1. 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

2. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Types of Synovial Joints Plane joints (Nonaxial)  Articular surfaces essentially flat  Allow only slipping or gliding movements  Only examples of nonaxial joints Figure 8.7a

3. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Types of Synovial Joints Hinge joints (Uniaxial)  Cylindrical projections of one bone fits into a trough-shaped surface on another  Motion is along a single plane  Uniaxial joints permit flexion and extension only  Examples: elbow and interphalangeal joints

4. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Hinge Joints (Uniaxial) Figure 8.7b

5. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Pivot Joints (Uniaxial)  Rounded end of one bone protrudes into a “sleeve,” or ring, composed of bone (and possibly ligaments) of another  Only uniaxial movement allowed  Examples: joint between the axis and the dens, and the proximal radioulnar joint

6. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Pivot Joints (Uniaxial) Figure 8.7c

7. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Condyloid or Ellipsoidal Joints (Biaxial)  Oval articular surface of one bone fits into a complementary depression in another  Both articular surfaces are oval  Biaxial joints permit all angular motions  Examples: radiocarpal (wrist) joints, and metacarpophalangeal (knuckle) joints

8. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Condyloid or Ellipsoidal Joints Figure 8.7d

9. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Saddle Joints  Similar to condyloid joints but allow greater movement  Each articular surface has both a concave and a convex surface  Example: carpometacarpal joint of the thumb

10. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Saddle Joints (Biaxial) Figure 8.7e

11. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Ball-and-Socket Joints (Multiaxial)  A spherical or hemispherical head of one bone articulates with a cuplike socket of another  Multiaxial joints permit the most freely moving synovial joints  Examples: shoulder and hip joints

12. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Ball-and-Socket Joints (Multiaxial) Figure 8.7f

13. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Specific Synovial Joints: Knee  Largest and most complex joint of the body  Allows flexion, extension, and some rotation  Three joints in one surrounded by a single joint cavity  Femoropatellar joint  Lateral and medial tibiofemoral joints

14. (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.

15. 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

16. 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.

17. 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.

18. Figure 8.9 A common knee injury. LateralMedial Patella (outline) Tibial collateral ligament (torn) Medial meniscus (torn) Anterior cruciate ligament (torn) Hockey puck

19. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Specific Synovial Joints: Shoulder (Glenohumeral)  Ball-and-socket joint in which stability is sacrificed to obtain greater freedom of movement  Head of humerus articulates with the glenoid fossa of the scapula

20. 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

21. 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

22. 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

23. 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

24. 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)

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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.

31. Sprains Stretching or tearing of ligaments Partially torn ligaments slowly repair themselves

32. 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

33. Department of Kinesiology and Applied Physiology Inflammatory and Degenerative Conditions Bursitis Tendonitis Arthritis

34. 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

35. 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.

36. Tendonitis Inflammation of tendon and surrounding tissues, typically caused by overuse Symptoms and treatment are similar to bursitis Also spelled tendinitis

37. 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

38. 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?

39. 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

40. 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.

41. Department of Kinesiology and Applied Physiology Gout at right MTP joint. Gouty tophus on right foot

42. Department of Kinesiology and Applied Physiology Skip remaining slides

43. 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.

44. 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

45. 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.

47. Image Challenge Q: What is the diagnosis? 1. Psoriatic arthropathy 2. Reflex sympathetic dystrophy 3. Osteoarthritis 4. Gout 5. Rheumatoid arthritis

48. 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

49. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Developmental Aspects of Joints  By embryonic week 8, synovial joints resemble adult joints  Few problems occur until late middle age  Advancing years take their toll on joints:  Ligaments and tendons shorten and weaken  Intervertebral discs become more likely to herniate  Most people in their 70s have some degree of OA

50. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Developmental Aspects of Joints  Prudent exercise (especially swimming) that coaxes joints through their full range of motion is key to postponing joint problems

51. 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)

52. 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)

53. College or Department name here

54. Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings Temporomandibular Joint (TMJ)  Mandibular condyle articulates with temporal bone  Two types of movement  Hinge – depression and elevation of mandible  Side to side – (lateral excursion) grinding of teeth

55. 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

56. 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