Brain, Behavior and Movement

Joints
Dr. Art Dalley
Office: MCN B-2323 (2-6572)
art.dalley@vanderbilt.edu

Introduction to Joints
I. Types of Joints
A. Fibrous
B. Cartilaginous
C. Synovial

II. Synovial joints – most common; provide free movement; contain lubricating substance,
i.e., synovial fluid, in the joint cavity; lined with synovial membrane or articular cartilage
[COA I.16-7]
A. Features of a synovial joint
1. bone ends are covered with articular cartilage
2. joint cavity enclosed by articular capsule
3. fibrous capsule lined with synovial membrane (vascular CT that produces synovial
fluid)
4. reinforced by accessory ligaments
a) extrinsic – separate, outside the joint capsule
b) intrinsic – part of the joint capsule
B. Types of synovial joints [COA I.17]
1. Plane joints: permit gliding or sliding in one plane of motion; uniaxial; movement
limited by tight articular capsules e.g., acromioclavicular joint
2. Hinge joints: (ginglymus): uniaxial; move in only one plane (sagittal) around only
one axis; permit flexion and extension only; e.g., elbow joint (humeroulnar)
3. Condyloid joints: biaxial; allows movement in two planes (sagittal and coronal);
flexion/extension, abduction/adduction, circumduction; e.g., MP joints, radiocarpal
joints
4. Saddle joints: multi-axial; opposing surfaces shaped like a saddle, e.g.,
carpometacarpal joint of the 1st digit (thumb); sternoclavicular joints
5. Ball and socket joints: multiaxial; move in multiple axes and in multiple planes;
flex/ext, abd/add, IR/ER, circumduction; e.g., glenohumeral joint, hip joint
6. Pivot joints: uniaxial; allows rotation; a rounded process of bone rotates within a
sleeve or ring; e.g., atlanto-axial joint (C1-C2), proximal radioulnar joint
III. Innervation (Nerve Supply) and Vascular Supply of Joints
A. Nerve Supply (innervation)
1. Nerve endings are located in the articular capsule. They provide pain and
proprioception (awareness of movement and position of the parts of the body)
sensory information.
2. Hilton’s Law – nerves supplying a joint also supply the muscles that move the joint
and the skin covering the attachments of these muscles, or, a joint is commonly
supplied by nerves supplying the muscles that cross (act on) the joint.
However, subcutaneous joints often receive innervation from cutaneous nerves.
• Question: following a ‘total hip’, how does a patient know where their hip is in
space?
3. Pain associated with joints:
a. Cartilage is aneural – thus, no pain from cartilage
b. Synovial membrane – has relatively few pain afferents
c. Capsule and ligaments – well-innervated
d. Subchondral bone – well innervated
B. Vascular Supply – located in the articular capsule
1. Arterial blood
a. articular arteries supply joints
b. arise from arteries around the joint (in the neighborhood)
c. most often communicate or anastomose with other arteries to form a network or
peri-articular plexus.
2. Venous drainage – drain subsynovial capillary beds; veins accompany arteries

Joints of the Upper Limb

I. Joints of the pectoral girdle and shoulder
A. Sternoclavicular (SC) Joint
 Sternal end of clavicle articulating with clavicular notch of manubrium of sternum
o only articulation between the superior appendicular (upper limb) and axial
(trunk) skeletons
1. Morphologically a saddle type of synovial joint; however . . .
o functions as a modified ball and socket joint in terms of movements possible
 Divided into two compartments by an articular disc (fibrocartilage) firmly attached to
the fibrous capsule and SC ligaments.
o Strong fibrous capsule firmly attached to articulating bones and disc prevents
clavicle from being driven medially over sternum (e.g., during fall onto shoulder);
clavicle will break first.

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  Movements (observed as movements of shoulder):
o Elevation/depression, protraction/retraction, circumduction
o Movement here facilitate movements of pectoral girdle and free upper limb.
 Ligaments
o Costoclavicular ligament – extrinsic ligament that limits elevation
 Nerve Supply (deduce using Hilton law)
o Medial supraclavicular nerve (cutaneous br. of cervical plexus)
o Nerve to the subclavius
B. Acromioclavicular (AC) Joint
 Acromial end of the clavicle articulates with the acromion of the scapula
o articular surfaces covered with fibrocartilage
o partially separated by incomplete articular disc.
 Plane type of synovial joint.
 Movements:
o Scapula pivots and rotates while fixed to acromial end of the clavicle
o Movements are associated with motion at (conceptual) scapulothoracic joint.
o No muscles originate from one of the articulating bones to insert on the other
o Axioappendicular muscles attaching to/acting directly on scapula indirectly
cause movement here.
 Ligaments
a. AC ligament – thickening in otherwise relatively weak joint capsule
b. Coracoclavicular ligament
o compound extrinsic ligament providing integrity/stability of AC joint
o bears weight of free limb when axioappendicular and scpulohumeral
muscles are relaxed
i. conoid ligament – medial and vertical, attaches from coracoid process
to conoid tubercle of the clavicle
ii. trapezoid ligament – lateral and oblique, attaches coracoid process to
trapezoid line of clavicle
 Nerve Supply
a. Supraclavicular nerve (cutaneous branch of cervical plexus)
b. Lateral pectoral nerve
c. Axillary nerve

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 C. Glenohumeral (Shoulder) Joint \
 Ball and socket type of synovial joint
o permits a wide range of movement
o high mobility results in a relatively unstable joint
 Large round head of humerus articulates with the relatively small and shallow
glenoid cavity of scapula
o Joint capsule must be loose to allow wide range of motion
o Glenoid cavity deepened slightly but effectively by the ring-like,
fibrocartilaginous glenoid labrum
o Role of labrum evident via the instability that results when torn or loose
o Glenoid cavity + labrum accepts little more than a third of head of humerus
o Head of humerus held in the cavity by tonus of rotator cuff (SITS) muscles
 Ligaments
o Glenohumeral ligaments –strengthen the joint anteriorly; intrinsic ligament (part
of fibrous capsule), distinct only from internal aspect of joint
o Osseofibrous coracoacromial arch –
a. acromion
b. coracoid process
c. coracoacromial ligament—connects these two parts of same bone (scapula)
 Inferior part of articular capsule only part not reinforced by the rotator cuff muscles
or capsular ligaments
o Dislocation in most directions resisted by rotator cuff
o Upward dislocation resisted also by coracoacromial arch
o Inferior (downward) dislocation resisted primarily by reflexive isometric
contraction of shunt muscles
 Movements – flexion/extension, abduction/adduction, medial (internal)/lateral
(external) rotation, circumduction
 Prime movers (deduce these given your knowledge of their location relative to the
joint)
o Flexion – pectoralis major (clavicular part), deltoid (clavicular part), assisted by
the coracobrachialis and biceps brachii
o Extension – latissimus dorsi and deltoid (spinous part)
o Abduction – deltoid (especially acromial part) following initiation by the
supraspinatus
o Adduction – pectoralis major and latissimus dorsi
o Medial rotation (internal) – subscapularis

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 o Lateral rotation (external) – infraspinatus & t. minor
 Subtendinous bursae – located where tendons slide across bone, ligaments or
other tendons.
o Subscapular bursa—continuous (in open communication)with articular cavity of
joint
o Subacromial bursa (subdeltoid)
 Nerve Supply
o Suprascapular nerve
o Axillary nerve
o Lateral pectoral nerve
II. Joints of Free Upper Limb
A. Elbow Joint
 appears simple because of its primary function as a hinge joint, the fact that it
involves the articulation of a single bone proximally with two bones distally, one of
which rotates, confers surprising complexity on this compound (three-part) joint.
o Typically, hinge joints have medial and lateral collateral ligaments holding the
bones together. Otherwise, fibrous capsule is thin and relatively loose.
o Radial collateral ligament cannot attach distally to radius, which must be free to
rotate (pronate-supinate), so it attached to the anular ligament that forms the
“socket” within which the head of the radius rotates (pivots).
 The hinge movement, the ability to transmit forces, and the high degree of stability
of the joint primarily result from the conformation of the articular surfaces of the
humero-ulnar joint (i.e., of the trochlear notch of the ulna to the trochlea of the
humerus).
 The integrity and functions of the humeroradial joint and proximal radio-ulnar joint
complex depends primarily on the combined radial collateral and anular ligaments.

B. Proximal radioulnar joint

 Child (columnar) vs. adult (conical) shape of annular lig. & head of radius
o Subluxation occurs more easily in children
C. Radioulnar syndesmosis
o Interosseous membrane connecting radius and ulna
D. Distal Radio-ulnar Joint
 Pivot type of synovial joint.
 Distal radius moves around the relatively fixed head of ulna (radius crosses ulna
anteriorly for pronation, uncrosses for supination).
 Fibrocartilaginous triangular articular disc of distal radioulnar joint binds the ends of
ulna and radius together.

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  Nerve Supply
o anterior interosseous nerve
o posterior interosseous nerve
III. Joints of Hand
A. Wrist Joint
 Radiocarpal (RC) Joint
a. Condyloid type of synovial joint
b. Position of joint is indicated superficially by a line joining the styloid processes of
the ulna and radius (~proximal crease at wrist).
c. The distal end of the radius and articular disc of the distal radioulnar joint
articulate with the proximal row of carpal bones except the pisiform, i.e.,
scaphoid, lunate and triquetrium
d. Movements:
i. flexion/extension
ii. radial (abduction) deviation
iii. ulnar (adduction) deviation
iv. circumduction
e. Ligaments
i. palmar radiocarpal ligament
ii. dorsal radiocarpal ligament
iii. ulnar collateral ligament
iv. radial collateral ligament
f. Nerves
 Anterior interosseous nerve
 Posterior interosseous nerve
 Ulnar nerve
 Midcarpal Joint
o Augments especially flexion and extension movements at radiocarpal joint
B. Joints of Fingers
 Carpometacarpal/Intercarpal Joints
o plane synovial joints except the thumb which is a saddle joint
 Metacarpophalangeal (MCP) Joints
o condyloid synovial joints; flexion/extension and abduction/adduction;
strengthened by collateral ligaments
 Proximal (PIP) and Distal Interphalangeal (DIP) Joints

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 o condyloid synovial joints; strengthened by collateral ligaments

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 JOINTS OF THE HIP, LEG AND FOOT

I. Hip Joint
A. Bony elements/articular surfaces: Acetabulum and head of femur
1. Lunate surface and acetabular fossa accomodating ligament of head of femur
2. Acetabular labrum and transverse acetabular ligament
B. Passive elements of joint stability: Ligaments of hip joint:
1. Iliofemoral
2. Pubofemoral
3. Ischiofemoral
C. Dynamic support and movements of hip joint
1. Importance of “bend” in femur (angle of inclination) to function of hip joint
2. Muscles acting on this hip joint
D. Neurovasculature of hip joint
1. Blood supply to head/neck of femur and clinical consequences.
a. medial vs. lateral circumflex femoral arteries
b. retincular arteries
c. acetabular branch of obturator artery (artery to head of femur)
2. Nerve supply of hip joint (applying the Hilton law)
a. femoral nerve
b. obturator nerve
c. superior gluteal nerve
d. nerve to quadratus femoris
II. Knee Joint
 hinge joint with a wide range of motion (primarily flexion and extension, with rotation
increasingly possible with flexion).
 our most vulnerable joint, owing to its incongruous articular surfaces and the
mechanical disadvantage resulting from bearing the body’s weight plus momentum
while serving as a fulcrum between two long levers.
 Compensation is attempted by several features, including (1) strong intrinsic (tibial
collateral), extracapsular (fibular collateral), and intracapsular (cruciate) ligaments; (2)
splinting by many surrounding tendons (including the iliotibial tract); and (3) menisci that
fill the spatial void, providing mobile articular surfaces.

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  Of particular clinical importance are (1) collateral ligaments that are taut during (and
limit) extension and are relaxed during flexion, allowing rotation for which they serve as
check ligaments; (2) cruciate ligaments that maintain the joint during flexion, providing
the pivot for rotation; and (3) the medial meniscus that is attached to the tibial collateral
ligament, and is frequently injured because of this attachment.
II. The Fibula and Its Joints
 weight of the body is transmitted from the femur to the tibia; the femur does not contact
the fibula; therefore the fibula carries no weight to the ground.
 distally, the fibula holds the talus in its socket and does so in a resilient manner.
 a main function of the fibula is to give origin to muscles:
o of the nine muscles attached to it, only the biceps pulls upwards; all the others pull
downwards on the fibula.
o all ligamentous connections between tibia and fibula, including the interosseous
membrane, are directed accordingly.
 fibula is pushed upward when talocrural joint is strongly dorsiflexed as the wide
part of superior talar facet becomes tightly wedged between the malleoli.
A. Tibiofibular Joints:
1. Proximal tibiofibular joint:
 synovial joint of the plane or gliding variety between head of fibula and
inferolateral aspect of lateral condyle of tibia
 the popliteus bursa, between the joint and the popliteus tendon, may
communicate with the joint.
2. Middle and distal (inferior) tibiofibular joints:
 syndesmoses:
 middle tibiofibular joint = interosseous membrane.
 distal tibiofibular joint = interosseous tibiofibular ligament.
o Fibula, proximal to malleolus, is held against fibular notch of tibia
o the interosseous ligament stabilizes the distal tibiofibular joint and:
 keeps malleoli held against the malleolar surfaces of the talus.
 is continuous superiorly with the interosseous membrane.
 the distal tibiofibular joint is further strengthened by:
 ant. tibiofibular ligament
 posterior tibiofibular ligament
o the latter helps to deepen the "socket" of the ankle (talocrural) joint
posteriorly.
III. The Ankle (Talocrural) Joint:

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 A. Description, Joint Morphology:
1. Classification: diarthrodial (synovial), joint of the ginglymus (hinge), type.

2. Bony parts

a. Tibia: inferior and malleolar articular surface.

b. Fibula: malleolar articular surface.
c. Talus: superior and malleolar surfaces. The talus:
 is unique in have NO muscular/tendinous attachments
 because it participates in multiple joints (ankle, subtalar and
talocalcaneonavicular) it is almost completely covered with articular cartilage
3. Movements possible:
 dorsiflexion (extension) and plantar flexion (flexion) of the foot [inversion and
eversion of the foot are not movements of this joint; however, because the
superior articular surface of the talus is wedge shaped (narrower posteriorly)
there is a “looseness” in the plantarflexed position that allows some “wobble”,
making it relatively unstable in this position].
B. Articular Capsule:
1. Fibrous capsule:
 attaches closely to the articular margins of the bones as described above.
 as with all hinge joints, the capsule is thin anteriorly and posteriorly in order to
facilitate its functional movements, but reinforced medially and laterally by
collateral ligaments that hold the articulating bones together:
a. Medial (collateral) ligament of ankle = "deltoid ligament"
 apex at medial malleolus; base fans out to attach to the tarsal bones.
 four component parts:
i. Anterior: anterior tibiotalar ligament: to neck of talus.
ii. Intermediate anterior: tibionavicular lgt. (most superficial part).
iii. Intermediate posterior: tibiocalcaneal lgt. (to sustentaculum tali).
iv. Posterior: posterior tibiotalar ligament (deepest part to side of talus).
 between the two intermediate portions -- i.e., between the navicular
and sustentacular portions -- fibers of the deltoid ligament are
continuous with the "spring" (plantar calcaneonavicular) ligament,
forming part of the socket for the head of the talus.
 resists eversion and prevents talar subluxation
b. Lateral (collateral) ligament of the ankle
 three distinct bands:
i. Anterior talofibular ligament (thin, weak, easily sprained).
o Weakest, most frequently injured ligament

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 ii. Posterior talofibular ligament.
o strongest, resists forward dislocation of lig. in foot.
iii. Calcaneofibular ligament.

o longest, almost vertically placed. Injured when foot is at 90 o to lig.

 Limits inversion and prevents subluxation of the talus
 these three bands are the most frequently injured in traumatic injuries
especially anterior talofibular; inversion during plantar flexion injures it --
which is how most injuries are produced
o Ottawa Ankle Rules (OAR)—when to order radiographic study:
1. unable to walk more than four steps post-injury
2. tender to palpation at tips of malleoli
2. Synovial membrane:
 lines the inner aspect of the joint capsule extending well forward onto the neck
of the talus, and may extend upward between the tibia and fibula to the lower
border of the interosseous ligaments.
 effusions within the joint readily expand anteriorly and posteriorly because of the
laxity of the capsule in these areas.
C. Musculotendinous Relations
 The related muscles and tendons add little to the support of the ankle. Although no
tendons attach to the talus, it is completely surrounded by them.
 Principle muscles acting on the joint:
1. producing dorsiflexion:
 tibialis anterior.
 peroneus tertius.
 long extensors of the toes.
2. producing plantar flexion:
 gastrocnemius tendocalcaneus
 soleus
 the five tendons passing behind the ankle are too close to the axis of the
joint to act to advantage on the joint; (in fact, if the tendocalcaneus is cut,
the power to plantarflex under one’s own weight is lost). The 5 tendons are:

o crossing the posterior portion of the deltoid ligament (deep to flexor

retinaculum):
 tibialis posterior.
 flexor digitorum longus.
 flexor hallucis longus.
o crossing the lateral collateral ligament (deep to peroneal retinaculum):

 peroneus longus.

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  peroneus brevis.
D. Nerve Supply
 anteriorly: deep peroneal and saphenous nerves. NOTE: joint innervation by
 posteriorly: tibial and sural nerves. cutaneous nerves!
E. Blood Supply
 perforating branch of the fibular artery.
 malleolar branches of the anterior and posterior tibial (or peroneal) aa.
F. Other Observations Relevant to the Ankle Joint:
 fibular malleolus (sharp) is 2 cm. lower than tibial malleolus (blunt) (Netter 501/513)
 the sides of the malleoli and of the shafts of the bones above them are
subcutaneous -- there are no muscles at the sides of the ankles.
 with the exception of the tendocalcaneus, all tendons cross both the ankle
(talocrural) and the transverse tarsal joints, acting on both.
 the most unstable position of the ankle joint is plantar flexion, as when you rise on
your toes. On going down hill you instinctively dig your heels in (1) because in this
position of dorsiflexion, the broad anterior end of the wedge-shaped articular
surface of the talus jammed between the malleoli, and (2) because the heel is at the
short end of a lever; the toes being at the long end.
 the mediolateral axis of rotation of the hinge joint of the ankle is usually not quite
parallel to that of the knee joint, because of torsion between the upper and lower
ends of the tibia. The axis is thus not normally at a right ankle to the line of
progression; it normally deviates externally about 20 o. This can be easily
demonstrated by standing on both feet and bending the knees: in most individuals,
unless they are standing pigeon-toed, the knees diverge as they are bent.
IV. Joints of Inversion and Eversion:
 Posterior talocalcaneal, talocalcaneonavicular, transverse tarsal (talonavicular +
calcaneocuboid) joints
 Muscles producing inversion and eversion:
1. Muscles of inversion:
a. Tibialis anterior
b. Tibialis posterior
2. Muscles of eversion:
a. Fibularis longus
b. Fibularis brevis
c. Fibularis tertius
 the subtalar joint has a tendency toward inversion, especially during
plantarflexion; the primary role of the muscles of eversion is to resist
inadvertent inversion of the foot.
A. The Subtalar (Post. Talocalcaneal)

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  terminology is unfortunate; clinically, the term is used to refer to both the post. and
ant. talocalcaneal joints, which is a physiological unit rather than an anatomical one.
The anatomical subtalar joint refers to the anatomically discrete posterior
talocalcaneal articulation. It is separated from the anterior talocalcanean
articulation (which is actually part of the talocalcaneonavicular joint) by the
interosseous talocalcaneal ligament. This ligament occupies the sinus tarsi
(formed by the sulcus tali superiorly and the sulcus calcanei inferiorly). The joint
capsule of the posterior talocalcaneal (subtalar) joint does not communicate with
any other joint.
 the (clinical) subtalar joint allows most of the inversion and eversion of the foot,
around an obliquely-placed (but mostly longitudinal) axis.
B. The Talocalcaneonavicular Joint
 includes the anterior talocalcaneal articulation (ant. to the talocalcaneal
interosseous ligament) and the talonavicular articulation. These two articulations
form essentially a single joint within a single joint capsule. The socket for the head
of the talus is completed inferiorly by the plantar calcaneonavicular or "spring"
ligament -- the most important ligament of the joint.
o as well as binding the navicular to the calcaneus, the spring ligament directly
supports the head of the talus. It is vital to the support of the medial longitudinal
arch of the foot. It is said to include elastic fibers that provide resilience to the
arch--thus its common name. The ligament is supported in turn by the tendon of
the tibialis posterior, and fibers of the deltoid ligament blend with its medial
border. If ruptured, the weight of the body may force the head of the talus may
become insinuated between the calcaneus and the navicular, flattening the
medial arch and forcing the anterior part of the foot into eversion (abduction).
 the capsule of this joint is thin dorsally, as are those of all the intertarsal joints.
 dorsolaterally, a much stronger ligament, the calcaneonavicular (a part of the
"bifurcate" ligament) reinforces the capsule
 medially, the joint capsule is strengthened by the tibionavicular part of the deltoid
ligament.
C. The Calcaneocuboid Joint
 high point of the lateral longitudinal arch of the foot.
 consequently it too requires special reinforcement, as did the talonavicular joint.
 dorsally, the joint receives one relatively strong enforcement, the calcaneocuboid
ligament (the other part of the "bifurcate" ligament).
 the plantar surface of the joint is strengthened by two series of special fibers:

o some of these belong to the plantar calcaneocuboid (short plantar) ligament.

o superficial to this and separated from it by loose connective tissue is the long
plantar ligament -- the chief ligamentous support of the lateral arch.
D. The Transverse Tarsal Joint
 actually consists of the two separate joints described above:

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 1. Calcaneocuboid Joint.
2. Talocalcaneonavicular Joint.
 the cavities of these two joints have no communication with each other; however,
the two together form a functional joint (a physiological unit) that permits movement
of the anterior part of the foot relative to the posterior part around a longitudinal
axis, augmenting the inversion and eversion movements of the subtalar joints.
 Distally, the contiguous surfaces of the navicular and cuboid bones are united by an
interosseous (cuboideonavicular) ligament.
V. Joints of the Forefoot
A. Distal intertarsal, tarsometatarsal, and intermetatarsal joints
 Form arches of foot, distributing weight, absorbing shock, and providing stability.
 Bones are so tightly joined by ligaments that only slight movement occurs between
them
B. Metatarsophalangeal (MTP) and interphalangeal (IP) joints [N5: 511-2, 510, 512-
3;
N4: 523-4, 528, 530-1; GA Table 5.19,
5.85]
 Extension at the MTP joints allow heel to be elevated from ground as line of gravity
advances anterior to midstance (terminal stance/toe off)
 Active flexion of MTP and IP joints propels limb forward (pre-swing/toe off) for
swing phase of walking and running
 MTP joints are involved in several clinical syndromes:
o Hallux valgus (bunions) [COA5, p. 712]
o Hammer toe [COA5, p. 712-3]
o Claw toes [COA5, p. 713]

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