fall on outstretched hand (FOOSH) → fracture; dislocation can involved hemorrhage of subclavian v.

cleidocranial dystosis

defective or absent clavicle → hypermobile shoulders; growth plate visible until 25 years

EX: gaten matarazzo

greenstick fracture

bone bends & cracks instead of complete break into 2 pieces

EX: midshaft of clavicle (80% of kids), lat clavicle (15% of kids), med clavicle (5% of kids)

sup transverse scapular l.

calcifies & separates the suprascapular a. & n.

army (a.) over the bridge & navy (n.) under the bridge

suprascapular neuropathy

atrophy of supraspinatus/infraspinatus due to suprascapular n. pathology

prox humeral fractures account for ___% of all fractures, commonly in older, osteoporotic pts due to FOOSH or high-energy trauma

5

fracture at humeral anatomical neck can cause ___ ___ of the head

avascular necrosis

fracture at the humeral surgical neck can cause injury to…

axillary n., post humeral circumflex a. (quadrangular space)

fracture at the humeral shaft can cause injury to…

radial n., profunda brachii a. (triangular interval)

fracture at the supracondylar region of the humerus can cause injury to ___ a. & ___ n.

brachial a.; median n.

fracture at the med epicondyle of the humerus can cause injury to ___ n.

ulnar n.

sternoclavicular (SC) joint

double synovial planar joint; allows scapular movement

acromioclavicular (AC) joint

planar joint; allows gliding during scapular rotation; reinforced by acromioclavicular & coracoclavicular ligaments

shoulder separatiion

shoulder separation from clavicle; FOOSH → coracoclavicular l. rupture → pain & tenderness over AC joint, limited shoulder mobility, sulcus sign

ST joint elevators

upper traps, levator scapulae, rhomboids

ST joint depressors

lower traps, pec minor

ST joint protractors/abd

serratus ant, pec minor

ST joint retractors/add

middle traps, rhomboids

ST joint upward rotators

traps, serratus ant

ST joint downward rotators

rhomboids, levator scapulae, serratus ant

long thoracic nerve palsy

in 30% of mastectomies & axilla dissection OR middle scalene compresses the n. → scapula winging & joint disarticulation

glenohumeral (GH) joint

innervated by axillary, suprascapular, & lat pectoral nerves; vascularized by suprascapular, ant & post humeral circumflex, & scapular circumflex arteries; most mobile & least stable joint

glenoid labrum

deepends glenoid fossa of scapular by ~50%; tears from overhead activities → popping clicking, catching sensations, shoulder weakness, limited ROM

sup GH l.

checks shoulder add; checks humeral inf & ant glide

mid GH l.

checks shoulder ER; checks humeral ant glide

inf GH l. ant band

checks shoulder abd & ER; IGHL is most important for ant dislocation

inf GH l. post band

checks shoulder abd & IR; IGHL is most important for ant dislocation

SLAP tear

tear of sup labrum → compromised shoulder stability

rotator cuff injury s/s

pain, shoulder instability, limited ROM, commonly at supraspinatus

subacromial bursitis

calcification of supraspinatus tendinitis → inflammation of subacromial bursa → painfaul abd arc

0-15 degrees of GH abd movers

initiated by supraspinatus

15-110 degrees of GH abd movers

deltoid & supraspinatus

110-180 degrees of GH abd movers

traps & serratus ant for upward scapular rotation

scaplar anastomosis

branches of 1st part of subclavian a. & 3rd part of axillary a. linked around body of scapula (branches suprascapular, circumflex scapular, & deep transverse cervical a.) & over acromion process (acromial branches of thoracoacromial, suprascapular, & post circumflex humeral a.); ensure adequate circulation to UE

development of UE begins rotating ___ & the LE begins rotating ___

lat (ant = ventral); med (ant = dorsal)

brachial plexus

C5-T1 ventral primary rami nerve roots → MARMU branches that innervate the UE

dermatomes are ___ of skin innervation & cutaneous innervations are ___

strips; patches

axilla

contains brachial plexus branches, axillary a. & v., lymph nodes

Erb’s point

initial combination of C5 & C6 roots → upper trunk of brachial plexus → branches innervates shoulder & arm

Erb-Duchenne Palsy/upper brachial palsy

shoulder dystocia birthing trauma → stretched neck & nerves/lesions of axillary, suprascapular, and musculocutaneous nerves → paralysis of shoulder & ant arm muscle → “waiter’s tip” hand (shoulder add, arm IR, elbow ext, forearm prone)

Klumpke Palsy/lower brachial palsy

sudden pull of UE → stretch/tear of inf brachial plexus (C8-T1) → ulnar n. & median n. lesions → hand clawing & ape hand, PAM

PAM

Horner syndrome sympathetics associated with Klumpke palsy; ptosis, anhydrosis, miosis

ansa pectoralis

origin of thoracoacromial a. where med & lat pectoral nerves communicat

axillary n. injury

possible surgical neck fracture or dislaction of humerus → sensory loss of deltoid (silver dollar pain) & incomplete shoulder abd

radial n.

largest branch of brachial plexus; most frequently injured branch of brachial plexus; injury → wrist drop/saturday night palsy

motor: all extensors of UE

cutaneous: dorsal-med hand & half of digits 1-2.5

median n.

CTS injury → ape hand/loss of opposition & thenar atrophy OR benediction hand → pt can’t make fist when asked (DYNAMIC test)

motor: flexors of forearm & hand

cutaneous: palmar-lat hand & tips of digits 1-2.5

CTS contents

forearm rigid tunnel to hands & fingers; contains 9 tendons & median n.

ulnar n. injury

atrophy of hypothenar muscles, digits 4-5 flexed; STATIC observation where prox phalanges can’t flex & mid-distal phalanges can’t extend (ulnar claw hand)

thoracic outlet syndrome

numbness/tingling in fingers; pain in shoulder & neck; ache in arm or hand; thenar muscle atrophy; weakening grip’ poot hand/forearm circulation

elbow joint

modified/loose hinge joint formed by ulna on humerus; pivot radioulnar joint

cubital fossa

triangle site of venipuncture formed by med cubital/basilic v. (med), cephalic v. (lat), elbow crease (sup)

contents: biceps brachii tendon, brachial a., median n.