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By H. Dan. University of Texas Medical Branch.

The relative positions of the muscles of the thigh are illustrated in figure 9 purchase 25mg indocin amex arthritis umbrella. The injury usually occurs when sudden lateral or medial stress to the knee joint tears the muscles or tendons generic indocin 75 mg on line rheumatoid arthritis cure. Because of its struc- ture and the stress applied to it in competition, the knee joint is highly susceptible to injury. Altering the rules in contact sports could reduce the incidence of knee injury. At the least, additional support and pro- tection should be provided for this vulnerable joint. Muscles of the Leg That Move the Joints of the Ankle, Foot, and Toes The muscles of the leg, the crural muscles, are responsible for the movements of the foot. There are three groups of crural mus- cles: anterior, lateral, and posterior. The anteromedial aspect of the leg along the body of the tibia lacks muscle attachment. Anterior Crural Muscles The anterior crural muscles include the tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius mus- cles (figs. Adductor longus Pubis—below pubic crest Linea aspera of femur Adducts, flexes, and laterally rotates Obturator n. Muscular System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 TABLE 9. Muscular System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 Chapter 9 Muscular System 283 Patellar tendon FIGURE 9. These two muscles are synergistic in flexing the ankle joint palpated on the anterior lateral portion of the tibia (fig. The extensor digitorum longus muscle is positioned lateral to the tibialis ante- Posterior Crural Muscles rior on the anterolateral surface of the leg. The superficial group is composed of the gas- small peroneus tertius muscle is continuous with the distal por- trocnemius, soleus, and plantaris muscles (fig. It consists of two distinct heads that arise from the posterior brevis (figs. This The long, flat peroneus longus muscle is a superficial lat- muscle and the deeper soleus muscle insert onto the calcaneus eral muscle that overlies the fibula. The peroneus brevis muscle via the common tendo calcaneus (tendon of Achilles). This is the lies deep to the peroneus longus and is positioned closer to the strongest tendon in the body, but it is frequently ruptured from Van De Graaff: Human IV. Muscular System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 284 Unit 4 Support and Movement FIGURE 9. The popliteus muscle two muscles are frequently referred to as a single muscle, the tri- is a medial rotator of the knee joint during locomotion. The soleus and gastrocnemius muscles have a bipennate flexor hallucis longus muscle lies deep to the soleus common insertion, but the soleus acts on only the ankle joint, in muscle on the posterolateral side of the leg. It has a very long, slender ten- soleus, and it parallels the flexor hallucis longus muscle on the don of insertion onto the calcaneus. Its distal tendon passes posterior to the frequently mistaken for a nerve by those dissecting it for the first medial malleolus and continues along the plantar surface of time. The plantaris is a weak muscle, with limited ability to flex the foot, where it branches into four tendinous slips that at- the knee and plantar flex the ankle joint. Muscular System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 Chapter 9 Muscular System 285 Muscles of the Foot With the exception of one additional intrinsic muscle, the ex- tensor digitorum brevis (fig. The functions of the muscles of the foot are different, however, because the foot is adapted to provide support while bearing body weight rather than to grasp objects. The muscles function either to move the toes or to support the arches of the foot through their contraction. Because of their complexity, the muscles of the foot will be presented only in il- lustrations (see figs. List all the muscles that either originate from or insert on the scapula. On the basis of function, categorize the muscles of the upper extremity as flexors, extensors, abductors, adduc- tors, or rotators.

The diagram (A) was designed according to the decrease in sensibility (hy- poesthesia) resulting from disk prolapse; it shows how the dermatomes extending around the trunk become elongated in the limbs safe 50 mg indocin arthritis relief hip pain. They become translocated to the distal limb areas during embryonic development when the limbs are budding (C) buy indocin 75mg on-line living with arthritis in feet. Thedermatomesoverlaplikerooftiles,asil- lustrated by the shift in boundaries that have been determined according to the ex- Kahle, Color Atlas of Human Anatomy, Vol. Dermatomes 67 C 2 C 3 C 3 C 4 C 4 C 5 C 5 C 6 C 6 T 1 C 7 C 8 A Dermatomes T 3 T 1 (according to T 6 Keegan and Garrett) T 6 T 12 T 9 L 1 L 3 C 5 C 6 L 5 C 6 T 12 C 7 L 1 C 8 L 2 C 7 S 1 S 2 L 3 C 8 S 3 S 2 S 3 L 4 L 5 C 3 C 4 C 5 S 1 T 1 T 2 S 1 3 L 5 4 S 2 L 4 5 6 7 8 C 3 3 9 4 4 3 10 5 5 4 11 6 6 5 7 7 7 6 L 1 12 8 8 8 1 T 1 1 2 2 2 3 L 2 3 L 3 3 B Overlap of dermatomes (accord- C Development of dermatomes in ing to Förster) the upper limb (according to Bolk) Kahle, Color Atlas of Human Anatomy, Vol. The anatomy of the spinal cord causes very However, pain and temperature sensations specific patterns of functional deficiencies are lost (analgesia and thermoanesthesia), be- after injury; depending on the site of lesion, cause their fibers, which cross through the different pathways and therefore different white commissure, are interrupted (C5). Complete transection (A) cuts off all de- scending motor pathways, causing complete paralysis below the injured level. At the same time, it interrupts all ascending path- ways, causing a complete loss of all sensa- tions. If the lesion is above the sacral spinal cord, it results in the loss of voluntary con- trol over urination and defecation. If the le- sion lies above the lumbar enlargement, both lower limbs are paralyzed (paraplegia), and if it lies above the cervical enlargement, both upper limbs are also paralyzed (tet- raplegia). For example, hemisection on the left interrupts the lateral and anterior corticospinal tracts (B1) and results in left-sided paralysis. Transec- tion of the vasomotor pathway causes ipsi- lateral vasomotor paralysis. Transection of the posterior funiculi (B2) and the cerebel- lar lateral funiculi (B3) leads to severely im- paired deep sensibility (posture sensation). On the same side as the lesion, there is also hyperesthesia (touch is perceived as pain). This is thought to be caused by a loss of epicritic sensibility (posterior funiculi) with retention of the protopathic sensibility (crossing pathways of the anterior corti- cospinal tract ascend contralaterally) (B4). Finally, there is dissociated anesthesia on the intact right side from the lesion downward; while touch sensation is hardly impaired, pain and temperature sensations are lost (ipsilateral interruption of the crossing pathway of the anterior corticospinal tract) (B5). The anesthetic zone (B6) above the transection ontheaffected side is attributed to destruction of the posterior root entrance zone at the level of the spinal cord lesion. Central injury (C) to the gray substance of the spinal cord also causes dissociated anes- thesia at the corresponding levels. Spinal Cord Syndromes 69 A Complete transection of the spinal cord 1 3 4 5 6 2 B Brown–Séquard’s syndrome in hemisection of the spinal cord 2 5 C Dissociated anesthesia in case of injury to the central spinal cord Kahle, Color Atlas of Human Anatomy, Vol. The peripheral nerves may contain four different types of fibers: Nerve Plexusus (B)! Somatomotor (efferent) fibers (A1) for At the level of the limbs, the anterior striated muscles branches of the spinal nerves form networks! Somatosensory (afferent) fibers (A2) for (plexusus) in which fibers are exchanged. Visceromotor fibers (A3) for smooth tend to the periphery, possess a newly or- muscles ganized supply of fibers derived from differ-! The somatomotor fibers pass from the nerves originate here: the lesser occipital anteriorhorncells(A5)throughtheanterior nerve (B18), the greater auricular nerve root (A6); the somatosensory and (B19), the transverse nerve of the neck viscerosensory fibers originate from the (B20), the supraclavicular nerves (B21), the nerve cells of the spinal ganglia (A7); and phrenic nerve (B22), and also the roots of the visceromotor fibers of the lateral horn the deep cervical ansa (B23). Anterior and posterior roots (A9) join arm is formed by the anterior branches of to form the spinal nerve (A10), which con- spinal nerves C5 to C8 and by a part of the T1 tains all types of fibers. We distinguish between a section trunk then divides into four branches: lying above the clavicle, the supraclavicular! The meningeal branch (A11), a recurrent part, and a section lying below the clavicle, sensory branch extending to the spinal the infraclavicularpart. The anterior branches meninges pass through the scalene gap into the poste-! The posterior branch (A12) rior cervical triangle, where they form three!

This is a patient with an obvious major deformity in whom it is clear that any degree of improvement will be regarded with satisfaction purchase indocin 25mg on line rheumatoid arthritis quinine. Second discount 75 mg indocin fast delivery arthritis in dogs statistics, there is the patient with the minor deformity but extreme concern. In contrast, this is the patient with a deformity that the surgeon perceives to be minor but who demonstrates an inordinate degree of concern and emotional turmoil. These are the patients who are most likely to be dissatisfied with any outcome. The anxiety expressed over the deformity is merely a manifestation of inner turmoil, which is better served by a psychiatrist’s couch than a surgeon’s operating table. Most who seek aesthetic surgery fit somewhere on a diagonal between the two contralateral corners shown in Fig. The closer the patient comes to the upper left-hand corner, the more likely an unfavor- ably outcome is perceived, as is a visit to an attorney. Effective Communication Most litigation in plastic surgery has the common denominator of poor communication. This doctor–patient relationship can be shattered by the surgeon’s arrogance, hostility, coldness (real or imagined), or simply by the fact that “he [or she] didn’t care. Although the doctor’s skill, reputation, and other intangible factors contribute to a patient’s sense of confidence, rapport between patient and doctor is based on forthright and accurate communication. This will normally prevent the vicious cycle of disappointment, anger, and frus- tration by the patient and reactive hostility, defensiveness, and arro- gance from the doctor, which deepens the patient’s anger and ultimately may provoke a lawsuit. Anger: A Root Cause of Malpractice Claims Patients feel both anxious and bewildered when elective surgery does not go smoothly. The borderline between anxiety and anger is tenuous, and the conversion factor is uncertainty—fear of the unknown. A patient frightened by a postoperative complication or uncertain about the future may surmise: “If it is the doctor’s fault, then the responsibil- ity for correction falls on the doctor. At this delicate juncture, the physician’s Chapter 14 / Plastic and Reconstructive Surgery 197 reaction can set in motion or prevent a chain reaction. The physician must put aside feelings of disappointment, anxiety, defensiveness, and hostility to understand that he or she is probably dealing with a fright- ened patient who is using anger to gain control. The patient’s perception that the physician understands that uncer- tainty and will join with him or her to help to overcome it may be the deciding factor in preserving the therapeutic relationship. One of the worst errors in dealing with angry or dissatisfied patients is to try to avoid them. It is necessary to actively participate in the process rather than attempting to avoid the issue. Body Dysmorphic Disorder As the popularity of aesthetic surgery increases, one is reminded of the fairy tale that asks the question: “Mirror, mirror on the wall, who’s the fairest of them all? Beyond the unrealistic expectations of aesthetic correction, many patients are seeking surgery when the need for it is dubious at best. The physical change sought through surgery usually is more a manifestation of flawed body image than a measurable deviation from physical normal- ity. Body dysmorphic disorder (BDD) represents a pathological pre- occupation by the patient about a physical trait that may be within normal limits or so insignificant as to be hardly noticeable. As the trend to advertising and marketing cosmetic surgery grows worldwide there is greater probability that those living in the shadow of this diagnosis will eventually decide on the surgeon’s scalpel as an answer to their problem rather than the psychiatrist’s consultation. Increasingly, we see traditional surgical judgment replaced either by financial consideration or plain ego on the part of the surgeon. Because patients with BDD never carry that diagnosis openly into the consulta- tion with the plastic surgeon, medical disputes about the surgical out- come depend entirely on what was said vs what was understood. In the best of all possible worlds, the prospective patient would project from the mind onto a screen exactly the changes he or she conceives for the surgeon to decide whether or not he or she can translate that image into reality. Lamentably, we are still many decades short of achieving such imaginary technology. It is easy for the well-meaning surgeon to be deceived about the patient’s pathological motivation. It is also con- ceivable the physical deformity really is at the center of the patient’s psychological fragility. There are many examples of beneficial change 198 Gorney wrought through successful aesthetic corrective surgery. Nonetheless, statistically the odds for an unfavorable result and a claim are much greater when the disproportion between the objective deformity and the distress it creates in the patient is larger.

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