Joints of the lower limb Feb. 28, 2012 Shifa College of Medicine Islamabad NAS1 Dr. Najam Siddiqi MBBS, PhD (Japan) Postdoc (USA) Department of Anatomy Oman Medical College, Sohar, Sultanate of Oman The hip joint Dr. Najam Siddiqi MBBS, PhD (Japan) Postdoc (USA) 05/10/2010NAS2 Oct.12, 2011 Human structure Course NBAN- 403 Fall- 2011 Learning Objectives You should know Surface anatomy of the hip joint Type of the joint, Know the bony and ligamentous structures that comprise the hip joint. Be able to define coxa valga and coxa vera Know the blood supply of the hip joint Understand the clinical significance of the cruciate anastomosis 05/10/2010NAS3 OBJECTIVES: Know the innervations and function(s) of the muscles acting on the hip joint Understand the mechanism involved in hip stability and how the hip is locked. Know how the ligaments act to restrain hip motion Be able to differentiate between hip fractures and hip dislocation by the position of the limb. Know how nerve lesions may affect movements of the hip joint. Be able to distinguish between the effects of peripheral nerve lesions on the functioning of the hip from lesions to the roots of the lumbosacral plexus. 05/10/2010NAS4 Topics Type of the joint Articular surfaces Stability of the joint Capsule Synovial membrane Ligaments Bursa Relations Movements Normal radiograph Clinical 05/10/2010NAS5 05/10/2010NAS6 Hip joint is a weight bearing joint NAS7 Type Multiaxial Synovial Ball & socket variety Simple joint Articulation: Head of femur forms 2/3 of a sphere Acetabulum forms an incomplete ring, termed the lunate surface, covered by articular cartilage; broadest at its upper part which is the weight bearing area in standing position Hip joint type & articular surfaces 05/10/2010NAS8 Acetabular labrum and transverse ligament of the acetabulum Acetabular labrum is fibrocartilage attached to the margin of the acetabulum It also bridges the acetabular notch as the transverse acetabular ligament; converts the acetabular notch into a foramen through which acetabular branch of obturator artery and nerve enter the joint. 05/10/2010NAS9 Posterior attachment Acetabulum attached to its margin and Transverse Acetabular ligament. Femur it surrounds the neck of the femur Anterior: to the intertrochanteric line Posterior : almost half of the neck above the intertrochanteric crest Circular and longitudinal retinacula Blood vessels to the femoral head passes through the capsule Fibrous capsule Anterior attachment 05/10/2010NAS10 Synovial membrane of the hip joint Lines in inner surface of the capsule and the ligament of the head of femur 05/10/2010NAS11 Iliofemoral ligament Lateral / oblique band Medial / vertical band 1. Iliofemoral ligament: Y- shaped : ant. inferior iliac spine to intertrochanteric line STRONGEST LIGAMENT Prevent hyperextension of hip during standing Hip in locked position: Iliofemoral Ligament becomes taut in extension preventing the femur from moving past vertical position ( resists hyperextension) Maintains hip in locked or stable configuration Weight of the body supported by iliofemoral ligament 05/10/2010NAS12 Ligaments--Posterior 3. Ischiofemoral ligament: Ischial part of acetabular rim Medial to base of greater trochanter Prevents hyperflexion of the hip 2. Pubofemoral ligament from pubic bone and distally with the capsule and iliofemoral ligament Prevents overabduction Ligaments--Anterior 05/10/2010NAS13 Ligament of the femoral head Arterial supply of the joint Retinacula Composed of fibers derived from fibrous capsule Retinacula fibers reflect back along femoral neck towards the femoral head Convey small arteries to head of femur Arterial supply branches of : Medial circumflex femoral artery (main artery): Retinacular arteries Lateral circumflex femoral artery Superior gluteal artery Inferior gluteal artery First perforating artery Obturator artery (acetabular branch) 05/10/2010NAS14 Fractures/ Dislocation Fracture of femoral neck More common in women than the men (osteoporosis). Could disrupt retinacula and blood supply to femoral head Avascular necrosis of femoral head Limb outwardly rotated Pull of lateral rotator muscles Dislocation Limb is shortened and inwardly rotated 05/10/2010NAS15 05/10/2010NAS16 Injury of the branch of the obturator artery in a child may lead to necrosis of the headepiphysis prevents anastomosis, but in the adult nothing happens. Avascular necrosis of femoral head in neck fractures 05/10/2010NAS17 Blood supply is preserved in trochanteric fractures Nerve supply Femoral nerve via nerve to rectus femoris Obturator nerve Sciatic nerve via nerve to quadratus femoris Accessory obturator nerve (when present) Referred pain to the knee joint: In any disease of hip, pain is referred to the knee as well because Tibial, common peroneal, sciatic and obturator nerves also supplies the knee joint 05/10/2010NAS18 Muscles acting on the hip joint 05/10/2010NAS19 Lumbar and Lumbosacral Nerve Root Involvement L 1,2 These roots are mainly involved with innervating the iliopsoas muscle. Damage to these roots would result in very weak hip flexion L 2,3 These roots are concerned with the innervation of the hip adductors. Damage to these roots can lead to a waddling type of gait. L 5 This is the main root innervating the gluteus medius and minimus muscles. A positive Trendelenburg Sign could indicate damage to this root 05/10/2010NAS20 The Effect of Nerve Lesions on the Hip Joint During Gait Superior gluteal nerve (L 4, 5, S 1) Trendelenburg Gait Marked downward tilting of the hip on the non weight bearing side due to inability of the gluteus medius and minimus to actively abduct the hip on the weight bearing side during walking Trendelenburg Sign Clinical test to determine the integrity of the superior gluteal nerve Patient's hip tilts down when the limb is non weight bearing because of superior gluteal nerve is damaged on weight bearing side. Obturator nerve (L 2,3,4) "Waddling gait" Hip is in a marked abducted position due to paralysis of hip adductor muscles When walking, the foot on the affected side, can not be placed under pelvis. Patient has to "throw" their weight laterally when taking a step thus, waddling to the affected side. 05/10/2010NAS21 AP PELVIS: Adult vs child 05/10/2010NAS22 05/10/2010NAS23 Normal angle of inclination is about 135 (range ) in a child & in the adult. Coxa vara (abnormally decreased angle of inclination) e.g. fracture neck of femur Coxa valga (abnormally increased angle of inclination) e.g. congenital dislocation of the hip joint Acquired / traumatic dislocations of the hip It is rare because of its strength Posterior dislocations are the most common (80%). Anterior dislocations occur infrequently and involved disruption of the capsule and strong iliofemoral ligament. In all dislocations, the blood supply of the head of the femur may be compromised with resulting avascular necrosis of the head of the femur. 05/10/2010NAS24 Complications: Posterior Dislocation Posterior wall fracture Intra-articular fragment, which can prevent reduction Sciatic nerve injury Femur head fracture Avascular necrosis 25 Knee joint and its injuries 17 th Oct, 2011 Human structure Course NBAN- 403 Fall Dr. Najam Siddiqi MBBS, PhD (Japan) Postdoc (USA) Objectives: Know the. bony, ligamentous and cartilaginous structures that comprise the knee joint proper alignment of the knee Be able to distinguish genu valgum from genu varus functions of the ligaments and menisci of the knee joint. bursas around the joint and their inflammation actions, innervations of the muscles acting on the knee mechanisms involved with locking and unlocking of the knee the site of appropriate nerve lesion by deficits in knee movement few common diseases of the knee joint Knee Joint Type of the joint Articular surfaces Factors supporting the knee Capsule Ligaments Menisci Bursa Relations Movements (locking/unlocking) Clinical Type of the joint Largest & most complicated weight bearing joint of the body Modified Hinge type of synovial joint: flexion/extension (gliding & rolling and rotation possible) Complex joint: menisci present between the articular surfaces Bi-axial joint Stability of the knee joint: Mechanically it is a weak joint with almost no bony support Factors supporting the joint are: Ligaments connecting the femur and tibia Surrounding muscles and tendons eg. Quadriceps femoris Articular surfaces: large, complicated, incongruent surfaces, femur slants medially on tibia whereas tibia is almost vertical 3 articulation: 2 condyles of femur and condyles of tibia Patella and patellar surface of femur called patellofemoral joint Femoral articulating surface Femur lie obliquely on tibia making a Q angle more in female femoral condyles wholly convex, inverted U shaped covered by hyaline cartilage; concave anterior forming a groove for the patella Mechanically very unstable because articulation with no bony support Tibial articular surfaces Oval medial articular surface, medial meniscus Circular lateral articular surface, lateral miniscus Patellas articular surface Patellofemoral joint: Synovial gliding type Articular surface of patella: lateral & medial facets Femur: both condyles like an inverted U Patella slides up and down with flexion and extension Patella dislocation Patellofemoral joint: quadriceps mechanism: the quadriceps tendon, patellar and patellar tendon Medial and lateral retinacula Infrapatellar fat The patella acts like a fulcrum and increase liver arm to increase the force of the quadriceps muscles. Capsule Posteriorly margins of articular surfaces of femur and tibia and intercondylar fossa Enclosed the tendon of popliteus Each side of the patella, capsule supported by tendons of vastus lateralis and medialis forming retinacula Posteriorly expansion of semimembranous muscle called oblique popliteal ligament Capsule deficient anteriorly Capsule is deficient anteriorly, permitting the synovial membrane to pouch upwards to form suprapatellar bursa Synovial membrane Synovial membrane lines internal aspect of capsule Reflects from the post aspects of the capsule onto the cruciate ligaments Covers the infrapatellar fat pad between tibia and patella The joint cavity extends superior to the patella as suprapatella bursa Extracapsular ligaments: 1. Ligamentum Patellae 2. Tibial Collateral 3. Fibular Collateral 4. Oblique Popliteal 5. Arcuate popliteal ligament 6. Coronary ligament 7. Transverse meniscal ligament Posterior meniscofemoral ligament Anterior meniscofemoral ligament Extracapsular ligaments Stabalize the knee posteriorly Oblique Popliteal: tendon of semimembranosus passing from medial to lateral femoral condyle and attaching to post. capsule Arcuate popliteal ligament: Arise from fibular head to posterior surface of knee joint over the popliteus muscle Collateral (Lateral and medial) ligaments Lateral collateral ligament: lateral epicondyle of femur posterior to popliteus tendon to fibular head Medial collateral ligament: medial epicondyle of femur to medial tibia Intracapsular (intra-articular) ligaments Anterior cruciate ligament Posterior cruciate ligament refer to tibial attachments Cruciate Ligaments: prevents antero- posterior displacement ACL slacks at flexion and taut at fully extended knee, prevents anteriolateral movement of tibia on femur or posterior movement of femur on tibia (when tibia on ground) PCL tightens during flexion, prevents posterior movement of tibia on femur or anterior movement of femur on tibia (when tibia on ground) Anterior cruciate ligament rupture Posterior cruciate ligament rupture Meniscus Semilunar fibrocartilage, cresentric shape deepens the articulation on tibial surface Outer thick border attached to tibial condyle by coronary ligament, inner margins concave, thin and free Attached to the femur by meniscofemoral ligament They spread load by increasing the congruity of the articulation Parts of the meniscus: Anterior horn Posterior horn Body Function of meniscus Shock absorbers in the knee; acts like springs Walking puts up to two times your body weight on the joint. Running puts about eight times your body weight on the knee. As the knee bends, the back part of the menisci takes most of the pressure. Intercondylar eminence (area) Structures attached to the intercondylar space (ant to post) 1.Ant horn of medial meniscus 2.Ant cruciate ligament 3.Ant horn of Lateral Meniscus 4. Post horn of Lateral Meniscus 5.Post horn of medial meniscus 6.Post cruciate ligament Code: Medical College Lahore-- Lahore Medical College medial Meniscus Injury: Medial meniscus: more prone to injury--- why? Medial meniscus attached to the medial collateral ligament Attached to tibia by Coronary ligament Fixed in its place and if twisting or shear forces act on the meniscus, it cannot move thus ruptures Most common in basket ball players Arthroscopic repair or resection Bursae-- 12 or more around the knee joint Anterior Bursae 1. Supra patellar: SUPERIOR EXTENSION OF THE KEE JOINT CAVITY 2. Prepatellar: lower patella and skin 3. Deep Infra Patellar: between tibia and patellar tendon 4. Superficial Infra Patellar: distal part of tibial tuberosity and skin Bursae (Posterior) 1. Gastro and capsule 2. Popliteal bursa: Tendon of popliteus and lateral femoral condyle Popliteus bursa Gastro bursa Bursae (Medial) 1. Semimembranosus bursa 2. Medial collateral ligament and Semitendo, Satorius, Gracilis (pes bursa or Anserine bursa) 4 bursae communicate with the knee joint: Suprapetallar, Popliteus, Gastro, Anserine; Infection in the bursae may go to the knee joint The pes anserine bursa provides a buffer or lubricant for motion that occurs between these three tendons and the medial collateral ligament (MCL). The MCL is underneath the semitendinosus tendon. Clinically important bursae Bursitis of the knee joint Prepatellar & infrapatellar bursae inflammation usually due to repeated friction, direct blow or fall--Housemaids knee Anserine or Pes bursa inflamed in athletes Popliteus bursa in degenerating disease of the knee joint in elderly A popliteal cyst, or Baker's cyst: is a soft, often painless bump due to arthritis, gout, injury, or inflammation in the knee joint. Blood & Nerve Supply 10 Arteries forming the genicular anastomosis Middle Genicular artery: cruciate ligaments, synovial membrane Obturator Femoral Tibial Common Peroneal Saphenous Nerve supply Movements Flexion Extension Medial & lateral rotation Locking/unlocking LockingDuring extension medial rotation of femur Unlockinglateral rotation of femur by popliteus Locking and unlocking of the knee Femur rotates medially on full extension (due to shape of the articular surfaces) Because of rotation of the femur, all the ligaments becomes tight and thus knee locks in extension For flexion to begin, the femur must rotate laterally to relax the ligaments, then flexion starts. Popliteus is the muscle to rotate femur and unlock the knee Disc herniation L5-S1: Flexion weakness L3-4: Extension weakness L2-4: Patellar tendon reflex Mechanical axis of the lower limb Genu varumGenu valgum Knee deformities: mostly due to osteoarthritis Can you name the deformities? High heels causes osteoarthritis Ankylosis of the jointjoint cavity is obliterated Wearing high heels puts extra pressure on inside of woman's knee, increasing risk for osteoarthritis later in life. Heels also alter muscle and tendon structure. Injuries of the knee joint Rupture of the cruciate ligaments: foot ball players, skiing accidents ACL: Severe force directed anteriorly in semiflexed knee kicking the football PCL: player lands on tibial tuberosity with the knee flexed knocked to floor in basketball Anterior/posterior drawer signs positive Unhappy triad of knee injuries 1.Rupture of the Medial meniscus 2.Rupture of Medial collateral ligament 3.Rupture of anterior cruciate ligament Patellofemoral syndrome runners knee Pain deep to the patella Due to excessive running especially downhill Osteoarthritis of the Patellofemoral joint Ankle and Subtalar joints Oct 18, 2011 Human structure Course NBAN- 403 Fall Dr. Najam Siddiqi MBBS, PhD (Japan) Postdoc (USA) Department of Anatomy Oman Medical College, Sohar, Sultanate of Oman Ankle Joint (talocrural) : Topics Type of the joint: hinge type; uni-axial Articulation Capsule Ligaments Blood supply and nerve supply Movements and muscles involved Clinical importance Articulation: 1. lower end of tibia and its medial malleolus, 2. trochlear surface of talus, 3. lateral malleolus of fibula 1. Ligaments between Tibia and Fibula: tibiofibular syndesmosis Anterior Tibiofibular ligament Posterior Tibiofibular ligament 2. Medial ligaments : Deltoid 3. Lateral ligaments (most frequently damaged ligaments during ankle twisting) Ant. Talo fibular ligament sprains (Part of the lateral ligament) Nerve supply: Deep peroneal, saphenous, sural and tibial nerves Blood supply: Malleolar rami of ant. & post Tibial arteries Peroneal artery branch from post Tibial artery Movement of Ankle joint Planter flexion: Gastrocnemius, soleus, Assisted by plantaris, Tibialis posterior, flexor hallusis longus, digitorum longus Dorsiflexion (20-30) Tibialis anterior Extensor digitorum longus, hallucus longus and peroneus tertius Nerve: Deep peroneal nerve Foot drop Normal radiograph (AP view) Potts fracture dislocation of the ankle joint Foot forcibly everted Medial ligament (Deltoid) is torn Talus moves laterally tearing the lateral ligament and/or fracture of fibula Fracture dislocation of ankle joint Subtalar Joint Modified multi-axial synovial joint of plane variety Talus articulates with calcaneus and navicular Inbetween: Interosseous talocalcanean ligament Subtalar joint Eversion Inversion Movements Inversion: Tibialis anterior and posterior Extensor digitorum longus Eversion: Peroneus longus and brevis Total range of motion of forefoot and hindfoot Eversion & pronation 30 degrees Inversion & supination 60 degrees Effects of high heel shoes; foot in planter flexed position Fashionable and make you feel taller Cause back pain, knee osteoarthritis, foot problems Like walking on a balance beam without any support Lumber spine flattening, curves are lost, body readjust balance, lower part lean forward and upper part lean back so abnormal posture of body Hip flexors work hard and longer while walking Limit power and motion at ankles. Calf muscles become shorter and loose power, shortening of achilles tendon Foot plantar flexed so cannot push off, hip flexors to work harder Foot position increases pressure on the forefoot Clubfoot (Talipes equinovarus) Congenital anomaly 2 per 1000 livebirths Involves the subtalar joint 05/10/2010NAS86 Thank you