Joints of the Lower Limb The Dance Hall by Vincent van Gogh ,1888 Kaan Yücel M.D., Ph.D 5.February.2014 Wednesday

JOINTS OF LOWER LIMB Hip joint Knee joint Tibiofibular joints Articulations of the pelvic girdle Lumbosacral joints, sacroiliac joints & pubic symphysis The remaining joints of the lower limb Hip joint Knee joint Tibiofibular joints Ankle joint Foot 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

Ligaments Transverse acetabular ligament continuation of acetabular labrum 3 intrinsic ligaments Iliofemoral ligament anteriorly and superiorly , strongest ligament of the body Pubofemoral ligament anteriorly and inferiorly Ischiofemoral ligament posteriorly –weakest of the 3 Ligament of the head of the femur

Ligaments Iliofemoral ligament Y-shaped From Ant. Inf. Iliac Spine &Acetabular rim To Intertrochanteric line prevents hyperextension of the hip joint during standing by screwing the femoral head into the acetabulum Pubofemoral ligament obturator crest of pubic bone blends with the medial part of the iliofemoral ligament tightens during both extension and abduction prevents overabduction of the hip joint

Ligaments Ischiofemoral ligament from the ischial part of the acetabular rim spirals 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.

Ligament of the head of the femur 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 ligament narrow end attaches to the fovea for the ligament of the head.

MOVEMENTS OF HIP JOINT Flexion-extension Abduction-adduction Medial-lateral rotation Circumduction

MOVEMENTS OF HIP JOINT During 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 JOINT From 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 JOINT 2 femorotibial articulations (lateral and medial) Feature 1: Largest & most superficial joint Feature 2: Hinge movements (Ext/Flex) combined with gliding & rotation Synovial Joint Type: Hinge 2 femorotibial articulations (lateral and medial) between lateral & medial femoral and tibial condyles 1 intermediate femoropatellar articulation between patella & femur No fibula involvment in the knee joint

Extracapsular ligaments Patellar ligament Fibular (Lateral) collateral ligament Tibial (Medial) collateral ligament Oblique popliteal ligament Arcuate popliteal ligament

INTRA-ARTICULAR LIGAMENTS Cruciate ligaments & menisci Anterior cruciate ligament (ACL) Posterior cruciate ligament (PCL)

Start: anterior intercondylar area of tibia just posterior to the attachment of the medial meniscus End: Medial side of the lateral condyle of the femurr Start: Posterior intercondylar area of tibia End: Lateral surface of the medial condyle of femur

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.

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 helps prevent hyperflexion of the knee joint.

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

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.

MOVEMENTS OF KNEE JOINT Flexion 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 JOINT There 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.

TIBIOFIBULAR JOINTS (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.

Syndesmosis (inferior tibiofibular) joint stability of the ankle joint keeps the lateral malleolus firmly against the lateral surface of the talus interosseous tibiofibular ligament anterior and posterior tibiofibular ligaments

LIGAMENTS OF ANKLE JOINT Talocrural joint Distal ends of the tibia & fibula & superior parts of the talus Synovial Joint Type: Hinge LIGAMENTS OF ANKLE JOINT Lateral ligament of the ankle Medial ligament of the ankle (deltoid ligament)

anterior talofibular ligament flat, weak band Lateral ligament of the ankle anterior talofibular ligament flat, weak band extends from lateral malleolus to neck of talus posterior talofibular ligament calcaneofibular ligament round 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

strong and triangular in shape 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.

strong and triangular in shape ANKLE JOINT Medial (Deltoid) ligament of the ankle strong and triangular in shape tibionavicular part tibiocalcaneal part posterior tibiotalar part anterior tibiotalar part

FOOT JOINTS The major joints at which movements occur Subtalar Talocalcaneonavicular Calcaneocuboid joints Intertarsal joints between the cuneiforms and between the cuneiforms and the navicular allow only limited movement. Transverse tarsal joint

Inversion and eversion of the foot are the main movements FOOT JOINTS Subtalar (talocalcaneal) joint Transverse tarsal joint (calcaneocuboid and talonavicular joints) Inversion and eversion of the foot are the main movements

SUBTALAR JOINT between posterior calcaneal facet on inferior surface of talus corresponding posterior talar facet on superior surface of calcaneus

SUBTALAR JOINT 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 Orthopedic surgeons anatomical subtalar joint + talocalcaneal part of talocalcaneonavicular joint The subtalar joint (by either definition) is where the majority of inversion and eversion occurs, around an axis that is oblique.

TRANSVERSE TARSAL JOINT compound joint formed by two separate joints aligned transversely: Talocalcaneonavicular Calcaneocuboid 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

TALOCALCANEONAVICULAR JOINT complex joint head of the talus articulates with calcaneus plantar calcaneonavicular ligament (spring ligament) below navicular in front.

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

TALOCALCANEONAVICULAR JOINT Capsule reinforced posteriorly by interosseous talocalcaneal ligament superiorly by talonavicular ligament inferiorly by plantar calcaneonavicular ligament (spring ligament)

TALOCALCANEONAVICULAR JOINT Lateral 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 JOINT synovial joint between: facet on the anterior surface of the calcaneus corresponding facet on the posterior surface of the cuboid.

CALCANEOCUBOID JOINT allows 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 strong Connects calcaneal tubercle to the inferior surface of the cuboid. Supports the calcaneocuboid joint Assists 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.

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

Tarsometatarsal joints 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.

MAJOR LIGAMENTS OF FOOT Plantar calcaneonavicular ligament (spring ligament) Long plantar ligament Plantar calcaneocuboid ligament (short plantar ligament)

MAJOR LIGAMENTS OF FOOT Plantar calcaneonavicular ligament (spring ligament) Long plantar ligament Plantar calcaneocuboid ligament (short plantar ligament)

FOOT JOINTS In 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 FOOT Spreading the weight

Longitudinal arch of the foot ARCHES OF FOOT Spreading 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. 2 3

Transverse arch of the foot ARCHES OF FOOT Spreading the weight Transverse arch of the foot Runs from side to side Formed by cuboid, cuneiforms & bases of metatarsals