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PAPER – 01
TOPIC – 11
TERM – 02
MARKS - 10
ARTHROLOGY
Dr. Vinay Pareek
PPT According to NCISM
INDEX
JOINTS : STRUCTURE , TYPES &
MOVEMENTS
3
DESCRIPTION OF JOINTS OF
EXTREMITIES WITH THEIR CLINICAL
ANATOMY
21
DESCRIPTION OF JOINTS OF INTER-
VERTEBRAL JOINTS WITH THEIR
CLINICAL ANATOMY
71
DESCRIPTION OF JOINT OF
TEMPOROMANDIBULAR JOINT WITH
THEIR CLINICAL ANATOMY
75
THANKS
ARTHROLOGY
ARTHROLOGY IS THE SCIENTIFIC
STUDY OF JOINTS / ARTICULATIONS.
JOINTS
• SITE WHERE RIGID ELEMEMTS OF THE
SKELETON MEET ARE CALLED JOINTS /
ARTICULATIONS.
• JOINT IS A JUNCTION BETWEEN TWO OR
MORE BONES OR CARTILAGES.
3
CLASSIFICATION
OF
JOINTS
ON THE BASIS OF STRUCTURE
FIBROUS
o BONES CONNECTED
BY FIBROUS TISSUE
o NO JOINT CAVITY
o SUB – TYPES
1. SUTURES
2. SYNDESMOSES
3. GOMPHOSES
CARTILAGINOUS
o BONES CONNECTED
BY CARTILAGE
o NO JOINT CAVITY
o SUB – TYPES
1. SYNCHONDROSIS
2. SYMPHYSES
SYNOVIAL
o MOST MOVABLE JOINTS IN THE BODY
o THERE IS A JOINT CAVITY
o ARTICULAR CARTILAGE COVERS THE ENDS OF THE
OPPOSING BONES
o ARTICULAR CAPSULE ENCLOSES THE JOINT CAVITY
o SUB – TYPES
1. PLANE
2. HINGE
3. PIVOT
4. CONDYLOID
5. SADDLE
6. BALL & SOCKET
5
SUTURES
The suture joints are immovable
or fixed joints consisting of a thin
layer of dense fibrous
connective tissue, which are
found between all the bones of
the skull except the mandible.
These joints also provide
strength to the joint by attaching
the irregular interlocking edges
of cranial bone. Sutures are the
sites of active bone growth.
6
SYNDESMOSES
 It is a type of fibrous joint, where two parallel bones
are united with each other by interosseous
membrane or ligaments based on the gap between
the bones.
 This type of fibrous joint is present in the forearm
and leg.
 In the forearms, the shaft of the radius and ulna are
joined strongly by an interosseous membrane. This
membrane in the forearms is flexible enough to
rotate the forearms.
 In the legs, the shafts of the tibia and fibula are also
joined strongly by an interosseous membrane. The
distal tibiofibular joint is made of fibrous connective
tissue and ligaments. These ligaments along with the
interosseous membrane form the Syndesmosis in
the leg. The interosseous membrane in the legs is
firm to lock the ankle joint for weight-bearing and
stability.
7
GOMPHOSES
 It is a specialized fibrous joint, which provides an
independent and firm suspension for each tooth.
 It fits the teeth into their sockets, which are situated
in the maxilla and the mandible.
 The gomphosis fibrous joints are also referred to as
peg and socket joints.
8
SYNCHONDROSIS
 It is a type of cartilaginous joint
where hyaline cartilage completely joins
together two bones.
 Synchondroses are immovable joints and
are thus referred to as synarthroses.
9
SYMPHYSIS
 It is a fibrocartilaginous fusion between two
bones.
 It is a type of cartilaginous joint.
 It is an amphiarthrosis, a slightly movable
joint.
10
TYPES OF SYNOVIAL
PLANE JOINT
 Plane joints permit two or more round or flat bones to
move freely together without any rubbing or crushing
of bones.
 This joint is mainly found in those regions where the
two bones meet and glide on one another in any of
the directions.
 The lower leg to the ankle joint and the forearm to
wrist joint are the two main examples of gliding
joints.
11
TYPES OF SYNOVIAL
HINGE JOINT
 Hinge joints are like door hinges, where only back
and forth movement is possible.
 Example of hinge joints is the ankle, elbows and
knee joints.
12
TYPES OF SYNOVIAL
PIVOT JOINT
 In this type of joint, one bone has tapped into the
other in such a way that full rotation is not possible.
 This joint aid in sideways and back-forth movement.
 An example of a pivotal joint in the neck.
13
TYPES OF SYNOVIAL
CONDYLOID JOINT
 Condyloid joints are the joints with two axes which
permit up-down and side-to-side motions.
 The condyloid joints can be found at the base of the
index finger, carpals of the wrist, elbow and the wrist
joints.
 This joint is also known as a condylar or ellipsoid
joint.
14
TYPES OF SYNOVIAL
SADDLE JOINT
 Saddle joint is the biaxial joint that allows the
movement on two planes –flexion/extension &
abduction/adduction.
 For example, the thumb is the only bone in the
human body having a saddle joint.
15
TYPES OF SYNOVIAL
BALL & SOCKET JOINT
 Ball & socket joints possess a rounded,
ball-like end of one bone fitting into a
cuplike socket of another bone.
 This organization allows the greatest range
of motion, as all movement types are
possible in all directions.
 Examples of ball-and-socket joints are the
shoulder and hip joints.
16
ON THE BASIS OF FUNCTION
SYN - ARTHROSES
o IMMOVABLE JOINTS
(SUTURES)
o LARGELY
RESTRICTED TO THE
AXIAL SKELETON
AMPHI - ARTHROSES
o SLIGHTLY MOVABLE
JOINTS
(INTERVERTEBRAL DISCS)
o FIBROUS CONNECTION
o LARGELY RESTRICTED TO
THE AXIAL SKELETON
DI - ARTHROSES
o FREELY MOVABLE
JOINTS (SYNOVIAL)
o PREDOMINATE IN THE
LIMBS
17
SYN-ARTHROSES
 Synarthrosis (Fibrous) – are fixed joints at
which there is no movement.
 The articular surfaces are joined by tough
fibrous tissue. As in the sutures of the skull.
18
AMPHI-ARTHROSES
In this type of joints the bones are joined by cartilage. It
has no joint cavity.
1. Primary cartilaginous joints (synchondrosis, or
hyaline cartilage joints):-
The bones are united by the plate of hyaline cartilage
so that the joint is immovable and strong.
These joints are temporary in nature because after a
certain age the cartilaginous plate is replaced by bone.
E.g. (1) The joint between the 1st rib and the sternum.
(2) The joint between body of the sphenoid and
basilar part of the occipital bone.
2. Secondary Cartilagenous joint (Symphysis)-
The connecting material in between the articular area
is a broad and flat disc of fibro-cartilage. These are
permanent joints and allow a limited movement
E.g. The intervertebral joint, a portion of the inter
vertebral disc is cartilaginous material.
Symphysis pubis
Manubrio-sternal joint.
19
DI-ARTHROSES
 Joints are characterized by the presence of an articular
cartilage, the articular cartilage covers the surface of
the articulating bones, but does not bind the bones
together.
 The articular cartilage is hyaline cartilage.
 A sleeve like articular capsule, which encloses the joint
cavity and unites the articulating bones and surrounds
the joints. The fibrous capsule and accessory
ligaments covers the joint.
 The fibrous capsule is composed of two layers.
• The outer layer- It consists of dense connective tissue:
it is attached to the periosteum of the articulating
bones at a variable distance. The fibres of some
fibrous capsules are arranged in parallel bundles such
fibres are called ligaments and are gives specific
names. The strength of the ligaments is one of the
principal factors in holding a bone to the other.
• The inner layer- The synovial membrane forms the
inner layer: it is composed of loose connective tissue
with elastic fibres and variable amount of adipose
tissue. It secretes the synovial fluid, which lubricates
the joint and provides nourishment for the articular
cartilage. 20
DESCRIPTION OF JOINTS OF
EXTREMITIES
WITH THEIR
CLINICAL ANATOMY
JOINTS OF UPPER EXTREMITIES -
Acromioclavicular
Joints
located where the lateral end of the clavicle articulates with the
acromion of the scapula
Sternoclavicular
Joints
synovial joint between the clavicle and the manubrium of
the sternum
Shoulder Joints ball and socket joint between the scapula and the humerus
Elbow Joints joint connecting the upper arm to the forearm
Radioulnar
Joints
Proximal & Distal are two radioulnar joints in which
the radius and ulna articulate in the forearm
Wrist Joints a synovial joint in the upper limb, marking the area of transition between
the forearm and the hand
22
23
ACROMIOCLAVICULAR JOINT
• The acromioclavicular joint consists of
an articulation between the lateral
end of the clavicle and
the acromion of the scapula.
• It has two atypical features :-
1. The articular surfaces of the joint are
lined with fibrocartilage.
2. The joint cavity is partially divided by
an articular disc.
24
Ligaments -
There are three main ligaments that strengthen the acromioclavicular
joint. They can be divided into intrinsic and extrinsic ligaments:
• Intrinsic:
• Acromioclavicular ligament – runs horizontally from the
acromion to the lateral clavicle.
It covers the joint capsule, reinforcing its superior aspect.
• Extrinsic:
• Conoid ligament – runs vertically from the coracoid
process of the scapula to the conoid tubercle of the clavicle.
• Trapezoid ligament – runs from the coracoid process of the scapula to the
trapezoid line of the clavicle.
Collectively, the conoid and trapezoid ligaments are known as the coracoclavicular
ligament.
25
CLINICAL ASPECT
• Acromioclavicular joint dislocation (also known as a
separated shoulder) occurs when the two articulating
surfaces of the joint are separated. It is associated
with joint soft tissue damage.
• It commonly occurs from a direct blow to the joint or a
fall on an outstretched hand.
• The injury is more serious if ligamental rupture occurs
(acromioclavicular or coracoclavicular). If the
coracoclavicular ligament is torn, weight of the upper
limb is not supported and the shoulder moves
inferiorly. This increases the prominence of the
clavicle.
• Management of AC joint dislocation is dependent on
injury severity and impact on quality of life. The
treatment options range from ice and rest to ligament
reconstruction surgery.
• Note: This injury is not to be confused with shoulder
dislocation – an injury affecting the glenohumeral
joint.
Fig. Radiograph of
shoulder
separation
26
STERNOCLAVICULAR JOINT
• The sternoclavicular joint consists of
the sternal end of the clavicle, the
manubrium of the sternum, and part
of the 1st costal cartilage.
• The articular surfaces are covered
with fibrocartilage (as opposed to
hyaline cartilage, present in the
majority of synovial joints).
• The joint is separated into two
compartments by a
fibrocartilaginous articular disc.
Clavicl
e
27
Ligaments -
The ligaments of the sternoclavicular joint provide much of its stability.
There are four major ligaments:
• Sternoclavicular ligaments (anterior and posterior) – these strengthen
the joint capsule anteriorly and posteriorly.
• Interclavicular ligament – this spans the gap between the sternal
ends of each clavicle and reinforces the joint capsule superiorly.
• Costoclavicular ligament – the two parts
of this ligament (often separated by a bursa)
bind at the 1st rib and cartilage inferiorly
and to the anterior and posterior borders
of the clavicle superiorly. It is a very strong
ligament and is the main stabilizing force for
the joint, resisting elevation of the pectoral girdle.
28
CLINICAL ASPECT
• A dislocation of the sternoclavicular joint is
quite rare and requires significant force.
The costoclavicular ligament and
the articular disc are highly effective at
absorbing and transmitting forces away from
the joint into the sternum.
There are two major types of dislocation : -
• Anterior dislocations are the most common
and can happen following a blow to the
anterior shoulder which rotates the shoulder
backwards.
• Posterior dislocations normally result from a
force driving the shoulder forwards or from
direct impact to the joint.
• In younger people, the epiphyseal growth
plate of the sternal end of the clavicle has not
fully closed. In this population, the dislocation
is usually accompanied by a fracture through
the plate.
Fig. Radiograph of a right
sternoclavicular
joint dislocation.
29
SHOULDER JOINT
• The shoulder joint is formed by the articulation
of the head of the humerus with the glenoid
cavity (or fossa) of the scapula. This gives rise
to the alternate name for the shoulder joint –
the glenohumeral joint.
• Like most synovial joints, the articulating
surfaces are covered with hyaline
cartilage. The head of the humerus is much
larger than the glenoid fossa, giving the joint a
wide range of movement at the cost of inherent
instability. To reduce the disproportion in
surfaces, the glenoid fossa is deepened by a
fibrocartilage rim, called the glenoid labrum.
30
Joint Capsule and Bursae -
• The joint capsule is a fibrous sheath which encloses the structures of the joint.
• It extends from the anatomical neck of the humerus to the border or ‘rim’ of the
glenoid fossa. The joint capsule is lax, permitting greater mobility.
• The synovial membrane lines the inner surface of the joint capsule, and produces
synovial fluid to reduce friction between the articular surfaces.
• To reduce friction in the shoulder joint, several synovial bursae are present.
• A bursa is a synovial fluid filled sac, which acts as a cushion between tendons and
other joint structures.
The bursae that are important clinically are:
• Subacromial – located deep to the deltoid and acromion,
and superficial to the supraspinatus tendon and joint capsule.
The subacromial bursa reduces friction beneath the deltoid,
promoting free motion of the rotator cuff tendons. Subacromial
bursitis can be a cause of shoulder pain.
• Subscapular – located between the subscapularis tendon and
the scapula. It reduces wear and tear on the tendon during
movement at the shoulder joint.
31
Ligaments -
In the shoulder joint, the ligaments play a key role in stabilizing the bony structures.
• Glenohumeral ligaments (superior, middle and inferior) – the joint capsule is formed by this group of ligaments
connecting the humerus to the glenoid fossa. They are the main source of stability for the shoulder, holding it in
place and preventing it from dislocating anteriorly. They act to stabilize the anterior aspect of the joint.
• Coracohumeral ligament – attaches the base of the coracoid process to the greater tubercle of the humerus. It
supports the superior part of the joint capsule.
• Transverse humeral ligament – spans the distance between the two tubercles of the humerus. It holds the
tendon of the long head of the biceps in the intertubercular groove.]
• Coracoclavicular ligament – composed of the trapezoid and
conoid ligaments and runs from the clavicle to the coracoid process
of the scapula. They work alongside the acromioclavicular ligament
to maintain the alignment of the clavicle in relation to the scapula.
They have significant strength but large forces (e.g. after a high energy fall)
can rupture these ligaments as part of an acromio-clavicular joint (ACJ) injury.
In severe ACJ injury, the coraco-clavicular ligaments may require surgical repair.
The other major ligament is the coracoacromial ligament. Running between the acromion and coracoid process of
the scapula it forms the coraco-acromial arch. This structure overlies the shoulder joint, preventing displacement
of the humeral head.
32
Movements -
As a ball and socket synovial joint, there is a wide range of movement permitted:-
• Extension (upper limb backwards in sagittal plane) – posterior deltoid,
latissimus dorsi and teres major.
• Flexion (upper limb forwards in sagittal plane) – pectoralis major, anterior
deltoid and coracobrachialis. Biceps brachii weakly assists in forward flexion.
• Abduction (upper limb away from midline in coronal plane):
• The first 0-15 degrees of abduction is produced by the supraspinatus.
• The middle fibres of the deltoid are responsible for the next 15-90 degrees.
• Past 90 degrees, the scapula needs to be rotated to achieve abduction – that is carried out by
the trapezius and serratus anterior.
• Adduction (upper limb towards midline in coronal plane) – pectoralis major,
latissimus dorsi and teres major.
• Internal rotation (rotation towards the midline, so that the thumb is pointing
medially) – subscapularis, pectoralis major, latissimus dorsi, teres major and
anterior deltoid.
• External rotation (rotation away from the midline, so that the thumb is
pointing laterally) – infraspinatus and teres minor.
• Circumduction (moving the upper limb in a circle) – produced by a combination
of the movements described above.
33
Mobility and Stability -
Factors that contribute to mobility:
• Type of joint – ball and socket joint.
• Bony surfaces – shallow glenoid cavity and large
humeral head – there is a 1:4 disproportion in surfaces.
A commonly used analogy is the golf ball and tee.
• Inherent laxity of the joint capsule.
Factors that contribute to stability:
• Rotator cuff muscles – surround the shoulder joint, attaching to the tuberosities of the humerus,
whilst also fusing with the joint capsule. The resting tone of these muscles act to compress the
humeral head into the glenoid cavity.
• Glenoid labrum – a fibrocartilaginous ridge surrounding the glenoid cavity. It deepens the cavity
and creates a seal with the head of humerus, reducing the risk of dislocation.
• Ligaments – act to reinforce the joint capsule, and form the coraco-acromial arch.
• Biceps tendon – it acts as a minor humeral head depressor, thereby contributing to stability.
34
CLINICAL ASPECT
• Clinically, dislocations at the shoulder are described by
where the humeral head lies in relation to the glenoid
fossa. Anterior dislocations are the most prevalent
(95%), although posterior (4%) and inferior (1%)
dislocations can sometimes occur. Superior
displacement of the humeral head is generally prevented
by the coraco-acromial arch.
• An anterior dislocation is usually caused by
excessive extension and lateral rotation of
the humerus. The humeral head is forced anteriorly and
inferiorly – into the weakest part of the joint capsule.
Tearing of the joint capsule is associated with an
increased risk of future dislocations.
• The axillary nerve runs in close proximity to the
shoulder joint and around the surgical neck of the
humerus, and so it can be damaged in the dislocation or
with attempted reduction. Injury to the axillary nerve
causes paralysis of the deltoid, and loss of sensation
35
ELBOW JOINT
It consists of two separate articulations :-
• Trochlear notch of the ulna and the
trochlea of the humerus
• Head of the radius and the capitulum of
the humerus
There are many bursae in the elbow, but
only a few have clinical importance:
• Intratendinous – located within the
tendon of the triceps brachii.
• Subtendinous – between the olecranon
and the tendon of the triceps brachii,
reducing friction between the two
structures during extension and flexion of
the arm.
• Subcutaneous (olecranon) bursa –
between the olecranon and the overlying
connective tissue (implicated in olecranon
bursitis).
36
Ligaments -
The joint capsule of the elbow is
strengthened by ligaments medially
and laterally.
• The radial collateral ligament is
found on the lateral side of the
joint, extending from the lateral
epicondyle, and blending with the
annular ligament of the radius (a
ligament from the proximal
radioulnar joint).
• The ulnar collateral ligament
originates from the medial
epicondyle, and attaches to the
coronoid process and olecranon of
the ulna.
37
CLINICAL ASPECT
Bursitis
• Subcutaneous bursitis: Repeated friction and pressure on the bursa can cause it to become inflamed. Because this bursa lies relatively
superficially, it can also become infected (e.g cut from a fall on the elbow)
• Subtendinous bursitis: This is caused by repeated flexion and extension of the forearm, commonly seen in assembly line workers. Usually
flexion is more painful as more pressure is put on the bursa.
Dislocation
• An elbow dislocation usually occurs when a young child falls on a hand with the elbow flexed. The distal end of the humerus is driven through the
weakest part of the joint capsule, which is the anterior side. The ulnar collateral ligament is usually torn and there can also be ulnar nerve
involvement. Most elbow dislocations are posterior, and it is important to note that elbow dislocations are named by the position of the ulna and
radius, not the humerus.
Epicondylitis (Tennis elbow or Golfer’s elbow)
• Most of the flexor and extensor muscles in the forearm have a common tendinous origin. The flexor muscles originate from the medial
epicondyle, and the extensor muscles from the lateral. Sportspersons can develop an overuse strain of the common tendon – which results in
pain and inflammation around the area of the affected epicondyle.
• Typically, tennis players experience pain in the lateral epicondyle from the common extensor origin. Golfers experience pain in the medial
epicondyle from the common flexor origin. This is easily remembered as golfers aim for the ‘middle’ of the fairway, while tennis players aim for the
‘lateral’ line of the court!
Supracondylar Fracture
• A supracondylar fracture usually occurs due to a fall onto on outstretched, extended hand in a child (95%) but more rarely can occur by a direct
impact onto a flexed elbow. It is typically a transverse fracture, spanning between the two epicondyles in the relatively weak epicondylar region
formed by the olecranon fossa and coronoid fossa which lie opposite each other in the distal humerus.
• Direct damage, or swelling can cause the interference to the blood supply of the forearm via the brachial artery. The resulting ischaemia can
cause Volkmann’s ischaemic contracture – uncontrolled flexion of the hand, as flexors muscles become fibrotic and short. There also can
be damage to the medial, ulnar or radial nerves. As a result, the neurovascular examination and documentation of all patients presenting with
these injuries is vital. Sometimes, the blood supply can be interrupted acutely leading to a ‘pale, pulseless’ limb often in a child, usually requiring
38
Fig. X-ray
of a
posterior
dislocation
of the
elbow
39
RADIOULNAR JOINT
The radioulnar joints are two locations in
which the radius and ulna articulate in the
forearm:
• Proximal radioulnar joint – located near
the elbow. It is articulation between the
head of the radius and the radial notch of
the ulna.
• Distal radioulnar joint – located near
the wrist. It is an articulation between the
ulnar notch of the radius and the ulnar
head.
Both of these joints are classified as pivot
joints, responsible
for pronation and supination of the
40
Proximal Radioulnar Joint -
• The proximal radioulnar joint is located
immediately distal to the elbow joint, and is
enclosed with in the same articular capsule. It is
formed by an articulation between the head of the
radius and the radial notch of the ulna.
• The radial head is held in place by the annular
radial ligament, which forms a ‘collar’ around the
joint. The annular radial ligament is lined with a
synovial membrane, reducing friction during
movement.
• Movement is produced by the head of the radius
rotating within the annular ligament. There are two
movements possible at this joint; pronation and
supination.
• Pronation: Produced by the pronator quadratus
and pronator teres.
• Supination: Produced by the supinator and biceps
brachii.
41
Distal Radioulnar Joint -
• This distal radioulnar joint is located just proximally to
the wrist joint. It is an articulation between the ulnar
notch of the radius, and the ulnar head.
• In addition to anterior and posterior ligaments
strengthening the joint, there is also a
fibrocartilaginous ligament present, called
the articular disk. It serves two functions:
Binds the radius and ulna together, and holds them
together during movement at the joint.
Separates the distal radioulnar joint from the wrist
joint.
• Like the proximal radioulnar joint, this is a pivot joint,
allowing for pronation and supination. The ulnar notch
of the radius slides anteriorly over the head of the
ulnar during such movements -
Pronation: Produced by the pronator quadratus and
pronator teres
Supination: Produced by the supinator and biceps
42
Interosseous Membrane -
• The interosseous membrane is a sheet of connective tissue that
joins the radius and ulna together between the radioulnar joints.
• It spans the distance between the medial radial border, and the
lateral ulnar border. There are small holes in the sheet, as a
conduit for the forearm vasculature.
This connective tissue sheet has three major functions:-
Holds the radius and ulna together during pronation and
supination of the forearm, providing addition stability.
Acts as a site of attachment for muscles in the anterior and
posterior compartments of the forearm.
Transfers forces from the radius to the ulna.
43
CLINICAL ASPECT
Fractures to the Radius and Ulna
• Although the radius and ulnar are two distinct and separate
bones, when dealing with injuries to the forearm, they can be
thought of as a ring.
• A ring, when broken, usually breaks in two places. The best
way of illustrating with is with a polo mint – it is very difficult to
break one side without breaking the other.
• This means that a fracture to the radius or the ulna usually
causes a fracture or dislocation of the other bone. There are
two classical fractures:
• Monteggia fracture – fracture of the proximal ulna AND
dislocation of the radial head at the proximal radioulnar joint.
• Galeazzi fracture – fracture of the distal radius AND dislocation
of the ulnar head at the distal radioulnar joint.
44
WRIST JOINT
The wrist joint is formed by:
• Distally – The proximal row of the carpal bones
(except the pisiform).
• Proximally – The distal end of the radius, and the
articular disk.
• The ulna is not part of the wrist joint –
it articulates with the radius, just proximal to the
wrist joint, at the distal radioulnar joint. It is
prevented from articulating with the carpal bones by
a fibrocartilaginous ligament, called the articular
disk, which lies over the superior surface of the
ulna.
• Together, the carpal bones form a convex surface,
which articulates with the concave surface of the
radius and articular disk.
45
Ligaments -
There are four ligaments of note in the wrist joint, one for
each side of the joint
• Palmar radiocarpal – Found on the palmar (anterior)
side of the hand. It passes from the radius to both rows
of carpal bones. Its function, apart from increasing
stability, is to ensure that the hand follows the forearm
during supination.
• Dorsal radiocarpal – Found on the dorsum (posterior)
side of the hand. It passes from the radius to both rows
of carpal bones. It contributes to the stability of the wrist,
but also ensures that the hand follows the forearm
during pronation.
• Ulnar collateral – Runs from the ulnar styloid process
to the triquetrum and pisiform. It acts to prevent
excessive radial (lateral) deviation of the hand.
• Radial collateral – Runs from the radial styloid process
to the scaphoid and trapezium. It acts to prevent
excessive ulnar (medial) deviation of the hand.
P
R
RC
UC
46
Movements of the Wrist Joint -
• The wrist is an ellipsoidal (condyloid) type synovial joint, allowing
for movement along two axes. This means that flexion, extension,
adduction and abduction can all occur at the wrist joint.
• All the movements of the wrist are performed by the muscles of the
forearm.
Flexion – Produced mainly by the flexor carpi ulnaris, flexor carpi
radialis, with assistance from the flexor digitorum superficialis.
Extension – Produced mainly by the extensor carpi radialis longus
and brevis, and extensor carpi ulnaris, with assistance from the
extensor digitorum.
Adduction – Produced by the extensor carpi ulnaris and flexor
carpi ulnaris
Abduction – Produced by the abductor pollicis longus, flexor carpi
radialis, extensor carpi radialis longus and brevis.
47
CLINICAL ASPECT
Scaphoid Fracture -
• The scaphoid bone of the hand is the most commonly fractured carpal bone – typically by falling on an
outstretched hand (FOOSH).
• In a fracture of the scaphoid, the characteristic clinical feature is pain and tenderness in the anatomical
snuffbox.
• The scaphoid is at particular risk of avascular necrosis after fracture because of its so-called ‘retrograde
blood supply’ which enters at its distal end. This means that a fracture to the middle (or ‘waist’) of the
scaphoid may interrupt the blood supply to the proximal part of the scaphoid bone rendering it avascular.
• Patients with a missed scaphoid fracture are likely to develop osteoarthritis of the wrist in later life.
Anterior Dislocation of the Lunate -
• This can occur by falling on a dorsiflexed wrist. The lunate is forced anteriorly, and compresses the
carpal tunnel, causing the symptoms of carpal tunnel syndrome.
• This manifests clinically as paraesthesia in the sensory distribution of the median nerve and weakness of
thenar muscles. The lunate can also undergo avascular necrosis, so immediate clinical attention to the
fracture is needed.
Colles’ Fracture -
• The Colles’ fracture is the most common fracture involving the wrist, caused by falling onto an
outstretched hand.
• The radius fractures, with the distal fragment being displaced posteriorly. The ulnar styloid process can
also be damaged, and is avulsed in the majority of cases.
• This clinical condition produces what is known as the ‘dinner fork deformity’.
48
Scaphoid Fracture Anterior Dislocation of the Lunate Colles’
Fracture
JOINTS OF LOWER EXTREMITIES -
Hip Joints
ball and socket synovial joint, formed by an articulation between the
pelvic acetabulum and the head of the femur
Knee Joints
hinge type synovial joint, which mainly allows for flexion and
extension
Tibiofibular
Joints
plane type synovial joint, where the bones to glide over one
another to create movement
Ankle Joints hinge type joint, permitting dorsiflexion and plantarflexion of
the foot
Subtalar Joints joint is classed structurally as a synovial joint, and functionally as
a plane synovial joint
49
50
HIP JOINT
• The hip joint consists of an articulation between
the head of femur and acetabulum of the
pelvis.
• The acetabulum is a cup-like depression
located on the inferolateral aspect of the pelvis.
Its cavity is deepened by the presence of a
fibrocartilaginous collar – the acetabular
labrum. The head of femur is hemispherical,
and fits completely into the concavity of the
acetabulum.
• Both the acetabulum and head of femur are
covered in articular cartilage, which is thicker
at the places of weight bearing.
• The capsule of the hip joint attaches to the
edge of the acetabulum proximally. Distally, it
attaches to the intertrochanteric line anteriorly
and the femoral neck posteriorly.
51
There are three main extracapsular ligaments,
continuous with the outer surface of the hip joint
capsule:
• Iliofemoral ligament – arises from the
anterior inferior iliac spine and then bifurcates
before inserting into the intertrochanteric line
of the femur.
• It has a ‘Y’ shaped appearance, and prevents
hyperextension of the hip joint. It is the strongest
of the three ligaments.
• Pubofemoral – spans between the superior
pubic rami and the intertrochanteric line of the
femur, reinforcing the capsule anteriorly and
inferiorly.
• It has a triangular shape, and prevents excessive
abduction and extension.
• Ischiofemoral– spans between the body of
the ischium and the greater trochanter of the
femur, reinforcing the capsule posteriorly.
• It has a spiral orientation, and prevents
hyperextension and holds the femoral head in the
acetabulum.
52
Movements and Muscles -
The movements that can be carried out at the hip joint are listed below,
along with the principle muscles responsible for each action:
Flexion – iliopsoas, rectus femoris, sartorius, pectineus
Extension – gluteus maximus; semimembranosus, semitendinosus and
biceps femoris (the hamstrings)
Abduction – gluteus medius, gluteus minimus, piriformis and tensor
fascia latae
Adduction – adductors longus, brevis and magnus, pectineus and
gracilis
Lateral rotation – biceps femoris, gluteus maximus, piriformis, assisted
by the obturators, gemilli and quadratus femoris.
Medial rotation – anterior fibres of gluteus medius and minimus, tensor
fascia latae
• The degree to which flexion at the hip can occur depends on whether the
knee is flexed – this relaxes the hamstring muscles, and increases the
range of flexion.
• Extension at the hip joint is limited by the joint capsule and
the iliofemoral ligament. These structures become taut during extension
53
CLINICAL ASPECT
Posterior dislocation (90%) – the
femoral head is forced posteriorly, and
tears through the inferior and posterior
part of the joint capsule, where it is at its
weakest.
• The affected limb becomes
shortened and medially rotated.
• The sciatic nerve runs posteriorly to
the hip joint, and is at risk of injury
(occurs in 10-20% of cases). This is
often associated with anterior
femoral head and posterior wall
fractures.
54
KNEE JOINT
• The knee joint consists of two articulations –
tibiofemoral and patellofemoral. The joint surfaces
are lined with hyaline cartilage and are enclosed
within a single joint cavity.
• Tibiofemoral – medial and lateral condyles of the
femur articulate with the tibial condyles. It is the
weight-bearing component of the knee joint.
• Patellofemoral – anterior aspect of the distal
femur articulates with the patella. It allows the
tendon of the quadriceps femoris (knee extensor)
to be inserted directly over the knee – increasing
the efficiency of the muscle.
• As the patella is both formed and resides within
the quadriceps femoris tendon, it provides a
fulcrum to increase power of the knee extensor
and serves as a stabilising structure that reduces
frictional forces placed on femoral condyles.
55
Menisci -
The medial and lateral menisci
are fibrocartilage structures in the knee that
serve two functions:
To deepen the articular surface of the tibia,
thus increasing stability of the joint.
To act as shock absorbers by increasing
surface area to further dissipate forces.
• They are C shaped and attached at both ends
to the intercondylar area of the tibia.
• In addition to the intercondylar attachment,
the medial meniscus is fixed to the tibial
collateral ligament and the joint capsule.
Damage to the tibial collateral ligament usually
results in a medial meniscal tear.
• The lateral meniscus is smaller and does not
have any extra attachments, rendering it fairly
mobile.
56
Bursae -
There are four bursae found in the knee joint:
• Suprapatellar bursa – an extension of the
synovial cavity of the knee, located between
the quadriceps femoris and the femur.
• Prepatellar bursa – found between the apex
of the patella and the skin.
• Infrapatellar bursa – split into deep and
superficial. The deep bursa lies between the
tibia and the patella ligament. The superficial
lies between the patella ligament and the skin.
• Semimembranosus bursa – located
posteriorly in the knee joint, between the
semimembranosus muscle and the medial
head of the gastrocnemius.
57
Ligaments -
The major ligaments in the knee joint are:
• Patellar ligament – a continuation of the quadriceps femoris tendon distal
to the patella. It attaches to the tibial tuberosity.
• Collateral ligaments – two strap-like ligaments. They act to stabilize the
hinge motion of the knee, preventing excessive medial or lateral movement
• Tibial (medial) collateral ligament – wide and flat ligament, found on the medial side of
the joint. Proximally, it attaches to the medial epicondyle of the femur, distally it
attaches to the medial condyle of the tibia.
• Fibular (lateral) collateral ligament – thinner and rounder than the tibial collateral, this
attaches proximally to the lateral epicondyle of the femur, distally it attaches to a
depression on the lateral surface of the fibular head.
• Cruciate Ligaments – these two ligaments connect the femur and the tibia.
In doing so, they cross each other, hence the term ‘cruciate’ (Latin for like a
cross)
• Anterior cruciate ligament – attaches at the anterior intercondylar region of the tibia
where it blends with the medial meniscus. It ascends posteriorly to attach to the femur
in the intercondylar fossa. It prevents anterior dislocation of the tibia onto the femur.
• Posterior cruciate ligament – attaches at the posterior intercondylar region of the tibia
and ascends anteriorly to attach to the anteromedial femoral condyle. It prevents
posterior dislocation of the tibia onto the femur.
58
59
CLINICAL ASPECT
Collateral Ligaments -
• Injury to the collateral ligaments is the most common pathology affecting the knee
joint. It is caused by a force being applied to the side of the knee when the foot is
placed on the ground.
• Damage to the collateral ligaments can be assessed by asking the patient to
medially rotate and laterally rotate the leg. Pain on medial rotation indicates damage
to the medial ligament, pain on lateral rotation indicates damage to the lateral
ligament.
• If the medial collateral ligament is damaged, it is more than likely that the medial
meniscus is torn, due to their attachment.
Bursitis -
• Friction between the skin and the patella cause the prepatellar bursa to become
inflamed, producing a swelling on the anterior side of the knee. This is known
as housemaid’s knee.
• Similarly, friction between the skin and tibia can cause the infrapatellar bursae to
become inflamed, resulting in what is known as clergyman’s
knee (classically caused by clergymen kneeling on hard surfaces during prayer).
60
Cruciate Ligaments -
• The anterior cruciate ligament (ACL) can be torn by hyperextension of the
knee joint, or by the application of a large force to the back of the knee with the
joint partly flexed. To test for this, you can perform an anterior drawer test,
where you attempt to pull the tibia forwards, if it moves, the ligament has been
torn.
• The most common mechanism of posterior cruciate ligament (PCL) damage is
the ‘dashboard injury’. This occurs when the knee is flexed, and a large force
is applied to the shins, pushing the tibia posteriorly. This is often seen in car
accidents, where the knee hits the dashboard. The posterior cruciate ligament
can also be torn by hyperextension of the knee joint, or by damage to the upper
part of the tibial tuberosity.
• To test for PCL damage, perform the posterior draw test. This is where the
clinician holds the knee in flexed position, and pushes the tibia posteriorly. If
there is movement, the ligament has been torn.
Unhappy Triad (Blown Knee) -
• As the medial collateral ligament is attached to the medial meniscus, damage
to either can affect both structure’s functions. A lateral force to an extended
knee, such as a rugby tackle, can rupture the medial collateral ligament,
damaging the medial meniscus in the process. The ACL is also affected, which
completes the ‘unhappy triad’.
61
TIBIOFIBULAR JOINT
1. Proximal -
Articulating Surfaces -
• The proximal tibiofibular joint is formed by an
articulation between the head of the fibula and the
lateral condyle of the tibia.
• It is a plane type synovial joint; where the bones to
glide over one another to create movement.
Supporting Structures -
The joint capsule receives additional support from:
• Anterior and posterior superior tibiofibular
ligaments – span between the fibular head and
lateral tibial condyle
• Lateral collateral ligament of the knee joint
• Biceps femoris – provides reinforcement as it
inserts onto the fibular head.
62
TIBIOFIBULAR JOINT
2. Distal -
Articulating Surfaces -
• The distal (inferior) tibiofibular joint consists of an
articulation between the fibular notch of the distal
tibia and the fibula.
• It is an example of a fibrous joint, where the joint
surfaces are by bound by tough, fibrous tissue.
Supporting Structures -
The distal tibiofibular joint is supported by:
• Interosseous membrane – a fibrous structure
spanning the length of the tibia and fibula.
• Anterior and posterior inferior tibiofibular
ligaments
• Inferior transverse tibiofibular ligament – a
continuation of the posterior inferior tibiofibular
ligament.
63
CLINICAL ASPECT
Dislocation of the Proximal Tibiofibular Joint -
• A proximal tibiofibular joint dislocation is a rare and often missed
diagnosis. It accounts for <1% of all knee injuries.
• The typical mechanism of injury is a fall onto an adducted and
flexed knee. They can also occur as a result of high-energy trauma.
• Common clinical features include inability to weight-bear, lateral
knee pain and tenderness/prominence of the fibular head.
• This type of injury is typically treated with a closed reduction (a
reduction is a procedure to restore the joint to its natural alignment).
Complications of proximal tibiofibular joint dislocation include
common fibular nerve injury (the nerve winds around the neck of the
fibula), and recurrent dislocation.
64
ANKLE JOINT
The ankle joint is formed by three bones;
the tibia and fibula of the leg, and the talus
of the foot:
• The tibia and fibula are bound together by
strong tibiofibular ligaments. Together,
they form a bracket shaped socket,
covered in hyaline cartilage. This socket is
known as a mortise.
• The body of the talus fits snugly into the
mortise formed by the bones of the leg.
The articulating part of the talus is wedge
shaped – it is broad anteriorly, and narrow
posteriorly.
65
66
Medial Ligament -
• The medial ligament (or deltoid ligament) is
attached to the medial malleolus (a bony
prominence projecting from the medial aspect of
the distal tibia).
• It consists of four ligaments, which fan out from the
malleolus, attaching to the talus, calcaneus and
navicular bones. The primary action of the medial
ligament is to resist over-eversion of the foot.
Lateral Ligament -
• The lateral ligament originates from the lateral
malleolus (a bony prominence projecting from the
lateral aspect of the distal fibula).
• It resists over-inversion of the foot, and is
comprised of three distinct and separate ligaments:
Anterior talofibular – spans between the lateral
malleolus and lateral aspect of the talus.
Posterior talofibular – spans between the lateral
malleolus and the posterior aspect of the talus.
Calcaneofibular – spans between the lateral
malleolus and the calcaneus.
67
CLINICAL ASPECT
• A Pott’s fracture is a term used to describe
a bimalleolar (medial and lateral malleoli)
or trimalleolar (medial and lateral malleoli,
and distal tibia) fracture.
• This type of injury is produced by forced
eversion of the foot. It occurs in a series of
stages:
• Forced eversion pulls on the medial ligaments,
producing an avulsion fracture of the medial
malleolus.
• The talus moves laterally, breaking off the
lateral malleolus.
• The tibia is then forced anteriorly, shearing off
the distal and posterior part against the talus.
68
SUBTALAR JOINT
The subtalar joint is an articulation
between two of the tarsal bones in the
foot – the talus and calcaneus. The joint
is classed structurally as
a synovial joint, and functionally as
a plane synovial joint.
The subtalar joint is formed between two
of the tarsal bones:
• Inferior surface of the body of the talus
– the posterior talar articular
surface.
• Superior surface of the calcaneus –
the posterior calcaneal articular
facet.
• As is typical for a synovial joint, these
69
• The subtalar joint is enclosed by a joint capsule, which is lined
internally by synovial membrane and strengthened externally by a
fibrous layer. The capsule is also supported by three ligaments:
• Posterior talocalcaneal ligament
• Medial talocalcaneal ligament
• Lateral talocalcaneal ligament
• An additional ligament – the interosseous talocalcaneal
ligament – acts to bind the talus and calcaneus together. It lies
within the sinus tarsi (a small cavity between the talus and
calcaneus), and is particularly strong; providing the majority of the
ligamentous stability to the joint.
70
CLINICAL ASPECT
Calcaneal Fracture
• The calcaneus is often fractured in a
‘crush‘ type injury. The most common
mechanism of damage is falling onto the
heel from a height – the talus is driven
into the calcaneus. The bone can break
into several pieces, known as
a comminuted fracture. Upon x-ray
imaging, the calcaneus will appear
shorter and wider.
• A calcaneal fracture can cause
chronic problems, even after treatment.
The subtalar joint is usually disrupted,
causing the joint to become arthritic.
The patient will experience pain upon
inversion and eversion – which can
make walking on uneven ground
particularly painful.
DESCRIPTION OF JOINTS OF
INTER VERTEBRAL JOINTS
WITH THEIR
CLINICAL ANATOMY
72
INTER VERTEBRAL JOINT
The mobile vertebrae articulate with each other via joints between their bodies and articular facets:-
• Left and right superior articular facets articulate with the vertebra above.
• Left and right inferior articular facets articulate with the vertebra below.
• Vertebral bodies indirectly articulate with each other via the intervertebral discs.
• The vertebral body joints are cartilaginous joints, designed for weight-bearing.
• The articular surfaces are covered by hyaline cartilage, and are connected by the intervertebral disc.
• Two ligaments strengthen the vertebral body joints: the anterior and posterior longitudinal
ligaments, which run the full length of the vertebral column.
• The anterior longitudinal ligament is thick and prevents hyperextension of the vertebral column.
• The posterior longitudinal ligament is weaker and prevents hyperflexion.
• The joints between the articular facets, called facet joints, allow for some gliding motions between the
vertebrae.
• They are strengthened by several ligaments:-
• Ligamentum flavum – extends between lamina of adjacent vertebrae.
• Interspinous and supraspinous – join the spinous processes of adjacent vertebrae. The
interspinous ligaments attach between processes, and the supraspinous ligaments attach to the tips.
• Intertransverse ligaments – extends between transverse processes.
73
74
CLINICAL ASPECT
There are several clinical syndromes resulting from
an abnormal curvature of the spine:
• Kyphosis – excessive thoracic curvature, causing
a hunchback deformity.
• Lordosis – excessive lumbar curvature, causing a
swayback deformity.
• Scoliosis – lateral curvature of the spine, usually
of unknown cause.
• Cervical spondylosis – decrease in the size of
the intervertebral foramina, usually due to
degeneration of the joints of the spine. The smaller
size of the intervertebral foramina puts pressure
on the exiting nerves, causing pain. SCOLIOSIS
DESCRIPTION OF JOINT OF
TEMPOROMANDIBULAR JOINT
WITH THEIR
CLINICAL ANATOMY
76
TEMPOROMANDIBULAR JOINT
• The temporomandibular joint (TMJ) is
formed by the articulation of the mandible and
the temporal bone of the cranium. It is
located anteriorly to the tragus of the ear, on
the lateral aspect of the face.
• The temporomandibular joint consists of
articulations between three surfaces; the
mandibular fossa and articular tubercle (from
the squamous part of the temporal bone),
and the head of mandible.
• This joint has a unique mechanism; the
articular surfaces of the bones never come
into contact with each other – they are
separated by an articular disk.
The presence of such a disk splits the joint
into two synovial joint cavities, each lined by
a synovial membrane. The articular surface of
the bones are covered by fibrocartilage, not
hyaline cartilage.
77
Ligaments -
There are three extracapsular ligaments.
They act to stabilize the
temporomandibular joint.
• Lateral ligament – runs from the
beginning of the articular tubule to the
mandibular neck. It is a thickening of the
joint capsule, and acts to prevent
posterior dislocation of the joint.
• Sphenomandibular ligament –
originates from the sphenoid spine, and
attaches to the mandible.
• Stylomandibular ligament – a thickening
of the fascia of the parotid gland. Along
with the facial muscles, it supports the
78
Movements -
Movements at this joint are produced by the muscles of mastication, and the
hyoid muscles. The two divisions of the temporomandibular joint have
different functions.
1. Protrusion and Retraction
• The upper part of the joint allows protrusion and retraction of the mandible
– the anterior and posterior movements of the jaw.
• The lateral pterygoid muscle is responsible for protrusion (assisted by the
medial pterygoid), and the posterior fibres of the temporalis perform
retraction. A lateral movement (i.e. for chewing and grinding) is achieved by
alternately protruding and retracting the mandible on each side.
2. Elevation and Depression
• The lower part of the joint permits elevation and depression of the mandible;
opening and closing the mouth. Depression is mostly caused
by gravity. However, if there is resistance, the digastric, geniohyoid, and
mylohyoid muscles assist. Elevation is very strong movement, caused by
the contraction of the temporalis, masseter, and medial pterygoid muscles.
79
CLINICAL ASPECT
Temporomandibular Joint Dislocation
• A dislocation of the temporomandibular
joint can occur via a blow to the side of the
face, yawning, or taking a large bite. The
head of the mandible ‘slips’ out of the
mandibular fossa, and is pulled anteriorly.
• The patient becomes unable to close their
mouth. The facial and auriculotemporal
nerves run close to the joint, and can be
damaged if the injury is high-energy.
• Posterior dislocations of the TMJ are
possible, but very rare, requiring a large
amount of force to overcome the postglenoid
tubercle and strong intrinsic lateral ligament.
Thank You
Dr. VINAY PAREEK
( M.D. RACHANA SHARIR)
vinaypareek612@gmail.com
09462479053

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ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS

  • 1. PAPER – 01 TOPIC – 11 TERM – 02 MARKS - 10 ARTHROLOGY Dr. Vinay Pareek PPT According to NCISM
  • 2. INDEX JOINTS : STRUCTURE , TYPES & MOVEMENTS 3 DESCRIPTION OF JOINTS OF EXTREMITIES WITH THEIR CLINICAL ANATOMY 21 DESCRIPTION OF JOINTS OF INTER- VERTEBRAL JOINTS WITH THEIR CLINICAL ANATOMY 71 DESCRIPTION OF JOINT OF TEMPOROMANDIBULAR JOINT WITH THEIR CLINICAL ANATOMY 75 THANKS
  • 3. ARTHROLOGY ARTHROLOGY IS THE SCIENTIFIC STUDY OF JOINTS / ARTICULATIONS. JOINTS • SITE WHERE RIGID ELEMEMTS OF THE SKELETON MEET ARE CALLED JOINTS / ARTICULATIONS. • JOINT IS A JUNCTION BETWEEN TWO OR MORE BONES OR CARTILAGES. 3
  • 5. ON THE BASIS OF STRUCTURE FIBROUS o BONES CONNECTED BY FIBROUS TISSUE o NO JOINT CAVITY o SUB – TYPES 1. SUTURES 2. SYNDESMOSES 3. GOMPHOSES CARTILAGINOUS o BONES CONNECTED BY CARTILAGE o NO JOINT CAVITY o SUB – TYPES 1. SYNCHONDROSIS 2. SYMPHYSES SYNOVIAL o MOST MOVABLE JOINTS IN THE BODY o THERE IS A JOINT CAVITY o ARTICULAR CARTILAGE COVERS THE ENDS OF THE OPPOSING BONES o ARTICULAR CAPSULE ENCLOSES THE JOINT CAVITY o SUB – TYPES 1. PLANE 2. HINGE 3. PIVOT 4. CONDYLOID 5. SADDLE 6. BALL & SOCKET 5
  • 6. SUTURES The suture joints are immovable or fixed joints consisting of a thin layer of dense fibrous connective tissue, which are found between all the bones of the skull except the mandible. These joints also provide strength to the joint by attaching the irregular interlocking edges of cranial bone. Sutures are the sites of active bone growth. 6
  • 7. SYNDESMOSES  It is a type of fibrous joint, where two parallel bones are united with each other by interosseous membrane or ligaments based on the gap between the bones.  This type of fibrous joint is present in the forearm and leg.  In the forearms, the shaft of the radius and ulna are joined strongly by an interosseous membrane. This membrane in the forearms is flexible enough to rotate the forearms.  In the legs, the shafts of the tibia and fibula are also joined strongly by an interosseous membrane. The distal tibiofibular joint is made of fibrous connective tissue and ligaments. These ligaments along with the interosseous membrane form the Syndesmosis in the leg. The interosseous membrane in the legs is firm to lock the ankle joint for weight-bearing and stability. 7
  • 8. GOMPHOSES  It is a specialized fibrous joint, which provides an independent and firm suspension for each tooth.  It fits the teeth into their sockets, which are situated in the maxilla and the mandible.  The gomphosis fibrous joints are also referred to as peg and socket joints. 8
  • 9. SYNCHONDROSIS  It is a type of cartilaginous joint where hyaline cartilage completely joins together two bones.  Synchondroses are immovable joints and are thus referred to as synarthroses. 9
  • 10. SYMPHYSIS  It is a fibrocartilaginous fusion between two bones.  It is a type of cartilaginous joint.  It is an amphiarthrosis, a slightly movable joint. 10
  • 11. TYPES OF SYNOVIAL PLANE JOINT  Plane joints permit two or more round or flat bones to move freely together without any rubbing or crushing of bones.  This joint is mainly found in those regions where the two bones meet and glide on one another in any of the directions.  The lower leg to the ankle joint and the forearm to wrist joint are the two main examples of gliding joints. 11
  • 12. TYPES OF SYNOVIAL HINGE JOINT  Hinge joints are like door hinges, where only back and forth movement is possible.  Example of hinge joints is the ankle, elbows and knee joints. 12
  • 13. TYPES OF SYNOVIAL PIVOT JOINT  In this type of joint, one bone has tapped into the other in such a way that full rotation is not possible.  This joint aid in sideways and back-forth movement.  An example of a pivotal joint in the neck. 13
  • 14. TYPES OF SYNOVIAL CONDYLOID JOINT  Condyloid joints are the joints with two axes which permit up-down and side-to-side motions.  The condyloid joints can be found at the base of the index finger, carpals of the wrist, elbow and the wrist joints.  This joint is also known as a condylar or ellipsoid joint. 14
  • 15. TYPES OF SYNOVIAL SADDLE JOINT  Saddle joint is the biaxial joint that allows the movement on two planes –flexion/extension & abduction/adduction.  For example, the thumb is the only bone in the human body having a saddle joint. 15
  • 16. TYPES OF SYNOVIAL BALL & SOCKET JOINT  Ball & socket joints possess a rounded, ball-like end of one bone fitting into a cuplike socket of another bone.  This organization allows the greatest range of motion, as all movement types are possible in all directions.  Examples of ball-and-socket joints are the shoulder and hip joints. 16
  • 17. ON THE BASIS OF FUNCTION SYN - ARTHROSES o IMMOVABLE JOINTS (SUTURES) o LARGELY RESTRICTED TO THE AXIAL SKELETON AMPHI - ARTHROSES o SLIGHTLY MOVABLE JOINTS (INTERVERTEBRAL DISCS) o FIBROUS CONNECTION o LARGELY RESTRICTED TO THE AXIAL SKELETON DI - ARTHROSES o FREELY MOVABLE JOINTS (SYNOVIAL) o PREDOMINATE IN THE LIMBS 17
  • 18. SYN-ARTHROSES  Synarthrosis (Fibrous) – are fixed joints at which there is no movement.  The articular surfaces are joined by tough fibrous tissue. As in the sutures of the skull. 18
  • 19. AMPHI-ARTHROSES In this type of joints the bones are joined by cartilage. It has no joint cavity. 1. Primary cartilaginous joints (synchondrosis, or hyaline cartilage joints):- The bones are united by the plate of hyaline cartilage so that the joint is immovable and strong. These joints are temporary in nature because after a certain age the cartilaginous plate is replaced by bone. E.g. (1) The joint between the 1st rib and the sternum. (2) The joint between body of the sphenoid and basilar part of the occipital bone. 2. Secondary Cartilagenous joint (Symphysis)- The connecting material in between the articular area is a broad and flat disc of fibro-cartilage. These are permanent joints and allow a limited movement E.g. The intervertebral joint, a portion of the inter vertebral disc is cartilaginous material. Symphysis pubis Manubrio-sternal joint. 19
  • 20. DI-ARTHROSES  Joints are characterized by the presence of an articular cartilage, the articular cartilage covers the surface of the articulating bones, but does not bind the bones together.  The articular cartilage is hyaline cartilage.  A sleeve like articular capsule, which encloses the joint cavity and unites the articulating bones and surrounds the joints. The fibrous capsule and accessory ligaments covers the joint.  The fibrous capsule is composed of two layers. • The outer layer- It consists of dense connective tissue: it is attached to the periosteum of the articulating bones at a variable distance. The fibres of some fibrous capsules are arranged in parallel bundles such fibres are called ligaments and are gives specific names. The strength of the ligaments is one of the principal factors in holding a bone to the other. • The inner layer- The synovial membrane forms the inner layer: it is composed of loose connective tissue with elastic fibres and variable amount of adipose tissue. It secretes the synovial fluid, which lubricates the joint and provides nourishment for the articular cartilage. 20
  • 21. DESCRIPTION OF JOINTS OF EXTREMITIES WITH THEIR CLINICAL ANATOMY
  • 22. JOINTS OF UPPER EXTREMITIES - Acromioclavicular Joints located where the lateral end of the clavicle articulates with the acromion of the scapula Sternoclavicular Joints synovial joint between the clavicle and the manubrium of the sternum Shoulder Joints ball and socket joint between the scapula and the humerus Elbow Joints joint connecting the upper arm to the forearm Radioulnar Joints Proximal & Distal are two radioulnar joints in which the radius and ulna articulate in the forearm Wrist Joints a synovial joint in the upper limb, marking the area of transition between the forearm and the hand 22
  • 23. 23 ACROMIOCLAVICULAR JOINT • The acromioclavicular joint consists of an articulation between the lateral end of the clavicle and the acromion of the scapula. • It has two atypical features :- 1. The articular surfaces of the joint are lined with fibrocartilage. 2. The joint cavity is partially divided by an articular disc.
  • 24. 24 Ligaments - There are three main ligaments that strengthen the acromioclavicular joint. They can be divided into intrinsic and extrinsic ligaments: • Intrinsic: • Acromioclavicular ligament – runs horizontally from the acromion to the lateral clavicle. It covers the joint capsule, reinforcing its superior aspect. • Extrinsic: • Conoid ligament – runs vertically from the coracoid process of the scapula to the conoid tubercle of the clavicle. • Trapezoid ligament – runs from the coracoid process of the scapula to the trapezoid line of the clavicle. Collectively, the conoid and trapezoid ligaments are known as the coracoclavicular ligament.
  • 25. 25 CLINICAL ASPECT • Acromioclavicular joint dislocation (also known as a separated shoulder) occurs when the two articulating surfaces of the joint are separated. It is associated with joint soft tissue damage. • It commonly occurs from a direct blow to the joint or a fall on an outstretched hand. • The injury is more serious if ligamental rupture occurs (acromioclavicular or coracoclavicular). If the coracoclavicular ligament is torn, weight of the upper limb is not supported and the shoulder moves inferiorly. This increases the prominence of the clavicle. • Management of AC joint dislocation is dependent on injury severity and impact on quality of life. The treatment options range from ice and rest to ligament reconstruction surgery. • Note: This injury is not to be confused with shoulder dislocation – an injury affecting the glenohumeral joint. Fig. Radiograph of shoulder separation
  • 26. 26 STERNOCLAVICULAR JOINT • The sternoclavicular joint consists of the sternal end of the clavicle, the manubrium of the sternum, and part of the 1st costal cartilage. • The articular surfaces are covered with fibrocartilage (as opposed to hyaline cartilage, present in the majority of synovial joints). • The joint is separated into two compartments by a fibrocartilaginous articular disc. Clavicl e
  • 27. 27 Ligaments - The ligaments of the sternoclavicular joint provide much of its stability. There are four major ligaments: • Sternoclavicular ligaments (anterior and posterior) – these strengthen the joint capsule anteriorly and posteriorly. • Interclavicular ligament – this spans the gap between the sternal ends of each clavicle and reinforces the joint capsule superiorly. • Costoclavicular ligament – the two parts of this ligament (often separated by a bursa) bind at the 1st rib and cartilage inferiorly and to the anterior and posterior borders of the clavicle superiorly. It is a very strong ligament and is the main stabilizing force for the joint, resisting elevation of the pectoral girdle.
  • 28. 28 CLINICAL ASPECT • A dislocation of the sternoclavicular joint is quite rare and requires significant force. The costoclavicular ligament and the articular disc are highly effective at absorbing and transmitting forces away from the joint into the sternum. There are two major types of dislocation : - • Anterior dislocations are the most common and can happen following a blow to the anterior shoulder which rotates the shoulder backwards. • Posterior dislocations normally result from a force driving the shoulder forwards or from direct impact to the joint. • In younger people, the epiphyseal growth plate of the sternal end of the clavicle has not fully closed. In this population, the dislocation is usually accompanied by a fracture through the plate. Fig. Radiograph of a right sternoclavicular joint dislocation.
  • 29. 29 SHOULDER JOINT • The shoulder joint is formed by the articulation of the head of the humerus with the glenoid cavity (or fossa) of the scapula. This gives rise to the alternate name for the shoulder joint – the glenohumeral joint. • Like most synovial joints, the articulating surfaces are covered with hyaline cartilage. The head of the humerus is much larger than the glenoid fossa, giving the joint a wide range of movement at the cost of inherent instability. To reduce the disproportion in surfaces, the glenoid fossa is deepened by a fibrocartilage rim, called the glenoid labrum.
  • 30. 30 Joint Capsule and Bursae - • The joint capsule is a fibrous sheath which encloses the structures of the joint. • It extends from the anatomical neck of the humerus to the border or ‘rim’ of the glenoid fossa. The joint capsule is lax, permitting greater mobility. • The synovial membrane lines the inner surface of the joint capsule, and produces synovial fluid to reduce friction between the articular surfaces. • To reduce friction in the shoulder joint, several synovial bursae are present. • A bursa is a synovial fluid filled sac, which acts as a cushion between tendons and other joint structures. The bursae that are important clinically are: • Subacromial – located deep to the deltoid and acromion, and superficial to the supraspinatus tendon and joint capsule. The subacromial bursa reduces friction beneath the deltoid, promoting free motion of the rotator cuff tendons. Subacromial bursitis can be a cause of shoulder pain. • Subscapular – located between the subscapularis tendon and the scapula. It reduces wear and tear on the tendon during movement at the shoulder joint.
  • 31. 31 Ligaments - In the shoulder joint, the ligaments play a key role in stabilizing the bony structures. • Glenohumeral ligaments (superior, middle and inferior) – the joint capsule is formed by this group of ligaments connecting the humerus to the glenoid fossa. They are the main source of stability for the shoulder, holding it in place and preventing it from dislocating anteriorly. They act to stabilize the anterior aspect of the joint. • Coracohumeral ligament – attaches the base of the coracoid process to the greater tubercle of the humerus. It supports the superior part of the joint capsule. • Transverse humeral ligament – spans the distance between the two tubercles of the humerus. It holds the tendon of the long head of the biceps in the intertubercular groove.] • Coracoclavicular ligament – composed of the trapezoid and conoid ligaments and runs from the clavicle to the coracoid process of the scapula. They work alongside the acromioclavicular ligament to maintain the alignment of the clavicle in relation to the scapula. They have significant strength but large forces (e.g. after a high energy fall) can rupture these ligaments as part of an acromio-clavicular joint (ACJ) injury. In severe ACJ injury, the coraco-clavicular ligaments may require surgical repair. The other major ligament is the coracoacromial ligament. Running between the acromion and coracoid process of the scapula it forms the coraco-acromial arch. This structure overlies the shoulder joint, preventing displacement of the humeral head.
  • 32. 32 Movements - As a ball and socket synovial joint, there is a wide range of movement permitted:- • Extension (upper limb backwards in sagittal plane) – posterior deltoid, latissimus dorsi and teres major. • Flexion (upper limb forwards in sagittal plane) – pectoralis major, anterior deltoid and coracobrachialis. Biceps brachii weakly assists in forward flexion. • Abduction (upper limb away from midline in coronal plane): • The first 0-15 degrees of abduction is produced by the supraspinatus. • The middle fibres of the deltoid are responsible for the next 15-90 degrees. • Past 90 degrees, the scapula needs to be rotated to achieve abduction – that is carried out by the trapezius and serratus anterior. • Adduction (upper limb towards midline in coronal plane) – pectoralis major, latissimus dorsi and teres major. • Internal rotation (rotation towards the midline, so that the thumb is pointing medially) – subscapularis, pectoralis major, latissimus dorsi, teres major and anterior deltoid. • External rotation (rotation away from the midline, so that the thumb is pointing laterally) – infraspinatus and teres minor. • Circumduction (moving the upper limb in a circle) – produced by a combination of the movements described above.
  • 33. 33 Mobility and Stability - Factors that contribute to mobility: • Type of joint – ball and socket joint. • Bony surfaces – shallow glenoid cavity and large humeral head – there is a 1:4 disproportion in surfaces. A commonly used analogy is the golf ball and tee. • Inherent laxity of the joint capsule. Factors that contribute to stability: • Rotator cuff muscles – surround the shoulder joint, attaching to the tuberosities of the humerus, whilst also fusing with the joint capsule. The resting tone of these muscles act to compress the humeral head into the glenoid cavity. • Glenoid labrum – a fibrocartilaginous ridge surrounding the glenoid cavity. It deepens the cavity and creates a seal with the head of humerus, reducing the risk of dislocation. • Ligaments – act to reinforce the joint capsule, and form the coraco-acromial arch. • Biceps tendon – it acts as a minor humeral head depressor, thereby contributing to stability.
  • 34. 34 CLINICAL ASPECT • Clinically, dislocations at the shoulder are described by where the humeral head lies in relation to the glenoid fossa. Anterior dislocations are the most prevalent (95%), although posterior (4%) and inferior (1%) dislocations can sometimes occur. Superior displacement of the humeral head is generally prevented by the coraco-acromial arch. • An anterior dislocation is usually caused by excessive extension and lateral rotation of the humerus. The humeral head is forced anteriorly and inferiorly – into the weakest part of the joint capsule. Tearing of the joint capsule is associated with an increased risk of future dislocations. • The axillary nerve runs in close proximity to the shoulder joint and around the surgical neck of the humerus, and so it can be damaged in the dislocation or with attempted reduction. Injury to the axillary nerve causes paralysis of the deltoid, and loss of sensation
  • 35. 35 ELBOW JOINT It consists of two separate articulations :- • Trochlear notch of the ulna and the trochlea of the humerus • Head of the radius and the capitulum of the humerus There are many bursae in the elbow, but only a few have clinical importance: • Intratendinous – located within the tendon of the triceps brachii. • Subtendinous – between the olecranon and the tendon of the triceps brachii, reducing friction between the two structures during extension and flexion of the arm. • Subcutaneous (olecranon) bursa – between the olecranon and the overlying connective tissue (implicated in olecranon bursitis).
  • 36. 36 Ligaments - The joint capsule of the elbow is strengthened by ligaments medially and laterally. • The radial collateral ligament is found on the lateral side of the joint, extending from the lateral epicondyle, and blending with the annular ligament of the radius (a ligament from the proximal radioulnar joint). • The ulnar collateral ligament originates from the medial epicondyle, and attaches to the coronoid process and olecranon of the ulna.
  • 37. 37 CLINICAL ASPECT Bursitis • Subcutaneous bursitis: Repeated friction and pressure on the bursa can cause it to become inflamed. Because this bursa lies relatively superficially, it can also become infected (e.g cut from a fall on the elbow) • Subtendinous bursitis: This is caused by repeated flexion and extension of the forearm, commonly seen in assembly line workers. Usually flexion is more painful as more pressure is put on the bursa. Dislocation • An elbow dislocation usually occurs when a young child falls on a hand with the elbow flexed. The distal end of the humerus is driven through the weakest part of the joint capsule, which is the anterior side. The ulnar collateral ligament is usually torn and there can also be ulnar nerve involvement. Most elbow dislocations are posterior, and it is important to note that elbow dislocations are named by the position of the ulna and radius, not the humerus. Epicondylitis (Tennis elbow or Golfer’s elbow) • Most of the flexor and extensor muscles in the forearm have a common tendinous origin. The flexor muscles originate from the medial epicondyle, and the extensor muscles from the lateral. Sportspersons can develop an overuse strain of the common tendon – which results in pain and inflammation around the area of the affected epicondyle. • Typically, tennis players experience pain in the lateral epicondyle from the common extensor origin. Golfers experience pain in the medial epicondyle from the common flexor origin. This is easily remembered as golfers aim for the ‘middle’ of the fairway, while tennis players aim for the ‘lateral’ line of the court! Supracondylar Fracture • A supracondylar fracture usually occurs due to a fall onto on outstretched, extended hand in a child (95%) but more rarely can occur by a direct impact onto a flexed elbow. It is typically a transverse fracture, spanning between the two epicondyles in the relatively weak epicondylar region formed by the olecranon fossa and coronoid fossa which lie opposite each other in the distal humerus. • Direct damage, or swelling can cause the interference to the blood supply of the forearm via the brachial artery. The resulting ischaemia can cause Volkmann’s ischaemic contracture – uncontrolled flexion of the hand, as flexors muscles become fibrotic and short. There also can be damage to the medial, ulnar or radial nerves. As a result, the neurovascular examination and documentation of all patients presenting with these injuries is vital. Sometimes, the blood supply can be interrupted acutely leading to a ‘pale, pulseless’ limb often in a child, usually requiring
  • 39. 39 RADIOULNAR JOINT The radioulnar joints are two locations in which the radius and ulna articulate in the forearm: • Proximal radioulnar joint – located near the elbow. It is articulation between the head of the radius and the radial notch of the ulna. • Distal radioulnar joint – located near the wrist. It is an articulation between the ulnar notch of the radius and the ulnar head. Both of these joints are classified as pivot joints, responsible for pronation and supination of the
  • 40. 40 Proximal Radioulnar Joint - • The proximal radioulnar joint is located immediately distal to the elbow joint, and is enclosed with in the same articular capsule. It is formed by an articulation between the head of the radius and the radial notch of the ulna. • The radial head is held in place by the annular radial ligament, which forms a ‘collar’ around the joint. The annular radial ligament is lined with a synovial membrane, reducing friction during movement. • Movement is produced by the head of the radius rotating within the annular ligament. There are two movements possible at this joint; pronation and supination. • Pronation: Produced by the pronator quadratus and pronator teres. • Supination: Produced by the supinator and biceps brachii.
  • 41. 41 Distal Radioulnar Joint - • This distal radioulnar joint is located just proximally to the wrist joint. It is an articulation between the ulnar notch of the radius, and the ulnar head. • In addition to anterior and posterior ligaments strengthening the joint, there is also a fibrocartilaginous ligament present, called the articular disk. It serves two functions: Binds the radius and ulna together, and holds them together during movement at the joint. Separates the distal radioulnar joint from the wrist joint. • Like the proximal radioulnar joint, this is a pivot joint, allowing for pronation and supination. The ulnar notch of the radius slides anteriorly over the head of the ulnar during such movements - Pronation: Produced by the pronator quadratus and pronator teres Supination: Produced by the supinator and biceps
  • 42. 42 Interosseous Membrane - • The interosseous membrane is a sheet of connective tissue that joins the radius and ulna together between the radioulnar joints. • It spans the distance between the medial radial border, and the lateral ulnar border. There are small holes in the sheet, as a conduit for the forearm vasculature. This connective tissue sheet has three major functions:- Holds the radius and ulna together during pronation and supination of the forearm, providing addition stability. Acts as a site of attachment for muscles in the anterior and posterior compartments of the forearm. Transfers forces from the radius to the ulna.
  • 43. 43 CLINICAL ASPECT Fractures to the Radius and Ulna • Although the radius and ulnar are two distinct and separate bones, when dealing with injuries to the forearm, they can be thought of as a ring. • A ring, when broken, usually breaks in two places. The best way of illustrating with is with a polo mint – it is very difficult to break one side without breaking the other. • This means that a fracture to the radius or the ulna usually causes a fracture or dislocation of the other bone. There are two classical fractures: • Monteggia fracture – fracture of the proximal ulna AND dislocation of the radial head at the proximal radioulnar joint. • Galeazzi fracture – fracture of the distal radius AND dislocation of the ulnar head at the distal radioulnar joint.
  • 44. 44 WRIST JOINT The wrist joint is formed by: • Distally – The proximal row of the carpal bones (except the pisiform). • Proximally – The distal end of the radius, and the articular disk. • The ulna is not part of the wrist joint – it articulates with the radius, just proximal to the wrist joint, at the distal radioulnar joint. It is prevented from articulating with the carpal bones by a fibrocartilaginous ligament, called the articular disk, which lies over the superior surface of the ulna. • Together, the carpal bones form a convex surface, which articulates with the concave surface of the radius and articular disk.
  • 45. 45 Ligaments - There are four ligaments of note in the wrist joint, one for each side of the joint • Palmar radiocarpal – Found on the palmar (anterior) side of the hand. It passes from the radius to both rows of carpal bones. Its function, apart from increasing stability, is to ensure that the hand follows the forearm during supination. • Dorsal radiocarpal – Found on the dorsum (posterior) side of the hand. It passes from the radius to both rows of carpal bones. It contributes to the stability of the wrist, but also ensures that the hand follows the forearm during pronation. • Ulnar collateral – Runs from the ulnar styloid process to the triquetrum and pisiform. It acts to prevent excessive radial (lateral) deviation of the hand. • Radial collateral – Runs from the radial styloid process to the scaphoid and trapezium. It acts to prevent excessive ulnar (medial) deviation of the hand. P R RC UC
  • 46. 46 Movements of the Wrist Joint - • The wrist is an ellipsoidal (condyloid) type synovial joint, allowing for movement along two axes. This means that flexion, extension, adduction and abduction can all occur at the wrist joint. • All the movements of the wrist are performed by the muscles of the forearm. Flexion – Produced mainly by the flexor carpi ulnaris, flexor carpi radialis, with assistance from the flexor digitorum superficialis. Extension – Produced mainly by the extensor carpi radialis longus and brevis, and extensor carpi ulnaris, with assistance from the extensor digitorum. Adduction – Produced by the extensor carpi ulnaris and flexor carpi ulnaris Abduction – Produced by the abductor pollicis longus, flexor carpi radialis, extensor carpi radialis longus and brevis.
  • 47. 47 CLINICAL ASPECT Scaphoid Fracture - • The scaphoid bone of the hand is the most commonly fractured carpal bone – typically by falling on an outstretched hand (FOOSH). • In a fracture of the scaphoid, the characteristic clinical feature is pain and tenderness in the anatomical snuffbox. • The scaphoid is at particular risk of avascular necrosis after fracture because of its so-called ‘retrograde blood supply’ which enters at its distal end. This means that a fracture to the middle (or ‘waist’) of the scaphoid may interrupt the blood supply to the proximal part of the scaphoid bone rendering it avascular. • Patients with a missed scaphoid fracture are likely to develop osteoarthritis of the wrist in later life. Anterior Dislocation of the Lunate - • This can occur by falling on a dorsiflexed wrist. The lunate is forced anteriorly, and compresses the carpal tunnel, causing the symptoms of carpal tunnel syndrome. • This manifests clinically as paraesthesia in the sensory distribution of the median nerve and weakness of thenar muscles. The lunate can also undergo avascular necrosis, so immediate clinical attention to the fracture is needed. Colles’ Fracture - • The Colles’ fracture is the most common fracture involving the wrist, caused by falling onto an outstretched hand. • The radius fractures, with the distal fragment being displaced posteriorly. The ulnar styloid process can also be damaged, and is avulsed in the majority of cases. • This clinical condition produces what is known as the ‘dinner fork deformity’.
  • 48. 48 Scaphoid Fracture Anterior Dislocation of the Lunate Colles’ Fracture
  • 49. JOINTS OF LOWER EXTREMITIES - Hip Joints ball and socket synovial joint, formed by an articulation between the pelvic acetabulum and the head of the femur Knee Joints hinge type synovial joint, which mainly allows for flexion and extension Tibiofibular Joints plane type synovial joint, where the bones to glide over one another to create movement Ankle Joints hinge type joint, permitting dorsiflexion and plantarflexion of the foot Subtalar Joints joint is classed structurally as a synovial joint, and functionally as a plane synovial joint 49
  • 50. 50 HIP JOINT • The hip joint consists of an articulation between the head of femur and acetabulum of the pelvis. • The acetabulum is a cup-like depression located on the inferolateral aspect of the pelvis. Its cavity is deepened by the presence of a fibrocartilaginous collar – the acetabular labrum. The head of femur is hemispherical, and fits completely into the concavity of the acetabulum. • Both the acetabulum and head of femur are covered in articular cartilage, which is thicker at the places of weight bearing. • The capsule of the hip joint attaches to the edge of the acetabulum proximally. Distally, it attaches to the intertrochanteric line anteriorly and the femoral neck posteriorly.
  • 51. 51 There are three main extracapsular ligaments, continuous with the outer surface of the hip joint capsule: • Iliofemoral ligament – arises from the anterior inferior iliac spine and then bifurcates before inserting into the intertrochanteric line of the femur. • It has a ‘Y’ shaped appearance, and prevents hyperextension of the hip joint. It is the strongest of the three ligaments. • Pubofemoral – spans between the superior pubic rami and the intertrochanteric line of the femur, reinforcing the capsule anteriorly and inferiorly. • It has a triangular shape, and prevents excessive abduction and extension. • Ischiofemoral– spans between the body of the ischium and the greater trochanter of the femur, reinforcing the capsule posteriorly. • It has a spiral orientation, and prevents hyperextension and holds the femoral head in the acetabulum.
  • 52. 52 Movements and Muscles - The movements that can be carried out at the hip joint are listed below, along with the principle muscles responsible for each action: Flexion – iliopsoas, rectus femoris, sartorius, pectineus Extension – gluteus maximus; semimembranosus, semitendinosus and biceps femoris (the hamstrings) Abduction – gluteus medius, gluteus minimus, piriformis and tensor fascia latae Adduction – adductors longus, brevis and magnus, pectineus and gracilis Lateral rotation – biceps femoris, gluteus maximus, piriformis, assisted by the obturators, gemilli and quadratus femoris. Medial rotation – anterior fibres of gluteus medius and minimus, tensor fascia latae • The degree to which flexion at the hip can occur depends on whether the knee is flexed – this relaxes the hamstring muscles, and increases the range of flexion. • Extension at the hip joint is limited by the joint capsule and the iliofemoral ligament. These structures become taut during extension
  • 53. 53 CLINICAL ASPECT Posterior dislocation (90%) – the femoral head is forced posteriorly, and tears through the inferior and posterior part of the joint capsule, where it is at its weakest. • The affected limb becomes shortened and medially rotated. • The sciatic nerve runs posteriorly to the hip joint, and is at risk of injury (occurs in 10-20% of cases). This is often associated with anterior femoral head and posterior wall fractures.
  • 54. 54 KNEE JOINT • The knee joint consists of two articulations – tibiofemoral and patellofemoral. The joint surfaces are lined with hyaline cartilage and are enclosed within a single joint cavity. • Tibiofemoral – medial and lateral condyles of the femur articulate with the tibial condyles. It is the weight-bearing component of the knee joint. • Patellofemoral – anterior aspect of the distal femur articulates with the patella. It allows the tendon of the quadriceps femoris (knee extensor) to be inserted directly over the knee – increasing the efficiency of the muscle. • As the patella is both formed and resides within the quadriceps femoris tendon, it provides a fulcrum to increase power of the knee extensor and serves as a stabilising structure that reduces frictional forces placed on femoral condyles.
  • 55. 55 Menisci - The medial and lateral menisci are fibrocartilage structures in the knee that serve two functions: To deepen the articular surface of the tibia, thus increasing stability of the joint. To act as shock absorbers by increasing surface area to further dissipate forces. • They are C shaped and attached at both ends to the intercondylar area of the tibia. • In addition to the intercondylar attachment, the medial meniscus is fixed to the tibial collateral ligament and the joint capsule. Damage to the tibial collateral ligament usually results in a medial meniscal tear. • The lateral meniscus is smaller and does not have any extra attachments, rendering it fairly mobile.
  • 56. 56 Bursae - There are four bursae found in the knee joint: • Suprapatellar bursa – an extension of the synovial cavity of the knee, located between the quadriceps femoris and the femur. • Prepatellar bursa – found between the apex of the patella and the skin. • Infrapatellar bursa – split into deep and superficial. The deep bursa lies between the tibia and the patella ligament. The superficial lies between the patella ligament and the skin. • Semimembranosus bursa – located posteriorly in the knee joint, between the semimembranosus muscle and the medial head of the gastrocnemius.
  • 57. 57 Ligaments - The major ligaments in the knee joint are: • Patellar ligament – a continuation of the quadriceps femoris tendon distal to the patella. It attaches to the tibial tuberosity. • Collateral ligaments – two strap-like ligaments. They act to stabilize the hinge motion of the knee, preventing excessive medial or lateral movement • Tibial (medial) collateral ligament – wide and flat ligament, found on the medial side of the joint. Proximally, it attaches to the medial epicondyle of the femur, distally it attaches to the medial condyle of the tibia. • Fibular (lateral) collateral ligament – thinner and rounder than the tibial collateral, this attaches proximally to the lateral epicondyle of the femur, distally it attaches to a depression on the lateral surface of the fibular head. • Cruciate Ligaments – these two ligaments connect the femur and the tibia. In doing so, they cross each other, hence the term ‘cruciate’ (Latin for like a cross) • Anterior cruciate ligament – attaches at the anterior intercondylar region of the tibia where it blends with the medial meniscus. It ascends posteriorly to attach to the femur in the intercondylar fossa. It prevents anterior dislocation of the tibia onto the femur. • Posterior cruciate ligament – attaches at the posterior intercondylar region of the tibia and ascends anteriorly to attach to the anteromedial femoral condyle. It prevents posterior dislocation of the tibia onto the femur.
  • 58. 58
  • 59. 59 CLINICAL ASPECT Collateral Ligaments - • Injury to the collateral ligaments is the most common pathology affecting the knee joint. It is caused by a force being applied to the side of the knee when the foot is placed on the ground. • Damage to the collateral ligaments can be assessed by asking the patient to medially rotate and laterally rotate the leg. Pain on medial rotation indicates damage to the medial ligament, pain on lateral rotation indicates damage to the lateral ligament. • If the medial collateral ligament is damaged, it is more than likely that the medial meniscus is torn, due to their attachment. Bursitis - • Friction between the skin and the patella cause the prepatellar bursa to become inflamed, producing a swelling on the anterior side of the knee. This is known as housemaid’s knee. • Similarly, friction between the skin and tibia can cause the infrapatellar bursae to become inflamed, resulting in what is known as clergyman’s knee (classically caused by clergymen kneeling on hard surfaces during prayer).
  • 60. 60 Cruciate Ligaments - • The anterior cruciate ligament (ACL) can be torn by hyperextension of the knee joint, or by the application of a large force to the back of the knee with the joint partly flexed. To test for this, you can perform an anterior drawer test, where you attempt to pull the tibia forwards, if it moves, the ligament has been torn. • The most common mechanism of posterior cruciate ligament (PCL) damage is the ‘dashboard injury’. This occurs when the knee is flexed, and a large force is applied to the shins, pushing the tibia posteriorly. This is often seen in car accidents, where the knee hits the dashboard. The posterior cruciate ligament can also be torn by hyperextension of the knee joint, or by damage to the upper part of the tibial tuberosity. • To test for PCL damage, perform the posterior draw test. This is where the clinician holds the knee in flexed position, and pushes the tibia posteriorly. If there is movement, the ligament has been torn. Unhappy Triad (Blown Knee) - • As the medial collateral ligament is attached to the medial meniscus, damage to either can affect both structure’s functions. A lateral force to an extended knee, such as a rugby tackle, can rupture the medial collateral ligament, damaging the medial meniscus in the process. The ACL is also affected, which completes the ‘unhappy triad’.
  • 61. 61 TIBIOFIBULAR JOINT 1. Proximal - Articulating Surfaces - • The proximal tibiofibular joint is formed by an articulation between the head of the fibula and the lateral condyle of the tibia. • It is a plane type synovial joint; where the bones to glide over one another to create movement. Supporting Structures - The joint capsule receives additional support from: • Anterior and posterior superior tibiofibular ligaments – span between the fibular head and lateral tibial condyle • Lateral collateral ligament of the knee joint • Biceps femoris – provides reinforcement as it inserts onto the fibular head.
  • 62. 62 TIBIOFIBULAR JOINT 2. Distal - Articulating Surfaces - • The distal (inferior) tibiofibular joint consists of an articulation between the fibular notch of the distal tibia and the fibula. • It is an example of a fibrous joint, where the joint surfaces are by bound by tough, fibrous tissue. Supporting Structures - The distal tibiofibular joint is supported by: • Interosseous membrane – a fibrous structure spanning the length of the tibia and fibula. • Anterior and posterior inferior tibiofibular ligaments • Inferior transverse tibiofibular ligament – a continuation of the posterior inferior tibiofibular ligament.
  • 63. 63 CLINICAL ASPECT Dislocation of the Proximal Tibiofibular Joint - • A proximal tibiofibular joint dislocation is a rare and often missed diagnosis. It accounts for <1% of all knee injuries. • The typical mechanism of injury is a fall onto an adducted and flexed knee. They can also occur as a result of high-energy trauma. • Common clinical features include inability to weight-bear, lateral knee pain and tenderness/prominence of the fibular head. • This type of injury is typically treated with a closed reduction (a reduction is a procedure to restore the joint to its natural alignment). Complications of proximal tibiofibular joint dislocation include common fibular nerve injury (the nerve winds around the neck of the fibula), and recurrent dislocation.
  • 64. 64 ANKLE JOINT The ankle joint is formed by three bones; the tibia and fibula of the leg, and the talus of the foot: • The tibia and fibula are bound together by strong tibiofibular ligaments. Together, they form a bracket shaped socket, covered in hyaline cartilage. This socket is known as a mortise. • The body of the talus fits snugly into the mortise formed by the bones of the leg. The articulating part of the talus is wedge shaped – it is broad anteriorly, and narrow posteriorly.
  • 65. 65
  • 66. 66 Medial Ligament - • The medial ligament (or deltoid ligament) is attached to the medial malleolus (a bony prominence projecting from the medial aspect of the distal tibia). • It consists of four ligaments, which fan out from the malleolus, attaching to the talus, calcaneus and navicular bones. The primary action of the medial ligament is to resist over-eversion of the foot. Lateral Ligament - • The lateral ligament originates from the lateral malleolus (a bony prominence projecting from the lateral aspect of the distal fibula). • It resists over-inversion of the foot, and is comprised of three distinct and separate ligaments: Anterior talofibular – spans between the lateral malleolus and lateral aspect of the talus. Posterior talofibular – spans between the lateral malleolus and the posterior aspect of the talus. Calcaneofibular – spans between the lateral malleolus and the calcaneus.
  • 67. 67 CLINICAL ASPECT • A Pott’s fracture is a term used to describe a bimalleolar (medial and lateral malleoli) or trimalleolar (medial and lateral malleoli, and distal tibia) fracture. • This type of injury is produced by forced eversion of the foot. It occurs in a series of stages: • Forced eversion pulls on the medial ligaments, producing an avulsion fracture of the medial malleolus. • The talus moves laterally, breaking off the lateral malleolus. • The tibia is then forced anteriorly, shearing off the distal and posterior part against the talus.
  • 68. 68 SUBTALAR JOINT The subtalar joint is an articulation between two of the tarsal bones in the foot – the talus and calcaneus. The joint is classed structurally as a synovial joint, and functionally as a plane synovial joint. The subtalar joint is formed between two of the tarsal bones: • Inferior surface of the body of the talus – the posterior talar articular surface. • Superior surface of the calcaneus – the posterior calcaneal articular facet. • As is typical for a synovial joint, these
  • 69. 69 • The subtalar joint is enclosed by a joint capsule, which is lined internally by synovial membrane and strengthened externally by a fibrous layer. The capsule is also supported by three ligaments: • Posterior talocalcaneal ligament • Medial talocalcaneal ligament • Lateral talocalcaneal ligament • An additional ligament – the interosseous talocalcaneal ligament – acts to bind the talus and calcaneus together. It lies within the sinus tarsi (a small cavity between the talus and calcaneus), and is particularly strong; providing the majority of the ligamentous stability to the joint.
  • 70. 70 CLINICAL ASPECT Calcaneal Fracture • The calcaneus is often fractured in a ‘crush‘ type injury. The most common mechanism of damage is falling onto the heel from a height – the talus is driven into the calcaneus. The bone can break into several pieces, known as a comminuted fracture. Upon x-ray imaging, the calcaneus will appear shorter and wider. • A calcaneal fracture can cause chronic problems, even after treatment. The subtalar joint is usually disrupted, causing the joint to become arthritic. The patient will experience pain upon inversion and eversion – which can make walking on uneven ground particularly painful.
  • 71. DESCRIPTION OF JOINTS OF INTER VERTEBRAL JOINTS WITH THEIR CLINICAL ANATOMY
  • 72. 72 INTER VERTEBRAL JOINT The mobile vertebrae articulate with each other via joints between their bodies and articular facets:- • Left and right superior articular facets articulate with the vertebra above. • Left and right inferior articular facets articulate with the vertebra below. • Vertebral bodies indirectly articulate with each other via the intervertebral discs. • The vertebral body joints are cartilaginous joints, designed for weight-bearing. • The articular surfaces are covered by hyaline cartilage, and are connected by the intervertebral disc. • Two ligaments strengthen the vertebral body joints: the anterior and posterior longitudinal ligaments, which run the full length of the vertebral column. • The anterior longitudinal ligament is thick and prevents hyperextension of the vertebral column. • The posterior longitudinal ligament is weaker and prevents hyperflexion. • The joints between the articular facets, called facet joints, allow for some gliding motions between the vertebrae. • They are strengthened by several ligaments:- • Ligamentum flavum – extends between lamina of adjacent vertebrae. • Interspinous and supraspinous – join the spinous processes of adjacent vertebrae. The interspinous ligaments attach between processes, and the supraspinous ligaments attach to the tips. • Intertransverse ligaments – extends between transverse processes.
  • 73. 73
  • 74. 74 CLINICAL ASPECT There are several clinical syndromes resulting from an abnormal curvature of the spine: • Kyphosis – excessive thoracic curvature, causing a hunchback deformity. • Lordosis – excessive lumbar curvature, causing a swayback deformity. • Scoliosis – lateral curvature of the spine, usually of unknown cause. • Cervical spondylosis – decrease in the size of the intervertebral foramina, usually due to degeneration of the joints of the spine. The smaller size of the intervertebral foramina puts pressure on the exiting nerves, causing pain. SCOLIOSIS
  • 75. DESCRIPTION OF JOINT OF TEMPOROMANDIBULAR JOINT WITH THEIR CLINICAL ANATOMY
  • 76. 76 TEMPOROMANDIBULAR JOINT • The temporomandibular joint (TMJ) is formed by the articulation of the mandible and the temporal bone of the cranium. It is located anteriorly to the tragus of the ear, on the lateral aspect of the face. • The temporomandibular joint consists of articulations between three surfaces; the mandibular fossa and articular tubercle (from the squamous part of the temporal bone), and the head of mandible. • This joint has a unique mechanism; the articular surfaces of the bones never come into contact with each other – they are separated by an articular disk. The presence of such a disk splits the joint into two synovial joint cavities, each lined by a synovial membrane. The articular surface of the bones are covered by fibrocartilage, not hyaline cartilage.
  • 77. 77 Ligaments - There are three extracapsular ligaments. They act to stabilize the temporomandibular joint. • Lateral ligament – runs from the beginning of the articular tubule to the mandibular neck. It is a thickening of the joint capsule, and acts to prevent posterior dislocation of the joint. • Sphenomandibular ligament – originates from the sphenoid spine, and attaches to the mandible. • Stylomandibular ligament – a thickening of the fascia of the parotid gland. Along with the facial muscles, it supports the
  • 78. 78 Movements - Movements at this joint are produced by the muscles of mastication, and the hyoid muscles. The two divisions of the temporomandibular joint have different functions. 1. Protrusion and Retraction • The upper part of the joint allows protrusion and retraction of the mandible – the anterior and posterior movements of the jaw. • The lateral pterygoid muscle is responsible for protrusion (assisted by the medial pterygoid), and the posterior fibres of the temporalis perform retraction. A lateral movement (i.e. for chewing and grinding) is achieved by alternately protruding and retracting the mandible on each side. 2. Elevation and Depression • The lower part of the joint permits elevation and depression of the mandible; opening and closing the mouth. Depression is mostly caused by gravity. However, if there is resistance, the digastric, geniohyoid, and mylohyoid muscles assist. Elevation is very strong movement, caused by the contraction of the temporalis, masseter, and medial pterygoid muscles.
  • 79. 79 CLINICAL ASPECT Temporomandibular Joint Dislocation • A dislocation of the temporomandibular joint can occur via a blow to the side of the face, yawning, or taking a large bite. The head of the mandible ‘slips’ out of the mandibular fossa, and is pulled anteriorly. • The patient becomes unable to close their mouth. The facial and auriculotemporal nerves run close to the joint, and can be damaged if the injury is high-energy. • Posterior dislocations of the TMJ are possible, but very rare, requiring a large amount of force to overcome the postglenoid tubercle and strong intrinsic lateral ligament.
  • 80. Thank You Dr. VINAY PAREEK ( M.D. RACHANA SHARIR) vinaypareek612@gmail.com 09462479053