BONES of the LOWER

LIMB
Lower limb starts from the sacroiliac joint

Lower limb can be divided into four regions

Gluteal region
It is the posterior part of the pelvis and extends
between the iliac crest and the lower border of the
gluteus maximus muscle
Femoral region (thigh)
The region between the hip and knee joints
Leg (cruris)
The region between the knee and ankle joints
Foot (pedis)
The region distal to the ankle joint
 Sacroiliac joint:
The lower limb is
connected to
vertebral column
with this joint

Hip joint

Knee joint

Ankle joint

Figure: Right lower limb, anterior view

Bones of the gluteal region
 Hip bones (coxae) are the
bones of the gluteal region

 Coxa is formed by the union

of three bones
 Iliac bone Ilium
 Ischial bone
 Pubic bone
ACETABULUM
 The depression on the lateral
aspect of the hip bone is Ischium Pubis
called the ACETABULUM
 Articultes with the head
of the femur

Right coxa viewed from lateral

Each coxa posteriorly
articulates with sacrum
and form the sacroiliac
joints

Sacrum

Coxae of both sides

anteriorly articulate and
form the pubic Coxa
symphysis
pubic symphysis
 BONY PELVIS
(PELVIC SKELETON)

Bony pelvis is formed of four bones

 Two hip bones
 Sacrum
 Coccyx
BONY PELVIS (continued)

Hip bones (coxa)

 Formed by the fusion of ilium, ischium and pubis,
which unites at the acetabulum
 The hip bones join with sacrum posteriorly at the
sacroiliac joint, and with each other anteriorly at
the pubic symphysis
 Pelvic bones are connected to each other through
firm ligaments
BONY PELVIS (continued)

Ilium
 Ala of the ilium
 Anterior superior iliac spine (asıs)
 Anterior inferior iliac spine
 Posterior superior iliac spine
 Posterior inferior iliac spine
 Iliac crest
 Arcuate line
BONY PELVIS (continued)

Ischium
 Body
 Ramus (unites with the rami of pubis to form the
obturator foramen)
 Ischial tuberosity
 Ischial spine
 Lesser sciatic notch is between the ischial spine
and ischial tuberosity
 Greater sciatic notch is superior to the ischial
spine
BONY PELVIS (continued)

Pubis
 Body
 Superior ramus
 Inferior ramus
 Pubic tubercle
 Pubic crest (superior rough surface of the body)
 Pecten pubis (ridge extending laterally from the pubic
tubercle)
 Obturator foramen is formed between the rami of the
pubis and ramus of ischium
BONY PELVIS (continued)

The bony pelvis is divided into two parts

by a line passing through the terminal line
(pectineal line, arcuate line and sacral
promontory)

Terminal line determines the border of the

pelvic inlet (line of passage from greater
pelvis to lesser pelvis)
BONY PELVIS (continued)

 Greater (false) pelvis

 Lies superior to the pelvic inlet
 Anteriorly bounded by the abdominal wall
 Some of the abdominal viscera are situated here

 Lesser (true) pelvis (lies inferior to the pelvic inlet)

 Lies between the pelvic inlet and pelvic outlet
 Inferiorly bounded by the pelvic diaphragm
 Pelvic viscera (i.e. urinary bladder, uterus, ovaries,
part of rectum) are situated here
BONY PELVIS (continued)

 Pelvic inlet is bordered by the terminal line

 The rim of pelvic inlet is called the pelvic brim

 Pelvic outlet is bordered by

 Inferior margin of the pubic symphysis
 Inferior rami of the pubis
 Ischial tuberosities
 Sacrotuberous ligaments
 Tip of coccyx
BONY PELVIS (continued)

Pelvic inlet diameters

 Diameter conjugata
 Narrowest of the pelvic inlet diameters
 Also called conjugata vera or obstetric conjugate
 Extends between the promontorium and the most posterior part
of the pubic symphysis
 About 11,2 cm in an adult female
 Smaller diameters may cause difficulty in delivery
BONY PELVIS (continued)
There are two additional versions of the antero-posterior
diameter:
 Anatomical conjugate (diameter anatomica, true
conjugate, antero-posterior diameter)
 Extends between the promontorium and the upper border of
the pubic symphysis
 About 12,5 cm in an adult female

 Diagonal conjugate (diameter diagonalis)

 Extends between the promontorium and the lower border of
the pubic symphysis
 About 13,5 cm in an adult female
 Can be measured by vaginal examination
BONY PELVIS (continued)

Pelvic inlet diameters (continued)

 Transverse diameter (diameter transversa)

 Usually the widest diameter of the inlet
 Extends between the widest points of the right and left side of
the terminal line
 About ma 13,5 cm or more in an adult female

 Diameter obliqua
 Extends from the sacroiliac joint of one side to iliopubic
eminence of the opposite side
 Diameter from the right sacroilic joint to left iliopubic eminence
is about 13 cm, other side is 12,5 cm in an adult female
Sexual Differences in Pelvis
BONY PELVIS (continued)

Pelvis types
 The pelvis of any individual may have some features of
the opposite sex (see the following figure)
 A and C is common in males
 B and A is common in white females
 B and C is common in black females
 D is uncommon in both sexes
Pelvic Diameters (conjugates)
Clinical note

Pelvic fractures
The weak areas of the pelvis are common sites of
fractures
 Pubic rami
 Acetabulum
 Region of sacroiliac joint
 Ala of ilium
PELVIC JOINTS and LIGAMENTS

 Lumbosacral joints
 Sacrococcygeal joint
 Sacroiliac joints
 Pubic symphysis
PELVIC JOINTS and LIGAMENTS (continued)

Lumbosacral joints
 Anterior intervertebral joint between L5 and S1
 Two posterior zygoapophysial joints between the
articular processes
 Supported by the iliolumbar ligament

Sacrococcygeal joints
 Has an intervertebral disc
 Anterior and posterior sacrococcygeal ligaments
support the joint
PELVIC JOINTS and LIGAMENTS (continued)

Sacroiliac joints
 Synovial joints having little movement ability
 Sacrum is suspended between two iliac bones
 The joint is supported by the interosseous and
sacroiliac ligaments
PELVIC JOINTS and LIGAMENTS (continued)

Sacroiliac joints (continued)

 Superior movement of the sacrum is further limited by
two ligaments
 Sacrotuberous ligament
 Extends from the posterior inferior iliac spine, sacrum and
coccyx to the ischial tuberosity
 Forms the greater sciatic foramen together with the
sacrospinous ligament
 Priformis muscle further divides this foramen into
suprapriform and infrapriform foramens
 Sacrospinous ligament
 Extends from the anterior surface of the sacrum and coccyx to
the ischial spine
 Forms the lesser sciatic foramen together with the
sacrotuberous ligament
PELVIC JOINTS and LIGAMENTS (continued)

Pubic symphysis
 Formed by the union of the bodies of the pubic bones
in the median plane
 Interpubic disc lies between the articulating surfaces
 Superior and inferior pubic ligaments support the
joint
Clinical note

Relaxation of pelvic ligaments and joints during

pregnancy
 Relaxation is due to the hormonal changes, especially due to
the presence of hormone called relaxin
 Results in a small increase in pelvic diameters, which
facilitates the passage of fetus through the pelvic canal
Bones of the thigh and leg

FEMUR

PATELLA

FIBULA TIBIA

Right lower limb, anterior view

 TALUS
Bones of the foot
 Three groups of bones CALCANEUS
TARSAL
form the skeleton of the
foot BONES
 Tarsal bones CUBOID
 Metatarsal bones
 Phalanges NAVICULAR

CUNEIFORM
There are seven tarsal bones S
 Talus
 Calcaneus
METATARSAL
 Os cuboideum BONES
 Os naviculare
 Os cuneiforme mediale
 Os cuneiforme
intermedium,
PHALANGES
 Os cuneiforme laterale

Figure: Right foot, superior

view
TARSAL METATARSAL
BONES PHALANGES
BONES

Figure: Right foot, lateral view

 TALUS NAVICULAR

CUNEIFORMS

CALCANEUS

CUBOID

TARSAL METATARSAL
BONES PHALANGES
BONES

Figure: Right foot, lateral view

CLINICAL NOTE

Fractures of the femur

 Most common site of the femoral fractures is its neck

 Mostly occur in elderly people having osteoporosis, commonly
after a fall
 Avascular necrosis of the femoral head is a common
complication due to the disruption of the arteries supplying the
femoral head
 Risk of fat embolism is relatively high in femoral shaft
fractures
Hip replacement
CLINICAL NOTE

Fractures of the tibia and fibula

 Fractures of these two bones are relatively common
 Fractures of the tibia commonly occurs at its lower 1/3
where it gets thinner
 Fractures of the fibula most commonly occurs at 3-5
centimeters above the lateral malleolus
 Fractures involving both the medial and lateral
malleoli are called the Pott’s fracture
CLINICAL NOTE

Fractures of the calcaneus

 Fractures of this bone are mostly due to the falls on
foot from height
 Flattening and widening of the heel, as well as the collapse of
the long arch of the of the foot (traumatic flat foot) is observed

 Another type of fracture is the avulsion fracture of the

calcaneus occuring due to the sudden pull of the
calcaneal tendon
 Part of calcaneus where the calcaneal tendon attaches detaches
from the rest of the bone
CLINICAL NOTE

Fractures of the metatarsal bones

 Stress fractures most commonly involve the 2nd and
3rd metatarsal bones
 Stress fractures (fatigue fractures) is the general term
describing the fractures occuring as a result of
prolonged periods of excessive exercise
 Commonly affects the bones of the lower limb, foot
bones being the most commonly affected
 Art. coxa

 Hip joint
 Knee joint
 Proximal and distal
tibiofibular joints
Art. genus
 Ankle joint
 Intertarsal joints
 Metatarsophalangeal
joints
 Interphalangeal joints Art. talocruralis

Figure: Right lower extremity, anterior view

 Hip joint
 Between the
acetabulum and
the head of
femur Acetabulum

Head of femur

Figure: Right hip joint, opened. Lateral view

 Joint capsule
 Iliofemoral ligament
 Ischiofemoral ligament
 Pubofemoral ligament
 Orbicular zone
 Ligament of the head of the femur
(ligamentum teres)
 This ligament attaches to the fovea of the
head of the femur; inside this ligament
passes the acetabular branch of the posterior
branch of the obturator artery
 Transverse acetabular ligament
 Attaches the sides of the acetabular notch
and converst it to a foramen through which
the vessels and nerves of the joint pass
CLINICAL NOTE

Congenital hip dysplasia (dislocation)

 A congenital problem in which the head of the femur is

not secured in the acetabulum

 The limitation of abduction as well as shortness of the

related limb is observed in the newborn
CLINICAL NOTE

Traumatic hip dislocation

 Usually occurs in traffic accidents due to a blow from
anterior direction, which forces the femur posteriorly
and results with a posterior dislocation of its head
 Avascular necrosis of the head of the femur might
develop if the ligament of the head of the femur is
ruptured
 In posterior dislocations of the femur, the sciatic nerve
might be damaged
 Knee joint Lateral
Medial condyle, condyle, femur
femur
 Betwen the femur
and tibia

 There are two Medial condyle,

tibia
menisci between
the condyles of
the femur and
tibia
 Medial menicus Lateral
Lateral and
 Lateral meniscus medial menisci
condyle, tibia

Figure: Left knee joint, opened. Anterior view

 Knee joint, sagittal section

Patella

Patellofemoral joint

Distal end of the femur

Meniscus
Proximal end of the tibia
 Medial (tibial) collateral
ligament
 Lateral (fibular) collateral
ligament
 Anterior cruciate ligament
Lateral
 Posterior cruciate ligament collateral
Medial ligament
collateral
ligament

Left knee joint, opened. Anterior view

 The ligaments providing stability of the
joint are classified as the intrinsic
(intracapsular) and extrinsic (extracapsular)
ligaments
Following are the intrinsic ligaments
 Anterior cruciate ligament
 Extends between the anterior intercondylar are of the tibia
and lateral condyle of the femur
 Posterior cruciate ligament
 Extends between the posterior intercondylar are of the tibia
and medial condyle of the femur
 Transverse genicular ligament (transverse ligament
of knee)
 Extends between the anterior parts of the medial and
lateral menisci
 Anterior meniscofemoral ligament
 Extends between the posterior end of the lateral meniscus
and medial condyle of the femur; passes anterior to the
posterior cruciate ligament
 Posterior meniscofemoral ligament
 Same as above, but passes posterior to the posterior
cruciate ligament
Following are the extrinsic ligaments
 Patellar ligament
 It is the tendon of the rectus femoris (one of the bellies of the
quadriceps femoris muscle); during its extend, it partially encloses
the patella but mostly passes anterior to it before it attachesto the
tibial tuberosity
 Medial (tibial) collateral ligament
 Lateral (fibular) collateral ligament
 Medial patellar retinaculum
 It is the continuation of the tendon of the vastus medialis (one of
the bellies of the quadriceps femoris muscle)
 Lateral patellar retinaculum
 It is the continuation of the tendon of the vastus lateralis (one of
the bellies of the quadriceps femoris muscle)
 Oblique popliteal ligament
 This ligament is the extension of the tendon of semimembranosus
muscle
 Arcuate popliteal ligament
 At one end it attaches to the head of the fibula, the other hand
splits into two and attaches to the tibia and the femur
CLINICAL NOTE

Injuries of the knee joint

 Sports injuries of the knee joint are relatively common

 The most commonly damaged ligament of the knee
joint is the tibial collateral ligament
 The knee joint is commonly exposed to direct traumas
from its lateral aspect
 This forces the tibial collateral ligament
CLINICAL NOTE
Injuries of the knee joint (continued)

 Tibial collateral ligament has attachment to the medial

meniscus
 Excessive strain of this ligament may lead to the tear of the
medial meniscus
 Rupture of the tibial collateral ligament is commonly
associated with the tear of the medial meniscus as well as
rupture of the anterior cruciate ligament
 Excessive rotation movements, especially when the
knee is flexed, may also cause tears of the medial
meniscus
 Injuries of the lateral meniscus are rare as it is
relatively small and loosely attaches to the fibular
collateral ligament
 Proximal and distal
tibiofibular joints
Proximal tibio-fibular joint

Distal tibio-fibular joint

Figure: Right tibia and fibula, anterior view

 Ankle joint (talocrural joint)

 Takes place
between the tibia,
fibula and the talus

Ankle Joint
Ligaments of the talocrural joint

 Joint capsule
 Medial collateral ligament (deltoid ligament)
 A ligament complex formed of four ligaments
 Lateral collateral ligament has three parts
 Anterior talofibular ligament
 Posterior talofibular ligament
 Calcaneofibular ligament

 This joint can make plantar flexion (flexion) and

dorsal flexion (extention) movements
Lateral
ligament
complex
 Art. subtalaris (talocalcanea)
 This joint can make some
amount of sliding movement
 Art. talocalcaneonavicularis
 This joint must be considered as
the anterior part of of subtalar
joint and talonavicular joint

 Can make inversion and eversion

movements besides some sliding
CLINICAL NOTE

Traumatic injuries of the ankle joint

 Among the most commonly injured joints

 Mostly occur as ankle sprains
 As the inversion angle is higher than the eversion
angle, sprains are mostly in the form of inversion
injuries
 Damage usually effects the lateral ligament complex
 Anterior and posterior talofibular ligaments and the
calcaneofibular ligament
 Most commonly effects the anterior talofibular ligament
Joints of the foot

 Intertarsaljoints

 Tarsometatarsal joints

 Metatarsophalangeal
joints

 Interphalangeal joints
CLINICAL NOTE
Gout
 A metabolic disease
 Increased production or more commonly decreased
excretion of uric acid
 Uric acid crystals accumulate in the joints causing joint
inflammation
 Signs of inflammation such as pain, swelling, redness and heat around
the affected joint are common signs
 The first metatarsophalangeal joint is the most
commonly affected one in gout
 Crystals may precipitate in the soft tissues such as
tendons, bursae and cartilage, as well as in the kidneys
forming stones
 Joints types of the lower limb

JOINT JOINT TYPE

Hip joint Spheroid

Knee joint Hinge

Proximal tibifibular joint Plane

Distal tibiofibular joint Syndesmosis

Talocrural joint Hinge

Subtalar (talocalcanea) joint Plane

Talocalcaneonavicular joint Plane