NAS 1
Joints of the lower limbFeb. 28, 2012
Shifa College of MedicineIslamabad
Dr. Najam SiddiqiMBBS, PhD (Japan) Postdoc (USA)
Department of AnatomyOman Medical College, Sohar, Sultanate of
Oman
NAS 2
The hip joint
Dr. Najam SiddiqiMBBS, PhD (Japan) Postdoc (USA)
05/10/2010
Oct.12, 2011Human structure Course NBAN- 403
Fall- 2011
NAS 3
Learning ObjectivesYou 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
05/10/2010
NAS 4
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.
05/10/2010
NAS 5
Topics• Type of the joint• Articular surfaces• Stability of the joint• Capsule• Synovial membrane• Ligaments• Bursa• Relations• Movements• Normal radiograph• Clinical
05/10/2010
NAS 605/10/2010 Hip joint is a weight bearing joint
NAS 7
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
NAS 805/10/2010Acetabular 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.
NAS 905/10/2010Posterior 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
NAS 1005/10/2010
Synovial membrane of the hip joint
Lines in inner surface of the capsule and the ligament of the head of femur
NAS 1105/10/2010Iliofemoral ligament
Lateral / oblique band
Medial / vertical band
1. Iliofemoral ligament: Y-shaped : ant. inferior iliac spine to intertrochanteric lineSTRONGEST 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
NAS 1205/10/2010
Ligaments--Posterior3. 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 ligamentPrevents overabduction
Ligaments--Anterior
NAS 1305/10/2010 Ligament of the femoral head
NAS 14
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 arteriesLateral circumflex femoral arterySuperior gluteal arteryInferior gluteal arteryFirst perforating arteryObturator artery
(acetabular branch)
05/10/2010
NAS 15
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
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NAS 1605/10/2010
Injury of the branch of the obturator artery in a child may lead to necrosis of the head—epiphysis prevents anastomosis,
but in the adult nothing happens.
NAS 17
Avascular necrosis of femoral head in neck fractures
05/10/2010
Blood supply is preserved in trochanteric fractures
NAS 18
Nerve supplyFemoral nerve via nerve to rectus femorisObturator nerve Sciatic nerve via nerve to quadratus femorisAccessory 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
05/10/2010
NAS 19
Muscles acting on the hip joint
05/10/2010
NAS 20
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
05/10/2010
NAS 21
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.
05/10/2010
NAS 22
AP PELVIS: Adult vs child
05/10/2010
NAS 2305/10/2010
Normal angle of inclination is about
135 (range 115-140) in a child & 1350 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
NAS 24
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.
05/10/2010
25
Complications: Posterior Dislocation
• Posterior wall fracture• Intra-articular fragment,
which can prevent reduction
• Sciatic nerve injury• Femur head fracture• Avascular necrosis
Knee joint and its injuries
17th Oct, 2011Human structure Course NBAN- 403
Fall- 2011
Dr. Najam SiddiqiMBBS, 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
Patella’s 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 Patellae2. Tibial Collateral3. Fibular Collateral4. Oblique Popliteal5. Arcuate popliteal ligament6. Coronary ligament7. Transverse meniscal ligament• Posterior meniscofemoral ligament• Anterior meniscofemoral ligament
Extracapsular ligamentsStabalize 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 hornPosterior hornBody
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 meniscus2. Ant cruciate ligament3. Ant horn of Lateral Meniscus4. Post horn of Lateral Meniscus5. Post horn of medial meniscus6. 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 capsule2. Popliteal bursa:
Tendon of popliteus and lateral femoral condyle
Popliteus bursa
Gastro bursa
Bursae (Medial)
1. Semimembranosus bursa2. 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--Housemaid’s 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 – Locking—During extension medial rotation of
femur– Unlocking—lateral 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 varum Genu valgum
Knee deformities: mostly due to osteoarthritis
Can you name the deformities?
High heels causes osteoarthritis
Ankylosis of the joint—joint 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‘runner’s knee’
• Pain deep to the patella• Due to excessive running especially downhill• Osteoarthritis of the Patellofemoral joint
Ankle and Subtalar joints
Oct 18, 2011Human structure Course NBAN- 403
Fall- 2011
Dr. Najam SiddiqiMBBS, PhD (Japan) Postdoc (USA)
Department of AnatomyOman 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: 40-50
• 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)
Pott’s 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 & pronation30 degrees
Inversion & supination60 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
NAS 8605/10/2010
Thank you
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