1. Clinical anatomy of the lower limb
Ákos Lukáts M.D., Ph.D.

2. Lesser sciatic foramen : They enter the ischiorectal fossa!
Gluteal region
Suprapiriform hiatus :
superior gluteal a., v., n.
Infrapiriform hiatus:
inferior gluteal a., v., n.
sciatic n.
posterior femoral cut. n.
internal pudendal a., v.
pudendal n.
Lesser sciatic foramen :
internal pudendal a., v.
pudendal n.
They enter the ischiorectal fossa!
Sobota - Atlas of Human Anatomy

3. Intramuscular injection
Triangular technique
(trochanter major, anterior superior iliac spine, iliac crest)
NOT to hit: superior gluteal
a., v., n.
Sobota - Atlas of Human Anatomy

4. Sobota - Atlas of Human Anatomy
Hip joint: summary
Sobota - Atlas of Human Anatomy
Mechanism: free (ball and socket) joint
Acetabular labrum - enarthrosis
Strong capsule and ligaments, zona orbicularis
Limited movements compared to shoulder joint.
Dislocated rarely, bones break before dislocation
Movements: (ante)flexion:130° (flexed knee!) ; extension (retroflexio):0-10° ;
rotation:90° ; abduction:40° ; adduction:0°

5. Hip joint: ligaments iliofemoral lig. Ishiofemoral lig Pubofemoral lig
Forrás: Sobota - Atlas of Human Anatomy
Strongest ligaments of the human body, spiral around the neck of femur: inhibit retroflexion, relax during anteflexion
zona orbicularis
Dislocation in adults is highly unlikely

6. lig. capitis femoris (round lig.)
Minimal mechanichal role
Blood supply of the head of femur
Forrás: Sobota - Atlas of Human Anatomy

7. Blood supply of the head and neck of femur
Arteries located immediately under the periosteum: often damage in case of cervical fracture of femur.
In this case, the only supply to the head is the artery in the round ligament (lig. capitis femoris – from obturator artery).
avascular necrosis
importance of quick reposition and fixation

8. Normal X-ray
acetabulum
trochanter major
head
neck
trochanter minor

9. Acetabular fracture

10. Hip dysplasia, dislocation
Intrauterine developmental defect: the acetabular fossa is too shallow, the head dislocates easily
Multicausal (twin pregnancy, oligohydramnion, ???)
Screening programs

11. (anteflexio, abductio)
Treatment:
Pavlik Harness
(anteflexio, abductio)
Apply a constant force on the femur to deepen the acetabular fossa!
Rarely require surgery.
Larger angle bw head and neck in children!

12. Hip dysplasia, untreated case
arthrosis, Pinguin walk, walking disability

13. Femoral neck fractures
Medial
neck fracture
1 year mortality 20-35%!
Especially in elderly osteoporotic (female) patients.
Cadaver position!
(extremity shorter, rotated outwards)
Problems with the blood supply of the head: avascular necrosis
Quick reposition, mobilization important
(necrosis, other side-effects)
Intertrochanteric fracture
Lateral
neck fracture
Subtrochanteric fracture
Sobota - Atlas of Human Anatomy

14. Lateral neck fracture

15. Medial neck fracture

16. Intertrochanteric fracture

17. Femoral triangle (iliopectineal fossa)
Borders:
m. iliopsoas, m. pectineus (iliopectineal fascia)
fascia lata (sapheneal hiatus – cribriform plate
Connections:
subinguinal hiatus : femoral a., v., genitofemoral n. (femoral br.), lymph vessels
sapheneal hiatus : greater saphenous v. genitofemoral n. (femoral br.), lymph vessels
adductor canal : femoral a., v.
Femoral nerve runs under the iliopectineal fascia!!!
Sobota - Atlas of Human Anatomy

18. Femoral artery in superficial position – risk of injury!!!
Sobota - Atlas of Human Anatomy
Palpatable femoral artery!
First aid!!
Regions supplied by spf. and deep inguinal lymph nodes:
lower extremity, inferior superficial part of abdominal wall, external genital organs (NOT THE TESTIS!!!)
drain further to the pelvic nodes near the. Iliac artery.
Lymph node enlargement is fairly common, mostly caused by banal infection.

19. Subinguinal hiatus Lacuna musculonervosa: lateral cutaneus femoral n.
m. iliopsoas
femoral n.
Lig. lacunare
Lacuna vasorum:
femoral a., v.
genitofemoral n. (femoral br.)
Lacuna lymphatica (herniosa):
lymph vessels
Inner opening of femoral canal!!
(anulus femoralis)
Sobota - Atlas of Human Anatomy
Femoral canal: septum femorale, l. lymphatica, femoral triangle (iliopectineal fossa), saphenous hiatus
Femoral herniation (especially common in females)

20. Popliteal fossa Borders: m. semitendinosus et semimembranosus
m. biceps femoris
m. gastrocnemius medialis et lateralis
Base:
femur (linea aspera), m. adductor magnus, capsule of knee joint, m. popliteus
Deep outflow under the origin of soleus m.
Covered superficially by popliteal fascia.
Contents: popliteal a., v., tibial n. , common peroneal n. (sciatic n.), lesser saphenous v., lymph vessels, med. and lat. cut. surral nerve. (surral n.), collateral arteries/veins of the knee.
Palpatable popliteal artery!
Sobota - Atlas of Human Anatomy

21. Sobota - Atlas of Human Anatomy
Knee joint: summary
Mechanism: trochoginglymus !!!
Originally two joints: 4 collateral ligaments!
Incongruent surfaces: menisci
Great workload, frequently damaged, especially the ligaments and the menisci.
Sobota - Atlas of Human Anatomy
Movements: flexion:130° ; extension:0-5° ;
rotation:50° (only at flexed knee!!!)

22. Sobota - Atlas of Human Anatomy
Collateral ligaments
Streched and therefore work only at extended knee. If the joint is flexed to at least 30 degrees, they relax (they do not limit any movements - rotation is possible).
Test at extended knee (try to open the joint medially (adduct) or laterally (abduct)).
At a flexion more than 30 degrees the cruciate ligaments take over the same functions.
Sobota - Atlas of Human Anatomy

23. Cruciate ligaments
Some parts are streched at every position, with greater workload at flexed kneed – higher chance of damage (skiing).
Limit medial lateral opening, rotation, antero-posterior movements.
Test: drawer sign.
Anterior drawer sign: ant. cruciate lig. injury.
Posterior drawer sign: post. cruciate lig. injury
Sobota - Atlas of Human Anatomy

24. Anterior cruciate ligament injury

25. Menisci Incongruent surfaces.
Fixed but also mobile structures, obtain different positions at different stages of movements.
Medial meniscus is more fixed – damaged more often.
Symptoms: pain, „stop of movement”
Sobota - Atlas of Human Anatomy

26. Forrás: Sobota - Atlas of Human Anatomy

27. Passive movements of the menisci
Forrás: Sobota - Atlas of Human Anatomy

28. Meniscal tear
Arthroscopic removal of damaged part: in case of central injury

29. Arthroscopic reconstruction: at peripheral injury (blood supply!)

30. Normal knee

31. A child’s knee
Growth cartilage

32. Prothesis of cartilaginous surface
Cartilage (in joint) does not regenerate!

33. The quadriceps femoris m. pulls the proximal piece up.
Fracture of patella
The quadriceps femoris m. pulls the proximal piece up.

34. „Compatrments” of the leg, compartment syndrome
Especially in the peroneus and extensor compartments
Strong osteofibrous capsule
Injury
Oedema
Compression of vessels and nerves
Further damage etc.
Therapy: decrease compression, cut the compartment longitudinally

35. Chiasms
M. flexor digitorum longus has the most medial origin, but the most lateral insertion:
MUST CROSS the other two deep flexors!
First crossing with m. tibialis posteriort at the leg: chiasma cruris
Second crossing with m. flexor hallucis longus at the sole: chiasma plantare
The order of structures behind the medial ankle is thus:
m. tibialis posterior
m. flexor digitorum longus
vessels and nerves: posterior tibial a., tibial n.
m. flexor hallucis longus
The posterior tibial artery is palpatable!
Sobota - Atlas of Human Anatomy

36. Ankle joint: summary Talocrural joint (upper ankle joint)
Mechanism: hinge joint
Axis: at the tip of lateral malleolus
Loose capsule, strong, compound collateral ligaments
Trochlea of talus is wider anteriorly: a dorsalflexed foot is more stabile
Connections between tibia and fibula!
Sobota - Atlas of Human Anatomy
Movements: dorsalflexion:15° ; plantarflexion:40° ;
The rest of the movements are in the distal joints!

37. Deltoid ligament: medial collateral ligament
Tibionavicular lig.
Tibiocalcaneal lig.
Anterior tibiotalar lig.
Posterior tibiotalar lig.
Forrás: Sobota - Atlas of Human Anatomy

38. Lateral collateral ligament
Anterior talofibular lig.
Posterior talofibular lig.
Calcaneofibular lig.
Forrás: Sobota - Atlas of Human Anatomy

39. Connections of tibia and fibula
Membrana interossea
Anteror tibiofibular lig.
Posterior tibiofibular lig.
Forrás: Sobota - Atlas of Human Anatomy
Ankle „fork”

40. Lower ankle joint Common mechanism: Pivot joint Talocalcaneo-
Axis:
starts anteriorly, up and medially goes posteriorly, down and laterally
Inversion (supination + adduction + plantarflexion)
Eversion (pronation + abduction + dorsalflexion)
Talocalcaneo-
navicular joint
(ball and socket)
Facies articularis talaris of navicular bone
Facies articularis
talaris anterior
Facies articularis
talaris media
Subtalar joint
(pivot joint)
Facies articularis
talaris posterior
Sobota - Atlas of Human Anatomy

41. Normal ankle joint

42. Injuries
Disruption of lateral collateral ligament (sometimes with broken fibula)
Fracture of (or near) med. malleolus
Fracture of fibula
Disruption of deltoid lig.
Sobota - Atlas of Human Anatomy

46. Plantar arches 3 point reach the suface: Tuber calcanei
Head of metatarsus I. and V.
Highermost point: trochlea of talus
Two feet together: cone
longitudinal arch
Role:
elastic transfer of force
protection of vessels and nerves
transverse arch

47. Most important ligaments
Plantar calcaneonavicular lig.
Plantar aponeurosis
Long plantar lig.

48. Most important muscles
Vízkelety Tibor: Az ortopédia tankönyve
M. tibialis posterior
M. tibialis anterior
M. peroneus longus
Short flexors
M. flexor hallucis longus

49. Insufficiencies of longitudinal arch
Deformity: pes planus
Pes planus,
Pes planovalgus
Insufficiencies of longitudinal arch
normal
Pes planus

51. pes cavus normal pes planus
pes planus

52. Lábdeformitások: dongaláb
pes equinovarus
veleszületett deformitás 1. 2. 3. 4.

54. Literature
Szentagothai J, Réthelyi M: Funkcionális anatómia, Medicina, 1989
Sobota - Atlas of Human Anatomy, 20th edition, Urban and Schwarzenberger, 1993
Renner Antal: Traumatológia, 2nd edition, Medicina, Budapest, 2003
Vízkelety Tibor: Az ortopédia tankönyve, 2nd edition, Semmelweis Kiadó, 1999
Radiologic images: