Anatomy

Front 1

Draw the line representing the course of the spine of scapula on the posterior surface of the thorax.

Back 1

Ask the model to place a hand on the opposite shoulder, with the thumb nestling in at the neck. Immediately below the resting fingertips a distinct bony ridge can be palpated which moves when the shoulder girdle is moved. This prominent bony ridge running from medial to lateral, upwards and outwards is the spine of scapula which ends at the acromion process

Hint 1

Place hand on opposite shoulder Bony ridge below fingertips Moves when shoulder shrugged

Front 2

Demonstrate and identify by palpation the tendon of palmaris longus

Back 2

Ask model to flex elbow with palm up ask to flex wrist with thumb and little finger together it's the tendon that stands out some people don't have this

Hint 2

flexes wrist

Front 3

Mark the project position of the acromial angle with a circle.

Back 3

Palpate the spine of scapula and move along it in a lateral and superior direction towards the top of the shoulder. Approximately 2cm from the summit of the shoulder a sharp bony angle can be identified at the most lateral extremity of the spine of scapular. This bony feature is the acromial angle.

Hint 3

Find Spine of scapula move lateral to the top of the shoulder 2cm from top - there is a sharp bony angle it is more towards the back

Front 4

Draw the projected outline of the apex of the coracoid process of the scapula

Back 4

Find the ends of the clavicle palpate from the medial end 3/4 way along move down 2 cm it's a bony prominence under the muscle

Front 5

Identify by palpation and surface mark the greater tubercle of humerus. Mark with a circle

Back 5

With the model in the anatomical position, identify the lateral edge of the acromion process. Slide off laterally and inferiorly about 2cm. The greater tubercle forms the most lateral bony feature of the shoulder beneath the middle fibres of deltoid muscle and lies in an antero-lateral position. With a couple of fingertips on the greater tubercle as the model to rotate the arm so that the greater tubercle of the humerus moves under the palpating fingertip of the examiner.

Hint 5

Identify the lateral edge of acromion process slide laterally & down 2cm the greater tubercle is the most lateral bony bit ask the model to rotate the arm and can feel the tubercle moving

Front 6

Identify by palpation and surface mark the lesser tubercle of humerus. Mark with a circle

Back 6

Identify and mark the tip of the coracoid process of the scapula and the greater tubercle of humerus. Draw a horizontal line between these two points and mark the midpoint. The lesser tubercle of the humerus lies just below the mid point of this line. Palpate the lesser tubercle and ask the model to rotate the arm. The lesser tubercle of humerus moves under the palpating fingertip

Hint 6

identify the coracoid process identify the greater tubercle of humerus draw a line between the 2 mark the midpoint the lesser tubercle is just below this point ask the model to rotate the arm and can feel it moving

Front 7

Identify by palpation and surface mark the medial epicondyle of humerus. Mark with a circle.

Back 7

Flex elbow to a right angle Palpate down medial surface towards the elbow The palpating finger will meet a prominent bony projection on the medial surface of the lower extremity of the humerus This is the medial epicondyle of humerus

Hint 7

Flex elbow to a right angle Palpate down medial surface towards the elbow The palpating finger will meet a prominent bony projection on the medial surface of the lower extremity of the humerus This is the medial epicondyle of humerus

Front 8

Identify by palpation and surface mark the lateral epicondyle of the humerus.

Back 8

Flex elbow to right angle Using firm pressure on lateral surface of humerus palpate towards the elbow Two thirds of way down a bony ridge begins to become distinct This is the lateral supracondular ridge of the humerus. Continued palpation down the ridge leads directly to the lateral margin of the lateral epicondyle of the humerus superior to the elbow joint

Front 9

Identify by palpation and surface mark the olecranon process of the ulna

Back 9

Ask the model to flex elbow and mark obvious bony prominence with circle

Front 10

Identify by palpation and surface mark the head of the radius

Back 10

'Shake Hands' with your model. With other had locate the lateral epicondyle of humerus Slide distally off the epicondyle into a small ditch between the humerus and the radius The head of the radius is an indistinct mound distal to the ditch With finger on this bony structure, ask the model to supinate and pronate their forearm, you will feel the head of the radius rotate under your finger

Front 11

Identify by palpation and mark the posterior border of the shaft of ulna

Back 11

Identify by palpation the olecranon process of ulna Palpate the distinct ridge of bone which runs from the tip of the olecranon process to the head of ulna Mark with a line this subcutaneous ridge which is the posterior border of the ulna shaft.

Front 12

Identify by palpation and surface mark the head of the ulna.

Back 12

Slide your fingers distally along the shaft of the ulna On the posterior medial aspect of the wrist a prominent, rounded projection of bone can be observed and palpated. This is the posterior head of ulna

Front 13

Identify by palpation and surface mark the styloid process of the radius.

Back 13

Ask the model to flex the elbow to a right angle. Hand in thumbs up position Place a fingertip in anatomical snuffbox and palpate the tip of the radius. The styloid process of the radius is a small process of bone projecting into the joint space of the wrist. It can be more easily palpated when the wrist is relaxed

Front 14

Identify by palpation and surface mark the styloid process of ulna.

Back 14

Identify the head of the ulna The styloid process of the ulna lies distally on the posterior and medial surface of the head of ulna Like styloid process of radius projects in to wrist space and more easily found when wrist is relaxed. The process should remain still as you flex and extend the wrist.

Front 15

Identify by palpation and surface mark the dorsal tubercle of the radius. Mark with a circle

Back 15

Identify the head of the ulna. Palpate towards the distal end of the radius about 2.5 cm from the end of the ulna a prominent tubercle can be distinguished. This is the dorsal tubercle of the radius

Front 16

Identify by palpation and surface mark the position of the pisiform bone.

Back 16

Identify flexor crease of the wrist. Distal to this crease on the ulnar side a small pea shaped bone is palpable and may be tender With the wrist flexed it should be possible to slide this bone from side to side

Front 17

Identify and surface mark the position of the hamate bone

Back 17

Identify the pisiform bone Palpate a point approximately 2.5 cm distal to the pisiform bone on the palmar surface of the hand in the direction of the cleft between the 4th & 5th fingers. Apply firm pressure with the fingertip and a bony projection can be identified deep to the hypothenar muscles.

Front 18

Identify and surface mark the position of the scaphoid bone

Back 18

Ask the model to flex the elbow joint and fully extend the wrist joint At the base of the thenar eminence immediately distal to the inferior extremity of the radius the skin colour pales as a bone projects forwards during extension of the wrist against the skin. This is the anterior surface of the scaphoid bone

Front 19

Identify and surface mark the position of the trapezium bone.

Back 19

Identify the anterior position of the scaphoid Move the fingertip approximately 2.5 cm distally to the cleft between the thumb and first finger Palpate with firm pressure at this point into the muscles of the thenar eminence Mark a circle around crest like projection at this point

Front 20

Identify and surface mark the position of the lunate bone.

Back 20

Identify and mark the scaphoid and pisiform bones on the palmar surface Ask the model to flex the wrist joint Identify the tendon of palmaris longus which crosses the lunate bone Lunate bone is between the pisiform and scaphoid bones

Front 21

Identify and surface mark the projected anterior line of the gleno-humeral joint.

Back 21

Identify the tip of the coracoid process Just lateral to this point, draw a vertical 5cm line with slight concavity facing towards the head of the humerus This line represents the glenoid cavity of the shoulder joint

Front 22

Identify and surface mark the line marking of the sterno-clavicular joint. Draw a line.

Back 22

Place a finger at the jugular notch at the base of the throat Palpate laterally for the prominent medial extremity of the clavicle Ask the model to raise the point of the shoulder while palpating around the medial end of the clavicle to determine where movement can be felt. At this point draw an oblique line to represent the joint

Front 23

Identify and mark the joint line of the acromio-clavicular joint.

Back 23

Identify the clavicle and palpate to find the lateral end, a smallstep down takes the palpating finger to the acromion process. The acromio-clavicular joint line is between these two bones. If the model raise the shoulder the joint space widens slightly

Front 24

Identify and mark the anterior surface marking of the radio-carpal joint

Back 24

Identify and mark the tip of the styloid process of radius Identify and mark the styloid process of ulna Draw a line convex upwards between the two The lateral two thirds mark the radio-carpal joint

Front 25

Mark the line of the carpo-metacarpal joint of the thumb in the anatomical snuffbox

Back 25

Palpate from the base of the thumb down both sides of the first metacarpal towards the wrist In the crease between the thumb and forefinger you will encounter bone protuberance which is the trapezium Slightly distal to this protuberance is a small depression, this is the first carpo-metacarpal joint. Ask the model to fully flex and extend the thumb while maintaining the position of the palpating fingertip. Detect the gliding movement at the joint between the trapezium and the base of the first metacarpal bone of the thumb and mark the joint line.

Front 26

Mark the line of the second metacarpo-phalangeal joint on the dorsal surface of the hand. Mark the joint line

Back 26

Ask the model to make a clenched fist and identify the head of the 2nd metacarpal bone. Ask the model to relax the hand and palpate just distal to the head of 2nd metacarpal bone whilst applying gentle traction to the index finger You should be able to feel the space in the joint widen when traction is applied. Confirm you have found the joint line by passively flexing and extending the joint.

Front 27

Mark on the dorsum o f the hand, lines to indicate the interphalangeal joints of the index finger.

Back 27

Ask the model to fully extend and flex the index finger Palpate where the movement occurs between the proximal, middle and distal phalanges of the index finger Mark a line on the dorsal surface where movements can be detected.

Front 28

Draw a line to indicate the anterior surface marking of the elbow joint

Back 28

Identify and mark the medial and lateral epicondyles of the humerus on the posterior surface and draw a horizontal line between 2 points Draw a parallel line 2cm distal to the first line the 2nd line indicates the surface marking of the elbow joint. Ask the model to extend the elbow joint and palpate the head of the radius The line should cut through a depression between the head of radius and the capitulum of the humerus which forms the lateral part of the elbow joint

Front 29

Demonstrate the action of trapezius in a daily activity

Back 29

Ask the model to maintain the anatomical position and hold a weight in one hand to demonstrate how trapezius maintains the position of the clavicle and acromion process. Ask the model to strongly adduct the vertebral borders of the scapula towards the medial plane. Ask the model to abduct and elevate the arm to demonstrate the way in which the trapezius aids rotation of the scapula

Hint 29

elevates/adducts/rotates scapula

Front 30

Demonstrate the action of latissumus dorsi in a daily activity

Back 30

Ask the model to grasp the seat of the chair on which they are sitting with both hands, take both feet off the ground and lift bodyweight from the chair seat. Or - Ask the model to rotate , extend and adduct the gleno-humeral joint so the hand is positioned as if ready to be handcuffed

Hint 30

extends, adducts and medially rotates arm

Front 31

Demonstrate the action of rhomboid major and minor

Back 31

Ask the model to retract the vertebral borders of the scapulae towards each other. The rhomboid muscles work as together with trapezius to rotate, elevate and adduct the scapula when the hand is raised above the head. The rhomboid muscles cannot be palpated.

Hint 31

adduct scapulae

Front 32

Demonstrate the action of levator scapulae

Back 32

Ask the model to abduct the shoulder joint and elevate the hand above the head Note the action of the levator scapulae in elevation, rotation and slight protraction of the scapula. Muscle cannot be palpated

Hint 32

elevates scapula

Front 33

Draw the projected outline of the clavicle on the anterior surface on the thorax. Mark the outline of the bone.

Back 33

Start at the jugular notch, a small hollow at the base of the throat Lateral to this is the expanded and raised medial extremity of the clavicle Palpate in a lateral direction from the medial end of the clavicle along its shaft to the lateral junction with the acromion process of the scapula. Mark the outline of the bone

Front 34

Demonstrate the action of serratus anterior

Back 34

Ask the model to push strongly against resistance (such as pushing against a wall) This will result in winging of the scapula. Ask the model to elevate the upper limb against resistance. Note rotation of the scapula Observe and palpate the pronounced serrated digitations of serratus anterior on the antero-lateral aspect of the thoracic wall

Hint 34

stabilise/retract scapulae

Front 35

Demonstrate the action and palpate pectoralis major

Back 35

Identify the clavicle near lateral margin of the sternum Ask the model to press the palms together strongly Palpate immediately inferior to the medial third of the clavicle to identify the clavicular attachment to pectoralis major. Palpate the sternal attachment of pectoralis major inferior to the clavicular attachment and lateral to the mid-line of the sternum and over the costal cartilages 1 to 6

Hint 35

adduct and medially rotate arm

Front 36

Demonstrate the action of deltoid

Back 36

Identify the lateral one third of the shaft of the clavicle, acromion process and the spine of scapula. Ask the model to abduct the shoulder to 90 degrees. The middle fibres of the deltoid can be palpate along the lateral margin of the acromion process passing towards the deltoid tuberosity. The anterior fibres can be palpated inferior to the lateral one third of the clavicle passing towards the deltoid tuberosity The posterior fibres can be palpated passing from the spine of scapula towards the deltoid tuberosity

Hint 36

abducts arm

Front 37

Demonstrate the action of subscapularis

Back 37

Ask the model to medially rotate and adduct the shoulder The tendon of subscapularis passes high up in the axillary space to its attachment on the lesser tubercle of humerus and cannot be palpated.

Hint 37

medially rotates arm

Front 38

Palpate and demonstrate the action of supraspinatus

Back 38

Note the locations of the spine of scapula, acromion process and greater tubercle of humerus. Ask the model to abduct the shoulder to 30 degrees to demonstrate the action of supraspinatus. To palpate supraspinatus support the models arm in 90 degrees of abduction to reduce muscle tone and gently palpate immediately superior to the spine of scapula moving in a lateral direction towards the humerus.

Hint 38

helps to abduct arm

Front 39

Palpate and demonstrate the action of infraspinatus

Back 39

Note the posterior fibres o the deltoid and the axillary border of the scapula immediately inferior to the spine of scapula. Place one palm on the scapula to fix its position against the thoracic wall. Ask the model to strongly laterally rotate and extend the gleno-humeral joint. Palpate the posterior surface of the scapula and the axillary border of the scapula moving in a lateral direction towards the posterior fibres of the deltoid

Hint 39

laterally rotates and adducts arm

Front 40

Palpate and demonstrate the action of teres minor

Back 40

Note the posterior fibres o the deltoid and the axillary border of the scapula immediately inferior to the spine of scapula. Place one palm on the scapula to fix its position against the thoracic wall. Ask the model to strongly laterally rotate and extend the gleno-humeral joint. Palpate the posterior surface of the scapula and the axillary border of the scapula moving in a lateral direction towards the posterior fibres of the deltoid

Hint 40

laterally rotates and adducts arm

Front 41

Palpate and demonstrate the action of teres major

Back 41

Ask the model to adduct, extend and medially rotate the gleno-humeral joint. Palpate immediately superior and just lateral to the upper border of the latissimus dorsi and it crosses the inferior angle of the scapula in the area of posterior wall of the axillary space

Hint 41

medially rotates, adducts and extends arm

Front 42

Palpate and demonstrate the action of Coracobrachialis

Back 42

This muscle runs across the gleno-humeral joint from the coracoid process to a point halfway down the medial humerus. Ask the model to adduct the gleno-humeral joint with the elbow flexed as if holding a textbook in the axillary space. Palpate the contraction of Coracobrachialis from the tip of coracoid process to the antero-medial aspect of the upper one third of the shaft of the humerus medial to the short head of biceps brachii.

Hint 42

stabilises and weakly adducts arm

Front 43

Palpate and demonstrate the action of biceps brachii

Back 43

Ask the model to fully supinate the wrist , then flex the elbow against resistance The muscle of biceps brachii may be palpated on the antero-medial surface of the humerus approximately 8-10cm above the line of the elbow joint. The distal tendon of attachment of biceps brachii can be identified as it passes across the mid-line of the cubital fossa. The pulse of the brachial artery can be identified medial to the biceps tendon in the cubital fossa.

Hint 43

flexes elbow

Front 44

Palpate and demonstrate the action of Brachialis

Back 44

Ask the model to flex the elbow joint to 90 degrees against resistance with the wrist fully pronated. Brachialis is positioned deep to biceps brachii and can be palpated against the posterior surface of the humerus below the deltoid tuberosity of humerus

Hint 44

flexes elbow

Front 45

Palpate and demonstrate the action of triceps brachii

Back 45

Ask the model to fully flex the elbow joint and then extend against maximum resistance. the triceps brachii can be palpated on the posterior surface of the arm during extension of the elbow joint and gleno-humeral joint. The tendon of triceps brachii forming the distal attachment can be palpated and traced to its insertion on the olecranon process of ulna

Hint 45

extends elbow

Front 46

Demonstrate the action of pronator teres.

Back 46

Ask the model to flex and fully supinate the wrist, then fully pronate it so that the palm faces down. The pronator teres is a weak flexor of the elbow joint and works with pronator quadratus, a strong pronator to bring about pronation. Pronator Teres may be palpated on the anterior surface of the forearm passing from the medial epicondyle of humerus and coracoid process of ulna to the lateral surface of the ulna

Hint 46

pronates and flexes forearm

Front 47

Demonstrate the action of flexor Carpi Radialis and palpate the tendon

Back 47

Ask the model to flax the elbow with the palm supinated. Ask the model to strongly flex and radially deviate the wrist. The tendon of flexor-carpi-radialis can be palpated and its position marked immediately lateral to the mid-line of the forearm, adjacent to the tendon of palmaris longus.

Hint 47

flexes wrist

Front 48

Demonstrate and identify the flexor carpi-ulnaris and palpate the tendon

Back 48

Ask the model to flex the elbow joint at a right angle and supinate the hand Note the position of the pisiform bone Ask the model to strongly flex and ulnar deviate the radio-carpal joint The subcutaneous tendon of flexor-carpi-ulnaris can be palpated on the antero-medial surface of the forearm as it passes to its distal attachment on the pisiform bone.

Hint 48

flexes wrist

Front 49

Demonstrate and palpate the tendon of flexor digitorum superficialis

Back 49

Ask the model to place a hand flat on a table with the palmar surface facing upwards. Surface mark the proximal phalanx of the index finger Ask the model to flex the proximal interphalangeal joint against maximum manual resistance During this movement the therapist isolates movement to the proximal interphalangeal joint by the application of manual resistance to the middle phalanx

Hint 49

flexes fingers

Front 50

Demonstrate and palpate the tendon of flexor digitorum profundus

Back 50

Ask the model to place a hand flat on a table with the palmar surface upwards. Surface mark the distal and middle phalanx of the index finger and the distal interphalangeal joint of the index finger. Ask the model to flex the distal interphalangeal joint against maximum manual resistance During this movement the therapist isolates movement to the distal interphalangeal joint by the application of manual resistance to the middle phalanx.

Hint 50

flexes fingers

Front 51

Demonstrate and palpate the tendon of flexor pollicis.

Back 51

Ask the model to place the hand flat on a table with the palmar surface upwards Ask the model to flex the interphalangeal joint of the thumb During this movement the therapist isolates movement to the interphalangeal joint of the thumb by applying resistance to the proximal phalanx.

Hint 51

flexes thumb

Front 52

Demonstrate the action and palpate the Brachioradialis

Back 52

Ask the model to flex the elbow joint to 90 degrees Ask the model to place the hand in midway position between full pronation and full supination (thumbs up) Ask the model to flex the elbow joint against resistance applied to the forearm The prominent muscle belly of Brachioradialis can be identified and palpated in the upper two thirds of the forearm on the antero-lateral surface

Hint 52

flexes forearm

Front 53

Demonstrate the action of Supinator and indicate its position

Back 53

Identify the position of head of the radius Ask the model to flex the elbow joint to 90 degrees with the wrist pronated, then strongly supinate the wrist. The Supinator may be palpated distal to the head of radius during supination

Hint 53

supinates forearm

Front 54

Demonstrate the action and palpate the tendon of extensor carpi-radialis longus

Back 54

Locate and mark the base of the 2nd metacarpal (palm down). Ask the model to pronate the forearm and fully extend the wrist with slight radial deviation. A few millimetres proximal to the base of the 2nd metacarpal bone of the index finger is a small depression immediately ver the distal row of carpal bones. Place the tip of the finger in this depression and ask the model to extend and relax the wrist. The tendon of extensor carpi-radialis longus can be palpated at this point as it passes to its distal attachment at the base of the second metacarpal bone

Hint 54

extends wrist

Front 55

Demonstrate and palpate the tendon of extensor carpi-radialis brevis

Back 55

Ask the model to place the palm of a hand on a table Please your fingertip at the base of the 3rd metacarpal. Move your fingertip 3mm proximally (capitate bone) and ask the model to strongly extend the radiacarpal joint (wrist). The tendon of extensor carpi-radialis brevis can be palpated as it passes to the base of the third metacarpal bone. It is lateral to the tendon of extensor carpi-radialis longus

Hint 55

extends and abducts wrist

Front 56

Demonstrate and palpate the extensor digitorum muscle

Back 56

Ask the model to pronate the forearm and strongly extend the wrist and fingers against resistance. The muscle belly can be clearly identified on the posterior surface of the forearm inferior to the lateral epicondyle of humerus. The four extensor tendons of the fingers, passing to their distal attachments on the middle and distal phalanx of each of the four fingers, can be observed and palpated on the dorsal surface of the hand

Hint 56

extends fingers and wrist

Front 57

Demonstrate and palpate the extensor carpi-ulnaris

Back 57

Surface mark the lateral epicondyle of humerus and the dorsal surface of the base of the 5th metacarpal bone. Ask the model to place pronate the hand and extend the wrist with some ulna deviation. The muscle belly can be palpated inferior to the lateral epicondyle of humerus, on the middle third of the forearm, on the ulna side. The distal tendon can be palpated immediately superior and inferior to the head of the ulna

Hint 57

extends and adducts wrist

Front 58

Demonstrate the action of extensor digiti minimi

Back 58

Place palm down on table surface Ask model to raise the little finger The tendon can be palpated lateral and distal to the head of the ulna before it unites with the tendon of extensor digitorum.

Hint 58

extends little finger

Front 59

Demonstrate the action of extensor indicis.

Back 59

Ask the model to make a loose fist, then extend the index finger (pointing to an object). The extensor indicis extends the proximal phalanx of the index finger and joins with the individual tendon from the extensor digitorum to the index finger to reinforce the action.

Hint 59

Ask the model to make a loose fist, then extend the index finger (pointing to an object) (that's it) extends forefinger

Front 60

Demonstrate the action and palpate the tendon of abductor pollicis longus

Back 60

Ask model to fully extend the thumb then fully adduct it. Observe the position of extensor pollicis brevis tendon forming the anterior boundary of the anatomical snuffbox The tendon of abductor pollicis longus lies parallel and immediately anterior to the tendon of extensor pollicis brevis as it passes to its distal attachment on the lateral surface of the base of the first metacarpal bone of the thumb.

Hint 60

abducts thumb

Front 61

Demonstrate the action and palpate the tendon of extensor pollicis brevis

Back 61

Ask the model to put hand in thumbs up position. The tendon of extensor pollicis brevis forms the anterior boundary of the anatomical snuffbox. Palpate the tendon of extensor pollicis brevis as it passes to its distal attachment on the dorsal surface of the base of the first phalanx of the thumb

Hint 61

extends the thumb

Front 62

Demonstrate the action and palpate the tendon of extensor pollicis longus

Back 62

Ask the model make thumbs up position. The tendon forms the posterior boundary of the anatomical snuffbox and can be palpated from where it passes round the dorsal tubercle of radius to its distal attachment on the dorsal surface of the base of the distal phalanx of the thumb

Hint 62

extends thumb

Front 63

Demonstrate the action and palpate abductor pollicis brevis.

Back 63

Ask the model to place back of the hand on a table. Ask to abduct the thumb at right angle to plane of the palm against resistance. The belly of muscle can be palpated on the antero-lateral aspect of the thenar eminence as its fibres pass to the lateral aspect of the base of the proximal phalanx of the thumb

Hint 63

abducts thumb

Front 64

Demonstrate the action and palpate adductor pollicis

Back 64

Ask the model to place hand on table palm up and abduct the thumb to right angle and hold the position. Ask the model to adduct the thumb against maximum manual resistance in a direction towards the index finger The muscle belly can be palpated on the antero-medial surface of the metacarpo-phalangeal joint of the thumb as it passes towards its distal attachment on the medial aspect of the base of the proximal phalanx of the thumb.

Hint 64

adducts thumb

Front 65

Demonstrate the action and palpate opponens pollicis

Back 65

Ask the model to place the hand on the table palm up Mark the shaft of the first metacarpal bone Ask the model to bring together the tip of the thumb to the tip of the little finger in the action of opposition using maximal resistance. The muscle belly can be palpated along the anterior surface of the shaft of the first metacarpal bone as it passes to its distal attachment

Hint 65

moves thumb towards fingers

Front 66

Demonstrate the action and palpate flexor pollicis brevis

Back 66

Ask the model to place hand on the table palm up Note the base of the proximal phalanx of the thumb Ask the model to strongly flex the proximal phalanx of the thumb parallel to the plane of the palm. Supply resistance if necessary Part of the muscle belly of flexor pollicis brevis may be palpated on the medial aspect of abductor pollicis brevis as it passes to its distal attachments on each side of the base of the proximal phalanx of the thumb

Hint 66

flexes thumb

Front 67

Demonstrate the action and palpate abductor digiti minimi

Back 67

Note the position of the pisiform bone an dbase of the proximal phalanx of the little finger. Ask the model to strongly abduct the little finger against maximal resistance maintaining the middle and distal fingers in extension. The muscle belly of abductor digiti minimi may be palpated on the ulnar border of the hypothenar eminence from the pisiform bone to the base of the proximal phalanx of the little finger

Hint 67

abducts little finger

Front 68

Demonstrate the action and palpate the tendon of flexor digiti minimi

Back 68

Ask the model to place hand flat on table palm up. Note the position of the hook of the hamate bone at the base of the proximal phalanx of the little finger. Ask the model to flex the metacarpo-phalangeal joint of the little finger against resistance with the interphalangeal joints maintained in extension. The muscle belly of flexor digiti minimi may be palpated lateral and adjacent to the muscle belly of abductor digiti minimi as it passes from the hook of the hamate bone to the base of the proximal phalanx of the little finger

Hint 68

flexes little finger

Front 69

Demonstrate the action and palpate the opponens digiti minimi

Back 69

Note the position of the hook of the hamate bone and the medial border of the shaft of the fifth metacarpal bone. With the model's hand on the table palm up, ask the model to bring little finger to the thumb, using firm pressure in the action of opposition. The belly of opponens digiti minimi lies lateral to flexor digiti minimi and can be palpated with deep pressure on the hypothenar eminence as it passes from the hook of hamate to its distal attachment on the medial border of the fifth metacarpal bone.

Hint 69

moves little finger towards thumb

Front 70

Demonstrate the action and palpate the dorsal interossei

Back 70

Ask the model to spread the fingers as wide as they can. The belly of the first dorsal interosseous muscle can be palpated between the first and second metacarpal bones.

Hint 70

abducts fingers

Front 71

Demonstrate the action and palpate palmar interossei

Back 71

Ask the model to bring the fingers close together. Place a sheet of paper between the fingers and ask the model to demonstrate the action of the palmar interossei by resisting the removal of the sheet by adducting the fingers.

Hint 71

adducts fingers

Front 72

Draw the projected outline of the iliac crest

Back 72

Ask the model to place hands on the hips, thumbs to back. Tip o the little finger will rest on or close to anterior iliac spine which is palpable subcutaneously. This is the anterior limit of the iliac crest. Palpate outwards and upwards following the line of the iliac crest towards the sides of the pelvis The iliac crest continues to rise slightly on the posterior before descending to its termination at the posterior superior iliac spine which feels like a shallow hump 5cm from the medial plane (dimples of venus) A line drawn between the two posterior iliac spines cuts through the body of the second sacral vertebra.

Back 73

Identify the posterior superior iliac spines - draw a line between them The apex of the natal (gluteal) cleft lies on a level with the 3rd sacral spine Draw a line from each PSIS to the tip of the natal cleft to form an equilateral triangle

Hint 73

Will only need to point out where this is. Not necessary to draw it Draw the projected outline of the sacrum on a model

Front 74

Mark the position of the ischial tuberosity lying beneath the inferior fibres of gluteus maximus.

Back 74

Ask the model to sit on their palms with fingertips facing towards the medial plane. Fingertips will palpate a bone mass which is the ischial tuberosity.

Front 75

Draw a line on a model the position of the greater trochanter of the femur.

Back 75

Locate the middle of the iliac crest Slide finger tips down about 9-12 cm to a superficial hump about 10cm which will fit comfortably in the palm of the hand. As thigh is medially and laterally rotated will feel this swivelling. A line drawn between the middle of the iliac crest and the most prominent point of the ischial tuberosity will cross the superior aspect of the greater tronchanter of the femure and the centre of the acetabulum

Hint 75

Feel with palm of the hand The widest pat of the hip

Front 76

Draw the borders of the patella

Back 76

Ask the model to sit on a chair with knee extended and mucsles relaxed Grasp the patella between fingers and thumb and move it passively over the anterior surfaces of the femoral condyles Palpate and draw the borders of the patella. Note that the inferior pole of the patella lies 1cm above the line of the knee joint Palpate the inferior pole of the patella and trace the ligamentum patellae down to the tibial tubercle

Front 77

Draw the outline of the medial condyle of femur

Back 77

Sit the model down with the knee flexed to a right angle. Palpate down the medial side of the thigh towards the knee The medial condyle of the femur is a large mass of bone which flares out from the medial surface of the distal end of the femur. It is bordered latterally by the patella an dends distally with the space of the knee joint. The posterir surface of the medial condyle of femur is obscured by muscle tendons and joint structures

Front 78

Mark the position of the adductor tubercle of femur

Back 78

It is a small bony point on the medial condyle of the femur. Use the thumb to palpate firmly alon the medial side of the thigh towards the medial condyle. A small bony prominence should become apparent on the superior medial surface of the medial condyle of the femur. Ask the model to adduct the hip joint with resistance to the adductor tubercle. The strong cord-like tendon of adductor magnus can be identified passing downwards to its distal attachment on the femur.

Front 79

Draw the subcutaneous outline of the lateral condyle of the femur

Back 79

With the model seated identify the patella. Slide the fingers laterally from the inferior point of the patella into the joint space of the knee joint. Immediately above this lateral joint space lies the prominent bony mass of the lateral condyle of the femur. Mark the borders of the lateral condyle of the femur.

Front 80

Draw the position of the tibial tubercle/tuberosity

Back 80

Palpate immediately inferior to the patella and identify the patellar ligament by asking the model to extend the knee joint. The patellar ligament is a strong broad ligament below the patella. Trac ethe ligament downwards to its attachment at the tibial tubercle. The tibial tubercle/tuberosity can be palpated as a prominent bony projection in the midline on the ahaft of tibia immediatley inferior to the anterior surface marking of the knee joint

Front 81

Mark with a circle the position of the head of the fibula

Back 81

With the model seated, locate the tubercle of the tibia. Slide the palpating fingers laterally about 8-9cm towards the lateral side of tibia. The head of the fibula lies 1 cm inferior to the knee joint and is about 2.5cm wide. Draw a circle around the head of the fibula. The tendon of the biceps fermoris inserts here and can be felt when the knee is flexed against resistance

Front 82

Mark with two parallel lines the position of the neck of fibula

Back 82

Identify and palpate the head of fibula and the tendon of biceps femoris which attaches to it. Palpate the neck of fibula located inferior to the head of fibula. Draw two vertical parallel 3cm lines to represent the neck of the fibula. Note that the common peroneal nerve passes subcutaneously across the posterior aspect of the head of fibula and then forwards round the neck of fibula

Front 83

Draw the subcutaneous outline of the medial condyle of tibia

Back 83

With the model seated, identify the patella. With one finger on the medial border of the patella move medially to identify a shallow depression which is the joint space of the knee. The subcutaneous bony edge of the tibial plateau forms the inferior border of the depression and is the upper edge of the medial condyle of tibia. Below this, the prominent mass of the medial condyle of tibia can be palpated. Draw the borders of this mass

Front 84

Draw the subcutaneous outline of the lateral condyle of tibia

Back 84

Ask the model to sit down. Identify the head of fibula. Palpate the bony edge of the tibial plateau (superior surface of tibia) approximately 1cm superior and slightly anterior to the head of fibula. Trace the edge of the tibual plateau to the lateral border of the ligamentum patellae. Below this edge overhanging the shaft of tibia, lies the mass of the prominent lateral condyle of tibia. Circle this prominence.

Front 85

Draw the subcutaneous anterior border of the shaft of tibia

Back 85

Palpate and mark the tibial tubercle/tuberosity. Palpate and mark the sharp, sinuous subcutaneous anterior border of tibia downwards towards the ankle region. Noter that as the anterior boder of tibia approaches the lower extremity of the shaft of tibia it becomes covered by the tendon of tibialis anterior

Front 86

Draw the projected outline of the medial malleolus

Back 86

Explore the antero-medial flat surface of the shaft of tibia. The distal medial end of tibia becomes continuous with a blunt bony visible prominence at the ankle. This is the medial malleolus of the tibia. The inferior border of the medial malleolus is more anterior and 1.5cun superior to the lateral malleolus of the fibula

Front 87

Draw the projected outline of the lateral malleolus

Back 87

Explore the antero-medial flat surface of the shaft of tibia. The distal medial end of tibia becomes continuous with a blunt bony visible prominence at the ankle. This is the medial malleolus of the tibia. The inferior border of the medial malleolus is more anterior and 1.5cun superior to the lateral malleolus of the fibula

Front 88

Surface mark the peroneal tubercle

Back 88

Mark the tip of the lateral malleolus of the fibula. Slide 2-3cm inferiorly to find a small superficial tubercle. Passively everting the foot will soften the surrounding tissues. Ask the model to alternatively evert and invert the foot. The peroneal tendons pass along either side of the tubercle which may feel like a small ridge.

Front 89

Draw the projected outline of the sustentaculum tali

Back 89

With the ankle in a neutal position locate the medial malleolus. Approximately 2cm below the inferior border of the medial malleolus a projecting shelf of bone is encountered by the palpating finger tip. This is the sustentaculum tali. Passively inverting the foot will soften the tissue around it. Distal to this point are the thick tissues of the sole of the foot

Front 90

Palpate and surface mark on a model the medial process of the calcaneal tuberosity

Back 90

Mark the inferior border of the medial malleolus of tibia and the sustentaculum tali. Palpate a point approximately 2.5cm below the sustentaculum tali and move the palpating finger tip in a posterior direction for about 2.5cm on the medial surface of the calcaneus and identify a firm bony prominence which is the medial process of the calcaneal tuberosity

Front 91

Draw the position of the tuberosity of navicular

Back 91

Identify the sustentaculum tali. Move the tip of the index finger forwards approximately 2cm in the same horizxonatl place. A prominent, subcutaneous, raised bony projection can be palpated at this point. This is the tuberosity of navicular. When the foot is inverted against resistance, the prominent tendon of tibialis posterior is observed passing to the tiberosity of navicular from the medial malleolus

Front 92

Draw the projected outline of the head and neck of talus

Back 92

Identify and mark the tiberosity of navicular. Draw a line on the medial aspect of the foot from the inferior border of the medial malleolus to the tuberosity of navicular with a slight upwards convexity crosses the head of talus. The head of talus can be identified at the mid-point with the neck of talus, proximal to the head of talus. Passively invert the foot, the superior and lateral aspect of the head and neck of talus can be identified and palpated 3cm anterior to the lateral malleolus.

Back 93

The base of the fifth metatarsal bone is a bony tubercle located on the lateral border of the foot halfway between the tip of the little toe and the border of calcaneus. When the lateral border of the foot is raised in eversion against maximal resistance, the tendon of peroneus brevis may be identified passing round the lateral malleolus of the fibula to the base of the fifth metatarsal

Front 94

Draw the projected outline of the cuboid bone (draw a square)

Back 94

On the lateral border of the foot halfway between the top of the little toe and the posterior border of the calcaneus us a prominent tubercle marking the base of the fifth metatarsal. Proximal to th ebase of the fifth metatarsal lies the cuboid bone. Grasp the cuboid firmly betwwen thumb and forefinger. With the other thumb and index finger grasp the base of the fourth and fifth metatarsals and note the sliding action when they are moved against the cuboid.

Front 95

Draw the projected outline of the medial cuneiform bone

Back 95

Dorsi-flex the ankle joint and invert the foot to demonstrate the action of the tibialis anterior. The thick tendon of the tibialis anterior can be observed and plapated passing distal to the tuberosity of navicular on the medial side of the foot. The tendon of tibialis anterior attaches to the medial cuneiform and base of the first metatarsal bone and can be palpated at this point.

Front 96

Draw the projected posterior centre point of the sacro-iliac joints on a model in the anatomical position

Back 96

Identify and mark the position of the posterior superior iliac spines which are overlaid by two dimples. The posterior superior iliac spine is positioned over the centre of the sacro-iliac joint With the model lying prone the joint space can be operned fractionally by passively externally rotating the hip with the knee bent to 90°

Front 97

Draw the anterior surface marking of the centre of the hip joint

Back 97

Identify the anterior superior iliac spine and surface mark. Explain technique and ask the model to self identify the position of sympysis pubis. Imagine a line between these two points. 2cm inferior to the mid-point of the above line is the anterior surface marking of the hip joint

Hint 97

Just explain how to find - don't actually have to mark

Front 98

Draw the line of the knee joint on a model

Back 98

In a seated position identify the lateral bony edge of the tibial plateau. Palpate the line of the knee joint towards the anterior midleine of the ligamentum patellae. Identify the bony edge of the tibial plateau of themedial condyle of tibia. Project an imagined line round the medial, posterior and lateral aspects of the knee crossing ligaments, muscles and tendons`

Front 99

Draw the anterior joint line of the ankle joint

Back 99

Palpate the lateral malleolus of the fibula and mark a point 2cm above the inferior border. Palpate the medial malleolus of the tibia and mark a pint 1 cm above the inferior border. The line between these points represents the horizontal component of the ankle joint. Support the foot and passively plantar and dorsiflex the ankle joint. Palpate along the anterior and inferior edge of the shaft of tibia adjacent to the medial malleolus to detect the joint line. The remaining joint line is obscured by tendons crossing the anterior aspect of the ankle joint.

Front 100

Draw the line of the joint between the cuboid bone and the base of the fifth metatarsal bone of the foot

Back 100

Identify and mark the outline of the cuboid bone. Identify and mark the base of the fifth metatarsal bone. Grasp these two points and produce transverse gliding action between the cuboid and the base of the fifth metatarsal bone. The gliding movement takes place at the fifth tarso-metetarsal joint

Front 101

Draw the line of the metatarso-phalangeal joint of the 5th toe on the dorsal surface of the foot.

Back 101

Identify and mark the base of the fifth metatarsal bone. Move distally along the shaft and identify the neck and head of the fifth metatarsal bone. Keeping a fingertip on the head of the metatarsal bone extend and flex the fifth toe and note the position, where movement takes place immediately distal to the head of the fifth metatarsal bone. Mark this position to indicate the joint space.

Front 102

Demonstrate the action and palpate the ilio-psoas muscle against resistance on a model.

Back 102

Ask the model to lie supine with comfortable support to reduce muscle tone in the abdominal muscles. Passively flex the hip and knee joint to ninety degrees and support manually. As the hip is flexed against resistance the ilio-psoas can be palpated at the groin as it passes to its distal attachment on the lesser tronchanter and shaft of femur

Hint 102

Ask model to lie on back and bend the knee and hip push against the knee flexes hip joint

Front 103

Demonstrate the action and palpate tensor fasciae latae

Back 103

Surface mark the greater tronchanter of femur. Ask the model to flex and abduct the hip joint against resistance. The muscle belly of tensor fasciae latae can be palpated approximately 5 cm anterior to the surface marking of the greater tronchanter of femur

Hint 103

tenses iliotibial tract

Front 104

Demonstrate the action and palpate vastus medialis

Back 104

Ask the model to sit down and fully extend the knee joint against resistance. Vastus medialis functions as a member of teh quadriceps group during extension of the knee joint. Vastus medialis can be palpated on the anteromedial aspect of the thig, medial to rectus femoris and fibres identified passing to their distal attachment on the medial aspect of the patella to the tibial tuberosity through the ligamentum patellae.

Hint 104

extends knee

Front 105

Demonstrate the action and palpate vastus lateralis

Back 105

Ask the model to sit down and fully extend the knee joint against resistance. Vastus lateralis can be palpated on the anterolateral aspect of the thigh, lateral to rectus femoris and fibres identified passing to their distal attachment on the lateral aspect of the patella and indeirectly to the tibial tuberosity through the ligamentum patellae

Hint 105

extends knee

Front 106

Demonstrate the action and palpate vastus intermediu

Back 106

Ask the model to sit and etend the knee fully against resistance. Vastus intermedius muscle fibres cannot be palpated as they are deep to the rectus femoris

Front 107

Demonstrate the action and palpate rectus femoris

Back 107

Ask the model to sit down. Surface mark the tuberosity of tibia Ask the mdel to fully extend the knee joint against resistance. The rectus femoris may be palpated on the anterior inferior iliac spine to its distal attachment on the patella and finally by the patella ligament to the tuberosity of tibia.

Hint 107

extends knee, flexes hip

Front 108

Demonstrate the action of the lateral rotators of the hip joint

Back 108

The following muscles are demonstrated simultaneously: obturator externus, obturnator internusm, gemellus superior, gemellus inferior, quadratus femoris and piriformis Ask the model to rotate the hip joint in a lateral direction against resistance to demonstrate the group action of the above muscles. With the exception of piriformis they cannot be palpated.

Hint 108

Ask the model to stand up. Turn one foot outwards. This shows lateral rotation of hip. Muscles are on the back (posterior) rotate hip laterally

Front 109

Demonstrate the action and surface mark the lower border of piriformis

Back 109

Ask the model to lie prone. Mark the half way point between the top of the coccyx and posterior superior iliac spine. From this midpoint, draw a line to the upper border of the greater trochanter. This line marks the inferior border of piriformis. Ask the model to rotate the hip joint in a lateral direction to demonstrate the action of piriformis

Hint 109

Lie on front Ask model to find their coccyx Mark point midway between coccyx and PSIS Ask model to rotate hip laterally rotate hip laterally

Front 110

Demonstratr the action and palpate gracilis against resistance

Back 110

As the model to lie on their back. With the hip and knee slightly flexed, ask model to strongly adduct the thigh against resistance. Palpate gracilis on the medial aspect of the thigh, anterior to seminteninosus and trace the fibres and it passes to its distal attachment on the medial surface of the shaft of tibia immediately inferior to the condyle of tibia.

Hint 110

adducts thigh, flexes knee

Front 111

Demonstrate the action and palpate adductor magnus

Back 111

Ask the model to lie on their back. Surface mark the adductor tubercle. Ask the model to press leg into surface of couch whilst adducting the leg against resistance. Palpate the fibres of adductor magnus on the medial surface of the middle part of the thigh as they pass the the shaft of femur and adductor tubercle on the medial condyle of femur.

Hint 111

adducts thigh

Front 112

Demonstrate the action and palpate the muscle fibres of adductor longus (with a chaperone)

Back 112

Ask the model to lie on their back. Ask model to slightly flex the hip joint and strongly adduct the hip joint against resistance. Palpate the muscle fibres of adductor longus on the medial aspect of the mid-thigh lateral to gracilis.

Hint 112

adducts thigh

Front 113

Demonstrate the action of pectineus (with a chaperone)

Back 113

Ask the model to lie on their back. Ask model to slightly flex the hip joint and adduct the hip joint against maximal resistance. The muscle fibres of pectineus can be palpated lateral to adductor longus as the fibres pass from the pubis to their distal attachment below the lesser trochanter of femur. Adductor Brevis passes from the ramus of pubis to its distal instertion of the shaft of femur immediately below the lesser trochanter and is difficult to palpate without causing discomfort to the model.

Hint 113

Just point to location, don't need to palpate. flexes hip, adducts thigh

Front 114

Demonstrate the action and palpate the muscle belly of gluteus maximus against resistance.

Back 114

Ask the model to lie face down with one knee bent at 90 degrees. Ask model to extend hip joint against resistance The contracting fibres of glueteus maximus can be observed and palpated as a distinct rounded muscular contour forming the buttock on the posterior aspect of the hip

Hint 114

abducts thigh, extends hip

Front 115

Demonstrate the action and palpate the muscle belly of gluteus medius against resistance

Back 115

Ask the model to stand on one foot keeping the hips level. The muscle belly of gluteus medius can be palpated on the weight bearing leg 5cm superior to the greater tronchanter of femur as it contracts to maintain the pelvis level working with quadratus lumborum of the opposite side.

Hint 115

abducts thigh

Front 116

Demonstrate the action and palpate gluteus minimus against resistance

Back 116

Ask the model to lie prone and medially rotate one leg then flex the knee joint to 90 degrees. Ask model to abduct the hip joint against resistance. The gluteus minimus is mainly overlaid by the gluteus maximus but some fibres may be palpated approximately 5cm superior to the greater tronchanter of femur and slightly anterior to the contraction of gluteus medius

Hint 116

abducts and medially rotates thigh

Front 117

Demonstrate the action and palpate the tendon of biceps femoris against resistance.

Back 117

Ask the model to lie supine with knee joint flexed and laterally rotated against resistance. Observe and palpate the long thick tendon on the lateral aspect of the popliteal fossa passing to its major diatal attachment on the head of fibula and minor attachment on the lateral condyle of tibia.

Hint 117

flexes knee, extends hip

Front 118

Demonstrate the action and palpate the tendon of semitendinosus against resistance

Back 118

With the model lying supine ask them to flex and medially rotate the knee joint and flex against resistance. Observe and palpate the long thin tendon of semiteninosus on the medial side of theknee as it passes to its distal attachment on the upper and medial surface of the tibia.

Hint 118

flexes knee, extends hip

Front 119

Demonstrate the action and palpate the tendon of semimembranosus

Back 119

Ask the model to medially rotate and flex knee joint against resistance. Palpate on each side of the tendon of semitendinosus on the medial side of the popliteal fossa. The tendon of semimembranosus lies deep to the tendons of gracilis and semitendinosus at the level of the knee joint as it passes to its distal attachment on the posterior surface of the medial condyle of tibia

Hint 119

flexes knee, extends hip

Front 120

Demonstrate and palpate the sartorius

Back 120

Ask the model to cross one foot over onto the lower part of the other leg so that the knee is bent and droppingf towards the floor. Apply resistance to the medial surface of the bent knee and ask the model to press against your hand. Palpate artorius from the anterior superior iliac spine and adjacent bone, down and across the thigh to its distall attachment on the anterior and medial surface of the medial condyle of tibia. The muscle is narrow and superficial.

Hint 120

flexes & rotates at hip an dknee

Front 121

Palpate and demonstrate the action of the tibialis anterior.

Back 121

Ask the model to sit down and dorsi-flex and invert the ankle joint against resistance. Palpate the muscle belly of tibialise anterior lateral to the anterior border of tibia in the upper two thirds of the leg. Observe and palpate the tendon of tibialis anterior as it passes in the lower one third of the leg to the medial side, anterior to the medial malleolus to its distal attachment on the plantar surface of the base of the first metatarsal bone and medial surface of the medial cuneiform.

Hint 121

dorsiflexes and inverts foot

Front 122

Demonstrate the action and palpate the tendon of extensor hallucis longus

Back 122

Ask the model to sit down, dorsi-flex the ankle joint and fully extend the hallux against resistance. Observe and palpate the distinct tendon of extensor hallucis longus as it becomes subcutaneous in the lower one third of the leg and passes slightly medially across the dorsum of the foot towards its distal attachment on the dorsal surface of the base of the distal phalanx of the big toe (hallux)

Hint 122

extends big toe

Front 123

Demonstrate the action and palpate the tendon of extensor digitorum longus

Back 123

Ask the model to sit down, dorsi-flex the ankle joint and fully extend the lateral four toes. Observe and palpate the tendon of extensor digitorum longus as it crosses the anterior aspect of the ankle joint and dorsum of the foot where it divides into 4 distinct tendons, each passing to its distal attachment on the dorsal surface of the middle and distall phalanges of the lateral four toes.

Hint 123

extends big toe

Front 124

Demonstrate the action and palpate the muscle belly of extensor digitorum brevis

Back 124

Ask the model to sit down and dorsi-flex the ankle joint and extend the interphalangeal joints of the lateral four toes against maximal resistance. The muscle belly of extensor digitorum brevis can be observed and plapated on the dorsum of the foot lateral to the tendon of extensor digitorum longus passing to its distal attachment on the little toe. Palpate the muscle belly of extensot digitoum brevis on the dorsum oof the foot approximately 5 cm distal to the anterior border of the lateral malleolus.

Hint 124

extends toes 2-5

Front 125

Demonstrate the action and palpate the tendon of peroneus brevis

Back 125

Ask the model to sit down, plantar flex the ankle joint and evert the tarsal joints against resistance applied to the lateral border of the foot. Observe and palpate the muscle belly of peroneus brevis arising from the lateral surface of the lower two thirds of the shaft of fibula and the tendon passing close to the posterior border of the lateral malleolus round and inferior to the peroneal tubercle to its distal attachment on the tuberosity of the base of the fifth metatarsal bone.

Hint 125

plantarflexes and everts foot

Front 126

Demonstrate the action and palpate the peroneus longus

Back 126

Ask the model to strongly platanflex and evert the ankle joint. Palpate the muscle belly of peroneus longus in the lateral compartment, upper one third of the leg anterior to soleus. The tendon of peroneus longus runs posterior to the border of the lateral malleolus of fibula as it passes down and round the peroneal tubercle its distal attachment on the plantar surface of the medial cuneiform and base of the first metatarsal bone.

Hint 126

plantarflexes and everts foot

Front 127

Demonstrate the contraction and palpate the tendon of gastocnemius

Back 127

Ask the model to plantar flex the ankle joint against maximal as in the action of walking up stairs of standing tip-toe. Palpate the medial and lateral heads of gastrocnemius forming the lower boundaries of the popliteal space as far down as the middle of the calf where they fuse to form the tendo-calcaneus (achilles tendon) The tendo-calcaneus can be observed and palpated as it passes to its distal attachment on the posterior surface of the calcaneus.

Hint 127

plantarflexes foot

Front 128

Demonstrate the action and palpate the tendon of peroneus tertius (this muscle is not always present)

Back 128

Ask the model to strongly dorsi-flex and evert the ankle joint and evert and abduct the ankle. Palpate the muscle belly of peroneus tertius on the anterior surface of the lower one third of the fibula. The tendon passes over the peroneal tubercle and can be palpated proximal to the dorsal surface of the base of the fifth metatarsal.

Hint 128

dorsiflexes and everts foot

Front 129

Demonstrate and palpate soleus

Back 129

Ask the model to sit down with the knee joint flexed to 90 degrres. Ask the model to raise the deel against resistance (ie pressing toes into the floor) The soleus can be observed and palpated on the anterior and lateral aspect of the lower part of the leg.

Hint 129

plantarflexes foot

Front 130

Demonstrate the action of popliteus

Back 130

Ask the model to walk forward two paces. The popliteus muscle unlocks the knee joint at the start of flexion which occurs in the first phase of walking when talking a step forwards with the non weight baring lower limb. Popliteus acts as a medial rotator of the tibia on the femur. The muscle belly of popliteus cannot be palpated as it lies deep to medial and lateral heads of gastrocnemius.

Hint 130

flexes knee

Front 131

Demonstrate the action and palpate the tendon of flexor hallucis longus

Back 131

Ask the model to plantar flex and invert the ankle joint while flexing the big toe. Palpate on a curved line from the medial border of the calcaneal tendon to the inferior border of sustentaculum tali to identify the position of the tendon of flexor hallucis longus.

Hint 131

flexes big toe

Front 132

Demonstrate the action and palpate the tendon of flexor digitorum longus

Back 132

Ask the model to plantar-flex and invert the ankle joint while flexing the outer four toes. Palpate the medial surface of the sustentaculum talk and the plantar surface of the base of the distal phalanx of the outer toes to identify the tendon(s) of flexor digitorum longus.

Hint 132

flexes toes

Front 133

Demonstrate the action and palpate the tendon of tibialis posterior

Back 133

Surface mark the medial malleolus, sustentaculum tali and tuberosity of navicular. Ask the model to lie supine plantar flexing the ankle joint and inverting the tarsal joints against resistance. Observe and palpate the tendon of tibialis posterior as it passes round the posterior border of the medial malleolus, superior to the sustentaculum tali and to one of its principal distal attachments, the tuberosity of the navicular bone.

Hint 133

plantarflexes & inverts foot

Front 134

Demonstrate the action of the dorsal interossei of the foot

Back 134

The simplest way to demonstrate this action eithout ncessarily isolating the dorsal interossei is to ask the model to spread the toes as far apart as possible. This ability varies between individuals

Hint 134

abducts the toes

Front 135

Demonstrate the action of the plater interossei of the foot.

Back 135

The simplest way to demonstrate the action without necessarily isolating the plantar interossei is to ask the model to hold a sheet of paper between the 4th and 5th toes.

Hint 135

adducts the toes

Front 136

Palpate and surface mark the position of the sternal angle

Back 136

Identify the jugular notch and surface mark. Move the fingertip down the median place approximately 5 cm until a horizontal ridge is encountered and surface mark with a line. This raised ridge is a cartilaginous joint formed between the manubrium and body of the sternum. The second costal cartilage articulates with the sternum at the sternal angle.

Front 137

Palpate and surface mark the position of the xiphi-sternal-synchodrosis (mark with a line)

Back 137

Palpate or glide the fingers down the sternum inferiorly until you encounter soft tissue. Back track superiorly to the xiphoid process. This is the most inferior part of the sternum and varies in shape between individuals. It may be pointed, broad or perforated with a hole. In childhood it is composed of hyaline cartilage which becomes completely ossified around the age of 40. A short horizontal ridge marks the point of attachment between the manubrium and the body of the sternum. This is cartilaginous joint called the xiphisternal synchrondrosis.

Front 138

Palpate and surface mark the costal cartilages No 1,2,3,4,5,6,and 7

Back 138

Palpate immediately below the medial extremity of the clavicle to find the first costal cartilage which articulates with the manubrium of the sternum. Place the tip of one finger on the first costal cartliage and the next finger on the first intercostal space immediately below. Place the tip of a third finger on the next costal cartilage which is the second and articulates with the sternum at the sternal angle. Mark the second costal cartilage and repeat the process to mark the 3rd and 4th costal cartilage, always keeping one finger in contact with the previous structure. To identify the fifth and sixth costal cartilages move the fingers laterally into the mid-clavicular line as the intercostal spaces are more clearly defined here. Identify the costal margin and follow the contour medially to where the 7th costal cartialge articulates with the sternum.

Front 139

Identify by palpation on the model and surface mark the tip of C2, C6 or C7 spinous process. Mark with a box

Back 139

With the model sitting up, ask them to flex the neck. The most prominent point at the base of the neck is the spinous process of C7. Mark this point, which remains relatively stable as the neck is flexed and extended. Keeping one finger on this point, move another finger to the spinous process. This vertebra will slife forward away from your finger, when the neck is extended. Walk the fingers down approximately 5cm inferiorly from the occipital protuberence to locate the spinous process of C2. Palpate the bifid spones of c3, C4 and C5 keeping one fingertip on the identified spious process while moving inferiorly to the next.

Front 140

Palpate and surface mark the spinous process of thoracic vertebrae no 2

Back 140

Ask the model to place the back of the hand against the small of their back, then identify by palpation the inferior angle, the superior angle and the base of the spine of scapula. Ask the model to return to the anatomical position and mark these three points. A horizontal line from the superior angle of the scapula to median place will meet the spinous process of the 2nd thoracic vertebra.

Front 141

Palpate and surface mark the spinous process of thoracic vertebrae no 3

Back 141

Ask the model to place the back of the hand against the small of their back, then identify by palpation the inferior angle, the superior angle and the base of the spine of scapula. Ask the model to return to the anatomical position and mark these three points. A horizontal line from the base of spine of scapula will meet the spinous process of the 3rd thoracic vertebra.

Front 142

Palpate and surface mark the spinous process of thoracic vertebrae no 7

Back 142

Ask the model to place the back of the hand against the small of their back, then identify by palpation the inferior angle, the superior angle and the base of the spine of scapula. Ask the model to return to the anatomical position and mark these three points. A horizontal line from the inferior angle of the scapula will meet the spinus process of the 7th thoracic vertebra.

Front 143

Palpate and surface mark the spinous process of thoracic vertebrae no 12

Back 143

Ask the model to place the back of the hand against the small of their back, then identify by palpation the inferior angle, the superior angle and the base of the spine of scapula. Ask the model to return to the anatomical position and mark these three points. Mark a point midway between the inferior angle of the scapula and the iliac crest. A horizontal line at this point will cut through the spinous process of the 12th thoracic vertebra.

Front 144

Palpate and surface mark the spinous process of the 3rd, 4th or 5th Lumbar vertebrae

Back 144

Identify and surface mark the summit of each iliac crest and draw a horizontal line connecting them across the posterior aspect of the trunk. In the median place this line cuts the spinous process of the 4th lumbar vertabra. Mark this with a small rectangle. Each spinous process is approximately 10 to 15 mm in length with a gap between each of about 10mm Placing thumb tips together against the lateral aspect of individual lumbar spinous processes and gently applying light pressure identify the interspinous gap and edge of the ridge-ike process. Palpate superiorly to identify L3 and inferiorly to identify L5

Front 145

Palpate and surface mark the position of the body of the first rib

Back 145

Place th epalm of the hand on the shoulder with the thumb tip in the supra-clavicular fossa lateral to the sterno-cleido-mastoid. Gently press the thumb tip downwards and in a posterior direction to encounter a springy resistance. This resistance is due to the body of the first rib. Mark this position with 2 short parallel lines. The pulse of the subclavian artery may be countered at this point

Front 146

Palpate and surface mark the position of the bodies of the third, fourth, fifth, sixth and seventh

Back 146

Palpate and surface mark the sternal angle, and the body of the 2nd rib. Identify and mark the position of the 2nd intercostal space inferior to the body of the 2nd rib. Identify and surface mark the body of the 3rd rib in the mid-clavicular line. Identify fourth intercostal space inferior to the body of the 3rd rib. From the 4th intercostal space move in a lateral direction to identify the bodyof the fifth rib and surface mark. Continue moving inferiorly and laterally to identify and mark the body of the 6th and 7th ribs. The intercostal spaces are filled with intercostal muscles which are easily palpated.

Front 147

Palpate and surface mark the position of the body of the second rib

Back 147

Palpate and surface mark the sternal angle. Palpate in a lateral direction along the sternal angle to the 2nd costal cartilage, where it joins the sternum. Continue in a lateral direction along the costal cartilage to the body of the 2nd rib. This is identified as a spring like resistance under the light pressure ofthe palpating fingertip. The first intercoastal space liews superior to the 2nd rib and the 2nd intercostal space is below.

Front 148

Palpate and surface mark the position of the body and the costal cartilage tip of the eleventh and twelfth rib

Back 148

Reach across the lumbar area to place the palm on the waist. Use firm, gentle, gradual and deep palpation pressure upwards and in a medial direction until you are met by a firm spring like resistance. This resistance is the body of the 12th rib and can be identified forwards to, and occasionally beyond the mid-axillary line to the costal cartialge tip of the 12 rib, which is free and unattached. The 11th intercostal space can be identified superior to the body of the 12th rib and inferior to the inferior border of the 11th rib, which can be identified above. Palpate gently upwards with the index finger to identify the body of the 11th rib and trace the bony contour forwards towards and occasionally beyond the mid-axillary line to its anterior extremity terminating in costal cartilage which is free and unattached. Mark as much of these ribs as you can palpate.

Front 149

Surface mark the position of the brachial plexus in the posterior triangle of the neck

Back 149

Ask the model to demonstrate the action of the left sternoceidomastoid muscle - rotate the head to the right through 70 degrees and side flex to the left against slight resistance. Identify and mark the mid-point of the posterior border of sternomastoid. Identify and mark the mid-point of the shaft of the clavicle. Draw a line between these 2 points. The trunks of the brachial plexus pass downwards and in a lateral direction within the triangle formed by the line, the upper border of the clavicle and the posterior border of the sternocleidomastoid.

Front 150

Draw a line marking the course ofthe subclavian artery in the posterior triangle of the neck

Back 150

Identify and mark the line of the sterno-claviclar joint. Divide the clavicle into quarters and mark a point in the supracavicular fossa 2cm above the medial quarter. Mark the outer border of the 1st rib in the supraclavicular fossa. Draw a curved line which begins at the sterno-clavicular joint reaches its apex at the point marked above and terminates at the lateral border of the first rib.

Front 151

Surface mark the projected outline of the apical segment of the upper lobe of the lung

Back 151

Divide the length of the clavicle into 3rds and mark the point where the medial 3rd meets the middle 3rd. Mark a point in the supraclavicular fossa 3cm superior to the point marked above. Mark the position of the outer border of the 1st rib in the supraclavicular fossa. Draw a steep curve which begins at the sternoclavicular joint, reaches its apex at the point marked above and ends at the outer border of the first rib. This line represents the projected borders of the apex of the upper lobe of the right or left lungs

Front 152

Draw a line on the surface of the thorax to indicate the position of the oblique fissure of the lung

Back 152

Identify the tip of the spinous process of the 2nd thoracic vertebra and mark a point 2cm lateral to its tip. Identify and mark the position of the 6th sterno-costal junction on the anterior torso. Ask the model to raise their arm and draw a curving line round the thoracic wall from step 1 to step 2 which passes parallel to the vertebral border of the scapula, crosses the body of the 5th rib in the mid-axillary line and terminates at the 6th sterno-costal junction 7.5 cm from the median plane

Front 153

Surface mark the projected outline of the apical segment of the lower lobe of the lung

Back 153

Draw a curved line to represent the upper one third of the oblique fissue of the lung. Draw a vertical line 2.5cm lateral to the spinous process of the 2nd thoracic vertebra to point level with the spinous process of teh 5th thoracic vertebra. this trangular area represents the apex of the lower lobe of the lung lying immediately inferior and lateral to the spinous process of the second thoracic vertebra below the oblique fissue.

Front 154

Draw a line on the surface of the thorax to indicate the position of the transverse/horizontal fissure of the right lung

Back 154

Ask the model to fully elevate the right upper limb. Identify and mark the body of the 5th rib in the mid-axillary line. Identify the body of the 4th rib and mark the point where its cartilage meets the sternum. Draw a line passing from step 2 along the 4th costal cartilage, where it terminates at the sternum to represent the transverse/horizontal fissure of the right lung.

Front 155

Identify and surface mark the projected outline of the heart on the anterior surface of the thorax on a male model.

Back 155

On a male model. Mark the lower border of the 2nd left costal cartilage 2cm from the sternal edge. Mark the upper border of the 3rd right costal cartilage 1.5cm from the sternal border. Mark the lower border of the 6th right costal cartilage 2cm from the sternal border. Mark the 5th left intercostal space in the mid-clavicular line. Connect steps 1 and 2 with a straight line. Connect steps 2 and 3 by a curved line. Greatest point of curvature is 3.5cm in the 4th intercostal space. Connect steps 3 and 4 with a line presenting a slight downward convexity passing just superior to the xiphod-sternal synchrondrosis Connect steps 1 and 4 with a line presenting convexity to the left. Observe, listen to and mark the aprx beat of the heart at the point marked 4.

Front 156

Draw the projected outline of the pariteal pleura of the right lung

Back 156

1. Divide the length of the clavicle into thirds and mark a point 3cm above the junction of the medial third and the middle third. 2. From the lateral border of the first rib draw a line to the point marked at 1. 3. Continue the line to the sternoclavicular joint. 4. Then to the sternal angle just lateral to the median plane. 5. The line continues to the junction of the 6th costal cartilage with the sternum. 6. Then to the eight costal cartilage in the mid-clavicular line. 7. Then it continues to the 10th rib in the mid-axillary line. 8. On the posterior thorax continue to point 2cm lateral to the tip of the 12th thoracic spinous process. 9. Continue parallel to the spine and end at the level of teh superior angle of the scapula.

Front 157

Draw the projected outline of the pariteal pleura of the left lung

Back 157

1. Divide the length of the clavicle into thirds and mark a point 3cm above the junction of the medial third and the middle third. 2. From the lateral border of the first rib draw a line to the point marked at 1. 3. Continue the line to the sternoclavicular joint. 4. Then to the sternal angle just lateral to the median plane. 5. Then to the 4th left costal-sternal junction. 6. Then the line arches away from the midline to the left 8th rib in the mid-clavicualr line. 7. The line continues to the 10th rib in the mid-axillary line. The curve is convex inferiorly. 8. On the posterior thorax continue to a point 2cm lateral to the tip of the 12th thoracic spinous process. 9. Continue parallel to the spine and end at the level of the superior angle of the scapula.

Front 158

Surface mark the projected outline of the spleen on the posterior torso of a model.

Back 158

Ask the model to line prone. Identify by palpation and mark the position of the upper border of the left 11th rib and lower border of the left 9th rib. These mark the borders of the long axis of the speel. The posterior margin of the spleen is approximately 5cm lateral to the midline. The anterior margin of the speeln is about level with the mid-axillary line. The spleen forms an oval shap 7.5 cm in width and 12.5 cm in length following the line of the10th rib

Front 159

Surface mark the projected outline of the liver on the anterior abdominal wall of a model in the anatomical position.

Back 159

With the model lying supine, mark a point on the 5th left rib in the mid-clavicular line. Mark the point at the 6th right strnocostal junction. Join the first point to the second. Continue the line to the mid-axillary line level with the 6th rib. Draw a line from point one to the medial margin of the 9th costal cartilage. Continue to the inferior tip of the right 10th costal margin in the mid-axillary line. Connect these two lines in the mid-axillary line.

Front 160

Surface mark the projected position of the fundus of the gall bladder on a model in the anatomical position.

Back 160

Ask the model to lie supine and demonstrate the action of rectus abdominis muscle (by doing a partial sit up). Surface mark the right lateral margin of this muscle. Identify by palpation the right 9th and 10th costal margin. The fundus of the gall bladder projects from under the anterior border of the liver at the point where the right 9th costal margin is cut by the lateral margin of rectus abdominis muscle

Front 161

Surface mark the projected position of the kidneys on the posterior surface of the trunk

Back 161

Draw a vertical line to represent the posterior median line. Find the spinous process of the 12th thoracic vertebra, which is at a level halfway between the inferior angle of the scapula and the summit of the iliac crest. Mark the spinous process of T11 and draw a horizontal line which cuts through this point. Identify the spinous process of the 3rd lumbar vertebra (the summits of the iliac crest are in line with the space below the spine of L3) and mark a 2nd horizontal line. Draw 2 vertial lines on each side 3cm and 9cm from the median plane to create rectangles with th elines drawn in 2 and 3. Surface mark the kidneys in these rectangles, plaing the right kidney slightly lower then the left kidney. The long axis of each kidney is slightly inclined with the upper pole towards the median plane.

Front 162

Surface mark the projected outline of the thyroid gland.

Back 162

Mark the cricoid cartilage in the median plane. This is a prominent palpable horizontal ridge of cartilage below the thyroid cartialge (adam's apple) Draw a horizontal line 1.5 cm in length, 1cm inferior to the arch of the cricoid cartilage to respresent the isthmus of the thyroid gland. Draw a horizontal line 1cm inferior to the line marked above to represent the inferior margin of the thyroid gland. The upper pole of the lateral lobes lie on a level with the larynheal prominence adjacent to the anterior border of the sterno-cleido-mastoid muscle. Draw the projected outline of the thyroid gland which can be described loosely as a butterful of 'H' shape.

Front 163

Surface mark the projected position ofthe pancreas on the anterior abdominal wall of the model.

Back 163

Draw a vertical line to represent the median plane. Draw a horizontal line mid-way between the jugular notch and the symphysis pubis to represent the transpyloric placce. Surface mark the pancreas 3 cm wide and 12cm long diagonally over the cross you have drawn. The head of pancreas is positioned to the right of the median placem on and slightly below the transpyloric plane. the tail of the pancreas extends laft as far as the hilum of the spleen.

Front 164

Demonstrate the action and palpate the tendon of extensor hallucis brevis

Back 164

Ask the model to sit down and extend the toes against resistance. Palpate the muscle belly of extenson digitorum brevis and four tendons passing to the medial four toes. Identify the tendon of extensor hallucis brevis on the lateral side of the tendon of extensor hallucis longus as it passes to its distal attachment on the base of the proximal phalanx of the first toe. The muscle fibres and tendon of extensor hallucis brevis cross the dorsalis pedis artery.

Hint 164

extends big toe

Front 165

Surface mark the projected position of the trachea on the model

Back 165

Identify and mark the arch of the cricoid cartilage in the median plane. Draw two parallel lines 2cm apart commencing immediately inferior to the cricoid cartilage. Continue these two lines downwards declining very slightly to the right. Terminate the two lines at the level of the sternal angle, where the trachea bifurcates.

Front 166

Surface mark the position o fthe cardiac orifice and pylorus of the stomach on a model.

Back 166

Draw a vertical line to represent the median place. Identify and mark the left 7th costal cartilage. Mark a point 2.5cm to the left of the median plane on the 7th costal cartilage. Draw two short parallel lines 2cm apart downwards and to the left to represent the cardiac orifice. Draw a horizontal line to represent the transpyloric plane. Draw two short parallel lines 2cm apart directed upwards and to the right to represent the pylorus of the stomach.

Front 167

Demonstrate the action and palpate the sterno-cleido-mastoid against resistance.

Back 167

Surface mark the mastoid process, clavicle and manubrium of sternum. Ask the model to rotate the neck against resistance. Palpate the muscle fibres passing from the mastoid process to their attachments on the clavicle and manubrium of sternum. The borders of sterno-cleido-mastoid form a boundary of the posterior and anterior triangles of the neck

Front 168

Surface mark the position of the mastoid process of the temporal bone

Back 168

Ask the modelto demonstrate the action of the sterno-cleido-mastoid muscle. Palpate the muscle from its clavicular attachment upwards to its attachment on the temporal bone behind the lobule of the auricle. Palpate and identify a prominent subcutaneous bony mass which is the mastoid process of the temporal bone and surface mark.

Front 169

Palpate and surface mark the angle of the mandible.

Back 169

Locate the point of the chin in the mid-line. Palpate in a posterior direction along the inferior border of the body of the mandible crossing an indentation where the pulse of the facial artery can be identified. Continue palpating to a point where the bone changes direction upwards and starts to form the ramus of the mandible. The prominent angle at this point where there is a change of direction is the angle of the mandible.

Front 170

Surface mark the projected position o fthe tip of the transverse process of the first cervical vertebra.

Back 170

Note: caution is to be observed and gentle palpation is required. Identify and mark the angle of the mandible and the tip of the mastoid process. Draw a line connecting these two points passing behind the ear and mark the mid-point. Gently and with a light touch, palpate until resistance is encountered. The resistance to the palpating finger is produced by the tip of the lateral process of the first cervical vertebra.

Front 171

Identify by palpation the external occipital protuberence.

Back 171

Place the fingers along the back of the neck at the body's midline. Slide the fingers superiorly to loacte a prominent bony protuberance of the occipital bone.

Front 172

Identify by palpation and mark the outline of the zygomatic arch.

Back 172

Identify and mark the tempero-mandibular joint line 1cm anterior to the tragus of the ear. Draw a horizontal line from the termpero-mandibular joint to the bony prominence of the zygomatic bone. Palpate with the fingertips along this line, identify and mark a prominent bony ridge, the zygomatic arch. On clenching the teeth the temporalis muscle can be identified superior to the zygomatic arch the masseter muscle can be identified inferior to the zygomatic arch.

Front 173

Identify by palpation and mark the position of the zygoma (zygomatic bone) on the model

Back 173

Place the palpating fingertip 1.5 cm below and lateral to the infra-orbital margin. This bony prominence is the zygomatic bone. Palpate and surface mark the lateral surface of this bone, tracing it posteriorly into the zygomatic arch.

Front 174

Demonstrate the action and palpate the scalene against resistance

Back 174

Identify the boundaries of the posterior triangle of the neck. Ask the model to flex the cervical spine to one side and elevate the shoulder. Palpate the contracting muscle fibres as they passto their separate attachments on the first and second ribs between anterior border of the upper fibres of trapezius and the posterior border of sterno-cleido mastoid.

Front 175

Demonstrate the action and palpate the erector spinae.

Back 175

Ask the model to lie prone and extend the neck and spine by raising the head and shoulders from the couch Observe and palpate the parallel contours of the erector spinae formed in the lumbar and lower thoracic sections as two distinct vertical columns on each side of the vertebral column. Side flexion and rotation of the vertebral column to one side against maximal resistance will bring erector spinae into action

Front 176

Demonstrate the action of the diaphragm

Back 176

Ask the model to lie supine with a small pillow placed to support and maintain the normal lumbar curve. Place light manual resistance against the lower abdominal wall on each side of the mid-line. Ask the model to inspire and maintaining the lumbar spine position, to gently push out against the resistance placed against the lower abdominal wall as inspiration takes place.

Front 177

Demonstrate the external abdominal oblique

Back 177

Ask the model to lie supine with legs astride. Ask the model to touch left foot with right hand to demonstrate action ofthe right external abdominal oblique working with the left internal abdominal oblique. Palpate the external abdominal oblique as its attachments to the lower eight ribs where it interdigitates with the fibres of serratus anterior. Palpate obliquely downwards towards the rectus abdominis where it assists in forming the sheath of rectus.

Front 178

Demonstrate the internal abdominal oblique.

Back 178

Ask t he model to lile supine with legs astride, then touch left foot with right hand to demonstrate the action of the left internal abdominal oblique working with the right external abdominal oblique. To palpate the internal abdominal oblique requires the external abdominal oblique to be completely relaxed which is difficult to acheive.

Front 179

Demonstrate the action and palpate rectus abdominis

Back 179

Ask the model to lie supine. Ask the model to flex the trunk against gravity (a partial sit up) Rectus abdominis can be palpated on each side of the mid-line from the xiphoid process and costal cartilages of the 5th, 6th and 7th ribs to its attachment on the crest of pubis.

Front 180

Demonstrate the action and palpate quadratus lumborum.

Back 180

Ask the model to balance on one foot. Quadratus lumborum acts on the non weight-bearing side to maintain the pelvis level and the anterior superior iliac spines in the same horizontal place. Quadratus lumborum acts with gluteus medius of the opposite side to maintain the pelvis level during walking and similar actions of locomotion. Quadratus lumborum can be palpated immediately lateral to the erector spinae as fibres pass downwards from the twelth rib, and transverse processes of the upper four lumbar vertebrae to its inferior attachments on the iliac crest and ilio-lumbar ligament

Front 181

Identify by palpation, surface mark the position and count the pulse of the common carotid artery.

Back 181

Surface mark the sterno-clavicular joint Draw a line from the sterno-clavicular joint to the depression between the angle of the mandible and the mastoid process. Palpate the upper lateral border of the thyroid cartialge (Adam's apple). The common carotid artery correspins the line in step 2. At the level of the upper border of the thyroid cartilage, the common carotid usually divides into the internal and external carotid arteries. Note: Do not compress the common carotid artery against the prominent anterior tubercle of the transverse process of the 6th cervical vertebra Note: The common carotid arteries are placed on each side of the trachea.

Front 182

Identify by palpation, surface mark the position and count the pulse of the External Carotid artery.

Back 182

As with the common carotid artery, first surface mark the sterno-clavicular joint. Draw a line from the sterno-clavicular joint to the depression between the angle of the mandible and the mastoid porcess. Identify and mark the position of the head and neck of the mandible. The portion of the line which runs from the upper border of the thyroid cartilage to the neck of the mandible corresponds to the course of the external carotid artery in the anterior triangle of the neck.

Front 183

Identify by palpation, surface mark the position and count the pulse of the superficial temporal artery.

Back 183

Locate the temporal artery at the root of the zygomatic arch, directly anterior to the ear. Count the pulse.

Front 184

Surface mark the boundaries of the posterior triangle of the neck.

Back 184

Draw a line to represent the anterior boundary along the posterior border of sterno-cleido-mastoid. Draw a line to represent the posterior boundary along the anterior border of the upper fibres of trapezius. Draw a line to represent the base of the posterior triangle of the neck along the superior border of the middle third of the shaft of clavicle. These lines represent the posterior triangle of the neck.

Front 185

Surface mark the boundaries of the right anterior triangle of the neck.

Back 185

Draw a vertical line in the median plane from the chin to the supra-sternal notch on the manubrium. This line represents the anterior border of the anterior triangle of the neck. Idnetify and mark the anterior border of the sterno-cleido-mastoid muscle which represents the posterior boundary of the anterior triangle of the neck. Palpate and surface mark the inferior border of the ramus of mandible from the chin to the angle of the mandible. This line represents the base of the anterior triangle of the neck.

Front 186

Draw the course of the cephalic vein.

Back 186

Mark the cephalic vein, where it drains the dorsal surface of the hand on the lateral aspect at the base of the thumb and winds around the wrist to run up the radial side of the forearm to the cubital fossa. The cephalic vein lies in the sulcus on the lateral aspect of biceps brachii and ascends the arm. The cephalic vein passes between the deltoid muscle and the pectoralis major to peirce fascia immediately inferior to the shaft of the clavicle.

Front 187

Surface mark the course of the basilic vein

Back 187

Mark the basilic vein on the back of the hand on the medial aspect close to the base of the 2nd metacarpal bone. The basilic vein winds round the medial side of the wrist to the anterior of the forearm and ascends on the ulnar side to the cubital fossa. The cephalic vein ascends lying in a sulcus on the medial side of the biceps brachii muscle. At a point midway between the medial epicondyle of humerus and the tip of the coracoid process of scapula on the medial side of the arm, the basilic vein pierces fascia and becomes the axillary vein

Front 188

Surface mark the course of the median cubital vein

Back 188

Idnetify and mark the cephalic vein as it crosses the cubital fossa Identify and mark the basilic vein as it crosses the cubital fossa Draw a line ascending from the cephalic vein crossing the cubital fodda to join the basilic vein. This line joining with the cephalic and basilic veins represent the median cubital vein. When the superficial venous blood flow is restricted by light pressure to the upper limb, these veins are made prominent.

Front 189

Draw a line marking the position of the course of the axillary artery in the upper limb and count the pulse out loud.

Back 189

Identify the lateral border of the body of the first rib in the supraclvicular fossa. Draw a line from the mid-point of the shaft of the clavicle and the lateral border of the first rib, which lies immediately posterior. Complete the line from step 2 above to a point representing the junction of the anterior and middle thirds of the lateral wall of the axillary space (more or less the crease of the armpit) Count the pulse of the axillary artery immediately medial to the tip of the coracoid process.

Front 190

Draw the projected course of the brachial artery in the arm and at the cubital fossa and count the pulse aloud.

Back 190

Mark the position of the axillary artery as above. At this point the artery name is changed from axillary to brachial. Surface mark the anterior line of the elbow joint. Mark the mid-point of this horizontal line at the level of the head of radius. Draw a line from step 1 to step 4. The projected line lies on the medial surface of biceps brachii and its tendon at the elbow joint

Front 191

Draw the projected course of the radial artery in the upper limb and count the pulse aloud.

Back 191

Identify the head of radius and mark the projected position on the anterior surface of the forearm. Mark a point immediately lateral to the tendon of flexor carpi radialis proximal to the base of the thenar eminence. Connect steps 1 & 2 with a line Count the pulse of the radial artery at the wrist.

Front 192

Draw the course of the ulnar artery in the forearm and at the wrist joint and count the pulse aloud.

Back 192

Identify and mark the anterior surface of the elbow joint. Mark the mid-point at the level of teh head of radius. Identify the pisiform bone and mark a point immediately proximal to it. Draw a line from step 2 to step 3 Count the pulse of the ulnar artery lying lateral to the tendon of flexor carpi ulnaris

Front 193

Mark the position of the median nerve at the elbow joint and at the wrist joint

Back 193

Identify the medial and lateral epicondyles of the humerus and mark a line joining them on the cubital fossa. Mark the half way point of this line. Identify the tendon of the palmaris longus muscle at the first wrist crease (strongly oppose the thumb and little finger to find this). Draw a line to join the points marked in two and three to represent the course of the median nerve

Front 194

Draw the projected course of the circumflex/axillary nerve

Back 194

Draw a vertical line from the midpoint of the lateral border of the acromion process to the distal attachment (deltoid tubercle/tuberosity) Draw a horizontal line at right angles to the long axis of the humerus at a point midway on the vertical line in step one. This horizontal line represents the course of the axillary/circumflex nerve as it crosses the surgical neck of humerus

Front 195

Mark the position of the ulnar nerve at the elbow joint and on the anterior aspect of the wrist joint.

Back 195

Identify and mark a point in the sulcus between the medial epicondyle of humerus ad olecranon process of ulna on the posterior arm. Identify and mark the position of the pisiform bone and mark a point just lateral to it. Join the points marked with a line curving around the arm. This line represents the projected course of the ulnar nerve from the elbow joint to the wrist joint.

Front 196

Draw the projected course of the radial nerve in the arm.

Back 196

Draw a vertical line on the lateral surface of the arm from the distal attachment of the deltoid muscle to the lateral epicondyle of the humerus. Mark a point halfway down this line. Draw a line from the posterior boundary of the axillary space to point above. This line represents the course of the radial nerve.

Front 197

Mark the position of the musculo-cutaneous nerve in the arm.

Back 197

Identify the tip of the coracoid process of scapula and mark a point 3cm inferior to it. Draw a line from this point to the lateral bicipital sulcus (lateral to biceps tendon in the cubittal fossa) immediately superior to the lateral epicondyle of humerus. the line cuts across the countours of coraco-brachialis, biceps-brachii and brachialis and represents the projected course of the musculo-cutaneous nerve in the arm

Front 198

Draw the course of the long saphenous vein in the lower limb.

Back 198

Draw an oval on the medial aspect of the thigh immediately inferior to the medial attachment of teh inguinal ligament (imagine a line drawn from the anterior superior iliac spine to the pubic symphysis). This represents the saphenous opening. Identify and mark the position of the medial mallelous of tibia. Identify and mark the adductor tubervle of femur. Draw a line on the skin from the medial aspect of the dorsal venous network, passing anterior to the medial malleolus, ascending on the medial border of soleus, crossing the knee joint, ascending the thigh on the medial aspect in the region of the adductor tubercle to reach the saphenous opening to pierce fascia to join the femoral vein. The long/great saphenous vein is often visible as it ascends anterior to the medial malleolus.

Front 199

Draw the course of the short saphenous vein in the lower limb.

Back 199

Identify and mark the lateral malleolus of fibula. Identify and mark the tendo-calcaneus (achilles tendon) Identify the boundaries of the popliteal fossa (formed by the hamstring tendons and the two heads of the gastrocnemius) and mark the midpoint. Draw a line from the lateral aspect of the dorsal venous network of the foot, moving posterior to the lateral malleolus of the fibula, ascending to cross the tendo-calcaneus to the midline. Continue the line between the medial and lateral heads of gastrocnemius to the midpoint of the popliteal fossa. This line marks the course of the short saphenous vein from the lateral aspect of the dorsal venous network to the popliteal fossa where it pierces fascia to join the popliteal vein.

Front 200

Identify by palpation and mark the course of the femoral artery in the region of the hip joint.

Back 200

Identify and mark the anterior superior iliac spine. Ask the model to place a fingertip on the symphsis pubis. Select a point on a line midway between the two. At this point identify and count the pulse of the femoral artery as it crosses the ramus of pubis and the anterior surface of the head of femur.

Front 201

Draw the course of the popliteal aartery in the region of the knee joint.

Back 201

Ask the model to sit down. Identify and mark the adductor tubercle of femur. Draw a horizontal line in the popliteal fossa between the medial and lateral condyles of femur and mark its midway point. The pulse of the popliteal artery can be identified and counted at this midway point or just medial to it at a level with the adductor tubercle of the femur.

Front 202

Draw the course of the posterior tibial artery in the region of the ankle joint and count the pulse aloud.

Back 202

Identify and mark the medial malleolus of tibia. Identify and mark the sustentaculum tali. Draw a line which curves from a point posterior to the medial malleolus, passing under its tip to end inferior to the sustentaculum tali. The pulse of the posterior tibial artery can be identified and counted against the posterior surface of the medial malleolus.

Front 203

Draw the course of the dorsalis pedis artery in the region of the ankle joint and count the pulse aloud.

Back 203

Idnetify and surface mark the ankle joint. Request the model to extend the big toe against resistance. Identify and mark the tendon of extensor hallucis longus. Identify the dorsalis pedis artery lying lateral to the tendon of extensor hallucis longus on the dorsum of the foot. Count the pulse of the dorsalis pedis artery.

Front 204

Mark the projected course of the sciatic nerve from the greater sciatic foramen under the gluteus maximus to the apex of the popliteal foosa.

Back 204

Surface mark the posterior superior iliac spine, the position of the ischial tuberosity and the position of the greater trochanter. Draw a vertical line connecting the posterior superior iliac spine and ischial tuberosity and mark a point just lateral to the mid-point. Draw a horizontal line from the ischial tuberosity to the greater trochanter and mark a point just medial to the mid-point. Join lateral point in step 2 to the medial point in step 3 with a line convex gently towards the lateral aspect. Continue to draw the line in a vertical direction down towards the apex of the popliteal fossa. The line drawn represents teh course of the sciatic nerve.

Front 205

Mark the projected course of the common peroneal nerve from the apex of the popliteal fossa to the neck of fibula.

Back 205

Ask model to flex the knee joint to a right angle. Identify the tendon of biceps femoris. Mark the apex of the popliteal fossa and draw a line along the medial edge of the tendon of biceps femoris to the inferior surface and posterior border of the head of fibula. Continue the line inferior to the head of fibula and round the lateral aspect of the neck of fibula to the proximal part of the belly of peroneus longus. this line represents the course of the common peroneal nerve.

Front 206

Mark the course of the tibial nerve in the popliteal fossa and its continuation as the posterior tibial nerve.

Back 206

Ask the model to flex the knee joint so you can identify and mark the boundaries of the popliteal fossa. Identify and mark the medial malleolus and medial tubercle of calcaneus. Draw a line connecting the medial malleolus to the medial tubercle of calcaneus. Mark the mid-poiint of the line drawn in step 3. Draw a line from a point just above the apex of the popliteal fossa, down the midline of the popliteal fossa. Continue the line on the posterior surface of the leg inclining towards the medial aspect of the heel to end at the point marked in step 4. The line drawn indicates the course of the tibial nerve and its continutation, the posterior tibial nerve.

Front 207

Mark the position of teh femoral nerve in the region of the hip joint.

Back 207

Identify the pulse of the femoral artery and mark the position. Mark a point adjacent to the femoral artery on its lateral side. At this point the femoral nerve enters femoral triangle of the thigh liying lateral to the femoral artery as it crosses the anterior aspect of the hip joint.