Lower+Extremity+Osteology+Olinger.docx

Anthony Olinger, Ph.D. Reference Reading: Clinically Oriented Anatomy, 9th ed., Chapter 7 Clinical box Objectives: After reviewing/ attending the lecture, reading/viewing the textbook, dissector, atlas, participating in the laboratories, the student should be able to meet the following objectives:...

Anthony Olinger, Ph.D. Reference Reading: Clinically Oriented Anatomy, 9th ed., Chapter 7 Clinical box Objectives: After reviewing/ attending the lecture, reading/viewing the textbook, dissector, atlas, participating in the laboratories, the student should be able to meet the following objectives: In order to explain a normal patient presentation, identify each bone and describe each of their major bony landmarks including the Hip Bone, Femur, Patella, Tibia, Fibula, Tarsal Bones and bones of the foot In order to explain fractures and fracture healing of the pelvis, describe pelvic crush fractures In order to explain fractures and fracture healing of the Femur, describe fractures of the Femoral Neck and what they are erroneously referred to as a broken hip In order to explain bone and joint diseases, describe the angles associated with the Femur and distinguish between Coxa Vara and Coxa Valga In order to explain fractures and fracture healing of the Femur, describe the multiple varieties of Femoral fractures In order to explain fractures and fracture healing of the Patella, define Chondromalacia Patella and describe Patellar fractures as well as abnormal ossification of the Patella In order to explain fractures and fracture healing of the Tibia and Fibula, describe the multiple fractures that can occur with those two bones. In order to explain fractures and fracture healing, describe Osgood-Shlatter’s disease and the bony and cartilaginous elements involved. In order to explain traumatic bone injuries of the lower extremity, describe Fibular bone grafts In order to explain fractures and fracture healing of the Tarsal bones, explain how the Tarsal bones are frequently fractured In order to explain a normal patient presentation involving the Tarsal bones, explain the Os Trigonium In order to explain fractures and fracture healing of the Metatarsal bones, explain how the Tarsal bones are frequently fractured I. Lower Extremity- Consists of the Gluteal Region, Femoral Region, Knee, Leg, Ankle and Foot II. Osteology A. Os Coxae (Hip Bones, Innominate Bones) 1. Ilium (superior part of the Os Coxa) a. Iliac Ala 1. Anterior Gluteal Line (lateral aspect, attachment point for the Gluteal Ms.) 2. Posterior Gluteal Line (lateral aspect, attachment point for the Gluteal Ms.) 3. Inferior Gluteal Line (lateral aspect, attachment point for the Gluteal Ms.) b. Iliac Fossa (medial aspect, contains the Iliacus M.) Arcuate Line (medial aspect, one of three component to the Pelvic Brim) Auricular Surface of the Ilium (medial aspect, articulates with the Auricular Surface of the Sacrum) Iliac Crest (along the superior edge of the Iliac Ala) 1. Iliac Tubercle (projects superiorly) 2. Iliac Tuberosity (medial aspect) f. Anterior Superior Iliac Spine (superior attachment for the Inguinal L.) g. Anterior Inferior Iliac Spine h. Posterior Superior Iliac Spine i. Posterior Inferior Iliac Spine 2. Pubis (inferoanterior part of the Os Coxa) Body (anterior most part of the Pubis) Pubic Symphyseal Surface (articulates with contralateral Os Coxa to form the Pubic Symphysis) 2. Pubic Crest (anterior aspect) 3. Pubic Tubercle (on the lateral aspect of the Pubic Crest) b. Superior Pubic Ramus (projects toward Acetabulum) 1. Pectin Pubis (Pectineal Line, continuous with the Arcuate line of the Ilium forming the coxal part of the Pelvic Brim) 2. Obturator Crest (ridge on the lateral aspect of the Superior Pubic Ramus) 3. Obturator Groove (inferior to the Obturator Crest, continuous with the Obturator Foramen, transmits Obturator N., A. and V.) c. Inferior Pubic Ramus (projects toward Ischial Ramus) 3. Ischium (inferoposterior part of the Os Coxa) a. Body of the Ischium (posterior to the Obturator Foramen, anterior to the Ischial Spine) Ischial Spine (projects posteriorly between Greater and Lesser Sciatic Notches) 2. Ischial Tuberosity (posteroinferiorly directed roughened area) 3. Greater Sciatic Notch (posterior edge of the Ischium, inferior to the Iliac Ala, superior to the Ischial Spine) Lesser Sciatic Notch (posterior edge of the Ischium, between Ischial Spine and Ischial Tuberosity) d. Ischial Ramus (projects toward Inferior Pubic Ramus) 4. Acetabulum (lateral aspect, made up of all three parts of the Os Coxa) a. Acetabular Notch (inferior gap in the Acetabular Rim) b. Acetabular Fossa (depression in the central Acetabulum) Lunate Surface (smooth surface around the Acetabular Fossa) Rim (surrounds the Acetabulum) Obturator Foramen (formed by Superior and Inferior Pubic Rami, the Ischial Ramus and the Body of the Ischium) 6. Iliopubic Eminence (at Iliopubic junction, projects anteriorly) 7. Ischiopubic Ramus (area of overlap between the Ischial Ramus and Inferior Pubic Ramus) 8. Pubic Arch (Bony arch between Right and Left Inferior Pubic and Ischial Rami, the apex of the Pubic arch is at the Pubic Symphysis) 9. Subpubic Angle (angle immediately inferior to the Pubic Symphysis) HN: The Bony Pelvis includes the Paired Os Coxae, The Sacrum and the Coccyx. The Pelvic Girdle describes the paired Os Coxae, which are joined anteriorly at the Pubic Symphysis. CN: Injuries to the Hip Bone: Injuries to the Bony Pelvis will be covered in the Pelvis (GIGU Section). Avulsion fractures of the Hip bone and Femur may occur as a result of sudden acceleration or deceleration. B. Femur (longest bone of the body, Thigh Bone) Proximal End Head (smooth rounded prominence, covered in Articular Cartilage, articulates with Lunate Surface of the Acetabulum) 1. Fovea for the Ligament of the Femoral Head b. Neck (stretch of bone between the Femoral Head and Femoral Body) CN: “Hip Fractures” generally erroneously refer to fracture of the Femoral Neck. c. Greater Trochanter (projects superoposterirly, attachment point for the Piriformis M. and Obturator Internus M.) Trochanteric Fossa (depression medial to the Greater Trochanter, attachment point for the Obturator Externus M.) d. Lesser Trochanter (projects medially, attachment point for the Iliopsoas M.) e. Intertrochanteric Crest (ridge joining the Trochanters on the posterior aspect) 1. Quadrate Tubercle (rounded prominence on the Intertrochanteric Crest, attachment point for the Quadratus Femoris M.) Intertrochanteric Line (anterior aspect, attachment point for the large Iliofemoral L., continuous posteriorly around the Femur with the Spiral Line, separates Femoral Neck from Femoral Body) g. Spiral Line (posterior aspect, posteroinferior continuation of the Intertrochanteric Line, becomes the Medial Lip of Linea Aspera) h. Gluteal Tuberosity (posterior aspect, continues inferiorly as Lateral Lip of Linea Aspera, attachment point for the Gluteus Maximus M.) i. Pectineal Line (intermediate ridge on the posterior aspect between the two separating Lips of the Linea Aspera as they transition to the Spiral Line and Gluteal Tuberosity, respectively, extends toward and terminates at the base of the Lesser Trochanter, attachment point for the Pectineus M.) Body (smooth anterior surface, Linea Aspera on the Posterior Surface) Linea Aspera (begins as the Spiral line and Gluteal Tuberosity on the posterior aspect of the Proximal End, extends inferiorly to the Distal End where it divides into Medial and Lateral Supracondylar Lines) Medial Lip (proximally continuous with the Spiral Line, distally continuous with the Medial Supracondylar Line) Lateral Lip (proximally continuous with the Gluteal Tuberosity, distally continuous with the Lateral Supracondylar Line) Distal End Medial Supracondylar Line (continuous superiorly with the Medial Lip of the Linea Aspera) Lateral Supracondylar Line (continuous superiorly with the Lateral Lip of the Linea Aspera) Popliteal Surface (posterior aspect, between Supracondylar Lines) Lateral Femoral Epicondyle (attachment point for the Lateral Collateral L. of the Knee, superior from the Lateral Femoral Condyle) Medial Femoral Epicondyle (more pronounced than the Lateral Femoral Epicondyle, attachment point for the Medial Collateral L. of the Knee) Adductor Tubercle (elevation on the superomedial aspect of the Epicondyle, attachment point for the Adductor Magnus M.) f. Lateral Femoral Condyle (rounded prominence, articulates with Lateral Tibial Condyle and Lateral Meniscus) g. Medial Femoral Condyle (rounded prominence, articulates with Medal Tibial Condyle and Medial Meniscus) h. Intercondylar Fossa (posterior aspect, between Femoral Condyles) i. Patellar Surface (anterior aspect, between Femoral Condyles, covered in Articular Cartilage, articulates with the Articular Surface of the Patella) HN: The Angle of Inclination of the Femur is the Angle between the Long Axis of the Head and Neck and the Long Axis of the body of the Femur. The Torsion Angle of the Femur is the angle that the Head and Neck of the Femur are turned compared to the Femoral Condyles when looking down the Long axis of the Femur. CN: If the Angle of Inclination of the Femur is increased it is a clinical condition known as Coxa Valga, if the angle is decreased the condition is called Coxa Vara. CN: Dislocation of the Epiphysis of the Femoral Head typically occurs in older children and adolescents as a result of excessive shearing force on the epiphyseal plate associated with the Femoral Head. CN: Femoral fractures typically occur at the proximal end and body of the Femur despite the size and strength of the bone. Multiple varieties of Femoral fracture can occur. Patella (largest Sesamoid bone, embedded within tendon, rests anteriorly on the Patellar Surface of the Femur) 1. Base (superior part of the bone, broad and thick, attachment point for the Quadracipital muscles) Apex (pointed inferiorly, attachment point for the Patellar L. extending to the Tibial Tuberosity) Anterior Surface (rounded and roughened, buried in the Quadracipital T.) 4. Posterior Surface (smooth, covered in Articular Cartilage, possesses two facets that slope away from a central longitudinal ridge) a. Lateral Articular Facet (larger than the Medial Facet, articulates with the Patellar Surface of the Femur) b. Medial Articular Facet (articulates with the Patellar Surface of the Femur) CN: Overstressing the knee, or a blow to the Patella can result in Chondromalacia Patellae (Runner’s Knee) and results in soreness and aching around or deep to the Patella. CN: The Patella ossifies between the 3rd and 6th year of life, occasionally the Patella will fail to ossify into a single bone resulting in a Bipartite or Tripartite Patella, which can be confused for a fractured Patella on a radiograph. Tibia (the medial of the two Leg bones, articulates with the Femur proximally and the Talus distally, transmits body weight) Proximal End Lateral Tibial Condyle (articulates with the Lateral Femoral Condyle, possesses a large, flat superior articular surface) Lateral Tibial Plateau (flat, superiorly facing articular surface covered in Articular Cartilage and by the cup shaped fibrocartilaginous Lateral Meniscus) 2. Anterolateral Tibial Tubercle (Of Gerdy) (attachment point for the Iliotibial Tract) 3. Fibular Articular Facet (articulates with the Head of the Fibula) Medial Tibial Condyle (articulates with the Medial Femoral Condyle, possesses a large, flat superior articular surface) 1. Medial Tibial Plateau (flat, superiorly facing articular surface covered in Articular Cartilage and by the cup shaped fibrocartilaginous Medial Meniscus) Intercondylar Eminence (bony elevation between Tibial Condyles, corresponds to the Femoral Intercondylar Fossa) Medial Intercondylar Tubercle (project superiorly, provide attachment points for the Menisci and ligaments of the knee) Lateral Intercondylar Tubercle (project superiorly, provide attachment points for the Menisci and ligaments of the knee) Anterior Intercondylar Area (roughened area anterior to the Intercondylar tubercles providing attachment points for the menisci and ligaments of the Knee) Posterior Intercondylar Area (roughened area posterior to the Intercondylar tubercles providing attachment points for the menisci and ligaments of the Knee Body (vertical in anatomical position, triangular in cross section, possesses an Anterior, Medial and Interosseous Border, that divide the surfaces into Posterior, Medial and Lateral) Tibial Tuberosity (immediately superior to the Anterior Border, rounded broad area, attachment point for the Patellar L.) Soleal Line (oblique line on the posterior aspect, attachment point for the Soleus M.) Distal End (flares out only on the medial side, inferior aspect of the distal end an lateral side of the Medial Malleolus are covered with Articular cartilage and articulate with the Trochlea of the Talus B.) Medial Malleolus (prominent projection of bone, articulates on its lateral surface with the Trochlea of the Talus B.) Groove for the Tibialis Posterior T. (smooth groove that accommodates the Tibialis Posterior T.) c. Fibular Notch (continuous superiorly with the Interosseous Border, accommodates the attachment to the distal end of the Fibula) CN: Tibial fractures may result from a variety of injuries: being hit by the bumper of a car (“bumper” fracture), excessive hiking (“march” fractures), extreme force (“diagonal” fractures) and skiing falls (“boot-top” fracture). CN: Fractures involving the Epiphyseal Plate can lead to a condition known as Osgood-Schatter disease resulting in pain and an overly pronounced Tibial Tuberosity. E. Fibula (the lateral of the two Leg bones, serves as an attachment point for muscles and stabilizes the Ankle Joint, does not bear weight, is firmly attached to the Tibia allowing no movement) Proximal End Head (flared out proximal portion, articulates with the Fibular facet on the Lateral Tibial Condyle) Apex (projects superiorly, attachment point for the Biceps Femoris M.) Neck (stretch of bone between Fibular Head and Fibular Body) Body (shaft) Distal End a. Lateral Malleolus (prominent projection of bone, articulates on its medial surface with the Trochlea of the Talus B., extends more distal than the Medial Malleolus) 1. Malleolar Fossa (depression on the medial side of the Lateral Malleolus, attachment point for the Posterior Talofibular L.) CN: Fibular fractures are often the result of inversion and eversion injuries that lead to the avulsion of the medial and lateral malleoli. CN: Fibular Bone grafts: because the fibula is not primarily weight bearing and well vascularized it can be harvested and used to replace bones that have experienced a debilitating injury. F. Tarsal B. (seven irregularly shaped bones) 1. Talus B. (transfers weight from the Tibia to the Calcaneus and forefoot via the Spring L.) Body (rests superiorly on the Calcaneus) 1. Trochlea of the Talus (superiorly projecting articular surface, articulates laterally and medially with the Lateral and Medial Malleoli respectively) 2. Lateral Malleolar Facet (articulates with the Lateral Malleolus of the Fibula) 3. Medial Malleolar Facet (articulates with the Medial Malleolus of the Tibia) 4. Posterior Process (narrow posterior projection from the Body of the Talus) a. Groove for the Flexor Hallucis Longus T. (accommodates the Flexor Hallucis Longus T.) b. Medial Tubercle (less prominent than the Lateral Tubercle) c. Lateral Tubercle (posteriorly projecting bump) 5. Calcaneal Articular Surface (three facets facing inferiorly that articulate with the Talus) a. Anterior Calcaneal Articular Facet (often described as part of the Head, involved with the Talocalcaneonavicular Joint) b. Middle Calcaneal Articular Facet (often described as part of the Head, involved with the Talocalcaneonavicular Joint) c. Posterior Calcaneal Articular Facet (articulates with the Posterior Talar Articular Facet of the Calcaneus at the Subtalar Joint) Head (projects anteriorly, articulates with the Navicular B. and Calcaneus B. at the Talocalcaneonavicular Joint) Neck (stretch of bone between Talar Head and Talar Body) CN: Fractures of the Talar Neck may result from extreme dorsiflextion as one might experience by pressing extremely hard on the brake pedal of a vehicle during a collision, the resultant collision forces all of the body weight forward resulting in the involuntary extreme dorsiflexion. CN: A secondary ossification site exists between the Lateral Tubercle and the rest of the Talus, occasionally (14-25% of the time) the Lateral Tubercle will not properly untie with the Talus resulting in a loose bone posterior to the Talus called an Os Trigonum. Calcaneus B. (heel bone, largest and strongest bone of the Foot, transmits the majority of the body’s weight from the Talus, articulates superiorly with the Talus B. and anteriorly with the Cuboid B.) Calcaneal Tuberosity (large, rough, weight-bearing prominence, insertion for the Calcaneal T.) 1. Medial Process (contacts the ground when standing) 2. Lateral Process b. Anterior (Calcaneal) Tubercle (on the inferior surface immediately posterior to the Cuboid B.) Sustentaculum Tali (Talar Shelf) (projects from the medial aspect, supports the Talar Head) Fibular Trochlea (rounded oblique elevation on the lateral aspect of the Calcaneus, acts as a pulley for the everters of the Foot) e. Talar Articular Surface (superiorly facing, comprising three facets) 1. Anterior Talar Articular Facet (articulates with the Head of the Talus at the Talocalcaneonavicular Joint) 2. Middle Talar Articular Facet (articulates with the Head of the Talus at the Talocalcaneonavicular Joint) 3. Posterior Talar Articular Facet (articulates with the Posterior Calcaneal Articular Facet of the Talus at the Subtalar Joint) Articular Surface for the Cuboid (articulates with the Cuboid) CN: Calcaneal fractures may occur as the result of a hard fall onto the heel. These fractures are usually debilitating due to the disruption of the Talocalcaneal Joint Navicular B. (on the medial side of the Foot between the Talar Head and the three Cuneiform bones) a. Navicular Tuberosity (medial projection of bone, attachment point for the Tibialis Posterior M.) Cuboid B. (on the lateral side of the foot between the Calcaneus and the Bases of the 4th and 5th Metatarsal bones) a. Tuberosity of the Cuboid (oblique ridge on the inferior aspect of the Cuboid B., posterior to the Groove for the Fibularis Longus T.) Groove for the Fibularis Longus T. (anterior to the Tuberosity of the Cuboid, accommodates the Fibularis Longus T.) Medial Cuneiform B. (largest Cuneiform bone, articulates with the Navicular proximally and Base of the 1st Metatarsal distally) Intermediate Cuneiform B. (smallest cuneiform bone, articulates with the Navicular Proximally and the Base of the 2nd Metatarsal distally) Lateral Cuneiform B. (articulates with the Navicular and Cuboid bones proximally and the Base of the 3rd Metatarsal distally) G. Metatarsal B. (1-5; from medial to lateral) 1. Base (proximal) a. 1st (short and stout, articulates with the Medial Cuneiform B.) b. 2nd (longest of the Metatarsal bones, articulates with the Intermediate Cuneiform B.) 3rd (articulates with the Lateral Cuneiform B.) d. 4th (articulates with the Cuboid B.) e. 5th (articulates with the Cuboid B.) 1. Tuberosity (posterolateral projection of bone on the base of the 5th Metatarsal, attachment point for the Fibularis Brevis M.) Body Head (distal) CN: Fractures of the Metatarsal bones can occur for a variety of reasons: a heavy object falling on the foot (blunt-force fractures), losing one’s balance and putting the full body weight on the Metatarsals (“dancer’s” fractures), Avulsion of the base of the 5th Metatarsal from rolling one’s ankle and fatigue fractures from prolonged walking. H. Sesamoid Bones of the Foot 1. Medial Sesamoid B. (inferior to the Head of the 1st Metatarsal, embedded within Plantar Ligaments) 2. Lateral Sesamoid B. (inferior to the Head of the 1st Metatarsal, embedded within Plantar Ligaments) I. Proximal Phalanges (1-5; from medial to lateral) Base (proximal) Body Head (distal) J. Middle Phalanges (1-4; starting with 2nd Toe, absent in Hallux) Base (proximal) Body Head (distal) K. Distal Phalanges (1-5; from medial to lateral) Base (proximal) Body Head (distal) III. Chondrology A. Interpubic Disc (Fibrocartilaginous disc between right and left Pubic Symphyseal Surfaces) B. Menisci of the Knee Joint 1. Medial Meniscus (“C” shaped Fibrocartilage, thick on the periphery, thin at the interior of the joint, sits on Medial Tibial Plateau, broader posteriorly, attached to the Fibrous Capsule via Coronary L.) 2. Lateral Meniscus (more circular Fibrocartilage, thick on the periphery, thin at the interior of the joint, sits on Lateral Tibial Plateau)