Presentation on theme: "Joints Slides by Vince Austin and W. Rose. figures from Marieb & Hoehn 7 th and 8 th eds., and other sources as noted. Portions copyright Pearson Education."— Presentation transcript:
Joints Slides by Vince Austin and W. Rose. figures from Marieb & Hoehn 7 th and 8 th eds., and other sources as noted. Portions copyright Pearson Education
(a) Sagittal section through the right knee joint Femur Tendon of quadriceps femoris Suprapatellar bursa Patella Subcutaneous prepatellar bursa Synovial cavity Lateral meniscus Posterior cruciate ligament Infrapatellar fat pad Deep infrapatellar bursa Patellar ligament Articular capsule Lateral meniscus Anterior cruciate ligament Tibia Figure 8.8a The knee joint.
Figure 8.8c The knee joint. Quadriceps femoris muscle Tendon of quadriceps femoris muscle Patella Lateral patellar retinaculum Medial patellar retinaculum Tibial collateral ligament Tibia Fibular collateral ligament Fibula (c) Anterior view of right knee Patellar ligament
Fibular collateral ligament Posterior cruciate ligament Medial condyle Tibial collateral ligament Anterior cruciate ligament Medial meniscus Patellar ligament Patella Quadriceps tendon Lateral condyle of femur Lateral meniscus Fibula Tibia (e) Anterior view of flexed knee, showing the cruciate ligaments (articular capsule removed, and quadriceps tendon cut and reflected distally) Figure 8.8e The knee joint.
Department of Kinesiology and Applied Physiology Primary Knee Ligaments LigamentTibial Motion Limited Tibial or Med. Collat. (MCL) Valgus rotation (medial gapping) Lateral rotation Fibular or Lat. Collat. (LCL) Varus rotation (lateral gapping) Lateral rotation Anterior Cruciate (ACL) Anterior translation Medial rotation Posterior Cruciate (PCL) Posterior translation Medial rotation Magee, 4 th ed., 2002.
Figure 8.9 A common knee injury. LateralMedial Patella (outline) Tibial collateral ligament (torn) Medial meniscus (torn) Anterior cruciate ligament (torn) Hockey puck
Figure 8.10a The shoulder joint. Acromion of scapula Synovial membrane Fibrous capsule Hyaline cartilage Coracoacromial ligament Subacromial bursa Fibrous articular capsule Tendon sheath Tendon of long head of biceps brachii muscle Synovial cavity of the glenoid cavity containing synovial fluid Humerus (a) Frontal section through right shoulder joint
Figure 8.10c The shoulder joint. Acromion Coracoacromial ligament Subacromial bursa Coracohumeral ligament Greater tubercle of humerus Transverse humeral ligament Tendon sheath Tendon of long head of biceps brachii muscle Articular capsule reinforced by glenohumeral ligaments Subscapular bursa Tendon of the subscapularis muscle Scapula Coracoid process (c) Anterior view of right shoulder joint capsule
Figure 8.10d The shoulder joint. Acromion Coracoid process Articular capsule Glenoid cavity Glenoid labrum Tendon of long head of biceps brachii muscle Glenohumeral ligaments Tendon of the subscapularis muscle Scapula PosteriorAnterior (d) Lateral view of socket of right shoulder joint, humerus removed
Elbow Joint Radius and ulna articulate with humerus in a hinge joint – flexion and extension Radius & ulna articulate with each other, and radius articulates with humerus, in a pivot joint: radius pivots about its long axis to allow pronation & supination
Figure 8.11a The elbow joint. Articular capsule Synovial membrane Synovial cavity Articular cartilage Coronoid process Tendon of brachialis muscle Ulna Humerus Fat pad Tendon of triceps muscle Bursa Trochlea Articular cartilage (a) Median sagittal section through right elbow (lateral view)
Figure 8.11b The elbow joint. Humerus Lateral epicondyle Articular capsule Radial collateral ligament Olecranon process Anular ligament Radius Ulna (b) Lateral view of right elbow joint
Figure 8.11d The elbow joint. Articular capsule Anular ligament Coronoid process (d) Medial view of right elbow Radius Humerus Medial epicondyle Ulnar collateral ligament Ulna
Department of Kinesiology and Applied Physiology “Tommy John surgery” Reconstruct torn or overstretched ulnar (medial) collateral ligament UCL highly stressed in throwing, esp late cocking/early accel. Restore elbow medial stability (resistance to valgus stress) Use autograft tendon (palmaris longus, gracilis, toe extensor,…) Humerus Radius Ulna Right elbow, medial aspect http://www.eorthopod.com/public/patient_education/9633/ulnar_ collateral_ligament_reconstruction_tommy_john_surgery.html
Hip (Coxal) Joint Ball-and-socket joint Head of femur articulates with acetabulum Good range of motion (less than shoulder), limited by deep socket, acetabular labrum, strong ligaments
Figure 8.12a The hip joint. Articular cartilage Coxal (hip) bone Ligament of the head of the femur (ligamentum teres) Synovial cavity Articular capsule Acetabular labrum Femur (a) Frontal section through the right hip joint
Ankle Joint Dorsi/plantarflex mainly at talocrural joint: tib, fib, talus Invert/evert mainly at subtalar joint: talus, calcaneus Ankle sprain – most common joint injury Low ankle sprain: tear of ligaments “below the ankle” Inversion sprain – more common – damage to lateral ligaments (ant. & post. talofibular, calcaneofibular) Eversion – damage to medial (deltoid) ligament High ankle sprain: tear of ligaments “above the ankle” Tear of syndesmotic ligaments of distal tibiofibular joint (tibiofibular joints are syndesmotic, a subset of fibrous, and amphiarthrotic, i,.e. slightly movable.) High ankle sprain generally takes longer to heal.
Sprains Stretching or tearing of ligaments Partially torn ligaments slowly repair themselves
Dislocations Occur when bones are forced out of alignment Usually accompanied by sprains, inflammation, and joint immobilization Causes: serious falls, sports, motor vehicle accidents, etc. Subluxation – partial dislocation of a joint
Department of Kinesiology and Applied Physiology Inflammatory and Degenerative Conditions Bursitis Tendonitis Arthritis
Bursitis An inflammation of a bursa, usually caused by a blow or friction Symptoms are pain and swelling Treated with anti-inflammatory drugs, local glucocorticoid injection; excessive fluid may be aspirated
Department of Kinesiology and Applied Physiology Olecranon bursa. A case of olecranon bursitis in a patient with rheumatoid arthritis. A rheumatoid nodule is also shown. Infected olecranon bursitis.
Tendonitis Inflammation of tendon and surrounding tissues, typically caused by overuse Symptoms and treatment are similar to bursitis Also spelled tendinitis
Arthritis Joint inflammation Many different types; most widespread crippling disease in U.S. Symptoms: pain, stiffness, swelling of joint Acute forms are caused by bacteria and are treated with antibiotics Chronic forms include Osteoarthritis (OA) Rheumatoid arthritis (RA) Gouty arthritis
Department of Kinesiology and Applied Physiology Osteoarthritis (OA) Loss/damage to articular cartilage → hardening, cyst formation in underlying bone, osteophyte (bone spur) formation → osteophyte break-off → synovitis (inflammation of synovial membrane), joint capsule thickening. Risk factors: old age, joint trauma, obesity, diabetic neuropathy, skeletal deformities, etc. Most people >70 y.o. have some degree of OA. Symptoms: pain, stiffness, loss of range of motion. Treatment: rest, PT, weight loss, surgery (total knee, total hip), glucosamine?, hyaluronic acid?
Department of Kinesiology and Applied Physiology Rheumatoid arthritis (RA): Inflammatory joint disease Autoimmune disease: genetically susceptible person is triggered, by unknown agent, to attack his/her own synovium. T-cells do the damage ; cartilage gets replaced with pannus (scar tissue); synovium gets thick & swollen. RANKL is produced and stimulates osteoclasts which destroy bone. Hand joints often affected first. Pain & loss of range of motion → muscle atrophy, wasted appearance, further joint destabilization. Drug treatment: improving a lot but very expensive
Department of Kinesiology and Applied Physiology Gouty Arthritis (Gout): Inflammatory joint disease Inflammatory response to high levels of uric acid in blood (hyperuricemia), synovial fluid. Meat, fat, beer in diet increases risk. 10:1 male:female. Urate crystals in synovial space -> gouty arthritis. Subcutaneous urate crystals cause tophi. Painful acute attacks may be triggered by uric acid level exceeding a critical value, trauma, etc.
Department of Kinesiology and Applied Physiology Gout at right MTP joint. Gouty tophus on right foot
Department of Kinesiology and Applied Physiology Skip remaining slides
Department of Kinesiology and Applied Physiology A, Cartilage and degeneration of the hip joint resulting from osteoarthritis. B, Heberden nodes and Bouchard nodes. C, Characteristics of OA. Normal versus osteoarthritic synovial joint.
Department of Kinesiology and Applied Physiology Rheumatoid arthritis treatment Goal of therapy now is to cure Rest of body or joint; ice, heat, PT NSAIDs (aspirin, ibuprofen, naproxen) to reduce inflammation & pain; acetominophen for pain Prednisone (steroidal anti-inflammatory): dramatic short term effects, but long term risk of weight gain, osteoporosis, glaucoma, diabetes, etc. Disease-modifying anti-rheumatic drugs (DMARDs) Methotrexate: old, many side FX; inexpensive “Biologics”: TNF- blockers, fewer side FX, much more $ Surgery: Remove synovial membranes; joint replacement
Department of Kinesiology and Applied Physiology Ankylosing Spondylitis: A chronic inflammatory joint disease Enthesis (point of ligament/tendon/joint capsule attachment to bone) is attacked, usually in vertebral column. Inflammation of fibrocartilage in intervertebral joints. Stiffening & fusion (ankylosis) of vertebral column, sacroiliac joints. Primary AS: low back pain in early 20s. Secondary AS: older age, assoc with other inflammatory diseases, e.g. inflammatory bowel disease. Treat: NSAIDs for symptoms; TNF- antagonists infliximab (Remicade*), etanercept (Enbrel*), etc.
Image Challenge Q: What is the diagnosis? 1. Psoriatic arthropathy 2. Reflex sympathetic dystrophy 3. Osteoarthritis 4. Gout 5. Rheumatoid arthritis
Image Challenge Q: What is the diagnosis? Answer: 3. Osteoarthritis Examination of this patient's right hand reveals typical changes of osteoarthritis, with both Heberden's (→) and Bouchard's (→) nodes in association with irregular deformities. Read More: N Engl J Med 2002;346:e3
Department of Kinesiology and Applied Physiology ACL Injury ACL protects against anterior translation of tibia relative to femur, knee hyperextension Lachman test (knee flexed 20-30°, + if soft end feel) Anterior drawer test (knee flexed 90°, + if >6mm anterior mvmt)
Department of Kinesiology and Applied Physiology Lachman test: positive if no solid stop, i.e. if end point is soft Spindler KP, Wright RW (2008). NEJM 359:2135-2142. (2008-11-13)
Figure 8.13a The temporomandibular (jaw) joint. Zygomatic process Mandibular fossa Articular tubercle Infratemporal fossa External acoustic meatus Articular capsule Ramus of mandible Lateral ligament (a) Location of the joint in the skull
Figure 8.13b The temporomandibular (jaw) joint. Articular capsule Mandibular fossa Articular disc Articular tubercle Superior joint cavity Inferior joint cavity Mandibular condyle Ramus of mandible Synovial membranes (b) Enlargement of a sagittal section through the joint