SPINE AND LIMBS

CERVICAL VERTERAE

◌Other than the fracture , what are the abnormal signs in this radiograph:
1- abnormal alignment(the distance between the dens and the lateral masses of c1 on both sides is
not equal).
2- prevertebral soft tissue swelling due to fracture edema.

MRCS OSCE REVISION GUIDE 3rd EDITITION 1 1

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◌Ligaments attached to the odontoid process:
- transverse Atlantal ligament.
- Apical odontoid ligament.
- Alar ligament.
Type of Atlanto axial joint: synovial pivot.

◌Ligaments between C1 and C2:

- ant. Atlanto axial ligament.
- Post. Atlanto axial ligament.
- Transverse ligament.
1st spinous process to be felt: of C7 (has a long spine = vertebra prominence). Demonstrate it on
the subject.
Q:Why we can not feel the upper spinous processes?
A: As they are short, bifid and attached to the nuchal ligament.



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◌Atypical cervical vertebrae and the atypical features:
C1(atlas): no body , no spine.
C2(axis): body projects upwards to form the ofontoid process, thick spine.
C7(vertebra prominence): very long spine, smaller foramen transversium.

Q:How many vertebrae make the spinal column? How many spinal nerves?
A: 7 cervical. 8 cervical.
12 thoracic. 12 thoracic.
5 lumbar 5 lumbar.
5 fused sacral. 5 sacral.
3 fused coccygeal. 1 coccygeal.

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LUMBAR VERTERAE

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 Infective endocarditis

INTERVERTEBRAL FORAMEN
◌The root of each spinal nerve.
◌Dorsal root ganglion.
◌The spinal artery of the segmental
artery.
◌Communicating veins between the
internal and external plexuses.
◌Recurrent meningeal (sinu-vertebral)
nerves.
◌Transforaminal ligaments.

LUMBAR PUNCTURE
◌Level of the lumbar puncture:
L4/L5 (at the supracrestal line).
◌Layers to pass through:
- skin,sc fat, fascia.
- Supraspinous ligament.
- Interspinous ligament.
- Ligamentum flavum.
- Epidural space.
- Dura matter.
- Arachinoid matter.
- CSF

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◌IV disc anatomy:
Internal nucleus pulposus surrounded by fibrocartilagenous
annulus fibrosus.
Degenerative changes in disc : spondylosis
Type of IV joint: secondary cartilagenous joint.

◌Movement on lumbar vertebrae: Flexion, extension, lateral

flexion.

◌Level of the spinal cord in newborn and adult: L3 ( at birth) ,

L1/2(adult).

◌Contents of the spinal canal below L2: filum terminnale and cauda
equina

◌Location of the paravertebral venous plexus:
- anterior external vertebral venous plexus, the small system around
the vertebral bodies.
- posterior external vertebral venous plexus, the extensive system
around the vertebral processes.
- anterior internal vertebral venous plexus, the system running the length of the vertebral canal anterior
to the dura.
- posterior internal vertebral venous plexus,the system running the length of the vertebral canal posterior
to the dura.

Tumours metastatising to the spine:

-Lung - 31% -Breast - 24%
-GI tract - 9% -Prostate - 8%
-Lymphoma - 6% -Melanoma - 4%
-Unknown - 2% -Kidney - 1%
-Others including multiple myeloma - 13%

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Demonstrate on a living subject :
- hyoid bone(c3)
- cricoid cartilage(c6)
- roots of brachial plexus
- posterior triangle

◌Structures found at c6:

- termination of the pharynx and begining of the oesphagus.
- Termination of the larynx and begining of the trachea.
- Entry of the vertebral artery to the foramen

transversium.
- Intermediate tendon of omohyoid crosse the carotid sheath.
- Middle thyroid vein emerging from the thyroid gland.
- Inferior thyroid artery entering the thyroid gland.

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 UPPER LIMB
BRACHIAL PLEXUS
Where are parts of brachial plexus found:
- roots: exits from iv foramina between scalenus ant. And medius
- Trunks: base of the post. Triangle of the neck behind the 3rd part of subclavian artery
- Divisions: behind middle 1/3 of the clavicle
- Cords : related to the 2nd part of axillary artery
Erb’s paralysis
◌Damage to the uppert nerve roots (c5,c6)
◌Motor affection: ( waiter's tip deformity)
-Paralysis of arm abductors( supraspinatous + deltoid) -----
-> arm adduction.
-Paralysis of arm external rotators( infraspina- tous
+teres minor) ------> arm internal rotation.
-Paralysis of forearm flexors and supinators
(biceps ,brachialis, brachioradialis) -------> forearm
extension and pronation.
-Paralysis of extensor carpi radialis longus-à
wrist flexion
◌Sensory affection: loss of sensation of radial
side of arm and forearm.
Klumbek's paralysis
◌ Injury to lower trunk ( C8,T1).
◌Motor affection: (claw hand deformity).
-Paralysis of all intrinsic muscles of the hand(muscle
wasting and loss of fine finger movements)
-Paralysis of wrist and finger flexors( weak
wrist and finger flexion)
-Hyperextension of MCP joints(unopposed action of
the extensor digitorum by impaired lumbricals and
interossei)
- Flexion of PIP (unopposed action of flexor digitorum
superficialis by lumbricals and interossei)
◌Sensory affection: loss of senastion over ulnar
border of forearm and hand.
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BONES OF THE UPPER LIMB

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 ◌Articulate humerus, radius and ulna:
-Capitulum of the humerus + radial head.
-trochlea of the humerus +trochlear notch of
the ulna.
-olecranon of the ulna+ olecranon fossa of
the humerus

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 Scaphoid bone blood supply:
It receives its blood supply pri-
marily from lateral and distal
branches of the radial artery,
via palmar and dorsal branches.
These provide an "abundant" sup-
ply to middle and distal bone,
but neglects the proximal portion,
which relies on retrograde flow.

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MEDIAN AND ULNAR NERVES

◌Median nerve sensory distribution in the

hand:
a) lateral 2/3 of the palm of the hand.
b) lateral (radial) three and a half digits on the
palmar side.
c) dorsum of the tips of index, middle and
thumb.
◌Median nerve motor distribution in hand :
LOAF muscles:
lateral 2 lumbricals
opponenece polics
abductor policis brevis
flexor policis brevis

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 C/p of ulnar nerve injury at wrist: ( complete claw hand)

- Clawing of the 4th and 5th digits ( paralysis of the medial lumbricals and interosseii).
- Loss of sensation of the medial 1/3 of the palmar and dorsal aspects of hand and fingers.

◌Why ulnar paradox: In proximal ulnar nerve

injuries, there will be paralysis of the
medial 1/2 of the FDP which will decrease flexion of the IP joints

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 CARPAL TUNNEL

Attachments of flexor retinaculum:

◌Proximal: pisiform+ tubercle of scaphoid

◌Distal: hook of hamate + trapezium

◌Structrues passing through carpal tunnel:

- 4 tendons of flexor digitorum superficialis.
- 4 tendons of flexor digotorum profundus.
- 1 tendon of flecor policis longus.
- 1 tendon of flexor carpi radialis.
- Median nerve.

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 ID
-Ulnar art.
- Radial art.
-Superficial palmar
arch.

◌Superficial palmar arch: formed mainly by the arch of the superficial division of the ulnar artery
and is completed by the superficial palmar branch of the radial artery.

MOVEMENTS OF THE THUMB

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Q:Where are tendons of FDS and FDP insert?
FDS: splitted tendon on both sides of the middle phlanax.
FDP: passes throgh the splitted tendon of FDS to be inserted into the terminal phalanx.

Q:How to test FDP?

A:By fixing the PIP

Q:How to test FDS?

A:adjacent digits must be held in extension, in order to eliminate FDP
motion in adjacent fingers, which otherwise might give the impression of
FDS motion in the examined finger.

Q:How to test ulnar artery( allen' s test)?

A: -Elevate the hand and ask the patient to make a fist for 30
sec..
- Apply pressure on both ulnar and radial aa. to occlude both.
- While still elevated, open the hand, it should be blanched.
- Release pressure over the ulnar artery, colour should return in 7
seconds.

Q:When you are doing power grip of the hand, what is the role of radial nerve?
A:Radial nerve supplies wrist extensors which give mechanical advantage to power grip by synergistic
activity which cause more efficient flexion of the digits.

Q:Why hand grip is powerful in extension than flexion?

A:Because the flexor muscles in extension position is in a state of tension than in flexion position, so contraction
in this position is more powerful

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1: Extensor digitorum tendon. 2: Extensor indicies tendon.
3: intertendinous connections . 4: 1st dorsal interosseus muscle.
5: radial styloid process. 6: ulnar styloid process.
7: Extensor carpi ulnaris. 8: abductor digiti minimi

◌Tendon attached to pisiform : flexor carpi ulnaris.

◌1st dorsal interosseus :

-Origin: from the first metacarpal.
-Insertion: into the lateral side of extensor expansion of index finger.
-Action: abduction of index finger.

Q:What makes extensor tendons attached to the phalanges?

A:Extensor expansion
Q:What is the function of intertendinous connections?
A: - create space between extensor tendons.
- redistribute force between tendons.
- coordinate extension of fingers.
- stabilize MCP joint.

ANATOMICAL SNUFF BOX

◌Boundaries:
-Anterolateral: tendons of : - abductor policis longu - extensor
policis brevis.
-Posteromedial: tendon of. Extensor policis longus.

Insertion of EPL: dorsum of the base of the terminal phalanx of

the thumb
Insertion of EPB: dorsum of the base of the proximal phalanx of
the thumb.
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FOREARM MUSCLES

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20
 CUBITAL FOSSA

◌Boundaries:
- superolateral:
bravhioradialis muscle.
- Medially: pronator teres.
- Floor: brachialis.

Contents:(M-L)
- Median nerve
- Brachial artery
- Biceps tendon

◌Strucutres passing in spiral groove:

- radial nerve, profunda brachii
vessels.

◌C/p of radial nerve injury at the spiral groove:

- paralysis of wrist extensors ------> wrist drop.
- Paralysis of finger extensors ------> finger drop.
- Loss of sensation in the 1st web space.

Median nerve injury at elbow:

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◌Supracondylar fracture humerus:

Associated injuries:
-Brachial artery injury( absent distal pulses).
- Anterior interosseus nerve injury( unable to flex the interphalangeal joint of his thumb and the distal
interphalangeal joint of his index finger).
- Ulnar nerve injury ( claw hand).
- Radial nerve injury ( wrist drop,finger drop).

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 ROTATOR CUFF MUSCLES
◌Supraspinatous:
-Origin:
supraspinous fossa.
-Insertion:
greater tubrosity.
-N. Supply:
suprascapular n.

◌Infrainatous:
-Origin:
infraspinous fossa.
-Inserion:
greater tubrosity.
-N.supply:
suprascapular n.

◌Teres minor:
-Origin: upper 2/3
of lateral border of
scapula. ( dorsal
aspect)
-Insertion:
greater tubrosity
-N.supply: axillary
n.

◌Subscapularis:
-Origin: sbscapular
fossa.
-Insertion:
lesser tubrosity.
-N.supply: upper
and lower
subscapular n.

◌Shoulder joint abduction:

- Supraspinatous ( 0-15).
- Deltoid ( middle fibres) 15-90.
- Trapezius and serratus anterior ( over 90).
which will require upward rotation of the scapula with lateral rotaion of the humerus

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 Factors decreasing the stability of the shoulder joint:
1- shallow glenoid cavity
2- lax capsule with few ligaments
3- inferior aspect is not supported due to the presence of quadrangular space
◌The main stabilizer of the shoulder joint is the rotator cuff
muscles.

QUADRANGULAR SPACE

◌sup.: teres minor.

◌Inf.: teres major.
◌Lat.: Surgical neck of humerus.
◌Med.: long head of triceps.
◌Contents: axillary n.--post. Circumflex humeral
vessels.

AXILLARY NERVE

Motor : deltoid + teres minor.

Sensory: skin to the lower half of deltoid ( badge
area).
Injury: inability to abduct the shoulder over 15, loss
of sensation over the badge area.

AXILLARY ARTERY
◌Divided by pectoralis minor to 3 parts: [ screw the
lawyer save a patient]
- 1st part: medial to pectoralis: superior thoracic
artery.
- 2nd part: behind the pectoralis: thoracoacromial,
lateral thorcic.
- 3rd part: lateral to pectoralis: ( subscapular,
ant.circuflex humeral, post, circumflex humeral).

◌Muscles inserted in bicepital groove : ( lady bw 2

majors)
- teres major: ( medial lip).
- Latismus dorsi(floor).
- Pectoralis major( lat. lip).
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.

BICEPS MUSCLE
◌Origin:
- long head : ( supraglenoid tubercle).
- Short head ( coracoid process).
◌Insertion:
- biceptal tendon into radial tubrosity.
◌Relation to tendon:
-Median nerve , brachial aa.( medially).
-Radial nerve ( lateral).
◌N.supply: musculocutaneous nerve.

TRICEPS MUSCLE
◌Origin:
-Long head: infraglemoid tubercle.
-Lat . Head: anove the spiral groove.
-Med. head: below the spiral groove.
◌Insertion: Olecranon.
◌N.supply: radial nerve.

UPPER LIMB RELEXES

1. Biceps reflex (C5/6) – located in the antecubital fossa -tap your finger overlying the biceps tendon.
2. Triceps reflex (C7) – place forearm rested at 90º flexion.
3. Supinator reflex (C6) – located 4 inches proximal to base of the thumb.

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 ◌Surface marking of coracoid
process:
-Medial 3/4 and Lateral 1/4 of the
clavicle
-1 cm below that point.

◌Structures attached to the coracoid process:

1- ligaments: coracoclavicular- coracohumeral- coravoacromial.
2- muscles: pectoralis minor( insertion)'- coracobrachialis( origin)- short
head of biceps( origin).

PECTORALIS MAJOR

◌Origin :
-Clavicular head: from the medial half of
the anterior surface of the clavicle.
-Sternocostal head: ant. Surface of the
sternum- upper 6 costal cartilages- EOA.
◌Insertion: Lateral lip of bicepital groove.
◌Nerve supply: medial ( c8-T1) and
lateral pectoral nerve ( c5-c7)
◌Action:
- adduction and medial rotation of the
arm( the whole muscle).
- Clavicular head: flexion of the arm.
- Sternocostal head: extends the flexes
arm.
- Acts as accessory respiratory muscle by
MRCS OSCE REVISION GUIDE 3rd EDITITION 45
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 elevating the ribs.

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TRAPEZIUS MUSCLE

◌Origin: ext.occipital protuberance,superior nuchal

line ,spinous process of c7, spinous processes of all
thoracic vertebrae.
◌Insertion: lateral 1/3 of clavicle,medial acromion,
aponeurosis over the spine of the scapula
◌N.supply: spinal accessory n.

SERRATUS ANTERIOR MUSCLE

◌Origin: 9-10 slips from the 1st to 8 th ribs.

◌Insertion: Medial border of scapula.
◌N.supply:Long thoracic nerve of bell( c5,c6).

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 LOWER LIMB

ARCHES OF THE FOOT

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Q:What are the components of the Medial Longitudinal arch?
A:◌Bones - calcaneum, talus, navicular, all 3 cuneiforms, medial 3
metatarsals.
◌Ligaments – short , long plantar ligaments and spring ligaments.
◌Muscles - flexor hallucis longus, peroneus longus, tibialis anterior and posterior.
Q:What are the components of the Lateral Longitudinal arch?
A:◌Bones - Calcaneum, cuboid and lateral 2 metatarsals.
◌Ligaments - long and short plantar ligaments.
◌Muscles - peroneus longus and brevis, short plantar muscles
Q:What are the components of the Transverse arch?
A:◌Bones - the bases of all 5 metatarsals (each foot actually forms one half of
an arch).
◌Muscles - peroneus longus

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CHAPT
◌ID ligaments on the medial and lateral aspects of the ankle:
◌Attachements of deltoid ligament:
-Superior: medial malleolus
-Inferior: 1- tubrosity of the navicular. 2- spring ligament. 3- neck of talus. 4- sustanecukum tali.
5- body of talus.

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Q:What movements occur at the subtalar joint?

A:Inversion and eversion of the foot occur at the subtalar joint.

Q:Which muscles perform these actions?
A:Inversion - Tibialis anterior and posterior (with some help from the extensor and flex or
hallucis longus muscles).
Eversion - Peroneus longus and brevis.

Q:What are the bones forming ankle joint: ( synovial-hinge)?

A:Trochlear surface of talus, lower end of tibia and fibula.
Q:What are the movements of ankle joint?
A:◌Plantar flexion: gastrocnemius ,soleus. Plantaris. + tibialis post. , flexor didgitorum
longus, flexor jalicius longus.
◌Dorsiflexion: tibialis ant., extensor halicius longus, extensor digitorum longus, proneus tertius.
Q:Ankle joint is most stable in dorsiflexion why?
A :The most stable position of the ankle is in dorsiflexion. As the foot moves into dorsiflexion,
the talus glides posteriorly and the wider anterior portion of the talus becomes wedged into the
ankle mortise. As the ankle moves into plantarflexion, the talus glides anteriorly and the ankle
less stable, some “wobble” (small amounts of abduction, adduction, inversion, and eversion) is
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Q:What is the type of inferior talofibular joint?
A: syndsmosis
Associated injury in syndesmotic fracture: fractures lateral mallelus
Q:Where to palpate dorsalis pedis and post. Tibial A.?
A:Lateral to the EHL tendon---- halfway between the post.border of the
medial mallelus and tendoachilles.
◌Structures passing behind the medial malleolus: (TOM DOES VERY
NICE HATS)
- tibialis post . Tendon. - flexor digitorum longus tendon. - post. Tibial
vessels.
- Post. Tibial nerve. - FHL tendon.

◌Demonstrate the foot pulses on this actor:

-The dorsalis pedis pulse is found between the first two metatarsal bones.
-The posterior tibial pulse is found 2-3cm below and behind the medial malleolus.

ARTERIES OF THE FOOT

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 Q:What muscles make the achilles tendon?
A:Three muscles insert into the Achilles or calcaneal tendon:
-Soleus.
-Gastrocnemius.
-Plantaris.

ID tendons on the dorsum of the foot

MRCS OSCE REVISION GUIDE 3rd EDITITION 49 34

 Leg compartments

Interosseus membrane: separates anterior from

posterior

Anterior intermuscular septum :

Separartes anterior from lateral

Transverse intermuscular septum :

Separates superficial post. From deep post.

Posterior intermuscular septum :

Separates the posterior from latetal

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MRCS OSCE REVISION GUIDE 3rd EDITITION 53 37
Q:On an actor demonstrate how you would test the knee and ankle reflexes?
A:Knee reflex: The foot should be unsupported, relaxed and off the ground. The thigh should be
fully exposed.
-Test by tapping the patellar tendon with a tendon hammer. You are looking for reflex contraction
of the quadriceps muscles.
Ankle reflex: The foot should be pointing laterally, be flexed, and relaxed. the leg should be fully
exposed.
-Test by tapping the Achilles tendon with a tendon hammer. You are looking for reflex
contraction of the calf muscles.

Q:What nerve roots do these reflexes originate from?

A: -Ankle: S1.
-Knee: L3/4.
Q:What movement is ankle dorsiflexion?
A:Dorsiflexion is the upwards movement of the foot in relation to the leg.

54 38
 Q:At what joint does dorsiflexion occur?
A:At the ankle joint between the tibia/fibula and the
talus.

Q:What muscles are involved in dorsiflexion?

A:Muscles of the anterior compartment of leg are involved:
-Tibialis anterior.
-Extensor hallucis longus.
-Extensor digitorum longus.
-Peroneus tertius.

Q:How would you demonstrate ankle plantarflexion?

A:Plantarflexion is the downwards movement of the foot in relation to the leg.

Q:What muscles are involved?

A:Both the superficial and deep posterior compartments of the leg are involved
◌Superficial posterior compartment:
-Gastrocnemius.
-Soleus.
-Plantaris (only weak participation).
◌Deep posterior compartment:
-Flexor hallucis longus.
-Flexor digitorum longus.
-Tibialis posterior.
-Popliteus.
Q:What action occurs when tibialis anterior and tibialis posterior contract together? At what
joint does this occur?
A:Ankle inversion.
Inversion and eversion both occur at the subtalar joint.

MRCS OSCE REVISION GUIDE 3rd EDITITION 55 39

Q:What muscles are responsible for ankle eversion?and what nerve innervates them?
A:Peroneus brevis and peroneus longus, The superficial peroneal nerve.

Q:What motor and sensory function is lost with damage to the superficial peroneal nerve?

A:Inability to evert the foot and loss of sensation over the dorsum of the foot, apart from the
first web space, which is innervated by the deep peroneal nerve.

Q:Common peroneal (fibular) nerve injury:

A:This is a relatively common injury because of its superficial and vulnerable position as it
winds around the neck of the fibula. Dorsiflexion (extensor muscles) and eversion (the
peronei) are lost; the foot drops and becomes inverted. There is sensory loss over the
dorsum of the foot

Q: How would you recognise compartment syndrome in the lower leg?

A:Compartment syndrome is an emergency that presents with pain out of proportion to the
injury sustained, in someone with a swollen leg, particularly acute on passive stretching of the
ankle. There may be paraesthesia,
pulselessness and paralysis, all late signs and suggestive of impending limb necrosis.

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42
Describe the blood supply to the
head of the femur head:
The majority of the blood supply to
the head of the femur is from
retinacular arteries, which arise as
ascending cervical branches from
the extracapsular arterial
anastomosis. This is formed
posteriorly by the medial femoral
circumflex artery and anteriorly
from branches of the lateral femoral
circumflex artery with minor
contributions from the superior and
inferior gluteal arteries.

There is also supply from the artery of the ligamentum teres, also know as the artery of the round
ligament of
the femoral head (a branch of the obturator artery).

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Infective endocarditis 2

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 FEMORAL TRIANGLE

Base: inguinal ligament

Medial border: medial margin of the adductor longus muscle
Lateral border: medial margin of the Sartorius muscle
Floor:
*medially: pectineus and adductor longus
*laterally: iliopsoas

Contents: (FROM LATERAL TO MEDIAL)

- femoral nerve
- femoral artery
- femoral vein
- deep inguinal lymph nodes and lymphatics

Femoral artery can be palpated in the femoral triangle midway

between the ASIS and the pubic symphysis

FEMORAL SHEATH
The femoral sheath is a funnel-shaped, fascial tube of varying length (usually 3 to 4 cm) that passes deep
to the inguinal ligament and encloses proximal parts of the femoral vessels and creates the femoral canal
medial to them .

The sheath is formed by an inferior

prolongation of the transversalis and
iliopsoas fascia from the abdomen/greater
pelvis. The femoral sheath does not enclose
the femoral nerve. The sheath terminates
inferiorly by becoming continuous with the
tunica adventitia, the loose connective tissue
covering of the femoral vessels.

The femoral sheath is subdivided into three

compartments by vertical septa of
extraperitoneal connective tissue that extend
from the abdomen along the femoral vessels.
The compartments of the femoral sheath are
lateral compartment : for the femoral artery
. Intermediate compartment: for the femoral vein
. Medial compartment: which constitutes the femoral canal.
FEMORAL CANAL
The femoral canal is the smallest of the three compartments. It is short and conical and lies between the medial wall of the femoral sheath
and the femoral vein. The femoral canal • Extends distally to the level of the proximal edge of the saphenous opening

• Allows the femoral vein to expand when venous return from the lower limb is increased or when increased intraabdominal pressure causes
a temporary stasis in the vein.
• Contains loose connective tissue, fat, a few lymphatic vessels, and sometimes a deep inguinal lymph node ( Cloquet node)
• The base of the femoral canal, formed by the small ( approximately 1 cm in diameter) proximal opening at its abdominal end, is the femoral
ring .
The boundaries of the femoral ring are as follows: laterally, a femoral septum between the femoral canal and the femoral vein; posteriorly, the
superior ramus of the pubis covered by the pectineal ligament; medially, the lacunar ligament; and anteriorly, the medial part of the inguinal
ligament.

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 ADDUCTOR CANAL

Hunter's canal, also known as the subsartorial or adductor canal, runs from the apex of the
femoral triangle to the popliteal fossa.(adductor hiatus)
Boundaries:

-Anterolaterally :Vastus
medialis.
-Anteromedially/Roof
:Sartorius .
-Posteriorly : Adductor
longus and magnus.
Contents:
-Femoral artery and vein.
- Saphenous nerve.
-Nerve to vastus
medialis.

Q:What is the surface marking of the adductor hiatus?

A:The adductor hiatus lies 2/3rds along the line between the ASIS and the adductor tubercle of the
femur.

POPLITEAL FOSSA
◌Boundaries:
- upper medial: semimebrnosus and semitennosus.
- Upper lateral: biceps femoris.
- Lower medial: medial head of
gastrocnemius.
- Lower lateral : lateral heaad of
gastrocnemius.
◌Contents ( superficia to deep):
- common peroneal nerve.
- Tiibial nerve.
- Politeal vein.
- Popliteal artery.
- Lymph nodes: they receive from a
small area of the skin above the heel
and from the deep structures of the
calf

◌DD of lump from popliteal fossa:

- backer's cyst. - pop. Artery
aneurysm. - lipoma
- Schwanoama. - Popliteal vein
varicosities

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Q:Where does the iliotibial tract attach?
A:The Iliotibial tract is attached to the anterolateral iliac tubercle of
the iliac crest proximally and the lateral condyle of the tibia distally.
Q:What muscles insert onto it?
A:Gluteus maximus and tensor fasciae lata muscles insert onto
the iliotibial.

Q:What is its clinical significance?

A:The iliotibial tract stabilises the knee in extension and in partial
flexion. It is important in walking and running.

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Q:What clinical sign is evident with weakness of gluteus medius and minimus?
A:A Trendelenburg gait or a positive Trendelenburg test.

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 1 53
PATHOLOGY CHAPTER

Q:What is the surface markings of the sciatic nerve?

-The surface marking of the sciatic nerve is a curved line drawn

from 2 points: halfway between the posterior superior iliac spine
to the ischial tuberosity to halfway between the ischial tuberosity
and the greater trochanter.

Q:What is the course of the sciatic nerve?

The sciatic nerve runs inferolaterally under cover of the gluteus maximus,
midway between the greater trochanter and the ischial tuberosity . It
descends from the gluteal region into the posterior thigh, where it lies
posterior to the adductor magnus and deep (anterior) to the long head of
the biceps femoris.

Q:What variations do you know with regard

to the sciatic nerve exiting the pelvis?

the sciatic nerve is composed of the tibial (L4-s3) and common fibular
(L4-s2) nerves, which usually enter the gluteal region bound in a
common connective tissue sheath (A). In some cases (12%), the two
nerves enter the gluteal region separately: the tibial nerve at the inferior
border of piriformis and the common fibular nerve pierces piriformis (B).
In another variation (0.5%), the common fibular nerve enters the gluteal
region along the superior border of the muscle and the tibial nerve along
its inferior border (C).

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54 ANATOMY
Infective endocarditis 2

Q:What is the nerve related to ASIS?

A:Lateral cutaneous nerve of the thigh
◌Meralgia parathetica:
A painful mononeuropathy of the lateral femoral cutaneous nerve (LFCN), it is commonly due to focal entrapment of
this nerve as it passes through the inguinal ligament

VASCULAR LACUNA
◌Vascular lacuna : is an anatomical structure placed behind/below the inguinal
ligament. Lacuna vasorum is medially, while muscular lacuna is laterally.
◌Contents of lacuna vasorum (order from medial part):
-Deep inguinal lymph nodes.
-Femoral vein.
-Femoral artery.
-Femoral branch of the genitofemoral nerve.
◌Contents of lacuna musculorum:
-Femoral nerve.
-Iliopsoas.
-Lateral femoral cutaneous nerve.

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