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Definições de marcadores esqueléticos

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  • 1. Copyright ©: the University of Brussels (ULB), Belgium, through Serge VAN SINT JAN, has the full ownership of the 46 pages included in this document (including all texts, images and illustrations). Reproduction of any part for commercial purposes is totally forbidden without the written approval of the main author. © ulb http://www.ulb.ac.beCopyright ©: the University of Brussels (ULB) © ulb
  • 2. Skeletal Landmark Definitions by Serge VAN SINT JAN, PhD This work has been entirely performed at: The Department of Anatomy Faculty of Medicine University of Brussels - ULB Belgium URL: www.ulb.ac.be/~anatemb Email: anatemb@ulb.ac.be Acknowledgments. This document was made possible thanks to the help of my colleagues (by alphabetical order): Mr. Christophe CIAVARELLA, MSc Prof. Véronique FEIPEL, PhD Prof. Stéphane LOURYAN, PhD Mr. Jean-Louis LUFIMPADIO, Msc Prof. Marcel ROOZE, MD, PhD Mr. Patrick SALVIA, PhD Prof. Victor SHOLUKHA, PhD Mr. Stéphane SOBZACK, MScCopyright ©: the University of Brussels (ULB) © ulb
  • 3. Table of Contents Introduction________________________________________________________________________ 4 Sacral Bone________________________________________________________________________ 8 1. Sacrum - Spinous Process of 2nd sacral vertebrae (SS2)[M]____________________________ 10 Iliac Bone ________________________________________________________________________ 11 2. Iliac bone - Anterior Superior iliac spine (IAS)[R, L] ________________________________ 13 3. Iliac bone - Posterior Superior iliac spine (IPS)[R, L] ________________________________ 14 4. Iliac bone - Ischial Tuberosity, inferior angle (IIT)[R, L]______________________________ 15 5. Iliac bone - Pubic sYmphysis, upper edge (IPY)[M] _________________________________ 16 6. Iliac bone - Centre of Acetabulum (IAC)[R, L] _____________________________________ 17 Femur ___________________________________________________________________________ 18 7. Femur - greater Trochanter Center (FTC)[R, L] _____________________________________ 20 8. Femur - tubercle of the Adductor Magnus muscle (FAM)[R, L] ________________________ 21 9. Femur - Medial Epicondyle (FME)[R, L]__________________________________________ 22 10. Femur - Lateral Epicondyle (FLE)[R, L] ________________________________________ 23 11. Femur - antero-Medial ridge of the patellar surface Groove (FMG)[R, L]_______________ 24 12. Femur - antero-Lateral ridge of the patellar surface Groove (FLG)[R, L] _______________ 25 13. Femur - most distal point of the Medial Condyle (FMC)[R, L] _______________________ 26 14. Femur - most distal point of the Lateral Condyle (FLC)[R, L]________________________ 27 15. Femur - Center of Head (FCH)[R, L] ___________________________________________ 28 Tibia ____________________________________________________________________________ 29 16. Tibia - tibial Tuberosity (TTT)[R, L] ___________________________________________ 31 17. Tibia - Medial Ridge of tibial plateau (TMR)[R, L] ________________________________ 32 18. Tibia - Lateral Ridge of tibial plateau (TLR)[R, L] ________________________________ 33 19. Tibia - Gerdy’s Tubercle (TGT)[R, L] __________________________________________ 34 20. Tibia - Apex of the Medial malleolus (TAM)[R, L] ________________________________ 35 Fibula ___________________________________________________________________________ 36 21. Fibula - ApeX of the styloid process (FAX)[R, L] _________________________________ 38 22. Fibula - Apex of the Lateral malleolus (FAL)[R, L]________________________________ 39 Foot_____________________________________________________________________________ 40 23. Foot/Calcaneus - posterior surface (FCC)[R, L] ___________________________________ 42 24. Foot/Calcaneus - Sustentaculum Tali (FST)[R, L] _________________________________ 43 25. Foot/Calcaneus - Peroneal Trochlea (FPT)[R, L] __________________________________ 44 26. Foot/Metatarsus - Tuberosity of 5th metatarsal bone (FMT)[R, L] _____________________ 45 27. Foot/Metatarsus - 1st, 2nd, 3rd, 4th and 5th head (FM1, FM2, FM3, FM4, FM5)[R, L]_______ 46Copyright ©: the University of Brussels (ULB) © ulb
  • 4. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible PalpationIntroduction This document presents definitions for the location of anatomical landmarks. Locating anatomicallandmarks is presented using two protocols: 1) manual palpation that allows spatial location of landmarkswhen combined to three-dimensional (3D) digitizer, and 2) virtual palpation on 3D computer modelsobtained, for example, from medical imaging. Use of standardized definitions allows better result comparison and exchange; this is a key element forpatient follow-up or the elaboration of quality clinical or research databases. This document presents accurateskeletal landmark definitions to help her/him achieving the above goals with better precision, higherreproducibility and therefore, in most cases, less data post-processing. This book includes description for both manual palpation, i.e. using fingertips, and virtual palpation, i.e.using a computer input device like a mouse. Both manual and virtual descriptions of the same landmark havebeen written in order to allow a palpator (i.e., the individual performing the palpation) to decrease thedifference resulting from both kinds of palpation protocols. This should also lead to better results ifcombination of landmarks from both palpation protocols must be performed. Finally, this guidebook would like to emphazise that palpation is an Art, and requests serious practisebefore reaching acceptable accuracy. Unfortunately, palpation is often see as a secondary task probablybecause it is cheap, simple of conception (compared to the costly high-tech hardware used for medicalimaging or to collect motion data) and does not require complicated setting (unlike some state-of-the-artpieces of electronical equipment). The truth is different: spatial location of anatomical landmarks isnecessary for fundamental operations. For example, to measure some bone parameters, to define anatomicalframes in clinical motion analysis, or to perform data registration. Inacurracy in landmark selection willalways lead to serious discrepancies in the interpretation of the data whatever the quality of the hardware usedfor measurements. This document will help the reader to strive into that direction thanks to detailed definitions andinstructions related to palpation of skeletal landmarks. Each landmark is described in a way to increase thereproducibility of its spatial location.Warnings One of the necessary conditions of efficiency of definitions is of course that they are scrupulouslyfollowed to obtain reproducible results. It is also assumed that the palpator is seriously experienced with bothHuman Anatomy and Palpation. The present guidelines aim at proposing accurate definitions to allow a betterrepeatability and communication between scientists. On the other hand this document is neither a HumanAnatomy textbook, nor a guide to learn Manual or Virtual Palpation. The Art of Palpation should be obtainedfrom other sources, if possible, before using the following definitions. The description given in the text for manual palpation assumes that the individual performing thepalpation (named as “the palpator”) uses a special table like those used by physiotherapists to manipulate ©patients. The authors advise to use such table to perform better palpation by allowing the palpated subject tobe in a comfortable position. Muscle tension would therefore be decreased and bony landmarks will be betterpalpable. Relative position of both palpator and palpated subject given in the following descriptions areCopyright ©: the University of Brussels (ULB) 4 ulb
  • 5. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpationindicative althought they are probably the most convenient ones. However, some environments might not letapplying these working position strictly (for example, some settings adopted in a motion analysis lab). Some areas to palpate manually can be painfull, especially where muscles or ligaments are attaching.Sensitive landmarks are indicated in the text. Manual palpation of these landmarks should be gentlyperformed to avoid reactions of the individual being palpated that could compromise any further palpation.New ideas ? Please, send them ! The hope of the author is to keep this document updated with new definitions to follow newstandards and conventions. Therefore, feel free to communicate ideas to improve or to update the content ofthis document. Enjoy the reading! Serge VAN SINT JANCopyright ©: the University of Brussels (ULB) © 5 ulb
  • 6. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible PalpationBone description Landmarks are presented by bone. Each bone section starts with a general presentation of the current boneincluding both bone orientation and a rough description of the position of the bone features used asanatomical landmarks in this document.Landmark description Each anatomical landmark is described in various ways (spatial location, manual palpation, and virtualpalpation) that are related to one another and show some complementary. These descriptions are presented intable format (page 7).All landmarks are related to bony areas that can be palpated in a clinical or research context. Some landmarksare recommended by the various standardization committees of the International Society of Biomechanics(ISB, see http://www.isbweb.org/standards/index.shtml)1 in order to define both local and joint coordinatesystems. Description of such landmarks is indicated by the ISB logo (Figure 1, top). A few of theserecommended landmarks are, according to the author, difficult to palpate manually. Although palpationdirections are given, a warning sign (Figure 2) indicates that manual palpation is not accurate (one warningsign indicates that manual palpation is approximate, two warning signs indicates that accurate manualpalpation is irrealistic). Figure 1. ISB logo Figure 2. Warning signs. Accuracy of such landmark location is either low (one sign) or very poor (two signs). Two signs also indicate that further experimental research should be performed to validate the given definition. Such definitions have been given, despite the inaccuracy, because these landmarks are either recommended in the literature or accessible by palpation but not in an accurate way.1 Also see: - Wu, G., Cavanagh, P., 1995. ISB recommendations for standardization in the reporting of kinematic data. J. Biomech. 28, 1257-1261. © - Wu, G., Siegler, S., Allard, P., Kirtley, C., Leardini, A., Rosenbaum, D., Whittle, M., DLima, D., Cristofolini, L., Witte, H., Schmid, O., Stokes, I., 2002. ISB recommendation on definitions of joint coordinate systems of various joints for the reporting of human joint motion - Part I: ankle, hip, spine. J. Biomech. 35, 543-548. - Wu, G., van der Helm, F.C., Veeger, H., Makhsous, M., Van Roy, P., Anglin, C., Nagels, J., Karduna, A., McQuade, K., Wang, X., Werner, F., Buchholz, B. IN PRESS. ISB recommendation on definitions of joint coordinate systems of various joints for the reporting of human joint motion - Part II: shoulder, elbow, wrist and hand. J. Biomech.Copyright ©: the University of Brussels (ULB) 6 ulb
  • 7. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible PalpationTable format used for landmark description Landmark Name (Landmark Acronym) [side prefix : R, L, M]. “Landmark Name” indicates both bone and landmark name.2 “Landmark acronym” proposes a 3-character acronym for the current landmark.3 “side prefix” indicates if the current landmark is even or odd.4 [link to relevant illustrations] A general anatomical definition to allow the location on a dried bone is given. Manual Palpation Manual palpation definition for the location of the landmarks through soft tissue is given here. The palpation is generally done with either the pulp angle of the fingers. Use of forefinger (sometimes the thumb or the middle finger) is usually adviced. However, the reader should use the finger and pulp area which give her/him the greatest confidence. The subject being palpated is usually lying (prone or supine) to allow muscle relaxation and an easier palpation. These landmarks can be extended to the upright position althought the palpation will then be more difficult. Virtual Palpation Virtual palpation definition proved to be useful when using 3D modeling to locate a landmark (e.g. on data collected from medical imaging). The definition include point of view that must be strictly followed before selecting the landmark of interest. Two different views are sometimes used to compensate the loss of information on the 2D screen during virtual palpation. Virtual palpation is illustrated in this book using accurate 3D models of bones obtained from medical imaging (computed tomography - CT). Table 1. Example of table description (see text for explanation).2 © For example: « Femur - Greater Trochanter ».3 For example: « FTc » for the center of the great trochanter. Each acronym is unique and redundancy has been avoidedwhen writing this document. Using the given acronyms will make sure that all landmarks have different acronyms. Note:the first letter of the acronym is the same as the first letter of the related bone (except for the hand).4 Even markers are characterized with either « L » or « R » (left and right respectively), while odd markers are given by« M » (i.e., middle). The full acronym of each landmark is therefore a 4-character string, e.g. « LFTc » for the center ofthe left great trochanter.Copyright ©: the University of Brussels (ULB) 7 ulb
  • 8. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation Sacral BoneOrientation and general presentation (Figure 3 and Figure 4:The sacral bone has a triangular shape; its base (1) is oriented proximally, while the apex (2) is distal. Thesacral bone is the result of the fusion of five sacral vertebrae (S1 to S5). Therefore, many characteristics ofthis bone are related to features of a ‘normal’ vertebra. The median sacral crest (3) is actually the result ofthe fusion of the spinous processes of the primitive sacral vertebrae. This crest is made of at least threeprominences, i.e. spinous processes (S1, SS2, S3). Note the spinous process of S2 is along a horizontal linepassing through the posterior superior iliac spine of the iliac bone (see this bone, page 11). Both posterior andanterior faces show 4 pairs of sacral foramens (4) (only a few foramens are indicated on the illustrations).The coccyx (5) is below the sacral bone. Other structures: iliac bones (6), femurs (7). 6 6 1 S1 SS2 3 4 S3 4 2 7 5 7 5 Figure 3. The sacral bone (3D model). Left (anterior view, slightly lateral): location in the pelvis. Right (posterior view): sacral bone.Copyright ©: the University of Brussels (ULB) © 8 ulb
  • 9. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 6 1 6 4 5 7 7 1 S1 SS2 3 4 S3 2 Figure 4. The sacral bone (anatomical specimen). Top (anterior view, slightly lateral): location in the pelvis. Bottom (posterior view): posterior aspect.Copyright ©: the University of Brussels (ULB) © 9 ulb
  • 10. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 1. Sacrum - Spinous Process of 2nd sacral vertebrae (SS2)[M] Posterior eminence on the posterior aspect of the Figure 3 and Figure 4, structure SS2. sacral bone. SS2 S L5 1 L4The subject is lying prone. The palpator standing at the subject’s pelvis, one hand placed flat on the lateralsurface of the pelvis (left hand on image). Place the thumb near the spine along a horizontal projection fromthe iliac crest. This projection on the spine (blue arrow) indicates the level of the 4th lumbar vertebra (L4).With the forefinger of the opposite hand, glide down on the spinous process of the 5th lumbar vertebra (L5).Keeping down, the next two bony eminences are respectively S1 and SS2.Control of the selection can be obtained by verifying that the horizontal projection of a line starting from SS2runs through the posterior superior iliac spine (see IAS, page 11). Turn the sacral bone in posterior frontal view. Locate the median sacral S1 crest. Along this crest, S1 select the top of the second spinous process S2, just SS2 proximal to a horizontal plane running through the 2nd pair of posterior SS2 foramens (dotted blue line). Then, turn the bone along a lateral view and control the selected point is on the S2 apex.Copyright ©: the University of Brussels (ULB) © 10 ulb
  • 11. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation Iliac Bone Orientation and general presentation (Figure 5 and Figure 6): To orient the iliac bone, turn the acetabulum (IAC) laterally, the obturator foramen (1) below, and behind the greater sciatic notch (2). The iliac crest (3) is on top. The sharp anterior superior iliac spine (IAS) is located on the anterior aspect of 3. The posterior superior iliac spine (IPS) is located on the other side of 3 and is less sharp. The postero-inferior aspect of the iliac bone shows a large tuberosity: the ischial tuberosity (IIT). Both iliac bones articulate anteriorly by the pubic symphysis (IPY). Each iliac bone articulates with a femur (4) by the joint surface located into IAC. This crescent-shaped joint surface is called the lunate surface (5). 3 IAS IAC 4 4 3 IPY 3 IAS IPSIPS 2 5 2 IAC 1 1 IPY IIT IIT Figure 5. The iliac bone (3D model). Top (anterior view): position in the pelvis. Bottom left (lateral view) and bottom right (medial view): isolated bone. Copyright ©: the University of Brussels (ULB) © 11 ulb
  • 12. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible PalpationIAS IAC IAC 4 IPY 4 A 4 B IPY 4 C D IPS IAS 2 IAS IIT E IAS F 5 1 IAC IIT 1 IPY Figure 6. The iliac bone (anatomical specimens). A (antero-lateral view) and B (anterior view): position in the pelvis. C (latero-superior view): superior landmarks. D (latero-inferior view): the ischial tuberosity. E (anterior © view). F (lateral view): the acetabulum. Copyright ©: the University of Brussels (ULB) 12 ulb
  • 13. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 2. Iliac bone - Anterior Superior iliac spine (IAS)[R, L] Prominent anterior and superior end of the Figure 5 and Figure 6, structure IAS. iliac crest. The subject is lying supine. The palpator facing the subject’s pelvis. Place your hand on the subject’s hip on the side concerned, with your fingers on the anterior part of the iliac crest. Follow the anterior part of the iliac crest forwards IAS (dotted blue arrow). At the anterior extremity of the iliac crest, your thumb will feel a prominent bony bump under which it can get around, below and to the side. This is IAS. [note: IAS is just under the skin and is usually easily palpable; however, this procedure may be more difficult on obese subjects.] Observe the iliac bone from a lateral point of view. Follow anteriorly the anterior part of the iliac crest until IAS (dotted blue arrow). IAS Then turn the model 90° to an anterior frontal view, and make sure the selected landmark is IAS correctly located on the center of AS.Copyright ©: the University of Brussels (ULB) © 13 ulb
  • 14. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 3. Iliac bone - Posterior Superior iliac spine (IPS)[R, L] Prominent posterior and superior end of the Figure 5 and Figure 6, structure IPS. iliac crest. The subject is lying prone. The palpator standing at the subject’s pelvis, hand placed flat on the lateral surface of the pelvis. Place your thumb on the posterior part of the IPS iliac crest. Move backwards over the iliac crest just to the point where the thumb feels a prominent bump: IPS. Observe the iliac bone from a lateral view. Go backwards (dotted blue arrow) on the posterior part of the iliac crest until IPS is met. IPS Next, rotate the model 90° along a posterior frontal view, and control the selected landmark is correctly located on the center of IPS the posterior spine.Copyright ©: the University of Brussels (ULB) © 14 ulb
  • 15. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 4. Iliac bone - Ischial Tuberosity, inferior angle (IIT)[R, L] Figure 5 and Figure 6, structure IIT. Large posterior tuberosity of the ischium. The subject is lying prone. The palpator stands next to the subject’s knees. Place your forearm along the thigh axis, and the hand flat on the lateral part of the buttocks-thigh junction IIT (i.e., buttocks fold, dotted blue line). With the thumb, spread from the hand, goes up and pass under the inferior edge of the gluteus major muscle. The thumb reached the inferior angle of the ischium (IIT). [tip: to control the selection palpate both medial and lateral edges of the ischium. Then follow these edges down to their junction, which is the inferior angle.] Observe the iliac bone from a posterio-lateral point of view. Follow both medial and lateral edges (dotted arrows) of the ischium to their intersection, which is ITT. IIT To verify your selection, turn the model approximately 45° towards the back of the screen. The selected point should be on the angle made by the medial and lateral edges of the ischium. IITCopyright ©: the University of Brussels (ULB) © 15 ulb
  • 16. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 5. Iliac bone - Pubic sYmphysis, upper edge (IPY)[M] The pubic symphysis is the anterior joint Figure 5 and Figure 6, structure IPY. between the two iliac bones. The subject is lying supine. The palpator standing next to the subject’s pelvis, hand IPY placed flat on the belly. Put one thumb on the central part of the belly above the pubic symphysis. With the thumb, gently depress the belly and glides down towards the pubic symphysis (blue dotted area). Find the upper edge of the latter and select its anterior part. IPY is not directly observable on a 3D bone model and must be interpolated. At first, turn the iliac bone to an anterior frontal view. Select a point on each iliac bone next to the pubic symphysis. Next, turn the bones to an RIPY LIPY upper view, and check both selected landmarks (LPY and RPY) are correctly located on the anterior edge of bone. IPY is the average of the spatial coordinates of both RIPY LIPY LIPY and RIPY landmarks. [note: IPY is usually not directly available from CT imaging because © it is made of fibrous tissu and cartilage, which are not very X-ray sensitive. This explains the gap visible between both iliac bones on the illustrations.]Copyright ©: the University of Brussels (ULB) 16 ulb
  • 17. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 6. Iliac bone - Centre of Acetabulum (IAC)[R, L] The acetabulum is the hip component of the hip joint. Figure 5 and Figure 6, structure IAC.This point is not palpable and is found after interpolation only. Because of the limitations of the manual palpation, IAC isassumed equal to the centre of the femoral head (see FCH landmark, page 28). This is not the case when using virtualpalpation (see below). An estimation of IAC can be found by averaging the spatial coordinates of the following 6 ACi points all located along the circumference of the AC4 AC3 lunate surface (Figure 5, structure 5) within the acetabulum: AC5 AC2 1. anterior edge of the lunate surface (AC1). 2. center of anterior wall (AC2). 3. anterior part of roof (AC3). AC6 4. posterior part of roof (AC4). AC1 5. center of posterior wall (AC5). 6. posterior edge of the lunate surface (AC6). AC3 AC4 AC5 AC2 AC1 AC6 Copyright ©: the University of Brussels (ULB) © 17 ulb
  • 18. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible PalpationFemurOrientation and standard presentation (Figure 7 and Figure 8):The head of the femur (FCH) is oriented upwards and medially; it is part of the hip joint (1). The femoralhead is linked to the greater trochanter (FT) by the femoral neck (2). The inferior epiphysis shows aposterior notch: the intercondylar notch (3). On both sides of the latter are the lateral (FLC) and medial(FMC) condyles. Each condyle shows an epicondyle (FLE or FME). The lower part (anterior aspect) of thefemur supports the patellar groove (4) making up the femoral-patellar joint. This groove shows two edges:one lateral (FLG) and one medial (FMG). FT FT 2 2 1 FCH FME FLE FLE 4 FME 3 FLG FMG FME FLE 4 FLC FMC Figure 7. The femur (3D model). Top left (anterior view): femur with pelvic bone, patella and tibia. Top center (anterior view) and top right (posterior view): isolated bone. Bottom left (anterior view), bottom center (anterior view), bottm right (medial view): distal epiphysis.Copyright ©: the University of Brussels (ULB) © 18 ulb 3
  • 19. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation FT FCH FCH FT FT 2 FME A B C D E F G H FLG FMGFLE FME FLE 4 3 FLC I FLC FMC FPS FLC FME FMC Figure 8. The femur (anatomical specimen). A (anterior wiew) and B (posterior view): full bone. C (anterior view) and D (lateral view): proximal epiphysis. E (anterior view), F (medial view), G (posterior view), H (lateral view) and I (distal view): distal epiphysis.Copyright ©: the University of Brussels (ULB) ©19 ulb
  • 20. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 7. Femur - greater Trochanter Center (FTC)[R, L] Massive quadri-angular tubercle that extends to the top of the Figure 7 and Figure 8, structure FTC. lateral face of the femoral diaphysis. It has three edges: superior, anterior and posterior. FTCThe subject is standing and the palpator behind him. The subject’s leg is slightly flexed and in abduction (foot on asupport).Place first one thumb on the iliac crest (dotted line); the little finger meets the great trochanter. Once this performed, amore accurate palpation is done with the three first fingers.Both thumb and middle fingers pinch the greater trochanter on its posterior and anterior edges respectively. Place theindex finger in the middle of the virtual line traced between the thumb. The FTC landmark is pinpointed by the indexfinger between both thumb and middle finger.[note: with accuracy when soft tissue is well-develloped.] Turn the femur to a lateral view (in this position the femoral head is normally pointing forwards and both condyles are aligned). Locate the center of both anterior and posterior edges (dotted FTC lines) of the great trochanter. The FTC landmark is located at the center of the great trochanter between both edge centers. Copyright ©: the University of Brussels (ULB) © 20 ulb
  • 21. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 8. Femur - tubercle of the Adductor Magnus muscle (FAM)[R, L] Bony spine situated on the superior edge of Figure 7 and Figure 8, structure FAM. the medial condyle of the femur. The subject is lying supine, knees extended, the palpator at the subject’s knees. Place the palm of the medial hand on the FAM proximal tibial epiphysis in order to have both fourth and fifth finger located behind the knee. The second and third fingers of the medial hand searches for the tendon of the adductor magnus muscle (dotted blue arrow). Followed the latter until FAM is reached. [note: this tendon insertion is sometimes sensitive.] Observe the femur from a posterior (slightly medial) view. FAM FAM FAM is on the center of a protuberance above the medial condyle. Turn to a posterior view to verify the selection.Copyright ©: the University of Brussels (ULB) © 21 ulb
  • 22. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 9. Femur - Medial Epicondyle (FME)[R, L] This surface shows a small tubercle for the Figure 7 and Figure 8, structure FME. medial collateral ligament of the knee. The subject is lying supine, knee extended. Place the thumb on FAM (see page 21) and FME the middle finger on the knee joint (vertically FAM along the virtual line running through FAM). Place the index finger midway between the thumb and the middle finger and move it slightly forwards (towards the patella). The index finger should locate a small tubercle, which is FME. [note: this point can be sensitive.] FAM View the distal epiphysis from a medio-sagittal view. Find the center of the medial condyle at the intersection of the following virtual lines: − a vertical line starting at FAM (see page 21), FME − an horizontal line passing by the centre of the posterior and anterior edges of the condyle. In relation to this intersection, the landmark to select is found slightly FME forwards. Verify the validity of the landmark by turning the bone in a posterior- frontal view. Check the selected point is on the apex of the condyle.Copyright ©: the University of Brussels (ULB) © 22 ulb
  • 23. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 10. Femur - Lateral Epicondyle (FLE)[R, L] The lateral condyle is a bony surface located Figure 7 and Figure 8, structure FLE. laterally on the distal epiphysis of the femur. This surface shows a crest. The subject is lying supine, knee flexed. FLE Put your finger in the knee joint space and glide backwards until you meet the lateral collateral ligament. Follow the ligament up to its proximal insertion point, which is the FLE. Observe the distal epiphysis from a lateral point of view. Locate a bumpy tubercle near the centre of the lateral condyle. This tubercle is along a horizontal line running between the furthest FLE points of the condyle. Select the apex of the tubercle (FLE). Once the tubercle in selected, observe the selection from an antero-frontal point of view to control that FLE is on the apex of FLE epicondyle.Copyright ©: the University of Brussels (ULB) © 23 ulb
  • 24. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 11. Femur - antero-Medial ridge of the patellar surface Groove (FMG)[R, L] Bony angle located in the upper medial area of the Figure 7 and Figure 8, structure FMG. patellar surface. The subject is lying supine, knees extended. With the thumb of the proximal hand on the central part of the lateral edge of the patella, push the patella laterally (dotted blue arrow). FMG The thumb of the distal hand passes under the patella, and palpates the sharp edge of the patellar groove until an angle is found: FMG. Observe the distal epiphysis from an antero- frontal view. FLG From the most distal point of the inner edge of FMG the patellar surface, follow this edge up (dotted arrowed line). This inner edge bends forming an angle; this angle is FMG. [note: FMG is located more distally then FLG (see page 25).]Copyright ©: the University of Brussels (ULB) © 24 ulb
  • 25. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 12. Femur - antero-Lateral ridge of the patellar surface Groove (FLG)[R, L] Bony angle located in the upper lateral area of the Figure 7 and Figure 8, structure FLG. patellar surface. The subject is lying supine, knees extended. With the thumb of the proximal hand on the central part of the lateral edge of the patella, push the patella medially (dotted blue arrow). The thumb of FLG the distal hand passes under the kneecap, and palpates the patellar groove until an angle is found: FLG. [note: this point is difficult to palpate because of the orientation of the lateral aspect of the patellar surface.] Place the distal extremity of the femur in an anterior-frontal view. FLG From the most distal point of the lateral edge of the FMG patellar groove, follow this edge up (dotted arrowed line). This edge bends forming an angle; this angle is the FLG. [note: FLG is located more proximally then FMG (see page 24).]Copyright ©: the University of Brussels (ULB) © 25 ulb
  • 26. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 13. Femur - most distal point of the Medial Condyle (FMC)[R, L] The point is located on the distal extremity of Figure 7 and Figure 8, structure FMC. the medial condyle of the femur. The subject is lying supine, with the hip FMC flexed (100°) and the knee bent (120°). The hip flexion compensates partially for the quadriceps tension resulting from the knee flexion. This facilitates the palpation of the landmark. Follow the medial edge of the patellar tendon (dotted blue arrow) and follow it until you reach the knee joint space. Press the thumb into the joint cavity to palpate FMC. [note: FMC is difficult to palpate with accuracy because of the presence of the infrapatellar fat pad filling the space behind the patellar ligament.] View the femur from a medio- sagittal view with the femoral shaft FMC vertical. Rotate the femur along the plane perpendicular to the screen and visualize the distal aspect of the bone in a horizontal view. Select the center of the medial condyle. Then, rotate the femur back to a medio-sagittal view. Check that the selected landmark is well the most distal part of the medial condyle. © FMCCopyright ©: the University of Brussels (ULB) 26 ulb
  • 27. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 14. Femur - most distal point of the Lateral Condyle (FLC)[R, L] The point is located on the distal extremity of Figure 7 and Figure 8, structure FLC. the lateral condyle of the femur. The subject is lying supine, with the hip flexed (100°) and the knee bent (120°). The hip flexion compensates partially for the quadriceps tension resulting from the knee flexion. This facilitates the palpation of the FLC landmark. Follow the lateral edge of the patellar tendon (dotted blue arrow) and follow it until you reach the knee joint space. Press the thumb into the joint cavity to palpate FLC. [note: FLC is difficult to palpate with accuracy because of the presence of the infrapatellar fat pad filling the space behind the patellar ligament.] FLC View the femur from a latero-sagittal view with the femoral shaft vertical. Rotate the femur along the plane perpendicular to the screen and visualize the distal aspect of the bone in a horizontal view. Select the center of the lateral condyle. Then, rotate the femur back to a latero- sagittal view. Check that the selected landmark is well the most distal part of the lateral condyle. FLCCopyright ©: the University of Brussels (ULB) © 27 ulb
  • 28. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 15. Femur - Center of Head (FCH)[R, L] Spherical structure located on the proximal Figure 7 and Figure 8, structure FCH. epiphysis of the femur. It is part of the hip joint. This point is not palpable and is found after interpolation (Bell LIPS et al., 1990, Journal of Biomechanics, 23:617-621): RIPS • At first, a pelvic frame is defined: Op is the origin located LIAS between both LIAS and RIAS (see page 13 for description); Zp isRIAS oriented as the line passing through both IAS’s pointing from left Op to right; Xp lies in the plane defined by both IAS’s and the midpoint between the LIPS and RIPS (see page 14), Xp points forwards; Yp is orthogonal to the XZ plan. • RFCH and LFCH are given by: x = -019D; y = -0.3D; z = i 0.36 D, where D = distance between both IAS’s, i = -1 for LFCH and RFCH LFCH i = 1 for RFCH. FCH1 A good estimation of FCH can be FCH2 found by averaging the spatial FCH5 coordinates of the following 6 points FCH4 all located around the femoral head: 1. top (FCH1). 2. anterior (FCH2). FCH6 3. bottom (next to the neck)(FCH3). 4. posterior (FCH4). FCH3 5. lateral (above the neck)(FCH5). 6. medial (FCH6). [top left: anterior view; top right: medial view; bottom: posterior view with transparent femur to visualize the estimated FCH] FCHCopyright ©: the University of Brussels (ULB) © 28 ulb
  • 29. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible PalpationTibiaOrientation and general presentation (Figure 9 and Figure 10):The proximal epiphysis of the tibia shows the tibial plateau (1). The plateau shows two well-marked edges:one lateral (TLR) and one medial (TMR). Two tubercles are visible on the plateau: the lateralintercondylar tubercle (2) and the medial intercondylar tubercle (3). Anteriorly, a sharp tibial crest (fullline) is easily observable. The tibial tuberosity (TTT) is observable at the proximal end of the tibial crest.From TT, two crests climb upwards towards the tibial plateau; the lateral crest (dotted line) is usuallysharper than the medial one. The Gerdy’s tubercle (TGT) is along the latter crest. The distal epiphysiscarries the medial malleolus (TAM). 2 3 2 3 TLR 1 TLR 1 TGT TMR TT TAM © Figure 9. Tibia (3D model). Left (ventral view, slightly medial) and right (dorsal view): isolated bone.Copyright ©: the University of Brussels (ULB) 29 ulb
  • 30. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation TMR TLR 1 1 TTT TTT A B C 1 TMR TLR 3 2 TAM TMR TLR TGT TTT D E TAMFigure 10. Tibia. A (anterior view) and B (posterior view): general view. C (proximal view): the tibial plateau. D (anterior view): proximal epiphysis. E (medial view): the medial malleolus.Copyright ©: the University of Brussels (ULB) © 30 ulb
  • 31. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 16. Tibia - tibial Tuberosity (TTT)[R, L] Three points are palpated. Figure 9 and Figure 10, structure TTT Prominent oval tuberosity located at the superior extremity of the anterior tibial aspect. The patellar tendon inserts on this tuberosity. The subject is lying supine, knee extended. Gently pinch the patellar tendon between the thumb and the middle finger; follow distally the tendon until its insertion on the tibial tuberosity. The thumb and the middle finger are located on each side of the tuberosity on its lateral and medial edges respectively. TTT Once this manoeuvre is completed, place the index finger between the thumb and the middle finger; this is TTT. View the upper extremity of the tibia from an anterior view; locate a bony oval bump TTT on the anterior and proximal aspect of the tibia: the tibial tuberosity. The center of both lateral and medial edges of the tuberosity are first located. Then, find TTT at the intersection of an horizontal line running through both above-located points.Copyright ©: the University of Brussels (ULB) © 31 ulb
  • 32. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 17. Tibia - Medial Ridge of tibial plateau (TMR)[R, L] Point situated on the medial edge of the tibial Figure 9 and Figure 10, structure TMR. plateau and the furthest point from the medial intercondylar tubercle. The subject bends his knee to 90°; the palpator is in front of the subject. Place the 1st and 3rd fingers on the lateral and medial edges of the patellar tendon respectively (at the level of the tibial plateau). TMR The two fingers then glides backwards along the tibial plateau and reach for the greatest distance between both fingers. Once the greatest distance is found, press the middle finger on the surface of the tibial plateau to find TMR. Orientate the tibial plateau in a superior horizontal view. Draw a line running through 2 both lateral and medial intercondylar 3 tubercles (2 and 3, respectively, see also Figure 9). TMR is the most medial point of that line on the edge of the tibial plateau. TMR View the tibial plateau from a medial point of view. Make sure the selected point is slightly below the medial aspect of the tibial plateau.Copyright ©: the University of Brussels (ULB) © 32 ulb
  • 33. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 18. Tibia - Lateral Ridge of tibial plateau (TLR)[R, L] Point situated on the lateral edge of the tibial Figure 9 and Figure 10, structure TLR. plateau and the furthest point from the lateral intercondylar tubercle. The subject bends his knee to 90°; the palpator is in front of the subject. Place the 1st and 3rd fingers on the medial and lateral edges of the patellar tendon TLR respectively (at the level of the tibial plateau). The two fingers then glides backwards along the tibial plateau and reach for the greatest distance between both fingers. Once the greatest distance is found, press the middle finger on the surface of the tibial plateau to find TLR. [tip: if possible locate both TLR and TMR (see page 32) simultaneously.] 2 3 Orientate the tibial plateau in a superior TLR horizontal view. Draw a line running through both lateral and medial intercondylar tubercles (2 and 3, respectively, see also Figure 9). TLR is the most lateral point of that line on the edge of the tibial plateau. TLR View the tibial plateau from a lateral point of view. Make sure the selected point is slightly below the lateral aspect of the tibial plateau.Copyright ©: the University of Brussels (ULB) © 33 ulb
  • 34. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 19. Tibia - Gerdy’s Tubercle (TGT)[R, L] Tubercle located on the lateral aspect of the Figure 9 and Figure 10, structure TGT. tibial tuberosity. The iliotibial tract of the fascia lata inserts on this tubercle. TTl Locate first the lateral edge of the tibial tuberosity, (TTl, page 31). Then, from this point, two bony ridges start: one medial and one lateral. Follow the TGT lateral one until a thick tubercle is located: this is TGT. [note: the development of the Gerdy’s tubercle is variable. It is usually well palpable.] TGT View the upper extremity of the tibia from an anterior view; locate first TTl (see page 31). From TTl, follow a curved bony edge (dotted blue arrow) running laterally upward until a tubercule (its development is variable) is found: TGT. TTlCopyright ©: the University of Brussels (ULB) © 34 ulb
  • 35. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 20. Tibia - Apex of the Medial malleolus (TAM)[R, L] The medial malleolus, located distally on the Figure 9 and Figure 10, structure TAM. medial aspect the leg, is larger, less prominent, and shorter than the lateral malleolus. The subject is lying supine, the palpator facing the subject’s leg. Place the 1st and 2nd fingers on the anterior and posterior aspects of the medial malleolus respectively. TAM Move both fingers distally along the malleolus edges. The fingers when both edges are joining (white dot in image): the junction point is TAM. [note: the palpated point is not strictly spoken the real apex of the malleolus; indeed the latter is located deeper in the soft tissue. This must be kept in mind if virtual palpation is also performed (see below).] View the lower part of the tibia along medio-sagittal view. Select a point of the TAM malleolus slightly above its apex. Then, turn the tibia to a distal horizontal view. Verify that the selected point is located TAM slightly medially next to the real apex of the medial malleolus.Copyright ©: the University of Brussels (ULB) © 35 ulb
  • 36. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible PalpationFibulaOrientation and general presentation (Figure 11 and Figure 12):The fibula is located lateral and posterior to the tibia. The distal epiphysis (1) is flatter than the proximalepiphysis (2). The distal epiphysis shows the lateral malleolus (FAL). The articular facet of the talofibularjoint (3) is oriented medially, while the malleolar fossa (4) of the lateral malleolus is located behind the jointsurface. The fibula head has a styloid process (5) pointing upwards and showing a sharp fibula apex (FAX).Vertically below the lateral aspect of the head, the lateral edge (dotted line) runs downwards. FAX FAX 2 2 5 3 1 1 4 FALFigure 11. Fibula (3D model). Left (lateral view): fibula and tibia (semi-transparent). Right (medial view): isolated fibula.Copyright ©: the University of Brussels (ULB) © 36 ulb
  • 37. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 2 A 3 4 FAX B C 2 1 FAL Figure 12. Fibula (anatomical specimen). A (medial view): general view. B (lateral view): proximal epiphysis. C (lateral view): distal epiphysis.Copyright ©: the University of Brussels (ULB) © 37 ulb
  • 38. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 21. Fibula - ApeX of the styloid process (FAX)[R, L] Bony eminence located on the dorsal aspect Figure 11 and Figure 12, structure FAX. of the fibula head (structure 2, Figure 11). Both biceps femoris muscle and lateral collateral ligament insert on the head next to styloid process. The head of the fibula is visible under the skin when the knee is flexed with an internal rotation of leg. FAX The subject, lying supine, flexes his knee at about 90°, the palpator standing slightly lateral in front of the knee. Follow the tendon of the femoral biceps (dotted blue arrow) with your index finger until its insertion. FAX is the most lateral and posterior part of the fibula head next to the tendon. [note: the palpated point is not strictly spoken the real apex of the fibula head; indeed the latter is located deeper within the tendon of the femoral biceps. This must be kept in mind if virtual palpation is also performed (see below).]FAX Observe the proximal epiphysis of the fibula along a lateral sagittal view. Select a point slightly below the apex of the styloid process. Then turn, the bone in a proximal horizontal view and verify that the selected point is located slightly laterally to the apex. FAXCopyright ©: the University of Brussels (ULB) © 38 ulb
  • 39. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 22. Fibula - Apex of the Lateral malleolus (FAL)[R, L] The lateral malleolus presents a triangular prismatic form with both anterior and posterior Figure 11 and Figure 12, structure FAL. edges. Both edges join at the apex of the malleolus. In neutral position of the foot, the lateral malleolus is about 2 cm lower than the medial malleolus. The subject, lying supine, has his feet in a neutral position; the palpator facing the feet of the subject. Place your index finger on the posterior edge of the malleolus and your thumb on the anterior edge of the malleolus. Follow both edges distally until their junction FAL (black dot on image). The later is the apex of the malleolus: FAL. [note: the palpated point is not strictly spoken the real apex of the malleolus; indeed the latter is located deeper in the soft tissue. This must be kept in mind if virtual palpation is also performed (see below).] View the distal epiphysis along a latero-sagittal view. Select a point of the malleolus slightly above its apex. FAL Then, turn the fibula into a distal and horizontal FAL view. Verify that the selected point is located slightly laterally next to the apex of the lateral malleolus.Copyright ©: the University of Brussels (ULB) © 39 ulb
  • 40. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible PalpationFootOrientation and general presentation (Figure 13 and Figure 14):The bony foot consists of the seven tarsal bones, the five metatarsals and the phalanxes. The tarsus consists ofthe following bones: talus (1), calcaneus (2), navicular (3), cuboid (4), medial cuneiform (5), intermediatecuneiform (6) and lateral cuneiform (7). The five metatarsal bones (M1→M5) support the digital raysthrough the metarsophalangeal joints (FM1→FM5). The calcaneus presents a large posterior surface(FCC) and a prominent tubercle, the sustentaculum tali (FST) on its medial aspect. On its lateral aspect thecalcaneus shows the peroneal trochlea (FPT). The thickest digital ray is the hallux (8), which is medial. Thebasis of the 5th metatarsal bone supports a sharp tuberosity (FMT). 1 3 4 7 2 FM5 M5 FPT FMT 3 1 FM1 5 M1 2 8 FST FCC FM1 8 5 M1 1 3 6 M2 FM2 M3 FM3 2 7 M4 FM4 4 M5 FM5 FPT FMTFigure 13. Foot bones (3D model). Top (lateral view), center (medial view), and bottom (superior view): entire foot.Copyright ©: the University of Brussels (ULB) © 40 ulb
  • 41. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation A 1 3 7 4 2 M5 FPT FMT B 1 3 5 M1 2 FST FCC 9 FM1 C 8 5 M1 FM2 1 3 6 M2 FM3 2 7 M3 4 M4 M5 FM4 FPT FMT FM5 Figure 14. Foot bones (anatomical specimens). A (lateral view), B (medial view) and C (superior view).Copyright ©: the University of Brussels (ULB) ©41 ulb
  • 42. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 23. Foot/Calcaneus - posterior surface (FCC)[R, L] The posterior face of the calcaneus can be described as a square with four edges. Figure 13 and Figure 14, structure FCC. Both medial and lateral edges of the square are well observable. The subject is lying prone, feet slightly extended and at rest. Slightly pinch both lateral and medial edges of the Achilles tendon between your thumb and middle finger. Then, follow distally the edges until you reach the upper ridge of the calcaneus (dotted blue arrows). Move your fingers further until you reach the center of both medial and lateral calcaneus edges. FCC is located by pushing your forefinger FCC centrally between your thumb and middle finger. [note: the upper rigde of the posterior face of the calcaneus is difficult to palpate with accuracy because of the insertion of the calcaneal (Achilles) tendon.] View the calcaneus bone from a medial point of view and select the center of the medial edge. Repeat the selection from a lateral point of view for the lateral edge. View then the calcaneus from from posterior view. FCC is located on the posterior surface at the center of an horizontal line between both above- selected points. © FCCCopyright ©: the University of Brussels (ULB) 42 ulb
  • 43. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 24. Foot/Calcaneus - Sustentaculum Tali (FST)[R, L] The sustentaculum tali is a prominent tubercle at the medial aspect of the calcaneus. It also supports the medial part of the antero-medial Figure 13 and Figure 14, structure FST. joint surface of the talus. It is located on the border joining the superior and medial surfaces of the calcaneus. The subject is lying supine. From TAM (see page 35), move distally in direction of the medial border of the foot. The tubercle located one finger-width distally to TAM is the posterior edge of the sustentaculum tali. FST TAM Leave the index on this point and move the thumb anteriorly and distally to the anterior edge of the sustentaculum (about one finger- width). The mid-point between the posterior and anterior edges constitutes FST. FST View the foot along a medial sagittal view. Select the center of the sustentaculum tali. FST Then, view the foot along a distal horizontal view. Control the located point is on the most prominent aspect of the sustentaculum tali.Copyright ©: the University of Brussels (ULB) © 43 ulb
  • 44. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 25. Foot/Calcaneus - Peroneal Trochlea (FPT)[R, L] The peroneal trochlea (tubercle) is an oblong ridge process of the lateral surface of the calcaneus. It separates the tendons of peroneus longus and brevis Figure 13 and Figure 14, structure FPT. muscles. This ridge has an oblique orientation (downwards and anteriorly). [note: another tubercle, for the calcaneofibular ligament insertion, can also be present on the lateral aspect of the calcaneus. This tubercle is more dorsal and posterior compared to FPT.] The subject is lying supine, the palpator is lateral to the foot being palpated. Make sure that the peroneus muscles are relaxed. Place FPT your index finger on FAL (see page 39) and move FAL distally (downwards) and slightly anteriorly of about one finger-width. A small ridge is met. Select its centre. [note: keep in mind the variable development of a tubercle for the calcaneofibular ligament, see above note. Do not confuse the latter with FPT.] Place the foot in lateral sagittal view, locate the lateral surface of the calcaneus. Select the midpoint FPT of the peroneal trochlea. Then, turn the foot 90° to an inferior horizontal view and verify that the selected point is located on the central, prominent part of the trochlea. FPT [note: in some instances, the inferior view will show two tubercles on the lateral calcaneus. The peroneal trochlea is the most anterior of these processes (also see above notes).]Copyright ©: the University of Brussels (ULB) © 44 ulb
  • 45. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation 26. Foot/Metatarsus - Tuberosity of 5th metatarsal bone (FMT)[R, L] This tuberosity is located at the base (proximal end) of the 5th metacarpal bone (M5). It forms the midpoint of the lateral border of the foot. Figure 13 and Figure 14, structure FMT Also see Figure 13, structure FMT. [note: the tendon of the peroneus brevis muscle inserts on this tuberosity apex. This real apex of this tuberosity is therefore hidden in the tendon.] The subject is lying in supine position. Place the thumb on the FAL (see page 39), and FAL move it distally to the lateral border of the foot (dotted blue arrow). Follow this border anteriorly. FMT Midway between the heel and the 5th toe, the thumb hits the tuberosity. FMT is the posterior top of the tuberosity, the first point hit by the thumb. [note: the palpated point is not strictly spoken the real apex of the tuberosity; indeed the latter is located deeper in the soft tissue. This must be kept in mind if virtual palpation is also performed (see below).] Place the foot in lateral sagittal view (slightly posterior). Locate the tuberosity of the fifth metatarsal bone, and select the point located just outside the tuberosity apex. FMT Then, view the foot 90° along a superior horizontal view, and verify that the selected point is next to the tuberosity apex. FMTCopyright ©: the University of Brussels (ULB) © 45 ulb
  • 46. Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation27. Foot/Metatarsus - 1st, 2nd, 3rd, 4th and 5th head (FM1, FM2, FM3, FM4, FM5)[R, L] The head of a metatarsal bone is the anteriorFigure 13 and Figure 14, structure FM1, FM2, FM3, extremity of this bone, articulating with the first FM4, FM5 phalanx of the digital ray. For each digital ray, process as following. FM1 The subject is lying supine, the palpator standing contra-laterally to the foot being palpated. Take the first phalanx of the digital ray between the caudal thumb and index. Take the metacarpal head between the cranial thumb and index, with the thumb on the dorsal portion of the metacarpal bone. Move the phalanx in flexion and extension to locate the center of the dorsal aspect of the metatarsal head. This point is the landmark to select. FM1 FM1 For each digital ray, process as following. View the foot along a dorsal (superior) horizontal view. Select the most central point of the metacarpal head (here FM1). FM5 Then, view the foot along a medial sagittal FM4 view. Check that the selected point is the most FM3 prominent point of the margin between the joint surface and the dorsal surface. FM2 FM1 [note: FM2 is the most distal point; FM5 is the most proximal point.]Copyright ©: the University of Brussels (ULB) © 46 ulb