Joints of lower limb

k.Prashanth kumar1st yr pg

HIP JOINT TYPE: BALL & SOCKET VARIETY OF SYNOVIAL JOINT ARTICULAR SURFACES :The head of femur articulates with the acetabulam of the

hip bone to form hip joint.The head of femur forms more than half a sphere,and is

covered with the hyaline cartilage except at the fovea capitis.

The acetabulum presents a horseshoe shaped,lunate articular surface ,an acetabular notch and a acetabular fossa .

The lunate surface is covered with cartilage.

Though the articular surface on the head of femur and the acetabulum are reciprocally cured, they are not co-extensive.

The hip joint is unique in having a high degree of stability a well as mobility.

• The stability depends on:• 1)the depth of acetabulum & the narrowing of its

mouth by the acetabular labrum.• 2)tension & the strength of ligaments.• 3)strenth of surrounding muscles.• 4)length & obliquity of the neck of femur.• 5)atmospheric pressure:a fairly wide range of mobility is

possible becoz of fact that the femur has a long neckwhich is narrower than the equatoial diameter of the head.

MOVEMENTS AT THE HIP JOINT

Clinical anatomy• Congenital dislocation is more common in hip

than in any other joint of the body.the head of femur slips upwards on to the gluteal surface of the ilium because the upper margin of the acetabulum is developmentally deficient .this causes lurching gait & trendelenburg +ve.

• PERTHES disease or pseudocoxalgia is characterised by destruction & flattening of the head of the femur ,with an increased joint space on the x-ray .

• .

• COXA VERA is a condition in which the neck shaft angle is reduced from the normal angle of about 150 in a child,& 127 in a adult

• OSTEOARTHRITIS is a disease of old age,characterised by growth of osteophytes at the articular ends,which makes the movements limited & painfull.

• In arthritis of hipjoint,the position of the joint is partially flexed ,abducted& laterally rotated.

• FRACTURE OF THE NECK OF THE FEMUR may be subcapital,cervical,or near the trochanter.

• Damage to the retinacular arteries causes avascular necrosis of the head.such damage is max. in subcapital # & least in basal #.

• This # are more common in age 40-60 yrs.

• SHENTONS LINE in an x-ray,is a continous curve formed by upper border of obturator foramen 7 the lower border of the neck of the femur.In # neck femur ,line becomes abnormal.

• HIP DISEASES show an interesting age pattern:• <5 yrs: congenital dislocation & tuberculosis• 5-10 yrs:perthes disease• 10-20 yrs:coxa vera• >40 yrs :osteoarthritis

Knee jointLargest & most complex joint of the body.The complexity is the result of fusion of 3

joints in one.Formed by fusion of lateral

femorotibial,medial femorotibial,&femoropatellar

TYPE:Compound synovial joint,incorporating 2

condylar joints between the condyles of the femur & tibia,& 1 saddle joint between the femur and the patella.

ARTICULAR SURFACES:1. THE CONDYLES OF THE FEMUR2. THE PATELLA3. THE CONDYLES OF THE TIBIA The femoral condyles articulates with the

tibial condyles below and behind and with the patella in front.

LIGAMENTS:1. EXTRACAPSULARa. fibrous capsuleb. Ligamentum patellac. Medial collateral ligamentd. Lateral collateral ligamente. Oblique popliteal ligamentf. Arcuate popliteal ligament

2.INTRACAPSULAR:a. Anterior cruciate ligamentb. Posterior cruciate ligamentc. Medial meniscusd. Lateral meniscus

Bursae around the knee In anterior there are five bursae:1) the suprapatellar bursa or recess between the anterior

surface of the lower part of the femur and the deep surface of thequadriceps femoris. It allows for movement of the quadriceps tendon over the distal end of the femur

2) the prepatellar bursa between the patella and the skin, results in "housemaid's knee" when inflamed. It allows movement of the skin over the underlying patella.

3) the deep infrapatellar bursa between the upper part of the tibia and the patellar ligament. It allows for movement of the patellar ligament over the tibia.

4)the subcutaneous [or superficial] infrapatellar bursa between the patellar ligament and skin.

5)the pretibial bursa between the tibial tuberosity and the skin. It allows for movement of the skin over the tibial tuberosity.

Laterally there are four bursæ:1) the lateral gastrocnemius [subtendinous]

bursa between the lateral head of the gastrocnemius and the joint capsule

2) the fibular bursa between the lateral (fibular) collateral ligament and the tendon of the biceps femoris

3) the fibulopopliteal bursa between the fibular collateral ligament and the tendon of the popliteus

4) and the subpopliteal recess (or bursa) between the tendon of the popliteus and the lateral condyle of the femur

Medially, there are five bursae:1. the medial gastrocnemius [subtendinous] bursa between

the medial head of the gastrocnemius and the joint capsule2. the anserine bursa between the medial (tibial) collateral

ligament and the tendons of the sartorius, gracilis, and semitendinosus (i.e. the pes anserinus)

3. the bursa semimembranosa between the medial collateral ligament and the tendon of the semimembranosus

4. there is one between the tendon of the semimembranosus and the head of the tibia

5. and occasionally there is a bursa between the tendons of the semimembranosus and semitendinosus

BLOOD SUPPLY • The femoral artery and the popliteal artery help form the

arterial network surrounding the knee joint (articular rete). There are 6 main branches:

• 1. Superior medial genicular artery• 2. Superior lateral genicular artery• 3. Inferior medial genicular artery• 4. Inferior lateral genicular artery• 5. Descending genicular artery• 6. Recurrent branch of anterior tibial artery• The medial genicular arteries penetrate the knee joint.

CLINICAL ANATOMY

• DEFORMITIES OF KNEE

• MENISCAL INJURIES:

CRUCIATE LIGAMENT INJURIES:

• COLLATERAL LIGAMENT INJURIES:

• Semimembranosus bursitis is quite common .it causes swellling in the popliteal fossa region on the posteromedial aspect.

• In knee joint disease ,vastus medialis is first to atrophy and last to recover.

• Bakers cyst is a central swelling occurs due to osteoarthritis of knee joint.

• Synovial membrane protudes through a hole in the posterior part of capsule of knee joint.

ANKLE JOINT• TYPE: synovial joint of hinge variety.• ARTICULAR SURFACES:• Upper articular surface is formed by :I. The lower end of tibia including the medial

malleolusII. The lateral malleolus of the fibulaIII. The inferior transverse tibiofibular

ligament .these structures form a deep socket

• The inferior articular surface is formed by the articular areas on the upper,medial,&lateral aspects of talus.

• Structurally,the joint is very strong.the stability of the joint is ensuredby:

I. Close interlocking of the articular surfacesII. Strong collateral ligaments on the sidesIII. The tendons that crosses the joint ,4 in

front& 5 behind

• The depth of the superior areticular socket is contributed by:

I. The downward projection of medial and lateral malleoli,on the corresponding sites of talus.

II. By the inferior transverse tibiofibular ligament that bridges across the gap between the tibia and the fibulabehind the talus.thesocket is provided flexibility by strong tibiofibular ligaments and by slight movement of fibula at the superior tibiofibular ligament.

• There are 2 factors,however,that tend to displace the tibia and the fibula forwards over the talus.these factors are

a) The forward pull of tendons which pass from the leg to the foot.

b) The pull of gravity when the leg is raised.

• Displacement is prevented by the following factors:I. The talus is wedge shaped,being wider anteriorly .the

malleoli are oriented to fit this wedge.II. The posterior border of the lower end of the tibia is

prolonged downwards.III. The presence of inferior transverse tibiofibular

ligament.IV. The tibiocalcanean,posterior tibiotalar,calcaneofibular

and posterior talotalar ligament pass backwards and resist forward movement of the tibia and fibula.

• LIGAMENTS:• The joint is supported by:a. The fibrous capsuleb. The deltiod or medial ligament c. Lateral ligament

• BLOOD SUPPLY: from anterior tibial, posterior tibial,and peroneal arteries.

• NERVE SUPPLY: from deep peroneal and tibial nerves

Clinical anatomy

• The so called sprains of the ankle are almost always abduction sprains of the subtalar joints,although a few fibres of the deltiod ligament are also torn.

• True sprains of the ankle joint are caused by forced plantar flexion ,which leads to tearing of the anterior fibres of the capsule.

• The joint is unstable during plantar flexion.

• Dislocations of the ANKLE are rare because joint is very stable due to the presence of deep tibiofibular socket.whenever dislocation occurs,it is accompained by fractues of one of the malleoli.

• Acute sprains of the ankle when the foot is plantar flexed and excessively inverted.

• The lateral lligaments of the ankle joint are torn giving rise to pain and swelling.

• Acute sprains of the medial ankle occur in excessive eversion ,leading to tear of strong deltiod ligament.these are less common.

• The optimal position of the ankle to avoid ankylosis is one of slight plantar flexion.

• For injection in to ankle joint,the needle is introduced between tendons of EHL and TA with the ankle partially plantar flexed.

• During walking the plantar flexors raie the heel from the ground.

• When the limb is moved forwards the dorsiflexors help the foot in clearing the ground.

• The value of ankle joint resides in this hinge action,in this to and fro movements of the joint during walking.

• GAIT: gait is defined as bipedal, biphasic forward propulsion of center of gravity of the human body, in which there are alternate sinuous movements of different segments of the body with least expenditure of energy.

• 2 phases of gait: swing and stance

• SWING PHASE:a) FLEXION OF HIP,FLEXION OF KNEE,PLANTAR

FLEXION OF ANKLEb) FLEXION OF HIP,EXTENSION OF KNEE,AND

DORSIFLEXION OF ANKLE• STANCE PHASE:C) FLEXION OF HIP ,EXTENSION OF KNEE,AND

FOOT ON THE GROUNDD) EXTENSION OF HIP,EXTENSION OF KNEE,AND

FOOT ON THE GROUND

PROXIMAL TIBIOFIBULAR JOINT• Articulation is between the lateral condyle of the tibia and the head

of the fibula.the articular surfaces are flatenned and covered by hyaline cartilage.

• This is a synovial,plane,gliding joint• LIGAMENTS:• Anterior and posterior ligaments strengthens the capsule.• Capsule and synovial membrane attached to line of the articular

surface.• Common peroneal nerve supplies the joint.• MOVEMENTS:• A small amount of gliding movement takes place during

movements at the ankle joint.

DISTAL TIBIOFIBULAR JOINT• TYPE: FIBROUS JOINT• ARTICULATION:• Articulation is between fibular notch at the lower

end of the tibia and the lower end of the fibula• There is no capsule• BLOOD SUPPLY:perforating branch of the

peroneal artery,and the malleolar branch of the anterior and posterior tibial arteries.

• NERVE SUPPLY: deep peroneal ,tibial and saphenous nerves

• The joint permits slight movements,so that the lateral malleolus can rotate laterally during dorsiflexion of the ankle

joints of the foot• Joints of the foot are numerous.they can be

classified are:a. Intertarsalb. Tarsometatarsalc. Intermetatarsald. Metatarsophalanges ande. Interphalanges

• The main intertarsal joints are the subtalar or talocalcanean joint,the talocalcaneonavicular joint and the calcaneocubiod joint.

• Smaller intertarsal joints include the cuneonavicular,cubiodonavicular,intercuneiform and cuneocuboid joints

MOVEMENTS:1) The intertarsal,tarsometatarsal and intermetatarsal

joints permit gliding and rotatory movements ,which jointly bring about inversion ,eversion,supination,and pronation of the foot.pronation is a component of eversion,while supination is a component of inversion.

2) The metatarsophalangeal joints are similar to the metacarpophalangeal joints of the hand.they permit flexion , extension, adduction,and abduction of thec toes.

3) The interphalangeal joints of hinge variety permit flexion and extension of the distal phalanges.

Clinical anatomy

• Deformities of the foot: