Unit4 DM - Vb.indd
Unit4 DM - Vb.indd
Unit4 DM - Vb.indd
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G24: Upper Limb Overview and Shoulder and Axilla
At the end of this lecture, students should be able to master the following:
1) Upper limb overview
a) Cutaneous innervation of the upper limb
• Compare and contrast the dermatomes and cutaneous fields of the upper limb
• Dermatome: area of skin supplied by a single spinal cord level
• Cutaneous field: area of skin supplies by a single peripheral nerve branch ( multilple spinal cord lev-
els)
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b) Major vessels
i) Superficial veins
Describe the location and direction of flow through the major superficial veins of the upper limb
- Cephalic
- Basilic
- Median cubital
ii) Arteries
Trace the pathway and distribution of the principle arteries through the upper limb
- Subclavian
- Axillary
- Brachial
- Radial and ulnar
- Superficial and deep palmar arches
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3) Fascia of the Upper Limb
a) Describe the fascial organization of the upper limb:
Between the skin and bone are two fascial layers in the upper limb termed the superficial and deep fascia:
- Superficial fascia: located deep to the skin and contains superficial veins (cephalic, median cubital, ba-
silic), cutaneous nerves, superficial lymphatics and fat.
- Deep fascia: located deep to the superficial fascia and contains muscles, nerves, vessels and deep lym-
phatics. The deep fascia is a continuation of the deep fascia covering the deltoid and pectoralis major
muscles. As the deep fascia extends distally, intermuscular septa extend to the bone dividing the arm and
forearm into anterior and posterior compartments in the arm and forearm. Each compartment contains
muscles that perform similar actions and have common innervation and attachments.
Arm Forearm
- Anterior: Flexors, musculocutaneus nerve - Anterior: Flexors, medial epicondyle, median
- Posterior: Extensors, radial nerve and ulnar nerves
- Posterior: Extensors, lateral epicondyle,
radial nerve
The term “contraction” implies a shortening or reduction, however, in reality contraction refers to the genera-
tion of tension by muscle fibers with the help of motor neurons.
While under tension, the muscle may shorten, remain the same or lengthen (muscle cells do not push)
- Concentric contraction: muscle shortens (biceps curl)
- Isometric contraction: no change in length of muscle (muscles of the hand and forearm while gripping
an object)
- Eccentric contraction: muscle lengthens while under pressure due to an opposing force being greater
than the force generated by the muscle (setting an object down gently)
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5) Axilla: Muscles of the shoulder girdle
a) Describe the attachments, principle actions, and relations of the muscles of the shoulder girdle as grouped
below
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6) Brachial Plexus- Shoulder
a) Draw and label all parts of the brachial plexus; describe the topographical relations of the plexus as it passes through
the neck, shoulder, and axilla; and describe the origin, course and distribution of the branches that supply the shoulder
• Roots (Randy) - 5 roots between anterior and middle scalene mm.
• Trunks (Travis) - 3 trunks lateral to the interscalene space and superior to the clavicle
• Divisions (Drinks) - 6 divisions deep to the clavicle (3 anterior and 3 posterior)
• Cords (Cold) - 3 cords in the axilla, deep to the pectoralis minor m. named according to their position to axillary a.
• Branches (Beer) - 5 branches to the upper limb (3 anterior division and 2 posterior division)
(See tutorial on DIGANAT on drawing the brachial plexus)
i) Roots (C5-T1)- pass between the anterior and middle scalenes with the subclavian a. (subclavian vein courses
anterior to the anterior scalene m.)
• Dorsal scapular nerve- (C5) pierces the middle scalene, descends deep to the levator scapulae, rhomboideus
mm. along with the deep branch of the transverse cervical a. supplying both rhomboideus mm. and partially the
levator scapulae
• Long thoracic nerve- (C5-C7) descends posterior to the roots of the plexus and the axillary a., descends along
the lateral surface of the serratus anterior m. with the lateral thoracic a. while supplying the muscle
ii) Trunks (superior, middle, inferior)- emerge between anterior and middle scalenes and descend towards the clavicle
• Suprascapular nerve- (C5,C6) branches off the upper trunk, courses across the posterior triangle of neck,
through the suprascapular foramen, inferior to the transverse scapular ligament, (suprascapular a. and v. pass su-
perior to the transverse scapular ligament) to supply the supraspinatus m.; continues through the greater scapu-
lar notch to supply the infraspinatus m.
• Nerve to the subclavius- (C5, C6) branches off the upper trunk to the subclavius m.
• No branches arise from the middle and infeiror trunks
iii) Divisions (anterior, posterior)- anterior divisions innervate anterior compartments of the limb (flexor muscles);
posterior divisions innervate posterior compartments of the limb (extensor muscles)
iv) Cords (medial, lateral, posterior)- medial and lateral cords arise from the anterior divisions and are named for their
relation to the axillary a.; the posterior cord arises from the posterior division and runs posterior to the axillary a.
• Lateral pectoral nerve- (C5-C7) branches off the lateral cord, sends a branch to the medial pectoral n. anterior to
the axillary a., passes proximal to the pectoralis minor to reach the pectoralis major m.
• Medial pectoral nerve- (C8, T1) branches off the medial cord, receives a contribution from the lateral pectoral
n., pierces the pectoralis minor m., supplying it as it passes, continues deep to the pectoralis m.
• Medial brachial cutaneous nerve (C8-T1)
• Medial antebrachial cutaneous nerve (C8-T1)
• Upper subscapular nerve- (C5, C6) branches off posterior cord, enters anterior surface of the subscapularis m.
• Thoracodorsal nerve (middle subscapular)- (C6-C8) branches off the posterior cord, descends to the posteriolat-
eral thorax to supply the latissimus dorsi m.
• Lower subscapular nerve- (C5, C6) branches off the posterior cord, splits to send one branch to the anterior
surface of the subscapularis m. and one to the anterior surface of the teres major m.
v) Branches
• Musculocutaneous nerve (C5-C7)
• Median nerve (C5-T1)
• Ulnar nerve (C7-T1)
• Axillary nerve- (C5, C6) terminal branch of the posterior cord, courses through the quadrangular space then
splits, sending one branch to the teres minor m.and the other to the deltoid m; also contributes to the lateral bra-
chial cutaneous nerve, supplying the glenohumeral joint and the skin over the deltoid m.
• Radial nerve (C5-T1)
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7) Brachial plexus lesions
1. Waiter’s tip
2. Claw hand
3. Wrist drop
4. Winged scapula
5. Deltoid paralysis
6. Saturday night palsy (wrist drop)
7. Difficulty flexing elbow, variable sensory loss
8. Decreased thumb function; Sign of Benediction
9. Intrinsic muscles of hand; claw hand
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8) Vascularization of the Shoulder
a) Subclavian artery- branches directly from the aortic arch on the left and from the brachiocephalic artery on the right,
passes between the anterior and middle scalenes (subclavian v. is anterior to the anterior scalene)
i) Describe the origin, course, and destination of the following subclavian artery branches to the shoulder
(b) Suprascapular artery- crosses anterior to the anterior scalene as it courses laterally towards the supraspinous fos-
sa (passes superficial to the transverse scapular ligament and suprascapular nerve), then through the greater scapular
notch to the infraspinous fossa, forms a collateral circuit with the circumflex scapular and dorsal scapular arteries
b) Axillary artery- continuation of the subclavian artery from the external border of the first rib to the distal border of the
teres major muscle where it gives rise to brachial artery
ii) Describe the three parts of the axillary artery and the origin, course, and destination of the branches of each part
(1) First part- (one branch) external border of the first rib to the proximal border of the pectoralis minor muscle
(a) Superior thoracic artery- supplies the upper part of the anterior and medial axillary walls
(2) Second part- (two branches) runs posterior to the pectoral is minor muscle
(a) Thoraco-acromial artery- wraps around the proximal border of the pectoralis minor then branches into the
pectoral, acromial, clavicular, and deltoid branches; each are named for the region they supply
(b) Lateral thoracic artery- runs with the long thoracic nerve along the lateral surface of the thorax supplying the
serratus anterior and surrounding tissue; one of very few arteries that runs superficial to the muscle it supplies
(3) Third part- (three branches) distal border of the pectoralis minor muscle to the distal border of the teres major
muscle
(a) Subscapular artery- runs along the anterior surface of the subscapularis, branches into the circumflex scapular
artery and thoracodorsal artery
• Circumflex scapular artery- courses through the triangular space to the posterior side of the scapula and anas-
tamoses with the suprascapular and dorsal scapular (deep transverse cervical) arteries
• Thoracodorsal artery- runs with the thoracodorsal nerve along the posteriolateral thorax, supplying the latis-
simus dorsi
(b) Anterior circumflex humeral artery- courses anteriorly around the surgical neck of the humeral and anasta-
moses with the posterior circumflex humeral artery supplying surrounding tissue including the deltoid muscle, the
glenohumeral joint, and the head of the humerus
(c) Posterior circumflex humeral- passes through the quadrangular space with the axillary nerve, wraps around
the surgical neck of the humerus, and forms anastamoses with the anterior circumflex humeral, profunda brachii,
suprascapular, and thoraco-acromial arteries; supplies surrounding muscles and glenohumeral joint
c) Lymphatics of the shoulder- describe the location and drainage areas of the five groups of axillary lymph nodes
• Humeral (lateral) nodes- posterior to the axillary vein; drain from the brachium
• Pectoral (anterior) nodes- along distal border of the pectoral is minor muscles; drain abdominal wall, thoracic wall,
and mammary gland
• Subscapular (posterior) nodes- posterior axillary wall; drain posterior axillary wall, neck, shoulder, and upper back
• Central nodes- embedded in axillary fat; drain humeral, pectoral, and subscapular nodes
• Apical nodes- proximal to the pectoralis minor, surrounding the axillary vein; drain all other axillary nodes and
other lymphatic vessels from the mammary gland; drain into the subclavian trunk 9
9) Axillary Borders and Spaces
a) Describe the borders of the axillary space
• Anterior border- pectoralis major and minor muscles and clavicopectoral fascia
• Posterior border- subscapularis, teres major, and latissimus dorsi muscles
• Lateral border- intertubercular groove of the humerus and coracobrachialis muscle
• Medial border- serratus anterior (first to fourth ribs)
• Apex- first rib, clavicle, and proximal edge of the subscapularis
• Base- skin, subcutaneous tissue and axillary fascia that spans from the arm to the thorax
b) Describe the borders and anatomical contents of the following anatomical spaces associated with the axilla
i) Quadrangular space:
• Borders- teres major, teres minor, long head of the triceps brachii muscles, and the surgical neck of the
humerus
• Contents- axillary nerve and posterior circumflex humeral artery
b) Describe the location and function of the ligaments of the glenohumeral joint:
- Capsular ligaments (superior, middle, and inferior glenohumeral)
- Coracohumeral
- Posterior capsular)
- Coracoacromial ligaments
d) Describe the function of the bursae associated with the glenohumeral joint
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G25: Arm and Elbow
At the end of this lecture, students should be able to master the following:
1) Muscles of the Arm
a) Describe the attachments, actions, and relations of the muscles of the brachium (see muscle table)
Anterior Compartment
Coracobrachialis Coracoid process of the Medial surface of the Flexes and adducts the Musculocutaneous n.
scapula humerus humerus (C5-C7)
Biceps brachii Long head: supraglenoid Radial tuberosity Flexes and supinates the Musculocutaneous n.
tubercle elbow (C5-C6)
Short head: coracoid process
Brachialis Distal, ventral surface of the Coronoid process of Flexes the elbow
humerus the ulna
Posteiror Compartment
Triceps brachii Long head: infraglenoid
tubercle Olecranon process of Extends the elbow Radial n. (C6-C8)
Lateral head: posterior the ulna
humerus
Medial head: posterior
humerus
Arm Forearm
- Anterior: Flexors, musculocutaneus nerve - Anterior: Flexors, medial epicondyle, median
- Posterior: Extensors, radial nerve and ulnar nerves
- Posterior: Extensors, lateral epicondyle,
radial nerve
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3) Vascularization of the arm
a) Brachial artery- the axillary artery becomes the brachial artery at the distal border of the teres major muscle;
courses through the medial side of anterior brachial compartment, terminates in the cubital fossa as it bifurcates
into the ulnar and radial arteries
i) Describe the course and distribution of the following branches of the brachial artery
• Profunda brachii (deep brachial) artery- travels with the radial nerve through triangular interval and
through the radial groove; forms an anastomosis with the posterior circumflex humeral artery; bifurcates
mid brachium into the radial and middle collateral arteries
• Superior ulnar collateral artery-courses posterior to the medial epicondyle of the humerus; forms an
anastamosis with the posterior ulnar recurrent artery
• Inferior ulnar collateral artery- splits around the medial epicondyle of the humerus; forms an anastamo-
sis with the anterior recurrent ulnar artery and the middle collateral artery
b) Ulnar artery- passes through the cubital fossa, courses though the anterior antebrachium between the flexor
carpi ulnaris and the flexor digitorum profundus muscles supplying the medial muscles of the anterior ante-
brachium; terminates as the deep and superficial ulnar palmar aches
i) Describe the course and distribution of the following branches of the ulnar artery
• Ulnar recurrent artery- splits into anterior and posterior branches which anastamose with the inferior
and superior ulnar collateral arteries respectively
• Common interosseous artery- courses towards the interosseous membrane and splits into anterior and
posterior interosseous branches
• Anterior interosseous artery- travels along the anterior surface of the interosseous membrane
• Posterior interosseous artery- travels along the posterior surface of the interosseous membrane, con-
tributes to the recurrent interosseous artery
c) Radial artery- travels through the cubital fossa, courses deep to the brachioradialis supplying lateral ante-
brachial muscles; terminates as deep and superficial radial palmar arches
i) Describe the course and distribution of the following branches of the radial artery
• Radial recurrent artery- anterior to lateral epicondyle of the to anastamose with the radial collateral a.
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4) Joints of the Arm and Forearm
a) Elbow joint
i) Describe the classifications and articulations of the elbow joint complex
• Humeroulnar joint- synovial hinge; trochlea of the humerus and trochlear notch of the ulna
• Humeroradial joint- synovial gliding; capitulum of the humerus and head of the radius
• Proximal radioulnar- synovial pivot; head of the radius and the radial notch of the ulna
ii) Describe the location and function of the ligaments of the elbow joint complex
- Capsular
- Ulnar collateral
- Radial collateral
- Annular ligaments
iii) Describe the function of bursae associated with the elbow joint complex
• Describe the location of the olecranon bursa
ii) Describe the relation between the elbow complex, distal radioulnar joint, and interosseous membrane
during movement
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G26: Forearm and Wrist
At the end of this lecture, students should be able to master the following:
1) Muscle of the antebrachium
a) Describe the attachments, actions, and relations of the forearm muscles (see muscle table)
i) Ulnar nerve- arises from the medial cord, travels with the brachial artery along the medial side of the
brachium, pierces the intermuscular septum mid brachium to enter the posterior compartment, courses pos-
terior to the medial epicondyle of the humerus in the osseous groove, then enters the anterior compartment
of the antebrachium passing between the two heads flexor carpi ulnaris; descends though the anterior ante-
brachium supplying the flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus, continues
into the hand superficial to the carpal tunnel
ii) Median nerve- arises from the medial and lateral cords, travels with brachial artery along the medial side
of the brachium, courses through the cubital fossa deep to the bicipital aponeurosis and between the two
heads of the pronator teres to enter the anterior antebrachium; descends through the antebrachium between
the flexor digitorum superficialis and profundus supplying the anterior antebrachial muscles less the ulnar
half of flexor digitorum profundus and flexor carpi ulnaris then travels through the carpal tunnel to enter the
hand
iii) Radial nerve- arises from the posterior cord, courses through the triangle interval with the deep brachial
artery supplying the triceps brachii, laterally pierces the intermuscular septum to enter the anterior compart-
ment, descends in the radial groove between the brachialis and brachioradialis; along the way gives rise to
the inferior lateral brachial cutaneous and dorsal brachial cutaneous nerves; the radial nerve then splits into a
superficial and deep branch
• Deep branch of the radial nerve- travels posterior to the lateral epicondyle of the humerus piercing the
anconeus to enter the posterior antebrachium supplying the muscles of the posterior antebrachium
• Superficial branch of the radial nerve- runs along the brachioradialis muscle then through the anatomical
snuff box
iv) Medial antebrachial cutaneous nerve- branches from the medial cord, supplies the medial skin of the
antebrachium
Arm Forearm
- Anterior: Flexors, musculocutaneus nerve - Anterior: Flexors, medial epicondyle, median
- Posterior: Extensors, radial nerve and ulnar nerves
- Posterior: Extensors, lateral epicondyle,
radial nerve
3) Radiocarpal joint
a) Describe the classification and articulations of the radiocarpal joint- synovial condyloid; distal end of the
radius, triangular fibrocartilage cartilaginous complex, scaphoid, lunate, and triquetrium
b) Describe the location and function of the ligaments of the radiocarpal joint (capsular, palmar and dorsal
radiocarpal, ulnocarpal, radial collateral, ulnar collateral)
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G27: Hand
At the end of this lecture, students should be able to master the following:
1) Fascia of the hand and the carpal tunnel
a) Describe the location and relations of the fascial layers of the palm (palmar aponeurosis, fibrous digital
sheaths, transverse carpal ligament)
ii) Metacapophalangeal (MP) joints of the thumb and fingers- flexion, extension, abduction, adduction for
fingers; flexion and extension for the thumb
iii) Interphalangeal (IP) joints of the fingers and thumb- flexion and extension
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3) Muscles of the hand
a) Describe the attachments, actions, and relations of the hand muscles (see muscle table)
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4) Brachial Plexus- Hand
a) Describe the pathway and distribution of the brachial plexus branches to the muscles of the hand
i) Ulnar nerve- enters the hand superficial to the carpal tunnel, lateral to the pisiform bone accompanying the
ulnar artery dividing into a deep and superficial branch
- Deep branch: crosses the palm in a fibro-osseous tunnel (Guyon’s tunnel) supplying the hypothenar com-
partment, adductor pollicis, dorsal interossei, palmar interossei, and the two medial lumbricals
- Superficial branch: supplies the palmaris brevis then splits into palmar digital branches to travel along
the fifth digit and the medial side of the fourth digit to supply the surrounding skin
ii) Median nerve- after passing through the carpal tunnel, branches into a recurrent branch and palmar digital
branches
- Recurrent branch: innervates the thenar muscles of the hand
- Palmar digital branches: travel along the first three digits and the lateral side of the fourth supplying the
lateral two lumbricals, the palmar skin of the first three digits, and lateral side of the fourth digit
iii) Radial nerve- the superficial branch enters the hand by passing superficial to the anatomical snuff box,
supplies skin on the dorsal side of the first three digits (provides no motor supply to the hand muscles)
b) Review ulnar, median and radial nerve contributions to the dermatomes of the hand
- Thumb (C6)
- Middle finger (C7)
- Pinky (C8)
a) Ulnar artery- enters the hand lateral to the pisiform with the ulnar nerve, principle contributor to the superfi-
cial palmar arch
i) Describe the course and distribution of the branches of the ulnar artery that supply the hand
• Superficial palmar arch- just deep to the palmar aponeurosis, anastamoses with the palmar branch of the
radial artery; gives rise to the common palmar digital arteries to supply the digits
• Deep palmar branch- curves medially around the hook of the hamate to the deep layer of the palm; anas-
tamoses with the deep palmar arch of the radial artery
b) Radial artery- passes through the anatomical snuff box then dives anteriorly deep into the hand, principle
contributor to the deep palmar arch
i) Describe the course and distribution of the branches of the radial artery that supply the hand
• Deep palmar arch- travels deep to the adductor pollicis, anastamoses with deep palmar branch of ulnar
artery
• Dorsal carpal arterial arch- courses along the dorsal side of wrist, gives rise to the dorsal metacarpal
arteries
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G28: Lower Limb Overview, Hip, and Posterior Thigh
At the end of this lecture, students should be able to master the following:
1) Cutaneous innervation of the lower limb
a) Compare and contrast the dermatomes and cutaneous fields of the lower limb
Dermatomes Cutaneous
fields
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3) Actions of the Lower Limb
a) Describe the actions of the following joints:
• Hip joint- flexion, extension, abduction, adduction, lateral rotation, medial rotation
• Knee joint- flexion, extension, medial rotation, lateral rotation
• Ankle joint (talocuraral joint) -plantar flexion, dorsal flexion
• Inertarsal joints (talocalcaneonavicular and subtalar joints)- inversion and eversion of the foot
Posterior compartment:
- Common muscles
- Common attachment
- Common action
- Common innervation
- Common blood supply
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5) Lumbosacral plexus- hip and posterior thigh (Table 5-4 GAFS good reference pg. 422)
a) Lumbar plexus- draw, label (DIGANAT tutorial)
i) T12-L4 Ventral rami- course through the psoas major muscle
ii) Branches:
• Subcostal (T12), iliohypogastric, and ilioinguinial (T1) nn.- supply abdominal body wall mm. and skin
• Genitofemoral n. (L1-L2)- supplies skin over the femoral triangle
• Lateral femoral cutaneous n. (L2-L3)- pierces body wall near the ASIS to supply skin of the lateral thigh
• Femoral nerve (L2-L4) - emerges lateral to the psoas major muscle, between the psoas and the iliacus
mm., deep to the inguinal ligament to supply the anterior compartment thigh muscles
• Obturator nerve (L2-L4) - emerges medial to the psoas major m., travels through the obturator foramen
to enter medial compartment of the thigh
ii) S1-Co1 Ventral rami- enter the pelvis anterior to the piriformis and pelvic floor mm., join the lumbosacral
trunk to form the sacral plexus
iii) Branches:
• Superior gluteal nerve (L4-S1) - travels superior to the piriformis m. with the superior gluteal artery to
supply the gluteus medius, gluteus minimis, and tensor fasciae latae mm.
• Inferior gluteal nerve (L5-S2) - travels inferior to piriformis m. with the inferior gluteal artery to supply
the gluteus maximus m.
• Nerve to quadratus femoris (L4-S1) - supplies quadratus femoris and inferior gemellus
• Nerve to the obturator internus (L5-S2) - travels inferior to the piriformis m., then between the sacrotu-
berous and sacrospinous ligaments to supply the obturator internus and superior gemellus
• Nerve to the piriformis (L5-S2) - sends fibers directly into the piriformis muscle
• Pudendal nerve (S2-S4) - travels inferior to the piriformis m., then between the sacrotuberous and
sacrospinous ligaments to enter the ischioanal fossa supplying the pelvic floor and perineum
• Perforating cutaneous nerve (S2-S3) - travels inferior to the piriformis m., perforates the sacrotuberous
ligament, curves around the inferior border of the gluteus maximus m. to supply skin of the gluteal fold
• Posterior femoral cutaneous nerve (S1-S3) - travels inferior to the piriformis m. just medial to the sciatic
nerve, deep to the gluteus maximus m.; supplies the skin of the posterior thigh
• Sciatic nerve (L4-S3) - (common peroneal and tibial nerves) travels inferior to the piriformis m., de-
scends deep to the gluteus maximus m., enters the posterior thigh deep to the biceps femoris, splits into
the tibial and common peroneal nerves
(a) Tibial nerve (L4-S3) - supplies the long head of the biceps femoris, semimembranosus, semitendi-
nosus mm. as well as the hamstring part of adductor magnus; passes through the popliteal fossa be-
tween the two heads of the gastrocnemius m. to enter the posterior leg
(b) Common fibular (peroneal) nerve (L4-S2) - supplies the short head of the biceps femoris and the
lateral skin of the crus (lateral sural cutaneous field), travels between the lateral head of the gastrocne-
mius and the insertion of the biceps femoris, curves around the neck of the fibula then branches into
the deep and superficial fibular (peroneal) nerves as it enters the leg 22
6) Vascularization of the hip
a) Internal iliac artery- describe the origin, course, and destination of the branches of the internal iliac artery
that supply the hip
i) Superior gluteal artery- travels superior to the piriformis m. with the superior gluteal nerve to supply the
gluteus medius, gluteus minimis, and tensor fasciae latae
ii) Inferior gluteal artery- travels inferior to the piriformis m. with the inferior gluteal nerve to supply the
gluteus maximus
iii) Internal pudendal artery- travels inferior to the piriformis with the pudendal nerve, between the sacrotu-
berous and sacrospinous ligaments to the ischioanal fossa to supply the pelvic floor and perineum
b) External iliac artery- describe the origin, course, and destination of branches of the external iliac artery that
supply the posterior thigh
i) Femoral artery- courses deep to the inguinal ligament, through the femoral triangle to the adductor canal
(1) Deep artery of the thigh (Profunda femoris artery)- branches posteriorly between the pectineus and
adductor longus muscles, descends through the thigh between the adductor longus and adductor magnus,
gives rise to the perforating arteries
(a) Perforating arteries- perforate the adductor magnus to supply the posterior compartment of the thigh
7) Hip joint
Describe the classification and articulations of the hip joint- synovial ball-and-socket; head of the femur, acetab-
ulum of the os coxa, acetabular labrum
Describe the location and function of the ligaments of the hip joint:
- Iliofemoral
- Pubofemoral
- Ischiofemoral
- Ligamentum teres
Describe the vascularization of the hip joint- circumflex femoral arteries and foveolar arteries
Describe the function of the bursae associated with the hip joint (subtendinous iliac bursa, synovial protrusion)
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G29: Anterior and Medial Thigh
At the end of this lecture, students should be able to master the following:
1) Fascia of the thigh
a) Describe the location and relations of the fascia of the thigh (fascia lata and medial, lateral, and posterior
intermuscular septa)
2) Muscles of the anterior and medial thigh
a) Describe the attachments, actions, and relations of the muscles of the anterior and medial thigh (see muscle
table)
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3) Lumbar plexus- thigh
a) Describe the origin course and distribution of the branches of the lumbar plexus that supply the anterior and
medial muscles of the thigh
• Femoral nerve (L2-L4)- enters the anterior thigh deep to the inguinal ligament, muscular branches supply
the muscles of the anterior thigh except the psoas major; cutaneous branches perforate the fascia to supply
the anterior skin of the thigh and knee; the saphenous branch travels in the adductor canal just deep to the
sartorius to become cutaneous on the medial side of the knee, crus, and foot
• Obturator nerve (L2-L4)- enters the medial thigh through the obturator canal then splits into an anterior
and posterior branch, named for their relation to the adductor brevis muscle; supplies the medial compart-
ment of the thigh except the pectineus and the skin of the medial thigh
b) External iliac artery- describe the origin, course, and destination of branches of the external iliac artery that
supply the anterior and medial thigh
i) Femoral artery- courses deep to the inguinal ligament, through the femoral triangle to the adductor canal
(1) Deep artery of the thigh (Profunda femoris artery)- branches posteriorly between the pectineus and
adductor longus muscles, descends through the thigh between the adductor longus and adductor magnus,
gives rise to the medial circumflex femoral, lateral circumflex femoral, and perforating arteries
(a) Medial circumflex femoral artery- wraps medially around the femur between the iliopsoas and
pectineus, courses over the superior margin adductor magnus, forms anastamoses with the lateral cir-
cumflex femoral branches, perforating arteries, and the inferior gluteal artery
(b) Lateral circumflex artery- travels deep to sartorius and rectus femorus, divides into three branches
(i) Ascending branch- ascends deep to the tensor fasciae latae, anastamoses with the medial circumflex
femoral artery to supply the femoral neck and head
(ii) Descending branch- descends deep to the vastus lateralis to anastamose with popliteal branches
(iii) Transverse branch- perforates the vastus lateralis to anastamose with the medial circumflex femo-
ral, inferior gluteal, and perforating arteries around the hip joint
c) Internal iliac artery- describe the origin, course, and destination of branches of the internal iliac artery that
supply the anterior and medial thigh
i) Obturator artery- travels through the obturator canal with the obturator nerve, but splits inside the canal
into an anterior and posterior branch; both branches supply medial thigh muscles and form anastamoses with
medial circumflex femoral and inferior gluteal arteries; the posterior branch helps supply the femoral head
d) Superficial veins- trace blood flow through the superficial veins of the of the lower limb (dorsal venous
arch, small saphenous, great saphenous, accessory saphenous veins)
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G30: Leg and Knee
At the end of this lecture, students should be able to master the following:
1) Muscles of the leg
a) Describe the attachments, actions and relations of the muscles of the leg (see muscle table)
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2) Sacral plexus- leg
a) Describe the origin, course and distribution of the branches of the sacral plexus that supply the leg
i) Sciatic nerve:
• Tibial nerve- (L4-S3) passes through the popliteal fossa between the two heads of the gastrocnemius to
enter the posterior crus, sends off the sural nerve to supply the skin of the posterior leg, then continues
through the posterior crus, deep to the soleus supplying all of the posterior cural muscles, travels posterior
to the medial malleolus in the tarsal tunnel, giving rise to the cutaneous medial calcaneal nerve, then con-
tinues to the plantal surface of the foot where it terminates as the medial and lateral plantar nerves
• Common fibular (peroneal) nerve (L4-S2)- courses laterally through the popliteal fossa between the lateral
head of the gastrocnemius and the insertion of the biceps femoris, gives rise to the lateral sural nerve to
supply the skin of the lateral crus before wrapping around the neck of the fibula and dividing into the deep
and superficial fibular nerves
• Superficial fibular (peroneal) nerve- descends through the lateral compartment of the of the leg be-
tween the fibularis longus and brevis innervating both muscles, travels anterior to the lateral malleo-
lus to the dorsal side of the foot
• Deep fibular (peroneal) nerve- passes through the intermuscular septum to enter the anterior compart-
ment of the leg, descends deep to the extensor digitorum longus to the dorsal side of the foot, supplies
all the muscles of the anterior compartment of the leg supplies
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3) Vascularization of the leg and knee
• Femoral artery- describe the origin, course, and distribution of thebranches of the femoral artery that sup-
ply the knee and leg
• Popliteal artery- arises from femoral artery after passing through the adductor hiatus to the popliteal fossa
• Superior and inferior medial geniculate arteries- wrap anteriorly around the medial side of the knee to
the anastamotic network of arteries on the anterior side of the knee
• Superior and inferior lateral geniculate arteries- wrap anteriorly around the lateral side of the knee to
joint the anastamotic network of arteries on the anterior side of the knee
• Anterior tibial artery- travels through the aperture of the interosseous membrane to enter the anterior
compartment of the leg, gives rise to the recurrent branch which joins the anastamotic network around
the knee, then descends through the anterior compartment of the leg anterior to the interosseous mem-
brane supplying anterior leg muscles, travels anterior to the medial malleolus to the dorsal side of the
foot as the dorsal pedis artery
• Posterior tibial artery- descends through the deep plane of the posterior leg supplying the posterior leg
muscles, gives rise to the fibular arteryjust distal to the knee, courses posterior to the medial malleolus
in the tarsal tunnel to enter the platar surface of the foot
• Fibular (peroneal) artery- descends along the lateral border of the posterior compartment of the leg
supplying the lateral compartment, courses posterior to the lateral malleolus
4) Knee joint
Describe the classification and articulations of the knee joint- synovial hinge (double condyloid); medial and
lateral femoral condyles, medial and lateral tibial condyles
- Menisci: fibrocartilaginous C-shaped cartilages, in the knee joint one medial and one lateral
- Medial meniscus: attached to the tibial collateral ligament
- Lateral meniscus: unattached to the joint capsule and is therefore more mobile
Describe the synovial membrane and bursae associated with the knee joint
Describe the muscular support for the knee joint (vastus medialis, vastus lateralis, posterior thigh muscles,
medial thigh muscles)
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G31: Foot and Ankle
At the end of this lecture, students should be able to master the following:
1) Plantar Aponeurosis
a) Describe the attachments and function of the plantar aponeurosis
2) Actions of the toes
a) Describe the actions of the following joints:
• Metatarsalphalangeal joints- flexion, extension, abduction, adduction
• Interphalageal joints- flexion, extension
3) Muscles of the foot
a) Describe the attachments, actions, and relations of the muscles of the foot (see muscle table)
Foot Muscles
Muscle Origin Insertion Action Innervation
Dorsal muscles
Extensor dig. brev Calcaneus bone Digits 1-5 Extension of Deep fibular n. (S1-
digits S2)
Plantar muscles
First layer
Adductor hallucis Digit 1 Adduct, flex Med plantar n. (S2-
digit 1 S3)
Flexor dig brevis Calcaneus bone Digits 2-5 Flex digits 2-5
Abd digiti minimi Digit 5 Abduct digit 5 Lat plantar n. (S2-S3)
Second layer
Quadratus plantae Calcaneus bone Tendon of flexor digi- Flex digits 2-5 Lat plantar n. (S1-S3)
torum longus
Lumbricals Tendon of flexor digi- Expansion over digits Flex prox. pha- 1: Med plant (S2-S3)
torum longus 2-5 langes, extend 2-4: Lat plant (S2-S3)
mid and distal
IP
Third layer
Flex halluc brevis Cuboid and lateral Digit 1 Flex digit 1 Med plant (S1-S2)
cuneiform bones
Adductor hallucis Oblique: Metatars 2-4 Digit 1 Adduct digit 1 Lat plant (S2-S3)
Transv: MP joints deep branch
Flex dig minimi 5th metatarsal Digit 5 Flex digit 1 Lat plant (S2-S3)
superficial branch
Fourth layer
Plant interossei Metatarsals 3-5 Digits 3-5 Adduct digits
2-4; flex MP
joints Lat plant (S2-S3)
Dorsal interossei Metatarsals 1-5 Dorsal expansion of Abduct digits
digits 2-4 2-4; flex MP
joints
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4) Lumbosacral plexus- foot
a) Common fibular (peroneal) nerve (L4-S2)
• Superficial fibular (peroneal) nerve- courses anterior to the lateral malleolus to supply skin of the dorsum
of the foot
• Deep fibular (peroneal) nerve- enters the dorsal side of the foot deep to the extensor hallucis longus to sup-
ply the extensor digitorum brevis and the skin between the first two toes
b) Tibial nerve- enters the foot from the tarsal tunnel, splits into the medial and lateral plantar nerves
• Medial plantar nerve- supplies the first lumbrical, abductor hallucis, flexor hallucis brevis, flexor digito-
rum brevis (1LAFF), and the medial plantar skin
• Lateral plantar nerve- supplies the second through fourth lumbricals, adductor hallucis, abductor digiti
minimi, flexor digiti minimi, quadratus plantae, dorsal interossei (DAB), plantar interossei (PAD), and the
lateral plantar skin
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6) Ankle and foot joints
a) Ankle (talocrural) joint
Describe the classification and articulations of the ankle joint- synovial joint; distal ends of tibia and fibula,
trochlear surface of the talus
Describe the muscular support for the ankle joint (anterior, posterior, and lateral compartments of the leg)
b) Foot joints
• Describe the location and function of the intertarsal joints- transverse tarsal joint, subtalar joint; inver-
sion, eversion of the foot
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