Tibia 8.

Fibula

The tibia and fibula articulate at two joints, allowing limite d muscles in the leg. It also acts with the tibiofibular syndesmosis to
E motion (rotation). The crural interosseous membrane is a sheet stabilize the ankle joint.
of tough connective tissue that serves as an origin for several

LowerLimb
Fig. 32.1 Tibia and fibula
Right leg.

Lateral condyle /Z Tibial plateau Tibial plateau Lateral condyle

Tibiofibular \ / Tibiofibular
joint joint
— Medial Medial —
Head of fibula — condyle condyle — Head of fibula
lntercondylar /
Neck offibula - eminence — Neck of fibula

_ Tibial Head of tibia /

tuberosity
Soleal line —

lnterosseous — — lnterosseous
- - membrane membrane
5;

1'. Tibia,
l Fibula, — shaft shaft
shaft
l Z Lateral
surface
Z Fibula,
_ ‘ ill l
shaft
Medial — Z Medial
surface surface

Lateral — Posterior Z
su rfa ce Z Anterior surface
border

Tibiofibular Z Malleolar groove

syndesmosis (for tibialis
- Medial posterior ten don) / Lateral
malleolus malleolar fossa
Lateral — Z Ankle Medial / Z Lateral
malleolus mortise malleolus malleolus

A Anterior view. B Posterior view.

4
 Clinical box 32.1

Fibular fracture
lntercondylar Posterior inter- When diagnosing a fibular fracture, it
eminence condylar area is important to determine whether the
Head of
tibiofibular syndesmosis (see p. 426) is
fibula
disrupted. Fibular fractures may occur distal
to, level with, or proximal to the tibiofibular
syndesmosis; the latter two frequently
involve tearing of the syndesmosis.
5a1
'333U)[3
J \'Q

’.

be
j. .I Fibula
Tibia
I»
2:1
<—Z-ZZ:
/ Tibiofibular
syndesmosis
Media
E Q0" I \ malleolus l-atetal
malleolus
Talus
Calcaneus
5; _

a
l
Lateral _ D Medial
condyle . condyle
Anterior
Tibial lntercondylar
tuberosity area

C Proximal view.

Posterior Posterior
surface Surface In this fracture located proximal to the
syndesmosis (arrow), the syndesmosis is
l ZL lnterosseous Zk torn, as indicated by the widened medial
:' ,'-I membrane Tibia - - space of the upper ankle joint
joint - - (see

I; Lateral pp. 450-451).

—I—J|— surface /€“*
'*-Z
F Medial
surface
l l- FllJUlZ:I |\/|edj3|
“U
I surface

Lateral Z Anterior
surface border
D Transverse section, proximal view.

Articular surface Inferior Articular surface of

of lateral malleolus articular surface medial malleolus

.<|,{‘f . $0.: P. ,
-..., as
_‘"\w-1_

; | I ff, I
j Fibula Z /
Vi .
I

i‘.
->‘1j_'
Lateral Medial
malleolus malleolus
Lateral
malleolar fossa Tibia

E Distal view.

427
 Knee joint Overview

In the knee joint the femur articulates with the tibia and patella in the knee joint (contrast to the humerus in the elbow see p 322)
Both joints are contained within a common c apsu I e an d h ave Instead it forms a separate rigid articulation with the tibia
communicating articular cavities Note: The fibula IS not included

LowerLimb Fig 322 Right knee joint

Z Femur

Z Popliteal surface

lntercondylar notch
.

Z Medial Z Z Lateral epicondyle

Lateral epicondyle Z
X Lateral femoral condyle
Lateral femoral condyle i — Medial femoral —
condyle
Lateral tibial condyle Z EITIITIETICE
Z Medial Z
tibial condyle Tibiofibularjoint

- Neck offibula

A Anterior view
B Posterior view
 Fig. 32.3 Patella

Base

_I\"l I kl
6a1
33U)
-3|35

A Anterior
pex surface
Fslxterepeteller A Anterior view

Articular
surface

Lateral -
femoral condyle
Patella

_ Lateral A pex
tibial
Head of — condyle
B Posterior view
fibula

Fig. 32.4 Patellofemoral

Transverse section through patellofemoral. Distal
_ Tibiaj view with right knee in slight flexion.
tuberosity
Patellar lig. Prepatellar
Z Tibia (quadriceps tendon) bursa

Medial facet
C Lateral view Z Radiographic
Patella Z
view in
Lateral facet — Fig. 35.10B
Z joint space

Patellar surface Z — Synovial

of femur membrane
Fibrous Z
membrane Z Medial
collateral
Lateral collateral lig.
lig. Z Cruciate
ligs.
Lateral femoral — Medial
condyle femoral
condyle
Common \
fibular n.

Popliteal a. and v.

Tibial n. I

Gastrocnemius ~

42
 Knee joint: Capsule, Ligaments 8. Bursae

Table 32.1
Fig. 32.5 Ligaments of the knee joint
Anterior view of right knee.

Extrinsic ligaments
LowerLimb f Patellar lig.
Medial longitudinal patellar Z Femur
, retinaculum
Lateral longitudinal patellar
Anterior side retinaculum I
Medial transverse patellar
retinaculum
Vastus
Lateral transverse patellar intermedius
_ retinaculum tendon of
.’ 1’ Me d ial ti b ial c o llat rall ' . E insertion
Mediaj and jateraj ........... ......... ............ ...... VEISlIUS Z
Sides Lateral (fibular) collateral lateralis Vastus
5 5 lig. medialis
Oblique popliteal lig.
.................................

Arcuate popliteal lig.

Intrinsic ligaments
Rectus femoris
Anterior cruciate lig. tendon of
insertion
Posterior cruciate lig.
Transverse lig. of knee
Posterior meniscofemoral lig.
Lateral transverse Z Medial collateral
patellar retinaculum lig.

Lateral longitudinal Z Medial

patellar retinaculum transverse
patellar
retinaculum
Lateral collateral lig. —
Medial
longitudinal
Head of fibula Z patellar
retinaculum

— Patellar lig.

— Tibial
tuberosity

Fibula Z
Z Tibia

Z lnterosseous
membrane

430
Fig. 32.6 Capsule, ligaments, and periarticular bursae (‘Iii-|i¢gI box 32,2
Posterior view of right knee. The joint cavity communicates with peri-
articular bursae at the subpopliteal recess, semimembranosus bursa, Gastrocnemio-semimembranosus bursa
and medial subtendinous bursa of the gastrocnemius. (Baker's cyst)
Painful swelling behind the knee may be caused by
a cystic outpouching of the joint capsule (synovial
popliteal cyst). This frequently results from an increase
I
r in intra-articular pressure (e.g., in rheumatoid arthritis).
I 531
'3aau)j3
i

.’ f
I
Femur

Medial
subtendinous Lateral
bursa of subtendinous
gastrocnemius bursa of
gastrocnemius

/ Oblique
popliteal lig.

Semi- l Axial MRI of a Baker's cyst in the popliteal fossa, inferior

membranosus view. Baker’s cyst in the right popliteal fossa. Baker’s
bursa _I_:;_-_, - Lateral cysts often occur in the medial part of the popliteal
collateral lig. fossa between the semimembranosus tendon and the
Medial — medial head of the gastrocnemius at the level of the
collateral Arcuate posteromedial femoral condyle.
lig. _ l I popliteal lig.

Popliteus

Subpopliteal
recess

l I l- Fibula

Tibia
j . I
l ‘i..ll\' ll ’ I

431
 Knee joint: Ligaments 8. Menisci

Fig. 32.7 Collateral and patellar ligaments of the knee joint

Right knee joint. Each knee joint has medial and lateral collateral liga-
ments. The medial collateral ligament is attached to both the capsule
and the medial meniscus, whereas the latera I co ll ateral ligament
' has no
LowerLimb
direct contact with either the capsule or the lateral meniscus. Both
collate ra I l'igaments are taut when the knee is in extension and stabilize
thejoint
' ' 'in the coronal plane.

Z Femur
Quadriceps femoris
tendon
Quadrice P s Z
femoris tendon

Femoropatellar
joint

~ Patella
— Medial epicondyle
Lateral Z‘
epicondyle — Patellar
surface
Z Medial femoral
Lateral femoral \ of femur
condyle
condyle
Z Lateral
Lateral collateral lig. Z meniscus
— Medial meniscus
Z Patellar
Patellar
— Medial Posterior lig. of —
lig.
collateral lig. fibular head
Z Anterior
lig. of
fibuhr
head

Tibial
tuberosity
— Fibula
Fibula Zr.
Tibia, Z
medial
surface

A Medial view. B Lateral view.

4 32
Fig. 32.8 Menisci in the knee joint
Right tibial plateau, proximal view.

Clinical box 32.3

Anterior cruciate lig. Z Patellar lig.
av‘
Injury to the menisci
The less mobile medial meniscus is more
Medial / Z Transverse lig. susceptible to injury than the lateral
meniscus of knee meniscus. Trauma generally results from
531
'333U)[3
sudden extension or rotation of the flexed
knee while the leg is fixed.
@

— Tibio- ,
fibular 5, ; » 5-'_
joint e Z '

\ -I ’.1e,li
Medial Lateral ' -; " ,
collateral lig. collateral lig. I '
l l -.
Posterior Posterior menisco- Lateral Head of A BuCket_hand|e tear
cruciate lig. femoral lig. menisc us fibula '
v-.
'1--¢»~
A Right tibial plateau with cruciate, patellar
and collateral ligaments divided. "e 1

Medial meniscus Anterior cruciate lig. -V 5; I

l .. .e e ‘I -- fie
i .._ \
- ‘ I . ' ' I
--

', I_ Synovial
\Q‘
J
..,| membrane
.:~j{ir
B Radial tear of posterior horn.
3Q
I
' ..

B Attachment sites of menisci and cruciate . -

ligaments. Red line indicates the tibial
attachment of the synovial membrane
All
i \
r
' \._-
Head of
fibula
that covers the cruciate ligaments. The
cruciate ligaments lie in the subsynovial
connective tissue. Posterior cruciate lig. Lateral meniscus

Fig. 32.9 Movements of the menisci

Right knee joint.

ll Z‘

Patel la
\\\ Extension

l/7 I"
l
Patellar \ _<\: N
lig.

... I)I 52:I9- 22:. . ./I N‘I > I‘,

/ //‘
I Flexion

A Extension. B Flexion. C Tibial plateau, proximalview.

4 33
 Cruciate Ligaments

Fig. 32.10 Cruciate and collateral ligaments

Right knee joint. The cruciate ligaments keep the articular surfaces of the femur and tibia in
contact, while stabilizing the knee joint primarily in the sagittal plane. Portions of the cruciate
ligaments are taut in everyjoint position.
LowerLimb

lntercondylar
notch
Patellar _
surface / Lateral femoral
of femur condyle
Medial
Anterior Anterior
femoral
cruciate lig. X cruciate lig.
condyle
Transverse Z Posterior \ X Posterior
. Z
lig. of knee cruciate lig. menisco-
femoral lig.
Lateral Z Z Medial Z / Lateral
meniscus meniscus meniscus
_ Lateral
Lateral / Z Medial Z
collateral lig.
collateral lig. collateral lig.

Anterior lig. ‘ ~ Posterior lig. of

— Patellar lig. fibular head
of fibular head
(reflected
inferiorly)
\ Head of fibula

— Patella

Fibula Z lnterosseous
membrane
Tibia Z

A Anterior view. B Posterior view.

434
 Clinical box 32.4

Rupture of cruciate ligaments

Cruciate ligament rupture destabilizes
the knee joint, allowing the tibia to
move forward (anterior “drawer sign") or
backward (posterior “drawer sign") relative
Fig. 32.11 Right knee joint in flexion to the femur. Anterior cruciate ligament
Anterior view with joint capsule and patella removed. ruptures are approximately 10 times more
common than posterior ligament ruptures. 531
'333U)[3
The most common mechanism of injury
is an internal rotation trauma with the leg
fixed. A lateral blow to the fully extended
knee with the foot planted tends to cause
concomitant rupture of the anterior cruciate
Patellar surface Z and medial collateral ligaments, as well as
of femur tearing of the attached medial meniscus.
/ Posterior
cruciate lig.

Lateral femoral X / Medial femoral

condyle condyle

Lateral Z Z Anterior
collateral lig. cruciate lig.

Lateral Z e Z Medial ll‘ i I

meniscus meniscus

Head offibula —
.. _u.
L l
Z Medial collateral lig. A Right knee in flexion, rupture of anterior
cruciate ligament, anterior view.
Z Tibial
Fibula tuberosity

'l //3
Z Tibia
4i
./
/

41/’
ll
‘I
.

Fig. 32.12 Cruciate and collateral ligaments in flexion and extension

B Right knee in flexion, anterior “drawer
Right knee, anterior view. Taut ligament fibers in red.
sign,” medial view. During examination
of the flexed knee, the tibia can be pulled
forward.

)\
. / (1

ll
1
(\c
. /; I

J \\\\_ €e\;4V
__
T
ea

b ll %/ e %/ll
I-./ \\ \
\\\\
Y5 “

A Extension. B Flexion. C Flexion and internal rotation.

4 35
 Knee joint Cavity

Fig. 32.13 joint cavity Fig. 32.14 Opened joint capsule

Right knee, lateral view. The joint cavity was demonstrated by injectin 9 Right knee, anterior view with patella reflected downward.
liquid plastic into the knee joint and later removing the capsule.

/ Quadriceps tendon
LowerLimb ‘ex

/ Suprapatellar
pouch
Femur —

Femur ’

Suprapatellar
pouch
— Patella

/ Lateral
Lateral collateral \ meniscus — Femur,
patellar
Z Patellar lig. surface
Lateral
Subpopliteal femoral
recess M lnfrapatellar condyle
bu rsa
Anterior Medial
cruciate lig. femoral
condyle
Lateral — Medial
Fibula Z Z Tibia collateral lig. meniscus

Lateral ' — Alar folds

meniscus
Z lnfra-
patellar
Fig. 32.15 Attachments of the joint capsule fat pad
Right knee joint, anterior view. — Patella,
articular
surface

— oint capsule
(cut edge)

— Suprapatellar
pouch

Fibula Z Z Tibia

4 36