Clinical aspects of lower limb (leg region)

1. ClinicalAnatomy
Dr. Aunum Iqbal
Demonstrator
Sialkot Medical College

2. TibialFractures

3. Types:
1.Compound/Open fractures
2.Transverse march/stress fractures
3.Diagonal fractures

4. Compound/open fractures
Commonest site: junction of upper 2/3rds and lower 1/3rd of
shaft of Tibia
Cause: Direct trauma to leg
Poor blood supply in this area leads to non-union of
fractured ends
This area is subcutaneous, thus fracture is of open/
compound type, i.e where skin is damaged as well

5. Transversemarch/stressfractures
Commonest site is lower 1/3rd of shaft of Tibia
Cause: long hikes without training

6. Diagonalfractures
Commonest site: Junction of upper 2/3rds and lower 1/3rd of
shaft of Tibia
Cause: Torsion (twisting) of leg during skiing
Associated fracture of Fibula
Shortening of limb due to overriding of fractured ends

7. Importantbursae
andBursitis

8. Bursaearoundkneejoint 1. Deep suprapatellar bursa (b/w Femur and
Quadriceps tendon; communicates with synovial
membrane of knee joint)
2. Subcutaneous prepatellar bursa (b/w Patella
and skin)
3. Deep infrapatellar bursa (b/w Tibia and
ligamentum patellae)
4. Subcutaneous infrapatellar bursa (b/w lower
half of Tibial tuberosity and skin)
5. Popliteal bursa (b/w tendon of Popliteus and
capsule of knee joint; communicates with
synovial membrane of knee joint)
6. Semimembranosus bursa (beneath the
Semimembranosus tendon)
7. Pes anserinus/subsartorial bursa (beneath the
Sartorius, Gracilis and Semitendinosus
tendons)
Quadriceps femoris
tendon
Ligamentum patellae
Patella
67
Pes anserinus
Popliteus
Semimembranosus

9. Pesanserinus
a.k.a. Goose foot
Conjoined tendons of 3 muscles that insert onto
the medial surface of upper part of shaft of
Tibia: Sartorius, Gracilis and Semitendinosus
The name, "goose foot", arises from the 3 pronged
manner in which the conjoined tendon inserts onto
the tibia.
Behind this common insertion, Pes anserinus bursa
is present.

10. 1. Subcutaneous calcaneal bursa
(b/w skin and Calcaneum)
2. Retrocalcaneal bursa (b/w
Achilles tendon and Calcaneum)
– Inflammation is called
Calcaneal Bursitis
3. Subcutaneous bursa of medial
malleolus of Tibia
Bursaearoundanklejoint

11. Calcaneal
Tendinitisand
RupturedAchilles
tendon

12. • Inflammation of Achilles tendon
• Cause: Running injuries lead to
tearing of Collagen fibers in the tendon
• Symptoms: Pain during walking
• If untreated, it may lead to rupture
of Achilles tendon

13. Calcanealtendon
reflex/Anklereflex

14. • Achilles tendon is struck with a hammer, just above
Calcaneum, while the foot is dorsiflexed
• Normal result: Plantar flexion at ankle joint –
showing intact spinal nerves
• Spinal nerves tested: S1 and S2
• If S1 or S2 spinal nerves are damaged, this reflex
would be absent i.e. no plantar flexion

15. FabellaandFabellar
syndrome

16. Fabella: (little bean-Latin)
A small sesamoid bone found in
the tendon of lateral head of
the Gastrocnemius muscle behind
the lateral condyle of the femur
Present in 3-5% of people
Fabellar Syndrome:
Tenderness over the posterior
aspect of the lateral Femoral
condyle due to repetitive
friction of Fabella over it
Fabella

17. Musculocutaneous/
venouspump

18. • a.k.a second heart/ peripheral heart
• Contraction and relaxation of deep
muscles of posterior compartment of
leg, causes pumping of blood
• Blood from superficial veins goes
towards deep veins and then towards
the heart
• This direction of blood flow is due
to the presence of one-way valves in
the veins
• This mechanism increases venous
return to the heart: hence prevents
pooling of blood in the peripheries

19. Compartment
Syndrome

20. •Posterior compartment of leg has two groups of muscles;
superficial and deep.
•Deep group of muscles lie in a tightly packed space;
the deep compartment
•Nerves and vessels of posterior compartment of leg pass
through the deep compartment
•When swelling occurs, it causes compression of these
nerves and vessels, leading to Compartment Syndrome
•It leads to:
•Necrosis (death) of muscles – due to damaged arterial
supply
•Paralysis of muscles – due to compression of nerves

21. Handypoints• Triceps surae/Calf: Medial and
lateral bellies of Gastrocnemius and
Soleus
• Muscles of posterior compartment
mainly produce plantar flexion at
ankle joint
• Damage to Tibial nerve will cause
loss of plantar flexion
• Plantar flexion is stronger than
dorsiflexion
• Muscles involved in standing on
tiptoes: Triceps surae (93% force)
• Nerve involved in standing on
tiptoes: Tibial nerve
• Damage to Tibial nerve: Patient
can not stand on tiptoes

22. HandypointsTibia - Shin bone
Patella - Knee cap
Calcaneum - Heel bone
Plantaris - Freshman's nerve
Triceps surae/Calf: Medial and lateral
bellies of Gastrocnemius and Soleus
Pes anserinus: Common insertion of
Sartorius, Gracilis and Semitendinosus
on Tibia
Anti-gravity muscle in posterior leg:
Soleus
Popliteus – unlocking of knee joint by
5 degree lateral rotation of Femur on
Tibia
Achilles tendon – largest tendon in
body
Patella – largest sesamoid bone in body

23. DIFFERENCEBETWEENACTIONSOF
GASTROCNEMIUSANDSOLEUS:
• Gastrocnemius: Plantar flexion at
ankle joint and flexion at knee
joint
Soleus: Plantar flexion at ankle
joint only
• Muscle for walking and running:
Soleus
Muscle for long jump: Gastrocnemius
• Gastrocnemius can plantar flex
with the extended knee. When knee is
flexed, Soleus causes plantar
flexion
• Soleus: anti gravity muscle; helps
in standing
• Line of gravity passes
anterior to Tibia in leg
• Therefore gravity tends to
pull the body forward over
the feet
• It is prevented by
contraction of Soleus
• During standing on both
the legs, Soleus is
continuously active

25. Thankyou!