Section 1 Basic science

Anatomy

5
Chapter

Anatomical snuffbox
What is the anatomical snuffbox?
The anatomical snuffbox (Figure 5.1) is a triangular deepening on the dorsal
aspect of the wrist on the radial side. The name originates from the use of this
surface for placing and sniffing ‘snuff’ or powdered tobacco in the past.
What are the boundaries of the anatomical snuffbox?
Radial Parallel tendons of extensor pollicis brevis and abductor pollicis
longus,
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Ulnar Tendon of extensor pollicis longus,

Floor Tip of radial styloid, scaphoid (majority) and trapezium, and the
base of the thumb metacarpal (proximal to distal).

Dorsal tubercle of radius

Extensor pollicis longus
Cephalic
vein Scaphoid
First dorsal interosseous
Extensor expansion

Radial Extensor pollicus brevis

artery
Trapezium
Abductor
Thumb
pollicus longus
metacarpal
Figure 5.1 The anatomical snuffbox.
87
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 88 Section 1: Basic science

What neurovascular structures lie within this area?

 Radial artery (deep),
 Dorsal cutaneous branch of the radial nerve,
 Cephalic vein (superficial).
What does tenderness in the anatomical snuffbox classically signify?
Fracture of the scaphoid. This is most commonly caused from a fall onto the
outstretched hand in a young adult.
What is particular about the blood supply of the scaphoid and what is its
significance?
The proximal segment of the scaphoid lacks any independent blood supply. The
blood supply of the scaphoid comes from the radial artery. It is characteristic in the
fact that it supplies the bone from distal to proximal. Therefore, a fracture through
the waist of the scaphoid may result in avascular necrosis (AVN) of the proximal
pole. The more proximal the fracture position, the higher the risk of AVN.
What other bones have a risk of developing AVN?
The femoral head and the talus.

Antecubital fossa and elbow joint

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Where is the cubital fossa situated and what are its boundaries?
The cubital fossa (Figure 5.2) is a triangular area found on the anterior aspect
of the elbow,1 with its base (superior border) forming a line between the
medial and lateral epicondyles.

a b

Biceps Biceps
Basilic v.
Brachial a.
Cephalic v.
Medial Median n
Lateral antebrachial
antebrachial Radial n. Pronator
cutaneous n.
cutaneous n. teres
Median
Posterior cubital v. Brachioradialis Bicipital
antebrachial Bicipital aponeurosis
cutaneous n. aponeurosis Radial a.

Figure 5.2 The cubital fossa. (a) The superficial nerves and veins. (b) The contents of the
cubital fossa.

1
www.joint-pain-expert.net/elbow-anatomy.html.

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 Chapter 5: Anatomy 89

Medial (ulnar) border Lateral aspect of pronator teres (a muscle that

pronates and flexes the forearm), innervated by
the median nerve.
Lateral (radial) border Medial aspect of brachioradialis muscle
(another forearm flexor, commonly known as
the ‘beer drinkers’ muscle’), innervated by the
radial nerve.
Apex The tip of the triangle is directed distally and is
formed by the meeting point of the medial and
lateral boundaries.
Floor (deep) Brachialis muscle and supinator.
Roof (superficial) Deep fascia reinforced by the bicipital
aponeurosis, superficial fascia (containing the
median cubital vein and the medial and lateral
cutaneous nerves of the forearm) and skin.

What are the contents of the cubital fossa?

Lateral to medial present in the fossa in a vertical configuration:
Radial nerve Found between the brachioradialis and brachialis – this
nerve is not always considered to be part of the cubital
fossa.
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Biceps brachii Can be palpated clinically.

tendon
Brachial artery Distal aspect of the artery and the bifurcation (at the
apex of the triangle) into the radial and ulnar arteries.
Median nerve
If excluding the radial nerve, the mnemonic TAN (‘tendon artery nerve’)
can be applied from lateral to medial.
The ulnar nerve is in the vicinity of the cubital fossa but not considered to
be within the fossa. It is found medial to the median nerve.
The median cubital, cephalic and basilic veins, and the medial and lateral
cutaneous nerve are considered to be superficial to the cubital fossa. However,
they are important structures to bear in mind in any laceration or fracture that
involves the region around the cubital fossa.
What clinical aspects are useful with the anatomical knowledge
of the cubital fossa?
 Palpation of the brachial pulse, in addition to manual blood pressure
measurements with the stethoscope places over the brachial artery,
 Peripheral venous cannulation and phlebotomy,

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 90 Section 1: Basic science

 Assessment of neurovascular injuries in any fracture involving this region,

especially supracondylar fractures in children with increased threat to
these structures (most common is the median nerve’s anterior
interosseous branch, followed by the ulnar and radial).

What type of joint is the elbow joint?

It is a synovial hinge joint. It consists of the distal humerus articulating with
both the proximal radius and ulna. Stability of the joint is reinforced by the
concavity of the olecranon and its articulation with the trochlea. Various
ligaments around the elbow joint also aid stability. Given the nature of the
hinge joint, the movements that are produced around the elbow are of flexion
and extension. Pronation and supination of the forearm and movements that
are produced from the radioulnar joints despite the articulation of the radial
head with the capitellum.

Arterial supply of the lower limb

What are the main branches of the arterial blood supply to the lower limb?
See Figure 5.3.
 The external iliac artery (bifurcation of the common iliac artery)
becomes the femoral artery at the point beyond the inguinal ligament.
 The femoral artery anatomically begins at the mid-inguinal point (midway
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between the anterior superior iliac spine (ASIS) and the symphysis pubis).
 The femoral artery then bifurcates into the superficial femoral artery and
the profunda femoris. This division occurs just below the femoral sheath.
 The superficial femoral artery continues into the adductor canal and forms
the popliteal artery in the adductor hiatus as it goes into the popliteal
fossa.
 The profunda femoris is the main blood supply of the thigh and runs deep
in the thigh. It branches into the medial and lateral circumflex femoral
arteries to supply the proximal thigh and the hip joint, as well as three
or four perforating arteries.
 After the formation of the popliteal artery at the adductor hiatus, it runs
deep in the popliteal fossa and along the medial aspect of the femur,
almost in contact with bone. It lies at the posterior capsule of the knee
as it travels distally in the fossa.
 The popliteal artery branches into two genicular arteries on the lateral
aspect of the knee and three medially (the middle genicular artery
supplies the cruciate ligaments).
 The popliteal artery divides into the anterior and posterior tibial arteries.
The anterior tibial artery continues as the dorsalis pedis artery after it

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 Chapter 5: Anatomy 91

Figure 5.3
Arterial supply of
the lower limb.

Major Arterial
conduits

Common
iliac artery

External iliac
artery

Femoral
artery

Profunda
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femoris

Superficial
femoral artery

Popliteal
artery

Genicular
arteries
(4 branches)

Posterior
tibial arteries

Anterior
tibial arteries

Dorsalis pedis
artery
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 92 Section 1: Basic science

crosses the ankle anteriorly, beneath the extensor retinaculum and

midway between both malleoli. It finally forms the dorsal arch artery of
the foot. The posterior tibial artery is the main blood supply to the foot
and runs posterior to the medial malleolus. It finally branches into the
medial and lateral plantar arteries.

Carpal tunnel
Where is the carpal tunnel situated and what are its attachments?
The carpal tunnel (Figure 5.4) is situated in the upper limb. It is a space on the
volar surface of the wrist between the concavity of the carpus and the overly-
ing flexor retinaculum. The flexor retinaculum (carpal ligament) is a strong
fibrous band the size of a postage stamp. The proximal edge of the flexor
retinaculum underlies the distal wrist crease.
Attachments of the flexor retinaculum:
Radial aspect Proximally the scaphoid tubercle and distally the ridge
of trapezium.
Ulnar aspect Proximally the pisiform (sesamoid bone within flexor
carpi ulnaris) and distally the hook of hamate.
What are the contents of the carpal tunnel?
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Median nerve Most superficial; just beneath the

retinaculum radial to midpoint,
Flexor pollicis longus (FPL) Has its own synovial sheath; runs radial to
finger flexors,

Ulna nerve and artery

Thenar
muscles Hypothenar muscles

Flexor retinaculum
Flexor Median nerve
carpi radialis
Tendons of flexor
Flexor pollicis digitorum superficialis
longus
Tendons of flexor
Trapezium digitorum profundus

Trapezoid Hamate

Capitate

Figure 5.4 A diagrammatic cross-section through the carpal tunnel.

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 Chapter 5: Anatomy 93

Flexor carpi radialis (FCR) Within its own fascial compartment and
radial to finger flexors,
Flexor digitorum Running in two pairs,
superficialis (FDS)
Flexor digitorum Running more dorsal to flexor digitorum
profundus (FDP) superficialis, in a row of four.

Compartments of the lower limb

How many compartments are there in the lower limb?
Four: anterior, lateral, superficial posterior and deep posterior (see Figure 5.5).
What are the contents of the anterior compartment of the lower leg?
The anterior compartment lies between the deep fascia of the anterior aspect
of the lower leg and the interosseous membrane between the tibia and fibula.
Its contents include:
 Tibialis anterior,
 Extensor hallucis longus,
 Extensor digitorum longus,
 Peroneus tertius,
 Anterior tibial artery,
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 Deep peroneal nerve.

What are the contents of the lateral compartment of the lower leg?
 Peroneus longus,
 Peroneus brevis,
 Branches of the peroneal artery,
 Superficial peroneal nerve.

What are the contents of the posterior compartment of the lower leg?
Superficial
 Gastrocnemius,
 Soleus,
 Plantaris,
 Underlying deep transverse fascia separating superficial from deep.
Deep
 Tibialis posterior,
 Flexor digitorum longus,
 Flexor hallucis longus,

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 94 Section 1: Basic science

Anterior compartment

Tibia Interosseous membrane

Anterior intermuscular septum

Lateral compartment

Fibula

Skin Posterior intermuscular septum

Fat Deep posterior compartment

Crural Transverse intermuscular septum
fascia
Superficial posterior compartment

Figure 5.5 Cross-section through the middle third of the leg.

 Popliteus,
 Posterior tibial artery,
 Peroneal artery,
 Tibial nerve,

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Sural nerve.

Dermatomes and myotomes of the upper and lower limb

What are dermatomes?
Dermatomes (Figure 5.6) are areas of skin that are supplied by a single
posterior spinal nerve root. They can be identified in examinations of the
limbs.
Dermatomes of the upper limb
C4 Shoulder tip,
C5 Outer part of the upper arm,
C6 Lateral aspect of the forearm and the thumb,
C7 Middle finger,
C8 Little finger,
T1 Medial aspect of the upper arm.
Other useful dermatomes on the trunk
T4 Nipples,
T7 Xiphisternum,
T10 Level of umbilicus.

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 Chapter 5: Anatomy 95

Figure 5.6
Dermatomes.
C2,3

C2,3

C4

T2
T3
C5 T4
T5

T2 T6
T7
T8

T9
C6

T10
T1

T11
T12
L1

S2,3
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C8,1
L2
C7

L3

L4

L5,1

L4,5

L5, S1

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 96 Section 1: Basic science

Dermatomes of the lower limb

L1 Around inguinal region and anterior perineum,
L3 Front of knee,
L4 Over tibia/medial leg,
L5 Over fibula/lateral leg,
L5 Medial side of foot,
S1 Lateral side of foot.
One stands on S1, sits on S3 (around the anus) and S2 is a narrow strip up
the middle of the calf and hamstrings.

Note that there are extensive overlaps between dermatomes and therefore
various references will have slight variations of the exact mapping of the
dermatomes. These maps are a guide to ease examination and aid in diagnosis.

Femoral triangle
What are the boundaries of the femoral triangle?
See Figure 5.7.
Superiorly Inguinal ligament,
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Medially Medial border of adductor longus muscle,

Laterally Medial border of sartorius muscle,
Floor Iliacus, tendon of pectineus, psoas and adductor longus,
Roof Superficial fascia and fascia lata.

Inguinal triangle Figure 5.7

Femoral triangle.
Inguinal ligament

Femoral nerve

Femoral artery

Femoral vein

External pudendal vein

Sartorius

Adductor longus

Great saphenous vein

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 Chapter 5: Anatomy 97

What are the contents of the femoral triangle?

From lateral to medial:
 Femoral nerve,
 Femoral artery,
 Femoral vein,
 Femoral canal (containing extra-peritoneal fat and Cloquet’s lymph
node), and
 Deep inguinal lymph nodes within the femoral triangle.

What operative procedures occur in and around the femoral triangle?

Femoral embolectomy for acute limb ischaemia, and femoral hernia repairs.

Hip and femur

See Figure 5.8.

Figure 5.8 Hip

and femur.
Ilium
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Synovial
membrane (cut)
Iliofemoral ligament
(cut to show Cotyloid ligament
underlying structures)
Head of femur
Greater
trochanter Pubofemoral
ligament

Pubis

Ischium
Pubocapsular
ligament
Obturator
membrane
Femur
Lesser trochanter

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 98 Section 1: Basic science

What kind of joint is the acetabulofemoral joint?

The hip joint is a synovial ball-and-socket joint lined by hyaline cartilage,
involving the acetabulum and femur.
What are the factors that contribute to the intrinsic stability of the hip?
All three factors of the bony, ligamentous and muscular components affect
and contribute to the stability of the hip. Note that while performing a total
hip replacement (THR) some of these factors are compromised; therefore,
there is a risk of dislocation.
Osseous –– The ball and socket, which is further deepened by the labrum, are
the primary stabilizing factors.
Ligamentous –– Including the capsule, there are three main ligaments –
iliofemoral, pubofemoral and ischiofemoral. The iliofemoral (strongest
ligament) is shaped like an inverted Y, originating from above the anterior
superior iliac spine (ASIS) with the limbs of the Y attaching around the
intertrochanteric line. The pubofemoral ligament is found at the inferior joint
capsule between the iliopubic eminence and the obturator crest. The ischio-
femoral ligament (weakest ligament) winds around the joint and attaches into
the capsule.
Muscular –– The short lateral rotators of the hip, as well as the hip abductors
(gluteus medius and minimus).
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What are the attachments of the hip capsule on the proximal femur?
On the anterior aspect, the capsule attaches along the intertrochanteric line.
Posteriorly, it attaches more proximally halfway along the femoral neck.
Superiorly, it is attached circumferentially around the labrum and the trans-
verse ligament.
What is the shape of the acetabulum?
The acetabulum is a concave surface of the pelvis with a horseshoe-shaped
articular surface. The acetabular labrum is attached to the rim of the acetabu-
lum to deepen the socket (it is triangular in cross-section). The transverse
acetabular ligament is found between the two limbs of the horseshoe.
What three bones form the acetabulum?
 Ischium,
 Ilium,
 Pubis.
If given a femur how do you orientate it to the correct side?
 Femoral condyles face posteriorly,
 Linea aspera is posterior,

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 Chapter 5: Anatomy 99

 Lesser trochanter is medial and posterior,

 Femoral neck and head angled supero-medially, and from posterior
to anterior.
Where does the iliopsoas muscle attach on the femur and what is its action?
The iliopsoas (iliacus and psoas major muscles) inserts to the lesser trochan-
ter. Its action is to flex the hip.
What does tenderness at the greater trochanter commonly indicate without
the presence of an acute injury?
Trochanteric bursitis.
What muscles attach to the linea aspera at the posterior aspect of the femur?
The linea aspera is extended by three ridges superiorly and two ridges posteriorly.
Superior third
 Pectineus,
 Iliacus,
 Adductor longus,
 Adductor brevis.
Middle third
 Gluteus maximus,
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 Short head of biceps femoris.

Inferior third
 Adductor magnus,
 Vastus lateralis and medialis.

Knee joint
What type of bone is the patella?
The patella is a sesamoid bone. It is the largest sesamoid bone in the body,
lying within the tendon of the quadriceps, which attaches at the tibial tubercle.
What shape is the patella?
The patella is circular-triangular, with its apex facing distally. It articulates
with the distal femur (the articular surface of the knee joint). The cartilaginous
posterior surface is divided by a vertical ridge into a larger lateral portion for
articulation with the lateral condyle of the femur and a smaller medial portion
for articulation with the medial condyle of femur.
What is the common age of patella subluxation or dislocation?
It can occur in childhood but is more common in adolescence and early
adulthood (16–20). It is also seen more commonly in young female athletes.

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 100 Section 1: Basic science

In what direction does the patella usually dislocate?

Laterally.
What are the predisposing factors for patella subluxation or dislocation?
Age 16–20,
Sex Female,
Athletic population Particularly in twisting rotational motions of the
knee, or direct trauma to the knee,
Family history
Anatomic factors Insufficient oblique insertion of vastus medialis
(VMO) muscle, laxity or injury to the medial
patellofemoral ligament (MPFL), misalignment of
the patella, patella alta or dysplastic patella shallow
trochlear groove and decreased prominence of the
lateral femoral condyle.
Describe the attachments of the capsule of the knee
Anteriorly, the synovial membrane is attached to the femur proximal to the articular
surface, while distally on the tibia the attachment is near the articular cartilage.
Posteriorly, the femoral attachments lie at the cartilaginous margin of the medial and
lateral femoral condyles, with the tibial attachments similarly at the cartilage margin.
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What are the attachments of the cruciate ligaments of the knee?

The anterior and posterior cruciate ligaments (ACL and PCL) are named after
their points of attachment on the tibial plateau.
Anterior cruciate ligament –– This originates from the medial wall (posterior
part) of the lateral femoral condyle and attaches to the anterior and lateral
intercondylar eminence of the tibia.
Posterior cruciate ligament –– This originates from the lateral wall of the medial
femoral condyle and attaches to the posterior intercondylar eminence of the tibia.
What are the symptoms of a ruptured anterior cruciate ligament?
Immediate swelling of the knee (haemarthrosis), as the ACL is a vascular
structure, and inability to bear weight fully. The patient often hears a pop.
After injury, symptoms of instability and ‘giving way’ of the knee occur, and
the patient often states that the knee cannot be trusted. Pain is not often a
classical symptom of the injury.
How is the anterior cruciate ligament commonly injured?
The ACL is ruptured most commonly in athletes, at the time of pivoting the
leg with a lateral rotational movement of the knee. The most common sports
that lead to an ACL injury are netball, football and rugby.

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 Chapter 5: Anatomy 101

What types of graft are used to reconstruct the ACL?

Autologous (hamstrings or patella tendon), allograft (cadaveric) or synthetic
material. Autologous grafts are most commonly used, in particular hamstring
tendons. Patients can experience weak hamstrings in hamstring grafts, and can
develop tendonitis in patella grafts.

What is the O’Donoghue’s triad (or unhappy triad, terrible triad)?

It is an injury to the anterior cruciate ligament, medial collateral ligament
(MCL) and meniscus (medial or lateral). The original triad described by
O’Donoghue stated the medial meniscus but the lateral has been incorporated
as it is more commonly seen among athletes with such injuries.

Lumbar vertebrae
What are the five divisions of the spinal column?
 Cervical,
 Thoracic,
 Lumbar,
 Sacrum,
 Coccyx.
How many lumbar vertebrae are usually present?
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Five.
What are the characteristic features of the lumbar vertebra?
See Figure 5.9.

Cortical rim Figure 5.9

Lumbar vertebra
(axial view).
Body Cancellous

Transverse Pedicle
process

Superior articular
process Lamina Vertebral foramen

Spinous process

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 102 Section 1: Basic science

 Large vertebral body (lateral plane is wider than the anteroposterior plane).
 Pedicles are very strong and positioned at the posterior end of the
vertebral body.
 Superior articular surface is vertical and concave. The facets are
positioned backwards and medially, while the inferior articular
processes are convex and directed forward and laterally.
 Laminae are broad, short and strong (the lamina connects the pedicles
to the spinous process).
 The spinous process that points posteriorly is quadrangular in shape.
 Quadrangular vertebral foramen (larger than the foramen in the
thoracic vertebra).
 Absence of foramina in the transverse processes (cf. cervical).
 Absence of costal facets on the side of the body or on the transverse
process (cf. thoracic).
 Transverse processes are long and horizontal in the upper three lumbar
vertebrae and incline upwards in the lower two vertebrae. They are situated
anterior to the articular surface (cf. posterior in the thoracic vertebrae).
What is the term given when the L5 vertebra is fused to the first sacral vertebra?
Sacralization. This is a congenital anomaly; L5 can be fused on one or both sides.
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This can cause confusion in assessing the radiographs of the lumbar spine. It is
best identified by counting down from T12 as opposed to counting up from L5.
What is the term given when the first sacral vertebra has an articulation with
the second sacral vertebra?
Lumbarization. This is less common than sacralization: S1 appears like a sixth
lumbar vertebra and may have a disc space or a rudimentary disc space.
Which lumbar vertebra is the commonest site of spondylolysis and
spondylolisthesis?
The fifth lumbar vertebra.
What structures are attached to the lumbar transverse processes?
Psoas fascia and the origin or psoas muscle before it joins the iliacus to form
the iliopsoas. The iliolumbar ligament (from which the quadrates lumborum
muscle arises) is attached to the transverse ligament of the fifth vertebra.
What are the intervertebral discs?
They are secondary cartilaginous joints found between pairs of vertebral
bodies throughout the vertebral column to allow slight movement of the
vertebrae. The intervertebral disc is comprised of the outer or peripheral
annulus fibrosus and the central nucleus polposus.

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 Chapter 5: Anatomy 103

What is their purpose?

With the tough annulus fibrosus, the nucleus polposus acts as a shock absorber
absorbing the impact of daily activities. The intervertebral discs also act to
separate the vertebrae. However, as people age, the nucleus polposus dehydrates,
which limits its ability to absorb axial forces, and the annulus undergoes degen-
erative tears. These pathological processes can lead to chronic back pain.
In which direction do discs usually prolapse?
The most common prolapse is in the posterolateral direction, as the posterior
longitudinal ligament usually prevents a direct posterior prolapse. The former
can cause nerve root compression. However, if posterior prolapse occurs, it may
cause compression of the cauda equina, which is an orthopaedic emergency.

Popliteal fossa
Where is the popliteal fossa situated and what are its boundaries?
The popliteal fossa (Figure 5.10) is a diamond-shaped area situated in the
posterior aspect of the knee.

Proximal Figure 5.10

Popliteal fossa.
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Tibial n. Common
peroneal n.

Medial Lateral

1 cm

Biceps
femoris
Semimembranosus m. m.

Semitendinosus m. 5 cm Cephalolateral
quadrant

Gastrocnemius m.

Distal

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 104 Section 1: Basic science

Supra-medial border Biceps femoris muscle,

Supra-lateral border Semi-tendinosus and semi-membranosus muscles,
Infra-medial border Medial head of gastrocnemius muscle,
Infra-lateral border Lateral head of gastrocnemius muscle,
Floor (deep) Popliteal surface of the femur, posterior capsule of
the knee joint and the oblique popliteal ligament,
and the fascia covering the popliteal muscle,
Roof (superficial) Deep fascia, superficial fascia (containing short
saphenous vein, three cutaneous nerves) and skin.

What are the contents of the popliteal fossa?

From deep to superficial (important in any patient with an open injury or
laceration in this region):
 Popliteal artery (a continuation of the femoral artery).
 Popliteal vein.
 Tibial and common peroneal nerve (branches of the sciatic nerve – the
division could occur anywhere from the sciatic notch to the popliteal
fossa). The common peroneal nerve is the most superficial structure,
and runs along the supra-lateral border of the fossa, adjacent to the
biceps femoris, exiting the fossa at the infra-lateral aspect over the
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lateral head of gastrocnemius and into and along the peroneus longus.
 Popliteal lymph nodes.
 Short saphenous vein.
 Posterior cutaneous nerve of the thigh.
What clinical aspects are useful with the anatomical knowledge
of the popliteal fossa?
 Palpation of the popliteal pulse. This can be difficult, especially in an obese
patient, because the artery is the deepest structure. An aid to palpating it
is to flex the knee to 30 and palpate the artery against the bony floor.
 Knowledge of the superficial nature of the nerves enables the anaesthetist
to deliver a popliteal local anaesthetic block.
 The assessment of neurovascular injuries in any fracture or knee
dislocation, especially in high velocity or sporting injuries, is aided.

Radial nerve
From what part of the brachial plexus does the radial nerve branch?
The radial nerve is the largest branch of the posterior cord of the brachial
plexus (nerve roots C5–T1).

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 Chapter 5: Anatomy 105

Describe the course of the radial nerve in the arm

The radial nerve runs from its origin as a continuation of the posterior cord
of the brachial plexus exiting the axilla into the posterior compartment
of the arm along the posterior aspect of the axillary artery through the
triangular space bordered by the long head of triceps, the humerus and the
teres major.
Along its path, the radial nerve gives off motor branches to the long and
medial heads of the triceps, and the posterior cutaneous nerve of the arm
(sensory). It lies in the spiral groove of the humerus, giving off branches to the
lateral head of triceps and anconeus, as well as the posterior cutaneous nerve
of the forearm distally.
The radial nerve exits the posterior compartment through the lateral
intramuscular septum and into the cubital fossa. This is where it divides into
its two terminal branches; the (predominantly sensory) radial nerve and the
(predominantly motor) posterior interosseous nerve (PIN).
The PIN enters and supplies the extensor compartment of the forearm,
travelling around the proximal radius and through the supinator.
The radial nerve continues within the forearm under the brachioradialis.
It travels briefly along with and medial to the radial artery. It eventually
pierces the deep fascia posteriorly and supplies the skin at the dorsal aspect
of the wrist and hand.
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At what site is the radial nerve commonly injured?

It is injured at the spiral groove of the humerus in humeral fractures (middle
third) and its fixation, and at the axilla, secondary to traction injuries from
shoulder dislocations, ‘axilla’ crutches, or ‘Saturday night palsy’ (these traction
injuries are usually temporary – neuropraxia).
The posterior interosseous nerve can be injured from proximal radial
fractures.

What are the clinical presentations of radial nerve injuries in the various areas
along its route?
At the axilla –– Leads to paralysis of triceps and the forearm and wrist
extensors. This gives loss of extension in the elbow, wrist and hand with
unopposed flexors – wrist drop. Loss of sensation is most pronounced over
the dorsum of the hand.
At the distal humerus or spiral groove –– Wrist drop, as above.
At the proximal radius –– Injury to the posterior interosseous nerve causing
loss of finger extension without a wrist drop. Extensor carpi radialis (and
brachialis) function are preserved, as they are supplied by the main radial
nerve. The PIN is a motor nerve.

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 106 Section 1: Basic science

How would you test for the radial nerve?

Motor function is tested by the power of wrist dorsiflexion and finger exten-
sion (to include the posterior interosseous nerve).
Sensory function is tested in the autonomous sensory area of the radial
nerve, which is over the dorsal aspect of the first web space.

Sciatic nerve
Where is the greater sciatic foramen?
The greater sciatic foramen is situated in the pelvis between the greater sciatic
notch and both the sacrospinous and sacrotuberous ligaments.

What passes through it?

Various structures pass through the foramen. The major structures include:
 Piriformis muscle (lateral rotator of the hip),
 Sciatic nerve,
 Superior and inferior gluteal nerves,
 Pudendal nerve,
 Superior and inferior gluteal vessels.

What are the surface markings of the sciatic nerve?

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The sciatic nerve lies in the medial and posterior (lower, inner) quadrant of
the buttock and travels inferiorly midway between the ischial tuberosity and
the greater trochanter of the femur. It runs vertically initially deep to the
gluteus maximus, then down the midline of the posterior compartment of the
thigh until its bifurcation into the tibial and common peroneal nerves (usually
two-thirds of the way down). Superiorly, it is in close proximity to the posterior
rim of the acetabulum. This needs to be considered, especially in the posterior
approach to the hip during total hip replacement.

Where would you give buttock intramuscular injections?

They should be given in the supra-lateral (upper, outer) quadrant of the
buttock to avoid the sciatic nerve, which lies in the medial posterior quadrant.

What are the nerve roots of the sciatic nerve?

The anterior primary rami of L4, L5, S1, S2, and S3.

What are the branches of the sciatic nerve and where does it divide?
The sciatic nerve divides into the tibial and common peroneal nerves. Division
can occur anywhere from the sciatic notch to the popliteal fossa (most
commonly two-thirds of the way down the thigh).

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 Chapter 5: Anatomy 107

Note that the sciatic nerve gives off a branch to the posterior compartment
of the thigh supplying some of the short lateral rotators of the hip and the
hamstrings.
What motor deficits are seen in a sciatic nerve injury?
 If the injury is proximal to the knee, loss of hamstring function occurs.
 If the injury is distal to the knee joint, loss of function in all the leg muscles
and the patient will produce a foot drop.
What sensory deficits are seen in a sciatic nerve injury?
Loss of sensation below the knee. The saphenous nerve is a sensory nerve and
a branch of the femoral nerve and therefore the areas supplied by the saphe-
nous nerve are spared. This includes the medial aspect of the leg, medial side
of the ankle and up to the mid foot (some crossover exists between the nerves).

Shoulder
What type of joint is the shoulder joint and what joint does it correspond to in the
lower limb?
The shoulder joint (Figure 5.11) is a synovial ball-and-socket joint between the
humeral head (with the articular surface facing medially) and the glenoid. It
corresponds to the hip joint, which is another ball-and-socket joint.
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Acromioclavicular Figure 5.11

(AC) joint Clavicle Shoulder.
Acromion

Bursa
Rotator cuff
tendons:
Supraspinatus
Subscapularis
Teres minor
Infraspinatus
(behind, not shown)

Humerus

Biceps muscle
(long head)
Gleno-
humeral
Biceps muscle joint
(short head) Scapula

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 108 Section 1: Basic science

Is the shoulder joint seen to be intrinsically stable or unstable?

Unstable.
What structures around the glenohumeral joint augment its stability?
Muscles Rotator cuff muscles (supraspinatus, infraspinatus, teres
minor, subscapularis).
Ligaments Glenohumeral, coracohumeral, coracoacromial.
Tendons Long head of biceps and tendon of triceps.
Capsule Weakest inferiorly.
Glenoid As with the labrum in the hip, this increases the depth of
labrum the ‘socket’ and aids stability.
What muscles insert to the greater tuberosity and the proximal humerus?
Greater tuberosity Supraspinatus, infraspinatus and teres minor,
Proximal humerus Pectoralis major, latissimus dorsi and teres minor.

What muscles are attached to the coracoid process?

The short head of the biceps and the coracobrachialis originate at the coracoid
process, and the pectoralis minor attaches to it.

What is the role of the bursae around the shoulder?

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They permit smooth gliding of the rotator cuff muscles, and protect them
from the bony arches of the acromion.
What is the most common shoulder dislocation?
 Anterior dislocations account for around 95% of shoulder dislocations. The
mechanism is usually a fall onto an outstretched hand or a direct trauma onto
the shoulder, where the humeral head goes into abduction and externally rotates
out of the joint, leaving the arm clinically held in an abducted, externally rotated
position. The resultant position of the humeral head is anterior to the scapula.
 Posterior dislocations account for the remaining 5%. This type of dislocation
is most commonly associated with epileptic fits and electrocutions. These
injuries are also more commonly missed, leading to significant morbidity.
What associated injuries are seen with shoulder dislocations?
Rotator cuff injury including tears, bony injury to the articular surface of the
humeral head (Hill-Sachs lesion), or injury to the glenoid labrum (Bankart lesion).
What nerve injury can occur with an anterior dislocation, what does it supply and
how is it tested?
An injury to the axillary nerve. This causes paralysis of the deltoid muscle,
which leads to inability to abduct the shoulder. To test whether this nerve is

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 Chapter 5: Anatomy 109

intact, sensation is tested over the ‘regimental badge area’ across the proximal
lateral aspect of the arm. This, as well as distal pulses, needs to be clearly
documented in any patient with a shoulder dislocation, pre- and post-reduction.

Spinal cord
Describe the internal structure of the spinal cord
 The spinal cord (Figure 5.12) consists of grey and white matter.
 The grey matter is found centrally and is arranged in a ‘butterfly’ shape.
It is organized as ten laminae on each side, containing sensory and
motor nerve cells:
Laminae I–VI Receive cutaneous and visceral primary afferent
fibres,
Laminae VII, VIII Centrally positioned and receive no peripheral
and X fibres,
Laminae IX Lies in the anterior horn and contains a and g
motoneurons.
 The white matter contains the ascending and descending tracts.
Ascending tracts (sensory)
Dorsal columns Deep touch, fine tactile, proprioception,
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vibration,
Lateral spinothalamic Pain, temperature, tactile sense,
Anterior spinothalamic Light touch,
Spinocerebellar Proprioception
Descending tracts (motor)
Lateral corticospinal Skilled voluntary movements,
Anterior corticospinal Voluntary control,
Vestibulospinal and reticulospinal Controls tone and posture.
Note: the corticospinal tract is the main motor descending tract and is also
known as the pyramidal tract. The other (vestibulospinal and reticulospinal)
tracts constitute the extrapyramidal tract.
Where do motor pathways decussate?
The descending corticospinal tracts decussate as they exit the medulla and
travel down the cord on the contralateral side.
Where do sensory pathways decussate?
The ascending spinothalamic tract decussates obliquely in the cord before
ascending.

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 110 Section 1: Basic science

Dorsal (posterior) columns

(Sensations from same side of body)
Cuneate fasciculus Gracile fasciculus
(Discriminative touch and (Discriminative touch,
proprioception, lower limb)
Lateral corticospinal
upper limb)
(pyramidal) tract
Dorsal spinocerebellar; (From contralateral cerebral
tract (Proprioception; cortex; skilled and willed
movements, same side
lower limb, same side) of body)

Nucleus proprius of dorsal

horn (Origin of contralateral Lateral horn (Origin of
preganglionic sympathetic
spinothalamic tract)
fibres; in segments T1 to L2)
Ventral spinocerebellar tract
(Proprioception, both lower limbs) Limb muscles Motor neurons
Trunk muscles in ventral horn
Spinothalamic tract Vestibulospinal tract (Uncrossed;
(Simple touch, pain and temperature, stimulates extensors of trunk and lower
opposite side of body) limb,and flexors of upper limb)
Nucleus thoracicus Reticulospinal fibres
(Origin of dorsal (Crossed and uncrossed;
spinocerebeller tract; unskilled and involuntary
in segment T1 to L3) movements)

Figure 5.12 Spinal cord.

Spinal cord: blood supply

What three major arteries run the length of the spinal cord?
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Blood to the vertebral column and the spinal cord is supplied by several
segmental arteries that arise from the aorta and nearby arteries. The three
major arteries that supply the cord are:
 Two posterior spinal arteries lying around the posterolateral sulci,
 An anterior spinal artery running in the ventral midline from foramen
magnum to the filum terminale.
These three arteries anastomose around the spinal cord and supply it.

Which of these arteries is considered the predominant supply to the cord?

The anterior spinal artery. It is supplied by 4–10 large unpaired medullary
or radicular arteries that originate from vertebral arteries and the aorta
(often one to the cervical, two to the thoracic and one to the lumbar cord).
It supplies the anterior two-thirds of the spinal cord, including most of the
grey matter.

What is the artery of Adamkiewicz?

This artery, which has many variations, is a single medullary artery positioned
usually on the left of the aorta (around T10–T12), supplying the thoracolum-
bar cord via the anterior spinal artery.

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 Chapter 5: Anatomy 111

What are the consequences of injury or damage to the artery of Adamkiewicz?

This could lead to cord ischaemia and paralysis from an anterior cord
syndrome.
Does the posterior spinal artery have any equivalent large branches, such as the
artery of Adamkiewicz?
No. The posterior spinal artery receives 30–40 smaller medullary tributaries,
but none is as large as the anterior branches.
Where are the veins of the spinal cord located?
They are in the pia mater, where they form a plexus. They drain into the
internal vertebral venous plexuses, which are located between the dura and the
vertebrae within the vertebral canal.
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University Press, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/warw/detail.action?docID=866837.<