Joints of the Lower Limb

Kaan Yücel M.D., Ph.D 5.February.2014 Wednesday

The Dance Hall by Vincent van Gogh ,1888

Articulations of the pelvic girdleLumbosacral joints, sacroiliac joints & pubic symphysis

The remaining joints of the lower limb Hip jointKnee jointTibiofibular jointsAnkle jointFoot joints

JOINTS OF LOWER LIMB

Feature 1: Connection between lower limb & pelvic girdle

Feature 2: 2nd most movable after the shoulder joint

Synovial Joint Type: Ball and socket (Head of the femur & acetabulum)

Weight transfer: To the heads and necks of the femurs

Transverse acetabular ligament continuation of acetabular labrum

3 intrinsic ligaments1)Iliofemoral ligament anteriorly and superiorly , strongest

ligament of the body2)Pubofemoral ligament anteriorly and inferiorly3)Ischiofemoral ligament posteriorly –weakest of the 3Ligament of the head of the femur

Ligaments

Iliofemoral ligament Y-shapedFrom Ant. Inf. Iliac Spine &Acetabular rim To Intertrochanteric lineprevents hyperextension of the hip joint during standing by screwing the femoral head into the acetabulumPubofemoral ligament obturator crest of pubic boneblends with the medial part of the iliofemoral ligament tightens during both extension and abduction prevents overabduction of the hip joint

Ligaments

Ischiofemoral ligament

Ligaments

from the ischial part of the acetabular rimspirals around the femoral neck, medial to the base of the greater trochanter.

Ligaments

The ligaments and periarticular muscles (the medial and lateral rotators of the thigh) play a vital role in maintaining the structural integrity of the joint.

Ligaments

Ligament of the head of the femur primarily a synovial fold conducting a blood vessel weak and of little importance in strengthening the hip joint.

wide end attaches to the margins of the acetabular notch and the transverse acetabular ligamentnarrow end attaches to the fovea for the ligament of the head.

Flexion-extension Abduction-adduction Medial-lateral rotation Circumduction

MOVEMENTS OF HIP JOINT

MOVEMENTS OF HIP JOINTDuring extension of the hip joint, the fibrous layer of the joint capsule, especially the iliofemoral ligament, is tense.

The hip can usually be extended only slightly beyond the vertical except by movement of the bony pelvis (flexion of lumbar vertebrae).

MOVEMENTS OF HIP JOINTFrom the anatomical position, the range of abduction of the hip joint is usually greater than for adduction.

About 60° of abduction is possible when the thigh is extended, and more when it is flexed.

Lateral rotation is much more powerful than medial rotation.

KNEE JOINTFeature 1: Largest & most superficial joint

Feature 2: Hinge movements (Ext/Flex) combined with gliding & rotation

Synovial Joint Type: Hinge2 femorotibial articulations (lateral and medial) between lateral & medial femoral and tibial condyles1 intermediate femoropatellar articulation between patella & femurNo fibula involvment in the knee joint

Extracapsular ligaments1) Patellar ligament

2) Fibular (Lateral) collateral ligament

3) Tibial (Medial) collateral ligament

4) Oblique popliteal ligament

5) Arcuate popliteal ligament

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INTRA-ARTICULAR LIGAMENTS Cruciate ligaments & menisci

Anterior cruciate ligament (ACL)

Posterior cruciate ligament (PCL)

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23Start: Posterior intercondylar area of tibiaEnd: Lateral surface of the medial condyle of femur

Start: anterior intercondylar area of tibia just posterior to the attachment of the medial meniscusEnd: Medial side of the lateral condyle of the femurr

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Limits posterior rolling (turning and traveling) of the femoral condyles on the tibial plateau during flexion. Prevents posterior displacement of the femur on the tibia and hyperextension of the knee joint.

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Llimits anterior rolling of the femur on the tibial plateau during extension. Prevents anterior displacement of the femur on the tibia or posterior displacement of the tibia on the femur and helpsprevent hyperflexion of the knee joint.

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In the weight-bearing flexed knee, Posterior Cruciate Ligamentthe main stabilizing factor for the femur (e.g., when walking downhill).

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Menisci of the knee joint are crescentic plates of fibrocartilage on the articular surface of the tibia that deepen the surface and play a role in shock absorption.

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MOVEMENTS OF KNEE JOINTFlexion and extension are the main knee movements; some rotation occurs when the knee is flexed. When the knee is fully extended with the foot on the ground, the knee passively “locks” because of medial rotation of the femoral condyles on the tibial plateau (the “screw-home mechanism”). This position makes the lower limb a solid column and more adapted for weight-bearing.

http://www.pt.ntu.edu.tw/hmchai/kinesiology/KINlower/Knee.files/KneeKinematics.htm

BURSAE AROUND KNEE JOINTThere are at least 12 bursae around the knee joint because most tendons run parallel to the bones and pull lengthwise across the joint during knee movements. The subcutaneous prepatellar and infrapatellar bursae are located at the convex surface of the joint, allowing the skin to be able to move freely during movements of the knee. The large suprapatellar bursa is especially important because an infection in it may spread to the knee joint cavity.

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(Superior) Tibiofibular joint

Syndesmosis (inferior tibiofibular) joint In addition, an interosseous membrane joins the shafts of the two bones.

TIBIOFIBULAR JOINTS

(Superior) Tibiofibular joint

Syndesmosis (inferior tibiofibular) joint In addition, an interosseous membrane joins the shafts of the two bones.

TIBIOFIBULAR JOINTS

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Syndesmosis (inferior tibiofibular) joint TIBIOFIBULAR JOINTS

stability of the ankle joint keeps the lateral malleolus firmly against the lateral surface of the talus

interosseous tibiofibular ligamentanterior and posterior tibiofibular ligaments

ANKLE JOINT Talocrural joint

Distal ends of the tibia & fibula & superior parts of the talus

Synovial Joint Type: HingeLIGAMENTS OF ANKLE JOINT

1) Lateral ligament of the ankle2) Medial ligament of the ankle (deltoid ligament)

Lateral ligament of the ankle anterior talofibular ligamentflat, weak bandextends from lateral malleolus to neck of talus posterior talofibular ligament

calcaneofibular ligamentround cord passes from tip of lateral malleolus to lateral surface of calcaneus

thick, strong band runs posteriorly from malleolar fossa to lateral tubercle of talus

ANKLE JOINT Medial (Deltoid) ligament of the ankle strong and triangular in shape

apex attached above to medial malleolus

broad base attached below to a line extends from the tuberosity of the navicular bone in front to medial tubercle of talus behind.

ANKLE JOINT Medial (Deltoid) ligament of the anklestrong and triangular in shape

1. tibionavicular part 2. tibiocalcaneal part 3. posterior tibiotalar part 4. anterior tibiotalar part

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FOOT JOINTSThe major joints at which movements occur SubtalarTalocalcaneonavicularCalcaneocuboid joints

Intertarsal joints between the cuneiforms and between the cuneiforms and the navicular allow only limited movement.

Transverse tarsal joint

Subtalar (talocalcaneal) joint

Transverse tarsal joint (calcaneocuboid and talonavicular joints)

Inversion and eversion of the foot are the main movements

FOOT JOINTS

SUBTALAR JOINTbetween

posterior calcaneal facet on inferior surface of taluscorresponding posterior talar facet on superior surface of calcaneus

allows gliding and rotation, involved in inversion and eversion of the foot.

SUBTALAR JOINT

Lateral, medial, posterior, and interosseous talocalcaneal ligaments stabilize the joint.Interosseous talocalcaneal ligament Lies within the tarsal sinus. Separates the subtalar and

talocalcaneonavicular joints. Especially strong.

SUBTALAR JOINT

The subtalar joint (by either definition) is where the majority of inversion and eversion occurs, around an axis that is oblique.

SUBTALAR JOINTOrthopedic surgeons

anatomical subtalar joint + talocalcaneal part of talocalcaneonavicular joint

compound joint formed by two separate joints aligned transversely:TalocalcaneonavicularCalcaneocuboid joints

TRANSVERSE TARSAL JOINT

At this joint, the midfoot and forefoot rotate as a unit on the hindfoot around a longitudinal (AP) axis, augmenting the inversion and eversion movements occurring at the clinical subtalar joint.

Transection across the transverse tarsal joint a standard method for surgical amputation of the foot

TRANSVERSE TARSAL JOINT

TALOCALCANEONAVICULAR JOINT

complex joint head of the talus articulates with calcaneus plantar

calcaneonavicular ligament

(spring ligament) below navicular in front.

TALOCALCANEONAVICULAR JOINTallows gliding and rotation movements, which together with similar movements of the subtalar joint are involved with inversion and eversion of the foot.

TALOCALCANEONAVICULAR JOINTCapsule reinforced posteriorly by interosseous talocalcaneal ligamentsuperiorly by talonavicular ligamentinferiorly by plantar calcaneonavicular ligament (spring ligament)

TALOCALCANEONAVICULAR JOINTLateral part reinforced calcaneonavicular part of the bifurcate ligament

a Y-shaped ligament superior to the joint Base attached to anterior aspect of superior surface of calcaneus Arms attached to: dorsomedial surface of the cuboid (calcaneocuboid ligament)dorsolateral part of the navicular (calcaneonavicular ligament).

CALCANEOCUBOID JOINTsynovial joint between:

facet on the anterior surface of the calcaneuscorresponding facet on the posterior surface of the cuboid.

CALCANEOCUBOID JOINTallows sliding and rotating movements involved with inversion and eversion of the foot.

reinforced by bifurcate ligament long plantar ligament plantar calcaneocuboid ligament (short plantar ligament).

Short plantar ligament plantar calcaneocuboid ligament

Short, wide, and very strongConnects calcaneal tubercle to the inferior surface of the cuboid.Supports the calcaneocuboid jointAssists the long plantar ligament in resisting depression of the lateral arch of the foot

Long plantar ligament Longest ligament in the sole of the foot. Lies inferior to the plantar calcaneocuboid ligament.Between calcaneus and cuboid bone (inferior surfaces)More superficial fibers extend to the bases of the metatarsal bones.Supports the calcaneocuboid joint. Strongest ligament, resisting depression of lateral arch of the foot.

Ellipsoid synovial joints between heads of metatarsals and bases of proximal phalanges. Allow extension and flexion, and limited abduction, adduction, rotation, and circumduction. Four deep transverse metatarsal ligaments link heads of metatarsals together and enable the metatarsals to act as a single unified structure.

Metatarsophalangeal joints

Interphalangeal joints Hinge joints Reinforced by medial and lateral collateral ligaments and by plantar ligaments.

between metatarsal bones and adjacent tarsal bones plane joints limited sliding movements.

The range of movement of tarsometatarsal joint between metatarsal of great toe and medial cuneiform greater than that of other tarsometatarsal joints allows flexion, extension, and rotation.

Tarsometatarsal joints

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MAJOR LIGAMENTS OF FOOTPlantar calcaneonavicular ligament (spring ligament)

Long plantar ligament

Plantar calcaneocuboid ligament (short plantar ligament)

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MAJOR LIGAMENTS OF FOOT

Plantar calcaneonavicular ligament (spring ligament)

Long plantar ligament

Plantar calcaneocuboid ligament (short plantar ligament)

FOOT JOINTSIn the foot, flexion and extension occur in the forefoot at the metatarsophalangeal and interphalangeal joints. Inversion is augmented by flexion of the toes (especially the great and 2nd toes), and eversion by their extension (especially of the lateral toes).

ARCHES OF FOOTSpreading the weight

ARCHES OF FOOTSpreading the weight

Longitudinal arch of the foot Medial longitudinal arch Calcaneus, talus, navicular, 3 cuneiforms & 3 metatarsals. higher and more important than the lateral longitudinal arch. talar head keystone of the medial longitudinal arch.

Lateral longitudinal arch much flatter, rests on ground during standing. Calcaneus, cuboid, and lateral two metatarsals.

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ARCHES OF FOOTSpreading the weight

Transverse arch of the footRuns from side to sideFormed by cuboid, cuneiforms & bases of metatarsals