joints slides by vince austin and w. rose. figures from marieb & hoehn 7 th and 8 th eds., and...

Joints

Slides by Vince Austin and W. Rose.

figures from Marieb & Hoehn 7th and 8th eds.,

and other sources as noted.

Portions copyright Pearson Education

Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings

Types of Synovial Joints

Plane joints (Nonaxial)

Articular surfaces essentially flat

Allow only slipping or gliding movements

Only examples of nonaxial joints

Figure 8.7a


Types of Synovial Joints

Hinge joints (Uniaxial)

Cylindrical projections of one bone fits into a trough-shaped surface on another

Motion is along a single plane

Uniaxial joints permit flexion and extension only

Examples: elbow and interphalangeal joints


Hinge Joints (Uniaxial)

Figure 8.7b


Pivot Joints (Uniaxial)

Rounded end of one bone protrudes into a “sleeve,” or ring, composed of bone (and possibly ligaments) of another

Only uniaxial movement allowed

Examples: joint between the axis and the dens, and the proximal radioulnar joint


Pivot Joints (Uniaxial)

Figure 8.7c


Condyloid or Ellipsoidal Joints (Biaxial)

Oval articular surface of one bone fits into a complementary depression in another

Both articular surfaces are oval

Biaxial joints permit all angular motions

Examples: radiocarpal (wrist) joints, and metacarpophalangeal (knuckle) joints


Condyloid or Ellipsoidal Joints

Figure 8.7d


Saddle Joints

Similar to condyloid joints but allow greater movement

Each articular surface has both a concave and a convex surface

Example: carpometacarpal joint of the thumb


Saddle Joints (Biaxial)

Figure 8.7e


Ball-and-Socket Joints (Multiaxial)

A spherical or hemispherical head of one bone articulates with a cuplike socket of another

Multiaxial joints permit the most freely moving synovial joints

Examples: shoulder and hip joints


Ball-and-Socket Joints (Multiaxial)

Figure 8.7f


Specific Synovial Joints: Knee

Largest and most complex joint of the body

Allows flexion, extension, and some rotation

Three joints in one surrounded by a single joint cavity

Femoropatellar joint

Lateral and medial tibiofemoral joints

(a) Sagittal section through the right knee joint

Femur

Tendon ofquadricepsfemoris

SuprapatellarbursaPatellaSubcutaneousprepatellar bursaSynovial cavityLateral meniscus

Posteriorcruciateligament

Infrapatellarfat pad Deep infrapatellarbursaPatellar ligament

Articularcapsule

Lateralmeniscus

Anteriorcruciateligament

Tibia

Figure 8.8a The knee joint.

Figure 8.8c The knee joint.

Quadricepsfemoris muscle

Tendon ofquadricepsfemoris muscle

Patella

Lateral patellarretinaculum

Medial patellarretinaculum

Tibial collateralligament

Tibia

Fibularcollateralligament

Fibula

(c) Anterior view of right knee

Patellar ligament

Fibularcollateralligament

Posterior cruciateligament

Medial condyle

Tibial collateralligament

Anterior cruciateligament

Medial meniscus

Patellar ligament

Patella

Quadriceps tendon

Lateral condyleof femur

Lateralmeniscus

Fibula

Tibia

(e) Anterior view of flexed knee, showing the cruciateligaments (articular capsule removed, and quadricepstendon cut and reflected distally)

Figure 8.8e The knee joint.

Department of Kinesiology and Applied Physiology

Primary Knee Ligaments

Ligament Tibial Motion Limited

Tibial or Med. Collat. (MCL)

Valgus rotation (medial gapping)Lateral rotation

Fibular or Lat. Collat. (LCL)

Varus rotation (lateral gapping)Lateral rotation

Anterior Cruciate (ACL)

Anterior translationMedial rotation

Posterior Cruciate (PCL)

Posterior translationMedial rotation

Magee, 4th ed., 2002.

Figure 8.9 A common knee injury.

Lateral MedialPatella(outline)

Tibial collateralligament(torn)

Medialmeniscus (torn)

Anteriorcruciateligament (torn)

Hockey puck


Specific Synovial Joints: Shoulder (Glenohumeral)

Ball-and-socket joint in which stability is sacrificed to obtain greater freedom of movement

Head of humerus articulates with the glenoid fossa of the scapula

Figure 8.10a The shoulder joint.

Acromionof scapula

Synovial membraneFibrous capsule

Hyalinecartilage

Coracoacromialligament

Subacromialbursa

Fibrousarticular capsuleTendonsheath

Tendon oflong headof bicepsbrachii muscle

Synovial cavityof the glenoidcavity containingsynovial fluid

Humerus

(a) Frontal section through right shoulder joint

Figure 8.10c The shoulder joint.

Acromion

Coracoacromialligament

SubacromialbursaCoracohumeralligament

Greatertubercleof humerus

Transversehumeralligament

Tendon sheath

Tendon of longhead of bicepsbrachii muscle

Articularcapsulereinforced byglenohumeralligaments

Subscapularbursa

Tendon of thesubscapularismuscle

Scapula

Coracoidprocess

(c) Anterior view of right shoulder joint capsule

Figure 8.10d The shoulder joint.

Acromion

Coracoid process

Articular capsule

Glenoid cavityGlenoid labrum

Tendon of long headof biceps brachii muscle

Glenohumeral ligaments

Tendon of thesubscapularis muscle

ScapulaPosterior Anterior

(d) Lateral view of socket of right shoulder joint,humerus removed

Elbow Joint

• Radius and ulna articulate with humerus in a hinge joint – flexion and extension

• Radius & ulna articulate with each other, and radius articulates with humerus, in a pivot joint: radius pivots about its long axis to allow pronation & supination

Figure 8.11a The elbow joint.

Articularcapsule

Synovialmembrane

Synovial cavity

Articular cartilage

Coronoid process

Tendon ofbrachialis muscle

Ulna

Humerus

Fat pad

Tendon oftricepsmuscle

Bursa

Trochlea

Articular cartilage

(a) Median sagittal section through right elbow (lateral view)

Figure 8.11b The elbow joint.

Humerus

Lateralepicondyle

Articularcapsule

Radialcollateralligament

Olecranonprocess

Anularligament

Radius

Ulna

(b) Lateral view of right elbow joint

Figure 8.11d The elbow joint.

Articularcapsule

Anularligament

Coronoidprocess

(d) Medial view of right elbow

Radius

Humerus

Medialepicondyle

Ulnarcollateralligament

Ulna


“Tommy John surgery”Reconstruct torn or overstretched ulnar (medial) collateral ligament

UCL highly stressed in throwing, esp late cocking/early accel.

Restore elbow medial stability (resistance to valgus stress)

Use autograft tendon (palmaris longus, gracilis, toe extensor,…)

Humerus

Radius

Ulna

Right elbow, medial aspect

http://www.eorthopod.com/public/patient_education/9633/ulnar_collateral_ligament_reconstruction_tommy_john_surgery.html

Hip (Coxal) Joint

Ball-and-socket jointHead of femur articulates with acetabulumGood range of motion (less than shoulder),

limited by deep socket, acetabular labrum, strong ligaments

Figure 8.12a The hip joint.

Articular cartilageCoxal (hip) bone

Ligament ofthe head of the femur (ligamentum teres)

Synovial cavity

Articular capsule

Acetabularlabrum

Femur

(a) Frontal section through the right hip joint

Ankle JointDorsi/plantarflex mainly at talocrural joint: tib, fib, talus

Invert/evert mainly at subtalar joint: talus, calcaneus

Ankle sprain – most common joint injury

•Low ankle sprain: tear of ligaments “below the ankle”

• Inversion sprain – more common – damage to lateral ligaments (ant. & post. talofibular, calcaneofibular)

• Eversion – damage to medial (deltoid) ligament

•High ankle sprain: tear of ligaments “above the ankle”

• Tear of syndesmotic ligaments of distal tibiofibular joint (tibiofibular joints are syndesmotic, a subset of fibrous, and amphiarthrotic, i,.e. slightly movable.)

• High ankle sprain generally takes longer to heal.

Sprains

• Stretching or tearing of ligaments• Partially torn ligaments slowly repair

themselves

Dislocations

• Occur when bones are forced out of alignment

• Usually accompanied by sprains, inflammation, and joint immobilization

• Causes: serious falls, sports, motor vehicle accidents, etc.

• Subluxation – partial dislocation of a joint


Inflammatory and Degenerative Conditions

• Bursitis• Tendonitis• Arthritis

Bursitis

• An inflammation of a bursa, usually caused by a blow or friction

• Symptoms are pain and swelling• Treated with anti-inflammatory drugs,

local glucocorticoid injection; excessive fluid may be aspirated


Olecranon bursa. A case of olecranon bursitis in a patient with rheumatoid arthritis. A

rheumatoid nodule is also shown.Infected olecranon bursitis.

Tendonitis

• Inflammation of tendon and surrounding tissues, typically caused by overuse

• Symptoms and treatment are similar to bursitis

• Also spelled tendinitis

Arthritis• Joint inflammation • Many different types; most widespread

crippling disease in U.S.• Symptoms: pain, stiffness, swelling of joint• Acute forms are caused by bacteria and are

treated with antibiotics• Chronic forms include

• Osteoarthritis (OA)• Rheumatoid arthritis (RA)• Gouty arthritis


Osteoarthritis (OA)• Loss/damage to articular cartilage → hardening, cyst formation

in underlying bone, osteophyte (bone spur) formation → osteophyte break-off → synovitis (inflammation of synovial membrane), joint capsule thickening.

• Risk factors: old age, joint trauma, obesity, diabetic neuropathy, skeletal deformities, etc. Most people >70 y.o. have some degree of OA.

• Symptoms: pain, stiffness, loss of range of motion.

• Treatment: rest, PT, weight loss, surgery (total knee, total hip), glucosamine?, hyaluronic acid?


Rheumatoid arthritis (RA): Inflammatory joint disease

•Autoimmune disease: genetically susceptible person is triggered, by unknown agent, to attack his/her own synovium. •T-cells do the damage ; cartilage gets replaced with pannus (scar tissue); synovium gets thick & swollen.•RANKL is produced and stimulates osteoclasts which destroy bone.•Hand joints often affected first. •Pain & loss of range of motion → muscle atrophy, wasted appearance, further joint destabilization.•Drug treatment: improving a lot but very expensive


Gouty Arthritis (Gout):Inflammatory joint disease

•Inflammatory response to high levels of uric acid in blood (hyperuricemia), synovial fluid. Meat, fat, beer in diet increases risk. 10:1 male:female. Urate crystals in synovial space -> gouty arthritis. Subcutaneous urate crystals cause tophi.

•Painful acute attacks may be triggered by uric acid level exceeding a critical value, trauma, etc.


Gout at right MTP joint.Gouty tophus on right foot


Skip remaining slides


A, Cartilage and degeneration of the hip joint resulting from osteoarthritis. B, Heberden nodes and Bouchard nodes. C, Characteristics of OA. Normal versus osteoarthritic synovial joint.


Rheumatoid arthritis treatment

•Goal of therapy now is to cure•Rest of body or joint; ice, heat, PT•NSAIDs (aspirin, ibuprofen, naproxen) to reduce inflammation & pain; acetominophen for pain•Prednisone (steroidal anti-inflammatory): dramatic short term effects, but long term risk of weight gain, osteoporosis, glaucoma, diabetes, etc.•Disease-modifying anti-rheumatic drugs (DMARDs)

• Methotrexate: old, many side FX; inexpensive• “Biologics”: TNF- blockers, fewer side FX, much more $

•Surgery: Remove synovial membranes; joint replacement


Ankylosing Spondylitis:A chronic inflammatory joint disease

•Enthesis (point of ligament/tendon/joint capsule attachment to bone) is attacked, usually in vertebral column. •Inflammation of fibrocartilage in intervertebral joints.•Stiffening & fusion (ankylosis) of vertebral column, sacroiliac joints.•Primary AS: low back pain in early 20s. •Secondary AS: older age, assoc with other inflammatory diseases, e.g. inflammatory bowel disease.•Treat: NSAIDs for symptoms; TNF- antagonists infliximab (Remicade*), etanercept (Enbrel*), etc.

Image Challenge

Q: What is the diagnosis?

1. Psoriatic arthropathy2. Reflex sympathetic dystrophy3. Osteoarthritis4. Gout5. Rheumatoid arthritis

Image Challenge

Q: What is the diagnosis?

Answer:3. Osteoarthritis

Examination of this patient's right hand reveals typical changes of osteoarthritis, with both Heberden's (→) and Bouchard's (→) nodes in association with irregular deformities.

Read More: N Engl J Med 2002;346:e3


Developmental Aspects of Joints

By embryonic week 8, synovial joints resemble adult joints

Few problems occur until late middle age

Advancing years take their toll on joints:

Ligaments and tendons shorten and weaken

Intervertebral discs become more likely to herniate

Most people in their 70s have some degree of OA


Developmental Aspects of Joints

Prudent exercise (especially swimming) that coaxes joints through their full range of motion is key to postponing joint problems


ACL Injury

ACL protects against anterior translation of tibia relative to femur, knee hyperextension

Lachman test (knee flexed 20-30°, + if soft end feel)

Anterior drawer test (knee flexed 90°, + if >6mm anterior mvmt)


Lachman test: positive if no solid stop, i.e. if end point is softSpindler KP, Wright RW (2008). NEJM 359:2135-2142. (2008-11-13)

College or Department name here


Temporomandibular Joint (TMJ)

Mandibular condyle articulates with temporal bone

Two types of movement

Hinge – depression and elevation of mandible

Side to side – (lateral excursion) grinding of teeth

Figure 8.13a The temporomandibular (jaw) joint.

Zygomatic process

Mandibular fossaArticular tubercle

Infratemporal fossa

Externalacousticmeatus

ArticularcapsuleRamus ofmandible

Lateralligament

(a) Location of the joint in the skull

Figure 8.13b The temporomandibular (jaw) joint.

Articularcapsule

Mandibularfossa

Articular discArticulartubercle

Superiorjointcavity

Inferior jointcavity

Mandibularcondyle

Ramus ofmandible

Synovialmembranes

(b) Enlargement of a sagittal section through the joint

joints slides by vince austin and w. rose. figures from marieb & hoehn 7 th and 8 th eds., and...

Documents