CLINICALLY ORIENTED

ANATOMY of the LOWER LIMB

Beka Aroshidze
2016
 The regions of the
lower limb
 the gluteal region, which
includes the buttocks and
lateral hip region and
overlies the pelvic girdle;
 the thigh, between the hip
and the knee;
 the popliteal and genual
regions, at the knee;
 the leg, between the knee
and ankle; and
 the foot, which has dorsal
and plantar surfaces.
◦ The plantar surface is also
called the sole of the foot.
Intramuscular gluteal injections
 Intramuscular injections are commonly given in
the gluteal region. The injection site must be in
the superior lateral quadrant or above the line
connecting the posterior superior iliac spine and
the top of the greater trochanter to avoid the
large sciatic nerve and gluteal vascular structures.
 Movements of the joints of the lower limb are
similar to movements of the upper limb, with
some variations. They include
◦ flexion—plantar flexion indicates flexing the foot
or toes downward;
◦ extension—dorsiflexion indicates extension of
the foot, as when lifting the foot or toes upward;
◦ abduction and adduction—the axis for abduction
and adduction of the toes is the 2nd digit;
◦ external rotation and internal rotation—movement
around a longitudinal axis;
◦ inversion, or supination of the foot—lifting the
medial edge of the sole; and
◦ eversion, or pronation of the foot lifting the lateral
edge of the sole.
 As in the upper limb, muscles of the lower
limb can be described as intrinsic or
extrinsic.
◦ Intrinsic muscles of the foot originate and insert
on bones of the foot and ankle.
◦ Extrinsic flexor and extensor muscles of the
foot originate in the leg.
 Synovial tendon sheaths surround the long flexor and
extensor tendons as they cross the ankle joint.
 Bones of the Lower Limb:
The Femur
 Proximally, its large ball-shaped head articulates with the
acetabulum of the hip bone.
 The neck, angled inferolaterally, connects the head with the shaft.
 Greater and lesser trochanters, sites for muscle attachments,
are separated by an intertrochanteric crest posteriorly and an
intertrochanteric line anteriorly.
 Linea aspera, paired ridges on the posterior surface of the shaft,
diverge distally as the medial and lateral supracondylar lines.
 Distally, the medial and lateral epicondyles are attachment
sites for ligaments of the knee, and the adductor tubercle is an
attachment site for muscle.
 The femur articulates with the tibia at the medial and lateral
condyles, which are separated by the intercondylar notch.
 The femur articulates with the patella anteriorly at the patellar
surface.

 FOR HIP BONE ANATOMY SEE: Pelvis

 Bones of the Lower Limb:
The Patella
 a large sesamoid bone, forms the kneecap
◦ It articulates with the distal femur at the knee joint.
◦ Superiorly, its base is attached to the quadriceps
tendon.
◦ Inferiorly, its apex is attached to the patellar
ligament.
 Bones of the Lower Limb:
The Tibia and the fibula
 The tibia is the large medial long bone of the leg
◦ Proximally, it articulates with the femur at the tibial plateau, which has
flat medial and lateral condyles separated by an intercondylar
eminence.
◦ It articulates with the fibula proximally at the tibiofibular joint and
distally at the tibiofibular syndesmosis.
◦ A tibial tuberosity on the anterior surface below the tibial plateau is
an attachment site for thigh muscles.
◦ The sharp anterior border of the shaft is palpable between the knee
and ankle.
◦ An interosseous membrane connects the shaft of the tibia and
fibula.
 The fibula is the lateral bone of the leg
◦ Proximally, the head articulates with the lateral condyle of the tibia at
the proximal tibiofibular joint.
◦ A narrow neck connects the head to the shaft.
◦ A distal tibiofibular syndesmosis binds the fibula to the distal tibia.
Osgood-Schlatter disease (OSD)
 Bones of the Lower Limb:
The Tarsal bones
 seven short bones of the foot
◦ The talus is the most superior tarsal bone.
 ○ The body articulates with the tibia and fibula at the ankle joint.
 ○ The head, which articulates with the navicular bone, is the highest part
of the medial arch of the foot.
 ○ The inferior surface articulates with the calcaneus.
◦ The calcaneus is the large tarsal bone of the heel.
 It articulates superiorly with the talus and anteriorly with the cuboid.
 The sustentaculum tali, a medial process, forms part of the medial
arch of the foot.
◦ The navicular lies anterior to the talus and forms part of the
medial arch.
◦ The cuboid lies anterior to the calcaneus on the lateral side of
the foot.
◦ The medial, intermediate, and lateral cuneiform bones lie
anterior to the navicular and articulate distally with the
metatarsal bones.
 Bones of the Lower Limb:
The Metatarsal bones
 consist of five long bones that are designated 1st
(medial) through 5th (lateral).
 Proximally, their bases articulate with the tarsal
bones.
 Distally, their heads articulate with the proximal
phalanges.
 The shaft connects the heads and bases.
 Paired sesamoid bones are associated with the
head of the 1st metatarsal.
 A prominent tuberosity at the base of the 5th
metatarsal is a site of attachment for muscles of
the leg.
 Bones of the Lower Limb:
The Phalanges
 small long bones of the toes
 The 2nd through 5th digits have a
proximal, middle, and distal phalanx.
 The 1st digit, the hallux, or great toe,
has only a proximal and a distal phalanx.
 Piriformis syndrome

 The sciatic nerve normally passes into the gluteal

region inferior to the piriformis muscle.
Tightening or shortening of the muscle can
compress and irritate the sciatic nerve, causing
pain and paresthesia (tingling and numbness) in
the buttocks and posterior thigh. In some cases
the sciatic nerve, or its common fibular
component, is compressed as it passes through
the muscle. Piriformis syndrome should be
distinguished from sciatica in which the pain and
paresthesia result from compression of lumbar
nerve roots by a herniated intervertebral disk.
 Congenital hip dislocation

 Congenital hip dislocation (also known as

hip dysplasia) is a common problem that
occurs when the femoral head is not
properly seated in the acetabulum. Hip
abduction is impaired, and, since the femoral
head sits higher than normal, the affected
limb is shorter than the contralateral limb,
resulting in a positive Trendelenburg test.
 In routine neonatal screenings, a dislocated
hip will “click” when it is adducted and
pushed posteriorly.
 Acquired hip dislocation
 usually occurs as a result of trauma that
causes the femoral head to be displaced out
of the acetabulum; anterior dislocations are
rare, but posterior dislocations are common.
 Typically, in a head-on motor vehicle
accident, the knees strike the dashboard,
forcing the femoral head posteriorly through
the joint capsule and onto the lateral surface
of the ilium. The affected limb appears
shortened and internally rotated.
◦ The sciatic nerve is particularly vulnerable to
injury in these cases.
 Femoral neck fracture

 Fractures of the femoral neck commonly occur

following a low-energy impact in women over 60
years of age with osteoporosis. The distal
fragment of bone is pulled upward by the
quadriceps femoris, adductor, and hamstring
muscles, causing shortening and lateral (external)
rotation of the limb.
 Although an ample arterial anastomosis
surrounds the hip joint, only the medial
circumflex femoral artery supplies branches that
enter the joint capsule and supply the femoral
head. Tearing of those branches at the fracture
site leads to avascular necrosis of the femoral
head.
Obturator artery, acetabular branch
for ligamentum capitis femoris
Knee exam
Common knee conditions
 The calcaneofibular ligament is located inferior and just
anterior to the lateral malleolus and connects the lateral
malleolus to the calcaneus. The interosseous ligament
between the tibia and the fibula is located medially and
superior to the lateral malleolus. The tibionavicular ligaments
are located on the medial side of the ankle joint, and the
point of injury and tenderness is at the lateral side. The
anterior tibiofibular ligament is located anterior to the ankle
 joint, away from the point of injury.
 Popliteal aneurysm
 Aneurysms of the popliteal artery are the most
common peripheral arterial aneurysm. They can be
distinguished by a thrill (palpable pulse) and bruits
(abnormal arterial sounds) overlying the popliteal
fossa. Because the artery lies deep to the tibial nerve,
an aneurysm may stretch the nerve or occlude its
blood supply. Pain from nerve compression is referred
to the skin overlying the medial aspect of the calf,
ankle, and foot. Half of all popliteal aneurysms remain
asymptomatic, and ruptures are rare, but symptomatic
patients present with distal leg ischemia from acute
embolization or thrombosis. Fifty percent of patients
with a popliteal aneurysm have an aneurysm in the
contralateral artery, and 25% have an aortic aneurysm.
 The dorsal pedal pulse
 The dorsal pedal artery is readily palpable on the
dorsum of the foot as it runs toward the first web
space lateral to the extensor hallucis tendon.
Absence of the dorsal pedal pulse suggests arterial
occlusion in the peripheral vasculature
 Lower limb ischemia
 Ischemia of the lower extremity is almost always related to atherosclerotic
disease. Intermittent claudication is a symptom of chronic ischemic disease
characterized by pain while walking, which intensifies over time and
disappears at rest. Chronic disease has a benign course and, in the majority of
patients, is treated conservatively. Acute ischemia has an abrupt onset from
an embolitic or thrombolytic origin and usually requires aggressive treatment.
 The six signs (P signs) of acute ischemia are: pain, pallor, pulselessness,
paresthesia, paralysis, and poikilothermy.
 Deep vein thromboses (DVT)
 Thromboses (blood clots) in the deep veins of the leg
result from stasis, the slowing or pooling of blood.
This can result from prolonged inactivity (extended
airplane travel, immobilization following surgery) or
anatomic abnormalities such as laxity of the crural
fascia. Thrombi from the legs can break off and travel
to the heart and lungs, lodging in the pulmonary
arterial tree as pulmonary emboli. Large clots can
severely impair lung function and even cause death.
◦ Thrombophlebitis is the inflammation of a vein caused by
thrombosis.
 Veins in the calf (anterior, posterior, peroneal veins;
calf venous sinusoids); popliteal vein; femoral vein.
 Deep venous thrombosis

 Stasis dermatitis: hemorrhagic or orange discoloration of the

skin and ischemic ulcers (poor O2 perfusion) located around
the medial malleolus of the ankles
 Varicose veins
 Varicose disease of the superficial veins of the
lower limb is the most common chronic venous
disease. Degeneration of the wall of the vein leads
to dilated, tortuous vessels and incompetent
venous valves. Varices also develop when chronic
occlusion of the deep veins causes a reversal of
flow through the perforating veins. (Normal
venous drainage flows from superficial to deep
systems.) As the superficial veins dilate with
increased volume, valve leaflets separate and
become incompetent.
 Superficial saphenous veins (most common
site)
 Superficial veins are located in the
subcutaneous tissue and normally drain,
via perforating veins, to the deep venous
system.
 The largest superficial veins, the great
saphenous and small saphenous
veins, originate at the dorsal venous arch
on the dorsum of the foot.
 The great saphenous vein arises from the
medial side of the venous arch and passes
superiorly, anterior to the medial
malleolus and posteromedial to the knee.
It drains into the femoral vein at the
saphenous opening, an opening in
the fascia lata in the upper thigh.
 The small saphenous vein arises from the
lateral side of the venous arch, passes
posterior to the lateral malleolus, and
ascends the posterior leg. It drains into
the popliteal vein behind the knee.
 The flow of blood from lower parts of
the body must counter the downward
force of gravity. In the lower limbs, venous
return is assisted by
◦ the presence of valves in the veins,
◦ the pulsing of accompanying arteries, and
◦ the contraction of surrounding muscles.