Week 6, Monday

Anterior and Medial Thigh ppt

Boundaries of the Thigh: Hip joint, Greater Trochanter, and Knee Joint

Important Landmarks on the Pelvis: ASIS, Inguinal Ligament, AIISGreater Trochanter, Pubic Tubercle

Important Landmarks on Femur: Greater Trochanter, Lateral Epicondyle, adductor tubercle, medial epicondyle

Patella: Base, Apex

Lumbar plexus: a network of vertebral rami L1-L4 nerves

• 50% of people have Subcostal Nerve of T12

• All 5 receive gray Rami communicates from the sympathetic trunk

• L1 splits into: Iliohypogastric nerve and ilioinguinal nerve

• L1/L2 : Genitofemoral nerve- deep to the PSOAS minor, emerges from the anterior side of PSOAS major and splits into femoral branch and genital branch

• L2/L3: Lateral femoral cutaneous nerve

• L2-L4: Obturator Nerve

• L2-L4: Femoral nerve

• Cutaneous Nerves of the Thigh/Leg:

  • Anterior Femoral cutaneous and Saphenous nerves are branches off the femoral nerve

Dermatomes:

• Anterior Femoral cutaneous from L2,L3, L4

Fascia of the Thigh:

• Superficial (tela subcutanea)

  • Underlies the dermis no contains variable amounts of fat, cutaneous nerves, and superficial blood vessels

• Deep (Fascia Lata)

  • Lies between superficial fascia and the muscles

  • Wraps the muscles as if it were a stocking

Know which veins each vein drains into

Attachments of the deep fascia:

• posterior: Ischial tuberosity, sacrotuberous ligament, posterior surface of the coccyx and sacrum

• Posterolateral: external lip of iliac crest

• Anterior: inguinal ligament, the margin of the pubic arc, pubic tubercle, and the body of the pubis; continuous with the fascia of the lower anterior abdominal wall

• Inferior: All exposed bony points of the knee (e.g. condyles); continuous with the crural fascia

• Take note of the fiber direction!!!

Deep fascia (Fascia Lata):

• The lateral aspect forms the iliotibial tract (IT band) which runs from the tubercle of the iliac crest to the lateral condyle of the tibia (Gerdy’s Tubercle)

• The ITB receives tendinous reinforcements form the tensor fascia latae and the gluteus maximus

• ITB stabilizes the knee and prevents translation of the femur on the tibia

Anterior compartment of the thigh:

• flex the hip and extend the knee joint

• Femoral nerve (L2, L3, L4)

Posterior Compartment of the thigh:

• Flex the knee and extend the hip

• Sciatic Nerve (L4-S3)

Medial Compartment of the thigh:

• Adduct and help flex the hip

• Obturator Nerve (L2, L3, L4)

Arteries of the thigh:

• Abdominal Aorta

• Bificates into left and right common iliac arteries

  • Common iliac

  • Internal iliac

  • External iliac

• Femoral Artery

• Profunda Femoris Artery (CHIEF ARTERY (main blood supplier) of the thigh)

• To Deep femoral

• Femoral aka superficial femoral

• Lateral and medial circumflex femoral arteries off profunda femoris

• Descending genicular

Veins that travel with the Arteries usually have the same name, other than Saphenous

Superficial veins: found inside femoral sheath (allows veins and arteries to slide passed Inguinal ligament without friction)

• Great Saphenous

• Saphenous hiatus (deficit in the fascia Lata where the great Saphenous vein empties into the femoral vein)

Femoral Triangle:

• Base: Inguinal ligament

• Lateral: sartorius (longest muscle in body)

• Medial: adductor longus

• Apex where Sartorius cross adductor longus

• Roof: fascia Lata

• Floor: Iliacus muscle, Psoas major muscle, and Pectineus muscle

  • Iliacus and Psoas major look combined distal to the Inguinal ligament, often called Iliopsoas.

Contents of Femoral triangle:

• profunda femoris and its branches (lateral and medial circumflex femoral arteries)

• Sartorius, rectus femoris

• Femoral nerve and its branches

• Lateral femoral cutaneous nerve supplies the skin on the later side

• Superficial circumflex iliac artery

• Genitofemoal nerve

• Lymphatic vessels

• Inguinal lymph nodes

People with large bellies and pregnant women have Pressure on the lateral femoral cutaneous nerve, which causes numbness and tingling on the lateral thigh

Nerve to Vastus Medialis: travels in the bundle with Saphenous nerve and profunda femoris

Femoral Sheath: a fascial tube that encases the proximal part so the the femoral artery and vein BUT NOT THE FEMORAL NERVE

• subdivided into 3 compartments:

  • Lateral (Femoral Artery)

  • Intermediate (Femoral Vein)

  • Medial (Forms Femoral Canal)

• Allows femoral vessels to glide pas the inguinal ligament during movements of the hip

Femoral Canal:

• allows the femoral vein to expand during increased venous return from lower extremity

• Superior end (femoral ring) is closed by extraperitoneal fat, which is very weak

• Site of Femoral hernias (more Common in men)

Lacunar ligament: inferomedial edge of the femoral canal

• can strangulate a bowel there, and could kill you in 24 hours

Deep Femoral region:

• iliac artery and vein

• Femoral artery and vein

• Femoral nerve

• Obturator nerve

• Nerve to Vastus medialis

• Saphenous nerve

• Adductor canal (aka. Subsartorial or Hunter’s canal): leads to the adductor hiatus for the femoral artery and vein to travel posterior

  • The Saphenous nerve DOES NOT travel through the Adductor Hiatus. It enters the canal, but pierces the medial wall of the adductor canal, to continue down the lateral leg.

LEARN THE O, I, N, ACT, AND ART OF EACH OTHER MUSCLES!!!!!

Iliopsoas group: all hip flexers (flexion of the thigh at the hip)

• Iliacus

• Psoas major

• Psoas minor (weak flexor)

Anterior femoral group:

• Sartorius

  • Forms a muscular tripod: with the gracious and the semitendinosus.

    • They all have a distal attachments

    • Pes ansurinus complex

• Quadriceps Femoris: all innervated by L2, L3, L4. All extend the knee, all form the quadriceps tendon where they meet

  • Rectus femoris: has to heads:

    • straight head- Anterior inferior iliac spine

    • reflected head- rim of acetabulum

    • Both extend knee, but also initiates flexion of the thigh through origin on ilium

  • Vastus medialis (weakness of this will allow the patella to track laterally during knee extension resulting in a bony contact with the lateral femoral condyle)

  • Vastus lateralis: Origin= greater trochanter and lateral lip of the Linea Aspera

  • Vastus intermedius: eep to Rectus femoris

• Articularis Genu:

  • Deep to Vastus intermedius and may blend with it

  • Pulls the synovial capsule of the knee out of the way so it doesn’t get pinched between patella and femur during extension

Knee Disorders:

• Jumper’s Knee: Quadriceps or patella tendonitis

  • Max tenderness is at the Apex of the patella

• Iliotibial Band Syndrome: weak hip abductors on the involved side

• Osgood-Schlage’s Syndrome: repetitive strain on the secondary ossification center f the Tibial tuberosity

Bursae of the knee:

• Subcutaneuous prepaterllar bursa:

  • Housemaid’s knee

  • Caused by working on hands and knee without using knee pad

• Subcutaneous intrapatellar bursa:

  • Clergyman’s/Capet layer’s knee

  • Related to frequent kneeling with upright trunk

  • Common in carpet layers, roofers, and floor tilers who fail to wear knee pads

• Anserine Bursitis:

  • May be related to genu valgum (Knock knee deformity)

  • Causes are controversial

  • Painful when ascending/descending stairs

Medial Femoral group:

• all adduct the thigh (1 exception- obturator externus)

• Innervated by obturator nerve (2 exceptions-Femoral Nerve (Pectineus), TiB I’ll division of the Sciatic Nerve (Adductor Magnus))

• Iliopsoas

• Obturator externus

• Pectineus

• Adductor longus

• Adductor brevis

• Sartorius

• Gracilis

• Adductor magnus

Adductor brevis is deep to the line dividing Adductor longus and Pectineus

Gracilis crosses the knee, adductor longus and brevis do not

Obturator nerve:

• anterior branch lies between adductors longus and brevis

• Posterior branch lies superficial to the obturator externus, then travels between Adductors brevis and magnus

• Branch around the Adductor Brevis to form the “adductor sandwich”

  • Adductors superficial to deep: Longus, Brevis, Magnus

Hip Rotators ppt.

Muscles of the Gluteal Region:

• Superficial:

  • Glute Max.

  • Glute Med.

  • Glute Min.

  • Tensor Fasciae Latae (TFL)

• Deep:

  • Piriformis

  • Sup. Gemellus

  • Inf. Gemellus

  • Obturator internus

  • Quadratus Femoris

Lateral rotators of the hip:

• Superficial:

  • Glute Max

• Deep:

  • Piriformis

  • Sup. Gemellus

  • Inf. Gemellus

  • Obturator Internus

  • Quadratus Femoris

Medial rotators of the hip:

• Superficial:

  • Glute Med.

  • Glute Min.

• Deep:

  • None

Muscles that insert on the greater trochanter:

• Superficial:

  • Glute Med.

  • Glute Min.

• Deep:

  • Piriformis

  • Sup. Gemellus

  • Inf. Gemellus

  • Obturator internus

Joints and Ligaments of the Axial Skeleton ppt

Joints of vertebral column:

• Joints of vertebral ball bodies

• Joints of vertebral arches

• Craniovertebral (Atlanta-axial and atlanto-occipital)

• Sacroiliac Joints

Joints of the vertebral bodies

• Secondary cartilaginous joints (Symphyses)

• Located between the cartilaginous endplates of adjacent vertebrae (where the IVDs are found)

• Bodies are connected by IVDs and Ligaments

• Weight bearing and strength

IVD:

• provide strong attachments between vertebral bodes

• Forms the inferior Half of the anterior border of the IVF

• Comprised of 2 parts:

  • Annulus Fibrosus

  • Nucleus Pulposus

Annulus Fibrosus:

• fibers of each lamella run obliquely at a 30* angle between two vertebra

• Bulging fibrous ring consisting of concentric lamellar of fibrocartilage

• Fore’s the circumference of the IVD

• Attaches to the epiphysial rims on the articular surfaces of the vertebral bodies

• Adjacent lamellar run opposite, crossing each other at ~ 60*

• Limits the amount of rotation between adjacent vertebrae

• Easiest way to injury is to rotate while lifting

• Posterior part is thinner

• Poorly vascularized centrally

• Only the outer 1/3 receives sensory innervation

Nucleus Pulposus:

• semifluid core of IVD

• Provides the disc with much of its flexibility ad resilience

• Acts as a shock absorber by deforming due to vertical forces (becomes broad, or “squishes” when compressed)

• Acts as a fulcrum

• Avascular

• Centered more posteriorly due to the thinner annulus

• Receives nourishment through diffusion form blood vessels in the periphery of the annulus

Blood supply of the vertebrae (lumbar as example):

• Lumbar artery off Abdominal aorta, wraps around body, giving off periosteal and equatorial branches with nutrition arteries spreading around body.

• Pedicles surrounded by Spinal branch of lumbar artery, which leads to anterior vertebral canal branch (surrounds posterior aspect of body)

  • This gives off Posterior vertebral canal branch to the vertebral arch, meninges and spinal cord

    • This also branches further into the vertebral canal and gives off Radicular or Segmental medullary arteries

• The anterior continuation of lumbar artery branches off just before the Lamina/Transverse processes attachments, which is where the Posterior branch of lumbar artery wraps around

  • This branch also gives off small periosteal and nutrient branches that spread medial to the lamina and around the SP

• There is no IVD between skull and C1, nor between C1 and C2

• The most inferior functional disc is L5/S1

• Disc size increases as the vertebral column descends

Uncovertebral joints:

• Situated between the unci of the bodies of C3 or C4 -C6 or C7 and the beveled inferolateral surfaces of the vertebral bodies superior to them

• At the lateral and posterolateral margins of the IVDs

• some are synovial joints

Anterior Longitudinal Ligament (ALL)

• Strong, broad fibrous band Connecting and covering the anterolateral aspects of the Vertebral bodies and IVDs

• Thickest on the anterior aspect of the vertebral bodies, but also covers the lateral aspects all the way to the IVF

• Runs from the pelvic surface of the sacrum to he anterior tubercle of C1, along the anterior boundary of one body to the next

• Continues into the foramen magnum to attach to the inside of the floor of the skull

• ONLY spinal ligament that limits extension of the spine

Posterior Longitudinal Ligament (PLL)

• narrower and weaker than the ALL

• Runs within the vertebral canal along the posterior aspect of the bodies and IVDs

• Attachments mainly to the IVDs

• Extends from Sacrum to C2

• C2 is where it turns into the Tectorial Membrane (because this is where it widens).

  • Then goes through the Foramen magnum where it attaches to the floor of the cranial cavity

• Weakly resists hyper flexion

• Helps prevent central disc herniations

• Has an abundance of Nociceptive fibers

Zygapophsial joints (facet joints):

• Surrounded by a joint capsule

  • Capsule is thin and loose in the cervical region (thus the wide ROM)

  • Capsules are attached to the margins of the articular facets of articular processes (AP) of adjacent vertebrae

• Innervated by articular branches that arise from the medial branches of the Dorsal rami of spinal nerves

  • Articular branches lie in a groove on the posterior aspect of their respective TPs

  • Each branch supplies 2 joints

Accessory Ligaments of the Intervertebral Joints: Unite the laminae, TPs, and SPs, while helping stabilize the joints

• Ligamenta Flava

• Interspinous ligaments

• Supraspinous ligament

• Nuchal ligament

• Intertransverse ligament

Ligaments Flava: Yellow Ligament

• extends almost vertically for the laminar above to the lamina below

• Those of oposite sides meet and blend with one another in the midline

• Bind the lamina

• Forms part of the posterior wall of the vertebral canal

• Thickens as they proceed down the spine

• Limit spine flexion

• Helps preserve normal curvatures of the spine

Supraspinous ligaments:

• Connects the tips of SPs from C7 to the sacrum

• Merges superiorly it’s the nuchal ligament

Interspinous ligament

• connects adjoining SPs

• Attach from the rot to he apex of each SP

Nuchal Ligament:

• Strong and broad

• Thick fibroelastic tissue

• Extends as a median band from EOP and the posterior border of the foramen magnum, along the SPs of Cervical vertebrae to C7

Intertransverse Ligament

• connects adjacent TPs

• Range from scattered fibers (C/S) and fibrous cords (T/S) to membranous (L/S)

Craniovertebral Joints: both joints are Synovial and have no IVD. Designed for a wide ROM

• Atlanto-occipital

  • Articulates between the superior articular surfaces of the lateral masses of C1 and the Occipital Condyles

  • Condyloid joint with loose joint capsule

  • Nodding (total 15* range) and sideway titling of the head

  • Anterior Atlanta-occipital membrane

    • Broad, densely woven fibers

    • Continuous with the ALL

  • Posterior Atlanto-occipital membrane

    • Broad, but relatively weak

• Atlanto-Axial joint: 3 of these

  • 2 lateral Atlanto-axial joints (right and left)

    • Gliding -type joint

  • Median is a pivot joint

  • Both allow head to shake from side to side (the “no” motion)

  • Anterior Atlanto-axial membrane

  • Posterior Atlanto-axial membrane

Cruciate Ligament of the Atlas

• transverse ligfaent of the atlas

• Longitundial bands weaker than the transverse ligament

• Deep to the tectorial membrane

Alar Ligaments:

• check ligaments: prevent excessive rotation

• Attach the cranium to C1

• Extend form the sides of the dens of the axis to the lateral margins of the foramen magnum

Tectorial membrane:

• strong superior continuation of the PLL

• Broadens and passes posteriorly over the median Atlanta-axial joint and its ligaments

• Runs form the body of C2 through the foramen magnum to attach to the central part of the floor of the cranial cavity form by the occipital bone

Anterior Sacroiliac and Posterior Sacroiliac Ligaments

Iliolumbar ligament (Super and inferior )