Sobotta Atlas vol-1

M uscles -» T o p o g ra p h y -► S ections

Vessels and nerves of the dorsum of the hand

M. extensor carpi ulnaris M em brana interossea
A . interossea anterior M . extensor p ollicis brevis
N. radialis, R. profundus, M. a b d u cto r pollicis longus, Tendo
N. interosseus antebrachii posterior
Retinaculum m usculorum extensorum Rete carpale dorsale
A. ulnaris, R. carpalis dorsalis A. ra d ia lis
A. radialis, R. c arp a lis dorsalis
A. m etacarpalis dorsalis I
Aa. m e tacarp ales dorsales M. e xtensor pollicis longus, Tendo
M. a d d u cto r pollicis

M. interosseus dorsalis

Fig. 3.166 Arteries and nerves of th e dorsum of th e hand, for the dorsum of the hand and the Aa. digitales dorsales for the digits
Dorsum m anus, rig h t side; dorsal v ie w ; a fte r rem oval o f th e long up to the proximal interphalangeal joints. The interm ediate and distal
tendons o f the extensor muscles. phalanges are supplied by th e palm ar digital arteries. B efore th e A. ra­
Both, th e A. radialis and A. ulnaris send a R. carpalis dorsalis to the dialis courses betw een both heads of the M . interosseus dorsalis I to
dorsum o f th e hand w h e re th e y com m unica te. The radial branch is usu­ reach the palm of th e hand, the A. metacarpalis dorsalis I directly
ally stronger and predom inantly supplies the Aa. metacarpales dorsales branches o f the A. radialis.

dissection link 237

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Vessels and nerves of the dorsum of the hand

R etinaculum m usculorum extensorum N. radialis, Rr. su p e rficia le s
N. radialis, N. cutaneus antebrachii posterior A. radialis

Rete carpale dorsale Vagina tendinis m usculi flexoris carpi radialis
Fovea radialis
A. radialis, R. p alm aris superficialis
A. radialis, R. carpalis A. radialis
M . extensor carpi radialis brevis, Tendo
M. extensor carpi radialis longus, Tendo M . ab d u cto r pollicis longus, Tendo
M . e xten s o r pollicis brevis, Tendo
A. radialis M. a b d u cto r pollicis brevis
M . e xtensor digitorum , Tendines
M. opponens pollicis
Aa. m etacarpales dorsales M . exten s o r pollicis longus, Tendo
M . interosseus d orsalis I
Nn. digitales dorsales
M. lum bricalis I A. m etacarpalis dorsalis
M. adductor pollicis

Fig. 3.167 Arteries and nerves of th e dorsum of th e hand. through the firs t osseofibrous tunnel (M . abductor pollicis longus and
Dorsum m anus, right side; radial view. M. exte nsor pollicis brevis, -» Fig. 3.87) to reach th e Fovea radialis
The illustration dem onstrates the course of th e A. radialis in the area (Tabatière; betw een the tendons of M m . extensores pollicis brevis and
o f th e w ris t. A t th e proxim al w ris t joint, th e A. radialis is positioned longus) and delivers a R. carpalis dorsalis. A fte r having crossed beneath
betw een the tendons o f the M . brachioradialis and M . flexor carpi radi­ the tendon o f the M . extensor pollicis longus, th e A. radialis releases
alis. A fte r traversing beneath the Retinaculum m usculorum extenso­ the A. metacarpalis dorsalis to the thum b and passes betw een the tw o
rum , th e A. radialis provides th e R. palm aris superficialis w h ich com m u­ heads of the M. interosseus dorsalis I into the palm of the hand. Occa­
nicates w ith the superficial arterial palmar arch. The A. radialis then sionally, a superficial variant exists and the artery crosses the extensor
crosses underneath the tendons o f th e extensor m uscles passing tendons superficially.

238— ► dissection link

M uscles -» T o p o g ra p h y -► S ections Hand, sagittal section

A. interossea an terio r M em brana interossea
A . interossea p o sterio r
M. fle xor digitorum profundus, Tendines M . extensor digitorum
Retinaculum m usculorum flexorum
M . a b d u c to r pollicis longus, Tendines
M . fle x o r d igito ru m superficialis, Tendines M . extensor p ollicis longus, Tendo
R e te carp a le palm are Radius
A poneurosis palm aris A rticulatio radiocarpalis
Os lunatum
A. m e ta c a rp a lis p a lm a ris III R e te c arp a le dorsale
A rcus p alm aris superficialis O s capitatum
A. d ig ita lis p alm aris c o m m u n is III O s m e ta c a rp i III, B asis

M . lu m b rica lis III, Tendo M . in te ro sse u s p a lm a ris II
A. digitalis p alm aris propria M . in te ro sse u s d o rs a lis III
A. m e ta c a rp a lis d o rs a lis III
Phalanx proxim alis
Vagina tendinum A. digitalis dorsalis

Phalanx media
Phalanx distalis

Fig. 3.168 A rteries of th e hand, M anus, rig h t side; ulnar view ; from the dorsal arterial network. A t the volar side of the hand, th e me­
sagittal section at the level of th e Ulnar plane o f the third digit. tacarpal arteries originate fro m the deep and the digital arteries from
A t the distal forearm , the Aa. interosseae anterior and posterior run on the superficial palmar arterial arch. Each finger receives a total of four
both sides o f th e M em brana interossea antebrachii. The m etacarpus is digital arteries (palmar and dorsal at the radial and ulnar side, respec­
supplied from palm ar and dorsal by arterial netw orks (Rete carpale tively). The dorsal digital arteries only reach to the m iddle phalanx.The
palmare and dorsale) w hich derive fro m th e A. radialis and A. ulnaris. m iddle and distal phalanges are supplied by branches of the palmar
The metacarpal and digital arteries of the dorsum of the hand derive digital arteries.

239

3 Upper Extremity S urface a n a to m y -> D e ve lo p m e n t -► S keleton - * Im a g in g

Upper arm, transverse sections

Fascia brachii M. biceps brachii
V. ce p h a lica N. m usculocutaneus
A. brachialis
M. brachialis V. b r a c h ia lis
M. coracobrachialis N . m edianus
V. basilica
H um erus A. collateralis ulnaris superior
S eptum interm usculare brachii laterale N. ulnaris
S eptum interm usculare brachii mediale
N . radialis
A . profunda brachii M. trice p s brachii, C a pu t longum
M. tric e p s brachii, C aput laterale
M. trice p s brachii, C aput m ediale

Fig. 3.169 Upper arm , Brachium, right side; distal view ; transverse located in th e Sulcus bicipitalis medialis and an terior to th e S eptum in-
section at th e level o f the m iddle part of the upper arm. term uscu la re brachii m ediale (medial passageway). The V. basilica has
The cross-section clearly dem onstrates the tw o muscle groups of the already pierced th e fascia and is sho w n ju s t before m erging w ith th e V.
upper arm. Located on the ventral side are the flexors of the elbow brachialis. The N. ulnaris traverses th e S eptum interm usculare brachii
joint. The M . biceps brachii is positioned anterior to the M. brachialis mediale further distal to reach the posterior side of the Epicondylus
w h ic h originates fu rth e r lateral. The insertion o f th e M . coracobrachialis m edialis. Laterally, in th e Sulcus nervi radialis th e N. radialis w in d s
on the medial humeral shaft is delineated. The heads o f the M. triceps around the humeral shaft tog ether w ith the A. profunda brachii (dorsal
brachii occupy the posterior side o f the upper arm. passageway) and descends betw een the M. brachialis and M . triceps
N eurovascular structures course in tw o passagew ays.The N. m edi- brachii.
anus together w ith th e A. brachialis and concom itant Vv. brachiales are

V. c e p h a lic a M. biceps brachii

M. brachialis V. b ra ch ia lis
H um erus V. b a silica
S e p tu m S eptum interm usculare
brachii mediale
interm usculare
brachii laterale M. triceps brachii

Fig. 3.170 Upper arm , Brachium, right side; distal view ; magnetic
resonance im aging cross-section (axial MRI) at th e level o f th e m iddle
part o f the upper arm.

240

M uscles -» T o p o g ra p h y -► S ections

Forearm and carpus, transverse sections

M . palm aris longus, Tendo V. m e d ian a a n te b ra ch ii
M. fle xor digitorum superficialis M . fle xor carpi ulnaris
M . flexor carpi radialis A. ulnaris
N. ulnaris
N. m edianus M. flexor digitorum profundus
M. flexor pollicis longus
M. extensor carpi ulnaris
M. brachioradialis M. extensor pollicis longus
A. radialis M. extensor digiti minim i
N . interosseus a n te b rac h ii p o sterio r
N. radialis, R. superficialis
M . pro na tor teres

M. extensor carpi radialis longus
N. interosseus a n te b rac h ii an terio r

M. e xtensor carpi radialis brevis
Radius

M . extensor digitorum
M. a b d u cto r pollicis longus
M em brana interossea

Fig. 3.171 Forearm , A ntebrach ium , rig h t side; distal view ; nervi mediani) are positioned (medial neurovascular passageway). Be­
transverse section at the level o f the distal third of the forearm. neath th e M . fle xo r carpi ulnaris, th e N., A. and V. ulnaris are located
The forearm displays five neurovascular passageways w hich are (ulnar neurovascular passageway). The A. and V. interossea anterior
located betw een the superficial and deep layers o f the flexors and ex­ and the N. interosseus an terior course an terior to th e M em brana inter­
tensors, respectively.The A. and V. radialis to g e th e r w ith th e R. superfi­ ossea antibrachii (interosseal neurovascular passageway). The A. and V.
cialis o f th e N. radialis course beneath th e M . brachioradialis (radial neu­ interossea po sterior and th e N. interosseus po sterior are located bet­
rovascular passageway). w een the superficial and deep extensors (posterior neurovascular pas­
In th e m idline, b e tw een th e superficial and inte rm ed iate layers o f th e sageway).
flexors, th e N. m edianus and a delicate con com itan t artery (A. com itans

M. palm aris longus, Tendo H yp o th e n a r
Retinaculum m usculorum flexorum
A .; V.; N . u ln a r is * *
Thenar
N. m edianus* M m . flexores digitorum ,
M . fle xo r pollicis longus, Tendo Tendines
M . fle x o r carpi radialis, Tendo O s triquetrum
O s trapezium M . e xtensor carpi ulnaris, Tendo
M . a b d u cto r pollicis longus, Tendo
M . extensor p ollicis brevis, Tendo Os ham atum
M. extensor digiti m inim i, Tendo
V. ce p h a lica V. b a silica
A. radialis O s capitatum
M. extensor digitorum , Tendo
M m . extensores carpi radiales, Tendines M. extensor indicis, Tendo

M. e xtensor pollicis longus, Tendo

Os trapezoideum

Fig. 3.172 Carpus, righ t side; distal v ie w ; transverse section at the m ay result in com pression o f th e N. m edianus (carpal tunnel syndrom e,
level of the distal ro w of carpal bones. -» Fig. 3.125).The A., V. and N. ulnaris run above th e retinaculum in th e
The palm ar side of the carpus has tw o neurovascular passageways GUYON's canal w here they are vulnerable to com pression due to the
o f clinical im portance. The carpal bones together w ith the Retinaculum superficial location (distal lesion o f th e N. ulnaris -* Fig. 3.129).
m u sculorum flexo rum fo rm th e carpal tunnel (Canalis carpi). The N. m e­
dianus traverses the carpal tunnel together w ith the tendons of the * carpal tunnel
long flexors of the digits. Therefore swelling of the tendinous sheaths * * GUYON's canal

3 Upper Extremity Surface anatom y Sections

Metacarpus and third digit, transverse sections

M m . lum bricales Aa. digitales palm ares com m unes;
N. medianus
M. fle xor p ollicis brevis,
C aput superficiale M. fle xor d igitorum superficialis,
Tendines
M . fle xor pollicis longus, Tendo,
Vagina tendinis M. abductor
digiti minim i
M . abductor pollicis longus
M .opponens
M .opponens d igiti minim i

O s m etacarpi pollicis Os m etacarpi V

M. extensor pollicis brevis M . flexor digitorum profundus,
M. e xtensor pollicis longus, Tendines

Tendo, Vagina tendinis M . extensor digiti minim i
M . fle x o r p o llic is brevis, M . in te ro sse u s p a lm a ris III
C aput profundum
M. adductor M . in te ro sse u s d o rs a lis IV
M. interosseus dorsalis I
A. m etacarpalis palm aris O s m e ta ca rp i IV
Os m etacarpi indicis
M . interosseus palm aris I M . in terosse us p a lm a ris II
M . in terosse us d o rsa lis II
O s m e ta ca rp i III M . in terosse us d o rsa lis III

M . e xtensor digitorum , Tendines

Fig. 3.173 Metacarpus; transverse section at the level of the middle originate fro m th e se tendons. The deep layer of th e palm ar m uscles is
of the third metacarpal bone. form ed by the M m . interossei palmares and dorsales. Here it is obvious
This section de m onstrate s th e position o f th e m uscles in th e palm of the palm ar interosseal m uscles lie indeed nearer to the palm o f the
th e hand w hich are grouped in three layers (-* pp. 188-193). hand than th e dorsal m uscles. In addition, th is illustration also clearly
Superficially, th e M. abductor pollicis, M. flexor pollicis brevis, and M. sh o w s th e position o f th e digital arteries (Aa. digitales palm ares com ­
abductor digiti m inim i cover the other m uscles of the Thenar and Hypo- m unes) and th e sensory term inal branches o f th e N. m edianus w hich
thenar, respectively. The interm ediate layer harbours the tendons of run ventrally to th e fle xo r ten don s (-» Fig. 3.164).
the long flexor m uscles of the fingers. Also, the M m . lumbricales

Corpus phalangis M . extensor digitorum ,
N. digitalis dorsalis Tendo*

P e rio s te u m digitalis dorsalis
M esotendineum
M. flexor digitorum profundus, Tendo
N. digitalis palm aris proprius A. digitalis palm aris propria
M. flexor digitorum superficialis, Tendo
Vagina ten d inu m d igiti

Fig. 3.174 Third digit. Digitus medius [III]; transverse section dorsal arteries and nerves at th e m iddle phalanx are much thinner than
through the shaft of the m iddle phalanx. the corresponding palm ar structures. Thus, the m iddle phalanges are
The tendon o f the M. flexor digitorum profundus has pierced the ten­ predom inantly and the distal phalanges are exclusively supplied by
don of the M . flexor digitorum superficialis and both tendons are posi­ p alm ar branches (A. digitalis palm aris propria and N. digitalis palmaris
tioned w ith in a com m on tendinous sheath (Vagina ten dinum digiti). The proprius) (-* Fig. 3.168).

242

Lower Extremity

Surface A n a to m y ............................. 246
Skeleton .............................................. 248
Im a g in g ................................................ 290
M u s c le s ................................................ 296
T o p o g ra p h y ......................................... 326
S e ctio n s................................................ 369

The Lower Limb
the Erect Gait

The bipedal upright gait not only influenced the intellectual and socio­ Lower lim b
cultural d e velopm ent o f hum ans b u t also resulted in significant
changes of the human anatomy. The Pars libera m em bri inferioris consists o f the thigh (Femur), th e knee
(Genu), th e leg (Crus), and th e fo o t (Pes).
In humans, th e lo w e r extre m itie s - as seen in hom inids - are locom o­
tion and support organs, however, w ith a more stable and w ider pelvic The th ig h (Femur) is supported by th e identically nam ed bone, w h ich is
girdle and longer legs: The extensive pelvic bones bear th e w e ig h t of th e largest long bone o f th e body. In th e hip jo in t (A rticulatio coxae), the
the upper body and support the viscera o f the abdominal cavity, en­ ball-like head o f the Femur articulates w ith the hem ispherical socket of
abling prolonged standing w ith o u t much effort. The ability to take larger the Os coxae. The range of m ovem ent o f the hip joint, especially the
step s results in accelerated locom otion. Speed and greater range of extension, is restricted by pow erful, alm ost centim etre-thick ligam ents
action caused already the quadrupedal m am m als to develop limbs w hich are incorporated into the capsule. Since the Fem ur is w ell sur­
w hich m igrated ventrally underneath the body. The fro nt (upper) extrem ­ rounded by m uscles, one can only palpate th e tw o (epi-)condyles (bi­
ities w ere rotated dorsally w hile the rear (lower) extrem ities w ere rota­ laterally superior to the knee) and the greater trochanter (Trochanter
ted ventrally. Hence, in hum ans th e extensors o f th e thigh and low er major) in the hip region.
leg are positioned anteriorly, w hereas the upper arm and forearm ex­
tensors are located posteriorly. In the knee region (Regio genus), th e thigh bone and Tibia fo rm the
knee jo in t (A rticulatio genus). The kneecap (Patella) is th e ventral part of
The joints o f the fre e e xtrem ity such as hip, knee, and ankle joints are the knee joint and articulates w ith the Femur through its posterior sur­
supported by stable ligam ents. They ensure steadiness w hile standing face. The knee is prim arily a hinge jo in t b e tw een Fem ur and Tibia. In a
and relieve the m uscle groups on buttocks, knee, and calf, w hich are flexed position, it also allow s fo r a certain rotation o f the leg. The pos­
responsible fo r body posture. terior region o f the knee, the popliteal fossa (Fossa poplitea), is s o ft and
placable w h e n th e knee is flexed. D eep in th e fossa, branches o f th e N.
The stance stabilizing fo o t o f hum ans - in con trast to th e grasping ischiadicus and the A. poplitea descend from the thigh to the leg.
hand-like fo o t in hom inids - has led to less m obility o f the joints, espe­ Therefore, th e pulse o f th e A. poplitea is hardly palpable in a flexe d
cially o f the interphalangeal joints of the toes; the m uscles o f th e foo t position of the knee.
contribute to stabilization of the fo o t and bracing of the plantar arch
rather than enabling the fine-tuned m ovem ent of individual toes. The lo w er leg (Crus, leg) is supported by a m edially and anteriorly lo­
cated Tibia and a laterally positioned Fibula. The head o f th e Fibula is
Pelvic Girdle easily palpable distal to th e knee jo in t (of w h ich th e Fibula is n o t a part).
The N. fibularis co m m unis descends subcutaneously and dorsal to the
In con trast to th e shoulder girdle, th e pelvic girdle (Cingulum m em bri head o f th e Fibula. Damage to the N. fibularis co m m unis can occur at
inferioris or pelvicum ) is an alm ost rigid bony ring. Dorsally it consists of this point, e.g. due to pressure of a poorly padded cast.
the sacrum (Os sacrum), w hich is a con stituen t o f the spine. The sa­
crum is unpaired and it connects bilaterally through m inim ally flexible A t th e tra nsition to th e fo o t (Pes), one can easily palpate th e bilateral
joints (Articulationes sacroiliacae) w ith the paired pelvic bones (Ossa ankle bulges (M alleolus lateralis and medialis). The Malleolus lateralis
coxae). The Ossa coxae form tw o bony half shells w hich join ventrally (of th e Fibula) is alw ays positioned low er than the M alleolus medialis
beneath the M ons pubis at the fibrocartilaginous Symphysis pubica. (of th e Tibia). Ju s t infe rior and po sterior to th e M alleolus medialis a
This resem bles a bony floorless basin, w here the m uscles and liga­ bundle of blood vessels, nerves and tendons descends fro m the dorsal
m ents form th e pelvic floor. Each pelvic bone consists o f three single aspect of the Crus to the sole o f the foot. The pulse of the A. tibialis
bones w hich are connected by synostoses once gro w th is com pleted: posterior is palpable near the M alleolus medialis. Both malleoli o f the
th e ilium (Os ilium , cranial), the ischium (Os ischii, caudodorsal) and the Tibia and Fibula articulate w ith th e Talus, fo rm in g th e ankle jo in t (Articu­
pubis (Os pubis, caudoventral). latio talocruralis). It facilitates elevation and depression o f the foot. The
digital extensor tendons project on the dorsum of the foot. Between
W hen investigating the so ft tissues of the pelvic girdle, the follow ing the m , th e pulse o f th e A. dorsalis pedis is palpable. The skeleton o f the
picture em erges: A t th e ventral aspect, the inguinal region (Regio ingui- fo o t includes the Tarsus, th e M etatarsus, and the phalanges (Digiti).
nalis) is positioned on e ith e r side o f th e M ons pubis. In th e ten der There are seven tarsal bones (Ossa tarsi), the Talus being positioned on
inguinal canal, blood vessels, m uscles, and nerves (and th e sperm atic top. Just be lo w the Talus lies the heel bone (Calcaneus) to w hich the
cord in males) descend fro m th e inte rior o f th e abdom en to th e leg (and ACHILLES tendon (Tendo calcaneus) attaches at its posterior surface.
scro tum , respectively). The pulse o f th e fem ora l artery (A. fem oralis) is A t the medial side, the navicular bone (Os naviculare) lies inferior and
palpable slightly lateral to both sides o f the M ons pubis in the Regio anterior to the Talus. The above m entioned three bones form the talo­
inguinalis. The actual hip region (Regio coxae) is located m ore laterally. calcaneonavicular joint (Articulatio talocalcaneonavicularis). It perm its
Dorsally, the bilaterally curved buttocks of the gluteal region (Regio glu- rotating the fo o t inw ards (supination) and outw ards (pronation). The re­
tealis, "h o glu to s": the buttocks) rest on the bony pelvic girdle. Their maining tarsal bones, the three cuneiform bones (Ossa cuneiform ia)
convexity resulted fro m the adaptive evolution of the gluteal muscles and the cuboid (Os cuboideum), are interconnected by tig h t and alm ost
due to the transition to the bipedal gait. Both buttocks are separated by im m obile joints. The M etatarsus is supported by five long bones, the
a deep natal c le ft (Crena ani) and th e gluteal fold (Sulcus glutealis) sepa­ Ossa metatarsi. Together w ith the tarsal bones, they form the arch of
rates them from th e thigh. th e foo t. The flexible arch o f th e fo o t is m ainly supported by m uscles
and tendons located in th e sole o f th e fo o t (Planta pedis). The toes I to
V (Digiti) are form ed by shorter long bones, the phalanges. One starts
counting at th e great to e (Hallux, D igitus prim us); in analogy to the
thum b, the Hallux has only tw o phalanges.

244

r Clinical Remarks

Congenital deform ities such as hip dysplasia or clubfoot occur
frequently and require therapy during early childhood to ena­
ble walking and to w arrant normal developm ent. Am ong the
chronic degenerative diseases, such as arthrosis, w hich affect
eldery persons w ith variable severity and w hich contribute to a
substantial am o u n t o f th e costs in th e public health sector, th e
hip joint (coxarthrosis) and the knee joint (gonarthrosis) are m ore
frequently affected than the joints of the upper extrem ity. This
is caused by th e high im pact on th e w eight-bearing jo in ts th a t is
in part due to the erect bipedal posture, but also to civilisation-
based conditions such as obesity. In addition, tra u m a tic injuries
at w ork or during recreational activities affect the long bones and
predom inantly the joints of the low er extrem ities (injuries to the
ligam ents and menisci) and frequently require a surgical recon­
struction. The prim ary goal here is to restore the ability to w alk
and, thus, prevent secondary diseases caused by im m obility such
as throm bosis and pulm onary infections.

— ► Dissection Link
The m usculoskeletal system is dissected in layers (stratigraphically)
from superficial to deep structures.
V entral dissection: First, th e epifascial stru cture s in th e subcutaneous
adipose tissue are exposed. This involves several cutaneous nerves of
th e Plexus lum balis and at th e distal leg around th e N. fibularis super­
ficialis fro m th e Plexus sacralis. Then fo llo w s th e dissection o f th e V.
saphena magna ascending fro m the anterior aspect of the medial mal­
leolus via the medial aspect o f the knee up to the C onfluens venosus
subinguinalis in th e groin. The fascia is opened to expose th e individual
m uscles. Im m ediately beneath th e inguinal ligam ent (Lig. inguinale),
the Lacunae m usculorum and vasorum together w ith exiting neuro­
vascular stru cture s are dissected. From here, th e A. and V. fem ora lis as
w e ll as th e N. saphenus are traced to th e ir entrance into th e adductor
canal (Canalis adductorius). Next, th e origin and the branches o f the A.
profunda fem oris, the main blood vessel supplying the thigh, are dis­
sected. Finally, th e individual jo in ts (e.g. knee joint) are exposed.
Dorsal dissection: A fter exposure of the epifascial cutaneous nerves
fro m the Plexus sacralis, th e V. saphena parva is traced fro m th e poste­
rior aspect o f the lateral malleolus to its confluence in the popliteal
fossa. Next, th e opening o f the fascia displays the individual muscles.
In th e gluteal region, th e M . gluteus m axim us is exposed and reflected,
follow ed by the display o f the deep m uscles of the gluteal region. The
Regio glutealis w ith pathw ays is dissected. The N. ischiadicus is traced
to its divergence and fro m th e re th e N. tibialis and th e N. fibularis co m ­
m unis w ith its branches are traced to th e foo t. The popliteal fossa is
dissected including blood vessels. In th e leg, th e neurovascular
pathways are traced along th e A. tibialis anterior and posterior to the
foo t. A fte r th e rem oval o f th e plantar aponeurosis on th e Planta pedis,
the individual layers o f the short fo o t m uscles are exposed and the as­
sociated pathways are visualised.

EXAM CHECK LIST

• Bones w ith apophyses fo r m uscle o rig in s and insertions • jo in ts
and ligam ents (in pa rticular: A rtic u la tio genus w ith Ligg. cruciata
and collate rale and m enisci) • m uscles and th e ir course, fu n ctio n
and inne rvatio n • nerves w ith sup ply area, course and lesions •
arteries w ith branches, course and pulses • veins and th e ir course
• lym phatic drainage and N odi lym ph oide i inguinales superficia­
les • to p o g ra p h y : Lacunae m u s c u lo ru m and va so ru m , R egio g lu te ­
alis w ith in traglute al in jectio n, C analis o b tu ra to riu s, Canalis
adducto rius, Fossa poplitea and Planta pedis • co m p a rtm e n t
syndrom e • cross-sections: Coxa, Fem ur and Crus • surface
anatom y

Lower Extremity S urface a n a to m y -► Skeleton -► Im aging

Surface anatomy

S pina iliaca a n te rio r superior Regio inguinalis, Lig. inguinale
M. ten so r fasciae latae -
Tuberositas tibiae
Tro ch an ter m a jo r (F e m u r)- M a rg o a n te rio r (Tibia)
Regio fem oris anterior - M alleo lu s m ed ialis (Tibia)

M. quadriceps fem oris •
Regio genus anterior, P a te lla

C aput fibulae —

Regio cruris anterior

M alleo lu s lateralis (Fibula)
Dorsum pedis
Digiti -

Fig. 4.1 Surface relief o f th e lo w er ex tre m ity, righ t side; ventral The surface relief o f the legs is determ ined by m uscles and skeletal
vie w . elem ents. The skeletal elem ents w hich are palpable through the skin
are im portant landmarks fo r the physical examination.

246

M uscles -> T o p o g ra p h y -► S ections

Surface anatomy

Regio glutealis,
M. gluteus m axim us

T ro ch an ter m a jo r (Fem ur)

Sulcus glutealis

M. gastrocnem ius Regio genus posterior,
M alleo lu s m ed ialis (Tibia) Fossa poplitea

Regio cruris posterior,
Sura

M alleo lu s latera lis (Fibula)
------------D o rsu m p e d is

Fig. 4.2 Surface relief of th e low er extrem ity, right side; dorsal
vie w .

Lower Extremity Surface a n a to m y -» S keleton -► Im aging

Skeleton of the lower extrem ity

Cingulum Os coxae A rticulatio sacroiliaca
p e lv ic u m O s sacrum
A rticulatio coxae
Coxa

Femur -

a * . i„+;~ I A rticulatio fem orotibialis

Genu A rtic u la t.o g e n u s [ A rtic u |a tio fe m o ro p a te lla ris

Pars libera
m em bri inferioris

A rticulatio tibiofibularis

Long axis o f tibial shaft

Syndesm osis tibiofibularis talocruralis
c a lc a n e o c u b o id e a
Tarsus, O ssa tarsi s u b ta la r is
A rticulatio talocalcaneonavicularis
M etatarsus, A rticulatio cuneonavicularis
Ossa metatarsi A rticulatio cuneocuboidea
A rticulationes intercuneiform es
Digiti pedis, A rticulatio tarsom etatarsalis
Ossa digitorum :
- Phalanx proxim alis A rticulationes m etatarsophalangeae
- Phalanx media interphalangeae pedis
- Phalanx distalis

Fig. 4.3 Bones and joints of th e lo w er extrem ity, M em brum In th e knock-knee d e fo rm ity (Genu valgum ) th e Q-angle is sm aller, in
inferius, right side; ventral view. the bow leg de form ity (Genu varum) it is larger. For the de velopm ent of
W hereas th e shoulder girdle con sists o f tw o bones (Scapula and Cla- th e lo w e r e x tre m ity -» pages 132 and 133.
vicula), the pelvic girdle (Cingulum pelvicum) is form ed by tw o hip
bones (Os coxae) and th e sacrum (Os sacrum). Thigh and leg form a
laterally open angle of 174°, referred to as Q-angle.

248

M uscles -> T o p o g ra p h y -► S ections

Skeleton of the lower extrem ity

norm al Q -angle Genu valgum Genu varum
(knock-knee deform ity) (bowleg deform ity)

Fig. 4.4 M echanical axis of th e lo w er e x tre m ity (MIKULICZ'S In th e knock-knee d e fo rm ity (Genu valgum), th e knee is shifted m edi­
line), (according to [1]). ally aw ay fro m th e mechanical axis, in th e b o w leg d e fo rm ity (Genu
Normally, the great joints of the low er extrem ity are positioned on a varum), it is shifted laterally.
virtual straight line, the mechanical axis o f the low er extrem ity. This axis The size o f th e arrows depicts the stress on the medial and lateral parts
connects the centre of th e fem oral head w ith the m iddle of the m alleo­ o f the joint in relation to th e mechanical axis.
lar m ortice o f the ankle joint.

i- Clinical Remarks------------------------------------ of the m enisci or the jo in t cartilage may occur, causing arthrosis of
th e knee jo in t (gonarthrosis). A Genu valgu m results in lateral
Since th e w hole body w e ig h t is transferred via the mechanical axis arthrosis w hereas a G enu varu m causes arthrosis in th e medial
to the soles o f the feet, the stress on the joints is even if the joints com partm ent. For substantial deviations fro m the mechanical axis,
are aligned along th e m echanical axis. S hifting o f th e knee jo in t in surgical corrections by removal o f a bony w edge (osteotomy) may
the case o f a knock-knee (Genu valgum) or bow leg (Genu varum) be performed.
de form ity results in an uneven stress on both com partm ents o f the
knee jo in t (red arrow s, -* Fig. 4.4). A s a consequence, degeneration

249

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging -►

Pelvis P rom ontorium
A p e rtu ra pelvis s u p erio r
O s sacrum
A rticu latio sacroiliaca
Linea term inalis

Linea arcuata

O s ilium

Os ischii Pecten ossis pubis
S ym physis pubica
Os pubis
A p e rtu ra pelvis inferio r

Fig. 4.5 Pelvis, Pelvis; ventral cranial view. (Prom ontorium ). The Linea term inalis encircles the pelvic inlet (Aper­
Sacro-iliac joint (Articulatio sacroiliaca) and pubic sym physis (Symphysis tura pelvis superior) and separates the cranial false (large) pelvis
pubica) con nect th e tw o hip bones (Ossa coxae) and th e sacrum (Os (Pelvis major) fro m the caudal tru e (small) pelvis (Pelvis minor). The
sacrum). The resulting stable ring form ation encompasses th e viscera p rom on tory is th e part o f th e vertebral colum n th a t protrudes fa rth e st
w ith its iliac bones and transfers the w e ig h t o f the body to the low er into the pelvic inlet. The pelvic o u tlet (Aperura pelvis inferior) is con­
extrem ities. fined by the inferior margin o f the pubic sym physis anteriorly, the ischi­
The Linea term inalis begins at the pubic sym physis w ith the Pecten al tu b e ro sitie s laterally, and th e tip o f th e coccyx posteriorly.
ossis pubis and continues through the Linea arcuata to the prom ontory

D ia m e te r o b liq u a II Diam eter transversa

Diam eter obliqua I Linea term inalis
Diam eter vera

Fig. 4.6 and Fig. 4.7 Pelvis, Pelvis, of a w o m an (-» Fig. 4.6) and of The follow ing inner diam eters are used to determ ine the w idth o f the
a m an (-» Fig. 4.7). pelvic inlet: th e obstetric conjugate diam eter (Diam eter vera) betw een
The shape o f th e pelvis sh o w s diffe ren ces b e tw een th e sexes. In men, the posterior aspect o f the pubic sym physis and the promontory, the
the pelvic inlet is rather heart-shaped. The sm aller pubic angle is refer­ transverse diam eter (Diam eter transversa) betw een the m ost lateral
red to as A ngulus subpubicus (-» Fig. 4.41). In w o m e n , th e pelvic inlet points o f th e Linea term inalis on both sides, and the oblique diam eter
is transverse oval in shape. In addition, th e inferior pubic angle (Arcus (D iam eter obliqua I and II) w h ich con nects th e A rticulatio sacroiliaca o f
pubis, -* Fig. 4.42), th e distance b e tw een th e ischial tub ero sitie s, and each side w ith the corresponding m ost distal point on the Linea te rm i­
th e w in g s o f ilium are larger than in men. nalis.

250

M uscles -> T o p o g ra p h y -► S ections

a-b: Diam eter (clinical term : Conjugata) anatom ica: Pelvis
11.5 cm , from the prom ontory to the superior
a -c : margin o f the pubic sym physis Lig. sacrospinale
a-d: D ia m e te r vera: 11 c m , fro m th e p ro m o n to ry to Lig. sacrotuberale
the posterior aspect o f the pubic sym physis
Diam eter diagonalis: 12.5 cm , from the
prom ontory to the inferior m argin o f the pubic
sym physis

Linea term inalis
A pertura pelvis superior

Fig. 4.8 Pelvis, Pelvis, of a w o m an ; medial view ; median sectionThe m o st im portant is the Diam eter vera connecting the posterior as-

w ith illustration of the diverse straight inner diam eters and their normal pect of the pubic sym physis and the promontory,

length w hich may, however, sho w interindividual variations.

a-a: Diam eter transversa: 13.5 cm , distance between
the m ost laterally positioned points on each end
o f the Linea term inalis.

Fig. 4.9 Pelvis, Pelvis, of a w o m an w ith m easurem ents; dorsal
view.
A nother internal diam eter w ith a certain significance is the transverse
diam eter (Diameter transversa). The different external diam eters
(Distantiae), however, are of insignificant practical relevance and there­
fore not shown.

i- Clinical Rem arks------------------------------------ suspected, the exact dim ensions of the Conjugata vera are deter­
m ined by m agnetic resonance imaging (MRI). During caesar­
Because th e pelvic inlet and the true pelvis encom pass the birth ean section the Conjugata vera is routinely calculated to assess
canal, the determ ination o f the pelvic diam eters is o f great im por­ w h e th e r furth e r vaginal births are possible. During pregnancy, the
tance during pregnancy to assess w h e th e r a vaginal birth is possib­ pubic sym physis and sacro-iliac joints are loosened by the actions
le. The m o st im po rtan t diam eter fo r th e passage o f th e foetal head o f th e horm one relaxin w h ich is produced in th e placenta and the
is th e D iam ete r vera (clinical te rm : Conjugata vera; a t least 11 cm). ovary. Thus, the Conjugata vera is dilated by approxim ately 1 cm
It can be assessed by vaginal exam ination o f the D iam eter diagona- during parturition.
lis w hich spans fro m the inferior margin o f the pubic sym physis to
th e p rom on tory and is 1.5 cm longer than th e Conjugata vera. If an
incon gru ity b e tw een th e fo e ta l head and th e m aternal birth canal is

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Hip bone

Facies sacropelvica

Tuberositas iliaca

S pina iliaca a n te rio r inferio r Facies auricularis
Linea arcuata S pina iliaca p o s te rio r superior
S pina iliaca p o s te rio r inferio r
E m in e n tia Incisura ischiadica m ajor
Sulcus obturatorius-
Ramus superior ossis C orpus ossis ischii
P ec te n ossis pubis S pina ischiad ica
Foram en obturatum Incisura ischiadica m inor

Facies sym physialis Ram us ossis ischii
Ramus inferior ossis pubis Tuber ischiad icum

Fig. 4.10 Hip bone. Os coxae, right side; medial view. posterior and anterior, respectively. The Facies auricularis serves as
The hip bone con sists o f three parts, th e ilium (Os iliu m ), ischium (Os articular surface fo r th e sacro-iliac joint. The D iscus interpubicus is at­
ischium), and pubis (Os pubis). The ilium form s the false pelvis, ischi­ tached to th e Facies sym physialis.
um and pubis form the bony ring around the obturator foram en from

Labium internum
Linea interm edia

C ris ta iliaca Tuberositas iliaca
A la o ss is ilii
Labium
Facies sacropelvica
Fossa iliaca Facies auricularis
S p in a iliaca a n te rio r
Eminentia iliopubica
C o rp u s o ss is ilii C orpus ossis pubis
S pina iliaca a n te rio r inferio r Ramus superior ossis pubis
P ec te n ossis pubis
A cetabu lum Lim bus acetabuli Crista obturatoria
Crista pubica
Facies lunata F a cie s sym physialis
Fossa acetabuli
Tuberculum pubicum
. Incisura acetabuli Ramus inferior ossis pubis
Ramus ossis ischii
Corpus ossis ischii

Foram en obturatum
Tu b er ischiad icum

Fig. 4.11 Hip bone. Os coxae, right side; ventral view.

M uscles -> T o p o g ra p h y -► S ections Hip bone

Linea glutea anterior Labium internum C rista iliaca
F a c ie s g lu te a Linea glutea inferior Linea interm edia

Linea glutea posterior e x te rn u m
T uberculum iliacum

A la o ss is ilii
S pina iliaca anterior superior

Spina iliaca posterior superior C o rp u s o ss is ilii
Spina iliaca anterior inferior
Spina iliaca posterior inferior
Incisura ischiad ica m a jo r Facies lunata
Lim bus acetabuli Fossa acetabuli
Incisura acetabuli
S pina ossis pubis
Crista obturatoria
Incisura isc h iad ic a m in o r — Tuberculum pubicum

C o rp us ossis ischii Ramus inferior ossis pubis

T u b e r ischiad icum

Ram us ossis ischii

Fig. 4.12 Hip bone. Os coxae, righ t side; dorsolateral view .(Os ischium ) and th e pubis (Os pubis), con tribute to th e form atio n of

All three parts o f the hip bone, nam ely the ilium (Os ilium), the ischium the acetabular fossa (Acetabulum).

Facies lunata • C o rp u s o ss is ilii

Fossa acetabuli ■ C orpus ossis pubis
Corpus ossis ischii ■ Ramus superior ossis pubis
Ramus inferior ossis pubis
Ramus ossis ischii •

Fig. 4.13 Hip bone. Os coxae, of a 6-year-old child, right side; linked by a Y-shaped cartilaginous synchondrosis in the Acetabulum ,
lateral view . This cartilaginous synchondrosis ossifies b e tw e e n th e age o f 13 to 18.
The three parts of the hip bone (Os ilium, Os ischium , Os pubis) are

i- Clinical Rem arks------------------------------------

W ith high-energy trauma and high im pact on the stretched low er cartilaginous synchondroses in the area o f the A cetabulum needs to
limbs, a fracture of the acetabular fossa may occur w ith dislocation be considered fo r radiographic images in children and adolescents
o f th e fem oral head (central fracture-dislocation o f th e hip). to avoid confusion o f the cartilaginous synchondroses w ith an ace­
The developm ent of the juvenile hip bone w ith ossification of the tabular fracture cleft.

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Thigh bone

C ollum fem oris C aput fem oris Tro ch an ter m ajor
Fossa trochanterica Fovea capitis fem oris
Tro ch an ter m ajor Crista
C ollum fem oris in te rtro c h a n te ric a
C a p u t fem oris T ro c h a n te r
Tuberositas
C ollum fem oris Linea pectinea glutea
Linea intertrochanterica
Trochanter m inor Labium laterale Ï
Linea aspera
C orpus fem oris
Labium m ediale I

Tuberculum Tuberculum Linea supracondylaris lateralis
a d d u c to riu m a d d u c to riu m Linea supracondylaris medialis

Epicondylus lateralis Epicondylus m edialis E picondylus
Facies patellaris la te ra lis
C ondylus m edialis
Linea intercondylaris C ondylus lateralis
Fossa intercondylaris

Fig. 4.14 Thigh bone. Femur, right side; ventral view. Fig. 4.15 Thigh bone, Femur, righ t side; dorsal view .
Proximal at the fem oral shaft the Trochanter major is positioned The Linea aspera serves as apophysis fo r the origin of the M. quadri­
laterally and the Trochanter m inor dorsomedially. ceps fem oris as w ell as fo r the insertion of several m uscles of the ad­
ductor group.

254

M uscles -> T o p o g ra p h y -► S ections

Thigh bone

C aput fem oris Fovea capitis fem oris
C ollum fem oris m ajor

Fossa trochanterica

Trochanter minor

Linea aspera Fig. 4.17 Thigh bone. Femur, right side; proxim al view ; the
Corpus fem oris proximal and distal ends of the fem ur are projected on top of each
other.
The fem oral neck is rotated anteriorly by 12-14° against the axis con­
necting both fem oral condyles (transverse axis of the fem oral condy­
les). This is referred to as torsion angle of th e fem ur. In infants, this
angle is approxim ately 30°.
If th e torsion angle o f th e fe m u r is larger, th e leg is m edially rotated and
the toes point inwards during walking. If the torsion angle of the fem ur
is sm a lle r than 12°, th e to e s p o in t outw ards.

Epicondylus medialis Facies poplitea S ubstantia com pacta
Tuberculum adductorium S ubstantia spongiosa
Fossa intercondylaris
C o ndylus lateralis C avitas m edullaris

m e d ia lis

Fig. 4.16 Thigh bone. Femur, righ t side; medial view . Fig. 4.18 Thigh bone. Femur, right side; cross-section of the
fem oral shaft at mid-level; distal view.
The outer layer o f solid Substantia com pacta is follow e d by an inner
layer o f Substantia spongiosa and the central m edullary cavity (Cavitas
medullaris) w hich contains the bone marrow.

255

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Thigh bone

Fovea capitis fem oris Trochanter m ajor
Caput fem oris Tuberositas glutea

Fossa trochanterica
Collum fem oris

C rista intertrochanterica
Trochanter

Linea
Linea aspera, Labium medial'

Fig. 4.19 Proxim al end of th e fem ur. Femur, right side; dorsal Fig. 4.20 Proxim al end of th e fem ur. Femur, righ t side, w ith
view. illustration of the angle of inclination of the fem ur (neck-shaft
angle)
The fem oral neck form s an angle of 126° w ith the fem oral shaft. This
angle is referred to as the caput-collum-diaphyseal angle or CCD angle.
In th e new born, th e CCD angle m easures 150°. An increased CCD
angle results in a Coxa valga, a decreased CCD angle causes a Coxa
vara.

Fig. 4.21 Proxim al end of th e fem ur, Femur, right side, w ith Fig. 4.22 Proxim al end of th e fem ur. Femur, right side, w ith
illustration of th e spongiosa structure in th e case of an increased illu stration o f th e spongiosa structure in th e case of a decreased
angle of inclination (neck-shaft angle) (Coxa valga). Section at the angle of inclination (neck-shaft angle) (Coxa vara). Section at the
level of the torsion angle of the fem ur. level o f the torsion angle o f the fem ur.
The spongiosa trabeculae are trajectorial, i.e. they align w ith the In Coxa vara, increased tractio n forces cause a re in force m en t o f the
lines of maximal traction and com pression forces (the so-called trajec­ lateral spongiosa trabeculae (*) and at the sam e tim e a reduction of the
tories). Coxa valga causes higher compression forces and leads to a medial spongiosa trabeculae (**). As a result of an increased bending
reinforcem ent of the medial spongiosa trabeculae (**) and at the same stress, the corticalis at the inner side o f the fem oral neck is thickened.
tim e to a reduction of th e lateral spongiosa trabeculae (*).

Clinical Remarks in arthrosis o f the hip jo in t (coxarthrosis) or th e knee joint (gon-
arthrosis). In addition, Coxa vara predisposes to fractures of th e
A ltera tions o f th e caput-collum -diaphyseal (CCD) angle may restrict fem oral neck due to the increased bending stress.
m o vem en ts. In Coxa vara, reduced abduction is found. Changes in
th e forces acting on th e articular surfaces o f th e jo in t such as in
Coxa valga or Coxa vara may cause an increased attrition resulting

256

M uscles -> T o p o g ra p h y -► S ections

Thigh bone

E p ic o n d y lu s Fig. 4.23 Distal end of th e fem ur, Femur, right side; lateral view.
lateralis To understand th e flexion-extension m o ve m e n t in th e knee joint
(-» Fig. 4.69) know ledge about th e articular surfaces o f th e fem oral
C ondylus lateralis condyles is im portant. In relation to th e axis o f th e fem oral sh a ft the
articular surfaces are positioned dorsaily (retroposition). In addition,
the curvature o f the fem oral condyles is m ore pronounced posteriorly
(smaller radius of curvature) than anteriorly (larger radius of curvature)
resulting in a spiral curvature. This phenom enon is m ore d istin ct in the
m edial than in th e lateral condyle (-♦ Fig. 4.100).

S ubstantia E p ico n d ylu s Fig. 4.24 Distal end of th e fem ur. Femur, right side; frontal section
spongiosa m e d ia lis at the level o f the joint bodies; ventral view.

Facies patellaris Condylus
m e d ia lis

E p ico n d ylu s E p ic o n d y lu s
lateralis m edialis

C o n d y lu s C o n d y lu s
lateralis m e d ia lis

Fossa intercondylaris Fig. 4.25 Distal end of th e fem ur. Femur, right side; distal view .

i- Clinical Rem arks------------------------------------

Since degenerative diseases o f the knee joints (gonarthrosis) are radius of curvature and the shape of the articular surfaces different
com m on and frequently require prosthetic surgery (total knee re­ on either side of the joint. Thus, knee joint prosthetic surgery aims at
p lacem en t, TKR), th e know ledge o f th e anatom y o f both articulating con structin g articular surfaces w ith th e clo se st possible sim ilarity in
bones is o f utm o st im portance. Recent studies have show n th a t the shape to facilitate the natural m ovem ents of a healthy knee.

257

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging -►

Tibia

' -e a in te rco n d yla ris a n te rio r Facies Tuberculum intercondylare laterale
a rtic u la r is intercondylare m ediale
Facies articularis fib u la ris Facies
s u p e rio r a rtic u la ris
E m in e n tia fib u la ris
C ondylus in te r c o n d y la r is
m edialis Fora m e n
C o n d y lu s n u tric iu m
la te ra lis in te r c o n d y la r is

T u b e ro s ita s Area intercondylaris
tib ia e p o s te rio r

Linea

solei

M a rg o a n t e r io r ------------- *-• J H Fora m e n Facies
nutricium lateralis

Facies lateralis ~ HHZ M argo medialis Facies
Facies medialis p o s te rio r
Margo Margo Facies posterior
interosseus Margo • a n te rio r
interosseus -------- M a rg o interosse us
-------- Facies lateralis
M argo medialis

Corpus tibiae

Incisura M alleolus Incisura a rtic u la ris S u lc u s Facies articularis
fib u la ris m edialis fib u la ris m alleoli m edialis m alleolaris inferior
Facies articularis
Facies articularis inferior Facies
in fe r io r m alleoli m edialis
Facies articularis malleoli
m e d ia lis 4.27 4.28

4.26

Fig. 4.26 to Fig. 4.28 Tibia, Tibia, righ t side; ventral (-» Fig. 4.26), sally by 3 °-7 ° (retroversion). The retroversion is m o re pronounced at
lateral (-» Fig. 4.27), and dorsal (-* Fig. 4.28) view s. the medial condyle than at the lateral condyle and is here especially
The proxim al articular surface is sh ifte d dorsally fro m th e axis o f the distinet at the medial rim of the articular surface.
tibial shaft (retroposition). In addition, th e articular surface is tilte d dor­

A rea intercondylaris an terio r Tuberositas tibiae
Tuberculum intercondylare laterale

C ondylus m e d ia lis* C ondylus latera lis *
Tuberculum intercondylare mediale
C aput fibulae
A rticulatio tibiofibularis
A re a in tercond ylaris p o sterio r

Fig. 4.29 Tibia, Tibia, and fibula, Fibula, right side; proximal view.
The articular surfaces o f th e condyles (*) are collective ly referred to as
Facies articularis superior.

258

M uscles -> T o p o g ra p h y -► S ections

Fibula

4.30 4.31

Fig. 4.30 and Fig. 4.31 Fibula, Fibula, righ t side; m edial the articular surfaces of the fibular head and of the malleus both point
(-* Fig. 4.30) and lateral (-» Fig. 4.31) view s. medially.
W hen positioning an isolated fibula, orientation is given by the fa ct that

Facies articularis m alleoli lateralis Facies articularis inferior
M alleolus lateralis articularis m alleoli medialis

Fibula M alleo lu s m edialis

T ib ia

Fig. 4.32 Tibia, Tibia, and fibula. Fibula, right side; distal view.

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Skeleton of the foot

Hallux [D igitus primus] Phalanx distalis
Digitus secundus Phalanx m edia
D igitus tertius Phalanx proxim alis
Digitus quartus
D igitus m inim us [quintus] C aput phalangis
C orpus phalangis
Caput ossis m etatarsi Basis phalangis

Corpus ossis m etatarsi O s cu n eifo rm e laterale
T u be ro sitas ossfc
Basis ossis metatarsi quinti
Articulationes tarsom etatarsales Os cuboideum
A rticulatio tarsi transversa
(LISFR AN C's joint) (CHOPART's joint)

O s c u n eifo rm e m ed iale Proc. lateralis tali
O s cuneifo rm e interm edium Trochlea tali
C alcaneus
Os naviculare
C aput tali
T a lu s

Fig. 4 .33 Skeleton of th e fo ot, Ossa pedis, right side; dorsal view. culare), th e cuboid (Os cuboideum), and the three cuneiform bones
The fo o t (Pes) is organised in Tarsus w ith Ossa tarsi, M e tata rs u s w ith (Ossa cuneiform ia). Clinically, th e fo re fo o t is distinguished fro m the
Ossa m etatarsi, and toes (Digit!) w hich consist of several phalanges. hindfoot. Both are separated by the articular line in th e A rticulationes
The Tarsus com prises th e Talus, th e Calcaneus, th e navicular (Os navi- ta rs o m e ta ta rs a le s .

Clinical Remarks case of injuries, frostbite, or perfusion deficits w ith tissue necrosis.
In rare occasions, lu xations m ay occur in these joints.
The A rticulatio tarsi transversa (clinical term : CHOPART's joint; blue)
and the A rticulationes tarsom etatarsales (clinical term : LISFRANC's
jo in t; red) are preferred locations fo r surgical am putations in the

260

M uscles -> T o p o g ra p h y -► S ections Skeleton of the foot

Phalanx distalis Tuberositas phalangis distalis
Phalanx media
Phalanx proxim alis I Hallux [Digitus primus]
O ssa digitorum II D ig itu s se cu n d u s
[P h a la n g e s ] III D ig itu s te rtiu s
IV D igitus q uartus
O ssa m etatarsi l-V V D igitus m inim us [quintus]

Tuberositas ossis m etatarsi quinti O ssa sesam oidea
Sulcus tendinis m usculi fibularis
Tuberositas ossis Tuberositas ossis m etatarsi prim i
Os
C alcaneus Os c u n eifo rm e m ed iale
Os cuneifo rm e interm edium
Proc. lateralis tuberis O s cuneifo rm e laterale
Tuberositas ossis navicularis
O s naviculare

Caput tali

T a lu s
S ustentaculum tali
Proc. m edialis tuberis calcanei

Fig. 4.34 Skeleton of th e fo ot. Ossa pedis, right side; plantar
v ie w .

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Skeleton of the foot

C aput tali

C ollum tali

m alleolaris T a lu s
m e d ia lis
Os c u n eifo rm e m ed iale
O ssa m etatarsi C orpus tali

posterior tali

Phalanx proxim alis S ustentaculum tali
P h a la n x
Phalanx distalis

C a lc a n e u s , Proc. medialis
tuberis calcanei

Tuberositas ossis Sulcus tendinis m usculi flexoris
metatarsi V hallucis longi

Tuberositas ossis cuboidei

O ssa tarsi

Trochlea tali ta rs i tra n s v e rs a (CHOPART's joint)
n a v ic u la re
C ollum tali
Facies malleolaris cuneifo rm e interm edium
lateralis cu n eifo rm e laterale
Proc. poste rio r tali A rtic u la tio n e s ta r s o m e ta ta rs a le s (LISFR AN C's joint)
O ssa m etatarsi
S inus tarsi
C alcaneus O ssa d igito ru m [Phalanges]
Trochlea fibularis

Tuber

o s s is
metatarsi V

Fig. 4.35 and Fig. 4.36 S keleton of th e fo o t. Ossa pedis, rig h tThe Sinus tarsi is a h o llo w space w h ich is fo rm e d by th e Sulcus tali and

side; m edial (-» Fig. 4.35) and lateral (-* Fig. 4.36) view s. the Sulcus calcanei.

M uscles -> T o p o g ra p h y -► S ections

Talus and calcaneus

4.37

Fig. 4 .37 and Fig. 4.38 Talus, Talus, righ t side; dorsal (-* Fig. 4.37)
and plantar vie w s (-* Fig. 4.38).
The trochlea is broader at its posterior aspect than at its anterior aspect.

S u sten tacu lu m tali Facies articularis talaris posterior
Facies articularis talaris m edia Tuber calcanei

Facies articularis talaris anterior

Sulcus tendinis m usculi
flexoris hallucis longi

Facies articularis cuboidea

4.39

Proc. m edialis tuberis calcanei

Facies articularis talaris posterior Facies articularis talaris m edia
Trochlea fibularis Facies articularis talaris anterior
Sulcus calcanei
Facies articularis cuboidea

Sulcus tendinis m usculi
fibularis longi

Proc. lateralis tuberis calcanei

Fig. 4.39 and Fig. 4.40 Calcaneus, Calcaneus, right side; medial
(-» Fig. 4.39) and lateral v ie w s (-* Fig. 4.40).

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Ligaments of the pelvis Lig. longitudinale anterius
Lig. iliolum bale
V ertebra lum balis IV
Ligg. s acro iliaca a n terio ra Lig. inguinale
A rticu latio sacroiliaca
Lig. p u bicum superius
C analis ob tu rato riu s Lig. iliofem orale
A rticulatio coxae
M em b ran a obturatoria

S ym physis p ubica,
Discus interpubicus

C analis obtu ratorius Lig. iliolum bale

Lig. inguinale
A rtic u latio sacroiliaca

Lig. iliofem orale
A rticulatio coxae

Fig. 4.41 and Fig. 4.42 Joints and ligam ents of th e m ale IV and V w ith th e Crista iliaca. These strong ligam ents only a llo w small
(-» Fig. 4.41) and th e fe m ale pelvis (-» Fig. 4.42); ventral view . tiltin g m o ve m e n ts o f th e pelvis o f about 10°.
The pelvic girdle (Cingulum pelvicum ) is a ring-shaped bony construc­ The pubic sym physis is bridged superiorly by th e Lig. pubicum supe­
tion created by both the dorsal am phiarthroses of the sacro-iliac joints rius, and inferiorly by th e Lig. pubicum inferius.
(Articulationes sacroiliacae) and by th e ventrally located pubic sym­ In both sexes th e Foramen o b tura tum is alm o st co m p le te ly closed by
physis (Sym physis pubica). Each sacro-iliac jo in t is stabilised by the the M em brana obturatoria w hich only leaves the Canalis ob tu rato­
Ligg. sacroiliaca anteriores ventrally, and by the Lig. iliolum bale su­ rius as a passageway fo r the neurovascular bundles to the inner side of
periorly. The latter connects th e Proc. costalis o f the lumbar vertebrae th e th ig h (A./V. obturatoria, N. obturatorius).

264

M uscles -► T o p o g ra p h y -► S ections Ligaments of the pelvis

Spina iliaca anterior superior Lig. iliolum bale
Lig. inguinale A rticu latio s acroiliaca,
Lig. s acro iliacu m anterius
Lacuna m usculorum
A rcus iliopectineus F o ra m en ischiad icum m ajus
Lig. s ac ro tu b e rale
Lig. sacrosp inale

F o ra m en ischiad icum m inus

Lacuna vasorum superius

Lig. iliolum bale

A rticulatio sacroiliaca,
Lig. sacroiliacum anterius

S pina iliaca anterior superior Foram en isc h iad ic u m m ajus
Lig. inguinale Lig. sacrosp inale
Lig. s ac ro tu b e rale
Lacuna m usculorum Foram en ischiad icum m inus
A rcus iliop ectineus

Fig. 4.43 and Fig. 4.44 Jo ints and lig am ents of th e m ale ischiadicum m ajus and minus. These openings constitute im portant
(-► Fig. 4.43) and th e fem ale pelvis (-» Fig. 4.44); ventral cranial passageways fo r blood vessels and nerves of the Plexus sacralis to the
view. gluteal region (Regio glutealis). The space beneath the inguinal liga­
The alm ost horizontally oriented Lig. sacrospinale connects the sacrum m e n t (Lig. inguinale) is divided by th e A rcus iliopectineus into th e lateral
w ith th e Spina ischiadica, dorsal o f w hich the Lig. sacrotuberale Lacuna m u sculorum and th e m edial Lacuna vasorum (-» Fig. 4.177)
courses obliquely to th e Tuber ischiadicum. Both ligam ents com ple­ through w hich the neurovascular structures course to the anterior side
m ent the Incisura ischiadica major and m inor to form the Foramen of the thigh.

265

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Ligaments of the pelvis Lig. iliolum bale
Ligg. s ac ro ilia ca in terossea
Lig. supraspinale Ligg. s ac ro ilia ca posteriora

Lig. s ac ro tu b e rale

Lig. sacrosp inale

p o s te riu s Lig. p ubicum inferius

Lig. sacrococcygeum Spina iliaca posterior superior
posterius superficiale
Lig. s ac ro tu b e rale
Foramen ischiadicum m ajus Lig. sacrosp inale

Foramen ischiadicum minus

Lig. p ubicum inferius

Fig. 4.45 and Fig. 4.46 Joints and ligam ents of th e fem ale pelvis; The alm o st horizontally oriented Lig. sacrospinale connects th e sa­
dorsal (-* Fig. 4.45) and caudal v ie w s (-» Fig. 4.46). crum w ith the Spina ischiadica, dorsal o f w hich the Lig. sacrotuberale
On th e dorsal side, th e sacro-iliac jo in t is stabilised by th e Ligg. sacro­ courses obliquely to the Tuber ischiadicum. Both ligam ents confine the
iliaca posteriora and interossea. Due to the strong ligam ents on the Foramina ischiadica majus and m inus as passageways fo r blood ves­
po sterior side o f th e pelvis, o n ly sm all tiltin g m o ve m e n ts o f up to 10° sels and nerves of the Plexus sacralis to the gluteal region.
are possible.

266

M uscles -> T o p o g ra p h y -► S ections Ligaments of the pelvis

Ligg. s acro iliaca p o sterio ra Ligg. s acro iliaca in terossea
Ligg. s acro iliaca a n terio ra A rticu latio sacroiliaca
Lig. s ac ro sp in a le
F o ra m en isc h iad ic u m m ajus
Lig. s ac ro tu b e rale
Lig. ca pitis fem oris
F o ra m en ischiad icum m inus

4.47

Mem brana obturatoria S ym physis pubica, D iscus interpubicus
Lig. p ubicum inferius

Linea term inalis Linea arcuata Os sacrum
Pecten ossis pubis
A rticu latio s acroiliaca,
Facies sym physialis Lig. sacroiliacum anterius

4.48 Foram en ischiad icum m ajus
Lig. sacrosp inale
Os coccygis
Foram en ischiad icum m inus
Lig. s ac ro tu b e rale
Foramen obturatum

Fig. 4.47 and Fig. 4.48 Jo ints and lig am ents of th e fe m a le pelvis; le, and Lig. sacrotuberale). The Lig. ilio lum bale is n o t visible. The Lig.
oblique transverse section; ventral caudal v ie w (-♦ Fig. 4.47) and sacrospinale and Lig. sacrotuberale confine the Foram ina ischiadica
m edian section; v ie w fro m th e le ft side (-» Fig. 4.48). m ajus and m inus as passageways fo r blood vessels and nerves of the
Illustrated is th e sacro-iliac jo in t w ith its ligam ents (Ligg. sacroiliaca Plexus sacralis to the gluteal region.
anteriora, posteriora, and interossea as w ell as the Lig. sacrospina­

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Ligaments of the pelvis

A rticu latio zygapophysialis

V erte b ra lu m b a lis V, P roc. c o s ta l is

Lig. s acro iliacu m posterius

Ligg. s acro iliaca in terossea

O s ilium
A rticu latio sacroiliaca

Lig. sacroiliacu m anterius

Fig. 4.49 Sacro-iliac jo int, A rticulatio sacroiliaca; frontal section; iliac joint and enable th e transm ission of w eigh t fro m the trunk to the
dorsal view. pelvic girdle. In particular, th e dorsal Ligg. sacroiliaca interossea and
These strong ligaments, of w hich the Ligg. sacroiliaca anteriora and posteriora broadly connect the Sacrum and Ilium.
interossea and Lig. iliolum bale are visible here, stabilise the sacro­

Fig. 4.50 Pubic symphysis. Sym physis pubica; oblique section; sym physiales o f both pubic bones consists o f hyaline cartilage. Fol­
ventral caudal view. low ing the firs t decade o f life, an oblong gap frequently fo rm s (Cavitas
The connection o f th e pubic bones is a sym physis. The Discus interpu- sym physialis). This gap o f th e jo in t is bridged superiorly by the Lig.
bicus consists o f fibrous cartilage; only the surface area to the Facies pubicum superius and infe riorly by th e Lig. pubicum inferius.

i- Clinical Remarks-----------------------------------------------------------------------------------------------------

Pain in th e sacro-iliac jo in t m ay be caused by injuries, degenera- innervated dire ctly by branches o f th e sacral plexus, pain may radiate
tiv e conditions, or rheum atic diseases w hich in part preferentially into th e leg (-» p. 326).
a ffe c t th is jo in t (BEKHTEREV'S disease). Since th e sacro-iliac jo in t is

268

M uscles -► T o p o g ra p h y -► S ections

Hip joint

Lig. capitis fem o ris Lig. c a p itis fe m o ris
C aput fem oris
Plane o f a cetabular rim
Z o n a orbicu laris
Transverse or
axial plane
A rticu latio coxae,
C a p s u la a rticularis

Fig. 4.51 Hip joints, A rticulationes coxae; oblique transverse acetabular rim and th e transverse (axial) plane is 40°. The hip joint
section; ventral cranial view. transfers the w hole body w eigh t onto the low er extrem ities. Therefore,
In th e hip joint, th e A cetab ulum o f th e hip bone fo rm s th e socket. th e jo in t capsule (Capsula articularis) is reinforced by strong liga­
Together w ith the Labrum acetabuli, the A cetabulum covers more m ents. Circular fib re s o f th e jo in t capsule surround th e fem ora l neck in
than half o f the fem oral head (Caput fem oris). Thus, the hip jo in t is a particular on the dorsal side and are referred to as Zona orbicularis
special form o f a ball-and-socket jo in t referred to as cotyloid jo int w hich ligam ents o f th e capsule also join. The Lig. capitis fem oris lacks
(Articulatio cotylica, enarthrosis). The angle betw een the plane of the a mechanical function.

M . rectus fem oris, Tendo Canalis obturatorius reflexum 1 M . rectus
M em brana obturatoria rectum ƒ fem oris, Tendo
Lig. ilio fe m o ra le J Pars
I Pars Lig. sacrotuberale Lig. iliofem orale
Trochanter Lig. ischiofem orale
Trochanter major
Trochanter m ajor
C ollum fem oris

Trochanter m inor

Fig. 4.52 and Fig. 4.53 Hip jo in t, A rticu latio coxae, rig h t side; • Lig. iliofem orale (anterior and superior): inhibits extension and ad­
ventral (-* Fig. 4.52) and dorsal (-» Fig. 4.53) view s. duction and, thus, supports the small gluteal muscles
There are three major ligam ents of the hip joint w hich surround the
fem oral head in a spiral manner. Their principle fun ction is to lim it the • Lig. pubofem orale (anterior and inferior): inhibits extension, abduc­
range o f hip extension and to prevent the backward tilting o f the pelvis: tion, and lateral rotation

• Lig. ischiofem orale (posterior): inhibits extension, medial rotation,
and adduction

i- Clinical Rem arks------------------------------------ acetabular rim and the horizontal plane as w ell as by a larger than
usual roof of the hip joint. A larger roof of the hip joint may be caused
Orthopaedic studies have show n tha t position and shape o f the by an anteriorly extended acetabular rim in cases o f a dorsally tilted
Acetabulum and th e fem oral head are im portant factors in degene­ Acetabulum (retroversion of the Acetabulum ), or if the articular
rative changes of the hip jo in t (coxarthrosis). Premature degene­ surface is located very deep in the Acetabulum (Coxa profunda).
rative changes may be induced by a flattened roof of the jo in t (hip
dysplasia) w hich show s a sm aller than usual angle betw een the

269

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Hip joint Lig. iliofem orale
Labrum acetabuli
M. rectus fem oris, Tendo Lig. c a p itis fe m o ris
C aput fem oris
Canalis obturatorius

Lig. p u b o fem o ra le
Mem brana obturatoria

Fig. 4.54 and Fig. 4.55 Hip jo in t, A rticu latio coxae, righ t side; Lig. iliofem orale; C apsula articularis
ventral v ie w ; a fte r opening o f th e capsule and partial (-» Fig. 4.54) or Labrum acetabuli
c om plete (-» Fig. 4.55) exarticulation o f th e fem ora l head. Facies lunata
B esides th e external ligam ents (Lig. ilio fem orale, Lig. pubofem orale,
Lig. ischiofem orale) th e internally located Lig. capitis fem o ris is visi­ Fossa acetabuli
ble w hich lacks mechanical function in the joint. The Lig. transversum
acetabuli inferiorly closes the Acetabulum, and together w ith the Lab­ Lig. ca p itis fem oris
rum acetabuli, w hich also consists of fibrous connective tissue, it transversum acetabuli
serves to guide th e fem oral head. Lig. is c h io fe m o ra le ; Capsula articularis

V

b o°
o°

Figs. 4.56a to d Range of m o v e m e n t in th e hip jo in t, A rticu latio a much higher degree and exclusively lim ited by s o ft tissues. In
coxae, (according to [1]) addition, medial and lateral rotation as w ell as adduction and abduction
The hip jo in t is an enarthrosis (A rticulatio cotylica) w h ich as a ball-and- are lim ited by ligaments.
socket joint possesses three axes of m ovem ent. All axes pass through
th e cen tre o f th e fem oral head. The range o f m o vem en t is lim ited by Range of movement:
the stric t guidance o f the Acetabulum and the strong ligam ents. All liga­ a extension-flexion: 10°- 0°-130°
m ents together restrict extension (retroversion) by enclosing the fem o­ b abduction-adduction: 4 0 °- 0 ° - 30°
ral head like a spiral ligam entous scre w , th u s enabling a stable upright c and d lateral rotation-m edial rotation: 5 0 °- 0 ° - 40°
position. Im portant fo r w alking, th e flexion (anteversion) is possible to

270

M uscles -> T o p o g ra p h y -► S ections

A. c ircu m flexa Blood supply of the hip joint
fe m o ris m edialis
A. circum flexa fem oris lateralis
R. a c e ta b u la ris A. circum flexa
fe m o ris m edialis
A . c ircu m flexa fe m o ris m edialis

A. c ircu m flexa fe m o ris lateralis
A. profunda fem oris

R. a scen de n s (A. circum flexa
R. tra n sve rsu s fem oris lateralis)
R. descendens

A. c irc u m fle xa fe m o ris lateralis
A. c ircu m flexa fe m o ris m edialis

A. profunda fem oris

Fig. 4.57 and Fig. 4.58 Blood supply o f th e hip jo in t, rig h t side; one-third of the proximal epiphysis. However, the A. circum flexa fem o­
ventral {-* Fig. 4.57) and dorsal (-» Fig. 4.58) view s. ris m edialis supplies th e fem oral head and neck via several sm aller
In th e adult, th e A. circum flexa fe m o ris m edialis is th e m ajor blood branches coursing on the posterior side w ithin the joint capsule. The A.
vessel supplying th e fem oral head. In infants, how ever, th e R. aceta­ circumflexa fem oris lateralis mainly supplies th e fem oral neck at its
bularis (from A. obturatoria and A. circum flexa fem oris medialis), which anterior side. The A cetabulum is supplied fro m ventral and dorsal by
runs w ithin the Lig. capitis fem oris, provides the major part o f the blood the A. obturatoria and fro m cranial by the A. glutea superior.
supply to th e fem oral head. In th e adult, it supplies only on e -fifth to

r- Clinical Rem arks------------------------------------ short hip m uscles of the pelvitrochanteric group. Hence, these mus­
cles should be preserved during surgery to avoid injury to the artery.
The arterial blood supply is crucial fo r th e integrity o f the fem oral Since the Aa. circum flexa fem oris m edialis and lateralis pass
head. O xygen deprivation (ischaemia) results in necrosis of th e fe ­ b e tw een th e layers o f th e jo in t capsule th e y are at risk o f injury in
m oral head w hich, in the w o rs t case scenario, requires the replace­ intracapsular fractures of th e fem oral neck. As a result an im m edi­
m ent of the head by an endoprosthesis. Therefore, the supplying ate replacem ent o f th e fem ora l head by an endoprosthesis is m ore
arteries need to be preserved during hip surgery. This is particularly com m only performed.
im po rtan t in cases o f arthrosis if not th e w h o le fem ora l head b u t only It is suggested th a t th e spontaneous necrosis o f the fem oral head
th e articular surface is replaced by a prosthesis ("ca p prosthe sis"). during early puberty (PERTHES' disease) is also caused by a com ­
Therefore, the know ledge of the exact anatom y of the arterial supply prom ised arterial supply.
has gained im portance during the last years. One has to consider that
the A. circum flexa fem oris m edialis courses on the posterior side
o f th e fem oral neck w h e re it is covered and w e ll protecte d by the

271

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Knee joint Facies articularis

Basis patellae

A pex patellae

Fig. 4.59 and Fig. 4.60 Patella, Patella, right side; ventral the tendon on its w ay to th e insertion on the Tuberositas tibiae over the
(-» Fig. 4.59) and dorsal (-» Fig. 4.60) view s. distal end o f the fem ur. This results in an increase o f the virtual lever
The patella is a sesam oid bone (Os sesam oideum ) w ith in the tendon arm and torque of the muscle.
of the M. quadriceps fem oris. It serves as a hypom ochlion by guiding

R o tatio n a l axis

Femur Facies poplitea Femur

E picon dylus lateralis T u b e rc u lu m Tuberculum Fossa
P a te lla a d d u c to riu m a d d u c to riu m in te r c o n d y la r is
C ondylus lateralis
C ondylus lateralis E p ic o n d y lu s E p ico n d ylu s fem oris
fem oris m edialis fem oris m edialis fem oris A rticulatio
T ransverse axis fem orotibialis
C ondylus lateralis Condylus
tibiae fem o ro p a te lla ris C ondylus m edialis lateralis tibiae
fem oris A rticulatio tibiofibularis
A rticulatio tibiofibularis C ondylus m edialis
proxim alis fem oris C ondylus m edialis C aput fibulae
tibiae
C aput fibulae A rticu latio C ollum fibulae
fem orotibialis E m in e n tia
C ollum fibulae in te r c o n d y la r is
Condylus
m edialis
tib ia e

Tuberositas tibiae

T ib ia

Fig. 4.61 and Fig. 4.62 Knee jo in t, A rticu latio genus, rig h t side; The knee jo in t is a bicondylar jo in t (A rticulatio bicondylaris) w hich
ventral (-* Fig. 4.61) and dorsal (-* Fig. 4.62) view s. [10] functions as a pivot-hinge jo in t (trochoginglymus) and possesses tw o
In th e knee jo in t th e Fem ur articulates w ith Tibia (A rticulatio fe m o ro ­ axes of m ovem ent. The transverse axis fo r extension and flexion
tibialis) and Patella (A rticulatio fem o ro patellaris; -» Fig. 4.209). m ovem ents extends through both fem oral condyles. The longitudinal
A ll bones are ensheathed by a com m on jo in t capsule. In th e A rticulatio axis fo r rotational m ovem ents is positioned eccentrically and perpen­
fem orotibialis, the fem oral condyles constitute the head and the upper dicular through the Tuberculum intercondylare mediale. For the range
articular surface o f the Tibia (Facies articularis superior) and both tibial o f m o ve m e n t in th e knee jo in t -» page 276.
condyles form the socket of the joint.

i- Clinical Remarks------------------------------------ scopy, a process that requires profound knowledge of the anatom y
o f th e knee joint. Dysplasia o f th e Patella o r th e fem ora l Facies pa-
In addition to th e hip joint, th e knee jo in t is strained by th e w e ig h t tellaris m ay cause re petitive p a tellar luxations. In addition to the
of the body. Thus, degenerative changes (gonarthrosis) are a exercise of the respective M . vastus m edialis or lateralis, the surgi­
com m on disease o f the knee joint frequently requiring prosthetic cal correction w ith tightening of the joint capsule (capsulorrhaphy) or
substitution o f the joint bodies. Since the knee joint lacks a strong displacem ent o f the Lig. patellae is the tre atm e nt o f choice.
m uscular guidance, injuries to th e ligam ents and th e m enisci are
com m on. These may partly be treated minimally-invasive by arthro­

272

M uscles -> T o p o g ra p h y -► S ections

knee joint

Femur M. articularis genus Facies patellaris

B ursa su p rap atellaris Plica synovialis C ondylus medialis
M. q uadriceps fem oris, in fra p a te lla ris
Patella, Facies
Tendo M . quadriceps fem oris a rtic u la r is
C ondylus lateralis
Patella, Facies anterior B ursa
Lig. c o lla te rale su p rap atellaris
R etinaculum fib u la re T ib ia
p atellae laterale
C orpus adiposum R etinaculum
p a te lla e m ed iale
infrapatellare
Lig. c o lla te rale C a p s u la
a rtic u la r is
fib u la re
Lig. c o lla te ra le tib ia le
Bursa infrapatellaris Lig. p atellae
p ro fu n d a
C aput fibulae Tuberositas tibiae

Fibula

4.64

Fig. 4.63 and Fig. 4.64 Knee jo in t, A rticu latio genus, righ t side; don o f the M . quadriceps fem oris (M m . vasti medialis and lateralis).
w ith closed jo in t capsule (-» Fig. 4.63), and after opening of th e M edially and laterally, there are tw o collateral ligam ents (Ligg. collate-
capsule (-» Fig. 4.64); ventral view . ralia tib iale and fibulare) w hich insert in the Tibia and Fibula. The joint
The ligam ents of the knee joint consist of external ligam ents which capsule encloses the articular surfaces. The HOFFA's fa t pad (Corpus
support the joint fro m the outside, and internal ligam ents w hich are adiposum infrapatellare) is positioned b e tw e e n the Capsula fibrosa and
positioned w ith in the Capsula fibrosa. Here, the external ligam ents are th e Capsula synovialis. This adipose tissue is connected to th e anterior
illustrated. They com prise the Lig. patellae as the continuation of the cruciate ligam ent by a fold, th e Plica synovialis infrapatellaris, and lat­
tendon o f the M. quadriceps fem oris, and the Retinacula patellae m e­ erally possesses tw o Plicae alares. The knee jo in t is associated w ith
diate and laterale. Both of these latter ligam ents have superficial longi­ several bursae som e o f w h ich com m unica te w ith th e jo in t capsule as
tudinal and deep circular fibres and can be view ed as parts of the ten­ show n here fo r the Bursa suprapatellaris.

dissection link 273

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Knee joint Femur

M. adductor magnus, Tendo M . plantaris
M. gastrocnem ius, C aput mediale M . gastrocnem ius, C a pu t laterale
Lig. c o lla te rale fibulare
Lig. p o p lite u m obliquum Lig. p o p lite u m a rcu a tu m
Lig. c o lla te rale tib ia le biceps fem oris, Tendo

M . sem im em branosus, Tendo M . popliteus
Fibula
T ib ia
M em brana interossea cruris

Femur, C ondylus medialis Lig. c ru c ia tu m a n te riu s
Lig. m e n is c o fe m o ra le p o sterius
Femur, C ondylus lateralis
Lig. c o lla te rale tibiale
M. sem im em branosus, Tendo M . popliteus, Tendo
M eniscus lateralis
Lig. p o p lite u m obliquum Lig. c o lla te ra le fib u la re
Lig. c ru cia tu m posterius Tibia, C ondylus lateralis
Lig. ca pitis fibulae posterius
M . popliteus, Aponeurosis C aput fibulae
M.

4.66

Fig. 4.65 and Fig. 4.66 Knee jo in t, A rticu latio genus, rig h t side; ble. The anterior cruciate ligam ent (Lig. cruciatum anterius) courses
w ith closed jo int capsule (-* Fig. 4.65), and after opening of the fro m th e inner surface o f th e lateral fem ora l condyle in an an terior direc­
capsule (-» Fig. 4.66); dorsal view . tion to the Area intercondylaris anterior o f the Tibia. The posterior cru­
A t the rear side of the knee joint, additional external ligam ents sup­ ciate ligam ent (Lig. cruciatum posterius) courses in th e op posite di­
port the joint capsule. The Lig. popliteum obliquum projects m edially rection from the inner surface of the medial fem oral condyle to the
and inferiorly from the lateral fem oral condyle, and the Lig. popliteum Area intercondylaris posterior o f the Tibia. The Lig. m eniscofem orale
arcuatum courses in the opposite direction, thus, crossing the M . pop­ anterius (not visible here) and the Lig. m eniscofem orale posterius
liteus. O f the tw o collateral ligam ents, only the Lig. collaterale tibiale connect th e posterior horn o f the lateral m eniscus (M eniscus lateralis)
is connected to th e jo in t capsule. The Lig. co llaterale fib ulare is sepa­ anterior and posterior to the posterior cruciate ligam ent w ith th e medial
rated from the joint capsule by the tendon of the M . popliteus. condyle and, thus, support the posterior cruciate ligament.
A fter opening of the joint capsule several internal ligam ents are visi­

dissection link

M uscles -► T o p o g ra p h y -► S ections

Knee joint

M. q uadriceps fem oris, Epicondylus medialis
Tendo Lig. c o lla te rale tibiale
Fibula
Femur

Lig. patellae
M en iscu s m edialis

Tuberositas tibiae
T ib ia

A nterior superficial part
o f th e Lig. colla te ra le tibiale

(free part)

M eniscofem oral fibres
o f th e posterior, deep part
o f th e Lig. collaterale tibiale
(attached to the m eniscus)

M eniscotibial fibres
o f the posterior, d eep part
o f th e Lig. collaterale tibiale
(affixed to the bone)

Fig. 4.67 and Fig. 4.68 Inner (m edial) co llateral lig am en t, Lig. connected to the M eniscus lateralis. Because of the larger radius of
co llaterale m ediale, in extension (-► Fig. 4.67), and flexion curvature o f th e fem oral condyles in th e fro nt, th e collateral ligam ents
(-> Fig. 4.68); m edial view . are stretched in the extended knee. This position therefore does not
O nly th e po sterior fib re s o f th e inner collateral ligam ent (Lig. co llatera­ a llo w fo r rotational m o vem en ts. In a flexe d position o f th e knee, the
le tib iale) are connected to th e M eniscus m edialis. In flexion, th e con­ collateral ligam ents are relaxed due to the sm aller radius o f curvature of
to rtio n o f th e ligam ent fixe s th e M e niscus m edialis in its position. In the fem oral condyles at the back, thus enabling rotational movements.
contrast, th e lateral collateral ligam ent (Lig. co llaterale fibulare) is not

Clinical Remarks crease instability and laxity o f th e knee joint. This phenom enon is
utilised during physical exam ination to assess potential injuries to
The collateral ligam ents stabilise the knee jo in t m edially and laterally. the collateral ligaments.
The medial collateral ligam ent (clinical term : MCL) in particular stabi­
lises against abduction, the lateral collateral ligam ent (clinical term :
LCL) against adduction m o vem en ts. Injuries to th e se ligam ents in­

275

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging -►

Knee joint

Figs. 4.69a to c Range of m o v e m e n t in th e knee jo in t, A rticu latio sion m ovem ent, the tension of th e anterior cruciate ligam ent also cau­
genus, (c according to [1]) ses a forced lateral rotation of 5°-10°, during w hich the medial condyle
The knee joint is a bicondylar jo in t (Articulatio bicondylaris) w hich even loses its contact w ith the medial meniscus.
functions similar to a pivot-hinge joint (trochoginglymus) and has tw o The active flexion up to 120° can be increased up to 140° after pre-ex­
axes of m ovem ent. The transverse axis fo r extension and flexion ten sion o f th e ham string m uscles (a). Passive flexion is possible up to
m o ve m e n ts runs through both fem oral condyles (c). The longitudinal 160°, lim ited only by s o ft tissues. Extension is possible up to th e null-
axis fo r rotational m ovem ents: projects eccentrically and perpendicu­ position but can be further increased passively by 5°-10°. Rotational
lar through th e Tuberculum intercondylare mediale o f the Tibia. Due to m ovem ents are exclusively possible during flexion of the knee because
the sm aller posterior radius of curvature o f the fem oral condyles the the tension of the collateral ligam ents during knee extension prevents
transverse axis does not rem ain in a con stant position, b u t m oves pos­ rotational m o ve m e n ts (b). Lateral rotation is possible to a larger e xte n t
teriorly and superiorly during flexion in a convex line (c). The flexion than medial rotation because the cruciate ligam ents tw is t around each
m ovem ent thus is a com bined rolling and sliding m ovem ent in w hich other during medial rotation. Abduction and adduction are alm ost com ­
th e condyles roll up to 20° po steriorly and the n turn in th is position. pletely prevented by the strong collateral ligaments.
Since the shape of the medial and lateral condyles o f th e Femur and
Tibia is not identical, it is th e lateral fem oral condyle th a t predom inantly Range of movement:
rolls (sim ilar to a rocking chair) and th e m edial condyle rem ains in its a extension-flexion: 5 °-0 °-1 4 0 °
position to rotate (similar to a ball-and-socket joint). A t the same tim e b lateral rotation-m edial rotation: 3 0 ° - 0 °-1 0°
th e Fem ur rotates slightly ou tw ards. In th e term inal phase o f th e exten­

276

M uscles -> T o p o g ra p h y -► S ections Cruciate ligaments

C o ndylus lateralis Lig. c ru cia tu m posterius
M eniscus laterali C ondylus medialis

Lig. ca p itis fibulae M eniscus medialis
Lig. c ru cia tu m anterius
Lig. transversum genus

Fig. 4.70 Knee jo in t, A rticu latio genus, rig h t side, in 90°-flexed or lateral to an inferior anterior direction). The posterior cruciate liga­
position; ventral view ; after removal of the joint capsule and the m e n t (Lig. cru cia tum posterius) courses in an op posite direction fro m
collateral ligaments. the inner surface of the medial fem oral condyle to the Area intercon­
The m ost im portant inner ligam ents are the tw o cruciate ligam ents. dylaris po ste rio r o f th e Tibia (from a superior an terior m edial to a
The an terio r cruciate lig am en t (Lig. cruciatum anterius) courses fro m posterior inferior direction). A lthough the cruciate ligam ents are posi­
the inner surface o f the lateral fem oral condyle in an anterior direction tioned w ith in the fibrous joint capsule (intra-articular) they are outside
to the Area intercondylaris anterior o f the Tibia (from a superior posteri- the Capsula synovialis and thus extrasynovial.

Figs. 4.71a to b Stabilisation of th e knee joint, A rticulatio genus, o f th e knee and stabilise th e knee in th is position against rotational as
rig h t side, th ro u g h co llateral and cruciate lig am ents in extension w e ll as abduction/adduction m o vem en ts. In contrast, d istin ct parts of
(a), and flexion (b); ventral view. th e cruciate ligam ents are te n se during all positions o f th e knee joint:
The cruciate ligam ents together w ith the collateral ligam ents form a the medial com ponents during extension, and the lateral com ponents
functional unit. The collateral ligam ents are tense only during extension during flexion.

Clinical Remarks PCL; "p o sterio r d ra w e r" test). This is te ste d in th e supine position
of the patient. The exam iner sits (fixes) on the fo o t of the 90°- flexed
A fte r injury to th e cruciate lig am ents th e Fem ur can slide in sagit­ knee and pulls the leg anteriorly or pushes it posteriorly.
tal direction sim ilar to a drawer: anteriorly w ith injury to the anterior
cruciate ligam ent (clinical term : ACL; "anterior draw er" test), pos­
teriorly w ith injury to th e posterior cruciate ligam ent (clinical term :

277

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Menisci

(Lig. m e n is c o tib iale Lig. patellae
Lig. tra n s ve rsu m genus Lig. cruciatum anterius

M en iscu s m edialis M en iscu s lateralis

(Lig. m e n is c o tib ia le posterius)

Lig. cruciatum posterius Ligg. m e n is c o fe m o ralia
an te riu s and posterius

Fig. 4.72 M enisci o f th e knee jo in t, righ t side; cranial view . ga m ent by th e ten don o f th e M . popliteus (-► Fig. 4.77). The posterior
Both m enisci are roughly C-shaped and appear w edge-shaped in cross- horn is only indirectly and fle xib ly fixed to th e Tibia via th e M. popliteus.
sections. The m edial m eniscus is larger and anchored via th e Ligg. Anteriorly, both m enisci are connected through the Lig. transversum
m eniscotibialia anterius and posterius to the respective Area inter- genus. As a result, the range o f m ovem ent o f the lateral condyle is in­
condylaris o f th e Tibia. In addition, th e m edial m eniscus is fixed to the creased in flexion.
m edial collateral ligam ent. In contrast, th e lateral m eniscus is an­ Both m enisci are com posed o f fibrous carilage inside and dense con­
chored via the Ligg. m eniscofem oralia anterius and posterius to the nective tissue outside.
m edial fem ora l condyle, b u t it is separated fro m th e lateral collateral li­

Figs. 4.73a to c Sliding range of th e menisci. Menisci, during a extended position
flexion. b, c flexed position
In flexion, both m enisci are pushed po steriorly over th e rim s o f th e tib i­
al condyles. The m o bility o f th e lateral m eniscus is higher due to the
reduced fixation.

278

M uscles -► T o p o g ra p h y -► S ections

M e n is c i

A . m e d ia g e n u s , (R. ante rio r) Lig. cruciatum anterius
Lig. collaterale
A . m e d ia g e n u s , (R. p oste rio r)
A. inferio r m ed ialis genus
Lig. cruciatum posterius M. popliteus, Tendo
Lig. collatérale fibulare
A. inferio r lateralis genus

Fig. 4.74 A rterial supply of th e m enisci, M enisci, righ t side; m edialis and lateralis genus and from the A. media genus (branches of
cranial view. the A. poplitea). The internal portions are devoid o f blood vessels
The external portions of the M enisci are supplied through a perim e- and are nourished by diffusion from the synovial fluid.
niscal netw ork of blood vessels tha t derives fro m the Aa. inferiores

Figs. 4.75a to d S tages in th e develo p m en t of m eniscal tears. [4] c additional radial tear ("parrot beak"; often leading to a posterior or
a developm ent of a longitudinal tear anterior horn avulsion)
b elongation of the tear from the posterior to the anterior horn and d radial tear, lateral C-shaped m eniscus m o st com m only affected

shift into the joint ("b ucket handle" tear, b') or

r- Clinical Remarks------------------------------------ m alpositions. If the injuries a ffect the well-arterialised periphery of
th e M enisci, spontaneous repair is possible. Lessions o f th e central-
Meniscus injuries are com m on. The m edial meniscus is affected portions frequently require an arthroscopic removal o f the torn parts
m o st com m only due to its fixation to bone and capsule. A cute in­ to restore free m ovem ents. Despite treatm ent, frequently degen­
juries occur during sudden rotational m ovem ents of the w eighted erative changes in the knee joint (gonarthrosis) can develop.
flexed knee and result in a painful inhibition o f active and passive
extension. Chronic degenerative changes often occur as a result of

279

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Knee joint

B ursa su p rap atellaris
M . q uadriceps fem oris, Tendo

Lig. collaterale (B ursa subfascialis prepatellaris)
Bursa subpoplitea
M. popliteus, Tendo Lig. patellae
M eniscus lateralis
Lig. p opliteum arcuatum Bursa infrapatellaris profunda
M . biceps fem oris, Tendo

M. adductor magnus, Tendo Lig. cru cia tum posterius

Lig. collaterale tibiale Lig. m eniscofem orale posterius
M . sem im em branosus, Tendo
M . gastrocnem ius,
M eniscus medialis C a pu t laterale
Lig. popliteum obliquum Lig. collaterale fibulare

M eniscus lateralis
M. popliteus, Tendo
Bursa subpoplitea
M . biceps fem oris, Tendo

Lig. p opliteum arcuatum

4.77

Fig. 4.76 and Fig. 4.77 Knee jo int, A rticulatio genus, right side, M. popliteus. O ther bursae are positioned in places w ith exposure to
w ith bursae; lateral (-» Fig. 4.76) and dorsal (-* Fig. 4.77) view s; higher pressure (e.g. w hen kneeling) such as the Bursa prepatellaris or
illustration of the articular cavity by injection o f a synthetic polym er. the Bursa infrapatellaris. Some serve as gliding surface fo r tendons of
The knee joint is surrounded by up to 30 bursae (Bursae synoviales). m uscles such as the Bursa m usculi sem im em branosi or the Bursae
Som e bursae com m unicate w ith the jo in t capsule, such as the Bursa subtendineae m usculorum gastrocnem ii m edialis and lateralis (both not
suprapatellaris (anterior superior) beneath the tendon of the M. quadri­ shown).
ceps fem oris, or the Bursa subpoplitea (posterior inferior) beneath the

i- Clinical Remarks------------------------------------ m ay occur w h ich appear as sw elling in th e popliteal fossa. A fusion
of th e Bursa musculi sem im em branosi w ith the Bursa subtendinea
W ith extensive mechanical stress (activities in kneeling position) m usculi gastrocnem ii m edialis is referred to as BAKER's cyst.
inflam m ation o f th e bursae m ay occur (bursitis). In th e case of
chronic inflam m atory capsular effusions such as in rheum atic disea­
ses (e.g. rheum atoid arthritis), en largem ent and fusio n o f bursae

280

M uscles -> T o p o g ra p h y -► S ections Knee joint, arthroscopy

Fig. 4.78 Endoscopic ex am in atio n (arthroscopy) of th e knee
joint.
Arthroscopy allow s the minimally-invasive access to the articular cavity
to assess the intrasynovial structures of the knee joint and to perform
m inor repairs.
1 arthroscope
2 in- and outgoing w ash fluid

3 cold light source
4 ocular and adapter fo r video system
5 anterolateral access

6 anterom edial access

7 additional instrum ent

Patella, Facies articu laris*

Bursa suprapatellaris** Femur, C ondylus Femur, C ondyli
lateralis m edialis
Femur, C o ndylus lateralis
M eniscus lateralis Femur, Facies patellaris
Lig. cru cia tum anterius

T ibia, C ondylus lateralis

Figs. 4.79 a to c Knee jo in t, A rticu latio genus, righ t side;
arthroscopic images.
a distal v ie w in th e fem oro pate lla r jo in t
b medial view onto the inner rim of the lateral meniscus
c anterolateral vie w onto the anterior cruciate ligam ent

* patellar ridge: ridge betw een medial and lateral articular surfaces
* * clinical term : Recessus suprapatellaris
* * * groping hooks

I Clinical Remarks------------------------------------ m ent such as the removal of torn m eniscus parts, the repair of
cruciate ligam ents (cruciate ligam ent reconstruction), or to remove
Arthroscopies are frequently perform ed clinical procedures of the floating bodies w hich painfully inhibit m ovem ents.
knee joint. They serve as diagnostic tools, e.g. if a rupture of a
m eniscus cannot be excluded by MRI. They are also used fo r tre a t­

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Ligaments of the leg C aput fibulae

A rtic u latio tibiofibularis,
Lig. ca p itis fibulae anterius

C aput fibulae

Tuberositas tibiae

Linea m usculi solei

M em brana
in te ro ss e a cruris

C orpus tibiae C orpus fibulae

480 M alleolus M alleolus medialis Sulcus m alleolaris

S yndesm osis tibiofibularis,
Lig. tibiofibulare anterius

Fig. 4.80 and Fig. 4.81 Ligam ents of th e tibia. Tibia, and the ossea cruris serves as an additional stabiliser w ith dense connective
fib ula, Fibula, righ t side; ventral (-» Fig. 4.80) and dorsal (-» Fig. 4.81) tissue and collagen fibres, w hich predom inantly course obliquely dow n­
v ie w s . w ards fro m the Tibia to the Fibula. Together w ith the inferior articular
The proxim al Ligg. capitis fibulae anterius and posterius create an am- surface o f th e Tibia, th e m edial and lateral M alleus fo rm th e m alleolar
phiarthrosis (Articulatio tibiofibularis). Distally, both bones are fixed fork. The latter provides the socket fo r the ankle joint.
by th e Ligg. tibiofibularia anterius and posterius in a syndesm osis (S yn­
desmosis tibiofibularis). Between both bones, the M em brana inter- * malleolar fork

Fig. 4.82 Distal end of th e tibia. Tibia, and fibula, Fibula, right
side; distal view.

i- Clinical Remarks------------------------------------

Proximal fra cture s o f th e Fibula in th e region o f its head and neck are depending on th e involvem ent o f th e S yndesm osis tibiofibularis. All
referred to as M A ISO N N EUVE fractures. fractures are treated surgically w ith plates and screws because m i­
Fractures o f th e distal end o f the Fibula are called WEBER frac­ nor alterations in th e jo in t position o f th e ankle jo in t can cause dege­
tu res w h ic h are classified in th re e degrees (-* Figs. 4.107 to 4.109) nerative changes (arthrosis).

282

M uscles -► T o p o g ra p h y -► S ections Ankle joint

M alleolus m edialis Fibula
Lig. c o lla te rale m e d ia le [delto id eu m ], Lig. tib iofib u la re posterius
Lig. ta lo fib u lare p o sterius
P ars tib io ta laris p o sterio r
Lig. c o lla te ra le m e d ia le [d elto id e u m ], M alleolus lateralis
Lig. talocalcaneum posterius
P ars tib io calcan ea Lig. calcaneofibulare
T a lu s Tendo calcaneus
C a lc a n e u s
Lig. ta lo c a lc a n e u m m ed iale

Fig. 4.83 Ankle jo int (talocrural joint), A rticulatio talocruralis. Parts o f th e Lig. c o lla te ra l m ediale (Pars tibiotalaris posterior, Pars ti-
right side, w ith ligam ents; dorsal view. biocalcanea) and the lateral Lig. talofibulare posterius support the joint
fro m the posterior side.

Fibula T ib ia
M em brana interossea cruris
Lig. tib io fib u la re a n te riu s Facies articularis inferior
Facies a rticularis m alleoli lateralis Facies articularis m alleoli m edialis
M alleolus lateralis M alleolus medialis

Lig. tib io fib u la re p osterius

Fig. 4.84 Distal end o f th e tib ia . Tibia, and fib ula. Fibula, rig h t Tibia and Fibula are connected through the Syndesm osis tibiofibularis
side; distal view. and tog ethe r form the m alleolar fork, the socket o f the ankle joint.

283

Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Ankle joint

Lig. c o lla te rale m ed iale [deltoideum ] Pars tibiotalaris posterior Fibula
Pars tibiocalcanea Tibia

Pars tibiotalaris anterior Lig. tib iofib u la re posterius
Pars tibionavicularis

M. tibialis posterior, Tendo

M. tibialis anterior, Tendo

Lig. calcaneonaviculare
plantare

Ligg. tarsom etatarsalia Lig. plantare longum
p la n ta ria
naviculare plantare
4.85
Lig. talocalcaneum laterale
Lig. tib iofib u la re anterius Lig. talocalcaneum interosseum
Lig. ta lo fib u lare anterius Lig. cuboideonaviculare dorsale
Ligg. cuneonavicularia dorsalia
M alleolus lateralis Ligg. m etatarsalia dorsalia

Lig. c alc an e o fib u la re
Tendo calcaneus

Ligg. m etatarsalia
transversa profunda

Lig. plantare longum Ligg. tarsom etatarsalia dorsalia
fibularis [peroneus] brevis, Tendo

Lig. bifurcatum

Fig. 4.85 and Fig. 4.86 Ankle joint (talocrural joint), Articulatio Talus th e ball o f th e joint. M edially, both jo in ts are stabilised by a fan­
talocruralis, righ t side, w ith ligam ents; m edial (-» Fig. 4.85) and shaped radiation o f ligam ents that is referred to as Lig. collatérale m e­
lateral (-» Fig. 4.86) view s. diale (delto ideum ) and con sists o f fo u r parts (Pars tibiotalaris anterior,
The m o ve m e n ts o f th e fo o t take place in th e (upper) ankle jo in t and in Pars tibiotalaris posterior, Pars tibiocalcanea, and Pars tibionavicularis)
th e (lower) talocalcaneonavicular joint. The other joints of the Tarsus w hich connect the respective bones. There are three single ligam ents
and M etatarsus are am phiarthroses w hich increase the range of move­ on th e lateral side (Lig. ta lo fib u la re anterius, Lig. ta lo fib u la re po ste­
m e n t o f th e talocalcaneonavicular jo in t to a certain exte nt. In th e ankle rius, Lig. calcaneofibulare). These ligam ents provide additional stabi­
joint, the malleolar fork constitutes the socket and the trochlea of the lisation of the talocalcaneonavicular joint.

i- Clinical Remarks------------------------------------

Injuries to the ankle jo int are m ore com m on than injuries to the ta ­ w ith distension of the malleolar fork. The m ost com m on ligam en­
localcaneonavicular jo in t because th e ligam entous sup port in the to u s injury in th e hum an is th e tea r o f th e lateral ligam ents (Lig.
malleolar region is not very strong. Since the trochlea o f the Talus talofibulare anterius and Lig. calcaneofibulare) in hypersupination
is w id e r in th e an terior than th e po sterior part (-» Fig. 4.37), secure trau m a.
guidance o f th e bones is only guaranteed in dorsiflexion (-extension)

284

M uscles -► T o p o g ra p h y -► S ections

Talocalcaneonavicular joint

O s m e ta ta rsi II Ligg. tarsom etatarsalia dorsalia
O s metatarsi I m e ta ta rsi IV
Os metatarsi V

Ligg. intercuneiform ia dorsalia Tuberositas ossis m etatarsi quinti Lig. ta lo ca lca n e u m
Ligg. cuneonavicularia dorsalia in te ro s s e u m
cuneocuboideum dorsale
Os naviculare Os cuboideum Lig. collaterale
calcaneonaviculare plantare Lig. calcaneonaviculare 1 . . . . m ediale [deltoideum ]

Facies articu ia ris ta laris m edia > Lig. bifurcatum
Lig. ta lo c a lc a n e u m interosseum Lig. calcaneocuboideum J
Facies articu ia ris ta la ris p o sterio r A rticu latio talocalcaneonavicularis
M. fibularis [peroneus] brevis, Tendo
Facies articuiaris talaris an terio r

s u b ta la ris

Lig.
anterius

T a lu s

Lig. calcaneofibulare

Fig. 4.89 Talocalcaneonavicular joint,
Articulatio talocalcaneonavicularis,
proxim al jo int bodies, right side; distal
view.

A rticu latio ta lo ca lca n e o n a vic u la ris

O s naviculare (Facies a rticuiaris talaris)

Lig. cuboideonaviculare dorsale

A rticu latio subtalaris

Facies a rticuiaris
ta laris po sterio r

Facies a rticuiaris ta la ris m edia
Lig. ta lo c a lc a n e u m interosseum

Fig. 4.87 and Fig. 4.88 Talocalcaneonavicular jo in t, A rticu latio re anteriorly and w ith the Lig. calcaneonaviculare plantare inferiorly.
talocalcaneonavicularis, distal jo in t bodies, right side; proximal A t th is contact point the latter show s an articular surface o f hyaline
(-» Fig. 4.87) and lateral (-* Fig. 4.88) v ie w s a fte r rem oval o f th e Talus. cartilage and contributes to the plantar arch. Both parts of th e joint
In th e talocalcaneonavicular joint, Talus, Calcaneus and Os naviculare create a functional unit and are often collectively referred to as Articu­
articulate in tw o independent joints. The posterior jo in t (A rticulatio latio talocalcaneonavicularis.
subtalaris) is form ed by the posterior corresponding articular surfaces In addition to th e ligam ents o f th e ankle joints, th e re are several liga­
o f Talus and Calcaneus. This partial jo in t is separated by the Lig. ta lo ­ m ents w hich stabilize the skeletal elem ents of the talocalcaneonavicu­
calcaneum interosseum , positioned in th e Sinus tarsi, fro m th e ante­ lar joint. Besides th e Lig. talocalcaneum interosseum , these are th e Lig.
rior partial jo in t (A rticu latio talocalcaneonavicularis). In th e anterior talocalcaneum mediale and the Lig. talocalcaneum laterale (-» Figs.
partial joint, the anterior articular surfaces o f Talus and Calcaneus arti­ 4.83 and 4.86). For th e range o f m o ve m e n t in th e talocalcaneonavicular
culate as w ell as the head o f the Talus articulates w ith the Os navicula­ jo in t -* Figure 4.92.

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Lower Extremity Surface a n a to m y -► Skeleton -► Im aging

Joints of the foot

Ligg. co llateralia Ligg. plan taria
Lig. m e ta ta rs a le transversum
Ligg. tarsom etatarsalia plantaria
p ro fu n d u m Os cuneiform e mediale
Ligg. cuneonavicularia plantaria
Lig. c alc an e o c u b o id eu m plan tare Lig. cuboideonaviculare plantare
Lig. plan tare longum Os naviculare
Tuber calcanei Lig. calc an e o n a vic u lare plan tare
S ustentaculum tali

Fig. 4.90 Joints of th e fo ot, Articulationes pedis, right side, w ith tatarsales and distally by the Lig. m etatarsale transversum profun­
ligam ents; plantar view. dum . The joints of forefoo t and m idfoot are linked by strong plantar,
The remaining joints of the Tarsus and M etatarsus are am phiarthro- dorsal, and interosseous ligam ents. The CHOPART's jo in t is stabilised
ses w hich only minim ally contribute to the m ovem ent of the foot. To­ dorsally by th e Lig. bifurcatum w h ich divides into tw o ligam ents (Lig.
gether however, they extend the range of m ovem ent of the talocalca­ calcaneonaviculare and Lig. calcaneocuboideum , -» Fig. 4.87) and is
neonavicular joint and transform the fo o t into an elastic base. A t the opposed on th e plantar side by th e Lig. calcaneocuboideum plantare.
Tarsus, tw o joints can be emphasized w hich contribute to supination To geth er w ith th e Lig. calcaneonaviculare plantare, th e Lig. plantare
and pronation m ovem ents o f the foot. The CHOPART's jo in t (Articula- longum serves to stabilise th e plantar arch. The latter is m ore superfi­
tio tarsi transversa) is com posed o f th e A rticulatio talonavicularis and cial than the other plantar ligam ents and spans fro m the Calcaneus to
th e A rticu la tio calcaneocuboidea (-* Fig. 4.33). The LISFRANC's jo in t th e Os cuboideum and th e Ossa metatarsalia 11—IV. The digital joints
(A rticulationes tarsom etatarsales) is th e connection to th e M etatarsus can be categorised in m etatarsop halang eal jo in ts (A rticulationes m e-
(-» Fig. 4.33). These tw o articulation lines have clinical relevance as tatarsophalangeales) and in proxim al and distal interphalangeal
im portant am putation lines. joints (Articulationes interphalangeae proxim ales and distales). The
The metatarsal bones articulate in several separate joints. The m etatar­ range o f m o ve m e n t in all digital jo in ts is lim ited by tig h t collateral liga­
sal bones are connected proxim ally by the Articulationes interm e- m e nts (Ligg. collateralia) and inferiorly by th e Ligg. plantaria.

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