anatomy, physiology, kinesiology

ANATOMY, PHYSIOLOGY, KINESIOLOGY

Prepared By: Floriza P. de Leon, PTRP

Manual of Structural Kinesiology

Basic Biomechanical Factors & Concepts

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Biomechanics• Biomechanics - study of body

mechanics, as it relates to the functional and anatomical analysis of biological systems and especially humans

• Necessary to study the body’s mechanical characteristics & principles to understand its movements



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Biomechanics

• Mechanics - study of physical actions of forces

• Mechanics is divided into• Statics • Dynamics



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Biomechanics• Statics - study of systems that are in

a constant state of motion, whether at rest with no motion or moving at a constant velocity without acceleration

• Statics involves all forces acting on the body being in balance resulting in the body being in equilibrium



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Biomechanics• Dynamics - study of systems in

motion with acceleration

• A system in acceleration is unbalanced due to unequal forces acting on the body



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Biomechanics• Kinematics & kinetics

• Kinematics - description of motion and includes consideration of time, displacement, velocity, acceleration, and space factors of a system‘s motion

• Kinetics - study of forces associated with the motion of a body



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Types of machines found

in the body • Musculoskeletal system may be thought of

as a series of simple machines

• Machines - used to increase mechanical advantage

• Consider mechanical aspect of each component in analysis with respect to

components’ machine-like function



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in the body • Machines function in four ways

• balance multiple forces• enhance force in an attempt to reduce

total force needed to overcome a resistance

• enhance range of motion & speed of movement so that resistance may be moved further or faster than applied force

• alter resulting direction of the applied force



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in the body • Musculoskeletel system arrangement

provides for 3 types of machines in producing movement

• Levers (most common)• Wheel-axles• Pulleys



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Levers• Humans move through a system of levers

• lever - a rigid bar that turns about an axis of rotation or a fulcrum

• axis - point of rotation about which lever moves

• Levers cannot be changed, but they can be utilized more efficiently



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Levers• Levers rotate about an axis as a result of

force (effort, E) being applied to cause its movement against a resistance or weight

• In the body• bones represent the bars• joints are the axes• muscles contract to apply force



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Levers• Resistance can vary from maximal to

minimal• May be only the bones or weight of

body segment

• All lever systems have each of these three components in one of three possible arrangements



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Levers• Three points determine type of lever & for

which kind of motion it is best suited• Axis (A)- fulcrum - the point of rotation • Point (F) of force application (usually

muscle insertion)• Point (R) of resistance application

(center of gravity of lever) or (location of an external resistance)



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Levers

• 1st class lever – axis (A) between force (F) & resistance (R)

• 2nd class lever – resistance (R) between axis (A) & force (F)

• 3rd class lever – force (F) between axis (A) & resistance (R)



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• AFR3rd

| Resistance Arm |

• ARF2nd

| Force Arm |

Levers

• FAR1st

A

F R

| Force Arm || Resistance Arm |

A

R

| Resistance Arm |

F

A

R

| Force Arm |

F



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First-Class Levers

• Produce balanced movements when axis is midway between force & resistance (e.g., seesaw – postural mm, atlanto-occipital jt.)

• Produce speed & range of motion when axis is close to force, (triceps in elbow extension)

• Produce force motion when axis is close to resistance (crowbar)



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First-Class Levers

• Head balanced on neck in flexing/extending

• Agonist & antagonist muscle groups are contracting simultaneously on either side of a joint axis• agonist produces force while antagonist

supplies resistance



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First-Class Levers

• Elbow extension in triceps applying force to olecranon (F) in extending the non-supported forearm (R) at the elbow (A)



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First-Class Levers

• Force is applied where muscle inserts in bone, not in belly of muscle• Ex. in elbow extension with shoulder

fully flexed & arm beside the ear, the triceps applies force to the olecranon of ulna behind the axis of elbow joint

• As the applied force exceeds the amount of forearm resistance, the elbow extends



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Second-Class Levers

• Produces force movements, since a large resistance can be moved by a relatively small force• Wheelbarrow• Nutcracker• Loosening a lug nut• Raising the body up on the toes



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Second-Class Levers

• Plantar flexion of foot to raise the body up on the toes where ball (A) of the foot serves as the axis as ankle plantar flexors apply force to the calcaneus (F) to lift the resistance of the body at the tibial articulation (R) with the foot

• Relatively few 2nd class levers in body



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Third-Class Levers

• Produce speed & range-of-motion movements

• Most common in human body• Requires a great deal of force to move

even a small resistance• Paddling a boat• Shoveling - application of lifting force to a

shovel handle with lower hand while upper hand on shovel handle serves as axis of rotation



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Third-Class Levers

• Biceps brachii in elbow flexion

Using the elbow joint (A) as the axis, the biceps brachii applies force at its insertion on radial tuberosity (F) to rotate forearm up, with its center of gravity (R) serving as the point of resistance application



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Third-Class Levers

• Brachialis - true 3rd class leverage• pulls on ulna just below elbow• pull is direct & true since ulna cannot rotate

• Biceps brachii supinates forearm as it flexes so its 3rd class leverage applies to flexion only

• Other examples• hamstrings contracting to flex leg at knee while in a

standing position• using iliopsoas to flex thigh at hip



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Factors in use of anatomical levers

• Anatomical leverage system can be used to gain a mechanical advantage

• Improve simple or complex physical movements

• Some habitually use human levers properly

• Some develop habits of improperly use human levers



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Torque and length of lever arms

A, If the force arm and resistance arm are equal in length, a force equal to the resistance is required to balance it, B, As the force arm becomes longer, a decreasing amount of force is required to move a relatively larger resistance,C, As the force arm becomes shorter an increasing amount of force is required to more a relatively smaller resistance



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• Human leverage system is built for speed & range of movement at expense of force

• Short force arms & long resistance arms require great muscular strength to produce movement

• Ex. biceps & triceps attachments• biceps force arm is 1 to 2 inches • triceps force arm less than 1 inch



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• Human leverage for sport skills requires several levers• throwing a ball involves levers at

shoulder, elbow, & wrist joints

• The longer the lever, the more effective it is in imparting velocity• A tennis player can hit a tennis ball

harder with a straight-arm drive than with a bent elbow because the lever (including the racket) is longer & moves at a faster speed



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Torque and length of lever arms• Long levers produce more linear force and thus

better performance in some sports such as baseball, hockey, golf, field hockey, etc.



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Torque and length of lever arms• For quickness, it is desirable to have a short lever

arm

• baseball catcher brings his hand back to his ear to secure a quick throw

• sprinter shortens his knee lever through flexion that he almost catches his spikes in his gluteal muscles

Studying Kinesiology (Cont.)

• The forces affecting motion (gravity, muscle tension, external resistance, and friction) are never seen and seldom felt.

• Kinematics is the science of the motion of bodies in space.

• Osteokinematics is concerned with movements of bones

• Arthrokinematics addresses the movements occurring between joint surfaces.

• Describe the anatomical position?

• Identify the cardinal planes and axis.

Planar classification of position and motion (osteokinematics)

Figure 1-2

• Identify the position of the hip.

• Frontal plane abduction and adduction• Sagittal plane flexion and extension• Horizontal plane internal/external rotation pronation/supination • Special cases radial/ulnar deviation dorsi-/plantar flexion.• Goniometry (Gr. gonia, angle, and metron, measure)

Planar classification of position and motion (osteokinematics)

• Differentiate arthrokinematics and osteokinematics

Application of Goniometer

Summary Range of Joint Motion (Cont.)

Normal End-Feel

When a normal joint is moved passively to the end of its range of motion, resistance to further motion is felt by the examiner

The resistance is also called physiological end-feel

• What are the types of end feel?

Rotary and Translatory Motion

Movements are described as occurring around an axis or a pivot point, identified by mechanical terms as rotary motion, angular motion, or rotation

Translatory motion is used to describe movement of a body in which all of its parts move in the same direction with equal velocity

Degrees of freedom

Joints that move in one plane possess one axis and have one degree of freedom

If a joint has two axes, the segments can move in two planes, and the joint is said to possess two degrees of freedom motion

Ball-and-socket joint such as the hip joints, which permit flexion-extension, abduction-adduction, and transverse rotation, are said to possess three degrees of freedom

• Identify the degrees of freedom of the following• Elbow• Knee• Ankle• MCP• PIP

Kinematic chain

A combination of several joints uniting successive segments constitutes a kinematic chain

Distal segments can have higher degrees of freedom than do proximal ones

Open and closed kinematic chains

In an open kinematic chain, the distal segment of the chain moves in space whereas in a closed kinematic chain, the distal segment is fixed, and proximal parts move (Steindler,1995)

In the upper extremity, open-chain motion occurs when reaching or bringing the hand to the mouth, and closed-chain motion occurs when performing a chin-up

• Explain how does a chin-up became a closed kinematic chain

Arthrokinematics

Arthrokinematics is concerned with the movement of the articular surfaces in relation to the direction of movement of the distal extremity of the bone (osteokinematics)

Ovoid joint surfaces

The ovoid articular surfaces of two bones from a convex-concave paired relationship

Sellar joint surfaces

Joints have both convex and concave surface on each articulating bone

Movement of joint surfaces

Rolling or rocking Sliding or gliding Spinning

Convex-Concave Relationships

Convex-concave principles. Convex joint surfaces move in the opposite

direction to the bone segment Concave articular surfaces moves in the same

direction as the bone segment

Close-packed Position

The ovoid surfaces of joint pairs match each other perfectly in only one position of the joint.

This point congruency is called the close-packed position

In this position, (1) the maximum area of surface contact occurs, (2) the attachments of the ligaments are farthest apart and under tension, (3) capsular structures are taut, (4) the joint is mechanically compressed and difficult to distract

In all other position, the ovoid joint surfaces do not fit perfectly but are incongruent and called open-packed, or loose-packed

Open-packed Position

The close-packed position usually occurs at one extreme in the range of motion. This is in full extension at the elbow, wrist, hip, and knee; dorsiflexion at the ankle; and flexion at the metacarpophalangeal joints

Close-packed Position

In addition to angular motions such as flexion or abduction, joint surfaces can be moved passively a few millimeters in translatory motion.

These small motions called accessory movements or joint play

Accessory Motions

Joint mobilization techniques Normally, ligament and capsular structures limit

passive accessory motions in open-packed positions.

Has been severed or stretched out, the accessory motion that the ligament controls will be excessive or hypermobile.

Clinical Applications

Classification of joints

1. Immovable

2. Slightly movable

3. Movable

IMMOVABLE JOINT

SLIGHTLY MOVABLE JOINT

HIP BONE

MOVABLE JOINTI. Gliding Joint

II. Ball and socket Joint

III. Hinge Joint

IV. Pivot Joint

I. GLIDING JOINT• The first kind of joint is called

a gliding joint. Gliding joints are found in our wrists, ankles, and backbone.

• Gliding joints do what they say: they glide past one another, and help us move those body parts.

Carpals

II. BALL AND SOCKET

Hip joint, Arm joint

III. HINGE JOINT• These joints move up

and down in one direction, like a door opening and closing. This type of joint can be found in our fingers, elbows, and knees. Move these joints in your body.

A hinge joint allows extension and retraction of an appendage

IV. PIVOT JOINT

Move your neck from side to side.

Can you feel how a pivot joint moves?

Joint between 1st and 2nd neck vertebrae.

This type of joint lets bones roll over each other, like in our forearms and neck.

Hyoid bone – the only jointless bone

The hyoid is (uniquely in the vertebrate skeleton) not joined to any other bone but is suspended by the stylohyoid ligaments from the styloid process of each temporal bone at the base of the skull. It is formed from three separate parts – the body, and the left and right greater and lesser cornu (horns) – which fuse in early adulthood. The function of the hyoid is to provide an anchor point for the muscles of the tongue and for those in the upper part of the front of the neck.

A small, U-shaped bone situated centrally in the upper part of the neck, beneath the mandible but above the larynx near the level of the third cervical vertebra.

The hyoid bone can be felt by pressing one's finger into the crease where the chin becomes the neck.

Introduction• Muscular system consists of three muscle types:

cardiac, smooth, and skeletal

• Skeletal muscle most abundant tissue in the human body (40-45% of total body weight)

• Human body has more than 430 pairs of skeletal muscle; most vigorous movement produced by 80 pairs

Muscle Structure

• Structural unit of skeletal muscle is the multinucleated muscle cell or fiber (thickness: 10-100 m, length: 1-30 cm

• Muscle fibers consist of myofibrils (sarcomeres in series: basic contractile unit of muscle)

• Myofibrils consist of myofilaments (actin and myosin)

Microscopic-Macroscopic Structure of Skeletal Muscle

Muscle Structure (continued)• Composition of sarcomere

• Z line to Z line ( 1.27-3.6 m in length)• Thin filaments (actin: 5 nm in diameter)• Thick filaments (myosin: 15 nm in diameter)• Myofilaments in parallel with sarcomere• Sarcomeres in series within myofibrils

Muscle Structure (continued)• Motor unit

• Functional unit of muscle contraction• Composed of motor neuron and all muscle cells

(fibers) innervated by motor neuron• Follows “all-or-none” principle – impulse from

motor neuron will cause contraction in all muscle fibers it innervates or none

Size Principle• Smallest motor units recruited first• Smallest motor units recruited with lower stimulation

frequencies• Smallest motor units with relatively low levels of

tension provide for finer control of movement• Larger motor units recruited later with increased

frequency of stimulation and increased need for greater tension

Size Principle

• Tension is reduced by the reverse process• Successive reduction of firing rates• Dropping out of larger units first

Muscle Structure (continued)

• Motor unit• Vary in ratio of muscle fibers/motor neuron

• Fine control – few fibers (e.g., muscles of eye and fingers, as few as 3-6/motor neuron), tetanize at higher frequencies

• Gross control – many fibers (e.g., gastrocnemius, 2000/motor neuron), tetanize at lower frequencies

• Fibers of motor unit dispersed throughout muscle

• Motor Unit• Tonic units – smaller,

slow twitch, rich in mitochondria, highly capillarized, high aerobic metabolism, low peak tension, long time to peak (60-120ms)

• Phasic units – larger, fast twitch, poorly capillarized, rely on anaerobic metabolism, high peak tension, short time to peak (10-50ms)

Muscle Structure (continued)

• Motor unit (continued)• Weakest voluntary contraction is a twitch (single

contraction of a motor unit)• Twitch times for tension to reach maximum varies

by muscle and person• Twitch times for maximum tension are shorter in

the upper extremity muscles (≈40-50ms) than in the lower extremity muscles (≈70-80ms)

Shape of Graded Contraction• Shape and time period of voluntary tension

curve in building up maximum tension• Due to delay between each MU action potential

and maximum twitch tension• Related to the size principle of recruitment of

motor units• Turn-on times ≈ 200ms

• Shape and time period of voluntary relaxation curve in reducing tension• Related to shape of individual muscle twitches• Related to the size principle in reverse• Due to stored elastic energy of muscle• Turn-off times ≈ 300ms

Force Production – Length-Tension Relationship

• Force of contraction in a single fiber determined by overlap of actin and myosin (i.e., structural alterations in sarcomere) (see figure)

• Force of contraction for whole muscle must account for active (contractile) and passive (series and parallel elastic elements) components

Types of Muscle ContractionType of Contraction Definition Work

Concentric Force of muscle contraction resistance

Positive work; muscle moment and angular velocity of joint in same direction

Eccentric Force of muscle contraction resistance

Negative work; muscle moment and angular velocity of joint in opposite direction

Isokinetic Force of muscle contraction = resistance; constant angular velocity; special case is isometric contraction

Positive work; muscle moment and angular velocity of joint in same direction

Isometric Force of muscle contraction resistance; series elastic component stretch = shortening of contractile element (few to 7% of resting length of muscle)

No mechanical work; physiological work

Effect of Muscle Architecture on Contraction

• Fusiform muscle• Fibers parallel to long axis of muscle• Many sarcomeres make up long myofibrils• Advantage for length of contraction• Example: sartorius muscle• Force of contraction along long axis of muscle

of force of contraction of all muscle fibers• Tends to have smaller physiological cross

sectional area(see figure)

Fusiform Fiber Arrangement

Fa

Fa = force of contraction of muscle fiber parallel to longitudinal axis of muscle

Fa = sum of all muscle fiber contractions parallel to long axis of muscle

Effect of Muscle Architecture on Contraction (continued)

• Pennate muscle• Fibers arranged obliquely to long axis

of muscle (pennation angle)• Uni-, bi-, and multi-pennate• Advantage for force of contraction• Example: rectus femoris (bi-pennate)• Tends to have larger physiological

cross sectional area

Pennate Fiber Arrangement

FmFa

Fa = force of contraction of muscle fiber parallel to longitudinal axis of muscle

Fm = force of contraction of muscle fiber

= pennation angle

Fa = (cos )(Fm)

Fa = sum of all muscle fiber contractions parallel to long axis of muscle

Effect of Muscle Architecture on Contraction (continued)

• Force of muscle contraction proportional to physiological cross sectional area (PCSA); sum of the cross sectional area of myofibrils

• Velocity and excursion (working range or amplitude) of muscle is proportional to length of myofiblril

Muscle Fiber TypesType I

Slow-Twitch Oxidative (SO)

Type IIAFast-Twitch Oxidative-

Glycolytic (FOG)

Type IIBFast-Twitch

Glycolytic (FG)

Speed of contraction

Slow Fast Fast

Primary source of ATP production

Oxidative phosphorylation

Oxidative phosphorylation

Anaerobic glycolysis

Glycolytic enzyme activity

Low Intermediate High

Capillaries Many Many Few

Myoglobin content High High Low

Glycogen content Low Intermediate High

Fiber diameter Small Intermediate Large

Rate of fatigue Slow Intermediate Fast

Muscle Fiber Types (continued)• Smaller slow twitch motor units are

characterized as tonic units, red in appearance, smaller muscle fibers, fibers rich in mitochondria, highly capillarized, high capacity for aerobic metabolism, and produce low peak tension in a long time to peak (60-120ms).

• Larger fast twitch motor units are characterized as phasic units, white in appearance, larger muscle fibers, less mitochondria, poorly capillarized, rely on anaerobic metabolism, and produce large peak tensions in shorter periods of time (10-50ms).

Muscle Fiber Types (continued)• Nerve innervating muscle fiber determines its type;

possible to change fiber type by changing innervations of fiber

• All fibers of motor unit are of same type• Fiber type distribution in muscle genetically

determined• Average population distribution:

• 50-55% type I• 30-35% type IIA• 15% type IIB

Muscle Fiber Types (continued)

• Fiber composition of muscle relates to function (e.g., soleus – posture muscle, high percentage type I)

• Muscles mixed in fiber type composition• Natural selection of athletes at top levels of

competition

Electrical Signals of Muscle Fibers• At rest, action potential of muscle fiber -90

mV;caused by concentrations of ions outside and inside fiber (resting state)

• With sufficient stimulation, potential inside cell raised to 30-40 mV (depolarization); associated with transverse tubular system and sarcoplasmic reticulum; causes contraction of fiber

• Return to resting state (repolarization)• Electrical signals from the motor units (motor unit

action potential, muap) can be recorded (EMG) via electrodes

Summary of Function of Cranial Nerves

Figure 13.5b

Cranial Nerve I: Olfactory

• Arises from the olfactory epithelium• Passes through the cribriform plate of the

ethmoid bone• Fibers run through the olfactory bulb and

terminate in the primary olfactory cortex• Functions solely by carrying afferent

impulses for the sense of smell

Cranial Nerve I: Olfactory

Figure I from Table 13.2

Cranial Nerve II: Optic

• Arises from the retina of the eye• Optic nerves pass through the optic

canals and converge at the optic chiasm

• They continue to the thalamus where they synapse

• From there, the optic radiation fibers run to the visual cortex

• Functions solely by carrying afferent impulses for vision

Cranial Nerve II: Optic

Figure II Table 13.2

Cranial Nerve III: Oculomotor

• Fibers extend from the ventral midbrain, pass through the superior orbital fissure, and go to the extrinsic eye muscles

• Functions in raising the eyelid, directing the eyeball, constricting the iris, and controlling lens shape

• The latter 2 functions are parasympathetically controlled

• Parasympathetic cell bodies are in the ciliary ganglia

Cranial Nerve III: Oculomotor

Figure III from Table 13.2

Cranial Nerve IV: Trochlear

• Fibers emerge from the dorsal midbrain and enter the orbits via the superior orbital fissures; innervate the superior oblique muscle

• Primarily a motor nerve that directs the eyeball

Cranial Nerve IV: Trochlear

Figure IV from Table 13.2

Cranial Nerve V: Trigeminal

• Composed of three divisions• Ophthalmic (V1)

• Maxillary (V2)

• Mandibular (V3)

• Fibers run from the face to the pons via the superior orbital fissure (V1), the foramen rotundum (V2), and the foramen ovale (V3)

• Conveys sensory impulses from various areas of the face (V1) and (V2), and supplies motor fibers (V3) for mastication

• Tic douloureux or trigeminal neuralgia - Most excruciating pain known (?) - Caused by inflammation of nerve - In severe cases, nerve is cut; relieves agony but results in loss

of sensation on that side of the face

Cranial Nerve V: Trigeminal

Cranial Nerve VI: Abducens• Fibers leave the inferior pons and enter the orbit via the

superior orbital fissure• Primarily a motor nerve innervating the lateral rectus

muscle (abducts the eye; thus the name abducens)

Cranial Nerve VII: Facial

• Fibers leave the pons, travel through the internal acoustic meatus, and emerge through the stylomastoid foramen to the lateral aspect of the face

• Motor functions include;• Facial expression• Transmittal of parasympathetic impulses to lacrimal

and salivary glands (submandibular and sublingual glands)

• Sensory function is taste from taste buds of anterior two-thirds of the tongue

Cranial Nerve VII: Facial

Figure VII from Table 13.2

Facial Nerve (CN VII)• Bell’s palsy: paralysis of facial muscles on affected side and loss of taste sensation• Caused by herpes simplex I virus• Lower eyelid droops• Corner of mouth sags• Tears drip continuously and eye cannot be completely closed (dry eye may occur)• Condition my disappear spontaneously without treatment

Cranial Nerve VIII: Vestibulocochlear

• Fibers arise from the hearing and equilibrium apparatus of the inner ear, pass through the internal acoustic meatus, and enter the brainstem at the pons-medulla border

• Two divisions – cochlear (hearing) and vestibular (balance)

• Functions are solely sensory – equilibrium and hearing

Cranial Nerve VIII: Vestibulocochlear

Figure VIII from Table 13.2

Cranial Nerve IX: Glossopharyngeal

• Fibers emerge from the medulla, leave the skull via the jugular foramen, and run to the throat

• Nerve IX is a mixed nerve with motor and sensory functions

• Motor – innervates part of the tongue and pharynx, and provides motor fibers to the parotid salivary gland

• Sensory – fibers conduct taste and general sensory impulses from the tongue and pharynx

Cranial Nerve IX: Glossopharyngeal

Figure IX from Table 13.2

Cranial Nerve X: Vagus

• The only cranial nerve that extends beyond the head and neck

• Fibers emerge from the medulla via the jugular foramen

• The vagus is a mixed nerve• Most motor fibers are parasympathetic fibers to

the heart, lungs, and visceral organs• Its sensory function is in taste• Paralysis leads to hoarseness• Total destruction incompatible with life

Cranial Nerve X: Vagus

Cranial Nerve XI: Accessory

• Formed from a cranial root emerging from the medulla and a spinal root arising from the superior region of the spinal cord

• The spinal root passes upward into the cranium via the foramen magnum

• The accessory nerve leaves the cranium via the jugular foramen

• Primarily a motor nerve • Supplies fibers to the larynx, pharynx, and soft

palate• Innervates the trapezius and sternocleidomastoid,

which move the head and neck

Cranial Nerve XI: Accessory

Figure XI from Table 13.2

Cranial Nerve XII: Hypoglossal

• Fibers arise from the medulla and exit the skull via the hypoglossal canal

• Innervates both extrinsic and intrinsic muscles of the tongue, which contribute to swallowing and speech

• If damaged, difficulties in speech and swallowing; inability to protrude tongue

Cranial Nerve XII: Hypoglossal

Figure XII from Table 13.2

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Surface Anatomy

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Surface Anatomy of Head

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Surface Anatomy of the Neck• Thyroid Cartilage• Hyoid Bone• Cricoid Cartilage• Thyroid Gland• Sternocleidomastoid Muscle• Arteries• Veins• Trapezius Muscle• Vertebral Spines• Anterior Triangle• Posterior Triangle

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Surface Anatomy of the Trunk• Scapulae• Latissimus dorsi muscle• erector spinae muscle• infraspinatus muscle• trapezius muscle• teres major muscle• posterior axillary fold• triangle of auscutation

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Surface Features of the Chest

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Surface Features of the Abdomen

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Surface features of Pelvis

• Iliac Crest• Anterior Superior Iliac Crest• Posterior Superior Spine• Pubic Tubercle• Pubic Symphysis• Mons Pubis• Sacrum• Coccyx• Perineum

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Surface Anatomy of the Upper Limb• Surface features of the Shoulder

• Acromioclavicular Joint• Acromiun• Humerus

• Greater Tubercle• Deltoid Muscle

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Surface Anatomy of the Upper Limb

• Surface Features of the Armpit• apex• base

• axillary lymph nodes• anterior wall• posterior wall• medial wall• lateral wall

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• Surface Features of the Arm & Elbow• Humerus• Biceps brachii muscle• Triceps brachii muscle• Medial epicondyle• Lateral epicondyle• Olecron• Ulnar nerve• Cubital fossa• Median cubital vein• Brachial Artery• Bicipital aponeurosis

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• Surface Features of the Forearm & Wrist• Ulna• Radius• Muscles• Radial Artery• Pisiform Bone• “Anatomical

Snuffbox”• Wrist Creases

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Surface Anatomy of the Lower Limb• Gluteus maximus muscle• Gluteus medius muscle• Gluteal cleft• Gluteal fold• Ischeal tuberosity• Greater trochanter

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Surface Anatomy of the Lower Limb

• Surface features of the Thigh• Sartorius muscle• Quadriceps femoris muscle• Adductor longus muscle• Hamstring muscles• Femoral triange

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• Surface Anatomy of the Knee• Patella• Patellar ligament• Medial condyle of femur• Medial condyle of thigh• Lateral condyle of femur• Lateral condyle of thigh• Popliteal fossa

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• Surface features of the Leg, Ankle & Foot• Tibial tuberosity• Tibialis anterior muscle• Tibia• Peroneus longus muscle• Gastrocnemius muscle• soleus muscle

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Surface Features of the Leg, Ankle & Foot

• Achilles (Calcaneal) tendon• Lateral malleolus of fibula• Medial malleolus of tibia• Dorsal venous arch• Tendons of extensor digitorum

longus muscle

SHOULDER ANATOMY

Shoulder Complex Bone Anatomy• Clavicle

• Sternal end• Acromion end

• Scapula• Surfaces

• Costal • Dorsal

• Borders• Angles

Acromion end Sternal

end

Shoulder Complex Bone Anatomy

• Scapula1. spine 2. acromion 3. superior border 4. supraspinous fossa 5. infraspinous fossa 6. medial (vertebral) border 7. lateral (axillary) border 8. inferior angle 9. superior angle 10. glenoid fossa (lateral angle) 11. coracoid process 12. superior scapular notch 13 subscapular fossa 14. supraglenoid tubercle 15. infraglenoid tubercle

Shoulder Complex Bone Anatomy• Humerous

• head • anatomical neck • greater tubercle • lesser tubercle • greater tubercle • lesser tubercle • intertubercular sulcus

(AKA bicipital groove) • deltoid tuberosity

Shoulder Complex Bone Anatomy• Humerous

• Surgical Neck• Angle of Inclination

• 130-150 degrees

• Angle of Torsion• 30 degrees posteriorly

Shoulder Complex Articulations

• Sternoclavicular Joint• Sternal end of clavicle

with manubrium/ 1st costal cartilage

• 3 degree of freedom• Articular Disk• Ligaments

• Capsule• Anterior/Posterior

Sternoclavicular Ligament

• Interclavicular Ligament• Costoclavicular

Ligament


• Acromioclavicular Joint• 3 degrees of freedom• Articular Disk• Ligaments

• Superior/Inferior Acromioclavicular Ligaments

• Coracoclavicular • Trapezoid• Conoid


• Glenohumeral Joint• Configuration• 3 degrees of freedom• Labrum• Ligaments

• Capsule• Coracohumeral Ligament• Glenohumeral Ligaments

• Superior• Middle• Inferior of Weitbrecht• Foramen of

• Posterior Capsule


• Scapulothoracic• Not a joint• Movements here very

important

Other Shoulder Complex Structures• Axilla

• Anterior Border• Posterior Border• Medial Border• Lateral Border

• What structure comprises the 4 borders of the axilla?

Shoulder Complex Muscles

Scapular Muscles

Levator Scapulae

• O – Transverse processes of C1-C4

• I – Medial border of scapula between superior angle and root of spine of scapula

• N – Nerve root C3-5• F

• scapular elevation• retraction

Rhomboid Major

• O –• Major – T2-T5 spinous

processes• Minor – Ligamentum

nuchae, C7-T1 spinour processes

• I – • Major – Medial borde of

scapula between spine and inferior angle

• Minor – medial border at root of spine of scapula

• N – Dorsal Scapular

Upper Trapezius• O –

• Occiptal protuberance• Medial 1/3 of nuchal line• Upper part of ligamentum

nuchae• C7 spinous process

• I –• Posterior border of lateral 1/3

of clavicle• Acromion process

• N – spinal accessory• F –

• Scapular elevation, retraction• Rotation of head to opp. Side• Lateral flexion of head to opp.

side

Middle Trapezius

• O – • Inferior part of ligamentum

nuchea• T1-T5 spinous processes

• I –• Medial margin of acromion

process• Superior lip of spine of

scapula• N – Spinal accessory• F –

• Scapular retraction

Lower Trapezius

• O –• T6-T12 spinous

processes• I –

• Tubercle at apex of root of spine of scapula

• N – spinal accessory• F –

• Scapular depression, retraction and upward rotation

Serratus Anterior• O –

• Outer surfaces and superior border of ribs 1-8

• I –• Ventral scapular surface on

medial border from superior angle to inferior angle

• N –• Long Thoracic

• F –• Scapular protraction,

upward rotation• Scapular depression (lower

fibers)• Scapular elevation (upper

fibers

Pectoralis Minor• O –

• Superior margins and outer surface ribs 3-5 near cartilages

• Fascia overlying corresponding intercostal muscles

• I –• Medial border, superior

surface of coracoid process

• N –• Medial Pectoral

• F –• Scapular depression,

downward rotation, protraction

Glenohumeral Muscles

Biceps Brachii• O

• Short head – coracoid process

• Long head – supraglenoid tubercle of scapula

• I –• Radial tuberosity• Biceps brachii aponeurosis

• N – Musculocutaneous• F –

• Shoulder – flexion• Elbow – flexion, forearm

supination

Coracobrachialis

• O – • Coracoid process

• I –• Medial surface of mid-

humerus, opposite to deltoid tuberosity

• N –Musculocutaneous• F –

• GH flexion, adduction, Hor. Adduction

Pectoralis Major• O –

• Sternal – anterior surface of sternum, cartilages of ribs 1-6 or7

• Clavicular – anterior surface of sternal ½ clavicle

• I –• crest of humerus’s greater

tuberosity• N –

• Sternal – medial pectoral• Clavicular – lateral pectora

• F –• GH ADD, H. ADD and IR

Fibers twist in themselves

Anterior Deltoid

• O –• Anterior border,

superior surface of lateral third of clavicle

• I –• Deltoid tuberosity

• N – Axillary• F –

• GH H. ADD, flexion• IR when in supine

position

Middle Deltoid

• O –• Lateral margin and

superior surface of acromion

• I –• Deltoid Tuberosity

• N –• Axillary

• F –• GH ABD

Posterior Deltoid

• O –• Inferior lip of posterior

border of spine of scapula

• I –• Deltoid tuberosity

• N – Axillary• F –

• GH extension, H. ABD, • ER when in prone

position

Triceps Brachii• O –

• Long Head – infraglenoid tubercle• Lateral Head – lateral and

posterior surface of proximal ½ of body of humerus

• Medial Head – distal 2/3 of medial and posterior surfaces of humerus below radial groove

• I –• Posterior surface of olecranon

proess• N – Radial• F –

• Shoulder – long head – Ext and ADD

• Elbow -- extension

Latissimus Dorsi

• O –• Posterior layer of lumbodorsal

fascia, then attaching to the T6-T12, lumbar and sacral vertabrae

• External lip of iliace creast lateral to erector spinae

• Ribs 9-12• Slip from inferior angle of

scapula• I –

• Intertubercular groove (distal aspect)

• N – Thoracodorsal• F –

• GH IR, ADD, Ext,

Teres Major (Lat’s Little Helper)

• O –• Dorsal surface of inferior

angle• Lower 1/3 of scapula

lateral border• I –

• Crest of lesser tuberosity• N – Lower Subscapular• F –

• GH IR, ADD, Ext

Rotator Cuff

Suprspinatus

• O –• Medial 2/3 supraspinatus

fossa• I –

• Superior portion of greater tuberosity

• N – Suprascapular• F –

• Intiates shoulder ABD• Humeral head

stabilization

Infraspinatus

• O –• Medial 2/3 infraspinatus

fossa• I –

• Middle portion of greater tuberosity

• N – Suprascapular• F –

• GH ER• Humeral head

stabilization

Teres Minor

• O –• Upper 2/3 dorsal surface of

lateral border of scapula

• I --• Lowest portion of greater

tuberosity

• N – • Axillary

• F –• GH ER• Humeral head stabilization

Subscapularis

• O –• Subscapular Fossa

• I –• Lesser tuberosity • Anterior capsule of GH joint

• N –• Upper and lower

subscapular

• F –• GH IR• Humeral head stabilization

Basic Shoulder Complex Mechanics

Performing Abduction

• Initiation• Scapulohumeral

Ryhthm• First 30 degrees• > 30 degrees

• Clavicle

Brachial Plexus

Mechanism of Injury (Erb’s Palsy)

Erb’s Palsy

Deltopectoral Groove

Scapula

Winging of the Scapula

What is the muscle paralyzed which will cause the lateral winging of the scapula?

• What do you call a congenital undescended scapula?

Sprengel’s Deformity

SITS Muscles

• What is the primary function of the SITS muscles?

• What is the innervation of the SITS muscles?

Elbow Anatomy

Bone Anatomy

• Radius• Proximal

• Radial Head• Radial Tuberosity• Radial Neck

• Distal• Ulnar Notch• Radial styloid process

Bone Anatomy

• Ulna• Proximal

• Olecranon• Olecranon Process• Coronoid Process• Trochlear notch• Radial notch• Ulnar tuberosity

• Distal• Ulnar Styloid Process

Elbow Articulations

• Humeroulnar Joint• Humeroradial Joint• Proximal Radioulnar

Joint• Distal Radioulnar Joint

Ligamentous Support

• Capsule

anterior posterior

Ligamentous Support

• Medial (Ulnar) Collateral Ligament• Anterior• Posterior• Oblique

Ligamentous Support

• Lateral (Radial) Collateral Ligament

Ligamentous Support

• Annular Ligament

Ligamentous Support

• Quadrate Ligament

Ligamentous Support

• Dorsal and Plamar Radioulnar Ligaments

Ligamentous Support

• Interosseous Membrane

Muscles

Biceps Brachii

• O• Short head – coracoid process• Long head – supraglenoid

tubercle of scapula• I –

• Radial tuberosity• Biceps brachii aponeurosis

• N – Musculocutaneous• F –

• Shoulder – flexion• Elbow – flexion, forearm

supination

Brachialis

• O • Distal 2/3 anterior

humerus

• I• Ulna tuberosity• Coronoid process

• N• Musculocutaneous

• F• Elbow flexion

Triceps Brachii • O –• Long Head – infraglenoid tubercle• Lateral Head – lateral and

posterior surface of proximal ½ of body of humerus

• Medial Head – distal 2/3 of medial and posterior surfaces of humerus below radial groove

• I –• Posterior surface of olecranon

proess• N – Radial• F –

• Shoulder – long head – Ext and ADD

• Elbow -- extension

Anconeus• O –

• Posterior lateral humeral epicondyle

• I –• Lateral side of olecranon

process• Upper ¼ posterior ulnar

body• N –

• Radial• F –

• Assist with elbow extension

Brachioradialis

• O –• Upper 2/3 of lateral humeral

supracondylar ridge• I –

• Lateral radius just proximal to base of styloid process

• N –• Radial

• F –• Elbow flexion• Supination to midposition• Pronation to midposition

Supinator• O –

• Lateral humeral epicondyle• LCL• Annular ligament

• I –• Lateral upper 2/3 of radius

• N –• Radial

• F –• Forearm supination

Extensor Carpi Radialis Longus• O –

• Lower 1/3 of lateral supraconsylar ridge

• I –• Dorsal surface of base of

2nd metacarpal• N –

• Radial• F –

• Wrist extension• Wrist radial deviation• Elbow flexion

Extensor Carpi Radialis Brevis• O –

• Lateral epicondyle of humerus

• I –• Dorsal surface of base of

3rd metacarpal• N –

• Radial• F –

• Wrist extension• Wrist radial deviation• Elbow flexion

Extensor Digitorum Communis• O –

• Lateral humeral epicondyle• I –

• Extensor expansions of digits 2-5

• N –• Posterior interosseus nerve

(continuation of radial)• F –

• 2-5 MCP extension• 2-5 IP extension

Extensor Carpi Ulnaris

• O –• Lateral humeral condyle

• I –• Posterior base of 5th

metacarpal• N –

• Posterior interosseus• F –

• Wrist extension• Wrist ulnar deviation

Pronator Teres• O –

• Medial humeral epicondyle• Coronoid process

• I –• Lateral radius near its

center• N –

• Median• F –

• Forearm pronation• Elbow flexion

Flexor Carpi Radialis • O –

• Medial humeral epicondyle• I –

• Palmar surface at base of 2nd metacarpal

• Slip to base of 3rd metacarpal• N –

• Median• F –

• Wrist flexion• Wrist radial deviation• Elbow flexion

Palmaris Longus• O –

• Medial humeral epicondyle• I –

• Palmar aponeurosis• Wrist flexor retinaculum

• N –• Median

• F –• Wrist flexion• Elbow flexion

Flexor Carpi Ulnaris• O –

• medial epicondyle of humerus• olecranon and posterior border of

ulna • I –

• Pisiform bone, hook of hamate bone, and 5th metacarpal bone

• N –• Ulnar

• F –• Wrist flexion• Ulnar deviation• Elbow flexion

Pronator Quadratus

• O –• Distal ¼ anterior ulna

• I –• Distal ¼ anterior radius

• N –• Anterior interosseus

(median)• F –

• Forearm pronation

Cubitus Valgus/Varus

Olecranon Bursitis

Elbow Joint

Cubital Fossa

Radia Head Fracture

Distal Radioulnar Joint

• Uniaxial pivot joint that has one degree of freedom

• Resting position: 10 supination• Close packed position: 5 supination• Capsular pattern: full ROM with pain at

extreme of rotation

Radiocarpal (Wrist) Joint• Biaxial ellipsoid joint• Radius articulates with scaphoid and lunate• Distal radius is not straight but is angled toward the

ulna (15-20), and its posterior margin projects more distally to provide a “buttress effect”

• Lunate and triquetrium also articulate with the triangular cartilaginous disc and not the ulna. (the disc extends from the ulnar side of the distal radius and attaches to the ulna at the base of the ulnar styloid process)

• The disc adds stability to the wrist; creates a close relation between the ulna and carpal bones and binds together the distal ends of the radius and ulna.

Radiocarpal (Wrist) Joint• With the disc in place, the radius bears 60% of the load

and the ulna bears 40%. If the disc is removed, the radius transmits 95% of the axial load and the ulna transmits 5%

• Therefore, the cartilaginous disc acts as a cushion for the wrist joint and as a major stabilizer of the distal radioulnar joint; the disc can be damage by forced extension and pronation

• Distal end of radius is concave and the proximal row of carpals is convex

• Has two degrees of freedom• Resting position: neutral with slight ulnar deviation• Close packed position: extension• Capsular pattern: flexion and extension equally limited

Intercarpal Joints• Include the joints between the individual bones of the

proximal row of carpal bones (scaphoid, lunate, and triquetrium) and the joints between the individual bones of the distal row of carpal bones (trapezium, trapezoid, capitate and hamate).

• Bound together by small intercarpal ligaments (dorsal, palmar and interosseus), which allow only a slight amount of gliding movement between the bones.

• Close packed position: extension• Resting position: neutral or slight flexion• Capsular pattern is none• Pisotriquetral joint is considered separately because

the pisiform sits on the triquetrium and does not take a direct part in the other intercarpal movements

Midcarpal Joints• Form a compound articulation between the proximal and

distal rows of carpal bones with the exception of pisiform• On the medial side, the scaphoid, lunate, and triquetrium

articulate with capitate and hamate, forming a compound sellar (saddle-shaped joint).

• On the lateral aspect, the scaphoid articulates with the trapezoid and trapezium, forming another compound sellar joint

• These articulations are bound together by dorsal and palmar ligaments; however, there are no interosseus ligaments between the proximal and distal rows

• Therefore, greater movement exists at the midcarpal joints than at the intercarpal joints

• Close packed position: extension with ulnar deviation• Resting position: neutral or slight flexion with ulnar deviation• Capsular pattern: equal limitation of flexion and extension

Carpometacarpal Joint• Sellar joint that has 3 degrees of freedom (thumb)• Plane joint for 2nd to 5th CMC joints• Capsular pattern of CMC jt (thumb): abduction is most limited,

followed by extension• Resting position (thumb): midway between the abduction and

adduction and midway between flexion and extension• Close packed position (thumb): full opposition• Capsular pattern (2-5): equal limitation in all directions• Bones of are held together by dorsal and palmar ligaments• Thumb articulation has a strong lateral ligament extending from

the lateral side of the trapezium to the radial side of the base of the 1st metacarpal, and the medial four articulations have an interosseus ligament similar to that found in the carpal articulation

• CMC articulations of fingers allow only gliding movements• CMC articulations of thumb is unique that it allows flexion,

extension, abduction, adduction, rotation, and circumduction

Intermetacarpal Joints

• Have only a small amount of gliding movements between them and do not include the thumb articulation

• They are bound together by palmar, dorsal and interosseus ligaments

Metacarpophalangeal Joints • Condyloid joints• 2nd and 3rd MCP joints tend to be immobile and are the

primary stabilizing factor of the hand, whereas the 4th and 5th joints are more mobile.

• Collateral ligaments of these joints are tight on flexion and relaxed on extension

• These articulations are also bound by palmar ligaments and deep transverse metacarpal ligaments

• Has two degrees of freedom• 1st CMC has 3 degrees of freedom• Close packed position: maximum opposition (thumb);

maximum flexion (fingers)• Resting position: slight flexion• Capsular pattern: more limitation of flexion than

extension

Interphalangeal Joints

• Uniaxial hinge joints with one degree of freedom• Close packed position: full extension• Resting position: slight flexion• Capsular pattern: flexion more limited than

extension• During flexion, there is some rotation in these joints

so that the pulp of the fingers face more fully the pulp of the thumb

• Cascade sign – if the MCP jts and PIP jts of the fingers are flexed, they converge toward the scaphoid tubercle

• If one or more fingers do not converge, it usually indicates trauma to the digits that has altered their normal alignment

Common Hand Deformities• Swan-neck deformity

• Involves only the fingers. • There is flexion of the MCP and DIP. • There is hyperextension of the PIP jt.• Result of contracture of intrinsic mm and is often seen in RA

• Boutonniere deformity• Extension of the MCP and DIP and flexion of PIP jt• Result of the rupture of the central tendinous slip of the extensor hood• Most common after trauma or in RA

• Ulnar drift• Commonly seen in patients with RA but can occur with other

conditions• Results in ulnar deviation of the digits due to weakening of the

capsuloligamentous structures of the MCP jts and the accompanying “bowstring effect of the extensor communis tendons

• Extensor plus deformity• Caused by adhesions or shortening of the extensor communis tendon

proximal to the MCP jt• Results in inability to simultaneously flex the MCP and PIP jts,

although they may be flexed individually

Common Hand Deformities• Claw fingers

• Results from loss of intrinsic mm action and the overaction of the extrinsic (long) extensor mm on the proximal phalanx of the fingers.

• MCP jts are hyperextended, and the proximal and distal IP jts are flexed.• If intrinsic function is lost, the hand is called intrinsic minus hand• Normal cupping of the hand is lost, both the longitudinal and transverse

arches of the hand disappear.• There is intrinsic mm wasting• Often caused by a combined median and ulnar nerve palsy

• Trigger finger• Aka digital tenovaginitis stenosans• Result of a thickening of the flexor tendon sheath which causes sticking of

the tendon when the patient attempts to flex the finger• A low grade inflammation of the proximal fold of the flexor tendon leads to

swelling and constriction (stenosis) in the digital flexor tendon.• When px attempts to flex the finger, the tendon sticks, and the finger “lets

go”, often with a snap• Usually occurs in middle aged women• Trigger thumb usually occurs in young children; condition usually occurs in

the third or fourth finger. • Often associated with RA and tends to be worse in the morning

Common Hand Deformities• Ape hand deformity

• Wasting of the thenar eminence of the hand occurs as a result of the median nerve palsy

• Thumb falls back in line with the fingers as a result of the pull of the extensor mm

• Px is unable to oppose or flex the thumb• Bishop’s hand or Benediction hand deformity

• Wasting of the hypothenar mm of the hand, the interossei mm, and the 2 medial lumbrical mm

• Occurs because of the ulnar nerve palsy• Flexion of the 4th and 5th fingers is the most obvious

resulting change• Drop-wrist deformity

• Extensor mm of the wrist are paralyzed as a result of the radial nerve palsy, and the wrist and fingers cannot be extended

Common Hand Deformities• “Z” deformity of the thumb

• Thumb is flexed at the MCP jt and hyperextended at the IP jt.

• Caused by heredity, or it may be associated with RA• Dupuytren’s deformity

• Result of contracture of the palmar fascia • There is a fixed flexion of deformity of MCP and PIP jts. • Usually seen in ring or little finger. • Skin is often adherent to the fascia• Affects men more than women and seen in 50-70 year

age group• Mallet finger

• Result of the rupture or avulsion of the extensor tendon where it inserts into the distal phalanx of the finger.

• Distal phalanx rests in a flexed position

Types of Grip• Power Grip

• Requires fine control and gives greater flexor asymmetry to the hand

• Used whenever strength or force is the primary consideration• Digits maintain the object against the palm• Thumb may or may not be involved, and the extrinsic mm are

more important• For a power grip to be formed, fingers are flexed and the wrist in

ulnar deviation and slightly extended• Hook grasp – in which all or the second and third fingers

are used as a hook controlled by the FA flexors and extensors; involve the IP and MCP jts (thumb not involved)

• Cylinder grasp – type of palmar prehension, thumb is used, and the entire hand wraps around an object

• Fist grasp/digital palmar prehension - hand moves around a narrow object

• Spherical grasp – type of palmar prehension, in which there is more opposition and the hand moves around the sphere

• Precision or prehension grip• An activity limited mainly to the MCP

joints and involves primarily the radial side of the hand

• Used whenever accuracy and precision are required

• Radial digits (index and long fingers) provide control by working in concert with the thumb to form a “dynamic tripod” for precision handling

• There is pulp to pulp contact between the thumb and fingers, and the thumb opposes the fingers.

• Intrinsic mm are more important• Types of pinch grip

• Three point chuck, three fingered, or digital prehension, in which palmar pinch, or subterminal opposition, is achieved; precision grip with power

Wrist and Hand Anatomy

Bone Anatomy

• Scapoid• Lunate• Triquetrium• Pisiform• Trapeziod• Trapezium• Capitate• Hamate

Wrist Articulations

• Radiocarpal Joint• Proximal portion• Distal portion• Most surface contact

found

Articulations

• Midcarpal Joint• Articulation between

proximal and distal row of carpals

• Not an uninterupted joint

• Distal Row• 2 degrees of freedom• Moves as a fixed unit

Ligament Support

• Volar Carpal Ligaments• Volar Radiocarpal

Ligament• Three bands

• Volar Ulnocarpal Ligament

• Scapholunate Interosseous Ligament

• Lunotriquetral Ligament

Ligament Support

• Dorsal Carpal Ligaments• Dorsal Radiocarpal

Ligament• Dorsal Intercarpal

Ligament• Radial Collateral

Ligament• Ulnar Collateral

Ligament

Triangular Fibrcartilage Complex

• Composition• Role

Carpometacarpal (CMC) Joints of 2-5• Composition• Carpal Arch

Carpometacarpal (CMC) Joints of 2-5• Composition• Carpal Arch• Ligament Support

• Transverse Carpal Ligament

• Dorsal and Palmar CMC Ligaments

• Dorsal and Palmar Metacarpal Ligaments

• Metacarpal Interosseous Ligaments

Carpometacarpal (CMC) Joints of 2-5• Composition• Carpal Arch• Ligament Support

• Transverse Carpal Ligament

• Dorsal and Palmar CMC Ligaments

• Dorsal and Palmar Metacarpal Ligaments

• Metacarpal Interosseous Ligaments

• Movement of CMC Joints

Metacarpophalangeal (MCP) Joints of 2-5 Fingers• Ligament Support

• Capsule• Volar Plate• Collateral Ligaments• Motions

Interphalangeal Joints of 2-5 Fingers• Hinge Joints• Motions

CMC of Thumb

• Saddle Joint• Ligament Support

• Capsule• Intermetacarpal

Ligament

MCP of Thumb

• Ligament Support

• IP Joint of Thumb

Extrinsic Hand Muscles

Extensor Indicis

• O• Dorsal surface lower ½

body of ulna• Interosseus membrane

• I • Ulnar side of index finger’s

EDC tendon

• N• Radial (posterior

interosseus)

• F• MCP and IP Ext of 2nd digit

Extensor Pollicis Longus

• O• Posterior 1/3 ulna• Interosseus membrane

• I• Posterior surface of base

of thumb distal phalanx

• N • Radial (posterior

interosseus)

• F• CMC, MCP and IP Ext of

1st digit

Extensor Pollicis Brevis

• O• Dorsal 2/3 of radius

• I• Dorsal surface of base of

proximal 1st phalanx


interosseus)

• F• CMC & MCP Ext of thumb• CMC ABD of thumb

Abductor Pollicis Longus

• O• Posterior distal 2/3 of ulna• Posterior middle 1/3 of

radius• Interosseus membrane

• I• Radial side of base of 1st

metacarpal


interosseus)

• F• CMC ABD & Ext of thumb

Flexor Pollicis Longus

• O • Anterior middle ½ of radius• Interosseus membrane

• I • Palmar surface of base of

distal 1st phalanx

• N• Median (anterior

interosseus)

• F• IP Flexion of thumb

Extensor Digiti Minimi

• O• Lateral epicondyle of

humerus• I

• Extensor expansion of 5th digit

• N• Radial (posteior

interosseus)• F

• MCP and IP extension of 5th digit

Flexor Digitorum Superficialis• O

• Medial epicondyle of humerus

• Coronoid process• Middle ½ anterior radius

• I• Four tendons separating

into two parts that insert into sides of bases of middle 2-5 phalanxes

• N• Median

• F• MCP flexion digits 2-5• PIP flexion digits 2-5

Flexor Digitorum Profundus

• O• Anteriomedial surface of

ulna• Interosseus membrane

• I• Four tendons inserting into

distal phalanxes of digits 2-5

• N• Media 2-3 digits• Ulna 4-5 digits

• F• DIP flexion of 2-5 digits

Intrinsic Hand MusclesThenar Eminance

Abductor Pollicis Brevis

• O• Scaphoid tuberosity• Trapezium ridge• Transverse carpal ligament

• I• Lateral base f proximal 1st

phalanx

• N• Median

• F• CMC & MCP ABD of thumb

Flexor Pollicis Brevis• O

• Superficial head – trapezium

• Deep head – trapezoid, capitate and palmar ligaments of distal carpal bones

• I• Base of prximal 1st phalanx

on radial side• Extensor expansion

• N• Superficial – median• Deep – Ulnar

• F• CMC & MCP Flexion of

thumb

Opponens Pollicis

• O• Trapezium• Transverse Carpal

Ligament• I

• Radial side of 1st metacarpal shaft

• N• Median

• F• Opposition

Intrinsic Hand Muscles

Hypothenar Eminence

Abductor Digiti Minimi

• O• Pisiform

• I• Ulnar side base of 5th

proximal phalanx

• N• Ulnar

• F• MCP ABD of 5th digit

Opponen Digiti Minimi

• O• Hook of hamate• Transverse carpal ligament

• I• Ulnar border of entire 5th

metacarpal bone

• N• Ulnar

• F• MCP flexion & rotation of

5th digit

Flexor Digiti Minimi

• O• Hamate bone• Transverse carpal

ligament• I

• Ulnar side of proximal 5th phalanx

• N• Ulnar

• F• MCP Flexion of 5th

digit

Other Intrinsic Hand Muscles

Adductor Pollicis

• O• Oblique Head

• Capitate bone• Bases of 2-3 metacarpals

• Transverse Head• Proximal 2/3 of palmar

surface of 3rd metacarpal

• I• Ulnar side of base of 1st

proximal phalanx• N

• Ulnar• F

• CMC ADD of thumb

Palmar Interossei• O

• 1st – ulnar side base of 1st metacarpal bone

• 2nd – ulnar side of 2nd MC bone

• 3rd – radial side of 4th MC bone

• 4th – radia side of 5th MC bone

• I• Extensor expansion of 2,4

and 5th digits• N

• Ulnar• F

• ADD of 1st, 2nd, 4th and 5th digits toward midline of hand

Dorsal Interossei• O• 1st lateral head – ulnar side

of 1st metacarpal bone• 1st medial head – radial

side of 2nd metacarpal bone• 2nd, 3rd, 4th space between

metacarpal bones• I

• 1st – radial side 2nd proximal phalanx

• 2nd – radial side of 3rd

• 3rd – ilnar side of 3rd

• 4th – ulnar side of 4th

• N• Ulnar

• F• ABD of 2nd, 3rd, and 5th

finger from midline

Lumbricales

• O• Tendons of FDP

• I• Extensor expansion on

dorsal aspect of each digits radial side

• N• 1 and 2 – median• 3 and 4 – ulnar

• F• MCP flexion 2-5 digits• DIP & PIP ext 2-5 digits

Palmaris Brevis

• O• Flexor retinaculum

• I• Palmar surface skin on

ulnar side of hand• N

• Ulnar• F

• Wrinkles skin of hand on ulnar side

Biomechanics of Hand

Biomechanics of Finger Flexion

• Gliding mechanisms • Retinaculae• Ligaments• Bursa• Digital tendon sheaths

• Annular Pulleys• A1-A5

• Cruciate Ligaments• C1-C3

• Function of Pulleys

Biomechanics of Finger Extension• Extensor Hood

• EDC tendons• DI and PI tendons• Lumbricales• Central tendon• Oblique Retinacular

Ligaments• Sagittal Bands

• Effects on MCP joints• Effects on IP Joints

Syndactyly

Polydactyly

Koilonchyia (spoon nails)

Clubbed Nails

Carpal Bones

Anatomic Snuffbox

Tunnel of Guyon

Carpal Tunnel

Dupuytren’s Contracture

Trigger Finger

Bouchard’s Nodes

Heberden’s Nodes

Boutonniere Deformity

Swan Neck Deformity

Mallet Finger

Hip Anatomy

Prepared By: Floriza P. de Leon, PTRP

Bony Anatomy

• Femur• Femoral Head• Femoral Neck• Greater Trochanter• Lesser Trochanter• Intertrochanteric Crest• Intertrochanteric Line• Gluteal Tuberosity

Bony Anatomy

• Pelvic Girdle• Acetabulum• 3 bones fused

together• Ilium

• Iliac fossa• Iliac Crest• ASIS• AIIS• PSIS• PIIS• Gluteal Lines• Greater Sciatic Notch

Lateral View

Bony Anatomy

• Ilium• Iliac fossa• Iliac Crest• Iliac Tuberosity• ASIS• AIIS• PSIS• PIIS• Gluteal Lines

Medial View

Bony Anatomy

• Ilium• Ishium

• Ramus of ishium• Ishial tuberosity• Ishial spine• Lessor Sciatic Notch

Bony Anatomy

• Ilium• Ishium• Pubis

• Superior Ramus of Pubis

• Inferior Ramus of Pubis

• Pubic Crest• Pubic Tubercle• Pectin• Symphyseal Surface

Articulations of the Hip and Pelvis

• Pubic Symphysis• Interpubic disk• Some movement

Articulations of the Hip and Pelvis

• Pubic Symphysis• Sacroiliac Joints

Articulations of the Hip and Pelvis• Pubic Symphysis• Sacroiliac Joints• Hip Joints

Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle

• Sacroiliac Joint• Sacrotuberous• Sacrospinous• Function of these two

ligaments• Iliolumbar • Interosseous

Sacroiliac


• Sacroiliac Joint• Sacrotuberous• Sacrospinous• Function of these two

ligaments• Iliolumbar • Interosseous

Sacroiliac• Dorsal Sacroiliac


• Sacroiliac Joint• Hip Joint

• Capsule• Three thickenings of

the capsule• Iliofemoral• Pubofemoral• Ishiofemoral

• Ligamentum Teres• Inguinal

Hip Muscles

• Anterior• Rectus Femoris• Sartorius• Iliopsoas Muscle

Group• Iliacus• Psoas Major

Hip Muscles

• Posterior• Semimembranosus• Semitendinosus• Biceps Femoris• Gluteus Maximus

Hip Muscles

• Medial• Adductor Brevis• Adductor Longus• Adductor Magnus• Pectineus• Gracilus

Hip Muscles

• Lateral• Gluteus Medius• Gluteus Minimus• Tensor Fascia Lata• Six Intrinsic External

Rotators• Periformis• Quadratus Femoris• Obturator Internus• Obturator Externus• Gemellua Superior• Gemellus Inferior

Femoral Triangle

• Borders• Superior• Lateral• Medial• Posterior• Anterior

• Structures

Movements of the Pelvis

• Forward and Backward Tilt• Left and right Lateral Tilt• Left and Right Rotation

Primary Movements of the Pelvis as Performed in a Standing Position

Pelvis Spinal Joints Hip Joints

Forward Tilt Hyperextension Slight Flexion

Backward Tilt Slight Flexion Complete Ext.

Lateral Tilt Left Slight Lateral Flexion RT

R = ADD L= ABD

Rotation Left Rotation RT R = Slight ERL= Slight IR

Movements of the Pelvis Secondary to those of the Spine

Spine Pelvis

Flexion Posterior Tilt

Hyperextension Anterior Tilt

Lateral Flex Left Lateral Tilt Left

Rotation Left Rotation Left

Movements of Pelvis secondary to LE

• Moves with LE to supplement the LE ROM for 3 types of motion• Movements of the limbs acting in unison• Movements when LE is moving in opposite directions• Movements of one limb

The Lower Limb

Frolich, Human Anatomy, Lower LImb

Lower Limb

• Skeleton (homologous with upper limb)• Muscles--anterior, posterior compartments• Nerves--sciatic, femoral• Surface anatomy


Upper-Lower Limb ComparisonSee Table M&M, Table 8.1


Tibia/fibula

• Tibia--big toe side• Fibula--little toe side

(no pronation/supination)


Ankle

• Tarsus--forms ankle joint

• Calcaneus--forms heel


Foot Function: Support weight Act as lever when walking

Tarsals Talus = ankle

• Between tibia + fibula• Articulates w/both

Calcaneus = heel• Attachment for Calcaneal

tendon• Carries talus

Metatarsals Homologous to metacarpals

Phalanges Smaller, less nimble


Joints of Lower Limb

Hip (femur + acetabulum) Ball + socket Multiaxial Synovial

Knee (femur + patella) Plane Gliding of patella Synovial

Knee (femur + tibia) Hinge Biaxial Synovial


Joints of Lower Limb

Proximal Tibia + Fibula Plane Gliding Synovial

Distal Tibia + Fibula Slight “give” Fibrous

Ankle (Tibia/Fibula + Talus) Hinge Uniaxial Synovial

pg 218


Lower Limb Movements

• Hip• Flexion/extension• Abduction/adduction• Lateral/medial rotation

• Knee• Flexion/extension

• Ankle• Dorsiflexion/plantarflexion• Inversion/eversion

• Toes• Flexion/extension

• Bending on posterior side is flexion (except hip)

• Bending on anterior sided is extension (except hip)


Anterior/Posterior compartments

ANTERIOR COMPARTMENT

POSTERIOR COMPARTMENT

MOVEMENT Extension Flexion

MUSCLES QuadsShin

HamstringsGastrocs

NERVES Femoral n.(lumbar plexus)

Sciatic n.(sacral plexus)


Thigh movements by compartment


Posterior Thigh

• Gluts (gluteal nn.)• Maximus—extensor of thigh• Medius--pelvic tilt

• Lateral rotators (spinal nn.)• Piriformis syndrome

• Hamstrings (sciatic n.)• Biceps femoris• Semimembranous• Semitendinous


Anterior thigh (femoral n.)

• Sartorius (Tailor’s muscle)

• Quads (four)• Rectus femoris

(crosses hip)• 3 vastus mm.

(vast--big)


Medial compartment (obturator n.)

• Adductor muscles• Gracilis• Adductor

• Magnus• Longus• brevis


Leg movements by compartment (in leg all nn are branches of sciatic)


Anterior Leg (deep fibular n.)

• Fibularis (peroneus) longus

• Extensor digitorum longus

• Extensor hallicus longus

• Tibialis anteriorus


Lateral Leg (superficial fibular n.)

• Fibularis brevis/longus


Posterior Leg (tibial n.)

• Gastrocs and soleus• Flexor digitorum

longus• Flexor hallucus

longus


Intrinsics of foot


• Lumbar plexus (femoral nerve)

• Sacral plexus (sciatic nerve)

With leg out to side like quadruped, lumbar-anterior, sacral-posterior makes sense


Dermatomes show twisting of leg in development


Blood supply to lower limb

Internal Iliac Cranial + Caudal Gluteals= gluteals Internal Pudendal = perineum, external

genitalia Obturator = adductor muscles

External Iliac Femoral = lower limb

• Deep femoral = adductors, hamstrings, quadriceps

Popliteal (continuation of femoral) • Geniculars = knee• Anterior Tibial = ant. leg muscles, further

branches to feet• Posterior Tibial = flexor muscles, plantar

arch, branches to toes


Surface Anatomy: Posterior Pelvis

• Iliac crest• Gluteus maximus = cheeks• Natal/gluteal cleft = crack• Gluteal folds = bottom of cheek

pg 789


Surface Anatomy: Anterior Thigh + Leg

• Palpate• Patella• Condyles of femur

• Femoral Triangle• Sartorius (lateral)• Adductor longus (medial)• Inguinal ligament

(superior)• Femoral a + v, lymph

nodes

pg 785

pg 792


Surface Anatomy: Posterior Leg

• Popliteal fossa• Diamond-shape fossa

behind knee• Boundaries

• Biceps femoris (sup-lat)• Semitendinosis +

semimembranosis (sup-med)

• Gastrocnemius heads (inf)• Contents

• Popliteal a + v

• Calcaneal (Achilles) tendon

pg 793

Foot Anatomy

Bone Anatomy

• Tarsal Bones• Calcaneus

• Sustentaculum Tali• Peroneal Tubercle

• Cuboid• Navicular• 3 Cuneiforms• 5 metatarsals• 5 phalanges

(proximal, middle, distal)• Exception

Division of the Foot

• Rearfoot• Midfoot• Forefoot

Hindfoot (Rearfoot)

• Subtalor Joint• Talus and calcaneus

articulation• Individual Bone

Formation• Calcaneus

• Calcaneal Tuberosity• Sustentaculum Tali

• Inferior Talus• Three facets• Five functional

articulation

Midfoot

• Composed of • Navicular • 3 cuneiforms• cuboid

Forefoot

• 5 MT’s • Proximally 1-3

articulate with cuneiforms

• Proximally 4-5 articulate with cuboid

• Bases articulate with:

• Phalanges

Articulations and Ligamentous Support

• Subtalor Joint• Three facets• Motions of the

Subtalor Joint• Supination

Components• Pronation Components

• WB vs NWB Status of Foot at Subtalor joint

Hindfoot Articulations and Ligamentous Support

• Subtalor Joint• Ligamentous Support

• Intra-articular Ligaments

• Interosseous Talocalcaneal

• Ligamentum Cervis

• Medial Talocalcaneal

• Lateral Talocalcaneal

Midfoot Articulations and Ligamentous Support

• Six Joints• Talocalcaneonavicular • Calcaneocuboid• Cuboideonavicular• Intercuneiform• Cuneocuboid• Cuneonavicular

• Transverse Tarsal• Comprised by

calcaneocuboid & talonavicular

• Stability Related to subtalor joint


• Ligamentous Support• Talocalcaneonavicular Joint

• Plantar Calcaneonavicular (Spring Ligament)

• Talonavicular• Bifurcate

• Calcaneonavicular• Calcaneocuboid

• Calcaneocuboid Joint• Bifurcate Ligament

• Calcaneocuboid portion• Plantar Calcaneocuboid• Long Plantar Ligament


• Ligamentous Support• Intercuneiform Joints

• Dorsal and Plantar Intercuneifrom Ligaments

• Cuneocuboid• Plantar and Dorsal

Cuneocuboid Ligaments

• Cuneonavicular Joints• Plantar and Dorsal

Cuneonavicular Ligaments

Forefoot Articulations and Ligamentous Support

• Tarsometatarsal Joint (Lisfranc’s Joint)

• Intermetatarsal Joint• Metatarsalphalangeal

Joint (MTP)• Interphalangeal Joint

• PIP• DIP

Forefoot Articulations and Ligamentous Support

• Ligamentous Support• Intermetatarsal Joint

• Proximal• Distal

• MTP Joints• Plantar Fascia• Plantar Ligament• MCL and LCL

• Interphalangeal Joints• Plantar and dorsal joint

capsule• MCL and LCL

Arches of the Foot

• Function• Medial Longitudinal

Arch• Lateral Longitudinal

Arch• Transverse Arch

Arches of the Foot

• Medial Longitudinal Arch• Calcaneus• Talus• Navicular• 1-3 cuneiforms• 1-3 MT’s• Function

Arches of the Foot

• Medial Longitudinal Arch continued• Ligament Support

• Plantar Calcaneonavicular

• Long Plantar Lig• Deltoid• Plantar fascia

Arches of the Foot

• Medial Longitudinal Arch continued• Muscular Support

• Intrinsic• Abductor Hallucis• Flexor Digitorum Brevis

• Extrinsic • Tibialis Posterior• Flexor Hallucis Longus• Flexor Digitorum

Longus• Tibialis Anterior• Flexor Digitorm Longus

Arches of the Foot

• Lateral Longitudinal Arch• Composed of

• Calcaneus• Cuboid• 4-5th MT’s

• Ligament Support• Long & Short Plantar• Plantar Fascia

Arches of the Foot

• Lateral Longitudinal Arch continued• Muscle Support

• Intrinsic• Abductor Digiti

Minimi• Flexor Digitorum

Brevis• Extrinisic

• Peroneus Longus, Brevis & Tertius

Summary of Arches

Arches of the Foot

• Transverse Arch• Formed By:• Ligament Support

• Intermetatarsal Ligaments• Plantar Fascia

• Muscle Support• All intrinsic muscles• Extrinisic

• Tibialis Posterior• Tibialis Anterior• Peroneus Longus

Foot Muscles – Plantar Surface

• Superficial Layer• Abductor Hallucis• Abductor Digiti Minimi• Flexor Digitorum

Brevis


• Middle Layer• Quadratus Plantae• Lumbricales


• Deep Layer• Flexor Hallucis Brevis• Adductor Hallucis

• Transverse and Oblique Heads

• Flexor Digiti Minimi


• Interosseus Layer• Plantar Interossei• Dorsal Interossei

Foot Muscles – Dorsal Surface

• Extensor Digitorum Brevis

• Extensor Hallucis Brevis

Common Pediatric Foot Deformities

Anatomy/Terminology

• 3 main sections

1.Hindfoot – talus, calcaneus

2.Midfoot – navicular, cuboid, cuneiforms

3.Forefoot – metatarsals and phalanges

Anatomy/Terminology

• Important joints 1. tibiotalar (ankle) – plantar/dorsiflexion 2. talocalcaneal (subtalar) – inversion/eversion

• Important tendons 1. achilles (post calcaneus) – plantar flexion 2. post fibular (navicular/cuneiform) – inversion 3. ant fibular (med cuneiform/1st met) – dorsiflexion 4. peroneus brevis (5th met) - eversion

Anatomy/Terminology

• Varus/Valgus

Calcaneovalgus foot

Calcaneovalgus foot

• ankle joint dorsiflexed, subtalar joint everted• classic positional deformity• more common in 1st born, LGA, twins• 2-10% assoc b/w foot deformity and DDH• treatment requires stretching: plantarflex and invert foot• excellent prognosis

Congenital Vertical Talus

• true congenital deformity• 60% assoc w/ some neuro impairment • plantarflexed ankle, everted subtalar joint, stiff• requires surgical correction (casting is generally ineffective)

Talipes Equinovarus (congenital clubfoot)

A. General- complicated, multifactorial deformity of

primarily genetic origin

- 3 basic components(i) ankle joint plantarflexed/equines (ii) subtalar joint inverted/varus(iii) forefoot adducted


B. Incidence- approx 1/1,000 live births- usually sporadic- bilateral deformities occur 50%

C. Etiology- unknown- ?defect in development of talus leads to soft tissue changes in joints, or vice

versa


D. Diagnosis/Evaluation - distinguish mild/severe forms from other disease - AP/Lat standing or AP/stress dorsiflex lat films

E. Treatment• Non-surgical

- weekly serial manipulation and casting - must follow certain order of correction- success rate 15-80%

• Surgical- majority do well; calf and foot is smaller

Pes Planus (flatfoot)

A. General- refers to loss of normal medial long. arch- usually caused by subtalar joint assuming an everted position while weight bearing- generally common in neonates/toddlers

B. Evaluation- painful?- flexible? (hindfoot should invert/dorsiflex approx 10 degrees above neutral- arch develop with non-weight bearing pos?


C. Treatment (i) Flexible/Asymptomatic - no further work up/treatment is necessary! - no studies show flex flatfoot has increased risk for pain as an adult

(ii) rigid/painful - must r/o tarsal coalition – congenital fusion or failure of seg. b/w 2 or more tarsal bones - usually assoc with peroneal muscle spasm - need AP/lat weight bearing films of foot

In-Toeing

A. General- common finding in newborns and children- little evidence to show benefit from treatment

In-Toeing

B. Evaluation - family hx of rotational deformity? - pain? - height/weight normal? - limited hip abduct or leg length discrepancy? - neuro exam

C. 3 main causes (i) metatarsus adductus (ii) internal tibial torsion (iii) excessive femoral anteversion

In-Toeing

(i) metatarsus adductus- General

• normal hindfoot, medially deviated midfoot

• diagnosis made if lateral aspect of foot has “C” shape, rather than straight

In-Toeing

(i) metatarsus adductus- Evaluation

• should have normal

ankle motion

• assess flexibility by

holding heel in neutral position, abducting forefoot

In-Toeing

(i) metatarsus adductus

• treatment- if flexible, stretching; Q diaper change, 10 sec- if rigid, or if no resolution by 4-8 months, refer to ortho- prognosis is good: 85-90% resolve by 1yr

In-Toeing

(ii) Internal Tibial Torsion

• usually presents by walking age

• knee points forward, while feet point inward

In-Toeing

(ii) Internal Tibial Torsion

• Treatment- reassurance! spontaneous resolution in 95% children, usually by 7-8yrs- controversy with splints, casts, surgery

In-Toeing

(iii) Excessive Femoral Anteversion

• both knees and feet point inward

• presents during early childhood (3-7yrs)

• most common cause of in-toeing

In-Toeing


• int rotation 70-80 deg ext rotation 10-30 deg

• “W” position

In-Toeing


• increase in internal rotation early with gradual decrease

In-Toeing


• Treatment- no effective non-surgical treatment

- surgical intervention usually indicated if persists after 8-10 yrs and is cosmetically

unacceptable or functional gait problems- derotational osteotomy

Anatomy of the spine

The spine is one of the most important parts of your body. Without it, you could not keep yourself upright or even stand up. It gives your body structure and support. It allows you to move about freely and to bend with flexibility. The spine is also designed to protect your spinal cord.

At BirthThe spine of a newborn is C-shaped, with one curve

At About Six MonthsAs the infant lifts his or her head during the first few months, the neck (cervical) curve and its muscles develop

At About Nine Months As the infant learns to crawl and stand, the lower back (lumbar) curve and its muscles develop. Strong back muscles help give your child the strength and balance to walk and run.

The spine has three major components:

• the spinal column (i.e., bones and discs)

• neural elements (i.e., the spinal cord and nerve roots)

• supporting structures (e.g., muscles and ligaments)

A. The spinal column

The spinal column consists of individual bones called vertebrae, the building blocks, which provide support for the spine. These vertebrae are connected in the front of the spine by intervertebral discs.

The spinal column consists of:• seven cervical vertebrae (C1–C7) i.e. neck• twelve thoracic vertebrae (T1–T12) i.e.

upper back• five lumbar vertebrae (L1–L5) i.e. lower

back• five bones (that are joined, or "fused,"

together in adults) to form the bony sacrum

• three to five bones fused together to form the coccyx or tailbone

http://www.spineuniverse.com/anatomy/normal-spinal-column






In general a typical vertebra consists of :

1. large vertebral body in the front2. two strong bony areas called

pedicles connecting the vertebral body and the posterior arch

3. an arch of bony structures in the back (posterior arch) = (the spinous process).

BODY

PEDICLE

transverse process

spinous process

2 special cervical vertebrea:

1. Atlas:

The atlas is the topmost vertebra

The Atlas has no body, and this is due to the fact that the body of the atlas has fused with that of the next vertebra (the Axis)

it has no spinous process, is ring-like, and consists of an anterior and a posterior arch and two lateral masses

2. Axis:

The second cervical vertebra (C2) of the spine is named the axis

The most distinctive

characteristic of this bone is the strong dens which rises perpendicularly from the upper surface of the body.

B. Neural Elements:

The neural elements consist of the spinal cord and nerve roots.

The spinal cord runs from the base of the brain down through the cervical and thoracic spine. Below the L1–L2 level the spinal cord ends, as an array of nerve roots continues, looking somewhat like a horse's tail (cauda equina).

At each vertebral level of the spine there are a pair of nerve roots. These nerves go to supply particular parts of the body.

The intervertebral discs make up one fourth of the spinal column's length. There are no discs between the Atlas (C1), Axis (C2), and Coccyx. Discs are not vascular and therefore depend on the end plates to diffuse needed nutrients

Discs are composed of two parts: a tough outer portion and a soft inner core:

• The outer portion of the disc (annulus fibrosus) composed of concentric sheets of collagen fibers that seal the gelatinous nucleus and evenly distribute pressure and force imposed on the vertebral column.

• The inner core (nucleus pulposus) contains a loose network of fibers suspended in a mucoprotein gel.

The outer portion and inner core of the spinal disc fit together like two concentric cylinders and are interconnected by cartilaginous end-plates

C. the supporting structures:

1. Ligaments

2. Fascia

3. Muscles

4. Nerves

Ligaments:

Ligaments are rope-like bands of tissue that connect bones together. Most ligaments are lined up to keep joints from bending in the wrong way

The most important ones are:

1. Anterior and posterior longitudinal ligaments

2. Ligamentum flavum3. Intervertebral discs

Fascia:

Fascia is similar to ligaments, but fascia is more like a sheet than a rope.

The most important of which

is the thoracolumbar fascia (TLF) which has the following functions:

As the spinal muscles work,

the TLF pulls tightly the low back, keeping the lumbar spine from bending out of the neutral position.

It augments the power generated by spinal muscles.

Muscles:

Because of their location toward the center of the body, and because of their importance in spine stability, these key stabilizers are called "core, paraspinal" muscles

Core muscles help grip and hold the spine. They keep each spinal segment from shifting and sliding as you do your activities

Nerves:

• Motor nerves signal the key muscles to grip and hold and to guide and control the spine.

• Sensory nerves transmit sensations such as heat, cold, touch, pressure, and pain. They also give us our sense of position

Q. What are the functions of the spinal curves?

Absorbs the shocks of walking on hard surfaces More weight can be supported by a curved spine

than if it were straightAdditional space for the viscera is provided by the

concavities of the thoracic and pelvic regions.Lastly, the S-curvature protects the vertebral

column from breakage

What are the functions of the spinal column?

The major functions of the vertebral column are:oProtection of the spinal cord. oProviding stiffening for the body and attachment for the pectoral

and pelvic girdle and many other muscles.oProviding motion for the human skeleton.oThe S-curvature enables the vertebral column to absorb the

shocks of walking on hard surfaces

Spinal Cord Anatomy

Spinal Cord• Runs through the vertebral canal• Extends from foramen magnum to second

lumbar vertebra• Regions

• Cervical • Thoracic • Lumbar• Sacral• Coccygeal

• Gives rise to 31 pairs of spinal nerves• All are mixed nerves

• Not uniform in diameter• Cervical enlargement: supplies upper

limbs• Lumbar enlargement: supplies lower

limbs• Conus medullaris- tapered inferior end

• Ends between L1 and L2• Cauda equina - origin of spinal nerves

extending inferiorly from conus medullaris.

Meninges• Connective tissue membranes

• Dura mater: outermost layer; continuous with epineurium of the spinal nerves

• Arachnoid mater: thin and wispy• Pia mater: bound tightly to surface

• Forms the filum terminale• anchors spinal cord to coccyx

• Forms the denticulate ligaments that attach the spinal cord to the dura

• Spaces• Epidural: external to the dura

• Anesthestics injected here • Fat-fill

• Subdural space: serous fluid• Subarachnoid: between pia and

arachnoid• Filled with CSF

Cross Section of Spinal Cord

• Anterior median fissure and posterior median sulcus• deep clefts partially separating left and

right halves• Gray matter: neuron cell bodies,

dendrites, axons• Divided into horns

• Posterior (dorsal) horn• Anterior (ventral) horn• Lateral horn

• White matter• Myelinated axons• Divided into three columns

(funiculi)• Ventral• Dorsal• lateral

• Each of these divided into sensory or motor tracts

Cross section of Spinal Cord• Commissures: connections between

left and right halves• Gray with central canal in the

center• White

• Roots• Spinal nerves arise as rootlets

then combine to form dorsal and ventral roots

• Dorsal and ventral roots merge laterally and form the spinal nerve

Organization of Spinal Cord Gray Matter

• Recall, it is divided into horns• Dorsal, lateral (only in thoracic region), and ventral

• Dorsal half – sensory roots and ganglia• Ventral half – motor roots• Based on the type of neurons/cell bodies located in

each horn, it is specialized further into 4 regions• Somatic sensory (SS) - axons of somatic sensory neurons• Visceral sensory (VS) - neurons of visceral sensory neur.• Visceral motor (VM) - cell bodies of visceral motor neurons• Somatic motor (SM) - cell bodies of somatic motor neurons

Gray Matter: Organization

Figure 12.31

White Matter in the Spinal Cord

• Divided into three funiculi (columns) – posterior, lateral, and anterior• Columns contain 3 different types of fibers (Ascend., Descend.,

Trans.)

• Fibers run in three directions• Ascending fibers - compose the sensory tracts• Descending fibers - compose the motor tracts• Commissural (transverse) fibers - connect opposite sides of cord

White Matter Fiber Tract Generalizations

• Pathways decussate (most)• Most consist of a chain of two or three neurons• Most exhibit somatotopy (precise spatial relationships)• All pathways are paired

• one on each side of the spinal cord

White Matter: Pathway Generalizations

Descending (Motor) Pathways• Descending tracts deliver motor instructions from the

brain to the spinal cord• Divided into two groups

• Pyramidal, or corticospinal, tracts• Indirect pathways, essentially all others

• Motor pathways involve two neurons • Upper motor neuron (UMN)• Lower motor neuron (LMN)

• aka ‘anterior horn motor neuron” (also, final common pathway)

Pyramidal (Corticospinal) Tracts• Originate in the precentral gyrus of brain (aka, primary motor area)

• I.e., cell body of the UMN located in precentral gyrus• Pyramidal neuron is the UMN

• Its axon forms the corticospinal tract• UMN synapses in the anterior horn with LMN

• Some UMN decussate in pyramids = Lateral corticospinal tracts• Others decussate at other levels of s.c. = Anterior corticospinal tracts

• LMN (anterior horn motor neurons)• Exits spinal cord via anterior root • Activates skeletal muscles

• Regulates fast and fine (skilled) movements

Corticospinal tracts

1. Location of UMN cell body in cerebral cortex

2. Decussation of UMN axon in pyramids or at level of exit of LMN

3. Synapse of UMN and LMN occurs in anterior horn of s.c.

4. LMN axon exits via anterior root

Extrapyramidal Motor Tracts

• Includes all motor pathways not part of the pyramidal system• Upper motor neuron (UMN) originates in nuclei deep in cerebrum (not

in cerebral cortex)• UMN does not pass through the pyramids!• LMN is an anterior horn motor neuron• This system includes

• Rubrospinal• Vestibulospinal• Reticulospinal• Tectospinal tracts

• Regulate:• Axial muscles that maintain balance and posture• Muscles controlling coarse movements of the proximal portions of limbs• Head, neck, and eye movement

Extrapyramidal Tract

Note:1. UMN cell body location2. UMN axon decussates in pons3. Synapse between UMN and LMN occurs in anterior horn of sc3. LMN exits via ventral root4. LMN axon stimulates skeletal muscle

Extrapyramidal (Multineuronal) Pathways

• Reticulospinal tracts – originates at reticular formation of brain; maintain balance

• Rubrospinal tracts – originate in ‘red nucleus’ of midbrain; control flexor muscles

• Tectospinal tracts - originate in superior colliculi and mediate head and eye movements towards visual targets (flash of light)

Main Ascending Pathways

• The central processes of first-order neurons branch diffusely as they enter the spinal cord and medulla

• Some branches take part in spinal cord reflexes• Others synapse with second-order neurons in the cord

and medullary nuclei

Three Ascending Pathways

• The nonspecific and specific ascending pathways send impulses to the sensory cortex• These pathways are responsible for discriminative

touch (2 pt. discrimination) and conscious proprioception (body position sense).

• The spinocerebellar tracts send impulses to the cerebellum and do not contribute to sensory perception

Nonspecific Ascending Pathway

• Include the lateral and anterior spinothalamic tracts

• Lateral: transmits impulses concerned with pain and temp. to opposite side of brain

• Anterior: transmits impulses concerned with crude touch and pressure to opposite side of brain

• 1st order neuron: sensory neuron

• 2nd order neuron: interneurons of dorsal horn; synapse with 3rd order neuron in thalamus

• 3rd order neuron: carry impulse from thalamus to postcentral gyrus

Specific and Posterior Spinocerebellar Tracts• Dorsal Column Tract 1. AKA Medial lemniscal pathway 2. Fibers run only in dorsal column 3. Transmit impulses from receptors in skin and joints 4. Detect discriminative touch and body position sense =proprioception• 1st O.N.- a sensory neuron

• synapses with 2nd O.N. in nucleus gracilis and nucleus cuneatus of medulla

• 2nd O.N.- an interneuron• decussate and ascend to

thalamus where it synapses with 3rd O.N.

• 3rd-order (thalamic neurons)• transmits impulse to somato-

sensory cortex (postcentral gyrus)Spinocerebellar Tract• Transmit info. about trunk and

lower limb muscles and tendons to cerebellum

• No conscious sensation

Spinal Cord Trauma and Disorders

• Severe damage to ventral root results in flaccid paralysis (limp and unresponsive)• Skeletal muscles cannot move either voluntarily or involuntarily• Without stimulation, muscles atrophy.

• When only UMN of primary motor cortex is damaged• spastic paralysis occurs - muscles affected by persistent spasms and

exaggerated tendon reflexes

• Muscles remain healthy longer but their movements are no longer subject to voluntary control.

• Muscles commonly become permanently shortened. • Transection (cross sectioning) at any level results in total motor and sensory loss in body regions inferior to site of damage.• If injury in cervical region, all four limbs affected (quadriplegia)• If injury between T1 and L1, only lower limbs affected (paraplegia)

Spinal Cord Trauma and Disorders

• Spinal shock - transient period of functional loss that follows the injury• Results in immediate depression of all reflex activity caudal to

lesion.• Bowel and bladder reflexes stop, blood pressure falls, and all

muscles (somatic and visceral) below the injury are paralyzed and insensitive.

• Neural function usually returns within a few hours following injury

• If function does not resume within 48 hrs, paralysis is permanent.

• Amyotrophic Lateral Sclerosis (aka, Lou Gehrig’s disease)• Progressive destruction of anterior horn motor neurons and

fibers of the pyramidal tracts

• Lose ability to speak, swallow, breathe.• Death within 5 yrs• Cause unknown (90%); others have high glutamate levels

• Poliomyelitis• Virus destroys anterior horn motor neurons• Victims die from paralysis of respiratory muscles• Virus enters body in feces-contaminated water (public

swimming pools)

anatomy, physiology, kinesiology

Documents

flexor digiti

iliofemoral

internal acoustic

carrying afferent

ligamentum

iliacus psoas

superior orbital

cranial nerve