Anatomical terminology

Anatomical terms
Most of today’s medical terms are formed from Greek and Latin roots,
few have Arabic origins. All terms used in medicine to describe human
body are standardized in an international reference
guide, Terminologia Anatomica. These terms are the foundation of
medical terminology and it is important that doctors and scientists
throughout the world use the same name for each structure. Even
though different nations elaborate and use their own set of medical
terms, based on standard Latin terms, the communication and
progress in the medical field are possible thanks to the common and
precise scientific language. Hence, you should always rely on this
resource guide, which lists the proper anatomical terms and
organizes them for all body systems. Similar resources are available
for histological and embryological terminology.
Terminologia anatomica
Eponyms
The general rule of the Terminologia Anatomica system is that there
should be one term for each structure and that the term should have
some informative and descriptive value. The eponyms, i.e., terms
derived from the name of a real or mythical individual, are often used
in medicine, but are not recommended, because they do not provide
anatomical context and often are not standardized.

Take these three terms as an example: Bertin’s bone, Bertin’s column,

Bertin’s ligament. The first one is not actually a bone, but a part of the
sphenoid bone, called sphenoidal concha. The second term refers to
the structure located in the kidney (renal column), while the third term
indicates a ligament strengthening the coxofemoral joint, properly
called iliofemoral ligament. Hence, these eponyms give no indication
as to the type or localization of the structure. Another problem with
eponyms is that, in some cases, the name given to a certain structure
is not actually that of the researcher who described it first. Also, the
correct pronounciation of such terms requires the knowledge of
person’s nationality. All in all, it is best to avoid eponyms while
describing human anatomy.

Anatomical position
Description of the body, with its parts, regions, and organs, requires an
initial point of reference and the use of common descriptors. Hence, in
anatomy, and in medical practice, it is assumed that the body is in an
anatomical position.

In the anatomical position, an individual stands upright in front of an

examiner, with the lower limbs close together, the feet parallel and
slightly separated, and the toes directed anteriorly; the head is leveled
and the eyes look forward; the upper limbs run down at the sides of
the body with the palms facing forward.

All the anatomical descriptors refer to the body in the anatomical

position, even if only parts or sections of the body are being
considered. In practice, anatomists identify and locate body
structures, while health-care professionals observe and locate any
change to them, using descriptive terms based on the premise that the
body is the anatomical position. Hence, you should always keep that
position in mind, in order to be able to do the same throughout your
anatomy studies.

Anatomical planes
Anatomists typically study and describe human body and organs in
dissection, often referring to slices or sections, performed along
different planes; similarly, radiologists examine human body by means
of diagnostic imaging techniques in different planes.

A horizontal plane (also called transverse plane) cuts perpendicularly

across the long axis of the body, hence it separates the body into
superior (upper) and inferior (lower) parts. The horizontal planes lie at
right angle to the coronal and sagittal planes. It is the most common
plane used in computed tomography and magnetic resonance imaging;
radiologists often call it an axial plane and use it obtain transverse
sectional images (scans) of the body for study.

A coronal plane, also called a frontal plane, is a vertical plane passing

through the body from side to side, thus dividing it into anterior and
posterior parts. The coronal planes lie perpendicular to sagittal planes.

A sagittal plane, is a vertical plane passing through the body from the
front to the back and divides the structures into left and right parts.
The sagittal planes lie perpendicular to coronal planes. The sagittal
plane that divides the body into right and left halves (equal parts) is
referred to as the median plane.
Anatomical planes
Sections
Sections may be obtained by anatomical sectioning or medical
imaging techniques. The three anatomical sections used for displaying
internal structures are the longitudinal, transverse and oblique
sections.

Regardless of the position of the body, a longitudinal section runs

lenghtwise or parallel to the long axis, while a transverse section
(cross section) runs perpendicular to the long axis of the whole body
or body part, hence crossing it at right angle. Finally, an oblique
section does not run along any standard anatomical plane.

It is worth noting that a transverse section of the foot is made in the

coronal plane of the body (the long axis of the foot runs horizontally
and the transverse section must be perpendicular to it), while the
same section of the trunk runs along the horizontal plane of the body
(the transverse section is done perpendicularly to the long axis of the
trunk, which runs vertically). Importantly, a longitudinal section can be
actually obtained in any plane, as long as it runs along the long axis of
the body or its part, and not only in two standard anatomical vertical
planes, i.e. coronal and sagittal planes.

While there is only one median plane, the number of horizontal, coronal
and sagittal planes sectioning the body is unlimited. For this reason, it
is important to specify the location or level of every
described section (e.g. transverse section through the forth thoracic
vertebra).
Transverse sections
Anatomical position is a stance in which

a person stands erect with their feet flat

on the floor arms at the sides and palms

and face facing forward. This position

provides precise and standard reference

for anatomical description and dissection

so unless stated otherwise in the text

we should always assume that all anatomical

descriptions referred to this anatomical

position regardless of the actual subjects

position during the examination. It is

important to note and to learn to acknowledge

this fact during a medical examination

that if a person is facing you in anatomical

position their left will be on your right

and vice versa. The same is true for most

anatomical illustrations that show organs

in arterial view. The position of the forearm

is particularly important in the description

of the upper limb anatomy and movements.

In the anatomical position the palms as

we said face forward or up if the elbow

is flexed and the forearm is said to be

supine in the opposite position when the

palm faces posteriorly or down the forearm

is [ ]. This movement is important in the

description of the anatomy of the upper

limbs and the forearm in particular as

in the supine position the two forearm

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to it is solely in the wrist in topographic

anatomy all the descriptions of muscles

nerves and vessels in the forearm assume

that the forearm in the anatomical position

so it is supine and since I’ve just talked

about the upper limb it is important to

note that the term arm commonly used to

talk about the upper limb was a hole in

anatomy the notes just departs between

the shoulder and elbow the same is true

for the leg which in anatomy indicates

just a part of the lower limb between the

knee and the foot and not the entire lower

limb. The trunk part of the external skeleton

includes thought arcs in the abdomen compared

to limbs terms of movement have limited

applications here but another aspect of

descriptive anatomy emerges so called reference

lines. These lines are drawn on the surface

based on the location of the palpable skeletal

landmarks and they are used in order to

specify the location of the structures

lying within body cavities. One way of

referring to the location of abdominal

organs also used to describe for instance

the sight of abdominal pain or abnormality

is to divide abdominal region into acquaintance

to do this we need just two perpendicular

lines and they intersect at umbilicus so

they divide the abdomen into a right upper

right lower left upper and left lower acquaintance

but the optimist can also be divided into

nine regions defined by four lines two

vertical lines that are called Meet clavicle

because each passes through the mid-point

of the clavicle and then a superior horizontal

line which is called the sub costal line

because it connects the inferior borders

of the lowest costal cottages and inferior

horizontal line which is called into tubercular

line it actually passes between the tuberculosis

on the Ottoman mansion of the hip bone

and this are two points on the bone that

you touch when you are told to put your

hands on your hips. The three lateral regions

of discreet from upper to lower are their

hype or Quantum flung or Lotte and region

and groin or in Greenock region are the

three media the region’s again from upper

to lower are the epic gastric umbilical

and [ ] pubic regions obviously you will

here and use these terms throughout your

medical studies in practice so make sure

to remember and visualise them. Now you

can use the following slides to review

some common anatomical terms.

 Anatomical terms of
position and movements
Terms of position and relationship
Directional terms are used to describe the location of one body part
with respect to another. They can be arranged as pairs of opposites.

Two ipsilateral structures lie on the same side of the body, while those
on the opposite sides (left and right) are called contralateral. Superior
refers to a structure
located above
another structure in
the body in the
anatomical position,
hence nearer the
head; inferior refers
to a structure that is
below another
structure, or closer
to the feet. Anterior
means in front of
another structure,
or closer to the front
surface of the body,
while posterior
means behind
another structure or
toward the back.
Medial is used to
indicate that a
structure lies closer
to the median plane
of the body; lateral
denotes that a
structure is further away from the median plane than another
structure. Proximal refers to a part that is closer to, while distal is
further away from, the origin or attachment point of a structure.
Terms of position and relationship

Terms of movements - flexion and extension

Movements occur in anatomical planes and around axes. Flexion and
extension occur in a sagittal plane, around a transverse axis. Flexion,
generally, is a reduction in the angle between two body parts and a
movement in an anterior direction, while extension is related to a

straightening or an increase in the angle between two body parts,

caused by a movement in a posterior direction.

Two exceptions are evident in humans, i.e. the knee and ankle joints,
which acquired particular orientation related to the upright position.
Flexion of the knee involves posterior movement and extension
involves anterior movement of the leg. An upward movement at the
ankle joint, lifting only the front of the foot and toes off the ground, is a
dorsiflexion, while plantarflexion is a downward movement of the foot.

Flexion and extension

Terms of movements - abduction and adduction

Abduction and adduction occur in a frontal plane, around a sagittal
(anteroposterior) axis. Abduction, generally, is a movement away from
the median plane of the body, while adduction moves a body part
toward it.

When movements of the digits are considered, the reference plane is

the median plane of
the hand or foot and
it is assumed that it
runs through the
3rd (middle) finger
or the 2nd toe. For
instance, abduction
of fingers means
spreading them
apart away from,
while adduction
means bringing the
fingers together
toward, the middle
finger.

<-Abduction and
adduction
 Terms of movement -
rotation
Rotation of a body part occurs
around its long axis. Medial
rotation, also called internal
rotation, brings the anterior
surface of the limb closer to the
median plane of the body.
Movement in the opposite
direction, which brings the
anterior surface of the limb
away from the median plane, is
called lateral or external
rotation. When the head rotates
around the longitudinal axis to
face sideways, the movement is
simply called lateral, left or
right, rotation of the head and
neck.

Rotation

Terms of movement -
rotation of hand and feet
Specific terms are used to describe rotational movements of the distal
upper limb and feet. Rotational movements of the forearm and hand
are called pronation and supination. Pronation moves the hand so that
the palm faces posteriorly, when starting from the anatomical position,
or inferiorly, when the elbow is flexed. Supination is the opposite
movement, directing the palm of the hand, respectively, anteriorly or
superiorly. If you find it difficult to associate these two terms with the
movements they describe, remember that you can hold a coffee cup in
the supinated hand, but it is prone to fall if you pronate your hand.

Rotational movements of the feet are called eversion and inversion.

Eversion moves the feet so that the sole turns outwards, i.e. away
from the body median plane, raising the lateral margin of the foot.
Eversion is not an isolated movement of the foot, as it is associated
with dorsiflexion and abduction of the foot; this combined movement is
called pronation of the foot. Inversion is the opposite movement,
which rotates the sole inwards, i.e. toward the median plane, raising
the medial margin of the foot. When the foot inverts, it also adducts
and plantarflexes; this combined movement produces supination of the
foot.

Rotation of hand and feet

Movements of thumb
Movements of the thumb occur in the planes different from that of
other digits, since the thumb is medially rotated by 90o at its
carpometacarpal joint in the anatomical position. Hence, flexion and
extension occur in a coronal plane, while abduction and adduction
occur in a sagittal plane. Opposition is a particular and complex
 movement that brings the tip of the thumb in contact with the pads of
other fingers.

Reference lines - vertical lines of the thorax

It is important to know the location of body organs and their projection
on the body surface, so that an examiner knows where to auscultate,
percuss, or palpate them and can document precisely the location of
pathological findings during a physical examination. To that scope,
several imaginary lines on the anterior or posterior trunk wall are often
used as reference.

Vertical lines of the thorax:

 anterior median line – lies in the median plane over the sternum; the
apex beat of the heart is typically felt in the 5th left intercostal space, 9 cm
laterally from the anterior midline;

 sternal line – runs next to the lateral margin of the sternum;

 midclavicular line – runs from the midpoint of the clavicle;

 parasternal line – lies midway between the sternal and midclavicular

lines;

 anterior axillary line – runs from the anterior axillary fold, formed by the
margin of the pectoralis major muscle;

 midaxillary line – runs from the apex of the axillary fossa;

 posterior axillary line – runs from the posterior axillary fold, formed by
the margin of the lattissimus dorsi muscle;

 scapular line – passes through the inferior angle of the scapula;

 paraverterbal line – typically used in radiology, runs along the tips of

the transverse processes;

 posterior median line – along the tips of the spinous processes of the
vertebrae.
 Vertical lines thoracic wall

Reference lines - transverse planes of the trunk

Transverse planes of the trunk:

 transverse thoracic plane – runs horizontally across the sternal angle

(at the junction between the manubrium and body of the sternum) and the
intervertebral disc between the 4th and 5th thoracic vertebrae; the trachea
bifurcates at this level;

 transpyloric plane – runs horizontally midway between the superior

border of the manubrium of the sternum and the superior border of the pubic
symphysis, typically crossing the 1st lumbar vertebra; it is termed so,
 because it commonly crosses the pylorus (the distal end of the stomach)
when a patient is lying down;

 subcostal plane – passes through the lowermost palpable points of the

costal arch, which correspond to the costal cartilages of the 10th ribs;

 transumbililcal plane - passes through the umbilicus and generally

marks the level of the disc between the 3rd and 4th lumbar vertebrae;

 supracristal plane – passes through the uppermost palpable points of

the iliac crest, typically crossing the 4th lumbar vertebra;

 intertubercular plane – passes through the iliac tubercles, which can

be palpated approximately 5 cm posterior to the anterior superior iliac spine
on each side, typically crossing the 5th lumbar vertebra;

 interspinous plane – passes through the easily palpated left and right
anterior superior iliac spines.
Transverse lines abdominal wall

Abdominal regions
For general descriptions, clinicians usually divide the abdomen into for
quadrants, using the vertical anterior median line and horizontal
transumbilical line. These lines, intersecting at a right angle, create 4
quadrants (right and left upper and lower).

For more accurate descriptive and diagnostic purposes, two vertical

lines and two horizontal lines can be drawn in order to create nine
abdominal regions. The vertical lines are the right and left
midclavicular lines, while the horizontal lines run along the subcostal
(or, alternatively, transpyloric) and intertubercular (or interspinous)
planes. The abdominal regions are, on either side, right and left
hypochondrium, flank or lateral region, and groin or inguinal region;
centrally located regions are called epigastric region or epigastrium,
umbilical region, and pubic region or hypogastrium.

Correct use of these descriptive quadrants and regions is essential in

clinical practice, as each area overlies the parts of abdominopelvic
cavity containing different organs. The knowledge of their location
allows examination of single organs and correlation of pain to specific
structures (in the referred pain, though, the pain and the organ where
the pathology occurred may lie in different regions).
Abdominal quadrants and regions

Summary
Anatomical terms are descriptive terms standardized in an
international reference guide, Terminologia Anatomica, and should be
used worldwide. Colloquial terminology can be used to communicate
with patients.

Anatomical directional terms refer to the body in the anatomical

position. Three standard anatomical planes (transverse, frontal, and
sagittal) divide the body to obtain sections. Other anatomical terms
describe relationships of body parts, compare the position of
structures, or describe movement.
In 1985 the discovery of the X-ray created
an amazing step forward in the history
of medicine. As was the case with many
inventions also this one was somehow accidental.
It was of course [ ] a German professor
of physics and he was exploring the path
of electrical rays passing from an induction
coyle through a partially evacuated glass
tube although the tube was covered in black
paper and the room was completely dark
he noticed that a screen a nearby screen
covered in fluorescent material became
illuminated by the rays. It might have
been accidental but of course it takes
a great mind to understand the significance
and realise the potential application of
this discovery and try again later realised
that a number of objects could be penetrated
by this rays and that a projected image
of his own hand show the contrast between
the Epoc bonds and the translucent flesh.
In fact the first no writer graph captured
on a photographic plate is perhaps that
of his wife’s hand in this way an extraordinary
discovery had been made that the internal
structures of the body could be made visible
without the necessity of surgery. The rays
were called x-rays because at that time
no one knew what they wear. Nowadays we
know that X-rays are a form of electromagnetic
radiation radio waves infrared radiation
visible light ultraviolet radiation or
microwaves. For x-rays though the electromagnetic
wave has high energy and very short wavelength.
The x-rays trans illuminating the body
show tissues of different densities as
images of deferring intensities forming
areas of relative light and dark. A tissue
or organ that is relatively dense for example
compact bone attenuates most x-rays thus
produces a bright area on a film or monitor
because fewer x-rays reach the photosensitive
surface. Such tissues are called Radio
pack a tissue with less density for example
fat is more radio loosened and the area
of the film or monitor reached by the x-rays
will be dark. If there is an unexpected
increase or decrease in the density of
a known anatomical structure than this
may help in determining the presence and
type of an abnormality. The process of
examining the body with x-rays is called
radiography the term x-ray though also
applies to a photograph radiograph made
obtained by this method. A major limitation
of radiograph is though is that they gave
on their flat two-dimensional image of
the body which is a three-dimensional structure
so images of overlapping organs can be
confusing and slight differences in tissue
density are not easily detected. Moreover
it was eventually recognised that frequent
exposure to x-rays could be harmful and
today special measures are taken to protect
both patient and doctor. Nevertheless radiography
still accounts for over half of all clinical
imaging until the 1960s actually it was
the only diagnostic imagining method widely
available. You can now go through the slides
and see how the conventional radiography
evolved and how it is used today in medical
diagnosis in anatomy study of the musculoskeletal
system.
Conventional radiography
Introduction
Medical imaging is an extremely useful tool for the study of the
structure and function of the body in health and illness. On the one
hand, the knowledge of normal structure and its variations is essential
for the study and diagnosis of changes caused by injury or disease.
Accordingly, anatomy is a foundation science for radiologists. On the
other hand, medical imaging has become a modern method of the
study of normal structure and its variations, hence radiography and
other diagnostic imaging techniques are an essential part of
anatomical studies.

Some of the most commonly used medical imaging techniques for the

locomotor system study are conventional radiography (X-ray images),
computerized tomography (CT), and magnetic resonance imaging
(MRI).

Conventional radiography
Conventional radiographic images (also called x-rays or plain films) are
produced by a highly penetrating beam of ionizing radiation (x-rays)
passing through the patient and striking a photosensitive surface. At
first, it was always a photographic film, with a latent image that had to
be subsequently processed in a darkroom and viewed on a lighted
view box. Nowadays, the film is often replaced by a photosensitive
cassette or plate that can be processed directly by an electronic
reader, stored in a digital format and viewed on a monitor.

Since basic knowledge of X-ray physics is complementary to

knowledge of X-ray interpretation, you may want to complete
this tutorial, before engaging in radiographic anatomy study.

Five basic densities in conventional radiography

The x-rays transilluminating the body show tissues of different
densities as images of differing intensities, forming areas of relative
light and dark. A tissue or organ that is relatively dense (e.g. compact
bone) attenuates most x-rays, thus produces a bright area on a film or
monitor, because fewer x-rays reach their photosensitive surface.
Such tissue is radiopaque. A tissue with less density (e.g. fat) is more
radiolucent and the area of the film or monitor reached by the x-rays
will be darker. An unexpected increase or decrease in the density
(intensity) of a known anatomical structure on x-ray may indicate an
abnormality.

Conventional radiography demonstrates five basic densities:

(1) air, which absorbs the least x-rays and appears the blackest on the
radiograph;

(2) fat, which is visible as a very dark shade of gray, but not as black
as air;

(3) soft tissue and fluid, both appear the same;

(4) calcium, the most dense (absorbs most x-rays) naturally occurring
component of the body, contained within bones, visible as nearly white
on the x-ray

(5) metal, which absorbs all the x-rays and appears the whitest on the
radiograph.
Standard projections
In basic radiologic nomenclature, anteroposterior (AP) projection
refers to a radiograph in which the x-rays traversed the patient from
anterior to posterior, i.e. the x-ray tube was anterior to the patient and
the x-ray detector was posterior. The posteroinferior (PA) projection is
also possible and the choice will actually influence the relative
size of the structures within the body when viewed on x-rays, as the
structures the x-ray beam hits first will be magnified in relation to
those which are nearer the detector.

When looking at the x-ray film, both AP and PA projections will be

referred to as AP view and they should be described as if the examiner
and the patient were facing each other (hence, the patient’s right side
is on the examiner’s left side). For lateral radiographs, a radiopaque
letter R or L is included on the film to indicate the side placed closest
to the detector and the image is viewed from the same direction that
the beam was projected.

Most radiologic examinations are performed in at least two projections

at right angles to each other. Since the structures sequentially
penetrated by the x-ray beam in the three-dimensional space overlap
each other when viewed on a plain film, more than one view is
necessary to detect and localize abnormalities within the body.

Computed tomography
In this technique, a beam of x-ray passes across the body while the x-
ray tube and detector rotate around the long axis of the body. Multiple
overlapping signals are measured and recorded; the data are
processed by sophisticated computer algorithms to determine the
radiodensity of each volumetric pixel (voxel) of the chosen body plane.
The radiodensity of each voxel is determined by the amount of air, fat,
water, or bone in that space. The computer projects the voxels into a
planar image (slice) that can be viewed on a monitor or printed.

Hounsfield units
A CT image is composed of a matrix of thousands of tiny squares
(pixels), each of which is assigned a CT number, from -1000 to +1000,
expressed in Hounsfield Units (HU). The CT number will vary
according to the attenuation coefficient of the tissue at a given point
(this, in turn, will depend on the density of the tissue) and will be
obtained based on the formula that arbitrarily assigns a number of
-1000 HU to the radiodensity of air and 0 to the radiodensity of water.
Bone typically has CT number from 400 to 600 HU, fat is -40 to -100 HU
and soft tissue can be between 20 and 100 HU.

CT vs x-ray
Like conventional x-ray machines, CT scanners use ionizing radiation
(x-rays) to produce the images. The radiodensity expressed in HU
correlates with conventional x-ray densities. Denser substances that
absorb more x-rays have high CT numbers, as they demonstrate
increased attenuation, and are displayed as whiter areas on CT scans.
On conventional radiographs, these substances would also appear
whiter and would be said to have increased density or to be
radiopaque.

Importantly, CT scans enable differentiation of many more than the

five basic densities recognizable on conventional radiographs. What is
more, CT scans can be windowed, i.e. the range of CT number values
can be selected and displayed in the available grey scale, in order to
enhance contrast and visualize the structures of interest to their best
advantage without repeating the study. Another advantage of CT is the
fact that the images can be obtained in any plane: axial, sagittal or
coronal, depending on the diagnostic task. Moreover, the series of thin
sections can be reassembled for a three-dimensional reconstruction.

CT applications in musculoskeletal system diagnosis

With respect to conventional x-ray, CT provides a more detailed
radiographic image of the area that is being examined. It is often used
as a follow-up to an abnormal conventional radiograph or is requested
when the radiographs fail to completely answer the clinical question.
CT scans provide very good bone detail and improved soft tissue
resolution.

X-ray safety
Ionizing radiation has the potential to produce mutations, causing
alterations of cellular divisions and other intracellular processes,
which could lead to many forms of tumors. The sievert (Sv) is a unit of
ionizing radiation dose that is used to describe the effects of ionizing
radiations on the human body. An exposure to 1 Sv is associated on
average with a 5% risk of developing cancer.
CT scans are associated with the highest radiation exposure delivered
in the current medical imaging practice, with a doses ranging from 2 to
20 mSv in diagnostic and from 5 to 70 mSv in interventional
procedures. Patients and staff alike are at potential risk from
radiation exposure. Hence, several safety principles should be adhered
to and only medically necessary diagnostic examinations should be
performed, using the lowest possible dose, and avoiding highly risky
periods of life, such as growth and pregnancy.

Other diagnostic imaging

techniques: CT and MRI
Magnetic resonance imaging
Magnetic resonance imaging (MRI) is based on manipulation of the
electromagnetic activity of tissue hydrogen molecules using a very
strong magnetic field. The patient is placed in the scanner magnet
that aligns the protons in all the hydrogen nuclei, making them parallel
(or antiparallel) to the external magnetic field. Then, the transmitter
coils send a short electomagnetic pulse (called radiofrequency pulse)
at a particular frequency, which changes the orientation of the protons
to perpendicular. When the radiofrequency pulse is turned off, the
displaced protons relax and realign with the magnetic field again,
releasing energy in the form of radiofrequency signals (echo) that are
detected by the receiver coils. A computer reconstructs the
information from the echo to generate an image.
T1 and T2
MRI image contrast is influenced by several characteristics of tissues,
including T1 and T2 time constants. T1 is called the longitudinal
relaxation time (or recovery time). It is the time it takes for the tissue
protons to recover to their longitudinal (parallel or antiparallel to the
magnetic field) state. T2 is called the transverse relaxation time. It is
the time it takes for the tissue protons to acquire their transverse
(perpendicular to the magnetic field) orientation after the
radiofrequency pulse was applied.

Different tissues have different T1 and T2 values, hence they will

appear different from each other on the images. These differences can
also be influenced by modulating the parameters of pulse sequences:
repetition time (TR, amount of time between the radiofrequency
impulses) and echo time (TE, amount of time between the
radiofrequency pulse and echo detection) set by the MRI operator will
determine how the image is “weighted”. Short TR and TE will create a
T1-weighted image, while long TR and TE will create a T2-weighted
image.

T1 vs T2-weighted images
So-called dark tissues, which appear blacker on CT scan, have
decreased signal intensity, while bright tissues, which appear whiter,
have increased signal intensity. Water is T1-dark and T2-bright,
meaning it will appear dark on T1-weighted images and bright on T2-
weighted images.

Hence, when looking at an MR image, it is useful to observe something

we know should contain fluid first. If the fluid is dark, then we are
probably looking at a T1-weighted image; if the fluid is bright, then it is
probably a T2-weighted image.

MRI safety concerns

Ferromagnetic objects can be moved by the strong magnetic field of
the MRI scanner and damage tissues, or they can become heated and
cause burns. Those inside the patient could be aneurysm repair clips,
 vascular clips, or surgical staples, as well as bullets or other metallic
foreign bodies. Also, MRI cannot usually be performed in patients who
have pacemakers (unless it is specifically manufactured to be MR
safe), pain stimulator implants, insulin pumps (or other implantable
drug infusion pumps) and cochlear implants.

The biological effects of MRI on the fetus are not definitively known,
hence it should be avoided in early-term pregnancy and can be
performed only if it is decided that the benefits from obtaining the
results outweigh the potential risk of the examination method.

Advantages and disadvantages of MRI

The advantages of MRI include:

 the ability to obtain an image without the use of ionizing radiation (x-
ray), unlike CT scanning;

 the possibility to acquire images in multiple planes (axial, sagittal,

coronal, or oblique) with the same spatial resolution, without repositioning
the patient (recently possible also in CT);

 superior soft tissue contrast than CT scans and plain films, making MRI
the ideal examination method for the brain, spine, joints and other soft
tissues;

 the possibility for specific tissue characterization, using advanced

techniques such as diffusion, spectroscopy and perfusion MRI.

There are a number of disadvantages and challenges to implementing

MRI scanning:

 MRI scans are more expensive than CT scans;

 the images take longer to acquire, so patient comfort is sometimes an

issue;

 images are subject to unique artifacts (e.g. patient’s motion) that must
be recognized;

 careful attention to safety measures is necessary to avoid serious

injury to patients and staff.
MRI applications
Since MRI is based on the detection of the molecular tissue
composition (water content, in particular), it can be used to detect
soft tissue abnormalities in much higher detail than CT. Accordingly,
MRI is one of the most commonly used tests in neurology and
neurosurgery; in musculoskeletal diagnosis, it can be used to evaluate
menisci, ligaments, tendons, muscles, bones and spine.

Normal knee MRI

Contrast agents
Contrasts agents are substances used to enhance the appearance of
body structures in medical imaging studies. Iodinated contrast is often
used for CT scans. It is primarily used to visualize vessels, after
intravenous administration. Gadolinium is the most common
intravenous contrast agent used in MRI. It has paramagnetic
properties and shortens the T1 relaxation time of the hydrogen nuclei,
yielding a brighter signal from the blood vessels. Thus, highly
vascularized structures, such as tumors, and areas of inflammation
enhance (become brighter) after gadolinium administration. The use of
contrasts agents can be associated with serious risks to patients.

Radiographic anatomy study

The conventional radiography is the most commonly available and
used imaging modality. The only way to learn to interpret radiographs
is by reviewing and analyzing as many of them as possible.

Learn to correlate your knowledge of normal anatomy with at least

two orthogonal images of the same region. When looking for a possible
pathology, use a systematic approach: evaluate bone alignment,
density, and integrity of bone cortex; then look at the joint space to
indirectly evaluate the cartilage; finally, look at the soft tissues
surrounding the skeleton. Remember that an x-ray is a two-
dimensional representation of a three-dimensional space and
structures within it. Therefore, structures that overlie each other on an
x-ray can be actually distant from each other in the real space. Hence,
it is important to evaluate at least two views of the same region
(typically AP and lateral).

Radiographic anatomy study resources

There are many professionally edited and peer-reviewed resources
showing medical diagnostic images of the musculoskeletal system.
Below there is a list of useful websites you can access freely on-line
anytime. It is not necessary to look at all of them immediately; on the
contrary, it is better to do it one image at a time, but to do it
frequently.

 Trauma x-ray galleries and courses accredited by the Royal College of

Radiologists (London, UK)  www.radiologymasterclass.co.uk/gallery/galleries
 Radiographic Anatomy of the Skeleton (University of
Washington)  uwmsk.org/RadAnatomy.html
 Diagnostic Imaging Pathways, endorsed by the Government of Western
Australia  www.imagingpathways.health.wa.gov.au/index.php/image-
galleries/normal-anatomy/musculoskeletal-trauma
 Image Interpretation Course, endorsed by the Society and College of
Radiographers (London, UK)  www.imageinterpretation.co.uk/
 Skeletal trauma radiology self-tutorial for residents and medical students
(University of Virginia)  www.med-ed.virginia.edu/courses/rad/ext/index.html
 Anatomy on x-ray, CT and MRI images  http://w-radiology.com/index.html
 Musculoskeletal MRI atlas  http://freitasrad.net/
The skeletal system is composed of bones

cartilages and ligaments that together

form a strong flexible framework for the

body. Cartilage forms the model of most

of the bones during community development

allows bone growth during childhood and

covers the articular surfaces in mature

skeleton. Ligaments on the other hand hold

bones together at joints. The bone itself

is actually an organ made of different

types of connective tissue with its vessels

and nerves. Bones are typically classified

 into four groups according to their shapes

and then different shapes correspond to

different functions. Long bones for example

have greater length then width they are

found in the arm, forearm, metacarpals

and digits of the upper limb and in the

thigh leg and metatarsals of the lower

limb. They typically form levers on which

muscles act to produce movement. Short

bones have length nearly equal to their

width. The carcass for example is formed

by eight short bones while the Tarsus in

the foot is made of seven short bones,

they have limited motion against one another

and yes later on you will have to learn

all the names of the bones. Flat bones

have a flat surface and form for example

the roof of the skull other examples include

scapula in the stand in the ante with all

of the thoracic cavity. These bones enclose

 and protect soft organs and provide broad

surfaces for muscle attachment. And finally

regular bones they have complex shapes

that are difficult to classify and describe

such as those of the vertebra or the [

] bone. bone specific tissue responsible

for this particular structural characteristics

and functional properties is called Austria’s

or bone tissue as every tissue the bone

tissue consist of sense and extra cinematics

and extra cinematics of the bone tissue

is hardened by the position of calcium

phosphate and other minerals. This imposes

certain requirements on bone tissue cells

which assume particular localisation structure

in order to be able to survive and maintain

tissue homeostasis in the micro environment

where the diffusion of nutrients metabolites

is limited. This inorganic mineral components

of the extra seller Matic’s enables bone

 to support the weight of the body without

sagging when the bones are deficient in

calcium salts they are soft and the bend

easily this is the main problem in the

childhood disease called rickets in which

the soft bones of the lower limbs bend

under the body’s weight and become permanently

deformed. The organic components on the

other hand represented mainly by collagen

fibres gives bone on a degree of flexibility

and tensile strength without collagen bones

successively friable and breaks easily

as seen in a condition called the still

genesis in perfect. Mature bone tissue

has a highly organised Lamela structure

with stress oriented lomeli which forms

spongey Bakula compact cortical bone. In

a spongy bone La Maley are organised in

[ ] this [ ] then form a three-dimensional

lattice however they are not randomly arranged

 but developed along the lines of stress

acting on a bone. The spaces between the

[ ] contain blood vessels nerves and bone

marrow. Importantly spongy bone is capable

of imparting strength to a bone by allowing

a minimum of weight. In a compact bone

layers of La Malia concentric highly organised

around the central canal called [ ] canal

where the blood vessels run. Bones themselves

they lie between the [ ] in the [ ] which

communicate through canal equally. The

central canal lomeli constituted an [ ]

which is the basic structural unit of a

compact bone. Such structure and in particular

the peculiar orientation of collagen fibres

that run in a helical arrangement angled

in the opposite direction and alternating

between right and left in adjusting lomeli

this enhances greatly the strength of purpose.

As a living dynamic tissue bone receives

 a rich blood supply from nutrient arteries

usually one of the few large arteries that

enter the bone in the long bones the nutrient

arteries pass through the cortical bone

of the dire offices and supply the compact

and sponge bone as well as the bone marrow

inside and then additionally there are

smaller arteries which really branch for

martyrs supplying the joint they also reached

the pieces of the long bones and again

numerous small periodical branches from

adjusts investors that supply the compact

cortical bone. Later on while studying

the form and characteristics of the single

bones of our skeleton you could know the

location of the nutrient for Ayman on this

surface knowledge about bone blood supply

will be useful in surgical orthopaedic

procedures in predicting the course of

bone healing after trauma that Adele Duffy

 where the presence of a nutrient can be

erroneously interpreted as a fracture political

vision.

Bone tissue structure and

function
Functions of bones
Bones are not merely a framework of a body and attachment site for
muscles, they also protect organs, store minerals, and contain blood
cell precursors.

Bone functions:

 Support and protection – bones provide structural support for the entire
body and protect organs from injury: the rib cage protects the heart and
lungs, the cranial bones protect the brain, the vertebrae enclose the spinal
cord, and the pelvis encloses reproductive organs and distal parts of the
urinary and digestive tracts.

 Movement – bones function as levers that are pulled when skeletal

muscles, which are attached to them via tendons, contract.

 Storage of minerals – more than 90% of the body’s calcium is stored in

bone tissue and can be released into the bloodstream when it is needed;
calcium is essential for muscle contraction, blood clotting, nerve impulse
transmission, and numerous intracellular processes in virtually all cell types.

 Hemopoiesis and organ regeneration – spongy bone tissue contains red

bone marrow with hemopoietic and mesenchymal stem cells, where blood
cells are produced. Recent data indicate that bone marrow-derived stem
cells can home to other organs and contribute to their regeneration. Stem
cell-based regeneration is a new and extensively studied field that has
triggered the progress of regenerative medicine.
Composition of bone tissue
Bone is made of organic and inorganic components.

The organic phase represents approximately 35% of bone weight and

consists of cells embedded in abundant extracellular matrix. The
matrix is composed mostly of the type I collagen fibers, which give
tensile strength to the bone (bone becomes friable if collagen is
missing). Non-collagen proteins include osteocalcin, osteonectin and
ostepontin. Proteoglycans, enriched in chondroitin sulfate, keratan
sulfate and hyaluronic acid, bind water and give bone compressive
strength. The matrix is deposited by osteoblasts and its continuous
turnover is accomplished by osteocytes and osteoclasts. Before it
becomes mineralized, the organic phase is called osteoid.

The inorganic phase accounts for approximately 65% of bone weight.

The primary mineral is calcium hydroxyapatite Ca10(PO4)6(OH)2, which
adds compressive (weight-bearing) strength to the bone (bone
becomes flexible if mineral is missing). Matrix becomes mineralized
between and at the ends of collagen fibers.

Cells of bone tissue

Bone tissue is composed of several cell populations. Osteoprogenitor
cells, which reside in the periosteum and endosteum, differentiate into
osteoblasts, thus participate in bone formation and fracture
healing. Osteoblasts line bone surface during bone formation and
accompany osteoclasts during bone remodelling, producing organic
phase of bone matrix (osteoid); their activity is regulated by
parathormone (PTH), vitamin D, estrogen, and
glucocorticosteroids. Osteocytes represent 90% of all bone cells and
derive from osteoblasts that became entrapped in the matrix. They
reside in small cavities, called bone lacunea, and communicate with
each other and with vascular spaces via long cell processes they send
out inside bone canaliculi connecting adjacent lacunae. Osteocytes
secrete substances necessary for bone maintenance. These cells have
also been implicated in regulation of bone remodeling, as they can
sense mechanical signals placed upon the bone and release signaling
molecules, which orchestrate the recruitment and activity of
osteoblasts or osteoclasts, resulting in the adaptation of bone mass
and structure.
Osteoclasts are large, multinucleated cells that resorb bone. They
derive from hematopoietic progenitors in the bone marrow that also
give rise to monocytes and macrophages. During bone resorption,
osteoclasts form and occupy osteoclastic cripts or erosion lacunae,
also called Howship’s lacunae. Activated osteoclasts develop a ruffled
border towards bone tissue and secrete hydrochloric acid, which
dissolves the inorganic components, thus liberating calcium and
phosphate into the blood; enzymes secreted by osteoclasts dissolve
the organic phase. Their activity is regulated by osteoblasts,
calcitonin and estrogens, and it can be pharmacologically inhibited by
bisphosphonates.

The bone composition and blood calcium/phosphate concentration

depend upon the delicate balance between the osteoclasts and
osteoblasts activity.

Cells of bone tissue

Histological types of bone tissue
Developing (immature) or pathologic (fracture callus) bone is a poorly
organized tissue, called woven bone. Mature bone, which subsequently
substitutes the woven type, has a highly organized lamellar structure,
with stress-oriented lamellae, which form spongy (trabecular) or
compact (cortical) bone.

Every bone of the body contains compact and spongy bone tissue;
these two types of lamellar bone are arranged in different ways in
bones of different forms. In a flat bone, the compact bone forms
external and internal tables that together enclose a layer of spongy
bone, called diploë. Similarly, in short or irregular bones, the external
surface is covered by compact bone and the interior is composed of
spongy bone (with red, hemopoietic, or yellow, fat-storing, bone
marrow in the spaces between the trabeculae of the spongy bone). In
a long bone, the compact bone tissue forms the bone cortex on the
surface, while the spongy bone tissue forms the inside of the bone
extremities (epiphyses) and lines the marrow cavity that runs in a
bone shaft (diaphysis).

Flat bone structure

Long bone structure
Spongy bone
Spongy bone tissue, also called trabecular or cancellous bone,
typically forms the inside of bones. In a spongy bone, slender bony
plates, called trabeculae, form a crossed lattice structure. Osteocytes
lie between the lamellae of matrix in the trabeculae, while osteoblasts
and osteoclasts lie on the surface of the trabeculae. The spaces
between trabeculae contain bone marrow and blood vessels. This bone
tissue is characterized by a high turnover of its components and any
imbalance in the resorption and deposition rate influences its
structure and properties. In fact, osteoporosis is common in spongy
bone, making it susceptible to fractures (e.g. vertebrae, neck of femur,
distal part of radius).

Spongy bone

Compact bone
Compact bone is a strong, dense bone tissue that typically forms the
outer shell (cortex) of bones. Within a compact bone, the lamellae form
cylindrical structures, called osteons. Each osteon has a central canal,
known as haversian canal, that contains a blood vessel, with a
concentric layers of lamellae around it. In the adjacent lamellae,
collagen fibers form helices angled in the opposite direction,
alternating between right- and left-handed helices from lamella to
lamella.

Osteocytes occupy small spaces between neighbouring lamellae,

called lacunae, and communicate with each other through canaliculi.
Canaliculi house osteocyte cytoplasmic processes, which permit
intercellular contact, and give passageway to nutrients, minerals,
gases and wastes, which travel between the central canal, containing
blood vessel, and the lacunae, containing osteocytes. Adjacent
osteons are connected by radially-oriented perforating canals, called
Volkmann’s canals, which contain arterioles.

Compact bone
Classification of bones
Based on their form and shape, bones are classified as long, short, flat,
and irregular.

Long bones have a greater length than width. They are found in the
arm, forearm, metacarpus, and digits of the upper limb, as well as in
the thigh, leg, metatarsus, and digits of the lower limb. Long bones
form levers on which muscles act to produce movement.

Short bones have a length nearly equal to their width. The carpus, for
example, consists of eight short bones, while the tarsus is made of
seven short bones. Sesamoid bones also typically have this form;
unlike other bones, they lie in the tendons of some muscles.

Flat bones have a flat surface and form, for example, the roof of the
skull, the scapulae, the sternum. These bones enclose and protect soft
organs and provide broad surfaces for muscle attachment.

Finally, irregular bones have complex shapes, such as those of the

ethmoid bone in the cranium or the vertebrae.
 Classification of bones based on their form and shape

Structure of a long bone

A typical long bone consists of the following parts:

 diaphysis, or shaft, a tube of cortical compact bone that surrounds a

medullary cavity filled with bone marrow;

 epiphysis, a typically expanded extremity, composed of spongy bone

covered by an outer layer of compact bone; the articular surface is typically
lined with a thin layer of hyaline cartilage;
 metaphysis, a thin widening of bone sandwiched between the
diaphysis and epiphysis, which in a growing bone is separated from the
epiphysis by a layer of hyaline cartilage that forms the epiphysial plate; at
maturity, this growth plate ossifies and the metaphysis fuses with the
epiphysis at the epiphysial line.

Parts of a long bone

Periosteum and endosteum

The periosteum, externally, and endosteum, internally, cover the
surface of the bones (periosteum is missing from the articular surfaces
of the bones). The periosteum consists of an outer layer of dense
fibrous connective tissue and an inner layer containing
osteoprogenitor cells that give origin to osteoblasts, active in bone
growth, repair and remodelling throughout life. A monolayer of
osteoprogenitor cells lies within the much thinner endosteum.
The formation of bone is called osteogenesis

or simply ossification. There are two methods

of ossification interim intramembranous

and endochondral and they will be examined

 in the following section. Intramembranous

ossification is typical of the flat bones

of the skull. We’ve already seen that these

bones are formed by spongy bone sandwiched

between two surface layers of compact bone.

In the growing skull the surface covered

by the flat bones increases as the brain

grows but the spaces between the adjacent

bones are filled with fibrous connective

tissue forming fontanelles locally called

soft spots you can see the anterior and

posterior fontanelle what’s left of it

in the skull. Importantly during birth

fontanelles enable the bony plates of the

skull to flex and slide allowing the child’s

head to pass through the birth canal. In

an infant in particular participation of

the fontanelle enables physician to evaluate

the degree of hydration or the level of

intracranial pressure because depressed

fontanelle may indicate dehydration while

a bulging fontanelle may indicate increased

pressure in the cranial cavity. Endochondral

ossification instead is the method in which

a hireling cartilage model that resembles

the shape of the bone to come is transformed

into that bone as the primary and secondary

ossificaion centres develop and ossification

proceeds the cartilage plates persist between

 the [ ] and the [ ] of the long bones.

These [ ] plates allow bone growth in length

until they become calcified or we say close.

What’s interesting this [ ] plate calcification

which leads to fusion of the [ ] with the

[ ] occurs in an orderly manner without

the skeleton and the typical timings of

such fusion in different long bones have

been determined in population studies hence

clinicians can use this anatomical information

to the time in the biological skeletal

age based on the presence of [ ] plates

typically examine hand and wrist radiographs.

Radiologists then should know the time

of development and location of the ossification

centres in the bones especially around

the joint area in order to diagnose correctly

skeletal trauma and you will see during

this course many examples of such X-rays

in the following lessons. For now I invite

you to review the basis of ossification

processes.

Bone ossification and

growth
 Bone formation
Formation of bone tissue - osteogenesis or ossification - begins before
birth and is not complete until about the 21st year of life. Flat bones,
e.g., some bones of cranium, develop from intramembranous
ossification, during which mesenchymal cells of connective tissue
differentiate directly into osteoblasts, which then produce bone. Long,
short and irregular bones develop as a result of endochondral
ossification, during which a hyalin cartilage model of a future bone is
converted into bone by osteoclasts and osteoblasts.

Intramembranous ossification
Intramembranous ossification is typical of flat bones and follows the
following basic steps:

1. Osteoprogenitor cells within mesenchymal connective tissue

differentiate into osteoblasts, which then secrete osteoid; thus, ossification
center develops.

2. Osteoid undergoes mineralization (calcium salt deposition) and

entrapped osteoblasts become osteocytes; accumulating osteoid forms a
bony lattice with disarrayed (irregularly aligned) collagen fibers (immature,
primary, woven bone).

3. Mesenchyme surrounding lattices of woven bone forms periosteum and

ossification proceeds with the formation of organized lamellae that form
spongy bone trabeculae (secondary, trabecular bone).

4. Compact bone tissue develops on the surface of the spongy bone; thus,
the typical structure of a flat bone results.
Intramembraneous ossification

Fontanelle
Flat bones of cranial vault develop through intramembranous
ossification and increase their surface during growth. In a newborn,
they are still separated by fibrous connective tissue, particularly wide
between the angles of the flat bones, where it forms fontanelles. The
largest anterior fontanelle is diamond-shaped and lies between the
frontal and parietal bones. It disappears by 18 months of age, as the
bones enlarge and form sutures between them. The posterior
fontanelle is triangular and bounded by the parietal and occipital
bones. It closes by the end of the 1st year. Clinically less important
are the paired sphenoidal, anterolateral, and mastoid, posterolateral,
fontanelles.

Palpation of the fontanelles during infancy enables physician to

evaluate the degree of hydration of an infant (a depressed fontanelle
may indicate dehydration) and the level of intracranial pressure (a
bulging fontanelle can indicate an increased pressure in the cranial
cavity).

Fontanelle (lateral view of skull)

 Fontanelle (superior view of skull)

Endochondral ossification
The basic steps of endochondral bone growth are the following:

1. A hyaline cartilage forms a precursor of bone in fetal life.

2. The perichondrium lines the surface of the cartilage; the matrix in the
center of this cartilaginous model of bone calcifies and hypertrophic
chondrocytes degenerate.

3. Blood vessels invade the disintegrating cartilage, bringing

osteoprogenitor cells and a primary ossification center develops in the
diaphysis.

4. Bone tissue (first woven, then lamellar) replaces hyaline cartilage in

the diaphysis as endochondral ossification proceeds from the center in
opposite directions within the diaphysis.

5. After birth, secondary ossification centers develop in the epiphyses, as

the space occupied by hypertrophic chondrocytes is invaded by blood
vessels and osteoprogenitor cells; most of the hyaline cartilage of the
epiphyses is replaced by the spongy bone.

6. Epiphysial plates of cartilage continue to separate the diaphysis from

the epiphyses and allow bone elongation.
Endochondral ossification
 Structure of epiphysial cartilage
The epiphysial cartilage allows elongation of bones. It is divided into
several zones, each with a different significance:

1. Resting zone or quiescent zone, nearest to the epiphysis, is a mature

hyaline cartilage with small chondrocytes.

2. Proliferation zone, where chondrocytes divide and stack into adjacent

columns.

3. Hypertrophic zone, where chondrocytes increase in size.

4. Calcification zone, where proteoglycans are degraded, matrix becomes

mineralized and chondrocytes die.

5. Ossification zone, nearest to the diaphysis, where branching blood

vessels penetrate in the spaces between columns of degenerated
chondrocytes, bringing osteoprogenitor cells; these differentiate into
osteoblasts and produce primary bone trabeculae; immature woven bone is
then substituted, in cooperation with osteoclasts, by the trabeculae of the
lamellar bone tissue.

As the epiphysial cartilage turns into bone near the diaphysis, new
chondrocytes are added to it by proliferation near the epiphysis; as a
result, the thickness of the epiphysial cartilage does not change, while
the bone elongates. With time, the epiphysial plates ossify completely
and lenghtwise bone growth ceases.
Epiphysial cartilage (Masson Goldner trichrome staining)
Postnatal bone growth and remodeling
Growth in length of the long bones occurs through cell division,
hypertrophy and matrix calcification taking place within the epiphysial
cartilage. Growth in width, or thickness, occurs through appositional
growth due to deposition of bone matrix by osteoblasts beneath the
periosteum.

Throughout life, bone remodels in response to mechanical stress and

gravity, in ways that allow it to withstand the stresses it experiences.
This ongoing process occurs at both the periosteal and endosteal
surfaces of a bone and involves the removal (resorption) of bone tissue
by the osteoclasts and the deposition of new bone tissue by the
osteoblasts.

Determination of biological age based on the skeleton

The epiphysial plate calcification, leading to the fusion of epiphysis
with diaphysis, occurs in an orderly manner throughout the skeleton
and the typical timings of such fusion in different long bones in
different populations have been determined. Clinicians use this
information to determine the biological skeletal age based on the
presence of secondary ossification centers and epiphysial plates,
typically, in hand and wrist radiographs. Forensic anthropologists can
also approximate the age of skeletal remains observing the
metaphyses of the bones.

As the cartilage does not appear readily on x-ray film, in an

adolescent’s wrist, the epiphysial plates (on the image - in the radius
and ulna) seem to separate the diaphysis from epiphysis. As the
growth in length ceases, in an adult’s wrist, the cartilage in the
epiphysial plates becomes ossified and bone parts are continuous with
each other. Hence, a child’s long bones are still growing if a
radiograph shows epiphysial plates. If epiphysial cartilage is
damaged, for example as a result of a fracture, elongation of the
involved bone may be uneven or may cease prematurely.
Adolescent's and adult's wrist

Radiographic anatomy of bone

Normal bone has a smooth cortex (compact bone), which is thicker
along the shaft of a long bone, e.g. femur, compared with a short bone,
e.g. carpal bones. The smooth cortex is interrupted at entry points of
the nutrient arteries supplying bone. Medullary and epiphysial
trabeculae of spongy bone appear as thin white lines running in the
direction of weight-bearing forces within a bone.

Principles of musculoskeletal imaging

Knowledge of normal bone, joint and soft tissue appearance enables
accurate description of abnormalities seen on X-ray. Both normal and
abnormal X-rays will be used throughout this course to illustrate
musculoskeletal system and some common medical conditions
associated with its structures. Before proceeding, you should carefully
study and complete this comprehensive tutorial, which illustrates
some principles of musculoskeletal X-ray interpretation for normal and
pathological anatomy study.
Challenge yourself
In achondroplasia, a gene mutation leads to the synthesis of the constitutively active form of the
receptor for fibroblast growth factor (FGFR3), resulting in inhibition of the chondroblast
proliferation. Which process in the bone development will be affected as a result of the loss of
chondroblast proliferation in the epiphysial cartilage?

Osgood-Schlatter disease is an inflammation at the insertion of the patellar tendon into the tibial
tuberosity, which typically affects growing children. What is the name of a bony protrusion near
the metaphysis of the tibia that arises from a separate ossification centre and fuses to the bone
later in development to form tibial tuberosity?
 Bone tissue with its particular composition

and organisation which was discussed in

the previous lesson is an extremely active

tissue as it undergoes continuous remodelling

throughout life accommodating for the changing

forces applied to the skeleton. Moreover

bone tissue with its calcified matrix is

a calcium storage the other body actually

contains about one gram of calcium and

99 percent of it is in the bones. While

in the bones calcium and the mineral it

forms in the matrix is essential for bone

tissue mechanical properties but in other

tissues and organs calcium is the second

 messenger in many cells signalling processes

and the co-factor for many enzymes. Calcium

is also needed for communication between

neurons muscle contraction for blood clotting.

Fortunately calcium deposited in the bones

can be withdrawn when it is needed for

other purposes thanks to [ ] which can

restore the bone tissue and release calcium

phosphate into the blood. The major systemic

regulators of blood calcium concentration

include parathyroid hormone growth hormone

glucocorticoid thyroid hormones sex hormones

and calcioral which is the active form

of the vitamin D. Vitamin D is mainly produced

indigenously from [ ] contained in the

skin and then it is activated when ultraviolet

rays from sunlight act on the skin. Next

the vitamin D must undergo two hydrox relations

the first one is cut it out in the liver

and the second one in the kidneys in this

way the calcioral is formed and it is the

most active form of vitamin D. Accordingly

children who remain mostly indoors in general

do not produce adequate quantities of vitamin

D. Other causes of vitamin D deficiency

will included diseased liver or kidney

and seeing small quantities of vitamin

D can be derived also from food or some

dietary deficiency or gastrointestinal

 male absorption. In response to a fall

in plasma calcium concentration parathyroid

hormone activates osteoid class to release

calcium from bone tissue in order to provide

other cells and tissues with the calcium

so much needed for the processes. However

this leads to the lack of mineralization

of the osteoid in the bone. As a result

bones exhibit excessive flexibility and

this is called rickets in children or osteomalacia

in adults. As regards to the systemic effects

of changes in calcium blood concentration

it is important to remember that hyper-local

seniors on deficiency of blood calcium

can be a serious medical condition it causes

excessive exitility of the nervous system

and leads to muscle tremors spasms or tightening

characters by the inability of the muscle

to relax. This hypoglycemia can result

from a wide variety of causes including

vitamin D deficiency and also diarrhoea

and malabsorption thyroid tumours also

pregnancy in lactation put women at risk

of hypoglycemia because of the high calcium

demand for diversification of the foetal

and then foetal bones and then infant skeleton

in synthesis of milk but the leading cause

of hypoglycemic that on is perhaps accidentally

removal of the parathyroid glance during

 thyroid surgery. The condition increased

in blood calcium concentration is relatively

there it may present in hyper [ ] when

the secretion of [ ] increases only no

multiple myeloma and your plastic malignant

disease of plasma cells in the bone marrow.

The clinical symptoms of hypoglycemic can

be easily remembered as painful bones kidney

stones abdominal groans and physical moans.

So while reading about some of the hormones

and vitamins that effect of [ ] and blood

calcium concentration keep in mind that

calcium is essential for all tissues not

only the bone for this reason I talked

briefly about the systemic effects of changes

in calcium blood concentration it’s lack

in the bone issue will have also devastating

consequences on the skeletal system such

conditions would be reviewed in this lesson.

Patient's case
A 69-year-old sedentary woman, who has been a heavy smoker since
she was a teenager and recently has developed a hunchback posture,
presented to her physician with back pain that radiated laterally to the
flanks.

Upon examination, the doctor noticed pronounced kyphosis of her

vertebral column. Radiographs revealed vertebral compression
fractures in the thoracic and upper lumbar region. Bone densitometry
showed significant loss of bone mineral density.

You will learn more about this diagnosis by the end of this lesson.

Bone remodelling
The skeleton is a metabolically active system that undergoes
continuous remodelling throughout life. Bone remodelling involves the
removal of mineralized bone by osteoclasts, followed by the formation
of bone matrix (osteoid) by osteoblasts and its subsequent
mineralization. Bone remodelling serves to adjust bone architecture
according to changing mechanical needs and to repair microdamages
in bone matrix. It also plays an important role in maintaining plasma
calcium homeostasis.

The regulation of bone remodelling is both systemic and local. As far

as local regulation of bone remodelling is concerned, numerous
cytokines and growth factors that affect bone cell functions have been
recently identified. You will study or have studied them in a molecular
and cellular biology course. Some of them are already being targeted
in the therapy of common bone disorders. The major systemic
regulators include parathyroid hormone, growth hormone,
glucocorticoids, thyroid hormones, sex hormones, and calcitriol.

Effects of hormones on bone growth and maintenance –

growth hormone and thyroid hormones
Hormones regulate bone growth and, once it is completed, bone
remodelling and repair by influencing the osteoblast and osteoclast
activity.

Growth hormone, also called somatotropin, is produced by the anterior

lobe of the pituitary gland (adenohypophysis). It stimulates liver to
produce somatomedins (also known as insulin-like growth factors or
IGFs), which activate proliferation of cells in the epiphysial cartilage,
hence bone elongation. Excessive action of IGFs while the epiphysial
plates are still open leads to abnormally high growth of bones in length
(gigantism). In adulthood, after the growth plate cartilage ossifies, it
will produce acromegaly, usually caused by a benign growth hormone
secreting pituitary adenoma.

Tri-iodothyronin (T3) and tetra-iodothyronin (T4), secreted by the

thyroid gland, stimulate the basic metabolic rate of bone cells.
Together, growth hormone and thyroid hormones maintain normal
activity at the epiphysial plates until puberty. Deficiency of either can
result in short stature in the child.
Growth hormone action on musculoskeletal system
Effects of hormones on bone growth and maintenance –
calcitonin and parathyroid hormone
Calcitonin from the thyroid gland and parathyroid hormone (PTH) from
the parathyroid glands are involved in homeostasis of calcium in blood
and bone.

Secretion of calcitonin increases when the concentration of calcium in

the plasma is elevated (hypercalcemia). Calcitonin rapidly inhibits
osteoclast activity, thus transiently shifting the balance towards
calcium bone deposition. The more prolonged effect of calcitonin
consists in the decrease of the formation of new osteoclasts from the
bone marrow precursors. In the long term, however, this action leads
secondarily to a reduction in osteoblast activity; hence, the overall
effect on calcium turnover is negligible. Calcitonin also has minor
effects on calcium handling in the kidney (increasing its excretion in
urine) and the intestine (reducing its absorption), but these effects
contribute very little to the overall calcium content in the body and are
seldom considered.

PTH is secreted when the concentration of calcium in the plasma is

low (hypocalcemia). This hormone increases osteoclast activity, thus
causes bone calcium liberation into the plasma. It does so indirectly,
through the activation of osteoblasts, which then signal to bone
marrow-derived osteoclast precursors to stimulate their fusion,
differentiation and activation. In the kidney, PTH stimulates calcium
re-absorption from urine and activates the production of active vitamin
D (calcitriol). Vitamin D, in turn, stimulates the intestinal absorption of
Ca2+. If the secretion of PTH is excessive (hyperparathyroidism), the
resulting increase in blood calcium concentration can provoke kidney
stones, abdominal pain, muscle weakness, and lethargy. The opposite
condition, i.e., hypoparathyroidism, most commonly seen as a result of
thyroid gland surgery, leads to decreased calcemia and increased
phosphatemia, which can provoke tingling, cramps, or seizures.
Role of PTH and calcitonin in calcium homeostasis
Effects of hormones on bone growth and maintenance –
sex hormones and glucocorticoids
Estrogens and testosterone, which begin to be secreted in great
amounts at puberty, stimulate osteoblasts and accelerate bone
growth. Increase in bone formation in the ossification centres within
epiphysis eventually leads to the reduction of the epiphysial cartilage
thickness and so called closure of the epiphysial plate. Importantly, a
normal reduction in sex hormones in the elderly is associated with a
decrease in bone mass (osteoporosis).

The prolonged excess of glucocorticoids, i.e., steroid hormones

secreted by the cortex of the adrenal glands, results in bone
resorption and bone mass loss, due to increased osteoclastogenesis
and reduced number and function of osteoblasts.

In metabolic diseases, an interplay of different hormones triggers

complex and not always completely understood mechanisms that
influence bone composition and functional characteristics.

Effects of vitamins on bone growth and maintenance –

vitamins A and C
An adequate dietary intake of vitamins is required for normal bone
growth and maintenance. Vitamin A, for example, promotes skeletal
growth by activating osteoblasts. Its precursor, beta-carotene, is
present in fruits and vegetables, such as carrot, cantaloupe, apricot,
sweet potato, pumpkin, winter squash, mango, spinach, kale, broccoli;
the preformed vitamin A is found in meat, poultry, fish and diary
products.

Vitamin C is required for the biosynthesis of collagen, the main organic

component of the bone. Fruits and vegetables, especially those that
can be eaten raw, are the best sources of vitamin C. One can get
recommended amounts of vitamin C by eating a variety of foods,
including citrus fruits (such as orange and grapefruit) and their juices,
as well as red and green pepper, kiwifruit, broccoli, strawberries,
cantaloupe, tomatoes and baked potatoes.
Effects of vitamins on bone growth and maintenance –
vitamin D
Vitamin D stimulates the absorption of calcium and phosphate from
the intestine. The resulting rise in calcium and phosphate levels in the
blood promotes bone mineralization. Very few foods contain vitamin D,
with the flesh of fatty fish (such as salmon, tuna or mackerel) and fish
liver oils being the best, and the beef liver, cheese and egg yolks being
the secondary sources. Vitamin D is mainly produced endogenously,
from a lipid precursor contained in the skin and activated when
ultraviolet rays from sunlight strike the skin.

Calcitriol
Vitamin D obtained from sun exposure, food, or supplements is
biologically inert and must undergo two hydroxylations for activation.
The first occurs in the liver and converts vitamin D to 25-hydroxy-
vitamin D, also called calcidiol. The second occurs in the kidney and
forms the physiologically active 1,25-dihydroxy-vitamin D, also known
as calcitriol. This last step, in particular, is stimulated by the
parathyroid hormone.

Calcitriol is the most active form of vitamin D, produced by the

sequential action of skin, liver and kidneys. Vitamin D 3 increases
calcium, phosphate and magnesium absorption from the small
intestine, increases calcium reabsorption in the kidneys (both these
effects cause an increase in calcium blood levels) and promotes bone
mineralization. The consequences of vitamin D deficiency include
secondary hyperparathyroidism and bone loss, leading
to osteoporosis and fractures; mineralization defects, which may lead
to osteomalacia in the long term; and muscle weakness, causing falls
and fractures.
Calcitriol synthesis

Rickets
Rickets is a disease caused by vitamin D deficiency in childhood
(analogous condition in adults is called osteomalacia). Children who
remain mostly indoors in general do not produce adequate quantities
of vitamin D. Other causes of vitamin D deficiency include dietary
deficiency or gastrointestinal malabsorption, as well as disease of
liver or kidney. In response to fall in plasma calcium concentration,
parathyroid hormone activates osteoclasts to release calcium from
bone tissue. The osteoid is not mineralized; as a result, bones exhibit
excessive flexibility and, in severe cases, patients develop a bow-
legged appearance. Radiographic features include osteopenia
(generalized reduction in bone density), loss of corticomedullary
differentiation (outer compact bone tissue layer and inner spongy bone
are no longer seen as different structures), widening of the growth
plate and bone shape deformities.
Anteroposterior view of the lower limbs in a 2-year-old child
with rickets
Two adult femoral bones, the one on the left is deformed due to
childhood rickets

Effects of exercise on bone remodelling

Bone tissue is deposited in proportion to the physical load, i.e., weight
and gravitational force bearing, and mechanical stress, associated
with repeated skeletal muscle contraction, that the bone must
support. Accordingly, the bones of athletes become considerably
heavier than those of non-athletes. Also, if a person has one leg in a
cast but continues to walk on the opposite leg, the bone of the leg in
the cast becomes thin and less calcified within a few weeks, whereas
the opposite bone remains thick and normally mineralized. Therefore,
continual physical stress and regular exercise stimulate, while
immobilization reduces deposition and calcification of bone.
 in the second part of this lesson we’ll

discuss and see many examples if you decide

to follow the links to the online tutorials

of skeletal trauma, bone fractures in particular.

This can be classified in number of ways

based on the number of bone fragments resulting

from fracture will have a simple fracture

if it involves a single fracture line through

a bone, comminuted fracture produces more

than two bone fragments in an open fracture

the fragments are exposed through the wounded

skin. This type of fracture is in particular

risk of infection and other complications.

Another classification is based on the

direction of a fracture line through the

bone. This can be quite straightforward

in the long bonds for example a fracture

passing perpendicular across a bone shaft

is described as transfers. The fraction

that passes at an oblique angle to the

long axis of the shaft is called oblique.

Then a twisting entry can produce a spiral

fracture with the fracture line that spirals

along the shaft then at times the line

fracture can be described based on its

direction through the bone using general

terms related to anatomical planes horizontal

 vertical coronal surgerical and excel.

These are particularly useful in short

and the regular bone fractures. Following

fracture bone fragments can become displaced

and this is described strictly based on

their normal position of the distant bone

fragment in relation to the proximal fragment.

What can happen for example is undulation

or rotation of the distal fragment in relation

to the proximal part or shortening of the

bone if the distal fragment migrated proximal

or becomes impacted being driven into the

proximal bone. This description has to

be very precise and exact as the severity

in nature of displacement are key factors

when considering fracture treatment. There

are indeed several factors that can delay

fracture healing such us poor alignment

mobility bone infection but also malnutrition

efficient blood supply. Some bones are

particularly vulnerable to inadequate healing

or even lack of it with necrosis of bone

fragment due to the particular anatomical

blood supply invested distribution. Two

most commonly cited examples are fractures

of the neck of femur and fractures of the

scuffle bone. The femoral neck supports

the head of femur. In adults blood supply

to the head of femur is chiefly from the

 medial circumflex femural artery a branch

of the department of thigh the thermal

branches that reach directly the head of

femur are called inoculated arteries as

they run underneath the joint capsule from

the level of two canters along the neck

towards the head when the femoral neck

is fractured the aerteries are often thorn

and the consequence will be a vascular

necrosis of the femoral head so death of

bone or [ ] resulting from inadequate blood

supply. The scaphoid which we mentioned

is the most frequently fractured carpal

bone. Interestingly it receives its blood

supply from branches of the radial aertery

that reached the bone from its distant

part so the proximal part of the bone has

a relatively poor blood supply hence the

repair of the fractured scaphoid with the

union of the fractured parts can take at

least three months in some cases are vascular

necrosis of the proximal fragment of the

scaphoid may occur and this will contribute

to the generative disease of the wrist

joint. Typically high forces are required

to fracture a normal bone but deceased

bones may fracture even as a result of

low impact trauma. Fracture arising within

a normal born tissue is turned pathological

 so in the second part of this lesson we

learn about the commonist conditions associated

with pathologic fractures In one of them

in one such condition bone mass so the

amount of bone tissue in a bone is reduced

because it’s the position does not keep

pace with the absorption of the inorganic

and organic components. This condition

is called osteoporosis. Actually peak bone

mass occurs around thirty five years of

age and then it gradually declines in both

sexes. However lowered oestrogen levels

after the menopause in women are associated

with a period of accelerated bone loss.

There is a similar decline of sex hormones

in men as well but either case later in

life and has slowly effects in bone tissue

hence osteoporosis is two and half times

more common in women than in men. So as

the bone mass decreases susceptibility

to fractures increases and compression

fractures of vertebrae distal radius fractures

femural necks fractures become more common.

To decrease the chance of having osteoporosis

you should be sure that your diet has the

recommended amount of calcium and your

locomotor system has sufficient level of

activity and exercise. It’s good to remember

that it’s worth the effort to develop your

 locomotive system to the full while it

is still possible.

Skeletal trauma
Bone fracture
Bone fracture, colloquially called a broken bone, is a medical condition
in which there is a damage in the continuity of the bone. A bone
fracture can be the result of high force impact or a minimal trauma
injury of a bone weakened by another medical condition, e.g.,
osteoporosis or bone tumor (so called pathological fractures).
Childhood fractures most commonly occur with a fall. Arm fractures
are more common than leg fractures, since the common reaction is to
throw out your arms for support while falling.

Fractures of the bones are classified in a number of ways. A simple

fracture involves a single fracture line through a bone. A comminuted
fracture produces more than two bone fragments. In an open fracture,
the fragments are exposed through the wounded skin; it is at
particular risk of infection and other complications. A greenstick
fracture is a particular type of fracture in which the bone cracks,
instead of breaking completely. It occurs mostly in children younger
than 10 years of age.
Types of fractures

Bone fracture repair

Fracture healing restores the tissue to its original physical and
mechanical properties and is influenced by a variety of systemic and
local factors. Healing occurs in three distinct but overlapping stages,
each involving one main process: inflammation, repair and
remodelling. In the inflammatory stage, a hematoma develops within
the fracture site during the first few hours. Granulation tissue is
invaded by vessels which supply hematopoietic/osteoprogenitor cells.
During the repair stage, cells produce soft callus that bridges the bone
ends. In terms of resistance to movement, this callus is very weak and
requires protection offered by bracing (cast or slab) or fixation device.
Eventually, the soft callus is replaced by immature (woven) bone. If
proper immobilization is not used, ossification may not occur and an
unstable fibrous union may develop instead.
 Fracture healing continues through the remodelling stage, which is
facilitated by mechanical stress placed on the bone. Adequate shape,
structure and strength are typically restored in 3 to 6 months.

Stages of fracture healing

Local factors influencing fracture healing

A number of requirements must be met for normal fracture healing to
occur, including:

 viability of fragments (i.e., intact blood supply),

 mechanical immobilization,

 absence of infection.

Various local and systemic factors affect the course and duration of
fracture healing. Any disturbance may lead to abnormally slow healing
(delayed union) or failure to heal (non-union). Local factors that
influence healing of fractures include the following:

 degree of local trauma – a comminuted fracture with tissue fragments

between the ends of bone and more soft tissue injury is slower to heal;

 disruption of vascular supply - deficient blood supply delays healing;

 poor alignment of bone ends;

 insufficient immobilization of fracture - continuous movement of bone
ends delays healing;

 abnormal bone tissue – infection, tumour, or irradiation of bone tissue

delay or impede healing.

Bone fracture treatment

There are three main treatment options for bone fractures:

1. Plaster or fiberglass cast, or splint application – as a rule of thumb a

cast should block a joint above and below the fracture, as movement of
either joint can cause movement of fracture fragments.

2. Open reduction and internal fixation - this involves a surgery to repair

the fracture; the bone fragments are first repositioned (reduced) into their
normal alignment and then are held together with special implants, such as
plates, screws, rods and wires. This procedure is recommended for
complicated fractures unlikely to be realigned (reduced) by casting or in
cases in which the long-term use of a cast is undesirable. Internal fixation
allows shorter hospital stays, enables patients to return to function earlier,
and reduces the incidence of non-union (improper healing) and malunion
(healing in improper position) of broken bones.

3. External fixation - metal pins or screws are placed into the bone
through small incisions into the skin and muscle. The pins and screws are
then attached to a bar outside the skin. This technique is generally applied
to complicated fractures that cannot be repaired using open reduction and
internal fixation.
Internal fixation of fractured bones

Osteoporosis
Osteoporosis is a decrease in bone mass; in other words, quantity of
bone tissue, including both organic and inorganic components, in the
bones is reduced. It is different from osteomalacia and rickets, which
result from poor bone calcification. Osteoporosis occurs when the rate
of bony lamellae resorption exceeds the rate of lamellae deposition
during bone remodelling. This is particularly evident in the spongy
bone tissue.

The occurrence of osteoporosis increases with age and it is much

more common in women than men. Conditions that may result in
osteroporosis include primary endocrine abnormalities, inadequate
dietary intake or absorption of calcium (hypocalcaemia leads to
secondary endocrine abnormalities), chronic liver disease, inactivity.
The main endocrine abnormality that may cause osteoporosis is the
decreased production of estrogens, typical in postmenopausal women.
Other causes of estrogens depletion or activity reduction include
extreme exercise and amenorrhea, anorexia nervosa, and cigarette
smoking. Overproduction of PTH, glucocorticoids or T3/T4 can also
cause osteoporosis.

The loss of bone tissue makes bones porous and weakened, thus
prone to fracture. The most common fracture sites are the vertebral
bodies, neck of femur and distal part of the radius.

Comparison between normal and osteoporotic bone

Radiographic features of osteoporosis

Radiographic features of osteoporosis include reduced bone density,
loss of trabeculae, cortical thinning and fractures, such as vertebral
wedge compression fractures. Vertebral wedge compression fractures
may develop gradually and cause initially only mild or no symptoms,
but will later often lead to back pain, increased curvature of vertebral
column and loss of height.
Compression fracture of a vertebra
X-ray of the lumbar spine with a compression fracture of the
third lumbar vertebra

Bone density scanning

Dual-energy x-ray absorptiometry (DXA or DEXA) is currently the most
commonly used modality for the diagnosis of osteoporosis, allowing
fast, accurate, and noninvasive measurements of bone mineral density
(BMD). A bone density scan using DXA measures how much bone
mineral is in the area being scanned – usually the femur and lumbar
vertebrae. Although a DXA scan does not directly measure bone
strength, low bone mineral density diagnosed on a DXA scan should be
considered as a risk factor for fracture.

The scan results are commonly given as a standard deviation (SD), i.e.
the number of units above or below average in a young population
matched for sex and ethnicity. If the bone mineral density is 2.5 SD
below average (-2.5 SD), this is described as osteoporosis. Osteopenia
is the name for the category between normal and osteoporosis
(between -1 and -2.5 SD), when bone is less dense than the average
but not low enough to be considered osteoporotic.
Lumbar spine DXA image
Proximal femoral (hip) DXA image
 A joint is a union between two or more

bones of the skeleton. The synovial joint

in particular termed their trousers they

are much more mobile than cartilaginous

and fibrous joints. They also have particular

components and structures associated with

them and it is useful to learn to appreciate

the role of these components in joint health

and disease. The normal function of the

synovial joint is actually largely dependent

on the articular cartilage and synovial

fluid. These components make movements

of joints almost friction-free. The sumpvoa;

fluid is secreted by the synovial membrane

that surrounds the joint cavity. It is

rich in [ ] and hyaluronic acid which gives

it a viscous slippery texture similar to

that of a raw egg white. Importantly narrows

and lubricates the articular cartilage

and removes its metabolites because cartilage

actually is a vascular meaning it lacks

blood vessels. It’s repetitive compression

during movement is important to its nutrition

and waste removal. Each time a cartilage

is compressed fluid and metabolic waste

are squeezed out of it when weight is taken

off the joint the cartilage absorbes synovial

fluid like a sponge and the fluid carries

oxygen and nutrients to the Qandil sites

 inside so accordingly lack of regular exercise

or in particular joint and mobility because

the articular cartilage to deteriorate

more rapidly from lack of nutrition oxygenation

and waste removal. In fact many joint diseases

are associated with injury in the generation

of the Hireling cartilage on particular

surface of the bones or inflammation of

the synovial membrane. In this part of

the course you will see the structure and

function of joints in health and disease.

Synovial joint structure
Patient's case
A 37-year-old woman gradually developed painful wrists over 3 months
and the early morning stiffness that lasted for more than 30 minutes.
She attained some relief from ibuprofen, but, despite some initial
symptomatic improvement, the pain, stiffness and swelling of the
hands persisted and 1 month later both knees became similarly
affected. When pain stopped her from her favourite pastime,
gardening, she consulted her doctor.

On examination, wrists and the metacarpophalangeal joints of both

hands were swollen and tender. On investigation, she was found to
have a raised erythrocyte sedimentation rate (ESR 68 mm/h, normal
<20) and C-reactive protein level (CRP 38mg/l, normal <10) but a
normal haemoglobin and white-cell count. A test for rheumatoid
factor was positive (titre 1/64), and the cyclic citrullinated
peptide (CCP) antibody test was moderately positive (55 EU/ml,
normal <20). X-rays of the hands showed bony erosions in the heads of
the metacarpals.

By the end of this lesson, you will know what the possible diagnosis is.

Joints
A joint is a site at which two or more bones articulate. Some joints
permit no movement, some only slight movement and some are freely
movable.

Based on their structure, there are three types of joints: fibrous,

cartilaginous and synovial.
Types of joints
Fibrous joints
In a fibrous joint, the articulating bones are united by fibrous
connective tissue. There is no space between the bones and the joint
is typically immovable or only slightly movable. There are three
subtypes of fibrous joints: suture, syndesmosis, and gomphosis. In a
suture, typical of skull, cranial bones interlock along their margins. A
syndesmosis unites the bones with a sheet of fibrous tissue passing
between them. An example of this fibrous joint is the interosseus
membrane in the forearm, which joins the radius and ulna. Finally, a
gomphosis (dento-alveolar syndesmosis) is a particular type of fibrous
joint in which the periodontal ligament holds the roots of a tooth in a
dental alveolus.

Fibrous joints

Cartilaginous joints
In a cartilaginous joint, the articulating bone surfaces are united by
cartilage. In synchondrosis, a primary cartilaginous joint, bones are
united by a hyaline cartilage, such as that present during the
development of a long bone between the epiphysis and the diaphysis
(epiphysial cartilage). When bone growth is complete, the cartilage
ossifies and the joint converts to synostosis.

Symphysis is a secondary cartilaginous joint in which the articular

surfaces of bones, covered by a thin layer of hyaline cartilage, are
united by a fibrocartilage. These joints are slightly movable and
include the intervertebral joints, in which the fibrocartilaginous discs
unite the bodies of the adjacent vertebrae, acting as a shock absorber
and providing flexibility to the vertebral column. Another example is
the pubic symphysis, where the anterior parts of the pelvic bones join
through the interpubic fibrocartilage, also called interpubic disc.

Cartilaginous joints

Synovial joints
The bones articulating in synovial joints (also called diarthroses) are
united by a joint capsule, composed of an outer fibrous layer lined by
an inner synovial membrane. The fibrous layer of the joint capsule
continues with the periosteum investing the surface of bones. The
synovial membrane inserts along the margins of the articular surfaces
of the bones, covered by a hyaline cartilage (articular cartilage). The
joint capsule encloses an articular cavity, a potential space between
the articulating surfaces of bones, containing synovial fluid. Synovial
joints are reinforced by ligaments. Some synovial joints have an
articular disc or meniscus, formed by fibrocartilage, located internally
to the joint capsule.
Typical structure of a synovial joint

Characteristics of a synovial joint – articular cartilage

Hyaline articular cartilage forms a smooth surface cover on the ends
of the articulating bones. This cartilage is able to absorb compression
forces and protect the underlying bone from damage. Chondrocytes
produce collagen type II (gives tensile strength) and proteoglycans
(give compressive strength and bind water, which represents up to
80% of cartilage weight).

Cartilage does not contain any blood vessels. This means that it
receives its nourishment from the synovial fluid. The compressive
forces that occur at the joint actually help to move the nutrients and
metabolites, respectively, into (during “squeezing”) and out of the
cartilage (when the pressure is released during joint movements). This
is why the prolonged immobilization can cause deterioration of
articular surfaces and the regular use of joints is important to keep
them healthy.

Structural organization of collagen fibers and chondrocytes

within articular cartilage; scheme and section stained by
haemotoxylin and eosin (from Matsiko et al. Materials 2013;6:637-
668). Note the tidemark, at the interface between the calcified
and uncalcified cartilage.
 Characteristics of a synovial joint – synovial membrane
Synovial membrane of the joint capsule consists of the intima and
subintima layers. Loose connective tissue forms the subintima of the
synovial membrane and contains lymphatic and blood capillaries and
nerve fibers. The intima lies on the luminal surface of the synovial
membrane and exhibits a unique cellular lining formed by synovial
cells, called synoviocytes. These cells are responsible for
blood/synovial fluid exchanges that take place during the production
and absorption of the synovial fluid components.

Two types of synoviocytes, macrophagic-like type A and fibroblast-like

type B cells have been identified. Type A synoviocytes are non-fixed
cells that can actively phagocytise cell debris and wastes from the
joint cavity, and possess an antigen-presenting ability. Type B
synoviocytes send dendritic processes which form a regular network
on the luminal surface of the synovial membrane and are involved in
the production of specialized matrix constituents, including hyaluronic
acid, collagens and fibronectin. They are also implicated in the
pathogenesis of rheumatoid arthritis.

Characteristics of a synovial joint – synovial fluid

Synovial fluid is a clear, transparent, highly viscous fluid of egg-white
consistency. It is formed as an ultrafiltrate of plasma, thus it contains
some serum proteins and glucose in the same concentration as in the
blood. Synoviocytes secrete hyaluronic acid and proteoglycans, such
as lubricin. Normal synovial fluid contains also white blood cells.

Functions of synovial fluid:

 nutrient and waste transportation to/from articular cartilage;

 lubrication, reduction of friction;

 shock absorption, amortization;

 joint stabilization, as the thin layer of synovial fluid prevents the bone
ends from being separated during movements (comparable to water film
layer between two glass surfaces).
 Synovial fluid may be collected by a syringe in a procedure
called arthrocentesis. Depending on the clinical scenario, it can be
then analysed for cell number, cell type, and crystal or pathogen
presence. Based on the results, synovial fluid may be classified into
normal or pathological non-inflammatory, inflammatory, septic, and
hemorrhagic group.

Arthropathy
Arthropathy is a general term indicating any inflammatory and/or
degenerative joint disease. Degenerative joint disease (arthrosis) is
caused by a wear and tear of articular cartilage. Arthritis is a form of
arthropathy that is caused by inflammation of one or more joints and
typically presents itself as a painful swollen joint. Joint inflammation
can be caused by the presence of antibodies against its components,
deposition of crystalized metabolites or infection. Since practically
most of the joint diseases are associated with inflammation at some
stage, the term arthritis is often used as a general term for all,
degenerative and inflammatory joint diseases.

Some common types of arthropathy:

 degenerative joint disease (arthrosis, osteoarthrosis, often called

osteoarthritis);

 rheumatoid arthritis;

 crystal-induced arthritis (e.g., gout);

 infective arthritis.

Osteoarthrosis
Osteoarthrosis (or osteoarthritis) is defined as a non-inflammatory
localized degeneration of the hyaline cartilage on the articular surface
in synovial joints. It is common in weight-bearing joints (vertebral
column, hip, knee) and typically develops slowly, over many years to
decades.

Numerous factors predispose to osteoarthrosis:

 age >55 years, female;

 physical activity with repetitive movements associated with sport or
occupation;

 joint trauma, pre-existing joint disease or deformity.

Early degenerative changes consist in disruption of articular cartilage

surface, with increased water content and decreased proteoglycans in
the matrix molecular framework. Clinically, roughened articular
surface and minimal narrowing of joint space can be discernible. As a
degenerative process advances, it is associated with enzymatic
degradation and thinning of the articular cartilage. The underlying
subchondral bone becomes dense (sclerotic) and thickens.
Remodelling of gradually exposed bone tissue will proceed with the
formation of osteophytes (bone outgrowth or excrescence which
produce a bony spur or projection) and subchondral cysts.

Example of normal joint and joint with osteoarthrosis

Rheumatoid arthritis
While osteoarthrosis, the most common form of joint disease, is
caused primarily by the degeneration of the articular cartilage, in
rheumatoid arthritis, it is the synovial membrane that becomes first
inflamed, causing pain and swelling. Articular cartilage erosion may
follow.

Rheumatoid arthritis is a progressive inflammatory autoimmune

disease with articular (commonly in joints of the hand and feet) and
systemic effects (including skin, lungs, heart, blood vessels).
The pathogenesis is not completely understood and
many pathways may be involved. Development of autoimmunity may
be triggered by microbial infection, possibly by viruses, in genetically
susceptible people. Auto-antibodies against Fc fragments of patient’s
IgG (rheumatoid factors) are formed and are often found in blood and
the synovial fluid.

The patient in our clinical case, described at the beginning of this

lesson, presents many typical signs and symptoms of rheumatoid
arthritis. Patient education and counselling help to reduce pain,
disability, and frequency of physician visits.
Advanced rheumatoid arthritis of the hand and wrist in x-ray: the
joint spaces are narrowed, there are erosions and subluxations of
the metacarpophalangeal joints and deformations of the
interphalangeal joints

Features of the two main types of arthropathy

Characteristics of a synovial joint – ligaments

Ligaments are connective tissue structures that typically stretch
between two bones. They are made of collagen fibers (primarily type I
collagen) and attach to bones directly, with dense connective tissue of
ligament mingling with that of periosteum, or via a fibrocartilagineous
segment. Only few, like the ligamenta flava between the vertebrae or
ligaments of auditory ossicles, are rich in elastic fibers.

Some ligaments appear as thickenings of the fibrous joint capsule

(e.g., glenohumeral ligaments in the shoulder joint), while others form
discrete structures (e.g., anterior and posterior cruciate ligaments in
the knee joint). Those that bind the articulating ends of bones are
called intrinsic, while extrinsic ligaments spread between the bones
away from the joint.

Ligaments tighten during joint movements, thus provide stability to a

joint, limiting excessive and allowing for a physiological range of
motion. Similarly to joint capsule, most ligaments serve as sense
organs, because of their rich nerve supply, and are important in
monitoring the position and movements of joints (proprioception).

Ligament injuries
In adults, ligament is the weakest component of a joint and excessive
stress at a joint can damage it. Ligament injuries are called sprains
and are graded into grade 1 - stretching, grade 2 - partial tear, and
grade 3 - complete tear of ligament. Common examples of ligament
injury include ankle sprain, when the foot inverts excessively and
ligaments on the lateral side of the ankle joint are stretched or thorn,
and anterior cruciate ligament rupture, which typically occurs in
soccer players.

Healing is usually slow and the ligament can take a long time to return
to its original strength. Depending on ligament and grade of damage,
treatment may require only immobilization (keeping the limb elevated,
cooling the area of sprain and wrapping it in an elastic compression
bandage are usually sufficient to relieve mild ligament sprain) or even
surgical repair.
According to the shape of the particular

surface synovial joints can be classified

into plain cylindrical pivot or hinge cylindrical

joints saddle Conde de la and Boland socket

joints let’s see some examples now so the

next time you read about a particular joint

you know its general structure and movement

joint just by using this times. The particular

surfaces of a plain joint unusually flat

and the opposed surfaces glide or slide

in the plane of the particular surfaces

hence it is a unique axial joint. This

is for instance the [ ] clavicle joint

between the exclusion of the scapula and

the clavicle. In the cylindrical joint

their post articular surfaces are cylindrical

but one is full while the other is hollow.

In this case the joint is called pivot

joint when the other surface instead is

trough shaped the joint is called hinge

joint and didn’t or couldn’t envision actually

of the upper limb we can see both types

of the cylindrical joint. The pivot joint

forms between the head of traders and radio

a notch on the ALMO then here there is

this ligament that actually completes a

ring around the head of radius so as a

consequence this is a uni axil joint as

the movement occurs along longitudinal

axes of the radius and this movement is

called [ ]. And then in the same region

there is the hinge joined with it full

cylinder formed by a troika on the humans

and that trough shaped chocolate troika

notch this talent a of the humorous and

then dropped a notch on Diana and this

is the movement of flexion an extension

permitted at the level permitted by the

hinge joint so again this is a uni axil

joint as well as the movement of crises

sagittal plane around transverse excess.

In the saddle joint the opposing particular

surfaces are shaped like a saddle so they

both have a concave and convex area and

concave surface of one bone fits into convex

surface of the other and vice versa. The

movement occurs around two axes so at right

angles to each other so this is biaxial

joint as an example you can see permit

or carpal joint off thumb it is a saddle

joint between repeats one of the Kabul

boats in the first metacarpal bone. This

joint permits abduction and abduction as

well as flexion and extension of the thumb.

In the condola joint which is also called

ellipsoid joint they’ll posed a particular

surfaces are ellipsoid one is convicts

in forms corn Dial and the other is concave.

Example metacarpal joints in the hand also

this type of joint is biaxial it better

meets flexion and extension as well as

abduction and abduction. You will note

that in both subtle and Qandil adjoins

it is possible also to perform this movement

in a circualr sequence and this movement

is called circle induction. And finally

multi axle ball and socket joints. Here

we have this furore they’ll surface hence

ball in the name of the joint but anatomy

this part of the bone will be called head

and this head moves within a cap shaped

cavity so socket of another bone. This

is an example the hip and shoulder joints

are of this type. These joints allow movements

around multiple axes so we have flexion

and extension abduction and reduction medial

and lateral rotation and again second action

all these movements are possible. Now you

can review what you’ve just heard and see

the schemes and radio graphic images showing

different types of joints in the following

slides.

Synovial joint movements

Synovial joint classification
The articulating surfaces of synovial joints have a variety of shapes,
which determine type of movement allowed at a joint. Hence, based on
the shape of articulating facets and the type of movement they permit,
these joints can be classified into five major types: plane, cylindrical,
condylar, saddle, and ball and socket joints.
Types of synovial joints

Plane joint
The opposed articular surfaces of a plane joint are nearly flat and slide
or glide one over the other (uni-axial joint). Range of movement is
limited by a tight joint capsule. There are many plane joints in our
skeleton; the examples are the acromioclavicular joint, between the
acromion of the scapula and the clavicle, and the zygapophysial joints,
between the articular processes of the adjacent vertebrae.
Plane joint

Cylindrical joints
In the cylindrical joints, the opposed articular surfaces are cylindrical;
one is full, while the other is hollow or trough-shaped.

In a pivot joint, a cylindrical process of one bone rotates within a ring

of another bone (if the bony ring is incomplete, it may include fibrous
tissue). Hence, this is a uni-axial joint. The median atlanto-axial joint is
a pivot joint in which the first cervical vertebra (atlas) rotates around a
finger-like process (dens) of the second cervical vertebra (axis) during
lateral rotation of the head. Another example is a proximal radio-ulnar
joint, where the head of the radius rotates in a ring formed by the ulna
and the anular ligament.
In a hinge joint, the convex surface of a cylindrical or rounded process
on one bone fits into the trough-shaped concave surface of another.
Hinge joints permit flexion and extension only, which occur in a
sagittal plane around transverse axis, thus they are uni-axial joints.
The humero-ulnar joint at the elbow and interphalangeal joints in the
digits are hinge joints. To allow movement, the joint capsule may be
thin and lax anteriorly and posteriorly, but the joint is stabilized by
strong, laterally placed, collateral ligaments.

Cylindrical joints

Condylar joint (ellipsoid joint)

In a condylar joint, the opposed articular surfaces are ellipsoid - one is
convex, and forms a condyle, and the other is concave. This type of
joint permits flexion and extension, as well as abduction and
adduction. These movements occur in two planes around two axes at
right angles to each other; thus, it is a bi-axial joint. It is also said to
have two degrees of freedom. Movement in one plane (sagittal) is
usually greater than in the other (frontal), as in the case of the wrist
joint or metacarpophalangeal joints at the knuckles.
Condylar joint

Saddle joint
A saddle joint forms when the opposing articular surfaces are shaped
like a saddle, i.e., they both have concave and convex areas and the
surface of one bone fits the reciprocal surface of the other. Saddle
joints permit abduction and adduction, as well as flexion and
extension; thus they are bi-axial joints. The circumduction is also
possible. The sternoclavicular joint and the carpometacarpal joint of
the thumb are saddle joints.

Saddle joint

Ball and socket joint (spheroidal joint)

In a ball and socket joint, the spheroidal surface (usually called head)
of one bone moves within a cup-shaped cavity of another. This joint
allows movements in all three planes around three axes: flexion and
extension, abduction and adduction, medial and lateral rotation, and
circumduction. Thus, ball and socket joints are said to have three
degrees of freedom and are called multi-axial joints. The hip and the
shoulder joints are of this type.

Ball and socket joint

Summary
A joint is a union between two or more bones of the skeleton. The
synovial joints are termed diarthroses. They are more mobile than
cartilaginous joints and fibrous joints. Based on the shape of articular
surface, the synovial joints can be classified into plane, cylindrical
(pivot or hinge), saddle, condylar or ball and socket joints. The normal
function of the synovial joints is largely dependent on the articular
cartilage and synovial fluid properties. Many joint diseases are
associated with inflammation of the synovial membrane and
degeneration of the hyaline cartilage on the articular surface.

virtually all sales has constructed properties

which are essential for sub division or

migration only the muscle says this function

is expressed at its most and serves to

produce mechanical work at the organ and

system level. Skeletal muscle indeed is

an organ which consists of long cylindrical

cells called muscle fibres or microfibres

in the microfibres the number localisation

and function of practically all organelles

are dictated by and dedicated to the same

function of the cell as a whole in this

construction accordingly skeletal muscle

contraction is responsible for movement

of the body and its parts. Skeletal muscle

and its fibres are described as voluntary

and striated. The first term refers to

the fact that we normally have conscious

control over skeletal muscles as they are

innovative by somatic mortal neurons. The

second term refers to the presence of alternating

light and dark bands or striations which

can be visible when observing intoxicating

stained longitudinal sections of the skeletal

 muscle fibres in light microscope. At much

higher level of resolution offered by an

electron microscope one can see that these

bans are created by the regular pattern

of cytoplasmic protein filaments that actually

cause muscle contraction and these are

called myofilaments. There are two types

of myofilaments so called thin myofilaments

are composed mainly of the protein acting

with important associated proteins [1:59]

Thick myofilaments instead are composed

of two hundred to three hundred miles in

molecules this to have complex yet very

precisely regulated interactions with the

act in filaments sliding along the miles

in filaments within the structural and

functional units called sad commuters and

this actually represents basic events responsible

of muscle contraction regulation of contraction

then involves calcium irons Sakho plasma

critical transfers tubular system and acting

associated proteins so first I invite you

to get better acquainted with all these

structures and molecules.

 Skeletal muscle structure:
from myofibers to
myofilaments
Patient's case
A 25-year-old woman presents with recurrent slurring of speech that
worsens as she continues to talk. She has trouble swallowing, which
deteriorates halfway through the meal, and has double vision that gets
worse when reading or watching TV. She reports that her head is
heavy and hard to hold up. Her symptoms have progressively
deteriorated over the past 6 months. She is fearful of falling due to her
legs giving way and she has trouble combing her hair. She complains
of generalized fatigue and is occasionally short of breath.

You will be able to associate the patient’s symptoms with one of the
neuromuscular disorders by the end of this lesson.

Skeletal muscles
There are more than 600 muscles in the body, which together account
for about 40 percent of a person's weight. Most skeletal muscles have
names that describe some feature of the muscle. Often several criteria
are combined into one name. Associating the muscle's characteristics
with its name will help you learn and remember them. The following
are some terms relating to muscle features that are used in naming
muscles:

 size - vastus (huge), maximus (large), longus (long), minimus (small),

brevis (short);
 shape - deltoid (triangular), rhomboid (like a rhombus), latissimus
(wide), teres (round), trapezius (like a trapezoid);

 direction of fibres - rectus (straight), transverse (running across),

oblique (diagonal), orbicularis (circular);

 location - pectoralis (chest), gluteus (buttock), brachii (arm); supra-

(above), infra- (below), sub- (under or beneath), lateralis (lateral);

 number of origins - biceps (two heads), triceps (three heads),

quadriceps (four heads);

 origin and insertion - for example, sternocleidomastoideus (origin on

the sternum and clavicle, insertion on the mastoid process), brachioradialis
(origin on the arm, insertion on the radius);

 action - abductor (abducts a structure), adductor (adducts a structure),

flexor (flexes a structure), extensor (extends a structure), levator (elevates a
structure), masseter (for chewing).

Skeletal muscles can be classified based on the arrangement of fibre

fascicles into circular, convergent, parallel, fusiform, and pennate
(unipennate, bipennate, multipennate muscles).
Most common types of muscles based on the arrangements of fibre
fascicles

Skeletal muscle structure

Skeletal muscles are organs formed by skeletal muscle fibers, satellite
cells, and connective tissue. The entire muscle is surrounded by the
layer of connective tissue called epimysium. From here, connective
tissue extends inward and forms perimysium around the fascicles of
skeletal muscle fibers. Finally, a thin layer of connective tissue, called
endomysium, surrounds each muscle fiber and is connected to its
mebrane via specialized proteins of the costameres. The connective
tissue of the muscle constitutes the passive elastic component, as it
lengthens or shortens working parallel with the muscle fibers and their
contractile units (sarcomeres).

At the myotendinous junction, tension generated within the muscle is

transmitted onto the connective tissue of the tendon, which attaches
to a bone and becomes continuous with the periosteum.

Structure of a skeletal muscle

Satellite cells
Satellite cells are small mononuclear cells with scant cytoplasm,
interposed between the sarcolemma and the basal membrane of the
skeletal muscle fibre. These cells represent myogenic precursors of
muscle cells and are responsible for the skeletal muscle ability
to regenerate after injury. The self-renewing proliferation of satellite
cells not only maintains the stem cell population but also provides
numerous myogenic cells, which proliferate, differentiate, fuse, and
lead to new myofibre formation and reconstitution of a functional
contractile apparatus.

Skeletal muscle fiber

Each muscle fiber (myofiber) forms from many precursor cells
(myoblasts) that fuse together during development; thus skeletal
muscle fibres are multinucleated and form elongated cylinders (up to
40 mm long and 0,1 mm wide). The membrane of the skeletal muscle
fiber is called sarcolemma, while the cytoplasm is called sarcoplasm.
The sarcolemma forms a physical barrier against the external
environment and also mediates signals between the motor neuron
terminal and the muscle cell. The sarcoplasm is the specialized
cytoplasm of the striated muscle fiber that contains the usual
intracellular organelles along with many mitochondria, a modified
endoplasmic reticulum known as the sarcoplasmic reticulum, the
bundles of myofibrils, glycogen granules, and myoglobin.

In most skeletal muscles, each fibre extends through the entire length
of the muscle. Typically, each fiber is innervated by one motor neuron
terminal, located near the middle of the fibre.

Sarcoplasmic reticulum
Sarcoplasmic reticulum of a skeletal muscle fiber corresponds to the
endoplasmic reticulum of other cells and it represents a storage space
for calcium ions. It consists of terminal cisternae connected by a
system of parallel sarcotubules, surrounding and running parallel to
myofibrils. Invaginations of the sarcolemma, called transverse tubules
(T-tubules) lie between the two adjacent terminal cisternae of the
sarcoplasmic reticulum (these three structures form a triad) and bring
the stimulus that triggers calcium release. The release of calcium from
the sarcoplasmic reticulum is an important step in muscle contraction,
responsible for excitation-contraction coupling.
Sarcoplasmic reticulum and T-tubules

Myofibrils
Each muscle fiber contains several hundred to several thousand
myofibrils in the sarcoplasm. The myofibrils play a fundamental role in
the muscle contraction mechanism. Each myofibril contains two types
of myofilaments, thick myosin filaments and thin actin filaments,
which are distributed in a highly organized manner, forming numerous
sarcomeres along the myofibril. This particular organization of thick
and thin myofilaments into sarcomeres is responsible for the presence
of dark and light transverse bands visible in skeletal muscle fibers at
microscopic examination.
Myofibril

Skeletal muscle fibres at microscopic examination

Sarcomere
Each sarcomere stretches between the two Z lines, which are the
sites of attachment for thin myofilaments. From here, thin
myofilaments run towards the centre of the sarcomere, forming its
light bands (I bands, i.e. isotropic bands), until they overlap thick
myofilaments. Where thick myofilaments are present, the dark band (A
band, i.e. anisotropic band) forms along the sarcomere. As the thin
myofilaments overlap the thick ones only in the peripheral part of the
A band, the slightly lighter H zone, which contains thick myofilaments
only, is visible at its centre. This is crossed by the M line, which is an
attachment site for thick myofilaments.

Sarcomere

Thick and thin myofilaments

Thick myofilaments are composed of many molecules of the protein
myosin. Each myosin molecule consists of two twisted protein strands,
resolving into two globular heads at one end. The heads of myosin
molecules project outward along the length of the thick myofilament.
They can reversibly attach to the thin myofilaments and bend, using
energy released due to their ATPase activity, thus pulling the thin
myofilaments deeper inside the A band of the sarcomere.

Thin myofilaments are composed of double strands of actin twisted

into a helix. Actin monomers are globular and each has a binding site
for the myosin head. Two other proteins, tropomyosin and troponin,
associate with actin filaments. In a troponin-tropomyosin complex,
each rod-shaped tropomyosin is held in the longitudinal groove of the
actin helix by a troponin, blocking the binding sites for the myosin
head until the stimulus for muscle contraction arrives.
 Thick and thin myofilament structure

Filament associated proteins

Accessory proteins maintain precise alignment of thin and thick
filaments and keep them at an optimal distance from one another in
every sarcomere. These structural proteins include the following:

 titin, one of the largest proteins in the body (about 2.500 kDa), which
crosses the half-sarcomere from the Z line to the M line and acts as the
framework that maintains the position of the thick filaments during muscle
contraction; within the I-band, titin is extensible and functions as a
 molecular spring that develops passive tension upon stretch; in the A band,
titin is inextensible due to its strong interaction with the thick filament;

 alfa-actinin, which anchors the thin filaments at the Z line;

 nebulin, which runs along the thin filaments, anchoring them at the Z
line and regulating their length during muscle development;

 myomesin, which holds thick filaments in register at the M line;

 desmin, which forms intermediate filaments that attach sarcomeres to

one another and to the plasma membrane, thus stabilizing cross-linking
between neighbouring myofibrils.

Titin, together with its ligands in the Z-disk, I-band, and M-line region
of the sarcomere, probably acts as a “tensiometer” and when it senses
that stress levels rise or fall beyond physiological limits, it triggers
adjustments in muscle structural and functional characteristics.

Sliding filament theory of muscle contraction

The myofilaments play a fundamental role in the muscle contraction
mechanism. According to the sliding filament theory (H.E. Huxley and
J. Hanson, 1954), when muscle contracts, the thin myofilaments slide
past the thick myofilaments, being pulled towards the centre of the
sarcomere from its both ends. When this occurs, the filaments do not
change their length (neither does the A band, determined by the length
of the myosin filaments), but as the zone of filament overlap increases,
the I and H bands get narrower, and the Z lines move closer together,
shortening the sarcomere.
Sliding filament model of muscle fibre contraction
 Skeletal muscles are richly innovative

by motor neurons that originate in the

spinal cord and then running the spinal

nerves or originate from the brainstem

and then run into cranial nerves. The excellence

of these neurons branch as they approach

the muscle and here they give rise to tweaks

or taming of branches that end on individual

on muscle fibres. The area of the functional

contact between the accent terminal and

the muscle fibre is called neuromuscular

junction. Here are suited colin released

from the accent a minute into the synaptic

cleft binds receptors on the circle. This

causes deep polarisation of the suckling

next two tubes bring it into the cell towards

the plasma the interaction between the

two tubes and the systems of the sucker

plasma in particular initiates massive

calcium release and we’ve already seen

in the first part the role of costume in

triggering muscle contraction. This whole

process is called excitation contraction

coupling the sliding off myofilaments that

follows causes sad commute shortening the

core players of the mechanism of filment

sliding are calcium and magnesium as well

as ATP. Briefly once calcium is released

from the sacroplasmic reticulum it binds

to a trope on in sub unit this causes conformational

changes in Trapani anthropomorphising complex

in uncovers the introduction sites between

acting and miles in sodomising heads in

the thick filament combine to act in the

thin filaments. Magnesium ions on the other

hand are necessary for ATP activity optimising

heads hydrolysis of ATP releases the energy

which is then used to move the Myerson

head with the act in myofilament to which

it is attached. Now if you follow again

the mechanism of filament sliding you will

notice that the new molecule of ATP has

to arrive at the Myerson head in order

to separate it from the acting and make

it returned to its original right angle

with respect to the acting myofilament.

What happens when the ATP isn’t there anymore

the thick filaments remain attached to

the thin filaments and the whole system

becomes rigid and that’s exactly what happens

after death when blood supply to massive

cells ceases and there are no substrates

for energy production. A condition known

to forensics as rigor mortis to you it

should have to remember one of the stages

of the filament sliding theory ATP is needed

to detach the Mizen Head from the active.

Now it’s time to ask and see how the interactions

between myofilaments leading to the shortening

of the sarcoplasm generate false at the

level of cell membrane and provoke shortening

of the entire cell there has to be a system

that transmits the forces generated inside

the cell and the circle and muscle connective

tissue the structure with this function

is called costamere. It is composed of

Newman’s proteins that interact one with

the other. Of this this often has a particular

significance it is located in the south

just beneath the circle and binds to act

in the sacro then two groups of transmembrane

glycol proteins link dystrophin to the

extrasolar protein looming. Importantly

absence of dystrophin causes muscle fibre

damage during construction and on the whole

it causes progressive muscular weakness

this condition results from genetic mutations

that affect dystrophin expression and it

is called duchenne muscular dystrophy.

This suffering is encoded by the X chromosome

which explains why only boys suffer from

duchenne muscular dystrophy but other forms

of muscular dystrophy are also known and

they can be close mutations in genes of

other costamere related proteins. Currently

there is no cure for muscular dystrophy

and available treatment mostly aimed at

controlling symptoms to maximise quality

of life. The ongoing research efforts are

dedicated to the possibility of gene therapy

or stem cell transplantation for treatment.

You may want to explore these fields in

your future studies and work for now let’s

review the basics.

Skeletal muscle contraction
Motor neuron and motor units
A skeletal muscle fibre contracts upon stimulation by a motor neuron.
As the axon is extensively branched near its termination, one motor
neuron can form a neuromuscular junction with many muscle fibres. A
motor neuron and all the muscle fibres it controls form a motor unit.
When a motor neuron, with its body in the spinal cord, is stimulated, it
initiates a cascade of events that causes all the muscle fibres in the
motor unit to contract simultaneously.

The number of muscle fibres in a motor unit varies from one to several
hundred, according to the size and function of the muscle. Large trunk
and thigh muscles are formed by large motor units, in which one motor
neuron supplies hundreds of muscle fibres, while small hand muscles,
responsible for precision movements, contain the motor units that
include only a few muscle fibres. During movement, an increasing
number of motor units is sequentially recruited for effective muscle
contraction.

Motor units

Neuromuscular junction
Each skeletal muscle fibre has a specialized area of interaction with
the motor neuron, called motor endplate, where mitochondria
accumulate and sarcolemma is extensively folded. When a nerve
action potential reaches the axon terminal, synaptic vesicles release
acetylcholine into a small gap, called synaptic cleft, that separates
the membrane of the neuron from the motor endplate on the muscle
fibre. Acetylcholine diffuses rapidly across the synaptic cleft and binds
to the acetylcholine-gated ion channels (nicotinic acetylcholine
receptors) inserted in the sarcolemma of the motor endplate. As a
consequence, these channels open and allow large quantities of
sodium ions to diffuse into the muscle fibre. This initiates an action
potential, which travels along the sarcolemma and its T-tubules
(positioned at the A-I band junction of the sarcomeres) towards the
terminal cisternae of the sarcoplasmic reticulum.
Neuromuscular junction
Neuromuscular junction disorders
Several diseases are associated with the inefficient transmission of
the stimulus at the neuromuscular junction. Botulism, for example,
develops due to the action of botulinum toxin, a neurotoxic protein
produced by the bacterium Clostridium botulinum, which prevents the
release of acetylcholine from the vescicles in the axon terminal.

Myasthenia gravis is a heterogeneous autoimmune disease, with a

postsynaptic defect of neuromuscular transmission. The symptoms
can be caused by autoantibodies (IgG) against nicotinic receptors for
the acetylcholine. In their presence, the neurotrasmission is
inefficient, as the number of available receptors is reduced and fewer
excitatory endplate potentials can be produced even if the amount of
the released acetylcholine is normal.

Normally, when the frequency of action potentials reaching the axon

terminal is high, the amount of acetylcholine released by the
presynaptic motor neuron decreases, because of a temporary
depletion of the neurotransmitter stores (a phenomenon termed
presynaptic rundown). In myasthenia gravis, inefficient neuromuscular
transmission, together with the presynaptic rundown phenomenon,
results in a progressive decrease in the amount of muscle fibers being
activated by successive nerve impulses. This explains the fatigability
seen in myasthenia gravis patients.

Excitation-contraction coupling
The opening of the voltage-sensing dihydropyridine receptor (DHP) L-
type Ca2+ channels in the T-tubules activates ryanodine receptors,
which are expressed in the membranes of the terminal cisternae and
mediate the release of calcium ions from the sarcoplasmic reticulum
into the sarcoplasm. The calcium ions bind with the troponin and
cause its conformational changes that move the tropomyosin deeper
into the actin filament groove, exposing the interaction sites with the
myosin head. The sliding of the thin myofilaments along thick
myofilaments can take place.
Cross-bridge cycle
Myosin heads contain the ATPase, which catalyses the breakdown of
ATP to ADP and phosphate. This reaction puts the myosin head in such
conformation that it extends perpendicularly toward the actin
filament. When the troponin-tropomyosin complex binds with calcium
ions and active sites on the actin filament are uncovered, the myosin
heads can bind with actin. The bond causes a conformational change
in the head that tilts toward the myosin tail. The energy that activates
this power stroke for pulling the actin filament is the energy stored in
the myosin head at the moment of the ATP cleavage. Once the power
stroke develops, the ADP and phosphate detach and a new molecule of
ATP can bind to the head of myosin. When a new ATP binds, the head
is released from the actin binding site. Cleavage of ATP again “cocks”
the head back to its perpendicular position. This cross-bridge
cycle can repeat over and over as long as calcium ions and ATP are
present.
Cross bridge cycle events
Relaxation
When nerve impulses terminate, the acetylcholine that remains in the
synaptic cleft is rapidly cleaved by acetylcholinesterase. As the
activation of acetylcholine-gated ion channels in the motor endplate
ceases, calcium is no longer released from the sarcoplasmic
reticulum, while the ATP-dependent pump, called Sarco/Endoplasmic
Reticulum Ca2+-ATPase (SERCA), actively transports calcium ions back
from the sarcoplasm into the cisterns. As a consequence, the troponin-
tropomyosin complex blocks the active sites on the actin filaments
and the muscle fibre relaxes.

Costameres
For muscle contraction to function properly, there is a need for not
only sarcomeres, but also costameres. These are complex structures
associated with the sarcolemma that, on one hand, maintain cell
structure during muscle fibre contraction, on the other hand, allow
muscle fibre adhesion to the extracellular matrix and transmission of
tension developed at the sarcomeres to the connective tissue within a
muscle. An extensive list of costameric proteins and their putative
molecular partners has been created over the past decades. Many of
these proteins are associated with muscle wasting disease when
ablated or mutated.

Dystrophin, the product of the gene that is defective in Duchenne

muscular dystrophy, plays central role in assembling and maintaining
the link between cytoskeletal actin and the extracellular matrix and it
is important in the maintenance of the sarcolemma integrity.
 Summary of the events during muscle fibre contraction

1. An action potential reaches a motor neuron axon terminal and

acetylcholine is released into the synaptic cleft at the neuromuscular
junction.

2. Acetylcholine activates channel proteins, nicotinic receptors, on the

motor endplate and sodium inward flow initiates depolarization of the
sarcolemma.

3. Muscle action potential travels along the T tubules, which activate

ryanodine receptors in the membranes of the sarcoplasmic reticulum.

4. Sarcoplasmic reticulum releases calcium ions, which bind to the

troponin.

5. Troponin-tropomyosin complex uncovers the myosin docking site on

actin filaments.

6. Myosin heads bind to the actin filaments, causing it to slide.

7. Calcium ions are actively pumped back into the sarcoplasmic

reticulum and troponin-tropomyosin complex covers the active sites on actin
filaments.

8. Muscle fibre contraction ceases until a new muscle action potential

comes along.
The vertebral column supports the weight

of the body and contains the spinal cord

and spinal nerves radishes with their major

coverings and vessels. It is a strong but

flexible structure composed of a series

of vertebrae with associated introverted

discs that are stacked one on top of the

other. There are seven cervical 12 thoracic

5 lumbar vertebrae and then the sacrum

and coccyx are formed by fused vertebrae

five in the sacrum and three four in the

coccyx so all together we have 32 - 33

vertebrae the number of the introverted

discs is much lower as they are absent

from between the first and second cervical

and from between all the sacral and then

all the coccygeal vertebrae. At birth the

vertebral column shows the primary curvature

and it is concave anti-viral but as the

infant lifts its head and then with time

stands up to walk secondary care which

is developing the cervical and lumber regions

and these are concave posteriorly they

are called low doses so in the adult there

will be a cervical low doses and lumber

low doses while the concave anterior curvatures

they persist in the thoracic and sacral

coccygeal region and they are called Kye

forces a typical vertebra has a body two

particles imagine from the posterior surface

of the body into laminar which fuse the

origin of the spine process and then latterly

there are two transfer processes the posterior

surface of the body together with the arch

formed by the pedals and Flamini surround

the vertebral for Hayman there are another

four processes and these are inferior and

superior articulate processes they have

particular faces which for Psychoville

joints with their respective faces it’s

on the vertebral above and below the orientation

of this articulate face it changes from

one vertebral region to the other and this

will actually determine largely the type

of movement made in different regions of

the vertebral column and then there are

introverted discs these are made of fibre

cartilage which forms so called Oculus

fibrosis and closing it gelatinous nucleus

poll pauses these structures are responsible

for shock absorption during movements.

The typical veracity of the same region

share common structure a typical cervical

vertebrae from C3 to C6 have a relatively

small but wide body. The edges of the upper

surface turned upwards before they form

so called unconscious and it makes actually

the other aspect of the cervical vertebrae

look like an armchair ankle vertebral joints

so can be present between the bodies of

the adjacent cervical vertebrae. What’s

also unique in this region is the presence

of the forearm earner in the transverse

processes the vertebral artery which is

a branch of the Sub Club in Ottery runs

through this phenomena along the neck towards

the cranial cavity starting from the C6

from the transfer framing of the six cervical

vertebrae. It’s also evident that the spines

process is by feet the orientation of the

particular favourites in this region can

be approximated us nearly horizontal and

it’s easy to remember just by keeping in

mind that that Khan dials of the occipital

bone of the skull sit on the first cervical

vertebra. For this reason the C1 is called

Atlas and it shows some important distinct

features so you can say doesn’t have it

body but it has two lateral masses that

are linked by a short anterior and why

the posterior arch. C2 which is the access

is also particular as it has this peg like

tens or Don toyed process that projects

superiorally from the body and this dense

actually lies behind the anterior arch

of the atlas and then C7 vertebra this

has a very prominent spines process which

is not by fit anymore and it is easily

palpable along the neck. The thoracic vertebrae

have borders that are longer onto posterity

the spineless processes are also quite

long and point downwards what’s unique

the bodies and the transverse processes

show Face it for the ripes let’s remember

also the orientation of the superior articulate

faces on the superior articulate processes

they look posteraro laterally thin figure

once of course we believe that in the opposite

direction as they are articulate with a

superior that secular processes of the

vertebrae below the land vertebrae are

the largest with a wide weight-bearing

bodies then they have a short Lemina spineless

process orientated in the saddle play their

particular face it’s are also nearly in

the saddle plain and the superior ones

look merely and finally as already said

sacrament coccyx form distinct bones following

fusion of the vertebrae. Now you can use

the following material to review the structure

of the vertebral column in this lesson.

Vertebral column structure
Vertebral column
The vertebral column comprises 33 vertebrae and a lower number of
the intervertebral discs. There are 7 cervical, 12 thoracic, 5 lumbar, 5
sacral (fused), and 4 coccygeal (fused) vertebrae, which form
corresponding regions of the vertebral column. The vertebral column
supports the head and trunk for posture maintenance and movements,
provides attachment for the limbs, and encloses the spinal cord.
Vertebral column regions
Vertebral column curvatures
The vertebral column in adults has four curvatures in a sagittal plane.
The thoracic and sacral kyphoses are concave anteriorly and are
present already in the fetus (hence, they are primary curvatures). The
cervical and lumbar lordoses are convex anteriorly and become
apparent postnatally, when infants begin to raise and hold their head
erect and then toddlers begin to assume the upright posture (hence,
they are secondary curvatures).
Vertebral column curvatures
Typical vertebra
Although each vertebra is unique, most vertebrae share a typical form
and have an anterior vertebral body and a posterior vertebral arch; the
latter is formed by paired pedicles (which attach to the vertebral body)
and paired laminae (which converge posteriorly towards a spinous
process). Seven processes extend from the arch: paired superior and
inferior articular processes, which participate in synovial joints with
adjacent vertebrae, paired transverse processes and a median spinous
process, for muscle attachment and leverage. A small superior and a
larger inferior vertebral notch flank the pedicle.

The vertebral arch and the posterior surface of the vertebral body form
the walls of the vertebral foramen. The combined vertebral foramina of
all the vertebrae form the vertebral canal (spinal canal), which
contains the spinal cord and the roots of spinal nerves that emerge
from it, as well as the meninges, vessels and fat that surround them.
The superior vertebral notch of the vertebra below, the inferior
vertebral notch of the vertebra above and the intervertebral disc
between the two vertebrae limit the intervertebral foramen, through
which a spinal nerve emerges.

Typical vertebra
Radiographic anatomy of the vertebral column
When reviewing the radiographs of the vertebral column, the following
features should be assessed in each region:

vertebral alignment – smooth lines should run along the anterior

margin of the vertebral bodies, along the posterior margin of the
vertebral bodies and along the bases of the spinous processes;

spinous process alignment – the spinous processes should lie in a

straight line on the AP view and be equidistant on the lateral view;

vertebral body height – the vertebral bodies should have a relatively

uniform rectangular shape; in the frontal projection, each vertebral
body displays two pedicles, which project as small ovals on each side
of the vertebral body;

disc space height – in the thoracic spine they are usually slightly
decreased in height with respect to the cervical spine, but equal to
each other in height within the same region; in the lumbar spine, the
disc spaces progressively increase in height with each successive
vertebrae to reach maximum at L4/L5 intervertebral disc;

prevertebral soft tissues – swelling may be present in bone injury.

Typical cervical vertebrae

The cervical vertebrae are the smallest of the 24 movable vertebrae,
as they bear less weight than the thoracic and lumbar vertebrae.
Typical cervical vertebrae, C3-C6, have a small body, which is wider
from side to side than anteroposteriorly. Lateral edges of the superior,
concave surface of the body turn upward, forming an uncinate process
(uncus of body). The vertebral foramen is large and triangular. The
spinous process is bifid, while the transverse processes each have a
foramen transversarium, for the vertebral vessels, and terminate with
the anterior and posterior tubercle. The articular processes bear the
articular facets that are nearly horizontal. The C7 vertebra is marked
by the longest, palpable spinous process (not bifid), hence it is called
vertebra prominens.
Seventh cervical vertebra, called vertebra prominens
Typical cervical vertebra

Atypical cervical vertebrae

C1, the atlas, lacks a vertebral body and spinous process. It is ring-
shaped, with its anterior and posterior arches that are connected on
each side by the lateral masses. The lateral masses have the superior
articular surfaces, for the articulation with the occipital condyles, and
the inferior articular surfaces, for the lateral atlanto-axial joints. The
anterior arch bears a facet for dens of the axis on its internal surface.

C2, the axis, has a peg-like dens projecting superiorly from its body.
This odontoid process has anterior and posterior articular surfaces for
the median atlanto-axial joint.
Atlas (C1 vertebra), superior view
Axis (C2 vertebra), posterosuperior view

Radiographic anatomy of the cervical region

In the lateral view of the cervical spine, three parallel arcuate lines
should smoothly run along (1) the anterior aspects of the vertebral
bodies, (2) the posterior aspects of the vertebral bodies, and (3) the
junctions between the lamina and the spinous process. Alterations in
the curvature of these lines may indicate spinal fracture or
subluxation, with forward or backward displacement of all or part of
the vertebral body.

It is particularly important to exclude an occult cervical spine fracture

with a lateral radiograph in any unconscious patient in whom trauma
to the neck is suspected, as it may provoke serious damage to the
spinal cord. Further imaging with CT or MRI is often appropriate in the
context of a high risk injury, neurological deficit, limited clinical
examination, or where there are unclear X-ray findings.
Cervical region of the vertebral column, posterolateral view
Normal cervical spine radiograph

Typical thoracic vertebrae

The thoracic vertebrae have heart-shaped bodies and long spinous
processes that slope postero-inferiorly, extending to the level of the
body of the vertebra below. The vertebral foramen is small and
circular. The articular processes are oriented approximately in the
coronal plane, with the superior facets directed posteriorly and slightly
laterally and the inferior facets directed anteriorly and slightly
medially (thus, a tangential line forms an arc centered at the vertebral
body). Other distinctive features of the thoracic vertebrae are
associated with their articulations with ribs: there are superior and
inferior costal facets on the bodies (each forming a demi-facet for a
joint of head of rib) and transverse costal facets near the tips of the
transverse processes of the typical thoracic vertebrae (for a
costotransverse joint).

Thoracic region of the vertebral column, posterolateral view

Typical thoracic vertebra, lateral view
Typical thoracic vertebra, superior view

Atypical thoracic vertebrae

The vertebra T1 is considered atypical, as it has a long spinous
process, very similar to the vertebra prominens above. While the
bodies of the vertebrae T1-T9 articulate with two ribs, the vertebrae
T10-T12 have only one costal facet on the sides of their pedicles. The
last two, at times also T10, lack the transverse costal facet.

The transition between the thoracic region allowing primarily

rotational movement and the lumbar region where the rotation is
strongly limited occurs abruptly at the level of the T12. In fact, this
vertebra has thoracic features on its superior aspect and lumbar
features in the inferior part. Thus, vertebra T12 is the most commonly
fractured non-cervical vertebra.
Atypical thoracic vertebrae, lateral view
Typical lumbar vertebrae
The lumbar vertebrae are the largest and have massive kidney-shaped
bodies. The vertebral foramen is triangular and larger than in the
thoracic region, but smaller than in the cervical one. The transverse
processes (costal processes) are long and slender, while the spinous
process is short and broad, sagittally-oriented. Additional processes
develop at the base of the transverse processes (accessory
processes) and near the superior articular processes (mammillary
processes), as muscular attachment sites. The superior articular
facets are directed medially (or posteromedially), while the inferior
facets are directed laterally (anterolaterally).

Lumbar region of the vertebral column, posterolateral view

 Typical lumbar vertebra, lateral view

Radiographic anatomy of the thoracolumbar region

In the context of trauma similar principles apply to imaging both the
thoracic spine and the lumbar spine. Vertebral column stability can be
assessed following a three column model (instability occurs when
injuries affect two contiguous columns).

The three columns and the main structures they include are the
following:

 anterior column

o anterior longitudinal ligament

o anterior two-thirds of the vertebral bodies and intervertebral

discs

 middle column

o posterior one-third of the vertebral bodies and intervertebral

discs
o posterior longitudinal ligament

 posterior column

o vertebral arches (pedicles and laminae)

o articular processes and facet joints

o ligamentum flavum, interspinous ligament, supraspinous

ligament
Thoracolumbar region of the vertebral column, posterolateral view
Three-column concept of the vertebral column stability

Scottie dog
An oblique posterolateral radiograph of a normal lumbar spine shows
an outline of a “scottie dog”. It is defined by the following vertebral
structures: the transverse process forms the head, the pedicle
represents the eye, the superior articular process represents the ear,
the lamina and spinous process form the body and tail, the inferior
articular process represents the foreleg.

An interarticular part (pars interarticularis) of the lumbar vertebrae is

the part of the lamina between the superior and inferior articular
processes of the same side. It is a common site of fracture in the
lumbar region of the vertebral column. In an oblique view of lumbar
vertebral column it forms the neck of the scottie dog. A separation of
the pars interarticularis will form a visible collar at the dog’s neck,
indicating spondylolysis. It may be a result of a congenital defect or
weakness of the bone at this site and a stress fracture. If it is
associated with a slippage of the affected vertebra body forward with
respect to the vertebra below, it is called spondylolisthesis.
Scotty dog on an oblique posterolateral radiograph of a normal
lumbar spine

Sacrum and coccyx

The five sacral vertebrae are fused into a single bone, which also
forms the posterosuperior part of the pelvis, articulating with the hip
bones. The base of the sacrum is formed by the superior surface of the
S1 vertebra. Its anterior projecting edge is the promontory. Laterally,
the ala, or wings, project from the body of the S1 towards the lateral
part, which is the site of the synovial (at the auricular surface) and
fibrous (at the sacral tuberosity) sacro-iliac joint. Four pairs of anterior
and posterior sacral foramina give passage to the spinal nerve
branches, as they emerge from the sacral canal. On the dorsal surface,
the fusion between the sacral vertebrae brings about the median
sacral crest (fused spinous processes), paired medial sacral crests
(fused articular processes) that end inferiorly as the sacral cornua,
and paired lateral sacral crests (fused transverse processes). As the
lamina and spinous process of the S5 and sometimes S4 are absent,
the sacral canal opens posteriorly at the sacral hiatus, delimitated by
the sacral cornua.

Typically four small coccygeal vertebrae fuse into a single triangular

bone, the coccyx, which articulates with the sacrum.

Sacrum and coccyx, anterior view

Sacrum, lateral view
Sacrum, posterior view

Scoliosis
Scoliosis is an abnormal lateral curvature of the spine that is
associated with the rotation of the vertebrae (structural scoliosis). It
may be congenital, i.e. caused by a bone abnormality present at birth,
or acquired due to neuromuscular disorders or bone degeneration. The
most common type of scoliosis, though, is idiopathic scoliosis, in
which there is no specific identifiable cause. During the examination,
the patient is asked to bend forward as far as possible. This is known
as the Adams forward bend test and is often performed on school
students. If a rib or scapula prominence is noted, then scoliosis is a
possibility and the patient should be sent for an x-ray to confirm the
diagnosis.
Scoliosis, scheme and x-ray
In this part of the lesson we will discuss the joints and movements of the vertebral column and indeed
the easiest possible way if you remember the orientation of the superior articular facet you’ll
immediately know also the main movements between the vertebra in different vertebra columne
regions in the atlanto occipital joint it is flexion and extension as in saying yes and the atlantoaxial joined
with pens surrounded by the anterior arch of the atlas and then transfers ligament of waxes posteriorly
the main movement is rotation as in saying no and then the atlanto occipital joints between the typical
cervical vertebrae will allow movements of flexion extension rotation and lateral flexion making the
cervical region actually the part of the vertebral column with this particularly mobile. In the thoracic
region the superior articular surfaces look posteraro laterally we set so they form a part of an arch
centred on the vertebral body so accordingly the easiest movement will be that of rotation and finally in
the lumbar region where the articular facets are oriented sangita that trunk remaining flecks and
extend. Another important feature of the vertebral column is the vertebral canal and vertebral framing
and the knowledge of these structures

is important for the study of the spine

spinal cord and peripheral nervous system

including skeletal muscle innovation. Let’s

look at the vertebral column again as we’ve

said the Pericles emerging from the posterior

surface of the vertebral body are notched

on the superior and inferior borders forming

superior and inferior veretral notches

on each side the superior notch of one

vertebra and the inferior notch of the

vertebra above together form an internet

vertebral For Ayman these phenomena in

an articulated skeleton serve to transmit

the spinal nerves each spinal nerve forms

from the anterior and posterior roots stealing

the veretral canal which then emerged from

the spinal cord and unite within the [02:55]

The spinal cord runs in the vertebral canal

from the foramen magnum in the base of

the skull downwards because of the greater

growth in length of the vertebral column

during development compared to that of

the spinal cord however the spinal cord

terminates at about the level of the L

1 L 2 they skinned available on disc in

adults slightly lower even during childhood

the spinal cord is connected to 31 pairs

of spinal nerves and we have eight cervical

12 thoracic 5 lumbar 5 sacral and 1 coccygeal

spinal nerve. These nerves exit from the

vertical canal through the intervertebral

foramen. Each spinal exits through its

interventional foramen between the two

adjacent vertebrae having emerged from

the intervertebral foramen each spinal

nerve then divides into dorsal ventral

ramus the dorsal ramus continues to run

segmenttally to supply skin and muscles

around the posterior mid-line while the

ventral drama instead intermingled to form

the cervical breakable and Lambeth sacral

Lexuses from which then the terminal nerves

to the upper and lower limbs emerge. These

nerves have the proper names and you hear

them while studying the innovation of the

muscles and skin in different body regions

and body parts. The interior drama of the

thoracic spinal nerves instead continue

to run segment Ali along the latter an

anterior wall of the trunk forming the

intercostal nerves. Going back to the vertebral

canal given the difference in length between

the long and longer vertebral canal and

shorter spinal cord as the spinal nerve

roots run between the spinal cord and their

intervertebral Liberal phenomena the length

of the routes increases progressively from

above downard. In the upper cervical region

the spinal nerves routes are short and

they run almost horizontally as they emerge

from the cervical segments of the spinal

cord which actually lie right opposite

the corresponding internet phenomena but

since the spinal cord is shorter than the

vertebral column it’s this style lumbering

sacred segments lie against the thoracic

and first lumbar vertebrae of the vertebral

column hence the roots of the lumbering

sacred nerves run downwards vertically

toward the introverted phenomena that lie

inferior to the distal end of the spinal

cord and in doing so together they form

so called cow DUP Quina or a horse’s tail

another important detail it has to be appreciated

is the fact that we have seven cervical

vertebrae but eight cervical spinal segments

and spinal nerves hence the spinal nerves

C1 through C7 exit through data available

for him in that list above the vertebra

with the same number for instance the seventh

cervical spinal nerves exits for the interval

suitable for in between the sixth and seventh

cervical vertebrae but then we have spinal

nerve C 8 and it exits between the seventh

cervical and first thoracic vertebrae so

the next one first thoracic spinal nerve

and from this level down all the other

spinal left exit below the vertebra with

the same number so for instance the fourth

lumber nerve exits from the interval suitable

for them in between the fourth and the

fifth lumbar vertebrae and then it can

be noted that the spinal nerves actually

exit through the upper part of the interval

suitable for him and what it is limited

by the vertebral body and not the introverted

disc therefore this prolapse or discrimination

we look at below the narrative that this

actually passing through the internet Isobel

Freeman at the level of the Head ignited

disc so it will impinge on the nerve emerging

from the next frame and down rather than

on the same net and if we got it all this

anatomical fact for example will understand

that even though the L 5 spinal net emerges

through the interval suitable for I’m in

between the M and they’ll five vertebrae

and this collapse between this relatively

we likely compress the L 5 and indeed the

lateral L for L 5 discrimination is most

common in the symptoms are preferable to

the compression of the L 5 net and this

will include pain over the latter a leg

and do some of the food weakness in the

uncle dos inflection it’s the muscle fibres

of L 5 spinal if supply mostly the extensive

digital room Longo’s an extensive loses

Longo’s this was just an example of how

you can build on the anatomical knowledge

to solve a common medical problems now

let’s review again the basics in the following

slides.
Vertebral column joints

Vertebral joints
Joints of the vertebral column include articulations between the
adjacent vertebral bodies and articulation between the adjacent
vertebral arches. Although individual vertebral joints allow small local
movements , the summation and combination of these movements
over multiple vertebral levels accounts for the considerable mobility of
the head and trunk.

Intervertebral joints
Intervertebral discs connect the articulating, hyaline cartilage-layered,
surfaces of the adjacent vertebral bodies. The joints of the vertebral
bodies, thus, are secondary cartilagineous joints (symphyses). There
are no intervertebral discs directly above and below the C1 body and
between the fused sacral and coccygeal vertebrae; hence, there are
typically 24 intervertebral discs.

The intervertebral discs consist of an outer tough fibrocartilagineous

ring, the anulus fibrosus, and a gelatinous central mass, called the
nucleus pulposus. The semifluid consistency of the latter is
responsible for much of the flexibility and resilience of the
intervertebral discs, while they act as “shock absorbers” along the
vertebral column. During flexion and extension movements, the
nucleus pulposus becomes thinner on one side and thicker on the
other, while the anulus fibrosus is simultaneously placed under
compression and tension.
Intervertebral disc

Intervertebral joint

Herniation of nucleus pulposus

The anulus fibrosus is thinner posteriorly. As its resistance to the
repetitive compression-relaxation forces declines with age and the
nucleus pulposus becomes dehydrated and its resilience reduces or,
even in younger individuals, it is put under excessive stress during
violent hyperflexion, the nucleus pulposus may herniate into the
vertebral canal and compress the spinal cord or the roots of the spinal
nerves.
The most common sites for disc herniation are the lumbar and, less
frequently, cervical regions. Approximately 95% of lumbar disc
herniations occur in the posterolateral direction at the L4/L5 level,
evoking symptoms of the compression of the L5 nerve roots (pain over
the lateral leg and dorsum of the foot, weakness at dorsiflexion), and
L5/S1 level, with the compression of S1 nerve roots (pain over the
posterior leg and lateral foot, weakness at plantarflexion). In the
cervical region, it occurs most often at the C5/C6 and C6/C7 level,
compressing C6 and C7 nerve roots, respectively.
MRI (T2-weighted) of a spinal disc protrusion at the L5/S1 level,
compressing the nerve root.
Posterior views of vertebral bodies in the cervical and lumbar
region showing the relationship between the herniated nucleus
pulposus and the spinal nerve roots.

Zygapophysial joints
The zygapophysial joints are synovial joints between the superior and
inferior articular facets of the adjacent vertebrae. Although they
permit only slight gliding movements, the direction of movement is
largely influenced by the orientation of the facets. In the cervical
region, the articular surfaces are nearly horizontal (the superior
articular facets actually slope slightly from anterior to posterior, the
inferior ones – in the opposite direction), thus allowing movement in
most directions. In the thorax, they are vertical and lie nearly in the
coronal plane, allowing mostly rotation and some lateral flexion. In the
lumbar region, the articular surfaces lie in the sagittal plane,
facilitating flexion and extension.
Zygapophysial joints (facet joints)

Atlanto-occipital joints
These craniovertebral joints form between the superior articular
surfaces of the lateral masses of the atlas and the occipital condyles.
The atlanto-occipital joints are condyloid-type synovial joints and have
thin, loose joint capsules. The main movement is flexion and extension
(nodding of the head, as in indicating “yes”), with a little lateral flexion
and rotation.

The anterior and posterior atlanto-occipital membranes extend from

the anterior and posterior arches of the atlas to the corresponding
margins of the foramen magnum and help prevent excessive
movement of the atlanto-occipital joints.
Articular surfaces of the atlanto-occipital joints

Atlanto-axial joints
There are three joints between the C1 and C2 vertebrae: two lateral
and one median. The lateral atlanto-axial articulations are plane-type
synovial joints formed between the inferior facets of the lateral
masses of the atlas and the superior facets of the axis. The median
atlanto-axial joint is a pivot joint between the dens of the axis and the
anterior arch of the atlas.

The strong transverse ligament of atlas, extending between the

tubercles on the medial aspects of the lateral masses, contributes to
this articulation and completes, from behind, the collar that holds the
dens against the anterior arch of the atlas. Together with two weaker
longitudinal bands, passing upward to the occipital bone and
downward to the body of C2, it forms the cruciate ligament of atlas.
The alar ligaments extend from the sides of the dens to the lateral
margins of the foramen magnum, preventing excessive rotation.
Movement at atlanto-axial joints permits the rotation of the head from
side to side, as in indicating disapproval (the “no” movement).

Atlas and axis

Ligaments of the atlanto-axial joints

Ligaments of the spine

The vertebral laminae of the adjacent vertebrae are linked by the
ligamentum flavum, rich in elastic fibers, the transverse processes are
connected by the intertransverse ligaments, and the spinous
processes are linked by the relatively weak interspinous ligaments and
tough supraspinous ligament. The latter, superiorly to C7, is
continuous with the nuchal ligament, which forms a median fibro-
elastic membrane extending from the external occipital protuberance
to the spinous processes of the cervical vertebrae and providing
attachment for muscles of the vertebral column.

Running the whole lenght of the vertebral column, along the anterior
and posterior aspects of the verterbal bodies, are the tough anterior
and posterior longitudinal ligaments, preventing hyperextension and
hyperflexion, respectively. The posterior longitudinal ligament is
narrower and weaker than the anterior longitudinal ligament. It is
attached mainly to the intervertebral discs and less to the posterior
aspects of the vertebral bodies. Above the atlas, it broadens and
continues as a tectorial membrane passing over the median atlanto-
axial joint and its ligaments to attach to the internal surface of the
occipital bone.

Ligaments of the cervical spine

Ligaments of the vertebral column
Nuchal ligament
Cervical spine injury
Footbal, diving, falls from horse and motor vehicle collisions cause
most injuries of the cervical region of the vertebral column. Severe
hyperextension of the neck can provoke painful stretching or tearing
of the anterior longitudinal ligament (whiplash injury). Forceful
extension of the head on the upper neck may result in the fracture of
the vertebral arch, with a cervical spondylolysis of C2. If this injury
occurs, the cranium, C1 and dens and body of C2 are separated from
the rest of the axial skeleton and the cervical spinal cord is usually
severed. Vertical forces (as in striking the bottom of a pool in a diving
accident) can compress the lateral masses of the atlas between the
occipital condyles, fracturing the arches and rupturing the transverse
ligament of atlas (burst fracture or Jefferson’s fracture).

Extrinsic muscles of the spine

Many strong muscles attach to the vertebrae to support the body
weight and move the vertebral column. The extrinsic back muscles
include muscles that produce the movements of limbs (superficially
lying axio-appendicular muscles – trapezius, lattissimus dorsi, levator
scapulae, and superior and inferior rhomboids) and control respiratory
movements (serratus posterior superior and inferior).
Extrinsic muscles of the spine
Intrinsic muscles of the spine
The intrinsic back muscles act specifically on the vertebral column,
producing its movements and maintaining posture. These muscles are
enclosed by deep fascia that attaches medially to the nuchal ligament,
to the tips of the spinous processes and the supraspinous ligament,
down to the median crest of the sacrum. Laterally it attaches to the
transverse processes of the vertebrae and extends laterally as the
thoracolumbar fascia.

The intrinsic back muscles are grouped into superficial

(spinotransversales), intermediate (erector spinae) and deep
(transversospinales and deep segmental muscles) layers. A detailed
knowledge of their origins and insertions is out of the scope of the
undergraduate study.

The intrinsic muscles provide primarily extension and work

synergistically with the muscles of the anterolateral abdominal wall to
stabilize and produce movement of the trunk. Suboccipital muscles,
extending between the vertebrae C1, C2 and the occipital bone,
produce movements at the craniovertebral joints.
Intrinsic muscles of the spine
Movements of the spine
Movements of the vertebral column are freer in the cervical and
lumbar regions than in the thoracic region. The thoracic region is most
stable because of the external support of the ribs, which articulate
posteriorly with the thoracic vertebrae and anteriorly with the
sternum.

Movements of spine
 Summary

 Typical vertebra consists of a body, which bears weight, and a

verterbal arch, which protects spinal cord and roots of spinal nerves.

 Processes extending from the arch provide attachement and leverage

for muscles of vertebral column.

 Vertebrae are joined to form a semi rigid vertebral column by

intervertebral discs and zygapophysial joints . The orientation of articular
facets determine the type of movement allowed between the adjacent
vertebrae.

 The anterior longitudinal ligament resists hyperextension; all other

ligaments control flexion.

 The atlanto-occipital joints enable the nodding (“yes”) movement; the

atlanto-axial joints enable the rotational (“no”) movement of the head.

 The cervical and lumbar regions are most mobile (and consequently
most vulnerable to injury). Flexion and extension occur primarily in the
cervical and lumbar regions; rotation occurs in the cervical and thoracic
regions.

 Primary curvatures (thoracic and sacral kyphosis) are developmental;

secondary curvatures (cervical and lumbar lordoses) are acquired with the
erect posture. The curvatures provide shock-absorbing resiliance and
flexibillity to the axial skeleton.

 Plain radiograph is a useful tool in detecting degenerative or traumatic

changes in the vertebral column. MRI scanning is valuable in diagnosis of
disease or injury of the spine and spinal cord.
 The skeleton of the thorax consists of

12 thoracic vertebrae 12 pairs of ribs

and costal cartilages and the sternum with

the exception of the first 11th and 12th

rips the head of each rib articulates with

its corresponding vertebra the one above

and the disc between the two so for example

the fourth rib articulates with thoracic

vertebrae 3 and 4 and introverted disc.

Then the tubercle of the rib articulates

with the transverse process of the vertebra

with the same number. The shaft of which

rib slopes downwards as it curves around

the chest and then the distal end the hireling

costal cartilages pass towards the sternum

in the ribs from first to seventh in the

ribs from eighth to 10th instead the costal

cartliages join the cartilage above and

together they form the costal merging.

The first four costal cartilages are short

and horizontal the others are longer and

slope upwards the 11th and 12th rips don’t

articulate with the sternum or the costal

and they are called floating rips together

with the ribs eighth ninth and 10th which

 articulate with a sternum only indirectly

these are false ribs. The number of the

rips and intercostal spaces is used when

describing normal and abnormal findings

of the chest wall or thoracic cavity inside

so you should be able to count ribs and

intercostal spaces. To do this note the

clavicle actually over lies the first rib

making it difficult to participate the

second rib instead is easy to locate because

its costal cartilage articulates with the

sternum and sternal angle located between

them a new broom and the border of the

sternum and then starting from the second

rib the third to 10th ribs can be participated

in sequence also the costal merging is

sometimes visible and always palpable and

also on the tips of the 11th and 12th floating

vertebrae can be sometimes palpated postal

laterally. Superiorally the superior thoracic

aperture also called as thoracic inlet

in anatomy is the passage between the neck

in the thoracic cavity. It is bounded by

the first thoracic vertebra austerely then

the first ribs in the superior border of

the sternum. In the adult this aperture

the superior thoracic aperture measures

approximately 6.5 centimeters until posteriorally

and 11 centimeters transversely if you

actually visualise this diameters you certainly

notice that it’s a really narrow space

and structures that pass through this apenture

include the trachea and nerves and vessels

that supply and drain the neck, head and

upper limbs. Interestingly clinicians refer

to the superior thoracic aperture as the

thoracic outlet and this then probably

emphasises that the important arteries

and T 1 spinal nerves enter the lower neck

and then the upper limb in this area. They

can become compressed at the level of the

superior thoracic operative or directly

above and the route of the neck where they

pass between the sculling muscles the signs

and symptoms will typical involved the

upper limb and this is called thoracic

outlet syndrome as different structures

can be compressed for different reasons

there are various types of this thoracic

outlet syndrome one example is the costa

vehicular syndrome with paler and coldness

of the skin of the upper limb and diminished

radial pulse and it can result from the

compression of the sub club artery between

the clavicle and the first rib. Now coming

back to the ribs movement of the true ribs

primarily from the second to sixth is largely

by rotation around the axis passing through

 the downward sloping neck of the rib. This

slight rotation at the joint of the head

of the rib and costal transfers joint causes

the anterior ends of the ribs to rise so

called palm handle movement and this will

translate into the anterior movement of

the sterum especially at its inferior end

and as a result the anterior posterior

diameter of the thorax increases considerably

in the lower ribs from eighth to 10th the

gliding movement takes place with the sliding

in an inferior direction at the joint of

the head of the rib and in a sober postnatal

direction in the costal transfers joint

this produces rising of the middle lateral

most part of the ribs so called bucket

hung the movement as a result the transverse

diameter of the thorax increases. The combination

of this movement’s moves the walls of the

thoracic cage anteriorally superiorally

and laterally. Before you get to know the

muscles of respiration that provoked this

movement study the material included in

the first part of this lesson.

 Thoracic skeleton
Thoracic skeleton
Thorax is the part of the body between the neck and abdomen. The
thoracic skeleton is called thoracic cage, with the vertical bars formed
by the sternum and thoracic vertebrae and the horizontal bars formed
by the ribs and costal cartilages. It is cone-shaped and narrows from
the base, where it is closed by the skeletal muscle called diaphragm,
up towards the truncated apex, where it opens into the neck.

Even if its components are relatively light, the thoracic cage offers
remarkable rigidity and serves the following functions:

 protects thoracic and abdominal organs;

 anchors and supports the weight of the upper limbs;

 provides the attachment sites for muscles of respiration and many

muscles of the upper limb, neck, back, and abdomen.
Thoracic cage

Sternum
Sternum forms the middle part of the anterior thoracic wall. It is a long
flat bone composed of three parts, namely manubrium, body, and
xiphoid process. The synchondroses that connect these parts ossify
during middle to late adulthood; the xiphisternal joint as late as at 40-
50 years of age. The manubrium and the body of the sternum lie in
slightly different planes as they form the manubriosternal joint, hence
a sternal angle, open posteriorly, forms at this level and its projection
can be palpated in a patient. It is a useful landmark, as it marks the
site of articulation of the second ribs with the sternum (useful for
counting ribs and intercostal spaces). The transverse thoracic plane
runs horizontally through the sternal angle, anteriorly, and the T4/T5
intervertebral disc, posteriorly, and separates the superior and inferior
mediastinum within the thoracic cavity.

The superior border of the manubrium forms the jugular (or

suprasternal) notch. It is deepened by the medial ends of the clavicles
that form the sternoclavicular joints at the clavicular notches. The
lateral border of the sternum is indented by the costal notches: the
1st at the manubrium, the 2nd at the level of the manubriosternal joint,
than 3rd through 6th along the body, and the 7th typically at the
xiphisternal joint and xiphoid process.
Sternum, anterior and lateral view

Ribs
12 pairs of ribs and associated costal cartilages form the largest part
of the thoracic cage. All ribs are flat bones that contain red bone
marrow.

Posteriorly, all ribs articulate with the thoracic vertebrae. Anteriorly,

ribs I-VII, called true ribs, attach to the sternum via a costal cartilage.
Ribs VIII-XII are called false ribs; the pairs VIII, IX and X connect with
the sternum indirectly, as their cartilages join the cartilage of the rib
above, while ribs XI and XII are free or floating, as their rudimentary
cartilages end in the abdominal musculature.
The hyaline cartilage at the sternal ends of the ribs adds significant
resilience to the thoracic skeleton and protects the sternum and ribs
from fractures. In old age, the costal cartilages may undergo
ossification; as a result, they become radio-opaque and may confuse a
person examining a chest radiograph.

Ribs, anterior and lateral view

Typical ribs
A typical rib has a head, neck, tubercle, and body. The head
articulates with two adjacent vertebral bodies and the vertebral disc
between them. The tubercle is located at the junction of the neck and
body; it has a smooth articular part, for the articulation with the
corresponding thoracic vertebra, and a rough non-articular part, for the
attachment of the costotransverse ligament. The body is thin and flat;
at the costal angle, it curves anterolaterally. The concave internal
surface has a costal groove running along its inferior margin.
Typical rib (red lines indicate insertions of the external and
internal intercostal muscles along the inferior margin of the
rib)

Atypical ribs
The first rib is short, broad and sharply curved; it runs nearly
horizontally around the superior thoracic aperture. Its superior surface
has a scalene tubercle for the attachment of the anterior scalene
muscle (the subclavian vein and artery run, respectively, anterior and
posterior to the scalene tubercle). The floating ribs (XI and XII) are
short and do not have a neck or tubercle. The ribs I and X-XII
articulate with a single corresponding vertebra via their heads.

First rib

Cervical rib
Cervical rib occurs in less than 1% of the general population and is
bilateral in most of the cases. It articulates with the seventh cervical
vertebra (C7) and is typically attached to the first rib through an
articulation or a fibrous band reaching from its distal extremity.
If the cervical rib is present, it can produce so called thoracic outlet
syndrome. If the cervical rib compresses the lower trunk of the
brachial plexus, it can evoke paresthesia along the medial side of the
forearm and wasting of the small muscles of the hand innervated by
the T1 spinal nerve. Less commonly, pressure on the subclavian artery
caused by the presence of a cervical rib may lead to vessel narrowing
(stenosis) and thrombosis resulting in limb ischemia.

Costovertebral joints
The synovial plane-type costovertebral joints include the joints of head
of rib and the costotransverse joints. The head of a typical rib
articulates with the inferior costal facet on the body of the vertebra
above, the superior costal facet on the body of the vertebra of the
same number, and the intervertebral disc uniting the two vertebrae.
The costal tubercle forms the costotransverse joint with the tip of the
transverse process of the corresponding vertebra. For example, the
2nd rib forms the joint of head of rib with the bodies of the 1st and 2nd
thoracic vertebrae and the costotransverse joint with the transverse
process of the 2nd vertebra.

The two facets on the head of the rib are separated by the crest of the
head, which is attached to the intervertebral disc by an intra-articular
ligament of head of rib. The fibrous joint capsule is reinforced
anteriorly by a radiate ligament of head of rib. A costotransverse
ligament passes between the neck of the rib and the transverse
process of the vertebra; a lateral costotransverse ligament is its
continuation and unites the tubercle of the rib and the tip of the
transverse process of the vertebra. A superior costotransverse
ligament is formed by the fibres that stretch between the neck of the
rib and the transverse process of the vertebra above.
Costotransverse joints
Joints of head of rib

Sternocostal joints
The sternal ends of the ribs articulate with the lateral ends of the
costal cartilages in costochondral joints, which are synchondroses,
i.e., primary cartilaginous joints. Then, the costal cartilages of the ribs
II-V typically form the synovial plane-type sternocostal joints. The
anterior and posterior radiate sternocostal ligaments continue over
the surface of the sternum and cover it, forming a sternal membrane.

The costal cartilages of the ribs I, VI, and VII articulate with the
sternum through synchondroses. The costal cartilages of the false ribs
VIII-X form the synovial interchondral joints. These joints may ossify
and fuse with age.
Sternocostal joints
Movements of the thoracic wall
The articular surfaces on the tubercles of the upper ribs (true ribs I-
VII) are slightly convex and permit subtle rotation of the rib along the
axis running through the centers of the costovertebral and
costotransverse joints, which lies nearly in the frontal plane. This
movement causes the sternal ends of the ribs to rise and the sternum
to move in the sagittal plane (pump-handle movement); as a result, the
antero-posterior diameter of the thoracic cavity increases.

The articular surfaces of the lower costotransverse joints are flat and
the axis through the costovertebral and costotransverse joints lies
close to the sagittal plane; as a result, the middle parts of the rib
bodies in the lateral thoracic wall rise in a bucket-handle movement
and the transverse diameter of the thorax increases.

The most marked increase in the dimensions of the thoracic cavity,

responsible and necessary for the inspiration, occurs along its vertical
diameter and is caused by the contraction of the diaphragm.

Thoracic wall movements

Movements of the thoracic wall which we

discussed before produce an increase in

the diameters of the thorax and hence in

the intro thoracic volume during inspiration

consequent pressure reduction results in

air being drawn into the lungs through

the nose mouth larynx and trachea. During

exploration which is normally passive the

muscles relax the creasing into thoracic

volume and increasing the infra thoracic

pressure this allows the stretched elastic

tissue of the lungs to recoil expelling

the air. Movements that evoke this movements

form three layers within the intercostal

spaces and you can use your hand and your

trousers pockets in order to remember the

cause of the muscular fibres of this muscles

the external intercostal muscles pass downward

and fore forth from one rib to the next

becoming external intercostal membranes

between the coastal cartilages so it’s

like putting your hand in the front pocket

and when your fingertips point so anteriorally

the muscle continues with the connective

tissue memory. Now put your hand in the

back pocket and you remember that the internal

intercostal muscles pass downward and backwards

from one costal cartilage and rib to the

next below they become the internal intercostal

membranes posteriorally reaching the tubercle

of the rib. Finally the passage of the

intercostal neuro vascular bundle along

the intercostal space separates the innermost

layer of muscular fibres from the internal

intercostal muscles and these form the

innermost intercostal muscles that are

particularly evident only in the laterally

part of the thoracic wall. Additional muscles

at present anteriorly trans versus thoracic

and posteriorly this will be subbed off

starless these muscles cross more than

one intercostal space. The intercostal

neuromuscular bundle that I’ve just mentioned

comprises the intercostal vein artery and

nerve any transcendent groove present along

the lower order of each rib the intercostal

nerve is the most inferior structure in

the bundle so it is also the least sheltered

in the intercostal groove. The collateral

branches these structures arise at the

angle of the rib and then they run along

the upper body of the rib below together

these structures supply the intercostal

muscles overlying skin and underlying [03:03].

Sometimes though it is necessary to insert

a neuro through the intercostal space into

the plural cavity for example to obtain

a sample of plural fluids or to drain it

if the fluid accumulates this procedure

is called thoracentesis and if you remember

the relationships of the intercostal bundle

to the rib you should be able to avoid

damage to the intercostal nerve and vessels.

The needle should be inserted slightly

superior to the rib high enough to avoid

the collateral branches but definitely

not right below the lower boarder of the

rib where the actual neuromuscular bundle

runs. As regards the function of the intercostal

muscles the externall intercostal musles

are active in inspiration as they move

the rbps superiorly and also supports the

intercostal spaces so they don’t collapse

as the thoracic pressure diminishes during

diaphragm contracted. Other muscles that

support inspiration are the scalene muscles

in the neck they stretch between the cervical

spine and the first ribs if the fixed and

is in the attachment to the cervical spine

the scalene muscles will raise the upper

ribs similarly the muscles that extend

from the exoskeleton to the upper limb

and these are for example [04:36] muscles

if they distil attachments so the humerus

and the pectoral girdle are fixed they

can raise the ribs in the sterum. Their

action is particularly evident in forced

inspiration. The internal and innermost

intercostal muscles instead are masses

of exploration as they move rips inferiorly

these muscles come into play when again

deep and fast breaths are needed apart

from the internal and inner most intercostals

also the transfer staraces sub hostels

in the abdominal muscles will be involved

when the abdominal muscles contract in

particular they push the abdominal content

against diaphragm and the thoracic space

gets smaller. Now the main muscle of inspiration

is indeed the diaphragm it’s origins are

divided into lumber costal and sternal

parts and it has a large upon neurosis

in the centre called the central tendon.

The lumbar part consists of the left and

right group of the diaphragm and they originate

from the first three lumbar vertebrae.

The media not equate ligament then passes

over the outer to connect the two kruder

and then the medial larduet ligaments stretches

on both sides between the L1 vertebra and

its transverse process and then the lateral

argue at ligament goes towards the tip

of the 12 rib. This ligament actually forms

thickening seen the face of the HP sauce

major in the quadrant islam bottom muscles

respectively. The costal part of the diaphragm

attaches to the internal surface of the

inferior six ribs in coastal cartilages

and the sternal part originates from [01:47]

process of the sternum. Then the diaphragm

slopes down from its attachment to the

process of sternum towards its posterior

attachment to the lumber vertebae. The

costal part forms the right and left domes

as the diaphragm curves superiorly inside

the thoracic cage normally the right dome

is slightly higher than the left and this

is due to the presence of the liver right

below the diaphragm. During expiration

when the diaphragm relaxes and it is even

pushed upwards by the increasing inter

dominal pressure the right dome can reach

as high as the fifth rib and the left dome

ascents up to the 15th inter costal space

the contraction of the diaphragm and the

contrary flattens the domes which are pulled

inferiorly as a result the vertical dimension

of the central part of the thoracic cavity

increases and this increases the volume

of the thoracic cavity decreases that inter

thoracic pressure resulting in inspiration.

The diaphragm is innovated by the frantic

nerves the right and left franek nerves

contain the motor and sensitive fibres

from the spinal segments C3 C4 and C5 so

from the cervical part of the spinal cord

and this fibres nerve fibres ran in the

anterioral rama of the respective spinal

nerves then they unite in the neck as they

participate in the formation of the cervical

plexes and they live it the framework nerve

then the nerve descends on the anterior

sculling muscle through the superior thoracic

aperture to the [03:47] in the thoracic

cavity and then it descends towards the

diaphragm and compression along the course

of the nerve can lead to elevation of the

diaphragm on the damaged side injury to

the upper cervical spine will even cause

the paralysis of the muscle which can be

fatal so you should remember that C3 C4

and C5 keep the diaphragm alive.

Intrinsic thoracic muscles
Diaphragm
Diaphragm is a musculotendinous septum dividing the thoracic from
the abdominal cavity. Its peripheral muscular part arises from the
margins of the inferior thoracic aperture; the fibres converge radially
toward the trifoliate aponeurotic part, called central tendon. The
muscular fibres are arranged in three parts.

1. A lumbar part arises from two crura and three arcuate ligaments.
The right crus attaches to the anterior surface of the bodies of the
upper three lumbar vertebrae and intervertebral discs between them;
the left crus is shorter, as it is attached only to the first two vertebrae.
The arcuate ligaments are fibrous arches; the medial, stretched
between the lumbar vertebral bodies and the tip of the L1 transverse
process, being a thickening of the fascia covering the psoas major
muscle, and the lateral, continuing to the tip of the 12th rib, being a
thickening of fascia of the quadratus lumborum muscle; the median
arcuate ligament unites two crura, arching over the anterior aspect of
the aorta.

2. A costal part consists of broad muscular slips attached to the

internal surfaces of the lower six ribs and costal cartilages.

3. A sternal part consists of two small slips attached to the posterior

surface of the xiphoid process.
Diaphragm (seen from below)

Action of diaphragm
The diaphragm is dome-shaped, which makes it the primary muscle of
respiration. As the diaphragm contracts during inspiration, its right
and left domes descend and the muscle flattens. Consequently, the
volume of the thoracic cavity increases and the intrathoracic pressure
decreases, resulting in air flowing into the lungs.

At the same time, movements of the diaphragm help return venous

blood to the heart and reduce the risk of the gastro-esophageal reflux.

Innervation of diaphragm
The diaphragm receives its entire motor supply from the right and left
phrenic nerves. Each phrenic nerve arises from the anterior rami of the
spinal nerves C3-C5 in the neck (C3, 4, and 5 keep the diaphragm
alive). It descends along the neck on the anterior surface of the
anterior scalene muscle and then traverses the thoracic cavity to
reach the diaphragm.

Injury to the phrenic nerve results in paralysis of the corresponding

half of the diaphragm. During respiration, a paradoxical movement will
occur, as the paralyzed dome, instead of descending on inspiration,
will be forced upwards by the pressure in the abdominal cavity that
will increase due to the contraction and flattening of the functioning
contralateral diaphragmatic dome. This elevation and paradoxical
movement can be recognized on a radiograph.

Intercostal muscles
Intercostal muscles are arranged in layers: the superficial layer is
formed by the external intercostals and the inner layer by the internal
intercostals. Moreover, as the intercostal neurovascular bundle runs
within the latter, its deepest fibres are designated as the innermost
intercostals.

The external intercostal muscles occupy the intercostal spaces from

the tubercles of the ribs to the costochondral junctions, with the fibres
that slope down and anteriorly from the rib above to the one below
(their direction is indicated by the fingers of a hand inserted in a front
pocket of your trousers). Anteriorly, the muscular fibres are replaced
by external intercostal membranes that extend from the costochondral
junctions to the sternum. These muscles are most active during
inspiration.

The internal intercostal muscles close the intercostal spaces from the
lateral border of the sternum to the angles of the ribs. Their fibres run
at right angles to the external intercostals (their direction is indicated
by the fingers of a hand placed in your back pocket). Posteriorly to the
rib angles, the muscular fibres are replaced by the internal intercostal
membranes. These muscles (or at least their parts running between
the ribs, as opposed to those running at the level of the costal
cartilages) are most active during expiration.

The innermost intercostals occupy the middle parts of the intercostal

spaces, in the most lateral parts of the chest wall, and have the same
characteristics of the inner intercostals.
Intercostal muscles (anterior view of the posterior thoracic
wall)
Other muscles of the thoracic wall
Several muscles attached to the thoracic cage reach other regions of
the body. The axio-appendicular muscles (including pectoralis major,
pectoralis minor and serratus anterior) act primarily on the upper limb;
the scalene muscles generate movements of the neck. All these
muscles may also function as accessory muscles of respiration, as
they help elevate the ribs during forceful inspiration. The serratus
posterior superior and inferior muscles, lying in the back at the
junction of the thoracic with the cervical and lumbar column,
respectively, may serve mainly as “regulatory muscles” with
a proprioceptive function.

Other thoracic muscles with a weak role in respiration and possible

proprioceptive role are levatores costarum, subcostales and
transversus thoracis. The subcostales run deep and parallel to the
internal intercostals , but they cross the intercostal spaces from the
angle of the rib above to the inner surface of the rib 1-2 spaces below.
The transversus thoracis consists of 4-5 slips that attach to the
xiphoid process and inferior part of the sternal body and radiate
superiorly and laterally towards the costal cartilages.
Transversus thoracis muscle (posterior view of the anterior
thoracic wall)

Intercostal vessels and nerves

Intercostal neurovascular bundle consists, from above downwards, of
vein, artery, and nerve running in the costal groove along the lower
border of a rib, between the internal and innermost intercostal
muscles. Their smaller collateral branches run along the upper border
of the rib below. Each intercostal bundle supplies the intercostal
muscles, overlying skin and underlying parietal pleura.

Intercostal neurovascular bundle (anterior view of the posterior

thoracic wall and posterior mediastinum)
Thoracic apertures
The superior thoracic aperture (thoracic inlet) in adult measures about
6.5 cm anteroposteriorly and 11 cm transversely. It is limited by the
1st thoracic vertebra, 1st pair of ribs, and superior border of the
sternal manubrium. The aperture slopes slightly anteroinferiorly.
Structures that pass through the thoracic inlet include the trachea and
esophagus, but it will be vessels and nerves of the upper limbs that
will be compressed in the thoracic outlet syndrome.

The inferior thoracic aperture (thoracic outlet) is relatively spacious,

but it is closed by the diaphragm. It is bounded by the 12th thoracic
vertebra, floating ribs, costal margin (formed by the joined costal
cartilages of ribs from 7th to 10th), and xiphisternal joint. As the
anterior wall of the thoracic cage is shorter than the posterior wall,
the aperture slopes posteroinferiorly. It is important to remember that
the floor of the thoracic cavity actually lies higher than the inferior
thoracic aperture, as the domes of the diaphragm rise to the level of
the 4th intercostal space; for the same reason, some abdominal
viscera lie within the thoracic cage. The esophagus and inferior vena
cava pass between the thoracic and abdominal cavities through their
openings in the diaphragm; aorta descends along the vertebral column
posterior to the median arcuate ligament between the diaphragmatic
crura.
Have you ever noticed that the only bone

connection of the three part of the upper

limbs exoskeleton is the glenohumeral joint

here the large round humoral head articulates

with a relatively shallow glenoid cavity

of the scalpel which accepts actually slightly

more than one third of the humoral head

so how is the stability of the joint guaranteed.

Now before you’ll be able to answer this

question let’s just describe briefly the

most important features of this articulation

in more detail. The glenoid cavity of the

scapula is deep and slightly by the ring

like fibro cartilaginous glenoid like room

the fibrous layer of the joint capsule

is attached laterally to anatomical neck

of the humorous and medially to the merging

of the glenoid cavity superiorly this part

of the capsule encloses the proximal attachment

of the long head of biceps brachii to the

sub wrangler noise to critical of the scapula.

This tendon will then actually cross the

joint cavity surrounded by the synovial

membrane. Even the large range of motion

the capsule of the shoulder joint is particularly

loose and it can be further expanded thanks

to its exemplary recess which will unfold

during flexion and abduction then superiorly

and anteriorly the capsule is strengthened

by the intrinsic ligaments glenn humoral

and caracas humoral and then there is the

[01:50] arch it is an extrinsic structure

formed by the chromium of the scapula and

the quarter coit process of the scapula

with the corridor coup chromeo ligament

spanning between them. This austill ligaments

structure forms a protective arch that

over lies the humoral head preventing its

superior dislocation. The corica cromwell

arch is so strong that the forceful superior

thrust of the humorous will not damage

it the humoral shaft on the clavicle will

fracture more easily. Importantly that

sabra spiny to see muscle passes and that

this arch from the surplus binaries force

of the scapula towards the greater tubercle

of the humorous and it lies deep to detail

movement of the surplus tendon as it passes

through this sabah chromeo space is facilitated

by the sabah chromeo bears which lies between

the arch and the ligament in the tendon

inferiorly. Distally it continues over

the joint capsule as the subtitle toy but

let me remind them that particular investor

sax line by sign of membrane and containing

thin layer of synovial fluid bears are

located where tendons rub against bone

ligaments or other tendons or where skin

moves over the bonnet prominence given

the relationships that we have just discussed

several burdsey are situated near the glen

of humeral joint some of them have special

clinic are important because they communicate

actually with the joint cavity consequently

inflammation of a bursar may involve also

the cavity of the joint the sub scapula

bursts for example is actually an extension

of the glen of humeral joint cavity and

it usually communicates with it through

an opening in the fibrous layer of the

joint capsule it is actually located between

the tendon of the sub scapula and the neck

of the scapula now going back to the space

between the head of the humerus and the

head of the chromeo arch it contains sabah

chromeo bedser the tendon of the supplier

speculators and part of the tendon of the

infrastructure muscles parts of the joint

capsule and intrinsic ligaments and the

tendon of the long head of biceps importantly

when degenerative processes may occur in

this area the surplus spinby knitters and

infra spinal tendons are particularly stressed

during repetitive use of the upper limb

above the horizontal for instance during

activities that involve throwing or lifting

the current inflammation of these tendons

is a common cause of shoulder pain and

can result in tiers of the muscular tenderness

structures that form so called rotator

cuff around the head of the humerus and

here is the answer the earlier question

about the joint stability while the head

of the humerus is actually held in the

cavity by detention of the muscular tenderness

rotator cuff we will discuss it in the

second part of this lesson.

Shoulder joint structure
Regions and components of the upper limb
The upper limb skeleton is has its free part joined to the trunk by the
pectoral girdle. The pectoral girdle and the shoulder joint belong to the
shoulder region. Along the free part of the upper limb, the arm lies
between the shoulder joint and the elbow joint; the forearm lies
between the elbow joint and the the wrist joint; finally, the hand is
distal to the wrist joint.

Pectoral girdle
The pectoral girdle is composed of the scapula and the clavicle. In the
pectoral girdle, the scapula articulates with the lateral end of the
clavicle; the medial end of the clavicle articulates with the sternum.
These are the only bony connections of the free part of the upper limb
to the axial skeleton. The humerus articulates directly with the
scapula.
Pectoral girdle

Clavicle
Clavicle is an S-shaped bone that forms the anterior part of the
pectoral girdle. It is palpable along its entire lengh, as it lies in a
subcutaneous position. It articulates with the manubrium of the
sternum medially, in the sternoclavicular joint, and with the acromion
of the scapula laterally, in the acromioclavicular joint. The clavicle
acts as a strut, holding the free part of the upper limb away from the
trunk, hence improving its range of motion.

Interestingly, it is the first part of the skeleton to form (it occurs

during the 5th and 6th week of gestation), but at the same, it is the
last to ossify completely (at the sternal end, around the ages of 25 – 30
years). It starts to ossify by intramembranous ossification of the shaft,
but than the process continues with endochondral ossification at the
ends of the clavicle. Hence, the clavicle is considered a long bone,
although it does not have a true medullary cavity in its shaft.
Clavicle

Clavicle fracture
The clavicle is the most commonly fractured bone in the body. The
slender clavicles of neonates may be fractured during delivery, while
teenagers and young adults present this fracture following sport-
related injuries or after a fall on an outstretched hand. The weakest
part of the clavicle is the junction of its lateral and middle thirds, thus
the fractures commonly occur at this site. The weight of the upper
limb depresses the lateral fragment, while the medial fragment is
pulled upward by the sternocleidomastoid muscle of the neck. As a
result, tenting of the skin can be visible in a patient. The free end of
the medial part can be depressed by pushing against it with a finger,
but it will return to its elevated position, producing so-called piano key
sign.
Sternoclavicular joint
Sternoclavicular joint is the only bony articulation between the upper
limb and the trunk. It is a saddle joint, in which the sternal end of
clavicle articulates with the manubrium and the 1st costal cartilage. It
is an atypical synovial joint, because its articular surfaces are covered
by fibrocartilage rather than hyaline cartilage. The articular surfaces
on the medial end of the clavicle and the manubrium are incongruent.
An articular disc separates the joint into two cavities. The
sternoclavicular ligaments (anterior and posterior), costoclavicular
ligaments and interclavicular ligament strengthen the joint.

Given its specific position and function, the sternoclavicular joint is

extremely strong, but also very mobile. It permitts
elevation/depression, protraction/retraction and posterior/anterior
rotation of the lateral, acromial end of the clavicle.

Sternoclavicular joint (the joint capsule has been removed on the

right side)

Scapula
Scapula is a flat bone that forms the posterior part of the pectoral
girdle. It overlies the ribs II-VII on the posterior thoracic wall. It is
triangular in shape and has a medial, lateral, and superior border and a
superior, lateral and inferior angle. At the lateral angle, a shallow
depression, called glenoid cavity, articulates with the humerus. The
coracoid process extends from the superior margin of the scapula
anteriorly and superiorly over the glenoid cavity. The anterior, costal
surface of the scapula forms the subscapular fossa, while on the
posterior surface, the scapular spine separates the supraspinous and
infraspinous fossae. Laterally, the spine expands to form the acromion,
which is palpable at the tip of the shoulder.

Scapula

Acromioclavicular joint
Acromioclavicular joint is a plane synovial joint between the lateral
end of the clavicle (acromial end) and the medial surface of the
acromion of the scapula. It is also an atypical synovial joint, with the
articular surfaces covered by fibrocartilage. A wedge-shaped
fibrocartilaginous articular disc can be present within the joint cavity.
These characteristics of the joint are directly related to its
development: after about 2 years from birth, a joint space develops
within the fibrocartilaginous union between the bones.

A thickening of the articular capsule forms the acromioclavicular

ligament, which supports the joint superiorly. The integrity of the
joint, however, is maintained mainly by an extrinsic ligament, the
coracoclavicular ligament, which spans the distance between the
coracoid process of the scapula and the clavicle. It has two
components, the conoid ligament, medially and the trapezoid ligament,
laterally.

In the acromioclavicular joint, the acromion of the scapula rotates on

the acromial end of the clavicle. This movement occurs during
depression or elevation of the glenoid cavity at the lateral angle of the
scapula. As no muscles connect the articulating bones, the movement
is caused by the axio-appendicular muscles that attach to the scapula.

Acromioclavicular joint and coracoclavicular ligament

Humerus
The humerus is a long bone of the arm. Proximally, its head articulates
with the glenoid cavity of the scapula. Anteriorly, the intertubercular
sulcus (also called bicipital groove) separates the greater and lesser
tubercle. The anatomical neck lies between the head and the
tubercles, while the surgical neck is the narrow part of the shaft
immediately distal to the tubercles. A radial sulcus runs obliquely
around the posterior and lateral surface of the shaft and is related to
the radial nerve.

Proximal humerus

Fracture of the surgical neck of the humerus

The surgical neck of the humerus is commonly fractured. The
importance of this fracture is its relationship to the axillary nerve and
the anterior and posterior circumflex humeral arteries, which wind
around the surgical neck. Injury to the axillary nerve would lead to the
weakness of shoulder abduction, due to paralysis of deltoid muscle,
and loss of sensation over the lateral side of the proximal part of the
arm.
AP view of a fracture of the surgical neck of humerus
Glenohumeral joint
Glenohumeral joint (shoulder joint) is a ball-and-socket joint. It has
more freedom of movement than any other joint in the body; however,
this comes at the expense of joint stability. The head of the humerus is
large, compared with the shallow glenoid cavity on the scapula, and
the joint capsule is relatively lax.

Several structures help to increase joint stability. The

fibrocartilaginous glenoid labrum deepens the articular surface on the
scapula. The articular capsule, attached to the glenoid labrum and the
anatomical neck of the humerus, is reinforced by the intrinsic
glenohumeral ligaments (superior, middle and inferior). Another
intrinsic ligament, the coracohumeral ligament, runs over the capsule
between the coracoid process and the lesser tubercle of the humerus.
The superior dislocation of the joint is prevented by the coraco-
acromial ligament, which is the part of the coraco-acromial arch.
Finally, the tendons of the rotator cuff muscles – supraspinatus,
infraspinatus, teres minor and subscapularis (the first letters form the
acronym SITS) – form dynamic stabilizers and help to keep the head of
the humerus in place, against the glenoid cavity, during movements.

Loose fibrous capsule contains two apertures: between the tubercles

of the humerus, for the tendon of the long head of biceps brachii
muscle, and below the coracoid process, for communication between
the subscapular bursa and synovial cavity of the joint.
 Shoulder joint and surrounding structures

Glenohumeral joint bursae

Three main bursae are located where the tendons of shoulder muscles
rub against bone or ligaments, or where the skin moves directly over
bones.

1. Subtendinous bursa of subscapularis, between the tendon of the

subscapularis muscle and the neck of the scapula at its lateral angle; this
bursa is an extracapsular extension of the joint synovial lining, hence it
communicates freely with the joint cavity.

2. Subacromial bursa, between the supraspinatus tendon and coraco-

acromial arch; if the bursa becomes inflamed, 90o abduction of the arm at the
shoulder joint (movement produced by the supraspinatus and deltoid
muscles) becomes painful, as the bursa moves within the decreased
subacromial space.
3. Subdeltoid bursa, between the deltoid muscle and greater tubercle of
the humerus; it may be separate from or continuous with the subacromial
bursa.

Glenohumeral joint bursae. Several ligaments of the pectoral

girdle joints are also shown: 1 – acromioclavicular; 2 – coraco-
acromial; 3 – coracoclavicular, trapezoid; 4 – coracoclavicular,
conoid; 5 – superior transverse scapular
 Glenohumeral joint stability
The glenohumeral joint has the following supporting structures:

 Superiorly

o coracoacromial arch, formed by the coracoid process, acromion

and coracoacromial ligament

o superior part of the glenoid labrum

o tendon of the long head of biceps brachii muscle

o tendon of the supraspinatus muscle

 Anteriorly

o anterior part of the glenoid labrum

o superior, middle and inferior glenohumeral ligaments

o tendon of the subscapularis muscle

 Posteriorly

o posterior part of the glenoid labrum

o inferior glenohumeral ligament

o tendons of the infraspinatus and teres minor muscles

Shoulder joint supporting structures

Glenohumeral joint dislocation

The glenohumeral joint is the commonest joint dislocated in the body
(50% of all dislocations, although uncommon in children). The
dislocation can be classified by the position of the humeral head with
respect to the glenoid cavity. The most common is an
anterior dislocation (95%). It is usually caused by excessive
extension and lateral rotation of the humerus (as in the preparation for
a throw), which can be associated with the tear of the anterior rim of
the glenoid labrum (Bankart’s lesion). The head of the humerus
actually moves anteroinferiorly, but then the tension of the adductor
and flexor muscles pulls it under the coracoid process of the scapula,
hence it ends up lying anterior to the glenoid cavity. The posterior
dislocation is uncommon; it is said to occur during epileptic seizure or
electrocution.
The shoulder joint is a ball and socket

joint which permits flexion extension abduction

adduction medial lateral rotation and serco

induction of the arm. One group of muscles

that the shoulder joint is called action

perpendicular because these muscles originate

from the axe steel skeleton comprising

the skull vertebral column and thoracic

cage and incidentally up indicators skeleton

that of the upper limb with a pectoral

girdle and humerus in the arm. Anterior

perpendicular muscles flex the shoulder

joint while posterior muscles will extend

it among the anterior axioappendicular

muscles there is the pectoralis major which

covers the superior part of the anterior

thoracic wall stretching from the middle

part of the clavicle manu brims sternum

and 6 costal cartilages towards the lattral

leap of the inter to build coloured circles

it’s slow and managing surely forms until

you do auxiliary fault and can be easily

palpated. Then the pectoralis minor lies

beneath it and it represents surely a useful

surgical landmark for the structures in

axilla from the third to fifth rib it reaches

the coracoid process of the scapula. The

pseudoscientific over lies the lateral

part of the thorax and inserts on the medial

border of the scapula. It is one of the

most powerful muscles of the pectoral girdle

actually it keeps the scapula against the

thoracic wall and protracts it when reaching

forward weakness of paralysis of the Cerrado

Santería following injury the long thoracic

nerve allows winging of the scapula as

its medial border moves away from the posterior

thoracic wall among the posterior axioappendicular

muscles there is the trapezes which originates

from the skull cervical and thoracic spine

processes and inserts on the spine in a

chromium of this scapula and lateral third

of the clavicle it is triangular but forms

the trapezium with one on the opposite

side then the latissimus dorsi collates

a wide area on the back as it descends

from the trunk to attach to the floor of

the inter tubercular sol purse of the humerus.

The movement it evokes can be reproduced

by folding the arms behind the back so

it’s extension abduction and medial rotation

of the humerus and then there are rhomboid

Major major and minor from the spineless

processes of the cervical and the first

thoracic vertebrae they reached a medial

border of the scaupla it and can elevate

and retract the scapula. The extensive

range of motion of the arm is only possible

through the co-operatoin of several joints

and the movement of the shoulder joint

actually is accompanied by the movements

of the pectoral girdle so this copula and

clavicle this movements involve the [03:34]

joints as well as so called scapula thoracic

joint this term refers in fact to the gliding

movements of the scapula against the thoracic

one and not to a structural joint which

actually at this level doesn’t exist the

arm and the scapula move together in relationship

of two to one during abduction. The movements

of the scapula revolt muscles that reach

it from the skull vertebral column and

ribs. In the neutral position the scapula

over lies the ribs from the second to the

seventh in the spine of the scapula the

route of the spine of the scapula lies

at the level of the spineless process of

the third thoracic vertebrae from this

position the scapula can be elevated as

much as 10 centimeters in the superior

direction as shrugging the shoulders the

main muscle involved will be trapezes with

its descending fibres then the scapula

can also be depressed this happens by gravity

alone or by muscle action. Then upward

rotation occurs during abduction of the

upper limb and here are the main muscles

are a descending part of the trapezes and

inferior part of the survey to santería

downward rotation during the abduction

is caused mainly by latissimus dorsi muscle.

Then protraction which occurs in arm reflection

and allows us actually to reach forward

for example if you need to grasp an object

that is slightly further than the length

of the upper limb you can use [00:31] retraction

of the scapula is possible mainly through

the contraction of the middle part of the

trapezius. And finally there is another

group of shoulder muscles so called scapulohumeral

muscles which extend from this scapula

to the humerus. Interestingly four of six

muscles in this group are called rotator

cuff muscles and these are [01:03] which

originate respectively from the surplus

by natives for some infrastructure fossa

and lateral boarded of the scapula in insert

own the greater tubercle of the humerus

and then the sub scrupulous muscle which

originates from the sub scrupulous fawcett

and inserts on the lesser geometrical of

the humerus. The [01:36] as we’ve already

seen runs just below the [01:40] of the

scapula and its tendon can became inflamed

or even thrown of as a consequence of repetitive

movements of abduction the [01:53] rotate

the arm laterally while the sub scrabulous

is the primary medial rotator of the arm.

Importantly the tendons of rotator cuff

muscles blend with and rain falls into

fibres capsule of the glen humoral joint

the tongue of this muscles holds the head

of the humerus glenoid cavity of the scapula

during our movements. Rotator cuff injuries

are quite common especially in older people

so be sure to understand the cause and

action of these muscles. Now that we’ve

talked briefly about joint movements and

muscles that produce them let’s analyse

the abduction of the arm as an example.

A range of motion for abduction is 180

degrees the movement can be broken down

into three components first the arm abducts

in the glen humoral joint and the muscles

that extent from this copulate to the humerus

are active supper spineless and dealt with

it being the muscles primary involved in

the movement. Second the scapula rotates

and this is coupled with the movement and

the [03:18] joints in addition to the previously

mentioned muscles also the trapezius will

be active. Finally the vertebral column

also participates rotating to the same

side and flexing to the opposite side if

one arm is being abducted or extending

if the movement is bi lateral. Also as

the arm is raised in abduction automatic

external rotation of the humerus occurs

to prevent compression of the greater [03:54].

You can try to abduct your arm when it

is internally rotated and you will see

the total about 60 degrees of movement

is possible you need to externally rotated

it in order to continue the abduction.

So to sum up the complete mobility is dependent

on several factors the ability of the joint

 capsule to unfold from the auxiliary recess

the ability of tendons to glide within

the super chromeo space the mobility of

the chrome nucla vehicular instead nucla

vehicular joints the automatic external

rotation of the humerus and even the mobility

of the spinal column so you should remember

about it when evaluating patients with

the reduced range of motion at the shoulder

joint.

Muscles acting on shoulder

joint
Shoulder joint complex
Movements of the upper limb depend on the shoulder joint complex,
which comprises the following:

 three bones - humerus, scapula, clavicle;

 three joints - glenohumeral, acromioclavicular, sternoclavicular;

 one physiological joint - scapulothoracic joint;

 one anatomical area - subacromial space.

Glenohumeral joint movements
The glenohumeral joint has more freedom of movement than any other
joint in the body. However, also the movements of the scapula in
relation to the posterior thoracic wall are essential for the particularly
high range of motion of the upper limb.

The glenohumeral joint allows movements around three axes and

permits flexion/extension, abduction/adduction, medial/lateral rotation
and circumduction. As the greater tubercle approaches the coraco-
acromial arch during arm abduction, lateral rotation of the humerus is
necessary to increase the range of movement. Circumduction is an
orderly sequence of flexion, abduction, extension and adduction.
These movements at the glenohumeral joint are accompanied by
movements at two other joints of the pectoral girdle, i.e.
sternoclavicular and acromioclavicular.
Muscles involved in the movements of the glenohumeral joint
Scapulothoracic joint
Scapulothoracic joint is a functional term describing movements of the
scapula on the thoracic wall - elevation and depression, protraction
(lateral or forward movement of the scapula) and retraction (medial or
backward movement of the scapula), upward and
downward rotation of the glenoid cavity - that accompany the
movements of the upper limb at the glenohumeral joint. Indeed, the
movements of the free part of the upper limb occur in a ratio of
approximately 2:1 at the glenohumeral joint and the scapulothoracic
joint (so-called scapulohumeral rhythm). In practice, it means that in
the 180o abduction of the arm, 120o of the movement occur at the
glenohumeral joint, while the other 60o result from the movement at
the scapulothoracic joint (although this ratio is not constant
throughout the entire range of motion). The movements of the scapula
over the thoracic wall result from the movements at the
sternoclavicular and acromioclavicular joints.

Muscles around the shoulder region

The posterior axio-appendicular muscles (extrinsic back muscles)
attach the upper limb (appendicular skeleton) to the trunk (axial
skeleton), while the scapulohumeral muscles (intrinsic shoulder
muscles) attach the free part of the upper limb to the pectoral girdle.
Additionally, anterior axio-appendicular muscles (thoraco-appendicular
or pectoral muscles) act on the upper limb. The following tables
summarize the attachments, nerve supply and actions of the muscles
in the shoulder region. Some of these muscles will be discussed more
in depth in the following slides.

Anterior axio-appendicular muscles

Four anterior axio-appendicular muscles move the free part of the
upper limb or the pectoral girdle: pectoralis major, pectoralis minor,
subclavius, and serratus anterior.

The pectoralis major muscle covers the superior part of the anterior
thoracic wall. Its sternocostal part forms most of the anterior wall of
the axilla and its inferior border can be grasped with the fingers, as it
forms the anterior axillary fold.
The pectoralis minor lies beneath the pectoralis major and represents
a useful surgical landmark for structures in the axilla, e.g. branches of
the axillary artery and lymph nodes.

The serratus anterior overlies the lateral part of the thorax and forms
the medial wall of the axilla. It is one of the most powerful muscles of
the pectoral girdle and it protracts the scapula when reaching
anteriorly or punching. Importantly, it holds the scapula against the
thoracic wall, especially when pushing against resistance with
outstretched limb. The long thoracic nerve, which supplies the
serratus anterior muscle, is particularly susceptible to injury, due to
its long and superficial course. This will result in a sign called winged
scapula, as the medial border of the scapula will move away from the
thoracic wall.

Anterior axio-appendicular muscles

Anterior axio-appendicular muscles, superficial (on the right)
and deep (on the left side of the body)
Course of the right long thoracic nerve (C5-C7) on the serratus
anterior muscle
Posterior axio-appendicular muscles
The trapezius attaches the pectoral girdle to the cranium and vertebral
column. This large triangular muscle (forming a trapezium with its
counterpart on the opposite side of the body) can be divided in three
parts, which have different actions at the scapulothoracic joint:
descending fibres elevate the scapula, as when shrugging the
shoulders; middle fibres retract the scapula; ascending fibres depress
the scapula.

The lattissimus dorsi covers a wide area of the back region, as it

ascends from the back of the trunk to attach to the floor of the
intertubercular sulcus of the humerus. The movement it evokes can be
reproduced by folding the arms behind the back. Its action is
particularly evident in climbing, while the trunk is being lifted on a
fixed upper limb, or during the crawl stroke, while swimming. The
thoracodorsal nerve, which supplies the lattissimus dorsi muscle, is
particularly vulnerable in surgery within the axilla, as it runs along its
posterior wall. In the paralysis of the muscle, a person cannot use an
axillary crutch, due to lack of the active depression of the scapula.

Posterior axio-appendicular muscles

Posterior axio-appendicular muscles
Scapulohumeral muscles
Six relatively short muscles pass from the scapula to the humerus and
act on the glenohumeral joint. Hence, they are also called intrinsic
shoulder muscles. Of these, the deltoid forms the rounded contour of
the shoulder region. This muscle consists of the unipennate anterior
(clavicular) and posterior (spinal), and multipennate middle (acromial)
parts; the muscle fibres converge inferiorly to attach to the deltoid
tuberosity on the lateral surface of the humeral shaft. Different parts
of the deltoid can act simultaneously to abduct the arm, or separately
to flex or extend the arm. Importantly, the deltoid also stabilizes the
head of the humerus in the glenoid cavity during joint movements. The
axillary nerve, which supplies this muscle, winds around the surgical
neck of the humerus, hence it can be damaged in fracture or joint
dislocation. As a consequence, the muscle atrophies and the shoulder
acquires a flattened appearance.
Deltoid muscle. It attaches proximally to the clavicle, acromion
and spine of the scapula and inserts distally on the humeral
shaft

Scapulohumeral muscles

Rotator cuff muscles

Four of the scapulohumeral muscles form a musculotendinous cuff
around the glenohumeral joint, as they pass from the scapula to the
greater (supraspinatus, infraspinatus and teres minor muscles) and
lesser (subscapularis muscle) tubercle of the humerus. The individual
muscles of the rotator cuff participate in the movements of the arm:
the subscapularis in internal rotation, the infraspinatus and teres
minor in external rotation; importantly, the supraspinatus assists the
deltoid muscle in abduction.

The tendons of the rotator cuff muscles reinforce the fibrous capsule
of the glenohumeral joint. The tone of these muscles holds the head of
the humerus in the glenoid cavity of the scapula during arm
movements.
 Rotator cuff muscles, lateral view of the right shoulder

Subacromial space
The head of the humerus, inferiorly, and the coracoacromial arch,
superiorly, limit the subacromial space. The following structures are
located in the subacromial space:

 the tendon of the long head of biceps;

 the superior aspect of the joint capsule;

 the supraspinatus and upper margins of the subscapularis and

infraspinatus muscles;

 the subacromial and subdeltoid bursa.

Rotator cuff injuries
Repetitive movements of the upper limb above the shoulder,
associated with sport or professional activity, can cause inflammation
of the rotator cuff tendons as they pass between the scapula and the
humeral tubercles. Such recurrent inflammation, especially of the
most vulnerable tendon of the supraspinatus muscle within the
subacromial space, can result in a tendon tear and is a common cause
of shoulder pain. Because the tendons blend with the fibrous capsule
of the glenohumeral joint, the integrity of the capsule can become
compromised in the tendon tear.

Radiographic anatomy of the shoulder joint

Standard AP radiographs are always obtained with the humerus
positioned in slight external rotation. The AP radiograph of the
shoulder region shows the following bones and their parts: clavicle
(1) ; coracoid process (2) , acromion (3) and glenoid fossa (4) of the
scapula; head (5) , anatomical neck (6) and surgical neck (7) of the
humerus. The radiograph shows the greater tuberosity (8) in profile
when the humerus is externally rotated. If the humerus is internally
rotated, the lesser tuberosity (9) is seen in profile. The
coracoclavicular space (10), between the coracoid process and the
clavicle, marks the location of the coracoclavicular ligament. The
acromioclavicular space (11), between the acromion and the lateral
end of the clavicle, represents the articular cartilages and cavity of
the acromioclavicular joint. The inferior cortices of the acromion and
clavicle should align perfectly. In the glenohumeral joint area, the
head of the humerus may be superimposed on the glenoid fossa; the
region of the overlap approximates an elipse in shape.
Normal shoulder AP radiograph in external rotation
Normal shoulder AP radiograph in internal rotation
The elbow joint which we will discuss now

is composed of three sets of articular

surfaces enclosed in a common joint capsule

given the differences in the surface shapes

and the types of motion they permit this

can actually be described as three different

joints. First the spoon or hourglass shaped

throckley of the humerus articulates with

throckley notch of the arm in the [00:39]

joint along the throckley notch there is

a ridge that fits in the [00:00:50] ends

with an electron which serves as the inspiration

for the triceps Brocka muscle and origin

of the flex or [00:01:02] projects from

[00:01:09] border from the functional point

of view this is a hinge joint that permits

flexion and extension. When the elbow joint

is extended the electron sits in the electron

forcer on the posterior aspect of the humoral

condale with flexion instead the court

process is accommodated in the coronet

four-star on Dante to aspect of the humoral

[00:01:43] emerges from the election enforcer

and becomes accessible to poor patient

forming schwalier visible projection on

the posterior aspect of your elbow. Second

that the spirit and capitulation of the

humorous articulate with the slightly concave

radial head and this form humoral radial

joint above the anterior part of the capital

is the radial forsa which accommodates

the head of the Rangers during maximum

reflection the radius is also closely coupled

to the [00:02:26] during its movements

through the iron lot ligament of radius

thus the HIU middle our lot and humorous

radial joints don’t move separately but

act together in a hinge like flexion and

extension of the forearm and the arm and

finally this coupling of the radius and

villagers and dullness represents a third

joined called Proxima radio on adjoining

develops between the slightly concave radial

notch on Diana and that particular said

conference on the radius the annular ligament

of the re-use and cycles most of the radial

hat and his fixed on the anterior and posterior

trim of the radial knowledge of Diana then

there’s the quite rate ligament that attaches

an inferior aspect of the radio notch and

extends to the base of their particular

self-confidence of the Raiders disjoint

actually is a pivot joined by meeting quotation

which together with the movement that this

style radio ulnar joint will translate

into for a nation and its supine nation

of the forearm and hand. The fibres layer

of the joint capsule surrounds all three

parts of the elbow joint and it is attached

to the humerus and the lateral and medial

emergence of the articular surfaces of

the capitulation trachea some dispensations

excluded the epicondyles and a groove for

the ulnar nerve these concessions exclude

the epicondyles in the groove for the ulnar

nerve which lies on the posterior aspect

of the medieval epicondyle anteriorly and

posteriorly there Taylor capsule encloses

also called annoyed radial and Dalek run-on

foresee this the lead passes from the co-ordinated

process of the electron it round the neck

of the radius and closing the proximal

radio ulnar joint the sign of a mentoring

originates from the edges of the highland

cartilage on that particular surfaces in

lines the internal surface of the fibrous

layer of the capsule but it also lies that

intro capsular none particular parts of

the humans so they co-ordinated radial

newly-crowned foresee these are also lined

by the sign of a membrane in this region’s

exhorted the sign of remembering seven

separated from the famous layer of joint

capsule by pods of fat. The joint capsule

is weak and Tyrion posterior early but

it is strengthened on each side by collateral

ligaments the radial collateral ligament

extent from the lateral epicodyle of the

humerus and blends with the annular ligament

of the radius the ulnar collateral ligament

extends from the media epicondyle humerus

the Coronet process and to the election

of the ulnar between these anterior and

posterior buns intermediate transverse

bent extent between the colonised process

and selection and deepening media early

the socket for the top layer of the humerus.

This is one of the sites where the canonical

at syndrome in the upper limb can develop

as the ulnar nerve passes in its groove

on the posterior aspect of the media content

and then enters the so-called copytele

cubicle tunnel. This tunnel is limited

superficial by the fibrous arcades stretching

between the two heads of origin of the

flexor caught by a large muscle and by

your fibrous band dependent on that are

not collateral ligament extending for the

media epicondyle to the media side of the

election. This band in clinic is called

The Osbournes ligament epic quality local

action on ligament or even epic Throckley

are all like run on ligament and this name

actually highlights its medial location

asked the media epicondyle lies in the

above the top layer of the humerus so it

is sometimes called epitrockley this stems

not used in official anatomical terminology

Jassim clinic. Tshe ulnar nerve innovates

this skin and the Masters of the forearm

and hand so the signs and symptoms of the

net stretching in the cubicle tunnel with

regard those structures those areas for

now let’s review the structure of the humerus

and elbow joint.

Elbow joint structure
Arm
The arm lies between the shoulder and elbow joints. It consists of the
anterior and posterior regions, centred around the humerus. The deep
fascia that invests muscles of arm, lying deep to the skin and
subcutaneous tissue with the superficial fascia of the body, is called
brachial fascia. It encloses the arm like a tight sleeve and sends out
the medial and lateral intermuscular septa, which attach to the
humerus and divide the arm into anterior and posterior compartments.

The knowledge of compartments in all regions of the upper and lower

limb is extremely useful, because they contain muscles serving similar
functions and sharing common innervation and vascularization. The
fascial compartments are also important clinically, as they define the
spaces for the spread of infection or haemorrhage in the limb.

The skeleton of the arm is formed by the humerus, which articulates at

its distal end with the ulna and radius.
Upper limb skeleton

Humerus
The humerus is a long bone of the arm. Distally, its shaft widens and
the medial and lateral margins develop into the medial and lateral
supra-epicondylar (also called supracondylar) ridges. These ridges end
in a prominent medial epicondyle and a smaller lateral epicondyle. The
bony ridges and epicondyles are attachment sites for muscle tendons.

Distal end of the humerus forms a condyle, made up of the trochlea,

capitulum, olecranon, and the coronoid and radial fossae. The condyle
has two articular surfaces: the capitulum, for articulation with the
radius, and the trochlea, for articulation with the ulna. On the anterior
surface of the condyle, a coronoid fossa above the trochlea
accommodates the coronoid process of the ulna, while a shallow
radial fossa above the capitulum accommodates the edge of the head
of the radius when the elbow is fully flexed. The olecranon fossa,
superior to the posterior aspect of the trochlea, receives the olecranon
of the ulna during full extension of the elbow. Medially, an ulnar groove
separates the medial epicondyle from the posterior aspect of the
trochlea.

Distal humerus

Ulna and radius

The ulna is a long bone of the forearm that lies, in the anatomical
position of the upper limb, medially to the radius. Proximally, a
trochlear notch, limited by the olecranon posteriorly and the coronoid
process anteriorly, articulates with the trochlea of the humerus. A
rounded concavity on the lateral side of the coronoid process, the
radial notch, articulates with the radius. An ulnar tuberosity, on the
anterior surface, provides attachment for the brachialis muscle.

The radius is the lateral and shorter of the forearm bones. Proximally,
a radial head sits on a narrow neck. The head has a concave articular
fovea on top, which articulates with the capitulum of the humerus, and
an articular circumference, for the articulation with the radial notch of
the ulna. A radial tuberosity, on the anterior surface, provides
attachment for the biceps brachii muscle.

Proximal radius and ulna

Elbow joint
Elbow joint is a compound synovial joint involving three articulations,
which share a common synovial cavity. The articular surfaces
comprise the capitulum of the humerus, which forms the humeroradial
joint with the head of the radius; the trochlea of the humerus, which
forms the humero-ulnar joint with the trochlear notch of the ulna; and
the articular circumference of the radial head, which forms a proximal
radio-ulnar joint with the radial notch of the ulna and annular ligament.
An even more inclusive term "elbow complex" is useful when
describing movements of the forearm. These movements involve the
humero-ulnar and humeroradial joints (functionally, these two joints
are often considered "elbow joint"; it is a modified hinge joint that
allows mainly flexion and extension, with slight rotation and lateral
movement of the ulna) and the proximal and distal radio-ulnar joints
(these two are linked and function together; they are pivot type
synovial joints, allowing pronation and supination of the forearm and
hand).

Elbow joint dissection showing some of the articular surfaces

Elbow joint is a compound joint involving three articulations

Elbow joint capsule

The synovial membrane inserts along the edges of the hyaline
cartilage on the articular surfaces and then lines the radial, coronoid
and olecranon fossae on the humerus. In these regions, it is separated
from the fibrous capsule by pads of fat.

The fibrous capsule overlies the synovial membrane and encloses the
joint. While passing around the neck of the radius towards the
coronoid process and the base of the olecranon on the ulna, it has a
free inferior margin; a pocket of synovial membrane (sacciform recess)
protrudes from beneath and facilitates rotation of the radial head
during pronation and supination of the forearm. The capsule is lax
posteriorly and anteriorly, but it thickens on each side of the joint to
form collateral ligaments.
Elbow joint, sagittal section

Elbow joint ligaments

The ulnar collateral ligament lies on the medial side of the joint
capsule. From the medial epicondyle of the humerus, it forms the
anterior cord-like and strong band attached to the coronoid process of
the ulna and the posterior fan-like and weak band stretching to the
olecranon. Another slender oblique band deepens the socket for the
trochlea along the medial border of the olecranon.

The radial collateral ligament runs on the lateral side of the joint
capsule from the lateral epicondyle; distally, it blends with the anular
ligament of the radius, which encircles the head of the radius and
holds it in the radial notch of the ulna while it rotates during the
pronation and supination of the forearm.
Radial collateral ligament
Ulnar collateral ligament

Elbow joint bursae

Three bursa around the elbow joint are clinically important. The
subcutaneous olecranon bursa overlies olecranon directly underneath
the skin, while the subtendinous olecranon bursa is located between
the olecranon and the triceps tendon, just proximal to its attachment.
The bicipitoradial bursa lies between the biceps tendon and the
anterior part of the radial tuberosity. All bursae reduce abrasion
between the tissues during movements.

Repeated pressure or friction on a bursa may lead to its inflammation.

Subcutaneous olecranon bursitis is most common, particularly in
students who rest their elbows on a desk while reading.

Elbow joint dislocation

Elbow is the third commonest site of joint dislocation in the adult,
after shoulder and fingers, and it is the most common site of
dislocation in children under 10 years of age. Most dislocations (85%)
occur in the posterior or posterolateral direction, with the trochlear
notch of the ulna lying behind the humeral trochlea and the head of the
radius lying behind the capitulum of the humerus. Posterior
dislocation of the elbow joint may occur after a fall on one's hands
with elbows flexed or when the elbow is forcefully hyperextended.
Approximately 50% of cases are accompanied by fractures of the head
of the radius, coronoid process or olecranon of the ulna. Ulnar nerve
may be injured as it passes on the posteromedial aspect of the joint.

Pulled elbow
Preschool children are vulnerable to radial head subluxation
(incomplete dislocation). It happens typically when the child is
suddenly lifted by the hand while the forearm is pronated, hence the
name “nursemaid’s elbow” (although it is the child, and not the
nursemaid, that suffers). The force causes the head of the radius to
slip out of the anular ligament, hence yet another name for this
condition is “pulled elbow”. The ligament itself may be torn, while the
head of the radius can be displaced superiorly by the pull of the
muscles.
Anular ligament of radius, from above. The head of the radius has
been sawn off and the bone dislodged from the ligament

Carrying angle
When the elbow joint is fully extended and placed against the waist in
the anatomical position, the forearm diverges laterally. The long axis
of the forearm makes an angle, called carrying angle, of approximately
170o in men and 160o in women with the long axis of the arm. This
angulation in the frontal plane is caused by the configuration of the
trochlea. While some explain it by the larger transverse diameter of
the pelvis in females than in males, others propose that it is related to
the lenght of the forearm bones and overall body height (the shorter
the forearm bones, the greater the carrying angle).
Carrying angle
Muscles in the arm are separated into anterior

and posterior compartments maddington muscular

septa stretching between the deep fair

share of the arm and the humerus. The facial

compartments in the arm and in the limbs

in general are important clinically because

they contain direct the spread of infection

or haemorrhage in the limb but it is also

extremely useful to know that each compartment

contains muscles serving similar functions

and sharing common innovation the main

action of arm muscles is the elbow joint

but some muscles also act glencore humoral

shoulder joint there are only four major

muscles in the arm three of them lie in

the anterior compartment and they are flexed

us these are biceps Bracher darkies and

caught a cobra kills muscles and they are

all enervated by the muscular nerve the

Chief flex of the elbow joint other brocades

and biceps rocker you can note the biceps

Bracco has no attachment to the humerus

it’s two heads of origin long one from

the [00:01:25] and a short one from the

complicated process of the scapula this

two heads unite just distil the middle

of the art and the biceps tendon inserts

on to the radial veracity distended stands

out very clearly in the cubicle fossa and

media to this than by Sylvie de la neurosis

can be perpetuated as it runs from the

tender towards the ulnar over which it

blends with a deprivation of the forarm.

Importantly in this region also the breaker

aertery can be palpated medial to the tendon

and media nerve is the most medial structure.

When the elbow is extended the biceps flexs

the elbow then when the elbow is flexed

close to 90 degrees and the formarm is

the biceps continues flexion however when

the foremare is promulgated the biceps

is the primary and most powerful sappy

nature of the forearm for example it is

used when right handed people drive a screw

into the wood then the brachial is it lies

deep to the biceps it originates from the

humerus runs over the anterior part of

the elbow joint and inserts on the coral

annoyed process and to Boro’s City Of ulnar

the Broccolis is the main flex or of the

forearm acting in all positions and situations

when the forearm is extended slowly for

instance while you put down a tea cut carefully

the blockade is steadies the movement by

contracting eccentrical while the briquettes

muscles spans over the elbow joint the

third of the anterior compartment muscles

the kora Cobra Kayleigh’s spans over the

shoulder joint this muscle originates from

the corrugated process of the scapula and

inserts the middle third of the menial

surface of the humerus shaft this muscle

helps flecks and not docked the arm and

also stabilises the glen or humid out joint

the posterior compartment contains just

one major muscle which is the triceps Blackeye

and one small unconscious they hadn’t advocated

by the radial nerve and they are extensive

use of the elbow joint of the three heads

of triceps the long credit or originates

from the raglan annoyed tubercle of the

scapula so it actually also resists the

inferior dislocation of the head of the

humerous in addaction the menial and lateral

heads originate from the posterior surface

of the shaft of the humerus from areas

respectively below and above the radio

group they all attach to the electron they

medial ahead of the triceps is the main

elbow flexor then corneas Marcel said Grant

similarly distant lateral head of the triceps

and can be considered actually continuation

of it it tenses the capsule of the elbow

joint and prevents it from being pinched

by the electron during extension the main

arterial supply to the arm is the brachial

artery which is a continuation of the auxiliary

artery below the inferior boarder of the

terrace major muscle he transformed anti-royal

compartment what it can be participated

in the media by Cibitas groove towards

that cubicle fossa along the arm it sends

ff with the bar set over which accompanies

the radial nerve to the posterior on compartment

near the elbow joint these vessels give

off carlotta arteries which participate

in the particular arterial alistair moses

of the elbow formed with the more distils

originate in collateral branches from the

radial and alnar arteries. Now let’s review

the muscles of the arm in the slides included

in this lesson.
Muscles acting on elbow
joint
Elbow joint movements
A total of 17 muscles cross the elbow. Only few act on the elbow joint
exclusively, whereas most of them act also on the shoulder (arm
muscles) or wrist and fingers (forearm muscles). The flexion and
extension of the forearm occurs at the humero-ulnar and humeroradial
joints of the elbow complex. The pronation and supination of the
forearm and hand involve the proximal and distal radio-ulnar joints.

The flexor muscles are almost twice as strong as the extensors. The
main flexors of the elbow joint are the muscles of the anterior
compartment of the arm: brachialis and biceps brachii muscles.
Additionally, the brachioradialis and pronator teres, in the posterior
and anterior compartment of the forearm, respectively, assist in
producing slow flexion, but are efficient mostly in the absence of
resistance. The main extensor of the elbow joint is the muscle of the
posterior compartment of the arm, triceps brachii, especially its
medial head. The extensors of the elbow are particularly important
when using the chair’s arms to push oneself up from a seated position
or for wheelchair propulsion.

The main muscles producing pronation and supination at the radio-

ulnar joints are the pronator teres, pronator quadratus, biceps brachii,
and supinator. The function and efficiency of these muscles depend on
the elbow starting position.
Main flexors of the elbow joint. Biceps brachii and brachialis
lie in the anterior arm compartment, while the brachioradialis is
the most lateral muscle of the posterior forearm compartment
Triceps brachii is the main extensor of the elbow joint. The
anconeus muscle tenses the articular capsule while the olecranon
enters the olecranon fossa

Anterior compartment of arm

Three flexors form the anterior compartment of the arm (biceps
brachii, brachialis and coracobrachialis) and they are all supplied by
the musculocutaneous nerve.

The biceps brachii has no attachment to the humerus, as it spans the

arm between the scapula and radius, crossing and moving the
glenohumeral and elbow joints. Its action will depend on the position
of the elbow and forearm. When the elbow is extended and supinated,
the biceps simply flexes it; when the elbow is flexed to nearly 90o and
the forearm is pronated (the palm of the hand faces downwards), the
biceps becomes the most powerful supinator of the forearm (as in
driving a screw into a wooden wall).
The proximal tendon of the long head of biceps brachii crosses the
head of the humerus within the glenohumeral joint cavity, surrounded
by synovial membrane. The short head attaches to the coracoid
process of the scapula (next to the coracobrachialis and pectoralis
minor muscles). Distally, a common tendon of the biceps brachii can
be palpated and observed in the cubital fossa and the pulsation of the
brachial artery can be felt directly medially to it.

The brachialis muscle, instead, flexes the forearm in all positions. It

is, indeed, the main flexor of the forearm, as it always contracts when
the elbow is being flexed. Its excentric contraction will accompany
the slow extension of the forearm, as in putting down a teacup
carefully.

The coracobrachialis muscle does not act on the elbow joint, but helps
flex and adduct the arm at the glenohumeral joint. Together with the
deltoid and long head of triceps, it resists downward dislocation of the
head of the humerus, for example, when carrying a heavy handbag.

Muscles of the anterior arm and their nerve supply

Muscles of the anterior compartment of arm

Posterior compartment of arm

One large elbow extensor, called triceps brachii, and small anconeus
muscle, usually blended with it, form the posterior compartment of the
arm. They are supplied by the radial nerve.

Given their proximal insertion, the long head of triceps is a multi-joint,

while the medial and lateral heads are single-joint muscles. The long
head aids in extension and adduction of the arm and helps to stabilize
the glenohumeral joint; thus, it is the least active of the heads of
triceps in the movements of the forearm. The medial head is the
primary forearm extensor, active in all circumstances, while the
lateral head is strongest, hence it is recruited mainly for movements
against resistance.

The main role attributed to the anconeus is to tense the capsule of the
elbow joint, preventing it from being pinched by the olecranon during
extension. Apparently, it also acts as a stabilizer during pronation and
supination.
Muscles and neurovasculature of the posterior arm compartment
(posterior view). The radial nerve and profunda brachii artery
run in the radial groove on the posterior surface of the humeral
shaft

Muscles of the posterior compartment of arm

Radiographic anatomy of the elbow joint - lateral
A lateral radiograph of the elbow is typically obtained with the forearm
flexed at 90o and placed in midprone position (i.e. midway between
the fully prone and fully supine positions). The trochlea (1) has a highly
radiopaque, circular profile; immediately above it, the coronoid and
olecranon fossae are separated only by a thin plate of bone (2). The
round, anterior border of the capitulum (3) can be visible anterior to
the trochlea profile. The lower outline of the trochlea is encircled by
the trochlear notch (4), with the olecranon (5) and coronoid process (6)
at its extremities. Most of the head of the radius (7) overlaps the
coronoid process of the ulna; the neck (8) and tuberosity of the radius
(9) are unobstructed. The line drawn along the long axis of the
proximal 2–3 cm of the shaft of the radius should pass through the
capitulum (radiocapitellar line), while the line drawn along the anterior
cortex of the humerus (anterior humeral line) should have at least one
third of the capitulum anterior to it.

The shallow coronoid and deeper olecranon fossa contain adipose

tissue, forming anterior and posterior fat pad, respectively. In the
normal elbow x-ray only the anterior fat pad (10) is visible (fat is
slightly more radiolucent than muscle).
Elbow, lateral radiograph
Radiographic anatomy of the elbow joint - anteroposterior
An AP radiograph of the elbow demonstrates the medial (1) and lateral
epicondyles (2) unobstructed. The trochlea (3) and olecranon fossa (4)
on the humerus overlap the olecranon (5). The proximal ulna overlaps
the radial tuberosity (6) and the medial margin of the radius head.
Elbow, AP radiograph

Radiographic anatomy of the pediatric elbow joint

Because of the complex anatomy of the elbow joint, even significant
injuries may appear subtle on radiographs. During childhood, six
separate ossification centres appear at various intervals from 6
months to 12 years of age and then fuse gradually up to early
adulthood. Four of these centres develop in the humerus, one belongs
to the radius and one to the ulna. The exact age at which each
ossification centre appears is not so important, but knowing the
sequence in which they ossify is extremely useful in the evaluation of
the paediatric elbow injuries. Typically, the ossification proceeds in
the following order - capitulum, radial head, medial (internal)
epicondyle, trochlea, olecranon and lateral epicondyle (CRITOL).