Lower limb

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6 Lower limb

Chapter contents

Femur

Fractures

Patella

Fractures

Tibia

Fibula

Fractures

Foot

Tarsal bones
Individual bones
Metatarsal bones
Phalanges
Fractures
Pathology

Knee joint

Pathology
Superior tibiofibular joint
Inferior tibiofibular joint

Ankle joint

Fractures
Pathology

Femur (Figs 6.1 and 6.2)

Type

Long bone.

image

Fig. 6.1 Right femur (anterior aspect).

A–Fovea

B–Head of femur

C–Neck of femur

D–Greater trochanter

E–Intertrochanteric line

F–Shaft

G–Lateral border

H–Lateral epicondyle

I–Lateral condyle

J–Patellar surface

K–Medial condyle

L–Medial epicondyle

M–Adductor tubercle

N–Medial border

O–Lesser trochanter.

image

Fig. 6.2 Right femur (posterior aspect).

1 – Trochanteric fossa

2 – Head of femur

3 – Lesser trochanter

4 – Spiral line

5 – Linea aspera

6 – Medial supracondylar line

7 – Adductor tubercle

8 – Medial condyle

9 – Intercondylar notch

10 – Lateral condyle

11 – Lateral supracondylar line

12 – Gluteal tuberosity

13 – Intertrochanteric crest

14 – Greater trochanter.

Position

Largest bone of the lower limb forming the thigh.

Articulations

Head of femur with the acetabulum of the hip bone to form the hip joint.

Femoral condyles with the tibial condyles, and the patellar articular surface of the femur with the posterior aspect of the patella to form the knee joint.

Main parts

Features of the upper end of the femur

Head of femur –

rounded, forming two-thirds of a sphere.

Fovea –

depression in the head of femur for the ligament of the head of femur.

Neck –

narrow portion about 5 cm long joining the head to the shaft; lies at an average angle of approximately 125° (it is more acute in the male than in the female).

Greater trochanter –

lies superiorly on the lateral aspect at the junction of the shaft with the neck; provides insertion for the gluteus and piriformis muscles.

Lesser trochanter –

inferiorly on the junction between the neck and the shaft, projecting medially; provides insertion of ilio-psoas muscle.

Intertrochanteric line –

anterior line, between the trochanters; marks part of the junction between the neck and shaft.

Intertrochanteric crest –

posterior crest, between the trochanters; marks part of the junction between the neck and the shaft.

Trochanteric fossa –

depression below the medial aspect of the greater trochanter.

Features of the shaft of the femur

Spiral line –

posterior aspect, continuous with the intertrochanteric line.

Gluteal tuberosity –

lateral surface of the upper end of the shaft, for the gluteus maximus muscle.

Linea aspera –

sharp ridge forming the posterior border below the junction of the spiral line and the gluteal tuberosity.

Medial border

Lateral border

Anterior surface

Lateral surface

Medial surface –

the location of the nutrient foramina.

Features of the lower end of the femur

Medial and lateral condyles –

fused together anteriorly, separated by the intercondylar notch posteriorly.

Medial epicondyle –

most prominent point of the medial condyle; provides attachment for the tibial collateral ligament.

Lateral epicondyle –

most prominent point of the lateral condyle; provides attachment for the fibular collateral ligament.

Intercondylar notch –

between the condyles, inferiorly and posteriorly.

Adductor tubercle –

above the medial epicondyle; provides attachment for the adductor magnus muscle.

Patellar articular surface –

anterior aspect of the lower end of femur, joining the condyles.

Medial supracondylar line –

from the adductor tubercle to the linea aspera.

Lateral supracondylar line –

from the lateral epicondyle to the linea aspera.

Popliteal surface –

flattened triangular area between the supracondylar lines.

Ossification

Primary centre

Shaft –

7th week intrauterine life.

Secondary centres

4 centres:

lower end appears just before birth;

head appears age 6 months;

greater trochanter appears age 4;

lesser trochanter appears age 13.

Fuse with shaft age 16–18.

Radiographic appearances of the femur

(Figs 6.3, 6.4, 6.5 and 6.6)

image

Fig. 6.3 Right femur: upper two-thirds; anteroposterior projection.

A–Greater trochanter

B–Lesser trochanter

C–Medullary cavity

D–Head of femur

E–Acetabulum.

(From Bryan 1996.)

image

Fig. 6.4 Femur: upper two-thirds; lateral projection.

1 – Medullary cavity

2 – Shaft

3 – Lesser trochanter

4 – Femoral neck and greater trochanter superimposed

5 – Head of femur

6 – Acetabulum.

(From Bryan 1996.)

image

Fig. 6.5 Right femur: lower third; anteroposterior projection.

A–Lateral condyle

B–Fibula

C–Tibia

D–Medial condyle

E–Patella

F–Shaft of femur.

(From Bryan 1996.)

image

Fig. 6.6 Left knee: lateral projection.

1 – Femur

2 – Intercondylar notch

3 – Condyles of femur

4 – Intercondylar eminence

5 – Superior tibiofibular joint

6 – Fibula

7 – Tibia

8 – Tibial tuberosity

9 – Ligamentum patellae

10 – Apex of patella

11 – Patella

12 – Quadriceps femoris.

(From Bryan 1996.)

Fractures

Neck of femur

Cause –

due to a fall. Common in elderly women.

Example of treatment –

reduction under anaesthetic; nail inserted, e.g. Smith–Peterson.

Intertrochanteric fracture

Cause –

due to a fall. Common in elderly women.

Example of treatment –

reduction under anaesthetic; nails and plate inserted.

Shaft of femur

Fracture pattern variable.

Cause –

due to severe violence, e.g. a road traffic accident.

Example of treatment –

traction using a Thomas’ splint.

Pathological fracture

Shaft of femur.

Cause –

bone disease, e.g. metastases.

Example of treatment –

internal fixation by an intramedullary nail.

Supracondylar

Cause –

due to direct violence. Damage to the popliteal artery or major nerves may occur.

Example of treatment –

reduction under anaesthetic; traction using a

Thomas’ splint.

Stress fracture (Figs 6.7 and 6.8)

Cause –

due to prolonged exercise, e.g. athletics, ballet.

image

Fig. 6.7 Right femoral neck, stress fracture (arrowed). MR scan.

(From Resnick Kransdorf, 2005.)

image

Fig. 6.8 Left femoral neck, stress fracture (arrowed). Radionuclide imaging.

(From Resnick Kransdorf, 2005.)

Example of treatment –

resting the affected area, a plaster cast may be required.

Patella (Figs 6.9 and 6.10)

Type

Sesamoid bone.

image

Fig. 6.9 Left patella (anterior aspect).

A–Base

B–Apex.

image

Fig. 6.10 Left patella (posterior aspect).

1 – Facet for lateral condyle of femur

2 – Apex

3 – Facet for medial condyle of femur

4 – Base.

Position

Anterior to the lower end of the femur.

Articulation

Facets of the patella with the femoral condyles to form part of the knee joint.

Main parts

Base –

superior aspect, attached to quadriceps femoris by the suprapatellar tendon.

Apex –

inferior aspect, attached by the patellar ligament to the tibial tuberosity.

Facet for the lateral condyle of the femur –

large, on the posterior aspect of the bone.

Facet for the medial condyle of the femur –

small, on the posterior aspect of the bone.

Ossification

Primary centre

Appears age 3–6.

Ossification is complete at puberty.

N.B. A bipartite or tripartite patella may be seen radiographically in some patients.

Radiographic appearances of the patella

(Figs 6.11 and 6.12)

image

Fig. 6.11 Patella: postero-anterior projection.

A–Lateral border

B–Lateral condyle of femur

C–Apex of patella

D–Fibula

E–Tibia

F–Medial condyle of femur

G–Medial border

H–Superior border of patella.

(From Bryan 1996.)

image

Fig. 6.12 Patella: infero-superior (‘skyline’) projection.

1 – Medial condyle of femur

2 – Femur

3 – Lateral condyle of femur

4 – Patella.

(From Bryan 1996.)

Fractures

Horizontal

Cause –

sudden, violent contraction of the quadriceps femoris muscle, e.g. due to a stumble.

Examples of treatment –

internal fixation by a screw or excision of the patella.

Crack

Cause –

direct blow; not to be confused with a bipartite patella, which has ‘clean’ edges.

Example of treatment –

plaster of Paris (groin to ankle) for 3 weeks.

Comminuted

Cause –

direct blow.

Example of treatment –

excision of the patella at operation.

Tibia (Figs 6.13 and 6.14)

Type

Long bone.

image

Fig. 6.13 Left tibia (anterior aspect).

A–Fibular facet

B–Lateral condyle

C–Tubercles of the intercondylar eminence

D–Medial condyle

E–Tibial tuberosity

F–Interosseous border

G–Anterior border

H–Medial surface

I–Medial malleolus

J–Fibular notch.

Left fibula (anterior aspect).

K–Head of fibula

L–Interosseous border

M–Lateral surface

N–Lateral malleolus.

image

Fig. 6.14 Left tibia (posterior aspect).

1 – Lateral condyle

2 – Tubercles of the intercondylar eminence

3 – Medial condyle

4 – Soleal line

5 – Medial border

6 – Interosseous border

7 – Fibular notch

8 – Medial malleolus.

Left fibula (posterior aspect).

9 – Head of fibula

10 – Interosseous border

11 – Posterior border

12 – Lateral malleolus

13 – Malleolar fossa.

Position

Medial bone of the lower limb.

Articulations

Tibial condyles with the femoral condyles to form the knee joint.

Articular facet on the lateral condyle of the tibia with the head of fibula to form the superior tibiofibular joint.

Lower end of tibia with the talus to form part of the ankle joint.

Fibular notch of the tibia with the lower end of fibula to form the inferior tibiofibular joint.

Main parts

Features of the upper end of tibia

Tubercles of the intercondylar eminence –

on the superior aspect of the tibia between the articular surfaces.

Medial condyle –

medial part of the upper end, larger of the 2 condyles.

Lateral condyle –

lateral part of the upper end.

Articular facet –

on the postero-lateral aspect of the lateral condyle for the head of fibula.

Tibial tuberosity –

anterior aspect; can be palpated 2.5 cm below the condyles; forms attachment for the patellar ligament.

Features of the shaft of tibia

Soleal line –

‘horseshoe-shaped’ oblique line; posterior aspect of the shaft which receives the soleus muscle.

Anterior border –

subcutaneous and easily palpated.

Medial border

Interosseous border –

attached to the medial aspect of the fibula by an interosseous membrane to form the middle tibiofibular joint.

Medial surface

Lateral surface

Posterior surface –

nutrient foramen is situated inferior to the soleal line.

Features of the lower end of the tibia

Medial malleolus –

palpable feature at the medial aspect of the lower end.

Fibular notch –

lateral aspect of the lower end, for the lower end of the fibula.

Inferior articular surface –

concavo-convex for articulation with the superior surface of the talus.

Anterior surface

Posterior surface

Ossification

Primary centre

Shaft –

7th week intrauterine life.

Secondary centres

2 centres:

upper end appears just before or after birth;

lower end appears age 1.

Lower end fuses with the shaft age 15–17.

Upper end fuses with the shaft age 16–18.

Fibula (Figs 6.13 and 6.14)

Type

Long bone.

Position

Lateral bone of the lower leg.

Articulations

Head of fibula with the articular facet of the lateral condyle of the tibia to form the superior tibiofibular joint.

Lower end of fibula with the fibular notch of the tibia to form the inferior tibiofibular joint.

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