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Joints of the Vertebral Column. Joints of the vertebral bodies Joints of the vertebral arches (Zygapophysial joints, Facet joints) Craniovertebral (atlanto-axial and atlanto-occipital) joints Costovertebral joints Sacroiliac joints .

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slide1

Joints of the Vertebral Column

  • Joints of the vertebral bodies
  • Joints of the vertebral arches
  • (Zygapophysial joints, Facet joints)
  • Craniovertebral (atlanto-axial and atlanto-occipital) joints
  • Costovertebral joints
  • Sacroiliac joints
slide2

A typical vertebra has 6 joints with adjacent vertebrae.

4 synovial joints (2 above & 2 below)

2 symphyses (1 above & 1 below)

Each symphysis includes an intervertebral disc.

slide3

JOINTS OF VERTEBRAL BODIES

Symphyses(Secondary cartilaginous joints)

Designed for weight-bearing and strength.

The articulating surfaces of adjacent vertebrae are connected by intervertebral discs and ligaments.

The intervertebral disc consists of an outer anulus fibrosus, which

surrounds a central nucleus pulposus.

slide4

Anulus fibrosus consists of an outer ring of collagen surrounding a wider zone of fibrocartilage arranged in a lamellar configuration.

This arrangement of fibers limits rotation between vertebrae.

Nucleus pulposus (L. pulpa, fleshy) core of the intervertebral disc.

Fills the center of the intervertebral disc, is gelatinous, and absorbs compression forces between vertebrae.

Their semifluid nature is responsible for much of the flexibility and resilience of the intervertebral disc/column.

slide5

Intervertebral discs

Provide strong attachments between the vertebral bodies

Unite them into a continuous semirigid column

Form the inferior half of the anterior border of the IV foramen.

In aggregate, the discs account for 20-25% of the length (height) of the vertebral column.

slide6

No intervertebral disc between C1 & C2

Most inferior functional disc is between L5 & S1

Thickness of the discs increases - Vertebral column descends.

Relative thickness (Disc thickness/Body size)- Range of movement

Most clear--- Cervical & Lumbar regions

Disc thickness most uniform in thoracic region.

The discs are thicker anteriorly in the cervical and lumbar regions, their varying shapes producing the secondary curvatures of the vertebral column.

slide7

Function of the Intervertebral Discs

The semifluid nature of the nucleus pulposus allows it to change shape and permits one vertebra to rock forward or backward on another, as in flexion and extension of the vertebral column.

slide8

A sudden increase in the compression load on the vertebral column causes the semifluid nucleus pulposus to become flattened.

The outward pushing of the nucleus is accommodated by the resilience of the surrounding anulus fibrosus.

slide9

Sometimes, outward push is too great for anulus fibrosus

It ruptures

Allows nucleus pulposus to herniate

Protrude into the vertebral canal, where it may press on the spinal nerve roots, spinal nerve, or even the spinal cord.

slide10

With advancing age, the water content of the nucleus pulposus diminishes and is replaced by fibrocartilage.

The collagen fibers of the anulus degenerate and, as a result, the anulus cannot always contain the nucleus pulposus under stress.

In old age the discs are thin and less elastic, and it is no longer possible to distinguish the nucleus from the anulus.

66 year old male

20 y old male

slide11

JOINTS OF VERTEBRAL ARCHES

(ZYGAPOPHYSIAL JOINTS-FACET JOINTS

Plane synovial joints

between superior and inferior articular processes of adjacent vertebrae.

Those in the cervical region are especially thin and loose, reflecting the wide range of movement.

Accessory ligaments unite the laminae, transverse processes, and spinous processes and help stabilize the joints.

slide12

Zygapophysial joints permit gliding movementsbetween the articular processes.

  • Shape and disposition of the articular surfaces determine the types of movement possible.
slide13

«UNCOVERTEBRAL» JOINTS

Clefts (of Luschka

UNCINATE PROCESS

Lateral margins of the upper surfaces of typical cervical vertebrae; elevated into crests or lips.

slide14

May articulate with the body of the vertebra above to form small "uncovertebral" synovial joints.

Commonly develop between the unci of the bodies of C3 or 4-C6 or 7.

@ lateral and posterolateral margins of the intervertebral discs.

Considered as synovial joints by some; others; by others as degenerative spaces (clefts) in the discs occupied by extracellular fluid.

1= First rib

2 = Vertebral body of C7

3 = Spinous processes

4 = Uncinate process

5 = Uncovertebral

(apophyseal or Luschka's) joint

slide15

LIGAMENTS

Joints between vertebrae are reinforced and supported by numerous ligaments, which pass between vertebral bodies and interconnect components of the vertebral arches.

Anterior and posterior longitudinal ligaments

On the anterior and posterior surfaces of the vertebral bodies.

Extend along most of the vertebral column.

slide16

Anterior longitudinal ligament

Attached superiorly to the base of the skull

Extends inferiorly to the anterior surface of the sacrum

Along its length it’s attached to vertebral bodies & intervertebral discs.

slide17

Posterior longitudinal ligament

On the posterior surfaces of vertebral bodies

Lines the anterior surface of the vertebral canal

Attached along its length to vertebral bodies &intervertebral discs.

Tectorial membrane

Upper part of posterior

the longitudinal ligament

Connects C2 to

intracranial aspect of

the base of the skull

slide18

Ligamenta flava

  • Between the laminae of adjacent vertebrae on each side.
  • Thin, broad ligaments , and of elastic tissue
  • Form part of the posterior surface of the vertebral canal.
  • Runs between posterior surface of the lamina on the vertebra below to the anterior surface of the lamina of the vertebra above.
  • Resist separation of the laminae in flexion
  • Assist in extension back to anatomical position.
slide19

Supraspinous ligament

Along the tips of the spinous processes from C7 to the sacrum

slide20

Ligamentum nuchae

  • From C7 to the skull
  • A triangular, sheet-like structure in the median sagittal plane.
  • Base of the triangle attached to the skull
  • Apex attached to the tip of the spinous process of C7
  • Deep side of the triangle attached to the posterior tubercle of C1 & spinous processes of the other cervical vertebrae
  • Supports the head
  • Resists flexion & facilitates returning head to anatomical position
slide21

Interspinous ligaments (Interspinal ligaments)

  • Between adjacent vertebral spinous processes.
  • Attach from the base to the apex of each spinous process
  • Blend with the supraspinous ligament posteriorly
  • Blend with the ligamenta flava anteriorly
  • on each side.
slide22

CRANIOVERTEBRAL JOINTS

2 sets of joints

Atlanto-occipital joints

Between atlas(C1) & occipital bone of the cranium

Atlanto-axial joints

Between atlas and axis (C2)

A wider range of movement than in rest of the vertebral column.

Articulations: Occipital condyles, Atlas& Axis.

  • Synovial joints without intervertebral discs
slide23

Atlanto-occipital Joints

Articulations between

Superior articular surfaces of the lateral masses of the atlas

&

Occipital condyles

Synovial joints of the condyloid type

slide24

Atlanto-occipital Joints

Nodding of the head, flexion and extension of the head occurring when indicating approval (the “yes” movement).

Sideways tilting of the head.

Main movement

Flexion, with a little lateral flexion & rotation

slide25

The cranium and C1 are also connected by

  • Anterior & posterior atlanto-occipital membranes
  • Extend from the anterior and posterior arches of C1 to the anterior and posterior margins of the foramen magnum.
  • Help prevent excessive movement of atlanto-occipital joints.
slide26

Atlanto-axial Joints

3 atlanto-axial articulations

2 (right & left) lateral atlantoaxial joints – plane type joint

between inferior facets of lateral masses of C1 & superior facets of C2

1 median atlantoaxial joint – pivot type joint

between dens of C2 & anterior arch of atlas

slide27

Atlanto-axial Joints

Head turns from side to side, disapproval (“no” movement).

Cranium and C1 rotate on C2 as a unit.

.

slide28

Atlanto-axial Joints

During rotation of the head, dens of C2

axis or pivot held in a socket or collar formed

Anteriorly by anterior arch of the atlas

Posteriorly by transverse ligament of the atlas

A strong band extending between tubercles on the medial aspects of lateral masses of C1

slide29

Ligaments

Superior and inferior longitudinal bands

Apical ligament

Alar ligaments

Cruciate ligament of the atlas

Tectorial membrane (Membrana tectoria)

slide30

Movements of the Vertebral Column

Range of movement

Region & individual

The mobility primarily from the intervertebral discs.

The normal range of movement possible in healthy young adults is typically reduced by 50% or more as they age.

Although the movement between any two vertebrae is limited, the summation of movement among all vertebrae results in a large range of movement by the vertebral column.

slide31

Movements by the vertebral column

  • Flexion
  • Extension
  • Lateral flexion
  • Rotation
  • Circumduction
  • The range of movement of the vertebral column is limited by the:
  • Thickness, elasticity, and compressibility of the IV discs
  • Shape and orientation of the zygapophysial joints
  • Tension of the joint capsules of the zygapophysial joints
  • Resistance of the back muscles and ligaments (e.g., the ligamentaflava and the posterior longitudinal ligament)
  • Attachment to the thoracic (rib) cage
  • Bulk of surrounding tissue.
slide33

Disc Hernia & Back Pain

A tear within the anulus fibrosus

Material of the nucleus pulposus can track

This material tracks into the vertebral canal or into the intervertebral foramen

Pressure on neural structures.

This is a common cause of back pain.

slide35

Discectomy/laminectomy

A prolapsed intervertebral disc may impinge upon the meningeal (thecal) sac, cord, and most commonly the nerve root, producing symptoms attributable to that level.

Neurological signs- Surgery

It is of the utmost importance that the level of the disc protrusion is identified before surgery. This may require MRI scanning and on-table fluoroscopy.

slide36

PELVIS

L. Basin

Part of the trunk inferoposterior to the abdomen

Area of transition between the trunk and the lower limbs

Pelvic cavity

Inferiormost part of the abdominopelvic cavity.

Anatomically, the pelvis is the part of the body surrounded by the pelvic girdle (bony pelvis), part of the appendicular skeleton of the lower limb.

slide37

Pelvis is subdivided into greater and lesser pelves.

Greater pelvis

Surrounded by the superior pelvic girdle.

Occupied by inferior abdominal viscera, affording them protection.

Lesser pelvis

Surrounded by the inferior pelvic girdle, which provides the skeletal framework for both the pelvic cavity and the perineum—compartments of the trunk separated by the musculofascial pelvic diaphragm.

slide38

A basin-shaped ring of bones that connects the vertebral column to the two femurs.

  • Primary functions of the pelvic girdle:
  • Bear the weight of the upper body when sitting and standing.
  • Transfer that weight from the axial to the lower appendicular skeleton for standing and walking.
  • Provide attachment for the powerful muscles of locomotion and posture and those of the abdominal wall.

PELVIC GIRDLE

slide39

The pelvic bone is irregular in shape and has two major parts separated by an oblique line on the medial surface of the bone:

  • pelvic bone above this line represents lateral wall of the false pelvis, part of the abdominal cavity.
  • pelvic bone below this line represents the lateral wall of the true pelvis, contains the pelvic cavity.
  • Linea terminalis lower two-thirds of this line & contributes to the margin of the pelvic inlet.
slide40

Pelvic girdle is formed by 3 bones:

  • Right and left hip bones (coxal bones; pelvic bones): large, irregularly shaped bones, each of which develops from the fusion of three bones
  • Ilium
  • Ischium
  • Pubis
  • Sacrum: formed by the fusion of five, originally separate, sacral vertebrae.
slide41

In infants and children, hip bones are 3 separate bones united by a triradiate cartilage at the acetabulum, the cup-like depression in the lateral surface of the hip bone, which articulates with the head of the femur.

After puberty, the ilium, ischium, and pubis fuse to form the hip bone. The two hip bones are joined anteriorly at the pubic symphysis (L. symphysis pubis) and articulate posteriorly with the sacrum at the sacroiliac joints to form the pelvic girdle.

slide42

Ilium

Superior, fan-shaped part of the hip bone

Ala, or wing, of the iliumspread of the fan

Body of the ilium, the handle of the fan.

On its external aspect, the body participates in formation of the acetabulum.

slide43

Ilium

The entire superior margin of the ilium is thickened to form a prominent crest (iliac crest) terminates anteriorly as the anterior superior iliac spine and posteriorly as the posterior superior iliac spine.

slide44

A prominent tubercle, tuberculum of iliac crest, projects laterally near the anterior end of the crest; the posterior end of the crest thickens to form the iliac tuberosity.

Inferior to the anterior superior iliac spine, rounded protuberance called anterior inferior iliac spine.

slide47

Ilium

Posteriorly, the sacropelvic surface of the ilium has

an auricular surface and an iliac tuberosity articulation with sacrum.

slide48

Ischium

Has a body and ramus (L. branch).

Body of the ischium forms the acetabulum

Ramus of the ischium forms part of the obturator foramen.

slide50

Ischium

Ischial tuberosity: large posteroinferior protuberance of ischium

Ischial spine: Small pointed posteromedial projection near the junction of the ramus and body

Lesser sciatic notch: Concavity between the ischial spine and the ischial tuberosity

Greater sciatic notch: Larger concavity superior to the ischial spine and formed in part by the ilium.

slide51

Pubis

An angulated bone

Superior ramus helps form the acetabulum

Inferior ramus helps form the obturator foramen.

Pubic crest thickening on the anterior part of the body

Pubic tubercle Pubic crest ends laterally as a prominent swelling

Pecten pubis Oblique ridge@ lateral part of superior pubic ramus

slide52

Pelvic Inlet & Pelvic Outlet

The pelvis divided into greater (false) and lesser (true) pelves by the oblique plane of the pelvic inlet (superior pelvic aperture).

slide54

Pelvic Brim

  • The bony edge (rim) surrounding and defining the pelvic
  • Formed by the:
  • Promontory and ala of the sacrum
  • A right and left linea terminalis (terminal line)
slide55

Pubic arch

formed by the ischiopubic rami(conjoined inferior rami of the pubis and ischium) of the 2 sides.

These rami meet at the pubic symphysis, their inferior borders defining the subpubic angle.

The width of the subpubic angle is determined by the distance between the right and the left ischial tuberosities, which can be measured with the gloved fingers in the vagina during a pelvic examination.

slide56

Pelvic outlet (inferior pelvic aperture) is bounded by:

  • pubic arch,anteriorly
  • ischialtuberosities, laterally
  • sacrotuberousand sacrospinous ligaments, posterolaterally
  • tip of the coccyx, posteriorly
slide57

Medial to the anterior inferior iliac spine is a broad, shallow groove which is bounded medially by the iliopubic eminence (or iliopectineal eminence), which marks the point of union of the ilium and pubis. It constitutes a lateral border of the pelvic inlet.The iliopectineal line is the border of the eminence.

slide58

Pelvic Inlet (Superior Pelvic Aperture)

Circular opening between abdominal cavity and pelvic cavity. Promontory of the sacrum protrudes into the inlet, forming its posterior margin in the midline.

Formed anteriorly by the pubic symphysis, posteriorly by the sacrum, and laterally by the iliopectineal line.

slide59

Greater pelvis (False pelvis)

  • Part of the pelvis superior to the pelvic inlet.
  • Bounded by the iliac alae posterolaterally and the anterosuperior aspect of the S1 vertebra posteriorly.
  • Occupied by abdominal viscera (e.g., the ileum and sigmoid colon).
slide60

Lesser pelvis (True pelvis)

  • Part of the pelvis between the pelvic inlet and the pelvic outlet.
  • Bounded by the pelvic surfaces of the hip bones, sacrum, and coccyx.
  • Includes the true pelvic cavity and the deep parts of the perineum (perineal compartment).
  • That is of major obstetrical and gynecological significance.

The blue line in this 3-D volume rendered CT image (above) represents the lineaterminales that separates the false pelvis, which is above it from the true pelvis below it. The false pelvis consists of the iliac wings and has no anterior wall. The pubis bones, sacrum and coccyx, and both ischium bones delimit the false pelvis.

slide62

Linea terminalis consists of the arcuate line, pecten pubis, pubic crest.

The pecten pubis forms part of the pelvic brim and the continuation on the superior ramus pubis of the lineaterminalis, forming a sharp ridge.

slide63

Arcuate line of the ilium is a smooth rounded border on the internal surface of the ilium.

It is immediately inferior to the iliac fossa. It forms part of the border of the pelvic inlet.

slide64

Joints and Ligaments of Pelvic Girdle

The primary joints

Sacroiliac joints & pubic symphysis

Sacroiliac joints link the axial skeleton and the inferior appendicular skeleton.

Lumbosacral & sacrococcygeal joints, although joints of the axial skeleton, are directly related to the pelvic girdle. Strong ligaments support and strengthen these joints.

slide65

SACROILIAC JOINTS

Strong, weight-bearing compound joints

An anterior synovial joint

between the earshaped auricular surfaces of the sacrum & ilium

A posterior syndesmosis

between the tuberosities of the same bones

Differ from most synovial joints in that limited mobility is allowed, a consequence of their role in transmitting the weight of most of the body to the hip bones.

slide66

Weight from the axial skeleton:

Sacroiliac ligaments ilia

Femurs –during standing-

Ischial tuberosities –during sitting-

Sacrum is actually suspended between the iliac bones

Firmly attached to iliac bones by posterior and interosseous sacroiliac ligaments.

slide68

Anterior sacroiliac ligaments

Anterior part of the fibrous capsule of the synovial part of the joint.

Interosseous sacroiliac ligaments

Lie deep between the tuberosities of the sacrum and ilium.

Primary structures involved in transferring the weight.

Posterior sacroiliac ligaments

Posterior external continuation of the same mass of fibrous tissue.

slide70

Sacrotuberous ligament

Formed by the posterior sacroiliac ligaments joined by fibers extending from posterior margin of the ilium & base of the coccyx

Passes from posterior ilium, lateral sacrum & coccyx to ischial tuberosity, transforming the sciatic notch of the hip bone into a large sciatic foramen.

slide72

Sacrospinous ligament, from lateral sacrum & coccyx to ischial spine, further subdivides this foramen into greater and lesser sciatic foramina.

slide74

Most of the time, movement at the sacroiliac joint is limited by interlocking of the articulating bones and the sacroiliac ligaments.

By allowing only slight upward movement of the inferior end of the sacrum relative to the hip bones, resilience is provided to the sacroiliac region when the vertebral column sustains sudden increases in force or weight.

slide75

PUBIC SYMPHYSIS

Secondary cartilaginous joint

Consists of a fibrocartilaginous interpubic disc & surrounding ligaments uniting the bodies of the pubic bones in the median plane. Interpubic disc is generally wider in women.

slide76

Superior & inferior pubic ligaments

Superior & inferior margins of the symphysis

Superior pubic ligament connects the superior aspects of the pubic bodies and interpubic disc.

Inferior (arcuate) pubic ligamenta thick arch of fibers connects the inferior aspects of the joint components, rounding off the subpubic angle as it forms the apex of the pubic arch.

slide77

LUMBOSACRAL JOINTS

L5 & S1 articulate

Anterior intervertebral (IV) joint formed by L5/S1 IV disc

between their bodies

&

2 posterior zygapophysial joints (facet joints)

between the articular processes of these vertebrae

Fan-like iliolumbar ligaments radiating from the transverse processes of the L5 vertebra to the ilia.

slide78

SACROCOCCYGEAL JOINT

Secondary cartilaginous joint with an intervertebral disc.

Fibrocartilage & ligaments join apex of the sacrum base of coccyx.

Anterior & posterior sacrococcygeal ligaments

long strands that reinforce the joint.

slide81

Male Pelvis v.s. Female Pelvis

Sexual differences are related mainly

Heavier build and larger muscles of most men

Adaptation of the pelvis (particularly the lesser pelvis)

in women for parturition (childbearing).

The difference between the male and female pelvis

Difference Between Male & Female Pelvis

slide82

Although anatomical differences between male and female pelves are usually clear cut, the pelvis of any person may have some features of the opposite sex.

Gynecoid pelvis normal female type; its pelvic inlet typically has a rounded oval shape and a wide transverse diameter.

Android pelvis (masculine or funnel-shaped) in a woman may present hazards to successful vaginal delivery of a fetus.

slide83

In forensic medicine (the application of medical and anatomical knowledge for the purposes of law), identification of human skeletal remains usually involves the diagnosis of sex.

  • A prime focus of attention is the pelvic girdle because sexual differences usually are clearly visible.
  • Even fragments of the pelvic girdle are useful in determining sex.
slide88

PELVIC DIAMETERS (CONJUGATES)

Size of the lesser pelvis important in obstetrics

Because it is the bony canal through which the fetus passes during a vaginal birth.

To determine the capacity of the female pelvis for childbearing, diameters of the lesser pelvis are noted radiographically or manually during a pelvic examination.

slide89

Diameters of pelvic outlet

Antero - posterior diameters:

Anatomical antero-posterior diameter =11cm

from the tip of the coccyx to the lower border of symphysis pubis.

Obstetric antero-posterior diameter = 13 cm

from the tip of the sacrum to the lower border of symphysis pubis as the coccyx moves backwards during the second stage of labour.

Transverse diameters:

Bituberous diameter = 11 cm

between the inner aspects of the ischial tuberosities.

Bispinous diameter = 10.5 cm

between the tips of ischial spines.

slide90

Diameters of pelvic inlet

Antero -posterior diameters:

Anatomical antero-posterior diameter (true conjugate) = 11cm

from the tip of the sacral promontory to the upper border of the symphysis pubis.

Obstetric conjugate= 10.5 cm

from the tip of the sacral promontory to the most bulging point on the back of symphysis pubis which is about 1 cm below its upper border. It is the shortest antero-posterior diameter.

Diagonal conjugate= 12.5 cm

i.e. 1.5 cm longer than the true conjugate. From the tip of sacral promontory to the lower border of symphysis pubis (or inferior pubic ligament)

slide91

Minimum anteroposterior (AP) diameter of the lesser pelvis

True (obstetrical) conjugate

From Middle of the sacral promontory

To Posterosuperior margin (closest point) of the pubic symphysis

Narrowest distance through which the baby's head

must pass in a vaginal delivery.

This distance, however, cannot be measured directly during a pelvic examination because of the presence of the bladder.

slide92

Diagonal conjugate (from inferior pubic lig. to promontory)

Measured by palpating sacral promontory with the tip of the middle finger, using the other hand to mark the level of the inferior margin of the pubic symphysis on the examining hand.

After the examining hand is withdrawn, the distance between the tip of the index finger (1.5 cm shorter than the middle finger) and the marked level of the pubic symphysis is measured to estimate the true conjugate, which should be 11.0 cm or greater.

slide96

Transverse diameter is the greatest distance between the linea terminalis on either side of the pelvis.

slide97

Pelvic Fractures

  • Anteroposterior compression of the pelvis occurs during crush accidents (as when a heavy object falls on the pelvis).
  • This type of trauma commonly produces fractures of the pubic rami.
  • When the pelvis is compressed laterally, the acetabula and ilia are squeezed toward each other and may be broken.
slide98

Fractures of the bony pelvic ring are almost always multiple fractures or a fracture combined with a joint dislocation.

Pelvic fractures can result from direct trauma to the pelvic bones, such as occurs during an automobile accident, or be caused by forces transmitted to these bones from the lower limbs during falls on the feet.

slide99

Weak areas of the pelvis, where fractures often occur:

Pubic rami

Acetabula

Region of the sacroiliac joints

Alae of the ilium

25 Year Old Male with displaced fracture of the sacrum andsymphysis pubis.

The most severe pelvic fractures separate the two sides of the pelvis from each other.

slide100

Pelvic fractures may cause injury to pelvic soft tissues, blood vessels, nerves, and organs.

Fractures in the pubo-obturator area are relatively common and are often complicated because of their relationship to the urinary bladder and urethra, which may be ruptured or torn.