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Download PDF File Folia Morphol. Vol. 70, No. 2, pp. 61–67 Copyright © 2011 Via Medica R E V I E W A R T I C L E ISSN 0015–5659 www.fm.viamedica.pl Human ligaments classification: a new proposal G.K. Paraskevas Department of Anatomy, Medical School, Aristotle University of Thessaloniki, Greece [Received 24 January 2011; Accepted 22 March 2011] A high concern exists among physicians about surgically important ligaments such as cruciate and collateral ligaments of the knee, patellar ligament, tibiofibular syndesmosis, collateral ligaments of the ankle, and coracoclavicular ligament. However, the classification of the ligaments is insufficient in the literature, due to their origin from connective tissue. A new classification is proposed, based on various parameters such as the macroscopic and microscopic features, the function and the nature of their attachment areas. (Folia Morphol 2011; 70, 2: 61–67) Key words: ligaments, classification, Nomina Anatomica INTRODUCTION connective tissue surrounding neurovascular bundles There was always some confusion concerning the or ducts as “true ligaments” [4]. classification of ligaments of the human body, presu- The “false ligaments”, could be subdivided in the mably due to their origin from the connective tissue following categories: that is considered a low quality tissue compared to oth- a) Splachnic ligaments, which are further subdivid- ers. Moreover, orthopaedists are focused only on surgi- ed into “peritoneal” (e.g. phrenocolic ligament), cally important ligaments. For these reasons there is an “pericardiac” (e.g. sternopericardial ligaments), absence of a well-designated classification system that “pleural” (e.g. suprapleural membrane), and subdivides the ligaments into subgroups according to “pure splachnic ligaments” (e.g. hyoglossus various parameters such as their relation to the joint membrane and phrenoesophageal ligament). capsule, their morphology, histological structure, and b) Neuronic ligaments that interconnect either sym- the nature of the original anatomical structure. metrical areas of the two halves of the central nervous system and consist of nerve fibres and DISCUSSION bodies of neurons (e.g. corpus callosum, fornix, In gross anatomy a ligament is considered an ana- anterior and posterior cerebral commissure, and tomical structure interconnecting two anatomical ele- white and grey commissure of spinal cord), which ments. We believe that the ligaments should be sub- represent thickenings of the dura mater of the divided into true and false ligaments. True ligaments spinal cord contributing to its support (e.g. den- should be defined as those which are found in the tate and coccygeal ligament). structures of the musculoskeletal system and they c) Cutaneous ligaments that are skin folds (e.g. an- should be named “motor or articular ligaments”, while terior and posterior commissure of large labia of false ligaments should be defined as those found apart the pudendum). from the musculoskeletal system. Pansky named the d) Arterial ligaments that form after transformation peritoneal folds “false ligaments” [8], while Healey et of embryonic vessels into connective tissue (e.g. al. depicted the peritoneal reflections as “false liga- ligament of Botallo, lateral umbilical ligaments, ments” and certain thickenings of the subperitoneal teres ligament of the liver). Address for correspondence: Dr. G.K. Paraskevas, MD, PhD, Assist. Professor of Anatomy, Department of Anatomy, Medical School of Aristotle University of Thessaloniki, P.O. Box: 300, Postal Code: 54124, Thessaloniki, Greece, tel: +302310 999330, e-mail: [email protected] 61 Folia Morphol., 2011, Vol. 70, No. 2 Ligaments passing over joints or located adja- 2) Intracapsular ligaments. In our opinion, these cent to them are called “motor or articular liga- ligaments are divided into the following sub- ments”. It is difficult to determine the total num- categories: ber of “motor ligaments”, because of the incon- a) Intracapsular extra-articular ligaments. These li- stant existence of most of them (e.g. the intra-ar- gaments line the inner surface of the fibrous cap- ticular sternocostal ligaments are usually located sule without extending into the articular space. at the second sternocostal joint, the costotransverse This group includes the three glenohumeral li- ligaments of the eleventh and twelfth ribs are ru- gaments (superior, middle, inferior), which be- dimentary, while the oblique chord may be dupli- come most prominent when viewed from inside. cated or even absent). Furthermore, there are nu- b) Intracapsular intra-articular ligaments. These li- merous bundles of connective tissue (ligaments) not gaments are located within the articular cavity listed in Nomina Anatomica [19]. We consider that and are classified as follows: i) Totally intra-ar- it is more convenient to record the total number of ticular ligaments, totally surrounded by the ar- motor ligaments which are found in Nomina Ana- ticular synovial membrane. This group includes tomica, and their number was estimated at approxi- the round ligament of the femoral head, the mately 745. intra-articular ligaments of the head of the ribs, In classic anatomical textbooks, the “motor liga- and the intra-articular sternocostal ligaments. ments“ are classified as: ii) Partial intra-articular ligaments, surrounded A) Accessory ligaments. These ligaments are local partially by articular synovial membrane, such thickenings of the fibrous capsule and contri- as the cruciate ligaments. bute to the articular surface restraining. These li- B) Interosseous ligaments. These are short and gaments are flexible enough to allow normal joint strong ligaments, covering the narrow spaces movement. Simultaneously, these ligaments are formed between the opposite surfaces of adjacent inflexible and they can be ruptured in extreme bones, thus greatly reducing their mobility. These distension. In our opinion, the “accessory liga- ligaments are located in synovial joints (wrist and ments” may be further subdivided into extracap- tarsal joints), synarthroses (inferior tibiofibular syn- sular and intracapsular. desmosis, interosseal membranes of the forearm 1) Extracapsular ligaments. There are two groups: and tibia), and amphiarthroses (sacroiliac joint). a) Periarticular or distal extracapsular ligaments. C) Independent ligaments. These ligaments, may These ligaments are cylindrical or strip-like be subdivided into the following two categories: thickenings of the fibrous capsule that in 1) Motor ligaments not participating in joint some way have been detached from the cap- function. These ligaments belong mainly to sule, migrating into adjacent areas (e.g. co- the periarticular ligaments (e.g. lumbocostal racohumeral ligament). ligaments), the interosseous ligaments (e.g. b) Proximal extracapsular ligaments. These li- interspinal ligaments), and the syndesmoses gaments are usually band-like thicknesses of (e.g. interosseous membrane of forearm). The the fibrous capsule, which are distinct from most prominent feature of these ligaments the fibrous capsule and are attached in close is that they do not participate, or participate proximity to sites of capsule attachment (e.g. to a lesser extent, in the movements of the medial collateral ligament of the knee). Ro- neighbouring joint. The term “independent gers subdivided the extracapsular ligaments ligament” is used with respect to the joint into extrinsic ligaments that are not in con- capsule, not the joint function [3, 11]. tact with the joint capsule and intrinsic liga- 2) Ligaments forming fibro-osseal foramina or ments that are in contact with the capsule obstructing foramina. These ligaments are and are capsular thickenings [11]. In the 7th subdivided into two categories: edition of Nomina Anatomica the ligaments a) Proper ligaments that connect two different are classified as: “Extracapsular ligaments” areas of the same bone (usually bridge bony which are far apart from the capsule, “cap- notches). This category includes the thyroid sular ligaments” that are thickenings of the membrane, the inguinal ligament, the ilio- fibrous capsule, and “intracapsular liga- pectineal ligament, the superior and inferior ments” that are found interior to the joint transverse ligaments of the scapula, the trans- capsule [19]. verse ligament of the acetabulum, the trans- 62 G.K. Paraskevas, Human ligaments classification verse humeral ligament, the transverse liga- The distinction between ment of the atlas, and the pterygospinous liga- ligaments and membranes ment. It is possible for a “proper ligament” There is a great deal of confusion in anatomical to participate in the formation and function literature regarding the determination of an ana- of a synovial joint, like the transverse ligament tomical structure either as a ligament or as a mem- of the atlas and the acetabulum. brane. The following report of the famous Cana- b) Ligaments interconnecting two or more bones. dian anatomist J. Grant is characteristic “…this struc- These ligaments are extended between two ture is a membrane, called cricothyroid ligament” or more bones, bridging various bony notch- [1]. Searching for the “motor membranes”, refer- es, thus transforming them into foramina or ring to the last edition of Nomina Anatomica [19], canals containing vessels and nerves. Exam- we estimated there to be 34 in number. The follow- ples of this category include the transverse liga- ing criteria have been established in the present work ment of the wrist joint, the ischiospinal and in order
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