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245 Cards in this Set
- Front
- Back
Skin thickness
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Variable thickness, back is thickest area
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Skin and its derivatives (sweat glands, sebaceous glands, nails and body hair) innervation
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cutaneous nerves
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Fxns of skin
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sensory receptors for pain, touch, temperature and pressure
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Involuntary fxns of skin caused by ANS
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Stimulate glandular secretion, control blood vessel diameter (vasodilation and vasoconstriction), and contraction of erector pili muscles, which cause hairs to stand up
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Palpable bony landmarks of back
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1. Spinous processes of vertebrae - C7, T1-T12, L1-L5.
2. Scapula - spine and acromion process 3. Iliac crests |
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Superfiicial Fascia fxn and characteristics
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subcutaneous fat (adipose) tissue. Provides insulation against cold temperature. Amount of fat deposited depends on nutritional status, age and secondary sexual characteristics (hormonally controlled).
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Deep layer fascia fxns and characteristics
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surrounds individual muscles.
a. Provides packing material between muscles b. Provides a channel for vessels and nerves c. Amount and type of connective tissue determines mobility of organs |
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Thoracolumbar fascia fxns
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surrounds intrinsic (true) back muscles. It is most prominent in the lumbar region
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3 muscles whose aponeuroses make up thoracolumbar fascia
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1. Internal abdominal oblique
2. Transversus abdominis 3. Latissimus dorsi |
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Superficial muscles of the back- fxns and attachments
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1. Trapezius - attached to the spine of the scapula, acromion process and clavicle (lateral third)
2. Latissimus dorsi - attached to the humerus (crest of lesser tubercle) |
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5 muscles that make up middle layer of back
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1. Rhomboideus major and minor
2. Levator scapulae 3. Serratus posterior superior 4. Serratus posterior inferior 5. Splenius |
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Rhomboideus major and minor attachment and fxn
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attached to medial border of scapula (they retract the scapula)
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Levator scapulae fxn and attachment
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attached to superior angle of scapula (elevates the scapula
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Serratus posterior superior fxn
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– accessory respiratory muscle elevates upper ribs
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Serratus posterior inferior
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accessory respiratory muscle depresses lower ribs. Acting together, the serratus posterior muscles increase volume of thorax during deep breathing
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Splenius fxn and structure
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- wraps around the deep muscles of the neck. If only one splenius muscle contracts the head moves back (dorsally) and the face turns to the same side. If both splenius muscles contract simultaneously, the neck is extended.
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Deep layer intrinsic, true muscles of back 2 groups
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erector spinae and transversospinalis
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Erector spinae fxn and attachments
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- has three portions which take origin from the sacrum, iliac crests, and lumbar vertebrae. Function to extend the spine
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illeocostalis characteristics
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(most lateral of erector spinae) - inserts on ribs and C4,5,6 vertebrae
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longissimus characteristics
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(intermediate of erector spinae muscles) - inserts on ribs, cervical vertebrae (transverse processes) and mastoid process of skull.
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Spinalis characteristics
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(most medial of erector spinae muscles) - smallest, best developed in thorax, inserts on spinous processes.
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transversospinalis characteristics
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has three layers whose fibers pass superomedially from transverse processes to spinous processes. Function to rotate and laterally bend the spine.
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semispinalis characteristics
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most superficial of transversospinalis
spans 5 vertebrae |
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multifidi characteristics
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Middle layer of transversospinalis - spans three vertebrae
(in lumbar region the multifidus extends the spine to maintain the lumbar lordosis) |
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characteristics of rotatores
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deepest layer of transversopinalis
spans one interspace |
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innervation of intrinsic back muscles
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innervated by dorsal primary rami of the nearest spinal nerves.
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Actions of intrinsic back muscles
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a. Flexion of spine- gravity; degree of flexion controlled by erector spinae as they stretch.
b. Extension of spine controlled erector spinae. c. Lateral flexion (bending) of spine is muscles on the same (ipsilateral) side. d. Rotation of spine-abdominal muscles and the transversospinalis on the ipsilateral side |
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Appendicular skeleton includes
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upper extremity and its pectoral girdle (clavicle and scapula), and the lower extremity and its pelvic girdle (ilium, pubis, and ischium)
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Axial skeleton includes
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skull, mandible, hyoid bone, vertebral column including the sacrum and coccyx, ribs and sternum.
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fxns of vertebral column
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(1) supports the skull over the vertical axis, (2) provides attachment for respiratory muscles, (3) provides attachment for muscles that move the torso (4) protects the spinal cord, thoracic organs and some abdominal organs
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Composition of vertebral column
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Cervical region-(C1-C7)
Thoracic region-(T1-T12) Lumbar region – typically (L1-L5); some people have six Sacrum-fusion of 5 vertebrae. Fusion begins at 16-18 years of age and is completed by the mid-20's. Coccyx-fusion of 3-5 vertebrae. Fusion is typically complete by age 30. |
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Primary curvature of spine characteristics
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exists in utero. It is concave anteriorly
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Cervical curve characteristics
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Secondary curve, normally seen at 3 months of age. It is convex anteriorly and develops from holding the head upright.
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Lumbar curve characteristics
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secondary curve normally seen at 6 months of age. It is convex anteriorly and develops due to sitting up. At 12 months of age it becomes accentuated due to bipedal locomotion.
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Development of varying spinal curves is due to
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differences in the anterior and posterior depths of the vertebral bodies and the intervertebral discs.
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Kyphosis
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affects the thoracic region and presents as an increased posterior convexity (hunchback appearance).
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Lordosis
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affects the lumbar region and presents as an increased anterior convexity (sway back). It is more frequent in pregnant women, particularly during the third trimester. This condition is reversible after pregnancy.
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Scoliosis
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two lateral curves. The primary curve in the thoracolumbar region. The secondary curve develops in thoracocervical region as a compensatory curve. The secondary curve maintains the skull over the vertical axis of the body. A rotational deformity results that is visible in the thoracic cage. Most commonly seen in adolescent girls.
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Intervertebral discs characteristics
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Ligament between vertebral bodies. Comprised of a gelatinous core (nucleus pulposis) and a collagenous fibrous ring (annulus fibrosus). Its shape and size is defined by the vertebral bodies and the curvature of the spine.
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Anterior longitudinal ligament
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Ligament between vertebral bodies. Broad and flat, on the front side of the vertebrae and intervertebral discs. This ligament is quite strong and found along the entire length of the vertebral column.
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Posterior longitudinal ligament
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Ligament between vertebral bodies. Narrow and flat, on the posterior side of the vertebral bodies and the intervertebral discs. It is contained within the vertebral canal and is found along the entire length of the vertebral column.
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supraspinous ligament
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Ligament between vertebral arches. continuous structure attached to the tips of the spinous processes along the entire length of the vertebral column. Expanded in the cervical region and known as the "ligamentum nuchae" (spans the distance between the inion of the skull and the spinous process of C7)
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interspinous ligaments
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Ligament between vertebral arches.
are interposed between adjacent spinous processes |
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Ligamentum flavum
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Ligament between vertebral arches. elastic and positioned between adjacent laminae. Yellow, allows spinal cord to not be compessed, makes more room
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intertransverse ligaments
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Ligament between vertebral arches.
interposed between adjacent transverse processes |
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Basic movements of vertebral column
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flexion, extension, lateral flexion and rotation. Possible due to the compression and distortion of the intervertebral discs. Limited by the orientation of the (zygapophyseal) joints between adjacent vertebrae.
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Movements of cervical spine
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- flexion, extension, rotation and lateral flexion
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Movements of thoracic spine
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flexion and extension. Lateral flexion is possible, but to a limited extent. However, free rotation is possible due to the alignment of the articular processes on an arc about the axis of rotation.
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Movements of lumbar spine
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- flexion, extension, and lateral flexion; however, rotation is limited by inwardly facing articular processes
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Spinal cord length in adults
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18 in (45 cm)
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Spinal cord spans from where to where
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From foramen magnum to level of L2 vertebrae
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Cervical enlargement of spinal cord due to
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- provides origin for nerves to upper extremity.
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Lumbar enlargement of spinal cord due to
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provides origin for nerves to lower extremity
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Cauda equina
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collection of nerve roots streaming inferiorly below the conus medularis (termination of spinal cord).
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Somatic reflex arc is made up of
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sensory neuron, motor neuron, and interneuron
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Ganglion
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cluster of sensory nerve cell bodies in PNS (anything outside of spinal cord and brain)
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Pia mater characteristics
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1. Most intimate covering of spinal cord - forms outer layer of spinal cord.
2. Forms filum terminale at inferior limit of spinal cord. |
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Denticulate ligament characteristics
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lateral extensions of pia mater which attach to inner surface of dura mater. These ligaments function to anchor the spinal cord to the dura mater
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Arachnoid membrane
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1. Outer layer-smooth, in physical contact with the dura mater.
2. Inner layer gives rise to fibers that attach to the pia mater, thereby traversing the subarachnoid space. 3. Extends inferiorly to the level of S2 vertebra |
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Subarachnoid space
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- located between the arachnoid membrane and the pia mater.
1. Contains cerebrospinal fluid (CSF). 2. Extends from the cranial cavity to the level of S2 vertebra. 3. Continuous with the cranial subarachnoid space |
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Dura mater
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1. Continuous with the cranial dura mater.
2. Extends to the level of S2 vertebra. 3. Composed of tough collagenous tissue. 4. In pathological situations it can be separated from the arachnoid membrane by fluid or tumor tissue which occupies the subdural space. |
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Subdural space
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1. Continuous with cranial subdural space.
2. Extends to the level of S2 vertebra. 3. Normally a "potential space" - since the dura mater is normally in contact with the arachnoid membrane no space is present; however, in pathological situations these two membranes can be separated by fluid (blood) or a tumor located between the dura mater and arachnoid membrane. |
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Epidural space
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1. Extends from the foramen magnum to the sacrum (sacral canal).
2. Located between spinal dura mater and vertebral canal. 3. Contains blood vessels and fatty connective tissue. 4. Excellent location for regional anesthesia such as an "epidural", which is frequently given during labor and delivery. |
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Spinal nerves organization
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1. There are 31 pairs that correspond to the 31 levels of the spinal cord.
8 cervical (C1-C8) 12 thoracic (T1-T12) 5 lumbar (L1-L5) 5 sacral (S1-S5) 1 coccyxgeal (Co) B. One pair of spinal nerves corresponds to one spinal cord level, from which it originates. |
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Dermatome
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an area of skin innervated by one pair of spinal nerves.
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Anterior spinal artery
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formed from the union of two anterior spinal branches of the two vertebral arteries. It descends on the surface of the spinal cord to the conus medullaris.
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Posterior spinal arteries
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branches of the vertebral arteries. They are smaller than the anterior spinal artery and connected across the midline.
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Segmental spinal arteries
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enter the vertebral canal via intervertebral foramina. Cervical branches originate from vertebral arteries, thyrocervical trunk and costocervical trunk. Thoracic branches come from posterior intercostal arteries. Lumbar branches come from lumbar arteries. These segmental arteries supply vertebrae, intervertebral discs, contents of the epidural space and dura mater.
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Artery of Adamkiewicz
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greater anterior medullary artery which reinforces circulation to the lumbar enlargement of the spinal cord. It is a unilateral artery at the lower thoracic or upper lumbar portion of the spinal cord on the left side
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Venous drainage of spinal cord
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1. drains to a venous plexus on the surface of the spinal cord, located in the subarachnoid space.
2. Surface venous plexus connects to internal vertebral plexus located in the epidural space. 3. Internal vertebral plexus drains via intervertebral veins to the external vertebral plexus, which surrounds the vertebral column. 4. Vertebral venous plexuses have NO functional valves. Therefore, blood can flow in any direction as influenced by gravity. |
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Batson's veins
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includes both the external and internal vertebral venous plexuses, which connect the cranial cavity with venous plexuses in the pelvic cavity. Since the vertebral plexuses have no functional valves metastatic cells (from a malignant tumor) originating in the pelvic region can travel to the cranial cavity where secondary malignant tumors may develop.
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3rd week of gestation
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1. Neural plate (ectoderm) – at rostral end of embryo (in front of primitive pit) appears at 21 days
2. Neural folds – formed from lateral edges of neural plate 3. Neural tube – formed from closure of neural folds 4. Neuropores – close on 25th and 27th days |
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Prosencephalon (forebrain) parts at 5 weeks gestation
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a. Telencephalon – cerebral hemispheres
b. Diencephalon – outgrowth of optic vesicles |
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Mesencephalon is also called
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midbrain
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Rhombencephalon (hindbrain) parts
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a. Metencephalon – pons & cerebellum
b. Myelencephalon – medulla oblongata |
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Cephalic flexure location
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located in midbrain region
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cervical flexure
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at junction of hindbrain and spinal cord
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pontine flexure
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at junction of metencephalon and myelencephalon
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Central canal
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lumen of spinal cord – continuous with brain vesicles
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brain vesicles-where ventricles are
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1. Rhombencephalon – contains 4th ventricle
2. Diencephalon – contains 3rd ventricle 3. Cerebral hemispheres – contain lateral ventricles |
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Ventricular system of brain
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1. Lateral ventricles connect to third ventricle via foramena of Monroe (interventricular foramena)
2. 3rd and 4th ventricles connect to each other via aqueduct of Sylvius (cerebral aqueduct) |
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Pectoral region surface anatomy of male
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1. Contour of pectoral region formed mainly by pectoralis major m.
2. Nipple usually located in 4th intercostal space along mid-clavicular line. |
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Pectoral region surface anatomy of female
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1. Contour of pectoral region formed mainly by the breast.
2. Nipple has indefinite location after puberty |
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Platysma
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- a skeletal muscle of facial expression extends from mandible to upper thorax, just inferior to the clavicle (upper pectoral region).
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Cutaneous nerves of pectoral superficial fascia
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1. Supraclavicular nn (C3 - C4) from cervical plexus - innervate skin of 1st and 2nd intercostal spaces.
2. Intercostal nn (T1 - T7) – supply skin associated with respective intercostals spaces. |
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Location of female breast
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1. Vertically - from ribs 2-6.
2. Horizontally - from sternum to mid-axillary line. 3. Completely contained within the superficial fascia. 4. Located anterior to pectoralis major. 5. Retromammary space lies between breast and pectoralis major. |
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lactiferous ducts of nipple
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- contains 15 to 20 openings for the lactiferous ducts; each lacteriferous duct drains milk from one mammary gland.
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composition of breast
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1. Mammary glands (15-20)
2. Fatty connective tissue. 3. Condensations of fascia form suspensory ligaments and septa which separate the lobules from one another. |
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vasculature of female breast
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1. Arteries - lateral thoracic, intercostal, internal thoracic (perforating branches in intercostal spaces 3-6).
2. Veins - internal thoracic and axillary. |
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Lymphatics of breast
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1. Most lymph vessels converge on the subareolar lymph plexus beneath the skin of the areola. From here several major lymph vessels transport lymph to the nodes listed below.
2. 75% of lymph goes to pectoral nodes, which drain to the axillary nodes. 3. 25% of lymph goes to infraclavicular, parasternal, contralateral, and abdominal nodes (right breast cancer can spread to the liver). 4. Parasternal nodes on one side are connected to the contralateral nodes by lymphatic vessels which cross the anterior mid-line. |
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Most commonly injured muscle of rotator cuff in the elderly
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supraspinatus
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Supraspinatus impingement syndrome
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A type 2 (curved) or 3 (hooked) acromion compresses supraspinatus tendon. Leads to inadequate blood flow to tendon
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Boundaries of quadrangular space
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Superior border - lateral border of scapula and capsule of shoulder joint.
Lateral border - surgical neck of humerus. Inferior border - teres major m. Medial border - long head of triceps brachii m. |
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Contents of quadrangular space
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1. Axillary n.
2. Posterior humeral circumflex a. and v. |
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Transverse cervical a. (branch of thyrocervical trunk) supplies
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supplies levator scapulae, trapezius and rhomboidei mm.
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Suprascapular a. (branch of thyrocervical trunk) supplies
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supplies supraspinatus and infraspinatus. Anastomoses with deep branch of transverse cervical a. and with circumflex scapular branch of subscapular a.
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Deltoid branch of thoracoacromial trunk a.
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supplies deltoid
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lateral thoracic artery supplies
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serratus anterior
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subscapular artery supplies
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has two branches - thoracodorsal a. supplies subscapularis, teres major, latissimus dorsi and serratus anterior mm. The circumflex scapular a. - supplies infraspinatus m. and anastomoses with suprascapular a.
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Posterior humeral circumflex a. supplies
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supplies deltoid m. and anastomoses with the anterior humeral circumflex a.
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Lymphatics of scapula
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deep lymphatic vessels of the shoulder follow the blood vessels and, therefore, drain largely into the axillary lymph nodes
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What vessels form collateral circulation around scapua
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1. transverse cervical
2. suprascapular artery 3. Deltoid branch of thoracoacromial trunk 4. Lateral thoracic a. 5. Subscapular a. 6. Posterior humeral circumflex a. |
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Axilla basic characteristics
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A. Provides continuity between the cervical region and upper extremity.
B. Provides passageway for vessels, nerves and lymphatics destined for the upper extremity. C. A pyramidal-shaped space with four sides, a base and an apex. |
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Boundaries of axilla
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A. Anterior- clavicle, pectoralis major and pectoralis minor.
B. Posterior- scapula, subscapularis, teres major and latissimus dorsi. C. Medial wall- by ribs, intercostal mm, and serratus anterior. D. Lateral wall formed by the intertubercular sulcus of humerus containing the tendon of the long head of the biceps brachii. E. Base formed by the skin and superficial fascia of the armpit. F. Apex is the opening bounded by the clavicle (anterior), scapula (posterior) and first rib (medial). This opening is the junction between the axilla and the neck. |
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Contents of axilla
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1. cords of brachial plexus
2. Axillary aa. 3. axillary vein 4. axillary lymph nodes 5. muscle tendons |
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parts of axillary artery
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First part- supreme thoracic artery
2nd part- thoracromial trunk and lateral thoracic artery 3rd part- subscapular, anterior humeral circumflex and posterior humeral circumflex aa. |
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Axillary V. (continuation of basilic v. in arm)
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1. Begins at lower border of teres major.
2. Terminates at lateral border of first rib where it becomes continuous with the subclavian v. 3. Tributaries correspond to branches of axillary a. |
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Axillary lymph nodes
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Number varies from 12-36
a. Apical (infraclavicular) nodes located medially on proximal part of axillary v. close to apex. Receive lymph from all other axillary nodes. Give rise to subclavian lymph trunk. Also connects with supraclavicular nodes in neck. b. Central nodes on axillary v. posterior to pectoralis minor. Receives lymph from three remaining subgroups; sends lymph to apical nodes. c. Lateral nodes on distal part of axillary v. Receive lymph from upper extremity, but not the shoulder. Sends lymph to central nodes. d. Subscapular nodes next to subscapular a. and v. Sends lymph to central nodes. e. Pectoral nodes adjacent to lateral thoracic a. and v. Receive lymph from breast and anterior thoracic wall. Send lymph to apical and central nodes. |
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3 muscle tendons in axilla
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1. Coracobrachialis
2. Biceps brachii - short head 3. Biceps brachii - long head |
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Laceration in axillary artery treatment
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Blood flow to arm can be maintained if a clamp is put in above the subscapular artery. Allows continuum of blood flow through collateral circulation
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Brachial plexus origin
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originates from the ventral primary rami of C5-T1
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brachail plexus is made up of
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5 Roots
3 Trunks (upper C5-C6/middle C7/lower C8-T1) 6 Divisions (3 ant/3 post) 3 Cords (lat/med/post) relative to axillary aa. 5 Branches |
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Branches of lateral cord
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1. Lateral pectoral n. (C5 - C7)
2. Musculocutaneous n. (C5 - C7) – terminal branch 3. Lateral root of median n. |
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Branches of medial cord
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1. Medial pectoral n. (C8 - T1)
2. Medial brachial cutaneous (C8 - T1) 3. Medial antebrachial cutaneous (C8 - T1) 4. Ulnar n. (C8 - T1) – terminal branch 5. Medial root of median n. |
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Branches of posterior cord
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1. Upper subscapular n. (C5 - C6)
2. Thoracodorsal n. (C6 - C8) 3. Lower subscapular n. (C5 - C6) 4. Axillary n. (C5 - C6) – terminal branch 5. Radial n. (C5 - T1) – terminal branch |
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Erb's palsy
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- involves upper part of the plexus, especially C5 - C6, affects the shoulder and arm. Usually results from excessive separation of the neck and shoulder. Motorcycle accidents and athletic injuries can produce this type of paralysis. Also, severe stretching of an infant's neck during delivery can result it this condition. Such injuries can result in the dorsal and ventral nerve roots being pulled out of the spinal cord from C5 - C6. In such cases the deltoid, supraspinatus, infraspinatus, teres minor and subscapularis muscles are paralyzed, and the flexors of the elbow are weak resulting in the following symptoms: adduction and medial rotation of the arm, extension of the elbow, flexion of the hand, and loss of sensation in the C5 - C6 dermatomes supplied by dorsal and ventral primary rami (skin of back and lateral surface of upper extremity).
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Klumpke's
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- involves lower part of plexus, especially C8 - T1, affects the distal part of the upper extremity (forearm and hand. This paralysis may occur when the upper extremity is suddenly pulled upward, e.g., at delivery as the result of a forceful pull of an infant's shoulder (upper extremity), or when an individual grasps something (a tree limb) to break a fall. The resulting paralysis and anesthesia usually affect the muscles and skin innervated by the ulnar nerve. Therefore, there would be impairment of wrist flexion and movements of many of the intrinsic muscles of the hand. In addition, there would be reduced sensation along the medial side of the arm, forearm, and hand. If this injury occurs at birth the affected upper extremity will not grow to the same size or length of the unaffected extremity
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Thoracic outlet syndrome
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or "cervical rib syndrome" - chronic injury to brachial plexus in lower part of the neck, often also involving injury to the subclavian artery. Injury usually includes involvement of the lower trunk of the brachial plexus at, or close to the level where it crosses the first rib (the location of the entrance of the neurovascular bundle into the axilla, otherwise known as the apex of the axilla). In general, the symptoms consist of pain in the fingers, hand, forearm, arm and shoulder, along with paresthesia perceived in the dermatomes of C8 - T1.
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Most commonly injured rotator cuff muscle in young athletes
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subscapularis
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ventral primary rami of C3 - T3 provide
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Cutaneous innervation of brachium
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supraclavicular nerve
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innervates skin of upper shoulder
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brachial plexus innervates skin of
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innervates skin of brachium, antebrachium, and hand
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Inferior lateral brachial cutaneous n. (from radial nerve) supplies
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supplies skin of lateral aspect of lower arm.
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Posterior brachial cutaneous n. (from radial n.)
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supplies the skin of posterior aspect.
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Superior lateral brachial cutaneous n. (from axillary n.)
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supplies skin over deltoid
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Medial brachial cutaneous n. (from medial cord of brachial plexus)
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supplies skin of upper medial aspect of arm.
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Medial antebrachial cutaneous n. (from medial cord of brachial plexus)
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supplies skin of lower medial and anterior aspects of the arm
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Intercostobrachial n. (T2 - T3)
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supplies skin of armpit and part of medial arm.
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Deep (brachial) fascia
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surrounds muscles of arm like a sleeve
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Two fascial septa (partitions) connect deep brachial fascia with the humerus and
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Lateral and medial intermuscular septums
divide the arm into two muscular compartments - anterior containing flexor mm. and posterior containing extensor mm. |
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brachial artery characteristics
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. begins at lower border of teres major as a continuation of axillary a., then courses inferiorly on the medial aspect of arm until it disappears deep to the bicipital aponeurosis. It bifurcates, approximately one inch distal to the crease of the elbow, into the radial and ulnar aa
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Profunda brachii a.
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branch of brachial artery
arises just distal to the teres major. Supplies the triceps brachii as it travels with the radial n. in the posterior muscular compartment. It anastomoses with the axillary a. thereby connecting the axillary a. w/ the ulnar and radial aa |
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Superior ulnar collateral a
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supplies elbow joint
branch of brachial artery |
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Inferior ulnar collateral a.
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supplies elbow joint
branch of brachial artery |
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Nutrient a.
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supplies humerus
branch of brachial artery |
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Radial collateral artery characteristics
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anastomoses with the radial recurrent a.
branch of brachial artery |
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Veins of brachium
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Deep brachial vv. found in pairs (venae commitantes) running parallel to brachial a.; start at elbow and eventually become tributaries to the axillary v.
2. Cephalic v. passes upward from the forearm in the superficial fascia in the groove lateral to the biceps, then in the groove between the deltoid and the pectoralis major m. (deltopectoral triangle); becomes a tributary to the axillary v. 3. Basilic v. passes from forearm to arm in superficial fascia on medial side of the front of the elbow. At the junction between the distal and middle of the arm this vein penetrates the brachial fascia to enter the anterior muscular compartment. Eventually becomes the axillary v. |
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Lateral antebrachial cutaneous (continuation of musculocutaneous n.) supplies
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supplies anterior and posterior aspects of radial (lateral) side of forearm to the wrist.
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Medial antebrachial cutaneous (branch of medial cord of brachial plexus) supplies
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supplies anterior and posterior aspects of ulnar (medial) side of forearm.
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Posterior antebrachial cutaneous (branch of radial n.) supplies
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posterior surface of forearm between distributions of the two nerves listed above
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Antebrachial (deep) Fascia characteristics
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A. A cylindrical sheath that encloses both flexor and extensor mm.
B. Fused to medial border of ulna; sends a interosseous membrane to the radius, forming anterior and posterior muscular compartments. C. In the distal anterior compartment this fascia splits into two layers, one anterior to three muscles (palmaris longus, flexor carpi ulnaris and flexor carpi radialis) and one between these muscles and the other more deeply located flexor muscles. D. At the wrist, stout transverse fibers span the carpal groove, between the pisiform bone and hamulus of the hamate on the ulnar side, and the scaphoid and trapezium on the radial side, thereby converting this groove into the carpal tunnel. This thick band of fibers is known as the flexor retinaculum |
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Relationships of important structures passing superficial or deep to the flexor retinaculum
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1. Palmaris longus tendon passes anterior to it.
2. Ulnar n. and a. pass anterior to it. 3. Median n. and tendons of long flexors of thumb and fingers pass posterior to it, through the carpal tunnel |
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Arteries of flexor muscles
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A. Radial a. gives a recurrent branch to the elbow region and muscular branches to flexor mm.
B. Ulnar a. gives recurrent branches to elbow region and the common interosseous a. which has anterior and posterior branches. The anterior interosseous a. supplies the bulk of the flexor mm. |
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Arteries to extensor muscles
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A. Posterior interosseous a. (branch of the common interosseous a.) and its interosseous recurrent branch.
B. Radial recurrent a. supplies the brachioradialis and the radial carpal extensors. It eventually anastomoses with the radial collateral branch of the profunda brachii a. C. Terminal (posterior) branch of the anterior interosseous a. pierces the distal part of the interosseous membrane to supply muscles in the distal part of the extensor compartment |
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Anterior and posterior interosseous arteries both supply
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muscles on posterior side
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dorsal surface of hand features
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1. Extensor tendons
2. Knuckles (heads of metacarpals) 3. Anatomical "snuff box" |
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boundaries and contents of anatomical snuff box
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bounded by the tendons of the abductor pollicis longus, extensor pollicis brevis (laterally) and extensor pollicis longus (medially)
Contained within this space are the radial a. and the styloid process of the radius |
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Palmar (ventral) surface of hand features
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1. Palmar and digital creases
2. Thenar eminence of thumb 3. Hypothenar eminence of 5th digit 4. Abundance of sweat glands and absence of hair. 5. Well-patterned ridges on the ventral surface of the distal phalanges (finger prints) to prevent slippage of grasped objects. |
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Skeleton of hand
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A. Metacarpals (1-5)
B. Phalanges (total of 14) 1. Digits 2-5 each have three (proximal, middle and distal) phalanges. 2. First digit (thumb) has two (proximal and distal) phalanges. C. Articulations (4 sets) 1. Carpometacarpal joints and intermetacarpal joints. 2. Metacarpophalangeal (MP) joints. 3. Proximal interphalangeal (PIP) joints. 4. Distal interphalangeal (DIP) joints. |
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Short muscles of the thumb
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thenar eminence (abductor pollicis brevis, flexor pollicis brevis and opponens pollicis)
and the adductor pollicis |
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short muscles of the thumb attachments
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1. All thenar muscles arise from the flexor retinaculum and the trapezium.
2. All thenar muscles insert on the shaft (body) of the 1st metacarpal. 3. The adductor pollicis inserts at the base of the proximal phalanx but arises by two heads (transverse head from the shaft of the 3rd metacarpal and oblique head from the bases of the 1st, 2nd and 3rd metacarpals) |
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short muscles of the thumb innervations
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thenar muscles- supplied by the recurrent branch of the median nerve, except the deep head of the flexor pollicis brevis which when present is typically supplied by the ulnar nerve
adductor pollicis- also supplied by the same roots of the ulnar nerve. |
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hypothenar muscles
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palmaris brevis
abductor digiti minimi flexor digiti minimi brevis opponens digit minimi |
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palmar brevis origin
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the flexor retinaculum and palmar aponeurosis.
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abductor minimi digiti origin
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the pisiform bone
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Flexor digiti minimi brevis and the opponens digiti minimi origin
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the flexor retinaculum and hook of the hamate
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hypothenar muscles insertion
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muscles insert at the base of the proximal phalanx of the 5th digit except the opponens digit minimi which inserts on the shaft of the 5th metacarpal
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nerve supply of hypothenar muscles
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deep branch of the ulnar nerve except the palmaris brevis which is innervated by the ulnar nerve or its superficial branch
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# of interossei muscles
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3 palmar and 4 dorsal
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3rd digit interosseous muscles
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No palmar interossei muscles insert on the 3rd digit
Two dorsal interossei muscles insert on the 3rd digit |
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dorsal interossei muscles fxn
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abduct the 2nd, 3rd and 4th digits
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palmar interossei muscles fxn
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adduct the 2nd, 4th, and 5th digits
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The interossei muscles may assist in
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flexion of the MP joints or with extension of the PIP and DIP joints
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Lumbricales characteristics
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4 lumbricales
1. They arise from the flexor digitorum profundus tendons. 2. The medial lumbricales (3rd and 4th) are innervated by the ulnar nerve, while the lateral lumbricales (1st and 2nd) are innervated by the median nerve. 3. Their primary function is to extend the interphalangeal joints, while their secondary function is to flex the MP joints. |
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Palmar aponeurosis characteristics
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a thickening of the deep fascia in the central area of the palm. This structure is strong and overlies the long flexor tendons and other soft tissues. Proximally, it is continuous with the flexor retinaculum, while distally it divides into four longitudinal bands that attach to the bases of the proximal phalanges and fuse with the fibrous digital sheaths of each of the four fingers. The tendon of the palmaris longus inserts into this aponeurosis
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Fascial compartments of the palm
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Forms thenar and hypothenar compartments. Between the two septa lies a central compartment containing the flexor tendons and their sheaths, the superficial palmar arch and branches of the median and ulnar nerves. From the lateral border of the palmar aponeurosis, another septum, the oblique septum, passes deeply and obliquely to the 3rd metacarpal; thus dividing the central compartment into lateral and medial mid-palmar spaces. In addition to all the compartments and spaces described above, an adductor compartment containing the adductor pollicis muscle alone
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flexor retinaculum characteristics
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heavy thickening of the anterior antebrachial fascia at the level of the wrist joint. The median nerve and all the flexor tendons, except the palmaris longus tendon, course deep to this retinaculum to pass into the hand. Together with the carpal bones this retinaculum forms a "carpal tunnel" through which pass the aforementioned structures
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extensor retinaculum characteristics
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a thickening of the posterior antebrachial fascia. As it passes from the lateral border of the radius to the medial border of the ulna and the triquetrum and the pisiform, it sends septa into the underlying bone, thus separating the space deep to it into six typical compartments
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Cutaneous innervation of hand
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provided by the radial, ulnar and median nerves
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Long extensor tendons
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too long, see lecture notes
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extrinsic muscles of the hand (long flexors and extensors) innervation
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1. The median nerve and its major branch in the forearm, the anterior interosseous nerve supply all the extrinsic flexors except the flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus, which are innervated by the ulnar nerve.
2. All the extensor muscles are supplied by the radial nerve and its main branch in the forearm, the posterior interosseous nerve. |
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All the intrinsic muscles of the hand are supplied by the ulnar nerve except ________ which are supplied by __________
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1. Abductor pollicis brevis
2. Flexor pollicis brevis (superficial head) 3. Opponens pollicis 4. Lumbricales (1st and 2nd) supplied by median nerve |
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blood supply of hand
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arterial supply is provided mainly by the superficial palmar arch, a continuation of the ulnar artery, and the deep palmar arch, a continuation of the radial artery. The superficial palmar arch gives off common digital arteries which then divide to form the proper palmar digital arteries. The deep palmar arch gives off palmar metacarpal arteries which communicate with the common digital arteries
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applied anatomy of hand- skin creases
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at the creases, the skin is firmly bound to the subcutaneous tissue beneath. An incision across a crease produces much scar tissue and remarkable reduction in range of motion. Therefore, surgical incisions across skin creases are to be avoided
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Dupuytren's contracture
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The palmar aponeurosis may become abnormally thickened by fibrous bands that extend from the aponeurosis to the bases of the phalanges. As the bands pull the fingers into flexion, the aponeurosis becomes contracted (shortened) so that the flexed MP joints cannot be straightened. Cause unknown but appears to be hereditary
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fascial infection of hand applied anatomy
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When one compartment becomes infected the accumulated pus is contained within that compartment by the septa. Therefore, depending on the site of the infection, pus may accumulate in either the thenar, hypothenar or adductor compartments. If the infection site is properly treated, infection rarely spreads to other compartments, although it may spread proximally into the forearm
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Injury to median nerve in forearm applied anatomy
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produces paralysis of the thenar muscles. The major sign is usually loss of opposition of the thumb. However, the abductor pollicis longus may be spared; and together with the adductor and the deep intrinsic flexor and the interossei the action of opposition may be closely imitated if the ulnar nerve is intact
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recurrent branch of median nerve applied anatomy
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lies superficial and may be severed by minor lacerations involving the thenar eminence. Such injury may render the thumb useless as most of the thenar muscles are paralyzed
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injury to median nerve at the wrist applied anatomy
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may result in paralysis of most of the thenar muscles, sensory impairment in most of the fingers supplied by the median nerve, and subsequent atrophy of the thenar muscles which become flattened, producing the characteristic "ape hand" deformity
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injury to ulnar nerve at the wrist
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common as this nerve lies very superficial in this area. The neurological deficits may include loss of sensation in the 5th finger and the ulnar half of the 4th finger; impaired abduction and adduction of the 5th finger; and paralysis of the adductor pollicis, the 3rd and 4th lumbricales and the interossei. Subsequent atrophy of all of these muscles will produce the characteristic furrows between the metacarpals. The classic deformity called "claw hand" may not become obvious until several weeks after the occurrence of the injury
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injury to radial nerve in arm or forearm
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The radial nerve does not supply any of the intrinsic muscles of the hand. However, it supplies all the extensors of the wrist and digits. Injury to this nerve in the arm or forearm characteristically produces inability to extend the wrist. Therefore, the hand remains flexed and flaccid, a condition known as "wrist drop"
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Metacarpal bones and their joints
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- the proximal ends (bases) of these bones articulate with the carpal bones. In addition, the bases of metacarpals 2-5 articulate with each other. The MP joints permit flexion and extension, and when the hand is open, the fingers can also be abducted and adducted. These movements are possible because of the convex shape of the heads of the metacarpals and the concave shape of the bases of the proximal phalanges. When the interphalangeal joints are flexed, neither abduction nor adduction is possible.
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metacarpal bone of thumb
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The metacarpal of the thumb is short and stout, and possesses a saddle-shaped base. The unique shape of this articulation (carpometacarpal joint of the thumb) makes possible the different movements of this digit
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phalanges and their joints
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The dorsal surfaces of the proximal and middle phalanges are smooth, rounded, and covered by the extensor expansion. The palmar surfaces take part in the floor of the osteofibrous tunnels through which the flexor tendons move. The distal ends of the distal phalanges have a smooth area on the dorsal surface just deep to the fingernail. On the palmar surface of the distal phalanges, the area for the finger pad is rough, due to the attachment of the fibrous bands that attach skin to it. The interphalangeal joints (DIP and PIP) are hinge joints which permit only flexion and extension
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Shoulder (glenohumeral joint) type
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ball and socket
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bones of glenohumeral joint
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head of humerus (1/3 of a sphere), glenoid fossa of scapula including glenoid labrum (fibrocartilage). Glenoid labrum surrounds the rim of the glenoid fossa, thereby deepening the socket and providing a soft elastic cushion for the head of the humerus
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movements of glenohumeral joint
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three axes of motion provide for flexion-extension, abduction-adduction, and medial and lateral rotation. When all three axes of motion are combined in one continuous movement, the movement is known as circumduction
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ligaments of glenohumeral joint
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1. Capsular – fibrous capsule is very loose, allowing a wide range of motion. In the adducted position the capsule tightens superiorly preventing downward displacement of the humerus.
2. Glenohumeral – superior, middle and inferior (provide static stability) 3. Transverse humeral 4. Coracohumeral 5. Coracoacromial |
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contents of glenohumeral joint cavity
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1. Tendon of the long head of the biceps brachii – located in the intertubercular sulcus.
2. Transverse humeral ligament – retains the tendon of the long head of the biceps brachii in the intertubercular sulcus |
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coracoacromial arch structures and fxn
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consists of the coracoids process, coracoacromial ligament and the acromion. This arch forms a secondary socket for the head of the humerus, preventing its upward displacement
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muscles crossing glenohumeral joint
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1. Subscapularis
2. Supraspinatus 3. Infraspinatus 4. Teres minor 5. Biceps brachii, long head |
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sensory nerve supply of glenohumeral joint
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(C5-C6):
1. Suprascapular n. 2. Axillary n. 3. Lateral pectoral n. |
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acromioclavicular (AC) joint type
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gliding with articular disk
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bones of AC joint
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distal end of clavicle and acromion process of scapula
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ligaments of AC joint
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1. Joint capsule
2. Acromioclavicular 3. Coracoclavicular |
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movements of AC joint
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1. Sliding to accommodate scapula
2. Rotation (very small amount) |
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AC joint muscles
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none specific to this joint
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fxns of AC joint
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1. Permits vertical movement of scapula on the thoracic wall when pectoral girdle rises and falls.
2. Permits anterior and posterior movement of scapula on the clavicle. 3. Permits upward rotation of scapular necessary whenever arm is abducted above 90 degrees |
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sternoclavicular (SC) joint type
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gliding with disk
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SC joint bones
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- proximal end of clavicle and manubrium of sternum
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Articular cartilage (fibrocartilage) of SC joint
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attached to clavicle superiorly and 1st costal cartilage inferiorly
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SC joint ligaments
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1. Articular capsule
2. Sternoclavicular – anterior and posterior 3. Interclavicular 4. Costoclavicular |
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SC joint motions
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sliding with some rotation
1. Elevation of clavicle (pectoral girdle) 2. Protraction of scapula |
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SC joint muscles
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- most muscles moving clavicle and scapula also move this joint
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SC joint fxns
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prevents medial displacement of clavicle
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Elbow joint type
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hinge
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Elbow joint bones
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1. Distal end of humerus includes the trochlea on the medial side.
2. Proximal end of ulna includes the trochlear notch. |
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humeroulnar joint location
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between the trochlear notch of the ulna and the trochlea of the humerus
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movements of elbow joint
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- flexion and extension
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articular capsule of elbow joint
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attaches proximally all around articular surface of humerus and distally to neck of radius, coronoid process and olecranon of ulna
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ligaments of elbow joint
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1. Medial (ulnar) collateral - fan shaped from medial epicondyle of humerus to coronoid process of ulna.
2. Lateral (radial) collateral - cord extending from lateral epicondyle of humerus to annular ligament and radius below it. |
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muscles crossing elbow joint
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1. Flexors - biceps brachii and brachialis assisted by pronator teres and brachioradialis.
2. Extensors - triceps brachii and anconeus |
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innervation of elbow joint
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– the nerves of the elbow joint are derived from all four nerves that cross this joint (musculocutaneous, radial, median and ulnar nerves).
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dislocations of the elbow joint usually occur
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because the ulnar cannot be dislocated anteriorly without fracturing this bone, most dislocations occur posteriorly. The ulnar nerve is frequently injured by such dislocations. Dislocation of only the head of the radius usually occurs anteriorly
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proximal radioulnar joint type
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- trochoid or pivot, included in elbow joint capsule.
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bones of proximal radioulnar joint
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1. Ulna - radial notch
2. Radius - head |
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motions of proximal radioulnar joint
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pronation and supination of hand
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proximal radioulnar joint ligaments
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the annular ligament is a band that forms 4/5’s of a circle, the remainder of the circle being formed by the radial notch. This ligament is attached to the edges of the radial notch. In some children displacement (dislocation) of the head of the radius occurs without tearing the ligament.
This phenomenon is thought to be due to poor development of the head of the radius. |
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proximal radioulnar joint muscles
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1. Pronators - pronator teres and pronator quadratus.
2. Supinators - supinator and biceps brachii. |
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middle radioulnar joint type
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syndesmosis known as the interosseous membrane
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middle radioulnar joint fxn
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provides no movement; serves to transfer force received from the hand via the radius to the ulna and by doing so sends the force along the stronger side of the forearm. It also serves as the area of muscle origin for the deeper members of the flexor-pronator group on the anterior aspect, and the extensor-supinator group on the posterior aspect. Finally, it assists in maintaining the socket of the wrist joint.
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distal radioulnar joint type
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trochoid or pivot.
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distal radioulnar joint bones
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1. ulna - head plus the ulnar disc.
2. radius - ulnar notch. |
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distal radioulnar joint motions and muscles
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pronation and supination of the hand
1. Pronators - pronator teres and pronator quadratus. 2. Supinators - supinator and biceps brachii. |
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distal radioulnar joint ligaments
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1. Distal radioulnar - anterior and posterior.
2. Attachments of disc to fovea of ulna and edges of ulnar notch on radius. The joint capsule is shared with the wrist joint. |
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wrist (radiocarpal joint) type
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ellipsoid
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wrist joint bones
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1. Radius - distal surface.
2. Ulnar disc. 3. Carpals - proximal row to include the scaphoid, lunate and triquetrum |
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wrist joint motions
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1. Flexion and extension.
2. Abduction and adduction |
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wrist joint ligaments
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1. Joint capsule
2. Dorsal and palmar radiocarpal ligaments. 3. Radial collateral - styloid process of radius to scaphoid and trapezium. 4. Ulnar collateral - styloid process to triquetra and hamate |
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muscles crossing wrist joint
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1. Flexors - flexor carpi radialis, flexor carpi ulnaris, palmaris longus, long flexors of thumb and fingers.
2. Extensors - extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensors of thumb and fingers. 3. Abductors - combined action of flexor carpi radialis and extensor carpi radialis. 4. Adductors - combined action of flexor carpi ulnaris and extensor carpi ulnaris. |
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transverse carpal joint type
|
gliding
|
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transverse carpal joint bones
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proximal row of carpals and distal row of carpals (trapezium, trapezoid, capitate and hamate)
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transverse carpal joint motions
|
nothing independent, supplemental to motions of wrist
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transverse carpal joint ligaments
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- joint capsule reinforced by dorsal and palmar ligaments
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transverse carpal joint muscles
|
any muscle crossing this joint can move it
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carpometacarpal joint types
|
1. 1st - saddle joint with three axes of motion.
2. 2nd through 5th - gliding joints |
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carpmetacarpal joint motions
|
1. 1st - flexion and extension, adduction and abduction, medial and lateral rotation.
2. 2nd and 3rd - very limited, area of strength in hand. 3. 4th and 5th - some flexion and extension increases grasp. |
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Metacarpophalangeal (MCP) Joints type
|
condyloid
|
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Metacarpophalangeal (MCP) Joints bones
|
1. Metacarpals (1st - 5th)
2. Proximal phalanges (1st - 5th) |
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Metacarpophalangeal (MCP) Joints motions
|
1. Flexion and Extension.
2. Adduction and Abduction |
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Metacarpophalangeal (MCP) Joints ligaments
|
- joint capsule reinforced by dorsal and palmar ligaments with heavy transverse metacarpal ligament on palmar side
|
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Metacarpophalangeal (MCP) Joints muscles crossing
|
1. Flexion and extension - long flexors and extensors of digits.
2. Flexion - also by way of the lumbricales. 3. Abduction - dorsal interosseous muscles. (DAB) 4. Adduction - palmar interosseous muscles. (PAD) |
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interphalangeal joint types
|
condyloid
|
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Interphalangeal joints (PIP and DIP) motions
|
flexion and extension
|
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muscles acting on interphalangeal joints
|
1. Extensors - all extensor muscles via extensor hood mechanism; lumbricales by insertion into extensor tendons.
2. Flexors - DIP exclusively by flexor digitorum profundus; PIP by both digital flexors. |