Lecture Note

Lecture Note
Medical Course, 353241 Musculoskeletal System

Revision 2 (build 1411211837)
Kitchanan Kosalathip
Second year medical student, Khon Kaen University
2014 Kitchanan Kosalathip. All right reserved.
Lecture 1-2 Introduction to musculoskeletal system, osteology and arthrology
Examination
1. - ?
Coronal plane
2. axial bone ( axis)?
Clavicle
3. Costal process?
Ribs
4. ?
Pelvic cavity
5. Anatomical postion?
lateral
6. Sesamoid bone?
Patella bone Patella, pisiform
7. ?
Abduction Abductor pollicis longus
8. ?
Phalanges, metacarpals
9. Cranial bone?
?
Cranial bone: ethmoid, sphenoid, frontal, parietal, occipital, temporal
Facial bone: nasal, maxillae, zygomatic, mandible, lacrimal, palatine, vomer, inf. nasal conchae
Lecture 3 Spinal Nerve and Dermatome

Typical spinal nerve
Pass though intervertebral foramen
31 pairs: C1-8, T1-12, L1-5, S1-5, Co
Dorsal nerve root: dorsal root ganglion, sensory
Ventral nerver root: motor
Dorsal primary ramus
Medial branch, lateral branch
Contains: motor to deep back m., sensory to cutaneous n. of the back
Ventral primary ramus
Connect to sympathetic ganglion EXAM
White ramus communicans: outer,T1-T12 and L1-2, spinal cord to sympathetic ganglion
Grey ramus communicans: inner, sym. g. to spinal n.
Supply blood vessel, sweat glands, arrector pili
Neck, body, upper and lower limb, superficial back m.
T1-T12 intercostal n., subcostal n. (T12)
C1-C4 cervical plexus
C5-8, T1 brachial plexus
L1-L4 lumbar plexus
L4-5, S1-4 sacral plexus
S4-5, Co coccygeal plexus
C1 pass between skull and vertebra
Dermatome
Dermatome: area of skin supplied by a dorsal root of spinal n. EXAM
Myotome: group of muscles innervated by a single spinal n. root
C6 thumb
C7 middle finger
C8 little finger
T4 nipple
T10 umbilicus
Lecture 4-6 The back and posterior shoulder

Area EXAM
Deltoid region
Scapular region
Subscapular region
Vertebral region
Lumber region
Inguinal region
Surface anatomy
C7 vertebral prominens EXAM EXAM
L4 highest portion of iliac spine, lumbar puncture EXAM
T2-3 root of spine of scapular
T2-T7 medical border of scapular (T7, inferior angle of scapular) EXAM
S2 skin dimple, posterior superior iliac spine, bone marrow biopsy EXAM
EOP (external occipital protuberance)
Vertebral column
Body, pedicle, lamina, transverse processes, spinous process
Vertebral foramen
Superior articular surface pointed posteriorly
Inferior articular surface pointed anteriorly
C1 Atlas no body
C2 Axis dens
C1-C7 bifid spinous process, transverse process foramen: vertebral a. (except C7), v., vertebral nerve plexus EXAM
Thoracic 4 incomplete costal facets (except T1, T10-12 have complete facets)
Lumbar massive body
Sacrum 5 fused vertebra, 8 pelvic sacral foramina
Coccyx 4 fused vertebrae, no pedicle, lamina or spinous process
Primary curvature concave, thoracic and sacrococcygeal
Secondary curvature convex, cervical and lumbar
Kyphosis increased primary curvature
Lordosis increased secondary curvature
Scoliosis lateral curvature
Levels
C1 mouth
C2 superior cervical ganglion
C3 body of hyoid
C4 upper thyroid cartilage, bifurcation of common carotid artery
C6 cricoid cartilage
T4 manubrium (angle of louis), arch of aorta EXAM
Intercostal 4 nipple
T10 xiphoid process
L1 superior mesenteric artery
L3/4 umbilicus
L4 bifurcation of aorta
Superficial Muscles of Back

Supplied by ventral rami motor n.
Separated from deep m. by thoracolumbar fascia
Muscles
Origin
Insertion
Action
Innervation
Blood supply
Trapazius
EOP to T12
Clavicle
Scapular spine
Scapular
Occipital bone
CN XI
VR C3-C4
Superficial cervical
artery
Latissimus dorsi
T6-T12
Humerus
ARM
Scapular
Thoracodorsal n.
Thoracodorsal
branch of the
subscapular artery
Levator scapulae
C1-C4
Scapular
Scapular
Neck
Dorsal scapular n.
Rhomboid minor
C7-T1
Root of spine of
scapular
Scapular
Dorsal scapular n.
Rhomboid major
T2-T5
Scapular
Scapular
Dorsal scapular n.
Serratus posterior
superior
C7-T3
Rib 2-5
Elevate rib
VR ICN1-3
Serratus posterior
inferior
T11-L3
Rib 9-12
Depress rib
VR ICN9-11
Subcostal n.
Origin
Insertion
Action
Innervation
Blood supply
Nuchal ligament
Spinous process
C7-T6
Nuchal ligament
DR
Muscular branches
of the aorta
Transverse
process
DR
Transverse
cervical artery and
occipital artery
Capitis
Cervicis
Thoracis
Lumborum
DR
DR
Deep Muscles of the Back

Supplied by dorsal rami motor n.
Muscles
Superficial group
Splenius capitis
Splenius cervicis
Intermediate (transversocostal) group

Sarcospinalis (erector spinae)
Iliocostalis (outer)
Longissimus
Spinalis (inner)
Deep (transversospinal) group
Semispinalis
Spinalis
Multifidus
Rotatores
Interspinalis
Intertransverse
Suboccipital muscles
Rectus capitis
posterior minor
C1
Inf. nuchal line
Suboccipital n.
(DR C1)
Rectus capitis
posterior major
C2
Inf. nuchal line
Suboccipital n.
(DR C1)
Oblique capitis
superior
C1 transverse p.
Occipital bone
Suboccipital n.
(DR C1)
Oblique capitis
inferior
C2
C1 transverse p.
Suboccipital n.
(DR C1)
Suboccipital Triangle
Boundary
Rectus capitis posterior major
Oblique capitis inferior
Oblique capitis superior
Contents: suboccipital n. (DR C1), vertebral a.
Muscles of Posterior Shoulder
Muscles
Origin
Insertion
Action
Innervation
Blood supply
Deltoid
Clavicle
Acromion
Spine of scapular
Deltoid tuberosity
of humerus
Axillary n.
Thoracoacromial
a.
Humeral
circumflex a.
Supraspinatus
Supraspinous
fossa of scapula
Greater tubercle of humerus
Suprascapular n.
Suprascapular a.
Infraspinatus
Infraspinous fossa
of scapula
Suprascapular n.
Suprascapular a.
Circumflex
scapular a.
Teres major
Inferior angle of
scapula
Medial lip of the

intertubercular
sulcus of the
humerus EXAM
EXAM
Lower subscapular Subscapular a.

n.
Circumflex
scapular a.
Teres minor
Lateral border of
scapula
Axillary n.
Posterior
circumflex humeral
a.
Circumflex
scapular a.
Triangular space teres major, teres minor, long head of triceps; circumflex scapular a.
Quadrangular space teres major, teres minor, long and lateral head of triceps brachii; axillary n., posterior humeral
circumflex a.
Rotator cuff supraspinatus, infraspinatus, teres minor, subscapularis
Abduction at Shoulder
0-40 supraspinatus (prime mover)
40-90 supraspinatus, deltoid
90-180 rotation of scapular: trapezius, serratus anterior
180 external rotation of humerus: infraspinatus
Examination
1. Vertebral prominent?
Spinous process of C7
2. Lateral rotation scapula? Lateral rotation of scapular = adduction of the scapula
Trapezius Trapezius and rhomboids
3. ?
Deltoid 40-90 degress
4. ?
Latissimus dorsi
5. sarcospinalis?
Longissimus Iliocostalis (outer), longissimus, spinalis (inner)
6. medial border?
Teres major Inferior angle of scapula
7. lesser tubercle?
Subscapularis Lesser tubercle: subscapularis, Greater tubercle: supra/infraspinatus, teres minor
8. Levator scapulae supply artery ?
Dorsal scapular a.
9. Ligament lamina?
Ligamentum flavum Connect the laminae of adjacent vertebrae
10. ligament of vertebral herniation ?
Posterolateral Anterior longitudinal ligament, posterior longitudinal ligament
11. Joint C1-C2?
Pivot joint
12. lordosis, kyphosis?
?
Kyphosis increased primary curvature
Lordosis increased secondary curvature
Scoliosis lateral curvature
13. lateral?
Splenius
14. ligament of vertebral herniation ?
Posterolateral
15. Levator scapulae supply artery ?
Dorsal scapular a.
16. ?
Deltoid m.
17. ?

18. sarcospinalis?
Longissimus Iliocostalis (outer), longissimus, spinalis (inner)
19. medial border of scapular?
Teres major
20. ?
Great occipital n.
21. Scoliosis vertebral column ?
Lateral curvature
22. Nerve supply of trapezius?

Accessory nerve Spinal accessory n., C3-4
23. Deltoid Nerve ?
Axillary nerve
24. content suboccipital triangle?
3rd part of vertebral artery Suboccipital triangle: suboccipital n., vertebral a., suboccipital plexus of v.
25. ?
Supraspinatus
26. Nerve ?
Subscapularis m. Upper and lower subscapular n.
27. Root of spine of scapula vertebra ?
T2-3
28. vertebra cervical?
Costal facet Thoracic vertebra
29. transversospinalis?
? Transversospinalis: semispinalis, spinalis, multifidus, rotatores, interspinalis, intertransverse
30. spinous process of C2?
Oblique capitis superior Spinous p. of C2: rectus capitis posterior major, oblique capitis inferior, semispinalis cervicis
31. Sternal angle ?
Rib 2, T4
32. medial lip intertubercular groove?
Teres major
33. Iliac crest ?

L4
Lecture 7-8 Muscle contraction

Organization: Muscle epimysium fascicle perimysium endomysium muscle fibre sarcolemma myofilbril
Muscle fiber
Myosin filament (M line, A band or dark band)
Acting filament (Z disc, I band or light band)
Active site (myosin binding site)
Tropomyosin close over active site
Troponin
Troponin C bind to calcium
Troponin I inhibit troponin T
Troponin T attach to tropomyosin
Triad
T tubule
Sarcoplasmic reticulum store calcium ions
Mechanism
Action potential motor n. neuromuscular junction muscle fiber
Nerve ending secretes ACh
ACh receptor Na+ influx to muscle fiber depolarization of sarcolemma Ca2+ release
Ca2+ bind to troponin C tropomyosin separate from active site
Sliding
Ca2+ pump back to SR muscle relaxation
Contraction
Motor unit all muscle fibers innervated by a single motor nerve fiber
Twitch contraction
Threshold stimulus, maximum stimulus
Twitch duration, contraction time
Latent period period of contraction period of relaxation
Motor unit summation graded response
Wave summation (frequency summation): incomplete fusion tetanus (complete fusion) fatigue
Length of sarcomere and tension develop
Resting length
Length-tension curve of muscle
Active tension force from muscle contraction
Passive tension force from muscle elastic components
Total tension
Source of energy
ATP 1-2 seconds
Phosphocreatine 7-8 seconds
Glycogen (stored in muscle cells) 1 min; glycogen ATP + lactic acid (muscle fatigue)
Oxidative metabolism 1 hours; glycolysis, Krebs cycle
Characteristic of whole muscle contraction
Isometric contraction constant length but tension increase
Isotonic contraction constant tension but length of muscle change
Concentric length of muscle shorten
Eccentric length of muscle increase
Types of muscle fiber EXAM
Type I muscle fiber (red muscle fiber, slow fibers)
Small fibers, extensive blood supply, oxidative metabolism, myoglobin
Endurance
Type
II muscle fiber (white muscle fiber, fast fibers)
Large
fibers, extensive sarcoplasmic reticulum, large amount of glycolytic enzyme
Strength
Muscle hypertrophy
Hypertrophy of individual muscle fiber maximal force contraction synthesis of contractile protein
Increase number of myofibril
Increase number of sarcomere eccentric contraction
Muscle atrophy
Muscle denervation
3 months full return of function
1-2 years fibrosis no return of function
Rigor mortis
Several hours loss ATP during relaxation period state of contracture
15-25 hours muscle protein autolysis by lysosome
Smooth muscle
Spindle-shaped cell, centrally mononucleated
Single unit smooth m. cells are interconnected via gap junction (nexuses), contract as a unit e.g. GI tract, urogenital tract
Multi unit smooth m. cells are independent e.g. airways, vasculature
Mechanism of contraction
Neurotransmitter: ACh, NE
Ca2+ released from SR and ECM
Ca2+ + calmodulin Ca2+-calmodulin complex myosin light-chain kinase (MLCK)
Cardiac muscle
Branching pattern intercalated disc
1 T tubule per sarcomere (vs 2 T tubule in skeletal m.)
Diseases
Pathophysiology
Clinical manifestation
Myofascial pain syndrome

(MPS)
Energy crisis
Calcium leak
Muscle tissue trauma
Lump, pain in trigger point, referred pain

Treatment: dry needle, ultrasound, stretching
Muscle cramp
Vitamin deficiency
Lactic acid accumulation
Dehydration, low Ca2+, K+ or Mg2+
Treatment: stretching
Delay onset muscle

soreness (DOMS)
Microscopic tearing of muscle fibers
Electromyography (EMG) detects the electrical potential generated by muscle cells

Examination
1. muscle contraction?
A. muscle fiber
B. calcium reabsorbed back to SR
C. sarcomere
D. troponin Ca2+
E. myosin-ATPase covert ATP to ADP+Pi
2. What is the different between slow-twitch fibers and fast-twitch fibers?
A. red fiber sarcoplasmic reticulum
B. white fiber energy from glycolytic process
C. red fiber low density capillary
D. white fiber small
E. red fiber strength
3. ?
pacemaker
4. ?
C. , plasticity,
5. ?
A. isokinetic
B. isometric
C. concentric isotonic
D. eccentric isotonic
6. ?
Troponin C
7. ?
? Branching pattern intercalated disc, 1 T tubule per sarcomere
8. ?
A. Troponin C
B.
C. active site Actin Tropomyosin
D. sarcoplasmic reticulum
E. filament theory
9. complete tetanus?
Plateau phase of cardiac muscle
10. tetanus?
long absolute refractory period
11. ?
Subthreshold stimulus
12. ?
1 power stroke
2 motor end plate.....
3 release Ca
4 uptake Ca
2314
13. ?
Muscle fiber
14. ?

Lecture 9-9.5 Cartilage, Bone, Joint

Cartilage
Specialized CNT, avascular tissue poor regeneration EXAM

Development: mesenchymal cells (mesoderm) chondroblasts chondrocytes (in lacuna) cartilage cell nest
Hematoxylin dye
Compositions
Chondroblasts, chondrocytes
Intercellular substances (ICS, ECM)
Collagen fiber (type II, elastic)
Ground substance (proteoglycans, glycosaminoglycan, chondroitin sulfate)
Water (semi-fluid)
Perichondrium: dense CNT, except articular surface
Fibrous layer (outer)
Chondrogenic layer (inner)
Regenerate by perichondrial cells, or by CNT (scar, dense CNT)
Degeneration dead, or calcification (intracartilagenous ossification)
Cartilage Classification
Type
Characteristics
Sites
1 Hyaline cartilage
ICS: collagen fiber type II

Transparent matrix
articular cartilage, nasal and septal cartilage, trachea, larynx, costal

cartilage EXAM
2 Elastic cartilage
ICS: elastic fiber
Pinna, auditory tube, epiglottis
3 Fibrocartilage
ICS: collagen fiber type I

No perichondrium
Intervertebral disc, pubic symphysis, tendon insertion
Cartilage Growth
Type
Characteristics
1 Interstitial growth
Cell mitosis (inner to outer)

Occur in early life
2 Appositional growth
Chondrogenic cell layer differentiation (outer to inner)

Occur in childhood and adult
Bone (osseous tissue)
Specialized CNT, highly vascularized tissue

ICS: inorganic substance hardness
Composition
Bone cells: osteoblasts osteocytes, osteoclasts (multinucleated cells, bone resorption, monocyte precursor
Howships lacuna)
ECM trabecular
Organic substance: collagen fiber type I, proteoglycans, bone proteins EXAM
Inorganic substance: hydroxyapatite (calcium phosphate)
Periosteum EXAM
Fibrous layer dense CNT
Osteogenic layer osteoprogenitor cells, Sharpeys fibers
Endosteum
Single layer of osteoprogenitor cells
Medullary cavity (contains yellow marrow)
Bone Classification by Microscopic Examination

Type
1 Immature (primary, woven) bone
Characteristics
Sites
Osteocytes, proteoglycans
Collagen fiber unstructured
Tooth socket, osseous labyrinth, bone repair
2 Mature (secondary, lamina) bone -
Bone Classification by Macroscopic Examination

Type
Characteristics
1 Spongy (cancellous) bone 2 Compact (cortical) bone
Haversian system Haversian canal, canaliculi, Volkmanns canal (perforating cannel)

Interstitial system (lies between Haversian system)
Outer and inner circumferential system
Bone Ossification
Type
Characteristics
1 Intramembranous ossification Mesenchymal cells osteoblasts
Sites
Nasal, sphenoid (medial pterygoid plate) bone

Frontal, parietal, temporal (squamous part) bone
Vomer, maxilla, mandible
Pelvis
Clavicle
Subperiosteal surface of long bone
2 Intracartilagenous ossification 4-5 wk. cartilage formation

6-7 wk. replace by bone formation
Ossification EXAM
Formation of the cartilage model
Primary center of ossification at diaphysis
Secondary center of ossification at epiphysis
Zone: transitional zone, etc.
Epiphyseal plate (growth plate) epiphyseal line
Bone Healing
Phase
Descriptions
1 Inflammatory phase
0-1 wk. granulation tissue formation
2 Reparative phase
2-6 wk. callus formation (internal and external callus)
3 Remodeling phase
Joint (Articulation) Functional Classification

Type
1 Non-synovial joint
2 Synovial joint
Subtype
Descriptions
Synarthroses
Permits little or no mobility

Most are fibrous joints e.g. skull sutures EXAM
Amphiarthrosis
Permits slight mobility

Most are cartilaginous joints e.g. intervertebral discs
Diarthrosis
Freely movable
All are synovial joints
Articular surface (hyaline cartilage)
Synovial cavity
Joint capsule
Fibrous capsule (outer)
Synovial membrane (inner) synovial fluid
Specialized collagenous CNT
Discontinuous 1-4 cell layer
No basement membrane
No junctional complex
Joint (Articulation) Structural Classification

Type
1 Fibrous joints
(little to no movement)
2 Cartilaginous joints
3 Synovial joints
Subtype
Descriptions
Sutures
Peculiar to skull and are immovable
Syndesmosis
Joints the bones are connected with interosseus ligament
Gomphosis
Peg and socket joints e..g tooth socket.
Primary cartilaginous joints

(synchondrosis)
Bones are united by a plate of hyaline cartilage
Secondary cartilaginous j.
(symphysis)
Also known as fibrocartilaginous joints
Examination
1. Hyaline cartilage in adult?
Articular surface
2. ?
Avascular tissue
3. ?
Periosteum
4. ?
Bone remodeling
5. Intracartilaginous start at?
Diaphysis Intracartilaginous ossification: diaphysis, epiphysis (vs intramembranous ossification)
6. Suture joint ?
Synarthroses
7. organic substance?
Collagen type I Bone: collagen type I, cartilage: collagen type II
8. canaliculi ?
Osteocyte process
9. fibrocartilage ?
Tendon insertion Fibrocartilage: intervertebral disc, pubic symphysis, tendon insertion
10. ( epiphyseal plate ) ?
18-20
11. Secondary ossification ?
Epiphysis Primary ossification: diaphysis, secondary ossification: epiphysis
12. ?
25-30
13. suture ?
Syndesmosis ?
14. Havasian system ?
Cement line Cement line outer circumferential lamellae havasian system
Lecture 10-11 Axillary and Pectoral Region

Surface anatomy
Mid (sternal) line
Midclavicular line
Anterior/mid/posterior axillary line
Jugular notch
Sternum manubrium (upper), sternal angle (2nd rib), body
Xiphisternal joint joint (T9)
Xiphoid process (T10)
Deltopectoral triangle (infraclavicular fossa) EXAM Contents

Coracoid process
Cephalic v. axillary v.
Deltoid branch of thoracoacromial a.
Lateral pectoral n.
Deltopectoral lymph node
Application
Brachial plexus block
Venous cut down (cephalic v.)
Cutaneous n. ventral rami of thoracic spinal n. 1-6
Muscles of Pectoral Region
Muscles
Origin
Insertion
Action
Innervation
Blood supply
Pectoralis major
Clavicular head
Sternocostal head
Abdominal head
Lateral lip of
intertubercular
sulcus of the
humerus EXAM
Humerus
Lateral pectoral n.
Medial pectoral n.
Pectoral and
deltoid branch of
thoracoacromial a.
Pectoralis minor
Rib 3-5
Coracoid process
Protract scapular
Medical pectoral n. Pectoral branch of

thoracoacromial a.
Subclavious
Rib 1
Inferior surface of
clavicle
Depress clavicle
Nerve to
subclavious
Serratus anterior
Rib 1-8
Medial border of
scapular
Protract scapular
Long thoracic n.
Lateral thoracic a.
CC winged scapular
Fascia
Pectoral fascia pectoralis major
Clavipectoral fascia costocoracoid membrane (upper), suspensory ligament of axilla (lower)
* Mastectomy risk damage long thoracic n. winged scapular
Clavicular branch
of
thoracoacromial a.
Axillary Artery
Subclavian a. axillary a. (rib 1 teres major) brachial a.
Divided into 3 parts by pectoralis minor
Part
Division
Subdivision
Supply
1st
Supreme (superior) thoracic a.
ICS 1-2
Serratus anterior
Brest
2nd
Thoracoacromial a.
A acromial branch
P pectoral branch
C clavicular branch
D deltoid branch
Lateral thoracic a.
(with long thoracic n.) EXAM
Serratus anterior
Subscapular a.
Circumflex scapular a.
Thoracodorsal a.
(with thoracodorsal n.) EXAM
Latissimus dorsi
Posterior circumflex humeral a.

(with axillary n.) EXAM
3rd
Anterior circumflex humeral a.
Axillary Veins
Cephalic vein
Basilic v. axillary v. (teres major rib 1) subclavian v.
Axillary Lymph Nodes EXAM
Groups
Drainage
1 Pectoral (anterior) group
Thoracic wall, chest
2 Subscapular (posterior) group
Scapular
3 Humeral (lateral) group
Upper limb
4 Central group
5 Apical group Supraclavicular node
Brachial Plexus EXAM EXAM

Root
(ventral rami)
Trunk
Division
C5
Upper trunk
Anterior division
Dorsal scapular n. Nerve to subclavious
Suprascapular n.
C6
C7
Branches
Lateral cord
Lateral pectoral n.
Musculocutaneous n.
Lateral root of median n.
Posterior cord
Upper subscapular n.
Thoracodorsal n.
Lower subscapular n.
Axillary n.
Radial n.
Posterior division
Middle trunk
C8
T1
Cords
Anterior division
Posterior division
Lower trunk
C5-C7
Long thoracic n.
Anterior division
Medial cord
Ulnar n.
Medial pectoral n.
Median root of median n.
Medial cutaneous n. of arm
Medial cutaneous n. of forearm
Posterior division
Clinical correlation
Brachial plexus block
Cervical approach (sternocleidomastoid m.) root ,
Supraclavicular approach (clavicle to rib 1) trunk and division
Axilla approach cord
Brachial
plexus injuries
Erbs
palsy
(ErbDuchenne palsy) root C5-C6 (upper trunk), waiters tip palsy
Klumpke's
palsy
root C8-T1 (lower trunk)
Compression
Cutaneous nerve of arm EXAM

Inferior lateral cutaneous nerve of arm branch of the radial nerve
Superior lateral cutaneous nerve of arm branch of the axillary nerve
Lateral cutaneous nerve of forearm continuation of the musculocutaneous nerve
Posterior cutaneous nerve of arm another branch of the radial nerve
Examination
1. Content deltopectoral triangle?
Cephalic v.
2. wing scapula .?
Serratus anterior Long thoracic n.
3. masectomy () ?
Serratus anterior
4. Dual innervation?
Pectoralis major Medial pectoral n. and lateral pectoral n.
5. Root of brachial plexus?
Long thoracic n.
6. Axillary nerve ?
Teres minor Deltoid and teres minor
7. Erb (waiter tip's syndrome) ?
Upper trunk of C5-C6
8. Claw hand?
C8-T1 Klumpke's palsy
9. ?
Anterior axillary node
10. lower subscapular nerve ?
Teres major Lower subscapular nerve: subscapularis and teres major
11. Claw hand (Klumpkes palsy)?
C8, T1
12. Nerve brachial plexus clavicle?
Dorsal scapula n., long thoracic n., n. to subclavius, suprascapular n.
13. Deltopectoral triangle ?
Cephalic v., lateral pectoral n., deltoid br. of thoracoacromial a.
14. flex, adduct and rotate arm medially ?
Pectoralis major
15. root of T1 Nerve ?
Medial cutaneous n. of arm Anterior division of lower trunk medial cord
16. Lower lateral cutaneous n. of arm nerve ?

Radial n.
Lecture 12.5-14.5 Pathology of bone, cartilage and soft tissue

Osteoblast-derived proteins: alkaline phosphatase, etc. EXAM
Osteoprotegrin block RANK-RANK ligand interaction inhibit osteoclast differentiation EXAM
Pathology of bone, cartilage and soft tissue EXAM

Diseases
Etiology
Pathophysiology
Dysostosis
Mutation in TF
EXAM
Migration of mesenchymal cells
Congenital absents
Syndactyly
Achondroplasia
AD mutation (new
mutation)
FGFR3 mutation inhibition of

cartilage proliferation abnormal
growth plate
Heterozygous: normal
Homozygous: narrow foramen magnum,
small thorax death
Osteogenesis
AD
imperfecta
(brittle bone disease)
Collagen type I osteoid
Fracture, short stature

Blue sclera
Dentinogenesis imperfecta
Osteopetrosis
(marble bone
disease)
Carbonic anhydrase
II deficiency
Impaired acidification of resorption Severe AR pattern bone marrow

pit impaired osteoclasts
failure
bone resorption skeletal
Mild pattern anemia
sclerosis
Radiologic examination
Absent corticomedullary demarcation
Erlenmayer flask deformity
Fracture
Osteomalacia and
rickets
Vit. D def.
Inadequate mineralization
excess unmineralized matrix
Inadequate synthesis
Decrease absorption
Vitamin D metabolism
Osteoporosis
Localized: disuse
Diffuse: metabolic diseases
Primary osteoporosis: menopause, senile
Secondary osteoporosis: endocrine, neoplasia, GI,
rheumatologic disease drug e.g. steroids, alc.
Vertebral fracture
Pain
Bone loss
Osteonecrosis
(avascular necrosis)
Fracture
Steroids etc.
Ischemia
Empty lacuna
Osteomyelitis
Infections
S. aureus
Acute inflammation
Bone necrosis (sequestrum)
resorption deposit
involucrum EXAM
Chronic inflammation: 1 wk
Hyperparathyroidism
Osteomalacia
Osteopenic radiologic pattern
Poorly localized bone pain
Osteoid seam (unmineralized bone)
EXAM
Rickets
Cup-shaped epiphysis
Pigeon chest EXAM
Harrison groove
Triangular/wedge shaped
Acute systemic illness

Throbbing pain
Osteolytic lesion
Tuberculous osteomyelitis
AIDS multifocal
Extensive necrosis Pott disease (paravertebral
abscesses) EXAM
Localized tenderness
Low grade fever
Weight loss
Primary: parathyroid adenoma

Secondary: renal failure
Cystic brown tumor (pseudo-tumor)

Hypercalcemia
Fracture
Osteopenia
Subperiosteal bone resorption EXAM
Fibrous dysplasia
Bone maturation disorder halted remodeling,
abnormal fibrous tissue proliferation

Monostoyic
Polyostotic: Albrights syndrome
Mature CNT with irregular woven

bone trabeculae
No osteoblastic rimming
Osteopenia
Ground-glass appearance EXAM
Tumor of bone, cartilage and soft tissue EXAM

Diseases
Characteristics
Benign Osteogenic Tumors

Osteoid osteoma
Site: cortex of metaphysis
Nocturnal pain
Relieved by aspirin
Radiolucent nidus 2 cm surrounded
by osteosclerosis (sclerotic reactive
bone)
Well demarcated
Osteoblastoma
Giant osteoid osteoma

Site: metaphysis or diaphysis of long bone
Radiolucent nidus >2 cm
No surrounding osteosclerosis
Malignant Osteogenic Tumors

Osteosarcoma
EXAM EXAM
Primary osteosarcoma: RB gene

Secondary osteosarcoma: radiation, chronic
osteomyelitis
Osteoid production of neoplastic cells
Site: metaphysis (conventional type) of femur and tibia
Bimodal age distribution: 10 (de novo), 40 years old
Fast growing (vs chondrosarcoma)

Codmans triangle
Sunburst periosteal reaction
Treatment: amputation
Benign Chondrogenic Tumors

Chondroma
Site: metaphysis
Multiple lobulated translucent mass
C/O ring sign (bubble-like)
Osteochondroma
Site: metaphysis
Outgrowth of medullary bone and cartilage covered
Rapid growth, pain
with cartilaginous cap (exostosis)

10-20 years old, AD (EXT gene) EXAM
Mushroom-shaped, or sessile
protuberance from bone shaft
Chondroblastoma
Site: epiphyses
Pain
Biopsy: round cell, osteoclast-like giant
cells
Chondromyxoid
fibroma
Rare
Biopsy: spindle shaped or stellate cells

in mixed or chondroid stroma
Malignant Chondrogenic Tumors

Chondrosarcoma
Age 40 years old

No osteoid production osteosarcoma
Slow growing (vs osteosarcoma)

Radiologic examination: snowstorm
Biopsy
Double lacuna
Bizarre giant cells
Treatment: amputation
Differentiated
chondrosarcoma
Mesenchymal
chondrosarcoma
Malignant Hematopoietic Tumors

Myeloma
Malignant lymphoma -
Benign Fibrogenic Tumors

Malignant Fibrogenic Tumors
Fibrosarcoma
Other
Osteoclastoma
(giant cell tumor)
Site: epiphysis
Common in distal radius, proximal femur
Neoplastic stromal cells (mesenchymal cells)
osteoclasts
Ewing sarcoma
Translocation (11,12) EXAM

Site: diaphysis
CD99+
Locally aggressive
Soap bubble
Lytic lesion without sclerosis
Onion-skin periosteal reaction
Biopsy
Uniform small round-nuclei cells
Pseudorosette (Homer-Wright r.)
Joint diseases EXAM

Diseases
Characteristics
Osteoarthritis (OA)
Etiology: degenerative joint disease

Cartilage fracture synovial fluid leak into subcondral
region subchondyal cyst
Bone eburnation
Achy pain
Crepitus
Morning stiffness
Woman: Heberden nodes in the finger
(prominent osteophytes at the distal
interpharyngeal joint) EXAM
Loose bodies EXAM
Etiology: autoimmune disease

Synoviocytes proliferation (CD4+)
Rice bodies (fibrin deposition) EXAM
Osteoclast activity
Bony ankylosis
Rheumatoid nodules (skin)
Etiology: hyperuricemia (>7 mg/dl) urate crystal

deposition inflammation
Acute gouty arthritis
Chronic gouty arthritis tophi
Gouty nephropathy (renal uric acid
Calcium
pyrophosphate
crystal deposition
disease (CPCD)
Deposition of crystal in articular matrix

Geometric or oval shape (vs urate crystal)
Similar to gout, OA
Infectious arthritis
Bacterial infection
Acute monoarticular arthritis
Tuberculous arthritis
Progressive monoarticular arthritis
Fibrous ankylosis
Pain
Limited range of motion
Rheumatoid arthritis
Gout
palisading granuloma with fibrinoid

necrosis
Swollen, painful, morning stiffness
Symmetrical arthritis
Swan-Neck deformity (DIP
hyperflexion with PIP hyperextension)
EXAM
stone)
Associated with Lesch-Nyhan
syndrome EXAM
Tumor and Tumor-like Lesion of Joint

Diseases
Characteristics
Ganglion cyst
No epithelial lining (pseudo cyst)

Occur at tissue around joint capsule and tension
Firm nodule 1-1.5 cm, mostly at wrist
sheath
Not communicate with joint space

Cyst contains gelatinous fluid EXAM
Synovial cyst
Synovial cell lining

Herniation of synovium trough joint capsule or bursa
Bakers cyst (popliteal cyst) RA of knee joint EXAM
Pigmented
villonodular synovitis
(PVNS)
(diffuse giant cell t.)
Benign neoplasm of synovial lining of joint

Histology: giant cell
Finger-like formation
Arthritis, pain
Mass
Giant cell tumor of

tendon sheath
Arthritis, pain
Mass
Synovial cell lining

Herniation of synovium trough joint capsule or bursa
Histology: giant cell
Well circumscribed mass
Most common tumor of digits EXAM
Soft Tissue Tumors EXAM

Mostly benign, occur in elders
Cell morphology spindle cell, small round cell, epitheloid cell
Pattern fascicles, storiform, herring-bone, biphasic, nuclear palisading
Diseases
Characteristics
Benign tumor of fat cell

Well-encapsulated
Age: Adulthood
Treatment: surgical removal
Tumor of adipocyte
Lipomas
Variants
Angiolipoma
Myxoid lipoma
Intramuscular lipoma
Liposarcoma
Biopsy: atypical lipomatous tumor (well differentiated

liposarcoma)
Age: 40-60 years old

Site: tight and peritoneum
Tumors of fibroblast and myofibroblast

Dermatofibrosarcom
a protuberans
Biopsy: storiform pattern EXAM EXAM

CD34 positive
Treatment: wide excision
Dermatofibroma
(cutaneous fibrous
histiocytoma)
Biopsy: storiform pattern, collagen

CD34 negative EXAM
Fibromatoses
Superficial fibromatoses
Benign tumor at palm and sole (palmar and plantar
fibromatosis)
Herring-bone pattern, spindle-shaped cell EXAM
Dupuytrens contracture (palmar

fibromatosis) EXAM
Desmoid-type fibromatoses
Fibrosis mixed with collagen
Subtypes
Extraabdominal desmoid
Abdominal desmoid
Intrabdominal desmoid
Fibrosarcoma
Undifferentiated (unclassified) sarcoma high grade tumor

Undifferentiated pleomorphic sarcoma
Undifferentiated spindle cell sarcoma
Undifferentiated round cell sarcoma
Undifferentiated epitheloid sarcoma
Skeletal muscle tumors
Rhabdomyoma
Rare
Rhabdomyosarcoma
Round cell (tad-pole)

Non-specific marker: desmin, muscle-specific actin
Specific marker: myogenin, MyoD1
Types
Embryonal rhabdomyosarcoma (sarcoma botryoides)
EXAM EXAM
Polypoid grape-like growth pattern
Alveolar rhabdomyosarcoma
Pleomorphic rhabdomyosarcoma
Benign tumors of blood and lymph vessels
Hemangioma
Types: carvernous, venous, capillary, etc.

Granulation tissue-type hemangioma
Pyogenic granuloma EXAM rapid growing red
nodule, easily bleed or ulcerated
Intramuscular hemangioma
Lymphangioma
Malignant tumors of blood and lymph vessels

Angiosarcoma
Marker: CD31*, CD34, vWF
Types
Juvenile hemangioma strawberry nevus
Tumors of uncertain histogenesis
Synovial sarcoma
(SS)
Not related to synoviocytes

Monophasic (spindle-shaped) or biphasic (spindle and
Aggressive
epithelium cells)
Translocation of X:18 EXAM

Examination
1. Cyst RA?
Bakers cyst
2. Congenital dwarfisms caused by derangement in epiphyseal cartilaginous growth ?
A. Achondroplasia AD, FGFR3 mutation inhibit cartilaginous proliferation
B. OI type IV Collagen type I osteoid
C. Fibrous dysplasia Bone maturation disorder, ground-glass appearance
D. Osteoporosis
E.
3. Tuberculosis osteomyelitis and paravertebral abscess ?
Pott's disease Bone necrosis (sequestrum) resorption deposit involucrum
4. osteosarcoma?
fibrous dysplasia
Primary osteosarcoma: RB gene
Secondary osteosarcoma: radiation, chronic osteomyelitis
Radiology: Codmans triangle, sunburst periosteal reaction
5. Osteochondroma gene 2 hit hypothesis ?
EXT gene
6. Which is the characteristic of swan neck deformity of late onset rheumatoid arthritis?
DIP hyperflexion with PIP hyperextension
7. Hebernen's node osteoarthritis ?
osteophyte prominent osteophytes at the distal interpharyngeal joint
8. malignant ?
Lung cancer
9. histo show storiform?
A. Adult fibrosarcoma
B. Synovial sarcoma
C. Desmoid fibromatosis fascicular pattern, spindle-shaped cell
D. Undif pleo sarcoma
E. Dermofibrosarcoma protuberance storiform pattern
10. Tumor most common (digits)?
Giant cell tumor of tendon sheath (nodular tenosynovitis)
11. Mutated transcription factor?
Syndactyly Dysostosis
12. osteoid seam?
A. Rickets Pigeon chest
B. Osteomalacia
C. Hyperparathyroid
13. specimen ?
Synovial fluid
14. soft tissue tumor?
A. Fat cell Lipoma, liposarcoma
B. Fibroblast Dermatofibroma, dermatofibrosarcoma protuberans, fibromatoses, fibrosarcoma
C. Melanocyte
D. Langhan's cell
E. Skeletal muscle Rhabdomyoma, rhabdomyosarcoma
15. Dupuytrens contracture tumor ?
A. Palmar fibromatosis fixed flexion contracture of the hand due to a palmar fibromatosis
B. Fibrosarcoma
C. Dermatofibroma
D. Neurofibroma
E. Hemangioma
16. Osteoprotegrin (decay receptor for RANKL) cell ?
Precursor osteoblast
17. osteomalacia? Vit. D. deficiency PTH, phosphate reabsorption in kidney bone resorption,
phosphate
A. Ca2+ serum Decrease calcium absorption from GI
B. Density bone film X-rays
C. Phosphate serum
D. Parathyroid serum
18. Sarcoma botryoides?
Embryonal rhabdomyosarcoma
19. t(x,18)?
Synovial sarcoma
20. Loose bodies?
Osteoarthritis
21. TB spine with paravertebral abscess?
Pott's disease
22. Ganglion ( no membrane lining + gelatinous fluid) ?
Myxoid degeneration of CNT
23. diagnosis dermatofibroma?
Acanthosis Hyperplasia of epidermis
24. Herring-bone pattern?
Fibrosarcoma
25. Recurrence ?
26. ?
Synovium
27. x-ray osteopenia?
Osteoarthritis
28. ?
calcium pyrophosphate pseudogout Calcium pyrophosphate crystal deposition disease (CPCD)
29. Osteochondroma ?
Epiphyseal plate
30. Tumor ?
31. Ewing sarcoma small round cell tumor?

t(11,12)
32. autoimmune rice body?
Rheumatoid arthritis
Lecture 15.5-17.5 Upper Limb

Bones
Shoulder (pectoral) girdle
clavicle, scapular
Arm (brachium)
Humerus
Head of humerus articulate with glenoid cavity glenohumeral joint
Anatomical neck joint capsule attachment
Greater/lesser tubercle rotator cuff muscle attachements
Surgical neck axillary n., posterior humeral circumflex a. EXAM EXAM
Intertubercular/bicipital groove long head of biceps brachii tendon
Radial/spiral groove radial n., profunda brachii (deep brachial) a. EXAM EXAM
Deltoid tuberosity
Trochlea articulate with ulna
Capitulum (lateral) articulate with radius
Medial epicondyle flexor muscle of forearm (golfers elbow, medial e.), ulnar n. EXAM
Lateral epicondyle extensor muscle of forearm (tennis elbow, extensor epicondylitis)
Coronoid fossa, olecranon fossa
* Distal end of humerus median n. EXAM
Forearm (antebrachium)
Radius
Radius head
Radial tuberosity biceps brachii m.
Radial styloid process brachioradialis m.
Ulna
Olecranon process
Coronoid process
Trochlear notch
Ulnar head
Ulnar styloid proces
Colles fracture
Fall on outstretched hand
Distal fragment displace posteriorly dinner fork deformity EXAM
Median n. compression carpal tunnel syndrome
hand (manus)
Wrist: carpal bones (lateral to medial)

Proximal row: scaphoid, lunate, triquetrum, pisiform EXAM
Distal row: trapezium, trapezoid, capitate, hamate (Guyons canal syndrome (ulnar n. i.))
Palm: metacarpal bones (lateral to medial) I (thumb, pollex) to V
Finger: phalanges
Proximal phalanges
Middle phalanges not present in thumb
Distal phalanges
Upper limb length

Total length acromial angle to radial styloid process tip
Arm length acromial angle to lateral epicondylar tip
Forearm length lateral epicondylar tip to radial styloid process tip
Fascia of Upper Limb

Superficial fascia of arm
Cutaneous n.
Superficial veins
Deep fascia of arm
Intramuscular septum
Anterior/flexor compartment
Posterior/extensor compartment
Deep fascia of forearm
Intramuscular septum: interosseous membrane

Anterior/flexor compartment
Posterior/extensor compartment
Deep fascia of wrist
Carpal tunnel
Passage of 9 flexor tensions
Median n. carpal tunnel syndrome apes hand deformity EXAM
Flexor retinaculum
Extensor retinaculum
Palmar aponeurosis
Muscles of Brachium EXAM

Muscles
Origin
Insertion
Action
Innervation
Blood supply
Bicipital
aponeurosis (ulna)
Radial tuberosity
Supinate EXAM
Flex forearm
Musculocutaneous n.
Anterior compartment musculocutaneous n. EXAM

Biceps brachii
(long head)
Supraglenoid
tubercle of
humerus
Biceps brachii
(short head)
Coracoid process
of scapular
Brachialis
Anterior surface of
humerus
Coronoid process
and tuberosity of
ulna
Flex forearm
Musculocutaneous n.
Coracobrachialis
Coracoid process
of scapular
Surface of
humerus
Flex forearm
Adduct arm
Musculocutaneous n.
Brachioradialis
Supracondylar
ridge of humerus
Radial styloid
process
Flex forearm
Radial n.
Olecranon process Extend, adduct

of ulna EXAM
shoulder
Extend forearm
Radial n.
Posterior compartment radial n.

Triceps brachii
(long head)
Infraglenoid
tubercle of
scapular
Triceps brachii
(lateral head)
Humerus
Extend forearm
Radial n.
Triceps brachii
(medial head)
Humerus
Extend forearm
Radial n.
Cubital fossa
Boundary: brachioradialis, pronator teres, imaginary line between epicondyles of humerus
Contents (lateral to medial): TAN tendon of biceps brachii, brachial a., median n. EXAM
Bicipital aponeurosis covered the contents
Muscles of Antebranchium EXAM

Muscles
Origin
Insertion
Action
Innervation
Blood supply
Superficial Anterior/Flexor Compartment medial epicondyle, median n. except flexor carpi ulnaris (ulnar n.)
Flexor carpi ulnaris Medial epicondyle
Metacarpal
Ulnar n.
Palmaris longus
Medial epicondyle
Flexor retinaculum
Median n.
Flexor carpi
radialis
Medial epicondyle
Metacarpal
Median n.
Pronator teres
Medial epicondyle
Radius
Flex, adduct
Median n.
Flexor digitorum
superficialis
Medial epicondyle
Middle phalanges
Flex proximal and

middle phalanges
Median n.
Deep Anterior/Flexor Compartment

Flexor digitorum
profundus
Interosseous
membrane
Distal pharanges
Flex distal
phalanges
Lateral half
anterior
interosseous n.
(median n.)
Medial half
ulnar n.
Flexor pollicis
longus
Interosseous
membrane
Distal pharanges
Anterior
interosseous n.
Pronator
quadratus
Ulna
Radius
Anterior
interosseous n.
Superficial Posterior/Extensor Compartment n.

Brachioradialis
Humerus
Styloid process of
radius
Flex forearm
Radial n.
Extensor carpi
radialis longus
(ECRL)
Humerus
Metacarpal
Radial n.
Extensor carpi
radialis brevis
(ECRB)
Lateral epicondyle
of humerus
Metacarpal
Radial n.
Extensor digitorum Lateral epicondyle

communis
of humerus
Extensor
expansion
Posterior
interosseous n.
(radial n.)
Extensor digiti
minimi (EDM)
Lateral epicondyle
of humerus
Extensor
expansion
Posterior
interosseous n.
Extensor carpi
ulnaris (ECU)
Lateral epicondyle
of humerus
Metacarpal
Posterior
interosseous n.
Anconeus
Lateral epicondyle
of humerus
Olecranon and
surface of ulna
Abduct, extend
elbow
Radial n.
Deep Posterior/Extensor Compartment n.

Supinator
Lateral epicondyle
of humerus
Radius
Radial n.
Abductor pollicis
longus (APL)
Ulnar, radius, IM
Metacarpal
Posterior
interosseous n.
Extensor pollicis
brevis (EPB)
Ulnar, IM
Posterior
interosseous n.
Extensor pollicis
longus (EPL)
Ulnar, IM
Posterior
interosseous n.
Extensor indicis
Ulna, IM
Posterior
interosseous n.
Assessment
Pinch grip test
Posterior interosseous n. syndrome inability to extend wrist, or weak extension with radial deviation (extensor carpi
radialis longus, ulnar n.)
Anatomical snuff box
Boundary: extensor pollicis longus, abductor pollicis longus, extensor pollicis brevis
Contents: radial a. blood gases (lateral to flexor carpi radialis) EXAM
Muscles of Hand EXAM
Muscles
Origin
Insertion
Action
Innervation
Thenar muscles recurrent branch of median n.; clinical: ape hand

Opponens pollicis
Flexor retinaculum
Recurrent branch
of median n.
Abductor pollicis
brevis
Flexor retinaculum
Recurrent branch
of median n.
Flexor pollicis
brevis
Flexor retinaculum
Recurrent branch
of median n.
Adductor pollicis
(thenar eminence)
Ulnar n.
Hypothenar muscles deep branch of ulnar n.

Abductor digiti
minimi
Deep branch of
ulnar n.
Flexor digiti minimi

brevis
Flexor retinaculum
Deep branch of
ulnar n.
Opponens digiti
minimi
Flexor retinaculum
Deep branch of
ulnar n.
Intrinsic Muscles of Hand

Palmar interosseii
(3)
Adduction
Ulnar n.
Dorsal interosseii
(4)
Abduction
Ulnar n.
Lumbrical (4)
Flexor digitorum
profundus
Extensor
expansion
Flex MPJ
Extend IPJ
1-2 (lateral half)

Median n.
3-4 (medial half)
Ulnar n.
Palmaris brevis
Deepens hollow of
hand
Ulnar n.
Blood supply
Neuromuscular supply
Dermatome
Reflexes
Deep tendon reflexes

Biceps reflex C5-6
Brachioradialis reflex C6
Triceps reflex C7
Patella reflex L4
Achilles tendon S1
Scale
0 absent
1 hypoactive
2 normal
3 hyperactive
4 hyperactive with clonus
5 sustained clonus
Musculocutaneous n.
Motor innervation anterior compartment of arm

Sensory innervation lateral forearm
Median n.
Motor innervation
Anterior compartment of forearm, thenar m., lumbrical 1-2
Except flexor carpi ulnaris, ulnar half of flexor digitorum profundus
Sensory
innervation
Palmar
digit 1-3, half 4
Ulnar n.
Motor innervation
Flexor carpi ulnaris
Ulnar half of flexor digitorum profundus
Muscles of hand, except thenar m. and lumbrical 1-2
Sensory
innervation
Palmar
digit half 4, 5
Weak point medial epicondyle cubital tunnel syndrome

Ulnar nerve palsy claw hand EXAM
Radial n.
Motor innervation
Posterior compartment of arm and forearm
Sensory innervation
Inferior lateral cutaneous n. of arm
Posterior forearm
Dorsum of digit 1-3, half 4
Radial nerve palsy wrist drop EXAM
C5 lateral arm and forearm

C6 thumb EXAM
C7 index, middle and ring fingers
C8 little finger
T1 medial arm and forearm
Vessels of Arm and Forearm

Arteries and veins
Brachial a. radial a., ulnar a. superficial, deep palmar arch

Superficial v.
Basilic v. (medial) enter deep fascia (deep v.)
Cephalic v. (lateral) enter deltopectoral triangle
Median cubital v. bicipital aponeurosis
Deep v.
Axillary v.
Lymphatic drainage
Medial Cubital lymph node axillary lymph node

Lateral Deltopectoral (infraclavicular lymph node)
Examination
1. Musculocutaneous n. .?
Biceps brachii
2. ?
A. Scaphoid
B. Lunate
C. Distal radial end
D. Proximal radial end
3. dissect cadaver lateral + dorsal tendon ?
Abductor pollicis longus
4. flex wrist and abduct hand ?
A. Flexor carpi radialis
5. n. lateral cutaneous n. of forearm ?
Musculocutaneous n.
6. medial, n.?
Ulnar n.
7. supination?
Biceps brachii Biceps brachii, supinator
8. Humerus midshaft n. ?
Radial n. wrist drop
9. pronate distal phalanges ?
Flexor digitorum profundus, median n. (anterior interrosscous n.)
10. dermatome ?
C6
11. wrist drop?
Radial n.
12. n. ?
Cutaneous branch of median n.
13. supination?
A. Extensor pollicis brevis
B. Extensor pollicis longus
C. Triceps brachii
D. Biceps brachii Biceps brachii, supinator
E. Brachioradialis
14. flex wrist and abduct hand ?
A. Flexor carpi radialis
B. Flexor carpi ulnaris
C. Flexor digitorum superficialis
D. Flexor digitorum profundus
E. Flexor pollicis longus
15. median cubital vein n. ?
Median n.
16. head of radius ?
Annular ligament
17. Proximal radio-ulnar jt.?
Pronation Proximal radio-ulnar jt. pronation, supination
18. ?
Coracoacromion
19. Extrinsic ligament of acromioclavicular jt.?

Coracoclavicular lig.
20. extensor muscle ?
Olecranon process of ulnar
21. carpal tunnel syndrome nerve ?
Median n.
22. carpal tunnel syndrome ?
Ape hand
23. surgical neck nerve ?
Axillary n. Surgical neck: axillary n., posterior humeral circumflex a.
24. pulse brachial artery ?
Medial border of biceps
25. anatomical snuffbox?
Scaphoid
26. ?
Palmar interosseous m.
27. ?
Opponens pollicis
28. ?
Acromial angle Landmark: acromial angle, lateral epicondylar tip of humerus, radial styloid process tip
29. O2 ?
Radial a.
30. ?
Anterior dislocation humerus pulled downward (inferiorly)
31. Extrinsic ligament ?
Coracoacromial ligament
32. flex extend?
Elbow joint
33. Articular disc ?
Distal radioulnar jt.
34. ?
Radial head annular ligament
Lecture 19.5-20.5 Analgesic, antipyretic, NSAIDs and DMARDs

NSAIDs
Types
Non-selective NSAIDs (tNSAIDs) inhibit COX
COX-2 selective NSAIDs: celecoxib
COX-1
constitutive enzyme e.g. mucus secretion
COX-2
inducible enzyme in inflammatory cells
Properties
Mechanism
Drugs
Analgesic
Peripheral: PGE2 , PGI2 reduce nociceptor threshold
Antipyretic
hyperalgesia EXAM
Central: PGE2 increase spinal dorsal horn neuron excitability
hyperalgesia
IL-1, TNF, INF COX-1, -2 endothelial or glia cells in preoptic area
No: diflunisal
in anterior HyTh PGE2 increase set point
Anti-inflammatory -
Strong: indomethacin
Moderate: naproxen, ibuprofen
Mild: paracetamol
Other Applications
Close ductus arteriosus
Ibuprofen
Anti-platelet aggregation
COX-2 inhibitors induce platelet aggregation
COX-2 in blood vessels source of PGI2 dilates blood vessels and prevents the
activation of platelets EXAM
Aspirin
Dysmenorrhea
Prevent colon cancer
Mastocytosis (PGD2)
Reduce niacin-induced intense flushing (PGD2)
Adverse Drug Reaction

Gastric bleeding
EXAM
Inhibit PGE2 synthesis reduce gastric mucosa cells

Not occur in COX-2 selective NSAIDs
May co-administered with ranitidine, omeprazole
Analgesic
nephropathy
PGE2, PGI2 reduce [renal blood flow, glomerular filtration, sodium -
and water excretion]
CHF, chronic renal disease

Other
Aspirin prolong bleeding time
COX-2 selective inhibitors MI, stroke, thrombosis
Premature ductus arteriosus closure
Delayed gestation and delayed labor
Postpartum hemorrhage
Hypersensitivity
NSAIDs
Properties
Aspirin acetylsalicylic acid (ASA)
Acetaminophen (paracetamol)
Alkalinized urine to increase aspirin excretion

Half-life varies with dosage
Acetylation irreversible blocking anti-platelet
NASIDs + aspirin decrease anti-platelet activity *competitive inhibition EXAM
Colon cancer
Inflammatory bowel diseases
Overdose salicylism
Stimulate RC in medulla hyperpnea respiratory alkalosis
Uncoupling oxidative phosphorylation pyretic effect
VMC (vascular muscle cell) depression metabolic acidosis
Reyes syndrome in children: liver failure and encephalopathy esp. in children with
viral infection
Low dose decrease urate excretion
Effective analgesic and antipyretic effects
No anti-inflammatory effect high amount of peroxide in inflammatory area
Lack platelet-inhibiting property
Metabolism
Conjugation with glucuronide
Cytochrome P450 NAPQI (toxic metabolite, hepatotoxicity) glutathione
conjugation
Recommend dosage: 650 mg q4-6h, maximum 2600 mg/day EXAM
ADR: hepatotoxicity, nephrotoxicity
Acute paracetamol poisoning: 10-15 g, orally
Initial sings N/V/D, diaphoresis
24hr abdominal pain
24-48 hr. hepatic enzyme, birubin, PTT
Treatment: N-acetylcysteine (PO, IV) within 8-16 hr EXAM
Sulindac
Contain sulfur group SJS
Mefenamic acid (Ponstan)
Analgesic for dysmenorrhea
Celecoxib
Indication
Osteoarthritis, RA
Acute pain e.g. postoperative pain
Prevention of polyposis coli
Contraindication: hypertension, CHF, MI, advanced renal disease
ADR: SJS
Disease-modifying anti-rheumatic drugs (DMARDs)

Mechanism
Drugs
Properties
TNF- inihibitor
Adalimumab
Etanercept
Infliximab
IL-1 blocker
Anakinra
B-cell cytotoxic agent
Rituximab
T-cell modulating agent
Abatacept
Biologic DMARDs
Non-biologic DMARDs
Anti-malarials
Chloroquine
ADR: melanin-containing tissue e.g. retina EXAM
Hydroxychloroquine
Sulfasalazine
Sulfapyridine affect lymphocyte function
Immune suppressant
agents
Methotrexate
Leflunomide
Inhibit dyhydroorotate dehydrogenase ribonucleotide synthesis
First DMARDs of choice

Mechanism: folate antagonist inhibit DNA, RNA synthesis
Teratogenic effect
May co-administered with folic acid mucosal adverse effects
inhibitor inhibit T, B cell proliferation
ADR: diarrhea
Azathioprine
Cyclosporin
Cyclophosphamide
Gold compound
Chelators
RA treatment approach reevaluate every 3 months

MTX
Active disease, erosive
Add TNF- inhibitor or abatacept
If still active switch to another TNF- inhibitor or another biologic agents
Active disease, non-erosive
Triple therapy (MTX + SSZ or HCQ), or
Add TNF- or abatacept
If still active stop SSZ and HCQ, add TNF- inhibitor to triple therapy, or add other biologic agents to TNF- or
abatacept `
Examination
1. At the site of tissue damage and inflammation, what is the mediator that can lower threshold of the pain receptor?
A. serotonin
B. prostaglandins
C. angiotensin I
D. dopamine
E. histidine
2. What is the enzyme which plays major role in gastric mucus synthesis?
COX-1
3. nsaid nsaid?
cycloxygenase
4. pharmacologic effect aspirin?

Prevent thrombosis in atherosclerosis
5. naproxen .... ADR ?
? Gastric bleeding, analgesic nephropathy, hypersensitivity
6. NSAIDs ?
A. PGE analog
B. alcohol
C. histamine
D. eat before meal
E. N-acetylcystein
7. 7 ?
Paracetamol
8. Thromboxane A2?
COX-1
9. non-selective COX-2 inhibitor coronary thrombosis thrombosis ?
Inhibit PGI2 synthesis COX-2 PGI2 dilates blood vessels and prevents the activation of platelets
10. gastritis NSAID ?
A. NSAID + PGE analogue
B. NSAID + antacid
C. NSAID +
D.
11. paracetamol?
A.
B. hemophilia
C.
E. hyperthyroidism
12. Which is the serious adverse effect of hydroxychloroquine in the treatment of RA?
Retinopathy
13. 7?
Paracetamol
14. side effect traditional NSAIDs?
? ADR: GI bleeding, nephropathy
15. traditional NSAIDs?
? Effect: analgesic, antipyretic, anti-inflammatory
16. paracetamol?

17. NSAIDs?
Inhibit enzyme COX
18. paracetamol?
Bleed, anti-platelet
19. NSAIDs ?
20. celecoxib thrombosis?

Inhibit PGI synthesis from vascular endothelial cells
21. ?
methotrexate first choice
22. Side effect hydroxychloroquine?

Maculopathy (retinopathy)
23. TNF-?
Infliximab TNF- inhibitors: adalimumab, etanercept, infliximab
Lecture 21.5-22.5 Parasite in Musculoskeletal System

Parasitic Infection in Musculoskeletal System EXAM
Diagnosis
Muscle biopsy
Muscle enzyme level: CPK, LDH
Serologic test: ELISA
Diseases
Characteristic
Trichinellosis
Nematode
Etiology: Trichinella spp. T. spiralis, T. pseudospiralis

Transmission: raw undercook meats
Morphology
encysted muscle larva (L1)
stichosomal esophagus
Life cycle
Infective stage encysted muscle larva (L1)
Diagnosis stage encysted muscle larva (L1)
2-3 days: adult GI irritation diarrhea
5 days: newborn larva
8-9 days encysted within skeletal muscle myalgia
Sarcocystosis
Protozoa
Etiology: Sarcocystis spp. S. suihominis, S. bovihominis

Transmission: feces
Life cycle
Infective stage oocysts
Sporocysts, oocysts sporozoites schizonts merozoites invades muscle cell bradyzoites in
sarcocyst
Cysticercosis
Etiology: Cysticercus cellulosae

Transmission: Tinea eggs
Morphology
Invaginated scolex, hooks
Gravid proglottis: uterine branch T. solium (15), T. saginata
Life cycle
Egg or gravid proglottis oncospheres cysticerci in muscle
Sparganosis
Etiology: Pseudophyllidian tape worm (Spirmetra sp.)

Transmission
Procercoid in crustaceans
Plerocercoid larva (sparganum) in 2nd IH fish, reptiles,
amphibians
Diarrhea
Conjunctivitis, swollen eyes EXAM
Splinter hemorrhages
Myalgia
Diagnosis: immuno-histopathological
analysis EXAM
Treatment: mebendazole, albendazole
MCQ Part 1 (late 2013)

1. trichinellosis 1 ?
A. Elisa Ab
B. Immunohistochemistry
C. Stool examination
D. Tissue biopsy
E. Eosinophil
2. ?
Trichinella spiralis Diarrhea, conjunctivitis, swollen eyes, splinter hemorrhages, myalgia
3. Trichinellosis swollen eye splinter hemorrhage ?
A.
B. capsule
C.
D.
E.
4. Trichinella biopsy biopsy ?

5. ?
Trypanosoma sp.
6. ?
Trichinella spiralis
7. cyst ?
Egg
Lecture 22.5-24.5 The face & scalp, temporal and infratemporal regions
Facial Bones
Frontal bone
Supraorbital margin superciliary arch, supraorbital foramen

Articulate
Nasal bones
Nasal bones
Maxilla
Infraorbital foramen
Alveolar processes
Zygomatic bone
Inferior nesal concha
Lacrimal bone
Mandile
Mental foramen
Temporal bone
Facial Cutaneous Nerves

Pons (brain stem) trigeminal n. (CN V) trigeminal ganglion
V1 ophthalmic division
Superior orbital fissure supraorbital foramen

Branches
Supraorbital n.
Supratrochlear n.
Infratrochlear n.
External nasal n.
Lacrimal n. lacrimal gland
V2 maxillary division
Foramen rotundam
Branches
Infraorbital n.
Zygomaticofacial n.
Zygomaticotemporal n.
V3 mandibular division
Foramen ovale
Branches
Mental n.
Buccal n.
Auriculotemporal n.
Great auricular n.
C2-3
Trigeminal neuralgia
Paroxysm (sudden sharp pain) for 15 mins
Initiated by touching sensitive trigger zone
Prevalent V2 > V3 > V1
Infraorbital nerve block
For treating wound of upper lip, cheek, maxillary incisor teeth risk IV leakage to orbit paralysis of extra ocular m.
Inferior alveolar nerve block
Inject at mandibular foramen risk IV leakage to parotid gland and branches of facial n. unilateral facial paralysis
Mental and incisive nerve block
Inject at mental foramen block mental n.
Muscles of Facial Expression

Muscles
Origin
Insertion
Action
Innervation
Blood supply
Orbicularis oculi
(orbital part)
Medial palpebral
ligament
Tightly close eyelid -
Orbicularis oculi
(palpebral part)
Close eyelid
Corrugator
supercilii
Medial-ward
eyebrows
Procerus
Nasal bone
Skin between
eyebrows
Glare of bright
sunlight
Compressor naris
Canine eminence
of maxilla
Pars transversa
(aponeurosis)
Dilator naris
Canine eminence
of maxilla
Pars alaris
(aponeurosis)
Depressor septi
nasi
Maxilla above
central incisor
Nasal septum
Levator labii
superioris alaeque
nasi
Frontal process of
maxilla
Ala
Upper lip
Elevate lip
deepen nasolabial
sulcus
Levator labii
superioris
Upper lip
Elevate lip*
Levator anguli oris
Canine fossa of
maxilla
Angle of mouth
Elevate angle of
mouth
Zygomaticus minor Zygomatic bone

(medial)
Upper lip
Elevate lip*
Zygomaticus major Zygomatic bone

(lateral)
Angle of mouth
Smile
Risorius
Fascia over
parotid gland
Angle of mouth
Depressor anguli
oris
Mandible
Angle of mouth
Depressor labii
inferioris
Mandible
Lower lip
Mentalis
Mandible
Skin of chin
Orbicularis oris
Buccinator
Alveolar process
of maxilla and
mandible
Lip
Blow out
Sucking
Orbital muscles
Nasalis muscles
Buccal muscles
Branches of external carotid a.

Facial a.
Maxillary a.
Mental a.
Infraorbital a.
Buccal a.
Transverse facial a. EXAM
Superficial temporal a.
Inferior labial a.
Superior labial a.
Lateral nasal a.
Angular a.
Facial Veins *valve not present infection

Facial veins
Pterygoid venous plexus
Drain to maxillary v.
Connect to
Facial v. via deep facial v.
Carvernous sinus via emissary v.
Opthamic v. via inferior ophthalmic v.
Superficial temporal v.
Retromandibular v. EXAM
Facial v. danger triangle of face (infection)
External jugular v.
Internal jugular v.
Facial Nerve (CN VII) exit skull at stylomastoid foramen enter parotid gland exit as branches *all motor n.
Posterior auricular branch

Temporal branch
Zygomatic branch
Buccal branch
Marginal mandibular branch
Cervical branch not supply muscle of facial expression
Facial nerve palsy (Bells palsy)

Lesion at geniculate ganglion ipsilateral loss of motor function of the whole face, taste of tongue, lacrimation, salivation
Lesion at stylomastoid foramen ipsilateral loss of motor function of the whole face
Layers of scalp
S skin
C connective tissue
A aponeurosis epicranialis *SCA skull proper
L loose CNT
P periosteum (pericranium)
Scalp injury
Separation of skull proper and loose CNT layer
Facial laceration and incision
Incision along cleavage (wrinkle) line minimal collagen fiber disruption minimal scarring
Muscles of Forehead
Muscles
Origin
Frontalis
Occipitalis
Insertion
Action
Innervation
Blood supply
Galea aponeurosis Subcutaneous

tissue of eyebrows
Galea aponeurosis -
Temporal and Infratemporal Bones

Temporal bone
Zygomatic process zygomatic arch
Zygomatic bone
Sphenoid bone
Mandible
Pterion
Articulate area of fontal, parietal, temporal and sphenoid bone

Content: middle meningeal a.
Body of mandible
Ramus of mandible
Angle of mandible
Mandibular notch processes: coronoid process (anterior), and condylar process (posterior)
Mental foramen
Mental protuberance
Alveolar process
Mandibular foramen mandibular canal
Submandibular fossa
Retromolar triangle mandibular nerve block
Temporal fossa
Boundary: temporal line, sphenoid, zygomatic arch
Covered with temporal fascia
Infratemporal fossa
Boundary: maxilla, sphenoid, zygomatic arch
Muscles of Mastication action at mandible
Muscles
Origin
Insertion
Action
Innervation
Blood supply
Temporalis
Temporal fascia
Coronoid process
of mandible
Elevate
Retrusion
Anterior trunk of
mandibular n. via
temporal branch
Maxillary a.
Superficial
temporal a.
Massester
Superficial layer
Deep layer
Zygomatic arch
Ramus of
mandible
Elevate
Protrusion
Retrusion
Anterior trunk of
mandibular n. via
masseteric n.
Maxillary a.
Lateral pterygoid
Upper head
Lower head
U: Infratemporal
crest of sphenoid
L: Pterygoid plate
Pterygoid fovea
(mandibular neck)
Depress
Protrusion
Anterior trunk of
mandibular n. via
lateral pterygoid n.
Maxillary a.
Medial pterygoid
Superficial head
Deep head
S: Maxillary
tubercle
D: Pterygoid plate
Ramus of
mandible
Elevate
Protrusion
Anterior trunk of
Maxillary a.
mandibular n. via
medial pterygoid n.
Maxillary artery branch of external carotid a. enter parotid gland exit with branches EXAM
Mandibular part
Deep auricular a.
Anterior tympanic a.
Accessory meningeal a. enter foramen ovale
Middle meningeal a.
Enter foramen spinosum
Inferior alveolar a.
Inferior alveolar n.
Enter mandibular foramen
Pass trough mental foramen mental a.
Pterygoid part
Deep temporal a.
Masseteric a.
Pterygoid a.
Buccal a.
Pterygopalatine (sphenopalatine) part
Posterior superior alveolar a.
Motor branches of mandibular n.
Motor and sensory (semilumar (gasserian) ganglion)
Main trunk
Meningeal n. foramen spinosum meninges
Median (internal) pterygoid n.
Medial pterygoid m.
Tensor veli palatini m.
Tensor tympani m.
Division
Anterior division EXAM
Deep temporal n. temporalis
Nerve to lateral pterygoid pterygoid
Masseteric n. massester
Buccal n. (sensory)
Posterior division
Auriculotemporal n. loop across middle meningeal a., parasympathetic of CN IX to parotid gland
Lingual n. (sensory: tongue) sublingual and submandibular gland
Chorda tympani n. (CN VII; sensory: taste; preganglionic parasympathetic fiber to sublingual and submandibular g.)
Inferior alveolar n. enter mandibular foramen incisive, mental, mylohyoid n.
Lingual nerve injury
Proximal to chorda tympani joined site lost sensation of anterior tongue
Distal to chorda tympani joined site lost sensation of anterior tongue, abnormal salivary gland secretion
Temporomandibular joint
Structure
Glenoid (mandibular) fossa of temporal bone
Postglenoid tubercle prevent joint dislocation to auditory canal anterior dislocation
Anterior articular tubercle
Head of mandible articular surface
Articular disc fibrocartilage (vs hyaline cartilage of other joint)
Articular capsule
Lateral (temperomandibular) ligament
Sphenomandibular ligament
Stylomandibular ligament
Anterior
masseteric a.
Medial
maxillary a., v., auriculotemporal n.
Examination
1. superficial parotid gl.? lateral to medial: facial n., retromandibular v., external carotid a., superficial
temporal a., branches of the great auricular n., maxillary a.
A. Retromandibular v.
B. Facial n.
C. Ext. jugular v.
D. Ext carotid a.
2. TM jt. . hinge jt ?
Head of mandibular + articular disc
3. retract mandibular ?
Temporalis
4. ?
Great occipital n.
5. block nerve . 3rd mandibular molar teeth?
Inferior alveolar n.
6. Lesser petrosal n. preganglionic parasympathetic fibers ?
A. Otic ganglion
B. Ciliary gg.
C. Semilunar gg.
D. Geniculate gg.
E. Submandibular gg.
7. 48 mandibular branch facial nerve ?
Depressor anguli oris m. Depressor anguli oris, depressor labii inferioris, mentalis
8. block n. ?
Buccal n. block
9. ?
Inferior laryngeal n.
10. Lesion protract mandible ?
Anterior division of mandibular nerve
11. ?
Buccinator
12. Anterior belly of digastric nerve ?
Mylohyoid n.
13. ?
Emissary v.
14. masseter structure ?
Tranverse facial a.
15. Galea aponeurosis muscle ?
Occipitalis, frontalis m.
16. parotid gland ?
Retromandibular v.
17. ?
Trigeminal neuralgia
18. ?
Zygomaticus major m.
19. Pterygoid venous plexus ?
Cavernous sinus via emissary v.
20. pterion ?
Middle meningeal a.
21. (Blinking) branch facial n.?

Temporal branch
22. nerve ?
Chorda tympani n.
Lecture 25.5-26.5 Muscle Relaxant Drug

Ach Nm (nicotinic receptor type N2)
Docking fusion release
Muscle Relaxant Drugs

Characteristics
Drugs
Centrally acting muscle relaxants
Membrane stabilizing effect (non specific)

Indication
Use combined with rest and physical therapy
ADR
Local anesthetic effect sedate
Euphoria (mood enhancement) abuse
Carisoprodol + steroid (Alaxan)

Orphenadrine + paracetamol (Norgesic)
Chlorzoxazone + paracetamol
Tolperisone (Mydocalm)
Diazepam (Valium)
Chlorpromazone
Balcofen
GABA derivative bind with GABA-B receptor
in brain and spinal cord reduce nerve
activation
Direct acting muscle relaxants
Inhibit Ca2+ release from sarcoplasmic reticulum
Dantrolene
Indication
Malignant hyperthermia
ADR
Hepatotoxic effect
Neuromuscular blockers
Sensitivity: ocular m. mastication m. limb abdominal m. respiratory m.
Indication
Adjunct with general anesthetics to increase skeletal muscle relaxant
Respiration maneuver
Reduce muscle damage in electroshock therapy
Pre-synaptic neuromuscular blockers
Reduce ACh release from cholinergic n.

Motor n.
Autonomic ganglion (preganglionic neuron)
Parasympathetic terminal
Sweat gland
Botulinum toxins (Clostridium botulinum)

ADR: focal hand dystonia
Indication
Hyperactive m., inject every 3-4 months (sprouting nerve terminal)
Blephorospasm, hemifocal spasm
Cervical dystonia, focal hand dystonia
Hyperhidrosis
Post-synaptic neuromuscular blockers
Non-depolarizing/competitive NMJ blockers
Competitive antagonist block ACh end plate potential flaccid
paralysis
Neostigmine inhibit AChE EXAM
ACh at nicotinic site counter competitive NMJ blocker
ACh at muscarinic site parasympathetic hypotension
Administered with muscarinic antagonist e.g. atropine
ADR
Histamine release allergic, hypotension (N1, Nn)
Respiratory depression
d-Tubocurarine (d-Tc, curare)

Pancuronium
Vercuronium
Atracurium
Depolarizing/non-competitive NMJ blockers

Bind to Nm recepter depolarization non-synchronous contraction
spastic paralysis, fibrillation, fasciculation prolong depolarization
flaccid paralysis
Not degraded by AchE
Phase I block (depolarizing)
Phase II (desensitizing) EXAM
Phase I block conformational changes of receptor
repolarization
Train of four test (TOF test) for TOF ratio
ADR
Butyrylcholinesterase mutation severe blockade apnea
Malignant hyperthermia
Hyperkalemia
Increase intraocular m. (slow fiber)
Succinylcholine (Suxamethonium)
Examination
1. atropine d-tc ?
Prevent hypotension
Neostigmine inhibit AChE
ACh at nicotinic site counter competitive NMJ blocker
ACh at muscarinic site parasympathetic hypotension
2. Neostigmine antagonize d-Tc atropine ?
parasym
3. Phase 2 succinylcholine?
Deformational changes of receptor
4. Test of TOF?
A. Pre-synapse
B. Post-synapse
C. Docking
D. Excitation contraction
E. All above
5. Phase II block of succinylcholine, the blockade could be antagonized by?
A. d-Tc
B. Neostigmine
C. Botulinum toxin
D. Dantrolene
6. Succinylcholine anesthetic medication ()?
muscle tone
7. Dantrolene ?
calcium ion sarcoplasmic reticulum
8. non-depolarizing blocking drug ?
Pancuronium
9. malignant hyperthermia dantrolene ?
calcium
10. electroconvulsive therapy ?
neuromuscular blocking drug spasmolytic drug
11. ?
Succinylcholine
12. cerebral palsy 3 ?

Botulinum toxin
13. ?
Carisoprodol
14. Botulinum toxin ?
Sprouting neuron terminals
15. carisoprodol orphenadrine?
Euphoria, abuse
16. Competitive NMJ blockers Atropine ?
Hypotension
17. Muscle relaxant Fasciculation ?
Succinylcholine
Lab Conference: Neuromuscular Blocker and Screening for Analgesic Drug

Case 1: respiratory insufficiency, cyanosis
tracheal food aspiration bronchoscopy
atropine drying secretion, produce bronchodilation, prevent vasovagal reaction
propofol sedation, secretion
succinylcholine interventional rigid bronchoscopy (muscle relaxant)
1mm pupil myosis Ach excess
diarrhea, PR parasympathetic
bronchial secretion, salivation, diaphoresis secretion (diaphoresis cholinergic excess)
coma CNS effect
Ach excess organophosphate
succinylcholine + organophosphate prolong depolarization complete blockage
Case 2: phrenic n. diaphragm
TOF test (train-of-four): presynaptic nicotinic receptor reserve to releasable pool synaptic vesicle availability
TOF ratio
>0.75 Succinylcholine phase I block presynaptic nAChR
0.75 block both post and pre synaptic d-tubocurarine (dTc), succinylcholine phase II (desensitization)
Neostigmine anticholineesterase
d-tubocurarine (dTc), succinylcholine phase II (receptor desensitization binding disassociation) stimulation
Succinylcholine phase I block blockage
Case 4: mild reflux, CHF, renal impairment

Pathophysiology: Age (mucosal fragility), CHF (decrease blood supply) GI bleeding
Treatment: paracetamol + NSAID (to reduce NSAID dosage GI bleeding )
Caution: ACE inhibitors + NSAIDs + diuretics iatrogenic acute renal failure (renal blood flow , GFR )
Lecture 26.5-27.5 Gout Drugs

Gout
Etiology
Pathophysiology
Hyperuricemia
Reduced excretion
Acute arthritis
Female >6 mg/dl Primary idiopathic
Monosodium urate deposit in joint
(cold, acidic)
Male >7 mg/dl
Diuretics
Renal insufficiency
Renal stone
Chronic arthritis
Low dose aspirin
Overproduction
Tophus (plu: tophi)
Primary idiopathic
Renal failure
Stage of gout
Obesity
Alcohol organic anion metabolite uric acid reabsorption Asymptomatic hyperuricemia
Acute attack of gout peak: 1-2
Purine-rich diet
days, resolved: 7-10 days
Hemolytic process purine accumulation
Chronic gout
Urate crystal in joint phagocytosis by synoviocytes IL-1
neutrophil chemotaxis release lysosomal enzyme (acid)
inflammation and further urate precipitation
Gout Drugs
Group
Characteristics
Drugs
Asymptomatic hyperuricemia no treatment required

Lifestyle
modification
Low purine diet

Exercise
Well hydrated
Acute attack of gout

NSAIDs
Indomethacin, naproxen , sulindac etc.

except aspirin
Colchicine
Bind to tubulin inhibit neutrophil chemotaxis

Inflammation reduced in 12-24 hr.
Colchicine
Indication
Prophylaxis for gouty attack
Initiation of urate lowering drug (4-6 months)
ADR
GI epithelium (inhibit cell division) diarrhea, abdominal p.
Interact w/ CYP3A4, P-gp inhibitors
Glucocorticoids
Indication
Reserve for patient who can't tolerate NSAIDs and
colchicine
Prednisone (PO)
Prednisolone (IV)
Triamcinolone (IV)
Xanthine
oxidase
inhibitors
Purine nucleotide hypoxanthine xanthine uric acid
Allopurinol
Febuxostat (non-purine)
ADR: hepatotoxicity, CVS, MI, stroke
Uricases
Uric acid Allantoin (soluble)

Recombinant urate oxidase IV
Pegloticase
ADR: infusion reaction, gout flare (3
months), G-6-PD def., anaphylaxis
Rasburicase
Indication: tumor lysis syndrome
(TLS)
Uricosurics
Inhibit URAT-1 (urate transporter) inhibit urate reabsorption

Interaction
Inhibit tubular secretion of acid agents e.g. penicillin,
methotrexate, NSAIDs
Contraindication
Renal stone, renal insufficiency
ADR: GI irritation, hypersensitivity
Probenacid
ADR: respiratory failure, renal stone
Benzbromarine
Excrete via bile, use in renal
insufficiency patients
ADR: hepatotoxicity
Chronic gout
[xanthine oxidase]
Metabolism: allopurinol (non-competitive inhibitor)
alloxanthine (competitive inhibitor)
Indication
First line for gout EXAM
Hyperuricemia from blood dyscrasia, cancer (tumor lysis s.)
Interaction
Xanthine-metabolized drugs e.g. azathioprine, 6mercaptopurine EXAM
Allopurinol + probenacid Allo.cl, Pro.hl
ADR
Hypersensitivity (rare, SJS/TEN, HLA-B*5801 allele)
Examination
1. right metatarsophalangeal joint colchicine ?
Gout
2. 55-year-old Pt consult the physical with painful, red, hot at left knee joint. After history taking and physical examination,
needle-like crystal were found in the synovial fluid. Which is the drug of choice of this patient?
A. Probenecid
B. Allopurinol
C. Indomethacin
3. Gout + urine uric acid >800mg chronic?
Allopurinol
4. chronic gouty arthritis ?
Allopurinol
5. 6-MP + allopurinol ?
Allopurinol 6-MP
6. colchicine?
Tubulin inhibit microtubules
7. allopurinol ?
Febuxostat
Lecture 27.5-29.5 The Neck

Surface anatomy of neck Langers (cleavage) line
Sternocleidomastoid (sternal head)
Anterior border of trapezius
Supraclavicular fossa pressure point of subclavian a.
Jugular fossa investing fascia anterior jugular a.
Superficial structure of neck
Tracheal ring 2-4 thyroid gland
C6 cricoid cartilage, junction of pharynx-esophagus and larynx-trachea
Boundary of the neck
Superior: mandible, mastoid process, superior nuchal line, EOP
Anterior: sternal (jugular) notch, sternoclavicular joint, clavicle
Lateral: acromioclavicular joint
Posterior: spine of scapular
Bones of Neck
Hyoid (lingual) bone
Greater horns
Lesser horns
Tip of greater horn lingual a.
Body
* laryngeal protuberance Adam apple

Carotid line
Imaginary line between sternoclavicular joint and midpoint between mastoid process and angle of mandible
Carotid sheath
Muscles of Neck EXAM

Muscles
Origin
Insertion
Action
Innervation
Blood supply
Platysma
Superficial fascia
of neck
Mandible
Cervical branch
of facial n.
Sternocleidomastoid
Sternal head
Clavicular head
Mastoid process
Flex neck
Rotate head (c.)
Tilt head (ips.)
Spinal part of
accessory n.
Anterior belly of
digastric
Mandible
Intermediate
tendon (fascial
sling)
Open mouth
Nerve to
mylohyoid
(inf. alv. n., CN V)
Posterior belly of
digastric
Mastoid notch
Intermediate
tendon (fascial
sling)
Open mouth
Digastric branch
of facial n.
(CN VII)
Stylohyoid
Styloid process
of temporal bone
Body of hyoid
Stylohyoid
branch of facial
n. (CN VII)
Myohyoid
Mandible
Fascial raphe
Hyoid
Depress
mandible
Nerve to
mylohyoid
(inf. alv. n., CN V)
Geniohyoid
Mental spine of
mandible
Body of hyoid
VR C1
(via hypoglossal)
Sternohyoid
Ansa cervicalis
Omohyoid
Superior belly
Inferior belly
Ansa cervicalis
Sternothyroid
Ansa cervicalis
Thyrohyoid
VR C1
(via hypoglossal)
Suprahyoid
Infrahyoid (stap muscles)
Prevertebral
Anterior prevertebral muscles
Longus capitis
Longus colli
Rectus capitis anterior
Rectus capitis lateralis
Posterior prevertebral muscles

Scalenus anterior
Cervical tr. p.
Rib 1
VR C4-6
Ascending
cervical a.
Scalenus medius
Cervical tr. p.
Rib 1
VR C4-6
Ascending
cervical a.
Scalenus posterior
Cervical tr. p.
Rib 2
VR C4-6
Ascending
cervical a.
*Ansa cervicalis originate from cervical plexus (C1-C3)

*Thyrohyoid membrane superior laryngeal a., internal laryngeal n. (sensory)
Triangle of neck sternocleidomastoid

Anterior cervical triangle divided by digastric m.
Submandibular (digastric) triangle submandibular gland, submandibular lymph node, facial a. and v.
Submental triangle submental lymph nodes, anterior jugular v.
Muscular triangle thyroid gland tracheostomy, thyroidectomy
Carotid triangle
Carotid sheath: common, internal and external carotid a., internal jugular v., CN IX-XII (IX: glossopharyngeal n., X:
vagus n., XI: accessory n., XII: hypoglossal n.)
Carotid angiography
Posterior cervical triangle divided by omohyoid m.
Occipital triangle
Spinal part of accessory n. careful half, carefree half
Cutaneous n. of cervical plexus (nerve point of neck)
Omoclavicular (supraclavicular, subclavian) triangle root and trunk of brachial plexus, subclavian a. and v.
Phrenic n.
Originate from C6-8
Pass anterior to scalenus anterior
Supply diaphragm
Torticolis (twisted or wry neck)
Congenital
Birth trauma (breeched baby) tear of sternocleidomastoid shortened muscle
Congenital absence of C4 pedicles
Acquired
Spasmodic spasm of sternocleidomastoid
Deep cervical fascia
Investing layer of deep fascia sternocleidomastoid
Prevertebral fascia axillary sheath
Cervical visceral fascia
Pretracheal fascia
Buccopharyngeal fascia *alar fascia
Carotid sheath
Compartments
Visceral compartment pretracheal fascia, buccopharyngeal fascia
Neurovascular compartment carotid sheath
Musculoskeletal compartment prevertebral fascia
Interfacial space potential space EXAM
Retropharyngeal space indistinguishable in healthy person
True retropharyngeal space (alar portion of deep layer of cervical fascia) located between visceral and alar fascia
Danger space (prevertebral portion of deep layer of cervical fascia) located between alar and prevertebral fascia
Carotid sheath EXAM EXAM *sympathetic chain located outside of carotid sheath
Contents
Internal jugular v.
Common carotid a.
CN X (vagus n.)
Ansa cervicalis
Deep cervical lymph node
Internal jugular v. tributaries jugular foramen
Occipital v.
Internal petrosal sinus
Pharyngeal v.
Facial v.
Lingual v.
Thyroid v. superior and middle thyroid v. (inferior thyroid v. brachiocephalic trunk)
CN X (vagus n.)
Superior laryngeal n.
Internal branch of superior laryngeal n. thyrohyoid membrane
External branch of superior laryngeal n. superior thyroid a., supply cricothyroid m. (vocal cord)
injury monotone (monotonus) voice (inability to make pitched sound)
Recurrent (inferior) laryngeal n.

Travel beneath Lt.: subclavian a. and Rt: aortic arch
Injury unilateral horseness, bilateral aphonia, breathing difficulties EXAM
Common carotid a.
Internal carotid a.
External carotid a. separate from common carotid a. at thyroid cartilage
Superior thyroid a.
Lingual a.
Facial a.
Ascending pharyngeal a.
Occipital a.
Posterior auricular a.
Maxillary a.
Superficial temporal a.
Carotid body located at bifurcation of common carotid a., chemoreceptive cells pH
Carotid sinus barorereceptor blood pressure
Subclavian a. divided by scalenus anterior m.
1st part
Vertebral a. foramen transversarium
Thyrocervical trunk inferior thyroid a., transverse cervical a., suprascapular a.
Internal thoracic a. intercostal a.
2nd part
Costocercivical trunk superior intercostal a. and deep cervical a.
3rd part
Dorsal scapular a.
Deep cervical lymph node divided by omohyoid m. EXAM
Superior deep cervical lymph node
Jugulo-digastric node
Jugulo-omohyoid node
Inferior deep cervical lymph node
Virchows node
Drainage: Rt.: right lymphatic duct, Lt.: thoracic duct
Cervical plexus
VR C1-4
Cutaneous n. of cervical plexus (nerve point of neck) EXAM
Great auricular n.
Transverse cervical n.
Lesser occipital n.
Supraclavicular n.
Ansa cervicalis
Superior root (C1) descendens hypoglossi or ansa hypoglossi *go with hypoglossal n. geniohyoid, thyrohyoid
Inferior root (C2-3) descendens cervicalis
Loop of ansa cervicalis
Examination
1. phrenic ?
Scalenus anterior
2. Torticollis muscle ?
Sternocleidomastoid
3. Birth trauma wry neck?
Sternocleidomastoid
4. Platysma?
Cervical branch of facial n.
5. Content carotid sheath C6 level?
Internal jugular v., common carotid a., CN X
6. Muscular triangle?
Thyroid gland
7. muscular compartment?
Prevertebral fascia
8. rib 1?
Scalenus anterior, medius
9. ?
10. scalenus anterior, medius?
Brachial plexus + subclavian a.
11. Phrenic n. ?
Scalenus anterior
12. Tense the skin of the neck and draw angle of the mouth inferiorly action ?
Platysma
13. Platysma m. nerve ?
Cervical branch of facial nerve
14. elevate hyoid bone ?
Suprahyoid muscle
15. flex neck + rotate head?
Sternocleidomastoid
16. infrahyoid ventral rami of C1 hypoglossal n.?
Thyrohyoid m. VR C1 (via hypoglossal) supply geniohyoid, tyrohyoid m.
17. transverse process cervical vertebra rib 2?
Scalenus posterior Rib 1: scalenus anterior, scalenus medius
18. mylohyoid muscle muscle?
Geniohyoid
19. Left sternocleidomastoid ?
Turn face to right, tilt head to left
20. Nerve cervical plexus ?
Phrenic nerve
21. deep lymph node ?
Jugulo-digastric node Deep cervical lymph node: jugulo-digastric, jugulo-omohyoid, Virchows node
22. ?
Carotid triangle
23. Nerve ?
Greater occipital n.
24. Danger space ?
Ala fascia prevertebral fascia
25. nerve ?
26. Nerve cervical plexus C3-C4?
Supraclavicular n.
Lecture 30.5-31.5 Microbial Agents in Musculoskeletal System

Bacterial Infections in Musculoskeletal System
Diseases
Etiology
Pathophysiology
Septic arthritis
Nongonococcal bacterial arthritis Hematogenous spreading

S. aureus
Extension from a contiguous
site of infection
Streps
H. influenzae
Direct penetration
Gonococcal bacterial arthritis
CD4 TNF inflammation
N. gonorrheae
Special group
destruction of articular
cartilage
TB
Burkholderia pseudomallei
Predisposing factors
Immune suppression
Chronic rheumatic diseases
Nongonococcal bacterial
arthritis
Tenderness
Limited joint motion
Fever
Gonococcal bacterial arthritis
Monoarthritis
Polyarthritis
Disseminated
Hemorrhagic macule
Diagnosis
Joint fluid: WBC >50k w/
PMN >90%, culture
Infectious arthritis
Viral infections
Pavovirus B19
Hepatitis B v.
Rubella
Alphavirus
Fungal infections
Osteomyelitis
S. aureus
Peripheral osteomyelitis
Age: 1 year
Subperiosteal abscess
Vertebral osteomyelitis
Subperioustium access
Local invasion
Metaphysis of vertebra
Treatment
Neonate: Antistaphylococal
penicillin+ third generation
cephalosporin/
aminoglycoside
Tuberculous
spondylitis
TB
Hematogenous spreading
Destroy vertebral body and
Potts paraplegia
disc kyphosis
Prosthetic joint
infection
S. epidermidis
S. aureus
Streptococcus
Septic bursitis
Trauma
RA
Infection septic bursitis
Inflammation of fluid-filled sac

(bursa)
Microbial Agents in Musculoskeletal System

Genus
Characteristics
Virulence factors
Staphylococci
Surface antigens
Protein A bind to IgG Fc antiphagocytic activity
Teichoic acid endotoxin-like activity
Extracellular enzymes
Coagulase in S. aureus coagulate citrated plasma
Hyaluronidase (spreading factor)
Lipase/esterase
DNase (deoxyribonuclease)
Staphylokinase (fibrinolysin) proteolytic enzyme
Penicillinase
Collagen binding protein EXAM
Toxins
Cytolytic toxin
Hemolysin
Leukocidin kills WBCs
Enterotoxin
Exfoliative (epidermolytic) toxin split desmoglein 1
Toxic shock syndrome toxin-1 (TSST-1)
Gram cocci, cluster

Non-motile, no spore
Enzyme catalase
Coagulase S. aureus
superantigen
Streptococci
Gram cocci, chain

Culture on blood agar
-hemolytic streptococci (partial)
-hemolytic streptococci (total)
-hemolytic streptococci (no h.)
Surface antigens
M protein antiphagocytic activity
Capsule
Hyaluronidase
Hemolysin (streptolysin)
Streptolysin O antistreptolysin O (ASO) test
Streptolysin S
Streptokinase (fibrinolysin)
Toxin
Erythrogenic toxin (pyogenic toxin) scarlet fever
EXAM
Pneumococci
Streptococcus pneumoniae
Surface antigens
Capsular polysaccharide
Gram diplococci
Adhesin
Blood
agar:
-hemolytic
streptococci
Teichoic acid, peptidoglycan

Phosphorylcholine adhesion
Extracellular enzyme
Secretory IgA protease
Pneumolysin
Neisseria spp.
Enterobacteriaceae
Gram, bacilli
Facultative ferment sugars
Oxidase test
Esherichia coli
Motile
Lactose fermenter
Surface antigens
Lipooligosaccharide (endotoxin)
Pili (fimbriae) resistant, antiphagocytic, adhesion
Gram, bacilli, aerobe

Non-fermentative
Oxidase test
Pseudomonadaceae
Neisseria meningitidis meningitis

N. gonorrheae gonorrhea
Gram, diplococci, kidney-shaped
Oxidase test
Surface antigens
Pili, opacity protein adhesion
Porin protein PorA serum killing ?
Lipooligosaccharide (LOS) inflammation EXAM
Lipooligosaccharide (endotoxin)
Capsule
Extracellular
enzyme
IgA1
protease
Mycobacterium
Pseudomonas aeruginosa
Gram, bacilli
Monotrichous flagellum
Blood agar: -hemolysis streptococci
Pigments
Pyocyanin (blue-green)
Fluorescein (yellow-green)
Pyorubin (red-brown)
Grape-like odor
Oxidase
Surface antigens
Adhesin
Lipopolysaccharide (LPS)
Extracellular
enzymes
Exoenzyme
S
Alkaline
protease,
phospholipase
Alginate
synthesis
Toxin
Exotoxin A
Acid fastness EXAM

Colony
Dysgonic type (smooth)
Eugonic type (rough)
Growth: Rapid grower 1 wk.
Surface antigens
Lipopolysaccharide (LPS)
Mycolic acid
Cord factor granuloma
Sulfolipid survive in macrophage
Lipoarabinomannan (LAM)
Hemolysin
Mortality enhancing polypeptide
Lecithinase, lipase, protease, malleobactin
Toxin
Exotoxin
NTM (non-mycobacterium TB)

Slow grower 4-6 wk.
Examination
1. 5 1 Gram positive cocci in cluster
catalase coagulase virulent factor ?
A. Protein M Streptococci
B. Pili neisseria spp., enterobacteriaceae
C. Fibrinolysis
D. Collagen binding protein
E. Erythrogenic toxin Streptococci
2. hemorrage pappule ?
Neisseria gonorrhea Skin lesion
3. thoracic and lumbar acid-fast
?
Mycobacterium tuberculosis
4. 65 Gram positive cocci, oxidase
test positive, coagulase test negative ?
S. epidermidis prosthetic joint
5. 5 1 Gram+ cocci in cluster coagulase
test+, catalase test+ virulent factor?
A. Fibrinolysin Strep, Staph
B. Collagen binding protein Staph
C. Erythrogenic toxin Strep
D. Protein M Strep
6. virulence factor Neisseria gonorrheae ?
Lipooligosaccharide
7. hemorrhagic skin ?
Neisseria gonorrhea LOS, skin lesion
8. gram + ve cocci, catalase +ve, coagulage ve ?
Staphylococcus epidermidis
9. pigment fluorescein, grape like odor?
Pseudomonas aeruginosa
10. gram gram ve coccobacilli pleomorphic virulence factor ?

Capsule
Lecture 31.5-32.5 Gluteal, Tight and Popliteal Fossa

Boundary: Iliac crest to gluteal fold/crease
Bones of Gluteal, Tight and Popliteal Fossa
Hip bone
Acetabulum
Ilium (superior)
articular surface sacroiliac joint
Iliac fossa (ala)
Iliac crest L4
ASIS (anterior superior iliac spine)
PSIS (posterior superior iliac spine)
Greater sciatic notch
Ischium (posterior)
Body
Ischial spine
Lesser sciatic notch
Ischial tuberosity bed sore
Ramus
Pubis (anterior)
Body
Ramus
Obturator foramen obturator membrane
Femur
Proximal end
Head
Neck
Greater trochanter
Lesser trochanter
Intertrochanteric line(anterior)
Intertrochanteric crest (posterior)
Gluteal tuberosity gluteus maximus
Body (shaft)
Linea aspera
Medial lip medial supracondylar line
Lateral lip lateral supracondylar line
Distal end
Adductor tubercle
Patellar surface
Medial condyle
Medical epicondyle
Lateral condyle
Lateral epicondyle
Nerve of Gluteal, Tight and Popliteal Fossa

Superficial gluteal nerve
Deep gluteal n.
Superior gluteal n. and a.

Inferior gluteal n. and a.
Sciatic n.
Superior cluneal nerve (DR L1-3)

Middle cluneal nerve (DR S1-3)
Inferior cluneal nerve (branch of posterior femoral cutaneous nerve)
Iliohypogastric nerve
Femoral cutaneous n.
Superficial vein greater siphons vein
Muscles of Gluteal
Muscles
Origin
Insertion
Action
Innervation
Blood supply
Superficial group abduct and extend hip

Gluteus maximus
Ilium
Iliotibial tract
Gluteal tuberosity
of femur
Extend hip joint
Inferior gluteal n.
Gluteus medius
Ilium
Greater trochanter
of femur
Abduct hip joint
Superior gluteal n.
Gluteus minimus
Ilium
Greater trochanter
of femur
Abduct hip joint
Superior gluteal n.
Iliotibial tract
Abduct hip joint
Superior gluteal n.
Tensor fascia latae Iliac crest

Deep group lateral rotate hip
Piriformis
Anterior surface of
sacrum
Greater trochanter
of femur
Lateral rotate hip

joint
VR S1-2
Superior gemellus
Spine of ischium
Greater trochanter
of femur
Lateral rotate hip

joint
Nerve to obturator
internus
Obturator internus
Obturator
membrane
Greater trochanter
of femur
Lateral rotate hip

joint
Nerve to obturator
internus
Inferior gemellus
Ischial tuberosity
Greater trochanter
of femur
Lateral rotate hip

joint
Nerve to
quadratus femoris
Quadratus femoris
Ischial tuberosity
Quadrate tubercle Lateral rotate hip

on
joint
upper end of femur
?
Nerve to
quadratus femoris
Greater trochanter
of femur
Obturator n.
Obturator externus obturator

membrane
Lateral rotate hip

joint
Trendelenburg sign test hip abductors: gluteus medius, gluteus minimus
Muscles of Tight and Popliteal Fossa

Muscles
Origin
Insertion
Action
Innervation
Blood supply
Anterior compartment femoral n. except psoas

Sartorius
ASIS
Medial surface of
tibia
Flex, abduct hip

Flex knee
Femoral n.
Iliopsoas
Iliacus
Psoas
T12-L1
Lesser trochanter
Flex hip
Iliacus: Femoral n.
Psoas: VR L1-2
Rectus femoris
AIIS
Quadricep tendon
Flex hip
Extend knee
Femoral n.
Vastus medialis
Intertrochanteric
line
Quadricep tendon
Flex hip
Extend knee
Femoral n.
Vastus lateralis
Greater trochanter
Quadricep tendon
Flex hip
Extend knee
Femoral n.
Vastus
Surface of femur
Quadricep tendon
Flex hip
Extend knee
Femoral n.
Quadriceps femoris
intermedius
Medial compartment thigh adduction, obturator n. except pectineus (femoral n.)

Gracilis
Ramus of pubis
Medial surface of
tibia
Obturator n.
Pectineus
Ramus of pubis
Pectineal line of
femur
Femoral n.
Adductor part
Ramus of pubis
Linear aspera of
femur
Obturator n.
Hamstring part
Ischial tuberosity
Adductor tubercle
of femur
Tibial division of
sciatic n.
Adductor longus
Body of pubis
Linear aspera of
femur
Obturator n.
Adductor brevis
Ramus of pubis
Linear aspera of
femur
Obturator n.
Adductor magnus
Posterior compartment sciatic n.

Semitendinosus
Ischial tuberosity
Medial surface of
tibia
Flex knee
Extend hip
Tibial division of
sciatic n.
Semimembranosu
s
Ischial tuberosity
Medial condyle of
tibia
Flex knee
Extend hip
Tibial division of
sciatic n.
Long head
Ischial tuberosity
Lateral side of
head of fibular
Flex knee
Tibial division of
sciatic n.
Short head
Linea aspara
Lateral side of
head of fibular
Flex knee
Common fibular
division of sciatic
n.
Biceps femoris
Rider bones ossification of tendon of adductor muscles
Triangles of Gluteal, Tight and Popliteal Fossa

Femoral triangle
Boundary
Inguinal ligament
Adductor longus
Sartorius
Contents (lateral to medial)
Femoral n. (lateral) and its branches
Femoral a. and its branches
Femoral v. (medial) and its tributaries
Popliteal fossa
Boundary
Biceps femoris
Semimembranosus, semitendinosus
Lateral head of the gastrocnemius
Medial head of the gastrocnemius
Contents
Popliteal artery and vein
Tibial nerve
Common fibular nerve
Small saphenous vein
Blood supply
External iliac a.
Deep femoral a. (profunda femoris a.) medial, posterior and lateral part of anterior compartments
Femoral a. anterior compartment
At adductor hiatus, change to popliteal a.
Anterior tibial a. dorsalis pedis a.
Posterior tibial a. medial and lateral plantar a.
Examination
1. (abduct) ?
Gluteus medius
2. Superior gluteal n. ?
Gluteus medius Gluteus medius, gluteus minimus, tensor fascia latae
3. ?
Ischial spine
4. 2 n.?
Iliopsoas
5. ?
Iliopsoas
6. Femoral n. ?
Knee extension Hip flex, knee extend
7. great saphenous v. ?
Medial malleolus Medial
8. adductor of thigh nerve ?
Obturator nerve
9. ?
Gluteus medius Gluteus medius, gluteus minimus, tensor fascia latae
10. flex hip, flex knee?
Sartorius
11. 2 nerve?
Adductor magnus Adductor part: obturator n., hamstring part: tibial division of sciatic n.
12. piriformis ?
Superior gluteal n.
Lecture 33.5-34.5 Leg and foot

Bones of Gluteal, Tight and Popliteal Fossa
Tibia (medial)
Fibular (lateral)
Lateral malleolus
Hindfoot
Calcaneus
Achilles tendon (tendo calcaneus)
Talus
Midfoot
Cuneiform (lateral)
Cuboid
Peroneus longus tendon
Navicular tibialis posterior
Forefoot
Metatarsal
Phalanges
Medial condyle
Lateral condyle
Medial intercondylar tubercle
Lateral intercondylar tubercle
Tibial tuberosity
Soleal line soleus m.
Medial malleolus
Arch of foot
Medial longitudinal arch
Lateral longitudinal arch calcaneus, cuboid, metatarsal and phalange IV-V
Transverse arch tarsometatarsal joint line
Fascia of foot
Deep fascia
Cural fascia
Continuous of tensor fascia lata
Intermuscular septum
Anterior
Posterior
Intermuscular septum
Plantar fascia
Plantar aponeurosis
Interosseous membrane
Retinaculum
Flexor retinaculum
Medial
Superior extensor retinaculum
Inferior extensor retinaculum
Lateral
Superior peroneal retinaculum
Inferior peroneal retinaculum
Cutaneous n. of leg
Deep perennial n.
Medial plantar n.
Lateral plantar n. (lateral 1-1.5 phalanges)
Nerve of leg
Sciatic n.
Tibial n. posterior compartment
Medial plantar n.
Lateral plantar n.
Common peroneal n.
Superficial peroneal n. lateral compartment
Deep peroneal n. anterior compartment
Superficial veins
Great sphenous v.
Small sphenous v.
Muscles of Foot
Muscles
Origin
Insertion
Action
Innervation
Blood supply
Anterior compartment extensor, deep peroneal n. (sciatic n. common peroneal n.), anterior tibial a. (femoral a.
popliteal a.)
Tibialis anterior
(TA)
Lateral condyle
and body of tibia
Medial cuneiform
Dorsiflex ankle
Inversion
Deep peroneal n.
Extensor hallucis
longus (EHL)
Surface of fibular
Distal phalanges
Dorsiflex ankle
Inversion
Deep peroneal n.
Extensor digitorum Interosseous

longus (EDL)
membrane
Distal phalanges
Dorsiflex angle
Extend toe
Deep peroneal n.
Peroneus tertius
Metatarsal
Dorsiflex ankel
Eversion
Deep peroneal n.
Interosseous
membrane
Lateral compartment superficial superficial peroneal n., peroneal a.

Peroneus longus
Fibula
Metatarsal I
Eversion
Superficial
peroneal n.
Peroneus brevis
Fibula
Metatarsal V
Plantaflexion
Superficial
peroneal n.
Superficial group of posterior compartment tibial n., posterior tibial a.

Gastrocnemius
Medial and lateral

condyle of femur
Calcaneus
Plantaflexion
Flex knee
Tibial n.
Soleus
Soleal line
Calcaneus
Plantaflex ankle
Tibial n.
Plantaris
Popliteal surface
Calcaneus
Plantaflex ankle
Tibial n.
Deep group of posterior compartment tibial n., posterior tibial a.

Popliteus
Lateral condyle of
femur
Tibia
Tibial n.
Tibialis posterior
Interosseous
membrane
Navicular
Tibial n.
Flexor digitorum
longus
Surface of tibia
Distal phalanges
Flex toes
Plantar flex ankle
Tibial n.
Flexor hallucis
longus
Surface of fibular
Distal phalanges
Flex toe
Plantar flex ankle
Tibial n.
Triceps sulae EXAM

Sciatic n. common peroneal n. superficial and deep peroneal n.
Femoral a. popliteal a. anterior and posterior tibial a. dorsalis pedis (palpate pulse)
Tarsal tunnel (medial malleolus) tibial n.
Tibialis posterior tendon
Posterior tibial a.
Tibial n.
Flexor digitorum longus tendon
Flexor hallucis longus
Muscles of Foot
Muscles
Origin
Insertion
Action
Innervation
Blood supply
Anterior compartment lateral tarsal n. (deep peroneal n.), lateral tarsal a. and dorsalis pedis a.
Extensor digitorum Calcaneus
brevis
Extensor
degitorum longus
Extensor hallucis
brevis
Muscles of Sole of Foot medial and lateral plantar n., dorsalis pedis, medial and lateral plantar a.
Muscles
Origin
Insertion
Action
Innervation
Blood supply
Abductor hallucis
Medial calcaneus
Proximal phalange
Medial plantar n.
Flexor digitorum
brevis
Plantar
aponeurosis
Middle phalanges
Medial plantar n.
Abductor digiti
minimi
Proximal phalange
Lateral plantar n.
Quadratus plantae
Calcaneus
Flexor digitorum
longus
Lateral plantar n.
Lumbricals
Flexor digitorum
longus
Proximal
phalanges
Medial one:
Medial plantar n.
Lateral three:
Lateral plantar n.
Flexor hallucis
brevis
Lateral head
Medial head
Cuboid cuniform
Proximal phalange
Medial plantar n.
Adductor hallucis
Transverse h.
Oblique head
Proximal phalange
Lateral plantar n.
Flexor digiti minimi

brevis
Metatarsal bone
Proximal phalange
Lateral plantar n.
Plantar interossei
Adduct
metatarsophalang
eal joint
Lateral plantar n.
Dorsal interossei
Adduct
metatarsophalang
eal joint
Lateral plantar n.
1st layer
2nd layer
3rd layer
4th layer
Clinical correlation
Bone fracture
Neck of fibular common perineal n.
Anterior compartment
syndrom
Compression of artery and nerve reduce blood supply

Foot drop
Loss sensation of 1-2nd toe
Flat foot
Treatment: arch support shoe
Plantar fasciitis
Treatment: ultrasound, tape fixation
Achilles tendonitis
Over dorsifexion inflamed Achilles tendon
Tarsal tunnel syndrom (TTS)
Deep peroneal n. injury
Loss of sensation of 1-2nd toes

Foot drop
Anterior tibial a. injury
Diagnosis: Dorsalis pedis impalpable
Varicose vein
Valve vein does not close properly

Grading: 0-6
Claw foot
Club foot
Hallux valgus (bunion)
Lateral deviation of the great toe at metatarsophalangeal joint

Treatment: bunion sprint
Hallux varus
Abductor (too strong) and adductor (too weak) hallucis m.

Medial deviation of the great toe at metatarsophalangeal joint
Examination
1. flexor retinaculum flexor ?
Tibial n.
2. Lateral plantar n.?
Flexor digiti minimi brevis
3. tricep surae?
Soleus Gastrocnemius, soleus
4. navicular?
Talus
5. tarsal injury?
Calcaneus
6. Nerve anterior compartment of leg?
Deep peroneal n.
7. origin calcaneus and long plantar fascia?
Flexor digitorum brevis
8. ?
Popliteus
9. Muscle tibial nerve L5, S1, S2?
Flexor hallucis longus m. Flexor hallucis longus, flexor digitorum longus m.
10. sole of foot fascia ?
Plantar fascia
11. ?
Deep peroneal n. ?
12. dorsiflexion inversion?
Tibialis anterior m.
13. 3?
Flexor hallucis brevis m. Flexor hallucis brevis, adductor pollicis, flexor digiti minimi
14. fracture head of fibula ?
Common peroneal n.
Lecture 35-36 Therapeutic exercise in common MS problem

Deconditioning
Muscle mass
Muscle strength
Done density (osteoporosis)
CVS
Pulmonary
Postural hypotension
Joint stiffness
Psychological function
Exercise
Muscle strength, muscle hypertrophy
Bone mass
HR, stroke volume, CO tissue perfusion, BP
Lung volume gas diffuse capacity
Endocrine: GH, thyroid, estrogen, testosterone, insulin, glucagon, cortisol, cholesterol
Psychological: anxiety, depression
Type
Range of motion
Joint stiffness
Increase range of motion
Types repeated 3-5 times, 1-2 times/day

Active exercise grade 3 or higher motor power
Active assistive exercise grade 2 motor power
Passive exercise grade 1, isometric exercise
Passive stretching exercise joint stiffness
Strengthening exercise
Endurance exercise
Low load, high repetition
Coordination exercise
Prime mover
Application: cerebellar lesion
Type
Aerobic excercise
Continuous exercise
Intensity: target heart rate
Generic formula EXAM EXAM
60-80% of maximum heart rate
Maximum heart rate (MHR) = 220-age
Karvonen formula EXAM EXAM
Target HR = HR at rest + 60% HR reserve
HR reseve = Maximum HR - resting HR
Duration >30 mins
Frequency: >3 times/week
Anaerobic exercise
Range of motion
Increase flexibility
Overload principle high load, low repetition EXAM
Delormas technique
Progressive resistant exercise at 10RM (repetition maximum)
25% 10RM 50% 10RM 75% 10RM 100% 10RM
Oxford technique
Regressive resistant exercise at 10RM (repetition maximum)
100% 10RM 75% 10RM 50% 10RM 25% 10RM
Types EXAM
Isometric exercise
Isotonic exercise concentric, eccentric, progressive resistant exercise
Isokinetic exercise variable resistant training
Application: frozen shoulder (wall climbing), osteoarthritis (isometric or isotonic)
ATP <2 seconds

Creatinine phosphate 0-8 seconds
Glycolysis 6-90 seconds
Oxidative >2 mins
Warm up 5-10 minutes, stretching exercise

Cool down postural hypotension, delayed onset muscle soreness (DOMS)
Disease
DM
Exercise type Exercise Prescription

Target
Duration
(mins/week)
Frequency
(times/week)
Precaution
Aerobic
50-70% MHR
150 (moderate)
90 (intense)
20-60 min/day
3-7
Hypoglycemia
Insulin drug dosage
Resistant
2-3 set, 8-12 rep
2-3
50-70% MHR
30-60 mins/day
2-3
Resistant
(supplement)
1 set, 8-12 rep
Aerobic
70% MHR (>30 mins)
300 (moderate)
150 (intense)
>5
Resistant
(supplement)
Hypertension Aerobic
Obesity
Exercise complication: exercise induce asthma, musculoskeletal injury

Examination
1. injury ms system ?
2. Excessive load ?
A. low back pain
B. neck pain
C. wrist pain
D. forearm pain
E.
3. ?
, , =
4. cool down
?
5. O2?

6. motor power=0 ?
Passive ROM Passive stretching exercise
7. ?
Isometric exercise
8. ?
Eccentric exercise
9. strengthening exercise?
Low load, high repetition
10. warm up?
Increase growth hormone
Uncontrolled hypertension
Beta-blockers
Weight baring joint
11. Target heart rate 20 ?

120-160
12. Target hearth rate Karvonen formula?
HR at rest + 60% HR reserve
Lecture 37.5 Plain Film of Bone and Joint

Abnormal radiologic finding in plain radiography
Epiphysis secondary ossification center
Metaphysis epiphyseal plate
Diaphysis
Fracture
Disruption of cortex may affect proximal and distal joint

Type of fracture
Complete fracture
Transverse
Oblique
Spiral
Comminuted >3 pieces
Segmental
Avulsed tendon or ligament
Impacted
Incomplete fracture
Torus
Greenstick
Alignment of fracture
Displacement: medial, lateral displacement (reference from proximal fragment)
Angulation: medial, lateral angulation
Epiphyseal plate injury
Salter-Harris classification type 1-5

Prognosis: early epiphyseal plate closure
Fracture healing
Evidence of healing
Unsharpness of fracture border
Periosteal callus formation
Fracture line replaced by sclerosis
Dislocation, subluxation
Pathological fracture
Osteolytic lesion
Types
Geographic permeative
Well demarcated border
Suggest non-aggressive pathology e.g. benign tumor giant cell tumor, aneurysmal bone
cyst
Motheaten
Ill-defined border, course lesion
Suggest aggressive pathology
Primary malignant e.g. osteosarcoma, Ewing sarcoma, chondrosarcoma
Secondary malignant (metastasis)
Permeative
Poor demarcated, fine lesion
Periosteal reaction
Types
Non-aggressive periosteal reaction
Solid periosteal reaction calcified periosteal suggestion infection e.g. osteomyelitis
Aggressive
periosteal reaction suggest aggressive primary malignant tumor e.g.
osteosarcoma
Laminated periosteal reaction
Sunburst periosteal reaction
Codmans triangle periosteal reaction
Sclerosis
Types
Reactive sclerosis
Osteoblast response to pathology sclerotic border
Suggest progressive pathology e.g. chronic osteomyelitis, benign tumor
Sclerotic tumor e.g. osteosarcoma
Osteomyelitis
Ill-defined lesion
Types
Acute permeative osteolytic, solid periosteal reaction
Chronic sclerosis, sequestrum, involucrum
Examination
1. X-ray
?
2. ?
Dual energy X-ray absorptiometry Measuring bone mineral density (BMD)
3. Osteomyelitis ? ill-defined osteolytic lesion, extensive reactive sclerosis, solid periosteal reaction
A. Pathogenesis
B. Permeative osteolytic lesion with solid periosteal reaction
C. Geographic osteolytic lesion with sunburst periosteal reaction
E. Geographic osteolytic lesion with pathological fracture
4. ulnar radius?
Healing of proximal ulnar and radial
5. X-ray
Healing process of bone by callus
6. incomplete fracture?
Incomplete disruption of cortex
7. permeative osteolytic lesion sunburst periosteal reaction ?

Osteosarcoma
Lecture 38.5 Joint of the Lower Limb

Joint of the Lower Limb
Hip joint
Type: synovial joint

Bone:
Hip bones
Head of femur (acetabular labrum lunate surface, acetabular branch of obturator n.)
EXAM
Ligament
pubofermoral prevent abduction of hip joint
Illiofemoral ligament
Ischiofemoral (weakest)
Ligament of head of femur (acetabular branch of obturator a.) EXAM
Nerve supply: multiple e.g. femoral n.
Angles
Angle of Wiberg plane of acetabular rim
Angle of torsion 7-12 degree
Injury: acetabular branch of obturator a. EXAM
Knee joint
Type: hinge type of synovial joint

Articulation
2 femorotibial articulation (lateral and medial femoral and tibial condyles)
Femoropatellar articulation
Bursa
Suprapatella bursa
External ligaments of knee joint
Tibial (medial) collateral ligament (TCL) medial meniscus
Fibular (lateral) collateral ligament (FCL) lateral meniscus
Arcuate popliteal ligament
Oblique popliteal ligament
Intra-articular structure of knee joint EXAM EXAM
Anterior cruciate ligament anterior intercondylar area, limit posterior rolling
Posterior cruciate ligament posterior intercondylar area, limit anterior rolling
Lachman tested EXAM
Anterior drawer sign + anterior cruciate ligament tear
Posterior drawer sign + posterior cruciate ligament tear
Menisci C-shaped
Medial meniscus (less mobile)
Lateral meniscus
Angle
Q-angle weight-baring line (line of gravity) and ASIS EXAM
Decrease Q-angle genu varum
Increase Q-angle genu valgum
Ankle joint
Medial (deltoid) ligament tear in acute eversion EXAM

Lateral ligament
Anterior talofibular ligament tear in lateral angle sprain
Calcaneofibular ligament
Posterior talofibular ligament
Joint of foot
Subtalar (posterior talocalcanean) joint

Transverse tarsal (midtarsal or Chopart) joint consist of talonavicular and calcaneocuboid
EXAM
Intertarsal (intercuneiform) joint

Tarsometatarsal and intermetatarsal joints
Metatarsophalangeal and interphalangeal joints
Ligament
Iliofemoral ligament prevent hip hyperextension
Pubofermoral ligament prevent hip hyperabduction
Ischiofemoral ligament prevent hip hyperflexion
Examination
1. ?
Hip
2. Chopart's amputation ?
Interosseous talocalcaneous
3. deltoid lig. ?
Eversion
4. fibrocartilage acetabular labrum?
Hip
5. Hip ligament ?
Hip extension
6. knee hyperextension + forward displacement of tibia?
Anterior cruciate ligament
7. Ligament hip extension?
Iliofemoral ligament
8. Ligament Medial meniscus ?
Medial (tibial) collateral ligament
9. tibia ?
Anterior cruciate ligament
10. ?
Head of fibula
11. ?
Anterior talofibular ligament
12. Chopart's ligament ?

A. Spring ligament
B. Bifurcate ligament
C. Short plantar ligament
D. Long plantar ligament
E. Interosseous talocalcaneous ligament
Case Study: Case 1 Open Floating Shoulder Fracture with Brachial Plexus Injury
Scenario 1.1
A 20-year-old male, wearing a safety helmet, slipped and fell off from high speed motorcycle riding. His left shoulder hit the
ground resulting in severe pain. Emergency Medical Service carried him to a general hospital.
An emergency physician took physical examination and recorded as follows.
Vital sign: BT 37.2, RR 24 bpm, PR 90 bpm, BP 120/70 mmHg

HEENT, heart, lung, and abdomen: within normal limit
Left shoulder: a lacerated wound of left chest wall extending toward shoulder
Muscle of left upper limb: weakness
Initial emergency management

ABCD airway, breathing, circulation, disability
Wound dressing
Splinting
Initial assessment
Vital sign
Blood pressure 90/60 to 120/80 mmHg
Pulse rate 60 to 100 beats per minute
Body temperature 36.5 to 37.5C
Respiratory rate 12 to 18 breaths per minute
Pain
HEENT: head, eye, ear, nose, throat
Pain physiology
Mechanism
Direct mechanical injury
Muscle injury
Stimulate nociceptors nerve impulse transmitted via small A-delta fibers and C-fibers spinal cord thalamus
somatosensory cortex pain
C-fibers small unmyelinated neurons diffuse burning, aching sensations
A-delta fibers larger, myelinated fibers well-localized, sharp pain sensations
Muscle spasm
Ischemia
Scenario 1.2
Following a physical examination, an X-ray of the patients shoulder was carried out. The radiograph showed an open
fracture of the left clavicle.
The physician applied urinary catheter, intravenous fluid and 1 gm cefazolin, and intramuscular tetanus toxoid to the patient.
The debridement and open reduction were then performed.
Fracture definition: discontinuity of trabeculae

Fracture
Open fracture broken bone that is in communication through the skin with the environment contamination
Close fracture
Management of open fracture
Tetanus prophylaxis tetanus toxoid
Prophylactic antibiotics
Debridement
Fracture stabilization
Tetanus prophylaxis
Wound type
Patient receive
last tetanus shot
<5 years
Patient receive
last tetanus shot
5-10 years
Patient receive
last tetanus shot
>10 years
Patient never receive

tetanus shot
Clean wound
Not required
Not required
Tetanus toxoid
Tetanus toxoid
Contaminated wound
Not required
Tetanus toxoid
Tetanus toxoid
Tetanus toxoid
Tetanus immunoglobulin (TIG)
Scenario 2
Two weeks after medical operation the patients pain was over but he got fever. There was pus oozing from the surgical
wound which became red and swelling (inflammation). The patient could neither abduct the arm nor move his elbow and
hand. He also experienced the numbness of the whole upper limb. Physical examination of the second hospital visit was
recorded as follows.
Motor power (left side)
Rhomboideus
Deltoid
Pectoralis major
Supraspinatus
Infraspinatus
Latissimus dorsi
Biceps brachii
Triceps brachii
Flexor digitorum superficialis
Flexor digitorum profundus
Intrinsic muscle of hand
Grade
0
0
0
0
0
0
0
0
0
0
0
Inflammation
Infection, microbial toxin macrophage
Synthesis of IL-1, IL-6, TNF, IFN
Neutrophil recruitment
Hypothalamus
Synthesis of PGE2 in brain raising the hypothalamic set point for core temperature
Synthesis of PGE2 in peripheral tissue non-specific myalgia and arthralgia
IL-8 chemokine, induce chemotaxis of neutrophils
Present antigen to T-helper cell
IL-2 clonal expansion of T cells
IL-4 clonal expansion of B cells
Antibiotics selection
Grage I 1st generation cephalosporin
Grade II 1st generation cephalosporin gentamycin
Grade III 1st generation cephalosporin + gentamycin anti-anaerobe
War wounds 1st generation cephalosporin + gentamycin + anti-anaerobe
Motor power *apply for joint with full range of motion not apply for joint stiffness
0 no movement
1 trace movement
2 active movement without gravity
3 active movement with gravity
4 active movement with resistant
5 normal power
Brachial plexus
Brachial Plexus
Root (VR)
Trunk
Division
Cords
Branches
C5
Upper trunk
Anterior division
Dorsal scapular n. Nerve to subclavious
Lateral cord
Lateral pectoral n.
Musculocutaneous n.
Levator scapulae m.
Rhomboids m.
Pectoralis major m.
Subclavius m.
Suprascapular n.
Lateral root of median n.
Supra/infraspinatus m.
C6
C7
Flexor m. of forearm
Thenar m.
Lumbrical m. 1-2
Posterior division
Middle trunk
Anterior division
Posterior cord
Upper subscapular n.
Subscapularis m.
Thoracodorsal n.
Latissimus dorsi m.
Lower subscapular n.
C8
T1
Flexor m. of arm
Lateral cutaneous nerve of
forearm
Axillary n.
Deltoid m.
Teres minor m.
Superior lateral cutaneous
nerve of arm
Radial n.
Subscapularis m.
Teres major m.
Extensor m. of arm
Extensor m. of forearm
Inferior lateral cutaneous nerve
of arm
Medial cord
Medial pectoral n.
Ulnar n.
Posterior division
Lower trunk
Anterior division
Pectoralis major/minor m.
Medial cutaneous n. of arm

Medial cutaneous n. of forearm
C5-C7
Long thoracic n.
Intrinsic muscle of hand

Flexor carpi ulnaris
Flexor digitorum profundus
(medial half)
Median root of median n.
Posterior division
Serratus anterior m.
Brachial plexus injury

UBP injury Erbs palsy
LBP injury Klumpkes palsy
Total BP injury
Classification of nerve injury
Neurapraxia
Grade I myelin
Axonotmesis
Grade II myelin, axon
Neurotmesis
Grade III myelin, axon, endoneurium disrupt axon continuity, perineurium is protected
Grade IV myelin, axon, endoneurium, perineurium nerve fascia damage, sheath continuity is maintained
Grade V myelin, axon, endoneurium, perineurium, epineurium
Physical examination
Evaluation of C-spine injury
Evaluation of upper extremity function
Joint ROM and stiffness
Sign of nerve recovery
Specific sign
Imaging evaluation
Plain film evaluate shoulder joint, C-spine transverse process fracture
Myelography detect root avulsion (plain film or CT myelography, invasive)
MRI
CT angiography
Pulmonary function test phrenic n. indicate pulmonary injury
Electrodiagnosis evaluation
Sequence of surgical intervention
Elbow flexion reinnervation of biceps or brachialis m.
Shoulder stabilization
Hand sensation
Wrist and finger flexion
Wrist and finger extension
Intrinsic hand function
Primary reconstruction
Neurolysis fibrosis surround and compress nerve inhibit nerve recovery
Direct nerve repair (neurorrhaphy)
Nerve grafting from sural n.
Nerve transfer (neurotization) repair of a distal denervated nerve element by using a proximal foreign nerve
Secondary reconstruction
Tendon transfer
Free functioning muscle transfer (muscle transplantation)
Arthrodesis artificial induction of joint ossification between two bones via surgery
Scenario 3
The physician of Srinagarind Hospital requested Gram stain test of the patients pus obtained from the wound and the result
showed Gram positive cocci. The bacterial culture test revealed Staphylococcus aureus.
The physician adjusted the dose and order 1 gm IV cefazolin every 8 hours.
After a week of hospital stay, the test for infection showed negative result. He was still unable to abduct the arm and hand.
Total brachial plexus injury was diagnosed.
Common bacterial infection in open fracture

Blunt trauma, low energy gun shot wound Stapylococcus spp., Streptococcus spp.
Farm wounds Clostridia spp.
Fresh water Pseudomonas spp., Aeromonas spp.
Sea Water Aeromonas app., Vibrios spp.
War wounds, high energy gunshot wound Gram negative
Gram staining
Bacterial identification
Gram
Gram
Cocci
Catalase
Staphylococci spp.
Coagulase S. aureus
Coagulase
Novobiocin-sensitive S. epidermidis
Novobiocin-resistant S. saprophyticus
Catalase
Streptococcus spp.
-hemolytic pattern (partial)
Optochin S. pneumoniae
Optochin S. mutan, other viridians
-hemolytic pattern (clear)
Bacitracin-sensitive S. pyogenes
Bacitracin-negative S. agalactiae
-hemolytic pattern e.g. Enterococcus spp.
Rod
Clostridium spp.
Bacillus spp.
Coccobacilli
Haemophilus influenzae
Cocci
Neisseria spp. N. meningitidis, N. gonorrheae
Bacilli
Klebsiella spp.
E. coli
P. aeruginosa
Clinical Correlation
Anterior shoulder dislocation
Test for axillary n. if damaged
Treatment
Traction and counter traction
Hippocratic technique risk brachial plexus injury
Stimson technique
Leverage (Kocher) traction external rotation adduction internal rotation
Confirm diagnosis: by internal rotation
Humerus fracture
Associated injury: radial n. test for wrist extension
Dinner folk deformity
Treatment
Cast
Open reduction
Carpal tunnel syndrome
Palmaris longus lie outside carpal tunnel
Treatment
Decompress n.
Anatomical snuff box pain
Scaphoid fracture scaphoid avascular necrosis
Treatment: Herberts screw
De Quervain disease
Stenosing tenosynovitis of abductor pollicis longus and extensor pollicis brevis tendon
Radial styloid pain, Finkelstein test +
Embryology and congenital malformation of MS

Development of skeletal system
Mesoderm, neural crest cell
Intraembryonic mesoderm paraxial mesoderm somites
Somite
Ventromedial: sclerotome bone EXAM
Dorsolateral: dermomyotome
Myotome myoblast myotube myofilament synthesis in cytoplasm muscle
Dermatome dermis
Iris muscle, mammary gland, sweat gland develop from ectoderm EXAM EXAM
Myotomes
Preotic myotomes
Occipital myotomes
Cervical myotomes
Thoracic myotomes
Lumbar myotomes
Regressing caudal myotomes
Smooth muscle splanchnic mesoderm EXAM
Cardiac muscle splanchnic mesoderm intercalated disc, Purkinje fiber
Development by region
Trunk muscle myotome region of somite
Limb muscle somatic mesoderm (somatic layer of lateral mesoderm)
Tongue head mesenchyme
Face, jaw, neck, pharynx, larynx mesenchyme in brachial arch mastication, facial expression
5th week
Epaxial division small dorsal extensor muscle
Hypaxial division large, ventral flexor muscle
Development of bone and cartilage
5th week
Mesenchyme chondroblast chondrocyte
Hyaline cartilage
Elastic cartilage
Fibrocartilage
Skull
Neurocranium
Viscarocarnium
Membranous: frontonasal process maxillary process mandibular maxilla
Anterior fontanelle ?
Development of vertebral column
Stages
Precartilagenous stage
Sclerotome 3 main areas
Surrounding notochord
Densely packed cells (annulus fibrosus) intervertebral disc
Mesenchymal body of vertebra
Notochord degenerate nucleus pulposus
Surrounding neural tube
Vertebral (neural) arch
Body wall
Costal process rib (thoracic region)
Cartilaginous stage
6th week
Chondrification center
Occur in mesenchymal centrum
Bony stage
Ossification
Development of ribs
Mesenchymal
Clavicle first bone to start ossification
?
process mandible
Development of sternum
?
Development of limb
?
Apical ectodermal ridge
Examination
1. Muscle of iris ?
Ectoderm
2. ?
Sclerotome
3. Myotome?
Paravertebral muscle
4. Intramembranous ossification?
Frontal bone Nasal, sphenoid, frontal, parietal, temporal, vomer, maxilla, mandible, pelvis, clavicle
5. Muscle of iris ?
Ectoderm Iris muscle, mammary gland, sweat gland
6. Smooth muscle ?
Splanchnic mesoderm
Gross Anatomy Checklist EXAM
Gross Anatomy Checklist

#
Name
Description
Chondrocyte
Elastic cartilage
Fibrocartilage
Osteoclast
Haversian canal
Suboccipital n.
Suboccipital triangle (DR C1)
Semispinalis cervicis
Located behind splenius cervicis
Supraspinatus m.
Originate from supraglenoid fossa, insert to greater tubercle of humerus
Suprascapular a., n.
Passes through the suprascapular notch

Nerve inferior to the superior transverse scapular ligament
Artery superior to the superior transverse scapular ligament
10 Teres major m.
Originate from interior angle of scapular, insert to medial lip of intertubercular

sulcus of the humerus
11 Posterior humeral circumflex a.
Quadrangular space: posterior humeral circumflex a., axillary n.
12 Coracoid process
13 Rhomboid major m.
Supply by dorsal scapular n., a.
14 Transverse cervical a.
15 Erector spinae m.
Erector spinae: Iliocostalis (outer), longissimus, spinalis (inner)
16 Thoracodorsal a.
Subbranch of subscapular a. (2nd branch of axillary a.)
17 Circumflex scapular a.
Triangular space, subbranch of subscapular a. (2nd branch of axillary a.)
18 Musculocutaneous n.
Lateral cord of brachial plexus
19 Ulnar n.
Medial cord of brachial plexus
20 Radial n.
Posterior cord of brachial plexus
21 Median n.
Lateral root of median n. (lateral cord), and medial root of median n. (medial c)
22 Serratus anterior m.
Long thoracic n., lateral thoracic a. (2nd part of axillary a.)
23 Right clavicle
24 Thoracoacromial trunk
2nd part of axillary a., APCD: acromial, pectoral, clavicular and deltoid branch
25 Cephalic v.
Deltopectoral triangle
26 Coracobrachialis m.
Originate from coracoid process, insert to humerus
27 Short head of biceps brachii m.
Originate from coracoid process, insert to bicipital aponeurosis
28 Flexor carpi radialis m.
29 Extensor carpi radialis brevis m.
30 Basilic v.
31 Extensor retinaculum
32 Scaphoid bone
Proximal row (lateral to medial): scaphoid, lunate, triquetrum, pisiform

Distal row (lateral to medial): trapezium, trapezoid, capitate, hammate
33 Radial a.
Anatomical snuffbox: abductor pollicis longus, extensor pollicis longus/brevis
34 Opponens pollicis m.
Thenar m. opponens pollicis, abductor pollicis brevis, flexor pollicis brevis
35 Abductor digiti minimi m.
Hypothenar m. abductor digiti minimi, flexor digiti minimi brevis, opponens

digiti minimi
36 Lingual n.
Otic ganglion lingual n., inferior alveolar n.
37 Inferior alveolar n.
Otic ganglion lingual n., inferior alveolar n.
38 Orbicularis oris m.
39 Buccinator m.
40 Parotid duct
41 Facial a.
External carotid a. facial, maxillary, transverse facial, superior temporal,

posterior auricular, and occipital a.
42 Retromandibular v.
43 Deep temporal a.
Maxillary a. deep temporal a.
44 Buccal branch of facial n.
Facial n. posterior auricular, temporal, zygomatic, buccal, marginal

mandibular, and cervical branch
45 Foramen ovale
posterior part of the sphenoid bone mandibular n. (trigeminal n.), lesser

petrosal n. (glossopharyngeal n., CN IX)
46 External carotid a.
47 Internal jugular v.
48 Ansa cervicalis
C1 (with hypoglossal n.) geniohyoid, thyrohyoid m.

Ansa cervicalis Sternohyoid, omohyoid, sternothyroid m.
49 Recurrent laryngeal n.
50 Phrenic n.
Lie anteriorly to scalenus anterior m.
51 Scalenus anterior m.
52 Anterior belly of digastric m.
Supplied by n. to mylohyoid (inferior alveolar n., CN V)
53 Mylohyoid m.
Supplied by n. to mylohyoid (inferior alveolar n., CN V)
54 Tyrohyoid m.
55 Vagus n.
56 Gluteus medius m.
Supplied by superior gluteal n., a.
57 Piriformis m.
58 Gracilis m.
59 Sartorius m..
Supplied by femoral n.
60 Popliteal a.
61 Superior gluteal a.
62 Iliotibial tract
63 Semimembranosus m.
64 Obturator n.
65 Profunda femoral a.
External iliac a.
Deep femoral a. (profunda femoral a.) medial, posterior and lateral part
of anterior compartments
Femoral a. anterior compartment
At adductor hiatus, change to popliteal a.
Anterior tibial a. dorsalis pedis a.
Posterior tibial a. medial and lateral plantar a.
66 Soleus m.
67 Achilles tendon
68 Peroneus tertius
Anterior compartment of foot: tibialis anterior, extensor hallucis longus,

extensor digitorum longus, peroneus tertius
69 Flexor digitorum brevis m.
70 Small saphenous v.
71 Common fibular (peroneal) a.
72 Navicular bone
73 Medial malleolus
74 Posterior tibial a.
75 Dorsalis pedis a.
76 Glenoid labrum
77 Acromioclavicular joint
Laboratory 1 Muscle contraction
Laboratory ? Histology of Cartilage, Bone and Joint
Histology of Cartilage, Bone and Joint

#
Name
Description
1. Identify

Hyaline cartilage
- Perichondrium
- Chondroblast, chondrocytes
- Matrix and capsule
Elastic cartilage
- Perichondrium
- Chondrocytes
- Intercellular matrix elastic fibers
Fibrocartilage
Chondrocytes
collagen fibers
Decalcified bone X.S
- Cross section of compact bone

- Periosteum
- Inner and outer
circumferential lamellae
- Haversian system
- Interstitial system
- Volkmann's canal
- Osteocytes in the lacunae
- Bone marrow
Bone, decalcified l.s
- NO. 19 section
plane
Bone,human,ground thin x.s
Ground bone,x.s human
-
Haversian system
interstitial system
compact bone
Bone,human, ground thin,
lacunae and canaliculi
7
Bone,human,ground,x.s and l.s
- lacunae,canliculi cement line,

Volkmann's canal
Cancellous bone
- Trabeculae
- Osteocytes in lacunae
- Osteoblasts &
Osteoclasts
- Bone marrow
- Cartilage core ()
Bone, developing,
cartilage
cartilage type
bone
woven compact bone
-
cartilage
diaphysis
10 Bone,developing,x.s.
- Woven cancellous bone
intramembranous ossification
osteblasts,
osteocyte & osteoclasts
- Mesenchymal cells
periosteum
- Developing tooth
11
Bone, developing, x.s.
- Cross section 2
- Periosteum
- Trabeculae
-
periosteum intramembranous
medullary cavity
intracartilagenous ossification
12 Joint
- Synovial membrane joint cavity

free surface 2-4
dense CNT
- blood vessels
- villi joint
cavity
- Articular cartilage
Hyaline
cartilage
- free surface perichondrium
- matrix collagen
type I
fibrous cartilage
Laboratory 4 Pathology of Bone and Joint

Noted that some photos are referenced from AccessMedicine, thus are intellectual properties of McGraw-Hill Global
Education Holdings and assorted third party. Any application of this note must also comply with the following AccessMedicine
EULA.

EULA Image and PowerPoint Usage Guidelines
Users may display, download, or print out PowerPoint slides and images associated with the site for personal and
educational use only. Educational use refers to classroom teaching, lectures, presentations, rounds, and other instructional
activities, such as displaying, linking to, downloading, printing and making and distributing multiple copies of said isolated
materials in both print and electronic format. Users will only display, distribute, or otherwise make such PowerPoint slides
and images from the applicable materials available to students or other persons attending in-person presentations, lectures,
rounds or other similar instructional activities presented or given by User.
Pathology of Bone and Joint

#
1
Name
Description
Giant cell tumor of long bone
Location: epiphysis or metaphysis of long bones
Benign, locally aggressive cortical expansion and cortical thinning
Gross morphology: red-brown mass
Long bone: Giant cell tumor; Specimen No. G-MS-1, S19-190
Osteosarcoma (femur)
Location: metaphysis tumor does not invade epiphyseal plate, medullary
canal, nor have joint space involvement
Gross morphology: gray-white mass, Codmans triangle
Femur: Osteosarcoma, conventional; Specimen No. G-MS-2, G-MT-7
Lipoma
Gross morphology
Well-circumscribed adipose tissue mass
Fibrous capsule
No lobulation within tumor
Soft tissue: Lipoma: Specimen No.G-BT-3

4
Giant cell tumor of bone

Microscopic morphology
Uniform round to oval mononuclear cells (neoplastic cells mitotic
figures)
Multinucleated giant cells (reactive cells)
Reactive osteoid formation
Bone: Giant cell tumor; Specimen No. M-MS-3
Osteosarcoma
Microscopic morphology: osteoblastic lesions with osteoid deposition
Bone: Osteosarcoma, conventional; Specimen No. M-MS-4, M-MS-5, M-MT-7
Chronic tophaceous arthritis

Synovium hyperplasia, chronic inflammation, fibrosis
Foreign bodies (uric acid crystals), surrounded by histiocytes, foreign
body giant cells
Synovium: Chronic tophaceous arthritis; Specimen No. M-MS-6
Giant cell tumor of tendon sheath

Gross morphology
Well-circumscribed nodular firm mass with a deep brown color due to the
large amount of hemosiderin content
Microscopic
morphology
Fibrosis
Mononuclear cells grooved nuclei, or prominent nucleoli

Scattered multinucleated cells (osteoclast-like appearance)
Foamy macrophage (xanthoma cells)
Hemosiderin deposition
Cholesterol cleft
Soft tissue of finger: Giant cell tumor of tendon sheath; Specimen No. M-MS-9
Chondrosarcoma
Malignant cartilage
Multinucleated chondrocytes (atypical chondrocyte) binucleation, small
nucleoli
Double lacuna
Endochondral ossification (calcification area) in cartilaginous matrix
Well differentiated type (low grade or grade I chondrosarcoma) low
anaplasia and mitosis chondrocyte
Bone: Chondrosarcoma; Specimen No. M-MS-12
Lipoma
Mature adipose tissue
Fibrous capsule well encapsulated mass
Soft tissue: Lipoma; Specimen No. M-BT-4
10
Lymphangioma
Poorly circumscribed
Dilated thin-walled lymphatic channels lined by attenuated, bland
endothelial cells
Vascular lumina may be empty or contain pink proteinaceous lymph,
lymphocytes
Connective tissue stroma may contain variable numbers of lymphocytes
Soft tissue: Lymphangioma; Specimen No. M-ST-2
11
Mostly occur in lower extremities
Poorly circumscribed
Increased number of vessels (proliferated blood vessels)
Red blood cells or transudate
Lined by monolayer of typical (normal) endothelial cells
Soft tissue: Intramuscular hemangioma; Specimen No. M-ST-4
12
Pyogenic granuloma (lobular hemangioma)

Type: capillary hemangioma
Gross morphology: sessile polyp on skin or mucosa surfaces
Lobulated capillary hemangioma in edematous fibromyxoid stroma
Skin: Pyogenic granuloma; Specimen No. M-ST-5
13
Extraabdominal desmoid-type fibromatoses

Microscopic examination
Poorly circumscribed with infiltration of adjacent tissue e.g. skeletal
muscle
Elongated spindle-shaped cells (bipolar fibroblasts and myofibroblasts)
Collagen fibers, fascicles pattern
Atrophic muscle fibers (multiple nucleus)
Soft tissue: Desmoid-type fibromatoses, extraabdominal; Specimen No. MST-6
14
Dermatofibroma (fibrous histiocytoma)

Occur at dermis or upper subcutaneous tissue
Hyperplastic change of epidermis e.g. acanthosis
Benign proliferating fibroblasts
Storiform pattern (crisscross short fascicles pattern)
Skin: Dermatofibroma (fibrous histiocytoma); Specimen No. M-ST-7
15
Malignant fibrous histiocytoma, pleomorphic type

Malignant plump spindled cells, short fascicles pattern
Plump round histiocytic cells
Marked pleomorphism, hyperchromatic nuclei, atypical mitotic figures
Soft tissue: Malignant fibrous histiocytoma, pleomorphic type; Specimen No.

M-ST-9
16
Embryonal rhabdomyosarcoma
Sheets of poorly differentiated round to spindle cells in myxoid stroma
Tadpole or strap cells (round and elongated cells) rhabdomyoblast-like
neoplastic cells (eosinophilic granular cytoplasm)
Soft tissue: Rhabdomyosarcoma, embryonal; Specimen No. M-ST-10
Laboratory 7 Parasite in Musculoskeletal System

Noted that some photos are referenced from AccessMedicine, thus are intellectual properties of McGraw-Hill Global
Education Holdings and assorted third party. Any application of this note must also comply with the following AccessMedicine
EULA.

EULA Image and PowerPoint Usage Guidelines
Users may display, download, or print out PowerPoint slides and images associated with the site for personal and
educational use only. Educational use refers to classroom teaching, lectures, presentations, rounds, and other instructional
activities, such as displaying, linking to, downloading, printing and making and distributing multiple copies of said isolated
materials in both print and electronic format. Users will only display, distribute, or otherwise make such PowerPoint slides
and images from the applicable materials available to students or other persons attending in-person presentations, lectures,
rounds or other similar instructional activities presented or given by User.
Parasite in Musculoskeletal System

1
Trichinella spiralis
Disease: trichinellosis
Transmission: raw undercook meats
Life cycle
Infective stage encysted muscle larva (L1)
Diagnosis stage encysted muscle larva (L1)
2-3 days: adult GI irritation diarrhea
5 days: newborn larva
8-9 days encysted within skeletal muscle myalgia
Diarrhea
Conjunctivitis, swollen eyes
Splinter hemorrhages
Myalgia
Diagnosis: immuno-histopathological analysis
Treatment: mebendazole, albendazole
Adult female
Stichosomal esophagus
Larva in uterus
Adult male
Smaller
Larva
Stage: encysted muscle larvae
Infective and diagnostic stages
Taenia solium
Disease: Cysticercosis
Transmission: Tinea eggs
Life cycle
Egg or gravid proglottis oncospheres cysticerci in
muscle
Adult
Scolex: 4 suckers, rostellum, 2 row rostellar hook
Proglottid: immature mature gravid proglottid
Gravid proglottid
Common genital pore
Uterine branch: 7-12 (>12 in T. saginata)
Egg
Spherical
Thick striated wall
Oncosphere hexacanth (six-hooked) embryo
Larva
Known as cysticercus, Cysticercus cellulosae
Fluid-filled bladders
Invaginated scolex: 4 suckers, rostellum, 2 row
rostellar hook
Sarcocystis spp. S. suihominis, S. bovihominis

Disease: Sarcocystosis
Transmission: feces
Life cycle
Infective stage oocysts
Sporocysts, oocysts sporozoites schizonts
merozoites invades muscle cell bradyzoites in
sarcocyst
Sarcocystis
Cyst wall compartments contain bradyzoites
Spirometra spp. (pseudophyllidian tape worm) sparganum

Etiology: (Spirmetra sp.)
Transmission
Procercoid in crustaceans
Plerocercoid larva (sparganum) in 2nd IH fish, reptiles,
amphibians
Sparganum
White, wrinkled, ribbon-shaped
Absence scolex

Lecture Note - Medical Course, 353241 Musculoskeletal System

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Lecture Note - Medical Course, 353241 Musculoskeletal System

Transféré par

Droits d'auteur :

Formats disponibles

Medical Course, 353241 Musculoskeletal System

Lecture 3 Spinal Nerve and Dermatome

Lecture 4-6 The back and posterior shoulder

Superficial Muscles of Back

Deep Muscles of the Back

Intermediate (transversocostal) group

Inf. nuchal line

Inf. nuchal line

Greater tubercle of humerus

Greater tubercle of humerus

Medial lip of the

Lower subscapular Subscapular a.

Greater tubercle of humerus

22. Nerve supply of trapezius?

33. Iliac crest ?

Lecture 7-8 Muscle contraction

Myofascial pain syndrome

Lump, pain in trigger point, referred pain

Delay onset muscle

Microscopic tearing of muscle fibers

Electromyography (EMG) detects the electrical potential generated by muscle cells

Lecture 9-9.5 Cartilage, Bone, Joint

Specialized CNT, avascular tissue poor regeneration EXAM

ICS: collagen fiber type II

articular cartilage, nasal and septal cartilage, trachea, larynx, costal

ICS: elastic fiber

Pinna, auditory tube, epiglottis

ICS: collagen fiber type I

Intervertebral disc, pubic symphysis, tendon insertion

Cell mitosis (inner to outer)

Chondrogenic cell layer differentiation (outer to inner)

Bone (osseous tissue)

Specialized CNT, highly vascularized tissue

Bone Classification by Microscopic Examination

Tooth socket, osseous labyrinth, bone repair

2 Mature (secondary, lamina) bone -

Bone Classification by Macroscopic Examination

1 Spongy (cancellous) bone 2 Compact (cortical) bone

Haversian system Haversian canal, canaliculi, Volkmanns canal (perforating cannel)

1 Intramembranous ossification Mesenchymal cells osteoblasts

Nasal, sphenoid (medial pterygoid plate) bone

2 Intracartilagenous ossification 4-5 wk. cartilage formation

0-1 wk. granulation tissue formation

2-6 wk. callus formation (internal and external callus)

Joint (Articulation) Functional Classification

Permits little or no mobility

Permits slight mobility

Joint (Articulation) Structural Classification

Peculiar to skull and are immovable

Joints the bones are connected with interosseus ligament

Peg and socket joints e..g tooth socket.

Primary cartilaginous joints

Bones are united by a plate of hyaline cartilage

Also known as fibrocartilaginous joints

Lecture 10-11 Axillary and Pectoral Region

Deltopectoral triangle (infraclavicular fossa) EXAM Contents

Medical pectoral n. Pectoral branch of

Supreme (superior) thoracic a.

Posterior circumflex humeral a.

Anterior circumflex humeral a.

1 Pectoral (anterior) group

Thoracic wall, chest