Chapter 12: The bones of the lower limb
The hip bones (which have been named - they are no longer "innominate"!) meet anteriorly at the pubic symphysis. Together with the sacrum, they form a ring termed the bony pelvis. Each hip bone consists of an ilium, an ischium, and a pubis, all three of which in the adult are fused at the acetabulum to form a single bone.
The hip bone connects the trunk to the lower limb by extending from the sacrum to the femur. The terminology of the hip bone is based on the anatomical position, in which the articular surface of the pubic symphysis is in a sagittal plane and the pubic tubercle and anterior superior iliac spine are in the same coronal plane. The internal (or visceral) aspect of the body of the pubis then faces almost directly superiorward so that the urinary bladder rests upon it.
The ilium consists of a body and an ala (or wing), which are not visibly demarcated from each other on the lateral aspect. The body of the ilium is fused with the ischium and pubis and forms about the superior two fifths of the acetabulum. The iliac crest, which is the superior border of the bone, is readily palpable. The anterior extent of the iliac crest is the anterior superior iliac spine, to which the inguinal ligament is attached, and the posterior extent is the posterior superior iliac spine. The anterior superior iliac spine is an important landmark, which can be palpated (and sometimes seen) by tracing the iliac crest forward or the inguinal ligament upward. Clinically, the lower limb is measured from the anterior superior iliac spine to the tip of the medial malleolus of the tibia. The measuring tape is kept along the medial side of the patella. The posterior superior iliac spine is usually marked by a dimple in the skin just lateral to the sacrum. A line connecting the right and left dimples is at the level of the second sacral vertebra (S2) and indicates approximately the level of the middle of the sacro-iliac joints. Most of the iliac crest presents outer and inner lips and a rough intermediate line for attachment of muscles. The tubercle of the crest is the lateralmost part of the crest and is a projection of the outer lip about 5 cm posterior to the anterior superior iliac spine. The highest point of the iliac crest is slightly posterior to its midpoint. The supracristal plane, which is a horizontal plane that connects the highest points of the right and left iliac crests, is at the level of the L4 vertebra, generally at the interval between the spines of L3 and 4.
The ala (or wing) of the ilium presents three surfaces (the gluteal and sacropelvic surfaces and the iliac fossa) separated by three borders (anterior, posterior, and medial, respectively). The gluteal surface is crossed by variable muscular ridges (posterior, anterior, and inferior gluteal lines) that define attachments of gluteal muscles (fig. 12-1). Medially, a smooth surface, the iliac fossa, forms a part of the lateral wall of the greater (or "false") pelvis (fig. 12-4). Posterior to the iliac fossa, a rough sacropelvic surface includes the iliac tuberosity, which is a very rough, ligamentous area, and, inferior to it, the auricular (meaning "ear shaped") surface which is the iliac contribution to the sacro-iliac joint. The anterior border begins at the anterior superior spine and includes the anterior inferior iliac spine, situated superior to the acetabulum. Inferior to the anterior inferior spine and anterior to the acetabulum, the junction of the ilium and pubis forms a diffuse swelling, the iliopubic eminence. The posterior border of the ilium begins at the posterior superior spine and includes the posterior inferior iliac spine; it then runs anteriorward and forms the greater sciatic notch. The medial border includes the anterior edge of the auricular surface. Its inferior aspect forms a rounded ridge, the arcuate line, which continues to the iliopubic eminence.
The ischium, which forms the postero-inferior part of the hip bone, consists of a body and a ramus. The body is fused with the ilium and pubis and forms approximately the posterior two fifths of the acetabulum. The inferior end of the body forms a rough impression known as the ischial tuberosity, to which the hamstrings are attached (figs. 12-1, 12-2, 12-3, 12-4 and 12-5). The tuberosity is covered by a bursa, which may become enlarged ("weaver's bottom"). The ischial tuberosity is obscured by the gluteus maximus when the hip is extended but is palpable when the thigh is flexed. The body weight rests on the ischial tuberosities in the sitting position. The body of the ischium presents three surfaces: one facing the thigh (femoral), another related to the ischiorectal fossa (pelvic), and still another (posterior), which is continuous with the gluteal surface of the ilium. Superiot to the ischial tuberosity, the lesser sciatic notch leads to the ischial spine, which is at the inferior limit of the greater sciatic notch. These notches are converted into foramina by the sacrospinous and sacrotuberous ligaments. The ramus of the ischium extends medially from the body and tuberosity and joins the inferior ramus of the pubis. The conjoined rami of the ischium and pubis complete the inferior aspect of the obturator foramen. They have two surfaces: one faces the thigh and the other the pelvis and perineum.
The pubis consists of a body and two rami. The bodies of the two sides meet in the median plane at the pubic symphysis. The medial, or symphysial, surface is rough and covered by cartilage. The body also presents a pelvic surface, which faces superiorward and supports the bladder, and a femoral surface, which is roughened for muscular attachments. On the anterior aspect, a ridge termed the pubic crest ends laterally in the pubic tubercle. The pubic tubercle is an important landmark in the lower part of the abdominal wall, about 3 cm from the median plane (see fig. 25-7). It can be found by tracing the tendon of the adductor longus superiorward. The pubic tubercle is crossed by the spermatic cord and is a guide to the superficial inguinal ring, femoral ring, and saphenous opening. In the anatomical position, the pubic tubercles and the anterior superior iliac spines are all in the same coronal plane. The superior ramus of the pubis extends superolaterally to the acetabulum, where it is fused with the ilium and ischium, and forms about the anterior one fifth of the acetabulum. Anteriorly, the pecten, or pectineal line, extends along the superior pubic ramus from the pubic tubercle to the iliopubic eminence. The pubic crest and the pectineal line form a part of the linea terminalis. On the inferior aspect of the superior pubic ramus, the obturator crest extends from the pubic tubercle to the acetabular notch. A triangular pectineal surface lies between the pectineal line and the obturator crest. The superior ramus also presents a pelvic surface and an obturator surface, the latter crossed by the obturator groove, which lodges the obturator nerve and vessels; the groove is converted by the obturator membrane into the obturator canal. The inferior ramus of the pubis joins the ramus of the ischium.
The acetabulum (resembling a Roman vinegar cup; cf. acetic acid) is formed by the ilium, ischium, and pubis (see figs. 12-1 and 15-12). It opens inferiorward, anteriorward, and lateralward and forms a socket for the head of the femur. Its horseshoe-shaped, articular surface is known as its lunate surface, whereas its rough, nonarticular floor is the acetabular fossa. The rim, which is deficient on the inferior side at the acetabular notch, gives attachment to the acetabular labrum that deepens the hip socket. The obturator foramen is bounded by the ischium and the pubis and their rami. Except at the obturator groove, the foramen is closed by the obturator membrane, which is attached along its margin.
The three parts of the hip bone begin to ossify during the fetal period. By late childhood, the three primary centers are separated in the acetabulum by the Y-shaped triradiate cartilage (figs. 12-8C and 12-9). Secondary centers appear chiefly in that cartilage and also in the iliac crest, anterior inferior iliac spine, ischial tuberosity, and pubic symphysis.
The femur, or thigh bone (figs. 12-7, 12-8, 12-10, 12-11, 12-12, 12-13, 12-14, 12-15, 12-16, 12-17 and 12-18), is the longest and heaviest bone in the body. Its length varies from one fourth to one third of that of the body; hence stature can be estimated from it. When a subject is in the standing position, the femur transmits weight from the hip bone to the tibia. The femur is well covered with muscles, so that only its superior and inferior ends are palpable.
The superior end consists of a head, neck, and two trochanters. Its trabeculae are well seen radiographically (see fig. 12-7). The head faces superiorward, medialward, and slightly anteriorward and presents a pit (or fovea) to which the ligament of the head is attached (figs. 12-10 and 12-12). The blood supply to the head of the femur is important, because it may be interrupted when the neck is fractured. Metaphysial and epiphysial arteries from the femoral circumflex vessels are carried in retinacula from near the femoral trochanters along the neck of the femur to reach the head. Other epiphysial arteries from the obturator enter the head by way of the ligament of the head (see fig. 15-15). The femoral neck is separated from the shaft in front by the intertrochanteric line, which can be traced inferiorly to a spiral line that joins the medial lip of the linea aspera (fig. 12-13). Posteriorly, about two thirds of the neck is intracapsular (fig. 12-18). The plane of the neck, followed medially, usually lies anterior to that of the femoral condyles (anteversion of head of femur), and the two planes form an angle (fig. 12-16). This angle of femoral torsion is about 15 degrees in the adult but is approximately twice as great in infancy. The degree of anteversion may be altered in pathological conditions, and its determination may be important in diagnosis and treatment. In addition, the long axes of the femoral neck and shaft make an angle of inclination (fig. 12-17), which may be altered by any pathological condition that weakens the neck of the femur. When the angle of inclination is diminished, the condition is known as coxa vara; when it is increased, as coxa valga. The neck is a common site of fracture in older people, with danger of avascular necrosis of the head if blood flow is compromised. The greater trochanter is situated laterally and can be palpated (most easily with the hip abducted) on the lateral side of the thigh, a hands-breadth or more below the iliac crest. When a subject is in the erect position, the greater trochanters are in the same horizontal plane as the pubic tubercles, the heads of the femora (and hence the hip joints), and the coccyx. Posteriorly, the greater trochanter can be traced downward into the intertrochanteric crest, which presents an elevation termed the quadrate tubercle (fig. 12-13). A depression medial to the greater trochanter posteriorly is the trochanteric fossa (fig. 12-12). The lesser trochanter projects medially at the junction of the neck with the shaft.
The shaft of the femur, which is convex anteriorly, presents anterior, medial, and lateral surfaces. In the middle third, the prominent posterior border is known as the linea aspera (figs. 12-13 and 12-14). It has medial and lateral lips and an intermediate area that broadens into a posterior surface in the upper and lower thirds of the shaft. The superior aspect of the medial lip of the linea aspera is continuous with the spiral line and the lateral lip is continuous with with the gluteal tuberosity. Between the continuations of the lips, the pectineal line extends superiorly toward the posterior part of the lesser trochanter. The inferior part of the medial lip of the linea aspera is continuous with the medial supracondylar line, which is interrupted to allow the passage of the femoral artery and ends in the adductor tubercle. The lateral lip is continuous with the lateral supracondylar line, which descends to the lateral epicondyle. The posterior, or popliteal, surface lies between the two supracondylar lines at the posteroinferior part of the femur.
The inferior end of the femur consists of two condyles, which are continuous anteriorly but separated inferiorly and posteriorly by the intercondylar fossa. On their anterior aspects, the condyles form the patellar surface, which comprises a wider lateral and a narrower medial part (fig. 12-10); these articulate with corresponding facets on the patella. Medially, the most prominent part of the medial condyle is the medial epicondyle. The adductor tubercle, a small prominence on the superiormost portion of the medial condyle, can be found by tracing the tendon of the adductor magnus inferiorward. Laterally, the lateral condyle presents the lateral epicondyle, near which are the origins of the lateral head of the gastrocnemius and the popliteus.
The obliquity of the femur results in an obtuse, lateral angle at the knee. Its exaggeration is termed genu valgum (knock-knee). Genu valgum may tend to encourage lateral dislocation of the patella.
To determine whether shortening of the limb is in the head or neck of the femur (or in both), the relative positions of certain anatomical points are verified. For example, a line (Nelaton's) from the anterior superior iliac spine to the most promient part of the ischial tuberosity should normally lie superior to the greater trochanter.
The shaft of the femus begins to ossify during the eighth postovulatory week, and an epiphysial center is usually present in the distal end at birth. Centers appear for the head, the greater trochanter, and the lesser trochanter during infancy, childhood, and late childhood, respectively (see figs. 12-8 and 15-15).
The patella, or knee cap (figs. 12-19, 12-20 and 12-21), is a triangular sesamoid bone embedded in the tendon of insertion of the quadriceps femoris muscle. The superior border of the patella is the base of the triangle, and lateral and medial borders descend to converge at the apex. The patella can be moved from side to side when the quadriceps is relaxed. A part of the quadriceps tendon covers the anterior surface of the bone and is continued, as the patellar ligament, to the tuberosity of the tibia. The patella articulates on its posterior side with the patellar surface of the condyles of the femur. The articular surface of the patella comprises a larger, lateral facet and a smaller, medial one. Lateral dislocation of the patella is resisted by the shape of the lateral condyle of the femur and by the medial pull of the vastus medialis. Excision of the patella results in minimal functional deficiency. The patella ossifies from several centers, which appear during childhood.
The tibia, or shin bone (figs. 12-20, 12-21, 12-22, 12-23, 12-24, 12-25, 12-26 and 12-27), measures about one fourth to one fifth of the length of the body. It can be palpated on the anterior and medial sides of the leg. When a subject is in the standing position, the tibia transmits the weight from the femur to the foot.
The superior end is expanded for articulation with the inferior end of the femur. It consists of medial and lateral condyles, and a tuberosity is found anteriorly at the junction with the shaft. The superior end of each condyle articulates with the corresponding femoral condyle. Irregularities of the superior surface of the tibia between the two tibial condyles form a series of intercondylar areas, an eminence, and tubercles. The inferior aspect of the lateral condyle presents posteriorly a circular facet for the head of the fibula. In the position of kneeling, the body rests on the lower part of the tuberosity, the ligamentum patellae, the anterior portion of the tibial condyles, and the patella.
When viewed from the superior aspect, the shaft of the tibia appears twisted (as if the upper end were rotated more medially than the lower). The angle of tibial torsion (usually 15 to 20 degrees) is that between a horizontal line through the condyles and one through the malleoli. This angle of tibial torsion increased over early childhood. The shaft of the tibia has medial, lateral, and posterior surfaces that are separated from one another by anterior, interosseous, and medial borders. The medial surface is readily palpable on the anteromedial aspect of the leg. The posterior surface, which is crossed superiorly by a rough ridge termed the soleal line, may be considered to have medial and lateral parts, and these may be separated by an indistinct vertical ridge. The anterior border, or crest, forms the easily palpable "shin" and descends from the lateral side of the tibial tuberosity to the anterior aspect of the medial malleolus. The interosseous (or lateral) border gives attachment to the interosseous membrane.
The inferior end of the tibia presents: (1) an anterior surface; (2) a lateral surface, which ends in the fibular notch (for articulation with the lower end of the fibula); (3) a posterior surface (grooved by the tibialis posterior and flexor digitorum longus tendons); (4) a medial surface, which runs onto the distal prolongation of the tibia known as the medial malleolus; and (5) an inferior surface, which articulates with the talus. It should be noted that the talus also articulates with the lateral surface of the medial malleolus.
The shaft begins to ossify during the eighth postovulatory week, and an epiphysial center is usually present in the superior end at birth. Centers appear for the inferior end during infancy (see fig. 12-30), commonly for the tuberosity (which ossifies mainly by inferiorward growth from the upper epiphysis) and sometimes for the tip of the medial malleolus.
The fibula (figs. 12-20, 12-21, 12-22, 12-23, 12-25, 12-26, 12-27, 12-28 and 12-31) is the slender, lateral bone of the leg. It does not bear weight. The term "peroneal" is synonymous with fibular, and has been used in the past interchangably. The fibula articulates with the tibia superiorly and with the talus inferiorly and is anchored in between to the tibia by the interosseous membrane. The superior and inferior ends of the bone are palpable, but muscles cover its middle portion.
The superior end, or head, articulates with the posteroinferior aspect of the lateral condyle of the tibia. The head of the fibula is readily palpable by tracing the biceps tendon inferiorward (see figs. 12-23 and 12-25). It is on the same level as the tuberosity of the tibia. The head is prolonged superiorward into an apex (or styloid process) posterolaterally. The common peroneal nerve winds from posterior to the head and onto the lateral aspect of the "neck," where it can be palpated by rolling it between a finger and the bone (see fig. 12-26). The shaft of the fibula is arched anteriorward in such a way that the plane of the interosseous membrane is almost sagittal, except at its inferior end, where it becomes coronal. The seeming torsion of the fibula and the changing relationships of the fibula and tibia must be kept in mind in order to understand the topography of the leg. The shaft of the fibula has a roughly triangular cross section, although the surfaces and borders vary considerably (as does their nomenclature: the Birmingham Revision is followed here). When well-developed, at least three surfaces (anterior, lateral, and posterior) and three borders (anterior, posterior, and interosseous) can be distinguished. Moreover, the posterior surface is subdivided by a prominent ridge, the medial crest, as a result of which the medial portion of the posterior surface may be described as a separate, medial surface. In terms of muscular attachments, the anterior, lateral, and posterior surfaces are extensor, peroneal, and flexor, respectively (see fig. 16-1).
The inferior end of the fibula, or the lateral malleolus, is more prominent, more posterior and extends about 1 cm more distally than the medial malleolus. It articulates with the tibia and with the lateral surface of the talus; the talus fits between the two malleoli. Posteromedially, a malleolar fossa gives attachment to ligaments. Posteriorly, a groove on the lateral malleolus is occupied by the peroneal tendons. The classic (Pott's) fracture at the ankle involves the lower end of the fibula.
The shaft begins to ossify at about the junction of the embryonic and fetal periods. Centers appear for the inferior end during infancy and for the superior end during childhood. It should be noted that the inferior epiphysial line of the fibula is in line with the superior surface of the talus in the ankle joint (figs. 12-27 and 12-30).
The tarsus (figs. 12-30, 12-31, 12-32, 12-33, 12-34 and 12-35) usually comprises seven bones, one of which, the talus, articulates with the bones of the leg. The tarsus is convex superiorly and concave inferiorly. The tarsal bones are the talus, navicular, and three cuneiforms on the medial side, and the calcaneus and cuboid, which are more laterally placed. Accessory ossicles may be found, e.g., a fibular sesamoid, the os tibiale externum (near the tuberosity of the navicular and sometimes called the "accessory navicular"), and the os trigonum (at the posterior aspect of the talus; see fig. 12-30B).
The navicular, cuneiforms, and cuboid, together with the five metatarsals, form the transverse arch of the foot. Medially, a longitudinal arch is established by the calcaneus, talus, navicular, cuneiforms, and the first three metatarsals. Laterally, a longitudinal arch is formed by the calcaneus, cuboid, and the lateral two metatarsals.
The talus, or ankle bone, has no muscular attachments. Its body is its posterior part, and it has a superior projection called the trochlea. The trochlea has superior and medial surfaces for articulation with the tibia and a lateral surface for the fibula. Various tubercles and processes have received conflicting names. The most important is the lateral (or posterior) tubercle, which may be found as a separate skeletal element, the os trigonum (see fig. 12-30B). The neck and head of the talus are directed anteriorward and medially. A deep depression under the lateral side of the neck and above the calcaneus is known as the tarsal sinus. It becomes narrow medially to form the tarsal canal. The head of the talus, which rests on the sustentaculum of the calcaneus, articulates with the navicular and the plantar calcaneonavicular ("spring") ligament. Inferiorly, the talus has three facets for articulation with the calcaneus (fig. 12-36). Small portions of the talus may be palpable, especially in children but most of it is obscured within the ankle joint.
The navicular lies between the talus on the posterior side and the three cuneiforms that are immediately anterior to it. Its medial projection, the tuberosity of the navicular, can be palpated just anteroinferior to the medial malleolus and anterior to the sustentaculum tali. The posterior aspect of the tuberosity is the medial end of the transverse tarsal joint. (The lateral end of the transverse tarsal joint is about halfway between the lateral malleolus and the tuberosity of the fifth metatarsal, which is also palpable.) The tuberosity provides the main insertion for the tibialis posterior tendon.
The three cuneiform bones, so called because they are wedge-shaped, lie anterior to the navicular and posterior to the first three metatarsals. The medial and lateral cuneiforms project farther anteriorward than does the intermediate one, leaving a depression over the middle cuneiform that is occupied by the base of the second metatarsal. The line of the tarsometatarsal joints is thus irregular. The medial cuneiform can be identified by tracing the tibialis anterior tendon to it in the dorsiflexed foot.
The calcaneus, or os calcis, transmits much of the weight of the body from the talus to the ground. Its trabeculae are well seen radiographically (see fig. 12-30D). The anterior portion of the superior aspect is prolonged medially: this projection, the sustentaculum tali, can be felt in vivo immediately inferior to the medial malleolus. The superior surface of the sustentaculum has a facet for the talus, and its inferior surface is grooved by the flexor hallucis longus tendon. The posterior part of the calcaneus is known as the calcaneal tuberosity. It gives attachment posteriorly to the calcaneal tendon and inferiorly to some of the short muscles of the sole as well as to the plantar aponeurosis. The calcaneus articulates with the cuboid on its anterior aspect. The anterior ends of the talus and calcaneus are more or less flush, and they form the posterior joint surface of the transverse tarsal joint. Various tubercles and processes of the calcaneus have received confusing names.
The cuboid articulates posteriorly with the calcaneus, anteriorly with the fourth and fifth metatarsals, and medially with the lateral cuneiform and sometimes the navicular. The fibularis longus tendon lies in a notch laterally and may occupy a groove on the inferior surface.
Ossification (see fig. 12-30).
The calcaneus and talus begin to ossify during fetal life, and the cuboid shortly before birth. Epiphysial centers appear for the calcaneal tuberosity and the posterior tubercle of the talus during childhood.
The tarsus is connected to the phalanges by five metatarsal bones, referred to collectively as the metatarsus. They are numbered from 1 to 5, from medial to lateral. They are longer and thinner than the metacarpals.
Each metatarsal is technically a long bone, consisting of a base proximally, a shaft, and a head distally. Each bone has characteristic features, e.g., the first (which carries more weight) is short and thick. The base of the fifth presents a tuberosity, which projects posterolaterally and is palpable at the lateral aspect of the foot.
The shaft of each metatarsal begins to ossify during fetal life, and centers appear postnatally in the heads of the four lateral bones and in the base of the first metatarsal (see fig. 12-30C). The first metatarsal, like the first metacarpal, may have a center for its head as well as its base. The tuberosity of the fifth metatarsal frequently shows a separate center and lack of fusion of this center must be distinguished from fracture.
The great toe (and frequently the little toe) has two phalanges, whereas each of the other toes has three. They are designated proximal, middle, and distal. Each phalanx is technically a long bone, consisting of a base proximally, a shaft, and a head distally. Although the phalanges of the foot are shaped differently from those of the hand, their basic arrangement is similar; e.g., each distal phalanx ends distally in a tuberosity. The middle and distal phalanges of the little toe are often fused. The phalanges usually begin to ossify during fetal life, and centers appear postnatally in the bases of most of them (see fig. 12-30C).
Sesamoid bones are found related to the inferior aspect of some of the metatarsophalangeal and interphalangeal joints. Two located just inferior to the head of the first metatarsal are almost always present.
Frazer's Anatomy of the Human Skeleton, 6th ed., rev. by A. S. Breathnach, Churchill, London, 1965. A detailed, regional synthesis of skeletal and muscular anatomy.
12-1 How is the hip bone oriented in the anatomical position?
12-2 On what does the body weight rest in the sitting position?
12-3 To which features is the pubic tubercle a guide?
12-4 Compare the acetabulum with the glenoid cavity of the scapula.
12-5 Why is the blood supply to the head of the femur important clinically?
12-6 On which structures does one kneel?
12-7 How are (a) the adductor tubercle of the femur and (b) the head of the fibula found?
12-8 What is the relationship of the lateral malleolus to the medial?
12-9 What is the classic fracture at the ankle?
12-10 Do any tarsals show ossification at birth?
Figure 12-1 The right hip bone, lateral view, anatomical position.
Figure 12-2 The right hip bone, inferolateral view, muscular and ligamentous attachments.
Figure 12-3 The right hip bone, posterolateral view, muscular and ligamentous attachments. The origin of the tensor fasciae latae often extends more posteriorly.
Figure 12-4 The right hip bone, anterior view, anatomical position.
Figure 12-5 The right hip bone, medial view, anatomical position.
Figure 12-6 The right hip bone, medial view, muscular origins and ligamentous attachments.
Figure 12-7 The hip in various positions. A, Maximum lateral rotation. Note the apparent foreshortening of the neck of the femur. The lesser trochanter is clearly visible. B, anatomical position. Although the neck shows well, it is still slightly foreshortened, and a slight degree of medial rotation would be necessary to show it correctly. C, Maximum medial rotation. Note that the lesser trochanter is now overlapped completely by the shaft of the femur.
Figure 12-8 A, Child's hips, abducted. Note the epiphysis for the lesser trochanter on each side. B, Hip of an adult, abducted. Note the greater trochanter (above) and lesser trochanter (below). C, Child's hip. Note the site of the triradiate cartilage (arrow) and the epiphyses for the head and greater trochanter of the femur.
Figure 12-9 A, The hip bone at birth. lined regions indicate bony areas in the ilium, ischium, and pubis. The rest is cartilage. B, The hip bone at puberty, showing the increase in ossification and secondary centers (black). C, Adult acetabulum. The lines indicate the site of fusion of the ilium, ischium, and pubis.
Figure 12-10 The right femur, anterior view, anatomical position. The asterisk indicates the cervical tubercle.
Figure 12-11 The right femur, showing muscular attachments. The inferior part of the origin of the vastus intermedius fuses with that of the vastus lateralis.
Figure 12-12 The right femur, medial and lateral views.
Figure 12-13 The right femur, posterior view, anatomical position.
Figure 12-14 Schematic representation of the posterior femur. A, The linea aspera and its superior and inferior extensions. B, Muscular attachments.
Figure 12-15 Muscular and ligamentous attachments to the superior and inferior ends of the right femur. Anterior, The fascia that encloses the tensor fasciae latae meets at the anterior edge of that muscle, turns around the anterior edge of the gluteus minimus, and fuses with the fascia of the rectus femoris muscle and with the iliofemoral ligament at the ilium and with the tendon of the gluteus minimus below at the greater trochanter. This fascial strip constitutes the iliotrochanteric band. Medial, The attachment of the iliofemoral ligament turns superiorward at the superior aspect of the lesser trochanter and constitutes the femoral attachment of the pubofemoral ligament. Posterior, See also fig. 12-14 for details. Lateral, The gluteus medius muscle is inserted along an oblique line on the lateral aspect of the greater trochanter, contiguous on the anteroinferior aspect with the gluteus minimus (a bursa intervenes) and posterosuperiorly with the piriformis.
Figure 12-16 Anteversion of the head of the right femur as viewed from the superior aspect. The angle of torsion is the angle between the long axis of the head (upper arrow) and the horizontal axis of the condyles (lower arrow).
Figure 12-17 The angle of inclination, which averages about 125 degrees in adults.
Figure 12-18 The superior and inferior ends of the femur, showing the usual position of the epiphysial lines and the usual line of attachment of the joint capsule. The posterior part of the neck is covered by a reflection of synovial membrane but has little if any capsular attachment. (Based on Mainland.)
Figure 12-19 The right patella.
Figure 12-20 A, Anteroposterior view of the knee. Note the obliquity of the femur, outline of the patella, radiolucent interval occupied by the menisci and articular cartilage, and intercondylar eminence of the tibia (showing the lateral and medial intercondylar tubercles). B, lateral view of the flexed knee. Note the patella, condyles of the femur, head of the fibula, (superior) tibiofibular joint, and tuberosity of the tibia. (Courtesy of V. C. Johnson, M.D., Detroit, Michigan.)
Figure 12-21 A, Child's knee, lateral view. Note the epiphyses for the inferior end of the femur and the superior end of the tibia. The patella has begun to ossify, and the fat deep to the ligamentum patellae is visible as a radiolucent area. B, lateral radiograph of the knee, showing fabella (arrow). C, Radiograph of the flexed knee. Note the radiological joint space between the femur and patella. The lateral condyle of the femur is that on the right-hand side of the illustration. D, Radiograph of dried bones of a 5-year old boy. Note the outline of the cartilage. E, Pneumoarthrogram of the knee produced by injecting air into the joint cavity. Note the medial meniscus and the cruciate ligaments. (A courtesy of V. C. Johnson, M.D., Detroit, Michigan. E courtesy of Sir Thomas lodge, Sheffield, England.)
Figure 12-22 The right tibia and fibula, anterior view.
Figure 12-23 The right tibia and fibula, anterior aspect, muscular and ligamentous attachments. Note that the fibularis longus and extensor digitorum longus muscles arise from the tibia as well as from the fibula.
Figure 12-24 The right tibia. Note that the soleal line (posterior view) is interrupted. (See fig. 16-4.) The vertical line that subdivides the posterior surface separates the origins of the flexor digitorum longus and the tibialis posterior.
Figure 12-25 The right tibia and fibula, posterior aspect, muscular and ligamentous attachments. Note that, because of the twisting shaft of the fibula, the origins of the fibularis longus and brevis are visible in part in this posterior view. The attachment of the deep transverse fascia of the leg is indicated by a single asterisk; the attachment of the aponeurosis covering the tibialis posterior muscle is indicated by two asterisks. The flexor (like the extensor) hallucis longus arises from the fibula.
Figure 12-26 Muscular and ligamentous attachments of the superior ends of the right tibia and fibula. In the lateral view, note that the interosseous border of the tibia separates the attachments of the tibialis anterior and the tibialis posterior. The origin of the fibularis longus and extensor digitorum longus from the tibia is not shown. (See fig. 12-23.) Lower right, Schematic representation of the relations of the tibial collateral ligament, which crosses the semimembranosus tendon but which is deep to the tendons of the gracilis, semitendinosus, and sartorius (the pes anserinus).
Figure 12-27 The superior and inferior ends of the right tibia and fibula, showing the usual position of the epiphysial lines and the usual line of attachment of the joint capsule. (Based on Mainland.)
Figure 12-28 The right fibula. Note that: (1) in the medial view, the medial crest subdivides the posterior surface; (2) in the posterior view, the lateral surface turns posteriorly in passing downward; and (3) in the lateral view, the anterior surface turns laterally in passing downward.
Figure 12-29 A, Anteroposterior view of the left ankle. Note the medial and lateral malleoli (and their different levels) and the trochlea of the talus. B, lateral view of the ankle. Note the line of the talotibial part of the joint and the outlines of the talus, navicular, and calcaneus. (B courtesy of V. C. Johnson, M.D., Detroit, Michigan.)
Figure 12-30 The ankle and foot. A, Child's ankle. Note the epiphyses for the inferior ends of the fibula and tibia. The epiphysial line of the fibula is in line with the ankle joint. B, lateral view of an adult ankle. Note the os trigonum (arrow) at the posterior aspect of the talus. C, Child's foot. Note the epiphyses for the metatarsals and phalanges. Note also the irregularity in the ossification of the phalanges of the fifth toe. D, lateral view of child's foot. Note the epiphyses for the base of the first metatarsal (arrow) and for the calcaneus (A, B, and C courtesy of V. C. Johnson, M.D., Detroit, Michigan. D courtesy of George L. Sackett, M.D., Painesville, Ohio.)
Figure 12-31 A, Dorsoplantar view of the foot. At least a portion of all seven tarsal bones can be identified. Note the os tibiale externum (arrow) near the tuberosity of the navicular. Note also the sesamoid bones below the head of the first metatarsal. B, lateral view of the foot. Note the navicular and its tuberosity (overlapped by the head of the talus), the cuboid, a peroneal sesamoid, and the tuberosity of the fifth metatarsal. The numerals 1, 2, and 3 indicate the lines of the first, second, and third cuneometatarsal joints, respectively. C, Oblique view of the foot. Note the region where the calcaneus may meet the navicular. A peroneal sesamoid (arrow) is visible near the tuberosity of the cuboid. (Courtesy of V. C. Johnson, M.D., Detroit, Michigan.)
Figure 12-32 Bones of the right foot.
Figure 12-33 Bones of the right foot, muscular and ligamentous attachments. The attachments of the interossei are omitted.
Figure 12-34 Bones of the right foot.
Figure 12-35 Bones of the right foot, medial aspect, muscular and tendinous attachments.