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Anatomy: The Abdomen and Pelvis

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Summary

This on-demand teaching session invites medical professionals to join a detailed exploration of anatomy, specifically focused on the abdomen and pelvis, upper lower limb, and general anatomy. The session aims to get participants exam-ready using a highly interactive and at times informal method. It covers crucial subjects such as embryology of the GI tract, the peritoneum, hernias, and the blood supply of the stomach, with ample time for discussion and questions. Attendees will also have access to the lecture slides and recordings and self-paced assessments after submitting their feedback on the session. The presenter has a pioneering background in medicine and promises a discussion-based session instead of a unidirectional lecture.
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Learning objectives

1. Understand the embryology of the GI tract and be able to relate this to specific conditions such as bowel abnormalities. 2. Develop a strong understanding of the anatomy and function of the peritoneum, particularly distinguishing between the parietal and visceral layers. 3. Gain insight into the causes, symptoms and treatments of both direct and indirect hernias through comprehensive analysis of their distinguishing features. 4. Understand the blood supply of the abdominal cavity, focusing on the major supplies to the stomach. 5. Be able to explain the anatomical details of key abdominal organs and their functional significance in various diseases.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

And I'll just quickly introduce you. Yeah, thanks. Hi, everyone. Can everyone hear us if we can just get a thumbs up in the chat or just a Yes, that would be great. Just wait until we get that. So we know for sure. Can you guys hear us if someone can just put yes in the chat? That would be great. Yeah. Yes. Ok. Brilliant. Thanks guys. Um So thank you all for coming. Um As you guys know, this is one of the final teaching series that we're going to be doing the Creche courses and today it's about a um, anatomy. So we've got some amazing lectures lined up to you, uh, for you, we've got the abdomen and pelvis first and then after that, we've got upper lower limb and then your anatomy as well. So this is meant just to get you um, exam ready. So just a few housewarming tips, if you guys have any questions, then put them in the chat and we'll read them out and alongside that, if you guys can all just fill in the feedback form after when you fill out the feedback, feedback form, then before your exams you guys will get access to the lecture slides and to the lecture recordings and some S PA S as well. So I'll hand over to our first speaker then. So you go. Great. So, um thanks for the introduction and if you go, my name is me. I'm a finally a medical student at Brighton and Sussex Medical School. Um I'm gonna have this be relatively informal. So if anyone's got any questions, um please just do interrupt me and we can just talk about it and my slides are pretty minimalist. And um so there should be more of a discussion than me just talking at you for an hour. Um So, yeah, thing is confusing. Just stop me. So, yeah, they have this in there. Who am I? I'm a pioneer at the SMS and I'm going into um doing an S FP in coastal medicine in Pembrokeshire Wales. Um So these are the topics covered today, but we'll do more than this. So, the first thing I'd like to talk about is um embryology of the gi tract. So, developmentally, it's endodermal, only the mucosal layer of the ab uh bowel is endodermal. The rest of the layers have different origins. So the muscle layer will be mesodermal and et cetera. Um I wouldn't worry much about the embryology of the gi tract other than the clinical significance of certain um developmental anomalies such as um does anyone know a vine duct is or what anal is enteric defective. Has anyone heard of those things? Someone said yes. Um Yeah. So you can, you, can you answer? She said yes. Why did that happen? Why does any phal I happen? Does anyone know? No? Well, so, um, developmentally, um, part of your small bowel goes into, um, the vitelline tract whilst it develops and if this tract remains into adulthood, you can get something called a called an omphalocele, which is where your bowels still herniate through your abdominal wall. So this is probably the most important thing I'd get away from embryology of the gi tract. The rest of it in real life in clinical years is not very important. Most doctors and surgeons don't really know it. So I wouldn't worry too much about it. The next key point is the peritoneum. So, the way I used to teach the peritoneum back when I used to teach anatomy was, um, imagine the abdominal peritoneal sac as a balloon. And the inside of the balloon is the peritoneum. And you've got the flat side of your left hand, the balloon in your left hand and you're pushing your fist into the balloon with your right hand. So the balloon covering your right handed fist is the visceral peritoneum. And the layer of the balloon covering your flat left hand is the parietal peritoneum if that makes sense. So all of the intraperitoneal organs push into the peritoneal cavity and those that are covered by it are intraperitoneal and those that, that are behind it are retroperitoneal. Um Does that make sense? Just say yes or no. Do you want me to explain that again? Go back to the previous slide. Yep. So slide for that one. What, what did you have to ask? Do you have a question there? Oh OK. Yeah. Sure. No worries. Do you have any questions as well? Just put them in the chat? Yeah. Great. Does this make sense? The thing about the peritoneum? So any organ that pushes into it? Just imagine it? Yeah. Yeah, I'll, I'll explain it again. So if you imagine a slightly flaccid balloon in a flat palm of your hand on the left hand and you push into this slightly flaccid balloon with your right handed fist. The layer of the balloon covering your fist is the visceral peritoneum. Viscera just means organ and parietal peritoneum is the peritoneum covering your flat left hand. So it's just the abdominal wall. So, visceral peritoneum is the protein covering the organs. And parietal peritoneum is the peritoneum covering the abdominal wall as simple as that. And the way I used to remember it when I was back in first year was parietal sound a bit like parent and parents surround their Children. And so the parietal peritoneum covers the entire abdominal cavity and the visceral peritoneum, viscera means organ and it covers the organs. Does that make sense? I hope that does, I hope it makes sense. Um Yeah, the, the best way to think about it is just there's a flaccid balloon. And yeah, you, you, you sort of punch into it. The layer of the balloon covering your fist is visceral layer of balloon on the flat side of your left hand is parietal as simple as that. Um, I've written here, greater sac and lesser sac. So greater sac is the thing in. So, um, it's the whole abdominal cavity, basically, the whole abdominal cavity is the greater sac and the lesser sac is a small space behind the stomach, which is left there after the rotations of the bowel, I'd only, I'd only remember that in terms of distinction, I wouldn't much go into the way of how they form and the clinical significance of it just yet. I think you, you sort of learn that into 3rd, 4th and final year when you learn about gastroenteritis and pancreatitis and that sort of thing when Pseudois form behind the stomach. So I wouldn't worry about it just yet. Just know that there was a greater sac, which is the entire abdominal cavity and a lesser sac which is behind the stomach and they've written their recesses. So there's three important recesses. I'd like everyone to remember. So, there's one called the recto uterine pouch or the pouch of Douglas, which is between the uterus and the rectum. There's another pouch in the female called the Vasica uterine pouch, which doesn't have an autonomous name and it's between the bladder and the uterus. These two are important because it, if someone has any free fluid, it's where these collections of fluid gather. And so it's important in terms of putting an acidic drains or any drains into any abdominal collections, you want to point these downwards. So it drains downwards in a man. There's only one pouch called the vy recto versal pouch between the rectum and the bladder. And there's also one other recess called the pouch of Morrison between the right kidney, the right liver and yeah, in that area, it's called the pouch of Morrison. And it's the lowest point in a supine abdomen where fluid collects if you're lying flat. Does that make sense? I hope this stuff isn't new and I hope it's not too difficult. If anyone's got any questions, please feel free to ask or just wait here for a second. Right? I think everyone's happy with that. So hernias. So um the way I used to teach hernias is think about it like a, a piece of card that's rolled up and it, it's in a 3d space. So think of your abdomen as a 3d structure. And the internal ring goes into this gutter from inside of the abdomen. The canal is the gutter itself, the rolled up paper and then it has an exit hole lower down near the scrotum or the labium majus in a female. And that's the external b and that's as simple as the inguinal canal is, there's nothing more that can complicate it. And the way to differentiate a hernia from a direct and an indirect is very confusing because they say if it's uh lateral to the inferior epigastric, it's a uh indirect hernia. But you can't see the inferior gastric in a real human. In a living patient, you can't see them on an examination. It's more of a laparoscopic or a surgical finding when you repair the hernia. So um the more important things just to remember are mm like nine out of 10, a direct hernia goes directly into the scrotum or labium matrix because it goes through Hassleback triangle. Does anyone know what Hassleback triangle is? Just write it in um the chat thing. So, Hassleback triangle, if no one's heard of it is um is a triangle of weakness in the anterior abdominal wall where direct hernias go through. And the way I remember HAC triangle is the inferior epigastric vessels shown here in red in the diagram. That's one of the boundaries, the rectus abdominis muscles which are the midline ab muscles form another boundary. And the inguinal canal forms the third boundary. And that has a triangle of weakness where bowels connects it. Um If there's higher intraabdominal pressure and um the way I remember direct hernias from indirect hernias is the bowel goes directly into the scrotum and it goes not through the ring. Whereas in an indirect hernia the bowels go through the inguinal ring and then into the scrotum. So that's an indirect route into the scrotum. Does that make sense? Direct tenures go directly into the scrotum bypassing the ring? An indirect tenure goes through the ring and into the scrotum. Easiest way to remember it. Hopefully, that makes sense. Great. Thanks Ryan. So, uh I was told to briefly go over some of the organs. Um I'm not gonna go through the entire blood supply of the abdomen here because it's too much to cover in an hour. But it's one thing I'd say is if you spend some time learning the blood supply of the stomach, you've learnt the whole abdominal cavity, cos it's got such a varied and split supply from four vessels in the lesser and greater curvatures that if you, if you clock that you've basically understood abdominal surgery. And um yeah, that's probably the hardest part in the whole of the abdomen. If anyone's got any specific questions around it, I'm happy to answer them, but I'm not gonna go through the whole blood supply of the stomach here. Just know that the greater curvature is supplied by the right and left gastroepiploic arteries and the lesser curvature supplied by the right and left gastric arteries. That's a very surface level explanation. But to properly understand that you do need to sit down and learn it. So if anyone's got any questions, I'm happy to answer them in their comments Um I, to be honest, I've written a very nice chapter about the blood supply of the stomach and the abdominal cavity. I can pass it on to the organizers of this talk. Um No, no, I'm not gonna recommend that. I, I've, I'm saying I've written a very nice chapter on the abdominal blood supply so I can just pass that on to whoever's organizing this series and they can maybe distribute it. Um Yeah, so there's no copyrights or anything for that. So I can just pass that around. Um, as a general rule. Um Just remember that the abdominal blood supply is split into three. So the four gut is supplied by the celiac trunk. The mid gut is supplied by the S MA and the hind gut is supplied by the inframesenteric artery. So these are the three main midline arteries of the um uh small bowel and the large bowel and the abdomen basically. And developmentally this is how the um, valves develop. And then this carries on into adulthood and it gives you the full gut midgut and hindgut. I'll just briefly talk through it and I'm sure it's gonna be confusing for everyone now. But um, you can probably read up on it after. So the elect trunk comes off at the abdominal aorta at the level of T 12 and it trifurcates into three vessels. The left gastric, the common hepatic and the splenic artery, the left gastric goes and supplies the lesser curvature of the stomach. The common hepatic divides into the hepatic artery proper. And the uh gastroduodenal artery, gastroduodenal artery gives supply to the um superior pancreaticoduodenal artery which supplies the proximal 2, 2/4 of the duodenum and the pancreas. And it also gives the right gastroepiploic artery which supplies the greater curvature of the stomach. The common hepatic artery after it gives the hepatic artery proper, gives you the um, right gastric artery. And then it supplies arterial blood to the liver. The splenic artery on its way to the spleen, supplies the pancreas, giving off the arterial pancreatic and magna and then the left gastroepiploic artery as well. And then it divides into a few lowbar branches before going into the hilum of the spleen. That's probably the hardest part of the abdominal blood supply. And I'm sure it's very confusing. But if you sit down and read it, it's easy. Super mesenteric is relatively easy because you just go from proximal to distal in terms of the bowel. So you find the top end of the bowel and then you just follow it down. So you've got the inferior pancreaticoduodenal artery supplying the 2/4 of the distal duodenum. You've then got the vaginal arteries, the ileal arteries, the ileo colic arteries supplying the cecum and appendix, the right colic artery and the middle colic artery. And that's sma done. Then you've got the I MA carrying on supplying there. You've got the left colic artery anastos with the middle colic artery with the marginal artery drummond. Then you've got the sigmoidal arteries and the superior rectal artery. And that's where the abdomen ends and rectum starts, which is not technically, um, abdominal viscera, it's more parietal because it has parietal blood supply. So, yeah, if anyone's got any questions on that, do put them in the chat, hopefully I can answer them. So I've kept it relatively simple. Small bowel is made up of three parts. The duodenum, the Jejunum, the ilium, the duodenum and Jejunum have a clear anatomical boundary with the ligament of trites where the suspensory ligament of trites tells you this is where duodenum ends. This is where Jejunum starts. JJ and Ili on the other hand, have a very indistinct boundary and it's more of a gradual transition from one to another where certain changes are notable where, so for example, the ili mesentery is fattier because you have the Payers patches in the small bowel absorbing lipid. So the ilium mesentery is fattier also as you go from proximal to distal, you'll see in real life, the lumen of the small bowel narrows as you go more distally. And then there's also histological things like there's fewer plica circularis and more distribution of um mucus producing cells and that sort of thing. So that's more histological but gross differences. Look at the mesentery, if it's fattier, it's probably ilium and look at the blood vessels in the mesentery as well. They change to go proximal to distally. Bye. So that's the small bowel. Um, I'd know the commonest cause of obstruction if anyone knows. Um, just put that in the chat. Most common cause is small bowel obstruction, small bowel and large bowel have different common causes of obstruction, but small bowel is way more common than do bar obstruction. So it's probably useful to know if anyone knows, put it in the chat. You don't know that's fine as well. So that um not a hernia, so it's adhesions. So, um common, the common causes of adhesions include previous abdominal surgery. Yeah, adhesions. Uh Ryan's just had a adhesions. So, um adhesion is the most common cause of small bowel obstruction. Common causes of adhesions include previous abdominal surgery. Um uh other things like endometriosis or pelvic inflammatory syndrome or Crohn's disease. Loads of things cause adhesions and the small, um small bowel is very prone to them because it's covered by peritoneum which is very um prone to forming adhesions. And I'd know the diseases. This is more um gastroenterology than surgery or anatomy, but I'd, I'd learn the small bowel diseases. There's only a few. So, Celiac disease and Crohn's disease. Um People often ask me why is not a small bowel disease, but the answer is in the name, it's called ulcerative colitis, which is a disease of the large bowel, not small bowel, right? Um Brian, you said tumors, um small bowel tumors are exceedingly uncommon. Um, almost like super rare S II wouldn't say small bowel tumors as a common differential for small bowel obstruction. I'd agree with hernia. I'd agree with adhesions. And the third one, which is relatively common is volvulus. So you can have a twisting of your small bowel. But yeah, they're the most common ones. Tumors is uncommon. Yeah, embryology into adult life. So, um the key points are so four guts supplied by the celiac trunk, artery wise drained by the portal vein and celiac lymph nodes drain it as well. Midgut supplied by the superior mesenteric artery, very large, superior mesenteric vein and drained by the super mesenteric lymph nodes. I gut supplied by the inframesenteric artery, drained by the inframesenteric vein and drained by the inframesenteric lymph nodes. I mean abdominal anatomy is easy after all. It's just follow the neurovascular bundles and they all have the same name. Any questions on this, right? So let's move on. So, appendicitis. Um So first question is to you guys, why do you get referred to pain in appendicitis? This is an exam question favorite or a um sort of U university style favorite. Sorry, cons strictures called small bowel obstruction. So, strictures, yes, they can do. You know what diseases can cause strictures in the small bowel stricture by definition isn't an obstruction stricture by definition is a narrowing, but you know what conditions can cause strictures. One main one. Yeah, Crohn's disease. Exactly. So, it's very stricturing and it's very ulcerating, that sort of thing. Um And then onto appendicitis, does anyone know why you get referred pain in appendicitis? So any time you do any surgical job or any surgical rotation, you get asked this. So it's useful to know why did you get abdominal umbilical pain? And then right, I fossa pain. Yeah. How does that work? Sensory nerves. So I I'd break up the nerves into um visceral and somatic visceral just means nerves, supplying the organ viscera. After all means organ, somatic means outside and peripheral. So initially, when the appendix is inflamed, the pain signals, the pain signals enter the spinal cord around the level of T 10. And so that is the dermatome of the umbilicus. So, just inflammation of the organ itself sends base signals into the spinal cord and it enters at the level of T 10. So you get referred pain at the level of the umbilicus, but as the appendix becomes more inflamed and it forms an inflammatory mass and it touches the parietal peritoneum on the outside of the abdomen, um you get more uh localized somatic pain. So that's why you get referred pain initially and then you get localized pain later. Does that make sense? So, the visceral nerve fibers of the appendix enter the spinal cord at the level of T 10, which is the same dermatome as the umbilicus as you then progress into appendicitis, you get localized pain at the level of mcburney's point, because the appendix touches the parietal peritoneum, which is very sensitive prior to protein, in fact, has the same localized pinpoint discrimination, nerve sensation as the skin on the outside. So it's the same sort of pain and touch and that sort of thing. And onto mcburney's point, does anyone know what this is and where you'd find it in terms of an examination? It's the old landmark for an open appendicectomy. Not so much used anymore because of laparoscopic surgery. Sorry, Max, I don't know why you can't hear anything. I don't know if there's any, any admins on the call who can help. II think there's a recording of this as well that, that we sent her after. Um, but yeah, if anyone knows how you'd find mcburney's Point, um, just put it in the chat. Yeah, it's between the Aces and the Emboli cos. Do you know what distance? So, 22 3rd away from the, um, umbilicus, one third away from the ASIS. So it's quite low down and it's the historical landmark used in, um, abdominal palpation in diagnosing appendicitis in re you get maximum rebound tenderness over this area. And it's also the landmark used to do an open appendicectomy. Um, does anyone know why laparoscopic is preferred to open? This is not really anatomy. This is just real life. So, um, laparoscopic surgery has got much quicker outcomes, fewer wound infections, fewer risks of bleeding and perforating bowel and that sort of thing, minimally invasive. Exactly. So, um, financially speaking, it's more beneficial for a hospital to have patients come in and leave on the same day and have day case surgery rather than opening up someone's abdomen and then making the main patient after like time of stay after lap operation is much shorter than an open because you have to have an eye on the wound, see if it's oozing if it's dry, if there's any structure and all of that stuff for a surgical wound. Whereas if you've only got five millimeter scars at port sites, much, much quicker outcomes and recovery hope that is useful next year's large bowel. So key points are here. So identifying large bowel overall structure and surface landmarks. So the large bowel has um Hatra which are just balloonings of the bowel, Taenia Coli and appendices, epichloe or mental appendices. So if you look onto this very rubbish um cartoon diagram on the left side, you can see the haustra are sort of bulges of bowel and these are caused by the Taenia Coli. So the Taenia Coli are shorter than the entire length of the large bowel, which is why you get these balloonings and out pouchings of the mucosal and um muscularis layers of the large bowel. So it sort of contracted down because the tia coli are shorter and the tia Coli are involving peristalsis and moving colonic contents along the pile from proximal to distal, your mental appendices are also surface landmarks in finding differentiating large and small bowel because sometimes they look very similar. Zeta. Um Does anyone know how you'd locate the appendix using the large colon? It's a very common exam question that I was asked back in the day, how would you find the appendix once you found the large bowel? So the obvious answer is you just find the s and find it at its end. But the less obvious answer is you'd find the Taenia Coli, which are the thin strips of longitudinal muscle and all three converge onto the appendix. So that's a good surface landmark for finding the appendix. Yeah, that's it. Someone's had it. Yeah. Comments. Um So well done. Um So that's the large bowel. Does anyone know how diabetic killer form on the large bowel and sigmoid codon? So, a diverticular disease is caused by um mucosal herniation through the muscularis layer of the bowel. And it causes loads of tiny pockets of mucosa protruding through the muscularis layer of the tmo colon. It's caused by high pressure. And um you, you get the, the, the, the the theory was you get these mucosal herniations through the structure of the bowel because veins and arteries which perforate through the muscle layer give small muscular openings and defects in the muscle layer. So when there's high pressure in the sigmoid colon, mucosa, actually herniates through these weaknesses. So you get tiny pockets of mucosa pushing out and, um, mostly it's asymptomatic diverticulosis. But if they become infected, you call it diverticulitis. It's very common in GP. Um So that's diverticulitis. It's very common. So I'd learn about it and the rectum is the distal portion of the sigmoid colon and then it just meets with the outside. Um So, yeah, that's me done. Um I've kept it short on purpose. Um, having an opportunity for any questions that you might have because I didn't want to go through the entire curriculum. Cos I'm sure you already know it coming to the end of the year. So if you've got any specific questions, I'm happy to answer them. If you just put them in the chat, I'll try and answer them and do my best. It's the same advice everyone always gives. Um, make sure you enjoy your time and get some time traveling, having come to the end of my time at medical school. II agree with it. Do you recommend any specific book for anatomy other than letters? So the way I did it was, um I'm not much of a reader and um so II found, I don't know if your universities give you access to Alan's anatomy, I'll put it in the chat. It's a video sort of service and people used it for the MRC S exam. And so they're like 2 to 3 minute videos on very specific anatomical regions, for example, a joint or a muscle or a nerve. And I just watched that the weekend before my anatomy dissecting room sessions. I thought that really helped me. The other way I learnt was to just teach it to my peers and younger years and that sort of thing cos your anxiety and O CD will make you learn way more just in case, then you need to know for passing exams. So the best way to learn is teach it any other questions. If anyone has any questions, just put them in the chat and I'm sure we will be happy to answer them. You can ask really specific and niche things as well. I'll try and do my best. Ok. Well, if no one has any questions, then thank you so much for that lecture. It was, it was really, really helpful. I'm sure everyone appreciated a quick summary of the abdomen, anatomy and pelvis. Thank you so much. Um What we can do guys is just a quick reminder. Please do fill out the feedback forms which you'll get at the end of the session. Um as that's really important for both the lecturers, but also for yourself. So you get access to all of this um material after as well. We'll take a 10 minute break and then at exactly 1045 we can start with lower limb and upper limb. So if you guys just wanna go get a coffee, coffee or just relax for 10 minutes. And at 1045 we'll start with lower limb and upper limb. Ok. Um I also wanted to ask Anushka. Um So I've said to these guys, I'll send them my um bit on the vascular of the abdomen. Can I send it to you and then you can pass it on? Yeah. Yeah. So if you send it to me now, what I can do is to put it in the chat for these guys. Cool. Yeah, I'll do that now then. Ok, thank you back here at 1045. Ok, see them. Thanks, bye. Uh Yeah, so just for the questions that just got put in the chat guys. So what will happen is that once you guys fill out the feedback forms then automatically on medal, the um video recordings and the video slides will be actually just pick up and once you fill out the feedback, you have access to that. So that'll be on medal, ok? Um But I will send, you'll also get an email to your account so that you have access to it. I'm just telling you how to access it. Ok? And that will be the same for your certificates after the event as well. Um So you guys remember all of these things that you attend. Um They count for uh things that you can put in your portfolio. So make sure you keep those certificates nice and safe. Um As that'll be useful for you later. Hi guys. So we'll just start the um uh limb lectures very soon. Just in the meantime, um meet you just gave, the last lecture has very, very kindly sent over um his um bit in the book about the vasculature of the abdomen and pelvis. So, what I'll do is I'll put it on the catch up content. Um after uh you guys fill out the feedback forms and you'll get access to that as well. So it'll be um alongside the slides as the electric Y doctor Cameroon. Uh Yeah. So um everyone, we're live right now. So if you just wanna share your slides as well, how do I do the, so if you press um present now at the bottom next to the camera, OK. Um And then you can either share them as a PDF or you can just share your screen. OK? Uh Fine uh tr pages. I just um share my screen actually make it easier as my uh so we can't see a screen yet, but I, I'm so I can Yeah. Oh Yeah, it's just uh yeah, so we can see your screen. It just fine. Um Can you see that? I can see Metal? I can't see powerpoint. All right. Yeah. II can see it now. Yeah. All right. Sorry. Oh So you guys is um uh I'm assuming everyone's back now. So we'll just start our next two lectures which will be upper limb and then lower limb going straight into it. It's on them. Presented you by the way. She's, I'm sorry. Uh I still present to be. How do I, you press um, that thing? Uh, the fourth button, the fourth iron. What one? Sorry. Bye bye. Uh Oh, do you have, do, do you have um, two desktops? Yeah. Um That's good. Yeah. Yeah. Ok. Yes. So I'll just pass on now guys and remember if you guys have any questions about the talks, just put them on the chat. Ok, so yeah. Um hi guys. Uh my name's Fu uh I'm 1/4 year medical student at UCL and uh I'll just be given a upper limit tutorial. So we'll um so yeah, that's just a bit about me for myself. Uh Yeah. So um today, yeah, we'll just cover bones and articulations, muscles, innovation, arterial and venous supply, lymphatics. But I haven't, I haven't gone too much into detail about lymphatics, but it is, it's important to just know about them and uh I've got a couple of SBA questions at the end. So, yeah, so just starting off, we have the shoulder. Um Now the shoulder joint is um essentially made up of three main bones. Uh You've got the clavicle, the scapula and the humerus. Um they all articulate, there are, there are multiple joints within the shoulder itself. So the main one is the um glenohumeral joint uh here and you have, so then sterno cla clavicular, um sterno clavicular here and then the acromioclavicular and um S scapular thoracic joint. Um that's not, that's not too much involved in the actual shoulder joint, but it's just um it's good to know. Um So the shoulder joint itself is a, is a synovial ball and stock joint, um which essentially it gives a very wide range of motion in multiple different um planes. So you've got a abduction and adduction. So away from the midline of the body and then towards the midline, um it's due to it being so mobile, it is inherently a unstable joint. So it is quite easily dislocated, um which is quite a common um injury that can happen. And the most common out of the three dislocations you can get is the anterior dislocation. So the anterior dislocation essentially is so it's dislocated forward, then you have posterior, which is backwards and then inferior which where it goes downwards on this side, I've also um er included some X rays of what they possibly look like. So it's, it's a bit difficult to make out the difference between anterior and posterior, but there, there it's very slightly different and then with the inferior one, it you can see it's gone downwards away from the um glenohumeral joint where it should be. So, a normal shoulder joint would essentially the ball of the humerus would be um in that um in that ball or in that socket essentially. So, to help with stability, um there are multiple ligaments uh that uh a part of the shoulder joint. The um you've got the coracohumeral ligament, which is probably one of the big bigger ones in there. The um that essentially stops the stops, the um inferior dislocations, I believe uh there uh there's also the acromial, no uh choroid arom acromial and then the other major ligament is the transverse humeral ligament that rubs across. And there's also um burs bursa there which um essentially are are there to stop the robbing and start as a decrease the friction game for um for the motion of the dryer. Um So yeah, moving on. So the, the next joint going downwards is um the elbow. Now the elbow is uh made up of three bones. So you have the humerus. So the distal end of the humerus and the proximal ends of the radius and ulnar. Um Now this, this joint, uh this joint again, ligaments are um there for stability. But the elbow is um an example of a synovial hinge joint which has two main planes of motion which is flexion and extension. Um The muscles that are involved in that are cover later. But um so here, so common conditions for the elbow are um so lateral epicondylitis or tennis elbow is known as and a medial epicondylitis. So, golfer elbow, now, the area of pain for each of these is different. So for the lateral one, it's on the outside of the elbow. And so due to the um due to the inflammation of the lateral ligament and then the medial is on the inside. So, yeah, moving on to the wrist. Um the wrist bone again, I've just included pictures here which I, I'll go over again in the next slide. But um it's made up of the carpal bones, metacarpals and the um the carpals which interact with the metacarpals and the carpal bones also interact with the distal ends of the radius and ulnar. Um The wrist i the wrist joint is a um condyloid joint and it's formed of the radius, ulnar and carpal bones. So the joint allows for flexion extension, abduction, and abduction and um a good new pneumonic to remember the bones. Uh I've just included here. So, like so long to pinky, here comes the thumb. Now, common conditions of the wrist um are probably scaphoid fractures and carpal tunnel syndrome. Uh specifically with scaphoid fractures. Uh One thing that you should uh that you should be aware of is um with the scaphoid fracture, it has a high risk of um injuring the radial artery again, which I'll come on you later because that artery is uh passes over the scaphoid bone and that's quite important as that supplies the whole of your hand. So, moving on to the hand in, in the hand itself, um there are three main uh joints. So you have the distal interphalangeal joints, the proximal interphalangeal joints, and then the um metacarpal phalangeal joints now, um, as I said, from, from the carpal bones, you have the uh metacarpals and then you have the proximal phalange and the distal phalange. Um, those are the three areas because, um, and the hand itself is used to grip and, er, perform quite intricate movements. So, writing, uh, picking, picking up er, objects, er, and holding onto objects. Um, common conditions are osteoarthritis and rheumatoid arthritis. But it is important to be aware that these can, er, these aren't er, specifically to the hand. It can occur in any joint in the body. So, uh so moving on so onto muscles. Now, the proximal muscles uh of the upper limb are mainly. So the, the, the deltoid, the pex. So you've got the pectoral major and the minor which sits under it and the trapezius muscles. Now, um on, on the back you have the levator scapulae, um rhomboid minor and rhomboid major in the Latius dorsi and anteriorly to the Dorsa, you have the serratus anterior muscle. Um Now the function of each of these muscles. So, with the deltoids is it is used in abduction, flexion and extension of the arm. Uh with abduction specifically, it mainly is involved after the 1st 15 degrees of ab abduction. The pectoralis major is uh abduction, internal rotation and flexion of the arm. Now, the trapezius has three separate parts. Um you have the upper middle and lower er fibers. Now, the upper one elevates the scapula the middle retracts and the lower depresses the scapula. So each having their own function, the um latus dorsi are, are used in adduction and internal rotation and can help in extension of the arm. Um The rhomboid major and minor. Both uh uh do the same function of retracting and rotating the scapula while the serratus anterior holds your scapular forward. Um So, um if innervation to that muscle is uh compromised, um common condition is W sc and then the levator scapulae does as it is elevate the scapula. So then the rotator cuff muscles, uh there are four rotator cuff muscles. You got sub, you have the subscapularis supraspinatus, infraspinatus and Teres minor. Now, on these pictures, you can see um where each of them are uh color coded and each of them have their own function. Um So the subscapularis is used in internal rotation and the supraspinatus is used at the start of arm arm abduction. So the 1st 15 degrees of abduction and then the deltoids take over and then the infraspinatus and Teres minor are used in external rotation. Both um there's also the Teres major, but that's not a part of the rotator cuff. So it's, it's quite easy to get confused. Um That's something to remember. Um then moving on to the upper arm muscles. Uh the anterior aspect of the upper arm is made up of the biceps and the biceps are made up of two heads. You have the short head and the long head and the um the posterior side is triceps, which are made up of three heads. Hence the name tri um you have the long head, the lateral head and underneath the short head which uh can't be seen at the photo. Now, um the biceps uh so the biceps are used for mainly flexion uh of flexion and forearm supination uh from the elbow joint and then the triceps are extension at the elbow joint. Now, the there's also the brachialis, uh which can also be considered as a forearm muscle as it wraps around to the forearm. And that's also used in flexion of the elbow joint. So, moving on uh the forearm muscles uh can be divided into er anterior and posterior compartments. Um as as a um common thing, the anterior compartments are usually used for flexion of the wrist while the posterior is extension of the wrist. Now, um then the anterior muscles again are further subdivided into superficial and deep. There are uh there's seven superficial er muscles. So you've got the flexor carpi radialis and the flexor carpi ulnaris. Um They're both used in wrist flexion. Um while the radialis is with radial deviation, the ulnaris is with ulnar deviation. Um The palmaris longus is uh wrist flexion and is it's, it's absent in some people. The flexor digitorum superficialis is used in flexion, uh finger flexion at the proximal inter pharyngeal joints. Um and these are for main main. So the finger flexion, um pronator terras is a form pronation and brachialis again. So, as I said before, is used for flexion at the elbow, then the deep compartment which lies underneath uh you have the flexor digitorum profundus and these are finger flexion at the distal interphalangeal joints. So the furthest joints away from um so the furthest distal joints away er flexor poly poly longus is thumb flexion and pronator quadratus is er forearm pronation and then the supernate as it says, supernate, the arm um moving on to the posterior compartment. So in the posterior compartment, again, further dis uh divided into deep and superficial and these are mainly used for um extension of the wrist. Um So the superficial uh again, so brachial radialis as it wraps around, it can be considered in the pro posterior extensor carpi radialis. You have two. So you have Longus and brevis and this extends and abdu abducts the uh wrist, er extensor digitorum extends the medial uh four fingers at the metacarpal inter pharyngeal joint. Um The extensor digiti minimi is uh mainly extension of the little finger. Um extensor carpi, ulnaris is extension and adduction of the wrist and the anconeus extends and stabilizes the elbow joints and also helps to abduct uh during ulnar pronation or when the ulnar is pronated, then moving on to the deep muscles. You have the supinator, which is used for supination. You have extensor digitorum uh which uh is involved in finger extension at the metacarpal joints. Uh extensor digiti minimum is pinky finger extension. Uh Sorry, I've repeated that. Uh my, my fault and um the extensive carpi ulnaris and radialis which is used in wrist extension, but ulnaris with ulnar deviation and then radialis with radial deviation. So, uh moving on to the hand muscles. Now, the hand muscles aren't as important but um should be mentioned. So here you have the uh thenar muscles, hyperthenar and the lumbar cause um the thenar muscles, uh abductor, pollicis, brevis, flexor pollicis, brevis abducts the flexor, the thumb of the metacarpal joints respectively. And hypothenar abducts the pinky finger or the digital mini me or abduct, the digiti minimi and flexor digiti minimi abducts and flexes the pinky finger at the metacarpal joints. Um The L lumbrical are used in flex flexion at the metacarpal extension at the proximal interphalangeal and distal interphalangeal joints, the interosseal. So the dorsal interossei and then the palmar interossei abduct and abduct fingers, the fingers respectively. So, uh moving on all the way back up to the shoulder, uh which was uh the brachial plexus. So the brachial plexus is split up into five different sections. You have the, the roots that come from the spinal cord that which are then, then the trunks which split off into deviations cords and then um terminal nerves. Now the um n terminal nerves, the five main ones are the musculocutaneous, uh axillary, median radial and ulnar, uh each with um different functions. Um Each of before going on to what each of those nerves do. I'm just gonna cover um, what dermato dermatomes and myotomes. So, dermatomes are the sensory aspect of the upper limb. And you, uh it's what nerve root supplies. What area of sensation as I've put in the picture here, you can see, um, the C four C five and then, um, C 678 and T one. Um and myo toms are the a motor function of each of the nerve roots. So for example, C five is used in shoulder abduction, external rotation and elbow flexion. Uh wrist, ex uh C six is wrist extension extension. C seven is elbow extension and wrist flexion. And um C eight is thumb extension and finger flexion and T one is finger abduction. Uh So the main nerves of the upper lemmas I described earlier axillary musco cutaneous, radial, median and ulnar uh each having a different function. So, starting with the musculocutaneous, it's um roots are C five to C seven and the motor function is for elbow flexion as it supplies the biceps. And um sensory is the lateral part of the forearm. Uh Axillary nerve is C five to C six and the motor function is shoulder abduction as it supplies the deltoid muscle and inferior. And the sensory is the inferior region of the deltoid muscle, also known as the regimental badge area. Um The medial nerve, median nerve is the C six to T one nerve roots and that innervates the anterior part of the forearm, except for the flexor carpal naris and part of the flexor digital and profundus. So the median nerve is mainly flexion of the forearm. In addition, it supplies the thenar muscles and the lateral two lumbrical. So the sensory aspect is the palmar aspect of the lateral 3.5 fingers. Uh The radial nerve is from C five to T one and is used in extension in the forearm, wrist fingers and thumb. So the radial radial nerve is all about extension. And the sensory is the area between the dorsal aspect of the 1st and 2nd metacarpals. And then finally, the ulnar nerve is from C eight to T one. The supply, this supplies the intrinsic hand muscles except for the lateral two lumbrical as are supplied by another nerve and then the opponent's policies, er abductor pollicis brevis and um flexor pollicis brevis. And the sensory is the media 1.5 fingers and then just ii this but the long thoracic nerve as I as I supplies the er serratus anterior. And I said earlier, uh if this nerve is compromised, then it can lead to a condition known as wing scapula. It has no uh sensory um function. And the musculocutaneous nerve uh is um it's APL oh I think I've already repeated it but innervates the upper arm muscles. So bicep brachia, brachialis and coracobrachialis. So, uh moving on to arterial and venous supply. So, um starting off with arterial supply, um the all the artery in the upper limb are derived from the subclavian. And as that passes passes the axillary area, it forms the axillary artery. Um, the axillary artery then has a branch which is the humeral circumflex. This mainly supplies um the head of the humerus and parts of the neck. Then this follows down and splits into uh no, down follows the humerus uh and forms the brachial or the deep brachial and brachial arteries. And one split, it splits into the ulnar and radial and ulnar arteries which uh follow into the hand. And then as I said earlier, the radial artery is quite important as with the scaphoid fracture. It can cause compromise of that artery. And as this is one of the major arteries supplying the whole of the hand, the deep palmar, superficial palmar branches, it can cause um that it can cause damage further down. Um Now the hand itself as so it has two branches, the deep and superficial palmar arches which then split into the common digital artery, supplying each of the digits. Then with venous apply, you have the palma venous arches which go up into the ulnar radial and basal. Now, the deep veins are different to the superficial veins. So, as you can see here, the radial is one of the deep and so is the ulnar or the basal is a superficial vein. You also have the cephalic vein pa which when it passes the meaning cital forms into, it joins with the basal and it goes upwards towards the uh subclavian and there's the auxiliary and axil and then subclavian, sorry and yep so quickly over the lymphatic system. So it's just good to know about the main uh lymphatic nodes in the upper limb. You have the supra supraclavicular, um deltopectoral infraclavicular which are underneath the clavicle and then the axillary nodes, there are multiple axillary nodes, but a good way, a good pneumonic to remember the axillary nodes is um apical. So you have the anterior posterior infraclavicular, central apical and lateral. So, uh just uh I've got a couple of S pa s now, um I'm just gonna, I'll give you a couple of minutes just to answer and I'll just explain why to answer that. So which, which is not a muscle of the rotator cuff? Ok. Um OK. Um So yeah, I just, as I said earlier, Terry's major, it's um it's not a muscle of the rotator cuff. Uh But yeah, that's just, hm. Um So yeah, a 25 year old man comes to the emergency emergency department following a fall from a step ladder onto his left arm, he complains of pain er, in his elbow, sorry and reduced movement of his hand. There is a, a palpable tendons over the left elbow with reduced flexion and adduction of the wrist, which nerve is involved in this patient's injury? Mhm. Ok. Yeah. So, yeah. Um it's main, it's the ulnar nerve as uh so as he has um complained about a flexion and adduction, the major flexor and adductor of the wrist is the um anterior muscles which was supplied by the ulnar nerve other than um one and a part of the other part of another muscle. So, so um what muscles used in the 1st 15 degrees of abduction? Ok. So yeah. Um the answer, yeah, supraspinatus. So the two muscles are used in abduction are supraspinatus and the deltoid. Er but the deltoid is uh mainly involved after the first is 15 degrees, 15 to 90 degrees while the supraspinatus is the 1st 15 degrees. Ok. And how many movements can the elbow joint perform? I think so. Fine. So, yeah, um the answer to that is two. So as um if you can, as you remember, um the elbow joint is a snoal hinge joint which has two movements control, which is flexion and extension. And then finally, I think, yeah, so a 74 year old man is brought to the emergency department after a fall onto an out stretched arm. He has a past medical history of osteoporosis and his medic medication include calcium and Vitamin D and a alendronic acid on examination. He is tender at the proximal humerus and unable to abduct his shoulder, abduct his shoulder sorry, examination of the elbow, wrist and hand is unremarkable. Plain radiography demonstrates a fracture of the proximal humerus. What nerve has been injured? Ok. So yeah, with that is the axillary nerve. So as I said again, um it says in the um it says there that he's unable to abduct his shoulder. Um and abduction of shoulder is obviously supraspinatus and deltoid. The deltoid is uh supplied by the axillary nerve, the major muscle and um I should have mentioned this earlier, but as, as the axillary nerve runs over the humerus, a fracture of the proximal humerus um can uh be a cause of axillary nerve compromise. So, yeah, um I think that's it. Uh Thank you for listening. Uh If you could also fill out this QR code, be grateful and any questions? OK. I just close this out, that's fine. Um Just open up. All right. OK. Um So yeah. Uh I'll just move straight onto the lower limb tutor tutorial as well. So, yeah, um again, uh again by me. So lower limb tutorial uh just skip over this. Um So yeah, once again, the topics I will cover again is uh bones, articulations, muscles, innovation, arterial and venous supply, lymphatics. And again, some SBA questions at the end. So, starting off with bones and articulations. So the first uh major uh joint is the hip and pelvis. Uh the hip joint, the hip joint itself is made up of the uh femur and the acetable which uh articulate together. So it's the head of the femur to the uh acetal. There are multiple areas of the hip which are, which would be good to know. But the main areas are the anterior uh anterior si iliac spine, uh anterior inferior iliac spine and um which have a lot of attachments of multiple muscles. The there are three major ligaments in the hip joint. So you have the iliofemoral ligament, pubofemoral and underneath the is ischiofemoral ligament. OK. So, the hip uh in, as I said involves the head of the femur which articulates with the acetal of the pelvis. Now, this is this is also a, so a ball and socket joint. So again, it has a wide range of motion and thus can be dislocated quite easily, cos inherently unstable. Uh common injuries of the hip are hip fractures. Now, the, the proximal end of the fever is uh the femur is split into different areas. You have the head, the neck and the underneath the trochanteric uh line, intratrochanteric trochanteric line from the lesser to the greater trochanter you have um uh so that you have underneath that now, different areas of a fracture uh and uh cause different um uh a name, different things. Sorry. So you have an intracapsular fractures which are anything proximal to the intra trochanter, trochanteric line and um extracapsular or anything distal or outside of it. OK. Then the knee. So the knee is um the knee is the distal end of the femur which uh articulates with the tibia and has a patella bone uh on top of it, um the knee is quite important to know about the bursa in the knee. So, suprapatella, infrapatellar, uh prepatellar bursa and then er semimembranous. Now, these are all there to prevent um the rubbing of the tendons uh just for comfort. Um and then the ligaments of the knee, you have a major ligament which is the ACL. So the anterior cruciate ligament you have the, which passes over the front and then posterior cruciate, which is behind, there's also the medial collateral and then the lateral collateral and the menisci which uh pads to stop the rubbing of the bone. So, yeah, the knee again is an example of a hinge joint. So femur tibia and patella and the knee has two planes of movement. It has extension and flexion. Now, common conditions of the knee are tendonitis, bursitis and arthritis. So, tendonitis being inflammation of the tendons, bursitis, inflammation of the bursa and then um arthritis which is inflammation of the knee joint. So then moving on to the ankle, the um ankle is the articulation between the fibia tibula and um uh uh the ankle bones. So that um the, the tus mainly. Uh again, here you have uh multiple ligaments which hold it together. Uh You have the main ones are from the tus to the tibia and then from the tip, tibial navicular and you also have the calcaneal fibrillar ligament which hold, hold it in place mainly. So the ankle joint is composed um of the tibia and fibula superiorly superiorly and the tus inferiorly. Um The joint allows for flexion extension or and inversion and e good pneumonic for the tarsal bones, eyes. Um so a tiger cub needs milk. So you have the tais um the keyboard, the navicular and then you have the medial inter intermediate and lateral cuneiform bones. Um So common conditions again, are sprains of the ligaments, uh fractures, um tendonitis and arthritis, then the foot. Uh So you have in the foot, you have your tarsal bones which uh articulate with your metatarsals and then the phalanges. Uh you have the proximal middle and distal, unlike the hand where you only have the proximal and distal in the foot, you have um three different uh bones of ph phalangeal bones. Um Oh sorry. So, yeah. Uh then that's about it about the artificial bones of the lower limb. So, the proximal muscles uh you have four. So you have the gluteal muscles which are mainly the, the gluteus maximus and underneath lie the minimus and medius. Um yeah, have the tensor fas la la and um underneath also you have the pi piriformis, uh gimelli, um obturator, internus and quadratus for moris, which um extends onto the thigh. So, the proximal muscles are mainly those of the hip, the gluteus maximus is in extension and external rotation of the thigh. The medius and minimus abduct and uh medially rotate the thigh. The tensor fascia latter assists in abduction and medial rotation. Uh while the pisciformis uh is lateral rotation and abduction, the obturator internus is lateral rotation and abduction also uh similar similarly to the er gemlii superior and inferior. While the quadra quadratus femoris is only used in lateral rotation and does not uh is not, is not helping in um abduction, moving on to the thigh muscles. So here at the thigh muscle, you have the obturator externus, adductor pollicis, brevis, adductor longus and adductor magnus. You have anteriorly the um quadricep muscles which is made up of the rectus femoris, vastus, medialis, vastus lateralis and the um iliacus er are the muscles are the psoas major, the sartorius, which is, which is known as the longest muscle in the body if I'm not mistaken. And the Pectineus which lies underneath and then uh on the posterior, you have the biceps femoris, uh which is so you have the long head, short head, semimembranosus, semitendinosis. So, yeah, the um iliopsoas, it flexes the um thigh at the hip joint and it assists in lateral rotation at the hip, the vastus lateralis and the vastus intermedius as well as the vastus. Uh edis extends the knee joint and stabilizes the patella, the rectus femoris flexes the thigh at the hip and extends at the knee joint. The sartorius is used to flex at the hip and the knee and is an abductor and lateral rotator of the hip. Um The Pectineus A is used in abduction and flex flex flexion of at the hip. So the posterior muscles. So the bicep femoris, uh both along head are used in uh flexion uh of the knee and extends the leg at the hip while the semitendinosis flexes the leg at the knee and extends the thigh at the hip. But it also mediate immediately rotates the thigh at the hip and the leg at the knee at, at, at the knee joints respectively. While semi uh membras flexes the leg at the knee extends the thigh at the hip, immediately rotates the thigh and leg at the hip and knee joints respectively. Um The other compartment is the media compartment. So that's it, that's involves the adapt maus adaptol longus aa brevis and then the externus and gracilis. The adductor magnus adducts the thigh, uh SS similar with the Longus, but the adduct longus is also used in media rotation of the thigh. And the adducta brevis again, just adducts the thigh, obturator externus is used to laterally rotate the thigh while the gracilis adducts the thigh at the hip and flexes the leg at the knee. So, moving on to the leg muscles here, you have the um anterior compartment and then the posterior compartment uh in the anterior compartment, you have the extensor digitorum longus, the tibialis, anterior and the ex extensor ha ha longus posteriorly, you have the head of the um so you have the gastrocnemius and they have two heads, the plantaris soleus and um the flexor digitorum longus tibialis, posterior and flexor halysis longus. So your posterior muscles of the leg are two compartments. You have the superficial and the deep, the superficial compartment has the gastrocnemius which is used in plantar flexion, the plantaris again, plantar flexion and the soleus is plantar flexion. Also the pos the deep posterior compartment. So the popliteus is laterally rotates the femur, the tibialis posterior is used in inversion and plantar flexion. While the flexor digitorum longus is flexes the lateral for toes and then the flexor Hallisey longus flexor, the big toe, the anterior compartment is mainly used for dorsiflexion. But the so the tibialis anterior is dorsiflexion and inversion. The extensor Haas's longus is dorsi flexion and extension of the er so extension of the big toe, uh fib uh fibrillar er tertius is eer and dorsiflexion. And then you have the fibularis or also known as proteins per uh per peroneus longus and brevis, which is ex aversion and the longus is used in plant affliction. So, um innovation is so we have the lumbar plexus, a good pneumonic for the lumbar plexus is so, ii get laid on Fridays. So you have the iliohypogastric ilioinguinal genito, femoral lateral cutaneous femoral and obturator. And each of these are supplied from t 12 to L5 then the sacral plexus, you have the um superior gluteal, inferior gluteal sciatic which is has a fibrillar and tullar portion. So the anterior and posterior portion portion, sorry, uh posterior femoral and predental. Now, there are. So here in this image, you can see the anterior divisions uh of these and then the posterior divisions. But a good pneumonic is some Irish sailors sope a poly. Uh it's quite, quite good to learn these as I know these can be quite hard um quickly before I go onto the main nerves, uh the dermatomes are myotomes. So as from my previous lecture, uh the dermatomes being sensory and the myotomes being uh motor, the sensory aspects of the lower limb are here. Um and then for the myotomes. So for the hip flexion is L2 L3 and extension is L4 L5 at the knee extension, extension, L3 L4 and flexion, L5 S one for the ankle extension is L4 L5 and flexion is S one S two. So and then inversion, L4 L5, E version L5 S one. OK. So the main nerves, so starting with the lumbar plexus, we have the ilioinguinal nerve. So that's applied by L1 and its motor function is to supply the internal ob obliques and the transverse abdominis. And the sensory is the upper and so upper anterior part of the thigh in the middle ileal hypogastric nerve. So L1. Yeah. It again uh supplies the internal obliques and the transverse abdominis. But the sensory is the posterior lateral gluteal skin in the pubic region. So next, the janitor femoral is L1 to L2. So it innervates the CCC chromatic muscle. And the sensory has two different branches. The genital branch innervates the skin of the anterior scrotum and the skin over the mons pu pubis and the labia morra. While the femoral branch er innervates the skin of the upper anterior thigh, the lateral cutaneous nerve of the thigh um has no motor function. It's applied by L2 L3 and the sensory is the anterior and lateral thigh to the knee, the obturator nerve. So L2 to L4 supplies the medial abductor compartments. So the ob obturator externus, Pectineus adductor longus, uh a adducta brevis and the gracilis. And that also supplies sensory area of the skin over the thigh. Um The femoral nerve L2 to L4 supplies the anterior thigh muscles that flex the hip. So the Iliacus Pectineus sartorius and extend extends knee. Uh so all all the quadriceps, femoris muscles, uh the sensory uh aspect of this innervates the anterior thigh and the medial aspect of the leg to lower down this then moving on to the um sacral plexus. You have the superior gluteal nerve. So the L4 S one. So innervates this innervates the gluteus minimus and medius and the tensor fascial latter. So, it is mainly used in flexion, the inferior gluteal nerve, L5 to S two innervates the gluteus maximus and has no sensory input. Then the sciatic nerve, the sciatic nerve is one of the uh one of the major nerves of the lower limb. And it has uh quite, quite a lot of functions. So the roots are from L4 to S3. The motor aspect is the tibial portion, all the muscles in the um posterior compartment of the thigh. So including the hamstring portion of the adductor magnus, apart from the short head of the biceps, from MRI and all the posterior com compartment, muscles of the leg. So, and all the muscles in the sole of the foot, the common fibular portion or also known as common perineal nerve, er supplies the short head of the biceps from morus and all the muscles in the anterior and lateral compartments of the leg extends the digitorum brevis. The sensory, the tibial portion supplies the skin on the posterior lateral medial surfaces of the foot of the sole of the foot and the sole of the foot. Sorry. And the common fibular portion uh supplies the skin over the anterior lateral surface of the leg and the dorsal aspect of the foot. So the posterior femoral cutaneous nerve of the thigh, uh S 1 to S3 er has no motor function, but the sensory function innervates the skin on the posterior surface of the thigh and the skin on the peri er over the perineum. So uh just a good way to remember if, if. Um so for example, you have the cutaneous nerve, they usually don't have a motor function. So it's, it's, it can be good to remember that. So then the pudendal nerve which is from S two to S four supplies, uh mo motor supply for the uh skeletal muscle in the perineum, uh the external urethral sphincter and the external anal sphincter and the levator ani. While the sensory is the penis in clitoris and most of the skin of the perineum then moving on to the arterial supply. So the arterial supply starts with the external uh iliac artery and the internal iliac artery which uh come from the common iliac arteries. This then splits off into the femoral arteries. Then past the popliteal fossa forms the popliteal arteries. There is the deep femoral artery which um it splits off the branches to supply the femur. And also you have the superior infero gluteal arteries uh above near the pelvis, the popal artery splits into the tibial tibial artery. So the anterior tibial artery, the posterior tibial artery and then the perineal artery or can be the fibular artery. Um This then forms the medial plantar arch and the lateral plantar arch which supplies the foot. Um You can a good um the dorsalis pedis artery is in the foot, which is a good area to measure the uh measure the pulse as a good uh little um thing to know. So the venous supply of the lower limb, you have superficial and deep veins. So the deep veins are the femoral veins which then form the popliteal vein and the posterior tibial vein, anterior tibial vein and the perineal vein. And with um the superficial veins, you have the small saphenous at the bottom which then join to form the great saphenous vein, which is then into the femoral vein. The great saphenous vein uh is um can be used for uh and uh so vessel replacement in the heart. So the long long sa the long saphenous vein drains into the femoral er into the femoral vein. And the short saphenous vein drains into the pop popliteal vein, which are the two deep veins. They drain into um the lymphatic supply. So you have again, so you have the inguinal inguinal nodes, the popal nodes uh and usually in. So, in the lower limb, it's um the lymphatic supply follows the venous supply. So they run with the veins. So the popal nodes drain the distal, drain the distal limb and then the inguinal nodes uh drain the limb and pred drain the limb and pred uh predal regions. Uh the perineal anus and parts of the abdomen as well. So again, just uh a couple of quick ba s uh so a 26 year old man is urgently brought to the emergency department following a stab injury to his thigh, the trauma quicker, the trauma team quickly stabilize and upon stabilization. Uh A detailed examination reveals his inability to extend his leg at the knee joint. Coupled with a noticeable sensory loss to the anterior and medial, medial thigh. What was the most likely affect, affected nerve? Give it a couple of minutes? Ok. So yeah, um it's it is the femoral nerve. So as the examination reveals that he's unable to extend his leg at the knee joint and that's coupled with uh sensory loss over the anterior medial thigh. Uh The femoral nerve is the um nerve that supplies that area all there and there functions. So, a 28 year old woman presents with difficulty moving her leg right leg. Um On examination, she's unable to perform dorsiflexion of her right foot. However, she can perform e and inversion and plantar flexion of the lower limb. Uh Examination is otherwise normal. What compartment of the right leg is most likely affected? Ok. So, yeah, um it is the anterior compartment of the lower leg. So in, in the stent, it does, it says that she's unable to dorsiflex her leg or, or her foot. And the main muscles are used in dorsiflexion of the foot are located in the anterior compartment of the leg. So that must, that must mean um that's the area of damage. Um So yeah, uh a 45 year old man presents to the GP with difficulty in climbing stairs standing up from a steep seated position on examination, he exhibits uh weakness in hip extension and external rotation. There are no sensory deficits uh noted uh what muscle is most likely affected in this patient? No, uh just yeah, fine. Um Sorry about that. But so the answer is er gluteus maximus. Um So the reason for this, it says that his weakness in hip extension and that's the key part of this stem. Er the only muscle in those five that do that are that perform extension at the hip is the gluteus maximus. Uh It's the last one. So a 55 a 54 year old man presents a GP with complaints of loss of sensation. He describes he's not able to feel anything over the la anterior and lateral aspects of his thigh. Uh What nerve roots could potentially be damaged in this patient. So, yeah, so the nerve roots uh it would be L2 to L3. Um It because as, as um I mentioned earlier, uh the musculocutaneous ner ner cutaneous nerve of the thigh is what supplies the sensory aspect of that area. And so as it says on the stem that he's unable to feel anything over the anterior and lateral aspect, uh it must be that nerve that's damaged and L2 to L3 is where um that nerve originates from. Uh again, uh Thank you for listening. Um If you have any questions, happy to answer but otherwise if you could also fill out this feedback form, that'd be great. Uh Cheers. Thank you so much for that lecture. It was really, really good. Um Right. So what we'll do guys is if you have any questions, please put them in the chat. Now, um Feel free to answer on either upper limb or lower limb. And then what we'll do, I think guys is we'll take about a 10 minute break and we can restart with neuro anatomy um, at uh 1150. So hopefully you guys should also be finished a little bit early today, which will be nice. So, yeah, if anyone has any questions, put them in now and if not, then take a little bit of a break, 10 minute break and we'll be back. Right.