Book - An Atlas of Topographical Anatomy 19

From Embryology

XIX. Vertical section of an injected knee-joint; right foot, close to its inner edge

Fig. 1. Vertical section of an injected knee-joint; female, middle age. Fig. 2. Vertical section through the right foot, close to its inner edge, from the same body


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Braune W. An atlas of topographical anatomy after plane sections of frozen bodies. (1877) Trans. by Edward Bellamy. Philadelphia: Lindsay and Blakiston.

Plates: 1. Male - Sagittal body | 2. Female - Sagittal body | 3. Obliquely transverse head | 4. Transverse internal ear | 5. Transverse head | 6. Transverse neck | 7. Transverse neck and shoulders | 8. Transverse level first dorsal vertebra | 9. Transverse thorax level of third dorsal vertebra | 10. Transverse level aortic arch and fourth dorsal vertebra | 11. Transverse level of the bulbus aortae and sixth dorsal vertebra | 12. Transverse level of mitral valve and eighth dorsal vertebra | 13. Transverse level of heart apex and ninth dorsal vertebra | 14. Transverse liver stomach spleen at level of eleventh dorsal vertebra | 15. Transverse pancreas and kidneys at level of L1 vertebra | 16. Transverse through transverse colon at level of intervertebral space between L3 L4 vertebra | 17. Transverse pelvis at level of head of thigh bone | 18. Transverse male pelvis | 19. knee and right foot | 20. Transverse thigh | 21. Transverse left thigh | 22. Transverse lower left thigh and knee | 23. Transverse upper and middle left leg | 24. Transverse lower left leg | 25. Male - Frontal thorax | 26. Elbow-joint hand and third finger | 27. Transverse left arm | 28. Transverse left fore-arm | 29. Sagittal female pregnancy | 30. Sagittal female pregnancy | 31. Sagittal female at term
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Pages where the terms "Historic Textbook" and "Historic Embryology" appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms and interpretations may not reflect our current scientific understanding.     (More? Embryology History | Historic Embryology Papers)


IN order to demonstrate the shape of the cavity of the knee-joint and the extent of its capsule correctly, I injected water into the articulation with a Pravaz's needle under great pressure, and, having slightly flexed the joint, froze it. The limb was taken from a normal body (young female). The section passed tolerably nearly through the middle, and divided the extremity into two nearly equal halves, of which the right one was used for the plate, after the removal of the frozen water.


All the joints, not the hip and shoulder only, are subject to atmospheric pressure ; and, on account of the small quantity of synovia which they contain, can retain their normal position and not show free cavities, as one finds on opening a joint in a soft preparation. Accordingly the synovial cavity appears in the section of a normal joint as a narrow crevice:, which in the following section of a normal uninjected knee-joint is represented by a single black line.


If this joint be compared with the injected specimen, as represented in Plate XIX, one can understand the meaning of the black line which indicates the joint cavity. Further, the position of the patella is seen in normal and abnormal joints. Whilst in the normal condition of the joint the patella touches the femur with a small portion of its cartilaginous surface like a tangent, in the case of the distended synovial membrane it is completely lifted off it. The patella floats, supported by the fluid as a board on water, and must therefore yield under pressure of the finger until it reaches the femur, which lies behind it.


The capacity of the joint-cavity is well shown, whilst in the woodcut the synovial membrane of the extensor muscles appears as separated from it, since the wide aperture of communication which unites it with the bulging out of the capsule is not opened by the section ; and on the injected joint represented in Plate XIX no such separation is to be seen. The fluid injected has penetrated into all the portions and hollows of the joint, and has raised up the posterior wall of the capsule, so that the posterior portion of the condyle of the femur is brought into view.



Fig. 1. The ligamentum mucosum of the patella and the anterior crucial ligament lie in the plane of section.


It is well known that Bonnet was the first to apply the method of injection to the investigation of joints, and to prove thereby what position of the joint corresponded with the greatest distension of the synovial cavity. It appeared in all joints that it was the position of flexion that allowed of the greatest amount of fluid entering the articular cavity; and that, with strong pressure of injection, all joints, no matter what position they may have had beforehand, acquire the position of flexion and maintain it so long as the pressure is continued. It is natural to suppose also that in diseases of the joint, associated with effusion into the synovial cavity, the position of flexion which the patients involuntarily affect is brought about by the direct pressure of the fluid.


But against such a supposition the following points may be adduced, as can be well explained after consideration of this plate.



Longitudinal section of the frozen knee-joint of a full-grown man. . 4

1. Femur. 2. Tibia. 3. Patella. 4. Posterior crucial ligament divided. 5. Bursa mucosa. 6. Quadriceps extensor. 7. Ligamentum patellae. 8. Semi-membranosus. 9. Gastrocnemius.



The capacity of the joint-cavity also depends on the possibility of the separation of the patella which is developed in the extensor tendon from the surfaces of the condyles. This is, however, the case when the extensor tendon is relaxed, as in extension, or in only slight flexion of the joint ; in greater flexion the patella must be pressed against the condyles, by the tension of the quadriceps, thus causing a diminution of the capsular cavity. It will therefore be expected that in consequence of the extension of the synovial space upwards beneath the extensor tendon, a considerable quantity of fluid may be injected, and that a greater degree of flexion must directly diminish the amount. I therefore considered it necessary to undertake a repetition of Bonnet's researches with the greatest possible care, and that on entire bodies. The method I used was the following :


The subject was fresh and normal, and, after violently breaking down the rigor mortis of the lower extremities, was laid on its back on a horizontal table. The thigh hung down over the free edge, and during the investigation was fixed by means of a support under the heel by an assistant in the necessary position. A screw was driven into the upper third of the tibia, to the free extremity of which a flat piece of wood was fastened ; which served to fix a dial plate, provided with a graduated semicircle ; and it was so arranged that a plumbline fastened to the centre of the circle stood at zero in complete extension of the bone, and the amount of flexion could be immediately read off. No regard was taken of the rotation of the thigh during flexion. In order to prevent diffusion through the capsule, the fluid used for injection was a solution of common salt, contained in a graduated tube about sixty inches in length, to the inferior end of which was fastened a short piece of tubing of india rubber, carrying a strong Pravaz's needle. The tube was fixed in an oblique position by means of a movable support, so that the vertical line, indicating the difference in height of the point of introduction of the needle and of the level of the fluid, always remained the same ; by which means the pressure indicated by the constant height of the support was maintained. The apparatus thus formed a right-angled triangle whose hypothenuse was represented by the obliquely directed tube, the perpendicular by a portion of the support, and the base by a horizontal line running parallel to the table and extending from the point of introduction of the needle to the support. The point of introduction of the needle being as near as possible in the axis of rotation, it remained almost unaltered in flexion of the knee-joint ; consequently it was possible from the changing level of the water in the tube, to read off the diminution or the increase of the fluid in cubic centimetres. Of course, the support had to be constantly placed under the meniscus of the fluid, whilst the zero point of the tube was kept in an unaltered position relatively with the point of introduction of the needle. Thus, whilst the side of the triangle indicating the pressure was constant, the length of the hypothenuse and that of the other side varied, becoming larger on diminution of the volume of the synovial space, and smaller in the contrary condition.


By means of this method of investigation it was possible to determine the following points which Bonnet's proceeding could not afford. We could immediately ascertain the dependence of the capacity of the synovial cavity on the angle at which the bone was placed, since the pressure of the fluid in the walls of the capsule always remained one and the same, and these in the intact condition of the body and extremity presented their original relations to skin, fat, muscle, &c. Thus the grade of flexion, in which the synovial cavity reached the maximum of its capacity (described by Bonnet as the mid-position between flexion and extension), could be accurately recorded. Finally, the volume of the synovial space during the different positions of the bone could be measured by cubic centimetres. The following figures, which indicate each angle of flexion, will be easily understood after the preceding description. corresponds with complete extension, 10 would indicate that the thigh made an angle of 170 with the leg, &c.


The figures referring to the volume give the quantity of fluid in the capsule in each case, in cubic centimetres ; those referring to pressure, in centimetres.

Experiment 1. Body of a man, aet. 50; tolerably recent. Muscular development and nourishment good. The rigor mortis of the limb forcibly broken down. Pressure 19 centimetres.


Angle . 10 20 30 40 50 60 70 80 90 100

Volume . 312 328 332 331 330 326 316 303 283 265 255 c.c.

Experiment 2. Body quite recent. No rigor mortis. Pressure 23 centimetres.

Angle . 10 20 30 40 50 60 70 80 90 100 110

Volume . 114 128 137 141 141 140 135 125 112 99 76 75 c.c.

Experiment 3. The opposite knee of the same body. Pressure 34 centimetres.

Angle . 10 20 30 40 50 60 70 80 90 100 110

Volume . 83 95 104 111 110 109 107 93 91 83 66 54 c.c.

Experiment 4. Body of a man, set. 50; eight days dead, poorly nourished. Rigor mortis forcibly broken down. Pressure 14 centimetres.

Angle . 10 20 30 40 50 60 70 80 90

Volume . 143J 149J 154J 146i 139 136 118 102 88 78 c.c.

Experiment 5. Body of a muscular man, set. 36 ; rigor mortis broken down.

Angle . 10 20 30 40 50 60 70 80 90 100

Volume . 79 90 98 104 101 98 82 91 67 50 32 c.c.

Experiment 6. Well-nourished male, set. 30. Knee very rigid. Pressure 52 centimetres.

Angle ' . 10 20 30 40 50 60 70 80

Volume . 108J H2 125 125J 124 115 105 101 95 c.c.

The results which follow from these researches I may sum up in the following propositions :

1. That the knee-joint, in equal stages of flexion in different individuals, shows a very great difference in the capacity of its synovial membrane.

The difference of the pressure need not be taken into account, as, indeed, at the lowest pressure the volume of fluid in the joint was a maximum. It is the connection of the joint cavity with neighbouring synovial sacs which causes this phenomenon.

  • I have left the figures referring to the volumes in cubic centimetres and the pressures in centimetres, since, for any practical purpose for which this table may be available, the following equations will facilitate their reduction to English measure :

1 centimetre = -3937 inch = -4 inch nearly.

1 cubic centimetre = "061 cubic inch = '0352 fl. oz. nearly TR.


2. That the capacity of the sync-vial cavity reaches its maximum in a definite degree of flexion, and that the angle at which this happens is 25.

We learn from this that the statement of Bonnet, that the maximum capacity happens in the position of semi-flexion is incorrect, as we see that the position in which this condition exists is rather at the commencement of flexion .

But a second and not less interesting relation is evident from the preceding experiments. It is that the increase of capacity is the greatest from extreme extension to 10 of flexion, less from 10 20, and still less from 20 30. An important practical fact follows from this, that a slight degree of flexion, such as 10, determines the relatively greatest increase of capacity of the capsule.


If the joint be in the position attained, when filled with fluid to its greatest extent, it may be forcibly extended without fear of rupture of the capsule ; and here, again, my results differ from those of Bonnet.


3. The minimum of the capacity of the synovial cavity coincides with the maximum of flexion. Hence, the idea expressed by Bonnet on the method of treating penetrating wounds of joints is disproved that the extension is the position in which the capacity of the capsule diminishes. Although in extension, as sections of frozen tnee-joints show, the joint surfaces are closely approximated by means of the tensely stretched lateral ligaments, the spaciousness of the capsule in this position is, nevertheless, very considerable ; and it is larger in seraiflexion than in complete. If the knee be forcibly flexed, and if the joint be now entirely filled with fluid, there ensues a degree of flexion by which the wall of the capsule is ruptured and the fluid escapes into the cellular tissue.


Moreover the clinical relations throw considerable doubt upon the correctness of Bonnet's theory of the mechanism of the knee-joint. In such cases as acute arthro-synovitis, the ligamentous structures specially suffer, and disease is distinguished by copious effusion into the articulation. We frequently find complete extension of the knee-joint throughout the course of the disease an observation which I have repeatedly made, and which is corroborated by Volkmann (' Krankheiten der Bewegungsorgane,' 1865, p. 195). Again, effusion of blood into the joint in an extended position of the extremity exhibits symptoms compatible with this.


Figure 2. This section of a normal right foot is from the same body. The section runs near the inner border of the foot, and divides in succession the tibia, astragalus, scaphoid, internal cuneiform and first metatarsal bones, and the first phalanx of the great toe. The saw has missed the second phalanx, as the toe was somewhat bent outwards.


The section passes nearer the inner border of the foot than that represented by Weber (' Gehwerkzeuge,' tab. xi), Volz ('Beitrag zur Chirurg Anat.,' tab. x), Henle (* Gelenke,' figs. 136, 137). It was only just possible to avoid the cuboid and third cuneiform bones which project inwards so much that they would have been divided by any section passing further outwards, and made the relations of the plate more complicated. The bones of the foot are not placed so that they simply form an arch from before backwards, but there is also one in a transverse direction.


It can be easily proved by measurement, that from the pressure exerted by the weight of the body, in the upright position, the curves of the skeleton of the foot are flattened in both directions, and that the foot is not only lengthened but broadened.


It is clearly seen from the plate, that the astragalus which has been divided exactly at the attachment of the interosseous ligament, is set as the keystone of the arch. It is wedged in between the scaphoid and os calcis, is pressed against them both, and thus prevents their approach.


The ligaments correspond with the structure of the arch, which the several bones of the foot form. They are proportionally weaker on the convex dorsum, where they hold the separate bones in position during pressure on the arch; and extraordinarily strong on the plantar aspect, where their function is to act as a tie beam, and prevent separation of the bones : and it is not the form of the bones alone that renders the arch secure, since they would fall apart were it not for the immensely strong ligamentous arrangement of the sole of the foot, strengthened by the plantar fascia.


There is no necessity for mentioning the individual parts. The accurate drawing itself sufficiently explains the soft parts. Some notice must be taken of the pad of fat which is so largely developed at the point of greatest pressure on the sole, and which diminishes and distributes as much as possible this pressure over different points. Over the heel and in the region of the ball of the great toe it is half an inch thick ; thus affording a soft support, which partially equalises the irregularities of the ground.


Fig.I.



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Pages where the terms "Historic Textbook" and "Historic Embryology" appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms and interpretations may not reflect our current scientific understanding.     (More? Embryology History | Historic Embryology Papers)
Braune Plates (1877): 1. Male - Sagittal body | 2. Female - Sagittal body | 3. Obliquely transverse head | 4. Transverse internal ear | 5. Transverse head | 6. Transverse neck | 7. Transverse neck and shoulders | 8. Transverse level first dorsal vertebra | 9. Transverse thorax level of third dorsal vertebra | 10. Transverse level aortic arch and fourth dorsal vertebra | 11. Transverse level of the bulbus aortae and sixth dorsal vertebra | 12. Transverse level of mitral valve and eighth dorsal vertebra | 13. Transverse level of heart apex and ninth dorsal vertebra | 14. Transverse liver stomach spleen at level of eleventh dorsal vertebra | 15. Transverse pancreas and kidneys at level of L1 vertebra | 16. Transverse through transverse colon at level of intervertebral space between L3 L4 vertebra | 17. Transverse pelvis at level of head of thigh bone | 18. Transverse male pelvis | 19. knee and right foot | 20. Transverse thigh | 21. Transverse left thigh | 22. Transverse lower left thigh and knee | 23. Transverse upper and middle left leg | 24. Transverse lower left leg | 25. Male - Frontal thorax | 26. Elbow-joint hand and third finger | 27. Transverse left arm | 28. Transverse left fore-arm | 29. Sagittal female pregnancy | 30. Sagittal female pregnancy | 31. Sagittal female at term

Reference

Braune W. An atlas of topographical anatomy after plane sections of frozen bodies. (1877) Trans. by Edward Bellamy. Philadelphia: Lindsay and Blakiston.


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Cite this page: Hill, M.A. (2019, September 17) Embryology Book - An Atlas of Topographical Anatomy 19. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_An_Atlas_of_Topographical_Anatomy_19

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