This document discusses injuries to the lower limb, including fractures and dislocations. It describes the anatomy of bones in the leg such as the fibula and tibia. Specific fracture locations are examined, including the neck of the fibula which can injure the common peroneal nerve. Ossification patterns of bones in the leg and foot from birth through adulthood are also outlined. Ligament injuries that can occur from ankle twisting are explained.

1. Dr.AkramJaffar
Imaging Anatomy of Fractures and Dislocations inImaging Anatomy of Fractures and Dislocations in
the Lower Limbthe Lower Limb
Injuries of the leg and footInjuries of the leg and foot
Akram Jaffar, Ph.D.
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2. Dr.AkramJaffar
References and suggested reading
• Ellis H (2006): Clinical anatomy, A revision and applied anatomy for clinical students.
11th
Ed. Blackwell Publishing. Massachusetts.
• Moore KL et al. (2013): Clinically Orientated Anatomy. 7th Ed. Lippincott, Williams &
Wilkins. Philadelphia.
• Hamblen DL & Simpson HRW (2007): Adam’s outline of fractures including joint
injuries. 12th
ed. Churchill Livingstone Elsevier. Edinburgh.
• Solomon L, Warwick DJ & Nayagam S (2001): Apley's System of Orthopedics and
Fractures. 8th ed. Arnold Publishing.

3. Dr.AkramJaffar
Objectives
After completion of this session, students should be able to discuss, identify, and
describe:
• The anatomical factors predisposing to the etiology of a fracture or dislocation.
• The anatomy of displacement or deformity.
• Imaging anatomy features and how to differentiate from epiphyseal lines.
• Anatomy related to correct relocation and alignment.
• Anatomical complications of a fracture or dislocation.

4. Dr.AkramJaffar
Bones of the leg
• Fibula
• Provides for muscle attachments and is
NOT a weight bearing bone.
• Participates in the formation of the ankle
joint.
• Fracture at the distal end is usually
associated with dislocation of the ankle
joint.
• Tibia
• Has a subcutaneous surface; thus is a
common site for compound fracture.
• Is a weight bearing bone
• Participates in the formation of the knee
and ankle joints.
head
neck
Lateral
malleolus
Lateral condyle
medial condyle
tuberosity
Subcutaneous
surface
medial
malleolus
Tibia
Fibula

5. Dr.AkramJaffar
Fracture of the neck of the fibula
• Anatomical complication:
• Injury of the common peroneal nerve:
• The nerve winds superficially around the neck of
the fibula.
Common peroneal nerve
Tibial plateau depressed fracture with proximal fibular fracture
Fibular head
Fibular neck

6. Dr.AkramJaffar
Fracture of the distal third of the tibia
• The tibial shaft is narrowest at the junction
of the middle and distal thirds, which is the
most frequent site of fracture.
• Blood supply of long bones is derived
from three sources:
– Nutrient artery
– Anastomosis of vessels near the
ends
– Periosteal arteries that are derived
from locally attached muscles.
Metaphyseal a.
Nutrient a.
perioetum

7. Dr.AkramJaffar
Fracture of the distal third of the tibia
Nutrient
foramen
Soleal line
• No muscle is attached to the distal third of the tibia
 poor blood supply and depends mainly on its
nutrient artery.
• The nutrient artery of the tibia enters the nutrient
foramen located just distal to the soleal line.
• Fractures of the lower third of the tibia often suffer
from delayed union.
Muscle attachments to tibia
Anterior Posterior
tibia
fibula
Ankle joint

8. Dr.AkramJaffar
Ossification of the tibia
• Proximal end
– Appears at birth
– at about 10 years a thin anterior process
from it descends to the tibial tuberosity
– Fuses at 16-18th
years.
• Distal end
– Fuses at 15-17 years.
7th
weekofintrauterinelife
Immediately
before or after
birth
appears early in
the first year
New born
13 years
16 years
9 months

9. Dr.AkramJaffar
Ossification of the fibula
• Secondary centres:
– Proximal end
• Unites with the shaft 17th
- 19th
year (female/
male).
Appears 3-4
years
appears in the
first year
12 months
3 years
– Distal end
• Joins the shaft (15th
-17th
years
(female/male)

10. Dr.AkramJaffar
Injury of lateral collateral ligament
• When the foot is forcibly inverted as when the
weight-bearing foot trips on an uneven
surface.
• The anterior talofibular ligament is the
most vulnerable and most commonly torn.
• In severe cases, the calcaneofibular ligament
is torn and the lateral malleolus is fractured.
Inf tibiofibular joint
Lat malleolus
fracture

11. Dr.AkramJaffar
Injury of deltoid ligament
• So strong that when the foot is forcibly everted the
ligament is not torn but it causes
– avulsion of the medial malleolus
– talus moves laterally causing a break in the fibula
superior to the inferior tibio-fibular joint (Pott
fracture dislocation). eversion

12. Dr.AkramJaffar
Ossification of the tarsal bones
• Calcaneus and the talus, have an
ossification centre at birth.
• In 50% of neonates a centre is present in
the cuboid.
• Each of tarsal bones has a single centre,
except the calcaneus, which has a scale-
like posterior epiphysis (appears at 10th
year
and joins at 18 years).
10 years
At birth
talus
calcaneus
cuboid
talus
calcaneus
epiphysis

13. Dr.AkramJaffar
Occasional secondary ossification centres
• Os trigonum: posterior talar process.
• Os tibiale: tuberosity of the navicular.
• Os vesalium: the tubercle at the base of
the 5th
metatarsal.
talus
talus
Nav
Nav
talus
calcaneus
cuboid
Os trigonum
Os tibiale
Os vesalium

14. Dr.AkramJaffar
Ossification of metatarsals and phalanges
• The epiphysis of the 1st
metatarsal is at the base,
that of each of the other four is at the head
• The epiphyses are at the proximal end of the
phalanges.
• The epiphyseal patterns are as in the hand.
4 years
FootHand

15. Dr.AkramJaffar
“March” fracture of the 2nd
metatarsal bone
• The base of the 2nd
metatarsal is firmly
fixed between the anterior ends of the
medial and lateral cuneiforms.
• The 2nd
metatarsal and toe form the axis
of the foot.
• The immobility of the 2nd
metatarsal and
the slenderness of its shaft contribute to
its ‘spontaneous’ fracture following mild
repetitive trauma (stress fracture).
Nav
talus
calcaneus
cuboid
cuneiforms
David Beckham