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• results from neurologic or muscular diseases such as:
• (in these conditions the muscles that innervate the spinal cord are not able to function well) 

• Cerebral palsy
• Muscular dystrophy
• Spinal cord injury
• Spinal muscular atrophy
• spina bifida

patient bends forward and touches toes and examiner stands/sits behind to assess for structural scoliosis.

-Rib hump--the spinal cord is pushed more so towards one end and the rib cage lifts up and causes a narrowing in that space 

• -Uneven shoulder height
• -Prominent, uneven shoulder blade (medial border of scapula is more prominent)
• -Hips are not level; one hip is higher than the other.

Adolescent idiopathic scoliosis (AIS)-- abnormal lateral curvature of the spine

c or s shaped curve

• Obesity
• Muscle imbalances
• Spondylolisthesis

Osteoporosis-- can affect the shape of the spinal column 

pregnancy in lumbar regions (reversible)

• opposite of kyphosis--swayback concave posterior 
• cervical and lumbar regions

• o Difficulty getting out of a chair
• o Walking
• o Looking up

also attachment to the rib cage is altered and can cause limited space for the thoracic organs..heart is compressed and lung cannot fully expand

osteoporosis, vertebral fractures 

Disc degeneration--discs between vertebrae loose cushioning

Scheuermann's disease--vertebral body becomes wedge shaped secondary to an unknown cause

natural bending of the spine to cause hunchback appearance--concave anteriorly in the thoracic and sacral region 

occurs when the spinal cord becomes more wedge shaped

the entire spinal cord is concave anteriorly at the fetal stage (c shaped) but as the child starts to push himself against gravity, gravity and the pull of the muscles causes the cervical and lumbar to become posterior (reversal)

the other two segments do not undergo reversal because of their relative stability-- the thoracic is bound to the rib cage which gives it additional stability

• concave is where the spine is caving in--if it caves in at the posterior end then its posterior concavity and vv

natural curves--primary: at birth and secondary: after birth (NORMAL)

transverse plane 

• sagital 

frontal plane 

• flexion and extension 
• lateral flexion 
• rotational

clavicle and scapula

• Clavicle
• scapula
• pelvis 
• extremities

developmental defect of one or more vertebrae

They are attachment sites for muscles and ligaments 

transverse processes in the thoracic region also f(x) as attachment sites for ribs

ligaments and intervertebral discs (thick outer ring of fibrous cartilage termed the annulus fibrosus, which surrounds a more gelatinous core known as the nucleus pulposus;)

given through a catheter to manage post operative pain--it temporarily desensitizes the motor and sensory nerves at a particular area 

• carpal tunnel (c6-c7 or c7-t1)
• delivery 
• knee replacement (l2-l5)

anywhere below L3 and before S1..nothing beyond S1

Denticulate ligament

located in between the dorsal and ventral nerve root and extend from the pia to the dura mater laterally 

provides another form of stabilization so the spinal cord isn't flapping around side to side

s2

Foramen magnum and ends at the Sacral hiatus

fat and internal vertebral plexus (where a bunch of veins come together)

epidural space: vertebra and the dura mater

Subdural space: dura and arachnoid 

arachnoid space: arachnoid and pia mater: CSF produced here and pushes the arachnoid all the way against the dura

• anterior median fissure: where the anterior spinal cord travels through 

anterolateral sulcus: where the the motor roots come out of (ventrally exit) 

posterior median sulcus: 

posteriorlateral sulcus: dorsally the sensory nerve roots leave also where the posterior arteries travel up

The cervical and lumbar regions are larger to accommodate for the greater amount of motor neurons that innervate the upper and lower extremities 

• cervical site: brachial plexus--sensory and motor function of the upper extremity 
• lumbar: lumbosacral plexus leaves it--sensory and motor functions of the lower extremity

31

(8 cervical (7 vertebrae), 12 thoracic, 5 lumbar, 5 sacral 1 coccygeal)

• dura mater/sac/thecal sac: thick and strong layer extending to S2
• Arachnoid: also extends to S2 

Pia mater: covers the spinal cord only and the nerve roots

stems off the conus medullaris (end of the spinal cord) and extends to the coccyx. Anchors the spinal cord. 

NOT A NEURAL COMPONENT-no sensory or neural component

medulla goes straight into the spinal cord starting at the foramen magnum (opening of the skull) to L2/L3 in children and L1/L2 in adults 

• C7-- because it has the longest spinous process 
• c6 has the second longest

anterior aspect--closer to the front because it bares the most stress

can cause kyphosis if there are multiple fractures at one time 

can cause nerve roots to be compressed---foramen stenosis (the nerve is affected at the site the site it exits the column)

• bracing 
• observation 
• pain management 
• surgery

weak bones-- sneezing, turning too much, sitting down to hard, fall--> any axial force (in the same direction of the column (up and down) can cause a fracture in the vertebral body---> cause focal tenderness 

majority at the thoracic level

• purple: superior articular process 
• red: inferior articular process 

both are covered with cartilage 

both come together to create facet joints aka zygapophyseal joints.

• Atherosclerosis 
• Aortic dissection--low perfusion 
• AAA--can cause pressure on the lower lumbar region and cause compression 

surgical repairs of the AAA and lower back surgeries are common causes because lower areas are more susceptible to this due to less collateral innervation

the limbs (the anterior ramus of multiple levels join together to create a plexus--brachial plexus and the lumbarsacral plexus) and trunk

• the facet joints of the vertebra
• deep muscles (that control the vertebra and the head)
• and the overlying skin

• Segmental spinal arteries 
• dorsal root ganglia 
• spinal nerve 
• intervertebral veins

• cervical and lumbar is extension and flexion 
• thoracic is more rotational

the inferior articular process of the superior vertebra join the superior articular process of the inferior vertebrae they all allow for flexion/extension and rotation but some movement more than others depending on the area

the inferior vertebral notch of the superior vertebrae 

the superior vertebral notch of inferior vertebrae

it is the breakage of the pars interarticularis (located bilaterally)--the weakest part between the superior and inferior articulate process... but does not completely dissociate 

it can and when it does it causes spondylolisthesis-- which is complete detachment--causes forward slippage so if L5 was affected the vetebral body would go and slip onto S1

L5 and caused by hyperextension of the spine

• specific to the thoracic region to allow rib cage attachment

can tear the anterior and posterior longitudinal ligaments 

too much forward movement can damage the posterior ligament and vice versa

anterior longitudinal ligament--goes all the way to the sacrum and located on the anterior side of the vertebral body--prevents hyperextension... STRONG AND THICK

• posterior: extends from C2 down... all the opposite of above
• located on the posterior side of the vertebral body--so in the canal

lateral masses are more prominent in the atlas 

this is the superior view-- the articular processes are more round in the inferior view

transverse ligament of the atlas 

dens and the atlas together-- very strong-- the odontoid process will fracture before the ligament tears 

function: because there is space posteriorly-- it prevents the atlas from moving anteriorly and the axis from moving posteriorly-- to avoid spinal compression

the alar and the transverse ligament

• alar ligament-- dens to the occiput 
• prevents excessive rotation

Atlanto-occipital joint 

superior articulate process of the atlas and the chondyte of the occiput 

nodding-slight forward and backward movement

Odontoid process

medial atlanto-axial joint-- dens facet on the inferior side of the atlas... this is located more anteriorly

Right and left atlanto-axial joint-- made by the connections of the inferior and superior articular processes 

main movement: rotation

located from c1 to c6 and they house the vertebral arteries that are located on the neck

• when you extend it will move anteriorly 
• and vice versa

There is most water during the day and decreases as the day goes on (decreases with time in terms of the day and age) this is why you are taller in the early day and you decline in height as you age and go on with the day)

Because the posterior end of the disc is thinner than the anterior part of the disc 

remember in compression fractures though the anterior side which is the vertebral body is more prone to fractures because it is exposed to the most stress

made up of several layers--each layer is made up of obliquely positioned fibrocartilage (slanted) and the direction of the slant changes through each layer 

maximal stress resistance 

thinner posteriorly--so more prone to breaking

Nucleus pulposus--which is a jelly like substance made up of mainly water... shock absorber

annulus fibrosis

• between c1 and c2 
• between the sacral vertebrae

aka the wing 

flat part-- joins the ilium to make the sacroiliac joints (joins to the pelvis)

anterior sacral foramina-- anterior rootlets leave from here 

sacral promontory-- protrudes from the base of the region where the vertebral body of the above vertebrae sat

Ala of sacrum (wing of sacrum)

the fifth sacral vertebra does not have a spinal process or associated lamina--so there is an opening in the back

• the medial sacral crest-- fused spinal processes (4 of them) 
• the sacral canal
• the posterior sacral foramina 
• sacral hiatus

unlike others there are 4 foramen bilaterally in the back where the posterior nerves leave from and 4 in the front where the anterior nerves leave from 

total of 16 wholes 

5th sacrum does not have an associated foramen, spinal process or lamina-- leaves through the sacral hiatus

• skull (protuberance) to c7--on the spinal processes 
• resists hyper flexion

c7 and downwards--located on the spinal processes downwards

because posteriorly located-- helpful to prevent hyperflexion

The paraxial mesoderm segments into somites which then further break down into dermatomes, scleratome, and myotome

• dermatome: meninges, skin, and tissue (dorsal)
• myotome: muscle 
• sclerotome: ribs, vertebrae, INTERVETEBRAL DISCS

paraxial- closest to the neural tube-- going to form the dermatome, myotome, and the sclerotome 

intermediate: GU 

lateral: visceral and the parietal-- the parietal will form the peritoneum

peripheral nerves (schwann cell, nerve ganglia), pigment cells, ADRENAL MEDULLA 

they come from the neural groove of the ectoderm and migrate into the mesoderm creating a mesenchymal layer

thalidomide

• meromelia: partial absence of a limb 
• amelia: complete absence of a limb 
• phocomelia: loss of the intermediate portion of the limb (hand will be directly attached to the the shoulder in some cases)

spinal cord is directly exposed to the external environment-- in all the other cases it was contained in a sac

phocomelia-caused by thalidomide

meromelia

Poland Syndrome: absence of pectoralis MAJOR muscle 

• breast tissue can be missing
• hand and fingers on the side may be shorter or absent 
• syndactyly

prune belly syndrome--absence of abdominal muscles--can lead to urinary complications

leading cause of congenital scoliosis 

only half of the vertebra is present-- likely due to the absence of a cartilage center (there are 2)

fused hemivertebrae--two vertebraes that are fused together but only one side is present

when the vertebral arches fail to close properly and so cause 

a. occulta--where the gap is so small that is doesn't cause any issues maybe a dimple with a tuft of hair

b. meningocele-- the meninges are protruding out 

c. myleomenigocele: either the spinal nerve or the spinal cord and the meninges are involved--in a sac can be covered in skin or not

• ectoderm influences the mesoderm to release either
• WNT on the dorsal side 
• EN1 on the ventral side --it will oppose the dorsal side from growing any forward causing differentiation of the dorsal and ventral side

• arms: dorsal aspect: extension and supination 
•           ventral aspect: flexors and pronation 

• legs: dorsal: extension and abduction 
•         ventral: flexors and adductors

-limb bud formation: lateral mesoderm releases FG10 which causes ectoderm to thicken (AER)-- mesenchymal core 

-releases FG8 which causes paraxial mesoderm derived myotomes to enter and differentiate into myoblasts 

HOX genes are involved too

its the webbing of fingers-- due to misfunction in apoptosis

becomes the hand and feet 

it becomes the thickened layer of the ectodermal region of the limb bud--thickening is incited by the FG10 released by lateral mesoderm.

paraxial mesoderm-->somites--->sclerotome, myotome, dermatome

• sclerotome will form the axial skeleton
• myotome: axial and limb

• ACVR1 is mutated (BMP derivative)
• BONE mAN

attacks Fg23 (rickets tx)

• hypophos--bone pain and fractures 
• a. Rickets: overactive Fg23 (mutated)
• b: X linked hypophatemia: PHEX mutated prevents Fg23 breakdown

• --renal insufficiency 
• --HFTC--familial tumoral calcinosis

because concentration is increasing more likely to bind to calcium and calcify-- create a solid structure 

Antacids are main cause--bind phosphate (decreasing availability) 

• poor diet 
• genetic: peeing put too much 

variety of issues-cardiac metabolic muscles

pyrophosphate and osteopontin

• Rank L inhibitor 
• useful in ostoporosis and bone cancers

increased RANKL production

• renal damage 
• phosphate accumulates 
• binds to free calcium 
• -->hypocalcemia illusion--triggers bone break down

kidney damage affects 1a hydroxylase so active vitamin D is not made

post-menopausal women-- decreased estrogen so limited OPG-- cannot bind RANK L and osteoclast activity is increased

spongey bone is more affected because it already is porous to begin with and has a greater surface area, turnover

• bone breaks and so do the blood vessels--hematoma forms 
• angiogenesis--cartilage and other fibrous material is laid down 
• bone formation starts 
• remodeling to get it to look like before ---ability decreases as you age

thyroid

PTH to induce vitamin D formation which causes the production FG23 which causes peeing out of phosphate

• Sun --> stimulates skin to produce precursor 
• liver modifies
• kidney activates it 

• required for optimal GI and renal absorption of calcium
• absorption of phosphate too 

• diaphysis 
• metaphysis (especially) and epiphysis

• with stands compression and tension (hanging best)
• torsion and shear (lateral force) are the least tolerated

convoluted ruffled border that secretes proteases and ions

• apoptosis 
• osteocytes 
• becomes bone lining cell

• blasts-mesenchymal cells 
• clasts: macrophages

• there are blood vessels and nerves that travel longitudinally throughout each osteon (haversian system)
• each osteon is made up of many lamellae (circled layers) which have lacunae--housing osteocytes they contact other osteocytes via canalculli 

volkman's canal: connect the canals obliquely 

brachialis

• proximally attached to the coracoid process of the scapula 
• distally attached to the medial side of the medial shaft of the humerus 

also innervated by C5 C6 and C7

• proximally to the distal end of the anterior humerus 
• and distally to the ulnar tuberosity 

• causes forearm flexion 
• innervated by c5-c7

some weakness with forearm flexion--not complete loss because brachialis also causes forearm flexion

• long: shoulder and elbow flexion, forearm supination, shoulder abduction
• short: shoulder and elbow flexion, forearm supination

• C5, C6, C7-- 
• long (more outside) attaches to the supraglenoid tubercule of the scapula and short attaches to the coracoid of the scapula 

both attach to the radial tubercle (distally)

when the forearm and hand are in supinated positions

brachium 

in actuality the arm is the part from the shoulder joint to the elbow joint --not the entire upper limb

sling because you want to minimize the movement of the elbow

with pronation the radius wraps around the ulna and with supination it comes to more linear placement of both

occurs at the distal and proximal radial joints

pain on the lateral aspect of the elbow-- because the radius is located at the end closest to the thumb 

and pain with elbow/forearm movement-- extreme pain with pronation and supination

posterior interosseous nerve

Fall on a outstretched hand--FOOSH

houses the cephalic vein

the olecranon is located posterior to the humerus 

anterior if other way around

the olecranon is misaligned 

• --people present with elbow flexed
• -joint instability 
• -with simple ones: you can reduce (relocate it) but may not be as easy if unsure of a fracture (because reduction can worsen the fracture)

• simple: no fracture 
• complex: with fracture

Extends from the lateral epiconyl of the humerus to the annular ligament --provides lateral stability of the radiohumeral joint 

ulnar (medial collateral ligament) projects from the medial aspect of the humerous attaches to the ulna

keeps the proximal radius and ulnar joint in tact

on the anterior aspect

• -humeroradial 
• -humeroulnar
• -proximal radioulnar joint

allows for supination and pronation

where the humerus meets the radius and the ulna

• trochlea and trochlear notch ( humerus and ulna)
• radial head and capitulum of the humerus

• young people: MVA 
• old people: falls

superior labrum is torn--because torn the best treatment is PT

• -FOOSH injury 
• --overhead throw injury 

• Pain with overhead movement 
• --popping and clicking every time you move the shoulder

** Hill Sachs: fracture of the posterior superior humeral head near the glenoid 

**Bankart: tear of the anterior glenoid labrum

• fall: older people
• MVA: younger people

• high raised scapula and often medially rotated 
• because its medially rotated any movement that requires the shoulder to move laterally will cause a lot of pain 

• -Abduction (most) of the shoulder 
• -flexion of the shoulder

• profunda brachii artery 
• and the radial nerve

extension--walking and standing--narrows the spinal canal

in cervical the root affected will be the one that leaves that particular site because it leaves directly adjacent to the disc 

but in lumbar and below the nerve exiting that layer leaves above the disc-- and one coming down is most close to the disc so the one that is going down will be affected

avascular

• diner fork deformity 
• fracture of the distal head of the radius

scaphoid lunate triquetrum (radius to ulna)

• flexion and extension 
• abduction and adduction (also know ulnar deviation--more movement than radial deviation)

to abduct 15 degrees and give the shoulder a round appearance

the lateral border of the scapula

Trapezius is required for serratus anterior to upward rotate

• Medial rotation of the humerus
• Adduction
• Extension of the forearm

dorsal scapular nerve

• 1. long head attaches to the infraglenoid tubercle 
• 2. medial head: below the radial groove 
• lateral: above the groove

all the anterior brachial muscles are innervated by the musculocutaneous nerve (c5-c7)

• and the posterior triceps are innervated by the radial nerve 
• (c5-t1)

have them make and ok sign with their thumb and index finger if they can do damage, if they cant damage

axillary nerve damage and posterior humeral circumflex arerty damage

also quadrangular space (in the axilla) houses these structures

• bursa inflammation
• hypertrophy of corocoacromial ligament (because this crosses below the acromion) 
• calcification 

pain is worse at night especially if you sleep on it--stagnation causes more inflammation, gravity can cause inflammation to drain

attaching to the acromion and the coracoid process by ligaments

common flexor tendons 

lateral epicondyle is the attachment site for the common extensor tendons

palmar: the remaining of the palm that the ulnar and radial do not cover 

dorsal: tips of the fingers that ulnar does not cover

from wrist to pinky finger and half of the ring finger--- front and back

• dorsal: everything that the ulnar and medial do not cover 
• ventral: find the radius nerve and curve to the point of the visible nail bed

anything in the axilla is at risk--including all brachial plexus nerves--but the ones that are at most risk is the thoracodorsal and thoracic lateral nerves

axial only 

axial and limb muscles

• vertebrae and arch: primary ossification centers 
• processes: secondary ossification centers (after puberty)

cranial and caudal axis

mesechyml region called ZPA zone releasing sonic hedgehog

depending on what you use more or less those blood supplies will stay and the ones you do not use will go away-- high scope of variability

mesoderm

• upper limbs rotate laterally and thumbs rotate out 
• lower limbs rotate medially so that toes face in

• cranial to caudal manner 
• and are the primary segmentation of the body

• sclerotome: axial bones
• dermatome 
• myotome: axial muscles and limb muscles

bones and connective tissues of the craniofacial structures

Vitamin D does work to increase absorption of phosphate and calcium in the gut. 

But vitamin D is also required to get osteoblasts/cytes to make Fg23

jejunem

• 1. increase in phosphate 
• 2.PTH increased 
• 3. hydroxylase is increased 
• 4. Fg23
• 5. negative inhibition on hydroxylase (overall decreased activity) and decreased Phosphate transporters on kidney== more elimination

decrease the amount of phosphate in the body

(Fg23) -increases excretion by kidney by decreasing phosphate transporters and decreasing hydroxylase activity because vitamin d is required to absorb phosphate

naproxen

those individuals with gout because apsirin will prevent clearance of the uric acid

• selective for cox 2 only 
• whereas other NSAIDS are contraindicated for people with hx of GI bleeds GI ulcers-- you can give this to them 

but does have a risk for clotting and other cardiovascular occurrences

Avoid giving aspirin to children who have a viral infection or are just recently recovering from because it can cause acute liver issues and encephalopathy

extension of the spine 

unilateral: lateral flexion of the spine to the SAME side of the contraction

SIMIAN APE HAND-- THENAR MUSCLES DO NOT GET INNERVATION AND BEGIN TO DIE--FLAT PALM DIFFICULTY GRIPPING THINGS

THE RECURRENT BRANCH OF THE MEDIAN NERVE

DORSAL AND PALMAR INTEROSSEI MUSCLES

SNAPPING OF THE INVOLVED FINGER

LOCATED ON THE DISTAL PHALAX FROM THE BASE TO THE PIP JOINT OF ALL THE FINGERS

LOCATED ON THE PALMAR ASPECT OF THE PIP JOINTS AND PREVENTS HYPEREXTENSION--WHEN IT IS LAXED DOESNT DO FUNCTION PROPERLY AND CAUSES HYPEREXTENSION OF THE FINGERS AT THE PIP JOINT

CAUSED BY RUPTURE OF THE CENTRAL PART OF THE EXTENSOR HOOD

RUPTURE OF THE EXTENSOR TENDON 

CAUSES BY VOLAR PLATE LAXITY

• HIV 
• DM
• SEIZURES
• ALCOHOL

RETICULUM (CARPAL TRANSVERSE LIGAMENT) AND DIGITIAL FIBROUS SHEATHS WORK TO PREVENT TENDON BOWING 

IF THEY BOW IT CAUSES LESS OPTIMAL MOTION

Dupuytren Disease-- when the palmar aponeurosis-- triangular fascia of the palm thickens

early: nodules and cords--regions of fascia thickening 

later: pull on the flexor tendons located below-- pinky and ring finger most affected-- EXTENSION BECOMES HARDER

type of ehler danlos syndrome-- where type 1 collagen is mutated and the n cleaving site cannot be cleaved properly 

• bilateral hip dislocation 
• sparse hair

associated with trident interspaces of fingers

pulmonary tests and sleep apnea should be considered in these patients because at high risk

blocking arachnoid from establishing into the active site of COX enzymes

• skull
• sternum
• rib cage 
• vertebral column