Escolar Documentos
Profissional Documentos
Cultura Documentos
Kurtseva
M. G. Gaivoronskaya, G. I. Nichiporuk
ARTHROSYNDESMOLOGY
АРТРОСИНДЕСМОЛОГИЯ
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
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.
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
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
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.
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
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.
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).
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.
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
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).
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
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
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
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
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
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
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
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.
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
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
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
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.
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
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