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BONES
CLAVICLE: most frequently fractured bone
of body; break occurs where bone is weakest,
at junction of lateral and middle third; following
break, medial end is pulled superiorly by SCM
and lateral end is pulled inferiorly by weight of
arm and medially by pectoralis major
Fracture of clavicle usually occurs as result of
fall on shoulder or outstretched hand
HUMERUS
Fracture at surgical neck injures axillary nerve,
which innervates deltoid resulting in loss of
abduction of arm
Fracture at midshaft (spiral groove) injures
radial nerve, resulting in wrist drop and
decreased extension at elbow
Fracture inferiorly (at medial epicondyle) affects
ulnar nerve, major nerve to intrinsic hand
muscles, resulting in ulnar claw hand
Radius:
Colles fracture is fracture of distal
radius resulting from fall on outstretched hand;
common; produces "dinner fork effect whereby
distal fragment is posterior (top picture)
Smiths fracture (less common) results from fall
on back of hand with anterior displacement of
distal fragment (bottom picture)
Abduction of arm
Action is initiated by supraspinatus; deltoid is chief
abductor but can only abduct just beyond horizontal
plane without scapular rotation
For complete abduction of arm, scapula needs to be
rotated; upward rotators of scapula are (1) trapezius:
both upper fibers that pull acromial end of spine up,
and lower fibers that pull medial end down, and (2)
serratus anterior
Dupuytrens contracture
not nerve injury; localized
pathological thickening
and contracture of
palmar aponeurosis
Dupuytrens contracture
Starts at root of ring finger, drawing finger to palm;
fifth finger is affected later
More common in males
Begins as fibrous nodules which progress to dense
bands
HAND INNERVATION
MOTOR: all muscles are innervated by C8 and T1
SENSORY: Dermatomes
C6: thumb and index finger
C7: middle finger
C8: ring and little fingers
Cutaneous nerves
Median: 3 1/2 fingers on palmar side, related
palm, and middle and distal phalanges of
lateral 3 1/2 fingers on dorsal side
Ulnar: medial 1 1/2 fingers (both sides and
palm
Radial: dorsolateral aspect
NERVE INJURIES
Axillary: courses around surgical neck of humerus
(with posterior humeral circumflex artery) to pass
through quadrangular space; axillary nerve can be
injured with fracture of surgical neck; would result
in atrophy of deltoid and functional loss at shoulder
joint: major losses of abduction, flexion, extension,
and rotation
LOWER LIMB
Femur: head is about 2/3rds of sphere and has pit
(fovea) for attachment of round ligament of head
Neck joins shaft at angle of 1250, angle of
inclination; coxa vara: abnormally decreased angle;
coxa valga: abnormally increased angle
Neck often fractured in fall with elderly, especially
females
Greater trochanter: palpable landmark, site of
numerous muscular attachments (lateral rotators of
gluteal area)
Lesser trochanter: attachment site for iliopsoas, chief
flexor of thigh; not palpable
MUSCLES
Gluteus maximus: only muscle innervated by
inferior gluteal nerve; powerful lateral rotator and
chief extensor at hip when rising from chair (with
other situations, hamstring muscles, that is, long head
of biceps femoris, semitendinosus, and
semimembranosus, extend at hip)
Muscles attached to greater trochanter that laterally
rotate thigh are piriformis, superior and inferior
gemelli, obturator internus and externus, and
quadratus femoris
Intramuscular injections: given in upper, lateral
quadrant to avoid sciatic nerve
Lumbar plexus
Ventral rami T12 - L4; located in abdominal cavity,
related to psoas major muscle
Iliohypogastric (T12 and L1) and ilioinguinal (L1)
nerves innervate muscles of lower anterior abdominal
wall and are cutaneous; iliohypogastric to suprapubic
area and ilioinguinal to anterosuperior aspect of thigh
Femoral (L2 - 4) innervates muscles of anterior
compartment of thigh and has major cutaneous
distribution to anterior thigh and medial side of leg
and foot; obturator has same spinal levels,
innervates muscles of adductor compartment, and has
minor cutaneous distribution: medial side of knee
Sacral plexus
Ventral rami L4 - S3; located in pelvis, related to
piriformis muscle; ventral rami divide into anterior
and posterior divisions
Anterior (preaxial) nerves: tibial, nerves to obturator
internus and quadratus femoris
Posterior (postaxial) nerves: common fibular, superior
and inferior gluteal nerves
Posterior femoral cutaneous is large nerve formed by
both anterior and posterior divisions
Sural nerve: cutaneous nerve formed from both tibial
and common fibular portions of sciatic nerve
JOINTS
Hip joint is very stable ball-and-socket type of
synovial joint; 2/3rds of head of femur lies within
acetabulum, which is formed by union of pubis,
ilium, and ischium
Transverse acetabular ligament unites edges of
horseshoe-shaped acetabular labrum, fibrocartilage
that serves to deepen acetabular fossa
Ligament of head of femur conveys branch of
obturator artery to pit (fovea) of head of femur
BACK: Muscles
Superficial muscles act on upper limb or on ribcage;
trapezius is innervated by CN XI, shoulder droops
with injury to CN XI; other superficial muscles are
innervated by ventral rami
Latissimus dorsi, used in climbing, is innervated by
thoracodorsal nerve and muscle acts to adduct,
extend, and medially rotate arm
Triangle of auscultation overlies sixth interspace
and is bounded by trapezius, latissimus dorsi, and
rhomboid major; lumbar triangle, site of (fat) hernia
is bounded by iliac crest, external oblique and
latissimus dorsi
Suboccipital triangle
Rectus capitis posterior minor does not serve as
boundary
Boundaries are rectus capitis posterior major,
obliquus capitis superior, and obliquus capitis
inferior; all muscles are innervated by dorsal ramus
of C1 (suboccipital nerve)
Roof: semispinalis capitis; floor: posterior atlantooccipital membrane
Vertebral artery: inside cranial cavity gives rise to
PICA; dizziness with turning of head
THORAX
Costal groove lies on inferior border of rib; houses
posterior intercostal vein, artery, and intercostal
nerve
With thoracocentesis, the needle is inserted on the
superior surface of the rib, in order to avoid
collateral vessels and nerves
Middle ribs are ones most commonly fractured
Rib is weakest just anterior to its angle, site of
greatest curvature
Surfaces of heart
1. The sternocostal surface is formed mainly by the
right ventricle
2. The diaphragmatic surface is formed mainly by the
inferior wall of the left ventricle
3. The posterior surface is formed mainly by the left
atrium
Right atrium
Forms right border of heart
Fossa ovalis is major internal feature; was foramen
ovale prior to birth that shunted blood from right to
left
Crista terminalis: ridge of tissue between sinus
venarum and musculi pectinati; SA node, pacemaker
of heart, is located within crista terminalis
Atrial septal defect (ASD): common defect of heart;
usually involves foramen ovale; severity depends on
amount of blood passing to left
Right ventricle
Moderator band (septomarginal trabecula) is located
in right ventricle
Pulmonary stenosis results in hypertrophy of right
ventricle due to increased resistance to right
ventricular outflow caused by a stenotic pulmonic
valve
Ventricular septal defect (VSD) is common
defect of heart; involves membranous portion of
interventricular septum
ABDOMEN
Ventral rami of spinal nerves T7 through L1 supply
skin and musculature of anterolateral abdominal wall
T10 supplies skin around umbilicus; pain from ovary
or appendix is initially perceived at umbilical level;
intervertebral disc L3/L4 lies at level of umbilicus
L1 supplies skin of suprapubic area; pain from uterus
or prostate
ORGANS: Stomach
The celiac artery, the first unpaired visceral branch
of the abdominal aorta, has three branches: left
gastric, common hepatic and splenic
All three arteries supply the stomach: left gastric
arises directly from the celiac; right gastric and
right gastroepiploic arise from the hepatic; and
the left gastroepiploic and short gastric arteries
arise from the splenic
Venous blood from the stomach drains directly to the
portal vein
LARGE INTESTINE
Three classical identifying features are: (1) fatty
appendages; (2) haustra or sacculations; and (3)
tenia coli, three longitudinal bundles of smooth
muscle
Diverticulosis of the colon is common; herniation of
the lining mucosa through the circular muscle
between the tenia coli
Cancer of the large bowel is common; usually
spreads by lymphatics before the bloodstream is
involved
Psoas major
O = T12 - L5; I = joins iliacus to form iliopsoas
to insert on lesser trochanter of femur
Chief flexor at hip (flexes trunk with feet on
ground)
Subfascial space route for spread of infection;
spread of tuberculosis from lumbar vertebrae
to lower limb
Flexion of thigh against force: test for disorders of
posterior abdominal viscera
Psoas minor
Quadratus lumborum
Iliacus
Urinary bladder
Strong muscular wall known as the detrusor muscle
Apex is located anterior and is continuous with the
urachus, the fibrous cord that is the remnant of the
allantois; the urachus forms the median umbilical
ligament; base is located posterior and is outlined by
the trigone, which is bounded by the two ureters and
the urethra; oblique course of the ureter acts as valve
Blood supply: superior and inferior vesical arteries
Micturition reflex is entirely parasympathetic; S2 - 4
(pelvic splanchnic nerves)
FASCIA
1. Investing fascia: collar around entire neck, invests SCM
and trapezius
2. Infrahyoid fascia: surrounds the four strap muscles
3. Visceral fascia has two layers: (a) pretracheal fascia lies anterior
to trachea and surrounds thyroid gland; and
(b) buccopharyngeal fascia lies posterior
4. Prevertebral fascia: - surrounds muscles of vertebral column;
alar fascia is anterior layer of prevertebral fascia;
danger space lies between alar and prevertebral
5. Carotid sheath (paired) contains common and internal carotid
arteries, CN X, internal jugular vein & deep cervical lymph
nodes; sympathetic trunk lies posterior and ansa cervicalis lies
anterior
POSTERIOR TRIANGLE
Boundaries: clavicle (middle 1/3) , SCM, trapezius
Muscles of floor (from apex inferiorly): semispinalis
capitis, splenius capitis, levator scapulae, posterior
scalene, middle scalene, anterior scalene
Platysma muscle overlies pectoralis major, deltoid,
and posterior triangle; innervated by cervical branch
of CN VII
Anterior triangle
Boundaries: SCM, mandible and midline
Carotid triangle: omohyoid, posterior belly digastric
and SCM
Muscular triangle: omohyoid, SCM and midline
Digastric (submandibular): mandible and two bellies
of digastric muscle
Submental: hyoid bone and paired anterior bellies
of digastric
Fontanelles
Paired: sphenoid and mastoid
Unpaired: sagittal and coronal sutures intersect at
bregma, site of anterior fontanelle
Lambda, where sagittal and lambdoidal sutures
meet, site of posterior fontanelle
Paranasal sinuses
Frontal drains to middle meatus via frontonasal duct
Maxillary: largest; drains superiorly to middle
meatus; problem clinically
Sphenoid drains to sphenoethmoid recess
Ethmoid
Anterior: middle meatus
Middle: middle meatus
Posterior: superior meatus
Ophthalmic veins
Superior: formed by confluence of angular,
supraorbital, and supratrochlear veins; drains to
cavernous sinus
Inferior: drains eyelids; divides and passes through
both superior and inferior orbital fissures;
communicates with pterygoid plexus
CN I: telencephalon
CN II: diencephalon
CN III & IV: midbrain
CN V - VIII: pons
CN IX - XII: medulla
Special sensation: CN I - olfaction, CN II vision;
CN VIII hearing; CN VII, IX and X taste
Motor only: CN III, IV and VI for eye muscles;
CN XI for trapezius and SCM; CN XII tongue
Glossopharyngeal nerve
Tympanic branch re-enters skull, courses through the
Middle ear and exits as the lesser petrosal nerve that
goes to the otic ganglion (parasympathetics for the
parotid gland)
Very important branch to carotid sinus and body
(CN X also innervates both carotid sinus and body)
Only one muscle: stylopharyngeus
Sensation to tonsillar bed, posterior 1/3rd of tongue,
and muscles of pharynx