10

CHAPTER
Joints

CHAPTER OUTLINE

Introduction
Classification of Joints Different Types of Synovial Joints
Joints of the Upper Limb
Fibrous Joints Joints of the Shoulder Girdle
Sutures or Sutural Joints
The Shoulder Joint or the Glenohumeral Joint
Syndesmosis (Syndesmos = Ligament)
The Elbow Joint
Gomphosis The Radioulnar Joints
Cartlaginous Joints Wrist Joint
Primary Cartilaginous Joints (Hyaline Cartilaginous Carpometacarpal Joint of the Thumb
Joints or Synchondroses)
Joints of the Lower Limb
Secondary Cartilaginous Joints (Fibro-cartilaginous
Joints or Symphyses) Hip Joint
Ligaments
Synovial Joints The Knee Joint
Joint Cavity The Ankle Joint
Articular Cartilage
The Subtalar Joint
Ligaments

INTRODUCTION Sutures orSutural Joints (Fig. 10.1A)

Ajoint is formed, where two or more bones come (ar-
ticulate) together. There may or may not be movement
between them.
CLASSIFICATION OF JOINTS (TABLE 10.1)
The joints can be classified according to the tissues
that unite the bone ends. There are 3 types of
joints.
1. Fibrous joints
2. Cartilaginous joints
3. Synovial joints.
FIBROUS JOINTS(FIG.10.1)
In this type, the articulating surfaces of bones are con-
nected by fibrous tissue. There are 3 types of fibrous
joints:
Sutures occur only in the skll, e.g. coronal suture
between the frontal and parietals. No movement is
possible (But, in a skull of a newborn infant the skul
bones do not make full contact with each other. The
sutures form wide areas of fibrous tissue called fonta-
nelles. The anterior fontanelle is the most
prominent
among the 6 fontanelles)
Syndesmosis (Syndesmos = Ligament)
(Fig. 10.1B)
In this type, the bones are united by a sheet of fibrous
tissue. It may be a ligament or a fibrous membrane,
e.g. an interosseous membrane connects the radius
and ulna.
The degree of movement depends on the distance
between the bones and the degree of flexibility of the
membrane.
 Textbook of Anatom for
124
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Table10.1:Classification of joints
Cartilaginous joints Synovial joints
Fibrous joints
a. Primary cartilaginous joints, a. Ball and socket type,
a. Sutural joints or sutures,
e.g. epiphyseal plate between e.g. shoulder joint
skull bones
e.g. between the
epiphysis and diaphysis
b. Secondary cartilaginous joints b. Hinge joints,
b. Syndesmosis, e.g. elbow joint
e.g. an interosseous membrane, or symphysis,
connecting radius and ulna e.g. pubic symphysis
c. Gomphosis -joint between c. Pivot joint,
tooth and its socket e.g. radioulnar joint, Atlantoaxial joint
d. Condyloid joint,
e.g. wrist joint
e. Saddle joint,
e.g. carpometacarpal joint of thumb
f. Plane joint,
e.g. joint between articular processes of
vertebrae

The interosseous membrane between the radius

Frontal bone and ulna is flexible and wide enough to permit consi.
erable movement during pronation and supination.

Coronal suture- wwww.aakuea Bregma

Gomphosis
This is a special type offibrous joint, between a tooth
- Sagittal suture
and its socket. The fibrous tissue ofthe periodontal
Parietal bone
ligamentfirmly holds the tooth in its socket. Movement
of the tooth is a pathological condition in the adult
Parietal foramen
CARTILAGINOUS JOINTS
Lambdoidsuture
A Occipital bone Lambda Bones are united either by hyaline cartilage or by
fibrocartilage. Depending on this, the cartilaginous
carti-
joints are classified into primary and secondary
Anular ligament laginous joints.
- Oblique cord

Primary Cartilaginous Joints (Fig. 10.2A)

Ulna (Hyaline Cartilaginous Joints or Synchon-
Interosseous droses)
membrane
Aperture for anterior The bones are united by hyaline cartilage, whichper
Radius interosseous artery mits slight movement during early life. Thistype olo
Distal radio-ulnar joint of a longbone
Wrist joint- Is temporary, as in the development
ends) of tne
Articular disc During development, the epiphyses (or
of a bonea
long bone and the body (or diaphysis) This
cartilaginous plate. I
Separated by an epiphyseal hen
bone.
arrangement permits the growth of the d into
is converted
full growth is achieved, the cartilage
bone and the epiphyses
fuse with the diaphysib
Figs 10.1A and B: Different types of joints:
(A) Sutures, (B) Syndesmosis
Joints
125
Neck
Zygapophyseal joints
Fovea

Intervertebral discs

Intertrochanteric crest

Lesser trochanter
Anulus fibrosus
Nucleus pulposus

Gluteal tuberosity

Pectineal line FLayer of

(spiral line) hyaline carlilage
A B
Figs 10.2A and B: Cartilaginous joints: (A) Primary, (B) Secondary

Secondary Cartilaginous Joints (Fibro- carti-

laginous Joints or Symphyses) (Fig. 10.2B)
articulating bones are covered with Articular cartilage
The surfaces of the
hyaline cartilage; and the bones are united by strong
fibrous tissue or fibrocartilage. These joints usually
occur in the midline of the body, e.g. symphysis pubis,
joints between vertebral bodies, manubriosternal joint,
symphysis menti.
Fibrous
capsule
SYNOVIAL JOINTS Joint cavity
They are the most common and important joints in the
body. They normally provide free movement.
Synovial
They are called synovial joints because they are membrane
lined with a synovial membrane and contain a lubricat-
ing fluid called synovial fluid. Periosteum
Distinguishing features of a synovial joint (Fig. 10.3)
The synovial joints have Fig. 10.3: Features of synovial joint
1. Ajoint cavity
2. An articular cartilage lined by synovial membrane. The synovial fluid is pro-
3. An articular capsule, lined internally by a syno0- duced, as well as absorbed by the synovial membrane.
vial membrane.
Articular Cartilage
Joint Cavity This cartilage is usually hyaline type. It has no nerve

The joint cavity is enclosed within a fibrous capsule. supply, supply or perichondrium. It is nourished
blood
by the synovial fluid covering its free surface
Ihe inner surface of the capsule and the non-articu-
latng ends of bones, which are inside the capsule are
 126 Textbook of Anatomy for
arses
Ligaments Annular
ligament
The articular capsules are usually strengthened by
ligaments, which limit the movement of the joint in
-Humerus
unwanted directions; they also maintain the normal
relationship of the articulating bones. Radius
-UIna
In some joints, a fibrocartilaginous articular disc
of Ball and socket Hinge joint
is present, eg. Temporomandibular joint, menisci Pivot joint
knee joint, etc. A B
Different Types of Synovial Joints (Fig. 10.4)
Acromion
Bal and Socket Joint (Fig. 10.4A) Clavice
surfaces is spherical
type, one of the articular
In this

and bal-ike: the other articular surface presents a

take place around Saddle joint Plane joint
cup-like concavity. Movements can Condyloid

many axes (polyaxial), e.g.

shoulder joint. D
Figs 10.4A to F: Different types of synovial joints
Hinge Joint (Fig. 10.48)
Joints have a rich blood supply and nerve suphly
Movements take place plane only; It is usually
in one
Hilton's Law states that the nerves supplying a jpnt
exten-
a uniaxial joint, e.g.
elbow joint, only flexion and also supply the muscles moving the joint and the stin
sion is possible. covering the attachments of these muscles

Pivot Joint (Fig. 10.4) LIMB

movement. In these joints,
JOINTS OF THEUPPER
These joints allow rotation
of bone rotates within a ring, e.g. Joints of the Shoulder Girdle (Fig. 10.5)
a rounded process
radioulnar joint, atlantoaxial joint. 1. Sternoclavicular joint
2. Acromioclavicular joint
Joint (Fig. 10.4D) connects
The shoulder girdle or
the pectoral girdle
Condyioid Joint or Elipsoid The
limb with the axial skeleton.
c o n v e x and the the bones of the upper
In this type, one of
the articular ends is scapula. The
clavice
c o n c a v e . It is a
bi-axial joint
girdleconsists of clavicle and the
other end is reciprocally sternoclavicular joint,
adduction, the sternum at the
o c c u r in 2 a x e s . So, meets acromio-clavVC
where m o v e m e n t s can scapula at the
extension c a n occur; but no ro- clavicle unites with the
abduction, flexion and
m o v e m e n t s are possible, e.g.
wrist joint. ular joint. connection with the axa
tational direct
The scapula has
no o
articulates with the head
10.4E) skeleton. Its glenoid cavity
Saddle Joint or Sellar Joint (Fig. form the shoulder joint.
are reciprocally the humerus to and a c r o n
surfaces of
sternoclavicular

In this variety, the articular movements can

Abrief description
concavoconvex (saddle shaped) and clavicular joints is given
below.
of
Occur in all planes, e.g.
the carpometacarpal joint
Stermocla vicular
Joint
the thumb. The
joint-saddle joint.
Type: Synovial
Plane Joint (Fig. 10.4F) rtiliage

Bones foming the joint: covered byfibroca

In this type, the articular surfaces are flat
and move- clavicle
1. Sternal end ofthe sten
ments restricted to slight gliding, tilting and rotation, Clavicular notch of manubrium

2. costal cartilage
e.g-joints between the articular processes of the tho- of first
surface
3. Upper
racic vertebrae, acromio-clavicular joint.
Joints
127
Coracoclavicular
igament Acromion Trapezius
Acromioclavicular Clavicle Costoclavicular Bursa
igament ligament

Deltoid Supraspinatus
Fibrous capsule
Coracoid
process Manubrium Glenoid fossa
sterni covered with
Ist rib. articular cartiage
(Costal cartilage)
-Head of humerus,
covered with
articular cartilage
Fig. 10.5: Joints of upper limb: Sternoclavicular and acro-
mioclavicular joints Long headd
of biceps Fibrous
capsule
Ligeaments Fig. 10.6: Shoulder joint
1. Outer fibrous capsule
2. Anterior and posterior sternoclavicular ligament
The Shoulder Joint or
3. Interclavicular ligament
the Glenohumeral Joint (Fig. 10.6)
4. Costoclavicular ligament.
An articular disc, made of fibrocartilage intervenes It is a multiaxial, ball and socket type of synovial joint.
between the sternal notch and clavicle and divides the
joint cavity into two. Bones Forming the Joint
This joint is so strong that dislocation is very rare; 1. The 'ball' is represented by the spherical head of
under stress, the clavicle fractures, rather than dis- the humerus
location from sternum. 2. The 'socket is formed by the pear-shaped, shallow,
glenoid cavity of scapula.
The Acromioclavicular Joint oor Both the articular surfaces are covered by articu-
It is a plane, synovial joint. lar hyaline cartilage. Only one-third of the humeral
head comes in contact with the glenoid cavity at any
Bones fomming the joint are position. The shallow glenoid fossa is deepened by a
1. Lateral end of the clavicle
fibrocartilaginous rim-the glenoidal labrum, which is
2. Small aticular facet on the acromion process of attached to its peripheral margin.
scapula.
Ligaments Ligaments
1. Fibrous capsule- a part ofthe capsule is thickened The fibrous capsule-it forms a loose covering. permit-
to form the acromioclavicular
ligament. ting free movements.
2. Coracoclavicular ligament-It suspends the scap-
Medially it is attached to the periphery of the glenoid
ula from the lateral one-third of clavicle (its conoid
tubercle and trapezoid line) and forms a strong
cavity.
Laterally it is attached to the anatomical neck of
bond between them. The weight of the upper limb
the humerus.
is transmitted to the axial skeleton through this
ligament. A fracture of the clavicle, medial to the
Inferiorly it extends 1 cm below, to encroach on the
surgical neck of humerus.
attachment of this ligament leads to drooping of the The fibrous capsule is lined internally by synovial
upper limb. membrane.
Movements of shoulder girdle are elevation, depres- The long head of biceps takes origin from the
Sion, protraction or fonward movement, retraction or supraglenoid tubercle. It has an intracapsular
backward movement and rotation. origin.
 128 Textbook of Anatomy for Nurses
The rotator-cuff: The fibrous capsule is strengthened Table 10.2: Movements at the
by expansions from the tendons of the following mus- muscles producingshoulder
them joint and
cles ("SITS"). Movements Muscles producing movements
1. In front-subscapularis 1. Flexion Pectoralis major, anterior fibers of deltoi
2. Above-supraspinatus 2. Extension Posterior fibers of deltoid, Teres
3. Behind-Infraspinatus and teres major. 3. Abduction Deltoid, supraspinatus (initiatedmajor
by su
The lower part of the capsule is least supported praspinatus; up to 90° by
and forms a common site for dislocation of the humeral 180° by rotation of scapuladeltoid; 90 to
by
and serratus anterior) trapezius
head in violent abduction.
4. Adduction Pectoralis major, Teres major
Glenohumeral ligaments: There are three thickenings 5. Medial Pectoralis major, anterior fibers of deltoid
of the fibrous capsule, which form the superior, middle rotation
and inferior glenohumeral ligaments. 6. Lateral Posterior fibers of deltoid
rotation
The coracohumeral ligament: Extends from the cora- 7. Circum- A combination of all the above
coid process to the anatomical neck. duction movements

Transverse humeral Iigament: It connects the two lips

of the intertubercular sulcus. This ligament holds the Applied Anatomy
long tendon of biceps in position. Dislocation of the shoulder joint is common due to
of the ligaments and disproportionate articular laxity
The axillary nerve may be affected in inferior
surfaces.
Relations of Shoulder Joint dislocation
2. Frozen shoulder results from tendonitis involving the
The deltoid muscle covers the joint anteriorly, rotator cuff. So, all the shoulder movements are
entire
laterally restricted.
and posteriorly
Superiorly-supraspinatus tendon. The Elbow Joint (Figs 10.7A and B)
Inferiorly-The axillary nerve, long head of triceps It is a hinge joint. It has two parts:
and posterior circumflex humeral vessels.
1. Humeroulnar part
Anteriorly-subscapularis, coracobrachialis and 2. Humeroradial part.
short head of biceps.
Within the capsule-long head of biceps tendon. Humeroulnar Part (Fig. 10.7A)
Blood supply Anterior and posterior circumflex hu-
meral vessels.
The humeroulnar part is formed by the articulation
between the trochlea of humerus and the trochlear
Nerve supply From axillary nerve. notch of the ulna.
The movements permitted at the shoulder joint
Humeroradial Part (Fig. 10.7B)
are flexion-extension, adduction-abduction, me-
dial rotation-lateral rotation and circumduction. The The humeroradial part is a ball and socket type o
muscles producing these movements are given in articulation. The 'ball' is represented by the capitulu
Table 10.2. of the humerus. The disc-like, concave upper surtac
of the head of the radius forms the socket.
Bursae Around the Joint
Ligaments:
There are several bursae around the shoulder joint, 1. The fibrous capsule, lined internally by the s
The
containing capillary films of synovial fluid. They re- Vial membrane, envelops the joint completey.exion
to permitie
duce friction. Some of them communicate with the capsule is thin in front and behind,
joint cavity and extension.
Joints
129

Humerus this, the ulnar border of the forearm does not come
in close contact with the lateral surface of the thigh.
Fibrous capsule
This facilitates to carrya heavy object in the hand. The
and synovial carrying angle disappears when the elbow is fixed and
membrane
Lateral View
the forearm pronated.
Humerus

-Fibrous capsule Applied Anatomy

1. Supracondylar fracture ofhumerus is common in children
Capitulum It usually ocCurs due to a fall on the outstretched hand.
Ulnar -Radial collateral The brachial artery may be injured, resulting in ischemia
collateral ligament of the deep flexors of the forearm, followed by fibrosis and
Radius-
ligament -Annular ligament shortening-this phenomenon is known as Volkmann's
Ulna ischemic contracture.
A B Radius 2. Dislocation of elbow joint can occur in adults, often as-
Figs 10.7A and B: Elbow joint sociated with fracture of coronoid process.
3 Tennis elbow or lateral epicondylitis is a painful mus-
culoskeletal condition that may follow repetitive forceful
2. Medial or ulnar collateral ligament-It extends
pronation-supination movements (this condition is not
from the medial epicondyle to the medial margin confined to tennis players).
of trochlear notch.
3. The lateral or radial collateral ligament-It extends The Radioulnar Joints
from the lateral epicondyle to the annular ligament.
The radius and ulna are united by 3 joints.
Relations of Elbow Joint 1. Superior radioulnar joint
2. Inferior radioulnar joint synovial (Pivot) joints
Anteriorly 3. Middle radioulnar joint-Syndesmosis (fibrous
- Brachialis

Tendon of biceps
joint)
Median nerve The Superior Radioulnar Joint (Fig. 10.8A)
Brachial artery
It is a pivot joint.
Posteriorly
- Triceps Structures forming the joint
Medially 1. The articular circumference of the head of the
Common origin of flexor muscles of the forearm radius
The ulnar nerve 2. An osseofibrous ring-formed by radial notch of
Laterally Common extensor origin, radial nerve ulna and the annular ligament. 1/5th ofthis ringis
and its branches. bony and 4/5th, fibrous.
The annular ligament keeps the radial head in posi
Movements The chief movements at the elbow joint
tion. It is attached to the two ends of the radial notch
are flexion and extension.
of ulna. The radial head rotates within this ring.
Muscles producing flexion are Brachialis, Biceps bra-
chii and Brachioradialis Middle Radioulnar Joint (Fig. 10.8B)
Muscles producing extension are Triceps and an- It connects the shafts of the radius and una by syn-
Coneus and this movement is assisted by gravity. desmosis, which consists of (1) An oblique cord and
(2)An interosseous membrane.
arrying angle: When the elbow is fully extended
and the forearm supinated, the arm and the forearm The oblique cord passes at right angles to the
form an obtuse angle, which is open on the lateral fibers of the interosseous membrane. It extends from
SIde. This is known as the carrying angle. Because of the ulnar tuberosity to the radial tuberosity.
 Textbook of Anatomy for Nurs
130
lurses

Radial collateral Oblique

Trochlear
ligament cord
notch
of uina
Ulna
Interosseous-
membrane

Radial notch
of ulna

Radius

Supination Pronation
Annular ligament and pronation
ring of supe- Fig. 10.8B: Radioulnar joints: Supination
An osseofibrous
Fig. 10.8A: Radioulnar joints:
rior radioulnar joint

sheet Supination: In the

anatomical position, the palm is
broad fibrous
The interosseous membrane is a directed forward and the forearm is supinated so that
between the interosseous
borders of radius
extending side and almost
of the membrane is free and the radius and the ulna lie side by
and ulna. Upper border
gap between it and
the oblique cord for the parallel to each other.
presents a
interosseous vessels. The lower the head of the radius
passage of posterior Pronation: During pronation,
the passage of anterior around a vertical
part presents an oval gap for spins within the annular ligament
interosseous vessels to the back of the arm. its position
downward and
axis; the head of the radius, still retains
The fibers of the membrane slope lateral to the ulna.
medially from radius to ulna, except in the
lower part, hand
where they are arranged in reverse direction. But, the lower end of the radius, carrying the
ulna.
The interosseous membrane is stretched in with it, rotates medially across the lower part of
In this process, the interosseous membrane is spira-
mid-prone position; it is relaxed in extremes of supina-
lised.
tion and pronation. bones
supination, the rotation is reversed. The
In
s
Inferior Radioulnar Joint become parallel and the interosseous membrane

This is a pivot joint. despiralized.

The ulna also moves during pronation and sup
Bones forming the joint nation, it appears to be stationary.
Ine

1. Articular surface of the head of ulna

eventhough
distal end of the ulna moves backward and lateraluy
2. Concave ulnar notch of radius in pronation and forward and medially in supinauo
They are connected below by an articular disc. Both with ne

bones are enclosed in an articular capsule

The range of pronation and supination,
fixed elbow, is about 140-1500 when the elbow i
The articular disc is a triangular plate of to almost
fibrocartilage tended, the range of vement is increased
humeral
It separates the head of the ulna from the wrist joint. 360 (This is due to the sociated rotation of
Movements: The radioulnar joints permit the move- head at the shoulder joint).
ments of pronation and supination of the forearm.
 131
J o i n t s

Musclos producng moveme nents Behind:

P r o n a t i o n
Extensor tendons to thumb and other fingers
-Pronatorquadratus
Movements ond Musclos Producing them
-Pronatorteres
Flexor carpi radialis 1. Flexion-Flexor muscles of wrist and fingers
2. Extension-Extensor muscles of wrist and fingers
-Gravity
3. Adduction or ulnar deviation-flexor carpi ulnaris
Supination:
and extensor carpi ulnaris muscles
-Biceps brachii (in flexion)
Supinator(in extension) 4, Abduction or radial deviation-abductor pollicis
longus
10.9) 5, Circumduction-it is a combination of flexion ad-
Wrist Joint (Fig.
duction, extension and abduction
The wrist joint is a bi-axial ellipsoid (condyloid) joint;
also called the radiocarpal joint Applied Anatomy
this joint is
Colles' fracture results from a fall on the outstretched
the Joint
Bones Forming hand. It involves the distal end of radius. The fracture line
is transverse. The lower segment of the radius is displaced
1. Distal articular surface of radius and the articular upward and backward; it produces a characteristic "dinner
disc of inferior radioulnar joint. fork" deformity
lunate and part of triquetral bones. 2. Smith's fracture: It is the reverse of Colles' fracture pro0
2. Scaphoid,
duced by a fall on the back of the hand.
Ligaments
Carpometacarpal Joint of the Thumb (Fig. 10.10)
1. Capsular ligament, Iined by synovial membrane
2. Radial and ulnar collateral ligaments they are The first carpometacarpal joint is a saddle (sellar) joint.
thickenings of the fibrous capsule, The radial colI t permits great range of movements.
lateral ligament extends from the styloid process
of radius to the scaphoid and trapezium. The ulnar Bones Forming the Joint
collateral ligament extends from the ulnar stylold 1. Distal articular surface of trapezium
process to the triquetral and pisiform bones. 2. Base of first metacarpal bone
The articular ends of both bones are reciprocally
Relations
convexoconcave
In front
- The long flexor tendons to the fingers and thumb Ligaments
The median nerve Capsular igament lined internaly by the synovial
-The ulnar nerve and vessels membrane.
-The palmaris longus tendon
-The radial artery
Trapezium
- Ulna

Radius

Articular
disc
Ist metacarpal
-Pisiform
Scaphold
Triquetral
Lunate
Fig. 10.10: Carpometacarpal joint of thumb
Fig. 10.9: VWrist joint
132
Textbook of Anatom
Lateral ligament
oonnects lsterel surfare of
to the
lateral side of the base of trap67um
The
frst metacarpal bone
dorsal and palmar
ligaments are olique bards
extending from the dorsal and palmar surfaces
0f
rapezium to the ulnar side of the base of the 1s1
metacarpal bone
Relations
In front Flerion Elensien
Abductor pollicis brevis
Flexor pollicis brevis The thenar muscles
Opponens pollicis
Behind
Extensor pollicis longus and brevis
Laterally
Abductor pollicis longus and extensor policis
brevis
Medially odutien Oponten
1st dorsal interosseous muscle and the radial
Fig. 10.11: Moverments of thurrb at fest
artery Carpornetacarpal joint
Movements (Fig. 10.11)
and Muscles Producing Thom Because of the cormplexity of the movermert.coos
tion of the thurmb rmay be affected by nerveirjures inte
The first metacarpal bone lies on a more anterior plane
upper limb, sspecially the rmedian nerve. f fte medan
than the other metacarpal bones and undergoes me-
nerve is cutin the forearm or wrist, thethumb cannate
dial rotation through 90, so that its dorssl surface is
opposed, Similarly, an injury to the recurrentbrandhd
lateral and palmar surface, medial
median nerve, that supplies the thenar muscles resuts
Due to this peculiar anatomical position of the 1st
in the paralysis of these muscdles. The thurmb, as a resut
metacarpal, flexion and extension take place parallel
loses much of its usefulness.
to the plane of the palm, Adduction and abduction tako6
When a person falls on the outstretched hand
place at right angles to the palm
with the forsarm pronated, the mainforce of the falls
The combination of flexion, sbduction, extension
and adduction is known as circumduction
transmitted through the wrist (carpus) to the
bones, 6specially, the radius, then to the humerus,
foream
The opposition is a combination of abduction, flex
SCapula and clavicle, So, during such falls, fractars
ion and medial rotation at the frst carpometacarpal davoa
joint, so that the pulp of the thumb can be brought in may occur in the wrist, radius, humerus or the
Fracture of the scaphoid bone is also a comm
contact with the tip of any finger (serniflexed) This is
injury. The bone fractures at its waist', produng
0s06rtial for grasping an object
fragments, There will be tenderness in the analtom
Movoment Musclos snuff box.
1. Flexion Flexor pollicis brevis and ongus
2. Etension Exlensor pllicis longus, brovis, abductor
poallcis longius JOINTS OF THE LOWER LIMB
3.Aududion Abdutor poliois longus and brevis Hip Joint (Fig. 10.12)
4. hddustion Adductor policis
5.Opostion fis initated by the abductorsof thumb and Type
mairtained by opgonons policis It is a synovial joint, "ball and sockef' type
 Joints
133

Iliofemoral ligament
Acetabulum
-Head of femur

Fibrous
capsule

Ligament of
head of femur

Pubofemoral ligament

Fig. 10.12: Hip joint Fig. 10.13: Ligaments of hip joint

Articular Ends The capsule is made up of superficial longitudinal

which
acetabulum of hip bone fibers and deep circular fibers (zona orbicularis),
1. The
the femu. encircle the neck of the femur.
2. Head of

The acetabulum is a cup-shaped depression of the Transverse Ligament

hio bone, where ilium, ischium and pubis meet (They
the acetabular notch, which is gap
a
a tri-radiate Y-shaped cartilage, the It bridges across
are separated by
in the lower part of acetabular rim.
Ossification of which is complete by 20 years). The
acetabulum presents a horse-shoe-shaped "lunate 10.13)
surface" internally. Below this lunate surface is a non-
lliofemoral Ligament (Ligament ofBigelow) (Fig.
articular area filled with a pad of fat. A fibro-cartilagi- It is the strongest ligament in the body. It is inverted 'Y
anterior inferior
nous ribbon-like structure
called labrum acetabulare shaped. Superiorly, it is attached to the
which are
is attached to the margins of the acetabulum. iliac spine. Inferiorly, it splits into 2 bands
intertro-
attached to the upper and lower parts of the
The head of the femur is spherical, smooth and
cov-
the
chanteric line of femur. In between these bands,
ered with aticular (hyaline) cartilage. On the upper
fibrous capsule is weak.
part of the head is a small pit.
Pubofemoral Ligament
Ligaments It extends from the superior ramus of pubis and iliopubic
The Capsule eminence and merges with the fibrous capsule.

ltis a loose, thick fibrous sac enclosing the joint cavity. Ischiofemoral Ligament
Iis inner surface and the nonarticular surfaces of bone
Proximally, it is attached to the ischium below and
are lined by synovial membrane. it merges with the
behind the acetabulum. Distally,
Attachments of fibrous capsule fibrous capsule.
Proximally- to the margins of acetabulum Head of the Femur
Ligament of the
'Distally: Anteriorly, to the trochanteric line. It is triangular in shape. Its apex is attached to the
Posteriorly, 1 cm proximal to the trochanteric crest
Above: close to the greater trochanter pit on the femoral head. The base is attached to the
margins of acetabular notch.
Below: close to the lesser trochanter
 Textbook of Anatomy for
134 or Nursen
Contd.
Relations of Hip Joint 3. Coxa vara is a condition in which neck.sh
minished (The normal k-shaft angle haft angle is d
in
Anteriorly adults is 120
in children is 160). This may result from P r
- Pectineus or rickets. There will be marke limitation thes disease
Psoas major (see Fig. 9.27)
Iliacus
4. Fracture of the neck of the femur-May occur
the head (subcapital fractu re)or (b) along
abdudi
just obelnow
Rectus femoris line. the trochanterie
Femoral nerve Subcapital fracture (.e. fracture of the
part, just below the head of femur) roximal narrow
Femoral artery and vein commonly
fracture isOccurs in
elderly people due to trivia trauma. The
Posteriorly intracapsular. It often disrupts the
blood suppl entirely
The sciatic nerve head of femur, resulting in ascular to the
Lateral rotators of the hip (lying under cover of necrosis.
through the distal part of the neck (along the tactur
gluteus maximus) line) is more common in adults following se anteric
Inferior gluteal vessels and nerve This fracture, usually unites without
supply is not disrupted. difficulty, the
as
blo
Superiorly
5. Because of the close relationship of the sciatic
-Gluteus minimus erve
hip joint, it may be injured (either stretched or compresto the
Below
Pectineus and obturator externus
during posterior dislocations or fracture-dislocatio
hip joint. This may result in paralysis of the ations of
Arterial supply: From medial and lateral femoral cir- plied by the sciatic nerve, tnere will be muscles sup-
also.
sensory channe
cumflex arteries, superior and inferior gluteal arteries
6. In diseases of the hip joint, pain may be
and the obturator artery. referred to the
knee because both the hip and knee
joints are supplied
Nerve supply: Mainly the femoral nerve by the femoral and obturator nerves.

Unique Features of the Hip Joint

The Knee Joint (Fig. 10.14)
The hip joint is unique because it has a high degree
of stability as well as mobility. The knee joint is a modified hinge joint. It is the larg
The stability of the hip joint is due to: est and most complex joint of the
body. It is called a
1. The depth of the acetabulum, which is increased compound joint because it incorporates two condylar
further by a labrum acetabulare. joints between the condyles of the femur and tibia and
2. The strength and tension of the one saddle joint between the femur and the patella.
ligaments
3. The powerful muscles around it
4. The length and obliquity of the neck of the femur
Table 10.3: Movements at the hip joint and muscles
5. The atmospheric
pressure. producing them
The mobility depends
upon the neck of the femur, Movements Muscles producing movements
which is narrower than the head.
1. Flexion
llio-psoas
Movements (Table 2. Extension Gluteus maximus and hamstring musoes
10.3): Active movements permit-ted
at the hip joint 3. Adduction** Adductor longus, brevis and
non-ischne
are
flexion-extension, adduction-ab-
duction, medial-lateral rotations, and part of adductor magnus
circum-duction. 4. Abduction Gluteus medius and minimus
Applied Anatomy 5. Medial rotation
1.
Congenital dislocation of hip-it is due to the defective
Gluteus medius and minimus
m u s c l e s under

6. Lateral rotation Gluteus maximus and mupiriformis

development of the upper part of the acetabulum. It is COver of gluteus maximus ( i
more common in
females. internus and qua
2. Perthes' gemelli, obturator
disease-results from avascular necrosis of the femoris)
head of the femur, which might have ensionofthe
as a result of trauma. occurred in childhood Extension is limited; it is arrested by the tensi
ofemoral ligament O p p o s i t et n g i

Contd.
Adduction is limited by the apposition of the
 135

The ligamentum patellae: It is derived from the tendon

Joints Femur
of quadriceps femoris and extends from the apex of
the patella to the tibial tuberosity.

The tibial collateral ligament: This ligament has 2 parts,

superficial and deep. Both parts are attached above
to the medial epicondyle of femur. The superficial part
Cruciate is attached
Fibrous
ligaments extends downward as a flattened band and
of medial
to the medial condyle and adjacent part
Capsule

Medial border of the shaft of tibia.

meniscus
of medial
The deep part is attached to the periphery
blends with the fibrous capsule. In the
meniscus and it
FIbUlar

cOlaleral
gament lie the
Tibial
interval between the superficial and deep parts
collateral
inferior medial genicular vessels and
nerve.
ligament
Lateral

It extends as a fibrous
meniscus

The fibular collateral ligament:

of femur to the head
cord from the lateral epicondyle
is overlapped superficially
Tibia
of the fibula. The ligament
tendon of biceps femoris.
by the is not attached to
Fibula
10.14: Kneejoint The deep surface of this ligament
Fig. The gap between this ligament and
the fibrous capsule.
the inferior lateral
the fibrous capsule is occupied by
Articular S u r f a c e s
genicular vessels and
nerve.

by- the
is f o r m e d
(The tibial collateral ligament is morphologically
The knee joint the femur collateral
condyles of
the fibular
1. The distal part of adductor magnus;
the tibia derived from the primitive
condyles of ligament is morphologically
2. The
3. The patella. origin of peroneus longus muscle).
articulate with the tibial
con-

The femoral condyles front.

and with the patella in Cruciate ligaments: There are 2 ligaments which c r o s s
dyles below and behind,
like the letter "X", so they are called cruciate ligaments.
Ligaments of Knee Joint anterior and posterior cruciate
membrane
They are named a s
1. Capsular ligament with synovial ligaments according to their tibial attachments.
2. The ligamentum patellae extends from the
The anterior cruciate ligament
3. Tibial and fibular collateral ligaments medial surface of
intercondylar a r e a of tibia to the
4. Anterior and posterior cruciate ligaments and femur
lateral condyle of femur. It binds the
tibia
5. Oblique popliteal ligament. at the knee
together and prevents hyperextension
The capsular ligament: It envelopes the joint. It is
joint. from the
perced posteriorly by the tendon of the popliteus mus- The posterior cruciate ligament extends
oE. 1he capsule is attached anteriorly to the peripheral of tibia to the lat-
margins of the patella and fuses with the
posterior part of intercondylar area
of femur. This ligament
ligamentum eral surface of medial condyle
palellae. Inner side of the fibrous capsule provides binds the tibia and femur and prevents the backward
ciaChment to the peripheral
lateral menisci. margins
of andmedial displacement of tibial condyles.

ne synovial membrane Both cruciate ligaments prevent side to side dis-

lines the inner surface o
the ibrous
capsule and the portion of the bones within placement of femur and tibia.
capsule; but it does
and the menisci. not cover the articular The oblique popliteal ligament: It is an expansion from
surfaces
the lower end of semimembranosus muscle (from its
insertion).
196
Textbook of Anatomy for
Marss
The medial and lateral menisoi (s06
Fig. 8.10) (or
6emilunaf 6artlilagos) The merisoi are oomposed Table 104 Movements at the
knes joit
firocartilage They projeot fromn the fitrous capsule as Movernerts Muscles producing movements
if6omplete partitionis and ocupy a postion tetwse Extension Ouadriceps fernoris
fhe 0ondyles of fermur and
titia Flerion Hamstring musclessemimembr
The medial merisous (se0 fig. 8 10):1is serilunar in nosus, semitendinosus and
bicess
fernoris, flerion is iritiated by
sinpe ard lornger in the arteroposterior diredtion than popites
fhe laterl
rerisous, Hhas an arferior anid a posterior
Medial rotation
Seminembranosus,
sartorius,
semitendinous
gracilis
and popliteus
hon,try wich t is attached to the irnterconidylar area
of tiba Medially, it is attached to the fitrous capsule Lateral rotation Biceps femoris
and the titial oolatersl igarriert. ts superior surfacs
is 6ofave Subcutaneous prepatellar bursa lies between the skn
The laferal menisous is srrmaller, t is attached to and anterior surface of patella (This bursa may be
the irtercordylar area of titia try arterior and posterior swollen in a house-naid, due to washing thefior b
horns, Hs upper surface is concave, The lsteral margin kneeling-hence, it is called "house-maids bursa
is atfached to the fitrous capsule Subcutaneous infrapatellar bursa or Clergyman's
bursa, intervenes between the skin and the tbialt
Functions of rerisol
1 They inrease the concavity of the titial condyles berosity (1t is sometimes swollen in people who pray
in kneeldown position with the trunk upright-hence
for tetter adaptation with fernoral condyles
known as "Clergyman's bursa").
2. They act as shock atsorters
There are 4 or 5 bursae medial and lateral to e
3 They alow the gidirng movernerits during flerion
knee joint.
and erternision
Hutrition of these cartilsgos Sincs the peripheral part
Arterialsupply: Knee joint is highly vascular. t's
supplied by genicular branches of popliteal, femoral
is sttached to the fitrous capsule, it receives nutrition anterior and posterior tibial arteries.
from arteries supplying the capsule, The inner free
Nerve supply: It is richlyinnervated by branches d
part of the menisous is avascdar, it derives its nutri-
fion from synoial fuid, The semilunar cartilages can fermoral, tibial, common peroneal and obturator nenves
regenerate, proided the cartilage is rermoved eritirely.
Applied Anatomy
Movements at the knee joint (Table 104) are eten 1. The firm attachment of the tibial collateral ligament to
sion, flexion, medial rotation and lateral rotation
nedial meniscus is of great clinical will be oftenbeca.xe
importance,
Extension or straigtering continues till the leg and injury to the tibial collateral ligament ass
meniscus. It is a com
thigfh are in the sarne vertical line, Hyperextension is ated with injury to the medial

preverned try the tension of sl igarnenits and the ten type of injury in football players (when considerine
always think of three
the
sion of artagoristio musdes tissue injuries of the knee, and c a r t a
cruciate ligaments
the collateral ligaments,
Bursoo Around tho Knoo Joint 2. (menisci)
Genu valgum is due to the medial condyle and s
shatof

the fernur protruding too far medially. curvingof

A tursa is s flartened sae ('purse), hose walls aree 3. Genu varurn or bow-leg presents with outward c a
sepat sted try a capillary filrn of synoial fluid. This fluid the lower limb. These conditions may be cong
Ms as a utricard, eratling its walls to slide over each
miay be associated with rickets.
canocour
fher ttout friction, ne sprain of anterior cruciate ligament
The posterior cruciale
h et b i a
Brsas are presert terever a muscle or tendon is hyperextension of the knee. ofl
dislocation

nent may be injured in the posterior

abnoma

hely to rut on another muscde, tenidon, bone of skin. will lead

There wil te several tursas around active joints, like Conplete tear of these ligaments
aniteroposterior movements.
the kree ind
 137
J o i n t s

10.15)
Joint (Fig.
TheAnkle or the talocrural joint is a uniaxial, Fibula
ankle joint Tibia
The
hingejoint.

the Joint
Forming
Bones
Interosseous
surface of the lower end
of fibular
1. Above articular
inferior ligament
a
The
medial
malleolus
with its
tibia, fibula
m a l l e o l u s of
lateral Talus
b. The the tibia and fibula form
surfaces of Deltoid
Articular (socket). This socket, ligament
mortise"
"tibiofibular
a below.
talus from
receives the
Calcaneo
2. Below:
body of talus fibular
surface of the ligament
upper the medial
a. The articular facet on
comma-shaped
b. The malleolus Calcaneus
for medial
side of talus, lateral malleolus, on
facet, for the
C. A triangular These three articu-
surface of talus.
the lateral known a s 10.15: Coronal section through left ankle joint
c o n t i n u o u s surface Fig.
a r e a s form a
lar
"trochlea tali".

Ligaments
membrane
with synovial
1. Capsular ligament,
deltoid ligament
2. Medially, the talofibular and
anterior and posterior
3. Laterally,
calcaneofibular ligaments.
or delta-
The deltoid or medial ligament (triangular
2 parts
shaped). It is a strong triangular band, having Plantar flexion
a superficial part and a deep part. Dorsiflexion
ankle
the tip of Fig. 10.16: Movements at the
The superficial part is attached superiorly to
medial malleolus. Inferiorly, it is attached to the follow-
the angle between the
bones, from anterior to posterior-the navicular, The plantar flexion increases
ng stands on toes.
the calcaneus and the talus. leg and the foot, so that the person
The deep part extends from the medial malleolus
Muscles Producing Movements
tothe talus, below the comma-shaped facet.
muscles of the ante-
Dorsiflexionis produced by the
Movements (Fig. 10.16) are tibialis anterior,
rior compartment of the leg. They
Movements permitted at the ankle joint are dorsiflexion extensor hallucis longus
and plantar flexion. extensor digitorum longus,
and peroneus tertius.
Normally, the leg meets the foot, forming a right
gie. The dorsiflexion diminishes the angle between the muscles of posterior
Plantar flexion is produced by
em, so that, the and soleus are
lie above heel strikes the ground and the toes compartment - t h e gastrocnemius,
the flexor digitorum
ground. the main flexors; the tibialis posterior,
138 Textbook of Anatomy for Nurses
longus and flexor hallucis longus assist the gastro
cnemius and soleus.

Applied Anatomy
The ankle joint is the most frequently injured major joint in
our body. The lateral ligaments are the ones most frequenty
injured. A "sprained anke" results from twisting of the weight
bearing foot, when it is forcefully inverted, e.g. when a person

steps on an uneven surface and falls, most of the fibers of the

lateral ligament are stretched; some of them are tom. There
will be pain and swelling anteroinferior to the lateral malleolus.
Fracture-dislocation of the ankle joint occurs in severe inju-
ries. When the foot is everted, there may be a fracture
forcefully Eversion
of medial malleolus. The force of impact may push the talus Inversian
fracture of fibula,
against the lateral malleolus; this may lead to a Fig. 10.17: Movements at the subtalar joint
a combination
a few centimeters above the ankle joint. Such
fracture
of horizontal fracture of medial malleolus and oblique
of fibular shaft is known as 'Pott's fracture'. Eversion
In eversion, the lateral margin of the foot is raised
The Subtalar Joint
above the ground and the sole faces downward and
taloc-
The subtalar joint is also known as the posterior laterally.
surface
alcanean joint. It is formed between the lower These two movements are best demonstrated
the
of the body of the talus and the upper surface of when the foot is off the ground.
middle third of the calcaneus. The subtalar joint
has a These movements help us to walk on uneven
major role in the movements of inversion and eversion ground.
of the foot (Fig. 10.17) Muscles producing inversion
Inversion 1. Tibialis anterior
Inversion is a process by which the medial margin of
2. Tibialis posterior.
the foot is raised above the ground so that the sole is Muscles producing eversion:
directed downward and medially (e.g. as if to remove 1. Peroneus longus
a thorn from the sole). 2. Peroneus brevis.