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Bones and Joints of the Lower Limb Manchester T&O socLearning outcomes Slides & cert of attendance will be available after completion of feedback form at the end By the end of this lecture and private study, you should be able to: 1. Identify the bones of the lower limb and various anatomical structures on them 2. Identify the bony landmarks of the lower limb 3. Describe the features of joints of the lower limb (Capsule, ligaments, bursae and movements) 4. Identify anatomical structures on clinical imagingBones of the lower limb Pelvic Girdle • Hip bone, sacrum, coccyx Thigh • Femur • Patella Leg • Tibia (medially) • Fibula (laterally) Foot • Tarsal bones • Talus, calcaneus, navicular, cuboid, medial, intermediate and lateral cuneiforms • Metatarsal bones (x5) Phalanges (x14)Pelvic girdle • Formed by the hip bones, sacrum and coccyx • attaches the lower limbs to the axial skeleton • transfers the body weight to the lower limbs • provides an almost rigid, complete ring for weight bearing and childbirth • supports the pelvic organs • provides muscle attachment for limb movement • Provides “Gateways” for neurovascular structures to pass throughHip bone • Ilium, Ischium and Pubic bones are fused to form the Hip bone – together, form a cup-shaped socket = acetabulum • Tri-radiate cartilage between the 3 parts of the hip bone. The cartilage is visible radiologically, but ossifies by late teensPelvic joints Pubic symphysis • Is a secondary cartilaginous (or fibrocartilage) joint • Disc between articular surfaces of the pubis bodies of the two hip bones. • Supported by superior and arcuate ligaments Sacro-iliac joint x2 • between the ilium of the hip bones and the sacrum • Synovial anteriorly, fibrous posteriorly • Supported by the Anterior and Posterior sacro-iliac and Interosseous ligaments • Extremely limited movement the coccyx.eal symphysis – between the sacrum and Ligaments - For stability during standing, walking, and runningPelvic joints Anterior Posterior • Body weight wants to rotate S1 downwards and S4 upwards • The Sacrospinous and Sacrotuberous ligaments prevent the sacrum tilting forwards • support the sacro-iliac joint • The ligaments also convert the sciatic notches into Greater and Lesser sciatic foramina for the passage of nerves and vessels (gateway)Gateways of the pelvic girdle Sciatic Nerve and Gluteal Neurovascular Bundle Obturator Neurovascular Bundle Femoral Neurovascular Bundle Internal Pudendal Neurovascular Bundle ASIS L4 • Anterior superior iliac spine is on the same Mid-inguinal point – halfway between the ASIS and the coronal plane as the pubic tubercle and pubic centre of the pubic symphysis. Femoral artery can be crest palpated here. • The highest point of the iliac crest is at the level Mid-point of the inguinal ligament – halfway between of L4 – palpable for MSK exam the ASIS and the pubic tubercle.Hip joint • Ball and socket type synovial joint Intertrochanteric line (anterior) Intertrochanteric crest (posterior)Hip joint Acetabulum: • Weight bearing, stable • Deep socket. The rim is raised by the acetabular labrum • Labrum bridges across the acetabular notch as the Transverse acetabular ligament Head of femur • covered by hyaline cartilage all except for the fovea of head of femurHip joint: Joint capsule • Attached to the acetabular rim, transverse acetabular ligament, intertrochanteric line and neck of the femur • Synovial membrane • covers everything except the articular cartilage • forms a sleeve around the ligament of the head of femur. Hip joint: Ligaments Extracapsular ligaments • Iliofemoral - strongest • Prevents hyperextension of hip joint during standing • Pubofemoral • Prevents overabduction of hip joint; tightens during abduction and extension of hip • Ischiofemoral – weakest Intracapsular ligament All capsular ligaments of the hip joint spiral around the joint • Ligament of the head of femur and attach to femur so that they are taut in extension. • Prevent overextension • Stabilize the joint • Save energy during standingHip joint: Shenton’s line AP X-ray image of the hipKnee joint • Hinge joint • Synovial • Flexion and extension mainly • Some medial and lateral rotation • articulations between the patella, distal femur, and proximal tibiaKnee joint AP x-ray of knee Lateral x-ray of kneeKnee joint: Joint capsule Two articulating surfaces - tibiofemoral and patellofemoral Enclosed in fibrous capsule • attaches to the articular margins • lined by synovial membrane • Incomplete • Anteriorly, the fibrous capsule is replaced by the quadriceps tendon, patellar ligament, the patella and fat pads on either side of patellar ligament • iretinacula from quadricepsarKnee joint: Joint capsule • Posteriorly, the fibrous capsule is augmented by the • oblique popliteal ligament • expansion of the semimembranosus muscle • arcuate popliteal ligament • There is an opening in the capsule for the tendon of popliteusKnee joint: Bursae • Numerous - because most tendons run parallel to the bones and pull lengthwise across the joint during knee movements • 4 main ones Three main types of ligament in the knee joint: • Patellar ligament Knee joint: Ligaments • Collateral ligaments • Cruciate ligaments Collateral ligaments Medial collateral ligament = broad, flat band from medial femoral epicondyle to tibial condyle - Fused to joint capsule and medial meniscus - Prevents abduction of leg Lateral collateral ligament = strong cord from lateral femoral epicondyle to head of fibula - Prevents adduction of leg - Tendon of popliteus is between this ligament &capsule Tibial tuberosity Three main types of ligament in the knee joint: • Patellar ligament Knee joints: Ligaments • Collateral ligament • Cruciate ligament Cruciate ligaments • Anterior cruciate ligament ACL • Prevents anterior dislocation of tibia and hyperextension • Posterior cruciate ligament PCL • Prevents posterior dislocation of tibia (walking downhill) • Named according to their tibial attachmentKnee joint: Cruciate ligaments Anterior Posterior cruciate cruciate ligament ligament Sagittal MR image of the kneeKnee joint: Menisci • Two crescent-shaped fibrocartilage • Medial meniscus • Lateral meniscus • Increase the congruence of articular surfaces • Absorb shock - Dissipate the forces/stress on articular cartilage • Decrease friction • Participate in locking of knees • ProprioceptionKnee joint: Menisci Sagittal MR image of the knee Coronal MR image of the kneeAnkle joint: Distal tibia, fibula & talus *calcaneus is not part of the ankle joint Lateral malleolus Medial malleolusAnkle joint: Movements Weight bearing Hinge joint • Extension (dorsiflexion) • [Plantar] Flexion (more unstable because of narrow posterior aspect of talus) • Inversion Talus bone Ankle joint: Capsule & ligaments • Loose fibrous capsule • Synovial folds within capsule • at malleoli and fan out to tarsal bones:inate • Medial (deltoid) ligament: Resists dislocation during eversion of the foot • Lateral ligament: Resists over- inversionBones of the foot • Tarsal bones, metatarsals and phalanges • Proximal row: Talus, Calcaneus • Distal row (L ß M) medial (1) L cuneiform, lateral (3) cuneiform, 3 2 M 1 cuboid • Navicular (M) • Talus is the only foot bone to link leg with foot Talus boneJoints & movement of the foot and ankle • Distal Tibiofibular: Syndesmose • No movement, helps to stabilise ankle and foot • Ankle: hinge joint • Plantar flexion and dorsiflexion • Intertarsal: Plane joints • Subtalar (Talocalcaneal) • Talo-calcaneo-navicular Transverse • Calcaneo-cuboid tarsal joint • Intermetatarsal & Tarsometatarsal: Plane joints • Gliding movements • Metatarsophalangeal: Condyloid joints • Flexion, extension, Abduction, adduction • Interphalangeal: Hinge joints • Flexion and extensionSubtalar joint • Between talus and calcaneus • Synovial joint • Enclosed by joint capsule • Supported by three ligaments • Posterior talocalcaneal ligament • Medial talocalcaneal ligament • Lateral talocalcaneal ligament • interosseous talocalcaneal ligament – in sinus tarsi – strong and stable ligament • Eversion and inversion – no role in dorsiflexion or plantarflexionPlantar arches • Arches between the points of contact • Absorb and distribute downward forces from the body during standing and moving • Medial longitudinal arch: calcaneus, talus, navicular, all cuneiforms and medial 3 metatarsals • Lateral longitudinal arch: calcaneus, cuboid and 4th and 5th metatarsals • Transverse arch: cuneiforms and cuboidBones of the foot * x-ray of the footReferences • My own notes • TeachMeAnatomy • Moore et al. Clinically Oriented Anatomy • Hansen JT. Netter's Clinical Anatomy • Putz & Pabst. Sobotta Atlas of Human Anatomy With special thanks to Dr. Enis Cezayirli Scan me J Thank you for listening! Please leave some feedback J Slides and certificates will be sent out after completion of feedback form Neurovasculature of the lower limbs next Thursday! Make sure to sign up J