12 Joints

Chapter Outline
General Clinical Features Concerning Radioulnar Joint 174
Joints 169 Radioulnar Joint Disease 174
Examination of Joints 169 Wrist Joint 174
Wrist Joint Injuries 174
Dislocation of Joints 169
Falls on the Outstretched Hand 174
Presence of Cartilaginous Discs within Joints 169
Joints of the Pelvis 174
Loss of Joint Innervation 169
Changes in the Pelvic Joints with Pregnancy 174
Value of Joint Classification 169
Changes in the Pelvic Joints with Age 174
Joint Pain and Joint Innervation 169
Sacroiliac Joint Disease 175
Temporomandibular Joint 169
Joints of the Lower Limb 175
Clinical Significance of the Temporomandibular
Hip Joint 175
Joint 169
Referred Pain from the Hip Joint 175
Dislocation of the Temporomandibular Joint 169 Congenital Dislocation of the Hip 175
Joints of the Vertebral Column 170 Traumatic Dislocation of the Hip 175
Hip Joint Stability and Trendelenburg’s Sign 175
Abnormal Curves of the Vertebral Column 170 Arthritis of the Hip Joint 175
Dislocations of the Vertebral Column 170 Knee Joint 175
Fractures of the Vertebral Column 170 Strength of the Knee Joint 175
Fractures of the Spinous Processes, Knee Injury and the Synovial Membrane 176
Transverse Processes, or Laminae 170 Ligamentous Injury of the Knee Joint 176
Anterior and Lateral Compression Fractures 170 Medial Collateral Ligament 176
Fracture Dislocations 170 Lateral Collateral Ligament 176
Vertical Compression Fractures 170 Cruciate Ligaments 176
Fractures of the Odontoid Process of the Axis 172 Meniscal Injury of the Knee Joint 178
Fractures of the Pedicles of the Axis Pneumoarthrography of the Knee Joint 178
(Hangman’s Fracture) 172 Arthroscopy of the Knee Joint 179
Spondylolisthesis 172 Ankle Joint 179
Ankle Joint Stability 179
Joints of the Upper Limb 172
Acute Sprains of the “Lateral Ankle” 179
Sternoclavicular Joint 172 Acute Sprains of the “Medial Ankle” 179
Sternoclavicular Joint Injuries 172 Fracture Dislocations of the Ankle Joint 179
Acromioclavicular Joint 172 Joints of the Foot 179
Acromioclavicular Joint Injuries 172 Metatarsophalangeal Joint of the Big Toe 179
Acromioclavicular Joint Dislocation 172 Clinical Examination of the Arches of the Foot 179
Shoulder Joint 173 The “Stone Bridge” Mechanisms for Arch
Stability of the Shoulder Joint 173 Support 179
Dislocations of the Shoulder Joint 173 Maintenance of the Medial Longitudinal Arch 181
Anterior–Inferior Dislocations 173 Maintenance of the Lateral Longitudinal Arch 181
Posterior Dislocations 173 Maintenance of the Transverse Arch 181
Shoulder Pain 173
Physiologic Note: Muscle Tone and the
Elbow Joint 173 Arches of the Foot 181
Stability of the Elbow Joint 173 Clinical Problems Associated with the Arches
Dislocations of the Elbow Joint 173 of the Foot 181
Arthrocentesis of the Elbow Joint 173
Damage to the Ulnar Nerve with Elbow Joint Clinical Problem Solving Questions 182
Injuries 173
Radiology of the Elbow Region after Injury 174 Answers and Explanations 185
 Joints 169

such as the ankle, elbow, or wrist, whereas tuberculous

GENERAL CLINICAL arthritis also affects synovial joints and may start in the syn-
ovial membrane or in the bone.
FEATURES
CONCERNING Joint Pain and Joint Innervation
Remember that more than one joint may receive the same

JOINTS nerve supply. For example, the hip and knee joints are
both supplied by the obturator nerve. Thus, a patient with
disease limited to one of these joints may experience pain

Examination of Joints in both.

When examining a patient, the clinician should assess the

normal range of movement of all joints. When the bones
of a joint are no longer in their normal anatomic relation-
ship with one another, then the joint is said to be
TEMPOROMANDIB-
dislocated.
ULAR JOINT
Dislocation of Joints Clinical Significance of the
Some joints are particularly susceptible to dislocation be-
cause of lack of support by ligaments, the poor shape of the
articular surfaces, or the absence of adequate muscular sup-
Temporomandibular Joint
port. The shoulder joint, temporomandibular joint, and The temporomandibular joint lies immediately in front of
acromioclavicular joints are good examples. Dislocation of the external auditory meatus. The great strength of the lat-
the hip is usually congenital, being caused by inadequate eral temporomandibular ligament prevents the head of the
development of the socket that normally holds the head of mandible from passing backward and fracturing the tym-
the femur firmly in position. panic plate when a severe blow falls on the chin.
The articular disc of the temporomandibular joint may
become partially detached from the capsule, and this results
Presence of Cartilaginous Discs in its movement becoming noisy and producing an audible
click during movements at the joint.
within Joints
The presence of cartilaginous discs within joints, especially
weightbearing joints, as in the case of the knee, makes Dislocation of the
them particularly susceptible to injury in sports. During a
rapid movement the disc loses its normal relationship to Temporomandibular Joint
the bones and becomes crushed between the weightbear- Dislocation sometimes occurs when the mandible is de-
ing surfaces. pressed. In this movement, the head of the mandible and
the articular disc both move forward until they reach the
Loss of Joint Innervation summit of the articular tubercle. In this position, the
joint is unstable, and a minor blow on the chin or a sud-
In certain diseases of the nervous system (e.g., syringomyelia), den contraction of the lateral pterygoid muscles, as in
the sensation of pain in a joint is lost. This means that the warn- yawning, may be sufficient to pull the disc forward be-
ing sensations of pain felt when a joint moves beyond the nor- yond the summit. In bilateral cases the mouth is fixed in
mal range of movement are not experienced. This phenome- an open position, and both heads of the mandible lie in
non results in the destruction of the joint. front of the articular tubercles. Reduction of the disloca-
tion is easily achieved by pressing the gloved thumbs
Value of Joint Classification downward on the lower molar teeth and pushing the jaw
backward. The downward pressure overcomes the tension
Knowledge of the classification of joints is of great value be- of the temporalis and masseter muscles, and the back-
cause, for example, certain diseases affect only certain types ward pressure overcomes the spasm of the lateral ptery-
of joints. Gonococcal arthritis affects large synovial joints goid muscles.
170 Chapter 12

greatest. In unilateral dislocations the inferior articular process

JOINTS OF THE of one vertebra is forced forward over the anterior margin of
the superior articular process of the vertebra below. Because
VERTEBRAL the articular processes normally overlap, they become locked
in the dislocated position. The spinal nerve on the same side

COLUMN is usually nipped in the intervertebral foramen, producing se-

vere pain. Fortunately, the large size of the vertebral canal al-
lows the spinal cord to escape damage in most cases.
Bilateral cervical dislocations are almost always associ-
Abnormal Curves of the Vertebral ated with severe injury to the spinal cord. Death occurs im-
mediately if the upper cervical vertebrae are involved be-
Column cause the respiratory muscles, including the diaphragm
Kyphosis is an exaggeration in the sagittal curvature pre- (phrenic nerves C3 to C5), are paralyzed.
sent in the thoracic part of the vertebral column. It can be
caused by muscular weakness, by structural changes in the
vertebral bodies, or by intervertebral discs. In sickly adoles-
Fractures of the Vertebral Column
cents, for example, where the muscle tone is poor, long Fractures of the Spinous Processes,
hours of study or work over a low desk can lead to a gently Transverse Processes, or Laminae
curved kyphosis of the upper thoracic region. The person
Fractures of the spinous processes, transverse processes, or
is said to be “round-shouldered.” Crush fractures or tuber-
laminae are caused by direct injury or, in rare cases, by se-
culous destruction of the vertebral bodies leads to acute an-
vere muscular activity.
gular kyphosis of the vertebral column. In the aged, osteo-
porosis (abnormal rarefaction of bone) and/or degenera-
tion of the intervertebral discs leads to senile kyphosis, Anterior and Lateral Compression
involving the cervical, thoracic, and lumbar regions of the Fractures
column. Anterior compression fractures of the vertebral bodies are
Lordosis is an exaggeration in the sagittal curvature pre- usually caused by an excessive flexion compression type of
sent in the lumbar region. Lordosis may be caused by an in- injury and take place at the sites of maximum mobility or at
crease in the weight of the abdominal contents, as with the the junction of the mobile and fixed regions of the column.
gravid uterus or a large ovarian tumor, or it may be caused It is interesting to note that the body of a vertebra in such a
by disease of the vertebral column such as spondylolisthesis. fracture is crushed, whereas the strong posterior longitudi-
The possibility that it is a postural compensation for a kypho- nal ligament remains intact. The vertebral arches remain
sis in the thoracic region or a disease of the hip joint (con- unbroken and the intervertebral ligaments remain intact so
genital dislocation) must not be overlooked. that vertebral displacement and spinal cord injury do not
Scoliosis is a lateral deviation of the vertebral column. occur. When injury causes excessive lateral flexion in ad-
This is most commonly found in the thoracic region and dition to excessive flexion, the lateral part of the body is also
may be caused by muscular or vertebral defects. Paralysis of crushed.
muscles caused by poliomyelitis can cause severe scoliosis.
The presence of a congenital hemivertebra can cause scol-
iosis. Often scoliosis is compensatory and may be caused by
Fracture Dislocations
a short leg or hip disease. Fracture dislocations are usually caused by a combination of
a flexion and rotation type of injury; the upper vertebra is ex-
cessively flexed and twisted on the lower vertebra. Here
Dislocations of the Vertebral again, the site is usually where maximum mobility occurs,
as in the lumbar region, or at the junction of the mobile and
Column fixed region of the column, as in the lower lumbar verte-
brae. Because the articular processes are fractured and the
Dislocations without fracture occur only in the cervical re- ligaments are torn, the vertebrae involved are unstable, and
gion because the inclination of the articular processes of the the spinal cord is usually severely damaged or severed, with
cervical vertebrae permits dislocation to take place without accompanying paraplegia.
fracture of the processes. In the thoracic and lumbar re-
gions, dislocations can occur only if the vertically placed ar-
ticular processes are fractured.
Vertical Compression Fractures
Dislocations commonly occur between the fourth and Vertical compression fractures occur in the cervical and
fifth or fifth and sixth cervical vertebrae, where mobility is lumbar regions, where it is possible to fully straighten the
 Joints 171

site of
site of destruction
nipping of spinal cord
of spinal nerve

A B

waist fracture
anterior arch of odontoid process
of atlas
transverse ligament odontoid process base fracture
of atlas of atlas of odontoid process

fracture
of pedicle

D E
posterior arch
of atlas
CD Figure 12-1 Dislocations and fractures of the vertebral column. A. Unilateral disloca-
tion of the fifth or the sixth cervical vertebra. Note the forward displacement of the inferior
articular process over the superior articular process of the vertebra below. B. Bilateral dis-
location of the fifth on the sixth cervical vertebra. Note that 50% of the vertebral body
width has moved forward on the vertebra below. C. Flexion compression–type fracture of
the vertebral body in the lumbar region. D. Jefferson’s-type fracture of the atlas. E. Frac-
tures of the odontoid process and the pedicles (hangman’s fracture) of the axis.
172 Chapter 12

vertebral column (CD Fig. 12-1). In the cervical region,

with the neck straight, an excessive vertical force applied
from above will cause the ring of the atlas to be disrupted
JOINTS OF THE
and the lateral masses to be displaced laterally (Jefferson’s
fracture). If the neck is slightly flexed, the lower cervical ver-
UPPER LIMB
tebrae remain in a straight line and the compression load is
transmitted to the lower vertebrae, causing disruption of the
intervertebral disc and breakup of the vertebral body. Pieces
Sternoclavicular Joint
of the vertebral body are commonly forced back into the Sternoclavicular Joint Injuries
spinal cord.
It is possible for nontraumatic compression fractures to The strong costoclavicular ligament firmly holds the medial
occur in severe cases of osteoporosis and for pathologic frac- end of the clavicle to the first costal cartilage. Violent forces
tures to take place. directed along the long axis of the clavicle usually result in
In the straightened lumbar region, an excessive force fracture of that bone, but dislocation of the sternoclavicular
from below can cause the vertebral body to break up, with joint takes place occasionally.
protrusion of fragments posteriorly into the spinal canal. Anterior dislocation results in the medial end of
the clavicle projecting forward beneath the skin; it
Fractures of the Odontoid Process of may also be pulled upward by the sternocleidomastoid
the Axis muscle.
Posterior dislocation usually follows direct trauma ap-
Fractures of the odontoid process are relatively common plied to the front of the joint that drives the clavicle back-
and result from falls or blows on the head (see CD Fig. 12- ward. This type is the more serious because the displaced
1). Excessive mobility of the odontoid fragment or rupture clavicle may press on the trachea, esophagus, and major
of the transverse ligament can result in compression injury blood vessels in the root of the neck.
to the spinal cord. If the costoclavicular ligament ruptures completely, it is
difficult to maintain the normal position of the clavicle once
Fracture of the Pedicles of the Axis reduction has been accomplished.
(Hangman’s Fracture)
Severe extension injury of the neck, such as might occur in
an automobile accident or a fall, is the usual cause of hang- Acromioclavicular Joint
man’s fracture. Sudden overextension of the neck, as pro- Acromioclavicular Joint Injuries
duced by the knot of a hangman’s rope beneath the chin, is
the reason for the common name. Because the vertebral The plane of the articular surfaces of the acromioclavicular
canal is enlarged by the forward displacement of the verte- joint passes downward and medially so that there is a ten-
bral body of the axis, the spinal cord is rarely compressed (see dency for the lateral end of the clavicle to ride up over the
CD Fig. 12-1). upper surface of the acromion. The strength of the joint de-
pends on the strong coracoclavicular ligament, which binds
Spondylolisthesis the coracoid process to the undersurface of the lateral part
of the clavicle. The greater part of the weight of the upper
In spondylolisthesis, the body of a lower lumbar vertebra, limb is transmitted to the clavicle through this ligament,
usually the fifth, moves forward on the body of the vertebra and rotary movements of the scapula occur at this important
below and carries with it the whole of the upper portion of ligament.
the vertebral column. The essential defect is in the pedicles
of the migrating vertebra. It is now generally believed that, in
this condition, the pedicles are abnormally formed and
Acromioclavicular Joint Dislocation
accessory centers of ossification are present and fail to unite. A severe blow on the point of the shoulder, as is incurred
The spine, laminae, and inferior articular processes remain during blocking or tackling in football or any severe fall,
in position, whereas the remainder of the vertebra, having can result in the acromion being thrust beneath the lateral
lost the restraining influence of the inferior articular end of the clavicle, tearing the coracoclavicular ligament.
processes, slips forward. Because the laminae are left behind, This condition is known as shoulder separation. The dis-
the vertebral canal is not narrowed, but the nerve roots may placed outer end of the clavicle is easily palpable. As in the
be pressed on, causing low backache and sciatica. In severe case of the sternoclavicular joint, the dislocation is easily
cases the trunk becomes shortened, and the lower ribs con- reduced, but withdrawal of support results in immediate re-
tact the iliac crest. dislocation.
 Joints 173

Injury to the shoulder joint is followed by pain, limita-

Shoulder Joint tion of movement, and muscle atrophy owing to disuse. It is
important to appreciate that pain in the shoulder region can
Stability of the Shoulder Joint be caused by disease elsewhere and that the shoulder joint
The shallowness of the glenoid fossa of the scapula and the may be normal; for example, diseases of the spinal cord and
lack of support provided by weak ligaments make this joint vertebral column and the pressure of a cervical rib can cause
an unstable structure. Its strength almost entirely depends shoulder pain. Irritation of the diaphragmatic pleura or peri-
on the tone of the short muscles that bind the upper end of toneum can produce referred pain via the phrenic and
the humerus to the scapula—namely, the subscapularis in supraclavicular nerves.
front, the supraspinatus above, and the infraspinatus and
teres minor behind. The tendons of these muscles are fused
to the underlying capsule of the shoulder joint. Together,
Elbow Joint
these tendons form the rotator cuff. Stability of the Elbow Joint
The least supported part of the joint lies in the inferior
The elbow joint is stable because of the wrench-shaped ar-
location, where it is unprotected by muscles.
ticular surface of the olecranon and the pulley-shaped
trochlea of the humerus; it also has strong medial and lateral
Dislocations of the Shoulder Joint
ligaments. When examining the elbow joint, the physician
The shoulder joint is the most commonly dislocated large must remember the normal relations of the bony points. In
joint. extension, the medial and lateral epicondyles and the top of
the olecranon process are in a straight line; in flexion, the
Anterior–Inferior Dislocations bony points form the boundaries of an equilateral triangle.
Sudden violence applied to the humerus with the joint fully
abducted tilts the humeral head downward onto the inferior Dislocations of the Elbow Joint
weak part of the capsule, which tears, and the humeral head Elbow dislocations are common, and most are posterior. Pos-
comes to lie inferior to the glenoid fossa. During this move- terior dislocation usually follows falling on the outstretched
ment, the acromion has acted as a fulcrum. The strong flex- hand. Posterior dislocations of the joint are common in chil-
ors and adductors of the shoulder joint now usually pull the dren because the parts of the bones that stabilize the joint are
humeral head forward and upward into the subcoracoid po- incompletely developed. Avulsion of the epiphysis of the me-
sition. dial epicondyle is also common in childhood because then
the medial ligament is much stronger than the bond of union
Posterior Dislocations between the epiphysis and the diaphysis.
Posterior dislocations are rare and are usually caused by
direct violence to the front of the joint.
Arthrocentesis of the Elbow Joint
On inspection of the patient with shoulder disloca- The anterior and posterior walls of the capsule are weak, and
tion, the rounded appearance of the shoulder is seen to be when the joint is distended with fluid, the posterior aspect of
lost because the greater tuberosity of the humerus is no the joint becomes swollen. Aspiration of joint fluid can eas-
longer bulging laterally beneath the deltoid muscle. A sub- ily be performed through the back of the joint on either side
glenoid displacement of the head of the humerus into the of the olecranon process.
quadrangular space can cause damage to the axillary
nerve, as indicated by paralysis of the deltoid muscle and Damage to the Ulnar Nerve with
loss of skin sensation over the lower half of the deltoid. Elbow Joint Injuries
Downward displacement of the humerus can also stretch The close relationship of the ulnar nerve to the medial side
and damage the radial nerve. of the joint often results in its becoming damaged in dislo-
cations of the joint or in fracture dislocations in this re-
Shoulder Pain gion. The nerve lesion can occur at the time of injury or
The synovial membrane, capsule, and ligaments of the weeks, months, or years later. The nerve can be involved in
shoulder joint are innervated by the axillary nerve and the scar tissue formation or can become stretched owing to lat-
suprascapular nerve. The joint is sensitive to pain, pressure, eral deviation of the forearm in a badly reduced supra-
excessive traction, and distension. The muscles surrounding condylar fracture of the humerus. During movements of
the joint undergo reflex spasm in response to pain originat- the elbow joint, the continued friction between the medial
ing in the joint, which in turn serves to immobilize the joint epicondyle and the stretched ulnar nerve eventually results
and thus reduce the pain. in ulnar palsy.
174 Chapter 12

Radiology of the Elbow Region after

Injury
In examining lateral radiographs of the elbow region, it is
important to remember that the lower end of the humerus
is normally angulated forward 45° on the shaft; when exam-
ining a patient, the physician should see that the medial epi-
condyle, in the anatomic position, is directed medially and A
posteriorly and faces in the same direction as the head of the
humerus.

Radioulnar Joint
Radioulnar Joint Disease
B
The proximal radioulnar joint communicates with the el-
bow joint, whereas the distal radioulnar joint does not com- CD Figure 12-2 Fractures of the distal end of the radius.
municate with the wrist joint. In practical terms, this means A. Colles’ fracture. B. Smith’s fracture.
that infection of the elbow joint invariably involves the prox-
imal radioulnar joint. The strength of the proximal radioul-
nar joint depends on the integrity of the strong anular liga- the clavicle, and finally, to the sternum. If the forces are ex-
ment. Rupture of this ligament occurs in cases of anterior cessive, different parts of the upper limb give way under
dislocation of the head of the radius on the capitulum of the the strain. The area affected seems to be related to age. In
humerus. In young children, in whom the head of the ra- a young child, for example, there may be a posterior dis-
dius is still small and undeveloped, a sudden jerk on the arm placement of the distal radial epiphysis; in the teenager the
can pull the radial head down through the anular ligament. clavicle might fracture; in the young adult the scaphoid is
commonly fractured; and in the elderly the distal end of
Wrist Joint the radius is fractured about 1 in. (2.5 cm) proximal to the
wrist joint (Colles’ fracture) (CD Fig. 12-2).
Wrist Joint Injuries
The wrist joint is essentially a synovial joint between the dis-
tal end of the radius and the proximal row of carpal bones.
The head of the ulna is separated from the carpal bones by
JOINTS OF THE
the strong triangular fibrocartilaginous ligament, which sep-
arates the wrist joint from the distal radioulnar joint. The
PELVIS
joint is stabilized by the strong medial and lateral ligaments.
Because the styloid process of the radius is longer than
that of the ulna, abduction of the wrist joint is less extensive
Changes in the Pelvic Joints with
than adduction. In flexion–extension movements, the hand
can be flexed about 80° but extended to only about 45°. The
Pregnancy
range of flexion is increased by movement at the midcarpal During pregnancy, the symphysis pubis and the ligaments
joint. of the sacroiliac and sacrococcygeal joints undergo soften-
A fall on the outstretched hand can strain the anterior lig- ing in response to hormones, thus increasing the mobility
ament of the wrist joint, producing synovial effusion, joint and increasing the potential size of the pelvis during child-
pain, and limitation of movement. These symptoms and signs birth. The hormones responsible are estrogen and proges-
must not be confused with those produced by a fractured terone produced by the ovary and the placenta. An addi-
scaphoid or dislocation of the lunate bone, which are similar. tional hormone, called relaxin, produced by these organs
can also have a relaxing effect on the pelvic ligaments.
Falls on the Outstretched Hand
In falls on the outstretched hand, forces are transmitted
Changes in the Pelvic Joints with
from the scaphoid to the distal end of the radius, from the
radius across the interosseous membrane to the ulna, and
Age
from the ulna to the humerus; thence, through the glenoid Obliteration of the cavity in the sacroiliac joint occurs in
fossa of the scapula to the coracoclavicular ligament and both sexes after middle age.
 Joints 175

Hip Joint Stability and Trendelen-

Sacroiliac Joint Disease burg’s Sign
The sacroiliac joint is innervated by the lower lumbar and The stability of the hip joint when a person stands on one leg
sacral nerves so that disease in the joint can produce low back with the foot of the opposite leg raised above the ground de-
pain and pain referred along the sciatic nerve (sciatica). pends on three factors:
The sacroiliac joint is inaccessible to clinical examina-
tion. However, a small area located just medial to and below ■ The gluteus medius and minimus must be functioning
the posterior superior iliac spine is where the joint comes normally.
closest to the surface. In disease of the lumbosacral region, ■ The head of the femur must be located normally within
movements of the vertebral column in any direction cause the acetabulum.
pain in the lumbosacral part of the column. In sacroiliac ■ The neck of the femur must be intact and must have a
disease, pain is extreme on rotation of the vertebral column normal angle with the shaft of the femur.
and is worst at the end of forward flexion. The latter move- If any one of these factors is defective, then the pelvis
ment causes pain because the hamstring muscles hold the will sink downward on the opposite, unsupported side. The
hip bones in position while the sacrum is rotating forward as patient is then said to exhibit a positive Trendelenburg’s
the vertebral column is flexed. sign (CD Fig. 12-3).
Normally, when walking, a person alternately contracts

JOINTS OF THE the gluteus medius and minimus, first on one side and then
on the other. By this means he or she is able to raise the
pelvis first on one side and then on the other, allowing the
LOWER LIMB leg to be flexed at the hip joint and moved forward—that is,
the leg is raised clear of the ground before it is thrust forward
in taking the forward step. A patient with a right-sided con-
Hip Joint genital dislocation of the hip, when asked to stand on the
right leg and raise the opposite leg clear of the ground, will
Referred Pain from the Hip Joint exhibit a positive Trendelenburg’s sign, and the unsup-
ported side of the pelvis will sink below the horizontal. If the
The femoral nerve not only supplies the hip joint but, via
patient is asked to walk, he or she will show the characteris-
the intermediate and medial cutaneous nerves of the thigh,
tic “dipping” gait. In patients with bilateral congenital dislo-
also supplies the skin of the front and medial side of the
cation of the hip, the gait is typically “waddling” in nature.
thigh. It is not surprising, therefore, for pain originating in
the hip joint to be referred to the front and medial side of the
thigh. The posterior division of the obturator nerve supplies
Arthritis of the Hip Joint
both the hip and knee joints. This would explain why hip A patient with an inflamed hip joint will place the femur in
joint disease sometimes gives rise to pain in the knee joint. the position that gives minimum discomfort—that is, the po-
sition in which the joint cavity has the greatest capacity to
Congenital Dislocation of the Hip contain the increased amount of synovial fluid secreted. The
The stability of the hip joint depends on the ball-and-socket hip joint is partially flexed, abducted, and externally rotated.
arrangement of the articular surfaces and the strong liga- Osteoarthritis, the most common disease of the hip
ments. In congenital dislocation of the hip, the upper lip of joint in the adult, causes pain, stiffness, and deformity. The
the acetabulum fails to develop adequately, and the head of pain may be in the hip joint itself or referred to the knee (the
the femur, having no stable platform under which it can obturator nerve supplies both joints). The stiffness is caused
lodge, rides up out of the acetabulum onto the gluteal sur- by the pain and reflex spasm of the surrounding muscles.
face of the ilium. The deformity is flexion, adduction, and external rotation
and is produced initially by muscle spasm and later by mus-
Traumatic Dislocation of the Hip cle contracture.
Traumatic dislocation of the hip is rare because of its
strength; it is usually caused by motor vehicle accidents. Knee Joint
However, should it occur, it usually does so when the joint
is flexed and adducted. The head of the femur is displaced
Strength of the Knee Joint
posteriorly out of the acetabulum, and it comes to rest on the The strength of the knee joint depends on the strength of the
gluteal surface of the ilium (posterior dislocation). The ligaments that bind the femur to the tibia and on the tone of
close relation of the sciatic nerve to the posterior surface of the muscles acting on the joint. The most important muscle
the joint makes it prone to injury in posterior dislocations. group is the quadriceps femoris; provided that this is well
176 Chapter 12

normal positive Trendelenburg's sign

CD Figure 12-3 Trendelenburg’s test.

developed, it is capable of stabilizing the knee in the pres- occur at its femoral or tibial attachments. It is useful to re-
ence of torn ligaments. member that tears of the menisci result in localized tender-
ness on the joint line, whereas sprains of the medial collat-
Knee Injury and the Synovial eral ligament result in tenderness over the femoral or tibial
Membrane attachments of the ligament.

The synovial membrane of the knee joint is extensive, and if Lateral Collateral Ligament
the articular surfaces, menisci, or ligaments of the joint are
Forced adduction of the tibia on the femur can result in in-
damaged, the large synovial cavity becomes distended with
jury to the lateral collateral ligament (less common than
fluid. The wide communication between the suprapatellar
medial ligament injury).
bursa and the joint cavity results in this structure becoming
distended also. The swelling of the knee extends three or Cruciate Ligaments
four fingerbreadths above the patella and laterally and me-
dially beneath the aponeuroses of insertion of the vastus lat- Injury to the cruciate ligaments can occur when excessive
eralis and medialis, respectively. force is applied to the knee joint. Tears of the anterior cru-
ciate ligament are common; tears of the posterior cruciate
Ligamentous Injury of the Knee Joint ligament are rare. The injury is always accompanied by
damage to other knee structures; the collateral ligaments
Four ligaments—the medial collateral ligament, the lateral are commonly torn or the capsule may be damaged. The
collateral ligament, the anterior cruciate ligament, and the joint cavity quickly fills with blood (hemarthrosis) so that
posterior cruciate ligament—are commonly injured in the the joint is swollen. Examination of patients with a rup-
knee. Sprains or tears occur depending on the degree of tured anterior cruciate ligament shows that the tibia can be
force applied. pulled excessively forward on the femur; with rupture of
the posterior cruciate ligament, the tibia can be made to
Medial Collateral Ligament move excessively backward on the femur (CD Fig. 12-4).
Forced abduction of the tibia on the femur can result in par- Because the stability of the knee joint depends largely on
tial tearing of the medial collateral ligament, which can the tone of the quadriceps femoris muscle and the integrity
 Joints 177

direction of impact

direction
of fall medial meniscus

A foot on ground

test for anterior test for posterior

B cruciate ligament C cruciate ligament

ruptured anterior ruptured posterior

cruciate ligament cruciate ligament

CD Figure 12-4 A. Mechanism involved in damage to the medial meniscus of the knee
joint from playing football. Note that the right knee joint is semiflexed and that medial ro-
tation of the femur on the tibia occurs. The impact causes forced abduction of the tibia on
the femur, and the medial meniscus is pulled into an abnormal position. The cartilaginous
meniscus is then ground between the femur and the tibia. B. Test for integrity of the ante-
rior cruciate ligament. C. Test for integrity of the posterior cruciate ligament.
178 Chapter 12

of the collateral ligaments, operative repair of isolated torn being subjected to a severe grinding force, and it splits
cruciate ligaments is not always attempted. The knee is im- along its length (CD Fig. 12-5). When the torn part of the
mobilized in slight flexion in a cast, and active physiother- meniscus becomes wedged between the articular surfaces,
apy on the quadriceps femoris muscle is begun at once. further movement is impossible, and the joint is said to
Should, however, the capsule of the joint and the collat- “lock.”
eral ligaments be torn in addition, early operative repair is Injury to the lateral meniscus is less common, proba-
essential. bly because it is not attached to the lateral collateral liga-
ment of the knee joint and is consequently more mobile.
Meniscal Injury of the Knee Joint The popliteus muscle sends a few of its fibers into the lat-
eral meniscus, and these can pull the meniscus into a
Injuries of the menisci are common. The medial meniscus more favorable position during sudden movements of the
is damaged much more frequently than the lateral, and knee joint.
this is probably because of its strong attachment to the me-
dial collateral ligament of the knee joint, which restricts its Pneumoarthrography of the Knee
mobility. The injury occurs when the femur is rotated on
the tibia, or the tibia is rotated on the femur, with the knee
Joint
joint partially flexed and taking the weight of the body. Air can be injected into the synovial cavity of the knee joint
The tibia is usually abducted on the femur, and the medial so that soft tissues can be studied. This technique is based on
meniscus is pulled into an abnormal position between the the fact that air is less radiopaque than structures such as the
femoral and tibial condyles (CD Fig. 12-4A). A sudden medial and lateral menisci, so their outline can be visual-
movement between the condyles results in the meniscus ized on a radiograph (see text Fig. 12-43).

medial meniscus

A B

C D
CD Figure 12-5 Tears of the medial meniscus of the knee joint. A. Complete bucket han-
dle tear. B. The meniscus is torn from its peripheral attachment. C. Tear of the posterior
portion of the meniscus. D. Tear of the anterior portion of the meniscus.
 Joints 179

Arthroscopy of the Knee Joint

Arthroscopy involves the introduction of a lighted instru-
Joints of the Foot
ment into the synovial cavity of the knee joint through a Metatarsophalangeal Joint of the Big
small incision. This technique permits the direct visualiza- Toe
tion of structures, such as the cruciate ligaments and the
menisci, for diagnostic purposes. Hallux valgus, which is a lateral deviation of the great toe at
the metatarsophalangeal joint, is a common condition. Its
incidence is greater in women than in men and is associated
Ankle Joint with badly fitting shoes. It is often accompanied by the pres-
ence of a short first metatarsal bone. Once the deformity is
Ankle Joint Stability established, it is progressively worsened by the pull of the
The ankle joint is a hinge joint possessing great stability. flexor hallucis longus and extensor hallucis longus muscles.
The deep mortise formed by the lower end of the tibia and Later, osteoarthritic changes occur in the metatarsopha-
the medial and lateral malleoli securely holds the talus in langeal joint, which then becomes stiff and painful; the con-
position. dition is then known as hallux rigidus.

Acute Sprains of the “Lateral Ankle” Clinical Examination of the Arches of

the Foot
Acute sprains of the lateral ankle are usually caused by ex-
cessive inversion of the foot with plantar flexion of the ankle. On examination of the imprint of a wet foot on the floor
The anterior talofibular ligament and the calcaneofibular made with the person in the standing position, one can see
ligament are partially torn, giving rise to great pain and local that the heel, the lateral margin of the foot, the pad under
swelling. the metatarsal heads, and the pads of the distal phalanges are
in contact with the ground (see text Figs. 12-41 and 12-42).
The medial margin of the foot, from the heel to the first
Acute Sprains of the “Medial Ankle” metatarsal head, is arched above the ground because of the
Acute sprains of the medial ankle are similar to but less important medial longitudinal arch. The pressure exerted
common than those of the lateral ankle. They may occur on the ground by the lateral margin of the foot is greatest at
to the medial or deltoid ligament as a result of excessive the heel and the fifth metatarsal head and least between
eversion. The great strength of the medial ligament usually these areas because of the presence of the low-lying lateral
results in the ligament pulling off the tip of the medial longitudinal arch. The transverse arch involves the bases of
malleolus. the five metatarsals and the cuboid and cuneiform bones.
This is, in fact, only half an arch, with its base on the lateral
border of the foot and its summit on the foot’s medial bor-
Fracture Dislocations of the Ankle der. The foot has been likened to a half-dome, so that when
Joint the medial borders of the two feet are placed together, a
complete dome is formed.
Fracture dislocations of the ankle are common and are From this description, it can be understood that the
caused by forced external rotation and overeversion of the body weight on standing is distributed through a foot via the
foot. The talus is externally rotated forcibly against the lat- heel behind and six points of contact with the ground in
eral malleolus of the fibula. The torsion effect on the front, namely, the two sesamoid bones under the head of the
lateral malleolus causes it to fracture spirally. If the force first metatarsal and the heads of the remaining four
continues, the talus moves laterally, and the medial metatarsals.
ligament of the ankle joint becomes taut and pulls off the
tip of the medial malleolus. If the talus is forced to move
still farther, its rotary movement results in its violent con- The “Stone Bridge” Mechanisms for
tact with the posterior inferior margin of the tibia, which Arch Support
shears off.
Examination of the design of any stone bridge reveals the
Other less common types of fracture dislocation are
following engineering methods used for its support (CD
caused by forced overeversion (without rotation), in which
Fig. 12-6).
the talus presses the lateral malleolus laterally and causes it
to fracture transversely. Overinversion (without rotation), in ■ The shape of the stones: The most effective way of sup-
which the talus presses against the medial malleolus, pro- porting the arch is to make the stones wedge shaped,
duces a vertical fracture through the base of the medial with the thin edge of the wedge lying inferiorly. This
malleolus. applies particularly to the important stone that occupies
180 Chapter 12

"keystone"
keystone

shape of stones
shape of bones

short plantar
ligament

long plantar
ligament

calcaneonavicular
ligament

staples

strong plantar ligaments

tendon of flexor
hallucis longus

tie beam

peroneus longus

suspension bridge
CD Figure 12-6 Different methods by which the arches of the foot may be supported.

the center of the arch and is referred to as the “key- beam connecting the ends effectively prevents separation
stone.” of the pillars and consequent sagging of the arch.
■ The inferior edges of the stones are tied together: This is ■ A suspension bridge: Here, the maintenance of the arch
accomplished by interlocking the stones or binding their depends on multiple supports suspending the arch from
lower edges together with metal staples. This method ef- a cable above the level of the bridge.
fectively counteracts the tendency of the lower edges of the
stones to separate when the arch is weightbearing. Using the bridge analogy, one can now examine the
■ The use of the tie beams: When the span of the bridge is methods used to support the arches of the feet (see CD Fig.
large and the foundations at either end are insecure, a tie 12-6).
 Joints 181

Maintenance of the Medial Longitudi- ■ Suspending the arch from above are the peroneus
nal Arch longus tendon and the peroneus brevis.

■ Shape of the bones: The sustentaculum tali hold up

the talus; the concave proximal surface of the navicular
bone receives the rounded head of the talus; the slight P H Y S I O L O G I C N O T E
concavity of the proximal surface of the medial
cuneiform bone receives the navicular. The rounded Muscle Tone and the Arches of the Foot
head of the talus is the keystone in the center of the The arches of the feet are maintained by the shape of the
arch (see CD Fig. 12-6). bones, strong ligaments, and muscle tone. Which of
■ The inferior edges of the bones are tied together by these factors is the most important? Basmajian and
the plantar ligaments, which are larger and stronger Stecko demonstrated electromyographically that the tib-
than the dorsal ligaments. The most important ligament ialis anterior, the peroneus longus, and the small mus-
is the plantar calcaneonavicular ligament (see CD Fig. cles of the foot play no important role in the normal static
12-6). The tendinous extensions of the insertion of the support of the arches. They are commonly totally inac-
tibialis posterior muscle play an important role in this tive. However, during walking and running, all these
respect. muscles become active. Standing immobile for long pe-
■ Tying the ends of the arch together are the plantar riods, especially if the person is overweight, places
aponeurosis, the medial part of the flexor digitorum bre- excessive strain on the bones and ligaments of the feet
vis, the abductor hallucis, the flexor hallucis longus, the and results in fallen arches or flat feet. Athletes, route-
medial part of the flexor digitorum longus, and the flexor marching soldiers, and nurses are able to sustain their
hallucis brevis (see CD Fig. 12-6). arches provided that they receive adequate training to
■ Suspending the arch from above are the tibialis ante- develop their muscle tone.
rior and posterior and the medial ligament of the ankle
joint.
Clinical Problems Associated with the
Maintenance of the Lateral Longitudi- Arches of the Foot
nal Arch Of the three arches, the medial longitudinal is the largest
and clinically the most important. The shape of the
■ Shape of the bones: Minimal shaping of the distal end of
bones, the strong ligaments, especially those on the plan-
the calcaneum and the proximal end of the cuboid. The
tar surface of the foot, and the tone of muscles all play an
cuboid is the keystone.
important role in supporting the arches. It has been
■ The inferior edges of the bones are tied together by the
shown that in the active foot the tone of muscles is an im-
long and short plantar ligaments and the origins of the
portant factor in arch support. When the muscles are fa-
short muscles from the forepart of the foot (see CD Fig.
tigued by excessive exercise (a long-route march by an
12-6).
army recruit), by standing for long periods (waitress or
■ Tying the ends of the arch together are the plantar
nurse), by being overweight, or by illness, the muscular
aponeurosis, the abductor digiti minimi, and the lateral
support gives way, the ligaments are stretched, and pain is
part of the flexor digitorum longus and brevis.
produced.
■ Suspending the arch from above are the peroneus
Pes planus (flat foot) is a condition in which the medial
longus and the brevis (see CD Fig. 12-6).
longitudinal arch is depressed or collapsed. As a result, the
forefoot is displaced laterally and everted. The head of the
Maintenance of the Transverse Arch talus is no longer supported, and the body weight forces it
■ Shape of the bones: The marked wedge shaping of the downward and medially between the calcaneum and the
cuneiform bones and the bases of the metatarsal bones navicular bone. When the deformity has existed for some
(see text Fig. 12-42) time, the plantar, calcaneonavicular, and medial ligaments
■ The inferior edges of the bones are tied together by the of the ankle joint become permanently stretched, and the
deep transverse ligaments, the strong plantar ligaments, bones change shape. The muscles and tendons are also per-
and the origins of the plantar muscles from the forepart manently stretched. The causes of flat foot are both congen-
of the foot; the dorsal interossei and the transverse head ital and acquired.
of the adductor hallucis are particularly important in this Pes cavus (clawfoot) is a condition in which the medial
respect. longitudinal arch is unduly high. Most cases are caused by
■ Tying the ends of the arch together is the peroneus muscle imbalance, in many instances resulting from po-
longus tendon. liomyelitis.
182 Chapter 12

Clinical Problem Solving Questions

Read the following case histories/questions and give particularly daring dive, he surfaced quickly and climbed
the best answer for each. out of the pool, holding his head between his hands. He
said that he had hit the bottom of the pool with his head
and now had severe pain in the root of the neck, which
General Joint Questions
was made worse when he tried to move his neck. A lateral
A 31-year-old woman has a history of poliomyelitis af- radiograph revealed that the right inferior articular
fecting the anterior horn cells of the lower thoracic and process of the fifth cervical vertebra was forced over the
lumbar segments of the spinal cord on the left side. On anterior margin of the right superior articular process of
examination, she has severe right lateral flexion defor- the sixth cervical vertebra, producing a unilateral disloca-
mity of the vertebral column. tion with nipping of the right sixth cervical nerve.
1. The following statements are true about this case ex- 4. The following symptoms and signs confirmed the diag-
cept which? nosis except which?
A. The virus of poliomyelitis attacks and destroys the A. The head was rotated to the right.
motor anterior horn cells of the spinal cord. B. There was spasm of the deep neck muscles on the
B. The disease resulted in the paralysis of the muscles right side of the neck, which were tender to touch.
that normally laterally flex the vertebral column on C. The patient complained of severe pain in the region
the left side. of the back of the neck and right shoulder.
C. The muscles on the right side of the vertebral col- D. The slightest movement produced severe pain in the
umn are unapposed. right sixth cervical dermatome.
D. The right lateral flexion deformity is caused by the E. The large size of the vertebral canal in the cervical
slow degeneration of the sensory nerve fibers origi- region permitted the spinal cord to escape injury.
nating from the vertebral muscles on the right side.
A 50-year-old coal miner was crouching at the mine
A 20-year-old woman severely sprains her left ankle face when a large rock suddenly became dislodged
while playing tennis. When she tries to move the foot so from the roof of the mine shaft and struck him on the
that the sole faces medially, she experiences severe pain. upper part of his back. The emergency department
2. What is the correct anatomic term for the movement of physician suspected a displacement of the upper tho-
the foot that produces the pain? racic spines on the sixth thoracic spine.
A. Pronation 5. The following physical signs confirmed a diagnosis of
B. Inversion fracture dislocation between the fifth and sixth thoracic
C. Supination vertebrae except which?
D. Eversion A. A lateral radiograph revealed fractures involving the
superior articular processes of the sixth thoracic ver-
Joints of the Skull tebra and the inferior articular processes of the fifth
3. An exhausted medical student decided to brush up on thoracic vertebra.
gross anatomy by attending a lecture given by an old and B. Considerable forward displacement of the body of
revered visiting professor. After 45 minutes the lecture be- the fifth thoracic vertebra on the sixth thoracic ver-
gan to bore him, and his mind began to wander. He could tebra occurred.
not forget the attractive brunette nurse in the surgical C. The patient had signs and symptoms of spinal shock.
clinic whom he had dated the previous evening. After 5 D. The large size of the vertebral canal in the thoracic
more minutes he found he just could not keep his eyes region leaves plenty of space around the spinal cord
open. When would this lecture end? Just then, he invol- for bony displacement.
untarily opened his mouth wide and yawned. To his great E. The patient later showed signs and symptoms of
consternation he could not close his mouth. His jaw was paraplegia.
stuck in the open position. What is your diagnosis?
A 66-year-old woman was seen in the emergency de-
Joints of the Vertebral Column partment complaining of a burning pain over the upper
part of her right arm. The pain had started 2 days previ-
An 11-year-old boy was showing off in front of friends by ously and had progressively worsened. Physical exami-
diving into the shallow end of a swimming pool. After one nation revealed weakness and wasting of the right
 Joints 183

deltoid and biceps brachii muscles. The patient also A 22-year-old student was driving home from a party
had hyperesthesia in the skin over the lower part of the and crashed his car head on into a brick wall. On
right deltoid and down the lateral side of the arm. Ra- examination in the emergency department, he was
diologic examination showed extensive spur formation found to have a fracture dislocation of the seventh tho-
on the bodies of the fourth, fifth, and sixth cervical ver- racic vertebra, with signs and symptoms of severe dam-
tebrae. These signs and symptoms suggested severe os- age to the spinal cord.
teoarthritis of the cervical vertebral column.
8. On recovery from spinal shock, he was found to have
6. This disease produced the following changes in the ver- the following signs and symptoms except which?
tebrae and related structures except which? A. Fracture dislocation of the seventh thoracic verte-
A. Repeated trauma and aging had resulted in degen- bra, which would result in severe damage to the sev-
erative changes at the articulating surfaces of the enth thoracic segment of the spinal cord
fourth, fifth, and sixth cervical vertebrae. B. A band of cutaneous hyperesthesia extending around
B. Extensive spur formation resulted in narrowing of the abdominal wall on the left side at the level of the
the intervertebral foramina with pressure on the umbilicus that was caused by the irritation of the cord
nerve roots. immediately above the site of the lesion
C. The burning pain and hyperesthesia were caused by C. On the right side, total analgesia, thermoanesthesia,
pressure on the third and fourth cervical posterior and partial loss of tactile sense of the skin of the ab-
roots. dominal wall below the level of the umbilicus in-
D. The weakness and wasting of the deltoid and biceps volving the whole of the right leg
brachii muscles were caused by pressure on the fifth D. Upper motor neuron paralysis of his left leg
and sixth cervical anterior roots. E. Unequal sensory and motor losses on the two sides,
E. Movements of the neck intensified the symptoms by which indicate a left hemisection of the spinal cord
exerting further pressure on the nerve roots.
F. Coughing or sneezing raised the pressure within the Joints of the Ribs
vertebral canal and resulted in further pressure on
9. A 36-year-old woman went sailing with her husband
the roots.
and they were caught in a severe gale. While the hus-
A medical student offered to move a grand piano for his band at the helm desperately managed to keep the boat
landlady. He had just finished his final examinations in under control, the wife tried to get the sails down. Even-
anatomy and was in poor physical shape. He struggled tually the squall died down and they were able to return
with the antique monstrosity and suddenly experienced safely to port. The next morning, the woman woke up
an acute pain in the back, which extended down the with severe pain over the left side of her chest. On be-
back and outer side of his left leg. On examination in ing examined in the emergency department of the local
the emergency department, he was found to have a hospital for a suspected myocardial infarction, the
slight scoliosis with the convexity on the right side. The physician found that the patient was acutely tender over
deep muscles of the back in the left lumbar region felt her left costal margin, which was made worse on taking
firmer than normal. No evidence of muscle weakness a deep breath. What is the possible diagnosis?
was present, but the left ankle jerk was diminished.
Joints of the Upper Extremity
7. The symptoms and signs of this patient strongly suggest a
diagnosis of prolapsed intervertebral disc except which? 10. Separation of the acromioclavicular joint is common in
A. The pain was the worst over the left lumbar region football and soccer players. Explain why such separa-
opposite the fifth lumbar spine. tions are unstable after reduction.
B. The pain was accentuated by coughing.
A father, seeing his 3-year-old son playing in the garden,
C. With the patient supine, flexing the left hip joint
ran up and picked him up by both hands and swung
with the knee extended caused a marked increase in
him around in a circle. The child’s enjoyment sud-
the pain.
denly turned to tears, and he said his left elbow hurt.
D. A lateral radiograph of the lumbar vertebral column
On examination, the child held his left elbow joint
revealed nothing abnormal.
semiflexed and his forearm pronated.
E. A magnetic resonance imaging study revealed the
presence of small fragments of the nucleus pulposus 11. The following statements concerning this case are con-
that had herniated outside the anulus in the disc be- sistent with the diagnosis of dislocation of the superior
tween the fifth lumbar vertebra and the sacrum. radioulnar joint except which?
F. The pain occurred in the dermatomes of the third A. The head of the radius was pulled out of the anular
and fourth lumbar segments on the left side. ligament.
184 Chapter 12

B. At age 3 years, the child’s anular ligament has a large E. On reduction of the fracture the distal end of the ra-
diameter and the head of the radius can easily be dius should lie at an angle of 15° anteriorly.
pulled out of the ligament by traction. F. The hand should always be splinted in the position
C. The incidence of this condition is equal in both sexes. of function.
D. The pain from the joint caused reflex contraction of A 22-year-old medical student fell off her bicycle onto
the surrounding muscles to protect the joint from her outstretched hand. She thought she had sprained her
further movement. right wrist joint and treated herself by binding her wrist
E. The subluxation of the joint can be treated by with an elastic bandage. Three weeks later, however, she
pulling downward on the forearm and at the same was still experiencing pain on moving her wrist and so de-
time performing the movement of pronation and cided to visit the emergency department. On examina-
supination. Finally, the elbow joint is flexed and tion of the dorsal surfaces of both hands, with the fingers
held in that position. and thumbs fully extended, a localized tenderness could
A 60-year-old woman fell down the stairs and was admit- be felt in the anatomic snuffbox of her right hand. A di-
ted to the emergency department with severe right shoul- agnosis of fracture of the right scaphoid bone was made.
der pain. On examination, the patient was sitting up with 14. The following statements concerning this patient are
her right arm by her side and her right elbow joint sup- correct except which?
ported by the left hand. Inspection of the right shoulder A. The scaphoid bone is an easy bone to immobilize
showed loss of the normal rounded curvature and evi- because of its small size.
dence of a slight swelling below the right clavicle. Any at- B. A bony fragment deprived of its blood supply may
tempt at active or passive movement of the shoulder joint undergo ischemic necrosis.
was stopped by severe pain in the shoulder. A diagnosis C. Because the scaphoid bone articulates with other
of dislocation of the right shoulder joint was made. bones, the fracture line may enter a joint cavity and
12. The following statements concerning this patient are become bathed in synovial fluid, which would in-
consistent with the diagnosis except which? hibit repair.
A. This patient had a subcoracoid dislocation of the D. The fracture line on the scaphoid bone may deprive
right shoulder joint. the proximal fragment of its arterial supply.
B. The head of the humerus was dislocated downward E. Fractures of the scaphoid bone have a high inci-
through the weakest part of the capsule of the joint. dence of nonunion.
C. The pull of the pectoralis major and subscapularis 15. A 46-year-old woman slipped on a shiny floor and sus-
muscles had displaced the upper end of the tained a fracture of the fifth metacarpal bone on her left
humerus medially. hand. What type of angulation of the fragments is com-
D. The greater tuberosity of the humerus no longer dis- monly found in fractures at this site? When a splint is
placed the deltoid muscle laterally, and the curve of applied with the little finger flexed, in which direction
the shoulder was lost. should the little finger be pointing?
E. The integrity of the axillary nerve should always be
tested by touching the skin over the upper half of the Joints of the Lower Extremity
deltoid muscle. A medical student, while playing football, collided with
A 63-year-old man fell down a flight of stairs and sus- another player and fell to the ground. As he fell, the
tained a fracture of the lower end of the left radius. On right knee, which was taking the weight of his body, was
examination the distal end of the radius was displaced partially flexed; the femur was rotated medially; and the
posteriorly. This patient had sustained a Colles’ fracture. leg was abducted on the thigh. A sudden pain was felt
in the right knee joint, and he was unable to extend it.
13. The following statements concerning this case are cor- The student was diagnosed as having a torn medial
rect except which? meniscus of the knee joint.
A. Occasionally the styloid process of the ulna is also
fractured. 16. The following statements concerning this case con-
B. The median nerve may be injured at the time of the firmed the diagnosis except which?
fall. A. The right knee joint quickly became swollen.
C. When the fracture is reduced, the styloid process of B. Severe local tenderness was felt along the medial
the radius should come to lie about 0.75 in. (1.9 cm) side of the joint line.
proximal to that of the ulna. C. The medial meniscus split along part of its length,
D. The fracture produces posterior angulation of the and the detached portion became jammed between
distal fragment of the radius. the articular surfaces, limiting further extension.
 Joints 185

D. The trauma stimulated the production of synovial E. Because the cruciate ligaments are located outside
fluid, which filled the joint cavity. the synovial membrane, bleeding from a torn liga-
E. The distension of the suprapatellar bursa was re- ment does not enter the joint cavity.
sponsible for the large amount of swelling above the
A 25-year-old man was running across a field when he
injured knee.
caught his right foot in a rabbit hole. As he fell, the right
F. The pain sensation from the injured knee was con-
foot was violently rotated laterally and overeverted. On
fined to the femoral nerve as it ascended to the cen-
attempting to stand, he could place no weight on his
tral nervous system.
right foot. On examination by a physician, the right an-
A 27-year-old woman was found to have an unstable kle was considerably swollen, especially on the lateral
right knee joint following a severe automobile accident. side. After further examination, including a radiograph
On examination it was possible to pull the tibia exces- of the ankle, a diagnosis of severe fracture dislocation of
sively forward on the femur. A diagnosis of ruptured an- the ankle joint was made.
terior cruciate ligament was made.
18. The following statements concerning this patient are
17. The following statements concerning this patient are correct except which?
correct except which? A. This type of fracture dislocation is caused by forced
A. The anterior cruciate ligament is attached to external rotation and overeversion of the foot.
the tibia in the anterior part of the intercondylar B. The talus is externally rotated against the lateral
area. malleolus of the fibula, causing it to fracture.
B. The anterior cruciate ligament passes upward, back- C. The medial ligament of the ankle joint is strong and
ward, and laterally from its tibial attachment. never ruptures.
C. The anterior cruciate ligament is attached above to D. The torsion effect on the lateral malleolus produces
the posterior part of the medial surface of the lateral a spiral fracture.
femoral condyle. E. If the talus is forced to move farther laterally and
D. The anterior cruciate ligament is more commonly continues to rotate, the posterior inferior margin of
torn than is the posterior cruciate ligament. the tibia will be sheared off.

Answers and Explanations

1. D is the correct answer. The right lateral flexion defor- 4. A is the correct answer. The right inferior articular
mity is not caused by the slow degeneration of the sen- process of the fifth cervical vertebra was forced over the
sory nerve fibers originating from the vertebral muscle anterior margin of the right superior articular process of
on the right side. It is the motor nerves supplying the the sixth cervical vertebra, causing the head of the pa-
vertebral muscles on the left side that are affected in tient to be rotated to the left.
this patient.
5. D is the correct answer. The vertebral canal in the tho-
2. B is the correct answer. Moving the foot at the subtalar racic region is small and round and little space is
and midtarsal joints so that the sole faces medially is around the spinal cord for bony displacement to occur
called inversion. without causing severe damage to the cord.
3. The student had dislocated his temporomandibular 6. C is the correct answer. The burning pain and hyperes-
joints on both sides. When he yawned, his lateral thesia were caused by pressure on the fifth and sixth cer-
pterygoid muscles reflexly contracted forcibly and vical posterior roots.
pulled the head of the mandible and the articular disc
7. F is the correct answer. The pain occurred in the der-
forward over the summit of the articular tubercle in
matomes of the fifth lumbar and first sacral segments on
each joint. Reduction is easily performed by pressing
the left side.
gloved thumbs downward and backward on the last
molar teeth. The lateral pterygoid, the temporalis, and 8. A is the correct answer. Fracture dislocation of the
the masseter muscle tension is overcome and the head seventh thoracic vertebra would result in severe
of the mandible snaps back over the articular tubercle damage to the tenth thoracic segment of the spinal
to assume its normal anatomical position. cord.
186 Chapter 12

9. The localized tenderness over the left costal margin is of the deltoid muscle. The skin of the curve of the
strongly suggestive of subluxation of one of the inter- shoulder, including the skin covering the upper half of
chondral joints on the costal margin. Subluxation of a the deltoid muscle, is supplied by the supraclavicular
joint implies that the ligaments and capsule are nerves.
stretched or torn but the damage is not so severe that the
13. C is the correct answer. The normal position of the tip
articulating surfaces lose contact with one another.
of the styloid process of the radius is about 0.75 in. (1.9
This condition can be extremely painful and in this pa-
cm) distal to that of the ulna.
tient was secondary to trauma caused by excessive
pulling of the muscles connecting the thoracic cage to 14. A is the correct answer. The scaphoid bone is a difficult
the upper limb. The sixth, seventh, eighth, ninth, and bone to immobilize because of its position and small
tenth costal cartilages articulate with each other along size.
their borders by small synovial joints.
15. Fractured metacarpal bones show dorsal angulation
10. In subluxation of the acromioclavicular joint, the lat- caused by the forward pull of the long flexor tendons
eral end of the clavicle elevates and becomes more and the lumbricals and interossei on the distal frag-
prominent than normal; there is a definite step down ment. When flexed individually, all fingers (excluding
onto the acromion. A dislocation occurs when the dam- the thumb) point toward the tubercle of the scaphoid.
age to the restraining structures is more severe and the When a finger is unstable following a fracture, it
articulating surfaces lose contact with one another. In should be aligned so that its tip points to the scaphoid
the case of the acromioclavicular joint, the clavicle rises tubercle; failure to achieve this will result in malfunc-
above the acromion and the joint is very unstable. tion.
The main strength of the acromioclavicular joint de- 16. F is the correct answer. The sensation of pain from the
pends on the integrity of the strong coracoclavicular lig- knee joint ascends to the central nervous system via the
ament (see text Fig. 12-14). Should this ligament be dis- femoral, obturator, common peroneal, and tibial nerves.
rupted, the acromioclavicular joint dislocates; the lat-
17. E is the correct answer. The synovial membrane cover-
eral end of the clavicle rides over the acromion and the
ing the cruciate ligaments (see text Fig. 12-31) is torn
upper limb is depressed.
along with the ligaments, and the joint cavity quickly
11. B is the correct answer. Under age 6 years, the child’s fills with blood.
head of the radius is of a relatively small size and may
18. C is the correct answer. Although the medial ligament
easily be pulled out of the anular ligament by traction
of the ankle joint is strong, extreme force can result in
on the forearm.
rupture of the ligament, the ligament can be torn from
12. E is the correct answer. The integrity of the axillary the medial malleolus, or the pull on the ligament can
nerve is tested by touching the skin over the lower half fracture the medial malleolus.