JOINTS OF THE LOWER

LIMB

-Naveen Kumar
Anatomy Dept, MMMC Manipal
 HIP JOINT

• Type: Ball and socket variety of

synovial joint
• Articulating bones: Head of the
femur & lunate surface of
acetabulum (of hip)
• Articulating surfaces are covered
by hyaline cartilage
 Structures stabilizing the joint
• Fibrous capsule (capsular ligament): made up of
collagen and elastic fibers
Attachment:
- Distally:
– In front: inter-trochanteric line of the femur
– Behind: medial to inter-trochanteric crest
– Proximally- attached close to acetabular margin and
blends with transverse acetabular ligament
 Neck of the femur is intra-capsular, covered with
synovial membrane
• Capsule made up of
2 types of fibers
 Inner fibers: Circular(zona
orbicularis)
 Outer fibers: Longitudinal –
best developed
anterosuperiorly

Retinacular fibers: Reflected longitudinal fibers of

fibrous capsule towards the neck
 Carry blood vessels to neck & head of the femur
• Synovial membrane:
– Lines the inner surface of the fibrous capsule,
acetabular labrum & intra capsular part of the
neck of the femur, fat in the acetabular fossa
– Also covers the ligament of the head of the femur

• Acetabular labrum:
Fibro- cartilagenous rim attached to the
acetabular margin
Deepens the socket & holds the femoral
head tightly
• Trasverse acetabular ligament:
– Extend across the acetabular notch→ converts
the notch into foramen → through which
blood vessels and nerves enter the joint

• Ligament of the head of the femur

 Triangular shape-
 apex: to fovea capitis of femoral head
 base: to transverse acetabular ligament
 Transmits artery of ligamentum capitis
(foveolar artery) into the head of femur
 Ilio-femoral ligament (of Bigelow)
• Strongest ligament of the
body
• Triangular shape.
– Apex: to AIIS,
– Base: to inter-trochanteric
line
• Prevents hyperextension of
hip joint
 Pubo-femoral ligament
• Thickend part of fibrous
capsule on inferomedial
aspect
• Attached above: to ilio-pubic
eminence, obturator crest
• Below: blends with fibrous
capsule & ilio-femoral
ligament
 Ischio- femoral ligament
• Covers the joint posteriorly,
weak ligament
• Attached to ischium close to
acetabular margin
• Twisted fibers attached to
greater trochanter of femur
• Fibers also form zona
orbicularis of fibrous
capsule
 Arterial supply
• Supplied by obturator artery,
medial & lateral circumflex
femoral artery, superior & inferior
gluteal arteries
• Retinacular arteries- from the
anastomoses of medial and lateral
circumflex femoral arteries
• Acetabular branches of obturator
and medial circumflex femoral
arteries- supplies part of the head
 Nerve supply
• Femoral nerve via nerve to rectus femoris

• Anterior division of obturator nerve

• Accessory obturator nerve

• Nerve to quadratus femoris

• Superior gluteal nerve

Movements
Movements Muscles producing
Flexion Psoas major, iliacus, pectineus,
rectus femoris, sartorius

Extension Gluteus maximus & hamstring

muscles
Adduction Adductor longus, magnus &
brevis, gracilis, pectineus
Abduction Glutei medius & minimus, tensor
fascia latae
Medial rotation tensor fascia lata, Glutei medius
& minimus

Lateral rotation Obturators, gemelli, quadratus

femoris, piriformis
 Applied aspects
• Dislocation of the hip:
– May be congenital
– Or due to injuries
• Disease of the hip joint (tuberculosis,
osteoarthritis)- may cause referred pain in the
knee
• Perth’s disease- femoral head undergoes
avascular necrosis (due to trauma)
 Congenital hip dislocation

0.15% newborns suffer (mostly in girls)

- Femoral head slips towards gluteal surface of ilium

- Neck –shaft angle is exaggerated- coxa valga

- Causes lurching gait

- Trendelenburg’s test is positive

COXA VALGA
Angle between shaft and neck of femur is increased
so abduction is more free (adduction is limited)
COXA VARA
Angle between shaft and neck of femur is decreased
therefore abduction is limited
 Hip joint dislocates posteriorly

• Due to posterior tearing of joint capsule

• Head lies on the posterior surface of ischium
• Sciatic nerve may be injured
• Limb being shortened, adducted and medially rotated
 Anterior dislocation of hip…
• Results from violant injury

• Femoral head lies antero- inferior

to the pubic bone or the
acetabulum

• Limb in abduction& lateral

rotation
 Medial dislocation of hip…
• By tearing of the joint capsule medially
• Femoral head lies medial to pubic bone –
intra-pelvic dislocation
• Chances of rupture of the bladder
 Fracture of the neck of the femur

• Sub capital – near the

femoral head-
intracapsular
– common in elderly person
• Cervical- in the middle of
the neck
• Trochanteric –
– common in adults
 Displacement of the greater trochanter

• Due to fracture / dislocations

– Demonstrated by
• Nelaton’s line: joining ASIS to
ischial tuberosity- pass through the
highest part of greater trochanter
• Shenton’s line- on x-ray picture
– Curve formed by the upper border of
the obturator forament and the lower
border of the neck of the femur
KNEE JOINT
 KNEE JOINT
• Type: Modified hinge variety of synovial joint
• It is a complex (by the presence of menisci) &
compound (more than 2 bones taking part)
joint
• Articulating bones: condyles of femur with
tibia → Femoro-tibial joint → condylar variety
• Patellar articular surface of femur with
posterior surface of patella → femoro-patellar
→ saddle variety
 Ligaments
Fibrous capsule (capsular ligament)
• Very thin, deficient anteriorly → replaced by
tendon of Q.femoris, patella, ligamentum patelle
• Femoral attachment:
– Posteriorly- inter-condylar line,
– Laterally- encloses origin of popliteus muscle
• Tibial attachment:
– Anteriorly: margins of condyles-
upto tibial tuberosity
– Posteriorly: to intercondylar ridge
• Part of fibrous capsule attached peripheral
margin of minisci to tibial condyle → coronary
ligament
• Synovial membrane:- absent- inner aspect of
the patella
– Above the patella it is prolonged upwards-
suprapatellar bursa
– Below- separated from ligamentum patellae by
infrapatellar pad of fat
– Posteriorly- reflected by cruciate ligaments
suprapatellar bursa

infrapatellar pad of fat

Reflection by cruciate ligament
• Tibial collateral (medial)
ligament:
– Stabilizes the knee from medial side
– Morphologically- degenerated
tendon of Adductor magnus muscle
– Above it is attached to medial
epicondyle
– Below- divides into
• Superficial part- attached to upper part
of medial surface of tibia
• Deep part- attached to
– Medial condyle of tibia
– Medial meniscus
• Fibular collateral (lateral) ligament
– Above: attached to lateral epicondyle
– Below: to apex of fibula
– Separated from lateral miniscus
by tendon of popliteus

• Ligamentum patelle:
– extension of tendon of
quadriceps femoris
– Extends from apex of patella to tibial
tuberosity
• Oblique popliteal ligament:
– Extension of tendon of
semimembranous muscle
– Attached to lateral condyle of
femur
– Pierced by middle genicular vessels
& nerves

• Arcuate popliteal ligament:

– thickening of fibrous capsule
– Arches over the tendon of popliteus
 Cruciate ligaments
• Strong fibrous ligaments connecting
the tibia & femur
• Anterior cruciate ligament:
– extends from anterior part of
intercondylar area of tibia- passes
upwards-backwards- attached to medial
surface of lateral condyle of femur
– Stretched during extension of the knee
Posterior Menisco-
joint femoral ligament

– Prevents forward displacement of tibial

condyles
 • Posterior cruciate ligament:
– Extends from posterior part of
intercondylar area of the tibia-
upwards-forwards-to lateral
surface of medial condyle of
femur
– Stretched during flexion
– Prevents backward
displacement of tibial condyles
o 2 cruciate ligaments cross like letter X-
hence “cruciate”
o Both are covered by synovial membrane
in their anterior aspect
o Both prevent side-side displacement of
femur & tibia Anterior
 Menisci (semilunar cartilages)
• Fibrocartilagenous structures- deepens the
articular surfaces of tibia
• 2 in number- medial & lateral
• Each presents
– anterior & posterior ends /horns,
– upper & lower surfaces
• Upper- concave for femur,
• lower- flat- articulate with tibial condyles
– Medial & lateral margins
• Outer margin- thick- connected to fibrous capsule,
• inner margin – free
 Tendon of
• Medial meniscus popliteus

– Semilunar in shape
– Periphery is attached to tibial collateral
ligament (deep part)
– Its anterior ends are connected
by transverse ligament
• Lateral meniscus - Circular in shape
– Posterior end is connected with medial
condyle of femur by 2 menisco-femoral
ligaments

Few fibers of popliteus is attached to lateral

miniscus- which pulls it backward-
prevents its crushing during flexion of knee
Functions of menisci
• Deepen the tibial articular
surfaces
• Act as shock absorbers to
protect the articular cartilages
• Flush the synovial fluid to
provide nutrition to the articular
cartilages
• Anterior and posterior menisco-
femoral ligaments: extends from
posterior end of lateral meniscus
to medial condyle of femur
– pass anterior & posterior to the
posterior cruciate ligaments
respectively
• Regulate the forward movement of
lateral miniscus during extension of knee

Popliteus
• Transverse ligament:
Connects the anterior end of
medial meniscus to anterior
margin of lateral meniscus
• Coronary ligament: Parts of
fibrous capsule – provide
attachment to the peripheral
margins of menisci
• Arterial supply:
– By genicular anastomoses- formed by genicular
branches of poplitreal, femoral & anterior and
posterior tibial arteries
• Nerve supply:
supply by 10 nerves
– 3 from Femoral nerve through nerve to vasti
– 3 from tibial nerve- superior & inferior medial
genicular & middle genicular
– 3 from common peroneal- superior & inferior
lateral genicular & recurrent genicular
– 1 from posterior division of obturator nerve
Movements & muscles producing
• Flexion- Hamstring (biceps femoris,
semimembranosus. Semitendinosus) assisted
by gracilis, Sartorius
• Extension: Q.Femoris, TFL
• Medial rotation- Semitendinosus,
semimembranosus
• Lateral rotation: Biceps femoris
 Locking & Unlocking of knee
(when the foot is on the ground)
• Locking : Medial rotation of the femur on tibia
during final stages of extension of the knee
– By tendons of Q. femoris
– All the ligaments are stretched, so knee is held in
extended position without muscular contraction
• Unlocking: Lateral rotation of femur on tibia
during initial stages of flexion
– Popliteus unlocks & initiates flexion
– further flexion by hamstring muscles

Note: Lateral menisci is shorter than medial

 Applied anatomy
• Terrible triad: 3 most injured structures due to blow
to the lateral aspect of knee when foot is on the
ground
– Tibial collateral ligament
– Medial meniscus
– Anterior cruciate ligament (ACL)
• ACL torn in a blow to anterior aspect
of flexed knee
– Torn ACL exhibit anterior
displacement of tibia inflexion
– Medial meniscus tear- pain when leg
is medially rotated at knee
• Medial meniscus is more vulnerable
to injury- due to its attachment to
tibial collateral ligament
• Lateral meniscus is protected by
popliteus
• Strains to menisci – is slightly flexed
knee (eg: foot ball kicking). Menisci
may be torn, separated from
capsule
• Injuries of cruciate ligaments:
– Damage of ACL is more common
• Injured in violent hyperextension of the knee/ anterior
dislocation of tibia
– PCL injured in posterior dislocation of tibia
– Tear of ligaments leads to abnormal A-P mobility
• Injuries to collateral ligaments may be due to
severe abduction / adduction
 Drawer sign
• Anterior drawer sign: forward
sliding of the tibia due to
rupture of ACL
• Posterior drawer sign:
backward sliding of the tibia
due to rupture of PCL
• Genu valgum (knock- knee)-
angle between long axis of
thigh and leg- more- leg may
be abnromally abducted
• Genu varum (Bow leg)- angle –
less- abnormally adducted (as
in rickets, congenital
abnormalities)

• Fracture of the patella

– Fractured transversely- into
upper & lower fragments
 Bursae around the knee
• Supra-patellar bursa- Lies deep to Q.Femoris
• Prepatellar bursa: lies superficial to patella
(House-maid’s bursa )
• Infrapatellar bursa: subcutaneous-
over patellar ligament (Nun’s bursa)
– deep infrapatellar- deep to patellar ligament
• Anserine bursa: b/w tibial collateral
ligament and tendons of Sartorius,
Gracilis & Semitendinosus
 Case-1
• During a foot ball match, a player received a blow on the
lateral side of the right knee and felt a sharp pain on the
medial side of the knee. Following the incident, the knee was
swollen and was unable to extend the leg. Drawer signs were
negative and radiographs did not show any fracture.
• Name the intra-articular structure damaged in this patient
and give its structure and attachments
• Mention the nerve supply and the blood supply of the knee
joint
 Case-2
• Following a severe automobile accident, a 25 year old woman
was found to have an unstable knee joint. On examination
under an anaesthetic, it was possible to pull the tibia forward
excessively on the femur.
• What structure was damaged in the knee joint?
• What are its attachments?
• List the movements possible at the knee joint and mention
the muscles producing each of these movements.
 Case-3
• A foot ball player, collided with another player while playing
and fell on to the ground. As he fell, the right knee, which was
taking the weight of the body, was partially flexed and the
femur was rotated medially, and the leg was abducted on the
thigh. A sudden pain is felt on the knee joint and he was unable
to extend it. The rupture of an intra-articular structure of the
knee joint was diagnosed. With your knowledge of Anatomy:

• Name the structure ruptured and give its attachments.

• Name the intra-articular structures of the knee joint.
• Describe the locking mechanism of the knee joint
Continued…….