Bones & Joints of the Lower Limb

Kaan Yücel M.D., Ph.D 16.November.2012 Friday

The Dance Hall by Vincent van Gogh ,1888

2 functional components: Pelvic girdle & bones of the free lower limb

Body weight is transferred Vertebral column (Sacroiliac joints)

Pelvic girdle (Hip joints)

Femurs (L. femora)

Skeleton of the lower limb (inferior appendicular skeleton)

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longest and heaviest bone

Transmits body weight from the hip bone to the tibia.

FEMUR

Shaft (Body)

Superior / Proximal end

Inferior/ Distal end

Superior (proximal) end of the femur Proximal end of femur

HeadNeck 2 trochanters

Greater & Lesser

intertrochanteric lineintertrochanteric crest quadrate tuberclefovea capitis for lig.teres

Superior (proximal) end of the femur Shaft of femur

Gluteal tuberosityLinea asperaMedial and lateral lips of linea asperaMedial and lateral supracondylar linesPectineal line

Superior (proximal) end of the femur Distal end of femur

Adductor tubercleIntercondylar fossaMedial and lateral condylesMedial and lateral epicondylesMedial and lateral femoral condylesPatellar surface

Located on the anteromedial side of the legSecond largest bone in the body Flares outward at both ends to provide an increased area for articulation and

weight transfer.

TIBIA

Proximal end of tibiawidens to form medial & lateral condyles (1,2) flat superior articular surface tibial plateau (3)articular surfaces separated by intercondylar eminence (4) formed by 2 intercondylar tuberclesmedial and lateral (5,6)flanked by relatively rough anterior and posterior intercondylar areas (7,8)

Anterolateral view of left tibia

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Shaft of tibia

medial malleolus

Interosseous membrane unites the two leg bones.

Inferiorly, the sharp border is replaced by fibular notch.

Distal end of tibia

Largest sesamoid bone (a bone formed within the tendon of a muscle) in the body and is formed within the tendon of the quadriceps femoris muscle as it crosses anterior to the knee joint to insert on the tibia. The patella is triangular:

Apex is pointed inferiorly for attachment to the patellar ligament, which connects the patella to the tibia.Base is broad and thick for the attachment of the quadriceps femoris muscle from above.Posterior surface articulates with the femur and has medial and lateral facets, lateral facet is larger than the medial facet for articulation with the larger corresponding surface on the lateral condyle of the femur.

PATELLA (Knee cap)

Slender, lies posterolateral to the tibia No function in weight-bearing.Serves mainly for muscle attachment

FIBULA

Head (& a pointed apex) Articulates with the fibular facet on the posterolateral, inferior aspect of the lateral tibial condyle.Neck

Like the shaft of the tibia,

3 borders (anterior, interosseous, & posterior) 3 surfaces(medial, posterior, and lateral)

Proximal end & shaft of fibula

Distal end of fibula

Distal end enlarges, projects laterally & inferiorly lateral malleolus

more prominent and posterior than the medial malleolus extends approximately 1 cm more distally.

Tarsus (n=7) Metatarsus (n=5) Phalanges (n=14)

BONES OF FOOT

"flat surface, especially for drying,"Posterior foot/Proximal foot/Hindfoot

TARSUS

7 bonesTalusCalcaneusCuboidNavicularThree cuneiforms

Only one bone, the talus, articulates with the leg bones.

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HeadNeckBody

Superior surface trochlea of the talus is gripped by the two malleoli and receives the weight of the body from the tibia.

TALUS(L., ankle bone)

Talus transmits weight in turn, dividing it between the calcaneus, on which the body of talus rests, and the forefoot, via an osseoligamentous “hammock”

Hammock (Spring ligament;Calcenonavicular ligament) Across a gap between sustentaculum tali and navicular bone, lies anteriorly.

Largest and strongest bone in the foot Lateral surface of the calcaneus has fibular trochleaSustentaculum tali shelf-like support of the head of the talus

Calcaneus(L., heel bone)

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Flattened, boat-shaped bone Between head of the talus posteriorly & 3 cuneiforms anteriorlyMedial surface projects inferiorly to form, navicular tuberosity

Most lateral bone in the distal row of the tarsus

Navicular(L., little ship)

Cuboid

Medial (1st)Intermediate (2nd)Lateral (3rd)

Each cuneiform articulates with navicular posteriorly & base of its appropriate metatarsal anteriorly.

Lateral cuneiform also articulates with the cuboid.

Three cuneiform bones(L. cuneus, wedge shaped)

5 metatarsals numbered from the medial side of the foot

Metatarsals and phalanges located in anterior half (forefoot)

Tarsals in the posterior half (hindfoot)

METATARSUS (Anterior foot/distal foot)

14 phalanges 1st digit (great toe) 2 phalanges(proximal and distal) Other four digits 3 phalanges (proximal, middle, and distal)

Articulations of the pelvic girdleLumbosacral joints, sacroiliac joints & pubic symphysis

The remaining joints of the lower limb Hip jointKnee jointTibiofibular jointsAnkle jointFoot joints

JOINTS OF LOWER LIMB

Feature 1: Connection between lower limb & pelvic girdle

Feature 2: 2nd most movable after the shoulder joint

Synovial Joint Type: Ball and socket (Head of the femur & acetabulum)

Weight transfer: To the heads and necks of the femurs

Transverse acetabular ligament continuation of acetabular labrum

3 intrinsic ligaments1)Iliofemoral ligament anteriorly and superiorly , strongest

ligament of the body2)Pubofemoral ligament anteriorly and inferiorly3)Ischiofemoral ligament posteriorly

Ligament of the head of the femur

Ligaments

Flexion-extension Abduction-adduction Medial-lateral rotation Circumduction

MOVEMENTS OF HIP JOINT

KNEE JOINTFeature 1: Largest & most superficial joint

Feature 2: Hinge movements (Ext/Flex) combined with gliding & rotation

Synovial Joint Type: Hinge2 femorotibial articulations (lateral and medial) between lateral & medial femoral and tibial condyles1 intermediate femoropatellar articulation between patella & femurNo fibula involvment in the knee joint

Extracapsular ligaments1) Patellar ligament

2) Fibular (Lateral) collateral ligament

3) Tibial (Medial) collateral ligament

4) Oblique popliteal ligament

5) Arcuate popliteal ligament

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INTRA-ARTICULAR LIGAMENTS Cruciate ligaments & menisci

Anterior cruciate ligament (ACL)

Posterior cruciate ligament (PCL)

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Menisci of the knee joint are crescentic plates of fibrocartilage on the articular surface of the tibia that deepen the surface and play a role in shock absorption.

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MOVEMENTS OF KNEE JOINTFlexion and extension are the main knee movements; some rotation occurs when the knee is flexed. When the knee is fully extended with the foot on the ground, the knee passively “locks” because of medial rotation of the femoral condyles on the tibial plateau (the “screw-home mechanism”). This position makes the lower limb a solid column and more adapted for weight-bearing.

http://www.pt.ntu.edu.tw/hmchai/kinesiology/KINlower/Knee.files/KneeKinematics.htm

BURSAE AROUND KNEE JOINTThere are at least 12 bursae around the knee joint because most tendons run parallel to the bones and pull lengthwise across the joint during knee movements. The subcutaneous prepatellar and infrapatellar bursae are located at the convex surface of the joint, allowing the skin to be able to move freely during movements of the knee. The large suprapatellar bursa is especially important because an infection in it may spread to the knee joint cavity.

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(Superior) Tibiofibular joint

Syndesmosis (inferior tibiofibular) joint In addition, an interosseous membrane joins the shafts of the two bones.

TIBIOFIBULAR JOINTS

ANKLE JOINT Talocrural joint

Distal ends of the tibia & fibula & superior parts of the talus

Synovial Joint Type: HingeLIGAMENTS OF ANKLE JOINT

1) Lateral ligament of the ankle2) Anterior talofibular ligament3) Posterior talofibular ligament4) Calcaneofibular ligament5) Medial ligament of the ankle (deltoid ligament)

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Subtalar (talocalcaneal) joint

Transverse tarsal joint (calcaneocuboid and talonavicular joints)

Inversion and eversion of the foot are the main movements

FOOT JOINTS

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MAJOR LIGAMENTS OF FOOTPlantar calcaneonavicular ligament (spring ligament)

Long plantar ligament

Plantar calcaneocuboid ligament (short plantar ligament)

ARCHES OF FOOTSpreading the weight

Longitudinal arch of the foot Medial longitudinal arch Calcaneus, talus, navicular, 3 cuneiforms & 3 metatarsals. higher and more important than the lateral longitudinal arch. talar head keystone of the medial longitudinal arch.

Lateral longitudinal arch much flatter, rests on ground during standing. Calcaneus, cuboid, and lateral two metatarsals.

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ARCHES OF FOOTSpreading the weight

Transverse arch of the footRuns from side to sideFormed by cuboid, cuneiforms & bases of metatarsals

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The Neck of the Femur and Coxa Valga and Coxa Vara

fractures of the neck of the femur

125°in the adult 160° in the young child

congenital dislocation of the hip

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Fractures of the Femurcommon two types subcapital and trochanteric

Subcapital fracture elderly Subcapital femoral neck fractures women after menopauseFractures of the shaft of the femur young and healthy persons

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Fractures of the Tibia and FibulaCommon

1. If only one bone is fractured, other acts as a splint minimal displacement2.Fractures of the shaft of the tibia often open superifical3. Fractures of the proximal end of the tibia common middle-aged/elderlydirect violence to the lateral side of the knee joint, as when a person is hit by the bumper of an automobile.

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Fractures of the CalcaneusCompression from falls from a height. Talus downward----calcaneus not vertical- wider laterally

sustentaculum tali can be fractured by forced inversion of the foot.

Medial talocalconeal ligament

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Fractures of the TalusAt the neck or body of the talus

Neck fractures during violent dorsiflexion of the ankle joint when the neck is driven against the anterior edge of the distal end of the tibia.

Body of the talus jumping from a heightalthough the two malleoli prevent displacement of the fragments.

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Fractures of the Metatarsal BonesStress fractures common in joggers, soldiers after long marchesAlso in nurses & hikersFrequent in distal 1/3 of the 2nd,3rd or 4th metatarsal

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Deformities of the footFlat foot (Pes planus) medial longitudinal arch of the foot either rests on the ground or appears closer to the ground than the examiner would accept as normal.

Pes valgus (L, pes, foot, valgus, bent outward) deviation of the foot outward at the talocalcaneal joint.

Clubfoot or congenital talipes equinovarus common congenital deformity where the affected foot/feet are rotated internally at the ankle.

For more foot deformities

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MORE IMAGES

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