Joints of the lower limb
Feb. 28, 2012
Shifa College of Medicine
Islamabad
Dr. Najam Siddiqi
MBBS, PhD (Japan) Postdoc (USA)
jamsid69@gmail.com
Department
NAS of Anatomy
Oman Medical College, Sohar, Sultanate of Oman
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The hip joint
Oct.12, 2011
Human structure Course NBAN- 403
Fall- 2011
Dr. Najam Siddiqi
MBBS, PhD (Japan) Postdoc (USA)
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Learning Objectives
You should know
Surface anatomy of the hip joint
Type of the joint, Know the bony and
ligamentous structures that comprise the hip
joint.
– Be able to define coxa valga and coxa vera
• Know the blood supply of the hip joint
– Understand the clinical significance of the
cruciate anastomosis
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OBJECTIVES:
• Know the innervations and function(s) of the
muscles acting on the hip joint
• Understand the mechanism involved in hip
stability and how the hip is locked.
• Know how the ligaments act to restrain hip
motion
• Be able to differentiate between hip fractures
and hip dislocation by the position of the limb.
• Know how nerve lesions may affect movements
of the hip joint.
– Be able to distinguish between the effects of
peripheral nerve lesions on the functioning of the hip
from lesions to the roots of the lumbosacral plexus.
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Topics
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Type of the joint
Articular surfaces
Stability of the joint
Capsule
Synovial membrane
Ligaments
Bursa
Relations
Movements
Normal radiograph
Clinical
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Hip joint is a weight
bearing joint
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Hip joint type & articular
surfaces
Type– Multiaxial
Synovial Ball & socket variety
Simple joint
Articulation:
Head of femur – forms 2/3 of a sphere
Acetabulum – forms an incomplete ring,
termed the lunate surface, covered by
articular cartilage; broadest at its upper
part which is the weight bearing area in
standing position
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Acetabular labrum is fibrocartilage attached
to the margin of the acetabulum
It also bridges the acetabular notch as the
transverse acetabular ligament;
converts the acetabular notch into a
foramen through which acetabular branch
of obturator artery and nerve enter the
joint.
Acetabular labrum and transverse ligament of the
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acetabulum
Fibrous capsule
Acetabulum – attached to its
margin and Transverse Acetabular
ligament.
Femur – it surrounds the neck of
the femur
Anterior: to the
intertrochanteric line
Anterior attachment
Posterior : almost half of the
neck above the
intertrochanteric crest
Circular and longitudinal
retinacula
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Blood vessels to the femoral
head passes through the
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capsule
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Posterior attachment
Synovial membrane of the hip joint
Lines in inner surface of the
capsule and the ligament of
the head of femur
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Weight of the body supported by
1. Iliofemoral ligament: Yshaped : ant. inferior iliac
spine to intertrochanteric
line
iliofemoral ligament
STRONGEST LIGAMENT
Prevent hyperextension of
hip during standing
Lateral / oblique
band
Hip in locked position:
Medial / vertical
band
Iliofemoral ligament
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Iliofemoral Ligament becomes
taut in extension preventing
the femur from moving past
vertical position
( resists hyperextension)
Maintains hip in locked or
stable configuration
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Ligaments--Anterior
2. Pubofemoral ligament
from pubic bone and
distally with the capsule
and iliofemoral ligament
Prevents overabduction
Ligaments--Posterior
3. Ischiofemoral ligament:
Ischial part of acetabular rim
Medial to base of greater
trochanter
Prevents hyperflexion of the hip
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Ligament of the
femoral head
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Arterial supply of the joint
• Retinacula
– Composed of fibers derived from fibrous
capsule
– Retinacula fibers reflect back along femoral
neck towards the femoral head
– Convey small arteries to head of femur
Arterial supply – branches of :
Medial circumflex femoral artery (main artery):
Retinacular arteries
Lateral circumflex femoral artery
Superior gluteal artery
Inferior gluteal artery
First perforating artery
Obturator artery
(acetabular branch)
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Fractures/ Dislocation
– Fracture of femoral neck
• More common in women than the
men (osteoporosis).
• Could disrupt retinacula and blood
supply to femoral head
• Avascular necrosis of femoral head
• Limb outwardly rotated
– Pull of lateral rotator muscles
– Dislocation
• Limb is shortened and inwardly
rotated
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Injury of the branch of the obturator artery in a child may lead
to necrosis of the head—epiphysis prevents anastomosis,
but in the adult nothing happens.
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Avascular necrosis of femoral head
in neck fractures
Blood supply is preserved in
trochanteric fractures
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Nerve supply
Femoral nerve via nerve to rectus femoris
Obturator nerve
Sciatic nerve via nerve to quadratus femoris
Accessory obturator nerve (when present)
Referred pain to the knee joint: In any
disease of hip, pain is referred to the knee as
well because Tibial, common peroneal, sciatic
and obturator nerves also supplies the knee
joint
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Muscles acting on the hip joint
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Lumbar and Lumbosacral Nerve Root
Involvement
– L 1,2
• These roots are mainly involved with innervating the
iliopsoas muscle. Damage to these roots would result in very
weak hip flexion
– L 2,3
• These roots are concerned with the innervation of the hip
adductors. Damage to these roots can lead to a waddling
type of gait.
– L5
• This is the main root innervating the gluteus medius and
minimus muscles. A positive Trendelenburg Sign could
indicate damage to this root
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The Effect of Nerve Lesions on the Hip
Joint During Gait
– Superior gluteal nerve (L 4, 5, S 1)
• Trendelenburg Gait
– Marked downward tilting of the hip on the non weight bearing side due
to inability of the gluteus medius and minimus to actively abduct the hip
on the weight bearing side during walking
• Trendelenburg Sign
– Clinical test to determine the integrity of the superior gluteal nerve
– Patient's hip tilts down when the limb is non weight bearing because of
superior gluteal nerve is damaged on weight bearing side.
– Obturator nerve (L 2,3,4)
• "Waddling gait"
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– Hip is in a marked abducted position due to paralysis of hip adductor
muscles
– When walking, the foot on the affected side, can not be placed under
pelvis. Patient has to "throw" their weight laterally when taking a step
thus, waddling to the affected side.
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AP PELVIS:
Adult vs child
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Normal angle of
inclination is about
135
(range 115-140) in
a child & 1350 in the
adult.
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Coxa vara
(abnormally
decreased angle of
inclination)
e.g. fracture neck of
femur
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Coxa valga
(abnormally increased
angle of inclination)
e.g. congenital
dislocation of the hip
joint
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Acquired / traumatic
dislocations of the hip
It is rare because of its strength
Posterior dislocations are the most
common (80%).
Anterior
dislocations
occur
infrequently
and
involved
disruption of the capsule and
strong iliofemoral ligament.
In all dislocations, the blood
supply of the head of the femur
may be compromised with
resulting avascular necrosis of the
head
of the femur.
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Complications: Posterior Dislocation
• Posterior wall fracture
• Intra-articular
fragment, which can
prevent reduction
• Sciatic nerve injury
• Femur head fracture
• Avascular necrosis
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Knee joint and its
injuries
17th Oct, 2011
Human structure Course NBAN- 403
Fall- 2011
Dr. Najam Siddiqi
MBBS, PhD (Japan) Postdoc (USA)
Objectives: Know the….
• bony , ligamentous and cartilaginous structures that comprise
the knee joint
• proper alignment of the knee
– Be able to distinguish genu valgum from genu varus
• functions of the ligaments and menisci of the knee joint.
• bursas around the joint and their inflammation
• actions, innervations of the muscles acting on the knee
• mechanisms involved with locking and unlocking of the knee
• the site of appropriate nerve lesion by deficits in knee movement
• few common diseases of the knee joint
Knee Joint
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Type of the joint
Articular surfaces
Factors supporting the knee
Capsule
Ligaments
Menisci
Bursa
Relations
Movements (locking/unlocking)
Clinical
Type of the joint
• Largest & most complicated
weight bearing joint of the
body
• Modified Hinge type of
synovial joint:
flexion/extension (gliding &
rolling and rotation
possible)
• Complex joint: menisci
present between the
articular surfaces
• Bi-axial joint
Stability of the knee joint:
Mechanically it is a weak
joint with almost no bony
support
Factors supporting the
joint are:
• Ligaments connecting
the femur and tibia
• Surrounding muscles
and tendons eg.
Quadriceps femoris
Articular surfaces:
large, complicated, incongruent surfaces, femur slants
medially on tibia whereas tibia is almost vertical
3 articulation:
2 condyles of femur and
condyles of tibia
Patella and patellar surface
of femur called
patellofemoral joint
Femoral articulating
surface
• Femur lie obliquely on tibia making a
Q angle more in female
• femoral condyles wholly convex,
inverted U shaped covered by hyaline
cartilage;
• concave anterior forming a groove for
the patella
• Mechanically very unstable because
articulation with no bony support
Tibial articular surfaces
• Oval medial articular surface, medial meniscus
• Circular lateral articular surface, lateral miniscus
Patella’s articular surface
• Patellofemoral joint:
Synovial gliding type
• Articular surface of
patella: lateral & medial
facets
• Femur: both condyles
like an inverted U
• Patella slides up and
down with flexion and
extension
• Patella dislocation
• Patellofemoral joint:
• quadriceps mechanism: the quadriceps
tendon, patellar and patellar tendon
• Medial and lateral retinacula
• Infrapatellar fat
• The patella acts like a fulcrum and
increase liver arm to increase the force
of the quadriceps muscles.
Capsule
• Posteriorly margins of articular
surfaces of femur and tibia and
intercondylar fossa
• Enclosed the tendon of popliteus
• Each side of the patella, capsule
supported by tendons of vastus
lateralis and medialis forming
retinacula
• Posteriorly expansion of
semimembranous muscle called
oblique popliteal ligament
Capsule deficient anteriorly
• Capsule is deficient
anteriorly, permitting the
synovial membrane to
pouch upwards to form
suprapatellar bursa
Synovial membrane
• Synovial membrane lines
internal aspect of capsule
• Reflects from the post aspects
of the capsule onto the cruciate
ligaments
• Covers the infrapatellar fat pad
between tibia and patella
• The joint cavity extends
superior to the patella as
suprapatella bursa
Extracapsular ligaments:
1. Ligamentum Patellae
2. Tibial Collateral
3. Fibular Collateral
4. Oblique Popliteal
5. Arcuate popliteal ligament
6. Coronary ligament
7. Transverse meniscal ligament
• Posterior meniscofemoral ligament
• Anterior meniscofemoral ligament
Extracapsular ligaments
Stabalize the knee posteriorly
• Oblique Popliteal: tendon of
semimembranosus passing
from medial to lateral
femoral condyle and
attaching to post. capsule
• Arcuate popliteal ligament:
Arise from fibular head to
posterior surface of knee
joint over the popliteus
muscle
Collateral (Lateral and medial)
ligaments
• Lateral collateral
ligament: lateral
epicondyle of femur
posterior to popliteus
tendon to fibular
head
• Medial collateral
ligament: medial
epicondyle of
femur to medial tibia
Intracapsular (intra-articular) ligaments
• Anterior cruciate ligament
• Posterior cruciate ligament
– refer to tibial attachments
Cruciate Ligaments: prevents anteroposterior displacement
• ACL slacks at flexion and taut at
fully extended knee,
• prevents anteriolateral
movement of tibia on femur or
posterior movement of femur
on tibia (when tibia on ground)
• PCL tightens during flexion,
prevents posterior movement
of tibia on femur or anterior
movement of femur on tibia
(when tibia on ground)
Anterior cruciate ligament
rupture
Posterior cruciate
ligament rupture
Meniscus
• Semilunar fibrocartilage,
cresentric shape deepens the
articulation on tibial surface
• Outer thick border attached to
tibial condyle by coronary
ligament, inner margins concave,
thin and free
• Attached to the femur by
meniscofemoral ligament
• They spread load by increasing the
congruity of the articulation
Parts of the meniscus:
Anterior horn
Posterior horn
Body
Function of meniscus
• Shock absorbers in the knee;
acts like springs
• Walking puts up to two times
your body weight on the joint.
• Running puts about eight
times your body weight on the
knee.
• As the knee bends, the back
part of the menisci takes most
of the pressure.
Intercondylar eminence (area)
Structures attached to the
intercondylar space (ant to
post)
medial
1.
2.
3.
4.
5.
6.
Ant horn of medial meniscus
Ant cruciate ligament
Ant horn of Lateral Meniscus
Post horn of Lateral Meniscus
Post horn of medial meniscus
Post cruciate ligament
Code: Medical College Lahore-- Lahore Medical College
Meniscus Injury: Medial
meniscus: more prone to
injury--- why?
• Medial meniscus attached to the
medial collateral ligament
• Attached to tibia by Coronary
ligament
• Fixed in its place and if twisting or
shear forces act on the meniscus, it
cannot move thus ruptures
• Most common in basket ball players
• Arthroscopic repair or resection
Bursae-- 12 or more around the knee joint
Anterior Bursae
1. Supra patellar: SUPERIOR
EXTENSION OF THE KEE
JOINT CAVITY
2. Prepatellar: lower patella
and skin
3. Deep Infra Patellar:
between tibia and patellar
tendon
4. Superficial Infra Patellar:
distal part of tibial
tuberosity and skin
Bursae (Posterior)
Gastro bursa
1. Gastro and capsule
2. Popliteal bursa:
Tendon of popliteus
and lateral femoral
condyle
Popliteus bursa
Bursae (Medial)
1. Semimembranosus bursa
2. Medial collateral ligament
and Semitendo, Satorius,
Gracilis (pes bursa or
Anserine bursa)
4 bursae communicate with the knee joint:
Suprapetallar, Popliteus, Gastro, Anserine; Infection
in the bursae may go to the knee joint
• The pes anserine bursa provides a buffer or
lubricant for motion that occurs between
these three tendons and the medial
collateral ligament (MCL). The MCL is
underneath the semitendinosus tendon.
Clinically important bursae
Bursitis of the knee joint
• Prepatellar & infrapatellar
bursae inflammation usually
due to repeated friction, direct
blow or fall--Housemaid’s knee
• Anserine or Pes bursa inflamed
in athletes
• Popliteus bursa in degenerating
disease of the knee joint in
elderly
• A popliteal cyst, or Baker's cyst:
• is a soft, often painless bump
• due to arthritis, gout, injury, or inflammation
in the knee joint.
Blood & Nerve Supply
• 10 Arteries forming the genicular anastomosis
• Middle Genicular artery: cruciate ligaments,
synovial membrane
Nerve supply
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Obturator
Femoral
Tibial
Common Peroneal
Saphenous
Movements
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Flexion
Extension
Medial & lateral rotation
Locking/unlocking
– Locking—During extension medial rotation of
femur
– Unlocking—lateral rotation of femur by
popliteus
Locking and unlocking of
the knee
•Femur rotates medially on full
extension (due to shape of the articular
surfaces)
•Because of rotation of the femur, all
the ligaments becomes tight and thus
knee locks in extension
•For flexion to begin, the femur must
rotate laterally to relax the ligaments,
then flexion starts.
• Popliteus is the muscle to rotate
femur and unlock the knee
Disc herniation
• L5-S1: Flexion weakness
• L3-4: Extension weakness
• L2-4: Patellar tendon reflex
Knee deformities: mostly due to osteoarthritis
Genu varum
Mechanical axis of the lower limb
Genu valgum
Can you name the
deformities?
High heels causes
osteoarthritis
Wearing high heels puts extra pressure on inside of
woman's knee, increasing risk for osteoarthritis later in
life.
Heels also alter muscle and tendon structure.
Ankylosis of the joint—joint cavity is
obliterated
Injuries of the knee joint
• Rupture of the cruciate
ligaments: foot ball players,
skiing accidents
• ACL: Severe force directed
anteriorly in semiflexed knee—
kicking the football
• PCL: player lands on tibial
tuberosity with the knee flexed
–knocked to floor in basketball
• Anterior/posterior drawer signs
positive
“Unhappy triad’’ of
knee injuries
1. Rupture of the
Medial meniscus
2. Rupture of
Medial collateral
ligament
3. Rupture of
anterior cruciate
ligament
Patellofemoral syndrome
‘runner’s knee’
• Pain deep to the patella
• Due to excessive running especially downhill
• Osteoarthritis of the Patellofemoral joint
Ankle and Subtalar joints
Oct 18, 2011
Human structure Course NBAN- 403
Fall- 2011
Dr. Najam Siddiqi
MBBS, PhD (Japan) Postdoc (USA)
jamsid69@gmail.com
Department of Anatomy
Oman Medical College, Sohar, Sultanate of Oman
Ankle Joint (talocrural) : Topics
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Type of the joint: hinge type; uni-axial
Articulation
Capsule
Ligaments
Blood supply and nerve supply
Movements and muscles involved
Clinical importance
Articulation:
1. lower end of tibia and its medial malleolus,
2. trochlear surface of talus,
3. lateral malleolus of fibula
1. Ligaments between Tibia and Fibula:
tibiofibular syndesmosis
Anterior Tibiofibular
ligament
Posterior Tibiofibular
ligament
2. Medial ligaments : Deltoid
3. Lateral ligaments
(most frequently damaged ligaments during ankle
twisting)
Ant. Talo fibular ligament
sprains (Part of the lateral
ligament)
Nerve supply:
• Deep peroneal,
saphenous, sural and
tibial nerves
Blood supply:
– Malleolar rami of ant. &
post Tibial arteries
– Peroneal artery branch
from post Tibial artery
Movement of Ankle joint
Planter flexion: 40-50
• Gastrocnemius, soleus,
• Assisted by plantaris,
Tibialis posterior, flexor
hallusis longus, digitorum
longus
Dorsiflexion (20-30)
• Tibialis anterior
• Extensor digitorum
longus, hallucus longus
and peroneus tertius
• Nerve: Deep peroneal
nerve
• Foot drop
Normal radiograph (AP view)
Pott’s fracture dislocation of
the ankle joint
• Foot forcibly everted
• Medial ligament
(Deltoid) is torn
• Talus moves laterally
tearing the lateral
ligament and/or
fracture of fibula
Fracture dislocation of ankle joint
Subtalar Joint
• Modified multi-axial
synovial joint of plane
variety
Talus articulates with calcaneus and
navicular
• Inbetween: Interosseous
talocalcanean ligament
Subtalar joint
Eversion
Inversion
Movements
• Inversion: Tibialis
anterior and
posterior
• Extensor
digitorum longus
• Eversion:
Peroneus longus
and brevis
Total range of motion of forefoot and
hindfoot
Eversion & pronation Inversion & supination
30 degrees
60 degrees
Effects of high heel shoes; foot in planter
flexed position
• Fashionable and make you feel taller
• Cause back pain, knee osteoarthritis, foot
problems
• Like walking on a balance beam without any
support
• Lumber spine flattening, curves are lost, body
readjust balance, lower part lean forward and
upper part lean back so abnormal posture of
body
• Hip flexors work hard and longer while walking
• Limit power and motion at ankles. Calf muscles
become shorter and loose power, shortening
of achilles tendon
• Foot plantar flexed so cannot push off, hip
flexors to work harder
• Foot position increases pressure on the
forefoot
Clubfoot (Talipes equinovarus)
• Congenital anomaly
• 2 per 1000 livebirths
• Involves the subtalar joint
Thank you
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