HIP JOINT, and

KNEE JOINT.

1
POINT TO NOTE IN
DISCUSSING THE JOINT
 Location
 Bones and type
 Articular surfaces
 Supports and Stability factors e.g. capsule,
ligament, labrum etc
 Associated structures e.g. bursa and sesamoid
bones
 Movement
 Blood and nerve supply (remember Hilton’s rule)
 Applied anatomy
2
The Hip Joint

3
The Hip Joint
 Type: the hip is a synovial ball
and socket joint.
 The articulation is between the
rounded femoral head and the
acetabulum, it is deepened at its
margins by a fibrocartilaginous
rim acetabulum labrum.
 The central and inferior parts of
the acetabulum are devoid of
articulating surface.
 This region is termed the
acetabular notch from which the
ligamentum teres passes to the
fovea on the femoral head. 4
Hip (coxal) joint
 Moves in all axes but
limited by ligaments
and deep socket
 Three external
ligaments “screw in”
head of femur when
standing
 Iliofemoral
 Pubofemoral
 Ischiofemoral

5
 Bones
 Ilium
 Ischium
 Pubis
 Femur
 The acetabulum is formed
by the pubis, ischium and
ilium bones
 The inferior margin below
the acetabular notch is
completed by the
transverse acetabular
ligament.
6
Stability
Stability: is dependent
predominantly on bony
factors.
Ligamentous stability is
provided by three
ligaments:
 Iliofemoral
 Pubofemoral
 Ischiofemoral
 Joint Capsule is Strong
fibrous sleeve
7
 Hip Joint
Capsule
The capsule encloses the joint
Medial attachment

it is attached to

The margin of the acetabulum

outside the labrum
anterolateral posterolateral
Lateral attachment
Anteriorly, it is attached to the intertrochanteric line of the femur

Posteriorly, it is attached to halfway along the neck of the femur

8
 Hip Joint
Capsule
At its attachment to
the neck of the femur

some fibers of the capsule,

are reflected along the neck posterolateral
anterolateral as bands called
retinacula of the neck of the femur
The blood vessels pass between
the retinacula and neck of the femur
To supply the head and neck of the femur 9
Retinacula
 The capsular fibres are
reflected from the
lower attachment
upwards on the
femoral neck as
retinacula.
 These fibres are of
extreme importance as
they carry with them
a blood supply to the
femoral head.
10
 Hip Joint
posterolateral
anterolateral Ligaments
1- The iliofemoral ligament:
It is a strong, inverted
Y-shaped ligament
Its stem is attached to the
anterior inferior iliac spine
above
the two limbs of the Y are attached to
the upper and lower parts of the intertrochanteric line
It prevents overextension during standing.

2- The pubofemoral ligament It is triangular

The base of the ligament is attached to the superior pubic ramus
the apex is attached below to lower part of the intertrochanteric line.
11
It limits extension and abduction
 Hip Joint
posterolateral
anterolateral Ligaments

3- The ischiofemoral ligament:

It is spiral shaped

It is attached to

the body of the ischium near the acetabular margin.

The fibers pass upward and laterally

and are attached to the greater trochanter

This ligament limits extension.

12
 Ligaments
 Ischiofemoral ligament-
attaches from the ischial
part of the acetabular rim to
the femur. Posterior joint
capsule is reinforced by this
ligament.
 The majority of the fibres,
however, spiral and blend
with the capsule around the
neck of the femur as the
zona orbicularis.

13
 Ligaments (cont.)
 The round ligament of the
head of the femur is attached
to the transverse acetabular
ligament and extends to the
fovea centralis on the head
of the femur
 A fibrocartilaginous ring
called the acetabular labrum
deepens the acetabulum and
clasps the head of the femur
which makes the joint more
stable

14
 Intracapsular: Ligament of the head of the femur;
it is very Weak Conveys branches of obturator
artery to head of femur

15
 Hip Joint
posterolateral
anterolateral

Synovial Membrane:

It lines
the capsule
and is attached to
the margins of the articular surfaces
the margin of the head of the femur
the margin of the lunate surface of the acetabulum
inside the labrum 16
 Synovial Membrane:
posterolateral It is attached to the margin of
the lunate surface of the acetabulum

It covers
the pad of fat in the
Floor of the acetabular fossa.
It covers
the portion of the neck of the femur
that lies within the joint capsule.
Hip Joint
17
 Hip Joint
Synovial Membrane:

It ensheathes

the ligament of
the head of the femur

18
 anterolateral
Synovial Membrane:
A pouch of synovial membrane
frequently protrudes through
a gap in
the anterior wall of the capsule
between
The iliofemoral ligaments

And the pubofemoral ligament

and forms
the psoas bursa

Hip Joint Deep to the psoas tendon

19
Nerves
 Femoral
 Obturator
 Sciatic
 Nerve to quadratus femoris
 Direct branches of sacral plexus

20
 Blood Supply
 Medial Circumflex artery
 Lateral Circumflex artery
 Obturator artery
 Inferior gluteal artery

21
The trochanteric anastomosis
 It lies close to the trochanteric fossa and
provides branches that ascend the femoral
neck beneath the retinacular fibres of
the capsule to supply the femoral head.

22
 Trochanteric
Anastomosis
 This arterial
anastomosis is
formed by branches
from ascending brs.
of the medial and
lateral circumflex
femoral, the superior
gluteal and, usually,
the inferior gluteal
arteries.
23
 The cruciate anastomosis
 It is formed by:
I. The transverse branches
of the medial and
II. Lateral circumflex femoral
arteries,
III. The descending branch of
the inferior gluteal artery
and
IV. The ascending branch of
the 1st perforating branch
of the profunda femoris.
24
 Clinical importance
 It gives a collateral channels
of blood supply to the lower
limb avoiding the external
iliac and femoral arteries,
example, in ligation of
femoral artery above the
origin of profunda femoris
artery it keeps an efficient
blood supply through
collateral circulation.

25
Movements
The hip joint is the most mobile joint in the lower limb. It is
capable of flexion and extension, abduction and
adduction, medial and lateral rotation and all of these in a
circular motion- circumduction

second largest range of movement (second only to the shoulder) supports

the weight of the body, arms and head.
26
 Hip movements
 Flexion (0–120°): iliacus and psoas predominantly. Rectus
femoris, sartorius and pectineus to a lesser degree.
 Extension (0–20°): gluteus maximus and the hamstrings.
 Adduction (0–30°): adductor magnus, longus and brevis
predominantly. Gracilis and pectineus to a lesser degree.
 Abduction (0–45°): gluteus medius, gluteus minimus and
tensor fasciae latae.
 Lateral rotation (0–45°): piriformis, obturators, the gemelli,
quadratus femoris and gluteus maximus.
 Medial rotation (0–45°): tensor fasciae latae, gluteus
medius and gluteus minimus.
 Circumduction: this is a combination of all movements
utilizing all muscle groups mentioned.
27
FRACTURE OF FEMORAL
HEAD

28
Hip fracture classification
 Hip fractures can be
classified into
Intracapsular (femoral
neck) fractures and
extracapsular
fractures.

29
 Hip fracture classification
 The Intracapsular fractures
are contained within the hip
capsule itself.
 Those fractures are subcapital
neck fracture and
transcervical neck fracture.
 The extracapsular fractures
are intertrochanteric and
subtrochanteric fracture.
 You also have a greater and
lesser trochanter fractures

30
DISLOCATION OF HIP
 Dislocation of the hip. If
the hip is forced into
posterior dislocation while
adducted (a), there is no
associated fracture of the
posterior acetabular lip
(b) Dislocation in the
abducted position (c) can
only occur with a
concomitant acetabular
fracture (d).

31
Referred Pain From the Hip
Joint
The femoral nerve not only supplies the hip joint
but, via the intermediate and medial cutaneous
nerves of the thigh, also supplies the skin of the
front and medial side of the thigh.
Therefore, the pain originating in the hip joint
may be referred to the front and medial side of
the thigh.
The posterior division of the obturator nerve
supplies both the hip and knee joints.
This explains why hip joint disease may give rise
to pain in the knee joint.
32
KNEE JOINT

33
 Introduction
 Most sports place
extreme stress on the
knees
 Very commonly injured
joint
 Technically, it’s a hinge
joint.
 Not a TRUE hinge joint,
though i.e. there is a
rotational component in
the tibia.
34
35
 Skeletal Anatomy • Femur
 Distal end are medial
and lateral condyles.
 The medial condyle is
longer from front to
back than the lateral
condyle.
 This is what causes the
rotation at the tibia in
full extension.

36
Skeletal Anatomy • Tibia
 Tibial Tuberosity is
where the patellar
tendon attaches.
 Tibial Plateau is
where the menisci are
located.

37
Skeletal Anatomy Patella
 Patella: Largest sesamoid bone in the
body
 Functions: Increase angle of pull of quads
 Decrease friction between quad and
condyles
 Acts as bony shield to protect condyles
 Improves aesthetic appearance of knee

38
Patella • Located within tendon of
quadriceps femoris muscle
group
• Articulates with patella
groove of femur
• Holds tendon away from
distal end of femur 
change tendon angle thus
increasing forces that can
applied on muscle to tibia
 less muscle contraction
is required to move tibia

39
40
41
42
43
Meniscus
 Menisci (plural)
 Fibrocartilage disks
that sit on tibial
plateau
 Medial is “C” shaped
 Lateral is “O” shaped

44
MENISCI
 The menisci are sheets of fibrocartilage.
 The upper surfaces are in contact with the
femoral condyles.
 The lower surfaces are in contact with the
tibial condyles.
 The peripheral border is thick and attached to
the capsule
 The inner border is thin and concave and
forms a free edge

45
MENISCI
 Each meniscus is attached to the upper
surface of the tibia by anterior and
posterior horns.
 Because the medial meniscus is also
attached to the medial collateral
ligament, it is relatively immobile.

46
Meniscus
 Functions: increases stability of the joint by
deepening the tibial plateau.
 Cushions stress i.e. it absorbs shock.
 Distribute the load over a large surface area.
 It reduces friction by 20%
 It increases contact area by 70%
 Distributes pressure between femur and tibia in
weight bearing.

47
Meniscus
 Blood supply to
menisci:
 Inner 2/3 is avascular
(no blood supply).
 Outer 1/3 does have
blood supply.

48
Joint Stability
 Weak skeletal strength
 Moderate ligament strength
 Strong muscle strength

49
LIGAMENTS
 Ligaments may be divided into
1. Extracapsular ligaments: Those that lie
outside the capsule.
2. Capsular ligaments Those that are thicken
parts of the capsule.
3. Intracapsular Ligaments Those that lie
within the capsule

50
 LIGAMENTUM PATELLAE
 It is continuation of the central portion of the
common tendon of the quadriceps femoris
muscle.
 Attached Above: to the lower border of the
patella
 Below: to the tibial tuberosity.

 Rupture of the Ligamentum Patellae:

 Can occur when a sudden flexing force is
applied to the knee joint when the quadriceps
femoris muscle is actively contracting.
51
Stabilizing Ligaments
 Anterior Cruciate Ligament (ACL)
 Posterior Cruciate Ligament (PCL)
 Medial Collateral Ligament (MCL)
 Lateral Collateral Ligament (LCL)
 IT (ILIOTIBIAL) Band

52
INTRACAPSULAR
LIGAMENTS
 The cruciate ligaments are two strong
intracapsular ligaments that cross each
other within the joint cavity.
 They are named anterior and posterior,
according to their tibial attachments.
 These important ligaments are the main bond
between the femur and the tibia throughout
the joint's range of movement

53
Cruciate ligaments

54
ANTERIOR CRUCIATE
LIGAMENT
 Attached to the anterior intercondylar area
of the tibia
 Passes upward, backward, and laterally, to be
attached to the posterior part of the medial
surface of the lateral femoral condyle
 Functions: Prevent anterior displacement
of the tibia with the knee flexed.
 Prevents posterior displacement of the
femur on the tibia. 55
Stabilizing Ligaments• ACL:
 Prevents anterior
translation of the tibia.
 Keeps the tibia from
gliding forward.
 Very strong ligament
 Very susceptible to
injury.
 Women more prone to
tear ACL than men.

56
Stabilizing Ligaments• ACL:
 A torn anterior cruciate ligament can be
recognized by abnormal passive anterior
displacement of the tibia called an anterior
drawer sign.
 A hyperextension injury at the knee joint
will stretch the anterior cruciate ligament.

57
POSTERIOR CRUCIATE
LIGAMENT
 Attached to the posterior intercondylar
area of the tibia.
 Passes upward, forward, and medially to
be attached to the anterior part of the
lateral surface of the medial femoral
condyle.

58
POSTERIOR CRUCIATE
LIGAMENT
 Functions:
 Prevent posterior displacement of the tibia
with the knee flexed.
 Prevents anterior displacement of the femur
on the tibia.

59
Stabilizing Ligaments PCL:
 Prevents posterior
translation of the tibia.
 Only 90% of size of
ACL.
 It is the strongest of
the knee ligaments.

60
Stabilizing Ligaments• PCL:
 A torn posterior cruciate ligament can be
recognized by abnormal passive posterior
displacement of the tibia called a posterior
drawer sign.
 A hyperflexion injury at the knee joint will
stretch the posterior cruciate ligament.

61
Stabilizing Ligaments MCL
 Flat band and is attached above to the
medial condyle of the femur and below to
the medial surface of the shaft of the tibia.
 It is firmly attached to the edge of the
medial meniscus.

62
Stabilizing Ligaments • MCL:
 Forced abduction of the tibia on the femur
can result in partial tearing of the medial
collateral ligament, which can occur at its
femoral or tibial attachments.
 It is useful to remember that tears of the
menisci result in localized tenderness on the
joint line, whereas sprains of the medial
collateral ligament result in tenderness over
the femoral or tibial attachments of the
ligament.
63
Stabilizing Ligaments • MCL:
 Flat, broad ligament
located on the inside
of the knee
 Prevents a valgus
stress on the knee.

64
Stabilizing Ligaments LCL:
 Cordlike and is
attached above to the
lateral condyle of the
femur and below to
the head of the fibula.
 The tendon of
popliteus muscle
intervenes between
the ligament and the
lateral meniscus.
65
Stabilizing Ligaments • LCL:
 Prevents a varus
stress on the knee.
 Forced adduction of
the tibia on the femur
can result in injury to
the lateral collateral
ligament (less
common than medial
ligament injury).

66
Stabilizing Ligaments IT Band:
 Long, thick
ligament/tendon
 located on the
outer part of the
thigh.

67
Capsular ligaments
 OBLIQUE POPLITEAL LIGAMENT: Is a tendinous
expansion derived from the semimembranosus muscle.
 It strengthens the posterior aspect of the capsule.

68
OBLIQUE POPLITEAL
LIGAMENT

Oblique popliteal ligament

69
Capsular ligaments
 ARCUATE POPLITEAL LIGAMENT It is a
Y-shaped thickening of the posterolateral
capsule, which arises from the fibular
styloid and divides into two limbs:
 Medial limb: curves over the popliteus muscle
to join with the oblique popliteal ligament.
 lateral limb: ascends to blend with the capsule
near the lateral head of gastrocnemius
muscle
70
 Medial limb: curves over the popliteus muscle to join with
the oblique popliteal ligament.
 lateral limb: ascends to blend with the capsule near the
lateral head of gastrocnemius muscle

71
 Capsule.
 Surrounds the knee
joint and includes the
patellofemoral joint.
 The capsule extends
from the distal femur
to the proximal tibia
and contains areas of
laxity and recesses to
allow for range of
motion.
72
 SYNOVIAL MEMBRANE
 Lines the capsule and is
attached to the margins of the
articular surfaces.
 On the front and above the joint,
it forms a pouch, which extends
up beneath the quadriceps
femoris muscle for three
fingerbreadths above the patella,
forming the suprapatellar bursa.
 This is held in position by the
attachment of a small portion of
the vastus intermedius muscle,
called the articularis genu
muscle 73
BURSAE OF THE KNEE JOINT
COMPLEX
 The knee joint has many bursae (sacs of
synovial fluid) to decrease frictional forces.
 Suprapatellar bursa. Located between the
quadriceps tendon and the anterior femur.
 Subpopliteal bursa. Located between the
popliteus muscle and the lateral femoral
condyle.

74
75
Prepatellar bursitis
 AKA “housemaid’s knee”
 Caused by inflammation or bursitis of the
superficial infrapatellar bursa between the
skin and the patellar ligament.
 The mechanism of injury can be from
direct impact or from an irritation to the
knee that occurs over time.

76
BURSAE OF THE KNEE JOINT
COMPLEX
 Gastrocnemius bursa. Located between
the medial head of the gastrocnemius
muscle and the medial femoral condyle.
 Prepatellar bursa. Located between the
skin and the anterior patella.
 Subcutaneous infrapatellar bursa. Located
between the patellar ligament and the
tibial tubercle.
77
78
 MOVEMENT OF KNEE JOINT
 Flexion: Mainly by: biceps femoris, semitendinosus
Assisted by: sartorius, gracilis and popliteus muscles.
 Extension: Mainly by: Quadriceps femoris muscle.
Assisted by: tensor fasciae lata muscle.
 Medial rotation: Mainly by: popliteus muscle.
Assisted by: sartorius, gracilis, semitendinosus &
semimembranosus.
 Lateral rotation: Only done by the biceps femoris
muscle.
79
Biomechanics
 Screw Home Mechanism
 Med. Condyle causes external rotation of
tibia in full knee extension.
 The popliteus “unlocks” the knee to
begin flexion.

80
 LOCKING OF KNEE JOINT
 Terminal stage of full extension of the knee
joint.
 Mechanism: The leg (the tibia) is laterally rotated &
the thigh (the femur) is medially rotated.
 This rotatory movement locks the joint (which
means that the joint cannot be flexed unless it is
unlocked by the reverse rotation).
 In full extension with the locked knee, all the
ligaments are stretched and the joint is stable.
 Produced by biceps femoris muscle (the only lateral
rotator) 81
UNLOCKING OF KNEE JOINT
 Definition: Is the early stage of flexion of
the knee joint.
 Mechanism: The leg is medially rotated and
the thigh is laterally rotated.
 Muscles produce unlocking: This is done by
the action of:
 Popliteus
muscle, helped by:
 Semimembranosus, semitendinosus & gracilis
muscles
82
ARTERIAL SUPPLY (10)
1. Femoral artery: 2
1. Descending genicular.
2. Descending branch of the lateral circumflex femoral.
2. Popliteal artery: 5
1. Superior/Inferior medial genicular.
2. Middle genicular artery.
3. Superior/Inferior lateral genicular.
3. Anterior tibial artery: 2
1. Posterior tibial recurrent and
2. Anterior tibial recurrent.
4. Posterior tibial artery:1 - Circumflex fibular.
83
 Anastomosis around the Knee Joint
Is made by the following
branches:
 Descending branch of
lateral circumflex femoral
 Descending genicular of
femoral
 Anterior tibial recurrent
 Five branches of popliteal
artery
NERVE SUPPLY (10)
 Femoral nerve:3 gives twigs from the nerves to
the three vasti.
 Tibial nerve: 3 gives: 1) Superior medial
genicular. 2) Inferior medial genicular. 3) Middle
genicular nerve.
 Common peroneal nerve 3: gives: 1) Superior
lateral genicular. 2) Inferior lateral genicular. 3)
Recurrent genicular nerve.
 Obturator nerve:3 gives the genicular branch
from its posterior division
85
 Applied anatomy
 Patellar tendon reflex: A tap on the patellar tendon
elicits extension of the knee joint.
 Bothafferent and efferent limbs of the reflex arc are in the
femoral nerve (L2-L4).
 A portion of the patella ligament may be used for
surgical repair of the anterior cruciate ligament of
the knee joint.
 The tendon of the plantaris muscle may be used for
tendon autografts to the long flexors of the fingers.

86
INJURIES OF THE KNEE
JOINT
 Knee joint injuries are common because
1. It is a low-placed joint.
2. Mobile.
3. Weight-bearing joint,
4. Serving as a fulcrum between two long
levers (thigh and leg).
5. Its stability depends almost entirely on its
associated ligaments and surrounding
muscles.
87
INJURIES OF THE KNEE
JOINT
 6. The knee joint is essential for everyday
activities such as standing, walking, and
climbing stairs.
 7. It is also a main joint for sports that
involve running, jumping, kicking, and
changing directions. To perform these
activities, the knee joint must be mobile;
however, this mobility makes it susceptible
to injuries 88
INJURIES OF THE KNEE
JOINT
 The most common knee injuries in contact
sports are ligament sprains, which occur
when the foot is fixed in the ground.
 If a force is applied against the knee when
the foot cannot move, ligament injuries are
likely to occur.

89
TIBIAL COLLATERAL
LIGAMENT (MCL) INJURY
 The firm attachment of the TCL to the
medial meniscus is of considerable clinical
significance because tearing of this
ligament frequently results in concomitant
tearing of the medial meniscus.
 This injury is common in athletes who twist
their flexed knees while running (e.g. , in
basketball, the various forms of football,
and volleyball). 90
UNHAPPY TRIAD OF THE
KNEE JOINT
 May occur when a football player's shoe is
planted firmly in the turf and the knee is struck
from the lateral side. It is characterized by
 (a) rupture of the tibial collateral ligament, as a
result of excessive abduction;
 (b) tearing of the anterior cruciate ligament, as a
result of forward displacement of the tibia; and
 (c) injury to the medial meniscus, as a result of the
tibial collateral ligament attachment.

91
UNHAPPY TRIAD OF THE
KNEE JOINT
 The ACL, which serves
as a pivot for rotatory
movements of the
knee and is taut during
flexion, may also tear
subsequent to the
rupture of the TCL,
creating an “unhappy
triad” of knee injuries

92
 Knee injuries
 Flat tibial surface
predisposes to
horizontal injuries
 Lateral blow: multiple
tears
 ACL injuries
 Stop and twist
 Commoner in women
athletes
 Heal poorly
 Require surgery

93
Drawer sign
 Anterior drawer sign is a forward sliding
of the tibia on the femur due to a rupture of
the anterior cruciate ligament , whereas
 Posterior drawer sign is a backward
sliding of the tibia on the femur caused by
a rupture of the posterior cruciate
ligament.

94
95
LATERAL MENISCUS INJURY
 Injury to the lateral meniscus is less
common, probably because it is not attached
to the lateral collateral ligament of the knee
joint and is consequently more mobile.
 The popliteus muscle sends a few of its
fibers into the lateral meniscus, and these
can pull the meniscus into a more favorable
position during sudden movements of the
knee joint
96
Knee injuries
 A dislocated knee or fractured distal femur:
may injure the popliteal artery because of its
deep position adjacent to the femur and the knee
joint capsule.
 Emergency physicians should discipline
themselves about the risk of concomitant
vascular injury associated with knee dislocation
and its forthcoming consequences of belated
diagnosis.

97
Bumper fracture
 Bumper fracture: is a fracture of the lateral
tibial condyle that is caused by an automobile
bumper, and it is usually associated with a
common peroneal nerve injury.
 A fracture of the lateral tibial plateau caused by
a forced valgus applied to the knee.
 The lateral part of the distal femur and the lateral
tibial plateau to come into contact, compressing
the tibial plateau and causing the tibia to
fracture.
98
99
 Knee injuries
 Transverse patellar
fracture: results from a
blow to the knee or from
sudden contraction of the
quadriceps muscle.
 The proximal fragment of
the patella is pulled
superiorly with the
quadriceps tendon, and the
distal fragment remains
with the patellar ligament.
100
 Fracture of the fibular neck:
 May cause an injury to the
common peroneal nerve,
which winds laterally
around the neck of the
fibula. This injury results in
paralysis of all muscles in
the anterior and lateral
compartments of the leg
(dorsiflexors and evertors
of the foot), causing foot
drop.

101
Haemarthrosis
 Haemarthrosis (blood
in a joint): usually
causes a rapid
swelling of the injured
knee joint, whereas
inflammatory joint
effusion causes a
slow swelling of the
knee joint.

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