Joints

Bursae of the joint: Knee joint is vulnerable to external impacts, but it is surrounded by many thick and strong muscle tendons, and there are many bursae located between these structures (Figure 2.2.3.44).

The bursae are located in the anterior and lateral parts of the joint. The four bursae on the anterior are: Suprapatellar bursa: It is connected with the joint space between the femur and patellar ligament above the patella.

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Deep infrapatellar bursa: It is located between the tibia and patellar ligament below the patella. Subcutaneous infrapatellar bursa: It is between the skin and tibial tuberosity. Subcutaneous prepatellar bursa: It is between the patella and the skin (Figure 2.2.3.25, Figure 2.2.3.26, Figure 2.2.3.44).

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Some bursae inferior to the muscle tendons that pass close to the joint: Lateral subtendinous bursa of gastrocnemius: It is located between the joint capsule and the lateral head of gastrocnemius. Medial subtendinous bursa of gastrocnemius: It is located between the joint capsule and the medial head of gastrocnemius. This bursa is in contact with the joint cavity. Inferior subtendinous bursa of biceps femoris: It is located between the fibular collateral ligament and biceps femoris tendon.  Subpopliteal recess: It is located between popliteus tendon and the lateral condyle of the femur. It is an extension of the joint cavity. Anserine bursa: It is located between the tendons forming pes anserinus and tibial collateral ligament. It is connected with the joint cavity. Semimembranosus bursa: It is located between the semimembranosus tendon and the superior edge of the tibia (Figure 2.2.3.25, Figure 2.2.3.26, Figure 2.2.3.44).

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CLINICAL INFORMATION

Patella: It moves in the trochlear groove, its resting position is at the midpoint of the line drawn between the femoral condyles. The patella and its ligament are in the midline of the knee without any muscle contraction when the knee is extended. If the patella is displaced superiorly, it is called patella alta, if it displaces inferiorly, it is called patella baja, if it is displaced medially, it is called squinting patella, if it is displaced laterally, it is called bullfrog eyes, (frog's eye) (Figure 2.2.3.44.1). Q (Quadriceps angle): A line is drawn between the anterior superior of the spina iliaca and the centre of the patella. A second line is drawn from the center of the patella to the tibial tuberosity, the upper intersection angle of the two lines is called the Q angle (Figure 2.2.3.44.2). Prepatellar bursitis is usually caused by friction between the patella and the skin. In chronic cases, the prepatellar bursa fills with fluid and manifests itself as a soft swelling in front of the knee. This clinical picture is called Housemaid’s knee (Picture 2.2.3.44 and Picture 2.2.3.45). It is seen in people who work on their knees (such as miners, carpet and parquet installers). Large bursa suprapatellaris bursitis is important in terms of spreading the infection into the joint space (Figure 2.2.3.25, Figure 2.2.3.26, Figure 2.2.3.44).

Arteries of the joint: They are supplied by the branches from popliteal artery, lateral circumflex femoral artery and anterior tibial artery (Figure 2.2.3.46).

Nerves of the joint: They are innervated by the branches from femoral nerve, obturator nerve, tibial nerve and common peroneal (fibular) nerve (Figure 2.2.3.47).

3. Proximal tibiofibular joint:

Art. tibiofibularis proximalis: It is a planar joint formed between the articular surfaces called fibular articular surface in the lateral condyle of the tibia and the articular surface in the head of fibula. Because the ligaments connect the two bones tightly together, it makes a limited sliding movement back and forth (Figure 2.2.3.18, Figure 2.2.3.19, Figure 2.2.3.27, Figure 2.2.3.33 and Figure 2.2.3.34).

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Ligaments of the joint: Articular capsule, anterior and posterior ligament of fibular head, interosseous membrane of leg (Figure 2.2.3.18, Figure 2.2.3.19, Figure 2.2.3.27, Figure 2.2.3.33 and Figure 2.2.3.34). Interosseous membrane of leg: It is a structure attached to the facing sides of the tibia and fibula. Syndesmosis continues with the ligaments of the tibiofibularis in the inferior part. It ends freely just below the proximal tibiofibular joint in the superior part and this free edge creates a passage for the vascular branches on the back of the leg to pass forward (Figure 2.2.3.18, Figure 2.2.3.19, Figure 2.2.3.27, Figure 2.2.3.33 and Figure 2.2.3.34). Arteries of the joint: They are anterior and posterior tibial recurrent artery (Figure 2.2.3.46). Nerves of the joint: Common peroneal nerve (Figure 2.2.3.47).

4. Distal tibiofibular joint (tibiofibular syndesmosis): It is a joint formed between the fibular notch in tibia and the lower end of the fibula. It is the largest syndesmosis joint in the body. It plays a role in the stability of the ankle joint. Ligaments of the joint: Anterior tibiofibular ligament, posterior tibiofibular ligament, Arteries of the joint: anterior and posterior tibial artery, fibular artery. Nerves of the joint: deep peroneus nerve, tibial nerve, saphenus nerve  (Figure 2.1.2.16 and Figure 2.2.3.48, Figure 2.2.3.49, Figure 2.2.3.54 and Figure 2.2.3.55).

5. Ankle joint: It is a ginglymus type joint formed between the distal end of the bones that make up the crus (leg) and the talus. Tibia joins the joint with two different articular surfaces. Its lower surface, which is called inferior articular surface, forms the roof of the joint and articulates with the superior surface located in the trochlea of talus. The articular surface, called medial malleolararticular surface, articulates with the medial malleolar surface on the medial surface of the talus. The fibula joins the joint with the articular surface called lateral malleolar articular surface and articulates with lateral malleolar surface on the outer surface of the body of talus. Thus, the upper surface of the trochlea of talus enters the socket formed at the lower end of the bones forming the leg and forms the joint. The most compatible position of joint surfaces is the (extension) position. Ankle joint has strong lateral ligaments specific to the ginglymus group joints. It performs dorsal flexion (extension) and plantar flexion around the transverse axis. Although dorsal flexion is limited between 20° and 30°, plantar flexion can be performed to a relatively wider extent (Figure 1.2.2.14, Figure 2.1.2.18, Figure 2.1.2.19, Figure 2.1.2.24, Figure 2.2.3.48, Figure 2.2.3.50 and Figure 2.2.3.51).

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Ligaments of the joint: Articular capsule: Although the fibrous capsule is thin anteriorly and posteriorly, it is supported by strong collateral ligaments on the sides. It extends anteriorly to the neck of talus, although it attaches near the articular surfaces. It does not surround malleoli (Figure 2.2.3.52).

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Medial ligament (Deltoid ligament): It resembles a triangle with its apex up. In the superior part, it attaches to the anterior and posterior margins of the medial malleolus. It is observed in four sections as it expands in the inferior part. These parts are anterior tibiotalar part (attaches to the neck of talus), tibionavicular part (attaches to the navicular bone), tibiocalcaneal part (attaches to talar shelf) and posterior tibiotalar part (attaches to the inner surface of talus). Tendons of posterior tibialis posterior and flexor digitorum longus cross this ligament which prevents the excessive eversion of the foot from the outside (Figure 2.2.3.53).

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 Lateral collateral ligament: It starts from lateral malleolus and attaches to talus and calcaneus. This ligament, which prevents the excessive inversion of the foot, consists of three parts: Anterior talofibular ligament: It is the shortest of the three ligaments located in the lateral. It extends from the anterior part of the lower end of the fibula to the talus. It prevents the foot from slipping forward and limits plantar flexion. Posterior talofibular ligament: It is the strongest and deepest of the three ligaments. It extends from the posterior part of the lateral malleolar fossa to the lateral tubercle in the talus. It helps to prevent the foot from slipping backwards (Figure 2.2.3.54).

 Calcaneofibular ligament: It is the longest of the ligaments located in the lateral. It extends down from the lower end of the fibula and attaches to the calcaneus. In addition to preventing the foot from slipping backwards, it also plays an important role in the consolidation of the subtalar joint (Figure 2.2.3.54). All three ligaments prevent the excessive inversion of the foot and support the ankle joint. The tendons of fibularis logus and brevis cross this ligament (Figure 2.2.3.53). Arteries of the joint: anterior tibial artery and fibular artery. Nerves of the ligament: Tibial nerve and deep fibular nerve (Figure 2.2.3.49, Figure 2.2.3.55).