(Bca) Back, Lowerupperext Trans Combined

FEU-NRMF [HUMAN STRUCTURAL BIOLOGY DEPARTMENT]
Lecture: Basic Course Audit - Anatomy of the Back [Dr. Alvin B. Vibar]
Disclaimer: This trans is just a supplement to your studies/ readings. This is not
intended to replace nor substitute any written information in our prescribed text CLINICAL CORRELATION
books. Please use at your own risk. Goodluck! Godbless! KYPHOSIS: exaggeration in the SAGITTAL curvature in THORACIC
Sources: Snell 10th edition + PPT 2021 + Transes from previous batches ● AKA hunchback or humpback
● an abnormally increased thoracic curvature resulting from
THE VERTEBRAL COLUMN
osteoporosis
Functions: LORDOSIS: LUMBAR; increase in weight of the abdominal contents
❖ It protects the spinal cord ● AKA swayback or saddle back
❖ Supports the weight of the head and the trunk ● an abnormally increased lumbar curvature resulting from
❖ Allows the movement of the rib cage for respiration by trunk muscular weakness or osteomalacia
articulating with the ribs. ● Gravid Uterus, Large ovarian tumor
● Vertebrae separated by intervertebral discs SCOLIOSIS: LATERAL deviation; common in THORACIC
● The spine has a normal curvature ● condition of lateral deviation resulting from unequal growth of
○ The primary curvatures are located in the thoracic the vertebral column, pathologic erosion of vertebral bodies,
and sacral regions and develop during embryonic and or asymmetric paralysis or weakness of vertebral muscles.
fetal periods
■ CONCAVE VENTRALLY [T & S]
○ The secondary curvatures are located in the cervical
and lumbar regions and develop after birth and during
infancy
■ CONVEX VENTRALLY [C & L]
● Each vertebrae is given a name according to its location
★ Parts [consists of 33 vertebrae in total]
○ Cervical → 7
○ Thoracic → 12
○ Lumbar → 5
○ Sacral → 5 (fused into 1 to form the Sacrum)
○ Coccygeal → 4 (lower 3 commonly fused)
Question:
Primary curvature of the vertebral column corresponds to what segments?
Answer: Thoracic and Sacral
STRUCTURE OF A TYPICAL VERTEBRAE
● Consists of a body and a vertebral arch with several processes for

muscular and articular attachments.
● VERTEBRAL ARCH [gives rise to SEVEN PROCESSES namely]:
○ 1 spinous process → directed posteriorly
○ 2 transverse processes → directed laterally
○ 4 articular processes → vertically arranged [2 superior
and 2 inferior]
Question:
A 69 y/o man has an abnormally increased curvature of the thoracic
vertebral column. Which of the following conditions is most likely the
diagnosis? [Please Read! Excerpts from Snell 10th edition, pg 125-127 Chapter 2]
Answer: Kyphosis
TYPICAL VERTEBRAE REGIONAL CHARACTERISTIC
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TYPICAL CERVICAL VERTEBRA:
● Transverse processes posses a FORAMEN TRANSVERSARIUM
● Spines are small and bifid
● Vertebral foramen is LARGE and TRIANGULAR
● Superior articular processes have facets that face posteriorly
and superiorly
● Inferior articular processes have facets that face inferiorly
and anteriorly
THORACIC VERTEBRAE
Heart shaped body [T6] Mnemonic: BTL
1. Facets on their Bodies for articulation with Head of Ribs
2. Facets on their Transverse Processes for articulation with the
Tubercles
3. Long spinous process
Questions:
Which of the following is a characteristic feature of the first cervical vertebra
[C1[ ?
Answer: Absent Body
Which of the following is a characteristic feature of the second cervical
vertebra [C2]?
Answer: Presence of Odontoid Process /Dens
TYPICAL THORACIC VERTEBRA
The seventh cervical vertebra [C7] is characterized by having:
● Body is medium sized and Heart shaped
Answer: Long spinous process
When a person's neck and trunk are flexed, as in preparation for a spinal ● Vertebral foramen is small and circular
tap, the spinous process of C7 becomes visible and it is for this reason that it ● Spines are long
is called as: ● Costal facets: Bodies = articulation with HEADS of the ribs
Answer: Vertebra prominens ● Costal facets: Transverse Processes = articulation with
TUBERCLES of the ribs
CERVICAL VERTEBRAE
Typical Cervical: C3 TO C6 [short, bifid spinous process] LUMBAR VERTEBRAE
Atypical Cervical: C1, C2 and C7 TYPICAL LUMBAR VERTEBRA
Vertebra Prominens: C7 → long spinous process and not bifid ● Body is large and KIDNEY-SHAPED
Transverse Foramen: Transmit the vertebral artery (except for C7), ● Pedicles are strong and directed backward
vertebral veins, and autonomic nerves; present in transverse processes of ● Laminae are short in vertical dimension
the Cervical Vertebrae ● Vertebral foramina are Triangular
★ CERVICAL 1 = ATLAS, No Body ● Transverse processes are long and slender
★ CERVICAL 2 = AXIS, Presence of the Odontoid process/Dens ● Spinous processes are short, flat and quadrangular; project
posteriorly
[A. Typical cervical vertebra, superior aspect. B. Atlas, or first cervical vertebra,
SACRUM
superior aspect. C. Axis, or second cervical vertebra, from above and behind. D. ● Is a large, triangular, wedge-shaped bone composed of five
Seventh cervical vertebra, superior aspect; the foramen transversarium forms fused sacral vertebrae
passage for the vertebral vein but not for the vertebral artery ● Has four pairs of foramina for the exit of the ventral and dorsal
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primary rami of the first four sacral nerves T12 Celiac artery, Upper pole of LEFT KIDNEY
● Forms the posterior part of the pelvis and provides strength
and stability to the pelvis L1 Superior Mesenteric Artery [SMA]
CHARACTERISTIC STRUCTURES OF THE SACRUM Upper pole of RIGHT KIDNEY
1. Promontory End of spinal cord in Adults [conus medullaris] and Pia
➔ The prominent anterior edge of the first sacral vertebra (S1). mater
2. Ala
➔ The superior and lateral part of the sacrum, which is formed L2 RENAL ARTERY
by the fused transverse processes and fused costal processes
of the first sacral vertebra. L3 End of spinal cord in Newborns
3. Median sacral crest Inferior Mesenteric Artery [IMA]
➔ Formed by the fused spinous processes. Umbilicus [iba ito sa Dermatome ha?~]
4. Sacral hiatus
➔ Formed by the failure of the laminae of vertebrae S5 to fuse. L4 Iliac crest, BIFURCATION of AORTA
➔ It is used for the administration of caudal (extradural)
anesthesia. S1 Sacral Promontory
5. Sacral cornu or horn
➔ Formed by the pedicles of the fifth sacral vertebra. It is an
S2 End of dural sac, dura, arachnoid, subarachnoid space and
important landmark for locating the sacral hiatus.
CSF
S3 End of SIGMOID COLON
Question:
After an automobile accident, a back muscle that forms the boundaries of
the triangle of auscultation and the lumbar triangle receives no blood.
Which of the following muscles might be ischemic?
A. Levator scapulae
B. Rhomboid minor
C. Latissimus dorsi
COCCYX D. Trapezius
● Is a wedge-shaped bone formed by the union of the four E. Splenius capitis
coccygeal vertebrae. Answer: C. Latissimus dorsi
● Provides attachment for the coccygeus and levator ani TISSUES OF THE BACK
muscles.
Memorize!!! Triangles and Fascia
Vertebral Anatomic Structure 1. Triangle of Auscultation

Level ➔ Is bounded by the upper border of the latissimus dorsi, the lateral
border of the trapezius, and the medial border of the scapula.
C3 Hyoid Bone ➔ Has a floor formed by the rhomboid major.
➔ Is the site where breathing sounds can be heard most clearly
C4 Bifurcation of common carotid artery using a stethoscope invented by Laennec in 1816.
2. Lumbar Triangle (of Petit)
➔ Is formed by the iliac crest, latissimus dorsi, and posterior free
C5 Thyroid cartilage, Carotid pulse palpated
border of the external oblique abdominal muscle; its floor is
formed by the internal oblique abdominal muscle. It may be the
C6 Cricoid Cartilage, START of Trachea and Esophagus
site of an abdominal hernia.
3. Thoracolumbar (Lumbodorsal) Fascia
T2 Sternal Notch, ARCH of AORTA
➔ Invests the deep muscles of the back, having an anterior layer
that lies anterior to the erector spinae and attaches to the
T4 Sternal angle, Junction of Superior and Inferior vertebral transverse process, and a posterior layer that lies
Mediastinum, Bifurcation of the Trachea posterior to the erector spinae and attaches to the spinous
processes.
T5-T7 Pulmonary Hilum ➔ Provides the origins for the latissimus dorsi and the internal
oblique and transversus abdominis muscles.
T8 Inferior vena cava hiatus Point of Boundaries of the Back:
T9 Xiphisternal Joint → External occipital protuberance → Superior Nuchal Line

→ Spine of the Scapula → Acromion Process
T10 ESOPHAGEAL HIATUS → Vertebral spines
→ Iliac Crest
→ Sacrum
T12 AORTIC HIATUS
T12-L1 Duodenum
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➔ Gives off the descending branch, which divides into the
superficial branch, which anastomoses with the transverse
cervical artery, and the deep branch, which anastomoses with
the deep cervical artery from the costocervical trunk
2. Transverse Cervical Artery
➔ Arises from the thyrocervical trunk of the subclavian artery and
divides into the superficial and deep branches
➔ Has a superficial branch (superficial cervical artery) that
divides into an ascending branch that supplies the upper part of
the trapezius and adjacent muscles and a descending branch that
accompanies the spinal accessory nerve on the deep surface of
the trapezius
➔ Has a deep branch (dorsal scapular or descending scapular
artery) that accompanies the dorsal scapular nerve (C5) deep to
the levator scapulae and the rhomboids along the medial side of
Muscles of the Back: the scapula
1. Superficial → connected with the SHOULDER GIRDLE NERVE SUPPLY:
2. Intermediate → involved with movements of the THORACIC 1. Accessory nerve
CAGE 2. Dorsal Scapular nerve [C5]
3. Deep 3. Greater Occipital nerve [C2]
a. Superficial - ERECTOR SPINAE 4. Third [Least] Occipital nerve [C3]
b. Intermediate - TRANSVERSOSPINALIS 5. Lesser Occipital nerve [C2]
c. Deep - INTERSPINALIS, INTERTRANSVERSARII
Deep / INTRINSIC Muscles of the Back
Superficial / EXTRINSIC Muscles of the Back
1. Muscles of the Superficial Layer: Spinotransverse Group
➔ Consist of the splenius capitis and the splenius cervicis.
➔ Originate from the spinous processes and insert into the
transverse processes (splenius cervicis) and on the mastoid
process and the superior nuchal line (splenius capitis).
➔ Are innervated by the dorsal primary rami of the middle and
lower cervical spinal nerves.
➔ Extend, rotate, and laterally flex the head and the neck.
2. Muscles of the Intermediate Layer: Sacrospinalis Group
➔ Consist of the erector spinae (sacrospinalis), which is divided into
three columns: iliocostalis (lateral column), longissimus
(intermediate column), and spinalis (medial column).
➔ Originate from the sacrum, ilium, ribs, and spinous processes of
lumbar and lower thoracic vertebrae.
➔ Insert on the ribs (iliocostalis); on the ribs, transverse processes,
and mastoid process (longissimus); and on the spinous processes
(spinalis).
➔ Are innervated by the dorsal primary rami of the spinal nerves.
➔ Extend, rotate, and laterally flex the vertebral column and head.
3. Muscles of the Deep Layer: Transversospinalis Group
➔ Consist of the semispinalis (capitis, cervicis, and thoracis), the
multifidus, and the rotators.
➔ The semispinalis muscles originate from the transverse processes
and insert into the skull (semispinalis capitis) and the spinous
processes (semispinalis cervicis and thoracis).
➔ The rotators run from the transverse processes to the spinous
processes, two vertebrae above and one vertebra above (longus
and brevis respectively).
➔ The multifidus originates from the sacrum, ilium, and transverse
processes and inserts on the spinous processes. It is best
developed in the lumbar region.
➔ Are innervated by the dorsal primary rami of the spinal nerves.
Neurovascular Structures ➔ Extend and rotate the head, neck, and trunk
ARTERIAL BLOOD SUPPLY: Segmental Muscles of the Back
1. Occipital Artery
➔ Arises from the external carotid artery, runs deep to the ➔ Are innervated by the dorsal primary rami of the spinal nerves.
sternocleidomastoid muscle, and lies on the obliquus capitis Consist of the following:
superior and the semispinalis capitis 1. Interspinales
➔ Pierces the trapezius, is accompanied by the greater occipital ➔ Run between adjacent spinous processes and aid in extension of
nerve (C2), and supplies the scalp in the occipital region. the vertebral column.
2. Intertransversarii
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➔ Run between adjacent transverse processes and aid in lateral
flexion of the vertebral column.
3. Levatores Costarum (Longus and Brevis)
➔ Extend from the transverse processes to ribs, elevate the ribs, and
are innervated by the intercostal nerves.
Vertebral Artery
★ Arises from the subclavian artery and ascends through the
transverse foramina of the upper six cervical vertebrae
Vertebral Vein
★ Are formed in the suboccipital triangle by union of tributaries
from the venous plexus around the foramen magnum, the
suboccipital venous plexus, the intervertebral veins, and the
internal and external vertebral venous plexus
Suboccipital Nerve
➔ Supplies the muscles of the suboccipital triangle and
semispinalis capitis
★ Is derived from the dorsal ramus of C1 and emerges between the
vertebral artery above and the posterior arch of the atlas below
Joints & Occipitoaxial Ligament
● Atlanto Occipital Joint

○ Is a condylar synovial joint
○ involved primarily in flexion, extension, and lateral
Suboccipital Area
flexion of the head
● Atlantoaxial Joints
○ synovial joints consisting of two lateral plane joints,
which are between the articular facets of the atlas and
the axis, and one median pivot joint between the dens
of the axis and the anterior arch of the atlas
○ involved in rotation of the atlas and head as a unit on
the axis
● Components of the OCCIPITOAXIAL LIGAMENT
1. Cruciform ligament
a. Transverse ligament
b. Longitudinal ligament
2. Apical ligament
3. Alar Ligament
4. Tectorial Membrane
Suboccipital Triangle:
● Is bound medially by the rectus capitis posterior major muscle,
laterally by the obliquus capitis superior muscle, and inferiorly by
the obliquus capitis inferior muscle.
● Has a roof formed by the semispinalis capitis and longissimus
capitis.
● Has a floor formed by the posterior arch of the atlas and posterior
atlantooccipital membrane.
● Contains the vertebral artery and suboccipital nerve and vessels
“In due time we shall reap...if we don’t lose heart” <3
#ExcelSURE #Excelsior
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BCA-Human Structural Biology- Lower Extremity and Back by: Dr. Alvin B.Vibar
Basic Course Audit Anatomy-FEUNRMF MUSCLE ACTION NERVE SUPPLY
Lower Extremity and Back SARTORIUS flexes and Femoral
by: Alvin B. Vibar, MD, FPSA laterally rotates
the thigh
LOWER EXTREMITY TENSOR FASCIA flexes, abducts & Superior Gluteal
LATA medially rotates
FASCIAL COMPARTMENTS-THIGH
the thigh
 Anterior Compartment QUADRICEPS FEMORIS
 Posterior Compartment
ORIGIN INSERTION ACTION NERVE
 Medial Compartment SUPPLY
Rectus Ant. Patellar Flexes at Femoral
femoris Inferior tendon thigh at
Iliac hip joint;
Spine extends
leg at
knee
joint
Vastus Shaft of Extends
Lateralis femur leg at
knee
joint
Vastus shaft of
Medialis femur
Vastus Shaft of
Interme- femur
dius
TAKE NOTE:
 ANTERIOR
COMPARTMENT –
FLEXES the THIGH at HIP
ANTERIOR THIGH MUSCLES
JOINT and EXTENDS the
 Flexors of the thigh
LEG at the KNEE JOINT
 Extensors of the leg
 ONLY RECTUS FEMORIS
 NERVE SUPPLY: Femoral nerve
can Flex the Thigh and
 Consists of:
Extend the Leg
o Iliopsoas –
STRONGEST
MEDIAL THIGH MUSCLES
FLEXOR
o Tensor fascia  Adducts the thigh
lata  Obturator nerve
o Sartorius  Consists of:
o Pectineus  Adductor
o Quadriceps longus
femoris  Adductor
 Rectus brevis
femoris  Adductor
 Vastus magnus
lateralis  Gracilis-
 Vastus ADDUCTS
medialis THIGH and
 Vastus FLEXES LEG
intermedius
Reference: PPT from HSB Department Page 1 of 14

POSTERIOR THIGH MUSCLES FEMORAL SHEATH
 a funnel shaped
fascial tube formed
by inferior
prolongation of
iliopsoas and
transversalis fascia
of the abdomen
 Compartments:
o Lateral –
femoral
artery
 Extensors of the thigh
 Flexors of the leg
o Intermediate- femoral vein
 NERVE SUPPLY: Sciatic nerve
o Medial – femoral canal
 Consists of: (Hamstring muscles )
ADDUCTOR CANAL
o Semitendinosus
o Semimembranosus Subsartorial canal
o Biceps femoris – long head – TIBIAL part  Hunter’s canal -
short – COMMON PERONEAL a fascial tunnel
o Adductor magnus in the thigh
running from the
FEMORAL TRIANGLE
apex of the
femoral triangle
to the
ADDUCTOR
HIATUS in the
tendon of
adductor
magnus muscle
Boundaries:
BORDERS  Anterior – Sartorius
 Superior – Inguinal ligament  Lateral – Vastus medialis
 Medially – Adductor longus  Posterior & Medial – Adductor longus/ magnus
 Laterally – Sartorius Contents:
 Floor – Adductor longus, Pectineus and Iliopsoas  Femoral artery / vein
 Saphenous nerve
CONTENTS- [NAVEL]  Nerve to vastus medialis
MUSCLES OF THE GLUTEAL REGION

GROUP MUSCLES
SUPERFICIAL  Gluteus maximus- extensor
of thigh
INTERMEDIATE  Gluteus medius & gluteus
minimus- abductor and
medial rotator of the thigh
DEEP  Piriformis, obt.internus,
superior & inferior
 Femoral nerve and its branches gemelli, quadratus
 Femoral sheath and its contents femoris- lateral rotator of
 Femoral artery and its branches thigh
 Femoral vein and its tributaries

REVIEW: Muscles that act at the hip joint LESIONS

SUPERIOR GLUTEAL NERVE INJURY
 Results to weakened abduction of the thigh by
gluteus medius
 “Waddling” gait , pelvis sags on the side of
unsupported limb
 (+) Trendelenburg sign
FEMORAL-Obturator
HIP JOINT STABILITY

 Stability when a person stands on one leg with the
foot of the opposite leg raised above the ground
depends on 3 factors
 Gluteus medius and minimus must be
functioning normally
 Head of the femur must be located normally
SCIATIC NERVE within the acetabulum
 Largest nerve in the body  Neck of femur must be intact and must have a
 From L4 L5 S1 S2 S3- normal angle with shaft of femur
supplies NO muscles in the
gluteal region, skin of the foot
& leg, posterior thigh muscles
(HAMSTRING)

INFERIOR GLUTEAL NERVE LESIONS OBTURATOR NERVE LESIONS
 Weakness in the ability to laterally rotate and  Most commonly lesioned in the Pelvis
extend the thigh at hip joint  Patients are unable to adduct the thigh at the hip
 Difficulty extending the thigh at the hip from a  Paresthesia in the skin of the medial thigh
flexed position, as in climbing stairs or rising
from a chair
 Have a Gluteus maximus gait, in which patients
thrust their torso posteriorly in an attempt to
counteract the weakness of the gluteus maximus
SCIATIC NERVE LESIONS

 Susceptible to damage from an IM injection in the
lower medial quadrant of the gluteus maximus
muscle or it may be compressed as a result of a
posterior
 dislocation of the femur  Neck shaft angle changes: 160 degrees – young,
 * L5 and S1 roots are commonly compressed – 125 degrees – adults
 pain that radiates into the L5 and S1  COXA VARA – decreased; fractures of the neck;
 dermatomes of the leg and foot ABDUCTION is limited
 COXA VALGA – increased; congenital dislocation;
INTRAGLUTEAL INJECTIONS ADDUCTION is limited
FRACTURE OF THE NECK OF THE FEMUR

 Head of femur may undergo avascular necrosis
 SHORTENED WITH LATERAL ROTATION
 Pull upward by the Quadriceps femoris, adductors
and Hamstring muscles
 Avascular necrosis of the femoral head
 Common site for intramuscular injections -

should be made on the superolateral part of the
buttock to avoid hitting nerves & vessels
FEMORAL NERVE LESIONS
 May be damaged in the abdomen by an abscess of
the Psoas major
 Weakness in the ability to flex the thigh at the hip
 Obturator artery supplies a small branch to the
 Weakness in the ability to extend the leg at the
head
knee
 Medial femoral circumflex is the major supply
 Diminished Patellar tendon reflex
DISLOCATION OF THE HEAD OF THE FEMUR
SAPHENOUS NERVE LESIONS
 Most commonly occur in posterior direction
 May be lesioned during a surgical procedure of the  Thigh is shortened and MEDIALLY ROTATED by
leg to remove part of the great saphenous vein or the gluteus medius and minimus muscles
may be lacerated as it pierces the wall of the  Sciatic nerve may be compressed, resulting in
adductor canal weakness of muscles in the posterior thigh, leg
 Pain and Paresthesia in the skin of the medial and foot
aspect of the leg and foot
 NO MOTOR LOSS

 Paresthesia over the posterior and lateral parts of POSTERIOR-LEG MUSCLES
the leg and dorsal and plantar surfaces of the foot
FASCIAL COMPARTMENTS OF THE LEG
 Superficial group: Gastrocnemius, Plantaris,

Soleus
 Deep group: Popliteus, Flexor digitorum longus
Flexor hallucis longus, Tibialis posterior
ANTERIOR-LEG MUSCLES  Nerve Supply: Tibial nerve
 Actions: Plantarflexion / Flexion
 Tibialis anterior
 NOTE: Popliteus – Unlocks the knee; NO ACTION
 Ext. digitorum
on ankle joint
longus
 Gastrocnemius and Soleus
 Peroneus tertius
collectively called as TRICEPS
 Ext. Hallucis
SURAE
longus
 Common insertion: ACHILLES
 Ext. Digitorum
TENDON
brevis
SYMPTOMS of ACHILLES TENDON
RUPTURE:
 Nerve Supply:
Deep Peroneal
nerve
 Actions: Dorsiflexion / Extension
LATERAL-LEG MUSCLES
 Peroneus longus
 Peroneus brevis
 Nerve Supply:
Superficial Peroneal
nerve
 Actions: Evertion and
weak Plantarflexion
 Sudden acute pain at the back of the calf or ankle
 A snap may be heard
 Difficulty in walking and standing on TIPTOE
 A gap may be felt in the tendon
 Bruising and weakness of the ankle
 Severe swelling is present

PERONEUS VS TIBIALIS MUSCLE BLOOD VESSELS: COMMON ILIAC
 Internal iliac
 External iliac
 FEMORAL
 Popliteal
 Ant / Post Tibial
 Plantar arch
EXTERNAL ILIAC: BRANCHES
 INFERIOR EPIGASTRIC
 DEEP CIRCUMPLEX ILIAC
 “PERONEUS “muscles  FEMORAL
o Evert foot
o Plantar flex
 “TIBIALIS” muscles
o Invert foot
o Plantar flex
 PE–TI
POPLITEAL FOSSA & CONTENTS
MAIN BRANCHES OF EXTERNAL ILIAC ARTERY
Boundaries:
 Laterally: Biceps femoris above and lateral head of
Gastrocnemius below
 Medially: Semimembranosus and Semitendinosus
above and medial head of Gastrocnemius below
Contents:
DORSALIS PEDIS ARTERY

 “dorsalis pedis pulse”
 Laterally: tendons of
extensor digitorum
 Popliteal vessels longus
 Small saphenous vein  Medially: tendon of
 Common Peroneal N extensor hallucis longus
 Tibial N  Landmark – between
 Post. Cutaneous N medial and lateral
 Genicular branch of Obturator N malleoli or 1st
 LN’s intermetatarsal space

ARTERIAL PALPATION-LOWER LIMB GREAT SAPHENOUS VEIN CUTDOWN
 Femoral artery – behind inguinal ligament  Usually performed at the ANKLE
midway between the ASIS and symphysis pubis  The Saphenous nerve is blocked with local
 Popliteal artery – popliteal space fully relaxed by anesthetic (sensory nerve supply to the skin
passively flexing the knee joint immediately in front of the medial malleolus of the
 Posterior tibial – behind medial malleolus and tibia)
beneath flexor retinaculum; lies between tendons  A transverse incision is made through the skin and
of FDL and FHL / midway between medial subcutaneous tissue across the long axis of the
malleolus and heel vein just ANTERIOR and SUPERIOR to the
medial malleolus
VENA COMMITANTES  The vein is easily identified and the Saphenous
nerve lies just ANTERIOR to the vein
 SAPHENOUS NERVE - runs down the medial side

of the leg together with the Great Saphenous vein;
passes IN FRONT of the medial malleolus and
along the medial border of foot; SUPPLIES THE
SKIN ON THE ANTEROMEDIAL SURFACE OF THE
LEG
 SURAL NERVE – branch of the Tibial nerve;
accompanies the Small Saphenous vein BEHIND
the Lateral malleolus; SUPPLIES THE SKIN ON
THE LOWER PART OF THE POSTEROLATERAL
SURFACE OF THE LEG
SCIATIC NERVE
1. Tibial
2. Common Peroneal
o Ant / Post Tibial a. Superficial Peroneal
o Popliteal b. Deep Peroneal
o Femoral
o External iliac
o Internal iliac
o Common iliac
SAPHENOUS
REMEMBER!
 Great Saphenous drains into Femoral

 Small Saphenous drains into Popliteal

LESIONS SUPERFICIAL PERONEAL/ FIBULAR NERVE LESIONS
COMMON PERONEAL/FIBULAR NERVE LESIONS  May be injured as the nerve emerges from the
 Most frequently injured nerve in the lower limb lateral compartment of the leg
 Compression at neck of fibula, Hip fracture,  Pain and Paresthesia in the dorsal aspect of the
dislocation of femur foot
 Weakness in EVERSION of foot
TIBIAL NERVE LESIONS

 In patients with Tibial nerve lesions in the gluteal
region (hip fracture, dislocation of femur),
weakness may be evident in the ability to flex the
leg at the knee and plantar flex at the ankle
 FOOTDROP– which results from a loss of  CAN’T STAND ON TIPTOES
dorsiflexion at the ankle and loss of eversion  Paresthesia on skin of posterior leg, sole and
lateral foot
 “STEPPAGE” gait –
raise the affected leg
KNEE JOINT
high off the ground
 Synovial joint
and the foot slaps the
 Stabilized laterally by Biceps and Gastrocnemius
ground when walking
tendons, Iliotibial tract and Fibular collateral
 Pain and Paresthesia
ligaments
in the lateral leg and
 Stabilized medially by Sartorius, Gracilis,
dorsum of the foot
Gastrocnemius, Semitendinosus and
Semimembranosus muscles and Tibial Collateral
ligament
DEEP PERONEAL/FIBULAR NERVE LESIONS

 May be compressed in the anterior compartment
of the leg
 May have Footdrop and paresthesia in skin of the
webbed space between the great toe and the
second toe
 Extra capsular Ligaments

o Ligamentum patellae
o Lateral collateral ligament
o Medial collateral ligament
o Oblique popliteal ligament
 Intracapsular ligaments
o Cruciate ligaments
o Anterior cruciate ligament
o Posterior cruciate ligament

 STRENGTH OF THE KNEE JOINT UNHAPPY TRIAD OF DONOGHUE
o Depends on:
1. TONE of the muscles acting on the
knee joint; most important –
Quadriceps femoris
2. Strength of the ligaments
INTRACAPSULAR LIGAMENTS
ANTERIOR CRUCIATE POSTERIOR CRUCIATE
 Prevents forward sliding  Prevents backward
of the tibia on the femur sliding of the tibia on the
 Posterior displacement of femur
the femur on tibia  Anterior displacement of
 LAX during FLEXION the femur on tibia
 LAX during EXTENSION
 ACL
 MCL
 Medial meniscus
ANTERIOR DRAWER SIGN
EXTRACAPSULAR LIGAMENTS
MEDIAL COLLATERAL LATERAL COLLATERAL
 Forced ABDUCTION of  Forced ADDUCTION of
the TIBIA on FEMUR the TIBIA on FEMUR
 Less common
KNEE INJURIES
 3 most commonly injured structures are the Tibial  forward sliding of the Tibia on the Femur due to
collateral ligament, Medial meniscus and ACL (the rupture of the ANTERIOR CRUCIATELIGAMENT
terrible triad)
 Blow to the lateral aspect of the knee – may injure POSTERIOR DRAWER SIGN
the tibial collateral ligament; the attached medial
meniscus may also be torn
 Blow to the anterior aspect of the flexed knee may
tear only the ACL
 backward sliding of the Tibia on the Femur

caused by rupture of the POSTERIOR CRUCIATE
LIGAMENT

ANKLE JOINT TAKE NOTE!
 Diarthrodial synovial hinge joint 1. DORSIFLEXION and PLANTARFLEXION – occur
 BONES: at the ANKLE JOINT PROPER or TALOCRURAL
1. TIBIA JOINT – formed by distal ends of malleoli of fibula
2. FIBULA and tibia and trochlea of Talus bone
3. TALUS 2. INVERSION and EVERSION at the SUBTALAR
JOINT between the Talus and Calcaneus
LYMPHATIC DRAINAGE OF LOWER LIMB
 Superficial
lymph
vessels
ascend with
superficial
veins
ANKLE JOINT LIGAMENTS  Deep lymph
MEDIAL/DELTOID LATERAL vessels
- weaker follow deep
 Tibionavicular  Anterior Talofibular arteries and
 Tibiocalcaneal  Calcaneofibular veins
 Anterior Tibiotalar  Posterior Talofibular
 Posterior Tibiotalar  All ultimately
drain into Deep inguinal group of nodes situated
in the groin
Acute sprains-MEDIAL Acute sprains-lateral
ankle ankle
 Excessive EVERSION  Excessive INVERSION of
 * Medial or Deltoid the foot with
ligament PLANTARFLEXION of the
ankle
 Ant Talofibular and
Calcaneofibular
ligaments are partially
torn

MUST KNOW!
BACK  Primary Curvature
VERTEBRAL COLUMN o Concave ventrally
• Vertebrae separated by intervertebral o Thoracic and Sacral
• The spine has a normal curvature  Secondary Curvature
• Each vertebrae is given a name according to its  Convex ventrally
location  Cervical and Lumbar
STRUCTURE OF A TYPICAL VERTEBRAE
REGIONAL CHARACTERISTICS OF VERTEBRAE
CERVICAL VERTEBRA
 Typical Cervical – C3 to C6
o Short, bifid spinous process
ABNORMAL CURVATURES
 KYPHOSIS – exaggeration in the sagittal curvature
in THORACIC
 LORDOSIS – LUMBAR; increase in weight of the o Transverse processes possess a
abdominal contents ex. Gravid uterus. Large FORAMEN TRANSVERSARIUM
ovarian tumor o Spines are small and bifid
 SCOLIOSIS- lateral deviation; common in Thoracic o Body is small and broad

o Vertebral foramen is large and THORACIC VERTEBRAE
TRIANGULAR
o Superior articular processes have facets
that face posteriorly and superiorly;
Inferior = inferiorly and anteriorly
 Atypical Cervical – C1, C2 and C7

o Vertebra Prominence = C7 – long
spinous process and not bifid
 HEART shaped body

 facets on their Bodies for articulation with
 Head of ribs
 facets on their Transverse processes for
articulation with the Tubercles
o C1- ATLAS, NO BODY  Long spinous processes
TYPICAL THORACIC VERTEBRA
 Body is medium size and HEART shaped
 Vertebral foramen is small and circular
 Spines are long
 Costal facets – Bodies = articulation with Heads
of ribs
 Costal facets – Transverse processes =
articulation with Tubercles of ribs
TYPICAL LUMBAR VERTEBRA

 Body is large and Kidney shape
 Pedicles are strong and directed backward
 Laminae are short in vertical dimension
o C2-AXIS, presence of ODONTOID  Vertebral foramina are Triangular
PROCESS/DENS  Transverse processes are long and slender
 Spinous processes are short, flat and
quadrangular; project posteriorly
 Transverse foramen – for Vertebral artery

BACK-POINT OF BOUNDARIES
 External occipital protuberance

 Superior nuchal line
 Spine of the scapula
 Acromion process
 Vertebral spines
 Iliac crest
 Sacrum

MUSCLES OF THE BACK
1. Superficial – connected with shoulder girdle
2. Intermediate – involved with movements of the
thoracic cage
3. Deep
o Superficial – ERECTOR SPINAE
o Intermediate - TRANSVERSOSPINALIS
o Deep – INTERSPINALIS
INTERTRANSVERSARII
THANK YOU and GOOD LUCK.

MUSCULAR TRIANGLES OF THE BACK
“ in due time we shall reap…. if we don’t lose heart”
1. Auscultatory
-Dr. Vibar
2. Lumbar/ Triangle of Petit

Lecture: Basic Course Audit - Anatomy of the Lower Extremities [Dr. A.B. Vibar]
Disclaimer: This trans is just a supplement to your studies/ readings. This is not
intended to replace nor substitute any written information in our prescribed text arrangement divides the thigh into three compartments, each having its
books. Please use at your own risk. Goodluck! Godbless! own complement of muscles, nerves, and arteries
Sources: Snell 10th edition + PPT 2020 & 2021 + Transes from Previous Batches
FUNCTIONS of the Lower Extremities
★ Support the weight of the body
★ Stable foundation for standing, walking and running
REGIONS of the Lower Extremities
Thigh Knee
Glutes Ankle
Leg Foot
~this can serve as your checklist na rin as you go along studying. :D
FASCIAL COMPARTMENTS - Thigh

Part 1 simula tayo sa may hita or thighs~
Review of Anatomy:
Thighs: the proximal segment of the lower limb proper, from the hip to
the knee. The femur is the bony core of the thigh.
Fascia:[Plural: Fasciae]
1. Fatty layer of the superficial fascia
➔ On the anterior abdominal wall extends into the
thigh and continues down over the lower limb
without interruption
2. Membranous layer of the superficial fascia
➔ extends into the thigh and attaches to the deep
fascia (fascia lata) about a fingerbreadth below the
inguinal ligament *This general pattern of organization of the limb into defined compartments is the
same in both the upper and lower limbs
3. Deep fascia [fascia lata]
➔ encloses the thigh like a spandex legging Question:
➔ Its upper end attaches to the pelvis and the Which of the following muscles is a Flexor of the Thigh?
inguinal ligament. Answer: Iliopsoas
➔ It is thickened on its lateral aspect to form the
A. Anterior Fascial Compartment
iliotibial tract, which is attached above to the
iliac tubercle and below to the lateral condyle of Contents:
the tibia ● Muscles: Sartorius, iliopsoas, pectineus, and quadriceps femoris
◆ receives the insertion of the tensor ● Blood supply: Femoral artery
fasciae latae and the greater part of the ● Nerve supply: Femoral nerve
gluteus maximus muscle Anterior Thigh Muscles
➔ In the gluteal region, the deep fascia forms ● Flexors of the THIGH
investing sheaths that enclose the tensor fasciae ● Extensors of the LEG
latae and the gluteus maximus muscles. ● Innervated by the FEMORAL NERVE
● Consists of:
○ ILIOPSOAS → STRONGEST FLEXOR
Note: Recall that the iliacus and psoas major are separated muscles in the
abdomen, but merge together in the thigh to form a single iliopsoas muscle.
○ Tensor fascia lata
○ Sartorius
○ Pectineus
○ Quadriceps femoris [EXTENSORS of the Thigh] [Rf-V3]
■ Rectus femoris
■ Vastus lateralis
■ Vastus medialis
■ Vastus intermedius
Flexes & LATERALLY Rotates Innervated by
Sartorius the thigh FEMORAL NERVE
[L2 and L3]
Tensor Flexes, ABducts and Innervated by SUP.

fascia lata MEDIALLY Rotates the thigh GLUTEAL NERVE
[TFL] [L4 and L5]
Remember: Three fascial septa pass from the inner aspect of the deep
Remember!
fascial sheath of the thigh to the linea aspera of the femur. This
★ ASIS → origin of Sartorius and TFL
1 of 16 x
★ AIIS → origin of Rectus femoris ➔ The rectus femoris muscle is the only component of the
★ Lesser trochanter of the femur → common insertion of Iliacus quadriceps that crosses the hip joint, and it flexes the hip in
and Psoas addition to extending the knee.
★ Quadriceps / Patellar tendon → common insertion of ➔ Innervated by the FEMORAL NERVE L2,L3,L4
Quadriceps femoris
B. Medial Fascial Compartment
★ ANTERIOR COMPARTMENT: FLEXES the THIGH at the HIP JOINT
and EXTENDS the LEG at the KNEE JOINT Contents
★ ONLY the RECTUS FEMORIS can FLEX the THIGH and EXTEND the ● Muscles: Gracilis, adductor longus, adductor brevis, adductor
LEG [i.e. it steadies the hip joint and helps iliopsoas to flex thigh] magnus, and obturator externus
○ Vs. The THREE Vastus muscles EXTENDS LEG at the ● Blood supply: Profunda femoris artery and obturator artery
KNEE JOINT ● Nerve supply: Obturator nerve
Medial Thigh Muscles
● ADducts the thigh
● Innervated by the OBTURATOR NERVE
● Consists of:
○ Adductor longus
○ Adductor brevis
○ Adductor magnus
○ Gracilis → ADDUCTS the THIGH and “FLEXES LEG”
Remember!
★ Linea aspera of the femur → common insertion of adductor
muscles
★ Adductor tubercle of femur → insertion of hamstring part of
adductor magnus
Quadriceps Femoris
➔ This is the most important extensor muscle for the knee joint. C. Posterior Fascial Compartment
➔ Its tone greatly strengthens the joint; therefore, this muscle mass
Contents:
must be carefully examined when disease of the knee joint is
● Muscles: Biceps femoris, semitendinosus, semimembranosus,
suspected.
and a small part of the adductor magnus (hamstring portion)
◆ The vastus medialis muscle extends farther distally
● Blood supply: Branches of the profunda femoris artery
than the vastus lateralis.
● Nerve supply: Sciatic nerve
◆ The vastus medialis is the first part of the quadriceps
Posterior Thigh Muscles
muscle to atrophy in knee joint disease and the last to
● Extensors of the THIGH
recover
● Flexors of the LEG
● Innervated by the SCIATIC NERVE
2 of 16 x
● Consists of the Hamstring muscles: Note: NAVeL is used to remember the order of the structures, and the
○ Semitendinosus mnemonic NAVY is used to remember!
○ Semimembranosus FEMORAL SHEATH
○ Biceps femoris ➔ A funnel shaped fascial tube formed by the INFERIOR
■ Long head: TIBIAL Part PROLONGATION of the ILIOPSOAS and TRANSVERSALIS FASCIA of
■ Short head: COMMON PERONEAL the Abdomen.
○ Adductor magnus ➔ The femoral nerve lies outside the femoral sheath, lateral to the
★ Ischial tuberosity → common origin of Hamstring muscles femoral artery
★ Short head of the Biceps femoris → linea aspera and lateral ➔ Reaches the level of the proximal end of the saphenous opening
supracondylar ridge of the femur with its distal end.
Compartments:
★ Lateral → femoral artery
★ Intermediate → femoral vein
★ Medial → femoral canal
FEMORAL CANAL
➔ Lies medial to the femoral vein in the femoral sheath.
➔ Contains fat, areolar connective tissue, and lymph nodes and
vessels
➔ Transmits lymphatics from the lower limb and perineum to the
peritoneal cavity
➔ Is a potential weak area and a site of femoral herniation, which
occurs most frequently in women because of the greater width of
the superior pubic ramus of the female pelvis.
Facts to Remember! FEMORAL RING
★ The biceps femoris muscle has two heads: a long head ➔ abdominal opening of the femoral canal
(hamstring portion) and a short head (gluteal portion). Boundaries:
○ It also receives a dual nerve supply from the sciatic ● Anteriorly → Inguinal Ligament
nerve: ● Laterally → Femoral vein
■ The tibial nerve component innervates the ● Medially → Lacunar ligament
long head, and ● Posteriorly → Pectineal ligament
■ The common fibular (peroneal) component
supplies the short head.
★ The adductor magnus muscle also has two parts (an upper
adductor part and a lower hamstring part)
○ It has a dual innervation.
■ The tibial nerve component of the sciatic
nerve supplies the hamstring portion, and
■ The obturator nerve supplies the adductor
part
★ The semimembranosus insertion sends a fibrous expansion
upward and laterally, which reinforces the capsule on the back of
the knee joint. This expansion is called the oblique popliteal
ligament
FEMORAL TRIANGLE, SHEATH AND ADDUCTOR CANAL
Question:
A 6 month old boy needed a femoral tap for ABG determination. In what
compartment of the Femoral sheath will you aspirate?
Answer: Lateral
Tip! STUDY THE TERMS! :D
FEMORAL TRIANGLE ADDUCTOR CANAL
Boundaries: ➔ Subsartorial canal or HUNTER’S CANAL [check image below]
● Superior → Inguinal Ligament ➔ A fascial tunnel in the thigh running from the apex of the femoral
● Medially → Adductor longus triangle to the ADDUCTOR HIATUS in the tendon of the
● Laterally → Sartorius ADDUCTOR MAGNUS muscle.
● Floor → Adductor longus, Pectineus & Iliopsoas Boundaries:
● Roof → Skin and Fasciae of the Thighs ● Anterior → Sartorius
Contents: ● Lateral → Vastus MEDIALIS
★ Femoral NERVES [and its branches] ● Posterior → Adductor longus/magnus
★ Femoral SHEATH [and its contents] ● Medial → Adductor longus / magnus
★ Femoral ARTERIES [and it branches] Contents:
★ Femoral VEINS [and its tributaries] ● Femoral Artery / Vein
★ Femoral LYMPHATICS [i.e deep inguinal LNs] ● Saphenous nerve
● Nerve to the Vastus medialis
3 of 16 x
pubic tubercle and deep and inferior to the inguinal ligament;
its sac is formed by the parietal peritoneum
● Strangulation of a femoral hernia may occur because of the
sharp, stiff boundaries of the femoral ring, and the
strangulation interferes with the blood supply to the herniated
intestine, resulting in death of the tissues
● Mass [often tender/painful] in the femoral triangle
● Femoral ring is a weak area in the Ant. Abd. Wall [normally
admits the tip of the 5th digit]
ADDUCTOR HIATUS
➔ the aperture in the tendon of insertion of the adductor magnus
➔ Allows the passage of the femoral vessels into the popliteal fossa
Popliteal Fossa: [to be discussed further on the latter parts]

● Is bounded superomedially by the semitendinosus and
semimembranosus muscles, superolaterally by the biceps muscle,
inferolaterally by the lateral head of the gastrocnemius and plantaris
muscles, and inferomedially by the medial head of the gastrocnemius
muscle.
● Has a floor that is composed of the femur, the oblique popliteal
ligament, and the popliteus muscle.
● Contains the popliteal vessels, the common peroneal and tibial nerves,
and the small saphenous vein. Lower extremities continued...
GLUTEAL REGION
➔ Aka buttock, is bounded superiorly by the iliac crest and inferiorly

by the fold of the buttock.
➔ The region is largely made up of the gluteal muscles and a thick
layer of superficial fascia.
Muscles of the Gluteal Region
Superficial Group Intermediate Group Deep Group

PIRIFORMIS
GLUTEUS MAXIMUS GLUTEUS MEDIUS & OBT.INTERNUS
GLUTEUS MINIMUS SUP. GEMELLI
INF. GEMELLI
QUADRATUS FEMORIS
Extensor Abductor and MEDIAL LATERAL

of the Thigh ROTATOR ROTATOR of the
of the Thigh Thigh
SAPHENOUS OPENING
➔ Saphenous hiatus or FOSSA OVALIS
➔ Is an oval gap in the fascia lata below the inguinal ligament that is
covered by the cribriform fascia, which is a part of the superficial
fascia of the thigh
➔ Provides a pathway for the greater saphenous vein
CLINICAL CORRELATION
Femoral Vein Catheterization
● Skin of the thigh below the inguinal ligament is supplied by
the genitofemoral nerve → which is then blocked by a local
anesthetic
● Femoral pulse is palpated midway between the ASIS and
Symphysis pubis; Femoral vein lies immediately MEDIAL to it.
Femoral Hernia
● more common in women than in men, passes through the
femoral ring and canal, and lies lateral and inferior to the
4 of 16 x
★ Common origin of Gluteal muscles? Ans: OUTER SURFACE OF
ILIUM
★ Common Insertion? Ans: GREATER TROCHANTER OF FEMUR
○ Except: Glut.Max → Gluteal tuberosity, Iliotibial tract
Quad.Femoris → Quadrate tubercle
Facts to Remember!
★ The gluteus maximus is the largest muscle in the body.
○ It lies superficial in the gluteal region and is largely
responsible for the prominence of the buttock
★ The tensor fasciae latae runs downward and backward to its
insertion in the iliotibial tract.
○ Hence, assists the gluteus maximus muscle in
maintaining the knee in the extended position.
★ The piriformis lies partly within the pelvis at its origin. IMPORTANT NERVES OF THE LOWER LIMB
○ It emerges through the greater sciatic foramen to enter
OBTURATOR NERVE[L2-L4]
the gluteal region.
➔ Arises from the lumbar plexus and enters the thigh through the
○ Its position serves to separate the superior gluteal
obturator foramen
vessels and nerves from the inferior gluteal vessels
➔ Divides into anterior and posterior branches
and nerves.
◆ Anterior Branch:
★ The obturator internus is a fan-shaped muscle that lies within the
● Descends between the adductor longus
pelvis at its origin.
and adductor brevis muscles
○ Its tendon emerges through the lesser sciatic foramen
● Innervates the adductor longus, adductor
to enter the gluteal region.
brevis, gracilis, and pectineus muscles
○ The tendon is joined by the superior and inferior
● Posterior Branch
gemelli and is inserted into the greater trochanter of
○ Descends between the adductor
the femur
brevis and adductor magnus
★ Three bursae are usually associated with the gluteus maximus:
muscle
○ between the tendon of insertion and the greater
★ Damage to the obturator nerve causes a weakness of adduction
trochanter
and a lateral swinging of the limb during walking because of the
○ between the tendon of insertion and the vastus
unopposed abductors
lateralis, and
SCIATIC NERVE [L4-S3]
○ overlying the ischial tuberosity
➔ Arises from the sacral plexus and is the largest nerve in the body
Review! MUSCLES THAT ACT AT THE HIP JOINTS [Memorize!] ➔ Supplies NO STRUCTURES in the Gluteal region, skin of the foot
and leg, posterior thigh muscles
Anterior Compartment FLEXION Femoral Nerve ➔ Enters the buttock through the greater sciatic foramen below the
piriformis
Medial Compartment ADDUCTION Obturator Nerve ➔ Innervates the hamstring muscles by its tibial division, except for
the short head of the biceps femoris, which is innervated by its
Posterior Compartment EXTENSION Sciatic Nerve common peroneal division
➔ Provides articular branches to the hip and knee joints
Gluteus Maximus EXTENSION & Inferior Gluteal ★ Damage to the sciatic nerve causes impaired extension at the hip
weak LAT. ROT. Nerve and impaired flexion at the knee, loss of dorsiflexion and plantar
flexion at the ankle, inversion and eversion of the foot, and
Gluteus Medius and ABDuction & Superior Gluteal peculiar gait because of increased flexion at the hip to lift the
Minimus MED. ROT. Nerve dropped foot off the ground.
Additional Notes: HIP JOINT [COXAL JOINT]
Lumbar Plexus
● It is a network of nerve fibres that supplies the skin and ➔ Is a multiaxial ball-and-socket synovial joint between the
musculature of the lower limb. acetabulum of the hip bone and the head of the femur and allows
● It is located in the lumbar region, within the substance of the abduction and adduction, flexion and extension, and
psoas major muscle and anterior to the transverse processes circumduction and rotation
of the lumbar vertebrae. ➔ Is stabilized by the acetabular labrum; the fibrous capsule; and
● The plexus is formed by the anterior rami (divisions) of the capsular ligaments such as the iliofemoral, ischiofemoral, and
lumbar spinal nerves L1, L2, L3 and L4. pubofemoral ligaments
***It also receives contributions from thoracic spinal nerve 12 ➔ Has a cavity that is deepened by the fibrocartilaginous acetabular
labrum and is completed below by the transverse acetabular
5 of 16 x
ligament, which bridges and converts the acetabular notch into a
left side (sound side) of the pelvis falls (sags)
foramen for passage of nutrient vessels and nerves
instead of rising; normally, the pelvis rises
Question:
Which ligament of the hip is Y-shaped and check hyperextension of the joint
during standing?
Answer: Iliofemoral ligament
Ligaments of the Hip Joint:
Iliofemoral Ligament
● Is the largest and most important ligament that reinforces the
fibrous capsule anteriorly and is in the form of an inverted Y
● Resists hyperextension and lateral rotation at the hip joint
during standing. [excerpt from Snell 10th edition pg. 1394, Chapter 11]
Ischiofemoral Ligament Concept of HIP JOINT STABILITY:
● Reinforces the fibrous capsule posteriorly, extends from the ● Stability when a person stands on one leg with the foot of the
ischial portion of the acetabular rim to the neck of the femur opposite leg raised above the ground.
medial to the base of the greater trochanter, ● Depends on THREE IMPORTANT FACTORS:
● Limits extension and medial rotation of the thigh. ○ Gluteus medius and minimus MUST BE
Pubofemoral Ligament FUNCTIONING NORMALLY
● Reinforces the fibrous capsule inferiorly, extends from the pubic ○ Head of the femur must be located normally within
portion of the acetabular rim and the superior pubic ramus to the the acetabulum
lower part of the femoral neck ○ Neck of the femur must be intact and must have a
● Limits extension and abduction normal angle with shaft of the femur
Ligamentum Teres Capitis Femoris (Round Ligament of Head of Femur) INFERIOR GLUTEAL NERVE LESIONS
● Arises from the floor of the acetabular fossa ➔ Weakness in the ability to LATERALLY ROTATE and EXTEND the
● Attaches to the fovea capitis femoris thigh at the hip joint
● Provides a pathway for the artery of the ligamentum capitis ➔ Difficulty extending the thigh at the hip from a flexed position,
femoris (foveolar artery) from the obturator artery, which is of as in climbing stairs or rising from a chair
variable size but represents a significant portion of the blood ➔ Have a Gluteus maximus gait, in which patients thrust their
supply to the femoral head during childhood. torso posteriorly in an attempt to counteract the weakness of
Transverse Acetabular Ligament the gluteus maximus.
● Is a fibrous band that bridges the acetabular notch and converts
it into a foramen, through which the nutrient vessels enter the
joint
Question:
A patient walks with a waddling gait that is characterized by “pelvis falling
toward one side at each step”. What nerve is involved?
Answer: Superior Gluteal Nerve
SUPERIOR GLUTEAL NERVE LESIONS SCIATIC NERVE LESIONS
➔ Results to weakened ABduction of the thigh by Gluteus ➔ Susceptible to damage from an IM injection in the LOWER
medius MEDIAL QUADRANT of the Gluteus maximus muscle
➔ Waddling gait; pelvis sags on the side of the “unsupported ➔ It may be compressed as a result of POSTERIOR DISLOCATION
limb” [i.e. Gluteus medius gait] of the Femur.
★ (+) Trendelenburg sign ➔ L5 and S1 ROOTS are commonly compressed → pain that
◆ Positive Trendelenburg sign is seen in a fracture of radiates into the L5 and S1 dermatomes of the leg and foot
the femoral neck, dislocated hip joint (head of ★ Intragluteal Injections: common site for intramuscular
femur), or weakness and paralysis of the gluteus injections; should be made on the SUPEROLATERAL part of
medius ( abductor). the buttock to avoid hitting nerves and vessels
◆ If the right gluteus medius muscle is paralyzed, the
6 of 16 x
➔ It can be treated with progressive piriformis stretching.
➔ If this fails, then a corticosteroid may be administered into the
piriformis muscle.
➔ Finally, surgery may be opted as a last resort
Lower extremities continued...
ANATOMY OF THE FEMUR + CLINICAL CORRELATIONS
● Is the longest and strongest bone of the body

Parts of the Femur:
1. Head
Question: ➔ Forms about two-thirds of a sphere and is directed medially,
A basketball player fell on his left knee resulting into swelling and pain. A upward, and slightly forward to fit into the acetabulum.
fracture of the patella will result in: ➔ Has a depression in its articular surface, the fovea capitis femoris,
Answer: Difficulty in extending leg at the knee to which the ligamentum capitis femoris is attached
FEMORAL NERVE LESIONS 2. Neck
➔ May be damaged in the abdomen by an abscess of the Psoas ➔ Connects the head to the body (shaft), forms an angle of about
major. 125 degrees with the shaft, and is a common site of fractures.
➔ May result from the paralysis of the quadriceps femoris ➔ Is separated from the shaft in front by the intertrochanteric line,
➔ Weakness in the ability to flex the thigh at the hip to which the iliofemoral ligament is attached.
➔ Weakness in the ability to extend the leg at the knee ★ Neck Shaft angle changes:
★ Diminished Patellar tendon reflex ○ 160 degrees → young
SAPHENOUS NERVE LESIONS ○ 125 degrees → adults
Review of Anatomy:
Saphenous vein: Arises from the femoral nerve in the femoral triangle
and descends with the femoral vessels through the femoral triangle and
the adductor canal. It pierces the fascial covering of the adductor canal at
its distal end in company with the saphenous branch of the descending
genicular artery. This cutaneous nerve Innervates the skin on the medial
side of the leg and foot.
➔ May be lesioned during a surgical procedure of the leg to
remove part of the great saphenous vein or may be lacerated
as it pierces the wall of the adductor canal
◆ This is vulnerable to injury (proximal portion)
during surgery to repair varicose veins
Coxa valga is an alteration of the angle made by the axis of the
➔ Pain and Paresthesia in the skin of the MEDIAL ASPECT of the
femoral neck to the axis of the femoral shaft so that the angle exceeds
LEG AND FOOT
135 degrees and, thus, the femoral neck becomes straighter
➔ No Motor loss
★ Increased angle
OBTURATOR NERVE LESIONS
★ Congenital dislocation
➔ Most commonly lesioned in the Pelvis
★ ADDUCTION is limited
➔ Patients are unable to ADduct the thigh at the hip
➔ Paresthesia in the skin of the MEDIAL THIGH
Coxa vara is an alteration of the angle made by the axis of the femoral
Additional Notes [wala sa ppt kayo na bahala if gusto niyo basahin~]
neck to the axis of the femoral shaft so that the angle is less than 135
Piriformis Syndrome
degrees and, thus, the femoral neck becomes more horizontal.
★ Decreased angle
★ Fracture of the neck
★ ABDUCTION is limited
PPT ni doc: Normal angle [126-139°); Coxa Valga(>140°); Coxa Vara (<125°)
3. Greater Trochanter
➔ Projects upward from the junction of the neck with the shaft.
➔ Provides an insertion for the gluteus medius and minimus,
piriformis, and obturator internus muscles.
➔ Receives the obturator externus tendon on the medial aspect of
➔ It is a condition in which the piriformis muscle irritates and
the trochanteric fossa.
places pressure on the sciatic nerve, causing pain in the
4. Lesser Trochanter
buttocks and referring to pain along the course of the sciatic
➔ Lies in the angle between the neck and the shaft.
nerve.
➔ Projects at the inferior end of the intertrochanteric crest.
◆ This referred pain, called “sciatica,” in the lower
➔ Provides an insertion for the iliopsoas tendon.
back and hip radiates down the back of the thigh
5. Linea Aspera
and into the lower back (The pain initially was
➔ Is the rough line or ridge on the body (shaft) of the femur.
attributed to sciatic nerve dysfunction but now is
➔ Exhibits lateral and medial lips that provide attachments for
known to be due to herniation of a lower lumbar
many muscles and the three intermuscular septa.
intervertebral disk compromising nerve roots.)
6. Pectineal Line
7 of 16 x
➔ Runs from the lesser trochanter to the medial lip of the linea ◆ easily exposed and cannulated at the base of the
aspera. femoral triangle just inferior to the midpoint of the
➔ Provides an insertion for the pectineus muscle. inguinal ligament
7. Adductor Tubercle ◆ The superficial position of the femoral artery in the
➔ Is a small prominence at the uppermost part of the medial femoral triangle makes it vulnerable to injury by
femoral condyle. laceration and gunshot wounds
➔ Provides an insertion for the adductor magnus muscle. ◆ When it is necessary to ligate the femoral artery, the
cruciate anastomosis supplies blood to the thigh and
leg.
➔ Includes several branches:
1. Superficial Epigastric Artery
2. Superficial Circumflex Iliac Artery
3. Superficial External Pudendal Artery
4. Deep External Pudendal Artery
5. Profunda Femoris (Deep Femoral) Artery
6. Medial Femoral Circumflex Artery
7. Lateral Femoral Circumflex Artery
8. Descending Genicular Artery
AVASCULAR NECROSIS OF THE FEMORAL HEAD

The medial femoral circumflex artery is clinically important because its
branches run through the neck to reach the head, and it supplies most of
the blood to the neck and head of the femur except for the small
proximal part that receives blood from a branch of the obturator artery.
FEMORAL FRACTURES
Fracture of the neck of the femur
➔ Head of the femur may undergo AVASCULAR NECROSIS
➔ SHORTENED limb with LATERAL ROTATION
➔ Pull upward by the Quadriceps femoris, adductors and
Hamstring muscles
★ SUBCAPITAL → elderly; common in women after menopause
★ TROCHANTERIC → young; direct trauma
Fracture of the femoral head
➔ rare injury caused by posterior hip dislocation in advanced
age (osteoporosis) and requires hip replacement
➔ SHORTENED limb with MEDIAL ROTATION
Pertrochanteric fracture
➔ femoral fracture through the trochanters and is a form of the
extracapsular hip fracture
➔ The pull of the quadriceps femoris, adductors, and hamstring
muscles may produce shortening and lateral rotation of the
leg
➔ It is common in elderly women because of an increased
incidence of osteoporosis.
[Left: Normal Radiograph; Right: Osteonecrosis of the Femoral Head]
Fracture of the middle third of the femoral shaft
★ OBTURATOR ARTERY → supplies a small branch to the head
➔ The proximal fragment is pulled by the quadriceps and the
★ MEDIAL FEMORAL CIRCUMFLEX → major supply
hamstrings, resulting in shortening, and the distal fragment is
rotated backward by the two heads of the gastrocnemius Check discussion on Hip joint pg. 5
Question: DISLOCATIONS OF THE HIP JOINT

A 54 y/o man has just dislocated his right hip. The physician is concerned
about the integrity of the joint’s blood supply. Which artery is the main
blood supply to the hip joint?
Answer: Medial Femoral Circumflex
Blood Supply of the Femur
FEMORAL ARTERY
➔ Begins as the continuation of the external iliac artery distal to
the inguinal ligament, descends through the femoral triangle,
and enters the adductor canal. Posterior dislocation of the hip joint [Left image]
➔ Has a palpable pulsation, which may be felt just inferior to the ➔ It occurs through a posterior tearing of the joint capsule,
midpoint of the inguinal ligament accounts for approximately 90% of hip dislocations [most
★ Is vulnerable to injury because of its relatively superficial position common]
in the femoral triangle ➔ The fractured femoral head lies posterior to the acetabulum or
8 of 16 x
Question:
the ischium, as occurs in a head-on collision. Which of the following muscles DORSIFLEXES the Foot at the Ankle joint?
➔ It results in a probable rupture of both the posterior Answer: Tibialis Anterior
acetabular labrum and the ligamentum capitis femoris and Legs na tayo, wag malilito sa muscles and OINA nila~
usually in the injury of the sciatic nerve
◆ Sciatic nerve may be compressed, resulting in A. Anterior Fascial Compartment
weakness of muscles in the posterior thigh, leg and
Contents:
foot.
● Muscles: The tibialis anterior, extensor digitorum longus, fibularis
➔ Paresthesia over the POSTERIOR and LATERAL Parts of the Leg
tertius, and extensor hallucis longus
and Dorsal and Plantar Surfaces of the Foot.
● Blood supply: Anterior tibial artery
★ It results in the affected lower limb being shortened, flexed,
● Nerve supply: Deep fibular (peroneal) nerve
adducted, and medially rotated
Muscles of the Anterior Leg
○ Thigh is shortened and medially rotated by the
● Tibialis anterior
GLUTEUS MEDIUS and GLUTEUS MINIMUS
● Peroneus tertius
Anterior dislocation of the hip joint [Right image]
● Extensor digitorum longus
➔ It is characterized by the tearing of the joint capsule anteriorly
● Extensor digitorum brevis
with movement of the femoral head out from the acetabulum
● Extensor hallucis longus
➔ The femoral head is displaced anterior inferior to the
★ Innervated by DEEP PERONEAL/FIBULAR NERVE
acetabulum or the pubic bone.
★ Action: DORSIFLEXION and EXTENSION
★ The affected limb is slightly flexed, abducted, and laterally
rotated.
Medial (central or intrapelvic) dislocation of the hip joint [Not shown]
➔ occurs through a medial tearing of the joint capsule, and the
dislocated femoral head lies medial to the pubic bone.
➔ This may be accompanied by acetabular fracture and rupture
of the bladder.
Part 2 na tayo, baba na tayo sa Legs~
FASCIAL COMPARTMENTS - Leg

Additional notes ulit muna para mas magets~
Review of Anatomy: Facts to Remember!
LEGS ★ Extension (dorsiflexion) at the ankle is the movement of the foot
● the middle part of the lower limb proper, that is the part away from the ground, as in lifting the foot up toward the shin.
between the knee and the ankle. ★ Flexion (plantar flexion) is movement of the foot toward the
● Conversely, the arm is the proximal segment of the upper ground, as in standing on the toes
limb, that is the part between the shoulder and the elbow. ★ Inversion of the foot is the movement of turning the sole of the
FASCIA foot medially, toward the midline.
● The deep fascia of the leg forms the compartments of the leg ★ Eversion of the foot is turning the sole laterally, away from the
● forms a series of retinacula that aid the mechanical efficiency midline
of the muscles of the leg. ★ The fibularis tertius muscle extends/dorsiflexes the foot at the
Retinaculum ankle joint along with the other muscles in this compartment and
● a band of thickened deep fascia around tendons that holds is supplied by the deep fibular (peroneal) nerve.
them in place. It is not part of any muscle. Its function is ○ The muscle also everts the foot at the subtalar and
mostly to stabilize a tendon. transverse tarsal joints along with the fibularis longus
and brevis muscles but receives no innervation from
the superficial fibular (peroneal) nerve.
★ The extensor digitorum longus tendons on the dorsal surface of
each toe become incorporated into a fascial expansion called the
extensor expansion
○ The central part of the expansion is inserted into the
base of the middle phalanx, and the two lateral parts
converge to be inserted into the base of the distal
phalanx.
○ This is similar to the insertion of the extensor
digitorum in the hand. [Recall sa UpperExt Trans~]
B. Lateral Fascial Compartment
Contents:
● Muscles: Fibularis longus and fibularis brevis
● Blood supply: Branches from the fibular artery
● Nerve supply: Superficial fibular (peroneal) nerve
Muscles of the Lateral Leg
● Peroneus longus
● Peroneus brevis
9 of 16 x
★ Innervated by SUPERFICIAL PERONEAL NERVE ○ Because this arrangement produces a functionally
★ Action: EVERSION and Weak PLANTAR FLEXION three-headed muscle in the calf, they are sometimes
referred to as the triceps surae muscles.
Avulsion or rupture of the Achilles tendon
➔ It is a sports-related injury that disables the triceps surae
(gastrocnemius and soleus) muscles; thus, the patient is
unable to plantar flex the foot
➔ Sudden acute pain at the back of the calf or ankle
Facts to Remember! ➔ A snap may be heard
★ Both the fibularis longus and brevis muscles flex the foot at the ➔ Difficulty in walking and standing on TIPTOE
ankle joint and evert the foot at the subtalar and transverse tarsal ➔ A gap may be felt in the tendon
joints. ➔ Bruising and Weakness of the Ankle; Severe swelling is present
○ They also play an important role in holding up the ➔ The tendon should be sutured as soon as possible and the leg
lateral longitudinal arch in the foot. immobilized with the ankle joint plantar flexed and the knee
○ In addition, the fibularis longus tendon serves as a tie joint flexed.
to the transverse arch of the foot.
C. Posterior Fascial Compartment
Note: The deep transverse fascia of the leg is a septum that divides the
muscles of the posterior compartment into superficial and deep groups
Contents:
● Superficial group of muscles: Gastrocnemius, plantaris, and
soleus
● Deep group of muscles: Popliteus, flexor digitorum longus, flexor
hallucis longus, and tibialis posterior
● Blood supply: Posterior tibial artery
● Nerve supply: Tibial nerve
Muscles of the Posterior Leg: Check also discussion of Popliteal fossa on pg.4
● Action: PLANTAR FLEXION and FLEXION
● Gastrocnemius and Soleus are collectively called as: TRICEPS POPLITEUS AND POPLITEAL FOSSA
SURAE ★ Popliteus Muscles → Unlocks the Knee; NO ACTION on the Ankle
● Common Insertion: ACHILLES TENDON Joint
[Excerpt from Snell 10th Ed pg. 1331 Chapter 11]
Remember the Mnemonics: PE-TI

PERONEUS MUSCLES → EVERT FOOT [and Plantar Flex]
TIBIALIS MUSCLES → INVERT FOOT [and Plantar Flex]
★ Popliteal Fossa
● diamond-shaped intermuscular space situated at the
back of the knee
● The fossa is most prominent when the knee joint is
flexed.
● The popliteal fossa is comparable to the cubital fossa
in the upper limb, in that both connect the upper and
lower segments of the limb.
Boundaries:
Facts to Remember! ● Laterally → Biceps femoris ABOVE and Lateral Head of
★ Together, the soleus, gastrocnemius, and plantaris act as Gastrocnemius BELOW
powerful plantar flexors of the ankle joint. ● Medially → Semimembranosus and Semitendinosus ABOVE, and
○ They provide the main forward propulsive force in Medial Head of Gastrocnemius BELOW
locomotion by using the foot as a lever and raising the Contents:
heel off the ground ● Popliteal Vessels
★ The gastrocnemius and soleus insert into the calcaneum together ● Common Peroneal Nerve [most commonly injured!]
via the common tendo calcaneus (Achilles tendon). ● Post. Cutaneous Nerve
● Small Saphenous Veins
10 of 16 x
● Tibial Nerve d. POSTERIOR TIBIAL
● Genicular Br. of the Obturator e. PLANTAR ARCH
● Lymph Nodes EXTERNAL ILIAC Branches [Image: MAIN Branches of the EIA]
● Inferior Epigastric
● Deep Circumflex
● Femoral
Question:
A 50 y/o male patient was noted to have cyanosis and decreased sensation
of the left foot. You decided to assess the dorsalis pedis pulse. Where will
you palpate for the pulsation?
[1st: Boundaries and contents of the right popliteal fossa; 2nd: Deep structures in the Answer: Medially to the EHL tendon
right popliteal fossa]
BLOOD VESSELS OF THE LOWER LIMB
Arterial Palpation of the LOWER LIMB
COMMON ILIAC: DORSALIS PEDIS ARTERY / DORSALIS PEDIS PULSE
1. Internal Iliac ● Laterally: Tendons of the EDL
2. External Iliac ● Medially: Tendons of the EHL
a. FEMORAL ● Landmark: Between malleoli or 1st Intermetatarsal space
b. POPLITEAL FEMORAL ARTERY
c. ANTERIOR TIBIAL ● Behind the inguinal ligament midway between the ASIS and
11 of 16 x
Symphysis Pubis ★ This vein and its tributaries become dilated and varicose
POPLITEAL ARTERY commonly in the posteromedial parts of the lower limb.
● Popliteal space fully relaxed by passively flexing the knee joint Thrombophlebitis [Bottom Left]
POSTERIOR TIBIAL ● It is a venous inflammation with thrombus formation that
● Behind medial malleolus and beneath flexor retinaculum; lies occurs in the superficial veins in the lower limb, leading to
between tendons of FDL and FHL / midway between medial pulmonary embolism.
malleolus and heel ● However, most pulmonary emboli originate in deep veins, and
the risk of embolism can be reduced by anticoagulant
treatment.
Varicose Veins [Bottom Right]
● They develop in the superficial veins of the lower limb
because of reduced elasticity and incompetent valves in the
veins or thrombophlebitis of the deep veins
VENAE COMMITANTES
● Anterior and Posterior Tibial
● Popliteal
● Femoral
● External Iliac
CUTANEOUS INNERVATIONS
● Internal Iliac
● Common Iliac ● Lateral Cutaneous nerve → branch of the common peroneal n.
Question: ● Superficial Peroneal nerve → branch of the common peroneal n.
A dehydrated 3 y/o has only one prominent vein which is located in the ankle ● Saphenous nerve → branch of the femoral n.
in front of the medial malleolus. What vein is it?
Answer: Great Saphenous Vein
Review of Anatomy:
Superficial Veins of the Lower Limb
GREAT SAPHENOUS VEIN
➔ Begins at the medial end of the dorsal venous arch of the foot
➔ Ascends in front of the medial malleolus and along the
medial aspect of the tibia along with the saphenous nerve,
passes behind the medial condyles of the tibia and femur, and
then ascends along the medial side of the femur
➔ Passes through the saphenous opening (fossa ovalis)
SMALL/SHORT SAPHENOUS VEIN
➔ Begins at the lateral end of the dorsal venous arch
➔ Passes upward along the lateral side of the foot with the sural
nerve behind the lateral malleolus.
➔ Ascends in company with the sural nerve and passes to the
popliteal fossa, where it perforates the deep fascia and
terminates in the popliteal vein
Great Saphenous Vein Cutdown [VENOUS CUTDOWN]
➔ Usually performed at the ANKLE
➔ The Saphenous Nerve is blocked with a Local Anesthetic
(sensory nerve supply to the skin immediately in front of the
medial malleolus of the tibia)
➔ A transverse incision is made through the skin and SAPHENOUS NERVE
subcutaneous tissue across the long axis of the vein just ● Runs down the medial side of the leg together with Great
ANTERIOR AND SUPERIOR to the medial malleolus. Saphenous Vein
➔ The vein is easily identified and the Saphenous nerve lies just ● Passes in front of the medial malleolus and along the medial
ANTERIOR to the vein. border of the foot
Additional Notes: ● Supplies the skin on the ANTEROMEDIAL SURFACE OF THE LEG
★ The great saphenous vein accompanies the saphenous nerve, SURAL NERVE
which is vulnerable to injury when collected surgically. ● Branch of the Tibial Nerve
★ It is commonly used for coronary artery bypass surgery, and ● Accompanies the Small Saphenous Vein BEHIND the lateral
the vein should be reversed so its valves do not obstruct blood malleolus
flow in the graft. ● Supplies the skin on the LOWER PART of the POSTEROLATERAL
SURFACE OF THE LEG
12 of 16 x
SCIATIC NERVE [L4-S3]
SUPERFICIAL PERONEAL / FIBULAR NERVE LESIONS
● Arises from the sacral plexus and is the largest nerve in the body
● May be injured as the nerve emerges from the lateral
● Divided into branches:
compartment of the leg
○ Tibial Nerve [L4-S3]
● Pain and Paresthesia in the dorsal aspect of the foot
■ Medial Plantar N.
● Weakness in EVERSION of Foot
■ Lateral Plantar N.
● No FOOT DROP
○ Common Peroneal Nerve [L4-S2]
TIBIAL NERVE LESIONS
■ Superficial Peroneal N.
● In patients with Tibial nerve lesions in the gluteal regions
■ Deep Peroneal N.
[such as in hip fracture, dislocation of the femur], weakness
Remember! may be evident in the ability to flex the leg at the knee and
plantarflex at the ankle
ANTERIOR LATERAL POSTERIOR
● CAN'T STAND ON TIPTOES
COMPARTMENT COMPARTMENT COMPARTMENT
● Paresthesia on the skin of posterior leg, sole and lateral foot
Dorsiflexion of the EVERSION Plantarflexion of

FOOT at the ANKLE the FOOT at the
KNEE JOINT
JOINT ANKLE JOINT
● Is the largest and most complicated joint
Deep Peroneal Superficial Peroneal Tibial N. ● Although structurally it resembles a hinge joint, it is a condylar
type of synovial joint between two condyles of the femur and
ALL PERONEUS → EVERSION
tibia. In addition, it includes a saddle joint between the femur
ALL TIBIALIS → INVERSION
and the patella
Question: ★ Is stabilized laterally by the:
The nerve commonly injured in “foot drop”? ○ Biceps and gastrocnemius (lateral head) tendons
Answer: Common Peroneal Nerve [and Deep Peroneal Nerve] ○ The iliotibial tract, and
○ The fibular collateral ligaments.
CLINICAL CORRELATION[Must Know!] ★ Is stabilized medially by the:
COMMON PERONEAL / FIBULAR NERVE LESIONS ○ Sartorius
➔ Most frequently injured nerve in the lower limb ○ Gracilis
➔ Compression at neck of fibula, Hip fracture, dislocation of ○ Gastrocnemius (medial head)
femur ○ Semitendinosus
★ FOOT DROP → which results from a loss of DORSIFLEXION at ○ Semimembranosus muscles
the ankle and loss of eversion ○ The tibial collateral ligament
★ STEPPAGE GAIT → raise the affected leg high of the ground ● Permits flexion, extension, and some gliding and rotation in the
and the foot slaps the ground when walking flexed position of the knee; full extension is accompanied by
➔ Pain and Paresthesia in the lateral leg and dorsum of the foot medial rotation of the femur on the tibia, pulling all ligaments
taut
EXTRACAPSULAR LIGAMENTS INTRACAPSULAR LIGAMENTS

Ligamentum patellae Cruciate ligaments
Lateral collateral ligament / Lateral → Anterior cruciate ligaments
fibular ligament → Posterior cruciate ligaments
Medial collateral ligament / Medial
tibial ligament
DEEP PERONEAL / FIBULAR NERVE LESIONS
Oblique popliteal ligament
● May be compressed in the Anterior compartment of the leg
● May have foot drop and paresthesia in the skin of the webbed
space between the great toe and the second toe
13 of 16 x
[A. The right knee joint as seen from the lateral aspect. B. The anterior aspect, with the
joint flexed. C, D. The posterior aspect.] Fibula:
STRENGTH OF THE KNEE JOINT ➔ Has little or no function in weight-bearing but provides
● Depends on the: attachment for muscles
○ TONE of the muscles acting on the knee joint; most [Mnemonic: FIBULA “FAYAT”(payat), FIBU-LATERAL]
important → Quadriceps femoris ➔ Has a head (apex) that provides attachment for the fibular
○ STRENGTH of the Ligaments collateral ligament of the knee joint
Remember! INTRACAPSULAR LIGAMENTS ➔ Has a projection called the lateral malleolus
➔ It also has the sulcus for the peroneus longus and brevis
ANTERIOR CRUCIATE POSTERIOR CRUCIATE muscle tendons.
→ Prevents forward sliding of the → Prevents backward sliding of
tibia on the femur the tibia on the femur
→ Posterior displacement of the → Anterior displacement of the
femur on the tibia femur on tibia
→ LAX during FLEXION → LAX during EXTENSION
★ ACL = “APEX” ligament → attaches to the Anterior aspect of

Tibia and course Posteriorly and EXternally to attach to the
lateral condyle of femur
★ PCL = “PAIN” ligament → attaches to the Posterior aspect of
Tibia and course Anterior and INternally to attach to the medial
condyle of femur
Remember! EXTRACAPSULAR LIGAMENTS
MEDIAL COLLATERAL LATERAL COLLATERAL

→ Forced ABDUCTION of the TIBIA → Forced ADDUCTION of the TIBIA
on Femur on Femur
→ Less common CLINICAL CORRELATION
KNEE INJURIES
● 3 most commonly injured structures: [termed: TERRIBLE
Review of Anatomy: TRIAD]
Patella: ○ Tibial Collateral ligament
➔ Is the largest sesamoid bone and is located within the tendon ○ Medial Meniscus
of the quadriceps femoris, which articulates with the femur ○ ACL
but not with the tibia ● Blow to the lateral aspect of the knee → may injure the tibial
➔ Functions to obviate wear and attrition on the quadriceps collateral ligament; the attached medial meniscus may also be
tendon as it passes across the trochlear groove and to torn
increase the angle of pull of the quadriceps femoris, thereby ● Blow to the anterior aspect of the flexed knee may tear only
magnifying its power the ACL
Tibia: Unhappy Triad / O’Donoghue triad of the knee joint
➔ weight-bearing medial bone of the leg ➔ occurs when a football player’s cleated shoe is planted firmly
[Mnemonic: TIBIA “TABA”, “Malaki sa Medial”] in the turf and the knee is struck from the lateral side.
➔ Has the tibial tuberosity into which the patellar ligament ➔ indicated by a markedly swollen knee and results in
inserts tenderness on application of pressure along the tibial
➔ Has medial and lateral condyles that articulate with the collateral ligament.
condyles of the femur ➔ It is characterized by the: [Memorize!]
➔ Has a projection called the medial malleolus with a ◆ rupture of the tibial collateral ligament, as a result
malleolar groove [another groove (posterolateral to the of excessive abduction
malleolus groove) ◆ tearing of the anterior cruciate ligament, as a result
14 of 16 x
of forward displacement of the tibia
◆ injury to the medial meniscus, as a result of the
tibial collateral ligament attachment
➔ Nice to Note: Lateral meniscus injuries are commonly seen
among athletes
[Left-Right: Genu VALGUM; Normal Knee Position; Genu VARUM]

Mnemonic: VARUM [madaming “room”/space, Sakang in Tagalog]
VALGUM [parang naka”GLUE” yung knees, Piki in Tagalog]
ANKLE JOINT
● Is a hinge-type (ginglymus) synovial joint between the tibia and

fibula superiorly and the trochlea of the talus inferiorly,
permitting dorsiflexion and plantar flexion
● DIARTHRODIAL SYNOVIAL HINGE JOINT
● Consists of 3 bones: Tibia, Fibula and Talus
Bones of the Ankle and Foot
TARSUS: Consists of seven tarsal bones: talus, calcaneus, navicular bone,
cuboid bone, and three cuneiform bones
METATARSUS: Consists of five metatarsals and has prominent medial and
lateral sesamoid bones on the first metatarsal
ANTERIOR DRAWER SIGN POSTERIOR DRAWER SIGN PHALANGES: Consists of 14 bones (two in the first digit and three in each of
Forward sliding of the Tibia on Backward sliding of the Tibia on the others).
the femur due to rupture of the the femur caused by rupture of
ACL the PCL
Additional Notes:
KNOCK KNEE [GENU VALGUM] BOWLEG [GENU VARUM]
→ Tibia is bent/twisted → Tibia is bent MEDIALLY
LATERALLY → Collapse of the medial
→ Collapse of the lateral compartment of the knee and
compartment of the knee and rupture of the Lateral / Fibular
rupture of the Medial / Tibial collateral ligament
collateral ligament
15 of 16 x
Ligaments LYMPH NODES:
1. Superficial Inguinal Group of Lymph Nodes
MEDIAL / DELTOID LIGAMENT LATERAL LIGAMENT (weaker)
➔ Is located subcutaneously near the saphenofemoral
Tibionavicular Anterior Talofibular
junction and drains the superficial thigh region.
Tibiocalcaneal Calcaneofibular
➔ Receives lymph from the anterolateral abdominal wall
Anterior Tibiotalar Posterior Talofibular
below the umbilicus, gluteal region, lower parts of the
Posterior Tibiotalar
vagina and anus, and external genitalia except the
Question: glans, and drains into the external iliac nodes.
Which joint is mainly responsible for the INVERSION and EVERSION of the 2. Deep Inguinal Group of Lymph Nodes
foot? ➔ Lies deep to the fascia lata on the medial side of the
Answer: Subtalar Joint femoral vein
Remember the following!!! ➔ Receives lymph from deep lymph vessels (i.e efferents
★ DORSIFLEXION and PLANTAR FLEXION occur at the Ankle joint of the popliteal nodes) that accompany the femoral
Proper or TALOCRURAL JOINT vessels and from the glans penis or glans clitoris, and
○ Formed by the distal ends of malleolus of fibula and drains into the external iliac nodes through the
tibia and trochlea of Talus Bone femoral canal
★ INVERSION and EVERSION occur at the Subtalar Joint between LYMPH VESSELS:
the Talus and Calcaneus 1. Superficial Lymph Vessels
a. Medial group
b. Lateral group
2. Deep Lymph Vessels → Popliteal LNs
a. Anterior tibial
b. Posterior tibial
c. Peroneal vessels
Acute Ankle Sprains
Acute Sprains of the Acute Sprains of the

LATERAL ANKLE MEDIAL ANKLE
→ Excessive INVERSION of the → Excessive EVERSION
foot with PLANTAR FLEXION of → Medial or Deltoid Ligament
the ankle
→ Anterior Talofibular and
Calcaneofibular Ligaments are
partially torn
Question:
Condition wherein a person has high longitudinal arches of the foot:
Answer: Pes Cavus
PES PLANUS / FLAT FOOT [Left] PES CAVUS / CLAW FOOT[Right]

→ Medial longitudinal arch is → Medial longitudinal arch is
depressed or collapsed; foot is unduly HIGH
displaced laterally & everted
LYMPHATICS DRAINAGE OF THE LOWER LIMB
● Superficial Lymph vessels ascend with the Superficial Veins Me trying to stop myself from saying ‘yarn’ at the end of every sentence….
● Deep Lymph vessels follow deep arteries and veins #ExcelSURE #Excelsior
● All ultimately drain into the Deep Inguinal group of nodes
situated in the groin
16 of 16 x
Lecture: Basic Course Audit - Anatomy of the Upper Extremities [Dr. D.E. Gomez]
Disclaimer: This trans is just a supplement to your studies/ readings. This is not The neuromuscular bundle is enclosed by a connective tissue sheath called
intended to replace nor substitute any written information in our prescribed text the Axillary Sheath. These structures are covered by the Axillary Fascia
books. Please use at your own risk. Goodluck! Godbless!
Sources: Snell 10th edition + PPT 2020 + Pre-recorded Lecture Moodle (2021) Axillary Sheath:
➔ Is a tubular fascial prolongation of the prevertebral layer of
ANATOMY OF THE AXILLA
the deep cervical fascia into the axilla, enclosing the axillary
vessels and the brachial plexus
● Pyramidal in shape Axillary Fascia:

○ Is a pyramid-shaped space between the upper ➔ Is contiguous anteriorly with the pectoral and clavipectoral
thoracic wall and the arm. fascia (suspensory ligament of the axilla), laterally with the
★ Boundaries of the Axilla: brachial fascia, and posteromedially with the fascia over the
latissimus dorsi
➔ Forms the floor of the axilla and is attached to the suspensory
ligament of the axilla that forms the hollow of the armpit by
traction when the arm is abducted
➔ Lateral prolongation of the Prevertebral fascia and extends
up to the elbow
Anterior [Pectoral] Posterior [Scapular]

Pectoralis major Subscapularis
Pectoralis minor Latissimus dorsi
Subclavius Teres major
Medial [Costal] Lateral [Humeral]

2nd to 6th rib, and intercostal Humerus
muscles Long head of biceps brachii
Serratus anterior muscle Short head of biceps brachii
Coracobrachialis
Apex Base
ARTERIAL SUPPLY:
Bounded by 3 bones Skin, subcutaneous fascia and
● Continuation of Subclavian artery
1. Clavicle (anterior) axillary fascia
● From 1st rib to Teres Major
2. Scapula (posterior)
● Tendon of Pectoralis minor divides the vessel into 3 parts:
3. 1st rib (medially)
1st part: SUPERIOR THORACIC ARTERY [highest thoracic artery]
★ Contents of the Axilla
● Supplies muscles of the FIRST TWO INTERCOSTAL SPACES
○ Axillary Vein [and its tributaries[
○ Axillary Artery [and its branches]
○ Brachial Plexus [sp. The Infraclavicular part] 2nd part:
○ Intercostobrachial and Long Thoracic Nerves ● THORACOACROMIAL
○ Axillary Lymph Nodes ○ Pectoral
○ Loose Areolar CT and Fat ○ Acromial
○ Deltoid
1 of 15 x
● Cephalic vein → Axillary Vein
○ Clavicular
○ Cephalic vein: POSTERIOR to the styloid process of the
● LATERAL THORACIC
radius → ascend lateral side of Biceps brachii →
reaches Infraclavicular fossa → drains into Axillary
3rd Part: SUBSCAPULAR ARTERY vein
● Largest branch ● Basilic vein + Brachial Vein = Axillary Veins
● Supplies: ● Axillary Vein → Subclavian → Brachiocephalic
○ Subscapularis
○ Teres MAJOR
○ Latissimus dorsi
● Branches:
○ Thoracodorsal artery
■ Along the thoracodorsal nerve and Long
thoracic nerve
■ Supplies the Anterior Serratus Muscle
○ Circumflex scapular artery
○ Anterior Circumflex Humeral
○ Posterior Circumflex Humeral
Control of bleeding
● Profuse bleeding due to trauma to the axilla (stab or gunshot
wound/gsw)
● 3rd part of axillary artery may be compressed against the
humerus
○ if required, the 1st part may be compressed by
downward pressure in the angle between the
clavicle and the inferior attachment of the SCM
Percutaneous Arterial Catheterization
● Continues as: ● Employs the brachial artery (if the femoral artery is
○ Brachial Artery unavailable)
○ Radial or Ulnar Arteries ● Left brachial artery is preferred-allows access to the
○ Palmar Arch descending aorta without crossing the right brachiocephalic
trunk and left common carotid arteries
Radial Artery: Blood pressure
● Smaller of the terminal branches of the Brachial Artery ● The brachial artery is used to measure BP
● Begins in the cubital fossa at the level of the Neck of the ● Compresses the brachial artery against the humerus
Radius Access for Chronic Hemodialysis
● Passes downward and laterally beneath the Brachioradialis ● Uses the radial artery and cephalic vein to establish an
muscle and resting on the deep muscles of the forearm arteriovenous fistula
● In the distal part lies on the anterior surface of the radius
covered only by skin and fascia Case Discussion
● SITE OF TAKING THE RADIAL PULSE: tendon of the A 17 y/o football player’s left arm was outstretched and hit with substantial
Brachioradialis on its LATERAL SIDE and tendon of the FCR force. He has shoulder pain and his arm hangs down his side with external
/ Flexor Carpi Radialis on its MEDIAL SIDE. rotation. A radiograph is negative for a fracture but the head of the humerus
is superimposed on the neck of the scapula
Additional Notes:
PALPATION OF THE ARTERIES OF THE UPPER LIMB Review of Anatomy:
Subclavian artery: can be palpated in the root of the posterior triangle SHOULDER JOINT
of the next as it CROSSES the FIRST RIB ● Is a synovial ball-and-socket joint between the glenoid cavity
Axillary artery: THIRD PART: can be felt in the axilla as it lies IN FRONT of of the scapula and the head of the humerus. Both articular
the Teres major surfaces are covered with hyaline cartilage.
Brachial artery: can be palpated in the arm as IT LIES on the Brachialis ● Is surrounded by the fibrous capsule that is attached
and is overlapped from the lateral side by the Biceps brachii. superiorly to the margin of the glenoid cavity and inferiorly to
the anatomic neck of the humerus. The capsule is reinforced
by the rotator cuff, the glenohumeral ligaments, and the
coracohumeral ligaments.
VENOUS DRAINAGE:
2 of 15 x
● innervated by the axillary, suprascapular, and lateral pectoral
nerves
● Receives blood from branches of the suprascapular, anterior
and posterior humeral circumflex, and scapular circumflex
arteries
SUBLUXATION / DISLOCATIONS OF THE SHOULDER JOINT
Anterior-inferior dislocation of the Humerus ROTATOR CUFF MUSCLES
➔ Most common direction of shoulder dislocation
● Stabilizes the shoulder joint – anterior, superior and posterior
◆ Why? because of the lack of support by tendons of
parts
the rotator cuff
● Weakest on INFERIOR – unprotected by muscles
➔ May damage the axillary nerve or axillary artery
○ Supraspinatus - above
◆ It may damage the axillary nerve and the posterior
○ Infraspinatus - posterior
humeral circumflex vessels.
○ Teres minor - posterior
➔ Occurs due to the shallowness of GF [Glenoid Fossa]
○ Subscapularis - anterior
➔ Sudden violence applied to the humerus with the joint
Intrinsic Muscles of the Shoulder
fully abducted tilts the humeral head downward into the
inferior weak part.
➔ Signs: palpable depression under the acromion; humerus
palpable in the axilla
Posterior Dislocation
➔ Rare; caused by Direct violence to the front of the joint
● Rotator / Musculotendinous Cuff

○ Is formed by the tendons of supraspinatus
infraspinatus, teres minor, and subscapularis (SITS).;
fuses with the joint capsule; and provides mobility.
○ Keeps the head of the humerus in the glenoid fossa
during movements and thus stabilizes the shoulder
Shoulder Dislocation: Displacement of the bones of the joint
GLENOHUMERAL JOINT [another name for shoulder joint]
Shoulder Separation: Clavicle is torn away from the end of the

acromion; occurs at the acromioclavicular joint. Dislocation of the Nerve Supply Action
acromioclavicular joint can result from a fall on the shoulder with the
impact taken by the acromion or from a fall on the outstretched arm. SUPRASPINATUS Suprascapular ABDUCTOR
It is called a shoulder separation because the shoulder is separated
from the clavicle when the joint dislocation with rupture of the INFRASPINATUS Suprascapular LATERAL rotator
coracoclavicular ligament occurs.
TERES MINOR Axillary LATERAL rotator
Additional Notes:
Referred pain to the shoulder most probably indicates involvement of
SUBSCAPULARIS Upper Subscapular MEDIAL rotator
the phrenic nerve (or diaphragm). Examples of referred pain are
gallbladder pain radiating to right shoulder and splenic pain radiating to DELTOID Axillary ABDUCTOR
left shoulder
TERES MAJOR Lower Subscapular MEDIAL rotator
3 of 15 x
Rotator cuff continued...
QUADRANGULAR SPACE[Boundaries]
CLINICAL CORRELATION ★ Above – Teres minor
● Inflammation of the Rotator Cuff – tendons may become torn ★ Below - Teres major
or inflamed ★ Medial – Long head of Triceps brachii
● Most COMMONLY affected is the tendon of Supraspinatus ★ Lateral – Surgical neck of Humerus
muscle Content/s: AXILLARY nerve (CIRCUMFLEX nerve) & Posterior circumflex
● Patients experience pain anterior and superior to the shoulder humeral vessels
joint during abduction
TRIANGULAR SPACE[Boundaries]
★ Above - Teres minor
★ Below - Teres major
★ Laterally - Long head of the Tricep brachii
Content/s: Circumflex Scapular vessels
TRIANGULAR INTERVAL [Boundaries]

★ Above: teres major
★ Laterally: lateral head of the triceps or the humerus
★ Medially: long head of the tricep
Content/s: Radial Nerve & Profunda brachii artery
● Rupture of rotator cuff [middle] may occur by a chronic wear

and tear or an acute fall on the outstretched arm and is
manifested by severe limitation of shoulder joint motion, Question:
chiefly abduction. The defect called “WINGED SCAPULA” is a result of damage to:
● A rupture of the rotator cuff, most frequently attrition of the Answer: A nerve arising from the root of the brachial plexus [i.e. Long
supraspinatus tendon by friction among middle-aged Thoracic Nerve]
persons may cause degenerative inflammatory changes [right] Review of Anatomy:
(degenerative tendonitis) of the rotator cuff, resulting in a SCAPULA / SHOULDER BLADE
painful abduction of the arm or a painful shoulder. 1. Spine of the Scapula
○ Tendinitis: commonly involves the tendon of the ● Is a triangular-shaped process that continues laterally as the
Supraspinatus muscle and subacromial bursa acromion.
○ Acute tear: isolated tear of the Supraspinatus ● Divides the posterior scapula into the upper supraspinous and
tendon lower infraspinous fossa, and also provides an origin for the
■ Partial thickness>full thickness tears deltoid and an insertion for the trapezius.
2. Acromion
● Is the lateral end of the spine and articulates with the clavicle.
DORSAL SCAPULAR SPACES ● Provides an origin for the deltoid and an insertion for the
trapezius.
3. Coracoid Process
● Provides the origin of the coracobrachialis and short head of
biceps brachii, the insertion of the pectoralis minor, and the
attachment site for the coracoclavicular, coracohumeral, and
coracoacromial ligaments and the costocoracoid membrane
4. Scapular Notch
● Is bridged by the superior transverse scapular ligament and
converted into a foramen that transmits the suprascapular
nerve.
5. Glenoid Cavity
● Is deepened by the glenoid labrum for the head of the
humerus.
6. Supraglenoid and Infraglenoid Tubercles
● Provide origins for the tendons of the long heads of the biceps
4 of 15 x
shoulder and complete the delivery. The infant was noted to have a good cry
brachii and triceps brachii muscles, respectively. and pink color but was not moving its right arm.
Review of Anatomy:
BRACHIAL PLEXUS
➔ Is formed by the ventral primary rami of the lower four
cervical nerves and the first thoracic nerve (C5–T1).
➔ Is enclosed with the axillary artery and vein in the axillary
sheath, which is formed by a prolongation of the prevertebral
fascia
➔ Has roots that pass between the scalenus anterior and medius
muscles
➔ 5 ROOTS = 3 TRUNKS = 6 DIVISIONS = 3 CORDS
Rule of the Brachial Plexus:

★ Muscles in the ANTERIOR arm, anterior forearm and hand that
act mainly as FLEXORS are innervated by nerves that contain
ANTERIOR DIVISION FIBERS [MUM LMP]
○ Musculocutaneous n.
○ Ulnar n.
○ Median n.
○ Lateral and Medial Pectoral n.s.
Long Thoracic Nerve Lesions = “Winged Scapula”
★ Muscles in the POSTERIOR arm and posterior forearm that act
➔ Most commonly injured as it courses superficial to the
mainly as EXTENSORS are innervated by nerves that contain
SERRATUS ANTERIOR on the lateral wall of the thorax
POSTERIOR DIVISION FIBERS [AR SUB]
➔ Patients cannot hold the VERTEBRAL BORDER of the Scapula
○ Axillary n.
flat against the back and may have a “winging” of the
○ Radial n.
vertebral border
○ Upper, Middle and Lower Subscapular ns.
➔ Experience weakness in ability to PROTRACT the scapula and
difficulty in raising their arms above their head/ above the ROOTS
horizontal
➔ Etiologies: Thoracic surgery; Radical mastectomy; stab ● Dorsal Scapular [C5] → Rhomboids
wounds ● Long Thoracic [C5 -C7] → Serratus anterior
UPPER TRUNK
● Nerve to the Subclavius [C5 and C6]

● Suprascapular [C5 and C6] → Supraspinatus & Infraspinatus
CORDS
Lateral Cord:
● Lateral Pectoral [C5-C7] → Pectoralis Major
● Musculocutaneous [C5-C7]
○ Coracobrachialis
○ Biceps brachii
○ Brachialis
Case Discussion: ● Lateral Root of MEDIAN [C5,C6 & C7]
A 32 y/o woman delivered a large (4800 g) baby vaginally after some
difficulty with her labor. Her prenatal course was complicated by diabetes
Medial Cord:
which occurred during pregnancy. At delivery, the infant’s head emerged but
● Medial Pectoral [C8-T1] → Pectoralis Minor
the shoulders were “stuck” behind the maternal symphysis pubis, requiring
the obstetrician to apply some effort and maneuvers to free up the infant's
5 of 15 x
● DISTAL Musculature in the upper limb innervated by C8 AND
● Medial cutaneous nerve of the arm [C8-T1]
● Medial cutaneous nerve of the forearm [C8-T1]
T1 will be affected
● Ulnar [C8-T1] ● APE hand and CLAW hand combination
● Medial Root of MEDIAN [C8 AND T1] ○ Weakness of the intrinsic muscles of the hand
● Altered sensation in MEDIAL hand, ring and little
Posterior Cord:
● Upper subscapular [C5 AND C6] → Subscapularis
● Thoracodorsal [C6, C7 AND C8] → Latissimus dorsi
● Lower Subscapular [C5 AND C6] → Teres major
● Axillary [C5 AND C6] → Deltoids & Teres minor
● Radial [C5,C6,C7 AND T1]
➔ BRANCHES:
◆ Axillary nerve – Deltoid and Teres minor
◆ Musculocutaneous nerve – Anterior / Flexor
compartment of arm
◆ Radial nerve – Posterior / Extensor compartment of
arm and forearm
◆ Media”N” nerve – Anterior / Flexor compartment of
forearm except FCU and FDP - Media”L”
◆ Ulnar nerve – Intrinsic muscles of Hand
ERB-DUCHENNE KLUMPKE
Injury UPPER BRACHIAL LOWER BRACHIAL

PLEXUS PLEXUS
Fall on the shoulder Excessive

Mechanism of or during difficult ABDUCTION of the
Injury [MOI] delivery arm or by stab or
bullet wounds
Arm to be medially Weakness of the

Motor Deficit rotated and the wrist and finger
forearm pronated flexors of the hand
Acromioclavicular separation [Shoulder separation pg.3]
Sensory Loss LATERAL MEDIAL ● Acromioclavicular joint: Is a synovial plane joint that allows
a gliding movement when the scapula rotates and is
Muscles PROXIMAL DISTAL reinforced by the coracoclavicular ligament, which consists of
Involved the conoid and trapezoid ligaments.
● Common injury caused by a downward blow at the tip of the
Pronated and Loss of function of shoulder
medially rotated arm the wrist and hand ● Signs: injured arm hangs noticeably lower; bulge at the tip of
Clinical Sign/s [Waiter’s tip hand] [Ape Hand/Claw the shoulder
Ipsilateral Paralysis Hand] ● Piano Key Sign (+)
of Diaphragm Horner’s Syndrome ○ Indicates ulnar head subluxation [in rheumatoid
patients]
Additional Notes:
ERB-DUCHENNE SYNDROME [Top Image] ○ The prominent ulnar head can be manually
● Results from lesion of the C5 and C6 ventral rami in the depressed by 5 mm or more, usually accompanying
superior trunk of the plexus. with pain
● PROXIMAL Musculature in the upper limb is mainly affected ○ When pressure is released, the head of the ulna
○ Muscles acting at the shoulder and at the elbow springs back in its original position like the key of a
will be weakened piano
● WAITER’S TIP:
○ Arm is adducted, extended and medially rotated
○ Forearm is pronated
○ Carpal flexors flex the hand at the wrist
● Altered sensation in LATERAL arm, forearm, thumb and index
finger
KLUMPKE PARALYSIS [Bottom Image]
● Results from compression of the C8 and T1 ventral rami in the
inferior trunk of the plexus
6 of 15 x
Review of Anatomy: MUSCLES OF THE ARM AND FOREARM
CLAVICLE [COLLARBONE]
● Is a commonly fractured bone that forms the pectoral
(shoulder) girdle with the scapula, which connects the upper
limb to the sternum (axial skeleton), by articulating with the
sternum at the sternoclavicular joint and with the acromion of
the scapula at the acromioclavicular joint.
★ Is the first bone to begin ossification during fetal
development, but it is the last one to complete ossification, at
approximately 21 years of age
★ Medial 2/3rd convex forward; Lateral 1/3rd flattened
★ JUNCTION → WEAKEST POINT
ANTERIOR COMPARTMENT = POSTERIOR COMPARTMENT =

Flexor compartment of ARM Extensor compartment of ARM
-Innervated by Musculocutaneous -Innervated by Radial Nerve
Nerve
CORACOBRACHIALIS: adducts / TRICEPS BRACHII: main extensor
flexes arm: of forearm
BRACHIALIS: main flexor of
Fracture of the Clavicle
forearm
● Most common at the middle ⅓
BICEPS BRACHII: main supinator
● Subclavian artery, subclavian vein, brachial plexus divisions
of forearm
may be put in jeopardy [can lead to hemorrhage]
★ Proximal fragment: displaced upward Flexor Muscles of the FOREARM
★ Distal fragment :displaced downward ➔ Innervated by the MEDIAN NERVE except FCU and FDP
★ Medial segment: elevated by the pull of the SCM
★ Lateral segment: displaced downward by gravity and pull of Superficial Group Deep Group
Deltoids and Pectoralis major Pronator teres FPL
Additional notes: FCR FDP medial → Ulnar nerve
● Fracture of the clavicle may result from a fall on the shoulder Palmaris longus Pronator Quadratus
or outstretched hand or may be caused during delivery FCU → Ulnar nerve
through the birth canal of a baby who is breech Intermediate group
presentation.[‘B’reech = nauuna yung ‘B’utt] [Right] FDS
● Its fracture occurs most commonly at the junction of its
middle and lateral thirds [Left]
● It may cause injury to the brachial plexus (lower trunk), fatal
hemorrhage from the subclavian artery, and thrombosis of the
subclavian vein, leading to pulmonary embolism
Question:
A severe blow on the point of the shoulder can result in a clinical condition
called “shoulder separation”. This is a result of dislocation of which joint? Extensor Muscles of the FOREARM
Answer: Acromioclavicular joint ➔ Innervated by the RADIAL NERVE
A 37 year old female has a fracture of the clavicle at the junction of the inner Superficial Group Deep Group
and middle third. The arm is rotated medially but it is not rotated laterally. Brachioradialis - FLEXOR Abd PL
Which of the following muscles causes upward displacement of the medial ECRL EPB
fragment? ECRB EPL
Answer: Sternocleidomastoid ED EI
EDM Supinator
Inability to supinate the forearm could result from injury to which of the ECU
following pairs of nerves?
Anconeus
Answer: Musculocutaneous and Radial Nerve
7 of 15 x
◆ caused by a small tear or an inflammation or
irritation in the origin of the flexor muscles of the
forearm from the medial epicondyle.
➔ Repetitive flexion and pronation of the forearm at the elbow
➔ Treatment may include injection of glucocorticoids into the
inflamed area or avoidance of repetitive bending (flexing) of
the forearm in order to not compress the ulnar nerve.
Question:
Lateral epicondylitis is usually brought about by which of the following
movements?
Answer: Extension
Review of Anatomy:
MEDIAL EPICONDYLE of Humerus = “Common Flexor Tendon”

➔ Projects from the trochlea and has a groove on the back
for the ulnar nerve and superior ulnar collateral artery
➔ Provides attachment sites for the ulnar collateral ligament,
the pronator teres, and the common tendon of the forearm
flexor muscles
Common origin of:
★ Pronator teres → Humeral head
★ FCR
★ Palmaris longus
★ FCU → Humeral head
★ FDS → Humeroulnar head
LATERAL EPICONDYLE of Humerus = “Common Extensor Tendon”

➔ Projects from the capitulum and provides the origin of the
supinator and extensor muscles of the forearm. Case Discussion:
➔ It is an attachment site for the radial collateral ligament A 32 y/o man is involved in a motor accident. The patient has multiple
Common origin of: injuries including a displaced fracture of the left humerus. Radiologic exam
★ ERCB shows a fracture involving the midshaft of the left humerus. He complains of
★ ED an inability to open his left hand and loss of sensation to a portion of his left
★ EDM hand.
★ ECU Question:
★ Anconeus A supracondylar fracture of the humerus would most likely cause injury to
what nerve?
★ Supinator
Answer: Median Nerve
Review of Anatomy:
TENNIS ELBOW [Lateral Epicondylitis]
1. Head
➔ It is an inflammation of the common extensor tendon
➔ Articulates with the scapula at the glenohumeral joint.
◆ caused by a chronic inflammation or irritation of
2. Anatomic Neck
the origin (tendon) of the extensor muscles of the
➔ Is an indentation distal to the head and provides an
forearm from the lateral epicondyle of the humerus
attachment for the fibrous joint capsule.
as a result of repetitive strain
3. Greater Tubercle
➔ Results from forced extension and flexion of the forearm at the
➔ Lies just lateral and distal to the anatomic neck and provides
elbow
attachments for the supraspinatus, infraspinatus, and teres
➔ It is a painful condition and common in tennis players and
minor muscles
violinists.
4. Lesser Tubercle
GOLFER’S ELBOW [Medial Epicondylitis]
➔ Lies on the anterior medial side of the humerus, just distal to
➔ It is an inflammation of the common flexor tendon
8 of 15 x
the anatomic neck, and provides an insertion for the CLINICALLY IMPORTANT NERVE LESIONS
subscapularis muscle.
RADIAL NERVE LESION
5. Intertubercular (Bicipital) Groove
● As a result of a SPIRAL fracture of the MIDSHAFT of the humerus
➔ Lies between the greater and lesser tubercles, lodges the
● “WRIST-DROP” – weakness in the ability to extend the hand at the
tendon of the long head of the biceps brachii muscle, and is
wrist and a loss of extension at the MP joints of all digits
bridged by the transverse humeral ligament.
● May experience pain and paresthesia in skin over the first dorsal
➔ Provides insertions for the pectoralis major on its lateral lip,
interosseous muscle between the thumb and index finger
the teres major on its medial lip, and the latissimus dorsi on
★ Supination may be weakened but not lost
its floor.
★ Extension of the forearm is spared
6. Surgical Neck
AXILLARY NERVE LESION
➔ Is a narrow area distal to the tubercles that is a common site
● May be injured as a result of a dislocation of the head of the
of fracture and is in contact with the axillary nerve and the
humerus or by a fracture of the SURGICAL NECK of the humerus
posterior humeral circumflex artery.
★ Patients may experience weakness in the ability to ABDUCT the
7. Deltoid Tuberosity
arm and there may be altered sensation in the skin covering the
➔ Is a rough triangular elevation on the lateral aspect of the
Deltoid (may undergo atrophy – resulting in a loss of the rounded
midshaft that marks the insertion of the deltoid muscle.
contour of the shoulder); weakness in LATERAL ROTATION
8. Spiral Groove
because of weakness of Teres minor muscle
➔ Contains the radial nerve, separating the origin of the lateral
Question:
head of the triceps above and the origin of the medial head
An 18 y/o patient has been improperly fitted with crutches which put
below
pressure on the posterior cord of the brachial plexus. Which of the following
terminal nerves would most likely be affected?
Answer: Radial nerve
Which of the following is another name for Wrist drop?

Answer: Saturday night palsy
RADIAL NERVE PALSY

➔ Radial nerve injury results from acute trauma or compression
of the radial nerve
➔ Injury of the POSTERIOR CORD: It results in the loss in
function of the extensors of the arm, forearm, and hand and
produces a wrist drop.
➔ Condition is referred to as:
★ SATURDAY NIGHT PALSY
◆ Alcohol is sometimes a factor as a person falls
asleep with the back of their arm compressed by a
HUMERAL FRACTURES
chair back, bar edge etc.
★ Surgical Neck: Axillary Nerve may be affected and the
★ HONEYMOON PALSY
Posterior Circumflex artery may be lacerated
◆ From another individual sleeping on one’s arm
★ Midshaft / Spiral Groove: Radial Nerve may be affected and
overnight compressing the nerve
the Profunda brachial artery may be lacerated
★ CRUTCH PALSY
★ Supracondylar: Median Nerve may be affected; contraction of
◆ Compression on nerve from walking with crutches
the Triceps and Brachialis may shorten the arm
AXILLARY NERVE PALSY
★ Medial Epicondyle: Ulnar Nerve may be affected
➔ Causes: Crutch pressing upward into the armpit, Downward
Additional Notes:
➔ Fracture of the Greater Tuberosity shoulder dislocations, Fractures of the surgical neck of the
◆ It commonly occurs by direct trauma or by violent humerus, inferior dislocation of the humerus
contractions of the supraspinatus muscle. ➔ It results in weakness of lateral rotation and abduction of the
◆ The bone fragment has the attachments of the arm (the supraspinatus can abduct the arm but not to a
supraspinatus, infraspinatus, and teres minor horizontal level).
muscles, whose tendons form parts of the rotator
cuff. MUSCULOCUTANEOUS NERVE LESION
➔ Fracture of the Lesser Tuberosity ● Uncommon
◆ It accompanies posterior dislocation of the ● May be compressed as it passes through the Coracobrachialis
shoulder joint, and the bone fragment has the muscle
insertion of the subscapularis tendon ● Weakness in flexion of the forearm at the elbow and weakness in
supination
MEDIAN NERVE LESIONS
● PROXIMAL LESION– SUPRACONDYLAR fracture of the humerus;
compression between heads of pronator teres muscle
○ Altered cutaneous sensation – lateral 3 and ½ digits
and thenar eminence
○ Weakness in flexion at wrist; flexion of lateral fingers
and flexion of thumb
9 of 15 x
★ “HAND OF BENEDICTION” – index and middle fingers ★ “CLAW” HAND– caused by weakness of the medial 2
remain extended when attempting to flex in making a lumbricals that flex the MP joints and extend the IP
fist joints of the ring and little fingers
● DISTAL LESION – Carpal tunnel syndrome; LUNATE dislocation ○ Weakness in the ability to abduct / adduct fingers
○ Experience numbness and pain over the palmar (unable to hold a piece of paper between adjacent
aspects of thumb, index and middle fingers fingers)
○ Altered cutaneous sensation – lateral 3 and ½ digits
★ “APE” HAND - Weakness in OPPOSITION of thumb;
remains adducted and extended
Question:
Within the Carpal tunnel, the Median nerve is located?
Answer: Just lateral to the FCR Tendon
CARPAL TUNNEL SYNDROME

➔ It is caused by compression of the median nerve due to the
reduced size of the osseofibrous carpal tunnel, resulting from
inflammation of the flexor retinaculum, arthritic changes in
the carpal bones, or inflammation or thickening of the
synovial sheaths of the flexor tendons.
➔ It leads to pain and paresthesia (tingling, burning, and
numbness) in the hand in the area supplied by the median Cubital tunnel syndrome
nerve and may also cause atrophy of the thenar muscles in ➔ It results from compression on the ulnar nerve in the cubital
cases of severe compression. tunnel behind the medial epicondyle (funny bone), causing
➔ However, no paresthesia occurs over the thenar eminence of numbness and tingling in the ring and little fingers.
skin because this area is supplied by the palmar cutaneous ➔ The tunnel is formed by the medial epicondyle, ulnar
branch of the median nerve. collateral ligament, and two heads of the flexor carpi ulnaris
★ Carpal Tunnel → passageway for the NINE TENDONS and their muscle and transmits the ulnar nerve and superior ulnar
investing synovial sheaths of the flexor muscles of the thumbs collateral or posterior ulnar recurrent artery.
and fingers
○ 4 tendons each of the FDS
○ 4 tendons each of the FDP
○ 1 tendon for the FPL
★ The Median Nerve lies between the tendons of the Flexor
digitorum superficialis [FDS] MEDIALLY and Flexor carpi
radialis [FCR] LATERALLY
Nursemaid’s elbow or Pulled Elbow

➔ is a radial head subluxation and occurs in toddlers when the
child is lifted by the wrist.
➔ It is caused by a partial tear (or loose) of the annular ligament
and thus the radial head to slip out of position.
★ Severe distal traction of the radius
★ Subluxation of the head of the radius from the annular
ligament
★ Signs: child presenting with a flexed and pronated forearm
held close to the body
➔ BURNING PAIN or PINS & NEEDLES along the distribution of
the MEDIAN NERVE to the Lateral Three and Half Fingers and
Weakness of the Thenar Muscles
➔ Surgery: Decompressing the tunnel by making a longitudinal
incision through flexor retinaculum
ULNAR NERVE LESIONS

● PROXIMAL LESION – MEDIAL EPICONDYLE fracture of the
humerus
○ Altered cutaneous sensation – medial 1 and ½ digits
and hypothenar eminence
○ Weakness in flexion of medial fingers; flexion at wrist
● DISTAL LESION – Fracture of hook of HAMATE
○ Altered sensation in skin of the medial aspect of the
hand and digit
Please check the Tennis and Golfer’s elbow discussion and notes on page 8~
10 of 15 x
Clinical correlations continued...
Question:
If you are planning to draw a sample of blood for ABG from the Brachial
artery, you should insert the needle:
Answer: Just medial to the Biceps tendon of the cubital fossa
Supracondylar Fracture of the Humerus
[check discussion of Humerus, page 8~]
➔ May put the contents of the cubital fossa, specifically the
median nerve and brachial artery in jeopardy
➔ Contents of the Cubital Fossa [from medial to lateral]
◆ Median nerve
◆ Brachial Artery
◆ Biceps brachii tendon
◆ Radial Nerve
➔ Boundaries of the Cubital Fossa
◆ Lateral: Brachioradialis
◆ Medial: Pronator teres
◆ Upper: Horizontal line connecting the epicondyles [Top Left: Supracondylar fracture; Right: Little Leaguer’s Elbow
of the humerus Bottom Left: Elbow Dislocation; Right: Olecranon fracture]
◆ Floor: Brachialis and Supinator
Question:
The patient with inability to flex / extend the metacarpo-phalangeal joint of
the ring finger will be most likely due to injury to this pair of nerves?
Answer: Median and Ulnar Nerves
THENAR MUSCLES
● ABductor pollicis brevis

● Flexor pollicis brevis
● Opponens brevis
★ All are supplied by the Median Nerve
★ Intrinsic Muscles of the Hand [PAD DAB!] [Must know!]
ULNAR Palmar interossei [3] → ADduct fingers

NERVE Dorsal interossei [4] → ABduct fingers
ULNAR NERVE [Medial] & MEDIAN NERVE [Lateral]
Lumbricales [4] - flex the MCP joints
RADIAL NERVE → Extensor digitorum
★ Extrinsic Muscles of the Hand
Flexor digitorum superficialis → FLEXES the PROXIMAL IP joints →

supplied by MEDIAN NERVE
Flexor digitorum profundus → DISTAL IP joints → supplied by the

MEDIAN and ULNAR NERVES
Little Leaguer’s Elbow

➔ Avulsion of the medial epicondyle
➔ Due to violent or contractions of the forearm flexor muscles
Elbow Dislocation HYPOTHENAR MUSCLES
➔ Most common is a posterior dislocation of the radius and ulna
➔ Fractures of the distal humerus coronoid process of the ulna, ● ABductor digiti minimi
or radial head may occur ● Flexor digiti minimi
Fracture of the Olecranon ● Opponens digiti minimi
➔ May result from a fall on the forearm with the elbow flexed ★ All are supplied by the Ulnar nerve
11 of 15 x
Case Discussion:
A 23 y/o male trips while playing basketball and suffers trauma to the right
wrist. The wrist is slightly swollen, tender but not deformed. However, deep
palpation of the anatomical snuff box elicits extreme tenderness.
CARPALS
★ The bones are arranged in two rows of four (lateral to medial):

scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid,
capitate, and hamate
★ Mnemonic device: Sandra Likes To Pat Tom’s Two Cold Hands
(Trapezium precedes trapezoid alphabetically.)
★ For the Proximal Row: Except for the pisiform, articulates with the
radius and the articular disk (the ulna has no contact with the
carpal bones). The pisiform is said to be a sesamoid bone
contained in the flexor carpi ulnaris tendon
PROXIMAL ROW DISTAL ROW

● Scaphoid/Navicular ● Trapezium
● Lunate ● Trapezoid
● Triquetral ● Capitate
● Pisiform ● Hamate
ANATOMICAL SNUFF BOX

➔ Is a triangular interval bounded medially by the tendon of the
extensor pollicis longus muscle and laterally by the tendons of
the extensor pollicis brevis and abductor pollicis longus muscles.
➔ Is limited proximally by the styloid process of the radius.
➔ Has a floor formed by the scaphoid and trapezium bones and
crossed by the radial artery
● Lateral: tendons of the EPB and Abd PL
● Medial: tendon of EPL
● Floor: Scaphoid and Trapezium
[1st diagram: Superficial Muscles of the Hand; 2nd: Deep Muscles of the Hand]
12 of 15 x
● Radial artery; styloid process of radius; base of 1st metacarpal
bone can be palpated of the MEDIAN NERVE aponeurosis [image below]
-Thickening of the synovial -Starts -- ring finger draws into
sheaths of the Flexor tendons or the palm then little finger
arthritic changes of the carpal -Flexion of the PROXIMAL
bones INTERPHALANGEAL JOINTS
★ Boundaries of the Anatomical Snuffbox

○ Radial Artery
Question:
○ Radial Styloid Process
A patient complains of sensory loss over the anterior and posterior surfaces
○ Scaphoid of the medial one and one half fingers. Which of the ff. nerve injured?
○ Trapezium Answer: Ulnar Nerve
○ Base of the FIRST METACARPAL
○ Cephalic vein passes OVER THE SNUFF BOX Remember!!!
MEDIAN NERVE: Supracondylar fractures, Hand of Benediction, Carpal
CLINICAL CORRELATION Tunnel Syndrome [CTS]
ULNAR NERVE: Medial epicondyle fractures, Wrist abduction during wrist
flexion, Medial “Clawing”
DISLOCATIONS, FRACTURES etc. of the HAND

Fracture of the Scaphoid
➔ Common in young adults
➔ Exhibit pain and tenderness localized over the anatomical
snuffbox after a fall on the outstretched hand [FOOSH]
➔ Damages the radial artery and can cause avascular necrosis of
the bone and degenerative joint disease of the wrist.
Additional Notes: CLINICAL CORRELATION
Fracture of the Hamate Carpal Tunnel Syndrome [check discussion on page 10~]
➔ injure the ulnar nerve and artery because they are near the ➔ Tenosynovitis due to repetitive hand movements which
hook of the hamate. compresses the median nerve
Bennett Fracture ➔ Structures passing through the carpal tunnel: Tendons of FDS,
➔ fracture of the base of the FIRST metacarpal (bone) of the FDP, FPL and the Median nerve
thumb Dupuytren Contracture
➔ The thumb is forceful ABDUCTED ➔ Thickening and contracture of the Palmar Aponeurosis
Boxer’s Fracture ➔ Results in progressive flexion of the fingers
➔ Fracture of the necks of the second and third metacarpals, ➔ More pronounced in ring and little fingers
seen in professional boxers, and typically of the fifth ★ There is fibrosis of the palmar fascia, especially the palmar
metacarpal in unskilled boxers. aponeurosis, producing a flexion deformity of fingers in which
◆ Oblique fracture of the necks of the 4th or 5th the fingers are pulled toward the palm (inability to fully extend
metacarpals [In other references] fingers), especially the third and fourth fingers.
➔ Distal segment displaced proximally -- shortening of the finger Volkmann Ischemic Contracture
posteriorly ➔ Contracture of the forearm muscles commonly due to a
Lunate Dislocation supracondylar fracture causing spasm of the brachial artery
➔ Lunate: most commonly dislocated carpal bone; typically ★ ischemic muscular contracture (flexion deformity) of the
dislocated anteriorly fingers and sometimes of the wrist, resulting from ischemic
➔ May cause carpal tunnel syndrome necrosis of the forearm flexor muscles, caused by a pressure
injury, such as compartment syndrome, or a tight cast.
CARPAL TUNNEL SYNDROME DUPUYTREN CONTRACTURE
★ The muscles are replaced by fibrous tissue, which contracts,
-Burning pain/”Pins and -Localized thickening and
producing the flexion deformity.
needles” along the distribution contracture of the palmar
13 of 15 x
Deep Laceration Gamekeeper’s Thumb
➔ The deep palmar arch lies posterior to the tendons of FDS ➔ Disruption of the ulnar collateral ligament of the MP joint of
➔ Laceration at the MCP joint that cuts the deep palmar arch will the thumb
compromise flexion of the fingers ➔ Often associated with an avulsion fracture at the base of the
proximal phalanx of the thumb
Boxer's Fracture [check also discussion on page 13~]
➔ Fracture at the head of the 5th metacarpal
➔ Signs: Pain at the ulnar side of the hand, depression of the
head of the fifth metacarpal
Fracture of the Lower End of the Radius
COLLE FRACTURE SMITH FRACTURE

/DINNER/SILVER FORK
Deformity*
- Fracture of the distal end -ANTERIORLY

of the radius, where the -Distal radial
distal fragment is fracture; fragment is
displaced posteriorly VENTRALLY [From Left-Right: Colle’s Fx; Gamekeeper’s Thumb; Boxer’s Fx.]
Displacement (dinner fork deformity) DISPLACED
-The distal segment Additional Notes wala sa ppt pero kayo bahala kung gusto niyo basahin~
POSTERIORLY and
SUPERIORLY
-Distal radial fracture:
fragment is DORSALLY
placed
Mechanism of Fall On an Outstretched Fall On the Back of

Injury [MOI] Hand [FOOSH] the Hand [FOBOH]
*Commonly accompanied by a fracture of the ulnar styloid process
Question:
What is the dermatome level at the medial aspect of the Hypothenar
eminence? [The hypothenar eminence is the mound located at the base of
the fifth digit (little finger)/”BALL OF THE LITTLE FINGER]
Answer: C8
DERMATOMES
★ Area of the skin supplied by the somatosensory fibers from a

single spinal nerve
★ Useful in localizing the level of the lesions
Remember the following!

★ C2: BACK OF THE HEAD
★ C5: TIP OF THE SHOULDER
★ C6:THUMB
★ C7: MIDDLE FINGER
★ C8: LITTLE FINGER
★ T4-T5: NIPPLE
★ T10: UMBILICUS
★ L1: INGUINAL
★ L4: KNEE + MEDIAL LEG
★ L5: LATERAL LEG + BIG TOE
★ S1: SMALL TOE
★ S5: PERINEUM
[Complete figure from Netters on next page]
Question:
Which muscle reflex is preferred for testing involvement of the root of the
6th cervical spinal nerve with a herniation of the IVD at C5 TO C6?
A. Biceps brachii
B. Brachioradialis
14 of 15 x
C. Triceps brachii
➔ Lie along the inferolateral border of the pectoralis minor
D. Brachialis
muscle; receive lymph from the anterior and lateral thoracic
E. Flexor carpi radialis
walls, including the breast; and drain into the central nodes.
TENDON REFLEXES 5. Apical (Medial or Subclavicular) Nodes
★ Biceps brachii tendon reflex: C5 and C6 , flexion of the elbow ➔ Lie at the apex of the axilla medial to the axillary vein and
joint by tapping the biceps tendon above the upper border of the pectoralis minor muscle,
★ Triceps tendon reflex: C6, C7 and C8; extension of the elbow receive lymph from all of the other axillary nodes (and
joint by tapping the triceps tendon occasionally from the breast), and drain into the subclavian
★ Brachioradialis tendon reflex: C5, C6 and C7; supination of the trunks, which usually empty into the junction of the
radioulnar joints by tapping the insertion of the subclavian and internal jugular veins.
brachioradialis tendon
LYMPHATIC DRAINAGE OF THE UPPER EXTREMITIES
● Anterior / Pectoral LN
● Posterior / Scapular
● Lateral / Humeral LN
● Central LN
● Apical LN → Thoracic / Right Lymphatic ducts
AXILLARY LYMPHATICS
Axillary Lymph Nodes
1. Central Nodes
➔ Lie near the base of the axilla between the lateral thoracic and
subscapular veins; receive lymph from the lateral, anterior,
and posterior groups of nodes; and drain into the apical
nodes.
2. Brachial (Lateral) Nodes
➔ Lie posteromedial to the axillary veins, receive lymph from the
upper limb, and drain into the central nodes.
3. Subscapular (Posterior) Nodes
➔ Lie along the subscapular vein, receive lymph from the
posterior thoracic wall and the posterior aspect of the
shoulder, and drain into the central nodes.
4. Pectoral (Anterior) Nodes “OMYGAAAHD hala… birthday ko yun!!!”
15 of 15 x

(Bca) Back, Lowerupperext Trans Combined

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FEU-NRMF [HUMAN STRUCTURAL BIOLOGY DEPARTMENT]

STRUCTURE OF A TYPICAL VERTEBRAE

● Consists of a body and a vertebral arch with several processes for

S3 End of SIGMOID COLON

Memorize!!! Triangles and Fascia

Vertebral Anatomic Structure 1. Triangle of Auscultation

T9 Xiphisternal Joint → External occipital protuberance → Superior Nuchal Line

Joints & Occipitoaxial Ligament

● Atlanto Occipital Joint

Reference: PPT from HSB Department Page 1 of 14

MUSCLES OF THE GLUTEAL REGION

Reference: PPT from HSB Department Page 2 of 14

REVIEW: Muscles that act at the hip joint LESIONS

HIP JOINT STABILITY

Reference: PPT from HSB Department Page 3 of 14

SCIATIC NERVE LESIONS

FRACTURE OF THE NECK OF THE FEMUR

 Common site for intramuscular injections -

Reference: PPT from HSB Department Page 4 of 14

 Superficial group: Gastrocnemius, Plantaris,

Reference: PPT from HSB Department Page 5 of 14

MAIN BRANCHES OF EXTERNAL ILIAC ARTERY

DORSALIS PEDIS ARTERY

Reference: PPT from HSB Department Page 6 of 14

 SAPHENOUS NERVE - runs down the medial side

 Great Saphenous drains into Femoral

Reference: PPT from HSB Department Page 7 of 14

TIBIAL NERVE LESIONS

DEEP PERONEAL/FIBULAR NERVE LESIONS

 Extra capsular Ligaments

Reference: PPT from HSB Department Page 8 of 14

 backward sliding of the Tibia on the Femur

Reference: PPT from HSB Department Page 9 of 14

LYMPHATIC DRAINAGE OF LOWER LIMB

Reference: PPT from HSB Department Page 10 of 14

REGIONAL CHARACTERISTICS OF VERTEBRAE

Reference: PPT from HSB Department Page 11 of 14

 Atypical Cervical – C1, C2 and C7

 HEART shaped body

TYPICAL LUMBAR VERTEBRA

 Transverse foramen – for Vertebral artery

Reference: PPT from HSB Department Page 12 of 14

 External occipital protuberance

Reference: PPT from HSB Department Page 13 of 14

THANK YOU and GOOD LUCK.

Reference: PPT from HSB Department Page 14 of 14

FASCIAL COMPARTMENTS - Thigh

Tensor Flexes, ABducts and Innervated by SUP.

FEMORAL TRIANGLE, SHEATH AND ADDUCTOR CANAL

Popliteal Fossa: [to be discussed further on the latter parts]

➔ Aka buttock, is bounded superiorly by the iliac crest and inferiorly

Superficial Group Intermediate Group Deep Group

Extensor Abductor and MEDIAL LATERAL

Lower extremities continued...

ANATOMY OF THE FEMUR + CLINICAL CORRELATIONS

● Is the longest and strongest bone of the body

AVASCULAR NECROSIS OF THE FEMORAL HEAD

Question: DISLOCATIONS OF THE HIP JOINT

Part 2 na tayo, baba na tayo sa Legs~

FASCIAL COMPARTMENTS - Leg

B. Lateral Fascial Compartment

C. Posterior Fascial Compartment