Anatomy_Gray

Anatomy_Gray. The tarsal tunnel (Fig. 6.133) is formed on the medial side of the foot in the groove between the medial malleolus and the heel (calcaneal tuberosity) and by the overlying flexor retinaculum. The posterior tibial artery and tibial nerve enter the foot through the tarsal tunnel. The tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus also pass through the tarsal tunnel in compartments formed by septa of the flexor retinaculum. The order of structures passing through the tunnel from the anteromedial to posterolateral are the tendon of the tibialis posterior, the tendon of the flexor digitorum longus, the posterior tibial artery and associated veins, the tibial nerve, and the tendon of the flexor hallucis longus (“Tom, Dick, and a very nervous Harry”). The tibial artery is palpable just posteroinferior to the medial malleolus on the anterior face of the visible groove between the heel and medial malleolus.


Anatomy_Gray

Anatomy_Gray. The tibial artery is palpable just posteroinferior to the medial malleolus on the anterior face of the visible groove between the heel and medial malleolus. Identifying tendons around the ankle and in the foot Numerous tendons can be identified around the ankle and in the foot (Fig. 6.134) and can be used as useful landmarks for locating vessels or testing spinal reflexes. The tibialis anterior tendon is visible on the medial side of the ankle anterior to the medial malleolus. The calcaneal tendon is the largest tendon entering the foot and is prominent on the posterior aspect of the foot as it descends from the leg to the heel. A tap with a tendon hammer on this tendon tests reflex activity of spinal cord levels S1 and S2. When the foot is everted, the tendons of the fibularis longus and fibularis brevis raise a linear fold of skin, which descends from the lower leg to the posterior edge of the lateral malleolus.


Anatomy_Gray

Anatomy_Gray. When the foot is everted, the tendons of the fibularis longus and fibularis brevis raise a linear fold of skin, which descends from the lower leg to the posterior edge of the lateral malleolus. The tendon of the fibularis brevis is often evident on the lateral surface of the foot descending obliquely to the base of metatarsal V. The tendons of the fibularis tertius, extensor digitorum longus, and extensor hallucis longus are visible on the dorsal aspect of the foot from lateral to medial. Finding the dorsalis pedis artery The nature of the dorsalis pedis pulse (Fig. 6.135) is important for assessing peripheral circulation because the dorsalis pedis artery is the farthest palpable vessel from the heart. Also, it is the lowest palpable artery in the body when a person is standing.


Anatomy_Gray

Anatomy_Gray. The dorsalis pedis artery passes onto the dorsal aspect of the foot and anteriorly over the tarsal bones where it lies between and is parallel to the tendon of the extensor hallucis longus and the tendon of the extensor digitorum longus to the second toe. It is palpable in this position. The terminal branch of the dorsalis pedis artery passes into the plantar surface of the foot between the two heads of the first dorsal interosseous muscle. Approximating the position of the plantar arterial arch The blood supply of the foot is provided by branches of the posterior tibial and dorsalis pedis arteries. The posterior tibial artery enters the plantar surface of the foot through the tarsal tunnel and divides into a lateral and a medial plantar artery.


Anatomy_Gray

Anatomy_Gray. The posterior tibial artery enters the plantar surface of the foot through the tarsal tunnel and divides into a lateral and a medial plantar artery. The lateral plantar artery curves laterally across the posterior half of the sole and then curves medially as the plantar arch (Fig. 6.136) through the anterior sole. Between the bases of metatarsals I and II, the plantar arch joins the terminal branch (deep plantar artery) of the dorsalis pedis artery. Most of the foot is supplied by the plantar arch. The medial plantar artery passes anteriorly through the sole, connects with branches of the plantar arch, and supplies the medial side of the great toe. Superficial veins in the lower limb often become enlarged. Also, because the veins are long, they can be removed and used elsewhere in the body as vascular grafts.


Anatomy_Gray

Anatomy_Gray. Superficial veins in the lower limb often become enlarged. Also, because the veins are long, they can be removed and used elsewhere in the body as vascular grafts. Superficial veins (Fig. 6.137) in the lower limb begin as a dorsal venous arch in the foot. The medial side of the arch curves superiorly anterior to the medial malleolus and passes up the leg and thigh as the great saphenous vein. This vein passes through an aperture in the fascia lata (saphenous ring) to join with the femoral vein in the femoral triangle. The lateral side of the dorsal venous arch in the foot passes posterior to the lateral malleolus and up the posterior surface of the leg as the small saphenous vein. This vessel passes through the deep fascia in the upper one-third of the leg and connects with the popliteal vein in the popliteal fossa posterior to the knee.


Anatomy_Gray

Anatomy_Gray. Peripheral pulses can be felt at four locations in the lower limb (Fig. 6.138): femoral pulse in the femoral triangle—femoral artery inferior to the inguinal ligament and midway between the anterior superior iliac spine and the pubic symphysis; popliteal pulse in the popliteal fossa—popliteal artery deep in the popliteal fossa near the midline; posterior tibial pulse in the tarsal tunnel—posterior tibial artery posteroinferior to the medial malleolus in the groove between the medial malleolus and the heel (calcaneal tuberosity); dorsalis pedis pulse on the dorsal aspect of the foot—dorsalis pedis artery as it passes distally over the tarsal bones between the tendon of the extensor hallucis longus and the tendon of the extensor digitorum longus to the second toe. Fig. 6.1 Upper margin of the lower limb. Fig. 6.2 Regions of the lower limb. Fig. 6.3 Areas of transition. Inguinal ligamentFemoral trianglePopliteal fossa(posterior to knee)Tarsal tunnel


Anatomy_Gray

Anatomy_Gray. Fig. 6.1 Upper margin of the lower limb. Fig. 6.2 Regions of the lower limb. Fig. 6.3 Areas of transition. Inguinal ligamentFemoral trianglePopliteal fossa(posterior to knee)Tarsal tunnel Fig. 6.4 Center and line of gravity. Center ofgravityCenterof gravityposterior tohip jointLine of gravityAnterior to kneeAnterior to ankle Fig. 6.5 Movements of the hip joint. A. Flexion and extension. B. Abduction and adduction. C. External and internal rotation. D. Circumduction. Fig. 6.6 Movements of the knee and ankle. A. Knee flexion and extension. B. Ankle dorsiflexion and plantarflexion. Fig. 6.7 Some of the determinants of gait.


Anatomy_Gray

Anatomy_Gray. D. Circumduction. Fig. 6.6 Movements of the knee and ankle. A. Knee flexion and extension. B. Ankle dorsiflexion and plantarflexion. Fig. 6.7 Some of the determinants of gait. Pelvic rotation in transverse planeminimizes drop in center of gravity byeffectively lengthening the limbsKnee flexion on full stance. Limb minimizes rise incenter of gravity by effectively shortening the limbPelvic tilt (drop) on swing side minimizes rise incenter of gravityMovement of knees toward midline(adduction of hip) minimizes lateralshift in center of gravityAbduction on stanceside controls andlimits the dropLateral shift incenter of gravityWith adductionof hip (kneesmove towardmidline)No adductionof hip (knees donot move towardmidline)Vertical shift incenter of gravityInternal rotationof hip jointExternal rotation of hip jointCenter of gravity with knee not flexedCenter of gravity with knee flexedFlexion Fig. 6.8 Bones and joints of the lower limb. Fig. 6.9 Bones of the foot.


Anatomy_Gray

Anatomy_Gray. Fig. 6.8 Bones and joints of the lower limb. Fig. 6.9 Bones of the foot. Fig. 6.10 Longitudinal and transverse arches of the foot. Fig. 6.11 Muscles of the gluteal region. Extensor(gluteus maximus)Abductors(gluteus mediusand gluteus minimus)Rotators(piriformis, obturatorinternus, gemelli,quadratus femoris) Fig. 6.12 Major flexors of the hip. Fig. 6.13 Muscle compartments in the thigh and leg. Fig. 6.14 Apertures of communication between the lower limb and other regions. Fig. 6.15 Innervation of the lower limb. LumbarIliohypogastric (L1)Genitofemoral (L1, L2)Lateral cutaneous nerveof thigh (L2, L3)Obturator nerve (L2 to L4)Femoral nerve (L2 to L4)SacralSuperior gluteal nerve (L4 to S1)Sciatic nerve (L4 to S3)Inferior gluteal nerve (L5 to S2)Pudendal nerve (S2 to S4)Tibial nerve (branch of sciatic)(L4 to S3)Common fibular nerve (branch of sciatic)(L4 to S2)Sacrospinous ligamentIlio-inguinal (L1)LVLIVLIIILIILI


Anatomy_Gray

Anatomy_Gray. Fig. 6.16 Dermatomes of the lower limb. Dots indicate autonomous zones (i.e., with minimal overlap). Fig. 6.17 Movements generated by myotomes. L1, L2L3, L4L5 to S2S1, S2Adduction of toes S2, S3 Fig. 6.18 Major nerves of the lower limb (colors indicate regions of motor innervation). Femoral nerve(anterior compartmentof thigh)Obturator(medial compartmentof thigh)Commonfibular nerveSuperficial branch(lateral compartment of leg)Deep branch(anterior compartment of leg)Sciatic nerve(posterior compartmentof thigh, leg, andsole of foot)Superior and inferiorgluteal nerves Fig. 6.19 Regions of skin innervated by peripheral nerves.


Anatomy_Gray

Anatomy_Gray. Fig. 6.19 Regions of skin innervated by peripheral nerves. Obturator nerveFemoral nerve (anteriorcutaneous nerves of thigh)Femoral nerve (saphenous nerve)Common fibular nerve(lateral cutaneous of calf)Common fibular nerve(superficial branch)Common fibular nerve(deep branch)Medial plantar nervePosterior cutaneous nerve of thigh(from sacral plexus)Posterior rami (L1 to L3)Posterior rami (S1 to S3)Obturator nerveFemoral nerve (saphenous nerve)Tibial nerve (sural nerve)Tibial nerve (sural nerve)Lateral plantar nerveTibial nerve (medial calcanealbranches)Lateral cutaneousnerve of thigh(from lumbar plexus) Fig. 6.20 Nerves related to bone. Deep branchCommon fibularnerve (neck of fibula)Superficial branch Fig. 6.21 Superficial veins. Fig. 6.22 External surface of the bony pelvis. Lateral view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.20 Nerves related to bone. Deep branchCommon fibularnerve (neck of fibula)Superficial branch Fig. 6.21 Superficial veins. Fig. 6.22 External surface of the bony pelvis. Lateral view. LIV spineHorizontal plane through top of iliac crestAnterior gluteal linePosterior gluteal linePosterior superior iliac spineSacrumSacrospinous ligamentIschial spineSacrotuberous ligamentPosterior inferior iliac spineAcetabulumIschial tuberosityIliumInferior gluteal lineIschiumPubisPubic tubercleIliopubic eminenceAnterior inferior iliac spineInguinal ligamentAnterior superior iliac spineAnterior abdominal wallIliac crestTuberculum of iliac crest Fig. 6.23 Ischial tuberosity. Posterolateral view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.23 Ischial tuberosity. Posterolateral view. AcetabulumIschial spineFor attachment of sacrotuberous ligamentFor attachment of semitendinosus andlong head of biceps femoris muscleCovered by connective tissue and bursaFor attachment of adductor magnus muscleFor attachment of semimembranosus muscleIschiopubic ramusObturator foramenBody of pubic bone Fig. 6.24 Acetabulum. Fig. 6.25 Multiple fractures of the pelvis. Radiograph with contrast in the bladder. A large accumulation of blood is deforming the bladder. Fig. 6.26 Proximal end of the femur (right). A. Anterior view. B. Medial view. C. Posterior view. D. Lateral view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.26 Proximal end of the femur (right). A. Anterior view. B. Medial view. C. Posterior view. D. Lateral view. ABTrochanteric fossaHeadNeckNeckAttachment site for piriformis muscleGreater trochanterAttachment site for gluteus minimusShaftLesser trochanterIntertrochanteric lineTubercleGreater trochanterPiriformisFoveaObturator internusTrochanteric fossaEnd of intertrochanteric linePectineal line (spiral line)Lesser trochanterOval depression forobturator externusAttachment ofgluteus mediusQuadrate tubercleGreater trochanterFoveaNeckQuadrate tubercleLesser trochanterPectineal line (spiral line)Medial margin of linea asperaLinea asperaLateral margin of linea asperaGluteal tuberosityAttachment site for gluteus mediusIntertrochanteric crestGluteus minimusGluteus mediusLesser trochanterCD Fig. 6.27 Shaft of the femur. On the right is a posterior view of proximal shaft of right femur.


Anatomy_Gray

Anatomy_Gray. Fig. 6.27 Shaft of the femur. On the right is a posterior view of proximal shaft of right femur. Fig. 6.28 This radiograph of the pelvis, anteroposterior view, demonstrates a fracture of the neck of the femur. Fractured neck of femur Fig. 6.29 Anteroposterior radiograph showing an intertrochanteric fracture of proximal end of femur. Fig. 6.30 Hip joint. A. Articular surfaces. Anterior view. B. Movement of the neck of the femur during medial and lateral rotation. Superior view. Acetabulum of pelvic boneAcetabular labrumHead of femurSuperior viewLateral rotationMedial rotationAB Fig. 6.31 Hip joint. A. Transverse acetabular ligament. B. Ligament of the head of the femur. The head of the femur has been laterally rotated out of the acetabulum to show the ligament.


Anatomy_Gray

Anatomy_Gray. Fig. 6.31 Hip joint. A. Transverse acetabular ligament. B. Ligament of the head of the femur. The head of the femur has been laterally rotated out of the acetabulum to show the ligament. ABAcetabular labrum Lunate surfaceTransverseacetabular ligamentAcetabularforamenObturator foramenAcetabular fossaArtery of ligament of headSynovial sleeve around ligamentLigament of head of femurIschial tuberosityObturator membranePubisPubic tubercleObturator arteryAcetabular branchof obturator arteryCut synovial membrane Fig. 6.32 Synovial membrane of the hip joint. Synovial membraneLine of attachment around head of femurMembrane reflects back to attach to margin ofacetabulum Fig. 6.33 Fibrous membrane and ligaments of the hip joint. A. Fibrous membrane of the joint capsule. Anterior view. B. Iliofemoral and pubofemoral ligaments. Anterior view. C. Ischiofemoral ligament. Posterior view. Fig. 6.34 Blood supply of the hip joint.


Anatomy_Gray

Anatomy_Gray. Fig. 6.34 Blood supply of the hip joint. Internal iliac arteryCommon iliac arteryExternal iliac arteryLateral circumflex femoral artery1st perforating arteryDeep artery of thighMedial circumflex femoral arteryFemoral arteryObturator arteryInferior gluteal arterySuperior gluteal artery Fig. 6.35 Gateways to the lower limb.


Anatomy_Gray

Anatomy_Gray. Fig. 6.35 Gateways to the lower limb. Sacrospinous ligamentSacrotuberous ligamentPelvic cavityIlio-inguinal nerveAbdominal cavityGap between inguinal ligament and pelvic bone:• Psoas major, iliacus, pectineus muscles• Femoral artery• Femoral vein• Lymphatics• Femoral branch of genitofemoral nerve• Lateral cutaneous nerve of thigh• Femoral nerveObturator canal:• obturator nerve• obturator vesselsLesser sciatic foramen:• Obturator internus muscle tendon• Pudendal nerve and internal pudendal vessels pass into perineum from gluteal regionGreater sciatic foramen below piriformis muscle:• Sciatic nerve• Inferior gluteal nerve, artery, vein• Pudendal nerve• Internal pudendal artery and vein• Posterior femoral cutaneous nerve• Nerve to obturator internus and gemellus superior muscles• Nerve to quadratus femoris and gemellus inferior musclesGreater sciatic foramen abovepiriformis muscle:• Superior gluteal nerve, artery, veinPiriformis muscle


Anatomy_Gray

Anatomy_Gray. Fig. 6.36 Branches of the lumbosacral plexus. L3 anterior ramusPerforating cutaneous nerveLumbosacral trunkSuperior gluteal nerveNerves to quadratus femoris and obturator internusInguinal ligamentInferior gluteal nervePosterior cutaneous nerve of thighSciatic nerveS1S2Sacrotuberous ligamentSacrospinous ligamentObturator nerveFemoral branch of genitofemoral nerveFemoral nerveLateral cutaneous nerve of thighIlio-inguinal nerveL1 anterior ramusL2 anterior ramus Fig. 6.37 Arteries of the lower limb. Fig. 6.38 Veins of the lower limb. Fig. 6.39 Lymphatic drainage of the lower limb. Fig. 6.40 Fascia lata. A. Right limb. Anterior view. B. Lateral view. ABInguinal ligamentInguinal ligamentDeep fascia of legFascia lataSaphenous openingAnterior superior iliac spineAnterior superior iliac spineTuberculum of iliac crestFascia lataGluteus maximusTensor fascia lataIliotibial tractPubic tuberclePubic tubercle Fig. 6.41 Saphenous ring. Anterior view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.41 Saphenous ring. Anterior view. Fig. 6.42 Boundaries of the femoral triangle. Fig. 6.43 Contents of the femoral triangle. Fig. 6.44 Gluteal region. Posterior view. Fig. 6.45 Deep muscles in the gluteal region. A. Posterior view. B. Function. ABGemellus superior Gemellus inferiorObturator internusQuadratus femorisGluteus mediusGluteus minimusGreater sciatic foramen abovepiriformisPiriformis muscleGreater sciatic foramen belowpiriformisContraction of gluteus minimus and mediuson stance side prevents excessive pelvic tiltduring swing phase on opposite side Fig. 6.46 Gluteus maximus muscle. Posterior view. Gluteus mediusGluteus maximusAttachment of gluteus maximus to iliotibial tractIliotibial tractAttachment of deep fibers to gluteal tuberosity Fig. 6.47 Tensor fasciae latae. Left gluteal region, lateral view. Tensor fasciae lataeTubercle of crest of iliumGluteus mediusIliotibial tractGluteus minimusGluteus maximusFascia lataDeep fascia of legTibiaAttachment to tibia


Anatomy_Gray

Anatomy_Gray. Tensor fasciae lataeTubercle of crest of iliumGluteus mediusIliotibial tractGluteus minimusGluteus maximusFascia lataDeep fascia of legTibiaAttachment to tibia Fig. 6.48 Nerves of the gluteal region. Posterior view. Superior gluteal nerveTensor fasciae latae muscleInferior gluteal nerveIliotibial tractPosterior cutaneous nerve of thighNerve to quadratus femorismuscle (deep to gemelli, obturator internus, and quadratus femoris)Gluteus maximusPerforating cutaneous nerveNerve to obturator internusPudendal nervePiriformis muscleSciatic nerve Fig. 6.49 Site for intramuscular injections in the gluteal region. Fig. 6.50 Arteries of the gluteal region. Deep branchLateral femoral circumflex arteryMedial femoral circumflex arteryFirst perforating artery fromdeep artery of thighInferior gluteal artery and veinSuperficial branchSuperior gluteal artery and veinPiriformis muscle


Anatomy_Gray

Anatomy_Gray. Fig. 6.51 Anastomoses between gluteal arteries and vessels originating from the femoral artery in the thigh. Posterior view. Superior gluteal arteryFirst perforating arterySecond perforating arteryThird perforating arteryFemoral arteryDeep artery of thighMedial femoral circumflex arteryLateral femoralcircumflex arteryInferior gluteal artery Fig. 6.52 Thigh. A. Posterior view. B. Anterior view. C. Cross section through the midthigh. ABCInguinal ligamentAbdominal wallGap between inguinal ligament and pelvic boneObturator canalAnterior superior iliac spinePubic tubercleMedialAnteriorLateral Posterior Anterior compartmentPosterior compartmentMedial compartmentPopliteal fossa(posterior to knee)Popliteal fossaSciatic nerveQuadratus femorisInferior margin of gluteus maximusGluteal fold Fig. 6.53 Shaft and distal end of femur. A. Lateral view. B. Anterior view. C. Posterior view. D. Cross section through shaft of femur.


Anatomy_Gray

Anatomy_Gray. Fig. 6.53 Shaft and distal end of femur. A. Lateral view. B. Anterior view. C. Posterior view. D. Cross section through shaft of femur. Lateral epicondyleMedial epicondyleMedial condyleLateral borderLateral(posterolateral)surfaceMedial(posteromedial)surfaceMedialborderLateral condyleLateral epicondyleFacet for attachment of lateral head of gastrocnemiusFacet for attachment of the tendon of popliteus muscleFacet for attachmentof the tendon ofpopliteus muscleAdductor tubercleAdductor tuberclePatellar surfacePosterior surfaceMedial supracondylar lineLateral supracondylar lineIntercondylar fossaFacet for attachment of posterior cruciate ligamentFacet for attachment of anterior cruciate ligamentRoughened area for attachment of medial head of gastrocnemius muscleFacet for attachmentof lateral head ofgastrocnemius muscleLinea asperaLinea asperaAnterior surfaceABCD Fig. 6.54 Patella. A. Anterior view. B. Posterior view. C. Superior view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.54 Patella. A. Anterior view. B. Posterior view. C. Superior view. Fig. 6.55 Proximal end of the tibia. A. Superior view, tibial plateau. B. Anterior view. C. Posterior view. D. Cross section through the shaft of tibia. AIntercondylar regionAttachment of posterior cruciate ligamentPosterior attachment of lateral meniscusArea of articulation with lateral meniscusAnterior attachment of lateral meniscusAttachment of anterior cruciate ligamentTuberosityTubercles of intercondylar eminenceRoughened and perforated areaAnterior attachment of medial meniscusArea of articulation with medial meniscusPosterior attachment of medial meniscus


Anatomy_Gray

Anatomy_Gray. BCLateral condyleRoughened and perforated areaSite of attachment of sartorius, gracilis, and semitendinosus musclesShaft of tibiaGrooveTibial tuberosityMedial condyleAnterior attachment ofmedial meniscusTubercles of intercondylar eminenceAnterior Anterior borderLateral surfaceInterosseous borderPosterior surfacePosteriorMedial borderMedial surfaceAttachment of medial meniscusAttachment of posterior cruciate ligamentSoleal lineArticular facet for proximal head of fibulaD Fig. 6.56 Proximal end of the fibula. A. Anterior view. B. Cross section through the shaft of fibula. ABApexAttachment site for fibular collateral ligament of kneeAttachment site for tendon of biceps femoris muscleCommon fibular nerveLateral surfaceShaftMedial surfaceMedial part of posterior surfaceNeckFacet for articulationwith inferior surfaceof lateral condyle of tibiaHeadInterosseousborderPosterior borderLateral surfaceAnterior borderMedial surfacePosterior surfaceMedial crest onposterior surface


Anatomy_Gray

Anatomy_Gray. Fig. 6.57 Transverse section through the midthigh. Fig. 6.58 Psoas major and iliacus muscles. Fig. 6.59 Muscles of the anterior compartment of thigh. SartoriusSartoriusStraight head of rectus femorisReflected head of rectus femorisVastus lateralisRectus femorisVastus medialisQuadriceps femoris tendonPatellaPatellar ligamentPes anserinusSartoriusGracilisSemitendinosusAttachment of pes anserinusTibial tuberosityPatellar ligamentQuadriceps femoris tendonSuprapatellar bursaArticularis genusVastus medialisRectus femorisVastus intermediusVastus lateralisSartoriusPosterior compartment of thighVastus lateralisVastus medialisVastus intermediusMedial compartment of thighAdductor canal Fig. 6.60 Muscles of the medial compartment of thigh. Anterior view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.60 Muscles of the medial compartment of thigh. Anterior view. Obturator externusAdductor magnusPectineusAdductor longusAdductor brevisAnterior compartment of thighSartorius attachmentGracilisGracilisSemitendinosus attachmentAdductor hiatusAdductor canalAdductor longusAdductor magnusPosterior compartment of thighPes anserinus Fig. 6.61 Pectineus, adductor longus, and adductor brevis muscles. Anterior view. Fig. 6.62 Adductor magnus and obturator externus muscles. Anterior view. Obturator externusAdductor magnus (adductor part)Adductor magnus (hamstring part)Adductor tubercleAdductor hiatusPerforations for branches of deep artery of thigh• Terminal end of deep artery of thigh Fig. 6.63 Muscles of the posterior compartment of thigh. Posterior view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.63 Muscles of the posterior compartment of thigh. Posterior view. Ischial tuberosityQuadratus femorisAdductor magnusHamstring part of adductor magnusLong head of biceps femorisShort head of biceps femorisPart of semimembranosus thatinserts into capsule around knee jointOn anterior aspect of tibia attaches to pes anserinusSemimembranosusSemitendinosus Fig. 6.64 Coronal MRI of the posterior pelvis and thigh showing a hamstring avulsion injury. Fig. 6.65 Femoral artery.


Anatomy_Gray

Anatomy_Gray. Fig. 6.64 Coronal MRI of the posterior pelvis and thigh showing a hamstring avulsion injury. Fig. 6.65 Femoral artery. Superficial epigastric arterySartorius muscleDeep artery of thighRectus femoris muscleVastus medialis muscleGracilis muscleDeep externalpudendal arterySuperficial externalpudendal arteryVastus lateralis muscleVastus medialis muscleSartorius muscleArtery passes posteriorlythrough adductor hiatus andbecomes popliteal arteryArtery in adductor canalFemoral artery • Midway between anterior superior iliac spine and pubic symphysis inferior to inguinal ligamentExternal iliac arterySuperficial externaliliac arteryPubic symphysis Fig. 6.66 Deep artery of thigh. A. Anterior view. B. Posterior view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.66 Deep artery of thigh. A. Anterior view. B. Posterior view. BSuperior gluteal arteryLateral femoral circumflex arteryCruciate anastomosesMedial circumflex femoral arteryFirst perforating arterySecond perforating arteryThird perforating arteryTerminal end of deepartery of thighPopliteal arteryAdductor magnus muscleAdductor hiatusInferior gluteal arteryPiriformis muscleAPsoas and iliacus musclesSartorius muscleRectus femoris muscleLateral circumflex femoral arteryAscending branchDescending branchVastus lateralis muscleVastus intermedius muscleCut vastus medialis muscleQuadriceps femoris tendonTerminal end of deepartery of thighGracilis muscleSartorius muscleAdductor magnus muscleFirst, second, and third perforating arteriesAdductor brevis muscleAdductor longus musclePectineus muscleMedial circumflex femoral arteryDeep artery of thigh Fig. 6.67 Obturator artery.


Anatomy_Gray

Anatomy_Gray. Fig. 6.67 Obturator artery. Ligament ofhead offemurObturatorarteryAnterior branchAcetabular branchPosterior branchObturatorexternus muscleArtery of ligament of head of femur Fig. 6.68 Femoral nerve. Nerve to pectineusAnterior branchNerves to iliacusNerve to sartoriusRectus femoris muscleVastus lateralis muscleVastus medialis muscleSaphenous nerveSaphenous nervePes anserinusSartorius muscleGracilis muscleAnterior cutaneous branchesAdductor magnus musclePectineus muscleAdductor longus musclePosterior branchFemoral nerve Fig. 6.69 Obturator nerve. Posterior branchObturator externus musclePsoas and iliacus musclesPectineus muscleAdductor brevis muscleAdductor longus muscleBranch to adductor magnus from posterior branchAdductor magnus muscleGracilis muscleCutaneous branchAnterior branchObturator nerve Fig. 6.70 Sciatic nerve.


Anatomy_Gray

Anatomy_Gray. Fig. 6.70 Sciatic nerve. Piriformis muscleQuadratus femoris muscleSciatic nerveAdductor magnus muscleLong head of biceps femoris muscleLong head of biceps femoris muscleShort head of biceps femoris muscleCommon fibular nerveTibial nervePopliteal artery and veinSemimembranosus muscleSemitendinosus muscleBranch to part of adductor magnus originatingfrom ischial tuberosity Fig. 6.71 Knee joint. Joint capsule is not shown. Fig. 6.72 Articular surfaces of the knee joint. A. Extended. B. Flexed. C. Anterior view (flexed). Fig. 6.73 Menisci of the knee joint. A. Superior view. Menisci of the knee joint. B. Normal knee joint showing the medial meniscus. T2-weighted magnetic resonance image in the sagittal plane. C. Normal knee joint showing the lateral meniscus. T2-weighted magnetic resonance image in the sagittal plane. APatellar ligamentJoint capsuleMedial meniscusPopliteus tendonLateral meniscusTransverse ligament of the kneeInfrapatellar fat


Anatomy_Gray

Anatomy_Gray. APatellar ligamentJoint capsuleMedial meniscusPopliteus tendonLateral meniscusTransverse ligament of the kneeInfrapatellar fat Fig. 6.74 Meniscal injury and repair. A. Sagittal MRI of a knee joint showing tear of the medial meniscus. B. Coronal MRI of a knee showing a truncated lateral meniscus after partial meniscectomy to treat a tear. Fig. 6.75 Synovial membrane of the knee joint and associated bursae. A. Superolateral view; patella and femur not shown. B. Paramedial sagittal section through the knee. Fig. 6.76 Fibrous membrane of the knee joint capsule. A. Anterior view. B. Posterior view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.76 Fibrous membrane of the knee joint capsule. A. Anterior view. B. Posterior view. Fig. 6.77 Collateral ligaments of the knee joint. A. Lateral view. B. Medial view. C. Normal knee joint showing the patellar ligament and the fibular collateral ligament. T1-weighted magnetic resonance image in the sagittal plane. D. Normal knee joint showing the tibial collateral ligament, the medial and lateral menisci, and the anterior and posterior cruciate ligaments. T1-weighted magnetic resonance image in the coronal plane. Fig. 6.78 Cruciate ligaments of the knee joint. Superolateral view. Fig. 6.79 Knee “locking” mechanism. Medial rotation of femur on tibia tightens ligamentsFlat surface offemoral condylesis in contact withtibia and stabilizesjointLine of center of gravity isanterior to knee joint andmaintains extension Fig. 6.80 Anastomoses of arteries around the knee. Anterior view.


Anatomy_Gray

Anatomy_Gray. Fig. 6.80 Anastomoses of arteries around the knee. Anterior view. Femoral arteryAdductorhiatusDescendinggenicular arteryAdductormagnusSaphenousbranchSuperior medialgenicular arteryPoplitealarteryInferior medialgenicular arteryPosteriortibial arteryAnteriortibial arteryInterosseousmembraneRecurrent branchof anterior tibialCircumflexfibular arteryInferior lateralgenicular arterySuperior lateralgenicular arteryDescending branch of lateral circumflex femoral artery Fig. 6.81 Sagittal MRI of knee joint showing rupture of the anterior cruciate ligament. Fig. 6.82 Tibiofibular joint. Fig. 6.83 Popliteal fossa. A. Boundaries. B. Nerves and vessels. C. Superficial structures.


Anatomy_Gray

Anatomy_Gray. Fig. 6.82 Tibiofibular joint. Fig. 6.83 Popliteal fossa. A. Boundaries. B. Nerves and vessels. C. Superficial structures. ABCLinea asperaBiceps femoris muscle(short head)Biceps femorismuscle(long head)PoplitealfossaPlantarismuscleLateral head ofgastrocnemiusmusclePopliteusmuscleMedial head ofgastrocnemiusmuscleSemitendinosusmuscleSemimembranosus muscleAdductorhiatusAdductor magnus muscleSciatic nerveTibial nerveSmallsaphenousveinSmallsaphenousveinCommonfibular nervePopliteal arteryPopliteal veinFemoral veinFemoral arteryPosteriorcutaneousnerve of thighPosteriorcutaneousnerve of thighLateralNerveVeinArteryMedial Fig. 6.84 Posterior view of leg; cross section through the left leg (inset). Fig. 6.85 Tibia and fibula. A. Anterior view. B. Posterior view. C. Cross section through shafts. D. Posteromedial view of distal ends.


Anatomy_Gray

Anatomy_Gray. Fig. 6.85 Tibia and fibula. A. Anterior view. B. Posterior view. C. Cross section through shafts. D. Posteromedial view of distal ends. Lateral surfaceLateralsurfaceInterosseousmembraneInterosseousborderMedialsurfaceAnteriorborderMedialborderPosteriorborderPosterior surfacePosterior surfaceMedial crestInterosseous borderInterosseousborderMedialsurfaceAnteriorborderAnteriorborderGroove for fibularis longus and brevis musclesRoughened triangulararea that fits intofibular groove of tibiaABCDFibulaTibiaFibular grooveon tibiaSoleal lineArticular surfaces for talusMedial malleolusGroove for tendon oftibialis posterior muscleMalleolar fossaLateralmalleolusLateral malleolus Fig. 6.86 Interosseous membrane. A. Anterior view. B. Posteromedial view. Aperture for anterior tibial vesselsABAperture for perforating branch of fibular arteryAnterior tibiofibular ligamentInterosseous membraneInterosseous membranePosterior tibiofibular ligament


Anatomy_Gray

Anatomy_Gray. Aperture for anterior tibial vesselsABAperture for perforating branch of fibular arteryAnterior tibiofibular ligamentInterosseous membraneInterosseous membranePosterior tibiofibular ligament Fig. 6.87 Superficial group of muscles in the posterior compartment of leg. A. Posterior view. B. Lateral view. APlantarisMedial head ofgastrocnemiusPopliteal vessels and tibial nerveLigament spanning distance betweenfibular and tibial origins of soleusTendon of plantarisCalcaneal (Achilles) tendonCalcaneusGastrocnemiusSoleusLateral head of gastrocnemiusMedialLateralBSoleusCalcaneal tendonGastrocnemiusCalcaneus Fig. 6.88 Deep group of muscles in the posterior compartment of leg.


Anatomy_Gray

Anatomy_Gray. Fig. 6.88 Deep group of muscles in the posterior compartment of leg. PopliteusSoleal lineTibialisposteriorOrigin oftibialisposteriorVerticallineFlexordigitorumlongusOrigin of flexordigitorum longusOrigin of flexorhallucis longusGroove onmedialmalleolusMedialTuberosity ofnavicularMedialcuneiformGroove on inferiorsurface of sustentaculumtali of calcaneus boneGroove on posteriorsurface of talusFlexor hallucislongusLateral Fig. 6.89 Arteries in the posterior compartment of leg. Adductor hiatusSuperior medialgenicular arterySuperior lateralgenicular arteryAdductormagnus musclePopliteal arterySural arteriesMedial head ofgastrocnemiusmuscle Popliteus musclePosterior tibial arteryPosterior tibial arteryPerforating terminalbranch of fibular arteryBranches thatperforate intermuscularseptum to enter lateralcompartmentFibular arteryCircumflexfibular arteryAnterior tibial artery(passes throughaperture ininterosseousmembrane)Popliteal vein


Anatomy_Gray

Anatomy_Gray. Fig. 6.90 Tibial nerve. A. Posterior view. B. Sural nerve. Fig. 6.91 Muscles in the lateral compartment of leg. A. Lateral view. B. Inferior view of the right foot, with the foot plantarflexed at the ankle. ABCommon fibular nerveFibularislongusFibularisbrevisFibular trochleaof calcaneus boneAnteriorborder of fibulaInterosseousmembraneMedialcuneiformMetatarsal IGroove oninferior aspectof cuboidFibularisbrevistendonFibularislongustendon Fig. 6.92 Common fibular nerve, and nerves and arteries of the lateral compartment of leg. A. Posterior view, right leg. B. Lateral view, right leg. ABSural communicating nervePenetrates deep fasciaSural nervePenetrates deep fasciaLateral sural nerveCommon fibular nerveSuperficial fibular nervePerforating branches of fibular arteryin posterior compartment(vessels in and around fibula)Deep fibularnerve Fig. 6.93 Muscles of the anterior compartment of leg.


Anatomy_Gray

Anatomy_Gray. Fig. 6.93 Muscles of the anterior compartment of leg. Anterior surfaceof fibulaExtensordigitorumlongusOrigin of extensordigitorum longusLateral surfaceof fibulaExtensor hallucis longusOrigin of extensorhallucis longusFibularistertiusAttachment to inferior surface of medial cuneiform and metatarsal ISubcutaneoussurface of tibiaTibialisanteriorOrigin of tibialisanterior Fig. 6.94 Anterior tibial artery and deep fibular nerve. Fig. 6.95 Foot. A. Dorsal aspect, right foot. B. Plantar aspect, right foot, showing the surface in contact with the ground when standing. AbductionAdductionGreat toeDigit IDigit IIDigit IIIDigit IVDigit VPhalangesLittle toeMetatarsals (I–V)Tarsal bonesABCut surface of medialmalleolus (tibia)Cut surface of lateralmalleolus (fibula)Calcaneal tendonMedial malleolusLateral malleolusHeelSesamoid bones Fig. 6.96 Bones of the foot. A. Dorsal view, right foot. B. Lateral view, right foot.


Anatomy_Gray

Anatomy_Gray. Fig. 6.96 Bones of the foot. A. Dorsal view, right foot. B. Lateral view, right foot. TalusPosteriorprocessof the talusBCalcaneusFibular trochleaGrooveCuboidMedial tubercleCuneiformsNavicularPhalangesMetatarsalsNavicularIntermediatetarsal boneTuberosity (on undersurface)CalcaneusTalusLateral processLateraltubercleGroove for tendon offlexor hallucis longusProximal groupof tarsal bonesMedialIntermediateLateralCuneiformsDistal groupof tarsal bonesCuboidDistalMiddleProximalA Fig. 6.97 Talus. A. Medial view. B. Inferior view. ABPosterior AnteriorArticular surfacefor navicularArticular surfacefor navicularNeckHeadBodyAnteriorPosteriorArticular surface withmedial malleolusMedialtubercleLateraltubercleGroove for flexorhallucis longusGroove for flexorhallucis longusArticular surface withdistal end of tibiaAnterior calcanealsurfaceMiddle calcanealsurfaceSulcus taliPosterior processof talusPosteriorcalcaneal surfaceArticular surface forcalcaneonavicularligament


Anatomy_Gray

Anatomy_Gray. Fig. 6.98 Calcaneus. A. Superior view. B. Inferior view. C. Lateral view. ABCAnterior talar articular surfacePosterior talararticular surfacePosterior talararticular surfaceAnterior talararticular surfaceMiddle talararticular surfaceMiddle talararticular surfaceSustentaculum taliMedialMedialMiddle part of posterior surface(insertion of calcaneal tendon)Upper part ofposterior surfaceLateralCalcanealsulcusArticular surface with cuboid boneCalcanealtubercleLateralprocessNotchCalcaneal tuberosity(lower part of posterior surface)MedialprocessGroove for tendon offlexor hallucis longusAttachment of calcaneofibularpart of lateral collateral ligamentof ankle jointFibular trochleaCalcaneal sulcus Fig. 6.99 Tarsal sinus. Lateral view, right foot. Fig. 6.100 Metatarsals and phalanges. Dorsal view, right foot. Fig. 6.101 Radiograph of ankle showing talar beak.


Anatomy_Gray

Anatomy_Gray. Fig. 6.99 Tarsal sinus. Lateral view, right foot. Fig. 6.100 Metatarsals and phalanges. Dorsal view, right foot. Fig. 6.101 Radiograph of ankle showing talar beak. Fig. 6.102 Ankle joint. A. Anterior view with right foot plantarflexed. B. Schematic of joint, posterior view. C. Superior view of the talus to show the shape of the articular surface. ABCInterosseousligamentTibiaMedialmalleolusLateralmalleolusLateral malleolusTalusFibulaFibulaTibiaArticular surface of talusArticular surfacenarrow posteriorlyPosteriorMedial malleolusAnteriorArticular surface wide anteriorly Fig. 6.103 Medial ligament of the ankle joint, right foot. Medialtubercleof talusSustentaculum taliof calcaneus bonePlantar calcaneonavicular ligamentTuberosity ofnavicular bonePosteriortibiotalar partTibiocalcaneal partTibionavicular partAnterior tibiotalar partMedial ligament of the ankle joint Fig. 6.104 Lateral ligament of the ankle joint. A. Lateral view, right foot. B. Posterior view, right foot.


Anatomy_Gray

Anatomy_Gray. Fig. 6.104 Lateral ligament of the ankle joint. A. Lateral view, right foot. B. Posterior view, right foot. Malleolar fossaAnterior talofibular ligamentCalcaneofibular ligamentPosteriortalofibularligamentPosteriortalofibular ligamentPosteriorprocess of talusMalleolar fossaFibulaTibiaTalusAB Fig. 6.105 Intertarsal joints, right foot. Fig. 6.106 Interosseous talocalcaneal ligament. Lateral view, right foot. Fig. 6.107 Talocalcaneonavicular joint. A. Medial view, right foot. B. Superior view, right foot, talus removed. C. Ligaments, medial view, right foot. D. Ligaments, lateral view, right foot. Fig. 6.108 Plantar ligaments, right foot. A. Plantar calcaneocuboid ligament (short plantar ligament). B. Long plantar ligament. Fig. 6.109 Tarsometatarsal, metatarsophalangeal, and interphalangeal joints, and the deep transverse metatarsal ligaments, right foot.


Anatomy_Gray

Anatomy_Gray. Fig. 6.109 Tarsometatarsal, metatarsophalangeal, and interphalangeal joints, and the deep transverse metatarsal ligaments, right foot. Fig. 6.110 Tarsal tunnel and flexor retinaculum. Posteromedial view, right foot. A. Bones. B. Tarsal tunnel and flexor retinaculum. ABTibiaTalusCalcaneusFlexor retinaculumTarsaltunnelTendon of flexordigitorum longusTendon oftibialis posteriorPulse of post-tibial arterymidway between heeland medial malleolusTendon offlexorhallucislongusTibial nervePosteriortibial arteryTibialis posteriorFlexor digitorumlongusTibial arteryTibial veinTibial nerveFlexor hallucislongus Fig. 6.111 Extensor retinacula, right foot. Anterior tibial arteryTendon of extensorhallucis longusTendon oftibialis anteriorDorsalispedis arteryFirst dorsalinterosseousmuscleInferior extensorretinaculumSuperior extensorretinaculumExtensordigitorum longusFibularis tertius Fig. 6.112 Fibular retinacula. Lateral view, right foot.


Anatomy_Gray

Anatomy_Gray. Fig. 6.112 Fibular retinacula. Lateral view, right foot. Tendons of fibularis longus andbrevis musclesSuperior fibular retinaculumInferior fibular retinaculum(at fibular trochlea on calcaneus) Fig. 6.113 Arches of the foot. A. Longitudinal arches, right foot. B. Transverse arch, left foot. Fig. 6.114 Support for arches of the foot. A. Ligaments. Medial view, right foot. B. Cross section through the foot to show tendons of muscles supporting the arches, left foot. Fig. 6.115 Plantar aponeurosis, right foot. Superficial transversemetatarsal ligamentsMedial process ofcalcaneal tuberosityPlantar aponeurosisAnterior arm of inferiorextensor retinaculum Fig. 6.116 Fibrous digital sheaths, right foot. Fig. 6.117 Extensor hoods. 1st dorsal interosseous muscleExtensor tendonsExtensor hoodDeep transverse metatarsal ligamentLumbricalFlexor digitorum longusExtension of PIP joints prevents overflexionFlexion of MTP jointprevents overextension


Anatomy_Gray

Anatomy_Gray. Fig. 6.118 Extensor digitorum brevis muscle, right foot. Fig. 6.119 First layer of muscles in the sole of the right foot. Fig. 6.120 Second layer of muscles in the sole of the right foot. Fig. 6.121 MRI of posterior foot in a patient with plantar fasciitis shows thickening of the plantar aponeurosis at the calcaneal insertion and a calcaneal spur. Fig. 6.122 Third layer of muscles in the sole of the right foot. FlexorhallucisbrevisTransverse headOblique headAdductor hallucisFlexor digitiminimi brevisTendon of fibularislongus muscleTendon of tibialisposterior muscleTendon of flexorhallucis longus Fig. 6.123 Fourth layer of muscles in the sole of the right foot. Fig. 6.124 Arteries in the sole of the right foot. Digital branchesDeep plantar artery: terminal branchof dorsalis pedis arteryPlantar metatarsal arteriesPerforatingvesselsDeepplantar archLateral plantararteryPosterior tibial arteryMedial plantarartery Fig. 6.125 Dorsalis pedis artery right foot.


Anatomy_Gray

Anatomy_Gray. Fig. 6.125 Dorsalis pedis artery right foot. ExtensorhoodDorsaldigitalarteriesAnterior tibial arteryDorsalis pedisarteryAnterior medialmalleolar arteryAnterior lateralmalleolar arteryMedial and lateraltarsal branchesExtensorhallucislongusDorsalis pedisarteryDeep plantararteryFirst dorsalmetatarsalarteryFirst dorsalinterosseousmuscleArcuate arteryTendon of extensordigitorum longusto toe II Fig. 6.126 Superficial veins of the right foot. Fig. 6.127 Lateral and medial plantar nerves. A. Sole of the right foot. B. Cutaneous distribution of right foot. Fig. 6.128 A.Terminal branches of superficial and deep fibular nerves in the right foot. B. Cutaneous distribution right foot. Deep fibularnerveABBranches tofirst and seconddorsal interosseiExtensordigitorumbrevisBranch of deepfibular to extensordigitorum brevisSuperficialfibular nerveSaphenous nerveSuperficialfibular nerveDeep fibular nerveSural nerve


Anatomy_Gray

Anatomy_Gray. Fig. 6.129 Avoiding the sciatic nerve. A. Posterior view of the gluteal region of a man with the position of the sciatic nerve indicated. B. Posterolateral view of the left gluteal region with gluteal quadrants and the position of the sciatic nerve indicated. Fig. 6.130 Position of the femoral artery in the femoral triangle. Anterior thigh. Inguinal ligamentAnterior superior iliac spineFemoral nerveFemoral arteryFemoral veinLymphatics passing through femoral canalMedial margin ofsartorius muscleMedial margin of adductor longus musclePubic tuberclePubic symphysis Fig. 6.131 Identifying structures around the knee. A. Anterior view of the right knee. B. Lateral view of the partially flexed right knee. C. Lateral view of the extended right knee, thigh, and gluteal region.


Anatomy_Gray

Anatomy_Gray. C. Lateral view of the extended right knee, thigh, and gluteal region. ABCVastus lateralisVastus medialisQuadriceps tendonQuadriceps femoris musclePatellaPatellaPatellarligamentPatellar ligamentTibial tuberosityTendon ofbiceps femorisHead of fibulaCommon fibular nerveTensor fasciae lataeIliotibial tractHamstring musclesGluteus maximus Fig. 6.132 Visualizing the contents of the popliteal fossa. Posterior view of the left knee. Popliteal fossaPopliteal arteryPopliteal veinCommon fibular nerveBiceps femoris muscle and tendonHead of fibulaPenetrates deep fasciaLateral head of gastrocnemius muscleMedial head of gastrocnemius muscleTibial nerveSemimembranosus muscleSemitendinosus tendonSmall saphenous vein Fig. 6.133 Finding the tarsal tunnel—the gateway to the foot. Fig. 6.134 Identifying tendons around the ankle and in the foot. A. Medial side of the right foot. B. Posterior aspect of the right foot. C. Lateral side of the right foot. D. Dorsal aspect of the right foot.


Anatomy_Gray

Anatomy_Gray. Fig. 6.135 Finding the dorsalis pedis artery. Dorsalis pedis arteryExtensor digitorumlongus tendon to second toeExtensor hallucislongus tendon Fig. 6.136 Position of the plantar arch. Fig. 6.137 Major superficial veins. A. Dorsal aspect of the right foot. B. Anterior view of right lower limb. C. Posterior aspect of the left thigh, leg, and foot. Fig. 6.138 Where to feel peripheral arterial pulses in the lower limb. Fig. 6.139 A. Normal knee joint showing the tibial collateral ligament and the medial and lateral menisci. Proton density (PD)-weighted magnetic resonance image in the coronal plane. B. Knee joint showing a torn tibial collateral ligament. PD-weighted magnetic resonance image in the coronal plane. Fig. 6.140 A. Knee joint showing an intact anterior cruciate ligament. T2-weighted magnetic resonance image in the sagittal plane.


Anatomy_Gray

Anatomy_Gray. Fig. 6.140 A. Knee joint showing an intact anterior cruciate ligament. T2-weighted magnetic resonance image in the sagittal plane. B. Knee joint showing a torn anterior cruciate ligament. T2-weighted magnetic resonance image in the sagittal plane. C. Knee joint showing a torn medial meniscus (the broken off portion of the posterior horn has moved into the anterior aspect of the joint giving the impression of a ‘double meniscus’ in this location). Proton density-weighted magnetic resonance image in the sagittal plane. AFemurPatellaAnterior cruciate ligamentTibiaBFemurTorn anteriorcruciate ligamentTibiaAnterior cruciateligament fragmentPatellaCMedial femoral condyleTorn posterior “horn”of medial meniscusTibiaAnterior “horn” of medial meniscusDisplaced fragment of posterior hornof medial meniscus


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Anatomy_Gray. Fig. 6.141 Radiograph (A) and MRI (B) of soft tissue ulceration and erosion in the adjacent calcaneus. After debridement and placement of antibiotics beads in the wound there is progressive healing (C). eFig. 6.142 Popliteal fossa showing position of the popliteal artery and vein and sciatic nerve. T1-weighted magnetic resonance image in the axial plane. eFig. 6.143 Pulmonary embolus. Axial computed tomogram. Left atriumAortaRight inferior pulmonary artery with embolusEmbolus eFig. 6.144 Ankle showing a ruptured calcaneal tendon. T2-weighted magnetic resonance image in the sagittal plane. eFig. 6.145 A. Normal ankle joint showing an intact anterior talofibular ligament. T1-weighted magnetic resonance image in the axial plane. B. Ankle joint showing a torn anterior talofibular ligament. T2-weighted magnetic resonance image in the axial plane. Table 6.1 Branches of the lumbosacral plexus associated with the lower limb


Anatomy_Gray

Anatomy_Gray. Table 6.1 Branches of the lumbosacral plexus associated with the lower limb Table 6.2 Muscles of the gluteal region (spinal segments in bold are the major segments innervating the muscle) Table 6.3 Muscles of the anterior compartment of thigh (spinal segments in bold are the major segments innervating the muscle) Table 6.4 Muscles of the medial compartment of thigh (spinal segments in bold are the major segments innervating the muscle) Table 6.5 Muscles of the posterior compartment of thigh (spinal segments in bold are the major segments innervating the muscle) Table 6.6 Superficial group of muscles in the posterior compartment of leg (spinal segments in bold are the major segments innervating the muscle) Table 6.7 Deep group of muscles in the posterior compartment of leg (spinal segments in bold are the major segments innervating the muscle) Table 6.8 Muscles of the lateral compartment of leg (spinal segments in bold are the major segments innervating the muscle)


Anatomy_Gray

Anatomy_Gray. Table 6.8 Muscles of the lateral compartment of leg (spinal segments in bold are the major segments innervating the muscle) Table 6.9 Muscles of the anterior compartment of leg (spinal segments in bold are the major segments innervating the muscle) Table 6.10 Muscles of the dorsal aspect of the foot (spinal segments in bold are the major segments innervating the muscle) Table 6.11 First layer of muscles in the sole of the foot (spinal segments in bold are the major segments innervating the muscle) Table 6.12 Second layer of muscles in the sole of the foot (spinal segments in bold are the major segments innervating the muscle) Table 6.13 Third layer of muscles in the sole of the foot (spinal segments in bold are the major segments innervating the muscle) Table 6.14 Fourth layer of muscles in the sole of the foot (spinal segments in bold are the major segments innervating the muscle) In the clinic


Anatomy_Gray

Anatomy_Gray. Table 6.14 Fourth layer of muscles in the sole of the foot (spinal segments in bold are the major segments innervating the muscle) In the clinic The pelvic bones, sacrum, and associated joints form a bony ring surrounding the pelvic cavity. Soft tissue and visceral organ damage must be suspected when the pelvis is fractured. Patients with multiple injuries and evidence of chest, abdominal, and lower limb trauma should also be investigated for pelvic trauma. Pelvic fractures can be associated with appreciable blood loss (concealed exsanguination) and blood transfusion is often required. In addition, this bleeding tends to form a significant pelvic hematoma, which can compress nerves, press on organs, and inhibit pelvic visceral function (Fig. 6.25). There are many ways of classifying pelvic fractures, which enable the surgeon to determine the appropriate treatment and the patient’s prognosis. Pelvic fractures are generally of four types.


Anatomy_Gray

Anatomy_Gray. There are many ways of classifying pelvic fractures, which enable the surgeon to determine the appropriate treatment and the patient’s prognosis. Pelvic fractures are generally of four types. Type 1 injuries occur without disruption of the bony pelvic ring (e.g., a fracture of the iliac crest). These types of injuries are unlikely to represent significant trauma, though in the case of a fracture of the iliac crest, blood loss needs to be assessed. Type 2 injuries occur with a single break in the bony pelvic ring. An example of this would be a single fracture with diastasis (separation) of the symphysis pubis. Again, these injuries are relatively benign in nature, but it may be appropriate to assess for blood loss. Type 3 injuries occur with double breaks in the bony pelvic ring. These include bilateral fractures of the pubic rami, which may produce urethral damage. Type 4 injuries occur at and around the acetabulum.


Anatomy_Gray

Anatomy_Gray. Type 4 injuries occur at and around the acetabulum. Other types of pelvic ring injuries include fractures of the pubic rami and disruption of the sacro-iliac joint with or without dislocation. This may involve significant visceral pelvic trauma and hemorrhage. Other general pelvic injuries include stress fractures and insufficiency fractures, as seen in athletes and elderly patients with osteoporosis, respectively. In the clinic


Anatomy_Gray

Anatomy_Gray. Femoral neck fractures (Fig. 6.28) can interrupt the blood supply to the femoral head. The blood supply to the head and neck is primarily from an arterial ring formed by the branches of the medial and lateral circumflex femoral arteries around the base of the femoral neck. From here, vessels course along the neck, penetrate the capsule, and supply the femoral head. The blood supply to the femoral head and femoral neck is further enhanced by the artery of the ligamentum teres, a branch of the obturator artery, which is generally small and variable. Femoral neck fractures may disrupt associated vessels and lead to necrosis of the femoral head. Femoral neck fractures can be divided into three categories depending on the location of the fracture line: subcapital (fracture line passes across the femoral head-neck junction), transcervical (fracture line passes through the midportion of the femoral neck), and basicervical (fracture line passes across the base of the neck). Subcapital


Anatomy_Gray

Anatomy_Gray. the femoral head-neck junction), transcervical (fracture line passes through the midportion of the femoral neck), and basicervical (fracture line passes across the base of the neck). Subcapital fractures have the highest risk of developing necrosis of the femoral head, and basicervical fractures have the lowest risk. Elderly patients with osteoporosis tend to have transverse subcapital fractures following low-energy trauma such as a fall from a standing height. Conversely, younger patients usually sustain more vertical fractures of the distal femoral neck (basicervical) after high-energy trauma such as a fall from a great height or due to axial load applied to an abducted knee, such as during a motor vehicle accident.


Anatomy_Gray

Anatomy_Gray. In the clinic In these fractures, the break usually runs from the greater trochanter through to the lesser trochanter and does not involve the femoral neck. Intertrochanteric fractures preserve the femoral neck blood supply and do not render the femoral head ischemic. They are most commonly seen in the elderly and result from low-energy impact (Fig. 6.29). Sometimes isolated fractures of the greater or the lesser trochanter can occur. An isolated fracture of the lesser trochanter in adults is most commonly pathological and due to an underlying malignant deposit. In the clinic An appreciable amount of energy is needed to fracture the femoral shaft. This type of injury is therefore accompanied by damage to the surrounding soft tissues, which include the muscle compartments and the structures they contain. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic The normal flow of blood in the lower limbs is from the skin and subcutaneous tissues to the superficial veins, which drain via perforating veins to the deep veins, which in turn drain into the iliac veins and inferior vena cava. The normal flow of blood in the venous system depends upon the presence of competent valves, which prevent reflux. Venous return is supplemented with contraction of the muscles in the lower limb, which pump the blood toward the heart. When venous valves become incompetent they tend to place extra pressure on more distal valves, which may also become incompetent. This condition produces dilated tortuous superficial veins (varicose veins) in the distribution of the great (long) and small (short) saphenous venous systems.


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Anatomy_Gray. Varicose veins occur more commonly in women than in men, and symptoms are often aggravated by pregnancy. Some individuals have a genetic predisposition to developing varicose veins. Valves may also be destroyed when a deep vein thrombosis occurs if the clot incorporates the valve into its interstices; during the process of healing and recanalization the valve is destroyed, rendering it incompetent. Typical sites for valvular incompetence include the junction between the great (long) saphenous vein and the femoral vein, perforating veins in the midthigh, and the junction between the small (short) saphenous vein and the popliteal vein.


Anatomy_Gray

Anatomy_Gray. Varicose veins may be unsightly, and soft tissue changes may occur with chronic venous incompetence. As the venous pressure rises, increased venular and capillary pressure damages the cells, and blood and blood products extrude into the soft tissue. This may produce a brown pigmentation in the skin, and venous eczema may develop. Furthermore, if the pressure remains high the skin may break down and ulcerate, and many weeks of hospitalization may be needed for this to heal. Treatments for varicose veins include tying off the valve, “stripping” (removing) the great (long) and small (short) saphenous systems, and in some cases valvular reconstruction. In the clinic Thrombosis may occur in the deep veins of the lower limb and within the pelvic veins. Its etiology was eloquently described by Virchow, who described the classic triad (venous stasis, injury to the vessel wall, and hypercoagulable states) that precipitates thrombosis.


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Anatomy_Gray. In some patients a deep vein thrombosis (DVT) in the calf veins may propagate into the femoral veins. This clot may break off and pass through the heart to enter the pulmonary circulation, resulting in occlusion of the pulmonary artery, cardiopulmonary arrest, and death. A significant number of patients undergoing surgery are likely to develop a DVT, so most surgical patients are given specific prophylactic treatment to prevent thrombosis. A typical DVT prophylactic regimen includes anticoagulant injections and graduated stockings (to prevent deep venous stasis and facilitate emptying of the deep veins). Although physicians aim to prevent the formation of DVT, it is not always possible to detect it because there may be no clinical signs. Calf muscle tenderness, postoperative pyrexia, and limb swelling can be helpful clues. The diagnosis is predominantly made by duplex Doppler sonography or rarely by ascending venography.


Anatomy_Gray

Anatomy_Gray. If DVT is confirmed, intravenous and oral anticoagulation are started to prevent extension of the thrombus. In the clinic Vascular access to the lower limb Deep and inferior to the inguinal ligament are the femoral artery and femoral vein. The femoral artery is palpable as it passes over the femoral head and may be easily demonstrated using ultrasound. If arterial or venous access is needed rapidly, a physician can use the femoral approach to these vessels. Many radiological procedures involve catheterization of the femoral artery or the femoral vein to obtain access to the contralateral lower limb, the ipsilateral lower limb, the vessels of the thorax and abdomen, and the cerebral vessels. Cardiologists also use the femoral artery to place catheters in vessels around the arch of the aorta and into the coronary arteries to perform coronary angiography and angioplasty.


Anatomy_Gray

Anatomy_Gray. Cardiologists also use the femoral artery to place catheters in vessels around the arch of the aorta and into the coronary arteries to perform coronary angiography and angioplasty. Access to the femoral vein permits catheters to be maneuvered into the renal veins, the gonadal veins, the right atrium, and the right side of the heart, including the pulmonary artery and distal vessels of the pulmonary tree. Access to the superior vena cava and the great veins of the neck is also possible. In the clinic Trendelenburg’s sign occurs in people with weak or paralyzed abductor muscles (gluteus medius and gluteus minimus) of the hip. The sign is demonstrated by asking the patient to stand on one limb. When the patient stands on the affected limb, the pelvis severely drops over the swing limb.


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Anatomy_Gray. Positive signs are typically found in patients with damage to the superior gluteal nerve. Damage to this nerve may occur with associated pelvic fractures, with space-occupying lesions within the pelvis extending into the greater sciatic foramen, and in some cases relating to hip surgery during which there has been disruption of and subsequent atrophy of the insertion of the gluteus medius and gluteus minimus tendons on the greater trochanter. In patients with a positive Trendelenburg’s sign, gait also is abnormal. Typically during the stance phase of the affected limb, the weakened abductor muscles allow the pelvis to tilt inferiorly over the swing limb. The patient compensates for the pelvic drop by lurching the trunk to the affected side to maintain the level of the pelvis throughout the gait cycle. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic From time to time it is necessary to administer drugs intramuscularly, that is, by direct injection into muscles. This procedure must be carried out without injuring neurovascular structures. A typical site for an intramuscular injection is the gluteal region. The sciatic nerve passes through this region and needs to be avoided. The safest place to inject is the upper outer quadrant of either gluteal region. The gluteal region can be divided into quadrants by two imaginary lines positioned using palpable bony landmarks (Fig. 6.49). One line descends vertically from the highest point of the iliac crest. Another line is horizontal and passes through the first line midway between the highest point of the iliac crest and the horizontal plane through the ischial tuberosity.


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Anatomy_Gray. It is important to remember that the gluteal region extends as far forward as the anterior superior iliac spine. The sciatic nerve curves through the upper lateral corner of the lower medial quadrant and descends along the medial margin of the lower lateral quadrant. Occasionally, the sciatic nerve bifurcates into its tibial and common fibular branches in the pelvis, in which case the common fibular nerve passes into the gluteal region through, or even above, the piriformis muscle. The superior gluteal nerve and vessels normally enter the gluteal region above the piriformis and pass superiorly and forward. The anterior corner of the upper lateral quadrant is normally used for injections to avoid injuring any part of the sciatic nerve or other nerves and vessels in the gluteal region. A needle placed in this region enters the gluteus medius anterosuperior to the margin of the gluteus maximus. In the clinic


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Anatomy_Gray. In the clinic Compartment syndrome occurs when there is swelling within a fascial enclosed muscle compartment in the limbs. Typical causes include limb trauma, intracompartment hemorrhage, and limb compression. As pressure within the compartment elevates, capillary blood flow and tissue perfusion is compromised, which can ultimately lead to neuromuscular damage if not treated. In the clinic Muscle injuries to the lower limb Muscle injuries may occur as a result of direct trauma or as part of an overuse syndrome. Muscle injuries may occur as a minor muscle tear, which may be demonstrated as a focal area of fluid within the muscle. With increasingly severe injuries, more muscle fibers are torn and this may eventually result in a complete muscle tear. The usual muscles in the thigh that tear are the hamstring muscles. Tears in the muscles below the knee typically occur within the soleus muscle, though other muscles may be affected.


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Anatomy_Gray. Injury to the hamstring muscles is a common source of pain in athletes, particularly in those competing in sports requiring a high degree of power and speed (such as sprinting, track and field, football) where the hamstring muscles are very susceptible to injury from excessive stretching.


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Anatomy_Gray. The injury can range from a mild muscle strain to a complete tear of a muscle or a tendon. It usually occurs during sudden accelerations and decelerations or rapid change in direction. In adults, the most commonly injured is the muscle-tendon junction, which is a wide transition zone between the muscle and the tendon. An avulsion of the ischial tuberosity with proximal hamstring origin attachment is common in the adolescent population, particularly during sudden hip flexion because the ischial apophysis is the weakest element of the proximal hamstring unit in this age group (Fig. 6.64). Both ultrasound and MRI can be used to assess the hamstring injury with the MRI providing not only the information about the extent of the injury but also give some indication about the prognosis (future risk of re-tear, loss of function, etc). In the clinic


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Anatomy_Gray. In the clinic Peripheral vascular disease is often characterized by reduced blood flow to the legs. This disorder may be caused by stenoses (narrowing) and/or occlusions (blockages) in the lower aorta and the iliac, femoral, tibial, and fibular vessels. Patients typically have chronic leg ischemia and “acute on chronic” leg ischemia. Chronic leg ischemia is a disorder in which vessels have undergone atheromatous change, and often there is significant luminal narrowing (usually over 50%). Most patients with peripheral arterial disease have widespread arterial disease (including cardiovascular and cerebrovascular disease), which may be clinically asymptomatic. Some of these patients develop such severe ischemia that the viability of the limb is threatened (critical limb ischemia).


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Anatomy_Gray. The commonest symptom of chronic leg ischemia is intermittent claudication. Patients typically have a history of pain that develops in the calf muscles (usually associated with occlusions or narrowing in the femoral artery) or the buttocks (usually associated with occlusion or narrowing in the aorto-iliac segments). The pain experienced in these muscles is often cramplike and occurs with walking. The patient rests and is able to continue walking up to the same distance until the pain recurs and stops walking as before. In some patients with chronic limb ischemia, an acute event blocks the vessels or reduces the blood supply to such a degree that the viability of the limb is threatened. Occasionally a leg may become acutely ischemic with no evidence of underlying atheromatous disease. In these instances a blood clot is likely to have embolized from the heart. Patients with mitral valve disease and atrial fibrillation are prone to embolic disease.


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Anatomy_Gray. Critical limb ischemia occurs when the blood supply to the limb is so poor that the viability of the limb is severely threatened, and in this case many patients develop gangrene, ulceration, and severe rest pain in the foot. These patients require urgent treatment, which may be in the form of surgical reconstruction, radiological angioplasty, or even amputation. In the clinic Menisci can get torn during forceful rotation or twisting of the knee, but significant trauma is not always necessary for a tear to occur. There are various patterns of meniscal tearing depending on the cleavage plane such as vertical tears (perpendicular to the tibial plateau), horizontal tears (parallel to the long axis of the meniscus and perpendicular to the tibial plateau), or bucket handle tears (longitudinal tear where the torn portion of the meniscus forms a handle shaped fragment which gets displaced into the intercondylar notch).


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Anatomy_Gray. The patient usually complains of pain localized to the medial or lateral side of the knee, knee locking or clicking, sensation of knee giving way, and swelling, which can be intermittent and usually delayed. MRI is the modality of choice to assess meniscal tears and detect other associated injuries, such as ligamentous tears and articular cartilage damage (Fig. 6.74A). Arthroscopy is usually performed to repair a tear, debride the damaged meniscal material, or rarely remove the entire torn meniscus (Fig. 6.74B). In the clinic The collateral ligaments are responsible for stabilizing the knee joint, controlling its sideway movements, and protecting the knee from excessive motion.


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Anatomy_Gray. In the clinic The collateral ligaments are responsible for stabilizing the knee joint, controlling its sideway movements, and protecting the knee from excessive motion. Injury to the fibular collateral ligament occurs when excessive outward force is applied to the medial side of the knee (varus force), and is less common than an injury to the tibial collateral ligament that is damaged when excessive force is applied inward to the lateral side of the joint (valgus force). Injuries to the tibial collateral ligament can be part of a so called “unhappy triad” that also involves tears of the medial meniscus and the anterior cruciate ligament. The spectrum of injuries to collateral ligaments of the knee range from minor sprains where the ligaments are slightly stretched, but still able to stabilize the knee joint, to full thickness tears where all fibers are torn and the ligaments lose their stabilizing function. In the clinic


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Anatomy_Gray. The anterior cruciate ligament (ACL) is most frequently injured during non-contact activities when there is a sudden change in the direction of movement (cutting or pivoting) (Fig. 6.81). Contact sports may also result in ACL injury due to sudden twisting, hyperextension, and valgus force related to direct collision. The injury usually affects the mid-portion of the ligament and manifests itself as a complete or partial discontinuity of the fibers or abnormal orientation and contour of the ligament. With an acute ACL tear, a sudden click or pop can be heard and the knee becomes rapidly swollen. Several tests are used to clinically assess the injury, and the diagnosis is usually confirmed by MRI. A full thickness ACL tear causes instability of the knee joint. The treatment depends on the desired level of activity of the patient. In those with high activity levels, surgical reconstruction of the ligament is required. Those with low activity levels may opt for knee bracing and


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Anatomy_Gray. on the desired level of activity of the patient. In those with high activity levels, surgical reconstruction of the ligament is required. Those with low activity levels may opt for knee bracing and physiotherapy; however, in the long term the internal damage to the knee leads to the development of early osteoarthritis.


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Anatomy_Gray. A tear to the posterior cruciate ligament (PCL) requires significant force, so it rarely occurs in isolation. It usually occurs during hyperextension of the knee or as a result of a direct blow to a bent knee such as when striking the knee against the dashboard in a motor vehicle accident. Typically, the injury presents as posterior displacement of the tibia on physical examination (the so called tibial sag sign). Patients complain of knee pain and swelling, inability to bear weight, and instability. The diagnosis is confirmed on MRI. The management, as in ACL injury, depends on the degree of the injury (sprain, partial thickness, full thickness) and the level of desired activity. In the clinic Degenerative joint disease occurs throughout many joints within the body. Articular degeneration may result from an abnormal force across the joint with a normal cartilage or a normal force with abnormal cartilage.


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Anatomy_Gray. Typically degenerative joint disease occurs in synovial joints and the process is called osteoarthritis. In the joints where osteoarthritis occurs the cartilage and bony tissues are usually involved, with limited change within the synovial membrane. The typical findings include reduction in the joint space, eburnation (joint sclerosis), osteophytosis (small bony outgrowths), and bony cyst formation. As the disease progresses the joint may become malaligned, its movement may become severely limited, and there may be significant pain. The commonest sites for osteoarthritis include the small joints of the hands and wrist, and in the lower limb, the hip and knee are typically affected, though the tarsometatarsal and metatarsophalangeal articulations may undergo similar changes.


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Anatomy_Gray. The etiology of degenerative joint disease is unclear, but there are some associations, including genetic predisposition, increasing age (males tend to be affected younger than females), overuse or underuse of joints, and nutritional and metabolic abnormalities. Further factors include joint trauma and pre-existing articular disease or deformity. The histological findings of osteoarthritis consist of degenerative changes within the cartilage and the subchondral bone. Further articular damage worsens these changes, which promote further abnormal stresses upon the joint. As the disease progresses the typical finding is pain, which is usually worse on rising from bed and at the end of a day’s activity. Commonly it is aggravated by the extremes of movement or unaccustomed exertion. Stiffness and limitation of movement may ensue.


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Anatomy_Gray. Treatment in the first instance includes alteration of lifestyle to prevent pain and simple analgesia. As symptoms progress a joint replacement may be necessary, but although joint replacement appears to be the panacea for degenerative joint disease, it is not without risks and complications, which include infection and failure in the short and long term. In the clinic Examination of the knee joint It is important to establish the nature of the patient’s complaint before any examination. The history should include information about the complaint, the signs and symptoms, and the patient’s lifestyle (level of activity). This history may give a significant clue to the type of injury and the likely findings on clinical examination, for example, if the patient was kicked around the medial aspect of the knee, a valgus deformity injury to the tibial collateral ligament might be suspected.


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Anatomy_Gray. The examination should include assessment in the erect position, while walking, and on the couch. The affected side must be compared with the unaffected side. There are many tests and techniques for examining the knee joint, including the following. Lachman’s test—the patient lies on the couch. The examiner places one hand around the distal femur and the other around the proximal tibia and then elevates the knee, producing 20° of flexion. The patient’s heel rests on the couch. The examiner’s thumb must be on the tibial tuberosity. The hand on the tibia applies a brisk anteriorly directed force. If the movement of the tibia on the femur comes to a sudden stop, it is a firm endpoint. If it does not come to a sudden stop, the endpoint is described as soft and is associated with a tear of the anterior cruciate ligament.


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Anatomy_Gray. Anterior drawer test—a positive anterior drawer test is when the proximal head of a patient’s tibia can be pulled anteriorly on the femur. The patient lies supine on the couch. The knee is flexed to 90° and the heel and sole of the foot are placed on the couch. The examiner sits gently on the patient’s foot, which has been placed in a neutral position. The index fingers are used to check that the hamstrings are relaxed while the other fingers encircle the upper end of the tibia and pull the tibia. If the tibia moves forward, the anterior cruciate ligament is torn. Other peripheral structures, such as the medial meniscus or meniscotibial ligaments, must also be damaged to elicit this sign.


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Anatomy_Gray. Pivot shift test—there are many variations of this test. The patient’s foot is wedged between the examiner’s body and elbow. The examiner places one hand flat under the tibia pushing it forward with the knee in extension. The other hand is placed against the patient’s thigh pushing it the other way. The lower limb is taken into slight abduction by the examiner’s elbow with the examiner’s body acting as a fulcrum to produce the valgus. The examiner maintains the anterior tibial translation and the valgus and initiates flexion of the patient’s knee. At about 20°–30° the pivot shift will occur as the lateral tibial plateau reduces. This test demonstrates damage to the posterolateral corner of the knee joint and the anterior cruciate ligament.


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Anatomy_Gray. Posterior drawer test—a positive posterior drawer test occurs when the proximal head of a patient’s tibia can be pushed posteriorly on the femur. The patient is placed in a supine position and the knee is flexed to approximately 90° with the foot in the neutral position. The examiner sits gently on the patient’s foot placing both thumbs on the tibial tuberosity and pushing the tibia backward. If the tibial plateau moves, the posterior cruciate ligament is torn. Assessment of other structures of the knee Assessment of the tibial collateral ligament can be performed by placing a valgus stress on the knee. Assessment of lateral and posterolateral knee structures requires more complex clinical testing. The knee will also be assessed for: joint line tenderness, patellofemoral movement and instability, presence of an effusion, muscle injury, and popliteal fossa masses.


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Anatomy_Gray. The knee will also be assessed for: joint line tenderness, patellofemoral movement and instability, presence of an effusion, muscle injury, and popliteal fossa masses. After the clinical examination has been carried out, further investigations usually include plain radiography and possibly magnetic resonance imaging, which allows the radiologist to assess the menisci, cruciate ligaments, collateral ligaments, bony and cartilaginous surfaces, and soft tissues. Arthroscopy may be carried out and damage to any internal structures repaired or trimmed. An arthroscope is a small camera that is placed into the knee joint through the anterolateral or anteromedial aspect of the knee joint. The joint is filled with a saline solution and the telescope is manipulated around the knee joint to assess the cruciate ligaments, menisci, and cartilaginous surfaces. In the clinic Anterolateral ligament of the knee


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Anatomy_Gray. In the clinic Anterolateral ligament of the knee A ligament associated at its origin with the fibular collateral ligament of the knee has been described. This ligament (anterolateral ligament of the knee) courses from the lateral femoral epicondyle to the anterolateral region of the proximal end of the tibia and may control internal rotation of the tibia. (J Anat 2013;223:321–328) In the clinic The popliteal artery can become abnormally dilated, forming an aneurysm. The artery is considered aneurysmal when its diameter exceeds 7 mm. Although popliteal artery aneurysms can occur in isolation, they are most commonly associated with aneurysms in other large vessels such as the femoral artery or the thoracic or abdominal aorta. Therefore, once a popliteal aneurysm has been detected, the entire arterial tree needs to be investigated for the presence of coexisting aneurysms elsewhere in the body.


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Anatomy_Gray. Popliteal artery aneurysms tend to undergo thrombosis and are less likely to rupture than other aneurysms. Therefore the complications are mainly related to distal embolization of the arterial tree and lower limb ischemia, which in the most severe cases can lead to leg amputation. Ultrasound with duplex Doppler is the most helpful way of diagnosing a popliteal artery aneurysm because it can demonstrate abnormal dilation of the artery, confirm or rule out thrombus within the aneurysm, and help distinguish it from other masses of the popliteal fossa such as a synovial cyst (Baker’s cyst). Popliteal artery aneurysms are usually repaired surgically in view of high risk of thromboembolic complications. In the clinic


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Anatomy_Gray. In the clinic Rupture of the calcaneal tendon is often related to sudden or direct trauma. This type of injury frequently occurs in a normal healthy tendon. In addition, there are certain conditions that may predispose the tendon to rupture. Among these conditions are tendinopathy (due to overuse, or to age-related degenerative changes) and previous calcaneal tendon interventions such as injections of pharmaceuticals and the use of certain antibiotics (quinolone group). The diagnosis of calcaneal tendon rupture is relatively straightforward. The patient typically complains of “being kicked” or “shot” behind the ankle, and clinical examination often reveals a gap in the tendon. In the clinic Neurological examination of the legs


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Anatomy_Gray. In the clinic Neurological examination of the legs Some of the commonest conditions that affect the legs are peripheral neuropathy (particularly associated with diabetes mellitus), lumbar nerve root lesions (associated with pathology of the intervertebral discs), fibular nerve palsy, and spastic paraparesis. Look for muscle wasting—loss of muscle mass may indicate loss of or reduced innervation.


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Anatomy_Gray. Look for muscle wasting—loss of muscle mass may indicate loss of or reduced innervation. Test the power in muscle groups—hip flexion (L1, L2—iliopsoas—straight leg raise); knee flexion (L5 to S2—hamstrings—the patient tries to bend the knee while the examiner applies force to the leg to hold the knee in extension); knee extension (L3, L4—quadriceps femoris—the patient attempts to keep the leg straight while the examiner applies a force to the leg to flex the knee joint); ankle plantarflexion (S1, S2—the patient pushes the foot down while the examiner applies a force to the plantar surface of the foot to dorsiflex the ankle joint); ankle dorsiflexion (L4, L5—the patient pulls the foot upward while the examiner applies a force to the dorsal aspect of the foot to plantarflex the ankle joint).


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Anatomy_Gray. Examine knee and ankle reflexes—a tap with a tendon hammer on the patellar ligament (tendon) tests reflexes at the L3–L4 spinal levels, and tapping the calcaneal tendon tests reflexes at the S1–S2 spinal levels. Assess status of general sensory input to lumbar and upper sacral spinal cord levels—test light touch, pin prick, and vibration sense at dermatomes in the lower limb. In the clinic


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Anatomy_Gray. Assess status of general sensory input to lumbar and upper sacral spinal cord levels—test light touch, pin prick, and vibration sense at dermatomes in the lower limb. In the clinic Footdrop is an inability to dorsiflex the foot. Patients with footdrop have a characteristic “steppage” gait. As the patient walks, the knee of the affected limb is elevated to an abnormal height during the swing phase to prevent the foot from dragging. At the end of the swing phase, the foot “slaps” the ground. Also, the unaffected limb often acquires a characteristic tiptoe pattern of gait during the stance phase. A typical cause of footdrop is damage to the common fibular nerve, which may occur with fractures of the fibular neck. Other causes include disc protrusion compressing the L5 nerve root, disorders of the sciatic nerve and the lumbosacral plexus, and pathologies of the spinal cord and brain. In the clinic


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Anatomy_Gray. In the clinic The common fibular nerve is susceptible to injury as it passes around the lateral aspect of the neck of the fibula. It can be injured as a result of a direct trauma (blow or laceration), secondary to knee injury (knee dislocation), or as a consequence of a proximal fibular fracture. Sometimes damage to the nerve can be iatrogenic, that is, damaged during arthroscopy or knee surgery. Symptoms of common fibular nerve injury are often observed in bed-bound patients, particularly in those with decreased levels of consciousness, due to prolonged external pressure to the knee leading to nerve compression and neuropathy. Similarly, application of a tight cast or a brace to the leg can compress the nerve, producing symptoms of fibular muscle palsy. Apart from a foot drop, other symptoms of common fibular nerve injury include loss of sensation over the lateral aspect of the leg and dorsum of the foot, and wasting of fibular and anterior tibial muscles. In the clinic


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Anatomy_Gray. In the clinic Occasionally there is a superior projection of the distal aspect of the talus, which is beak-shaped (Fig. 6.101). It is often associated with the presence of a bony or fibrous joint between the talus and calcaneus. In the clinic Fracture of the talus The talus is an unusual bone because it ossifies from a single primary ossification center, which initially appears in the neck. The posterior aspect of the talus appears to ossify last, normally after puberty. In up to 50% of people there is a small accessory ossicle (the os trigonum) posterior to the lateral tubercle of the posterior process. Articular cartilage covers approximately 60% of the talar surface and there are no direct tendon or muscle attachments to the bone.


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Anatomy_Gray. One of the problems with fractures of the talus is that the blood supply to the bone is vulnerable to damage. The main blood supply to the bone enters the talus through the tarsal sinus from a branch of the posterior tibial artery. This vessel supplies most of the neck and the body of the talus. Branches of the dorsalis pedis artery enter the superior aspect of the talar neck and supply the dorsal portion of the head and neck, and branches from the fibular artery supply a small portion of the lateral talus. Fractures of the neck of the talus often interrupt the blood supply to the talus, so making the body and posterior aspect of the talus susceptible to osteonecrosis, which may in turn lead to premature osteoarthritis and require extensive surgery. In the clinic An appreciation of ankle anatomy is essential to understand the wide variety of fractures that may occur at and around the ankle joint.


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Anatomy_Gray. In the clinic An appreciation of ankle anatomy is essential to understand the wide variety of fractures that may occur at and around the ankle joint. The ankle joint and related structures can be regarded as a fibro-osseous ring oriented in the coronal plane. The upper part of the ring is formed by the joint between the distal ends of the fibula and tibia and by the ankle joint itself. The sides of the ring are formed by the ligaments that connect the medial malleolus and lateral malleolus to the adjacent tarsal bones. The bottom of the ring is not part of the ankle joint, but consists of the subtalar joint and the associated ligaments. Visualizing the ankle joint and surrounding structures as a fibro-osseous ring allows the physician to predict the type of damage likely to result from a particular type of injury. For example, an inversion injury may fracture the medial malleolus and tear ligaments anchoring the lateral malleolus to the tarsal bones.


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Anatomy_Gray. The ring may be disrupted not only by damage to the bones (which produces fractures), but also by damage to the ligaments. Unlike bone fractures, damage to ligaments is unlikely to be appreciated on plain radiographs. When a fracture is noted on a plain radiograph, the physician must always be aware that there may also be appreciable ligamentous disruption. The Ottawa ankle rules were developed to assist clinicians in deciding whether patients with acute ankle injuries require investigation with radiographs in order to avoid unnecessary studies. Named after the hospital where they were developed, the rules are highly sensitive and have reduced the utilization of unwarranted ankle radiographs since their implementation. An ankle x-ray series is required if there is ankle pain and any of the following: Bone tenderness along the distal 6 cm of the posterior tibia or tip of the medial malleolus


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Anatomy_Gray. An ankle x-ray series is required if there is ankle pain and any of the following: Bone tenderness along the distal 6 cm of the posterior tibia or tip of the medial malleolus Bone tenderness along the distal 6 cm of the posterior fibula or tip of the lateral malleolus Inability to bear weight for four steps both immediately after the injury and in the emergency department A foot x-ray series is required if there is midfoot pain and any of the following: Bone tenderness at the base of the fifth metatarsal Bone tenderness at the navicular bone Inability to bear weight for four steps both immediately after the injury and in the emergency department In the clinic


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Anatomy_Gray. Bone tenderness at the navicular bone Inability to bear weight for four steps both immediately after the injury and in the emergency department In the clinic A bunion occurs on the medial aspect of the first metatarsophalangeal joint. This is an extremely important area of the foot because it is crossed by tendons and ligaments, which transmit and distribute the body’s weight during movement. It is postulated that abnormal stresses in this region of the joint may produce the bunion deformity. Clinically, a bunion is a significant protuberance of bone that may include soft tissue around the medial aspect of the first metatarsophalangeal joint. As it progresses, the toe appears to move toward the smaller toes, producing crowding of the digits. This deformity tends to occur among people who wear high-heeled or pointed shoes, but osteoporosis and a hereditary predisposition are also risk factors.


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Anatomy_Gray. This deformity tends to occur among people who wear high-heeled or pointed shoes, but osteoporosis and a hereditary predisposition are also risk factors. Typically the patient’s symptoms are pain, swelling, and inflammation. The bunion tends to enlarge and may cause problems in obtaining appropriate footwear. Initial treatment is by adding padding to shoes, changing the type of footwear used, and taking anti-inflammatory drugs. Some patients may need surgery to correct the deformity and realign the toe. In the clinic


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Anatomy_Gray. In the clinic The plantar aponeurosis is a flat band of connective tissue that supports the arch of the sole of the foot. It runs from the calcaneal tuberosity to the base of the toes. Overuse and increased strain on the plantar aponeurosis, such as excessive running and standing, and increased body weight, can lead to micro-tears and degeneration within the aponeurosis at the heel with disorganization of the collagen fibers. Patients typically present with mild to severe heel pain, which appears thickened on imaging (Fig. 6.121). It is usually successfully treated with intense physiotherapy, but may require image-guided injection therapies. In severe cases, the diseased section of the fascia needs to be surgically removed. In the clinic


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Anatomy_Gray. In the clinic A Morton’s neuroma is an enlarged common plantar nerve, usually in the third interspace between the third and fourth toes. In this region of the foot the lateral plantar nerve often unites with the medial plantar nerve. As the two nerves join, the resulting nerve is typically larger in diameter than those of the other toes. Also, it is in a relatively subcutaneous position, just above the fat pad of the foot close to the artery and the vein. Above the nerve is the deep transverse metatarsal ligament, which is a broad strong structure holding the metatarsals together. Typically, as the patient enters the “push-off” phase of walking the interdigital nerve is sandwiched between the ground and the deep transverse metatarsal ligament. The forces tend to compress the common plantar nerve, which can be irritated, in which case there is usually some associated inflammatory change and thickening.


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Anatomy_Gray. Typically, patients experience pain in the third interspace, which may be sharp or dull and is usually worsened by wearing shoes and walking. Treatment may include injection of anti-inflammatory drugs, or it may be necessary to surgically remove the lesion. In the clinic Clubfoot is a congenital deformity in which babies are born with one or both feet pointing inward and downward. It is treated with gentle manipulation of the affected foot and with plaster casts to straighten the foot, which is usually followed by a minor surgical procedure where the calcaneal tendon is cut to release the foot into a better position.


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Anatomy_Gray. A young man was enjoying a long weekend skiing at a European ski resort. While racing a friend he caught an inner edge of his right ski. He lost his balance and fell. During his tumble he heard an audible “click.” After recovering from his spill, he developed tremendous pain in his right knee. He was unable to carry on skiing for that day, and by the time he returned to his chalet, his knee was significantly swollen. He went immediately to see an orthopedic surgeon. The orthopedic surgeon carefully reviewed the mechanism of injury.


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Anatomy_Gray. The orthopedic surgeon carefully reviewed the mechanism of injury. The man was skiing down the slope with both skis in parallel. The ankles were held rigid in the boots and the knees were slightly flexed. A momentary loss of concentration led to the skier catching the inner edge of his right ski. This effect was to force the boot and calf into external rotation. Furthermore, the knee was forced into a valgus position (bowed laterally away from the midline) and the skier tumbled. Both skis were detached from the boots as the bindings released them. A series of structures within the knee joint were damaged sequentially.


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Anatomy_Gray. A series of structures within the knee joint were damaged sequentially. As the knee went into external rotation and valgus, the anterior cruciate ligament became taut, acting as a fulcrum. The tibial collateral ligament was stressed and the lateral compartment of the knee compressed. As the force increased, the tibial collateral ligament was torn (Fig. 6.139A,B), as was the medial meniscus (Fig. 6.140C). Finally, the anterior cruciate ligament, which was taut, gave way (Fig. 6.140A,B). The joint became swollen some hours afterward. Disruption of the anterior cruciate ligament characteristically produces marked joint swelling. The ligament is extrasynovial and intracapsular and has a rich blood supply. As the ligament was torn it ruptured into the joint. Blood from the tear irritates the synovial membrane and also enters the joint. These factors produce gradual swelling of the joint over the ensuing hours with significant fluid accumulation in the joint cavity.


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Anatomy_Gray. The patient had a surgical reconstruction of the anterior cruciate ligament. It is difficult to find a man-made substance that can act in the same way as the anterior cruciate ligament and demonstrate the same physical properties. Surgeons have devised ingenious ways of reconstructing the anterior cruciate ligament. Two of the commonest methods use the patellar ligament (tendon) and hamstrings to reconstruct the ligament. The patient had further surgical procedures. The tibial collateral ligament was explored and resutured. Using arthroscopic techniques, the tear in the medial meniscus was débrided to prevent further complications. A 45-year-old man with diabetes mellitus visited his nurse because he had an ulcer on his foot that was not healing despite daily dressings.


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Anatomy_Gray. A 45-year-old man with diabetes mellitus visited his nurse because he had an ulcer on his foot that was not healing despite daily dressings. Diabetes can lead to vascular disease of large and medium arteries, narrowing the lumen and reducing blood supply to the extremities, thereby impairing healing. In addition, diabetes can also affect blood supply to nerves, which leads to peripheral neuropathy. Peripheral neuropathy results in reduced sensation, and therefore minor injuries can often go unnoticed. This patient has developed an ulcer on his heel, which is a pressure point and likely to be under repeated strain. The nurse examined the ulcer and found that the ulcer was looking infected with pus at the base of the ulcer and asked for a specialist orthopedic opinion, who requested an x-ray and an MRI. The MRI and x-ray both demonstrated infection invading into the calcaneus with destruction of the bone (Fig. 6.141A,B).


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Anatomy_Gray. The patient required surgical washout with removal of the dead and infected bone (debridement) and was given long-term antibiotic treatment (Fig. 6.141C). A young woman came to a vascular surgeon with a series of large dilated tortuous veins in her right leg. The rest of her leg was otherwise unremarkable. A diagnosis of varicose veins was made and the surgeon needed to determine the site of valvular incompetence.


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Anatomy_Gray. A diagnosis of varicose veins was made and the surgeon needed to determine the site of valvular incompetence. There are typical points where incompetent valves occur between the superficial and the deep veins. In these regions the varicosities tend to become marked. The typical sites are: at the saphena varix—the saphenofemoral junction where the femoral vein is joined by the great saphenous vein; in the midthigh perforating vein between the great saphenous vein and the femoral vein; in the calf the three sites where perforators occur, 5, 10, and 15 cm above the medial malleolus between the great saphenous vein and the deep veins of the calf; and at the junction of the small saphenous vein and the popliteal vein.


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Anatomy_Gray. The surgeon asked the patient to lie supine on the bed and elevated the leg. A tourniquet was placed around the upper thigh below the saphenofemoral junction and the patient was asked to stand up. No veins were demonstrated filling on the medial aspect of the thigh and lower limb. The effect of the tourniquet is to compress the great saphenous vein while permitting blood to flow in the deep venous system of the femoral vein and the deep femoral vein. Because there was no filling of the medial varicose veins below the level of the tourniquet, the surgeon assumed that the valve at the saphenofemoral junction was incompetent and would require surgical treatment. However, during the tourniquet maneuver the surgeon also noted some veins around the posterior and posterolateral aspect of the calf.


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Anatomy_Gray. However, during the tourniquet maneuver the surgeon also noted some veins around the posterior and posterolateral aspect of the calf. A similar technique was performed by application of a tourniquet just below the level of the knee joint while the leg was elevated. The patient stood up and no veins were demonstrated filling in the posterior and posterolateral aspect of the calf. These findings suggested to the surgeon that there was also incompetence of the valve for the small saphenous system where it anastomoses with the popliteal vein. Surgery was planned.