Applied anatomy of lower

extremity
Knee
• Patella
– Triangular sesamoid
bone
– Protects knee joint
– Improves leverage of
thigh muscles acting
across the knee
– Contained within
patellar ligament
Leg
• Tibia
– Receives the weight of body from
femur and transmits to foot
– Second to femur in size and weight
– Articulates with fibula proximally
and distally
• Interosseous membrane
• Fibula
– Does NOT bear weight
– Muscle attachment
– Not part of knee joint
– Stabilize ankle joint
 • Function:
Foot – Supports the weight of the
body
– Act as a lever to propel the
body forward
• Parts:
– Tarsals
• Talus = ankle
– Between tibia and fibula
– Articulates with both
• Calcaneus = heel
– Attachment for Calcaneal
tendon
– Carries talus
• Navicular
• Cuboid
• Medial, lateral and
intermediate cuneiforms
– Metatarsals
– Phalanges
Foot

• 3 arches
– Medial Longitudinal
– Lateral
– Transverse
• Has tendons that run
inferior to foot bones
– Help support arches
of foot
• Function
– Recoil after stepping
 Joints of Lower Limb
• Hip (femur + acetabulum)
– Ball + socket
– Multiaxial
– Synovial
• Knee (femur + tibia)
– Hinge (modified)
– Biaxial
– Synovial
– Contains menisci, bursa, many ligaments
• Knee (femur + patella)
– Plane
– Gliding of patella
– Synovial
Joints of Lower Limb

• Proximal Tibia + Fibula

– Plane, Gliding
– Synovial
• Distal Tibia + Fibula
– Slight “give” (synarthrosis)
– Fibrous (syndesmosis)
• Ankle (Tibia/Fibula + Talus)
– Hinge, Uniaxial
– Synovial
• Intertarsal & Tarsal-metatarsal
– Plane, synovial
• Metatarsal-phalanges
– Condyloid, synovial
• Interphalangeal
– Hinge, uniaxial
Clinical anatomy
Of
The Lubosacral
Plexus
62
NECK OF THE FEMUR

Trochanteric anastomosis

1. Superior gluteal artery

2. Inferior gluteal artery
3. Medial circumflex femoral
artery
4. Lateral circumflex femoral
artery

From this anastomosis, there

are small arteries called
“Retinacular arteries” supply
the NOF and the head

“Artery of ligament of head”

supplies blood to the head of
femur for some extent.
FRACTURE NECK OF THE FEMUR

Fracture of the neck may occur very

close to the head of the femur
(subcapital fracture), near the
midpoint (cervical fracture) or very
close to the shaft (basal)

Subcapital fracture is common in old

age because the spongy bone of the
neck is atrophic and the cortical bone
is thinner.

In case the fracture is complete it

interrupts the blood vessels passing
in the retinacula to the head of the
femur.

The vessels in the round ligament of the head are insufficient to prevent
‘avascular necrosis’.
FRACTURE NECK OF THE FEMOR

Non-union may be due to the effect of the synovial fluid which bathes the
fractured fragments and inhibits osteogenesis.

When the fracture of the neck is close to the shaft it is partly intracapsular and
partly extracapsular and union is better than the subcapital fracture.

In case the fracture is not impacted the following deformity is present

a.  There is a definite (true) shortening of the limb because the distal fragment
is pulled upward by the rectus femoris, the adductors and the hamstrings
with overlap of the two fragments.

b.  The distal fragment is also laterally rotated by the lateral rotators which are
stronger than the medial rotators.
FRACTURE SHAFT OF THE FEMUR
(Just below the lesser trochanter)

The following deformity is produced

Proximal fragment
• Abducted by the gluteus medius and
minimus.
• Laterally rotated by the gluteus
maximus, piriformis, obturators and
quadratus femoris.
• Flexed by the iliopsoas which is
attached to the lesser trochanter.

Distal fragment
• Pulled upward behind the proximal
fragment by the hamstrings and the
quadriceps femoris
• Adducted and laterally rotated by the
adductors
FRACTURE SHAFT OF THE FEMUR
(At its middle third)

The distal fragment is

drawn upward to a great
extent behind the
proximal fragment (much
overlap) by the
quadriceps and the
hamstrings, thus
resulting in considerable
shortening
FRACTURE SHAFT OF THE FEMUR
(Supracondylar)

Distal fragment

Drawn backward by the pull of the 2

heads of the gastrocnemius.

So it may injure the popliteal artery

as it lies in  direct contact with the
popliteal surface of the femur.

Pulled upward behind the proximal

fragment by the hamstring muscles.

(biceps femoris, semimembranosus and

ischial part of the adductor magnus)

Similarly ‘Slipped epiphysis’ may also

cause injury to popliteal artery
PATELLA

Patella is the largest sesamoid bone in the body

Lies within the tendon of quadriceps femoris
PATELLA

The stability of the patella is

maintained by

• Superiorly by quadriceps

• Inferiorly by patellar ligament

• Medially by horizontal fibers of

vastus medialis

• Laterally by prominent lateral

condyle of femur
PATELLA DISLOCATION

Due to twisting nature of sports, the

patella can come out of joint with an
awkward twist of the femur on tibia.

A twisting motion causes the patella to

shift to the side. Usually, the patella
moves laterally.

Because the quadriceps muscle

contracts to maintain the stability of the
body.

The shin has shifted so that the line of

pull of the quadriceps causes the patella
to shift laterally.

The patella is pulled laterally because it

wants to remain in line with the muscle.
PATELLA DISLOCATION

Is it common in women?

Females seem to have a greater risk for patellar dislocations than males.

This may be due, in part, to the shape of their hips.

A female’s hips are shallower and wider to accommodate pregnancy.

This tends to cause genu valgum (“knock-kneed” appearance)

in other words, their knees are closer together than their ankles like in the
above example.
PATELLA FRACTURE

Two major mechanisms of injury, direct and indirect.

Direct

Direct blow during fall onto knee or when it hits dashboard in RTA.

Because of small amount of prepatellar soft tissue and direct contact with the
femur posteriorly, nearly all of force is delivered to patella.

Frequently causes considerable comminution, but often there is little

displacement of fractured fragments.

Indirect

Can be due to jumping or unexpectedly rapid flexion of the knee against fully
contracted quadriceps.

Fractures of this type tend to be less comminuted than those from direct
trauma, but they are displaced and are often transverse.
PATELLA FRACTURE
FRACTURE OF TIBIA AND FIBULA

In case of fracture of only one bone

there is little displacement because the
intact bone acts as a splint.

In fracture of both bones, the distal

fragments are drawn upward behind
the proximal fragments by the action of
the gastrocnemius and soleus muscles

Fractures of tibia commonly to be

open because the medial surface is
subcutaneous throughout the course.

The nutrient artery to the tibia is directed towards the lower end.
Therefore, it may be torn in fracture of the distal 1/3 of the tibia resulting in
ischaemic necrosis with delayed union or non-union.
FRACTURE IN DISTAL END OF THE LEG

These fractures are very common and result from indirect violence with the
following possibilities.

• The lateral malleolus may be fractured alone.

• Both the medial malleolus and the lateral malleolus may be fractured
together (Pott’s fracture).

• The talus may be thrust upward between the tibia and fibula
(Dupuytren’s fracture).

It is associated with high fibular fracture

and disruption of syndesmosis
FRACTURE IN DISTAL END OF THE LEG

Pott’s fracture

A fracture to the lateral or medial malleoli is

known as Pott's fracture

In severe ankle sprains the force may pull

the bone off with the ligament.

This injury will occur when the ankle is

rolled inward or outward beyond its normal
range of movement.

Specially forcible eversion of the ankle

Symptoms include
• Severe pain
• Unable to put weight on the injured leg and the ankle will feel unstable
• Tenderness at the point of the fracture, usually over malleoli.
FRACTURES OF THE FOOT

Metatarsal stress fractures

• Takes place in the distal 1/3 of metatarsal bones

(MTB)

• These occur as the result of applied load to the

bone in an amount, or at a rate, that is greater
than the ability of the bone to repair and heal
itself.

• MT stress fractures are also known as march

fractures.

• MT stress fractures are most commonly seen in the 2nd and 3rd MTB.

• Stress fractures of the 4th and 5th MTB are rare and least on1st MTB.

• Minimal displacement due to the attachment of the interosseous muscles that act
as a splint.