Lower limb

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6 Lower limb

Femur (Figs 6.1 and 6.2)

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

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)

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

(From Bryan 1996.)

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.)

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

(From Bryan 1996.)

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.

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

(From Resnick Kransdorf, 2005.)

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.

Fig. 6.9 Left patella (anterior aspect).

A–Base

B–Apex.

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.

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)

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.)

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.)

Tibia (Figs 6.13 and 6.14)

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

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.

Lateral malleolus of the fibula with the talus to form part of the ankle joint.

Main parts

Features of the upper end of the fibula

Head –

rounded upper aspect; can be palpated 2.5 cm inferior to the lateral aspect of the knee joint.

Styloid process –

pointed, upper part of the head.

Neck –

narrow area below the head; common fracture site.

Ossification

Primary centre

Shaft –

8th week intrauterine life.

Secondary centres

2 centres:

lower end appears age 1;

upper end appears age 3–4.

Lower end fuses with shaft age 15–17.

Upper end fuses with shaft age 17–19.

Radiographic appearances of the tibia and fibula

(Figs 6.15 and 6.16)

Fig. 6.16 Left tibia and fibula: lateral projection.

1 – Condyles of femur

Foot

Tarsal bones (Fig. 6.18)

Position

Two rows situated between the tibia proximally and the bases of the metatarsals distally.

Insight

To remember the tarsal bones:

Right foot dorsal aspect

Articulations

Talus with the tibia, fibula, calcaneus, navicular.

Calcaneus with the talus, cuboid.

Navicular with the talus, cuboid, medial cuneiform, intermediate cuneiform, lateral cuneiform.

Cuboid with the calcaneus, navicular, lateral cuneiform, 4th metatarsal, 5th metatarsal.

Lateral cuneiform with the navicular, cuboid, intermediate cuneiform, 2nd, 3rd and 4th metatarsals.

Intermediate cuneiform with the navicular, lateral cuneiform, medial cuneiform, 2nd metatarsal.

Medial cuneiform with the navicular, intermediate cuneiform, 1st and 2nd metatarsals.

Individual bones

Proximal row

Radiographic appearances of the calcaneus (Fig. 6.19)

Fig. 6.19 Right calcaneus: axial projection.

A–Medial surface

B–Sustentaculum tali

C–Medial malleolus

D–Posterior talocalcanean articulation

E–Lateral malleolus

F–Lateral surface

G–Posterior surface.

Type

Miniature long bones.

Position

Distal to the tarsal bones.

Articulations

The head of the metatarsals with the phalanges to form the metatarsophalangeal joints.

The base of the metatarsals with the tarsal bones to form the tarsometatarsal joints.

1st metatarsal with the proximal phalanx of the hallux and the medial cuneiform.

2nd metatarsal with the proximal phalanx of the 2nd toe, the medial, intermediate and lateral cuneiform bones.

3rd metatarsal with the proximal phalanx of the 3rd toe and the lateral cuneiform.

4th metatarsal with the proximal phalanx of the 4th toe, the lateral cuneiform and the cuboid.

5th metatarsal with the proximal phalanx of the 5th toe and the cuboid.

The bases of the 2nd–5th metatarsals with the adjacent metatarsal.

Main parts

Head –

rounded; articulates with the corresponding proximal phalanx.

Shaft –

plantar aspect concave, dorsal aspect convex.

Base –

expanded; articulates with the appropriate tarsal bone(s).

First metatarsal

Short and thick.

Articular facets –

2 on the plantar aspect of the head for the sesamoid bones.

Second metatarsal

Longest.

Fifth metatarsal

Tuberosity –

projects laterally from the base.

Ossification

Primary centre

Shaft –

9th–10th week of intrauterine life.

Secondary centre

1 centre:

base of 1st metatarsal appears age 3.

Heads of 2nd–5th metatarsals appear age 3–4.

Secondary centre unites with the shaft age 17–20.

Phalanges (Fig. 6.18)

Type

Miniature long bones.

Position

Distal to the metatarsals, forming the toes.

Articulations

The base of the phalanx with the metatarsal to form the metatarsophalangeal joints.

With each other to form the interphalangeal joints.

5 proximal phalanges with the corresponding metatarsal; the 1st with the distal phalanx of the hallux, and the 2nd–5th with the corresponding middle phalanx.

4 middle phalanges with the corresponding proximal and distal phalanges.

5 distal phalanges with the corresponding middle phalanges and the proximal phalanx of the hallux.

Main parts

Head –

expanded.

Shaft –

plantar aspect is concave.

Base –

expanded; articulates with either the phalanx or the metatarsal proximal to it.

Ossification

Primary centre

Shaft –

9th–15th week of intrauterine life.

Secondary centre

1 centre:

base of phalanges appears age 2–8.

Base unites with the shaft age 18.

Arches of the foot

Medial longitudinal arch –

formed by the calcaneus, talus, navicular, 3 cuneiform bones and 1st, 2nd and 3rd metatarsals; is higher than the lateral longitudinal arch.

Lateral longitudinal arch –

formed by the calcaneus, cuboid and the 4th and 5th metatarsals.

Radiographic appearances of the foot (Figs 6.20, 6.21 and 6.22)

Fig. 6.20 Right foot: dorsiplantar projection.

A–Head of distal phalanx

B–Base of proximal phalanx

C–Medial and lateral sesamoid bones

D–1st tarsometatarsal joint

Fig. 6.21 Right foot: dorsiplantar oblique projection.

1 – Distal phalanx

2 – 1st metatarsal bone

3 – Medial cuneiform

4 – Intermediate cuneiform

12 – Base of 5th metatarsal bone

13 – Lateral cuneiform

14 – 5th metatarsal bone.

(From Bryan 1996.)

Fig. 6.22 Left foot: lateral projection.

A–Calcaneus

B–Medial and lateral processes

C–Long plantar ligament

D–Anterior tubercle

E–Short plantar ligament

(From Bryan 1996.)

Calcaneus

Cause –

compression, due to a fall from a height onto both heels.

Example of treatment –

bed rest for 4–6 weeks; physiotherapy. Arthrodesis if pain persists.

Metatarsals

Cause –

direct blow, often due to a heavy object falling on the foot.

Example of treatment –

walking plaster (below knee) for 3–4 weeks.

March fracture

Shafts of the metatarsals.

Cause –

prolonged walking.

Example of treatment –

often no treatment required. If severe pain, walking plaster (below knee) for 3–4 weeks.

Phalanges

Cause –

crush injury.

Example of treatment –

soft dressing.

Pathology

Gout (Fig. 6.23)

Disorder of protein metabolism with uric acid crystals deposited into the joints. Great toe is the most common site. Joints become swollen, red and painful.

Fig. 6.23 Gout. Radionuclide imaging. Note: Patient had normal radiographs.

(From Resnick Kransdorf, 2005.)

Radiological signs –

erosion of bone surfaces and soft tissue swelling.

Hallux valgus (Fig. 6.24)

Lateral deviation of the great toe from the 1st metatarsal.

Fig. 6.24 Hallux valgus.

(Courtesy of Ernest Higginbottom.)

Cause –

wearing tight fitting shoes.

Radiological sign –

prominent 1st metatarsophalangeal joint is seen.

Pes planus (Fig. 6.25)

Flat feet.

Fig. 6.25 Pes planus.

(Courtesy of Ernest Higginbottom.)

Cause –

muscular weakness (lack of muscle support stretches the ligaments).

Radiological sign –

longitudinal arch of the foot is decreased.

Knee joint (Figs 6.26, 6.27, 6.28 and 6.29)

Type

Synovial condylar joint.

Fig. 6.26 Right knee joint (schematic coronal section).

A–Femur

B–Fibrous capsule

C–Articular hyaline cartilage

D–Popliteus tendon, enclosed in synovial membrane

I–Articular hyaline cartilage

J–Medial meniscus

K–Synovial membrane

L–Anterior cruciate ligament

M–Posterior cruciate ligament

N–Fibrous capsule

O–Synovial membrane.

Fig. 6.27 Right knee joint (anterior aspect).

1 – Fibular collateral ligament

2 – Lateral meniscus

3 – Iliotibial tract

4 – Patellar ligament

5 – Tibial collateral ligament

6 – Medial meniscus

7 – Anterior cruciate ligament

8 – Posterior cruciate ligament.

Fig. 6.28 Left knee joint (sagittal section).

A–Suprapatellar tendon

B–Suprapatellar bursa

C–Patella

D–Subcutaneous prepatellar bursa

E–Articular hyaline cartilage

F–Intrapatellar pad of fat

G–Synovial membrane

H–Patellar ligament

I–Deep intrapatellar bursa

J–Tibia

K–Fibrous capsule

L–Posterior cruciate ligament

M–Anterior cruciate ligament

N–Femur.

Fig. 6.29 Right tibia (superior aspect).

1 – Transverse ligament

2 – Anterior cruciate ligament

3 – Medial meniscus

4 – Posterior cruciate ligament

5 – Lateral meniscus.

Insight

In some publications the knee joint is incorrectly classified as a hinge joint. This is incorrect as when the joint is flexed there is a slight amount of medial and lateral rotation making it a synovial condylar joint.

Bony articular surfaces

The femoral condyles with the tibial condyles. Posterior aspect of the patella with the patellar articular surface of the femur. The articular surfaces are covered with articular hyaline cartilage.

Fibrous capsule

Blends with the suprapatellar tendon and the patellar ligament; elsewhere it is attached to the margins of the femoral and tibial condyles and to the head of the fibula.

Synovial membrane

Lines part of the fibrous capsule, and covers the intracapsular popliteus tendon. Anteriorly it forms the suprapatellar bursa and covers the anterior and lateral surfaces of the cruciate ligaments. The central posterior aspect of the joint has no synovial covering. The membrane secretes synovial fluid, which lubricates the joint.

Suprapatellar bursa –

a sac containing synovial fluid, situated above the patella between the lower end of femur and the suprapatellar tendon.

Prepatellar bursa –

a sac containing synovial fluid, situated between the anterior surface of the patella and the skin.

Infrapatellar bursa –

a sac containing synovial fluid, situated below the patella between the upper tibia and the patellar ligament.

Movements

Flexion by the hamstring muscles aided by the gastrocnemius.

Extension by the quadriceps femoris.

When the knee is in flexion there is a minimal degree of:

Medial rotation by the popliteus.

Lateral rotation by the biceps femoris.

Blood supply

Branches of the femoral, popliteal and anterior tibial arteries, forming an anastomosis.

Nerve supply

Obturator, femoral, tibial and common peroneal nerves.

Fabella

Sesamoid bone found in the lateral head of gastrocnemius muscle where it passes over the lateral condyle of the femur. Smooth, round structure posterior to the knee joint on a lateral radiograph.

Radiographic appearances of the knee (Figs 6.30 to 6.35)

Fig. 6.30 Left knee: anteroposterior projection.

A–Adductor tubercle

B–Medial epicondyle

C–Medial condyle

D–Tubercles of intercondylar eminence

J – Lateral epicondyle

K – Patella

L – Femur.

(From Bryan 1996.)

Fig. 6.31 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

11 – Patella

12 – Quadriceps femoris.

(From Bryan 1996.)

Fig. 6.32 Left knee: CT scan.

A–Fabella

B–Femur

C–Patella.

(From Bryan 1996.)

Fig. 6.33 Knee: MR scan.

(From Bryan 1996.)

Fig. 6.34 Normal lateral meniscus of the knee (arrowed). MR scan.

(From Resnick Kransdorf, 2005.)

Fig. 6.35 Normal collateral ligaments of the knee (arrowed). Ultrasound scan.

F–medial femoral condyle,

T–medial tibial plateau.

(From Resnick Kransdorf, 2005.)

Pathology

Osteochondritis dissecans

Cause –

local bone necrosis resulting in loose fragments of bone in the joint space.

Radiological signs –

dense bone fragments in the region of the femoral condyle, loose bodies within the joint capsule.

Osgood–Schlatter’s disease (see Fig. 3.18)

Non-inflammatory condition affecting the tibial tuberosity.

Cause –

unknown. May be due to defective blood supply causing necrosis. It is an example of juvenile osteochondritis.

Radiological signs –

increased bone density and fragmentation of the area.

Torn meniscus (Fig. 6.36)

Cause –

usually a twisting force, e.g. football injury. The medial meniscus is torn more commonly than the lateral.

Fig. 6.36 Medial collateral ligament tear (arrowhead) and displaced medial meniscus (arrowed). MR scan.

(From Resnick Kransdorf, 2005.)

Radiological signs –

demonstrated by arthrography (the radiographic examination of the intracapsular structures of the joint following the direct injection of a contrast agent into the joint cavity).

Superior tibiofibular joint

Type

Synovial plane joint.

Bony articular surfaces

Lateral condyle of the tibia with the head of fibula. Both surfaces are covered with articular hyaline cartilage.

Fibrous capsule

Attached to the margins of the articular facets on the tibia and fibula.

Synovial membrane

Lines the fibrous capsule and secretes synovial fluid, which lubricates the joint.

Supporting ligaments

Anterior ligament.

Movements

Gliding.

Blood supply

Branches of the anterior tibial artery.

Nerve supply

Common peroneal nerve.

Radiographic appearances of the superior tibiofibular joint

(Fig. 6.37)

Fig. 6.37 Left superior tibiofibular joint: oblique projection.

E–Superior tibiofibular joint

(From Bryan 1996.)

Ankle joint (Figs 6.38 and 6.39)

Bony articular surfaces

The distal end and the medial malleolus of the tibia, the medial aspect of the lateral malleolus of the fibula, with the talus. The articular surfaces are covered with articular hyaline cartilage.

Fibrous capsule

Attached to the tibia and fibula above the malleoli; to the posterior and lateral surfaces of the talus and anteriorly to the neck of the talus. The capsule is weak anteriorly and posteriorly but is strengthened laterally by ligaments.

Synovial membrane

Lines the fibrous capsule and the parts of the bone not covered with articular hyaline cartilage. A small fold extends between the distal ends of the tibia and fibula. The synovial membrane secretes synovial fluid, which lubricates the joint.

Movements

Main movements

Dorsiflexion by the anterior tibialis muscle.

Plantarflexion by the soleus and gastrocnemius.

Accessory movements

slight movement in plantar-flexion.

Blood supply

Branches of the anterior tibial and peroneal arteries.

Nerve supply

Posterior and lateral popliteal nerves.

Radiographic appearances of the ankle joint (Figs 6.40, 6.41, 6.42 and 6.43)

Fig. 6.40 Left ankle joint: anteroposterior projection.

A–Tibia

B–Medial malleolus

C–Trochlear surface of talus

D–Malleolar fossa

E–Lateral malleolus

F–Inferior tibiofibular joint

G–Fibula.

(From Bryan 1996.)

Fig. 6.41 Left ankle joint: lateral projection.

1 – Fibula

2 – Tendo calcaneus

3 – Malleoli medial and lateral

4 – Calcaneus

5 – Sustentaculum tali

6 – Cuboid

7 – Navicular

8 – Head of talus

9 – Trochlear surface of talus

10 – Ankle joint

11 – Tibia.

(From Bryan 1996.)

Fig. 6.42 Ankle joint: MR scan, sagittal section.

E–Posterior talo- calcaneal joint

F–Achilles tendon

G–Tibia.

(From Bryan 1996.)

Fig. 6.43 Normal anterior fibular ligament (curved arrow) and posterior talofibular ligament (open arrow). MR scan.

(From Resnick Kransdorf, 2005.)

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Lower limb

Femur (Figs 6.1 and 6.2)

Stress fracture (Figs 6.7 and 6.8)

Patella (Figs 6.9 and 6.10)

Tibia (Figs 6.13 and 6.14)

Fibula (Figs 6.13 and 6.14)

Tibial condyle (Fig. 6.17)

Tarsal bones (Fig. 6.18)