Transcript chapter 8b

Joints
Slides by Vince Austin and W. Rose.
figures from Marieb & Hoehn 7th and 8th eds.,
and other sources as noted.
Portions copyright Pearson Education
Types of Synovial Joints
Plane joints
(Nonaxial)

Articular surfaces
essentially flat

Allow only slipping
or gliding
movements

Only examples of
nonaxial joints
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Figure 8.7a
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
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Hinge Joints (Uniaxial)
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Figure 8.7b
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
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Pivot Joints (Uniaxial)
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Figure 8.7c
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
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Condyloid or Ellipsoidal Joints
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Figure 8.7d
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
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Saddle Joints (Biaxial)
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Figure 8.7e
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
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Ball-and-Socket Joints (Multiaxial)
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Figure 8.7f
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
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Figure 8.8a The knee joint.
Femur
Articular
capsule
Posterior
cruciate
ligament
Lateral
meniscus
Anterior
cruciate
ligament
Tibia
Tendon of
quadriceps
femoris
Suprapatellar
bursa
Patella
Subcutaneous
prepatellar bursa
Synovial cavity
Lateral meniscus
Infrapatellar
fat pad
Deep infrapatellar
bursa
Patellar ligament
(a) Sagittal section through the right 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
Fibular
collateral
ligament
Patellar ligament
Fibula
Tibia
(c) Anterior view of right knee
Figure 8.8e The knee joint.
Fibular
collateral
ligament
Posterior cruciate
ligament
Medial condyle
Lateral condyle
of femur
Tibial collateral
ligament
Lateral
meniscus
Anterior cruciate
ligament
Tibia
Medial meniscus
Patellar ligament
Fibula
Patella
Quadriceps tendon
(e) Anterior view of flexed knee, showing the cruciate
ligaments (articular capsule removed, and quadriceps
tendon cut and reflected distally)
Primary Knee Ligaments
Ligament
Tibial Motion Limited
Tibial or Med. Collat. Valgus rotation (medial gapping)
(MCL)
Lateral rotation
Fibular or Lat. Collat. Varus rotation (lateral gapping)
(LCL)
Lateral rotation
Anterior Cruciate
(ACL)
Anterior translation
Medial rotation
Posterior Cruciate
(PCL)
Posterior translation
Medial rotation
Magee, 4th ed., 2002.
Department of Kinesiology and Applied Physiology
Figure 8.9 A common knee injury.
Lateral
Hockey puck
Medial
Patella
(outline)
Tibial collateral
ligament
(torn)
Medial
meniscus (torn)
Anterior
cruciate
ligament (torn)
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
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Figure 8.10a The shoulder joint.
Acromion
of scapula
Coracoacromial
ligament
Subacromial
bursa
Fibrous
articular capsule
Tendon
sheath
Synovial cavity
of the glenoid
cavity containing
synovial fluid
Hyaline
cartilage
Synovial membrane
Fibrous capsule
Tendon of
long head
of biceps
brachii muscle
(a) Frontal section through right shoulder joint
Humerus
Figure 8.10c The shoulder joint.
Acromion
Coracoacromial
ligament
Subacromial
bursa
Coracohumeral
ligament
Coracoid
process
Greater
tubercle
of humerus
Subscapular
bursa
Transverse
humeral
ligament
Tendon sheath
Tendon of long
head of biceps
brachii muscle
Articular
capsule
reinforced by
glenohumeral
ligaments
Tendon of the
subscapularis
muscle
Scapula
(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
Posterior
Anterior
(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
Humerus
Synovial cavity
Articular cartilage
Fat pad
Tendon of
triceps
muscle
Bursa
Coronoid process
Tendon of
brachialis muscle
Ulna
Trochlea
Articular cartilage
(a) Median sagittal section through right elbow (lateral view)
Figure 8.11b The elbow joint.
Humerus
Anular
ligament
Radius
Lateral
epicondyle
Articular
capsule
Radial
collateral
ligament
Olecranon
process
(b) Lateral view of right elbow joint
Ulna
Figure 8.11d The elbow joint.
Articular
capsule
Anular
ligament
Humerus
Coronoid
process
Medial
epicondyle
Radius
Ulnar
collateral
ligament
Ulna
(d) Medial view of right elbow
“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)
Humerus
Radius
Ulna
Use autograft tendon (palmaris
longus, gracilis, toe extensor,…)
Right elbow, medial aspect
http://www.eorthopod.com/public/patient_education/9633/ulnar_
collateral_ligament_reconstruction_tommy_john_surgery.html
Department of Kinesiology and Applied Physiology
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.
Coxal (hip) bone
Articular cartilage
Acetabular
labrum
Femur
Ligament of
the head of
the femur
(ligamentum
teres)
Synovial cavity
Articular capsule
(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
Inflammatory and
Degenerative Conditions
• Bursitis
• Tendonitis
• Arthritis
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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
Olecranon bursa. A case of olecranon bursitis in
a patient with rheumatoid arthritis. A
rheumatoid nodule is also shown.
Infected olecranon bursitis.
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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
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?
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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
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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.
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Gouty tophus on right foot
Gout at right MTP joint.
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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-a 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-a antagonists infliximab
(Remicade*), etanercept (Enbrel*), etc.
Department of Kinesiology and Applied Physiology
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
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
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Developmental Aspects of Joints

Prudent exercise (especially swimming) that
coaxes joints through their full range of motion is
key to postponing joint problems
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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
Spindler KP, Wright RW (2008). NEJM 359:2135-2142. (2008-11-13)
Lachman test: positive if no solid stop, i.e. if end point is soft
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College or Department name here
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
Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings
Figure 8.13a The temporomandibular (jaw) joint.
Mandibular fossa
Articular tubercle
Zygomatic process
Infratemporal fossa
External
acoustic
meatus
Lateral
ligament
Articular
capsule
Ramus of
mandible
(a) Location of the joint in the skull
Figure 8.13b The temporomandibular (jaw) joint.
Mandibular
fossa
Articular disc
Articular
tubercle
Superior
joint
cavity
Articular
capsule
Synovial
membranes
Mandibular
condyle
Ramus of
Inferior joint
mandible
cavity
(b) Enlargement of a sagittal section through the joint