1. 肌肉骨骼系统
关节&软骨

2. Content
关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生

3. Joints Joints and their classification Synovial joints
bony joints
fibrous joints
cartilaginous joints
Synovial joints
Anatomy of selected diarthroses
humeroscapular joint 肱肩胛关节
elbow joint
coxal joint 髋关节
knee joint
9-3

4. Joints and Their Classification
Arthrology = study of the joints
Kinesiology = study of musculoskeletal movement
Classified by freedom of movement
diarthrosis (freely movable)
amphiarthrosis (slightly movable)微动关节
synarthrosis (little or no movement)不动关节
Classified how adjacent bones are joined
Fibrous
Cartilaginous
bony or synovial
9-4

5. Bony Joint (Synostosis)骨性结合
Gap between two bones ossifies
frontal and mandibular bones in infants 额骨和下颌骨
cranial sutures in elderly 颅缝
attachment of first rib and sternum 胸骨
Can occur in either fibrous or cartilaginous joint

6. Fibrous Joints (Synarthrosis)
Collagen fibers span the space between bones
Sutures
gomphoses 钉状关节
Syndesmoses 韧带联合
9-6

7. Fibrous Joint -- Sutures
Immovable fibrous joints
bind skull bones together
Serrate - interlocking lines(齿状联合)
Coronal(冠状缝), sagittal(矢状缝) and lambdoid sutures(人字缝)
Lap - overlapping beveled edges
temporal and parietal bones(颞和颅顶骨)
Plane - straight, nonoverlapping edges
palatine processes(腭突) of the maxillae
9-7

8. Types of Sutures
9-8

9. Fibrous Joint – Gomphoses钉状关节
Attachment of a tooth to its socket
Held in place by fibrous periodontal ligament(牙周韧带)
collagen fibers attach tooth to jawbone(颚骨)
Some movement while chewing

10. Fibrous Joint – Syndesmosis韧带联合
Two bones bound by ligament only
interosseus membrane
Most movable of fibrous joints
Interosseus membranes unite radius to ulna and tibia to fibula

11. Cartilaginous Joint – Synchondrosis软骨结合
Bones are joined by hyaline cartilage(透明软骨)
rib attachment to sternum(胸骨)
epiphyseal plate(骺板) in children binds epiphysis(骨骺) and diaphysis(骨干)
9-11

12. Cartilaginous Joint – Symphysis骨联合
2 bones joined by fibrocartilage(纤维软骨)
pubic symphysis(耻骨联合) and intervertebral discs
Only slight amount of movement is possible

13. Synovial Joint(滑膜关节)
Joint in which two bones are separated by a space called a joint cavity
Most are freely movable
9-13

14. General Anatomy Articular capsule encloses joint cavity
continuous with periosteum(骨膜)
lined by synovial membrane
Synovial fluid = slippery fluid; feeds cartilages
Articular cartilage = hyaline cartilage covering the joint surfaces
Articular discs and menisci(半月板)
jaw, wrist, sternoclavicular and knee joints
absorbs shock, guides bone movements and distributes forces
Tendon attaches muscle to bone
Ligament attaches bone to bone
9-14

15. Tendon Sheaths and Bursae
Bursa = saclike extension of joint capsule 滑囊
between nearby structures so slide more easily past each other
Tendon sheaths = cylinders of connective tissue lined with synovial membrane and wrapped around a tendon
9-15

16. Components of a Lever
A lever is a rigid object that rotates around a fixed point called a fulcrum(支点)
Rotation occurs when effort overcomes resistance
resistance arm and effort arm are described relative to fulcrum
9-16

17. Mechanical Advantage of a Lever
Two kinds of levers
lever that helps increase output of force
human moving a heavy object with help of crowbar(撬棍)
lever move object further and faster
movement of row boat with paddle(桨)
Types of levers produce either increase in speed or force
9-17

18. Mechanical Advantage
Mechanical advantage is calculated from the length of the effort arm divided by the length of the resistance arm
Contraction of the biceps muscle (肱二头肌)causes the hand to move fast and further (MA <1.0)
9-18

19. First-Class Lever
Has fulcrum in the middle between effort and resistance
Atlantooccipital joint(寰枕关节) lies between the muscles on the back of the neck and the weight of the face
loss of muscle tone(肌张力) occurs when you nod off in class
9-19

20. Second-Class Lever Resistance between fulcrum and effort
Resistance from the muscle tone of the temporalis(颞肌 ) muscle lies between the jaw joint(下颌关节) and the pull of the diagastric muscle(二腹肌前腹) on the chin(下巴) as it opens the mouth quickly
9-20

21. Third-Class Lever Effort between the resistance and the fulcrum
most joints of the body
The effort applied by the biceps muscle is applied to the forearm between the elbow joint and the weight of the hand and the forearm
9-21

22. Range of Motion Degrees through which a joint can move Determined by
structure of the articular surfaces
strength and tautness of ligaments, tendons and capsule
stretching of ligaments increases range of motion
double-jointed people have long or slack ligaments
action of the muscles and tendons
nervous system monitors joint position and muscle tone
9-22

23. Axes of Rotation
Shoulder joint has 3 degrees of freedom = multiaxial joint多轴关节
Other joints – monoaxial or biaxial
9-23

24. Types of Synovial Joints
9-24

25. Ball-and-Socket Joints
Smooth hemispherical(半球) head fits within a cuplike depression
head of humerus(肱骨) into glenoid cavity of scapula
head of femur into acetabulum(髋臼) of hip bone
Multiaxial joint
9-25

26. Condyloid (ellipsoid) Joints
Oval convex surface(椭圆凸面) on one bone fits into a similarly shaped depression on the next
Radiocarpal joint(腕桡关节) of the wrist
metacarpophalangeal joints(掌指关节) at the bases of the fingers
Biaxial joints
9-26

27. Saddle Joints 鞍状关节
Each articular surface is shaped like a saddle鞍, concave(凹面) in one direction and convex(凸面) in the other
trapeziometacarpal joint(拇指腕关节) at the base of the thumb
Biaxial joint
more movable than
a condyloid or hinge joint(铰链关节)
forming the primate(灵长目)
opposable thumb
9-27

28. Gliding Joints(arthrodia) 滑动关节
Flat articular surfaces in which bones slide over each other
Limited monoaxial joint
Considered amphiarthroses
9-28

29. Hinge Joints枢纽关节
One bone with convex surface that fits into a concave depression on other bone
ulna and humerus at elbow joint
femur and tibia at knee joint
finger and toe joints
Monoaxial joint
9-29

30. Pivot Joints车轴关节
One bone has a projection that fits into a ringlike ligament of another
First bone rotates on its longitudinal axis relative to the other
atlantoaxial joint寰枢关节
(dens and atlas)
proximal radioulnar
joint allows the
radius during
pronation and supination
9-30

31. Flexion, Extension and Hyperextension
Flexion decreases the angle of a joint
Extension straightens and returns to the anatomical position
Hyperextension = extension beyond 180 degrees过伸
9-31

32. Flexion, Extension and Hyperextension
9-32

33. Abduction and Adduction
Abduction is movement of a part away from the midline 外展
hyperabduction – raise arm over back or front of head
Adduction is movement towards the midline 内收
hyperadduction – crossing fingers
9-33

34. Elevation and Depression
Elevation is a movement that raises a bone vertically垂直
Mandibles(下颌) are elevated during biting and clavicles(锁骨) during a shrug
Depression is lowering the mandible or the shoulders
9-34

35. Protraction and Retraction
Protraction = movement anteriorly on horizontal plane 伸长
thrusting the jaw forward, shoulders or pelvis forward
Retraction is movement posteriorly 收回
9-35

36. Circumduction
Movement in which one end of an appendage remains stationary while the other end makes a circular motion
Sequence of flexion, abduction, extension and adduction movements
baseball player winding up for a pitch
9-36

37. Rotation Movement on longitudinal axis
rotation of trunk, thigh, head or arm
Medial rotation turns the bone inwards
Lateral rotation turns the bone outwards
9-37

38. Supination and Pronation
In the forearm and foot
Supination 旋后
rotation of forearm so that the palm faces forward
inversion and abduction of foot (raising the medial edge of the foot)
Pronation 旋前
rotation of forearm so the palm faces to the rear
Eversion外翻 and abduction外展 of foot (raising the lateral edge of the foot)
9-38

39. Movements of Head and Trunk屈曲 过伸 侧屈
Flexion, hyperextension and lateral flexion of vertebral column
9-39

40. Rotation of Trunk and Head
Rotation of head
Right rotation of trunk
9-40

41. Movements of Mandible下颌骨
Lateral excursion偏移 = sideways movement
Medial excursion = movement back to the midline
side-to-side grinding during chewing
Protraction – retraction缩进 of mandible
9-41

42. Movement of Hand and Digits
Radial and ulnar flexion 桡偏尺偏
Abduction of fingers and thumb 拇外展
Opposition is movement of the thumb to approach or touch the fingertips对指运动
Reposition is movement back to the anatomical position
9-42

43. Movements of the Foot
Dorsiflexion is raising of the toes as when you swing the foot forward to take a step (heel strike) 背屈
Plantarflexion is extension of the foot so that the toes point downward as in standing on tiptoe 跖屈
Inversion is a movement in which the soles are turned medially
Eversion is a turning of the soles to face laterally 外翻
9-43

44. Content
关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生

45. PERICHONDRIUM 软骨膜
Dense irregularly arranged connective tissue (type I collagen)
Ensheaths the cartilage
Houses the blood vessels that nourish滋养 chondrocytes

46. CHONDROBLAST成软骨细胞 Progenitor of chondrocytes
Lines border between perichondrium and matrix
Secretes type II collagen and other ECM components
Chondroblasts build

47. CHONDROCYTE软骨细胞 Mature cartilage cell
Reside in a space called the lacuna
Clear areas = Golgi and lipid droplets

48. CHONDROCYTE软骨细胞 Chondrocytes completely fill their lacunae
RER(粗面内质网) and euchromatic nuclei
Synthetically active, secrete matrix N ?
RER
Cartilage matrix 48

49. MATRIX Provides the rigidity, elasticity, & resilience回复力 FIBERS
Collagenous and elastic
GROUND SUBSTANCE
Glycosaminoglycans粘多糖 (chondroitin sulfates, keratin sulfate, hyaluronic acid)
Proteoglycans蛋白聚糖: GAGs + core protein
Water
Basophilic嗜碱性
Territorial matrix - high [sulfated proteoglycans ]
Territorial matrix surrounds lacuna (space in which chondrocyte lives) 49

50. CARTILAGE GROWTH Appositional Interstitial
Increasing in WIDTH; chondroblasts deposit matrix on surface of pre-existing cartilage
Interstitial
Increasing in LENGTH; chondrocytes divide and secrete new matrix , expanding the cartilage from within (inside out)

51. TYPES OF CARTILAGE
HYALINE透明
ELASTIC弹性
FIBROUS纤维

52. HYALINE CARTILAGE FUNCTION MATRIX LOCATION Support tissue and organs
Model for bone development
MATRIX
Type Ⅱ collagen (thin fibrils)
Chondroitin sulfate, keratin sulfate, hyaluronic acid
Water
LOCATION
Tracheal rings, nasal septum, larynx, articular surfaces of joints
Trachea 52

53. ELASTIC CARTILAGE FUNCTION MATRIX LOCATION STAINS
Support with flexibility
MATRIX
Normal components of hyaline matrix plus ELASTIC fibers
LOCATION
External ear, external auditory canal, epiglottis
STAINS
Elastic fibers stain BLACK with Weigert stain
Ear
perichondrium 53

54. FIBROCARTILAGE
Intervetebral disk – Anulus fibrosus – High compression, shear
Surrounds nucleus proposus
Orcein van Giesen Elastic stain - fibrocartilage - reddish brown
hyaline cartilage - yellow 54

55. FIBROCARTILAGE FUNCTION MATRIX LOCATION
Support with great tensile strength
MATRIX
Type Ⅰ collagen - Oriented parallel to stress plane
LOCATION
Intervertebral disks, pubic symphysis

56. FIBROCARTILAGE Chondrocytes align between collagen fibers
软骨细胞在胶原纤维中成行排列
Collagen fibers lie parallel to lines of stress
胶原纤维与受力方向平行

57. Content
关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生

58. The Humeroscapular Joint肱肩胛关节
Most freely movable joint in the body
shallowness and looseness
deepened by glenoid labrum肩胛盂
Supported by ligaments and tendons
3 glenohumeral盂-肱, coracohumeral喙-肱, transverse humeral and biceps tendon are important joint stabilizer
Supported by rotator cuff 肩袖musculature
tendons fuse to joint capsule and strengthens it
supraspinatus, infraspinatus, teres minor and subscapularis (冈上肌、冈下肌、小圆肌、肩胛下肌)
4 Bursae associated with shoulder joint
9-58

59. Stabilizers of the Shoulder Joint 稳定肩关节的结构
9-59

60. Tendons of Rotator Cuff Muscles 肩袖的肌腱
9-60

61. Shoulder Joint Capsule, Anterior View

62. Dissection of Shoulder Joint
9-62

63. Shoulder Joint Capsule, Posterior View
A. Acromion肩峰
B. Scapular spine肩胛冈
C. Coracohumeral ligament喙肱韧带
D. Supraspinatus muscle冈上肌
(cut away)
E. Infraspinatus muscle (cut away)冈下肌
F. Teres minor muscle (cut away)小圆肌
G. Triceps muscle (cut away)肱三头肌
H. Capsule

64. Shoulder Joint Capsule, Lateral View
A. Acromion process
B. Coracoid process喙突
C. Coracoacromial ligament
D. Coracoclavicular ligament
E. Glenoid labrum盂唇
F. Triceps muscle (cut away)
G. Biceps muscle (cut away)

65. The Elbow Joint
Single joint capsule enclosing the humeroulnar and humeroradial joints肱尺肱桡关节
Humeroulnar joint is supported by collateral ligaments.
Radioulnar joint is head of radius held in place by the anular ligament 环形韧带encircling the head
9-65

66. Elbow Joint
9-66

67. The Coaxal (hip) Joint Head of femur articulates with acetabulum髋臼
Socket deepened by acetabular labrum髋臼唇
Blood supply to head of femur found in ligament of the head of the femur Joint capsule strengthened by ligaments
9-67

68. Hip Joint Joint capsule strengthened by ligaments Pubofemoral耻骨-股骨
Ischiofemoral坐骨-股骨
Iliofemoral髂骨-股骨
9-68

69. Dissection of Hip Joint
9-69

70. The Knee Joint Most complex diarthrosis 最复杂可动关节
patellofemoral = gliding joint(髌骨股骨关节滑动关节)
tibiofemoral = gliding with slight rotation and gliding possible in flexed position一定的选择和充分的屈曲
Joint capsule anteriorly consists of patella and extensions of quadriceps femoris tendon股四头肌肌腱
Capsule strengthened by extracapsular and intracapsular ligaments囊内外韧带
9-70

71. Knee Joint – Sagittal Section矢状面
9-71

72. Knee Joint – Anterior and Posterior Views
Anterior and lateral cruciate ligaments limit anterior and posterior sliding movements前交叉韧带和后交叉韧带限制前后滑动
Medial and lateral collateral ligaments prevent rotation of extended knee侧副韧带限制旋转
9-72

73. Knee Joint – Superior View
Medial and lateral meniscus半月板 absorb shock and shape joint
9-73

74. Dissection of Knee Joint解剖图
9-74

75. Knee Joint Structures
Cruciate Ligaments- within the joint capsule, they cross. They are intracapsular ligaments and named for their attachment on the tibia.十字交叉韧带，命名根据胫骨位置

76. Knee Ligaments膝关节的韧带
Anterior Cruciate Ligament- It attaches to the anterior side of the tibia just medial to the medial meniscus. It attaches to the posterior side of the femur. It prevents anterior translation of the tibia on the femur.前交叉韧带的位置，防止胫骨过度前移
详细可参考7年制或八年制外科学骨科学部分，也可参考实用骨科学

77. Knee Ligaments
Posterior Cruciate Ligament- attaches to the posterior side of the tibia. 胫骨后方 It attaches to the anterior femur and prevents posterior translation of the tibia on the femur.后交叉韧带，防止胫骨向后方的过度移动

78. Knee Ligaments
Medial Collateral Ligament- Attached to the tibia and femur on the medial内侧 side of the knee joint. Also attached to the medial meniscus, so injury to one can result in injury to both.内侧副韧带

79. Knee Ligaments
Lateral Collateral Ligament- attached from the femur to the fibula腓骨 on the lateral side of the knee. Shorter and stronger than the MCL. 外侧副韧带

80. Knee Joint Structures半月板
Meniscus- medial and lateral meniscus are two half moon, wedge shaped fibrocartilage纤维软骨 located on the superior tibia. They provide shock absorption in the knee. Medial is more often torn.

81. Knee Structures
Pes Anserine muscle group- made up of Sartorius, Gracilis and semiTendinosus. (SGT). They come from posterior to medial anterior knee, there is a bursa 滑囊under the insertion.
缝匠肌
半腱肌腱
鹅足滑囊

82. Content
关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生

83. Intervertebral Disc椎间盘
Soft fibro-cartilaginous cushions垫
Between two vertebra椎体
Allows some motion
Serve as shock absorbers
Total – 23 discs
¼ th of the spinal column's length脊柱长度
Avascular 缺乏血管
Nutrients diffuse through end plates养分弥散

84. Intervertebral Disc Functions
Movement of fluid within the nucleus
Allows vertebrae to rock back and forth
Flexibility弹性
Act to pad and maintain the space between the twenty-four movable vertebrae
Act as shock absorbers
Allow extension and flexion 伸展屈曲

85. Intervertebral Disc Anatomy解剖
Spongy center
Nucleus pulposus髓核
Surrounded by a tougher outer fibrous ring
Anulus fibrosus纤维环

86. Anulus Fibrosus纤维环 Strong radial tire–like structure 放射样结构
Series of lamellae薄片
Concentric sheets of collagen fibers
Connected to end plates
Orientated定向 at various angles
Under compression
Become horizontal水平的
Encloses nucleus pulposus髓核

87. Anulus 环 In Bending 弯曲 In Rotation 旋转
Increased tensile force posteriorly 拉力
Increased compressive force anteriorly压力
In Rotation 旋转
Reorientation of collagenous fibers
Tightening of fibers traveling in one direction
Loosening of fibers traveling in opposite direction

88. Nucleus Pulposus髓核 Has more water and PGs蛋白多糖 PG are macro-molecules
Attract and retain water
Hydrophilic gel–like matter 水凝胶样
Resists compression
Amount of water
Activity related
Varies throughout the day

89. LACTIC ACID 乳酸IS THE MAJOR METABOLITE
GLUCOSE
OXYGEN
LACTATE H+ H+
LACTIC ACID 乳酸IS THE MAJOR METABOLITE
PRODUCED BY DISC CELLS

90. Metabolism of Disc cells
椎间盘细胞的代谢
Disc cells require glucose and oxygen to 糖和氧maintain viability生存 and activity
They produce lactic acid as a metabolic product.乳酸
Accumulation of lactic acid is detrimental有害 and can adversely affect viability and activity
乳酸积累是有害可反过来影响细胞的存活和活性

91. Sections through human lumbar discs
椎间盘的两个截面
Cross section
Sagittal section

92. Blood supply to the avascular intervertebral disc
无血管的椎间盘的血供
Thin midsagittal section cut from adjacent upper lumbar vertebral bodies from a young adult filled by arterial injection
包括上下两个椎体的薄层矢状位切片图
adapted from: HV Crock and H Yoshizawa ‘Blood supply of the Vertebral column’

93. Schematic view of nutritional routes
into the intervertebral disc椎间盘营养路径示意图
Vertebral body
endplate
endplate终板
nucleus
Holm et al, 1981
From Holm et al, 1981

94. Details of blood vessels at disc-endplate junction
and of cartilaginous endplate椎间盘与终板连接处血管
bone
disc
blood vessels
From Crock, Goldwasser, Yoshizawa, 1991Roberts et al, 1989

95. Effects of cigarette smoke components on blood supply to disc 吸烟对椎间盘血供影响
Holm and Nachemson, 1988

96. Stress-Strain Curve 应力应变曲线

97. Compressive Strength of Spine 脊柱不同节段压力图

98. Failure Strength of Spinal Ligaments 脊柱各韧带极限承重力

99. Types of motion 脊柱运动的类型

100. Motion Segment 活动节段

101. Theory of weight bearing 脊柱的承重原理
Nucleus pulpous imbibes water吸收水分
Develops internal pressure内部压力的升高
Pressure exerted in all directions各方向向外释放
Lateral forces
Against annulus纤维环
Superiorly and inferiorly directed forces
Against end plates终板
Increases stiffness
Of end plate and annulus fibrosus

102. Theory of weight bearing (cont’d)

103. Disc Pressure And Positions 不同姿势椎间盘压力
Raymond Damadian, MD., President, Fonar Corporation Melville, N.Y., June 12, 2006

105. Herniated Disk 椎间盘突出
Can Occur when there is enough pressure from the vertebrae above and below
This can force some or all of the nucleus pulposus through a weakened or torn part of the annulus fibrosus.
可导致部分或全部的髓核从纤维环薄弱或破损处突出

106. Disc Herniation
The ruptured nucleus will often come incontact with and press on nerves near the disc.突出髓核压迫神经
This can result in severe pain严重疼痛
About 90% of herniated discs occur in the lumbar region. The discs in the cervical region are affected about 8%, those of the thoracic region only about 1-2%大部分发生在腰椎
Herniated disks are one of the most common causes of back pain背部疼痛的原因

107. Disc Herniation 椎间盘突出

108. Content
关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生

109. TJA: Indications 全关节置换适应症

110. Anatomy — Hip 髋的解剖 骨盆 髋臼
股骨头 股骨
股骨颈
大转子

111. THA Implants 全髋置换植入物 臼杯
聚乙烯膜(随时代发展而变化)

112. Technique: Total Hip Replacement 全髋置换术
Femoral head impaction股骨头嵌入
Final implant
最终植入物

113. Anatomy — Knee 膝关节解剖

114. Knee Replacement—Implants 全膝置换植入物
股骨处材料
髌骨处材料
Patellar component
胫骨处材料

115. Knee Replacement—Implants

116. Knee Replacement—Implants
膝关节置换术

117. Causes of TJR Failure 全关节置换术失败原因
Wear of articular bearing surface关节承重面磨穿
Aseptic/mechanical loosening无菌性/机械性松动
Osteolysis骨质疏松
Infection感染
Instability关节不稳
Peri-prosthetic fracture假体周围骨折
Implant Failure植入物毁损

118. Wear of Articular Bearing Surface 关节承重面磨损

119. Aseptic/Mechanical Loosening 无菌性/机械性松动

120. Osteolysis 骨质疏松

121. Infection 感染

122. Dislocation/Instability 脱位/关节不稳

123. Peri-Prosthetic Fracture 假体周围骨折
Sri: PP fracture

124. Implant Failure 假体毁损

125. Take Home Message 知识点： 思考题（面对疾苦和疑难，我们能做些什么？）： 关节的种类、运动、力学模式
滑膜关节的结构组成、主要关节（肩关节、肘关节、髋关节、膝关节）的结构
关节软骨的种类和组织学特点
椎间盘的结构、组织学、力学和代谢特点
思考题（面对疾苦和疑难，我们能做些什么？）：
1） 骨关节炎功能失衡的解剖和组织学机制是什么？如何尽可能预防和恢复？
2）椎间盘突出的解剖和组织学机制是什么？如何尽可能预防和恢复？