SECOND YEAR

MEDICINE
MUSCULOSKELETAL
SYSTEM

2013

School of Medicine

musculoskeletal system
year 2 md/bmbs 2013
coordinator // ian gibbins@flinders.edu.au

aims and learning objective of the MSS block

page 2

teaching staff

page 6

suggested texts and sources of information

page 7

notes for practical classes

page 9

information for examinations past exam feedback

page 65

student art

page 109

copyright 2013

aims of the musculoskeletal system block...

The overall aim of this component of Knowledge of Health and Illness 2 is for you to understand
the normal structure and function of the musculoskeletal system, and some of the more common
pathological changes that affect it.
The specific things you need to learn in this subtopic are identifeid in the learning objectives for
each week, the consolidated learning objectives on the following pages, and are supplemented by
material in this course booklet. The core material includes:
***

the normal microscopic and macroscopic structure of bones and joints as they relate
to their functions, radiological appearance, and surface features. Macroscopic
features include major structural landmarks, ligaments, joint capsules, synovial
cavities, intra-articular discs, normal ranges of movement. Microscopic features
include the various cells of bone, cartilage, synovial membrane and skeletal
connective tissues, their functional relationships, development and usual patterns of
turnover.

***

the normal metabolic activity of bone and cartilage; its control by hormones and
physical activity ; the ways it can be disrupted in common pathological conditions,
including osteoporosis, osteopaenia, inflammation, infection and fractures;
recognition of different conditions affecting bone and cartilage metabolism; and
common treatments for these conditions.

***

common conditions, including rheumatoid arthritis, osteoarthritis and gout that lead
to pathological and degenerative changes in joints, their causes, pathophysiology,
functional consequences, recognition, and usual treatments.

***

the normal structure and function of the major muscles of the body, including their
actions in day-to-day activities, such as grasping and manipulating objects,
locomotion, and posture; how the muscles relate to each other and their skeletal
attachments; the roles of agonists and antagonists in controlling movements around
joints; the roles of concentric and eccentric contractions in motility and load bearing;
the most common ways in which muscles are damaged.

***

recognition and identification of major skeletal and muscular elements in surface

anatomy, gross anatomy and radiology; simple tests of dysfunction or injury;
radiological identification of common degenerative changes and injuries to the
skeleton.

***

the main peripheral nerve and vascular supplies to the muscle groups, and the
functional consequences of lesions to these nerves.

The assessment for MSS tests your knowledge and understanding of some aspect of each of these
core areas.

consolidated learning objectives for MSS...

These more detailed LOs are derived from the weekly cases, mini-cases, lecture material and
practical classes...

General structure, function and pathology of the MSS

In each region of the body, recognise and identify the key structures defined below in anatomical
specimens, living surface anatomy, and radiological images, as appropriate.
Understand the main functions of muscles, the normal ranges of movement of joints, and the major
functional consequences of injury to peripheral nerves.
Understand the basic pathophysiological processes underlying bone disease and joint disease, their
functional consequences, and their usual treatments.

Head and jaws structure, function and innervation

Identify the major bones and sutures of the skull. Define the anterior, middle and posterior cranial
fossae and their foramina. Identify the structures that pass through the foramina. Identify the
locations, relations and functions of the air spaces in the skull.
Describe the structure and function of the temporomandibular joint, the muscles moving this joint
and their innervation.
Identify the muscles of facial expression, their nerve supply and the consequences of nerve injury
on their function.

Upper limb structure, function and innervation

Identify the bones of the shoulder complex, upper arm, forearm, wrist and hand. Identify and
describe the joints of the upper limb, including their main ligaments, and the factors that contribute
to their mobility and stability.
Describe the movements of the shoulder complex, elbow, wrist and digits together the features that
limit their ranges of movement.

Identify the muscles which move or stabilise the shoulder complex, elbow, wrist and hand. Define
their innervation and functions.

Identify the contribution of the shoulder girdle and its muscles to mobility and strength of the
shoulder. Describe the factors contributing to mobility and strength of the forearm and hand.
Outline the differences between a power grip and a precision grip. Understand the consequences of
common injuries reducing mobility of the upper limb and its components.
Describe the components of the brachial plexus and their relations to the glenohumeral joint.
Identify the paths, relations and targets of the major nerves distributing from the brachial plexus.
3

Describe the main consequences of major nerve injury on the functions of the upper limb.

Pelvis and lower limb structure, function and innervation

Describe the structure and function of the pelvis, the hip joint and their ligaments. Describe the
main muscle groups which act on the hip joint, their functions and their nerve supply.
Outline the roles of the pelvis and hip joint during weight-bearing.
Identify the major skeletal structures of the lower limb, including the knee, ankle and foot. Describe
the structure and movements of the knee, ankle and foot joints, including the organisation and
functions of the major ligaments.
Identify the muscles acting on the knee, ankle and feet and describe their functions and innervation.
Describe the main factors contributing to mobility and strength of the knee, ankle and foot during
weight bearing in a normal range of activities, including standing, walking and running.
Describe the most common injuries to the hip, knee and ankle, and their causes.

Back, thorax, abdominal structure, function and innervation

Identify the bony structures of the vertebral column and differentiate between the vertebrae of the
different regions. Describe the joints of the vertebral column and explain the movements that occur
at each type of joint, including the sacroiliac joint. Identify the ligaments associated with the
vertebral column and explain their function.
Understand the structure and function of intervertebral discs together with the main causes and
consequences of their injury.
Identify and describe the actions and innervation of the muscles associated with the vertebral
column and trunk.
Understand the basic loading forces acting on the lumbar spine during standing, sitting, reclining,
lifting, bending and twisting, walking and running.
Identify the joints between the ribs and the vertebral column and describe their movements. Explain
the functional consequences of the relationship of the ribs to the vertebral column.
Relate the structure and function of the abdominal wall to the function of the vertebral column.
Describe the lumbar and sacral plexuses and their contributions to nerves of the lower limb.
Describe the factors involved in returning an employee to work following a back injury .

Growth and metabolism of cartilage and bone and their disorders

Describe the microscopic structure and properties of different types of cartilage.
4

Describe the microscopic structure and function of bone, and its cells. Outline the nutritional and
hormonal control of bone metabolism and bone mass.
Describe the basic steps in the healing of a bone fracture. Describe the processes of bone
remodelling, including after a fracture.
Outline the causes and mechanism of avascular necrosis of bones.
Outline the metabolic basis of bone diseases, especially osteoporosis, and the consequences of
osteoporosis on bone structure. Compare the different types of metabolic bone diseases.
Outline the mechanisms of bone infections and common approaches to their prevention and
treatment.

Joint structure, function and pathology

Describe the general principles affecting stability and mobility of joints. Describe in general terms
the functional consequences of minor nerve injury.
Describe the formation of synovial fluid and its role in joint lubrication.
Describe the main components of the development of inflammatory joint disease and its associated
pathology, using rheumatoid arthritis as an example. Describe the mechanisms of action and the
main adverse drug reactions of disease-modifying anti-rheumatic drugs, including the newer
cytokine inhibitors.
Recognise rheumatoid arthritis as a common chronic inflammatory and destructive arthropathy
which cannot be cured and which has substantial personal, social and economic costs. Understand
the impact of inflammatory joint disease on quality of life and ability to live independently.
Describe the factors leading to the development of osteoarthritis and its most common
complications.

Neuromuscular control
Review the basic processes of neuromuscular transmission and muscle contraction. Describe the
basic organisation of motor units and their relevance to the fine control and strength of muscle
activity.

Pharmacology
Describe the use of non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of musculoskeletal injuries.
Describe the mechanisms of action and the main adverse drug reactions of disease-modifying antirheumatic drugs, including the newer cytokine inhibitors.
Review the pharmacology of non-steroidal anti-inflammatory drugs.
5

Outline common approaches to treatment of bone infections.

Vascular structures
Revise major vascular pathways to and from cranial structures.
Revise vascular supply to the upper limb.
Revise the vascular supply to major pelvic structures.
Review vascular supply to lower limb.

teaching staff
Although Ian Gibbins has ended up doing a substantial amount of the MSS block, several other
people are involved in teaching or preparation of the material. If you need assistance in anything,
your best first port of call is Ian, who will be able to direct you to the best person, if he cannot help
you directly. The best way of getting any of these people, including Ian, outside class time is by
email or via their departmental office.

The following people have important input into the course, although others will be involved at
various stages.
Co-ordinator: Ian Gibbins, Anatomy & Histology, Room 6E121, ext. 65271
Malcolm Smith, Clinical Immunology: inflammatory joint disease.
Kathy Knights, Clinical Pharmacology
John Slavotinek, Medical Imaging : clinical insights to MSS radiology.

suggested texts and sources of information

Unfortunately, there is no single text that includes all the material we cover in MSS. On the other
hand, much of it can be found in standard texts. For example, all of the core anatomy and histology,
including bone formation, is in any decent text you happen to have access to. Any physiology text
will fill you in on how muscles contract and how neuromuscular transmission works. Similarly, the
pathology and underlying pathophysiology of MSS conditions and their treatments can be found in
any textbook of medicine and the recommended pathology texts (eg Robbins). Orthopaedics,
radiology and neurology texts also provide valuable information.
The major difficulty in trying to learn about the MSS is getting a good idea of the functional stuff:
ie how the various muscle groups work in day-to-day life, how they are co-ordinated, and what
happens when they go wrong ... Most anatomy texts are 100% accurate when they describe the
bones, joints, and which muscles are where. However, they usually have been woefully inadequate
when it comes to explaining how the muscles work (ie what they actually do). A valuable exception
is the following (smallish) text:
Jenkins DB (2008) Hollinsheads Functional Anatomy of the Limbs and Back
9th ed. WB Saunders.
Nevertheless, the recent editions of of Moore's anatomy text (5th or later) and the 2nd edition of
Gray's Anatomy for Students have pretty good functional material now.
For the clinical testing end of things look at:
Apley AG, Solomon L (2001) Physical examination in Orthopaedics. Arnold.
and
Aids to the Examination of the Peripheral Nervous System 4th ed Elsevier Saunders
More detail can be found in:
Solomon L, Warwick DJ, Nayagam S (2005) Apleys Concise System of Orthopaedics
and Fractures 3rd ed. Hodder Arnold

In general, the functions of the MSS are often better described in texts for biomechanics and sports
medicine (eg Oatis CA, 2009 Kinesiology: the mechanics and pathomechanics of human movement,
2nd ed, LWW). Overall, much of the relevant information is very scattered and usually you will not
have time to look up all this material in detail. That is what the lectures are for - in most cases, the
lecture before the practical class will put the anatomy, radiology, etc, into a functional and clinical
context.

So what should you do to quickly get on top of things?

Recent developments in cognitive neuroscience and its application to learning help us understand
why it so hard to learn something like functional anatomy. On one hand, there is all the structure where things are, how they are related to each other spatially, how the structure interacts with
function. This information is largely in the visuo-spatial domain. Then there are all the names of
everything, and descriptions of which things connect to what, and knowledge of what happens when
things go wrong. This information is largely in the verbal domain.
Visuo-spatial information is hard to learn from text. You have to experience it! This means you
need to physically explore the material, to literally get a feel for how structures relate to each
other. It means you have to use your own body (or that of friend...) to see how different muscles
really work, either alone or in combination with others. You need to use devices like anatomy
colouring books, or do your own diagrams, to test your spatial knowledge. The colouring books are
really good! Photocopy the pages and colour them in different ways depending on the context:
eg:
according to the innervation
according to their function
according to their attachments...
So how do you link all this with the text? The old tricks of rote learning by recitation actually work!
Saying the names of structures and you explore or recount them spatially really helps to assign the
names to structures and vice versa. Ultimately, you can string all these domains of information
together to explain how you carry out apparently simple day-to-day activities, and then imagine and
describe what would be different in the face of various injuries or pathologies.
In 2010-2011, Ian and Catherine Truman, Artist-in-Residence in Anatomy & Histology, had a
Teaching and Learning Innovation Grant and an Australian Network for Art & Technology Grant to
study how students interact with the various materials we use in teaching MSS to develop an
internal representation of the body. We found out a lot about how you use the anatomy teaching
space and which things matter most to you in understanding how the MSS works. We have used
this knowledge to continue improving the classes.

exams
You need to pass a written exam to pass MSS. The format of the MSS exam and the way it is
marked are different from other components of KHI. To see what the exams are like, have a look at
the section at the end of this book, where previous exams, their sample answers and analysis of
what your predecessors did right or wrong is presented. The pass-fail criteria, which are different to
previous exams you have done in KHI, also are explained there. In addition, the practical
components (ie structure-function, radiology, etc) of MSS will be examined in the final Anatomy
practical exam, along with neuroanatomy and any thing else that you have done during the year.

notes for practical classes and lectures

A large amount of the content of MSS subtopic is based on functional anatomy and much of the
teaching is based on practical classes. The notes for the classes are included here. There also are
notes on related areas for which we do not have specific prac classes or lectures - these are for your
reference.
The information in the notes, and the answers to the questions therein take you a long way to
defining what you need to know for the functional anatomy part of the course...
Additional notes for some sessions may be put on FLO separately.

mini-cases and mini-case feedback sessions

Each week, in addition to the main case, there will be a set of mini-cases, that illustrate specific
aspects of MSS dysfunction relevant to the week. They will tend to get more complex as we move
through the course. We will run half-class sessions in the Anatomy Teaching area, when we will go
through with you what these mini-cases are showing you, using whatever teaching resources we
have. You should use these sessions as an important way to build up and refine your knowledge.
The better prepared you are for these sessions, the more you will get out of them. We will run them
in a pretty informal way, so there should be plenty of time for you to ask questions and get some
answers. Most importantly, the mini-cases model the exam question format very closely... In
particular, they encourage you to practise applying basic MSS knowledge to new clinical situations.

web-based resources
There are now many web-based resources that can help you through MSS, but there are a lot of
crappy ones too. We will try to put up-dated links to some of the better ones on the GEMP/MSS
area. Wherever we can, we will also put our own resources on the MSS site (eg movies, notes etc).
If you find a site or resource that seems to be particularly good, please let us know!

biomechanics of the musculoskeletal system

A few biomechanical principles go a long way in helping us to understand how the musculoskeletal system
works. You dont need to know this material explicitly (ie there wont be an exam question on it!!) but it
really does help to have some idea of mechanical advantage...

1.

Levers
A lever is defined as "a rigid bar which can rotate around a fixed point when a force is applied to
overcome a resistance".
To define any particular lever, we must therefore define:
the applied force (Fa)
the resistance force (Fr)
the point of rotation, known as the "fulcrum"
The relative location of these features along the length of the lever identifies the type (or class) of
lever.

a)

First class lever

The fulcrum lies between the points of the applied force and the resistance force, e.g. a seesaw or a crow-bar:
Examples in your body include nodding your head and extending your elbow.

b)

Second class lever

The point of resistance lies between the fulcrum and the point of the applied force, e.g. a
wheelbarrow or a bottle-opener:

Examples of second class levers in your body are a bit tricky to find. One potential example is
raising up on your toes, where the fulcrum is your toes, the resistance force is your body weight
running down through your ankles, and the applied force is being exerted by your calf muscles
plantar flexing via your Achilles tendon. However, some experts believe that the forces are not really
set up like this...
If you hold something relatively heavy (eg. an anatomy text) with your arm extended and abducted,
and then lower your arm slowly against gravity, the fulcrum of the movement is your shoulder, the
applied force is gravity and the resistance force comes from your deltoid muscle which is contracting
eccentrically - voila! A second class lever...

c)

Third class lever

The point of the applied force lies between the fulcrum and the point of resistance, e.g. a
spring closing a door:

Most examples of flexing a joint involve third class levers eg biceps brachii flexing the elbow joint,
or hamstrings flexing the knee.

10

2.

Mechanical advantage

For any lever to be balanced around its fulcrum,

(the distance from the point of the applied force to the fulcrum) x
(the size of the applied force)
=
(the distance from the point of the resistance force to the fulcrum) x
(the size of the resistance force).
These distances are known as the "force arm" (FA) and the "resistance arm" (RA), respectively.
Thus, the previous statement can be written:
Fa x FA = Fr x RA
where Fa is the applied force and Fr is the resistance force.
It should be clear that to keep balance, if Fa decreases, for example, then FA must increase to keep
the equation (and the lever!) balanced. This is the "see-saw principle" whereby an overweight adult
car can balance a see-saw with a small child on the other end.
If you think about it, you should be able to find numerous examples of this principle in operation all
around you. If you don't understand it, then get out a ruler, some lumps of chewing gum or other
sticky, weighty substance and try it out for yourself!
"Mechanical advantage" (MA) is the ratio of the force arm to the resistance arm:
MA = FA / RA
The greater this ratio, the more efficient the lever will be. In other words, less applied force will be
required to move against a given resistance, or alternatively, the same applied force will shift a
greater resistance. This is why you use a long crowbar for heaving blocks of concrete and just an old
screw driver to open a tin of paint.

Increasing MA requires the force arm to move through a large distance compared with the resistance
arm. This results in a slow movement of the resistance arm but with relatively great force,
equivalent to the low gears on a car or bicycle (think how much you have to pedal to move not very
far up a steep hill...).
Conversely, decreasing MA means that the force arm moves through a relatively small distance
compared with the resistance arm, producing a more rapid movement of the resistance arm at the
cost of decreased force generation (high gear is great for cruising, but try a standing start in top...).
How is the musculoskeletal system adapted to take advantage of these properties of MA? What
limits are set on the optimisation of MA for speed or strength in our bodies? How have these
problems been solved in other types of animals?

3.

Pulleys
Pulleys allow muscles to pull around corners. Where are some pulleys in your body?
They also allow muscles to be situated quite a distance from the parts of the body they are moving.
Why is this an advantage?
11

4.

Kinematic chains
Many simple levers can combine together to produce a wide range of movements at the periphery of
a limb. If one end of a chain of levers is fixed and the other end is free, then you have an "open"
kinematic chain. Your arm is a good example.

Compare the amount of space you can outline just by moving your finger (and nothing else). Now
start moving your wrist, then your elbow, your shoulder, your waist. What's happening?? You have
probably noticed by now that in an open kinematic chain, you can move any link in the chain
without necessarily changing the positions of the other ones relative to each other. Clever, eh?
What is the situation when both ends of the chain are fixed? This is a "closed" kinematic chain.
Your arm is still a good example. Try doing a push up moving just your elbows, without any
movement at your shoulder joints. What's happening now??

5.

Stress and strain

All of the foregoing assumes that bones are inflexible rods. This is not really true. Application of an
external force to a solid object will tend to deform it in some way. For example, if you apply a
compressive force along the long axis of a long bone, it will tend to become shorter and broader.
The measured differences in dimension are called "strains". Strain can also be developed in an
object like a bone by tensile (stretching), torsional (twisting) or bending forces. "Stress" is the
measure of the forces set up in a particular directions in the bone to resist the strain deformation.

6.

Elastic and plastic behaviour

As the strains on a material increase, so do the stresses. If a material returns to its original state once
the strains are removed, then it is "elastic". This means that the stresses fall to zero when the strains
are zero. However, if excessive strains are applied, a material may "yield" and begin to deform
without any further increase in stress. In this case, when the deforming force is removed, the stress
will fall to zero before the strain does and the material will be deformed permanently: this is
"plastic" behaviour. (Why do you think substances like polyethylene and PVC are called plastics?).

A material that shows little plastic deformation is "brittle", whereas one with a reasonable amount of
plastic deformation is regarded as being "tough".
In living bones, the degree of brittleness or toughness is determined by the relative amount of
mineralisation of the organic bone matrix. Tougher bones are less mineralised making them more
flexible and less likely to be broken. The microscopic structure of bone is organised in such a way
to provide a compromise between resistance to bending (why is this so important?) and resistance to
breaking.

7.

Hollow bones
Why are the shafts of long bones shaped like hollow cylinders?
Why is tubular steel or aluminium used so much in making things?
Consider a lateral bending force applied to a cylinder.
What stresses and strains will be set up in the cylinder? Which parts will be under tension? Which
part will be under compression? What will be happening in the middle of the cylinder? How thick
do the walls of the cylinder need to be?
12

BONES & JOINTS

This is some background information that will be useful for most of the classes. Sooner or later, we will
answer all the questions raised in this section...

Most of the bones you will see in the museum are dried bones containing only their mineralised content. In
life they also contain large amounts of organic material including the all the various cell type that form,
maintain and remodel the living bone. Living bones also contain large amounts of collagen and associated
proteoglycans - they provide tensile strength and elasticity to the bones. Finally, living bone tissue has a rich
supply of blood vessels and nerves, including those in the membranes covering the inner and outer surfaces
of the bone (endosteum and periosteum, respectively). If you look carefully at dry bone, you will see many
small holes (foramina) where blood vessels run through the compact bone.
What would a bone be like if it contained only organic components? Have a look in the museum at the bone
tied in a knot....
Bones respond to loading by growing thicker. Conversely, lack of load bearing will lead to loss of bone
mass. You can see this most clearly in jaw bones that have lost some teeth - look in the museum cabinet.
>> What sorts of forces are generated by biting and chewing?

Much of the shape of the bones is determined by the attachments for muscles and ligaments, and for load
bearing at joints.
>> Why are bones commonly enlarged at points of muscle attachments?

Most bones have an outer (cortical) layer of dense compact bone. The inner parts of the bone are made of
thin interconnecting rods and spars called trabeculae. The orientation of the trabeculae tend to become
aligned in parallel and perpendicular to the directions of the forces set up in the bones under normal loading
conditions. Have a look at the museum specimens of bones that have been cut longitudinally so that the
trabecular structure is revealed.
Many bones, especially the long bones are hollow, and the spaces are filled with blood forming tissue and
fat, which tends to predominate in older people.
>> Why are the long bones hollow?

Joints are connections of the skeleton between any of its rigid (bony) components.
On the basis of the type of tissue applied between two bones joints can be fibrous (syndesmosis),
cartilaginous (synchondrosis) or synovial (true joints). In some places, adjacent bones ossify together to
form a synostosis. You need to know the composition of synovial joints, their functional classification and
the possible range of movements in various joints of the body.

Fibrous joints
In these joints, the bones are joined by collagen fibres that have great tensile strength.

13

a.

Sutures - connections between the bones of the skull.

Sutures are designed to prevent movement between the bones of the skull.
>> Look carefully at the complex interlocking connections between the bones of the roof of
the skull. Are all the joints in the skull like this?

b.

Ligamentous connections - tibiofibular syndesmosis, interosseous membranes of arm and leg

and long ligaments of vertebral column.
These joints usually allow some degree of twisting to take place between one bone and the
next, while ensuring that the two bones do not spread apart from each other under loading.

Cartilaginous joints
In these joints, the bones are joined via a bridge of cartilage.
a.

Temporary cartilaginous connections - epiphyseal cartilages; these form as part of the

development of many bones. They allow the bones to elongate whilst they are in use.

b.

Permanent cartilaginous connections - pubic symphysis; This is the somewhat flexible

fibrocartilage (cartilage rich in collagen) that joins one half of the pelvis with the other half
ventrally. During childbirth, the cartilage softens and allows the pelvis to spread more
widely to enlarge the birth canal.

True (synovial) joints

These are joints we usually think of. In most cases, the joints allow at least some movement between the
apposing bones. The amount of movement in these joints depends on many factors, including the shapes of
the bones and their articular surfaces; the strength, length, and orientation of the ligaments surrounding the
joint, and the organisation of the muscles around the joint.
Synovial joints consist of several components that contribute to their function:
articular surface and cartilage: the articular surface of the bone is covered with a layer of hyaline
cartilage that is very smooth macroscopically, although is somewhat roughened microscopically by a surface
lattice of collagen fibres. The cartilage helps to protect the articular surfaces of the bones. When it is
damaged, osteoarthritis can develop.
joint capsule: synovial joints are enclosed in a capsule of connective tissue that encloses the joint
cavity. In many cases, parts of the capsule are thickened to form ligaments. The overall tightness or
looseness of the joint capsule can contribute to the amount of movement that can occur at the joint.
articular cavity: this is the actual space between the bones forming the joint. Sometimes, several
bones can contribute to a joint complex in a single articular cavity.
synovial fluid: joints are lubricated by the remarkable properties of synovial fluid. It is secreted by
the synovial membrane that lines most of the joint capsule. The fluid contains complex mucopolysaccharides
(glycosaminoglycans) that provide viscosity and lubrication. During exercise, synovial fluid is absorbed into
the articular cartilage, providing further protection for the joint. The fluid is non-newtonian, meaning that the
further it is compressed, the more it resists further compression. This is an ideal property for a load bearing
lubricant.
ligaments: the bones articulating at synovial joints are held together by ligaments made of collagen.
They play a major role in determining the range of movements at a joint. In some cases, they may be inside
14

the joint capsule (eg the cruciate ligaments of the knee).

intra-articular disc: some synovial joints contain disc-like structures made of fibrocartilage. Usually
these joints have a wide range of movement, but are not strictly load bearing. It is most likely that the intraarticular discs help to spread the synovial fluid in a large joint with a loose capsule.

Types of synovial joints

They can be classified according to the axes of movement :
(i)

Uniaxial eg interphalangeal (finger joints)

Biaxial eg wrist, joint between finger and metacarpals of hand.
Multiaxial eg hip, shoulder.

or according to shape:
(ii)

Plane eg between vertebrae

Hinge eg elbow, between humerus and ulnar
Pivot eg between atlas and axis (1st and 2nd vertebra of the neck)
Saddle eg at base of 1st metatarsal (base of thumb)
Ellipsoid ( = condyloid)
eg between metacarpals and phalanges (finger bones)
Ball and socket eg shoulder, hip.

Further Considerations
>> What factors restrict or reduce the range of movements?
>> You already may have experienced how painful joints can become. A very rich nerve supply goes to
joints, in particular to the articular capsule and to adjacent soft tissue, although the articular cartilage itself is
not innervated. Different classes of sensory nerve fibres convey pain sensation and proprioceptive sensation
from the joints. The latter type of sensory fibres are important for the normal neural control of movements
of the joints.
>> Imagine what it would be like if any of your joints were immobilised. Try not moving your shoulder,
elbow, metacarpophalangeal joints, hip, knee, ankle ... as you go about to perform some day to day activities.
>> What does it really mean to be "double-jointed"?

15

SKULL AND JAWS

In this practical you will investigate the bony structure of the head and neck, the muscles of facial
expression.

1. THE SKULL
The skull provides a case for the brain (cranial cavity), cavities for organs of special senses (orbital cavity;
external, middle and inner ear). It also forms the nasal cavity and the bony framework of the mouth (oral
cavity).

i. On the dry skull identify the following bones:

frontal*, occipital, sphenoid and ethmoid bones (single)
parietal and temporal bones (paired)
These bones provide a base and covering for the brain
vomer (single)
maxilla, palatine, zygomatic, lacrimal nasal bones (paired), mandible,
These bones form the facial skeleton and jaws.
The fissures you can see between some of the bones are specialised joints called sutures. What is their
structure? Identify the three major sutures.
* The frontal bone develops from two centres of ossification which are separated by the metopic (or
frontal) suture in fetal and infant skulls. This suture normally fuses and becomes invisible by the age
of 6 years.

ii. In the cranial cavity of the dry skull:

Identify the anterior, middle and posterior cranial fossae and establish the position of the following
structures in these fossae. The nerves and blood vessels associated with each of these structures are
given in brackets.
a. Anterior cranial fossa:
cribriform plate

(olfactory nerve)

b. Middle cranial fossa:

hypophysial fossa
(pituitary gland)
optic canal
(optic nerve, ophthalmic artery)
carotid groove
(internal carotid artery)
round foramen
(maxillary nerve)
oval foramen
(mandibular nerve)
spinous foramen
(meningeal artery)
superior and inferior orbital fissures
(nerves to extraocular muscles and branches of trigeminal
nerve)

c. Posterior cranial fossa

foramen magnum
(medulla of the brain)
hypoglossal canal
(hypoglossal nerve)
jugular foramen
(internal jugular vein)
transverse and sigmoid sulci
(dural sinuses of the same name)
16

internal acoustic meatus

(facial and vestibulocochlear nerves)
d. Petrous part of the temporal bone (internal ear)
Tympanic part of the temporal bone (external acoustic meatus)

iii. Surface anatomy

Identify the following palpable landmarks of the skull on yourself or on another student:
external occipital protuberance
zygomatic arch
supraorbital margins
glabella (ridge above the nose)
mastoid process
mandible (angle, mental protuberance, head)
temporal bone
nasal bones

3. Orbital cavity
Identify the bones forming the medial, lateral, superior and inferior walls of the orbital cavity.
>> Which canals or foramina connect the orbital cavity to the nasal cavity and the middle cranial
fossa?

4. Nasal cavity
Identify the bones forming the medial and lateral walls, the roof and
the floor of the nasal cavity.
Establish through which the canal or foramen the nasal cavity connects with the:
i. orbital cavity
ii. oral cavity
iii. anterior cerebral fossa
iv. paranasal sinuses
Identify the locations of the paranasal sinuses in sectional material of the head.
>> What air cavities other than the paranasal sinuses are found in the skull?
>> What is the function of the sinuses?

5. Oral cavity and temporomandibular joint

The bony framework of the oral cavity includes: maxilla, mandible and the hard palate. The teeth are
accommodated in the maxilla (upper jaw) and the mandible (lower jaw).
a. Identify the bones forming the hard palate. The hard palate separates the nasal cavity from the oral
cavity.
>> What advantage is there in this arrangement?
b. Identify the following landmarks on the mandible:
17

i. base, angle, arch and head

ii. mandibular notch, coronoid process and condylar process
iii. mandibular foramen, mandibular canal and mental protuberance

The mandible articulates with the skull through the temporomandibular joint. Study the construction of the
temporomandibular joint on the dry skull and on the wet specimen.
Characterise the temporomandibular joint in anatomical terms and in terms of the type of movements
occurring at this joint.
- anatomy
- movements
- ligaments
- articular capsule
Test on yourself what movements are possible at the temporomandibular joint.
>> How does it work?

6. MUSCLES OF THE FACE

Identify the muscles of facial expression around the mouth, eye and nose. Familiarise yourself with the
position and function of the following muscles on the prosections:

orbicularis oculi
orbicularis oris
levator labii superioris
depressor labii
buccinator
zygomaticus
risorius
depressor anguli oris
frontalis and occipitalis
nasalis
platysma

(around the eyes)

(around the mouth)
(extending upwards from the upper lip)
(extending down from the lower lip)
(the muscle of the cheek)
(from the corner of the mouth to the zygomatic arch)
(from the coner of the mouth across the cheek)
(from the corner of the mouth down towards the mandible)
(on the forehead and over the occipital region posteriorly)
(bridge of the nose)
(extends from lower border of the mandible to the deep fascia over
pectoralis major and the anterior deltoid)

>> What is unusual about these muscles?

The muscles of facial expression are second pharyngeal arch derivatives and are innervated by the facial
nerve (7th cranial nerve).
Find the exit of the facial nerve on the skull (stylomastoid foramen) from where it courses through the
parotid gland towards the facial muscles. Within the substance of the parotid gland, the nerve splits up into
the following branches:
18

temporal
zygomatic
buccal
mandibular
cervical

(frontalis)
(frontalis, orbicularis oculi)
(buccinator, orbicularis oris, levator labii superioris)
(orbicularis oris)
(platysma)

Identify the muscles of mastication (all innervated by the mandibular branch of the trigeminal nerve, the 5th
cranial nerve):
masseter
temporalis
medial and lateral pterygoids
>> What are the actions of these muscles on the lower jaw?
>> Which way does the temporomandibular joint move as the lower jaw is depressed or elevated by
these muscles?
Some of the suprahyoid muscles (muscles of the neck), mostly the digastricus
muscle also participate in the movement of the temporomandibular joint.
>> How?

What are the attachments and the actions of these muscles?

Muscle

Attachments

Action

masseter
temporalis
medial pterygoid
lateral pterygoid

Identify the course of the mandibular division of trigeminal nerve which carries motor fibres via the oval
foramen to the muscles of mastication.

19

Problems to Consider:
>> How can a blow on the vault of the skull injure the underlying brain without fracturing the bone?
>> Why are fractures of the middle cranial fossa common?
>> Compare the skull of a neonate with that of the adult. (There are examples of neonatal skulls in the
Anatomy Museum). Why are they different?
>> Why does dislocation of the jaw (temporomandibular joint) occur relatively frequently?
What is the most effective way of reduction?
>> What are the most common consequences of facial nerve injury?
>> What differences would there be in our skull and jaw muscles if we were primarily carnivores? ... or
herbivores?
>> Why do we have movable eyebrows?

20

BONES AND JOINTS OF THE UPPER LIMB

The bones and joints of the upper limb down to the wrist will be studied in this practical class. The skeleton
of the upper limb is attached to the skeleton of the trunk via the shoulder (or pectoral) girdle. Overall, the
upper limb and the shoulder girdle is well adapted for both strength and flexibility. In particular, they are
adapted for taking large tensile loads (as when hanging from your arms, or carrying heavy objects) - this is
a direct evolutionary link with our arboreal primate ancestors.

1. BONES OF THE UPPER LIMB

The skeleton of the upper limb includes the shoulder girdle (clavicle and scapula) and the bones of the arm
(humerus) and forearm (radius and ulna).
Identify the following bones on the skeleton, on X-rays and on yourselves:
clavicle, scapula, humerus, radius, ulna.
On the articulated skeleton and on X-rays and, where possible, on yourself, note their characteristic features .
. . what is attached to each of them?

Clavicle
The clavicle is the only direct skeletal attachment between the upper limb and the trunk.
Identify the acromial and sternal ends of the clavicle. The bone has a double curve in the horizontal plane.
>> How can you distinguish a left clavicle from a right clavicle?
>> Where is the weakest area in the bone?

Scapula
The scapula is a highly mobile element of the shoulder girdle, with several large muscles attached to it.
Identify and name its:
3 angles
3 borders
2 processes
2 surfaces
Spine and fossae
>> Which parts of the scapula can you feel on yourself?
>> Much of the scapula is very thin, yet it is rarely fractured. Why?

21

Humerus
The humerus is the bone of the upper arm (brachium). It is a strong, hollow long bone, with easily
identifiable features on it marking muscle attachments.
Identify the following:
Head
Neck - anatomical and surgical
Greater and lesser tuberosities (tubercles)
Bicipital groove (intertubercular groove)
Shaft and the deltoid tuberosity
Radial or spiral groove
Medial and lateral epicondyles
Trochlea
Capitulum of the humerus
Radial, coronoid and olecranon fossae
>> Why is the proximal end of the shaft called the surgical neck?

Ulna
The ulna is the medial bone of the forearm (when in anatomical position). It is the load bearing bone of the
elbow joint.
Identify the:
Olecranon Process
Trochlear notch of the olecranon process
Coronoid process
Radial notch
Styloid process
Capitulum of ulna (=distal head)
Note the position of the olecranon with reference to the medial and lateral epicondyles of the humerus during
flexion and extension of the elbow joint

Radius
The radius is the lateral bone of the forearm (when in anatomical position). It is the load bearing bone of the
wrist joint.
Identify the:
Head
Neck
Bicipital tuberosity (radial tuberosity)
Interosseous border
Styloid process
Ulnar notch

22

2. JOINTS OF THE UPPER LIMB

Study the following joints with respect to:
- the bones forming the articulation
- the type of articulation and shape of the articular surfaces
- ligamentous or bony factors strengthening or stabilising the articulation
- movements and the factors limiting them

A. Shoulder girdle
(i) Joints formed by the clavicle
The clavicle is important as a brace that keeps the shoulder joint far enough laterally to allow movements of
the arm. At its ends, it forms the acromioclavicular and sternoclavicular joints, which provide the only bony
connection between the upper limb and the trunk.

Note the costoclavicular, coracoclavicular and acromioclavicular ligaments which prevent dislocation of the
clavicle against forces transmitted from the arm through the scapula to the clavicle.

>> What movements take place at the joint between the clavicle and the manubrium of the sternum
(the sternoclavicular joint)?

>> What movements take place at the joint between the clavicle and the acromion of the scapula (the
acromioclavicular joint?

>> What is the relationship between movements at proximal and distal ends of the clavicle? Where is
the fulcrum for these movements?

(ii) Shoulder (glenohumeral) joint

Movements of this joint occur about 3 different axes, i.e. it is a multiaxial, ball and socket joint. Establish its
range of:
- flexion-extension
- abduction-adduction
- rotation
The combination of flexion-extension and abduction-adduction results in circumduction, when the arm
outlines the surface of a cone, the apex of the cone being the shoulder joint.
>> What features of the shoulder joint contribute to its mobility?

>> Compare the size of the articular surface of the glenoid fossa and the of the humeral head.
How does the discrepancy in size affect range of motion?

23

>> How do the articular surfaces of the shoulder joint move with respect to each other?

>> What structures contribute to stability of the shoulder joint anteriorly, superiorly, posteriorly and
inferiorly?

>> In which direction is the shoulder most likely to dislocate? Why?

>> Which nerves are at risk when a shoulder dislocates?

(iii) Movements of the scapula

The scapula is highly mobile. Any movement of the scapula is associated with movement of the
acromioclavicular and the sternoclavicular joints.

>> What range of movements can the scapula undertake?

>> What contributes to the spatial stability of the scapula?

>> How do the joints of the shoulder complex move when the arm is abducted to a horizontal
position and to an overhead position? Try to work this out on yourselves.

B. Elbow complex
The elbow is basically a load bearing hinge joint, but it also contributes to the pronation / supination
movements.
Identify the joints of the elbow complex and determine the movements and the range of movement at each
articulation. Consider the distal as well as the proximal radioulnar joint.

>> Which of these articulations are enclosed within the capsule of the elbow joint?

>> What is the angle between the ulnar and the humerus, when the elbow is fully extended?

>> In which position is the elbow most stable? Why?

>> In what direction does the elbow most commonly dislocate? Why?

>> In posterior dislocation of the elbow, which important nerve could be at risk?

>> Why is dislocation of the radius at the proximal radioulnar joint more common in young children
than in adults?
24

>> What happens at the proximal and distal radioulnar joints and at the humeroradial joint during
pronation and supination? How does the radius move in relation to the ulna?
>> Which is the more powerful movement: pronation or supination? Why?

Further Considerations
>> Try scratching your right elbow with your right hand. Imagine what it would be like if your left
arm were paralysed.
>> Compare the length of the upper arm with the length of the forearm? How well would you
manage if the forearm was half the length of the upper arm or vice versa?
>> How do the movements at each joint of the upper limb combine to maximise flexibility?

25

MUSCLES AND MOVEMENTS OF THE

SHOULDER & ELBOW
Most of the time, the shoulders and elbows do not move by themselves (when do they?) - usually, the
movements at these joints are generated and controlled by the muscles that cross them. Muscles come in all
shapes and sizes and you will see many different forms in this class. Once again, the muscles do not normally
move by themselves - they are controlled by the somatic motor pathways of the nervous system along with
the various forms of sensory feedback coming from tension and position receptors in the joints, ligaments
and muscles themselves. Today, we will just look at the major anatomical arrangements of the nerves
controlling the shoulder and upper limb.

1.

Muscles of the upper limb traditionally are divided into two main groups, namely:
**** Shoulder muscles
**** Muscles of the freely moving limb
(although some of these muscles do cross the shoulder joint...)

2.

Muscles of the shoulder

a.

Extrinsic muscles:
Extending between the vertebral column or ribs and the scapula Trapezius
Rhomboids
Serratus anterior
Levator scapulae
Pectoralis minor
Extending from the trunk to the humerus Latissimus dorsi
Pectoralis major

b.

Intrinsic muscles:
Extending between scapula and humerus Deltoid
Subscapularis
Supraspinatus
Infraspinatus
Teres minor
Teres major

>> Which of these muscles form the rotator cuff of the shoulder joint?
>> What are the functions of the rotator cuff muscles?

c.

Identify the muscle groups elevating, depressing, rotating, protracting and retracting the
scapula.
Remember that some apparently simple movements of the scapula require the action of more
than one muscle group.
26

d.

Identify the muscles which act on the glenohumeral joint as flexors, extensors, abductors,
adductors, lateral and medial rotators.
>> How often do these movements occur simply, ie by themselves?
>> How do the sites of their attachments to bones determine the movements generated by
the muscles?
>> What specialisations of the bones increase the efficiency of these movements?
>> Think carefully about the actions of muscles in the real world - for example, how can the
deltoid, traditionally identified as an abductor, control adduction?

e.

>> How do muscles acting on the scapula and muscles acting at the glenohumeral joint
work together in generating co-ordinated movements of the shoulder?

f.

Note that muscles that usually cause movements at the shoulder joint can do other things as
well. In particular, remember that muscles exert forces at both ends! Consider the pectoralis
major, for example... what happens when you fix the ends of your arms (eg by leaning on
them) and then contract the pectoralis major? Hint: why do you fix the ends of your arms
when you are puffing?

***************************************************************************
time out - - - eccentric muscle contractions
Usually, when a muscles contracts and exerts a force, the muscle shortens in length. This is called a
concentric contraction, and is the usual way we think about muscles working. However, muscles also can
exert a force as they lengthen - this is called an eccentric contraction. Eccentric contractions are surprisingly
common - you will see more about them when we look at walking later in the course - and often go on at the
same time as a concentric contraction of an opposing muscle. When might this happen?
It turns out that muscles tend to expend more energy when they are contracting eccentrically than when they
are contracting concentrically. They also are more likely to tear during an eccentric contraction. Why this is
so is not clear - at least partially because it is not entirely clear what is happening at a molecular level under
these conditions... However, one of the big problems is trying to anticipate what is going to happen next
when an external force (due to gravity, movement of the body itself or whatever) is being applied.
***************************************************************************

27

3.

Muscles of the Arm

The muscles of the arm (ie brachium) are mostly involved with flexing and extending the elbow:
Flexors:
Biceps brachii
(the brachii is important - there is another biceps in your lower limb!)
Brachialis
[NOTE: there is another elbow flexor, brachoradialis, that is found in the forearm
- more about this later]
Extensor:
Triceps
Identify the position and attachments of these muscles, the joints they act upon and the range of
movement they cause whilst contracting.

>> What is the difference in the functions of the brachialis and biceps brachii in flexing the elbow?
How do these differences relate to their distal attachments?
>> Why do the proximal heads of biceps brachii and the long head of triceps cross the shoulder
joint?
Another muscle also is present in the arm, namely the coracobrachialis. It goes from the coracoid
process to the humerus and has an important role on stabilising the shoulder joint, especially when it
is moving whilst loaded under tension. It is not involved in moving the elbow.
Remember that the elbow also is flexed by another muscle that is in the dorsal compartment of the
forearm, known as brachioradialis. We will see more about its relations in a later class.

***************************************************************************
time out - - - length-tension curves
If you plot out the relationship between the force generated by a contracting muscle and its length, you
usually will get a bell shaped curve. In other words, if the muscle is stretched too much, the force
development will decrease; and if the muscle is shortened too much, the force development also will
decrease. Thus, there is an optimal length at which the muscle will develop maximal contractile force. At a
molecular level, this corresponds fairly well to the region of maximum overlap between the actin-containing
thin filaments and the myosin-containing thick filaments, so that there is the maximum number of crossbridges to generate contractile force. (If you want to know more about these matters, look up any decent
physiology textbook.) Throughout the musculo-skeletal system, muscle attachments to bones tend to be set
so that the maximal mechanical advantage at a joint is achieved at a point where the length of muscles
matches their peak force production.

***************************************************************************

28

4.

Brachial plexus

Dont worry if you dont get time to look at all this material in this class - there will be a review session later
when you can have another go.
The brachial plexus is formed from the ventral rami of spinal nerves C5 to T1. It extends from the neck into
the axilla and supplies the muscles of the upper limb. The plexus is a developmental device that ensures that
the spinal nerves connect with the appropriate muscles of the upper limb as it grows from the limb bud.
It should be noted right at the start that the posterior cord of the brachial plexus supplies all extensor muscles
in the morphological posterior aspect of the limb distal to the axilla (armpit). The flexor muscles are supplied
by the medial and lateral cords. More of this later.

In the brachial plexus:

a.

The five ventral rami sometimes are termed the "roots" of the brachial plexus.

b.

The five ventral rami combine into 3 trunks:

Upper ( = superior)
Middle
Lower ( = inferior)

:
:
:

from rami C5 and C6

from rami C7
from rami C8 and T1

c.

Each of the three trunks splits into an anterior and posterior division.

d.

The divisions recombine into 3 cords.

e.

Lateral cord

from anterior divisions of the upper and middle trunks

Medial cord

from anterior division of the lower trunk

Posterior cord

from the posterior divisions of all three trunks.

The cords then give rise to the main nerves of the upper limb:
Musculocutaneous nerve
Ulnar nerve
Radial nerve
Axillary nerve
(= circumflex)
Median nerve

:
:
:
:

from the lateral cord

from the medial cord
from the posterior cord
from the posterior cord

from the lateral and medial cords

>> From which segments are each of these nerves derived?

29

f.

The brachial plexus also gives rise to nerves supplying the pectoral muscles and muscles of the
shoulder region. Identify the origin, course and target of each of the following nerves:
Nerve

Origin

Muscle

Dorsal scapular
Suprascapular
Long thoracic
Medial pectoral
Lateral pectoral
Thoracodorsal
Subscapular
Axillary

>> Where, and under what circumstances, might some of these nerves be injured?

g.

Note that the nerves derived from the brachial plexus contain various combinations of somatic motor
fibres, autonomic fibres and sensory fibres.
We will look more carefully at the distal target of these nerves in a subsequent class.

h.

What are relationships of the brachial plexus (especially the cords) to the axillary artery?

30

wrists, hands and fingers

In this class, we will look at the structure of the wrist, hand and fingers, and the muscles that move them.
Many of these muscles are not in the hand itself, but in the forearm, with some of the muscles having their
proximal attachments at the humerus. In trying to understand and learn the roles of the various muscles in
generating the movements of the hands, it is easiest to think of the muscles as making up a series of natural
groups. These groups are defined by the position of the muscles, their actions, and their innervation.

1.

Bones and joints

a.

Wrist:

8 carpal bones are arranged in 2 rows. The proximal row articulates with the radius
to form the radio-carpal joint. This joint acts as an ellipsoid or condyloid joint
allowing flexion, extension, abduction, adduction and circumduction. The carpal
bones are separated from the ulnar by a fibrocartilage disk.
- proximal row of carpals = scaphoid, lunate, triquetral, pisiform
- distal row of carpals = trapezium, trapezoid, capitate, hamate

>> Which movement of the wrist has greater range: abduction (radial deviation) or adduction (ulnar
deviation)? What is the anatomical reason for this? Why would this difference have evolved?
>> The scaphoid is commonly fractured in young adults falling on outstretched hands. Why does this
sometimes result in a surprisingly troublesome injury?
>> Which bones make up the carpal tunnel?
>> The pisiform is not really part of the main carpal bone series, but is a sesamoid bone. Which
tendon is it associated with?

b.

Hand:

5 metacarpal bones each having a base, a shaft and a head. 3 phalanges for each of
the fingers but only 2 for the thumb.

Joints:

For each of the following joints, identify:

a.
bones forming the articulation
b.
type of articulation
c.
ligaments strengthening or stabilising the articulation
d.
movements of the articulation and their range

i.

Intercarpal joints:

Irregular surfaces, little movement is permitted.

ii.

Mid-carpal joints:

Between bones of proximal and distal rows, slight

displacement only during forced flexion and
extension.

iii.

Common carpometacarpal joints:

Because of irregular articular surfaces and tight

ligaments they are largely non-movable, except for:

1st carpometacarpal joint:

Saddle joint, critical in allowing

movements of the thumb, as in :
Opposition-reposition

flexible

31

Abduction-adduction
Circumduction
The flexibility of the first carpometacarpal joint is essential allowing the opposition of the
tip of the thumb against the ends of the other fingers in a wide variety of precision and
power movements.
>> How much movement is there at the 5th carpometacarpal joint? Why?

iv.

Metacarpophalangeal joint:

Condyloid joints, important in the gripping

movements of the hand.
- extension-flexion
- abduction-adduction
- circumduction
- passive rotation

>> How does the degree of flexion and extension at these joints affect their range of
abduction-adduction?
>> Why is there so much passive rotation at these joints?

v.

Interphalangeal joints:

These articulations are hinge joints, allowing only flexion

and extension.

>> If you look at these joints carefully, you can see that they are really a kind of double
condyloid joint - how does this arrangement restrict their range of movements?
>> The proximal interphalangeal joints have wider range of flexion-extension than the distal
joints. How does this interact with the way we grip things?

Study the radiological anatomy of the hand and compare the articulated bony hand with X-ray pictures.
Match up the features on the skeleton and radiographs with the bony features on your own hands.

32

***************************************************************************
revision time out - - - types of joints
Joints can be classified functionally according to their shape or according to the types of movements they
allow. Obviously, the two characteristics are related.
A typical classification is:
degrees of freedom

type

movements

1 - uniaxial

hinge
bicondyloid
axle

flexion-extension
flexion-extension
rotation

2 - biaxial

condyloid
(=ellipsoid)

flexion-extension
abduction-adduction
circumduction

3 - multiaxial

ball and socket flexion-extension

abduction-adduction
circumduction
rotation
saddle

flexion-extension
abduction-adduction
circumduction
rotation

Of course, the exact range of movement is determined not only by the joint itself, but the ligaments and
muscles crossing the joint. You should be able to think up examples of each of these joint types.

***************************************************************************
2.

Muscles of the forearm

The muscles of the forearm are classified initially into two main groups:
- those on the flexor aspect = anterior or ventral compartment
- those on the extensor aspect = posterior or dorsal compartment
Each compartment is arranged in a series of layers. On both sides of the forearm, the most superficial
muscles move the wrist. Most of the remaining muscles move the fingers and thumb.
Most of the extensors have a common attachment to the lateral epicondyle of the humerus, whilst most of the
flexors have a common attachment to the medial epicondyle of the humerus.
The forearm muscles attach to bones in the wrist and digits via long tendons, which are held in place by
bands of connective tissue called retinacula on each aspect of the wrist. The tendons are surrounded by
synovial sheaths which provide lubrication as the tendons move to and fro deep to the retinacula.

The muscles of the forearm include many muscles that move the fingers and thumb. These muscles comprise
the extrinsic hand muscles.
33

a.

Muscles of the flexor aspect of the forearm

Majority arise from the medial epicondyle of the humerus and pass across both the elbow and wrist
joints to gain insertion upon the metacarpals or the phalanges.

These muscles can be divided into three layers:

i.

Superficial:

pronator teres
flexor carpi radialis
palmaris longus
flexor carpi ulnaris

ii.

Intermediate:

flexor digitorum superficialis

iii.

Deep:

flexor digitorum profundus

flexor pollicis longus
pronator quadratus

The tendons of the finger flexors pass into the hand via the carpal tunnel and share a common
synovial sheath in the tunnel.
Note carefully the locations and distal attachments of the superficial and deep finger flexors:
- the superficial flexors attach to the middle phalanx of each finger, and are mostly involved
in precision movements of the fingers;
- the deep flexors attach to the distal phalanx of each finger and are mostly involved in
power movements of the fingers.
>> How is this arrangement achieved?
>> To see the difference between these muscles working, look at the flexor side of your wrist whilst
wriggling your fingers compared with making a tightly clenched fist.
>> Why are these muscles so long?

b.

Muscles of the extensor aspect of the forearm

Many of these muscles have a proximal attachment to the lateral epicondyle of the humerus. They
form two layers:
i.

Superficial:

brachioradialis (an elbow flexor !!!)

extensor carpi radialis longus
extensor carpi radialis brevis
extensor digitorum
extensor digiti minimi
extensor carpi ulnaris

All the superficial extensor muscles have a proximal attachment to the lateral
epicondyle of the humerus.

34

ii.

Deep:

supinator
abductor pollicis longus
extensor pollicis brevis
extensor pollicis longus
extensor indicis

The extensor muscle tendons, on the dorsum of the hand run in 6 compartments, each with its own
synovial sheath, set from radial to ulnar in the following order:
- Abductor pollicis longus and extensor pollicis brevis
- Extensor carpi radialis longus and brevis
- Extensor pollicis longus
- Extensor digitorum and extensor indicis
- Extensor digiti minimi
- Extensor carpi ulnaris

The tendons of the finger extensors end in a broad expansion over the distal ends of the fingers, called the
extensor hood, expansion, or sheath.

>> Look at the extensor compartment of your forearm while you are making a tightly clenched fist. Which
muscles are contracting on the extensor side? Why?

>> Why would you have an extra extensor muscle each for the index finger and for the little finger?

>> Where is the anatomical snuff box? Why do you need to know?

3.

Intrinsic muscles of the hand

The intrinsic muscles of the hand mostly are involved in precision movements of the thumb and fingers. The
only muscles causing abduction and adduction of the fingers are intrinsic to the hand.
The intrinsic hand muscles are arranged in 3 groups (their names describe their function)
a.

Thenar - moving the thumb:

abductor pollicis brevis
flexor pollicis brevis
opponens pollicis
adductor pollicis
(part of this muscle is really a palmar interosseus muscle, in
the mesothenar group)

b.

Mesothenar - associated with all the digits

dorsal interossei
- abduct digits II, III, IV
palmar interossei
- adduct digits II,IV,V (and thumb, as part of adductor
pollicis)
lumbricals
- flex the metacarpophalangeal joint and extend the interphalangeal joints of the fingers (not the thumb)

c.

Hypothenar - moving the little finger

35

abductor digiti minimi

flexor digiti minimi
opponens digiti minimi

Note that the hypothenar muscles form a mirror image of the thenar muscles, and do more or less the same
things.
>> The lumbricals (earthworms) are odd in that they run between the tendons of two other muscles,
namely flexor digitorum profundus and extensor digitorum. They work together with these muscles to cause
flexion of the metacarpophalangeal joints and extension at the interphalangeal joints. How?

4.

Innervation
Learning the basic innervation of the forearm and hand muscles is easy:
- three named nerves derived from the brachial plexus are involved:
radial nerve
median nerve
ulnar nerve.
- all of the muscles in the posterior compartment are innervated by the radial nerve, no
matter what they do.
- none of the intrinsic muscles of the hand is innervated by the radial nerve.
- most of the forearm flexors are innervated by the median nerve.
- the forearm flexors that not are innervated by the median nerve are innervated by the ulnar
nerve - they are flexor carpi ulnaris and the ulnar half of flexor digitorum profundus, past
which the ulnar nerve runs. Easy!
- the thenar muscles are innervated mostly by the median nerve.
- the hypothenar muscles are innervated by the ulnar nerve (which runs down the little finger
side of the forearm - easy!).
- the interosseus muscles are innervated by the ulnar nerve, including the bit of adductor
pollicis that is really a palmar interosseus.
- the lumbricals on the ulnar side of the hand (digits IV and V) are innervated by the ulnar
nerve, the other two are innervated by the median nerve (what else could it be?)

***************************************************************************
time out - - - power v precision: motor units
How do we control the force, speed and precision of movement of our fingers? Many things are involved,
especially in the CNS. But the basic building blocks of this control can be seen in the periphery. For any
individual muscle fibre, the speed of contraction is inversely related to the applied load: the greater the load,
the slower the contraction, and vice versa. However, the real trick lies in the way in which the motor neurons
are connected up to the muscle fibres.

36

Each motor neuron and the muscle fibres it innervates comprise a motor unit. Some motor neurons innervate
only a few muscle fibres (as small as 2 or 3), forming a small motor unit, whilst other motor neurons
innervate many muscle fibres (up to several hundred), forming a large motor unit. Fine control is achieved by
activating small motor units, whilst coarse control mostly involves large motor units.
When a graded increase in force or speed of muscle contraction is required, smaller motor units are recruited
first, followed by larger and larger motor units. The level of activation of motor units required for a
particular movement under a particular load is determined initially by feedback (from proprioreceptors and
tension receptors etc) and then, after repetition, by experience.
Part of training or practice in co-ordination or strength skills involves learning to use the minimum
number of appropriate motor units to do the required task. Some of the smallest motor units in the body are
in the intrinsic muscles of the hands. In skilled manual tasks, individual small motor units may be recruited
as required.
***************************************************************************

37

pelvis and hip joint

The pelvis and hip joints of humans are adapted to allow efficient bipedal locomotion, whilst at the same
time allowing for the birth of large-brained babies. This means that there is a trade-off in the design of the
pelvis, since efficient bipedal locomotion requires the hip joints to be as close to the midline as possible
(why??), while big-brained babies require as large a pelvis as possible. Many of the special features of the
pelvis are related to the distribution of loads generated during weight-bearing exercise, such as walking,
running and jumping.

1.

The bony pelvis is formed by the two hip bones and the sacrum. The space in and above the bony
pelvis is the pelvic cavity. The linea terminals subdivides it to the upper greater pelvis and lower
true pelvis. The hip bone, during fetal life and in babies, is composed of three bones, the ilium,
ischium, and pubis. They are fused together at the acetabulum. In many animals, these three
components of the pelvis remain separate from each other. The shape of the pelvis helps align the
muscles of the hip joint to maximise their mechanical advantages during standing and locomotion. It
also provides support and protection for the abdominal and pelvic organs in our upright posture.
Note that the pelvis effectively consists of a series of arches diverging away from the acetabulum.

2.

First, identify the principal named parts of the hip-bone. Place the hip-bone from a half-skeleton
alongside a living model, and identify the following bony landmarks both on the bone and the model
(You can use yourself as the model..!!):
iliac crest
anterior superior iliac spine
anterior inferior iliac spine
pubic tubercle
ischial tuberosity
posterior superior iliac spine
centre of sacroiliac joint

3.

a.

The intact pelvis has a superior aperture (linea terminalis), a cavity and an inferior aperture.
The latter is formed by the pubis, ischium and the sacrum together with the sacrospinous
and sacrotuberous ligaments. The inferior aperture or pelvic outlet is supported by the
perineal muscles (levator ani and urogenital diaphragm). Compare the dimensions of the
three parts (inlet, cavity and outlet).

b.

Position the articulated pelvis alongside the living model, in the standing and sitting
positions.
>> How does the orientation of the pelvis and the palpable features of the hip-bone change
when we sit down?
>> What happens to the pelvis when you slouch forward while sitting down?
>> How is the weight of the body transmitted from the vertebral column to the floor in the
two cases?

4.

Look at the shape of the sacrum (formed by the fusion of 5 sacral vertebrae) and note how it is
slotted between the two hip-bones. Two displacements of the sacrum must be prevented:
38

- downward displacement of the whole sacrum.

- forward rotation of the upper part of the sacrum, with backwards rotation of the
caudal part, pivoting around the sacro-iliac joints.
There are two main sets of ligaments preventing these displacements:
- the short sacro-iliac ligaments;
- the sacrospinous and the sacrotuberous ligaments
>> Where are these ligaments?
>> Which movements do they prevent?

5.

The hip joint is formed by the head of the femur and the acetabulum. It is a deep ball and socket
joint, with three degrees of freedom of movement allowing:
- flexion / extension
- abduction / adduction
- circumduction
- medial and lateral rotations
The acetabulum is deepened somewhat by a rim of fibrocartilage, the acetabular labrum.
The joint capsule is thickened and reinforced by three strong ligaments: iliofemoral, pubofemoral
and ischiofemoral ligaments.
>> How do the ligaments restrict the possible movements and stabilize the joint?
>> Is the hip more or less stable than the shoulder? Why?
>> In particular, look at the role of the iliofemoral ligament in supporting the body weight during
quiet standing.

6.

The hip joint is surrounded by strong sets of muscles that act to generate and control the movements
of the hip joint. Many of these muscles run from the pelvis to the proximal end of the femur, and are
similar in arrangement and function to the corresponding muscles of the shoulder.
Use the prosected specimens to identify the following muscles associated with the hip joint. All of
them attach to the proximal parts of the femur. Examine both their proximal and distal attachments
in order to see how they work in generating the movements of the hip.
ilio-psoas

flexor

internal obturator

lateral rotator *

external obturator

lateral rotator *

piriformis

abductor *

quadratus femoris

adductor *

gluteus minimus

medial rotator, abductor #

gluteus medius
gluteus maximus

medial rotator, abductor #

extensor, lateral rotator #

* These muscles are somewhat similar to the rotator cuff muscles of the shoulder in their
arrangement and functions. Their main function probably is to provide dynamic stability to the hip
joint during a wide range of movements. The lateral rotators play an important role in keeping the
feet pointing forward during walking.
39

# The gluteal muscles as a group have some similarities in arrangement and function to the deltoid
muscle of the shoulder. The gluteus medius and minimus muscles have a vital role in walking,
contracting on the same side as the leg supporting the body weight. Here they abduct to stop the
body falling toward the unsupported side as the free leg takes a forward stride. They also generate a
medial rotation from the supported side to swing the pelvis forward.

There also are several other muscle groups that generate movements of the hip joint: they mostly
form the muscles of the thigh. Most of them also have actions at the knee joint. They include:
adductors
hamstrings
rectus femoris

adduct hip
extend hip, flex knee
flex hip, extend knee

We will look at these muscles and their functions more fully in a subsequent class...

7.

The muscles of the pelvis and lower limb are innervated by nerves arising from the lumbosacral
plexus.

a.

Lumbar plexus
The lumbar plexus is formed from the ventral rami of L1 - L3 and the superior part of L4. It gives
rise to two main nerves, the obturator and the femoral nerves, which supply muscles of the lower
limb.
On the prosected specimens, observe the formation of the obturator and femoral nerves from the
lumbar plexus and follow their path through the pelvis and its associated structures.
>> The lumbar plexus also gives rise to the ilioinguinal and iliohypogastric nerves. What muscles
do they supply?

b.

Sacral plexus
The sacral plexus is formed from the ventral rami of the inferior part of L4 and L5 - S4. The largest
nerve derived from this plexus is the sciatic nerve, which in turn forms two major branches, the
common peroneal and tibial nerves. Also derived from the sacral plexus are the superior and
inferior gluteal nerves.
On the prosected specimens, trace the origin and path of the sciatic nerve through the pelvis and its
associated structures.
>> What are their relations to the muscles of the hip and the foramina of the pelvis?

Further Problems
>> Why is the hip usually dislocated backwards?
>> Consider the consequences of the anatomical construction of the pelvis, especially the dimensions of the
inlet and outlet, during delivery of a baby.
>> What soft tissue injuries would you expect to find associated with pelvic fractures?
>> How can a dancer or a gymnast produce such extreme movements of the hip joint?
>> Stand upright beside a wall, touching it, but not leaning against it. Now try to abduct the leg on the side
away from the wall. What is going on?
40

BONES AND JOINTS OF THE LOWER LIMB

In this class, you will be dealing with the individual bones and joints of the lower limb, including the foot.
Overall, the plan of the bones and muscles of the lower limb is similar to that of the upper limb, but with
obvious modifications associated with weight bearing and bipedal locomotion.

1.

Identify the following features of the lower limb bones on dry bones, on wet specimens, and, where
possible, their surface markings on yourself:
Femur (thigh bone)

head, neck, greater and lesser trochanters, inter-trochanteric line,

shaft, medial and lateral epicondyle, intercondylar fossa, patellar
surface, popliteal surface, medial and lateral condyles

The femur is angled inwards towards the midline to bring the lower part of the limb closer to
the centre of gravity.
>> Why is this important for efficient walking and running?
>> Why is the femur curved in the anterior-posterior plane?
Patella (knee cap)
Tibia (shin bone)

medial and lateral condyles, intercondylar eminence, medial and

lateral intercondylar tubercles, tibial tuberosity, shaft, medial
malleolus, fibular notch

>> The tibia is most commonly broken distally. Why?

Fibula

head, lateral malleolus

The fibula is attached to the tibia proximally by the proximal tibiofibular joint (a gliding
synovial joint) and distally by the tibiofibular syndesmosis, a peculiar fibrous joint. Most of
the shaft is joined to the shaft of the tibia by a strong interosseus membrane.

Tarsals (ankle) -

talus, calcaneus (heel bone), navicular, cuboid and three cuneiforms

Metatarsals (foot)

base, head, shaft (x5)

The tarsals and the metatarsals combine to form the arches of the foot. More about this
below...

Digits (toes)

proximal, middle and distal phalanges for digits II-V; proximal and
distal phalanges for digit I (big toe = hallux)

41

2.

Joints of the lower limb

You should be familiar with the following items on each of the principal joints:
a.

The articular surfaces of the component bones

b.

The nature of the articular capsule (slack or taut, thin or thick etc)

c.
d.

The ligaments reinforcing the joint

The movements occurring at the joint and their normal range.

Hip joint
Revise the features contributing to the unique construction of the hip joint that allows relatively free
movement with the combination of admirable stability.

Knee
The knee is a complex modified hinge joint. It main movements are flexion and extension, although
there is a reasonable amount of rotation possible when the knee is flexed. There normally is no
adduction or abduction. The joint has to bear very large loads during locomotion, and the articular
surfaces are greatly expanded to accommodate these loads. Indeed, the articular surface of the femur
is much greater than that of the tibia, so that there is considerable gliding of the joint surfaces past
each other during flexion and extension. The mobility of the joint is controlled largely by four
ligaments: the anterior and posterior cruciate ligaments and the medial (tibial) and lateral (fibular)
collateral ligaments. Nevertheless, much of the strength of the joint comes from the muscles that
cross it.

a.

The cruciate ligaments act together to maintain contact and alignment of the femur and
tibia during the flexion-extension cycle. The anterior cruciate prevents hyperextension,
whilst the posterior cruciate is under more tension during flexion of the knee. However,
because the way they cross over each other, the ligaments are relatively taut throughout the
flexion-extension cycle, and, together with the collateral ligaments, they help to fix the axis
of movement of the joint.
Identify the cruciate ligaments in the wet specimens and observe their interactions during the
flexion-extension cycle. Note that the cruciate ligaments lie within the joint capsule but are
outside the synovial cavity.
>> How do the cruciate ligaments interact to "lock in" the fully extended knee?
>> Under what conditions are you most likely to damage the anterior or the posterior
cruciate ligament?

b.

The tibial (medial) and fibular (lateral) collateral ligaments are formed from thickenings of
the joint capsule. Their main function is to prevent abduction and adduction of the knee
joint.

>> The medial collateral ligament is more likely to be damaged than the lateral collateral
ligament. Why?

c.

The knee joint contains two large intra-articular fibrocartilage disks, or menisci, that
project into the synovial cavity from the joint capsule. The lateral meniscus is more free to
move than the medial meniscus, which is tied to the medial collateral ligament. Both menisci
are tied to the tibia and each other by the transverse ligament. The function of the menisci is
42

still not really understood - they probably do not absorb much load themselves - rather,
they probably help spread the synovial fluid over the large articular surfaces of the joint,
especially over the femur.
>> When are the menisci most likely to be damaged?
>> Why is the medial meniscus more likely to be the one that is damaged?

d.

The knee has a very large and complex synovial cavity with out-pocketings (bursae)
between the patella and the femur that extends proximal and distal to the patella itself. The
extent of the synovial cavity is not the same as the joint capsule.
>> What is the functional significance of the supra- and infrapatellar bursae?

e.

The patella is really a sesamoid bone within the tendon of the quadriceps muscle. It helps to
protect the anterior aspect of the knee joint and increases the mechanical advantage of the
quadriceps.

>> Compound fracture of the patella is quite common, with poor prospect for healing.
Why?

Ankle (talocrural joint)

The ankle also is a modified hinge joint. It allows flexion (towards the sole of the foot = plantar
flexion) and extension (towards the top of the foot = dorsiflexion). The joint is formed proximally by
the medial malleolus of the tibia and the lateral malleolus of the fibula, and distally by the talus,
which is the only bone of the foot to articulate with the leg. Because of the shape of the talus, which
is wider anteriorly than posteriorly, the ankle is much more stable in the dorsiflexed position than in
the plantarflexed position.

The talocrural joint is strengthened by the medial and lateral collateral ligaments of the ankle. They
run from the malleoli to the tarsal bones.
>> Under what conditions are the collateral ligaments of the ankle most likely to be damaged?
>> How does the range of movements at the talocrural joint compare with that of the radio-carpal
joint?

Intertarsal joints
The joints between the tarsal bones allow the foot to change shape and orientation so that maximum
contact is maintained with the ground during a variety of movements over a range of terrains.
Eversion means turning the foot outwards, so that the plantar surface (sole) tends to face laterally.
The opposite movement is inversion, so that the plantar surface turns to face more medially.

43

The movements of inversion and eversion of the foot occur at three of the intertarsal joints:
Subtalar joint
Talocalcaneonavicular joint
Calcaneocuboid joint
The last two constitute the transverse or midtarsal joint.
If you make the inversion-eversion movement with your toes and ankle strongly dorsiflexed, then the
movement is taking place almost entirely at the subtalar joint, with the axis of the movement running
almost longitudinally down the foot. If you move your foot from a fully everted position to a fully
inverted position with your ankle and toes strongly plantarflexed, you also will be moving at the
transverse tarsal joint, which more-or-less flexes and twists during the movement, allowing a greater
degree of inversion to occur.
Identify on the dry and wet specimens and on yourself, how these movements of inversion and
eversion take place.

>> What types of movements occur between each of the tarsal bones themselves?

The tarsometatarsal and the metatarsophalangeal joints are similar in shape and function to the
carpometacarpal and metacarpophalangeal joints of the hand. The metatarsophalangeal joints allow
flexion-extension, abduction-adduction and circumduction, just as in the hands. In the foot the axis
for abduction-adduction is centred on the second digit (not the third as in the hand).
Arches of the foot
The human foot is characterised by its arches: the lateral and medial longitudinal arches and the
transverse arch. The highest point of the arches is the apex of the medial longitudinal arch (instep)
which corresponds to the talus. During quiet standing, weight is supported evenly by the heels and
the distal ends of the metatarsals. During walking, weight is transferred forward from the heel, along
the lateral longitudinal arch, and then medially across the transverse arch to the big toe. The medial
longitudinal arch flexes and absorbs some of the impact forces set-up during the transfer of weight in
the walking cycle.

Both the bones and ligaments of the foot are important in maintaining the longitudinal and transverse
plantar arches:
-- The bones lock together like the blocks in a stone arch (especially across the transverse
arch);
-- They are held together by a series of short strong ligaments on both their dorsal and
plantar surfaces.
-- The ends of the arches are tied by the plantar aponeurosis that underlies the skin of the
foot.
-- The longitudinal arches are supported on the plantar side by strong longitudinal
ligaments.
-- The plantar calcaneonavicular ligament contains elastin, which helps support the talus at
the apex of the medial longitudinal arch, while allowing it absorb and spring back from
deforming forces generated during weight bearing.
-- During activity, the intrinsic and extrinsic muscles of the foot help to provide dynamic
support for the arches, but during quiet standing, the ligaments do it all.
Define the components of the arches:
44

Medial longitudinal arch

Lateral longitudinal arch

Transverse arch

>> How much energy does you foot absorb (and give back to you by elastic recoil) compared with
fabulously expensive sports shoes?

45

MUSCLES AND MOVEMENTS OF THE LOWER LIMB

During quiet standing, very few muscles are used to support the body weight. However, once we start
walking, all of the muscles of the lower limb are used at least once in the walking cycle. During running, the
muscles are used very efficiently, with the tendons and muscles themselves storing and releasing a lot of
energy as elastic deformation. The best way to understand about how these muscles work is to think of them
as functional groups, rather than individual muscles with individual actions.

1.

Hip and Gluteal Region

You have already examined the muscles of this region in the class on the pelvic girdle.
Revise the locations and actions of these muscles in standing, walking and climbing.
In addition, note the location of the tensor fasciae latae muscle which applies longitudinal tension
to the ilio-tibial tract. It helps to support the pelvis along with the gluteus medius and minimus
muscles, and is very important is stabilising the knee in almost any position from fully flexed to fully
extended.

2.

Thigh Muscles
In the thigh, there are three distinct sets of muscles, forming anterior, posterior and medial groups.

a.

Anterior group
These muscles mostly are united into one large powerful muscle, the quadriceps femoris.
This muscle has four components:
rectus femoris
vastus medialis
vastus lateralis
vastus intermedius

- flex hip, extend knee

- extend knee
- extend knee
- extend knee

All the components of the muscle join into a common tendon which contain the patella and
attaches distally to the tibial tuberosity. On the prosections, look carefully at the orientation
of the muscle fibres in each part of quadriceps. Why are they arranged the way they are?

Running across the anterior aspect of the quadriceps is sartorius. It is able to flex both the
hip and the knee joints. How? Its name means belonging to a tailor. What characteristic
action of the lower limb does it contribute to?

46

b.

Posterior group
These are also known as the "hamstrings" (why?) and contain three muscles:
- biceps femoris
- semimembranosus
- semitendinosus

(lateral)
(medial, deep)
(medial, superficial)

All of them share a common proximal attachment at the ischial tuberosity, and they extend
to attach to the tibia or fibula just distal to the knee. Thus, they extend the hip and flex the
knee, but have difficulty doing both at once. As in many of the muscles of the lower limb,
they do much of their work eccentrically, acting to slow the forward movement of the limb
prior to the heel making contact with the ground.
Identify the distal tendons of these muscles on yourself.
>> Why are the hamstrings torn to frequently?
>> Why are they so long?
>> What is meant by a torn muscle?

c.

Medial group
These muscles all adduct the thigh.
Identify the size, location and attachments of the following muscles:
- pectineus
- gracilis
- adductor longus
- adductor brevis
- adductor magnus
These muscles act together in a similar way to the pectoralis major and latissimus dorsi
muscles acting on the upper limb: ie, they pull the lower limbs back towards the midline
from wherever they have been. This means that they are active during nearly every phase of
the walking cycle. Make sure you understand why...

>> Sporting types often refer to pulling a groin muscle. What muscles are they talking
about? Why do they get injured?

3.

Leg muscles
The muscles of the (anatomical) leg are grouped into three compartments separated by strong
fasciae. These muscles are similar in their overall arrangement to the forearm muscles. Here they
mostly flex and extend the ankle and toes. Remind yourself why the muscle mass is concentrated as
proximally as possible within the limbs.
a.

Anterior (extensor) compartment

tibialis anterior

- extends (dorsiflexes) ankle

47

extensor hallucis longus

extensor digitorum longus

- extends big toe

- extends digits

Determine the surface markings of these muscles and their tendons on yourself. Note that as
the tendons pass to the foot, they are held in place by extensor retinacula at the ankle.
>> When are these muscles likely to be active? Work it out for yourself by watching your
feet as you walk around bare-footed...

b.

Lateral (peroneal) compartment

fibularis / peroneus longus
the
fibularis / peroneus brevis

- everts and plantarflexes ankle and helps support

arches during locomotion
- everts the foot

Determine the surface markings of these muscles and trace the course of their tendons. It is
easy to see them if your try to evert your foot against some resistance.

c.

Posterior (flexor) compartment

These muscles all flex (plantarflex) the ankle and toes. As the tendons pass to the foot, they
are held in place by flexor retinacula at the ankle.
This compartment is sub-divided into a superficial and a deep component.
Superficial:

triceps surae
= gastrocnemius
and soleus

- plantarflex ankle

Identify their surface markings and their common attachment to the calcaneal (Achilles)
tendon.
Deep:

tibialis posterior
flexor digitorum longus
flexor hallucis longus

- flex ankle, support arch

- flex toes
- flex big toe

These are important and powerful muscles that provide the force for pushing off from the
ankles and toes during walking running and jumping. The tendons of these muscles also are
important in storing a large amount of elastic energy which can be regained during the
rebound phase of running.
>> What are their functions during quiet standing?

48

4.

Intrinsic muscles of the foot

The intrinsic muscles of the foot are arranged in three functional groups, similar to those in the hand:
Thenar
Mesothenar
Hypothenar

(medial group for big toe)

(central group)
(lateral group for fifth digit)

They mostly act to change the shape of the foot, the positions of the toes, and some (eg the
lumbricals, quadratus plantae) also modify the actions of some extrinsic muscles.
These muscles form 4 main layers beneath the plantar aponeurosis
First layer:
(most superficial)

abductor hallucis
flexor digitorum brevis
abductor digiti minimi

Second layer:

quadratus plantae (= flexor accessorius)

lumbricals (four)

Third layer:

flexor hallucis brevis

adductor hallucis (oblique and transverse heads)
flexor digiti minimi brevis

Fourth layer:
(deepest)

interossei (4 dorsal = abduct, 3 plantar = adduct)

Identify these muscles on the prosected specimens and plastic models. Which of them can you see
working in your own feet?

5.

Motor innervation of the lower limb

The lower limb is innervated by nerves arising from the lumbosacral plexus.
Sciatic nerve -> muscles in posterior compartment of thigh eg hamstrings
-> branches
= tibial nerve -> posterior leg muscles
-> medial & lateral plantar nerves of foot
= common peroneal nerve
-> branches
= deep peroneal nerve -> anterior leg mm
= superficial peroneal nerve -> lateral leg mm
Femoral nerve -> muscles in anterior compartment of thigh eg quadriceps.
Obturator nerve -> muscles in medial compartment of thigh eg adductors.
(except......
femoral n -> pectineus, usually;
sciatic n
-> posterior part of adductor magnus)

49

6.

Summary of walking
When you take a step (leading with the right leg, in this example):
a

The gluteus medius and minimus muscles on the side supporting your weight (here, the left
side) contract.
They abduct the pelvis, raising it slightly on the opposite side (the right side, where the leg
is swinging forward).
They also medially rotate the pelvis, swinging the non-weight bearing (right) side forward.

The (right) leg that is stepping forward is flexed at the hip by the quadriceps and the
iliopsoas, and at the knee by the hamstrings. The ankle and toes are dorsiflexed by tibialis
anterior and the toe extensors to help stop them dragging along the ground.

The swinging (right) leg is rotated laterally by the deep muscles of the hip. This ensures
that the foot is facing forward in the direction of movement when it hits the ground.

Prior to heel strike, the hamstrings on the forward swinging (right) leg start to contract
eccentrically to slow the leg down.

At heelstrike, the ankle and toes are dorsiflexed and stabilised by the anterior muscles of
the shin. They contract eccentrically to control the transfer of weight from the heel to the
rest of the foot.

Weight is transferred to the leading (right) foot by contraction of the plantar flexors of the
weight-bearing (left) leg.

The quadriceps on the right side contracts eccentrically to stop the right knee flexing under
the newly applied body weight.

The hamstrings extend the hip on the leading (right) side.

... and the adductors on both sides contract to bring the body over the leading (right) foot.

Then the process is repeated on the other side as the (left) leg leads off. Got it? Try it for
yourself. Work out where the muscle groups are on your own legs, and then slowly walk
through the sequence while watching what is happening at your hips, knees, ankles and
toes... The whole sequence normally takes less than a second!

During steady walking and running, the legs develop considerable momentum as they swing forward. Much
of the activity of the leg muscles is to control these ballistic movements, generally using eccentric
contractions to oppose their "normal" actions. This is part of the reason why your muscles get tired and sore
after walking down hill.

50

Further Problems to Consider

>>

What are the consequences of common peroneal nerve injury (e.g. when the bumper of a car hits the
lateral aspect of the knee?)

>>

Sit on a chair with your back straight and your feet flat on the floor. Try to stand up without leaning
forward. What's going on?

>>

What structural deformation would lead to flat foot (pes planus)?

>>

Consider the consequences of not being able to invert and evert your feet in running, walking over
rough ground, skiing, surfing, playing tennis ......

>>

Why is flexor hallucis longus such a large muscle?

>>

We usually walk with our legs more-or-less straight when they are in contact with the ground, but
with our knees bent during ground contact when running. Why?

51

VERTEBRAL COLUMN AND MUSCLES OF THE TRUNK

The vertebral column is the flexible axis of the body and is composed of vertebrae, intervertebral discs and
ligaments.
1. Study the parts of a typical vertebra first and identify the following structures on it:
a.
b.
c.
d.
e.
f.

body
arch (pedicles and laminae)
spinous, transverse and articular processes
vertebral foramen
intervertebral foramina between two adjacent vertebrae
the articular surfaces

2. Look carefully at the articulated vertebral column

Identify the cervical, thoracic, lumbar, sacral and coccygeal regions of the vertebral column.
>> How many vertebrae are there in each region?
>> How do the vertebrae of each region differ?

The vertebral column has four curvatures in the sagittal plane:

Establish the two anterior convexities (lordosis) in the cervical and lumbar regions and the two
posterior convexities (kyphosis) in the thoracic and sacral regions.
You may also notice very slight lateral curvatures. If they are exaggerated with apparent
accompanying rotation, the deformity is termed scoliosis.

3. The atlas and the axis

Study the 1st (atlas) and 2nd (axis) vertebrae in detail. Since they take part in the formation of the occipitalvertebral joint, their structure is different from other cervical vertebrae.
a. On the atlas (C1) identify:
i. The anterior and posterior arch and the vertebral foramen.
ii. The lateral masses and articular surfaces. The atlas articulates with the occipital bone of
the skull through its superior articular facets and with the axis through the inferior facets.
iii. Transverse process and transverse foramen.
b. On the axis (C2) identify
i. The body and the dens (odontoid process which represents the detached body of the atlas).
ii. Spinous, articular and transverse processes and transverse foramen
iii. Arch and vertebral foramen.
4. Radiology
Identify all the above mentioned parts of the vertebrae on lateral and antero-posterior radiographs.
>> Can you see any other components of the vertebral column on radiographs?
52

5. Surface anatomy
Establish, on yourself or another student, which vertebrae can be readily palpated.
>> Which part of the vertebra is felt in each case?

6. Joints of the vertebral column

Except for the first two cervical vertebrae, the fused vertebrae of the sacrum and the coccyx, the vertebrae
articulate with each other via fibrocartilaginous joints (the intervertebral discs between the bodies) and
synovial joints (between the articular processes).

a. Fibrocartilaginous joints (intervertebral discs).

Hyaline cartilage covers the upper and lower surfaces of the vertebral bodies. Between these surfaces
identify the intervertebral disc. The disc is subjected to a combination of compression, bending and
torsional forces. It bears and distributes loads and restrains excessive movement. It has two
components:
i. The annulus fibrosus composed of fibrocartilage. Collagen fibre bundles in a crisscross
arrangement withstand high bending and torsional loads.
ii. The nucleus pulposus is a gelatinous mass located within the annulus fibrosus. It contains
hydrophilic glycosaminoglycans. The glycosaminoglycans content diminishes with age. The
nucleus pulposus acts hydrostatically to distribute pressure throughout the disc.
>> Measure your height first thing in the morning and last thing at night. Does your height
change during the day? If it has changed, what can you attribute this to?
>> Other than allowing movement, what other functions does the disc have?

b. Facet joints (apophysial joints)

Identify the joints between the superior articular facets of a vertebra and the inferior facets of the
adjacent superior vertebra. These are plane type synovial joints.

7. Ligaments of the vertebral column

Six ligaments reinforce the intervertebral joints.
On the wet specimens identify
i. the anterior longitudinal ligament, a dense band on the anterior surface of the vertebral bodies
extending from C2 to the sacrum.
ii. the posterior longitudinal ligament on the posterior surface of the vertebral bodies within the
vertebral canal from C2 to the sacrum.
iii. the ligamentum flavum, a thick elastic ligament which connects the lamina of adjacent
vertebrae.
iv. the interspinous ligament connecting the lower border of the spinous process of the vertebra
above with the upper border of the spinous process below.
v. the intertransverse ligament connecting the transverse processes of adjacent vertebrae.
53

vi. the supraspinous ligaments between the tips of adjacent vertebrae.

8. Movements of the vertebral column.

Limited movement occurs between the adjacent vertebrae. However, the compound effect of movement at
several intervertebral joints produces a large range of movement.
>> Determine the possible movements of the vertebral column on yourself or on another student and
list them.
>> Which part of the vertebral column is the most mobile?
>> How does movement in the thoracic region compare with that in the cervical and lumbar
regions? What structures promote and restrict movement in each region?

Tilting and rotation occur at the fibrocartilaginous joints. Compare the height of the disc in relation to its
anteroposterior and the mediolateral diameter in the cervical, thoracic and lumbar regions.
>> How does disc height relate to the amount of movement that can occur?
>> What happens to the disc during extension, flexion, lateral flexion and rotation?

Tilting and gliding occur at the facet joints. Note the orientation of the articular surfaces of these joints in the
cervical region the thoracic and lumbar regions.
>> What effect does the orientation of the facets have on movement?

>> How do the ligaments of the vertebral column influence its movements?
>> What effect do the articulations between the ribs and the vertebra have on the mobility of the
vertebral column?
>> How does the pelvis contribute to the range of movement of the spine?

9. The atlanto-occipital and atlanto-axial joints

The occipital bone, the first and the second cervical vertebrae move together as a multiaxial occipitovertebral joint with limited degree of movement.
a. Note the shape of the superior articular facets of the atlas and compare their shape with that of the
occipital condyles on the skull.
>> What sort of movement occurs at the atlanto-occipital joint?

b. The atlas articulates with the axis via two lateral (facet) joints and a median pivot joint between
the dens of the axis and the osteo-ligamentous ring formed by the arch of the atlas and a transverse
ligament.
c. Many ligaments contribute to stability of these joints.
i. the tectorial membrane between the body of the axis and the occipital bone is a
continuation of the posterior longitudinal ligament.
54

ii. the transverse ligament between the lateral masses of the atlas holds the dens of the axis
in place.
iii. the apical ligament extends from the tip of the dens to the occipital bone.
iv. The anterior atlanto-occipital ligament is an extension of the anterior longitudinal
ligament.
v. Alar ligaments between the dens and the occipital bone limit rotation.
>> At which of the above joints does nodding (flexion and extension) and lateral
flexion occur?
>> Where does rotation occur?

d. Movements at the atlanto-occipital and atlanto-axial joints are generated by a complex of small
deep muscles. They include:
i. rectus capitis posterior major and minor
ii. obliquus capitis superior and inferior
>> What do these muscles do?

10. Muscles which act on the vertebral column

As a rule the flexors are placed anteriorly, extensors and lateral flexors posteriorly, or laterally and the
rotators obliquely in relation to the vertebral column.
a. Flexors (prevertebral muscles) situated anterior to the vertebral column:
i. the longus colli (capitis and cervicis) in the cervical and upper thoracic regions;
ii. the psoas in the lumbar region.
iii. rectus abdominis of the abdomen.
This muscle extends between the xiphoid process and pubic tubercle. Along its course 3 or 4
tendinous intersections are present. These intersections extend across the entire thickness of
the muscle.
>> What importance do they play in the proper functioning of the muscle?
>> What is the function of the rectus sheath? Name the aponeuroses forming the anterior
and posterior walls of the rectus sheath. Note that the tendinous intersections of rectus
abdominis are firmly attached to the rectus sheath. Determine the location of the arcuate line
(of Douglas) and the linea alba.

b. Extensors (postvertebral muscles) situated posterior to the vertebral column:

i. superficial muscles:
- splenius capitis and cervicis.
Note these muscles are deep to the extrinsic muscles, trapezius, latissimus dorsi,
levator scapulae and the rhomboids which move the upper limb. The upper fibres of
trapezius assist in extension of the vertebral column.
55

ii. intermediate muscles:

- bands of muscles, the sacrospinalis or erector spinae, extending from the pelvis to the
skull. (You do not need to learn the names of the individual bands).
iii. deep muscles:
- semispinalis
extending from T10 to the occipital bone
- rotatores
running from transverse process of a vertebra to the base of the spinous process of
the vertebra above.
iv. quadratus lumborum
extending from the 12th rib to the iliac crest and the iliolumbar ligament.

c. Lateral flexors and rotators:

Rotation is usually combined with some degree of lateral flexion.
i. the extensor muscles acting unilaterally
ii. multifidius in the groove on each side of the spinous processes extending from the sacrum to the
axis
iii. external oblique and internal oblique muscles of the anterior abdominal wall.
Notice the origin and the course of the muscle fibres in each of these muscles. They insert
into the aponeurosis of the muscle which forms the linea alba in the mid line. (The third and
deepest abdominal muscle, transversus abdominis, is not involve in movement of the
vertebral column but assists in supporting the loaded spine when lifting heavy objects.)
iv. The intercostal muscles contribute to rotation.

11. Nerve supply to muscles acting on the vertebral column

a. Postvertebral muscles are supplied by the dorsal rami of the corresponding segmental nerves.
Each muscle (because they are long, flat substantial muscles) has a multisegmental nerve supply.
b. Abdominal muscles are supplied by intercostal nerves 7 to 12, the ilioinguinal and the
iliohypogastric nerves.
c. Quadratus lumborum is supplied by the 12th intercostal and first lumbar nerves.

12. Inguinal canal

Study the boundary of the canal, its anterior and posterior walls, roof, and floor and finally the position of the
superficial and deep inguinal rings.
Anterior wall - aponeurosis of external oblique.
Superior wall - lower margin of internal oblique.
Posterior wall - transversalis fascia
Inferior wall - inguinal ligament
>> How long is the canal?
>> What are the contents of the inguinal canal in the female and in the male?
56

Problems to Consider:
>> Why do fractures of the spine most commonly involve T12, L1 and L2.
>> Dislocation or fracture of cervical vertebrae frequently occur in motor-car or aeroplane crashes - why?
What are the consequences of such injuries?
>> The annulus fibrosus may rupture most commonly at L1 - L5, allowing the nucleus pulposus to protrude
posteriorly into the vertebral canal (prolapsed intervertebral disc). What symptoms might this condition
cause?
>> What is the function of the muscles of the back when you are standing?
>> Compare the mechanisms of direct and indirect inguinal hernia.
>> What implications does the arrangement of the fibres of the external oblique, the internal oblique and the
tranversus abdominis and the structure of the rectus sheath have for abdominal surgery?
>> Why do you hold your breath when you lift a heavy load?

Reminder
Many of the muscles you have looked at today and in previous classes (including practical sessions last
year!) are involved in respiration.
inspiration
diaphragm
pectoralis major
erector spinae
quadratus lumborum
sternocleidomastoid
scalenes
intercostals
rotatores

expiration
abdominal muscles
intercostals

>> How do each of these muscles contribute to respiratory movements?

57

CARTILAGE

a specialised form of connective tissue

comprised of "chondrocytes" which synthesise an amorphous, firm gel-like matrix.

1.

Properties
*
*
*
*
*

2.

3.

high tensile strength

resilience and elasticity
avascular and aneuronal
capacity for continued rapid growth
poor regenerative abilities

Types of cartilage
Hyaline cartilage:

nose, larynx, trachea

ventral ends of the ribs
articular surfaces of synovial joints
"model" for most developing bones

Elastic cartilage:

ears, external auditory canal

epiglottis
parts of the larynx

Fibrocartilage:

intervertebral discs
pubic symphysis
lining of tendon grooves
attachments of some tendons to bones
intra-articular discs
Eustachian tube

Embryology
- origins from

* neural crest
* sclerotome
* lateral plate mesoderm

- two types of cartilage growth:

* interstitial growth (most of matrix)
* appositional growth (perichondrium)

58

4.

Matrix composition
Hyaline cartilage:

Elastic cartilage:

Fibrocartilage:

type II collagen embedded

glycosaminoglycan matrix

in

highly

hydrated

basophilic matrix around chondrocytes

similar to hyaline cartilage but penetrated by meshwork of

elastin

transitional between cartilage and dense connective tissue

*

sparse matrix with large bundles of type I collagen

acidophilic

always in association with other connective tissues

no true perichondrium

59

BONE AND BONE FORMATION

Bone is a specialised connective tissue, its main distinguishable feature is that the interstitial part contains
inorganic components in the form of calcium hydroxyapatite crystal deposition.
The outer and inner surfaces of the bone are covered with periosteum and endosteum, respectively, which
contain blood vessels, nerves, and cells capable of making and remodelling bone.
Composition:

i.

ii.
iii.
iv.
Structure:

cells:

osteocytes, maintain the bone

osteoblasts, form new bone, some resorption
osteoclasts, resorb bone during remodelling
connective tissue fibres, mostly collagen, provide elastic strength
amorphous ground substance, mostly glycosaminoglycans
inorganic components, mostly crystalline calcium hydroxyapatite

The histological and functional unit of most bone tissue is the Haversian system ( = osteon).
The centre of the unit is the Haversian canal which accommodates blood vessels and some
nerves and is surrounded by concentrically arranged lamellae of bone matrix. The alternating
orientation of collagen fibres in concentric lamellae gives much of the elastic strength to
bone. The osteocytes sit within spaces (lacunae) in the matrix. Osteocytes communicate
with each other via thin processes and gap junctions which lie in tiny canals running more or
less radially through the matrix (canaliculi).
In living bone, there is a continuous formation and reformation of the Haversian systems.
This process, known as remodelling, also is important in fracture healing, when the callus
formed in the initial stages of healing is remodelled to mature bone.

Bone formation is commonly described as being as intramembranous or endochondral, but really the bone
formation process itself is the same in each case. The difference is that intramembranous ossification starts
directly from connective tissue, whereas in endochondral ossification the bone forms from a cartilage model
precursor.
In both cases, osteoprogenitor cells differentiate into osteoblasts and lay down a dense meshwork of
connective tissues fibres containing mostly collagen, known as osteoid, to form a woven bone precursor. The
osteoid becomes mineralised (primary spongiosa), but it is still not proper bone. Osteoclasts begin to resorb
the osteoid as it is remodelled into new bone by osteoblasts and osteocytes.
In endochondral ossification, this process happens first in a region around the shaft of a long bone, for
example, followed by the ends (epiphyses) as the cartilage model becomes invaded by blood vessels. The
cartilage calcifies and breaks down, as osteoid is laid down around it. This osteoid then develops into bone.
The epiphyseal plate persists as a specialised region of cartilage formation and subsequent ossification that
allows the bones to continue to grow longitudinally whilst in use. The shaft of the bone increases in thickness
by appositional growth from cells in the periosteum.
The mechanism of bone healing and fracture repair is similar to normal remodelling and growth. Around
the site of damage osteoblasts proliferate and make a callus of woven bone that is ossified and remodelled,
initially as trabeculae, but eventually as compact bone following the lines of maximum loading.

60

The balance between bone formation and resorption in remodelling is determined by many factors,
including:
Parathyroid hormone (PTH):
decreased blood calcium -> increased PTH secretion from parathyroid glands -> activation
of receptors on osteoblasts, which then release osteoclast stimulation factor -> increased
resorptive activity of osteoclasts -> calcium returned to blood.
NB: PTH also increases blood calcium by
- increasing calcium resorption from glomerular filtrate in proximal tubules of
kidney;
- increasing formation of metabolite of vitamin D (calcitriol) -> increased absorption
of calcium from the small intestine.
Calcitonin:
high blood calcium -> release of calcitonin from C-cells of thyroid -> activation of receptors
on osteoclasts -> decreased bone resorption.
Vitamin D:
deficiency -> excessive production of osteoid compared with mineralised matrix -> rickets in
children, osteomalacia in adults.
Growth hormone:
increase -> growth of epiphyseal plates; excess -> acromegaly; deficiency -> dwarfism.
Oestrogens, androgens:
receptors on osteoblasts increase bone formation compared with resorption; contribute to
closure of epiphyseal plates during puberty; excess in childhood / early puberty may ->
precocious sexual maturity accompanied by dwarfism.
Vitamin C:
decrease -> decreased ability to produce and maintain connective tissue matrix -> deficient
collagen production -> deficient bone matrix -> scurvy.
Vitamin A:
- decrease -> slowed rate of growth and remodelling;
- increase -> loss of cartilage production -> early obliteration of epiphyseal plates.
Thyroid hormone:
increase -> increased collagen turnover -> increase in osteoid and bone resorption.

****

A really important factor in increasing bone formation and decreasing resorption is mechanical
loading, although the underlying mechanisms still are not well understood. The loading can come
either from forces applied directly to the bone, as in weight bearing, or more indirectly, by the load
exerted on the bones by the muscles attaching to them.

****

Over the last few years, there have been great advances made in understanding the molecular
interactions regulating bone metabolism, including the control of differentiation of osteoblasts and
61

osteocytes, as well as the regulation of the mineralisation processes. As a result of this research,
there are likely to be a whole new range of therapeutic strategies to deal with metabolic bone disease.

HISTOLOGY OF BONE TISSUE

On the following histological slides identify the cellular (osteocytes, osteoblasts, osteoclasts) and
extracellular (lamellae) components of bone tissue. Notice the three dimensional arrangement of the
elements in a long bone in relation to the Haversian (running longitudinally) and Volkmann's (right angles to
its long axis) canals. Determine the position of the periosteum and endosteum. From your observations,
complete the following table:
Osteoblast

Osteocyte

Osteoclast

Position
Shape
Size
Distinguishable
Character
Staining reaction
Relative frequency

Slide 5A: Decalcified bone, transverse section (Pig fibula; H & E)

Identify the Haversian canals and the lamellae arranged concentrically around them. Relate the position of
osteocytes to the Haversian canal and the lamellae.
>> Where is the periosteum? What does it contain?
>> How are lamellae arranged beneath the periosteum?
>> How do oxygen and nutrients reach the osteocytes in compact bone?
>> Is collagen present in bone? How could you demonstrate the presence of collagen?
>> Where would you expect most of the inorganic components of bone to be deposited?

62

Slide 8A: Ground bone, transverse section (unstained)

>> What component/s of the bone tissue can you see now?
>> Are all the Haversian systems (osteons) complete?
incomplete?

If not, what has happened to those that are

Skull, transverse section

Slide 6A:
Slide 18:

Sheep, H & E
Cat, H & E

>> How are the lamellae arranged?

Examine carefully the relations between the collagen and bone tissue in the suture included in the section on
slide 6A.

Developing membrane bone

Slide 7A:
Slide 17:

Fetal skull, H & E

Young cat skull, Masson trichrome

Identify osteoblasts, osteocytes and osteoclasts.

>> Where can you find osteoclasts most frequently? Why?
>> How does growth in size of a membrane bone take place?

Slide 9A: Developing long bone (H & E)

Look first at the cartilage adjacent to the area of new bone formation.
Make a labelled sketch to illustrate the principal characteristics of cartilage in this zone.
>> What elements preserve the structural continuity between bone and cartilage?
Spicules of calcifying matrix are arranged between the rows of cartilage cells.
>> How are osteoblasts and osteoclasts distributed around the spicules?
Compare the mechanisms of membranous and chondrogenic bone formation.
During the practical class the ultrastructure of bone will also be demonstrated.

63

Questions to consider
>> What is the function of collagen in bone?
>> What are the similarities and differences in bone
formation
resorption
remodelling?
>> How do stress and weightless conditions influence the fine structure of the bone?
>> What is the rate of bone turnover
under normal conditions
osteoporosis
osteomalacia?

64

information for examinations

In 2013, we will assess MSS in the same way as the last several years, to take full advantage of the pass-fail
environment and to make the assessment of MSS as simple as possible for staff and students alike. Our aim
is to create a less threatening exam environment, so you can concentrate on learning what you really have to
know, while still giving us a chance to find if you do actually know it (that is our responsibility to the
profession!) and if you can apply that knowledge in a meaningful way.
You need to accept two important things about exams - they are stressful, and, if you know your work, you
will never have enough time to answer the questions in the way you would ideally like. As such, exams test
your ability to access and apply your knowledge under conditions that are largely outside your control. This
is a very good model for real life! There will be very many occasions when you must provide information
accurately and in the appropriate context and detail, perhaps whilst being seriously stressed out. Job
interviews... explaining a medical condition to an emotional patient... presenting a case report for your
colleagues or for publication... and so on... So, stressed out? Not enough time? Better start getting used to it!!

The written exam

It should be obvious from looking at previous exam papers that we usually test pretty much the same core
knowledge base each year. The questions cover material that comes straight out of the learning objectives of
the cases with an emphasis that matches that given in the lectures, pracs etc... The questions are introduced
by mini-cases similar to those we have used from week to week of the course. Some of the mini-cases may
be based upon presentation of conditions that may not have been covered explicitly in the course. However,
all the new information you need to answer the questions is provided in the exam - this means that with a bit
of luck, you might even learn something in the exam...
For each case there will be a more-or-less generic set of questions for you to consider, along the lines of:
what is going on?
how do you know?
what mechanisms underlie the pathophysiology?
what might you do about it?
what is the likely outcome?
It is possible that one or more of the weekly minicases might turn up in some form on the exam... if you
think you recognise one, be careful: the presentation may have been changed to suit the exam format. So
don't think that learning the answers to the minicases off rote is a short cut to instant exam success.
As in previous years, we will determine if you pass or fail the exam by the number of questions you pass.
The exam will have 10 equally-weighted questions; you will need to pass 7 of them to pass the exam. Each
questions is marked according to a three-point scale as follows:
A = a clear pass, given the exam conditions
B = borderline
C = clearly unsatisfactory
A clear pass means that you have effectively got the answer completely right: youve covered everything
and have not made any mistakes. Just getting half of the key items is not enough. You cannot compensate a
bad failing question by doing really well on another. A borderline answer might be one that is incomplete (ie
no mistakes but not answering everything) or one that contains a mixture of correct and incorrect statements.
A failing answer is one the has not provided the core information required, either by leaving this material out
or by getting it wrong.
Any papers that are near the borderline will be checked again and any questions on these papers that had
been scored at borderline level will be remarked so that a decision will be forced as to whether the answer
passed or failed. Then the number of passed and failed questions will be tallied up to confirm an overall pass
65

or fail for the paper. If you clearly pass the paper overall, any borderline grades are not rechecked. This
process works very well and is very efficient. There is no evidence at all to believe that anyone has been or
will be disadvantaged by this marking method.
If this seems tough, it is, in the sense that the pass criterion is set high. But hundreds of students have done
really well on this exam over recent years and there is no reason to expect you cannot join them! This level
of knowledge reflects what clinicians expect of you in third year.

The practical exam

This is the second part of your anatomy assessment, making up 67% of the total marks for this part of KHI.
The MSS component is a straightforward structure-recognition exam: ie. what is it? what does it do? where
does it go? what attaches to it? etc etc . There also will be neuroanatomy in the exam and perhaps some
questions from material studied earlier in the year
The preparations are the usual ones we use for teaching, and include prosections, pots, dry bones,
radiographs etc. We do not have a special set of exam specimens!
You will need to get 65% overall to pass the anatomy practical component of KHI. Previous years results
have shown that this score represents the minimum level of competence you require in functional anatomy,
especially for MSS. Any papers near the borderline will be remarked.
You may be reassured that generations of students before you have worried themselves half to death about
the prac exam, but usually have done extremely well at it.
The details of the prac exam organisation will be given to you closer to the time...

66

FLINDERS UNIVERSITY ADELAIDE AUSTRALIA

SCHOOL OF MEDICINE

AUGUST EXAMINATIONS 2012

SECOND YEAR BMBS

MMED8203 KNOWLEDGE OF HEALTH & ILLNESS

MUSCULOSKELETAL SYSTEM
[ with sample answers & exam feedback ]

TIME: 1 hour and 30 minutes (90 minutes)

MATERIALS ALLOWED IN THE EXAMINATION ROOM:

None

INSTRUCTIONS TO CANDIDATES:
1.

Write your student number on each examination booklet.

2.

Start answers to each question on a new page.

MARKING SCHEME:

Each question will be marked to a pass/fail set of criteria.

To pass the exam, you must pass seven (7) of the ten (10) questions.

All questions are weighted equally.

You are encouraged to make use of diagrams in your answers.

GENERAL COMMENTS ON EXAM:

This exam was done really well by the class!! 10% of the class got full marks
(ie no errors and no omissions for every answer). Another 36% made only
one or two small errors. Overall around 72% of the class achieved 7 clear
passes out of 10. Hooray!!
67

While chasing goannas on a Rural Medical Students Society Big Bush Bash Fund Raiser
Weekend, Shane OConnor, aged 24, steps in a rabbit burrow and falls forward
awkwardly, severely hyperextending his knee. Subsequent testing of his knee indicates
an anterior drawer sign, and abnormal instability in response to attempted abduction of
the knee.
Question 1.
What factors contribute to the stability of the knee during running?
How do they contrast with factors supporting the knee in quiet standing?
What has been damaged in this accident? How do you know?
Once the knee has been repaired, what could Shane do to build up strength in his knee?

(9 mins)
Answer: [Source = Peter Latimer PBL; minicase]
Stability in running due mainly to muscles crossing the joint: quadriceps most important; lateral
support by tensor fascia lata; medial by gracilis & sartorius; [possible help from hamstrings,
gastrocnemius]. Ligaments (cruciates, collaterals) keep knee tracking properly during flexion /
extension; prevent ab/adduction.
Quiet standing => almost entirely due to ligaments, especially ACL limiting extension [ Centre of
Gravity in front of knee => helps lock it in extension; also helped by medial rotation of femur on
tibia].
Anterior drawer sign => rupture of ACL.
Instability to abduction => ruptured medial (tibial) collateral ligament. [ real possibility of concurrent
medial meniscus tear = unhappy triad ... ]
Post-repair, non-weight bearing exercise builds up muscles crossing knee joint [especially quadriceps
] ; strap knee; refrain from risky activity...
Comment: [97% passed, 89% got full marks]
Very well done. Some people missed the possibility of a ruptured medial collateral ligament, but if you
had already defined its function, you got the points ... (going a bit easy on the first question...).
----------------------------------------------

Meanwhile, back in the bar of the Shearers Arms hotel, the publicans wife, Lorna
Frankenburg, aged 71, is telling anyone who will listen that her back hurts most of the
time and that nothin much seems to help the pain... She appears somewhat overweight and very round-shouldered, consistent with moderate osteoporotic degeneration
of her vertebrae.
Question 2. [Source: Eva Kominski, Matt Tonetti PBL cases; minicase]
Briefly discuss the pathogenesis of osteoporosis, especially in aging women.
What are the most likely sources of Mrs Frankenburgs back pain?
What treatments are available for her at this stage?

(9 mins)
Answer:
Main factor => OP = age-related (post-menopausal) decreased oestrogen production.
Oestrogen promotes bone formation by facilitation osteoblast activity and inhibiting osteoclast activity
(reduces generation and proliferation of OCs; promote apoptosis of OCs via differential expression of
OPG / RANKL). Decreased oestrogen => gradual shift on balance to osteoclasts over osteoblasts.
Also:
> decreased exercise => reduced stimulus to maintain bone density
68

> possible decreased Vitamin D intake (lack of sun, reduced dietary intake, reduced intestinal
absorption) => reduced Ca levels (reduced intestinal uptake, reduced renal resorption) => increased
PTH => increased bone resorption (increased osteoclast activity via action on osteoblasts).
Back pain => fractured / collapsed vertebral bodies (consistent with round-shouldered appearance)
=> direct pain, potential pressure / inflammation on spinal nerves.
Treatments => bisphosphonates most likely to be useful; supplement with Ca and PTH supplements;
check Vitamin D levels in diet / sun exposure. Reduce weight would help. Shes probably too old for
realistic effects of increased exercise or HRT.
Comment: [96% passed, 83% got full marks]
Very well done. Nearly everyone got this. although some of you didnt really get much detail in about
the mechanisms of OP...
----------------------------------------------

You old Misery Guts, Lorna! shouts bar regular Miss Gloria MacWilliams, aged 63. You
want some pain? You can have my fingers and toes any morning you like!
Casual observation reveals that Miss MacWilliams hands are badly deformed, with her
knuckles prominent and her fingers shortened, as seen in rheumatoid arthritis. She has
trouble holding her sherry glass.
Question 3. [Source: Mary ORiordan PBL; minicases]
How does rheumatoid arthritis lead to deformation of the digits?
Assuming her toes are affected in a similar way to her hands, what structural changes would you
expect to see on a plain radiograph of Miss MacWilliams feet?
What are the main sources of pain associated with this degree of damage from rheumatoid arthritis?
How can the pain be treated?

(9 mins)
Answer:
RA => autoimmune-induced synovial inflammation => hypertrophied pannus => digit deformation
via erosion of articular cartilage, joint capsule damage, inflammatory destruction of ligaments /
tendon attachments, peri / subchondral bone erosion => subluxation, abnormal deviation.
X-ray => reduced joint space in metatarsophalangeal joints, subchondral sclerosis of distal
metatarsals, erosion of perichondral bone at MTP joints, osteopaenia, subluxation of MTP joints,
possible loss of joint spaces between tarsal bones.
Pain => from inflammation of joint and surrounding soft-tissues, subluxed / eroded joints => bone
on bone.
Treat with anti-inflammatories (NSAIDs) and DMARDs, (eg methotrexate, TNFa antagonists) to
reduce primary cause and inflammatory pain. Standard analgesics (paracetamol) should help.
Comment: [99% passed, 93% got full marks]
Excellent answers overall. Most of you got all of this.
----------------------------------------------

The publican, Miles Frankenburg, aged 68, walks with the aid of a stick, carved from local
mulga wood. He explains that he has arthritis in his right hip and that hes looking
forward to having a replacement operation. The affected hip is in constant pain and his
mobility is significantly compromised. Although the pain gets worse after activity, even
quiet standing causes him pain.

69

Question 4.
Briefly discuss the factors that limit the mobility of the hip joint in healthy individuals.
How would his arthritis, presumably osteoarthritis, further limit his hip mobility?

(9 mins)
Answer: [Source: Eva Kominski PBL; Peter Latimer PBL]
Limiting factors =>
: shape of joint (deep ball and socket between head of femur and acetabulum, further
deepened by acetabular labrum);
: tight joint capsule; strong reinforcing ligaments (iliofemoral limits extension);
: shapes of bones (greater trochanter limits abduction, overcome by lateral rotation);
: rest of body (eg adduction, flexion with flexed knees);
: limits of muscle stretch (eg hamstrings can limit flexion when knees extended).
OA => at first, not much pain, but possible roughness / grinding in joint; further damage to articular
cartilage => pain on movement especially once eroded to subchondral bone; later osteophyte
formation, bone erosions => physical limits to movement. More advanced OA => secondary joint
inflammation => increase pain => less inclined to move.
Comment: [100% passed, 83% got full marks]
Another excellent set of answers some of you gave a list of all the muscles crossing the joint, which
wasnt really enough... only some of them really limit the movements of the hip joint, even though
they obviously affect / control all movements of the joint.
----------------------------------------------

Alex Giacometti, aged 32, is the town mechanic. He takes great delight in telling the
students about his accident several years ago, when an angle grinder sliced into his
forearm. There is a large scar on the anterior aspect of his forearm. According to Alex, the
surgeons repaired his injuries and he feels as strong as ever. However, he admits that he
cant feel much in his thumb and hes pretty clumsy, even before I have a few beers...
Question 5.
How do the forearm muscles contribute to movements of the wrist and fingers?
How can Alex retain grip strength, yet experience clumsiness and impaired sensation in his hand?
What are his chances of regaining fully normal function of his hand? Why?

(9 mins)
Answer: [Source: Mary ORiordan PBL; minicases]
Wrist => two extensors and two flexors (each on radial and ulnar sides); flexor and extensor on
radial side => radial deviation; similarly on ulnar side; wrist extensors stabilise wrist angle in power
grip. [ wrist also pronates / supinates via pronator quadratus / teres & supinator / biceps brachii ]
Fingers => fl dig. sup to middle phalanx => precision movements (at MCP & PIP joints); fl. dig. prof
to distal phalanx => precision & power grips (at MCP, PIP, DIP joints); ext dig => extension at all
joints (MCP, PIP, DIP). Additional extensor each for index and little fingers.
The injury probably cut the median nerve => loss of sensation to thumb and first two fingers; also
loss of motor innervation to thenar muscles (loss of fine control of thumb position) and 1st two
lumbricals (loss of fine control of index and middle finger). The innervation of fl dig prof (for power
grip) is from more proximal median n + ulnar n (for digits 4 & 5). Low capability for nerve
regeneration => not much chance of further recovery.
Comment: [88% passed, 52% got full marks]
Most of you got the muscles and their actions. A lot of you got on the track for the nerve injury but
got lost along the way. The presentation is very similar to that of carpal tunnel syndrome in the Mary
ORiordan PBL case: damage to the median nerve in the distal forearm / wrist region. Its possible that
70

the distal ulnar nerve also could have been damaged as well as the median nerve: this would lead to
loss of function and sensation for all intrinsic muscles without affecting power generated by the
superficial and deep finger flexors.
If you didnt get that median nerve injury was distal and got both the motor innervation of the thenar
muscles / 1st two lumbricals as well as the sensory innervation to the thumb / index finger / middle
finger, you didnt get full marks (but plenty of people did!).
----------------------------------------------

As part of the fund-raising activities, 2nd year student, Ronnie Stevenson-Hart, aged 28,
tries to ride a bull. He is quickly thrown off, lands heavily on his forearm, and badly
fractures his distal radius. He is taken to the local hospital where his forearm is set in
plaster. External fixation is deemed not necessary.
Question 6.
Discuss the usual mechanism of bone fracture healing.
How long will Ronnie probably need to have his forearm in plaster?
What possible complications can follow a bone fracture?
What risks are associated with external fixation?

(9 mins)
Answer: [Source: Mary ORiordan PBL; minicases]
After the fracture, the bone bleeds and a fibrin clot forms => cleaned up by macrophages => callus
=> proliferation of osteoprogenitor / osteoblast cells (plus maybe some chondroprogentitors /
chondroblasts) => osteoid => initial mineralisation (woven bone) => remodelling (via coordinated
osteoclast / osteoblast activity).
Healing usually takes about 6 weeks for a simple fracture. (8-12 for more complex).
Complications include avascular necrosis, malunion, entrapment of nearby nerves, infection,
misalignment, nerves compressed by cast, concurrent medication (eg steroids).
Risks of external fixation => infection (also malunion can still occur... especially if device is knocked
out of alignment).
Comment: [100% passed, 70% got full marks]
Very well done overall. It seems that some of you dont know what external fixation is: it is a kind
of metal brace with pins screwed into the bones to hold them in place. It is not a cast and pressure
on nerves or blood vessels, as some of you said, is not a high risk... If you didnt get infection /
osteomyelitis as a risk, you didnt get full marks.
----------------------------------------------

In preparation for the Saturday night barbecue in the hotel carpark, the local butcher and
former State champion cricketer, Janice Wilkie, aged 41, is unloading sides of lamb from
her van, when she feels a sudden sharp pain in her lower back. The pain is exacerbated
by leaning to one side, and is accompanied by pins and needles down her lower limb but
it is relieved to some degree if she leans to the opposite side.
Question 7.
Discuss the factors that provide a combination of strength and mobility to the lower back.
What injury is Ms Wilkie most likely to have suffered? Could she have avoided it? Explain.

(9 mins)
Answer: [Source: Matt Tonetti PBL; minicases]
Strength = ligaments (especially anterior / posterior longitudinal ligs); limited mobility at most
71

intervertebral joints (tight joint capsules, strong short ligaments); large intervertebral disks =>
considerable shock absorbing; muscles of back => eccentric support (esp. erector spinae, quadratus
lumborum, psoas); abdominal muscles => direct support (+ indirect support via increased intraabdominal pressure); lumbo-sacral / thoraco-lumbar fasciae.
Mobility => small intervertebral movements add up to large overall movement; more movement at
lumbar levels due to size / orientation of spines; large intervertebral disks. Lumbar facets => large
and mostly sagittal => flexion / extension; some rotation); back and abdominal muscles => support
and mobility.
Injury => prolapsed disc (unilateral pain, relieved by leaning to one side) => pressure on spinal
nerve (pins & needles).
Potentially avoid injury by good lifting technique, build up muscle strength in back / abdominals.
Comment: [98% passed, 82% got full marks]
Very well done overall. Just about everyone got the disk injury.
----------------------------------------------

Late on Saturday night, a fight breaks out between some female students. The fight ends
abruptly when Tina Chieu, aged 22, screams and drops to the floor with blood streaming
from her cheek. She has a deep jagged slash across the side of her face, apparently
inflicted by a broken glass wielded by class-mate, Stephanie Gribner. Tina is taken to the
local hospital and her wound is stitched up. It heals well, but several weeks later,
sensation in her cheek and movements of her facial muscles remain impaired.
Question 8.
What persistent damage has Tina most probably sustained? Explain.
What are the long-term functional consequences of these injuries?
What are her chances of regaining full function?

(9 mins)
Answer: [Source: Justin Mills PBL; minicases]
Damage = severed trigeminal nerve (V2, maxillary n., infraorbital n.) => impaired sensation in cheek;
severed branches of facial nerve (VII, most probably zygomatic and buccal branches) => impaired
movement of facial muscles.
Impaired sensation => nothing too major; loss of nociception may lead to unnoticed injuries, some
possibility of neuropathic pain syndromes developing.
Impaired facial muscles => loss of cheek / lip motility => difficulties in eating (eg dribbling lost
orbicularis oris; moving food out of cheek region (lost buccinator; => increased risk for tooth decay);
potential speech impediment (lost orbicularis oris).
Relatively low chances of functional recovery; some neural regrowth may be possible but if none until
now, then further growth is unlikely.
Comment: [95% passed, 52% got full marks]
Just about everyone got the facial nerve injury and its consequences. Some of you twigged to the
possibility that only some branches would be affected, but if you gave a complete list, you still got the
marks.
However, to get full marks, you also had to identify the loss of sensation as an injury to the
trigeminal nerve. There is no sensory innervation of the face by the facial nerve; similarly a lesion of
its superficial branches will not affect sensation from the tongue (that pathway is via the chorda
72

tympani to the lingual nerve.) A lot of you missed this.

----------------------------------------------

One of Tinas former boyfriends, Sam Dimic, aged 32, a 3rd year student and former
competitive weight-lifter, grabs Stephanie and pushes her into a chair. As he does so, he
feels a sharp pain in his shoulder. After things settle down, Sam reports that his shoulder
hurts when he tries to internally or laterally rotate his humerus against resistance.
Question 9.
Briefly discuss the factors leading to the combination of strength and mobility in the shoulder.
Based on Sams report, what injury is he most likely to have sustained?
How could he have done it?

(9 mins)
Answer: [Source: Amanda Bridges PBL]
Mobility => shallow glenohumeral (ball & socket joint); loose joint capsule; mobile scapula (eg
additional 60 degrees abduction cf glenohumeral joint alone): full range of movement requires
movement of scapula.
Strength mostly from muscles, eg rotator cuff at glenohumeral joint; trapezius & serratus anterior for
scapula in abduction; (rhomboids, pectoralis minor for stabilizing scapula against body wall; trapezius
+ rhomboids => strength in retraction of shoulder, eg pulling against resistance)
Injury most likely = rotator cuff tear, hurts with both concentric & eccentric contraction. Deltoid
(anterior or posterior fibres) also is a real possibility. Some possibility of pec major tear near
attachment to humerus.
Pushing action => more likely to be subscapularis (+/- anterior deltoid, => medial / internal
rotation), but pain on external / lateral rotation against resistance => infraspinatus (+/- posterior
deltoid torn during eccentric contraction in pushing action...)
Comment: [90% passed, 61% got full marks]
Done quite well overall, although many of you missed the most likely source of the injury. Several of
you suggested that the shoulder was dislocated. This is not likely from the presentation if there had
been dislocation, there would be some kind of obvious shoulder deformation and rotation movements
would have been almost impossible, not just painful. The sudden onset of the pain tends to rule out
chronic bursitis, as some people suggested.
----------------------------------------------

The publican, Mr Frankenburg, calls in the local police to take control of the fighting
students, despite calls from some locals for the action to continue. As he bounds up the
steps to the hotel verandah, Constable Wilson, aged 43, trips and badly sprains his ankle.
As he gets up, he complains loudly about the poor design of the hotel steps, his boots and
his feet...
Question 10.
What features normally provide strength and stability to the ankles and feet?
How are the impact forces during walking and running absorbed by the ankles and feet?

(9 mins)
Answer: [Source: Peter Latimer PBL; minicases]
Strength in ankles => wide part of talus tight in talocrural joint when dorsiflexed; strong collateral
ligaments at talocrural joint; dynamic support by muscles crossing joint, eg tibialis ant & post;
fibularis longus & brevis. Also strong ligaments bind and support tarsal bones.
73

Strength of feet => ligaments binding adjacent tarsal / metatarsal bones; support for arches via
plantar aponeurosis & long plantar ligaments. Spring ligament => support for longitudinal arch (+
sustentaculum tali on calcaneus to support talus). Shapes of bones (eg cuboids, proximal
metatarsals) => support to transverse arch; muscles => dynamic support to arches during activity
(eg tibialis anterior & posterior; fibularis longus & brevis).
Impact forces absorbed mainly eccentric contractions of extrinsic muscles (tibialis ant & post; fibularis
longus / brevis) as well as gastrocnemius and toe flexors (fl hallucis longus; fl digitorum longus)
when landing on toes. Ligaments between tarsal bones also important during all types of weight
bearing.
Comment: [91% passed, 76% got full marks]
Well done overall: most of you got the combination of ligaments, bone shapes (arches) and dynamic
support from the various groups of leg muscles; if you didnt you didnt get the full marks.

************************************
END OF EXAMINATION

74

FLINDERS UNIVERSITY ADELAIDE AUSTRALIA

SCHOOL OF MEDICINE

AUGUST EXAMINATIONS 2011

SECOND YEAR BMBS

MMED8202 INTRODUCTION TO CLINICAL PERFORMANCE

MUSCULOSKELETAL SYSTEM
{ with sample answers }
TIME: 1 hour and 30 minutes (90 minutes)

MARKING SCHEME:

Each question will be marked to a pass/fail set of criteria.

To pass the exam, you must pass seven (7) of the ten (10) questions.

All questions are weighted equally.

OVERALL COMMENTS ON RESULTS:

The class did very well on the written exam this year. As in 2010, you had to get the answer to a
question pretty much completely right to get a clear pass on it. Most people achieved clear passes
most questions, thereby easily passing the exam overall. This is a great outcome!
Nevertheless, the questions on the ankle and hands were not so well done: although few of you
failed these questions outright, not many got clear passes either...
The prac exam was done very well overall, with a class average of 65/80.
Nine of you got Gold Stars: effectively full marks for the exam = 10/10 on the written exam and >
70/80 for the prac. Well done! Another big bunch made up the peloton, not far behind...
See comments on individual questions for more info...

75

Bob The Brat Ng crashes his high-performance motorcycle during his first heat in the
Black Buffalo Extreme Sports Showdown leading to severe dislocation of his talo-crural
joint and a spiral fracture of his distal fibula. Also, his medial malleolus is avulsed. As part
of his treatment, his fibula is pinned and his leg is placed in cast.
Question 1.
What features normally contribute to the stability and strength of the talo-crural joint?
How do other joints in the ankle contribute to overall mobility of the foot?
What potential risk does the leg cast pose for the future stability of his ankle?

(9 mins)
Source: Week 5 minicases / main pracs
Answer:
Talo-crural joint stability = strong collateral ligaments limit ab/adduction. Joint more stable in dorsiflexion when wider anterior part of talus is tightly held by medial and lateral malleoli (tibia and fibula).
Additional stability by muscles crossing joint eg soleus / tibialis anterior control anterior / posterior
sway during standing.
Other joints: subtalar joint (talus -> calcaneus) => inversion / eversion (inversion by tibialis anterior
/ posterior; eversion by fibularis longus / brevis); transverse tarsal joint => more inversion/eversion
+ flexion/extension.
Risk of cast => pressure on common fibular (= peroneal) nerve could lead to its damage => loss of
innervation to anterior and lateral compartments => foot-drop = loss of dorsiflexion and eversion.
Comment: 50/121 clear passes
I hope I dont get a sore ankle and have to be treated by most of you... this question was done pretty
badly overall! Very few of you answered the second part well, either with regard to subtalar /
transverse tarsal joints or the inversion / eversion movements.

Bobs manager, Knobby Knox, aged 62, hobbles down to the track to help collect Bobs
damaged motorcycle. He complains to anyone wholl listen that he needs a new hip joint,
as soon as he pays off the other one. Kills me every time I bend over... he informs a
bystander.
Knobbys history reveals that he has osteoarthritis in his hips. Already, he has had one
total hip replacement.
Question 2.
Briefly discuss the pathogenesis of osteoarthritis.
How would osteoarthritis interfere with the normal range of movement at the hip?
What are the main longer-term risks for Knobby subsequent to a total hip replacement?

(9 mins)
Source: Weeks 4 & 5 main cases
Answer:
Osteoarthriitis = abnormal loading on normal articular cartilage OR normal loading on abnormal
cartilage. In either case, primarily a disease / disorder of the articular cartilage. Once triggered (injury
/ idiopathic), chondrocytes => increased secretion of matrix metalloproteinases => breakdown of
extracellular matrix => more hydrated, reduced strength, exposure of articular collagen fibres =>
fibrillation => increased friction => more wear & tear => more breakdown => subchondral bone
sclerosis and breakdown => exposure of subarticular bone => eburnation => pain, osteophyte
76

formation, secondary inflammtion & synovitis => more cartilage and bone loss => cycle continues...
Reduced RoM of hip due mostly to pain; at extreme limits may be due to osteophyte impingement.
Secondary inflammation could contribute to joint stiffness.
Long term risks of hip replacement = relatively few; fracture distal to femoral implant after a fall;
loosening of implant (after 10-15 years). [ Infection is a risk but likely to appear within 6 months;
however, prosthesis could be long-term site for haematogenous spread. DVTs = short-term risk. ]
Comment: 108/121 clear passes
Well done overall. Some of you seemed to get sidetracked by the original Eva Kominski case and
talked about risk of avascular necrosis of the femoral head, which is irrelevant here, since its gone as
a result of the prosthesis...

The bystander, Maria Scarpantoni, aged 43, tells Knobby to stop complaining. But she
declines to help, since her own hands are severely deformed: her fingers seem stiff,
shortened, deviated to the little finger side, and her knuckles are very swollen. Been like
this for years, she mutters, and the drug theyre giving me now helps, but it makes me
feel awful...
Maria clearly has rheumatoid arthritis, probably an early onset form, given her age.
Question 3.
How does rheumatoid arthritis lead to deformation of the hands?
What structural changes would you expect to see on a plain radiograph of Marias hands?
Which drug is she most likely to be receiving, given her description? How does it work?

(9 mins)
Source: Week 3 main case
Answer:
RA -> degeneration of joints (initially MCP joints) via chronically inflamed synovial membrane /
invasive pannus -> loss of articular cartilage + weakened ligaments => increased joint instability =>
subluxation / ulnar deviation due to pull of extrinsic forearm muscles. Apparent swelling of knuckles
(MCP joints) due to combination of subluxation and inflammation. Apparent shortening of fingers due
to subluxation of MCP joints.
Plain radiographs => subluxed MCP joints with ulnar deviation (subluxation seen as overlapping
profiles of proximal phalanges and distal metacarpals; articular surfaces of MCP joints => probably
eroded with underlying sclerosis and surrounding osteophytes [ if subluxed, then joint space would
not be present at all... ]. With this level of RA, would look out for degeneration of carpal / radiocarpal / IP joints.
Drug could be any of a range of DMARDs, since many have nauseating side effects; at this level of
disease progression, most likely would be methotrexate (inhibit T-cell proliferation and production of
cytokines probably via DNA synthesis inhibition, perhaps in combination with a TNFa inhibitor. Both
drugs generate malaise and nausea as side effects. [ NSAIDs much less likely to make people feel
awful... ]
Comment: 104/121 clear passes
Quite well answered by most people. Many of you seemed to forget or overlook the obvious feature
of the presentation: her fingers seem shortened ... and knuckles are very swollen. This is a classic
appearance due to subluxation of the MCP joints. This was often mentioned in general as a feature of
RA, but a surprising number of people negelected to mention this in the radiological appearance.

77

After the semi-finals of the MegaPipe Freestyle Skateboard competition, a fight breaks
out between defending champion, M-Fix Smith, aged 28, and popular young challenger,
Ahmed Khan, aged 19. Following a vicious exchange of heavy punches, both skaters are
hurt.
M-Fix has a severe pain in his hand proximal to his index finger. The pain is worse when
he forms a power grip or when tension is applied to his index finder, consistent with a
fracture of the second metacarpal.
Question 4.
Compare the mechanisms of a power grip and a precision grip.
What are the main muscle groups used in each grip?
Why does forming a power grip cause pain in this case?

(9 mins)
Source: Week 3 main case and minicases
Answer:
Precision grip = holding object between thumb and tips of fingers, nearly always involves opposition
of thumb. Finger movements controlled mainly by superficial finger flexors (fl. dig. superficialis;
ending on middle phalanx) working together with lumbrical and interossei (fingers) and the thenar
muscles (thumb). Deep finger flexors (fl. dig. profundus, ending on distal phalanx) used to flex DIP.
Power grip = holding object tightly against flexed fingers and palm, thumb may or may not flex
across the object. Main muscle here is fl.dig. profundus. Requires co-activation of wrist extensors
(ext. carpi ulnaris / radialis) to keep wrist stable. [ flexion of MCP => help lock knuckles to stop
forced abduction ]
Pain during the power grip is due to compression of the fractured metacarpal as a result of
contraction of the fl.dig. profundus; pulling on the index finger -> tension across the fracture -> pain,
either from the fracture itself or the damaged perisoteum.
Comment: 54/121 clear passes
Another functional anatomy question not very well done by many people. If you didnt mention the
function of the thumb in the precision grip, you couldnt get a clear pass on the question: its
essential!! A lot of people considered that the finger extensors were co-activated with the flexors in a
powergrip: this is not so only the wrist extensors are involved; furthermore, the wrist flexors are
not involved either, contrary to the suggestions in many answers.
This should have been a relatively simple answer: all you needed to do was to make a fist or look at
your hand holding a pen and describe what you see... if so, you would not have made these types of
errors...

M-Fix almost certainly broke his metacarpal when he punched Ahmed in the mouth.
Ahmed has had several lower jaw teeth knocked out, his mandible is fractured, and he is
in considerable pain. He will need to have his jaw wired.
Question 5.
Discuss the process of bone healing after a fracture. How does wiring help?
If Ahmeds teeth are not replaced, what will happen to his jaw? Why?
Which nerve is responsible for transmitting pain from his injury?

(9 mins)

78

Source: Week 1 minicases + week 4 main case, week 6 revision sessions

Answer:
Bone healing = bleeding from fracture -> haematoma / fibrin clot -> debirsi cleaned up by
macrophages -> callus -> proliferation of osteoprogenitor cells / osteoblasts, sometimes with
chondroblasts -> osteoid -> calcification -> woven bone -> remodelling (osteoclasts and
osteoblasts) -> increased density and alignment with loading forces.
Wiring keeps fractured surfaces applied to each other => prevent movement => maximise chance of
callus forming and healing quickly with minimal subsequent remodelling.
Long-term loss of teeth => loss of mandibular bone mass around roots due to loss of loading
(increased activity of osteoclasts cf osteoblasts in these areas).
Pain due to inferior alveolar nerve (mandibular = third branch of trigeminal nerve).
Comment: 99/121 clear passes
Very well done overall. However, quite a few of you mistakenly thought the pain came from a branch
of the facial nerve (it doesnt).

While shifting equipment around to set up the start of the Ultra-XS marathon crosscountry cycling event, Scotty Maclaren feels a sudden severe pain in his back. It is worse
if he twists or bends to the right, when it is accompanied by shooting pins-and-needles
down his right lower limb. Scotty is 49 years old, 182cm tall and weighs 103kg.
Subsequent investigation reveals a prolapsed disc in his lower back.
Question 6.
Discuss the structure and function of the inter-vertebral discs.
What causes intra-vertebral discs to rupture or prolapse?
How does the prolapsed disc lead to unilateral pain in the back and pins-and-needles in the
lower limb?
How could the pain associated with a prolapsed disc be distinguished from pain arising from a
strained back muscle?

(9 mins)
Source: Week 6 main case and minicases
Answer:
IV discs = central nucleus polposus (jelly-like) surrounded by tough annulus fibrosus (fibrocartilage
and concentric rings of criss-crossed collagen fibres). [ attached to bodies of vertebrae via layer of
hyaline cartilage ].
Function = act as shock absorbers between adjacent vertebrae; also increase range of movement
between vertebrae => larger from superior to inferior spinal levels.
Prolapse = rupture of annulus fibrosus due to excessive [compressive] loading +/- structural
weakness (eg due to age) => nucleus pulposus protrudes, most commonly -> posterior.
Pins & needles => direct [mild] pressure on roots of spinal nerve => sensation mapped to territory of
that nerve.
Pain from disc prolapse usually unilateral, relieved by leaning to one side (releases pressure of
prolapse on [inflamed] nerve root cf muscle strain -> pain leaning both ways => concentric or
eccentric loading -> pain. Femoral / sciatic nerve stretch tests give pain due to root inflammation
from prolapsed disc, not very likely for a pulled muscle.
79

Comment: 117/121 clear passes

Also very well done by just about everyone.

The carnage continues on the BMX HyperStunt cycle track. Professional BMX cyclist,
Jonty Wiedersheim, 31 years old, misjudges his landing from a large jump when he is
distracted by a photographers flash. He flips over the handle-bars and falls heavily on his
outstretched arm. He knows immediately that he has an anterior dislocation of his
shoulder, having done so several times previously.
Question 7.
Discuss the main features providing a combination of strength and mobility to the shoulder.
Why is the shoulder dislocated anteriorly in this case?
How might the previous shoulder injuries that Jonty has suffered contribute to this one?

(9 mins)
Source: Week 2 main case
Answer:
Mobility = wide RoM at glenohumeral joint due to shallow ball-and-socket + loose joint capsule;
total RoM increased by mobility of scapula (via A-C joint and sterno-clavicualr joints)
Strength = mostly muscular: rotator cuff + deltoid at glenohumeral joint itself; scapula -> trunk
muscles for overall strength = trapezius, serratus anterior (+ rhomboids, levator scapulae, pec
minor), especially for abduction / elevation / retraction.
Anterior dislocation: outstretched arm => abducted, extended, externally rotated => head of
humerus anterior and inferior in glenohumeral joint; joint capsule weakest inferior where there is no
rotator cuff; once dislocated, spasm of pec major holds it there.
Previous dislocations-> damage to joint capsule and supporting ligaments -> more loose than normal
=> even less support.
Comment: 83/121 clear passes
Reasonably well done by most people, although many didnt mention the role of the scapula in
increasing the mobility and strength of the shoulder.
Many people said that the anterior dislocation was because the joint capsule was least strong
anteriorly, but it is actually the inferior part of the capsule that is not reinforced by anything (no
ligaments or rotator cuff). The main reason for going anterior is the line of force from the fall,
combined with the absence of any bony protection such as the coracoacromial arch.

During the final of the SuperCross ExOrbital MonsterJump competition, a stunt goes
horribly wrong and the riders motor-bike careens into the crowd. Mrs Doreen OLaughlin,
72 year old sister-in-law of Knobby Knox, breaks her left distal radius and ulna when she
is knocked to the ground during the chaos. Not again... she moans. Her history reveals
that this is third fracture she has sustained in the last 6 years and that she has a
moderate level of osteoporosis.
Question 8.
Discuss the factors that lead to the development of osteoporosis in later life.
What can be done to minimise the risk of osteoporotic fractures?

(9 mins)
80

Source: Week 4 main case + week 3 minicases

Answer:
Major factors = reduced Vitamin D levels via diet / intestinal absorption / exposure to sunlight / renal
or liver disease => increased PTH => increased bone resorption; decreased oestrogen levels,
especially post-menopausal; decreased loading of bones due to reduced exercise; age-related
reduced ability of osteoprogenitor cells to produce osteoblasts / osteocytes.
All processes lead to increased osteoclast activity cf osteoblast activity -> net loss of bone mass,
especially trabecular bone.
Minimise risk of fracture by:
>> building and maintaining high peak bone density early in life via weight-bearing exercise, good
diet (sufficient Vit D and Ca) and maintaining good BMI.
>> if already osteoporotic, consider disease modifying drugs, eg bisphosphonate; check endocrine
function re PTH, Vit D metabolism, thyroid status.
>> life-style issues to minimise chances of falls, eg no loose carpets, rugs, powercords, good lighting,
handrails if necessary for steps, etc.
Comment: 106/121 clear passes
Well done overall. However, Im not sure how much weight-bearing exercise a 72 year old would be
able to do and how long it would take to build up bone mass, as some of you thought might help..

Back at the MegaPipe Skateboard competition, former womens champion, Missy

Jackster, aged 24, junks a big aerial move, lands very heavily, and badly hurts her knee,
taking her out of the competition. Subsequent testing of her knee indicates an anterior
drawer sign, and abnormal instability in response to attempted abduction of the knee.
Question 9.
What factors contribute to the stability of the knee during a range of activities from quiet
standing to running or landing from a jump?
What has been damaged in this accident? How do you know?
Once the knee has been repaired, what could Missy Jackster do to minimise re-occurrence of the
injury?

(9 mins)
Source: Week 5 main case + minicases
Answer:
Stability in standing = cruciate ligaments, especially anterior cruciate in full extension (knee screwed
home) pulling across posterior cruciate; lateral stability via medial and lateral collateral ligaments.
Few if any muscles required.
Running / landing from a jump => muscles take much loading, including quadriceps (eccentric),
tensor fascia lata (lateral), gracilis + sartorious medially; possibly also gastrocnemius + hamstrings.
Accident => torn ACL shown by anterior drawer sign, and probably medial collateral also damaged
shown by abduction instability. [ Possible secondary damage to menisci and / or articular cartilage,
but no evidence from presentation... ]
Minimise future injury by strengthening muscles crossing joint, especially quadriceps via non-weightbearing exercise. Use a knee brace or strapping to support knee. Give up high risk sport.
81

Comment: 102/121 clear passes

Well done overall.

At the Black Buffalo Extreme Sports Showdown Presentation Dinner, Bilby Gronitz,
aged 47, special guest presenter and former BMX star, falls off the stage whilst guzzling a
bottle of champagne. He lands on his upper back and hits his head against the wall.
Although shaken, he doesnt appear badly hurt. However, two days later his neck is stiff
and sore, especially when he extends or rotates his head. The pain is relieved to a
reasonable degree by aspirin.
Question 10.
What are the skeletal mechanisms that allow flexion-extension and rotation of the head?
Which main muscle groups are involved in generating these movements?
Why would Mr Gronitz feel stiff in the neck two days after his accident?

(9 mins)
Source: Week 6 practical class and minicases + Week 2 main case
Answer:
Flexion / extension: atlas-occipital condyles => gentle flexion / extension; further flexion / extension
involve all cervical vertebrae.
Rotation => atlanto-axial joint => atlas rotates around dens (=odontoid process) of axis; further
rotation via other cervical vertebrae.
Extension via splenius capitis / semispinalis capitis.
Flexion via gravity + longus capitis / cervicis (for neck)
Rotation via ipsilateral splenius + contralateral sternocleidomastoid
Subtle adjustments of head position via deep muscles, including rectus capitis major / minor + and
inferior / superior obliques. [ Sternocleidomastoid extends at atlanto-occipital joint, flexes lower
cervical joints. ]
Stiffness due to mild muscle tearing of extensors / rotators due to forced flexion at impact of fall.
Relief via aspirin => pain mostly due to inflammation associated with minor injury. Pain two days
later common after stretch-induced (including eccentric) injury.
Comment: 96/121 clear passes
Well done overall. Nearly everyone got the clue that if aspirin helped the stiffness a couple of days
after the fall, it was probably due to soft tissue damage and associated inflammation (eg pulled
muscle, ligaments), but not a broken bone...

************************************

END OF EXAMINATION

82

AUGUST
EXAMINATIONS 2010

SECOND YEAR BMBS

MMED 8220A/B KNOWLEDGE OF HEALTH & ILLNESS
2A/B

MUSCULOSKELETAL SYSTEM
{with sample answers}
TIME: 1 hour and 30 minutes (90 minutes)
MATERIALS ALLOWED IN THE EXAMINATION ROOM:
None

INSTRUCTIONS TO CANDIDATES:
1.

Write your student number on each examination booklet.

2.

Start answers to each question on a new page.

MARKING SCHEME:
Each question will be marked to a pass/fail set of criteria.
To pass the exam, you must pass seven (7) of the ten (10) questions.
All questions are weighted equally.

You are encouraged to make use of diagrams in your answers.

83

While setting up the public address system for the Big Day on Park Green Music
Festival, Steve The Crunch Hobbs, aged 47, 196 cm tall and weighing 122 kg, felt a
sudden severe pain in his lower back as he bent forward to pick up a heavy speaker box.
Question 1.
Discuss the most likely causes of the Mr Hobbs back pain.
How could you distinguish between them?
How could Mr Hobbs reduce his risk of developing back pain in the first place?

(9 mins)

A. Source: main case, week 6.

Most likely causes:
pulled muscle / ligament; prolapsed disc;
Less likely, but possible:
avulsed vertebral spine / transverse process; collapsed vertebra due to cancer (eg multiple
myeloma)
Distinguish by testing pain on movements: muscles will hurt on any movement due to
concentric / eccentric contractions; probably painful on palpation. Disc prolapse most likely
to cause pain on bending in a particular direction, relieved by bending in opposite direction.
Test possible nerve involvement with femoral / sciatic nerve stretch tets. Avulsed spine /
transverse process detected by tapping vertebral spines. Vertebral body collapse may be
painful to touch, probably need radiology. Osteporotic collapse of the vertebral body is
possible but unlikely due to age and gender of the patient.
Reduce risk by good lifting practice: bend knees and keep back straight with centre of gravity
through lumbar vertebrae => much less loading on back muscles (erector spinae, quadratus
lumborum). Holding breath (usually automatic) helps to spread load to abdominal muscles.
In the workplace, a good idea to get assistance or use some device to help lifting heavy
items. In lifestyle, reduce weight to reduce loading on back.
Comment: Very well done by just about everyone. Some answers failed to provide a decent
test to distinguish between the possibilities you suggested.

During the performance by electro-prog-punk band I Did It for Sid, die-hard fan,
Doreen Summerhayes, aged 23, fell heavily while crowd-surfing and badly hurt her
forearm. In the First Aid tent, examination revealed a so-called dinner fork deformity,
such that her wrist and hand appeared to be shifted dorsally to the rest of her forearm. The
hand also was deviated radially with the wrist somewhat supinated in relation to the
forearm. She was sent to hospital with a suspected broken radius.
Question 2.
Why is Ms Summerhayes hand displaced in this injury?
If she had not broken her radius, what other injuries to her upper limb might she had suffered in her
fall?
Discuss the normal mechanism of pronation and supination of the forearm.
How do these actions contribute to overall functions of the upper limb?

(9 mins)

A. Source: main case, week 3; mini-cases, week 2 and week 3.

Most likely injury = fracture of the distal radius (Colles fracture). Hand is displaced because it
is attached to radius at the radio-carpal joint. Direction of displacement mostly due to pull of
muscles unopposed by radius.
84

Other possible injuries include fractured scaphoid, proximal ulna (maybe with elbow
dislocation), distal humerus, shoulder dislocation, fractured clavicle. Which one happens
depends mainly on the angle of the fall and the position of the upper limb.
Pronation-supination occurs at the proximal and distal radio-ulnar joints: proximal = pivot
joint where head of radius is held against ulnar (radial notch) by the annular ligament; distal
= radius rotates around end of ulna, taking the radio-carpal joint (and hand) with it. Radius
and ulna are parallel when supine; pronation => radius rolls over ulna. Muscles: pronation =
pronator teres and quadratus; supination = supinator and biceps brachii => much stronger.
Pronation-supination => increase range of movement of hand: most daily tasks difficult or
impossible with out it! Position of forearm pronation-supination determines recruitment of
elbow flexors (eg brachoradialis at mid-position; biceps at supine).
Comment: Generally well done.
Around sunset, Francesca, an iconic folk singer from the 1960s, now aged 72, performed
some of her famous songs, accompanied on guitar by her grandson. She explained to the
audience that she has not been able to play guitar herself for many years due to painful
arthritis which has progressively crippled her fingers and hands. Holding up her hands,
she showed the audience her badly deformed and swollen knuckles. Her fingers appeared
shortened and deviated to the ulnar side.
Question 3.
Francesca most probably has rheumatoid arthritis.
If so, how would rheumatoid arthritis interfere with her ability to play a guitar?
What structural changes would contribute to her impaired function?
Briefly discuss the possible sources of pain in her hands.
How might the pain be treated?

(9 mins)

A. Source: main case, week 3.

RA would interfere with guitar playing by reducing movements of fingers: eg subluxed MCP
joints, perhaps also PIP joints; reduced range of motion due to altered joint structure,
stiffness due to inflammation, and pain; also reduced movement and pain in wrist => more
difficulty in holding / playing guitar.
As well as joint subluxation, articular cartilage would be eroded; subchondral cysts => pain
and reduced range of movement of joints even if not subluxed. Possible ligament / tendon
destruction further reduces mobility. If wrist is involved, carpal tunnel syndrome could involve
median nerve => decreased sensation, motor weakness with intrinsic hand muscles (thenar,
1st two lumbricals) and inflammatory pain.
Pain could arise from joint damage, inflammation, nerve inflammation. Apart from analgesia,
try to treat cause => reduce inflammation via NSAIDs, coriticosteroids, DMARDS, eg
methotrexate, TNFa blockers; test for median nerve involvement and carpal tunnel release.
Comment:
Generally well done. Some answers neglected to relate the condition to the presentation.

85

Roger Baleena, a 36 year-old camera operator, was preparing to video-record the

evening sessions of the Festival, when he tripped on a cable and fell 5 metres from a
scaffolding tower. He landed hard on his knees with his hips flexed. He was in
considerable pain from his right hip, which remained flexed, adducted and internally
rotated. His right lower limb appeared to be shorter than his left limb.
Question 4.
Mr Baleena clearly has damaged his hip.
What is his most likely injury? How has this happened?
Briefly discuss the major features that contribute to stability and load bearing of the hip joint.
How is hip joint be protected from injury in a controlled landing from a jump?

(9 mins)

A. Source: mini-case, week 4

Most likely injury = posterior dislocation of femur (fractured neck not so likely given age of
patient, nature of fall, and direction of rotation: internal not external, as usually the case with
fractured NoF). Hip joint is generally strong and well supported but is most susceptible to
posterior dislocation due to high-force impact on distal femur when the hip is flexed and
ligaments are least taut.
Stability of the hip due to deep acetablum, enhanced by acetabular labrum, encloses most of
spherical head of femur. Strong joint capsule, reinforced by strong ligaments: iliofemoral /
ischiofemoral / pubofemoral. Iliofemoral lig limits extension and takes most of the load of
quiet standing (with centre of gravity behind the joint).
Muscles crossing the joint (ilio-psoas, rectus femoris, hamstrings) take a lot of loading off hip
when landing from a jump via eccentric contractions. Total load to hip is reduced by
eccentric contractions of muscles around knee (quadriceps) and ankle (gastrocnemius /
soleus; tibialis posterior; probably peroneus (fibularis) longus and brevis).
Comment: generally well done. Some people tried to argue the case for a fracture rather
than dislocation, but used wrong info to do so (eg actions of muscles). Most people got the
importance of eccentric contractions of muscles crossing the ankle and knee in unloading
the hip, but you had to mention the muscle groups (at least) by name.
Nicolette van Ostenliederhoek, sensational 18 year-old bass player and vocalist for The
Rainy Day Sunshine Orchestra, appeared on stage with her lower leg in a cast. She said
that she had broken both bones in her lower leg whilst skiing in New Zealand a few
weeks previously.
Question 5.
Discuss the process of bone healing after a fracture.
How does remodelling correct for any misalignment in the re-united bones?
Under what conditions might a fractured bone not heal properly?

(9 mins)

A. Source: mini-cases, weeks 4 and 5; revision session, week 6

Bone healing after a fracture:
Clot (haematoma) forms around broken ends of bones => fibrin => callus => proliferation of
osteoprogenitor cells (osteoblasts) and maybe chondroblasts => lay down osteoid =>
mineralisation to woven bone => remodelled by osteoclasts => mature bone.

86

Abnormal loading on misaligned bone leads to selective remodelling by osteoclasts and

osteoblasts: new bone formation enhanced on one side (usually concave surface, under
compression) and bone resorption enhanced on opposite side (usually convex surface,
under tension). Loading may be sensed by piezoelectric effects.
Bone may not heal properly if: ends are not apposed; ends keep moving relative to each
other; infection or other source of inflammation at the fracture site; blood supply to bone
interrupted by fracture (=> avascular necrosis); there is serious metabolic bone disease (eg
osteoporosis).
Comment: Generally well done. You needed to get at least three of the reasons for failed
fracture healing to get a clear pass.
Unfortunately, the set by psychometal-Goth band, Blood Type Black was cancelled
when their 32-year old lead singer, Jim-Bob Schultz, was sent to hospital with a fractured
skull. According to television reports, he had been hit in the head by an amplifier thrown
during an off-stage fight with the bands lead guitarist, Bob The Scalpel Hunt.
Question 6.
Briefly discuss the structural features that contribute to the overall strength of the skull?
Which areas of the skull are most likely to be damaged as a result of heavy direct impact?
How can fractures of the skull lead to soft tissue damage?
Which soft tissues are most at risk?

(9 mins)

A. Source: main case, week 1

Strength of the skull:
strongly interlocking immovable sutures between most of the flat bones; dome shape helps
to distribute force of impact (bones somewhat elastic, helped by diploic structure)
Direct impact => depression fracture at point of impact (especially over maxillary / frontal
sinuses; impact to face => le Fort type fractures => mobile face; impact to dome of skull =>
(countre-coup) fracture to base of skull opposite impact point. Weak areas at thinner bones,
eg temporal bone around pterion; nasal bones, ethmoid.
Skull fractures => soft tissue damage by dislocation of skull pieces => tearing of soft tissue;
pieces of bone can embed in soft tissue (eg in brain); fracture edges themselves could sever
soft tissues, eg meninges, blood vessels, cranial nerves
Tissues at risk include meninges (eg at cribriform plate), blood vessels (eg venous sinuses
draining brain; middle meningeal artery benath pterion), cranial nerves, eyes (eg fractures
around orbit), ear drum (eg fractures in tympanic bone), and brain itself, either by impact or
consequences of subarachnoid or epidural bleeding.
Comment: This question was done terribly! Many people did not answer it at all, and most
answers did not much anything sensible to say about sites of skull or soft tissue damage.
This outcome is surprising given that all these issues were explicitly addressed in the first
main case where the patient suffered a wide range of head injuries affecting his skull and
soft tissues (brain, meninges, blood vessels) following a motor vehicle accident...

87

In a change of pace for the Festival, radical hip-hop artist, Q-tox, teamed up with the
infamous juggling-acrobatic-harmony quartet, The Blue Ivories. As part of their act,
one member of The Blue Ivories lifted another member high overhead, supporting her
with only one hand, while Q-tox rhymed and mixed beats.
Question 7.
Explain the movements of the shoulder and associated structures when lifting a heavy load overhead.
How do movements at the various joints of the shoulder girdle contribute to the overall lifting action?
Which muscle groups are involved?
What kinds of injuries could impair or limit ones ability to lift a load overhead?

(9 mins)

A. Source: main case, week 2

Lifting a heavy load => abduction / upward rotation of the scapula as well as flexion /
abduction at the glenohumeral joint. During the initial lift, the scapula also may be retracted.
This is necessary since abduction at glenohumeral joint is about 120 degrees: full lift (eg 180
degrees abduction) requires 60 degrees abduction of scapula.
Movement of the scapula requires movement at sternoclavicular and acromioclavicular joints
(about 30 degrees each).
Main muscles in moving the scapula during lifting are trapezius (abduction, retraction,
elevation) and serratus anterior (abduction, stabilisation), helped by levator scapulae
(elevation) and rhomboids (retraction). Abduction at glenohumeral joint = supraspinatus and
deltoid. Flexion during initiation of lifting a load = pectoralis major (upper fibres) and anterior
deltoid.
Lifting impaired by nerve damage: most common => to serratus anterior (long thoracic n) or
trapezius (accessory n) or deltoid (axillary n). Inflammation of subacromial bursa => pain
during abduction => may limit lifting. Muscle strains, inflammation of glenohumeral, A-C, S-C
joints (eg over use, sprain, arthritis), joint pain (typically osteoarthritis in these joints).
Comment: Generally very well done. Most of you understood the coordinated movements of
the glenohumeral joint and the scapula. Many of you noted (correctly!) that this type of lifting
involves flexion of the shoulder as well as abduction. Given the wording of the question you
didnt need to talk about muscles in the forearm or back also involved in picking up a heavy
load.
Former manager of the Blue Ivories, Albert Aardvark Henry, aged 37, recently was
eliminated from a national television cooking competition after he attempted a dish
showcasing the health benefits of smoked salmon souffl with sashimi tuna and grilled
mushroom jam, all good sources of vitamin D.
Question 8.
Discuss the role of vitamin D metabolism in the regulation of bone density.
How can alterations in vitamin D metabolism contribute to the development of osteoporosis during
ageing?
What can be done to minimise the risk of developing osteoporosis in later life?

(9 mins)

A. Source: main case, week 4.

Vitamin D => required for net increase in bone formation / preservation of bone mass.
Synthesised in skin via sunlight (UV) or gained from diet as D3, converted to 25-OH-D3 in
liver then to 1,25-OH2-D3 in kidney => increase gut absorption of calcium; increased
88

movement of calcium from osteoblasts to osteoclasts. Synthesis of 1,25-OH2-D3 enhanced

by PTH in response to low blood Ca2+. Vitamin D probably also directly stimulates turn over
of both osteoclasts and osteoblasts, and is essential for the normal mineralisation of bone.
Vitamin D works synergistically with oestrogen in maintaining bone mass. Aging =>
possibility of less GIT absorption, less sunlight exposure, combined with decreased
oestrogen / androgen and reduced weight-bearing activity => overall tendency for reduced
bone mass.
By itself, vitamin D deficiency => osteomalacia. But if low vitamin D results in low blood
calcium, PTH levels rise, activating osteoclasts via actions on osteoblasts, and this is what
leads to osteoporosis.
Vitamin D effectively cannot be stored => need to keep up dietary intake and some sun
exposure; dietary calcium supplements can help if Ca2+ levels are low (but check for
malabsorption...). Best prevention of OP is to build up peak bone mass by middle age =>
maintained weight bearing exercise => increased mass of trabecular and cortical bone.
Comment: Well done by many, but many others didnt really identify the difference between
the role of vitamin D deficits in osteomalacia compared with osteoporosis (which was the
question): you really had to mention the link between vitamin D and PTH or oestrogen to get
a clear pass on this question.
The members of the once influential Reggae-and-Western dance band, Ska Rodeo,
reformed especially for the Festival. Their drummer, Simon Ellis, now aged 54, also was a
semi-professional footballer until he gave up the game when he was 32, after recurrent
injuries to the cruciate ligaments and intra-articular disks of his right knee. Now he can
only play drums for relatively short periods before the pain in his knee becomes too
severe to continue. He often complains of grating in his knee, even if he is not playing
drums.
Question 9.
Simon Ellis has the outward signs of osteoarthritis in his knee.
Briefly discuss the pathogenesis of osteoarthritis. Why does Mr Ellis knee grate?
How might previous knee injuries have contributed to the development of osteoarthritis in Mr Ellis?
If you took a plain radiograph of his knee, what would you expect to see?

(9 mins)

A. Source: main case, week 5.

OA = abnormal loading on normal cartilage / normal loading on abnormal cartilage.
Articular cartilage breaks down by physical damage or metabolic dysfunction. Chondrocytes
=> increased secretion of matrix metalloproteinases => breakdown of extracellular matrix =>
more hydrated, reduced strength, exposure of articular collagen fibres => fibrillation =>
increased friction => more wear & tear => more breakdown => subchondral bone sclerosis
and breakdown => exposure of subarticular bone => eburnation => pain, osteophyte
formation, secondary inflammtion & synovitis => more cartilage and bone loss => cycle
continues...
Knee grating could be pieces of articular cartilage or intra-articular disc fragments; possibly
small bony fragments if very severe OA with eburnation (continuous pain => may be at this
stage).

89

Torn mensici => increased risk of OA, due to reduced ability to lubricate properly (by
spreading synovial fluid); damaged ligaments => abnormal loading patterns => abnormal
wear of articular cartilage. (articular cartilage also may have been damaged in original knee
injury => fibrous repair => further damage).
Plain radiograph => reduced joint space (due to articular cartilage loss); subchondral
sclerosis (hyperdense bone) and maybe cysts (areas of bone loss) beneath areas of wear;
osteophytes around margin of joint; mal-alignment if severe eburnation.
Comment: generally very well done. Some forgot the radiological findings...

After the Festival concluded, an intoxicated patron, known to her friends simply as
Marz stepped out onto the road without looking and was hit on the lateral side of the
right leg by a car. Luckily the car was not moving fast. Nevertheless, Marz suffered a
fracture of the proximal end of the fibula which was set in plaster. Three weeks later,
with her limb still in a cast, Marz complained of numbness in her right shin and foot.
Question 10.
What structures are at risk with a fracture of the proximal end of the fibula?
Why has Marz developed numbness in her lower leg?
If nothing is done to remediate the situation, what would be the long term consequences for her
lower limb function and mobility?
Explain your answer.

(9 mins)

A. Source: mini-case, week 5.

Structures at risk = mainly the common peroneal (fibular) nerve.
Numbness could be due to initial impact on nerve; broken fibula compressing / damaging
nerve; pressure of cast putting pressure on the nerve. From the presentation, the last is most
likely.
Common peroneal / fibular nerve => lateral compartment (peroneus / fibularis longus and
brevis) via superficial branch; anterior compartment (tibailis anterior, ext hallucis longus, ext
dig longus) via deep branch. Loss of whole nerve => loss of eversion and dorsiflexion =>
"footdrop".
Functionally, need to lift foot higher off ground during walking to prevent toes dragging on
ground (eg more hip abduction contra-laterally; more knee flexion ipsilaterally => high
stepping gait); lose function of tib ant to control weight transfer from heel across arches of
foot via eccentric contractions => foot tends to slap down. Reduced of support of arches via
tib ant and fibularis mm during running / jumping. Reduced postural stability via same mm in
quiet standing. Reduced ankle stability (no lateral support) via fibularis mm (concentric =
eversion; eccentric control inversion).
Comment: Very well done overall.

90

FLINDERS UNIVERSITY ADELAIDE

AUSTRALIA
SCHOOL OF MEDICINE

AUGUST
EXAMINATIONS 2009

SECOND YEAR BMBS

MMED 8220A/B KNOWLEDGE OF HEALTH & ILLNESS
2A/B

MUSCULOSKELETAL SYSTEM
TIME: 1 hour and 30 minutes (90 minutes)
MATERIALS ALLOWED IN THE EXAMINATION ROOM:

None

INSTRUCTIONS TO CANDIDATES:
1.

Write your student number on each examination booklet AND the attached marking slip.

2.

Start answers to each question on a new page.

MARKING SCHEME:

Each question will be marked to a pass/fail set of criteria.

To pass the exam, you must pass seven (7) of the ten (10) questions.

All questions are weighted equally.

This examination is in 2 sections: Section A and Section B, which are weighted equally.
Section A

Short Answer Questions

(Questions 1-5) Suggested time: 45 minutes

Section B

Short Answer Questions

(Questions 6-10)

Suggested time: 45 minutes

91

You are encouraged to make use of diagrams in your answers.

SECTION A

Suggested writing time: 45 minutes

Robert The Rat Johnson, a 42 year old member of a well-known criminal family, was
stabbed repeatedly in the torso after a fight in a nightclub. Although his wounds were not
life-threatening and healed well overall, he cannot fully abduct his right arm. When asked
to push his flexed right arm against resistance, his right scapula shows a characteristic
winged appearance.
Question 1.
Discuss the muscle groups that provide mobility and strength to the shoulder.
What is the mechanism of arm abduction?
What has happened to Mr Johnson? Why is his scapula winged?

(9 mins)

Answer: [cf Bridges case, mini-cases ]

Three muscle groups -> strength and mobility:
: trunk to humerus = pec major; lat dorsi => adduction, bringing arms back to anatomical position
from anywhere in space [pec maj more from behind; lat dorsi more from in front]
: trunk to scapula = serratus anterior, trapezius mostly for strength and additional range of motion
during abduction; [also rhomboids => retraction of scapula; pec minor => stabilise; adduction of
scapula against resistance]
: scapula to humerus = deltoid => abduction; rotator cuff [=supraspinatus => initiate abduction;
infraspinatus, teres minor => lat rotation; subscapularis => med rotation]; teres major => adductor.
All can work eccentrically to stabilise shoulder position
[other scapula to humerus = coracobrachialis => stabilise glenohumeral joint; biceps, long head of
triceps => probably help stabilise joint too]
Abduction of the arm requires abduction at glenohumeral joint; initiated by supraspinatus, then
powered by deltoid. But only about 120 degrees of abduction available there [ due to bony
constraints ]. Rest of abduction (about 60 degrees) achieved by upward rotation of scapula mostly
via serratus anterior & trapezius. [ movements occur at acromio-clavicular and sterno-clavicular
joints ]
Mr Johnsons long thoracic nerve has been severed => loss of function of serratus anterior =>
winging when trying to abduct or elevate upper limb.

Comment:

Generally well done. Most of you realised that the scapula needs to move for full abduction, although
some of you suggested some novel muscle actions to do so. Most of you got that the injury was
something to do with serratus anterior. The stabbing could have damaged the muscle rather than the
long thoracic nerve, so if you said this, you got the points.

In a subsequent interview with the police, Mr Johnson claims the fight started when his
72 year old mother was accused of being a witch.
Just because she lost all her teeth 25 years ago, and shes hunched over something
terrible since she turned 60 says Johnson, shes no witch, shes an old sweetheart.
Police medical files (from another recent incident) confirm significant reduction in the
92

bone mass of her mandible and bone density in the bodies of her vertebrae.
Question 2.
Explain the skeletal changes you would predict to accompany the altered appearance of Mr Johnsons
mother as she aged?
What features do they have in common?

(9 mins)

Answer: [cf Kominski case, minicases ]

Facial changes: as a result of losing her teeth, reduced bone mass of the jaws (mandible and
probably maxilla) is due to lack of load bearing via the teeth.
Hunchback: reduced bone density of the bodies of her vertebrae => osteoporosis => reduced levels
of cortical and trabecular bone => reduced load bearing capacity => collapse under loading [due to
body weight and daily activities] => exaggerated thoracic kyphosis.
Features in common: in each case, osteoclast activity exceeds osteoblast activity; in each case, the
microscopic structure of the bone (ie its mineralisation) would be fundamentally normal.
In the jaws, the lack of loading drives the balance towards net bone resorption [maybe via
piezoelectric effects in the bone matrix ]. In the back, osteoporotic degeneration is most likely due to
post menopausal decreases in oestrogen. [Oestrogen inhibits osteoclast proliferation and activation,
and promotes activity of osteoblasts]. At 72 years old, it is possible that the osteoporosis also could
be due in part to vitamin D deficits, perhaps due to diet, poor absorption, inadequate exposure to
sunlight, or associated with renal disease.
[Conceivably, there also could be osteoporotic changes in the jaws which would make the bone loss
following tooth loss more severe...]

Comment:

Generally well done the presentation was a combination of cases or minicases we explicitly
discussed in class. A few of you thought that the hunched back was due to prolonged bad posture,
and didnt comment on the likelihood of osteoporosis: this is not very likely.

The owner of the nightclub, 64 year old James Cobber McCracken, complained that he
had tried to stop the fight by throwing a fire-extinguisher at the combatants.
However, as he told reporters, With all the rheumatism in my hands, I could hardly pick
the thing up.
Television news footage that night focussed on his knuckles, which were deformed and
swollen. His fingers appear shortened and deviated to the ulnar side.
Question 3.
Presumably Mr McCracken has rheumatoid arthritis. If so, how would the arthritis interfere with his
ability to pick up a fire extinguisher (which weighs several kilograms)?
What structural changes would be responsible for his impaired function?
What would you expect to see on a radiograph of his hands?

(9 mins)

Answer: [cf ORiordan case, minicases ]

RA => reduced ability to pick up fire extinguisher due to:

: reduced flexion at MCP joints due to erosion, subluxation, tendon displacement depending on the
level of disease progression;
: pain in joints due to inflammation associated with RA
: if RA has progressed to include wrist, pain in wrist joints [due to compressive loads] would
reduce effectiveness of finger flexors; may involve synovial sheaths in carpal tunnel => pain and
reduced range of motion; inflammation and possible carpal bone collapse => carpal tunnel syndrome
93

due to pressure on median nerve => pain, reduced sensory feedback from fingers, joints
: since the extinguisher weighs several kg, Cobber would need to recruit his deep finger flexors (fl
dig prof) for a power grip, which would exacerbate all the features above.
Radiographs: damage mainly to MCP joints => reduced joint space, some subluxation, ulnar
deviation, subchondral sclerosis, bone erosions or cysts around perimeter of joint, possible
osteophytes; if RA more advanced, then similar observations for joints between carpal bones and
perhaps radio-carpal joint.

Comment:

This question was a straight re-write of the presentation of RA in the ORiordan case. It was a bit
surprising that more of you didnt do better on this question. If you just listed a whole lot of generic
factors associated with RA without relating them to the presentation, you did not pass the question.

One of the television camera operators, Cherie-Marie Schwartz, aged 29 and a

competitive netballer, slipped and fell down some steps when filming outside the
nightclub. She felt intense pain in her right knee which had been reconstructed after a
netball injury three years previously. Although she had extensive physiotherapy
following the surgery, the knee still felt weak sometimes, and showed a modest anterior
drawer sign.
Question 4.
Compare the features that provide structural stability to the knee during quiet standing and more
vigorous activity such as carrying a load up and down steps.
What was the most likely injury that Ms Schwartz suffered when playing netball?
Why would her knee still feel weak three years after the reconstructive surgery?

(9 mins)

Answer: [cf Latimer case; minicases]

Stability during quiet standing: mostly ligaments = ACL, PCL, lateral and medial collaterals. Centre of
gravity runs anterior to knee, forces it into extension and most load is taken by ACL which limits
extension.
During activity, additional support from muscles crossing knee [up to about 25% of strength ]. Most
important = quadriceps anteriorly; tensor fascia lata laterally; sartorius and gracilis medially;
hamstrings posteriorly. [ these muscles often work eccentrically to support knee under loading ].
Anterior drawer sign => she probably ruptured her ACL [ presumably due to hyper-extension ].
Weakness probably due to poor healing of ligaments. If anterior drawer sign is present, then this is
evidence that the ACL has healed at a longer length than normal. This deficit is corrected only slowly
if at all.

Comment:

Well done overall, although some of you mixed up the functions of the collateral ligaments. If you
didnt give a reasonably good account of the role of the muscles in providing dynamic support for the
knee, it was hard to pass the question.

After several hours of unhelpful interviews with witnesses of the nightclub fight, the
detective in charge of the case, Broderick Van Noorden, aged 51,184 cm tall, weighing
121 kg, hypertensive and borderline diabetic, complains to his workmates that he has a
dreadful pain in his lower back.
Must be the cheap chairs they give us these days, he mutters.
Question 5.
Discuss the most common causes of lower back pain in middle aged adults.
How could you distinguish between them?
How could you reduce the risk of back pain developing in the first place?
94

(9 mins)
Answer: [cf Tonetti case, minicases]

Sources of back pain: muscle strain / damage; ligament damage [could be associated with avulsion of
attachments to vertebrae]; intervertebral disk prolapse => pain from the prolapse, or via pressure on
spinal nerve; osteoporotic degeneration => bone pain, pressure on nerves; osteoarthritis => joint
pain, osteophytes => inflammation, pressure on nerves; inflammatory joint disease of vertebrae;
osteomyelitis; osteosarcoma.
Examination => flex / extend / lateral flexion => source of pain = first pass distinction between
muscular or discs [ usually muscular give pain bending both ways cf discs only one side ]; tap
vertebral spines for bone damage; sciatic / femoral nerve stretch tests for root inflammation; bone
scans for OP [DEXA]; CT for OA or other degenerative disease; perhaps MRI for osteomyelitis,
osteosarcoma.
Reduce risk: => good lifting practice; reduced body weight; increased fitness; [ reduce diabetes =>
reduced risk of microvascular disease and perhaps consequential bone degeneration ]. If OP, then
adjustments to diet, VitD intake if necessary.

Comment:

Given that this question comes straight out of the presentation of the Matt Tonetti case, it was not
done well overall. Most of you gave a couple of potential causes, a cursory differentiation of them,
and then a decent list of suggestions to prevent injury. However, if you managed this without any
errors, you squeaked a pass on the question.

Three weeks after the nightclub incident, a male aged about 25 years, referring to
himself only as Dog, presents to a regional hospital with an extremely painful wrist. He
says he must have hurt it playing football. Examination reveals that dorsiflexion, radial
deviation or generating a power grip all produce pain in the region of the anatomical
snuffbox. X-rays reveal a line of reduced density across the mid-section of the scaphoid
bone.
Question 6.
Discuss the process of bone healing after a fracture.
Under what conditions might a fractured bone not heal properly?
What is the likely outcome of this case?
How will the outcome affect the function of the wrist in the future?

(9 mins)

Answer: [cf ORiordan and Kominski cases, minicases]

Process of bone healing is not very different from basic bone formation. After the break, a clot forms
between the fractured ends of the bone [bones are heavily vascularised], and the gap between the
fractured surfaces is spanned by fibrin (assuming the bone has been set so that the fractured
surfaces abut). The fibrin clot is invaded by mesenchymal stem cells including osteoblasts [probably
derived from nearby periosteum] => a callus. In some cases, chondroblasts appear first [probably
also from the periosteal stem cells]. Osteoblasts form osteoid and then woven bone to bridge the
fracture via the callus. [if chondrocytes have made cartilage, the osteoblasts will use this cartilage as
a model and eventually replace it ]. Then remodelling, involving osteoclasts and osteoblasts, will realign the repaired bone with the loading forces if it has been set out of alignment.
Healing may not occur if:
: the fractured ends are not set adjacent to each other.
: the blood supply to the bone is compromised (=> avascular necrosis)
: the bone is badly osteoporotic
[other factors that impair healing are concurrent infection and inflammation, no matter what the
cause ]
95

Fracture of the scaphoid can lead to avascular necrosis. If the scaphoid had been broken 3 weeks
previously, and the fracture is still evident on X-ray, then the chances of avascular necrosis are high.
If so, the movements of the wrist will be compromised mainly due to pain, especially during loading
in a power grip or during radial deviation.

While Dog is being treated in the regional hospital, his mother calls the police,
reporting him missing. Aged 67, she is 157 cm tall, weighs 88 kg, and only recently gave
up smoking. She now is awaiting hip replacement surgery due to severe osteoarthritic
degeneration of the hip joint.
Question 7.
Discuss the pathogenesis of osteoarthritis.
What specific features would you expect to see in advanced osteoarthritis of the hip joint?
How would hip mobility be affected by the arthritis?

(9 mins)

Answer: [cf Kominski and Latimer cases and minicases]

OA can be a result of abnormal articular cartilage and normal loading, or normal cartilage and
abnormal loading => can be caused by injury or it can be idiopathic. In either case, the primary
defect is in the biochemical composition of the matrix of the articular hyaline cartilage. Normally
highly hydrated matrix of glycoproteins / proteoglycans [mostly chondroitin sulphate and hyaluronic
acid along with collagen type II; matrix = avascular, aneuronal, low metabolic activity]. During
pathogenesis of OA, over activity of matrix metalloproteinases => breakdown of articular cartilage
=> fibrillation => reduced ability to act as smoothly lubricated surface => further wear and
breakdown, made worse by continued use. Eventually the articular cartilage breaks down totally and
exposes subchondral bone surfaces leading to erosion and eburnation. Subsequent bone pathology
includes subarticular scelerosis and osteophytes. There may be secondary inflammation of the joint.
In the hip, expect to see reduced joint space between head of femur and acetabulum; possibly
osteophytes around rim of acetabulum and neck of femur.
Hip mobility reduced by pain and potentially reduced range of movement due to osteophytes.

Called in by the police for further questioning, Robert The Rat Johnson now admits that
he started the nightclub fight with Dog. The fight was over a woman known as Two
Faced Jane, whose face had been severely cut by a broken beer glass many years
previously. The police photograph clearly shows a deep scar running from behind her eye,
across her cheek, down to the angle of her jaw. Much of this side of her face remains
expressionless.
Question 8.
Which main muscle groups contribute to facial expression?
Why has Jane lost expression on one side of her face?
What other problems is she likely to have developed as a result of the injury?
Is her ability to eat and drink likely to have been affected? Explain.

(9 mins)

Answer: [cf Justin Mills and minicases]

Muscles of facial expression include groups associated with forehead (eg frontalis, corrugator
supercilii), nose (eg nasalis), orbit (eg orbicularis orbis / oculi), cheeks (eg buccinator), mouth
(egorbicularis oris, zygomaticus, risorius, levator / depressor labii), and chin (eg mentalis, platysma).
Janes scar suggests her facial nerve has been severed.
96

Other problems might include dry eyes (inability to blink properly [although tear production should
still be normal]), problems with speech due to impaired ability to move lips properly on one side,
increased risk of tooth decay on affected side due to paralysis of buccinator and reduced ability to
move food scraps from lateral region of mouth.
Chewing and biting will be OK, since muscles of mastication [masseter => chewing, temporalis =>
biting, pterygoids => grinding] innervated by [mandibular branch of] trigeminal nerve. However,
impaired actions of orbicularis oris and buccinator => increased chance of drooling. Swallowing is OK
no damage to nerves to these muscles [mostly CN IX]

Despite Mr Johnsons confession and unwillingness to press charges, the police search for
Dog to charge him with attempted murder. During an ensuing car chase through the
outer suburbs, Dog hits a 17 year old girl riding a bicycle. She was wearing a helmet
and seemed at first not to be seriously hurt. However, she reported a severe pain in her
neck, and she felt as though her head was about to fall off. X-rays revealed a fracture
at the base of the odontoid process of the axis with some dislocation of the atlanto-axial
joint. She was treated with a halo brace that immobilized the joint and she made a full
recovery.
Question 9.
How do movements at the atlanto-axial and atlanto-occiptal joints contribute to the orientation of the
head?
How is the position of the head normally set and stabilised?
What would have been the most probable outcome if the cyclists odontoid process had become
dislocated rather than fractured?

(9 mins)
Answer: [cf Justin MIlls case and minicases]

Atlanto-occipital joints => gentle nodding [via pair ellipsoid / condyloid joints] = flexion /extension
Atlanto-axial joints => gentle rotation to left / right [via dens / odontoid process held in place by
transverse ligament]
Position of the head is set by complex of muscles [centre of gravity of the head lies in front of the
atlanto-occipital joint => tend to flex with gravity]
: support via sternocleidomastoid, splenius capitus, erector spinae.
Turn to one side via contralateral sternocleidomastoid and ipsilateral splenius and erector spinae.
Precise setting of head position by deep small muscles assocaited with atlas and axis [rectus capitus
major / minor; superior / inferior obliques]
Flexion via longus capitus, gravity.
Dislocation of the odontoid process => probably tear into adjacent spinal cord / brain stem => fatal.

97

Many years later, Broderick Van Noorden, Robert The Rat Johnson and a character
known even to his mother as Dog are sharing a drink in the bar they bought together
after securing a lucrative deal with up and coming television producer Cherie-Marie
Schwartz. They are watching their grandchildren play around the barbeque. When one of
them falls off a chair, with little apparent lasting injury, Broderick remarks Its amazing
how tough those kids seem to be ...
Question 10.
How do the different components of bone contribute to its strength?
Why do childrens bones seem to be tougher than those of adults? In other words, why do childrens
bones resist fracture better than adult bones?
Conversely, which features of childrens bones could lead to permanent impairment if damaged prior
to maturity?

(9 mins)

Answer: [cf minicases]

Compressive strength and hardness due to the mineral component = calcium hydroxyapatite.
Tensile strength and toughness / elasticity = organic component = collagen [type I]
[Collagen matrix provides the structural framework for bone calcification eg in osteons / Haversian
systems ]
Childrens bones have higher proportion of collagen => somewhat more flexible => less likely to
fracture completely => Greenstick fracture.
[very young children - babies - still have significant regions of cartilaginous skeleton that is much
more flexible that bone]
Childrens bone have epiphyseal plates => continued longitudinal growth via ongoing proliferation of
cartilage and replacement by osteogenesis in the growth plate. If growth plates are damaged, any
further longitudinal growth of the bones is prevented.

END OF EXAMINATION

98

feedback on mss exam 2007

THE PROCESS:
This was the third year in which we used a pure pass / fail criterion based marking system for
MSS. The sample answers were generated by Ian using realistic time constraints: ie each
sample answer was initially written in 9 minutes. A few of them were edited subsequently to
take into account some of the acceptable alternative ways of answering that some of you
came up with.
In order to clearly pass any question, you had to get nearly all of the key points in the sample
answers. This sounds tough, but by setting the standards this high, we can be sure that when
we say youve passed, we can be confident that you really do know the material. If you did
not show a clear pass on the question it was usually scored as a borderline. Fails were
reserved for badly incomplete or erroneous answers.
You had to get clear passes on 7 of the 10 questions to pass the exam. Any paper that did not
reach this criterion on the first marking was looked at again and each borderline question was
re-marked by both Sue and Ian, until it was clear that the paper was an overall pass or fail.

THE ANALYSIS:
Overall, we were somewhat disappointed by the quality of the answers this year.
Nevertheless. some of you did really well right across the paper. Two of the questions should
have been familiar to you: question 3 asked about a set of actions that were a key element of
the Mary ORiordan case; and question 8 was an extension of one of the mini-cases that we
spent quite a bit of time working through in one of the half-class sessions. Nevertheless,
neither of these questions was done very well.
Part A and Part B of the written paper were matched: in each part there was a question about
bone metabolism, joint pathology, upper limb function, lower limb function, and the axial
skeleton / trunk. One question in each pair was somewhat more straight forward than the
other. In general, you did the questions with a higher component straight recall better than
those where you had to interpret the question a little more carefully and synthesise an answer
from what you know. This suggests that many of you did not really come to grips with
notions of how things work. There is a statistical analysis of these outcomes following the
sample answers.
Many of you gave us the impression that you had not carefully read the question. For
example, in each question, we told you what the presenting complaint was: you didnt need to
try to come up with a diagnosis - and those of you who did, usually got it wrong...

99

FLINDERS UNIVERSITY ADELAIDE AUSTRALIA

SCHOOL OF MEDICINE

AUGUST
EXAMINATIONS
2007
SECOND YEAR BMBS
KNOWLEDGE OF HEALTH & ILLNESS

MUSCULOSKELETAL SYSTEM
TIME:

1 hour 30 minutes

MATERIALS ALLOWED IN THE EXAMINATION ROOM:

None

INSTRUCTIONS TO CANDIDATES:
Write your student number on each examination booklet AND the attached marking slip.
Start answers to each question on a new page.

MARKING SCHEME:
Each question will be marked to a pass/fail set of criteria.
To pass the exam, you must pass seven (7) of the ten (10) questions.
All questions are weighted equally.
This examination is in 2 sections: Section A and Section B, which are weighted equally.
Section A

Questions 1-5 (Suggested time 45 minutes)

Answer these 5 questions in the answer booklets marked Section A

Section B

Questions 6-10 (Suggested time 45 minutes)

Answer these 5 questions in the answer booklets marked Section B

You are encouraged to make use of diagrams in your answers.

100

SECTION A

(allow 45 minutes to answer this section; all questions are

weighted equally)

Walter Smithson, aged 47, has been battling alcoholism for more than 20 years. He reports
increasingly severe pain and stiffening in his right hip that suddenly has become even worse.
Radiographic investigation reveals collapse and marked sclerosis of the head of the femur with
adjacent areas of rarefaction. This appearance is consistent with avascular necrosis due to
microvascular disease associated with prolonged alcoholism.
Question 1.
How do you explain these abnormalities in the appearance and strength of Mr Smithsons femur? Why
has the head of the femur collapsed? How would you treat the problem with his hip? Explain your
rationale.

[9 mins]
ANSWER:
Normal bone is highly vascularised: strong link between microvasculature and microscopic structure
of the bone in that each osteon / Haversian system has a blood vessel / capillary running inside the
Haversian canal. The blood vessels provide nutrients to the bone cells, and interact with them in the
regulation of bone metabolism (eg: remodelling of bone must include remodelling of the
microvasculature; calcium moves between the bone matrix and the circulation).
If the microvasculature is compromised, so is bone metabolism and bone structure. Initial response is
an attempt by bone to recover / repair leading to sclerosis (like bone scarring): hyperdense, but not
very strong. Then, ischaemic / sclerotic bone collapses and degenerates, leading to reduced bone
density. Increased resorption also could be a consequence of an inflammatory reaction to the
necrosis.
Head of the femur experiences very high loads during normal activity: probably collapsed at point of
contact between head of femur and acetabulum.
Pain due mostly to bone damage; possible osteoarthritic degeneration and inflammation around joint
secondary to on-going ischaemic damage to bone.
Most likely treatment is hemi-arthroplasty (ie replace head of femur). (bone cannot recover in face of
ongoing ischaemia). Depending on level of any associated osteoarthritic damage to joint, may require
total replacement. Try to manage alcohol abuse, in attempt to prevent further vascular disease,
including risk of DVTs after surgery. Consider dietary deficit in vitamin D secondary to alcoholism.
COMMENT:
Overall, this question was not done very well. Many of you commented about the poor blood supply
to the neck of the femur, which is true and certainly contributes to worsening the problem. However,
very few of you made the straightforward connection between the necessity for a functional
microcirculation in the bone, and the maintenance of normal bone function. Remember: every osteon
/ Haversian system has a blood vessel within that is essential for providing nutrients to the bone cells,
and is an critical part of the remodelling process... A lot of you didnt mention the sclerosis at all (it
featured in at least two of the mini-cases). It was hard to pass the question clearly if you didnt
answer the last part: what you could do about Mr Smithsons condition...
Question 2.
What features limit the movement of a healthy hip joint? How do they contribute to the stability and
load bearing capabilities of the hip? What are the most common reasons for failure of the joint?

101

[9 mins]
ANSWER:
Overall stability provided by deep ball and socket structure (head of femur to acetabulum, deepened
by acetabular labrum, and stabilised by tight joint capsule).
Extension limited by ligaments of joint capsule: iliofemoral / ischiofemoral / pubofemoral,
Flexion limited by hamstrings when knees are extended; by rest of body when knees flexed.
Abduction limited by contact between greater trochanter and rim of acetabulum; range extended by
lateral rotation which moves greater trochanter out of the way.
Adduction limited by other limb and ligaments.
During quiet standing with hip extended, most of the load is taken by iliofemoral ligament (tightened
by centre of gravity going behind the hip joint). [Some postural stability provided by iliopsoas,
quadratus lumborum, and erector spinae.]
Hip joint failure:
- avascular necrosis: vascular disease, fractured neck of femur
- osteoarthritis: wear and tear, idiopathic disease
- posterior dislocation when flexed (following impact onto knees)
- osteoporosis, leading to fractured neck of femur, collapsed femoral head
- consequences of developmental dysplasia
COMMENT:
The question was mainly about the limits to hip joint movement... many of you went off talking
about all the muscles that move the hip without addressing the limits to movement: if this is all you
talked about, it was hard to pass the question. The stabilisation of the sacro-iliac joint, while
important to the strength of the pelvis, it not part of the hip joint...
--------------------------------------------------------------------------------------------------------------------------

Mrs Millie OToole, aged 72, has had considerable pain and stiffness in the muscles of her shoulders
and pelvic region for the preceding 6 weeks. Picking up even light objects has become difficult. Her
ESR (erythrocyte sedimentation rate) is abnormally high. Suspecting polymyalgia rheumatica, an
inflammatory condition affecting muscles, her doctor prescribes prednisolone, and two days later, her
pain and stiffness have regressed significantly .
Question 3.
Briefly describe the muscles and their actions involved in picking up a light object, such as a piece of
clothing on the floor. Why would Mrs OTooles shoulder stiffness impair this activity?

[9 mins]

ANSWER:
Starting at the hand: picking up light object requires precision grip:
- flex fingers with flexor digitorum superficialis (attach to middle phalanx) in combination with
lumbricals to set angles of MCP / IP joints (the object is light so not much call on fl. dig. profundus)
- thumb position set by thenar muscles (flexor pollicis brevis, opponens pollicis, adductor pollicis)
and flexor pollicis longus.
- wrist position set by flexor carpi radialis & ulnaris, extensor carpi radialis & ulnaris; may be some
setting of pronation / supination position using pronator teres & quadratus / supinator.
- elbow flexion mostly by brachialis; may be also brachoradialis depending on pronation /
supination position and weight of object.
102

- overall position of arm set by position of shoulder using rotator cuff and deltoid. Also serratus
anterior, pectoralis minor, rhomboids position shoulder and provide strength for the lift. Almost any
movement of the upper limb requires movement of the scapula as well as the gleno-humeral joint.
Therefore, inflammation and pain in any of these muscles would generate stiffness and reduced
strength / mobility.
COMMENT:
This question was almost exactly the same situation as seen in the Mary ORiordan case, where she
had a problem in picking up her kettle. Despite this, many of you could not give a precise description
of a sequence of muscle actions involved in picking up a light object, and very few of you mentioned
the simple point that if you move your arm, you nearly always move the shoulder in some way.
Some of you took a cue from the question stem and decided to focus on the muscles of the
shoulders, back and hips. This was OK, but you still had to get them correct: lots of eccentric
contractions going on to hold the body against gravity, eg erector spinae, , hamstrings at hips,
quadriceps acting at knees, triceps surae (mostly soleus) at ankle.
Another strange track that some of you took was to speculate on the cause of the shoulder stiffness,
and went on to talk about various ideas of arthritis etc. But the question told you that the problem
was muscle stiffness... there was no need to consider anything else. So no credit for doing so.
--------------------------------------------------------------------------------------------------------------------------

Shoulder pain and impaired function also can be caused by generalised rheumatoid arthritis. Some
improvement may be obtained by operative synovectomy (ie, surgical removal of some of the
synovium) of the glenohumeral joint.
Question 4.
What changes would you expect to see in a plain radiograph of the glenohumeral joint affected by
severe rheumatoid arthritis? Explain your predictions. Why would removing some of the synovium
improve joint function?

[9 mins]

ANSWER:
Serious RA of a large joint would include:
- loss of joint space due to erosion of the articular cartilage (inflammation from enlarged pannus
derived from synovial membrane).
- degeneration of bone under joint surfaces (subchondral cysts) seen as regions of sclerosis
adjacent to areas of reduced bone density;
- probably further osteoporosis of bone adjacent to joint due to on-going inflammation promoting
osteoclast activity over osteoblast activity.
- possible osteophytes around margins of joint in response to damaged articular bone and
secondary osteoarthritic changes.
- possible misalignment of joint due to damaged / degenerated joint surfaces / glenoid labrum; also
possible involvement of tendons near joint (eg. long head of biceps)
Shoulder joint has a large loose capsule, lined with synovial membrane; removing some of this will
reduce amount of inflamed synovium and thereby reduce total joint inflammation and help slow down
or prevent further damage to the joint from the RA. Reduced swelling etc also would help increase
joint mobility if the articular damage has not gone too far.
COMMENT:
This question was well done overall. Some of you fell into the trap of forgetting that the question was
about the shoulder, not the hands or feet...
--------------------------------------------------------------------------------------------------------------------------

103

Frank Fittler (known to his associates as Freaky), aged 35, felt a severe pain in his back while lifting a
bag of fertilizer destined for his hydroponic herb garden. He was unable to straighten his back, and
felt additional pain radiating through his lower right leg. Two days later the pains were still present.
CT scans revealed a prolapsed disc between the 4th and 5th lumbar vertebrae.
Question 5.
What is the normal function of an intervertebral disc? How does it work? What happens when a disc
prolapses? How could this lead to pain in Freaky Franks lower leg?

[9 mins]

ANSWER:
Main function of intervertebral disc is to act as shock absorber between adjacent vertebrae. Also acts
to allow some degree of movement between the vertebrae.
Disc consists of jelly-like core = nucleus polposus, made of highly hydrated glycoprotein matrix, so
mostly = water.
Outer layer = annulus fibrosus = fibrocartilage with concentric bands of collagen fibres; each layer of
collagen runs in an opposite direction (similar to cross-ply tyre).
Core of the disc is largely incompressible, as long as outer layers hold => resists compressive forces,
typically generated during flexion / lateral flexion.
Prolapse occurs when the annulus fibrosus ruptures leading to expulsion / protrusion of the nucleus
polposus when loaded. This generates pain due to tissue damage in the disc itself, associated
inflammation affecting nearby tissues, such as longitudinal ligaments of vertebrae.
Pain in leg could be due to inflammation spreading to sheath of nearby spinal nerve roots; pressure
from disc on the nerves with associated inflammation; potentially also could be segmentally referred
pain from the disc and surrounding tissue.
COMMENT:
This question was well done by most of you. Some of you did an excellent job of explaining the
various options for generating the radiating pain. A few of you didnt seem to notice that the
questions told you the level at which the prolapse occurred and headed off into other areas of the
vertebral column...
-------------------------------------------------------------------------------------------------------------------------

As a teenager, Helen Vander fell down some stairs and badly broke her ankle. She went on to play
basketball semi-professionally, and during her playing career, she severely sprained the same ankle
on several occasions. Now, aged 53, she has severe degenerative arthritis of talo-crural and subtarsal joints. It is likely the ankle will need to be treated by arthrodesis (surgical fusion of the joints).
Question 6.
Briefly discuss the normal pathogenesis of osteoarthritis? How can injury to a joint pre-dispose it to
developing osteoarthritis?

[9 mins]

ANSWER:
OA can be idiopathic or as a result of injury to the articular cartilage. Initial damage associated with
eburnation or fibrillation of the cartilage. Collagen fibres just below articular surface of cartilage start
to fray as matrix breaks down; matrix metalloproteinases increase activity leading to hydration and
degeneration of matrix. All this leads to reduced ability to act as lubricating / load bearing surface
=> further wear => further damage and so on.

104

As articular cartilage degenerates further, small pieces may flake off into joint => clicks and
crepitations; further wears gets down to subchondral bone, leading to more pain, reduced joint
function. Continued wear / abnormal loading on bone may lead to formation of osteophytes around
joint margins. Secondary inflammation may contribute to pain, swelling, osteoporosis around joint.
Injury to cartilage not well repaired. Hyaline cartilage tends to be replaced by fbrous connective
tissue => reduced / impaired lubrication properties => predisposed to further degenerative change.
COMMENT:
Quite a few of you mixed up the involvement of chondrocytes and osteocytes iin the pathogenesis of
the bone abnormalities.
Question 7.
Compare how the ankle and foot absorb the loading forces generated by quiet standing, walking and
landing from a jump. What are the relative contributions of the skeleton, ligaments and muscles in
each case?

[9 mins]

ANSWER:
Quiet standing: load taken by bones and ligaments holding them together. Ankle tends to be
dorsiflexed, which is more stable (held together by collateral ligaments).
Longitudinal arches of feet supported by longitudinal ligaments (eg plantar calcaneo-navicular; spring
ligament); talus supported as top of arch (keystone) by sustentaculum tali of calcaneus. Transverse
arches supported by wedge-shaped cuneiforms and proximal ends of metatarsals, held together by
ligaments.
Walking: at heel-strike, tibialis anterior contacts eccentrically to transfer load from heel to front of
foot. Loading in foot mostly taken by the bone of the arched.
Landing from a jump: landing on toes => posterior calf muscles (esp. gastrocnemius) contract
eccentrically to absorb load; tibialis posterior; fibularis (=peroneus) longus help support arches and
contract eccentrically to absorb impact forces / loads.
COMMENT:
A common error here was confusing the eccentric and concentric contractions of the muscles around
the ankle: if you land from a jump onto your toes, the posterior compartment (plantar-flexors) work
eccentrically; if you place you weight onto your heels as in normal walking, then the anterior
compartment (dorsiflexors = extensors) work eccentrically.
--------------------------------------------------------------------------------------------------------------------------

You may remember Mrs McGuiness, who was suffering from Pagets disease. One consequence of the
disease was that her skull showed areas of low bone density (osteoporosis) adjacent to areas of high
bone density (osteosclerosis) accompanying a net increase in apparent thickness of her skull. Her
disease is now being treated with bisphosphonates that inhibit osteoclast activity.
Question 8.
Briefly discuss the main factors that contribute to the maintenance of normal bone density in healthy
people. How would inhibition of osteoclast activity slow the progression of Mrs Guiness disease?

[9 mins]
ANSWER:
Bone density depends on maintaining proper balance between osteoblast and osteoclast activity:
regulated by levels of oestrogen / vitamin D / parathyroid hormone / weight-bearing exercise.

105

Oestrogen promotes activity of osteoblasts and inhibits activity of osteoclasts (inhibits formation of
osteoclasts from precursor cells; promotes apoptosis of osteoclasts).
PTH levels increase in response to low blood calcium levels; promotes osteoclast activity via receptors
on osteobalsts; also promotes calcium retention by kidneys.
Vitamin D required to maintain bone mineralisation; activates both osteoblasts and osteoclasts;
activated osteoclasts release calcium to be used by nearby osteoblasts.
Cytokines (eg IL-1, IL-6, TNFalpha) generated by inflammation around joints or bone infection
activate osteoclasts => localised reduction in bone density
Overall bone mass maintained / increased by weight-bearing exercise (sensor may be piezo-electric
effects); peak bone mass probably achieved in most people as young adult / early middle-age; bone
loss proceeds from there.
Inhibition of osteoclasts will lead to reduction of bone loss in Pagets disease; likely to help break
cycle of out-of-control feedback between osteoclasts and osteoblasts => reduces rampant
remodelling.
----------------------------------------------------------------------------------------------------------------------------

Kane LeMont, aged 19, fell into an alcoholic stupor after a night of heavy drinking with his mates. He
had passed out in a kitchen chair with his right arm draped over the back of the chair. When he
finally awoke several hours later, he realised that he could not move his arm properly and got taken
to hospital. Examination revealed compression damage to the posterior cord of his brachial plexus.
Question 9.
How would this injury affect the function of Kanes upper limb? Which muscle groups and actions
would be affected? If the lesion to the brachial plexus did not recover, how could you maximise the
remaining function in his limb?

[9 mins]
ANSWER:
Posterior cord continues on as radial nerve => loss of function to all extensor compartment =>
- no active elbow extension (triceps; could use gravity and elbow flexors eccentrically)
- brachoradialis inactive => reduced elbow flexion strength, especially in mid supine/prone position
- no extension of wrist (extensor carpi ulnaris / radialis) and weakened ulnar / radial deviation (only
flexors available)
- impaired power grip due to inability to hold wrist steady
- loss of finger extension => reduced fine control of fingers (must rely on lumbricals interacting
with flexors)
Function improved by providing a wrist splint / support to prevent passive flexion => more power
grip strength; more stability at wrist for precision movements.
COMMENT:
Many of you didnt really define very well which muscles at which joints would be affected by the
lesion.
Also, its important to get the names of the nerves correct: the one that goes around the neck of the
humerus is the axillary nerve, not the axial or ax-anything else...
----------------------------------------------------------------------------------------------------------------------------

106

Jody-Louise Heffernan, aged 17, was knocked off her bicycle by a car. She went over the handle bars
and landed on the back of her head and neck. She was wearing a helmet and was lucky not to be
more seriously injured. However, she had a severe pain in her neck, and she felt as though her head
was about to fall off. X-rays revealed a fracture at the base of the odontoid process of the axis with
some dislocation of the atlanto-axial joint. She was treated with a halo brace that immobilised the
joint and she made a full recovery.
Question 10.
How do movements at the atlanto-axial and atlanto-occiptal joints contribute to the orientation of the
head? How does the rest of the cervical spine contribute to the full range of movements of the head?
What would have been the most probable outcome if Jody-Louises odontoid process had become
dislocated rather than fractured?

[9 mins]

ANSWER:
Atlanto-occipital joint (C1 => occipital condyles of skull) => gentle flexion / extension (ie nodding)
Atlanto-axial joint (C1 => C2) => gentle rotation from side to side (ie shaking head); atlas rotates
around the odontoid process (= dens) of axis; held in place by transverse ligament.
[Position of head at these joints controlled by vestibular and visual inputs via brain stem motor
pathways]
Facets of cervical vertebrae oriented more or less in transverse plane (+ flexible intervertebral discs;
small spinous processes) => some movement in nearly every direction: flexion / extension; rotation;
lateral flexion. Contribute to more extreme movements of head and neck (eg turning to look behind).
Dislocation of the odontoid process => tear / rupture of transverse ligament => highly likely that it
would spear into brainstem / cervical spinal cord => almost certainly fatal.
COMMENT:
You really needed to use correct anatomical terminology here: you are training to be professionals...

END OF EXAMINATION
************************************

107

mss written exam 2007

fail

borderline

pass

strong pass

---------------------------------------------------------------------------------------------------------------------Q1. bone metabolism*

13

27

49

18

Q2. lower limb

14

22

59

12

Q3. upper limb*

19

40 +

38 -

10

Q4. joint disease*

3-

16

79 +

Q5. axial

0-

81 +

19

Q6. joint disease

3-

15

74 +

15

Q7. lower limb*

23 +

24

51

Q8. bone metabolism

14

30

58

5-

Q9. upper limb / nerves

20 +

20

52

15

Q10. axial*

14

29

44

20

----------------------------------------------------------------------------------------------------------------------

OVERALL

12

23

59

13

---------------------------------------------------------------------------------------------------------------------* bold questions

non-bold questions

= require synthesis
= mostly recall

bold numbers = significant deviation from overall pattern:

+ => more than expected
- => less than expected

fail

borderline

pass

strong pass

---------------------------------------------------------------------------------------------------------------------recall questions

9%

18%

61%

12%

synthesis questions

14%

25%

49%

12%

----------------------------------------------------------------------------------------------------------------------

108

and now a bit of art ....

ODE TO A KNIGHT-IN-GA
by
Simon Marrable, Paul Lambert, Shona Charlton & Chris Brampton
Year 2 BMBS 2001
reprinted here by permission of the authors
{published originally in placebo november 2001}

Twas a strange time in August

When I came to this land,
A place of head
And of arm
And of foot
And of hand.
Here I found a problem
Of a muscular kind
And a problem with brains
But pay that no mind.
We picked up some dead bits
And flopped them around,
Delved superficious
And skimmed past profound.
Is this rectus of longus?
Or brevis supine?
Does it adduct my leg?
Or hold up my spine?
What say you Prof Gibbo?
To this problem of mine.
Id look in a book
But I dont have the time.
Well he looked at me strangely
And said Youll be fine
As he pulled up a corpse
And told me this rhyme.
Its a body you see
just how it goes.
Dont fret about latin
or coracoid crows.
Learn whats important
And the questions I pose.
But dont forget thumbs
And opposable toes.
Now longus is long
And rectus is straight.
109

Brevis is short
But may help your gait.
Quadratus is square
And vastus is great,
Frontalis is one
And biceps are eight.
Find a pec
Now a lat
Now a quad
And an ab...
No not over there
Did you not attend lab?
Now you see,
Sartorius helps when sowing up suits,
Though sitting cross leggeds
A pain in the glutes;
It also is known for sartorial splendour,
This rotator of legs
And inner knee bender.
Your knowledge seems little
Your future looks grim,
But tell a good story
And Ill pass you on a whim.
Just remember my words
And learn what you see.
And make sure you know
Your arse from your knee.

***************************

110