anatomy review session l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Anatomy Review Session PowerPoint Presentation
Download Presentation
Anatomy Review Session

Loading in 2 Seconds...

play fullscreen
1 / 121

Anatomy Review Session - PowerPoint PPT Presentation


  • 523 Views
  • Uploaded on

Anatomy Review Session. Summer 2009. Approach to Anatomy. Osteology Arthrology Nerves Vessels Approaches Questions. References. Miller Self assessment exams OITE References Primary articles Hoppenfeld. Upper extremity Shoulder Arm Forearm Wrist Spine. Lower extremity Hip

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Anatomy Review Session' - saburo


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
approach to anatomy
Approach to Anatomy
  • Osteology
  • Arthrology
  • Nerves
  • Vessels
  • Approaches
  • Questions
references
References
  • Miller
  • Self assessment exams
  • OITE References
  • Primary articles
  • Hoppenfeld
format
Upper extremity

Shoulder

Arm

Forearm

Wrist

Spine

Lower extremity

Hip

Thigh

Knee and leg

Ankle and foot

Format
osteology
Osteology
  • Clavicle
    • First bone to ossify (5 weeks)
    • Last to fuse (medial epiphysis at 25 years old)
    • Fracture of clavicle  most common birth injury
osteology7
Osteology
  • Scapula
    • Glenoid retroverted 5 degrees
    • Humerus retroverted 30 degrees
    • Attachments: 17 muscles, 4 ligaments
coracoid
Coracoid
  • Coracoid attachments
    • Coracoacromial ligament
    • Coracoclavicular ligs
      • Conoid (medial)
      • Trapezoid (lateral)
    • Conjoined tendon
      • Coracobrachialis
      • Short head of biceps
    • Pec Minor
notches
Notches
  • Suprascapular notch
    • Superior transverse scapular ligament
      • Nerve below
      • Artery above
  • Spinoglenoid notch
    • Inferior transverse scapular ligament
      • Nerve and artery below

** Compression (ganglion/cyst) = infraspinatus atrophy

arthrology
Arthrology
  • Glenohumeral joint
  • Key stabilizers
static dynamic restraints
Static

Articular anatomy

Glenoid Labrum

Negative Pressure

Capsule

Ligaments

Dynamic

Rotator cuff

Biceps tendon

Scapulothoracic motion

Static/Dynamic restraints
arthrology12
Arthrology
  • Acromioclavicular joint
    • Incomplete intra-articular disc (arthritis)
    • AC ligaments provide A-P stability
    • CC ligaments provide sup-inf stability
  • Sternoclavicular joint
    • Complete intra-articular disc
    • Rotates 30 deg w/shoulder flexion
arthrology13
Arthrology
  • Scapulothoracic joint
    • 2:1 ratio of GH:ST motion
  • Coracoacromial ligament – superior-anterior restraint in rotator cuff deficient shoulder
    • Acromial branch of thoracoacromial artery runs on the medial aspect of the CA lig (caution during subacromial decompression)
muscles
Muscles
  • Greater tuberosity
    • Supraspinatus (ant)
    • Infraspinatus (mid)
    • Teres minor (post)
  • Lesser tuberosity
    • Subscapularis
  • IR stronger than ER
    • Posterior shoulder dislocations occur with seizures/electrical shock
brachial plexus
Brachial Plexus
  • Ventral rami C5-T1
  • Under clavicle between scalenus anterior and scalenus medius
  • Roots (5) / Trunks (3) / Divisions (6) /

Cords (3) / Branches

(“Ron Taylor Drinks Cold Beer”)

  • 4 preclavicular branches
    • Dorsal Scapular nerve
    • Long Thoracic nerve
    • Suprascapular nerve
    • Nerve to the subclavius
cord terminations
Cord terminations
  • Lateral
    • Musculocutaneous
  • Posterior
    • Radial and axillary nerve
  • Medial
    • Ulnar nerve
  • Medial and Lateral
    • Median nerve
brachial plexus palsies
Brachial Plexus Palsies
  • Erb-Duchenne Palsy
    • Roots C5-6
      • Deficit: Deltoid, RTC, elbow flexors, wrist/hand extensors (“Waiter’s tip”)
  • Klumpke Palsy
    • Roots C8-T1
      • Deficit: Wrist flexors/intrinsic

Horner’s syndrome

  • Total plexus
    • C5-T1
      • Deficit: flaccid arm
scapular winging
Scapular winging
  • Scapular trapezius winging (lateral)
    • Injury to the spinal accessory nerve
    • Shoulder depression, scapular translation laterally
    • Inferior angle rotated laterally due to unopposed pull of serratus anterior
  • Serratus anterior scapular winging (medial)
    • Injury to the long thoracic nerve
    • Shoulder elevation, scapular translation medially
    • Inferior angle rotated medially
axillary artery
Axillary artery
  • 3 parts based on relationship to pec minor
axillary artery21
Axillary artery
  • Part 1
    • Supreme thoracic- medial
  • Part 2
    • Thoracoacromial (four branches)
      • deltoid, acromial (SAD at CA lig), pectoral, clavicular
    • Lateral thoracic
  • Part 3 (Most vulnerable to traumatic injury)
    • Subscapular (2 branches)
      • Thoracodorsal
      • Circumflex scapular triangular space
    • Anterior humeral circumflex: main supply to humeral head
    • Posterior humeral circumflex – with axillary nerve in quadrangular space
shoulder approaches
Shoulder Approaches
  • Anterior approach
    • Deltopectoral (Interval: Axillary nerve and Med/Lat Pectoral nerves)
      • Axillary nerve along inferior border of subscap
      • Musculocutaneous nerve: 5-8cm below coracoid – terminal branch is lateral antebrachial cutaneous
      • Adduction/ER of arm protects axillary nerve
  • Lateral approach
    • Deltoid split
    • Axillary nerve is 5 cm below tip of acromion
shoulder approaches24
Shoulder Approaches
  • Posterior approach
    • Between infraspinatus (suprascapular n.) and teres minor (axillary n.)
    • Quadrangular space
      • Axillary nerve, posterior humeral circumflex artery
    • Triangular space
      • Circumflex scapular artery
    • Triangular interval
      • Radial nerve, Profunda Brachii artery
slide25

Axillary nerve

Post humeral circumflex artery

Circumflex scapular artery

Radial nerve

Profunda Brachii artery

osteology27
Osteology
  • Spiral groove 13cm above articular surface of trochlea
  • Normal carrying angle of elbow
    • 7 degrees valgus
  • Maximal distension of capsule at 70-80 deg flexion
coranoid attachments
Coranoid attachments
  • Anterior bundle of MCL (18mm distal to tip)
  • Brachialis (11mm distal to tip)
  • Anterior capsule (6mm distal to tip)
  • Coranoid is intra-articular
elbow ligaments
Elbow ligaments
  • MCL
    • Anteroinferior portion of medial epicondyle to sublime tubercle
    • Anterior bundle: most important in resisting valgus force
    • **Valgus stability w/arm pronated = intact anterior bundle of MCL
  • LCL: most important is the LUCL
    • Deficiency = posterolateral rotatory instability
    • From lateral epicondyle to ulna crista supinatoris
elbow ligaments30
Elbow Ligaments

LATERAL

MEDIAL

nerves
Nerves
  • Musculocutaneous – pierces CB 5-8cm below insertion, LABC
  • Radial – 21cm from medial epicondyle and 14cm from lateral
    • Found at the BR/ brachial interval
    • Dual innervation to brachialis (MC/radial)
  • Median – crosses lateral to medial over brachial artery, no branches in the arm
  • Ulnar- no branches to arm
surgical approaches
Surgical Approaches
  • Anterolateral approach to humerus: splits brachialis
    • Dual innervation (Radial and MC)
    • Radial n. (Brachialis and BR interval)
  • Kocher approach
    • Ancones (radial n.) and ECU (PIN)
    • Pronate arm to protect PIN
      • 38mm in pronation / 22mm in supination
elbow arthroscopy
Elbow arthroscopy
  • Direct lateral portal
    • “soft spot” in triangle (joint insufflation)
  • Anterolateral portal
    • 2-3cm distal to lateral epicondyle and 1cm anteriorly
      • WATCH FOR RADIAL NERVE/PIN
  • Medial portal
    • 2cm distal and 2cm anterior to medial epicondyle
      • WATCH FOR MEDIAL ANTEBRACHIAL CUTANEOUS NERVE
  • Posterior portal
    • 3cm prox to tip of olecranon and 2cm lateral
  • Pohling portals
    • 2cm proximal and anterior to medial epicondyle (anterior to septum)
osteology arthrology
Osteology/Arthrology
  • Radius is convex laterally
    • Restoration of radial bow important in ORIF of shaft fractures
  • DRUJ most stable in supination
  • Volar wrist ligaments stronger than dorsal
  • Radial styloid and radial tuberosity are 180 deg rotated from one another
slide36
TFCC
  • TFCC
    • Dorsal and volar radioulnar ligaments
    • Articular disc
    • Meniscal homologue
    • UCL (ulnolunate/ulnotriquetral)
    • ECU
radial nerve
Radial nerve
  • Between BR and brachialis
  • Supplies BR, ECRL, ECRB (mobile wad)
    • PIN supplies the rest
  • Order of reinnervation
    • Supinator, ECU, EDC, EDM, APL, EPL, EPB, EIP last to return w/PIN palsy (most distally innervated)
  • Wartenberg’s syndrome – pain from radial sensory nerve entrapment at wrist
    • Superficial radial nerve: between BR & ECRL
pin compression
PIN compression
  • Potential sites of PIN compression (FREAS)
    • Fibrous bands
    • Recurrent leash of Henry
    • ECRB (site of tennis elbow)
    • Arcade of Frohse (proximal edge supinator)
    • Supinator distal margin
median nerve
Median nerve
  • Splits two heads of the pronator teres
  • Runs between FDS and FDP
  • Supplies PT, FCR, PL, FDS, thenars, FPB (supinator head), 1st and 2nd lumbrical
slide40
AIN
  • Runs between FPL and FDP
  • Supplies PQ, FPL and FDP to index and long
ain compression
AIN compression
  • Potential sites of AIN Compression
    • Deep head of PT
    • FDS
    • Aberrant vessels
    • Gantzer’s muscle (accessory FPL)
ulnar nerve
Ulnar nerve
  • Cubital tunnel (ulnar groove, fascial arch, muscles of FCU)
  • Between FCU and FDP (supplies ulnar ½)
  • Distally at Guyon’s—more superficial
  • Supplies FCU, ulnar ½ of FDP, hypothenars, 3rd and 4th lumbrical, deep head of FPB
ulnar nerve compression
Ulnar nerve compression
  • Potential sites of ulnar nerve compression
    • Arcade of Struthers
      • band from medial head of triceps to medial IM septum8cm prox to med epicondyle
    • Medial IM septum
    • Medial epicondyle
    • Cubital tunnel
    • Proximal edge of FCU (Osborne’s fascia)
    • Deep flexor pronator aponeurosis
cutaneous nerves
Cutaneous nerves
  • LABC – continuation of musculocutaneous nerve, lateral to bicep at elbow
  • MABC – arises from medial cord, crosses 6cm proximal to 4cm distal from medial epicondyle
  • PABC – arises from radial nerve, crosses from posterior to anterior compartment
nerves splitting muscles
Nerves splitting muscles
  • PIN splits supinator
  • Median nerve splits pronator teres
  • Ulnar nerve splits FCU
nerve anastomoses
Nerve anastomoses
  • Martin-Gruber anastomosis
    • Between median and ulnar nerve in forearm
  • Riches-Cannieu anastomosis
    • Between ulnar and median nerve in the palm
vessels
Vessels
  • Radial artery
    • Splits at level of radial neck
    • Between BR and PT proximally and between BR and FCR distally
  • Ulnar artery
    • Between FDS and FDP proximally
    • On FDP between FDS and FCU distally
forearm approaches
Forearm approaches
  • Henry (anterior)
    • BR (radial n.) and PT (median n.) proximally
    • BR and FCR (median n.) distally
      • Elevate PQ off radius
  • Thompson (dorsal)
    • ECRB (radial n.) and EDC (PIN) proximally
    • ECRB and EPL (PIN) distally
    • Excessive retraction of the supinator can injure PIN
osteology50
Osteology
  • Carpal bones
    • Ossification begins at capitate (1 year of age) and runs counterclockwise
    • Pisiform (9 years) **Last to ossify
osteology51
Osteology
  • Scaphoid
    • Branch of radial artery – dorsal and distal
    • Risk of AVN
      • Middle 1/3 fx 30-50%
      • Proximal 1/3 fx 100%
arthrology52
Arthrology
  • Radiocarpal Joint
    • Volar ligaments are stronger
    • Space of Poirer is weak area volarly for perilunate dislocation
  • Intercarpal Joints
    • S-L-T interosseous ligament
    • Dorsal ligaments are stronger
arthrology53
Arthrology
  • Thumb CMC
    • Saddle joint (highly mobile)
    • Arthritis is common
  • CMC Joints
    • Dorsal ligaments are strongest
    • Subluxations must be reduced
other important structures
Other important structures
  • Extensor retinaculum
    • 6 extensor compartments
    • EIP/EDM/EPL all ulnar to EDC and EPB, respectively
    • ECRB ulnar to ECRL
    • EPB ulnar to APL
    • APL can have multiple slips (DeQuervain’s)
extensor compartments
Extensor compartments

EIP: distal, deep, ulnar

Rupture after DRF

Vaughn-Jackson syndrome

Intersection Syndrome

Snapping ECU

DeQuervain’s

transverse carpal ligament
Transverse carpal ligament
  • Roof of carpal tunnel
    • Pisiform/hamate to scaphoid/trapezium
  • Floor of Guyon’s (roof is volar carpal lig)
    • Pisiform ulnarly/hook of hamate radially
carpal tunnel
Carpal tunnel
  • Decreases in volume with wrist flexion
  • Median nerve
  • FPL
  • FDS x 4 (long/ring volar to index/small)
  • FDP x 4
other important structures58
Other important structures
  • Interossei
    • Dorsal – abduct (4) DAB
    • Palmar – adduct (3) PAD
  • Lumbricals
    • Originate on tendon of FDP and insert onto radial lateral bands of extensor expansion at MPs
pulley system
Pulley system
  • A2 (prox) and A4 (middle)
    • Most important
    • Prevent bowstringing
  • A3: PIP and volar plate
  • A1: trigger finger
  • Cruciate pulleys
median nerve60
Median nerve
  • Palmar cutaneous branch– 5cm proximal to crease between FCR and PL
  • Motor branch
        • 46% extraligamentous (distal)
        • 31% subligamentous
        • 23% transligamentous
ulnar nerve61
Ulnar nerve
  • Guyon’s canal
    • Ulnar to artery
    • Superficial branch (palmaris brevis and skin)
    • Deep branch (3 hypothenars, all IO, 3rd and 4th lumbricals, Adductor pollicis and deep head of FPB)
    • ½ LOAF ½
radial artery
Radial artery
  • Dorsal branch in snuffbox
  • Between 1st and 2nd DIO
  • Enters scaphoid dorsally and distally
  • Princeps pollicis
  • Bifurcates to thumb digital artery and radialis indicis
  • Remaining volar branch connects to make superficial arch
  • Main supply of DEEP arch
ulnar artery
Ulnar artery
  • Main supply to superficial arch
    • Distal to the deep arch
  • Incomplete arch in 20%
  • Digital arteries
    • Arise from superficial arch
    • Volar in hand to nerves
    • Dorsal in digits to nerves
neurovascular bundles
Neurovascular bundles
  • Volar to Cleland’s ligament (“ceiling”)
  • Dorsal to Grayson’s ligament (“ground”)
approaches
Approaches
  • FCR approach to DRfx
    • Watch for palmar cutaneous nerve 5 cm proximal to wrist crease
    • FCR sheath > FCR subsheath > fat > PQ > radius
surface anatomy
Surface Anatomy

Hyoid: C3

Thyroid: C4-5

Cricoid: C6

Carotid tubercle: C6

Vertebral prominens: C7

Iliac crest: L4-5 interspace

PSIS: S2 body

ligaments
Ligaments
  • Ligamentum flavum
    • Strong, yellow, elastic
    • Runs anterior surface superior to posterior surface inferiorly of the lamina
    • Hypertrophy causes cord/cauda compression
  • Supraspinous
    • Occiput to C7 = ligamentum nuchae
  • Iliolumbar ligament
    • Connects L5 TP to ilium
    • TP fx may imply pelvic injury
cervical spine
Cervical spine
  • Highest neck flexion and extension at C1/occiput (50%)
  • Highest rotation is C1/C2 (50%)
  • Pannus formation at C1/C2 in RA can cause subluxation
  • Dens fuses at 7 years of age
  • Bifid spinous process except for C7
  • Nerve roots leave ABOVE numbered pedicle
  • Normal canal diameter = 17mm
    • Cord compromise < 13mm
ligaments c spine
Ligaments: C-spine
  • Tectorial membrane becomes PLL
  • Transverse ligament
    • Major stabilizer of the median atlantoaxial joint
  • Cruciate ligament
    • made up of longnitudinal apical ligament and transverse ligament
  • Alar ligaments
    • tips of dens, check rein function
stability c spine
Stability: C-spine

Atlantodens interval (ADI) should be <7mm

osteology c spine
Osteology: C-spine
  • Vertebral artery:
    • In foramen C1-C6
    • Medial & anterior to lateral mass
    • Posterior to longus colli muscle
    • Distance from spinous process of C1 laterally to vertebral artery = 2cm (safe zone)
lateral mass screws
Lateral Mass Screws
  • Lateral mass screws directed up and out
  • Starting point just medial to center of box
anterior neck
Anterior neck
  • Carotid sheath
    • Internal carotid artery
    • Common carotid artery
    • Internal jugular vein
    • Vagus nerve
  • Sympathetic chain posterior and medial to carotid sheath, anterior to longus capitus
    • Disruption of inferior ganglia = Horner’s
surgical approaches77
Surgical approaches
  • Anterior approach to C-spine (ACDF)
    • Through platysma
    • Carotid sheath lateral
    • Esophagus/trachea medial
    • Protect recurrent laryngeal nerve
    • Mobilize longus coli over vertebral body
lumbar spine
Lumbar spine
  • Lordosis 55-60 (higher anteriorly than posteriorly)
    • L3 is the apex
    • Majority of lordosis L4-sacrum
  • Pedicles large/Lamina short
  • Nerves exit BELOW corresponding vertebrae
  • Spondylolysis:defect in pars interarticularis
    • Most common cause of back pain in children and adolescents
intervertebral disc
Intervertebral disc
  • Annulus fibrosus
    • Type I collagen
  • Nucleus pulposus
    • Type II collagen
  • 25% of total spinal columnar height
  • Water content 88% - decreases with age
  • Intradiscal pressure lowest when supine
disc herniation
Disc Herniation
  • PLL hourglass shape with poor coverage over lateral aspect of posterior disc (weak area)
  • Typical disc herniation effects TRAVERSING nerve root (hernation at L4-5 gets L5 nerve)
  • Far lateral herniation: gets exiting root (L4-5 herniation gets L4 root)
surgical approaches81
Surgical approaches
  • Anterior approach to L-spine
    • Superior hypogastric plexus of the sympathetic plexus lies over L5 body
      • Sexual dysfunction and retrograde ejaculation
    • Protect genitofemoral nerve lying over psoas
  • Posterior approach to L-spine
    • Lumbar pedicle screw placement:
      • Junction of TP, pars, superior facet
      • Angle 15 degrees medially with slope of vertebra
vascular supply
Vascular supply
  • Artery of Adamkiewicz
    • Left, T8-T12
    • Supplies anterior 2/3 cord
nerve cord injuries
Nerve: Cord Injuries

CENTRAL: upper>lower, most common, recovery 75%

BROWN-SEQUARD: unilateral cord injury, ipsilateral motor loss and contral lateral pain and temp 2 levels below, 90% recovery

ANTERIOR: complete motor loss – poor prognosis

POSTERIOR: loss of deep pressure and pain – poor prognosis

halo traction
Halo traction
  • Pin placement
    • 1cm superior to the orbital rim in the outer 2/3 of the orbit below the equator of the skull
    • Avoids the supraorbital nerve
    • Most commonly injured cranial nerve w/halo abducens (CN VI)
      • Loss of lateral gaze
osteology87
Osteology
  • Acetabulum anteverted 15-20 degrees, abducted 45 degrees
    • condyloid notch inferiorly bordered by transverse acetabular ligament
  • Femoral neck anteverted 14 degrees relative to condyles
  • Femoral neck-shaft angle average 127 degrees
    • Starts at 141 in fetus and decreases with growth
    • SCFE – at epiphysis zone of hypertrophy
slide88

Acetabular lines

Iliopectineal line

Sourcil

Iliosicheal line

Anterior wall

Teardrop

Posterior wall

Obturator ring

Shenton’s line

slide89

Anterior wall

Anterior column

Posterior column

Posterior wall

Judet views

Iliac oblique

Obturator oblique

arthrology90
Arthrology
  • Hip
    • Capsule extends anteriorly over neck to crest
    • Capsule less extensive posteriorly
    • Basicervical region exposed
    • Y-ligament of Bigelow: iliofemoral ligament (strongest ligament of the body)
    • Ligament of teres – apex of condyloid notch, posterior division of obturator
vessels91
Vessels
  • Aorta
    • Common iliacs split at L1
    • Internal and external iliacs split at L4
  • Corona Mortis
    • Anastamosis between External Iliac and Obturator vessels (found in 30% people)
vessels92
Vessels
  • External iliac artery
    • No important branches in pelvis
    • EI art. -> femoral art. -> MFC art.
  • Internal iliac branches
    • Obturator -> branch to ligamentum teres
    • Superior gluteal (posterior ilium retractor or ICBG)
    • Inferior gluteal
    • Pudendal
    • Blood supply to inner table of pelvis
vessels93
Vessels

Femoral Artery Branches:

  • Profunda
    • Gives rise to MFC & LFC
  • Superficial femoral
    • Between adductors and VMO
    • Pierces adductor magnus at hiatus
vessels94
Vessels
  • Medial femoral circumflex
    • Runs medial to IP & lateral to pectineus as it courses from anterior to posterior in thigh
    • Found directly under quadratus m. in posterior approach
  • Lateral femoral circumflex
    • Between sartorius and rectus
    • Main blood supply to greater trochanter
femoral head blood supply
Femoral Head Blood Supply
  • Blood supply to femoral head

Birth to 4yrs – Medial and lateral circumflex (from profunda) + ligamentum teres

4yrs to adult – posteriosuperior and posterioinferior retinactular vessles from MFC

Adult: MFC

nerves96
Nerves
  • Genitofemoral nerve pierces the psoas
  • Femoral nerve runs between iliacus and psoas muscles within the pelvis
  • LFCN exits pelvis at lateral attachment of inguinal ligament
  • Sciatic
    • Peroneal division is more lateral than tibial and more prone to injury during surgery
    • Short head of biceps femoris is only muscle in thigh innervated by peroneal division
nerves97
Nerves
  • NAVL
    • Lateral to medial (spell NAVL towards NAVEL)
    • Nerve / artery / vein / lymph
    • Iliacus hematoma can irritate nerve
  • Obturator n
    • Exits pelvis via obturator canal
    • Anterior branch to OE, pectineus, A-longus, A-brevis and grascilis
    • Posterior branch to OE, A-brevis, ½ A-magnus
    • Retractor under TAL can get obturator nerve/artery
sciatic notch
Sciatic Notch
  • Piriformis = beacon of the hip
  • Only two important structures exit the pelvis superior to the piriformis:
    • Superior gluteal nerve and artery
  • Six important structures exit the pelvis inferior to the piriformis:
    • POPS IQ
    • Pudendal nerve and nerve to IO re-enter the pelvis through lesser sciatic notch
    • Sciatic n. exits pelvis through piriformis 2%
pops iq
POPS IQ
  • P – Pudendal nerve & internal pudendal artery
  • O – Obturator Internus, nerve to-
  • P – Posterior femoral cut. nerve
  • S – Sciatic n.
  • I – Inferior Gluteal artery & nerve
  • Q – Quadratus muscle, nerve to -
acetabular quadrants
Acetabular Quadrants

Posterior superior: SAFE

Posterior inferior: SAFE (sciatic n, inf gluteal)

Anterior superior: E. iliac VEIN + artery

Anterior inferior: Obturator vein, artery, nerve

approaches101
Approaches
  • Posterior (Kocher)
    • G-max splitting (no internerv. plane)
    • Dangers: Sciatic, inferior gluteal artery, MFC
  • Posterior approach to iliac crest
    • Used for ICBG harvest
    • Cut down on PSIS
    • Superior cluneal nerves at risk (posterior and superior to iliac spine)
approaches102
Approaches
  • Anterior (Smith-Peterson)
    • Superficial interval: Sartorius (Fem) / TFL (SG)
    • Deep interval: Rectus (Fem) / Glut Med (SG)
    • Dangers:
      • LFCN
      • Ascending branch of lateral femoral circumflex (runs superficial to rectus)
approaches103
Approaches
  • Anterolateral (Watson-Jones)
    • Interval: TFL & gluteus medius (both sup glut n.)
    • Dangers: femoral nerve by retraction
  • Direct Lateral (Hardinge)
    • Interval: Glut med (SG) and VL (fem)
osteology105
Osteology
  • Femoral Condyles
    • MFC larger and longer
    • LFC smaller and rounder
  • Patella
    • Largest sesmoid in body
    • Bipartate – superior lateral might not fuse
  • Fabella
    • Small sesmoid bone within lateral gastroc
arthrology106
Arthrology

Capsule extendes 1.5 cm distal to surface of tibial plateau

Menisci – peripheral 1/3 are vascular

MM not mobile so tears 3x more often than LM

LM is mobile, associated with discoid meniscus and cysts

ligaments107
Ligaments
  • PCL
    • Between Humphrey (superfical) and Wrisberg (deep) femoral/meniscal ligaments
    • Anterolateral bundle = tight in flexion (PAL)
    • Posteromedial bundle
  • ACL
    • Anteromedial bundle = tight in flexion
    • Posterolateral bundle
ligaments108
Ligaments
  • Posterior Lateral Corner (PLC)
    • Arcuate ligament, popliteus, posterior lateral capsule, LCL and lateral head of gastroc
  • PCL: stability at 90 degrees
  • PLC: stability at 30 degrees
  • Dial test
    • Increasing instability from flexion to extension with isolated PLC injury
vessels109
Vessels
  • Middle geniculate
    • Supplies the ACL/PCL
  • Superior lateral geniculate
    • Injured in lateral release
  • Inferior geniculate
    • Between popliteus and LCL
nerves110
Nerves
  • Tibial
    • Terminates in medial and lateral plantar nerves
  • Superficial Peroneal
    • Supplies dorsal medial sensation of great toe
  • Sural
    • Combination tibial (medial sural cutaneous) and common peroneal (lateral sural cutaneous)
nerves111
Nerves
  • Femoral
    • Largest branch is saphenous
    • Infrapatellar branch of saphenous nerve provides sensation to medial side of knee
compartments
Compartments
  • 4 compartments of leg
    • ANTERIOR
      • Deep peroneal nerve
    • LATERAL
      • Common peroneal nerve
    • DEEP POSTERIOR
      • Tibial nerve
    • SUPERFICIAL POSTERIOR
approaches113
Approaches
  • Medial approach
    • 3 layers: pes tendons (Say Grace before Tea)
    • Superficial and deep MCL
      • Superficial MCL = ligament
      • Deep MCL = capsular
  • Posterior approach
    • Medial head of gastroc and semimembranosus
osteology115
Osteology
  • Talus
    • Wider anteriorly
    • No muscular attachments
    • Primary blood supply from ARTERY OF TARSAL CANAL (branch of posterior tibial artery)
    • Secondary blood supply from artery of tarsal sinus (branch of anterior tibial artery)
  • Calcaneus
    • 3 facets, posterior facet weight bearing
ligaments116
Ligaments
  • Syndesmosis
      • Anterior and posterior inferior tibiofibular ligaments
      • Transverse tibiofibular ligaments
      • Interosseous ligament
  • AITFL
    • Scarring causes impingement in high ankle sprain
    • Avulsion fx of bone in child: Tillaux fx
ligaments117
Ligaments
  • Deltoid ligament
    • Talonavicular and talocalcaneal
    • Causes medial widening when injured
  • Spring ligament
    • Acts as a sling for talar neck
  • ATFL
    • Injured w/ ankle PF/inversion
  • CFL
    • Injured w/ ankle DF/inversion
ligaments118
Ligaments
  • Lis franc ligament
    • Between medial cuneiform and base of 2nd MT
    • Mainly plantar
    • 20% of people w/ both plantar and dorsal
  • Transverse metatarsal ligament
    • Digital nerves course under -> Morton’s neuroma
  • Plantar Plate
    • Main stabilizer of MTP (injured in Turf Toe)
muscles119
Muscles

Tom, Dick and very nervous Harry

(PT, FDL, artery, vein, nerve, FHL)

FDL and FHL cross each other at knot of Henry

Heel spurs originate in the FDB

nerves120
Nerves
  • Tibial nerve
    • Supplies all intrinsic muscles of the foot except EDB (deep peroneal)
    • Splits into medial and lateral plantar
    • 1st branch of lateral plantar nerve – nerve to abductor digiti quinti (Baxter’s nerve), implicated in heel pain
  • Third webspace
    • Medial and lateral plantar nerves meet at site of Morton’s neuroma
nerves121
Nerves
  • Superficial peroneal nerve
    • Exits fascia ~10cm proximal to tip of fibula
  • Dorsal medial cutaneous nerve
    • Branch of superficial peroneal nerve, crosses EHL from lateral to medial
    • Supplies dorsomedial aspect of great toe