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COVER

FRONTMATTER
PREFACE
ABOUT THE AUTHOR
INTRODUCTION
CHAPTER 1 - SPINE
CHAPTER 2 - SHOULDER
CHAPTER 3 - ARM
CHAPTER 4 - FOREARM
CHAPTER 5 - HAND
CHAPTER 6 - PELVIS
CHAPTER 7 - THIGH/HIP
CHAPTER 8 - LEG/KNEE
CHAPTER 9 - FOOT/ANKLE
CHAPTER 10 - BASIC SCIENCE
ABBREVIATIONS USED IN THIS BOOK
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

Netter's Concise Atlas of Orthopaedic Anatomy

Jon C. Thompson, M.D.

Dedication
To my parents, for their unwavering faith in me.
To my in-laws, for their continual support.
To my daughters, who make it meaningful and fun.
Especially to my wife Tiffany, who inspires me in every aspect of my life.

SAUNDERS ELSEVIER
Elsevier Inc.
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Suite 1800
Philadelphia, PA 19103-2899
Netter's Concise Atlas of Orthopaedic Anatomy
ISBN-13: 978-0-914168-94-2
ISBN-10: 0-914168-94-0
Published by Icon Learning Systems LLC, a subsidiary of Elsevier, Inc.
Copyright © 2002 Elsevier Inc. All rights reserved.
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NOTICE

Medicine is an ever-changing field. Standard safety precautions must be followed, but


as new research and clinical experience broaden our knowledge, changes in treatment
and drug therapy may become necessary or appropriate. Readers are advised to
check the most current information provided by the manufacturer of each drug to be
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administration, and contraindications. It is the responsibility of the licensed health care
provider, relying on experience and knowledge of the patient, to determine dosages
and the best treatment for each individual patient. Neither the publisher nor the editor
assumes any liability for any injury and/or damage to persons or property arising from
this publication.
The Publisher

Library of Congress Catalog No: 00-130477


Printed in U.S.A.
Last digit is the print number: 9 8 7 6 5 4

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PREFACE

While working on the Orthopedic Service as a medical student I found myself in need of a quick,
but comprehensive reference to help me get through my busy clinics and morning rounds.
Having had success with pocket references, I searched the bookstores for something similar for
orthopedics. Several were available, but none of them had the quick and easy-to-read format I
wanted. As a result, I made pocket-sized note cards for my own use.
These cards started with basic anatomy such as diagrams of the Brachial plexus or fascial
compartments of the leg. I then added cards for various conditions including notes on pertinent
History and Physical Exam findings and treatment options. Many years later, when the growing
stack of note cards was too big, unwieldy and tattered to use any longer, I converted the
information into a more usable book format. That original hand-assembled book is the
foundation of the atlas you are now holding.

One well-drawn anatomic picture often explains far more than several pages of
detailed text.

This concise, quick-reference atlas covers the spine and extremities as well as diagnosis and
treatment of orthopedic conditions with primary emphasis on illustrations that educate,
oftentimes without the need for explanatory text. Text, when necessary, is presented in tabular
form to allow for fast review of essential information.
The first nine chapters are divided anatomically. Because I believe quite strongly that the
treatment of orthopedic problems is based in anatomy, I have incorporated an extensive review
of the anatomy of both the spine and extremities. There are also subsections within each
chapter to help in the clinical diagnosis and treatment of the orthopedic patient. For example,
the History table offers help in developing a differential diagnosis while the Trauma and
Disorder tables assist in the work-up and treatment options of many orthopedic conditions.
Chapter Ten is a brief introduction to orthopedic-related basic science.
From the first time I opened Frank Netter's Atlas of Human Anatomy, I was impressed, and even
inspired, by the clarity and the incredible amount of information contained within each of his
illustrations. I consider his work incomparable. As the basis for this text is also deeply rooted in
its extensive use of illustrations, you can imagine how pleased I was when Icon Learning
Systems asked me to combine our efforts to create this new publication. I thank them for their
diligence, expertise,and patience with this project. I would also like to thank Dr. Jim Heckman
for lending his wisdom and years of publishing experience to this effort.
This book is the result of several years of accumulating and condensing Orthopedic-related
data. Indeed, as it stands now, this is truly the reference I had searched for as a medical student,
but was never able to find. The information inside these covers served to help me synthesize
and retain a large body of information when I was a student and young physician. I trust its
readers will be as equally well served.
Jon C. Thompson, MD

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ABOUT THE AUTHOR

Jon Thompson, MD, received his medical degree from the Uniformed Services University of the
Health Sciences in Bethesda, Maryland. He received his undergraduate degree from Dartmouth
College. Dr. Thompson has worked as both an emergency room physician and a research
assistant in the Extremity Trauma Branch of the Institute of Surgical Research. Currently, he is a
resident in orthopedic surgery in the San Antonio Uniformed Services Health Education
Consortium at Brooke Army Medical Center and is a corresponding member of the Department
of Surgery at the Uniformed Services University of the Health Sciences.

Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com


Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

INTRODUCTION

Netter's Concise Atlas of Orthopedic Anatomy is an easy-to-use reference and compact atlas of
orthopedic anatomy for students and clinicians. Using images from both the Atlas of Human
Anatomy and the 13-Volume Netter Collection of Medical Illustrations, this book brings together
over 450 Netter images together for the first time in one book.
Tables are used to highlight the Netter images and offer key information on bones, joints,
muscles and nerves, and surgical approaches. Clinical material is presented in a clear and
straightforward manner with emphasis on trauma, minor procedures, history and physical exam,
and disorders.
Users will appreciate the unique color-coding system that makes information look-up even
easier. Key material is highlighted in black, red, and green to provide quick access to clinically
relevant information.
BLACK for standard text
RED highlights key information that if missed could result in morbidity or mortality
GREEN highlights “must know” clinical information.

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CHAPTER 1 - SPINE
TOPOGRAPHIC ANATOMY
OSTEOLOGY
TRAUMA
SPINAL CORD TRAUMA
JOINTS
LIGAMENTS
HISTORY
PHYSICAL EXAM
MUSCLES: ANTERIOR NECK
MUSCLES: POSTERIOR NECK
SUPERFICIAL MUSCLES: POSTERIOR NECK AND BACK
DEEP MUSCLES: POSTERIOR NECK AND BACK
NERVES OF THE UPPER EXTREMITY: CERVICAL PLEXUS
NERVES: BRACHIAL PLEXUS
NERVES: LUMBAR PLEXUS
NERVES: SACRAL PLEXUS
ARTERIES
DISORDERS
PEDIATRIC DISORDERS
SURGICAL APPROACHES
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 1 – SPINE
TOPOGRAPHIC ANATOMY

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY

CHARACTERISTICS OSSIFY FUSE COMMENT


C1 ATLAS
• Ring shaped
Anterior Superior facet articulates with
Two lateral masses • occiput, anterior arch articulates
• arch (1)
with facets on them with dens
Posterior 6 yrs
No body, no spinous arch (2) Birth • Fractures: most have 2 sites

process (1 for each Vertebral artery runs in groove on
Post. Arch has a half) •
• posterior arch
sulcus/groove
C2 AXIS
Odontoid has precarious vascular
6yrs supply watershed area):
Dens/odontoid Lower •
Birth increased incidence of nonunion
• articulates w/atlas at body (2) Body
median atlantoaxial Dens (2) Tip with fractures
12yrs
joint Arch (2) Rotation in neck mostly occurs
Birth •
between C1 and C2
CERVICAL (C3-7)

Foramina in Vertebral artery runs through


• •
transverse process transverse foramina
Facets: “semi- 7- Nerve roots at risk of
1-2 yr

coronal” allow Primary 8wk compression
• 7-10
flex/extension, no Arch (fetal) No foramina in transverse
rotation yr •
Body process of C7
18-
Narrow intervertebral Secondary 11-
• 25 yr • C7 is vertebral prominens,
foramina 14 yr nonbifid spinous process
Bifid spinous Klippel-Feil syndrome: congenital
• •
processes fusion of cervical vertebrae
THORACIC
Facets: form semi-

circle: allow rotation
7- T1 spinous process is as
Costal facets (for 1-2 yr

Costal facets (for 7- •
1-2 yr prominent as that of C7
ribs) Primary 8wk
7-10
Arch (fetal) Rotation of spine occurs within
T1-9: on the yr •
Body the thoracic region
• transverse 18-
Secondary 11- Spinous processes overlap the
process 25 yr •
14 yr next lower vertebrae
T10-12: on the
pedicle
CHARACTERISTICS OSSIFY FUSE COMMENT
LUMBAR
• Large vertebral bodies
Primary Arch
Short lamina and 1-2 L5 is the largest
• 7-8 •
pedicles vertebrae
pedicles 7-8 vertebrae
yrs
wk
Mamillary and accessory 7-10 Large vertebral bodies
• (fetal)

processes Body yrs capable of bearing
Facets: sagittal: good for 18- weight
11-14
• flexion/extension, not Secondary 25 L5 has a ligamentous
yrs •
rotation Mamillary yrs attachment to the ilium
process
• No costal facets
SACRAL
2-8
yrs Transmits weight of
• 5 vertebrae are fused Body 8 wk •
(fetal) body to the pelvis
4 pairs of sacral 2-8
• Arches
• Nerves exit through the
foramina yrs
Cpstal sacral foraminae
Sacral canal opens to 2-8
• elements 11-14 Segments fuse to each
hiatus yrs •
Secondary yrs other at puberty
20
yrs
COCCYGEAL
• 4 vertebrae are fused 1-2
Primary Arch 7-8 yrs Is attached to Gluteus
Lacks most of the wk • maximus and
• features of typical Body (fetal) 7-10 coccygeal muscle
vertebrae yrs
Ossification: Typically 3 primary (body each arch), 5 secondary ossification centers (spinous
process, transverse process (2), upper and lower plates of the body (2))
The arches fuse dorsally; spina bifida occurs when it does not fuse
The arches unite with the bodies (6-10years old) in order: thoracic, cervical, lumbar, sacral (7
years). Neurocentral joint (fusion of arch and body) is in the body

GENERAL INFORMATION
• 33 Vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused), 4 coccygeal
• Cancellous bone in cortical shell
• Vertebral canal between body and lamina: houses the spinal cord.
• Spinal Curves:
Cervical: lordosis
Thoracic: kyphosis (increase in Scheuermann's
disease)
Lumbar: lordosis

Body (centrum): have articular cartilage on superior/inferior aspects; get


1.
larger inferiorly
• 2. Arch (pedicles lamina) [no arch develops in spina bifida]
Vertebrae:
3. Processes: spinous, transverse, costal, mamillary
4. Foramina: vertebral, intervertebral, transverse
• 3 Columns
Anterior ALL, anterior half of body annulus
Middle PLL, posterior half of body annulus
Posterior Ligamentum flavum, lamina, pedicles, facets
LEVEL CORRESPONDING STRUCTURE
C2-3 Mandible
C3 Hyoid cartilage
C4-5 Thyroid cartilage
C6 Cricoid cartilage
C7 Vertebral prominens
T3 Spine of scapula
T7 Xiphoid, tip of scapula
T10 Umbilicus
L1 End of spinal cord
L3 Aorta bifurcation
L4 Iliac crest
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


CERVICAL FRACTURE
Based on level
location: Immobilize all
C1-Jefferson fractures, traction
High energy injury: HX: Trauma. fracture: both on unstable, lower
• Young - MVA, old Pain, worse with arches c-spine fractures
- fall movement, +/- fractured C1 and 2:
Axial numbness C1-Lateral Stable:
compression weakness. mass Collar or
(most common PE: Tender to fracture halo

mech.-anism) palpation, +/- C2-
results in burst Unstable:
“step off” Hangman's
fracture Halo for 3
neurologic or (isthmus): months
myelopathic
months
Flexion/distraction myelopathic Levine and/or fusion
• injury results in signs. Do rectal classification
dislocation genital exams. Odontoid type 2:
C2-
XR: AP, lateral, ORIF (worse with
Neurologic injury Odontoid:
rare (esp. with odontoid: note Type 1,2,3 traction)
• anterior soft C3-7:
C12 fracture) C3-7
seen tissue Stable:
Fracture
Often have CT: Shows canal Collar or
(fragments may Spinous halo
• associated process
injuries compress canal) Unstable:
(Clay
9 criteria checklist MR: Evaluate shoveler's Fusion
• soft tissues
predicts instability fracture): C6, Spinous process:
7, T1 (C7
most Symptomatic
common)

COMPLICATIONS: Neurologic injury (e.g., CN VIII with C1 fracture, etc.); Residual pain;
Osteoarthritis; Nonunion (especially odontoid type 2 fracture)

Three-Column Concept of Spinal Stability

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


THORACOLUMBAR FRACTURE
HX: Trauma.
Pain, +/-
numbness
Mechanism: MVA, weakness

fall
PE: Tender
1 column fracture: Mechanism:
• to palpation,
stable +/- “step off” Compression/wedge:
2 column fracture: neurologic or anterior column

unstable myelopathic Burst: fragments
signs. Stable fractures: bed
Anterior column displace posteriorly; rest, orthosis (TLSO)
(Wedge) fracture Do rectal anterior middle
• 50% height loss is genital columns (unstable) Unstable (or with
exams
• 50% height loss is
considered 2 exams neurologic
Flexion/distraction
columns XR: AP, symptoms/compressed
(Chance/seatbelt
lateral T-L canal): Spinal canal
Compression/wedge fracture): 2 (or 3)
spine: body decompression and
• fracture: (most columns: posterior
height, spinal fusion
common) middle (anterior).
splaying
Chance fracture: pedicle Fracture/dislocation:
• all 3 columns
rare
CT: Shows involved.
Neurologic deficits any canal
• rare, but seen with impingement
Burst fractures
MR:
Evaluate soft
tissues
COMPLICATIONS: Neurologic injury; Osteoarthritis; Associated injuries.

Stable Fracture

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SPINAL CORD TRAUMA

Cervical Spine Injury: Incomplete Spinal Syndromes

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


HX: Trauma.
Symptoms depend
on injury/lesion.
PE: Depends on
injury
Complete: no
motor or
Young males sensory
• Complete cord
most common function below injury: cord
Complete cord injury level.
severed, no
injury: no function Anterior: LEUE function (spinal Treat
AND paralysis, pain shock must be associated
• bulbocavernosus temperature resolved to injuries:
reflex has sensory loss, diagnose it) lifethreatening
returned. (spinal vibratory first.
shock over) Incomplete:
proprioception Mannitol and
intact. Anterior:
Incomplete cord early IV
• Spinothalamic
injury: 4 types Central: steroids may
corticospinal
Anterior cord: #2. Weakness improve
tracts out,
• Flexion injury; UELE, sacral neurologic
posterior
worst prognosis sensation function
columns
spared. spared. Immobilization
Central cord:
most common. Posterior: is the key to
Central: gray
Hyperextension Loss of treatment
matter injury
• injury, seen in vibratory Stable injures:
sensation and Posterior:
elderly (who fall), collar, brace
proprioception. posterior
associated with Unstable
columns
spondylosis B-S: Ipsilateral injuries: Halo
disrupted
Posterior: very motor, vest or
• vibratory, Brown-
rare (may not internal
proprioception Séquard
exist) (lateral): hemi- fixation
loss;
Brown-Sequard: contralateral section of
• rare, best pain cord
prognosis temperature
loss.
XR: C-spine
series, +/- TL
spine
CT: if evidence
of fracture

COMP: Neurogenic shock; Autonomic dysreflexia (requires urinary catheterization and/or fecal
disimpaction); Neurologic sequelae
Spinal Shock: Physiologic cord injury/dysfunction (often from compression or swelling) including
paralysis areflexia. Return of bulbocavernosus reflex (arc reflexes) marks the end of spinal shock.
Neurogenic Shock: Hypotension with bradycardia. Cord injury results in decreased sympathetic
release (unopposed vagal tone)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

JOINTS

LIGAMENT ATTACHMENT COMMENT


ATLANTOOCCIPITAL (Ellipsoid)
Primarily involved in flexion, extension, lateral bending movements
Tectoral
Extension of the PLL
membrane Axis body to occiput
Joint stabilized by attachment to dens;
Anterior/Posterior around facets
known to be weak in Down's Syndrome
capsule
MEDIAN ATLANTOAXIAL C1-2 (Plane and Pivot)
Primarily involved in rotation; dependent on ligaments for stability; instability in Down's syndrome
Lateral mass-
dens-lateral
Transverse
mass
Apical Strongest ligament: holds dens in place
Dens to occiput
Alar Part of cruciate ligament
Dens to occiput
Superior condyles Prevent excessive head rotation
Longitudinal With transverse apical forms cruciate
Dens to basilar
Inferior occiput ligament
Longitudinal
Dens to axis
body
LIGAMENT ATTACHMENT COMMENT
ZYGAPOPHYSEAL (Facet Plane)
Has articular discs: this joint allows the most mobility in the spine
Changes orientation at different vertebral levels
Capsule Around facets Orientation dictates plane of motion; C5-6 most
mobile (#1 degeneration site) L4-5 most flexion
INTERVERTEBRAL
Inferior superior
aspect of
Intervertebral Strongest attachments of bodies
bodies
disc Thicker than PLL
Anterior: body
ALL Thinner, disc herniation usually
to body
PLL posterolateral.
Posterior: body
to body
COSTOVERTEBRAL (Luschka)
Surrounds rib
head joint
Capsule
Intraarticular Head of rib to
disc Holds head to vertebrae
Radiate Reinforces joint
Anterior head
to both bodies anteriorly

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

LIGAMENTS

LIGAMENT LOCATION COMMENT


Anterior surface of
Anterior
Longitudinal vertebral bodies
[ALL] Posterior surface of
bodies (connects discs]
Posterior Strong; thicker in center of body
Longitudinal Between transverse
processes Weaker thinner [herniation occurs
[PLL]
laterally or posterolaterally]
Intertransverse Around facet joint
Weak, adds little support
Apophyseal Connects anterior
surfaces of laminae Weak, adds little support
joint capsule
C7 to occipital Strong; constantly in tension
Ligamentum
Flavum protuberance Extension of supraspinous ligament
Ligamentum Along dorsal spinous Unknown contribution to stability
Nuchae processes to C7 Unknown contribution to stability
Supraspinous Between spinous Extension of PLL
Interspinous processes
Part of cruciate ligament, major
Posterior aspect of bodies stabilizer
Tectoral
dens to clivus
membrane Resists excessive rotation
Lateral mass to dens to
Transverse Avulsion fracture can occur in trauma
lateral mass
ligament
Dens to occiput tubercles
Alar
L5 transverse process to
Iliolumbar
ilium
INTERVERTEBRAL DISCS [made of fibrocartilage]
Annulus Outside, type I collagen, connects to vertebral hyaline cartilage, buffers
fibrosis compression
Nucleus Inside, type II collagen, high water content until old age, derived from
pulposus notochord, can protrude/herniate through annulus, is avascular
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY

QUESTION ANSWER CLINICAL APPLICATION


Disc injuries, spondylolisthesis
Young
Sprain/strain, herniated disc, degenerative disc disease
1. AGE Middle age
Elderly Spinal stenosis, herniated disc, degenerative disc
disease, arthritis
2. PAIN
Radiating
(shooting) Radiculopathy (Herniated disc, spondylosis)
a. Character
Diffuse, dull, non- Cervical or lumbar strain (soft tissue injury)
radiating
Unilateral vs.
Unilateral: herniated disc; Bilateral: systemic or metabolic
bilateral
disease;space occupying lesion
Neck Cervical spondylosis, neck sprain or muscle strain
b. Location Arms (+/- Cervical spondylosis (+/- myelopathy), herniated disc
radiating)
Degenerative Disc Disease, back sprain or muscle strain,
Lower back
spondylolisthesis, tumor
Legs (+/-
Herniated disc, spinal stenosis
radiation)
Night pain Tumor
c. Occurrence
With activity Usually mechanical etiology
Arms elevated Herniated cervical disc
d. Alleviating
Sit down Spinal stenosis (stenosis relieved)
e. Exacerbating Back extension Spinal stenosis (e.g. going down stairs)
Cervical strain (whiplash), cervical fractures, ligamentous
3. TRAUMA MVA (seatbelt?)
injury
Sports
4. ACTIVITY “Burners/stingers” (especially in football)
(stretching injury)
Pain, numbness,
tingling
Radiculopathy, neuropathy
5. NEUROLOGIC Spasticity, Myelopathy
SYMPTOMS clumsiness
Cauda equina syndrome
Bowel or bladder
symptoms
6. SYSTEMIC Fever, weight
6. SYSTEMIC Fever, weight
Infection, tumor
COMPLAINTS loss

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAM TECHNIQUE CLINICAL APPLICATION


INSPECTION
Leaning forward Spinal stenosis
Gait
Wide-based Myelopathy
Alignment Malalignment Dislocation, scoliosis, lordosis, kyphosis
Head tilted Dislocation, spasm, spondylosis, torticollis
Posture
Pelvis tilted Loss of lordosis: spasm
Cafe-au-lait spots, growths: possibly
neurofibromatosis
Skin Disrobe patient
Port wine spots, soft masses: possibly spina
bifida
PALPATION
Spinous Focal/point tenderness: fracture. Step-off:
Bony structures
processes dislocation/spondylolisthesis
Cervical facet
joints
Tenderness: osteoarthritis, dislocation
Coccyx-via rectal Tenderness: fracture or contusion
exam
Diffuse tenderness indicates sprain/muscle
Soft tissues Paraspinal
strain. Trigger point: spasm
muscles
Swelling suggests clavicle fracture
Supraclavicular
Fatty masses: possibly spina bifida
fossa
Skin
RANGE OF MOTION
Chin to Normal: Flexion: chin within 3-4cm of chest;
Flexion/extension: Cervical chest/occiput back
Extension 70 degrees
Lumbar Touch toes with Normal: 45-60 degrees in flexion, 20-30
straight legs degrees in extension
Cervical Ear to shoulder Normal: 30-40 degrees in each direction
Lateral flexion:
Lumbar Bend to each side Normal: 10-20 degrees in each direction
Stabilize
Rotation: Cervical shoulders: rotate Normal: 75 degrees each direction
Lumbar Stabilize hip: Normal: 5-15 degrees in each direction
rotate
NEUROVASCULAR
A complete neurologic examination should be performed
Sensory
CERVICAL
Anterior neck
Supraclavicular (C2-3) clavicle area
Axillary nerve (C5) Lateral shoulder Deficit indicates corresponding nerve/root lesion
Musculocutaneous nerve Lateral forearm Deficit indicates corresponding nerve/root lesion
(C6) Dorsal thumb web Deficit indicates corresponding nerve/root lesion
Radial Nerve (C6) space Deficit indicates corresponding nerve/root lesion
Median Nerve (C7) Radial border mid Deficit indicates corresponding nerve/root lesion
Ulnar Nerve (C8) finger Deficit indicates corresponding nerve/root lesion
Medial Cutaneous nerve Ulnar border small Deficit indicates corresponding nerve/root lesion
forearm(T1) finger
Medial forearm

Straight Leg Test

EXAM TECHNIQUE CLINICAL APPLICATION


LUMBAR
Deficit indicates corresponding
Femoral/Saphenous
nerve/root lesion
nerve (L4) Medial leg ankle
Deficit indicates corresponding
Superficial/Deep Dorsal foot 1 st -2 nd toe web
nerve/root lesion
Peroneal Nerve (L5) space
Deficit indicates corresponding
Tibial/sural nerve (S1) Lateral foot
Sacral nerves (S 2, 3, Perianal sensation nerve/root lesion
Deficit indicates corresponding
4)
nerve/root lesion
Motor
CERVICAL

Spinal accessory Weakness = Sternocleidomastoid or


nerve/root lesion
(CN11)
Neck flexion rotation Weakness = Deltoid or nerve/root lesion
Axillary nerve (C5)
Resisted shoulder abduction Weakness = Brachialis or nerve/root
Musculocutaneous
Resisted elbow flexion lesion
nerve (C5-6)
Radial nerve (PIN) Finger extension Weakness = EDC, EIP, EDM or
Thumb flexion, opposition, nerve/root lesion
(C7)
abduction Weakness = FPL/thenar muscles or
Median nerve (C8)
Ulnar nerve (Deep Finger cross (abduct/adduct) corresponding nerve/root lesion
Weakness = DIO/VIO or nerve/root
branch) (T1)
lesion
LUMBAR

Deep Peroneal nerve Weakness = Tibialis anterior or


nerve/root lesion
(L4)
Foot inversion dorsiflexion Weakness = Extensor hallucis longus or
Deep Peroneal nerve
(L5) Great toe extension nerve/root lesion
Superficial Peroneal Foot eversion Weakness = Peroneus longus/brevis or
Superficial Peroneal
(S1) Great toe flexion nerve/root lesion
Weakness = Flexor hallucis longus or
Tibial nerve (S1)
nerve/root lesion
Reflexes
Hypoactive/absence indicates C5
radiculopathy
Hypoactive/absence indicates C6
C5 Biceps radiculopathy
C6 Brachioradialis Hypoactive/absence indicates C7
C7 Triceps radiculopathy
L4 Patellar Hypoactive/absence indicates L4
S1 Achilles reflex radiculopathy
S1, 2, 3 Bulbocavernosus Hypoactive/absence indicates S1
radiculopathy
Finger in rectum, squeeze/pull penis
(Foley), anal sphincter contracts
Upgoing toe is consistent with upper
UMN Babinski/clonus
motor neuron lesion
Pulses
Diminished/absent = vascular injury or
Brachial, radial, ulnar
Upper extremity compromise
Femoral, popliteal, dorsalis
Lower extremity pedis, posterior tibial Diminished/absent = vascular injury or
compromise

Forward Bending Test

EXAM TECHNIQUE CLINICAL APPLICATION


SPECIAL TESTS
CERVICAL

Spurling Axial load, then laterally Radiating pain indicates nerve root compression
flex rotate neck

Distraction Upward distracting force Relief of symptoms indicates foraminal compression of


nerve root
LUMBAR
Flex hip to pain, dorsiflex Symptoms reproduced (pain below knee) indicative of
Straight leg
foot radicular etiology
Straight leg Supine: flex hip knee
20° of flexion = tight hamstrings: source of pain
90/90 90°, extend knee

Bowstring Raise leg, flex knee, Radicular pain with popliteal pressure indicates sciatic
Bowstring
apply popliteal pressure nerve etiology
Sitting root Sit: distract patient, Patient with sciatic pain will arch or flip backward on
(flip sign) passively extend knee knee extension

Kernig Supine: flex neck Pain in or radiating to legs indicates meningeal


irritation or infection

Brudzinski Supine: flex neck, flex hip Pain reduction with knee flexion indicates meningeal
irritation.
Forward Standing, bend at waist Asymmetry of back (scapula/ribs) is indicative of
Bending scoliosis

Trendelenburg Stand on one leg Drooping pelvis on elevated leg side: gluteus medius
weakness
Supine: hands under Pressure should be felt under opposite heel (not being
Hoover heels, patient then raises raised). No pressure indicates lack of effort, not true
one leg weakness
Presence indicates non-organic pathology: 1) exaggerated response or
Waddell signs overreaction, 2) pain to light touch, 3) non-anatomic pain localization, 4) negative
flip sign with positive straight leg test.

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: ANTERIOR NECK

MUSCLE ORIGIN INSERTION ACTION NERVE


ANTERIOR NECK
Fascia:
Mandible;
Platysma Deltoid/pectoralis Depress jaw CN 7
skin
major
SUPRAHYOID MUSCLES
Anterior:
Anterior: Mandible Mylohyoid (CN
Elevate hyoid,
Digastric Posterior: Mastoid Hyoid body 5)
depress mandible
notch Posterior: Facial
(CN 7)
Raphe on Mylohyoid (CN
Mylohyoid Mandible Same as above
hyoid 5)
Body of Facial nerve
Stylohyoid Styloid process Elevate hyoid
hyoid (CN 7)

Geniohyoid Genial tubercle of Body of Elevate hyoid C1 Via CN 12


mandible hyoid
INFRAHYOID MUSCLES [STRAP MUSCLES INCLUDES THE SCM]
SUPERFICIAL
Body of Ansa cervicalis
Sternohyoid Manubrium clavicle Depress hyoid
hyoid (C1-3)

Omohyoid Suprascapular Body of Depress hyoid Ansa cervicalis


notch hyoid (C1-3)
DEEP
Greater horn Depress/retract
Thyrohyoid Thyroid cartilage C1 via CN 12
of hyoid hyoid/larynx

Sternothyroid Manubrium Thyroid Depress/retract Ansa cervicalis


cartilage hyoid/larynx (C1-3)
Mastoid Turn head opposite
Sternocleidomastoid Manubrium clavicle CN 11
process side
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: POSTERIOR NECK

MUSCLE ORIGIN INSERTION ACTION NERVE


POSTERIOR NECK: SUBOCCIPITAL TRIANGLE
Rectus capitis Spine of axis Inferior nuchal line Extend, rotate, Suboccipital
posterior: major laterally flex nerve
Rectus capitis Posterior tubercle Occipital bone Extend, laterally Suboccipital
posterior: minor of atlas flex nerve
Obliquus capitis Atlas transverse Extend, rotate, Suboccipital
Occipital bone
superior process laterally flex nerve
Obliquus capitis Atlas transverse Extend, laterally Suboccipital
Spine of axis
inferior process rotate nerve

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SUPERFICIAL MUSCLES: POSTERIOR NECK AND BACK

MUSCLE ORIGIN INSERTION ACTION NERVE


SUPERFICIAL (EXTRINSIC)

Trapezius Spinous process Clavicle; Scapula Rotate scapula CN 11


C7-T12 (AC, SP)

Latissimus dorsi Spinous process Humerus Extend, adduct, Thoracodorsal


T6-S5 IR arm
Transverse
Levator scapulae Scapula (medial) Elevate scapula C3, 4, Dorsal
process C1-4 scapular
Spinous process
Rhomboid minor Scapula (spine) Adduct scapula Dorsal scapular
C7-T1
Spinous process Scapula (medial
Rhomboid major Adduct scapula Dorsal scapular
T2-T5 border)
Serratus posterior Spinous process Ribs 2-5 (upper Intercostal nerve
Elevate ribs
superior C7-T3 border) (T1-4)
Serratus posterior Spinous process Ribs 9-12 (lower Depress ribs Intercostal nerve
inferior T11-L3 border) (T9-12)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DEEP MUSCLES: POSTERIOR NECK AND BACK

MUSCLE ORIGIN INSERTION ACTION NERVE


DEEP (INTRINSIC)
SUPERFICIAL LAYER: SPINOTRANSVERSE GROUP
Dorsal rami
Splenius Ligamentum nuchae Mastoid Both: laterally flex rotate of inferior
capitis nuchal line neck to same side cervical
nerves
Splenius Spinous process T1-6 Transverse
cervicus process C1-4
INTERMEDIATE LAYER: SACROSPINALIS GROUP (Erector spinae) All have 3 parts: thoracis,
cervicis and capitis
Ribs
TC spinous
Iliocostalis Common origin: process, Laterally flex, extend, Dorsal rami
Longissimus Sacrum, iliac crest, and mastoid rotate head (to same of spinal
Spinalis lumbar spinous process. process side) and vertebral column nerves
T-spine:
spinous
process
MUSCLE ORIGIN INSERTION ACTION NERVE
DEEP (INTRINSIC)
DEEP LAYERS: TRANSVERSOSPINALIS GROUP
Semispinalis Transverse Spinous Extend, rotate opposite Dorsal
(CT) process process side primary rami
Semispinalis Transverse Dorsal
Nuchal ridge
capitis process T1-6 primary rami

Multifidi [C2-S4] Transverse


Spinous Flex laterally, rotate Dorsal
process process opposite primary rami
Transverse Spinous Rotate superior vertebrae Dorsal
Rotatores
process process +1 opposite primary rami
Spinous Dorsal
Interspinales Spinous process Extend column
process +1 primary rami

Intertransversarii Transverse
Transverse Dorsal
Laterally flex column
process process +1 primary rami

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Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES OF THE UPPER EXTREMITY: CERVICAL PLEXUS

CERVICAL PLEXUS (C1-C4 ventral rami) Behind IJ and SCM

Lesser Occipital Nerve(C2-3): arises from posterior border of SCM


Sensory: Superior region behind auricle
Motor: NONE

Great Auricular Nerve (C2-3): exits inferior to Lesser Occipital nerve,


then ascends on SCM
Sensory: Over parotid gland and below ear
Motor: NONE

Transverse Cervical Nerve (C2-3): exits inferior to Greater


Auricular nerve, then to anterior neck
Sensory: Anterior triangle of the neck
Motor: NONE

Supraclavicular (C2-3): splits into 3 branches: anterior,


middle, posterior
Sensory: Over clavicle, outer trapezius deltoid
Motor: NONE
1.
Ansa Cervicalis (C1-3): superior (C1-2) inferior
(C2-3) roots form loop
2.
Sensory: NONE
Omohyoid
3. Motor: Sternohyoid
Sternothyroid

4.
Phrenic Nerve (C3-5): On anterior
scalene, into thorax between subclavian
artery and vein
5.
6. Pericardium and
Sensory:
mediastinal pleura
Motor: Diaphragm

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reserved. - www.mdconsult.com
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES: BRACHIAL PLEXUS

BRACHIAL PLEXUS (C5-T1 ventral rami) [variations: C4-T2] (also see Shoulder)

SUPRACLAVICULAR [approach through posterior triangle]


ROOTS

Dorsal Scapular (C5): pierces middle scalene, deep to Levator Scapulae Rhomboids.
Sensory: NONE
Levator scapulae
Motor:
Rhomboid Minor and Major

Long Thoracic (C5-7): on anterior surface of Serratus Anterior with Lateral Thoracic artery.
Sensory: NONE
Motor: Serratus Anterior (wing scapula with nerve dysfunction)

UPPER TRUNK

Suprascapular (C5-6): through scapular notch, under superior transverse scapular ligament.
Sensory: Shoulder joint
Supraspinatus
Motor:
Infraspinatus

Nerve to Subclavius (C5-6): descends anterior to plexus, posterior to clavicle


Sensory: NONE
Motor: Subclavius

INFRACLAVICULAR [approach through axilla]


LATERAL CORD

• Lateral root to Median nerve

Lateral Pectoral (C5-7): named for lateral cord, is medial to Medial Pectoral nerve runs with pectoral artery.
Sensory: NONE
Pectoralis Major
Motor:
Pectoralis Minor (via loop to MPN]

Musculocutaneous (C5-7): pierces coracobrachialis, runs between biceps brachialis.


Sensory: Lateral forearm [via Lateral cutaneous nerve]
ANTERIOR COMPARTMENT OF ARM
Motor: Coracobrachialis
Biceps brachialis
Brachialis

INFRACLAVICULAR [approach through axilla]


MEDIAL CORD

• Medial root to Median nerve

Medial Pectoral (C8-T1): named for medial cord, is lateral to Lateral Pectoral nerve
Sensory: NONE

Motor: Pectoralis Minor


Pectoralis Major (overlying muscle]

Medial Cutaneous Nerve of Arm (Brachial, C8-T1): joins Intercostalbrachial


Sensory: Medial (inner) arm
Motor: NONE

Medial Cutaneous Nerve of Forearm (Antibrachial, (C8- T1): runs with basilic vein.
Sensory: Medial forearm anterior arm
Motor: NONE

Ulnar (C (7) 8-T1): runs behind medial epicondyle in groove. Multiple sites of possible compression
Sensory: Medial palm 1 1/2 digits via: palmar palmar digital branches
Medial dorsal hand 1 1/2 digits via: dorsal, dorsal digital, proper palmar digital branches
FOREARM [runs between the two muscles]
Flexor carpi ulnaris
Flexor digitorum profundus [digits 4,5]
HAND [divides at hypothenar eminence]
Superficial Branch [lateral to pisiform]
Palmaris brevis
Deep (Motor) Branch
[around hook of hamate]
10. Adductor pollicis
Motor: THENAR MUSCLES
Flexor pollicis brevis[FPB][with median]
HYPOTHENAR MUSCLES
Abductor digiti minimi [ADM]
Flexor digiti minimi brevis [FDMB]
Opponens digiti minimi [ODM]
INTRINSIC MUSCLES
Dorsal interossei [DIO] [abduct DAB]
Volar interossei [VIO] [adduct PAD]
Lumbricals [medial two (3,4)]
Lumbricals [medial two (3,4)]

BRACHIAL PLEXUS (C5-T1 ventral rami) [variations: C4-T2] (also see Shoulder)

INFRACLAVICULAR [approach through axilla]


MEDIAL AND LATERAL CORDS

Median (C (5) 6-T1): runs anteromedial, no branches in arm Multiple sites of possible compression
Sensory: Dorsal distal phalanges of lateral 3 1/2 digits via: proper palmar digital branches
Volar 3 1/2 digits and lateral palm via: palmar palmar digital branches
ANTERIOR COMPARTMENT OF FOREARM
Superficial Flexors
Pronator Teres [PT]
Flexor Carpi Radialis [FCR]
Palmaris longus [PL]
Flexor digitorum superficialis [FDS] [sometimes considered a “middle” flexor]
1. Deep Flexors: AIN (Anterior Interosseous Nerve)
Motor: Flexor digitorum profundus [digits 2,3]
Flexor pollicis longus [FPL]
2. Pronator Quadratus [PQ]
HAND: Motor Recurrent (Thenar motor) Thenar
Abductor pollicis brevis [APB]
3. Opponens pollicis
Flexor pollicis brevis [FPB][with ulnar]
Intrinsic
Lumbricals [lateral two (1,2)]
4.
POSTERIOR CORD

Upper Subscapular (C5-6)


5. Sensory: NONE
Motor: Subscapularis [upper portion]

6.
Lower Subscapular (C5-6)
Sensory: NONE

Motor: Subscapularis [lower portion]


Teres major

7. Thoracodorsal (C7-8): runs with Thoracodorsal artery


Sensory: NONE

8. Motor: Latissimus dorsi

9. Axillary (C5-6): runs with Posterior Circumflex Humeral artery through the Quadrangular
space
Sensory: Lateral upper arm: via Superior lateral cutaneous nerve of arm

Motor: Deltoid (Deep branch)


Teres minor (Superficial branch)

Radial (C5-T1): runs with Deep Artery of Arm in Triangular Interval


Lateral arm: via Inferior lateral cutaneous nerve
Posterior arm: via Posterior cutaneous nerve
Sensory: Posterior forearm: via Posterior cutaneous nerve
Dorsal 3 1/2 digits and hand: via superficial branch (dorsal digit
branches)
POSTERIOR COMPARTMENT OF ARM
Triceps [medial, long, lateral heads]
Anaconeus
MOBILE WAD: (Radial nerve-Deep branch) Superficial Extensors
11. Brachioradialis [BR]
Extensor carpi radialis longus [ECRL]
Extensor carpi radialis brevis [ECRB]
16. POSTERIOR COMPARTMENT OF FOREARM:
PIN Multiple possible compression sites
Motor: (see Forearm)
Superficial Extensors
Extensor carpi ulnaris [ECU]
Extensor digiti minimi [EDM]
Extensor digitorum [ED]
Deep Extensors
Supinator
12. Abductor pollicis longus
Extensor pollicis longus
13. Extensor pollicis brevis
Extensor indicis proprius

14.
15.

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES: LUMBAR PLEXUS

LUMBAR PLEXUS (Deep to Psoas muscle)

ANTERIOR DIVISION

Subcostal (T12):
Sensory: Subxiphoid region
Motor: NONE

Iliohypogastric (L1):
Sensory: Above pubis
Posterolateral buttocks
Transversus abdominus
Motor:
Internal Oblique

Ilioinguinal (L1):
Sensory: Inguinal region
Motor: NONE

Genitofemoral (L1-2): pierces Psoas, lies on anteromedial


surface.
Sensory: Scrotum/mons
Motor: Cremaster

Obturator (L2-4): exits via obturator canal, splits


into anterior posterior divisions. Can be injured by
retractors placed behind the transverse acetabular
ligament.
Sensory: Inferomedial thigh via cutaneous
branch of Obturator nerve
External oblique
Adductor longus (anterior division)
Adductor brevis (ant post division)
Motor:
Adductor magnus (posterior division)
Gracilis (anterior division)
Obturator externus (posterior division)

Accessory Obturator (L2-4): inconsistent


Sensory: NONE
Motor: Psoas

POSTERIOR DIVISION

Lateral Femoral Cutaneous


1. [LFCN](L2-3): crosses ASIS, can
be compressed at ASIS
2. Sensory: Lateral thigh
Motor: NONE

3. Femoral (L2-4): lies


between psoas major
4. and iliacus
Anteromedial
thigh via
5. anterior
intermediate
cutaneous
nerves
Sensory: Medial leg
foot via
medial
6. cutaneous
nerves
(Saphenous
Nerve)
7. 8.
Psoas
Iliacus
Pecineus
Quadriceps
Rectus
femoris
Vastus
Motor: lateralis
Vastus
intermedialis
Vastus
Medialis
Sartorius
Articularis
genu

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES: SACRAL PLEXUS

SACRAL PLEXUS

ANTERIOR DIVISION

Tibial (L4-S3): descends between heads of Gastrocnemius to medial malleolus


Posterolateral proximal calf: via Medial sural
Posterolateral distal calf: via Sural
Sensory: Medial plantar heel: via Medial calcaneal
Medial plantar foot: via Medial plantar
Lateral plantar foot: via Lateral plantar
POSTERIOR THIGH
Biceps femoris [long head]
Semitendinosus
Semimembranosus
SUPERFICIAL POST. COMPARTMENT OF LEG
Soleus: via nerve to Soleus
Gastrocnemius
Plantaris
DEEP POSTERIOR COMPARTMENT OF LEG
Popliteus: via nerve to Popliteus
Tibialis posterior [TP] (Tom)
Flexor digitorum longus [FDL] (Dick)
Flexor hallucis longus [FHL] (Harry)
Motor: FIRST PLANTAR LAYER of FOOT
Abductor hallucis: Medial plantar
Flexor digitorum brevis [FDB]: Medial plantar
Abductor digiti minimi: Lateral plantar
SECOND PLANTAR LAYER of FOOT
Quadratus plantae: Lateral plantar
Lumbricals: Medial lateral plantar
THIRD PLANTAR LAYER of FOOT
Flexor hallucis brevis [FHB]: Medial plantar
Adductor hallucis: Lateral plantar
Flexor digitorum minimus brevis [FDMB]:
Lateral plantar
FOURTH PLANTAR LAYER of FOOT
Dorsal interosseous: Lateral plantar
Plantar interosseous: Lateral plantar

Nerve to Quadratus femoris (L4-S1):


Sensory: NONE
Quadratus femoris
Motor:
Inferior gemelli

Nerve to Obturator internus (L5-S2): exits greater sciatic foramen


Sensory: NONE

Motor: Obturator internus


Superior gemelli

Pudendal (S2-4): exit greater then re-enters lesser sciatic foramen


Perineum: via Perineal (scrotal/labial branches)
Sensory: via Inferior rectal nerve
via Dorsal nerve to penis/clitoris
Bulbospongiosus: Perineal nerve
Ischiocavernosus: Perineal nerve
Motor: Urethral sphincter: Perineal nerve
Urogenital diaphragm: Perineal nerve
Sphincter ani externus: Inferior rectal nerve

Nerve to Coccygeus (S3-4)


Sensory: NONE
Coccygeus
Motor:
Motor:
Levator ani

POSTERIOR DIVISION

Common Peroneal (L4-S2): in groove between biceps lateral head of


Gastrocnemius. Wraps around fibular head, deep to peroneus longus; then
divides
Proximal lateral leg: via Lateral sural nerve
Distal lateral leg dorsal foot: via Superficial peroneal
Sensory: Lateral foot: via Sural (lateral calcaneal dorsal cutaneous
branches)
1st/2nd interdigital space: Deep peroneal
POSTERIOR THIGH
Biceps femoris [short head]
ANTERIOR COMPARTMENT of LEG:
Deep Peroneal
Tibialis anterior [TA]
1.
Extensor hallucis longus [EHL]
Extensor digitorum longus [EDL]
Peroneus tertius
Motor:
LATERAL COMPARTMENT of LEG:

Superficial Peroneal
Peroneus longus
Peroneus brevis
FOOT: Deep Peroneal
Extensor hallucis brevis [EHB]
Extensor digitorum brevis [EDB]

Superior Gluteal (L4-S1):


Sensory: NONE
Gluteus medius
Motor: Gluteus minimus
2. Tensor fascia lata

Inferior Gluteal (L5-S2):


3.
Sensory: NONE
Motor: Gluteus maximus
4.
Nerve to piriformis (S2):
Sensory: NONE
Motor: Piriformis
5.
Posterior Femoral Cutaneous Nerve
[PFCN] (S1-3)
6. 10. Sensory: Posterior thigh
Motor: NONE
7.

8.

9.

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Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

ARTERY COURSE BRANCHES COMMENT


Vertebral Major arterial supply of cervical spine and cord.
Anterior and
Off both subclavian
posterior Feed Anterior Posterior spinal
through transverse
segmental arteries respectively
foramen of C1-6
medullary

Anterior spinal Forms superiorly from both


vertebrals
Each branch superiorly from
Posterior spinal
vertebrals
Contributes to Anterior Posterior spinal arteries via
Ascending cervical From Thyrocervical
segmental medullary arteries
Contributes to Anterior Posterior spinal arteries via
Deep cervical From Costocervical
segmental medullary arteries
Dorsal branch
Dorsal branch Supplies dura, posterior
Spinal branch elementsSupplies cord and
Ventral branch bodies
Segmental/Intercostal Branch from aorta Major anterior Supplies vertebral bodies
segmental Supplies inferior thoracic
medullary superior, L-spine, feeds anterior
(Adamkiewicz spinal artery in L-spine
Artery)
Anterior
segmental
medullary On ventral root; feeds anterior
Posterior spinal artery
Along vertebral
Spinal branch segmental Feeds posterior spinal arteries
bodies
medullary Along nerve roots, do not feed
Radicular spinals
arteries (Anterior
Posterior)
Anterior
segmental
medullary On
Posterior On ventral root; feeds anterior
Lumbar arteries Branch from aorta segmental spinal artery
medullary Feeds Posterior spinal arteries
Radicular
arteries (Anterior
Posterior)
Anterior spinal
Anterior segmental artery Single artery, runs midline
Along nerve roots
medullary Anterior Do not feed spinal arteries
radicular arteries
Posterior spinal
Posterior segmental Along nerve roots artery Paired arteries (left/right)
medullary Posterior Do not feed spinal arteries
radicular arteries
Midline anterior Supplies anterior 2/3 of cord; has multiple
Anterior spinal
surface of cord contributions from segmental arteries
Sulcal branches
Supplies center of cord
Pial arterial
Supplies cord peripheries
plexus

Posterior spinal Off midline (L R) Supplies post 1/3 of cord; has multiple
contributions from segmental arteries
Each nerve root has either a segmental medullary or a radicular artery associated with it.

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Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS

WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
CAUDA EQUINA SYNDROME
Compression of

cauda equina HxPE: Back, buttock, XR: no emergent
Etiology: usually leg pain. Bladder (#1) Immediate surgical
need MR (or
• a large midline and bowel decompression (when
myelography): to
disc herniation dysfunction. Leg diagnosis is confirmed)
show compression
A surgical numbness paralysis

emergency
CERVICAL SPONDYLOSIS
Disc
degeneration Discogenic: soft
• XR: AP, lateral: collar, NSAID,
with vertebral and
facet arthritis Hx: Older, men. Neck 1. Osteophytes 1. Physical
UE pain, stiffness or therapy, +/-
3 pain sources: grinding. Spinal
2. traction
• disc, ligament, PE: Decreased stenosis
root (HNP) ROM, midline neck Disc space Persistent
3. radiculopathy or
• C5-6 #1 site TTP. Radicular or narrowed
myelopathic signs if myelopathy:
PLL ossifies, Facet 2. decompression
HNP or cord 4.
results in osteoarthritis and fusion (not
compressed
• stenosis (most 5. Instability for discogenic
common in pain)
Asians)
CERVICAL STRAIN/MUSCLE STRAIN (Whiplash)
Soft collar
Not a sprain. Soft Hx: Stiffness, pain immobilization
tissue (dull/nonradiating) in 1.
• XR: if history of (Philadelphia
(muscle/ligament) neck traps collar)
strain trauma or neurologic
PE: Paraspinal
muscles tender to or persistent 2. NSAID, muscle
Etiology: trauma symptoms relaxant
• or some minor palpation (+/-
movement spasm). Spurling test +/- Ice, heat,
3.
massage
DEGENERATIVE DISC DISEASE (DDD)
NSAIDs (no
Aging process: 1.
Hx: Chronic LBP (+/- narcotics)
disc desicates
• and tears. Facet buttock), stiffness XR: AP, lateral: Antidepressants
2.
degeneration and (worse with activity) aging, osteophytes, if indicated
sclerosis PE: Back tender to disc space narrowed, Physical
palpation +/- “vacuum sign” therapy,
Associated with Waddell's signs. 3.
• exercise, weight
tobacco use
control
HERNIATED CERVICAL DISC (Herniated nucleus pulposus)

Nucleus pulposus Hx: Young or middle 1. Soft collar, rest


• protrudes age. Numbness
XR: AP, lateral: Physical
presses on root. radiating pain.
spondylosis MR: 2. therapy,
PE: 1weakness,
Usually bulging nucleus NSAIDs
decreased sensation pulposus
• posterolateral at reflexes, 1 Spurling Surgical
C5-6 or C6-7. 3.
test decompression

DESCRIPTION HP WORK-UP/FINDINGS TREATMENT


HERNIATED LUMBAR DISC (HNP)
DDD annulus Bed rest,
1.
tear: nucleus NSAIDs
• herniates, +/- Physical
root or cauda Hx: DDD sx (+/-
radicular sx). Increased therapy,
compression. 2.
with sneeze, decreased XR: AP, lateral: age fitness
Can be with hip flexion changes EMG/NCS: + program

Asymptomatic PE: Root weakness, after 3 weeks MR: 3. Discectomy
L4-5 most decreased sensation shows herniation
• reflexes, 1straight leg Cauda
common
bowstring tests. Equina
Most 4. Syndrome:
• posterolateral a surgical
(PLL weak) emergency
WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
LUMBAR BACK SPRAIN/MUSCLE STRAIN
Strain or lifting Rest (1-2 day

injury Hx: LBP (+/- radiation to bed rest),
buttock, not leg), XR: if neurologic
1.
Soft tissue injury NSAIDs (no
(muscle spasm, paraspinous spasm symptoms present narcotics)
ligament or tenderness or refractory to
• Physical
tendon injury, PE: Normal neurologic treatment 2.
therapy
disc tear-without exam
bulge) 3. Increase fitness

SCHEUERMANN'S DISEASE
Increased
thoracic XR: AP, lateral T-
kyphosis (Cobb spine:
• Hx: Adolescent with
angle 45°) with 3
vertebrae with poor posture, +/-back 1. Increased Immature: exercise,
pain PE: “rounded kyphosis brace or orthosis
anterior wedging
back” on examination, Anterior Mature: Anterior release
Unknown 2.
• usually nontender to wedging (3) and posterior fusion
etiology
palpation Schmorl
Schmorl nodes 3.
nodes
• (cartilage) in the
vertebral body
SCOLIOSIS
Lateral spine
• curve (+/-
rotation)
XR: Full length AP,
Multiple Hx: +/-pain, fatigue, lateral: Lateral curve Curves:
• etiologies: #1 visible physical on AP.
idiopathic deformity. Measure Cobb 1. 30°
observation
Girls.boys PE: Neurologic exam angle: angle
• 2. 30-40° bracing
(needing tx) usually normal. 1forward between lines drawn
Find on school bend test. Determine perpendicular to
• plumb line (hang string most superior 3. 40° surgery:
screening spinal fusion.
from C7) inferior affected
Progression: vertebrae
based on

skeletal maturity,
curve angle
SPINAL STENOSIS
Congenital vs. Physical
• acquired (most Hx: Neurogenic Therapy:
common) claudication (fatigue), XR: AP, lateral: age abdominal
1.
Canal narrowing +/-pain; Back extension changes CT/MR: strength back
• flexion
with symptoms reproduces sx. better to evaluate
PE: Weakness, canal, shows exercises
Etiology: DDD or
facet decreased pin prick stenosis NSAIDs (+/-
• 2.
osteoarthritis reflexes steroids)
ligament laxity 3. Laminectomy
SPONDYLOLISTHESIS
Forward
• slipped
vertebrae
6 Types
• XR: AP, lateral:
(common sites):
measure forward Activity
Congenital: 1. modification,
1. Hx: Type: slippage for grade
facet defect rest, NSAIDs
I (peds), II (young), III (I-V, 0-100°)
(S1)
(elderly). Type: Flexion
Isthmic (most 2.
Mechanical back pain, Scottie exercises
common): pars +/-radicular symptoms 1. dog: long
2. defect (L5-S1; Surgical
2. defect (L5-S1; PE: +/-palpable step-off Surgical
neck decompression
associated with spasm. +/-radicular
hyperextention); signs (e.g. weakness, Scottie and fusion for
2. dog: broken 3. progressive
Degenerative: decreased sensation slippage or
neck
facet reflexes) radicular
3. Facet
arthropathy (L4- 3. symptoms
5) arthritis
4. Traumatic
5. Pathologic
6. Post-surgical
SPONDYLOLYSIS
Defect or stress
Symptomatic
fracture (without 1.
• treatment
slippage) in pars Hx: Young, athlete
interarticularis (football, gymnast). Low XR: Oblique L-spine Activity
back pain, worse with “Scottie dog has a 2. restriction, +/-
Leads to
• activity (#1 cause in collar” brace
spondylolisthesis pediatrics)
Back muscle
L5 most 3.
• strengthening
common site
TUMORS
Metastatic are most common. Most common primary: Multiple Myeloma (malignant)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PEDIATRIC DISORDERS

DESCRIPTION EVALUATION TREATMENT/COMPLICATIONS


MYELODYSPLASIA

• Neural tube
(closure) defect; Hx: Some have family
history
No function below PE/XR: Depends on type
level of lesion; level Must individualize for each patient: Most
of defect:
• determines function need ambulation assistance, orthoses,
(L1 paraplegic/S1 1. Spina bifida surgical releases, etc.Common
occulta problems requiring treatment:
near normal)
2. Meningocele Deformities and/or contractures of
Associated with spine, hips, knees, ankles, and feet
• 3. Myelomeningocele
increased AFP

• Associated with 4. Rachischisis


many deformities
SCOLIOSIS
Lateral spine curve

+/- rotation
• Multiple etiologies:
#1 idiopathic Hx: +/- pain fatigue, visible
Cases needing tx: deformity, found in school
• screening Based on curves and Risser stage;
girls boys
PE: + forward bend test 1. 30°: observation (most)
Curve progression (asymmetric). Neurologic
predicted: 30-40°:bracing (Boston, for
exam usually normal.
2. apex below T8 vs. Milwaukee
1. Angle of Determine plumb line from
brace)
curve C7
Skeletal XR: AP full length: measure 3. 40°: spinal fusion
• Cobb angle. (See Disorder
maturity
Table)
2. (Risser
stages:
iliac
Apophysis)

TORTICOLLIS
Contracture of

SCM
Hx: Parents note deformity Physical therapy/stretching of
Associated with PE: Head tilted to one 1.
• the sternocleidomastoid
other disorders side, chin to opposite side,
1/2facial asymmetry Surgical release if persistent
Associated with 2.
• XR: Spine hips: rule out Complication: poor eye
intrauterine position
intrauterine position XR: Spine hips: rule out
other anomalies development
• Etiology: several
theories

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SURGICAL APPROACHES

USES INTERNERVOUS PLANE DANGERS COMMENT


ANTERIOR APPROACH
Recurrent
1. laryngeal
nerve • Access C3 to T1
Herniated
1. disc Superficial: Sympathetic Right recurrent
2. laryngeal nerve
removal 1. SCM (CN 11) nerve
more susceptible
Vertebral Carotid • to injury-most
2. Strap muscles 3.
fusion (C1-3) Deep: artery choose
Osteophyte 2. Between left and Internal approach on left
3. 4. side.
removal right Longus colli jugular
Tumor or muscles 5. Vagus nerve Thyroid arteries
4. • limit extension of
biopsy
Inferior the approach
6. thyroid
artery
INTERNERVOUS
USES DANGERS COMMENT
PLANE
POSTERIOR APPROACH
Spinal
1.
cord
CERVICAL Most common c-spine
Nerve 1.
2. approach
1. Posterior Left and Right roots
fusion Mark the level of
paracervical Posterior pathology with a
2. Herniated 3.
disc muscles (posterior rami radiopaque marker pre-
cervical rami) 2.
Vertebral op to assist finding the
3. Facet 4. appropriate level
artery
dislocation intraoperatively
Segmental
5.
vessels
LUMBAR
1. Herniated Left and Right
disc
paraspinal muscles Segmental vessels Incision is along the spinous
Explore to paraspinals processes.
(dorsal rami)
2. nerve
roots

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CHAPTER 2 - SHOULDER
TOPOGRAPHIC ANATOMY
OSTEOLOGY
TRAUMA
JOINTS
MINOR PROCEDURES
HISTORY
PHYSICAL EXAM
MUSCLES: INSERTIONS AND ORIGINS
MUSCLES: BACK/SCAPULA REGION
MUSCLES: ROTATOR CUFF
MUSCLES: DELTOID/PECTORAL REGION
NERVES
ARTERIES
DISORDERS
SURGICAL APPROACHES
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 2 – SHOULDER
TOPOGRAPHIC ANATOMY

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY

CHARACTERISTICS OSSIFY FUSE COMMENT


CLAVICLE

Cylindrical; S 9 weeks Clavicle is first to


• 7 fetal •
shaped Primary (2) ossify, last to fuse
weeks
Middle: (medial/lateral) 25 years It starts as
fetal
narrowest, no Secondary (sternal) intramembranous
• 18-20 •
ligament (sternal/acromial) years 19-20 yrs ossification, ends
attachments (acromial) as membranous.

SCAPULA
8 Blood supply:
Flat, triangular 1. Body weeks

shape (fetal) Subscapular
2. Coracoid All fuse
Only 1 year between 1. (and circumflex
attachments 3. Coracoid/glenoid scapular
15-20 arteries)
• to axial 4. Acromion 15 yrs
years
skeleton are
5. Inferior angle
15 yrs 2. Suprascapular
muscular. artery
16 yrs

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


CLAVICLE FRACTURE
I. Middle 1/3: 80%
II Distal 1/3: 15%
Type I: minimally
displaced;
between
ligaments.
Most common Type II:
• HX: Trauma. Cannot Closed treatment (no
fracture Displaced,
raise arm. Pain. reduction) with figure of
Fall on fracture medial to
PE: Gross deformity CC ligament. eight brace or sling for
• shoulder or
at fracture site with mid/ proximal 1/3, distal
direct blow. Type IIA: CC
ttp. Must do 1/3 (Types I and III) (3-4
Football, ligaments both weeks; ROM)
• neurological and
hockey attached to distal
vascular exams. Open treatment for Type II
fragment
Rare XR: AP and 45° to prevent nonunion. (also
neurovascular cephalad Group II: Type IIB: Conoid open fracture, vascular
• ruptured
damage stress views injury)
(subclavians) Trapezoid
ligament
attached.
Type III: Fracture
through AC joint.
Ligaments intact.
III Proximal 1/3: 5%
COMPLICATIONS: Nonunion: esp. with distal 1/3: type II injury; Brachial plexus (medial cord/ulnar nerve) or
subclavian injury; Pneumothorax.
SCAPULAR FRACTURE
Anatomic
classification: A-G
Idleberg (glenoid
• Relatively fracture)
uncommon Type I: Anterior
• Males-young HX: Trauma. Pain in avulsion fracture
High-energy back and/or Type II:
• shoulder. Tranverse/oblique
trauma Closed treatment with a
PE: Swelling and fracture thru sling for 2 weeks for most
85% glenoid; exits
w/associated tenderness to fractures. Then early
inferiorly
• injuries palpation ROM.
(including Type III: Oblique
XR: AP/Axillary ORIF for intraarticular fx
(including XR: AP/Axillary ORIF for intraarticular fx
severe) fracture through
lateral/ scapular Y; and/or large displaced
CXR glenoid, exits (25%) fragments
Dx often superiorly
delayed due to CT: intraarticular
associated Type IV:
• glenoid
injuries (esp Transverse
pulmonary fracture exits
great vessels). through the
scapula body
Type V: Types II +
IV

COMPLICATIONS: Associated injuries: Rib fracture #1, pneumothorax, pulmonary contusion, vascular injury,
brachial plexus inury; AC injury (esp w/type III; acromion fx); Suprascapular nerve injury

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


ACROMIOCLAVICULAR (AC) SEPARATION
6 Grades:
(based on
ligament tear
clavicle position)
Grade I:
Sprain, AC
HX: Trauma. ligament
Range of pain: intact
minimal to Grade II:
severe. AC tear,
Separation is PE: AC joint CC sprain Grade I, II: sling until pain
subluxation or TTP, gross Grade III: subsides (+/-
• injection/pain
dislocation of AC deformity with AC/CC
joint grade III up. (both) torn medication) for 1-2 wks,
AC joint is then increase ROM
• Fall onto acromion XR: AP, stress
view: grade II dislocated. Grade III: nonoperative
Contact sports: for most; operative for
• vs. grade III Grade IV: III
hockey football, laborers/athletes
wrestling I: normal, with clavicle
posterior Grade IV-VI: Open
• Males II: minimal into/thru reduction and repair.
separation, trapezius
III and up: muscle
clavicle Grade V: III
displaced. with clavicle
elevated
100%
superiorly
Grade VI: III
with clavicle
inferior

COMPLICATIONS: Permanent deformity; Stiffness, early OA; Distal clavicle osteolysis (pain); Associated
injuries: Fracture, pneumothorax.
GLENOHUMERAL DISLOCATION
Anterior: Abd/ER
injury 2
mechanisms HX: Trauma or
TUBS hx of shoulder
[Traumatic slipping out. Reduce dislocation:
Pre and Post
1. Unilateral, Intense pain.
neurological exam
Bankart PE: Deformity, Anatomic
lesion, flattened Classification: Conscious sedation
Surgery] shoulder where humeral (IV benzo +
AMBRI silhouette. head is: narcotic)
• [Atraumatic Exquisitely
Multi- tender. Do full • Anterior Methods:
(90%)
directional, neurovascular 1. Traction/counter-
Bilat- eral, PE • Posterior traction
(5%)
2. responds XR: AP/axillary Inferior
2. Hippocratic
to Rehab, lateral (also 3. Stimson
Inferior Stryker notch) • (luxatio
capsule erecta) 4. Milch
Anterior: Hill
repair) 20 very rare
Sacks Lesion Immobilize (2-6 weeks),
yo: 80% Posterior: Rev Superior:
recur • very, very rehabilitation
Hill Sachs,
Hill Sachs Bankart “empty glenoid” rare Surgery for
lesions recurrent/TUBS,
MRI: Bankart posterior dislocation 3
predisposed to lesion
recurrence wks
(anterior/inferior
Posterior: after labral tear)
• seizure often
missed
COMPLICATIONS: Recurrence rate (young age predicts it, decreases w/increased age); Axillary nerve
injury; Rotator cuff tear; Glenoid/Greater tuberosity fracture; Dead arm syndrome

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

JOINTS

JOINT TYPE LIGAMENTS COMMENTS


Spheroidal Highly mobile, decreased stability (needs Rotator cuff);
Glenohumoral Ball and
#1 dislocated joint (anterior 90%)
Socket

Capsule Loose, redundant, with gaps;


minimal support
Coracohumoral Provides anterior support
Discrete capsular thickenings; 3
Glenohumoral ligaments: superior, middle, inferior-
strongest
Increases surface area depth of
Glenoid labrum glenoid. Injuries: SLAP
lesion/Bankart lesion
Transverse
Holds biceps (LH) tendon in groove
humeral

Sternoclavicular Double Capsule


sliding
Anterior and Posterior stronger; Anterior
Posterior SC dislocation more common
ligaments
Interclavicular
Costoclavicular Strongest SC ligament
Acromioclavicular Plane/Gliding Capsule has a
[AC joint] disc in joint;

Acromioclavicular Horizontal stability; torn in Grade II


AC injury
Coracoacromial Can cause impingement

Coracoclavicular Vertical stability; torn in Grade III AC


injury
Trapezoid Anterior/lateral position
Conoid Posterior/medial position; stronger

Scapulothoracic not an Allows scapula to move along the posterior rib cage.
articulation
Superior
Separates Suprascapular Artery
Other ligaments transverse
Other ligaments transverse
and Nerve
scapular

STRUCTURE FUNCTION
MUSCLES
ROTATOR CUFF Holds humeral head in glenoid
Supraspinatus Most commonly torn tendon
Infraspinatus
Teres Minor
Subscapularis Anterior support
LIGAMENTS
Capsule Rotator cuff tendons fused to it
Glenohumeral Superior: resists inferior translation
Middle: resists anterior translation
Inferior: resists ant/inf translation
Coracohumeral Resists post/inferior translation
Labrum Deepens glenoid

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MINOR PROCEDURES

STEPS
INJECTION OF THE ACROMIOCLAVICULAR (AC) JOINT
1. Ask patient about allergies
2. Palpate clavicle distally to AC joint (sulcus)
3. Prepare skin over AC joint (iodine/antiseptic soap)
4. Anesthetize skin with local (quarter size spot)
Use 21 gauge or smaller, insert needle into joint vertically. Aspirate to ensure not
5. in a vessel, then inject 2ml of 1:1 local/ corticosteroid preparation into AC joint.
(You will feel the needle "pop/give" into the joint)
6. Dress injection site
INJECTION OF SUBACROMIAL SPACE
1. Ask patient about allergies
2. Palpate the acromion: define it's borders
3. Prepare skin over shoulder (iodine/antiseptic soap)
4. Anesthetize skin with local (quarter size spot)
Hold finger (sterile glove) on acromion, insert needle under posterior acromion
w/cephalad tilt. Aspirate to ensure not in a vessel, then inject 5-10cc of
preparation-will flow easily if in joint). Use:
5.
a. diagnostic injection: local only
b. therapeutic injection: local/corticosteroid 5:1
6. Dress injection site
GLENOHUMERAL ARTHROCENTESIS
1. Palpate the coracoid process/humeral head
2. Prepare skin over shoulder (iodine/antiseptic soap)
3. Anesthetize skin (quarter size spot)
4. Abduct arm/downward traction (by an assistant)
5. Insert needle between humeral head and coracoid process
6. Synovial fluid should aspirate easily
7. Dress insertion site

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY

QUESTION ANSWER CLINICAL APPLICATION


Rotator cuff tear/impingement,
arthritis (OA), adhesive
capsulitis (frozen shoulder),
OLD
1. AGE humerus fracture (after
YOUNG trauma)
Instability, AC injury, osteolysis,
impingement in athletes

Acute Fracture, rotator cuff tear,


Chronic acromioclavicular injury,
PAIN dislocation
a. Onset On top/AC
joint Impingement, arthritis
b. Location
2. Night pain AC joint arthrosis
c. Occurrence
Classic for Rotator Cuff tear,
Overhead
Exacerbating worse tumor
d.
/relieving Rotator Cuff tear
Overhead
better Cervical radiculopathy

3. STIFFNESS Yes Osteoarthritis, adhesive capsulitis


Dislocation: 90% anterior - occurs
4. INSTABILITY “Slips in and out” with abduction external rotation (e.g.
throwing motion)
Direct blow
Acromioclavicular injury
5. TRAUMA Fall on
Glenohumeral
outstretched
dislocation
hand

Overhead
usage
Osteolysis (distal clavicle)
Osteolysis (distal clavicle)
Weight lifting
Rotator cuff
6. WORK/ACTIVITY Athlete: tear/impingement
throwing type
Arthritis (OA)
Long term
manual labor

Neurologic Numbness/tingling/ Thoracic outlet syndrome, brachial


7.
Symptoms “heavy” plexus injury

8. PMHx Cardiopulmonary/GI Referred pain to shoulder

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAM TECHNIQUE/FINDINGS CLINICAL APPLICATION


INSPECTION
Symmetry Compare both sides
Loss of contour/muscle
Wasting Rotator Cuff tear
mass
Gross deformity Superior displacement Acromioclavicular injury (separation)
Gross deformity Anterior displacement Anterior dislocation (glenohumeral joint)
Biceps tendon rupture (usually proximal
Gross deformity "Popeye" arm
end of long head)
PALPATION
Pain indicates Acromioclavicular
AC joint Feel for end of clavicle
pathology
Subacromial Feel acromion-down to Pain: bursitis and/or supraspinatus
bursa acromiohumeral sulcus tendon rupture
Coracoclavicular Feel between acromion Pain indicates impingement
ligament coracoid
Greater Prominence on lateral
Pain indicates Rotator Cuff tendinitis
tuberosity humeral head

Biceps tendon Feel proximal insertion on Pain indicates biceps tendinitis


humerus
RANGE OF MOTION
Forward flexion Arms from sides forward 0-160° normal
Abduction Arms from sides outward 0-160/180° normal

Internal rotation Reach thumb up back-note Mid thoracic normal-compare sides


level
Elbow at side,
1. rotate forearms 30-60° normal
External rotation lateral External rotation decreased in
2. Abduct arm to 90°, adhesive capsulitis
externally rotate up
Rotator Cuff tear: AROM decreased, PROM ok, Adhesive Capulitis: both are decreased
NEUROVASCULAR
Sensory Light touch, pin prick, 2 pt
Supraclavicular Superior shoulder/ clavicular Deficit indicates corresponding
nerve (C4) area nerve/root lesion
Axillary nerve Lateral shoulder Deficit indicates corresponding
(C5) nerve/root lesion
T2 segmental Deficit indicates corresponding
Axilla
nerve nerve/root lesion
Motor
Spinal accessory Resisted shoulder shrug Weakness = Trapezius or
(CN11) corresponding nerve lesion.
Suprascapular Weakness = Supraspinatus or
Resisted abduction
(C5-6) corresponding nerve/root lesion.
Weakness = Infraspinatus or
Resisted external rotation
corresponding nerve/root lesion.
Axillary nerve Weakness = Deltoid or corresponding
Resisted abduction
(C5) nerve/root lesion.
Weakness = Teres minor or
Resisted external rotation
corresponding nerve/root lesion.
Dorsal scapular Weakness = Lev Scap/Rhomboid or
Shoulder shrug
Shoulder shrug
nerve (C5) nerve/root lesion.
Thoracodorsal Weakness = Latissimus dorsi or
Resisted adduction
nerve (C7-8) nerve/root lesion.
Lateral pectoral Weakness = Pectoralis major or
Resisted adduction
nerve (C5-7) corresponding nerve/root lesion.
U/L subscabular Weakness = Teres min or subscapularis
Resisted internal rotation
nerve (C5-6) or nerve/root lesion.
Long thoracic Weakness = Serratus anterior or
Scapular protraction /reach
nerve (C5-7) nerve/root lesion

EXAM TECHNIQUE/FINDINGS CLINICAL APPLICATION


SPECIAL TESTS

Supraspinatus Bilateral:30°add,90°FF,IR,resist Weakness indicates Rotator


cuff (supraspinatus) tear,
(empty can) down force
impingement
Passively abduct 90°, lower Weakness or arm drop
Drop Arm
slowly indicates rotator cuff tear
Hand behind back, push Weakness or inability indicates
Liftoff
posteriorly subscapularis rupture
Speed Resist forward flexion of arm Pain indicates biceps tendinitis
Pain indicates biceps tendinitis,
Yergason Hold hand, resist supination
biceps tendon subluxation
Impingement Pain indicates Impingement
Forward flex greater than 90°
sign (Neer) Syndrome

Hawkins sign Forward flex 90°, elbow @ 90°, Pain indicates Impingement
then IR Syndrome
Pain indicates
Cross Body 90°Forward flex then adduct Acromioclavicular pathology,
Adduction arm across body Decreased ROM indicates tight
posterior capsule
Cup hands over Pain/movement indicates AC
AC Shear
clavicle/scapula: then squeeze pathology
Active
Compression 90°FF, max IR, then adduct/flex Pain or pop indicates a
SLAPlesion
(O’Brien's)

Push into glenoid, translate Motion indicates instability in


Load and shift ant/post that direction (anterior vs.
posterior)
Apprehension Throwing position- continue to Apprehension indicates anterior
sign externally rotate instability

Relocation 90°abd, full ER, posterior force Relief of pain/apprehension, or


(Jobe) on humeral head increased externalrotation
indicates anterior instability
Posterior
FF 90°,internally rotate, Apprehension indicates
Apprehension
posterior force posterior instability
sign
Slippage of humeral head or
Inferior Abd 90°, downward force on
instability mid- humerus apprehension: inferior instability
or Multidirectional instability
Increased acromiohumeral
Sulcus sign Arm to side, downward traction sulcus: inferior instability or
Multidirectional instability

Palpate radial pulse, rotate Reproduction of symptoms


Adson indicates thoracic outlet
neck to ipsilateral side
syndrome
Reproduction of symptoms
Bilateral arm: abduct/ER, open
Roo (EAST) indicates thoracic outlet
and close fist 3 minutes
syndrome
Reproduction of symptoms
Lateral flex/axial compression
Spurling of neck indicates cervical disc
pathology

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: INSERTIONS AND ORIGINS

CORACOID GREATER ANTERIOR MEDIAL LATERAL


PROCESS TUBERCLE PROXIMAL EPICONDYLE EPICONDYLE
ORIGINS INSERTIONS INSERTIONS ORIGINS ORIGINS
Biceps (SH) Supraspinatus Pectoralis major Pronator Teres Anaconeus

Corcobrachialis Infraspinatus Latissimus dorsi Common Flexor Common.


Extensor
Tendon [FCR, Tendon
INSERTIONS Teres minor Teres major
PL, [ECRB,ED,
Pectoralis minor FCU, FDS] EDM, ECU]

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: BACK/SCAPULA REGION

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


C7-T12 Clavicle, Cranial nerve Elevate rotate Connect
Trapezius spinous Acromion spine of XI scapula UE to
process scapula spine

Latissimus T7-T12, iliac Humerus Adduct, Connect


dorsi crest (intertubercular Thoracodorsal extend arm, UE to
groove) IR humerus spine

Levator C1-C4 Superior medial Dorsal Elevates Connect


scapulae transverse scapula scapular/ C3- scapula UE to
process 4 spine

Rhomboid C7-T1 Medial scapula Dorsal Adduct Connect


minor spinous (at the spine) scapular scapula UE to
process spine

Rhomboid T2-T5 Dorsal Adduct Connect


major spinous Medial scapula scapular scapula UE to
process spine

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: ROTATOR CUFF

SPACE BORDERS STRUCTURES


Triangular Space Teres Minor Circumflex Scapular Artery
Teres Major
Triceps (Long Head)
Quadrangular Space Teres Minor Axillary Nerve
Teres Major Posterior Circumflex Artery
Triceps (Long Head) Humeral Artery
Triceps (Lateral Head)
Triangular Interval Teres Major Radial Nerve
Triceps (Long Head) Deep Artery of Arm
Triceps (Lateral Head)

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Clavicle, Atrophy:
Humerus
Acromion Abduct Axillary
Deltoid (Deltoid Axillary
spine of arm nerve
tuberosity)
scapula damage
Protects
Humerus IR,
Inferior angle (intertubercular Lower radial nerve
Teres major adduct
of the scapula groove) subscapular in posterior
arm
approach
Rotator Cuff(4)
Trapped in
Supraspinatus Greater Abduct impingement
1.Supraspinatus fossa tuberosity Suprascapular arm #1 torn
(scapula) (superior) (initiate), tendon (RC
tear)

Infraspinatus Greater Weak ER:


2.Infraspinatus fossa tuberosity Suprascapular ER arm, damage to
stability nerve. lesion
(scapula) (middle)
in notch
Dissection
Dissection
Greater
Lateral ER arm, can damage
3.Teres Minor tuberosity Axillary
scapular stability circum-flex
(inferior)
vessels
IR, Can
Subscapular
Lesser Upper Lower adduct rupture in
4.Subscapularis fossa
(scapula)
tuberosity Subscapular arm, anterior
stability dislocation

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: DELTOID/PECTORAL REGION

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Atrophy:
Clavicle, Humerus Axillary
Abduct
Deltoid Acromion, spine (Deltoid Axillary
of scapula tuberosity)
arm nerve
damage
Can rupture
Humerus Adducts
Pectoralis 1.Clavicle during
(intertubercular Lateral/medial arm, IR
major 2.Sternum groove) pectoral humerus weight
lifting
Coracoid Divides
Pectoralis Medial Stabilizes
Ribs 3-5 process Axillary artery
minor pectoral scapula
(scapula) into 3 parts
Scapula Holds Paralysis
Serratus
Ribs 1-8 (lateral) (antero-medial Long thoracic scapula to indicates
anterior
border) chest wall wing scapula
Clavicle
Cushions
Subclavius Rib 1 (and
(inferior Nerve to Depresses sub- clavian
costal cartilage) border/mid subclavius clavicle
vessels
3rd)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

BRACHIAL PLEXUS

• C5-T1 ventral rami Variations: C4 (prefixed) T2 (post-fixed)


• Rami (Roots), Trunks, Divisions, Cords, Branches (Rob Taylor Drinks Cold Beer)
Supraclavicular (rami trunks) portion in posterior triangle of neck Rami exit
• between Anterior Medial Scalene, then travel with Subclavian artery in axillary
sheath
Divisions occur under (posterior) to clavicle and subclavius muscle
• Anterior Divisions: Flexors
Posterior Divisions: Extensors
• Infraclavicular (cords branches) portion in the axilla
1. Spinal Accessory (CN11,C1-C6): in posterior cervical triangle on levator scapulae
Sensory: NONE Motor: Trapezius, Sternocleidomastoid
CERVICAL PLEXUS
2. Supraclavicular(C2-3): splits into 3: anterior middle, posterior branches
Sensory: over clavicle, outer
Motor: NONE
trap, deltoid
BRACHIAL PLEXUS
SUPRACLAVICULAR
[approach through posterior INFRACLAVICULAR [approach through axilla]
triangle]
LATERAL CORD
ROOTS •Lateral root to Median nerve
3.Dorsal Scapular (C3, 4, 5): 7. LateralPectoral(C5-7):named for cord,runs with
pierces middle scalene, deep to pectoral artery
Levator
Sensory: NONE
Scapulae Motor: Pectoralis Major
Sensory: NONE Pectoralis Minor
MEDIAL
Motor: Levator scapulae
CORD
Rhomboid Minor
•Medial root to Median nerve
and Major
4.Long Thoracic(C5-7): on
anterior surface of Serratus 8. MedialPectoral(C8-T1): named for cord
Anterior. Runs with lateral
thoracicartery
Sensory: NONE
Motor: Pectoralis Minor
Sensory: NONE Pectoralis Major (overlying muscle]
Motor: Serratus Anterior POSTERIOR CORD
UPPER
9. UpperSubscapular(C5-6)
TRUNK
5.Suprascapular(C5-6): thru
scapular notch, under Sensory: NONE
ligament
Motor: Subscapularis [upper portion]
Sensory: Shoulder joint 10. LowerSubscapular(C5-6)
Motor: Supraspinatus Sensory: NONE
Infraspinatus Motor: Subscapularis [lower portion]
6.Nerve to Subclavius (C5-6):
descends anterior to plexus, Teres major
posterior to clavicle
11. Thoracodorsal(C7-8): runs with thoracodorsal
artery
Sensory: NONE
Sensory: NONE Motor: Latissimus dorsi
12. Axillary(C5-6):with posterior circumflex
humeral arterythrough Quadranglar space. Injured
Motor: Subclavius
in Anterior dislocations, or proximal humerus
fractures
Lateral upper arm: via Superior Lateral
Sensory:
Cutaneous Nerve of arm
Motor: Deltoid: via deep branch
Teres minor: via superficial branch

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

TRUNK BRANCH COURSE/COMMENT


Thyrocervical Suprascapular Over superior transverse scapular ligament.
Trunk
Infraspinatous
Bends around spine of scapula
branch
Subclavian artery comes off: Left - aorta, Right - brachiocephalic. Then goes between
anterior and middle scalene muscles with brachial plexus
Subclavian
Dorsal Scapular Splits around levator scapulae; descends medial to
Artery scapula
Parts determined by pectoralis minor. Part I of the axillaryartery has 1 branch,
Part II has 2 branches, Part III has 3 branches
Axillary (Part Superior
To serratus anterior and pectoralis muscles
I) thoracic
Axillary (Part Thoracoacromial
II)
Clavicular
branch
Acromial branch
Deltoid branch Courses with basilic vein
Pectoral branch
Lateral thoracic To serratus anterior with Long Thoracic nerve.
Axillary (Part Subscapular
III)
Circumflex
Seen posteriorly in Triangular space
scapular
Thoracodorsal Follows Thoracodorsalnerve
Anterior
Supplies humeral head ( anterior humerus)
circumflex
Posterior Seen posteriorly in Quadrangular space. Injury in
circumflex proximal humeral fracture.

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS

WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
ADHESIVE CAPSULITIS (FROZEN SHOULDER)
Hx: Middle age
•Inflammatoryprocess; women, DM XR: Usually
1.NSAIDs
leads to joint fibrosis Slow onset: normal
pain/stiffness
Arthrogram: 2.Physical therapy and
decreased joint home therapy program (3
volume. month minimum)
PE: Decreased
•3 stages: 1. Pain, 2.
active ROM
Stiffness3. Resolving;
passive ROM
•Associated with old
Colles fracture
ARTHRITIS:ACROMIOCLAVICULAR (AC) JOINT
Hx: Pain at AC, XR: Osteophytes,
•Usually osteoarthritis 1.NSAIDs, rest
esp. with motion joint narrowing
2.Distal clavicle resection
(Mumford)
PE: Tender to
palpation
ARTHRITIS:GLENOHUMORAL JOINT

Hx: Older, pain XR: True 1. NSAIDs, ice/heat,


•Multiple etiologies: OA, increases with AP,axillary lateral: ROM steroid inject
RA, post-traumatic joint space
activity controversial
narrowed
PE:+/- wasting,
•Often overuse condition crepitus,
2.Refractory: hemi vs.total
decreased joint arthroscopy
AROM
BICEPS TENDINITIS
•Associated with XR: Normal
impinge- ment or Hx : Pain in
views: usually 1.Treat the impingement
subluxation/transverse shoulder
normal
humeral ligament tear
PE: Tenderness
2.Biceps strengthening
along groove
+Speed, + 3.Tenodesis (rare
Yergason procedure)
BICEPS TENDON RUPTURE
Hx: Old, or
•Long Head of biceps young weight XR: Normal; rule 1.Old: conservative
rupture lifter, sudden out fracture treatment
pain
Arthrogram: rule
2.Young/laborer: surgery
out RC tear
PE: Proximal
•Due to impingement,
micro- trauma or trauma arm bulge
(Popeye arm)
•Associated with RC
tear
BRACHIAL PLEXUS INJURY
Hx: Football
•Traction of brachial players, XR: Shoulder
Most resolve with rest
plexus parathesias in series: normal
arm
BURSITIS:SUBACROMIAL
•Often from Hx/PE: Pain at
Treat the impingement
impingement shoulder
IMPINGEMENT
Decrease/modify
1.
activity
•RC (supraspinatus), Hx: Older, or XR: Normal views NSAID, ROM,
Biceps tendon trapped athlete. +outlet view: 2.
strengthen
under acromion or Pain/inability to type III acromion
coracoacromial do overhead or subacromial Corticosteroid
3.
ligament activity. spur injection
Subacromial
4.
decompression
•Associated with Type III PE:
acromion +Neer,+Hawkins
INSTABILITY/DISLOCATION: GLENOHUMORAL JOINT TWO TYPES
XR: Trauma (+/- 1. Reduce (if dislocated):
1. TUBS [Trauma Hx:Pain, "arm
Stryker) 3 ways. Immobilize in IR
Unilateral Bankart slips out" TUBS
Bankart/Hill for 4 weeks, RC
lesion, Surgery] history
Sachs lesion strengthening, then ROM
PE: +PE for Axillary nerve
•90% anterior (posterior
unilateral injury (esp. with
after seizure)
instability (e.g. + anterior)
2. Surgical repair for
Apprehension,
•Pts 20yrs: 80% recur recurrence (notin
relocation)
posterior)
2. AMBRI Atraumatic
Multi- directional, Hx: Pain, "arms XR: Trauma 1. Reduce if dislocated: 3
Bilateral, Rehab slip out" +
series
ways2. Long term
responsive, Inferior AMBRI history conservative treatment
capsule repair
PE: +sulcus,
general joint 3. Life style modifications
laxity in MDI

WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
INSTABILITY/DISLOCATION:STERNOCLAVICULAR JOINT
Hx: Large force:
sports/MVA, pain Anterior:
(anterior: ant XR: May not
•Tear of capsule sling/closed
prominence, show injury
reduction
posterior: +/- pulm,
GI)
•Most anterior;
Posterior rare, has CT: Helpful in Posterior: early
increased diagnosis closed reduction
Complications immobilize, PT
(great vessels)
LABRUM INJURY (SLAP LESION)
Bicep tendon
attachment injury
I. Bicep By type:
fraying/anchor I.
intact XR: Shoulder Debridement
Hx: Pain, series
II.Tear in 1/2instability II.
anchor MR/Arthroscopy Reattachment
symptoms
(labrum) to diagnose
PE: 1 O’Brien test SLAP lesion III.Debridement
III. Bucket IV.Repair vs.
handle tear tenodesis
IV.III 1tear in
bicep
LONG THORACIC NERVE INJURY
Conservative
•Nerve injuryresults Hx: Usually trauma
treatment, most
in serratus anterior PE: Winged NONE
dysfunction scapula resolve within
weeks/ months
OSTEOLYSIS
•Often in weight- Hx: Pain in shoulder XR: Distal 1.Activity
lifters clavicle lucency modification.
2.Mumford
PECTORALIS MAJOR RUPTURE
Hx/PE: Sudden,
•Maximal eccentric
pain, palpable NONE Surgical repair
contraction
defect
ROTATAR CUFF TEAR
•Due to poor
vascularity, overuse, Hx: Older; pain is XR: Trauma 1.Conservative:
micro or macro deep at night, series: high- NSAID, rest, activity
trauma, worse with riding humerus modification, ROM,
degeneration, or overhead activity RC strengthening
abnormal acromion
PE: Arthrogram (or
Atrophy,decreased MR/Arthrogram):
2.Surgical repair
•Supraspinatus AROM, normal Gold standard: with subacromial
most common PROM, + drop shows decompression for
arm/empty can, +lift communication complete tears
off (subscapular with subdeltoid
tear) bursa
THORACIC OUTLET SYNDROME
•Compression of
Hx: Women 20-50 1. Activity
neuro- vascular
yo. Worse with XR: Shoulder modification (until
structure (vein, overhead activity usually normalC- symptoms
artery, or plexus) Vein: edema, spine: Rule out resolve)2. Posture
between first rib and discolor,stiff Artery: massCXR: Rule training3. Surgery:
scalene
cool, claudication out mass especially for a
muscle•Also seen
Plexus: parathesias cervical rib
with cervical ribs
PE: +Adson, +Roos
tests

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SURGICAL APPROACHES

USES INTERNERVOUS PLANE DANGERS COMMENT


ANTERIOR (DELTOPECTORAL) APPROACH (HENRY)
1.Keep arm
1.Shoulder 1.Musculocutaneous adducted to
reconstruction 1.Deltoid [Axillary]
avoid bringing
nerve
brachial plexus
into the field.
2.Biceps 2.Pectoralis major [lat/med
2.Cephalic vein
tendon repair. pectoral]
3.Arthroplasty 3.Axillary nerve
2.Keep
dissection to
lateral side of
coracobrachialis:
protect MC
nerve.
ARTHROSCOPY PORTALS
“Soft spot” between biceps 1.Musculocutaneous 1.Usually placed
1.Anterior tendon, anterior glenoid, superior nerve AFTER the
edge of subscapular tendon posterior portal
2.Cephalic vein
3.Axillary nerve
“Soft spot”between teres minor 1.Superior AC 1.Primary portal
2.Posterior
and infraspinatus ligament for shoulder
2.Aim to
2.RC tendons coracoid when
placing
1.To access
3.Lateral Through deltoid 1.Axillary nerve subacromial
space

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CHAPTER 3 - ARM
TOPOGRAPHIC ANATOMY
OSTEOLOGY
TRAUMA
ELBOW JOINTS
MINOR PROCEDURES
HISTORY
PHYSICAL EXAM
MUSCLES: INSERTIONS AND ORIGINS
ANTERIOR MUSCLES
POSTERIOR MUSCLES
MUSCLES: CROSS SECTION
NERVES
ARTERIES
DISORDERS
SURGICAL APPROACHES
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 3 – ARM
TOPOGRAPHIC ANATOMY

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY
CHARACTERISTICS OSSIFY FUSE COMMENT
HUMERUS
8-9 th
• Long bone By • Surgical neck: common fracture
Primary: Shaft wk
characteristics birth site
(fetal)
• Lateral condyle • Blood supply
Secondary
1. Epicondyle: non- Proximal: Anterior/Posterior
Proximal
articular circumflex
(3):
17-
2. Capitellum: Middle: Nutrient artery (from Deep
1. Head 20
articular artery)
yrs
2.
• Medial condyle Tuberosities Birth
(2)
1. Epicondyle: non- 3-5
Distal: Branches from anastomosis
articular yrs
• Elbow ossification order:
Capitellum, Radial head, Medial
2. Trochlea:
epicondyle, Trochlea, Olecranon,
articular
Lateral epicondyle (Captain Roy
Makes Trouble On Leave)
3. Cubital tunnel:
covered with Distal (4):
Osbourne's fascia.
1.
1 yr
Capitellum
13-
2. Medial
4-6 yr 14
epicondyle
yrs
9-10
3. Trochlea
yr
15-
4. Lateral
12 yr 20
epicondyle
yrs

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


PROXIMAL HUMERUS FRACTURE
Neer: based on
HX: Fall/trauma.
• Common number of
Pain worse with 1 part: sling, early motion.
fracture movement fragments(parts)
1-4
PE: Swelling,
• Multiple 2 part: closed reduction splint. Irreducible,
Osteoporosis, ecchymosis, good combinations of intraarticular anatomic neck fx: ORIF. Greater
elderly, female neurovascular fractures possible tuberosity fx: ORIF and Rotator Cuff repair
exam
• Mechanism:
1. Elderly: fall XR: Trauma Also fracture
on outstretched series dislocation, and 3 4 part : ORIF or hemiarthroplasty (elderly)
hand intraarticular fx
CT: shows
intraarticular
glenoid
involvement
2. Young: high MR: sensitive for 4 parts: head,
energy trauma AVN shaft, greater and Fracture/Dislocation:
(e.g. MVA, fall) lesser tuberosities
• 80% non or
Each part: 1cm
minimally 2 part: closed treatment except when
displaced or 45°
displaced (1 displaced
angulated
part fx)
• Most heal well 3-4 part: ORIF or hemiarthorplasty
• Early Fragment
pendulum displacement due Intraarticular: ORIF or hemiarthroplasty
motion is key to attached
for full ROM muscle
COMPLICATIONS: Stiffness/adhesive capsulitis; Avascular necrosis (AVN):4 part anatomic neck,
axillary nerve and brachial plexus injury; axillary artery injury, nonunion

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


HUMERUS SHAFT FRACTURE
HX: Trauma, fall. Closed: Most fractures:
• Common fracture Severe pain, Descriptive: coaptation splint or fracture
swelling brace for 6-8 weeks
Open Neurovascular injury,
multitrauma, pathologic
• Mechanism: direct PE: Swelling,
Location: level fracture. Severe
blow or fall on deformity + / - radial
outstretched arm nerve findings of humerus comminution requires
plates/screws or
intermedullary (IM) nail
• Displacement based XR: AP lateral arm,
Pattern: oblique,
on fracture site relation shoulder and elbow
spiral,
to deltoid pectoralis
series transverse
major insertion
Displacement or
• Almost 100% union
comminution
• Site of pathologic fx
COMPLICATIONS: Radial nerve injury (esp. Holstein/Lewis fracture, spiral fracture of distal
third) most resolve. Malunion is rare.
DISTAL HUMERUS FRACTURE
HX: Pain, deformity, Displaced vs. Early motion important to
• Uncommon discoloration,
nondisplaced avoid loss of motion
swelling
PE: Swelling,
Intercondylar: ORIF or total
ecchymosis
joint arthroplasty (closed
• High morbidity crepitus, Multiple types: treatment if comminuted or
tenderness, good
elderly)
neurovascular exam
XR: AP lateral:
Transcondylar: reduce,
• Often intraarticular posterior fat pad/sail Intercondylar
percutaneous pinning
sign
• Mechanism: fall onto CT: Optional: useful
hand, ulna forced into in pre-operative Transcondylar Others:
humerus planning
• Intercondylar most Nondisplaced: closed
common in adults Supracondylar treatment; 10-14 days and
early motion.
• Condylar, capitellum, Displaced or comminuted
Trochlea, Epicondylar Condylar
(or elderly) require ORIF
all rare
Capitellum
Trochlea
Epicondylar
(medial or
lateral)
COMPLICATIONS: Stiffness/arthritis; Compartment syndrome; Median/Ulnar nerve injury;
Brachial artery injury; Nonunion

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


SUPRACONDYLAR FRACTURE
Extension
(common): Neurovascularly intact:
Undisplaced closed reduction and
HX: Fall. Pain,
• Common percutaneous pinning
swelling, will not use Partially
childhood fracture under general
arm. displaced anesthesia
Fully (fluoroscopy)
displaced
PE: Swelling, point
•Occurs at tenderness, + / - Pulseless/Perfused:
metaphysis, above neurovascular signs: Flexion (rare) same
growth plate check distal pulses do
neurologic exam
• Extension type
most
XR: AP lateral (note Pulseless/Unperfused:
common(90%): capitellum position to open reduction
shaft is anterior, anterior humeral line) exploration
distal fragment is
posterior
• Associated with
signifcant morbidity; Arteriogram: if
prompt treatment pulseless
essential.
COMPLICATIONS: Neurovascular injury: brachial artery; AIN injury; Compartment
syndrome can lead to Volkmann's ischemic contracture; Deformity: cubitus varus

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


ELBOW DISLOCATION
Location of ulna
(radius)
Posterior Closed
(common) reduction: + /
• Common in - local
HX: Fall/trauma. Pain, Posterolateral
children and young anesthesia
inability to flex elbow (90%)
adults and/or
Anterior conscious
Lateral sedation
Medial
PE: Deformity,
Splint 7days
• Younger, sports tenderness, + / - for comfort,
neurovascular signs.
related fall on hand then early
Check distal pulses
ROM
neurologic exam
Open: if
• Associated with
unstable or
radial head
fracture, brachial XR: AP lateral: rule out with
fracture entrapped
artery, median
artery, median
bone or soft
nerve injury
tissue
• Both collateral
ligaments ruptured
Divergent (ulna
and radius
opposite)
COMPLICATIONS Neurovascular injury: brachial artery; median or ulnar nerve;
Loss of extension; Instability/redislocation; Heterotopic ossification
RADIAL HEAD SUBLUXATION (NURSEMAID'S ELBOW)
Reduce: with
gentle, full
• Common in
children Usually Hx: Pulled by hand, NONE supination
child will not use arm. and flexion
ages 2-4, 7 rare
(should feel it
“pop” in).
• Mechanism: child PE: Arm held
Immobilize a
pulled or swung by pronated/flexed. Radial
recurrence
hand or forearm head supination tender.
• Annular ligament
stretches, radial XR: only if suspect
head lodges within fracture
it.
COMPLICATIONS: Recurrence

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ELBOW JOINTS

JOINT TYPE ARTICULATION LIGAMENTS COMMENTS

ELBOW Includes 3 joints Capsule (common Carrying angle:


to all 3) 10-15°valgus
Ulnar(medial)
collateral:
Torn in posterior
1. Anterior dislocation
Ulnohumeral Ginglymus Trochlea and band
Strongest:
“Trochlear joint” [Hinge] trochlear notch 2. Posterior resists valgus
band
stress
3. Transverse
band
Radial (lateral)
Weak
collateral
Trochoid Capitellum radial Gives
Radiohumeral 1. Ulnar part
[Pivot] head posterolateral
2. Radial part stability
Proximal Radial head Annular Keeps head in
radioulnar radial notch radial notch
Oblique cord
Supports rotary
Quadrate
movements

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MINOR PROCEDURES

STEPS

ELBOW ARTHROCENTESIS

Extend elbow, palpate lateral condyle, radial head and olecranon laterally; feel
1.
triangular sulcus between all three
2. Prepare skin over sulcus (iodine/antiseptic soap)
3. Anesthetize skin locally (quarter size spot)

4. May keep arm in extension or flex it. Insert needle in the “triangle” between bony
landmarks
5. Fluid should aspirate easily
6. Dress injection site
OLECRANON BURSA ASPIRATION

1. Prepare skin over olecranon (iodine/antiseptic soap)


2. Anesthetize skin locally (quarter size spot)
3. Insert 18 gauge needle into bursa and aspirate fluid.
4. If suspicious of infection, send fluid for Gram stain and culture
5. Dress injection site
TENNIS ELBOW INJECTION

1. Ask patient about allergies


2. Flex elbow 90°, palpate ERCB distal to lateral epicondyle.
3. Prepare skin over lateral elbow (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
Insert 22 gauge or smaller needle into ERCB tendon at its insertion just distal to the
5. lateral epicondyle. Aspirate to ensure needle is not in a vessel, then inject 2-3ml of
1:1 local/corticosteroid preparation.
6. Dress insertion site
7. Annotate improvement in symptoms

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY

QUESTION ANSWER CLINICAL APPLICATION


1. AGE Young Dislocation, fracture
Middle age,
Tennis elbow (epicondylitis), arthritis
elderly
2. PAIN

a. Onset Acute Dislocation, fracture, tendon avulsion/rupture,


ligament injury
Chronic Cervical spine pathology
b. Location Anterior Biceps tendon rupture, arthritis
Posterior Olecranon bursitis

Lateral Lateral epicondylitis, fracture (especially radial head-


hard to see on x-ray)
Medial epicondylitis, nerve entrapment, fracture,
Medial
MCL strain

c. Occurrence Night pain/at Infection, tumor


rest
With activity Ligamentous and/or tendinous etiology

3. STIFFNESS Without Arthritis, effusions (trauma)


locking
With locking Loose body, Lateral collateral ligament injury
Over
4. SWELLING Olecranon bursitis. Other: dislocation, fracture, gout
olecranon
Fall on
5. TRAUMA Dislocation, fracture
elbow, hand
Sports,
6. ACTIVITY repetitive Epicondylitis, ulnar nerve palsy
motion
Pain,
7. NEUROLOGIC Nerve entrapments (multiple possible sites), cervical
numbness,
SYMPTOMS spine pathology, thoracic outlet syndrome
tingling
Multiple
8. HISTORY OF
joints Lupus, rheumatoid arthritis, psoriasis
ARTHRITIDES
involved

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION


INSPECTION
Gross deformity,
Compare both sides Dislocation, fracture, bursitis
swelling
Carrying angle (normal Negative ( 5 degrees) Cubitus varus: physeal damage (e.g.
5-15°) malunion supracondylar fracture)
Positive ( 15 Cubitus valgus: physeal damage (e.g.
degrees) lateral epicondyle fracture)
PALPATION
Epicondyle Pain: medial epicondylitis (Golfer's
Medial
supracondylar line elbow), fracture, MCL rupture
Ulnar nerve in ulnar Parathesias indicate ulnar nerve
groove entrapment
Epicondyle Pain: lateral epicondylitis (Tennis elbow),
Lateral
supracondylar line fracture
Radial head Pain: arthritis, fracture, synovitis

Anterior Biceps tendon in Pain can indicate biceps tendon rupture


antecubital fossa
Flex elbow: olecranon Olecranon bursitis, triceps tendon
Posterior
olecranon fossa rupture

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION


RANGE OF MOTION
Elbow at side, flex extend Normal: 0-5° to 140-150°;
Elbow at side, flex extend Normal: 0-5° to 140-150°;
Flex and extend
at elbow note if PROM AROM
Normal: supinate 90
Tuck elbows, pencils in
Pronate and supinate degrees, pronate 80-90
fists, rotate wrist
degrees
NEUROVASCULAR
Sensory (LT, PP, 2 pt)
Deficit indicates
Axillary nerve (C5) Superolateral arm corresponding nerve/root
lesion
Deficit indicates
Inferolateral and posterior
Radial nerve (C5) corresponding nerve/root
arm
lesion
Deficit indicates
Medial Cutaneous
Medial arm corresponding nerve/root
nerve of the Arm (T1)
lesion
Motor
Weakness =
Musculocutaneous n. Brachialis/biceps or
Resisted elbow flexion
(C5-6) corresponding nerve/root
lesion.

Musculocutaneous n. Weakness = Biceps or


Resisted supination corresponding nerve/root
(C6)
lesion.
Weakness = Pronator Teres
Median nerve (C6) Resisted pronation or corresponding nerve/root
lesion.
Weakness = FCR or
Median nerve (C7) Resisted wrist flexion corresponding nerve/root
lesion.
Weakness = Triceps or
Radial nerve (C7) Resisted elbow extension corresponding nerve/root
lesion.
Weakness = ECRL-B/ECU
Radial nerve/PIN (C6-
Resisted wrist extension or corresponding nerve/root
7)
lesion.
Weakness = FCU or
Ulnar nerve (C8) Resisted wrist flexion corresponding nerve/root
lesion.
Reflexes
Hypoactive/absence
C5 Biceps indicates corresponding
radiculopathy
Hypoactive/absence
C6 Brachioradialis indicates corresponding
radiculopathy
Hypoactive/absence
C7 Triceps indicates corresponding
radiculopathy
Pulses Brachial, Radial, Ulnar
SPECIAL TESTS
Make fist, pronate, extend Pain at lateral epicondyle
Tennis Elbow wrist and fingers against suggests lateral
resistance epicondylitis
Pain at medial epicondyle
Supinate arm, extend wrist
Golfer's Elbow Elbow suggests medial
epicondylitis

Ligament Instability 25° flexion, apply Pain or laxity indicates


varus/valgus stress LCL/MCL damage
Tinel's Sign (at the Tap on ulnar groove Tingling in ulnar distribution
elbow) (nerve) indicates entrapment

Elbow Flexion Maximal elbow flexion for Tingling in ulnar distribution


Elbow Flexion
3-5min indicates entrapment

Pinch tips of thumb and Inability (or pinching of pads,


Pinch Grip not tips) indicates AIN
index finger
pathology

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: INSERTIONS AND ORIGINS

ANTERIOR
CORACOID GREATER MEDIAL LATERAL
PROXIMAL
PROCESS TUBEROSITY EPICONDYLE EPICONDYLE
HUMERUS
ORIGINS INSERTIONS INSERTIONS ORIGINS ORIGINS
Pronator
Biceps (SH) Supraspinatus Pectoralis major Anconeus
Teres

Common Common
Coracobrachialis Infraspinatus Latissimus dorsi Flexor Tendon Extensor
Tendon

INSERTIONS Teres minor Teres major [FCR, PL, [ECRB, ED,


FCU, FDS] EDM, ECU]
Pectoralis minor

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ANTERIOR MUSCLES

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

Coracoid Middle Flex and


Coracobrachialis process humerus Musculocutaneous adduct
arm

Distal Often split


Brachialis anterior Ulnar Musculocutaneous Flex in anterior
tuberosity forearm surgical
humerus
approach
Biceps brachii
Can
Radial Flex rupture
Long Head Supraglenoid tuberosity Musculocutaneous supinate proximally-
tubercle (proximal
forearm results in
radius) Popeye
arm
Radial
Flex Covers
Coracoid tuberosity
Short Head Musculocutaneous supinate brachial
process (proximal
forearm artery
radius)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

POSTERIOR MUSCLES

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Triceps
Brachii
Long Infraglenoid Olecranon Radial Extends Border of quadrangular
Head tubercle (proximal) n. forearm triangular space interval

Lateral Posterior Olecranon Radial Extends Border in lateral


Head humerus (proximal) n. forearm approach
(proximal)
Medial Posterior Olecranon Radial Extends One muscular plane in
Head humerus (distal) (proximal) n. forearm posterior approach

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Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: CROSS SECTION

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

INFRACLAVICULAR [approach through axilla]

LATERAL CORD
1. Musculocutaneous (C5-7): pierces coracobrachialis between bicep and
brachialis. At risk for injury during anterior approach to shoulder.

Sensory: NONE (in arm)


Motor: ANTERIOR COMPARTMENT OF ARM
Coracobrachialis
Biceps brachii
Brachialis

MEDIAL CORD
2. Medial Cutaneous Nerve of Arm (C8-T1): joins intercostal-brachial nerve

Sensory: Medial (inner) arm


Motor: NONE

3.Ulnar (C(7)8-T1): travels from anterior to posterior compartment via arcade of


Struthers [*] , then to cubital tunnel [*] .

Sensory: NONE (in arm)


Motor: NONE (in arm)

POSTERIOR CORD
4.Radial (C5-T1): runs with deep artery of arm in triangular interval, then spiral groove
15cm from elbow (injured in shaft fx; at risk in surgery), then it divides at the elbow: 1.
PIN (motor), 2. superficial radial nerve (sensory)

Sensory: Lateral arm: via Inferior Lateral Cutaneous Nerve of arm


Posterior arm: via Posterior Cutaneous Nerve of arm
Motor: POSTERIOR COMPARTMENT OF ARM
Triceps [medial, long, lateral heads]
Anconeus
* possible compression site

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

ANASTOMOSES AROUND THE ELBOW


SUPERIOR INFERIOR
Superior Ulnar Collateral Posterior Ulnar Recurrent
Inferior Ulnar Collateral Anterior Ulnar Recurrent
Middle Collateral (branch of Deep Artery) Interosseous Recurrent
Radial Collateral (branch of Deep Artery) Radial Recurrent

TRUNK BRANCH COURSE/COMMENT


Brachial Continuation of
Medial to biceps, runs with median nerve
Artery axillary artery
1. Deep artery Runs with radial nerve in radial groove (posterior
of arm humerus)
2. Nutrient
Enters nutrient canal
humeral artery
3. Superior
Branches in middle of arm, runs with ulnar nerve
ulnar collateral
*Anastomosis with posterior ulnar collateral at
elbow
*Anastomosis with anterior ulnar collateral at elbow
4. Inferior ulnar
Brachial artery can be clamped below this branch:
collateral
collateral circulation is usually sufficient.
5. Muscular
5. Muscular
Variable, usually branch laterally
branches

6. Radial artery These are the two terminal branches of Brachial


artery, it divides in the cubital fossa.
7. Ulnar artery
Deep
Artery of Radial collateral *Anastomosis with Radial recurrent artery at elbow
arm
Middle *Anastomosis with Recurrent interosseous artery
collateral at elbow
Radial Radial
Artery Recurrent *Anastomosis with radial collateral artery at elbow

Ulnar Anterior ulnar *Anastomosis with inferior ulnar collateral artery at


Artery recurrent elbow
Posterior ulnar *Anastomosis with superior ulnar collateral artery
recurrent at elbow
Common
interosseous
artery
Recurrent
interosseous
artery
*Anastomosis with middle collateral artery at elbow
Collateral branches are all superior branches, recurrent branches are all inferior
branches of the anastomosis at the elbow

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS

WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
ARTHRITIS

• Uncommon condition Hx: Chronic pain XR: OA vs. 1. Conservative (rest,


stiffness inflammatory NSAID)
• Osteoarthritis seen in PE: Decreased Blood: RF, ESR, 2. Debridement
athletes ROM tenderness ANA
Joint fluid:
• Site for arthritides crystals, cells, 3. Joint replacement
culture
BICEPS TENDON RUPTURE
• Trauma: forced
Hx: Acute onset of XR: usually
elbow flexion against pain normal Surgical reattachment
resistance
PE: Decreased or
• Rare (proximal distal)
absent elbow flexion
CUBITAL TUNNEL SYNDROME
Hx:
• Trauma or stretching
Numbness/tingling XR: Usually
of ulnar nerve in cubital 1. Rest, ice, NSAID
tunnel (+ / - pain) in ulnar negative
distribution
Nerve
PE: + / - decreased
• Occurs near FCU grip strength, Tinel's conduction: gives 2. Splints (day and/or
origin and/or elbow flexion objective data, night)
test but often not
necessary
• Can also be trapped 3. Casting
at arcade of Struthers
4. Nerve
decompression and
transposition
LATERAL EPICONDYLITIS (Tennis Elbow)
XR: Rule out
Hx: Age 30-60,
fracture OA.
• Degeneration of chronic pain at
Calcification of 1. Activity modification,
common extensor lateral elbow, worse
tendons (esp. ECRB) with wrist finger tendons can ice, NSAIDs
extension occur (esp.
ECRB)
• Due to overuse (e.g. PE: +Tennis elbow
tennis) or injury test 2. Use of brace or strap
(microtrauma)
3.
Stretching/strengthening
4. Corticosteroid
injection
5. Surgical release of
tendon
LCL SPRAIN
Conservative unless
• Rare condition Hx: + / - catching XR: Usually recurrent subluxation,
and locking negative then surgical
reconstruction
PE: + instability with
varus stress, +
posterolateral (pivot
shift) drawer
MCL SPRAIN
Hx: Young, throwing
XR: occasional
• Due to single athletes, chronic
spur; rule out Grade I II: conservative
traumatic or repetitive pain or acute onset
fracture (+ / - (rest, ice, NSAID)
valgus stress of pain at MCL, + / - stress view)
“pop”
Grade III (complete
• Usual mechanism: PE: + / - instability MRI: before
tear): surgical repair
throwing with valgus stress surgery
(use PL)
• Anterior Band is
affected
MEDIAL EPICONDYLITIS (Golfer's Elbow)
XR: Rule out
• Degeneration of fracture OA.
Hx: Medial elbow
pronator/ flexor group Calcification of Same as Tennis elbow
pain
(PT FCR) tendons can
occur
PE: Focal medial
Surgery is less effective
• Due to injury or epicondyle
than for lateral
overuse tenderness, +
epicondylitis
Golfer's elbow test
OLECRANON BURSITIS
Aspirate bursa:
• Inflammation of bursa Hx: Swelling, acute send purulent 1. Compressive
(Infection/trauma/other) or chronic fluid for culture dressing
and Gram stain
PE: Palpable mass
2. Reaspirate if recurs
at olecranon
3. Corticosteroid
injection
OSTEOCHONDRITIS DISSECANS OF ELBOW: OCD
Hx: Young, active
• Repetitive valgus XR: lucency Type I (fragment stable):
stresses (e.g. throwing (thrower or and/or loose Ice, discontinue activity,
or gymnastics) gymnast), lateral body NSAID
elbow pain

• Vascular PE: + / - catching CT/MRI:


and/or locking, determine Type II-III (loose
compromise and
crepitus with articular and fragment): Drill or
microtrauma of
pronation and subchondral curette fragment
capitellum
supination involvement
TRICEPS TENDON RUPTURE
• Trauma: forced Hx: Pain in posterior XR: usually
elbow extension Surgical reattachment
elbow normal
against resistance
PE: Loss of active
elbow extension

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SURGICAL APPROACHES

INTERNERVOUS
USES DANGERS COMMENT
PLANES
HUMERUS: ANTERIOR APPROACH
Proximal Proximal
1. Deltoid 1. Axillary
1. ORIF of [Axillary] nerve • Anterior humeral circumflex
fractures Pectoralis Humeral artery may need ligation.
2. Major 2. circumflex
[Pectoral] artery
2. Bone biopsy • The brachialis has a split
or tumor innervation which can be used
removal. for an internervous plane.
Distal
Brachialis
splitting Distal
Lateral
1. 1. Radial
[Radial] nerve
Medial
[MC]
ELBOW: LATERAL APPROACH (KOCHER)
Most radial
1. Anconeus • Protect PIN: stay above annular
head [Radial] 1. PIN ligament; keep forearm pronated
procedures
2. ECU [PIN] 2. Radial nerve
INTERNERVOUS
USES DANGERS COMMENT
PLANES
ELBOW: POSTERIOR APPROACH (BRYAN/MORREY)
Triceps is
1. Arthroplasty detached

Distal humerus from the
2. and olecranon Ulnar olecranon.
No planes
fractures nerve MCL
Loose body release may
3. •
removal be
necessary.

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CHAPTER 4 - FOREARM
TOPOGRAPHIC ANATOMY
OSTEOLOGY OF THE FOREARM
OSTEOLOGY OF THE WRIST
TRAUMA
JOINTS: WRIST
OTHER WRIST STRUCTURES
MINOR PROCEDURES
HISTORY
PHYSICAL EXAM
MUSCLES: ORIGINS & INSERTIONS
ANTERIOR COMPARTMENT MUSCLES: SUPERFICIAL FLEXORS
POSTERIOR COMPARTMENT MUSCLES: SUPERFICIAL EXTENSORS
ANTERIOR COMPARTMENT MUSCLES: DEEP FLEXORS
POSTERIOR COMPARTMENT MUSCLES: DEEP EXTENSORS
MUSCLES: CROSS SECTIONS
NERVES
ARTERIES
DISORDERS: ARTHRITIS & INSTABILITY
DISORDERS: NERVE COMPRESSION
OTHER DISORDERS
SURGICAL APPROACHES
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 4 – FOREARM
TOPOGRAPHIC ANATOMY

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Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY OF THE FOREARM

CHARACTERISTICS OSSIFY FUSE COMMENT


RADIUS
Elbow
ossification:
used to

determine
bone age in
Cylindrical peds

long bone
Elbow
Head within Primary: Shaft ossification
• 8-9
elbow joint Secondary order:
weeks 14- Capitellum,
Tuberosity
• 1. Proximal (fetal) 21 Radial head,
outside joint epiphysis
1-9 years Medial
• Palpate head 2. Distal years epicondyle,
laterally epiphysis • Trochlea,
Styloid is Olecranon,
• Lateral
distal
Epicondyle
(Captain
Roy Makes
Trouble On
Leave)
ULNA
Cylindrical

long bone 8-9
Primary: Shaft weeks
Olecranon Olecranon
(fetal)
Olecranon Olecranon
palpable Secondary (fetal) 16- and coronoid
• 1. Olecranon •
posteriorly at 10 20 give the
elbow Distal years years elbow bony
2. stabilization.
Styloid epiphysis 5-6
• process yrs
distally

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY OF THE WRIST

CHARACTERISTICS OSSIFY FUSE COMMENT


PROXIMAL ROW
• Lies beneath the anatomic snuffbox
Scaphoid: boat shaped, 14-
5th 5 Distal (to waist) blood supply (radial
80% of surface is 16
years • artery); proximal pole is susceptible to
articular (not the waist) yrs
necrosis if injured

• Dislocations often missed


14- Blood supply is palmar: palmar
Lunate: moon shaped 4th 4 16
years fractures need ORIF to protect against
yrs •
osteonecrosis; dorsal fractures
treated nonsurgically
14-
Triquetrum: pyramid 3rd 3
16
shaped years
yrs
8th 9- 14-
Pisiform: large • In the FCU tendon; TCL attaches
12 16
sesamoid bone years yrs
DISTAL ROW

6th 5-6 14- Articulates with 1st metacarpal; TCL


Trapezium: most radial 16 •
years attaches, FCR
yrs

Trapezoid: wedge 7th 5-6 14-


16 • Articulates with 2nd metacarpal
shape years
yrs
14-
Capitate: largest carpal 1st 1
• First to ossify
16
bone year
yrs

2nd 1-2 14-


Hamate: has a hook 16 • TCL, FCU attach to the hook
Hamate: has a hook 16 • TCL, FCU attach to the hook
years
yrs
Ossification: each from a single center: counterclockwise (anatomic position) starting with
capitate
Carpal tunnel borders: Roof: Transverse carpal ligament; Lateral wall: scaphoid
trapezium; Medial wall: pisiform hamate Contents: Median nerve, flexor tendons
Guyon's canal: Roof: volar carpal ligament; Floor: TCL; Lateral wall: hamate (hook);
Medial wall: pisiform Contents: Ulnar nerve and artery
Anatomic snuffbox: Between tendons of EPL and EPB; Contents: Radial artery (scaphoid
directly deep to snuffbox)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


OLECRANON FRACTURE
Undisplaced:
Colton: Cast at 45-90°
for 3 weeks,
Mechanism: fall HX: Fall/trauma. Swelling, Undisplaced: 2mm then gentle
• directly on elbow; pain, +/- numbness. Displaced ROM
fall on hand PE: Effusion, tenderness -avulsion Displaced:
+/- decreased elbow ORIF with
Articular surface -
• extension. Good tension band
always involved transverse/oblique
neurovascular exam (esp. wires or
Triceps tendon pulls ulnar nerve) -comminuted bicortical screw.

fragment (comminuted
XR: AP/lateral -
fracture/dislocation fracture: excise
bone then
reattach triceps)
COMPLICATIONS: Ulnar nerve injury (most resolve); Decreased ROM; Arthritis
RADIAL HEAD FRACTURE
Type I: Splint for
3 days, then
early ROM
Type II: If motion
• Common HX: Fall. Pain, swelling, Mason: 4 Types intact-splint,
decreased function. then early ROM.
Fall on outstretched I: Undisplaced
• arm radius pushed If 1/3 of
PE: Tenderness of radial II: Displaced
into capitellum head
head, decreased ROM
III: Comminuted involved or
• Intraarticular fracture especially
(head) 3mm
pronation/supination. Test
Can be associated displaced-
MCL stability IV: Fracture with
• with elbow ORIF or
XR: AP/lateral: +fat pad elbow dislocation excision
dislocation
Type III:
Radial
head
excision

COMPLICATIONS: Decreased ROM; Instability


BOTH BONE FRACTURE
ORIF (usually
Mechanism: high plates and

energy injuries screws) through
HX: Trauma. Pain,
Fractures in shaft of swelling. two separate
Descriptive: incisions.
single bone shorten,
• PE: Tenderness, deformity. • Undisplaced
resulting forces Nightstick:
Check compartments and
cause fracture in • Displaced Undisplaced-
do neurovascular PE
other bone • Comminuted closed
XR:AP/lateral: including treatment;
Nightstick fracture: wrist and elbow
• ulnar shaft fracture Displaced-ORIF
only Peds: closed,
LAC 6-8wks
COMPLICATIONS: Loss of Pronation and supination; Nonunion

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


MONTEGGIA FRACTURE
Bado (based on
HX: Fall. Pain, radial head
Proximal ulna location): Ulna: ORIF
swelling.
fracture, shortening I: Anterior (plates/screws)
• forces result in PE: Tenderness, (common) Radial head: closed
radial head deformity. Check
II: Posterior reduction (open if
dislocation. compartments and irreducible or
dislocation. irreducible or
neurovascular exam. III: Lateral unstable).
Mechanism: direct
• blow or fall on XR: AP/lateral: IV: Anterior with Peds: closed
outstretched hand. including wrist and associated reduction cast.
elbow series. both bone
fracture.

COMPLICATIONS: Radial nerve/PIN injury (most resolve); Decreased ROM; Compartment Syndrome;
Nonunion
GALEAZZI/PIEDMONT FRACTURE
Radius: ORIF
HX: Fall. Pain, By mechanism: (plate/screws)
swelling.
• Mechanism: fall on Pronation: DRUJ: closed
outstretched hand. PE Tenderness, Galeazzi reduction, +/-
deformity. Check percutaneous pins.
Distal radial shaft compartments and Supination:
fracture, shortening Reverse (open treatment if
do neurovascular unstable)
• forces result in exam. Galeazzi (ulna
distal radioulnar shaft fracture Cast immobilization
dislocation. XR: AP/lateral: with DRUJ for 4-6wks.
including wrist and dislocation)
elbow Peds: closed
reduction, cast.
COMPLICATIONS: Nerve injury; Decreased ROM; Nonunion; Distal radioulnar joint (DRUJ) arthrosis

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


DISTAL RADIUS FRACTURE

• Very common Close reduce,


(Colles#1) HX: Fall. Pain, Frykman (for Colles): immobilize with
Fall on swelling. Type I, II: WELL molded
• cast. (volar
outstretched arm PE: Swelling, extraarticular
flexion ulnar
flexion ulnar
Colles fracture: deformity, Type III, IV: deviation).
dorsal tenderness to radiocarpal joint.
displacement palpation.Good If unstable add
• Type V, VI: radioulnar percutaneous
(apex volar), neurovascular joint
radial shortening, exam. pins, ORIF or
dorsal angulation. Type VII, VIII: external fixation.
XR: AP/lateral: radiocarpal and
Smith fracture: normal radius: Smith: closed
radioulnar joints treatment +/-
volar

displacement 1. 23° radial involved (even percutaneous
inclination numbers also have
(apex dorsal) pinning (often
13 mm ulna styloid fx) unstable needs
Barton fracture: 2. radial Barton: ORIF)
• radial rim carpus height
displace together 1. Dorsal Barton fracture:
3. 11° volar Volar (most Most need ORIF
Radial styloid tilt 2.
• (chauffeur common) Styloid fracture:
fracture) ORIF

COMPLICATIONS: Loss of motion; Deformity; Median nerve injury; Malunion; Scapholunate


dislocation

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


SCAPHOID FRACTURE

HX: Fall. Pain If clinical


Most common symptoms
• worse with
carpal fracture with negative
gripping,
Fall on swelling. xray: thumb
• By location: spica for 10-
outstretched
arm PE: “Snuffbox” Proximal pole 14days then
tenderness, re-evaluate.
High swelling on Middle (“waist”)
• complication most common Nondisplaced:
radial wrist
rate Distal pole cast 6-12 wks
XR: AP/lateral:
Proximal pole Displaced:
Proximal pole also PA with Displaced:
• with tenuous ORIF (K-wire
ulnar
blood supply or Herbert
deviation/oblique
screw)
COMPLICATIONS: Nonunion/malunion; Osteonecrosis: especially of proximal pole;
Degenerative Joint Disease (DJD)
CARPAL DISLOCATION: PERILUNATE INSTABILITY
Uncommon:
hyperextension HX: Fall. Pain.
• Closed
supination PE: Wrist pain, + Mayfield (4 stages):
injury reduction and
Watson sign.
I: Scapholunate cast simple
Injury XR: AP/lateral: diastasis cases.
determined by 3mm SL gap is
a progression Terry Thomas
II: Perilunate Open
• dislocation reduction, pin
of ligament sign.+/-2
disruption (see Scaphoid ring III: Lunotriquetral fixation, and
joint chart) diastasis primary
sign
ligament
Space of Cinearthrogram: IV: Volar lunate repair usually
Poirer is weak dislocation.
• definitive required.
(Capitate- diagnosis
lunate joint)
COMPLICATIONS: Wrist instability and/or pain; SLAC wrist

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


INCOMPLETE FRACTURE: TORUS GREENSTICK FRACTURE
Common in Hx:
• children Trauma. Torus:
(usually ages Pain, reduction
6-12) inability to Torus(Buckle):concave
rarely
use arm. cortex compresses
Mechanism: needed,
Mechanism: use arm. needed,
(buckles),
• fall on hand PE:+/- splint 2-4
convex/tension side:
most common deformity. weeks
intact
Distal radius Point Greenstick:
• tenderness Greenstick: concave
most common reduce if
swelling. cortex intact,
Increased 10° of
convex/tension side
flexibility of XR: AP fracture/plastic angulation.
pediatric bone and lateral: Long arm
• deformity
allows only one only one cast for 6
cortex to be cortex weeks.
involved involved.

COMPLICATIONS: Deformity; Malunion; Neurovascular injury (rare)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

JOINTS: WRIST

LIGAMENTS ATTACHMENTS COMMENTS


RADIOCARPAL (Ellipsoid type)
Bones: radius, scaphoid, lunate, triquetrum
Capsule Surrounds joint Loose, provides little support
Multiple
Volar radiocarpal Strong; space of Poirier (lunocapitate) is weak.
intracapsular
[VRC] Injury leads to instability.
ligaments
Radioscaphocapitate Radial styloid to Stabilizes radial wrist, distal row, midcarpal
[RCL] capitate joint. Disrupted in perilunate instability stage II.
Radioscapholunate Radial styloid to Stabilizes radial wrist, scapholunate joint;
[RSL] lunate Disrupted in DISI, perilunate instability stage I.

Radiolunotriquetral Radial styloid to Largest, volar sling for lunate, lunotriquetral joint
stabilizer. Disrupted in perilunate instability
[RTL] triquetrum
stage III.
Radius,
Dorsal radiocarpal Weak; stabilizes proximal row, radiolunate joint.
scaphoid, lunate, Disrupted in perilunate instability stage IV.
[DRC]
triquetrum
Radius,
Stabilizes proximal row. Radial artery runs
Radial collateral scaphoid,
adjacent to it.
trapezium, TCL
RADIOULNAR (Pivot type)
Triangular Fibrocartilage Complex (TFCC): Multiple components stabilize joint, absorbs
axial load; any tear or injury results in pain
COMPONENT ORIGIN INSERTION
Dorsal Volar
Ulnar radius Caput ulna
Radioulnar
Triangular Radius/ulna Triquetrum
fibrocartilage (disc)
Meniscus homologue Ulna/disc Triquetrum
Ulnar collateral/ECU Ulna Fifth metacarpal
OTHER LIGAMENTS
Ulnocarpal: Often considered part of TFCC; Stabilizes proximal row of carpus
Ulnolunate Ulna Lunate
Ulnotriquetral Ulna Triquetrum

JOINT
LIGAMENTS ATTACHMENTS COMMENTS
TYPE
INTERCARPAL
Dorsal
stronger
Stabilize
Scapholunate, Stabilize
2 Dorsal SL or LT
lunotriquetral
intercarpal joints
Proximal Scapholunate,
Gliding 2 Palmar DISI: SL
Row lunotriquetral
intercarpal ligament
Scapholunate, injury
2 Interosseous
lunotriquetral.
VISI: LT
ligament
injury

Pisiform Holds it
triquetrum proximally
Capsule Ulna to Holds it
Ulnar collateral pisiform proximally
RCL to Assists
Pisiform Volar
Articulation radiocarpal pisifrom FCU; roof
Pisiform to of Guyon's
Pisohamate canal
hamate
Pisometacarpal Assists
Pisiform to
5 th FCU
metacarpal flexion

All four bones


3 Dorsal in distal row
intercarpal All four bones Thicker
Distal Row Gliding 3 Palmar in distal row than
intercarpal Trapezoid to proximal
2 interosseous capitate to
hamate
MIDCARPAL
1/3 of
wrist
extension,
2/3 of
Palmar (Volar)
intercarpal Proximal wrist
distal carpal flexion
Carpal rows occurs
Ellipsoid
collaterals here
Capitate to
Capitotriquetral triquetrum Radial
(CTL) stronger
than ulnar
Stabilizes
distal row

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OTHER WRIST STRUCTURES

STRUCTURE FUNCTION COMMENT


Forms six fibroosseous dorsal
compartments
Covers dorsum DeQuervain's tenosynovitis can
of the wrist develop here
I: APL, EPB Tendinitis (carpal bossing)
Extensor Retinaculum II: ECRL, ECRB Around Lister's tubercle: tendon
Dorsal III: EPL can rupture
Compartments
IV: EDC, EIP Tenosynovitis, ganglions
V: EDM Jackson-Vaughn syndrome
VI: ECU (rupture from RA)
Tendon can “snap” over ulnar
styloid

Covers volar
wrist Attaches
to:
Medial:
Transverse Carpal pisoform
Ligament (TCL, Flexor Roof of carpal tunnel, floor of Guyon's
hook of canal (ulnar nerve can entrap here)
Retinaculum) hamate
Lateral:
scaphoid
trapezium
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MINOR PROCEDURES

STEPS

WRIST ASPIRATION/INJECTION

1. Ask patient about allergies


Palpate radiocarpal joint dorsally for EPL,ECRB, Lister's tubercle and the space
2.
ulnar to them
3. Prepare skin over dorsal wrist (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
Aspiration: Insert 20 gauge needle into space ulnar to Lister's tubercle/ECRB and
5. radial to EDC, aspirate.
Injection: Insert 22 gauge needle into same space,aspirate to ensure not in vessel,
then inject 1-2ml of local or local/steroid preparation into RC joint.
6. Dress injection site
7. If suspicious for infection, send fluid for Gram stain culture
CARPAL TUNNEL INJECTION/MEDIAN NERVE BLOCK

1. Ask patient about allergies


Ask patient to pinch thumb and small finger tips, Palmaris longus (PL) tendon will
2. protrude (10-20% do not have one) median nerve is directly beneath PL, just ulnar
to FCR
3. Prepare skin over volar wrist (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
Insert 22 gauge or smaller needle into wrist under PL at flexion crease. Aspirate to
5.
ensure needle is not in a vessel. Inject 1-2ml of local or local/steroid preparation.
6. Dress injection site

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY

QUESTION ANSWER CLINICAL APPLICATION


Young Trauma: fractures and dislocations,
1. AGE Middle age- ganglions
elderly Arthritis, nerve entrapments, overuse

Trauma
Acute Arthritis
Chronic Kienbock's disease, ganglion
PAIN
Dorsal Carpal tunnel syndrome (CTS),
2. a. Onset
ganglion (especially radiovolar)
Volar
b. Location Scaphoid fracture, DeQuervain's
Radial
tenosynovitis, arthritis
Ulnar
Triangular Fibrocartilage
Complex(TFCC) tear, tendinitis

with dorsal
pain Kienbock's disease
3. STIFFNESS with volar Carpal tunnel
pain (at syndrome
night)

Joint: after
trauma Fracture or sprain
4. SWELLING Joint: no Arthritides, infection, gout
trauma Flexor or extensor tendinitis (calcific),
Along DeQuervain's disease
tendons
Popping,
5. INSTABILITY Scapholunate dissociation
snapping
6. MASS Along wrist joint Ganglion

7. TRAUMA Fall on hand Fractures: distal radius, scaphoid;


Dislocation: lunate, ulna TFCC tear
Repetitive Carpal Tunnel Syndrome (CTS),
8. ACTIVITY
motion (typing) DeQuervain's tenosynovitis
Nerve entrapment, thoracic outlet
Numbness,
9. NEUROLOGIC syndrome, radiculopathy
tingling
SYMPTOMS Nerve entrapment (median (e.g.
Weakness
CTS), ulnar, or radial)
10. HISTORY OF Multiple joints
Arthritides
ARTHRITIDES involved

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAMINATION TECHNIQUE CLINICAL APPLICATION


INSPECTION
Bones and soft
tissues Fractures, dislocations: forearm and wrist
Gross deformity
Swelling Especially dorsal or Ganglion
radial Trauma, infection
Diffuse
PALPATION

Skin changes Warm, red Infection, gout


Cool, dry Neurovascular compromise
Radial and Ulnar Palpate each Tenderness may indicate fracture
styloids separately
Both proximal and Snuffbox tenderness: scaphoid fracture; lunate
Carpal bones
distal row tenderness: Kienbock's disease.
Scapholunate dissociation
Proximal row
Tenderness: pisotrequetral arthritis or FCU
Pisiform
tendinitis
6 dorsal extensor Tenderness over 1 st compartment:
compartments DeQuervain's disease
Soft tissues TFCC: distal to Tenderness indicates TFCC injury
ulnar styloid Firm/tense compartments: compartment
Compartments syndrome
RANGE OF MOTION
Flex (toward palm), Normal: flexion 80°, extension 75°
Flex and extend
extend opposite

In same plane as
Radial/ulnar
the palm Normal: radial 15-20°, ulnar 30-40°
deviation
Flex elbow 90°: Normal: supinate 90°, pronate 80-90° (only
Pronate and
hold pencil, rotate 10-15° is in the wrist, most motion is in elbow)
supinate
wrist
NEUROVASCULAR
Sensory (LT, PP, 2 pt)
Musculocutaneous Deficit indicates corresponding nerve/root
Lateral forearm
nerve (C6) lesion
Medial Cutaneous
Deficit indicates corresponding nerve/root
nerve of forearm Medial forearm
lesion
(T1)
Motor
Resisted wrist Weakness=ECRL/B or corresponding
Radial Nerve (C6-7)
extension nerve/root lesion
Resisted ulnar Weakness=ECU or corresponding nerve/root
PIN (C6-7)
deviation lesion
Resisted wrist Weakness=FCR or corresponding nerve/root
Ulnar Nerve (C8)
flexion lesion
Resisted wrist Weakness=FCR or corresponding nerve/root
Median Nerve (C7)
flexion lesion
Weakness=Pronator Teres or nerve/root
Median Nerve (C6) Resisted pronation
lesion
Musculocutaneous Resisted supination Weakness=Biceps or corresponding
(C6) nerve/root lesion
Reflex
Hypoactive/absence indicates corresponding
C6 Brachioradialis
radiculopathy

Pulses Radial, Ulnar Diminished/absent = vascular injury or


compromise (perform Allen test)

EXAMINATION TECHNIQUE CLINICAL APPLICATION


SPECIAL TESTS

Maximal flexion of both Reproduction of symptoms


Phalen (numbness or tingling): Carpal
wrists for several minutes
Tunnel Syndrome (CTS)
Tap volar wrist (carpal Pain, numbness suggests Median
Tinel
tunnel/TCL) nerve compression (CTS)
Pain over 1 st compartment (APL,
Make fist with thumb
Finkelstein inside, then ulnar deviation EPB) suggests DeQuervain's
tenosynovitis
Push scaphoid Positive if scaphoid subluxes or
Watson anteroposterior with wrist in reduces: carpal ligament injury
radial or ulnar deviation
Occlude radial ulnar Delay or absent of “pinking up” of
Allen arteries, pump fist then palm suggest arterial compromise
release one artery only of artery released

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: ORIGINS INSERTIONS

PROXIMAL ULNA PROXIMAL RADIUS


ANTERIOR
INSERTIONS INSERTIONS
Brachialis Biceps
Supinator
ORIGINS ORIGINS
Flexor Digitorum Flexor Digitorum
Superficialis [1 head] Superficialis [1 head]
Pronator teres
Flexor Pollicis longus
Supinator
PROXIMAL ULNA PROXIMAL RADIUS
POSTERIOR
INSERTIONS INSERTIONS
Triceps Biceps
Anaconeus Supinator
ORIGINS ORIGINS
Flexor carpi ulnaris NONE

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ANTERIOR COMPARTMENT MUSCLES: SUPERFICIAL FLEXORS

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Medial Pronate
Pronator epicondyle Lateral radius- Median and flex May trap AIN (AIN
Teres [PT] coronoid middle 1/3 syndrome)
forearm
process
Flexor Flex
carpi Medial Base of 2nd 3rd
Median wrist,
Radial artery is
radialis epicondyle metacarpal radial immediately lateral
[FCR] deviation
Flexor
Palmaris Used for tendon
Medial retinaculum
Longus Median Flex wrist transfers. 10%
epicondyle palmar
[PL] congenitally absent
aponeurosis
Flexor Flex
Medial Pisoform, hook
carpi wrist, Most powerful wrist
epicondyle of hamate, 5th Ulnar
ulnaris ulnar flexor
posterior ulna MC
[FCU] deviation
MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT
Flexor 1. Medial Middle Flex PIP Sublimus
digitorum epicondyle, phalanges of
Median (also flex
test will
superficialis coronoid digits (not digit and isolate test
[FDS] process thumb) hand) function
2.
Anteroproximal
radius

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

POSTERIOR COMPARTMENT MUSCLES: SUPERFICIAL EXTENSORS

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Flexor Anterior ulna Distal Flex DIP
digitorum Interosseus phalanx Median/AIN (also flex Avulsion: Jersey
profundus digit and finger.
membrane (IF/MF)
[FDP] hand)

Distal FDP and FPL are


most susceptible to
phalanx Ulnar
Volkmann's
(RF/SF)
contracture.
Flexor Anterior radius Distal
Flex
pollicis coronoid phalanx of Median/AIN thumb (IP)
longus [FPL] process thumb
Pronator
Medial distal Anterior Pronate Primary pronator
quadratus
ulna distal radius Median/AIN forearm (initiates pronation)
[PQ]

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ANTERIOR COMPARTMENT MUSCLES: DEEP FLEXORS

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Posterior- Posterior-poximal Forearm Must retract on
Anaconeus lateral ulna Radial extension Kocher
epicondyle approach
Mobile Wad(3)
Lateral
Is a deforming
Brachioradialis supra- Lateral distal
Radial Forearm force in radius
[BR] condylar radius flexion
fractures.
humerus

Extensor carpi Lateral


radialis longus supra- Radial Wrist
Used for tendon
Base of 2nd MC
condylar extension transfer
[ECRL]
humerus
Inflamed in
Extensor carpi
radialis brevis Lateral Radial Wrist
Tennis elbow,
Base of 3rd MC
[ECRB] epicondyle extension can compress
PIN
Sagittal bands, Distal avulsion
Extensor Lateral Radial- Digit
digitorum [ED] epicondyle central slip, distal PIN extension is mallet finger
phalanx injury
Sagittal bands,
Extensor digiti Lateral Radial- SF In 5th dorsal
central slip, distal
minimi [EDM] epicondyle PIN extension compartment.
phalanx of SF
Hand
Must retract on
Extensor carpi Lateral Radial- extension Kocher
Base of 5th MC
ulnaris [ECU] epicondyle PIN and
approach
approach
adduction

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

POSTERIOR COMPARTMENT MUSCLES: DEEP EXTENSORS

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Posterior Radial- Forearm Can compress
Supinator medial Proximal lateral radius PIN supination PIN
ulna

Abductor Abduct and 1st


pollicis Posterior Base of 1st MC Radial- extend compartment:
longus [APL] radius/ulna
PIN thumb DeQuervain
(CMC) Disease

Extensor Extend Same as


Posterior Base of proximal Radial- thumb above, radial
pollicis
brevis [EPB] radius
phalanx of thumb PIN border of
(MCP)
snuffbox
Extensor Tendon turns
Posterior Base of thumb distal Radial- Extend
pollicis 45° on Lister's
ulna phalanx PIN thumb (IP)
longus [EPL] tubercle
Border of
snuffbox
Extensor Sagittal bands, central
indicis Posterior Radial- Index finger Used in tendon
slip, distal phalanx of
proprius ulna PIN extension transfer
index finger
[EIP]

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: CROSS SECTIONS

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

INFRACLAVICULAR

LATERAL CORD

Musculocutaneous (C5-7): only sensory in the forearm

Sensory: Lateral forearm [via Lateral cutaneous nerve of forearm]


Motor: NONE (in forearm)

MEDIAL CORD

Medial Cutaneous Nerve of Forearm (Antibrachial) (C8-T1): runs with basilic vein

Medial
Sensory: forearm
anterior
arm
Motor: NONE

Ulnar (C(7)8-T1): runs behind medial epicondyle in


groove and between 2 heads of ECU [*] , then under
FCU [*] , then to Guyon's canal [*] .
Sensory: NONE (in forearm)
Motor: Flexor carpi ulnaris
Flexor digitorum profundus [digits 4, 5]

MEDIAL AND LATERAL CORDS

Median(C(5)6-T1): runs between 2 heads of


PT [*] , through ligament of Struthers [*] and lacertus
fibrosus [*] , under FDS [*] into carpal tunnel [*]
(Martin Gruber formation: ulnar motor branches
run with median nerve then branch to ulnar nerve
distally). In wrist, median divides to Motor branch
and palmar cutaneous (runs between FCR/PL): at
risk in CTS release

3.
Sensory: NONE (in forearm)
ANTERIOR COMPARTMENT
OF FOREARM Superficial
Flexors Pronator Teres
[PT]Flexor Carpi Radialis
4. Motor:
[FCR]Palmaris longus
[PL]Flexor digitorum
superficialis[FDS][sometimes
considered a “middle” flexor]
Deep Flexors Anterior
Interosseous N. (AIN) AIN
compressed by PT in
forearm, injuredin
supracondylar fractures
Flexor digitorum profundus
[digits 2, 3]
Flexor pollicis longus [FPL]
Pronator Quadratus [PQ]
* Potential nerve compression site
1.

2.

INFRACLAVICULAR

POSTERIOR CORD

Radial (C5-T1): Divides into 2 branches:


superficial radial (sensory) and 2. deep (motor)-which then
pierces supinator and becomes PIN)

Posterior forearm: via Posterior


Sensory:
CutaneousNerve of forearm
MOBILE WAD(3): Radial Nerve (deep
Motor: branch): runs around radius into posterior
compartment, through radial
tunnel [*] becomes PIN
Superficial Extensors Brachioradialis
[BR]Extensor carpi radialis longus
5. [ECRL]Extensor carpi radialis brevis [ECRB]
1.
POSTERIOR COMPARTMENT: PIN-
PosteriorInterosseous Nerve Multiple sites
ofcompression: 1. fibrous tissue of
radialhead, 2. leash of Henry, 3. Arcade
ofFrohse, 4. distal supinator, 5. ECRB
Superficial Extensors Extensor carpi ulnaris
[ECU]Extensor digiti minimi [EDM]Extensor
digitorum communis [EDC]
Deep Extensors SupinatorAbductor pollicis
longusExtensor pollicis longusExtensor
pollicis brevisExtensor indicis proprius
* Potential nerve compression site
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

ARTERY COURSE BRANCHES


over PronatorTeres, Radial recurrent muscularbranches (leash of Henry)
Radial
underBrachioradialis.
Anterior ulnar recurrentPosterior ulnar recurrentCommon
Ulnar on FDP, underFDS interosseousAnterior interosseousPosterior
interosseousRecurrent interosseousMuscular branches
See Arm chapter for arterial anastomosis around the elbow

ARTERY COURSE BRANCHES COMMENT


3
Is in anatomic snuffboxDeep
branchesPalmar
Volar: to flexor tendonsDeep to
carpal
lateral to extensor
FCRDorsal: branchDorsal tendonsAnastomoses with
Radial carpal
between ulnar artery completes
EPL branchSuperficial superficial palmar
APL/EPB palmar archTerminal branch of radial
branchDeep
artery
palmar arch
4
branchesPalmar Deep to FDSDeep to
on the TCL, carpal extensor
Ulnar lateral to branchDorsal tendonsAnastomoses with
pisoform. carpal radial artery completes
branchDeep deeppalmar arch
palmar branch
Superficial Terminal branch of ulnar
palmar arch artery
Allen test
Occlude
both
1. radial
and ulnar
arteries
at wrist
Patient
should
2. squeeze Hand perfusion (“pinking up”)
fist after release indicates patent
several arches collateral circulation.
times
Release
pressure
3.
on one
artery
Repeat
4. releasing
other
artery

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS: ARTHRITIS INSTABILITY

DESCRIPTION HP WORK-UP/FINDING TREATMENT


ARTHRITIS
OSTEOARTHRITIS/DEGENERATIVE JOINT DISEASE
“Wear tear”:
• articular cartilage Hx: Older, NSAID,
loss women, pain 1. splint, steroid
(worse with XR: OA findings: injection
1° or 2° (e.g.
• activity) spurs, joint
trauma.) Arthrodesis
PE: Swelling, space loss, sclerosis 2.
Seen in SLAC decreased (pain relief)

wrist ROM
DEQUERVAIN'S DISEASE

Hx: Often Splint,


Stenosing
history of tennis 1. NSAID,
tenosynovitis of XR: Possible
• 1st dorsal or golf. Pain, calcified tendons injection
swelling.
compartment Lab: Uric acid (rule Surgical
PE: 2.
(APL/EPB) out gout) release
1Finkelstein
test
RHEUMATOID ARTHRITIS
Medical
Systemic 1. management,
inflammatory splint joints
Hx: Pain,
• disorder affecting stiffness (worse Synovectomy
synovium, XR: Hand series: 2.
In AM) (single joint)
destroys joint joint destruction
PE: Swelling Tendon
erosion
Wrist common throughout joint. 3. transfer or
• Labs: RF, ANA,
site Decreased repair
WBC, ESR, uric acid
Associated with ROM, ulnar drift
• at MCPs. Arthrodesis
tenosynovitis CTS 4. or
arthroplasty
INSTABILITY
SLAC: SCAPHOLUNATE ADVANCED COLLAPSE
Degenerative Scaphoid
arthritis Hx/PE: XR: excision,
secondary to Chronic 1.
Radioscaphoid capitolunate
instability (SL pain, fusion
• OA: (CL joint
ligament remote
also involved, Proximal row
disruption or history of
RL joint spared) 2. carpectomy
scaphoid trauma.
fracture/injury) or fusion

SCAPHOLUNATE DISSOCIATION: (static/dynamic)


SL/RCL ligament
Hx: Fall
disrupted: lunate
(extension
displaced dorsally Early: closed
supination XR: SL space
• [DISI: Dorsal reduction, splint/cast.
wrist .3mm 5 “Terry
Intercalated injury). Repair ligament if full
Segment Thomas” sign.
Pain in tear
Instability] Closed fist:
wrist. Late: STT fusion,
increases SL
LT ligament carpectomy, or wrist
PE: gap
disrupted: lunate fusion.
• 1Watson's
displaced volarly test
[VISI:Volar ISI]

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS: NERVE COMPRESSION

WORK-
DESCRIPTION HP TREATMENT
UP/FINDING
AIN (Anterior Interosseous Nerve) SYNDROME
• AIN trapped under:
1. PT XR: Rule out
1. Conservative
Hx: No sensory findings other
2. FDS treatment
pathology
3. FCR
PE: decreased thumb
2. Surgical release
flexion, no “OK” sign (+
if does not resolve
Kiloh-Nevinsign)
CARPAL TUNNEL SYNDROME (CTS)
Hx: Repetitive motion, XR: Rule out 1. Activity
• Median nerve trapped in
carpal tunnel night pain, parathesias, other modification
clumbsy pathology
PE: Weak thenar EMG/NCS: 2. Cock-up splint,
• Most common nerve
entrapment muscles, + Tinel Phalen Localize the NSAID, steroid
tests lesion injection
• Associated with metabolic 3. Carpal tunnel
disease (DM, EtOH, release [avoid
pregnancy, thyroid disease) palmar branch]
PIN SYNDROME (Saturday Night Palsy)
• PIN trapped by:
1. Supinator (proximal
border most common)
XR: Rule out 1. Observe. It may
2. Arcade of Frohse Hx: +/- pain other
resolve
3. Leash of Henry pathology
4. Fibrous bands 5.
ECRB
PE: No sensory
EMG/NCS: 2. Surgical
findings. Wrist drop,
findings. Wrist drop,
Localize the decompression if
decreased wrist digit
lesion symptoms persist
extension
PRONATOR SYNDROME
• Median nerve trapped by:1. XR: Rule out
Hx: Forearm pain, 1. NSAID, rest,
PT, 2. Ligament of Struther, other
increases with activity splint
3. Lacertus fibrosus, 4. FDS pathology
EMG/NCS:
PE: Thenar weakness, 2. Surgical release
Localize the
Tinel Phalen tests after 3-4 months
lesion
RADIAL TUNNEL SYNDROME
XR: Rule out
• Radial nerve trapped in Hx: Pain in lateral 1. Rule out lateral
other
radial tunnel (1 of 4 places) forearm epicondylitis
pathology
2. Activity
PE: No motor/sensory
modification,
findings
splinting
3. Surgical
exploration/release
ULNAR TUNNEL SYNDROME
1. Activity
• Ulnar nerve trapped in Hx: Pain, numbness, XR: not
modification, rest,
Guyon's canal intrinsic weakness indicated
immobilize
EMG/NCS:
PE: +Tinel of ulnar 2. Surgical
• Can be trauma related nerve at wrist will localize decompression
lesion

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OTHER DISORDERS

WORK-
DESCRIPTION HP TREATMENT
UP/FINDING
GANGLION
Hx/PE: Round, large XR: Wrist series,
• Cyst with or small no radiographic 1. Asymptomatic:
mucinous/joint fluid transilluminating evidence of reassurance
mass, +/-pain ganglion
2. Symptomatic:
• Communicates aspirate or surgically
with joint excise (with stalk or it will
recur)
• Most common
mass in wrist1.
Dorsal (SL)2. Volar
(ST)
KIENBÖCK'S DISEASE
• Osteonecrosis of Hx: Pain, swelling, XR: Opacity of
I. NSAID, splinting
lunate stiffness lunate
Bone scan/MRI:
• Wrist trauma or PE: Grip strength II/III. Joint leveling
will confirm
short ulna may be reduced. procedure/carpal fusion
diagnosis
• 4 stages: based IV. Proximal row
on collapse carpectomy or fusion
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SURGICAL APPROACHES

INTERNERVOUS
USES DANGERS COMMENT
PLANE
FOREARM: ANTERIOR APPROACH (HENRY)
Distal1. 1. Radial recurrent artery
1. ORIF Brachioradialis 1. PIN (Leash of Henry) vein need
fractures [Radial]2. FCR
ligation.
[Median]
Proximal1. 2. If not ligated, hemorrhage
Brachioradialis 2. Superficial could result in Compartment
2. Osteotomy
[Radial]2. Pronator radial nerve syndrome and/or Volkmann's
Teres [Median] contracture
3. Biopsy bone
3. Radial artery
tumors
WRIST: DORSAL APPROACH
1. Incise to the extensor
1. 3rd dorsal
Radial nerve retinaculum. This leaves
1. Fusion compartment
(Superficial) cutaneous nerves intact in the
[EPL]
subcutaneous fat.
2. 4th dorsal
2. Neuroma can develop from
2. Stabilization compartment
cutting cutaneous nerves.
[EDC, EIP]
3. ORIF
fractures
4. Carpectomy
WRIST: VOLAR APPROACH
1. Median nerve•
1. Carpal tunnel No planes Palmar cutaneous 1. Retract PL/FPL radially
No planes
decompression branch• Recurrent Retract FDS/FDP ulnarly
motor
2. ORIF volar 2. Dissect TCL carefully to
2. Palmar arch
fracture avoid nerve damage.
3. Dislocated
lunate
4. Tendon
laceration
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CHAPTER 5 - HAND
TOPOGRAPHIC ANATOMY
OSTEOLOGY OF THE HAND
TRAUMA
JOINTS
OTHER STRUCTURES: FLEXOR TENDON SHEATH AND PULLEYS
OTHER STRUCTURES: HAND SPACES
OTHER STRUCTURES: FINGER
FLEXOR TENDON INJURY ZONES
MINOR PROCEDURES
HISTORY
PHYSICAL EXAM
MUSCLES
INTRINSIC MUSCLES
NERVES
ARTERIES
DISORDERS: ARTHRITIS
DISORDERS: LIGAMENT INJURIES
DISORDERS: INFECTIONS
DISORDERS: MASSES & TUMORS
SURGICAL APPROACHES
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 5 – HAND
TOPOGRAPHIC ANATOMY

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY OF THE HAND

CHARACTERISTICS OSSIFY FUSE COMMENT


METACARPALS
• Triangular in cross section: 9
Primary: 18 • Named I-V (thumb to small
gives 2 volar muscular wks yrs
Body finger)
attachment sites (fetal)
• Only one epiphysis per bone
• Thumb MC has saddle shaped
Epiphysis 2 yrs in the head. In thumb MC it is
base: increases it mobility
in the base.
PHALANGES
8 14- • 3 phalanges in each digit
Primary:
• Palmar surface is almost flat wks 18
Body except thumb
(fetal) years
• Tubercles and ridges are sites Epiphysis 2-3 yr • Only one epiphysis per bone
for attachment. in base.
Nomenclature for digits: thumb, index finger, middle finger, ring finger, small finger

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


METACARPAL FRACTURES
• Common in
adults
HX: Trauma. Nondisplaced:
• 5 th MC most Swelling, ulnar gutter
common pain, splint 4
(Boxer's deformity. By location: weeks, then
fracture at ROM.
neck) PE: • Head
Swelling, Severely
• 1 st MC • Neck (most common)
tenderness, Angulated or
base. Bennett +/- rotational • Shaft (transverse, shortened:
Rolando deformity, spiral, Oblique) percutaneous
fracture: shortening. • Base (Bennett, pins or ORIF
displaced, Decreased Rolando, “Baby Bennett Displaced or
intraarticular. ROM. ”-base of 5 th MC) intraarticular:
• 4 th 5 th MC XR: PA, reduce then
tolerate lateral, pin. Unstable:
angulation; oblique ORIF
2 nd 3 rd do
not
COMPLICATIONS: Rotational deformity grip abnormalities (malunion)
PHALANGEAL FRACTURES
Descriptive/location: Extraarticular
• Intra vs extraarticular Undisplaced:
buddy tape
HX: Trauma. •Displaced/undisplaced
and/or splint
• Childrenadults Swelling, pain, • Open/closed
Displaced:
deformity. • Transverse/oblique reduce, splint
• Base, shaft, neck, Unstable: pin
condyle or ORIF
PE: Swelling,
• Distal phalanx tenderness, +/-
rotational
most common
deformity,
(MF) shortening.
Decreased
• Early ROM ROM, 2 pt
important for good discrimination,
results capillary refill.
• Articular surfaces
do not Tolerate
incongruity. Close Splint must have
follow up is XR: AP, lateral,
MCP in flexion, IPs
critical for blique extended
intraarticular
fractures
Intraarticular: ORIF
Repair nail bed if
needed
COMPLICATIONS: Rotational deformity (malunion); Decreased motion; Degenerative
Joint Disease (DJD)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

JOINTS

JOINT TYPE LIGAMENTS ATTACHMENTS COMMENTS


CARPOMETACARPAL
Highly mobile; common site
Thumb Saddle Capsule
for arthritis
Dorsal, palmar, Trapezium to
radial CMC metacarpals
Finger Gliding Capsule
Dorsal palmar Carpal to
Dorsal strongest
CMC metacarpal bones
Interosseous CMC
METACARPOPHALANGEAL
Metacarpal to
Ellipsoid Capsule
proximal phalanx
2 collateral (radial Metacarpal to Loose in extension, tight
and ulnar) proximal phalanx in flexion
Cast in flexion or
ligaments will shorten
Thumb ulnar collateral:
• stabilizes pinch
• injury is
Gamekeeper's
Palmar [volar Metacarpal to
plate] proximal phalanx
Deep transverse
metacarpal
INTERPHALANGEAL
Hinge Capsule
2 collateral Adjacent phalanges Obliquely oriented
Palmar [volar
Adjacent phalanges Prevents hyperextension
Adjacent phalanges Prevents hyperextension
plate]

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OTHER STRUCTURES: FLEXOR TENDON SHEATH AND PULLEYS

STRUCTURE CHARACTERISTICS COMMENT


Pulleys (5 annular, 3 cruciate) are thickenings of
Flexor tendon Fibroosseous tunnel, sheath. A2, A4 most important mechanically .
sheath lined with A1, 3, 5 cover joints; A1 common cause of
tenosynovium
triggering.
Protect, lubricate,
nourish tendons
In sheath: vinculae
are vascular supply to
tendons
Site of potential infection: Kanavel signs often
present (see Disorders)
Intrinsic
Sagittal bands EDC attaches extends MCP
Apparatus

Central Slip EDC attaches extends PIP: injury can result in


Boutonniere deformity
Lateral bands Lumbricals attach extend PIP
Volar plate
FDS attaches flexes PIP
(transverse fibers)
Oblique retinacular
Interossei attach flex MCP
ligaments
EDC attaches extends DIP
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OTHER STRUCTURES: HAND SPACES

STRUCTURE CHARACTERISTICS COMMENT


HAND SPACES

Thenar Between flexor tendon and Adductor Potential space: site of possible
pollicis infection
Between flexor sheath and Potential space: site of possible
Mid-palmar
metacarpal infection
Radial bursa Proximal extension of FPL sheath Infection can track proximally
Communicates with SF, FDS, FDP Flexor sheath infection can track
Ulnar bursa
flexor tendon sheath proximally into bursa

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OTHER STRUCTURES: FINGER

STRUCTURE CHARACTERISTICS COMMENT


FINGERTIP
If completely avulsed, replace to keep eponychium
Nail Cornified epithelium
and matrix separated until nail can grow back.
Nail Germinal: to lunula, Where nail grows (1mm a week), must be intact
bed/Matrix under eponychium (repaired) for nail growth
Sterile: distal to lunula If injured, does not need repair to function

Pulp Multiple septae, Felon is an infection of the pulp


nerves, arteries

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

FLEXOR TENDON INJURY ZONES

ZONE BOUNDARIES COMMENT

I FDS insertion Injuries amenable to repair (e.g. Jersey finger)


to distal tip
Midpalm Called “No man's land” because high rate of complications.
fibroosseous Careful PE is required for diagnosis, the injury may not be at
II
tunnel to FDS skin laceration site . FDS FDP may both require repair. A2, A4
insertion must be preserved.
Repair in zones 3-5 should be immediate
Transverse
Carpal
Injuries often associated with Median nerve or arterial arch
III ligament to
injuries. Explore and repair all.
fibro-osseous
tunnel
Transverse
Uncommon site of injury. Repair usually requires carpal tunnel
IV carpal ligament release and repair. Median nerve at risk.
(carpal tunnel)
Proximal to the Injuries require end-to-end repair
V
TCL
Thumb Thumb IP to
Similar to finger
I distal tip
Thumb Thumb CMC to Similar to finger
II IP
Thumb Thenar
Repair may require lengthening or graft procedure
III eminence
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MINOR PROCEDURES

STEPS

INJECTION OF THUMB CMC JOINT

1. Ask patient about allergies


2. Palpate thumb CMC joint on volar radial aspect
3. Prepare skin over CMC joint (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
Palpate base of thumb MC, pull axial distraction on thumb with slight flexion to open
joint. Use 22 gauge or smaller needle, and insert into joint. Aspirate to ensure
5. needle is not in a vessel. Inject 2-3ml of 1:1 local (without
epinephrine)/corticosterioid preparation into CMC joint. (The fluid should flow
easily if needle is in joint)
6. Dress injection site
FLEXOR TENDON SHEATH BLOCK

1. Ask patient about allergies


2. Palpate the flexor tendon at the distal palmar crease.
3. Prepare skin over palm (iodine/antiseptic soap)
Insert 22 gauge needle into flexor tendon at the level of the distal palmar crease.
4. Withdraw needle so it is just outside tendon, but inside sheath. Inject 2-5ml of local
anesthetic without epinephrine.
5. Dress injection site
DIGITAL BLOCK

1. Prepare skin over dorsal proximal finger web space (iodine/antiseptic soap)
Insert 22 gauge needle between metacarpal heads on both sides of finger.
Aspirate to ensure needle is not in a vessel. Inject 2- 5ml of local anesthetic
2.
without epinephrine. The dorsum of the proximal digit may also require
anesthesia for adequate anesthesia.
Care should be taken not to inject too much fluid into the closed space of the
3.
proximal digit
4. Dress injection site

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY

QUESTION ANSWER CLINICAL APPLICATION


1. HAND
Right or left Dominant hand injured more often
DOMINANCE
2. AGE Young Trauma, infection
Middle age, elderly Arthritis, nerve entrapments
3. PAIN
a. Onset Acute Trauma, infection
Chronic Arthritis
b. Location CMC (thumb) Arthritis (OA) especially in women
Volar (fingers) Purulent tenosynovitis (1 Kanavel signs)
In AM, with
4. STIFFNESS Trigger finger, rheumatoid arthritis
“catching”
Infection (e.g. purulent tenosynovitis, felon,
5. SWELLING After trauma
paronychia)
No trauma Arthritides, gout, tendinitis
Ganglion, Dupuytren's contracture, giant cell
6. MASS
tumor
Fall, sports injury in
7. TRAUMA Fracture, tendon avulsion
dirty environment
Infection
Trauma (e.g. fracture, dislocation, tendon
8. ACTIVITY Sports, mechanic
rupture)
9. NEUROLOGIC Pain, numbness, Nerve entrapment (e.g. carpal tunnel), thoracic
SYMPTOMS tingling outlet syndrome, radiculopathy
Nerve entrapment (usually in wrist or more
Weakness
Weakness
proximal)
10. HISTORY OF Multiple joints
Rheumatoid arthritis, Reiter syndrome, etc.
ARTHRITIDES involved

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAMINATION TECHNIQUE CLINICAL APPLICATION


INSPECTION
Ulnar drift or swan
Gross deformity Rheumatoid arthritis
neck
Rotational or angular
Fracture
deformity
Finger position Flexion Dupuytren contracture, purulent tenosynovitis
Skin, hair, nail Cool, hairless, spoon Neurovascular disorders: Raynaud's, diabetes, nerve
changes nails, etc. injury
Nodes from osteoarthritis: Heberden's (at DIPs:
Swelling DIPs
#1), Bouchard's (at PIPs)
PIPs
MCP's Rheumatoid arthritis
Fusiform shape
Purulent tenosynovitis
finger

Muscle wasting Thenar eminence Median nerve injury, CTS, C8/T1 pathology, CMC
arthritis
Hypothenar eminence
Ulnar nerve injury
or intrinsics
EXAMINATION TECHNIQUE CLINICAL APPLICATION
PALPATION
Skin Warm, red Infection
Cool, dry Neurovascular compromise
Metacarpals Each along its length Tenderness may indicate fracture
Phalanges Each separately Tenderness: fracture, arthritis; Swelling: arthritis
finger joints
Thenar hypothenar Wasting indicates median ulnar nerve injury
Soft tissues
eminences respectively
Nodules: Dupuytren's contracture; Snapping
Palm (palmar fascia)
with finger extension: Trigger finger
Flexor tendons: along
Tenderness suggests purulent tenosynovitis
volar finger
Sides of finger Giant cell tumors
All aspects of finger tip Tenderness: paronychia or felon
RANGE OF MOTION
Finger: MCP Flex 90°, extend 0°, Decreased flexion if casted in extension
joint Add/abd 0-20° (collateral ligaments shorten)
PIP joint Flex 110°, extend 0° Hyperextension leads to swan-neck deformity
All fingers should point to scaphoid at full
DIP joint Flex 80°, extend 10°
flexion
Thumb: CMC Radial abduction: Flex
Motion is in plane of palm
joint 50°, extend 50°
Palmar abduction:
Motion is perpendicular to plane of the palm
Abduct 70°, adduct 0°
In plane of palm: Flex
MCP joint
50°, extend 0°
In plane of palm: Flex
IP joint
90°, extend 10°

Opposition Touch thumb to small Motion is mostly at CMC joint


fingertip
EXAMINATION TECHNIQUE CLINICAL APPLICATION
NEUROVASCULAR
Light touch pinprick,
Sensory
2 point
Radial Nerve Dorsal thumb web Deficit indicates corresponding
(C6) space nerve/root lesion
Median Nerve Radial border middle Deficit indicates corresponding
(C6-7) finger nerve/root lesion
Ulnar Nerve Ulnar border small Deficit indicates corresponding
(C8) finger nerve/root lesion
Number in parenthesis indicates
Motor
compartment
Radial Weakness 5 EDC(4), EIP(4), EDM(5)
Finger extension
nerve/PIN (C7) or nerve lesion
Thumb abduction Weakness 5 APL(1) / EPL(3) or
extension nerve/root lesion
Median PIP flexion Weakness 5 FDS or corresponding
nerve/AIN (C8) nerve/root lesion

DIP flexion Weakness 5 FDP (1/2 of muscle) or


nerve lesion

Thumb IP flexion Weakness 5 FPL or corresponding


nerve/root lesion
Motor Recurrent “OK” sign Weakness 5 APB, OP, 1/2 FPB or
Branch nerve lesion; (CTS)
MCP flexion Weakness 5 IF, MF lumbricals or c
(index/middle nerve/root lesion
fingers)
Ulnar nerve Finger cross Weakness 5 Dorsal/Volar
(Deep branch)
(abduct/adduct) interosseous or nerve lesion
(T1)
Small finger Weakness 5 FDM, ODM, ADM or
abduction nerve/root lesion
MCP flexion Weakness 5 RF, SF lumbricals or
(ring/small fingers) nerve/root lesion
Reflex: Tap a finger distal Only pathologic (1 if different phalanx
Hoffmann phalanx flexes): UMN syndrome
Tests ulnar and radial artery patency
Pulses/capillary
Allen's test
refill
Doppler: arches,
digital pulses
SPECIAL TESTS
Stabilize PIP in
Stabilize PIP in
Inability to flex DIP alone indicates
Profundus extension, flex DIP FDP pathology
only
Extend all fingers, Inability to flex PIP of isolated finger
Sublimis flex a single finger at indicates FDS pathology
PIP
Hold paper with Thumb PIP flexion is positive, suggest
Froment's sign thumb index finger, Adductor Pollicis or Ulnar nerve palsy
pull paper
Axial compress Pain indicates arthritis at CMC and/or
CMC grind
rotate CMC joint MCP joints of thumb
Stabilize proximal
Laxity indicates collateral ligament
Finger instability joint, apply varus
damage
valgus stress
Laxity indicates ulnar collateral
Thumb Stabilize MCP, apply
ligament strain (Gamekeeper's
instability valgus stress
thumb)

Make fist, observe If 3 rd MC (normally elevated) is flat


Murphy sign height of MCP's with 2 nd 4 th MC, suggests lunate
dislocation
Tight or inability to flex PIP, improved
Extend MCP,
Bunnel-Littler with MCP flexion indicates tight
passively flex PIP
intrinsic muscles

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


THENAR COMPARTMENT
Abductor Lateral proximal Palpable in
Scaphoid, Thumb
pollicis brevis phalanx of Median abduction lateral thenar
trapezium
[APB] thumb eminence
Base of
Palpable in
Flexor pollicis proximal
Trapezium Median Thumb medial thenar
brevis [FPB] phalanx of MCP flexion eminence
thumb
Oppose Opposition is
Opponens Lateral thumb
Median thumb,
most
Trapezium
pollicis MC rotate important
medially action
ADDUCTOR COMPARTMENT
Base of Radial artery
Adductor 1. Capitate, proximal Ulnar Thumb between its
pollicis 2 nd 3rd MC phalanx of adduction
two heads
thumb
2. 3 rd
Metacarpal
HYPOTHENAR COMPARTMENT

Palmaris brevis Transverse Skin on medial Wrinkles Protects ulnar


carpal ligament palm Ulnar
[PB] skin nerve
[TCL]
Base of
Abductor digiti SF Palpable
Pisiform proximal Ulnar
minimi [ADM] abduction laterally
phalanx of SF
Flexor digiti Base of
SF MCP Palpable
minimi brevis Hamate, TCL proximal Ulnar
flexion medially
[FDMB] phalanx of SF
Oppose SF, Deep to other
Oppose SF, Deep to other
Opponens digiti Medial side 5 th
minimi [ODM] Hamate, TCL MC Ulnar rotate muscles in the
laterally group

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Copyright © 2001 Saunders, An Imprint of Elsevier

INTRINSIC MUSCLES

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


INTRINSICS

Lumbricals 1 FDP
Extend Only muscles in body
tendons Lateral bands Median PIP, flex to insert on their own
2
(lateral 2) MCP antagonist.

Lumbricals 3 FDP
Extend
tendons Lateral bands Ulnar PIP, flex
4
(medial 3) MCP
Proximal phalanx
Interosseous: Adjacent Digit
Dorsal [DIO] metacarpals extensor
Ulnar
abduction DAB: Dorsal ABduct
expansion
Proximal phalanx
Interosseous: Adjacent Digit PAD: Palmar Adduct
metacarpals extensor
Ulnar
Volar [VIO] adduction (volar 5 palmar)
expansion

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Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

INFRACLAVICULAR
MEDIAL CORD
1. Ulnar (C(7)8-T1): through Guyon's canal, past hook of hamate
Sensory: Medial palm 1 1/2 digits via: palmar, palmar digital branches
Medial dorsal hand 1 1/2 digits via: dorsal, dorsal digital, proper digital
branches
Nerve divides at hypothenar eminence
Motor: Superficial Branch @[lateral to pisiform]
Palmaris brevis
Deep (Motor) Branch [around hook of hamate]
Adductor pollicis
THENAR MUSCLES
Flexor pollicis brevis [FPB] [with median]
HYPOTHENAR MUSCLES
Abductor digiti minimi [ADM]
Flexor digiti minimi brevis[FDMB]
Opponens digiti minimi [ODM]
INTRINSIC MUSCLES
Dorsal interossei [DIO] [abduct DAB]
Volar interossei [VIO] [adduct PAD]
Lumbricals [medial two (3,4)]
INFRACLAVICULAR
MEDIAL AND LATERAL CORDS
2. Median (C(5)6-T1): runs through carpal tunnel, then cutaneous branches off at
(risk in Carpal Tunnel release)
Sensory: Palmar Cutaneous Branch
Dorsal distal phalanges of 3 1/2 digits: via proper palmar digital
branches
Volar wrist capsule
Volar 3 1/2 digits and lateral palm: via palmar palmar digital branches
(multiple variations of thumb sensory innervation)
Motor Recurrent (Thenar motor) Branch: Usually branches off
Motor:
median before carpal tunnel
THENAR
Abductor pollicis brevis [APB]
Opponens pollicis
Flexor pollicis brevis [FPB]
l(Joint innervation with ulnar nerve)/l
INTRINSIC
Lumbricals [lateral two (1,2)]
POSTERIOR CORD
3. Radial
(C5-T1):

Sensory: Dorsal 3 1/2 digits and hand: via superficial branch (dorsal digit
branches)
Dorsal wrist capsule
Motor: NONE (in hand)

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Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

COURSE BRANCHES COMMENT


DEEP PALMAR ARCH
Through heads of the adductor Terminal branch of radial artery deep branch of the ulnar
pollicis artery
Princeps pollicis
Radialis indicis Under FPL, along 1 st
Proper digital artery of metacarpal
thumb
May come from deep arch

Palmar metacarpal (3) Joins common digital artery


SUPERFICIALS PALMAR ARCH
Terminal branch of ulnar artery superficial branch of the
Just deep to aponeurosis.
radial artery
Common palmar digital (3) Bifurcates
Proper palmar digital Along sides of fingers
Proper palmar digital Of small finger only

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Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS: ARTHRITIS

HISTORY/PHYSICAL WORK-
DESCRIPTION TREATMENT
EXAM UP/FINDINGS
ARTHRITIS: OSTEOARTHRITIS/DEGENERATIVE JOINT DISEASE (DJD)
XR: OA
• Wear and tear Hx: Older, women, findings:osteophytes, 1. NSAID, splint,
pain worsewith joint spaceloss,
arthritis steroid injection
activity sclerosis,subchondral
cysts
PE: + IP (DIP and/or
• Loss of articular 2. DIP: arthrodesis,
PIP)nodes, + CMC
cartilage CMC/PIP: arthroplasty
grind test
• DIP #1
[Heberden's nodes]
CMC, IP #2
[Bouchard's nodes]
ARTHRITIS: RHEUMATOID
• Systemic I. Medical management
inflammatorydisease Hx: Painful, stiff XR: Hand series: joint
affecting (worse in AM) destruction
synovium:destroys splinting
joints. MCP #1
PE: Multiple joint
swelling. deformities: Labs: RF, ANA, II. Synovectomy (single
• Has 4 stages
ulnar drift (MCP)swan WBC, ESR, uric acid joint)
neck, boutonniere
• Associated with III/IV. Tendon transfer
tenosynovitis,Carpal orrepair,
Tunnel Syndrome arthrodesis,arthroplasty
FLEXOR TENOSYNOVITIS: TRIGGER FINGER/THUMB
• Nodule on tendon
Hx: Age: 401, tender 1. Steroid injection (+/-
Hx: Age: 401, tender 1. Steroid injection (+/-
catcheson pulley (A1 XR: None needed
nodule splint)
most common)
• Also seen in PE: Pain. Locking 2. A1 release [must
Diabetes Mellitus with flexion extension spare A2]

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Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS: LIGAMENT INJURIES

HISTORY/PHYSICAL WORK-
DESCRIPTION TREATMENT
EXAM UP/FINDINGS
CENTRAL SLIP INJURY: BOUTONNIERE DEFORMITY
• Extensor tendon (central slip) 1. Splint PIP in
XR: Hand
at PIP ruptures, lateral bands Hx: Hand trauma
series: normal extension, DIP
slip volar and flex PIP. free
PE: PIP flexed, no 2. Reconstruct
active extension, DIP central slip and
extended bands
3. Severe: fusion
• Associated with RA
or arthroplasty
FLEXOR TENDON INJURY: JERSEY FINGER
XR: Rule out
• Flexor tendon avulses from Hx: Extension injury, fracture (1/2
1. Primary repair
forceful extension 1/2 pain. avulsion
fracture)
PE: FDS: 1
sublimus test 2. Older patient:
• In football; RF#1; FDPFDS
FDP: 1 DIP fusion
profundus test
MALLET FINGER
XR: 1/2 1. CONSTANT
• Extensor tendon rupture
Hx: Minor trauma avulsion splint (DIP only)
atdistal phalanx
fracture for 8 weeks
PE: Cannot extend
DIP, minimal pain
swelling
2. Repair if large
• FDP unopposed so DIP
. bony avulsion
flexes
fracture
SWAN NECK DEFORMITY

• FDS rupture/volar plate injury Hx: Trauma, RA, XR: Hand 1. Early: splint
spastic series
2. Late: surgical
• Lateral bands subluxes PE: PIP
repair
dorsally, PIP hyperextends DIP yperextended, DIP
(individualize
flexes flexed
flexes flexed
each case)
ULNAR COLLATERAL OF THUMB: GAMEKEEPER'S THUMB
XR: 1/2
Hx: Trauma. Pain 1. Incomplete:
• Ulnar collateral ligament torn avulsion
swelling. splint 2-4 weeks
fracture.
2. Complete:
PE: Ulnar thumb
• Mechanism: forceful radial unstable with radial Stress view surgical repair
deviation shows injury (treat Stener
extension/abduction
lesion)
• Often in ski pole injury

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS: INFECTIONS

HISTORY/PHYSICAL WORK-
DESCRIPTION TREATMENT
EXAM UP/FINDINGS
BITES: HUMAN/ANIMAL
Hx: Laceration or
• Usually dominant XR: Rule out 1. Thorough ID, Td
puncture,dorsal MCP most
hand fracture if necessary
common location

Labs: Aerobic 2. IV
• Classic anaerobic antibioticsAnimal:
mechanism: fist fight Unasyn Human:
cultures, WBC
Augmentin

• Human: poly PE: Red, swollen, 1/2 [Contact health


drainage, streaking.
bacterial including officials if animal
Eikenella corrodens Decreased extension if possibly rabid]
tendon torn
3. Do not close
wound, dress
appropriately
• Animal: Pasteurella
multocida
DEEP SPACE INFECTION
• From palm
puncture or spread Hx/PE: Erythema, XR: Usually Dorsal volar ID and
from finger (+/- fluctuance, and tenderness normal IV antibiotics
Horseshoe)
FELON
• Deep infection or Hx/PE: Erythematous, XR: Usually 1. ID, release
abscess in pulp swollen, and painful. normal septae
2. IV antibiotics
• Staph Aureus #1
organism
PARONYCHIA/EPONYCHIA
• Nail bed infection Hx/PE: Red, painful,
XR: Usually 1. Soaks and oral
(most common swollen, often purulent
normal antibiotics
finger infection) drainage
2. ID with nail
removal if
necessary
• Staph Aureus #1
organism
PURULENT TENOSYNOVITIS
XR: Possible 1. Mild (early): IV
• Infection of flexor foreign body or antibiotics, re-
Hx: Puncture wound
tendon sheath subcutaneous evaluate within 24
air hours
PE: KANAVEL SIGNS:
1. Flexed position,
2. Pain on passive 2. Most: I D (1/2
• Usually from
extension, drain) and IV
puncture wound
antibiotics
3. Fusiform swelling,
4. Tender flexor sheath
• May extend into No treatment
palm and develop results in
“horseshoe” infection adhesions necrosis
SPOROTRICHOSIS
• Lymphatic infection Hx/PE: Discoloration or Potassium iodine
XR: None
(from roses) rash solution

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS: MASSES TUMORS

HISTORY/PHYSICAL WORK-
DESCRIPTION TREATMENT
EXAM UP/FINDINGS
DUPUYTREN'S DISEASE

• Proliferation of fascia XR: None 1. No proven


Hx: Male, 401 years old conservative
(long bands) needed
treatment
PE: nodule, non-tender,
• Northern European
descent flexed digit (RF#1,
SF#2)
• Associated with DM,
2. Fasciotomy
epilepsy
ENCHONDROMA

• #1 Primary bone tumor Hx: Pain after XR: Lytic lesion Curettage and
pathologic fracture bone graft
• Usually proximal
phalanx
EPIDERMAL INCLUSION CYST
• Epidermal cells Excision (get all
embedded deep into Hx: Trauma or puncture XR: Normal epidermal cells or
tissue it will recur)
PE: Painless mass,
usually on digits, no
transillumination
GANGLION RETINACULAR CYST
XR: No
• Cyst (arises from joint Aspiration of cyst if
osteophyte in
or tendon) with Hx: Young patient symptomatic. (may
corresponding
mucinous joint fluid recur)
area
PE: Visible, firm mass
(volar MCP flexor
tendon #1 site).
• Most common mass in
hand
GIANT CELL TUMOR (FIBROXANTHOMA)

• Originates from tendon Hx/PE: Firm, painless Excise, they do


mass, usually volar XR: Normal
sheath recur
finger (IF,MF)
• 2nd most common
hand mass
MALIGNANT TUMORS
• #1 Primary: squamous Hx/PE: Mass, usually
XR: Normal Excise
cell on dorsum of hand
• #1 Metastatic: lung
MUCOUS CYST
Excision and
• A ganglion of dorsal Hx: Women, older XR: OA and/or
osteophyte or joint
DIP patients spur at DIP
debridement
• Associated with OA at PE: Dorsal DIP mass,
DIP 1/2 pain

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SURGICAL APPROACHES

USES INTERNERVOUSPLANE DANGERS COMMENT


FINGER: VOLAR APPROACH
1. Flexor tendons No planes 1. Digital 1. Make a “zig-zag”
(repair/explore) artery incision with angles of 90°

2. Digital nerve 2. Digital


nerve
3. Soft tissue 2. Neurovascular bundle is
releases lateral to the tendon sheath
4. Infection drainage
FINGER: MID-LATERAL APPROACH
Soft tissues are thin,
Phalangeal 1. Digital
No planes capsule can be incised if
fractures nerve
care is not taken.
2. Digital
artery

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CHAPTER 6 - PELVIS
TOPOGRAPHIC ANATOMY
OSTEOLOGY
LANDMARKS AND OTHER STRUCTURES
TRAUMA
JOINTS
HISTORY AND PHYSICAL EXAM
PHYSICAL EXAM OF THE PELVIS
PHYSICAL EXAM
MUSCLES: ORIGINS AND INSERTIONS
ANTERIOR MUSCLES (also see muscles of the thigh/hip)
GLUTEAL MUSCLES (also see muscles of the thigh/hip)
NERVES
ARTERIES
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 6 – PELVIS
TOPOGRAPHIC ANATOMY

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY

CHARACTERISTICS OSSIFY FUSE COMMENT


INNOMINATE: COXAL BONE
• Iliac wing
• One bone: started as 3, connected by tri-
radiate cartilage at acetabulum Ilium: body Primary
2- to and superior
ala Ischium: body ramus Pubis: body 2 (one in each 6 acetabulum pubic ramus
rami body) mo 15 yrs are “weak
spots”
• ASIS:
avulsion
fracture can
result from
sartorius
Secondary
• AIIS:
Iliac crest
avulsion
Acetabulum 15 All fuse 20
fracture can
Ischial
yrs yrs result from
tuberosity rectus
AIIS femoris
Pubis
• Iliac crest
ossification
used to
determine
• Two innominate per pelvis (L R)
skeletal
maturity
(Risser
stage)
• Iliac crest
• Acetabulum: anteverted and oblique contusion
orientation (approx. 45°) referred to as
“hip pointer”
SACRUM
See spine chapter

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

LANDMARKS AND OTHER STRUCTURES

ATTACHMENTS/
STRUCTURE RELATED COMMENT
STRUCTURES

ASIS Sartorius Inguinal ligament • LFCN crosses the ASIS can be


compressed there (Meralgia paresthetica)
Transverse internal
• Sartorius can avulse from it (avulsion
oblique abdominal fracture)
muscles
Rectus femoris Tensor • Rectus femoris can avulse from it
AIIS fascia lata Iliofemoral
(avulsion fracture)
ligament (hip capsule)

PSIS Posterior sacroiliac • Excellent bone graft site


ligaments
Marked by skin dimple
Arcuate line Pectineus muscle • Strong, weight bearing region
3 lines: anterior, inferior,
Gluteal lines • Separate origins of gluteal muscles
posterior
Greater SEE • Tender with trochanteric bursitis
trochanter ORIGINS/INSERTIONS
Lesser
Iliacus Psoas muscles
trochanter
SEE
• Excessive friction can cause bursitis
Ischial tuberosity ORIGINS/INSERTIONS
(Weaver's bottom)
Sacrotuberous ligaments
Coccygeus Levator ani
Ischial spine attach Sacrospinous
ligaments
Consists of:
Anterior 1. Pubic ramus
(iliopubic) • Involved in several different fracture
2. Anterior
column of patterns
acetabulum
acetabulum
3. Anterior iliac wing
Consists of:
Posterior 1. Ischial tuberosity
(ilioischial) • Involved in several different fracture
column of 2. Posterior patterns
acetabulum
acetabulum
3. Sciatic notch
Short external rotators
Lesser sciatic exit:
foramen Obturator externus
Obturator internus
Structures that exit:
1. Superior gluteal
nerve
2. Superior gluteal
artery
3. Piriformis muscle
4. Pudendal nerve
5. Inferior pudendal • Piriformis muscle is the reference
artery point
6. Nerve to the • Superior Gluteal nerve and artery
Greater sciatic Obturator internus exit superior to the piriformis
foramen
7. Posterior • POP'S IQ is a mnemonic for the
Cutaneous nerve of nerves (structures) that exit inferior to
thigh the piriformis (medial to lateral)
8. Sciatic nerve
9. Inferior gluteal
nerve
10. Inferior gluteal
artery
11. Nerve to
Quadratus femoris

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

Classification of Pelvic Fractures (Young and Burgess)

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


PELVIC FRACTURE

Mechanism
Young and Burgess:
1: High
energy force • AP
(e.g. MVA). compression
Lateral force (APC):
more I. 2.5cm
common pubic
than AP diastasis
Treat life
• Usually fracture of 1-
threatening
associated 2 rami
injuries first
with other II. 2.5cm (ABC's).
injuries diastasis; SI
Treat pelvic
(often life disruption,
hemorrhage
threatening). but stable
with external
• Open HX: Trauma. Swelling, III. Complete fixation (+/-
pelvic pain, deformity. disruption 2embolization)
fracture with pubis Diverting
associated PE: ABC's. Affected LE symphysis SI
shortened, +/-blood in colostomy for
GI and/or joint:
rectum/vagina/urethra. GI injury (avoid
GU injury: unstable
Do good neurovascular sepsis)
50% fracture
mortality exam: +/-pulses in groin Stable
LE with neurologic • Lateral fractures:
• Posterior deficits including loss of Compression (single ramus,
SI ligament rectal tone (LC): avulsion fx,
is key to bulbocavernosus reflex. I. Sacral APC or LC I):
pelvic conservative
XR: AP, Inlet, Outlet compression
stability
Judet views of the with rami treatment;
• pelvis. fractures bedrest,
Mechanism decreased
II. Rami
Mechanism decreased
CT: Scan entire pelvis II. Rami
2: Minor activity
fracture,
trauma (e.g. AGRAM: for Unstable
posterior SI
fall on hemorrhage ligment fractures:
osteopenic
disrupted, external
bone):
but stable fixation with
stable single
ORIF as
ramus III. LC II, with
needed
fracture contralateral
APC III Early
• mobilization
(“windswept”
Mechanism
) aids recovery
3: Stable
avulsion • Vertical shear:
fracture - anterior posterior
ASIS pelvic injury
(Sartorius) - (displacement):
AIIS (Rectus vertically
femoris) - unstable.
Ischium
(hamstring)

COMPLICATIONS: Associated injuries (especially with APC III): 1. GI, 2. GU, 3.


Vascular/hemorrhage, 4. Neurologic; Prolonged hospital stay with associated risks
(infection, DVT, etc.); Residual deformity and/or pain (lower back or SI); Leg length
discrepancy
DESCRIPTION EVALUATION CLASSIFICATION TREATMENT
ACETABULAR FRACTURE
Judet/Letournel:
I. Posterior
wall
II. Posterior
column
• Uncommon, HX: Trauma (e.g. Traction on
dashboard injury). III. Anterior
younger wall affected side
Pain, deformity.
• High energy or IV. Anterior Nondisplaced,
violent injury; PE: LE shortened, congruent
rotated. Usually column
femoral head is joint,
forced into neurovascularly V. Transverse
intact distally. Displaced,
acetabulum VI. Posterior dislocation,
• Dislocation XR: AP. Internal column wall unstable fx:
external obliques VII.
of hip is often ORIF
(Judet views): Transverse
associated many possible XRT (600
post. wall
• Also GI, GU, fracture sites rads)
vascular VIII. T-type prophylaxis for
CT: shows fracture heterotopic
associated pattern and loose IX. Anterior
injuries. column bone.
fragments
posterior
emi-
transverse
X. Both
columns

COMPLICATIONS: Need for Total Hip Arthroplasty; Nerve injury (sciatic);


Heterotopic bone formation; Osteonecrosis steoarthritis
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

JOINTS

LIGAMENTS ATTACHMENTS COMMENTS


SACROILIAC (GLIDING)
Strongest SI ligaments: key to
Sacrum to ilium:
Posterior SI (short stability.
Short are horizontal
long) Long are vertical Short: resist rotation
Long: resist vertical shear
Disruption: rotational vertical
instability
Sacrum to ilium
Anterior SI Rotational stability
(horizontal)
Interosseous Sacral to iliac tuberosities Strong
LIGAMENTS ATTACHMENTS COMMENTS
SYMPHYSIS PUBIS
Superior pubic Both pubic bones There is a fibrocartilage disc between the
ligament superiorly two hemipelvi
Arcuate pubic Both pubic bones
ligament inferiorly
OTHER LIGAMENTS

Sacrospinous Anterior sacrum to


Divides greater lesser sciatic foramina;
ischial spine provides rotational stability

Sacrotuberous Anterior sacrum to


Inferior border of lesser sciatic foramina;
ischial tuberosity provides vertical stability
L5 transverse
Iliolumbar Can result in avulsion fracture
process to crest
L5 transverse
Lumbosacral Vertical stability
process to ala

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY AND PHYSICAL EXAM

QUESTION ANSWER CLINICAL APPLICATION


Young
Ankylosing Spondylitis (1HLA-b27)
1. AGE Middle age,
Decreased mobility
elderly
Acute
Trauma: fracture, sprain
2. PAIN Chronic
Systemic inflammatory disorder
Deep, non-
a. Onset Sacroiliac etiology
specific
To thigh or buttock on ipsilateral side: SI joint
b. Character Radiating injury
c. Occurrence In out of bed, on
Sacroiliac etiology
stairs Symphysis pubis etiology
Adducting legs
3. PMHx Pregnancy Laxity of ligaments of SI joint causes pain

4. TRAUMA Fall on buttock, Sacroiliac joint injury


twist injury
High velocity:
Fracture
MVA, fall

5. ACTIVITY/WORK Twisting, stand Sacroiliac etiology


on one leg
6. NEUROLOGIC Pain, numbness, Spine etiology, sacroiliac etiology
SYMPTOMS tingling
7. HISTORY of Multiple joints SI involvement of RA, Reiter's syndrome,
ARTHRITIDES involved Ankylosing Spondylitis, etc.

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM OF THE PELVIS

EXAM/
TECHNIQUE CLINICAL APPLICATION
OBSERVATION
INSPECTION
Skin Discoloration, wounds
ASIS's, Iliac Both level (same plane) If on different plane: Leg length discrepancy,
crests sacral torsion
Lumbar Increased lordosis Flexion contracture
curvature
Decreased lordosis Paraspinal muscle spasm
PALPATION

Bony structures Standing: ASIS, Pubic Unequal side to side 5pelvic obliquity: leg
Iliac tubercles, PSIS length discrepancy
Lying: Iliac crest, Ishial
Mass: cluneal neuroma
tuberosity
Soft tissues Inguinal ligament Protruding mass: hernia
Diminished pulse: vascular injury; palpable
Femoral pulse nodes
nodes: infection
Muscle groups Each group should be symmetric bilaterally
RANGE OF MOTION
Forward flexion Standing: bend forward PSIS's should elevate slightly (equally)
Extension Standing: lean backward PSIS's should depress (equally)
PSIS should drop but will elevate in
Hip flexion Standing: knee to chest
hypomobile SI joint
Ischial tuberosity should move laterally, will
elevate in hypomobile SI joint
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAM/
TECHNIQUE CLINICAL APPLICATION
OBSERVATION
NEUROVASCULAR
Sensory
Iliohypogastric Suprapubic, lateral Deficit indicates corresponding nerve/root
nerve (L1) buttocks thigh lesion
Ilioinguinal nerve Deficit indicates corresponding nerve/root
Inguinal region
(L1) lesion (e.g. abdominal muscle compression)
Genitofemoral Deficit indicates corresponding nerve/root
Scrotum or mons
nerve (L1-2) lesion
Lateral femoral
Deficit indicates corresponding nerve/root
cutaneous nerve Lateral hip thigh
lesion (e.g. Meralgia paresthetica)
(L2-3)
Pudental nerve (S2- Perineum Deficit indicates corresponding nerve/root
4) lesion
Motor
Weakness 5Iliopsoas or corresponding
Femoral (L2-4) Hip flexion
nerve/root lesion
Inferior Gluteal Weakness 5Gluteus maximus or nerve/root
External rotation
nerve lesion
Nerve to Quadratus External rotation Weakness 5Short rotators or corresponding
femoris nerve/root lesion
Nerve to Obturator
internus
Nerve to Piriformis
Superior Gluteal Weakness 5Gluteus medius/minimus, TFL or
Abduction
nerve corresponding nerve/root lesion
Finger in rectum, squeeze or pull penis
Reflex Bulbocavernosus
(Foley), anal sphincter should contract
Pulses Femoral pulse
SPECIAL TESTS
Supine: extend
Straight leg Pain radiating to LE: HNP with radiculopathy
Straight leg Pain radiating to LE: HNP with radiculopathy
knee, flex hip
Press ASIS, iliac
SI stress Pain in SI could be SI ligament injury
crest, sacrum
Standing: lift one leg Flexed side: pelvis should elevate; if pelvis
Trendelenburg sign
(flex hip) falls: Abductor or gluteus medius dysfunction
Flex, ABduct, ER
Positive if pain or LE will not continue to
Patrick (FABER) hip, then abduct abduct below other leg: SI joint pathology
more
Pressure medial to Reproduction to pain, burning, numbness:
Meralgia
ASIS LFCN entrapment
Rectal Vaginal Especially after Gross blood indicates trauma communicating
exam trauma with those organ systems

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: ORIGINS AND INSERTIONS

PUBIC RAMI GREATER ISCHIAL LINEA ASPERA/


(ASPECT) TROCHANTER TUBEROSITY POSTERIOR FEMUR
Pectineus (pectineal Piriformis
Inferior gemellus Adductor magnus
line/superior) (anterior)
Adductor magnus Obturator internus Quadratus femoris
Adductor longus
(inferior) (anterior)
Adductor longus
Superior gemellus Semimembranosus Adductor brevis
(anterior)
Adductor brevis Gluteus medius
Semitendinosus Biceps femoris
(inferior) (posterior)

Gracilis (inferior) Gluteus minimus Biceps femoris Pectineus


(anterior) (LH)
Psoas minor Adductor magnus Gluteus maximus
(superior)
Vastus lateralis
Vastus medialis

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ANTERIOR MUSCLES (also see muscles of the thigh/hip)

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


HIP FLEXORS
ANTERIOR
T12-L5 Lesser
Psoas Femoral Flex hip Covers lumbar
vertebrae trochanter plexus
Lesser
Iliacus Iliac fossa Femoral Flex hip Covers anterior
trochanter ilium

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

GLUTEAL MUSCLES (also see muscles of the thigh/hip)

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


HIP ABDUCTORS
Tensor Superior Abducts, A plane in anterior
fascia Iliac crest, ASIS Iliotibial band flex, IR approach to hip
Gluteal
latae thigh
HIP ABDUCTORS
Ilium between
Gluteus Greater Superior Abduct Trendelenburg
anterior posterior trochanter
medius Gluteal (IR) thigh gait if muscle is
gluteal lines out.
Ilium between
Gluteus Anterior greater Superior Abduct Works in
anterior interior
minimus trochanter Gluteal (IR) thigh conjunction with
gluteal lines medius
HIP EXTERNAL ROTATORS

Gluteus Ilium, dorsal Gluteal Inferior Extend, Must detach in


tuberosity
maximus sacrum Gluteal ER thigh post. approach to
(femur), ITB hip
Superior
Piriformis Anterior sacrum greater Piriformis ER thigh Used as landmark
trochanter

Obturator Ischiopubic rami, Trochanteric Muscle actually in


externus obturator
Obturator ER thigh medial thigh
fossa
membrane
Short
Rotators

Obturator Ischiopubic rami,


N. to ER,
Medial greater Muscle makes a
obturator Obturator abduct
internus trochanter right turn
membrane internus thigh
N. to
Superior Medial greater Assists obturator
Ischial spine Obturator ER thigh internus
gemellus trochanter
internus
N. to
Inferior Medial greater Assists obturator
Ischial tuberosity Quadratus ER thigh internus
gemellus trochanter
femoris
Runs with
N. to
Quadratus Ischial tuberosity Intertrochanteric Quadratus ER thigh ascending branch
femoris crest of medial
femoris
circumflex artery
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

LUMBAR PLEXUS
ANTERIOR DIVISION
1. Subcostal (T12):
Sensory: Subxyphoid region
Motor: NONE
2. Iliohypogastric (L1)
Sensory: Above pubis
Posterolateral buttocks
Motor: Transversus abdominus
Internal Oblique
3. Ilioinguinal (L1)
Sensory: Inguinal region
Motor: NONE
4. Genitofemoral(L1-2): pierces Psoas, lies on anteromedial surface.
Sensory: Scrotum or mons
Motor: Cremaster
5. Obturator (L2-4): exits via obturator canal, splits into ant. post. divisions. Can be
injured by retractors placed behind the transverse acetabular ligament.
Sensory: Inferomedial thigh via cutaneous branch of Obturator nerve
Motor: External oblique
Obturator externus (posterior division)
6. Accessory Obturator (L2-4): inconsistent
Sensory: NONE
Motor: Psoas
POSTERIOR DIVISION
7. Lateral Femoral Cutaneous [LFCN](L2-3): crosses, ASIS, can be compressed at
ASIS
Sensory: NONE (in pelvis)
Motor: NONE
8. Femoral (L2-4): lies between psoas major and iliacus
Sensory: NONE (in pelvis)
Motor: Psoas
Iliacus
Pectineus

SACRAL PLEXUS
ANTERIOR DIVISION
9. Nerve to Quadratus femoris (L4-S1):
Sensory: NONE
Motor: Quadratus femoris
Inferior gemelli
10. Nerve to Obturator internus (L5-S2): exits greater sciatic foramen
Sensory: NONE
Motor: Obturator internus
Superior gemelli
11. Pudendal (S2-4): exits greater then re-enters lesser sciatic foramen

Sensory: Perineum:via Perineal (scotal/labial branches)via Inferior rectal


nervevia Dorsal nerve to penis/clitoris
Motor: Bulbospongiosus: Perineal nerve
Isiocavernosus: Perineal nerve
Urethral sphincter: Perineal nerve
Urogenital diaphragm: Perineal nerve
Sphincter ani externus: Inf. rectal nerve
12. Nerve to coccygeus (S3-4)
Sensory: NONE
Motor: Coccygeus
Levator ani
POSTERIOR DIVISION
13. Superior Gluteal (L4-S1):
Sensory: NONE
Motor: Gluteus medius
Gluteus minimus
Tensor fascia lata
14. Inferior Gluteal (L5-S2):
Sensory: NONE
Motor: Gluteus maximus
15. Nerve to piriformis (S2):
Sensory: NONE
Motor: Piriformis
OTHER NERVES (non-plexus)
16. Cluneal nerves: branches of lumbar and sacral dorsal rami. Can be injured
during bone grafts.
Sensory: Skin of gluteal region
Motor: NONE

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

COURSE BRANCHES COMMENT


AORTA
Common iliacs at
Along anterior vertebral bodies ALL L4 Lumbar arteries
(4 sets)
Paired: posterior branch
supplies cord, meninges
paraspinal muscles
Median sacral
artery 5th Lumbar Unpaired vessel
arteries (2)
Anastomoses with lat. sacral
artery
COMMON ILIACS
Divide into internal
Still on anterior L-spine sacrum
external iliacs at S1
INTERNAL ILIAC
Under ureter near SI joint, divides Supplies most of
into its divisions at edge of greater pelvis and the
sciatic foramen pelvic organs
ANTERIOR
DIVISION
Runs with nerve through
Obturator
foramen
Fovea artery (artery Minor contributions to the
of ligamentum teres vascular supply of the femoral
in hip) head
Supplies muscles of the
Inferior gluteal
Inferior gluteal
buttocks
Multiple visceral
branches [*]
POSTERIOR
DIVISION
Supplies muscles of the
Superior gluteal
buttocks
Iliolumbar Supplies iliopsoas and ilium
Supplies sacral roots,
Lateral sacral meninges, muscles covering
sacrum
EXTERNAL ILIAC
Under inguinal ligament over the Does not supply
pubic rami, on the psoas muscle much in the pelvis
Deep circumflex
iliac artery
Inferior epigastric
artery
Femoral artery
At risk Total Hip Arthroplasty
(under inguinal
(THA)
ligament)
* Other branches of the Internal iliac include: Umbilical, Vaginal/Inferior vesical, Uterine, Middle rectal, Inferior
pudendal

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CHAPTER 7 - THIGH/HIP
TOPOGRAPHIC ANATOMY
OSTEOLOGY
TRAUMA
JOINTS
MINOR PROCEDURES
HISTORY
PHYSICAL EXAM
MUSCLES: ORIGINS AND INSERTIONS
MUSCLES: ANTERIOR
MUSCLES: MEDIAL
MUSCLES: POSTERIOR (HAMSTRINGS)
THIGH MUSCLES: CROSS SECTIONS
NERVES
ARTERIES
ARTERIES OF THE FEMORAL NECK
DISORDERS
TOTAL HIP ARTHROPLASTY
TIPS ON TOTAL HIPS
PEDIATRIC DISORDERS
SURGICAL APPROACHES
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 7 – THIGH/HIP
TOPOGRAPHIC ANATOMY

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY

CHARACTERISTICS OSSIFY FUSE COMMENT


FEMUR
Blood supply
Head
neck:
branches
• Long bone of the
characteristics Medial
Proximally: Lateral
head, neck, • circumflex
• artery
greater lesser
trochanters (from
profunda)
Neck: bone
comprised of Shaft:
• tensile 16- nutrient
Primary (Shaft) 18
compressive (from
groups Secondary 7-8 years profunda)
wks
Distally: 2 1. Distal (fetal)
19
Head neck
condyles physis years
vascularity
2. Head Birth 18 tenuous:
Lateral:
more Greater 1 yr years • increased risk
anterior 3. of ischemia in
trochanter 4-5 yr 16
• proximal years fracture or
Medial: Lesser 10 yr dislocation.
4.
larger, trochanter 16
years Femoral neck
more weakens with
posterior • age:
distal susceptable to
susceptable to
Femoral fracture
• anteversion: Anatomic axis:
12-14° • along shaft of
Neck/shaft femur

angle: 126° Mechanical
axis: femoral
• head to
intercondylar
notch

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


HIP DISLOCATION
Posterior. Thompson:
Simple, no
I. posterior
fragment
Simple, large
II. posterior
fragment Early reduction
HX: Trauma. Severe pain, essential, then repeat
Comminuted XR neurologic exam
Cannot move thigh/hip. III. posterior
High energy trauma PE: Thigh position: fragment Posterior:
(esp MVA- I: Closed
• Post: adducted, flexed,
dashboard injury or
IR IV. Acetabular reduction
significant fall.) fracture abduction pillow
Ant: abducted, flexed, Femoral head
Orthopaedic V. II-V: 1. Closed
• ER. fracture
emergency Reduction (open
Pain (esp. with motion), if irreducible)
Multiple associated Anterior. Epstein:
good neurovascular
injuries +/- fractures, ORIF

(e.g. femoral head
exam I. (A, B, C): fracture
Superior
neck) XR: AP pelvis, frog lateral 2. or
(A, B, C): excise
Posterior most (Femoral head is different Inferior
• size) Also femur knee series fragment
common (85%) A: No
CT: Rule out fracture or bony associated Anterior: closed
fragments fracture reduction, ORIF if
II. B: Femoral necessary.
head
fracture
C:
Acetabular
fracture

COMPLICATIONS: Osteonecrosis (AVN) reduced risk with early reduction; Sciatic nerve injury (posterior dislocations);
Femoral artery nerve injury (anterior dislocations); Instability recurrence; Osteoarthritis; Heterotopic ossification
DESCRIPTION EVALUATION CLASSIFICATION TREATMENT
FEMORAL NECK FRACTURE
Mechanism:
Fall by
elderly
1. woman Garden (4 types):
most Incomplete Early reduction essential
• common; I. fracture; All fractures:
HX: Fall. Pain, inability valgus
High Closed (open)
to bear weight or walk. impaction
velocity reduction then IF of
2. injury in PE: LE shortened, Complete
fracture:
young abducted, externally II. fracture;
adults rotated. Pain with nondisplaced Young: 3
“rolling” of leg. parallel screws
Intracapsular Complete Old: hemi-
• XR: AP pelvis (+/-IR), fracture, arthroplasty
fractures
groin lateral III. Partial
Associated with displacement
• MR: If symptomatic with (Stable fracture, type I,
osteoporosis (varus)
negative XR may heal without surgery,
Often caused by Complete ORIF because of
• medical condition IV. fracture, total displacement risk)
(syncope, etc) displacement
High morbidity
• complication rate
(25%)
COMPLICATIONS: Osteonecrosis (AVN) incidence increases with fracture type (displacement) +/- late segmental
collapse; Nonunion; Hardware failure
DESCRIPTION EVALUATION CLASSIFICATION TREATMENT
SUBTROCHANTERIC FRACTURE
HX: Fall.
Fall by a more Pain,
• elderly woman inability to Nonoperative
most common bear weight is very rarely
Associated with or walk indicated.

osteoporosis PE: LE Operative
Occurs along or shortened, treatment
below the ER. Pain Evans (based on post-reduction with sliding
• stability) compression
intertrochanteric with “log
line rolling” of leg Type I. Stable hip screw
and side
Extracapsular XR: AP Type II. Unstable plate.

fractures pelvis (+/-
IR), groin Early
• Stable mobilization
vascularity lateral
with partial
Most heal well MR: If weight-
• with proper symptomatic bearing
fixation with
negative XR
COMPLICATIONS: Nonunion/Malunion; Hardware failure or loss of reduction; Infection. Mortality rate, first 6
months after fracture, is 15-25%
SUBTROCHANTERIC FRACTURE
Mechanism:
1. Fall in Nonoperative
elderly
• treatment:
Trauma HX: Trauma traction hip
2. in or fall. Pain, Seinsheimer (5 types): spica cast for
young swelling 6-8 wks (not
I. Non or minimally displaced
Occurs below PE: commonly
Swelling, II. Displaced: 2 parts used)
Swelling, II. Displaced: 2 parts used)
the lesser
• trochanter (up tenderness III. Displaced: 3 parts Operative
to 5cm below +/- IV. Comminuted (41parts) treatment:
it). shortening Locked IM
of LE V. Subtrochanteric/intertrochanteric nail,
Pathologic fracture.
• XR: AP compression
fractures seen
here. lateral screw, or
Zickel nail,
Decreased +/-bone graft
• vascularity =
tenuous healing
COMPLICATIONS: Nonunion/Malunion; Hardware failure or loss of reduction; Refracture with hardware
removal

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


FEMORAL SHAFT FRACTURE
Winquist/Hansen (4
types):
Orthopaedic
• Stable
emergency
HX: Trauma.
• High energy
Pain, swelling I. No/minimal
injury comminution
deformity
Multiple Comminuted: Extensive irrigation of any
PE:
• associated
Deformity, +/- II. 50% of open fractures
injuries (many cortices
open wound intact Operative: Interlocking
serious) soft tissue intramedullary rods
Potential injury; Check Unstable (closed)
• source of distal pulses Comminuted: Early mobilizaton with
significant
blood loss
XR: AP III. 50% of crutch ambulation
lateral thigh, cortices
Patient should knee trauma intact
• be transported series. Complete
with leg in
traction IV. comminution,
no intact
cortex

COMPLICATIONS: Neurovascular injury and/or hemorrhagic shock; Nonunion/Malunion; Hardware


failure or loss of reduction; Knee injury (5%)
DISTAL FEMUR FRACTURE
HX: Trauma.
Mechanism: Cannot bear

direct blow weight, pain,
Metaphysis or swelling.

epiphysis PE: Effusion, +/- aspirate hemarthroses
Quadriceps or tenderness, Undisplaced/extraarticular:
gastrocnemius do good Extraarticular
• Supracondylar reduce, immobilize (less
often displace neurovascular commonly used method)
fragments exam Intraarticular
Displaced/intraarticular:
Restoration of XR: Knee Intercondylar: T or Y
ORIF: plates and screws
articular trauma series Condylar
or intramedullary nails
surface is CT: Better
• Early mobilization
essential to defines
regain normal fracture
knee mobility
function AGRAM: if
pulseless
COMPLICATIONS: Osteoarthritis and/or pain; Decreased range of motion; Malunion/nonunion;
Instability

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

JOINTS

LIGAMENTS ATTACHMENTS COMMENTS


HIP JOINT (Spheroidal/Ball and Socket type)
Anteroinferior to
Transverse acetabular Cups the acetabulum
posteroinferior acetabulum
Labrum Acetabular rim Deepens stabilizes acetabulum

JOINT CAPSULE Acetabular rim to femoral


neck
Pubofemoral Femoral neck to superior
Covers femoral NECK
(anterior/inferior) pubic ramus
Iliofemoral (anterior) (Y AIIS to intertrochanteric
Strongest, most support
ligament of Bigelow) line
Posterior rim to Posterior femoral neck only
Ishiofemoral (posterior)
intertrochanteric crest partially covered (weak)
Zona orbicularis (posterior)
Ligament of Teres Fovea to cotyloid notch Artery runs in ligament

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MINOR PROCEDURES

STEPS

HIP INJECTION OR ASPIRATION

1. Ask patient about allergies


2. Place patient supine, palpate the greater trochanter.
3. Prepare skin over insertion site (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
ANTERIOR: Find the point of intersection between a vertical line below ASIS and
horizontal line from Greater trochanter. Insert 20 gauge (3 inch/spinal needle)
upward slightly medial direction at that point.
LATERAL: Insert a 20 gauge (3 inch/spinal needle) superior and medial to
5. greater trochanter until it hits the bone (the needle should be within the
capsule which extends down the femoral neck).
Inject (or aspirate) local or local/steroid preparation into joint. (The fluid
should flow easily if needle is in joint)
6. Dress injection site
TROCHANTERIC BURSA INJECTION

1. Ask patient about allergies


2. Place patient in lateral decubitus position, palpate the greater trochanter.
3. Prepare skin over lateral thigh (iodine/antiseptic soap)
Insert 20 gauge needle (at least 1 1/2inches) into thigh to the bone at the point of
most tenderness. Withdraw needle (1—2mm) so it is just off the bone and in the
4. bursa. Aspirate to ensure needle is not in a vessel.
Inject 10ml of local or 4:1 local/corticosteroid preparation into
bursa
5. Dress injection site
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY

QUESTION ANSWER CLINICAL APPLICATION


1. AGE Young Trauma, developmental disorders

Middle age, elderly Arthritis (inflammatory conditions), femoral neck


fractures
Acute Trauma, infection
Chronic Arthritis (inflammatory conditions)
2. PAIN Lateral hip or thigh Bursitis, LFCN entrapment, snapping hip
a. Onset Buttocks/posterior Consider spine etiology
b. Location thigh Hip joint or acetabular etiology (less likely to be
Groin/medial thigh from pelvis or spine)
c. Occurrence Anterior thigh Proximal femur
Ambulation/motion Hip joint etiology (i.e. not pelvis or spine)
At night Tumor, infection
Snapping hip syndrome, loose bodies, arthritis,
3. SNAPPING With ambulation
synovitis
4. ASSISTED Cane, crutch, Use (and frequency) indicates severity of pain
AMBULATION walker condition
5. ACTIVITY Walk distance Less distance walked and fewer activities no
TOLERANCE activity cessation longer performed = more severe
6. TRAUMA Fall, MVA Fracture, dislocation, bursitis
7.
Repetitive use Femoral stress fracture
ACTIVITY/WORK
8. NEUROLOGIC Pain, numbness,
LFCN entrapment, spine etiology
SYMPTOMS tingling
9. HISTORY OF Multiple joints
Systemic inflammatory disease
ARTHRITIDES involved
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION


INSPECTION
Discoloration,
Skin Trauma
wounds
Gross deformity Fracture, dislocation

Gait 60%stance, Normal gait: 20% double stance (both feet on


40%swing ground)
Decreased stance
Antalgic (painful) Knee, ankle, heel (spur), midfoot, toe pain
phase

Lurch (Trendelenburg) Laterally (on WB


Gluteus medius weakness, hip disease (OA,
side) AVN)
Posteriorly (hip
Lurch Gluteus maximus weakness
extended)
More hip knee
Steppage Foot drop, weak anterior leg muscles
flexion
Flat foot No push off Hallux rigidus, gastrocnemius/soleus weakness
Wide Feet 4 inches apart Neurologic/cerebellar disease
Less than previous
Decreased step size Pain, age, other pathology
normal
PALPATION
Greater Pain/palpable bursa: infection/bursitis, gluteus
Bony structures
trochanter/bursa medius tendinitis

Soft tissues Sciatic nerve (hip Pain: disc herniation, piriformis spasm
Soft tissues Pain: disc herniation, piriformis spasm
flexed)
Muscle groups Each group should be symmetric bilaterally

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION


RANGE OF MOTION
Supine: knee to
Flexion Normal: 130 degrees
chest
Thomas test: see Rule out flexion contracture
next page
Prone: lift leg off
Extension Normal: 20 degrees
table
Supine: leg Normal: Abd: 40 degrees, Add: 30
Abduction/adduction
lateral/medial degrees
Seated: foot Normal: IR: 30 degrees, ER: 50
Internal / External rotation
lateral/medial degrees
Prone: flex knee Normal: IR: 30 degrees, ER: 50
leg: in out degrees
NEUROVASCULAR
Sensory
Proximal
Deficit indicates corresponding
Genitofemoral nerve (L1-2) anteromedial
nerve/root lesion
thigh

Obturator nerve (L2-4) Inferomedial thigh Deficit indicates corresponding


nerve/root lesion
Lateral Femoral Cutaneous Lateral thigh Deficit indicates corresponding
nerve (L2-3) nerve/root lesion

Femoral nerve (L2-4) Anteromedial Deficit indicates corresponding


thigh nerve/root lesion
Posterior Femoral Posterior thigh Deficit indicates corresponding
Cutaneous nerve (S1-3) nerve/root lesion
Motor

Obturator nerve (L2-4) Thigh adduction Weakness =Adductor muscle group or


nerve/root lesion.

Superior Gluteal nerve (L5) Thigh abduction Weakness =Gluteus medius or


nerve/root lesion.

Femoral nerve (L2-4) Hip flexion Weakness =Iliopsoas or corresponding


nerve/root lesion.
Weakness =Quadriceps or
Knee extension Weakness =Quadriceps or
corresponding nerve/root lesion.
Inferior Gluteal nerve (L5- Hip extension Weakness =Gluteus maximus or
S2) nerve/root lesion.
Sciatic:

Tibial portion (L4-S3) Knee flexion Weakness =Biceps Long Head or


nerve/root lesion.

Peroneal portion (L4-S2) Knee flexion Weakness =Biceps Short Head or


nerve/root lesion
Reflex None
Pulses Femoral

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION


SPECIAL TESTS

Thomas sign Supine: one knee to If opposite thigh elevates off table:
chest flexion contracture of that side

Ober On side: flex abduct Leg should then adduct, if stays in


hip abduction: ITB contracture
Pain in hip/pelvis indicates tight
Piriformis On side: adduct hip piriformis (compressing sciatic
nerve)
ASIS to medial A measured difference of 1cm is
Leg length discrepancy
malleolus positive
Flex hip knee 90°, 20 degrees of flexion after full
90-90 straight leg
extend knee knee extension =tight hamstrings
Prone: passively If hip flexes as knee is flexed: tight
Ely's
flex knee rectus femoris muscle
Supine, hip Pain in hip is consistent with
Log roll
extended: IR/ER arthritis
Flex, ABduct, ER Positive if pain or LE will not
Patrick (FABER) hip, then abduct continue to abduct below other
more (figure of 4) leg: Hip or SI joint pathology

Meralgia Pressure medial to Reproduction to pain, burning,


ASIS numbness: LFCN entrapment

Ortolani (Peds) Hips at 90°, abduct A clunk indicates the hip(s) was
hips dislocated and now reduced

Hips at 90°, A clunk indicates the hip(s) is now


Barlow (Peds) posterior force dislocated, should reduce with
Ortolani

Galeazzi (Peds) Supine:Flex hips Any discrepancy in knee height :


knees 1. Dislocated hip, 2. Short femur

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: ORIGINS AND INSERTIONS

PUBIC RAMI GREATER ISCHIAL LINEA ASPERA/


(ASPECT) TROCHANTER TUBEROSITY POSTERIOR FEMUR
Pectineus (pectineal Piriformis
Inferior gemellus Adductor magnus
line/sup) (anterior)
Adductor magnus Obturator internus
Quadratus femoris Adductor longus
(inferior) (anterior)
Adductor longus
Superior gemellus Semimembranosus Adductor brevis
(anterior)
Adductor brevis Gluteus medius
Semitendinosus Biceps femoris
(inferior) (posterior)

Gracilis (inferior) Gluteus minimus Biceps femoris Pectineus


(anterior) (LH)
Psoas minor Adductor magnus Gluteus maximus
(superior)
Vastus lateralis
Vastus medialis

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: ANTERIOR

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Pulls May join with
Articularis Distal anterior Synovial Femoral capsule vastus
genu femoral shaft capsule superiorly in intermedius
extension
Proximal medial Can avulse
Sartorius ASIS tibia (Pes Femoral Flex, ER hip from ASIS
anserinus) (fracture)
QUADRICEPS
Can avulse
Rectus AIIS, superior rim Patella/tibial Flex thigh,
femoris of acetabulum tubercle Femoral extend leg from AIIS
(fracture)
LEG EXTENSORS

Vastus Greater Lateral patella, Oblique fibers


trochanter, lateral tibial tubercle Femoral Extend leg can affect Q
lateralis
linea aspera angle

Vastus Proximal femoral Patella; tibial Covers


Femoral Extend leg articularis
intermedius shaft tubercle
genu

Vastus Intertrochanteric Medial patella, Weak in many


line, medial linea tibial tubercle Femoral Extend leg patello-femoral
medialis
aspera disorders.
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: MEDIAL

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

Obturator Ischiopubic Trochanteric Tendon posterior


externus rami, obturator fossa Obturator ER thigh to femoral neck
membrane
HIP ADDUCTORS
Adductor Body of pubis Linea aspera
Obturator Adducts
Tendon can
longus (inferior) (mid 1/3) thigh ossify

Adductor Body and


Pectineal line,
Adducts Deep to
inferior pubic upper linea Obturator thigh
brevis pectineus
ramus aspera
2 portions:
Ischiopubic Linea Adducts
Adductor ramus ischial
aspera/adductor Obturator/ flex/ extend separate
magnus tuberosity Sciatic insertions
tubercle thigh
innervation
Body and Proximal medial Adducts Used in ligament
Gracilis inferior pubic tibia (Pes Obturator (flex) thigh reconstruction
ramus anserinus) flex, IR leg (ACL)
HIP FLEXORS (also iliopsoas)

Pectineal line of Pectineal line of Flex and Part of femoral


Pectineus pubis Femoral adduct
femur triangle floor
thigh

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: POSTERIOR (HAMSTRINGS)

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Proximal Extend Used in
Semitendinosus Ischial medial tibia Sciatic thigh, ligament
tuberosity (Pes (tibial) reconstructions
flex leg
anserinus) (ACL)

Ischial Posterior Sciatic Extend A border in


Semimembranosus tuberosity medial tibial thigh, medial
(tibial)
condyle flex leg approach

Biceps femoris: Ischial Sciatic Extend Covers sciatic


Head of fibula thigh,
Long Head tuberosity (tibial) nerve
flex leg
Linea Extend Shares
Biceps femoris: aspera, Fibula, lateral Sciatic insertion
thigh,
Short Head supra tibia (peroneal) flex leg tendon with
condylar line Long Head

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

THIGH MUSCLES: CROSS SECTIONS

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

LUMBAR PLEXUS
ANTERIOR DIVISION

Genitofemoral (L1-2): pierces Psoas, lies on anteromedial surface


Sensory: Proximal anteromedial thigh
Motor: NONE (in thigh)

Obturator (L2-4): exits via obturator canal, splits into anterior posterior divisions. Can be injured
by retractors placed behind the transverse acetabular ligament.
Sensory: Inferomedial thigh: via cutaneous branch of obturator nerve
2. Gracilis (anterior division)
Adductor longus (anterior division)
Motor:
Adductor brevis (ant/post divisions)
Adductor magnus (posterior division)
LUMBAR PLEXUS
POSTERIOR DIVISION

Lateral Femoral Cutaneous [LFCN](L2-3): crosses ASIS, can be compressed at ASIS.


Sensory: Lateral thigh
Motor: NONE

Femoral (L2-4): lies between psoas major and iliacus; Saphenous nerve branches
in Femoral Triangle runs under sartorius.
Sensory: Anteromedial thigh: via anterior/intermediate cutaneous nerves
Psoas
Sartorius
4. Articularis genu
QUADRICEPS
Motor:
Rectus femoris
Vastus lateralis
Vastus intermedius
Vastus medialis
1.
3.

SACRAL PLEXUS
ANTERIOR DIVISION

Tibial (L4-S3): descends (as sciatic) in posterior thigh


Sensory: NONE (in thigh)
POSTERIOR THIGH
Motor: Biceps femoris [long head]
Semitendinosus
Semimembranosus

POSTERIOR DIVISION

Common peroneal (L4-S2): descends(as sciatic) in posterior


thigh
Sensory: NONE (in thigh)
5. Motor: Biceps femoris [short head]

Posterior Femoral Cutaneous Nerve [PFCN] (S1-3)


Sensory: Posterior thigh
6. 7.
Motor: NONE

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Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

ARTERY BRANCHES COMMENT


Obturator Anterior posterior branches Runs through obturator foramen
Femoral In femoral triangle, runs in medial thigh between vastus medialis and
(Superficial
adductor longus, to obturator canal, through adductor hiatus, then
Femoral)
becomes Popliteal Artery behind knee.
[SFA]
Superficial circumflex iliac
Superficial epigastric
Superficial external pudendal
Deep external pudendal
Deep artery of thigh
See below
(Profunda)
Descending genicular artery Anastomosis at knee to supply knee
Articular branch
Saphenous branch
Deep Artery of
the thigh Medial circumflex Supplies femoral neck
(Profunda)
Lateral circumflex Supplies femoral neck
Ascending branch Forms anastomosis at femoral neck
Contributes to anastomosis at femoral
Transverse branch
neck
Contributes to anastomosis at femoral
Descending branch
neck
Perforators/muscular
Supplies femoral shaft and thigh muscles
branches
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES OF THE FEMORAL NECK

ARTERY COURSE COMMENT


Obturator: Fovea Runs through the ligament of femur Relatively minor contribution
artery (A. of head to femoral head
Ligament Teres)

Deep Artery of thigh Branches from Femoral in Femoral Supplies anterior medial
triangle. thigh
Between pectineus iliopsoas to Anastomosis: posterior
Medial circumflex
posterior femoral neck supply
Can be injured in posterior
Ascending branch Runs on Quadratus femoris
approach
Deep to sartorius and rectus Extracapsular anastomosis
Lateral circumflex
femoris at neck
Ascending branch To greater trochanter anteriorly Anastomosis: anterior supply
Extracapsular branches of
Cervical branches Pierce the capsule
anastomosis
Intracapsular branches: run along Most of femoral head supply
Retinacular arteries neck, enter bone at base of femoral is posterior (at risk in injury:
head. AVN)
Minor contribution to
Transverse branch Extends laterally
anastomosis

Descending branch Under rectus femoris Minor contribution to


anastomosis
Inferior Superior
Branches make small contributions to femoral neck anastomosis
Gluteal arteries
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS

WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
INFLAMMATORY ARTHRITIS
Physical
Host
1. therapy,
immunologic Hx: Pain, NSAIDs
• stiffness, +/- XR: AP, frog leg
response results Cane or
other joints lateral Labs: RF, 2.
in synovitis. crutch
involved. ESR, CRP
RA, Lupus, PE: Antalgic gait, ANA, CBC, uric 3. Synovectomy
SeroNegative decreased ROM acid, crystals, culture (early)

arthropathies, (especially IR) Total hip
gout, etc. 4. Arthroplasty
(late)
OSTEOARTHRITIS
NSAIDs,
1. Physical
Therapy
Loss or damage Hx: Chronic hip XR: AP/lateral hip Injection,
• to articular or groin pain, activity
increasing over 1. Joint space 2.
modification,
cartilage narrowing
time with activity cane
Etiology: PE: Decrease 2. Osteophytes
developmental, ROM (first IR), + 3. Osteotomy
• trauma, infection, log roll, +/- flexion 3. Subchondral (young)
sclerosis
metabolic, contracture Arthrodesis
idiopathic 4. Bony cysts 4.
antalgic gait (young)
Total Hip
5. Arthroplasty
(elderly)
LATERAL FEMORAL CUTANEOUS NERVE ENTRAPMENT (Meralgia Paresthetica)
Nerve trapped Hx: Pain/burning
• Remove
near ASIS. in lateral thigh 1.
XR: AP/lateral of hip: compressive
Due to activity PE: Decreased rule out other entity
(hip extension), sensation on pathology
• lateral thigh, + 2. Surgical
or clothing (e.g.
Meralgia release: rare
belt)
OSTEONECROSIS (Avascular necrosis: AVN)
Necrosis of
• femoral head
(trabecular bone) Hx: Insidious
Due to vascular onset dull hip
• ache Early: core
disruption XR: AP, frog leg
PE: With decompression or
Associated with collapse: pain lateral: femoral head vascularized fibular
• trauma, Etoh, sclerosis
with IR ER graft
steroid use, RA MR: Double line sign
Without Late or collapse: Total
(T2)
Ficat collapse: hip arthroplasty
classification: 4 discomfort with
• stages based on IR ER
sx, XR, bone
scan
SNAPPING HIP (Iliotibial band)
ITB snapping 1. Reassurance
over greater Hx: Snapping in Avoid
trochanter of hip with walking XR: AP pelvis,
• 2. activity,
iliopsoas tendon (as hip extends). AP/latearl of hip: Physical
over pectineal Pain rare. therapy
eminence usually normal, rule
PE: Adduct flex
eminence PE: Adduct flex
out other pathology Injection for
Women (wide hip, then extend: 3.
+ snap acute bursitis
• pelvis) most
common 4. Surgery rare

TROCHANTERIC BURSITIS
Hx: Lateral hip 1. NSAIDs
pain. Cannot
Physical
• Inflammation of bursa sleep on affected XR: AP pelvis,
therapy (IT
over greater trochanter
side. AP/lateral of hip: rule 2.
Band
PE: Point out spur, OA,
or gluteal tendons stretching)
tenderness at calcified tendons
greater Steroid
3.
trochanter injection

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TOTAL HIP ARTHROPLASTY

TIPS ON TOTAL HIPS


GENERAL INFORMATION

Types of implants: cemented, noncemented (press fit porous ingrowth), hybrid


- “Supermetals”: cobalt chrome titanium (shaft/head)
• - Acetabular cup: Ultra high-molecular weight polyethylene
- Porous ingrowth: best pore size 200-400 microns
- Cemented usually used in elderly patients, noncemented for younger patients
• Cement: Polymethylmethacralate
• Head size: 26-28mm is optimal
INDICATIONS

Arthritis of hip: common etiologies: OA, RA, AVN


Most patients complain of pain, worsening over time (wakes them from sleep), and
decreased ability to ambulate.
Patient should have appropriate radiographic evidence of arthritis
It is preferable when the patient is elderly (needs only one replacement)
OSTEOARTHRITIS RHEUMATOID ARTHRITIS
1. Joint space narrowing 1. Joint space narrowing
2. Sclerosis 2. Periarticular osteoporosis
3. Subchondral cysts 3. Joint erosions
4. Osteophyte formation 4. Ankylosis

Failed conservative treatment: activity modification, weight loss, physical


2.
therapy/strengthening, NSAIDs, ambulation assistance (cane used on
unaffected side, walker, etc.), injections.
3. Other: Fractures, tumors, developmental disorders (DDH, etc.)
CONTRAINDICATIONS

• Young, active patient (will wear out replacement many times)


• Medically unstable (e.g. severe cardiopulmonary disease)
• Neuropathic joint

Any infection
ALTERNATIVES

• Considerations: Age, activity level, overall health


• Osteotomy: Femoral or pelvic; not common in U.S.
1. Arthrodesis/Fusion: good for young patients/laborers, unilateral disease, no

other joint disease (e.g. spine, knee). Fuse with hip in slight flexion
PROCEDURE

• Posterior or lateral approach usually used


• Femoral component should be in valgus (“Thou shalt not Varus”)

Acetabular cup at 45°
COMPLICATIONS

Failure of Implant
1. Loosening (#1 complication in cemented joints)
• 2. Varus alignment

3. Implant breakage (patients: active, heavy, young, will wear out


prosthetic)
• Hip thigh pain post-operatively (#1 complication in noncemented joints)

• Deep Venous Thrombosis (DVT)/Pulmonary emboli: patients should be


anticoagulated (Heparin/warfarin) postoperatively
• Infection: often leads to removal of prosthesis (Staph #1 cause)
• Dislocation: posterior are most common (abduction pillow can help prevent)

• External iliac/Femoral artery and vein injury with anterior/superior quadrant


screw
Obturator nerve, artery, vein injury with anterior/inferior quadrant screw.

Posterior screw placement is preferable
• Nerve injury (sciatic: peroneal portion) by retractors: Foot drop
• Heterotopic ossification: one dose prophylactic XRT can help prevent it.
• Osteolysis: Macrophage response; due to polyethylene wear debris

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TIPS ON TOTAL HIPS

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PEDIATRIC DISORDERS

DESCRIPTION EVALUATION TREATMENT/COMPLICATIONS


DEVELOPMENTAL DYSPLASIA
• Capsule/ligament laxity, Goal: maintain femoral
1. or Hx: Twins, other risk head in the acetabulum
Acetabular roof factors. Often (concentric reduction):
2. abnormal: hip does not unnoticed by
develop correctly parents. 1. Pavlik harness
• (3mo)
Associated with: First PE: + Barlow
female, breech (dislocation), + 2. Closed reduction
cast (6-18mo)
• delivery, + family health, Ortalani (relocation),
decreased intrauterine + Galeazzi tests. 3. Osteotomy
space conditions Decreased (18mo)
abduction
Early diagnosis and Post reduction films
• treatment essential XR: In older patients essential
(3mo) US: if PE not • COMPLICATIONS:
conclusive Osteonecrosis (femoral
• Poor outcomes if head)
diagnosis delayed
FEMORAL ANTEVERSION
Internal rotation of femur, Hx: Usually presents Most spontaneously
1.
• femoral anteversion 3-6 yrs resolve
does not decrease PE: Femur IR (IR Derotational osteotomy if
properly 65°), patella is 2. it persists past age 10
• #1 cause of intoeing medial, intoeing gait (mostly cosmetic)
DESCRIPTION EVALUATION TREATMENT/COMPLICATIONS
LEGG-CALVE-PERTHES DISEASE
Hx:
Boys(4:1)
usually 4-8
yo,
unilateral
thigh or
Osteonecrosis of femoral knee pain The femoral head must
• limp revascularize
head
Idiopathic, vascular PE: Based on age:
• etiology Decreased 5 yrs: observation
(hypercoaguable/sludging) abduction, NSAIDs
no point
Associated with: + family 5-8 yrs: concentric
• tenderness
history, breech birth containment: abduction
on exam
Catteral classification: 4 brace or osteotomy
• XR: AP
stages 9+ yrs: operative
pelvis, frog
Poor prognosis: after age lateral treatment often fails
• 9 or with large femoral (density of (many need THA as
head involvement the femoral adult)
head is
indicative;
crescent
sign:
subchondral
fx)
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
Hx: 11-14
yo, often
obese, slow
onset hip,
thigh, knee Do not attempt reduction
Proximal femoral
pain, +/-
epiphysis falls off femur 1. Non weight-bearing
• limp
(posterior) head in
acetabulum PE: 2. Percutaneous pinning
Decreased COMPLICATIONS:
• Obese adolescents
ROM Osteonecrosis,
Early diagnosis and (especially chondrolysis, osteoarthritis,

treatment essential IR, decreased ROM
abduction)
XR: AP
pelvis, frog
lateral

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SURGICAL APPROACHES

INTERNERVOUS
USES DANGERS COMMENT
PLANE
POSTERIOR (Moore/Southern) APPROACH TO HIP

1. Total Hip
Arthroplasty Superior and
inferior gluteal
2. Arthroplasty
1. Sciatic 1.
Split gluteus arteries need to
nerve
ORIF maximus be controlled.
3. posterior [Inferior Inferior
2. gluteal The short external
acetabulum gluteal n] rotators must be
Posterior artery 2.
detached to
3. hip access the joint.
dislocations
LATERAL (Hardinge) APPROACH TO HIP
No osteotomy of
Superior greater trochanter
1. gluteal 1. required. Leads to
Total Hip Split gluteus artery earlier
Arthroplasty medius Femoral mobilization.
2.
(not used for [Superior nerve Less exposure
revisions) gluteal n] Femoral than posterior
3. Artery 2. approach, thus not
vein used for revision
THA.
LATERAL APPROACH TO THIGH
Incision can be
large or small; it is
Branch of made along the
Lateral 1. line between
Split vastus 1. femoral greater
1. Fractures lateralis (and circumflex trochancter and
intermedius) artery lateral condyle.
2. Tumors [Femoral
2. Tumors [Femoral Superior Arteries (#1 2 at
nerve] lateral left) encountered if
2.
geniculate incision extended
2.
artery proximally or
distally; ligate
them.

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CHAPTER 8 - LEG/KNEE
TOPOGRAPHIC ANATOMY
OSTEOLOGY
TRAUMA
KNEE JOINTS
MINOR PROCEDURES: KNEE
HISTORY
PHYSICAL EXAM
MUSCLES: ORIGINS AND INSERTIONS
MUSCLES: ANTERIOR COMPARTMENT
MUSCLES: LATERAL COMPARTMENT
MUSCLES: SUPERFICIAL POSTERIOR COMPARTMENT
MUSCLES: DEEP POSTERIOR COMPARTMENT
MUSCLES: CROSS SECTIONS
NERVES
ARTERIES
DISORDERS
DISORDERS: LIGAMENT INJURIES
DISORDERS
TOTAL KNEE ARTHROPLASTY
TOTAL KNEE ARTHROPLASTY
PEDIATRIC DISORDERS
SURGICAL APPROACHES
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 8 – LEG/KNEE
TOPOGRAPHIC ANATOMY

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Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY

CHARACTERISTICS OSSIFY FUSE COMMENT


TIBIA

Primary: 7 18 • Ossification site at the tibial


• Long bone characteristics Body wks years tuberosity can be confused with a
(fetal) fracture.
• Wide proximal end (plateau) 18- • Traction (quadriceps) apophysitis at
articulates with the femoral Secondary 20 the tibial tuberosity: Osgood Schlatter
condyles years disease
1.
• Distal end (plafond) cups the
talus Proximal 9 mo • Primary weight-bearing bone in leg
epiphysis

• Medial malleolus is distal end 2. Distal 1 yr


epiphysis
• IT Band inserts on Gerdy's 3. Tibial
tubercle tuberosity
FIBULA
8 • Common peroneal nerve runs
Primary: 20
• Long bone characteristics Body wks years across the neck, injured in fractures
(fetal) (foot drop)
18- • Used to determine “lateral” on
• Distal end (lateral malleolus)
is lateral wall of ankle mortise. Secondary 22 radiographs
years
1.
Proximal 1-3 yr
epiphysis
2. Distal
2. Distal
4 yr
epiphysis

CHARACTERISTICS OSSIFY FUSE COMMENT


PATELLA

• Largest sesamoid bone in Primary 11-13 • Failure to fuse: Bipartite patella


the body (single 3 years years (can be confused with patella
center) fracture).
• Functions:
• Two facets (lateral is 1. Enhances quadriceps pull
larger)
2. Protects knee
• Triangular in cross-section
• Very thick articular
cartilage (bearing heavy
loads)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


PATELLA FRACTURE
Mechanism:
direct indirect:
• (e.g. fall,
dashboard or HX: Trauma. Pain,
kicking injury) cannot extend Nondisplaced or
knee, swelling. Descriptive location: comminuted:
Pull of
quadriceps PE: ”Dome” Nondisplaced cylinder cast for 6
and patella effusion. Transverse wks

tendons Tenderness, +/- Displaced(2-3mm):
Vertical
displace most palpable defect. ORIF (e.g. tension
fractures Inability to extend Stellate bands) to restore
If intact, knee. Inferior/superior articular surface
retinaculum XR: Knee trauma pole Severely

resists series Comminuted comminuted: may
displacement CT: Not usually require patellectomy
Do not needed
confuse with

bipartite
patella
COMPLICATIONS: Osteoarthritis and/or pain, Decreased motion and/or strength; Osteonecrosis;
Refracture
TIBIAL PLATEAU FRACTURE
Mechanism:
• Direct blow Schatzker (6 types):
(e.g. MVA) I. Lateral
Intraarticular HX: Trauma. plateau split fx
• Cannot bear
fracture II. Lateral +/- Aspirate
weight. Pain, hemarthroses
Restoration of swelling. split/depression
articular fx Undisplaced (6 mm):
• /PE: Effusion,
surface is cast, ROM at 6 wks,
tenderness, do III. Lateral
important WB 3mos.
good plateau
Most often neurovascular PE depression Displaced/unstable:

lateral ORIF: plates and
XR: Knee trauma IV. Medial
Metaphyseal plateau split fx screws +/- bone
series graft
injury: bone
CT: Better defines V. Bicondylar
compresses, Mobilize early,
• fracture. plateau fx
leads to weight- bear at 2
functional AGRAM: if VI. Fx with months
bone loss. pulseless metaphyseal-
diaphyseal
Associated
• separation
with ligament
injuries
COMPLICATIONS: Compartment syndrome; Hardware failure or loss of reduction; OA; Popliteal
artery or nerve injury
KNEE DISLOCATION
Rare: Ortho

emergency
HX: Trauma. Pain, Early reduction
Usually high
• inability to bear essential Post
energy injury
weight. By position: reduction neuro-
Ligaments logic exam and x-
other soft PE: Effusion, Anterior
• rays.
tissue are deformity, pain, +/-
Posterior Immobilize (cast): 6-
disrupted distal pulses
peroneal nerve Lateral 8 wks (not if
High function ligaments torn)
Medial
incidence of
XR: AP/lateral Rotatory: Open: If irreducible,
associated
• Anteromedial vascular injury (+/-
fracture AGRAM: ID arterial
or anterolateral. pro-phylactic
neurovascular injury fasciotomy), early
injury MR: Ligament repair of ligaments if
Close follow injury needed.
• up is important
for good result
COMPLICATIONS: Neurovascular: Popliteal artery, peroneal nerve injury; Decreased motion;
Instability
DESCRIPTION EVALUATION CLASSIFICATION TREATMENT
TIBIA SHAFT FRACTURE
HX: Trauma.
Common long Cannot bear

bone fracture weight, pain,
• Young adults swelling. Stable, non or minimally
Often tibia/fibula PE: Swelling, Descriptive: displaced, closed injury:
fracture or tibia deformity, +/- Long leg cast 4-6 wks
tense Location then shorter cast
• fracture/dislocation
combination compartments Displaced/comminuted Unstable, displaced,
injuries open wound. Type: transverse, spiral comminuted injury:
Palpate pulse oblique ORIF Intramedullary
Tenuous blood
• supply: union is a XR: AP/lateral Rotation/angulation nails (external fixation
problem. leg, + knee for severe open
and ankle fractures)
Up to 5% residual series
• angulation is
acceptable AGRAM: if
pulseless
COMPLICATIONS: Malunion/nonunion: especially mid-distal 1/3; Compartment syndrome; Decreased
motion; Hardware failure; Neurovascular injury; Reflex Sympathetic Dystrophy (RSD)
MAISONNEUVE FRACTURE
HX: Trauma.
Complete Ankle pain, +/-
syndesmosis knee pain.
• disruption with
PE: Ankle
diastasis proximal
pain, swelling,
fibula fracture Reduce and stabilize
+/- knee
syndesmosis with a screw
Variant of ankle signs.
• fracture deltoid
XR: Knee
ligament rupture
series with
• Unstable fracture each ankle
fracture
COMPLICATIONS: Ankle instability; Ankle arthritis
PILON (DISTAL TIBIA) FRACTURE
HX: Trauma.
Intraarticular: Cannot bear
through distal weight, pain,

articular/WB swelling
surface.
PE: Effusion, Ruedi-Allgower (3 types): Nondisplaced: Long leg
Comminution tenderness, I. Non or minimally cast NWB for 6 wks

common do good displaced. Displaced/Comminuted:
Associated soft neurovascular II. Displaced: articular ORIF: plates screws +/-
• PE
• PE
tissue injuries surface incongruous. bone grafting
Articular surface XR: AP/lateral III. Comminuted Severely comminuted:
• repair is difficult (obliques) articular surface. external fixation
essential CT: Needed:
Healing is often better image
• of articular
slow
surface
COMPLICATIONS: Post-traumatic Osteoarthritis (almost 100% in comminuted fractures); Decreased
motion; Malunion/nonunion

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

KNEE JOINTS

SUPPORT ATTACHMENTS COMMENTS


FEMORAL/TIBIAL: CONDYLOID
ANTERIOR
Patellofemoral joint See page 212

Anterior cruciate (ACL) Tibial eminence to medial


Prevents anterior translation, tight in
aspect of lateral femoral condyle flexion, must reconstruct if injured
Transverse meniscal
Anterior menisci Meniscus support stability
ligament
MEDIAL
Between femoral condyle tibial
Meniscus More crescentic than lateral
plateau
Capsule (III) Surrounds joint Minimal support

Medial collateral (MCL) Medial epicondyle to tibia (II) Superficial (II) and Deep (III) portion
meniscus (III)
Coronary ligament (III) Meniscus to medial tibia Stabilizes meniscus
Semimembranous
Attach to posterior tibial condyle
membrane (II)
Pes anserinus tendons
Medial tibial condyle Tendinitis can occur at insertion
(I)
LATERAL

Meniscus Between femoral condyle tibial More circular than medial


plateau
Popliteus muscle
Proximal tibia Intraarticular tendon
tendon
Capsule (III) Surrounds joint Minimal support
Posterolateral femoral condyle
Arcuate ligament (III) Covers popliteus tendon
to fibular head
Fabellofibular ligament
Fabella to fibula Variable
(III)
Lateral collateral (LCL) Lateral femoral condyle to
Prevents varus angulation
Prevents varus angulation
(III) fibular head
Biceps muscle tendon
Gerty's tubercle fibular head
(I)
Iliotibial band (I) Lateral tibial condyle If tight, ITB syndrome can occur
POSTERIOR
Capsule (III) Surrounds joint Minimal support
Posterior lateral meniscus to
Ligament of Humphrey In front of PCL
medial femoral condyle
Posterior cruciate Tibial sulcus to anterior medial
Prevents posterior translation
(PCL) femoral condyle
Posterior lateral meniscus to
Ligament of Wrisberg Behind the PCL
medial femoral
condyle
Oblique popliteal Semimembranous to lateral Derived from semimembranous
ligament femoral condyle
Gastrocnemius/plantaris Origin: posterior medial lateral
Two heads originate above knee
muscle femoral condyles
SUPPORT ATTACHMENTS COMMENTS
PATELLOFEMORAL
Quadriceps tendon Attach on superior patellar pole Superior extensor mechanism
Inferior patella pole to tibial
Patellar ligament (tendon) Inferior extensor mechanism
tuberosity
Medial lateral retinaculum Quadriceps extensions to Stabilizes patella in motion.
(quadriceps oblique fibers) (II) patella, then to tibial condyles Can affect Q angle if tight
Medial lateral patellofemoral
Patella to femoral condyles Stabilizes patella
ligaments (II)
Medial lateral patellotibial
Patella to tibial condyles Stabilizes patella
ligaments
PROXIMAL TIBIOFIBULAR : Plane
Anterior ligament of head of
Fibula head to lateral tibia Broader than posterior
fibula
Posterior ligament of head of
Fibula head to lateral tibia Weaker than anterior
fibula
OTHER STRUCTURES
Interosseous membrane Lateral tibia to medial fibula Strong; runs length of leg
• Three compartments in the knee: Medial, Lateral, Patellofemoral
• Meniscus: Made of fibrocartilage. Function: 1) Protects articular cartilage (increases weight
bearing surface area, 2) Stabilizes by deepening facet, 3) Load transmission
Peripheral 1/3 vascular (geniculate arteries): can be repaired; Inner 2/3 supplied by synovial fluid:
must debride in injured
• There are three layers of support in the knee: I, II, III (noted in parentheses next to structure)
• Posterolateral corner complex: Arcuate ligament, popliteus, posterolateral capsule
• Muscles attaching at the pes anserinus: sartorius, gracilis, semitendinosus

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MINOR PROCEDURES: KNEE

STEPS
ARTHOCENTESIS/INJECTION
1. Ask patient about allergies
2. Place patient supine, knee extended, palpate the lateral patella and lateral distal femur.
3. Prepare skin over the knee (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
5. Insert an 18 gauge needle laterally into the suprapatella pouch (between the patella and femur)
proximal to the joint. Aspirate fluid from joint (or inject 3-5cc of local/steroid preparation). Fluid
should flow easily if needle is in joint.
6. If suspicious of infection, send fluid for GS culture.
7. Dress injection site

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY

QUESTION ANSWER CLINICAL APPLICATION


1. AGE Young Trauma: fractures, ligamentous or meniscal injury
Middle age, Arthritis
elderly
2. PAIN
Trauma: fracture, dislocation, soft tissue
a. Onset Acute
(ligament/meniscus) injury, septic bursitis
Chronic Arthritis, infection, tendinitis/bursitis, tumor
Quadricep or patellar tear or tendinitis, prepatellar
b. Location Anterior
bursitis, patellofemoral arthritis

Posterior Meniscus tear (posterior horn), Baker's cyst, popliteal


aneurysm
Meniscus tear (jointline), collateral ligament injury,
Lateral
arthritis, ITB friction syndrome
Meniscus tear (jointline), collateral ligament injury,
Medial
arthritis, pes bursitis
c. Occurrence Night pain Tumor, infection
With activity Etiology of pain likely from joint
3. STIFFNESS Without locking Arthritis, effusion (trauma, infection)
With locking or Loose body, meniscal tear (especially bucket handle),
catching arthritis, synovial plica
4. SWELLING Within joint Infection, trauma
Acute (post Acute (hours): ACL injury; Subacute (day): meniscus
injury) injury
Acute (without
Infection: prepatellar bursitis, septic joint
injury)
Giving
5. INSTABILITY Cruciate ligament injury, extensor mechanism injury
away/collapse
Giving away,+/- Patellar subluxation/dislocation, pathologic plica,
pain osteochondritis dissecans

6. TRAUMA Mechanism: MCL injury (+/- terrible triad: MCL, ACL, medial
valgus force meniscus injuries)
Varus force LCL injury
Flexion/posterior PCL injury (e.g. dashboard injury)
force
Contact injury Non-contact: ACL injury, Contact: multiple ligaments
Cruciate ligament injury (especially ACL),
Popping noise
osteochondral fracture
NONE Degenerative and overuse etiology
7. ACTIVITY Agility sports Cruciate and/or collateral ligament injury
Running, cycling,
Patellofemoral etiology
climbing
Squatting Mensicus tear
Distance able to ambulate equates with severity of
Walking
arthritic disease
8. NEUROLOGIC Pain, numbness,
Neurologic disease, trauma
SYMPTOMS tingling
9. SYSTEMIC
Fevers, chills Infection, septic joint
COMPLAINTS
10. HISTORY OF Multiple joints
Rheumatoid Arthritis, gout, etc.
ARTHRITIDES involved

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAM TECHNIQUE/FINDINGS CLINICAL APPLICATION


INSPECION

Gait Observe patella tracking Abnormal patella tracking can lead to patellofemoral
problems

Flexed knee gait Tight Achilles tendon or hamstrings: patellofemoral


problems
Genu valgum (knock knee) Normal: 7 degrees valgus; varus or valgus deformity
Anterior
Genu varum (bow leg) with ligamentous or osseous deficiency

Swelling Effusion (arthritis, trauma, infection/inflammation),


bursitis (prepatellar, infrapatellar)
Posterior Swelling, mass Effusion (arthritis), Baker's cyst
Back knee, high/low riding Genu recurvatum (PCL injury), patella alta (patellar
Lateral
patella instability)
Vastus medialis atrophy: can lead to patellofemoral
Musculature Atrophy
problems
PALPATION
Bony Patella: medial lateral Tenderness at distal pole: tendinitis (Jumpers knee)
structures aspects
Tibial tubercle Tenderness with Osgood Schlatter disease

Soft tissues Compress suprapatellar Ballotable patella (effusion): arthritis, trauma, infection
pouch (“milk” knee)
Prepatellar/infrapatellar Edematous or tender bursae indicate correlating
bursae bursitis
Pes anserine bursa Tenderness indicates bursitis
Plica (medial to patella) Thickened, tender plica is pathologic
Medial jointline MCL Tenderness: medial meniscus tear or MCL injury
Lateral jointline LCL Tenderness: lateral meniscus tear or LCL injury
Iliotibial band (anterolateral
Pain or tightness is pathologic
knee)

Popliteal fossa Mass consistent with Baker's cyst, popliteal aneurysm


Compartments of leg
Firm or tense compartment: Compartment syndrome
(anterior, posterior, lateral)
EXAM TECHNIQUE/FINDINGS CLINICAL APPLICATION
RANGE OF MOTION
Flexion Supine: knee to chest,
Normal: Flex 0 to 125-135°, Extend 0 to 5-15°;
extension then straight
Extensor lag (final 20° difficult): weak quadriceps;
Decreased extension with effusion
Note patellar tracking, Abnormal tracking leads to anterior knee pain; pain
pain, crepitus crepitus: arthritis
Stabilize femur, rotate
Tibial IR ER Normal: 10-15° IR ER
tibia
NEUROVASCULAR
Sensory
Femoral nerve Medial leg (Medial
Deficit indicates corresponding nerve/root lesion
(L4) cutaneous nerves)
Peroneal nerve Lateral leg (common
Deficit indicates corresponding nerve/root lesion
(L5) superficial)

Tibial nerve (S1) Posterior leg (Sural Deficit indicates corresponding nerve/root lesion
nerves)
Motor
Femoral nerve
Knee extension Weakness = Quadriceps or nerve/root lesion
(L2-4)
Sciatic: Tibial
Knee flexion Weakness = Biceps (LH) or nerve/root lesion
(L4-S3)
Peroneal (L4-
Knee flexion Weakness = Biceps (SH) or nerve/root lesion
S2)
Tibial nerve (L4- Foot plantarflexion
Weakness = TP, FHL, FDL or nerve/root lesion
S3)
Peroneal (deep) Foot dorsiflexion
Weakness = TA, EHL, EDL or nerve/root lesion
n. (L4-S2)
Reflex
L4 Patellar Hypoactive/absence indicates L4 radiculopathy
Pulse Popliteal

EXAM TECHNIQUE/FINDINGS CLINICAL APPLICATION


SPECIAL TESTS
Q
ASIS to mid-patella to tibia Normal: 13° male, 18° female; Increased angle:
(quadriceps) tubercle
PF Syndrome, subluxation
angle
Extend knee: fire quads, Pain: patellofemoral joint pathology, patella
Patella grind
compress patella chondromalacia
Patella
Relax knee: push patella lateral Pain/apprehension: subluxation; Medial
apprehension retinaculum injury
Flex/ER leg/valgus force, then Pop/click on extension indicates medial meniscal
McMurray
extend knee tear
Flex/IR leg/varus force, then Pop/click on extension indicates lateral meniscal
extend knee tear
Apley Prone: knee 90°, compress
Pain/popping: meniscal injury, arthritis
compression rotate tibia
Ligament
Stability
Tests

Valgus stress Lateral force: knee at: 1) 30°,


Laxity at: 1) 30°: MCL, at 2) 0°:
2) 0° MCL/PCL/posterior capsule injury
Medial force: knee at 1) 30° 2) Laxity at: 1) 30°: LCL, at 2) 0° LCL/PCL/posterior
Varus stress
0° capsule injury
Flex knee 30°: anterior force Laxity/displacement: ACL injury (most sensitive
Lachman
on tibia exam for ACL)
Anterior Flex knee 90°: anterior force
Laxity/displacement: ACL injury
drawer on tibia
Posterior Flex knee 90°: posterior force
Posterior translation: PCL injury
drawer on tibia
Supine: hip 45°/knee 90°:
Posterior sag Posterior translation of tibia on femur: PCL injury
lateral view
Quadriceps Supine: flex knee 90°, fire Posterior translated tibia will translate anterior
active quadriceps when quadriceps fire: PCL injury
Supine: extend knee, IR, valgus Clunk with flexion: AnteroLateral Rotary Instability
Pivot shift force on proximal tibia, then
(ALRI): ACL and/or posterior capsule injury
flex
Supine: knee at 45°, ER, Clunk with extension: PosteroLateral Rotary
Reverse pivot
valgus force on proximal tibia, Instability (PLRI): PCL and/or Posterolateral
shift
extend corner injury
Knee 90°, ER foot 15°, anterior
Slocum Displacement: AnteroMedial Rotary Instability
force
Knee 90°, IR foot 30°, anterior Displacement: AnteroLateral Rotary Instability
force (ALRI): ACL injury
Posterior Knee 90°, ER foot 15°, Displacement: PosteroLateral Rotary Instability
lateral drawer posterior force (PLRI): PCL/corner
Posterior
Knee 90°, IR foot 30°, posterior Displacement: PosteroMedial Rotary Instability
medial
force (PMRI): PCL
drawer
Prone ER at Prone: ER both knees at: Increased ER at: 1) 30: PL corner, 2) 90: PCL PL
30° 90° 1)30°, 2)90° corner injury
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: ORIGINS AND INSERTIONS

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Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: ANTERIOR COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Lateral tibia, Medial cuneiform,
Tibialis Deep Dorsiflex Test L4 motor
interosseous base of 1 st
anterior [TA] peroneal invert foot function
membrane metatarsal
Extensor Medial fibula, Base of distal Dorsiflex
Deep Test L5 motor
hallucis longus interosseous phalanx of great
peroneal extend great function
[EHL] membrane toe toe
Dorsiflex
Extensor Lateral tibia Base of middle Single tendon
condyle proximal distal phalanges (4 Deep
extend
digitorum divides into four
peroneal lateral 4
longus [EDL] fibula toes) tendons
toes
Distal fibula,
Peroneus Base of 5 th Deep Dorsiflex Often adjoined to
interosseous
tertius metatarsal peroneal Evert foot the EDL
membrane

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Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: LATERAL COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

Peroneus Proximal Medial cuneiform, base Superficial Evert, Test S1 motor function.
lateral
longus of 1 st MT (plantarly) peroneal plantar flex Runs under the foot
fibula foot

Peroneus Distal Superficial Can cause avulsion fx


lateral Base of 5 th metatarsal peroneal Evert foot
brevis at base of 5 th MT
fibula

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Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: SUPERFICIAL POSTERIOR COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

Lateral and medial Calcaneus (via Plantarflex Test S1 motor


Gastrocnemius femoral condyles
Achilles tendon) Tibial
function Has two
foot
heads
Posterior fibular
Calcaneus (via Plantarflex Fuses to
Soleus head/soleal line of
Achilles tendon) Tibial
gastrocnemius at
foot
tibia Achilles tendon

Lateral femoral Plantarflex Short muscle belly


Plantaris Calcaneus Tibial is proximal, has a
supracondylar line foot
long tendon.

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: DEEP POSTERIOR COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


Proximal Flex ( IR) Anterior distal to
Popliteus Lateral condyle Tibial
posterior tibia knee LCL on femur
Flexor Base of distal
Plantarflex Test S1 motor
hallucis Posterior fibula phalanx of great Tibial
great toe function
longus [FHL] toe
Flexor Bases of distal Plantarflex At ankle, tendon is
digitorum Posterior tibia phalanges of 4 Tibial lateral 4 just anterior to
longus [FDL] toes toes tibial artery.
Posterior, Tendon can
Navicular
Tibialis interosseous Plantarflex degenerate
tuberosity, Tibial
posterior [TP] membrane, tibia, invert foot rupture: 2° pes
cuneiform, MT's
fibula planus

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Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: CROSS SECTIONS

SUPERFICIAL
ANTERIOR LATERAL DEEP POSTERIOR
POSTERIOR
MUSCLES
Tibialis anterior [TA] Peroneus longus Gastrocnemius Popliteus
Extensor hallucis longus Flexor hallucis longus
Peroneus brevis Soleus
[EHL] [FHL]
Extensor digitorum Flexor digitorum longus
Plantaris
longus [EDL] [FDL]
Peroneus tertius Tibialis posterior [TP]
NEUROVASCULAR

Deep peroneal nerve Superficial peroneal NONE Tibial nerve


nerve
Anterior tibial artery and Posterior tibial artery
vein and vein
Peroneal artery and
vein

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Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

LUMBAR PLEXUS
POSTERIOR DIVISION
1. Femoral (L2-4):
Sensory: Medial leg: via medial cutaneous nerve (Saphenous N)
Motor: NONE (in leg)

SACRAL PLEXUS
ANTERIOR DIVISION
2. Tibial (L4-S3): descends between heads of gastrocnemius to medial malleolus
Sensory: Posterolateral proximal calf: via Medial sural
Posterolateral distal calf: via Sural
Motor: SUPERFICIAL POSTERIOR COMPARTMENT OF LEG
Soleus: via nerve to soleus
Plantaris
Gastrocnemius
DEEP POSTERIOR COMPARTMENT OF LEG
Popliteus: via nerve to popliteus
Tibialis posterior [TP] (Tom)
Flexor digitorum longus [FDL] (Dick)
Flexor hallucis longus [FHL] (Harry)
POSTERIOR DIVISION
3. Common peroneal (L4-S2): in groove between biceps lateral head of Gastrocnemius. Wraps
around fibular head, deep to peroneus longus, then divides. Can be injured in lateral approach to
the knee.
Sensory: Proximal lateral leg: via Lateral sural
Distal lateral leg: via superficial peroneal
Motor: ANTERIOR COMPARTMENT of LEG:
Deep Peroneal Nerve
Tibialis anterior [TA]
Extensor hallucis longus [EHL]
Extensor digitorum longus [EDL]
Peroneus tertius
LATERAL COMPARTMENT of LEG:
Superficial Peroneal Nerve
Peroneus longus
Peroneus brevis
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Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

COURSE BRANCHES SUPPLY/COMMENT


POPLITEAL
All four arteries
Through popliteal fossa. Terminates at the popliteus Superior Inferior anastomose around
muscle. Medial Geniculate knee patella (supply
meniscus)
Superior Inferior
Lateral Geniculate
Cruciate ligaments
Middle Geniculate
synovium
Anterior Posterior
Terminal branches
Tibial
ANTERIOR TIBIAL
Supplies muscles of the ANTERIOR
COMPARTMENT
Through 2 heads of Tibialis Posterior interosseous
membrane. Then lies on anterior surface of the Anterior Tibial
Supplies knee
membrane with deep peroneal nerve, between TA recurrent
and EHL.
Anterior Medial
Supplies ankle
malleolar
Anterior Lateral
Supplies ankle
malleolar

Dorsalis Pedis Terminal branch in


foot
POSTERIOR
TIBIAL
Supplies muscles of the POSTERIOR
COMPARTMENT
From popliteal, through posterior compartment with
Posterior Tibial
tibial nerve to behind medial malleolus (between Supplies the knee
recurrent
FDL FHL).
LATERAL
Peroneal artery COMPARTMENT
Posterior medial
malleolar
Perforating/muscular
branches
Medial calcaneal
Medial Lateral Terminal branches in
plantar sole
PERONEAL
Supplies muscles of the LATERAL
COMPARTMENT
From posterior tibial between tibialis posterior and Posterior lateral
Terminal branch
FHL. malleolar
Lateral calcaneal
Artery

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Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS

WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
ANTERIOR FAT PAD SYNDROME (Hoffa disease)
• Fat pad (under XR: AP/Lateral:
patellar tendon) Hx: Intermittent possible patella 1. RICE, activity modification
is pinched (2° to anterior knee pain baja
trauma)
PE: +/- click with
2. Surgical excision (rare)
motion
ARTHRITIS: INFLAMMATORY
• Synovitis Hx: Any age
(pannus
(disorder
formation)
dependent), female XR: Arthritis 1. Early: medical management
destroys articular
male, multiple joints, series
cartilage and
AM pain.
joint
Late:
Labs: RF, ESR, a) Conservative: like OA
• RA, Gout,
SeroNegative PE: +/- warm, CRP, ANA, 2. Operative:
effusion, crepitus CBC, crystals,
arthropathy b) 1. Synovectomy
culture
2. Total knee

ARTHRITIS: OSTEOARTHRITIS
Hx: Elderly, pain
• Primary or (worse with activity XR: Arthritis
or weight bearing), 1. NSAIDs, Physical Therapy
posttraumatic series
stiffness,
sticking/grinding.
PE: Effusion,
• Loss or jointline tenderness, 1. joint space
damage to +/- angular 2. Injection, activity modification (cane)
narrowing
articular cartilage deformity (varus #1)
or contracture.
• Knee (Medial
compartment) #1 2. osteophytes 3. Fusion (young/worker)
site
• All 3
compartments 3. subchondral 4. High tibial osteotomy (young, 1
are possible sclerosis compartment disease)
sites
5. Total Knee Arthroplasty (old, 1
4. bony cysts
compartment)
BAKER'S CYST
• Posterior knee Hx: Stiffness, +/- XR: AP/lateral:
1. Aspiration initially
(popliteal fossal) knee tenderness normal
• Arises from MM MR or
or hamstring PE: Mass in aspiration: 2. Surgical resection for recurrence or
tendon (may popliteal fossa confirm pain
communicate) diagnosis
BURSITIS: PREPATELLAR (Housemaid's knee)
XR: AP/lateral:
• Continuous
normal rule out
irritation of bursa
leads to Hx: Pain with activity infection 1. NSAID, knee pads, injection
(common
inflammation
problem)
• Most common PE: “egg” shaped
2. Bursal removal (rare)
bursitis in knee swelling over patella
3. Treat infection if present
BURSITIS: PES ANSERINE
• Bursa under
tendon insertion XR: AP/lateral:
Hx: Pain in medial
inflamed normal+/- OA, 1. NSAID, activity modification, stretch
knee
(overuse, runner, rule out tumor
etc.)
PE: Pes anserine
2. Partial excision (rare)
tenderness
DESCRIPTION HP WORK-UP/FINDINGS TREATMENT
CHONDROMALACIA: PATELLOFEMORAL SYNDROME [PFS]
1. Physical
XR: AP/lateral/sunrise
• Damage or softening of Hx: Anterior knee pain, therapy:
to evaluate alignment.
the patellar articular worse with sitting (theater Rule out patellofemoral quadricep
cartilage. sign), and/or stairs OA strengthening
stretching
• Multiple etiologies: PE: +/- VMO atrophy,
trauma, dislocation, valgus deformity, high Q 2. Orthosis if
malalignment leads to angle, patellar patella subluxes
patellofemoral OA apprehension, + crepitus
3. Lateral
release (early)
4. Tibial
tuberosity
realignment
COMPARTMENT SYNDROME

Hx: 5 P's: pain, Compartment 1. Fasciotomy


• Increased pressure in parathesias, pulseless, pressures: 40 mmHg within 4 hours
closed space pallor, paralysis. (normal: 0-10 mmHg) (Usually two
incisions)
• From: trauma, (e.g. PE: Firm compartments 2. Debride
fracture, burn, vascular nonviable soft
(check all three)
injury, overexertion) tissue.
• Results in nerve injuries
soft tissue necrosis
ILIOTIBIAL BAND FRICTION SYNDROME
1. NSAID,
• ITB rubs on lateral XR: AP/lateral: normal activity
Hx: Pain with activity
femoral condyle Rule out tumor modification,
stretching

• Common in runners, PE: Lateral femoral 2. Partial


cyclists condyle TTP (knee at 30° excision (rare)
flexion)
DESCRIPTION HP WORK-UP/FINDINGS TREATMENT
MENISCUS INJURY: TEAR
• Young: XR: AP (extension 30°
Hx: Pain, catching/locking 1. Conservative for
trauma/twisting flexion)/lateral/sunrise, +/-
(esp. bucket-handle tears) minor symptoms
injury arthrocentesis
• Old: PE: Effusion, jointline 2. Debride (inner
Degeneration/squat tenderness, + McMurray test 2/3 lesion)
injury

• Seen with ACL 3. Repair (outer 1/3


injuries or longitudinal
lesion)
• Medial lateral Improved results
(cysts develop) with ACL repair
OSTEOCHONDRITIS DISSECANS

• Subchondral bone Hx: Insidious onset knee XR: AP/lateral: shows 1. Often
radiolucency, +/- fragment spontaneously
injury pain
or loose body heals in children
• Unknown etiology: PE: Crepitus on flexion 2. Adults: drill lesion
AVN, repetitive extension, femoral condyle vs. bone
microtrauma tender to palpation graft/chondroplasty
• Lateral aspect of
medial femoral
condyle #1
DESCRIPTION HP WORK-UP/FINDINGS TREATMENT
PLICA
• Synovial tissue
(embryonic remnant) Hx: Anteromedial knee XR: AP/lateral
1. NSAIDs
thickens rubs medial pain, catching/popping Arthrography
femoral condyle.
• Medial patellar plica: PE: Palpable plica, 2. Activity
#1 jointline tenderness modification
3. Arthroscopic
debridement
PATELLAR COMPRESSION SYNDROME
• Compression of
1. Quadriceps
patella due to tight Hx: Anterior knee pain XR: AP/lateral: normal strengthening
lateral retinaculum
PE: Lateral patella
2. Lateral release of
(facet) tender to retinaculum
palpation
PATELLAR INSTABILITY
• Spectrum: XR: AP/lateral/sunrise:
malalignment-recurrent Hx: Knee buckles, +/- Lateral displacement 1. PT: VMO
subluxation-instability- pain of the patella. +/- strengthening
dislocation patella alta
PE: +/- genu valgum,
• Usually lateral, leads to increased Q angle, VMO 2. Orthosis for
OA atrophy, + patellar subluxation
apprehension
3. Lateral release,
realignment
procedures
(especially for
MMS)
Miserable Malalignment Syndrome (MMS): associated with femoral anteversion, increased Q
angle, genu valgum
WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
PATELLAR TENDINITIS: JUMPER'S KNEE
• Seen in jumpers Hx: Sports, anterior knee XR: AP/lateral: 1. NSAIDs, strengthen
(e.g. basketball quadriceps [no steroid
pain normal
volleyball players) injection-tendon rupture]

PE: Patella: inferior pole MR: Increased


signal in 2. Debride tendon (rare)
tender to palpation
inferior pole
PATELLAR TENDON (LIGAMENT) RUPTURE
• Direct trauma (also Hx: Young, history of XR: AP/lateral:
systemic/metabolic relative patella Primary surgical repair
trauma
disorders) alta
PE: Decreased or no
• Quadriceps patella
active extension, +
tendon rupture
palpable defect
QUADRICEPS TENDON RUPTURE
XR: AP/lateral:
• Result of minor Hx: Older, cannot
trauma actively extend knee relative patella Primary surgical repair
baja
• Metabolic disorders PE: Palpable defect or
weaken tendon sulcus
TUMORS
#1 in Adolescents: Osteosarcoma; #1 in Adults: Chondrosarcoma; #1 benign (young adult): Giant
cell

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Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS: LIGAMENT INJURIES

WORK-
DESCRIPTION HP TREATMENT
UP/FINDINGS
ANTERIOR CRUCIATE (ACL)
XR:
• Twisting injury, often 1. Closed chain
no contact Hx: “Popping,” swelling AP/lateral/sunrise:+/- exercises
capsular avulsion

• Associated with PE: Effusion. + Lachman, Arthrocentesis (+ /-): 2. Reconstruction


needed (usually
MCL meniscus tear anterior drawer and pivot shifts 70% have
(all 3 = Terrible Triad) tests (Lachman most sensitive) hemarthrosis after several weeks
of rehabilitation)
• Segond fracture: MR: confirms
avulsion fx diagnosis
POSTERIOR CRUCIATE (PCL)
• Anterior force on XR: AP/lat/sunrise: 1. Non-operative:
flexed knee (e.g. Hx: Pain, unable to ambulate
+/- avulsion fracture crutches
dashboard)

• Also with other PE: + posterior drawer, MR: confirms 2. Quadriceps


strengthening
ligament njuries posterior sag, quad active tests diagnosis
(Complication: OA)
MEDIAL COLLATERAL (MCL)
• Valgus force XR: AP/lateral: 1. Hinged knee
Hx: Medial knee pain
(football clip) possibly an avulsion. brace
• Graded 1, 2 2. Physical therapy:
PE: Laxity and/or pain with
(partial), 3 early ROM
valgus stress (at 30° flexion)
(complete) strengthening
LATERAL COLLATERAL (LCL)
• Varus force XR: AP/lateral: 1. Nonoperative:
Hx: Trauma. Pain swelling
(isolated, rare) possibly an avulsion. see MCL
• Associated with PE: Laxity pain with varus 2. Surgical for
other ligament and
stress (at 30°). Test for foot grade III (usually
peroneal nerve
drop combination injury)
injuries
Isolated PCL, MCL, and LCL injuries are primarily treated non-operatively; operative repair is
used when these injuries occur in combination.
POSTEROLATERAL CORNER COMPLEX (PLC)
• Often with PCL Early surgical
Hx: Pain, instability XR: AP/lateral
injury repair
PE: Increased ER at 30°
• LCL torn flexion, + posterolateral drawer
test
• Popliteofibular
ligament torn

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Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS

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Copyright © 2001 Saunders, An Imprint of Elsevier

TOTAL KNEE ARTHROPLASTY

KEYS TO TOTAL KNEES

GENERAL INFORMATION

Implants: unlike hip, all are cemented (to reduce complications with loosening)
Cement: Polymethylmethacralate
• Femoral condylar and tibia components are
metallic
Tibial component surface plate: Polyethylene
INDICATIONS

End stage DJD: results in disabling pain in knee secondary to arthritis in 2 +


compartments (medial lateral patellofemoral).
• Common etiologies: OA, RA, AVN
Most patients complain of PAIN, worsening over time (wakes them from

sleep), and decreased ability to ambulate
Patient should have appropriate radiographic evidence of arthritis
OSTEOARTHRITIS RHEUMATOID ARTHRITIS
1. Joint space narrowing 1. Joint space narrowing
2. Sclerosis 2. Periarticular osteoporosis
• 3. Subchondral cysts 3. Joint erosions
4. Osteophyte formation 4. Ankylosis
1.
It is preferable that the patient is elderly (needs only one

replacement)
Failed conservative treatment: activity modification, weight loss, orthosis,
2. physical therapy/strengthening, NSAIDs, ambulation assistance (cane,
walker, etc.), injections.
CONTRAINDICATIONS

• Young, active patient (will wear out replacement many times)


• Knee extensor mechanism dysfunction
• Medically unstable (e.g. severe cardiopulmonary disease)
• Neuropathic joint
• Any infection

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Copyright © 2001 Saunders, An Imprint of Elsevier

TOTAL KNEE ARTHROPLASTY

KEYS TO TOTAL KNEES

ALTERNATIVES

• Considerations: Age, activity level, overall health


Osteotomy: for unicompartmental disease, young, active (not in elderly patients)
Medial compartment (varus deformity): high tibial osteotomy

Lateral compartment (valgus deformity): distal femoral
osteotomy
• Arthrodesis/Fusion: totally destroyed, neuropathic, or septic joint
Unicompartment arthroplasty: for unicompartment disease. Only in selected patients

not eligible for osteotomy.
PROCEDURE

• Medial parapatellar approach used (lateral parapatellar for severe valgus deformity)
• ACL is sacrificed
Using specialized guides, the distal femur and proximal tibia are removed and
replaced with metallic/plastic components.

Underside of patella also
replaced.
• Flexion and extension gap should be equal
COMPLICATIONS

• Infection: often leads to removal of prosthesis (Staph #1)


• Loosening of components
• Patellofemoral joint pain
• Decreased ROM (usually from inadequate postoperative physical therapy)
• Patella fracture
• Superolateral geniculate artery is at risk
• Fat embolism
• Peroneal nerve palsy
Deep Venous Thrombosis (DVT)/Pulmonary emboli: patients should be

anticoagulated (Heparin/warfarin) postoperatively

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PEDIATRIC DISORDERS

DESCRIPTION EVALUATION TREATMENT/COMPLICATIONS


GENU VARUM: BOW LEGS
• Normal: neonate to 2 yrs 1. Most resolve spontaneously
Hx: Parents observe deformity
old with normal development
• Etiology: PE: Measure tibiofemoral angle 2. Night bracing rarely required
XR: Only large deformity or if
1. Blount's disease 3. Osteotomy if persistent (15°)
concerned about dysplasia.
2. Rickets (nutritional)
3. Skeletal dysplasia
4. Trauma
GENU VALGUM: KNOCK KNEES
1. Most resolve spontaneously
• Normal for 2 yrs to 4 yrs Hx: Parents observe deformity
with normal development
• Adult: 5-10° valgus is
PE: Measure tibiofemoral angle 2. Surgery if persists past age 10
normal
XR: Only large deformity or if
• Etiology:
concerned about dysplasia.
1. Rickets (renal)
2. Skeletal dysplasia
3. Trauma
OSGOOD SCHLATTER DISEASE
• Osteochondritis/traction
Hx: Early adolescent. Knee pain
apophysitis of tibial tubercle worse after activity 1. Activity restriction/modification
(at 2° ossification center)
(at 2° ossification center)
• From repetitive extensor 2. Most resolve with fusion of
PE: Pain, swelling at tubercle
(quadriceps) pull on tubercle apepnysis in midadolesence
XR: Knee AP/lateral: may show
heterotopic ossification
TIBIAL TORSION
• Congenital IR of tibia
Will resolve spontaneously
(associated with intrauterine Hx: 1-2 yo, often tripping, no pain
(between 24-48 months)
position)
PE: Negative foot to thigh angle
(normal 10-30°),with
• Often bilateral
knee/patella pointed forward,
intoeing gait observed

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SURGICAL APPROACHES

USES INTERNERVOUS PLANE DANGERS COMMENT


KNEE: MEDIAL PARAPATELLAR APPROACH
1. Infrapatellar
1. Ligament No planes: Capsule is 1. Most commonly used
branch of
reconstruction under skin approach
Saphenous Nerve
2. Total knee
2. Most/best exposure
arthoplasty
3. 3. Neuroma may develop from
Meniscectomy cutaneous nerves
LEG/TIBIA: POSTEROLATERAL APPROACH (Harmon)
1. 1. Lesser saphenous 1. A technically difficult
1. Fractures Gastrocnemius/soleus/FHL vein
approach
[Tibial]
2. Peroneus longus/brevis 2. Posterior tibial
2. Nonunions 2. Bone grafting of nonunion
[Superficial peroneal] artery
ARTHROSCOPY PORTALS
1. Anterior horn of Used to view lateral
Just above joint line,
Anteromedial medial menicus compartment
1 cm inferior to patella
1 cm medial to patellar
ligament
1. Used to view medial
2. Anterior horn of
Just above joint line, compartment, ACL, and
Anterolateral lateral meniscus
menisci
1 cm inferior to patella
1 cm lateral to patellar 2. PCL posterior structures
ligament hard to see

3. 2.5 cm above joint line, Used to view patellofemoral


articulation, patella tracking,
Superolateral lateral to quadricep tendon
Superolateral lateral to quadricep tendon
etc.
Flex knee to 90°, 1 cm
4. Used to view PCL, posterior
posterior to femoral
Posteromedial horns of menisci
condyle

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CHAPTER 9 - FOOT/ANKLE
TOPOGRAPHIC ANATOMY
OSTEOLOGY
TRAUMA
ANKLE JOINTS
FOOT JOINTS
OTHER STRUCTURES
MINOR PROCEDURES
HISTORY OF THE FOOT/ANKLE
PHYSICAL EXAM
MUSCLES: DORSUM
MUSCLES: FIRST PLANTAR LAYER
MUSCLES: SECOND PLANTAR LAYER
MUSCLES: THIRD PLANTAR LAYER
MUSCLES: FOURTH PLANTAR LAYER
NERVES
ARTERIES
DISORDERS
PEDIATRIC DISORDERS
SURGICAL APPROACHES TO THE ANKLE
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 9 – FOOT/ANKLE
TOPOGRAPHIC ANATOMY

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OSTEOLOGY

CHARACTERISTICS OSSIFY FUSE COMMENT


See leg chapter for Tiba and Fibula
TALUS

• Head (anterior-
navicular) Talus is only tarsal bone to articulate
Neck:
• with tibia and fibula. No muscular
• susceptible to attachments.
fracture AVN a concern due to retrograde blood
Body/trochlea: • supply from branches of posterior tibial
13- dorsalis pedis arteries
• in ankle Primary: 7mo. 15
mortise Body (fetal) years • Weight from tibia is transmitted through
Lateral the trochlea

process FHL runs between medial lateral

Posterior tubercle of posterior process
process: Unfused lateral tubercle: Os trigonum,
• •
medial lateral not a fracture
tubercles
CHARACTERISTICS OSSIFY FUSE COMMENT
CALCANEUS
Largest tarsal
bone; posterior

Multiple facets: support for
• longitudinal arch
posterior largest
Primary: 6 mo.
Sustentaculum Body (fetal) 13- FHL runs under
tali: has the 15 sustentaculum tali;
Secondary: 9 •
• middle facet; years spring ligament
Tubercle year attaches to it
supports talar
neck Painful spurs can
• develop on
tuberosity
NAVICULAR
Tibialis posterior
• inserts on to the
tuberosity
• “Boat-shaped” 13- Articulates with
Tuberosity Primary: 4 years 15 • talus, cuneiforms,
• years cuboid
(medial)
Shape of tarsals
• create transverse
arch
CUNEIFORMS
2nd MT is in
“recess” of short
• Three bones 3 intermediate bone;
years • can lead to
• Medial: largest
13- fracture of it's
Intermediate: 4 base, unstable
Primary:
• shorter than years 15 TMT joint.
years
others 1 Peroneus longus
• Lateral year partially inserts on

plantar aspect of
med. cuneiform
CHARACTERISTICS OSSIFY FUSE COMMENT
CUBOID
Most
• lateral
tarsal
bone
• Tuberosity
inferiorly Peroneus
Primary: Birth 13-15 yrs longus
Cuboid
• tendon
groove
inferiorly • passes
through
groove on
inferior
surface
METATARSALS
Numbered
• medial to
lateral: I to
V.
Only one
• Long bone epiphysis
characteristics per bone:
Base of 2nd 9 in the
• MT in tarsal Primary: wks Birth • head
“recess” Shaft (fetal) 14- except for
Anterior Secondary: 18 the 1st MT
5-8 [in the
support of Epiphysis yrs years
• longitudinal base]
arch of the Peroneus
foot brevis
inserts on
• base of
5th MT
(avulsion
can occur)
PHALANGES
14 total
phalanges

in each
foot
Only one
Great toe has epiphysis
• 10
only two Primary: • per bone:
wks
phalanges Body (fetal) 14-18 in the
years base
Great toe has Secondary: years base
• 2-3
two sesamoid Epiphysis yrs Sesamoid
bones bones
with other
• toes can
occur as a
normal
variant

Ossification of each tarsal bone occurs from a single center


Borders of ankle mortise: Superior: tibia (plafond), medial: medial malleolus
(tibia), lateral: lateral malleolus (fibula)
Tarsal Tunnel: A fibroosseous tunnel formed by the posterior medial malleolus,
medial walls of calcaneus and talus, and flexor retinaculum. Contents: Tendons
(TP, FDL, FHL), Posterior Tibial artery, Tibial nerve (can be compressed in
tunnel)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

TRAUMA

Lauge-Hansen Classification of Ankle Fractures

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


ANKLE FRACTURE
(see Knee Trauma table for Maisonneuve fracture)
Very
• common in
all ages
Malleoli
and/or talar Lauge-Hansen – 4 types

dome are with subdivided stages
involved HX: Trauma. Pain, SA:
1 malleolus swelling • supination/adduction Dislocation:
• PE: Effusion, intense immediately reduce
fx: stable; stage I, II
tenderness at 1 or both Stable/nondisplaced:
2 malleoli malleoli +/- proximal SER: short leg cast 4-6
and/or fibula. Check posterior • supination/external weeks
• ligaments tibial pulse and tibial rotation: stages I-IV Unstable/displaced:
injured: nerve function ORIF, repair articular
PA:
unstable XR: Ankle trauma • pronation/abduction surface fibular length,
Perfect seriesCT: Good for stages I, II, III +/- need for
symmetrical intraarticularfractures PER:
syndesmosis screw
• mortise needing repair
• pronation/external
reduction
rotation: stages I-IV
required
Also must
correct

fibular
length
COMPLICATIONS: Post-traumatic osteoarthritis/pain; Decreased motion and/or strength;
Instability; Nonunion/malunion; RSD

Extraarticular Fracture of Calcaneus

Intraarticular Fracture of Calcaneus

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


CALCANEUS FRACTURE
Most common

tarsal fracture
Mechanism: HX: Trauma. Cannot bear Extraarticular:
large axial load weight, pain, swelling. Body Extraarticular: Cast.

(e.g. high fall or PE: Tender to palpation. Tuberosity ORIF if unstable
jump) Check Tibial nerve Anterior/medial Displaced/intraarticular:
• Must rule out function, pulses arch process ORIF: plates and
spine injury swelling. Intraarticular: screws
Subtalar joint XR: AP/lateral (+/- Harris) Nondisplaced +/- bone graft
• and spine films Tongue-type Severely comminuted:
affected
CT: Needed to better Joint depression Closed treatment.
Most fractures define fx Comminuted
• are intraarticular
(worse
prognosis)

COMPLICATIONS: Osteoarthritis: subtalar; Decreased motion; Malunion/nonunion;


Compartment syndrome; Sural nerve injury
Fracture of Talar Neck

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


TALUS FRACTURE
HX: Trauma.
• MVA, fall from height Cannot bear Hawkins types [neck]
weight, pain, predicts
Neck most common site, head swelling. osteonecrosis: Type I: Cast 2 months.
• Manyprefer ORIF to
body rare PE: Tender to I. Nondisplaced reduce risk
• Tenuous blood supply adds palpation. Check II. Displaced; subtalar ofdisplacement
complications Tibial nerve
subluxation/dislocation Type II, III, IV: ORIF
• Semi-emergent injury function, pulses,
III. Displaced; talar emergentlyto avoid
arch swelling necrosis +/- bonegraft
Hawkins sign (on XR) XR: AP/lateral (+/- body dislocation
• resorption of subchondral bone Canale) Early ROM
IV. Talar head (+/-
indicates healing (no AVN) CT: usually not body) dislocation
needed

COMPLICATIONS: Osteoarthritis: ankle and subtalar joints; Osteonecrosis of body (incidence decreased with
ORIF); Delayed union/nonunion
Injury to Tarsometatarsal (Lisfranc) Joint Complex

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT


MIDFOOT FRACTURES
Midtarsal:
Nondisplaced:
• Involves tarsal bones cast.
Midtarsal: Other: ORIF
• Usually high energy HX: Trauma. Dorsal pain. Navicular:
Navicular fracture
Midtarsal joint injuries PE: Swelling, severe pain Reduce, +/-
Avulsion
• result from fractures of atMidtarsal or TMT
Tuberosity
PCP.
adjacent bones. jointincreases with Many require
Body
Cuneiform cuboid midfootmotion. Cuboid fracture ORIF
• XR: AP/lateral/oblique,+/- Lisfranc injury:
fractures are rare Cuneiform fracture
foot stress filmMed. 2nd MT Close reduce
2nd MT in tarsal Tarsometatarsal -
and middlecuneiform fracture
recess: fracture of its LisfrancFracture (2ndMT)
should align dislocationHomolateral, and/ordislocation
• base destabilizes CT/MR: if unsure of fracture (+/- PCP).
TMT joint, dislocation Isolated,Divergent
ORIF: if
may result. displaced
orirreducible-
most

COMPLICATIONS: Neurovascular injury: Dorsalis pedis artery; Compartment syndrome; Decreased


motion; Post-traumatic osteoarthritis or chronic pain.
DESCRIPTION EVALUATION CLASSIFICATION TREATMENT
METATARSAL AND PHALANGEAL FRACTURES
Metatarsal
• Common injuries: most Fractures:Undisplaced:
are benign. hard soledshoe or
HX: Pain with weight
Fracture at walking cast.
bearing, swelling Metatarsal:
metaphyseal/diaphyseal Displaced/angulated:
PE: Swelling, Head neck
• junction of 5 th MT ORIF5th MT Jones fx:
ecchymosis, bony fractureShaft
(Jones fracture) is not pain (increases Base (esp. of Cast andNWB 6
benign weeks vs. ORIF
with motion) 5th)Phalanges:
Phalange
Base of 5th MT avulsion XR: MT: Shaft
• Fractures:Great toe:
fracture [PB]: benign AP/lateral/oblique Toe: Joint injuries
Reduce. PCP
AP only
Toe fx: usually stub injury jointinjuries.
• Others: splint or buddy
5th toe most common
tape

COMPLICATIONS: Neurovascular injury: Dorsalis pedis artery; Osteoarthritis/pain; Decreased


motion; Nonunion, especially in 5th Metatarsal (Jones) fracture; Deformity

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ANKLE JOINTS

LIGAMENTS ATTACHMENTS COMMENTS


INFERIOR TIBIOFIBULAR
SYNDESMOSIS: Distal tibia/fibula support: must be stabilized if disrupted
Anterior/inferior Distal anterior
Oblique, connects bones anteriorly
tibiofibular [AITFL] tibia fibula
Posterior/inferior Distal posterior Weaker, posterior support of mortise
tibiofibular [PITFL] tibia fibula
Inferior transverse Inferior deep to
Strong posterior support of mortise
ligament PITFL
Interosseous Lateral tibia to A continuation of interosseous membrane, strong
ligament med. fibula support; torn in Maisonneuve fracture
• Syndesmosis widening seen on radiographs if both the AITFL and PITFL are ruptured
ANKLE (mortise/talus) (Ginglymus/hinge type)
Capsule Tibia to talus Extends to interosseous ligament
MEDIAL: Deltoid Medial malleolus Strong medial support: fewer sprains.
ligament (4 parts) to:
Navicular
Tibionavicular Overlaps the anterior tibiotalar ligament
tuberosity
Sustentaculum
Tibiocalcaneal Oriented vertically
tali
Medial tubercle Thickest part of deltoid ligament
Posterior tibiotalar
of talus
Anterior tibiotalar Talus Minimal support
Lateral malleolus
LATERAL: Weaker lateral support: more sprains
to:
Anterior talofibular Weak, most often sprained, positive anterior
Neck of talus
[ATFL] drawer test when ruptured
Calcaneofibular
Calcaneus Stabilizes subtalar joint
[CFL]
Posterior talofibular Posterior
Strong, seldom torn
[PTFL] process (talus)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

FOOT JOINTS

JOINT LIGAMENTS COMMENTS


INTERTARSAL
Subtalar (talocalcaneal) Allows inversion/eversion of foot (e.g. walking on uneven surface)
Medial tubercle to
Medial talocalcaneal
sustentaculum tali
Deep to calcaneofibular
Lateral talocalcaneal
ligament

Posterior talocalcaneal Short; Posterior process to


calcaneus
Interosseous talocalcaneal Strong; in sinus tarsus
Also supported by the ligaments of the ankle (see ankle joints)
Transverse/Midtarsal (Chopart's Joint): assists subtalar joint with inversion eversion
Sustentaculum tali to
Talonavicular Plantar calcaneonavicular (Spring) navicular: plantar support for
head of talus; Strong.
Dorsal talonavicular Dorsal support
Calcaneonavicular (Bifurcate 1) Lateral support
Calcaneocuboid Calcaneocuboid (Bifurcate 2) Stabilizes two rows of tarsus
Dorsal calcaneocuboid Dorsal support
Plantar calcaneocuboid (short
Strong plantar support
plantar)
Calcaneocuboid MT (long plantar) Additional plantar support
Cuboideonavicular Each of these four joints have dorsal, These joints are small, have
Cuneonavicular plantar, and interosseous ligaments, little motion or clinical
Intercuneiform each bearing the name of the significance. Share a
Cuneocuboid corresponding joint common articular capsule.
Plantar ligaments are stronger than the dorsal ligaments
TARSOMETATARSAL (Lisfranc) Gliding type
Medial cuneiform to 2 nd
Dorsal, plantar, interosseous,
metatarsal: Lisfranc's
tarsalmetatarsals (TMT) ligaments
ligament
INTERMETATARSAL
Dorsal, plantar, interosseous MT Strengthen transverse arch
Deep transverse metatarsal Connect the MT heads
METATARSOPHALANGEAL Ellipsoid/condyloid type
Plantar plate and Intersesamoid Part of weight bearing surface
Collateral Strong

Deep transverse metatarsal ligaments add support to this joint


INTERPHALANGEAL Ginglymus/hinge type
Similar to the IP joints of the
Plantar plate
hand
Collateral

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

OTHER STRUCTURES

STRUCTURE FUNCTION COMMENT


Superior Covers tendons, nerves
extensor vessels of anterior Distal fibula to medial tibia
retinaculum compartment at the ankle

Inferior extensor Surrounds covers tendons, “Y” shaped; calcaneus to medial


retinaculum etc. of the anterior malleolus and navicular
compartment in the foot
Flexor Covers tendons of posterior Medial malleolus to calcaneus. Roof of
retinaculum compartment tarsal tunnel.
Superior Inferior Covers tendons sheaths of the Superior: Lateral malleolus to
peroneal lateral compartment at the calcaneus Inferior: Inferior extensor
retinaculum hindfoot retinaculum to calcaneus
Plantar
Inflammed: plantar fascitis. Can develop
Aponeurosis Supports longitudinal arch nodules
(Plantar fascia)

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MINOR PROCEDURES

STEPS
ANKLE ARTHROCENTESIS
1. Ask patient about allergies
2. Plantarflex foot, palpate medial malleolus and sulcus
between it and the tibialis anterior tendon. Use the visible
EHL tendon if TA is not palpable.
3. Prepare skin over ankle joint (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
5. Insert 20 gauge needle perpendicularly into the
sulcus/ankle joint (medial to the tendon, inferior to distal
tibia articular surface, lateral to medial malleolus).
Aspirate fluid. If suspicious for infection, send fluid for
Gram Stain and culture. The fluid should flow easily if
needle is in joint.
6. Dress injection site
DIGITAL BLOCK
1. Same as in hand. See Hand chapter.

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Copyright © 2001 Saunders, An Imprint of Elsevier

HISTORY OF THE FOOT/ANKLE

QUESTION ANSWER CLINICAL APPLICATION


1. AGE Young Sprain, fractures
Middle age,
Overuse injuries, arthritis, gout
elderly
2. PAIN

a. Onset Acute (less Fracture, stress fracture


common)
Chronic Most foot ankle disorders are chronic

b. Location Ankle Fracture, osteoarthritis, instability, posterior


tibial tendinitis
Plantar fascitis, fracture, retrocalcaneal
Hindfoot
bursitis, Achilles tendinitis
Midfoot Osteoarthritis of tarsal joints, fracture
Hallux rigidus, fractures, metatarsalgia,
Forefoot
Morton's neuroma, bunions, gout
Bilateral Consider systemic illness, RA
Plantar fascitis (improves with
c. Occurrence Morning pain
stretching/walking)
With activity Overuse type injuries
3. STIFFNESS Without locking Ankle sprain, RA
With locking Loose body
4. SWELLING Yes Fracture, arthritis
Mechanism/foot Inversion: ATFL injury/sprain
5. TRAUMA
position
Bear weight? Yes: less severe injury;
No: more severe (rule out fracture)

6. Sports,
ACTIVITY/OCCUPATION repetitive Achilles tendinitis, overuse injuries
motion
Standing all day Overuse injuries
Tight/narrow toe Hallux valgus (bunion, overwhelmingly seen in
7. SHOE TYPE
box women)
Pain,
8. NEUROLOGIC
numbness, Tarsal tunnel syndrome
SYMPTOMS
tingling
9. HISTORY OF Manifestations Diabetes mellitus, gout, peripheral vascular
SYSTEMIC DISEASE in foot disease, RA, Reiter's syndrome

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PHYSICAL EXAM

EXAM TECHNIQUE CLINICAL APPLICATION


INSPECTION
Foot
Alignment/rotational deformities, toe
(standing/weight- Anterior view
deformities, bunions
bearing)
Minimal valgus is normal, “pump bump”
Posterior view
exostosis
Superior view Bunion, bunionette
Medial view Flat foot (pes planus); high arch foot (pes cavus)
Foot (supine/sitting/ Inferior/plantar
Callus, warts, ulcers (especially in diabetic foot)
non-WB) view
Swelling sign of infection, trauma (bilateral):
Swelling Foot and ankle
cardiovascular etiology
Change WB to If foot changes color: pink to RED: arterial
Color
non-WB insufficiency

Shoes All aspects of Abnormal wear may indicate disease (e.g.


the shoe scuffed toe, drop foot)
EXAM TECHNIQUE CLINICAL APPLICATION
PALPATION
1 st MTP joint Bunion, bursitis, callus; pain: gout,
Bony structures
(MT head) sesamoiditis, tendinitis
Other MTP
Pain: metatarsalgia, Freiberg's infraction,
joint (MT fracture, tailor's bunion (5 th MT head)
head)
Tarsal bones Tenderness suggests fracture,
(Talus) osteonecrosis, osteochondritis
Pain: fracture. Posterior: bursitis (pump
Calcaneus bump); Plantar: spur, plantar fascitis; Medial
pain: nerve entrapment
Pain indicates fracture, syndesmosis injury in
Both malleoli
leg
Cool: peripheral vascular disease. Swelling:
Soft tissue Skin
trauma or infection vs. venous insufficiency
Between
metatarsal Mass pain: neuroma
heads
Medial ankle Pain suggests ankle sprain (Deltoid
ligaments ligament)
Tendons at
med. Pain indicates tendinitis, rupture (sprain)
malleolus
Lateral ankle Pain suggests ankle sprain ATFL, CFL,
ligaments PTFL (rare)
Peroneal
tendons Pain indicates tendinitis, rupture/sprain,
(lateral dislocation
malleolus)
Achilles Pain: tendinitis. Defect suggests Achilles
tendon rupture
RANGE OF MOTION
Ankle: Stabilize Normal: Plantarflex 50°, Dorsiflex (extend) 25
dorsiflex/plantarflex subtalar joint °
Subtalar: Stabilize tibia Normal: Invert 5-10°, Evert 5°
inversion/eversion
Midtarsal: Stabilize
adduction/ heel/hindfoot Normal: Adduct 20°, abduct 10°
abduction
Great toe:

MTP: flex/extend Stabilize foot Normal: Flex 75°, extend 75°. Decreased in
hallux rigidus
IP: flex/extend Stabilize foot Normal: Flex 90, extend 0°

Pronation: dorsiflexion, eversion, abduction. Supination: plantarflexion,


inversion, adduction

EXAM TECHNIQUE CLINICAL APPLICATION


NEUROVASCULAR
Sensory

Saphenous (L4) Med. foot (med. Deficit indicates corresponding


cutaneous) nerve/root lesion

Tibial nerve (L4) Plantar foot Deficit indicates corresponding


(calcaneal/plantar) nerve/root lesion
Superficial Dorsal foot Deficit indicates corresponding
Peroneal (L5) nerve/root lesion
Deep Peroneal 1 st dorsal web Deficit indicates corresponding
(L5) space nerve/root lesion

Sural nerve (S1) Lateral foot Deficit indicates corresponding


nerve/root lesion
Motor
Deep Peroneal Foot Weakness = Tibialis Anterior or
nerve (L4) inversion/dorsiflexion nerve/root lesion
Deep Peroneal Great toe extension Weakness = EHL or
nerve (L5) (dorsiflex) corresponding nerve/root lesion
Tibial nerve Great toe Weakness = FHL or
(S1) plantarflexion corresponding nerve/root lesion
Superficial Foot eversion Weakness = Peroneus muscles
Peroneal (S1) or nerve/root lesion
Reflex

S1 Achilles reflex Hypoactive/absence indicates


S1 radiculopathy
Upper Motor Babinski reflex Upgoing toes indicates an Upper
Neuron Motor Neuron disorder
Decreased pulses: trauma or
Pulses Dorsalis pedis vascular compromise, peripheral
vascular disease
Posterior tibial
SPECIAL TESTS

Hold tibia, anterior Anterior translation:


Anterior drawer force to calcaneus AnteriorTaloFibular Ligament
(ATFL) rupture (sprain)
Hold tibia, invert Increased laxity compared to
Talar tilt
ankle contralateral: CFL/ATFL sprain
Increased laxity compared to
Eversion/abduct Hold tibia,
contralateral: Deltoid ligament
stress evert/abduct Ankle
sprain
“Too many toes” (more seen
“Too many toes” Standing, view foot
sign posteriorly laterally than other side):
acquired flat foot
Squeeze Compress distal Pain indicates a syndesmosis
tibia/fibula injury

Standing, raise onto Heel into varus is normal.


Heel lift toes Decreased lift with posterior
compartment pathology
Tinel's sign at Tap nerve posterior Tingling/parathesia is positive for
the Ankle to medial malleolus posterior tibial nerve entrapment

Compression Squeeze foot at MT Pain, numbness, tingling:


heads interdigital neuroma (Morton's)

Thompson Prone: feet hang, Absent plantar flexion indicates


squeeze calf Achilles tendon rupture
Knee extended:
Pain in calf suggestive of deep
Homans' sign passively dorsiflex
venous thrombophlebitis (DVT)
foot

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: DORSUM

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

Extensor hallucis Dorsal Base of proximal Deep Extends Assists EHL with
brevis [EHB] calcaneus phalanx of Great toe peroneal great its action
toe
Extensor Dorsal Base of proximal Deep Extends Injury can result in
digitorum brevis calcaneus phalanx: 4 lateral peroneal toes dorsal hematoma
[EDB] toes
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: FIRST PLANTAR LAYER


MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT
FIRST LAYER
Supports
Calcaneal Through med. Abducts
Abductor tuberosity medial sesamoid to proximal Medial great longitudinal
hallucis plantar arch
process phalanx of great toe toe
medially.
Flexor
Calcaneal Sides of middle Flex Supports
digitorum tuberosity medial phalanges: lateral 4 Medial lateral 4 longitudinal
brevis plantar
process toes toes arch
[FDB]
Abductor Supports
Calcaneal Lateral base of Abducts
digiti Lateral longitudinal
tuberosity medial proximal phalanx: 5th small
minimi plantar arch
lateral processes toe toe
[ADM] laterally

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: SECOND PLANTAR LAYER

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


SECOND LAYER
Two
Medial and Assists
Quadratus lateral plantar Lateral FDL Lateral heads/bellies
FDL with
plantae calcaneus tendon plantar toe flexion join on FDL
tendon
Proximal 1. Medial Flex MTP
1st lumbrical
Lumbricals Separate phalanges, plantar 2-4. joint, attaches to 1
FDL tendons extensor Lateral extend IP FDL tendon
expansion plantar joint

Tendons of FHL and FDL also pass through in the second layer
Medial and lateral plantar nerves are terminal branches of the Tibial nerve: they run in
the 2nd layer.

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: THIRD PLANTAR LAYER

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


THIRD LAYER
Flexor Assist
Through sesamoids Sesamoid bones
hallucis Cuboid, lateral
to proximal phalanx Medial great attach to each
brevis cuneiform of great toe plantar toe tendon
[FHB] flexion
Supports
Oblique: base 2- Through lateral
Adductor 4 MT sesamoid to Lateral Adducts transverse arch.
hallucis Transverse: proximal phalanx of plantar great 2 heads have
toe different
Lateral 4 MTP great toe
orientations
Flexor
digiti
Lateral Flex
Small, relatively
Base of 5th Base of proximal
minimi
plantar small
insignificant
metatarsal phalanx small toe
brevis toe muscle
[FDMB]

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES: FOURTH PLANTAR LAYER

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT


FOURTH LAYER
Plantar Adduct
interossei Med. 3, 4, Medial proximal Lateral toes Attachment to MT is
5th MTs phalanges: toes 3-5 plantar medial for all 3
(3) (PAD)
Dorsal Abduct
Adjacent Proximal phalanges Lateral toes Larger than the plantar
interossei
(4) MT shafts toes 2-5 plantar interossei muscles
(DAB)

Peroneus longus and Tibialis posterior tendons pass through the fourth layer
Medial and lateral plantar nerves are terminal branches of the Tibial nerve.
PAD = 5 Plantar ADduct, DAB 5 = Dorsal ABduct; the second digit is used as the
reference point for abduction/adduction in the foot

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

LUMBAR PLEXUS
POSTERIOR DIVISION
1. Femoral (L2-4): Saphenous nerve branches in proximal thigh, descends in superficial
medial leg, then anterior to medial malleolus in foot.
Sensory: Medial foot: via medial cutaneous nerve (Saphenous nerve)
Motor: NONE (in foot or ankle)
SACRAL PLEXUS
ANTERIOR DIVISION
2. Tibial (L4-S3): behind medial malleolus, splits on plantar surface
Sensory: Medial heel: via Medial calcaneal
Medial plantar foot: via Medial plantar
Lateral plantar foot: via Lateral plantar
Motor: FIRST PLANTAR LAYER of FOOT
Abductor hallucis: Medial plantar
Flexor digitorum brevis[FDB]: Medial plantar
Abductor digiti minimi: Lateral plantar
SECOND PLANTAR LAYER of FOOT
Quadratus plantae: Lateral plantar
Lumbricals: Medial Lateral plantar
THIRD PLANTAR LAYER of FOOT
Flexor hallucis brevis [FHB]: Medial plantar
Adductor hallucis: Lateral plantar
Flexor digiti minini brevis [FDMB]: Lateral plantar
FOURTH PLANTAR LAYER of FOOT
Dorsal interosseous: Lateral plantar
Plantar interosseous: Lateral plantar
POSTERIOR DIVISION
3. Common peroneal (L4-S2): Superficial peroneal divides into intermediate and medial
dorsal cutaneous branches in leg. Deep peroneal divides under extensor retinaculum into
medial lateral branches.
Sensory: Lateral foot: via Sural (lateral calcaneal dorsal cutaneous).
Dorsal foot: Superficial peroneal.
Dorsal (med.) (Med. dorsal cutaneous branch).
1st/2nd interdigital space: Deep peroneal (med. branch)
Motor: FOOT: Deep Peroneal (Lateral branch)
Extensor hallucis brevis [EHB]
Extensor digitorum brevis [EDB]

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ARTERIES

ARTERY STEM ARTERY/ COMMENT


Artery to the Tarsal Sinus Dorsalis pedis and Peroneal arteries
Artery to the Tarsal Canal Posterior tibial artery
Deltoid artery Posterior tibial artery; supplies medial body
Capsular ligamentous vessels Multiple sources
Interosseous anastomosis Extensive, protects against AVN

ARTERY COURSE COMMENT


(See Leg/Knee chapter for stem arteries)
Anterior Medial Under TA EHL tendons to medial From Anterior tibial artery,
Malleolar malleolus supplies medial malleolus
Anterior Lateral
Under EDL tendon to lateral malleolus From Anterior tibial artery,
Malleolar supplies lateral malleolus
Posterior Medial Under tendons of TP and FDL, not From Posterior tibial artery,
Malleolar FHL, to medial malleolus supplies medial malleolus
Posterior Lateral Under Peroneus longus/brevis From Peroneal artery, supplies
Malleolar tendons to lateral malleolus lateral malleolus
Perforating and From Peroneal artery,
Anastomosis with anterior lateral
communicating contributes supply to lateral
malleolar and posterior tibial arteries
branches malleolus

An anastomosis occurs at each malleolus between the above arteries


ARTERY COURSE BRANCHES COMMENT/SUPPLY
(see Leg Knee chapter for stem arteries)

Lateral with Lateral


NONE From Peroneal artery; supplies heel
Calcaneal calcaneal nerve
(Sural nerve)
with Medial
Medial From Posterior tibial artery;
NONE
Calcaneal calcaneal nerve supplies heel
(Tibial nerve)
Between quadratus
Lateral plantae FDB, runs Deep plantar Larger terminal branch of Posterior
plantar w/ lateral plantar arch tibial artery
nerve
Between Abductor Superficial Smaller terminal branch of Posterior
Medial hallucis FDB runs branch 1 proper tibial artery; supplies medial Great
plantar with medial plantar plantar digital toe Anastomose with plantar MT
nerve Deep branch artery
Dorsum of foot with
Dorsalis medial branch of Supplies dorsum
Pedis deep peroneal of foot via:
nerve
Medial Tarsal No branches
Lateral Tarsal No branches
Arcuate artery 3 Dorsal MT arteries branch off
Deep Plantar Descends to deep plantar arch
1st dorsal
Terminal branch of dorsalis pedis
metatarsal
3 dorsal digital
Supply dorsal great toe
arteries
ARTERY COURSE BRANCHES COMMENT/SUPPLY
(see Leg Knee chapter for stem arteries)

Medial Across tarsals, under Supplies dorsum of


NONE foot (can be 2 or 3 of
Tarsal EHL tendon
these arteries).
Across tarsals with Supplies EDB, lateral
Lateral
Tarsal lateral branch of Deep NONE tarsal bones,
peroneal nerve anastomoses laterally
Across bases of 2nd, 3rd, 4th dorsal
Arcuate metatarsals, under MT artery 7 dorsal
extensor tendons digital arteries
Deep Descends between Deep plantar arch Anastomosis with
plantar 1st 2nd MT's Lateral calcaneal
Deep On plantar 4 posterior Join dorsal metatarsal
plantar interosseous muscles
perforating arteries
arch in 4th layer of foot.
1 Common/proper Most lateral artery in
plantar digital foot toes
4 plantar metatarsal
4 anterior Join dorsal metatarsal
perforating arteries
4 Common plantar
digital
8 Proper plantar Supplies the distal tip
digital of phalanx

Total of 4 Dorsal Metatarsal arteries leading to 10 dorsal digital arteries.


They do not reach the distal tip of the digit.
Total of 4 Plantar Metatarsal arteries leading to 10 proper plantar digital
arteries via common plantar digital arteries.
Each digit has 2 dorsal digital and 2 proper plantar digital arteries. Dorsal
branch of proper plantar digital artery supply distal tip.
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

DISORDERS

HISTORY/PHYSICAL
DESCRIPTION WORK-UP/FINDINGS TREATMENT
EXAM
ACHILLES TENDINITIS

• Occurs at or Hx/PE: Heel pain, XR: Standing lateral: 1. Rest, NSAID,


heel lift
above insertion of worse with push off. spur at Achilles
2. Excise bone or
Achilles tendon Tender to palpation insertion
bursa (rare)
ACHILLES TENDON RUPTURE
• “Weekend
Hx: “hit with bat” XR: Standing Casting (in
warriors.” Middle sensation PE: Defect, AP/lateral: usually equinus) vs.
age men in + Thompson test normal surgical repair
athletics.
ACQUIRED FLAT FOOT (POSTERIOR TIBIALIS DYSFUNCTION)

• Tibialis posterior 1. Orthosis


2. Activity
tendon dysfunction: Hx: Pain and swelling
tears or PE: + “too many toes” XR: Standing modification
degeneration sign, no heel varus on AP/lateral: middle foot 3. Calcaneal
sag osteotomy and
• No arch support toe rise
results in valgus foot FDC transfer
4. Arthrodesis
ANKLE INSTABILITY
• Multiple/recurrent Hx: Inversion 1. PT: strengthen
sprains instability esp. on XR: AP/lateral/stress peroneals
• Also neurologic uneven groundPE: + view: gapping laterally 2. Surgical
etiology decreased anterior drawer talar reconstruction if
proprioception tilt test condition persists
ANKLE SPRAIN
• #1
musculoskeletal 1. RICE, NSAIDs
injury Hx: “Pop,”pain, 2. Immobilize
• Lateral 90% -
swelling, +/- ability to XR: only if cannot bear grade III
ATFL alone 60%,
bear weightPE: + weight or + bony point 3. PT ROM
with syndesmosis exercises
Anterior drawer, +/- tenderness
5% 4. Surgery:
talar tilt test
• Inversion most athletes or severe
common injury
mechanism
ARTHRITIS: OA/DJD
1. NSAID, activity
• Can occur in any
modifcation,
joint XR: Standing
Hx/PE: Older, pain at orthosis
• Associated with AP/lateral: classic OA
trauma, obesity, affected joint. findings 2.
Fusion/arthroplasty
overuse activity
(rare)
CHARCOT JOINT: NEUROPATHIC JOINT
• Neurologic
disease results in
decreased Hx/PE: Patient is XR: Standing 1. Immobilze (skin
sensation insensate-no pain. AP/lateral: fractures checks)
• Joint Red, warm, swollen (callus or unhealed), 2. Bony excision or
destroyed/deformed joint joint destroyed fusion
by fx undetected by
patient
CLAW TOE
• Deformity: MTP
extended, PIP 1. Shoes with extra
flexed. Usually all XR: Standing deep toe box
Hx: Toe painPE: Toe
toes AP/lateralMR/EMG/lab: 2. Surgical
deformity, +/- callus
• Etiology: to rule out neurologic reconstruction:
corn, neurologic exam
Neurologic disease disease based on
Neurologic disease disease based on
(e.g. Charcot-Marie- deformity
Tooth)
CORN
• Two types: 1. Hard
2.Soft 1. Wide toe box
1. Hyperkeratosis: shoe, pads
Hx/PE: Tight shoes. XR: AP/lateral: look for
pressure on bones 2. Debride callus
Pain at lesion site. bone spurs
(5 th toe #1) 3. Excise bony
2. Interdigital prominence
maceration
DIABETIC FOOT: NEUROPATHIC FOOT
• Neuropathy leads
1. Skin care
to unperceived
Hx: Burning tingling, XR: Standing (prevention)
injury (ulcer,
+/- painPE: +/-: skin AP/lateral: rule out 2. Protective shoe
infection) changes, ulcers, osteomyelitis or 3. Treat ulcers,
• Vascular
deformity, swelling, Charcot jointDo Ankle infections
insufficiency leads
warmth Brachial Index 4. Amputation if
to decreased
necessary
healing
GOUT (Podagra)
• Purine metabolism 1. NSAIDs,
defect Labs:
Hx: Men, acute colchicine
• Urate crystals 1. Elevated uric acid
exquisite pain PE: 2. Rest
create synovitis 2. Negatively
Red, swollen toe. 3. Allopurinol
• Great toe most birefringent crystals
(prevention)
common site

HISTORY/PHYSICAL WORK-
DESCRIPTION TREATMENT
EXAM UP/FINDINGS
HALLUX RIGIDUS
Hx: Middle age.
• DJD of MTP of XR: Standing
Painful, stiff 1. NSAID, stiff sole
Great toe AP/lateral OA
• Often post PE: MTP Tender to findings at 1 st shoe
traumatic palpation, decreased MTP 2. Arthroplasty/fusion
ROM
HALLUX VALGUS (Bunion)
• Great toe XR: Standing
valgus; MTP AP: measure:
1. Distal MT 1. Shoes: wide toe
bursitis Hx: Pain, swelling
Articulation box
• Multiple (worse with shoe
2. Refractory cases:
etiologies: wear (narrow toe box) Angle (normal multiple corrective
genetic, flat feet, PE: Medial 1st MTP 10°) surgical procedures
narrow shoes, TTP, +/- decreased 2. Inter MT based on deformity
RA great toe ROM angle (9°) and severity
• 10:1 women 3. Hallux Valgus
(shoes) angle (15°)
HAMMER TOE
• Toe PIP flexion
Hx: Toe pain, worse 1. Extra deep shoe
deformity when wearing shoes XR: Standing toe box
• Associated with PE: Toe deformity, +/- AP/lateral: PIP 2. Surgery: resect or
trauma, Hallux corn deformity fuse PIP
Valgus (shoes)
MALLET TOE
• Lesser toe DIP Hx: Toe pain XR: Standing
flexion deformity 1. Shoe modification
PE: Toe deformity, AP/lateral: DIP
• 2nd toe most 2. FDL release
callus deformity
common
METATARSALGIA
• Metatarsal
head pain 1. Metatarsal pads
Hx/PE: Pain under XR: Standing
• Etiology: flexor MT head (2nd MT AP/lateral: look 2. Modify shoes
tendinitis, most common) for short MT 3. Treat underlying
ligament rupture, cause
callus (#1)
MORTON'S NEUROMA (Interdigital)
• Fibrosis of
irritated nerve
Hx: Plantar MT pain XR: Standing 1. Wide toe shoes,
• Usually
PE: MT TTP, +/- AP/lateral: steroid injections, MT
between 2nd 3 rd numbness, + usually normal, pads
metatarsals compression test not helpful 2. Nerve excision
• 5:1
female(shoes)
PLANTAR FASCITIS
• Inflammation Hx: AM pain,
and/or improves with XR: Standing 1. Stretching, NSAID
degeneration of ambulation or
lateral: +/- 2. Heel cup
fascia. Female stretching
calcaneal bone 3. Splint (night),
2:1 PE: Medial plantar spur casting
• Associated with calcaneus tender to
obesity palpation
PLANTAR WARTS
• Hyperkeratosis Hx/PE: Painful plantar Histopathology 1. Pads vs. freeze or
• Due to lesions if necessary debride lesion
Papilloma virus
RETROCALCANEAL BURSITIS: HAGLUND'S DISEASE

• Bursitis at Hx: Pain on posterior XR: Standing 1. NSAID, heel lift,


insertion of heel lateral: spur at casting
PE: Red, tender to
Achilles tendon Achilles 2. Excise bone/bursa
palpation, “pump
on calcaneus insertion (rare)
bump”
RHEUMATOID ARTHRITIS
• Synovitis 1. Medical
Hx: Forefoot: pain,
destroys joints swelling XR: AP/lateral: management
• More common PE: Red, tender, +/- joint destroyed 2. Custom molded
in females deformity (e.g. Hallux Lab: positive shoes
deformity (e.g. Hallux
• Associated with RF, ANA 3. Fusion or
Valgus)
HLA-DR4 resection
SERONEGATIVE SPONDYLOARTHROPATHY: REITER'S, AS, PSORIASIS
• Multiple
manifestations XR: AP/lateral: 1. Conservative
Hx/PE: Young,
• Associated with +/- calcification treatment
forefoot/toe/ heel: red,
HLA-B27 swollen, tender Lab: negative 2. Rheumatology
• Most common RF, ANA consult
in males
TAILOR'S BUNION: BUNIONETTE

• Prominent 5th XR: Standing


MT head Hx/PE: Difficulty fitting AP: 5 th toe 1. Pads, stretch toe
shoes, painful lateral medially box
Laterally
5 th metatarsal deviated, MT 2. Metatarsal
• Bony
exostosis/bursitis prominence head laterally osteotomy
deviated

HISTORY/PHYSICAL WORK-
DESCRIPTION TREATMENT
EXAM UP/FINDINGS
TARSAL TUNNEL SYNDROME
1. NSAID,
XR: AP/lateral:
• Tibial nerve steroid
Hx/PE: Pain, tingling, normalEMG:
trapped by burning on sole confirms injection2.
flexor Surgical release
(made worse with diagnosisMR:
retinaculum activity) to find mass (must follow
and/or tendons plantar nerves
lesion
also)
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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

PEDIATRIC DISORDERS

DESCRIPTION EVALUATION TREATMENT/COMPLICATIONS


METATARSUS ADDUCTUS
• Forefoot adduction
Hx: Parent notices
(varus)
deformity 1. Most spontaneously resolve
• #1 pediatric foot
PE: ”Kidney bean” with normal development
disorder
deformity, negative 2. Serial casting
• Associated with thigh/foot angle, + intoeing 3. Rarely, midfoot osteotomies
intrauterine position or
gait
other disorders
TALIPES EQUINOVARUS: CLUBFOOT
• Congenital, boys, 50%
Hx: Deformity at birth
bilateral
PE: Rigid foot with:
• Genetic environment 1. plantarflexed ankle 1. Manipulation and casting 2-4
factors mo.
(equinus)
• Idiopathic or associated 2. Surgical correction (release,
2. inverted hindfoot (varus)
with other disorders lengthening, etc.) with post
3. adducted forefoot
(neuromuscular, etc.) operative casting
4. cavus midfoot
• 4 deformities with soft XR: if diagnosis is unclear
tissue contractures

COMPLICATION: recurrence of deformity


DESCRIPTION EVALUATION TREATMENT/COMPLICATIONS
PES PLANUS: CONGENITAL FLATFOOT
Hx: Usually
• Normal in infants (up adolescent, 1/2 foot
to 6 yo) pain
Flexible:
• No longitudinal arch PE: Rigid: always
1. Asymptomatic: no treatment
• Ankle everted (valgus) flat
2. Symptomatic: arch supports,
• Classified: Flexible: only flat
stretching
1. Rigid (tarsal when WB
Rigid: Treat underlying condition
coalition/vertical talus) XR: AP/lateral: may
(see tarsal coalition)
2. Flexible (variant of see coalition/or
normal) vertical talus in rigid
foot
PES CAVUS: HIGH ARCH FOOT
Hx: 8-10 yrs, ankle
pain
• High arch due to
muscle imbalance in PE: Toe walking,
tight heel cord
immature foot (T. A. and
decreased ankle
peroneus longus) 1. Braces/inserts/AFO as needed
dorsiflexion
• Ankle flexed: causes (used with mixed results)
XR: AP/lateral foot
pain 2. Various osteotomies
• Must rule out and ankle 3. Tendon transfer balance
EMG/NCS: test for
neuromuscular disease
weakness
(e.g. Charcot-Marie-
MR: spine: r/o
Tooth)
neuromuscular
disease
TARSAL COALITION
Hx: Foot pain during
• Connection (fibrous, adolescence
cartilage then bony) of PE: Stiff, decreased
two tarsals ROM (subtalar),
• #1 flatfoot (peroneal 1. Mild: observe
Calcaneus/navicular spasm) 2. Casting
(13-16yo) XR: 3. Coalition resection
• #2 Talus/calcaneus (9- AP/lateral/oblique: 4. Triple arthrodesis
13yo) coalitions can be
• Flatfoot deformity seen
results CT: often necessary
to confirm PE

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

SURGICAL APPROACHES TO THE ANKLE

INTERNERVOUS
USES DANGERS COMMENT
PLANE
ANKLE: ANTERIOR LATERAL APPROACH
Fusions/triple Peroneals Deep Can access
1. 1.
arthrodesis 1. [Superficial 1. peroneal hindfoot
Talar peroneal] nerve Preserving fat
2.
procedures EDL Ant. pad (sinus talus)
2. 2. 2.
Intertarsal [Deep Tibial helps wound
3. peroneal] artery healing.
joint access

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CHAPTER 10 - BASIC SCIENCE
BONES
NERVES
MUSCLES (SKELETAL)
MICROBIOLOGY
IMAGING
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

CHAPTER 10 – BASIC SCIENCE


BONES

STRUCTURE COMMENT
Attachment of muscles
Bone function Protection of organs
Reservoir of minerals for body
Hematopoiesis site
Bone Forms
Form by enchondral ossification, except clavicle Have a physis at each end
Long bones (except in hand foot) 4 parts: epiphysis, physis, metaphysis, diaphysis Length is
derived from the growing physis
Flat bones Form by intramembranous ossification, (e.g., pelvis)
Physeal
Divided into multiple zones
Anatomy
Reserve zone Matrix production and storage
Proliferative
Cell proliferation, matrix production
zone
Hypertrophic
Broken into 3 zones, calcification of matrix
zone
STRUCTURE COMMENT
Microscopic
Bone Types
Woven Immature bone; normal in infants, also found in callus tumors
Lamellar Mature bone; well organized, normal both cortical cancellous after age 4
Structural Bone
Types

Cortical (compact) 80% of bone, highly organized (osteons), blood supply in haversian canal.
Volkmann's canal has vessels connecting osteons.
Cancellous
20% of bone, crossed lattice structure, higher bone turnover
(spongy/trabecular)
STRUCTURE COMMENT
Cell Types
Osteoblasts Make bone (secrete matrix, collagen, GAG, stimulated by PTH)
Osteoclasts Resorb bone (giant cells, mineralized bone found only in Howship's lacunae)
Osteocytes Maintain bone (90% of cells, inhibited by PTH)

STRUCTURE COMMENT
Bone Composition
Organic matrix
Produced by osteoblasts—becomes osteocytes when trapped in matrix
(40%)
90% of matrix, gives strength. Mineralization occurs at gaps at the end of
Collagen (Type I)
each collagen fiber
Proteoglycan Glycosaminoglycans structure (GAGs)
Non-collagen
Osteonectin is most abundant
protein
Inorganic (60%) Mineralized portion
Calcium
Adds strength to bone, found in the collagen gaps
Hydroxyapatite
Types of
Ossification
Enchondral Bone replaces a cartilage template in long bones
Intramembranous Mesenchymal template in flat bones and clavicle
STRUCTURE COMMENT
Fracture
Point tenderness and swelling are common findings
Types
Open vs.
Break in skin is open. Gustilo classification (grade I, II, III A, B, C)
closed
Direction Transverse, spiral, oblique, comminuted
Displacement Displaced or nondisplaced
Salter-Harris—fracture involving an open physis in adults, growth plate in

children.
Other • Greenstick—only one cortex disrupted
• Torus—one cortex impacted, but intact
• Pathologic results—from bone tumor/disease
STRUCTURE COMMENT
Stages of Bone Healing
Inflammation Hematopoietic cells, fibroblasts, osteoprogenitor cells
Repair Callus formation (hard or soft), woven bone formation (enchondral)
Lamellar bone replaces woven, bone assumes normal shape, and repopulation of
Remodeling
the marrow

STRUCTURE COMMENT
Bone Healing Factors
Minerals Calcium, Phosphate
STRUCTURE COMMENT
Main Hormones Parathyroid hormone (PTH), Vitamin D, Calcitonin (see fig.__)
Other Hormones
Estrogen Inhibits bone resorption
Corticosteroids Increases bone loss
Thyroid hormone Normal levels promote bone formation, increased levels enhance resorption
Growth hormone Promotes bone formation

STRUCTURE COMMENT
Metabolic Disorders
Hypercalcemia Symptoms: constipation, nausea, abdominal pain, confusion, stupor, coma
1° Increased urine calcium, decreased serum phophate, “brown tumors”
hyperparathyroidism result

Malignancy #1, Multiple Endocrine Neoplasm (MEN) syndromes
hyperparathyroidism
Symptoms: hyperreflexia, tetany +Chvostek's/Trousseau's sign,
Hypocalcemia
papilledema, prolonged QT interval
1° Hair loss, vitiligo
hypoparathyroidism
Renal osteodystrophy Chronic renal failure, “Rugger jersey” spine
Rickets/osteomalacia Decreased/failed mineralization, Vitamin D deficiency
Osteoporosis Decreased bone mass, elderly
Scurvy Vitamin C deficiency results in defective collagen
Osteopetrosis Increased bone density due to reduced osteoclast activity
Simultaneous osteoblast osteoclast activity results in dense, but more
Paget's Disease
brittle bones
STRUCTURE COMMENT
Cartilage Several types:
Hyaline Articular surfaces, physeal plates
Fibrocartilage Annulus fibrosis, meniscus, pubic symphysis
Elastic Nose, ears
Articular
Cartilage
Function Distribute load over large surface, low friction motion surface
Components Water, collagen type II, proteoglycans, chondrocytes
Water content Decreases with age, increases in osteoarthritis
#1 form of arthritis , articular cartilage defect/damage.
Primary, “wear and tear”; or secondary, (e.g., posttraumatic.)
Often found in hands and weight-bearing joints, knees #1 site
Osteoarthritis Classic radiographic findings:
1. Osteophytes
2. Subchondral cysts
3. Subchondral sclerosis
4. Joint space narrowing
Inflammatory
Rheumatoid, SLE, spondyloarthropathy, gout
Arthritis
Rheumatoid Immune disorder targeting the synovium. Chronic synovitis and pannus ormation
Arthritis lead to articular surface and joint destruction.
3: 1 women, associated with HLA-DR4, +RF, increased ESR/CRP
Multiple joints affected: MCPs: ulnar deviation, feet: claw toe common
Findings: morning stiffness, nodules, radiographs:
1. Bone erosions (periarticular)
2. Osteopenia
3. Swelling
Reiter's
Triad: Urethritis, conjunctivitis, asymmetric arthritis; + HLA-B27
Syndrome
Mono-sodium urate crystals in the joint induce an inflammatory rxn
Gout Old men, great toe #1 site, elevated uric acid levels often seen
Crystals: negatively birefringent
Ligaments Attach one bone to another

Ligament bone 1. Ligament to fibrocartilage


attachment 2. Fibrocartilage to calcified fibrocartilage, (most injuries occur here)
3. Calcified fibrocartilage to bone (Sharpey's fibers)
Sprain Tear of a ligament.
Grade I Stretching of, or minor tear in, ligament; no laxity
Grade II Incomplete tear, laxity is evident (usually swelling)
Grade III Complete tear, increased laxity (swelling/hematoma)
Ligament
Relative strength difference between ligament and one predict injury
Strength
Pediatrics Stronger than physis. Injury will occur at physis first
Adult Bone stronger than ligament. Ligament will rupture first
Geriatrics Ligament stronger than bone. Bone will fracture first

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

NERVES

STRUCTURE COMMENT
Cellular Anatomy
Neuron Cell body. Dendrites receive signal, axon conveys signal
Glial cells Schwann cells produce myelin to cover the axon
Microanatomy Peripheral nerve has both afferent and efferent fibers
Afferent fibers Transmits sensory signals from peripheral nerve endings to the CNS Cell
(axon) bodies are in the dorsal root ganglion (DRG)
Efferent fibers Transmits motor signals from CNS via ventral horn/ventral root to peripheral
(axon) muscles.
Endoneurium Surrounds each individual fiber (axon)
Fascicles Group of endoneurium coated fibers
Perineurium Surrounds each fascicle
Peripheral nerve Groups of fascicles, blood vessels, and connective tissue
Epineurium Surrounds the groups of fascicles (nerves)
Nerve Injuries Based on microanatomy
Neuropraxia Conduction disruption, axon intact; resolves in days to weeks
Axon disrupted, endoneurium intact allows axon regeneration; recovery is slow,
Axonotmesis
growth 1mm/day, but usually full
Neurotmesis Nerve transection, recovery requires surgical repair
Viral destruction of ventral horn (motor) cells resulting in weakness/paralysis,
Poliomyelitis
but normal sensation. Vaccine for prevention.
Nerve
Facilitated by myelin coating on axon (larger/coated fibers are faster)
Conductions
Resting potential Maintained by a polar difference between intra/extracellular environments
Action potential Change in permeability of Na+ ions depolarizes cell.
Nodes of
Gaps between Schwann cells that facilitate conduction
Ranvier
Nerve
Evaluates motor and sensory peripheral nerves
Conduction

Studies (NCS) Stimuli is given and followed by surface electrodes. Latency (delay) and
amplitude (strength of signal) are measured.
Conduction velocities, 50m/s are abnormal
Guillain-Barré Ascending motor weakness/paralysis. Caused by demyelination of peripheral
Syndrome nerves following viral illness. Most self-limiting.

Charcot-Marie- Autosomal dominant disorder. Demyelinating disorder affecting motorsensory


nerves. Onset 5-15yrs, peroneal muscles first, then hand foot intrinsics. Can
Tooth
result in cavus foot, claw toe, intrinsic minus hand.
Neuromuscular
Axon of motor neuron synapses with the muscle (motor end plate)
junction

Neurotransmitter Acetylcholine stored in axon crosses synaptic cleft and binds to receptors on
sarcoplasmic reticulum and depolarizes
Pharmacologic
Nondepolarizing agents (e.g., vecuronium) competively bind Ach receptor
agents
Depolarizing agents (e.g. succinylcholine) bind short term to Ach receptor
Toxins/nerve gas: also bind these receptors competively; treat with
anticholinesterase agents (increase Ach levels in cleft)

Myasthenia Relative shortage of acetylcholine receptors due to competitive binding by


thymus derived antibodies. Treat with thymectomy or anti-acetylcholinesterase
gravis
agents (increase acetylcholine levels in cleft)
Motor Unit All the muscles innervated by a single motor neuron
Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MUSCLES (SKELETAL)

STRUCTURE COMMENT
Types of Muscle Smooth, cardiac, skeletal
Skeletal Voluntary control, have an origin and insertion
Anatomy Muscles cells have two types of contractile filaments: actin, myosin
Muscle Comprised of multiple bundles or fascicles; surrounded by epimysium
Bundle/Fascicle Comprised of multiple muscle fibers (cells); surrounded by perimysium
Fiber (cell) Comprised of multiple myofibril; surrounded by endomysium
Myofibril Comprised of multiple sarcomeres, end to end; no surrounding tissue
Comprised of interdigitated thick and thin filaments; organized into bands.
Sarcomere Z line to Z line defines the sarcomere
A band: length of thick filaments, does not change with contraction
I band, H zone, and sarcomere length all shorten with contraction
Myosin Thick filament: have “heads” that bind ATP and attach to thin filaments
Actin Thin filaments: fixed to Z bands; associated with troponin and tropomyosin
Troponin Associated with actin and tropomyosin, binds Ca++ ions
Tropomyosin Long molecule, lies in helical groove of actin and blocks myosin binding
Initiated when Acetylcholine binds to receptors on sarcoplasmic reticulum
and depolarizes them.
Depolarization causes a release of Ca++ which then binds to troponin
Contraction molecules. This binding causes the tropomyosin to move and the “charged”
head (ATP bound) of myosin can bind to actin.
Breakdown of ATP causes contraction of filaments, (shortening of
sarcomere), and the release of the myosin from the actin filament.

Electromyography Intramuscular electrodes used to evaluate muscle function.


Increased frequency, decreased duration, decreased amplitude indicate
(EMG)
myopathy; opposite findings indicative of neuropathy.
Types of Contraction
Isometric Muscle fires against increasing resistance, muscle length is constant
Isotonic Resistance is constant through contraction
Isokinetic Muscle contracts at a constant speed
Eccentric Muscle lengthens when it fires; can cause injury
Concentric Muscle shortens when it fires
Strength Related to cross sectional area of muscle
X-linked recessive disorder affecting boys. Progressive, noninflammatory
Duchene process affecting proximal muscles (increased CPK). Birth and
development to age 3-5 usually normal, then weakness, clumsy walking, +
Muscular
Gower's sign (uses hands to rise from floor) and calf pseudohypertrophy.
Dystrophy Most wheelchair bound by 15. Multiple associated deformities, contractures,
scoliosis, etc.
STRUCTURE COMMENT
Compartments Muscles are located within confined fibroosseous/fascial spaces
Compartment Multiple causes of increased compartment pressures. Increased pressures
Syndrome and decreased perfusion resulting in myonecrosis.
5 P's: Pain, parathesias, paralysis, pallor, pulselessness (not all needed for
diagnosis). Firm tense compartments on exam.
Fasciotomy within 6 hours needed. Contracture can result.
Musculotendinous Weakest portion of muscular attachment to bone (injuries occur here)
Junction Muscle strain is a partial tear of this unit
Tendon Anatomy Attaches muscles to bones
Type I collagen grouped into microfibrils, then subfibrils, then fibrils,
Fibril
surrounded by endotenon
Fascicle Fibroblasts and fibrils surrounded by peritenon
Tendon Groups of fascicles surrounded by epitenon
Vascular Tendon Vascular paratenon surrounds tendon to supply vascularity; no sheath
Avascular Tendon These tendons are in a sheath, have a vincula to supply vascularity
1. Tendon to fibrocartilage
Tendon bone
2. Fibrocartilage to calcified fibrocartilage (Sharpey's fibers)
Junction
3. Sharpey's fibers to bone.
Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com
Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

MICROBIOLOGY

INFECTION COMMENT
Osteomyelitis Bacterial infection of bone or bone marrow. Staph. aureus #1 organism.
Hematogenous spread most common. Classified as acute, subacute, or chronic.
Pain, swelling, increased WBC, ESR, positive blood cultures. XR shows
radiolucencies, +/-sequestrum (dead cortical bone), involucrum (periosteal new
bone). Bone scan helps diagnosis. I D abscess/sequestra, IV antibiotics followed
by a course of oral antibiotics
Infection of joint space (and synovium). Staph. aureus #1 organism.
Septic Joint Hematogenous or extension of osteomyelitis common routes. Knee #1, hip #2
most common sites. Painful, warm swollen joint.
Requires aspiration/surgical drainage IV antibiotics.
Tetanus Neuroparalytic disorder caused from exotoxin from Clostridium tetani
Vaccine prophylaxis: Tetanus and diphtheria toxoid (Td); Tetanus immunoglobulin
(TIG)
Previously vaccinated (5yrs), clean wound: no treatment
Previously vaccinated (5yrs), clean or dirty wound: 0.5mg Td
Unknown vaccination status or “dirty” wound: Td and TIG

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

IMAGING

STUDY COMMENT
X-ray (plain Standard study, multiple views needed, shows bones well, but soft tissues poorly.
film) The joint above and below a fracture should always receive plain films.
Best study for bony anatomy. Soft tissue seen, but not as well as MRI. Often used
CT
for comminuted fractures and preoperative planning.
Best study for soft tissues including intervertebral discs, ligaments, tendons.
Also highly sensitive for osteonecrosis; T1 images weighted for fat (good for
MRI
normal anatomy), T2 images weighted for water (better for pathology).
Also used for preoperative planning
Radioactive isotope injected into blood. Imaging of the whole body allows
Bone scan visualization of areas of increased uptake. Good for identifying tumor, fractures,
infections, and heterotopic bone activity (HO).

Arthrography Contrast injected into joint followed by plain films to evaluate capsular integrity
(e.g. used for rotator cuff tears)
Myelography Contrast injected into epidural space; evaluates disc herniation, cord tumors

Discography Contrast injected into nucleus pulposus to evaluate disc degeneration. Not a
common procedure.
Ultrasound Good for evaluating rotator cuff pathology

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Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed.
Copyright © 2001 Saunders, An Imprint of Elsevier

ABBREVIATIONS USED IN THIS BOOK

Abd abduct

AC acromioclavicular

ACL anterior cruciate ligament

ADM abductor digitiminimi

AGRAM arthrogram

AIIS anterior inferior iliac spine

AIN anterior interosseus nerve

ALL anterior longitudinal ligament

AMBRI atraumatic, multidirectional, bilateral instability

ANA antinuclear antibody

Ant. anterior

AP anteroposterior

APB abductor pollicis brevis

APC anterior-posterior compression

APL abductor pollicis longus

ASIS anterior superior iliac spine

AVN avascular necrosis

BR brachioradialis

Ca ++ ion calcium

CBC complete blood cell count


CL capitate-lunate joint

CMC carpal-metacarpal

CPK creatine phosphokinase

CRP C-reactive protein

C-spine cervical spine

CT computed tomography

CTL capitotriquetral ligament

CTS carpal tunnel syndrome

DDD degenerative disk disease

DIO dorsal interossei

DIP distal interphalangeal

DISI dorsal intercalated segment instability

DJD degenerative joint disease

DRC dorsal radiocarpal ligament

DRUJ distal radioulnar joint

DVT deep vein thrombosis

ECRB extensor carpi radialis brevis

ECRL extensor carpi radialis longus

ECU extensor carpi ulnaris

EDC extensor digitorum communis

EDL extensor digitorum longus

EDM extensor digiti minimi


EHL extensor hallucis longus

EIP extensor indicis proprius

EMG electromyogram

EPB extensor pollicis brevis

EPL extensor pollicis longus

ER external rotation

ESR erythrocyte sedimentation rate

FCR flexor carpi radialis

FCU flexor carpi ulnaris

FDB flexor digitorum brevis

FDL flexor digitorum longus

FDMB flexor digiti minimi brevis

FDP flexor digitorum profundus

FDS flexor digitorum superficialis

FHB flexor hallucis brevis

FHL flexor hallucis longus

FPB flexor pollicis brevis

FPL flexor pollicis longus

Fx fracture

GAG glycosaminoglycans

GI gastrointestinal

GU genitourinary
H

HNP herniated nucleus pulposus

Hx history

ID incision and drainage

IF index finger

IJ internal jugular

IM intramedullary

Inf. inferior

IP interphalangeal

IR internal rotation

ITB iliotibial band

IV intravenous

Lat. lateral

LBP low back pain

LC lateral compression

LCL lateral collateral ligament

LE lower extremity

LFCN lateral femoral cutaneous nerve

LH long head

LT lunotriquetral

MC metacarpal
MCL medial collateral ligament

MCP metacarpophalangeal

MDI multidirectional instability

Med. medial

MF middle finger

MRI magnetic resonance imaging

MT metatarsal

MVA motor vehicle accident

N. nerve

NCS nerve conduction study

NSAID non-steroidal anti-inflammatory drug

OA osteoarthritis

OP opponens pollicis muscle

ORIF open reduction, internal fixation

PAD palmar adduct

PCL posterior cruciate ligament

PCP percutaneous pinning

PE physical examination

PFCN posterior femoral cutaneous nerve

PFS patellofemoral syndrome

PIN posterior interosseus nerve


PIP proximal interphalangeal

PL palmaris longus

PLC posterolateral corner complex

PLL posterior longitudinal ligament

PLRI posterolateral rotary instability

PMHx past medical history

PMRI posterolateral rotary instability

PO postoperatively

Post. posterior

PQ pronator quadratus

PSIS posterosuperior iliac spine

PT pronator teres

PTH parathyroid hormone

PVNS pigmented villonodular synovitis

Q quadriceps

RA rheumatoid arthritis

RAD radiation absorbed dose

RC rotator cuff

RCL radioscaphocapitate ligament

RF rheumatoid factor, ring finger

RICE rest, ice, compression, and elevation

ROM range of motion


RSD reflex sympathetic dystrophy

RSL radioscapholunate ligament

RTL radiolunotriquetral ligament

SC sternoclavicular

SCM sternocleidomastoid

SF small finger

SFA superficial femoral artery

SH short head

SI sacroiliac

SL scapholunate

SLAC scapholunate advanced collapse

SLAP superior labrum anterior/posterior

STT scaphotrapezoid-trapezial

Sup. superior

Sx symptom

TA tibialis anterior

TCL transverse carpal ligament

Td tetanus and diphtheria toxoid

TFCC triangular fibrocartilage complex

TFL tensor fascia lata

THA total hip arthroplasty

TIG tetanus immunoglobulin


TLSO thoracolumbosacral orthosis

TP tibialis posterior

TTP tenderness to palpation

TUBS traumatic, unilateral instability, and Bankart lesion

UE upper extremity

UMN upper motor neuron

VIO volar interosseus

VISI volar intercalated segment instability

VMO vastus medialis obliquus

WB weight bearing

WBC white blood cell count

XR x-ray

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