This leading cause of dementia is the big neuropsychiatric disorder of our times, dominating not just psychogeriatric wards, but the lives of countless children and spouses who have given up work, friends

Alzheimer's disease (AD)

 This leading cause of dementia is the big neuropsychiatric disorder of our times, dominating not just psychogeriatric wards, but the lives of countless children and spouses who have given up work, friends, and all accustomed ways of life to support relatives through the last long years. Their lives can be tormented `l am chained to a corpse' (p329) or transformed, depending on how gently patients exit into their 'worlds of preoccupied emptiness'.% Mean survival: 7yrs from onset. Suspect Alzheimer's in adults with enduring,' acquired deficits of visual-spatial skill ('he gets lost easily), memory, and cogni-tion, eg tested by mental test scores + other neuropsychometric tests (p59). Onset may be from 40yrs (earlier, in Down's syndrome, so notions of 'senile' and 'pre-senile' dementia are blurred, and irrelevant). Cause: Accumulation 13-amyloid peptide, a degradation product of amyloid precursor protein, result-ing in progressive neuronal damage, neurofibrillary tangles, t numbers of senile plaques, and toss of tne neurotransmitter acetytcnotine trom damage to an ascending forebrain projection (nucleus basalis of Meynert; connects with cortex). AD shares some pathological processes with vascular dementias! Memory loss is not like loss of land with a rising tide: the last memories to be sunk in the sea of forgetfulness are not earliest or latest, but the deepest, the most personal, and the most bizarre: prime ministers come and go, but, for dementing British patients of a certain age, the last name retained is that of Mrs Thatcher. When this name sinks into oblivion (fame's eternal dump-ing ground'), often long after that of sovereigns, deities, spouses, and children, one may safely say that the waters have covered the sea. Risk factors Defective genes on chromosomes 1, 14, 19, 21; the apoE4 vari-ant brings forward age of onset. Insulin resistance (p295) may be important! t-Diagnosis is often haphazard, as the exact form of dementia used not to influence outcome, provided B12 and TSH were normal. This view is hard to justify now that specific treatments are available for Alzheimer's. Specialist input with imaging is the ideal (this helps rule out fronto-temporal demen-tias, Lewy body, vascular dementias, and Pick's disease). Presentation Memory/cognition 1; behavioural change (eg aggression, wan-dering, disinhibition); hallucinations; delusions; apathy; depression; irritability; euphoria. There is no standard natural history. Cognitive impairment is pro-gressive, but behavioural/psychotic symptoms may go after a few months or years. Towards the end, often but by no means invariably, patients become sedentary, taking little interest in anything. Parkinsonism (p382), wasting, mutism, incontinence ± seizures may occur. Theoretical issues Potential strategies (*indicates randomized trial evidence) • Prevent breakdown of acetylcholine,* eg anticholinesterases, etc. (see BOX). • Prevent overstimulation of NMDA receptors by glutamate; memantine (see BOX) is an NMDA antagonist. (NMDA = N-methyl-D-aspartate, p335.) • Stimulating nicotinic receptors may be protective (smoking is not a solution!).F5 • Preventing neurotoxicity from homocysteine by ensuring good B12 intake (p374). • NSAIDs to 1 production of 13-amyloid. NB: NSAIDs don't stop progression of AD.*2 • Some anti-oxidants may be protective, eg ginkgo biloba or vit C with D.,71 • 1Arteriopathy (AD risk rises with BPt) and normalize pulse pressure (PP = 70-84): if PP > 84mmHg (reflects arterial stiffness) risk of AD is t; if PP < 70 (reflects poor perfusion) risk of AD is also raised.% Statins* (p707) may prevent ADF9i eg by 1 brain cholesterol synthesis (.-. less amyloid plaque formation). • Cognitively stimulating hobbies may help: a 1-point rise in cognitive activit score can 1 risk of AD by 33%.N NB: HRT (OHCS p18) was thought turotect,82 but the WHIMS* trial found t risk of AD (2% vs 1% on placebo)

ADDUCTOR orHUNTER'Sor SUBSARTORIAL CANAL

ADDUCTOR orHUNTER'Sor SUBSARTORIAL CANAL 

Definition This is also called the subsartorial canal or Hunter's canal. John Hunter (1729-1793) was an anatomist and surgeon at London. Hunter's operation for the treatment ofpopliteal aneurysm by ligating the femoral artery in the adductor canal is a landmark in the history of vascular surgery. The adductor canal is an intermuscular space situated on the medial side of the middle one-third of the thigh 

All muscles of the anterior compartment

of the medial compartment of the thigh. They are described later. In the upper lateral corner of the front of the thigh. we see the tensor fasciae latae. This is a muscle of the gjuteal region and is described in Chapter 5.

The sartorius is long, narrow and ribbon-like.

 It runs downwards and medially across the front of the thigh. It is the longest muscle in the body. Its attachments are given in  Its nerve supply and actions are described below. The quadriceps femoris is so called because it consists of four parts. These are the rectus femoris, the vastus lateralis the vastus medians. and the vastus intermedius. The rectus femoris is fusiform. It runs more or less vertically on the front of the thigh superficial to the vasti. The three vasti are wrapped around the shaft of the femur in the positions indicated by their names. The attachments of the components of the quadriceps femoris are given in Table 3.1. Their nerve supply and actions are given below.

The articularis genu consists of few muscular slips that arise from the anterior surface of the shaft of the femur, a few centimeters above the patellar articular margin. They are inserted into the upper part of the synovial membrane of the knee joint. They pull the synovial membrane upwards during extension of the knee, thus preventing damage to it.

                                                      nerve supplay 

All muscles of the anterior compartment of the thigh are supplied by the femoral nerveas

  Actions               The sartorius is an abductor and lateral rotator of the thigh. and flexor of the leg. All these actions are 

 involved in assuming the position in which tailors sit and work, i.e. the 'palthit posture (Sartor = tailor). The quadriceps is a strong extensor of the knee joint. This action is very important in standing, walking and running. In addition. the rectus femoris flexes the hip joint along with the iliopsoas and helps to maintain the erect attitude; and the vastus medialis prevents lateral displacement of the patella. The muscle is tested by attempting to extend the knee joint against resistance and palpating the contracting quadriceps muscle .

                                 lliacus and Psoas Major 

These muscles form the lateral part of the floor of the femoral triangle. They are classified as muscles of the iliac region, and also among the muscles of the
posterior abdominal wall. Since the greater parts o their fleshy bellies lie in the posterior abdomina wall, they will be described in detail in the section oz the abdomen. However on account of their principa action on the hip joint, the following points may bi noted. 1. Both have a common insertion on the lesse trochanter of the femur and are the chief and powerfu flexors of the hip joint. 2. Because of their common insertion and action the two muscles are often referred to by a commm name, the iliopsoas. 3. Both are supplied by spinal segments L2 am L3. The psoas is supplied by the branches from the nerve roots, whereas the iliacus is supplied by thi femoral nerve.

MuscleOrigin fromInsertion intoSarforius
2. Quadriceps lemoris A. Rectus lemons Fusdorm, superficial fibres bipennate, deep fibres straighta Vastus lateralis Forms large part of quadriceps lemonsC. Vastus mediaksD. Vastus interned usa. Anterior superior iliac spine and b. Upper half of the notch below the spine
a Straight head: from the upper half of the anterior inferior iliac spine b. Reflected head: from the groove above the margin of the acetabulum and the capsule of the hip joint
The origin is linear The line runs along:a. Upper part of the medial surface of the shah of the tibia in front of the insertions of the gracilis and the semitondinosusBase ol patella
a. Upper part of intertrochanteric rine a. Lateral part of the base of patella b. Anterior and Inferior borders of greater Irochanter b. Upper one-third of the lateral border of patella c. Lateral lip of gluteal tuberosity c. Expansion to the capsule of knee d. Upper half ol lateral lip of I inea aspera joint. tibia and iliotibial tract
The origin in linear. The tine runs along: a. Lower part of intertrochanteric line b. Spiral line c. Medial lip of lined aspera d. Upper one-fourth of medial supracondylar line
a. Upper three-fourths of the anterior and lateral surfaces of the shaft of femur
Medial one-third of the base and upper two-thirds of the medial border of the patella
Base of patella Note. The patella is a sesamoid bone in the tendon of the quadricep femoris. The ligamentum patellae is the actual tendon of the quadriceps femoris, which is inserted to the tibial tuberosity

Femoral nerve dysfunction

                                                 FEMORAL NERVE study foot
 
It is marked by joining the following two points.
 (a) First point 1.2 cm lateral to the midinguinal point
(b) Second point 2.5 cm vertically below th point.
Introduction The femoral nerve is the chief nerve of the ante extensor compartment of
the thigh.
Origin and Root Value It is the largest branch of the lumbar plexus. It is formed by the dorsal divisions of the anterior primary [ rami of spinal nerves L2, L3 and IA. Course It enters the femoral triangle by passing behind the inguinal ligament just lateral to the femoral artery. In the thigh. it lies in the groove between the iliacus r and the psoas major, outside the femoral sheath, and lateral to the femoral artery. After a short course of about 2 cm below the inguinal ligament, the nerve divides into anterior and posterior divisions which L are separated by the lateral circumflex femoral artery.

  Branches and Distribution Muscular:(1) The anterior division supplies the sartorius; and 
(2) the posterior division supplies the rectus femoris, the three vasti and the articularis genu. The articularis genu is supplied by a branch from the nerve to vastus intermedius. Cutaneous:(1) The anterior division gives two cutaneous branches, the intermediate and the medial cutaneous nerves of the thigh; and (2) the posterior division gives only one cutaneous branch. the saphenous nerve. These nerves have been described earlier. Their areas of distribution are shown in picture Articular: (1) The hip joint is supplied by the nerve to the rectus femoris; and (2) the knee joint is supplied by the nerves to the three vasti. The nerve to the vastus medialis contains numerous proprioceptive fibres from the knee joint, accounting for the thickness of the nerve. This is in accordance with Hilton's law: Nerve supply to a muscle which lies across a joint, not only supplies the muscle. but also supplies the joint beneath and the skin overlying the muscle. Vascular: to the femoral artery and its branches. Note: The nerve to the pectineus arises from the medial side of the femoral nerve just above the inguinal ligament. It passes obliquely downwards and medially, behind the femoral sheath. to reach the anterior surface of the muscle. WNW                                                CLINICAL ANATOMY  
1. The femoral and obturator nerves which supply the hip joint, also supply the knee joint. Therefore, diseases of the hip may produce referred pain in the knee and also in the cutaneous area innervated by these nerves. 
2. Injury to the femoral nerve by wounds in the groin, though rare, causes paralysis of the quadriceps femoris and a sensory deficit on the anterior and medial sides of the thigh and medial side of leg.  
                               MUSCLES OF THE FRONT OF THE THIGH   
The muscles of the anterior compartment of the thigh are the sartorius, the quadriceps femoris, and the articularis genu . In addition to these. some muscles belonging to other regions are also encountered on the front of the thigh. The iliacus and psoas major muscles. which form part of the floor of the femoral triangle, have their origin within the abdomen. The pectineus and adductor longus, also seen in relation to the femoral triangle, are muscles

Profunda Femoris Artery and FEMORAL VEIN

(Anterior and posterior relation of the femoral artery in the femoral triangle)

(ill) the superficial circumflex iliac. Mese nave been described earlier. The deep branches are:(1) The profunda femoris: (Ii) the deep external pudendal: and(11I) muscular branches.

                                     Profunda Femoris Artery

This is the largest branch of the femoral artery. It is the chief artery of supply to all the three compartments of the thigh. It arises from the lateral side of the femoral artery about 4 cm below the Inguinal ligament. The origin lies in front of the illacus. As the artery descends, it passes posterior to the femoral vessels. It leaves the femoral triangle by paring deep to the adductor longus. Continuing downwards. it passes first between the adductor longus and the adductor brevis. and then between the adductor longus and the adductor magnus. Its terminal part pierces the adductor magnus to anastomose with upper muscular branches of the popliteal artery. The profunda femoris artery gives off the medial and lateral circumflex femoral arteries, and four perforating arteries. The medial circumflex femoral artery leaves the femoral triangle by passing posteriorly, between the pectineus and the psoas major muscles. Its further course is described in Chapter

4. The lateral circumflex femoral arteryruns laterally between the anterior and posterior divisions of the femoral nerve. passes behind the sartorlus and the rectus femoris. and divides into ascending. transverse and descending branches. The ascending branch runs deep to the tensor fasciae lathe, gives branches to the hip Joint and the greater trochanter, and anastomoses with the superior gluteal artery. The transverse branch pierces the vastus lateral's and takes part in the cruciate anastomosis on the back of the thigh just below the greater trochanter. The descending branch runs down along the anterior border of the vastus lateralis, accompanied by the nerve to that muscle.

The perforatingarteries are described in Chapte
                          Deep External Pudendal Artery 

This branch of the femoral artery passes deep to the spermatic cord, or the round ligament of the uterus. and supplies the scrotum or the labium majus.

                                                        Muscular branches 

 Numerous muscular branches arise from the femoral and profunda femoris artery.

                                              CLINICAL ANATOMY 
1. The femoral artery can be compressed at the midinguinal point against the head of the femur or against the superior ramus of the pubis to control bleeding from the distal part of the limb.

 2. Pulsations of the femoral artery can be felt at the midinguinal point. against the head of the femur and the tendon of the psoas major. A bilateral absence or feebleness of the femoral pulse may result from coarctation or narrowing of the aorta, or thrombosis. i.e. clotting, of blood within the aorta.
 3. Stab wounds at the apex of the femoral triangle may cut all the large vessels of the lower limb because the femoral artery and vein, and the profunda femoris artery and vein are arranged in one line from before backwards at this site.
 4. Since the femoral artery is quite superficial in the femoral triangle. it can be easily exposed for ligation. i.e. tying, or for passing a cannula or a thick needle.
 
                                                          FEMORAL VEIN 
 It begins as an upward continuation of the popliteal vein at the lower end of the adductor canal, and ends by becoming continuous with the external iliac vein behind the inguinal ligament, medial to the femoral artery 
 Its marking is same as that of the femoral artery. except that the upper point is taken 1 cm medial to the midinguinal point, and the lower point 1 cm lateral to the adductor tubercle. The vein is medial to the artery at the upper end, posterior to it in the middle, and lateral to it at the lower end.
 Tributaries.    it receives: (1) The great saphenous vein;
 (2) veins accompanying the three deep branches of the femoral artery in the femoral triangle, i.e. profunda, deep external pudendal. and muscular; 
(3) the lateral and medial circumflex femoral veins: and
 (4) the descending genicular and muscular veins in the adductor canal.  The femoral vein is commonly used for intravenous infusions in infants and in patients with peripheral circulatory failure.
 
                                                   FEMORAL NERVE
It is marked by joining the following two points. (a) First point 1.2 cm lateral to the midinguinal point ............................................