Rotator cuff,

CASE 1 Scapula, and

Humerus
Upper limb skeleton
Bones:
Axio-appendicular:
• Os. clavicula
• Os. scapula

Brachium:
• Os. humerus

Joints:
• Art. acromioclavicular
• Art. glenohumeral
• Art. sternoclavicular
• Art. scapulohumeral
 Art. Sternoclavicular
Type: synovial sellaris joint

Ligaments:
● Lig. sternoclavicular
anterior et posterior
Joints of the ● Lig. costoclavicular

upper limb:
Attachment to Art. Scapulothoracic
“Physiological” joint rather than anatomical
the thoracic joint, in which movement occurs between
cage the scapula and the associated thoracic
wall.

Movements:
● Elevations-depression
● Protraction-retraction
● Rotation
 Art. Acromioclavicular
Type: synovial plana joint

Ligaments:
● Lig. acromioclavicular
● Lig. coracoclavicular: Lig.
conoid et trapezoid
Joints of the
Art. Glenohumeral
upper limb: Type: synovial spheroid joint

Shoulder joints Scapular part: Glenoid cavity, glenoid

labrum

Stabilizer
● Static: rotator cuff muscles, ligaments
● Dinamyc: lig. Humeri transversa, lig.
glenohumeral, lig. coracohumeral
Muscles of
the upper
limb:
Anterior Axio-
appendicular
muscles
• M. pectoralis major
• M. pectoralis minor
• M. serratus anterior
• M. subclavius
Anterior Axio-appendicular Muscles:
Origo, Insertio, Innervation, and Action
Muscles of
the upper
limb:
Posterior Axio-
appendicular
muscles
• M. trapezius
• M. latissimus dorsi
• M. levator scapulae
• M. rhomboideus major et minor
 Posterior
Axio-
appendicular
Muscles:
Origo, Insertio,
Innervation, and
Action
 Scapular movements

Protraksi Retraksi
• M. serratus anterior • M. trapezius
• M. pectoralis major • M. rhomboideus
• M. pectoralis minor • M. latissimus dorsi
Muscles of
the upper
limb:
Scapulo-
humeral • M. deltoideus
muscles • M. supraspinatus
Rotator
• M. infraspinatus
cuff
• M. teres minor
muscles
• M. subscapularis
• M. teres major
 Scapulo-
humeral
muscles:
Origo, Insertio,
Innervation, and
Action
Muscles of
the upper
limb:
Brachium
muscles
 Brachium Muscles:
Origo, Insertio, Innervation, and Action
 Clinical
CASE 1 Correlation
 Winged scapula
2 types:
● Medial winging: due to M.
serratus anterior (n. Thoracicus
longus)
● Lateral winging: due to m.
trapezius (CN XI)

Damage on the nerves mentioned above

will lead to paralysis of the muscles. This Inspection of winged scapula:
will be visible when m. serratus anterior Patient leans on a hand or presses their upper limb against a
contract and the scapula fails to protract. wall
 Caused by excessive extension and lateral
rotation of the humerus.

Caput humeri gets driven infero-anteriorly

Anterior (subcoracoid position).
dislocation
of the
glenohumeral
joint
 Caused by excessive abduction and internal
rotation of the humerus.

Caput humeri gets driven to subacromial position.

Posterior
dislocation
of the
glenohumeral
joint
 Also called luxatio erecta (very rare).
Often occurs after an avulsion fracture in
tuberculum majus of the humerus.
Absence of upward and medial pull of some of
Inferior the rotator cuff muscles.
dislocation
of the
glenohumeral
joint
Reduction of Anterior Dislocation of
Glenohumeral Joint
• Hippocratic Maneuver
• Milch Maneuver
• Stimson Maneuver
 Condition in which the
tendons of the rotator
Tendinopathy cuff muscles become
and irritated and inflamed
as they pass through
Impingement
the subacromial
of Rotator space.
Cuff Muscles
This condition will lead
to weakness and loss
of shoulder movement
Fracture of the Clavicle

Weakest part of the clavicle: Junction between ⅓ middle and ⅓ lateral part
of the bone.
Some muscles may pull the fractured fragments of the clavicle.
Fracture of the Clavicle
Due to the fracture:
• Medial part of the clavicle will move
upward due to m.
sternocleidomastoideus
• Lateral part of the clavicle will be pulled
downwards due to incapability of m.
trapezius to withhold the opposing force
from the upper limb muscles (shoulder
drop)
• Lateral part of the clavicle, proximal part
of the humerus, and the scapula will be
pulled medially by m. pectoralis major
 Fracture of the Humerus

1. Proximal end
2. Humeral shaft
a. Transverse fracture: due to
direct blow. Proximal
fragment is elevated by
deltoid muscle.
b. Spiral fracture: due to
indirect injury resulting from
a fall on the outstretched
c. Comminuted fracture
3. Distal end (intercondylar
fracture)
 Regio
Brachium,
CASE 2
Antebrachium
and Manus
 Antebrachium skeleton
Os. Radius
● Caput radii → Os. Ulna
circumferentia articularis, ● Caput ulnae
fovea articularis circumferentia
● Collum radii articularis
● Tuberositas radii ● Collum ulnae
attachment of m.biceps ● Tuberositas ulnae
brachii attachment of
● Margo interossea m.brachialis
● Proc. styloideus radii ● Margo interossea
● Tuberculum dorsale ● Proc. styloideus ulnae
● Incisura ulnaris ● Incisura radialis
● Facies articularis carpalis
 Type: synovial gynglimus joint

Consists of:
● Art. humeroulnaris (trochlea
humeri+incisura trochlearis)
Type: gynglimus, diarthrosis
● Art. humeroradialis
Joints (capitulum humeri + fovea
articularis capitis radii)
of the Type: spheroidea, diarthrosis
Antebrachium: ● Art. radioulnaris proximalis
(incisura radialis +
Art. Cubiti circumferentia articularis)
Type: trochoidea, diarthrosis

Ligaments:
● Lig. radialis collateralis
● Lig. radialis annularis
● Lig. ulnaris collateralis
 Type: synovial trochoid
joint (diarthrosis)

Joints
Discus articularis art.
of the
Radioulnaris distalis =
Antebrachium: Triangular ligament
Art. ● Apex: basis proc.
Radioulnaris Styloideus ulna

distalis ● Basis: incisura

ulnaris
● Function: to fixate the
articulatio
 Superficial Layer
● M. Extensor Carpi Radialis
Longus et Brevis
● M. Extensor Digitorum
Communis → M. Extensor
Muscles of Digitorum et M. Extensor
Digiti Minimi
the Extensor ● M. Extensor Carpi Ulnaris
Deep Layer
● M. abductor pollicis longus
● M. extensor pollicis brevis
● M. supinator
● M. extensor pollicis longus
● M. extensor indicis

Compartment
of
Antebrachium
 Extensor
compartment of
antebrachium:
Origo, Insertio,
Innervation, and
Action
Muscles of the Flexor Compartment
of Antebrachium
Superficial Layer
● M. Pronator Teres
● M. Flexor Carpi Radialis
● M. Palmaris Longus
● M. Flexor Carpi Ulnaris
Intermediate Layer
● M. Flexor Digitorum Superficial
Deep Layer
● M. Flexor Digitorum Profunda
● M. Flexor Pollicis Longus
● M. Pronator Quadratus
 Flexor
compartment of
antebrachium:
Origo, Insertio,
Innervation, and
Action

(Superficial Layer)
 Flexor
compartment of
antebrachium:
Origo, Insertio,
Innervation, and
Action

(Intermediate and
Deep Layer)
Supination
and Pronation
Pronation
Prime Mover : M. Pronator quadratus
More Speed and Power : M. Pronator teres

Supination
Prime Mover : M. Supinator
More Speed and Power : M. Biceps brachii
(active when art. Cubiti flexed 90 degrees)
 Clinical
CASE 2 Correlation
Fracture of Antebrachium
Ulna and Radius
• Both bone fracture
• Single bone fracture
Fracture of Antebrachium
Os Radius
• Proximal → caput & collum
• Shaft → Galleazi
• Distal → Smith and Colles
Os Ulna
• Proximal → olecranon,
processus coronoideus
• Shaft → Monteggia
 Mason classification
• I → nondisplaced
• II → single displaced fragment
• III → comminuted
• IV → fracture with elbow dislocation
Fracture of
Proximal
Radius

Mechanism :
Fall onto hand
 Colton
classification
• I→
Fracture of nondisplaced
Ulna • II → displaced
(avulsion,
transverse/
Mechanism : • oblique,
Fall directly comminuted)
onto elbow or
hand Proc. coronoideus Olecranon
 Fracture of os.
Monteggia ulna with
dislocation of
Fracture caput radii
(proximal
radioulnar joint)

Fracture of os.
Galeazzi radius with
dislocation of
Fracture distal
radioulnar joint

“GRI-MUS”
(check notes!)
 Clinical view of
Monteggia and Galeazzi Fracture
 Cause: fall on hand with
palmar-flexion position.
Smith
Radiological finding:
Fracture Garden spade deformity

Colles Cause: fall on hand with

Fracture dorso-flexion position.
Radiological finding:
Dinner fork deformity
 Etiology:
fall on the palm when
hand is abducted

Treatment:
Arthroidesis (palmar
Scaphoid surgery)
Fracture
Complication:
Injuty to radial nerve or
artery (especially
proximal pole).
Avascular necrosis of
proximal fragment
Mallet Finger
(Baseball
Finger)

Etiology: Hyperflexion of DIP.

This causes the tendo of the extensor muscles to

loosen and DIP will not be able to extend further
 Subluxation of Radial Head
(Nursemaid/Slipped/Pulled elbow)

Subluxation: incomplete
dislocation

Predilection: preschool children

(Especially girls)

Pronated forearm is usually

lifted, which causes rupture of
the distal attachment of
lig.radioulnaris (at collum radii)
Reduction of Subluxation of Radial Head
 Inflammation of the tendons
of the elbow (epicondylitis)
caused by overuse of the
forearm muscles.
Epicondylitis • Lateral Epicondylitis:
(Tennis and tennis elbow
• Medial Epicondylitis:
Golfer’s
golfer’s elbow
Elbow)
Pronator
Syndrome

Etiology: Entrapment of n.medianus near the elbow

by m.pronator teres due to trauma or hypertrophy.
Usually pain is felt in the proximal forearm with
hyperesthesia of phalanx I-III
 Etiology:
Fibrous degeneration
of the longitudinal
bands of the palmar
aponeurosis, hereditary
Dupuytren’s predisposition
Contracture
Symptom:
The shortening,
thickening, fibrosis
causes partial flexion
of art. MCP & PIP

Treatment:
Surgical incision of
fibrotic tissue
CASE 3 Plexus Brachialis
Plexus Brachialis
Plexus Brachialis
Median Nerve
Median Nerve and Carpal Tunnel
Median Nerve
 Function Of Median Nerve
• Regio brachialis:
• Sensory: none
• Motor: none
• Regio antebrachialis:
• Sensory: none
• Motor: semua otot anterior
anterbrachii (kecuali m. flexor carpi
ulnaris, bagian ulnar dari m. flexor
digitorum profundus).
• M. pronator teres (PT)
• M. flexor carpi radialis (FCR)
• M. palmaris longus (PL)
• M. flexor digitorum superficial
(FDS)
• Nervus Interosseus Anterior (AIN):
• Sensory: Palmar wrist
• Motor: otot di bagian profunda dari antebrachii
anterior
• M. flexor digitorum profundus (FDP),
kecuali bagian ulnar
• M. flexor pollicis longus (FPL)
• M. pronator quadratus (PQ)
• Regio manus:
• Sensory (palmar cutaneous branch): sisi lateral
dari palmar, permukaan palmar jari 1,2,3 dan
sisi lateral dari jari 4 dan segmen distal dari
bagian dorsal keempat jari (sekitar kuku)
• Motor: otot thenar, m. lumbricales I dan II
Ulnar Nerve
Ulnar Nerve and Cubital Tunnel
Ulnar Nerve and Guyon’s Canal
 Function of Ulnar Nerve
• Regio manus:
• Regio brachialis:
• Sensory: none
• Motor: none
• Regio antebrachialis:
• Sensory: none
• Motor: m. flexor carpi ulnaris
dan flexor digitorum
profundus bagianulnar (4th
and 5th digit, maybe 3rd)
• Sensory: sisi medial dari palmar, permukaan palmar jari 5 dan sisi
medial dari jari 4, dorsal ulnar hand
• Motor:
• M. palmaris brevis
• Hypothenar compartment:
• M.abductor digiti minimi
• M. Flexor digiti minimi brevis
• M. Opponens digiti minimi
• Intrinsic muscles
• M. Lumbricales (3,4)
• M. Dorsal interossei
• M. Palmar interossei
• Adductor compartment: m. Adductor pollicis
• Thenar compartment: m. Flexor pollicis brevis (FPB)—deep
head only
Radial Nerve
Radial Nerve
Radial Nerve
Function of Radial Nerve
Regio Brachialis:
• Sensory: Posterior arm (posterior
cutaneous n. of arm) & lateral arm
(inferior lateral cutaneous n. of arm)
• Motor:
• Posterior compartment: Triceps
brachii
• Anterior compartment:
Brachialis (lateral portion)
Regio antebrachialis:
• Sensory: Posterior forearm (posterior
cutaneous nerve of forearm)
• Motor: Anconeus, Brachioradialis
(BR), Extensor carpi radialis longus
(ECRL)
• Posterior Interrosseous Nerve (PIN)-antebrachii:
• Sensory: Dorsal wrist
• Motor:
• Extensor carpi radialis brevis (ECRB)
• Posterior compartment—superficial extensors
• Supinator
• Extensor digitorum communis (EDC)
• Extensor digiti minimi (EDM)
• Extensor carpi ulnaris (ECU)
• Posterior compartment—deep extensors
• Abductor pollicis longus (APL)
• Extensor pollicis brevis (EPB)
• Extensor pollicis longus (EPL)
• oExtensor indicis proprius (EIP)
• Regio Manus
• Sensory: Dorsal radial hand (superficial branch)
• Motor: none

• M. Lumbicrales Manus
• M. Interossei Dorsalis et
Palmaris
• M. Palmaris Brevis
Muscle of
Manus Region
• Thenar
• M. Abductor Pollicis Brevis
• M. Flexor Pollicis Brevis
• M. Opponens Pollicis
• M. Adductor Pollicis
• Hypothenar Region
• M. Abductor Digiti Minimi Brevis
• M. Flexor Digiti Minimi
• M. Opponens Digiti minimi
Tabatiere
Anatomicum
(Anatomical
Snuffbox)
Terdapat arteri radialis (berjalan di
dalam anatomical snuffbox) dan nervus
radialis (superficial dari anatomical
snuffbox).
 Clinical
CASE 3
Correlation
 Injury and Entrapment of Median Nerve

Lesi proximal / high grade lesion

Disebabkan oleh kompresi n.

Medianus saat menembus m.
pronator teres
 Obstetric hand / Priest Hand / Hand of benediction

injury pada N. Medianus, pada region cubiti.

Gangguan gerak yang terjadi adalah :
•Fleksi dan abduksi (minimal) pada wrist
•Pronasi
•Fleksi art. metacarphophalangeal 2 dan 3
•Fleksi art. Proximal interphalangeal
•Fleksi ar. Distal interphalangeal 2 dan 3
•Gangguan gerakan Pollex
•Hilangnya inervasi sensorik di kulit pada sisi palmar 3 ½ jari lateral, dan
bagian distal dorsal 3 ½ jari lateral.
Anterior Interosseus Nerve (AIN) Syndrome

Sering disebut juga Kiloh-Nevin Syndrome, disebabkan

karena entrapment pada AIN pada bagian proximal dari
forearm. Etiology yang sering terjadi karena direct trauma
(post operative, injeksi), dan external compression (lipoma).
Manifestasi klinisnya adalah gangguan flexi dari pollex
(paralisis m. FPL), gangguan flexi art. Interphalangea
distal jari 2 dan 3 (paralisis m. FDP, jari 2-3), dan
gangguan pronasi (paralisis m. pronator quadratus). Sehingga
tampakannya adalah ketidakmampuan untuk membuat “OK
sign” atau bisa disebut juga “pinch sign”
 Carpal Tunnel Syndrome
Paling sering terjadi pada median nerve palsy. Dan sering terjadi pada wanitausia
middle-aged. pathofisiology adalah karena pengurangan ukuran daricarpal
tunnel, ataupun peningkatan ukuran dari komponen-komponenyang
melewati carpal tunnel.
● Gangguan abduksi, oposisi, dan sedikit flexi polex (paralisis m. abductor
policis longus, m. oppones policis, m. flexor policis brevis caput
superificial). Jika dibiarkan terlalu lama dapat terjadi atrofi thenar (ape hand
/ Simian hand)
● Tidak terdapat gangguan sensorik pada central palm 3 ½ jari lateral
(karena palmar cutaneous branch bercabang sebelum masuk ke carpal
tunnel
● paresthesia (tingling), hypo- esthesia (diminished sensation), or
anesthesia(absence of sensation) pada bagian tangan (paralisis lateral et
medial branches of median nerve)
● kelemahan pada fleksi art. Metacpophalageal jari 1 dan 2 (paralaisis
m.lumbricales 1-2)
Injury and Entrapment of Ulnar Nerve

Lesi proximal / high grade lesion

Claw Hand

Gangguan gerak yang terjadi adalah

● fleksi dan adduksi (minimal) wrist
● fleksi art. Interphalange distal
● •fleksi art. Metacarphophalangeal jari 4 dan 5
● adduksi dan flexi(minimal) pollex (Froment sign)*
● paralisis seluruh otot hypothenar
● finger abduksi
● finger adduksi
● kehilangan sensasi sensoris pada seluruh telapak
tanganbagian medial
Cubital Tunnel Syndrome

● Kompresi N. ulnaris di cubital tunnel

karena ligamentum arcuata.
● Pada saat fleksi art. Cubiti, terjadi
peyempitan dari cubital tunnel akibat dari
ligament tersebut, sehingga gerakan
repetitive yang berulang dapat
menyebabkan cubital tunnel syndrome.
Karena termasuk dalam high ulnar palsy,
tampakannya klinisnya jika dibiarkan
tanpa pengobatan adalah claw hand.
Guyon Canal Syndrome
● Type 1 : injury pada n. ulnaris pada bagian
proximal dari Guyon’s canal. Lesi akan
menyebabkan gangguan pada
○ Atrophy hypothenar karena dan otot intinsik
tangan karena paralisis deep branch of ulnar
nerve
○ Anasthesia pada kulit sisi palmar bagian
proximal jari 1 ½ jari medial karena paralisis
superficial branch of ulnar nerve
● Type 2 : kompresi pada deep branch of ulnar
nerve -> motoric deficit
● Type 3 : kompresi pada superficial branch of
ulnar neve -> sensory deficit
Injury and Nerve Entrapment of Radial
Nerve

● lesi tinggi di proksimal N. Radialis

sebelum menjadi cabang superficial dan
profunda (PIN), misalnya di sulcus N.
Radialis karena fraktur humeri.
● Lesi ini akan bermanifestasi klinis drop
hand / wrist drop disebabkan paralisis
m. brachioradialis dan m. ECRL
 Posterior interosseus nerve (PIN)
syndrome
•PIN / deep branch of radial nerve syndrome, etiology
tersering nya adalah kompresi saat masuk pada
proximal aponeurotic m. supinator (arcade of
frohse). Bisa juga karena trauma lacerasi dalam pada
bagian foream. Manifestasi klinisnya berupa Low
Grade lesion, tampakan klinis yang terjadi adalah
motor sign
Gangguan gerak yang terjadi adalah :

1.tidak terdapat wrist drop karena inervasi m. ECRL masih utuh.

2.kelemahan ekstensi wrist
3.gangguan ekstensi jari 2-5
4.gangguan supinasi forearm
5.gangguan ekstensi jari 2
6.kelemahan abduksi pollex
7.kelemahan ekstensi pollex
Ectrodactily,
Syndactyly,
Polydactily
Limb
Anomalies 2 main types of limb anomalies or defects:

• Amelia -> absence of a limb or limbs

• Meromelia -> absence of part of a limb, such as
• Phocomelia - >hands and feet are attached close to the
body
• Hemimelia -> congenital longitudinal deficiency of a
bone. Ex(hemimelia fibula, hemimelia radius)
 Regio Coxae &
CASE 4 Femoral
Ligaments of
The Hip Joint
Ligaments of
The Hip Joint
 Adductors of hip joint
• M. Adductor longus
• M. Adductor brevis
Medial • M. Adductor magnus
• M. Gracilis
Muscles of Innervation:
the Thigh • N. Obturatorius(L2-4) Except
m.adductor magnus pars
hamstring by n.ischiadicus
pas tibialis
 Flexors of hip joint
• M. Pectineus
• M. Iliopsoas
• M. Sartorius
Extensors of knee
• M. Rectus femoris*
Anterior • M. Vastus lateralis*
• M. Vastus medialis*
Muscles of • M. Vastus intermedius*
Innervation: N. Femoralis (L2-4)
the Thigh
 Posterior thigh: extensors of hip &
flexors of knee
• M. Semitendinosus*
• M. Semimembranosus*
Posterior • M. Biceps femoris (caput
longus* & brevis)
Muscles of Innervation: N. Ischiadicus pars
tibialis :
the Thigh
• Except m.biceps femoris
caput brevis by
n.ischiadicu pars fibularis
communis
 Endorotators
• M. Tensor fasciae latae*
• M. Gluteus medius
• M. Gluteus minimus
Exorotators
• M. Gluteus maximus* (+hip
Gluteal extensor)
• M. Piriformis
Muscles of • M. Obturator internus
• M. Rotator triceps :
the Thigh • m. Gemellus sup
• m. Gemellus inf
• m. Obturator int
• M. Quadratus femoris
Innervation: N. Glutealis
superior et inferior
 Clinical
CASE 4
Correlation
 Anterior
Hip
Dislocation
• Mechanism: high energy trauma (e.g., dashboard injury, significant
fall)
• Less common
• Thigh abducted, flexed, and exorotated
• Complication: osteonecrosis (avascular necrosis) and femoral
artery/nerve injury
Posterior
Hip
Dislocation
 • Mechanism: high energy
trauma (e.g., dashboard
injury, significant fall)
Posterior • Most common (85%)
• Thigh adducted, flexed,
Hip endorotated
• Complication:osteonecrosi
Dislocation s (avascular necrosis),
sciatic nerve injury
 • Determined by the inclination
angle of the collum femoris
(proximal element) relative to the
corpus femoris (distal element).

➔ Coxa vara is a deformity of the

hip, whereby the angle between
Coxa Vara the head and the shaft of the
femur is reduced to less than
120 degrees.

Coxa Valga ➔ Coxa valga is a deformity of the hip

where the angle formed between the
head and neck of the femur and its
shaft is increased, usually above 135
degrees.
Vara: distal element deviates toward
the midline*

Valga: distal element deviates away

from the midline*
 • Fracture: discontinuity of the bone
• Most common site of fracture:
collum femoris(weakest and
narrowest part)
• Increasingly vulnerable by ages
Fracture of The • Common in female secondary to
osteoporosis
Femoral Neck • Nampakan khas: hip joint
eksternal rotasi & abduksi, dan
ekstremitas inferior memendek
 Mechanism of Injury:
• Fall by elderly person
(most common);
• High energy trauma eg.
motor vehichle accident
Femoral head vascularity at risk
in displaced fractures

Intracapsular fractures
Fracture of The
Length shortened, abducted,
Femoral Neck exorotated

•Complication: osteonecrosis*
(avascular necrosis) -> non union
TREDELENBURG SIGN

Causes:
•Injury to n. glutealis
superior
•Fracture of trochanter
major
•Dislocation hip joint
Gluteal Intermuscular Injection
(AVOID N.ISCHIADIUS, N.GLUTEALIS SUP)

•Dorsogluteal •Ventrogluteal

Marker: SIPS – Trochanter major Marker: Tuberculum iliacum-Trochanter major,

SIAS
 Regio Cruris &
CASE 5 Genu
 Ligaments of the knee joint
Intracapsular Ligaments:
•Lig. Cruciatum anterior (ACL)
•Lig. Cruciatum posterior (PCL)
•Meniscus medial
•Meniscus lateral
Extracapsular ligaments:
•Lig. Patellar
•Lig. Collateral fibula/ lateral (FCL)
•Lig. Collateral tibia/ medial (TCL)
•Lig. Popliteal oblique
•Lig. Popliteal arcuata
•Popliteal fibular ligament/
Posterolateral corner (PLC)
Meniscus
Bursae on the knee joint
•Prepatellar bursa
•Suprapatellar bursa
•Infrapatellar bursa
 Dorsoflexors of ankle:
Anterior from medial to lateral (3
compartment muscles).
of crural •M. Tibialis Anterior
muscle •M. Extensor Digitorum
Longus
•M. Extensor Hallucis
Longus
 Evertors of ankle (+weak
Lateral plantarflexion):
compartment •M. Fibularis Longus
of crural •M. Fibularis Brevis
muscle
Posterior compartment of crural muscle

Superficial
Plantarflexors of ankle
(Triceps Surae) :
•M. Gastrocnemius
•M. Soleus
•M. Plantaris
Deep Layer
•M. FHL (flexes hallux)
•M. FDL (flexes 4 lateral digit & plantarflexes)
•M. TP (plantarflexes & inverts)
•M. Popliteus
 Clinical
CASE 5 Correlation
Genu Valgum (Knock Knee) and
Genu Varus (Bowleg knee)
Physiological Bowleg and Knock Knee:
Bow legs in babies and knock knees in 4-year-olds are so common that they are
considered to be normal stages of development.
Pathological Bowleg & Knock Knee:
Bowleg knee: Arthrosis (destruction of knee
cartilages) and overstressed the fibular collateral
ligament.
Knock knee: Overstreched tibial collateral
ligament, overstressed lateral meniscus and
cartilages of lateral femoral and tibial condyles.

If associated with joint instabillity can lead to

osteoarthritis

Genu Varus Genu Valgum

 Housemaid’s Knee
(Prepatellar Bursitis)
- Fluctuant swelling is confined to
the front of the patella. (the joint
is normal)
- Uninfected bursitis due to
constant friction between skin
and bone (patella)
 Clergyman’s Knee
(Infrapatellar Bursitis)

Swelling bellow patella and

superficial to patellar ligament.
Chronic friction between skin
and bone (tibial tuberosity)
 Patellar Dislocation

MOI: More often traumatic dislocation is due to indirect force: sudden, severe
contraction of the quadriceps muscle while the knee is stretched in valgus and
external rotation
The patella dislocates laterally and the medial patellofemoral ligament and
retinacular fibers may be torn.
Cruciate Ligament Injuries
 Anterior Cruciate Ligaments (ACL)
Injuries

Mechanism:
Sudden deceleration,
Hyperextension and internal rotation
of tibia on femur.
More Common.
Physical exam for
ACL tear
(anterior drawer test, lachman test, pivot shift test)
Posterior Cruciate Ligaments (PCL)
Injuries
Mechanism: Sudden posterior
displacement of tibia when knee is
flexed or hyperextended
Less common than ACL tear
because PCL is a strong ligament.
Physical exam for PCL tear
(posterior drawer test, posterior sag sign)
 MCL Tear:
Mechanism of injury: valgus
force to knee.
Physical examination → Valgus
Stress Test.

MCL & LCL LCL Tear:

Mechanism of injury: varus
Injury force to knee.
Physical examination → varus
stress test.
(uncommon)
Physical exam for MCL & LCL tear
(Varus & Valgus stress test)
 Meniscal Injury
Medial tear much more
common than lateral tear.
Mechanism: twisting force
on knee when it is partially
flexed (e.g. stepping down
and turning); requires
moderate trauma in young
person but only mild trauma in
elderly due to degeneration.
Physical exam for meniscal tear
(Thessaly, McMurray, Apley Grinding Test)

Apley Grinding Test Apley Distraction Test

Thessaly Test

McMurray Test
 O’Donghue Unhappy Triad
twisting force in a weightbearing knee
often tears the medial meniscus,
causing the well-recognized triad of
MCL, ACL and medial meniscal injury
described by O’Donoghue.
 Knee Arthroscopy

Arthroscopy is an endoscopic examination that

allows visualization of the interior of the knee joint
cavity with minimal disruption of tissue.
Arthroscopy is useful:
(1) to establish or refine the
accuracy of diagnosis;
(2) to help in deciding whether
to operate, and
(3) to perform certain operative procedures.
Arthralgia

• Arthralgia: joint pain. It is a symptom not a

diagnosis
• There are several causes of joint pain that range
from injuries, infections, inflammation to severe
degenerative systemic or whole body disorders.
Osteoarthritis of the Knee

A degenerative disease which

mechanical-joint wear and tear
destroys articular cartilage.
Predisposing factor: age, obesity,
joint trauma
Classic presentation: Pain in weight-
bearing joints after use, improving
with rest.
Ankylosis

Immobility and consolidation of a

joint due to disease, injury, or

surgical procedure.
Most often cause: chronic
rheumatoid arthritis. Other causes:
infection and traumatic injury to the
joint.
Knee Replacement Arthroplasty

The main indication for

knee replacement is pain,
especially when this is
combined with deformity
and instability. Most
replacements are
performed for rheumatoid
arthritis or osteoarthritis.
 Synovitis & Tenosynovitis

Synovitis is the inflammation of a

synovial (joint-lining) membrane, usually
painful, particularly on motion, and
characterized by swelling, due to effusion
(fluid collection) in a synovial sac.

Tenosynovitis is inflammation of a tendon

and its sheath.
Tibial Fracture
Fibular fracture
Fracture of
Calcaneus
 Compartment Syndrome
When the intracompartmental pressure within an
anatomical area (e.g. forearm or lower leg)
exceeds
the capillary perfusion pressure, eventually
leading to muscle/nerve necrosis

5P:
o Pain
o Pallor
o Paresis
o Paresthesia
o Pulselessness
Fasciotomy
 Volkmann’s Contracture
Following arterial injury or
compartment syndrome, the
patient may develop ischaemic
contractures of the affected
muscles. Fibrosis and contracture
of muscles that cross a joint will
cause a fixed deformity of the
joint.
Most commonly affected are the
forearm and hand, leg and foot.
 Regio Pedis &
CASE 6 Plexus Sacralis
Sacral plexus

“PED-TIP”
(check notes!)
Ligaments of the knee (lateral view)
Ligaments of the knee (medial view)
Tarsal Bone
Arches of the foot
NORMALNYA CAVUS
PLANUS AD DI KLM
 Foot drop

Cedera pada n. peroneus communis atau n. peroneus

profunda.
- Gangguan motorik otot kompartemen anterior dan
lateral tungkai → Kehilangan fungsi dorsofleksi dan
ekstensi jari kaki dan Kehilangan fungsi eversi.
- Gangguan sensasi pada dorsum pedis & anterolateral
cruris.
Kompensasi
(B) Waddling Gait → Penderita menumpukan
badannya ke panggul sisi kontralateral yang normal
(mengangkat/hiking tungkai yang paralisis)
(C) Swing-Out Gait → Tungkai diayun ke sisi lateral
(D) High-Steppage Gait → Tungkai diangkat
setinggi mungkin agar jari kaki tidak menabrak
tanah (fleksi panggul dan fleksi lutut lebih dari
biasanya)
Ankle Sprain

Grade 1 : mild damage to a ligament or

ligaments without instability of the
affected joint
Grade 2 : partial tear to the ligament, in
which it is stretched to the point that it
becomes loose
Grade 3 : complete tear of a ligament,
causing instability in the affected joint.
 • Anterior drawer test: To assess for ankle instability
• Prone anterior drawer test: Also tests for ligamentous
instability
• Talar tilt test (or inversion stress maneuver): To assess
integrity of the calcaneofibular ligament
• External rotation test: To evaluate the integrity of the
Physical syndesmotic ligaments
exam for
Ankle
sprain
 Pott’s fracture
● Ankle dislocation due to excessive everts
● Torn deltoid ligaments → fracture of medial
malleoli
● Talus shift to lateral → fracture of lateral
malleoli or fibula (superior to the distal
tibiofibular syndesmosis)
● If tibia shift to anterior → Fracture of distal-
posterior os. Tibia.
● These three fractures called trimalleolar
fracture (distal end of the tibia is called
malleolus)
Deformities of
the foot
Deformities of
the foot
Pes Valgus → An outward deviation of the foot at the talocalcaneal or subtalar
joint. Eversion of the foot
Pes Varus → inversion of the foot.
Pes Equinus → inability to dorsiflex the ankle passively to plantargrade with the
hindfoot in subtalar neutral and the knee extended.
Pes calcaneus → presence of a fixed position of foot extension without active
flexion.
 Pes Planus (flatfoot)
The term ‘flatfoot’ applies when the apex of the arch
has collapsed and the medial border of the foot is in
contact (or nearly in contact) with the ground; the
heel becomes valgus and the foot pronates at the
subtalar-midtarsal complex
 Pes Cavus
In pes cavus the arch is higher than
normal, and often there is also clawing of
the toe
 Congenital Talipes Equinovarus/CTEV
(Congenital Club Foot)
CAVE deformity:
- Midfoot Cavus
- Forefoot Adductus
- Hindfoot Varus
- Hindfoot Equinus
Occurence Male>Female, severity
Female>male
Treatment: largely non-operative via
Ponseti technique (serial
manipulation and casting)
Hallux Valgus & Bunion
lateral deviation of the great toe
(hallux valgus)
common in rheumatoid arthritis,
probably due to weakness of the
joint capsule and ligaments.
The elements of the deformity are
lateral deviation and rotation of
the hallux, together with a
prominence of the medial side of
the head of the first metatarsal (a
bunion).
Hammer Toe & Claw Toe

Dorsoflexi MTP Hiperekstensi MTP

Plantarflexi PIP Flexi PIP DIP
Hiperekstensi DIP
Plantar Fascitis

• Inflammation of the aponeurosis

plantaris on its attachment at the
calcaneus tubercle (overuse)
• The foot may have limited
dorsoflexion and hallux extension
due to tightness of the calf muscle or
the Achilles tendon
• Pain mediated by: n. tibialis r.
calcaneus medial
• Common in dancer
Arthritis