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Dr. Sarah Dirks RIBS: SPINAL ANATOMY copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 SOME VERTEBRAL LEVELS • • • • • • • • • • • • • • C3 = hyoid bone C4,5= Thyroid Cartilage C6 = cricoid cartilage C6,7, T1 = Thyroid gland T2 = superior angle of scapula T3/4 = base of spine of scapula standing and lying down T6/7 = inferior angle of scapula standing and lying down T4/5 IVD= trachea bifurcation and Sternal angle T10= xiphoid process T8, T10, T12= IVC, esophagus and aorta pierces diaphragm L4 = tubercle of iliac crest S2 = PSIS T4 dermatome = nipple line T10 dermatome = umbilicus 2 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS How many vertebra are there in an adult spine? Spinal column? How many pairs of spinal nerves are there? How many dermatomes are there? 3 copyright 2006 www.brainybetty.com; All Rights Reserved. THE AXIAL SKELETON Cranial bones, ossicles of inner ear, ribcage, and spinal column Spinal column 24 true and 2 false vertebra (sacrum and coccyx) 23 IVDs Begins between C2 & C3 Ends between L5 & S1 Named for the vertebrae ABOVE 31 pairs spinal nerves 10/25/2013 Begins between Occiput & C1 Ends with Co1 at sacral hiatus at S5 segment Ribcage 1-6 true ribs (attach to sternum), 7-10 false (indirect attachment to sternum), 11 and 12 floating ribs (no attachment) Sternum Manubrium Body Xyphoid process 4 copyright 2006 www.brainybetty.com; All Rights Reserved. SPINAL NERVES Cervical Spine: 8 pairs Nerves exit inferiorly thru IVF, disc protrusion effects nerve above as it passes Thoracic: 12 pairs Lumbar: 5 pairs 10/25/2013 Nerves exit superiorly thru IVF, disc protrusion effects nerve below as it passes Sacrum: 5 pairs Coccyx: 1 pair ONLY 30 DERMATOMES (none for C1) Key phrases C3,4,5 keeps the diaphragm alive L2,3,4 walks you out the door S2,3,4 keeps your “------” off the floor 5 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS What are the two plexuses that provide peripheral nerves to the upper and lower extremities? What are the spinal nerve levels for each? What are the terminal branches of each? 6 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 BRACHIAL PLEXUS (C5-T1) Musculocutaneus (C5C6) Median (C5-T1) Ulnar (C8-T1) Radial (C5-T1) Axillary (C5-C6) Phrenic (C3-5) Long thoracic (C5-7) Dorsal Scapular (C5-6) Suprascapular (C6) Subscapular Upper (C5-7) Middle (Thoracodorsal) (C6-8) Lower (C5-7) Medial Pectoral (C8-T1) Lateral Pectoral (C5-7) 8 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 LUMBOSACRAL PLEXUS (T12-S4) Iliohypogastric (T12,L1) Ilioilguinal (L1) Genitofemoral (L1,2) Lateral Femoral Cutaneous (L2,3) Femoral (L2-4) Obturator (L2-4) Superior Gluteal (L4-S1) Inferior Gulteal (L4-S1) Sciatic (L4-S3) Tibial (L4-S3) Common Peroneal (L4S2) Deep Peroneal (L4S2) Superficial Peroneal (L4-S2) Posterior Fermoral Cutaneous (S1-3) Pudendal (S2-4) 10 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS What type of curves are the thoracic and sacral curves? Cervical and lumbar? 11 copyright 2006 www.brainybetty.com; All Rights Reserved. TYPES OF VERTEBRAL CURVES Kyphotic / primary / accomodating Thoracic: bodies are thicker posterior Discs are equal height Lordotic / secondary / compensatory Cervical: bodies are equal height Discs are wedged, greater anteriorly Lumbar: varies 10/25/2013 Discs are wedged, greater anteriorly Vertebral canal (spinal canal) = 2+ vertebral foramen in a row 12 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Which vertebra are typical in the cervical spine? Atypical? What are the characteristics of a typical cervical vertebra? 13 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 TYPICAL CHARACTERISTICS: CERVICAL C3-C6 Oval body, triangular vertebral foramen Facets: 450 off horizontal, no medial lateral rotation Uncinate processes Anterior/Inferior (A/I) lipping Costotransverse lamellae True and false transverse processes (ant/post tubercles) Bifid SPs Transverse Foramen Key concepts: Vertebral artery travels in transverse foramen C6-C1 thru posterior vertebral groove Ligamentum nuchae: EOP to C7 14 copyright 2006 www.brainybetty.com; All Rights Reserved. ATYPICAL: CERVICAL C1 atlas Dens (odontoid), pivot joint with C1, first AI lipping C7 (typical vertebral prominence) Fovea dentalis, lateral masses, groove for vertebral artery C2 Axis (epistopheus) 10/25/2013 Uncinates but no AI lipping, no bifid SP Normal ADI .5 to 3mm in adults 3 to 5mm in children 15 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Which vertebra are typical in the thoracic spine? Atypical? What are the characteristics of a typical thoracic vertebra? 16 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 TYPICAL CHARACTERISTICS: THORACIC T2-T8 Heart body, circular vertebral foramen Facet orientation: 600 off horizontal, 200 lateral 4 demifacets (body), 2 costotransverse facets (TPs), costovertebral joints, costotransverse joint Keys concepts: Ribs named after vertebra BELOW (except Rib 1,10-12) Ex: 5th rib HEAD articulates with inf demifacet of T4 and sup demifacet T5 and the RIB TUBERCLE with TP of T5 Radiate ligaments covers the costovertebral joint 17 copyright 2006 www.brainybetty.com; All Rights Reserved. ATYPICAL: THORACIC T1 2 superior demifacets, no inferior demifacets, 2 costotransverse facets T10 2 full facets, 2 inferior demifacets, 2 costotransverse facets T9 10/25/2013 2 full facets, 2 costrotransverse facets T11 , T12 2 full facets, no costrotransverse facets 18 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Which vertebra are typical in the lumbar spine? Atypical? What are the characteristics of a typical lumbar vertebra? 19 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 TYPICAL CHARACTERISTICS: LUMBAR L1-L4 Facet orientation: 900 off horizontal, 450 medial Mamillary processes (multifidii) Accessory processes Triangular vertebral foramen Kidney shaped body 20 copyright 2006 www.brainybetty.com; All Rights Reserved. ATYPICAL: LUMBAR 10/25/2013 L5 Shorter SP points more horizontal Inferior APs face almost in the coronal plane to articulate with the sacrum Larger and wider 21 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS The lateral sacral crest is made by the fusion of what component of the vertebra? 22 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 TYPICAL CHARACTERISTICS: SACRUM AND COCCYX Sacrum 5 fused vertebra (adult) Base, apex, ala, anterior and posterior sacral foramen, cornu, hiatus, median(SP)/intermediate(AP)/lateral(TP sacral crests, sacral groove (lamina) Coccyx 4 fused vertebra Base, apex, cornu 23 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 24 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 OSSIFICATION CENTERS VERTEBRAE Primary ossification Cervical and Thoracic (3) Lumbar (5) each lateral mass and anterior arch Axis (5) Gets an extra one for each mamillary process Atlas (3) 1 VB, 1 each Vertebral arch 1VB, 1 each vertebral arch, 2 odontoid Secondary ossification (5) 1 each epiphyseal plate 1 each TP 1 each SP THE CLAVICLE IS THE FIRST BONE TO BEGIN OSSIFICATION AT 7 WEEKS POSTOVULATORY 25 copyright 2006 www.brainybetty.com; All Rights Reserved. IVFS Cervical Smallest Angles laterally and anterior Lumbar 10/25/2013 Largest Face laterally (as do thoracics) Boundaries: vertebral bodies, vertebral notches (pedicles), facets, IVDs Contents: spinal nerve trunk, dorsal root ganglion, spinal artery, radicular and intervertebral veins, recurrent meningeal nerves, lymphatics, adipose Recurrent meningeal nerves: sensory innervation to the posterior aspect of the annulus fibrosus, PLL, and the ant dura matter 26 copyright 2006 www.brainybetty.com; All Rights Reserved. BONES OF THE SKULL 10/25/2013 Ethmoid bone (1): bone between the orbits, nasal cavity (superior and middle conchae). Frontal bones(2): roof of the orbit, anterior part of the cranial floor. Inferior Nasal Conchae (2) Lacrimal bone (2): medial wall of the orbit Mandible (1): largest and strongest bone of the face Maxillae (2): upper jawbone, articulate with every bone of the face except the mandible Nasal bones (2): fusion forms the superior part of the bridge of the nose. Occipital bone (1): posterior and inferior part of the cranium. Palatine bones (2): posterior part of the hard palate Vomer (2): forms the inferior and posterior of the nasal septum. Parietal bones (2): sides and roof of the cranial cavity. Sphenoid bone (1): part of the floor of the anterior, middle, and posterior cranial fossae; keystone of the cranial floor because it articulates with all the other cranial bones. Temporal bones (2): contains the organs of hearing. Zygomatic bones (2) 27 copyright 2006 www.brainybetty.com; All Rights Reserved. THE CALVARIUM Sagittal suture: joins parietal bones Coronal suture: joins frontal and parietal bones Lambdoidal suture: joins parietal bones and occipital bone Parietomastoidal sutures (2): joins parietal bone and temporal bone BREGMA: intersection of the sagittal and coronal sutures LAMBDA: intersection of sagittal and lambdoid suture PTERION: 4 bones articulate: frontal, parietal, temporal, and sphenoid 10/25/2013 Weakest part of the skull Ant branch of middle meningeal artery runs under it ASTERION: at end of parietomastoid suture 28 copyright 2006 www.brainybetty.com; All Rights Reserved. BASE OF THE CRANIUM Frontal Bone Sella turcica/hypophyseal fossa: Pituitary gland Foramen rotundum: maxillary nerve Foramen ovale: mandibular nerve, accessory meningeal artery, lesser petrosal nerve Foramen spinosum: middle meningeal artery and vein, meningeal branch of mandibular nerve Optic canal: optic nerve, opthlamic artery Temporal Bone Cribiform Plate: olfactory nerve bundles Sphenoid Bone Foramen Cecum: emissary vein to sagittal sinus Ethmoid Bone 10/25/2013 Carotid canal: internal carotid artery and nerve plexus External auditory meatus and internal acoustic meatus: facial nerve, vestibulocochlear nerve Groove for occipital artery Greater and lesser petrosal nerve Jugular foramen: glossopharyngeal nerve, vagus nerve, Spinal accessory nerve, posterior meningeal artery, internal jugular vein Occipital Bone Hypoglossal canal: hypoglossal nerve Foramen magnum: vertebral arteries, medulla oblangata 29 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 CRANIAL NERVES Olfactory- cribiform plate Optic- optic canal Oculomotor- Superior orbital fissure Trochlear- Superior orbital fissure Trigeminal V1: Superior orbital fissure V2: Foramen Rotundum V3: Foramen Ovale Abducens- Superior orbital fissure Facial -Internal Auditory Meatus Stylomastoid Foramen Vestibulocochlear- Internal Auditory Meatus Glossopharyngeal- Jugular Foramen Vagus- Jugular Foramen Spinal accessory- Jugular Foramen Hypoglossal- Hypoglossal Canal 31 copyright 2006 www.brainybetty.com; All Rights Reserved. CRANIAL FOSSA 10/25/2013 Anterior Bordered by lesser wing of sphenoid and optic chiasm Formed by frontal, ethmoid, and sphenoid bone Middle Separated from posterior by clivus and petrous crest Contains temporal lobes of the brain Posterior Located between tentorium cerebelli and foramen magnum Contains brainstem and cerebellum 32 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 33 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS What does the ALL become? What does the PLL become? What does the Supraspinatus ligament become? 34 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 SYNDESMOLOGY OF AXIAL SKELETON Ligamentum nuchae (EOP to C7) suprapinous superficial posterior sacrococcygeal Tectorial membrane (starts at body of axis) Posterior longitudional deep posterior sacrococcygeal Anterior longitudinal anterior sacrococcygeal Ligamentum flavum (C2 to S1): elastic Capsular ligaments: surrounds facet joints Intertransverse and interspinous Atlantoaxial and Atlanto-occipital Cruciate: b/w C1 and C2 Alar: check ligaments (check rotation) around dens to the foramen magnum 35 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 ARTHROLOGY OF THE AXIAL SKELETON Arthology- study of joints Classification by material Classification by movement 36 copyright 2006 www.brainybetty.com; All Rights Reserved. CLASSIFICATION BY MATERIAL 10/25/2013 Fibrous Sutures Usually synarthrotic Cartilaginous (fibrocartilage or hyaline) Manubrium/sternal joint Syncondroses, symphysis Amphiarthrotic Synovial Capsule filled with lubricating synovial fluid and joint surfaces covered with hyaline cartilage 37 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 CLASSIFICATION BY MOVEMENT Synarthoritic Amphiarthrotic Immovable Most are Fibrous joints Gomphosis (teeth), synostoses (cranial bones fused), synchondrosis (growth plates) Slightly movable Symphysis (IVD and pubic symphysis) and syndesmosis Diarthrotic Very mobile Synovial joints (hinge, spheroid, pivot, etc) 38 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 SYNOVIAL JOINTS 1. Ball and socket/spheroid: all movements - Ex: GH, hip 2. Condyloid: 2 planes of motion - Ex: C0C1, metacarpophalange 3. Saddle:2 planes of motion - Ex: carpometacarpal, SC 4. Hinge/ ginglymus: 1 plane of motion - Ex: Humeral-ular 5. Pivot/ trochoid: 1 plane of motion - Ex: radial-ulnar, atlanto-axial 6. Planar/gliding: 1 plane of movement - Ex: Z-joints, AC, carpals 39 copyright 2006 www.brainybetty.com; All Rights Reserved. IVD 10/25/2013 25% height spinal column 3 parts Annulus fibrosus Sharpeys fibers attach annulus to vertebral bodies Mostly Type I collagen Nucleus pulposus Mostly Type II collagen, proteoglycans and GAGs Vertebral endplates (cartilage) Allow nutrition to IVD thru IMIBIBITION Bulge, Protrusion, Extrusion, Sequestration 40 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 41 copyright 2006 www.brainybetty.com; All Rights Reserved. MAIN MOTIONS CO-C1 Nodding C1-C2 Occipital condyles roll anterior and slide posterior during flexion and vice versa for extension Rotation ~55% of total C/S rotation occurs here From C2/3 to C5/6 the amount of available flexion/ext increases Thoracic 10/25/2013 Rotation Movement increases at top and bottom of T/S Lumbar Flexion/extension Greatest mobility b/w L4 and S1 42 copyright 2006 www.brainybetty.com; All Rights Reserved. MYOLOGY OF AXIAL SKELETON 10/25/2013 Layer 1: latissmus dorsi, trapezius, levator Layer 2-4: rhomboids, serratus posterior inf/sup, splenius capitus/cervicis, quadratus lumborum Deep layers Erector Spinae Layer 5: I love spaghetti Iliocostalis: lumborum, thoracics, cervicis Longissmus: thoracis, cervicis, capitis Spinalis: thoracis, cervicis, capitis Interspinalii, intertransversarii, levator costarum Layer 6: More Red Sauce Multifidi (christmas trees), Rotators, semispinalis 43 MYOLOGY OF AXIAL SKELETON MYOLOGY OF AXIAL SKELETON copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 SUBOCCIPITAL TRIANGLE Border Rectus capitis posterior major - above and medially Obliquus capitis superior - above and laterally Obliquus capitis inferior - below and laterally Contents third part of vertebral artery dorsal ramus of nerve C1-SUBOCCIPITAL NERVE Suboccipital venous plexus 46 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 DORSAL AND VENTRAL PRIMARY RAMI Dorsal primary rami, always only innervate the skin of the back, and the deep muscles of the back! Ventral Primary Rami innervate everything else, except the head and neck. Ex: brachial plexus, lumbar plexus 47 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS This nerve provides articular branches to the elbow and wrist joints and motor innervation to the majority of the muscles of the anterior forearm. a. Ulnar b. Radial c. Median d. axillary 48 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS This nerve provides articular branches to the elbow and wrist joints and motor innervation to the majority of the muscles of the anterior forearm. a. Ulnar b. Radial c. Median d. axillary 49 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Which nerve roots unite to form the ansa cervicalis of the cervical plexus? a. C1 and C5 b. C2 and C3 c. C3 and C4 d. C4 and C5 50 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Which nerve roots unite to form the ansa cervicalis of the cervical plexus? a. C1 and C5 b. C2 and C3 c. C3 and C4 d. C4 and C5 51 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS These nerves innervate the structures located on the anterior aspect of the vertebral canal. a. Lateral braches of the posterior primary divisions b. Recurrent meningeal nerves c. Anterior primary divisions d. Medial braches of the posterior primary divisions 52 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS These nerves innervate the structures located on the anterior aspect of the vertebral canal. a. Lateral braches of the posterior primary divisions b. Recurrent meningeal nerves c. Anterior primary divisions d. Medial braches of the posterior primary divisions 53 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS A 28 year old woman sustains an injury to the left arm during a fall off of her bicycle. Radiographs done at your clinic show an oblique fracture through the mid shaft of the humerus. Which nerve is most likely to be injured by the mid shaft fracture of the humerus? a. Radial nerve b. Median nerve c. Musculocutanous nerve d. Ulnar nerve 54 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS A 28 year old woman sustains an injury to the left arm during a fall off of her bicycle. Radiographs done at your clinic show an oblique fracture through the mid shaft of the humerus. Which nerve is most likely to be injured by the mid shaft fracture of the humerus? a. Radial nerve b. Median nerve c. Musculocutanous nerve d. Ulnar nerve 55 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS You perform your exam and find that the patient has sustained a lateral traction injury to the superior roots of the brachial plexus. Which of the following signs would you NOT expect to find in this patient? a. Dropped left shoulder b. Left scapula that falls laterally c. Inability to rotate the humerus medially d. Paresis of muscles of the anterior aspect of the left arm 56 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS You perform your exam and find that the patient has sustained a lateral traction injury to the superior roots of the brachial plexus. Which of the following signs would you NOT expect to find in this patient? a. Dropped left shoulder b. Left scapula that falls laterally c. Inability to rotate the humerus medially d. Paresis of muscles of the anterior aspect of the left arm 57 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 Review Questions Exam reveals a contusion around the head and neck of the fibula. Which nerve is susceptible to direct injury by a compression force applied to the lateral aspect of the head and neck of the fibula? a. Common peroneal nerve b. Tibial nerve c. Obturator nerve d. Saphenous nerve 58 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 Review Questions Exam reveals a contusion around the head and neck of the fibula. Which nerve is susceptible to direct injury by a compression force applied to the lateral aspect of the head and neck of the fibula? a. Common peroneal nerve b. Tibial nerve c. Obturator nerve d. Saphenous nerve 59 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Choose the incorrect statement with regard to the brachial plexus. a. The flexors of the upper extremity are innervated by the terminal branches of the medial and lateral cords b. The cords of the brachial plexus are named according to their relationship to the axillary artery c. The brachial plexus is derived from dorsal rami of C5, C6, C7, C8 and T1 d. The posterior cord is formed by the posterior divisions of all 3 trunks 60 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Choose the incorrect statement with regard to the brachial plexus. a. The flexors of the upper extremity are innervated by the terminal branches of the medial and lateral cords b. The cords of the brachial plexus are named according to their relationship to the axillary artery c. The brachial plexus is derived from dorsal rami of C5, C6, C7, C8 and T1 d. The posterior cord is formed by the posterior divisions of all 3 trunks 61 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Spinal nerve C7 exits the IVF located between which 2 of the following vertebrae? a. C4, C5 b. C5, C6 c. C6, C7 d. C7, C8 62 copyright 2006 www.brainybetty.com; All Rights Reserved. 10/25/2013 REVIEW QUESTIONS Spinal nerve C7 exits the IVF located between which 2 of the following vertebrae? a. C4, C5 b. C5, C6 c. C6, C7 d. C7, C8 63
