Applied Anatomy Of Joints By Dr Iram Iqbal,pg Trainee, M Phill,anatomy
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APPLIED ANATOMY OF JOINTS DR IRAM IQBAL PG TRAINEE MPHILL
UPPER LIMB
Acromioclavicular
Joint Sternoclavicular Joint Shoulder Joint
ELBOW JOINT RADIOULNAR JOINT WRIST JOINT INTER CARPAL JOINT CARPOMETECARPAL JOINT METACARPOPHALENGIAL JOINT INTERPHALENGIAL JOINT
Applied anatomy of sternoclavicular joint
Ankylosis of Sternoclavicular Joint Movement
at the SC joint is critical to movement of the shoulder. When ankylosis (stiffening or fixation) of the joint occurs, or is necessary surgically, a section of the center of the clavicle is removed, creating a pseudo joint or “flail” joint to permit scapular movement.
Dislocation of sternoclavicular joint
The strong costoclavicular ligament firmly holds the medial end of the clavicle to the first costal cartilage. Violent forces directed along the long axis of the clavicle usually result in fracture of that bone, but dislocation of the sternoclavicular joint takes place occasionally
Anterior dislocation
results in the medial end of the clavicle projecting forward beneath the skin; it may also be pulled upward by the sternocleidomastoid muscle.
Posterior dislocation of sternoclavicular joint
usually follows direct trauma applied to the front of the joint that drives the clavicle backward. This type is the more serious because the displaced clavicle may press on the trachea, the esophagus, and major blood vessels in the root of the neck. If the costoclavicular ligament ruptures completely, it is difficult to maintain the normal position of the clavicle once reduction has been accomplished.
Acromioclavicular Joint injuries
The strength of the joint depends on the strong coracoclavicular ligament, which binds the coracoid process to the undersurface of the lateral part of the clavicle. The greater part of the weight of the upper limb is transmitted to the clavicle through this ligament, and rotary movements of the scapula occur at this important ligament.
Acromioclavicular Dislocation (shoulder sepration)
A severe blow on the point of the shoulder, as is,
blocking or tackling in football
any severe fall,
acromion being thrust beneath the lateral end of the clavicle, tearing the coracoclavicular ligamen.
Glenoid Labrum Tears
Tearing of the fibro cartilaginous glenoid labrum commonly occurs in athletes who throw a baseball or football and in those who have shoulder instability and subluxation (partial dislocation) of the glenohumeral joint. The tear often results from sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum. Usually a tear occurs in the anterosuperior part of the labrum. The typical symptom is pain while throwing, especially during the acceleration phase, but a sense of popping or snapping may be felt in the glenohumeral joint during abduction and lateral rotation of the arm.
Adhesive Capsulitis of Glenohumeral Joint
Adhesive fibrosis and scarring between the inflamed joint capsule of the glenohumeral joint, rotator cuff, subacromial bursa, and deltoid usually cause (“frozen shoulder”), a condition seen in individuals 40-60 years of age. A person with this condition has difficulty abducting the arm and can obtain an apparent abduction of up to 45° by elevating and rotating the scapula. Because of the lack of movement of the glenohumeral joint, strain is placed on the AC joint, which may be painful during other movements (elevation, or shrugging, of the shoulder).
Dislocations of the Shoulder Joint The shoulder joint is the most commonly dislocated large joint
Anterior Inferior Dislocation Sudden
violence applied to the humerus
with the joint fully abducted tilts the humeral head downward onto the inferior weak part of the capsule, which tears, and the humeral head comes to lie inferior to the glenoid fossa
Posterior Dislocations Posterior dislocations are rare and are usually caused by direct violence to the front of the joint A subglenoid displacement of the head of the humerus into the quadrangular space can cause damage to the axillary nerve, as indicated by paralysis of the deltoid muscle and loss of skin sensation over the lower half of the deltoid Downward displacement of the humerus can also stretch and damage the radial nerve.
Shoulder Pain
Injury to the shoulder joint is followed by pain, limitation of movement, and muscle atrophy owing to disuse.
It is important to appreciate that pain in the shoulder region can be caused by disease elsewhere and that the shoulder joint may be normal; for example,
diseases of the spinal cord
and vertebral column
the pressure of a cervical rib can cause shoulder pain.
Irritation of the diaphragmatic pleura or peritoneum can produce referred pain via the phrenic and supraclavicular nerves.
Bursitis of Elbow
The subcutaneous olecranon bursa is exposed to injury during falls on the elbow and to infection from abrasions of the skin covering the olecranon. Repeated excessive pressure and friction, as occurs in wrestling,
for example, may cause this bursa to become inflamed, producing a friction (“student's elbow”) This type of bursitis is also known as “dart thrower's elbow” and “miner's elbow.” Occasionally, the bursa becomes infected and the area over the bursa becomes inflamed. is much less common. It results from excessive friction between the triceps tendon and olecranon, for example, resulting from repeated flexionextension of the forearm as occurs during certain assembly-line jobs. The pain is most severe during flexion of the forearm because of pressure exerted on the inflamed subtendinous olecranon bursa by the triceps tendon results in pain when the forearm is pronated because this action compresses the bicipitoradial bursa against the anterior half of the tuberosity of the radius.
Avulsion of Medial Epicondyle
Avulsion of the medial epicondyle in children can result from a fall that causes severe abduction of the extended elbow, an abnormal movement of this articulation. The resulting traction on the ulnar collateral ligament pulls the medial epicondyle distally. The anatomical basis of avulsion of the epicondyle is that the epiphysis for the medial epicondyle may not fuse with the distal end of the humerus until up to age 20. Usually fusion is complete radiographically at age 14 in females and age 16 in males. Stretching of Ulner nerve is a frequent complication of the abduction type of avulsion of the medial epicondyle. The anatomical basis for this stretching of the ulnar nerve is that it passes posterior to the medial epicondyle before entering the forearm.
Subluxation and Dislocation of Radial Head
Preschool children, particularly girls, are vulnerable to transient subluxation (incomplete dislocation) of the head of the radius (also called “nursemaid's elbow” and “pulled elbow”). The history of these cases is typical. The child is suddenly lifted (jerked) by the upper limb while the forearm is pronated (e.g., lifting a child) . The child may cry out, refuse to use the limb, and protect the limb by holding it with the elbow flexed and the forearm pronated. The sudden pulling of the upper limb tears the distal attachment of the anular ligament, where it is loosely attached to the neck of the radius. The radial head then moves distally, partially out of the “socket” formed by the anular ligament . The proximal part of the torn ligament may become trapped between the head of the radius and the capitulum of the humerus. The source of pain is the pinched anular ligament. Treatment of the subluxation consists of supination of the child's forearm while the elbow is flexed . The tear in the anular ligament heals when the limb is placed in a sling for 2 weeks.
Stability of Elbow Joint The elbow joint is stable because of the wrenchshaped articular surface of the olecranon and the pulley-shaped trochlea of the humerus; strong medial and lateral ligaments.
Dislocations of the Elbow Joint
Elbow dislocations are common, and most are posterior. Posterior dislocation usually follows falling on the outstretched hand. Posterior dislocations of the joint are common in children because the parts of the bones that stabilize the joint are incompletely developed
Arthrocentesis of the Elbow Joint The
anterior and posterior walls of the capsule are weak, and when the joint is distended with fluid, the posterior aspect of the joint becomes swollen.
Aspiration of joint fluid can easily be performed through the back of the joint on either side of the olecranon process
Damage to the Ulnar Nerve With Elbow Joint Injuries
The close relationship of the ulnar nerve to the medial side of the joint often results in its becoming damaged in dislocations of the joint or in fracture dislocations in this region. The nerve lesion can occur at the time of injury or weeks, months, or years later. The nerve can be involved in scar tissue formation Ulner nerve can become stretched owing to lateral deviation of the forearm in a badly reduced supracondylar fracture of the humerus. During movements of the elbow joint, the continued friction between the medial epicondyle and the stretched ulnar nerve eventually results in ulnar palsy.
Radioulnar Joint Disease
The proximal radioulnar joint communicates with the elbow joint
distal radioulnar joint does not communicate with the wrist joint.
this means that infection of the elbow joint invariably involves the proximal radioulnar joint.
Rheumatoid arthritis
It commonly affects the wrist and hands and is a major cause of serious loss of function and ugly deformities.
Affected joints are swollen from synovial thickening and movement is restricted.
In the later stages articular cartilage and the underlying bones are eroded and the fingers tend to deviate medially – ulnar deviation.
Rheumatoid arthritis
The
strength of the proximal radioulnar joint depends on the integrity of the strong anular ligament. Rupture of this ligament occurs in cases of anterior dislocation of the head of the radius on the capitulum of the humerus. In young children, in whom the head of the radius is still small and undeveloped, a sudden jerk on the arm can pull the radial head down through the anular ligament.
Wrist Joint Injuries A
fall on the outstretched hand can strain the anterior ligament of the wrist joint, producing synovial effusion, joint pain, and limitation of movement. These symptoms and signs must not be confused with those produced by a fractured scaphoid or dislocation of the lunate bone.
Madelung’s deformity
It is the congenital subluxation or dislocation of lower end of ulna from malformation of the bones. There may be minor generalised abnormalities of bone structure often with short stature. It may be also be caused by disease or fracture – a fracture at the lower end of the radius with upward displacement of the lower fragment. The deformity varies in degree from a slight prominence of lower end of ulna at the back of the wrist to complete dislocation of the inferior radio- ulnar joint with marked radial deviation of the hand. The more sever form is associated with congenital absence of the radius
Bull Rider's Thumb refers to a sprain of the radial collateral ligament and an avulsion fracture of the lateral part of the proximal phalanx of the thumb. This injury is common in individuals who ride mechanical bulls. Skier's Thumb Skier's thumb (historically, game-keeper's thumb) refers to the rupture or chronic laxity of the collateral ligament of the 1st MP joint . The injury results from hyperabduction of the MP joint of the thumb, which occurs when the thumb is held by the ski pole while the rest of the hand hits the ground or enters the snow. In severe injuries, the head of the metacarpal has an avulsion fracture.
Falls on the Outstretched Hand In falls on the outstretched hand, forces are transmitted from the scaphoid to the distal end of the radius, from the radius across the interosseous membrane to the ulna, and from the ulna to the humerus; through the glenoid fossa of the scapula to the coracoclavicular ligament and the clavicle; and finally, to the sternum.
Falls on the Outstretched Hand
If the forces are excessive, different parts of the upper limb give way under the strain. The area affected seems to be related to age. In a young child, for example, there may be a posterior displacement of the distal radial epiphysis; in the teenager the clavicle might fracture; in the young adult the scaphoid is commonly fractured; and in the elderly the distal end of the radius is fractured about 1 in. (2.5 cm) proximal to the wrist joint (Colles' fracture)
Applied anatomy of Joints of Lower Limb
Hip Joint Knee Joint Tibiofibular Joints Ankle Joint Joints of Foot
Applied anatomy of Hip joint
Dislocation of hip joint It can be of two types
1 Congenital dislocation 2 Acquired dislocation According to the direction of dislocation 1 Posterior dislocation - Commonest 2 Anterior dislocation 3 Central dislocation
Dislocation of Hip Joint acquired dislocation of hip acquired dislocation of hip joint –
Uncommon
– dislocation may occur during an automobile accident when the hip is flexed, adducted, and medially rotated, the usual position of the lower limb when a person is riding in a car. – Posterior dislocations are most common. – The fibrous layer of the joint capsule ruptures inferiorly and posteriorly, allowing the femoral head to pass through the tear in the capsule and over the posterior margin of the acetabulum onto the lateral surface of the ilium, – shortening and medially rotating the affected limb
congenital dislocation of hip joint
– common it affects more girls – bilateral in approximately half the cases. – Dislocation occurs when the femoral head is not properly located in the acetabulum. – The affected limb appears (and functions as if) shorter because the dislocated femoral head is more superior than on the normal side, resulting in a positive (hip appears to drop to one side during walking). – Inability to abduct the thigh is characteristic of congenital dislocation
Congenital dislocation of hip joint
AQUIRED DISLOCATION Dislocation occurring after the 1st year of life is usually due to one of the 3 cause -Pyogenic arthritis. -Muscle imbalance -Trauma Rare causes are -Tuberculosis -Charcot’s disease.
Poster dislocation Anterior dislocation
Posterior dislocation
.
Most common verity. usually occurs in a road accident, when someone is seated in a trunk or car is thrown forward & striking against the dashboard. Here the femur is thrust upwards and femoral head is forced out of it’s socket.
Here the leg is short and lies adducted, internally rotated and slightly flexed. the capsule ruptures inferiorly and posteriorly allowing the femoral head to pass through the tear in the capsule and over the posterior margin of the acetabulum.
ANTERIOR DISLOCATION
Rare Usual cause is a road accident or air crash .Dislocation of one or even both hips may occur when a weight falls on to the back of a person , with his legs wide apart , knees straight and back bent forwards. Here the leg lies externally rotated , abducted and slightly flexed. It is not short because the attachment of rectus femoris prevent the head from dislocation upwards. The prominent head is easy to feel.
CENTRAL DISLOCATION
A fall on the side or a blow over the greater trochanter may thrust the femoral head into the floor of the acetabulum and fracture of
the plevis. In this case trochanter and hip region are tender. Little movements are possible.
On X-ray The femoral head is displaced medically and the acetabular floor is fractured.
. Tuberculosis of hip The hip is one of the joints most frequently affected by tuberculosis. The patient may have a history of active pulmonary tuberculosis. Acute Suppurative arthritis This condition is more common in children. It is often secondary to osteomyelitis of the upper end of femur.
Rheumatoid arthritis
Hip joint is not affected usually in case of RA. But when they are affected the consequent disability is serious. Osteoarthritis It is a common cause of severe disablement especially in elderly. It also affect young persons, when there has been previous damage from injury or disease. The irritable hip Transient hip pain and restriction of movement in an otherwise healthy child. It is the commonest cause of hip pain in children. Boys are commonly affected. (age group -6-12 yrs of age) Presents with pain and a limp often intermittent & following activity and extremes of all movements are limited
OVERVIEW OF LIGAMENTS
Knee Joint Injuries
Hyperextension and severe force directed anteriorly against the femur with the knee semiflexed (a cross-body block in football) may tear the ACL. ACL ruptures are also common knee injuries in skiing accidents. This injury causes the free tibia to slide anteriorly under the fixed femur, known as anterior drawer sign , tested clinically via the lachman test The ACL may tear away from the femur or tibia; however, tears commonly occur in the midportion of the ligament.
Although strong, PCL ruptures may occur when a player lands on the tibial tuberosity with the knee flexed ( when knocked to the floor in basketball). PCL ruptures usually occur in conjunction with tibial or fibular ligament tears. These injuries can also occur in head-on collisions when seat belts are not worn and the proximal end of the tibia strikes the dashboard. PCL ruptures allow the free tibia to slide posteriorly under the fixed femur ,known as the posterior drawer sign
ANTERIOR CRUCIATE LIGAMENT INJURY
OVERVIEW OF INJURY
POSTERIOR CRUCIATE LIGAMENT
ILLUSTRATION
Meniscal tears
Meniscal tears usually involve the medial meniscus. The lateral meniscus does not usually tear because of its mobility. Pain on lateral rotation of the tibia on the femur indicates injury of the lateral meniscus , whereas pain on medial rotation of the tibia on the femur indicates injury of the medial meniscus Most meniscal tears occur in conjunction with TCL or ACL tears. Peripheral meniscal tears can often be repaired or may heal on their own because of the generous blood supply to this area. Meniscal tears that do not heal or cannot be repaired are usually removed (e.g., by arthroscopic surgery). Knee joints from which the menisci have been removed suffer no loss of mobility; however, the knee may be less stable and the tibial plateaus often undergo inflammatory reactions.
oVERVIEW OF MENISCI
MENISCUS DEGENERATION
BUCKET HANDLE TEAR
LATERAL MENISCUS INJURY
OVERVIEW OF COLLATERAL LIGAMENTS
ligament sprains The most common knee injuries in contact sports are ligament sprains , which occur when the foot is fixed in the ground . If a force is applied against the knee when the foot cannot move, ligament injuries are likely to occur. The tibial and fibular collateral ligaments (TCL and FCL) are tightly stretched when the leg is extended, normally preventing disruption of the sides of the knee joint. The firm attachment of the TCL to the medial meniscus is of considerable clinical significance because tearing of this ligament frequently results in concomitant tearing of the medial meniscus.
“unhappy triad
The injury is frequently caused by a blow to the lateral side of the extended knee or excessive lateral twisting of the flexed knee that disrupts the TCL and concomitantly tears and/or detaches the medial meniscus from the joint capsule. This injury is common in athletes who twist their flexed knees while running in basketball, the various forms of football, and volleyball). The ACL, which serves as a pivot for rotatory movements of the knee and is taut during flexion, may also tear subsequent to the rupture of the TCL, creating an “unhappy triad” of knee injuries.
Coxa Vara and Coxa Valga The angle of inclination varies with age, sex, and development of the femur (e.g., consequent to a congenital defect in ossification of the femoral neck). It also may change with any pathological process that weakens the neck of the femur (e.g., rickets). When the angle of inclination is decreased, the condition is Coxa vara, when it is increased, the condition is . Coxa valga causes a mild passive abduction of the hip.
Coxa Vara and Coxa Valga
Patellar Dislocation
When the patella is dislocated, it nearly always dislocates laterally. Patellar dislocation is more common in women, presumably because of their greater P.662 Q-angle, which, in addition to representing the oblique placement of the femur relative to the tibia, represents the angle of pull of the quadriceps relative to the axis of the patella and tibia (the term Qangle was actually coined in reference to the angle of pull of the quadriceps). The tendency toward lateral dislocation is normally counterbalanced by the medial, more horizontal pull of the powerful vastus medialis. In addition, the more anterior projection of the lateral femoral condyle and deeper slope for the larger lateral patellar facet provide a mechanical deterrent to lateral dislocation. An imbalance of the lateral pull and the mechanisms resisting it result in abnormal tracking of the patella within the patellar groove and chronic patellar pain, even if actual dislocation does not occur
Bursitis in the Knee Region
Prepatellar brusitis is usually a friction bursitis caused by friction between the skin and the patella. If the inflammation is chronic, the bursa becomes distended with fluid and forms a swelling anterior to the knee results from excessive friction between the skin and the tibial tuberosity; the edema occurs over the proximal end of the tibia. results in edema between the patellar ligament and the tibia, superior to the tibial tuberosity. The suprapatellar bursa communicates with the articular cavity of the knee joint; consequently, abrasions or penetrating wounds (e.g., a stab wound) superior to the patella may result in caused by bacteria entering the bursa from the torn skin. The infection may spread to the knee joint.
Popliteal Cysts
Popliteal Cysts (Baker cysts) are abnormal fluid filled sacs of synovial membrane in the region of the popliteal fossa. A popliteal cyst is almost always a complication of chronic knee joint effusion. The cyst may be a herniation of the gastrocnemius or semimembranosus bursa through the fibrous layer of the joint capsule into the popliteal fossa, communicating with the synovial cavity of the knee joint by a narrow stalk . Synovial fluid may also escape from the knee joint synovial effusion or a bursa around the knee and collect in the popliteal fossa. Here it forms a new synovial-lined sac, or popliteal cyst. Popliteal cysts are common in children but seldom cause symptoms. In adults, popliteal cysts can be large, extending as far as the midcalf, and may interfere with knee movements.
Ankle Injuries
The ankle is the most frequently injured major joint in the body. Ankle sprains (torn fibers of ligaments) are most common. A sprained ankle is nearly always an inversion injury , involving twisting of the weight-bearing plantarflexed foot. The person steps on an uneven surface and the foot is forcibly inverted Lateral ligament sprains . occur in sports in which running and jumping are common, particularly basketball
The lateral ligament is injured because it is much weaker than the medial ligament and is the ligament that resists inversion at the talocrural joint. The anterior talofibular ligament —part of the lateral ligament—is most vulnerable and most commonly torn during ankle sprains, either partially or completely, resulting in instability of the ankle joint . The calcaneofibular ligament may also be torn. In severe sprains, the lateral malleolus of the fibula may be fractured. Shearing injuries fracture the lateral malleolus at or superior to the ankle joint. Avulsion fractures break the malleolus inferior to the ankle joint; a fragment of bone is pulled off by the attached ligaments).
A occurs when the foot is forcibly everted . This action pulls on the extremely strong medial ligament, often tearing off the medial malleolus. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus, producing a “trimalleolar fracture.” In applying this term to this injury, the entire distal end of the tibia is erroneously considered to be a “malleolus.”
Pott fracture, dislocation of ankle joint
A Pott
fracturedislocation of the ankle
occurs when the foot is forcibly averted. This action pulls on the extremely strong medial ligament, often tearing off the medial malleolus. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus.
Pes Planus (Flatfeet)
The flat appearance of the foot before age 3 is normal and results from the thick subcutaneous fat pad in the sole. As children get older, the fat is lost, and a normal medial longitudinal arch becomes visible . Flatfeet can either be flexible ( (flat, lacking a medial arch, when weight-bearing but normal in appearance when not bearing weight or rigid (flat even when not bearing weight). The more common flexible flatfeet result from loose or degenerated intrinsic ligaments (inadequate passive arch support). Flexible flatfoot is common in childhood but usually resolves with age as the ligaments grow and mature.
The condition occasionally persists into adulthood and may or may not be symptomatic. with Rigid flatfeet a history that goes back to childhood are likely to result from a bone deformity (such as a fusion of adjacent tarsal bones). Rigid flatfeet (“fallen arches”) are likely to be secondary to dysfunction of the tibialis posterior (dynamic arch support) owing to trauma, degeneration with age, or denervation. In the absence of normal passive or dynamic support, the plantar calcaneonavicular ligament fails to support the head of the talus. Consequently, the head of the talus displaces inferomedially and becomes prominent . As a result, some flattening of the
medial
part of the longitudinal arch occurs, along with lateral deviation of the forefoot.
Flatfeet
are common in older people, particularly if they undertake much unaccustomed standing or gain weight rapidly, adding stress on the muscles and increasing the strain on the ligaments supporting the arches.
Claw Toes Claw Toes are characterized by hyperextension of the metatarsophalangeal joints and flexion of the distal interphalangeal joints. Usually, the lateral four toes are involved. Callosities develop on the dorsal surfaces of the toes because of pressure of the shoe. They may also form on the plantar surfaces of the metatarsal heads and the toe tips because they bear extra weight when claw toes are present.
) Clubfoot (Talipes equinovarus
Clubfoot (Talipes equinovarus) refers to a foot that is twisted out of position. Of the several types, all are congenital (present at birth). Talipes equinovarus, (present at birth). , the common type (2 per 1000 live births), involves the subtalar joint; boys are affected twice as often as girls. The foot is inverted, the ankle is plantar flexed, and the forefoot is adducted (turned toward the midline in an abnormal manner) . The foot assumes the position of a horse's hoof, hence the prefix “equino” (equinus horse). In half of those affected, both feet are malformed. A person with an uncorrected clubfoot cannot put the heel and sole flat and must bear the weight on the lateral surface of the forefoot. Consequently, walking is painful. The main abnormality is shortness and tightness of the muscles, tendons, ligaments, and joint capsules on the medial side and posterior aspect of the foot and ankle.
Hammer Toe
Hammer Toe is a foot deformity in which the proximal phalanx is permanently and markedly dorsiflexed (hyperextended) at the metatarsophalangeal joint and the middle phalanx strongly plantar flexed at the proximal interphalangeal joint. The distal phalanx of the digit is often also hyperextended. This gives the digit (usually the 2nd) a hammer-like appearance. This deformity of one or more toes may result from weakness of the lumbrical and interosseous muscles, which flex the metatarsophalangeal joints and extend the interphalangeal joints. A callosity or callus , hard thickening of the keratin layer of the skin, often develops where the dorsal surface of the toe repeatedly rubs on the shoe.
Hallux Valgus
Hallux valgus is a foot deformity caused by pressure from
footwear and degenerative joint disease; it is characterized by lateral deviation of the great toe . The in valgus indicates In some people, the painful deviation is so large that the great toe overlaps the 2nd toe , and there is a decrease in the medial longitudinal arch. Such deviation occurs especially in females, and its frequency increases with age. These individuals cannot move their 1st digit away from their 2nd digit because the sesamoids under the head of the 1st metatarsal are usually displaced and lie in the space between the heads of the 1st and 2nd metatarsals. The 1st metatarsal shifts medially and the sesamoids shift laterally. Often the surrounding tissues swell and the resultant pressure and friction against the shoe cause a subcutaneous bursa to form; when tender and inflamed.
UPPER LIMB
Acromioclavicular
Joint Sternoclavicular Joint Shoulder Joint
ELBOW JOINT RADIOULNAR JOINT WRIST JOINT INTER CARPAL JOINT CARPOMETECARPAL JOINT METACARPOPHALENGIAL JOINT INTERPHALENGIAL JOINT
Applied anatomy of sternoclavicular joint
Ankylosis of Sternoclavicular Joint Movement
at the SC joint is critical to movement of the shoulder. When ankylosis (stiffening or fixation) of the joint occurs, or is necessary surgically, a section of the center of the clavicle is removed, creating a pseudo joint or “flail” joint to permit scapular movement.
Dislocation of sternoclavicular joint
The strong costoclavicular ligament firmly holds the medial end of the clavicle to the first costal cartilage. Violent forces directed along the long axis of the clavicle usually result in fracture of that bone, but dislocation of the sternoclavicular joint takes place occasionally
Anterior dislocation
results in the medial end of the clavicle projecting forward beneath the skin; it may also be pulled upward by the sternocleidomastoid muscle.
Posterior dislocation of sternoclavicular joint
usually follows direct trauma applied to the front of the joint that drives the clavicle backward. This type is the more serious because the displaced clavicle may press on the trachea, the esophagus, and major blood vessels in the root of the neck. If the costoclavicular ligament ruptures completely, it is difficult to maintain the normal position of the clavicle once reduction has been accomplished.
Acromioclavicular Joint injuries
The strength of the joint depends on the strong coracoclavicular ligament, which binds the coracoid process to the undersurface of the lateral part of the clavicle. The greater part of the weight of the upper limb is transmitted to the clavicle through this ligament, and rotary movements of the scapula occur at this important ligament.
Acromioclavicular Dislocation (shoulder sepration)
A severe blow on the point of the shoulder, as is,
blocking or tackling in football
any severe fall,
acromion being thrust beneath the lateral end of the clavicle, tearing the coracoclavicular ligamen.
Glenoid Labrum Tears
Tearing of the fibro cartilaginous glenoid labrum commonly occurs in athletes who throw a baseball or football and in those who have shoulder instability and subluxation (partial dislocation) of the glenohumeral joint. The tear often results from sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum. Usually a tear occurs in the anterosuperior part of the labrum. The typical symptom is pain while throwing, especially during the acceleration phase, but a sense of popping or snapping may be felt in the glenohumeral joint during abduction and lateral rotation of the arm.
Adhesive Capsulitis of Glenohumeral Joint
Adhesive fibrosis and scarring between the inflamed joint capsule of the glenohumeral joint, rotator cuff, subacromial bursa, and deltoid usually cause (“frozen shoulder”), a condition seen in individuals 40-60 years of age. A person with this condition has difficulty abducting the arm and can obtain an apparent abduction of up to 45° by elevating and rotating the scapula. Because of the lack of movement of the glenohumeral joint, strain is placed on the AC joint, which may be painful during other movements (elevation, or shrugging, of the shoulder).
Dislocations of the Shoulder Joint The shoulder joint is the most commonly dislocated large joint
Anterior Inferior Dislocation Sudden
violence applied to the humerus
with the joint fully abducted tilts the humeral head downward onto the inferior weak part of the capsule, which tears, and the humeral head comes to lie inferior to the glenoid fossa
Posterior Dislocations Posterior dislocations are rare and are usually caused by direct violence to the front of the joint A subglenoid displacement of the head of the humerus into the quadrangular space can cause damage to the axillary nerve, as indicated by paralysis of the deltoid muscle and loss of skin sensation over the lower half of the deltoid Downward displacement of the humerus can also stretch and damage the radial nerve.
Shoulder Pain
Injury to the shoulder joint is followed by pain, limitation of movement, and muscle atrophy owing to disuse.
It is important to appreciate that pain in the shoulder region can be caused by disease elsewhere and that the shoulder joint may be normal; for example,
diseases of the spinal cord
and vertebral column
the pressure of a cervical rib can cause shoulder pain.
Irritation of the diaphragmatic pleura or peritoneum can produce referred pain via the phrenic and supraclavicular nerves.
Bursitis of Elbow
The subcutaneous olecranon bursa is exposed to injury during falls on the elbow and to infection from abrasions of the skin covering the olecranon. Repeated excessive pressure and friction, as occurs in wrestling,
for example, may cause this bursa to become inflamed, producing a friction (“student's elbow”) This type of bursitis is also known as “dart thrower's elbow” and “miner's elbow.” Occasionally, the bursa becomes infected and the area over the bursa becomes inflamed. is much less common. It results from excessive friction between the triceps tendon and olecranon, for example, resulting from repeated flexionextension of the forearm as occurs during certain assembly-line jobs. The pain is most severe during flexion of the forearm because of pressure exerted on the inflamed subtendinous olecranon bursa by the triceps tendon results in pain when the forearm is pronated because this action compresses the bicipitoradial bursa against the anterior half of the tuberosity of the radius.
Avulsion of Medial Epicondyle
Avulsion of the medial epicondyle in children can result from a fall that causes severe abduction of the extended elbow, an abnormal movement of this articulation. The resulting traction on the ulnar collateral ligament pulls the medial epicondyle distally. The anatomical basis of avulsion of the epicondyle is that the epiphysis for the medial epicondyle may not fuse with the distal end of the humerus until up to age 20. Usually fusion is complete radiographically at age 14 in females and age 16 in males. Stretching of Ulner nerve is a frequent complication of the abduction type of avulsion of the medial epicondyle. The anatomical basis for this stretching of the ulnar nerve is that it passes posterior to the medial epicondyle before entering the forearm.
Subluxation and Dislocation of Radial Head
Preschool children, particularly girls, are vulnerable to transient subluxation (incomplete dislocation) of the head of the radius (also called “nursemaid's elbow” and “pulled elbow”). The history of these cases is typical. The child is suddenly lifted (jerked) by the upper limb while the forearm is pronated (e.g., lifting a child) . The child may cry out, refuse to use the limb, and protect the limb by holding it with the elbow flexed and the forearm pronated. The sudden pulling of the upper limb tears the distal attachment of the anular ligament, where it is loosely attached to the neck of the radius. The radial head then moves distally, partially out of the “socket” formed by the anular ligament . The proximal part of the torn ligament may become trapped between the head of the radius and the capitulum of the humerus. The source of pain is the pinched anular ligament. Treatment of the subluxation consists of supination of the child's forearm while the elbow is flexed . The tear in the anular ligament heals when the limb is placed in a sling for 2 weeks.
Stability of Elbow Joint The elbow joint is stable because of the wrenchshaped articular surface of the olecranon and the pulley-shaped trochlea of the humerus; strong medial and lateral ligaments.
Dislocations of the Elbow Joint
Elbow dislocations are common, and most are posterior. Posterior dislocation usually follows falling on the outstretched hand. Posterior dislocations of the joint are common in children because the parts of the bones that stabilize the joint are incompletely developed
Arthrocentesis of the Elbow Joint The
anterior and posterior walls of the capsule are weak, and when the joint is distended with fluid, the posterior aspect of the joint becomes swollen.
Aspiration of joint fluid can easily be performed through the back of the joint on either side of the olecranon process
Damage to the Ulnar Nerve With Elbow Joint Injuries
The close relationship of the ulnar nerve to the medial side of the joint often results in its becoming damaged in dislocations of the joint or in fracture dislocations in this region. The nerve lesion can occur at the time of injury or weeks, months, or years later. The nerve can be involved in scar tissue formation Ulner nerve can become stretched owing to lateral deviation of the forearm in a badly reduced supracondylar fracture of the humerus. During movements of the elbow joint, the continued friction between the medial epicondyle and the stretched ulnar nerve eventually results in ulnar palsy.
Radioulnar Joint Disease
The proximal radioulnar joint communicates with the elbow joint
distal radioulnar joint does not communicate with the wrist joint.
this means that infection of the elbow joint invariably involves the proximal radioulnar joint.
Rheumatoid arthritis
It commonly affects the wrist and hands and is a major cause of serious loss of function and ugly deformities.
Affected joints are swollen from synovial thickening and movement is restricted.
In the later stages articular cartilage and the underlying bones are eroded and the fingers tend to deviate medially – ulnar deviation.
Rheumatoid arthritis
The
strength of the proximal radioulnar joint depends on the integrity of the strong anular ligament. Rupture of this ligament occurs in cases of anterior dislocation of the head of the radius on the capitulum of the humerus. In young children, in whom the head of the radius is still small and undeveloped, a sudden jerk on the arm can pull the radial head down through the anular ligament.
Wrist Joint Injuries A
fall on the outstretched hand can strain the anterior ligament of the wrist joint, producing synovial effusion, joint pain, and limitation of movement. These symptoms and signs must not be confused with those produced by a fractured scaphoid or dislocation of the lunate bone.
Madelung’s deformity
It is the congenital subluxation or dislocation of lower end of ulna from malformation of the bones. There may be minor generalised abnormalities of bone structure often with short stature. It may be also be caused by disease or fracture – a fracture at the lower end of the radius with upward displacement of the lower fragment. The deformity varies in degree from a slight prominence of lower end of ulna at the back of the wrist to complete dislocation of the inferior radio- ulnar joint with marked radial deviation of the hand. The more sever form is associated with congenital absence of the radius
Bull Rider's Thumb refers to a sprain of the radial collateral ligament and an avulsion fracture of the lateral part of the proximal phalanx of the thumb. This injury is common in individuals who ride mechanical bulls. Skier's Thumb Skier's thumb (historically, game-keeper's thumb) refers to the rupture or chronic laxity of the collateral ligament of the 1st MP joint . The injury results from hyperabduction of the MP joint of the thumb, which occurs when the thumb is held by the ski pole while the rest of the hand hits the ground or enters the snow. In severe injuries, the head of the metacarpal has an avulsion fracture.
Falls on the Outstretched Hand In falls on the outstretched hand, forces are transmitted from the scaphoid to the distal end of the radius, from the radius across the interosseous membrane to the ulna, and from the ulna to the humerus; through the glenoid fossa of the scapula to the coracoclavicular ligament and the clavicle; and finally, to the sternum.
Falls on the Outstretched Hand
If the forces are excessive, different parts of the upper limb give way under the strain. The area affected seems to be related to age. In a young child, for example, there may be a posterior displacement of the distal radial epiphysis; in the teenager the clavicle might fracture; in the young adult the scaphoid is commonly fractured; and in the elderly the distal end of the radius is fractured about 1 in. (2.5 cm) proximal to the wrist joint (Colles' fracture)
Applied anatomy of Joints of Lower Limb
Hip Joint Knee Joint Tibiofibular Joints Ankle Joint Joints of Foot
Applied anatomy of Hip joint
Dislocation of hip joint It can be of two types
1 Congenital dislocation 2 Acquired dislocation According to the direction of dislocation 1 Posterior dislocation - Commonest 2 Anterior dislocation 3 Central dislocation
Dislocation of Hip Joint acquired dislocation of hip acquired dislocation of hip joint –
Uncommon
– dislocation may occur during an automobile accident when the hip is flexed, adducted, and medially rotated, the usual position of the lower limb when a person is riding in a car. – Posterior dislocations are most common. – The fibrous layer of the joint capsule ruptures inferiorly and posteriorly, allowing the femoral head to pass through the tear in the capsule and over the posterior margin of the acetabulum onto the lateral surface of the ilium, – shortening and medially rotating the affected limb
congenital dislocation of hip joint
– common it affects more girls – bilateral in approximately half the cases. – Dislocation occurs when the femoral head is not properly located in the acetabulum. – The affected limb appears (and functions as if) shorter because the dislocated femoral head is more superior than on the normal side, resulting in a positive (hip appears to drop to one side during walking). – Inability to abduct the thigh is characteristic of congenital dislocation
Congenital dislocation of hip joint
AQUIRED DISLOCATION Dislocation occurring after the 1st year of life is usually due to one of the 3 cause -Pyogenic arthritis. -Muscle imbalance -Trauma Rare causes are -Tuberculosis -Charcot’s disease.
Poster dislocation Anterior dislocation
Posterior dislocation
.
Most common verity. usually occurs in a road accident, when someone is seated in a trunk or car is thrown forward & striking against the dashboard. Here the femur is thrust upwards and femoral head is forced out of it’s socket.
Here the leg is short and lies adducted, internally rotated and slightly flexed. the capsule ruptures inferiorly and posteriorly allowing the femoral head to pass through the tear in the capsule and over the posterior margin of the acetabulum.
ANTERIOR DISLOCATION
Rare Usual cause is a road accident or air crash .Dislocation of one or even both hips may occur when a weight falls on to the back of a person , with his legs wide apart , knees straight and back bent forwards. Here the leg lies externally rotated , abducted and slightly flexed. It is not short because the attachment of rectus femoris prevent the head from dislocation upwards. The prominent head is easy to feel.
CENTRAL DISLOCATION
A fall on the side or a blow over the greater trochanter may thrust the femoral head into the floor of the acetabulum and fracture of
the plevis. In this case trochanter and hip region are tender. Little movements are possible.
On X-ray The femoral head is displaced medically and the acetabular floor is fractured.
. Tuberculosis of hip The hip is one of the joints most frequently affected by tuberculosis. The patient may have a history of active pulmonary tuberculosis. Acute Suppurative arthritis This condition is more common in children. It is often secondary to osteomyelitis of the upper end of femur.
Rheumatoid arthritis
Hip joint is not affected usually in case of RA. But when they are affected the consequent disability is serious. Osteoarthritis It is a common cause of severe disablement especially in elderly. It also affect young persons, when there has been previous damage from injury or disease. The irritable hip Transient hip pain and restriction of movement in an otherwise healthy child. It is the commonest cause of hip pain in children. Boys are commonly affected. (age group -6-12 yrs of age) Presents with pain and a limp often intermittent & following activity and extremes of all movements are limited
OVERVIEW OF LIGAMENTS
Knee Joint Injuries
Hyperextension and severe force directed anteriorly against the femur with the knee semiflexed (a cross-body block in football) may tear the ACL. ACL ruptures are also common knee injuries in skiing accidents. This injury causes the free tibia to slide anteriorly under the fixed femur, known as anterior drawer sign , tested clinically via the lachman test The ACL may tear away from the femur or tibia; however, tears commonly occur in the midportion of the ligament.
Although strong, PCL ruptures may occur when a player lands on the tibial tuberosity with the knee flexed ( when knocked to the floor in basketball). PCL ruptures usually occur in conjunction with tibial or fibular ligament tears. These injuries can also occur in head-on collisions when seat belts are not worn and the proximal end of the tibia strikes the dashboard. PCL ruptures allow the free tibia to slide posteriorly under the fixed femur ,known as the posterior drawer sign
ANTERIOR CRUCIATE LIGAMENT INJURY
OVERVIEW OF INJURY
POSTERIOR CRUCIATE LIGAMENT
ILLUSTRATION
Meniscal tears
Meniscal tears usually involve the medial meniscus. The lateral meniscus does not usually tear because of its mobility. Pain on lateral rotation of the tibia on the femur indicates injury of the lateral meniscus , whereas pain on medial rotation of the tibia on the femur indicates injury of the medial meniscus Most meniscal tears occur in conjunction with TCL or ACL tears. Peripheral meniscal tears can often be repaired or may heal on their own because of the generous blood supply to this area. Meniscal tears that do not heal or cannot be repaired are usually removed (e.g., by arthroscopic surgery). Knee joints from which the menisci have been removed suffer no loss of mobility; however, the knee may be less stable and the tibial plateaus often undergo inflammatory reactions.
oVERVIEW OF MENISCI
MENISCUS DEGENERATION
BUCKET HANDLE TEAR
LATERAL MENISCUS INJURY
OVERVIEW OF COLLATERAL LIGAMENTS
ligament sprains The most common knee injuries in contact sports are ligament sprains , which occur when the foot is fixed in the ground . If a force is applied against the knee when the foot cannot move, ligament injuries are likely to occur. The tibial and fibular collateral ligaments (TCL and FCL) are tightly stretched when the leg is extended, normally preventing disruption of the sides of the knee joint. The firm attachment of the TCL to the medial meniscus is of considerable clinical significance because tearing of this ligament frequently results in concomitant tearing of the medial meniscus.
“unhappy triad
The injury is frequently caused by a blow to the lateral side of the extended knee or excessive lateral twisting of the flexed knee that disrupts the TCL and concomitantly tears and/or detaches the medial meniscus from the joint capsule. This injury is common in athletes who twist their flexed knees while running in basketball, the various forms of football, and volleyball). The ACL, which serves as a pivot for rotatory movements of the knee and is taut during flexion, may also tear subsequent to the rupture of the TCL, creating an “unhappy triad” of knee injuries.
Coxa Vara and Coxa Valga The angle of inclination varies with age, sex, and development of the femur (e.g., consequent to a congenital defect in ossification of the femoral neck). It also may change with any pathological process that weakens the neck of the femur (e.g., rickets). When the angle of inclination is decreased, the condition is Coxa vara, when it is increased, the condition is . Coxa valga causes a mild passive abduction of the hip.
Coxa Vara and Coxa Valga
Patellar Dislocation
When the patella is dislocated, it nearly always dislocates laterally. Patellar dislocation is more common in women, presumably because of their greater P.662 Q-angle, which, in addition to representing the oblique placement of the femur relative to the tibia, represents the angle of pull of the quadriceps relative to the axis of the patella and tibia (the term Qangle was actually coined in reference to the angle of pull of the quadriceps). The tendency toward lateral dislocation is normally counterbalanced by the medial, more horizontal pull of the powerful vastus medialis. In addition, the more anterior projection of the lateral femoral condyle and deeper slope for the larger lateral patellar facet provide a mechanical deterrent to lateral dislocation. An imbalance of the lateral pull and the mechanisms resisting it result in abnormal tracking of the patella within the patellar groove and chronic patellar pain, even if actual dislocation does not occur
Bursitis in the Knee Region
Prepatellar brusitis is usually a friction bursitis caused by friction between the skin and the patella. If the inflammation is chronic, the bursa becomes distended with fluid and forms a swelling anterior to the knee results from excessive friction between the skin and the tibial tuberosity; the edema occurs over the proximal end of the tibia. results in edema between the patellar ligament and the tibia, superior to the tibial tuberosity. The suprapatellar bursa communicates with the articular cavity of the knee joint; consequently, abrasions or penetrating wounds (e.g., a stab wound) superior to the patella may result in caused by bacteria entering the bursa from the torn skin. The infection may spread to the knee joint.
Popliteal Cysts
Popliteal Cysts (Baker cysts) are abnormal fluid filled sacs of synovial membrane in the region of the popliteal fossa. A popliteal cyst is almost always a complication of chronic knee joint effusion. The cyst may be a herniation of the gastrocnemius or semimembranosus bursa through the fibrous layer of the joint capsule into the popliteal fossa, communicating with the synovial cavity of the knee joint by a narrow stalk . Synovial fluid may also escape from the knee joint synovial effusion or a bursa around the knee and collect in the popliteal fossa. Here it forms a new synovial-lined sac, or popliteal cyst. Popliteal cysts are common in children but seldom cause symptoms. In adults, popliteal cysts can be large, extending as far as the midcalf, and may interfere with knee movements.
Ankle Injuries
The ankle is the most frequently injured major joint in the body. Ankle sprains (torn fibers of ligaments) are most common. A sprained ankle is nearly always an inversion injury , involving twisting of the weight-bearing plantarflexed foot. The person steps on an uneven surface and the foot is forcibly inverted Lateral ligament sprains . occur in sports in which running and jumping are common, particularly basketball
The lateral ligament is injured because it is much weaker than the medial ligament and is the ligament that resists inversion at the talocrural joint. The anterior talofibular ligament —part of the lateral ligament—is most vulnerable and most commonly torn during ankle sprains, either partially or completely, resulting in instability of the ankle joint . The calcaneofibular ligament may also be torn. In severe sprains, the lateral malleolus of the fibula may be fractured. Shearing injuries fracture the lateral malleolus at or superior to the ankle joint. Avulsion fractures break the malleolus inferior to the ankle joint; a fragment of bone is pulled off by the attached ligaments).
A occurs when the foot is forcibly everted . This action pulls on the extremely strong medial ligament, often tearing off the medial malleolus. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus, producing a “trimalleolar fracture.” In applying this term to this injury, the entire distal end of the tibia is erroneously considered to be a “malleolus.”
Pott fracture, dislocation of ankle joint
A Pott
fracturedislocation of the ankle
occurs when the foot is forcibly averted. This action pulls on the extremely strong medial ligament, often tearing off the medial malleolus. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus.
Pes Planus (Flatfeet)
The flat appearance of the foot before age 3 is normal and results from the thick subcutaneous fat pad in the sole. As children get older, the fat is lost, and a normal medial longitudinal arch becomes visible . Flatfeet can either be flexible ( (flat, lacking a medial arch, when weight-bearing but normal in appearance when not bearing weight or rigid (flat even when not bearing weight). The more common flexible flatfeet result from loose or degenerated intrinsic ligaments (inadequate passive arch support). Flexible flatfoot is common in childhood but usually resolves with age as the ligaments grow and mature.
The condition occasionally persists into adulthood and may or may not be symptomatic. with Rigid flatfeet a history that goes back to childhood are likely to result from a bone deformity (such as a fusion of adjacent tarsal bones). Rigid flatfeet (“fallen arches”) are likely to be secondary to dysfunction of the tibialis posterior (dynamic arch support) owing to trauma, degeneration with age, or denervation. In the absence of normal passive or dynamic support, the plantar calcaneonavicular ligament fails to support the head of the talus. Consequently, the head of the talus displaces inferomedially and becomes prominent . As a result, some flattening of the
medial
part of the longitudinal arch occurs, along with lateral deviation of the forefoot.
Flatfeet
are common in older people, particularly if they undertake much unaccustomed standing or gain weight rapidly, adding stress on the muscles and increasing the strain on the ligaments supporting the arches.
Claw Toes Claw Toes are characterized by hyperextension of the metatarsophalangeal joints and flexion of the distal interphalangeal joints. Usually, the lateral four toes are involved. Callosities develop on the dorsal surfaces of the toes because of pressure of the shoe. They may also form on the plantar surfaces of the metatarsal heads and the toe tips because they bear extra weight when claw toes are present.
) Clubfoot (Talipes equinovarus
Clubfoot (Talipes equinovarus) refers to a foot that is twisted out of position. Of the several types, all are congenital (present at birth). Talipes equinovarus, (present at birth). , the common type (2 per 1000 live births), involves the subtalar joint; boys are affected twice as often as girls. The foot is inverted, the ankle is plantar flexed, and the forefoot is adducted (turned toward the midline in an abnormal manner) . The foot assumes the position of a horse's hoof, hence the prefix “equino” (equinus horse). In half of those affected, both feet are malformed. A person with an uncorrected clubfoot cannot put the heel and sole flat and must bear the weight on the lateral surface of the forefoot. Consequently, walking is painful. The main abnormality is shortness and tightness of the muscles, tendons, ligaments, and joint capsules on the medial side and posterior aspect of the foot and ankle.
Hammer Toe
Hammer Toe is a foot deformity in which the proximal phalanx is permanently and markedly dorsiflexed (hyperextended) at the metatarsophalangeal joint and the middle phalanx strongly plantar flexed at the proximal interphalangeal joint. The distal phalanx of the digit is often also hyperextended. This gives the digit (usually the 2nd) a hammer-like appearance. This deformity of one or more toes may result from weakness of the lumbrical and interosseous muscles, which flex the metatarsophalangeal joints and extend the interphalangeal joints. A callosity or callus , hard thickening of the keratin layer of the skin, often develops where the dorsal surface of the toe repeatedly rubs on the shoe.
Hallux Valgus
Hallux valgus is a foot deformity caused by pressure from
footwear and degenerative joint disease; it is characterized by lateral deviation of the great toe . The in valgus indicates In some people, the painful deviation is so large that the great toe overlaps the 2nd toe , and there is a decrease in the medial longitudinal arch. Such deviation occurs especially in females, and its frequency increases with age. These individuals cannot move their 1st digit away from their 2nd digit because the sesamoids under the head of the 1st metatarsal are usually displaced and lie in the space between the heads of the 1st and 2nd metatarsals. The 1st metatarsal shifts medially and the sesamoids shift laterally. Often the surrounding tissues swell and the resultant pressure and friction against the shoe cause a subcutaneous bursa to form; when tender and inflamed.
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