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MUSCULOSKELETALSYSTEMANAKajvolonto Medic learnPARTSOFTHEBONE ➤ Diaphysis: shaft ➤ Epiphysis: ends ➤ Separated by growth plate during bone growth ➤Fuses when done growing ➤ Metaphysis: between the two ➤ Cortical bone: outside (denser than spongy bone —> whiter on x-ray) ➤ Spongy bone: insideROLEOFTHEMSKSYSTEM ➤ Support ➤ Protection ➤ Movement ➤ Storage of minerals ➤ Heamatopoesis ➤ Posture ➤ Heat generation (By muscles) ➤ Convert chemical energy to power mechanical workDIVISIONSOFTHESKELET ALSYSTEMANDBONECLASSIFICA TION ➤ Axial ➤Protective bones ➤ Skull ➤ Ribcage ➤ Vertebral column ➤ Sternum ➤ Appendicular ➤For motility ➤ Everything else ➤ Types of bones ➤Long ➤ Femur ➤Short ➤ Carpal bones ➤Flat ➤ Sternum ➤Irregular ➤ Vertebrae ➤Sesamoid ➤ PatellaJOINTS ➤ Where 2 or more skeletal elements articulate ➤ Classification by tissue type ➤ Fibrous ➤ Cartilaginous ➤ Synovial ➤ Classification by degree of movement ➤ Synarthrosis ➤ Amphiarthrosis ➤ DiarthrosisTYPESOFMOVEMENT ➤ Flexion and extension ➤ Pronation and supination ➤ Abduction and adduction ➤ Inversion and eversionTHEBACKTHEVERTEBRALCOLUMN ➤ 7 cervical vertebrate ➤ 12 thoracic ➤ 5 lumbar ➤ 5 fused sacral ➤ 3-4 fused coccygeal ➤ Wake up at 7, eat lunch at 12, go home at 5 ➤ Kyphosis ➤ Concave anteriorly ➤ Primary curvature ➤ Maintained in the thoracic, sacral and coccygeal regions ➤ Can be pathological ➤ Lordosis ➤ Concave posteriorly ➤ Secondary curvature ➤ Developed in cervical region when starts lifting head ➤ Developed in lumbar region when starts walking ➤ Can be pathological ➤ Scoliosis ➤ Abnormal lateral curvature of the spineSTRUCTUREOFTHEVERTEBRALCOLUMN ➤ Vertebral body ➤ Vertebral arch ➤ Vertebral formanen ➤ Spinal nerves come out below the vertebrae ➤ Except for in the cervical spine ➤ Body gets larder as you go down & foramen gets smaller ➤ Intervertebral disks make up 25% of length of vertebral column ➤ Nucleus pulpous in centre ➤ Annulus fibrosis peripherally ➤Avascular and aneural ➤Shock absorber ➤ Ligaments ➤ Anterior longitudinal ➤ Posterior longitudinal ➤ Ligamentum flavum ➤ Interspinous ligament ➤ Supraspinous ligament ➤ Ligamentum nuchaeEXCEPTIONS ➤ Cervical vertebrae have transverse foramen in transverse process for vertebral arteries and veins (except C7) ➤ C1 ➤ Atlas ➤ Articulates with the skull ➤ No body or spinous process ➤ Articulates with the dens of the Axis ➤ Jefferson’s fracture ➤ 2 fractures due to ring shape ➤ C2 ➤ Axis ➤ Has a dens that C1 articulates with ➤ Hangman’s fracture ➤ Fracture of posterior C2 ➤ C7 ➤ Spinous process called the vertebral prominence ➤ Thoracic vertebrae have facets for ribs to articulate with vertebraePROLAPSEDIVDISC ➤ Usually at the level of L4/L5 or L5/S1 ➤ Usually posterolaterally ➤ Neurosurgical emergency if posteriorly ➤ Stages ➤ Degeneration ➤ Prolapse ➤ Extrusion ➤ Sequestration ➤ Affects the traversing nerve not the exiting nerve ➤ Cauda equina syndrome ➤ Massive posterior disc herniation ➤ Neurosurgical emergency ➤ Symptoms ➤ Fecal and urinary incontinence ➤ Saddle anesthesia ➤ Loss of sexual sensation and function ➤ Back painREDFLAGSYMPTOMSFORBACKPAIN ➤ rauma ➤ Unexplained weight loss ➤ Neurological symptoms ➤ Age >50 ➤ Fever ➤ IV drug use ➤ Steroid use ➤ History of cancerLUMBARPUNCTURE ➤ Done at the level of L3/L4, or L4/L5 ➤ Skin, subcutaneous tissue, supraprinous ligament, interspinous ligament, ligaments flavum, epidural fat/vein, dura mater , arachnoid mater, subarachnoid space ➤ Some Saints Say I Love Everyone Days Are ShortSUPERFICIALGROUPOFTHEBACK ➤ Extrinsic ➤ Innervated by anterior ramus ➤ Connect upper limb to trunk ➤ Trapezius ➤ Latissimus dorsi ➤ Rhomboid major and minor ➤ Levator scapulaeINTERMEDITEGROUPOFTHEBACK ➤ Extrinsic ➤ Innervated by anterior ramus ➤ Contribute to respiratory movements ➤ Serratus posterior superior ➤ Serratus posterior inferiorDEEPMUSCLEGROUPOFTHEBACK ➤ Intrinsic ➤ Innervated by posterior primary ramus ➤ Maintains posture and controls movements of the vertebral column ➤ 3 divisions ➤ Superficial ➤ Splenius cervicis ➤ Joins vertebrae to neck ➤ Splenius capitis ➤ Joins head and neck to spine ➤ Intermediate ➤ Erector spinae divided into 3 columns ➤ Ilio-costalis (lateral) ➤ Longissimus (intermediate) ➤ Spinalis (medial) ➤ Deep ➤ Transversospinal ➤ Semispinalis ➤ Multifidus ➤ RotatorsTHEUPPERLIMB ➤ Made up of the: ➤Shoulder girdle ➤Arm ➤Forearm ➤ HandREGIONSOFTRANSITIONOFTHEUPPERLIMB ➤ Axilla ➤ Posterior fold - Lat. dorsi and teres major ➤ Anterior fold - Pec major and minor ➤ Boundaries ➤ Anterior - Pec major and minor ➤ Posterior - Lat. dorsi, subscapularis, teres major ➤ Medial - Serratus anterior and thoracic wall ➤ Lateral - Intertubercular sulcus ➤ Cubital fossa ➤ Boundaries ➤ Laterally - brachioradialis ➤ Medially - pronator teres ➤ Superiorly - imaginary line between the 2 humeral epicondyles ➤ Contents (MBTR) ➤ Median nerve, bifurcation of the brachial artery, tendon of the bicep muscle and radial nerve ➤ Carpal tunnel ➤ Attaches to pisiform, hook of the hamate, scaphoid tubercle and the trapezium tubercle ➤ Roof is the flexor retinaculum ➤ Contains the flexor digitorum superficialis and profundus, the flexor pollicis longus and the median nervePECTORALGIRDLE ➤ Superficial muscles of the back ➤ Teres major ➤ Deltoid ➤ Serratus anterior ➤ Innervated by long thoracic nerve ➤Winging of the scapula if nerve damaged ➤ Pectoralis minor and majorTHECLAVICLE ➤ Fractures affect middle third the most and medial third the least ➤ Junction between lateral and middle third the weakest ➤ Distinguish between clavicular fracture and AC joint dislocation ➤THESHOULDERTHEGLENOHUMERALJOINT ➤ Unstable ➤ Highly mobile ➤ Made of the head of the humerus and the glenoid cavity of the scapula ➤ Deepened by glenoid labrum ➤ Extracapsular ligaments ➤ Coracoacromial ligament (most important) ➤ Coracohumeral ligament ➤ Coracoclavicular ➤ Transverse humeral ligament ➤ Intracapsular ligament ➤ Superior, middle and inferior glenohumeral ligaments ➤ Coracoacromial arch ➤ Made of coracoacromial ligament, coracoid process and acromion ➤ Prevents upper displacement of the shoulder ➤ Painful arch syndrome - pain between 60-120 of shoulder abduction due to rubbing of supraspinatus tendon under CAA ➤ Dislocation usually anterior-inferior ➤ Squared off shoulder ➤ Head of humerus will lie under the coracoid process ➤ Posterior dislocation usually due to very high impact and very rareROTA TORCUFFMUSCLES ➤ Suprapsinatous ➤ Suprascapular nerve ➤ First 15-20 of shoulder abduction ➤ Infraspinatous ➤ Suprascapular nerve ➤ Lateral arm rotation ➤ eres minor ➤ Axillary nerve ➤ Lateral shoulder rotation ➤ Subscapularis ➤ Upper and lower sub scapular nerve ➤ Medial shoulder rotationTHEHUMERUS ➤ Osteology ➤ Surgical neck fracture can result in axillary nerve damage ➤ Loss of sensation in regimental badge area (RBA) ➤ Loss of motor function (too painful to test) ➤ Articulates inferiorly with the radius and the ulna and superiorly with the glenoid ➤ Annular ligament between radius and ulna (top) ➤ Radial collateral ligament ➤ Ulnar collateral ligament ➤ Medial and lateral epicondyles distally ➤ Olecranon bursa posteriorly ➤ Medical student’s elbow when inflamed ➤ Subtendinous bursa between tricep tendon and olecranonMOVEMENTSATTHEELBOWWHICHISSTRONGERPRONA TIONORSUPINATIONANDWHY ➤ Supination due to the help of the bicep brachiiCOMPARTMENTSOFTHEARM ➤ Enclosed in deep fascial sheath ➤ Anterior ➤ Flexion of the arm and supination ➤ Bicep brachii, coracobrachialis and brachialis muscles ➤ Brachial artery ➤ Musculocutaneous nerve ➤ Posterior ➤ Extension of the arm ➤ Tricep brachii and anconeus ➤ Profunda brachii and ulnar collateral arteries ➤ Radial nerve ➤ Reflexes ➤ Tricep tendon reflex C7, C8 ➤ Brachio-radialis C5, C6 ➤ Bicep tendon reflex C5, C6 ➤ C5 C6, pick up sticks, C7 C8, push the gateBLOODSUPPYTOTHEARMLYMPHNODESINTHEAXILLA ➤ Humeral, subscapular and pectoral drain into central which drains into apical which drains into supraclavicular ➤ Can have lymphoedema in the upper limb post surgical removal of cancerous lymph nodes from the axillaTHEBRACHIALPLEXUS ➤ From C5-T1 ➤ Innervates the upper limb ➤ Dermatomes: area of the skin supplied by a cutaneous branch of single spinal nerve ➤ Musculocutaneous C5-C7 ➤ Median (C5-T1) ➤ Axillary (C5-C6) ➤ Radial (C5-T1) ➤ Ulnar (C8-T1)BRACHIALPLEXUSINJURIES ➤ Erb’s palsy ➤ Axillary nerve ➤ Due to excessive increase of angle between neck and shoulder ➤ Ex. Pushing of neck during delivery ➤ Waiter’s tip appearance ➤ Arm medially rotated, shoulder adducted, elbow extended and flexion at the wrist. ➤ Klumpke’s palsy ➤ Ulnar nerve ➤ Upward traction of upper limb ex pulling of arm during delivery ➤ Compression of C8 & T1 ➤ Usually affects short muscles of the hand leading to a claw hand deformityTHEFOREARM ➤ Bones include radius and ulnar ➤ Interosseous membrane between the two ➤ Articulate inferiorly with scaphoid (radius), lunate (both) and triquetrium (ulna) ➤Articulation between ulna and carpal bones separated by articular disk ➤ They form a circle so if break one side likely to break the other at the same timeANTERIORCOMPARTMENT ➤ Flexion and pronation ➤ Mostly innervated by median nerve but also by ulnar nerve ➤ 3 layers ➤1 - pronator teres, flexor carpi radialis, palmaris longus and flexor carpi ulnaris ➤ Everything is median nerve other than flexor carpi ulnaris ➤ 2 - flexor digitorum superficialis ➤ 3 - flexor pollicis longus, flexor digitorum profundus, pronator quadratus ➤ Everything is median nerve other than flexor digitorum profundus 4 & 5POSTERIORCOMPARTMENT ➤ Extension, supination and thumb abduction ➤ Innervated by radial nerve ➤ 2 layers ➤ 1- anconeus, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, extensor carpi radialis longus and brevis ➤ MURDAR (murder with an A) ➤ 2- supinator, extensor pollicis longus and brevis, extensor indices and abductor pollicis longus ➤ Brachioradialis ➤ BR x 5 ➤ Beer Raising ➤ Breaks Rules ➤ Flexor But Radial ➤ Behind is Radial nerve in cubital fossa ➤ Attaches to Bottom of RadiusFOREARMNERVESDERMATOMESTHEHAND ➤ Made of phalanges, metacarpal and carpal bones ➤ Carpal bones ➤ Scaphoid, lunate, triquetrium, pisiform ➤ Trapezius, trapezoid, capitate, hamate ➤ She Likes To Play, ry o Catch Her ➤ Anatomical snuff box ➤ Borders: extensor pollicis longus medial, extensor pollicis brevis and abductor pollicis longs laterally ➤ Pain here can indicate scaphoid fracture often from FOOSH ➤ Cutaneous innervation ➤ Median lateral 3.5 ➤ Ulnar medal 1.5NAMETHECONTENTSOFTHEEXTENSORCOMPARTMENTSINTRINSICMUSCLESOFTHEHAND ➤ Innervated by the ulnar nerve ➤Palmaris brevis ➤Interossei muscles ➤PAD and DAB ➤Adductor pollicis ➤Hypothenar muscles ➤Medial 2 lumbricals ➤ Innervated by the media nerve ➤ Lateral 2 lumbricals ➤ Thenar musclesTHELOWERLIMB ➤ Made up of the: ➤Pelvis ➤Thigh ➤Leg ➤ FootAREASOFTRANSITIONOFTHELOWERLIMB ➤ Femoral triangle ➤ Boundaries: sartorius laterally, adductor longus medially and inguinal ligament superiorly ➤ Contents: NAVEL - femoral Nerve, Artery, VEin, Lymph nodes ➤ Opens into popliteal fossa and is continuous with the adductor canal ➤ Popliteal fossa ➤ Boundaries: semitendinosus superior-medially, bicep femoris superior-laterally, medial head of the gastroc inferior-medially and lateral head of the gastroc inferior-laterally ➤ Contains tibial nerve, popliteal artery and vein ➤ Tarsal tunnel ➤ Roof by flexor retinaculum and floor by calcaneus and medial malleolus ➤ Contains: tendon of the tibialis posterior, tendon of the flexor digitorum longus, posterior tibial artery and vein, tibial nerve, tendon of the flexor hallucis longus ➤ Tom, Dick Andery Nervous HarryLUMBO-SACRALPLEXUS ➤ Lumbar plexus ➤ L1-L4 ➤ Mostly anterior ➤ I, I Get Lunch On Fridays ➤ Iliohypogastric ➤ Ilioinguinal ➤ Genitofemoral ➤ Obturator ➤ Femoral ➤ Sacral plexus ➤ L4-S4 ➤ Mostly posterior ➤ Some Irish Sailors Pester Polly ➤ Sciatic ➤ Inferior gluteal ➤ Superior gluteal ➤ Posterior femoral cutaneous ➤ Pudendal ➤ Stand on S1, sit on S3 ➤ Ankle reflex L1, L2 (S1, S2, buckle my shoe) ➤ Knee reflex S3, S4 (L3, L4 kick the door)BLOODSUPPL Y,VENOUSDRAINAGEANDL YMPHA TICS ➤ Blood supply ➤External iliac onwards ➤ Venous ➤Superficial to deep, distal to proximal veins ➤Medial - great saphenous - drains into femoral vein ➤Lateral - short saphenous - drains into popliteal vein ➤Assisted by muscle pump ➤Varicose veins due to valve incompetence so can’t prevent back flow ➤ Veins become ➤ Risk factors ➤ Pregnancy, obesity and age >65 ➤Deep vein thrombosis if blood clot in deep veins causing blockage ➤ Can lead to pulmonary embolism ➤ Lymphatics ➤Also superficial to deep, distal to proximalGLUTEALREGION ➤ Gluteal cleft in the midline ➤ Gluteal fold at the bottom ➤ Superficial abductors and extenders of the hip ➤ Gluteus max, medius and minimus and tensor fascia lata ➤ Gluteus medius, gluteus minimus and tensor fascia lata- superior gluteal artery and nerve ➤ Gluteus maximus - inferior gluteal artery and nerve ➤ Deep lateral rotators ➤ Piriformis**, gemellus superior and infer, quadratus femoris and obturator internusTHEHIPANDTHEPEL VIS ➤ Ilium, ischium and pubis ➤ Pelvic differences ➤ Gynecoid ➤ Rounded inlet and wider pubic angle ➤ Typically female ➤ Android ➤ Heart shaped inlet and narrower pubic angle ➤ Typically male ➤ Pelvic girdle joints ➤ Lumbo-sacral ➤ L5 and S1 ➤ Sacroiliac joint ➤ Pubic symphysis ➤ Hip joint between acetabulum (3) and head of the femur ➤ Deepened by the labrum of the acetabulum ➤ Joint ligaments ➤ Iliofemoral - against hyperextension (strongest) ➤ Pubofemoral - against hyperabduction ➤ Ischiofemoral - against hyperextensionTHETHIGH ➤ Osteology of the femur ➤ Largest bone in human body ➤ Blood supply by femoral artery and obturator artery ➤ Circumflex arteries (L&M) around neck of femur ➤ Avascular necrosis ➤ Nerves of the thigh ➤ Femoral under inguinal ligament ➤ Sciatic through greater sciatic notch ➤ Obturator through obturator canalWHATISTHESMALLESTBONEINTHEHUMANBODY ➤ StapesCOMPARTMENTSOFTHETHIGH ➤ Wrapped in fascia ➤ Anterior ➤ Femoral nerve ➤ Femoral artery ➤ Knee extensors and hip flexors ➤ Iliopsoas (iliacus and psoas major), sartorius, tensor fascia lata (sup. glute nerve), vastus lateralis, intermedius and medialis and the rectus femoris ➤ Posterior ➤ Sciatic nerve ➤ Deep femoral artery ➤ Knee flexors, rotators and hip extensors ➤ Semitendinosus, semimembranosus, bicep femoris ➤ Medial ➤ Obturator nerve ➤ Obturator artery ➤ Hip adductors ➤ Adductor longus, magnus, brevis and pectineusTHELEG ➤ Tibia ➤W eight bearing (weight from femur) ➤Articulates with th, the talus, the fibula and the patella(?) ➤ Fibula ➤Not weight bearing ➤Not part of the knee joint ➤Stabilizes the ankle ➤Bottom forms lateral malleolusTHEKNEE ➤ 3 articulations ➤ Tibio-femoral x2 ➤ Patello-femoral ➤ Patella is a sesamoid bone ➤ Movements ➤ Locking and unlocking - rotation ➤ Lock Laterally ➤ Ligaments ➤ Medial and lateral collateral tested by valgus and varus stress test ➤ Anterior and posterior cruciate tested by anterior and posterior drawer (90 ) and lachman (20 ) (sensitive) tests ➤ Lateral and medial menisci (cartilage not ligament) ➤ Shock absorber ➤ Bursae of the knee ➤ Pre-patellar, subcutaneous and deep infrapatellar and suprapatellar ➤ Genicular branches of the femoral and popliteal arteries supply the kneeCOMPARTMENTSOFTHELEG ➤ Anterior ➤ Lateral ➤ Dorsiflexion ➤ Eversion ➤ Extension of the digits ➤ Superficial fibular nerve ➤ Inversion ➤ ➤ Deep fibular nerve Fibular artery ➤ Anterior tibial artery ➤ Peroneus longus and brevis ➤ Tibialis anterior, extensor digitorum longus and extensor hallucis longus ➤ Posterior ➤ Plantar flexion ➤ Inversion ➤ Flexion of the digits ➤ Tibial nerve ➤ Posterior tibial artery ➤ Superficial - gastroc and soleus ➤ Deep - popliteus, flexor digitorum longus, tibialis posterior and flexor hallucis longusTHEFOOT ➤ Osteology ➤ CCC, Call The Navy Captain ➤ Blood supply from medial (1.5) and lateral (3.5) plantar arteries ➤ Arches ➤ Lateral and medial longitudinal and transverse ➤ Inversion and eversion at subtalar joint ➤ Ligaments ➤ Medial collateral/deltoid - prevents excessive eversion (strong) ➤ Lateral collateral - prevents excessive inversion ➤ Anterior talofibular most commonly injured (test with drawer test) ➤ ATF is ATF: AnterioraloFibular is Alwaysorn First ➤ Long plantar, short plantar, spring and transverse metatarsal in foot ➤ Intrinsic muscle originate in the foot, extrinsic muscles don’t ➤ Support arches and digits ➤ Plantar fascia has 3 parts - lateral, medial and central ➤ Most problems at attachment onto the calcaneus ➤ Compartments - lateral, medial, superficial and deep - risk of compartment syndrome due to infectionPULSESOFTHEFOOT ➤ Dorsalis pedis ➤From anterior tibial artery ➤Felt on dorsum of foot between exterior hallucis longus and extensor digitorum (flex big toe) ➤ Posterior tibial pulse ➤Felt behind the medial malleolusTYPESOFINJURIES ➤ Sprains ➤ Fractures ➤ Subluxations ➤ Dislocations ➤ Fracture dislocations/subluxationREVIEWINGX-RA YS ➤ Details ➤ Pt name, DOB, hospital/NHS#, any previous x-rays, when was it take, PA, lateral, oblique, 2 views) ➤ Adequacy ➤ Joint above and below ➤ Penetrance ➤ Rotation ➤ ABCS ➤ Alignment ➤ Dislocations, subluxations, misaligned ➤ Bones ➤ Density, joint space, deformities ex osteophytes, cysts ➤ Cortices ➤ Discontinuation/fracture ➤ Soft tissue ➤ Swelling ➤ Foreign bodiesDESCRIPTORSOFOFFRACTURES ➤ Site ➤ Complete or incomplete ➤ Bone broken along whole width ➤ Open or closed ➤ Clean DIRT ➤ Clean ➤ Debridement ➤ IV Abx ➤ Reduce ➤ etanust status ➤ DisplacementTYPESOFFRACTURES