Joints of the lower limb Feb. 28, 2012 Shifa College of Medicine Islamabad

1. Joints of the lower limb Feb. 28, 2012 Shifa College of Medicine Islamabad Dr. NajamSiddiqi MBBS, PhD (Japan) Postdoc (USA) jamsid69@gmail.com Department of Anatomy Oman Medical College, Sohar, Sultanate of Oman NAS

2. The hip joint Dr. NajamSiddiqi MBBS, PhD (Japan) Postdoc (USA) Oct.12, 2011 Human structure Course NBAN- 403 Fall- 2011 NAS

3. 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 coxavalga and coxavera • Know the blood supply of the hip joint • Understand the clinical significance of the cruciateanastomosis NAS

4. 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. NAS

5. Topics • Type of the joint • Articular surfaces • Stability of the joint • Capsule • Synovial membrane • Ligaments • Bursa • Relations • Movements • Normal radiograph • Clinical NAS

6. Hip joint is a weight bearing joint NAS

7. 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 NAS

8. Acetabular labrumis 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 acetabulum NAS

9. Fibrous capsule Acetabulum– attached to its margin and Transverse Acetabular ligament. Femur– it surrounds the neck of the femur Anterior: to the intertrochanteric line Posterior : almost half of the neck above the intertrochantericcrest Circular and longitudinal retinacula Blood vessels to the femoral head passes through the capsule Anterior attachment NAS Posterior attachment

10. Synovial membrane of the hip joint Lines in inner surface of the capsule and the ligament of the head of femur NAS

11. Weight of the body supported by iliofemoral ligament • 1. Iliofemoral ligament: Y-shaped : ant. inferior iliac spine to intertrochantericline • STRONGEST LIGAMENT • Prevent hyperextension of hip during standing • Hip in locked position: • Iliofemoral Ligament becomes taut in extension preventing the femur from moving past vertical position • ( resists hyperextension) • Maintains hip in locked or stable configuration Lateral / oblique band Medial / vertical band Iliofemoral ligament NAS

12. Ligaments--Anterior 2. Pubofemoral ligament from pubic bone and distally with the capsule and iliofemoral ligament Prevents overabduction Ligaments--Posterior 3. Ischiofemoral ligament: Ischialpart of acetabular rim Medial to base of greater trochanter Prevents hyperflexionof the hip NAS

13. Ligament of the femoral head NAS

14. Arterial supply of the joint • Retinacula • Composed of fibers derived from fibrous capsule • Retinaculafibers 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 glutealartery • Inferior glutealartery • First perforating artery • Obturatorartery • (acetabularbranch) NAS

15. 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 NAS

16. 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. NAS

17. Avascular necrosis of femoral head in neck fractures Blood supply is preserved in trochantericfractures NAS

18. Nerve supply • Femoral nerve via nerve to rectus femoris • Obturator nerve • Sciatic nerve via nerve to quadratusfemoris • 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 NAS

19. Muscles acting on the hip joint NAS

20. 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. • L 5 • This is the main root innervating the gluteus medius and minimus muscles. A positive Trendelenburg Sign could indicate damage to this root NAS

21. The Effect of Nerve Lesions on the Hip Joint During Gait • Superior gluteal nerve (L 4, 5,S1) • 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" • 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. NAS

22. AP PELVIS: Adult vs child NAS

23. Normal angle of inclination is about 135 (range 115-140)ina child & 1350 in the adult. Coxavara(abnormally decreased angle of inclination) e.g. fracture neck of femur Coxavalga(abnormally increased angle of inclination) e.g. congenital dislocation of the hip joint NAS

24. 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 iliofemoralligament. • 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. NAS

25. Complications: Posterior Dislocation • Posterior wall fracture • Intra-articular fragment, which can prevent reduction • Sciatic nerve injury • Femur head fracture • Avascular necrosis

26. Knee joint and its injuries 17th Oct, 2011 Human structure Course NBAN- 403 Fall- 2011 Dr. NajamSiddiqi MBBS, PhD (Japan) Postdoc (USA)

27. Objectives: Know the…. • bony , ligamentous and cartilaginous structures that comprise the knee joint • proper alignment of the knee • Be able to distinguish genuvalgumfrom genuvarus • functions of the ligaments and menisci of the knee joint. • bursasaround 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

28. Knee Joint • Type of the joint • Articular surfaces • Factors supporting the knee • Capsule • Ligaments • Menisci • Bursa • Relations • Movements (locking/unlocking) • Clinical

29. 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 articularsurfaces • Bi-axial joint

30. 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

31. Articular surfaces: large, complicated, incongruent surfaces, femur slants medially on tibia whereas tibia is almost vertical 3 articulation: 2 condyles of femur and condylesof tibia Patella and patellar surface of femur called patellofemoraljoint

32. 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

33. Tibial articular surfaces • Oval medial articularsurface, medial meniscus • Circular lateral articular surface, lateral miniscus

34. 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

35. 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.

36. Capsule • Posteriorly margins of articular surfaces of femur and tibia and intercondylarfossa • Enclosed the tendon of popliteus • Each side of the patella, capsule supported by tendons of vastuslateralis and medialis forming retinacula • Posteriorly expansion of semimembranous muscle called oblique popliteal ligament

37. Capsule deficient anteriorly • Capsule is deficient anteriorly, permitting the synovial membrane to pouch upwards to form suprapatellar bursa

38. 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

39. Extracapsular ligaments: 1. Ligamentum Patellae 2. Tibial Collateral 3. Fibular Collateral 4. Oblique Popliteal 5. Arcuatepopliteal ligament 6. Coronary ligament 7. Transverse meniscal ligament • Posterior meniscofemoral ligament • Anterior meniscofemoral ligament

40. ExtracapsularligamentsStabalize the knee posteriorly • Oblique Popliteal: tendon of semimembranosuspassing from medial to lateral femoral condyleand attaching to post. capsule • Arcuatepopliteal ligament: Arise from fibular head to posterior surface of knee joint over the popliteus muscle

41. 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

42. Intracapsular (intra-articular) ligaments • Anterior cruciate ligament • Posterior cruciateligament • refer to tibial attachments

43. Cruciate Ligaments: prevents antero-posterior displacement • ACL slacks at flexion and taut at fully extended knee, • prevents anteriolateralmovement 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)

44. Anterior cruciate ligament rupture

45. Posterior cruciate ligament rupture

46. Meniscus • Semilunarfibrocartilage, cresentricshape deepens the articulation on tibial surface • Outer thick border attached to tibialcondyle 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

47. 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.

48. Intercondylar eminence (area) • Structures attached to the intercondylar space (ant to post) • 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 medial Code: Medical College Lahore-- Lahore Medical College

49. 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

50. 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 tibialtuberosity and skin