Gross Anatomy Learning Objectives Upper and Lower Limb Lecture 1 Introduction to the Anatomy of the Limbs Dr.

r. Mike Snow, April 30, 2012 1. Differentiate a fibrous joint from a cartilaginous joint from a synovial joint. Synovial joint (see above) Fibrous joint Cartilaginous joint
Articulating bones joined by dense CT No joint cavity None to very little movement Ex: Interosseous membrane, sutures of skull Found in mid-sagittal plane in adults and at the ends of growing long bones in kid Articulating bones joined by articular (hyaline) cartilage or fibrocartilage No joint space, Limited movement Ex: IV disks, growth/ epiphyseal plate Most common type of joint, with 5 features: 1. Have a true joint space high degree of movement 2. Weight bearing surfaces covered by articular (hyaline) cartilage -cushions articular surfaces 3. Bones held together by a capsule of dense CT loss of SS pain and propioceptive fibers 4. Synovial membrane lines capsule and all non-weight bearing surfaces 5. Synovial fluids fills joint space lubricates joint surfaces and provides nutrients for hyaline cartilage

2. Determine a muscles action(s) by its position relative to a joint axis. See Right 3. Define the actions possible at the shoulder and hip joints. See Right 4. List the muscles, actions and innervation associated with the dorsal scapular region. 5. List the muscles, actions, and innervation associated with the gluteal region.
Muscle Glenohumeral Joint
Supraspinatus M Deltoid M Infraspinatus Teres Minor Pectoralis Major Subscapularis Coracobrachialis Anterior Deltoid Short head of the biceps Teres Major Latissimus dorsi Long head of the triceps Posterior Deltoid Gluteus maximus Gluteus medius Gluteus minimus Tensor fasciae latae Piriformis Obturator internus Obturator externus Quadratus femoris Iliopsoas Sartorius Rectus Femoris Semitendinosus Semimembranosus Biceps femoris, short head Abduction Abduction, Flexion, Medial Rot. Lateral Rotator Lateral Rotator Medial Rotator, Flexion Medial Rotator Flexion Flexion Flexion Extension, Medial Rotator Extension, Medial Rotator Extension Extension

Action

Innervation Ventral Rami of C5-T1Brachial Plexus

Suprascapular nerve Axillary Nerve Suprascapular nerve Axillary Nerve Medial Pectoral Nerve, Lateral Pectoral N

Branch of the Brachial Plexus

Hip Joint
Abductor Abductor Abductor Lateral Rotator Lateral Rotator Lateral Rotator Lateral Rotator Flexor Flexor Flexor Extension Extension Extension

Ventral Rami of L2-S3Lumbosacral plexus

Inferior Gluteal Nerve Superior Gluteal Nerve Superior Gluteal Nerve Superior Gluteal Nerve

Tibial Nerve Tibial Nerve Common fibular Nerve

6. Define the concept of collateral circulation based on the dorsal scapular anastomosis Multiple pathways to each muscle so that muscles are rarely ischemic

Lecture 2 Human Limb Development Dr. Mike Snow, May 1, 2012 1. State which embryonic germ layer gives rise to skeletal muscle. Mesoderm 2. List the adult derivatives stemming from the three subdivisions of a somite. Sclerotome: vertebrae around the neural tube and notochord Dermomyotome: dermis and all muscles of the limb and trunk 3. Describe the embryonic processes by which nerves and muscles appear in the limb bud. Muscle precursor cells from the myotome region of the somite migrate to three regions to form the deep back, the trunk, and the limb muscles. These cells then migrate into the limb bud to form two groupings a post axial (posterior division, extensors) and pre-axial (anterior division, flexors). 4. Define the embryonic rationale for the extensor and flexor compartments of the adult. Muscles on the posterior side will pull a bone to resting position, or extend it, while the opposite is true or muscles on the anterior side. In the adult, flexors and extensors are on opposite sides. This occurs because the upper and lower limbs rotate in opposite directions. 5. Explain the embryonic rationale for the dermatome patterns seen in the limbs. At first, the limb bud is innervated in the same belt-like fashion of the trunk. As the limb bud elongates, the middle dermatomes are carried distally to the hand. Lower limb dermatomes reflect the medial rotation that occurs during embryonic development 6. Describe the steps by which a muscle fiber develops from a precursor cell (myoblast). Myoblast Myotube Muscle Fiber 7. Categorize the more common limb malformations. Reduction Defects: meromelia (part of limb), Amelia (entire limb) Duplication Defects: polydactyl (extra digit), supermumery (extra limb) Fusion of Digits: syndactyly (simple or complex) Lecture 3 Innervation Patterns of Limbs Dr. Mike Snow, May 2, 2012 1. Describe the innervation patterns within the compartments of the upper and lower limbs. 2. Define the brachial plexus in terms of its roots, trunks, divisions, cords and terminal branches.

Musculocutaneous: C5, C6, C7 Axillary is only C5, C6 Radial N.: C5-T1 Medial N: C5-T1

Ulnar N: C8, T1

3. Describe the concept of how axons from a given spinal cord segment are found in multiple nerves. Spinal nerves can take all exits from its initial root, but cannot go backwards, and thus will not be able to reach all parts of the brachial plexus. 4. List the nerves affected with an upper or a lower brachial plexus lesion. Describe the symptoms associated with upper and lower brachial plexus injuries.
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Upper Brachial Plexus Injury (Erb-Duschenne Palsy): Tearing, stretching or avulsion of the C5, C6 ventral rami or upper trunk. Occur with a strong force causing excessive stretching of neck relative to fixed shoulder.
1. 2. 3. 4. Suprascapular (all) loss of abduction at shoulder joint (limb adducted), loss of infraspinatus Axillary (all) loss of abduction at shoulder joint (limb adducted), waiters tip deformity Musculocutaneous (most) loss of elbow flexors (elbow slightly extended) Radial (some) weakness of wrist extension (slight flexion)

Lower Brachial Plexus Injury (Klumpkes Palsy): Can occur with any strong foreces causing excessive stretching of the upper limb relative to the trunk
1. Primarily affects ulnar nerve reduced function of the hand, claw hand

5. Define a dermatome and indicate the locations for clinically testing the dermatomes of the upper/lower limbs. Dermatomes are all SS axons from a single spinal nerve which innervate a specific area of the skin of the upper limb.
L4 over knee cap and big toe L5 on middle toes S1 on little toe C6 on thumb C7 on middle finger C8 on pinkie finger

6. Differentiate a dermatome from a peripheral cutaneous nerve. Cutaneous nerves are SS axons that are distributed to the skin of the upper limb via cutaneous branches of the terminal branches of the brachial plexus. Absence or reduced sensation in any of the fields shown in the diagram indicates damage to either the terminal nerve or its cutaneous branch.
Femoral n: anterior thigh Obturator n: medial thigh Common fibular n: Superficial: ant shin, dorsum of middle toes Deep: dorsal webbing between big and second toes A: axillary n R: radial n MC: Musculocutaneous n M: median n U: ulnar n

Lecture 4 Gross Structure and Function of Muscle, Part 1 Dr. Gene Albrecht, May 3, 2012 1. Define and apply the terms, principles and concepts shown in bold italic type
Muscular system Skeletal muscles Cardiac and smooth muscle Endomysium Muscle fibers Motor End plate (NMJ) Muscles fascicles (bundles) Perimysium Epimysium Motor nerve: SS, SM, Symp/post Motor unit Shoulder Position Glenohumeral joint Concentric contraction (shorten) Isometric contraction Eccentric contraction (lengthen) Parallel fibered muscles Pennate muscles Tendons + parallel muscles Tendons + pinnate muscles Prime mover Antagonist Fixator (stabilizer) Synergist Gravity Electromyography (EMG) Anatomical Inspection What to know about skeletal m: Name Form, shape, disposition Attachments Innervation Anatomical Action Muscle Function Relationships

2. Contrast the basic features of skeletal muscle compared to cardiac and smooth muscle
Skeletal M Cell Structure Function Type of Contraction Control Innervation
Striated, v. long, cylindrical, parallel, multinucleated muscle fiber, electrically isolated from neighboring muscle fibers Move bones and other structures to which muscles attach, acts as venous and lymphatic pump All-or-nothing of all muscle fibers innervated by a single motor unit Voluntary, except reflex and unconscious CNS influence Motor neuron with cell body in CNS (anterior horn of SC and brain stem)

Cardiac M
Striated, cylindrical, short, branching, mononucleated, electrically coupled Constrict heart to pump blood through chambers Rapid, continuous, spreading

Smooth M
Nonstriated, fusiform, short, mononucleated, electrically coupled Constricts lumen size of vessels, moves contents through ducts and organs via peristalsis, skin hairs Slow, sustained, and spreading; may contract in waves Involuntary

Involuntary with inherent rhythm ANS with preganglionic neuron in CNS and posts in symp or parasymp ganglia of PNS

3. Describe the hierarchical structure of muscle from molecules to whole muscle, including its CT layer. See Left 4. Discuss how you would determine if a muscle is specialized for movement as opposed to power in terms of fiber length, cross-sectional area, and fiber architecture. Force generated by a muscles is proportional to the cross-sectional area of its muscle fibers (not weight) and movement is proportional to the length (and orientation) of its muscle fibers, which can shorten by about 30%. 5. Discuss the meaning of the phrase muscles spared when ligaments suffice relative to muscle tone and posture using examples from the upper limb. Muscles are generally silent at rest. Ligaments hold the bones in their resting position. In some cases, ligaments are not enough and some minimal contraction of a muscle might be needed at rest, as is the case of the upper trapezius in the shoulder joint. Resting position is maintained with mechanisms that maintain joints against the downward pull due to the weight of the limb. 6. Define shortening (concentric), isometric, and lengthening (eccentric) contraction of muscle and give several examples of each. Concentric contraction occurs when a muscle becomes shorter during contraction. The muscle as a whole is doing active work by generating more force than any external forces there may be (gravity, inertia, etc). Isometric contraction occurs when a muscle remains the same length during contraction. The muscular force and external forces are balanced to keep the two attachments of the muscle the same distance apart. Eccentric contraction occurs when a muscle becomes longer while contracting. The muscular force is less than the external forces of the muscle stretched despite active contraction. 7. Discuss the role of tendons as part of the MSK system Tendons are 100-200 times stronger than muscles. They have the architectural advantage of small size where muscles cross joints and the physiological advantage of providing required length at low metabolic cost. Tendons in parallel muscles reduce movement but not force, and reduce force but not movement in pennate m. 8. Define prime mover (agonist), antagonist, fixator (stabilizer), and synergist relative to muscle function. Prime mover: main muscle for a motion Antagonist: opposes action of a prime mover Fixator: stabilizes joint position Synergist: eliminates and controls unwanted movements (fist flexors + extensors) 9. Discuss the importance of gravity and inertia in movement and muscle function. Gravity and inertia are often the prime movers. Muscles often function as antagonists to resist and/or control gravity and inertia acting on body parts 10. Differentiate anatomical action from muscle function when discussing what a muscle does. Anatomical Action refers to motions at a joint produced by the shortening contraction of a muscle acting alone. Muscle function is the way a muscle functions in everyday life in a coordinated effort with other muscles. Lecture 5 Gross Structure and Function of Muscle, Part 2 Dr. Gene Albrecht, May 3, 2012 1. Describe the anatomical actions of the deltoid muscle relative to each axis for movement that occur at the shoulder joint. Anterior Part: flexion around transverse axis of humeral head and medial rotation around longitudinal axis, most anterior fibers produce adduction Lateral Part: abduction, pinnate arrangement of lateral fibers Posterior part: extension around transverse axis, lateral rotation around longitudinal axis, adduction
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2. List the anatomical actions of the biceps brachii muscle and explain its role as an antagonist to gravity during extension at the elbow. Flexes arm at shoulder joint, flexes forearm at elbow joint, and supinate forearm. When extending the elbow, the biceps act as an antagonist to gravity, contracting eccentrically to control extension. 3. Define protonation and supination, explain how the radius rotates relative to the ulna and identify the muscles responsible for these movements Supination: rotate forearm so palms face up Protonation: rotate forearm so palms face down The radius rotates over the ulna in pronation Pronator quatrausn Pronator teres: pronation Supinator, biceps brachii: supination (biceps if elbow flexed, force) 4. Discuss the role of the biceps brachii, supinator, triceps, and shoulder muscles in supination
Muscles Supinator Biceps Triceps Shoulder muscles Role Prime Mover Prime Mover Synergist Stabilizers Slow unresisted supination Fast supination with elbow flexed Fast supination with elbow extended Supination against resistance

+ -

+ + + +

+ -

+ + + +

5. Describe the structure and function of the sternoclavicular, acromioclavicular, and Scapulothoracic joints. Sternoclavicular joint: Extremely strong, articular disc acts as a ligament that tethers the clavicle to the sternum, considerable ball-and-socket like mobility, elevated up to 60 and move forward/back up to 30 Acromioclavicular: strength provided by coracoclavicular ligament which causes the scapula to be pulled along with any movement of the clavicle and vice versa; Dislocation=shoulder separation Scapulothoracic joint: no bone-to-bone articulation but there is considerable movement of the scapula on the body wall, the scapula is held in place by the muscles of the shoulder girdle that pass from the body wall (pec minor, trap, serratus ant, rhomboids, and levator scapulae) 6. Discuss the role of each muscle involved in abducting the arm above the head. Trapezius: Upper fibers elevate clavicle (and scapula), and retract, middle fibers retract scapula, lower fibers depress scapula and rotate glenoid fossa upwards, and retract Serratus Anterior: Protract scapula, lower fibers rotate glenoid fossa upwards Deltoid and supraspinatus abduct the humerus ~90 Lecture 6 Human Gait Dr. Mike Snow, May 8, 2012 1. Define the gait cycle, including 4 of its parts (heel-strike, mid stance, toe-off, and swing).
Heel strike: the instant the heel touches the ground; "loading response" Foot Flat: entire plantar surface of the foot in contact with the ground Mid-stance: body directly over stance limb Heel-Off: heel leaves ground. Pre-swing: big toe leaves the ground; toe-off Early Swing: immed. After toe leaves the ground. Late Swing: just prior to heel touching ground. 5

2. Draw the vertical line of gravity relative to the sacral promontory, and hip, knee & ankle joints. Pass posterior to hip joint, tendency to extend trunk at hip resist by tautness of iliofemoral ligament in front of hip joint capsule Pass anterior to knee, tendency to extend resist by tautness of cruciate ligaments & joint capsule Pass anterior to ankle, tendency to dorsiflex resist by contraction of soleus 3. Describe how excessive pelvic tilt is controlled during gait and the muscles involved. Pelvic tilt is controlled by isometric contraction of the gluteus medius and minimus. 4. Indicate the muscles, or muscle groups, that are active during parts of the gait cycle, and indicate if each muscle is acting by an eccentric or a concentric contraction.
Phase
Heel-Strike

Muscles
Gluteus Maximus & Hamstring Gluteus Medius and Minimus Ankle dorsiflexors Gluteus Medius and Minimus Quadriceps Gluteus Medius and Minimus Plantar flexors Gluteus Medius and Minimus Plantar flexors (calf) Plantar flexors Hip flexors Ankle dorsiflexors Iliopsoas and hip flexors Quadriceps Hamstring Dorsiflexors

Contraction
Isometric Isometric Eccentric Isometric Eccentric Isometric Eccentric Isometric Concentric Concentric Concentric Concentric Concentric Isometric Eccentric Isometric

Action
Hip Extensors, prevent trunk from pitching forward Prevent pelvis from tilting to swing side Offset gravity and set foot on ground in controlled fashion Prevent pelvis from tilting to swing side Keep knee from buckling as entire body weight transferred to stance limb Keep pelvis from tilting to side of swing leg Prevent unwanted dorsiflexion at ankle Prevent pelvic tilt toward swinging limb Lift heel off ground and contribute to forward thrust Provide forward thrust Stop extension at hip, initiate forward movement of limb Lift toes, prevent from stubbing on ground Accelerate forward motion of limb Prevent Unwanted excessive flexion at knee Slow forward momentum of thigh/leg in preparation for setting heel on ground Hold toes up in readiness for heel strike

Foot Flat Mid-Stance Heel-Off Pre-Swing Early Swing

Late Swing

5. Describe abnormal gaits associated with nerve lesions to muscles of the lower limb.
Lesion Superior Gluteal n. Iliopsoas m paralysis Hip extensor paralysis
Tibial Nerve Deep Fibular (peroneal) Nerve Obturator Nerve

Deficit Gluteus medius and minimus Iliopsoas paralyzed Gluteus maximus or hamstrings
Calf muscles (plantar flexors) inability to raise the heel off the ground Ankle dorsiflexors foot cant decelerated after heelstrike, toes cant clear ground in swing phase Adductors of the upper leg

Gait Throwing upper body to side of lesion Impossible to walk, cannot bring limb forward Leaning backward at heel-strike to keep from pitching forward at waist Small steps and dragging the limb forward
High stepping gait Limb deviating laterally during swing phase

Lecture 7 Functional Anatomy of the Hand Dr. Thomas McNeil, May 10, 2012 1. Know the basic anatomical movements of the wrist, fingers and thumb. Radiocarpal: flexion, extension, abduction & adduction Carpometacarpal of the digits 1-5: flexion, extension, abduction, adduction & rotation Metacarpophalangeal (MP): flexion, extension, abduction, adduction & limited rotation Interphalangeal (IP) of digits 1-5: flexion & extension only Thumb itself: Flexion, extension, abduction, adduction & opposition
Carpal bones: S. Scaphoid L. Lunate T. Triquetrum P. Pisiform Tm. Trapezium Td. Trapezoid C. Capitate H. Hamate (*=hook)

2. Know the innervation and anatomical functions of the intrinsic muscles of the hand.
Muscle Thenar muscles of thumb
Abductor pollicis brevis Flexor pollicis brevis Opponens pollicis

Innervation Anatomical Function Median n (recurrent Abduct, flex and oppose the thumb branch) Ulnar n Abduct, flex and oppose the 5th digit

Hypothenal muscles of little finger

Abductor digiti minimi Flexor digiti minimi Opponens digiti minimi

Interossei Lumbricals Adductor pollicis

Ulnar n 1st, 2nd median n 3rd, 4th ulnar n Ulnar n

Dorsal Abduction, Extend IP, Flex MP Palmar Adduction, Extend IP, Flex MP Extend IP joint, Flex MP joint Brings thumb into the palm of the hand

3. Know the cutaneous innervation of the hand and fingers.

4. Know what clinical tests are used to test for median, ulnar and radial nerve injuries.
Nerve Lesion Ulnar N
-at elbow, fracture of medial epicondyle or dislocation of elbow - Klumpkes palsy

Median N
-at wrist in attempted suicide

Radial N
-fracture of humerus shaft

Deficit Claw hand due to effect on both intrinsic and extrinsic muscles in chronic state Pt cannot AD or ABduct their fingers Loss of sensory innervation to little finger and hypothenar eminence Ape hand in chronic state Pt cannot oppose thumb and finger Loss of sensory innervation to thenar eminence Pt cannot extend wrist Loss of sensory innervation to dorsal surface of hand

Clinical Test Patient unable to grip or squeeze a piece of paper if placed between their fingers Pt cant grip an object to pick it up

Pt can still extend digits due to lumbricals

Lecture 8 The Knee Joint Dr. Michelle Winfield, May 14, 2012 1. Describe the bones and articular surfaces that form the knee joint, and relate them to the motion at the joint Hinge: flexion/extension,
around transverse axis (140)

Rolling and Gliding: on

articular surfaces

Rotation: around vertical

axis (30-40)

2. Discuss the morphology and function of the menisci (cartilages) Morphology: thin, crescent-shaped fibrocartilage positioned on top of the tibial condyles to create slightly more concave tibial surfaces for receiving the convex femoral condyles. Medial meniscus is C-shaped, Lateral is circular. Attached by a variety of ligaments to the tibia, both as margins and to intercondylar region. Function: stabilization, shock absorption, lubrication, and spacing 3. Understand the position, function and importance of the collateral and cruciate ligaments Lateral/Medial collateral ligaments: vertical, thickened band; thickening of the joint capsule, MCL attaches to the medial meniscus, LCL does not attach to the lateral meniscus Function: Aid in transverse stability of the knee, prevent hyperextension Anterior/Posterior cruciate ligaments: strong rounded cords that cross each other as they span between the intercondylar eminence of the tibia and the intercondylar surface of the femur Function: tense during full flexion and extension, act to control rotation, ant-post stability 4. Describe the fibrous capsule, synovial membrane and the bursae of the knee Fibrous capsule closes the knee joint and is reinforced by multiple tendons and ligaments. The synovial membrane lining the synovial membrane of the knee joint is the moist extensive and complicated in the body. It connects every point of articulation within the knee. 5. Consider a clinical case of knee injury to illustrate functional anatomy