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肌肉骨骼系统 关节 & 软骨. Content  关节种类  软骨种类  主要四肢关节  椎间盘  关节置换 & 再生.

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Presentation on theme: "肌肉骨骼系统 关节 & 软骨. Content  关节种类  软骨种类  主要四肢关节  椎间盘  关节置换 & 再生."— Presentation transcript:

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 9-3 Joints  Joints and their classification  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

4 9-4 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

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 9-6 Fibrous Joints (Synarthrosis)  Collagen fibers span the space between bones  Sutures  gomphoses 钉状关节  Syndesm oses 韧带联合

7 9-7  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 Fibrous Joint -- Sutures

8 9-8 Types of Sutures

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

11 9-11 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 )

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

14 9-14 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

15 9-15 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

16 9-16 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

17 9-17 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

18 9-18 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)

19 9-19 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

20 9-20 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

21 9-21 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

22 9-22 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

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

24 9-24 Types of Synovial Joints

25 9-25 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

26 9-26 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

27 9-27 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

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

29 9-29 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

30 9-30 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

31 9-31 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

32 9-32 Flexion, Extension and Hyperextension

33 9-33 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

34 9-34 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

35 9-35 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

36 9-36 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

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

38 9-38 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)

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

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

41 9-41 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

42 9-42 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

43 9-43 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

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

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 ]

50 CARTILAGE GROWTH  Appositional  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  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

53 ELASTIC CARTILAGE  FUNCTION  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 perichondrium

54 FIBROCARTILAGE Orcein van Giesen Elastic stain - fibrocartilage - reddish brown hyaline cartilage - yellow

55 FIBROCARTILAGE  FUNCTION  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 9-58 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

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

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

61 Shoulder Joint Capsule, Anterior View

62 9-62 Dissection of Shoulder Joint

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 9-65 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

66 9-66 Elbow Joint

67 9-67 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

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

69 9-69 Dissection of Hip Joint

70 9-70 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

71 9-71 Knee Joint – Sagittal Section 矢状面

72 9-72 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

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

74 9-74 Dissection of Knee Joint 解剖图

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

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  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 PRODUCED BY DISC CELLS H+ LACTATE H+H+ GLUCOSE OXYGEN

90  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 Metabolism of Disc cells 椎间盘细胞的代谢

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

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

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

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

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

104

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  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 Disc Herniation

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 股骨 股骨颈 骨盆 股骨头 髋臼 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 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 Patellar component 髌骨处材料 股骨处材料 胫骨处材料

115 Knee Replacement—Implants

116 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:  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?


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