Limb Joints (Elliot)

e. Which of the two cruciate ligaments is more obliquely oriented?

ACL

e. Describe the more proximal one of those malalignments.

Abduction (medial deviation) of the first cuneometarsal joint.

b. What ligaments are there?

Acriomioclavicular ligament is part of joint capsule and located superiorly

a. With what part of the scapula does the distal end of the clavicle articulate?

Acromion (Acromionclavicular joint)

f. Describe the more distal one of those malalignments.

Adduction (lateral deviation) of the first metatarsophalangeal joint. Medial and lateral deviation reffereing with reference to 2nd pedal ray? o2nd digit is the central ray of the foot (Elliot 91) Abduction and adduction are with reference to midline of body

c. Relative to the posterior cruciate ligament, where on the tibial plateau does the anterior cruciate ligament attach to the tibia?

Anterior ACL goes from posterior femur to anterior(ish) tibia oFemur laterally, tibia medially PCL goes from anterior femur to posterior tibia oFemur medially, tibia laterally

f. Of course you know that the anterior cruciate ligament limits anterior displacement of the tibia and the posterior cruciate ligament limits posterior displacement of the tibia.

Anterior cruciate ligament = limits anterior displacement of the tibia Posterior cruciate ligament = limits posterior displacement of tibia

b. Relative to the femur where is the iliofemoral ligament located?

Anterior to the femoral neck

a. What ligament holds the radial head in place against the radial notch of the proximal ulna?

Anular ligament of the radius

f. What parts of the medial longitudinal arch are kept relatively close together by the plantar aponeurosis?

Calcaneal tuberosity, heads to medial metatarsals

d. What ligaments are between the coracoid process of the scapula and the clavicle?

Coracoclavicular ligaments

o. Here is a strange one. Name a muscle of the leg that has the potential to build the medial longitudinal arch by plantarflexing and everting the forefoot.

Fibularis longus

d. In a typical case of hallux valgus, what joints of the first ray are most significantly malaligned?

First cuneometarsal (tarsometatarsal) joint and first metatarsophalangeal joint.

b. Notice that that effect is prominent in mid-stance phase of walking gait.

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e. What part of what bone articulates with the superior surface of the spring ligament?

Head of talus

b. What part of what bone sits at the top of the medial longitudinal arch?

Head of the talus

i. Most instances of hip joint dislocation in adults are accompanied by fracture of the hip bone or the femoral head. Why?

Hip bone The acetabulum is deep and the femoral head sits deeply in it; relative to cartilage, bone is brittle.

e. We hope you know that one of those two ligaments connects the femur to the tibia and the other connects the femur to the fibula.

I DO NOW! Thanks elliot!!

b. What ligament of the hip joint is challenged by extension of the thigh at the hip? Name a major muscle that will be stretched when you assess the integrity of the ligament you just named. Obviously, if the muscle is resistant to stretching, you will have difficulty assessing the ligament.

Iliofemoral ligament is challenged by extension of the thigh at the hip Muscle that will be stretched when testing extension of the thigh at the hip = iliopsoas muscle (psoas major + iliacus muscle) Iliopsoas attaches to the lesser trochanter

f. Use proper anatomical terms to name the movement that the iliofemoral ligament limits most effectively.

Iliofemroal ligament limits extension of the thigh at the hip joint

c. Which muscles are in contact with the iliofemoral ligament?

Iliopsoas muscle contacts iliofemoral ligament Iliopsoas = psoas major + iliacus muscle

g. What effect do these malalignments have on the action of the flexor hallucis longus muscle?

It becomes an abductor at the proximal joint and an adductor at the distal joint, compounding the malalignments.

c. Suppose your patient shows excess range of motion when you passively adduct the tibia at the knee joint by pressing against the medial aspect of the knee to displace the entire knee laterally. What ligament appears to be damaged?

Lateral collateral ligament (fibular collateral ligament)

a. Where in the intercondylar fossa does the anterior cruciate ligament attach to the femur?

Laterally

d. Suppose your patient shows excess range of motion when you passively abduct the tibia at the knee joint by pressing against the lateral aspect of the knee to displace the entire knee medially. What ligament appears to be damaged?

Medial collateral ligament (tibial collateral ligament)

11.17. FOOT ARCHES. F-IAT review. Describe the medial longitudinal arch and the transverse arch of the foot by detailing the bone morphology and soft tissue attachments that produce the arches. a. Which is taller, the medial longitudinal arch or the lateral longitudinal arch?

Medial longitudinal arch

b. Where in the intercondylar fossa does the posterior cruciate ligament attach?

Medially

c. This objective and the previous one also serve as locations for exam items concerning major features of the joints that are not covered in the more specific objectives. For example, there is a muscle tendon inside the joint capsule of the knee joint. What is it? Where in the knee joint is it located?

Muscle tendon in the joint capsule of the knee joint = popliteus muscle tendon Located between the fibrous joint capsule and the lateral meniscus, it passes deep to the lateral collateral ligament of the knee

n. Name a muscle of the leg that has the potential to flatten the medial longitudinal arch by dorsiflexing the forefoot.

Muscle that dorsi flexes forefoot = tibialis anterior, extensor hallucis longus

d. What bones are connected by the spring ligament?

Navicular and calcaneous

n. Is the lateral collateral ligament securely attached to the knee joint capsule?

No

d. Which of the two cruciate ligaments is more longitudinally oriented?

PCL

Apply the logic you used for questions c and d above to state which ligament is likely to be injured if passive inversion of the foot is painful and to state which ligament is likely to be injured if passive eversion of the foot is painful.

Passive inversion of the foot is painful = anterior talofibular ligament damage Passive eversion of foot is painful = deltoid ligament damage

k. What is the shape of the medial collateral ligament of the knee?

Relatively broad and flat

m. What is the shape of the lateral collateral ligament of the knee?

Round and cord like

Both sets of ligaments between the clavicle and scapula should be assessed to evaluate shoulder separation. Radiograph the patient while *he or she is holding a weight* to distract the upper limb inferiorly. If the ligaments are intact, the scapula will stay aligned with the clavicle. Where will shoulder separation be externally visible?

Shoulder separation will be very visible acromioclavicular joint (the *acromion will be lower than the clavicle*)

m. Name a muscle of the leg that has the potential to flatten the longitudinal arch by plantarflexing the hindfoot. (Read the answer for this one.)

Soleus is the best choice because it does not invert as much as the gastrocnemius does, and it does not draw the medial side of the talus superiorly as effectively as the tibialis posterior does Muscle that flattens longitudinal arch by plantar flexing the hundfoot = Soleus

a. What named ligament is stretched when weightbearing pushes all the bones of the medial longitudinal arch toward the floor?

Spring ligament

a. What occupies the cavity between the bones of a synovial joint? (Here we are referring to the bones as whole organs, including the cartilage on them.)

Synovial fluid

j. What aspects of the anatomy of the hip bone of an infant allow dislocations to occur relatively easily, and without fracture?

The acetabulum is relatively shallow; relative to bone, cartilage is deformable

g. In what direction does the shape of the dome of the talus limit displacement of the foot relative to the tibia and fibula (anterior or posterior)?

The dome of the talus forces the tibiofibular mortise to widen when the foot is displaced posteriorly

g. How does the alignment of fibrous tissue within the capsular ligaments of the hip aid in limiting this movement?

The fibers spiral so they tighten when the thigh extends. For example, the iliofemoral ligament runs from superior on the anterior side of the ilium to inferior on the femur, and the ischiofemoral ligament wraps from the posterior side of the ischium over to the superior surface of the femoral neck

c. Between what two bones does that part of the bone rest?

The head of the talus rests between the navicular bone and calcaneous

b. In health, how large is the space between the bones in that cavity? (Keep in mind that the cartilages are parts of the bones, even though they are not bone tissue.)

Weight bearing or compressed: at their closest points, the bones will be very nearly contacting each other, with just a few microns of fluid between. Distracted or not weightbearing: less than a millimeter

c. The head of the talus is displaced inferiorly relative to neighboring bones in this process. Between what parts of what bones does the head of the talus move?

When weightbearing pushes all the bones of the medial longitudinal arch toward the floor, the head of the talus moves between: Navicular tubrosity of navicular bone and talar shaft of calcaneous

Passive eversion of foot is painful

deltoid ligament damage

c. Is there a synovial joint between the coracoid process of the scapula and the clavicle?

no

j. Is the lateral meniscus securely attached to the knee joint capsule?

no

g. How much blood and nerve supply does a meniscus get?

not much

i. Is the medial meniscus securely attached to the knee joint capsule?

yes

l. Is the medial collateral ligament securely attached to the knee joint capsule?

yes

g. If the arches of a foot become flatter with age, the head of the talus often becomes a visibly obvious bump on the foot. Refer to question c above. Where is that prominent bump located?

• Anterior and inferior to the medial malleolus on the medial side of the foot

b. Why can't this ligament attach directly to the radius?

• Because the radius needs to be free to rotate in supination and pronation

f. Who's radial head is much more easily deformed enough to slip distally away from the ligament that encircles it?

• Childs

m. Name the syndesmosis in the lower limb.

• Distal tibiofibular joint

h. What sagittal plane movement of the talus and calcaneus (representing the hindfoot) must occur to lift the head of the talus off the floor?

• Dorsiflexion

f. Details of the capsular ligaments of the shoulder are beyond the scope of this part of the course. They are a weaker anteriorly, so anterior dislocation of the humerus is common (often occurs when the arm is fully abducted). In the physical examination of a patient with such a glenohumeral dislocation, what will the shoulder region look like?

• During an anterior dislocation of the humerus the head of the humerus will be visible anteriorly and the arm will be slightly abducted

k. Give an individual example of a limb joint complex involving three or more bones, naming the joint and each bone in it.

• Elbow, knee

k. What coronal plane movement of the first metatarsal at the first cuneometatarsal joint must occur to return the hallux to the floor?

• Eversion

f. In addition to blood and lymphatic vessels, there are two main components of the joint capsule of a synovial joint. Which of the two components provides sturdiness?

• Fibrous joint capsule

b. What bones are in the hallucal ray?

• First metatarsal, first proximal (pedal) phalanx, first distal (pedal) phalanx.

a. Which numbered ray of the foot is the hallucal ray?

• First ray (space between digit 1 and 2) = hallucal ray • Including the bones of the 1st digit

e. How does tension in the flexor hallucis longus tendon influence the medial longitudinal arch during toe-off of stance phase in walking gait?

• Hallucis longus tendon contributes to the restoration of the medial longitudinal arch

j. Most joints in the limbs are synovial joints. Give an individual example of a limb joint involving only two bones.

• Hip joint

c. All synovial joints have cartilage. What particular kind of cartilage do almost all of them have?

• Hyaline (articular) cartilage

e. What tissue type is in the radial head of a young child?

• Hyaline cartilage

d. What tissue types are in the adult radial head?

• Hyaline cartilage, bone

c. In fact, no ligament attaches to the head of the radius. What ligament attaches to the shaft of the radius?

• Interosseous membrane

i. What coronal plane movement of the talus and calcaneus must occur to lift the head of the talus off the floor?

• Inversion

c. If the hallucal ray of a foot has normal alignment, what is the principal anatomical action of the flexor hallucis longus muscle?

• Job of flexor hallucis longus = Flexion at the first interphalangeal joint and flexion at the first metatarsophalangeal joint.

f. In what way does that more horizontal alignment limit movement of the tibia relative to the femur?

• More horizontal alignment = ACL • Prevents anterior glide of the tibia relative to the femur

h. A few centimeters anterior to the head of the talus you might see or palpate another bump. What bone is that?

• Navicular bone

e. Finish up this little run of questions by explaining why the space that is seen "between bones" in a radiograph of a healthy joint is much larger than your answer for "b" above.

• On the radiograph we see the gap between bone tissues of the bones, so the distance includes the thickness of the cartilage

j. What sagittal plane movement of the first metatarsal at the first cuneometatarsal joint (representing the forefoot) must occur to return the hallux to the floor?

• Plantar flexion • Hallux = bump on proximal big toe

l. In the adult, a few joints of the limbs are not synovial joints; those that are not synovial joints are a kind of fibrous joint called a syndesmosis. Name and describe the syndesmosis in the upper limb.

• Radioulnar syndesmosis; the connection of the shafts of the radius and the ulna by the oblique cord and the interosseous membrane

d. What is the radiographic appearance of this cartilage? (That is to say, what is its radiodensity?)

• Same as water or surrounding soft tissues

h. What is periarticular bone?

• Subchondral bone with a surface inside the cavity of a synovial joint

g. Which of the two components provides synovial fluid?

• Synovial membrane

h. What part of the medial meniscus or lateral meniscus has the least blood supply and nerve supply?

• The external edges of both menisci have the least blood and nerve supply

l. Where would the big toe be if the latter two movements did not occur?

• Up in the air

d. As weight is removed, is there a response from the spring ligament?

• Yes, it should recoil

c. This objective and the next one also serve as locations for exam items concerning major features of the joints that are not covered in the more specific objectives. For example, there is a muscle tendon inside the joint capsule of the shoulder joint. What is it?

•Muscle tendon that is inside the joint capsule of the shoulder = tendon of long head of biceps brachii