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Anatomy Exam 2 Blue Boxes Joints of Newborn Cranium pg. 28 The bones of the calvaria of a newborn infant’s cranium do not make fill contact with each other The sutures form wide areas of fibrous tissue called fontanelles The anterior fontanelle is the most prominent (soft spot, flat) Bulging frontanelle may indicate intracranial pressure Pulsations reflect pulses of cerebral arteries Depressed fontanelle if dehydrated Degenerative Joint Disease pg. 28 Normal aging of articular cartilage occurs on hip, knee, vertebral column, and hands Degenerative changes in joints cause articular cartilage to become less effective as shock absorber and lubricated surface Articulation becomes vulnerable to repeated friction Stiffness, discomfort, pain Osteoarthritis common in older people and common in joints that support weight (hips and knee) Traumatic infection of joint may be followed by arthritis and septicemia Arthroscopy pg. 29 Cavity of a synovial joint can be examined by inserting a cannula and arthroscope Useful to examine abnormalities in joints and surgical procedures (faster recovery) Hip and Thigh Contusions pg. 558 Hip pointer-contusion of the iliac crest which occurs anteriorly ( ie. Sartorius attaches to ASIS) Contusions cause bleeding from ruptured capillaries and infiltration of blood into the muscles, tendons, and other soft tissues May also refer to avulsion of bony muscle attachments Charley horse- cramping of an individual thigh muscle because of ischemia or to contusion and rupture of blood vessels sufficient enough to form a hematoma The most common site of a thigh hematoma is in the quadriceps Psoas Abscess pg. 558 A retroperitoneal pyogenic infection in the abdomen or greater pelvis, characteristically occurring in association with TB of the vertebral column, or secondary to regional enteritis of the ileum (Crohn disease) may results in the formation of a psoas abscess Edema can occur in the proximal part of the thigh Observed in inguinal region Paralysis of Quadriceps pg. 558 Cannot extend the leg against resistance and usually presses on the distal end of the thigh during walking to prevent inadvertent flexion of the knee joint Chondromalacia Patellae pg. 558 Runner’s knee Soreness and aching around patella results from quadriceps imbalance Can result from blow to patella or extreme flexion of the knee Patellar Fractures pg. 559 Transverse patellar fractures may result from a blow to the knee or sudden contraction of the quadriceps Proximal fragment is pulled superiorly with quadriceps tendon Distal fragment remains with patellar ligament Abnormal Ossification of Patella pg. 559 Patella is cartilaginous at birth but ossifies during 3rd-6th years Multiple ossification centers occur and if they remain separated, a bipartite or tripartite patella may form Ossification abnormalities are nearly always bilateral so use CT/radiograph to observe both Patellar Tendon Reflex pg. 559 Tapping the patellar ligament with a reflex hammer normally elicits the patellar tendon reflex Knee jerks- leg extends, quadriceps contract Tests the integrity of the femoral nerve and L2-L4 Diminution or absence of patellar tendon reflex may result from any lesion that interrupts the innervation of the quadriceps Transplantation of Gracilis pg. 559 Weak member of the adductor group Used to replace a damaged muscle in the hand ( good digital flexion and extension) Used as replacement for a nonfunctional external anal sphincter Groin Pull pg. 560 Injury involves flexor and adductor thigh muscles Attachment of these muscles are in the inguinal region Occur in quick start sports and extreme stretching Injury to Adductor Longus pg. 560 Occurs in horseback riders and produces pain Ossification may occur in the tendons and are called riders’ bones Palpation, Compression, and Cannulation of Femoral Artery pg. 560 Starts off as common femoral artery then continuation distally called superficial femoral artery (term not recommended because it is a DEEP artery) Femoral pulse may be palpated midway between the ASIS and pubic symphysis Compression can be done by pressing posteriorly against the superior pubic ramus, psoas major, and femoral head In left cardial angiography, a catheter is inserted into artery and passed up the external iliac artery, common iliac artery, and aorta to the left ventricle of the hear Blood may be taken for blood gas analysis Laceration of Femoral Artery pg. 560 Arteriovenous shunt- artery and vein lacerated in anterior thigh wounds Cruciate anastomosis is a four-way common meeting of the medial and lateral circumflex femoral arteries with the inferior gluteal artery superiorly, and the first perforation artery inferiorly, posterior to the femur (supplies blood to the lower limb) Potentially Lethal Misnomer pg. 560 Femoral vein is DEEP Pulmonary emboli originate in deep veins Risk of embolism can be reduced by anticoagulant treatment Saphenous Varix pg. 561 A localized dilation of the terminal part of the great saphenous vein May cause edema in femoral triangle Location of Femoral Vein pg. 561 Inferior to the inguinal ligament Femoral artery is lateral to the vein In varicose vein operations, it is important to identify the great saphenous vein correctly (it is more superficial) Cannulation of Femoral Vein pg. 561 Right cardiac angiography- catheter inserted into the femoral vein as it passes through the femoral triangle (through external and common iliac veins into the inferior vena cava and right atrium) Secure blood samples and take pressure recordings from the chambers of the right side of the heart Femoral Hernias pg. 561 Femoral rings is the usual originating site of a femoral hernia- a protrusion of abdominal viscera through the femoral ring into the femoral canal Hernia is bounded by the femoral vein laterally and the lacunar ligament medially Compresses contents of the femoral canal More common in females because of wider pelves Strangulation of a femoral hernia may occur because of the sharp, rigid boundaries of the femoral ring, particularly the concave margin of the lacunar ligament Can cause necrosis Replaced or Accessory Obturator Artery pg. 562 Enlarged pubic branch of the inferior epigastric artery either takes the place of the obturator artery (replaced obturator artery) or joins it as an accessory obturator artery Could be involved in a strangulated femoral hernia Surgeons placing staples during endoscopic repair of both inguinal and femoral hernias must be concerned with the presence of this common arterial variant Popliteal Abscess and Tumor pg. 604 Tend to spread superiorly and inferiorly because of the toughness of the popliteal fascia Popliteal Pulse pg. 604 Popliteal artery is deep so it may be difficult to feel pulse To find pulse, person is in prone position with knee flexed to relax the popliteal fascia and hamstrings Best felt in the inferior part of the fossa Weakening of pulse is a sign of femoral artery obstruction Popliteal Aneurysm and Hemorrhage pg. 604 Popliteal aneurysm (abnormal dilation of all or part of popliteal artery) usually causes edema and pain in the popliteal fossa Palpable pulsations (thrills) and abnormal arterial sounds (brutis) detectable with stethoscope An aneurysm may stretch the nerve or compress it blood supply (vasa vasorum) Fractures of the distal femur or dislocations of the knee may rupture the artery causing hemorrhage Injury to Tibial Nerve pg. 605 Uncommon because of its deep and protected position in the popliteal fossa Posterior dislocation of the knee joint can damage nerve Severance of the tibial nerve produces paralysis of the flexor muscles in the leg and the intrinsic muscles in the sole of the foot Unable to plantarflex their ankle or flex their toes Loss of sensation occurs on the sole of the foot Containment and Spread of Compartmental Infections in the Leg pg. 605 Increased volume consequent to infection with suppuration increases intracompartmental pressure Infection in lateral compartment can ascend proximally into popliteal fossa Fasciotomy (incision of fascia) may be necessary to relieve pressure and debride pockets of infection Tibialis Anterior Strain (Shin Splints) pg. 605 Edema and pain in the area of the distal two thirds of the tibia Results from repetitive microtrauma of the tibialis anterior which causes small tears in the periosteum covering the shaft of the tibia and/or of fleshy attachments to the overlying deep fascia of the leg Mild form of anterior compartment syndrome Fibrularis Muscles and Evolution of the Human Foot pg. 605 Feet of humans are everted (pronated) Fibularis longus and fibrularis tertius attached to the base of the 5th metatarsal developed Injury to Common Fibular Nerve and Footdrop pg. 605 Most often nerve injured in the lower limb because it winds around the fibular neck Paralysis of all muscles in the anterior and lateral compartments of the leg Loss of dorsiflexion of the ankle causes footdrop, making the limb too long (toes do not clear ground) Can be compensated by: 1. Waddling gait- hikes the hip 2. Swing out gait- swung out laterally (adducted) 3. Steppage gait- extra flexion employed at hip and knee to raise foot Braking action produced by eccentric contraction of dorsiflexors also lost (foot “clops”) Deep Fibular Nerve Entrapment pg. 606 Pain in the anterior entrapment, dorsum of foot, web space btwn 1st and 2nd toes Nerve passes deep to the inferior extensor retinaculum and extensor hallcus brevis Ski boot syndrome Superficial Fibular Nerve Entrapment pg.606 Chronic ankle sprains Pain along lateral side of the leg and the dorsum of the ankle and foot Numbness and paresthesia Fabella in Gastrocnemius pg. 606 Lateral head of the gastrocnemius may contain a sesamoid bone, the fabella which articulates with lateral femoral condyle 3-5% people have it Calcaneal Tendinitis pg. 606 Occurs in running injuries Repetitive activities, poor footwear or training surfaces Microscopic tears of collagen fibers in the tendon Ruptured Calcaneal Tendon pg. 607 Associated with history of calcaneal tendinitis Audible snap during a forceful push off (plantarflexion with the knee extended) followed immediately by sudden calf pain and sudden dorsiflexion of the plantarflexed foot Gastrocnemius, soleus, and plantaris affected Cannot plantarflex against resistance and dorsiflexion is excessive Lump appears in the calf owing to shortening of the triceps surae Calcaneal Tendon Reflex pg. 607 Ankle jerk reflex/triceps surae flex Normal result is plantarflexion of the ankle joint Tests the S1 and S2 nerve roots Absence of Plantarflexion pg. 607 If muscles of calf paralyzed, calcaneal tendon ruptured, or normal push off is painful, you can still push off (from midfoot) by the actions of the gluteus maximus and hamstrings in extending the thigh at the hip joint and the quadriceps in extending the knee Gastrocnemius Strain pg. 607 Partial tearing of the medial belly of the gastrocnemius at or near its musculotendinous junction Caused by overstretching the muscle by concomitant fill extension of the knee and dorsiflexion of the ankle joint Calcaneal Bursitis pg. 607 Inflammation of the deep bursa of the calcaneal tendon Pain posterior to the heal Venous Return from Leg pg. 607 Venous plexus deep to the triceps surae is involved in the return of blood from the leg Contraction of the calf muscles pumps blood superiorly in the deep veins Musclovenous pump is improved by the deep fascia that invests the muscles like an elastic stocking Accessory Soleus pg. 608 In 3% of people Appears as a distal belly medial to the calcaneal tendon May be associated with pain and edema during prolonged exercise Posterior Tibial Pulse pg. 608 Can be palpated between the posterior surface of the medial malleolus and the medial border of the calcaneal tendon Have the person invert the foot to relax the retinaculum (examine both simultaneously) Occlusive peripheral arterial disease- intermittent claudication (leg pain and cramps) develops during walking and disappears after rest