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Anatomy 303 OSCE Landmark About Ligaments Muscles To palpate • prominent bony ridge located on the superior portion of the ilium • very superficial & easy to palpate • part of the hip bone w ischium & pubis • runs A to P- anterior ASIS & posterior PSIS • landmark for L4 • internal surface of ilium= fossa • posterior= SI joint • anterior= viscera • superior= abdominal walls • lateral= greater trochanter • iliolumbar ligament (posterior) • thoracolumbar fascia • ASIS- inguinal ligament • • • • Quadradus Lumborum Gluteus Maximus Latissimus Dorsi Erectors- Iliocostalis & longissimus • External/internal abdominal obliques • Transverse Abdominus • ASIS- Tensor Fascia Latae * activate QL with a hip hike * do it sidelying ASIS anterior superior iliac spine • boney projection on the anterior portion of the iliac crest • easily palpated & helps form the hip bone • inferior= AIIS • superior= iliac crest • lateral/posterior= iliac crest/ PSIS • medial= abdominals/viscera • internal=fossa • inguinal ligament (ASIS to pubic symphysis) • Sartorius • Tensor Fascia Latae • internal abdominal oblique to inguinal ligament & transverse abdominis • activate sartorius- hip flexion w external rotation • supine AIIS anterior inferior iliac spine • bony projection on the anterior portion of the ilium • helps form the hip bone • superior= ASIS & iliac crest • inferior=ischium & pubis • lateral= greater trochanter • medial=pubis & lower abdomen & iliac fossa * Rectus Femoris * Iliacus on internal surface of ilium * activate Rectus Femoris- hip flexion w knees bent? * supine PSIS posterior superior iliac spine • bony projection on the posterior aspect of the iliac crest • easily palpated & helps from the hip bone • creates the dimples in the low back • inferior= PIIS • superior= iliac crest, spine, posterior abdominal wall • medial= SI joint • lateral= ilium & greater trochanter • sacrotuberous ligament • Mulitifdus (transverospinalis group) * prone Ischial Tuberosity • roughened bony projection known as the sits bone • posterior/inferior portion of the ischium thats a site of many muscle attachments • most exposed in a squat position • lateral=greater trochanter • superior= ischial spine • medial= coccyx & pelvic floor • inferior=femur • sacrotuberous ligaments • hamstrings- bicep femoris, semimembranousus, semitendinosus) • posterior head of adductor magnus • quadratus femoris & inferior gemelli • superficial= gluteus maximums • Urogenital diaphragm: Ischiocavernosus & Superficial transverse Perineal muscle • use palm first, prone • activate hamstrings w resisting hip extension Ischial Spine • thin pointed triangular eminence that projects from the ischium • part of the pelvis • superior/medial to ischial tuberosity • divides greater and lesser sciatic notch w the ligament attachment • lateral= greater trochanter • medial= coccyx & sacrum • inferior= ischial tuberosity • superior= PSIS, ilium • sacrospinus ligament (from ischial spine to coccyx) • superior gemelli • Pelvic floor: levator ani ) & coccygeus • prone • fine ischial tuberositycome superior/ medial Iliac Crest “hip bone” Landmark About Ligaments Muscles To palpate triangular, irregular shaped bone part of the spine- 5 fused vertebrae posterior roughened for mm attachment internal surface smooth for viscera spinal cord becomes cauda equina @ L2 & exits at the sacral hiatus fused bilaterally to the ilium to create the sacroiliac joint (SIJ) middle of sacrum is median sacral crest lateral- lateral sacral crest intermediate sacral crest foramen for nerve & blood supply superior= L5 inferior=coccyx lateral= ilium • sacroiliac ligament • sacrotuberous ligament • sacrospinous ligament • anterior/posterior longitudinal ligament • • • • Gluteus Maximus Latissimus Dorsi Piriformis Erectors- Iliocostalis & longissiumus • multifidus (transversospinalis group) • Coccygeus • prone • iliac crest landmark @ L4 • find L5 come inferior to find sacrum • use palm • then fingerspalpate all sides and inferior corners Coccyx • small irregular bone located on most distal spine • 4 undeveloped bones • articulates w the apex of the sacrum to form sacrococcygeal joint • provides attachment for filum terminale (end of the spinal cord) • posterior is roughened and internal is smooth • moves for child labour & defication • superior=sacrum • inferior=pelvic floor • lateral= ischial tuberosity • sacrotuberous ligament • sacrcoccygeal joint (interosseous ligament) • Gluteus Maximus • Pelvic floor: Levator Ani & Coccygeus • prone • use palm to find sacrum • fingers to come inferior off sacrum to coccyx Sacrotuberous Ligament • ligament on posterior pelvis • from PSIS/PIIS, lower 1/2 sacrum, lateral margin of coccyx to the ischial tuberosity • defines the medial border of the greater sciatic foramen • prevents tilting of the sacrum during wt bearing • anterior= sacrospinous ligament • posterior= deep 6, gluteals • gluteus maximus • piriformis • biceps femoris • palm ischial tuberosity • use hypothenar to draw a line coming medial to PSIS Sacrospinous Ligament • • • • ligament on posterior pelvis attachments from lower 1/2 sacrum, coccyx to ischial spine prevents tilt of sacrum during wt bearing helps create greater & lesser foramen with greater & lesser sciatic notches • anterior to large sacrotuberous ligament • posterior= deep 6 & gluteal group • located posterior are deep 6 & gluteal group • prone-palm ischial tuberosity • superior/medial to fine ischial spine- connect to sacrum Manubrium • • • • • sternoclavicular ligament • interclavicular ligament • Sternocleidomastoid (SCM) • Sternohyoid • Sternothyroid • Pectoralis Major • costal cartilages of ribs 1 & 2 • internal intercostals • supine • start at sternal notch • move laterally to clavivles • can pop up pect major • radiate sternocostal ligament (rib to sternum) • Intra-articular ligament (2nd rib & sternum) • Pectoralis Major • transverse thoracic • internal intercostals * find sternal notch of manubriumcome inferior * activate pect major Sacrum • • • • • • • • • • • • • • • • • • Sternum (Body) located on anterior trunk most superior portion of the sternum flat bone that becomes less mobile as we age articulates bilaterally w clavicles to form sternoclavicular joint (SCJ) articulates with ribs 1 & 2 superior= neck musculature inferior=sternal body lateral=clavicles posterior=heart & lungs • bone located on anterior trunk • moves with respiration • articulates with ribs 2-7- sternocostal joints (laterally) • articulates w manubrium @ angle of lewis (superior) - manubrium-sternal joint • articulates w xipoid process (inferior)xiphisternal joint- symphysis Landmark About Ligaments Muscles To palpate Xipoid Process • inferior portion of the sternum- on anterior trunk • triangular & at level of T9 • superior forms Xiphosternal joint, a symphysis, ossifies by age 40 • inferior= viscera & abdominals • lateral= rib cage • costoxiphoid ligament (7th costal cartilage & xiphoid) • radiate ligament • diaphragm • transverse thoracic • rectus abdominis * supine- locate sternal notch and come inferior to fine Costal Cartilage • flat bars of hyaline cartilage • connection btw ribs & sternum • forms part of the rib cage & ossifies w age • aids in respiration- allows for mobility & elasticity • upper 7-own cartilage • 8-10 common cartilage • 11 & 12- have free ends • 1-7 increase in length then decrease to 12th rib • convex on both sides to fit into notch • sternalcostal joints- costal cartilage to sternum • costochondral- ribs to costal cartilage • radiate ligament • internal intercostals • transverse thoracic (ribs 4-7) • diaphragm (ribs 7-12) • rectus abdominis • pectoralis major • transverse abdominis • supine- start at the sternal notch and come to sternum- palpate laterally to costal cartilage Rib 1 • most curved/shortest rib which is broad and flat • head is small & round w circulate facet that articulates wi T1 (neck/tubercle- costotransverse) • articulates with manubirum anteriorly (via costal cartilage) • moves with inspiration and expiration (pumphandle) • superior border 2 shallow grooves- subclavian vein/artery • no costal muscles pulling on top of it • radiate ligament • costotransverse joint to T1 • no intra-articular • costocorporgeal • anterior/middle scalene • subclavius • erectors- iliocostalis • levators costarum • external/internal intercostals • serratus anterior • supine • find clavicle/ fall onto 1st rib • goes under first rib Rib 2 • twice the length of rib 1 • has a tubercle- articulates with T2/T3 • articulates with manubrium/sternum via costal cartilages- costochondral joints) • inferior=rib 3 • superior= rib 1 • medial= costal cartilage • radiate ligament • intra-articular ligament (2nd rib & sternum) • serratus anterior • posterior scalene • external/internal intercostals • serratus posterior superior • levatores costarum • iliocostalis • supine then prone to cover a/p • T1- across for prone Rib 3-9 (typical ribs) • enclose & protect thoracic contents • have a shaft, elastic bony arches, costal end (small concave for cartilage: forms costochondral joint which can dislocate) • vertebral end- has head, neck, tubercle • 2 facets to attach onto 2 vertebrae • tubercle articulates w the TVP of vertebrae to make costotransverse joint • costocorporeal joint articulates w demifacet & margin of T/S bodies and IVD * radiate ligament * costotransverse ligament • erectors- iliocostalis, longissimus • rectus abdominis, external/ internal abdominal obliques • transverse abdominis • internal/external intercostals • diaphragm • serratus posterior superior, serratus posterior inferior, serratus anterior • levatores costarum • subcostales • pectoralis minor • anteriorsternum to rib • prone find SP to rib Rib 10 • enclosed & protect thoracic contents • articulates anteriorly with common costal cartilage • posteriorly only with T10- only has single facet (no demifacets) • radiate ligament • erectors- iliocostalis, longissimus • external/internal abdominal oblique • external/internal intercostals • diaphragm • serratus posterior inferior • levatores costarum • subcostales • landmark T7come down to T10- palpate out • anterior to costal cartilages Landmark About Ligaments Muscles To palpate Rib 11 & 12 • most inferior rib- enclosing & protecting thoracic contents • false/floating rib- has hyaline cartilage at endembeded in soft tissue • atypical- only articulates w corresponding T/S • single large articular facet • no tubercle, no neck • no costotransverse joint • helps in respiration • inferior= iliac crest • radiate ligamentposteriorly only • quadratus lumborum (12) • erectors- iliocostalis, longissimus • external/internal abdominal obliques • external/internal intercostals • diaphragm • serratus posterior inferior • levatores costarum • subcostales • side lying- find iliac crest & palpate up to 12th rib C7 • vertebrae prominens (SP very prominent) • no bifid • SP thick & almost horizontal • large transverse processes • where a cervical rib would originate • last bone in C/S • inferior=T1 & ribs • lateral= ribs & neck musculature • simple zygopophyseal joints in C/S • vertebral foremen- large & triangular in C/S • transverse foramen- vertebral artery in C/S • bodies= small, broad • C7 at level of cartilage below the 1st cricoid ring • ligamentum nuchae • anterior longitudinal ligament • posterior longitudinal ligament • ligamentum flavum (lamina to lamina) • start of Supraspinous ligament • poorly developed interspinous ligament • intertransverse ligament • erectors- iliocostalis, longissimus, spinalis • transversospinalissemispinalis, rotatores, multifidus • splenis capitis • trapezius • levatores costarum • intertransversarii • interspinalis • serratus posterior superior • prone- lift head to find C7 • shoulder hikeupper traps • neck extensionerectors • extension/ rotationtransversospinal is group T/S • increase in size caudally • upper T/S: change from C/S to T/S • upper 3 resemble cervical • upper 4 left side flattened for aorta • lower T/S: change from T/S to L/S • T4 heart shaped • all bodies have costal cartilages- articulates with ribs • some have demifacets • love rotation • pedicles overlap • anterior longitudinal ligament • posterior longitudinal ligament • ligamentum flavum • supraspinous ligament • interspinous ligament • intertransverse ligament • erectors- longissimus, spinalis • semispinalis, multifidus, rotatores • interspinalis, intertransversarii • splenius cervicis (T3-T6) • splenius capitis • serratus posterior superior/ inferior • levatores costarum • prone- find level • T2- superior angle of scap • T7- inferior angle of scap • T12- iliac crest and up • T1- lift head if on C7 T1 • articulates with 1& 1/2 ribs • shows circular upper costal facets articulating w the whole facet of 1st costal head • inferior costal facet is smaller & semilunar • articulate w demifacet of costal head • SP is thick, long. horizontal • rib 1 level of SP of T1 • if rib 1/5 cm above= cervical rib • erectors- longissimus • semispinalis, multifidus, rotatores • interspinalis, intertransversarii • splenius capitis • serratus posterior superior • levatores costarum T9 • often fails to articulate with 10th rib- demifacet absent T10 • articulates only w 10th rib- therefore demifacet is absent • TP may or may not be facetted for 10th rib • costocorporeal joints (rib/demifacet/T/S/ IVD) • radiate ligament • intra-articular ligament (costal articular facet to IVD)- absent in T1,10,11,12) • costotransverse joint (costal tubercle to TVP)- absent in 11& 12 • intertransverse ligament (TP to TP) * no costotransverse ligament * no intra-articular ligaments • semispinalis, multifidus, rotatores • longissimus • levatores costarum * semispinalis, multifidus, rotatores * longissimus * intertransversarii * levatores costarum • activate erectors w back extension ligament (TP to TP) Landmark About T11 • articulates only w the heads of the 11 ribs • has circular facets that are close to the upper border of the body • they have small TPs that lack costal facets (ribs attach to the body- not TVP) T12 • articulates w the heads of the 12th ribs by circular facets that are just below the upper border of the body • large body • small TPs replaces by 2 small tubercles L/S • large in size, box shaped • surfaces are kidney shaped- flat/smooth • built for wt bearing • wider transversely & deeper in front • upper/lower borders of bodies give attachments to anterior/posterior longitudinal ligaments • attachment of crura of diaphragm (L1-L3) • superior= T/S • inferior= sacrum/ SIJ • pedicles do not overlap (T/S) • lamina broad - project from each pedicle and fuse to form roof of neural arch • vertebral foramen- formed by neural arch/back of body- triangular • SP- quadrangular/ same level as body • TVP- flat, irregular, long, in line with own body (L1-3 increase in length, L5 is shorter) • neural arch= 2 lamina, 2 pedicles- aka vertebral foramen • intervertebral foramen- allows spinal nerve to exit • most convexity at level of L4/L5, L5/S1- sitting anterior on sacrum L5 L5 • most inferior vertebra of the spine • spinal cord becomes cauda equina at level above (L4) • superior=L4 • inferior=sacrum • L4/5, L5/S1 where L/S is most convex- sitting anterior on sacrum Rectus Sheath Ligaments * no costotransverse ligament * no intra-articular ligaments Muscles To palpate • erectors- longissimus, spinalis • multifidus, rotatores • interspinalis, intertransversarii • serratus posterior inferior • levatores costarum • erectors- longissimus, spinalis • mutlifidus rotatores • interspinalis, intertransversarii • psoas minor • serratus posterior inferior • zygoapophyseal joint (complex synovial in L/Slocking of inferior articular process w superior articular process)- resist sliding/twisting • anterior/posterior longitudinal ligaments • ligamentum flavum (thickes in L/S) • supraspinous ligament (thick/ broad in L/S) • interspinous ligament • intertransverse ligament • iliolumbar ligament (5 parts- prevents rotation L5/S1 and L5 from slipping off S1) • erectors- longissimus • multifidus, rotatores • interspinalies, intertransversarii • quadradus lumborum • psoas minor • psoas major • diaphragm • thoracolumbar fascia • prone- find level of SP • iliac crest level with L4 • palpate SP • activate QL w hip hike • activate erectors w extension • erectors- longissimus, • mutilifdus, rotatores • interspinalis, intertransversarii • thoracolumbar fascia • prone- find L4 in line with iliac crest • down one • activate erectors with back extension • a sheath of muscular fascia- part of anterior abdominal wall • the midline aponeuroses of the external/internal abdominal obliques, and transverse abdominis muscles come together to form the rectus sheath • rectus abdominis is enclosed within the rectus sheath • midline of rectus sheath is the linea alba • 3 fibrous bands called tendinous inscriptions transect the rectus abdominis- divides them into boxes- 8pack muscle • can compress the abdominal contents • supine- palpate • activate rect abdomimis w crunch