Superficial Fascia-the ---------layer, immediately ------to the skin/cutaneous layer; composed of loose connective tissue and adipose (fat) tissue

Contents of Superficial Fascia: superficial veins, superficial lymph nodes and lymph vessels, and cutaneous nerves

Superficial VEINS-carry blood from -----to -----; can generally be seen through the skin; in athletes, may bulge beneath the skin; in general, pass superficial to the cutaneous nerves.

Superficial Veins

a. ----------------------- Veins (8); label as 1 to 8 from medial to lateral or as medial and lateral of the *digit; collect blood from the toe and drain into dorsal metatarsal veins. 

Superficial Veins:

b. Proper Dorsal Digital Veins (2)

i.Proper Dorsal Digital Vein of the ------drains from the ---------aspect of the hallux and ------------; becomes the ---------------------

Proper Dorsal Digital Vein:

Proper Dorsal Digital Vein of the 5th Toe-drains from the ---------aspect of the 5th toe and --------; becomes the ----------------------.

Superficial Veins:

Marginal Veins-much variation with veins, and can be difficult to distinguish these, may be absent.

i. Medial Marginal Vein-drains from the ----------border of the ------and ------------; drains into the -------------------.

ii. Lateral Marginal vein-drains from the --------border of the forefoot and -------------; drains into the ------------------------.

medial border;forefoot and proper dorsal digital vein of the hallux; GREAT SAPHENOUS VEIN

lateral border; forefoot and proper dorsal digital vein of the 5th toe;

Superficial Veins

Dorsal Metatarsal Veins (4)

-one for each intermetatarsal space

-label as 1 through 4 from -----to------

-each receives blood from 2 adjacent ---------------veins and two perforating branches from deep layers of the foot

-drain into the ------------------

medial to lateral

dorsal venous arch

Superficial Veins

Dorsal Venous Arch

-passes across the -----of the foot often at the level of the metatarsal bases

-receives blood from ------------veins and sometimes the ----------

-drains into the -------------, medially and the----------- LATERALLY

dorsum;

dorsal metatarsal veins; proper dorsal digital veins

-Great saphenous vein (MEDIALLY), small saphenous vein(LATERALLY)

Superficial Veins

Small Saphenous Vein

-begins at the union of the ----- end of the dorsal venous arch and the -----------vein (or the --------------------)then passes ------to the lateral malleolus at the ankle region.

-travels-------near the midline of the leg, at the -------aspect, to the popliteal area where it passes through the deep fascia to join the popliteal vein, which is part of the ------------.

LATERAL; lateral marginal vein (or proper dorsal digital vein of the fifth digit);posterior

-superiorly;posterior;deep venous system

Superficial Veins

Great Saphenous Vein

-begins as the union of the MEDIAL part of the ----------- and the ------------(or the ----------), then passes ------to the medial malleolus at the ankle region.

-travels ------at the medial aspect of the leg, passes -----------along the popliteal surface (usually about 1 hand breadth posterior to the medial edge of the patella) and continues in a -------direction to the groin where it passes through the ------------------in the deep fascia to join the femoral vein which is part of the DEEP VENOUS SYSTEM.

dorsal venous arch; medial marginal vein(or the proper dorsal digital vein of the hallux); ANTERIOR;

-superiorly; posteriormedially;superolateral;saphenous opening/fossa ovalis

Superficial Veins

Superficial Plantar Venous Network

-very thin----and ---veins without-------!!

-drain into ----and ------or into------through perforating branches

-intradermal and subdermal veins; valves

-medial and lateral marginal veins; dorsal digital veins

Lymph Nodes:

inguinal lymph nodes-superficial inguinal lymph nodes (horizontal and vertical group), deep inguinal lymph nodes; popliteal lymph nodes, anterior tibial lymph node, subcutaneous pedal infections, deep pedal infections/deep infections of the foot

Lymph nodes

a)---------------located in the inguinal region, ---(where the thigh meets the hip), organized as 3 groups

i. Superficial Inguinal Lymph Nodes

-lie in the superficial fascia and are arranged as 2 groups

-usually are -------, but are firm and tender (painful to the patient) when inflamed

-most---vessels pass to the external iliac lymph nodes in the pelvis; a few pass to the deep inguinal lymph nodes

Inguinal Lymph nodes

-groin

-palpable

-EFFERENT

Superficial Inguinal Lymph Nodes

aa. Horizontal Group-lie along the --------------.

-drains the superficial areas of the ----------and a small area of the -------------.

bb. Vertical Group-lie along the TERMINATION of the --------and the --------

-drains from the superficial areas of the thigh, leg, and foot EXCEPT the -------aspect of the LEG and the -----aspect of the FOOT.

inguinal ligament

-inferior abdominal wall; proximal anterior thigh

-great saphenous vein and the fossa ovalis

-posterolateral; lateral

Deep Inguinal Lymph Nodes

-only -----when inflamed

-lie deep to the -----, along the -----vein near its termination

-not in the -------layer

-drain the deep tissues of the lower limb (tissues deep to the DEEP FASCIA)

-------vessels pass to the External Iliac Lymph Nodes in the pelvis

palpABLE

-fascia lata, femoral

-subcutaneous

-Efferent

Popliteal Lymph Nodes

-are ----lymph nodes and palpABLE only when inflamed

-lie along the --------vein near its termination and deep to the ---------

-drain the ----aspect of the leg and the ------aspect of the foot.

-efferent vessels pass to the ---------------.

deep

-small saphenous vein; popliteal fascia

-posterolateral; lateral

-deep inguinal lymph nodes

---------------------------Lymph Nodes

-usually one or two deep lymph node(s)

-lie near the----- end of the anterior tibial artery near the interosseous membrane, deep to the muscles here

-efferent vessels pass to the --------------

Anterior Tibial Lymph node

proximal

-deep inguinal lymph nodes

Subcutaneous/Superficial Pedal Infections

-an infection of the 5th toe will generally cause inflammation of the ------first, then inflammation of the ----------------.

-an infection of the Hallux will generally cause inflammation of the ----------first and this may pass to the ----, but will definitely pass to the ----------.

Popliteal lymph nodes; deep inguinal lymph nodes

-Vertical superficial inguinal lymph nodes; deep inguinal lymph nodes; external iliac lymph nodes

Deep Pedal Infections/Deep Infections of the Foot

-from ANY area, will creaste inflammation of the -----------

-from dorsum of foot,will generally create inflammation of the --------------FIRST

-from PLANTA of foot and Calcaneal region, will generally cause inflammation of the _________first

Deep inguinal lymph nodes

-Anterior tibial lymph node

-popliteal lymph nodes

Cutaneous nerves

-are nerves that exit the deep fascia and travel in the --------to supply the skin, -----and -------sympathetic fibers.

-are all from ---------rami except where noted (know These!!!!)

Cutaneous Nerves- Anterior View

Subcostal Nerve, (___)

-exits the deep fascia anterior to the -------- -----(lateral aspect of the hip)

-supplies a small area at the --------aspect of the thigh just inferior to the groin.

-cutaneous supply only in the lower extremity!

T-12

iliac tubercle

-anterolateral aspect

Cutaneous Nerve

Femoral Branch of the Genitofemoral Nerve, (    )

-passes deep to the -----------and exits the deep fascia near the fossa ovalis

-supplies a small area at the anterior thigh just inferior to the groin and ------to subcostal nerve distribution

L-1 & L-2 ("Femoral 1-2 punch)

-inguinal ligament

-medial

 Cutaneous Nerves

-------------Nerve, L-1

-exits the deep fascia through the ----- -------- -----(with the spermatic cord or round ligament of uterus)

-supplies a small area at the ---aspect of the thigh just inferior to the groin

ILIOinguinal Nerve

-superficial inguinal ring

-medial

Cutaneous Nerves

Lateral Femoral Cutaneous Nerve, (   )

-Also called the lateral cutaneous nerve of the thigh

-exits the deep fascia near the -------aspect of the iliac crest

-supplies the -----aspect of the thigh (from the subcostal nerve distribution to the knee)

L-2 & L-3 (Michael Jordan-Lateral Femoral)

anterior

-anterolateral

Cutaneous Nerves

Intermediate Femoral Cutaneous Nerve (   )

-also called the ----------------------

-sometimes replaced by the ---------or branches of the --------------------

-exits the deep fascia through the ------muscle lateral to the ----------------

-supplies the--------aspect of the thigh (from the ilioinguinal and genitofemoral nerve distributions to the knee)

(L-2 & L-3) 

-intermediate cutaneous nerve of the thigh

-femoral branch of the genitofemoral nerve or branches of the lateral femoral cutaneous nerve

-sartorius; fossa ovalis

-anterior

Cutaneous Nerves

Medial Femoral Cutaneous Nerve (L-2 & L-3)

-also called the medial cutaneous nerve of the thigh

-exits the deep fascia -----to the fossa ovalis

-supplies the --------aspect of the thigh (from the ilioinguinal nerve distribution to the knee)

        inferolateral

-anteromedial aspect of the thigh                                                                                                                                                                                                                                                                                                                                   inferolateral

Cutaneous Nerves-Anterior

---------Nerve, L-2, L-3, & L-4

-exits the deep fascia at the ----aspect of the thigh near the junction of the proximal and middle thirds

 -supplies the CENTRAL part of the ------aspect of the thigh (from the ilioinguinal nerve distribution to the inferior 1/3)

ObTUrator Nerve

-MEDIAL (supplies medial aspect of the thigh)

-MEDIAL

Cutaneous Nerves

Lateral Cutaneous Nerve of the Calf, (    )

-also called the ------------

-exits the deep fascia at the ----------edge of the knee region

-supplies the -----1/2 of the leg from the knee to the inferior 1/3 leg

L-5, S-1, S-2

lateral sural nerve

-posterolateral

-lateral

Saphenous Nerve, (    )

-the only nerve of the leg region that can be traced to the -------------

-exits the deep fascia at the inferomedial aspect of the thigh near the knee

-supplies the entire ------1/2 of the leg from the knee to the foot including the -----------; does NOt include the heel!

L-3 & L-4

lumbar plexus

-medial; medial longitudinal arch

---------------/-------------L-4, L-5, & S-1

-exits the deep fascia at the anterolateral aspect of the leg near midlevel

-supplies the anterolateral aspect of the ---1/3 of the leg, the anterolateral aspect of the ------ and the -----of the foot EXCEPT the lateral 1/2 of the ---and the ----------.

Superficial Fibular Nerve/Superficial PerONEAL Nerve

   -inferior

-ankle and Dorsum

-5th digit and the 1st web space

Deep Fibular Nerve/Deep Peroneal Nerve (   )

-exits the deep fascia at the --------

-supplies the -----and the adjacent sides of the --------- toes

L-5, S-1 & S-2

1st webspace

1st webspace; 1st and 2nd toes

Medial Calcaneal Nerve (   )

-exits the deep fascia at the posteromedial aspect of the ankle near the calcaneus; pierces the --------------

-supplies the ---1/2 of the HEEL; medially, plantarly, and posteriorly

S-1 & S-2

-flexor retiNAcuLUM

-medial

______Nerve, S-1 & S-2

-exits the deep facia at the posterior aspect of the leg in the proximal 1/3

-supplies a small area of the-------aspect of the leg from mid-calf, to the posterolateral aspect of the -------,the lateral aspect of the ---------, the lateral longitudinal ___and the lateral 1/2 of the -----.

Sural

posterior

ankle

foot

arch

Fifth toe

Cutaneous Nerves-POSTERIOR VIEW

Iliohypogastric Nerve, ()

-exits the deep fascia near the ----aspect of the Iliac Crest

-supplies the ==========area of the GLUteal skin, small area

L-1

lateral

superoposterolateral

Posterior View

****Superior CLUneal Nerves, ----RAMI of (   )

-also called the superior cutaneous nerves of the gluteal region

-exit the deep fascia at the ------aspect of the iliac crest

-supply skin of ------aspect of the GLUTEAL Region

DORSAL RAMI of L-1, L-2 & L-3

posterior

superolateral

Posterior View

Middle Cluneal Nerves, -----rami (   )

-also called the middle cutaneous nerves of the gluteal region

-exit the deep fascia over the -----------

-supply skin of the ---aspect of the Gluteal Region

DORSAL Rami (S-1, S-2, S-3 opp. of Superior Cluneal -L-1, L-2, L-3)

-Sacrum

-Medial

Posterior View

Posterior Femoral Cutaneous Nerve, ( )

-main branch passes inferiorly along the anterior aspect of the fascia lata

-small branches from the main branch exit the deep fascia all along the posterior aspect of the thigh, popliteal and calf regions

-supplies the inferior GLUTEAL region, the ______aspect of the thigh, the -------- and the superior ___aspect of the CALF

S-1, S-2 & S-3

Posterior; popliteal fossa, central

Posterior View

Posterior Femoral Cutaneous Nerve, S-1, S-2 & S-3

a. -------------------, S-1, S-2 & S-3

-branches of the posterior femoral cutaneous nerve that supply the _____area of the GLUTEAL region

-exit the deep fascia at the gluteal fold

Posterior View

Perforating Cutaneous Nerve, ( )

-From the ----plexus

-exits deep fascia the ------aspect of the gluteal region

-supplies the ---------- ------ area skin

S-2 & S-3

sacral plexus

-inferomedial

-inferomedial gluteal

Posterior View

Obturator Nerve (  )

Medial Femoral Cutaneous Nerve ( )

Lateral Femoral Cutaneous Nerve (  )

Saphenous Nerve (  )

Lateral Cutaneous Nerve of the Calf (  )

Superficial Fibular Nerve/Superficial Peroneal Nerve ( )

Medial Calcaneal Nerve ( )

-Descriptions on previous notecards

L-2, L-3 & L-4

L-2 & L-3

L-2 & L-3

L-3 & L-4

L-5, S-1 & S-2

L-4, L-5, S-1

S-1 & S-2

Posterior View

Sural Nerve (  )

-described previously

 aa. Lateral CaCANEAL nerves (  )

-branches of the Sural nerve

-arises in the superficial fascia between the ----and the --------

-supplies the -----1/2 of the HEEL; laterally plantarly and posteriorly

S-1 & S-2

S-1 & S-2

calf and the ankle

lateral

Posterior View

Medial Plantar Nerve (  )

-small branches exit the deep fascia along the MEDIAL 2/3 of the plantar midfoot and forefoot

-supplies the -------------aspect of the foot from just distal to the heel to the medial ------ ------.

L-4 & L-5

plantar medial

-3 1/2 toes

Posterior View

Lateral Plantar Nerve, (  )

-small branches exit the deep fascia along the LATERAL 1/3 of the plantar midfoot and forefoot

-supplies the _________of the foot from just distal to the heel to the LATERAL ----------.

S-1 & S-2

-plantar lateral aspect

1 1/2 toes

Cutaneous Nerves of the Dorsum of the Foot

Superficial Fibular nerve/Superficial Peroneal Nerve (    )

-courses inferomedially and divides just proximal to the ankle

Divides into:

L-4, L-5 & S-1 

aa. Medial Dorsal Cutaneous Nerve

bb. Intermediate Dorsal Cutaneous Nerve

Superficial Fibular Nerve/Superficial Peroneal Nerve, (    )

-courses inferomedially and divides just proximal to the ankle

aa. Medial Dorsal Cutaneous Nerve

-the medial division

-passes anterior to the ankle near the center and is palpable here

-supplies the medial part of the dorsal midfoot, then divides

-aids in supply to the -----webspace

L-4, L-5 & S-1

1st webspace

Medial Dorsal Cutaneous Nerve

-_____________-the medial branch; supplies the dorsoMEDIAL aspect of the HALLUX

_____________-the LATERAL branch, passes in the 2nd intermetatarsal space dorsally and divides to supply the adjacent sides of the 2nd and 3rd toes as __________________, respectively

-Proper Dorsal Digital Nerve

-1st Common Dorsal Digital Nerve; Proper Dorsal Digital Nerves 4 and 5

         bb. Intermediate Dorsal Cutaneous Nerve    

                       - the ------ division of the superficial fibular nerve           

                - passes anterior to the ankle near the lateral malleolus   - is easily palpated here          

                 - supplies the --------- part of the midfoot and divides

lateral

dorsolateral

Intermediate Dorsal Cutaneous Nerve

- 2^nd Common Dorsal Digital Nerve          

                    - the medial branch, passes in the ---- intermetatarsal space dorsally and

         divides to supply the adjacent sides of the 3^rd and 4th toes as______________

3rd

Proper Dorsal Digital Nerves 6 and 7 respectively

Intermediate Dorsal Cutaneous Nerve

3^rd Common Dorsal Digital Nerve    

                          - the lateral branch, passes in the ----- intermetatarsal space dorsally and divides to supply the adjacent sides of the 4^th and 5^th toes as ---------------------, respectively

4th

-Proper Dorsal Digital Nerves 8 and 9

ii. Lateral Dorsal Cutaneous Nerve, S-1 & S-2          

           - is already in the superficial fascia at this level      

               - the continuation of the -----------once it passes posterior to the lateral malleolus; the sural nerve is renamed at this point                     - supplies the ------border of the foot

Sural Nerve

-lateral

                   aa. Proper Dorsal Digital Nerve 10      

                      - the continuation of the ----------------- when it enters      the fifth toe; the --------------nerve is renamed at this point                          

- supplies the dorsolateral aspect of the 5^th toe

lateral dorsal cutaneous nerve

lateral dorsal cutaneous nerve

    iii. Deep Fibular Nerve / Deep Peroneal Nerve, L-5, S-1 & S-2                  

    - exits the deep fascia in the --------, supplies it and divides 

                      aa. -----------------------------

                      bb. ----------------------------------

1st interspace

Proper Dorsal Digital Nerve 2

Proper Dorsal Digital Nerve 3

iv. Saphenous Nerve, L-3 & L-4           

           - passes anterior to the ankle near the medial malleolus

                      - supplies the -----------border of the midfoot and part of the ----------------

medial

medial longitudinal arch

cutaneous nerves of the plantar foot    

               i. Medial Plantar Nerve, L-4 & L-5  

                   - passes along the foot deep to the plantar fascia, sends cutaneous branches to the skin and divides near the forefoot 

                     aa. -------------------------------

                           - passes along the medial side of the forefoot, plantarly, exiting the deep  fascia near the distal 1^st metatarsal shaft                     

      - supplies the plantar medial aspect of the hallux and 1^st   metatarsophalangeal joint

                            - passes in the area of the 1^st intermetatarsal

 space, plantarly

                            - exits the deep fascia at the level of the metatarsal necks

cc. 2nd Common Digital Plantar Nerve

-passes the area of the 2nd intermetatarsal space, PLANTARLY

-exits the deep fascia at the level of the metatarsal necks

-supplies this area and adjacent sides of the 2nd and 3rd toes as the -------------------, respectively

3rd Common Digital Plantar Nerve

-passes in the area of the 3rd intermetatarsal space, plantarly

-exits the deep fascia at the level of the metatrsal necks

-supplies this area and adjacent sides of the 3rd and 4th toes as the ---------------------------, respectively

ii. Lateral Plantar Nerve (   )

-passes alongg the plantar midfoot deep to the deep fascia, sends cutaneous branches to the skin and divides

aa.-------------------a medial branch which joins the 3rd common digital plantar nerve

  bb. 4^th Common Digital Plantar Nerve       

- passes in the area of the 4^th intermetatarsal space, plantarly

S-1 & S-2

Proper Digital Plantar Nerves 8 and 9

distal 5th metatarsal shaft

forefoot; plantar lateral aspect

Saphenous Nerve (   )-supplies a small area of the medial longitudinal arch of the foot, plantarly

Sural Nerve (  )-supplies a small area of the lateral longitudinal arch of the foot, plantarly.

Medial Calcaneal Nerve, (   )-small branches which supply the medial 1/2 of the calcaneal region.

Lateral Calcaneal Nerves (  )-small branches of the sural nerve which supply the lateral 1/3 to 1/2 of the calcaneal region

L-3 & L-4

S-1 & S-2

S-1 & S-2

S-1 & S-2

Deep Fasciae and Retinacula

-------------- - dense connective tissue layer that surrounds muscles and attaches to many bony prominences and structures

      - deep fascia is continuous from one region to the next

deep fascia

retinaculum

1. ------------deep fascia of the thigh

a.____________________

-thickening of the fascia lata at lateral aspect of the thigh

-provides partial origin or insertion site for several muscles

-often visible at lateral edge of extended knee; especially in athletes

b._____________-very thin area of the fascia lata over the fossa ovalis/saphenous opening near the groin

Fascia Lata

Iliotibial (IT) Band/Iliotibial Tract

Cribriform Fascia

_______________________-deep fascia of the leg region

-aids in forming several retinacula near ankle

_______________deep fascia of the politeal region

_______________deep fascia of the SUPERIOR aspect of the foot

-aids in forming several retinacula near ankle

Popliteal Fascia

Fascia Dorsalis Pedis

Plantar Fascia/Plantar Aponeurosis

-deep fascia of the _______aspect (   ) of the foot, a complex structure

-several layers, some fibers attach to skin at all points along the plantar foot

-aids in forming the __________near the ankle

inferior (sole)

retinacula

Retinacula

1. _________________/_____________

-thickening of fascia CRUris, fascia dorsalis pedis and plantar fascia

-attaches to the distal posterior aspect of the medial malleolus and to the medial aspect of the calcaneus

-holds flexor tendons of the foot and creates a pulley to improve the muscle function

-all tendons pass through the retinaculum and have separate sheaths here

Superior Extensor Retinaculum/______________

-thickening of the ____________

-attaches to the distal tibial shaft and to the distal fibular shaft, anteriorly

-holds extensor tendons of the foot and maintains their positions near the tibia

-only one tendon sheath at this level; for the tibialis anterior muscle

-all tendons pass DEEP to the retinaculum

Transverse CRUral ligament

fascia cruris

Inferior Extensor Retinaculum / ___________________

              - Y-shaped band with the stem laterally     

         - thickening of fasciae cruris and dorsalis pedis   

           - attaches to the distal anterior medial malleolus and the medial plantar medial cuneiform, then to the lateral talus (neck) and the superior aspect of the calcaneus (in the sinus tarsi); described with 3 roots and 7 sinus tarsi attachments

   - continuous with the -------------------------

               - all tendons have tendon sheaths at this level and pass through this retinaculum  

             - --------------- - the stem of the inferior extensor retinaculum, attaches in the sinus tarsi

Cruciate CruRAL ligament

inferior fibular retinaculum

fRONdiform ligament

Fibular Retinaculum / Peroneal Retinaculum / External Annular Ligament     

           - really 2 separate retinacula       

         - thickening of fasciae cruris and dorsalis pedis                 a. Superior Fibular Retinaculum / Superior ------------Retinaculum             

      - attaches to the posteroinferior lateral malleolus and to the lateral calcaneus  retrotrochlear eminence)       

            - formed by -----------------------

               - holds peroneal tendons and creates a pulley at the lateral malleolus      

             - both are in single tendon sheath here and pass deep to retinaculum                

   - fibers are continuous with------------------------- 

PeroNEAL

fascia cruris

superior extensor retinaculum

                b. Inferior Fibular Retinaculum / Inferior Peroneal Retinaculum    

               - attaches to the ----------- (   ) and to the ------------------- (    ) then to posterolateroinferior calcaneus (near the lateral tubercle)            

       - formed by fascia ------------------  

                 - holds peroneal tendons and creates a pulley for fibularis longus tendon at the distoplantar calcaneus    

               - tendon sheath divides at this point and each tendon passes deep, separately      

             - fibers continuous with lateral root of--------------ligament

sinus tarsi (anterolaterosuperior calcaneus) and

fibular trochlea (posterolaterocentral calcaneus)

-dorsalis pedis

-frondiform

-----------------------------        

 - extensions of deep fascia that attach to bone and separate muscles or groups of  muscles    

        - muscles often take partial origin from or partially insert onto septae   

         - in the leg, these septae aid in venous return (venous pump); there is little  elasticity of the septae and muscular action creates compression on the deep veins which forces fluids superiorly (the valves normally prevent inferior flow),  the empty deep veins refill from the superficial veins and so on

Nail Anatomy

1. ----------  - body of the nail (main part), normally .5 - .75 mm thick in an adult      

          - is a hardening of the epidermis  

  - cells have no ------, therefore are transparent, so can see the capillary bed            

    - function: protect the distal end of the digit / toe      

       2. ---------  - "root" of the nail  

  - specialized cells within the roof and floor of the proximal nail fold  

  - attached to the base of the distal phalanx  

              - extends ~= 5 mm proximal to visible nail edge                - function: ________________

Nail Plate

Nuclei

Matrix

Produce the Nail Plate

3. --------------------------------    

           - the skin fold at the proximal edge of the nail plate                - overlies the matrix 

4. ------------ - small ridge of transparent skin dorsal to the proximal edge of the nail plate which is continuous with the eponychium    

            - creates a seal around the nail       

         - function: prevent -------

 by sealing the area adjacent to the nail plate

Eponychium/Proximal Nail Fold

Cuticle

Infection

5. --------------- skin directly beneath and attached to the nail plate, contains some nail- forming cells; the cells that are attached to the nail plate migrate distally and are shed at the free edge of the nail        

        - from matrix and lunula to the hyponychium       

         - function: --------------the nail plate and allow its distal growth           

      - sensory innervation to the nail bed is variable and may be entirely from the  proper digital ----------nerves or from the ---------------------- therefore, you must take care when anesthetizing (blocking) digits for nail procedures     

            - it is safest to anesthetize both sets of nerves 

Nail bed

anchor

plantar

plantar and dorsal proper digital nerves

6. ------------ - the small pale half-moon-shaped area near the eponychium; whitish because        the cells retain nuclei and the capillaries beneath this portion of the nail       plate are not visible 

               - function: -----------          

   7. =========== - distal edge of nail plate that overhangs the toe             

   - function: protect the ------ of the digit from ------------- (being smashed) 

Lunula

produce nail

Free edge of the nail plate

distal tuft; blunt trauma

8. -------------- the thickened skin adjacent to the free edge of the nail plate 

  9.--------------- the shallow transverse groove between the hyponychium and the skin of the distal tuft of the toe 

Hyponychium  

 Distal Nail Groove  

10.-------------  - the convex skin fold at the sides of the nail plate         

         - after a successful permanent nail procedure the lateral nail folds will abut the  remaining nail plate         

    11.------------ the concave junction of the lateral nail fold with the nail bed 

Lateral Nail Folds /Ungualabia    

Lateral Nail Grooves   

B. Growth of Nails - nails grow primarily from the matrix and the proximal nail bed (level of the lunula) and are pushed distally; the cells of the nail bed migrate with the nail plate

- nails grow faster in younger people and faster in the summer       

     - finger nails grow faster than toe nails     

             - finger nail takes approximately--months for replacement                   

     - toe nail takes approximately ---months for replacement        

    - -----causes a disturbance in growth of the nail plate               - nail growth requires much protein synthesis and illness retards this    

           - have a resultant ----------------

 little white spots - due to incomplete keratinization of the nail plate, cells still have nuclei or an air bubble formed in the nail plate due to a minor disturbance in growth    

----- - often due to mechanical damage to the matrix cells  

6 months-fingernails

9 months-toe nails

sickness

transverse ridge / Beau’s Line           

longitudinal ridges

DERMATOMES    

    A. Def'n:  the sensory innervation of an area of skin which is supplied by a single spinal nerve’s dorsal root   

     B. Distribution in the lower limb  

          - there is overlap among adjacent segments, so often it is necessary to destroy  more than 1 spinal nerve dorsal root to have a noticeable area of deficit      

      - all begin at the spinal level indicated and travel in a general spiral manner as they pass distal

 1. L-1 / first lumbar  

               - posterior at the level of the 1^st lumbar vertebra                 - supplies an area----------to the hip, posteriorly and superior -----------at the  groin near its termination

 superior

thigh

 2. L-2 / second lumbar    

             - posterior at the level of the 2^nd lumbar vertebra                 - courses just inferior to L-1    

             - supplies an area over the--------------- (hip bone prominence) and the anterosuperior aspect of the thigh to the mid-level at the -----------------of the thigh

posterolateral iliac crest

medial aspect of the thigh

 3. L-3 / third lumbar

                 - posterior at the level of the 3^rd lumbar vertebra, the ---------------------area  

            - supplies an area over the------------ , the superior part of the lateralaspect of the-----------, the central part of the anterior aspect of the thigh, the inferior part of the medial aspect of the thigh, the medial aspect of the knee region (not the patellar surface) and the superior ½ of the medial aspect of the leg

mid-low back

posterior iliac crest

thigh

4. L-4 / fourth lumbar      

          - posterior at the level of the 4^th lumbar vertebra                - supplies an area over the posterosuperior ------------ region, the anteroinferiorthigh, the ----------- surface, the central part of the anterior aspect of the leg, the--------------  and the medial aspect of the---------- and ------ , including the hallux

gluteal

patellar
medial malleolus

midfoot and forefoot

5. L-5 / fifth lumbar      

          - posterior at the level of the 5^th lumbar vertebra, the low back     

           - supplies an area over the posterior iliac crest near the spine, thesuperolateral gluteal region, the inferior part of the lateral aspect of the thigh, the lateral aspect of the knee region, the anterolateral aspect of the leg, the anterior aspect of the ankle, the central part of the dorsum of the foot, toes 2 through 4, the central part of the plantar aspect of the forefoot and a small  part of the calcaneal region (plantar and posterior, lateral to midline) 

6. S-1 / first sacral      

          - posterior at the level of the 1^st sacral vertebra, the-------back             

   - supplies an area of the posterior mid-gluteal region, the posterolateral aspectsof the thigh and leg, the---------malleolus, and the ------- aspects of the calcaneal region, midfoot and forefoot, including the fifth toe 

 low

lateral

lateral aspects

7. S-2 / second sacral      

          - posterior at the level of the 2^nd sacral vertebra                - supplies an area of the------- -------- gluteal region, the posteromedialaspects of the thigh (including the perigenital area), knee and leg regions, and the ---------------------------

posterior central

 medial ½ of the calcaneal region            

            8. S-3, S-4, S-5 & Co-1 / third, fourth and fifth sacral and first coccygeal     

           - all begin posteriorly at the respective spinal vertebral level       

         - all form-------------- ; with the-----  -------being the largest over the posteromedial gluteal area, and the------------ being the smallest around the perianal area

concentric arcs

third sacral

first coccygeal

. MYOTOMES  

   A. Def'n:  the group of muscles that are supplied by a single spinal nerve’s --------- root  

   B. Distribution         - described in terms of movements at joints        

 - have overlap of the segments 

        - are sometimes reported with slightly different levels because it is difficult to trace nerves

1. Hip Joint     

         a. ---------- ----------- and -----------   

             - L-1 through L-4    

      b. Extension, Abduction, Lateral Rotation        

Flexion, Adduction, Medial Rotation 

  - L-4 through S-

2. Knee Joint         

     a.---------------     

            - L-2 through L-4   

   b.----------------     

- L-5 & S-1 

Extension

 Flexion   

3. Ankle Joint            

  a.------------  - L-4 & L-5     

      b. -------------------- S-1 & S-2 

 Dorsiflexion

Plantar flexion

4. Subtalar Joint   

           a. ----------------------  - L-4 & L-5    

     b. --------------------  L-5 & S-1 

Inversion/Supination

Eversion/Pronation

         5. Metatarsophalangeal Joints      

        a. -----------     - L-5 & S-1      

        b. --------------           - S-1 & S-2 

Dorsiflexion

  Plantar flexion      

. Deep Tendon Reflexes/Spinal Reflexes

          1. Def'n:  a. deep tendon reflex (DTR)    - a muscle_______ ________  (like what are commonly tested in a physician's office)    

             - mediated in the _________

           b.---------------- a withdrawal response        

         - a protective reflex  

               - mediated in the spinal cord

stretch reflex

spinal cord

   spinal reflex      

2. Deep Tendon Reflexes    

         We will discuss the most commonly tested reflexes.  There are others, but these test the majority of the spinal segments for the lower limb.    

          a. Patellar Reflex   - at the anterior knee/patellar tendon; with the knee flexed and relaxed, tap  the tendon and normally will get a small extension response    

             - tests spinal segments________________ the knee extensor myotome     

         b. Achilles Reflex   - at the posterior ankle/Achilles tendon; with the ankle slightly dorsiflexed,  tap the tendon and normally will feel the contraction of the calf muscles      

           - tests spinal segments S-1 & S-2; the-------------------------- myotome

 L-2, L-3 & L-4,

ankle plantar flexor

. Spinal Reflexes  

            a.------------    - stroke the sole of the foot from central plantar heel in an arc to the base of the fifth metatarsal with a firm blunt object (ex. pen cap, finger nail tip)       

          - normally will see----------  of the toes; expected reaction         

        - --------------------- of the ______with abduction of the lesser digits (flaring of toes) is abnormal after 2 years of age

Babinski Test

plantar flexion

dorsiflexion of the hallux