Lower Limbs 1

The Lower Limbs

Supports the weight of the body and

transfers that support to the axial
skeleton across the hip and sacroiliac
joints
Function in locomotion via the process of
walking (our gait)

Are anchored to the axial skeleton via the

pelvic girdle, which allows for less
mobility but significantly more stability

Regions of the Lower Limb

The gluteal region

The femoral region

the transitional region between the trunk and free lower

limbs.

the region of the free lower limb that lies between the
gluteal, abdominal, and perineal regions proximally and
the knee region distally.

The knee region

includes the prominences (condyles) of the distal femur

and proximal tibia, the head of the fibula, and the patella
(knee cap, which lies anterior to the distal end of the
femur), as well as the joints between these bony
structures and the posteriorly located popliteal fossa.

Regions of the Lower Limb

The leg region

The ankle or talocrural region

the part that lies between the knee and the narrow,
distal part of the leg. It includes most of the tibia
(shin bone) and fibula (calf bone)

includes the medial and lateral prominences

(malleoli) that flank the ankle (talocrural) joint.

The foot region

is the distal part of the lower limb containing the

tarsus, metatarsus, and phalanges (toe bones).

Pelvic (hip) Girdle

2 coxal (hip) bones

Ilium
Ischium
Pubis

Sacroiliac Joint
Pubic Symphysis
Function:

Support for vertebral

column
Protect pelvic organs
Attach lower limbs

Coxal Bone Markings

Ilium
Ischium
Pubis
Acetabulum
Iliac Crest
Greater Sciatic
Notch
Obturator Foramen

Pelvis

Combination of the sacrum,

coccyx, and the 2 hip bones
2 parts greater (false) and
lesser (true)

Pelvis

Ilium
Ischium
Pubis
Pubic Symphysis
Sacrum
Coccyx
Pelvic Brim
Pelvic Inlet
Pelvic Outlet
Pubic Arch
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X-Ray of Pelvis

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X-Ray of Pelvis

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Comparison of Male and Female

Pelvis
Point of
Comparison

Female

Male

General Structure

Light and Thin

Heavy and Thick

False Pelvis

Shallow

Deep

Pelvic Inlet

Larger and Oval

Smaller and Heart

Shaped

Acetabulum

Small, faces anteriorly

Large and faces

laterally

Obturator Foramen

Oval

Round

Pubic Arch

Greater than 90o

Less than 90o

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Pelvimetry

Measurement
of the size of
the inlet and
outlet of the
birth canal.

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Pelvic Insufficiency Fractures

Thin, weakened, osteoporotic bone trying

to carry the normal load of the body is
prone to fracture
Pelvic insufficiency fractures are among
the most common insufficiency fractures
that occur in patients with osteoporosis
Often there is no significant fall, but
patients often have significant difficulty
walking or are unable to walk all together.

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Nelatons line

From the anterior

superior lilac spine to the
ischial tuberosity,
passing over or near the
top of the greater
trochanter

The trochanter can be

felt superior to this line
in a person which a
dislocated hip or a
fractured femoral neck.
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Normal angle
of inclination
1250-1300

Coxa vara
(abnormally decreased angle of
inclination, it occurs in fractures
of the neck of the femur and
slipping of the femoral
epiphysis )

Coxa valga
(abnormally increased
angle of inclination, in
cases of congenital
dislocation of the hip)

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LOWER LIMB

30 bones in each

Femur
Patella
Tibia
Fibula
Tarsals
Metatarsals
Phalanges

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Femur

Longest, strongest
heaviest bone in
the body
Diaphysis has a
medial bend to
bring knees closer
to the midline of
the body
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Femur

Head
Neck
Trochanter
Condyles
Patellar Surface

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Congenital Hip Dislocation

In the United States, about 1.5 in

1000 infants are born with
congenital hip dislocation
Girls are affected more often than
boys.
About 60% of affected children are
firstborns
Ortolanis test of hip abduction
confirms the diagnosis
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Head and Neck

Head

Directed medially, upward, and slightly forward to fit into the

acetabulum.
Has a depression in its articular surface, the fovea capitis
femoris, to which the ligamentum capitis femoris is attached.

Neck

Connects the head to the body (shaft), forms an angle of about

125 degrees with the shaft, and is a common site of fractures.
Is separated from the shaft in front by the intertrochanteric
line, to which the iliofemoral ligament is attached.

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Trochanters

Greater Trochanter

Projects upward from the junction of the neck with the shaft.
Provides an insertion for the gluteus medius and minimus,
piriformis, and obturator internus muscles.
Receives the obturator externus tendon on the medial aspect of
the trochanteric fossa.

Lesser Trochanter

Lies in the angle between the neck and the shaft.

Projects at the inferior end of the intertrochanteric crest.
Provides an insertion for the iliopsoas tendon.

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Femoral Head Fractures

The Garden classification

identifies four fracture types:

I: impaction of superior portion

of femoral neck (incomplete
fracture)
II: nondisplaced fracture
(complete fracture)
III: partial displacement
between femoral head and neck
IV: complete displacement
between femoral head and neck

The occurrence of
complications related to
nonunion and avascular
necrosis of the femoral head
increases from type I to IV.

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Linea Aspera and Pectineal Line

Linea Aspera

Is the rough line or ridge

on the body (shaft) of
the femur.
Exhibits lateral and
medial lips that provide
attachments for many
muscles and the three
intermuscular septa.

Pectineal Line

Runs from the lesser

trochanter to the medial
lip of the linea aspera.
Provides an insertion for
the pectineus muscle.
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Adductor Tubercle

Adductor Tubercle

A small prominence at the uppermost

part of the medial femoral condyle.
Provides an insertion for the adductor
magnus muscle.

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Patella

Largest Sesamoid bone

Attaches to the tibial
tuberosity by a
continuation of the
quadriceps tendon called
the patellar ligament.
Functions to obviate wear
and attrition on the
quadriceps tendon as it
passes across thetrochlear
groove and to increase the
angle of pull of the
quadriceps femoris,
thereby magnifying its
power.
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Patellofemoral stress syndrome

AKA Runners
Knee
Patella does not
glide up and down
between the
femoral condyles
but rather
laterally causing
pain.

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Tibia

Is the weight-bearing medial

bone of the leg
Has the tibial tuberosity into
which the patellar ligament
inserts.
Has medial and lateral condyles
that articulate with the condyles
of the femur.
Has a projection called the
medial malleolus with a
malleolar groove for the
tendons of the tibialis posterior
and flexor digitorum longus
muscles and another groove
(posterolateral to the malleolus
groove) for the tendon of the fl
exor hallucis longus muscle. It
also provides attachment for the
deltoid ligament.
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Shin Splints

A spectrum of tibial
stress injuries is likely
involved in MTSS,
including tendinopathy,
periostitis, periosteal
remodeling, and stress
reaction of the tibia.
Dysfunction of the
tibialis posterior,
tibialis anterior, and
soleus muscles are
also commonly
implicated
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Shin Splints

Medial tibial stress

syndrome (MTSS) is an
overuse injury or
repetitive-stress injury
of the shin area.
Various stress reactions
of the tibia and
surrounding
musculature occur
when the body is
unable to heal properly
in response to
repetitive muscle
contractions and tibial
strain.
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Fibula

Has little or no function in weight

bearing but provides attachment for
muscles.
Has a head (apex) that provides
attachment for the fi bular collateral
ligament of the knee joint.
Has a projection called the lateral
malleolus that articulates with the
trochlea of the talus; lies more
inferior and posterior than the
medial malleolus; and provides
attachment for the anterior talofi
bular, posterior talofi bular, and
calcaneofi bular ligaments. It also
has the sulcus for the peroneus
longus and brevis muscle tendons.

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The Foot

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The Foot

The bones of the foot include the

tarsus, metatarsus, and phalanges

7 tarsal bones
5 metatarsal bones
14 phalanges

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Regions of Foot

Forefoot

Midfoot

Metatarsals
Phalanges
Navicular
Cuboid
3 Cuniforms

Hindfoot

Calcaneus
Talus
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Bones

Talus
Calcaneus

Sustentaculum Tali
Peroneal Tubercle

Cuboid
Navicular
3 Cuneiforms
5 metatarsals
5 phalanges (proximal, middle, distal)
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Talus

Transmits the weight of the body from the tibia to the foot and is
the only tarsal bone without muscle attachments.
Has a neck with a deep groove, the sulcus tali, for the
interosseous ligaments between the talus and the calcaneus.
Has a body with a groove on its posterior surface for the fl exor
hallucis longus tendon.
Has a head, which serves as keystone of the medial
longitudinal arch of the foot.

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Calcaneus

Is the largest and strongest bone of the foot and lies below the
talus.
Forms the heel of the foot, articulates with the talus superiorly
and the cuboid anteriorly, and provides an attachment for the
Achilles tendon.
Has a shelf-like medial projection called the sustentaculum tali,
which supports the head of the talus (with the spring ligament)
and has a groove on its inferior surface for the flexor hallucis
longus tendon (which uses the sustentaculum tali as a pulley).

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Calcaneus

Is the largest and strongest bone of the foot and lies below the
talus.
Forms the heel of the foot, articulates with the talus superiorly
and the cuboid anteriorly, and provides an attachment for the
Achilles tendon.
Has a shelf-like medial projection called the sustentaculum tali,
which supports the head of the talus (with the spring ligament)
and has a groove on its inferior surface for the flexor hallucis
longus tendon (which uses the sustentaculum tali as a pulley).

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Ankle Fractures

Ankle fractures refer to fractures of the distal tibia,

distal fibula, talus, and calcaneus.
Because an ankle fracture often presents with
symptoms similar to those of an ankle sprain, a
complete and thorough examination of the
involved extremity is needed to avoid
misdiagnosis and prevent unnecessary
radiographs.
Indicators suggesting fracture include gross
deformity, swelling (especially perimalleolar),
bony tenderness, discoloration, and ecchymosis.
Inability to bear weight on the injured foot also
indicates a fracture.

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Tarsal Fracture

The calcaneus is the most frequently fractured

tarsal bone.

These fractures represent approximately 2% of all

fractures but 60% of tarsal bone fractures.

Patients present with severe heel pain in

association with soft tissue swelling and
ecchymosis extending to the arch.

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Great Saphenous Vein

Drains the medial end of dorsal

venous arch of foot

Passes upward directly in front of the

medial malleolus.

Ascends on medial side of the leg

Passes behind the knee and curves

forward around the medial side of the
thigh
Passes through the saphenous hiatus
in the deep fascia and joins the
femoral vein about 4 cm below and
lateral to the pubic tubercle
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Great Saphenous Vein

Tributaries:

Superficial lateral femoral v.

Superficial medial femoral
v.
External pudendal v.
Superficial epigastric v.
Superficial iliac circumflex
v.

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Superficial epigastric v.

Superficial circumflex iliac v.

Superficial lateral femoral v.

External pudendal v.
Superficial medial femoral v.
Great saphenous v.

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Varicose Veins

Varicose veins are normal veins that

have dilated under the influence of
increased venous pressure
Varicose veins are caused by
weakened valves and veins

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Superficial Arteries and Nerves

Superficial arteries:
superficial epigastric a.
superficial iliac circumflex a.
external pudendal a.
Cutaneous nerves:
lateral femoral cutaneous n.
anterior and medial cutaneous
branches of femoral n.
cutaneous branches of
obturator n.
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Lateral femoral cutaneous n.

Anterior and medial

cutaneous branches of
femoral n.
Cutaneous branches of
obturator n.

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Superficial inguinal lymph nodes

Superior group:
Lie just distal to the inguinal
ligament
Receive lymph vessels from
anterior abdominal wall below
umbilicus, gluteal region, perineal
region, external genital organs
Inferior group:
Lie vertical along the terminal
great saphenous v.
Receives all superficial lymph
vessels of lower limb, except for
those from the posterolateral part
of calf

Efferent vessels drain into the

deep inguinal ln. or external iliac ln.
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Fascia Lata

Fascia lata

The deep fascia encloses the thigh

like a trouser leg.

Saphenous hiatus (opening)

A gap in the deep fasica which lies

about 4 cm below and lateral to
the pubic tubercle. The falciform
margin is the lower lateral border
of the opening, which lies anterior
to the femoral vessels.

Filled with loose connective tissue

called the cribriform fascia
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Case 9

After a motorcycle accident a 28

year old male patient is rushed to
the hospital with an open fracture of
his leg

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Questions to be Answered

What should you observe and ask

and assess in your initial contact
with this patient?
How should you treat the leg after
initial assessment?

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