Radiological anatomy of the Lower limb

1. Radiology of the Lower Extremity
DR. ASIF ALI KHAN
AUTHOR OF DOD TREATMENT GUIDE
J.P
.M.C KARACHI

2. Radiology of the Lower Extremity
 1-To correlate bone with the X Ray.
 2- To identify the bone and joint in X-ray.
 3- To know the different views of the X ray.
 4- To identify the different directions on X Ray.
LEARNING OBJECTIVES

3. INTRODUCTION:
 Radiological examination of the lower limb concentrates mainly on the bony structures,
since the muscles, tendons and nerves blend into a homogeneous mass.
 Blood vessels may be visualized by using special contrast media.
 A student must be cognizant of the age changes that take place in the body and how
these will influence the radiographic appearances.
 For example, knowing the times at which the primary and secondary centers of
ossification appear in the different bones, and the dates at which they fuse, is essential
since without this information an epiphysis line could be mistaken for a fracture.
 Remember that a person has two lower limbs, and that the normal side may serve as a
baseline for comparison with the potentially abnormal side.

4. HOW TO READ AN X-RAY:
 Patients
 Soft tissues
 Bones
 Joints
 Diagnostic Association.
The process of reading X-ray film should be as methodical as clinical
examination. A convenient sequence for examination is;

5.  Make sure that the name on the film is that of your patients; mistaken
identity is a potent source of error. Then try to look through the film
and to visualize the living person, especially the age, build and sex.
PATIENTS:
SOFT TISSUES:
 Look for variation in shape in density.
BONES:
 When studying the bones and joint, establish a search pattern based on
the local Anatomy. Throughout this search we record abnormalities of
shape, density and architecture.
Examine carefully Periosteal surface, Cortex and Endosteum

6.  The radiographic “joint” consists of the articulating bones and
space between them. The articular cartilage is radiolucent, varies in
thickness 1 – 8 mm.
 It looks much wider in children than in adults because much of the
epiphysis is still cartilaginous and therefore radiolucent.
JOINTS:
DIAGNOSTIC ASSOCIATION:
 The search for associated abnormalities, or clarification of some
poorly observed feature in the plain film, may call for further
examination by one of the other imaging techniques.

7. X-Ray - Rule of Two
 Two views - AP and Lateral
 Two limbs – Compare
 Two views – one view is always one view too few
 Two abnormalities – if you see one abnormality, always look for a second
 Two joints – image the joint above and below
 Two sides – if not sure or difficult X ray, compare with other side
 Two occasions – always compare with old films IF available, repeat x- rays
 Two visits – bring patient back for repeat examination
 Two opinions Two records – always ask a colleague if not sure & record findings
 Two specialists – always get your ED specialist & a radiologist’s opinion
 Two investigations – always consider whether US, CT or MRI would help in diagnosis Rule of
Two

8. Anatomy of Lower Extremity
The lower limb, or extremity, and its girdle are studied in four parts:
 (1) foot,
 (2) leg,
 (3) thigh, and
 (4) hip.
The bones are composed, shaped, and placed so that they can carry the
body in the upright position and transmit its weight to the ground with a
minimal amount of stress to the individual parts.

9. Anterior-Posterior View of Lower Limb

10. RADIOGRAPHIC APPEARANCES OF THE HIP REGION
 In AP view first, examine the relevant features seen in the pelvis, sacrum
and sacroiliac joints. The iliopectineal line and the symphysis pubis are well
shown. The boundaries of the obturator foramen and the ischial tuberosity
can be identified. The superior shelving margin of the acetabulum can be
seen.
 The articulating surfaces of the hip joint are seen to be parallel and
separated by a narrow space occupied by radiotranslucent articular
cartilage. The head, the neck, the greater and lesser trochanters, and the
intertrochanteric crest of the femur can all be visualized.

11.  The angle formed by the long axis of the neck of the
femur with the long axis of the shaft of the femur
measures between 120 and 130 degrees.
 The axial relationships of the hip joint should be studied. The inferior
margin of the neck of the femur should form a smooth continuous curve
with the superior margin of the obturator foramen (shenton’s line).

12.  In lateral view first identify as many of the relevant
parts of the pelvis as possible.
 The obturator foramen, the ischial spine and
tuberosity, the pubic ramus, and the body of the
pubis may all be recognized.
 The acetabular rims and the head and the whole neck
and lesser trochanters and the proximal part of the
shaft are visualized.
Lateral view

13. X-RAY
HIP
JOINT
AND
PELVIS

14. Normal
AP
view
of
pelvis
anatomy

15. PELVIS (ANTEROPOSTERIOR)
 1. Lateral part of the sacrum
 2. Gas in colon
 3. Ilium
 4. Sacroiliac joint
 5. Ischial spine
 6. Superior ramus of pubis
 7. Inferior ramus of pubis
 8. Ischial tuberosity
 9. Obturator foramen
 10. Intertrochanteric crest
 11. Pubic symphysis
 12. Pubic tubercle
 13. Lesser trochanter
 14. Neck of femur
 15. Greater trochanter
 16. Head of femur
 17. Acetabular fossa
 18. Anterior inferior iliac spine
 19. Anterior superior iliac spine
 20. Posterior inferior iliac spine
 21. Posterior superior iliac spine
 22. Iliac crest

16. Hip Joint (Anteroposterior)
 1. Anterior superior iliac spine
 2. Ilium
 3. Anterior inferior iliac spine
 4. Pelvic brim
 5. Acetabular fossa
 6. Head of femur
 7. Fovea
 8. Superior ramus of pubis
 9. Obturator foramen
 10. Inferior ramus of pubis
 11. Pubic symphysis
 12. Ischium
 13. Lesser trochanter
 14. Intertrochanteric crest
 15. Greater trochanter
 16. Neck of femur

18. Anatomy of Femur
 The femur is the longest, strongest, and heaviest bone in the body
 This bone consists of one body and two articular extremities.
 The body is cylindric, slightly convex anteriorly, and slants medially 5 to 15 degrees.
 The extent of medial inclination depends on the breadth of the pelvic girdle.
 The extent of medial inclination depends on the breadth of the pelvic girdle. When the
femur is vertical, the medial condyle is lower than the lateral condyle
 About a 5- to 7-degree difference exists between the two condyles. Because of this
difference, on lateral radiographs of the knee the central ray is angled 5 to 7 degrees
cephalad to “open” the joint space of the knee.
 The superior portion of the femur articulates with the acetabulum of the hip joint

19. Normal X-Ray of Femur

20. Normal Femur Anatomy

21. RADIOGRAPHIC APPEARANCES OF THE KNEE REGION:
 In the AP view the lower part of the shaft of the femur, the lateral and medial epincondyles,
and the adductor tubercle are easily visualized. The patella is seen superimposed in front of
the lateral and medial femoral condyles. The fabella , a sesamoid bone in the lateral head of
the gastrocnemius, is sometimes seen superimposed on the lateral femoral condyle.
 The parallel joint surfaces, separated by a wide space occupied by the articular cartilage and
the semilunar cartilages, which cast no shadow, are easily recognized. The intercondylar notch
of the femur and the intercondylar eminence of the tibia are well shown.
 The medial and lateral condyles of the tibia are seen. The head of the fibula partly overlaps the
lateral condyle of the tibia. The neck of the fibula and the upper parts of the shafts of the fibula
and tibia are usually clearly seen.
 In the lateral view the lower part of the shaft of the femur is seen, and the lateral and medial
femoral condyles are partly superimposed on each other. The patella is clearly visualized in
front of the femoral condyles.
 The intercondylar eminence of the femur and its summit is overlapped by the femoral
condyles. The lateral and medial tibial condyles are superimposed, and the tibial tuberosity is
seen on the anterior surface of the bone. The head, neck, and upper part of the shaft of the
fibula are seen, the fibula overlapping the tibia to some extent.

22. Normal X-Ray of Knee Joint
R

23.  1- Femur
 2- Lateral condyle
 3- Medial condyle
 4- Patella
 5- Tibia
 6- Fibula
 7- Lateral tibial spine
 8- Medial tibial spine
 9- Intercondyle notch
KNEE JOINT ANTEROPOSTERIOR VIEW

24.  1-Femur
 2- Femur condoyle
 3- Patella
 4- Tibia
 5- Fibula
 6- Tibial tuberosity
 7- Tibial spine
KNEE JOINT LATERAL VIEW

25. Normal
Knee
Anatomy
Joint

26. ANATOMY OF PATELLA
 The patella, or knee cap, is the largest and most constant sesamoid bone in the body.
 The patella is a flat, triangular bone situated at the distal anterior surface of the femur.
 The patella develops in the tendon of the quadriceps femoris muscle between 3 and 5 years of
age.
 The apex, or tip, is directed inferiorly, lies ½ inch (1.3 cm) above the joint space of the knee,
and is attached to the tuberosity of the tibia by the patellar ligament.
 The superior border of the patella is called the base.

27. PATELLA (DISTAL-PROXIMAL)
 1. Patella
 2. Medial part of patella
 3. Lateral part of patella
 4-5. Patellofemoral joint
 6. Lateral femoral condyle
 7. Medial femoral condyle

28. X-Ray showing the Sunrise View of a Right Knee

29. ANATOMY OF TIBIA
 The tibia is the larger of the two bones of the leg and consists of one body and two expanded
extremities.
 The proximal end of the tibia has two prominent processes—the medial and lateral condyles.
 The superior surfaces of the condyles form smooth facets for articulation with the condyles of the
femur.
 These two flatlike superior surfaces are called the tibial plateaus, and they slope posteriorly about
10 to 20 degrees.
 Between the two articular surfaces is a sharp projection, the intercondylar eminence, which
terminates in two peaklike processes called the medial and lateral intercondylar tubercles.
 The lateral condyle has a facet at its distal posterior surface for articulation with the head of the
fibula. On the anterior surface of the tibia, just below the condyles, is a prominent process called
the tibial tuberosity, to which the ligamentum patellae attach. Extending along the anterior surface
of the tibial body, beginning at the tuberosity, is a sharp ridge called the anterior crest.

30. ANATOMY OF FIBULA
 The fibula is slender compared with its length and consists of one body and two articular
extremities.
 The proximal end of the fibula is expanded into a head, which articulates with the lateral
condyle of the tibia.
 At the lateroposterior aspect of the head is a conic projection called the apex.
 The enlarged distal end of the fibula is the lateral malleolus.
 The lateral malleolus is pyramidal and marked by several depressions at its inferior and
posterior surfaces.
 Viewed axially, the lateral malleolus lies approximately 15 to 20 degrees more posterior than
the medial malleolus

31. Normal
X-Ray
of
Tibia
and
Fibula AP VIEW
Lateral VIEW

32. TIBIA & FIBULA (ANTEROPOSTERIOR)
 1. Femur
 2. Medial condyle of femur
 3. Lateral condyle of femur
 4. Knee joint
 5. Intercondylar eminence
 6. Lateral condyle of tibia
 7. Medial condyle of tibia
 8. Fibula
 9. Tibia
 10. Head of fibula
 11. Neck of fibula

33. TIBIA & FIBULA (LATERAL VIEW)
 1.Femur
 2. Knee joint
 3. Intercondylar eminence
 4. Tibial tuberosity
 5. Fibula
 6. Tibia
 7. Ankle joint
 8. Talus
 9. Calcaneus

34. Normal
Tibia
and
Fibula
Anatomy

35. RADIOGRAPHIC APPEARANCES OF THE ANKLE JOINT:
 In the AP view the lower ends of the tibia and fibula and the inferior tibiofibular joint are well
shown. The medial and lateral malleoli and the articular surfaces of the tibia and the body of
the talus are easily seen. The lateral malleolus usually partly overlaps the lateral aspect of
the talus.
 The articular surface of the lower end of the tibia and the superior surface of the talus are
seen to be parallel and separated by a narrow space occupied by the articular cartilage,
which is radiotranslucent. Other than the talus, the tarsal bones are not clearly visualized.
 The lateral view shows the lower ends of the tibia and fibula; the lateral and medial malleoli
are superimposed. The articuar surfaces of the ankle joint are clearly visualized. The talus
and calcaneum are seen in profile, and the subtalar and transverse tarsal joints can be
identified. The cuneiform bones and the cuboid are overlapped and not clearly seen.

36. Normal X-ray of Ankle Joint

37. 1- Fibula
2- Tibia
3- Talus
4- Calcenous
5- Navicular
ANKLE JOINT (LATERAL)

38. ANKLE JOINT (ANTEROPOSTERIOR)
1- Tibia
2- Medial malleolus
3- Fibula
4- Lateral melleolus
5- Dome of talus

39. Anatomy of Foot
 14 phalanges (bones of the toes)
 5 metatarsals (bones of the instep)
 7 tarsals (bones of the ankle)
The Foot consists of 26 bones

40. PHALANGES
 Each foot has 14 phalanges—2 in the great toe and 3 in each of the other
toes. The phalanges of the great toe are termed the distal and proximal
phalanges. The phalanges of the other toes are termed the proximal,
middle, and distal phalanges. Each phalanx is composed of a body and
expanded articular ends—the proximal base and the distal head.
METATARSALS
 The five metatarsals are numbered one to five beginning at the medial or
great toe side of the foot. The metatarsals consist of a body and two
articular ends. The expanded proximal end is called the base, and the
small, rounded distal end is termed the head. The five heads form the
“ball” of the foot. The first metatarsal is the shortest and thickest. The
second metatarsal is the longest. The base of the fifth metatarsal contains
a prominent tuberosity, which is a common site of fractures.

41. TARSALS
The proximal foot contains seven tarsals :
 Calcaneus
 Talus
 Navicular
 Cuboid
 Medial cuneiform
 Intermediate cuneiform
 Lateral cuneiform
Beginning at the medial side of the foot, the cuneiforms are described as medial, intermediate, and
lateral.
Beneath the head of the first metatarsal are two small bones called sesamoid bones. They are detached from
the foot and embedded within two tendons. These bones are seen on most adult foot radiographs. They are
a common site of fractures and must be shown radiographically
SESAMOID BONES

42. RADIOGRAPHIC APPEARANCES OF THE TARSUS,
METATARSUS AND PHALANGES
The views commonly used are:
 (1) Anteroposterior (AP)
 (2) Lateral, and
 (3) Oblique.

43. Normal Foot X-Ray
 The particular view used will depend on which bone is
need to be visualized to best advantage. The oblique view
of the metatarsal bones is often of greater value than the
lateral view, since in the later the bones are superimposed.
 In the Anteroposterior view, the tarsal bones the
metatarsals, and the phalanges are seen. The two
sesamoid bones of the big toe overlap the head of the
first metatarsal bone.

44. Normal Anatomy of Foot
 1-Medial cuneiform bone
 2- Intermediate cuneiform bone
 3- Lateral cuneiform bone
 4- Cuboid bone
 5- Navicular bone
 6- Calceneal bone
 7- Talus
 8- Metatarsal bone (1st toe)
 9- Proximal phalanx (1st toe)
 10- Distal phalanx (1st toe)

45. FOOT (DORSO-PLANTAR)
 A-E: Toes 1-5. (A: Great toe)
 I-V. Metatarsals
 1, 3: Distal phalax
 4: Middle phalax
 2,5: Proximal phalax
 6. Interphalangeal joints
 7. Metatarsophalangeal joints
 8. Sesamoids
 9. Head of metatarsal
 10. Shaft (body) of metatarsal
 11. Base of metatarsal
 12. Cuneiforms
 13. Navicular
 14. Cuboid
 15. Talus
 16. Calcaneus
 17. Tibia
 18. Fibula
 19. Tarsometatarsal joints
 20. Transverse midtarsal
joint.

46. FOOT (OBLIQUE)
 A-E: Toes 1-5. (A:Great toe)
 1,3: Distal phalax
 4: Middle phalax
 2,5: Proximal phalax
 6. Interphalangeal joints
 7. Metatarsophalangeal joints
 8. Sesamoids
 9. Head of metatarsal
 10. Shaft (body) of metatarsal
 11. Base of metatarsal
 12. Cuneiforms
 13. Navicular
 14. Cuboid
 15. Talus
 16. Calcaneus
 17. Tibia
 18. Fibula
 19. Tarsometatarsal joints
 20. Transverse midtarsal
joint

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