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e
Suprapatellar bursa
Quadriceps
CHAPTER 4 The Lower Limb
Popliteal artery
Lateral femoral condyl
101
Fig. 4.20 Sagittal MRI through lateral part of the right knee joint, showing lateral meniscus. (From Jacob S:
Atlas of Human Anatomy. Churchill Livingstone 2002, with permission.)
Synovium
• Lines the capsule.
• Surrounds the cruciate ligaments.
• Communicates with suprapatellar bursa.
• In adult, menisci are not covered by synovial membrane.
Intra-articular Structures
• Cruciate ligaments:
• Semilunar cartilages (menisci) (Fig. 4.21):
Anterior horn of
lateral meniscus
• strong connections between femur and tibia
• take their names from the tibial origins
• anterior cruciate: from the front of the intercondylar
area of the tibia obliquely upwards to the intercondylar notch of the femur
• posterior cruciate: from the posterior aspect of the
intercondylar area of the tibia upwards to the front
of the intercondylar notch of the femur
• anterior cruciate ligament resists forwards displacement of tibia on femur—taut in hyperextension of
the knee
• posterior cruciate ligament resists backwards displacement of tibia on femur and is taut in hyperexion.
• crescentic in shape
Posterior horn of
lateral meniscus
Tibial condyle
• triangular in cross-section
• medial larger than lateral
• attached by extremities to intercondylar notch
• attached at periphery to capsule
• popliteus inserts into posterior aspect of lateral
cartilage.
• Infrapatellar fat pad:
• lls space between ligamentum patellae and femoral
intercondylar notch
• synovium covering pad projects into knee joint, raising folds on each side of it (the alar folds).
Nerve Supply
• Femoral, obturator, sciatic (according to Hilton’s law).
Movements
• Flexion: hamstrings, gracilis, gastrocnemius, sartorius.
• Extension: quadriceps femoris.
• Rotation: when the knee is exed, medial rotation is
possible (via popliteus).
• Full extension of the knee is accompanied by slight lateral rotation of the tibia (medial rotation of the femur if
the foot is on the ground). is ‘locks’ the joint.
102
Ligamentum
Tendon of popliteus
(medial head)
Medial meniscus
Infrapatellar
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SECTION I Anatomy
Tibial
nerve
pad of fat
Transverse
ligament
Medial patellar
retinaculum
Sartorius
Gracilis
Semitendinosus
Semimembranosus
Gastrocnemius
Lateral
meniscus
Lateral
(fibular)
collateral
ligament
Posterior
cruciate
ligament
Lateral
patellar
retinaculum
Anterior
cruciate
ligament
Biceps
Gastrocnemius
(lateral head)
patellae
Popliteal
artery
and vein
Fig. 4.21 The left knee joint, transverse section. The meniscus, cruciate ligaments and the relations of the joint
are shown.
• Flexion from full extension is initiated by popliteus,
which rotates the femur laterally or the tibia medially
and is said to ‘unlock’ the joint.
• Interosseous membrane: bres directed downwards and
medially from tibia to bula.
• Crossed by anterior tibial vessels above and perforated
by peroneal artery below.
Clinical Points
• Because of the incongruity of the articular surfaces, sta-
• Inferior tibiobular joints (syndesmosis) between each
bone just above ankle joint.
bility of the knee depends on the surrounding muscles
and ligaments. Quadriceps femoris is important and, if
this is strong, the knee will function satisfactorily even
Ankle Joint (Fig. 4.22)
• Hinge joint.
with considerable ligamentous damage.
• e semilunar cartilages can tear only when the knee is
exed and able to rotate.
• e collateral ligaments are taut in full extension of
the knee and therefore liable to injury in this position.
e medial ligament is liable to damage with a violent
abduction strain, whereas an adduction strain will damage the lateral ligament. e anterior cruciate ligament,
which is taut in extension, may be torn in hyperextension injuries of the knee or in anterior dislocation of the
Articular Surfaces
• Mortice formed between lower ends of tibia and bula
and body of talus.
Capsule
• in.
• Attached round margins of articular surfaces.
• Reinforced medially and laterally by collateral
ligaments.
tibia on the femur. e posterior cruciate ligament may
be damaged in posterior dislocations.
• Stability depends on muscles and ligaments. e power
of quadriceps is most important, especially in ligamentous damage. If quadriceps wastes, failure of reconstructed ligament is likely.
Ligaments
• Lateral: three parts—anterior talobular, calcaneobular, posterior talobular.
• Medial: strong and triangular; runs from medial malleolus to medial aspect of body of talus.
Tibiofibular Joint
• Superior tibiobular joint: between head of bula and
lateral condyle of tibia.
Movements
• Dorsiexion: tibialis anterior, extensor hallucis longus,
extensor digitorum longus, peroneus tertius.
Flexor digitorum brevis
Lateral malleolus
A
Body of calcaneus
bductor digiti minimi
Fig. 4.22 Coronal MRI through right ankle joint.
CHAPTER 4 The Lower Limb
Tibia
Medial malleolus
Body of talus
Deltoid ligament
Abductor hallucis
103
• Plantarexion: gastrocnemius and soleus, tibialis posterior, exor hallucis longus, exor digitorum longus.
• lateral: calcaneum, cuboid, lateral two metatarsals.
• Transverse:
• bases of metatarsals
Relations
• Shown in Fig. 4.23.
• each foot is really half an arch—lateral side on
ground, medial side at upper limit of arch.
• Factors maintaining the arches include:
Clinical Point
• Forced abduction or adduction injuries sprain or tear
the collateral ligaments—more commonly, the lateral.
• shape of interlocking bones
• muscles
• ligaments.
If the ligament is completely torn, the talus can be tilted
in its mortice.
Medial Longitudinal Arch (Fig. 4.24)
is is supported as follows.
Foot Joints
• Inversion and eversion occur at the subtalar joints.
• Inversion is caused by tibialis anterior and tibialis posterior, aided by extensor hallucis longus and exor hallucis longus.
• Eversion is caused by peroneus longus and peroneus
brevis.
• Muscular:
• exor hallucis longus
• exor digitorum longus
• tibialis anterior
• tibialis posterior
• exor digitorum brevis.
• Ligaments:
• spring ligament
ARCHES OF THE FOOT
e bones of the foot are arranged in the form of two longitudinal arches (medial and lateral) and a transverse arch.
ey are formed as follows.
• Longitudinal:
• medial: calcaneum, talus, navicular, three cunei-
forms, medial three metatarsals
• interosseous ligaments.
Lateral Longitudinal Arch
is is maintained by:
• Muscular:
• peroneus longus
• exor digitorum longus to the fourth and h toes
• exor digitorum brevis.
104
Extensor hallucis
Saphenous nerve
longus
Dorsalis pedis
Superficial peroneal
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SECTION I Anatomy
Tibialis anterior
Great saphenous
vein
Medial malleolus
Tibialis posterior
Flexor digitorum
longus
Posterior tibial
artery
Tibial nerve
Flexor hallucis
longus
artery
nerve
Extensor digitorum
longus
Deep peroneal
nerve
Talus
Lateral malleolus
Peroneus brevis
Peroneus longus
Sural nerve
Small saphenous
vein
Tendo calcaneus
Fig. 4.23 Transverse section through lower part of the talocrural joint, showing relations of the ankle joint.
Fig. 4.24 Sagittal MRI of the foot, showing medial longitudinal arch. (From Jacob S: Atlas of Human Anatomy.
Churchill Livingstone 2002, with permission.)
CHAPTER 4 The Lower Limb
105
• Ligaments:
• long plantar ligament
• short plantar ligament.
Transverse Arch
is is supported by:
• Muscular:
• peroneus longus.
• Ligaments:
• interosseous.
Ligaments
• Short plantar ligament:
• from plantar surface of calcaneum to cuboid.
OSCE SCENARIOS
OSCE Scenario 4.1
An 85-year-old female trips over the edge of a carpet at
home. She cannot get up from the oor. On arrival at hospital she complains of pain in the right groin. On examination
the right leg is externally rotated, shortened and adducted.
1. Classify fractures of the neck of the femur.
2. Explain the anatomical basis for external rotation,
shortening and adduction.
3. What is the blood supply of the head of the femur?
4. Explain why some fractures require a dynamic hip
screw while others require a hemiarthroplasty.
• Long plantar ligament:
• from calcaneum to base of second, third and fourth
metatarsals
• covers short plantar ligament
• forms a tunnel for the tendon of peroneus longus
with the cuboid bone.
• Spring ligament:
• sustentaculum tali of calcaneum to tuberosity of
navicular.
• Action of all ligaments reinforced by plantar
aponeurosis.
OSCE 4.4
A 27-year-old male is impaled on a metal pole aer falling
from some scaolding. It has entered his right buttock. You
are asked to see him on the ward several days aer recovering from surgery. e nurse looking aer him is concerned
he has a nerve injury.
1. What is the likely nerve to be injured in a penetrating
injury to the buttock?
2. What are the roots of this nerve?
3. If he has a nerve injury, what are the likely clinical signs
and why?
OSCE Scenario 4.2
You are asked to examine the pulses in a patient’s lower limb.
1. Describe the anatomical landmarks you would use to
locate the peripheral pulses in the lower limb.
OSCE Scenario 4.3
A 60-year-old female presents with a swelling in the right
groin.
1. What are the boundaries of the femoral triangle?
2. On examination, the lump is below the inguinal liga-
ment. Based on your knowledge of the contents of the
femoral triangle, with the exception of lymphadenopathy, what pathological conditions may arise from the
contents of the triangle?
3. On examination, you believe that the lump is a lymph
node. Which structures drain to the inguinal lymph
nodes?
Please check your eBook at https://studentconsult.inkling.com/ for more self-assessment questions. See inside cover for
registration details.
OSCE 4.5
A 52-year-old male has been hit by a car on the outside
of his le leg as he crossed the road. It is obvious he has a
nasty fracture of his lower leg. e plain X-ray has shown
a nasty comminuted proximal bular fracture and a tibial
fracture.
1. What is the likely nerve to have been injured and what
would be the examination ndings?
2. What other nerves are injured in fractures/dislocations?
3. He is placed in a plaster cast but just aer midnight the
nurse on the ward calls to tell you he is in tremendous
pain and his leg feels ‘odd’. What is the likely diagnosis
and what would be the treatment?
Answers in Appendix pages 438–440
5
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The Head, Neck and Spine
DEVELOPMENT
Branchial Arches
Branchial arches lie in the side walls and oor of the fetal
pharynx. ey support the lateral walls of the cranial part
of the foregut or primitive pharynx. e arches are separated from one another by ectodermal branchial cles or
grooves. On the inside of the primitive pharynx are ve
endodermal pharyngeal pouches. Each arch has a mesodermal core covered by ectoderm and an internal layer of
endoderm.
A typical branchial arch contains:
• a skeletal element (cartilaginous bar), which will form
bones and ligaments
• an artery
• a nerve
• striated muscle supplied by the nerve of that arch.
e derivatives of the pharyngeal pouches and bran-
chial arches are shown in Box 5.1 and Table 5.1.
TABLE 5.1 Derivatives of the Branchial Arches
Arch Nerve Skeletal Structures Muscles Ligaments
First (mandibular) V Incus and malleus
(Meckel’s cartilage)
Second (hyoid) VII Stapes
Styloid process
Upper part of body of hyoid
Lesser cornu of hyoid
Third IX Lower part of body of hyoid
Greater cornu of hyoid
Fourth–sixth X (recurrent
laryngeal,
superior
laryngeal)
Thyroid cartilage
Arytenoid cartilage
Corniculate cartilage
Cuneiform cartilage
The Tongue
A nodule, the tuberculum impar, develops in the oor of
the pharynx.
• is is covered by two lingual swellings, which arise
from each side of the rst branchial arch to fuse in the
midline and form the anterior two-thirds of the tongue
(nerve supply V—trigeminal).
BOX 5.1 Derivatives of Pharyngeal
Pouches
Arch Structures
First Eustachian tube, middle ear, mastoid
antrum
Second Tonsillar fossa (palatine tonsil)
Third Thymus, inferior parathyroid
Fourth Superior parathyroid, part of thyroid
Mastication
Mylohyoid
Anterior belly of digastric
Tensor tympani
Tensor palati
Facial expression
Posterior belly of digastric
Stylohyoid
Stapedius
Stylopharyngeus –
Muscles of pharynx,
larynx, palate
Sphenomandibular
Anterior ligament of
malleus
Stylohyoid
–
106
• A part of the second branchial arch contributes to
the anterior two-thirds of the tongue (nerve supply
VII—chorda tympani).
• e posterior third of the tongue develops largely
from the third branchial arch (nerve supply
IX—glossopharyngeal).
• e tongue musculature is derived from migrating
occipital myotomes dragging their nerve supply with
them (XII—hypoglossal).
e tongue therefore develops from the rst, second and
third branchial arches and receives nerve contributions
from each:
• lingual nerve (V): anterior two-thirds—general
sensation
• chorda tympani (VII): anterior two-thirds—taste
• glossopharyngeal (IX): posterior third—general sensation and taste.
Development of the Face
e face develops around the primitive mouth, i.e. stomodaeum, as follows.
• Frontonasal process grows down from the cranium and
forms:
• nose
• nasal septum
• nostril
• philtrum (midline depression on upper lip)
• premaxilla (bearing four incisor teeth).
• e maxillary processes fuse with the frontonasal processes and form:
• cheeks
• upper lip (except philtrum)
• upper jaw
• palate (except premaxilla).
• Mandibular processes meet in the midline to form:
• lower jaw.
Abnormalities may arise from abnormalities of fusion of
the above elements. ese include:
• abnormalities of closure of the stomodaeum, e.g.
macrostoma (too big), microstoma (too small)
• cle lip
• cle palate
• inclusion dermoids.
Cleft Lip (‘Hare’ Lip; Fig. 5.1)
• On one or both sides of philtrum, occurring as failure of
fusion of maxillary and frontonasal processes.
• May extend into nostril or alongside nose as far as
orbit.
• May be associated with cle palate.
• Median cle is rare; occurs with failure of development
of philtrum from frontonasal process.
CHAPTER 5 The Head, Neck and Spine
A B
Fig. 5.1 Cleft lip. (A) Unilateral. (B) Bilateral.
A
C
Fig. 5.2 Types of cleft palate. (A) Cleft of soft palate.
(B) Partial cleft palate. (C) Unilateral complete cleft
palate. (D) Bilateral complete cleft palate.
B
D
107
Cleft Palate (Fig. 5.2)
• Fusion occurs between primary palate (anterior section
of premaxilla and attached four teeth) and secondary
palate (hard and so palate).
• Failure of fusion of segments may result in:
• cle of so palate (bid uvula)
• partial cle involving posterior part of hard palate
• unilateral complete cle: running the full length of the
maxilla and then alongside one aspect of the premaxilla
• bilateral complete cle: running full length of max-
illa and on both aspects of premaxilla, separating it
completely.
108
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SECTION I Anatomy
Inclusion Dermoids
• May form along lines of facial fusion.
• Commonest is at the lateral extremity of the eyebrow,
i.e. external angular dermoid.
Development of the Thyroid
• Develops as diverticulum from oor of embryonic
pharynx just caudal to the tuberculum impar (site of
developing tongue); site of origin remains as foramen
caecum of tongue.
• Grows caudally supercial to branchial arches and
hence to hyoid and larynx to its denitive position.
• As lobes expand, they come into contact with the ventral part of the fourth pharyngeal pouch, which contributes the parafollicular (C) cells.
Clinical Points
• Stem of diverticulum, the thyroglossal duct, usually
disappears, although traces may remain as thyroglossal
cysts.
• yroglossal duct attaches to body of hyoid bone and the
latter must be excised when dealing with the thyroglossal ducts surgically; or when dealing with a thyroglossal
cyst, which is adherent to the body of the hyoid bone.
• Aberrant thyroid tissue may appear anywhere between
the foramen caecum of the tongue and the normal site
of the gland.
• yroid tissue at the foramen caecum is known as lingual thyroid.
• e thyroid may sometimes descend too far and be
found in the superior mediastinum.
Parathyroids
• Superior parathyroids develop from the fourth pharyngeal pouch.
• Inferior parathyroids develop from the third pharyngeal
pouch in company with the thymus.
• e inferior parathyroid may be dragged beyond the
thyroid into the superior mediastinum and be found in
association with (or even within) the thymus.
Development of the Spine
A dorsal groove appears on the surface of the embryo: the
neural groove.
• Neural groove becomes closed o, forming the neural
canal, which becomes separated from the ectodermal
covering of the body.
• Anterior to the neural canal is a solid cord of cells: the
notochord.
• Vertebral bodies develop around the notochord, each
vertebra ossifying from three primary centres: one for
each side of the arch and one for the body.
• e two halves of the arch fuse initially in the thoracic
region, and this spreads up and down the column.
• Failure of the two arches to fuse posteriorly results in
spina bida, which is most common in the lumbar region.
Types of Spina Bifida
Spina bifida occulta
• Vertebral anomaly: failure of arches to fuse exists in
isolation.
• e cord and meninges are intact.
• ere may be an overlying dimple or tu of hair at the
site.
Spina Bifida Manifesta
ere are two types:
• Meningocele, where the meninges herniate through the
bony defect and are covered by skin of variable quality.
• Meningomyelocele, where there is a failure of closure of
the neural tube. e defect is formed by exposed neural
tissue.
Hydrocephalus frequently accompanies meningomyelocele. e likely reason for this is:
• the spinal cord is tethered at the site of the lesion
• dierential growth between spinal cord and vertebral
column pulls the hindbrain into the foramen magnum
(Arnold–Chiari malformation)
• this interferes with circulation of cerebrospinal uid
(CSF).
Growth of Spinal Cord and Vertebral Column
• In the embryo the spine is curved in a gentle C-shape.
• As the infant lis its head the cervical spine develops a
curvature concaved posteriorly, i.e. cervical lordosis.
• As the child learns to walk the lumbar spine develops a
curvature concaved posteriorly, i.e. lumbar lordosis.
• Up to the third month of fetal life the spinal cord occupies the full length of the vertebral canal.
• Vertebral growth then occurs more rapidly than that of
the spinal cord.
• At birth the cord reaches the level of the third lumbar
vertebra.
• By adolescence the cord is at its denitive position at
the level of the disc between the rst and second lumbar
vertebrae.
Clinical Points
• Lumbar puncture must be performed well clear of the
termination of the cord.
• A line joining the iliac crests passes through the fourth
lumbar vertebra, and therefore the intervertebral space
above and below this landmark can be safely used for
lumbar puncture (below is safer in babies and young
children).
CHAPTER 5 The Head, Neck and Spine
Frontal bone
Alveolar process
Zygomatic arch
Parietal bone
Suprameatal triangle
Coronoid process
Sphenoid (greater wing)
Temporal bone
109
HEAD
Face
e facial skeleton is shown in Figs. 5.3 and 5.4. e skeleton surrounds cavities at three levels:
• paired orbits housing the eyes
• paired nasal cavities: the openings of the respiratory
tract and organs of smell
• single buccal (oral) cavity: the opening of the alimentary tract.
e facial skeleton is braced against the base of the skull by
three pairs of struts, all meeting the cranial skeleton at the
level of the middle cranial fossa:
• the zygomatic arches dening the temporal fossae on
each side
• the pterygoid plates of the sphenoid forming the posterior walls of the pterygopalatine fossae
• the vertical rami of the mandible: meeting the base of
the skull at the temporomandibular joints.
Mandible
• e body of the mandible is the horizontal part bearing
the alveolar process and the lower teeth.
• Posteriorly, at the angle, the body joins the ramus, which
is almost vertical.
• e ramus bears an anterior coronoid and a posterior
condyloid process or head.
• Between the coronoid and condyloid processes is the
mandibular notch.
• On the medial aspect of the ramus is the mandibular
foramen for the inferior alveolar branch of the mandibular division of the trigeminal nerve.
• e inferior alveolar branch of the mandibular nerve
traverses the body of the mandible within the mandibular canal and emerges as the mental nerve through the
mental foramen on the lateral surface of the body.
• e mandibular foramen is shielded by a projecting
process, the lingula.
• A small groove runs inferiorly and forwards from the
mandibular foramen, i.e. the mylohyoid groove, in
which lie the nerve and vessels of the same name.
• Above this groove is a prominent ridge, the mylohyoid
line, which gives attachment to the mylohyoid muscle.
• e upper border of the body bears the alveolar border
with 16 dental sockets or alveoli.
Nasal bone
Zygomatic bone
Maxilla
Fig. 5.4 External view of the skull from the front.
Fig. 5.3 External view of the skull from the side.
Lambdoid suture
Occipital bone
External auditory
meatus
Mastoid
process
Coronal suture
Frontal bone
Orbit
Zygomatic process
(zygoma)
Zygomatic bone
Mandible
110
Ophthalmic nerve
Supraclavicular nerves (C3, C4)
Zygomaticofacial nerve
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SECTION I Anatomy
Fig. 5.5 The sensory innervation of the head and neck.
• e lateral surface is roughened by muscle attachment
on the angle and ramus.
• Masseter is inserted at the lateral surface.
• e midline of the mandible is oen referred to as the
symphysis menti, which is a joint up to the second year
of life, aer which fusion takes place.
Sensory Nerve Supply of the Face (Fig. 5.5)
is is via the trigeminal nerve, except for a small area
over the parotid, which is supplied by the greater auricular
nerve, a branch of the cervical plexus. e distribution of
the nerves is as follows:
• ophthalmic: nose, orbital region, frontal region of
scalp
• maxillary: upper jaw, including teeth
• mandibular: lower jaw and associated structures,
including the anterior two-thirds of the tongue.
e nerve supplied is carried by three major branches, one
of each division of the following nerves.
• Supraorbital nerve:
• branch of ophthalmic division
• passes through the supraorbital foramen
• travels back as far as the vertex of the skull
• supplies the skin of the scalp as far back as the vertex,
• Infraorbital nerve:
• a branch of maxillary nerve
Supraorbital nerve
Supratrochlear nerve
Maxillary nerve
External nasal nerve
Infraorbital nerve
Buccal nerve
Mental nerve
Transverse cervical nerve (C2, C3)
the skin of the forehead, the skin of the upper eyelid,
the skin of the front of the nose, the cornea.
Greater occipital nerve (C2, C3)
Mandibular nerve
Auriculotemporal nerve
Lesser occipital nerve (C2)
Greater auricular nerve (C2, C3)
Dorsal rami of C3, C4, C5
• emerges from the infraorbital foramen
• supplies the skin of the cheek, side of the nose,
mucous membrane of the inside of the corresponding part of the cheek, outer surface of the gum.
• Mental nerve:
• a branch of mandibular nerve
• supplies skin of chin, mucous membrane of lower
lip, outer surface of gums.
ese three nerves are supplemented by a number of
smaller nerves, whose distribution is shown in Fig. 5.5.
Dermatomes of the Head and Neck (Fig. 5.6)
• Anterior to the auricle, the scalp is supplied by the three
branches of the trigeminal nerve.
• Posterior to the auricle, the scalp is supplied by the spinal cutaneous nerves from the neck.
Facial Musculature
ere are two groups of muscles on the face.
• Muscles of mastication, supplied by the mandibular
division of the trigeminal nerve.
• e muscles of facial expression, supplied by the facial
nerve.
The muscles of mastication
• Temporalis can be seen in the temporal region, covered
by the tough temporal fascia.
• Masseter is on the side of the face and its anterior border
can be palpated when the teeth are clenched.
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