Bones of the leg and foot pdf - Lower limb

470

CHAPTER 10

The Lower Limb

normal

positive Trendelenburg's sign

FIGURE 10.34

Trendelenburg’s test.

(i.e., a bone that develops within the tendon of the

The patella (Fig. 10.35) is the largest sesamoid bone

and the ankle joint.

The leg is the part of the lower limb between the knee joint

Bones of the Leg

Patella

quadriceps femoris muscle in front of the knee joint). It is

(Fig. 10.35).

intercondylar eminence

these areas is the

lying between

posterior intercondylar areas;

anterior

ing the upper articular surfaces of the tibial condyles are

intervening. Separat

medial menisci

lateral

articulate with the lateral and medial condyles of the femur

), which

tibial plateaus

(sometimes called lateral and medial

medial condyles

and

lateral

At the upper end are the

expanded upper end, a smaller lower end, and a shaft.

the talus and the distal end of the fibula below. It has an

of the femur and the head of the fibula above and with

leg (Figs. 10.35 and 10.37). It articulates with the condyles

The tibia is the large weight-bearing medial bone of the

Tibia

dyle of the femur.

the vastus medialis and by the large size of the lateral con

of the quadriceps muscle by the lower horizontal fibers of

prevented from being displaced laterally during the action

to the different parts of the quadriceps femoris muscle. It is

The upper, lateral, and medial margins give attachment

cutaneous bursa (Fig. 10.36).

the skin. It is separated from the skin by an important sub

front of the knee joint and can easily be palpated through

femur. The patella is situated in an exposed position in

The posterior surface articulates with the condyles of the

to the tuberosity of the tibia by the ligamentum patellae.

triangular, and its apex lies inferiorly; the apex is connected

and the

and

capsule of knee joint

iliotibial tract

lateral condyle

lateral collateral ligament

head of fibula

biceps femoris

extensor digitorum longus

anterior border

anterior surface

interosseous border

peroneus tertius

peroneus brevis

lateral malleolus

lateral ligament

capsule of ankle joint

medial malleolus

interosseous border

medial surface

anterior border

tibialis anterior

semitendinosus

gracilis

sartorius

tuberosity of tibia

ligamentum patellae

medial collateral ligament

semimembranosus

intercondylar eminence

peroneus longus

extensor hallucis longus

lateral surface

medial ligament of ankle joint

ligamentum patellae

quadriceps femoris

FIGURE 10.35

aces of the right tibia and fibula. Attachments to the patella

Muscles and ligaments attached to the anterior surf

are also shown.

Basic Anatomy

471

articularis genus

quadriceps femoris

suprapatellar bursa

prepatellar bursa

patella

lateral
collateral
ligament

pad of fat

deep infrapatellar bursa

superficial infrapatellar bursa

lateral meniscus

tibia

fibula

popliteus

lateral collateral ligament

capsule

synovial membrane

femur

posterior cruciate ligament

medial collateral ligament

medial meniscus

lateral meniscus

oblique popliteal ligament

insertion of
semimembranosus

capsule

lateral collateral
ligament

medial meniscus

popliteus muscle

lateral collateral
ligament

lateral meniscus

tendon of popliteus

posterior cruciate ligament

medial collateral ligament

ligamentum patellae

anterior cruciate ligament

FIGURE 10.36

fibula are shown in Figures 10.35 and 10.37.

The important muscles and ligaments attached to the

malleolar fossa

the articular facet is a depression called the

ulation with the lateral aspect of the talus. Below and behind

for artic

articular facet

the lateral malleolus is a triangular

malleolus, which is subcutaneous. On the medial surface of

forms the triangular lateral

lower end of the fibula

The

ous border gives attachment to the interosseous membrane.

has four borders and four surfaces. The medial or interosse

is long and slender. Typically, it

shaft of the fibula

The

with the lateral condyle of the tibia.

for articulation

articular surface

. It possesses an

process

styloid

is surmounted by a

head,

upper end,

The

expanded upper end, a shaft, and a lower end.

but it provides attachment for muscles. The fibula has an

joint. It takes no part in the transmission of body weight,

joint, but below it forms the lateral malleolus of the ankle

and 10.37). It takes no part in the articulation at the knee

The fibula is the slender lateral bone of the leg (Figs. 10.35

tibia are shown in Figures 10.35 and 10.37.

The important muscles and ligaments attached to the

surface for articulation with the fibula.

of the tibia shows a wide, rough depression on its lateral

medial malleolus articulates with the talus. The lower end

. The lateral surface of the

medial malleolus

ally to form the

for the talus. The lower end is prolonged downward medi

its inferior aspect shows a saddle-shaped articular surface

The lower end of the tibia is slightly expanded and on

muscle.

(Fig. 10.37), for the attachment of the soleus

soleal line

The posterior surface of the shaft shows an oblique line,

der gives attachment to the interosseous membrane.

with the medial malleolus. The lateral or interosseous bor

der becomes rounded below, where it becomes continuous

attachment of the ligamentum patellae. The anterior bor

which receives the

tuberosity,

upper end of the tibia is the

the shin. At the junction of the anterior border with the

subcutaneous. The anterior border is prominent and forms

medial borders, with the medial surface between them, are

senting three borders and three surfaces. Its anterior and

is triangular in cross section, pre

shaft of the tibia

The

the semimembranosus muscle (Fig. 10.37).

medial condyle has on its posterior aspect the insertion of

. The

circular articular facet for the head of the fibula

The lateral condyle possesses on its lateral aspect a small

The

The anterior aspect, with the joint flexed.

The right knee joint as seen from the lateral aspect. B.

C, D.

posterior aspect.

the

Fibula

472

CHAPTER 10

The Lower Limb

medial condyle

semimembranosus

popliteus

soleus

soleal line

vertical line

medial border

flexor digitorum longus

groove for tibialis
posterior tendon

medial malleolus

capsule of ankle joint

lateral malleolus

groove for peroneal
tendons

interosseous border

flexor hallucis longus

tibialis posterior

soleus

head of fibula

lateral condyle

capsule of knee joint

FIGURE 10.37

Muscles and ligaments attached to the poste

rior surfaces of the right tibia and the fibula.

Patellar Fractures

the fracture line is transverse. Separation of the fragments

femoral condyles. The knee is in the semiflexed position, and

the quadriceps snapping the patella across the front of the

of indirect violence is caused by the sudden contraction of

the fracture being open. Fracture of the patella as a result

relationship of the patella to the overlying skin may result in

don, little separation of the fragments takes place. The close

automobile accident, is broken into several small fragments.

A patella fractured as a result of direct violence, as in an

Because the bone lies within the quadriceps femoris ten-

usually occurs.

venous line. The procedure is easy and rapid to perform, as

The technique may be used for the infusion of fluids and

of forced abduction of the knee joint, the medial collateral

dyles in the region of the intercondylar eminence. As a result

be because the nutrient artery is torn at the fracture line, with

Fractures of the Tibia and Fibula

Fractures of the tibia and fibula are common. If only one bone

is fractured, the other acts as a splint and displacement is min-

imal. Fractures of the shaft of the tibia are often open because

the entire length of the medial surface is covered only by skin

and superficial fascia. Fractures of the distal third of the shaft

of the tibia are prone to delayed union or nonunion. This can

a consequent reduction in blood flow to the distal fragment;

it is also possible that the splintlike action of the intact fibula

prevents the proximal and distal fragments from coming into

apposition.

Fractures of the proximal end of the tibia, at the tibial

condyles (tibial plateau), are common in the middle-aged and

elderly; they usually result from direct violence to the lateral

side of the knee joint, as when a person is hit by the bumper of

an automobile. The tibial condyle may show a split fracture or

be broken up, or the fracture line may pass between both con-

ligament can also be torn or ruptured.

Fractures of the distal end of the tibia are considered with

the ankle joint (see page 506).

Intraosseous Infusion of the Tibia in the Infant

blood when it has been found impossible to obtain an intra-

follows:

With the distal leg adequately supported, the anterior sub-

cutaneous surface of the tibia is palpated.

The skin is anesthetized about 1 in. (2.5 cm) distal to the

tibial tuberosity, thus blocking the infrapatellar branch of

the saphenous nerve.

The bone marrow needle is directed at right angles

be directed slightly caudad to avoid injury to the epiphy

through the skin, superficial fascia, deep fascia, and tibial

periosteum and the cortex of the tibia. Once the needle

tip reaches the medulla and bone marrow, the operator

senses a feeling of “give.” The position of the needle in the

marrow can be confirmed by aspiration. The needle should

seal plate of the proximal end of the tibia. The transfusion

may then commence.

Patellar Dislocations

direct trauma to the quadriceps attachments of the patella

ral condyle. Traumatic dislocation of the patella results from

patella are caused by underdevelopment of the lateral femo

The patella is a sesamoid bone lying within the quadriceps

tendon. The importance of the lower horizontal fibers of the

vastus medialis and the large size of the lateral condyle of the

femur in preventing lateral displacement of the patella has

been emphasized. Congenital recurrent dislocations of the

(especially the vastus medialis), with or without fracture of the

patella.

C L I N I C A L N O T E S

(continued)

Basic Anatomy

tendon).

and gives attachment to the tendo calcaneus (Achilles

forms the prominence of the heel

posterior surface

The

facet that articulates with the cuboid bone.

is small and forms the articular

anterior surface

The

cuboid. It has six surfaces.

It articulates above with the talus and in front with the

the prominence of the heel (Figs. 10.38, 10.39, and 10.40).

The calcaneum is the largest bone of the foot and forms

ankle joint.

the talus articulates with the tibia and the fibula at the

ular, the cuboid, and the three cuneiform bones. Only

The tarsal bones are the calcaneum, the talus, the navic

Tarsal Bones

phalanges

metatarsals,

tarsal bones,

The bones of the foot are the

473

Bones of the Foot

the

and the

Calcaneum

■

for talus

posterior facets

for medial malleolus

talus

neck

body

head

for tibia

medial tubercle

anterior middle and

medial tubercle

groove for flexor hallucis longus

sustentaculum tali

medial aspect

anterior surface of calcaneum

sulcus calcanei

sulcus tali

tuberosity

navicular

articular surface for
calcaneonavicular ligament

for lateral malleolus

lateral tubercle

posterior articular surface for talus

sulcus calcanei

calcaneum

lateral tubercle

lateral aspect

peroneal tubercle

groove for peroneus longus tendon

cuboid

talus

for lower end of tibia

calcaneum

FIGURE 10.38

Calcaneum, talus, navicular, and cuboid bones.

474

CHAPTER 10

The Lower Limb

extensor digitorum longus tendons

extensor hallucis longus

insertions of dorsal interossei

extensor digitorum brevis
(extensor hallucis brevis)

second dorsal interosseous

first dorsal interosseous

first metatarsal bone

medial cuneiform

intermediate cuneiform

lateral cuneiform

navicular

talus

tendo calcaneus

calcaneum

extensor digitorum brevis

cuboid

peroneus brevis

peroneus tertius

fourth dorsal interosseous

third dorsal interosseous

FIGURE 10.39

Muscle attachments on the dorsal aspect of the bones of the right foot.

flexor digitorum longus tendons

flexor digiti minimi brevis
abductor digiti minimi

first plantar interosseous

second plantar interosseous

third plantar interosseous

flexor digiti minimi brevis

peroneus brevis

cuboid

abductor digiti minimi

calcaneum

abductor hallucis

quadratus plantae

talus

tibialis posterior

tuberosity of navicular

flexor hallucis brevis

tibialis posterior

tibialis anterior

first metatarsal bone

peroneus longus

adductor hallucis (oblique head)

flexor hallucis brevis

adductor hallucis

abductor hallucis

insertions of plantar interossei

flexor hallucis longus

flexor digitorum brevis tendons

flexor digitorum brevis

FIGURE 10.40

ar aspect of the bones of the right foot.

Muscle attachments on the plant

Basic Anatomy

head

each possesses a

resemble the metacarpals and phalanges of the hand, and

The metatarsal bones and phalanges (Figs. 10.39 and 10.40)

the tarsal bones.

at birth. By the fifth year, ossification is taking place in all

neum and the talus, and often for the cuboid, are present

ossify before birth. Centers of ossification for the calca

The tarsal bones, unlike those of the carpus, start to

foot (see page 510).

mation and maintenance of the transverse arch of the

bones. Their wedge shape contributes greatly to the for

ular bone and distally with the first three metatarsal

10.39 and 10.40) articulate proximally with the navic

The three small, wedge-shaped cuneiform bones (Figs.

Cuneiform Bones

oneus longus muscle.

(Figs. 10.38, 10.39, and 10.40) lodges the tendon of the per

on the inferior aspect of the cuboid bone

groove

A deep

alis posterior tendon.

malleolus; it gives attachment to the main part of the tibi

the foot 1 in. (2.5 cm) in front of and below the medial

and 10.40) can be seen and felt on the medial border of

of the navicular bone (Figs. 10.38, 10.39,

tuberosity

The

Navicular Bone

following important features noted.

The remaining tarsal bones should be identified and the

talus, but no muscles are attached to this bone.

Numerous important ligaments are attached to the

rated by a groove for the flexor hallucis longus tendon.

sepa

tubercles,

posterior surface is marked by two small

for articulation with the medial malleolus of the tibia. The

articular facet

medial surface has a small, comma-shaped

articulation with the lateral malleolus of the fibula. Its

for

articular facet

Its lateral surface presents a triangular

before backward and slightly concave from side to side.

articulates with the distal end of the tibia; it is convex from

of the talus is cuboidal. Its superior surface

body

The

ligament

interosseous talocalcaneal

which is occupied by the strong

sinus tarsi,

canei in the articulated foot form a tunnel, the

. The sulcus tali and the sulcus cal

sulcus tali

groove, the

attachment to ligaments, and its lower surface shows a deep

slightly narrowed. Its upper surface is roughened and gives

of the talus lies posterior to the head and is

neck

The

calcaneonavicular ligament in front.

face, where it rests on the sustentaculum tali behind and the

bone. This articular surface is continued on its inferior sur

convex articular surface for articulation with the navicular

of the talus is directed distally and has an oval

head

The

(Figs. 10.38 and 10.39).

the navicular bone. It possesses a head, a neck, and a body

and fibula, below with the calcaneum, and in front with

The talus articulates above at the ankle joint with the tibia

Talus

caneum are shown in Figures 10.39 and 10.40.

The important muscles and ligaments attached to the cal

muscles.

separates the tendons of the peroneus longus and brevis

which

peroneal tubercle,

is a small elevation called the

is almost flat. On its anterior part

lateral surface

The

port of the talus.

which assists in the sup

sustentaculum tali,

termed the

possesses a large, shelflike process,

medial surface

The

surfaces.

tubercle at the junction of the inferior and posterior

lateral

and a smaller

medial

the midline and a large

anterior tubercle

inferior surface

The

sulcus calcanei

ets for the talus, separated by a roughened groove, the

is dominated by two articular fac

superior surface

The

475

■

has an

■

Cuboid Bone

Metatarsal Bones and Phalanges

possesses only two.

Each toe has three phalanges except the big toe, which

brevis tendon.

of the foot. The tubercle gives attachment to the peroneus

base that can be easily palpated along the lateral border

on its

tubercle

has a prominent

fifth metatarsal

The

lucis brevis.

in the tendons of the flexor hal

sesamoid bones

and lateral

The head is grooved on its inferior aspect by the medial

an important role in supporting the weight of the body.

bone is large and strong and plays

first metatarsal

The

to the lateral side.

mally. The five metatarsals are numbered from the medial

proxi

distally, a shaft, and a base

Fractures of the Talus

height and becomes wider laterally. The posterior portion of the

the calcaneum, crushing it in such a way that it loses vertical

a height. The weight of the body drives the talus downward into

Compression fractures of the calcaneum result from falls from

although the two malleoli prevent displacement of the fragments.

is driven against the anterior edge of the distal end of the tibia.

Fractures occur at the neck or body of the talus. Neck fractures

occur during violent dorsiflexion of the ankle joint when the neck

The body of the talus can be fractured by jumping from a height,

Fractures of the Calcaneum

calcaneum above the insertion of the tendo calcaneus can be

C L I N I C A L N O T E S

(continued)