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Anatomy_Gray_1600 | Anatomy_Gray | Type 4 injuries occur at and around the acetabulum. Other types of pelvic ring injuries include fractures of the pubic rami and disruption of the sacro-iliac joint with or without dislocation. This may involve significant visceral pelvic trauma and hemorrhage. Other general pelvic injuries include stress fractures and insufficiency fractures, as seen in athletes and elderly patients with osteoporosis, respectively. In the clinic | Anatomy_Gray. Type 4 injuries occur at and around the acetabulum. Other types of pelvic ring injuries include fractures of the pubic rami and disruption of the sacro-iliac joint with or without dislocation. This may involve significant visceral pelvic trauma and hemorrhage. Other general pelvic injuries include stress fractures and insufficiency fractures, as seen in athletes and elderly patients with osteoporosis, respectively. In the clinic | [
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Anatomy_Gray_1601 | Anatomy_Gray | Femoral neck fractures (Fig. 6.28) can interrupt the blood supply to the femoral head. The blood supply to the head and neck is primarily from an arterial ring formed by the branches of the medial and lateral circumflex femoral arteries around the base of the femoral neck. From here, vessels course along the neck, penetrate the capsule, and supply the femoral head. The blood supply to the femoral head and femoral neck is further enhanced by the artery of the ligamentum teres, a branch of the obturator artery, which is generally small and variable. Femoral neck fractures may disrupt associated vessels and lead to necrosis of the femoral head. Femoral neck fractures can be divided into three categories depending on the location of the fracture line: subcapital (fracture line passes across the femoral head-neck junction), transcervical (fracture line passes through the midportion of the femoral neck), and basicervical (fracture line passes across the base of the neck). Subcapital | Anatomy_Gray. Femoral neck fractures (Fig. 6.28) can interrupt the blood supply to the femoral head. The blood supply to the head and neck is primarily from an arterial ring formed by the branches of the medial and lateral circumflex femoral arteries around the base of the femoral neck. From here, vessels course along the neck, penetrate the capsule, and supply the femoral head. The blood supply to the femoral head and femoral neck is further enhanced by the artery of the ligamentum teres, a branch of the obturator artery, which is generally small and variable. Femoral neck fractures may disrupt associated vessels and lead to necrosis of the femoral head. Femoral neck fractures can be divided into three categories depending on the location of the fracture line: subcapital (fracture line passes across the femoral head-neck junction), transcervical (fracture line passes through the midportion of the femoral neck), and basicervical (fracture line passes across the base of the neck). Subcapital | [
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Anatomy_Gray_1602 | Anatomy_Gray | the femoral head-neck junction), transcervical (fracture line passes through the midportion of the femoral neck), and basicervical (fracture line passes across the base of the neck). Subcapital fractures have the highest risk of developing necrosis of the femoral head, and basicervical fractures have the lowest risk. Elderly patients with osteoporosis tend to have transverse subcapital fractures following low-energy trauma such as a fall from a standing height. Conversely, younger patients usually sustain more vertical fractures of the distal femoral neck (basicervical) after high-energy trauma such as a fall from a great height or due to axial load applied to an abducted knee, such as during a motor vehicle accident. | Anatomy_Gray. the femoral head-neck junction), transcervical (fracture line passes through the midportion of the femoral neck), and basicervical (fracture line passes across the base of the neck). Subcapital fractures have the highest risk of developing necrosis of the femoral head, and basicervical fractures have the lowest risk. Elderly patients with osteoporosis tend to have transverse subcapital fractures following low-energy trauma such as a fall from a standing height. Conversely, younger patients usually sustain more vertical fractures of the distal femoral neck (basicervical) after high-energy trauma such as a fall from a great height or due to axial load applied to an abducted knee, such as during a motor vehicle accident. | [
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Anatomy_Gray_1603 | Anatomy_Gray | In the clinic In these fractures, the break usually runs from the greater trochanter through to the lesser trochanter and does not involve the femoral neck. Intertrochanteric fractures preserve the femoral neck blood supply and do not render the femoral head ischemic. They are most commonly seen in the elderly and result from low-energy impact (Fig. 6.29). Sometimes isolated fractures of the greater or the lesser trochanter can occur. An isolated fracture of the lesser trochanter in adults is most commonly pathological and due to an underlying malignant deposit. In the clinic An appreciable amount of energy is needed to fracture the femoral shaft. This type of injury is therefore accompanied by damage to the surrounding soft tissues, which include the muscle compartments and the structures they contain. In the clinic | Anatomy_Gray. In the clinic In these fractures, the break usually runs from the greater trochanter through to the lesser trochanter and does not involve the femoral neck. Intertrochanteric fractures preserve the femoral neck blood supply and do not render the femoral head ischemic. They are most commonly seen in the elderly and result from low-energy impact (Fig. 6.29). Sometimes isolated fractures of the greater or the lesser trochanter can occur. An isolated fracture of the lesser trochanter in adults is most commonly pathological and due to an underlying malignant deposit. In the clinic An appreciable amount of energy is needed to fracture the femoral shaft. This type of injury is therefore accompanied by damage to the surrounding soft tissues, which include the muscle compartments and the structures they contain. In the clinic | [
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Anatomy_Gray_1604 | Anatomy_Gray | In the clinic The normal flow of blood in the lower limbs is from the skin and subcutaneous tissues to the superficial veins, which drain via perforating veins to the deep veins, which in turn drain into the iliac veins and inferior vena cava. The normal flow of blood in the venous system depends upon the presence of competent valves, which prevent reflux. Venous return is supplemented with contraction of the muscles in the lower limb, which pump the blood toward the heart. When venous valves become incompetent they tend to place extra pressure on more distal valves, which may also become incompetent. This condition produces dilated tortuous superficial veins (varicose veins) in the distribution of the great (long) and small (short) saphenous venous systems. | Anatomy_Gray. In the clinic The normal flow of blood in the lower limbs is from the skin and subcutaneous tissues to the superficial veins, which drain via perforating veins to the deep veins, which in turn drain into the iliac veins and inferior vena cava. The normal flow of blood in the venous system depends upon the presence of competent valves, which prevent reflux. Venous return is supplemented with contraction of the muscles in the lower limb, which pump the blood toward the heart. When venous valves become incompetent they tend to place extra pressure on more distal valves, which may also become incompetent. This condition produces dilated tortuous superficial veins (varicose veins) in the distribution of the great (long) and small (short) saphenous venous systems. | [
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Anatomy_Gray_1605 | Anatomy_Gray | Varicose veins occur more commonly in women than in men, and symptoms are often aggravated by pregnancy. Some individuals have a genetic predisposition to developing varicose veins. Valves may also be destroyed when a deep vein thrombosis occurs if the clot incorporates the valve into its interstices; during the process of healing and recanalization the valve is destroyed, rendering it incompetent. Typical sites for valvular incompetence include the junction between the great (long) saphenous vein and the femoral vein, perforating veins in the midthigh, and the junction between the small (short) saphenous vein and the popliteal vein. | Anatomy_Gray. Varicose veins occur more commonly in women than in men, and symptoms are often aggravated by pregnancy. Some individuals have a genetic predisposition to developing varicose veins. Valves may also be destroyed when a deep vein thrombosis occurs if the clot incorporates the valve into its interstices; during the process of healing and recanalization the valve is destroyed, rendering it incompetent. Typical sites for valvular incompetence include the junction between the great (long) saphenous vein and the femoral vein, perforating veins in the midthigh, and the junction between the small (short) saphenous vein and the popliteal vein. | [
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Anatomy_Gray_1606 | Anatomy_Gray | Varicose veins may be unsightly, and soft tissue changes may occur with chronic venous incompetence. As the venous pressure rises, increased venular and capillary pressure damages the cells, and blood and blood products extrude into the soft tissue. This may produce a brown pigmentation in the skin, and venous eczema may develop. Furthermore, if the pressure remains high the skin may break down and ulcerate, and many weeks of hospitalization may be needed for this to heal. Treatments for varicose veins include tying off the valve, “stripping” (removing) the great (long) and small (short) saphenous systems, and in some cases valvular reconstruction. In the clinic Thrombosis may occur in the deep veins of the lower limb and within the pelvic veins. Its etiology was eloquently described by Virchow, who described the classic triad (venous stasis, injury to the vessel wall, and hypercoagulable states) that precipitates thrombosis. | Anatomy_Gray. Varicose veins may be unsightly, and soft tissue changes may occur with chronic venous incompetence. As the venous pressure rises, increased venular and capillary pressure damages the cells, and blood and blood products extrude into the soft tissue. This may produce a brown pigmentation in the skin, and venous eczema may develop. Furthermore, if the pressure remains high the skin may break down and ulcerate, and many weeks of hospitalization may be needed for this to heal. Treatments for varicose veins include tying off the valve, “stripping” (removing) the great (long) and small (short) saphenous systems, and in some cases valvular reconstruction. In the clinic Thrombosis may occur in the deep veins of the lower limb and within the pelvic veins. Its etiology was eloquently described by Virchow, who described the classic triad (venous stasis, injury to the vessel wall, and hypercoagulable states) that precipitates thrombosis. | [
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Anatomy_Gray_1607 | Anatomy_Gray | In some patients a deep vein thrombosis (DVT) in the calf veins may propagate into the femoral veins. This clot may break off and pass through the heart to enter the pulmonary circulation, resulting in occlusion of the pulmonary artery, cardiopulmonary arrest, and death. A significant number of patients undergoing surgery are likely to develop a DVT, so most surgical patients are given specific prophylactic treatment to prevent thrombosis. A typical DVT prophylactic regimen includes anticoagulant injections and graduated stockings (to prevent deep venous stasis and facilitate emptying of the deep veins). Although physicians aim to prevent the formation of DVT, it is not always possible to detect it because there may be no clinical signs. Calf muscle tenderness, postoperative pyrexia, and limb swelling can be helpful clues. The diagnosis is predominantly made by duplex Doppler sonography or rarely by ascending venography. | Anatomy_Gray. In some patients a deep vein thrombosis (DVT) in the calf veins may propagate into the femoral veins. This clot may break off and pass through the heart to enter the pulmonary circulation, resulting in occlusion of the pulmonary artery, cardiopulmonary arrest, and death. A significant number of patients undergoing surgery are likely to develop a DVT, so most surgical patients are given specific prophylactic treatment to prevent thrombosis. A typical DVT prophylactic regimen includes anticoagulant injections and graduated stockings (to prevent deep venous stasis and facilitate emptying of the deep veins). Although physicians aim to prevent the formation of DVT, it is not always possible to detect it because there may be no clinical signs. Calf muscle tenderness, postoperative pyrexia, and limb swelling can be helpful clues. The diagnosis is predominantly made by duplex Doppler sonography or rarely by ascending venography. | [
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Anatomy_Gray_1608 | Anatomy_Gray | If DVT is confirmed, intravenous and oral anticoagulation are started to prevent extension of the thrombus. In the clinic Vascular access to the lower limb Deep and inferior to the inguinal ligament are the femoral artery and femoral vein. The femoral artery is palpable as it passes over the femoral head and may be easily demonstrated using ultrasound. If arterial or venous access is needed rapidly, a physician can use the femoral approach to these vessels. Many radiological procedures involve catheterization of the femoral artery or the femoral vein to obtain access to the contralateral lower limb, the ipsilateral lower limb, the vessels of the thorax and abdomen, and the cerebral vessels. Cardiologists also use the femoral artery to place catheters in vessels around the arch of the aorta and into the coronary arteries to perform coronary angiography and angioplasty. | Anatomy_Gray. If DVT is confirmed, intravenous and oral anticoagulation are started to prevent extension of the thrombus. In the clinic Vascular access to the lower limb Deep and inferior to the inguinal ligament are the femoral artery and femoral vein. The femoral artery is palpable as it passes over the femoral head and may be easily demonstrated using ultrasound. If arterial or venous access is needed rapidly, a physician can use the femoral approach to these vessels. Many radiological procedures involve catheterization of the femoral artery or the femoral vein to obtain access to the contralateral lower limb, the ipsilateral lower limb, the vessels of the thorax and abdomen, and the cerebral vessels. Cardiologists also use the femoral artery to place catheters in vessels around the arch of the aorta and into the coronary arteries to perform coronary angiography and angioplasty. | [
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Anatomy_Gray_1609 | Anatomy_Gray | Cardiologists also use the femoral artery to place catheters in vessels around the arch of the aorta and into the coronary arteries to perform coronary angiography and angioplasty. Access to the femoral vein permits catheters to be maneuvered into the renal veins, the gonadal veins, the right atrium, and the right side of the heart, including the pulmonary artery and distal vessels of the pulmonary tree. Access to the superior vena cava and the great veins of the neck is also possible. In the clinic Trendelenburg’s sign occurs in people with weak or paralyzed abductor muscles (gluteus medius and gluteus minimus) of the hip. The sign is demonstrated by asking the patient to stand on one limb. When the patient stands on the affected limb, the pelvis severely drops over the swing limb. | Anatomy_Gray. Cardiologists also use the femoral artery to place catheters in vessels around the arch of the aorta and into the coronary arteries to perform coronary angiography and angioplasty. Access to the femoral vein permits catheters to be maneuvered into the renal veins, the gonadal veins, the right atrium, and the right side of the heart, including the pulmonary artery and distal vessels of the pulmonary tree. Access to the superior vena cava and the great veins of the neck is also possible. In the clinic Trendelenburg’s sign occurs in people with weak or paralyzed abductor muscles (gluteus medius and gluteus minimus) of the hip. The sign is demonstrated by asking the patient to stand on one limb. When the patient stands on the affected limb, the pelvis severely drops over the swing limb. | [
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Anatomy_Gray_1610 | Anatomy_Gray | Positive signs are typically found in patients with damage to the superior gluteal nerve. Damage to this nerve may occur with associated pelvic fractures, with space-occupying lesions within the pelvis extending into the greater sciatic foramen, and in some cases relating to hip surgery during which there has been disruption of and subsequent atrophy of the insertion of the gluteus medius and gluteus minimus tendons on the greater trochanter. In patients with a positive Trendelenburg’s sign, gait also is abnormal. Typically during the stance phase of the affected limb, the weakened abductor muscles allow the pelvis to tilt inferiorly over the swing limb. The patient compensates for the pelvic drop by lurching the trunk to the affected side to maintain the level of the pelvis throughout the gait cycle. In the clinic | Anatomy_Gray. Positive signs are typically found in patients with damage to the superior gluteal nerve. Damage to this nerve may occur with associated pelvic fractures, with space-occupying lesions within the pelvis extending into the greater sciatic foramen, and in some cases relating to hip surgery during which there has been disruption of and subsequent atrophy of the insertion of the gluteus medius and gluteus minimus tendons on the greater trochanter. In patients with a positive Trendelenburg’s sign, gait also is abnormal. Typically during the stance phase of the affected limb, the weakened abductor muscles allow the pelvis to tilt inferiorly over the swing limb. The patient compensates for the pelvic drop by lurching the trunk to the affected side to maintain the level of the pelvis throughout the gait cycle. In the clinic | [
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Anatomy_Gray_1611 | Anatomy_Gray | In the clinic From time to time it is necessary to administer drugs intramuscularly, that is, by direct injection into muscles. This procedure must be carried out without injuring neurovascular structures. A typical site for an intramuscular injection is the gluteal region. The sciatic nerve passes through this region and needs to be avoided. The safest place to inject is the upper outer quadrant of either gluteal region. The gluteal region can be divided into quadrants by two imaginary lines positioned using palpable bony landmarks (Fig. 6.49). One line descends vertically from the highest point of the iliac crest. Another line is horizontal and passes through the first line midway between the highest point of the iliac crest and the horizontal plane through the ischial tuberosity. | Anatomy_Gray. In the clinic From time to time it is necessary to administer drugs intramuscularly, that is, by direct injection into muscles. This procedure must be carried out without injuring neurovascular structures. A typical site for an intramuscular injection is the gluteal region. The sciatic nerve passes through this region and needs to be avoided. The safest place to inject is the upper outer quadrant of either gluteal region. The gluteal region can be divided into quadrants by two imaginary lines positioned using palpable bony landmarks (Fig. 6.49). One line descends vertically from the highest point of the iliac crest. Another line is horizontal and passes through the first line midway between the highest point of the iliac crest and the horizontal plane through the ischial tuberosity. | [
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Anatomy_Gray_1612 | Anatomy_Gray | It is important to remember that the gluteal region extends as far forward as the anterior superior iliac spine. The sciatic nerve curves through the upper lateral corner of the lower medial quadrant and descends along the medial margin of the lower lateral quadrant. Occasionally, the sciatic nerve bifurcates into its tibial and common fibular branches in the pelvis, in which case the common fibular nerve passes into the gluteal region through, or even above, the piriformis muscle. The superior gluteal nerve and vessels normally enter the gluteal region above the piriformis and pass superiorly and forward. The anterior corner of the upper lateral quadrant is normally used for injections to avoid injuring any part of the sciatic nerve or other nerves and vessels in the gluteal region. A needle placed in this region enters the gluteus medius anterosuperior to the margin of the gluteus maximus. In the clinic | Anatomy_Gray. It is important to remember that the gluteal region extends as far forward as the anterior superior iliac spine. The sciatic nerve curves through the upper lateral corner of the lower medial quadrant and descends along the medial margin of the lower lateral quadrant. Occasionally, the sciatic nerve bifurcates into its tibial and common fibular branches in the pelvis, in which case the common fibular nerve passes into the gluteal region through, or even above, the piriformis muscle. The superior gluteal nerve and vessels normally enter the gluteal region above the piriformis and pass superiorly and forward. The anterior corner of the upper lateral quadrant is normally used for injections to avoid injuring any part of the sciatic nerve or other nerves and vessels in the gluteal region. A needle placed in this region enters the gluteus medius anterosuperior to the margin of the gluteus maximus. In the clinic | [
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Anatomy_Gray_1613 | Anatomy_Gray | In the clinic Compartment syndrome occurs when there is swelling within a fascial enclosed muscle compartment in the limbs. Typical causes include limb trauma, intracompartment hemorrhage, and limb compression. As pressure within the compartment elevates, capillary blood flow and tissue perfusion is compromised, which can ultimately lead to neuromuscular damage if not treated. In the clinic Muscle injuries to the lower limb Muscle injuries may occur as a result of direct trauma or as part of an overuse syndrome. Muscle injuries may occur as a minor muscle tear, which may be demonstrated as a focal area of fluid within the muscle. With increasingly severe injuries, more muscle fibers are torn and this may eventually result in a complete muscle tear. The usual muscles in the thigh that tear are the hamstring muscles. Tears in the muscles below the knee typically occur within the soleus muscle, though other muscles may be affected. | Anatomy_Gray. In the clinic Compartment syndrome occurs when there is swelling within a fascial enclosed muscle compartment in the limbs. Typical causes include limb trauma, intracompartment hemorrhage, and limb compression. As pressure within the compartment elevates, capillary blood flow and tissue perfusion is compromised, which can ultimately lead to neuromuscular damage if not treated. In the clinic Muscle injuries to the lower limb Muscle injuries may occur as a result of direct trauma or as part of an overuse syndrome. Muscle injuries may occur as a minor muscle tear, which may be demonstrated as a focal area of fluid within the muscle. With increasingly severe injuries, more muscle fibers are torn and this may eventually result in a complete muscle tear. The usual muscles in the thigh that tear are the hamstring muscles. Tears in the muscles below the knee typically occur within the soleus muscle, though other muscles may be affected. | [
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Anatomy_Gray_1614 | Anatomy_Gray | Injury to the hamstring muscles is a common source of pain in athletes, particularly in those competing in sports requiring a high degree of power and speed (such as sprinting, track and field, football) where the hamstring muscles are very susceptible to injury from excessive stretching. | Anatomy_Gray. Injury to the hamstring muscles is a common source of pain in athletes, particularly in those competing in sports requiring a high degree of power and speed (such as sprinting, track and field, football) where the hamstring muscles are very susceptible to injury from excessive stretching. | [
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Anatomy_Gray_1615 | Anatomy_Gray | The injury can range from a mild muscle strain to a complete tear of a muscle or a tendon. It usually occurs during sudden accelerations and decelerations or rapid change in direction. In adults, the most commonly injured is the muscle-tendon junction, which is a wide transition zone between the muscle and the tendon. An avulsion of the ischial tuberosity with proximal hamstring origin attachment is common in the adolescent population, particularly during sudden hip flexion because the ischial apophysis is the weakest element of the proximal hamstring unit in this age group (Fig. 6.64). Both ultrasound and MRI can be used to assess the hamstring injury with the MRI providing not only the information about the extent of the injury but also give some indication about the prognosis (future risk of re-tear, loss of function, etc). In the clinic | Anatomy_Gray. The injury can range from a mild muscle strain to a complete tear of a muscle or a tendon. It usually occurs during sudden accelerations and decelerations or rapid change in direction. In adults, the most commonly injured is the muscle-tendon junction, which is a wide transition zone between the muscle and the tendon. An avulsion of the ischial tuberosity with proximal hamstring origin attachment is common in the adolescent population, particularly during sudden hip flexion because the ischial apophysis is the weakest element of the proximal hamstring unit in this age group (Fig. 6.64). Both ultrasound and MRI can be used to assess the hamstring injury with the MRI providing not only the information about the extent of the injury but also give some indication about the prognosis (future risk of re-tear, loss of function, etc). In the clinic | [
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Anatomy_Gray_1616 | Anatomy_Gray | In the clinic Peripheral vascular disease is often characterized by reduced blood flow to the legs. This disorder may be caused by stenoses (narrowing) and/or occlusions (blockages) in the lower aorta and the iliac, femoral, tibial, and fibular vessels. Patients typically have chronic leg ischemia and “acute on chronic” leg ischemia. Chronic leg ischemia is a disorder in which vessels have undergone atheromatous change, and often there is significant luminal narrowing (usually over 50%). Most patients with peripheral arterial disease have widespread arterial disease (including cardiovascular and cerebrovascular disease), which may be clinically asymptomatic. Some of these patients develop such severe ischemia that the viability of the limb is threatened (critical limb ischemia). | Anatomy_Gray. In the clinic Peripheral vascular disease is often characterized by reduced blood flow to the legs. This disorder may be caused by stenoses (narrowing) and/or occlusions (blockages) in the lower aorta and the iliac, femoral, tibial, and fibular vessels. Patients typically have chronic leg ischemia and “acute on chronic” leg ischemia. Chronic leg ischemia is a disorder in which vessels have undergone atheromatous change, and often there is significant luminal narrowing (usually over 50%). Most patients with peripheral arterial disease have widespread arterial disease (including cardiovascular and cerebrovascular disease), which may be clinically asymptomatic. Some of these patients develop such severe ischemia that the viability of the limb is threatened (critical limb ischemia). | [
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Anatomy_Gray_1617 | Anatomy_Gray | The commonest symptom of chronic leg ischemia is intermittent claudication. Patients typically have a history of pain that develops in the calf muscles (usually associated with occlusions or narrowing in the femoral artery) or the buttocks (usually associated with occlusion or narrowing in the aorto-iliac segments). The pain experienced in these muscles is often cramplike and occurs with walking. The patient rests and is able to continue walking up to the same distance until the pain recurs and stops walking as before. In some patients with chronic limb ischemia, an acute event blocks the vessels or reduces the blood supply to such a degree that the viability of the limb is threatened. Occasionally a leg may become acutely ischemic with no evidence of underlying atheromatous disease. In these instances a blood clot is likely to have embolized from the heart. Patients with mitral valve disease and atrial fibrillation are prone to embolic disease. | Anatomy_Gray. The commonest symptom of chronic leg ischemia is intermittent claudication. Patients typically have a history of pain that develops in the calf muscles (usually associated with occlusions or narrowing in the femoral artery) or the buttocks (usually associated with occlusion or narrowing in the aorto-iliac segments). The pain experienced in these muscles is often cramplike and occurs with walking. The patient rests and is able to continue walking up to the same distance until the pain recurs and stops walking as before. In some patients with chronic limb ischemia, an acute event blocks the vessels or reduces the blood supply to such a degree that the viability of the limb is threatened. Occasionally a leg may become acutely ischemic with no evidence of underlying atheromatous disease. In these instances a blood clot is likely to have embolized from the heart. Patients with mitral valve disease and atrial fibrillation are prone to embolic disease. | [
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Anatomy_Gray_1618 | Anatomy_Gray | Critical limb ischemia occurs when the blood supply to the limb is so poor that the viability of the limb is severely threatened, and in this case many patients develop gangrene, ulceration, and severe rest pain in the foot. These patients require urgent treatment, which may be in the form of surgical reconstruction, radiological angioplasty, or even amputation. In the clinic Menisci can get torn during forceful rotation or twisting of the knee, but significant trauma is not always necessary for a tear to occur. There are various patterns of meniscal tearing depending on the cleavage plane such as vertical tears (perpendicular to the tibial plateau), horizontal tears (parallel to the long axis of the meniscus and perpendicular to the tibial plateau), or bucket handle tears (longitudinal tear where the torn portion of the meniscus forms a handle shaped fragment which gets displaced into the intercondylar notch). | Anatomy_Gray. Critical limb ischemia occurs when the blood supply to the limb is so poor that the viability of the limb is severely threatened, and in this case many patients develop gangrene, ulceration, and severe rest pain in the foot. These patients require urgent treatment, which may be in the form of surgical reconstruction, radiological angioplasty, or even amputation. In the clinic Menisci can get torn during forceful rotation or twisting of the knee, but significant trauma is not always necessary for a tear to occur. There are various patterns of meniscal tearing depending on the cleavage plane such as vertical tears (perpendicular to the tibial plateau), horizontal tears (parallel to the long axis of the meniscus and perpendicular to the tibial plateau), or bucket handle tears (longitudinal tear where the torn portion of the meniscus forms a handle shaped fragment which gets displaced into the intercondylar notch). | [
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Anatomy_Gray_1619 | Anatomy_Gray | The patient usually complains of pain localized to the medial or lateral side of the knee, knee locking or clicking, sensation of knee giving way, and swelling, which can be intermittent and usually delayed. MRI is the modality of choice to assess meniscal tears and detect other associated injuries, such as ligamentous tears and articular cartilage damage (Fig. 6.74A). Arthroscopy is usually performed to repair a tear, debride the damaged meniscal material, or rarely remove the entire torn meniscus (Fig. 6.74B). In the clinic The collateral ligaments are responsible for stabilizing the knee joint, controlling its sideway movements, and protecting the knee from excessive motion. | Anatomy_Gray. The patient usually complains of pain localized to the medial or lateral side of the knee, knee locking or clicking, sensation of knee giving way, and swelling, which can be intermittent and usually delayed. MRI is the modality of choice to assess meniscal tears and detect other associated injuries, such as ligamentous tears and articular cartilage damage (Fig. 6.74A). Arthroscopy is usually performed to repair a tear, debride the damaged meniscal material, or rarely remove the entire torn meniscus (Fig. 6.74B). In the clinic The collateral ligaments are responsible for stabilizing the knee joint, controlling its sideway movements, and protecting the knee from excessive motion. | [
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Anatomy_Gray_1620 | Anatomy_Gray | In the clinic The collateral ligaments are responsible for stabilizing the knee joint, controlling its sideway movements, and protecting the knee from excessive motion. Injury to the fibular collateral ligament occurs when excessive outward force is applied to the medial side of the knee (varus force), and is less common than an injury to the tibial collateral ligament that is damaged when excessive force is applied inward to the lateral side of the joint (valgus force). Injuries to the tibial collateral ligament can be part of a so called “unhappy triad” that also involves tears of the medial meniscus and the anterior cruciate ligament. The spectrum of injuries to collateral ligaments of the knee range from minor sprains where the ligaments are slightly stretched, but still able to stabilize the knee joint, to full thickness tears where all fibers are torn and the ligaments lose their stabilizing function. In the clinic | Anatomy_Gray. In the clinic The collateral ligaments are responsible for stabilizing the knee joint, controlling its sideway movements, and protecting the knee from excessive motion. Injury to the fibular collateral ligament occurs when excessive outward force is applied to the medial side of the knee (varus force), and is less common than an injury to the tibial collateral ligament that is damaged when excessive force is applied inward to the lateral side of the joint (valgus force). Injuries to the tibial collateral ligament can be part of a so called “unhappy triad” that also involves tears of the medial meniscus and the anterior cruciate ligament. The spectrum of injuries to collateral ligaments of the knee range from minor sprains where the ligaments are slightly stretched, but still able to stabilize the knee joint, to full thickness tears where all fibers are torn and the ligaments lose their stabilizing function. In the clinic | [
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Anatomy_Gray_1621 | Anatomy_Gray | The anterior cruciate ligament (ACL) is most frequently injured during non-contact activities when there is a sudden change in the direction of movement (cutting or pivoting) (Fig. 6.81). Contact sports may also result in ACL injury due to sudden twisting, hyperextension, and valgus force related to direct collision. The injury usually affects the mid-portion of the ligament and manifests itself as a complete or partial discontinuity of the fibers or abnormal orientation and contour of the ligament. With an acute ACL tear, a sudden click or pop can be heard and the knee becomes rapidly swollen. Several tests are used to clinically assess the injury, and the diagnosis is usually confirmed by MRI. A full thickness ACL tear causes instability of the knee joint. The treatment depends on the desired level of activity of the patient. In those with high activity levels, surgical reconstruction of the ligament is required. Those with low activity levels may opt for knee bracing and | Anatomy_Gray. The anterior cruciate ligament (ACL) is most frequently injured during non-contact activities when there is a sudden change in the direction of movement (cutting or pivoting) (Fig. 6.81). Contact sports may also result in ACL injury due to sudden twisting, hyperextension, and valgus force related to direct collision. The injury usually affects the mid-portion of the ligament and manifests itself as a complete or partial discontinuity of the fibers or abnormal orientation and contour of the ligament. With an acute ACL tear, a sudden click or pop can be heard and the knee becomes rapidly swollen. Several tests are used to clinically assess the injury, and the diagnosis is usually confirmed by MRI. A full thickness ACL tear causes instability of the knee joint. The treatment depends on the desired level of activity of the patient. In those with high activity levels, surgical reconstruction of the ligament is required. Those with low activity levels may opt for knee bracing and | [
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Anatomy_Gray_1622 | Anatomy_Gray | on the desired level of activity of the patient. In those with high activity levels, surgical reconstruction of the ligament is required. Those with low activity levels may opt for knee bracing and physiotherapy; however, in the long term the internal damage to the knee leads to the development of early osteoarthritis. | Anatomy_Gray. on the desired level of activity of the patient. In those with high activity levels, surgical reconstruction of the ligament is required. Those with low activity levels may opt for knee bracing and physiotherapy; however, in the long term the internal damage to the knee leads to the development of early osteoarthritis. | [
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Anatomy_Gray_1623 | Anatomy_Gray | A tear to the posterior cruciate ligament (PCL) requires significant force, so it rarely occurs in isolation. It usually occurs during hyperextension of the knee or as a result of a direct blow to a bent knee such as when striking the knee against the dashboard in a motor vehicle accident. Typically, the injury presents as posterior displacement of the tibia on physical examination (the so called tibial sag sign). Patients complain of knee pain and swelling, inability to bear weight, and instability. The diagnosis is confirmed on MRI. The management, as in ACL injury, depends on the degree of the injury (sprain, partial thickness, full thickness) and the level of desired activity. In the clinic Degenerative joint disease occurs throughout many joints within the body. Articular degeneration may result from an abnormal force across the joint with a normal cartilage or a normal force with abnormal cartilage. | Anatomy_Gray. A tear to the posterior cruciate ligament (PCL) requires significant force, so it rarely occurs in isolation. It usually occurs during hyperextension of the knee or as a result of a direct blow to a bent knee such as when striking the knee against the dashboard in a motor vehicle accident. Typically, the injury presents as posterior displacement of the tibia on physical examination (the so called tibial sag sign). Patients complain of knee pain and swelling, inability to bear weight, and instability. The diagnosis is confirmed on MRI. The management, as in ACL injury, depends on the degree of the injury (sprain, partial thickness, full thickness) and the level of desired activity. In the clinic Degenerative joint disease occurs throughout many joints within the body. Articular degeneration may result from an abnormal force across the joint with a normal cartilage or a normal force with abnormal cartilage. | [
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Anatomy_Gray_1624 | Anatomy_Gray | Typically degenerative joint disease occurs in synovial joints and the process is called osteoarthritis. In the joints where osteoarthritis occurs the cartilage and bony tissues are usually involved, with limited change within the synovial membrane. The typical findings include reduction in the joint space, eburnation (joint sclerosis), osteophytosis (small bony outgrowths), and bony cyst formation. As the disease progresses the joint may become malaligned, its movement may become severely limited, and there may be significant pain. The commonest sites for osteoarthritis include the small joints of the hands and wrist, and in the lower limb, the hip and knee are typically affected, though the tarsometatarsal and metatarsophalangeal articulations may undergo similar changes. | Anatomy_Gray. Typically degenerative joint disease occurs in synovial joints and the process is called osteoarthritis. In the joints where osteoarthritis occurs the cartilage and bony tissues are usually involved, with limited change within the synovial membrane. The typical findings include reduction in the joint space, eburnation (joint sclerosis), osteophytosis (small bony outgrowths), and bony cyst formation. As the disease progresses the joint may become malaligned, its movement may become severely limited, and there may be significant pain. The commonest sites for osteoarthritis include the small joints of the hands and wrist, and in the lower limb, the hip and knee are typically affected, though the tarsometatarsal and metatarsophalangeal articulations may undergo similar changes. | [
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Anatomy_Gray_1625 | Anatomy_Gray | The etiology of degenerative joint disease is unclear, but there are some associations, including genetic predisposition, increasing age (males tend to be affected younger than females), overuse or underuse of joints, and nutritional and metabolic abnormalities. Further factors include joint trauma and pre-existing articular disease or deformity. The histological findings of osteoarthritis consist of degenerative changes within the cartilage and the subchondral bone. Further articular damage worsens these changes, which promote further abnormal stresses upon the joint. As the disease progresses the typical finding is pain, which is usually worse on rising from bed and at the end of a day’s activity. Commonly it is aggravated by the extremes of movement or unaccustomed exertion. Stiffness and limitation of movement may ensue. | Anatomy_Gray. The etiology of degenerative joint disease is unclear, but there are some associations, including genetic predisposition, increasing age (males tend to be affected younger than females), overuse or underuse of joints, and nutritional and metabolic abnormalities. Further factors include joint trauma and pre-existing articular disease or deformity. The histological findings of osteoarthritis consist of degenerative changes within the cartilage and the subchondral bone. Further articular damage worsens these changes, which promote further abnormal stresses upon the joint. As the disease progresses the typical finding is pain, which is usually worse on rising from bed and at the end of a day’s activity. Commonly it is aggravated by the extremes of movement or unaccustomed exertion. Stiffness and limitation of movement may ensue. | [
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Anatomy_Gray_1626 | Anatomy_Gray | Treatment in the first instance includes alteration of lifestyle to prevent pain and simple analgesia. As symptoms progress a joint replacement may be necessary, but although joint replacement appears to be the panacea for degenerative joint disease, it is not without risks and complications, which include infection and failure in the short and long term. In the clinic Examination of the knee joint It is important to establish the nature of the patient’s complaint before any examination. The history should include information about the complaint, the signs and symptoms, and the patient’s lifestyle (level of activity). This history may give a significant clue to the type of injury and the likely findings on clinical examination, for example, if the patient was kicked around the medial aspect of the knee, a valgus deformity injury to the tibial collateral ligament might be suspected. | Anatomy_Gray. Treatment in the first instance includes alteration of lifestyle to prevent pain and simple analgesia. As symptoms progress a joint replacement may be necessary, but although joint replacement appears to be the panacea for degenerative joint disease, it is not without risks and complications, which include infection and failure in the short and long term. In the clinic Examination of the knee joint It is important to establish the nature of the patient’s complaint before any examination. The history should include information about the complaint, the signs and symptoms, and the patient’s lifestyle (level of activity). This history may give a significant clue to the type of injury and the likely findings on clinical examination, for example, if the patient was kicked around the medial aspect of the knee, a valgus deformity injury to the tibial collateral ligament might be suspected. | [
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Anatomy_Gray_1627 | Anatomy_Gray | The examination should include assessment in the erect position, while walking, and on the couch. The affected side must be compared with the unaffected side. There are many tests and techniques for examining the knee joint, including the following. Lachman’s test—the patient lies on the couch. The examiner places one hand around the distal femur and the other around the proximal tibia and then elevates the knee, producing 20° of flexion. The patient’s heel rests on the couch. The examiner’s thumb must be on the tibial tuberosity. The hand on the tibia applies a brisk anteriorly directed force. If the movement of the tibia on the femur comes to a sudden stop, it is a firm endpoint. If it does not come to a sudden stop, the endpoint is described as soft and is associated with a tear of the anterior cruciate ligament. | Anatomy_Gray. The examination should include assessment in the erect position, while walking, and on the couch. The affected side must be compared with the unaffected side. There are many tests and techniques for examining the knee joint, including the following. Lachman’s test—the patient lies on the couch. The examiner places one hand around the distal femur and the other around the proximal tibia and then elevates the knee, producing 20° of flexion. The patient’s heel rests on the couch. The examiner’s thumb must be on the tibial tuberosity. The hand on the tibia applies a brisk anteriorly directed force. If the movement of the tibia on the femur comes to a sudden stop, it is a firm endpoint. If it does not come to a sudden stop, the endpoint is described as soft and is associated with a tear of the anterior cruciate ligament. | [
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Anatomy_Gray_1628 | Anatomy_Gray | Anterior drawer test—a positive anterior drawer test is when the proximal head of a patient’s tibia can be pulled anteriorly on the femur. The patient lies supine on the couch. The knee is flexed to 90° and the heel and sole of the foot are placed on the couch. The examiner sits gently on the patient’s foot, which has been placed in a neutral position. The index fingers are used to check that the hamstrings are relaxed while the other fingers encircle the upper end of the tibia and pull the tibia. If the tibia moves forward, the anterior cruciate ligament is torn. Other peripheral structures, such as the medial meniscus or meniscotibial ligaments, must also be damaged to elicit this sign. | Anatomy_Gray. Anterior drawer test—a positive anterior drawer test is when the proximal head of a patient’s tibia can be pulled anteriorly on the femur. The patient lies supine on the couch. The knee is flexed to 90° and the heel and sole of the foot are placed on the couch. The examiner sits gently on the patient’s foot, which has been placed in a neutral position. The index fingers are used to check that the hamstrings are relaxed while the other fingers encircle the upper end of the tibia and pull the tibia. If the tibia moves forward, the anterior cruciate ligament is torn. Other peripheral structures, such as the medial meniscus or meniscotibial ligaments, must also be damaged to elicit this sign. | [
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Anatomy_Gray_1629 | Anatomy_Gray | Pivot shift test—there are many variations of this test. The patient’s foot is wedged between the examiner’s body and elbow. The examiner places one hand flat under the tibia pushing it forward with the knee in extension. The other hand is placed against the patient’s thigh pushing it the other way. The lower limb is taken into slight abduction by the examiner’s elbow with the examiner’s body acting as a fulcrum to produce the valgus. The examiner maintains the anterior tibial translation and the valgus and initiates flexion of the patient’s knee. At about 20°–30° the pivot shift will occur as the lateral tibial plateau reduces. This test demonstrates damage to the posterolateral corner of the knee joint and the anterior cruciate ligament. | Anatomy_Gray. Pivot shift test—there are many variations of this test. The patient’s foot is wedged between the examiner’s body and elbow. The examiner places one hand flat under the tibia pushing it forward with the knee in extension. The other hand is placed against the patient’s thigh pushing it the other way. The lower limb is taken into slight abduction by the examiner’s elbow with the examiner’s body acting as a fulcrum to produce the valgus. The examiner maintains the anterior tibial translation and the valgus and initiates flexion of the patient’s knee. At about 20°–30° the pivot shift will occur as the lateral tibial plateau reduces. This test demonstrates damage to the posterolateral corner of the knee joint and the anterior cruciate ligament. | [
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Anatomy_Gray_1630 | Anatomy_Gray | Posterior drawer test—a positive posterior drawer test occurs when the proximal head of a patient’s tibia can be pushed posteriorly on the femur. The patient is placed in a supine position and the knee is flexed to approximately 90° with the foot in the neutral position. The examiner sits gently on the patient’s foot placing both thumbs on the tibial tuberosity and pushing the tibia backward. If the tibial plateau moves, the posterior cruciate ligament is torn. Assessment of other structures of the knee Assessment of the tibial collateral ligament can be performed by placing a valgus stress on the knee. Assessment of lateral and posterolateral knee structures requires more complex clinical testing. The knee will also be assessed for: joint line tenderness, patellofemoral movement and instability, presence of an effusion, muscle injury, and popliteal fossa masses. | Anatomy_Gray. Posterior drawer test—a positive posterior drawer test occurs when the proximal head of a patient’s tibia can be pushed posteriorly on the femur. The patient is placed in a supine position and the knee is flexed to approximately 90° with the foot in the neutral position. The examiner sits gently on the patient’s foot placing both thumbs on the tibial tuberosity and pushing the tibia backward. If the tibial plateau moves, the posterior cruciate ligament is torn. Assessment of other structures of the knee Assessment of the tibial collateral ligament can be performed by placing a valgus stress on the knee. Assessment of lateral and posterolateral knee structures requires more complex clinical testing. The knee will also be assessed for: joint line tenderness, patellofemoral movement and instability, presence of an effusion, muscle injury, and popliteal fossa masses. | [
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Anatomy_Gray_1631 | Anatomy_Gray | The knee will also be assessed for: joint line tenderness, patellofemoral movement and instability, presence of an effusion, muscle injury, and popliteal fossa masses. After the clinical examination has been carried out, further investigations usually include plain radiography and possibly magnetic resonance imaging, which allows the radiologist to assess the menisci, cruciate ligaments, collateral ligaments, bony and cartilaginous surfaces, and soft tissues. Arthroscopy may be carried out and damage to any internal structures repaired or trimmed. An arthroscope is a small camera that is placed into the knee joint through the anterolateral or anteromedial aspect of the knee joint. The joint is filled with a saline solution and the telescope is manipulated around the knee joint to assess the cruciate ligaments, menisci, and cartilaginous surfaces. In the clinic Anterolateral ligament of the knee | Anatomy_Gray. The knee will also be assessed for: joint line tenderness, patellofemoral movement and instability, presence of an effusion, muscle injury, and popliteal fossa masses. After the clinical examination has been carried out, further investigations usually include plain radiography and possibly magnetic resonance imaging, which allows the radiologist to assess the menisci, cruciate ligaments, collateral ligaments, bony and cartilaginous surfaces, and soft tissues. Arthroscopy may be carried out and damage to any internal structures repaired or trimmed. An arthroscope is a small camera that is placed into the knee joint through the anterolateral or anteromedial aspect of the knee joint. The joint is filled with a saline solution and the telescope is manipulated around the knee joint to assess the cruciate ligaments, menisci, and cartilaginous surfaces. In the clinic Anterolateral ligament of the knee | [
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Anatomy_Gray_1632 | Anatomy_Gray | In the clinic Anterolateral ligament of the knee A ligament associated at its origin with the fibular collateral ligament of the knee has been described. This ligament (anterolateral ligament of the knee) courses from the lateral femoral epicondyle to the anterolateral region of the proximal end of the tibia and may control internal rotation of the tibia. (J Anat 2013;223:321–328) In the clinic The popliteal artery can become abnormally dilated, forming an aneurysm. The artery is considered aneurysmal when its diameter exceeds 7 mm. Although popliteal artery aneurysms can occur in isolation, they are most commonly associated with aneurysms in other large vessels such as the femoral artery or the thoracic or abdominal aorta. Therefore, once a popliteal aneurysm has been detected, the entire arterial tree needs to be investigated for the presence of coexisting aneurysms elsewhere in the body. | Anatomy_Gray. In the clinic Anterolateral ligament of the knee A ligament associated at its origin with the fibular collateral ligament of the knee has been described. This ligament (anterolateral ligament of the knee) courses from the lateral femoral epicondyle to the anterolateral region of the proximal end of the tibia and may control internal rotation of the tibia. (J Anat 2013;223:321–328) In the clinic The popliteal artery can become abnormally dilated, forming an aneurysm. The artery is considered aneurysmal when its diameter exceeds 7 mm. Although popliteal artery aneurysms can occur in isolation, they are most commonly associated with aneurysms in other large vessels such as the femoral artery or the thoracic or abdominal aorta. Therefore, once a popliteal aneurysm has been detected, the entire arterial tree needs to be investigated for the presence of coexisting aneurysms elsewhere in the body. | [
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Anatomy_Gray_1633 | Anatomy_Gray | Popliteal artery aneurysms tend to undergo thrombosis and are less likely to rupture than other aneurysms. Therefore the complications are mainly related to distal embolization of the arterial tree and lower limb ischemia, which in the most severe cases can lead to leg amputation. Ultrasound with duplex Doppler is the most helpful way of diagnosing a popliteal artery aneurysm because it can demonstrate abnormal dilation of the artery, confirm or rule out thrombus within the aneurysm, and help distinguish it from other masses of the popliteal fossa such as a synovial cyst (Baker’s cyst). Popliteal artery aneurysms are usually repaired surgically in view of high risk of thromboembolic complications. In the clinic | Anatomy_Gray. Popliteal artery aneurysms tend to undergo thrombosis and are less likely to rupture than other aneurysms. Therefore the complications are mainly related to distal embolization of the arterial tree and lower limb ischemia, which in the most severe cases can lead to leg amputation. Ultrasound with duplex Doppler is the most helpful way of diagnosing a popliteal artery aneurysm because it can demonstrate abnormal dilation of the artery, confirm or rule out thrombus within the aneurysm, and help distinguish it from other masses of the popliteal fossa such as a synovial cyst (Baker’s cyst). Popliteal artery aneurysms are usually repaired surgically in view of high risk of thromboembolic complications. In the clinic | [
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Anatomy_Gray_1634 | Anatomy_Gray | In the clinic Rupture of the calcaneal tendon is often related to sudden or direct trauma. This type of injury frequently occurs in a normal healthy tendon. In addition, there are certain conditions that may predispose the tendon to rupture. Among these conditions are tendinopathy (due to overuse, or to age-related degenerative changes) and previous calcaneal tendon interventions such as injections of pharmaceuticals and the use of certain antibiotics (quinolone group). The diagnosis of calcaneal tendon rupture is relatively straightforward. The patient typically complains of “being kicked” or “shot” behind the ankle, and clinical examination often reveals a gap in the tendon. In the clinic Neurological examination of the legs | Anatomy_Gray. In the clinic Rupture of the calcaneal tendon is often related to sudden or direct trauma. This type of injury frequently occurs in a normal healthy tendon. In addition, there are certain conditions that may predispose the tendon to rupture. Among these conditions are tendinopathy (due to overuse, or to age-related degenerative changes) and previous calcaneal tendon interventions such as injections of pharmaceuticals and the use of certain antibiotics (quinolone group). The diagnosis of calcaneal tendon rupture is relatively straightforward. The patient typically complains of “being kicked” or “shot” behind the ankle, and clinical examination often reveals a gap in the tendon. In the clinic Neurological examination of the legs | [
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Anatomy_Gray_1635 | Anatomy_Gray | In the clinic Neurological examination of the legs Some of the commonest conditions that affect the legs are peripheral neuropathy (particularly associated with diabetes mellitus), lumbar nerve root lesions (associated with pathology of the intervertebral discs), fibular nerve palsy, and spastic paraparesis. Look for muscle wasting—loss of muscle mass may indicate loss of or reduced innervation. | Anatomy_Gray. In the clinic Neurological examination of the legs Some of the commonest conditions that affect the legs are peripheral neuropathy (particularly associated with diabetes mellitus), lumbar nerve root lesions (associated with pathology of the intervertebral discs), fibular nerve palsy, and spastic paraparesis. Look for muscle wasting—loss of muscle mass may indicate loss of or reduced innervation. | [
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Anatomy_Gray_1636 | Anatomy_Gray | Look for muscle wasting—loss of muscle mass may indicate loss of or reduced innervation. Test the power in muscle groups—hip flexion (L1, L2—iliopsoas—straight leg raise); knee flexion (L5 to S2—hamstrings—the patient tries to bend the knee while the examiner applies force to the leg to hold the knee in extension); knee extension (L3, L4—quadriceps femoris—the patient attempts to keep the leg straight while the examiner applies a force to the leg to flex the knee joint); ankle plantarflexion (S1, S2—the patient pushes the foot down while the examiner applies a force to the plantar surface of the foot to dorsiflex the ankle joint); ankle dorsiflexion (L4, L5—the patient pulls the foot upward while the examiner applies a force to the dorsal aspect of the foot to plantarflex the ankle joint). | Anatomy_Gray. Look for muscle wasting—loss of muscle mass may indicate loss of or reduced innervation. Test the power in muscle groups—hip flexion (L1, L2—iliopsoas—straight leg raise); knee flexion (L5 to S2—hamstrings—the patient tries to bend the knee while the examiner applies force to the leg to hold the knee in extension); knee extension (L3, L4—quadriceps femoris—the patient attempts to keep the leg straight while the examiner applies a force to the leg to flex the knee joint); ankle plantarflexion (S1, S2—the patient pushes the foot down while the examiner applies a force to the plantar surface of the foot to dorsiflex the ankle joint); ankle dorsiflexion (L4, L5—the patient pulls the foot upward while the examiner applies a force to the dorsal aspect of the foot to plantarflex the ankle joint). | [
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Anatomy_Gray_1637 | Anatomy_Gray | Examine knee and ankle reflexes—a tap with a tendon hammer on the patellar ligament (tendon) tests reflexes at the L3–L4 spinal levels, and tapping the calcaneal tendon tests reflexes at the S1–S2 spinal levels. Assess status of general sensory input to lumbar and upper sacral spinal cord levels—test light touch, pin prick, and vibration sense at dermatomes in the lower limb. In the clinic | Anatomy_Gray. Examine knee and ankle reflexes—a tap with a tendon hammer on the patellar ligament (tendon) tests reflexes at the L3–L4 spinal levels, and tapping the calcaneal tendon tests reflexes at the S1–S2 spinal levels. Assess status of general sensory input to lumbar and upper sacral spinal cord levels—test light touch, pin prick, and vibration sense at dermatomes in the lower limb. In the clinic | [
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Anatomy_Gray_1638 | Anatomy_Gray | Assess status of general sensory input to lumbar and upper sacral spinal cord levels—test light touch, pin prick, and vibration sense at dermatomes in the lower limb. In the clinic Footdrop is an inability to dorsiflex the foot. Patients with footdrop have a characteristic “steppage” gait. As the patient walks, the knee of the affected limb is elevated to an abnormal height during the swing phase to prevent the foot from dragging. At the end of the swing phase, the foot “slaps” the ground. Also, the unaffected limb often acquires a characteristic tiptoe pattern of gait during the stance phase. A typical cause of footdrop is damage to the common fibular nerve, which may occur with fractures of the fibular neck. Other causes include disc protrusion compressing the L5 nerve root, disorders of the sciatic nerve and the lumbosacral plexus, and pathologies of the spinal cord and brain. In the clinic | Anatomy_Gray. Assess status of general sensory input to lumbar and upper sacral spinal cord levels—test light touch, pin prick, and vibration sense at dermatomes in the lower limb. In the clinic Footdrop is an inability to dorsiflex the foot. Patients with footdrop have a characteristic “steppage” gait. As the patient walks, the knee of the affected limb is elevated to an abnormal height during the swing phase to prevent the foot from dragging. At the end of the swing phase, the foot “slaps” the ground. Also, the unaffected limb often acquires a characteristic tiptoe pattern of gait during the stance phase. A typical cause of footdrop is damage to the common fibular nerve, which may occur with fractures of the fibular neck. Other causes include disc protrusion compressing the L5 nerve root, disorders of the sciatic nerve and the lumbosacral plexus, and pathologies of the spinal cord and brain. In the clinic | [
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Anatomy_Gray_1639 | Anatomy_Gray | In the clinic The common fibular nerve is susceptible to injury as it passes around the lateral aspect of the neck of the fibula. It can be injured as a result of a direct trauma (blow or laceration), secondary to knee injury (knee dislocation), or as a consequence of a proximal fibular fracture. Sometimes damage to the nerve can be iatrogenic, that is, damaged during arthroscopy or knee surgery. Symptoms of common fibular nerve injury are often observed in bed-bound patients, particularly in those with decreased levels of consciousness, due to prolonged external pressure to the knee leading to nerve compression and neuropathy. Similarly, application of a tight cast or a brace to the leg can compress the nerve, producing symptoms of fibular muscle palsy. Apart from a foot drop, other symptoms of common fibular nerve injury include loss of sensation over the lateral aspect of the leg and dorsum of the foot, and wasting of fibular and anterior tibial muscles. In the clinic | Anatomy_Gray. In the clinic The common fibular nerve is susceptible to injury as it passes around the lateral aspect of the neck of the fibula. It can be injured as a result of a direct trauma (blow or laceration), secondary to knee injury (knee dislocation), or as a consequence of a proximal fibular fracture. Sometimes damage to the nerve can be iatrogenic, that is, damaged during arthroscopy or knee surgery. Symptoms of common fibular nerve injury are often observed in bed-bound patients, particularly in those with decreased levels of consciousness, due to prolonged external pressure to the knee leading to nerve compression and neuropathy. Similarly, application of a tight cast or a brace to the leg can compress the nerve, producing symptoms of fibular muscle palsy. Apart from a foot drop, other symptoms of common fibular nerve injury include loss of sensation over the lateral aspect of the leg and dorsum of the foot, and wasting of fibular and anterior tibial muscles. In the clinic | [
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Anatomy_Gray_1640 | Anatomy_Gray | In the clinic Occasionally there is a superior projection of the distal aspect of the talus, which is beak-shaped (Fig. 6.101). It is often associated with the presence of a bony or fibrous joint between the talus and calcaneus. In the clinic Fracture of the talus The talus is an unusual bone because it ossifies from a single primary ossification center, which initially appears in the neck. The posterior aspect of the talus appears to ossify last, normally after puberty. In up to 50% of people there is a small accessory ossicle (the os trigonum) posterior to the lateral tubercle of the posterior process. Articular cartilage covers approximately 60% of the talar surface and there are no direct tendon or muscle attachments to the bone. | Anatomy_Gray. In the clinic Occasionally there is a superior projection of the distal aspect of the talus, which is beak-shaped (Fig. 6.101). It is often associated with the presence of a bony or fibrous joint between the talus and calcaneus. In the clinic Fracture of the talus The talus is an unusual bone because it ossifies from a single primary ossification center, which initially appears in the neck. The posterior aspect of the talus appears to ossify last, normally after puberty. In up to 50% of people there is a small accessory ossicle (the os trigonum) posterior to the lateral tubercle of the posterior process. Articular cartilage covers approximately 60% of the talar surface and there are no direct tendon or muscle attachments to the bone. | [
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Anatomy_Gray_1641 | Anatomy_Gray | One of the problems with fractures of the talus is that the blood supply to the bone is vulnerable to damage. The main blood supply to the bone enters the talus through the tarsal sinus from a branch of the posterior tibial artery. This vessel supplies most of the neck and the body of the talus. Branches of the dorsalis pedis artery enter the superior aspect of the talar neck and supply the dorsal portion of the head and neck, and branches from the fibular artery supply a small portion of the lateral talus. Fractures of the neck of the talus often interrupt the blood supply to the talus, so making the body and posterior aspect of the talus susceptible to osteonecrosis, which may in turn lead to premature osteoarthritis and require extensive surgery. In the clinic An appreciation of ankle anatomy is essential to understand the wide variety of fractures that may occur at and around the ankle joint. | Anatomy_Gray. One of the problems with fractures of the talus is that the blood supply to the bone is vulnerable to damage. The main blood supply to the bone enters the talus through the tarsal sinus from a branch of the posterior tibial artery. This vessel supplies most of the neck and the body of the talus. Branches of the dorsalis pedis artery enter the superior aspect of the talar neck and supply the dorsal portion of the head and neck, and branches from the fibular artery supply a small portion of the lateral talus. Fractures of the neck of the talus often interrupt the blood supply to the talus, so making the body and posterior aspect of the talus susceptible to osteonecrosis, which may in turn lead to premature osteoarthritis and require extensive surgery. In the clinic An appreciation of ankle anatomy is essential to understand the wide variety of fractures that may occur at and around the ankle joint. | [
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Anatomy_Gray_1642 | Anatomy_Gray | In the clinic An appreciation of ankle anatomy is essential to understand the wide variety of fractures that may occur at and around the ankle joint. The ankle joint and related structures can be regarded as a fibro-osseous ring oriented in the coronal plane. The upper part of the ring is formed by the joint between the distal ends of the fibula and tibia and by the ankle joint itself. The sides of the ring are formed by the ligaments that connect the medial malleolus and lateral malleolus to the adjacent tarsal bones. The bottom of the ring is not part of the ankle joint, but consists of the subtalar joint and the associated ligaments. Visualizing the ankle joint and surrounding structures as a fibro-osseous ring allows the physician to predict the type of damage likely to result from a particular type of injury. For example, an inversion injury may fracture the medial malleolus and tear ligaments anchoring the lateral malleolus to the tarsal bones. | Anatomy_Gray. In the clinic An appreciation of ankle anatomy is essential to understand the wide variety of fractures that may occur at and around the ankle joint. The ankle joint and related structures can be regarded as a fibro-osseous ring oriented in the coronal plane. The upper part of the ring is formed by the joint between the distal ends of the fibula and tibia and by the ankle joint itself. The sides of the ring are formed by the ligaments that connect the medial malleolus and lateral malleolus to the adjacent tarsal bones. The bottom of the ring is not part of the ankle joint, but consists of the subtalar joint and the associated ligaments. Visualizing the ankle joint and surrounding structures as a fibro-osseous ring allows the physician to predict the type of damage likely to result from a particular type of injury. For example, an inversion injury may fracture the medial malleolus and tear ligaments anchoring the lateral malleolus to the tarsal bones. | [
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Anatomy_Gray_1643 | Anatomy_Gray | The ring may be disrupted not only by damage to the bones (which produces fractures), but also by damage to the ligaments. Unlike bone fractures, damage to ligaments is unlikely to be appreciated on plain radiographs. When a fracture is noted on a plain radiograph, the physician must always be aware that there may also be appreciable ligamentous disruption. The Ottawa ankle rules were developed to assist clinicians in deciding whether patients with acute ankle injuries require investigation with radiographs in order to avoid unnecessary studies. Named after the hospital where they were developed, the rules are highly sensitive and have reduced the utilization of unwarranted ankle radiographs since their implementation. An ankle x-ray series is required if there is ankle pain and any of the following: Bone tenderness along the distal 6 cm of the posterior tibia or tip of the medial malleolus | Anatomy_Gray. The ring may be disrupted not only by damage to the bones (which produces fractures), but also by damage to the ligaments. Unlike bone fractures, damage to ligaments is unlikely to be appreciated on plain radiographs. When a fracture is noted on a plain radiograph, the physician must always be aware that there may also be appreciable ligamentous disruption. The Ottawa ankle rules were developed to assist clinicians in deciding whether patients with acute ankle injuries require investigation with radiographs in order to avoid unnecessary studies. Named after the hospital where they were developed, the rules are highly sensitive and have reduced the utilization of unwarranted ankle radiographs since their implementation. An ankle x-ray series is required if there is ankle pain and any of the following: Bone tenderness along the distal 6 cm of the posterior tibia or tip of the medial malleolus | [
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Anatomy_Gray_1644 | Anatomy_Gray | An ankle x-ray series is required if there is ankle pain and any of the following: Bone tenderness along the distal 6 cm of the posterior tibia or tip of the medial malleolus Bone tenderness along the distal 6 cm of the posterior fibula or tip of the lateral malleolus Inability to bear weight for four steps both immediately after the injury and in the emergency department A foot x-ray series is required if there is midfoot pain and any of the following: Bone tenderness at the base of the fifth metatarsal Bone tenderness at the navicular bone Inability to bear weight for four steps both immediately after the injury and in the emergency department In the clinic | Anatomy_Gray. An ankle x-ray series is required if there is ankle pain and any of the following: Bone tenderness along the distal 6 cm of the posterior tibia or tip of the medial malleolus Bone tenderness along the distal 6 cm of the posterior fibula or tip of the lateral malleolus Inability to bear weight for four steps both immediately after the injury and in the emergency department A foot x-ray series is required if there is midfoot pain and any of the following: Bone tenderness at the base of the fifth metatarsal Bone tenderness at the navicular bone Inability to bear weight for four steps both immediately after the injury and in the emergency department In the clinic | [
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Anatomy_Gray_1645 | Anatomy_Gray | Bone tenderness at the navicular bone Inability to bear weight for four steps both immediately after the injury and in the emergency department In the clinic A bunion occurs on the medial aspect of the first metatarsophalangeal joint. This is an extremely important area of the foot because it is crossed by tendons and ligaments, which transmit and distribute the body’s weight during movement. It is postulated that abnormal stresses in this region of the joint may produce the bunion deformity. Clinically, a bunion is a significant protuberance of bone that may include soft tissue around the medial aspect of the first metatarsophalangeal joint. As it progresses, the toe appears to move toward the smaller toes, producing crowding of the digits. This deformity tends to occur among people who wear high-heeled or pointed shoes, but osteoporosis and a hereditary predisposition are also risk factors. | Anatomy_Gray. Bone tenderness at the navicular bone Inability to bear weight for four steps both immediately after the injury and in the emergency department In the clinic A bunion occurs on the medial aspect of the first metatarsophalangeal joint. This is an extremely important area of the foot because it is crossed by tendons and ligaments, which transmit and distribute the body’s weight during movement. It is postulated that abnormal stresses in this region of the joint may produce the bunion deformity. Clinically, a bunion is a significant protuberance of bone that may include soft tissue around the medial aspect of the first metatarsophalangeal joint. As it progresses, the toe appears to move toward the smaller toes, producing crowding of the digits. This deformity tends to occur among people who wear high-heeled or pointed shoes, but osteoporosis and a hereditary predisposition are also risk factors. | [
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Anatomy_Gray_1646 | Anatomy_Gray | This deformity tends to occur among people who wear high-heeled or pointed shoes, but osteoporosis and a hereditary predisposition are also risk factors. Typically the patient’s symptoms are pain, swelling, and inflammation. The bunion tends to enlarge and may cause problems in obtaining appropriate footwear. Initial treatment is by adding padding to shoes, changing the type of footwear used, and taking anti-inflammatory drugs. Some patients may need surgery to correct the deformity and realign the toe. In the clinic | Anatomy_Gray. This deformity tends to occur among people who wear high-heeled or pointed shoes, but osteoporosis and a hereditary predisposition are also risk factors. Typically the patient’s symptoms are pain, swelling, and inflammation. The bunion tends to enlarge and may cause problems in obtaining appropriate footwear. Initial treatment is by adding padding to shoes, changing the type of footwear used, and taking anti-inflammatory drugs. Some patients may need surgery to correct the deformity and realign the toe. In the clinic | [
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Anatomy_Gray_1647 | Anatomy_Gray | In the clinic The plantar aponeurosis is a flat band of connective tissue that supports the arch of the sole of the foot. It runs from the calcaneal tuberosity to the base of the toes. Overuse and increased strain on the plantar aponeurosis, such as excessive running and standing, and increased body weight, can lead to micro-tears and degeneration within the aponeurosis at the heel with disorganization of the collagen fibers. Patients typically present with mild to severe heel pain, which appears thickened on imaging (Fig. 6.121). It is usually successfully treated with intense physiotherapy, but may require image-guided injection therapies. In severe cases, the diseased section of the fascia needs to be surgically removed. In the clinic | Anatomy_Gray. In the clinic The plantar aponeurosis is a flat band of connective tissue that supports the arch of the sole of the foot. It runs from the calcaneal tuberosity to the base of the toes. Overuse and increased strain on the plantar aponeurosis, such as excessive running and standing, and increased body weight, can lead to micro-tears and degeneration within the aponeurosis at the heel with disorganization of the collagen fibers. Patients typically present with mild to severe heel pain, which appears thickened on imaging (Fig. 6.121). It is usually successfully treated with intense physiotherapy, but may require image-guided injection therapies. In severe cases, the diseased section of the fascia needs to be surgically removed. In the clinic | [
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Anatomy_Gray_1648 | Anatomy_Gray | In the clinic A Morton’s neuroma is an enlarged common plantar nerve, usually in the third interspace between the third and fourth toes. In this region of the foot the lateral plantar nerve often unites with the medial plantar nerve. As the two nerves join, the resulting nerve is typically larger in diameter than those of the other toes. Also, it is in a relatively subcutaneous position, just above the fat pad of the foot close to the artery and the vein. Above the nerve is the deep transverse metatarsal ligament, which is a broad strong structure holding the metatarsals together. Typically, as the patient enters the “push-off” phase of walking the interdigital nerve is sandwiched between the ground and the deep transverse metatarsal ligament. The forces tend to compress the common plantar nerve, which can be irritated, in which case there is usually some associated inflammatory change and thickening. | Anatomy_Gray. In the clinic A Morton’s neuroma is an enlarged common plantar nerve, usually in the third interspace between the third and fourth toes. In this region of the foot the lateral plantar nerve often unites with the medial plantar nerve. As the two nerves join, the resulting nerve is typically larger in diameter than those of the other toes. Also, it is in a relatively subcutaneous position, just above the fat pad of the foot close to the artery and the vein. Above the nerve is the deep transverse metatarsal ligament, which is a broad strong structure holding the metatarsals together. Typically, as the patient enters the “push-off” phase of walking the interdigital nerve is sandwiched between the ground and the deep transverse metatarsal ligament. The forces tend to compress the common plantar nerve, which can be irritated, in which case there is usually some associated inflammatory change and thickening. | [
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Anatomy_Gray_1649 | Anatomy_Gray | Typically, patients experience pain in the third interspace, which may be sharp or dull and is usually worsened by wearing shoes and walking. Treatment may include injection of anti-inflammatory drugs, or it may be necessary to surgically remove the lesion. In the clinic Clubfoot is a congenital deformity in which babies are born with one or both feet pointing inward and downward. It is treated with gentle manipulation of the affected foot and with plaster casts to straighten the foot, which is usually followed by a minor surgical procedure where the calcaneal tendon is cut to release the foot into a better position. | Anatomy_Gray. Typically, patients experience pain in the third interspace, which may be sharp or dull and is usually worsened by wearing shoes and walking. Treatment may include injection of anti-inflammatory drugs, or it may be necessary to surgically remove the lesion. In the clinic Clubfoot is a congenital deformity in which babies are born with one or both feet pointing inward and downward. It is treated with gentle manipulation of the affected foot and with plaster casts to straighten the foot, which is usually followed by a minor surgical procedure where the calcaneal tendon is cut to release the foot into a better position. | [
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Anatomy_Gray_1650 | Anatomy_Gray | A young man was enjoying a long weekend skiing at a European ski resort. While racing a friend he caught an inner edge of his right ski. He lost his balance and fell. During his tumble he heard an audible “click.” After recovering from his spill, he developed tremendous pain in his right knee. He was unable to carry on skiing for that day, and by the time he returned to his chalet, his knee was significantly swollen. He went immediately to see an orthopedic surgeon. The orthopedic surgeon carefully reviewed the mechanism of injury. | Anatomy_Gray. A young man was enjoying a long weekend skiing at a European ski resort. While racing a friend he caught an inner edge of his right ski. He lost his balance and fell. During his tumble he heard an audible “click.” After recovering from his spill, he developed tremendous pain in his right knee. He was unable to carry on skiing for that day, and by the time he returned to his chalet, his knee was significantly swollen. He went immediately to see an orthopedic surgeon. The orthopedic surgeon carefully reviewed the mechanism of injury. | [
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Anatomy_Gray_1651 | Anatomy_Gray | The orthopedic surgeon carefully reviewed the mechanism of injury. The man was skiing down the slope with both skis in parallel. The ankles were held rigid in the boots and the knees were slightly flexed. A momentary loss of concentration led to the skier catching the inner edge of his right ski. This effect was to force the boot and calf into external rotation. Furthermore, the knee was forced into a valgus position (bowed laterally away from the midline) and the skier tumbled. Both skis were detached from the boots as the bindings released them. A series of structures within the knee joint were damaged sequentially. | Anatomy_Gray. The orthopedic surgeon carefully reviewed the mechanism of injury. The man was skiing down the slope with both skis in parallel. The ankles were held rigid in the boots and the knees were slightly flexed. A momentary loss of concentration led to the skier catching the inner edge of his right ski. This effect was to force the boot and calf into external rotation. Furthermore, the knee was forced into a valgus position (bowed laterally away from the midline) and the skier tumbled. Both skis were detached from the boots as the bindings released them. A series of structures within the knee joint were damaged sequentially. | [
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Anatomy_Gray_1652 | Anatomy_Gray | A series of structures within the knee joint were damaged sequentially. As the knee went into external rotation and valgus, the anterior cruciate ligament became taut, acting as a fulcrum. The tibial collateral ligament was stressed and the lateral compartment of the knee compressed. As the force increased, the tibial collateral ligament was torn (Fig. 6.139A,B), as was the medial meniscus (Fig. 6.140C). Finally, the anterior cruciate ligament, which was taut, gave way (Fig. 6.140A,B). The joint became swollen some hours afterward. Disruption of the anterior cruciate ligament characteristically produces marked joint swelling. The ligament is extrasynovial and intracapsular and has a rich blood supply. As the ligament was torn it ruptured into the joint. Blood from the tear irritates the synovial membrane and also enters the joint. These factors produce gradual swelling of the joint over the ensuing hours with significant fluid accumulation in the joint cavity. | Anatomy_Gray. A series of structures within the knee joint were damaged sequentially. As the knee went into external rotation and valgus, the anterior cruciate ligament became taut, acting as a fulcrum. The tibial collateral ligament was stressed and the lateral compartment of the knee compressed. As the force increased, the tibial collateral ligament was torn (Fig. 6.139A,B), as was the medial meniscus (Fig. 6.140C). Finally, the anterior cruciate ligament, which was taut, gave way (Fig. 6.140A,B). The joint became swollen some hours afterward. Disruption of the anterior cruciate ligament characteristically produces marked joint swelling. The ligament is extrasynovial and intracapsular and has a rich blood supply. As the ligament was torn it ruptured into the joint. Blood from the tear irritates the synovial membrane and also enters the joint. These factors produce gradual swelling of the joint over the ensuing hours with significant fluid accumulation in the joint cavity. | [
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Anatomy_Gray_1653 | Anatomy_Gray | The patient had a surgical reconstruction of the anterior cruciate ligament. It is difficult to find a man-made substance that can act in the same way as the anterior cruciate ligament and demonstrate the same physical properties. Surgeons have devised ingenious ways of reconstructing the anterior cruciate ligament. Two of the commonest methods use the patellar ligament (tendon) and hamstrings to reconstruct the ligament. The patient had further surgical procedures. The tibial collateral ligament was explored and resutured. Using arthroscopic techniques, the tear in the medial meniscus was débrided to prevent further complications. A 45-year-old man with diabetes mellitus visited his nurse because he had an ulcer on his foot that was not healing despite daily dressings. | Anatomy_Gray. The patient had a surgical reconstruction of the anterior cruciate ligament. It is difficult to find a man-made substance that can act in the same way as the anterior cruciate ligament and demonstrate the same physical properties. Surgeons have devised ingenious ways of reconstructing the anterior cruciate ligament. Two of the commonest methods use the patellar ligament (tendon) and hamstrings to reconstruct the ligament. The patient had further surgical procedures. The tibial collateral ligament was explored and resutured. Using arthroscopic techniques, the tear in the medial meniscus was débrided to prevent further complications. A 45-year-old man with diabetes mellitus visited his nurse because he had an ulcer on his foot that was not healing despite daily dressings. | [
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Anatomy_Gray_1654 | Anatomy_Gray | A 45-year-old man with diabetes mellitus visited his nurse because he had an ulcer on his foot that was not healing despite daily dressings. Diabetes can lead to vascular disease of large and medium arteries, narrowing the lumen and reducing blood supply to the extremities, thereby impairing healing. In addition, diabetes can also affect blood supply to nerves, which leads to peripheral neuropathy. Peripheral neuropathy results in reduced sensation, and therefore minor injuries can often go unnoticed. This patient has developed an ulcer on his heel, which is a pressure point and likely to be under repeated strain. The nurse examined the ulcer and found that the ulcer was looking infected with pus at the base of the ulcer and asked for a specialist orthopedic opinion, who requested an x-ray and an MRI. The MRI and x-ray both demonstrated infection invading into the calcaneus with destruction of the bone (Fig. 6.141A,B). | Anatomy_Gray. A 45-year-old man with diabetes mellitus visited his nurse because he had an ulcer on his foot that was not healing despite daily dressings. Diabetes can lead to vascular disease of large and medium arteries, narrowing the lumen and reducing blood supply to the extremities, thereby impairing healing. In addition, diabetes can also affect blood supply to nerves, which leads to peripheral neuropathy. Peripheral neuropathy results in reduced sensation, and therefore minor injuries can often go unnoticed. This patient has developed an ulcer on his heel, which is a pressure point and likely to be under repeated strain. The nurse examined the ulcer and found that the ulcer was looking infected with pus at the base of the ulcer and asked for a specialist orthopedic opinion, who requested an x-ray and an MRI. The MRI and x-ray both demonstrated infection invading into the calcaneus with destruction of the bone (Fig. 6.141A,B). | [
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Anatomy_Gray_1655 | Anatomy_Gray | The patient required surgical washout with removal of the dead and infected bone (debridement) and was given long-term antibiotic treatment (Fig. 6.141C). A young woman came to a vascular surgeon with a series of large dilated tortuous veins in her right leg. The rest of her leg was otherwise unremarkable. A diagnosis of varicose veins was made and the surgeon needed to determine the site of valvular incompetence. | Anatomy_Gray. The patient required surgical washout with removal of the dead and infected bone (debridement) and was given long-term antibiotic treatment (Fig. 6.141C). A young woman came to a vascular surgeon with a series of large dilated tortuous veins in her right leg. The rest of her leg was otherwise unremarkable. A diagnosis of varicose veins was made and the surgeon needed to determine the site of valvular incompetence. | [
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Anatomy_Gray_1656 | Anatomy_Gray | A diagnosis of varicose veins was made and the surgeon needed to determine the site of valvular incompetence. There are typical points where incompetent valves occur between the superficial and the deep veins. In these regions the varicosities tend to become marked. The typical sites are: at the saphena varix—the saphenofemoral junction where the femoral vein is joined by the great saphenous vein; in the midthigh perforating vein between the great saphenous vein and the femoral vein; in the calf the three sites where perforators occur, 5, 10, and 15 cm above the medial malleolus between the great saphenous vein and the deep veins of the calf; and at the junction of the small saphenous vein and the popliteal vein. | Anatomy_Gray. A diagnosis of varicose veins was made and the surgeon needed to determine the site of valvular incompetence. There are typical points where incompetent valves occur between the superficial and the deep veins. In these regions the varicosities tend to become marked. The typical sites are: at the saphena varix—the saphenofemoral junction where the femoral vein is joined by the great saphenous vein; in the midthigh perforating vein between the great saphenous vein and the femoral vein; in the calf the three sites where perforators occur, 5, 10, and 15 cm above the medial malleolus between the great saphenous vein and the deep veins of the calf; and at the junction of the small saphenous vein and the popliteal vein. | [
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Anatomy_Gray_1657 | Anatomy_Gray | The surgeon asked the patient to lie supine on the bed and elevated the leg. A tourniquet was placed around the upper thigh below the saphenofemoral junction and the patient was asked to stand up. No veins were demonstrated filling on the medial aspect of the thigh and lower limb. The effect of the tourniquet is to compress the great saphenous vein while permitting blood to flow in the deep venous system of the femoral vein and the deep femoral vein. Because there was no filling of the medial varicose veins below the level of the tourniquet, the surgeon assumed that the valve at the saphenofemoral junction was incompetent and would require surgical treatment. However, during the tourniquet maneuver the surgeon also noted some veins around the posterior and posterolateral aspect of the calf. | Anatomy_Gray. The surgeon asked the patient to lie supine on the bed and elevated the leg. A tourniquet was placed around the upper thigh below the saphenofemoral junction and the patient was asked to stand up. No veins were demonstrated filling on the medial aspect of the thigh and lower limb. The effect of the tourniquet is to compress the great saphenous vein while permitting blood to flow in the deep venous system of the femoral vein and the deep femoral vein. Because there was no filling of the medial varicose veins below the level of the tourniquet, the surgeon assumed that the valve at the saphenofemoral junction was incompetent and would require surgical treatment. However, during the tourniquet maneuver the surgeon also noted some veins around the posterior and posterolateral aspect of the calf. | [
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Anatomy_Gray_1658 | Anatomy_Gray | However, during the tourniquet maneuver the surgeon also noted some veins around the posterior and posterolateral aspect of the calf. A similar technique was performed by application of a tourniquet just below the level of the knee joint while the leg was elevated. The patient stood up and no veins were demonstrated filling in the posterior and posterolateral aspect of the calf. These findings suggested to the surgeon that there was also incompetence of the valve for the small saphenous system where it anastomoses with the popliteal vein. Surgery was planned. | Anatomy_Gray. However, during the tourniquet maneuver the surgeon also noted some veins around the posterior and posterolateral aspect of the calf. A similar technique was performed by application of a tourniquet just below the level of the knee joint while the leg was elevated. The patient stood up and no veins were demonstrated filling in the posterior and posterolateral aspect of the calf. These findings suggested to the surgeon that there was also incompetence of the valve for the small saphenous system where it anastomoses with the popliteal vein. Surgery was planned. | [
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Anatomy_Gray_1659 | Anatomy_Gray | Surgery was planned. A small transverse incision was made below the level of the inguinal ligament where the great saphenous vein passes through the saphenous ring in the deep fascia. This can be easily palpated as a small circular defect in the fascia. The saphenofemoral junction was identified and the great saphenous vein was ligated, at its anastomosis with the femoral vein. The great saphenous vein was stripped using special surgical techniques and removed. The patient was placed prone for the second part of the operation. A small incision was made transversely at the level of the skin crease in the popliteal fossa. However, the surgeon had difficulty identifying the junction between the small saphenous vein and the popliteal vein. After considerable time the surgeon located what he thought was the small saphenous vein and the structure was ligated and the wound closed. | Anatomy_Gray. Surgery was planned. A small transverse incision was made below the level of the inguinal ligament where the great saphenous vein passes through the saphenous ring in the deep fascia. This can be easily palpated as a small circular defect in the fascia. The saphenofemoral junction was identified and the great saphenous vein was ligated, at its anastomosis with the femoral vein. The great saphenous vein was stripped using special surgical techniques and removed. The patient was placed prone for the second part of the operation. A small incision was made transversely at the level of the skin crease in the popliteal fossa. However, the surgeon had difficulty identifying the junction between the small saphenous vein and the popliteal vein. After considerable time the surgeon located what he thought was the small saphenous vein and the structure was ligated and the wound closed. | [
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Anatomy_Gray_1660 | Anatomy_Gray | The following day the patient was sent home, but returned to the clinic after 2 weeks complaining of problems walking. On examination there was absence of dorsiflexion, a sensory disturbance over the lateral aspect of the leg and foot, and obvious wasting of the fibular muscles. As the patient walked, the foot was dragged between steps. A clinical diagnosis of footdrop was made and a common fibular nerve injury was diagnosed. The injury occurred at the time of surgery. | Anatomy_Gray. The following day the patient was sent home, but returned to the clinic after 2 weeks complaining of problems walking. On examination there was absence of dorsiflexion, a sensory disturbance over the lateral aspect of the leg and foot, and obvious wasting of the fibular muscles. As the patient walked, the foot was dragged between steps. A clinical diagnosis of footdrop was made and a common fibular nerve injury was diagnosed. The injury occurred at the time of surgery. | [
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Anatomy_Gray_1661 | Anatomy_Gray | Within the popliteal fossa are the popliteal artery, popliteal vein, and sciatic nerve (and its divisions). The popliteal artery is the deepest structure. The popliteal vein is superficial to the artery and the sciatic nerve is superficial to the vein (eFig. 6.142). Importantly, the sciatic nerve divides at the apex of the popliteal fossa. The tibial nerve continues into the lower popliteal fossa. The common fibular nerve passes laterally adjacent to the biceps femoris muscle to become superficial and wrap around the fibula neck. It was concluded that the surgeon had accidentally ligated the common fibular nerve rather than the small saphenous vein, thus producing this patient’s symptoms. A 72-year-old woman was admitted to the emergency room after falling at home. She complained of a severe pain in her right hip and had noticeable bruising on the right side of the face. On admission it was noted that the patient’s right leg was shorter than her left leg and externally rotated. | Anatomy_Gray. Within the popliteal fossa are the popliteal artery, popliteal vein, and sciatic nerve (and its divisions). The popliteal artery is the deepest structure. The popliteal vein is superficial to the artery and the sciatic nerve is superficial to the vein (eFig. 6.142). Importantly, the sciatic nerve divides at the apex of the popliteal fossa. The tibial nerve continues into the lower popliteal fossa. The common fibular nerve passes laterally adjacent to the biceps femoris muscle to become superficial and wrap around the fibula neck. It was concluded that the surgeon had accidentally ligated the common fibular nerve rather than the small saphenous vein, thus producing this patient’s symptoms. A 72-year-old woman was admitted to the emergency room after falling at home. She complained of a severe pain in her right hip and had noticeable bruising on the right side of the face. On admission it was noted that the patient’s right leg was shorter than her left leg and externally rotated. | [
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Anatomy_Gray_1662 | Anatomy_Gray | On admission it was noted that the patient’s right leg was shorter than her left leg and externally rotated. An initial series of investigations was carried out, including a plain radiograph of the pelvis. The plain radiograph of the pelvis demonstrated a displaced fracture through the right neck of the femur. | Anatomy_Gray. On admission it was noted that the patient’s right leg was shorter than her left leg and externally rotated. An initial series of investigations was carried out, including a plain radiograph of the pelvis. The plain radiograph of the pelvis demonstrated a displaced fracture through the right neck of the femur. | [
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Anatomy_Gray_1663 | Anatomy_Gray | The plain radiograph of the pelvis demonstrated a displaced fracture through the right neck of the femur. The apparent shortening and external rotation of the leg on clinical examination were accounted for by spasm of the muscles connecting the pelvis to the trochanters and proximal femur. Of the muscles that surround the hip joint the largest group is the adductor group (adductor longus, brevis, and magnus) and the psoas major. The psoas major inserts onto the lesser trochanter and its action is to externally rotate and flex the hip. The fulcrum of action of the psoas major is the femoral head in the acetabulum. However, when the femoral neck is detached its overriding action pulls the femur proximally and into external rotation. The external rotation is exacerbated by the spasm in the adductor muscles. Extensive medical testing was necessary before surgery. It is important to remember that elderly patients may have a number of coexisting diseases. | Anatomy_Gray. The plain radiograph of the pelvis demonstrated a displaced fracture through the right neck of the femur. The apparent shortening and external rotation of the leg on clinical examination were accounted for by spasm of the muscles connecting the pelvis to the trochanters and proximal femur. Of the muscles that surround the hip joint the largest group is the adductor group (adductor longus, brevis, and magnus) and the psoas major. The psoas major inserts onto the lesser trochanter and its action is to externally rotate and flex the hip. The fulcrum of action of the psoas major is the femoral head in the acetabulum. However, when the femoral neck is detached its overriding action pulls the femur proximally and into external rotation. The external rotation is exacerbated by the spasm in the adductor muscles. Extensive medical testing was necessary before surgery. It is important to remember that elderly patients may have a number of coexisting diseases. | [
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Anatomy_Gray_1664 | Anatomy_Gray | Extensive medical testing was necessary before surgery. It is important to remember that elderly patients may have a number of coexisting diseases. The patient then underwent a hemiarthroplasty. Hemiarthroplasty is a surgical procedure in which the femoral head is removed from the acetabulum. The femoral neck is trimmed close to the trochanters and the medullary cavity of the femoral shaft is reamed. A metal hip prosthesis is inserted into the medullary cavity of the femur and the head of the prosthesis is placed into the acetabulum, in which it articulates. Importantly, the acetabulum is not replaced in straightforward cases, though a prosthetic acetabulum may be inserted if clinically appropriate. An arthroplasty was the only procedure that could be performed. | Anatomy_Gray. Extensive medical testing was necessary before surgery. It is important to remember that elderly patients may have a number of coexisting diseases. The patient then underwent a hemiarthroplasty. Hemiarthroplasty is a surgical procedure in which the femoral head is removed from the acetabulum. The femoral neck is trimmed close to the trochanters and the medullary cavity of the femoral shaft is reamed. A metal hip prosthesis is inserted into the medullary cavity of the femur and the head of the prosthesis is placed into the acetabulum, in which it articulates. Importantly, the acetabulum is not replaced in straightforward cases, though a prosthetic acetabulum may be inserted if clinically appropriate. An arthroplasty was the only procedure that could be performed. | [
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Anatomy_Gray_1665 | Anatomy_Gray | An arthroplasty was the only procedure that could be performed. The blood supply to the femoral head is from three sources—the artery within the ligament of the head of the femur, vessels in the medullary cavity, and vessels deep to the synovium running in the retinacula of the fibrous capsule of the hip joint. With increasing age, the medullary cavity undergoes fatty replacement of the normal red marrow, thus attenuating the medullary blood supply. The artery within the ligament of the head of the femur also becomes attenuated and this is often associated with atherosclerotic arterial disease. | Anatomy_Gray. An arthroplasty was the only procedure that could be performed. The blood supply to the femoral head is from three sources—the artery within the ligament of the head of the femur, vessels in the medullary cavity, and vessels deep to the synovium running in the retinacula of the fibrous capsule of the hip joint. With increasing age, the medullary cavity undergoes fatty replacement of the normal red marrow, thus attenuating the medullary blood supply. The artery within the ligament of the head of the femur also becomes attenuated and this is often associated with atherosclerotic arterial disease. | [
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Anatomy_Gray_1666 | Anatomy_Gray | Unfortunately for this patient, the sole blood supply to the head of the femur was via the vessels in the retinacula fibers, which were transected at the time of the fracture. If the patient had an intertrochanteric fracture instead, the vessels of the retinacula fibers would not have been damaged and a different approach to surgical fixation could be undertaken without the need for a hemiarthroplasty. The patient has osteoporosis. Osteoporosis is a common condition affecting older people, but is significantly more frequent in postmenopausal women. Many fractures of the femoral neck in elderly patients occur because the strength of the bone is significantly reduced when it is osteoporotic. Other common sites for osteoporotic fractures include the distal radius and the thoracic and lumbar vertebrae. | Anatomy_Gray. Unfortunately for this patient, the sole blood supply to the head of the femur was via the vessels in the retinacula fibers, which were transected at the time of the fracture. If the patient had an intertrochanteric fracture instead, the vessels of the retinacula fibers would not have been damaged and a different approach to surgical fixation could be undertaken without the need for a hemiarthroplasty. The patient has osteoporosis. Osteoporosis is a common condition affecting older people, but is significantly more frequent in postmenopausal women. Many fractures of the femoral neck in elderly patients occur because the strength of the bone is significantly reduced when it is osteoporotic. Other common sites for osteoporotic fractures include the distal radius and the thoracic and lumbar vertebrae. | [
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Anatomy_Gray_1667 | Anatomy_Gray | A 28-year-old woman was seen by her family practitioner for a routine pregnancy checkup at 36 weeks’ gestational age. Neither the patient nor the family physician had any concerns about the pregnancy. However, the patient did complain of unilateral swelling of her left leg, which had gradually increased over the previous 2 days. Furthermore, the evening before her visit she developed some sharp chest pain, which was exacerbated by deep breaths. The family physician ordered a duplex ultrasound scan of the left leg venous system. Ultrasound scanning of the vascular tree can demonstrate flow and occlusion of arteries and veins. | Anatomy_Gray. A 28-year-old woman was seen by her family practitioner for a routine pregnancy checkup at 36 weeks’ gestational age. Neither the patient nor the family physician had any concerns about the pregnancy. However, the patient did complain of unilateral swelling of her left leg, which had gradually increased over the previous 2 days. Furthermore, the evening before her visit she developed some sharp chest pain, which was exacerbated by deep breaths. The family physician ordered a duplex ultrasound scan of the left leg venous system. Ultrasound scanning of the vascular tree can demonstrate flow and occlusion of arteries and veins. | [
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Anatomy_Gray_1668 | Anatomy_Gray | The family physician ordered a duplex ultrasound scan of the left leg venous system. Ultrasound scanning of the vascular tree can demonstrate flow and occlusion of arteries and veins. The probe was placed over the left femoral vein and no flow was demonstrated. Furthermore, the vein could not be compressed, and no alteration of flow with breathing could be demonstrated. Some flow was demonstrated in the deep femoral vein and in the great saphenous vein. No flow was demonstrated throughout the length of the left femoral vein, the popliteal vein, and the tibial veins. The technician scanned the opposite side, where excellent flow was demonstrated within the right femoral venous system. In addition, when the calf was gently massaged an augmentation to the flow was noted. It was possible to demonstrate alteration of flow with respiratory excursion and venous compression was satisfactory. A diagnosis of extensive left-sided deep vein thrombosis was made. | Anatomy_Gray. The family physician ordered a duplex ultrasound scan of the left leg venous system. Ultrasound scanning of the vascular tree can demonstrate flow and occlusion of arteries and veins. The probe was placed over the left femoral vein and no flow was demonstrated. Furthermore, the vein could not be compressed, and no alteration of flow with breathing could be demonstrated. Some flow was demonstrated in the deep femoral vein and in the great saphenous vein. No flow was demonstrated throughout the length of the left femoral vein, the popliteal vein, and the tibial veins. The technician scanned the opposite side, where excellent flow was demonstrated within the right femoral venous system. In addition, when the calf was gently massaged an augmentation to the flow was noted. It was possible to demonstrate alteration of flow with respiratory excursion and venous compression was satisfactory. A diagnosis of extensive left-sided deep vein thrombosis was made. | [
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Anatomy_Gray_1669 | Anatomy_Gray | Certain patients are more prone to deep vein thrombosis. Three major factors predispose a patient to thrombosis: reduced or stagnant blood flow in the veins—significant stasis of blood (which may be due to lack of movement), reduced muscular calf pump effect, and obstruction to flow may occur; injury to the vein wall—venous trauma may damage the vessel walls, promoting thrombus formation; hypercoagulability of the blood—hypercoagulable states are often associated with abnormal levels of certain clotting factors, such as antithrombin III, protein C, and protein S. In this patient, compression of the left external iliac veins by the gravid uterus was the likely cause of stasis, which led to the deep vein thrombosis. The chest pain was due to pulmonary emboli. | Anatomy_Gray. Certain patients are more prone to deep vein thrombosis. Three major factors predispose a patient to thrombosis: reduced or stagnant blood flow in the veins—significant stasis of blood (which may be due to lack of movement), reduced muscular calf pump effect, and obstruction to flow may occur; injury to the vein wall—venous trauma may damage the vessel walls, promoting thrombus formation; hypercoagulability of the blood—hypercoagulable states are often associated with abnormal levels of certain clotting factors, such as antithrombin III, protein C, and protein S. In this patient, compression of the left external iliac veins by the gravid uterus was the likely cause of stasis, which led to the deep vein thrombosis. The chest pain was due to pulmonary emboli. | [
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Anatomy_Gray_1670 | Anatomy_Gray | In this patient, compression of the left external iliac veins by the gravid uterus was the likely cause of stasis, which led to the deep vein thrombosis. The chest pain was due to pulmonary emboli. Small emboli were thrown off from the leading edge of the thrombus through the heart to lodge in the lungs. Small emboli cause typical pleuritic chest pain, which is exacerbated by breathing. In isolation these small pulmonary emboli may affect respiratory function, but they may be the precursor to a large and potentially fatal pulmonary embolus (eFig. 6.143). Anticoagulation was instituted and the patient had an uneventful delivery. A 45-year-old man had recently taken up squash. During a game he attempted a forehand shot and noticed severe sudden pain in his heel. He thought his opponent had hit him with his racket. When he turned, though, he realized his opponent was too far away to have hit him. | Anatomy_Gray. In this patient, compression of the left external iliac veins by the gravid uterus was the likely cause of stasis, which led to the deep vein thrombosis. The chest pain was due to pulmonary emboli. Small emboli were thrown off from the leading edge of the thrombus through the heart to lodge in the lungs. Small emboli cause typical pleuritic chest pain, which is exacerbated by breathing. In isolation these small pulmonary emboli may affect respiratory function, but they may be the precursor to a large and potentially fatal pulmonary embolus (eFig. 6.143). Anticoagulation was instituted and the patient had an uneventful delivery. A 45-year-old man had recently taken up squash. During a game he attempted a forehand shot and noticed severe sudden pain in his heel. He thought his opponent had hit him with his racket. When he turned, though, he realized his opponent was too far away to have hit him. | [
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Anatomy_Gray_1671 | Anatomy_Gray | Within minutes there was marked swelling of the ankle. The patient was unable to plantarflex his foot and had to stop the game. Afterward an appreciable subcutaneous hematoma developed in the ankle. The diagnostic possibilities include a bone or soft tissue injury. A bony injury was excluded because there was no bone tenderness. The patient had a significant soft tissue injury. On examination he had significant swelling of the ankle with a subcutaneous hematoma. He was unable to stand on tiptoe on the right leg, and in the prone position a palpable defect was demonstrated within the calcaneal tendon. A diagnosis of calcaneal tendon rupture was made. This patient has a typical history of ruptured calcaneal tendon and the clinical findings support this. Magnetic resonance imaging was carried out and confirmed the diagnosis (eFig. 6.144). The patient underwent an operative repair. The tendon healed well, though the patient has not gone back to playing squash. | Anatomy_Gray. Within minutes there was marked swelling of the ankle. The patient was unable to plantarflex his foot and had to stop the game. Afterward an appreciable subcutaneous hematoma developed in the ankle. The diagnostic possibilities include a bone or soft tissue injury. A bony injury was excluded because there was no bone tenderness. The patient had a significant soft tissue injury. On examination he had significant swelling of the ankle with a subcutaneous hematoma. He was unable to stand on tiptoe on the right leg, and in the prone position a palpable defect was demonstrated within the calcaneal tendon. A diagnosis of calcaneal tendon rupture was made. This patient has a typical history of ruptured calcaneal tendon and the clinical findings support this. Magnetic resonance imaging was carried out and confirmed the diagnosis (eFig. 6.144). The patient underwent an operative repair. The tendon healed well, though the patient has not gone back to playing squash. | [
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Anatomy_Gray_1672 | Anatomy_Gray | The patient underwent an operative repair. The tendon healed well, though the patient has not gone back to playing squash. A 67-year-old man was noted to have a mass at the back of his knee. The mass measured approximately 4 cm in transverse diameter. The patient was otherwise fit and well and had no other history of note. The mass was arising from one of the structures in the popliteal fossa. Within the popliteal fossa there is a neurovascular bundle that contains the sciatic nerve (and its two divisions), the popliteal artery and the popliteal vein. There are also numerous small bursae associated with the posterior aspect of the knee joint and the muscles and tendons in this region. It is possible that this mass is arising from the posterior structures of the knee joint, which include synovial outpouchings, the menisci, and the muscles and tendons of this region. | Anatomy_Gray. The patient underwent an operative repair. The tendon healed well, though the patient has not gone back to playing squash. A 67-year-old man was noted to have a mass at the back of his knee. The mass measured approximately 4 cm in transverse diameter. The patient was otherwise fit and well and had no other history of note. The mass was arising from one of the structures in the popliteal fossa. Within the popliteal fossa there is a neurovascular bundle that contains the sciatic nerve (and its two divisions), the popliteal artery and the popliteal vein. There are also numerous small bursae associated with the posterior aspect of the knee joint and the muscles and tendons in this region. It is possible that this mass is arising from the posterior structures of the knee joint, which include synovial outpouchings, the menisci, and the muscles and tendons of this region. | [
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Anatomy_Gray_1673 | Anatomy_Gray | The commonest masses demonstrated within the popliteal fossa are a popliteal cyst, a popliteal aneurysm, and an arterial adventitial cyst. Further clinical examination revealed that this mass was pulsatile and demonstrated a bruit (an audible rumbling made by turbulent blood flow) on auscultation. A diagnosis of popliteal artery aneurysm was made. A popliteal artery aneurysm is an abnormal dilation of the popliteal artery. It is unusual for it to be greater than 5 cm because symptoms usually develop before it reaches this size. Unlike aneurysms elsewhere in the body, the natural history of popliteal aneurysms is to embolize, with the mural thrombus producing ischemia distal to the lesion, rather than rupture. It is mandatory to examine the rest of the arterial tree in patients with a popliteal aneurysm because aneurysms may be bilateral and there is an association with abdominal aortic aneurysms. | Anatomy_Gray. The commonest masses demonstrated within the popliteal fossa are a popliteal cyst, a popliteal aneurysm, and an arterial adventitial cyst. Further clinical examination revealed that this mass was pulsatile and demonstrated a bruit (an audible rumbling made by turbulent blood flow) on auscultation. A diagnosis of popliteal artery aneurysm was made. A popliteal artery aneurysm is an abnormal dilation of the popliteal artery. It is unusual for it to be greater than 5 cm because symptoms usually develop before it reaches this size. Unlike aneurysms elsewhere in the body, the natural history of popliteal aneurysms is to embolize, with the mural thrombus producing ischemia distal to the lesion, rather than rupture. It is mandatory to examine the rest of the arterial tree in patients with a popliteal aneurysm because aneurysms may be bilateral and there is an association with abdominal aortic aneurysms. | [
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Anatomy_Gray_1674 | Anatomy_Gray | The other diagnostic possibilities include a popliteal cyst and an adventitial cyst. A popliteal cyst (Baker’s cyst) is a synovial outpouching that arises from the posteromedial aspect of the knee joint. The synovial membrane of the knee joint outpouches between the medial head of the gastrocnemius and the semimembranosus tendon to lie medially within the popliteal fossa. Occasionally it tracks inferiorly to lie in and around the tendons that form the pes anserinus (sartorius, gracilis, and semitendinosus). An arterial adventitial cyst is an uncommon cystic structure that arises from the wall of the artery. An ultrasound investigation was carried out. Using real-time ultrasound the dimensions of the popliteal aneurysm were characterized and the flow in the vessels was demonstrated. Furthermore, a popliteal cyst and adventitial cyst were completely excluded. The patient underwent a surgical excision and graft interposition and has made an uneventful recovery. | Anatomy_Gray. The other diagnostic possibilities include a popliteal cyst and an adventitial cyst. A popliteal cyst (Baker’s cyst) is a synovial outpouching that arises from the posteromedial aspect of the knee joint. The synovial membrane of the knee joint outpouches between the medial head of the gastrocnemius and the semimembranosus tendon to lie medially within the popliteal fossa. Occasionally it tracks inferiorly to lie in and around the tendons that form the pes anserinus (sartorius, gracilis, and semitendinosus). An arterial adventitial cyst is an uncommon cystic structure that arises from the wall of the artery. An ultrasound investigation was carried out. Using real-time ultrasound the dimensions of the popliteal aneurysm were characterized and the flow in the vessels was demonstrated. Furthermore, a popliteal cyst and adventitial cyst were completely excluded. The patient underwent a surgical excision and graft interposition and has made an uneventful recovery. | [
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Anatomy_Gray_1675 | Anatomy_Gray | The patient underwent a surgical excision and graft interposition and has made an uneventful recovery. A young long-distance runner came to her physician with acute swelling around the lateral aspect of her ankle. This injury occurred directly after accidentally running into a pothole in the pavement. A fractured ankle was suspected. Plain anteroposterior and lateral radiographs of the ankle revealed no evidence of any bone injury to account for the patient’s soft tissue swelling. The patient was given a pair of crutches and analgesics and told to rest. A diagnosis of a simple sprain was made. Over the ensuing weeks the swelling and edema within the soft tissue of the ankle decreased and the patient began to run, but noted that the ankle kept “giving way.” She went to an orthopedic surgeon for further assessment. There was a positive anterior drawer test of the ankle joint. | Anatomy_Gray. The patient underwent a surgical excision and graft interposition and has made an uneventful recovery. A young long-distance runner came to her physician with acute swelling around the lateral aspect of her ankle. This injury occurred directly after accidentally running into a pothole in the pavement. A fractured ankle was suspected. Plain anteroposterior and lateral radiographs of the ankle revealed no evidence of any bone injury to account for the patient’s soft tissue swelling. The patient was given a pair of crutches and analgesics and told to rest. A diagnosis of a simple sprain was made. Over the ensuing weeks the swelling and edema within the soft tissue of the ankle decreased and the patient began to run, but noted that the ankle kept “giving way.” She went to an orthopedic surgeon for further assessment. There was a positive anterior drawer test of the ankle joint. | [
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Anatomy_Gray_1676 | Anatomy_Gray | There was a positive anterior drawer test of the ankle joint. At this stage it is important to review the mechanism of injury. Typically when running on a hard surface the final phase of push-off involves supination of the foot. If the foot is caught in a pothole or divot, this supinating maneuver continues and inverts the ankle joint in plantarflexion. This puts significant strain on the lateral ligament complex and, given the appropriate circumstances, disruption (in order) of the ligament structures occurs from anterior to posterior. First, the anterior talofibular ligament is disrupted, followed by the calcaneofibular ligament, and then the posterior talofibular ligament. As each of these ligaments is disrupted, the severity of the soft tissue injury is significantly enhanced and the chance of permanent ankle instability is increased. | Anatomy_Gray. There was a positive anterior drawer test of the ankle joint. At this stage it is important to review the mechanism of injury. Typically when running on a hard surface the final phase of push-off involves supination of the foot. If the foot is caught in a pothole or divot, this supinating maneuver continues and inverts the ankle joint in plantarflexion. This puts significant strain on the lateral ligament complex and, given the appropriate circumstances, disruption (in order) of the ligament structures occurs from anterior to posterior. First, the anterior talofibular ligament is disrupted, followed by the calcaneofibular ligament, and then the posterior talofibular ligament. As each of these ligaments is disrupted, the severity of the soft tissue injury is significantly enhanced and the chance of permanent ankle instability is increased. | [
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Anatomy_Gray_1677 | Anatomy_Gray | On examination any positive anterior drawer test of the ankle (4–5 mm compared to the opposite side) suggests an injury to the anterior talofibular ligament. The anterior talofibular ligament can be assessed by placing the foot in marked plantarflexion. If there is over 10° of difference between the affected foot and nonaffected foot, an anterior talofibular ligament disruption is suspected. It is extremely rare for all three ligaments to be disrupted, and if so there are usually other significant ankle injuries. Magnetic resonance imaging (MRI) was carried out to assess ligament damage. MRI is excellent for demonstrating the medial and lateral ligament complexes of the ankle as well as the soft tissues that support the bones of the posterior foot. Unfortunately for this patient there was a tear of the anterior talofibular ligament (eFig. 6.145), which had to be repaired surgically. 670.e2 670.e1 In the clinic—cont’d | Anatomy_Gray. On examination any positive anterior drawer test of the ankle (4–5 mm compared to the opposite side) suggests an injury to the anterior talofibular ligament. The anterior talofibular ligament can be assessed by placing the foot in marked plantarflexion. If there is over 10° of difference between the affected foot and nonaffected foot, an anterior talofibular ligament disruption is suspected. It is extremely rare for all three ligaments to be disrupted, and if so there are usually other significant ankle injuries. Magnetic resonance imaging (MRI) was carried out to assess ligament damage. MRI is excellent for demonstrating the medial and lateral ligament complexes of the ankle as well as the soft tissues that support the bones of the posterior foot. Unfortunately for this patient there was a tear of the anterior talofibular ligament (eFig. 6.145), which had to be repaired surgically. 670.e2 670.e1 In the clinic—cont’d | [
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Anatomy_Gray_1678 | Anatomy_Gray | Unfortunately for this patient there was a tear of the anterior talofibular ligament (eFig. 6.145), which had to be repaired surgically. 670.e2 670.e1 In the clinic—cont’d Table 6.1 Branches of the lumbosacral plexus associated with the lower limb—cont’d Regional Anatomy • Deep Fascia and the Saphenous Opening Fig. 6.73, cont’d Surface Anatomy • Avoiding the Sciatic Nerve Surface Anatomy • Identifying Structures Around the Knee Surface Anatomy • Finding the Tarsal Tunnel—the Gateway to the Foot Surface Anatomy • Approximating the Position of the Plantar Arterial Arch Anterior compartment of the forearm 766 Posterior compartment of the forearm 775 Carpal tunnel and structures at the wrist 788 Bony landmarks and muscles of the posterior scapular region 810 Visualizing the axilla and locating contents and related structures 811 Locating the brachial artery in the arm 812 The triceps brachii tendon and position of the radial nerve 813 | Anatomy_Gray. Unfortunately for this patient there was a tear of the anterior talofibular ligament (eFig. 6.145), which had to be repaired surgically. 670.e2 670.e1 In the clinic—cont’d Table 6.1 Branches of the lumbosacral plexus associated with the lower limb—cont’d Regional Anatomy • Deep Fascia and the Saphenous Opening Fig. 6.73, cont’d Surface Anatomy • Avoiding the Sciatic Nerve Surface Anatomy • Identifying Structures Around the Knee Surface Anatomy • Finding the Tarsal Tunnel—the Gateway to the Foot Surface Anatomy • Approximating the Position of the Plantar Arterial Arch Anterior compartment of the forearm 766 Posterior compartment of the forearm 775 Carpal tunnel and structures at the wrist 788 Bony landmarks and muscles of the posterior scapular region 810 Visualizing the axilla and locating contents and related structures 811 Locating the brachial artery in the arm 812 The triceps brachii tendon and position of the radial nerve 813 | [
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Anatomy_Gray_1679 | Anatomy_Gray | Visualizing the axilla and locating contents and related structures 811 Locating the brachial artery in the arm 812 The triceps brachii tendon and position of the radial nerve 813 Identifying tendons and locating major vessels and nerves in the distal forearm 815 Normal appearance of the hand 816 Position of the flexor retinaculum and the recurrent branch of the median nerve 817 Motor function of the median and ulnar nerves in the hand 817 Visualizing the positions of the superficial and deep palmar arches 818 The upper limb is associated with the lateral aspect of the lower portion of the neck and with the thoracic wall. It is suspended from the trunk by muscles and a small skeletal articulation between the clavicle and the sternum—the sternoclavicular joint. Based on the position of its major joints and component bones, the upper limb is divided into shoulder, arm, forearm, and hand (Fig. 7.1A). | Anatomy_Gray. Visualizing the axilla and locating contents and related structures 811 Locating the brachial artery in the arm 812 The triceps brachii tendon and position of the radial nerve 813 Identifying tendons and locating major vessels and nerves in the distal forearm 815 Normal appearance of the hand 816 Position of the flexor retinaculum and the recurrent branch of the median nerve 817 Motor function of the median and ulnar nerves in the hand 817 Visualizing the positions of the superficial and deep palmar arches 818 The upper limb is associated with the lateral aspect of the lower portion of the neck and with the thoracic wall. It is suspended from the trunk by muscles and a small skeletal articulation between the clavicle and the sternum—the sternoclavicular joint. Based on the position of its major joints and component bones, the upper limb is divided into shoulder, arm, forearm, and hand (Fig. 7.1A). | [
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Anatomy_Gray_1680 | Anatomy_Gray | The shoulder is the area of upper limb attachment to the trunk (Fig. 7.1B). The arm is the part of the upper limb between the shoulder and the elbow joint; the forearm is between the elbow joint and the wrist joint; and the hand is distal to the wrist joint. The axilla, cubital fossa, and carpal tunnel are significant areas of transition between the different parts of the limb (Fig. 7.2). Important structures pass through, or are related to, each of these areas. The axilla is an irregularly shaped pyramidal area formed by muscles and bones of the shoulder and the lateral surface of the thoracic wall. The apex or inlet opens directly into the lower portion of the neck. The skin of the armpit forms the floor. All major structures that pass between the neck and arm pass through the axilla. | Anatomy_Gray. The shoulder is the area of upper limb attachment to the trunk (Fig. 7.1B). The arm is the part of the upper limb between the shoulder and the elbow joint; the forearm is between the elbow joint and the wrist joint; and the hand is distal to the wrist joint. The axilla, cubital fossa, and carpal tunnel are significant areas of transition between the different parts of the limb (Fig. 7.2). Important structures pass through, or are related to, each of these areas. The axilla is an irregularly shaped pyramidal area formed by muscles and bones of the shoulder and the lateral surface of the thoracic wall. The apex or inlet opens directly into the lower portion of the neck. The skin of the armpit forms the floor. All major structures that pass between the neck and arm pass through the axilla. | [
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Anatomy_Gray_1681 | Anatomy_Gray | The cubital fossa is a triangularly shaped depression formed by muscles anterior to the elbow joint. The major artery, the brachial artery, passing from the arm to the forearm passes through this fossa, as does one of the major nerves of the upper limb, the median nerve. The carpal tunnel is the gateway to the palm of the hand. Its posterior, lateral, and medial walls form an arch, which is made up of small carpal bones in the proximal region of the hand. A thick band of connective tissue, the flexor retinaculum, spans the distance between each side of the arch and forms the anterior wall of the tunnel. The median nerve and all the long flexor tendons passing from the forearm to the digits of the hand pass through the carpal tunnel. Positioning the hand Unlike the lower limb, which is used for support, stability, and locomotion, the upper limb is highly mobile for positioning the hand in space. | Anatomy_Gray. The cubital fossa is a triangularly shaped depression formed by muscles anterior to the elbow joint. The major artery, the brachial artery, passing from the arm to the forearm passes through this fossa, as does one of the major nerves of the upper limb, the median nerve. The carpal tunnel is the gateway to the palm of the hand. Its posterior, lateral, and medial walls form an arch, which is made up of small carpal bones in the proximal region of the hand. A thick band of connective tissue, the flexor retinaculum, spans the distance between each side of the arch and forms the anterior wall of the tunnel. The median nerve and all the long flexor tendons passing from the forearm to the digits of the hand pass through the carpal tunnel. Positioning the hand Unlike the lower limb, which is used for support, stability, and locomotion, the upper limb is highly mobile for positioning the hand in space. | [
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Anatomy_Gray_1682 | Anatomy_Gray | Positioning the hand Unlike the lower limb, which is used for support, stability, and locomotion, the upper limb is highly mobile for positioning the hand in space. The shoulder is suspended from the trunk predominantly by muscles and can therefore be moved relative to the body. Sliding (protraction and retraction) and rotating the scapula on the thoracic wall changes the position of the glenohumeral joint (shoulder joint) and extends the reach of the hand (Fig. 7.3). The glenohumeral joint allows the arm to move around three axes with a wide range of motion. Movements of the arm at this joint are flexion, extension, abduction, adduction, medial rotation (internal rotation), lateral rotation (external rotation), and circumduction (Fig. 7.4). | Anatomy_Gray. Positioning the hand Unlike the lower limb, which is used for support, stability, and locomotion, the upper limb is highly mobile for positioning the hand in space. The shoulder is suspended from the trunk predominantly by muscles and can therefore be moved relative to the body. Sliding (protraction and retraction) and rotating the scapula on the thoracic wall changes the position of the glenohumeral joint (shoulder joint) and extends the reach of the hand (Fig. 7.3). The glenohumeral joint allows the arm to move around three axes with a wide range of motion. Movements of the arm at this joint are flexion, extension, abduction, adduction, medial rotation (internal rotation), lateral rotation (external rotation), and circumduction (Fig. 7.4). | [
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Anatomy_Gray_1683 | Anatomy_Gray | The major movements at the elbow joint are flexion and extension of the forearm (Fig. 7.5A). At the other end of the forearm, the distal end of the lateral bone, the radius, can be flipped over the adjacent head of the medial bone, the ulna. Because the hand is articulated with the radius, it can be efficiently moved from a palm-anterior position to a palm-posterior position simply by crossing the distal end of the radius over the ulna (Fig. 7.5B). This movement, termed pronation, occurs solely in the forearm. Supination returns the hand to the anatomical position. At the wrist joint, the hand can be abducted, adducted, flexed, extended, and circumducted (Fig. 7.6). These movements, combined with those of the shoulder, arm, and forearm, enable the hand to be placed in a wide range of positions relative to the body. The hand as a mechanical tool | Anatomy_Gray. The major movements at the elbow joint are flexion and extension of the forearm (Fig. 7.5A). At the other end of the forearm, the distal end of the lateral bone, the radius, can be flipped over the adjacent head of the medial bone, the ulna. Because the hand is articulated with the radius, it can be efficiently moved from a palm-anterior position to a palm-posterior position simply by crossing the distal end of the radius over the ulna (Fig. 7.5B). This movement, termed pronation, occurs solely in the forearm. Supination returns the hand to the anatomical position. At the wrist joint, the hand can be abducted, adducted, flexed, extended, and circumducted (Fig. 7.6). These movements, combined with those of the shoulder, arm, and forearm, enable the hand to be placed in a wide range of positions relative to the body. The hand as a mechanical tool | [
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Anatomy_Gray_1684 | Anatomy_Gray | The hand as a mechanical tool One of the major functions of the hand is to grip and manipulate objects. Gripping objects generally involves flexing the fingers against the thumb. Depending on the type of grip, muscles in the hand act to: modify the actions of long tendons that emerge from the forearm and insert into the digits of the hand, and produce combinations of joint movements within each digit that cannot be generated by the long flexor and extensor tendons alone coming from the forearm. The hand as a sensory tool The hand is used to discriminate between objects on the basis of touch. The pads on the palmar aspect of the fingers contain a high density of somatic sensory receptors. Also, the sensory cortex of the brain devoted to interpreting information from the hand, particularly from the thumb, is disproportionately large relative to that for many other regions of skin. | Anatomy_Gray. The hand as a mechanical tool One of the major functions of the hand is to grip and manipulate objects. Gripping objects generally involves flexing the fingers against the thumb. Depending on the type of grip, muscles in the hand act to: modify the actions of long tendons that emerge from the forearm and insert into the digits of the hand, and produce combinations of joint movements within each digit that cannot be generated by the long flexor and extensor tendons alone coming from the forearm. The hand as a sensory tool The hand is used to discriminate between objects on the basis of touch. The pads on the palmar aspect of the fingers contain a high density of somatic sensory receptors. Also, the sensory cortex of the brain devoted to interpreting information from the hand, particularly from the thumb, is disproportionately large relative to that for many other regions of skin. | [
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Anatomy_Gray_1685 | Anatomy_Gray | The bones of the shoulder consist of the scapula, clavicle, and proximal end of the humerus (Fig. 7.7). The clavicle articulates medially with the manubrium of the sternum and laterally with the acromion of the scapula, which arches over the joint between the glenoid cavity of the scapula and the head of the humerus (the glenohumeral joint). The humerus is the bone of the arm (Fig. 7.7). The distal end of the humerus articulates with the bones of the forearm at the elbow joint, which is a hinge joint that allows flexion and extension of the forearm. The forearm contains two bones: The lateral bone is the radius. The medial bone is the ulna (Fig. 7.7). At the elbow joint, the proximal ends of the radius and ulna articulate with each other as well as with the humerus. In addition to flexing and extending the forearm, the elbow joint allows the radius to spin on the humerus while sliding against the head of the ulna during pronation and supination of the hand. | Anatomy_Gray. The bones of the shoulder consist of the scapula, clavicle, and proximal end of the humerus (Fig. 7.7). The clavicle articulates medially with the manubrium of the sternum and laterally with the acromion of the scapula, which arches over the joint between the glenoid cavity of the scapula and the head of the humerus (the glenohumeral joint). The humerus is the bone of the arm (Fig. 7.7). The distal end of the humerus articulates with the bones of the forearm at the elbow joint, which is a hinge joint that allows flexion and extension of the forearm. The forearm contains two bones: The lateral bone is the radius. The medial bone is the ulna (Fig. 7.7). At the elbow joint, the proximal ends of the radius and ulna articulate with each other as well as with the humerus. In addition to flexing and extending the forearm, the elbow joint allows the radius to spin on the humerus while sliding against the head of the ulna during pronation and supination of the hand. | [
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Anatomy_Gray_1686 | Anatomy_Gray | In addition to flexing and extending the forearm, the elbow joint allows the radius to spin on the humerus while sliding against the head of the ulna during pronation and supination of the hand. The distal portions of the radius and the ulna also articulate with each other. This joint allows the end of the radius to flip from the lateral side to the medial side of the ulna during pronation of the hand. The wrist joint is formed between the radius and carpal bones of the hand and between an articular disc, distal to the ulna, and carpal bones. The bones of the hand consist of the carpal bones, the metacarpals, and the phalanges (Fig. 7.7). The five digits in the hand are the thumb and the index, middle, ring, and little fingers. Joints between the eight small carpal bones allow only limited amounts of movement; as a result, the bones work together as a unit. The five metacarpals, one for each digit, are the primary skeletal foundation of the palm (Fig. 7.7). | Anatomy_Gray. In addition to flexing and extending the forearm, the elbow joint allows the radius to spin on the humerus while sliding against the head of the ulna during pronation and supination of the hand. The distal portions of the radius and the ulna also articulate with each other. This joint allows the end of the radius to flip from the lateral side to the medial side of the ulna during pronation of the hand. The wrist joint is formed between the radius and carpal bones of the hand and between an articular disc, distal to the ulna, and carpal bones. The bones of the hand consist of the carpal bones, the metacarpals, and the phalanges (Fig. 7.7). The five digits in the hand are the thumb and the index, middle, ring, and little fingers. Joints between the eight small carpal bones allow only limited amounts of movement; as a result, the bones work together as a unit. The five metacarpals, one for each digit, are the primary skeletal foundation of the palm (Fig. 7.7). | [
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Anatomy_Gray_1687 | Anatomy_Gray | The five metacarpals, one for each digit, are the primary skeletal foundation of the palm (Fig. 7.7). The joint between the metacarpal of the thumb (metacarpal I) and one of the carpal bones allows greater mobility than the limited sliding movement that occurs at the carpometacarpal joints of the fingers. Distally, the heads of metacarpals II to V (i.e., except that of the thumb) are interconnected by strong ligaments. Lack of this ligamentous connection between the metacarpal bones of the thumb and index finger together with the biaxial saddle joint between the metacarpal bone of the thumb and the carpus provide the thumb with greater freedom of movement than the other digits of the hand. The bones of the digits are the phalanges (Fig. 7.7). The thumb has two phalanges, while each of the other digits has three. | Anatomy_Gray. The five metacarpals, one for each digit, are the primary skeletal foundation of the palm (Fig. 7.7). The joint between the metacarpal of the thumb (metacarpal I) and one of the carpal bones allows greater mobility than the limited sliding movement that occurs at the carpometacarpal joints of the fingers. Distally, the heads of metacarpals II to V (i.e., except that of the thumb) are interconnected by strong ligaments. Lack of this ligamentous connection between the metacarpal bones of the thumb and index finger together with the biaxial saddle joint between the metacarpal bone of the thumb and the carpus provide the thumb with greater freedom of movement than the other digits of the hand. The bones of the digits are the phalanges (Fig. 7.7). The thumb has two phalanges, while each of the other digits has three. | [
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Anatomy_Gray_1688 | Anatomy_Gray | The bones of the digits are the phalanges (Fig. 7.7). The thumb has two phalanges, while each of the other digits has three. The metacarpophalangeal joints are biaxial condylar joints (ellipsoid joints) that allow abduction, adduction, flexion, extension, and circumduction (Fig. 7.8). Abduction and adduction of the fingers is defined in reference to an axis passing through the center of the middle finger in the anatomical position. The middle finger can therefore abduct both medially and laterally and adduct back to the central axis from either side. The interphalangeal joints are primarily hinge joints that allow only flexion and extension. | Anatomy_Gray. The bones of the digits are the phalanges (Fig. 7.7). The thumb has two phalanges, while each of the other digits has three. The metacarpophalangeal joints are biaxial condylar joints (ellipsoid joints) that allow abduction, adduction, flexion, extension, and circumduction (Fig. 7.8). Abduction and adduction of the fingers is defined in reference to an axis passing through the center of the middle finger in the anatomical position. The middle finger can therefore abduct both medially and laterally and adduct back to the central axis from either side. The interphalangeal joints are primarily hinge joints that allow only flexion and extension. | [
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Anatomy_Gray_1689 | Anatomy_Gray | Some muscles of the shoulder, such as the trapezius, levator scapulae, and rhomboids, connect the scapula and clavicle to the trunk. Other muscles connect the clavicle, scapula, and body wall to the proximal end of the humerus. These include the pectoralis major, pectoralis minor, latissimus dorsi, teres major, and deltoid (Fig. 7.9A,B). The most important of these muscles are the four rotator cuff muscles—the subscapularis, supraspinatus, infraspinatus, and teres minor muscles—which connect the scapula to the humerus and provide support for the glenohumeral joint (Fig. 7.9C). Muscles in the arm and forearm are separated into anterior (flexor) and posterior (extensor) compartments by layers of fascia, bones, and ligaments (Fig. 7.10). | Anatomy_Gray. Some muscles of the shoulder, such as the trapezius, levator scapulae, and rhomboids, connect the scapula and clavicle to the trunk. Other muscles connect the clavicle, scapula, and body wall to the proximal end of the humerus. These include the pectoralis major, pectoralis minor, latissimus dorsi, teres major, and deltoid (Fig. 7.9A,B). The most important of these muscles are the four rotator cuff muscles—the subscapularis, supraspinatus, infraspinatus, and teres minor muscles—which connect the scapula to the humerus and provide support for the glenohumeral joint (Fig. 7.9C). Muscles in the arm and forearm are separated into anterior (flexor) and posterior (extensor) compartments by layers of fascia, bones, and ligaments (Fig. 7.10). | [
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Anatomy_Gray_1690 | Anatomy_Gray | Muscles in the arm and forearm are separated into anterior (flexor) and posterior (extensor) compartments by layers of fascia, bones, and ligaments (Fig. 7.10). The anterior compartment of the arm lies anteriorly in position and is separated from muscles of the posterior compartment by the humerus and by medial and lateral intermuscular septa. These intermuscular septa are continuous with the deep fascia enclosing the arm and attach to the sides of the humerus. In the forearm, the anterior and posterior compartments are separated by a lateral intermuscular septum, the radius, the ulna, and an interosseous membrane, which joins adjacent sides of the radius and ulna (Fig. 7.10). Muscles in the arm act mainly to move the forearm at the elbow joint, while those in the forearm function predominantly to move the hand at the wrist joint and the fingers and thumb. | Anatomy_Gray. Muscles in the arm and forearm are separated into anterior (flexor) and posterior (extensor) compartments by layers of fascia, bones, and ligaments (Fig. 7.10). The anterior compartment of the arm lies anteriorly in position and is separated from muscles of the posterior compartment by the humerus and by medial and lateral intermuscular septa. These intermuscular septa are continuous with the deep fascia enclosing the arm and attach to the sides of the humerus. In the forearm, the anterior and posterior compartments are separated by a lateral intermuscular septum, the radius, the ulna, and an interosseous membrane, which joins adjacent sides of the radius and ulna (Fig. 7.10). Muscles in the arm act mainly to move the forearm at the elbow joint, while those in the forearm function predominantly to move the hand at the wrist joint and the fingers and thumb. | [
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Anatomy_Gray_1691 | Anatomy_Gray | Muscles in the arm act mainly to move the forearm at the elbow joint, while those in the forearm function predominantly to move the hand at the wrist joint and the fingers and thumb. Muscles found entirely in the hand, the intrinsic muscles, generate delicate movements of the digits of the hand and modify the forces produced by tendons coming into the fingers and thumb from the forearm. Included among the intrinsic muscles of the hand are three small thenar muscles, which form a soft tissue mound, called the thenar eminence, over the palmar aspect of metacarpal I. The thenar muscles allow the thumb to move freely relative to the other fingers. | Anatomy_Gray. Muscles in the arm act mainly to move the forearm at the elbow joint, while those in the forearm function predominantly to move the hand at the wrist joint and the fingers and thumb. Muscles found entirely in the hand, the intrinsic muscles, generate delicate movements of the digits of the hand and modify the forces produced by tendons coming into the fingers and thumb from the forearm. Included among the intrinsic muscles of the hand are three small thenar muscles, which form a soft tissue mound, called the thenar eminence, over the palmar aspect of metacarpal I. The thenar muscles allow the thumb to move freely relative to the other fingers. | [
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Anatomy_Gray_1692 | Anatomy_Gray | The upper limb is directly related to the neck. Lying on each side of the superior thoracic aperture at the base of the neck is an axillary inlet, which is formed by: the lateral margin of rib I, the posterior surface of the clavicle, the superior margin of the scapula, and the medial surface of the coracoid process of the scapula (Fig. 7.11). The major artery and vein of the upper limb pass between the thorax and the limb by passing over rib I and through the axillary inlet. Nerves, predominantly derived from the cervical portion of the spinal cord, also pass through the axillary inlet and the axilla to supply the upper limb. Muscles that attach the bones of the shoulder to the trunk are associated with the back and the thoracic wall and include the trapezius, levator scapulae, rhomboid major, rhomboid minor, and latissimus dorsi (Fig. 7.12). | Anatomy_Gray. The upper limb is directly related to the neck. Lying on each side of the superior thoracic aperture at the base of the neck is an axillary inlet, which is formed by: the lateral margin of rib I, the posterior surface of the clavicle, the superior margin of the scapula, and the medial surface of the coracoid process of the scapula (Fig. 7.11). The major artery and vein of the upper limb pass between the thorax and the limb by passing over rib I and through the axillary inlet. Nerves, predominantly derived from the cervical portion of the spinal cord, also pass through the axillary inlet and the axilla to supply the upper limb. Muscles that attach the bones of the shoulder to the trunk are associated with the back and the thoracic wall and include the trapezius, levator scapulae, rhomboid major, rhomboid minor, and latissimus dorsi (Fig. 7.12). | [
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Anatomy_Gray_1693 | Anatomy_Gray | The breast on the anterior thoracic wall has a number of significant relationships with the axilla and upper limb. It overlies the pectoralis major muscle, which forms most of the anterior wall of the axilla and attaches the humerus to the chest wall (Fig. 7.13). Often, part of the breast known as the axillary process extends around the lateral margin of the pectoralis major into the axilla. of the breast is predominantly into lymph nodes in the axilla. Several arteries and veins that supply or drain the gland also originate from, or drain into, major axillary vessels. Innervation of the upper limb is by the brachial plexus, which is formed by the anterior rami of cervical spinal nerves C5 to C8, and T1 (Fig. 7.14). This plexus is initially formed in the neck and then continues through the axillary inlet into the axilla. Major nerves that ultimately innervate the arm, forearm, and hand originate from the brachial plexus in the axilla. | Anatomy_Gray. The breast on the anterior thoracic wall has a number of significant relationships with the axilla and upper limb. It overlies the pectoralis major muscle, which forms most of the anterior wall of the axilla and attaches the humerus to the chest wall (Fig. 7.13). Often, part of the breast known as the axillary process extends around the lateral margin of the pectoralis major into the axilla. of the breast is predominantly into lymph nodes in the axilla. Several arteries and veins that supply or drain the gland also originate from, or drain into, major axillary vessels. Innervation of the upper limb is by the brachial plexus, which is formed by the anterior rami of cervical spinal nerves C5 to C8, and T1 (Fig. 7.14). This plexus is initially formed in the neck and then continues through the axillary inlet into the axilla. Major nerves that ultimately innervate the arm, forearm, and hand originate from the brachial plexus in the axilla. | [
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Anatomy_Gray_1694 | Anatomy_Gray | As a consequence of this innervation pattern, clinical testing of lower cervical and T1 nerves is carried out by examining dermatomes, myotomes, and tendon reflexes in the upper limb. Another consequence is that the clinical signs of problems related to lower cervical nerves—pain; pins-and-needles sensations, or paresthesia; and muscle twitching—appear in the upper limb. Dermatomes of the upper limb (Fig. 7.15A) are often tested for sensation. Areas where overlap of dermatomes is minimal include the: upper lateral region of the arm for spinal cord level C5, palmar pad of the thumb for spinal cord level C6, pad of the index finger for spinal cord level C7, pad of the little finger for spinal cord level C8, and skin on the medial aspect of the elbow for spinal cord level T1. Selected joint movements are used to test myotomes (Fig. 7.15B): Abduction of the arm at the glenohumeral joint is controlled predominantly by C5. | Anatomy_Gray. As a consequence of this innervation pattern, clinical testing of lower cervical and T1 nerves is carried out by examining dermatomes, myotomes, and tendon reflexes in the upper limb. Another consequence is that the clinical signs of problems related to lower cervical nerves—pain; pins-and-needles sensations, or paresthesia; and muscle twitching—appear in the upper limb. Dermatomes of the upper limb (Fig. 7.15A) are often tested for sensation. Areas where overlap of dermatomes is minimal include the: upper lateral region of the arm for spinal cord level C5, palmar pad of the thumb for spinal cord level C6, pad of the index finger for spinal cord level C7, pad of the little finger for spinal cord level C8, and skin on the medial aspect of the elbow for spinal cord level T1. Selected joint movements are used to test myotomes (Fig. 7.15B): Abduction of the arm at the glenohumeral joint is controlled predominantly by C5. | [
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Anatomy_Gray_1695 | Anatomy_Gray | Selected joint movements are used to test myotomes (Fig. 7.15B): Abduction of the arm at the glenohumeral joint is controlled predominantly by C5. Flexion of the forearm at the elbow joint is controlled primarily by C6. Extension of the forearm at the elbow joint is controlled mainly by C7. Flexion of the fingers is controlled mainly by C8. Abduction and adduction of the index, middle, and ring fingers is controlled predominantly by T1. In an unconscious patient, both somatic sensory and motor functions of spinal cord levels can be tested using tendon reflexes: A tap on the tendon of the biceps in the cubital fossa tests mainly for spinal cord level C6. A tap on the tendon of the triceps posterior to the elbow tests mainly for C7. The major spinal cord level associated with innervation of the diaphragm, C4, is immediately above the spinal cord levels associated with the upper limb. | Anatomy_Gray. Selected joint movements are used to test myotomes (Fig. 7.15B): Abduction of the arm at the glenohumeral joint is controlled predominantly by C5. Flexion of the forearm at the elbow joint is controlled primarily by C6. Extension of the forearm at the elbow joint is controlled mainly by C7. Flexion of the fingers is controlled mainly by C8. Abduction and adduction of the index, middle, and ring fingers is controlled predominantly by T1. In an unconscious patient, both somatic sensory and motor functions of spinal cord levels can be tested using tendon reflexes: A tap on the tendon of the biceps in the cubital fossa tests mainly for spinal cord level C6. A tap on the tendon of the triceps posterior to the elbow tests mainly for C7. The major spinal cord level associated with innervation of the diaphragm, C4, is immediately above the spinal cord levels associated with the upper limb. | [
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Anatomy_Gray_1696 | Anatomy_Gray | The major spinal cord level associated with innervation of the diaphragm, C4, is immediately above the spinal cord levels associated with the upper limb. Evaluation of dermatomes and myotomes in the upper limb can provide important information about potential breathing problems that might develop as complications of damage to the spinal cord in regions just below the C4 spinal level. Each of the major muscle compartments in the arm and forearm and each of the intrinsic muscles of the hand is innervated predominantly by one of the major nerves that originate from the brachial plexus in the axilla (Fig. 7.16A): All muscles in the anterior compartment of the arm are innervated by the musculocutaneous nerve. | Anatomy_Gray. The major spinal cord level associated with innervation of the diaphragm, C4, is immediately above the spinal cord levels associated with the upper limb. Evaluation of dermatomes and myotomes in the upper limb can provide important information about potential breathing problems that might develop as complications of damage to the spinal cord in regions just below the C4 spinal level. Each of the major muscle compartments in the arm and forearm and each of the intrinsic muscles of the hand is innervated predominantly by one of the major nerves that originate from the brachial plexus in the axilla (Fig. 7.16A): All muscles in the anterior compartment of the arm are innervated by the musculocutaneous nerve. | [
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Anatomy_Gray_1697 | Anatomy_Gray | All muscles in the anterior compartment of the arm are innervated by the musculocutaneous nerve. The median nerve innervates the muscles in the anterior compartment of the forearm, with two exceptions—one flexor of the wrist (the flexor carpi ulnaris muscle) and part of one flexor of the fingers (the medial half of the flexor digitorum profundus muscle) are innervated by the ulnar nerve. Most intrinsic muscles of the hand are innervated by the ulnar nerve, except for the thenar muscles and two lateral lumbrical muscles, which are innervated by the median nerve. All muscles in the posterior compartments of the arm and forearm are innervated by the radial nerve. In addition to innervating major muscle groups, each of the major peripheral nerves originating from the from patches of skin quite different from dermatomes (Fig. 7.16B). Sensation in these areas can be used to test for peripheral nerve lesions: | Anatomy_Gray. All muscles in the anterior compartment of the arm are innervated by the musculocutaneous nerve. The median nerve innervates the muscles in the anterior compartment of the forearm, with two exceptions—one flexor of the wrist (the flexor carpi ulnaris muscle) and part of one flexor of the fingers (the medial half of the flexor digitorum profundus muscle) are innervated by the ulnar nerve. Most intrinsic muscles of the hand are innervated by the ulnar nerve, except for the thenar muscles and two lateral lumbrical muscles, which are innervated by the median nerve. All muscles in the posterior compartments of the arm and forearm are innervated by the radial nerve. In addition to innervating major muscle groups, each of the major peripheral nerves originating from the from patches of skin quite different from dermatomes (Fig. 7.16B). Sensation in these areas can be used to test for peripheral nerve lesions: | [
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Anatomy_Gray_1698 | Anatomy_Gray | The musculocutaneous nerve innervates skin on the anterolateral side of the forearm. The median nerve innervates the palmar surface of the lateral three and one-half digits, and the ulnar nerve innervates the medial one and one-half digits. The radial nerve supplies skin on the posterior surface of the forearm and the dorsolateral surface of the hand. Nerves related to bone Three important nerves are directly related to parts of the humerus (Fig. 7.17): The axillary nerve, which supplies the deltoid muscle, a major abductor of the humerus at the glenohumeral joint, passes around the posterior aspect of the upper part of the humerus (the surgical neck). The radial nerve, which supplies all of the extensor muscles of the upper limb, passes diagonally around the posterior surface of the middle of the humerus in the radial groove. | Anatomy_Gray. The musculocutaneous nerve innervates skin on the anterolateral side of the forearm. The median nerve innervates the palmar surface of the lateral three and one-half digits, and the ulnar nerve innervates the medial one and one-half digits. The radial nerve supplies skin on the posterior surface of the forearm and the dorsolateral surface of the hand. Nerves related to bone Three important nerves are directly related to parts of the humerus (Fig. 7.17): The axillary nerve, which supplies the deltoid muscle, a major abductor of the humerus at the glenohumeral joint, passes around the posterior aspect of the upper part of the humerus (the surgical neck). The radial nerve, which supplies all of the extensor muscles of the upper limb, passes diagonally around the posterior surface of the middle of the humerus in the radial groove. | [
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Anatomy_Gray_1699 | Anatomy_Gray | The radial nerve, which supplies all of the extensor muscles of the upper limb, passes diagonally around the posterior surface of the middle of the humerus in the radial groove. The ulnar nerve, which is ultimately destined for the hand, passes posteriorly to a bony protrusion, the medial epicondyle, on the medial side of the distal end of the humerus. Fractures of the humerus in any one of these three regions can endanger the related nerve. Large veins embedded in the superficial fascia of the upper limb are often used to access a patient’s vascular system and to withdraw blood. The most significant of these veins are the cephalic, basilic, and median cubital veins (Fig. 7.18). The cephalic and basilic veins originate from the dorsal venous network on the back of the hand. | Anatomy_Gray. The radial nerve, which supplies all of the extensor muscles of the upper limb, passes diagonally around the posterior surface of the middle of the humerus in the radial groove. The ulnar nerve, which is ultimately destined for the hand, passes posteriorly to a bony protrusion, the medial epicondyle, on the medial side of the distal end of the humerus. Fractures of the humerus in any one of these three regions can endanger the related nerve. Large veins embedded in the superficial fascia of the upper limb are often used to access a patient’s vascular system and to withdraw blood. The most significant of these veins are the cephalic, basilic, and median cubital veins (Fig. 7.18). The cephalic and basilic veins originate from the dorsal venous network on the back of the hand. | [
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