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117 Cards in this Set

  • Front
  • Back

GC mech of action

They affect transcription of DNA


- interfere with protein synthesis


- interfere with pge synthesis (main anti inflammatory action but also causes fluid retention)


- have to get into cell to have affect

GC main uses

Immunosuppressive


- RA (pregnisolone)


- psoriasis


- crohns


- asthma


Anti inflammatory


- RA

GC Problems

Long term use accelerates bone loss


Increased hyperglycaemia


Disrupts flora


Increased sodium retention


Aggression


Adrenal suppression

Spinal cord vertebral length

Extends from foramen magnum in occipital bone to the level of the L1 or L2 vertebra



Areas of spinal cord enlargement

The spinal cord is enlarged in two regions in relationship to the innervation of the limbs:


The cervical enlargement - C4-T1


The lumbosacral (lumbar) enlargement - T11-S1

Dura mater

tough outermost layer

forms the dural sac


surrounds the nerve roots


Arachnoid mater

fine, delicate, avascular


lines dura mater


contains CSF


no space between the arachnoid and dura mater

pia mater

innermost layer of meninges


thin, transparent, vascular membrane covering the surface of the spinal cord


ends as the Filum Terminale

Spinal nerve roots exit according to vertebral level

C1-C7 nerve roots exit above the corresponding vertebra


C8-coccygeal nerves exit below corresponding vertebra


Cauda equina - nerve roots running in vertebral canal below L2

Innervation of zygapophysial joint innervation

articular branches of the medial branches of the posterior rami

Vertebral column innervation

Recurrent Meningeal Branches of Spinal Nerves


(arise from mixed spinal nerve, arising immediately after its formed and before its division into anterior and posterior rami)


2-4 of these fine meningeal branches arise on each side at all vertebral levels

Innervation of facet joints

Dorsai Rami


(also innervates intrinsic back muscles)

Arteries of the spinal cord

Longitudinal vessels


1x anterior spinal artery


2x posterior spinal arteries


Segmental vessels


Enter the IVF at every segmental level


Give rise to anterior and posterior radicular arteries

Veins of the spinal cord and column

Usually 3 anterior and 3 posterior longitudinal veins on cord


Internal vertebral venous plexus in epidural space


External vertebral venous plexus outside vertebra


(The plexuses communicate through intervertebral foramina)


Large, torturous basivertebral veins form within the vertebral bodies

Four main types of vertebral fractures

Compression/wedge


Burst


Seatbelt


Fracture-dislocation

The 3 column Model of Denis

describes the functional components of the spine which provide stability


If a fracture affects one column it's stable


If it affects all three columns it's an unstable fracture

Anterior Column components in Model of Denis

Anterior longitudinal ligament


Anterior half of vertebral body


Anterior annulis fibrosis


Anterior disc

Middle Column components in Model of Denis

Posterior half of vertebral body


Posterior annulus/posterior disc


PLL

Posterior Column components in Model of Denis

Spinous process


Laminae


Facets


Pedicles


Posterior ligaments:


(ligamentum flavum, intraspinous lig, supraspinous lig)

Compression/wedge fracture

Compression force cause anterior column to collapse


Stable unless other columns affected


Commonly found in osteoporosis


Surgery only required for unstable fractures

Burst Fracture


(Jefferson's fracture)

Extreme axial force causes vertebra to fracture in several places (land on head)


Unstable


At C1 = Jefferson's fracture


Up to 50% of people present with neurological symptoms (depends where the fractured bits of bone end up)


C1 highly dependent on transverse ligament being intact - if its injured or compromised in any way considered to be very unstable

Seatbelt/Chance fracture

Due to severe flexion force while wearing lap seatbelt


Destruction posteriorly, compression anteriorly


Damage to all 3 columns


Despite damage, fairly stable fracture


Consider potential injury to abdominal viscera

Fracture-dislocation

Dislocation - separation of the joint surfaces


Cx dislocation can occur without fracture


C5 and 6 most common


Slight dislocation likely to damage spinal cord


Fractures are generally associated with less risk of neurological symptoms due to fracture allowing more room for spinal cord to move instead of being compressed

C2 fractures

Hangmans fracture


- fracture of the pars interarticularis


Fracture of the dens


- Unstable fractures


- Can cut blood supply to dens

Lumbar Pars Fracture

Stress fracture


Repeated hyperextension


Common in gymnasts


L5 most common region


Spondylolysis - just fracture


Spondylolisthesis - bilateral and vertebra slips forward on inferior vertebra

IVD definition

The nucleus pulpous protrudes into or through the annulus fibrosis


IVD forms lower anterior border of IVF in Tx and Lx regions


Nucleus pulpous usually extend posterolaterally, where the annulus fibrosis is relatively thin and does not receive support from either the PLL or ALL



IVD causes

Flexion and Rotation forces


Smoking, poor posture and repeat sitting activities increase risk


Because the IV discs are the largest in the Lx and lumbosacral regions, where movements are consequently greater, posterolateral herniations are most common here (~90%)

What causes the pain from IVD?

Pressure on the longitudinal ligaments and periphery of the annulus fibrosus and from local inflammation caused by chemical irritation by substances from the ruptured nucleus pulposus

Function of the Extrinsic muscles of the back

Superficial


Movements of upper limbs




Intermediate


Respiratory function

What divides the extrinsic and intrinsic muscles of the back?

thoracolumbar fascia

Functions of the Intrinsic muscles of the back

Movement and stability of the vertebral column and head

Extrinsic Back Muscles:


Superficial Layer + innervation

Trapezius


Latissimus dorsi


Levator scapulae


Rhomboids major and minor




Innervated by anterior rami of cervical nerves


Trapezius receives motor fibres from spinal accessory nerve (CN XI)

Extrinsic Back Muscles:


Intermediate Layer + innervation

Serratus posterior superior


Serratus posterior inferior




Superior by first four intercostal nerves and inferior by last four intercostal nerves

Intrinsic Back Muscles:


Groups

Superficial - spinotransverseales muscles



Intermediate - Erector spinae muscles




Deep - Transversospinalis muscles


Intrinsic Back Muscles:


Superficial layer (spinotransverales muscle group) + innervation

Splenius Capitus


Rotate head to same side


Innervated by posterior rami of spinal nerves C3-4


Splenius Cervicis


Rotate head to same side


Innervated by posterior rami of lower Cx spinal nerves


Working together can also act to extend the head and neck

Intrinsic Back Muscles:


Intermediate layer (Erector Spinae muscle group) + innervation

Iliocostalis


Longissimus


Spinalis




Together produce extension and lateral flexion of the spine - common tendinous origin


Posterior rami of spinal nerves

Intrinsic Back Muscles:


Deep layer (Transverospinalis muscle group) + innervation

Semispinalis (3 regions - capitis, carvicis, thoracis)


Multifidus


Rotatores




Short muscles provide stability for the spine - may produce some extension and rotation


Posterior rami of spinal nerves

Segmental Muscles


(minor deep intrinsic muscles)


action + innervation

Interspinales


Stabilises vertebral column


Intertransversari


Stabilises vertebral column


Levatores costarum


Elevtaes the ribs




Posterior rami of spinal nerves

Suboccipital Triangle


- What is it?


- Where is it?

- A muscle "compartment" deep to the superior part of the posterior cervical region, underlying the traps, sternocleidomastoid, spenius and semispeinalis muscles




- A pyramidal space inferior to the external occipital prominence of the head that includes the posterior aspects of vertebra C1 and C2

Muscles of the sub occipital region


+ innervation

Lie deep to the semispinalis captious muscles and consist of:


- 2 rectus capitis posterior (major and minor)


- 2 obliquus capitis muscles (inferior and superior)




Innervated by posterior rams of C1 (suboccipital nerve)

Which captious muscle has no attachment to the cranium?

Obliquus capitis inferior

What is the thoracolumbar fascia?

3 layers in lumbar region (anterior, middle and posterior layers)


covers the deep muscles of the back


Provides attachment for transversus abdomens and internal oblique muscles

What are true ribs?

Vertebrocostal


1st-7th ribs


Attach directly to the sternum through their own costal cartilage



What are false ribs?



Vertebrochondral, free ribs


8th, 9th, and usually 10th ribs


Their cartilages are connected to the cartilage of the rib above them; thus their connection with the sternum is indirect



What are floating ribs?

Vertebral, free ribs


11th, 12th and sometimes 10th ribs


The rudimentary cartilages of these ribs do not connect even indirectly with the sternum; instead they end in the posterior abdominal musculature

Components of Typical Ribs

3rd- 9th ribs


- Wedge-shaped head with two facets


- Has a neck connecting the head of the rib with the body at the level of the tubercle


- Has a tubercle at the junction of the neck & body


- Thin, flat and curved body/shaft, curved most markedly at the costal angle where the rib turns anterolaterally

Why is 1st rib atypical?

Broadest (body is widest and nearly horizontal)


Shortest and most sharply curved of the 7 true ribs


Single facet on its head for articulation with the T1 vertebra and has 2 transversely directed grooves crossing its superior surface for the subclavian vessels


Also has scalene tubercle and ridge

Why is 2nd rib atypical?

Has a thinner, less curved body and is substantially longer than the 1st


Has 2 facets for articulation with bodies of T1 and T2


Main atypical feature is a rough area on its upper surface, the tuberosity for serratus anterior

Why are the 10th-12th ribs atypical?

Like the 1st rib, have only one facet on their heads and articulate with a single vertebrae

Why are the 11th and 12th ribs atypical?

Short and have no neck or tubercle

What is the angle of Louis?

The manubrium and body of sternum lie in slightly different planes superior and inferior to their junction, then manubriosternal joint; hence their junction forms a projecting sternal angle (of Louis)

Why is the xiphoid process an important landmark in the median plane?

It is a midline marker for the superior limit of the limit, the central tendon of the diaphragm, and the inferior boarder of the heart

What is Thoracic Outlet Syndrome?

Thoracic outlet syndrome (TOS) is a condition caused by compression of nerves or blood vessels in the thoracic outlet


Causes of enlargement of the tissues may include:Trauma or injury, Weight lifting, Cervical rib (an extra rib extending from the neck present at birth), Weight gain or Growth of a tumor

Name the 8 muscles of the thoracic wall

Serratus Posterior Superior - Elevate ribs


Serratus Posterior Inferior - Depress ribs


Levator Costarum - Elevate ribs


Subcostal - Elevate ribs


Transverse Thoracic - Depress ribs


Intercostals (external, internal and innermost)

What are the 3 arterial supplies of the Tx wall?



Thoracic aorta - through posterior intercostal and subcostal arteries




Subclavian artery - through internal thoracic and supreme intercostal arteries




Axillary arteries - through superior and lateral thoracic arteries

Venous drainage of the Tx wall?

The intercostal veins accompany the intercostal arteries and veins


Posterior intercostal veins drain into the azygos and hemi-azygos system


The anterior intercostal veins drain into the internal thoracic veins which are the accompanying veins of the internal thoracic artery

Neural supply of Tx wall?

The 12 pairs of thoracic spinal nerves supply the thoracic wall


As soon as they leave the IV foramina in which they are formed, the mixed Tx nerved divide into anterior and posterior (primary) rami or branches


The anterior rami of nerves T1-T11 form the intercostal nerves in intercostal spaces


The anterior rami of T12 is the the subcostal nerve

What are the 3 main apertures through the diaphragm?

Oesophageal opening (T10)


Aortic opening (T12)


Caval opening (T8)

Caval opening position and contents


(Vena Caval Foramen)

Level of T9 within the central tendon


Contents: IVC, right phrenic artery, lymphatics


The IVC is adherent to the margin of the openings; consequently when the diaphragm contracts during inspiration, it widens and dilates the IVC - increasing venous return to the heart

Oesophageal Hiatus position and contents

Level of T10, in the right crus of the diaphragm as it decussates distal to the hiatus forming a functional sphincter


Occasionally (30%) left crus forms part of the hiatus


Contents: oseophagus, and related vessels, anterior and posterior vagal trunks

Aortic Hiatus position and contents

Level of T12, technically posterior to the diaphragm


This means there is no insufficiency of blood flow caused by contractions of the diaphragm


Contains: Aorta, thoracic duct and azygos vein

Nerve supply of the diaphragm

Supplied from the levels of C3, C4 and C5


"3, 4 and 5 keep the diaphragm alive"


The phrenic nerves are also responsible for their half of the diaphragm

Muscles of the anterolateral abdominal wall


+ innervation

All innervated by thoracoabdominal nerves




External oblique (+ subcostal nerves)


Internal oblique (+first lumbar nerves)


Transversus abdominus (+first lumbar nerves)


Rectus abdominus





Muscles of the posterior abdominal wall, actions + innervation

Psoas major (A.Rami of lumbar nerves L1-3)


works with iliacus to flex thigh and trunk; can also flex vertebral column laterally


Iliacus (Femoral nerve (L2-L4)


Flexes thigh and stabilises hip joint


Quadratus Lumborum (A. branches of T12, L1-4 nerves)


Extends and laterally flexes vertebral column; fixes rib during inspiration



Why does the knee "lock" when standing?

Medial rotation of the femoral condyles on the tibial plateau (the "screw-home mechanism"


The thigh and leg muscles can relax briefly when the leg is locked without making the knee joint too unstable

How to unlock the knee?

Contraction of the popliteus causes rotation of the femur laterally on the tibial plateau so that flexion of the knee can occur

Primary and Secondary muscles producing extension of the knee

1 - Quadriceps femoris


2 - Tensor of fascia lata




Quads most effective when hip joint is extended

Primary and Secondary muscles producing flexion of the knee

1 - Hamstrings & short head of biceps


2 - Gracilis, sartorius, gastrocnemius, popliteus




Normally role of gastroc is minimal but in presence of supracondylar fracture, it rotates (flexes) distal fragment of femur

Primary and Secondary muscles producing medial rotation of the knee

1 - Semitendinosus and semimembranosus when the knee is flexed; popliteus when non-weight bearing knee is extended


2 - Gracilis, Sartorius




(When extended knee is bearing weight, action of popliteus laterally rotates femur; when not bearing weight popliteus medially rotates patella)

Primary and Secondary muscles producing medical rotation of the knee

1 - Biceps femoris when knee is flexed





Features of the Medial Meniscus

C shaped, broader posteriorly than anteriorly




Firmly adheres to the deep surface of the TCL




Because of its widespread attachments laterally to the tibial intercondylar area and medially to the TCL, the medial meniscus is less mobile on the tibial plateau than the lateral meniscus

Features of the Medial Meniscus

Nearly circular, smaller and more freely moveable than the medial meniscus

What are the five extra-capsular ligaments of the knee?

Patellar ligament


Fibular collateral ligament


Tibial collateral ligament


Oblique popliteal ligament


Arcuate popliteal ligament

Features of the patellar ligament

Distal part of the quadriceps tendon


The anterior ligament of the knee joint

Features of the collateral ligaments of the knee

Taut when the knee is fully extended


Contributing to stability when standing


As flexion proceeds they become increasingly slack, permitting and limiting (serving as check ligaments for) rotation of the knee


Includes the FCL, TCL, oblique popliteal ligament and arcuate popliteal ligaments

Features of Fibular collateral ligament


(Lateral collateral ligament)



Cord like extra-capsular ligament


Strong


It extends inferiorly from the lateral epicondyle of the femur to the lateral surface of the fibular head


The tendon of the biceps is split in half by this ligament

Features of tibial collateral ligament


(Medial collateral ligament)

Strong, flat, intrinsic (capsular) band that extends from the epicondyle of the femur to the medial condyle and medial surface of tibia


At midpoint, fibres are firmly attached to the medial meniscus


Weaker than the FCL and more often damaged


Resultantly, the TCL and medial meniscus is more commonly torn during contact sports

What are the intracapsular ligaments of the knee?

Cruciate ligaments and menisci

Features of both cruciate ligaments

Crisscross within the joint capsule but outside the synovial cavity


During medial rotation of the tib on fib, the cruciate ligs wind around each other; limiting medial rotation to about 10 degrees


In every position one, or both ligaments is tense


They maintain contact with the femoral and tibial articular surfaces during flexion of the knee

Features of Anterior Cruciate Ligament (ACL)

Weaker of the two


Relatively poor blood supply


Limits posterior rolling of the femoral condyles on the tibial plateau during flexion - covering it to spin


Prevents posterior displacement of femur on tibia and hyperextension of knee joint


Prevents anterior movement of tibia when knee is flexed

Features of Posterior Cruciate Ligament (PCL)

Stronger of the two


Limits anterior rolling of the femur on the tibial plateau during extension, covering it to spin


Prevents anterior displacement of the femur on the tibia AND posterior displacement of the tibia on the femur


Prevents hyperflexion of knee


Main stabilising factor for the femur in weight bearing flex knee (going down hill)

Role and features of the menisci

Deepen the surface of the tibial articulation in the knee and play a role in shock absorption


Thicker at external margins and thin intra-condylar


External margins attach to joint capsule of the knee


Transverse lig joins anterior edges of the menisci and tethers them together during knee movements

What does the strength of the knee rely on?

1 - the strength and actions of the surrounding muscles and their tendons


2 - the ligaments that connect the femur and tibia

What is the most stable position of the knee?

Erect, extended position


In this position the articular surfaces are most congruent, the primary ligaments for the joint (collateral and cruciates) are taut, and the many tendons surrounding the joint provide a splinting effect

What is the blood supply of the knee?

The genicular branches of the femoral, popliteal, and anterior and posterior recurrent branches of the anterior tibial recurrent and circumflex arteries

Which artery branch supplies the cruciate ligaments, synovial membrane, and peripheral margins of the menisci?

The middle genicular branches of the popliteal artery penetrate the fibrous layer of the joint capsule and supply the cruciate ligaments, synovial membrane, and peripheral margins of the menisci

Nerves of the knee

(Pretty much all)




Articular branches from the femoral (anterior), tibial (posterior) and common fibular nerves (lateral)




Obturator and saphenous (cutaneous) - articular branches to medial aspect

Differentiate between Grade I, II and III knee injuries

Grade I - No laxity




Grade II - Partial rupture; laxity




Grade III - Complete rupture

MCL Sprains

Valgus force + twisting force


Can be torn though both MCL and TCL and potentially ACL and PCL as well

ACL rupture - Mechanism of Injury

Occurs then bones of the leg twist in opposite directions under full body weight




Non-contact


Jumping, cutting (sudden change of direction)


Deceleration/valgus + rotation


Hyperextension



ACL associated injuries

Ligament sprains (MCL)


Meniscus tears - medial more than lateral


Chondral lesions


Bone bruising

Clinical signs of ACL rupture

Anterior drawer sign


Free tibia slides anteriorly under flexed femur

PCL - Mechanism of Injury

Posterior directed force to tibia (dashboard injury)


Forced hyeprflexion


Forced hyperextension


Significant values/varus force

PCL rupture clinical signs

Posterior sag/Posterior drawer


PCL ruptures allow the free tibia to slide posteriorly under the fixed femur



Associated Injuries with Anterior Knee Dislocations

Anterior dislocation particularly damages popliteal artery and nerve

Which meniscus tears more commonly and why?

The medial meniscus because of its lack of mobility.




The lateral meniscus is more mobile and can 'get out of the way' of compressive/destructive forces

Treatment of meniscal tears

Peripheral tears can often be repaired or may heal due to the generous blood supply to this area


Other tears which will not heal are usually remove - no mobility is lost however the knee may be less stable and the tibial plateaus may undergo inflammatory reactions

Rotator Cuff Intrinsic Impingement

(intrinsic = with tendon)




Tear


Calcific Tendinopathy


Secondary Swelling

Rotator Cuff Extrinsic Impingement

(extrinsic = outside tendon)




Acromion


Bursa


ACJ osteophyte


Tuberosity


Instability

What is Adhesive Capsulitis

"Frozen Shoulder"


- Inflammation and fibrosis in capsule causing restrictions to ROM


- Progressive pain and stiffness (joint contractors may result)


- May run for 18 months


- Usually 40-60yo, women > men


- Trivial trauma, poor sleep

What is Calcific Tendonitis?

- Deposition of hydroxyapatite crystals in critical zone


- Fibrocartilage metaplasia


- Intense inflammation and vascular reaction leads to swelling


- Insidious, rapid onset often after minor trauma


- Presents as acute pain or secondary impingement

Arthritis in the shoulder


- Types


- Common causes

Primary OA - often multi joint




Secondary OA - post instability or trauma (fracture - people who have recurring trauma have 20x risk of OA later in life), massive rotator cuff tear




Inflammatory - RA



Pathology resulting from Shoulder Trauma

Fractures of clavicle, proximal humerus, glenoid and scapula




Joint instabilty (A-C and G-H joints)




Soft tissue injury to rotator cuff, other local muscles/tendons/ligament

Mechanism of Acromio-clavicular joint injury

Medicalisation of shoulder girdle on a fixed clavicle, driving the accordion down




Get downward sag of shoulder - manage non-operatively




Common when football players land on shoulder tip - most common shoulder injury in contact sports

What nerve is compressed in cubital tunnel syndrome?

Ulnar nerve

What are the two promotors of the forearm?

Pronation teres


Pronator quadorum

What are the two supinators of the forearm

Supinator


Biceps - especially when elbow is flexed

Is supination or pronation a more powerful movement?

Supination because of involvement of the biceps

Flexors of wrist

Flexor carpi radialis


Flexor carpi ulnaris



Palmaris longus is minor flexor runs between other two - frequently absent

Extensors of the wrist

Extensor carpi radialis: brevis, longus


Extensor carpi ulnaris



All pass under extensor retinaculum


Act together to extend the wrist



Produce radial or ulnar abduction when working separately

Which is the joint which the fingers become separate from the hand?

MP JOINT

Which is the joint which the fingers become separate from the hand?

MP JOINT

Which joint gives the thumb its special movement (opposition) and position in relation to the other fingers?

CMC joint

Muscles that perform flexion of the fingers

Extensor digitorum superficialis


Extensor digitorum profundus



They have four separate tendons, the superficialis splits in half and let's the profundus come through so it can insert on middle phalanx, the superficialis then goes to insert distally



Profundus extends both joints and superficialis extend distal IP?

Extensor muscles of the fingers

Big one is extensor digitorum


Extensor digiti minimi


Extensor indicis (extends middle finger)



Produce extension at all three joints of finger

Muscles of thumb movement

Flexor pollicis longus (mp and ip)


Abductor pollicis longus


Extensor pollicis brevis


Extensor pollicis longus

Muscles of thumb movement

Flexor pollicis longus (mp and ip)


Abductor pollicis longus


Extensor pollicis brevis


Extensor pollicis longus