CHAPTER 5

ARTHROLOGY
Dr. Seetharama Mithanthaya

Introduction
In general joint is a site where two things join. However in anatomy, the joint is a junction
between two or more bone/cartilage.

Few related terms related to joints are arthron (G), from which terms like arthrology,
arthritis, etc are derived, articulatio (L) from which the term articulation is derived.

Definition
The joint site, where two or more bone come together whether or not there is movement
between them.

These joints may be between bone to bone or between bone to cartilage. The design of joint
in the human body varies from simple to complex. Simple joints have stability as a primary
function. Complex joints usually have mobility as a primary function. However, most joints have
to serve a duel action.

Classification of joints
Joints can be classified based on the function and structure.

Functional classification

Joints are of three types based on their degree of mobility, they are as follows –

1) Synarthrosis – Immovable joints, e.g. – cranial sutures

2) Amphiarthrosis – Slightly movable joints, e.g. – secondary cartilaginous joint
3) Diarthrosis – Freely movable joints, e.g. – shoulder joint

Structural classification

Based on the type of connecting structure between articulating bone the joint is of three types.

1) Fibrous joint
2) Cartilaginous joint
3) Synovial joint
 The structural classification will be discussed in detail as it is most commonly followed in
clinical practice.

1) Fibrous joint
In this a fibrous connective tissue connects adjacent bone and form joint. These joints are
either immovable or may produce very slight degree of movement.
The fibrous joints are of three types – sutures, syndesmoses, and gomphoses.
i) Suture – Sutural joint are those in which a thin layer of connective tissue connect the
adjacent bone. They are immobile in nature. Based on margin of articulating bone the
sutures are divided in to six subtypes.
a) Plane suture – Adjoining surfaces are plane. E.g. – suture between horizontal part of
palatine bone & palatal process of maxilla.
b) Squamous suture – The articular surface are flat and overlap each other. E.g. –suture
between parietal and temporal bone.
c) Limbous suture – This is similar to squamous suture but overlapping margins are
ridged. E.g. - suture between the parietal and frontal bones
d) Serrate suture – The saw edge shaped margin of two bone fit with each other. E.g. –
sagital suture.
e) Denticulate suture – The tooth-like articular border having broad end and narrow base,
articulate with reciprocal border in the other bone.
f) Schindylesis – A joint in which wedge like process of one bone fits into a V – shaped
groove of other bone. E.g. – articulation between the rostrum of sphenoid & the fissure
between ala of the vomer.
Applied anatomy – in elderly most of the sutures of the skull gets ossified leading to
rigid bony union which is known as synostosis.
ii) Syndesmosis – These are the joins where a greater amount of connective tissue in the
form of interosseous ligament/membrane which connect the adjacent bone. These joints
permit slight degree of mobility. E.g. – inferior tibiofibular joint, interosseous tibiofibular
joint, interosseous radioulnar joint.
iii) Gomphoses (peg and socket joint) – Peg like teeth fits into the alveolar sockets of jaw,
the roots of tooth are connected by periodontal ligament.
Clinical anatomy – Inflammation of periodontal ligament is known as perodentitis.

2) Cartilaginous joint

The cartilaginous joints are those in which the adjacent bones are connected by means of
hyaline or fibro-cartilage. These are of two types-
a) Primary cartilaginous joint (Synchondroses)
b) Secondary cartilaginous joint (Symphyses)
a) Primary cartilaginous joint (Synchondroses) – The bones are united by hyaline cartilage.
These joints are immovable and strong. These joints are temporary as after certain age the
cartilaginous plate get ossified and replaced by bone.
 E.g. – Joint between epiphysis and diaphysis of growing long bone, first costosternal joint.

b) Secondary cartilaginous joint (symphyses) – Articular surface are covered by a thin layer
of hyaline cartilage and united by a disc of fibro-cartilage. These joints are permanent and
persist throughout life. The symphyseal joints permit some degree of movement due to
elastic fibrocartilage. E.g. – symphysis pubis, intervertebral joint between vertebral
bodies.

Difference between primary and secondary cartilaginous joint

Primary cartilaginous joint Secondary cartilaginous joint

Articular structure Articular surface connected by Articular surface covered by
hyaline cartilge hyaline cartilage and connected by
fibrocartilage
Mobility immovable Slightly movable
Location Rarely in the midline Always in the midline
Ossification Ossifies and cartilage Do not Ossifies and cartilage do not
Disappears with age disappear

3) Synovial joint

The synovial joints are most common and most evolved variety of joints with maximum
degree of mobility. In synovial joints the articular surface of the adjacent bone are separated
by joint cavity and margins of articular surface are connected by capsular ligament.

Characteristic features of synovial joints

1. Articular surfaces are covered by hyaline cartilage, which is avascular, elastic and
devoid of nerve supply.

2. Between the articular surfaces there is a cavity filled with synovial fluid, called
articular cavity.

3. The cavity is lined by fibrous capsule known as articular capsule.

4. Cavity may be completely or incompletely subdivided into chambers by articular

discs or meniscus.

5. Articular capsule is richly supplied by nerve, and is sensitive to stretch, this prevent
sprain of joint due to over stretch. This is called watch-dog action of capsule.

6. The wall cavity of the cavity is lined by synovial membrane except articular surface.
 7. Cells of synovial membrane secrete a slimy viscous fluid called synovial /synovial
fluid which lubricates the joint cavity including articular surface and provides
slippery surface for free movement.

Components of synovial joints

Following are the essential components of a synovial joint

i) Articular surface – surface of bone which involve in the formation of joint, e.g. head of
femur, glenoid cavity of scapula.
ii) Capsular ligament / Fibrous capsule – It completely covers the joint and enclose the joint
cavity. This ligament stabilizes the joint, resist dislocation, and permits free movement.
iii) Ligaments – These are thickened band of collagen fiber. The ligaments stabilize the joint
and permit movement in a particular plane and prevent unwanted movement in other
plane. Tear in the ligament is known as sprain, which leads to pain and swelling in the
joint.
iv) Synovial membrane – A thin vascular membrane lining the walls of joint cavity except
articular surface. Synovial fluid secreted by this membrane lubricates the articular surface
and provide free movements of joint.
v) Articular cartilage – It is made up of hyaline cartilage. It resists compression and
provides smooth friction free movement.
vi) Articular disc / meniscus – These are fibro-cartilaginous pads placed between the
articular surfaces, these pads divides the joint cavity into two compartments, increase the
concavity of articular surface, acts as a ligament, by providing cushioning effect they
prevents wear and tear of articular cartilage e.g. knee joint, temporo-madibular joint,
acromio-clavicular joint.
vii) Bursae – These are synovial fluid filled sacs of connective tissue, found near synovial
joints. They commonly found between muscle and bone, tendon and bone, skin and bone
or skin and tendon. The bursae reduce the friction between two moving structures, and
they provide cushioning effect.
viii) Fatty pads (Haversian glands) – The pad of fat placed between synovial membrane and
fibrous capsule or bone, they provide enough cushion. e.g. infra-patellar pad of fat.

Classification of synovial joints

a) Based on shape of articular surface

Based on shape of articular surface the synovial joints are of seven type they are as follows

1. Plane joint
2. Hinge joint
3. Pivot joint
4. Condylar joint
 5. Ellipsoid joint
6. Saddle joint
7. Ball and socket joint

1. Plane joints – It is a joint formed by flat articular surfaces. These joints permit gliding
movement, e.g. intercarpal joints, intermetacarpal joints, joints between articular processes
of adjacent, etc.

2. Hinge/Ginglymus joints – The joints having pulley shaped articular surface, here the
movement is permitted in one plane around transverse axis like a hinge of a bone and the
other movements are prevented by the strong collateral ligament. Example – elbow joint,
elbow joint, interphalangeal joint.

3. Pivot joint/trochoid joints - The shape articular surface of one bone is rounded, pivot (peg)
like which fits into the ostio-ligamentus ring. These permit a rotation movement around a
vertical axis. Example – superior radio-ulnar joint, atlanto-axial joint.

4. Condylar joint – The joint in which the distinct convex condyles of one bone articulates
with the reciprocally concave articular surface of other bone (sometimes these are also
known as condyles as in tibia). The movement is permitted in two directions (biaxial)
where one is around the transverse axis and other around a vertical axis. Example knee
joint, temporo-mandibular joint.

5. Ellipsoidal joints – The joint is formed by fitting of elliptical convex surface of one bone in
to reciprocally concave surface of other bone. Ellipsoid joints show movement in two
directions where flexion and extension around transverse axis and adduction and abduction
around anteroposterior axis. Circumduction is produced by the combination of above
movements. Example – radio-carpal joint, metacarpo-phalangeal joint, atlanto-occipital
joint.

6. Saddle/sellar joints – The articular surfaces are reciprocally concavo convex and appear
like a saddle. These joints allow wide range of movement including flexion, extension,
adduction, abduction, and certain amount of rotation. Example – first corpo-metacarpal
joint, sterno-clavicular joint, incudo-malleolar joint.

7. Ball and socket/spheroidal joints – Rounded glob like articular surface of one bone fits into
cup shaped socket of other bone. In these joints the movements occur around an indefinite
number of axes which have a common centre. Movements include flexion, extension,
adduction, abduction, medial and lateral rotation, and circumduction. Example – hip joint,
shoulder joint.

b) Based on planes of movement

 Based on the planes of movement the joints are of three types, uniaxial joints, biaxial
joints, and multiaxial joints.

1. Uniaxial joints – In these joints the movement occurs around a single axis along only one
plane. Example – elbow joint, interphalangeal joint, atlanto-axial joint.

2. Biaxial joint – In these joints movements occur around two axes in two different planes.
Example – knee joint, radia-carpal joint, sterno-clavicular joint, temporo-mandibullar joint.

3. Multiaxial joint – In these joints movements occur around indefinite number of axes in
three different planes.

c) Based on number of articulating bones

Based on the number of articulating surface the joints are of two types
1. Simple joint
2. Compound joint
1. Simple joint – Only two articular surfaces involve in the formation of joint, e.g. inter-
phalangeal joint.
2. Compound joint – More than two bones involve and enclose within a single capsule, e.g.
elbow joint, ankle joint.

Complex joint – A joint in which the joint cavity is divided completely or incompletely into two
parts by an intra-articular disc, e.g. knee joint, temporo-mandibular joint.

Movements of synovial joints

The joints show two varieties of movements namely active movements and passive movements.

Active movement –

a) General rotator movement - They are of three types, i) Gliding/sliding movement

ii) Angular movement

iii) Rotatory / Circular movements

i) Gliding movement – one bone slips over the other, e.g. movements in a plane joint.
ii) Angular movement – Movement in which the angle of joint is increased or decreased,
e.g. flexion, extension, adduction, abduction.
iii) Rotator movement – there are two types of rotator movements, rotation and
circumduction.
Rotation – movement of body part around its own axis, e.g. medial and lateral
rotation of shoulder joint, side-to-side rotation of head, supination, pronation etc.
 Circumduction – it is combination of four angular movements in a successive order,
causing circular movement of distal free part resulting in a cone like movement of
body part, e.g. shoulder joint, hip joint.
b) Special active movements – few joints show some special active movements, they are
inversion, eversion, protraction, retraction, elevation, depression.

Passive movements

These movements are produced by external force such as examining doctor. Example –
gliding movement of wrist, which a patient cannot perform by himself actively, but an
examining doctor can produce it by careful manipulation of wrist.

Blood supply of synovial joints

The joints get their blood supply from the periarticular network of arteries which surround
the joint. These vessels supply capsule, synovial membrane, and epiphysis. Articular cartilages
are avascular where as ligaments and fibrous capsule are poorly supplied by blood.

Nerve supply of synovial joints

There are three types of nerves fibres, sensory nerve fibers conveying pain, sensory nerve
fibers conveying proprioceptive sensation, and autonomic fibers which has vasomotor effect.

The capsule is innervated by ruffini’s corpuscles encapsulated nerve endings which are
sensitive to proprioceptive sensation (position of joint sense) and also supplied by the nerve
fibers with free nerve endings which are sensitive to pain.

Ligaments are supplied by pain sensitive free nerve endings.

Synovial membrane is supplied by autonomic nerve fibers which are vasomotor in function.

Articular cartilages have no nerve supply and insensitive.

Articular discs are supplied b y nerve only on its margin.

Hilton’s law – Nerve supplying the joint also supply the muscles which regulate movements
of that joint and the skin over joint.

Position of joint

Close packed position

 It is a position in which the articular surfaces are fully congruent and have maximum area
of contact. In this position the ligaments of the joint become tout making the joint firm and
rigid. Following table explain the close packed position of few joints.

SHOULDER JOINT
Introduction
It is a multi axial, ball and socket variety of synovial joint of upper limb.
Articular surface
Proximal – Glenoid cavity of scapula
Distal – Head of the humerus

Ligaments

1. Capsular ligament
2. Glenohumeral ligament
3. Coracohumeral ligament
4. Transverse humeral ligament
5. Glenoidal labrum

Capsular ligament –

It is very loose and permits free movement.

Attachment –

Medially – Attached to scapula beyond supra-glenoid tubercle.

Laterally – Anatomical neck of humerus; with following exceptions, a) superiorly deficient
for the passage of long head of biceps brachii, b) inferiorly extends to the surgical neck.
Synovial membrane lines the inner surface of ligament. the joint cavity communicates with
subscapular bursa, infra-spinatus bursa and with synovial sheath around biceps brachii.

Glenohumeral ligament

These are three bands: superior, middle, and inferior, they reinforce the capsular ligament
anteriorly.

Attachment –

Scapular end – Anterior margin of glenoid cavity

Humeral end –
Superior band – Above the lesser tubercle
Middle band – In front of lesser tubercle
Inferior band – Medial and lateral part of anatomical neck of humerus
Coraco-humeral ligament

Attachment –
Medially – Root of the coracoid process.
Laterally – Neck of humerus in front of greater tubercle.

Transverse humeral ligament

This ligament bridges the upper part of bicipital groove. The tendon of the long head of the
biceps brachii passes deep to this ligament.

Attachment –
Anteriorly – To lesser tubercle
Posteriorly – To greater tubercle

Glenoidal labrum

It is fibrocartilaginous rim which is attached too margin of the glenoid cavity. This ligament
increases the concavity of glenoid cavity.

Bursa related to shoulder joint

1. Subacromial bursa
2. Subscapular bursa
3. Infraspinatus bursa
4. Bursa between coracoid process and capsule
5. Bursa below the tip of acromial process

Relations

Superiorly – Coracoacromial arch, subacromial bursa, supraspinatus and deltoid.

Inferiorly – Triceps brachii (long head)
Anteriorly – Subscapularis, coracobrachialis, short head of biceps brachii and deltoid.
Posteriorly – Infraspinatus, teres minor, and deltoid.
Within the joint cavity – Long head of biceps brachii.

Blood supply

Artery supply –

1. Anterior circumflex femoral artery

2. Posterior circumflex femoral artery
3. Suprascapular artery
4. Subscapular artery
Venous drainage –

Accompanied with artery

Nerve supply

1. Axillary nerve
2. Suprascapular nerve
3. Lateral pectoral nerve
4. Musculocutaneous nerve

Movements

1. Flexion
Muscles involved – Pectoralis major, deltoid, coracobrachialis, and short head of biceps
brachii.
2. Extension
Muscles involved – Deltoid, teres major, latissimus dorsi, long head of triceps brachii and
pectoralis major.
3. Abduction
Muscles involved – Deltoid, supraspinatus, serratus anterior, and trapezius.
4. Adduction – Pectoralis major, latissimus dorsi, short head of biceps brachii, long head of
triceps, teres major, coracobrachialis.
5. Medial rotation – Pectoralis major, deltoid, latissimus dorsi, teres major, and
subscapularis.
6. Lateral rotation – Deltoid, infraspinatus, and teres minor.
7. Circumbuction – it is the combination of different movements resulting in a circular
movement of arm.

Applied anatomy

1. Dislocation –
Dislocation of the shoulder is common due to following reasons –
a) Laxity of the capsule
b) Glenoid cavity is shallow so the head of the humerus is not fully accommodated.
2. Shoulder tip pain – Irritation of diaphragm by any pathology cause referred pain in the
shoulder.
3. Optimum attitude – Many diseases of shoulder joint is treated by keeping the joint in
optimum attitude. In this position the arm is abducted in 45-90 degrees, this prevent the
development of ankylosis.
 4. Frozen shoulder – It is a painful condition occurs due to adhesion of layers of synovial
membrane. Commonly occurs in the age group 40-60. Symptoms include pain, stiffness,
and restriction of all movement.
5. Any fracture of humerus at epiphyseal line will affect capsule and synovial membrane.
6. Aspiration of shoulder joint is done by introducing the needle either anteriorly through
deltopectoral triangle, or laterally below the acromion.

ELBOW JOINT

Introduction

This is a hinge verity of synovial joint between lower end of humerus and upper ends of
radius and ulna.

Articular surface

Proximal – Trochlea and capitulum of humerus

Distal – Trochlear notch of ulna and head of the radius.

Ligaments

1. Capsular ligament
2. Ulnar collateral ligament
3. Radial collateral ligament

Capsular ligament –

Attachment – Proximally in the humerus it is attached to antero-lateral surface above radial

and antero- medial surface above coronoid fossa in front and posteriorly attached above
olecranon fossa. Distally attached to margin of the trochlear notch of the ulna; infero-medially
attached to annular ligament of superior radioulnar joint. The inner surface of the capsule and
fossae mentioned above lined by the synovial membrane.

Ulnar collateral / medial collateral ligament –

It is triangular in shape with its apex is directed upwards and base directed downwards.
Attachment – Apex is attached to medial epicondyle of the humerus, base to the ulna. It has
thick anterior and posterior bands. These are attached to coronoid process and olacranon
process respectively, an oblique band connects lower end of these bands.

Radial collateral / lateral collateral ligament –

It is a fan shaped ligament.
Attachment – The ligament is attached to lateral epicondyle of humerus above and annular
ligament of the superior radioulnar ligament.
Blood supply

Anastomoses around the elbow joint

Nerve supply

Ulnar nerve, median nerve, radial nerve, and musculocutaneous nerve

Movements

1. Flexion –
Muscle involved – Brachialis, biceps brachii, brachialioradialis.
2. Extension –
Muscle involved – Triceps brachii, anconeus

Applied anatomy
1. Dislocation – Posterior dislocation of the elbow is common and is often associated with
fracture of coronoid process.
2. Subluxation of the head of radius (pulled elbow) from anular ligament occurs in children
when the forearm is pulled in pronation.
3. Aspiration – aspiration of elbow is done on posteriorly on either side of olacranon
process.
4. Student’s elbow/miner’s elbow – It occurs due to inflammation of bursa related to
subcutaneous posterior surface olecranon process. It is characterized by swelling on the
back of elbow.
5. Tennis elbow – It occurs due to abrupt pronation of fully extended elbow, which cause
sprain of radial collateral ligament, extensor carpi radialis. Tennis elbow occurs
commonly in tennis players. It is characterized by pain and tenderness over the lateral
epicondyle.
6. Golfer’s elbow – It occurs due to repetitive / overuse trauma of medial epicondyle of the
humerus, commonly occurs in golf players. It is characterized by pain and tenderness in
the medial epicondyle.
7. Carrying angle – An extended forearm is never on straight line with forearm and makes
an angle of about - away from the body or - towards the body, this angle is
known as carrying angle. The angle is more than in female. Carrying angle helps the
arms to swing without hitting the hips while walking.
The carrying angle more than the normal is known as cubitus vulgus, in this case the
forearm is deviated laterally. This causes weakness of intrinsic muscles of hand due to
trenching of ulnar nerve. Carrying angle is less than normal is known as cubitus varus,
where forearm is deviated medially as a consequence of this medial side of forearm
touches the hip.
WRIST JOINT/RADIO-CARPAL JOINT

The wrist joint is a ellipsoid verity of synovial joint between forearm and hand.

Articular surface –
Proximal – Inferior surface of lower end of the radius and articular disc of the inferior
radioulnar joint.
Distal – Scaphoid, lunate, and triquetral bones.

Ligaments
1. Capsular ligament
2. Anterior (palmar) radiocarpal ligament
3. Anterior (palmar) ulnocarpal ligament
4. Posterior (dorsal) radiocarpal ligament
5. Radial collateral ligament
6. Ulnar collateral ligament

1. Capsular ligament –
Attachment – Proximally it is attached to lower end of the radius along the articular margin
and margin of the articular disc of inferior radio-ulnar joint. Distally it is attached to
proximal articular surface of the schapoid, lunate and triquetral. Internal surface of the
capsular ligament is lined by synovial membrane.

2. Anterior (palmar) radioulnar ligament –

Attachment – It extends from anterior margin of lower end of the radius and styloid process
to the anterior aspect of the scaphoid, lunate and triquetral.

3. Anterior (palmar) radiocarpal ligamnent –

Attachment – It extends from base of the styloid process of ulna and anterior margin of the
articular disc to the lunate and triquetral bones.

4. Dorsal radiocarpal ligament –

Attachment – It extends from posterior margin of the lower end of the radius to the
posterior surface of the scaphoid, lunate, and triquetral.

5. Radial collateral ligament –

Attachment – It extends from the tip of styloid process of the radius to the lateral surface of
scaphoid.

6. Ulnar collateral ligament –

Attachment – It extends from tip of the styloid process of ulna to medial side of the
triquetral and pisiform bones.

Blood supply
 1. Anterior interosseous vessels
2. Anterior and posterior arches of radial and ulnar vessels.

Movement

1. Flexion –
Muscles involved – Flexor carpi ulnaris, Flexor carpi radialis, Palmaris longus, flexor
digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus.

2. Extension –
Muscles involved – Extensor carpi radialis longus, Extensor carpi radialis brevis,
extensor carpi ulnaris, and extensor digitorum.

3. Adduction –
Muscles involved – Flexor carpi ulnaris and extensor carpi ulnaris

4. Abduction –
Muscles involved – Flexor carpi ulnaris, extensor carpi radialis longus, extensor carpi
radialis brevis, abductor pollicis longus and extensor pollicis brevis.

5. Circumduction – It is the combination of the flexion, adduction, extension, and abduction

in that order.

Clinical anatomy

1. Back of the wrist is a common site for a ganglion (cystic swelling) resulting from mucoid
degeneration of synovial membrane around tendons.
2. Aspiration – Aspiration of wrist joint is done from posterior surface between extensor
digitorum and extensor pollicis longus.

HIP JOINT

Hip joint is a ball and socket variety of synovial joint. It is a multiaxial joint between hip
bone and femur connecting trunk with lower limb.

Articular surface –
Proximal – Acetabular cavity of hip bone
Distal – Head of the femur

Ligament –

1. Fibrous capsule
2. Ilifemoral ligament
3. Pubofemoral ligament
4. Ischiofemoral ligament
 5. Ligamentum teres (Ligament of the head of the femur)
6. Acetabular labrum
7. Transverse acetabular ligament

1. Capsular ligament –
Attachment – On the hip bone attached to the margin of the acetabulum including
acetabular labrum and transverse acetabular ligament. Inferiorly it is attached to the femur
anteriorly to intertrochanteric line and 1 cm above the intertrochanteric crest.

2. Iliofemoral ligament –
It is one of the strongest ligaments in the body which prevents the trunk from falling
backwards in the standing posture. The ligament is triangular in shape.
Attachment – Apex of the ligament is attached to the anterior inferior iliac spine, base is
attached to intertrochanteric line. It has upper oblique and lower vertical fibers which are
thick and strong while middle fibres are thin and weak.

vular ligament; its apex merges with antero-inferior part of the capsule and with the lower
part of the iliofemoral ligment and its base is attached to ilio-pubic eminence and obturator
margin of superior ramus of pubis.

3. Ischio-femoral ligament – It is a weak ligament located posterior to the joint. It extends

from the ischium below the acetabulum to the base of the greater trochanter.

4. Acetabular labrum –
Attachment – The labrum is attached to the margin of the acetabulum. It increases the
concavity of the acetabulum and narrows the mouth of it which prevents the dislodgement
of the head of femur.

5. Transverse acetabular ligament –

It is a part of acetabular labrum.
Attachment – It is attached to the margin of acetabular notch. The ligament bridges the
acetabular notch and converts it into a foramen which transmits acetabular vessels and
nerves.

6. Ligament of the head of the femur – This ligament is also known as ligamentum teres.
Attachment – Its apex is attached to pit on the head of the femur; its base is attached to the
margin of the acetabular notch. It transmits the arteries to the head of the femur.

Blood supply

Branches from –

1. Obturator artery
2. Medial circumflex femoral artery
 3. Lateral circumflex femoral artery
4. Superior gluteal artery
5. Inferior gluteal artery

Nerve supply

Branches from –

1. Femoral nerve
2. Superior gluteal nerve
3. Obturator nerve
4. Accessory obturator nerve
5. Nerve to quadrates femoris

Movements

Movement Muscles
Flexion Psoas major
Iliacus
Pectenius
Rectus femoris
Sartorius
Adductors of thigh
Extension Gluteus maximus Semimembranosus
semitendinosus
Long head of biceps femoris
Adductor magnus
Abduction Gluteus medius gluteus minimus
Tensor fascia lata Sartorius
Adduction Adductor longus adductor brevis
Adductor magnus pectineus
Gracilis
Medial rotation Tensor fascia lata
Gluteus maximus
Gluteus minimus
Lateral rotation Obturator externus and internus
Gemellus superior and inferior
Quadrates femoris
Piriformis
Gluteus maximus
Sartorius
Circumduction It is the combination of all movements

Applied anatomy
 1. Fractures of the neck of the femur – These fractures are usually common in individual
above 60 years of age especially in female. They are of four types. a) suboccipital (near
the head) b) cervical (in the middle) c) basal (near trochnters) d) pretrochanteric fracture
(below two trochanters).
The fracture of the neck is usually occurs due to indirect trivial violence. The affected
limb is shortened and rotated laterally.

2. Dislocation of hip joint –

Dislocation may be congenital or acquired dislocation.
a. Congenital dislocation – Compare to any joint congenital dislocation is very common
in hip joint, because the joint capsule is loose at birth and hypoplasia of the acetabulum
and femoral head. It is characterized by –
1. Inability to abduct the thigh
2. Shortening of the limb
3. Laterally rotated
4. Asymmetrical skin folds of thigh
5. Lurching gait with trendelenburg’s sign

b.Acquired dislocation –

As hip joint is very stable acquired dislocation of the hip joint is uncommon. And
usually occur as a result of automobile accident when the hip is flexed, adducted, and
medially rotated because in this position the hip joint is unstable as the femur head
posteriorly covered by capsule and not by the bone.
The dislocation may be anterior (less common) posterior (most common) or central
(least common).
3. Posterior dislocation may injure the sciatic nerve.
4. Perthes’ disease (pseudocoxalgia) – It is characterized by destruction and flattening of the
head of the femur with an increased joint space in the radiograph.
5. oxa vera – ormally the nec and shaft has an angle of in adults and in
children. If this angle is less than normal then it is known as coxa vara. It may be seen in
congenital dislocation of hip joint.
6. Coxa valga – If the angle is more than the normal then it is known as coxa valga. It may
be seen in perthes’ disease.
7. Osteoarthritis – It is characterized by the growth of osteophytes at the articular ends.
8. Aspiration – It is done by passing a needle 5 cm below the anterior superior iliac spine,
upwards, backwards, and laterally.
9. Referred pain – In disease of hip joint, the pain may be referred to knee joint, because of
common nerve supply.

KNEE JOINT
 The knee joint is largest and most complicated joint in the body. It is acondylar verity of
synovial joint and is a verity of modified hinge joint. Knee joint is a compound joint having two
distinct articular surface of femur (medial and lateral condyles) articulates with the
corresponding surface of the tibia.

Articular surface

1. Lateral and medial condyles of the femur with articular cartilage.

2. Lateral and medial condyles of the tibia with articular cartilage.
3. Articular surface of the patella.

Ligaments

1. Capsular ligament with synovial membrane

2. Ligamentum patellae
3. Oblique popliteal ligament
4. Arcuate popliteal ligament
5. Tibial collateral ligament
6. Fibular collateral ligament
7. Anterior cruciate ligament
8. Posterior cruciate ligament
9. Transverse ligament
10. Coronary ligament
11. Medial meniscus
12. Lateral meniscus

1. Capsular ligament – It is a thin fibrous sheet which surround the joint, anteriorly the
capsule is deficient and is replaced by patella, medial and lateral patellar retinacula,
quadriceps femoris and ligamentum patella.
Attachment – Proximally it is attached about ½ to 1 cm beyond articular margin of the
condyles of the femur, with following exceptions;
a) Anteriorly, it is deficient
b) Laterally, it encloses the origin of popliteus
c) Posteriorly, it is attached to intercondylar line.
Distally it is attached about ½ to 1 cm beyond the articular margins of condyles of tibia,
with following exceptions;
a) Anteriorly, it descends along the margins of the condyles to the tibial tuberosity,
where it is deficient.
b) Posteriorly, it is attached to intercondylar ridge.
c) Posteriorly, there is a gap for the passage of popliteus.
The inner surface of the capsule and both the menisci are lines by the synovial membrane.
2. Ligamentum patella – It is the tendon of insertion of quadriceps femoris.
 Attachment – Above it is attached to the margins and rough posterior surface of the apex of
the patella and below it is attached to tibial tuberosity. The ligament is about 7.5 cm long
and 2.5 cm broad.
3. Oblique popliteal ligament –
It is the expansion of the semimembranosus, which blends with the posterior surface of
capsule and strengthen it. it is closely related to popliteal artery and pierced by i) middle
genicular vessels, ii) middle genicular nerve iii) posterior division of obturator nerve.
4. Arcuate popliteal ligament
It is a ‘Y’ shaped ligament,
Stem – Head of the fibula
Posterior limb – Posterior border of intercondylar area of tibia.
Anterior limb – It is smaller than posterior and attached to lateral condyle of the femur.
5. Tibial/ medial collateral ligament – It is a strong ligament of about 10 cm long; it has
superficial and deep parts.
Both the parts above attached to medial epicondyle of the femur below the adductor
tubercle.
Superficial part is about 10 cm long and 1.25 cm wide, attaches to the medial border and
medial surface of the shaft of the tibia.
Deep part is short and blends with the capsular ligament and margin of medial meniscus. It
attaches to the medial condyle of the tibia above the groove for the semimembranosus.
6. Fibular/lateral collateral ligament – It is cord like and is about 5 cm long. It is separated
from the capsular ligament and lateral meniscus by the tendon of popliteus.
Attachment— Above – lateral epicondyle of the femur
Below – head of the fibula infront of its apex
7, 8. Anterior cruciate ligament & Posterior cruciate ligament
These are thick fibrous bands inside the knee joint, which forms a direct bond of union
between femur and tibia. They maintain antero-posterior stability of the knee joint. They
are named according to their attachment on the tibia. Two ligaments cross each other like
letter ‘X’ hence called as cruciate ligament.
7. Anterior cruciate ligament –
Above – Posterior part of the medial surface of the lateral condyle of the femur, the
ligament runs downwards forwards and medially.
Below – Anterior part of intercondylar area of tibia.
It is taut during extension of the knee and prevents the anterior dislocation of the tibia on
femur and posterior dislocation of femur on tibia.
8. Posterior cruciate ligament –
Above – Anterior part of the lateral surface of medial condyle of the femur, the ligament
runs downwards backwards and laterally.
Below – Posterior part of intercondylar area of tibia.
 It is taut during flexion of the knee and prevents the posterior dislocation of the tibia on
femur and anterior dislocation of femur on tibia.
9. Transverse ligament
It connects the anterior ends of the medial and lateral menisci.
10. Coronary ligament
It is a part of the capsular ligament, attached to peripheral margins of the medial and lateral
menisci to the tibia.
11&12. Medial meniscus and Lateral meniscus
These are crescent shaped fibrocartilaginous discs. They increase the concavity of the
articular surface of tibia, and divide the joint cavity into upper and lower compartments.
Flexion and extension of the knee takes place in the upper compartment, and medial and
lateral rotation of knee takes place in the lower compartment.
Each meniscus has
a) two ends / horns – Anterior and posterior
b) two borders – Thick outer border, attached to capsular ligament
Thin free inner border
c) two surfaces – Upper and lower surface
i) Medial meniscus – It is ‘ ’ shaped, its anterior end is attached to tibial intercondylar area
in front of anterior cruciate ligament and posterior end is attached to tibial intercondylar
area between attachment of posterior horn and posterior cruciate ligament. The medial
meniscus is more prone to injury.
ii) Lateral meniscus – It is nearly circular in shape, with more or less uniform width. Its
anterior end is attached to intercondylar eminence behind and lateral to the anterior
cruciate ligament, its posterior end is attached to intercondylar area of tibia in front of the
posterior end of medial meniscus.

Blood supply

1. Genicular branch of the popliteal artery

2. Descending genicular branch of the femoral artery
3. Descending genicular branch of the circumflex femoral artery
4. Recurrent anterior tibial artery
5. Circumflex fibular branch of the posterior tibial artery

Nerve supply

1. Femoral nerve
2. Genicular branch of common peroneal nerve
3. Genicular branch of tibial nerve
4. Posterior division of obturator nerve

Movements
 Movement Principle muscles Accessory muscles
Flexion Biceps femoris Gracilis
Semimembranosus Sartorius
Semitendinosus Popliteus
Extension Quadriceps femoris Tensor fascia lata
Medial rotation Semimembranosus Gracilis
Semitendinosus Sartorius
Popliteus
Lateral rotation Biceps femoris Tesor fascia lata

Applied anatomy

1. Genu valgum / knock knee – Abnormal angle between long axis of thigh and that of leg
and leg may be abnormally abducted.
2. Genu varum / bow knee – Abnormal angle between long axis of thigh and that of leg and
leg may be abnormally adducted.
3. Structurally, the knee is a weak joint because the articular surfaces are not congruent and
outward angulation between the long axis of the thigh and of the leg.
The stability of the knee is mainained by a) anterior and posterior cruciate ligament, b)
medial and lateral collateral ligament, c) iliotibial tract.
4. Osteoarthritis – Knee joint is a commonly involved in osteoarthritis caused by
degenerative wear and tear of articular cartilages. It causes grating, restricted and painful
movement.
5. Meniscal injury – Rupture of menisci may occur due to rotational stain during the flexion
of knee as in kicking a football. Medial meniscus is most commonly ruptured due to
lesser mobility as a result of attachment of the medial collateral ligament.
6. Injury to cruciate ligament – Anterior cruciate ligament is more commonly injured than
posterior cruciate ligament; it may be injured in anterior dislocation of tibia of violent
hyperextension. The posterior cruciate ligament is injured in the posterior dislocation of
the tibia. Tear of cruciate ligament cause abnormal anteroposterior mobility.
7. Injury to collateral ligament – Collateral ligament injury is uncommon, and may be result
of violent abduction and adduction.
8. Unhappy triad of the knee joint – It is a combination of the injury of a) tibial collateral
ligament, b) medial meniscus, and c) anterior cruciate ligament.
9. Aspiration of knee joint – Collection of fluid is common in the knee. Aspiration of the
fluid is done by approaching the knee from lateral side, in a triangular area which is
marked using three bony points i) tibial tuberosity, ii) lateral epicondyle, and iii) apex of
patella.
 10. Knee replacement – If the knee joint is completely destructed it is replaced by an
artificial knee consisting metal femoral component and plastic tibial component.
11. House-maid’s nee – It occurs due to inflammation of the subcutaneous prepatellar bursa,
it commonly seen in individuals who works by kneeling on floor e.g. house-maid.

ANKLE JOINT

It is a strong weight bearing joint between leg and foot. It is a hinge verity of synovial joint.

Articular surface

Proximal – Lower end of the tibia including its medial malleolus

Lateral malleolus of fibula
Inferior transverse tibiofibular ligament
These together form “tibiofibular soc et / mortise”.
Distal – Trochlear, medial, and lateral surface of the talus.

Ligaments

1. Capsular ligament
2. Deltoid ligament
3. Lateral ligament
1. Capsular ligament – It completely surround the joint and is attached to all around the
articular margins with few exceptions.

a) Postero-superiorly it is attached to inferior transverse tibiofibular ligament

b) Antero-inferiorly it is attached to dorsum of the neck of the talus at some distance from
the trochlear surface.

Anterior and posterior part of the capsule is thin and loose, on each side it is supported by
collateral ligament. Inner surface of the capsule is lined by synovial membrane.

2. Deltoid ligament – It is a strong triangular ligament. It has two parts superficial and deep
parts. Above, both parts have a common attachment to the apex and margins of the
medial malleolus. The lower attachment of the ligament differs in superficial and deep
parts.
 Superficial part divides into three parts anterior, middle, and posterior.
Anterior fibers (tibionavicular) – Attached to the tuberosity of navicular bone and the
medial margin of the spring ligament.
Middle fibers (tibiocalcanean) – Attached to the sustentaculum tali
Posterior fibers (posterior tibiotalar) – Attached to middle tubercle of talus
Deep part (anterior tibiotalar) – Attached to the anterior part of the medial surface of the
talus
3. Lateral ligament – It has three bands, anterior talofibular ligament, posterior talofibular
ligament, and calcaneofibular ligament.
Anterior talofibular ligament – It is flat, extends from anterior margin of lateral malleolus
to neck of the talus.
Posterior talofibular ligament – It extends from malleolar fossa to the lateral tubercle of
talus.
Calcaneofibular ligament – It is a long rounded cord which extends from notch on the
fibular malleolus to tubercle on the lateral surface of calcaneum.

Blood supply

Malleolar branches of anterior tibial, posterior tibial, and peroneal arteries.

Nerve supply

Tibial nerve
Deep peroneal nerve
Movements

Movement Principle muscles Accessory muscles

Dorsi Flexion Tibialis anterior Extensor digitorum
Extensor hallucis longus
Peroneus tertius
Planter Flexion Gastrocnemius Plantaris
Soleus Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus

Applied anatomy

1. Ankle sprain – Ankle sprain is the excessive stretching and / or tearing of the ligaments
of the ankle joint. It usually caused by the fall from height or twist of ankle.
In case of forced plantar flexion with excessively inverted, the joint may sprained
where anterior part of the capsule may get torn.
Abduction strain causes injury to deltoid ligament.
 2. Dislocation of ankle – As the joint is very stable dislocation of ankle is very rare, due to
deep tibiofubilar socket/mortise. However dislocation is always accompanied with
fracture of malleolus.
3. Ankle joint becomes slightly plantar flexed in ankylosis.

TEMPORO-MANDIBULAR JOINT

It is a joint between the temporal bone and mandible; it is a condylar verity of synovial joint.

Articular surface

Upper articular surface – Articular fossa of temporal bone

Articular eminence of temporal bone
Lower articular surface – Head of the mandible
The temporo-mandibular joint is a atypical synovial joint because the articular surfaces of the
joint are lined by fibrocartilage not by hyaline cartilage.

Joint cavity

The articular disc divide the joint cavity is into two parts, upper menisco-temporal part and
lower menisco-mandibular part. Upper part permits gliding movements, and lower part permits
gliding and rotational movements.

Ligaments

1. Capsular ligament
2. Lateral / temporomandibular ligament
3. Sphenomandibular ligament
4. Sylomandibular ligament

1. Capsular ligament – It encloses the joint cavity. Above it is attached to articular tubercle,
margin of articular fossa, and squamotympanic fissure; below it is attached to neck of the
mandible. The capsular ligament is loose above the articular disc, and tight below. Inner
surface of the capsule is lined by the synovial membrane.
 2. Lateral / temporalmandibular ligament – It is formed by the thickening of the lateral aspect
of the capsular ligament. It strengthens lateral aspect of the capsule.

Attachment -

Above to articular tubercle on the root of zygomatic process of temporal bone, and below
to the posterolateral aspect of the neck of the mandible.

3. Shenomandibular ligament – It extends from the spine of sphenoid to the lingula and
margin of msndibular foramen of mandible. The ligament near its lower end is pierced by
mylohyoid nerve and vessels.

4. Stylomandibular ligament – It extends from lateral side f the styloid process of temporal
bone to angle and adjoining posterior border of the ramus of mandible.

Blood supply

1. Maxillary artery
2. Superficial temporal artery

Nerve supply

1. Auriculotemporal nerve
2. Massetric branch of mandibular nerve

Movements

Movement Muscles involved

Depression Lateral pterigoid
(opening of mouth) Digastrics
Myelohyoid
Geniohyoid
Elevation Temporalis
(closing of the mouth) Masseter
Medial pterigoid
Protraction Lateral pterigoid
Medial pterigoid
Retraction Temporalis
Masseter
Digastric
Geniohyoid
Grinding / side-to-side Medial pterigoid
movement Lateral pterigoid
Both the muscle act alternately
Applied anatomy
1. Dislocation – The mandible is dislocated only anteriorly. Dislocation happens in
excessive opening of the mouth as in yawning or during convulsion. As a result of this
head of the mandible of one or both side may slips from articular fossa, this cause
inability to close the mouth.
2. Temporomandibular joint syndrome – It is characterized by following symptoms
i. Spasm of masseter causing diffuse facial pain
ii. Spasm of temporalis causing headache
iii. Spasm of lateral pterigoid causing jaw pain
This may be associated with clicking and pain in the joint. It occurs due to stretch or
detachment of the posterior attachment of the disc, which cause temporary or permanent
trapping of the disc anteriorly. This may be caused due to overclosure/malocculsion.

3. Facial nerve should be preserved with care during the surgery of the temporomandibular
joint.