M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Lower Limb

Bones, Joints and Proximal Muscles of the Lower Limb * Black font: Essential for Tutorial
(Compiled from Yunnan + Em’s + Wee’s + Moore) Red font: Notes for understanding

General Objectives
a) To understand the major features of the innominate bone and the bones of the lower limb and describe
the joints as a design for specific movements and stability.
b) To know how the proximal muscles produce movements at the hip joint.

Specific Objectives
1. The hip joint is more stable than the glenohumeral joint. It may, however, suffer dislocation (e.g. seated
passenger in a road traffic accident) which may potentially damage the sciatic nerve.
a. Give an account of the articulation between the femoral head and the acetabulum, including factors that
help to maintain stability.

Articulation between the femoral head and the acetabulum

The hip joint, a synovial ball-and-socket joint, is the articulation between the hemispherical head of the
femur and the cup-shaped acetabulum of the hip bone. The articular surfaces are lined with hyaline
cartilage. The hip joint is a very stable joint.

Factors which maintain stability at the hip joint

Factor Explanation
Bony - Femur head is firmly clasped within deep acetabulum cup, which is deficient
inferiorly
- Deepening of the acetabulum cavity by fibrocartilaginous acetabulum labrum
Muscular - Short articular muscles present
Ligaments - Iliofemoral: Prevents overextension during standing
- Pubofemoral: Limits extension, abduction
- Ischiofemoral: Limits extension
- Transverse acetabular ligament of head of femur: Stabilize the joint
Joint capsule Strong and dense capsule increases stability of the joint

Remarks:
1. The iliofemoral ligament is the most important ligament in maintaining stability at the hip joint.
2. The fibrous joint capsule goes through the intertrochanteric line around the neck of femur and folds
inwards inferiorly to the margin of articular hyaline cartilage.

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b. List the movements at this joint mentioning the muscles (including attachments) responsible.

Movements at the hip joint

Movements Muscles involved
Flexion Iliopsoas (iliacus + psoas major), sartorius, rectus femoris
Extension Gluteus maximus, hamstring muscles
Abduction Gluteus medius and minimus, tensor fasciae lata
Adduction Adductor longus and brevis, adductor fibres of adductor magnus, gracilis
Lateral rotation Piriformis, obturator int. and ext., gemellus superior and inferior, quadratus femoris
Medial rotation Anterior fibres of gluteus medius and minimus

Muscles (including attachments) responsible for movements at hip joint

Muscle Proximal attachment Distal attachment Main action
Iliacus Iliac crest, iliac fossa, ala of sacrum, Tendon of psoas major, lesser Act conjointly in flexing thigh
Iliopsoas

and anterior sacroiliac ligaments
Psoas Sides of T12 – L5 vertebrae and discs
major between them; transverse processes
of all lumbar vertebrae
Sartorius Anterior superior iliac spine and
superior part of notch inferior to it
Rectus femoris Anterior inferior iliac spine and ilium
superior to acetabulum (the only
muscle crossing the hip joint)
Gluteus maximus Ilium posterior to posterior gluteal
line; dorsal surface of sacrum and
coccyx; sacrotuberous ligament
Hamstrings Ischial tuberosity
Gluteus medius External surface of ilium between
anterior and posterior gluteal lines
Gluteus minimus External surface of ilium between
anterior and inferior gluteal lines
Tensor fasciae lata Anterior superior iliac spine;
anterior part of iliac crest
Adductor longus Body of pubis inferior to pubic crest
Adductor brevis Body and inferior ramus of pubis
Adductor fibres of Inferior ramus of pubis, ramus of
adductor magnus ischium
Gracilis Body and inferior ramus of pubis
Piriformis Anterior surface of sacrum;
sacrotuberous ligament
Obturator Pelvic surface of obturator
internus membrane and surrounding bones
Superior and Superior: ischial spine
inferior gemelli Inferior: ischial tuberosity
Obturator Of obturator foramen and
externus obturator membrane
Quadratus femoris Lateral border of ischial tuberosity
trochanter, and femur distal to it
Lesser trochanter of femur
Superior part of medial surface of
tibia
Via common quadriceps tendon
and independent attachments to
base of patella
Most fibres end in iliotibial tract,
which inserts into lateral condyle
of tibia; some fibres insert on
gluteal tuberosity
Tibia and fibula
Lateral surface of greater
trochanter of femur
Anterior surface of greater
trochanter of femur
Iliotibial tract, which attaches to
lateral condyle of tibia
Middle third of linea aspera of
femur
Pectineal line and proximal part
of linea aspera of femur
Gluteal tuberosity, linea aspera,
medial supracondylar line
Superior part of medial surface of
tibia
Superior border of greater
trochanter of femur
Medial surface of greater
trochanter (trochanteric fossa) of
femur
Medial surface of greater
trochanter (trochanteric fossa) of
femur
Trochanteric fossa of femur
Quadrate tubercle on
intertrochanteric crest of femur
and area inferior to it
at hip joint and in stabilizing
this joint
Flexes, abducts, and laterally
rotates thigh at hip joint
Steadies hip joint and helps
iliopsoas flex high
Extends thigh (especially
from flexed position) and
assists in its lateral rotation;
steadies thigh and assists in
rising from sitting position
Extends thigh
Abduct and medially rotate
thigh
Adducts thigh (no medial
rotation)
Adducts thigh; to some
extent flexes it
Adducts and flexes thigh
Adducts thigh
Laterally rotate extended
thigh and abduct flexed
thigh; steady femoral head in
acetabulum
Laterally rotates thigh;
steadies head of femur in
acetabulum

Remarks:
1. The piriformis is the landmark muscle in identifying muscles of the gluteal region.

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c. Briefly review the blood supply to the femoral head and how it may be compromised in a fracture of the
neck (of femur). Compare this to a trochanteric (more distal) fracture.

Blood supply to the femoral head

The trochanteric anastomosis provides the main blood supply to the head of the femur. The arteries pass
along the femoral neck beneath the capsule. The lateral and medial femoral circumflex arteries, both
branches of the profunda femoris anastomose around the femoral neck. The retinacular arteries (branch
of circumflex arteries) and small acetabular branch of the obturator artery in the ligament of the femoral
head also supplies blood directly to the head of the femur.

How blood supply is compromised in a fracture of the neck (of femur)

A dislocation or fracture of the femoral neck interferes with or completely interrupts the blood supply
from the root of the femoral neck to the head. The anastomosis between the small branch of the
obturator artery and branches of the medial circumflex femoral artery ascending the femoral neck deep
to the synovial membrane is disrupted. The scant blood flow along the small artery that accompanies the
ligament of the femoral head may be insufficient to sustain the viability of the femoral head, and
avascular necrosis of the ischium gradually occurs.

Subcapital fracture (i.e. fracture at neck of femur) vs Trochanteric fracture

- Subcapital fracture occurs in elderly women due to greater osteoporosis; trochanteric fracture occurs
in young, middle-aged
- Subcapital fracture:
o Commonly results in avascular necrosis
 Blood supply from the root of the femoral neck to the femoral head is interrupted
 Anastomosis between branch of obturator artery along ligament of femoral head and
branches of medial circumflex femoral artery ascending the femoral neck deep to the
synovial membrane is disrupted.
 The scant blood flow along the small obturator artery is insufficient to sustain the viability of
the femoral head and ischemic necrosis gradually takes place.
o Lateral rotation of the lower limb
- Trochanteric fracture:
o Results in similar displacement as a subcapital fracture
o No avascular necrosis

Remarks:
1. Subcapital fracture is also known as transcervical fracture or intracapsular fracture.
2. Subcapital fracture does not cause avascular necrosis in children because branches of obturator
artery are the main arteries supplying the femoral head; anastomosis has not developed within
children.

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 M1 Anatomy Tutorial: Bones, Joints and Proximal Muscles of the Lower Limb

2. The stability of the knee joint is often compromised in a game of football resulting in injury to menisci and
ligaments. Endoscopic study and surgical repair are often possible at this joint.
a. Describe the articulation at the knee joint as a modified hinge joint. What movements are possible at
this joint?

Articulation at the knee joint

The knee joint between the femur and tibia is a modified synovial hinge joint, as some degree of rotatory
movement is possible. The rounded condyles of the femur articulate with the medial and lateral tibial
condyles and their cartilaginous menisci.
The joint between the femur and patella is a synovial joint of plane gliding variety. The lower end of the
femur articulates with the patella.

Possible movements at the knee joint

Movements Muscles involved
Flexion Hamstrings
Extension Quadriceps femoris
Lateral rotation Biceps femoris
Medial rotation Popliteus, sartorius, gracilis, semitendinosus

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b. How do the various ligaments contribute to stability at this joint? How does one sustain injury to
ligaments and menisci?

How ligaments contribute to stability at the knee joint

Extracapsular:
- Ligamentum patellae: A continuation of the central portion of the common tendon of the quadriceps
femoris, strengthens ant. aspect of the joint capsule
- Oblique popliteal ligament: A tendinous expansion derived from semimembranosus, strengthens
posterior aspect of joint capsule
- Lateral (fibular) and medial (tibial) collateral ligaments: Strengthen joint collaterally

Intracapsular:
- Anterior cruciate: Prevents posterior displacement of the femur on the tibia. When the knee is flexed,
it prevents the tibia from being pulled anteriorly
- Posterior cruciate: Prevents anterior displacement of the femur on the tibia. When the knee is flexed,
it prevents tibia from being pulled posteriorly.

Injury to ligaments
Medial collateral ligament Can tear during excessive abduction of leg
Lateral collateral ligament Can tear during excessive adduction of leg
Cruciate ligaments Injury to cruciate ligaments can occur when excessive force
(extrasynovial but applied to knee joint; tears of ACL are common while tears of
intracapsular) PCL are rare. Joint cavity quickly fills with blood
(hemathrosis) so that joint is swollen
Stability of knee joint depends largely on tone of quadriceps & integrity of collateral ligaments, so
operative repair of cruciate ligaments not always attempted.

Injury to menisci
Menisci can be crushed between the condyles of femur and tibia
- Medial menisci
o More prone to damage because it is connected with the medial collateral ligament, which
restricts its movement.
- Lateral menisci
o Separated from the lateral collateral ligament by fibres of the popliteus muscle and thus more
mobile

c. What structures may be viewed in an endoscopy of the knee joint?

Structures seen in an endoscope

- Synovial membrane
- Menisci
- Anterior and posterior cruciate ligaments

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3. Mobility of the foot is facilitated by both ankle and subtalar joints.

a. Review the structure of the ankle (talocrural) as a typical hinge joint, mentioning features which
contribute to stability.

Structure of the ankle (talocrural) joint

The ankle joint is a synovial hinge joint. The lower end of the tibia articulates with the two malleoli and
the body of the talus

Features of joint which contribute to stability

Factor Explanation
Bony - Upper part of body of talus fits nicely in the deep socket formed by the lower ends of the tibia and fibula
- Inferior transverse tibiofibular ligament, which runs between the lateral malleolus and the posterior border
of the lower end of the tibia, deepens the socket into which the body of the talus fits snugly.
Ligaments - Medial (deltoid) ligament
- Lateral ligaments
o Anterior talofibular ligament
o Calcaneofibular ligament
o Posterior talofibular ligament
Joint capsule Strong and dense capsule increases stability of the joint

Movements of the ankle joint

Movements Muscles involved
Dorsiflexion Tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius
Plantar flexion Gastrocnemius, soleus, plantaris, peroneus longus and brevis, tibialis posterior, flexor digitorum longus
and flexor hallucis longus

b. What is the subtalar joint and what movements are possible here?

Subtalar joint and possible movements

The subtalar joint is the posterior synovial plane joint between the talus and the calcaneum. The inferior
surface of the body of the talus articulates with the facet on the middle of the upper surface of the
calcaneum. Gliding and rotator movements are possible here.

c. List the muscles (may be done later) involved in plantar flexion (flexion), dorsiflexion (extension),
inversion and eversion of the foot, mentioning the joint(s) involved.

Joints (and muscles) involved in foot movements

Movement Muscles involved Joint(s) involved

Dorsiflexion Tibialis anterior, extensor hallucis longus, extensor digitorum longus, Ankle joint
peroneus tertius
Plantar flexion Gastrocnemius, soleus, plantaris, peroneus longus and brevis, tibialis Ankle joint
posterior, flexor digitorum longus and flexor hallucis longus
Inversion Subtalar joint
Transverse tarsal joints
Eversion Subtalar joint
Transverse tarsal joints
Gliding and rotator Talocalcaneonavicular joint
movements

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4. A flattened arch may impair proper function of the foot as a lever, with ‘spring’. Such a foot is also subjected to
strain with resultant discomfort.
a. Identify the longitudinal arches of the foot including the bones involved.

Longitudinal arches of the foot

Arches of the foot allow the body’s weight to be distributed over a larger area and prevent crushing and
vessels and nerves nearing the sole.

Medial Extends from the medial process of the calcaneum to the heads of medial 3 metatarsals. Include the
longitudinal arch calcaneum, talus, navicular, 3 cuneiform bones and the 1st 3 metatarsals
Lateral Extends from the lateral process of the calcaneum to the heads of the 4th and 5th metatarsals. Include the
longitudinal arch calcaneum, cuboid, 4th and 5th metatarsal
Transverse arch Lies across the distal row of tarsal rows and adjacent metatarsal bones. Include the bases of the metatarsal
bones, cuboid, 3 cuneiform bones

b. Review the principles behind the support of these arches.

Principles behind support of arches

- 4 principles:
o Shape of the bones: A ‘keystone’ occupies the centre of the arch
o Inferior edges of the bones are tied together by ligaments and muscles
o Ends of the arch are tied together by muscles and aponeuroses
o Arch is suspended from above by ligaments and muscles

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