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Lecture Note

Medical Course, 353241 Musculoskeletal System


Revision 2 (build 1411211837)
Kitchanan Kosalathip
Second year medical student, Khon Kaen University
2014 Kitchanan Kosalathip. All right reserved.
Lecture 1-2 Introduction to musculoskeletal system, osteology and arthrology
Examination
1. - ?
Coronal plane
2. axial bone ( axis)?
Clavicle
3. Costal process?
Ribs
4. ?
Pelvic cavity
5. Anatomical postion?
lateral
6. Sesamoid bone?
Patella bone Patella, pisiform
7. ?
Abduction Abductor pollicis longus
8. ?
Phalanges, metacarpals
9. Cranial bone?
?
Cranial bone: ethmoid, sphenoid, frontal, parietal, occipital, temporal
Facial bone: nasal, maxillae, zygomatic, mandible, lacrimal, palatine, vomer, inf. nasal conchae

Lecture 3 Spinal Nerve and Dermatome


Typical spinal nerve
Pass though intervertebral foramen
31 pairs: C1-8, T1-12, L1-5, S1-5, Co
Dorsal nerve root: dorsal root ganglion, sensory
Ventral nerver root: motor
Dorsal primary ramus
Medial branch, lateral branch
Contains: motor to deep back m., sensory to cutaneous n. of the back
Ventral primary ramus
Connect to sympathetic ganglion EXAM
White ramus communicans: outer,T1-T12 and L1-2, spinal cord to sympathetic ganglion
Grey ramus communicans: inner, sym. g. to spinal n.
Supply blood vessel, sweat glands, arrector pili
Neck, body, upper and lower limb, superficial back m.
T1-T12 intercostal n., subcostal n. (T12)
C1-C4 cervical plexus
C5-8, T1 brachial plexus
L1-L4 lumbar plexus
L4-5, S1-4 sacral plexus
S4-5, Co coccygeal plexus
C1 pass between skull and vertebra
Dermatome
Dermatome: area of skin supplied by a dorsal root of spinal n. EXAM
Myotome: group of muscles innervated by a single spinal n. root
C6 thumb
C7 middle finger
C8 little finger
T4 nipple
T10 umbilicus

Lecture 4-6 The back and posterior shoulder


Area EXAM
Deltoid region
Scapular region
Subscapular region
Vertebral region
Lumber region
Inguinal region
Surface anatomy
C7 vertebral prominens EXAM EXAM
L4 highest portion of iliac spine, lumbar puncture EXAM
T2-3 root of spine of scapular
T2-T7 medical border of scapular (T7, inferior angle of scapular) EXAM
S2 skin dimple, posterior superior iliac spine, bone marrow biopsy EXAM
EOP (external occipital protuberance)
Vertebral column
Body, pedicle, lamina, transverse processes, spinous process
Vertebral foramen
Superior articular surface pointed posteriorly
Inferior articular surface pointed anteriorly
C1 Atlas no body
C2 Axis dens
C1-C7 bifid spinous process, transverse process foramen: vertebral a. (except C7), v., vertebral nerve plexus EXAM
Thoracic 4 incomplete costal facets (except T1, T10-12 have complete facets)
Lumbar massive body
Sacrum 5 fused vertebra, 8 pelvic sacral foramina
Coccyx 4 fused vertebrae, no pedicle, lamina or spinous process
Primary curvature concave, thoracic and sacrococcygeal
Secondary curvature convex, cervical and lumbar
Kyphosis increased primary curvature
Lordosis increased secondary curvature
Scoliosis lateral curvature
Levels
C1 mouth
C2 superior cervical ganglion
C3 body of hyoid
C4 upper thyroid cartilage, bifurcation of common carotid artery
C6 cricoid cartilage
T4 manubrium (angle of louis), arch of aorta EXAM
Intercostal 4 nipple
T10 xiphoid process
L1 superior mesenteric artery
L3/4 umbilicus
L4 bifurcation of aorta

Superficial Muscles of Back


Supplied by ventral rami motor n.
Separated from deep m. by thoracolumbar fascia
Muscles

Origin

Insertion

Action

Innervation

Blood supply

Trapazius

EOP to T12

Clavicle
Scapular spine

Scapular
Occipital bone

CN XI
VR C3-C4

Superficial cervical
artery

Latissimus dorsi

T6-T12

Humerus

ARM
Scapular

Thoracodorsal n.

Thoracodorsal
branch of the
subscapular artery

Levator scapulae

C1-C4

Scapular

Scapular
Neck

Dorsal scapular n.

Rhomboid minor

C7-T1

Root of spine of
scapular

Scapular

Dorsal scapular n.

Rhomboid major

T2-T5

Scapular

Scapular

Dorsal scapular n.

Serratus posterior
superior

C7-T3

Rib 2-5

Elevate rib

VR ICN1-3

Serratus posterior
inferior

T11-L3

Rib 9-12

Depress rib

VR ICN9-11
Subcostal n.

Origin

Insertion

Action

Innervation

Blood supply

Nuchal ligament
Spinous process
C7-T6

Nuchal ligament

DR

Muscular branches
of the aorta

Transverse
process

DR

Transverse
cervical artery and
occipital artery

Capitis
Cervicis
Thoracis
Lumborum

DR

DR

Deep Muscles of the Back


Supplied by dorsal rami motor n.
Muscles
Superficial group
Splenius capitis
Splenius cervicis

Intermediate (transversocostal) group


Sarcospinalis (erector spinae)
Iliocostalis (outer)
Longissimus
Spinalis (inner)
Deep (transversospinal) group
Semispinalis
Spinalis
Multifidus
Rotatores
Interspinalis
Intertransverse

Suboccipital muscles
Rectus capitis
posterior minor

C1

Inf. nuchal line

Suboccipital n.
(DR C1)

Rectus capitis
posterior major

C2

Inf. nuchal line

Suboccipital n.
(DR C1)

Oblique capitis
superior

C1 transverse p.

Occipital bone

Suboccipital n.
(DR C1)

Oblique capitis
inferior

C2

C1 transverse p.

Suboccipital n.
(DR C1)

Suboccipital Triangle
Boundary
Rectus capitis posterior major
Oblique capitis inferior
Oblique capitis superior
Contents: suboccipital n. (DR C1), vertebral a.
Muscles of Posterior Shoulder
Muscles

Origin

Insertion

Action

Innervation

Blood supply

Deltoid

Clavicle
Acromion
Spine of scapular

Deltoid tuberosity
of humerus

Axillary n.

Thoracoacromial
a.
Humeral
circumflex a.

Supraspinatus

Supraspinous
fossa of scapula

Greater tubercle of humerus

Suprascapular n.

Suprascapular a.

Infraspinatus

Infraspinous fossa
of scapula

Greater tubercle of humerus

Suprascapular n.

Suprascapular a.
Circumflex
scapular a.

Teres major

Inferior angle of
scapula

Medial lip of the


intertubercular
sulcus of the
humerus EXAM
EXAM

Lower subscapular Subscapular a.


n.
Circumflex
scapular a.

Teres minor

Lateral border of
scapula

Greater tubercle of humerus

Axillary n.

Posterior
circumflex humeral
a.
Circumflex
scapular a.

Triangular space teres major, teres minor, long head of triceps; circumflex scapular a.
Quadrangular space teres major, teres minor, long and lateral head of triceps brachii; axillary n., posterior humeral
circumflex a.
Rotator cuff supraspinatus, infraspinatus, teres minor, subscapularis
Abduction at Shoulder
0-40 supraspinatus (prime mover)
40-90 supraspinatus, deltoid
90-180 rotation of scapular: trapezius, serratus anterior
180 external rotation of humerus: infraspinatus
Examination
1. Vertebral prominent?
Spinous process of C7
2. Lateral rotation scapula? Lateral rotation of scapular = adduction of the scapula
Trapezius Trapezius and rhomboids
3. ?
Deltoid 40-90 degress
4. ?
Latissimus dorsi
5. sarcospinalis?
Longissimus Iliocostalis (outer), longissimus, spinalis (inner)

6. medial border?
Teres major Inferior angle of scapula
7. lesser tubercle?
Subscapularis Lesser tubercle: subscapularis, Greater tubercle: supra/infraspinatus, teres minor
8. Levator scapulae supply artery ?
Dorsal scapular a.
9. Ligament lamina?
Ligamentum flavum Connect the laminae of adjacent vertebrae
10. ligament of vertebral herniation ?
Posterolateral Anterior longitudinal ligament, posterior longitudinal ligament
11. Joint C1-C2?
Pivot joint
12. lordosis, kyphosis?
?
Kyphosis increased primary curvature
Lordosis increased secondary curvature
Scoliosis lateral curvature
13. lateral?
Splenius
14. ligament of vertebral herniation ?
Posterolateral
15. Levator scapulae supply artery ?
Dorsal scapular a.
16. ?
Deltoid m.
17. ?

18. sarcospinalis?
Longissimus Iliocostalis (outer), longissimus, spinalis (inner)
19. medial border of scapular?
Teres major
20. ?
Great occipital n.
21. Scoliosis vertebral column ?
Lateral curvature

22. Nerve supply of trapezius?


Accessory nerve Spinal accessory n., C3-4
23. Deltoid Nerve ?
Axillary nerve
24. content suboccipital triangle?
3rd part of vertebral artery Suboccipital triangle: suboccipital n., vertebral a., suboccipital plexus of v.
25. ?
Supraspinatus

26. Nerve ?
Subscapularis m. Upper and lower subscapular n.
27. Root of spine of scapula vertebra ?
T2-3
28. vertebra cervical?
Costal facet Thoracic vertebra
29. transversospinalis?
? Transversospinalis: semispinalis, spinalis, multifidus, rotatores, interspinalis, intertransverse
30. spinous process of C2?
Oblique capitis superior Spinous p. of C2: rectus capitis posterior major, oblique capitis inferior, semispinalis cervicis
31. Sternal angle ?
Rib 2, T4
32. medial lip intertubercular groove?
Teres major

33. Iliac crest ?


L4

Lecture 7-8 Muscle contraction


Organization: Muscle epimysium fascicle perimysium endomysium muscle fibre sarcolemma myofilbril
Muscle fiber
Myosin filament (M line, A band or dark band)
Acting filament (Z disc, I band or light band)
Active site (myosin binding site)
Tropomyosin close over active site
Troponin
Troponin C bind to calcium
Troponin I inhibit troponin T
Troponin T attach to tropomyosin
Triad
T tubule
Sarcoplasmic reticulum store calcium ions
Mechanism
Action potential motor n. neuromuscular junction muscle fiber
Nerve ending secretes ACh
ACh receptor Na+ influx to muscle fiber depolarization of sarcolemma Ca2+ release
Ca2+ bind to troponin C tropomyosin separate from active site
Sliding
Ca2+ pump back to SR muscle relaxation
Contraction
Motor unit all muscle fibers innervated by a single motor nerve fiber
Twitch contraction
Threshold stimulus, maximum stimulus
Twitch duration, contraction time
Latent period period of contraction period of relaxation
Motor unit summation graded response
Wave summation (frequency summation): incomplete fusion tetanus (complete fusion) fatigue
Length of sarcomere and tension develop
Resting length
Length-tension curve of muscle
Active tension force from muscle contraction
Passive tension force from muscle elastic components
Total tension
Source of energy
ATP 1-2 seconds
Phosphocreatine 7-8 seconds
Glycogen (stored in muscle cells) 1 min; glycogen ATP + lactic acid (muscle fatigue)
Oxidative metabolism 1 hours; glycolysis, Krebs cycle
Characteristic of whole muscle contraction
Isometric contraction constant length but tension increase
Isotonic contraction constant tension but length of muscle change
Concentric length of muscle shorten
Eccentric length of muscle increase
Types of muscle fiber EXAM
Type I muscle fiber (red muscle fiber, slow fibers)
Small fibers, extensive blood supply, oxidative metabolism, myoglobin
Endurance
Type
II muscle fiber (white muscle fiber, fast fibers)

Large
fibers, extensive sarcoplasmic reticulum, large amount of glycolytic enzyme

Strength

Muscle hypertrophy
Hypertrophy of individual muscle fiber maximal force contraction synthesis of contractile protein
Increase number of myofibril
Increase number of sarcomere eccentric contraction

Muscle atrophy
Muscle denervation
3 months full return of function
1-2 years fibrosis no return of function
Rigor mortis
Several hours loss ATP during relaxation period state of contracture
15-25 hours muscle protein autolysis by lysosome
Smooth muscle
Spindle-shaped cell, centrally mononucleated
Single unit smooth m. cells are interconnected via gap junction (nexuses), contract as a unit e.g. GI tract, urogenital tract
Multi unit smooth m. cells are independent e.g. airways, vasculature
Mechanism of contraction
Neurotransmitter: ACh, NE
Ca2+ released from SR and ECM
Ca2+ + calmodulin Ca2+-calmodulin complex myosin light-chain kinase (MLCK)
Cardiac muscle
Branching pattern intercalated disc
1 T tubule per sarcomere (vs 2 T tubule in skeletal m.)
Diseases

Pathophysiology

Clinical manifestation

Myofascial pain syndrome


(MPS)

Energy crisis
Calcium leak
Muscle tissue trauma

Lump, pain in trigger point, referred pain


Treatment: dry needle, ultrasound, stretching

Muscle cramp

Vitamin deficiency
Lactic acid accumulation
Dehydration, low Ca2+, K+ or Mg2+

Treatment: stretching

Delay onset muscle


soreness (DOMS)

Microscopic tearing of muscle fibers

Electromyography (EMG) detects the electrical potential generated by muscle cells


Examination
1. muscle contraction?
A. muscle fiber
B. calcium reabsorbed back to SR
C. sarcomere
D. troponin Ca2+
E. myosin-ATPase covert ATP to ADP+Pi
2. What is the different between slow-twitch fibers and fast-twitch fibers?
A. red fiber sarcoplasmic reticulum
B. white fiber energy from glycolytic process
C. red fiber low density capillary
D. white fiber small
E. red fiber strength
3. ?
pacemaker
4. ?
C. , plasticity,
5. ?
A. isokinetic
B. isometric
C. concentric isotonic
D. eccentric isotonic

6. ?
Troponin C
7. ?
? Branching pattern intercalated disc, 1 T tubule per sarcomere
8. ?
A. Troponin C

B.
C. active site Actin Tropomyosin
D. sarcoplasmic reticulum
E. filament theory
9. complete tetanus?
Plateau phase of cardiac muscle
10. tetanus?
long absolute refractory period
11. ?
Subthreshold stimulus
12. ?
1 power stroke
2 motor end plate.....
3 release Ca
4 uptake Ca
2314
13. ?
Muscle fiber

14. ?

Lecture 9-9.5 Cartilage, Bone, Joint


Cartilage

Specialized CNT, avascular tissue poor regeneration EXAM


Development: mesenchymal cells (mesoderm) chondroblasts chondrocytes (in lacuna) cartilage cell nest
Hematoxylin dye
Compositions
Chondroblasts, chondrocytes
Intercellular substances (ICS, ECM)
Collagen fiber (type II, elastic)
Ground substance (proteoglycans, glycosaminoglycan, chondroitin sulfate)
Water (semi-fluid)
Perichondrium: dense CNT, except articular surface
Fibrous layer (outer)
Chondrogenic layer (inner)
Regenerate by perichondrial cells, or by CNT (scar, dense CNT)
Degeneration dead, or calcification (intracartilagenous ossification)

Cartilage Classification
Type

Characteristics

Sites

1 Hyaline cartilage

ICS: collagen fiber type II


Transparent matrix

articular cartilage, nasal and septal cartilage, trachea, larynx, costal


cartilage EXAM

2 Elastic cartilage

ICS: elastic fiber

Pinna, auditory tube, epiglottis

3 Fibrocartilage

ICS: collagen fiber type I


No perichondrium

Intervertebral disc, pubic symphysis, tendon insertion

Cartilage Growth
Type

Characteristics

1 Interstitial growth

Cell mitosis (inner to outer)


Occur in early life

2 Appositional growth

Chondrogenic cell layer differentiation (outer to inner)


Occur in childhood and adult

Bone (osseous tissue)

Specialized CNT, highly vascularized tissue


ICS: inorganic substance hardness
Composition
Bone cells: osteoblasts osteocytes, osteoclasts (multinucleated cells, bone resorption, monocyte precursor
Howships lacuna)

ECM trabecular
Organic substance: collagen fiber type I, proteoglycans, bone proteins EXAM
Inorganic substance: hydroxyapatite (calcium phosphate)
Periosteum EXAM
Fibrous layer dense CNT
Osteogenic layer osteoprogenitor cells, Sharpeys fibers
Endosteum
Single layer of osteoprogenitor cells
Medullary cavity (contains yellow marrow)

Bone Classification by Microscopic Examination


Type
1 Immature (primary, woven) bone

Characteristics

Sites

Osteocytes, proteoglycans
Collagen fiber unstructured

Tooth socket, osseous labyrinth, bone repair

2 Mature (secondary, lamina) bone -

Bone Classification by Macroscopic Examination


Type

Characteristics

1 Spongy (cancellous) bone 2 Compact (cortical) bone

Haversian system Haversian canal, canaliculi, Volkmanns canal (perforating cannel)


Interstitial system (lies between Haversian system)
Outer and inner circumferential system

Bone Ossification
Type

Characteristics

1 Intramembranous ossification Mesenchymal cells osteoblasts

Sites

Nasal, sphenoid (medial pterygoid plate) bone


Frontal, parietal, temporal (squamous part) bone
Vomer, maxilla, mandible
Pelvis
Clavicle
Subperiosteal surface of long bone

2 Intracartilagenous ossification 4-5 wk. cartilage formation


6-7 wk. replace by bone formation
Ossification EXAM
Formation of the cartilage model
Primary center of ossification at diaphysis
Secondary center of ossification at epiphysis
Zone: transitional zone, etc.
Epiphyseal plate (growth plate) epiphyseal line
Bone Healing
Phase

Descriptions

1 Inflammatory phase

0-1 wk. granulation tissue formation

2 Reparative phase

2-6 wk. callus formation (internal and external callus)

3 Remodeling phase

Joint (Articulation) Functional Classification


Type
1 Non-synovial joint

2 Synovial joint

Subtype

Descriptions

Synarthroses

Permits little or no mobility


Most are fibrous joints e.g. skull sutures EXAM

Amphiarthrosis

Permits slight mobility


Most are cartilaginous joints e.g. intervertebral discs

Diarthrosis

Freely movable
All are synovial joints
Articular surface (hyaline cartilage)
Synovial cavity
Joint capsule
Fibrous capsule (outer)
Synovial membrane (inner) synovial fluid
Specialized collagenous CNT
Discontinuous 1-4 cell layer
No basement membrane
No junctional complex

Joint (Articulation) Structural Classification


Type
1 Fibrous joints
(little to no movement)

2 Cartilaginous joints

3 Synovial joints

Subtype

Descriptions

Sutures

Peculiar to skull and are immovable

Syndesmosis

Joints the bones are connected with interosseus ligament

Gomphosis

Peg and socket joints e..g tooth socket.

Primary cartilaginous joints


(synchondrosis)

Bones are united by a plate of hyaline cartilage

Secondary cartilaginous j.
(symphysis)

Also known as fibrocartilaginous joints

Examination
1. Hyaline cartilage in adult?
Articular surface
2. ?
Avascular tissue
3. ?
Periosteum
4. ?
Bone remodeling
5. Intracartilaginous start at?
Diaphysis Intracartilaginous ossification: diaphysis, epiphysis (vs intramembranous ossification)
6. Suture joint ?
Synarthroses
7. organic substance?
Collagen type I Bone: collagen type I, cartilage: collagen type II
8. canaliculi ?
Osteocyte process

9. fibrocartilage ?
Tendon insertion Fibrocartilage: intervertebral disc, pubic symphysis, tendon insertion
10. ( epiphyseal plate ) ?
18-20
11. Secondary ossification ?
Epiphysis Primary ossification: diaphysis, secondary ossification: epiphysis
12. ?
25-30
13. suture ?
Syndesmosis ?
14. Havasian system ?
Cement line Cement line outer circumferential lamellae havasian system

Lecture 10-11 Axillary and Pectoral Region


Surface anatomy
Mid (sternal) line
Midclavicular line
Anterior/mid/posterior axillary line

Jugular notch
Sternum manubrium (upper), sternal angle (2nd rib), body
Xiphisternal joint joint (T9)
Xiphoid process (T10)

Deltopectoral triangle (infraclavicular fossa) EXAM Contents


Coracoid process
Cephalic v. axillary v.
Deltoid branch of thoracoacromial a.
Lateral pectoral n.
Deltopectoral lymph node
Application
Brachial plexus block
Venous cut down (cephalic v.)
Cutaneous n. ventral rami of thoracic spinal n. 1-6
Muscles of Pectoral Region
Muscles

Origin

Insertion

Action

Innervation

Blood supply

Pectoralis major

Clavicular head
Sternocostal head
Abdominal head

Lateral lip of
intertubercular
sulcus of the
humerus EXAM

Humerus

Lateral pectoral n.
Medial pectoral n.

Pectoral and
deltoid branch of
thoracoacromial a.

Pectoralis minor

Rib 3-5

Coracoid process

Protract scapular

Medical pectoral n. Pectoral branch of


thoracoacromial a.

Subclavious

Rib 1

Inferior surface of
clavicle

Depress clavicle

Nerve to
subclavious

Serratus anterior

Rib 1-8

Medial border of
scapular

Protract scapular

Long thoracic n.
Lateral thoracic a.
CC winged scapular

Fascia
Pectoral fascia pectoralis major
Clavipectoral fascia costocoracoid membrane (upper), suspensory ligament of axilla (lower)
* Mastectomy risk damage long thoracic n. winged scapular

Clavicular branch
of
thoracoacromial a.

Axillary Artery
Subclavian a. axillary a. (rib 1 teres major) brachial a.
Divided into 3 parts by pectoralis minor
Part

Division

Subdivision

Supply

1st

Supreme (superior) thoracic a.

ICS 1-2
Serratus anterior
Brest

2nd

Thoracoacromial a.

A acromial branch
P pectoral branch
C clavicular branch
D deltoid branch

Lateral thoracic a.
(with long thoracic n.) EXAM

Serratus anterior

Subscapular a.

Circumflex scapular a.

Thoracodorsal a.
(with thoracodorsal n.) EXAM

Latissimus dorsi

Posterior circumflex humeral a.


(with axillary n.) EXAM

3rd

Anterior circumflex humeral a.

Axillary Veins
Cephalic vein
Basilic v. axillary v. (teres major rib 1) subclavian v.
Axillary Lymph Nodes EXAM
Groups

Drainage

1 Pectoral (anterior) group

Thoracic wall, chest

2 Subscapular (posterior) group

Scapular

3 Humeral (lateral) group

Upper limb

4 Central group

5 Apical group Supraclavicular node

Brachial Plexus EXAM EXAM


Root
(ventral rami)

Trunk

Division

C5
Upper trunk
Anterior division
Dorsal scapular n. Nerve to subclavious
Suprascapular n.
C6
C7

Branches

Lateral cord
Lateral pectoral n.

Musculocutaneous n.
Lateral root of median n.

Posterior cord
Upper subscapular n.
Thoracodorsal n.
Lower subscapular n.

Axillary n.
Radial n.

Posterior division
Middle trunk

C8
T1

Cords

Anterior division

Posterior division
Lower trunk

C5-C7
Long thoracic n.

Anterior division

Medial cord
Ulnar n.
Medial pectoral n.
Median root of median n.
Medial cutaneous n. of arm
Medial cutaneous n. of forearm

Posterior division

Clinical correlation
Brachial plexus block
Cervical approach (sternocleidomastoid m.) root ,
Supraclavicular approach (clavicle to rib 1) trunk and division
Axilla approach cord
Brachial
plexus injuries

Erbs
palsy
(ErbDuchenne palsy) root C5-C6 (upper trunk), waiters tip palsy

Klumpke's
palsy
root C8-T1 (lower trunk)

Compression

Cutaneous nerve of arm EXAM


Inferior lateral cutaneous nerve of arm branch of the radial nerve
Superior lateral cutaneous nerve of arm branch of the axillary nerve
Lateral cutaneous nerve of forearm continuation of the musculocutaneous nerve
Posterior cutaneous nerve of arm another branch of the radial nerve
Examination
1. Content deltopectoral triangle?
Cephalic v.
2. wing scapula .?
Serratus anterior Long thoracic n.
3. masectomy () ?
Serratus anterior
4. Dual innervation?
Pectoralis major Medial pectoral n. and lateral pectoral n.
5. Root of brachial plexus?
Long thoracic n.
6. Axillary nerve ?
Teres minor Deltoid and teres minor
7. Erb (waiter tip's syndrome) ?
Upper trunk of C5-C6

8. Claw hand?
C8-T1 Klumpke's palsy
9. ?
Anterior axillary node
10. lower subscapular nerve ?
Teres major Lower subscapular nerve: subscapularis and teres major
11. Claw hand (Klumpkes palsy)?
C8, T1
12. Nerve brachial plexus clavicle?
Dorsal scapula n., long thoracic n., n. to subclavius, suprascapular n.
13. Deltopectoral triangle ?
Cephalic v., lateral pectoral n., deltoid br. of thoracoacromial a.
14. flex, adduct and rotate arm medially ?
Pectoralis major
15. root of T1 Nerve ?
Medial cutaneous n. of arm Anterior division of lower trunk medial cord

16. Lower lateral cutaneous n. of arm nerve ?


Radial n.

Lecture 12.5-14.5 Pathology of bone, cartilage and soft tissue


Osteoblast-derived proteins: alkaline phosphatase, etc. EXAM
Osteoprotegrin block RANK-RANK ligand interaction inhibit osteoclast differentiation EXAM

Pathology of bone, cartilage and soft tissue EXAM


Diseases

Etiology

Pathophysiology

Clinical manifestation

Dysostosis

Mutation in TF
EXAM

Migration of mesenchymal cells

Congenital absents
Syndactyly

Achondroplasia

AD mutation (new
mutation)

FGFR3 mutation inhibition of


cartilage proliferation abnormal
growth plate

Heterozygous: normal
Homozygous: narrow foramen magnum,
small thorax death

Osteogenesis
AD
imperfecta
(brittle bone disease)

Collagen type I osteoid

Fracture, short stature


Blue sclera
Dentinogenesis imperfecta

Osteopetrosis
(marble bone
disease)

Carbonic anhydrase
II deficiency

Impaired acidification of resorption Severe AR pattern bone marrow


pit impaired osteoclasts
failure
bone resorption skeletal
Mild pattern anemia
sclerosis
Radiologic examination
Absent corticomedullary demarcation
Erlenmayer flask deformity
Fracture

Osteomalacia and
rickets

Vit. D def.

Inadequate mineralization
excess unmineralized matrix
Inadequate synthesis
Decrease absorption
Vitamin D metabolism

Osteoporosis

Localized: disuse
Diffuse: metabolic diseases
Primary osteoporosis: menopause, senile
Secondary osteoporosis: endocrine, neoplasia, GI,
rheumatologic disease drug e.g. steroids, alc.

Vertebral fracture
Pain
Bone loss

Osteonecrosis
(avascular necrosis)

Fracture
Steroids etc.

Ischemia

Empty lacuna

Osteomyelitis

Infections
S. aureus

Acute inflammation
Bone necrosis (sequestrum)
resorption deposit
involucrum EXAM
Chronic inflammation: 1 wk

Hyperparathyroidism

Osteomalacia
Osteopenic radiologic pattern
Poorly localized bone pain
Osteoid seam (unmineralized bone)
EXAM
Rickets
Cup-shaped epiphysis
Pigeon chest EXAM
Harrison groove

Radiologic examination
Triangular/wedge shaped

Acute systemic illness


Throbbing pain
Radiologic examination
Osteolytic lesion

Tuberculous osteomyelitis
AIDS multifocal
Extensive necrosis Pott disease (paravertebral
abscesses) EXAM

Localized tenderness
Low grade fever
Weight loss

Primary: parathyroid adenoma


Secondary: renal failure

Cystic brown tumor (pseudo-tumor)


Hypercalcemia
Fracture
Radiologic examination
Osteopenia
Subperiosteal bone resorption EXAM

Fibrous dysplasia

Bone maturation disorder halted remodeling,

abnormal fibrous tissue proliferation


Monostoyic
Polyostotic: Albrights syndrome

Mature CNT with irregular woven


bone trabeculae

No osteoblastic rimming
Radiologic examination
Osteopenia
Ground-glass appearance EXAM

Tumor of bone, cartilage and soft tissue EXAM


Diseases

Characteristics

Clinical manifestation

Benign Osteogenic Tumors


Osteoid osteoma

Site: cortex of metaphysis

Nocturnal pain
Relieved by aspirin
Radiologic examination
Radiolucent nidus 2 cm surrounded
by osteosclerosis (sclerotic reactive
bone)
Well demarcated

Osteoblastoma

Giant osteoid osteoma


Site: metaphysis or diaphysis of long bone

Radiologic examination
Radiolucent nidus >2 cm
No surrounding osteosclerosis

Malignant Osteogenic Tumors


Osteosarcoma
EXAM EXAM

Primary osteosarcoma: RB gene


Secondary osteosarcoma: radiation, chronic

osteomyelitis
Osteoid production of neoplastic cells
Site: metaphysis (conventional type) of femur and tibia
Bimodal age distribution: 10 (de novo), 40 years old

Fast growing (vs chondrosarcoma)


Radiologic examination
Codmans triangle
Sunburst periosteal reaction
Treatment: amputation

Benign Chondrogenic Tumors


Chondroma

Site: metaphysis

Radiologic examination
Multiple lobulated translucent mass
C/O ring sign (bubble-like)

Osteochondroma

Site: metaphysis
Outgrowth of medullary bone and cartilage covered

Rapid growth, pain

with cartilaginous cap (exostosis)


10-20 years old, AD (EXT gene) EXAM

Radiologic examination
Mushroom-shaped, or sessile
protuberance from bone shaft

Chondroblastoma

Site: epiphyses

Pain
Biopsy: round cell, osteoclast-like giant
cells

Chondromyxoid
fibroma

Rare

Biopsy: spindle shaped or stellate cells


in mixed or chondroid stroma

Malignant Chondrogenic Tumors


Chondrosarcoma

Age 40 years old


No osteoid production osteosarcoma

Slow growing (vs osteosarcoma)


Radiologic examination: snowstorm
Biopsy
Double lacuna
Bizarre giant cells
Treatment: amputation

Differentiated
chondrosarcoma

Mesenchymal
chondrosarcoma

Malignant Hematopoietic Tumors


Myeloma

Malignant lymphoma -

Benign Fibrogenic Tumors


Malignant Fibrogenic Tumors
Fibrosarcoma
Other

Osteoclastoma
(giant cell tumor)

Site: epiphysis
Common in distal radius, proximal femur
Neoplastic stromal cells (mesenchymal cells)
osteoclasts

Ewing sarcoma

Translocation (11,12) EXAM


Site: diaphysis
CD99+

Locally aggressive
Radiologic examination
Soap bubble
Lytic lesion without sclerosis
Radiologic examination
Onion-skin periosteal reaction
Biopsy
Uniform small round-nuclei cells
Pseudorosette (Homer-Wright r.)

Joint diseases EXAM


Diseases

Characteristics

Clinical manifestation

Osteoarthritis (OA)

Etiology: degenerative joint disease


Cartilage fracture synovial fluid leak into subcondral
region subchondyal cyst
Bone eburnation

Achy pain
Crepitus
Morning stiffness
Woman: Heberden nodes in the finger
(prominent osteophytes at the distal
interpharyngeal joint) EXAM
Loose bodies EXAM

Etiology: autoimmune disease


Synoviocytes proliferation (CD4+)
Rice bodies (fibrin deposition) EXAM
Osteoclast activity
Bony ankylosis

Rheumatoid nodules (skin)

Etiology: hyperuricemia (>7 mg/dl) urate crystal


deposition inflammation
Acute gouty arthritis
Chronic gouty arthritis tophi

Gouty nephropathy (renal uric acid

Calcium
pyrophosphate
crystal deposition
disease (CPCD)

Deposition of crystal in articular matrix


Geometric or oval shape (vs urate crystal)

Similar to gout, OA

Infectious arthritis

Bacterial infection
Acute monoarticular arthritis
Tuberculous arthritis
Progressive monoarticular arthritis
Fibrous ankylosis

Pain
Limited range of motion

Rheumatoid arthritis

Gout

palisading granuloma with fibrinoid


necrosis
Swollen, painful, morning stiffness
Symmetrical arthritis
Radiologic examination
Swan-Neck deformity (DIP
hyperflexion with PIP hyperextension)
EXAM

stone)
Associated with Lesch-Nyhan
syndrome EXAM

Tumor and Tumor-like Lesion of Joint


Diseases

Characteristics

Clinical manifestation

Ganglion cyst

No epithelial lining (pseudo cyst)


Occur at tissue around joint capsule and tension

Firm nodule 1-1.5 cm, mostly at wrist

sheath

Not communicate with joint space


Cyst contains gelatinous fluid EXAM
Synovial cyst

Synovial cell lining


Herniation of synovium trough joint capsule or bursa
Bakers cyst (popliteal cyst) RA of knee joint EXAM

Pigmented
villonodular synovitis
(PVNS)
(diffuse giant cell t.)

Benign neoplasm of synovial lining of joint


Histology: giant cell
Finger-like formation

Arthritis, pain
Mass

Giant cell tumor of


tendon sheath

Arthritis, pain
Mass

Synovial cell lining


Herniation of synovium trough joint capsule or bursa
Histology: giant cell
Well circumscribed mass
Most common tumor of digits EXAM

Soft Tissue Tumors EXAM


Mostly benign, occur in elders
Cell morphology spindle cell, small round cell, epitheloid cell
Pattern fascicles, storiform, herring-bone, biphasic, nuclear palisading
Diseases

Characteristics

Clinical manifestation

Benign tumor of fat cell


Well-encapsulated

Age: Adulthood
Treatment: surgical removal

Tumor of adipocyte
Lipomas

Variants
Angiolipoma
Myxoid lipoma
Intramuscular lipoma
Liposarcoma

Biopsy: atypical lipomatous tumor (well differentiated


liposarcoma)

Age: 40-60 years old


Site: tight and peritoneum

Tumors of fibroblast and myofibroblast


Dermatofibrosarcom
a protuberans

Biopsy: storiform pattern EXAM EXAM


CD34 positive

Treatment: wide excision

Dermatofibroma
(cutaneous fibrous
histiocytoma)

Biopsy: storiform pattern, collagen


CD34 negative EXAM

Fibromatoses

Superficial fibromatoses
Benign tumor at palm and sole (palmar and plantar
fibromatosis)
Herring-bone pattern, spindle-shaped cell EXAM

Dupuytrens contracture (palmar


fibromatosis) EXAM

Desmoid-type fibromatoses
Fibrosis mixed with collagen
Subtypes
Extraabdominal desmoid
Abdominal desmoid
Intrabdominal desmoid
Fibrosarcoma

Undifferentiated (unclassified) sarcoma high grade tumor


Undifferentiated pleomorphic sarcoma
Undifferentiated spindle cell sarcoma
Undifferentiated round cell sarcoma
Undifferentiated epitheloid sarcoma
Skeletal muscle tumors
Rhabdomyoma

Rare

Rhabdomyosarcoma

Round cell (tad-pole)


Non-specific marker: desmin, muscle-specific actin
Specific marker: myogenin, MyoD1

Types
Embryonal rhabdomyosarcoma (sarcoma botryoides)
EXAM EXAM
Polypoid grape-like growth pattern
Alveolar rhabdomyosarcoma
Pleomorphic rhabdomyosarcoma
Benign tumors of blood and lymph vessels
Hemangioma

Types: carvernous, venous, capillary, etc.


Granulation tissue-type hemangioma
Pyogenic granuloma EXAM rapid growing red
nodule, easily bleed or ulcerated
Intramuscular hemangioma

Lymphangioma

Malignant tumors of blood and lymph vessels


Angiosarcoma

Marker: CD31*, CD34, vWF

Types
Juvenile hemangioma strawberry nevus
Tumors of uncertain histogenesis
Synovial sarcoma
(SS)

Not related to synoviocytes


Monophasic (spindle-shaped) or biphasic (spindle and

Aggressive

epithelium cells)

Translocation of X:18 EXAM


Examination
1. Cyst RA?
Bakers cyst
2. Congenital dwarfisms caused by derangement in epiphyseal cartilaginous growth ?
A. Achondroplasia AD, FGFR3 mutation inhibit cartilaginous proliferation
B. OI type IV Collagen type I osteoid
C. Fibrous dysplasia Bone maturation disorder, ground-glass appearance
D. Osteoporosis
E.
3. Tuberculosis osteomyelitis and paravertebral abscess ?
Pott's disease Bone necrosis (sequestrum) resorption deposit involucrum
4. osteosarcoma?
fibrous dysplasia
Primary osteosarcoma: RB gene
Secondary osteosarcoma: radiation, chronic osteomyelitis
Radiology: Codmans triangle, sunburst periosteal reaction
5. Osteochondroma gene 2 hit hypothesis ?
EXT gene
6. Which is the characteristic of swan neck deformity of late onset rheumatoid arthritis?
DIP hyperflexion with PIP hyperextension
7. Hebernen's node osteoarthritis ?
osteophyte prominent osteophytes at the distal interpharyngeal joint
8. malignant ?
Lung cancer
9. histo show storiform?
A. Adult fibrosarcoma
B. Synovial sarcoma
C. Desmoid fibromatosis fascicular pattern, spindle-shaped cell
D. Undif pleo sarcoma
E. Dermofibrosarcoma protuberance storiform pattern
10. Tumor most common (digits)?
Giant cell tumor of tendon sheath (nodular tenosynovitis)
11. Mutated transcription factor?
Syndactyly Dysostosis
12. osteoid seam?
A. Rickets Pigeon chest
B. Osteomalacia
C. Hyperparathyroid

13. specimen ?
Synovial fluid
14. soft tissue tumor?
A. Fat cell Lipoma, liposarcoma
B. Fibroblast Dermatofibroma, dermatofibrosarcoma protuberans, fibromatoses, fibrosarcoma
C. Melanocyte
D. Langhan's cell
E. Skeletal muscle Rhabdomyoma, rhabdomyosarcoma
15. Dupuytrens contracture tumor ?
A. Palmar fibromatosis fixed flexion contracture of the hand due to a palmar fibromatosis
B. Fibrosarcoma
C. Dermatofibroma
D. Neurofibroma
E. Hemangioma
16. Osteoprotegrin (decay receptor for RANKL) cell ?
Precursor osteoblast
17. osteomalacia? Vit. D. deficiency PTH, phosphate reabsorption in kidney bone resorption,
phosphate
A. Ca2+ serum Decrease calcium absorption from GI
B. Density bone film X-rays
C. Phosphate serum
D. Parathyroid serum
18. Sarcoma botryoides?
Embryonal rhabdomyosarcoma
19. t(x,18)?
Synovial sarcoma
20. Loose bodies?
Osteoarthritis
21. TB spine with paravertebral abscess?
Pott's disease
22. Ganglion ( no membrane lining + gelatinous fluid) ?
Myxoid degeneration of CNT
23. diagnosis dermatofibroma?
Acanthosis Hyperplasia of epidermis
24. Herring-bone pattern?
Fibrosarcoma
25. Recurrence ?
Intramuscular hemangioma
26. ?
Synovium
27. x-ray osteopenia?
Osteoarthritis
28. ?
calcium pyrophosphate pseudogout Calcium pyrophosphate crystal deposition disease (CPCD)
29. Osteochondroma ?
Epiphyseal plate

30. Tumor ?

31. Ewing sarcoma small round cell tumor?


t(11,12)
32. autoimmune rice body?
Rheumatoid arthritis

Lecture 15.5-17.5 Upper Limb


Bones
Shoulder (pectoral) girdle

clavicle, scapular

Arm (brachium)

Humerus
Head of humerus articulate with glenoid cavity glenohumeral joint
Anatomical neck joint capsule attachment
Greater/lesser tubercle rotator cuff muscle attachements
Surgical neck axillary n., posterior humeral circumflex a. EXAM EXAM
Intertubercular/bicipital groove long head of biceps brachii tendon
Radial/spiral groove radial n., profunda brachii (deep brachial) a. EXAM EXAM
Deltoid tuberosity
Trochlea articulate with ulna
Capitulum (lateral) articulate with radius
Medial epicondyle flexor muscle of forearm (golfers elbow, medial e.), ulnar n. EXAM
Lateral epicondyle extensor muscle of forearm (tennis elbow, extensor epicondylitis)
Coronoid fossa, olecranon fossa
* Distal end of humerus median n. EXAM

Forearm (antebrachium)

Radius
Radius head
Radial tuberosity biceps brachii m.
Radial styloid process brachioradialis m.
Ulna
Olecranon process
Coronoid process
Trochlear notch
Ulnar head
Ulnar styloid proces
Colles fracture
Fall on outstretched hand
Distal fragment displace posteriorly dinner fork deformity EXAM
Median n. compression carpal tunnel syndrome

hand (manus)

Wrist: carpal bones (lateral to medial)


Proximal row: scaphoid, lunate, triquetrum, pisiform EXAM
Distal row: trapezium, trapezoid, capitate, hamate (Guyons canal syndrome (ulnar n. i.))
Palm: metacarpal bones (lateral to medial) I (thumb, pollex) to V
Finger: phalanges
Proximal phalanges
Middle phalanges not present in thumb
Distal phalanges

Upper limb length


Total length acromial angle to radial styloid process tip
Arm length acromial angle to lateral epicondylar tip
Forearm length lateral epicondylar tip to radial styloid process tip

Fascia of Upper Limb


Superficial fascia of arm

Cutaneous n.
Superficial veins

Deep fascia of arm

Intramuscular septum
Anterior/flexor compartment
Posterior/extensor compartment

Deep fascia of forearm

Intramuscular septum: interosseous membrane


Anterior/flexor compartment
Posterior/extensor compartment

Deep fascia of wrist

Carpal tunnel
Passage of 9 flexor tensions
Median n. carpal tunnel syndrome apes hand deformity EXAM
Flexor retinaculum
Extensor retinaculum
Palmar aponeurosis

Muscles of Brachium EXAM


Muscles

Origin

Insertion

Action

Innervation

Blood supply

Bicipital
aponeurosis (ulna)
Radial tuberosity

Supinate EXAM
Flex forearm

Musculocutaneous n.

Anterior compartment musculocutaneous n. EXAM


Biceps brachii
(long head)

Supraglenoid
tubercle of
humerus

Biceps brachii
(short head)

Coracoid process
of scapular

Brachialis

Anterior surface of
humerus

Coronoid process
and tuberosity of
ulna

Flex forearm

Musculocutaneous n.

Coracobrachialis

Coracoid process
of scapular

Surface of
humerus

Flex forearm
Adduct arm

Musculocutaneous n.

Brachioradialis

Supracondylar
ridge of humerus

Radial styloid
process

Flex forearm

Radial n.

Olecranon process Extend, adduct


of ulna EXAM
shoulder
Extend forearm

Radial n.

Posterior compartment radial n.


Triceps brachii
(long head)

Infraglenoid
tubercle of
scapular

Triceps brachii
(lateral head)

Humerus

Extend forearm

Radial n.

Triceps brachii
(medial head)

Humerus

Extend forearm

Radial n.

Cubital fossa
Boundary: brachioradialis, pronator teres, imaginary line between epicondyles of humerus
Contents (lateral to medial): TAN tendon of biceps brachii, brachial a., median n. EXAM
Bicipital aponeurosis covered the contents

Muscles of Antebranchium EXAM


Muscles

Origin

Insertion

Action

Innervation

Blood supply

Superficial Anterior/Flexor Compartment medial epicondyle, median n. except flexor carpi ulnaris (ulnar n.)
Flexor carpi ulnaris Medial epicondyle

Metacarpal

Ulnar n.

Palmaris longus

Medial epicondyle

Flexor retinaculum

Median n.

Flexor carpi
radialis

Medial epicondyle

Metacarpal

Median n.

Pronator teres

Medial epicondyle

Radius

Flex, adduct

Median n.

Flexor digitorum
superficialis

Medial epicondyle

Middle phalanges

Flex proximal and


middle phalanges

Median n.

Deep Anterior/Flexor Compartment


Flexor digitorum
profundus

Interosseous
membrane

Distal pharanges

Flex distal
phalanges

Lateral half
anterior
interosseous n.
(median n.)
Medial half
ulnar n.

Flexor pollicis
longus

Interosseous
membrane

Distal pharanges

Anterior
interosseous n.

Pronator
quadratus

Ulna

Radius

Anterior
interosseous n.

Superficial Posterior/Extensor Compartment n.


Brachioradialis

Humerus

Styloid process of
radius

Flex forearm

Radial n.

Extensor carpi
radialis longus
(ECRL)

Humerus

Metacarpal

Radial n.

Extensor carpi
radialis brevis
(ECRB)

Lateral epicondyle
of humerus

Metacarpal

Radial n.

Extensor digitorum Lateral epicondyle


communis
of humerus

Extensor
expansion

Posterior
interosseous n.
(radial n.)

Extensor digiti
minimi (EDM)

Lateral epicondyle
of humerus

Extensor
expansion

Posterior
interosseous n.

Extensor carpi
ulnaris (ECU)

Lateral epicondyle
of humerus

Metacarpal

Posterior
interosseous n.

Anconeus

Lateral epicondyle
of humerus

Olecranon and
surface of ulna

Abduct, extend
elbow

Radial n.

Deep Posterior/Extensor Compartment n.


Supinator

Lateral epicondyle
of humerus

Radius

Radial n.

Abductor pollicis
longus (APL)

Ulnar, radius, IM

Metacarpal

Posterior
interosseous n.

Extensor pollicis
brevis (EPB)

Ulnar, IM

Posterior
interosseous n.

Extensor pollicis
longus (EPL)

Ulnar, IM

Posterior
interosseous n.

Extensor indicis

Ulna, IM

Posterior
interosseous n.

Assessment
Pinch grip test
Posterior interosseous n. syndrome inability to extend wrist, or weak extension with radial deviation (extensor carpi
radialis longus, ulnar n.)
Anatomical snuff box
Boundary: extensor pollicis longus, abductor pollicis longus, extensor pollicis brevis
Contents: radial a. blood gases (lateral to flexor carpi radialis) EXAM
Muscles of Hand EXAM
Muscles

Origin

Insertion

Action

Innervation

Thenar muscles recurrent branch of median n.; clinical: ape hand


Opponens pollicis

Flexor retinaculum

Recurrent branch
of median n.

Abductor pollicis
brevis

Flexor retinaculum

Recurrent branch
of median n.

Flexor pollicis
brevis

Flexor retinaculum

Recurrent branch
of median n.

Adductor pollicis
(thenar eminence)

Ulnar n.

Hypothenar muscles deep branch of ulnar n.


Abductor digiti
minimi

Deep branch of
ulnar n.

Flexor digiti minimi


brevis

Flexor retinaculum

Deep branch of
ulnar n.

Opponens digiti
minimi

Flexor retinaculum

Deep branch of
ulnar n.

Intrinsic Muscles of Hand


Palmar interosseii
(3)

Adduction

Ulnar n.

Dorsal interosseii
(4)

Abduction

Ulnar n.

Lumbrical (4)

Flexor digitorum
profundus

Extensor
expansion

Flex MPJ
Extend IPJ

1-2 (lateral half)


Median n.
3-4 (medial half)
Ulnar n.

Palmaris brevis

Deepens hollow of
hand

Ulnar n.

Blood supply

Neuromuscular supply
Dermatome

Reflexes

Deep tendon reflexes


Biceps reflex C5-6
Brachioradialis reflex C6
Triceps reflex C7
Patella reflex L4
Achilles tendon S1
Scale
0 absent
1 hypoactive
2 normal
3 hyperactive
4 hyperactive with clonus
5 sustained clonus

Musculocutaneous n.

Motor innervation anterior compartment of arm


Sensory innervation lateral forearm

Median n.

Motor innervation
Anterior compartment of forearm, thenar m., lumbrical 1-2
Except flexor carpi ulnaris, ulnar half of flexor digitorum profundus
Sensory
innervation

Palmar
digit 1-3, half 4

Ulnar n.

Motor innervation
Flexor carpi ulnaris
Ulnar half of flexor digitorum profundus
Muscles of hand, except thenar m. and lumbrical 1-2
Sensory
innervation

Palmar
digit half 4, 5

Weak point medial epicondyle cubital tunnel syndrome


Ulnar nerve palsy claw hand EXAM

Radial n.

Motor innervation
Posterior compartment of arm and forearm
Sensory innervation
Inferior lateral cutaneous n. of arm
Posterior forearm
Dorsum of digit 1-3, half 4
Radial nerve palsy wrist drop EXAM

C5 lateral arm and forearm


C6 thumb EXAM
C7 index, middle and ring fingers
C8 little finger
T1 medial arm and forearm

Vessels of Arm and Forearm


Arteries and veins

Brachial a. radial a., ulnar a. superficial, deep palmar arch


Superficial v.
Basilic v. (medial) enter deep fascia (deep v.)
Cephalic v. (lateral) enter deltopectoral triangle
Median cubital v. bicipital aponeurosis
Deep v.
Axillary v.

Lymphatic drainage

Medial Cubital lymph node axillary lymph node


Lateral Deltopectoral (infraclavicular lymph node)

Examination
1. Musculocutaneous n. .?
Biceps brachii

2. ?
A. Scaphoid
B. Lunate
C. Distal radial end
D. Proximal radial end
3. dissect cadaver lateral + dorsal tendon ?
Abductor pollicis longus
4. flex wrist and abduct hand ?
A. Flexor carpi radialis
5. n. lateral cutaneous n. of forearm ?
Musculocutaneous n.
6. medial, n.?
Ulnar n.
7. supination?
Biceps brachii Biceps brachii, supinator
8. Humerus midshaft n. ?
Radial n. wrist drop
9. pronate distal phalanges ?
Flexor digitorum profundus, median n. (anterior interrosscous n.)
10. dermatome ?
C6
11. wrist drop?
Radial n.
12. n. ?
Cutaneous branch of median n.
13. supination?
A. Extensor pollicis brevis
B. Extensor pollicis longus
C. Triceps brachii
D. Biceps brachii Biceps brachii, supinator
E. Brachioradialis
14. flex wrist and abduct hand ?
A. Flexor carpi radialis
B. Flexor carpi ulnaris
C. Flexor digitorum superficialis
D. Flexor digitorum profundus
E. Flexor pollicis longus
15. median cubital vein n. ?
Median n.
16. head of radius ?
Annular ligament
17. Proximal radio-ulnar jt.?
Pronation Proximal radio-ulnar jt. pronation, supination
18. ?
Coracoacromion

19. Extrinsic ligament of acromioclavicular jt.?


Coracoclavicular lig.
20. extensor muscle ?
Olecranon process of ulnar
21. carpal tunnel syndrome nerve ?
Median n.
22. carpal tunnel syndrome ?
Ape hand
23. surgical neck nerve ?
Axillary n. Surgical neck: axillary n., posterior humeral circumflex a.
24. pulse brachial artery ?
Medial border of biceps
25. anatomical snuffbox?
Scaphoid
26. ?
Palmar interosseous m.
27. ?
Opponens pollicis
28. ?
Acromial angle Landmark: acromial angle, lateral epicondylar tip of humerus, radial styloid process tip
29. O2 ?
Radial a.
30. ?
Anterior dislocation humerus pulled downward (inferiorly)
31. Extrinsic ligament ?
Coracoacromial ligament
32. flex extend?
Elbow joint
33. Articular disc ?
Distal radioulnar jt.
34. ?
Radial head annular ligament

Lecture 19.5-20.5 Analgesic, antipyretic, NSAIDs and DMARDs


NSAIDs
Types
Non-selective NSAIDs (tNSAIDs) inhibit COX
COX-2 selective NSAIDs: celecoxib
COX-1
constitutive enzyme e.g. mucus secretion

COX-2
inducible enzyme in inflammatory cells

Properties

Mechanism

Drugs

Analgesic

Peripheral: PGE2 , PGI2 reduce nociceptor threshold

Antipyretic

hyperalgesia EXAM
Central: PGE2 increase spinal dorsal horn neuron excitability
hyperalgesia

IL-1, TNF, INF COX-1, -2 endothelial or glia cells in preoptic area

No: diflunisal

in anterior HyTh PGE2 increase set point

Anti-inflammatory -

Strong: indomethacin
Moderate: naproxen, ibuprofen
Mild: paracetamol

Other Applications
Close ductus arteriosus

Ibuprofen

Anti-platelet aggregation
COX-2 inhibitors induce platelet aggregation
COX-2 in blood vessels source of PGI2 dilates blood vessels and prevents the
activation of platelets EXAM

Aspirin

Dysmenorrhea

Prevent colon cancer

Mastocytosis (PGD2)

Reduce niacin-induced intense flushing (PGD2)

Adverse Drug Reaction


Gastric bleeding
EXAM

Inhibit PGE2 synthesis reduce gastric mucosa cells


Not occur in COX-2 selective NSAIDs
May co-administered with ranitidine, omeprazole

Analgesic
nephropathy

PGE2, PGI2 reduce [renal blood flow, glomerular filtration, sodium -

and water excretion]

CHF, chronic renal disease


Other
Aspirin prolong bleeding time
COX-2 selective inhibitors MI, stroke, thrombosis
Premature ductus arteriosus closure
Delayed gestation and delayed labor
Postpartum hemorrhage
Hypersensitivity

NSAIDs

Properties

Aspirin acetylsalicylic acid (ASA)

Acetaminophen (paracetamol)

Alkalinized urine to increase aspirin excretion


Half-life varies with dosage
Acetylation irreversible blocking anti-platelet
NASIDs + aspirin decrease anti-platelet activity *competitive inhibition EXAM
Colon cancer
Inflammatory bowel diseases
Overdose salicylism
Stimulate RC in medulla hyperpnea respiratory alkalosis
Uncoupling oxidative phosphorylation pyretic effect
VMC (vascular muscle cell) depression metabolic acidosis
Reyes syndrome in children: liver failure and encephalopathy esp. in children with
viral infection
Low dose decrease urate excretion
Effective analgesic and antipyretic effects
No anti-inflammatory effect high amount of peroxide in inflammatory area
Lack platelet-inhibiting property
Metabolism
Conjugation with glucuronide
Cytochrome P450 NAPQI (toxic metabolite, hepatotoxicity) glutathione
conjugation
Recommend dosage: 650 mg q4-6h, maximum 2600 mg/day EXAM
ADR: hepatotoxicity, nephrotoxicity
Acute paracetamol poisoning: 10-15 g, orally
Initial sings N/V/D, diaphoresis
24hr abdominal pain
24-48 hr. hepatic enzyme, birubin, PTT
Treatment: N-acetylcysteine (PO, IV) within 8-16 hr EXAM

Sulindac

Contain sulfur group SJS

Mefenamic acid (Ponstan)

Analgesic for dysmenorrhea

Celecoxib

Indication
Osteoarthritis, RA
Acute pain e.g. postoperative pain
Prevention of polyposis coli
Contraindication: hypertension, CHF, MI, advanced renal disease
ADR: SJS

Disease-modifying anti-rheumatic drugs (DMARDs)


Mechanism

Drugs

Properties

TNF- inihibitor

Adalimumab
Etanercept
Infliximab

IL-1 blocker

Anakinra

B-cell cytotoxic agent

Rituximab

T-cell modulating agent

Abatacept

Biologic DMARDs

Non-biologic DMARDs
Anti-malarials

Chloroquine
ADR: melanin-containing tissue e.g. retina EXAM
Hydroxychloroquine

Sulfasalazine

Sulfapyridine affect lymphocyte function

Immune suppressant
agents

Methotrexate

Leflunomide

Inhibit dyhydroorotate dehydrogenase ribonucleotide synthesis

First DMARDs of choice


Mechanism: folate antagonist inhibit DNA, RNA synthesis
Teratogenic effect
May co-administered with folic acid mucosal adverse effects
inhibitor inhibit T, B cell proliferation

ADR: diarrhea
Azathioprine
Cyclosporin
Cyclophosphamide

Gold compound

Chelators

RA treatment approach reevaluate every 3 months


MTX
Active disease, erosive
Add TNF- inhibitor or abatacept
If still active switch to another TNF- inhibitor or another biologic agents
Active disease, non-erosive
Triple therapy (MTX + SSZ or HCQ), or
Add TNF- or abatacept
If still active stop SSZ and HCQ, add TNF- inhibitor to triple therapy, or add other biologic agents to TNF- or
abatacept `
Examination
1. At the site of tissue damage and inflammation, what is the mediator that can lower threshold of the pain receptor?
A. serotonin
B. prostaglandins
C. angiotensin I
D. dopamine
E. histidine
2. What is the enzyme which plays major role in gastric mucus synthesis?
COX-1
3. nsaid nsaid?
cycloxygenase

4. pharmacologic effect aspirin?


Prevent thrombosis in atherosclerosis
5. naproxen .... ADR ?
? Gastric bleeding, analgesic nephropathy, hypersensitivity
6. NSAIDs ?
A. PGE analog
B. alcohol
C. histamine
D. eat before meal
E. N-acetylcystein
7. 7 ?
Paracetamol
8. Thromboxane A2?
COX-1
9. non-selective COX-2 inhibitor coronary thrombosis thrombosis ?
Inhibit PGI2 synthesis COX-2 PGI2 dilates blood vessels and prevents the activation of platelets
10. gastritis NSAID ?
A. NSAID + PGE analogue
B. NSAID + antacid
C. NSAID +
D.
11. paracetamol?
A.
B. hemophilia
C.
E. hyperthyroidism
12. Which is the serious adverse effect of hydroxychloroquine in the treatment of RA?
Retinopathy
13. 7?
Paracetamol
14. side effect traditional NSAIDs?
? ADR: GI bleeding, nephropathy
15. traditional NSAIDs?
? Effect: analgesic, antipyretic, anti-inflammatory
16. paracetamol?

17. NSAIDs?
Inhibit enzyme COX
18. paracetamol?
Bleed, anti-platelet
19. NSAIDs ?

20. celecoxib thrombosis?


Inhibit PGI synthesis from vascular endothelial cells
21. ?
methotrexate first choice

22. Side effect hydroxychloroquine?


Maculopathy (retinopathy)
23. TNF-?
Infliximab TNF- inhibitors: adalimumab, etanercept, infliximab

Lecture 21.5-22.5 Parasite in Musculoskeletal System


Parasitic Infection in Musculoskeletal System EXAM
Diagnosis
Muscle biopsy
Muscle enzyme level: CPK, LDH
Serologic test: ELISA
Diseases

Characteristic

Clinical manifestation

Trichinellosis
Nematode

Etiology: Trichinella spp. T. spiralis, T. pseudospiralis


Transmission: raw undercook meats
Morphology
encysted muscle larva (L1)
stichosomal esophagus
Life cycle
Infective stage encysted muscle larva (L1)
Diagnosis stage encysted muscle larva (L1)
2-3 days: adult GI irritation diarrhea
5 days: newborn larva
8-9 days encysted within skeletal muscle myalgia

Sarcocystosis
Protozoa

Etiology: Sarcocystis spp. S. suihominis, S. bovihominis


Transmission: feces
Life cycle
Infective stage oocysts
Sporocysts, oocysts sporozoites schizonts merozoites invades muscle cell bradyzoites in
sarcocyst

Cysticercosis

Etiology: Cysticercus cellulosae


Transmission: Tinea eggs
Morphology
Invaginated scolex, hooks
Gravid proglottis: uterine branch T. solium (15), T. saginata
Life cycle
Egg or gravid proglottis oncospheres cysticerci in muscle

Sparganosis

Etiology: Pseudophyllidian tape worm (Spirmetra sp.)


Transmission
Procercoid in crustaceans
Plerocercoid larva (sparganum) in 2nd IH fish, reptiles,
amphibians

Diarrhea
Conjunctivitis, swollen eyes EXAM
Splinter hemorrhages
Myalgia
Diagnosis: immuno-histopathological
analysis EXAM
Treatment: mebendazole, albendazole

Treatment: surgical removal

MCQ Part 1 (late 2013)


1. trichinellosis 1 ?
A. Elisa Ab
B. Immunohistochemistry
C. Stool examination
D. Tissue biopsy
E. Eosinophil
2. ?
Trichinella spiralis Diarrhea, conjunctivitis, swollen eyes, splinter hemorrhages, myalgia
3. Trichinellosis swollen eye splinter hemorrhage ?
A.
B. capsule
C.
D.
E.
4. Trichinella biopsy biopsy ?

5. ?
Trypanosoma sp.
6. ?
Trichinella spiralis
7. cyst ?
Egg

Lecture 22.5-24.5 The face & scalp, temporal and infratemporal regions
Facial Bones
Frontal bone

Supraorbital margin superciliary arch, supraorbital foramen


Articulate
Nasal bones

Nasal bones

Maxilla

Infraorbital foramen
Alveolar processes

Zygomatic bone

Inferior nesal concha

Lacrimal bone

Mandile

Mental foramen

Temporal bone

Facial Cutaneous Nerves


Pons (brain stem) trigeminal n. (CN V) trigeminal ganglion
V1 ophthalmic division

Superior orbital fissure supraorbital foramen


Branches
Supraorbital n.
Supratrochlear n.
Infratrochlear n.
External nasal n.
Lacrimal n. lacrimal gland

V2 maxillary division

Foramen rotundam
Branches
Infraorbital n.
Zygomaticofacial n.
Zygomaticotemporal n.

V3 mandibular division

Foramen ovale
Branches
Mental n.
Buccal n.
Auriculotemporal n.

Great auricular n.

C2-3

Trigeminal neuralgia
Paroxysm (sudden sharp pain) for 15 mins
Initiated by touching sensitive trigger zone
Prevalent V2 > V3 > V1
Infraorbital nerve block
For treating wound of upper lip, cheek, maxillary incisor teeth risk IV leakage to orbit paralysis of extra ocular m.
Inferior alveolar nerve block
Inject at mandibular foramen risk IV leakage to parotid gland and branches of facial n. unilateral facial paralysis
Mental and incisive nerve block
Inject at mental foramen block mental n.

Muscles of Facial Expression


Muscles

Origin

Insertion

Action

Innervation

Blood supply

Orbicularis oculi
(orbital part)

Medial palpebral
ligament

Tightly close eyelid -

Orbicularis oculi
(palpebral part)

Close eyelid

Corrugator
supercilii

Medial-ward
eyebrows

Procerus

Nasal bone

Skin between
eyebrows

Glare of bright
sunlight

Compressor naris

Canine eminence
of maxilla

Pars transversa
(aponeurosis)

Dilator naris

Canine eminence
of maxilla

Pars alaris
(aponeurosis)

Depressor septi
nasi

Maxilla above
central incisor

Nasal septum

Levator labii
superioris alaeque
nasi

Frontal process of
maxilla

Ala
Upper lip

Elevate lip
deepen nasolabial
sulcus

Levator labii
superioris

Upper lip

Elevate lip*

Levator anguli oris

Canine fossa of
maxilla

Angle of mouth

Elevate angle of
mouth

Zygomaticus minor Zygomatic bone


(medial)

Upper lip

Elevate lip*

Zygomaticus major Zygomatic bone


(lateral)

Angle of mouth

Smile

Risorius

Fascia over
parotid gland

Angle of mouth

Depressor anguli
oris

Mandible

Angle of mouth

Depressor labii
inferioris

Mandible

Lower lip

Mentalis

Mandible

Skin of chin

Orbicularis oris

Buccinator

Alveolar process
of maxilla and
mandible

Lip

Blow out
Sucking

Orbital muscles

Nasalis muscles

Buccal muscles

Branches of external carotid a.


Facial a.

Maxillary a.

Mental a.
Infraorbital a.
Buccal a.

Transverse facial a. EXAM

Superficial temporal a.

Inferior labial a.
Superior labial a.
Lateral nasal a.
Angular a.

Facial Veins *valve not present infection


Facial veins

Pterygoid venous plexus

Drain to maxillary v.
Connect to
Facial v. via deep facial v.
Carvernous sinus via emissary v.
Opthamic v. via inferior ophthalmic v.

Superficial temporal v.
Retromandibular v. EXAM
Facial v. danger triangle of face (infection)
External jugular v.
Internal jugular v.

Facial Nerve (CN VII) exit skull at stylomastoid foramen enter parotid gland exit as branches *all motor n.

Posterior auricular branch


Temporal branch
Zygomatic branch
Buccal branch
Marginal mandibular branch
Cervical branch not supply muscle of facial expression

Facial nerve palsy (Bells palsy)


Lesion at geniculate ganglion ipsilateral loss of motor function of the whole face, taste of tongue, lacrimation, salivation
Lesion at stylomastoid foramen ipsilateral loss of motor function of the whole face
Layers of scalp
S skin
C connective tissue
A aponeurosis epicranialis *SCA skull proper
L loose CNT
P periosteum (pericranium)
Scalp injury
Separation of skull proper and loose CNT layer
Facial laceration and incision
Incision along cleavage (wrinkle) line minimal collagen fiber disruption minimal scarring
Muscles of Forehead
Muscles

Origin

Frontalis
Occipitalis

Insertion

Action

Innervation

Blood supply

Galea aponeurosis Subcutaneous


tissue of eyebrows

Galea aponeurosis -

Temporal and Infratemporal Bones


Temporal bone

Zygomatic process zygomatic arch

Zygomatic bone

Sphenoid bone

Mandible

Pterion

Articulate area of fontal, parietal, temporal and sphenoid bone


Content: middle meningeal a.

Body of mandible
Ramus of mandible
Angle of mandible
Mandibular notch processes: coronoid process (anterior), and condylar process (posterior)
Mental foramen
Mental protuberance
Alveolar process
Mandibular foramen mandibular canal
Submandibular fossa
Retromolar triangle mandibular nerve block

Temporal fossa
Boundary: temporal line, sphenoid, zygomatic arch
Covered with temporal fascia
Infratemporal fossa
Boundary: maxilla, sphenoid, zygomatic arch
Muscles of Mastication action at mandible
Muscles

Origin

Insertion

Action

Innervation

Blood supply

Temporalis

Temporal fascia

Coronoid process
of mandible

Elevate
Retrusion

Anterior trunk of
mandibular n. via
temporal branch

Maxillary a.
Superficial
temporal a.

Massester
Superficial layer
Deep layer

Zygomatic arch

Ramus of
mandible

Elevate
Protrusion
Retrusion

Anterior trunk of
mandibular n. via
masseteric n.

Maxillary a.

Lateral pterygoid
Upper head
Lower head

U: Infratemporal
crest of sphenoid
L: Pterygoid plate

Pterygoid fovea
(mandibular neck)

Depress
Protrusion

Anterior trunk of
mandibular n. via
lateral pterygoid n.

Maxillary a.

Medial pterygoid
Superficial head
Deep head

S: Maxillary
tubercle
D: Pterygoid plate

Ramus of
mandible

Elevate
Protrusion

Anterior trunk of
Maxillary a.
mandibular n. via
medial pterygoid n.

Maxillary artery branch of external carotid a. enter parotid gland exit with branches EXAM
Mandibular part
Deep auricular a.
Anterior tympanic a.
Accessory meningeal a. enter foramen ovale
Middle meningeal a.

Enter foramen spinosum

Inferior alveolar a.

Inferior alveolar n.
Enter mandibular foramen
Pass trough mental foramen mental a.

Pterygoid part
Deep temporal a.
Masseteric a.
Pterygoid a.
Buccal a.
Pterygopalatine (sphenopalatine) part
Posterior superior alveolar a.
Motor branches of mandibular n.
Motor and sensory (semilumar (gasserian) ganglion)
Main trunk
Meningeal n. foramen spinosum meninges
Median (internal) pterygoid n.
Medial pterygoid m.
Tensor veli palatini m.
Tensor tympani m.
Division
Anterior division EXAM
Deep temporal n. temporalis
Nerve to lateral pterygoid pterygoid
Masseteric n. massester
Buccal n. (sensory)
Posterior division
Auriculotemporal n. loop across middle meningeal a., parasympathetic of CN IX to parotid gland
Lingual n. (sensory: tongue) sublingual and submandibular gland
Chorda tympani n. (CN VII; sensory: taste; preganglionic parasympathetic fiber to sublingual and submandibular g.)
Inferior alveolar n. enter mandibular foramen incisive, mental, mylohyoid n.
Lingual nerve injury
Proximal to chorda tympani joined site lost sensation of anterior tongue
Distal to chorda tympani joined site lost sensation of anterior tongue, abnormal salivary gland secretion
Temporomandibular joint
Structure
Glenoid (mandibular) fossa of temporal bone
Postglenoid tubercle prevent joint dislocation to auditory canal anterior dislocation
Anterior articular tubercle
Head of mandible articular surface
Articular disc fibrocartilage (vs hyaline cartilage of other joint)
Articular capsule
Lateral (temperomandibular) ligament
Sphenomandibular ligament
Stylomandibular ligament
Anterior
masseteric a.

Medial

maxillary a., v., auriculotemporal n.

Examination
1. superficial parotid gl.? lateral to medial: facial n., retromandibular v., external carotid a., superficial
temporal a., branches of the great auricular n., maxillary a.
A. Retromandibular v.
B. Facial n.
C. Ext. jugular v.

D. Ext carotid a.
2. TM jt. . hinge jt ?
Head of mandibular + articular disc
3. retract mandibular ?
Temporalis
4. ?
Great occipital n.
5. block nerve . 3rd mandibular molar teeth?
Inferior alveolar n.
6. Lesser petrosal n. preganglionic parasympathetic fibers ?
A. Otic ganglion
B. Ciliary gg.
C. Semilunar gg.
D. Geniculate gg.
E. Submandibular gg.
7. 48 mandibular branch facial nerve ?
Depressor anguli oris m. Depressor anguli oris, depressor labii inferioris, mentalis
8. block n. ?
Buccal n. block
9. ?
Inferior laryngeal n.
10. Lesion protract mandible ?
Anterior division of mandibular nerve
11. ?
Buccinator
12. Anterior belly of digastric nerve ?
Mylohyoid n.
13. ?
Emissary v.
14. masseter structure ?
Tranverse facial a.
15. Galea aponeurosis muscle ?
Occipitalis, frontalis m.
16. parotid gland ?
Retromandibular v.
17. ?
Trigeminal neuralgia
18. ?
Zygomaticus major m.
19. Pterygoid venous plexus ?
Cavernous sinus via emissary v.
20. pterion ?
Middle meningeal a.

21. (Blinking) branch facial n.?


Temporal branch
22. nerve ?
Chorda tympani n.

Lecture 25.5-26.5 Muscle Relaxant Drug


Ach Nm (nicotinic receptor type N2)
Docking fusion release

Muscle Relaxant Drugs


Characteristics

Drugs

Centrally acting muscle relaxants

Membrane stabilizing effect (non specific)


Indication
Use combined with rest and physical therapy
ADR
Local anesthetic effect sedate
Euphoria (mood enhancement) abuse

Carisoprodol + steroid (Alaxan)


Orphenadrine + paracetamol (Norgesic)
Chlorzoxazone + paracetamol
Tolperisone (Mydocalm)
Diazepam (Valium)
Chlorpromazone
Balcofen
GABA derivative bind with GABA-B receptor
in brain and spinal cord reduce nerve
activation

Direct acting muscle relaxants

Inhibit Ca2+ release from sarcoplasmic reticulum

Dantrolene

Indication
Malignant hyperthermia
ADR
Hepatotoxic effect
Neuromuscular blockers
Sensitivity: ocular m. mastication m. limb abdominal m. respiratory m.
Indication
Adjunct with general anesthetics to increase skeletal muscle relaxant
Respiration maneuver
Reduce muscle damage in electroshock therapy
Pre-synaptic neuromuscular blockers

Reduce ACh release from cholinergic n.


Motor n.
Autonomic ganglion (preganglionic neuron)
Parasympathetic terminal
Sweat gland

Botulinum toxins (Clostridium botulinum)


ADR: focal hand dystonia

Indication
Hyperactive m., inject every 3-4 months (sprouting nerve terminal)
Blephorospasm, hemifocal spasm
Cervical dystonia, focal hand dystonia
Hyperhidrosis
Post-synaptic neuromuscular blockers
Non-depolarizing/competitive NMJ blockers
Competitive antagonist block ACh end plate potential flaccid
paralysis
Neostigmine inhibit AChE EXAM
ACh at nicotinic site counter competitive NMJ blocker
ACh at muscarinic site parasympathetic hypotension
Administered with muscarinic antagonist e.g. atropine
ADR
Histamine release allergic, hypotension (N1, Nn)
Respiratory depression

d-Tubocurarine (d-Tc, curare)


Pancuronium
Vercuronium
Atracurium

Depolarizing/non-competitive NMJ blockers


Bind to Nm recepter depolarization non-synchronous contraction
spastic paralysis, fibrillation, fasciculation prolong depolarization
flaccid paralysis
Not degraded by AchE
Phase I block (depolarizing)
Phase II (desensitizing) EXAM
Phase I block conformational changes of receptor
repolarization
Train of four test (TOF test) for TOF ratio
ADR
Butyrylcholinesterase mutation severe blockade apnea
Malignant hyperthermia
Hyperkalemia
Increase intraocular m. (slow fiber)

Succinylcholine (Suxamethonium)

Examination
1. atropine d-tc ?
Prevent hypotension
Neostigmine inhibit AChE
ACh at nicotinic site counter competitive NMJ blocker
ACh at muscarinic site parasympathetic hypotension
2. Neostigmine antagonize d-Tc atropine ?
parasym
3. Phase 2 succinylcholine?
Deformational changes of receptor
4. Test of TOF?
A. Pre-synapse
B. Post-synapse
C. Docking
D. Excitation contraction
E. All above
5. Phase II block of succinylcholine, the blockade could be antagonized by?
A. d-Tc
B. Neostigmine
C. Botulinum toxin
D. Dantrolene
6. Succinylcholine anesthetic medication ()?
muscle tone
7. Dantrolene ?
calcium ion sarcoplasmic reticulum
8. non-depolarizing blocking drug ?
Pancuronium
9. malignant hyperthermia dantrolene ?
calcium
10. electroconvulsive therapy ?
neuromuscular blocking drug spasmolytic drug
11. ?
Succinylcholine

12. cerebral palsy 3 ?


Botulinum toxin
13. ?
Carisoprodol
14. Botulinum toxin ?
Sprouting neuron terminals
15. carisoprodol orphenadrine?
Euphoria, abuse
16. Competitive NMJ blockers Atropine ?
Hypotension
17. Muscle relaxant Fasciculation ?
Succinylcholine

Lab Conference: Neuromuscular Blocker and Screening for Analgesic Drug


Case 1: respiratory insufficiency, cyanosis
tracheal food aspiration bronchoscopy
atropine drying secretion, produce bronchodilation, prevent vasovagal reaction
propofol sedation, secretion
succinylcholine interventional rigid bronchoscopy (muscle relaxant)
1mm pupil myosis Ach excess
diarrhea, PR parasympathetic
bronchial secretion, salivation, diaphoresis secretion (diaphoresis cholinergic excess)
coma CNS effect
Ach excess organophosphate
succinylcholine + organophosphate prolong depolarization complete blockage
Case 2: phrenic n. diaphragm
TOF test (train-of-four): presynaptic nicotinic receptor reserve to releasable pool synaptic vesicle availability
TOF ratio
>0.75 Succinylcholine phase I block presynaptic nAChR
0.75 block both post and pre synaptic d-tubocurarine (dTc), succinylcholine phase II (desensitization)
Neostigmine anticholineesterase
d-tubocurarine (dTc), succinylcholine phase II (receptor desensitization binding disassociation) stimulation
Succinylcholine phase I block blockage

Case 4: mild reflux, CHF, renal impairment


Pathophysiology: Age (mucosal fragility), CHF (decrease blood supply) GI bleeding
Treatment: paracetamol + NSAID (to reduce NSAID dosage GI bleeding )
Caution: ACE inhibitors + NSAIDs + diuretics iatrogenic acute renal failure (renal blood flow , GFR )

Lecture 26.5-27.5 Gout Drugs


Gout
Etiology

Pathophysiology

Clinical manifestation

Hyperuricemia
Reduced excretion
Acute arthritis
Female >6 mg/dl Primary idiopathic
Monosodium urate deposit in joint
(cold, acidic)
Male >7 mg/dl
Diuretics
Renal insufficiency
Renal stone
Chronic arthritis
Low dose aspirin
Overproduction
Tophus (plu: tophi)
Primary idiopathic
Renal failure
Stage of gout
Obesity
Alcohol organic anion metabolite uric acid reabsorption Asymptomatic hyperuricemia
Acute attack of gout peak: 1-2
Purine-rich diet
days, resolved: 7-10 days
Hemolytic process purine accumulation
Chronic gout
Urate crystal in joint phagocytosis by synoviocytes IL-1
neutrophil chemotaxis release lysosomal enzyme (acid)
inflammation and further urate precipitation

Gout Drugs
Group

Characteristics

Drugs

Asymptomatic hyperuricemia no treatment required


Lifestyle
modification

Low purine diet


Exercise
Well hydrated

Acute attack of gout


NSAIDs

Indomethacin, naproxen , sulindac etc.


except aspirin

Colchicine

Bind to tubulin inhibit neutrophil chemotaxis


Inflammation reduced in 12-24 hr.

Colchicine

Indication
Prophylaxis for gouty attack
Initiation of urate lowering drug (4-6 months)
ADR
GI epithelium (inhibit cell division) diarrhea, abdominal p.
Interact w/ CYP3A4, P-gp inhibitors
Glucocorticoids

Indication
Reserve for patient who can't tolerate NSAIDs and
colchicine

Prednisone (PO)
Prednisolone (IV)
Triamcinolone (IV)

Xanthine
oxidase
inhibitors

Purine nucleotide hypoxanthine xanthine uric acid

Allopurinol
Febuxostat (non-purine)
ADR: hepatotoxicity, CVS, MI, stroke

Uricases

Uric acid Allantoin (soluble)


Recombinant urate oxidase IV

Pegloticase
ADR: infusion reaction, gout flare (3
months), G-6-PD def., anaphylaxis
Rasburicase
Indication: tumor lysis syndrome
(TLS)

Uricosurics

Inhibit URAT-1 (urate transporter) inhibit urate reabsorption


Interaction
Inhibit tubular secretion of acid agents e.g. penicillin,
methotrexate, NSAIDs
Contraindication
Renal stone, renal insufficiency
ADR: GI irritation, hypersensitivity

Probenacid
ADR: respiratory failure, renal stone
Benzbromarine
Excrete via bile, use in renal
insufficiency patients
ADR: hepatotoxicity

Chronic gout
[xanthine oxidase]
Metabolism: allopurinol (non-competitive inhibitor)
alloxanthine (competitive inhibitor)
Indication
First line for gout EXAM
Hyperuricemia from blood dyscrasia, cancer (tumor lysis s.)
Interaction
Xanthine-metabolized drugs e.g. azathioprine, 6mercaptopurine EXAM
Allopurinol + probenacid Allo.cl, Pro.hl
ADR
Hypersensitivity (rare, SJS/TEN, HLA-B*5801 allele)

Examination
1. right metatarsophalangeal joint colchicine ?
Gout
2. 55-year-old Pt consult the physical with painful, red, hot at left knee joint. After history taking and physical examination,
needle-like crystal were found in the synovial fluid. Which is the drug of choice of this patient?
A. Probenecid
B. Allopurinol

C. Indomethacin
3. Gout + urine uric acid >800mg chronic?
Allopurinol
4. chronic gouty arthritis ?
Allopurinol
5. 6-MP + allopurinol ?
Allopurinol 6-MP
6. colchicine?
Tubulin inhibit microtubules
7. allopurinol ?
Febuxostat

Lecture 27.5-29.5 The Neck


Surface anatomy of neck Langers (cleavage) line
Sternocleidomastoid (sternal head)
Anterior border of trapezius
Supraclavicular fossa pressure point of subclavian a.
Jugular fossa investing fascia anterior jugular a.
Superficial structure of neck
Tracheal ring 2-4 thyroid gland
C6 cricoid cartilage, junction of pharynx-esophagus and larynx-trachea
Boundary of the neck
Superior: mandible, mastoid process, superior nuchal line, EOP
Anterior: sternal (jugular) notch, sternoclavicular joint, clavicle
Lateral: acromioclavicular joint
Posterior: spine of scapular
Bones of Neck
Hyoid (lingual) bone

Greater horns
Lesser horns
Tip of greater horn lingual a.
Body

* laryngeal protuberance Adam apple


Carotid line
Imaginary line between sternoclavicular joint and midpoint between mastoid process and angle of mandible
Carotid sheath

Muscles of Neck EXAM


Muscles

Origin

Insertion

Action

Innervation

Blood supply

Platysma

Superficial fascia
of neck

Mandible

Cervical branch
of facial n.

Sternocleidomastoid

Sternal head
Clavicular head

Mastoid process

Flex neck
Rotate head (c.)
Tilt head (ips.)

Spinal part of
accessory n.

Anterior belly of
digastric

Mandible

Intermediate
tendon (fascial
sling)

Open mouth

Nerve to
mylohyoid
(inf. alv. n., CN V)

Posterior belly of
digastric

Mastoid notch

Intermediate
tendon (fascial
sling)

Open mouth

Digastric branch
of facial n.
(CN VII)

Stylohyoid

Styloid process
of temporal bone

Body of hyoid

Stylohyoid
branch of facial
n. (CN VII)

Myohyoid

Mandible

Fascial raphe
Hyoid

Depress
mandible

Nerve to
mylohyoid
(inf. alv. n., CN V)

Geniohyoid

Mental spine of
mandible

Body of hyoid

VR C1
(via hypoglossal)

Sternohyoid

Ansa cervicalis

Omohyoid
Superior belly
Inferior belly

Ansa cervicalis

Sternothyroid

Ansa cervicalis

Thyrohyoid

VR C1
(via hypoglossal)

Suprahyoid

Infrahyoid (stap muscles)

Prevertebral
Anterior prevertebral muscles
Longus capitis

Longus colli

Rectus capitis anterior

Rectus capitis lateralis

Posterior prevertebral muscles


Scalenus anterior

Cervical tr. p.

Rib 1

VR C4-6

Ascending
cervical a.

Scalenus medius

Cervical tr. p.

Rib 1

VR C4-6

Ascending
cervical a.

Scalenus posterior

Cervical tr. p.

Rib 2

VR C4-6

Ascending
cervical a.

*Ansa cervicalis originate from cervical plexus (C1-C3)


*Thyrohyoid membrane superior laryngeal a., internal laryngeal n. (sensory)

Triangle of neck sternocleidomastoid


Anterior cervical triangle divided by digastric m.
Submandibular (digastric) triangle submandibular gland, submandibular lymph node, facial a. and v.
Submental triangle submental lymph nodes, anterior jugular v.
Muscular triangle thyroid gland tracheostomy, thyroidectomy
Carotid triangle
Carotid sheath: common, internal and external carotid a., internal jugular v., CN IX-XII (IX: glossopharyngeal n., X:
vagus n., XI: accessory n., XII: hypoglossal n.)
Carotid angiography
Posterior cervical triangle divided by omohyoid m.
Occipital triangle
Spinal part of accessory n. careful half, carefree half
Cutaneous n. of cervical plexus (nerve point of neck)
Omoclavicular (supraclavicular, subclavian) triangle root and trunk of brachial plexus, subclavian a. and v.
Phrenic n.
Originate from C6-8
Pass anterior to scalenus anterior
Supply diaphragm
Torticolis (twisted or wry neck)
Congenital
Birth trauma (breeched baby) tear of sternocleidomastoid shortened muscle
Congenital absence of C4 pedicles
Acquired
Spasmodic spasm of sternocleidomastoid
Deep cervical fascia
Investing layer of deep fascia sternocleidomastoid
Prevertebral fascia axillary sheath
Cervical visceral fascia
Pretracheal fascia
Buccopharyngeal fascia *alar fascia
Carotid sheath
Compartments
Visceral compartment pretracheal fascia, buccopharyngeal fascia
Neurovascular compartment carotid sheath
Musculoskeletal compartment prevertebral fascia
Interfacial space potential space EXAM
Retropharyngeal space indistinguishable in healthy person
True retropharyngeal space (alar portion of deep layer of cervical fascia) located between visceral and alar fascia
Danger space (prevertebral portion of deep layer of cervical fascia) located between alar and prevertebral fascia
Carotid sheath EXAM EXAM *sympathetic chain located outside of carotid sheath
Contents
Internal jugular v.
Common carotid a.
CN X (vagus n.)
Ansa cervicalis
Deep cervical lymph node
Internal jugular v. tributaries jugular foramen
Occipital v.
Internal petrosal sinus
Pharyngeal v.
Facial v.
Lingual v.
Thyroid v. superior and middle thyroid v. (inferior thyroid v. brachiocephalic trunk)
CN X (vagus n.)
Superior laryngeal n.
Internal branch of superior laryngeal n. thyrohyoid membrane
External branch of superior laryngeal n. superior thyroid a., supply cricothyroid m. (vocal cord)
injury monotone (monotonus) voice (inability to make pitched sound)

Recurrent (inferior) laryngeal n.


Travel beneath Lt.: subclavian a. and Rt: aortic arch
Injury unilateral horseness, bilateral aphonia, breathing difficulties EXAM
Common carotid a.
Internal carotid a.
External carotid a. separate from common carotid a. at thyroid cartilage
Superior thyroid a.
Lingual a.
Facial a.
Ascending pharyngeal a.
Occipital a.
Posterior auricular a.
Maxillary a.
Superficial temporal a.
Carotid body located at bifurcation of common carotid a., chemoreceptive cells pH
Carotid sinus barorereceptor blood pressure
Subclavian a. divided by scalenus anterior m.
1st part
Vertebral a. foramen transversarium
Thyrocervical trunk inferior thyroid a., transverse cervical a., suprascapular a.
Internal thoracic a. intercostal a.
2nd part
Costocercivical trunk superior intercostal a. and deep cervical a.
3rd part
Dorsal scapular a.
Deep cervical lymph node divided by omohyoid m. EXAM
Superior deep cervical lymph node
Jugulo-digastric node
Jugulo-omohyoid node
Inferior deep cervical lymph node
Virchows node
Drainage: Rt.: right lymphatic duct, Lt.: thoracic duct
Cervical plexus
VR C1-4
Cutaneous n. of cervical plexus (nerve point of neck) EXAM
Great auricular n.
Transverse cervical n.
Lesser occipital n.
Supraclavicular n.
Ansa cervicalis
Superior root (C1) descendens hypoglossi or ansa hypoglossi *go with hypoglossal n. geniohyoid, thyrohyoid
Inferior root (C2-3) descendens cervicalis
Loop of ansa cervicalis
Examination
1. phrenic ?
Scalenus anterior
2. Torticollis muscle ?
Sternocleidomastoid
3. Birth trauma wry neck?
Sternocleidomastoid
4. Platysma?
Cervical branch of facial n.
5. Content carotid sheath C6 level?
Internal jugular v., common carotid a., CN X

6. Muscular triangle?
Thyroid gland
7. muscular compartment?
Prevertebral fascia
8. rib 1?
Scalenus anterior, medius
9. ?
Inferior laryngeal n.
10. scalenus anterior, medius?
Brachial plexus + subclavian a.
11. Phrenic n. ?
Scalenus anterior
12. Tense the skin of the neck and draw angle of the mouth inferiorly action ?
Platysma
13. Platysma m. nerve ?
Cervical branch of facial nerve
14. elevate hyoid bone ?
Suprahyoid muscle
15. flex neck + rotate head?
Sternocleidomastoid
16. infrahyoid ventral rami of C1 hypoglossal n.?
Thyrohyoid m. VR C1 (via hypoglossal) supply geniohyoid, tyrohyoid m.
17. transverse process cervical vertebra rib 2?
Scalenus posterior Rib 1: scalenus anterior, scalenus medius
18. mylohyoid muscle muscle?
Geniohyoid
19. Left sternocleidomastoid ?
Turn face to right, tilt head to left
20. Nerve cervical plexus ?
Phrenic nerve
21. deep lymph node ?
Jugulo-digastric node Deep cervical lymph node: jugulo-digastric, jugulo-omohyoid, Virchows node
22. ?
Carotid triangle
23. Nerve ?
Greater occipital n.
24. Danger space ?
Ala fascia prevertebral fascia
25. nerve ?
Inferior laryngeal n.
26. Nerve cervical plexus C3-C4?
Supraclavicular n.

Lecture 30.5-31.5 Microbial Agents in Musculoskeletal System


Bacterial Infections in Musculoskeletal System
Diseases

Etiology

Pathophysiology

Clinical manifestation

Septic arthritis

Nongonococcal bacterial arthritis Hematogenous spreading


S. aureus
Extension from a contiguous
site of infection
Streps
H. influenzae
Direct penetration
Gonococcal bacterial arthritis
CD4 TNF inflammation
N. gonorrheae
Special group
destruction of articular
cartilage
TB
Burkholderia pseudomallei
Predisposing factors
Immune suppression
Chronic rheumatic diseases

Nongonococcal bacterial
arthritis
Tenderness
Limited joint motion
Fever
Gonococcal bacterial arthritis
Monoarthritis
Polyarthritis
Disseminated
Hemorrhagic macule
Diagnosis
Joint fluid: WBC >50k w/
PMN >90%, culture

Infectious arthritis

Viral infections
Pavovirus B19
Hepatitis B v.
Rubella
Alphavirus
Fungal infections

Osteomyelitis

S. aureus

Peripheral osteomyelitis
Age: 1 year
Subperiosteal abscess
Vertebral osteomyelitis
Subperioustium access
Local invasion
Metaphysis of vertebra

Treatment
Neonate: Antistaphylococal
penicillin+ third generation
cephalosporin/
aminoglycoside

Tuberculous
spondylitis

TB

Hematogenous spreading
Destroy vertebral body and

Potts paraplegia

disc kyphosis

Prosthetic joint
infection

S. epidermidis
S. aureus
Streptococcus

Septic bursitis

Trauma
RA
Infection septic bursitis

Inflammation of fluid-filled sac


(bursa)

Microbial Agents in Musculoskeletal System


Genus

Characteristics

Virulence factors

Staphylococci

Surface antigens
Protein A bind to IgG Fc antiphagocytic activity
Teichoic acid endotoxin-like activity
Extracellular enzymes
Coagulase in S. aureus coagulate citrated plasma
Hyaluronidase (spreading factor)
Lipase/esterase
DNase (deoxyribonuclease)
Staphylokinase (fibrinolysin) proteolytic enzyme
Penicillinase
Collagen binding protein EXAM
Toxins
Cytolytic toxin
Hemolysin
Leukocidin kills WBCs
Enterotoxin
Exfoliative (epidermolytic) toxin split desmoglein 1
Toxic shock syndrome toxin-1 (TSST-1)

Gram cocci, cluster


Non-motile, no spore
Enzyme catalase
Coagulase S. aureus

superantigen
Streptococci

Gram cocci, chain


Culture on blood agar
-hemolytic streptococci (partial)
-hemolytic streptococci (total)
-hemolytic streptococci (no h.)

Surface antigens
M protein antiphagocytic activity
Capsule
Extracellular enzymes
Hyaluronidase
Hemolysin (streptolysin)
Streptolysin O antistreptolysin O (ASO) test
Streptolysin S
Streptokinase (fibrinolysin)
Toxin
Erythrogenic toxin (pyogenic toxin) scarlet fever
EXAM

Pneumococci

Streptococcus pneumoniae
Surface antigens
Capsular polysaccharide
Gram diplococci
Adhesin
Blood
agar:
-hemolytic
streptococci

Teichoic acid, peptidoglycan


Phosphorylcholine adhesion
Extracellular enzyme
Secretory IgA protease
Pneumolysin

Neisseria spp.

Enterobacteriaceae

Gram, bacilli
Facultative ferment sugars
Oxidase test

Esherichia coli
Motile
Lactose fermenter

Surface antigens
Lipooligosaccharide (endotoxin)
Pili (fimbriae) resistant, antiphagocytic, adhesion

Gram, bacilli, aerobe


Non-fermentative
Oxidase test

Pseudomonadaceae

Neisseria meningitidis meningitis


N. gonorrheae gonorrhea
Gram, diplococci, kidney-shaped
Oxidase test

Surface antigens
Pili, opacity protein adhesion
Porin protein PorA serum killing ?
Lipooligosaccharide (LOS) inflammation EXAM
Lipooligosaccharide (endotoxin)
Capsule
Extracellular
enzyme

IgA1
protease

Mycobacterium

Pseudomonas aeruginosa
Gram, bacilli
Monotrichous flagellum
Blood agar: -hemolysis streptococci
Pigments
Pyocyanin (blue-green)
Fluorescein (yellow-green)
Pyorubin (red-brown)
Grape-like odor
Oxidase

Surface antigens
Adhesin
Lipopolysaccharide (LPS)
Extracellular
enzymes

Exoenzyme
S

Alkaline
protease,
phospholipase

Alginate
synthesis

Toxin
Exotoxin A

Acid fastness EXAM


Colony
Dysgonic type (smooth)
Eugonic type (rough)
Growth: Rapid grower 1 wk.

Surface antigens
Lipopolysaccharide (LPS)
Mycolic acid
Cord factor granuloma
Sulfolipid survive in macrophage
Lipoarabinomannan (LAM)
Extracellular enzymes
Hemolysin
Mortality enhancing polypeptide
Lecithinase, lipase, protease, malleobactin
Toxin
Exotoxin

NTM (non-mycobacterium TB)


Slow grower 4-6 wk.

Examination
1. 5 1 Gram positive cocci in cluster
catalase coagulase virulent factor ?
A. Protein M Streptococci
B. Pili neisseria spp., enterobacteriaceae
C. Fibrinolysis
D. Collagen binding protein
E. Erythrogenic toxin Streptococci
2. hemorrage pappule ?
Neisseria gonorrhea Skin lesion
3. thoracic and lumbar acid-fast
?
Mycobacterium tuberculosis
4. 65 Gram positive cocci, oxidase
test positive, coagulase test negative ?
S. epidermidis prosthetic joint
5. 5 1 Gram+ cocci in cluster coagulase
test+, catalase test+ virulent factor?
A. Fibrinolysin Strep, Staph
B. Collagen binding protein Staph
C. Erythrogenic toxin Strep
D. Protein M Strep
6. virulence factor Neisseria gonorrheae ?
Lipooligosaccharide
7. hemorrhagic skin ?
Neisseria gonorrhea LOS, skin lesion
8. gram + ve cocci, catalase +ve, coagulage ve ?
Staphylococcus epidermidis
9. pigment fluorescein, grape like odor?
Pseudomonas aeruginosa

10. gram gram ve coccobacilli pleomorphic virulence factor ?


Capsule

Lecture 31.5-32.5 Gluteal, Tight and Popliteal Fossa


Boundary: Iliac crest to gluteal fold/crease
Bones of Gluteal, Tight and Popliteal Fossa
Hip bone

Acetabulum
Ilium (superior)
articular surface sacroiliac joint
Iliac fossa (ala)
Iliac crest L4
ASIS (anterior superior iliac spine)
PSIS (posterior superior iliac spine)
Greater sciatic notch
Ischium (posterior)
Body
Ischial spine
Lesser sciatic notch
Ischial tuberosity bed sore
Ramus

Pubis (anterior)
Body
Ramus
Obturator foramen obturator membrane

Femur

Proximal end
Head
Neck
Greater trochanter
Lesser trochanter
Intertrochanteric line(anterior)
Intertrochanteric crest (posterior)
Gluteal tuberosity gluteus maximus
Body (shaft)
Linea aspera
Medial lip medial supracondylar line
Lateral lip lateral supracondylar line
Distal end
Adductor tubercle
Patellar surface
Medial condyle
Medical epicondyle
Lateral condyle
Lateral epicondyle

Nerve of Gluteal, Tight and Popliteal Fossa


Superficial gluteal nerve

Deep gluteal n.

Superior gluteal n. and a.


Inferior gluteal n. and a.
Sciatic n.

Superior cluneal nerve (DR L1-3)


Middle cluneal nerve (DR S1-3)
Inferior cluneal nerve (branch of posterior femoral cutaneous nerve)
Iliohypogastric nerve

Femoral cutaneous n.

Superficial vein greater siphons vein

Muscles of Gluteal
Muscles

Origin

Insertion

Action

Innervation

Blood supply

Superficial group abduct and extend hip


Gluteus maximus

Ilium

Iliotibial tract
Gluteal tuberosity
of femur

Extend hip joint

Inferior gluteal n.

Gluteus medius

Ilium

Greater trochanter
of femur

Abduct hip joint

Superior gluteal n.

Gluteus minimus

Ilium

Greater trochanter
of femur

Abduct hip joint

Superior gluteal n.

Iliotibial tract

Abduct hip joint

Superior gluteal n.

Tensor fascia latae Iliac crest


Deep group lateral rotate hip
Piriformis

Anterior surface of
sacrum

Greater trochanter
of femur

Lateral rotate hip


joint

VR S1-2

Superior gemellus

Spine of ischium

Greater trochanter
of femur

Lateral rotate hip


joint

Nerve to obturator
internus

Obturator internus

Obturator
membrane

Greater trochanter
of femur

Lateral rotate hip


joint

Nerve to obturator
internus

Inferior gemellus

Ischial tuberosity

Greater trochanter
of femur

Lateral rotate hip


joint

Nerve to
quadratus femoris

Quadratus femoris

Ischial tuberosity

Quadrate tubercle Lateral rotate hip


on
joint
upper end of femur
?

Nerve to
quadratus femoris

Greater trochanter
of femur

Obturator n.

Obturator externus obturator


membrane

Lateral rotate hip


joint

Trendelenburg sign test hip abductors: gluteus medius, gluteus minimus

Muscles of Tight and Popliteal Fossa


Muscles

Origin

Insertion

Action

Innervation

Blood supply

Anterior compartment femoral n. except psoas


Sartorius

ASIS

Medial surface of
tibia

Flex, abduct hip


Flex knee

Femoral n.

Iliopsoas
Iliacus
Psoas

T12-L1

Lesser trochanter

Flex hip

Iliacus: Femoral n.
Psoas: VR L1-2

Rectus femoris

AIIS

Quadricep tendon

Flex hip
Extend knee

Femoral n.

Vastus medialis

Intertrochanteric
line

Quadricep tendon

Flex hip
Extend knee

Femoral n.

Vastus lateralis

Greater trochanter

Quadricep tendon

Flex hip
Extend knee

Femoral n.

Vastus

Surface of femur

Quadricep tendon

Flex hip
Extend knee

Femoral n.

Quadriceps femoris

intermedius

Medial compartment thigh adduction, obturator n. except pectineus (femoral n.)


Gracilis

Ramus of pubis

Medial surface of
tibia

Obturator n.

Pectineus

Ramus of pubis

Pectineal line of
femur

Femoral n.

Adductor part

Ramus of pubis

Linear aspera of
femur

Obturator n.

Hamstring part

Ischial tuberosity

Adductor tubercle
of femur

Tibial division of
sciatic n.

Adductor longus

Body of pubis

Linear aspera of
femur

Obturator n.

Adductor brevis

Ramus of pubis

Linear aspera of
femur

Obturator n.

Adductor magnus

Posterior compartment sciatic n.


Semitendinosus

Ischial tuberosity

Medial surface of
tibia

Flex knee
Extend hip

Tibial division of
sciatic n.

Semimembranosu
s

Ischial tuberosity

Medial condyle of
tibia

Flex knee
Extend hip

Tibial division of
sciatic n.

Long head

Ischial tuberosity

Lateral side of
head of fibular

Flex knee

Tibial division of
sciatic n.

Short head

Linea aspara

Lateral side of
head of fibular

Flex knee

Common fibular
division of sciatic
n.

Biceps femoris

Rider bones ossification of tendon of adductor muscles

Triangles of Gluteal, Tight and Popliteal Fossa


Femoral triangle

Boundary
Inguinal ligament
Adductor longus
Sartorius
Contents (lateral to medial)
Femoral n. (lateral) and its branches
Femoral a. and its branches
Femoral v. (medial) and its tributaries

Popliteal fossa

Boundary
Biceps femoris
Semimembranosus, semitendinosus
Lateral head of the gastrocnemius
Medial head of the gastrocnemius
Contents
Popliteal artery and vein
Tibial nerve
Common fibular nerve
Small saphenous vein

Blood supply
External iliac a.
Deep femoral a. (profunda femoris a.) medial, posterior and lateral part of anterior compartments
Femoral a. anterior compartment
At adductor hiatus, change to popliteal a.
Anterior tibial a. dorsalis pedis a.
Posterior tibial a. medial and lateral plantar a.
Examination
1. (abduct) ?
Gluteus medius
2. Superior gluteal n. ?
Gluteus medius Gluteus medius, gluteus minimus, tensor fascia latae
3. ?
Ischial spine
4. 2 n.?
Iliopsoas
5. ?
Iliopsoas
6. Femoral n. ?
Knee extension Hip flex, knee extend
7. great saphenous v. ?
Medial malleolus Medial
8. adductor of thigh nerve ?
Obturator nerve
9. ?
Gluteus medius Gluteus medius, gluteus minimus, tensor fascia latae
10. flex hip, flex knee?
Sartorius

11. 2 nerve?
Adductor magnus Adductor part: obturator n., hamstring part: tibial division of sciatic n.
12. piriformis ?
Superior gluteal n.

Lecture 33.5-34.5 Leg and foot


Bones of Gluteal, Tight and Popliteal Fossa
Tibia (medial)

Fibular (lateral)

Lateral malleolus

Hindfoot

Calcaneus
Achilles tendon (tendo calcaneus)
Talus

Midfoot

Cuneiform (lateral)
Cuboid
Peroneus longus tendon
Navicular tibialis posterior

Forefoot

Metatarsal
Phalanges

Medial condyle
Lateral condyle
Medial intercondylar tubercle
Lateral intercondylar tubercle
Tibial tuberosity
Soleal line soleus m.
Medial malleolus

Arch of foot
Medial longitudinal arch
Lateral longitudinal arch calcaneus, cuboid, metatarsal and phalange IV-V
Transverse arch tarsometatarsal joint line
Fascia of foot
Deep fascia

Cural fascia

Continuous of tensor fascia lata

Intermuscular septum

Anterior
Posterior
Intermuscular septum

Plantar fascia

Plantar aponeurosis

Interosseous membrane

Retinaculum

Flexor retinaculum
Medial
Superior extensor retinaculum
Inferior extensor retinaculum
Lateral
Superior peroneal retinaculum
Inferior peroneal retinaculum

Cutaneous n. of leg
Deep perennial n.
Medial plantar n.
Lateral plantar n. (lateral 1-1.5 phalanges)
Nerve of leg
Sciatic n.
Tibial n. posterior compartment
Medial plantar n.
Lateral plantar n.
Common peroneal n.
Superficial peroneal n. lateral compartment
Deep peroneal n. anterior compartment

Superficial veins
Great sphenous v.
Small sphenous v.

Muscles of Foot
Muscles

Origin

Insertion

Action

Innervation

Blood supply

Anterior compartment extensor, deep peroneal n. (sciatic n. common peroneal n.), anterior tibial a. (femoral a.
popliteal a.)
Tibialis anterior
(TA)

Lateral condyle
and body of tibia

Medial cuneiform

Dorsiflex ankle
Inversion

Deep peroneal n.

Extensor hallucis
longus (EHL)

Surface of fibular

Distal phalanges

Dorsiflex ankle
Inversion

Deep peroneal n.

Extensor digitorum Interosseous


longus (EDL)
membrane

Distal phalanges

Dorsiflex angle
Extend toe

Deep peroneal n.

Peroneus tertius

Metatarsal

Dorsiflex ankel
Eversion

Deep peroneal n.

Interosseous
membrane

Lateral compartment superficial superficial peroneal n., peroneal a.


Peroneus longus

Fibula

Metatarsal I

Eversion

Superficial
peroneal n.

Peroneus brevis

Fibula

Metatarsal V

Plantaflexion

Superficial
peroneal n.

Superficial group of posterior compartment tibial n., posterior tibial a.


Gastrocnemius

Medial and lateral


condyle of femur

Calcaneus

Plantaflexion
Flex knee

Tibial n.

Soleus

Soleal line

Calcaneus

Plantaflex ankle

Tibial n.

Plantaris

Popliteal surface

Calcaneus

Plantaflex ankle

Tibial n.

Deep group of posterior compartment tibial n., posterior tibial a.


Popliteus

Lateral condyle of
femur

Tibia

Tibial n.

Tibialis posterior

Interosseous
membrane

Navicular

Tibial n.

Flexor digitorum
longus

Surface of tibia

Distal phalanges

Flex toes
Plantar flex ankle

Tibial n.

Flexor hallucis
longus

Surface of fibular

Distal phalanges

Flex toe
Plantar flex ankle

Tibial n.

Triceps sulae EXAM


Sciatic n. common peroneal n. superficial and deep peroneal n.
Femoral a. popliteal a. anterior and posterior tibial a. dorsalis pedis (palpate pulse)
Tarsal tunnel (medial malleolus) tibial n.
Tibialis posterior tendon
Posterior tibial a.
Tibial n.
Flexor digitorum longus tendon
Flexor hallucis longus

Muscles of Foot
Muscles

Origin

Insertion

Action

Innervation

Blood supply

Anterior compartment lateral tarsal n. (deep peroneal n.), lateral tarsal a. and dorsalis pedis a.
Extensor digitorum Calcaneus
brevis

Extensor
degitorum longus

Extensor hallucis
brevis

Muscles of Sole of Foot medial and lateral plantar n., dorsalis pedis, medial and lateral plantar a.
Muscles

Origin

Insertion

Action

Innervation

Blood supply

Abductor hallucis

Medial calcaneus

Proximal phalange

Medial plantar n.

Flexor digitorum
brevis

Plantar
aponeurosis

Middle phalanges

Medial plantar n.

Abductor digiti
minimi

Proximal phalange

Lateral plantar n.

Quadratus plantae

Calcaneus

Flexor digitorum
longus

Lateral plantar n.

Lumbricals

Flexor digitorum
longus

Proximal
phalanges

Medial one:
Medial plantar n.
Lateral three:
Lateral plantar n.

Flexor hallucis
brevis
Lateral head
Medial head

Cuboid cuniform

Proximal phalange

Medial plantar n.

Adductor hallucis
Transverse h.
Oblique head

Proximal phalange

Lateral plantar n.

Flexor digiti minimi


brevis

Metatarsal bone

Proximal phalange

Lateral plantar n.

Plantar interossei

Adduct
metatarsophalang
eal joint

Lateral plantar n.

Dorsal interossei

Adduct
metatarsophalang
eal joint

Lateral plantar n.

1st layer

2nd layer

3rd layer

4th layer

Clinical correlation
Bone fracture

Neck of fibular common perineal n.

Anterior compartment
syndrom

Compression of artery and nerve reduce blood supply


Foot drop
Loss sensation of 1-2nd toe

Flat foot

Treatment: arch support shoe

Plantar fasciitis

Treatment: ultrasound, tape fixation

Achilles tendonitis

Over dorsifexion inflamed Achilles tendon

Tarsal tunnel syndrom (TTS)

Deep peroneal n. injury

Loss of sensation of 1-2nd toes


Foot drop

Anterior tibial a. injury

Diagnosis: Dorsalis pedis impalpable

Varicose vein

Valve vein does not close properly


Grading: 0-6

Claw foot

Club foot

Hallux valgus (bunion)

Lateral deviation of the great toe at metatarsophalangeal joint


Treatment: bunion sprint

Hallux varus

Abductor (too strong) and adductor (too weak) hallucis m.


Medial deviation of the great toe at metatarsophalangeal joint

Examination
1. flexor retinaculum flexor ?
Tibial n.
2. Lateral plantar n.?
Flexor digiti minimi brevis
3. tricep surae?
Soleus Gastrocnemius, soleus
4. navicular?
Talus
5. tarsal injury?
Calcaneus
6. Nerve anterior compartment of leg?
Deep peroneal n.
7. origin calcaneus and long plantar fascia?
Flexor digitorum brevis
8. ?
Popliteus
9. Muscle tibial nerve L5, S1, S2?
Flexor hallucis longus m. Flexor hallucis longus, flexor digitorum longus m.
10. sole of foot fascia ?
Plantar fascia

11. ?
Deep peroneal n. ?
12. dorsiflexion inversion?
Tibialis anterior m.
13. 3?
Flexor hallucis brevis m. Flexor hallucis brevis, adductor pollicis, flexor digiti minimi
14. fracture head of fibula ?
Common peroneal n.

Lecture 35-36 Therapeutic exercise in common MS problem


Deconditioning
Muscle mass
Muscle strength
Done density (osteoporosis)
CVS
Pulmonary
Postural hypotension
Joint stiffness
Psychological function
Exercise
Muscle strength, muscle hypertrophy
Bone mass
HR, stroke volume, CO tissue perfusion, BP
Lung volume gas diffuse capacity
Endocrine: GH, thyroid, estrogen, testosterone, insulin, glucagon, cortisol, cholesterol
Psychological: anxiety, depression
Type
Range of motion

Joint stiffness
Increase range of motion

Types repeated 3-5 times, 1-2 times/day


Active exercise grade 3 or higher motor power
Active assistive exercise grade 2 motor power
Passive exercise grade 1, isometric exercise
Passive stretching exercise joint stiffness
Strengthening exercise

Endurance exercise

Low load, high repetition

Coordination exercise

Prime mover
Application: cerebellar lesion

Type

Aerobic excercise

Continuous exercise
Intensity: target heart rate
Generic formula EXAM EXAM
60-80% of maximum heart rate
Maximum heart rate (MHR) = 220-age
Karvonen formula EXAM EXAM
Target HR = HR at rest + 60% HR reserve
HR reseve = Maximum HR - resting HR
Duration >30 mins
Frequency: >3 times/week

Anaerobic exercise

Range of motion
Increase flexibility
Overload principle high load, low repetition EXAM
Delormas technique
Progressive resistant exercise at 10RM (repetition maximum)
25% 10RM 50% 10RM 75% 10RM 100% 10RM
Oxford technique
Regressive resistant exercise at 10RM (repetition maximum)
100% 10RM 75% 10RM 50% 10RM 25% 10RM
Types EXAM
Isometric exercise
Isotonic exercise concentric, eccentric, progressive resistant exercise
Isokinetic exercise variable resistant training
Application: frozen shoulder (wall climbing), osteoarthritis (isometric or isotonic)

ATP <2 seconds


Creatinine phosphate 0-8 seconds
Glycolysis 6-90 seconds
Oxidative >2 mins

Warm up 5-10 minutes, stretching exercise


Cool down postural hypotension, delayed onset muscle soreness (DOMS)
Disease

DM

Exercise type Exercise Prescription


Target

Duration
(mins/week)

Frequency
(times/week)

Precaution

Aerobic

50-70% MHR

150 (moderate)
90 (intense)
20-60 min/day

3-7

Hypoglycemia
Insulin drug dosage

Resistant

2-3 set, 8-12 rep

2-3

50-70% MHR

30-60 mins/day

2-3

Resistant
(supplement)

1 set, 8-12 rep

Aerobic

70% MHR (>30 mins)

300 (moderate)
150 (intense)

>5

Resistant
(supplement)

Hypertension Aerobic

Obesity

Exercise complication: exercise induce asthma, musculoskeletal injury


Examination
1. injury ms system ?

2. Excessive load ?
A. low back pain
B. neck pain
C. wrist pain
D. forearm pain
E.
3. ?
, , =
4. cool down
?
5. O2?

6. motor power=0 ?
Passive ROM Passive stretching exercise
7. ?
Isometric exercise
8. ?
Eccentric exercise
9. strengthening exercise?
Low load, high repetition
10. warm up?
Increase growth hormone

Uncontrolled hypertension
Beta-blockers

Weight baring joint

11. Target heart rate 20 ?


120-160
12. Target hearth rate Karvonen formula?
HR at rest + 60% HR reserve

Lecture 37.5 Plain Film of Bone and Joint


Abnormal radiologic finding in plain radiography
Epiphysis secondary ossification center
Metaphysis epiphyseal plate
Diaphysis
Fracture

Disruption of cortex may affect proximal and distal joint


Type of fracture
Complete fracture
Transverse
Oblique
Spiral
Comminuted >3 pieces
Segmental
Avulsed tendon or ligament
Impacted
Incomplete fracture
Torus
Greenstick
Alignment of fracture
Displacement: medial, lateral displacement (reference from proximal fragment)
Angulation: medial, lateral angulation

Epiphyseal plate injury

Salter-Harris classification type 1-5


Prognosis: early epiphyseal plate closure

Fracture healing

Evidence of healing
Unsharpness of fracture border
Periosteal callus formation
Fracture line replaced by sclerosis

Dislocation, subluxation

Pathological fracture
Osteolytic lesion

Types
Geographic permeative
Well demarcated border
Suggest non-aggressive pathology e.g. benign tumor giant cell tumor, aneurysmal bone
cyst
Motheaten
Ill-defined border, course lesion
Suggest aggressive pathology
Primary malignant e.g. osteosarcoma, Ewing sarcoma, chondrosarcoma
Secondary malignant (metastasis)
Permeative
Poor demarcated, fine lesion

Periosteal reaction

Types
Non-aggressive periosteal reaction
Solid periosteal reaction calcified periosteal suggestion infection e.g. osteomyelitis
Aggressive
periosteal reaction suggest aggressive primary malignant tumor e.g.

osteosarcoma
Laminated periosteal reaction
Sunburst periosteal reaction
Codmans triangle periosteal reaction

Sclerosis

Types
Reactive sclerosis
Osteoblast response to pathology sclerotic border
Suggest progressive pathology e.g. chronic osteomyelitis, benign tumor
Sclerotic tumor e.g. osteosarcoma

Osteomyelitis

Ill-defined lesion
Types
Acute permeative osteolytic, solid periosteal reaction
Chronic sclerosis, sequestrum, involucrum

Examination
1. X-ray
?
2. ?
Dual energy X-ray absorptiometry Measuring bone mineral density (BMD)
3. Osteomyelitis ? ill-defined osteolytic lesion, extensive reactive sclerosis, solid periosteal reaction
A. Pathogenesis
B. Permeative osteolytic lesion with solid periosteal reaction
C. Geographic osteolytic lesion with sunburst periosteal reaction
E. Geographic osteolytic lesion with pathological fracture
4. ulnar radius?
Healing of proximal ulnar and radial
5. X-ray
Healing process of bone by callus
6. incomplete fracture?
Incomplete disruption of cortex

7. permeative osteolytic lesion sunburst periosteal reaction ?


Osteosarcoma

Lecture 38.5 Joint of the Lower Limb


Joint of the Lower Limb
Hip joint

Type: synovial joint


Bone:
Hip bones
Head of femur (acetabular labrum lunate surface, acetabular branch of obturator n.)
EXAM
Ligament
pubofermoral prevent abduction of hip joint
Illiofemoral ligament
Ischiofemoral (weakest)
Ligament of head of femur (acetabular branch of obturator a.) EXAM
Nerve supply: multiple e.g. femoral n.
Angles
Angle of Wiberg plane of acetabular rim
Angle of torsion 7-12 degree
Injury: acetabular branch of obturator a. EXAM

Knee joint

Type: hinge type of synovial joint


Articulation
2 femorotibial articulation (lateral and medial femoral and tibial condyles)
Femoropatellar articulation
Bursa
Suprapatella bursa
External ligaments of knee joint
Tibial (medial) collateral ligament (TCL) medial meniscus
Fibular (lateral) collateral ligament (FCL) lateral meniscus
Arcuate popliteal ligament
Oblique popliteal ligament
Intra-articular structure of knee joint EXAM EXAM
Anterior cruciate ligament anterior intercondylar area, limit posterior rolling
Posterior cruciate ligament posterior intercondylar area, limit anterior rolling
Lachman tested EXAM
Anterior drawer sign + anterior cruciate ligament tear
Posterior drawer sign + posterior cruciate ligament tear
Menisci C-shaped
Medial meniscus (less mobile)
Lateral meniscus
Angle
Q-angle weight-baring line (line of gravity) and ASIS EXAM
Decrease Q-angle genu varum
Increase Q-angle genu valgum

Ankle joint

Medial (deltoid) ligament tear in acute eversion EXAM


Lateral ligament
Anterior talofibular ligament tear in lateral angle sprain
Calcaneofibular ligament
Posterior talofibular ligament

Joint of foot

Subtalar (posterior talocalcanean) joint


Transverse tarsal (midtarsal or Chopart) joint consist of talonavicular and calcaneocuboid
EXAM

Intertarsal (intercuneiform) joint


Tarsometatarsal and intermetatarsal joints
Metatarsophalangeal and interphalangeal joints
Ligament
Iliofemoral ligament prevent hip hyperextension
Pubofermoral ligament prevent hip hyperabduction
Ischiofemoral ligament prevent hip hyperflexion
Examination

1. ?
Hip
2. Chopart's amputation ?
Interosseous talocalcaneous
3. deltoid lig. ?
Eversion
4. fibrocartilage acetabular labrum?
Hip
5. Hip ligament ?
Hip extension
6. knee hyperextension + forward displacement of tibia?
Anterior cruciate ligament
7. Ligament hip extension?
Iliofemoral ligament
8. Ligament Medial meniscus ?
Medial (tibial) collateral ligament
9. tibia ?
Anterior cruciate ligament
10. ?
Head of fibula
11. ?
Anterior talofibular ligament

12. Chopart's ligament ?


A. Spring ligament
B. Bifurcate ligament
C. Short plantar ligament
D. Long plantar ligament
E. Interosseous talocalcaneous ligament

Case Study: Case 1 Open Floating Shoulder Fracture with Brachial Plexus Injury

Scenario 1.1
A 20-year-old male, wearing a safety helmet, slipped and fell off from high speed motorcycle riding. His left shoulder hit the
ground resulting in severe pain. Emergency Medical Service carried him to a general hospital.
An emergency physician took physical examination and recorded as follows.

Vital sign: BT 37.2, RR 24 bpm, PR 90 bpm, BP 120/70 mmHg


HEENT, heart, lung, and abdomen: within normal limit
Left shoulder: a lacerated wound of left chest wall extending toward shoulder
Muscle of left upper limb: weakness

Initial emergency management


ABCD airway, breathing, circulation, disability
Wound dressing
Splinting
Initial assessment
Vital sign
Blood pressure 90/60 to 120/80 mmHg
Pulse rate 60 to 100 beats per minute
Body temperature 36.5 to 37.5C
Respiratory rate 12 to 18 breaths per minute
Pain
HEENT: head, eye, ear, nose, throat
Pain physiology
Mechanism
Direct mechanical injury
Muscle injury
Stimulate nociceptors nerve impulse transmitted via small A-delta fibers and C-fibers spinal cord thalamus
somatosensory cortex pain
C-fibers small unmyelinated neurons diffuse burning, aching sensations
A-delta fibers larger, myelinated fibers well-localized, sharp pain sensations
Muscle spasm
Ischemia

Scenario 1.2
Following a physical examination, an X-ray of the patients shoulder was carried out. The radiograph showed an open
fracture of the left clavicle.
The physician applied urinary catheter, intravenous fluid and 1 gm cefazolin, and intramuscular tetanus toxoid to the patient.
The debridement and open reduction were then performed.

Fracture definition: discontinuity of trabeculae


Fracture
Open fracture broken bone that is in communication through the skin with the environment contamination
Close fracture
Management of open fracture
Tetanus prophylaxis tetanus toxoid
Prophylactic antibiotics
Debridement
Fracture stabilization
Tetanus prophylaxis
Wound type

Patient receive
last tetanus shot
<5 years

Patient receive
last tetanus shot
5-10 years

Patient receive
last tetanus shot
>10 years

Patient never receive


tetanus shot

Clean wound

Not required

Not required

Tetanus toxoid

Tetanus toxoid

Contaminated wound

Not required

Tetanus toxoid

Tetanus toxoid

Tetanus toxoid
Tetanus immunoglobulin (TIG)

Scenario 2
Two weeks after medical operation the patients pain was over but he got fever. There was pus oozing from the surgical
wound which became red and swelling (inflammation). The patient could neither abduct the arm nor move his elbow and
hand. He also experienced the numbness of the whole upper limb. Physical examination of the second hospital visit was
recorded as follows.
Motor power (left side)
Rhomboideus
Deltoid
Pectoralis major
Supraspinatus
Infraspinatus
Latissimus dorsi
Biceps brachii
Triceps brachii
Flexor digitorum superficialis
Flexor digitorum profundus
Intrinsic muscle of hand

Grade
0
0
0
0
0
0
0
0
0
0
0

Inflammation
Infection, microbial toxin macrophage
Synthesis of IL-1, IL-6, TNF, IFN
Neutrophil recruitment
Hypothalamus
Synthesis of PGE2 in brain raising the hypothalamic set point for core temperature
Synthesis of PGE2 in peripheral tissue non-specific myalgia and arthralgia
IL-8 chemokine, induce chemotaxis of neutrophils
Present antigen to T-helper cell
IL-2 clonal expansion of T cells
IL-4 clonal expansion of B cells
Antibiotics selection
Grage I 1st generation cephalosporin
Grade II 1st generation cephalosporin gentamycin
Grade III 1st generation cephalosporin + gentamycin anti-anaerobe
War wounds 1st generation cephalosporin + gentamycin + anti-anaerobe
Motor power *apply for joint with full range of motion not apply for joint stiffness
0 no movement
1 trace movement
2 active movement without gravity
3 active movement with gravity
4 active movement with resistant
5 normal power
Brachial plexus

Brachial Plexus
Root (VR)

Trunk

Division

Cords

Branches

C5
Upper trunk
Anterior division
Dorsal scapular n. Nerve to subclavious

Lateral cord
Lateral pectoral n.

Musculocutaneous n.

Levator scapulae m.
Rhomboids m.

Pectoralis major m.

Subclavius m.

Suprascapular n.

Lateral root of median n.

Supra/infraspinatus m.

C6
C7

Flexor m. of forearm
Thenar m.
Lumbrical m. 1-2

Posterior division
Middle trunk

Anterior division

Posterior cord
Upper subscapular n.
Subscapularis m.

Thoracodorsal n.
Latissimus dorsi m.

Lower subscapular n.

C8
T1

Flexor m. of arm
Lateral cutaneous nerve of
forearm

Axillary n.
Deltoid m.
Teres minor m.
Superior lateral cutaneous
nerve of arm

Radial n.

Subscapularis m.
Teres major m.

Extensor m. of arm
Extensor m. of forearm
Inferior lateral cutaneous nerve
of arm

Medial cord
Medial pectoral n.

Ulnar n.

Posterior division
Lower trunk

Anterior division

Pectoralis major/minor m.

Medial cutaneous n. of arm


Medial cutaneous n. of forearm
C5-C7
Long thoracic n.

Intrinsic muscle of hand


Flexor carpi ulnaris
Flexor digitorum profundus
(medial half)

Median root of median n.

Posterior division

Serratus anterior m.

Brachial plexus injury


UBP injury Erbs palsy
LBP injury Klumpkes palsy
Total BP injury
Classification of nerve injury
Neurapraxia
Grade I myelin
Axonotmesis
Grade II myelin, axon
Neurotmesis
Grade III myelin, axon, endoneurium disrupt axon continuity, perineurium is protected
Grade IV myelin, axon, endoneurium, perineurium nerve fascia damage, sheath continuity is maintained
Grade V myelin, axon, endoneurium, perineurium, epineurium
Physical examination
Evaluation of C-spine injury
Evaluation of upper extremity function
Joint ROM and stiffness
Sign of nerve recovery
Specific sign
Imaging evaluation
Plain film evaluate shoulder joint, C-spine transverse process fracture
Myelography detect root avulsion (plain film or CT myelography, invasive)
MRI
CT angiography
Pulmonary function test phrenic n. indicate pulmonary injury
Electrodiagnosis evaluation
Sequence of surgical intervention
Elbow flexion reinnervation of biceps or brachialis m.

Shoulder stabilization
Hand sensation
Wrist and finger flexion
Wrist and finger extension
Intrinsic hand function

Primary reconstruction
Neurolysis fibrosis surround and compress nerve inhibit nerve recovery
Direct nerve repair (neurorrhaphy)
Nerve grafting from sural n.
Nerve transfer (neurotization) repair of a distal denervated nerve element by using a proximal foreign nerve
Secondary reconstruction
Tendon transfer
Free functioning muscle transfer (muscle transplantation)
Arthrodesis artificial induction of joint ossification between two bones via surgery

Scenario 3
The physician of Srinagarind Hospital requested Gram stain test of the patients pus obtained from the wound and the result
showed Gram positive cocci. The bacterial culture test revealed Staphylococcus aureus.
The physician adjusted the dose and order 1 gm IV cefazolin every 8 hours.
After a week of hospital stay, the test for infection showed negative result. He was still unable to abduct the arm and hand.
Total brachial plexus injury was diagnosed.

Common bacterial infection in open fracture


Blunt trauma, low energy gun shot wound Stapylococcus spp., Streptococcus spp.
Farm wounds Clostridia spp.
Fresh water Pseudomonas spp., Aeromonas spp.
Sea Water Aeromonas app., Vibrios spp.
War wounds, high energy gunshot wound Gram negative
Gram staining
Bacterial identification
Gram

Gram

Cocci

Catalase

Staphylococci spp.
Coagulase S. aureus
Coagulase
Novobiocin-sensitive S. epidermidis
Novobiocin-resistant S. saprophyticus

Catalase

Streptococcus spp.
-hemolytic pattern (partial)
Optochin S. pneumoniae
Optochin S. mutan, other viridians
-hemolytic pattern (clear)
Bacitracin-sensitive S. pyogenes
Bacitracin-negative S. agalactiae
-hemolytic pattern e.g. Enterococcus spp.

Rod

Clostridium spp.
Bacillus spp.

Coccobacilli

Haemophilus influenzae

Cocci

Neisseria spp. N. meningitidis, N. gonorrheae

Bacilli

Klebsiella spp.
E. coli
P. aeruginosa

Clinical Correlation
Anterior shoulder dislocation
Test for axillary n. if damaged
Treatment
Traction and counter traction
Hippocratic technique risk brachial plexus injury
Stimson technique
Leverage (Kocher) traction external rotation adduction internal rotation
Confirm diagnosis: by internal rotation
Humerus fracture
Associated injury: radial n. test for wrist extension
Dinner folk deformity
Treatment
Cast
Open reduction
Carpal tunnel syndrome
Palmaris longus lie outside carpal tunnel
Treatment
Decompress n.
Anatomical snuff box pain
Scaphoid fracture scaphoid avascular necrosis
Treatment: Herberts screw
De Quervain disease
Stenosing tenosynovitis of abductor pollicis longus and extensor pollicis brevis tendon
Radial styloid pain, Finkelstein test +

Embryology and congenital malformation of MS


Development of skeletal system
Mesoderm, neural crest cell
Intraembryonic mesoderm paraxial mesoderm somites
Somite
Ventromedial: sclerotome bone EXAM
Dorsolateral: dermomyotome
Myotome myoblast myotube myofilament synthesis in cytoplasm muscle
Dermatome dermis
Iris muscle, mammary gland, sweat gland develop from ectoderm EXAM EXAM
Myotomes
Preotic myotomes
Occipital myotomes
Cervical myotomes
Thoracic myotomes
Lumbar myotomes
Regressing caudal myotomes
Smooth muscle splanchnic mesoderm EXAM
Cardiac muscle splanchnic mesoderm intercalated disc, Purkinje fiber
Development by region
Trunk muscle myotome region of somite
Limb muscle somatic mesoderm (somatic layer of lateral mesoderm)
Tongue head mesenchyme
Face, jaw, neck, pharynx, larynx mesenchyme in brachial arch mastication, facial expression
5th week
Epaxial division small dorsal extensor muscle
Hypaxial division large, ventral flexor muscle
Development of bone and cartilage
5th week
Mesenchyme chondroblast chondrocyte
Hyaline cartilage
Elastic cartilage
Fibrocartilage
Skull
Neurocranium
Viscarocarnium
Membranous: frontonasal process maxillary process mandibular maxilla
Anterior fontanelle ?
Development of vertebral column
Stages
Precartilagenous stage
Sclerotome 3 main areas
Surrounding notochord
Densely packed cells (annulus fibrosus) intervertebral disc
Mesenchymal body of vertebra
Notochord degenerate nucleus pulposus
Surrounding neural tube
Vertebral (neural) arch
Body wall
Costal process rib (thoracic region)
Cartilaginous stage
6th week
Chondrification center
Occur in mesenchymal centrum
Bony stage
Ossification
Development of ribs
Mesenchymal
Clavicle first bone to start ossification
?

process mandible

Development of sternum
?
Development of limb
?
Apical ectodermal ridge
Examination
1. Muscle of iris ?
Ectoderm
2. ?
Sclerotome
3. Myotome?
Paravertebral muscle
4. Intramembranous ossification?
Frontal bone Nasal, sphenoid, frontal, parietal, temporal, vomer, maxilla, mandible, pelvis, clavicle
5. Muscle of iris ?
Ectoderm Iris muscle, mammary gland, sweat gland
6. Smooth muscle ?
Splanchnic mesoderm

Gross Anatomy Checklist EXAM

Gross Anatomy Checklist


#

Name

Description

Chondrocyte

Elastic cartilage

Fibrocartilage

Osteoclast

Haversian canal

Suboccipital n.

Suboccipital triangle (DR C1)

Semispinalis cervicis

Located behind splenius cervicis

Supraspinatus m.

Originate from supraglenoid fossa, insert to greater tubercle of humerus

Suprascapular a., n.

Passes through the suprascapular notch


Nerve inferior to the superior transverse scapular ligament
Artery superior to the superior transverse scapular ligament

10 Teres major m.

Originate from interior angle of scapular, insert to medial lip of intertubercular


sulcus of the humerus

11 Posterior humeral circumflex a.

Quadrangular space: posterior humeral circumflex a., axillary n.

12 Coracoid process

13 Rhomboid major m.

Supply by dorsal scapular n., a.

14 Transverse cervical a.

15 Erector spinae m.

Erector spinae: Iliocostalis (outer), longissimus, spinalis (inner)

16 Thoracodorsal a.

Subbranch of subscapular a. (2nd branch of axillary a.)

17 Circumflex scapular a.

Triangular space, subbranch of subscapular a. (2nd branch of axillary a.)

18 Musculocutaneous n.

Lateral cord of brachial plexus

19 Ulnar n.

Medial cord of brachial plexus

20 Radial n.

Posterior cord of brachial plexus

21 Median n.

Lateral root of median n. (lateral cord), and medial root of median n. (medial c)

22 Serratus anterior m.

Long thoracic n., lateral thoracic a. (2nd part of axillary a.)

23 Right clavicle

24 Thoracoacromial trunk

2nd part of axillary a., APCD: acromial, pectoral, clavicular and deltoid branch

25 Cephalic v.

Deltopectoral triangle

26 Coracobrachialis m.

Originate from coracoid process, insert to humerus

27 Short head of biceps brachii m.

Originate from coracoid process, insert to bicipital aponeurosis

28 Flexor carpi radialis m.

29 Extensor carpi radialis brevis m.

30 Basilic v.

31 Extensor retinaculum

32 Scaphoid bone

Proximal row (lateral to medial): scaphoid, lunate, triquetrum, pisiform


Distal row (lateral to medial): trapezium, trapezoid, capitate, hammate

33 Radial a.

Anatomical snuffbox: abductor pollicis longus, extensor pollicis longus/brevis

34 Opponens pollicis m.

Thenar m. opponens pollicis, abductor pollicis brevis, flexor pollicis brevis

35 Abductor digiti minimi m.

Hypothenar m. abductor digiti minimi, flexor digiti minimi brevis, opponens


digiti minimi

36 Lingual n.

Otic ganglion lingual n., inferior alveolar n.

37 Inferior alveolar n.

Otic ganglion lingual n., inferior alveolar n.

38 Orbicularis oris m.

39 Buccinator m.

40 Parotid duct

41 Facial a.

External carotid a. facial, maxillary, transverse facial, superior temporal,


posterior auricular, and occipital a.

42 Retromandibular v.

43 Deep temporal a.

Maxillary a. deep temporal a.

44 Buccal branch of facial n.

Facial n. posterior auricular, temporal, zygomatic, buccal, marginal


mandibular, and cervical branch

45 Foramen ovale

posterior part of the sphenoid bone mandibular n. (trigeminal n.), lesser


petrosal n. (glossopharyngeal n., CN IX)

46 External carotid a.

47 Internal jugular v.

48 Ansa cervicalis

C1 (with hypoglossal n.) geniohyoid, thyrohyoid m.


Ansa cervicalis Sternohyoid, omohyoid, sternothyroid m.

49 Recurrent laryngeal n.

50 Phrenic n.

Lie anteriorly to scalenus anterior m.

51 Scalenus anterior m.

52 Anterior belly of digastric m.

Supplied by n. to mylohyoid (inferior alveolar n., CN V)

53 Mylohyoid m.

Supplied by n. to mylohyoid (inferior alveolar n., CN V)

54 Tyrohyoid m.

55 Vagus n.

56 Gluteus medius m.

Supplied by superior gluteal n., a.

57 Piriformis m.

58 Gracilis m.

59 Sartorius m..

Supplied by femoral n.

60 Popliteal a.

61 Superior gluteal a.

62 Iliotibial tract

63 Semimembranosus m.

64 Obturator n.

65 Profunda femoral a.

External iliac a.
Deep femoral a. (profunda femoral a.) medial, posterior and lateral part
of anterior compartments
Femoral a. anterior compartment
At adductor hiatus, change to popliteal a.
Anterior tibial a. dorsalis pedis a.
Posterior tibial a. medial and lateral plantar a.

66 Soleus m.

67 Achilles tendon

68 Peroneus tertius

Anterior compartment of foot: tibialis anterior, extensor hallucis longus,


extensor digitorum longus, peroneus tertius

69 Flexor digitorum brevis m.

70 Small saphenous v.

71 Common fibular (peroneal) a.

72 Navicular bone

73 Medial malleolus

74 Posterior tibial a.

75 Dorsalis pedis a.

76 Glenoid labrum

77 Acromioclavicular joint

Laboratory 1 Muscle contraction

Laboratory ? Histology of Cartilage, Bone and Joint

Histology of Cartilage, Bone and Joint


#

Name

Description
1. Identify

Hyaline cartilage

- Perichondrium
- Chondroblast, chondrocytes
- Matrix and capsule

Elastic cartilage

- Perichondrium
- Chondrocytes
- Intercellular matrix elastic fibers

Fibrocartilage

Chondrocytes
collagen fibers

Decalcified bone X.S

- Cross section of compact bone


- Periosteum
- Inner and outer
circumferential lamellae
- Haversian system
- Interstitial system
- Volkmann's canal
- Osteocytes in the lacunae
- Bone marrow

Bone, decalcified l.s

- NO. 19 section
plane
Bone,human,ground thin x.s
Ground bone,x.s human

-
Haversian system
interstitial system

compact bone
Bone,human, ground thin,
lacunae and canaliculi
7

Bone,human,ground,x.s and l.s

- lacunae,canliculi cement line,


Volkmann's canal

Cancellous bone

- Trabeculae
- Osteocytes in lacunae
- Osteoblasts &
Osteoclasts
- Bone marrow
- Cartilage core ()

Bone, developing,

cartilage
cartilage type
bone
woven compact bone
-

cartilage

diaphysis

10 Bone,developing,x.s.

- Woven cancellous bone

intramembranous ossification
osteblasts,
osteocyte & osteoclasts
- Mesenchymal cells
periosteum
- Developing tooth

11

Bone, developing, x.s.

- Cross section 2
- Periosteum
- Trabeculae
-
periosteum intramembranous
medullary cavity
intracartilagenous ossification

12 Joint

- Synovial membrane joint cavity


free surface 2-4

dense CNT
- blood vessels
- villi joint
cavity
- Articular cartilage
Hyaline
cartilage
- free surface perichondrium
- matrix collagen
type I
fibrous cartilage

Laboratory 4 Pathology of Bone and Joint


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Pathology of Bone and Joint


#
1

Name

Description
Giant cell tumor of long bone
Location: epiphysis or metaphysis of long bones
Benign, locally aggressive cortical expansion and cortical thinning
Gross morphology: red-brown mass
Long bone: Giant cell tumor; Specimen No. G-MS-1, S19-190

Osteosarcoma (femur)
Location: metaphysis tumor does not invade epiphyseal plate, medullary
canal, nor have joint space involvement
Gross morphology: gray-white mass, Codmans triangle
Femur: Osteosarcoma, conventional; Specimen No. G-MS-2, G-MT-7

Lipoma
Gross morphology
Well-circumscribed adipose tissue mass
Fibrous capsule
No lobulation within tumor

Soft tissue: Lipoma: Specimen No.G-BT-3


4

Giant cell tumor of bone


Microscopic morphology
Uniform round to oval mononuclear cells (neoplastic cells mitotic
figures)
Multinucleated giant cells (reactive cells)
Reactive osteoid formation
Bone: Giant cell tumor; Specimen No. M-MS-3

Osteosarcoma
Microscopic morphology: osteoblastic lesions with osteoid deposition
Bone: Osteosarcoma, conventional; Specimen No. M-MS-4, M-MS-5, M-MT-7

Chronic tophaceous arthritis


Microscopic morphology
Synovium hyperplasia, chronic inflammation, fibrosis
Foreign bodies (uric acid crystals), surrounded by histiocytes, foreign
body giant cells
Synovium: Chronic tophaceous arthritis; Specimen No. M-MS-6

Giant cell tumor of tendon sheath


Gross morphology
Well-circumscribed nodular firm mass with a deep brown color due to the
large amount of hemosiderin content
Microscopic
morphology

Fibrosis

Mononuclear cells grooved nuclei, or prominent nucleoli


Scattered multinucleated cells (osteoclast-like appearance)
Foamy macrophage (xanthoma cells)
Hemosiderin deposition
Cholesterol cleft
Soft tissue of finger: Giant cell tumor of tendon sheath; Specimen No. M-MS-9

Chondrosarcoma
Microscopic morphology
Malignant cartilage
Multinucleated chondrocytes (atypical chondrocyte) binucleation, small
nucleoli
Double lacuna
Endochondral ossification (calcification area) in cartilaginous matrix
Well differentiated type (low grade or grade I chondrosarcoma) low
anaplasia and mitosis chondrocyte
Bone: Chondrosarcoma; Specimen No. M-MS-12

Lipoma
Microscopic morphology
Mature adipose tissue
Fibrous capsule well encapsulated mass
Soft tissue: Lipoma; Specimen No. M-BT-4

10

Lymphangioma
Microscopic morphology
Poorly circumscribed
Dilated thin-walled lymphatic channels lined by attenuated, bland
endothelial cells
Vascular lumina may be empty or contain pink proteinaceous lymph,
lymphocytes
Connective tissue stroma may contain variable numbers of lymphocytes
Soft tissue: Lymphangioma; Specimen No. M-ST-2

11

Intramuscular hemangioma
Mostly occur in lower extremities
Microscopic morphology
Poorly circumscribed
Increased number of vessels (proliferated blood vessels)
Red blood cells or transudate
Lined by monolayer of typical (normal) endothelial cells
Soft tissue: Intramuscular hemangioma; Specimen No. M-ST-4

12

Pyogenic granuloma (lobular hemangioma)


Type: capillary hemangioma
Gross morphology: sessile polyp on skin or mucosa surfaces
Microscopic morphology
Lobulated capillary hemangioma in edematous fibromyxoid stroma
Skin: Pyogenic granuloma; Specimen No. M-ST-5

13

Extraabdominal desmoid-type fibromatoses


Microscopic examination
Poorly circumscribed with infiltration of adjacent tissue e.g. skeletal
muscle
Elongated spindle-shaped cells (bipolar fibroblasts and myofibroblasts)
Collagen fibers, fascicles pattern
Atrophic muscle fibers (multiple nucleus)
Soft tissue: Desmoid-type fibromatoses, extraabdominal; Specimen No. MST-6

14

Dermatofibroma (fibrous histiocytoma)


Occur at dermis or upper subcutaneous tissue
Microscopic morphology
Hyperplastic change of epidermis e.g. acanthosis
Benign proliferating fibroblasts
Storiform pattern (crisscross short fascicles pattern)
Skin: Dermatofibroma (fibrous histiocytoma); Specimen No. M-ST-7

15

Malignant fibrous histiocytoma, pleomorphic type


Microscopic morphology
Malignant plump spindled cells, short fascicles pattern
Plump round histiocytic cells
Marked pleomorphism, hyperchromatic nuclei, atypical mitotic figures

Soft tissue: Malignant fibrous histiocytoma, pleomorphic type; Specimen No.


M-ST-9
16

Embryonal rhabdomyosarcoma
Microscopic morphology
Sheets of poorly differentiated round to spindle cells in myxoid stroma
Tadpole or strap cells (round and elongated cells) rhabdomyoblast-like
neoplastic cells (eosinophilic granular cytoplasm)
Soft tissue: Rhabdomyosarcoma, embryonal; Specimen No. M-ST-10

Laboratory 7 Parasite in Musculoskeletal System


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educational use only. Educational use refers to classroom teaching, lectures, presentations, rounds, and other instructional
activities, such as displaying, linking to, downloading, printing and making and distributing multiple copies of said isolated
materials in both print and electronic format. Users will only display, distribute, or otherwise make such PowerPoint slides
and images from the applicable materials available to students or other persons attending in-person presentations, lectures,
rounds or other similar instructional activities presented or given by User.

Parasite in Musculoskeletal System


1

Trichinella spiralis
Disease: trichinellosis
Transmission: raw undercook meats
Life cycle
Infective stage encysted muscle larva (L1)
Diagnosis stage encysted muscle larva (L1)
2-3 days: adult GI irritation diarrhea
5 days: newborn larva
8-9 days encysted within skeletal muscle myalgia
Clinical manifestation
Diarrhea
Conjunctivitis, swollen eyes
Splinter hemorrhages
Myalgia
Diagnosis: immuno-histopathological analysis
Treatment: mebendazole, albendazole

Adult female
Stichosomal esophagus
Larva in uterus
Adult male
Stichosomal esophagus
Smaller

Larva
Stage: encysted muscle larvae
Stichosomal esophagus
Infective and diagnostic stages

Taenia solium
Disease: Cysticercosis
Transmission: Tinea eggs
Life cycle
Egg or gravid proglottis oncospheres cysticerci in
muscle

Adult
Scolex: 4 suckers, rostellum, 2 row rostellar hook
Proglottid: immature mature gravid proglottid

Gravid proglottid
Common genital pore
Uterine branch: 7-12 (>12 in T. saginata)

Egg
Spherical
Thick striated wall
Oncosphere hexacanth (six-hooked) embryo

Larva
Known as cysticercus, Cysticercus cellulosae
Fluid-filled bladders
Invaginated scolex: 4 suckers, rostellum, 2 row
rostellar hook

Sarcocystis spp. S. suihominis, S. bovihominis


Disease: Sarcocystosis
Transmission: feces
Life cycle
Infective stage oocysts
Sporocysts, oocysts sporozoites schizonts
merozoites invades muscle cell bradyzoites in
sarcocyst

Sarcocystis
Cyst wall compartments contain bradyzoites

Spirometra spp. (pseudophyllidian tape worm) sparganum


Etiology: (Spirmetra sp.)
Transmission
Procercoid in crustaceans
Plerocercoid larva (sparganum) in 2nd IH fish, reptiles,
amphibians
Treatment: surgical removal

Sparganum
White, wrinkled, ribbon-shaped
Absence scolex