LOWER LIMB SECTION

1. Spinal cord a. Begins at medulla oblongata; is protected by: vertebra (ends at L2); meninges, CSF b. Meninges (Dura epidural space arachnoid subarachnoid space pia mater)

c.

31 vertebrae = 31 pairs of spinal nerves

i. 8 cervical ii. 12 thoracic iii. 5 lumbar

1.

Cross Section
Dorsal

2.

Vertebra end at L2 giving rise to Cauda equina Lumbar puncture: palpate iliac crest; insert between L4 & L5 into subarachnoid space (through dura & arachnoid) to sample CSF

iv. 5 sacral v. 1 coccygeal d. Cross section of spinal cord i. Gray matter: neuron cell bodies, dendrites, axons 1. Posterior (dorsal) horns: incoming (afferent/sensory); pseudo-unipolar a. Cell bodies in dorsal root ganglions

Ventral

2. Anterior (ventral) horns: motor cell bodies & efferent neurons; multipolar ii. Spinal nerves: mixing of dorsal (sensory) and ventral (motor) neurons 1. Divides into a. Doral primary ramus: motor neurons supplies back b. Ventral primary ramus: supply sensation & motor innervation to the rest of the muscles in the body 2. Disruption of spinal nerves paresthesia AND paralysis 2. PNS Plexus formation: ordered intermingling of ventral primary rami
a. b. c. d. Cervical plexus (C1-C5) Brachial plexus (C5-T1) (radial n.) Lumbar plexus (L1-L4) (femoral n.) Sacral plexus (L4-S4) (sciatic n.)

3. Innervation of the limbs a. Upper limb i. Anterior: muscles are flexors; preaxial innervation ii. Posterior: muscles are extensors; postaxial innervation b. Lower limb i. Anterior: muscles are extensors; postaxial innervation ii. Posterior: muscles are flexors; preaxial innervation 1

1. Locomotion The Gait cycle

a. b. c. d. Heel strike: Thigh flexed, leg extended Mid-stance: leg neutral Heel off: Thigh extended; leg extended Toe off: Leg fully flexed

2. HIP JOINT: a. Articular capsule: attaches acetabulum and transverse ligament i. Ilio-femoral: the Y ligament of Bigelow; prevents excessive extension ii. Pubo-femoral: prevents excessive abduction iii. Ishio-femoral: prevents excessive extension of thigh b. Medial femoral circumflex artery: major supply; passes posterior to femur head
and supplies both neck and head regions

c. Lateral femoral circumflex artery (transverse branch): anterior to anatomic

d. femur neck and supplies neck and greater trochanter Artery of the ligament of the head: minor supply; formed by an anastomosis of a branch from medial femoral circumflex and obturator INTRACAPSULAR FRACTURE: closer a fracture to femur surgical neck (between head & greater trochanter) occurs to head, more likely head will undergo necrosis

e.

f. Congenital dislocation of the hip: faulty development of acetabulum upper lip; results in shortening, adduction, and medial rotation of affected limb g. Hip fractures: (femur fracture) affected extremity shortened & externally rotated 3. PELVIS: ilium + pubis + ischium a. Anterior superior Iliac spine (ASIS): b. Anterior inferior iliac spine (AIIS): c. Ischial tuberosity: d. Acetabulum: socket for femoral head; formed by all 3 bones of pelvis i. Obturator foramen: passage for obturator nerve e. Pubic tubercle: f. Inguinal ligament: joins PT with ASIS; Femoral a., vein, & nerve pass under i. Femoral pulse palpated just below IL halfway between ASIS & PT ii. Subinguinal space: passageway deep to inguinal ligament 1. Femoral Hernia: protrusion through femoral canal medial to femoral v. 4. FEMUR: routed head with a neck, long shaft, and ended with a condyle a. Trochanters: attachment point for muscles which work across the hip joint i. Greater trochanter: attachment for glut. med., min. and piriformis ii. Lesser trochanter: attachment for iliopsoas b. Lateral & Medial condyle: c. Linea aspera: insertion for muscles that ADDuct d. Adductor tubercle: e. Fascia lata: f. Iliotibial tract: used to brace knee & maintain balance
i. Thick fascia starting at gluteus max. with tensor fascia lata; crosses knee joint laterally

g. Patella: quadriceps muscle extends over, allowing leg extension h. Tibial tuberosity: insertion for quadriceps to allow extension

5. ANTERIOR THIGH: femoral nerve i. Extend leg @ knee ii. Flex thigh @ hip joint {muscles attach anterior to hip & tibia} b. Sartorius: thigh flexion, lateral rotation, leg flexion (pulls tibia) at knee (tailor sits) c. Iliopsoas: thigh flexion; inserts on lesser trochanter
i. Psoas major muscle (lumbar vertebrae) + iliacus muscle

d. Quadiceps femoris: continues over patella to insert on tibial tuberosity & extend the knee i. Rectus femoris: leg extension; can also help flex hip ii. Vastus lateralis iii. Vastus medialis iv. Vastus intermedius 6. MEDIAL THIGH: obturator nerve ADDuct thigh; attach onto the linea aspera a. Superficial i. Pectineus: helps iliopsoas flex; thigh adduction
1. Crosses hip joint anteriorly & attaches below lesser trochanter

ii. iii. b. Deeper i. ii. iii.

Adductor longus: forms part of femoral triangle boundary Gracilis: medial side of thigh, crosses knee, inserts below sartorius Adductor brevis: short adductor Adductor magnus: can occlude the femoral artery
1. Hamstring is part of adductor magnus; flex leg @ knee

Obturator externus: lateral rotation

7. POSTERIOR THIGH : tibial division of Sciatic i. Flex leg @ knee ii. Extend @ hip {muscles attach posteriorly to both these joints} a. Hamstrings: cross two joints (hip & knee) i. Medial side: Semitendinosus & Semimembranous ii. Lateral side: Biceps femoris (short & long heads) insert on the fibular head 1. Biceps femoris has a dual innervation - short head innervated by common peroneal nerve iii. Pes anserinus (goose foot) tendons {hamstring insertion} 1. Tendon of: Sartorius; gracilis; semitendinosus b. Hamstring Pull: extend leg @ knee while flexing thigh @ hip a lot of tension
on hamstrings; can lead to evulsion of tendons origin away from ischial tuberosity

c. Bursitis: from constantly extending thigh @ hip using gluteus maximus & hamstrings 8. THE FEMORAL T RIANGLE : inguinal ligament; sartorius; adductor longus a. Nerve most lateral.. then.. b. Artery Femoral pulse palpable below inguinal ligament c. Vein: Femoral vein: medial side of femoral artery d. Lymphatics (femoral canal) most medial i. Inguinal and femoral lymph nodes: Superficial & palpable; drain lymph from skin & subcutaneous tissues below umbilicus 3

9. Thigh Blood Vessels a. Great saphenous vein: superior to fascia lata; from dorsal surface of foot to medial side of the thigh, disappearing into the Fascia lata i. Saphenous Cutdown used during surgery; found anterior to medial malleolus ii. Small saphenous vein: back of leg behind lateral malleolus; goes anterior to medial malleolus iii. Varicose vein: damaged valve results in retrograde venous flow into superficial veins; associated with venous stasis ulcers, fungal & bacterial infections, phlebitis, deep venous thrombosis b. Femoral artery: external iliac artery below IL i. Deep branch (Profunda Femoral artery) most of blood supply, exits femoral triangle between pectineus & adductor longus, branches into: 1. Lateral & medial circumflex arteries collateral blood flow to hip & femur head {anastomosis} 2. Avascular necrosis: due to fracture of head of femur ii. Superficial branch down medial thigh in adductor canal, to back of knee 1. Changes into popliteal artery iii. Catheters into femoral artery pass into the aorta to measure BP or inject
contract dye; ASIS & pubic tubercle important palpation points

c. Adductor hiatus: superficial femoral artery & vein go through and come outside back of knee, becoming popliteal a & v 10. Thigh Nerves a. Femoral nerves (L2, L3, L4): motor & sensory to quadriceps & sartorius; sensation to anterior thigh i. Saphenous nerve: terminal branch of femoral;
ii. Thigh innervation by compartment MAP OF Sciatic: Medial compartment: Obturator Anterior compartment: Femoral Posterior compartment: Sciatic

sensation to medial posterior leg below knee Patella tendon test: test femoral n.; stimulates saphenous n. causing motor reflex arc of femoral n. contraction of quadriceps

iii. iv.

Damage to femoral nerve: paralysis of quadriceps 1. Impaired hip flexion; impaired leg extension Lateral cutaneous nerve (L2, L3): from femoral nerve to anterior thigh skin

b. Obturator nerve (L2, L3, L4): supplies ADDuctor muscles; sensation to upper medial thigh i. Damage to opturator nerve: Weakness of adduction; lateral swinging during walking (due to unopposed abductors) 4

-------------------------------------------------------------1. Gluteal region bony landmarks a. Ischial tuberosity/spine: origin of hamstring muscles b. Sacrotuberous/sacrospinous ligaments: prevent upward motion; crossing of these two ligaments forms sciatic foramen on either side of ischial spine c. Greater/lesser sciatic foramina:
i. Greater: from pelvis to gluteal region (sciatic nerve, piriformis) ii. Lesser: from pelvis into perineum (pudendal nerve)

d. e. f. g.

Greater/lesser sciatic notch: form their respective sciatic foramen Greater trochanter of femur: Intertrochanteric crest: Trochanteric fossae:

2. Gluteal Muscles: extend, ABduct and laterally rotate the thigh a. Gluteus Medius: originates on lateral side of ilium; attaches on greater trochanter b. Gluteus Minimus: deep to medius; fibers run parallel to gluteus medius c. Trendelenburg Test: medius & minimum elevate pelvis on unsupported side during walking i. Positive Trendelenburg Test indicates weakness in gluteus medias &
minimus muscles due to hip sagging on unsupported side (tilt toward foot that is off the ground) damage to superior gluteal nerve

ii. Trendelenburg lurch: to compensate can lurch towards affected side, or hold a cane in the hand on the unaffected side d. Gluteus Maximus: Aponnerous tendon goes to IT tract; crosses hip posteriorly i. Bursitis: painful inflammation of bursae deep to gluteus maximus e. Tensor fascia lata: the TFL muscle is completely encased in the IL tract; stabilizes the
knee joint when it is fully extended

f. Piriformis: (pear-shaped) divides gluteal nerves & arteries i. Above = Superior gluteal a. & n. Gluteus medius & minimums 1. Damage unable to abduct & positive trendelenburg ii. Below = Inferior gluteal arteries & nerves Gluteus maximus 1. Damage unable to extend thigh @ hip iii. Piriformis Syndrome: compression of sciatic nerve by piriformis 1. Worsens when sitting (fat wallet syndrome) g. Obturator internus: joins the tendons of the two gemelli to form a common 3-headed
tendon that inserts below piriformis

h. Superior/inferior gemelli: (twins ~ paired) i. Quadratus femoris: (4-sided muscle) from ischial tuberosity to trochanteric fossa j. Hip lateral rotators (from top to bottom): Piece Goods Often Go On Quilts i. P (Piriformis) G (Gemellus superior) O (Obturator internus) G (Gemellus inferior) O (Obturator externus) Q (Quadratus femoris) 3. Nerves/arteries a. Gluteal arteries: branches of internal iliac that come through greater sciatic foramen i. Inferior gluteal nerve and artery: gluteus maximus ii. Superior gluteal nerve and artery: gluteus medius/minimus iii. Criciate Anastamosis: collateral blood flow around hip joint due to
connections of superior/inferior gluteal arteries, femoral circumflex arteries, and ascending branch of perforating artery (from deep femoral artery)

b. Sciatic nerve: Contributions from L4, L5, and S1, S2, S3; i. Supplies sensation to all of lower leg except medial side (saphenous nerve - branch of femoral) ii. Tibial division (posterior ventral primary rami) - posterior thigh (hamstring muscles) & everything below the knee (leg & foot) 1. Damage to tibial nerve: a. Paralysis of tibialis posterior: loss of foot plantar flexion & impaired inversion - unable to walk on tippy toes b. Difficulty getting heel off ground; gait shuffling iii. Common Peroneal (fibula) Nerve (anterior ventral primary rami) runs parallel & deep to biceps femoris tendon; supplies short head of biceps femoris, the lateral (superficial peroneal) & anterior (deep peroneal) leg compartments 1. Damage to common peroneal nerve: affects muscles in lateral &
anterior leg compartments (no eversion, no dorsiflexion, difficulty inverting foot)

a. Foot drop; loss of sensation on dorsum of foot & lateral leg; paralysis of dorsiflexor & everter foot muscles 2. Deep peroneal nerve: anterior compartment - dorsiflexion (extension)
a. Damage to deep peroneal n.: foot drop & high stepping gait

3. Superficial peroneal nerve: plantarflexion

a. Damage to superficial peroneal n.: loss of foot eversion but no foot drop

iv. Damage to sciatic nerve: impaired extension @ hip ( increased flexion @ hip peculiar gait to lift the dropped foot), impaired flexion @ knee, loss of dorsiflexion @ ankle, eversion of foot v. Foot drop: injection into mid-point of buttocks into sciatic nerve 1. Injections should be in superior-lateral (upper-outer) quadrant vi. Sciatica: Pain in lower back, buttock, down one leg, & possibly into foot; sometimes, leg muscle weakness; some causes
1. Spinal stenosis: narrowing of vertebral canal 2. Piriformis syndrome: compression of sciatic nerve by piriformis 3. Hematoma following trauma in gluteal region

4. Herniated intervertebral disc a. Medial protrusion = L4-L5 pain more widely distributed b. Lateral protrusion i. L5 compression lateral leg & dorsal foot 1. Weakness in dorsiflexion of foot and big toe; difficulty walking on heels ii. S1 compression back of thigh & leg to little toe 1. Weakness in plantarflexion of foot, big toe; difficulty walking on toes vii. Sural nerve (branch of sciatic): sensory to lateral leg & foot; contribution from common peroneal & tibial nerves c. Pudendal nerve (S2-S4): sensation from external genital & anus d. Internal pudendal artery: branch of internal iliac; travels with pudendal n. e. Cluneal nerves: Posterior cutaneous nerve of the thigh (S1, S2, S3): gives rise to inferior cluneal nerves sensation from posterior thigh 6

-------------------------------------------------------------4. POPLITEAL FOSSA a. Patella: attaches quadriceps muscle to the tibial tuberosity b. ACL: prevents anterior tibial displacement; ACL ruptured via hyperextending knee c. PCL: prevents posterior displacement; PCL ruptured via hyperflexing knee d. Lateral collateral ligament: not attached directly to lateral meniscus (closed C) e. Medial collateral ligament: IS attached directly to lateral meniscus i. Unhappy Triad Injury: lateral blow to the knee results in 1. Rupture of tibial (medial) collateral ligament from excessive abduction 2. Tearing of ACL from forward tibial displacement 3. Injury to medial meniscus from tibial collateral ligament attachment f. Popliteus: unlocks knee joint by pulling tibia medially or femur laterally g. Popliteal artery: continuation of superficial femoral a. as it goes through adductor hiatus behind knee to supply genicular arteries i. Occlusion of popliteal artery: cold, clammy leg & foot ii. Occlusion due to PVD: leg cold, pain while walking iii. Popliteal Artery Aneurysm: large pulsing mass iv. Popliteal (Bakers) Cyst: fluid-filled, non-pulsing mass impairs flexion and extension v. Intermittent claudication: pain in leg during exercise due to insufficient blood supply vi. Popliteal artery divides into 1. Anterior tibial (to anterior compartment of leg) 2. Posterior tibial (to posterior leg & foot plantar surface) 3. Peroneal (to lateral compartment of leg) vii. Geniculate arterial anastomoses: popliteal a. gives off 5 genicular a. h. Popliteal vein: small saphenous vein empties into this i. Popliteal lymph nodes: first nodes to get enlarged with infections of lateral leg & foot -------------------------------------------------------------1. TIBIA: most medial; bears the weight from the femur a. Tibial plateaus: where condyles attach b. Tibial tuberosity: where patella tendon attaches c. Medial malleolus: bony projection of tibia; forms rounded part of ankle joint *palpate posterior tibial a. pulse 2. Interosseous membrane: joins tibia to fibula 3. FIBULA: long, thin; attachment point for muscles
4.
Structures that pass behind the medial malleolus anterior to posterior

(Tom, Dick, AN Harry) Tibialis posterior Flexor digitorum longus Posterior tibial artery Tibial nerve Flexor halluces longus

COMPARTMENT SYNDROME: inflammation & compression of compartment structures

a. Clinical signs 5 Ps: Pain, Paresthesia (pins & needles), Pallor (pale), Paralysis, Pulselessness

b. Tx: Fasciotomy procedure 7

5. POSTERIOR LEG: flex leg @ knee; plantarflex the foot @ ankle (toe stand) a. Superficial i. Gastrocnemius: medial & lateral heads originate on femur condyles; crosses knee posteriorly ii. Soleus: deep to gastroc iii. Plantaris: also inserts in calcaneus; weakly flexes leg & plantarflexes foot b. Deeper: cross the ankle joint posteriorly and cause plantar-flexion i. Flexor digitorum longus: flexes the four toes outside the big toe ii. Flexor Hallucis longus: flexes the big toe 1. Crisscrosses with F.D.longus (more superficial vs. hallicus which is deeper) on sole of the foot at Knot of Henry iii. Tibialis posterior: can also invert the foot (turn towards midline)
1. Originates off interosseous membrane

c. Achilles/calcaneal tendon: formed by Gastrocnemius & Soleus attachment on calcaneus i. Achilles Tendon Rupture during forced dorsiflexion and extension of leg @ knee; cant stand on toes or elevate heel off floor ii. Calcaneal Tendon reflex: test S1 sensory nerve
1. Injury to S1 or S2 Decreased sensation; weak plantar-flexion foot

d. Lymphatic drainage from posterior-lateral side of the leg and foot drains along the Lesser Saphenous Vein into Popliteal Lymph Nodes first 6. LATERAL LEG: evert - turn foot out laterally a. Two muscles kept in place by fibular (peroneal) retinaculum i. Peroneus (fibularis) longus: superficial; attaches to 1st metatarsal ii. Peroneus (fibularis) brevis: deeper & shorter; attaches to 5th metatarsal b. Terminal cutaneous branches of peroneal nerve: i. Common peroneal: upper lateral leg ii. Superficial peroneal: lower lateral leg & dorsum of foot iii. Deep peroneal: 1st web space 7. ANTERIOR LEG: a. Muscles: attachments only on dorsum of foot dorsiflex the foot i. Tibialis anterior: can also invert foot 1. Shin splints: excessive stress on tibialis anterior
and/or over dorsifleixion

ii. Extensor digitorum longus: elevates toes

iii. Extensor digitorum brevis:

iv. Extensor hallucis longus (L5): extends big toe

v. Extensor hallucis brevis:

vi. Peroneus (fibularis) tertius: b. Anterior tibial artery: branch of popliteal artery c. Deep peroneal nerve: d. DROP FOOT: damage to deep peroneal nerve inability to dorsiflex (paralysis of anterior leg muscles); loss of sensation in first web space i. To compensate, individuals walk with a high steppage gait e. STRESS FRACTURES: overuse of bone & muscle pulling on tibia; results from repetitive loading that exceeds bones intrinsic ability to repair itself

Anterior Leg: The (Tibialis anterior) Hospitals (extensor Hallucis longus) Are (anterior tibial Artery) Not (deep fibular Nerve) Dirty (extensor Digitorum longus) Places (Peronius tertius)

-------------------------------------------------------------1. ANKLE JOINT : a. Extensor retinaculum: prevents bowstringing of tendons that cross from anterior leg to foot b. Deltoid: attaches medial malleolus to tarsals; prevents excessive eversion i. Flatfoot: may be due to deltoid ligament weakness ii. Trimalleolar fracture occurs when foot is everted and deltoid breaks
medial malleolus talus can break the lateral malleolus; tibia can also be broken

c. Lateral (anterior talofibular, posterior talofibular, calcaneofibular): prevent inversion

i. High Ankle Sprain: sprain of Posterior & Anterior tibiofibular ligaments ii. Low Ankle Sprain: injured during an inversion sprain (damages lateral ligaments)

-------------------------------------------------------------8. FOOT: a. Tarsals: 7 bones of ankle

i. Hindfoot transverse tarsal joint 1. Calcaneus: heel bone (largest foot bone) 2. Talus: articulates with tibia & fibula ii. Midfoot tarso-metatarsal joint 1. Navicular: (ship) medial side of foot 2. Cuboid: 3. Cuneiforms (3): medial, intermediate, & lateral
b. c.

Tarsals
(Right foot, superior to inferior, medial to lateral)

TALl (talus) CALifornian (calcaneus) NAVy (navicular) MEDical (medial cuneiform) INTerns (intermediate cuneiform) LAy (lateral cuneiform) CUties (cuboid)

Metatarsals (5): forefoot Phalanges: bones of the toes (proximal, medial, & distal phalanges in four toes) i. Hallux (big toe): has only 2 phalanges 1. Hallux Valgus (Bunion): lateral deviation of the big toe d. Subtalar joint: allows eversion/inversion and pronation/supination e. Arches (Medial/lateral longitudinal & transverse): help dissipate force & energy i. Supported by ligaments 1. Tibialis anterior/posterior: elevate medial side of foot 2. Long plantar ligament: 3. Calcaneonavicular (spring) ligament: ii. Pes Planus (flat foot): Congenital (asymptomatic) or Acquired (adult)
a. b. c. Posterior tibial tendon dysfunction spring ligament stretches Spring ligament laxity Over-pronation (eversion) and abduction of feet

iii. Plantar aponeurosis: protects underlying structures & helps maintain normal arch 1. Plantar Fascittis: inflammation at PF insertion into calcaneous
a. Causes: Repetitive stress; shortened Achilles tendon, hypermobile forefoot

f. Plantar surface: Lateral & Medial plantar arteries i. Medial & Lateral plantar nerves are Tibial division of Sciatic nerve 1. Tarsal tunnel syndrome: compression on tibial nerve g. Dorsal surface: Dorsalis pedis artery (continuation of anterior tibial artery) i. *Dorsalis pedis artery pulse felt just lateral to extensor hallicus longus ii. Occlusion of anterior tibial artery: minimal pulse in dorsalis pedis artery, although it is minimally maintained by perforating branch of the fibula artery which forms an anastomosis iii. Superficial peroneal nerve: 1st web space from Deep peroneal nerve 9

-------------------------------------------------------------1. PECTORAL REGION : shoulder a. Acromion process of scapula: shelf on lateral edge of posterior scapula b. Pectoral girdle = clavicle + scapula: is not a continuous ring of bone i. Clavicle: from sternum to scapula 1. Sternoclavicular joint: only bony attachment of upper limb 2. Acromioclavicular joint: articulation of clavicle and scapula ii. Scapula: freestanding & embedded within shoulder muscles 1. Coracoid process: crows break; projects up and laterally c. Pectoralis major: ADDucts and medially rotates humerus (bench-press & pushups)
i. Clavicular head only - flexes extended humerus ii. Sternocostal head only - extends flexed humerus iii. Dual innervation: medial and lateral pectoral nerves Pectoralis minor: stabilizes scapula; draws scapula forward (protraction) i. Innervation: medial pectoral nerve

d.

e. Subclavius: anchors & depresses clavicle i. Innervation: nerve to subclavius f. Cephalic vein: travels in the deltopectoral groove, passes through deltopectoral triangle to join axillary vein g. Branches of thoracoacromial artery: -------------------------------------------------------------2. AXILLA: a. Latissimus dorsi: ADducts, extends and medially rotates b. Serratus anterior muscle: protracts scapula and can help superiorly rotate i. Supplied by long thoracic nerve (S.A.L.T.) which runs on the superficial aspect of serratus anterior making it relatively exposed for injury/surgery ii. Winged Scapula: damage to long thoracic nerve paralyzes
serratus anterior; medial border of scapula moves posteriorly; especially notable when person presses their hand against a wall Difficulty protracting arm & rotating scapula

superiorly (when abducting arm above 90 degrees) c. Axillary vein: runs anterior & inferior to axillary artery d. Axillary artery: under pectoralis minor; continuation of subclavian artery i. First part: Supreme thoracic artery: intercostal space ii. Second part: 1. Thoracoacromial artery: Acromial; Clavicular; Deltoid; Pectoral br. 2. Lateral thoracic artery: iii. Third part: 1. Subscapular artery branches: Thoracodorsal; Scapular; Circumflex 2. Anterior/posterior circumflex a.: collateral circulation around shoulder Axillary artery branches from proximal to distal: Suzy Thompkins Loves Sex, Alcohol, and Pot 10

-------------------------------------------------------------3. THE BREAST: Mammary gland: in superficial fascia of the anterior thoracic wall
a. Circulation - Internal thoracic artery; Lateral thoracic artery
b. Lymph Vessels Axillary lymph nodes i. Brachial (lateral) axillary nodes: on humerus; drains upper limb ii. Subscapula (posterior) axillary nodes: iii. Pectoral (anterior) nodes: drains Lower lateral quadrant All the above drain into the Central axillary nodes which drains into: i. Apical (subclavian) nodes: right under clavicle; drains upper lateral quadrant of the breast into venous system via the right lymphatic duct

c.

d. Medial lateral quadrant drain into upper parasternal (upper medial quadrant) and lower parasternal (lower medial quadrant) lymph nodes: more difficult to palpate nodes & involves most dangerous cancers -------------------------------------------------------------1. BRACHIAL PLEXUS : ordered intermingling of ventral primary rami from C5 T1 a. Muscles closest to trunk supplied by nerves from roots of B.P. b. 5 Roots: ventral primary rami mixed nerves c. 3 Trunks: (neck region)
i. Superior (C5 C6) ii. Middle (C7) iii. Inferior (C8 T1) Divisions: (deep to clavicle)
i. Anterior & posterior for each trunk

d.

e. 3 Cords: named for relationship to axillary a. i. Lateral superior & middle anterior divisions ii. Medial inferior anterior division iii. Posterior all 3 posterior divisions f. 5 Terminal branches: each nerve has motor and sensory branches i. From lateral cord 1. Musculocutaneous nerve: anterior arm 2. Lateral head of median nerve: anterior forearm ii. From medial cord 1. Ulnar nerve: small muscles in the hand

Terminal branches
(Lateral to medial)

My - Musculocutaneous Aunt - Axillary Raped - Radial My Median Uncle- Ulnar

a. Funny bone: stimulation results in referred pain in hand b. Claw Hand: ulnar nerve injury weakness flexing wrist, little,
& ring fingers, hyperextended MP joints; Atrophy of hypothenar eminence

2. Medial head of median nerve: anterior forearm iii. From posterior cord 1. Radial nerve: posterior arm & forearm (extends)
a. b. a. Proximal injury weak ability to extend elbow, wrist, & fingers Lower injury might only result in wrist drop Dislocated shoulder weakened ability to abduct @ shoulder

2. Axillary nerve: supplies deltoid 11

g. Supraclavicular branches: i. Dorsal scapular nerve: from roots of C5 ii. Nerve to subclavius: iii. Long thoracic nerve: comes directly from C5-C8 roots; innervates serratus anterior
(c5-6-7 raise your arms to heaven)

iv. Suprascapular nerve: from superior trunk v. Nerve to longus colli: h. Infraclavicular branches: i. Lateral cord 1. Lateral pectoral nerve: supplies pectoralis major & minor a. Goes through pec major: Lateral is less ii. Medial cord 1. Medial pectoral nerve: supplies pectoralis major & minor
a. Goes through pec minor & major: Medial is more

2. Medial brachial cutaneous nerve: sensation to medial arm & forearm 3. Medial antebrachial cutaneous nerve: iii. Posterior cord 1. Subscapular nerve branches: upper, middle (thoracodorsal nerve), lower supply
scapula & rotator cuff muscles

2. Upper Brachial Plexus Injury: Erbs Palsy OR Shoulder Dystocia during childbirth (C5, 6): Damage to:
a. b. c. d. e. f. Superior trunk Suprascapular nerve - supplies supraspinatus & Infraspinous rotator cuff Dorsal scapula nerve - supplies rhomboids & levator scapula Long thoracic nerve Musculocutaneous nerve (from lateral cord & C7) supplies anterior arm muscles: brachialis, biceps, coracobrachialis flex forearm Axillary nerve supplies teres minor & deltoid abduction & lateral rotation Overall, results in upper limb being adducted, medially rotated, and extended waiters tip position in addition to loosing sensation to lateral shoulder & lateral arm Inferior trunk Medial cord Ulnar nerve & part of median nerve (medial cutaneous n. of arm & forearm) Overall, loose sensation around medial side of upper limb and fine motions in hand
NERVE Dorsal scapular (C5) Long thoracic (C5-C7/8) Upper trunk Lateral cord (Lucy Loves Me) Medial cord (Most Medical Men Use Morphine) Medial and lateral cords Suprascapular Subclavius Lateral pectoral Musculocutaneous Medial pectoral Ulnar Medial Cutaneous (of arm & forearm) Median Upper subscapular Thoracodorsal Posterior cord (ULTRA) Lower subscapular Axillary Radial MUSCLES INNERVATED Levator scapulae and rhomboids Serratus anterior Supraspinatus and infraspinatus Subclavius Pectoralis major Anterior compartment muscles of arm (biceps) Pectoralis minor and major Some anterior forearm and most hand muscles Sensory cutaneous innervation to medial arm & forearm Most anterior forearm and some hand muscles Subscapularis Latissimus dorsi Subscapularis and teres major Deltoid and teres minor Posterior compartment muscles of the arm & forearm (extendor muscles)

3. Lower Brachial Plexus Injury: Klumpkes Palsy (C8-T1): Damage to:

a. b. c.
ARISE FROM Roots

12

13

-------------------------------------------------------------1. SHOULDER: SCAPULA: a. Subacromial (subdeltoid) Bursitis: overuse of rotator muscles b. Frozen shoulder (Adhesive Capsulitis): shoulder joint with significant loss of range
of motion; causes pain & stiffness
i. Causes: tendinitis, bursitis, RC injury leading to inflammation & thickening of tissues

ii. Treatment: anti-inflammatory injections & physical therapy

c. d. e. f.

Quadrangular space: axillary n. and posterior humeral circumflex n. & a. Medial triangular space: scapular circumflex branch of subscapular a. Lateral triangular space: radial n. and profunda brachii a. Trapezius: depending on which portion contracts, scapula (elevation shrugging),
medially (retract squaring shoulders), or interiorly (depress via lower fibers)

g. Deltoid: i. Anterior muscle fibers flex the arm ii. Middle part: ABducts the arm up to ~100 o
1. Abduction to 180 o requires serratus anterior & trapezius

h. i. j.

k. l. m. n. o. p. q. r. s. t.

iii. Posterior fibers extend the arm iv. Inferior shoulder dislocation: damage to axillary nerve paralyzes teres minor & deltoid; difficulty abducting Rhomboids: retracts scapula (towards midline) Levator scapulae: helps trapezius in elevating scapula Rotator cuff (SITS): i. Supraspinatus: ABductor initiator of the arm for first 15o ii. Infraspinatus: lateral rotator of the arm at shoulder iii. Teres minor: lateral rotator humerus at shoulder & ADDuctor of arm iv. Subscapularis: medially (internally) rotates and ADDucts arm v. Rotator cuff injuries: lateral rotation puts stress on RC supraspinatus tear Teres major: medial rotator of shoulder, ADDuctor of arm, extends humerus @ shoulder
i. Small version of latissimus dorsi Triceps (long head): extends arm & forearm

Posterior humeral circumflex artery: Suprascapular artery: from the thyrocervical trunk of subclavian artery Scapular circumflex artery: Profunda brachii (deep brachial artery):

Glenohumeral: bind humerus to glenoid fossa; stability while allowing rotation Sternoclavicular: Acromioclavicular: Coracoclavicular-conoid and trapezoid: i. Separated shoulder: rupture of acromioclavicular & coracoclavicular ligaments; weight of upper limb causes it to sag; clavicle is displaced superiorly and its distance from the coracoid process is increased u. Coracoacromial: prevents upward displacement of humerus v. Transverse scapular: w. Transverse humeral: prevents long head of biceps from popping out during movement 14

-------------------------------------------------------------2. PROXIMAL HUMERUS : a. Head: fits into glenoid fossa i. Dislocated shoulder: head of humerus pops out from glenoid fossa and
lies below acromion; occurs from forceful injury during humerus abduction

Anatomical neck: between rounded head & greater/lesser tuberosity c. Surgical neck: more likely place where humerus fracture will take place d. Spiral (radial) groove: separates origin of the medial and lateral heads of triceps brachii e. Cubidal Fossa: contains medial n. & brachial a.; protected by bicipetal aponeurosis
b.

3. ANTERIOR ARM-FLEXOR compartment: a. Coracobrachialis: flexes the arm & ADDucts the shoulder b. Biceps brachii: strong (main) supinator & flexor of forearm i. Short & long heads ii. Biceps tendon rupture: due to forceful flexion at elbow joint against resistance; bulge due to detachment near intertubercle groove c. Brachialis: helps biceps flex forearm at elbow in both supinated & pronated positions d. Musculocutaneous nerve: innervates all muscles of anterior compartment i. Continues distally to supply cutaneous innervation to lateral forearm
(named the lateral cutaneous nerve of the forearm two-part innervation)

ii. Biceps tendon reflex: tests integrity of biceps brachialis and musculocutaneous nerve (C5, C6) iii. Damage to Musculocutaneous nerve: unable to flex the forearm and also loss of cutaneous innervation on lateral forearm e. Brachial artery: continuation of axillary artery past teres major

4. POSTERIOR ARM-EXTENSOR compartment: a. Triceps brachii: extends forearm at elbow; inserts on olecranon of ulna i. Lateral, Medial, & Long heads b. Anconeous: helps the triceps c. Radial nerve: i. Fractured humerus may transect radial n, paralyzing forearm extensor muscles;
will definitely result in Wrist Drop and numbness on back of forearm & hand

d. Profundi (deep) brachii artery: travels in the radial grove with nerve on back of humerus 5. Deep veins (brachial, ulnar, radial) all accompany and travel along with the arteries 6. Superficial veins: begin on dorsum of hand as a plexus and travel up arm to the cephalic & basilic a. Cephalic vein: through delto-pectoral groove b. Basilic vein: joins brachial v. to become the axial v. to eventually join cephalic v. c. Median Cubital vein: joins the cephalic & basilic v.; used for giving blood

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-------------------------------------------------------------1. FOREARM: a. DISTAL HUMERUS : i. Lateral epicondyle: origin of common extensor supinator tendon 1. Tennis elbow (lateral epicondylitis): inflammation around lateral epicondyle damage to radial nerve? ii. Medial epicondyle: origin of common flexor pronator tendon iii. Capitulum: articulates with radius iv. Trochlea: articulates with ulna at trochlear notch to allow flexion & extension b. RADIUS: articulates with capitulum (ulna) and two wrist bones i. Head: proximal; articulates with radial notch of ulna 1. Subluxation of radial head (Nursemaids elbow): radial head dislocation via annular ligament ii. Radial Tuberosity: attachment for biceps tendon iii. Styloid process: can rotate around distal head of fixed ulna in pronation iv. Dorsal radial (Listers) tubercle: v. Colles Fracture (Fracture of the Distal Radius): extensor fracture of the
radius; results from falling onto out-stretched hand (slipping on ice)

vi. Smiths Fracture: flexion fracture of radius; typically from falling backwards c. ULNA: medial; longer; trochlear notch (proximal) to head of ulna (distal) i. Olecranon: bony part of elbow ii. Coranoid process: iii. Ulnar Tuberosity: attachment point for brachialis muscle 2. ANTERIOR FOREARM - FLEXOR COMPARTMENT; also PRONATE forearm a. First layer (PFPF) i. Pronator teres: laterally rotate arm into pronation ii. Cross the wrist joint anteriorly & flex the hand at wrist: 1. Flexor carpi radialis longus: Flexing this muscle alone results in 2. 3.
flexion & radial (lateral) deviation (abduction) Palmaris longus: tendon that pops out when flexing wrist Flexor carpi ulnaris: Flexing this muscle alone results in flexion & ulnar (medial) deviation

iii. Brachioradialis: mobile wad of muscles 1. *Is the only flexor muscle innervated by radial nerve b. Second layer i. Flexor digitorum superficialis: four tendons that insert on middle phalanx to
flex digits at PIP joints

c. Third layer i. Flexor pollicis longus: flexes thumb at IP joint ii. Flexor digitorum profundus: inserts on distal phalanxs to curl fingers (flex
digits at IP joints) 1. Dual innervation: interosseous nerve (index & middle tendons) and ulnar nerve (ring & pinky tendons) 2. Cubital Tunnel Syndrome: compression of ulnar n. Weakness in flexing DIPs & tingling along 5th digit, medial side of 4th digit, and hand

iii. Pronator quadratus: four-sided pronator 16

3. POSTERIOR FOREARM - EXTENSOR compartment; also SUPINATE forearm a. Abductor pollicis longus: ABducts the thumb b. Extensor pollicis brevis: only goes to end of metacarpal on thumb c. Extensor carpi radialis longus: Extends & abducts hand d. Extensor carpi radialis brevis: e. Extensor pollicis longus: insert on distal phalanx of the thumb i. Snuff box: depression between EPL & EPB; radial artery runs through the
floor of the snuff box before supplying the deep palmar arch of the hand

f. g. h. i. j.

Extensor digitorum: extends fingers Extensor indicis: extends index finger Extensor digiti minimi: extends little finger Extensor carpi ulnaris: Extends & adducts hand Supinator: pivots the radius around laterally

k. Common extensor/supinator tendon: gives rise to extensor digitorum, extensor l.

carpi radialis (longus & brevis), & extensor carpi ulnaris Extensor digitorum tendons: extends digits at the proximal & distal IP joints

m. Radial nerve: enters forearm between brachialis and brachioradialis i. Deep branch radial nerve: superficial extensors of mobile wad and dorsal
muscles of forearm

1. Posterior interosseous nerve ii. Superficial branch of the radial nerve (cutaneous branch) sensory
innervation to dorso-lateral surface of hand

-------------------------------------------------------------1. Hand: a. Carpal bones:

i. Scaphoid: Scaphoid Fracture: injured usually during falling; difficult to heal because area is not very vascular ii. Lunate: Scaphoid & lunate articulate with radius Stop Letting Those People iii. Triquetrum: Proximal row, lateral-to-medial: iv. Pisiform: can palpate on medial side of wrist Scaphoid Lunate Triquetrum Pisiform v. Trapezium: vi. Capitate: Touch The Cadaver's Hand" vii. Hamate:
Distal row, lateral-to-medial:

b. Metacarpals: c. Metacarpal-phalangeal joints (MP) knuckles

Trapezium Trapezoid Capitate Hamate

d. Phalanges: (3) (*Only proximal & distal in thumb) i. Proximal - - Proximal interphalangeal joints (PIP) ii. Middle - - Distal interphalangeal joints (DIP) iii. Distal 17

e. Palmar aponeurosis: protects underlying hand structures i. Dupuytrens contracture: underlying contractures & thickening of palmar fascia 1. Flexed finger contracture of the hand where fingers bend toward the palm and cannot fully extend f. Transverse carpal ligament (flexor retinaculum): ties down tendons that pass through Carpal tunnel i. Long flexor tendons of the digits & thumb (FDS, FDP, FPL) ii. Median nerve 1. *Ulnar nerve DOES NOT pass; goes over flexor retinaculum iii. Carpal Tunnel Syndrome: median nerve compression from flexor tendon inflammation
1. 2. Numbness on thumb, index, middle, ring finger, & skin on distal palm Weakness in: a. Opposing, flexing, abducting thumb b. Flexing index, ring fingers at MP joints Untreated CTS can lead to muscle wasting in the thenar eminence Splints can be used to treat CTS without surgery to prevent wrist flexion

3. 4.

g. Tendon sheaths: i. Synovial sheaths: Infections may pass from thumb to little finger ii. Annular and cruciform fibrous sheath:
1. Infections in 2nd, 3rd, and 4th digits tend to remain confined to digit

2. Trigger finger: catching, snapping or locking of flexor finger tendon

caused by inflammation of the flexor tendons which develop nodules; results in difficulty flexing or extending the finger

h. Extensor expansion hood: broad aponeurosis goes to distal phalanx i. Boutonnieres Deformity: caused by injury or inflammatory conditions (R.arthritis) 1. PIP joint is permanently bent toward the palm (hyperflexion) while the DIP joint is bent back away (hyperextension) ii. Mallet (baseball) Finger: injury of the extensor digitorum tendon at the DIP; results from hyperflexion and then stretching or rupture of the extensor digitorum tendon i. Thenar eminence: thumb abduction; median nerve i. Abductor pollicis brevis: ii. Flexor pollicis brevis: flexes thumb at MP joint iii. Opponens pollicis: Opposes the thumb j. Hypothenar eminence: ulnar nerve i. Abductor digiti minimi: Flexes pinky ii. Flexor digiti minimi: Abducts pinky iii. Opponens digiti minimi: Flex & laterally rotate pinky k. 4 lumbricals: flex the digits at MP joints (hand cup waving) i. 1st & 2nd: Index & middle finger lumbricals supplied by median nerve ii. 3rd & 4th: Ring & pinky finger lumbricals supplied by ulnar nerve l. 3 palmar interossei: ADDuct index, ring & middle finger {PAD}; ulnar nerve m. 4 dorsal interossei: abducts ring, middle & index finger {DAB}; ulnar nerve n. Adductor pollicis: adducts thumb (e.g. holding glasses in hand) o. Palmaris brevis: folds the skin of the hypothenar eminence transversely 18

p. Recurrent branch of median nerve: Hand Muscles supplied by median nerve i. Thenar Eminence muscles "LOAF" ii. Injury to the median nerve (laceration; Lumbricals 1 & 2 carpal tunnel) makes it almost impossible Opponens pollicis to oppose thumb Abductor pollicis brevis iii. Hand of Benediction: injury to median Flexor pollicis brevis nerve near elbow 1. FDS, FDP, FPL to first 3 digits (and lumbricals to index & middle fingers) paralyzed iv. Deep branch of median nerve 1. Injury (e.g. deep penetrating injury to anterior forearm): unable to make OK sign, but will make a pinch movement instead q. Digital sensory branches of median nerve: Median Cutaneous Nerve r. Deep and superficial branches of ulnar nerve: most muscles of the hand i. Hypothenar eminence muscles ii. Superficial branch: Ulnar Cutaneous Nerves iii. Deep branch passes through Guyons Canal (between pisiform & hamate) 1. Thumb adduction (adductor pollicus) 2. Palmar & dorsal interossei muscles 3. Damage can result from fracture to pisiform or hamate bones s. Superficial radial nerve: i. There are no muscles in the hand innervated by the radial nerve t. Superficial palmar arterial arch: ulnar artery i. Common and proper digital arteries: to the base of each digit u. Deep palmar arterial arch radial artery i. Provides sensation to dorsal surface of thumb & hand up to MP joints v. Allen test: assess patency of ulnar & radial arteries & the palmar arches i. Occlude both arteries at wrist, then release one, to watch hand pink up as blood flows through the arches; < 3sec is suitable 2. Raynauds Disease: hyperactivation of the sympathetic system causing extreme vasoconstriction of peripheral blood vessels leading to tissue hypoxia; chronic, recurrent cases can result in atrophy of skin, subcutaneous tissues, and muscle

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