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Inferior gluteal line
Anterior gluteal line
Posterior superior
pubis
Obturator foramen
A
Iliac fossa
Pectineal line
pubis
surface fo
Line of
Lateral
promontory
Spinous
posterior primary rami
Sacral
hiatus
Posterior gluteal line
CHAPTER 4 The Lower Limb
81
iliac spine
Ilium
Anterior superior
iliac spine
Iliopubic eminence
Superior ramus
of pubis
Pubic
tubercle
Pubic crest
Inferior
ramus of
Acetabulum
Acetabular
notch
Ischium
Ischial
tuberosity
Articular
sacrum
Greater sciatic
Obturator foramen
Ischial tuberosity
B
Fig. 4.1 The innominate bone. (A) Lateral view. (B) Medial view.
vertebral fusion
Foramina for
anterior primary rami
Ala
r
notch
Ischial spine
Lesser sciatic
notch
Sacral
Sacroiliac
joint
process
Anterior
superior
iliac spine
Anterior
inferior
iliac spine
Arcuate line
Pubic
tubercle
Surface for
symphysis
Foramina for
Coccyx
A
Fig. 4.2 The sacrum and coccyx. (A) Ventral surface. (B) Lateral surface. (C) Dorsal surface.
• Extending from the sacral canal is a row of four posterior sacral foramina on each side.
• Inferiorly, the vertebral canal terminates in the sacral
hiatus, which transmits the h sacral nerve.
mass
Coccyx
B
Coccyx
C
• On either side of the hiatus lies the sacral cornu.
• On the lateral aspect of the sacrum is a large facet for
articulation with the corresponding surface of the
ilium.
82
Iliolumbar ligament
r
Anterior sacroiliac
Ilium
Sacrotuberous
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SECTION I Anatomy
Sacrum
Lumbosacral
ligament
ligament
Anterior
inferior
iliac spine
Sacrococcygeal
ligament
Coccyx
Symphysis
pubis
Iliac crest
Anterior superio
iliac spine
Sacrospinous
ligament
Sacrotuberous
ligament
Fig. 4.3 The male pelvis showing the major ligaments, viewed from the front and slightly above.
• Occasionally the h lumbar vertebra fuses with the
sacrum.
• e dural sheath terminates distally at the second piece
of the sacrum.
• Beyond this the sacral canal contains the extradural
space, the cauda equina and the lum terminale.
Coccyx
• Made up of three to ve fused vertebrae, which articulate with the sacrum.
Ischiofemoral
ligament
JOINTS AND LIGAMENTS OF
THE PELVIS (Figs. 4.3 and 4.4)
Sacrum
Posterior
sacroiliac
ligament
Sacrospinous
ligament
Coccyx
Symphysis Pubis
• Like all symphyses it lies in the median plane and comprises a disc of brocartilage rmly xed between two
articular surfaces of hyaline cartilage.
• Surrounded and strengthened by brous ligaments.
• A nonsynovial cavity oen appears in the disc of brocartilage in adult life.
Sacroiliac Joints
• Large and very stable joints connecting the girdle proper
with the axial skeleton.
• Joints change in character with age:
• in the very young they are synovial, with almost
• in the elderly they are almost entirely brous, with
plane surfaces
irregular surfaces.
Fig. 4.4 The ligaments of the pelvis and femur, pos-
terior view.
• Stability of the sacroiliac joints is dependent on powerful ligaments:
• posterior sacroiliac ligaments, which oppose the ten-
dency for downwards and backwards displacement
of the sacrum between the hip bones
ligament
CHAPTER 4 The Lower Limb
Gluteus maximus (cut)
Iliac crest
83
• the iliolumbar ligaments attaching to the transverse
processes of L5 and the iliac crest.
• e sacrotuberous and sacrospinous ligaments attach
the sacrum to the ischium and oppose downwards rotation of the sacrum in the sagittal plane.
• e sacrotuberous ligament passes from the ischial
tuberosity to the side of the sacrum and coccyx.
• e sacrospinous ligament passes from the ischial spine
to the side of the sacrum and coccyx.
• e sacrospinous and sacrotuberous ligaments dene
two important exits from the pelvis:
• the greater sciatic foramen, formed by the sacrospi-
nous ligament and the greater sciatic notch
• the lesser sciatic foramen, formed by the sacrotuber-
ous ligament and the lesser sciatic notch.
• Major anatomical relations include:
• sacroiliac joints: the internal iliac vessels pass
anteriorly
• pubic symphysis: urethra and deep dorsal vein of the
penis pass inferiorly.
GLUTEAL REGION (Fig. 4.5)
• e muscles of the gluteal region are:
• gluteus maximus
• gluteus medius
• gluteus minimus
• piriformis
• obturator internus
• superior and inferior gemelli
• quadratus femoris
• tensor fasciae latae.
e glutei form the mass of the buttock.
Gluteus Maximus
Origin
• Ilium above and behind posterior gluteal line.
• Sacrum and coccyx.
• Sacrotuberous ligament.
Insertion
• lliotibial tract: three-quarters.
• Gluteal tuberosity of femur: one-quarter.
Nerve Supply
• Inferior gluteal nerve (L5, S1, 2).
Actions
• Extension of the thigh.
• Lateral rotator of the thigh.
• Balances pelvis on thigh (with psoas and iliacus).
• Steadies femur on knee joint on standing (via iliotibial
tract).
General Points
• Large, coarse muscle with small nerve supply and therefore not capable of ne or precise movements.
• Covers posterior part of gluteus medius.
• Covers all short muscles around hip joints, the
sciatic nerve, the proximal part of hamstrings, both
sciatic foramina and the structures passing through
them.
• Lower border overlaps ischial tuberosity on standing
(but not sitting) and the sacrotuberous ligament.
• Its lower border does not correspond to the gluteal
fold.
Fig. 4.5 The gluteal region.
Superior gluteal
artery and nerve
Sacrum
Cut inferior
gluteal nerve
Sacrotuberous
ligament
Internal pudendal
artery and nerve
Posterior cutaneous
nerve of thigh
Gluteus medius
Gluteus maximus (cut
and reflected)
Cut inferior gluteal
nerve supplying
gluteus maximus
Piriformis
Sciatic nerve
Greater trochanter
Quadratus femoris
Sciatic nerve
84
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SECTION I Anatomy
Gluteus Medius
Origin
• Outer surface of ilium between anterior and posterior
gluteal lines.
Insertion
• Lateral side of greater trochanter of femur.
Nerve Supply
• Superior gluteal (L4, 5, S1).
Action
• Abduction of thigh.
• Tilting upwards of opposite side of pelvis.
• Gluteus medius of limb that is on the ground during
walking supports the pelvis and prevents it from tilting
to the other side.
Gluteus Minimus
Origin
• Outer aspect of ilium between anterior and inferior gluteal lines.
Insertion
• Anterior aspect of greater trochanter.
Nerve Supply
• Superior gluteal nerve (L4, 5, S1).
Insertion
• Passes out of greater sciatic foramen to upper border of
greater trochanter.
Nerve Supply
• Directly from second and third sacral nerves.
Action
• is and the following three small muscles cause lateral
rotation of the thigh.
Obturator Internus
Origin
• Obturator membrane and surrounding bone.
Insertion
• Tendon leaves by lesser sciatic foramen to insert into the
greater trochanter on its medial surface.
Nerve Supply
• Nerve to obturator internus (L5, S1, 2).
Gemelli (Superior and Inferior)
Origin
• Upper and lower margins of lesser sciatic notch.
Insertion
• Sides of tendon of obturator internus.
Action
• Abduction of thigh.
• Medial rotation of thigh.
• Assists gluteus medius in walking to prevent pelvis tilting.
Tensor Fasciae Latae
Origin
• Anterior part of iliac crest posterior to the anterior
superior iliac spine.
Nerve Supply
• Superior by nerve to obturator internus.
• Inferior by nerve to quadratus femoris.
Quadratus Femoris
Origin
• Outer border of tuberosity of ischium.
Insertion
• Quadrate tubercle of upper part of trochanteric crest.
Insertion
• Iliotibial tract.
Nerve Supply
• Nerve to quadratus femoris (L4, 5, S1).
Nerve Supply
• Superior gluteal nerve (L4, 5, S1).
Action
• Assists gluteus maximus in tightening the iliotibial tract.
Greater and Lesser Sciatic Foramina
Sacrotuberous and sacrospinous ligaments convert the sciatic notches into foramina.
Greater Sciatic Foramen
Piriformis
Origin
• Anterior surface of sacrum.
Boundaries
• Superior and anterior: greater sciatic notch.
• Posterior: sacrotuberous ligament.
CHAPTER 4 The Lower Limb
85
• Inferior: sacrospinous ligament and ischial spine.
Structures passing through the foramen include
• Piriformis.
• Above piriformis:
• superior gluteal vessels
• superior gluteal nerve.
• Below piriformis:
• inferior gluteal vessels
• inferior gluteal nerve
• internal pudendal vessels
• internal pudendal nerves
• sciatic nerve
• posterior cutaneous nerve of thigh
• nerve to quadratus femoris
• nerve to obturator internus.
Lesser Sciatic Foramen
Boundaries
• In front: body of ischium and sacrospinous ligament.
• Behind: sacrotuberous ligament.
Structures passing through the foramen include
• tendon of obturator internus
• nerve to obturator internus
• internal pudendal vessels
• pudendal nerve.
Clinical Points
• e buttock is a common site for intramuscular injections.
• It is important to remember that the buttock extends
upwards as far as the iliac crest and laterally as far at the
greater trochanter. It does not just include the aesthetically pleasing mound.
• e surface marking of the sciatic nerve is represented
by a curved line joining the midpoint between the posterior superior iliac spine and ischial tuberosity, with the
midpoint between the ischial tuberosity and the greater
trochanter. Injections into the upper and outer quadrant
of the buttock will therefore avoid accidental injection
into the sciatic nerve (see Fig. 4.17).
BONES OF THE LEG AND FOOT
The Femur (Fig. 4.6)
• e largest bone in the body, being about 45 cm long.
• Upper end of femur consists of the rounded head, the
neck and two processes, the greater and lesser trochanters.
• Head forms two-thirds of a sphere, facing upwards
medially and slightly forwards.
• It is covered with cartilage, except at the central fovea
where the ligamentum teres is attached.
• e neck is 5 cm long and lies at an angle of 125° to the
sha (in the female the angle is slightly smaller).
• e greater trochanter is a massive process which can be
palpated as the most lateral bony point in the region of
the hip.
• e lesser trochanter is much smaller and it is situated
most posteriorly on the femur.
• e junction between neck and sha is marked anteriorly by the intertrochanteric line, laterally by the greater
trochanter, medially and posteriorly by the lesser trochanter and posteriorly by the trochanteric crest, which
joins the two trochanters.
• e femoral sha is roughly circular in section at its
centre but is attened posteriorly at each extremity.
• e posterior surface carries a rough raised line in its
middle third, i.e. the linea aspera. In the upper and
lower thirds, this line splits into two diverging lines.
• Inferiorly the two diverging lines, i.e. the medial and lateral supracondylar ridges, mark the medial and lateral
boundaries of a smooth, attened area, i.e. the popliteal
surface of the femur.
• e medial supracondylar line ends distally in the
adductor tubercle.
• e lower end of the femur bears prominent condyles,
which are separated by a deep intercondylar notch posteriorly and join anteriorly to form the articular surface
for the patella.
• e lateral condyle is more prominent than the medial
and acts as a buttress to prevent lateral displacement of
the patella.
Blood Supply of the Femoral Head
• is is from:
• vessels from the hip capsule where this is reected
onto the neck in longitudinal bands or retinacula
(retinacular vessels)
• vessels travelling up the diaphysis
• an artery in the ligamentum teres, which is a negli-
gible source in the adult.
• e chief source is from the retinacular vessels.
Clinical Points
• Fractures of the femoral neck completely interrupt the
blood supply from the diaphysis. If the retinacula are
torn, avascular necrosis of the femoral head will occur.
Avascular necrosis of the femoral head is much more
likely to occur with intracapsular fractures than extracapsular fractures because intracapsular fractures are
more likely to disrupt the retinacular blood ow.
• Fractures of the femoral neck result in shortening,
external rotation and adduction of the aected limb.
Shortening is because of the strength of the longitudinally lying muscles, especially quadriceps and hamstrings. e adductors pull the limb superomedially.
86
Intertrochanteric
epicondyle
Greater trochanter
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SECTION I Anatomy
Fig. 4.6 The right femur. (A) Anterior view. (B) Posterior view.
Intertrochanteric line
Lateral epicondyle
Lateral condyle
A
Fovea
Head
Neck
Shaft
Lesser trochanter
Adductor
tubercle
Medial
condyle
B
Head
Spiral line
Linea aspera
Medial
supracondylar
ridge
Adductor
tubercle
Medial
Neck
Quadrate tubercle
crest
Gluteal
tuberosity
Lateral
supracondylar
ridge
Popliteal surface
Intercondylar
notch
Instead of rotating about an axis between hip and knee,
the femur now rotates about the axis of its sha. Because
of this, iliopsoas now acts as an external rotator.
gastrocnemius tilts the distal fragment posteriorly and
the sharp proximal edge of this fragment impinges upon
the popliteal artery.
• Fractures of the femoral sha are accompanied by considerable bleeding due to damage of the perforating
branches of the profunda femoris artery, which are in
close relation to the sha.
• Fractures of the femoral sha are also accompanied by
considerable shortening owing to contractions of the
powerful surrounding muscles:
• the proximal segment is exed by iliopsoas and
abducted by gluteus medius and minimus
• the distal segment is pulled medially by the adductor
muscles.
• e popliteal artery is closely related to the popliteal
surface of the femur. Supracondylar fractures of the
femur may damage the popliteal artery. is is because
The Patella
• Largest sesamoid bone in the body. Developed in the
expansion of the quadriceps tendon, which continues
from the apex of the patella as the ligamentum patellae.
• Anterior surface is roughened for the attachment of part
of the quadriceps tendon.
• Posterior surface is smooth and covered with hyaline
cartilage for articulation with the corresponding areas
of the femur.
• e lateral facet is the larger (this explains how you can
‘side’ a patella—if placed on a at surface with the apex
pointing away from you, it will fall to the side to which
it belongs).
Intercondylar eminence
r
Femur
CHAPTER 4 The Lower Limb
87
Lateral condyle
of tibia
Head of fibula
Neck of fibula
Anterior border
Interosseous border
Lateral malleolus
Medial
condyle
of tibia
Tibial tuberosity
Anterior border
Lateral surface
Medial surface
Medial
malleolus
Soleal line
Nutrient foramen
Posterior surface
Interosseous borde
Posterior surface
Lateral surface
Talus
Calcaneum
A
B
Fig. 4.7 The lower end of the femur, tibia, fibula, talus and calcaneum. (A) Anterior view. (B) Posterior view.
Clinical Points
• Lateral dislocation of the patella is resisted by the more
prominent lateral femoral condyle and by the pull of the
lowermost bres of vastus medialis, which insert almost
horizontally along the medial margin of the patella.
Recurrent dislocation of the patella may occur if the lateral condyle of the femur is underdeveloped.
• Direct trauma to the patella may shatter it into several
fragments. ese are not avulsed because the quadriceps expansion remains intact.
The Tibia (Fig. 4.7)
• e more medial bone of the lower leg. Comprises a
sha and an expanded upper and lower end. It alone
articulates with the femur at the knee joint, the bula
being excluded.
• e upper end is expanded into the medial and lateral
condyles, the medial having the greater surface area of
the two.
• Between the condyles is the intercondylar area,
which bears the intercondylar eminence. e cruciate
88
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SECTION I Anatomy
ligaments are attached to the intercondylar area, as are
the horns of the medial and lateral menisci.
• e tuberosity of the tibia is at the upper end of the
anterior border of the sha and gives attachment to the
ligamentum patellae.
• e sha of the tibia is triangular in cross section, its
anterior border and anteromedial surface being subcutaneous throughout its length.
• e posterior surface of the sha has the soleal line at its
upper end, which marks the origin of soleus.
• e interosseous border is on the lateral side and gives
attachment to the interosseous membrane, which runs
upwards to the sha of the bula.
• e lower end of the tibia expands from the triangular
sha into a quadrilateral mass of bone from the medial
surface of which the medial malleolus projects downwards and medially.
• e medial malleolus is grooved posteriorly by the tendon of tibialis posterior.
• e inferior surface of the lower end of the tibia is smooth,
being covered with hyaline cartilage and forms, with the
malleoli, the upper articular surface of the ankle joint.
Clinical Points
• e sha of the tibia is subcutaneous anteromedially
throughout its course. Being so exposed, it is not surprising that the tibia is the most commonly fractured
long bone and sustains most compound injuries.
• Lacerations over the subcutaneous surface of the tibia
heal poorly because of lack of vascularity in the subcutaneous tissues as only the periosteum supports the
skin.
The Fibula (Fig. 4.7)
• e bula is a long, thin bone with a small head at its
upper end and an expanded lateral malleolus distally.
• e upper end has a head which articulates with the
tibia, below which is a neck around which winds the
common peroneal nerve.
• e sha is slender and bears an attachment for the
interosseous membrane, the bres of which run downwards and medially towards the tibia.
• e lower end of the bula is expanded to form the lateral malleolus, which bears an articular facet medially
for articulation with the talus.
• e posterior aspect of the lateral malleolus is grooved
by the tendons of peroneus longus and peroneus brevis.
Clinical Points
• e common peroneal nerve winds round the neck of the
bula. Damage to the nerve at this point, e.g. fractures of
the neck of the bula owing to car-bumper injuries, or
tight below-knee plasters, will result in foot drop.
Bones of the Foot (Fig. 4.8)
ese consist of the tarsal bones, metatarsals and phalanges.
The Tarsal Bones
• ese consist of a proximal row and a distal row. e
proximal row is made up of:
• talus
• calcaneum
• navicular bone.
• e distal row is made up of:
• the cuboid bone
• the three cuneiform bones.
Talus
• Bears a large facet on the upper surface for articulation
with the tibia.
• Bears facets on the medial and lateral sides for the
medial and lateral malleoli, respectively.
e superior articular surface is wider in front than behind
such that, when the foot is dorsiexed, the talus is wedged
between the malleoli, but in plantarexion there is a little
play so that a minor degree of tilting can occur at this joint
(this is not inversion and eversion, which occurs at the subtalar joints).
• e talus is grooved posteriorly for the tendon of exor
hallucis longus.
• ere are no muscular or tendinous attachments to the
talus but a number of ligaments are attached to it (see
arches of the foot).
Calcaneum
• Medial side easily recognized because of sustentaculum
tali (which is cantilevered out to support the head of the
talus).
• ere are two facets for talocalcaneal joints.
• e posterior surface can be divided into three areas:
• the middle, roughened area is for the insertion of
tendo calcaneus
• the upper, smooth area is a site of the bursa between
tendo calcaneus and the bone
• the lower area is covered by a bro–fatty pad that
forms the heel.
• e undersurface has medial and lateral tubercles, of
which the former is the larger and is the weightbearing
part of the heel.
• e anterior surface consists of an almost plane facet for
the cuboid.
Cuboid
• Articulates with the anterior facet on the calcaneum.
• Grooved on its undersurface by the tendon of peroneus
longus.
Navicular
• Articulates with the head of the talus behind and with
the three cuneiforms in front.
r
Femoral
Sartorius
Proximal
cuneiform bone
cuneiform bone
Distal phalanx
Proximal phalanx
Lateral cuneiform bone
Groove for
phalanx
First
metatarsal
Medial
cuneiform bone
Navicular
Intermediate
Lateral
Cuboid
CHAPTER 4 The Lower Limb
peroneus
longus
Cuboid
89
Middle phalanx
Sesamoid bones
Medial cuneiform
bone
Intermediate
cuneiform bone
Navicular
Talus
Talus
Calcaneum
A
Calcaneum
B
Fig. 4.8 The bones of the foot. (A) Superior view. (B) Inferior view.
• Bears a tuberosity for the insertion of tibialis posterior.
• e spring ligament passes from the sustentaculum tali
of the calcaneum to the tuberosity of the navicular.
Cuneiforms
• Cuneus means wedge. e wedge-shaped bones help
maintain the transverse arch of the foot.
Metatarsals
• e rst metatarsal is thickest and sturdiest, bearing on
its undersurface two depressions lined with articular
cartilage for two sesamoid bones in the tendon of exor
hallucis brevis.
• e second metatarsal is the longest and thinnest
and in the event of fatigue is liable to break (march
fracture).
Fig. 4.9 The femoral triangle.
• e h metatarsal has a tuberosity on its base for
insertion of peroneus brevis.
• In the standing position the metatarsal heads are in contact with the ground.
FEMORAL TRIANGLE (Fig. 4.9)
Floor
• Iliacus.
• Psoas major tendon.
• Pectineus.
• Adductor longus.
Boundaries
• Above: inguinal ligament.
• Medially: medial border of adductor longus.
• Laterally: medial border of sartorius.
Roof
• Skin.
• Supercial fascia.
Femoral
artery
nerve
Femoral
vein
Adducto
longus
90
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SECTION I Anatomy
• Supercial inguinal lymph nodes.
• Great saphenous vein.
• Deep fascia of thigh (fascia lata).
• Cribriform fascia (part of fascia lata).
• Pierced by great saphenous vein and lymphatics at
saphenous opening.
Contents
• Femoral canal.
• Femoral vein.
• Femoral artery.
• Femoral nerve.
• Deep inguinal lymph nodes.
Femoral Sheath
• Prolongation of fascia derived from transversalis fascia
(anteriorly) and fascia over iliacus (posteriorly).
• Contains the femoral canal medially, the femoral vein in
the middle and the femoral artery laterally.
Femoral Canal
• Medial compartment of the femoral sheath.
• Entered via the femoral ring.
• Contains fat and lymph nodes (Cloquet’s node).
Femoral Ring
is is the entry to the femoral canal. Its relations are:
• anteriorly: inguinal ligament
• medially: the lacunar ligament (may contain an abnormal obturator artery in its free edge)
• posteriorly: the pectineal ligament
• laterally: the femoral vein.
Inguinal Lymph Nodes
ese are divided as follows.
• Supercial group:
• horizontal: below and parallel to inguinal ligament
• vertical: around the termination of the great saphe-
nous vein.
• Deep group:
• medial to femoral vein and in femoral canal (Cloquet’s
node).
• Sites draining to the inguinal nodes include:
• lower limb
• buttock
• lower trunk and back below the level of the umbilicus
• perineum, scrotal skin and penis
• vulva and lower third of vagina
• abdominal wall below and including the umbilicus
• lower half of the anal canal
• fundus of the uterus (lymphatics follow the round
ligament).
The Adductor Canal (Subsartorial
Canal, Hunter’s Canal)
is passes from the apex of the femoral triangle to the
popliteal fossa. Its relations are:
• Posteriorly: adductor longus and adductor magnus.
• Anteromedially: sartorius forming the roof of the canal.
• Anterolaterally: vastus medialis.
• Contents:
• femoral artery
• femoral vein (behind the artery)
• saphenous nerve.
The Popliteal Fossa (Fig. 4.10)
is is a diamond-shaped space behind the knee. Its
relations and contents are as follows.
• Above and medial: semimembranosus and semitend inosus.
• Above and lateral: biceps femoris tendon.
• Below and lateral: lateral head of gastrocnemius.
• Below and medial: medial head of gastrocnemius.
• Roof:
• skin
• supercial fascia
• deep fascia (pierced by the small saphenous vein).
• Floor (from above down):
• posterior surface of femur
• posterior aspect of knee joint
• popliteus muscle covering the upper surface of the
tibia.
• Contents:
• popliteal artery (deepest structure)
• popliteal vein
• sciatic nerve above
• common peroneal nerve below
• tibial nerve below
• lymph nodes (draining the lateral side of foot and
heel)
• fat
• bursae.
ARTERIES OF THE LOWER LIMB
(Figs. 4.11 and 4.12)
Femoral Artery
• Continuation of external iliac artery below the inguinal
ligament.
• Passes to the apex of the femoral triangle.
• Enters adductor canal.
• Terminates by passing through the hiatus in adductor
magnus to become the popliteal artery.
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