NAS 1

Joints of the lower limbFeb. 28, 2012

Shifa College of MedicineIslamabad

Dr. Najam SiddiqiMBBS, PhD (Japan) Postdoc (USA)

jamsid69@gmail.com

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

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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.

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Topics• Type of the joint• Articular surfaces• Stability of the joint• Capsule• Synovial membrane• Ligaments• Bursa• Relations• Movements• Normal radiograph• Clinical

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NAS 605/10/2010 Hip joint is a weight bearing joint

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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)

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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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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.

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Avascular necrosis of femoral head in neck fractures

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Blood supply is preserved in trochanteric fractures

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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

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Muscles acting on the hip joint

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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

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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.

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AP PELVIS: Adult vs child

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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.

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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)

jamsid69@gmail.com

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