ANATOMY I

BONES & JOINTS

2019 - 2020

10. INTRODUCTION TO THE BONES AND JOINTS ................................................................................... 2

11. OSTEOLOGY OF THE SPINE. THE ATLAS AND AXIS ......................................................................... 6
12. LIGAMENTS OF THE SPINE AND THE INTERVERTEBRAL DISC. THE THORACIC CAGE....... 9
13. THE SHOULDER GIRDLE .................................................................................................................... 14
14. THE ELBOW JOINT .............................................................................................................................. 18
15. JOINTS AND LIGAMENTS OF THE WRIST ......................................................................................... 21
15. JOINTS AND LIGAMENTS OF THE HAND .......................................................................................... 23
16. THE PELVIS. THE HIP JOINT............................................................................................................... 24
17. THE KNEE JOINT.................................................................................................................................. 31
18. TIBIOPERONEAL JOINTS .................................................................................................................... 35
18. THE ANKLE JOINT................................................................................................................................ 36
19. JOINTS AND LIGAMENTS OF THE FOOT........................................................................................... 39

Come to the lecture having thoroughly read and understood these notes,
with the complementary detailed reading of the textbook and atlas of anatomy.

BIBLIOGRAPHY
- Cunningham’s textbook of anatomy. GJ Romanes ed. 1981
- Gray’s anatomy. S Standring ed. 2015
- Human anatomy pocket atlas. Feneis. W Dauber, 5ª ed

For any comment on these notes, please write to [email protected]

10. INTRODUCTION TO THE BONES AND JOINTS
Axial skeleton: skull, vertebral column, ribs, sternum
Appendicular skeleton: bones of the upper and lower limbs

BONE
Concept
- Structure: composition (organic & inorganic). Mainly mineral (hydroxyapatite)
- Living tissue:
- Development growth, definitive shape.
- Metabolism. Cells: osteoblasts, osteoclasts, osteocytes.
Functions
- Supportive structures of the body
- Protects organs
- Dynamic: insertion of muscles, levers on which muscles act
- Movement
- Reservoir of calcium and phosphorus
- Hematopoietic
- Special: hearing, chewing
Internal conformation
- Compact
- Spongy (= trabecular, cancellous)
Marrow
- Red marrow formation of red and white blood cells
- Yellow marrow fat
External conformation
- Shape:
- Long femur, tibia…
- Short carpal, tarsal bones, sesamoids
- Irregular vertebrae, skull bones
- Pneumatic paranasal sinuses, mastoid cells
- Plane scapula
- Regions or descriptive elements: faces, borders, ends
- Morphologic elements:

Surfaces
- Base
- Head
- Facet: smooth, flat, for articulation
Prominences
- Border
- Condyle: rounded articular area
- Epicondyle: eminence superior to a condyle
- Crest: ridge of bone
- Line: linear elevation
- Malleolus: rounded process
- Protuberance: projection of bone
- Spine: thorn like process
- Spinous process: projecting spine like part
- Trochanter: large blunt elevation
- Tubercle: small raised eminence
- Tuberosity: large rounded elevation
Cavities
- Foramen: passage through a bone
- Fossa: hollow or depressed area
- Groove: elongated depression
- Notch: indentation at edge of a bone
- Hiatus: natural fissure in a structure

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Surface:
- Fresh: cartilage, perichondrium, periosteum. ligaments, tendons, aponeurosis, intermuscular septa
- Dry: smooth (cartilage) / slightly coarse (periosteum, vessels) / coarse (insertions)

- Periostium, 2 layers: osteogenic (deep), fibrous (superficial)

Covered by cartilage in the synovial joints, by periosteum in the remaining surface

Vascularization (nutrient artery)

Innervation

Embriogenic origin: mesenchyme

- Intramembranous ossification:
- Chondral ossification: (ossification of a chondral mould) endochondral / perichondral
-
Centres of ossification
- Primary centres
- Secondary centres

Long bones: Epiphysis, physis, metaphysis, diaphysis, apophysis

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CARTILAGE
Composition
- Water 70%
- Extracellular matrix: Collagen, proteoglycans, Glycoproteins
- Cells: chondrocytes
Main function:
- provide gliding surface to the bones (joints)
- growth of bones (physis)
Types of cartilage
- Hyaline: articular surfaces
- Elastic: external ear
- Fibrocartilage meniscus, intervertebral discs, labrum (glenohumeral, coxofemoral), pubic symphysis

Avascular
JOINTS
Types
- Solid: no cavity, components held together by connective tissue
- Synovial: elements separated by a cavity

SOLID JOINTS (synartrosis)

Bone (synostosis) sacrum
BoneBone
Fibrous (synfibrosis):
- Sutures skull periosteum & fibrous tissue (sutural lig) [plane, serrate, squamous,
schindylesis]
- Gomphosis teeth peg into socket, fibrous suture
- Syndesmosis distal tibiofibular dense fibrous suture

Cartilaginous:
- Synchondrosis epiphysial cartilage, sternocostal
- Amphiartrosis pubis, IV lamina of hyaline cartilage + fibrocartilage = symphysis

SYNOVIAL JOINTS (diartrosis)

CLASSIFICATION

Shape of articular surface

- Flat (plana, artrodia) one plane axis gliding carpo-metacarpal joint
- hinge (ginglymus, trochlea) one transverse axis flexion-extension interphalangeal joint
- pivot (trochoidea) one vertical axis rotation radioulnar, atlas-dens
- condylar (condyloid) 2 axis, no rotation in vertical axis metacarpophalangeal
- Bicondylear two axis (transverse, long) F-E, rotation knee, occipital-atlas
- saddle (sellaris) Two axis Trapezium-metacarpal joint
- ball and socket (spheroidea) multiaxial (enarthrosis) shoulder, hip

Movement:
- uniaxial
- biaxial
- multiaxial

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COMPONENTS
- Articular cartilage, hyaline
- Synovial membrane (highly vascular, synovial fluid)
- Fibrous capsule (fibrous membrane) (ligaments). Provide joint stability
- Bursae
- Fat pads
- Tendons
- Articular discs: meniscus (fibrocartilage) pubis, knee, ACJ, ECJ

MOVEMENTS
Abduction (away from the median plane) Adduction
Flexion (bending) Extension
Supination (palm goes anterior) Pronation
Rotation (around an axis) external / internal
Opposition Reposition
Circumduction (circumferential)

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11. OSTEOLOGY OF THE SPINE. THE ATLAS AND AXIS
Curves of the spine: lordosis, kyphosis
Thoracic due the shape of the vertebrae, Cervical and lumbar due to the shape of the discs
Vertebrae: 7 Cervical + 12 thoracic + 5 lumbar + 5 sacral + 4/5 coccygeal

TYPICAL VERTEBRA
Body:
- intervertebral surface: placa terminalis
- fovea vascularis: perforations in the surface for embryonic vessels
- epiphyseal ring
- venous plexus under the placa terminalis
- Basivertebral foramen in posterior surface
Arch: pedicles, lamina.
Vertebral foramen
Spinous process (processus spinosus)
Transverse process
Articular process (with its articular facet, facies articularis)
- Superior: posterior orientation
- Inferior: anterior orientation
Superior and inferior vertebral notch (incisura vertebralis sup / inf) à intervertebral foramina

Intervertebral foramina
Radicular nerves
Limits
- Superior: pedicle of upper vertebra
- Inferior: pedicle of lower vertebra
- Anterior: intervertebral disc
- Posterior: zygapophysial joint

CERVICAL
Small
Vertebral body:
- Short in height, square shaped
- Concave superiorly, convex inferiorly
- Uncinate process, articulates with the superior vertebral body (synovial)
- Inferior surface, bevelled off anteriorly
Vertebral foramen, triangular

Transverse process
- Foramen transversarium: vertebral artery
- Anterior tubercle (rib element)
- Costotransverse lamella (sulcus nervi spinalis)
- Posterior tubercle
Spinous process, bifid
1st (atlas) and 2nd (axis) have specialized morphology (see later)

Special features of C6
- Anterior tubercle of transverse process, large (carotid tubercle). Carotid artery just anterior

Special features of C7
- No foramen transversarium, may be small foramen for vein (not artery)
- Transverse process
- Anterior tubercle, small / absent
- Posterior tubercle, large
- Spine: non bifid, large: prominent

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THORACIC
Articulated ribs (incorporated to the transverse process in the rest of the non-thoracic spine)
Vertebral body: two hemifacets: superior and inferior
Vertebral foramen: rounded, smaller
Spinous process, long, caudal direction, three sided, sloping
Vertebral foramen round (spinal cord)
Laminae, broad, overlapping (superior over the inferior)
Pedicle: joints with the body superiorly: deep inferior notch
Superior articular process flat, facing posteriorly
Inferior articular process, faces anteriorly, projects from the laminae
Transverse process, club, posterolateral direction, costal facet (articulation with tubercle of the rib)

Articulation with ribs, double

- Hemifacets of the vertebral body. The superior costal facet articulates with the head of its own rib
- Transverse costal facet of the transverse process

T1, T10 (T11) articulate completely with their own rib

T1 has uncinate process
T4 irregularity due to aortic artery
T11, T12 articulate only with the head of the rib (no transverse costal facet): floating ribs
T11 facet for head of the rib is superior
T12 facet for head of the rib on the pedicle. Inferior articular processes have lumbar features.

LUMBAR
Body: large (size increases from L1 to L5)
Laminae: separated
No facets for articulation with ribs (incorporated in the transverse process)
Transverse processes thin and long. Except L5 (iliolumbar ligaments). It is the rib element incorporated: costiform
process.
Accessory process (true transverse process)
Mammillary process in the superior articular process

SACRAL
Fused into the sacrum
Triangular,
- base: promontorium
- apex inferior
Vertebral foramen: sacral canal
Vertebral arch: missing in S5 (S4): sacral hiatus (sacral cornu)

Anterior surface: concave Posterior surface convex, medial to Lateral surface:

- 4 pairs of anterior sacral foramina lateral: - auricular surface (for ilium)
- Median sacral crest (spinous tubercle)
- Intermediate crest
- Posterior sacral foramina (4)
- Lateral crest
- Depression interosseous sacro-iliac lig.
Articulates with
- Laterally: pelvic bone (ilium)
- Inferiorly: coccyx
- Superiorly: L5

COCCYGEAL
3 – 4 vertebrae, fused
Coccygeal cornu

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ATLAS AND AXIS

ATLAS
Lacks vertebral body (fuses with C2 to form the dens of C2) = no intervertebral disc C1-C2
Lateral masses connected by the anterior and posterior arch
- Tubercle for transverse ligament
Anterior arch
- Facet for dens (facies articularis dentis)
- Anterior tubercle
Lateral mass articulates
- above: condyle of occipital. Superior articular surface bean shaped, concave, antero-medial direction.
- below: with the superior articular process of C2. Inferior articular surface circular and flat (artrodia): rotation
Posterior arch
- Groove for vertebral artery (sulcus vertebralis)
- Posterior tubercle

AXIS
Vertebral body: dens.
Dens:
- Anterior articular facet for articulation with the anterior arch of C1 (facies articularis anterior dentis)
- Posterior articular facet for articulation with the transverse lig. of the axis. (facies articularis posterior dentis)
- Circular supero-lateral surfaces for insertion of the alar ligaments (from occipital condyles to dens)

Transverse ligament of the atlas: holds the dens in position

ATLANTO OCCIPITAL JOINTS

Bicondylear, axis converge anteriorly
Synovial
Ellipsoid
Components: occipital condyles + superior articular facets of the atlas
Anterior atlanto-occipital membrane
Posterior atlanto-occipital membrane
Movements: flexion - extension

ATLANTO-AXIAL JOINTS
Lateral atlanto-axial joint
Synovial
Plane shape (arthrodia)
Accessory atlanto-axial ligament
Median atlanto-axial joint
Pivot joint: trochoid
Two synovial cavities:
- Dens & Atlas
- Dens & transverse ligament
Transverse ligament (1): passes behind the dens spanning tubercles on medial sides of the lateral masses
of the Atlas.
- upward expansion (2) to anterior edge of foramen magnum
- downward expansion (3) to back of the body of the axis
1 + 2 + 3 = cruciform ligament of the atlas
Alar ligament: from each side of the apex of the dens to medial side of each occipital condyle.

Movement: rotation: combines rotation of the atlas centred on the dens and sliding of the plane lateral atlanto-
axial joints.

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12. LIGAMENTS OF THE SPINE AND THE INTERVERTEBRAL DISC.
THE THORACIC CAGE

JOINTS BETWEEN VERTEBRAE

Two types of joints:

SYMPHYSIS
= intervertebral disc
Inserts to vertebral body by a thin plate of hyaline cartilage (vertebral end plate).
In the aged it is calcified cartilage and bone.
The epiphyseal ring develops in the margin of this cartilage plate
Function: unite vertebrae, load transmission

Height
- increases from cephalic to caudal
- height relative to the body’s width is maximal in the cervical vertebrae (more mobility)

Annulus fibrosus (ring)

- Concentric layers of fibres
- Internal are vertical, intermediate are oblique, and external horizontal
- Outer (fibrous lamellae). Inner layers are fibrocartilage
- External layers may have vessels
- Interestriation angle between fibres, varies depending on compression
- Function: compresses one vertebra against the other
Nucleus pulposus
- central
- Collagen II, few cells. Extracellular matrix 80% water
- hydration and metabolic exchange through the fovea vascularis of the terminal plate and vessels in the annulus.
- no arteries or nerves

Composition
- 80% water (decreases with age)
- Neutral mucopolysaccharids
- Acid mucopolysaccharids
- Non collagenous proteins

Physical properties (functions as a liquid):

- Liquids are incompressible: resists the compressive effect of the annulus fibrosus and weight
- Liquids transmit pressure equally in all directions
- Liquids are maximally deformable: distributes loads deforming according to the load

SYNOVIAL JOINTS (Zygapophysial joints)

Articular capsule, thin and rigid. No specific ligaments
Orientation of articular line: Cervical oblique, Lumbar vertical
Innervated

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LIGAMENTS
ANTERIOR LONGITUDINAL LIGAMENT (Ligamentum longitudinale anterius)
Runs over the anterior surfaces of the vertebral bodies.
Widens from cranial to caudal

POSTERIOR LONGITUDINAL LIGAMENT (Ligamentum longitudinale posterius)

On the back of the vertebral bodies (anterior wall of the vertebral canal)
Attached to the discs and epiphyseal plate. Separated from middle portion of vertebral body (basivertebral veins)
Proximally continues at C1 & C2 with the Tectorial membrane, to the occipital bone
Distally finishes in the posterior sacrococcygeal ligament

LIGAMENTA FLAVA
Span the spaces between the laminae of adjacent vertebrae.
The only elastic ligament in the body

SUPRASPINOUS LIGAMENT
C7 - Sacrum
Ligamentum nuchae (C7 - External occipital protuberance)

INTERSPINOUS LIGAMENTS

INTERTRANSVERSE LIGAMENTS

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THORACIC CAGE

RIBS
12 ribs
All articulate with the vertebral column
Anteriorly
- 1 to 7 articulate with the sternum through the costal cartilage (synchondrosis)
- 8 to 10 articulate with the costal cartilages of the ribs above: false ribs
- 11 and 12 no anterior connection: floating ribs

Shape: curved

Posterior end articulates with the vertebral column

- Head
- Neck. Tubercle: Articular part / Non articular part

Angle

Shaft: thin, external and internal surfaces

- Superior margin rounded
- Interior margin sharp. Costal groove

Anterior end articulates with the sternum

RIB 1 Flat in horizontal plane: superior and inferior surfaces

Head only one articular surface: for T1
Scalene tubercle, in the superior surface
- Anterior groove: subclavian vein
- Posterior groove: subclavian artery

RIB 10 Head, single articular facet for T10

RIB 11 Head, single articular facet for T11

Short
No articulation with transverse process

RIB 12 No articulation with transverse process

STERNUM
Manubrium + body + xiphoid process

MANUBRIUM
Superior surface: jugular (suprasternal) notch
Clavicular notch: articular surface for clavicle.
Projection for articulation with 1st rib
Lateral border, hemifacet at the lower end (articulation with 2nd costal cartilage)

BODY
Anterior surface: transverse ridges (fusion of sternebrae)
Lateral margin: articular facets for costal cartilages (incisurae costales):
- 1 hemifacet
- 4 complete
- 1 hemi

XIPHOID PROCESS
Variable shape
1 hemifacet

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COSTOVERTEBRAL JOINTS
A typical rib articulates with
1. Bodies of adjacent vertebrae: joint with the head of the rib
2. Transverse process of its related vertebra: costotransverse joint
The ribs rotate around the longitudinal axes

JOINT WITH THE HEAD OF THE RIB

The two facets of the head of the rib articulate with
- Superior facet on the body of its own vertebra
- Inferior facet on the body of the vertebra above
Ligamentum capitis costae radiatum. Fascicles (3): superior body, intervertebral disc, inferior body
Two synovial compartments (intraarticular ligament: from the crest of the head to the intervertebral disc)
Single joint capsule

COSTOTRANSVERSE JOINT
Synovial
Tubercle of the rib and the transverse process
Ligaments
- Costotransverse ligament from neck of the rib to transverse process). Ligamentum costotransversarium
- Lateral costotransverse ligament from tubercle of the rib to transverse process of the same level
- Superior costotransverse lig from neck of the rib to the superior transverse process

Foramen costotransversarium: delimited by Sup CT lig. and neck of the rib. Exit of nerve.

STERNOCOSTAL JOINTS
Upper 7 costal cartilages to sternum
Ligaments
- Chondrosternal ligament
- Intraarticular sternocostal ligament
- Ligamenta sternocostale radiata, anterior (fusion of both sides à membrana sterni)

Rib I to sternum: fibrocartilaginous (not synovial)

Rib II – VII Divided in two compartments by intraarticular ligament. Synovial, becomes obliterated in elderly.

INTERCHONDRAL JOINTS
Between costal cartilages of adjacent ribs
VII to XI (± V and VI)
Synovial

MANUBRIOSTERNAL AND XIPHISTERNAL JOINTS

Symphyses
Sternal angle: reference of plane that passes through T4-T5 intervertebral disc:
- superior / inferior mediastinum
- superior border of pericardium
- end of ascending aorta, beginning of the arch of the aorta
- bifurcation of the trachea
- superior to pulmonary trunk

INTERCOSTAL SPACES
Costal groove (inferior border of superior rib)
Intercostal artery + vein + nerve

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FUNCTIONS OF THE THORAX
1. Protect
2. Elasticity
3. Dynamic: insertion for muscles
4. Haematopoiesis
5. Anatomical reference

FUNCTIONAL ANATOMY OF THE TRUNK

Functions:
1. Balance (centre of gravity along the centres of curvature)
2. Muscle insertion (transverse and spinous processes)
3. Load transmission (rigidity): through the bodies (static component, single)
4. Mobility: flexibility (double dynamic component: synovial joints)
5. Resistance to compression, increases with the number of curvatures (C2+1)

Movements
Flexion, Extension, Lateral flexion, Rotation
Movement is determined by the shape of the joints

- Mainly cervical and lumbar

- Flexion depends on the disc
- Rotations are greater in the inflexion points of curvature

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13. THE SHOULDER GIRDLE

SCAPULA
Triangular
Over 2nd – 7th ribs
Costal surface
Concave
- bone strip in the medial border, insertion of serratus anterior
- insertion for subscapularis (subscapular fossa)
Dorsal surface
- Spine of the scapula
- Supraspinous fossa: supraspinatus muscle
- Infraspinous fossa: infraspinatus muscle
Spine, insertion for the trapezius, continues with the acromion
Spinoglenoid notch, passage for nerve for the infraspinatus
Acromion: distally and inferior, insertion of coraco-acromial ligament. Posterior angle. Tuberosity.
Facet for the clavicle in the medial border
Lateral angle:
Glenoid fossa
- Pear shaped
- Anterior border slightly notched
- Labrum glenoidale: fibrous lip
- Cartilage thinner in the center, thicker at the rim
- Fibrous capsule attached to the rim of the cavity and labrum
- Supraglenoid tubercle: insertion of long head of the biceps
- Infraglenoid tubercle: long head of the triceps
Coracoid process:
- lateral margin of the upper surface is insertion for the coraco-humeral and coraco-acromial ligaments
- Tip: insertion for coracobraquialis and short head of the biceps
- Superior surface: insertion of coraco-clavicular ligaments (conoid tubercle and trapezoid line)
- Medial surface: insertion of pectoralis minor
Lateral border
- Insertion of teres minor
- Insertion of teres major
Inferior angle
Medial border
Superior border
Scapular notch for suprascapular nerve. Superior transverse ligament (omohioid)
CLAVICLE
Medial 2/3 convex forwards, triangular section
Lateral 1/3 concave forwards, flat
Inferior surface
Irregular
Lateral: Trapezoid line, Conoid tubercle
Intermediate part: groove for subclavius muscle and clavipectoral fascia
Medial: Impression for costoclavicular ligament
Superior surface
Smooth
Anterior border, insertion of deltoid (lateral 1/3) and pectoralis major (medial 2/3)
Posterior border, insertion of trapezius in the lateral 1/3
Medial: insertion of clavicular head of sternoclenomastoid
Insertion of cervical fascia
Lateral end (acromial)
Oval articular facet for acromion
Capsule attached to the ridge of the margin of the facet
Medial end (sternal)
- inferior ¾ moves on the articular disc
- superior ¼ rough, attachment for the disc

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HUMERUS
Proximal end
- Head of the humerus, articular surface, retroverted. Cartilage thicker at the centre, thinner at the rim
- Anatomical neck
- Surgical neck
- Greater tubercle (tuberositas major), on the anterolateral side, insertion for supraspinatus, infraspinatus, teres
minor
- Lesser tubercle (tuberositas minus), anterior, for subscapularis
- Intertubercular groove: long head of the biceps tendon. Covered by the transverse ligament.
- Crest of the greater tubercle,
- Crest of the lesser tubercle, teres major
- Latissimus dorsi inserts on the floor of the Groove (anterior to teres major)

Body
Triangular
Medial border: Insertion of coracobraquialis
Lateral border continues with the lateral supracondylar ridge (insertion of brachioradialis and extensor carpi
radialis longus)
- Deltoid tuberosity
- Groove for the radial nerve
Anterior surface, lower half, insertion of brachialis
Posterior surface: Spiral groove for the radial nerve

Lower end
Wide, flat, anteriorly angulated
Distal
- Trochlea: articulation with ulna
- Capitulum: articulation with head of the radius
Anterior:
- Coronoid fossa
- Radial fossa
Posterior: Olecranon fossa
Medial epicondyle
Lateral epicondyle

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STERNOCLAVICULAR JOINT (cleidosternal)
Synovial
Components:
- proximal end of the clavicle: concave anteroposteriorly
- clavicular notch of the manubrium: concave vertically. Surface smaller than that of the clavicle

Articular surface
Saddle shaped (selaris)
Plane: oriented to the back, superior and lateral
Two compartments (articular disc)

Ligaments
- Anterior sternoclavicular ligament
- Posterior sternoclavicular ligament
- Interclavicular ligament (interclaviculare)
- Costoclavicular ligament, the most relevant
- Anterior fibers, from the rib to the clavicle laterally oriented
- Posterior fibers, from the rib to the clavicle, medially oriented

Movements
Rotation about the long axis of the clavicle, centred in the SCJ, revolution figure, 30º in all directions

ACROMIOCLAVICULAR JOINT
Synovial.
Components: acromion (oval facet on the medial surface) + clavicle (facet on acromial end)
Plane shape (arthrodia)
Ligaments
- Acromioclavicular ligament
- Coracoclavicular ligaments (the most relevant):
- Trapezoid: lateral (from base of coracoid to clavicle)
- Conoid: medial, triangular: base in clavicle, vertex in base of coracoid

Vascular supply
- Branches of the Suprascapular artery
- Branches of the thoraco-acromial arteries

Innervation
- Branches from suprascapular nerve
- Branches from lateral pectoral nerve

Movements
AP plane + Sagittal plane + rotation

SCAPULAR LIGAMENTS
- Superior transverse scapular ligament
- Inferior transverse scapular ligament: from lateral border of the scapular spine to back of the neck of the
scapula
- Coracoacromial ligament

SCAPULOTHORACIC JOINT
Elevation – depression
Protraction – retraction
Lateral – medial rotation

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GLENOHUMERAL JOINT
Synovial
Enarthrosis (ball and socket)
Composition: Humerus (head) + scapula (glenoid cavity)
Surfaces:
- humeral head, spherical
- glenoid cavity, small, expanded and deepened by glenoid labrum
Hyaline cartilage
Glenoid labrum: superiorly continuous with the biceps tendon

SYNOVIAL MEMBRANE
Loose inferior, anterior and posteriorly. Gets taught only at the end of range of motion.
Folds around the long head of the biceps tendon as it goes into the intertubercular sulcus (bicipital groove)
Protrudes through aperture in the fibrous membrane: bursae
- Subtendinous bursa of subscapularis
- Subacromial
- Subdeltoid

FIBROUS MEMBRANE
Redundant inferiorly

LIGAMENTS
- Superior glenohumeral ligament superior region of glenoid rim to tuberositas major
- Middle glenohumeral ligament superior region of glenoid rim to tuberositas minor
- Inferior glenohumeral ligament inferior region of glenoid rim to tuberositas minor, humerus’ neck
- Coracohumeral ligament
- Transverse humeral ligament

JOINT STABILITY
Ligaments
Tendons: rotator cuff / collar
Skeletal arch (Acromion + coracoacromial ligament + coracoid process)
Tendon of the long head of the biceps

VASCULAR SUPPLY
- Anterior circumflex humeral artery
- Posterior circumflex humeral artery
- Suprascapular artery

INNERVATION
- Branches from the posterior cord
- Suprascapular nerve
- Axillary nerve
- Lateral pectoral nerve

MOVEMENTS
Flexion (50º-90º), with the STJ up to 180º Extension 25º-50º
Adduction 30º (includes flexion) Abduction (60º-80º) up to 140º with STJ (1/3 STJ, 2/3 GHJ)
Internal / medial rotation 95º External / lateral rotation 30º - 80º
Circumduction

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14. THE ELBOW JOINT

ULNA
Proximal end
Trochlear notch fits on the trochlea of the humerus. Cartilage transversely divided. Incisura trochlearis
Olecranon proximal end, insertion of Triceps and ligaments
Coronoid process anterior, completes the articular notch, larger medial than lateral
Radial notch lateral, for the head of the radius. Annular lig. attached to anterior & posterior margin
Tuberosity of ulna distal to coronoid process, for insertion of braquialis
Sublime tubercle insertion of anterior part of ulnar collateral ligament
Triangular fossa for origin of supinator
Supinator crest limits posteriorly this fossa. Insertion of radial collateral ligament

Body
Triangular in section, tapers distally to be cylindrical

Interosseous border, lateral, attachment of interosseous membrane

Anterior border
Posterior border

Posterior surface proximally, insertion of anconeus

Distal end
Head
Styloid process projects distally from the posteromedial region of the head.
Posterior groove for the extensor carpi ulnaris

RADIUS
Head
Concave proximal surface, for articulation with capitulum of the humerus
Articular circumference, contacts with the radial notch of the ulna, and the annular ligament

Neck

Body
Proximally is cylindrical, distally is triangular
Medial convexity

Radial tuberosity for insertion of the biceps tendon. Anterior part is smooth, contacts with bursa.
Interosseous border distally split in the anterior and posterior ridges of the ulnar notch.
Anterior border
Posterior border

Lateral surface
Anterior surface proximal ¾ for flexor pollicis longus, distal ¼ for insertion of pronator quadratus
Posterior surface middle 1/3 insertion for abductor pollicis longus and extensor pollicis brevis

Distal end
Anterior surface
Lateral surface: Styloid process extends from the lateral part
Medial surface: ulnar notch. Lateral edge is for insertion of articular disc
Posterior surface: convex, dorsal radial tubercle. Sulci musculorum extensorum
Carpal surface
- Concave
- Divided in two parts by a ridge: lateral triangular for scaphoid, medial quadrilateral for lunate.

The extensor tendons pass over the distal end of the radius and ulna along six grooves.

18
THE ELBOW JOINT
Composition: Humerus + Radius + Ulna
Hyaline cartilage

Type Surface Movement

Condylar Radius (head) + Humerus (Capitelum) Flexion-extension, Spinning (prono-supination)
Trochlea Ulna (trochlear notch) + Humerus (trochlea) Flexion-extension
Trochoid Radius (head) + Ulna (radial notch) Pronation-supination

ARTICULAR SURFACES
Humero-ulnar:
- Humerus trochlea angled forward, canal has spiral orientation
- Ulna: medial surface is bigger, transversal sulcus without cartilage

Humero-radial
- Humerus Hemispheric condyle (capitulum)
- Radiusshallow concavity

SYNOVIAL MEMBRANE
Single synovial membrane for all these joints
Overhangs the limits of articular cartilage
Origin: edges of the articular cartilage
Lines radial fossa, coronal fossa, olecranon fossa, deep surface of joint capsule, medial surface of trochlea
Includes 1 cm of the neck of the radius
Separated from fibrous membrane by fat pads in coronoid, radial and olecranon fossa
Sacciform recess around the radial head

INTEROSSEOUS FIBROUS MEMBRANE

Inserts in the interosseous border of ulna and radius
From the radius goes distally to the ulna (prevents the radius going proximally)

LIGAMENTS
Radial collateral ligament: from epicondyle to ulna (supinator crest)
The insertion point at the epicondyle is isometric, tension is constant during flexion and extension.
Medial collateral ligament:
- Anterior from epitrochlea to ulna (tuberculus sublimis). Biomechanically relevant. Tightens in extension.
- Posterior Tightens in flexion.
- Transverse
Anular ligament of the radius, articular ligament. From anterior to posterior borders of the radial notch of the
ulna
Quadrate ligament (ligamentum quadratum). From inferior border of radial notch to medial surface of the neck of
the radius.

VASCULARIZATION
Anastomotic network

INNERVATION
Branches of radial nerve
Musculocutaneous nerve

MOVEMENTS
Flexion
Extension

19
PROXIMAL RADIOULNAR JOINT
Annular ligament of the radius: from anterior border of radial fossa, around the radial head, to posterior border of
radial fossa.
Quadrate ligament

RADIOULNAR SYNDESMOSIS
Connection between shafts of radius and ulna
- Interosseous membrane
- Oblique cord

DISTAL RADIOULNAR JOINT

Composition: head of the ulna (circumferentia ulnaris), ulnar notch of the radius
Trochoid
Single axis with the proximal radioulnar joint, both move synchronically
Articular disc: from the base of the styloid to the medial margin of the carpal articular surface of the radius
Ligaments: radioulnar, palmar and dorsal
Recessus sacciformis, between radius and ulna, extends proximally.
Movement: prono-supination, 180º

20
15. JOINTS AND LIGAMENTS OF THE WRIST

CARPUS
Eight bones
Proximal row (radial to ulnar): scaphoid, lunate, triquetrum, pisiform.
Distal row (radial to ulnar): trapezium, trapezoid, capitate, hamate.
Dorsal carpal surface is convex, …as a general rule the dorsal surface of the bones is wider than the palmar
Palmar concavity deepened
- ulnarly by the hook of the hamate and the pisiform,
- radially by the tubercle of the scaphoid and the trapezium
The concavity is made a tunnel by the flexor retinaculum: flexor tendons and median nerve (not ulnar nerve!)

SCAHPOID
Long axis directed distal, radial and palmar
Tubercle in the distolateral part, attachment for flexor retinaculum
Crossed by the flexor carpi radialis
Dorsal surface: rough, foramina in the distal half
42% articular surfaces
- Radial surface convex
- Lunate surface flat, semilunar
- Capitate surface large, concave
- Trapezium & trapezoid continuous, convex, distal

LUNATE
Semilunar shape

TRIQUETRUM

PISIFORM

TRAPEZIUM
Double curved articular surface for the 1st metacarpal (sellar joint)

TRAPEZOID

CAPITATE
Proximal head
Dorsal surface: broad
Palmar surface: prominence for insertion of ligamentum carpi radiatum: fibres to all the bones of the carpum
(except pisiform)
Distal surface: three articular facets for 2nd, 3rd and 4th metacarpals

HAMATE
Palmar surface: palmar hook (hamulus)
Lateral facet for the capitate, flat
Medial facet for the triquetrum, sinuous
Distal surface: facets for the base of the 4th and 5th metacarpals

METACARPUS
Base
- Lateral articular surfaces for the neighbouring metacarpal (intermetacarpal joint).
- Lateral tubercle for insertion of ligament
Body
Head condylar surface

1st metacarpal Base has double curve (sellar joint)

3rd metacarpal The longest, longitudinal axis of the hand

21
RADIOCARPAL JOINT
Synovial
Articular surfaces
- Proximal: radius (divided by low ridge) & ulna (articular disc)
- Distal: scaphoid, lunate, triquetrum

Condylar joint
Glenoid cavity formed by the carpal surface of the radius & articular disc
Fibrous capsule
Ligaments
Radiocarpal ligament palmar Radioscaphocapitate
Long radiolunate
Radioscapholunate
Short radiolunate
Ulnocarpal ligament palmar Ulnolunate
Ulnotriquetral
Ulnocapitate
Radiocarpal ligament dorsal Radiolunotriquetral ligmament
Ulnocarpal ligament dorsal

Radial carpal collateral ligament to scaphoid tubercle, trapezium, metacarpal

Ulnar carpal collateral ligament to pisiform, hook of the hamate, base of the 5th metacarpal

Flexor retinaculum

Movements
Condylar joint, biaxial
Flexion, extension, adduction, abduction, circumduction

INTERCARPAL JOINT
JOINTS OF THE PROXIMAL CARPAL ROW
Two arthrodial: scapholunate, triquetrolunate
Ligaments
- Palmar intercarpal ligaments
- Dorsal intercarpal ligaments
- Interosseous ligament the ligaments are mainly proximal
Vascularization
- Deep palmar arch
- Dorsal arch

JOINTS OF THE DISTAL CARPAL ROW

The interosseous ligaments are mainly distal

MIDCARPAL JOINT
Irregular line, double curve, between the proximal and distal row
Common articular space with the intercarpal joints in the proximal and distal row
Sellar joint
Dart throwing motion

JOINT OF THE PISIFORM

Arthrodia
Joint capsule separate from the rest of the carpus
Ligaments:
- Pisohamate
- Pisometacarpal
- Fascicles of the ulnocarpal medial collateral ligament

22
15. JOINTS AND LIGAMENTS OF THE HAND

PHALANGES
14, 3 per finger, 2 in the thumb
Base, shaft, head

Bases: lateral tubercles for insertion of ligaments

- Proximal phalanges: concave oval facets
- Middle and distal: smooth middle ridge
Body
- Shaft tapers distally
- Dorsal surface transversely convex
Head
- Palmar surface transversely flat, concave anteriorly in its long axis
Heads of proximal and middle is trochlear
Heads of the distal phalanges are non-articular, palmar tuberosity (insertion of flexor digitorum profundus)
COMMON CARPOMETACARPAL JOINTS
Irregular, arthrodia
- 2nd metacarpal: trapezium, trapezoid and capitate
- 3rd metacarpal: capitate
- 4th metacarpal: capitate and hamate
- 5th metacarpal: hamate (flattened saddle)

Interosseous ligament, distal to the intermetacarpal joint surfaces

Palmar and dorsal carpometacarpal ligaments.
Very limited movement (most of all 5th metacarpal)
THUMB CARPOMETACARPAL JOINT
Highly mobile
Trapezium & base of the first metacarpal
Synovial
Saddle
Ligaments: palmar, lateral (triangular), dorsal
Movements: flexion, extension, abduction, adduction, opposition (medial rotation + flexion + adduction)
INTERMETACARPAL JOINTS
Arthrodia: Reciprocal articulation at the base from 2nd to 5th metacarpal
At the diaphysis is the interosseous metacarpal space.
Distally to the articular surfaces there is a syndesmosis (interosseous metacarpal ligament)

Ligaments: dorsal, palmar, interosseous

METACARPOPHALANGEAL JOINTS
Synovial
Condylar
Composition: head of metacarpal & base of proximal phalanx
Ligaments:
- Collateral ligament: from tubercle at each side of the metacarpal head to the base of the phalanx
- Palmar ligament, fibrocartilage (slides under the head), loose insertion proximally, firm fixation distally,
- Deep transverse metacarpal ligament, joins the 2nd to 5th palmar ligaments
Thumb: sesamoid bones
Movements:
- flexion, extension, adduction, abduction, rotation
- Insertion of lig. is not in rotation axis of condyle: tightens in flexion, loosens in extension, allows ab/adduction
INTERPHALANGEAL JOINTS
Trochlea
Ligaments
- Collateral ligaments: from head of proximal phalanx to base of distal phalanx
- Palmar ligament, fibrocartilage
Flexion and extension

23
16. THE PELVIS. THE HIP JOINT

COMPOSITION
Pelvis = coxal + sacrum
Hip bone (coxal) = ilium + pubis + ischium

Greater pelvis separated by plane formed by the linea terminalis and promontorium
Lesser pelvis

Linea terminalis (innominate): Arcuate line + Ileopectineal line + Pecten pubis

Superior aperture (pelvis inlet)

Inferior aperture (pelvis outlet)

MEASUREMENTS from to

Greater pelvis
- Intercrestal both outer lips of the iliac crest
- Interspinous both ASIS
- External anteroposterior spine of S1 anterior margin of pubic symphysis

Lesser pelvis
- Superior aperture
- AP anatomic Promontorium anterior margin of pubis
- AP, true, obstetric Promontorium middle part of pelvic surface of symphysis
- AP, conjugate diagonal promontorium inferior border of symphysis
- Transverse
- Oblique SIJ iliopubic eminence opposite
- Cavity
- AP, anatomic centre of sacrum pelvic surface of symphysis
- Transverse
- Oblique posterior end of SIJ centre of obturator membrane opposite
- Inferior aperture
- AP (conjugata vera) tip of coccyx posterior lower margin of symphysis
- Transverse both ischial tuberosities

The diameters cross at one point at the centre of the aperture

The centres of the apertures and cavity conform the axis of the pelvis

24
FUNCTIONS
1. Basement of the inferior limb
2. Weight transmission to the inferior limb
3. Containment and protection of viscera
4. Birth canal
5. Muscle insertion
6. Balance, walk

SEXUAL DIFFERENCES IN THE PELVIS

Male Female
Weight + -
Angles + -
Height + -
Inclination - +
PIIS goes inwards outwards
Ischial spines goes inwards outwards
Obturator foramen oval triangular
Innominate line heart oval or circular
Subpubian angle 60 – 70º 90º

25
ILIUM

ILIAC BORDERS
Iliac crest
- External lip Obliquus internus
- Tubercle of the iliac crest
- Intermediate line Transversus abdominis
- Internal lip Obliquus internus

Iliac tuberosity: thickening of the posterior portion

Anterior Superior iliac spine (ASIS) Sartorius, Inguinal ligament

Posterior Superior Iliac spine (PSIS)

Anterior border
Anterior inferior iliac spine: Rectus femoris

Posterior border
Posterior inferior iliac spine
Greater sciatic notch

SURFACES
POSTEROLATERAL SURFACE (gluteal)
Limits:
- Iliac crest
- Superior border of the acetabulum
- Anterior border
- Posterior border

Three lines:
- Inferior gluteal line: AIIS à Posterior border of acetabulum
- Anterior gluteal line: ASIS à Superior border of greater sciatic notch
- Posterior gluteal line: Iliac crest à PIIS

Supra-acetabular sulcus: insertion of reflected head of rectus femoris.

MEDIAL SURFACE
Iliac fossa
Sacropelvic surface
- Auricular surface for the SIJ
- Porción pélvica: forma parte de la pared ósea de la pelvis menor. Preauricular sulcus.
Iliac tuberosity: between the auricular surface and posterior part of the crest

Arcuate line: separates iliac fossa from lesser pelvis, continuous with pecten pubis, to form the iliopubic part of
linea terminalis.

26
ISCHIUM
Parts:
- Body
- Ramus
BODY
1. Femoral surface
2. Posterolateral surface
3. Pelvic surface
RAMUS
- Posterior surface
- Anterior surface
ISCHIAL TUBEROSITY
Ischial spine

Superior area
- Medial: Semitendinous + long head of the biceps
- Lateral area: Semimembranous
Inferior area
- Medial area bursa
- Lateral area Adductor magnus
Acetabulum
- Margo acetabularis
- Supraacetabular sulcus (attachment site for the reflected tendon of the rectus femoris muscle)
- Acetabular notch
- Acetabular ligament
- Acetabular fossa
- Lunate surface
- Acetabular margin
- Labrum (limbus)
- Ligament of the head of the femur: inserts in transverse ligament, borders of the notch, borders of the fossa
Obturator foramen
- Obturator groove: obturator nerve and vessels
- Anterior obturator tubercle
- Posterior obturator tubercle

PUBIS
Body
- Anterior surface
- Posterior surface
- Symphysial surface, insertion of the fibrocartilaginous interpubic disc
- Anterior border, pubic crest, lateral end projects as the pubic tubercle (insertion of inguinal ligament)

Superior ramus
3 surfaces, 3 borders
- Pelvic surface
- Pecten pubis: from the pubic tubercle to the iliopubic eminence
- Pectineal surface (anterior): limits
- Anterior Obturator crest
- Posterior Pectineal line (pectin pubis)
- Obturator surface, limits
- Anterior obturator crest
- Posterior inferior border

Inferior ramus
1. Anteroexternal surface
2. Posterointernal surface
3. External surface
4. Internal surface

27
FEMUR
Upper end
Head
2/3 sphere (actually is ovoid)
Fovea capitis femoris, in the postero-inferior quadrant of the articular surface, insertion for the ligament of the
head

Neck
Infero-lateral direction
Cervico-diaphyseal angle 125º
- coxa vara: under average
- coxa valga: over average
Declination angle (anteversion)

Anterior surface
- grooved and perforated for vessels
- Covered by synovial membrane down to the intertrochanteric line
- Intertrochanteric line, insertion for ligaments

Posterior surface
- groove of the obturator externus
- Intertrochanteric crest. Quadrate tubercle (for quadratus femoris)
- Only the medial half is covered by the synovial membrane

Greater trochanter
Medial surface trochanteric fossa, for obturator externus tendon. The obturator internus inserts medially
Superior border insertion for Piriformis and Gluteus medius
Anterior surface Insertion of gluteus minimus

Lesser trochanter
Posteromedial
Insertion of psoas

28
LUMBROSACRAL JOINT
Iliolumbar ligament: 5th transverse process à iliac crest

SACROCOCCYGEAL JOINT
Anterior sacrococcygeal ligament
Posterior sacrococcygeal ligament

SACROILIAC JOINT
Synovial
Articular surfaces
Components: auricular surfaces of sacrum and ilium
Plane with irregularities
Cartilage is thick

Proper ligaments
- Anterior sacro-iliac ligament
- Interosseous sacro-iliac ligament
- Posterior sacro-iliac ligament

Accessory ligaments
- Sacrospinous ligament
- Sacrotuberous ligament covers the dorsal surface of the sacrum (except the foramina)
Falciform process: the sacrotuberous ligament expands along the ischial ramus, whose concave edge blends
with the fascial sheath of the internal pundendal vessels and pudendal nerve.

Sciatic foramina
- Greater sciatic foramen leads from the lesser pelvis into the gluteal region
- Lesser sciatic foramen leads from gluteal region into perineum

Movements:
- Nutation: when standing up, coccix goes backwards, promontorium goes anterior
- Counter-nutation
During pregnancy the pelvic ligaments loosen under the influence of the hormone relaxin

PUBIC SYMPHYSIS
Articulating surfaces: Reciprocal crests and papillae
Interpubic disc
- Hyaline cartilage covering the bone
- Fibrocartilaginous lamina, connects both cartilages (may have a cavity, due to absortion. Is not a synovial joint)
Superior ligament
Inferior ligament (arquate)

OBTURATOR MEMBRANE

29
THE HIP
CLASSIFICATION
Synovial
Ball and socket, multiaxial

FUNCTION
- Stability
- Weight bearing
- Movement

MOVEMENTS
- Flexion, extension
- Abduction, adduction
- Rotation, medial (internal) & lateral (external)
- Circumduction
Passive range of motion is wider than active

ARTICULAR SURFACES
- Head of the femur
- Lunate surface of the acetabulum
Acetabulum covers 90% of the femoral head
The acetabular fossa is extrasinovial: insertion of ligamentum teres
Fovea of the femoral head: insertion of ligamentum teres
Acetabular labrum (limbus acetabulare): widens contact surface

SYNOVIAL MEMBRANE
Medially inserts 0,5 away form margo acetabularis
Lines the ligamentum teres, acetabular fossa
Reflected upwards on the neck (intracapsular part of the neck of the femur): Retinacula: vascular plexus for the
femoral head

FIBROUS MEMBRANE
Thick
Fibres in different directions
- Arciform both insertions in the same bone
- Transverse femur to coxal
- Arquate femur to coxal, oblique
- Orbicular deep, circular, no bony insertion, at the narrow (middle) region of the fibrous membrane

LIGAMENTS
Intracapsular
- Transverse acetabular ligament spans the borders of the acetabular notch
- Ligament of the head of the femur (ligamentum teres), with branch of the obturator artery. Inserts at the border
of the acetabular fossa and the transverse ligament.
Capsular
Spiral orientation: these ligaments tighten with the hip extension (standing), further stabilizing the joint.

1. Iliofemoral ligament anterior, shape of inverted Y

Apex between antero-inferior Iliac Spine and acetabular margin, base to the intertrochanteric line
- External fascicle, transverse
- Internal fascicle, descending
2. Pubofemoral ligament anterior (weakest) iliopectineal crest, pectin pubis intertrochanteric line
3. Ischiofemoral ligament posterior, intertrochanteric line

BURSAE
- Iiliopsoas
- Obturator externus, internus
- Quadratus femoris
- Gluteus maximus, medius, minimus

30
17. THE KNEE JOINT
The knee has three joints:
1. Tibiofemoral (bycondylear)
2. Patellofemoral (trochlea)
3. Proximal tibiofibular

1 & 2 are in the same articular space.

DISTAL FEMUR
Two condyles
Condyles anteriorly are confluent, continuous with the shaft
Posteriorly separated by the intercondylar fossa, project beyond the popliteal surface
Patellar surface
Extends proximally, specially in the lateral condyle
Transversely concave
Tibial surface
Divided by the intercondylar surface, anteriorly continuous with the patellar surface
Convex in all directions
Both have similar AP curvatures
Intercondylar fossa
Separates both condyles distally and posteriorly
Intracapsular but extrasynovial
Lateral wall, posterosuperior impression for insertion of the anterior cruciate ligament (ACL)
Medial wall, anterior impression for insertion of posterior cruciate ligament (PCL)
Lateral condyle
Larger anteroposteriorly than the medial
Lateral epicondyle, insertion of fibular collateral ligament
Groove for tendon popliteus, between epicondyle and articular surface (deep to FCL),
Tendon popliteus inserts inferior and anterior to FCL (groove for the popliteus)
Medial condyle
Adductor tubercle (adductor magnus)
Medial epicondyle, anteroinferior to the adductor tubercle, tibial collateral ligament
Projects distally (bycondylar plane is horizontal, diaphyseal axis has 97º lateral angulation, not 90º)
PROXIMAL TIBIA
Two condyles
Superior surface
- Articular surfaces (tibial plateau)
- Intercondylar area, non articular
- Intercondilar eminence (lateral and medial tubercles)
Lateral surface
- Fibular articular facet, faces distally and posterolaterally
- Interosseous border: margin for the attachment of the deep fascia
- Gerdy’s tubercle, distal attachment of the iliotibial tract
Anterior surface: tibial tuberosity
Posterior surface: smooth
PATELLA
Largest sesamoid
Flat, distally tapered
Embedded in the tendon of the quadriceps femoris

Anterior surface, perforated by vessels

Posterior surface, articular, vertical ridge which fits in the intercondylar groove
- medial and lateral facets (lateral is larger)
- odd facet: narrow strip at the medial border
- apex, distally, rough surface for insertion of the patellar tendon. Separated from articular surface by infrapatellar
fat pad
Superior border, thick, slopes anteroinferiorly
Medial and lateral border are thinner, converge distally at the apex
FABELLA
Small posterolateral sesamoid (biceps tendon)

31
TIBIOFEMORAL JOINT

ARTICULAR SURFACES
Single articular cavity
Femoral surface
Two femoral condyles: greater curvature in distal surface, smaller curvature in posterior surface
Lateral condyle: longer, narrow (more in the centre)
Medial condyle: shorter, more round
Proximal tibial surface
Medial (concave) and lateral (convex) articular surfaces
Superior aspect of the tibial condyles: V shaped
Posterior tilt relative to the long axis of the shaft
Medial articular surface: oval, longer than the medial
Lateral tibial condyle overhangs the shaft of the tibia. Has articular circular surface for the fibula.
Tibial intercondylar area
Narrowest centrally
Intercondylar eminence projects proximally as lateral and medial intercondylar tubercles
From anterior to posterior, insertion of
- anterior horn of medial meniscus
- anterior cruciate ligament
- anterior horn of lateral meniscus
- posterior horn of lateral meniscus
- posterior horn of medial meniscus
- posterior cruciate ligament

MENISCI
Fibrocartilaginous. Fibrous (vascularized) at the peripheral insertion, cartilaginous at the internal rim.
Attached at each end to facets in the intercondylar region of the tibial plateau
Borders are not parallel: the meniscus tapers in width as they go anterior (wider posterior that anterior)
Medial attached around to the capsule (coronary ligament) and tibial collateral ligament, C shape,
Lateral unattached to the capsule (popliteal tendon), O shape, wider citrôen
Functions: adjustment of articular surfaces, lubrication of surfaces
Internal meniscus has less ability to slide
Interconnected:
- anterior transverse ligament of the knee (present in 60%)
- posterior transverse ligament of the knee (present in 20%)
The lateral meniscus is connected posteriorly to the femur by two meniscofemoral ligaments.
- Anterior and posterior respective to their position to the PCL.
- Both go from posterior horn of lateral meniscus to the medial femoral condyle.

SYNOVIAL MEMBRANE
Attached to the margins of the articular surfaces of the superior and inferior outer margins of the menisci.
Cruciate ligaments: are outside the articular cavity but enclosed within the fibrous membrane of the knee joint.

PLICAE
Alar fold (plicae), converge posteriorly in the infrapatellar fold (adipose ligament), which goes into the
intercondylar fossa.
They limit the articular volume, producing invaginations of the synovial membrane adapting the shape of the
synovial membrane to the contour of the bones.
Volume of synovial liquid is approximately 1,5 cm3
Subpopliteal recess posterior to the lateral meniscus, related to the popliteal tendon

FAT PADS
Infrapatellar fat pad

32
FIBROUS MEMBRANE
Capsule and retinacula
Medial: blends with the tibial collateral ligament, attached on its internal surface to the medial meniscus
Lateral: the external surface is separated by a space from the fibular collateral ligament
the internal surface of the fibrous membrane is not attached to the lateral meniscus
Anteriorly: medial and lateral patellar retinacula, attached to the margins of the patella, reinforced with
tendinous expansions from the vastus lateralis and vastus medialis muscles
Posterior: Fibres go vertical. Oblique popliteal ligament: thickening, extension from the tendon of
Semimembranous
Medial soft tissues
Layer 1, Sartorius, medial patellofemoral ligament, patellotibial ligament
Tendons of gracilis and semitendinous
Layer 2: superficial part of the medial collateral ligament
Layer 3: capsule of the knee. Posteriorly blends with layer 2 to form the conjoined posteromedial capsule
Lateral soft tissues
Superficial: lateral patellar retinaculum (from patella to iliotibial band)
Middle: fibular collateral lig., popliteofibular lig., fabellofibular ligament, arquate lig., Anterolateral lig.
Deep: lateral part of the capsule

BURSAE
- Suprapatellar
- Patellar, deep and superficial
- Gastrocnemius (posterior to the femoral condyles)
- Tendons: Popliteus, Biceps, Sartorius, Gracilis, Semimembranosus

LIGAMENTS
Patellar ligament
Continuation of the quadriceps muscle
Inferior margin and apex of the patella à tibial tuberosity
Plica synovialis infrapatellaris
Tibial (medial) ligament
Wide, but thin
Attached to the fibrous membrane
Medial femoral epicondyle, inferior to adductor tubercle à medial margin of medial surface of tibia above and
behind the attachment of the S-G-St
Fibular (lateral) ligament
Cord-like
Above the groove of the popliteus tendon
Distally attached to a depression of the lateral surface of the fibular head
Separated from the fibrous membrane by a bursa
Anterior cruciate ligament
In the intercondylar region
Anterior facet of anterior part of intercondylar area of tibiaà ascends posteriorly to back of lateral wall of
intercondylar fossa at the lateral condyle
Prevents anterior displacement of the tibia relative to the femur
Rupture produces the anterior drawer sign: the tibia over-slides anteriorly
Posterior cruciate ligament
From Posterior aspect of intercondylar area à medial wall of intercondylar fossa of medial femoral condyle
Prevents posterior displacement of the tibia relative to the femur
Rupture produces the posterior drawer sign: the tibia over-slides posteriorly

33
MOVEMENTS
Flexion
Active 130º, passive 160º
Menisci move with condyles: the contour reduces (contact surface of posterior condyle is smaller, because it is
more round)
Slide backwards
This sliding is limited by the coronary ligament, mainly in the internal meniscus
The medial condyle is 1,5 larger than the lateral: Flexion implies internal rotation of the tibia (20º)
Untwisting of cruciate ligaments
The patella translates slightly anteroposteriorly
The crossing point of the cruciate ligament, in the sagittal plane goes cephalad
Extension
10º
The menisci get the wider contour
Anterior sliding of menisci, mainly the external meniscus due to the popliteal tendon
The twisting of the cruciate ligaments increases: stabilizes the knee, preventing lateral movements
Implies external rotation of the tibia, because the length of the medial condyle is larger that that of the lateral
Rotation
Possible in flexion
Vertical axis through the intercondylar eminence
Lateral (external of the femur): PCL tightens, ACL loosens. MCL tightens, pressure on anterior area of internal
meniscus
Medial (internal of the femur): PCL loosens, ACL tightens, LCL tightens, pressure on posterior area of internal
meniscus
Anterior / posterior translation
Very limited by the cruciate ligaments
Medial / lateral shift (translation)
Very limited by the ligaments.

34
18. TIBIOPERONEAL JOINTS

FIBULA
HEAD
Apex of the head
Facet for the tibia
Common peroneal nerve lies very close
BODY
Borders: anterior, posterior, interosseous
Surfaces: lateral, medial, posterior
DISTAL END (lateral malleolus)
Posterior relative to the medial malleolus
Posterior groove
Medial surface
- triangular articular facet, vertically convex, distal apex
- malleolar fossa, distal, for insertion of posterior talofibular ligament

PROXIMAL TIBIOFIBULAR JOINT

Synovial
Plane (arthrodia). Very little movement

Articular surfaces,
Fibular: round, covered by hyaline cartilage.
Tibial: posterolateral surface of lateral condyle. Faces down, lateral, back

Fibrous capsule, thicker anteriorly, weak

Ligaments (ligamentum capitis fibuli)
- Anterior ligament of the head of the fibula: three fascicles to the lateral condyle
- Posterior ligament of the head of the fibula, single. Covered by the popliteal tendon.

CRURAL INTEROSSEOUS MEMBRANE (syndesmosis tibiofibularis)

Inserts on the interosseous borders of fibula and tibia
Plane: proximal is sagittal, distal is frontal
Direction of fascicles: oblique: distal and lateral (prevents the fibula “going down”)
Proximal aperture: anterior tibial vessels
Distal aperture: perforating branch of peroneal artery
Area of insertion of muscles of the leg.

DISTAL TIBIOFIBULAR JOINT

Fibrous joint (syndesmosis)
Articular surfaces:
- tibial concave rough (fibular notch of the tibia: incisura fibularis)
- fibular convex
Ligaments
- Interosseous ligament extremely resistant, continuous with the interosseous membrane
- Anterior tibiofibular ligament fibres oriented lateral and distal
- Posterior tibiofibular ligament similar orientation, thicker
Movements
Very limited. Depend on the movement of the talus
The ligaments determine the width of the tibiofibular mortise

Ankle extension (dorsal flexion)

The wider anterior part of the trochlear surface of the talus fits in the tibiofibular mortise.
This produces that
- The anterior border of the fibula further separates from the tibia (external rotation of the fibula)
- The ligaments tighten, giving more stability
- The posterior tibiofibular ligament, which is stronger acts as hinge in this external rotation of the fibula

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18. THE ANKLE JOINT

BONES

DISTAL TIBIA
Anterior surface
Posterior surface
Lateral surface
Incisura fibularis
Medial surface
Medial malleolus
Distal surface (tibial plafond)
Wider anteriorly
Concave in sagittal plane, convex in coronal plane
Continues medially in the malleolar articular surface

TALUS
Head
Directed distally, inferomedial
Distal articular surface, convex, ovoid
Plantar surface, articular surfaces
- Surface for calcaneonavicular ligament
- Surface for calcaneonavicular part of bifurcate ligament
- Surface for the anterior calcaneal surface anterior TC joint

Neck
Plantar articular surface for calcaneus (sustentaculum tali), largest, oval, convex. middle TC joint
Sulcus tali, roof of the tarsal sinus
Axis directed down, distal, medial. 150º with the axis of the body

Body
Dorsal trochlear surface, convex in sagittal, concave in coronal, widest anteriorly, sagittal axis directed anterior
and lateral
Lateral triangular facet
Medial comma shaped articular facet
Posterior posterior process, groove (for Flexor Hallucis Longus) marks two tubercles.
Plantar articular surface for posterior articular surface of calcaneus posterior TC joint

CALCANEUS
Superior surface has three areas
- Posterior: rough and concavo-convex
- Middle: the posterior talar facet: oval, convex antero-posteriorly
- Anterior:
- Calcaneus sulcus
- Articular area: anterior and middle talar facet

Anterior surface: articular facet for the cuboid

Posterior surface: has three areas

- Superior: smooth, covered with fat
- Middle: Ridge for insertion of the calcaneal tendon
- Distal: Subcutaneous weight-bearing surface

Plantar surface

Lateral surface
- Fibular trochlea
- Elevation for insertion of the calcaneofibular ligament

Medial surface
- Sustentaculum tali
- Groove for flexor hallucis longus, under the sustentaculum tali

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Functions
1. Support the weight of the body
2. Distribute the weight
3. Movement: walk, adapt the foot to the ground

This is provided by multiple joints (for load sharing), with scarce movement, that summed altogether provide a
wider range of movement

ANKLE JOINT (talocrural, supratalar)

Synovial
Tibia + fibula + talus
Hinge (trochlea)

ARTICULAR SURFACES
Fibula + tibia = bracket-shaped socket (mortise)
Hyaline cartilage
- Roof: inferior surface of the distal end of the tibia
- Medial side: medial malleolus of the tibia
- Lateral side: lateral malleolus of the fibula, longer

Body of the talus

- Shape of articular surface the talus: half cylinder
- Wider anteriorly than posteriorly: most stable when foot is dorsiflexed

FIBROUS CAPSULE
Weak in front and behind (as in all hinge joints). Reinforced by ligaments medially and laterally

SYNOVIAL MEMBRANE:
Attaches around the margins of the articular surface

LIGAMENTS
Medial (deltoid) ligament
Triangular (capital delta)
Apex to the medial malleolus
Base to the navicular and talus
Has 4 parts (named parts, not ligaments)
- Deep Tibiotalar part, anterior: attaches to the medial surface of the neck of talus
- Deep Tibiotalar part, posterior: attaches to the medial side and medial tubercle of talus
- Superficial Tibionavicular part: attaches in front to tuberosity of the navicular & margin of spring lig.
- Superficial Tibiocalcaneal part: attaches to the sustentaculum tali

The tibiotalar parts are on a deeper plane than the rest

Lateral ligaments
- Anterior talofibular: from anterior margin of the lateral malleolus à adjacent region of the neck of the talus
- Calcaneofibular: from malleolar fossa (posteromedial side of lateral malleolus) à tubercle on lateral
surface of calcaneus
- Posterior talofibular: from malleolar fossa (medial side of the lateral malleolus) à posterior process of talus

MOVEMENTS
Extension (dorsal flexion)
Flexion (plantar flexion)
Trochlea: transverse axis
More stable in dorsal flexion, as the widest part of the talar trochlea is in the tibiofibular mortise

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SUBTALAR JOINT
Talus (posterior calcaneal facet on the inferior surface) + calcaneus (posterior talar facet on the superior surface)
Synovial membrane: two separate joints

POSTERIOR TALOCALCANEAL JOINT

Articular surfaces
- Talus: inferior (posterior) facet of the body, concave, long axis is transverse
- Calcaneus: posterior articular facet, convex
Trochoid
Ligaments
- Talocalcaneal ligaments: Lateral, Medial, Posterior
- Interosseous (tarsal sinus, sinus tarsi). Two layers

ANTERIOR TALOCALCANEAL JOINT

Articular surfaces
- Talus: two articular facets
- Calcaneus: middle and anterior articular facet, concave

MOVEMENT: inversion and eversion

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19. JOINTS AND LIGAMENTS OF THE FOOT

NAVICULAR
Proximal surface concave, for head of the talus
Distal surface convex, for cuneiform bones
Medial tuberosity
Plantar surface, groove for the tendon of tibialis posterior

CUBOID
Proximal surface for calcaneus
Distal surface: medial quadrangular area for 4th metatarsal, triangular lateral area for 5th metatarsal
Plantar surface
- Groove for tendon of fibularis longus
- Tuberosity for tendon of fibularis brevis

CUNEIFORM BONES (medial, intermediate, lateral)

The medial is the largest, the intermediate is the smallest.

METATARSALS
Base
Triangular (dorsal base, plantar apex)
Proximal articular surface (plane) for
- Cuboid (4th, 5th)
- Cuneiform (1st, 2nd, 3rd)
Body
Tapers distally
Longitudinal border longitudinally concave
Dorsal surface convex in transverse and longitudinal plane
Head:
Condyle.
Lateral tubercles for insertion of collateral ligaments

1st metatarsal: shortest, strongest. Tuberosity. Groove for sesamoid bones

2nd metatarsal: more rigid, the axis of the foot
3rd metatarsal: shorter
4th metatarsal: shortest
5th metatarsal: longest. Tuberosity in the base (insertion of tendon of peroneus brevis)

PHALANGES
Base: Base of the proximal phalanx: concavity
Body. Plantar surface plane, dorsal surface convex, oval section
Head: trochlea

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INTERTARSAL JOINTS

MIDTARSAL JOINT
The midtarsal joint (articulation tarsi transversa) is formed by
- Talocalcaneonavicular joint
- Calcaneocuboid joint

TALOCALCANEONAVICULAR JOINT
COMPOSITION:
Six bony articular surfaces (3 talus, 2 calcaneus, 1 navicular), one ligamentous
- Talus (anterior and middle calcaneal facets) + Calcaneus (anterior & middle talar facets)
- Talus (medial facet on inferior surface of head) + Calcaneonavicular ligament (spring ligament)
- Talus (ovoid anterior end of head) + Navicular (concave posterior surface)

MOVEMENTS:
- gliding + rotation –> inversion-eversion
- Pronation-supination

LIGAMENTS
- Posterior: interosseus talocalcaneal ligament
- Superior: Talonavicular ligament
- Inferior: Plantar calcaneonavicular ligament (spring ligament)
- Lateral: calcaneonavicular part of the bifurcate ligament.

Bifurcate ligament, from calcaneus to

- dorsomedial surface of the cuboid (calcaneocuboid ligament)
- Dorsolateral part of the navicular (calcaneonavicular ligament)

Plantar calcaneonavicular lig. (spring ligament): sustentaculum tali à navicular bone (supports head of talus)

CALCANEOCUBOID JOINT
Synovial
Sellar
Articular surfaces
- Calcaneus (facet on the anterior surface), concave vertically, convex transversely
- Cuboid (facet of the posterior surface)
MOVEMENTS: sliding, rotating à inversion-eversion, pronation-supination
LIGAMENTS
- Bifurcate ligament
- Calcaneonavicular
- Calcaneocuboid
- Plantar calcaneocuboid ligament (short plantar ligament)
- Long plantar ligament: interior surface of calcaneus à inferior surface of the cuboid)

CUNEOCUBOID JOINT
Cuboid + 3rd cuneiform
Arthrodia
Ligaments (cuneocuboid): dorsal, plantar, interosseous

CUNEONAVICUAR JOINT
Navicular + three cuneiforms
Arthrodias
Single articular capsule
Ligaments: cuneonavicular dorsal + plantar

CUBOIDEONAVICULAR JOINT
Arthrodia

INTERCUNEIFORM JOINTS
2nd cuneiform + 1st & 3rd
Arthrodia
Ligaments: dorsal, plantar, interosseous

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JOINTS OF THE FOOT

TARSOMETATARSAL JOINTS
Arthrodias

Movement:
- limited sliding
- Pronation-supination
Plane shape
Overall tarsometatarsal plane: irregular, oblique facing laterally

1st metatarsal – medial cuneiform bone

2nd metatarsal – all three cuneiform bones (socket)
3rd metatarsal – lateral cuneiform bone
4th metatarsal – cuboid
5th metatarsal – cuboid

Three synovial compartments

- Internal 1st cuneiform 1st metatarsal
- Middle nd rd nd rd
2 , 3 cuneiform 2 , 3 metatarsal communicates with cuneonavicular
- External Cuboid 4th, 5th metatarsal

Ligaments
- Dorsal tarsometatarsal ligaments
- Plantar tarsometatarsal ligaments
- Interosseous (internal, middle, lateral)

Innervation
- Medial plantar nerve
- Lateral plantar nerve
- Deep fibular nerve

INTERMETATARSAL JOINTS
Interosseous metatarsal ligament
Dorsal metatarsal ligaments
Plantar metatarsal ligaments

METATARSOPHALANGEAL JOINTS
Head of metatarsals + bases of the proximal phalanges
Head of the first metatarsal has a plantar ridge (between the two sesamoid bones)
Condylar
Synovial
Ligaments:
- Lateral collateral ligaments
- Plantar ligaments: wide, thicker in the phalangeal insertion
- Deep transverse metatarsal ligament, joins all the plantar ligaments
Movements:
Flexion: 30-40º. With some adduction
Extension: 50-60º active, 90º. With some abduction (5th toe also adduction)
The second is stiffer

INTERPHALANGEAL JOINTS
Trochlea
Collateral ligaments (medial, lateral)
Plantar ligament
Movements:
Flexion-extension
Locked position is flexion (collateral ligaments tighten)
Accessory ad/abduction, passive rotation

ARCHES OF THE FOOT

Transverse arch: Anterior, Posterior
Longitudinal arch: Medial, Lateral

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