Surface anatomy of the lower limb pdf - Lower limb

Surface Anatomy

the lower part of the anterior abdominal wall.

bodies of the pubic bones can be felt on palpation through

and the

upper margin of the symphysis pubis

10.80). The

in the midline between the bodies of the pubic bones (Fig.

is a cartilaginous joint that lies

symphysis pubis

The

pubic tubercle (Figs. 10.83 and 10.84).

ally to the anterior superior iliac spine and medially to the

groin and can be felt along its length. It is attached later

lies beneath the skin fold in the

inguinal ligament

The

and the ischial tuberosity (Figs. 10.82 and 10.83).

down, midway between the tip of the greater trochanter

superior iliac spine and the ischial tuberosity and, lower

ward, it is situated at first midway between the posterior

gluteus maximus muscle. As it curves laterally and down

in the buttock lies under cover of the

sciatic nerve

The

the lower border of the gluteus maximus muscle.

standing position; its lower border does not correspond to

is most prominent in the

fold of the buttocks

The

be palpated with a gloved finger in the anal canal.

the anus (Fig. 10.83). The anterior surface of the coccyx can

the cleft between the buttocks about 1 in. (2.5 cm) behind

can be palpated beneath the skin in

coccyx

The tip of the

cleft between the buttocks.

crest can be felt beneath the skin in the upper part of the

The

median sacral crest.

fused with each other to form the

of the sacrum (Fig. 10.79) are

spinous processes

The

ischial tuberosity (Fig. 10.83).

on a line connecting the anterior superior iliac spine to the

hip joint, the upper border of the greater trochanter lies

and extended. It is important to verify that, in the normal

moves beneath the examining finger as the hip joint is flexed

lateral surface of the thigh (Figs. 10.82 and 10.83) and

of the femur can be felt on the

greater trochanter

The

a pad of fat.

tuberosity is separated from the skin by only a bursa and

and supports the weight of the body; in this position, the

from beneath the lower border of the gluteus maximus

mus. In the sitting position, the ischial tuberosity emerges

ing position, the tuberosity is covered by the gluteus maxi

part of the buttock (Figs. 10.82 and 10.83). In the stand

can be palpated in the lower

ischial tuberosity

The

rior iliac spine (Fig. 10.83).

iliac crest about 2 in. (5 cm) posterior to the anterior supe

is a prominence felt on the outer surface of the

tubercle

vertebra and the middle of the sacroiliac joint. The

lies beneath a skin dimple at the level of the second sacral

(Fig. 10.82); the latter

posterior superior iliac spine

(Figs. 10.79 and 10.80) and behind

rior superior iliac spine

ante

(Figs. 10.82 and 10.83). Each crest ends in front at the

are easily palpable along their entire length

iliac crests

The

513

Gluteal Region

at the

iliac

-
-

Inguinal Region

FIGURE 10.69

y.)

Ectromelia. (Courtesy of G. Aver

FIGURE 10.70

Radiograph of bilateral congenital dislocation

shallow acetabular fossae. (Courtesy of J. Adams.)

of the hip showing that the femoral heads are not within the

FIGURE 10.71

Talipes equinovarus. (Courtesy of J. Adams.)

Surface Anatomy

519

spinous processes

of lumbar vertebrae

fused spinous

processes

of sacrum

greater trochanter

of femur

position

of sciatic nerve

site of ischial

tuberosity

hamstring

group of muscles

iliac crest

posterior superior
iliac spine

gluteus medius

gluteus maximus

natal cleft

fold of buttock

FIGURE 10.82

The gluteal region and the posterior aspect of the thigh of a 25-year-old woman.

iliac tubercle

anterior superior

iliac spine

pubic tubercle

greater
trochanter

ischial tuberosity

coccyx

posterior
superioriliac
spine

iliac crest

posterior superior iliac spine

iliac crest

sacral spines

iliac tubercle

sciatic nerve

greater trochanter

fold of buttock

natal cleft

anterior superior iliac spine

inguinal ligament

greater
trochanter

sartorius

lateral
condyle

tibial
tuberosity

patella

medial condyle

adductor
tubercle

femoral
triangle

adductor
longus

pubic
tubercle

iliac tubercle

anterior superior

iliac spine

pubic tubercle

greater
trochanter

chial tuberosity

crest

posterior superior iliac spine

iliac crest

sacral spines

iliac tubercle

sciatic nerve

greater trochanter

fold of buttock

natal cleft

anterior superior iliac spine

inguinal ligament

greater
trochanter

sartorius

lateral
condyle

tibial
tuberosity

patella

medial co

adductor
tubercle

femora
triangle

adduc
longus

p
t

FIGURE 10.83

Surface markings in the gluteal region and the front of the thigh.

520

CHAPTER 10

The Lower Limb

of femoral artery

pubic tubercle

symphysis pubis

site for palpation

rectus femoris

vastus medialis

patella

adductor longus

patella

vastus medialis

vastus lateralis

subsartorial

(adductor canal)

rectus femoris

sartorius

femoral triangle

anterior superior

iliac spine

inguinal ligament

FIGURE 10.84

The broken lines indicate the boundaries of the femoral

Anterior aspect of the thigh of a 27-year-old man.

to their bony attachments. Because the ligaments cover the

sides of the joint line; they can be followed above and below

can be palpated on the

lateral collateral ligament

rounded

medial collateral ligament

The bandlike

between them (Fig. 10.85).

on the sides of the knee, and the joint line can be identified

can be recognized

condyles of the femur and tibia

The

tuberosity of the tibia.

tum patellae can be traced downward to its attachment to

can be easily palpated (Fig. 10.85). The ligamen

patellae

ligamentum

patella

In front of the knee joint, the

and the saphenous nerve.

longus and magnus muscles. It contains the femoral vessels

the vastus medialis muscle and posteriorly by the adductor

beneath the sartorius muscle and is bounded laterally by

the femoral triangle. It is an intermuscular cleft situated

of the thigh (Fig. 10.84), immediately distal to the apex of

lies in the middle third

adductor (subsartorial) canal

The

tubercle (Figs. 10.3 and 10.19).

femoral vein 1.5 in. (4 cm) below and lateral to the pubic

ing in the deep fascia (fascia lata) of the thigh and joins the

pierces the saphenous open

great saphenous vein

The

femoral artery (Fig. 10.6).

of the inguinal ligament—that is, lateral to the pulsating

enters the thigh behind the midpoint

femoral nerve

The

lateral to the pubic tubercle (Figs. 10.3 and 10.6).

lies below and

femoral canal

The lower opening of the

(Fig. 10.6).

inguinal ligament medial to the pulsating femoral artery

leaves the thigh by passing behind the

femoral vein

The

sations are easily felt (Fig. 10.84).

symphysis pubis to the anterior superior iliac spine; its pul

ligament (Fig. 10.6) at the midpoint of a line joining the

enters the thigh behind the inguinal

femoral artery

The

and parallel to the inguinal ligament (Fig. 10.3).

can be palpated in the superficial fascia just below

nodes

superficial inguinal lymph

The horizontal group of

by the adductor longus muscle.

medial border

by the sartorius muscle,

lateral border

inguinal ligament, the

of the triangle is formed by the

and laterally rotated. The

triangle can be identified when the thigh is flexed, abducted,

and 10.84). In a thin, muscular subject, the boundaries of the

fold of the groin in the upper part of the thigh (Figs. 10.83

The femoral triangle can be seen as a depression below the

Femoral Triangle

of the body of the pubis, medial to the pubic tubercle (Figs.

is the ridge of bone on the upper surface

pubic crest

The

the lateral margin of the labium majus.

examining finger. In the female, it can be palpated through

palpated in the male by invaginating the scrotum with the

medial end of the inguinal ligament. The tubercle is easily

of the pubis (Figs. 10.83 and 10.84). Attached to it is the

can be felt on the upper border

pubic tubercle

The

triangle. The right leg is laterally rotated at the hip joint.

10.7 and 10.8).

base

and the

Adductor Canal

Knee Region

and the

the

and the

Surface Anatomy

521

subcutaneous
surface of tibia

ligamentum
patellae (attached
to tuberosity of tibia)

medial condyle
of tibia

medial condyle
of femur

patella (upper margin)

vastus medialis

rectus femoris

lateral

medial

vastus lateralis

lateral condyle

of femur

iliotibial tract

tibialis anterior

anterior border

of tibia

position of

joint line

fibula

FIGURE 10.85

Anterior aspect of the right knee of a 27-year-old man.

the examining finger just below the head of the fibula

can be rolled beneath

common peroneal nerve

The

(Fig. 10.85).

head of the fibula

on the lateral aspect of the knee and can be traced down to

can be felt as a rounded structure

tendon of biceps

The

and the medial and lateral collateral ligaments, respectively.

palpated on the joint line between the ligamentum patellae

the outer edges of the medial and lateral menisci can be

femoral and tibial condyles. Although not recognizable,

are located in the interval between the

menisci

The

collateral ligaments (Fig. 10.61).

joint line, the joint line cannot be palpated at the sites of the

the

(Fig. 10.86); here, it passes forward around the lateral side

posterior

tendon of flexor digitorum longus,

rior,

tendon of tibialis poste

structures, in the order named: the

and the medial surface of the calcaneum lie the following

In the interval behind the medial malleolus (Fig. 10.86)

the tip of the lateral malleolus (Figs. 10.86 and 10.87).

the tibia lies about 0.5 in. (1.3 cm) proximal to the level of

medial malleolus

(Figs. 10.86 and 10.87). The tip of the

lateral malleolus

can be followed downward to form the

In the region of the ankle, the fibula is subcutaneous and

(Fig. 10.85).

subcutaneous and can be felt throughout their length

are

tibia

The medial surface and anterior border of the

Tibia

cia is fully relaxed by passively flexing the knee joint.

the depths of the popliteal fossa, provided that the deep fas

can be felt by gentle palpation in

popliteal artery

The

beneath the finger.

With the knee joint partially flexed, the nerve can be rolled

as the latter passes to its insertion on the head of the fibula.

medial side of the tendon of the biceps femoris (Fig. 10.86),

can be palpated on the

common peroneal nerve

The

each side by one of the heads of the gastrocnemius muscle.

and semitendinosus muscles. Its lower part is bounded on

by the tendons of the semimembranosus

medially

cle and

by the tendon of the biceps femoris mus

laterally

bounded

and the boundaries are easily defined. Its upper part is

flexed, the deep fascia, which roofs over the fossa, is relaxed

(Fig. 10.86). When the knee is

popliteal fossa

sion called the

Behind the knee joint is a diamond-shaped skin depres

it (Fig. 10.86).

can be felt passing to

adductor magnus

string part of the

aspect of the femur just above the medial condyle; the ham

can be palpated on the medial

adductor tubercle

The

of the bone.

Ankle Region and Foot

the

522

CHAPTER 10

The Lower Limb

medial

semimembranosus

semitendinosus

adductor magnus tendon

adductor tubercle

patella

condyle of femur

joint line

ligamentum
patellae

anterior border
of tibia

head of fibula

common peroneal

nerve

lateral malleolus

extensor digitorum

brevis

extensor digitorum

longus tendons

head of talus

tuberosity of navicular bone

sustentaculum tali

tuberosity of fifth metatarsal

lateral malleolus

peroneus longus and brevis tendons

tendo calcaneus

tibialis posterio tendon

medial malleolus

extensor hallucis longus tendon

tibialis anterior
tendon

medial malleolus

gastrocnemius

(medial and lateral heads)

lateral malleolus

talus

extensor digitorum

longus tendons

extensor hallucis
longus tendon

tibialis anterior tendon

medial malleolus

common peroneal nerve

head of fibula

popliteal fossa

biceps femoris

lateral

medial aspect of foot

lateral aspect of foot

metatarsophalangeal joint of big toe

FIGURE 10.86

Surface markings in the popliteal fossa, the front of the leg, and the foot.

dorsal venous

tuberosity of navicular

great saphenous vein

digitorum brevis

extensor

longus and brevis

tendo calcaneus

tendons of peroneus

lateral malleolus

head of talus

head of first metatarsal

sustentaculum tali

medial malleolus

tendo calcaneus

tuberosity of fifth
metatarsal

arch

FIGURE 10.87

Lateral aspect

of the right ankle of a 29-year-old woman.

(A) and medial aspect (B)

Surface Anatomy

of the calcaneum can be palpated about 1 in. (2.5 cm) below

peroneal tubercle

On the lateral aspect of the foot, the

lateral malleolus (Fig. 10.19).

behind

the lateral part of the plexus and passes up

drains

small saphenous vein

malleolus (Fig. 10.87). The

of the medial

in front

part of the plexus and passes upward

leaves the medial

great saphenous vein

and 10.87). The

dorsal surface of the foot proximal to the toes (Figs. 10.19

can be seen on the

dorsal venous arch

The

toes (Fig. 10.86).

can be made prominent by dorsiflexing the

lucis longus

extensor hal

tendons of extensor digitorum longus

be palpated just in front of the malleoli (Fig. 10.87). The

head of the talus

On the dorsum of the foot, the

(Achilles tendon) (Fig. 10.88).

tendo calcaneus

heel is the

Above the

calcaneum.

nence of the heel is formed by the

On the posterior surface of the ankle joint, the promi

longus, midway between the two malleoli on the front of

tendons of extensor hallucis longus and extensor digitorum

can be felt between the

dorsalis pedis artery

sations of the

The pul

peroneus tertius.

extensor digitorum longus

tendons of

Lateral to the extensor hallucis longus lie the

stand out by extending the big toe (Figs. 10.86 and 10.88).

lies lateral to it and can be made to

sor hallucis longus

tendon of exten

and inverted (Figs. 10.86 and 10.88). The

can be seen when the foot is dorsiflexed

tibialis anterior

tendon of

On the anterior surface of the ankle joint, the

(Figs. 10.87

longus

tendons of peroneus brevis

are the

lus and the heel (Fig. 10.88). Behind the lateral malleolus

can be felt halfway between the medial malleo

tibial artery

posterior

The pulsations of the

of flexor hallucis longus.

tendon

posterior tibial nerve,

tibial vessels,

523

the

and the

and

and 10.88).

and

the ankle.

can

and

plexus

the

extensor

digitorum longus

lateral malleolus

dorsal venous arch

medial malleolus

site for palpation

of posterior tibial artery

tendons of peroneus

longus and brevis

lateral malleolus

tendo calcaneus

tendon of extensor
hallucis longus

tendon of tibialis
anterior

medial malleolus

FIGURE 10.88

Anterior aspect

of the right foot and ankle of a 29-year-old woman.

(A) and posterior aspect (B)

Arterial Palpation

and the symphysis pubis (Fig. 10.84). The artery is easily palpated

ment at a point midway between the anterosuperior iliac spine

Every health professional should know the precise position of the

main arteries within the lower limb, for he or she may be called

on to arrest a severe hemorrhage or palpate different parts of

the arterial tree in patients with arterial occlusion.

The femoral artery enters the thigh behind the inguinal liga-

here because it can be pressed backward against the pectineus

and the superior ramus of the pubis.

C L I N I C A L N O T E S O N T H E A R T E R I E S O F T H E L O W E R L I M B

(continued)

526

CHAPTER 10

alis posterior muscle.

receives the main part of the tendon of insertion of the tibi

can be seen and palpated (Fig. 10.87). It

navicular bone

tuberosity of the

In front of the sustentaculum tali, the

lower surface.

and the tendon of flexor hallucis longus winds around its

don of flexor digitorum longus crosses its medial surface;

rior lies immediately above the sustentaculum tali; the ten

medial malleolus (Fig. 10.87). The tendon of tibialis poste

can be palpated about 1 in. (2.5 cm) below the tip of the

sustentaculum tali

On the medial aspect of the foot, the

enter the groove on the under aspect of the cuboid bone.

passes forward to

tendon of peroneus longus

tubercle, the

(Fig. 10.87). Below the

5th metatarsal bone

base of the

forward to its insertion on the prominent tuberosity on the

tendon of peroneus brevis

Above the tubercle, the

and in front of the tip of the lateral malleolus (Fig. 10.86).

The Lower Limb

passes

-
-

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FIGURE 10.89

Footdrop. With this condition, the individual

catches his or her toes on the ground when walking.