ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS

PPT RELATED TO ARTHROLOGY ACCORDING TO NCISM AYURVEDA

1. PAPER – 01 TOPIC – 11 TERM – 02 MARKS - 10 ARTHROLOGY Dr. Vinay Pareek PPT According to NCISM Syllabus

2. INDEX JOINTS : STRUCTURE , TYPES & MOVEMENTS 3 DESCRIPTION OF JOINTS OF EXTREMITIES WITH THEIR CLINICAL ANATOMY 21 DESCRIPTION OF JOINTS OF INTER-VERTEBRAL JOINTS WITH THEIR CLINICAL ANATOMY 71 DESCRIPTION OF JOINT OF TEMPOROMANDIBULAR JOINT WITH THEIR CLINICAL ANATOMY 75 THANKS 80

3. ARTHROLOGY ARTHROLOGY IS THE SCIENTIFIC STUDY OF JOINTS / ARTICULATIONS. JOINTS SITE WHERE RIGID ELEMEMTS OF THE SKELETON MEET ARE CALLED JOINTS / ARTICULATIONS. JOINT IS A JUNCTION BETWEEN TWO OR MORE BONES OR CARTILAGES. 3

4. CLASSIFICATION OF JOINTS

5. ON THE BASIS OF STRUCTURE FIBROUS BONES CONNECTED BY FIBROUS TISSUE N O JOINT CAVITY SUB – TYPES SUTURES SYNDESMOSES GOMPHOSES CARTILAGINOUS BONES CONNECTED BY CARTILAGE NO JOINT CAVITY SUB – TYPES SYNCHONDROSIS SYMPHYSES SYNOVIAL MOST MOVABLE JOINTS IN THE BODY THERE IS A JOINT CAVITY ARTICULAR CARTILAGE COVERS THE ENDS OF THE OPPOSING BONES ARTICULAR CAPSULE ENCLOSES THE JOINT CAVITY SUB – TYPES PLANE HINGE PIVOT CONDYLOID SADDLE BALL & SOCKET 5

6. SUTURES The suture joints are immovable or fixed joints consisting of a thin layer of dense fibrous connective tissue, which are found between all the bones of the skull except the mandible. These joints also provide strength to the joint by attaching the irregular interlocking edges of cranial bone. Sutures are the sites of active bone growth. 6

7. SYNDESMOSES It is a type of fibrous joint, where two parallel bones are united with each other by interosseous membrane or ligaments based on the gap between the bones. This type of fibrous joint is present in the forearm and leg. In the forearms, the shaft of the radius and ulna are joined strongly by an interosseous membrane. This membrane in the forearms is flexible enough to rotate the forearms. In the legs, the shafts of the tibia and fibula are also joined strongly by an interosseous membrane. The distal tibiofibular joint is made of fibrous connective tissue and ligaments. These ligaments along with the interosseous membrane form the Syndesmosis in the leg. The interosseous membrane in the legs is firm to lock the ankle joint for weight-bearing and stability. 7

8. GOMPHOSES It is a specialized fibrous joint, which provides an independent and firm suspension for each tooth. It fits the teeth into their sockets, which are situated in the maxilla and the mandible. The gomphosis fibrous joints are also referred to as peg and socket joints. 8

9. SYNCHONDROSIS It is a type of cartilaginous joint where  hyaline cartilage completely joins together two bones. Synchondroses are immovable joints and are thus referred to as  synarthroses. 9

10. SYMPHYSIS It is a  fibrocartilaginous  fusion between two bones. It is a type of  cartilaginous joint. It is an  amphiarthrosis , a slightly movable joint. 10

11. TYPES OF SYNOVIAL PLANE JOINT Plane joints permit two or more round or flat bones to move freely together without any rubbing or crushing of bones. This joint is mainly found in those regions where the two bones meet and glide on one another in any of the directions. The lower leg to the ankle joint and the forearm to wrist joint are the two main examples of gliding joints. 11

12. TYPES OF SYNOVIAL HINGE JOINT Hinge joints are like door hinges, where only back and forth movement is possible. Example of hinge joints is the ankle, elbows and knee joints. 12

13. TYPES OF SYNOVIAL PIVOT JOINT In this type of joint, one bone has tapped into the other in such a way that full rotation is not possible. This joint aid in sideways and back-forth movement. An example of a pivotal joint in the neck. 13

14. TYPES OF SYNOVIAL CONDYLOID JOINT Condyloid joints are the joints with two axes which permit up-down and side-to-side motions. The condyloid joints can be found at the base of the index finger, carpals of the wrist, elbow and the wrist joints. This joint is also known as a condylar or ellipsoid joint. 14

15. TYPES OF SYNOVIAL SADDLE JOINT Saddle joint is the biaxial joint that allows the movement on two planes –flexion/extension & abduction/adduction. For example, the thumb is the only bone in the human body having a saddle joint. 15

16. TYPES OF SYNOVIAL BALL & SOCKET JOINT Ball & socket joints possess a rounded, ball-like end of one bone fitting into a cuplike socket of another bone. This organization allows the greatest range of motion, as all movement types are possible in all directions. Examples of ball-and-socket joints are the shoulder and hip joints. 16

17. ON THE BASIS OF FUNCTION SYN - ARTHROSES IMMOVABLE JOINTS (SUTURES) LARGELY RESTRICTED TO THE AXIAL SKELETON AMPHI - ARTHROSES SLIGHTLY MOVABLE JOINTS (INTERVERTEBRAL DISCS) FIBROUS CONNECTION LARGELY RESTRICTED TO THE AXIAL SKELETON DI - ARTHROSES FREELY MOVABLE JOINTS (SYNOVIAL) PREDOMINATE IN THE LIMBS 17

18. SYN-ARTHROSES Synarthrosis (Fibrous) – are fixed joints at which there is no movement. The articular surfaces are joined by tough fibrous tissue. As in the sutures of the skull. 18

19. AMPHI-ARTHROSES In this type of joints the bones are joined by cartilage. It has no joint cavity. Primary cartilaginous joints (synchondrosis, or hyaline cartilage joints):- The bones are united by the plate of hyaline cartilage so that the joint is immovable and strong. These joints are temporary in nature because after a certain age the cartilaginous plate is replaced by bone. E.g. (1) The joint between the 1 st rib and the sternum. (2) The joint between body of the sphenoid and basilar part of the occipital bone. 2. Secondary Cartilagenous joint (Symphysis)- The connecting material in between the articular area is a broad and flat disc of fibro-cartilage. These are permanent joints and allow a limited movement E.g. The intervertebral joint, a portion of the inter vertebral disc is cartilaginous material. Symphysis pubis Manubrio -sternal joint. 19

20. DI-ARTHROSES Joints are characterized by the presence of an articular cartilage, the articular cartilage covers the surface of the articulating bones, but does not bind the bones together. The articular cartilage is hyaline cartilage. A sleeve like articular capsule, which encloses the joint cavity and unites the articulating bones and surrounds the joints. The fibrous capsule and accessory ligaments covers the joint. The fibrous capsule is composed of two layers. The outer layer- It consists of dense connective tissue: it is attached to the periosteum of the articulating bones at a variable distance. The fibres of some fibrous capsules are arranged in parallel bundles such fibres are called ligaments and are gives specific names. The strength of the ligaments is one of the principal factors in holding a bone to the other. The inner layer- The synovial membrane forms the inner layer: it is composed of loose connective tissue with elastic fibres and variable amount of adipose tissue. It secretes the synovial fluid, which lubricates the joint and provides nourishment for the articular cartilage. 20

21. DESCRIPTION OF JOINTS OF EXTREMITIES WITH THEIR CLINICAL ANATOMY

22. JOINTS OF UPPER EXTREMITIES - 22

23. 23 ACROMIOCLAVICULAR JOINT The acromioclavicular joint consists of an articulation between the  lateral end of the clavicle and the  acromion of the scapula . It has two atypical features :- The articular surfaces of the joint are lined with  fibrocartilage . The joint cavity is partially divided by an  articular disc .

24. 24 Ligaments - There are three main ligaments that strengthen the acromioclavicular joint. They can be divided into intrinsic and extrinsic ligaments: Intrinsic : Acromioclavicular ligament – runs horizontally from the acromion to the lateral clavicle. It covers the joint capsule, reinforcing its superior aspect. Extrinsic: Conoid ligament – runs vertically from the coracoid process of the scapula to the conoid tubercle of the clavicle. Trapezoid ligament – runs from the coracoid process of the scapula to the trapezoid line of the clavicle. Collectively, the conoid and trapezoid ligaments are known as the  coracoclavicular ligament .

25. 25 CLINICAL ASPECT Acromioclavicular joint dislocation (also known as a separated shoulder) occurs when the two articulating surfaces of the joint are separated. It is associated with joint  soft tissue damage . It commonly occurs from a direct blow to the joint or a fall on an outstretched hand. The injury is more serious if ligamental rupture occurs ( acromioclavicular  or  coracoclavicular ). If the coracoclavicular ligament is torn, weight of the upper limb is not supported and the shoulder moves inferiorly. This increases the prominence of the clavicle. Management of AC joint dislocation is dependent on injury severity and impact on quality of life. The treatment options range from ice and rest to  ligament reconstruction  surgery. Note: This injury is not to be confused with shoulder dislocation – an injury affecting the glenohumeral joint. Fig. Radiograph of shoulder separation

26. 26 STERNOCLAVICULAR JOINT The sternoclavicular joint consists of the  sternal end  of the clavicle, the manubrium of the sternum, and part of the 1 st  costal cartilage. The articular surfaces are covered with  fibrocartilage  (as opposed to hyaline cartilage, present in the majority of synovial joints). The joint is separated into two compartments by a fibrocartilaginous  articular disc . Clavicle

27. 27 Ligaments - The ligaments of the sternoclavicular joint provide much of its stability. There are four major ligaments: Sternoclavicular ligaments  (anterior and posterior) – these strengthen the joint capsule  anteriorly and posteriorly . Interclavicular ligament  – this spans the gap between the sternal ends of each clavicle and reinforces the joint capsule  superiorly . Costoclavicular ligament  – the two parts of this ligament (often separated by a bursa) bind at the  1 st  rib and cartilage  inferiorly and to the anterior and posterior borders of the  clavicle  superiorly. It is a very strong ligament and is the main stabilizing force for the joint, resisting elevation of the pectoral girdle.

28. 28 CLINICAL ASPECT A dislocation of the sternoclavicular joint is quite rare and requires significant force. The  costoclavicular ligament  and the  articular disc  are highly effective at absorbing and transmitting forces away from the joint into the sternum. There are two major types of dislocation : - Anterior dislocations  are the most common and can happen following a blow to the anterior shoulder which rotates the shoulder backwards. Posterior dislocations  normally result from a force driving the shoulder forwards or from direct impact to the joint. In younger people, the epiphyseal growth plate of the sternal end of the clavicle has not fully closed. In this population, the dislocation is usually accompanied by a fracture through the plate. Fig. Radiograph of a right sternoclavicular joint dislocation.

29. 29 SHOULDER JOINT The shoulder joint is formed by the articulation of the  head  of the humerus with the  glenoid cavity  (or fossa) of the scapula. This gives rise to the alternate name for the shoulder joint – the glenohumeral joint. Like most synovial joints, the articulating surfaces are covered with  hyaline cartilage.  The head of the humerus is much larger than the glenoid fossa, giving the joint a wide range of movement at the cost of inherent instability. To reduce the disproportion in surfaces, the glenoid fossa is deepened by a fibrocartilage rim, called the  glenoid labrum .

30. 30 Joint Capsule and Bursae - The  joint capsule  is a fibrous sheath which encloses the structures of the joint. It extends from the  anatomical neck  of the humerus to the border or ‘rim’ of the glenoid fossa. The joint capsule is lax, permitting greater mobility. The  synovial membrane  lines the inner surface of the joint capsule, and produces synovial fluid to reduce friction between the articular surfaces. To reduce friction in the shoulder joint, several  synovial bursae  are present. A bursa is a synovial fluid filled sac, which acts as a cushion between tendons and other joint structures. The bursae that are important clinically are: Subacromial  – located deep to the deltoid and acromion, and superficial to the supraspinatus tendon and joint capsule. The subacromial bursa reduces friction beneath the deltoid, promoting free motion of the rotator cuff tendons. Subacromial bursitis can be a cause of shoulder pain. Subscapular  – located between the subscapularis tendon and the scapula. It reduces wear and tear on the tendon during movement at the shoulder joint.

31. 31 Ligaments - In the shoulder joint, the ligaments play a key role in stabilizing the bony structures. Glenohumeral ligaments  (superior, middle and inferior) – the joint capsule is formed by this group of ligaments connecting the humerus to the glenoid fossa. They are the main source of stability for the shoulder, holding it in place and preventing it from dislocating anteriorly. They act to stabilize the anterior aspect of the joint. Coracohumeral ligament  – attaches the base of the coracoid process to the greater tubercle of the humerus. It supports the superior part of the joint capsule. Transverse humeral ligament  – spans the distance between the two tubercles of the humerus. It holds the tendon of the long head of the biceps in the intertubercular groove.] Coracoclavicular ligament  – composed of the trapezoid and conoid ligaments and runs from the clavicle to the coracoid process of the scapula. They work alongside the acromioclavicular ligament to maintain the alignment of the clavicle in relation to the scapula. They have significant strength but large forces (e.g. after a high energy fall) can rupture these ligaments as part of an acromio -clavicular joint (ACJ) injury. In severe ACJ injury, the coraco -clavicular ligaments may require surgical repair. The other major ligament is the  coracoacromial ligament.  Running between the acromion and coracoid process of the scapula it forms the   coraco -acromial arch .  This structure overlies the shoulder joint, preventing displacement of the humeral head.

32. 32 Movements - As a  ball and socket  synovial joint, there is a wide range of movement permitted:- Extension (upper limb backwards in sagittal plane)  – posterior deltoid, latissimus dorsi and teres major. Flexion (upper limb forwards in sagittal plane)  – pectoralis major, anterior deltoid and coracobrachialis. Biceps brachii weakly assists in forward flexion. Abduction (upper limb away from midline in coronal plane): The first 0-15 degrees of abduction is produced by the supraspinatus. The middle fibres of the deltoid are responsible for the next 15-90 degrees. Past 90 degrees, the scapula needs to be rotated to achieve abduction – that is carried out by the trapezius and serratus anterior. Adduction (upper limb towards midline in coronal plane)  – pectoralis major, latissimus dorsi and teres major. Internal rotation (rotation towards the midline, so that the thumb is pointing medially)  – subscapularis, pectoralis major, latissimus dorsi, teres major and anterior deltoid. External rotation (rotation away from the midline, so that the thumb is pointing laterally)  – infraspinatus and teres minor. Circumduction (moving the upper limb in a circle)  – produced by a combination of the movements described above.

33. 33 Mobility and Stability - Factors that contribute to mobility: Type of joint  – ball and socket joint. Bony surfaces  – shallow glenoid cavity and large humeral head – there is a 1:4 disproportion in surfaces. A commonly used analogy is the golf ball and tee. Inherent laxity of the  joint capsule . Factors that contribute to stability: Rotator cuff muscles  – surround the shoulder joint, attaching to the tuberosities of the humerus, whilst also fusing with the joint capsule. The resting tone of these muscles act to compress the humeral head into the glenoid cavity. Glenoid labrum  – a fibrocartilaginous ridge surrounding the glenoid cavity. It deepens the cavity and creates a seal with the head of humerus, reducing the risk of dislocation. Ligaments  – act to reinforce the joint capsule, and form the coraco -acromial arch. Biceps tendon  – it acts as a minor humeral head depressor, thereby contributing to stability.

34. 34 CLINICAL ASPECT Clinically, dislocations at the shoulder are described by where the humeral head lies in relation to the  glenoid fossa . Anterior dislocations are the most prevalent (95%), although posterior (4%) and inferior (1%) dislocations can sometimes occur. Superior displacement of the humeral head is generally prevented by the  coraco -acromial arch . An anterior dislocation is usually caused by excessive  extension  and  lateral rotation  of the  humerus . The humeral head is forced anteriorly and inferiorly – into the weakest part of the joint capsule. Tearing of the joint capsule is associated with an increased risk of future dislocations. The  axillary nerve  runs in close proximity to the shoulder joint and around the surgical neck of the humerus, and so it can be damaged in the dislocation or with attempted reduction. Injury to the axillary nerve causes paralysis of the deltoid, and loss of sensation over regimental badge area .

35. 35 ELBOW JOINT It consists of two separate articulations :- Trochlear notch of the  ulna  and the trochlea of the  humerus Head of the  radius  and the capitulum of the  humerus There are many bursae in the elbow, but only a few have clinical importance: Intratendinous  – located within the tendon of the triceps brachii. Subtendinous  – between the olecranon and the tendon of the triceps brachii, reducing friction between the two structures during extension and flexion of the arm. Subcutaneous (olecranon) bursa  – between the olecranon and the overlying connective tissue (implicated in olecranon bursitis).

36. 36 Ligaments - The joint capsule of the elbow is strengthened by ligaments medially and laterally. The  radial collateral  ligament is found on the lateral side of the joint, extending from the  lateral epicondyle , and blending with the annular ligament of the radius (a ligament from the proximal radioulnar joint). The  ulnar collateral  ligament originates from the  medial epicondyle , and attaches to the coronoid process and olecranon of the ulna.

37. 37 CLINICAL ASPECT Bursitis Subcutaneous bursitis:    Repeated friction and pressure on the bursa can cause it to become inflamed. Because this bursa lies relatively superficially, it can also become infected ( e.g cut from a fall on the elbow) Subtendinous bursitis:  This is caused by repeated flexion and extension of the forearm, commonly seen in assembly line workers.  Usually flexion is more painful as more pressure is put on the bursa. Dislocation An elbow dislocation usually occurs when a young child falls on a hand with the elbow flexed. The distal end of the humerus is driven through the weakest part of the joint capsule, which is the anterior side. The ulnar collateral ligament is usually torn and there can also be ulnar nerve involvement. Most elbow dislocations are posterior, and it is important to note that elbow dislocations are named by the position of the ulna and radius, not the humerus. Epicondylitis (Tennis elbow or Golfer’s elbow) Most of the flexor and extensor muscles in the forearm have a  common tendinous origin.  The flexor muscles originate from the medial epicondyle, and the extensor muscles from the lateral. Sportspersons can develop an  overuse strain  of the common tendon – which results in pain and inflammation around the area of the affected epicondyle. Typically, tennis players experience pain in the lateral epicondyle from the common extensor origin. Golfers experience pain in the medial epicondyle from the common flexor origin. This is easily remembered as golfers aim for the ‘middle’ of the fairway, while tennis players aim for the ‘lateral’ line of the court! Supracondylar Fracture A supracondylar fracture usually occurs due to a fall onto on outstretched, extended hand in a child (95%) but more rarely can occur by a direct impact onto a flexed elbow. It is typically a  transverse  fracture, spanning between the two epicondyles in the relatively weak epicondylar region formed by the olecranon fossa and coronoid fossa which lie opposite each other in the distal humerus. Direct damage, or swelling can cause the interference to the blood supply of the forearm via the brachial artery. The resulting  ischaemia  can cause Volkmann’s ischaemic contracture – uncontrolled flexion of the hand, as flexors muscles become fibrotic and short. There also can be damage to the medial, ulnar or radial  nerves . As a result, the neurovascular examination and documentation of all patients presenting with these injuries is vital. Sometimes, the blood supply can be interrupted acutely leading to a ‘pale, pulseless’ limb often in a child, usually requiring emergency surgery.

38. 38 Fig. X-ray of a posterior dislocation of the elbow

39. 39 RADIOULNAR JOINT The radioulnar joints are two locations in which the  radius   and  ulna   articulate in the forearm: Proximal radioulnar joint  – located near the elbow. It is articulation between the head of the radius and the radial notch of the  ulna . Distal radioulnar joint  – located near the  wrist . It is an articulation between the ulnar notch of the  radius  and the ulnar head. Both of these joints are classified as pivot joints, responsible for  pronation  and  supination  of the forearm.

40. 40 Proximal Radioulnar Joint - The proximal radioulnar joint is located immediately distal to the  elbow joint , and is enclosed with in the same  articular capsule . It is formed by an articulation between the head of the radius and the radial notch of the ulna. The radial head is held in place by the  annular radial ligament , which forms a ‘collar’ around the joint. The annular radial ligament is lined with a synovial membrane, reducing friction during movement. Movement is produced by the head of the radius rotating within the annular ligament. There are two movements possible at this joint; pronation and supination. Pronation : Produced by the pronator quadratus and pronator teres. Supination :  Produced by the supinator and biceps brachii.

41. 41 Distal Radioulnar Joint - This distal radioulnar joint is located just proximally to the  wrist joint . It is an articulation between the ulnar notch of the radius, and the ulnar head. In addition to anterior and posterior ligaments strengthening the joint, there is also a fibrocartilaginous ligament present, called the  articular disk . It serves two functions: Binds the radius and ulna together, and holds them together during movement at the joint. Separates the distal radioulnar joint from the wrist joint. Like the proximal radioulnar joint, this is a  pivot  joint, allowing for pronation and supination. The ulnar notch of the radius slides anteriorly over the head of the ulnar during such movements - Pronation : Produced by the pronator quadratus and pronator teres Supination :  Produced by the supinator and biceps brachii

42. 42 Interosseous Membrane - The interosseous membrane is a sheet of  connective tissue  that joins the radius and ulna together between the radioulnar joints. It spans the distance between the medial radial border, and the lateral ulnar border. There are small holes in the sheet, as a conduit for the forearm vasculature. This connective tissue sheet has three major functions:- Holds the radius and ulna together  during pronation and supination of the forearm, providing addition stability. Acts as a site of attachment  for muscles in the anterior and posterior compartments of the forearm. Transfers forces  from the radius to the ulna.

43. 43 CLINICAL ASPECT Fractures to the Radius and Ulna Although the radius and ulnar are two distinct and separate bones, when dealing with injuries to the forearm, they can be thought of as a  ring . A ring, when broken, usually breaks in two places. The best way of illustrating with is with a polo mint – it is very difficult to break one side without breaking the other. This means that a fracture to the radius or the ulna usually causes a fracture or dislocation of the other bone. There are two classical fractures: Monteggia fracture  – fracture of the proximal ulna AND dislocation of the radial head at the proximal radioulnar joint. Galeazzi fracture  – fracture of the distal radius AND dislocation of the ulnar head at the distal radioulnar joint.

44. 44 WRIST JOINT The wrist joint is formed by: Distally  – The proximal row of the carpal bones (except the pisiform). Proximally –  The distal end of the radius, and the articular disk. The ulna is not part of the wrist joint  – it articulates with the radius, just proximal to the wrist joint, at the distal radioulnar joint. It is prevented from articulating with the carpal bones by a fibrocartilaginous ligament, called the articular disk, which lies over the superior surface of the ulna. Together, the carpal bones form a  convex  surface, which articulates with the  concave  surface of the radius and articular disk.

45. 45 Ligaments - There are four ligaments of note in the wrist joint, one for each side of the joint Palmar radiocarpal  – Found on the palmar (anterior) side of the hand. It passes from the radius to both rows of carpal bones. Its function, apart from increasing stability, is to ensure that the hand follows the forearm during supination. Dorsal radiocarpal  – Found on the dorsum (posterior) side of the hand. It passes from the radius to both rows of carpal bones. It contributes to the stability of the wrist, but also ensures that the hand follows the forearm during pronation. Ulnar collateral  – Runs from the ulnar styloid process to the triquetrum and pisiform. It acts to prevent excessive radial (lateral) deviation of the hand. Radial collateral  – Runs from the radial styloid process to the scaphoid and trapezium. It acts to prevent excessive ulnar (medial) deviation of the hand. PR RC UC

46. 46 Movements of the Wrist Joint - The wrist is an  ellipsoidal  (condyloid) type synovial joint, allowing for movement along two axes. This means that flexion, extension, adduction and abduction can all occur at the wrist joint. All the movements of the wrist are performed by the muscles of the forearm. Flexion   –  Produced mainly by the flexor carpi ulnaris , flexor carpi radialis, with assistance from the flexor digitorum superficialis. Extension   –  Produced mainly by the extensor carpi radialis longus and brevis, and extensor carpi ulnaris , with assistance from the extensor digitorum. Adduction   –  Produced by the extensor carpi ulnaris and flexor carpi ulnaris Abduction   –  Produced by the abductor pollicis longus, flexor carpi radialis, extensor carpi radialis longus and brevis.

47. 47 CLINICAL ASPECT Scaphoid Fracture - The scaphoid bone of the hand is the most commonly fractured  carpal bone  – typically by falling on an outstretched hand (FOOSH). In a fracture of the scaphoid, the characteristic clinical feature is pain and tenderness in the  anatomical snuffbox . The scaphoid is at particular risk of  avascular necrosis  after fracture because of its so-called ‘retrograde blood supply’ which enters at its distal end. This means that a fracture to the middle (or ‘waist’) of the scaphoid may interrupt the blood supply to the proximal part of the scaphoid bone rendering it avascular. Patients with a missed scaphoid fracture are likely to develop  osteoarthritis  of the wrist in later life. Anterior Dislocation of the Lunate - This can occur by falling on a  dorsiflexed  wrist. The lunate is forced anteriorly, and compresses the carpal tunnel, causing the symptoms of carpal tunnel syndrome. This manifests clinically as paraesthesia in the sensory distribution of the median nerve and weakness of thenar muscles. The lunate can also undergo avascular necrosis, so immediate clinical attention to the fracture is needed. Colles ’ Fracture - The Colles ’ fracture is the  most common  fracture involving the wrist, caused by falling onto an outstretched hand. The radius fractures, with the distal fragment being displaced  posteriorly . The ulnar styloid process can also be damaged, and is avulsed in the majority of cases. This clinical condition produces what is known as the ‘dinner fork deformity’.

48. 48 Scaphoid Fracture Anterior Dislocation of the Lunate Colles ’ Fracture

49. JOINTS OF LOWER EXTREMITIES - 49

50. 50 HIP JOINT The hip joint consists of an articulation between the  head of femur  and  acetabulum  of the pelvis. The acetabulum is a cup-like depression located on the inferolateral aspect of the pelvis. Its cavity is deepened by the presence of a fibrocartilaginous collar – the  acetabular labrum . The head of femur is hemispherical, and fits completely into the concavity of the acetabulum. Both the acetabulum and head of femur are covered in  articular  cartilage, which is thicker at the places of weight bearing. The capsule of the hip joint attaches to the edge of the acetabulum proximally. Distally, it attaches to the intertrochanteric line anteriorly and the femoral neck posteriorly.

51. 51 There are three main extracapsular ligaments, continuous with the outer surface of the hip joint capsule: Iliofemoral ligament  – arises from the anterior inferior iliac spine and then bifurcates before inserting into the intertrochanteric line of the femur. It has a ‘Y’ shaped appearance, and prevents hyperextension of the hip joint. It is the strongest of the three ligaments. Pubofemoral  – spans between the superior pubic rami and the intertrochanteric line of the femur, reinforcing the capsule anteriorly and inferiorly. It has a triangular shape, and prevents excessive abduction and extension. Ischiofemoral –   spans between the body of the ischium and the greater trochanter of the femur, reinforcing the capsule posteriorly. It has a spiral orientation, and prevents hyperextension and holds the femoral head in the acetabulum.

52. 52 Movements and Muscles - The movements that can be carried out at the hip joint are listed below, along with the principle muscles responsible for each action: Flexion  – iliopsoas, rectus femoris, sartorius, pectineus Extension  – gluteus maximus; semimembranosus, semitendinosus and biceps femoris (the hamstrings) Abduction  –  gluteus medius , gluteus minimus , piriformis and tensor fascia latae Adduction  – adductors longus, brevis and magnus, pectineus and gracilis Lateral rotation  – biceps femoris, gluteus maximus, piriformis, assisted by the obturators, gemilli and quadratus femoris. Medial rotation  – anterior fibres of gluteus medius and minimus , tensor fascia latae The degree to which flexion at the hip can occur depends on whether the knee is flexed – this relaxes the  hamstring muscles , and increases the range of flexion. Extension at the hip joint is limited by the joint capsule and the  iliofemoral ligament . These structures become taut during extension to limit further movement.

53. 53 CLINICAL ASPECT Posterior dislocation (90%)  – the femoral head is forced posteriorly, and tears through the inferior and posterior part of the joint capsule, where it is at its weakest. The affected limb becomes shortened and medially rotated. The sciatic nerve runs posteriorly to the hip joint, and is at risk of injury (occurs in 10-20% of cases). This is often associated with anterior femoral head and posterior wall fractures.

54. 54 KNEE JOINT The knee joint consists of two articulations – tibiofemoral and patellofemoral. The joint surfaces are lined with  hyaline  cartilage and are enclosed within a single joint cavity. Tibiofemoral  – medial and lateral condyles of the femur articulate with the tibial condyles. It is the weight-bearing component of the knee joint. Patellofemoral  – anterior aspect of the distal femur articulates with the patella. It allows the tendon of the quadriceps femoris (knee extensor) to be inserted directly over the knee – increasing the efficiency of the muscle. As the patella is both formed and resides within the quadriceps femoris tendon , it provides a fulcrum to increase power of the knee extensor and serves as a stabilising structure that reduces frictional forces placed on femoral condyles.

55. 55 Menisci - The medial and lateral menisci are  fibrocartilage  structures in the knee that serve two functions: To  deepen  the articular surface of the tibia, thus increasing stability of the joint. To act as  shock absorbers  by increasing surface area to further dissipate forces. They are C shaped and attached at both ends to the  intercondylar  area of the tibia. In addition to the intercondylar attachment, the  medial meniscus  is fixed to the tibial collateral ligament and the joint capsule. Damage to the tibial collateral ligament usually results in a medial meniscal tear. The  lateral meniscus  is smaller and does not have any extra attachments, rendering it fairly mobile.

56. 56 Bursae - There are four bursae found in the knee joint: Suprapatellar bursa  – an extension of the synovial cavity of the knee, located between the quadriceps femoris and the femur. Prepatellar bursa  – found between the apex of the patella and the skin. Infrapatellar bursa  – split into deep and superficial. The deep bursa lies between the tibia and the patella ligament. The superficial lies between the patella ligament and the skin. Semimembranosus bursa  – located posteriorly in the knee joint, between the semimembranosus muscle and the medial head of the gastrocnemius.

57. 57 Ligaments - The major ligaments in the knee joint are: Patellar ligament  – a continuation of the quadriceps femoris tendon distal to the patella. It attaches to the tibial tuberosity. Collateral ligaments  – two strap-like ligaments. They act to stabilize the hinge motion of the knee, preventing excessive medial or lateral movement Tibial (medial) collateral ligament – wide and flat ligament, found on the medial side of the joint. Proximally, it attaches to the medial epicondyle of the femur, distally it attaches to the medial condyle of the tibia. Fibular (lateral) collateral ligament – thinner and rounder than the tibial collateral, this attaches proximally to the lateral epicondyle of the femur, distally it attaches to a depression on the lateral surface of the fibular head. Cruciate Ligaments  – these two ligaments connect the femur and the tibia. In doing so, they cross each other, hence the term ‘cruciate’ (Latin for like a cross) Anterior cruciate ligament  –  attaches at the anterior intercondylar region of the tibia where it blends with the medial meniscus. It ascends posteriorly to attach to the femur in the intercondylar fossa. It prevents anterior dislocation of the tibia onto the femur. Posterior cruciate ligament  –  attaches at the posterior intercondylar region of the tibia and ascends anteriorly to attach to the anteromedial femoral condyle. It prevents posterior dislocation of the tibia onto the femur.

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59. 59 CLINICAL ASPECT Collateral Ligaments - Injury to the collateral ligaments is the most common pathology affecting the knee joint. It is caused by a force being applied to the  side  of the knee when the foot is placed on the ground. Damage to the collateral ligaments can be assessed by asking the patient to medially  rotate  and laterally rotate the leg. Pain on medial rotation indicates damage to the medial ligament, pain on lateral rotation indicates damage to the lateral ligament. If the medial collateral ligament is damaged, it is more than likely that the medial meniscus is torn, due to their attachment. Bursitis - Friction between the skin and the patella cause the prepatellar bursa to become inflamed, producing a swelling on the anterior side of the knee. This is known as  housemaid’s knee . Similarly, friction between the skin and tibia can cause the infrapatellar bursae to become inflamed, resulting in what is known as  clergyman’s knee  (classically caused by clergymen kneeling on hard surfaces during prayer).

60. 60 Cruciate Ligaments - The anterior cruciate ligament (ACL) can be torn by  hyperextension  of the knee joint, or by the application of a large force to the back of the knee with the joint partly flexed. To test for this, you can perform an anterior drawer test, where you attempt to pull the tibia forwards, if it moves, the ligament has been torn. The most common mechanism of posterior cruciate ligament (PCL) damage is the ‘dashboard injury’. This occurs when the knee is  flexed , and a large force is applied to the shins, pushing the tibia posteriorly. This is often seen in car accidents, where the knee hits the dashboard. The posterior cruciate ligament can also be torn by hyperextension of the knee joint, or by damage to the upper part of the tibial tuberosity. To test for PCL damage, perform the posterior draw test. This is where the clinician holds the knee in flexed position, and pushes the tibia posteriorly. If there is movement, the ligament has been torn. Unhappy Triad (Blown Knee) - As the medial collateral ligament is attached to the medial meniscus, damage to either can affect both structure’s functions. A lateral force to an extended knee, such as a rugby tackle, can rupture the medial collateral ligament, damaging the medial meniscus in the process. The ACL is also affected, which completes the ‘unhappy triad’.

61. 61 TIBIOFIBULAR JOINT 1. Proximal - Articulating Surfaces - The proximal tibiofibular joint is formed by an articulation between the head of the fibula and the lateral condyle of the tibia. It is a  plane  type synovial joint; where the bones to glide over one another to create movement. Supporting Structures - The joint capsule receives additional support from: Anterior and posterior superior tibiofibular ligaments  – span between the fibular head and lateral tibial condyle Lateral collateral ligament of the knee joint Biceps femoris  – provides reinforcement as it inserts onto the fibular head.

62. 62 TIBIOFIBULAR JOINT 2. Distal - Articulating Surfaces - The  distal (inferior) tibiofibular joint  consists of an articulation between the fibular notch of the distal tibia and the fibula. It is an example of a  fibrous joint , where the joint surfaces are by bound by tough, fibrous tissue. Supporting Structures - The distal tibiofibular joint is supported by: Interosseous membrane  – a fibrous structure spanning the length of the tibia and fibula. Anterior and posterior inferior tibiofibular ligaments  Inferior transverse tibiofibular ligament  – a continuation of the posterior inferior tibiofibular ligament.

63. 63 CLINICAL ASPECT Dislocation of the Proximal Tibiofibular Joint - A  proximal tibiofibular joint dislocation  is a rare and often missed diagnosis. It accounts for <1% of all knee injuries. The typical mechanism of injury is a fall onto an  adducted and flexed knee . They can also occur as a result of high-energy trauma. Common clinical features include inability to weight-bear, lateral knee pain and tenderness/ prominence of the fibular head . This type of injury is typically treated with a  closed reduction  (a reduction is a procedure to restore the joint to its natural alignment). Complications of proximal tibiofibular joint dislocation include common fibular nerve injury (the nerve winds around the neck of the fibula), and recurrent dislocation.

64. 64 ANKLE JOINT The ankle joint is formed by  three bones ; the tibia and fibula of the leg, and the talus of the foot: The tibia and fibula are bound together by strong  tibiofibular ligaments . Together, they form a bracket shaped socket, covered in hyaline cartilage. This socket is known as a mortise. The  body of the talus  fits snugly into the mortise formed by the bones of the leg. The articulating part of the talus is wedge shaped – it is broad anteriorly, and narrow posteriorly.

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66. 66 Medial Ligament - The  medial ligament  (or deltoid ligament) is attached to the medial malleolus (a bony prominence projecting from the medial aspect of the distal tibia). It consists of four ligaments, which fan out from the malleolus, attaching to the talus, calcaneus and navicular bones. The primary action of the medial ligament is to resist  over-eversion  of the foot. Lateral Ligament - The  lateral ligament  originates from the lateral malleolus (a bony prominence projecting from the lateral aspect of the distal fibula). It resists over-inversion of the foot, and is comprised of three distinct and separate ligaments: Anterior talofibular  – spans between the lateral malleolus and lateral aspect of the talus. Posterior talofibular  – spans between the lateral malleolus and the posterior aspect of the talus. Calcaneofibular  – spans between the lateral malleolus and the calcaneus.

67. 67 CLINICAL ASPECT A Pott’s fracture is a term used to describe a  bimalleolar  (medial and lateral malleoli) or  trimalleolar  (medial and lateral malleoli, and distal tibia) fracture. This type of injury is produced by forced eversion of the foot. It occurs in a series of stages: Forced eversion pulls on the medial ligaments, producing an avulsion fracture of the medial malleolus. The talus moves laterally, breaking off the lateral malleolus. The tibia is then forced anteriorly, shearing off the distal and posterior part against the talus.

68. 68 SUBTALAR JOINT The  subtalar joint  is an articulation between two of the tarsal bones in the foot – the talus and calcaneus. The joint is classed structurally as a  synovial  joint, and functionally as a  plane synovial  joint. The subtalar joint is formed between two of the tarsal bones: Inferior surface of the body of the talus – the  posterior talar articular surface. Superior surface of the calcaneus – the  posterior calcaneal articular facet. As is typical for a synovial joint, these surfaces are covered by  articular cartilage .

69. 69 The subtalar joint is enclosed by a  joint capsule , which is lined internally by synovial membrane and strengthened externally by a fibrous layer. The capsule is also supported by three ligaments: Posterior talocalcaneal ligament Medial talocalcaneal ligament Lateral talocalcaneal ligament An additional ligament – the  interosseous talocalcaneal ligament  – acts to bind the talus and calcaneus together. It lies within the  sinus tarsi  (a small cavity between the talus and calcaneus), and is particularly strong; providing the majority of the ligamentous stability to the joint.

70. 70 CLINICAL ASPECT Calcaneal Fracture The calcaneus is often fractured in a ‘ crush ‘ type injury. The most common mechanism of damage is falling onto the heel from a height – the talus is driven into the calcaneus. The bone can break into several pieces, known as a  comminuted  fracture. Upon x-ray imaging, the calcaneus will appear shorter and wider. A calcaneal fracture can cause chronic problems, even after treatment. The subtalar joint is usually disrupted, causing the joint to become  arthritic . The patient will experience pain upon inversion and eversion – which can make walking on uneven ground particularly painful.

71. DESCRIPTION OF JOINTS OF INTER VERTEBRAL JOINTS WITH THEIR CLINICAL ANATOMY

72. 72 INTER VERTEBRAL JOINT The mobile vertebrae articulate with each other via joints between their bodies and articular facets:- Left and right superior articular facets articulate with the vertebra above. Left and right inferior articular facets articulate with the vertebra below. Vertebral bodies indirectly articulate with each other via the intervertebral discs. The vertebral body joints are  cartilaginous  joints, designed for weight-bearing. The articular surfaces are covered by hyaline cartilage, and are connected by the intervertebral disc. Two ligaments strengthen the vertebral body joints: the  anterior and posterior longitudinal ligaments , which run the full length of the vertebral column. The anterior longitudinal ligament is thick and prevents hyperextension of the vertebral column. The posterior longitudinal ligament is weaker and prevents hyperflexion. The joints between the articular facets, called facet joints, allow for some gliding motions between the vertebrae. They are strengthened by several ligaments:- Ligamentum flavum  – extends between lamina of adjacent vertebrae. Interspinous and supraspinous  – join the spinous processes of adjacent vertebrae. The interspinous ligaments attach between processes, and the supraspinous ligaments attach to the tips. Intertransverse ligaments  – extends between transverse processes.

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74. 74 CLINICAL ASPECT There are several clinical syndromes resulting from an abnormal curvature of the spine: Kyphosis  – excessive thoracic curvature, causing a hunchback deformity. Lordosis  – excessive lumbar curvature, causing a swayback deformity. Scoliosis  – lateral curvature of the spine, usually of unknown cause. Cervical spondylosis  – decrease in the size of the intervertebral foramina, usually due to degeneration of the joints of the spine. The smaller size of the intervertebral foramina puts pressure on the exiting nerves, causing pain. SCOLIOSIS

75. DESCRIPTION OF JOINT OF TEMPOROMANDIBULAR JOINT WITH THEIR CLINICAL ANATOMY

76. 76 TEMPOROMANDIBULAR JOINT The  temporomandibular joint  (TMJ) is formed by the articulation of the mandible and the temporal bone of the cranium. It is located anteriorly to the tragus of the ear, on the lateral aspect of the face. The temporomandibular joint consists of articulations between  three  surfaces; the mandibular fossa and articular tubercle (from the squamous part of the  temporal bone ), and the head of mandible. This joint has a unique mechanism; the articular surfaces of the bones never come into contact with each other – they are separated by an  articular disk . The presence of such a disk splits the joint into  two  synovial joint cavities, each lined by a synovial membrane. The articular surface of the bones are covered by  fibrocartilage , not hyaline cartilage.

77. 77 Ligaments - There are three  extracapsular  ligaments. They act to stabilize the temporomandibular joint. Lateral ligament  – runs from the beginning of the articular tubule to the mandibular neck. It is a thickening of the joint capsule, and acts to prevent posterior dislocation of the joint. Sphenomandibular ligament  – originates from the sphenoid spine, and attaches to the mandible. Stylomandibular ligament  – a thickening of the fascia of the parotid gland. Along with the facial muscles, it supports the weight of the jaw.

78. 78 Movements - Movements at this joint are produced by the muscles of mastication, and the hyoid muscles. The two divisions of the temporomandibular joint have different functions. Protrusion and Retraction The upper part of the joint allows  protrusion and retraction  of the mandible – the anterior and posterior movements of the jaw. The  lateral pterygoid muscle  is responsible for protrusion (assisted by the medial pterygoid), and the posterior fibres of the temporalis perform retraction. A lateral movement (i.e. for chewing and grinding) is achieved by alternately protruding and retracting the mandible on each side. 2. Elevation and Depression The lower part of the joint permits elevation and depression of the mandible; opening and closing the mouth. Depression is mostly caused by  gravity.  However, if there is resistance, the digastric, geniohyoid, and mylohyoid muscles assist. Elevation is very  strong  movement, caused by the contraction of the temporalis, masseter, and medial pterygoid muscles.

79. 79 CLINICAL ASPECT Temporomandibular Joint Dislocation A  dislocation  of the temporomandibular joint can occur via a blow to the side of the face, yawning, or taking a large bite. The head of the mandible ‘slips’ out of the mandibular fossa, and is pulled anteriorly. The patient becomes unable to close their mouth. The facial and  auriculotemporal nerves  run close to the joint, and can be damaged if the injury is high-energy. Posterior dislocations  of the TMJ are possible, but very rare, requiring a large amount of force to overcome the postglenoid tubercle and strong intrinsic lateral ligament.

80. Thank You Dr. VINAY PAREEK ( M.D. RACHANA SHARIR) [email protected] 09462479053