Download 肌肉骨骼系统

肌肉骨骼系统
关节&软骨
Content




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关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生
Joints
Joints and their classification
bony joints
fibrous joints
cartilaginous joints
Synovial joints
Anatomy of selected diarthroses
humeroscapular joint 肱肩胛关节
elbow joint
coxal joint 髋关节
knee joint
9-3
Joints and Their Classification
Arthrology = study of the joints
Kinesiology = study of musculoskeletal movement
Classified by freedom of movement
 diarthrosis (freely movable)
 amphiarthrosis (slightly movable)微动关节
 synarthrosis (little or no movement)不动关节
Classified how adjacent bones are joined
 Fibrous
 Cartilaginous
 bony or synovial
9-4
Bony Joint (Synostosis)骨性结合
Gap between two bones ossifies
– frontal and mandibular bones in infants 额骨和下颌骨
– cranial sutures in elderly 颅缝
– attachment of first rib and sternum 胸骨
Can occur in either fibrous or cartilaginous joint
Fibrous Joints (Synarthrosis)
Collagen fibers span the space
between bones
Sutures
 gomphoses 钉状关节
Syndesmoses 韧带联合
9-6
Fibrous Joint -- Sutures
Immovable fibrous joints
 bind skull bones together
Serrate - interlocking lines(齿状联合)
 Coronal(冠状缝), sagittal(矢状缝) and
lambdoid sutures(人字缝)
Lap - overlapping beveled edges
 temporal and parietal bones(颞和颅顶骨)
Plane - straight, nonoverlapping
edges
 palatine processes(腭突) of the maxillae
9-7
Types of Sutures
9-8
Fibrous Joint – Gomphoses钉状关节
Attachment of a tooth to its
socket
Held in place by fibrous
periodontal ligament(牙周韧带)
collagen fibers attach
tooth to jawbone(颚骨)
Some movement while
chewing
Fibrous Joint – Syndesmosis韧带联合
Two bones bound
by ligament only
interosseus membrane
Most movable of fibrous joints
Interosseus membranes unite
radius to ulna and tibia to
fibula
Cartilaginous Joint – Synchondrosis软骨结合
Bones are joined by
hyaline cartilage(透明软
骨)
rib attachment to
sternum(胸骨)
epiphyseal plate(骺板)
in children binds
epiphysis(骨骺) and
diaphysis(骨干)
9-11
Cartilaginous Joint – Symphysis骨联合
2 bones joined by
fibrocartilage(纤维软骨)
pubic symphysis(耻骨联
合) and intervertebral
discs
Only slight amount
of movement is
possible
Synovial Joint(滑膜关节)
 Joint in which two bones are separated by a space called a
joint cavity
 Most are freely movable
9-13
General Anatomy
 Articular capsule encloses joint cavity
 continuous with periosteum(骨膜)
 lined by synovial membrane
 Synovial fluid = slippery fluid; feeds cartilages
 Articular cartilage = hyaline cartilage covering the joint surfaces
 Articular discs and menisci(半月板)
 jaw, wrist, sternoclavicular and knee joints
 absorbs shock, guides bone movements and distributes forces
 Tendon attaches muscle to bone
 Ligament attaches bone to bone
9-14
Tendon Sheaths and Bursae
 Bursa = saclike extension of joint capsule 滑囊
 between nearby structures so slide more easily past each other
 Tendon sheaths = cylinders of connective tissue lined with
synovial membrane and wrapped around a tendon
9-15
Components of a Lever
A lever is a rigid object that rotates around a fixed
point called a fulcrum(支点)
Rotation occurs when effort overcomes resistance
resistance arm and effort arm are described relative to
fulcrum
9-16
Mechanical Advantage of a Lever
Two kinds of levers
lever that helps increase output of force
human moving a heavy object with help of crowbar(撬棍)
lever move object further and faster
movement of row boat with paddle(桨)
Types of levers produce either increase in
speed or force
9-17
Mechanical Advantage
Mechanical advantage is calculated from the length of the
effort arm divided by the length of the resistance arm
Contraction of the biceps muscle (肱二头肌)causes the hand
to move fast and further (MA <1.0)
9-18
First-Class Lever
 Has fulcrum in the middle between effort and resistance
 Atlantooccipital joint(寰枕关节) lies between the muscles on the back
of the neck and the weight of the face
 loss of muscle tone(肌张力) occurs when you nod off in class
9-19
Second-Class Lever
Resistance between fulcrum and effort
Resistance from the muscle tone of the temporalis(颞肌 )
muscle lies between the jaw joint(下颌关节) and the pull of
the diagastric muscle(二腹肌前腹) on the chin(下巴) as it opens
the mouth quickly
9-20
Third-Class Lever
Effort between the resistance and the fulcrum
 most joints of the body
The effort applied by the biceps muscle is applied to the
forearm between the elbow joint and the weight of the
hand and the forearm
9-21
Range of Motion
Degrees through which a joint can move
Determined by
structure of the articular surfaces
strength and tautness of ligaments, tendons and
capsule
stretching of ligaments increases range of motion
double-jointed people have long or slack ligaments
action of the muscles and tendons
nervous system monitors joint position and muscle tone
9-22
Axes of Rotation
Shoulder joint has 3 degrees of freedom =
multiaxial joint多轴关节
Other joints – monoaxial or biaxial
9-23
Types of Synovial Joints
9-24
Ball-and-Socket Joints
Smooth hemispherical(半球) head fits within a
cuplike depression
head of humerus(肱骨) into glenoid cavity of scapula
head of femur into acetabulum(髋臼) of hip bone
Multiaxial joint
9-25
Condyloid (ellipsoid) Joints
Oval convex surface(椭圆凸面) on one bone fits
into a similarly shaped depression on the next
Radiocarpal joint(腕桡关节) of the wrist
metacarpophalangeal joints(掌指关节) at the bases of
the fingers
Biaxial joints
9-26
Saddle Joints
鞍状关节
Each articular surface is shaped like a saddle鞍,
concave(凹面) in one direction and convex(凸面) in the other
 trapeziometacarpal joint(拇指腕关节) at the base of the thumb
Biaxial joint
 more movable than
a condyloid or hinge joint(铰链关节)
forming the primate(灵长目)
opposable thumb
9-27
Gliding Joints(arthrodia) 滑动关节
Flat articular surfaces in which bones slide
over each other
Limited monoaxial joint
Considered amphiarthroses
9-28
Hinge Joints枢纽关节
One bone with convex surface that fits into a
concave depression on other bone
ulna and humerus at elbow joint
femur and tibia at knee joint
finger and toe joints
Monoaxial joint
9-29
Pivot Joints车轴关节
One bone has a projection that fits into a ringlike
ligament of another
First bone rotates on its longitudinal axis relative to
the other
 atlantoaxial joint寰枢关节
(dens and atlas)
 proximal radioulnar
joint allows the
radius during
pronation and supination
9-30
Flexion, Extension and Hyperextension
Flexion decreases the angle
of a joint
Extension straightens and
returns to the anatomical
position
Hyperextension = extension
beyond 180 degrees过伸
9-31
Flexion, Extension and Hyperextension
9-32
Abduction and Adduction
Abduction is movement of a part away from the midline
外展
 hyperabduction – raise arm over back or front of head
Adduction is movement towards the midline
内收
 hyperadduction – crossing fingers
9-33
Elevation and Depression
Elevation is a movement that raises a bone vertically垂直
 Mandibles(下颌) are elevated during biting and clavicles(锁骨)
during a shrug
Depression is lowering the mandible or the shoulders
9-34
Protraction and Retraction
Protraction = movement
anteriorly on horizontal
plane 伸长
thrusting the jaw forward,
shoulders or pelvis forward
Retraction is movement
posteriorly 收回
9-35
Circumduction
Movement in which one end of
an appendage remains
stationary while the other end
makes a circular motion
Sequence of flexion, abduction,
extension and adduction
movements
 baseball player winding up for a
pitch
9-36
Rotation
Movement on
longitudinal axis
rotation of trunk,
thigh, head or arm
Medial rotation
turns the bone
inwards
Lateral rotation
turns the bone
outwards
9-37
Supination and Pronation
In the forearm and foot
Supination 旋后
 rotation of forearm so that the palm
faces forward
 inversion and abduction of foot
(raising the medial edge of the foot)
Pronation
旋前
 rotation of forearm so the palm faces
to the rear
 Eversion外翻 and abduction外展 of foot
(raising the lateral edge of the foot)
9-38
Movements of Head and Trunk
屈曲
过伸
侧屈
Flexion, hyperextension and lateral flexion of vertebral
column
9-39
Rotation of Trunk and Head
Rotation of head
Right rotation of trunk
9-40
Movements of Mandible
下颌骨
Lateral excursion偏移 = sideways movement
Medial excursion = movement back to the midline
 side-to-side grinding during chewing
Protraction – retraction缩进 of mandible
9-41
Movement of Hand and Digits
Radial and ulnar
flexion 桡偏尺偏
Abduction of fingers
and thumb 拇外展
Opposition is
movement of the
thumb to approach or
touch the fingertips对指
运动
Reposition is
movement back to the
anatomical position
9-42
Movements of the Foot
 Dorsiflexion is raising of the toes as when you swing the foot
forward to take a step (heel strike) 背屈
 Plantarflexion is extension of the foot so that the toes point
downward as in standing on tiptoe 跖屈
 Inversion is a movement in which the soles are turned medially
 Eversion is a turning of the soles to face laterally 外翻
9-43
Content
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关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生
PERICHONDRIUM 软骨膜
Dense irregularly
arranged connective
tissue (type I collagen)
Ensheaths the cartilage
Houses the blood
vessels that nourish滋养
chondrocytes
CHONDROBLAST成软骨细胞
Progenitor of
chondrocytes
Lines border between
perichondrium and
matrix
Secretes type II collagen
and other ECM
components
Chondroblasts build
CHONDROCYTE软骨细胞
Mature cartilage cell
Reside in a space
called the lacuna
Clear areas = Golgi
and lipid droplets
CHONDROCYTE软骨细胞
Chondrocytes
completely fill their
lacunae
RER(粗面内质网) and
euchromatic nuclei
Synthetically active,
secrete matrix
N
RER
Cartilage matrix
MATRIX
 Provides the rigidity, elasticity, &
resilience回复力
 FIBERS
 Collagenous and elastic
 GROUND SUBSTANCE
 Glycosaminoglycans粘多糖 (chondroitin
sulfates, keratin sulfate, hyaluronic
acid)
 Proteoglycans蛋白聚糖: GAGs + core
protein
 Water
 Basophilic嗜碱性
 Territorial matrix - high [sulfated
proteoglycans ]
CARTILAGE GROWTH
Appositional
 Increasing in WIDTH;
chondroblasts deposit
matrix on surface of
pre-existing cartilage
Interstitial
 Increasing in LENGTH;
chondrocytes divide
and secrete new
matrix , expanding the
cartilage from within
(inside out)
TYPES OF CARTILAGE
HYALINE透明
ELASTIC弹性
FIBROUS纤维
HYALINE CARTILAGE
 FUNCTION
 Support tissue and organs
 Model for bone
development
 MATRIX
 Type Ⅱ collagen (thin
fibrils)
 Chondroitin sulfate, keratin
sulfate, hyaluronic acid
 Water
 LOCATION
 Tracheal rings, nasal
septum, larynx, articular
surfaces of joints
ELASTIC CARTILAGE
 FUNCTION
 Support with flexibility
 MATRIX
 Normal components of hyaline
matrix plus ELASTIC fibers
 LOCATION
 External ear, external auditory
canal, epiglottis
 STAINS
 Elastic fibers stain BLACK with
Weigert stain
perichondrium
FIBROCARTILAGE
Orcein van Giesen Elastic stain - fibrocartilage - reddish brown
hyaline cartilage - yellow
FIBROCARTILAGE
FUNCTION
 Support with great
tensile strength
MATRIX
 Type Ⅰ collagen Oriented parallel to
stress plane
LOCATION
 Intervertebral disks,
pubic symphysis
FIBROCARTILAGE
Chondrocytes align
between collagen fibers
软骨细胞在胶原纤维中成行排列
Collagen fibers lie
parallel to lines of stress
胶原纤维与受力方向平行
Content
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关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生
The Humeroscapular Joint肱肩胛关节
 Most freely movable joint in the body
 shallowness and looseness
 deepened by glenoid labrum肩胛盂
 Supported by ligaments and tendons
 3 glenohumeral盂-肱, coracohumeral喙-肱,
transverse humeral and biceps tendon are
important joint stabilizer
 Supported by rotator cuff 肩袖musculature
 tendons fuse to joint capsule and
strengthens it
 supraspinatus, infraspinatus, teres minor
and subscapularis (冈上肌、冈下肌、小圆肌、肩胛下肌)
 4 Bursae associated with shoulder joint
9-58
Stabilizers of the Shoulder Joint
稳定肩关节的结构
9-59
Tendons of Rotator Cuff Muscles
肩袖的肌腱
9-60
Shoulder
Joint
Capsule,
Anterior
View
Dissection of Shoulder Joint
9-62
Shoulder Joint Capsule,
Posterior View
A. Acromion肩峰
B. Scapular spine肩胛冈
C. Coracohumeral ligament喙肱韧带
D. Supraspinatus muscle冈上肌
(cut away)
E. Infraspinatus muscle (cut away)冈下肌
F. Teres minor muscle (cut away)小圆肌
G. Triceps muscle (cut away)肱三头肌
H. Capsule
Shoulder Joint Capsule,
Lateral View
A. Acromion process
B. Coracoid process喙突
C. Coracoacromial ligament
D. Coracoclavicular ligament
E. Glenoid labrum盂唇
F. Triceps muscle (cut away)
G. Biceps muscle (cut away)
The Elbow Joint
 Single joint capsule enclosing
the
humeroulnar and humeroradial
joints肱尺肱桡关节
 Humeroulnar joint is supported
by collateral ligaments.
 Radioulnar joint is head of
radius held in place by the
anular ligament 环形韧带
encircling the head
9-65
Elbow Joint
9-66
The Coaxal (hip) Joint
Head of femur articulates with acetabulum髋臼
Socket deepened by acetabular labrum髋臼唇
Blood supply to head of femur found in ligament of the
head of the femur Joint capsule strengthened by
ligaments
9-67
Hip Joint
 Joint capsule strengthened
by ligaments
 Pubofemoral耻骨-股骨
 Ischiofemoral坐骨-股骨
 Iliofemoral髂骨-股骨
9-68
Dissection of Hip Joint
9-69
The Knee Joint
Most complex diarthrosis 最复杂可动关节
 patellofemoral = gliding joint(髌骨股骨关节滑动关节)
 tibiofemoral = gliding with slight
rotation and gliding possible in
flexed position一定的选择和充分的屈曲
Joint capsule anteriorly consists
of patella and extensions of
quadriceps
femoris tendon股四头肌肌腱
Capsule strengthened by
extracapsular and intracapsular
ligaments囊内外韧带
9-70
Knee Joint – Sagittal Section矢状面
9-71
Knee Joint – Anterior and Posterior Views
 Anterior and lateral cruciate ligaments limit anterior and
posterior sliding movements前交叉韧带和后交叉韧带限制前后滑动
 Medial and lateral collateral ligaments prevent rotation of
extended knee侧副韧带限制旋转
9-72
Knee Joint – Superior View
 Medial and lateral meniscus半月板 absorb shock and shape joint
9-73
Dissection of Knee Joint解剖图
9-74
Knee Joint Structures
 Cruciate Ligaments- within the joint capsule, they cross. They
are intracapsular ligaments and named for their attachment
on the tibia.十字交叉韧带，命名根据胫骨位置
Knee Ligaments膝关节的韧带
 Anterior Cruciate Ligament- It attaches to the anterior side of
the tibia just medial to the medial meniscus. It attaches to
the posterior side of the femur. It prevents anterior
translation of the tibia on the femur.前交叉韧带的位置，防止胫骨过度前移
Knee Ligaments
Posterior Cruciate Ligament- attaches to the
posterior side of the tibia. 胫骨后方 It attaches to the
anterior femur and prevents posterior translation of
the tibia on the femur.后交叉韧带，防止胫骨向后方的过度移动
Knee Ligaments
Medial Collateral
Ligament- Attached
to the tibia and femur
on the medial内侧 side
of the knee joint.
Also attached to the
medial meniscus, so
injury to one can
result in injury to
both.内侧副韧带
Knee Ligaments
Lateral Collateral Ligament- attached from the
femur to the fibula腓骨 on the lateral side of the knee.
Shorter and stronger than the MCL. 外侧副韧带
Knee Joint Structures半月板
Meniscus- medial and lateral meniscus are two
half moon, wedge shaped fibrocartilage纤维软骨
located on the superior tibia. They provide shock
absorption in the knee. Medial is more often torn.
Knee Structures
Pes Anserine muscle group- made up of Sartorius,
Gracilis and semiTendinosus. (SGT). They come from
posterior to medial anterior knee, there is a bursa 滑囊
under the insertion.
缝匠肌
半腱肌腱
鹅足滑囊
Content





关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生
Intervertebral Disc椎间盘
Soft fibro-cartilaginous cushions垫
Between two vertebra椎体
Allows some motion
Serve as shock absorbers
Total – 23 discs
¼ th of the spinal column's length脊柱长度
Avascular 缺乏血管
Nutrients diffuse through end plates养分弥散
Intervertebral Disc Functions
Movement of fluid within the nucleus
 Allows vertebrae to rock back and forth
 Flexibility弹性
Act to pad and maintain the space between
the twenty-four movable vertebrae
Act as shock absorbers
Allow extension and flexion 伸展屈曲
Intervertebral Disc Anatomy解剖
Spongy center
 Nucleus pulposus髓核
Surrounded by a tougher
outer fibrous ring
 Anulus fibrosus纤维环
Anulus Fibrosus纤维环
Strong radial tire–like structure 放射样结构
Series of lamellae薄片
Concentric sheets of collagen fibers
 Connected to end plates
 Orientated定向 at various angles
 Under compression
– Become horizontal水平的
Encloses nucleus pulposus髓核
Anulus 环
In Bending 弯曲
Increased tensile force posteriorly 拉力
Increased compressive force anteriorly压力
In Rotation 旋转
Reorientation of collagenous fibers
Tightening of fibers traveling in one direction
Loosening of fibers traveling in opposite direction
Nucleus Pulposus髓核
Has more water and PGs蛋白多糖
PG are macro-molecules
Attract and retain water
Hydrophilic gel–like matter 水凝胶样
• Resists compression
Amount of water
Activity related
Varies throughout the day
GLUCOSE
glucose
GLUT
glucose
glycogen
glucose-6-phosphate
OXYGEN
O2
pyruvate
2 ATP
-
lactate
36 ATP
V
H+
MCT
LACTATE
lactate
-
CO2 + H2O
H+
+
H
H+
H+
H+
NHE
+
H -ATPase
LACTIC ACID 乳酸IS THE MAJOR METABOLITE
PRODUCED BY DISC CELLS
Metabolism of Disc cells
椎间盘细胞的代谢
Disc cells require glucose and oxygen to 糖和氧
maintain viability生存 and activity
They produce lactic acid as a metabolic
product.乳酸
Accumulation of lactic acid is detrimental有害
and can adversely affect viability and activity
•乳酸积累是有害可反过来影响细胞的存活和活性
Sections through human lumbar discs
椎间盘的两个截面
Cross section
Sagittal section
Blood supply to the avascular intervertebral disc
无血管的椎间盘的血供
Thin midsagittal section cut
from adjacent upper lumbar
vertebral bodies from a
young adult filled by arterial
injection
包括上下两个椎体的薄层矢状位切片图
adapted from: HV Crock and H Yoshizawa ‘Blood supply of the Vertebral column’
Schematic view of nutritional routes
into the intervertebral disc椎间盘营养路径示意图
Vertebral body
endplate终板
endplate
nucleus
Holm et al, 1981
From Holm et al, 1981
Details of blood vessels at disc-endplate junction
and of cartilaginous endplate椎间盘与终板连接处血管
bone
disc
blood vessels
From Crock, Goldwasser, Yoshizawa, 1991Roberts et al, 1989
Effects of cigarette smoke components on
blood supply to disc 吸烟对椎间盘血供影响
Holm and Nachemson, 1988
Stress-Strain Curve
应力应变曲线
Compressive Strength of Spine
脊柱不同节段压力图
Failure Strength of Spinal Ligaments
脊柱各韧带极限承重力
Types of motion
脊柱运动的类型
Motion Segment
活动节段
Theory of weight bearing
脊柱的承重原理
Nucleus pulpous imbibes water吸收水分
Develops internal pressure内部压力的升高
Pressure exerted in all directions各方向向外释放
Lateral forces
• Against annulus纤维环
Superiorly and inferiorly directed forces
• Against end plates终板
Increases stiffness
• Of end plate and annulus fibrosus
Theory of weight bearing (cont’d)
Disc Pressure And Positions
不同姿势椎间盘压力
Raymond Damadian, MD., President, Fonar Corporation Melville, N.Y., June 12, 2006
Herniated Disk
椎间盘突出
Can Occur when there is
enough pressure from
the vertebrae above and
below
This can force some or
all of the nucleus
pulposus through a
weakened or torn part of
the annulus fibrosus.
•
可导致部分或全部的髓核从纤维环薄
弱或破损处突出
Disc Herniation
 The ruptured nucleus will
often come incontact with
and press on nerves near
the disc.突出髓核压迫神经
 This can result in severe
pain严重疼痛
 About 90% of herniated
discs occur in the lumbar
region. The discs in the
cervical region are affected
about 8%, those of the
thoracic region only about
1-2%大部分发生在腰椎
 Herniated disks are one of
the most common causes of
back pain背部疼痛的原因
Disc Herniation
椎间盘突出
Content





关节种类
软骨种类
主要四肢关节
椎间盘
关节置换&再生
TJA: Indications
全关节置换适应症
Anatomy — Hip
髋的解剖
骨盆
髋臼
股骨头
股骨
股骨颈
大转子
THA Implants
全髋置换植入物
臼杯
聚乙烯膜(随时代发展而变化)
Technique: Total Hip Replacement
全髋置换术
• Femoral head
impaction股骨头嵌入

Final implant

最终植入物
Anatomy — Knee
膝关节解剖
Knee Replacement—Implants
全膝置换植入物
股骨处材料
髌骨处材料
Patellar
component
胫骨处材料
Knee Replacement—Implants
Knee Replacement—Implants
膝关节置换术
Causes of TJR Failure
全关节置换术失败原因
Wear of articular bearing surface关节承重面磨穿
Aseptic/mechanical loosening无菌性/机械性松动
Osteolysis骨质疏松
Infection感染
Instability关节不稳
Peri-prosthetic fracture假体周围骨折
Implant Failure植入物毁损
Wear of Articular Bearing Surface
关节承重面磨损
Aseptic/Mechanical Loosening
无菌性/机械性松动
Osteolysis
骨质疏松
Infection
感染
Dislocation/Instability
脱位/关节不稳
Peri-Prosthetic Fracture
假体周围骨折
Sri: PP fracture
Implant Failure
假体毁损
Take Home Message
知识点：
 关节的种类、运动、力学模式
 滑膜关节的结构组成、主要关节（肩关节、肘关节、髋关节、膝关
节）的结构
 关节软骨的种类和组织学特点
 椎间盘的结构、组织学、力学和代谢特点
思考题（面对疾苦和疑难，我们能做些什么？）：
1） 骨关节炎功能失衡的解剖和组织学机制是什么？如何尽可能预防和
恢复？
2）椎间盘突出的解剖和组织学机制是什么？如何尽可能预防和恢复？