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I. V. Gaivoronskiy, A. A.

Kurtseva
M. G. Gaivoronskaya, G. I. Nichiporuk

ARTHROSYNDESMOLOGY
АРТРОСИНДЕСМОЛОГИЯ

The manual for medical students

Учебное пособие для медицинских вузов


(специальность «Лечебное дело»)

Санкт-Петербург
СпецЛит
2015
УДК 611.71-72
А86

Авторы:
Гайворонский Иван Васильевич — доктор медицинских наук, профессор, заведую-
щий кафедрой морфологии медицинского факультета Санкт-Петербургского го-
сударственного университета и кафедрой нормальной анатомии
Военно-Медицинской академии им. С. М. Кирова;
Курцева Анна Андреевна — кандидат медицинских наук, доцент кафедры анато-
мии человека Курского государственного медицинского университета;
Гайворонская Мария Георгиевна — кандидат медицинских наук, доцент кафедры
морфологии медицинского факультета Санкт-Петербургского
государственного университета;
Ничипорук Геннадий Иванович — кандидат медицинских наук, доцент кафедры
морфологии медицинского факультета Санкт-Петербургского
государственного университета

Артросиндесмология : учебное пособие для медицинских вузов /


А86 И. В. Гайворонский, А. А. Курцева, М. Г. Гайворонская, Г. И. Ничипорук. —
Санкт-Петербург : СпецЛит, 2015. — 62 с. — ISBN 978-5-299-00661-2

Данное пособие является английской версией учебника профессора И. В. Гайворонско-


го «Нормальная анатомия человека», который был издан в России 9 раз и одобрен Мини-
стерством образования Российской Федерации.
Структура пособия соответствует современным стандартам медицинского образования
в России и важнейшим Европейским стандартам. Английская и латинская терминология
приведены в соответствии с Международной анатомической номенклатурой.
УДК 611.71-72

ISBN 978-5-299-00661-2 © ООО «Издательство „СпецЛит“», 2015


CONTENTS
List of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1. General arthrosyndesmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.1. Solid (non-synovial) joints (synarthroses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.2. Synovial (cavitated) joints (diarthroses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3. Movements at synovial joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.4. The principles of the synovial joints classification . . . . . . . . . . . . . . . . . . . . . . 14
1.5. Factors determining the range of movements at synovial joints . . . . . . . . . . . 16
Test questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2. The joints of trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.1. The joints between individual vertebrae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2. Joints between sacrum and coccyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.3. Joints between I Cervical Vertebra and II Cervical Vertebra
and between I Cervical Vertebra and Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.4. Vertebral column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.5. The joints of ribs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.6. Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Test questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Clinicoanatomical problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3. The joints of skull bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.1. The solid joints of skull bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.2. Temporomandibular joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Test questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Clinicoanatomical problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4. The joints of upper limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.1. The joints of shoulder girdle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.2. The joints of free upper limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Test questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Clinicoanatomical problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5. The joints of lower limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.1. The joints of pelvic girdle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.2. Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.3. The joints of free lower limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.4. The arches of foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Test questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Clinicoanatomical problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
LIST OF ABBREVIATIONS
Art., art. — articulatio
Artt., artt. — articulationes
For., for. — foramen
Lig., lig. — ligamentum
Ligg., ligg. — ligamenta
M., m. — musculus
Mm., mm. — musculi
N., n. — nervus
Nn., nn. — nervi
R., r. — ramus
Rr., rr. — rami
S., s. — sulcus
PREFACE
The creation of the manual «Arthrosyndesmology» in English meets the requirement
of modern Russian medicine and education. Nowadays many English-speaking oversea
students study in Medical Universities of Russia. Besides, many Russian school leavers
have a good command of the English language so they will be able to use this manual
taking into consideration the fact that many Russian specialists in medicine work abroad
after graduating from the universities or take part in different international conferences
and symposiums.
The English version of the manual is based on the Russian manual by professor I. V.
Gayvoronskiy «Normal Human Anatomy» which has been published in Russia 9 times
and is approved by the Ministry of education of Russia.
This manual introduces the main principles of Russian Anatomy School such as:
detailed study of the general aspects and items of Anatomy including the development
of organs and anomalies of the development. If we compare theoretical approaches to
Anatomy in Russia and in other countries we`ll see that our approach is based on the
system descriptions of organs, i. e. we describe separately Skeletal system, Articulations,
Muscular system etc. Moreover, we use Latin terminology while describing the organs
and discuss clinicoanatomical and functional problems. As for the manuals in other
countries many of them describe Anatomical systems in accordance with the regional
and topographical principles.
The structure of our manual meets the requirements of modern standards of medical
education in Russia which in their turn correspond to the major European standards. Af-
ter each chapter we give test questions and clinicoanatomical problems. The English and
Latin terminology is given in accordance with International Anatomical Nomenclature.
The authers srongly believe that the manual will allow future doctors to form the
morphological foundation for the further study of theoretical and clinical disciplines.
We also hope that it will be of great help to Anatomy teachers.
ПРЕДИСЛОВИЕ
Создание учебного пособия «Артросиндесмология» на английском языке яв-
ляется требованием современной системы медицинского образования в России. В
настоящее время в медицинских университетах нашей страны обучаются студен-
ты из различных регионов дальнего зарубежья. Кроме того, многие выпускники
российских школ хорошо владеют английским языком, поэтому они также смо-
гут пользоваться данным пособием, принимая во внимание, что зачастую русские
специалисты в медицине после окончания университета уезжают работать за ру-
беж или принимают участие в различных международных конференциях и сим-
позиумах.
Английская версия пособия базируется на русском учебнике профессора
И. В. Гайворонского «Нормальная анатомия человека», который был издан в Рос-
сии 9 раз и одобрен Министерством образования Российской Федерации.
Данное пособие познакомит читателей с главными принципами Русской Ана-
томической Школы, которые заключаются в подробном изучении общих вопро-
сов, в том числе развития органов и аномалий развития. В России преподавание
анатомии ведется с функционально-клинических позиций и основано на описа-
нии органов по системам, т. е. отдельно изучается опорно-двигательная система,
артросиндесмология, миология и другие системы. Также при описании строения
органов акцентируется внимание на латинской терминологии. Что касается за-
рубежных руководств по анатомии человека, многие из них основываются на
регионально-топографическом принципе без использования латинской термино-
логии.
Структура данного пособия соответствует современным стандартам медицин-
ского образования в России, которые, в свою очередь, соответствуют важнейшим
Европейским стандартам. После каждой главы мы приводим контрольные вопро-
сы и ситуационные клинические задачи. Английская и латинская терминология
приведена в соответствии с Международной анатомической номенклатурой.
Авторы выражают уверенность, что данное пособие позволит будущим док-
торам сформировать морфологический фундамент для последующего изучения
теоретических и клинических дисциплин. Мы также надеемся, что оно принесет
определенную пользу и преподавателям анатомии человека.
1. GENERAL ARTHROSYNDESMOLOGY
Arthrosyndesmology is the science, which deals with the anatomy and function of
joints. The definition of the term «arthrosyndesmology» is the science of articulations
and ligaments (from Greek arthros — articulation, desmos — ligament, logos — science).
Thus, arthrosyndesmology is the science of bone junctions. There is the great number
of various joints (more than 230 articulations, about 1000 ligaments etc.) in the human
body. It is important to know the phylogenesis and onthogenesis of the skeleton bones
to understand the function and the causes of joints appearance.
In onthogenesis the formation of the joints reflects the phylogenetic process. It is
known, that the bones pass through three stages of the development: connective-tissue,
cartilaginous and osseous. The bones of the neurocranium and viscerocranium are ex-
ceptions because they pass through only two stages — connective-tissue and osseous.
Therefore, there can be no cartilaginous joints between these bones, here only connec-
tive-tissue or osseous joints remain. On the first-second months of the fetal development
the anlagens of the skeletal units are connected with each other through mesenchyme
layers, which subsequently transform into connective-tissue or cartilage. Hence, de-
pending on the functional purpose, the junctions of bones can be bonded by connective-
tissue, cartilage, osseous tissue, or cavitated (synovial) joints develop.
The development of the synovial joints is especially interesting. On the second month
of the fetal development the condensation of mesenchyme is observed. It is the stage of the
precartilaginous concentration of mesenchyme. Then the next stage follows — when the dia-
physes of tubular bones become cartilaginous while epiphyses are still mesenchymal. In the
place of the future synovial joint mesenchyme becomes loose and an articular cavity starts to
form here. At first, it appears only in the central part of the mesenchymal condensation. On
the third-fourth months the diaphyses ossify, thereafter, a medullary canal is formed inside
each of them, and epiphyses become cartilaginous. Inside synovial joints the accessory struc-
tures (intra-articular ligaments, discs, menisci, folds) develop. Simultaneously, an articular
capsule and synovial membrane develop from surrounding mesenchyme.
The articular surfaces haven`t became congruent even by the time of birth because
a fetus and newborn are not subjected to functional loads. In a fetus the articular sur-
faces are flat or slightly spherical, articular cavity is large, intra-articular structures are
eventually formed only by the time of birth. Further, under the influence of functional
loads the articular surfaces get a definite shape, the capsule becomes stronger due to the
ligaments and tendons of surrounding muscles.
Thus, there are two basic types of joints in the human body — solid joints (synar-
throsis) and synovial (cavitated) joints (diarthrosis); each of these types can be divided
into several groups (see Table 1.1).
Table 1.1
Classification of Joints (Arthroses)

Solid (non-synovial) joints


Synovial (cavitated) joints (diarthroses)
(synarthroses)
I. Fibrous joints, juncturae I. Classification of joints based on the axes of movements and
fibrosae, (junctions of bones shapes of articular surfaces
by specialized solid connective- 1. Uni-axial: 2. Bi-axial: 3. Multi-axial:
tissue, or syndesmoses): а) throchoid, or pivot а) ellipsoid joint, а) shperoidal, or
1. Ligaments, ligamenta joint, art. trochoidea art. ellipsoidea ball-and-socket
2. Membrane, membranae b) ginglymus, b) sellar, or saddle joint, art. spheroidea,
3. Fontanelles, fonticuli or hinge joint, joint, art. sellaris a kind — cotyloid
4. Sutures, suturae ginglymus, a kind — c) bicondylar joint, art. cotylica
5. Gomphoses, gomphoses cochlear joint, art. joint, art. b) plane joint, art.
cochlearis bicondylaris plana
8 ARTHROSYNDESMOLOGY

The end of table 1.1


Solid (non-synovial) joints
Synovial (cavitated) joints (diarthroses)
(synarthroses)
II. Cartilaginous joints, II. Classification of joints based on the number of articular
juncturae cartilagineae surfaces:
(junctions of bones by cartilage, 1. Simple joint, art. simplex
or synchondroses): 2. Compound joint, art. composita
1. Temporary cartilaginous joint,
formed by hyaline cartilage
2. Permanent cartilaginous joint,
formed by fibrous cartilage
III. Synostoses, juncturae III. Classification of joints based on simultaneous joint
osseae (rigid bony union) function:
- combined joint, art. combinatoria

1.1. Solid (non-synovial) Joints (Synarthroses)


There are three groups of solid joints: fibrous, cartilaginous and osseous (fig. 1.1).
I. Fibrous joints, juncturae fibrosae seu syndesmoses, are junctions bonded by solid
connective-tissue. They include ligaments, membranes, fontanelles, sutures and gom-
phoses.
1. Ligaments, ligamenta, are the bundles of collagen and elastic fibers. The liga-
ments containing mainly collagenic fibers, are termed fibrous ligaments, the ligaments
containing mainly elastic fibers, are called elastic ligaments. Unlike fibrous ligaments,
elastic ones can be shortened and regain initial form after the cessation of strain.
According to the length, the ligaments can be divided into long and short ones. The
long ligaments connect several bones (posterior and anterior longitudinal ligaments
of the vertebral column, supraspinous ligament), the short ligaments connect adjacent
bones (interspinous ligaments and most ligaments of limbs).

Fig. 1.1. Types of joints:


a — synovial joint; b — syndesmosis; c — synchondrosis; 1 — periorsteum; 2 — bone; 3 — fibrous tissue;
4 — cartilage; 5 — synovial sheath; 6 — fibrous layer of capsule; 7 — articular cartilage; 8 — articular cavity
1. General arthrosyndesmology 9

The ligaments are classified into intra-articular (intrinsic) and extra-articular (ex-
trinsic) ones depending on the relation to the articular capsule. The extra-articular liga-
ments can be intracapsular and extracapsular in position. The intra-articular ligaments
are located within the articular cavity and they belong to accessory apparatus of the
synovial joint. The extra-articular ligaments strengthen the synovial joint. The intracap-
sular ligaments are in the thickness of the articular capsule and they can not be seen dur-
ing external examination of an anatomical preparation. The extra-articular ligaments
are located outside the articular capsule and they are visible as rather thick bundles of
connective-tissue. As independent type of joints, the ligaments carry out the following
functions:
— they hold or fix the bones (sacrotuberous, sacrospinous, interspinous, intertrans-
verse ligaments etc.);
— they play the role of soft skeleton because some muscles originate from and insert
to the ligaments (most ligaments of limbs, vertebral column etc.);
— some of them together with bones form openings or vaults for the passage of ves-
sels and nerves (superior transverse scapular ligament, the ligaments of pelvis etc.).
2. Membranes, membranae, are thin collagenous sheets, which fill up extensive
spaces between bones. Connective-tissue fibers of membranes are mainly collagenic;
they are arranged in such direction, which doesn’t hinder the movements. Like liga-
ments, they hold the bones together, form openings for the passage of vessels and nerves
and serve for the origin and insertion of muscles.
3. Fontanelles, fonticuli, are soft spots of an infant`s skull between incompletely
formed cranial bones of a fetus or an infant. They are structures of connective tissue
containing the great amount of ground substance and sparse collagen. The fontanelles
allow the infant`s head pass through the birth canal and contribute to the rapid growth
of skull bones after birth.
4. Sutures, suturae, are thin layers of connective tissue containing a lot of collagen-
ic fibers, they are formed between the bones of the skull. According to the shape, the
sutures may be serrate, squamous and plane ones. Sutures are the growth zone of the
skull bones and they provide cushion effect during movement of the head, protecting the
brain, the organ of vision, organ of hearing and balance.
5. Gomphoses, gomphoses, fix teeth in alveolar sockets of mandible and maxillae
with the help of specific connective tissue called the periodontium. This junction is very
strong and it also has cushioning properties during strain on the tooth. The periodon-
tium is 0,14—0,28 mm thick. It consists of collagenic and elastic fibers, oriented per-
pendicularly from the walls of alveolar socket to the root of the tooth. Between fibers
there is loose connective tissue containing a lot of vessels and nerves. During the strong
compression of jaws the periodontium is pressed and a tooth immerses into the alveolar
socket by 0,2 mm.
The amount of elastic fibers decreases with age, the periodontium damages at a load,
its blood supply and innervation disorder, as a result teeth shatter and fall out.
II. Cartilaginous joints, juncturae cartilagineae seu synchondroses, are junctions
bonded by hyaline or fibrous cartilage. The hyaline cartilage is more elastic but less du-
rable than the fibrous one. The hyaline cartilage connects metaphyses with epiphyses in
the tubular bones and also connects the parts of the pelvic bones together. The fibrous
cartilage is comprised of mainly collagenic fibers, therefore, it possesses more durability
and less elasticity. Such cartilage connects the vertebral bodies. The durability of the car-
tilaginous joints increases due to the periosteum of the connecting bones, which passes
continuously from one bone to another. In the region of the cartilage the periosteum
10 ARTHROSYNDESMOLOGY

transforms into the perichondrium which firmly fused with the cartilage and, moreover,
reinforced by ligaments.
According to the time of existence, the cartilaginous joints can be classified into per-
manent and temporary, i.e. existing until certain age and then replaced by osseous tissue.
In normal physiologic conditions the temporary cartilages are: metaepiphyses, cartilages
between the parts of flat bones, cartilage between the basilar part of the occipital bone
and the sphenoid`s body. These joints are formed by mainly hyaline cartilage. The per-
manent cartilages are: cartilages forming intervertebral discs, cartilages located between
the bones of the skull base (sphenopetrosal and petrooccipital cartilages, which fill the
corresponding fissures of the skull base) and anterior cartilaginous ends of ribs. These
joints are formed by mainly fibrous cartilage. The synchondroses provide the strong
junctions of the bones and amortize shocks during high strain on the bone. Simultane-
ously, the cartilaginous joints are rather mobile. The range of movements depends on the
thickness of cartilaginous layer: the greater it is the greater is the range of movements.
For example, there are various movements in the vertebral column: flexion and exten-
sion, lateral flexion, rotation.
A kind of cartilaginous joints is symphysis.
Symphysis, symphysis, or hemiarthrosis, is a transitional form between solid and syn-
ovial joints. Sympysis is the cartilaginous junction with a cavity inside; this cavity has no
synovial membrane, which is typical for the articular cavity (for example, the pubic sym-
physis, symphysis pubica). Sometimes, the symphyses are formed between the V lumbar
vertebra and the I sacral vertebra and also between the sacrum and coccyx.
III. Synostoses, juncturae osseae seu synostoses, are rigid bony unions. Synostosis is
the most durable joint of synarthroses; this joint is not elastic and it has no shock absorb-
ing properties. In normal conditions the temporary synchondroses and also sutures and
fontanelles ossify, i.e. transform into synostoses. In some diseases (ankylosing spondyli-
tis, osteochondrosis etc.) ossification can occur not only in all types of synchondroses,
but also in all types of syndesmoses.

1.2. Synovial (Cavitated) Joints (Diarthroses)


Sinovial joint, articulatio, is a cavitated joint between connecting articular surfaces,
which are covered by cartilage and enclosed into articular capsule. Synovial fluid fills up
the space between the articular surfaces.
The synovial joint consists of three main structures: articular surfaces covered
with cartilage, articular capsule, and articular cavity filled with small quantity of syn-
ovial fluid.
Articular surfaces, facies articulares, are areas of the bone, which are covered by
articular cartilage. In long tubular bones they occupy epiphyses, in short tubular bones
they are on heads and bases, in flat bones they are on processes and bodies. The shapes
of articular surfaces are strictly deterministic; most commonly, one bone has a head, the
other bone has a fossa, more rarely, articular surfaces are flat. The articular surfaces
must be corresponding to each other, i.e. be congruent. More often, the articular sur-
faces are covered by hyaline cartilage. Fibrous cartilage covers, for example, the articular
surfaces of temporomandibular joint. The cartilage on articular surfaces is 0,2–0,5 cm
thick, and in the articular fossa it is thicker along the edge, but on the articular head the
cartilage is thicker in its center.
Articular cartilage, cartilago articularis, is firmly linked with the bone. The deep
layer of the cartilage is impregnated with calcium salts. In this layer chondrocytes, sur-
1. General arthrosyndesmology 11

rounded by connective tissue fibers, are arranged perpendicularly to the surface, i.e. in
rows or in columns. They are able to resist the forces of pressure on the articular surface.
In the superficial layer of the cartilage arch-shaped connective tissue fibers prevail; they
start and terminate within the deep layer. These fibers are oriented parallelly to the car-
tilage surface. Moreover, this layer has a large amount of ground substance, therefore,
the cartilage surface is smooth and polished. The superficial layer is able to resist the
forces of friction (tangential forces). The cartilage gets weakened with age, its thickness
decreases and it becomes less smooth.
The articular cartilage smoothes the rough and uneven surface of the bone, it makes
the bones more congruent and it decreases the force of friction. The articular cartilage
is elastic and it is able to absorb shocks, therefore, the articular cartilage is thicker in the
joints subjected to high loads.
Articular capsule, capsula articularis, hermetically surrounds the articular cavity.
The capsule is attached along the edges of articular surfaces or at a short distance from
them. It consists of the external fibrous membrane and internal synovial membrane.
In its turn, the fibrous membrane is formed by two layers of dense connective tis-
sue — external longitudinal and internal circular layers; both layers contain blood ves-
sels. The fibrous membrane is reinforced by extra-articular (extrinsic) ligaments, which
form local thicknesses in the places of the highest load. Usually the ligaments are closely
linked with the capsule. The ligaments separated from the capsule are rare (for example,
the tibial collateral ligament). In slightly moveable joints (amphiarthroses) the fibrous
membrane is thickened. In freely moveable joints the fibrous membrane is thin and weak
tensioned. The fibrous membrane can be so thin in some places that the synovial mem-
brane protrudes outwards. The protruding synovial membrane forms the synovial bur-
sae, which are usually located under tendons.
The synovial membrane faces the articular cavity, has rich blood supply, from the inside it
is lined with synoviocytes, which produce synovial fluid. The synovial membrane entirely cov-
ers the internal surface of the articular cavity, extends on bones and intra-articular ligaments.
Only surfaces which constructed by cartilage, are not covered by the synovial membrane.
The synovial membrane is smooth, shining, it forms numerous synovial villi. Occasionally,
some of villi are detached and get between the articular surfaces as foreign body; this process
cause short-term pain and impede movements. Such status is known as joint mouse.
The synovial membrane can adjoin the fibrous membrane directly, or it can be sepa-
rated from the fibrous membrane by the subsynovial layer or adipose layer, therefore,
three types of synovial membrane are distinguished: fibrous, areolar and adipose.
The synovial fluid is the transudate of blood plasma and lymph from capillaries,
which adjoin the synovial membrane. In the articular cavity this fluid mixes with de-
tritus of dead synoviocytes and cells of erasing cartilage. Moreover, the composition of
synovial fluid is supplemented with mucin, mucopolysaccharides and hyaluronic acid,
which give it viscosity. The volume of synovial fluid depends on the size of the joint, and
it ranges from 5 mm3 to 5 cm3. The synovial fluid carries out the following functions:
— it lubricates the articular surfaces (decreases friction during movements, increases
sliding);
— it holds the articular surfaces relatively to each other;
— it lessens strain;
— it nourishes the articular cartilage;
— it participates in metabolism.
The articular cavity, cavitas articularis, is a hermetically closed space between the
articular surfaces and articular capsule. In the intact joint the articular cavity can be
12 ARTHROSYNDESMOLOGY

distinguished only conditionally, because there is no empty space between the articular
surfaces and capsule, this space is filled with synovial fluid. The shape and volume of
the articular cavity depend on the shape of the articular surfaces and the structure of the
articular capsule. In amphiarthroses the cavity is small, in moveable joints it is large and
it may continue into bursae, which are placed between bones, muscles and tendons. In
the articular cavity the negative pressure exists. If the articular capsule is damaged, the
air enters the articular cavity and the articular surfaces pull apart.
Besides the main structures, the accessory structures can be present in the synovial
joints; they ensure the optimal functioning of joints. Here belong: intra-articular ligaments,
intra-articular cartilages, articular labra, synovial folds, sesamoid bones and synovial bursae.
1. Intra-articular ligaments, ligamenta intraarticularia, are fibrous ligaments
which are covered by the synovial membrane and connect the articular surfaces of the
knee joint, joints of costal head and hip joint. They hold the articular surfaces relatively
to each other. This function is obviously shown on the example of the cruciate ligaments
of the knee joint. In case of their rupture the «drawer sign» is observed, when in flexion
of the knee the shin shifts relatively to the thigh 2—3 cm forwards or backwards. The
ligament of femoral head of the hip joint serves as a conductor of the vessels, which sup-
ply blood to the articular head.
2. Intra-articular cartilages, cartilagines intraarticulares, are fibrous cartilages
(discs or menisci) which have a shape of plates and are located between the articular sur-
faces. The articular disc, discus articularis, completely separates the joint into two floors.
Hence, two separated cavities occur in the joint (for example, in the temporomandibular
joint). The articular meniscus has semilunar shape and partially separates the articular
cavity. The edges of menisci are fused with the articular capsule. Menisci, menisci, are
present in the knee joint.
The intra-articular cartilages make the articular surfaces more congruent and as a
result, they increase the range of movements and their variety. Also the cartilages absorb
shocks and decrease pressure on the underlying articular surfaces.
3. Articular labrum, labrum articulare, is annular fibrous cartilage which comple-
ments the articular fossa. One edge of the articular labrum is fused with the articular
capsule, the other edge continues to the articular surface. The articular labrum is present
in two joints: shoulder and hip (labrum glenoidale et labrum acetabuli) joints. The labrum
increases the area of the articular surface, makes the articular surface deeper, therefore,
it limits the range of movements.
4. Synovial folds, plicae synoviales, are composed of connective tissue, rich in blood
vessels and covered by the synovial membrane. If they accumulate adipose tissue, they
form fatty folds. The folds fill up free spaces of the large articular cavities. They decrease
the volume of the articular cavity, indirectly enhance cohesion of the articulating sur-
faces, and as a result, the range of movements increases.
5. Sesamoid bones, ossa sesamoidea, are bones embedded within tendons surround-
ing the joints, and closely linked with the articular capsule. One of these surfaces is
covered by hyaline cartilage and facing the articular cavity. Sesamoid bones decrease the
volume of the articular cavity and indirectly increase the range of joint movements. Also,
they are hinges for the tendons of muscles acting on the joint. The largest sesamoid bone
is the patella. The small sesamoid bones are often located in the joints of hand and foot.
6. Synovial bursae, bursae synoviales, are small cavities lined with the synovial
membrane and often communicating with the articular cavity. Their volume ranges from
0,5 to 5 cm3. The great number of bursae is observed in the joints of limbs. The bursae
are filled with synovial fluid, which lubricates the surrounding tendons.
1. General arthrosyndesmology 13

1.3. Movements at Synovial Joints

Before the study of the classification


of synovial joints, it is necessary to know
the axes of movements and the types of
movements at the joints.
The movements at the joints may oc-
cur around three axes only:
1 — frontal (axis corresponding to
the frontal plane, which divides the body
into anterior and posterior surfaces);
2 — sagittal (axis corresponding to
the sagittal plane, which divides the body
into the right and left halves);
3 — vertical axis or own axis of the
joint.
The vertical axis of the upper limb pass-
es through the center of the humeral head,
capitulum humeri and the heads of the ra-
dius and ulna. The vertical axis of the lower
limb passes along the straight line connect-
ing the anterior superior iliac spine, inner
border of the patella and the big toe.
The articular surfaces of the ar-
ticulating bones can have the shape of
sphere, ellipse, saddle, cylinder or hinge.
The articular surface of one articulating
bone conforms to the articular surface of
another bone. It should be noted, that the Fig. 1.2. Different types of synovial joints:
articular surface can be formed by several 1 — ellipsoid; 2 — saddle; 3 — spheroidal;
bones which make a certain form of the 4 — hinge
articular surface (for example, the artic-
ular surface formed by the proximal row of carpal bones (fig. 1.2).
The movements at synovial joints are determined by the geometric form of the ar-
ticular surfaces. For example, movements in pivot and hinge joints occur around one
axis only; movements in ellipsoid and saddle joints occur around two axes; movements
in spheroidal and plane joints occur around three axes.
The number and possible types of movements around all existing axes are given in
Tables 1.2 and 1.3. Thus, around the frontal axis two types of movements occur — flex-
ion and extension, flexio et extensio; around sagittal axis also two types of movements
occur — adduction and abduction, abductio et adductio; while passing from one axis to
another, one more movement appears — circular or conical movement, called circum-
duction, circumductio; around vertical axis only one movement is possible — rotation,
rotation. The latter has two subtypes: rotation inwards and outwards, or supination and
pronation, supinatio et pronatio.
Thus, only 6 types of movements exist. But at the combined joints (for example,
intervertebral joints) the following additional movements appear: sliding, torsion and
springy-like (bouncing) movements.
14 ARTHROSYNDESMOLOGY

Table 1.2
Axes and Types of Movements

Number
Axes of movement of possible Types of movements
movements
Frontal 2 Flexion and extension
Sagittal 2 Adduction and abduction
Frontal and sagittal (passing from one Curcumduction
1
axis to another)
Vertical 1 Rotation (supination and pronation)

Table 1.3
Maximal Number of Possible Movements at Synovial Joints Depending
on Number of Axes of Movements and Shape of Articular Surface

Number of Number of
Shape of articular surface Axes of movements Types of movements
axes movements
Uni-axial Trochoid (pivot) joints
Vertical 1 Rotation
Ginglymi (hinge joints)
Frontal 2 Flexion
Extension
Ellipsoid joints Sagittal and frontal Flexion
Sellar (saddle) joints Extension
5 Abduction
Adduction
Bi-axial Circumduction
Bicondylar joints Frontal and vertical Flexion
3 Extension
Rotation
Spheroidal joints Frontal, sagittal and Flexion
Multi- Plane joints vertical 6 Extension
axial Abduction
Adduction
Circumduction
Rotation

1.4. Principles of the Synovial Joints Classification


I. Classification of Synovial Joints Based on Axes of Movements
and Shape of Articular Surfaces
1. Uni-axial joints — movements at these joints occur only around one axis, i. e.
they possess one degree of freedom. Actually, this axis is frontal or vertical. If the axis
is frontal, the possible movements at those joints are flexion and extension. If the axis is
vertical, the possible movement is only rotation.
1. General arthrosyndesmology 15

According to the shape of the articular surfaces, uni-axial joints are classified into
trochoid (pivot) joint, articulatio trochoidea, and gynglimus (hinge) joint, ginglymus. The
movements at trochoid joints occur around vertical axis, (rotation). The median atlanto-
axial joint and the proximal and distal radioulnar joints belong to trochoid joints.
A hinge joint has a crest on the articular head and a recess on the articular fossa. The
crest doesn`t permit the articular surfaces to displace to the sides. The capsules of such
joints are loose from the anterior and posterior sides and they are always strengthened by
the lateral ligaments, which don`t impede the joint movements. Movements at hinge joints
occur only around frontal axis. The example of hinge joint is interphalangeal joint.
A variant of hinge joints is a cochlear joint, articulatio cochlearis; its crest and recess
are oblique and have helical passage. Such a joint is the humeroradial joint; its move-
ments occur only around the frontal axis.
2. Bi-axial joints — movements at these joints occur around two axes, i. e. they
possess two degrees of freedom. The joints, which movements occur around frontal and
sagittal axes, have 5 types of movements: flexion, extension, adduction, abduction and
circumduction.
According to the shape of the articular surfaces, bi-axial joints are grouped into el-
lipsoid and sellar (saddle) joints, articulacio ellipsoidea et articulatio sellaris. The exam-
ples of the ellipsoid joints are the atlantooccipital and radiocarpal joints; the example of
the sellar joint is the first carpometacarpal joint.
The joints, which movements occur around frontal and vertical axes, have 3 types
of movements: flexion, extension and rotation. According to the shape, these joints are
bicondylar joints, articulaciones bicondylares. Here belong the knee and temporoman-
dibular joints.
The bicondylar joint is a transitional form between uni-axilal and bi-axial joints.
The frontal axis of movements is basic for these joints. The disparity of the articular
surfaces of bicondylar joints is greater than of uni-axial joints; as a result, the range of
movements increases.
3. Multi-axial joints — movements at these joints occur around all three possible
axes, i. e. they possess three degrees of freedom. Thus, all 6 possible types of movements
can occur at these joints.
According to the shape, they are spheroidal (or ball-and-socket) joints, articulationes
spheroideae, (for example, shoulder joint). A kind of spheroidal joints is cotyloid joint,
articulatio cotylica, (for example, hip joint). The cotyloid joints have deep articular fossa
and strong capsule reinforced by ligaments; the range of movements at these joints is
lesser. If the spheroidal articular surface has a very big radius of curvature, it is flat. The
joint having such articular surfaces, is termed plane joint, articulatio plana. Their char-
acteristic are: slight difference in the area of the articular surfaces, the presens of strong
ligaments which strengthen the articular capsule. The movements at the plane joints are
significantly limited or are absent (for example, at the sacroiliac joint). The joints with
significantly limited mobility (almost immobile) are called amphiarthroses.

II. Classification of Synovial Joints Based on Number


of Articular Surfaces
1. Simple joint, articulatio simplex, is a joint having only two articular surfaces; each
of the articular surfaces may be formed by one or several bones. For example, each of artic-
ular surfaces of interphalangeal joints is formed by only one bones, but one of the articular
surfaces of the radiocarpal joint is formed by three bones of the proximal row of carpus.
16 ARTHROSYNDESMOLOGY

2. Compound joint, articulatio composita, is a joint with capsule which encloses


several articular surfaces, i.e. several simple joints that are able to function both together
and separately. The example of such joint is elbow joint — it has six articular surfaces
between which three simple joints occur: humeroradial, humeroulnar and proximal ra-
dioulnar joints. Some scientists consider the knee joint to be a compound joint. Taking
into consideretion the presence of the articular surfaces on the menisci and patella, they
distinguish simple joints between the femur and menisci, menisci and tibia, femur and
patella. But we consider the knee joint to be a simple joint because, to our mind, the
menisci and patella belong to the accessory apparatus.

III. Classification of Synovial Joints Based


on Simultaneous Joint Function
Combined joints, articulationes combinatoriae, are the joints which are anatomi-
cally separated (i. e. situated in different articular capsules), but function only together.
Here belong the temporomandibular joints, the proximal and distal radioulnar joints.
It should be accentuated, that it is impossible to perform a movement at one of the true
combined joints (for example at only one temporomandibular joint). If the joints with
different shapes of articular surfaces are combined, the range of movements is deter-
mined by the joint with a fewer number of axes of movements.

1.5. Factors Determining Range of Movements


at Synovial Joints
The range of movements at each joint depends on various factors.
1. The main factor is the difference in the area of the articular surfaces. The greatest
disparity is in the shoulder joint (the area of the humeral head is 6 times bigger than the
area of the scapula`s glenoid cavity, therefore, the shoulder joint has the maximal degree
of freedom. In the sacroiliac joint the areas of the articular surfaces are approximately
equal, so the movements at this joint are almost absent.
2. The presence of the accessory structures influences the range of movements. For
example, menisci and discs improve the congruence of articular surfaces, therefore, they
enhance the degree of freedom. The articular labrum enlarges the articular surface,
therefore, it limits movements. The intra-articular ligaments limit movements only in
certain direction (for example, the cruciate ligaments of the knee joint don`t limit flex-
ion but limit excessive extension).
3. One more factor is the combination of joints. The movements of the combined
joints are determined by the joint having a fewer number of the axes of movements.
Thus, the range of movements at one combined joint is limited because of the combina-
tion with another joint. For example, according to the shape of the articular surfaces the
lateral atlantoaxial joints are plane, but due to the combination with the median atlan-
toaxial joint they function as trochoid jonts. This is also typical for the articulations of
ribs, some articulations of foot etc.
4. The condition of the articular capsule also determines the range of movements.
If the capsule is thin and elastic, the range of movements increases. In some joints the
thickness of the articular capsule is not even and this fact also influences the function-
ing of joints. For example, the temporomandibular joint` capsule is thinner from the
anterior side than from the posterior and lateral sides, therefore, the range of forward
movements is greater at this joint.
1. General arthrosyndesmology 17

5. The ligaments, strengthening the articular capsule, limit and direct the move-
ments, because collagenic fibers possess not only great strength but also low tensility.
In the hip joint the iliofemoral ligament limits extension and pronation of the thigh,
the pubofemoral ligament limits abduction and supination of the thigh. The strongest
ligaments are in the sacroiliac joints, therefore, the movements at these joints are almost
absent.
6. Muscles surrounding the joint have constant tone, they pull articulating bones
to each other and fasten them. The force of muscle tension reaches 10 kg per 1 cm2 of
the width of muscle. If we remove the muscles and preserve the articular capsule and
ligaments, the range of movements significantly increases. Besides, the direct inhibitory
effect on the movements at joints, the muscles also influence them indirectly (by means
of ligaments, from which they originate). During the contraction of muscles ligaments
become rigid.
7. Synovial fluid hold the articulate surfaces together and lubricates them. In case of
arthritis or arthrosis the production of fluid is disorderd and pain and crackling appear
in such joints, the range of movements decreases.
8. Helical deviation is typically for the humeroulnar joint only; it limits the move-
ments.
9. Atmospheric pressure contributes to the cohesion of the articular surfaces with
the force 1 kg per 1 cm2 and evenly pulls them together, moderately limiting the move-
ments.
10. Condition of skin and subcutaneous fat effects the movements. In overweight
people the range of movements is always less because of excessive subcutaneous fat. Vise
versa, in slender, athletically built people the range of movements is greater. In case of
skin diseases, when it loses its elasticity, the range of movements significantly decreases.
After severe burn or wounds, contractures are formed which limit the movements.
For the determination of the range of movements several methods are used. Trauma-
tologists measure it with the help of goniometer. For each joint its own starting position
is distinguished. The starting position for the shoulder joint is such a position of the
upper limb, when it is parallel to the body in the vertical plane. For the elbow joint the
starting position is full extension (1800). Pronation and supination are determined when
the elbow joint is bent at a right angle, and the hand is in sagittal plane.
In anatomic researches the angle of mobility can be calculated according to the dif-
ference between the archs of rotation on each of articulating surfaces. The size of this
angle depends on the following factors: sex, age, fitness level and individual features.

TEST QUESTIONS
1. What types of the bone junctions are distinguished?
2. List the groups of the solid joints.
3. Define the fibrous joints. What types of the fibrous joints do you know?
4. Give the description and examples of each type of the fibrous joints.
5. Define the cartilaginous joints. What types of the cartilaginous joints do you
know? Define a symphisis.
6. Give the description and examples of each type of the cartilaginous joints.
7. Define the osseous joints. Give the examples of such joints.
8. Define the synovial joints.
9. What three main structures are typical for each synovial joint?
10. Give the characteristic of the articular surfaces.
18 ARTHROSYNDESMOLOGY

11. Give the characteristic of the articular cavity.


12. Give the characteristic of the articular capsule.
13. List the structures of the accessory apparatus of synovial joints. Describe each of
these structures.
14. Describe the possible axes of movements and the types of movements at synovial
joints.
15. Describe the principles of the synovial joints classification.
16. Describe the uni-axial joints. What types of the uni-axial joints do you know?
Give the examples.
17. Describe the bi-axial joints. What types of the bi-axial joints do you know? Give
the examples.
18. Describe the multi-axial joints. What types of the multi-axial joints do you know?
Give the examples.
19. Define the simple joints. Give the examples.
20. Define the compound joints. Give the examples.
21. Define the combined joints. Give the examples.
22. What factors determine the range of movements at synovial joints?
2. THE JOINTS OF TRUNK
The joints of the trunk include the joints of individual vertebrae, joints of ribs and
joints of sternum.

2.1. The Joints between Individual Vertebrae


All vertebrae articulate with each other by the joints between their bodies, arches
and articular processes (table 2.1).
Table 2.1
Joints between Individual Vertebrae
Short joints (of adjacent vertebrae) Long joints (along the whole vertebral column)
Joints of vertebral bodies: intervertebral Anterior longitudinal ligament
disc Posterior longitudinal ligament
Joints of processes:
1. Joints of spinous processes: interspinous Supraspinous ligament
ligaments Nuchal ligament
2. Joints of transverse processes:
intertransverse ligaments
3. Joints of articular processes:
intervertebral (zygapophisial) joints
Joints of vertebral arches: ligamenta flava

The vertebral bodies of adjacent vertebrae ar-


ticulate by intervertebral discs, disci intervertebrales.
There is no disc between the I and II cervical verte-
brae only. The total height of all intervertebral discs
is about one fourth of the length of the vertebral
column.
The disc is composed of mainly fibrous cartilage
and it is made up of two parts, which gradually con-
tinues into each other (fig. 2.1). Along the periphery
there is an annulus fibrous, anulus fibrosus, consist-
ing of concentric plates. These plates are comprised
of spiral and decussated fibers. The decussation of
the spiral fibers is a basic factor, which limits torsion
of the vertebral column.
The central part of the disc is a nucleus pulpo- Fig. 2.1. Joints of individual verte-
sus, nucleus pulposus. It is composed of amorphous brae. Horizontal section between the
intercellular matrix, which is almost incompressible II and III lumbar vertebrae:
and always tends to retain its spheroidal form. The 1 — spinous process (processus spinosus);
nucleus pulposus is displaced slightly backwards, it 2 — ligamentum flavum (ligamentum fla-
is compressed by the bodies of two adjacent verte- vum); 3 — intervertebral joint (articulatio
brae and it possesses shock-absorbing properties. intervertebralis); 4 — transverse process
It is like elastic pillow, which decreases vertical load (processus transversus); 5 — annulus fibrosus
on the intervertebral disc pushing away the vertebral (anulus fibrosus); 6 — anterior longitudinal
ligament (ligamentum longitudinale ante-
bodies of the adjacent vertebrae to opposite sides. rius); 7 — nucleus pulposus (nucleus pul-
The diameter of discs is bigger than the diameter posus); 8 — posterior longitudinal ligament
of vertebral bodies, therefore, in normal, the inter- (ligamentum longitudinale posterius)
20 ARTHROSYNDESMOLOGY

vertebral discs protrude outside the limits of the vertebral bodies. The thickness of discs
(height) greatly differs at different levels of the vertebral column. The maximal discs
height in the cervical part is 5—6 mm, in the thoracic part — 3—4 mm, in the lumbar
part — 10—12 mm. The thickness of the discs changes front to back: in the thoracic part
the disc is thinner from the anterior side, in the cervical and lumbar parts it is thinner
from the posterior side.
From the anterior and posterior sides the vertebral bodies are connected by ante-
rior and posterior longitudinal ligaments correspondently (fig. 2.1, 2.4). The anterior
longitudinal ligament, ligamentum longitudinale anterius, is attached to the pharyngeal
tubercle of the occipital bone and the anterior tubercle of the atlas, then it descends
along the anterior surfaces of the vertebral bodies and intervertebral discs and attached
to the first sacral vertebra. This ligament is firmly linked with the discs and periosteum
of vertebrae. It limits excessive extension of the vertebral column.

Fig. 2.2. Middle section of vertebral column


at the level of thoracic vertebrae: Fig. 2.3. Frontal section through vertebral
1 — vertebral foramen (foramen vertebrale); 2,
canal at the level of I—II lumbar vertebrae
4 — ligamentum flavum (ligamentum flavum); (anterior aspect):
3 — interspinous ligament (ligamentum interspi- 1 — vertebral arch (arcus vertebrale); 2 — pedicle of
nale); 5 — inferior vertebral notch (incisura verte- vertebral arch (pediculus arcus vertebrae); 3 — liga-
bralis inferior); 6 — intervertebral disc (discus inter- menta flava (ligamenta flava); 4 — intervertebral
vertebralis); 7 — annulus fibrosus (anulus fibrosus); disc (discus intervertebralis); 5 — anterior longitu-
8 — nucleus pulposus (nucleus pulposus) dinal ligament (ligamentum longitudinale anterius)

The posterior longitudinal ligament, ligamentum longitudinale posterius, extends


along the posterior surfaces of vertebral bodies. It is attached to the clivus of the occipital
bone and continues caudally to the sacrum. It widens at the level of each intervertebral
disc. This ligament is loosely linked with the vertebral bodies, but it is firmly attached to
intervertebral discs. The posterior longitudinal ligament is the antagonist of the anterior
longitudinal ligament and it limits the excessive flexion of the vertebral column.
The vertebral arches are connected by the ligamenta flava, ligamenta flava. Their
color is caused by the prevalence of elastic fibers. These ligaments fill up the spaces be-
tween the arches, but they don`t occupy intervertebral foramina. The elastic fibers of the
2. The Joints of trunk 21

ligamenta flava are arranged as following: from the inferior border and internal surface
of the arch of overlying vertebra (beginning from the II cervical vertebra) to the superior
border and external surface of the arch of subjacent vertebra. The ligamenta flava are
elastic and they contribute to the strengthening of the vertebral column. Together with
the vertebral bodies, arches and intervertebral discs they form the vertebral canal, which
encloses the spinal cord.
There are short interspinous ligaments, ligamenta interspinalia, between the spinous
processes of the adjacent vertebrae, which are more developed in the lumbar region. These
ligaments continue to the unpaired supraspinous ligament, ligamentum supraspinale, ex-
tending along the apices of all spinous processes like a continuous cord (fig. 2.4, 2.5).

Fig. 2.4. Joints of vertebrae. Thoracic part


(lateral aspect):
1 — intervertebral disc (discus intervertebralis);
Fig. 2.5. Joints of vertebrae. Thoracic part
2 — supraspinous ligament (ligamentum supraspi-
nale); 3 — interspinous ligament (ligamentum in- (posterior aspect):
terspinale); 4 — intervertebral joint (articulatio in- 1 — intertransverse ligaments (ligamenta inter-
tervertebralis); 5 — anterior longitudinal ligament transversaria); 2 — costotransverse ligaments (liga-
(ligamentum longitudinale anterius); 6 — posterior menta costotransversaria); 3 — supraspinous liga-
longitudinal ligament (ligamentum longitudinale ment (ligamentum supraspinale); 4 — ligamentum
posterius) flavum (ligamentum flavum)

In the cervical part this ligament is termed the nuchal ligament, ligamentum nuchae,
it extends from the spinous process of the VII cervical vertebra to the external occipital
protuberance. It has the shape of triangular plate located sagittaly. The nuchal ligament
is comprised of mainly elastic fibers and it is much more developed in animals; in hu-
mans it is a rudimentary structure. All ligaments, connecting spinous processes, limit
flexion of the vertebral column.
Between transverse processes there are intertransverse ligaments, ligamenta inter-
transversaria. They limit lateral flexion of the vertebral column. There are no such liga-
ments in the cervical part.
Only intervertebral (zygapophisial) joints, articulationes intervertebrales (zygapophy-
siales), are synovial joints. Inferior articular processes of each overlying typical vertebra
22 ARTHROSYNDESMOLOGY

articulate with superior articular processes of the underlying vertebra. The articular sur-
faces of the articular processes are flat and covered by hyaline cartilage. The articular
capsule is attached to edges of the articular surfaces.
According to the function, the intervertebral joints are multi-axial and combined.
The movements at these joints are: flexion, extension, lateral flexion, torsion and cir-
cumduction.
The V lumbar vertebra articulates with the sacrum with the help of the same joints
as all individual typical vertebrae. Sometimes, the intervertebral disc between the fifth
lumbar vertebra and the first sacral vertebra has a small cavity. This joint is termed the
lumbosacral symphysis.

2.2. Joints between Sacrum and Coccyx


There is an intervertebral disc, discus intervertebralis, between the bodies of the V
sacral and I coccygeal vertebrae. In most cases within the disc there is a small cavity, so
this junction belongs to symphyses and is termed sacrococcygeal symphysis. Sacral and
coccygeal horns are connected by connetive tissue (syndesmosis).
The lateral sacrococcygeal ligament, ligamentum sacrococcygeum laterale, is paired,
it passes from the inferior border of the lateral sacral crest to the rudiment of the trans-
verse process of the I coccygeal vertebra. This ligament is the intertransverse ligament
analogue.
The anterior sacrococcygeal ligament, ligamentum sacrococcygeum anterius, is the
continuation of the anterior longitudinal ligament of the vertebral column. It is on the
anterior surface of the sacrococcygeal junction.
The deep posterior sacrococcygeal ligament, ligamentum sacrococcygeum posterius
profundum, is the continuation of the posterior longitudinal ligament and is located on
the posterior surface of the bodies of the V sacral and I coccygeal vertebrae.
The superficial posterior sacrococcygeal ligament, ligamentum sacrococcygeum pos-
terius superficiale, passes from the margin of sacral hiatus to the posterior surface of the
coccyx. It closes the sacral hiatus almost entirely and corresponds to the supraspinous,
inerspinous ligaments and ligamenta flava. The comparison of the ligaments of the ver-
tebral column and of the sacrococcygeal junction is given in Table 2.2.
Table 2.2
Joints between Sacrum and Coccyx
(in comparison with the joints between individual vertebrae)

Joints between individual vertebrae Joints between sacrum and coccyx

1. Intervertebral disc 1. Sacrococcygeal symphysis


2. Intervertebral joint 2. Sacrococcygeal syndesmosis
3. Intertransverse ligament 3. Lateral sacrococcygeal ligament
4. Anterior longitudinal ligament 4. Anterior sacrococcygeal ligament
5. Yellow, interspinous ans supraspinous 5. Superficial posterior sacrococcygeal ligament
ligaments 6. Deep posterior sacrococcygeal ligament
6. Posterior longitudinal ligament
2. The Joints of trunk 23

2.3. Joints between I Cervical Vertebra and II Cervical


Vertebra and between I Cervical Vertebra and Skull
The first cervical vertebra articulates
with the skull by means of the atlantoocipital
joints, articulationes atlantooccipitales. Be-
tween the I cervcal vertebra and the II cervi-
cal vertebrae there are three synovial joints:
median atlantoaxial joint, articulatio atlanto-
axialis mediana, and the right and left lateral
atlantoaxial joints, articulationes atlantoaxi-
ales laterales dextra et sinistra.
Atlantoocipital joint, articulatio atlan-
tooccipitalis, is paired ellipsoid, bi-axial, com-
bined joint (fig. 2.6). It is formed between
the occipital condyle, condylus occipitalis, and
the superior articular surface of the I cervi-
cal vertebra, facies articularis superior atlantis.
The articular surfaces are covered by hyaline
Fig. 2.6. Ligaments connecting I and II cer-
cartilage. The capsule of the joint is loose, it is vical vertebrae and occipital bone (posterior
attached along the edges of the articular sur- aspect):
faces. The atlantoaxial joints are anatomical-
1 — occipital bone (clivus) (os occipitale); 2 — su-
ly separated, but they function together. The perior longitudinal fascicle (fasciculus longitudina-
following movements occur at these joints: lis superior); 3 — alar ligament (ligamentum alare);
flexion and extension around frontal axis, i.e. 4 — transverse ligament of atlas (ligamentum trans-
the tilts of the head forwards and backwards versum atlantis); 5 — inferior longitudinal fascicle
(the range of movement is about 45 degrees); (fasciculus longitudinalis inferior); 6 — tectorial
membrane (membrana tectoria)
the tilts of the head to the right and to the left
around sagittal axis (the range of movement
is 15—20 degrees); conical movement (circumduction).
The anterior atlantooccipital membrane, membrana atlantooccipitalis anterior,
stretches between the basilar part of occipital bone and superior edge of the anterior arch
of atlas. The posterior atlantooccipital membrane, membrana atlantooccipitalis posterior,
connects the posterior arch of atlas with the posterior margin of the foramen magnum;
it is a modified ligamentum flavum. These membranes close the wide spaces between the
atlas and occipital bone.
Median atlantoaxial joint, articulatio atlantoaxialis mediana, is between the ante-
rior and posterior articular facets of the axial dens, facet for dens of the atlantal anterior
arch and the articular surface of the transverse atlantal ligament. The anterior articular
facet of dens, facies articularis anterior dentis, articulates with the facet for dens, fovea
dentis, on the posterior surface of the atlantal anterior arch. The posterior articular sur-
face of dens, facies articularis posterior dentis, articulates with articular area on the an-
terior surface of the transverse atlantal ligament, ligamentum transversum atlantis (fig.
2.7). This ligament extends between the medial surfaces of the atlantal lateral masses
behind the dens. It doesn`t permit the dens to displace backwards. The superior and
inferior longitudinal fascicles, fasciculi longitudinales superior et inferior, arise from the
central, slightly widened part of the transverse atlantal ligament — the first fascicle as-
cends to the anterior semicircle of the foramen magnum, the inferior fascicle descends
24 ARTHROSYNDESMOLOGY

to the posterior surface of the body of axis.


These two fascicles together with transverse
atlantal ligament form the cruciate ligament
of atlas, ligamentum cruciforme atlantis.
Therefore, the dens is enclosed into bony-
fibrous ring formed by the anterior arch of
atlas anteriorly and the transverse ligament
of atlas posteriorly.
According to the shape, the median at-
lantoaxial joint is pivot, articulatio trochoid-
ea. Only one movement occurs at this joint —
Fig. 2.7. Articuation of atlas with dens of
rotation around vertical axis passing through
axis. Horizontal section (superior aspect): the dens of axis. The rotation of atlas around
the axis occurs together with the skull (30—
1 — posterior articular facets of the dens (facies ar-
ticularis posterior dentis); 2 — lateral mass of atlas 40 degrees to the right and to the left).
(massa lateralis atlantis); 3 — dens (dens); 4 — facet Lateral atlantoaxial joints (right and
for dens (fovea dentis); 5 — anterior articular facet of left), articulationes atlantoaxiales laterales
dens (facies articularis anterior dentis); 6 — transverse dextra et sinistra, are combined with each
ligament of atlas (ligamentum transversum atlantis); other and with the median atlantoaxial joint.
7 — tectorial membrane (membrana tectoria)
Each of them is between the inferior articular
surface of the atlas, facies articularis inferior
atlantis, and superior articular facet of axis, facies articularis superior axis. The articular
surfaces are flat, covered by hyaline cartilage. The articular capsule is attached to the
edges of the articular surfaces.
The median and lateral atlantoaxial joints have accessory ligaments including the
alar ligaments and apical ligament of dens. The alar ligaments, ligamenta alaria, are two
strong ligaments, each of them arise from the apex and lateral sides of the dens, then
they pass obliquely upward to the medial surfaces of the occipital condyles. These liga-
ments limit the rotation at the atlantoaxial joints. The apical ligament of dens, ligamen-
tum apicis dentis, is a thin bundle which ascends from the apex of dens to the anterior
margin of the occipital bone`s basilar part.
The atlantoaxial joints are covered posteriorly, from the side of the vertebral canal,
by a broad strong fibrous plate termed tectorial membrane, membrana tectoria. It is the
upper part of the posterior longitudinal ligament. It descends from the clivus of the oc-
cipital bone and the body of axis.
The lateral atlantoaxial joints function together with the median atlantoaxial joint.
Only one movement occurs at these combined joints — rotation.
Taking together, the atlantoaxial and atlantooccipital joints have 6 types of move-
ments: the tilts of the head forwards and backwards; the tilts of the head to the sides; cir-
cumduction and rotation. These joints function as a multi-axial spheroidal joint, which
possesses maximally possible number of movements.

2.4. Vertebral Column


The vertebral column, columna vertebralis, is made up of the vertebrae and their joitns
(fig. 2.8). It includes the cervical, thoracic, lumbar and sacrococcygeal parts. The function of
the vertebral column is very important. It supports the head, serves as a flexiable axis of the
trunk, takes part in the formation of the walls of the thoracic and abdominal cavities and pel-
vis. Also it supports the body and protects the spinal cord enclosed into the vertebral canal.
2. The Joints of trunk 25

The lower parts of the vertebral column experience the most load. The vertebral bod-
ies have maximal width at the level of the sacrum, then they gradually narrow to the level
of the V thoracic vertebra, become wider again to the level of the lower cervical vertebrae
and at least narrow again at the level of the upper superior vertebrae. The superior por-
tion of the thoracic part enlarges due to attachment of the upper limb at this level.
When all vertebrae join together, 23 pairs of intervertebral foramina, foramina inter-
vertebralia, are formed; they transmit the spinal nerves.
In males of average height (170 cm) the length of the vertebral column is about
73 cm (the cervical part — 13 cm, thoracic part — 30 cm, lumbar part — 18 cm, sacro-
coccygeal — 12 cm). In females the vertebral column is 3—5 cm shorter than in males,
and its length is 68—69 cm. In old age the length of the vertebral column decreases. In
general, the length of the vertebral column is 2/5 of the whole
length of the body.
The vertebral column is not absolutely vertical. It is curved in
sagittal plane. The curves, which are convex dorsally, are termed
kyphoses, kyphoses; the curves, which are convex ventrally, are
termed lordoses, lordoses. The cervical and lumbar physiologi-
cal lordoses and thoracic and sacral physiological kyphoses are
distinguished. At the junction of the V lumbar vertebra with the
I sacral vertebra there is a prominence called the promontory,
promontorium.
The kyphoses and lordoses are specific features of the hu-
man vertebral column - they appeared due to the vertical posi-
tion of the human body. The vertical axis of the vertebral column
descends from the anterior tubercle of atlas, crosses the bodies
of the VI cervical, IX thoracic and III sacral vertebrae and termi-
nates on the apex of coccyx.
The physiological lordoses and kyphoses are constant for-
mations. The thoracic kyphosis and lumbar lordosis are greater
in females than in males. In the horizontal position of the body
the curvatures become slightly lesser, in the vertical position they
are more expressed and when the load increases (during carry-
ing heavy weight) the curvatures are significantly expressed.
The curvatures of the vertebral column appear after birth.
The vertebral column of newborns is arch-shaped and convex
dorsally. At the 2—3 months of life a child begins to hold up the
head and the cervical lordosis starts to form. At the 5–6 months
a child begins to sit upright and the thoracic kyphosis is formed.
The lumbar lordodsis appears at the 9—12 months because of
the adaptation of the human body to the vertical position, when
a child begins to walk. At the same time the thoracic and sacral
kyphoses become more expressed. Therefore, the curvatures of
the vertebral column are functional adjustments of the human
body to keep the balance in the vertical
position. Fig. 2.8. Vertebral column (lateral aspect):
In normal, the vertebral column has
1 — intervertebral foramina (foramina intervertebra-
no curvatures in the frontal plane. Its de- lia); 2 — promontory (promontorium); CL — cervical
viation from the median plane is known as lordosis; ThK — thoracic kyphosis; LL — lumbar lor-
skoliosis, skoliosis. dosis; SK — sacral kyphosis
26 ARTHROSYNDESMOLOGY

The flexbility of the vertebral column is determined by the functioning of numer-


ous joints between the vertebrae. The following movements in the vertebral column can
occur: tilts forwards and backwards; tilts to the sides; torsion (tiwsting); circumduction
and springy-like (bouncing) movements.
The tilts of the trunk forwards and backwards occur around frontal axis, their am-
plitude is 170—245 degrees. When the trunk is bent forwards, the vertebral bodies draw
closely together, but spinous processes move apart from each other. The anterior longi-
tudinal ligament of the vertebral column relaxes. The stretching of the posterior longi-
tudinal, interspinous, supraspinous ligaments and ligamentum flavum limit this move-
ment. While bending backwards, all the ligaments of the vertebral column relax, except
the anterior longitudinal ligament which limits this movement of the vertebral column.
Intervertebral discs change their form during tilts. Their thickness slightly decreases on
the side of movement and increases on the opposite side.
The tilts of the vertebral column to the right and to the left occur around sagittal
axis. The range of this movement is 165 degrees.
The torsion (twisting) of the vertebral column occurs around vertical axis. Its ampli-
tude is 120 degrees.
In conical movement (circumducton) the vertebral column makes a cone alternately
around sagittal and frontal axes. When we walk or jump, springy-like (bouncing) move-
ments occur in the vertebral column: the adjacent vertebrae either draw together or move
apart (during this movement the intervertebral discs amortize shocks).
The cervical and lumbar parts of the vertebral column are the most mobile owing to
higher intervertebral discs. The thoracic part is the least flexible because of the following
factors: the small height of intervertebral discs, the significant tilt of spinous processes
downwards and the frontal position of the articular surfaces of the intervertebral joints.

2.5. The Joints of Ribs


The ribs articulate with each other, with thoracic vertebrae and sternum (fig. 2.9,
2.10). They join with the vertebrae by means of the costovertebral joints, articulationes
costovertebrales, which include the joint of costal head and costotransverse joint. The
XI and XII ribs have no costotransverse
jonts.

Fig. 2.9. Joints of sternum with clavicle and ribs.


Shoulder joint:
1 — shoulder joint (capsule) (articulatio humeri (cap-
sula)); 2 — coracohumeral ligament (ligamentum
coracohumerale); 3 — coracoacromial ligament (liga-
mentum coracoacromiale); 4 — acromioclavicular joint
(articulatio acromioclaviculare); 5 — coracoclavicular
ligament (ligamentum coracoclaviculare); 6 — mem-
brane of sternum (membrana sterni); 7 — costoclvicu-
lar ligament (ligamentum costoclaviculare); 8 — ster-
noclavicular ligament (ligamentum sternoclaviculare);
9 — interclavicular ligament (ligamentum inter-
claviculare); 10 — articular disc (discus articularis);
11 — sternocostal joints (articulationes sternocostales);
12 — costal cartilage (cartilago costalis); 13 — inter-
chondral joints (articulationes interchondrales)
2. The Joints of trunk 27

Joint of costal head, articulatio capitis costae, is between the costal demi-facets of
two adjacent vertebrae (II—X), the costal facets of the I, XI, XII thoracic vertebrae and
the articular surfaces of the costal heads. Each joint of costal head from II to X has
intra-articular ligament termed the ligament of costal head, ligamentum capitis costae in-
traarticulare. It is attached to the crest of costal head and to the intervertebral disc which
separates the costal demi-facets of two adjacent vertebrae. The heads of the I, XI and
XII ribs have no crests: they articulate with complete costal facet located on the bodies
of the corresponding vertebrae; therefore, these joints have no intra-articular ligament.
From outside the capsule of the joint is reinforced by the radiate ligament of costal head,
ligamentum capitis costae radiatum. Its fibers diverge like rays and are attached to the in-
tervertebral disc and bodies of adjacent vertebrae. According to the shape the I, XI, XII
joints of costal head are spheroidal, but from II to X they are sellar, art. sellaris.
Costotransverse joint, articulatio costotransversaria, is between the articular sur-
face of the costal tubercle, facies articularis tuberculi costae, and transverse costal facet,
fovea costalis processus transverse, of vertebra. The XI and XII ribs has no such articula-
tion. The costotransverse joint is trochoid, art. trochoidea, its capsule is reinforced by the
costotransverse ligament, ligamentum costotransversarium, consisting of three bundles —
anterior costotransverse ligament, ligamentum costotransversarium anterius, which con-
nects the transverse process with the costal neck, the lateral costotransverse ligament,
ligamentum costotransversarium laterale, which connects the transverse process with the
costal tubercle and the superior costotransverse ligament, ligamentum costotransversari-
um superius, which connects the transverse process with the neck of subjacent rib.
Functionally the joint of costal head and the costotransverse joint are combined into
uni-axial pivot joint. The axis of the movement passes through the centers of both joints
and corresponds to the costal neck. The posterior end of the rib rotates around this axis
and, simultaneously, the anterior end of the rib is raised or depressed rotating outwards
because the rib is twisted. Due to the elevation of the anterior ends of the ribs the vol-
ume of thoracic cage increases, and together with the lowering of the diaphragm this
movement provides inspiration. During the depression of ribs, due to the relaxation of
muscles and elasticity of costal cartilages, expiration occurs. The elasticity of thoracic
cage and the mobility of ribs are significantly decreased with the age.
The ribs articulate with the sternum with the help of synovial joints and synchon-
droses (fig. 2.9). The hyaline synchondrosis named synchondrosis costae primae is formed
between the cartilage of the I rib and the sternum only.
Sternocostal jonts, articulationes sternocostales, are between the cartilages of the
II—VII ribs and the costal notches of the sternum. The articular capsules of these joints
are the prolongations of the perichondrium of the costal cartilages, which, in their turn,
continue to the periosteum of the sternum. The radiate sternocostal ligaments, ligamenta
sternocostalia radiata, strengthen the articular capsule from the anterior and posterior
sides. Anteriorly the radiate sternocostal ligaments are fused with the periosteum of the
sternum forming a dense sternal membrane, membrana sterni. In the joint of the II rib
there is a sternocostal intra-articular ligament, ligamentum sternocostale intraarticulare.
The anterior ends of the false ribs (VIII, IX and X) are not connected with the ster-
num directly. Their cartilages join to each other and, sometimes, modified interchon-
dral joints, articulationes interchondrales, are formed between them. The cartilages of
the false ribs form the costal arch, arcus costalis, on the right and on the left sides. These
arches bound an unpaired infrasternal angle, angulus infrasternalis, opened downwards.
The short cartilaginous ends of the XI and XII ribs terminate in the abdominal mus-
culature.
28 ARTHROSYNDESMOLOGY

The anterior ends of the ribs are connected with each other by means of an external
intercostal membrane, membrana intercostalis externa. Its fibers fill up the intercostal
spaces and extend obliquely downwards and forwards. The fibers of the internal inter-
costal membrane, membrana intercostalis interna, have opposite direction; this membrane
is well developed in the posterior parts of the intercostal spaces.

2.6. Thorax
The thoracic cage, cavea thoracis (thorax),
is a bony and cartilaginous structure consisting
of 12 thoracic vertebrae, 12 pairs of the ribs,
the sternum and their articulations (fig. 2.10).
The thorax forms the walls of the thoracic cav-
ity, which encloses the internal organs — the
heart, lungs, trachea, esophagus etc.
The anteroposterior size of the thorax is
smaller than the transverse size. The anterior
wall is the shortest, it is formed by the ster-
num and costal cartilages. The lateral walls
are longer, they are formed by the shafts of
12 ribs. The posterior wall is formed by the
thoracic part of the vertebral column and the
posterior parts of the ribs (from their heads
to the angles). The vertebral bodies protrude
into the thoracic cavity, therefore, pulmo-
Fig. 2.10. Thoracic cage (anterior aspect): nary grooves, sulci pulmonales, are formed
1 — I thoracic vertebra (vertebra thoracica I); on both sides of them. The posterior borders
2 — clavicle (clavicula); 3 — acromion (acromion); of the lungs are placed here.
4 — coracoid process (processus coracoideus); 5 — gle- Superiorly the thorax opens by a wide
noid cavity (cavitas glenoidalis); 6 — IV rib (costa IV); opening called the superior thoracic ap-
7 — XII thoracic vertebra (vertebra thoracica XII);
erture, apertura thoracis superior, which is
8 — XII rib (costa XII); 9 — I rib (costa I)
bounded by the manubrium of sternum, the I
rib and the body of the I vertebra. The plane
of the superior aperture is not horizontal and its anterior border is below than the pos-
terior one, that is why the jugular notch is projected at the level of the II—III thoracic
vertebrae. An inferior thoracic aperture, apertura thoracis inferior, is significantly wider
than the superior one; it is bounded by the body of the XII thoracic vertebrae, the XII
ribs, the ends of the XI ribs, the costal arches and by the xiphoid process.
The spaces between adjacent ribs (anteriorly the spaces between the costal cartilag-
es) are termed the intercostal spaces, spatia intercostalia. They are closed by intercostal
muscles, ligaments and membranes.
The vessels, nerves, trachea and esophagus pass through the superior thoracic ap-
erture. The inferior thoracic aperture is closed by the diaphragm which separates the
thoracic cavity from the abdominal cavity.
The shape of the thorax is like a truncated cone with the base directed downwards.
In accordance with the body types three shapes of the thorax are distinguished: coni-
cal, cylindrical and flat. The conical shape is typical for the mesomorphic body type,
the cylindrical shape — for the dolichomorphic body type and the flat shape — for the
brachymorphic body type.
2. The Joints of trunk 29

TEST QUESTIONS
1. What types of the joints between the individual vertebrae do you know?
2. How are the vertebral bodies connected?
3. How are the vertebral arches connected?
4. How are the vertebral processes connected?
5. Describe the short and long joints of the vertebrae.
6. Where are the longitudinal ligaments of the vertebral column located and attached?
7. Describe the function of the longitudinal ligaments of the vertebral column.
8. Where are short ligaments of the vertebral column attached?
9. Describe the function of the short ligaments of the vertebral column.
10. Describe the intervertebral jont according to the classifications of synovial joints.
11. How are the sacrum and the coccyx connected?
12. What movements may occur in the vertebral column?
13. Describe the joints between the atlas and the skull according to the classifica-
tions of synovial joints. What ligaments reinforce them? What movements occur at these
joints?
14. Describe the joints between the atlas and the axis according to the classifications of
synovial joints. What ligaments reinforce them? What movements occur at these joints?
15. Describe the function of the vertebral column.
16. Describe the physiological curvatures of the vertebral column. What is their value?
17. In what sequence do the physiological curves appear after birth?
18. What pathological curvature may appear in the vertebral column?
19. What bones are the true ribs connected with? Describe the joints of ribs according
to the classifications.
20. What bones are the false ribs connected with?
21. What bones are the floating ribs connected with?
22. What structures form the thorax?
23. Describe the function of the thoracic cage. What organs does it enclose?
24. What structures bound the superior and inferior aperture of the thoracic cage?
What organs pass through the superior thoracic aperture?
25. What ribs form the costal arch?
26. What is the infrasternal angle?
27. What types of the thorax do you know?

CLINICOANATOMICAL PROBLEMS
1. The patient complaines of pains in the thoracic part of the vertebral column and
the decrease of the range of movements. The frontal and lateral X-ray pictures demon-
strates the decrease of the height of the intervertebral discs and numerous osteophytes.
What joints are impaired in this patient? How does it affect the function of these joints
and patient’s posture?
2. In aircraft accident a patient felt an instant pain in the lumbar part of the vertebral column.
Besides, he couldn`t stand up. What impairement of the vertebral column can be supposed?
3. A 12-years old patient has a right sided scoliosis of the thoracic part of the verte-
bral column. The X-ray picture shows the fusion of the posterior ends of VIII-X ribs. The
function of which joints can be damaged?
4. The 70-years old patient complains of pains and the decrease of mobility in the
thoracic part of the vertebral column. The X-ray picture demonstrates ossification of the
intervertebral discs. What synovial joints can be involved into this process?
3. THE JOINTS OF SKULL BONES
The bones of the skull join with each other mainly by solid (non-synovial) joints:
syndesmoses and synchondroses (in the least). Only temporomandibular joint is a syn-
ovial joint (apart from the joints of auditory ossicles).

3.1. The Solid Joints of Skull Bones


The bones of the calvaria and the facial
bones articulate by means of sutures. The
serrate and squamous sutures connect the
bones of the calvaria. The serrate sutures are:
sagittal suture, sutura sagittalis (between the
parietal bones), coronal suture, sutura coro-
nalis (between the frontal and parietal bones)
and lambdoid suture, sutura lambdoidea (be-
tween the occipital and parietal bones). The
squamous part of the temporal bone joins
with the parietal bone and sphenoid`s great-
er wing by the squamous suture. The facial
bones articulate by harmonic plane sutures.
The names of the sutures are formed by the
names of the articulating bones (for ex-
ample, frontozygomatic suture, sutura fron-
tozygomatica; frontoethmoidal suture, sutura
frontoethmoidalis etc.).
Fig. 3.1. Skull of newborn (superior aspect): The skull of a fetus, newborn and the
1 — frontal (metopic) suture (sutura fronta- skull of a child during the first two years of
lis (metopica)); 2 — frontal tuber (tuber frontale); life is incompletely developed, and fibrous
3 — posterior fontanelle (fonticulus posterior); membranes separate the bones forming fon-
4 — occipital bone (os occipitale); 5 — lambdoid tanelles (fig. 3.1). The anterior fontanelle
suture (sutura lambdoidea); 6 — parietal tuber (tu-
ber parietale); 7 — sagittal suture (sutura sagittalis);
(major, frontal), fonticulus anterior (major,
8 — parietal bone (os parietale); 9 — coronal suture frontalis) is the largest, it is between two parts
(sutura coronalis); 10 — frontal bone (os frontale); of the frontal bone and the parietal bones. Its
11 — anterior fontanelle (fonticulus anterior) size is 30 × 25 mm, it has a rhomboid shape
and closes during the second year of life.
The posterior fontanelle (occipital, minor), fonticulus posterior (minor, occipitalis) is
between the occipital bone and two parietal bones. Its size is 10х10 mm, it is triangular-
shaped and it closes during the second month of life. The anterior and posterior fonta-
nelles are unpaired. Besides, there are paired fontanelles in infant`s skull: sphenoidal,
fonticulus sphenoidalis, and mastoid, fonticulus mastoideus, fontanelles. They close before
the birth or during the first two weeks of life. The closure of the fontanelles eventually
forms the serrate sutures.
The bones of skull base are connected by cartilaginous joints — synchondroses. They
are composed of fibrous cartilage. In children between the body of the sphenoid bone
and the basilar part of the occipital bone there is a temporary synchondrosis, synchon-
drosis sphenooccipitalis. Also there are permanent synchondroses: synchondrosis petrooc-
cipitalis between the pyramid of temporal bone and the basilar part of occipital bone
and synchondrosis sphenopetrosa between the sphenoid`s greater wing and the pyramid
3. The joints of skull bones 31

of temporal bone. The sphenopetrosal synchondrosis covers foramen lacerum. Usually,


with age the cartilages are gradually replaced with the osseous tissue.

3.2. Temporomandibular Joint


The temporomandibular joint, ar-
ticulatio temporomandibularis (fig. 3.2), is a
condylar combined joint. It is between the
head of the mandible, caput mandibulae,
mandibular fossa, fossa mandibularis, and the
articular tubercle, tuberculum articulare, of
temporal bone. The head of the mandible is
a condyle in shape, it is covered by cartilage
mainly from its anterior side. In front of the
petrotympanic fissure the mandibular fossa
is lined with the fibrous cartilage; the latter
also completely covers the articular tubercle.
On the temporal bone the articular cap-
sule is attached in front of the articular tu-
bercle and behind of it (at the level of the
petrotympanic fissure). On the mandible the
capsule is attached to the condylar process
in the region of its neck (anteriorly 0,5 cm
higher than posteriorly). The anterior part Fig. 3.2. Right temporomandibular joint.
of the capsule is thinner than other parts. Sagittal section:
The feature of the temporomandibular 1 — coronoid process (processus coronoideus);
joint is the presence of the articular disc, dis- 2 — ramus of mandible (ramus mandibulae);
cus articularis, which provides congruence of 3 — stylomandibular ligament (ligamentum stylo-
mandibulare); 4 — head of mandible (caput man-
the articular surfaces. The disc has the shape dibulae); 5 — mastoid process (processus mastoi-
of a biconcave lens. Its periphery is fused deus); 6 — external acoustic porus (porus acusticus
with the articular capsule, and as a result, externus); 7 — articular capsule (capsula articu-
the articular cavity is divided into two iso- laris); 8 — mandibular fossa (fossa mandibularis);
lated floors. In the lower floor the synovial 9 — articular disc (discus articularis)
membrane covers not only the articular cap-
sule, but the posterior surface of the neck of condylar process located inside the capsule.
In the upper floor the synovial membrane lines the internal surface of the capsule and
attached to the edge of the articular cartilage.
The lateral ligament, ligamentum laterale, strengthens the articular capsule from
the lateral side. This ligament arises from the base of the temporal bone`s zygomatic
process, its fibers diverge like rays backwards and downwards and attached to the pos-
terolateral surface of the mandibular neck. This ligament limits the movement of the
mandible backwards and outwards.
The joint is also reinforced by the sphenomandibular ligament, ligamentum sphe-
nomandibulare, and stylomandibular ligament, ligamentum stylomandibulare. The first
one stretches from the sphenoidal spine to the lingula of the mandible. The second one
extends from the styloid process of the temporal bone to the internal surface of the lower
edge of the mandible`s ramus.
The following movements occur at the temporomandibular joint:
1) around frontal axis the mandible can be depressed or elevated;
32 ARTHROSYNDESMOLOGY

2) during the displacement of the frontal axis the mandible can be protruded or
retracted;
3) around vertical axis slight rotation may occur.
During the depression the mandible makes an arch. This movement includes three
phases. In the first phase the movement occurs only in the lower floor of the articular
cavity. In the second phase the significant depression occurs and the articular disc to-
gether with the head of the mandible slides forwards to reach the articular tubercle. This
movement occurs in both floors at the same time. In the third phase the maximal depres-
sion of the mandible up to 35—40 ° takes place. It happens in the lower floor of the joint
and the disc reaches the articular tubercle. Sometimes, the excessive depression of the
mandible causes its dislocation. In elevation of the mandible all mentioned above phases
follow each other in reverse order. During the protruding of the mandible the condylar
processes together with the articular discs slide forwards and reach the articular tuber-
cles in both joints. The movements occur in upper and lower floors simultaneously.
During the lateral movements the both joints function together, but the movements
at the right and at the left joints are different. For example, when the mandible moves to
the right, at the right joint the articular head remains in the articular fossa and rotates
around vertical axis, but at the left joint the head together with the disc reaches the ar-
ticular tubercle making circumduction.

TEST QUESTIONS
1. What types of solid joints connect the skull bones?
2. What sutures, according to the classification, do you know?
3. What are the skull bones articulated by serrate sutures? Name these sutures.
4. What are the skull bones connected by squamous suture?
5. What are the bones of the skull connected by plane sutures?
6. What are the skull bones connected by synchondroses? Which of them are tempo-
rary (permanent)?
7. Define the fontanelles. What is their role in an infant`s skull?
8. List the fontanelles and describe the places of their location. Which of them are
paired (unpaired)?
9. Describe the articular surfaces of the temporomandibular joint.
10. What is the function of the artcular disc of the temporomandibular joint?
11. Describe temporomandibular joint according to the classifications of synovial
joints. What ligaments reinforce this joint? Describe the movements at the temporoman-
dibular joint.

CLINICOANATOMICAL PROBLEMS
1. Forensic pathologist must determine the age of a baby (1—3 years of age). What
features of the skull should he base on?
2. While yawning, a patient felt acute pain and was anable to close the mouth. A doc-
tor made the diagnosis of disclocation of the temporomandibular joint. What anatomical
structures can be damaged? How should the dislocation be set, taking into consideration
the anatomical features of this joint?
4. THE JOINTS OF UPPER LIMBS

4.1. The Joints of Shoulder Girdle


Proper ligaments of scapula are two
ligaments which have no relation to any syn-
ovial joints.
The first of them is the coracoacro-
mial ligament, ligamentum coracoacromi-
ale, which is the strongest ligament of the
scapula. It has the shape of a triangular plate
and connects the apex of the acromion with
the coracoid process (fig. 4.1), forming the
so-called «vault of the shoulder joint». It
protects the joint from above and limits the
movements of the humerus upwards.
The second one is the superior transverse
scapular ligament, ligamentum transversum
scapulae superius. It is a short thin bundle,
which stretches over the scapular notch and
converts the notch into the foramen for the
passage of the suprascapular nerve; quite of-
ten, this ligament ossifies.
Acromioclavicular joint, articulatio
acromioclavicularis, is between the clavicu- Fig. 4.1. Joint of shoulder girdle. Right shoul-
lar facet of the acrоmion, facies articularis der joint (dissected):
clavicularis acromii, and the acromial facet 1 — coracoacromial ligament (ligamentum cora-
of the clavicle, facies articularis acromi- coacromiale); 2 — trapezoid ligament (ligamentum
alis claviculae. These articular surfaces are trapezoideum); 3 — conoid ligament (ligamentum
slightly concave, sometimes they can be flat. conoideum); 4 — clavicle (clavicula); 5 — cora-
coid process (processus coracoideus); 6 — scapula
The capsule of the joint is taut, reinforced (scapula); 7 — glenoid labrum (labrum glenoidale);
by the acromioclavicular ligament, ligamen- 8 — glenoid cavity (cavitas glenoidalis); 9 — tendo
tum acromioclaviculare. Very rarely this joint m. biceps brachii (caput longum); 10 — acromion
contains an articular disc, discus articularis, (acromion); 11 — acromioclavicular ligament (lig-
which divides the cavity of the joint into two amentum acromioclaviculare)
floors.
At the acromioclavicular joint all types of movements are possible, but their range
is insignificant. Besides the acromioclavicular ligament, the coracoclavicular ligament,
ligamentum coracoclaviculare, strengthens the joint; it connects the conoid tubercle and
the trapezoid line of the clavicle with the coracoid process. Usually this ligament is di-
vided into two parts: quadrangular trapezoid ligament, ligamentum trapezoideum, lying
laterally and anteriorly, and triangular conical ligament, ligamentum conoideum, located
medially and posteriorly. Both ligaments converge together at an angle opened medially
and anteriorly.
Sternoclavicular joint, articulatio sternoclavicularis, is formed by articulation of
the clavicle and the manubrium of sternum. The articular surfaces of this joint are the
sternal end of the clavicle, extremitas sternalis claviculae, and clavicular notch of ster-
num, incisura clavicularis manubrii sterni (fig. 2.9). The surfaces are incongruent, they
34 ARTHROSYNDESMOLOGY

are covered by fibrous cartilage. There is


an articular disc, discus articularis, between
the articular surfaces — it makes them more
congruent.
This joint is saddle, articulatio sellaris, in
shape. The most free movements of the clav-
icle occur around sagittal axis - upwards and
downwards, and around vertical axis — for-
wards and backwards. In 5 % of people (for
example, in swimmers) this joint is spheroi-
dal. In this case slight rotation of the clavicle
around its own axis is possible.
The articular capsule is reinforced by the
anterior and posterior sternoclavicular liga-
ments, ligamentum sternoclaviculare anterius
et ligamentum sternoclaviculare posterius, ex-
cept the inferior surface of the capsule where
the capsule is thin.
Fig. 4.2. Shoulder joint (frontal section):
Besides, the sternoclavicular joint is re-
1 — coracoid process (processus coracoideus);
inforced by the interclavicular ligament,
2 — tendo m. biceps brachii in the place of its orig-
ine from tuberculum supraglenoidale; 3 — glenoid ligamentum interclaviculare, and by a very
cavity (cavitas glenoidalis); 4 — articular capsule strong costoclavicular ligament, ligamentum
(capsula articularis); 5 — tendo m. biceps brachii; costoclaviculare. The first one connects two
6 — intertubercular synovial sheath (vagina inter- sternal ends of the clavicles, stretches over
tubercularis synovialis); 7 — coracohumeral liga- the jugular notch of the sternum and limits
ment (ligamentum coracohumerale)
the movements of the clavicle downwards;
the second one extends from the cartilage of
the first rib to the impression of costoclavicular ligament and limits upward movements
of the clavicle.
Of all the shoulder girdle bones only clavicle is connected with the skeleton of the
trunk, therefore, the bones of the shoulder girdle possess a high mobility. The mechani-
cal function of the clavicle is important because the movements of the scapula follow
the movements of the acromial end of clavicle, and the clavicle directs and regulates the
movements of the scapula.

4.2. The Joints of Free Upper Limb


Here belong the joints connecting free upper limb with the bones of the shoulder
girdle (the scapula) and the joints connecting the bones of the free upper limb with each
other.
Humeral (shoulder) joint, articulatio humeri (fig. 2.9, 4.2), is formed by articula-
tion of the humeral head, caput humeri, with the glenoid cavity of the scapula, cavitas
glenoidalis scapulae. The area of the articular surface of the humeral head is one third (or
a little more) of a sphere. The glenoid cavity is oval-shaped and slightly concave; its area
is only a quarter of the surface of the head. It is supplemented with the glenoid labrum,
labrum glenoidale, which increases the congruence of the articulating surfaces. The ar-
ticular surfaces are covered by hyaline cartilage; on the glenoid cavity of the scapula the
cartilage is thinner in the central part, but on the head of the humerus it is thinner on
the periphery.
4. The joints of upper limbs 35

The articular capsule is loose and thin, it forms folds when the shoulder joint is in
the starting position. On the scapula the capsule is attached to the margin of the glenoid
labrum, on the humerus it is attached to the anatomical neck, leaving both tubercles
outside the articular cavity. The synovial layer of the capsule crosses the intertubercular
groove like a bridge, forming a tendon sheath called the intertubercular synovial sheath,
vagina synovialis intertubercularis. Its length is 2—5 cm. It passes in the intertubercular
groove enveloping the long tendon of the biceps brachii. The latter passes through the
articular cavity above the head of the humerus and is attached to tuberositas supraglenoi-
dalis.
The synovial membrane also forms a synovial bursa named the subtendinous bursa
of the subscapularis, bursa subtendinea m. subscapularis, communicating with the articu-
lar cavity. It is near the base of the coracoid process, under the tendon of the subscapu-
laris.
In the axillary fossa the articular capsule becomes significantly thinner and forms
the axillary synovial bursa, bursa synovialis axillaris.
Superiorly and posteriorly the capsule of the shoulder joint is reinforced by the
coracohumeral and glenohumeral ligaments. The coracohumeral ligament, ligamentum
coracohumerale, is a thick bundle, descending from the base of the coracoid process and
blending with the capsule from the superior and inferior sides. The orientation of its
fibers substationally corresponds to the direction of the tendon of biceps brachii. The
glenohumeral ligaments, ligamenta glenohumeralia, form three bundles which blend
with the internal layer of the fibrous membrane of the articular capsule anteriorly and
superiorly. On the humerus they are attached to the anatomical neck and reach the gle-
noid labrum.
Besides ligaments, the articular capsule is reinforced by the fibers of the tendons of the
surrounding muscles: тт. supraspinatus, infraspinatus, teres minor, subscapularis. Conse-
quently, the inferomedial part of the capsule of the shoulder joint is least strengthened.
According to the shape, the shoulder joint is a typical spheroidal multi-axial joint. It
is the most moveable joint of all synovial joints of the human body because its articulat-
ing surfaces significantly differ from each other in their areas and the capsule of the joint
is spacious. Depending on the type of movements, the capsule relaxes, forming the folds
on the one side, and tenses on the opposite.
The following movements occur at the shoulder joint: 1) around the frontal axis —
flexion and extension; 2) around the sagittal axis — abduction upwards to the horizontal
level (the further movement is limited by the vault of the shoulder, fornix humeri, which
is formed by the coracoid process and acromion of the scapula together with the cora-
coacromial ligament) and adduction; 3) while passing from one axis to another one —
circumduction; 4) around the vertical axis — supination and pronation of the shoulder.
The movements around the frontal and sagittal axes occur within the limits of 90 °.
Maximal flexion, extension, abduction are possible due to the mobility of the scapula
and additional movements at the steroclavicular joint.
Cubital (elbow) joint, articulatio cubiti (fig. 4.3, 4.4), is between the humerus, ulna
and radius. It includes three simple joints:
1) humeroulnar joint, articulatio humeroulnaris;
2) humeroradial joint, articulatio humeroradialis;
3) proximal radioulnar joint, articulatio radioulnaris proximalis.
All these joints are enclosed into the common capsule and have a single articular cav-
ity, hence, anatomically and surgically they are united into a single compound joint. All
the articular surfaces are covered by hyaline cartilage.
36 ARTHROSYNDESMOLOGY

Fig. 4.3. Elbow joint. Sagittal section:


1 — olecranon fossa (fossa olecrani); 2 — coronoid Fig. 4.4. Elbow joint (frontal aspect):
fossa (fossa coronoidea); 3 — articular capsule 1 — humerus (humerus); 2 — articular capsule
(capsula articularis); 4 — articular cavity (cavitas (capsula articularis); 3 — ulnar collateral ligament
articularis); 5 — trochlea of humerus (trochlea hu- (ligamentum collaterale ulnare); 4 — ulna (ulna);
meri); 6 — coronoid process (processus coronoide- 5 — radius (radius); 6 — tendo m. biceps brachii;
us); 7 — radius (radius); 8 — ulna (ulna); 9 — tro- 7 — annular ligament of radius (ligamentum anu-
chlea notch (incisura trochlearis); 10 — olecranon lare radii); 8 — radial collateral ligament (ligamen-
(olecranon) tum collaterale radiale)

On the humerus the capsule is attached far from the edge of the articular cartilage:
anteriorly it is attached 2 cm higher than the level of the epicondyles (as a result the
coronoid and radial fossae lie inside the articular cavity); posteriorly tha capsule is at-
tached below the superior edge of the olecranon. From the lateral sides the capsule is
attached to the edges of the articular surfaces leaving the epicondyles of the humerus
outside the articular cavity. Inferiorly the capsule is attached to the neck of the radius
and to the edge of the articular cartilage covering the ulna.
Humeroulnar joint, articulatio humeroulnaris, is between the trochlea humeri and
the trochlear notch of ulna. The trochlea humeri has the shape of a cylinder with the
recess having helical passage. The axis of the trochlea is oblique and crosses the lon-
gitudinal axis of the humerus. In the sagittal plane the trochlear notch is a half of the
circumference of the trochlea humeri. The humeroulnar joint is cochlear in shape, and
it is uni-axial joint.
Humeroradial joint, articulatio humeroradialis, is between the capitulum humeri
and the articular facet of the radial head. The joint is spheroidal in shape, the ratio of the
areas of its articular surfaces is 2 : 1.
4. The joints of upper limbs 37

Proximal radioulnar joint, articulatio radioulnaris proximalis, is a trochoid joint,


formed by the articulation of the articular circumference of the radius with the radial
notch of ulna.
In the region of the radial articular circumference the capsule becomes thicker and
forms the annular ligament of radius, ligamentum anulare radii, which holds the proxi-
mal end of the radius. Anteriorly and posteriorly the capsule is thin, it can form sacci-
form recess, recessus sacciformis.
From the sides the capsule is reinforced by strong collateral ligaments. The ulnar
collateral ligament, ligamentum collaterale ulnare, originates from the base of the medial
epicondyle of the humerus, its fibers diverge like rays and are attached to the edge of
the ulnar trochlear notch. The radial collateral ligament, ligamentum collaterale radiale,
arises from the lateral epicondyle of the humerus, passes down and, without attachment
to the radius, it is divided into two bundles. They walk round the head of the radius from
its anterior and posterior sides and are attached to the edges of the radial notch of ulna.
The superficial bundles of this ligament are intimately blended with the tendons of ex-
tensor muscles, the deep bundles continue to the annular ligament of radius.
The synovial membrane lines the parts of the radius and ulna, which are located in-
side the articular cavity and not covered by the cartilage. The synovial membrane forms
folds. Under synovial membrane adipous tissue is accumulated.
The humeroradial joint is spheroidal in shape, but actually, it possesses only two
degrees of freedom. The first axis of movements passes along the length of the radius
matching the vertical axis of articulatio radioulnaris proximalis, which is a typical pivot
joint. The radius performs the movement around this axis together with the hand. The
second axis matches the axis of the trochlea (frontal axis) and the ulna performs the
movements around this axis (flexion and extension) together with the radius. The lat-
eral movements at the humeroradial joint are absolutely absent because the movements
around sagittal axis can not occur as a result of the presence of inextensible collateral
ligaments and the interosseous membrane connecting the forearm`s bones.
The humeroulnar joint functions as a cochlear joint, art. cochlearis, which is a kind
of hinge joint, ginglymus. In full flexion the coronoid process enters the coronoid fossa
and the forearm forms an acute angle (30—40 degrees) with the shoulder. In full exten-
sion the humerus and bones of the forearm form one straight line and the olecranon
enters the olecranon fossa of humerus. The range of movements is approximately 140
degrees.
The axis of the trochlea humeri passes obliquely relatively to the axis of the humerus,
and as a result, during the flexion of the forearm, its distal part deviates to the me-
dial side and the hand reaches the region of the thorax. Such a position of the forearm
is functionally beneficial for the upper limb. Therefore, in trauma and fractures of the
bones of the upper limb its immobilization is made in this position only.
Joints of forearm. The epiphyses of the ulna and radius articulate with each other
by means of the proximal and distal radioulnar joints. The fibrous membrane termed
the interosseous membrane of forearm, membrana interossea antebrachii, stretches be-
tween the facing each other interosseous borders of the radius and ulna. This membrane
doesn`t impede movements at the proximal and distal radioulnar joints. Several deep
muscles of the forearm originate from it. Below the proximal radioulnar joint, above the
superior border of the interosseous membrane, a fibrous bundle named the oblique cord,
chorda oblique, extends between the bones of the forearm.
As already mentioned, the proximal radioulnar joint is a part of the elbow joint.
The distal radioulnar joint, articulatio radioulnaris distalis, is an independent joint. The
38 ARTHROSYNDESMOLOGY

articulating surfaces of these two joints are


similar in shape. In the distal radioulnar joint
the articular fossa — ulnar notch, incisura
ulnaris, — is on the radius, and the articular
head — the ulnar articular circumference, cir-
cumferentia articularis ulnae, — is on the ulna.
Between the inferior edge of the ulnar notch
of radius and the ulnar styloid process there
is an articular disc, discus articularis, having
the shape of a triangular plate with slightly
concave surfaces. It separates the distal ra-
dioulnar joint from the radiocarpal joint and
forms a peculiar articular fossa for the head
of the ulna.
The capsule of the distal radioulnar joint
is loose and strong, it is attached to the edges
of the articular surfaces and of the articular
disc. The capsule is reinforced by the pal-
mar and dorsal radioulnar ligaments, liga-
mentum radioulnare palmare et ligamentum
radioulnare dorsale. In the space between
the radius and ulna the capsule of the distal
radioulnar joint forms the sacciform recess,
recessus saсciformis.
The proximal and distal radioulnar joints
are anatomically isolated, i.e. they are abso-
lutely separated from each other, but they
function always together as combined pivot
Fig. 4.5. Wrist joint. Joints of hand (palmar joint. In full extension of the upper limb the
surface): axis of this joint is the continuation of the
1 — ulna (ulna); 2 — ulnar collateral carpal liga- vertical axis of the shoulder joint; together
ment (ligamentum collaterale carpi ulnare); 3 — they form the single axis of the upper limb.
pisiform bone (os pisiforme); 4 — pisohamate liga- This axis passes through the centers of сариt
ment (ligamentum pisohamatum); 5 — pisometa- humeri, capitulum humeri, caput radii and
carpal ligament (ligamentum pisometacarpale);
6 — hook of hamate bone (hamulus ossis hamati);
caput ulnae. Around it the upper epiphysis of
7 — hamatometacarpal ligament (ligamentum the radius rotates at both joints: in articulatio
hamatometacarpale); 8 — carpometacarpal liga- radioulnaris proximalis et articulatio humero-
ment (ligamentum carpometacarpale); 9 — deep radialis. Simultaneously, the lower epiphysis
transverse metacarpal ligament (ligamentum meta- makes an arch at articulatio radioulnaris dis-
carpale transversum profundum); 10 — fibrous
talis around the head of the ulna, but the ulna
sheath of fingers (vagina fibrosa digiti manus);
11 — tendon of flexor digitorum profundus (ten- remains stationary. The rotation of the ulna
do m. flexoris digitorum profundi); 12 — collateral occurs together with the rotation of the hand.
ligaments (ligamenta collateralia); 13 — capitate Rotation consists of two phases: rotation
bone (os capitatum); 14 — radiate carpal ligament outwards — supination, supinatio, and rota-
(ligamentum carpi radiatum); 15 — radial collateral tion inwards — pronation, pronatio. Based on
carpal ligament (ligamentum collaterale carpi radi-
ale); 16 — palmar radiocarpal ligament (ligamen-
the anatomic position in supination the palm
tum radiocarpale palmare); 17 — radius (radius); rotates forwards and the thumb is directed
18 — interosseous membrane (membrana interos- laterally. In pronation the palm rotates back-
sea antebrachii) wards and the thumb is oriented medially.
4. The joints of upper limbs 39

The range of movements in the radioulnar joints is about 180 °. If the shoulder and
scapula move together with radioulnar joints, the hand can rotate on almost 360 °. Rota-
tion of the radius is not limited in any position of the ulna.
Radiocarpal (wrist) joint. The radiocarpal joint, articulatio radiocarpalis (fig. 4.5,
4.6, 4.7), is formed by articulation of the carpal articular surface of radius, facies ar-
ticularis carpalis radii, and the articular sur-
faces of the proximal row of carpal bones
(ossa scaphoideum, lunatum et triquetrum).
The carpal articular surface is supplemented
by the articular disc, discus articularis, from
medial side. The articular disc is triangular-
shaped, it separates the head of the ulna from
the proximal row of carpal bones. As a result
the ulna doesn`t participate in the fromation
of the radiocarpal joint.
The listed above bones of the carpus are
strongly connected with each other by means
of interosseous ligaments, and together form
a single articular surface. This surface is el-
lipsoid in shape and bigger than the carpal
articular surface of radius.
The capsule of the joint is attached to
the edges of the articular surfaces. It is thin
(especially posteriorly), but from all sides
supplemented with ligaments. From the lat-
eral side there is a radial collateral carpal lig-
ament, ligamentum collaterale carpi radiale,
which extends from the radial styloid process
to the scaphoid bone. From the medial side
there is an ulnar collateral carpal ligament,
ligamentum collaterale carpi ulnare, passing
from the styloid process of the ulna to the tri-
quetral and pisiform bones.
On the palmar and dorsal surfaces of the
wrist joint there are palmar and dorsal radio-
carpal and ulnocarpal ligaments. The palmar Fig. 4.6. Wrist joint. Joint of hand (dorsal
radiocarpal ligament, ligamentum radiocarpale surface):
palmare, is thicker and stronger than the dor- 1 — radial collateral carpal ligament (ligamentum
sal one. It is attached to the base of the styloid collaterale carpi radiale); 2 — scaphoid bone (os
process, then descends medially and attached scaphoideum); 3 — dorsal intercarpal ligaments
(ligamenta intercarpalia dorsalia); 4 — trapezoid
to the carpal bones of proximal row (mainly bone (os trapezoideum); 5 — capitate bone (os capi-
to the triquetral and the capitate bones). The tatum); 6 — collateral ligaments (ligamenta collat-
dorsal radiocarpal ligament, ligamentum ra- eralia); 7 — dorsal metacarpal ligaments (ligamenta
diocarpale dorsale, descends medially from metacarpalia dorsalia); 8 — dorsal carpometacarpal
the dorsal surface of the distal epiphysis of ligaments (ligamenta carpometacarpalia dorsalia);
the radius to the carpal bones of proximal row 9bone — hamate bone (os hamatum); 10 — triquetral
(os triquetrum); 11 — ulnar collateral carpal
(mainly to the triquetral bone). ligament (ligamentum collaterale carpi ulnare);
The palmar ulnocarpal ligament, liga- 12 — dorsal radiocarpal ligament (ligamentum ra-
mentum ulnocarpale palmare, arises from diocarpale dorsale)
40 ARTHROSYNDESMOLOGY

the base of the ulnar styloid process, then


descends laterally and is attached to the sca-
phoid, lunate and triquetral bones. The dor-
sal ulnocarpal ligament, ligamentum ulnocar-
pale dorsale, is thinner than the palmar one, it
originates from the dorsal surface of the ul-
nar distal epiphysis, descends laterally and is
attached to the lunate and triquetral bones.
Joints of hand bones. According to the
classification of the hand bones, the follow-
ing main joints are distinguished: between the
carpal bones of proximal and distal rows —
the midcarpal joint; between the carpal bones
of distal row and metacarpal bones — carpo-
metacarpal joints; between the metacarpal
bones and proximal phalanges — metacar-
pophalangeal joints; between proximal and
middle phalanges, between middle and distal
phalanges — interphalangeal joints. All the
joints are strengthened with numerous liga-
ments.
Midcarpal joint, articulatio mediocar-
palis (fig. 4.7), is between the distal surfaces
Fig. 4.7. Joints of hand (frontal section):
of the carpal bones of proximal row (except
1 — interphalangeal joint (articulatio interphalan-
gea); 2 — metacarpophalangeal joint (articulatio
the pisiform bone) and the proximal sur-
metacarpophalangea); 3 — radiocarpal joint (ar- faces of the carpal bones of the distal row.
ticulatio radiocarpalis); 4 — distal radioulnar joint The articulating surfaces of this joint have a
(articulatio radioulnaris distalis); 5 — articular disc complicated configuration and the articular
(discus articularis); 6 — midcarpal joint (articulatio slit is S-shaped, hence, the midcarpal joint
mediocarpalis); 7 — V carpometacarpal joint (ar- is formed by two spheroidal articular heads.
ticulatio carpometacarpalis V)
The articulating surfaces are almost equal in
area, therefore, this joint is almost immobile.
The articular capsule is attached to the edges of the articular surfaces, it is rather
loose and from the dorsal side it is very thin. The interosseous ligaments firmly hold the
bones of distal row together, therefore, the movements between these bones are insig-
nificant. However, between the bones of distal row there are the spaces communicating
the cavity of articulatio mediocarpalis with articulationes carpometacarpales.
Intercarpal joints, articulationes intercarpales, are formed by articulation of the in-
dividual carpal bones of proximal and distal rows (fig. 4.7). They are between flat sur-
faces of the articulating bones, facing each other. The cavities of these joints are narrow,
they communicate with the midcarpal and carpometacarpal joints.
On the dorsal surface of the hand there are numerous ligaments connecting the in-
dividual bones of the carpus with each other and termed dorsal intercarpal ligaments,
ligamenta intercarpalia dorsalia.
On the palmar surface of the hand the ligaments are especially well developed, the
strongest ligament on the palmar surface is the radiate carpal ligament, ligamentum carpi
radiatum. The fibers of this ligament are attached to the capitate bone and diverge like
rays to the adjacent carpal bones. Also, on the palmar surface there are palmar inter-
carpal ligaments, ligamenta intercarpalia palmaria, which extend transversely between
4. The joints of upper limbs 41

carpal bones. All these ligaments line the carpal groove, sulcus carpi, and firmly hold the
vault formed by the carpal and metacarpal bones. The concavity of the vault is directed
to the palmar surface; the vault is expressed only in humans.
Above the carpal groove between the radial and ulnar eminences there is a strong
ligament called flexor retinaculum, retinaculum flexorum, which is a thickening of the
proper fascia of the forearm. The flexor retinaculum formes connective tissue septa to
the carpal bones, and as a result, three individual canals occur: radial carpal canal, cana-
lis carpi radialis; carpal tunnel, canalis carpi; and ulnar carpal canal, canalis carpi ulnaris
(these canals will be described in the chapter «Myology»).
The movements of articulatio radiocarpalis and articulatio mediocarpalis, are dis-
cribed together because these two joints functionally form a single combined joint called
the joint of the hand, articulatio manus. The proximal row of carpal bones plays the role
of the bony disc in the joint of the hand.
The movements of the hand occur around two mutually perpendicular axes: frontal
and sagittal. Around frontal axis flexion occurs (about 60—70 degrees), and extension
(about 45 degrees). Around sagittal axis adduction (about 35—40 degrees), and abduc-
tion (about 20 degrees) occur. Thus, the range of extension is significantly lesser than
the range of flexion, because the extension is limited by strong palmar ligaments. The
lateral movements are limited by the collateral ligaments and by the styloid processes.
The hand also performs conical movements (circumduction).
The pisiform joint, articulatio ossis pisiformis, is absolutely separated from other ar-
ticulations of the carpal bones. The loose capsule of this joint permits the pisiform bone
to move distally and proximally.
Two strong ligaments arise from the pisiform bone: pisohamate ligament, ligamentum
pisohamatum, which is attached to hamulus ossis hamati, and pisometacarpal ligament,
ligamentum pisometacarpale, passing to the bases of the V and partially, IV metacarpal
bones. These ligaments are formed by expansion of the flexor carpi ulnaris tendon.
Carpometacarpal joints, articulationes carpometacarpales (fig. 4.5, 4.6, 4.7), are
joints between the carpal bones of distal row and the bases of the metacarpals. The joint
of the thumb is isolated, but other four joints have common articular cavity and capsule.
The articular capsule is taut, and from the palmar and dorsal sides it is reinforced by car-
pometacarpal ligaments, ligamenta carpometacarpalia dorsalia et palmaria. The articular
cavity looks like transverse slit communicating with the cavity of articulatio mediocarpa-
lis by means of the intercarpal joints.
Articulationes carpometacarpales II—V are plane and almost immobile joints. Thus,
all four bones of distal row and the II—V metacarpal bones are strongly articulated with
each other and form the solid basis of the hand.
The I carpometacarpal joint, articulatio carpometacarpalis pollicis, is between the
trapezium and the I metacarpal bone. Their articulating surfaces have saddle shape.
The articular capsule is loose, from the palmar and dorsal sides it is reinforced by
accessory fibrous ligaments. The joint is anatomically and functionally isolated, its
movements occur around two axes: sagittal one, passing through the base of the I
metacarpal, and frontal one, passing through the trapezium. Around frontal axis, the
thumb, together with the metacarpal bone, performs flexion and extension. How-
ever, the frontal axis of this joint passes at an angle to the frontal plane and due to
this, in flexion the thumb displaces toward the palm and set in opposition to the
other fingers — such a movement is called oppositio. In extension, the thumb comes
back to the starting position — this movement is called repositio. Around sagittal
axis, the thumb performs abduction and adduction to the index finger. Owing to the
42 ARTHROSYNDESMOLOGY

combination of the movements around two axes, the circumduction is possible at


this joint.
Between two facing each other sides of the bases of the II—V metacarpals (fig. 4.7),
there are three narrow slit-like spaces, which are termed intermetacarpal joints, articula-
tiones intermetacarpales. Proximally they communicate with the carpometacarpal joints
and are reinforced by dorsal and palmar metacarpal ligaments, ligamenta metacarpalia
palmaria et dorsalia.
Metacarpophalangeal joints, articulationes metacarpophalangeae, are between the
heads of the metacarpal bones and the facets on the bases of the proximal phalanges.
The articular surfaces of the metacarpal bones are spheroidal, the articular surfaces of
the proximal phalanges are ellipsoid and smaller in size. The capsules are loose, thin
(especially on the dorsal surface) and reinforced by strong accessory ligaments. On the
medial and lateral sides of each metacarpophalangeal joint, there are collateral liga-
ments, ligamenta collateralia, extending from the pits on the lateral sides of the metacar-
pal heads to the tubercles on the bases of the proximal phalanges. On the palmar surface,
there are strong palmar ligaments, ligamenta palmaria. Their fibers blend with transverse
fibers of the deep transverse metacarpal ligament, ligamentum metacarpale transversum
profundum. The latter consists of three bundles connecting the bases of ossa metacarpa-
lia II—V with each other, limiting lateral movements of these bones and reinforcing the
solid basis of the hand.
According to the shape, the metacarpophalangeal joints are spheroidal joints (ex-
cept the I metacarpophalangeal joint). Due to the considerable disparity of the articulat-
ing surfaces, these joints possess wide mobility (especially in the direction of the palm).
The movements are: flexion and extension around frontal axis (the range of movements
up to 90 degrees), lateral abduction of fingers around sagittal axis (the general range of
movements of one finger is 45—50 degrees) and circumduction. The movements around
vertical axis are impossible because of the absence of the rotator muscles.
The I metacarpophalangeal joint, articulatio metacarpophalangea pollicis, is hinge
in shape. The articular surface of the head of the I metacarpal bone is wide and bears
two tubercles on the palmar side. The palmar part of the articular capsule encloses two
sesamoid bones (lateral and medial). One surface of these bones faces the articular cav-
ity and is covered by hyaline cartilage. The range of flexion at this joint is lesser than in
articulationes metacarpophalangeae II—V.
Interphalangeal joints, articulationes interphalangeae manus, are between the
proximal and middle, middle and distal phalanges of the II—V fingers. The same joint
is also between the proximal and distal phalanges of the I finger. The articular surfaces
are: the heads of the proximal or middle phalanges and the bases of the middle or distal
phalanges. The capsules of the interphalangeal joints are extensive, from the dorsal side
they are thin, from other sides they are reinforced by the palmar ligament, ligamentum
palmare (sometimes it contains one sesamoid bone at the thumb), and collateral liga-
ments, ligamenta collateralia. The collateral ligaments don`t permit lateral movements.
The interphalangeal joints are typical hinge joints. Their movements occur around
frontal axis only. The range of flexion and extension is 50—90 degrees.
TEST QUESTIONS
1. List the proper ligaments of the scapula. Why are they called proper ligaments?
Describe their attachement and functional purpose.
2. What synovial joints connect the bones of the shoulder girdle?
3. Describe the articular surfaces of the sternoclavicular joint.
Contents 43

4. Describe the sternoclavicular joint according to the classifications of synovial


joints.
5. What ligaments reinforce the sternoclavicular joint? Describe their attachement
and function.
6. Describe the articular surfaces of the acromioclavicular joint.
7. Describe the acromioclavicular joint according to the classifications of synovial
joints.
8. What ligaments reinforce the acromioclavicular joint? Describe their attachement
and function.
9. Describe the movements of the shoulder girdle.
10. Describe the articular surfaces of the shoulder joint.
11. Describe the shoulder joint according to the classifications of synovial joints.
12. What ligaments reinforce the shoulder joint? Describe their attachement and
function.
13. What is the glenoid labrum? What is its function?
14. List the bursae of the shoulder joint. Describe their position.
15. What movements can be performed at the shoulder joint?
16. Why is the elbow joint a compound joint?
17. What joints does the elbow joint involve?
18. Describe the articular surfaces of the each joint involved into the elbow joint.
20. What ligaments strengthen the elbow joint? Describe their attachement and function.
21. Describe the movements of the elbow joint.
22. Why can abduction not occur at the elbow joint?
23. What is the feature of the flexion at the elbow joint?
24. What joints connect the bones of forearm?
25. What type of articulations does the interosseous membrane belong to?
26. What joint is the distal radioulnar joint combined with? What movements can be
performed at this combined joint?
27. What bones form the articular surfaces for the wrist joint?
28. What is the function of the articular disc of the wrist joint?
29. Describe the wrist joint according to the classification of synovial joints.
30. What ligaments reinforce the wrist joint?
31. List the synovial joints of the hand in accordance with the subdivisions of the hand.
32. What joint combines with the wrist joint? How is it termed? Describe the articular
surfaces and movements at this joint.
33. Describe the articular surfaces of the carpometacarpal joints. Give the character-
istic of these joints according to the classifications of synovial joints. Describe the move-
ments at these joints. What is the difference between the first carpometacarpal joint and
others?
34. Describe the articular surfaces of the metacarpophalangeal and interphalangeal
joints. Give the characteristic of these joints in accordance with the classifications of
synovial joints. What movements occur at these joints?
35. List the ligaments of the hand and describe their attachment.

CLINICOANATOMICAL PROBLEMS
1. Having falling down from the horizontal bar, a patient got a trauma. During the
examination the doctor discovered a forward protrusion of the sternal end of the left
clavicle in the region of the left strenoclavicular joint. The palpation of this place was
44 ARTHROSYNDESMOLOGY

painful. In movement of scapulae medially the pain increased. The movements at the left
sternoclavicular jont were impossible. Why the function of this joint was disturbed?
2. The X-ray picture of the shoulder joint shows the change of the articular slit shape
of the shoulder joint and the dislocation of the humeral head upwards, under the acro-
mion. How can this case be diagnosed?
3. On the examination of an injured patient the fracture of the olecranon process of
the ulna is diagnosed. What movements at the elbow joint can not occur, what ligaments
of the elbow jont are damaged?
4. While falling down on the palmar surface of the hand, the patient fractured the
head of the radius. What movements at the elbow joint became limited, what anatomical
structures were damaged?
5. THE JOINTS OF LOWER LIMB

5.1. The Joints of Pelvic Girdle


The pelvic bones join with each other and with the sacrum by means of synovial
joints, hemiarthrosis (pubic symphysis) and solid joints.
Sacroiliac joit, articulatio sacroiliaca (fig. 5.1, 5.2), is formed by articulation of the
auricular surfaces, facies auriculares, of the sacrum and ilium.

Fig. 5.1. Ligaments of pelvis and of hip joint (anterior aspect):


1 — IV lumbar vertebra (vertebra lumbalis IV); 2 — anterior longitudinal ligament (ligamentum longitudinale
anterius); 3 — iliolumbar ligament (ligamentum iliolumbale); 4 — inguinal ligament (ligamentum inguinale);
5 — iliofemoral ligament (ligamentum iliofemorale); 6 — pubofemoral ligament (ligamentum pubofemorale);
7 — obturator membrane (membrana obturatoria); 8 — pubic symphisis (symphisis pubica); 9 — inferior pu-
bic ligament (ligamentum pubicum inferius); 10 — superior pubic ligament (ligamentum pubicum superius);
11 — anterior sacroiliac ligament (ligamentum sacroiliacum anterius)

The articular surfaces are covered by fibrous cartilage. The articular capsule is taut,
it is attached to the edges of articular surfaces and is firmly fused with the periosteum
of the sacrum and pelvic bone. The articular cavity is a very narrow slit. Anteriorly the
articular capsule is strengthened with the anterior sacroiliac ligament, ligamentum sacro-
iliacum anterius. This ligament is thin and intimately blended with the articular capsule.
On the posterior surface of the joint, there is posterior sacroiliac ligament, ligamentum
sacroiliacum posterius. Under these two ligaments there is an interosseous sacroiliac liga-
ment, ligamentum sacroiliacum interosseum, which is the strongest ligament of the sac-
roiliac joint. It is fused with the posterior part of the articular capsule and fills up the
depression between tuberositas ossis sacri et tuberositas iliaca. This ligament is visible only
on the horizontal section of the joint.
Also the iliolumbar ligament, ligamentum iliolumbale, strengthens this joint. The
ligament descends from the transverse process of the IV and V lumbar vertebrae to the
iliac crest and iliac tuberosity.
The sacroiliac joint is plane joint, the movements at this joint are absent.
46 ARTHROSYNDESMOLOGY

Fig. 5.2. Joints of pelvis and right hip joint (articular capsule is partially removed)
(posterolateral aspect):
1 — iliolumbar ligament (ligamentum iliolumbale); 2 — greater sciatic foramen (foramen ischiadicum majus);
3 — head of femur (caput ossis femoris); 4 — iliofemoral ligament (ligamentum iliofemorale); 5 — zona orbicu-
laris (zona orbicularis); 6 — ischiofemoral ligament (ligamentum ischiofemorale); 7 — lesser sciatic foramen
(foramen ischiadicum minus); 8 — sacrotuberous ligament (ligamentum sacrotuberale); 9 — sacrospinous liga-
ment (ligamentum sacrospinale); 10 — superficial posterior sacrococcygeal ligament (ligamentum scarococcy-
geum posterius superficiale); 11 — posterior sacroiliac ligament (ligamentum sacroiliacum posterius)

Pubic symphysis, symphysis pubica, connects two pubic bones with each other. The
symphysial surfaces of pubic bones are covered by fibrous cartilage which is thicker in
females than in males. In children this cartilage is hyaline. The symphysial surfaces of
the pubic bones are connected by the cartilaginous interpubic disc, discus interpubicus.
Most commonly, inside the disc in its superoposterior part there is a slit-like cavity,
which develops during the 1—2 years of life. Due to the presence of the cavity inside the
disc, this joint is considered to be a hemiarthrosis. Slight movements at the pubic sym-
physis are possible only in women during the process of delivery. The pubic symphysis
is reinforced by two ligaments: superiorly — by the superior pubic ligament, ligamentum
pubicum superius, and inferiorly — by the inferior pubic ligament, ligamentum pubicum
inferius, which rounds the subpubic angle. It is also called the arcuate pubic ligament,
ligamentum arcuatum pubis. Behind the pubic symphysis the retropubic eminence, emi-
nentia retropubica, protrudes into the pelvic cavity; it is formed partially by cartilage,
partially by the medial borders of the pubic bones.
Solid joints of the pelvic bone are: the junction of pelvic bone`s parts, iliolumbar,
sacrotuberous and sacrospinous ligaments, and also obturator membrane.
1. In children between the parts of the pelvic bone, in the region of the acetabulum
there is a temporary synchondrosis, which ossifies with age.
2. The iliolumbar ligament, ligamentum iliolumbale, descends from the transverse
processes of the lower two lumbar vertebrae to the posterosuperior part of the iliac
crest.
3. The sacrotuberous ligament, ligamentum sacrotuberale, connects the ischial tuber-
osity with the lateral edges of the sacrum and with the coccyx.
5. The joints of lower limb 47

4. The sacrospinous ligament, ligamentum sacrospinale, extends between the ischial


spine and the lateral edges of the sacrum and coccyx (fig. 5.2).
5. The obturator membrane, membrana obturatoria, incompletely closes the obtura-
tor foramen, forming a small space called obturator canal, canalis obturatorius, under the
lower border of the superior pubic ramus.

5.2. Pelvis
The pelvic bones, sacrum, coccyx and the ligaments connecting these bones form the
pelvis, pelvis. The bones of the pelvis connect the trunk with the lower limbs.
The pelvis is divided into the greater pelvis, pelvis major, and lesser pelvis, pelvis
minor. They are separated from each other by the terminal line, linea terminalis, which
passes from promontorium to both sides through linea arcuata along pecten ossis pubis to
tuberculum pubicum and then — along the superior edge of symphysis pubica.
The greater pelvis is bounded by vertebra lumbalis V and ligamenta iliolumbalia pos-
teriorly and by the wings of ilium. The pelvic cavity, cavitas pelvis, forms one whole with
the abdominal cavity, cavitas abdominis.
The lesser pelvis is a bony canal, which narrows downwards. The pelvic inlet, or
superior aperture, apertura pelvis superior, is bounded by the terminal line. The pelvic
outlet, or inferior aperture, apertura pelvis inferior, is bounded by coccyx, ligamentum
sacrotuberale, tuber ischiadicum, ramus ossis ischii, ramus inferior ossis pubis, ligamentum
pubicum inferius.
The walls of the lesser pelvis are formed: posteriorly — by facies pelviсa ossis sacri and
the anterior surface of the coccyx; anteriorly — by the anterior parts of the pubic bones
and the pubic symphysis with its ligaments; from the sides — by the internal surface of
the pelvic bone below linea terminalis, membrana obturatoria, ligamentum sacroturberale,
ligamentum sacrospinale. The obturator foramen is almost completely closed by the obtu-
rator membrane, except the opening of the obturator canal in the region of the obturator
groove.
On the lateral wall of the lesser pelvis there are greater and lesser sciatic foramina,
which transmit the vessels and nerves passing from the pelvic cavity to the gluteal re-
gion. The greater sciatic foramen, foramen ischiadicum majus, is bounded by ligamentum
sacrospinale and incisura ischiadica major. The lesser sciatic foramen, foramen ischiadi-
cum minus, is bounded by ligamentum sacrospinale, ligamentum sacrotuberale and incisura
ischiadica minor.
In the vertical position of the body the pelvis is inclined forwards; the plane of the
pelvic inlet forms an acute angle with the horizontal plane. In females this angle is 55—
60 degrees, in males — 50—55 degrees. The degree of the inclinaton of the pelvis, incli-
natio pelvis, varies in one and the same person depending on posture (military posture,
free vertical position etc.).
Sexual differences of pelvis. Female pelvis is wider, but smaller in vertical size.
The distance between the iliac spines and iliac crests is bigger because the iliac wings
are turned outside. In females the pelvic inlet is rounded, almost ellipsoid in shape with
frontally located long axis. In males the shape of the pelvic inlet resembles card heart
because of the pronounced promontory. The symphysis of the female pelvis is wider
and shorter, the pelvic cavity is more extensive (fig. 5.3). The female sacrum is wider
and shorter, the ischial tuberosities are turned outside, therefore, the transverse size of
the pelvic outlet is 1—2 cm bigger. In females the subpubic angle is 90—100 degrees, in
males — 70—75 degrees.
48 ARTHROSYNDESMOLOGY

Fig. 5.3. Male pelvis (a) and female pelvis (b) (superior aspect)

In obstetrics it is necessary to know average sizes of the female pelvis for predict-
ing of the process of delivery The average anteroposterior sizes of the lesser pelvis are
termed conjugates, conjugatae (fig. 5.4). The number of them is optional, but usually the
conjugates of the pelvic inlet, outlet and of the pelvic cavity are measured.
Anatomical conjugate, conjugata anatomica, (straight size of the pelvic inlet) is the
distance between the promontory and the superior border of the pubic symphysis. It is
11,5 cm .
True, or gynecological conjugate, conjugata vera seu gynecologica, is the distance
between the promontory and the most protruding backwards point of the symphysis
(eminentia retropubica). It is 10,5—11 cm.
Diagonal conjugate, conjugata diago-
nalis, is measured between the promontory
and the inferior border of the symphysis.
This conjugate can be determined in vaginal
examination. It is 12,5—13,0 cm. For conse-
quential measurement of the true conjugate
it is necessary to substract 2 cm from the
length of conjugata diagonalis.
Transverse diameter, diameter trans-
versa, of the pelvic inlet is between the most
distant points of the terminal line. It is 13,5
cm.
Oblique diameter, diameter obliqua, of
the pelvic inlet is the distance between the
sacroiliac joint of one side and the iliopubic
eminence of the other side. It is 13 cm.
Straight size of the pelvic outlet
(the conjugate of the outlet) is 9,5 cm.
It is measured between the apex of the
Fig. 5.4. Sagittal section of femail pelvis coccyx and the lower border of the pubic
(right part): symphysis. During delivery the coccyx is
1 — diagonal conjugate (conjugate diagonalis); inclined backwards at the sacrococcygeal
2 — true conjugate (conjugate vera); 3 — conjugate synchondrosis and this conjugate becomes
of inlet; 4, 5 — axis of pelvis 2—2,5 cm bigger.
5. The joints of lower limb 49

Transverse size of the pelvic outlet is 11 cm. It is measured between the internal
surfaces of the ischial tuberosities.
An imaginary line connecting the midpoints of all conjugates is called the axis of the
pelvis. It passes almost parallelly to the anterior surface of the sacrum and corresponds
to the way, made by the head of a fetus during the process of delivery.
Also some sizes of the greater pelvis are important in obstetrics. Knowing them it is
possible to foretell the sizes of the lesser pelvis.
Interspinous distance, distantia interspinosa, is measured between the anterior su-
perior iliac spines. It is 25—27 cm.
Intercristal distance, distantia intercristalis, is measured between the most distant
points of the iliac crests. It is 27—29 cm.
Intertrochanteric distance, distantia intertrochanterica, is the distance between
the greater trochanters. It is 30—31 cm.
External conjugate, conjugata externa, is measured for the assessment of the an-
teroposterior sizes of the pelvis. It is the distance between the external surface of the
pubic symphysis and the spinous process of the V lumbar vertebra. It is 20 cm.
Table 5.1 gives the data showing that the sizes of male pelvis are less than the sizes
of female pelvis by1,5—2 cm.
Table 5.1
Sizes of Lesser Pelvis

Diameters, cm
straight transverse oblique
Planes of lesser pelvis
(diameter recta) (diameter transversa) (diameter obliqua)
female male female male female male
Inlet 11,5 10,5 13,5 12,5 13,0 12,0
Wide part of pelvic cavity 12,5 11,0 12,5 11,0 — —
Narrow part of pelvic cavity 11,5 19,5 10,5 10,5 — —
Outlet 19,5 17,5 11,0 11,0 — —

The shape and sizes of the female pelvis are interrelated with the functioning of the
uterus where the fetus gestates.
The individual differences of the pelvis are significant: in the shape and size of the
sacrum, of the pelvic bones, in the degree of the development of the promontory etc.
The dramatic changes of the form and size of the pelvis occur in serious pathological
processes (flat rachitic pelvis, osteomalatic pelvis compressed from the sides).
The pelvis of a newborn is narrow, it has high iliac crests and funnel-shaped cavity,
the promontory is poorly developed. The sexual differences become apparent only after
10—12 years.
The pelvis of elderly persons has no any specific differences except age peculiarities
of the bones.

5.3. Joints of Free Lower Limb


Hip Joint
The coxal (hip) joint, articulatio сохае (coxofemoralis), is formed by articulation of
the lunate surface of acetabulum and the articular surface of the head of the femur, fa-
cies lunata acetabuli et facies articularis capitis femoris (fig. 5.5). The articular surfaces
50 ARTHROSYNDESMOLOGY

are covered by hyaline cartilage. Synovial


membrane lines the acetabular fossa located
in the center of the acetabulum and the ac-
etabular notch located below the acetabular
fossa. Acetabular fossa is filled with loose
fatty tissue accumulated under the synovial
membrane.
The accessory structures of this joint
are: acetabular labrum, labrum acetabuli;
fat body of the acetabulum, corpus adiposum
acetabuli; transverse acetabular ligament,
ligamentum transversum acetabuli; ligament
of femoral head, ligamentum capitis femoris.
The acetabular labrum is attached to
the bony edge of acetabulum and to liga-
mentun transversum acetabuli. It makes the
acetabulum 5—6 mm deeper. The fat body
of the acetabulum fills up fossa acetabuli; it
is lined with synovial membrane from the
side of the articular cavity. The transverse
acetabular ligament crosses over the ac-
etabular notch. The vessels and nerves pass
under the ligament to the bottom of the ac-
Fig. 5.5. Hip joint. Frontal section: etabulum.
1 — ilium (os ilium); 2 — ligament of head of femur The specific feature of the hip joint is
(ligamentum capitis femoris); 3 — ischial tuberosity the presence of the ligament of femoral
(tuber ishiadicum); 4 — articular cavity (cavitas ar- head. It extends from the transverse ac-
ticularis); 5 — articular capsule (capsula articularis); etabular ligament to the fovea for ligament
6 — femur (femur); 7 — greater trochanter (tro-
chanter major); 8 — zona orbicularis (zona orbicu-
of femoral head. Its length is 2—2,5 cm, its
laris); 9 — acetabular labrum (labrum acetabuli) thickness is variable. This ligament is en-
veloped by synovial membrane containing
the vessels which nourish the head of the
femur. The ligament of femoral head plays a great role in the development of the hip
joint — it holds the head of the femur near the acetabulum.
The articular capsule is very strong, it is attached to the edge of the acetabulum
and the transverse acetabular ligament beyond the acetabular labrum. On the femur the
articular capsule is attached: anteriorly — along the intertrochanteric line, postreiorly —
not reaching the intertrochanteric crest leaving the trochanteric fossa outside the articu-
lar cavity. Thus, the most part of the femoral neck lies inside the articular cavity and is
covered by synovial membrane.
The circular fibers of the fibrous articular capsule form so called zona orbicular-
is, zona orbicularis, embracing the middle part of the femoral neck. The capsule is also
strengthened by iliofemoral, pubofemoral and ischiofemoral ligaments. Their fibers are
longitudinal and blended with the zona orbicularis.
The iliofemoral ligament, ligamentum iliofemorale (Bertini), is the strongest ligament
in the human body, its thickness sometimes reaches 5 mm. It is attached to the anterior
superior iliac spine, its fibers diverge like rays and are attached to the whole length of
the intertrochanteric line. This ligament limits excessive extension of the thigh and its
rotation inwards.
5. The joints of lower limb 51

The pubofemoral ligament, ligamentum pubofemorale, is attached to the superior


pubuc ramus and to the body of the ilium. Then it descends laterally and blends into
the capsule from the medial and posterior sides and is attached to the medial part of the
intertrochanteric line. It limits abduction of the thigh and its rotation outwards.
Ischiofemoral ligament, ligamentum ischiofemorale, extends from the body of the
ischium to the trochanteric fossa of femur; it partially continues to the circular fibers of
the articular capsule. This ligament limits excessive adduction of the thigh and its rota-
tion inwards.
The articular capsule is thin posteriorly where the capsule is attached to the femoral
neck, and anteriorly, under the iliopubic eminence (sometimes, here is an opening com-
municating the articular cavity with the iliopectineal bursa, bursa iliopectinea, located
under т. iliopsoas).
The hip joint is a subtype of the spheroidal joints — cotyloid joint. Its movements are
performed around three orthogonal axes: flexion and extension (around frontal axis);
abduction and adduction (around sagittal axis); circumduction (around frontal and sag-
ittal axes); rotation (around vertical axis). The range of flexion and extension is up to
130 degrees. In full extension of the knee the tension of the postetior femoral muscles
limits flexion in the hip joint. The range of adduction and abduction is up to 45 degrees,
but in the half-bent position of the thigh the range of these movements increases up to
90 degrees. Rotation of the thigh occurs around the axis passing from the femoral head
to the midst of the intercondylar eminence, the range of rotation outwards is greater
than the range of rotation inwards. The general range of rotation is 40—50 degrees.
The tilts of the pelvis forwards and backwards around axis passing through the cen-
ters of the heads of both femurs, are the most important. During these movements the
degree of the tilt of the pelvis may be increased or decreased. When we sit the iliofemoral
ligaments relax, therefore, the range of extension in the hip joint significantly increases
and the pelvis with the trunk displaces relatively to the lower limbs.

Knee Joint
The genual (knee) joint, articulatio genus (fig. 5.6), is the largest and the most com-
plicated joint in the human body. It is formed between three bones: femur, tibia and
patella, femur, tibia et patella. The articular surfaces are: facies articulares condyli medialis
et lateralis femoris, facies articularis superior tibiae, facies articularis patellae, facies patel-
laris femoris. They are covered by hyaline cartilage. The articular surfaces of the femur
occupy the anterior surface of its distal epiphysis (patellar surface) and the distal ends
of the medial and lateral condyles. The superior articular surface of the tibia is formed
by two oval-shaped depressions. The articular surface of the patella articulates only with
the patellar surface of the femur.
The knee joint has many auxiliary structures such as patella, menisci, intra-articular
ligaments, synovial bursae, synovial folds. The menisci partly improve the incongru-
ence of the articular surfaces and play the role of shock absorber. They are semilunar
in shape. The thick borders of the menisci are fused with the articular capsule, but their
thin borders face the articular cavity. The superior surfaces of the menisci are concave
and correspond to the surfaces of the femoral condyles. The inferior surfaces are al-
most flat, they lie on the superior articular surface of the tibia. The menisci are formed
by dense connective tissue containing elastic fibers, and their surfaces are covered by
thin layer of fibrous cartilage. The medial meniscus, meniscus medialis, is narrow and
semicircular in shape. The lateral meniscus, meniscus lateralis, is wider, it looks like an
52 ARTHROSYNDESMOLOGY

Fig. 5.7. Right knee joint. Horizontal section


(superior aspect):
1 — patellar ligament (ligamentum patellae); 2 — deep
infrapatellar bursa (bursa infrapatellaris profunda);
3 — transverse genual ligament (ligamentum transver-
sum genus); 4 — articular capsule (capsula articularis);
5 — lateral meniscus (meniscus lateralis); 6 — fibular
collateral ligament (ligamentum collaterale fibulare);
7 — posterior cruciate ligament (ligamentum cruciatum
posterius); 8 — medial meniscus (meniscus medialis);
9 — tibial collateral ligament (ligamentum collaterale
tibiale); 10 — anterior cruciate ligament (ligamentum
cruciatum anterius)
Fig. 5.6. Left knee joint. Anterior aspect. The
articular capsule is removed. The patella with almost complete ring. Both menisci are con-
the tendon of quadriceps femoris is drawn nected with eminentia intercondylaris tibiae
downwards: by means of the short ligaments. Anteriorly
1 — patellar surface (facies patellaris); 2 — lateral menisci are connected with each other by
condyle (condylus lateralis); 3 — lateral meniscus the transverse genual ligament, ligamentum
(meniscus lateralis); 4 — fibular collateral ligament transversum genus (fig. 5.7).
(ligamentum collaterale fibulare); 5 — anterior The intra-articular cruciate ligaments re-
ligament of fibular head (ligamentum capitis fibu-
inforce the knee joint, they cross each other
lae anterius); 6 — fibula (fibula); 7 — tibia (tibia);
8 — interosseous membrane of leg (membrana in- like letter «X» strongly connecting the femur
terosseous crurus); 9 — tendo m. quadriceps femoris; with the tibia. These ligaments are covered
10 — articular surface of patella (facies articularis by synovial membrane. The anterior cruciate
patellae); 11 — patellar ligament (ligamentum pa- ligament, ligamentum cruciatum anterius, de-
tellae); 12 — deep infrapatellar bursa (bursa infra- scends from the medial surface of the lateral
patellaris profunda); 13 — tibial collateral ligament
(ligamentum collaterale tibiale); 14 — ransverse
condyle of the femur to the anterior inter-
genual ligament (ligamentum transversum genus); condylar area of tibia. The posterior cruciate
15 — medial meniscus (meniscus medialis); 16 —an- ligament, ligamentum cruciatum posterius, is
terior cruciate ligament (ligamentum cruciatum an- attached to the lateral surface of the medial
terius); 17 — posterior cruciate ligament (ligamen- condyle of the femur and descends postero-
tum cruciatum posterius); 18 — femur (femur) laterally to the posterior intercondylar area of
tibia. Synovial membrane passes to this liga-
ment from the posterior wall of the articular capsule and connects them with each other.
Therefore, the posterior part of the cavity of the knee joint is divided into two compart-
ments (right and left) communicating with each other only from the anterior side.
5. The joints of lower limb 53

In the articular cavity there are anterior and posterior meniscofemoral ligaments.
The anterior meniscofemoral ligament, ligamentum meniscofemorale anterius, is attached
to the anterior part of the medial meniscus, then it ascends laterally to the medial surface
of the femur`s lateral condyle. The posterior meniscofemoral ligament, ligamentum me-
niscofemorale posterius, is attached to the posterior border of the lateral meniscus, then it
ascends medially to the internal surface of the femur`s medial condyle.
The synovial membrane of the knee joint forms synovial folds. The folds contain fat,
project into the articular cavity and fill up the part of the articular cavity, which remains
free because of the incongruence of the articular surfaces. The alar folds, plicae alares, are
especially developed, they are paired and located below the patella on the both sides of the
patellar ligament, ligamentum patellae. The alar folds converge to form the unpaired infra-
patellar fold which descends vertically to the anterior part of area intercondylaris anterior.
Besides these two folds, in the knee joint there are numerous smaller synovial folds.
The capsule of the knee joint is very extensive, loose and thin. On the femur it is at-
tached 1cm above the edge of the articular cartilage, and anteriorly it continues to the
suprapatellar bursa, bursa suprapatellaris, located above the patella between the femur
and the tendon of the quadriceps femoris.
The extra-articular ligaments of the knee joint are: fibular and tibial collateral liga-
ments, oblique and arcuate popliteal ligaments, patellar ligament and medial and lateral
patellar retinacula.
The fibular collateral ligament, ligamentum collaterale fibulare, is a fibrous cord ex-
tending from the lateral epicondyle of the femur to the lateral edge of the fibular head.
This ligament is separated from the articular capsule by the layer of fat.
The tibial collateral ligament, ligamentum collaterale tibiale, is a broad fibrous plate
fused with the capsule and with the medial meniscus. It extends from epicondylus media-
lis femoris to the medial edge of the tibia.
The oblique popliteal ligament is on the posterior side of the knee joint, it expands
from tendo т. semimembranosi, ascends laterally from the medial condyle of the tibia
blending with the joint capsule.
The arcuate popliteal ligament, ligamentum popliteum arcuatum, is also on the pos-
terior side of the capsule of the knee joint. It is formed by the arch-shaped fibers start-
ing on the posterior surface of the fibular head and on the lateral epicondyle of the fe-
mur. The fibers of the ligament ascend, curve medially, partly blending with the oblique
popliteal ligament, and then descend to attach to the posterior surface of the tibia.
Anteriorly the capsule of the joint is reinforced by the tendon of т. quadriceps femoris
containing the patella in its thickness. The major part of the fibers of this tendon forms a
very strong cord termed the patellar ligament, ligamentum patellae, which extends from
the apex of the patella to the tibial tuberosity. The patellar ligament is separated from
the capsule of the joint by the synovial bursa. Other fibers of the tendon of m. quad-
riceps femoris pass as two ligaments termed the medial and lateral patellar retinacula,
retinaculum patellae mediale et retinaculum patellae laterale, to the anterior side of the
tibia, flanking the patella.
The knee joint has several synovial bursae, bursae synoviales; some of them commu-
nicate with the articular cavity (fig. 5.8):
1. The suprapatellar bursa, bursa suprapatellaris, is between the femur and the ten-
don of the quadriceps femoris. It extensively communicates with the cavity of the joint.
The superior border of the cavity is 3 cm above the superior border of the patella, but in
case of the union of the cavity with the suprapatellar bursa, it may rise up by 7—8 cm. In
a fetus and newborn bursa suprapatellaris is always isolated from the cavity of the joint.
54 ARTHROSYNDESMOLOGY

2. The deep infrapatellar bursa, bursa infrapa-


tellaris profunda, is between the patellar ligament
and the tibia.
3. The subcutaneous prepatellar bursa, bursa
prepatellaris subcutanea, is on the anterior side of
the knee joint at the level of the patella, in subcu-
taneous fat.
4. The bursa of semimembranosus, bursa т.
semimembranosi, is between the tendon of semi-
membranosus and the medial head of the gastroc-
nemius; in 1/3 of cases it communicates with the
cavity of the joint.
5. The proper bursa of semimebranosus, bursa
т. semimembranosi propria, is smaller than the pre-
vious bursa. It lies at the place of the attachment of
т. semimembranosus.
6. The bursa of popliteus, bursa т. poplitei, is
between т. popliteus and the posterior part of the
articular capsule, at the edge of the lateral meniscus
where the bursa joins with the cavity of the knee
joint. After birth, sometimes, this bursa communi-
cates with the cavity of the tibiofibular joint, articu-
Fig. 5.8. Knee joint. Sagittal section: latio tibiofibularis.
1 — femur (femur); 2 — cruciate ligaments The knee joint is a bicondylar joint. Its move-
(ligamenta cruciata); 3 — tibia (tibia); ments occur around two axes: frontal and vertical
4 — tibial tuberosity (tuberositas tibiae); (in flexion of the knee joint). Around frontal axis
5 — deep infrapatellar bursa (bursa infra-
patellaris profunda); 6 — patellar ligament
flexion and extension occur (the amplitude of the
(ligamentum patellae); 7 — alar fold (plica movements is up to 160 degrees). In flexion the leg
alaris); 8 — articular cavity (cavitas articu- forms with the thigh an angle about 40 degrees. In
laris); 9 — patella (patella); 10 — tendo extension the leg and the thigh form one straight
m. quadriceps femoris; 11 — suprapatellar line, the femoral epicondyles abut against the prox-
bursa (bursa suprapatellaris) imal epiphysis of the tibia.
In flexion of the knee joint the femoral condyles
touch the tibia with only their posterior part having ellipsoid shape, the collateral liga-
ments relax and the leg may rotate. The fibular collateral ligament relaxes in a greater
degree, therefore, the lateral condyle is more free and can rotate wider. Rotation inwards
is limited by cruciate ligaments (in rotation outwards they relax), but rotation outwards
is limited by the collateral ligaments. During each movement, the menisci change their
shape and position to a greater or lesser extent. They divide the cavity of the knee joint
into two spaces, or floors: superior and inferior. Superior floor is between the femoral
condyles and the superior surface of the menisci, and inferior floor is between the infe-
rior surface of the menisci and the superior articular surface of the tibia. The superior
floor functions in flexion and extension, the inferior floor functions in rotation.
Joints of Leg
The bones of the leg are connected with each other by means of solid and synovial
joints. The proximal ends of the leg bones are articulated by synovial tibiofibular joint,
articulatio tibiofibularis. The articular surfaces of this joint are: the fibular articular facet,
facies articularis fibularis, of the tibia and the articular facet of the fibular head, facies
5. The joints of lower limb 55

articularis capitis fibulae. The capsule of the


joint is taut, anteriorly it is reinforced by the
anterior ligament of fibular head, ligamen-
tum capitis fibulae anterius, posteriorly — by
the posterior ligament of fibular head, liga-
mentum capitis fibulae posterius. The joint is
plane and immobile.
The distal ends of the bones of the leg are
articulated by the tibiofibular syndesmosis,
syndesmosis tibiofibularis (fig. 5.9, 5.10). It is
formed by short fibers connecting the fibular
notch of the tibia`s distal epiphysis with the
rough surface of the fibula. Anteriorly and
posteriorly this syndesmosis is reinforced by
anterior and posterior tibiofibular ligaments,
ligamenta tibiofibularia anterius et posterius.
A dense fibrous membrane — the in-
terosseous membrane of leg, membrana in-
terossea cruri, — connects the interosseous
borders of the tibia and fibula. In the up-
per and lower parts of the membrane there
are openings transmitting the vessels and
Fig. 5.9. Talocrural and subtalar joints.
nerves.
Frontal section:
Joints of Foot
1 — tibia (tibia); 2 — medial malleolus (malleolus
All joints of the foot can be divided into medialis); 3 — talus (talus); 4 — deltoid ligament
four groups: (tibiocalcaneal part) (ligamentum deltoideum (pars
1) joints connecting the leg and the tibiocalcanea)); 5 — talocalcaneal interosseous
foot; ligament (ligamentum talocalcaneum interosseum);
2) joints connecting the tarsal bones; 6 — subtalar joint (articulatio subtalaris); 7 — cal-
3) joints connecting the tarsus and the caneus (calcaneus); 8 — articular capsule (capsula
articularis); 9 — lateral malleolus (malleolus lat-
metatarsus; eralis); 10 — talocrural joint (articulatio talocru-
4) joints connecting the metatarsus and ralis); 11 — tibiofibular syndesmosis (syndesmosis
the fingers; tibiofibularis); 12 — interosseous membrane of leg
5) joints connecting the phalanges of the (membrana interossea cruris); 13 — fibula (fibula)
fingers.
Talocrural joint, articulatio talocruralis (supratalar joint, articulatio supratalaris), is
formed between both bones of the leg and the talus (fig. 5.9, 5.10). Its articular surfaces
are: the articular fossa having the shape of a fork and formed by facies articularis inferior
tibiae, facies articularis malleoli medialis (on the tibia), facies articularis malleoli lateralis
(on the fibula). The articular head is formed by the trochlea of the talus with its articular
surfaces: facies superior, facies malleolaris medialis and facies malleolaris lateralis.
The capsule of the joint is attached to the edge of the articular cartilage, only ante-
riorly it departs from the edge (on tibia — by 0,5 cm, on talus — by almost 1 cm). From
anterior and posterior sides the capsule is loose. From the lateral sides it is taut and
reinforced by the strong ligaments.
The medial collateral (deltoid) ligament, ligamentum collaterale mediale (deltoide-
um), consists of four parts: tibionavicular part, pars tibionavicularis, anterior and poste-
rior tibiotalar parts, partes tibiotalares anterior et posterior, and tibiocalcaneal part, pars
tibiocalcanea. These parts connect the bones of the same names.
56 ARTHROSYNDESMOLOGY

Fig. 5.10. Talocrural joint. Joints of foot. Dorsal surface:


1 — medial malleolus (malleolus medialis); 2 — medial (deltoid) collateral ligament (ligamentum collaterale mediale
(deltoideum)); 3 — talonavicular ligament (ligamentum talonaviculare); 4 — calcaneonavicular ligament (ligamentum
calcaneonaviculare); 5 — calcaneocuboid ligament (ligamentum calcaneocuboideum); 6 — dorsal calcaneonavicular
ligaments (ligamenta calcaneonavicularia dorsalia); 7 — collateral ligaments (ligamenta collateralia); 8 — dorsal tar-
sometatarsal ligaments (ligamenta tarsometatarsalia dorsalia); 9 — dorsal cuneocuboid ligament (ligamentum cuneo-
cuboideum dorsale); 10 — dorsal calcaneocuboid ligament ( ligamentum calcaneocuboideum dorsale); 11 — talocalca-
neal interosseous ligament (ligamentum talocalcaneum interosseum); 12 — medial talocalcaneal ligament (ligamentum
talocalcaneum mediale); 13 — lateral talocalcaneal ligament (ligamentum talocalcaneum laterale); 14 — calcaneofibular
ligament (ligamentum calcaneofibulare); 15 — lateral mealleolus (malleolus lateralis); 16 — anterior talofibular liga-
ment (ligamentum talofibulare anterius); 17 — anterior tibiofibular ligament (ligamentum tibiofibulare anterius)

From the lateral side the capsule of the joint is reinforced by the lateral collateral
ligament, ligamentum collaterale laterale, which is formed by three ligaments (fig. 5.10).
The anterior talofibular ligament, ligamentum talofibulare anterius, extends horizontally
from the anterior edge of the lateral malleolus to the anterior edge of the lateral area of
the talus. The posterior talofibular ligament, ligamentum talofibulare posterius, connects
the posterior edge of the lateral malleolus with the posterior process of the talus. The
calcaneofibular ligament, ligamentum calcaneofibulare, descends from the external sur-
face of the lateral malleolus to the lateral side of the calcaneus.
The talocrural joint is a typical hinge joint. Its movements are: plantar flexion, flexio
plantaris, and extension (dorsal flexion, flexio dorsalis) around frontal axis, and lateral
(swinging) movements which can occur in maximal plantar flexion because the trochlea
of the talus is narrower posteriorly. The movements at the talocrural joint are combined
with the movements at the subtalar and talocalcaneonavicular joints.
Intertarsal joints. These joints are: subtalar, talocalcaneonavicular, calcaneocuboid
and cuneonavicular joints (fig. 5.12).
Subtalar joint, articulatio subtalaris, is formed by articulation of the posterior cal-
caneal articular facet, facies articularis calcanea posterior, of talus with the posterior talar
articular surface, facies articularis talaris posterior, of calcaneus. The joint is trochoid, its
movements occur around sagittal axis only.
5. The joints of lower limb 57

Fig. 5.11. Joints of foot. Plantar surface:


1 — plantar ligaments (ligamenta plantaria); 2 — plantar cuneonavicular ligaments (ligamenta cuneonavicu-
laria plantaria); 3 — tendo m. tibialis anterioris; 4 — tendo m. tibialis posterioris; 5 — plantar cuneonavicular
ligament (ligamentum cuneonavoculare plantare); 6 — long plantar ligament (ligamentum plantare longum);
7 — tendo m. peronei longi; 8 — tendo m. peronei brevis; 9 — plantar tarsometatarsal ligaments (ligamenta tarso-
metatarsalia plantaria); 10 — plantar metatarsal ligaments (ligamenta metatarsalia plantaria); 11 — collateral
ligaments (ligamenta collateralia)

Fig. 5.12. Joints of right foot. Sagittal section:


1 — tibia (tibia); 2 — capsule of talocrural joint (capsula articulatio subtalaris); 3 — talus (talus); 4 — subtalar
joint (articulatio subtalaris); 5 — calcaneus (calcaneus); 6 — talocalcaneal interosseous ligament (ligamentum
talocalcaneum interosseum); 7 — long plantar ligament (ligamentum plantare longum); 8 — fibrocartilago navicu-
laris; 9 — sesamoid bones (ossa sesamoidea); 10 — proximal phalanx (phalanx proximalis); 11 — metatarsopha-
langeal joint (articulatio metatarsophalangea); 12 — I metatarsal bone (os metatarsale I); 13 — tarsometatarsal
joint (articulatio tarsometatarsale); 14 — medial cuneiform bone (os cuneiforme mediale); 15 — cuneonavicular
joint (articulatio cuneonaviculare); 16 — navicular bone (os naviculare); 17 — talocalcaneonavicular joint (ar-
ticulatio talocalcaneonavicularis)

Talocalcaneonavicular joint, articulatio talocalcaneonavicularis, is a spheroidal


joint. Its articular surfaces form the articular head and articular fossa. The articular head
is formed by the navicular articular surface, facies articularis navicularis, and anterior
and middle facets for calcaneus, facies articularis calcanea anterior et facies articularis
calcanea media, located on the talus. The articular fossa is formed by the posterior artic-
ular surface, facies articularis posterior, of the navicular and by the anterior talar articular
surface, facies articularis talaris anterior, of the calcaneus.
58 ARTHROSYNDESMOLOGY

The plantar calcaneonavicular ligament, ligamentum calcaneonaviculare plantare,


strengthens the capsule of the joint inferiorly. In the place where this ligament adjoins
the head of the talus (in the thickness of this ligament), there is a layer of navicular
fibrous cartilage, fibrocartilago navicularis, which is involved into the articular fossa.
When the ligament tenses, the head of the talus depresses and the arches of the foot
become flattened.
On the dorsal surface of the joint there is a talonavicular ligament, ligamentum talo-
naviculare. This ligament connects the dorsal surface of the talar neck with the navicular
bone. On the lateral sides the joint is reinforced by the lateral talocalcaneal ligament,
ligamentum talocalcaneum laterale, and by the medial talocalcaneal ligament, ligamentum
talocalcaneum mediale. The lateral talocalcaneal ligament is a broad band located at the
entrance of sinus tarsi; its fibers have oblique direction and pass from the inferior and
external surfaces of the talar neck to the superior surface of the calcaneus. The medial
talocalcaneal ligament is narrow, it extends from the posterior tubercle of the talus to the
posterior edge of the talus. Sinus tarsi is filled with the interosseous talocalaneal liga-
ment, ligamentum talocalcaneum interosseum.
Despite the fact that the talocalcaneonavicular joint is spheroidal in shape, its movements
occur only around own axis of the foot, which also serves as the axis of the subtalar joint.
Hence, both joints function as a single combined talotarsal joint, articulatio talotarsalis.
In infants (especially during the first year of life) the foot is in the position of supina-
tion, therefore, while walking, a baby puts the foot on the lateral border.
The talocrural, subtalar and talocalcaneonavicular joints can function independent-
ly. At the talocrural joint flexion and extension prevail, at two other joints supination
and pronation prevail. But usually they work together, functionally forming a single
joint termed the joint of the foot, articulatio pedis, in which the talus plays the role of a
bony disc. During the movements at this joint the talus is static, but the movements are
performed by the whole foot including the calcaneus and navicular bone. The dorsal
flexion, flexio dorsalis, of the joint of the foot is accompanied by the pronation, pronatio,
i.e. the medial border of the foot is depressed, but the lateral border is elevated, and si-
multaneously the foot performs abduction, abductio. In plantar flexion, flexio plantaris,
the medial border rises up (supintion, supinatio) and perform the adduction, adduction.
Calcaneocuboid joint, articulatio calcaneocuboidea, is formed by articulation of
the articular surface for cuboid of the calcaneus with the posterior articular surface of
the cuboid, facies articularis cuboidea calcanei et facies articularis posterior ossis cuboidei.
The articular surfaces are saddle-shaped. The articular capsule is thick, strong and
taut from the medial side and it is thin and loose from the lateral side. The capsule is
reinforced by the ligaments which are especially well developed on the plantar side. The
strongest of them is the long plantar ligament, ligamentum plantare longum. It starts from
the inferior roughness of the calcaneus and consists of several layers. Its deep bundles
are attached to the tuberosity of the cuboid; its superficial bundles are the longest, they
cross over sulcus tendineus т. peronei longi (transforming the groove into the canal in
which tendo т. peronei longi is placed) and attach to the bases of the II—V metatarsals.
Deeper than the long plantar ligament, there is plantar calcaneocuboid ligament,
ligamentum calcaneocuboideum plantare, consisting of short fibers which lie directly on
the capsule of the joint and connect the plantar surfaces of the calcaneus and cuboid.
The calcaneocuboid joint is saddle in shape, but it functions as a uni-axial pivot joint
due to the combination with the talocalcaneonavicular and subtalar joints.
From the surgical point of view, articulatio calcaneocuboidea and articulatio talonavic-
ularis (the part of articulatio talocalcaneonavicularis) are considered to be a single joint
5. The joints of lower limb 59

known as the transverse tarsal joint, articulatio tarsi transversa (the joint of Chopart).
The articular surfaces of these joints have poorly expressed S-shaped configuration. The
amputation of the foot is made through the Chopart`s joint. For the amputation it is
necessary to cut the bifurcated ligament, ligamentum bifurcatum (the key of the trans-
verse tarsal joint), which holds the calcaneus, navicular and cuboid with each other. The
bifurcated ligament, ligamentum bifurcatum, starts from the superior edge of the calca-
neus and then it is divided into two ligaments: calcaneonavicular, ligamentum calcaneo-
naviculare, and calcaneocuboid, ligamentum calcaneocuboideum. The calcaneonavicular
ligament is attached to the superolateral edge of the navicular and the calcaneocuboid
ligament is attached to the dorsal surface of the cuboid.
Cuneonavicular joint, articulatio cuneonavicularis, is between facies articularis an-
terior ossis navicularis, facies articulares posteriores ossa cuneiformia I–III, and the lat-
eral articular facets of the cuneiform, cuboid and navicular bones, facing each other.
The cavity of the joint has the shape of frontal slit from which four slits start: the first
one is directed backwards (between the navicular and cuboid bones) and three slits
are directed forwards (between three cuneiform and the cuboid). The joint is plane in
shape, its capsule is attached to the edges of the articular surfaces. The cavity of the
joint always communicates with articulatio tarsometatarsea II by means of the slit be-
tween ossa cuneiformia mediale et intermedium. The joint is reinforced by the dorsal and
plantar cuneonavicular ligaments, ligamenta
cuneonavicularia plantaria et dorsalia, by
the interosseous intercuneiform ligaments,
ligamenta intercuneiformia interossea, by the
dorsal and plantar intercuneiform ligaments,
ligamenta intercuneiformia dorsalia et plantar-
ia. The interosseous ligaments can be visible
only in the horizontal section of the foot or in
the dissected joint, if we move apart the ar-
ticulating bones. This joint is a typical plane
joint, and it is almost immobile.
Tarsometatarsal joints. The tarsometa-
tarsal joints, articulationes tarsometatarsales
(fig. 5.13), are plane joints (only the articular
surfaces of the joint of the I metatarsal bone
slightly saddle shape). There are three tarso-
metatarsal joints: the first one — between os cu-
neiforme mediale and os metatarsale I; the second
one — between ossa cuneiformia intermedium et
laterale and ossa metatarsalia II et III (the cav-
ity of this joint communicates with articulatio
cuneonavicularis); the third one — between os
cuboideum and ossa metatarsalia IV et V.
From the surgical points of view all three
Fig. 5.13. Horizontal section of foot:
joints are united into a single joint known
1 — subtalar joint (articulation subtalaris); 2 — tal-
the joint of Lisfranc. It is used in surgery for ocalcaneal interosseous ligament (ligamentum
the amputation of the foot. The capsules of talocalcaneum interosseum); 3 — intercuneiform
these joints are reinforced by the dorsal and interosseous ligament (ligamentum intercuneiforme
plantar tarsometatarsal ligaments, ligamenta interosseum); 4 — tarsometatarsal joints (articula-
tarsometatarsalia dorsalia et plantaria. tiones tarsometatarsae)
60 ARTHROSYNDESMOLOGY

Between the cuneiform and metatarsal bones there are interosseous cuneometatar-
sal ligaments, ligamenta cuneometatarsalia interossea. The interosseous cuneometatarsal
ligament, which extends between the medial cuneiform and the II metatarsal bones, is
the key of the joint of Lisfranc. The tarsometatarsal joints are plane and almost immobile
(amphiarthrosis).
As well as in the hand, in the foot it is possible to distinguish the solid basis, i. e. the
rigid complex of the bones connected with each other. The solid basis of the foot in-
cludes the greater number of the bones than the solid basis of the hand (10 bones); this
difference in the number of bones is the result of the different function of the foot and
the hand. These bones are: os naviculare; ossa cuneiformia mediale, intermedium, laterale;
os cuboideum; ossa metatarsalia I—V.
Intermetatarsal joints, articulationes intermetatarseae, are between facing each
other surfaces of the metatarsal bones. Their capsules are reinforced by the dorsal and
plantar metatarsal ligaments, ligamenta metatarsalia dorsalia et plantaria, and by the in-
terosseous metatarsal ligaments, ligamenta metatarsalia interossea.
Metatarsophalangeal joints, articulationes metatarsophalangeae, are between the
heads of the metatarsal bones and the bases of the proximal phalanges. The articular
surfaces of the heads of ossa metatarsalia II—V have irregular spheroidal shape: the plan-
tar side of each articular surface is significantly flattened. The articular fossae of the
phalanges are oval-shaped. The capsules of the joints are loose, they are thinner from
the dorsal side than from the plantar side. They are attached to the edges of the articular
cartilages. From the lateral and medial sides the joints are reinforced by the collateral
ligaments, ligamenta collateralia. From the plantar side they are reinforced by the plan-
tar ligaments, ligamenta plantaria. Sometimes, these ligaments contain pieces of fibrous
cartilage and sesamoid bones. Between the heads of the I–V metatarsal bones, there is a
deep transverse metatarsal ligament, ligamentum metatarsale transversum profundum. It
looks like fibrous cord located transversely, it is fused with the capsules of the metatar-
sophalangeal joints to connect the heads of all metatarsal bones. This ligament plays a
great role in the formation of the transverse metatarsal arch of the foot.
Articulatio metatarsophalangea I has specific features: the plantar part of the capsule
of this joint encloses two sesamoid bones, therefore, this joint functions as a hinge joint.
Its movements are flexion and extension around frontal axis. Other four metatarsopha-
langeal joints function as ellipsoid joints. Their movements are: flexion and extension
around frontal axis, adduction and abduction around sagittal axis, and slight circumduc-
tion.
Interphalangeal joints, articulationes interphalangeae, are similar to the interpha-
langeal joints of the hand by shape and function. They are hinge joints. The collateral
and plantar ligaments, ligamenta collateralia et plantaria, reinforce them. In the resting
position the proximal phalanges are in the state of the dorsal flexion, but the middle
phalanges are in the state of the plantar flexion.

5.4. The Arches of Foot


In normal, the human foot is arched with concavity in the sole. As a result, the foot
rests upon the ground only by several points of its plantar surface: posteriorly the sup-
port point is the calcaneal tuberosity, anteriorly — the heads of metatarsal bones. The
phalanges only touch the ground. In accordance with the position of five metatarsal
bones, five longitudinal arches, arcus pedis longitudinales, are distinguished. The I—III
arches don`t touch the ground, therefore, they are called springy arches; the IV and V
5. The joints of lower limb 61

arches touch the ground and they are called support arches. Because of the difference in
shape and convexity of the longitudinal arches the lateral border of the foot (the IV—V
arches) rests upon the ground, while the medial border (the I—III arches) has a distinct
arch form.
Besides longitudinal arches, two transverse arches, arcus pedis transversus, are distin-
guished: proximal (tarsal) and distal (metatarsal) arches which are convex dorsally and
located in the frontal plane. The tarsal arch is in the distal part of the tarsus; the metatar-
sal arch is in the region of the metatarsal heads. In the metatarsal arch only heads of the
I and V metatarsals touch the ground.
The arches of the foot play the role of shock absorbers in static load and while walk-
ing. Also they prevent the compression of soft tissues during movements and provide
benefical conditions for normal blood circulation. The condition of the foot where the
arches are flattened so that the entire sole of the foot rests upon the ground, is called
flat foot (platypodia). In this disease, support and amortizing functions of the foot are
disordered and the people with the flat foot can not endure long physical strain.
In general, it is necessary to consider a foot to be the part of a single system «foot —
lower limb — vertebral column». In the support structures of the body, each overlying
joint depends on the underlying joint, and vice versa. The disease of the foot causes the
asymmetry of the whole body. The flattening of the foot causes cascading compensatory
changes and overloads of the lower limb, pelvis and vertebral column. The flat foot devi-
ates outwards and causes the outward rotation of the leg and the inward rotation of the
thigh. Thus, the harmoniously developed and well-formed foot plays a great role in the
good posture.

TEST QUESTIONS
1. What types of joints connect the bones of the pelvic girdle?
2. Describe the articular surfaces of the sacrococcygeal joint.
3. Describe the sacrococcygeal joint according to the classifications of synovial
joints.
4. What ligaments connect the pelvic bones? Describe their attachment and func-
tion.
5. What structures bound the greater and lesser sciatic notches?
6. Describe the pubic symphysis and ligaments, reinforcing it.
7. Describe the pelvis as a whole. What parts of the pelvis are distinguished? Define
the terminal line, what points does it connect?
8. Define the conjugates of the pelvis. What is their clinical importance? List the
main pelvic conjugates. Between what bone landmarks are they measured?
9. Define the axis of the pelvis.
10. Describe the articular surfaces of the hip joint.
11. Describe the hip joint according to the classifications of synovial joints.
12. Define the acetabular labrum. What is its function?
13. What ligaments reinforce the hip joint? Describe their attachment.Which of them
are intra-articular (extra-articular) ligaments? Describe the function of each ligament of
the hip joint.
14. Describe the movements of the hip joint.
15. Describe the articular surfaces of the knee joint.
16. Describe the knee joint according to the classifications of synovial joints.
17. Describe the menisci of the knee joint, their position and function.
62 ARTHROSYNDESMOLOGY

18. What ligaments reinforce the knee joint? Describe their attachment. Which of
them are intra-articular (extra-articular) ligaments? Describe the function of each liga-
ment of the knee joint.
19. List the bursae of the knee joint. Describe their location and communications
with the cavity of the knee joint.
20. What movements can be performed at the knee joint?
21. What joints connect the bones of leg?
22. Describe the articulations of the proximal and distal epiphyses of the leg
bones.
23. Describe the identity and differences between the joints of the leg and the joints
of the forearm.
24. What bones does the talocrural joint connect? Describe the articular surfaces of
this joint.
25. Describe the talocrural joint according to the classification of synovial joints.
26. What ligaments reinforce the talocrural joint? Describe their attachment.
27. Describe the movements of the talocrural joint.
28. List the synovial joints of the foot in accordance with the subdivisions of the
foot.
29. What joints form the joit of the foot? Describe its movements.
30. Describe calcaneocuboid joint and its ligaments.
31. What joints form the transverse tarsal joint? What are its role and the role of the
bifurcated ligament in surgery?
32. Describe the articular surfaces of the cuneonavicular joint. Give the character-
istic of this joint according to the classifications of synovial joints.
33. Describe the articular surfaces of the tarsometatarsal joints. How many tarso-
metatarsal joints exist? Give the characteristic of these joints according to the classifica-
tions of synovial joints. What is the role of the tarsometatarsal joints in surgery?
34. Describe the articular surfaces of the metacarpophalangeal and interphalangeal
joints. Give the characteristic of these joints according to the classifications of synovial
joints. What movements occur at these joints?
35. List main ligaments of the foot and describe their attachment.

CLNICOANATOMICAL PROBEMS
1. A 70-years old patient fell down on the right side. She couldn`t stand up because
of pain in the region of the hip joint. On examination the right lower limb was 2 cm
shorter than the left lower limb. The fracture of the femoral neck was diagnosed. What
anatomical structures could be damaged?
2. A patient spraned the ankle and felt acute pain. On examination swelling and
painfulness in the region of the talocrural joint were observed. The X-ray picture shows
that the distal ends of the tibia and fibula move apart. What ligaments were damaged?
3. A patient consulted the doctore in a day after contusion of the knee. On examina-
tion swelling of the knee and painfulness in flexion of the knee were observed. Durung
puncture pus was revealed. What bursae of the knee joint can be involved into the in-
flammatory process?
4. A patient complains of pains in the plantar side of the foot and rapid fatiguability
while walking. On examination: the shape of the foot is changed, the arches of the foot
are decreased. Stage II flat foot was diagnosed. What anatomical structures were dam-
aged?
ARTHROSYNDESMOLOGY
АРТРОCИНДЕСМОЛОГИЯ
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