The Leg

Orthopedic anatomy
Clinical anatomy
Radiologic anatomy

Presented by
Dr. Maryna
Kornieieva Asst. of
Anatomy
Leg: Orthopedic Anatomy
 Proximal leg: bones
Intercondilar eminence
Fibular Articular facet Medial tibial condyle
Medial tibial condyle Lateral tibial condyle

Styloid
Tibial tuberosity process
(patellar ligament) F Head

Neck
Soleal line
Lateral border Medial border
(interosseous)
T
Medial surface T
Lateral surface Posterior surface
(subcutaneous)
Anterior border

Anterior view: tibia(T) and Posterior view: tibia(T) and

fibula(F) fibula(F)
Proximal Tibiofibular Joint
Ligaments:
Proximal Type: synovial, plane, gliding joint
Tibiofibular Joint
Articulation: lateral
condyle of the tibia and the
head of the fibula
Movements: small amount
Interosseous
membrane Anterior and
Type: fibrous joint posterior
ligaments
Articulation: fibular The proximal TF joint is
Distal notch at the lower end synovial and of little clinical
Tibiofibular Joint of the tibia and the consequence (opposed to
lower end of the the fibrous distal TF joint
Movements:
fibula. small amount which is vital to ankle
stability)

The fibular neck has the
common peroneal (fibular)
nerve running around it that may
be injured by fracture, oedema or
compression.
Clinical notes
Posterior Intercondylar area
Intercondilar eminence
Tibial plateau
Anterior
Intercondil
ar area
CT (MIP)
Tibial plateau fractures occur due to a fall from a
height, direct trauma, valgus or varus injuries (usually
valgus due to lateral trauma causing lateral condyle
injury) and minor falls in an osteoporotic patient.
Clinical notes
Osgood-Schlatters disease -
(epiphysitis) is due to avulsion
and inflammation of the soft
young tibial tuberosity
epiphysis subject to the pull of
the powerful quadriceps
The
muscle.
tuberosity
may avulse
anteriorly
or
It usually
fragment.
responds
to
conservativ
e
treatment.
 Tibial shaft fractures
Oblique
Difficulties: (direct trauma
Transverse Spiral plus indirect
1) It is a weight-bearing bone (hit by a car) (torsion injury) torsion)
with little surrounding muscle
anteromedially (that would
improve blood supply for
healing).
2) There are only skin and
periosteum over the bone
increasing the chance of an
open fracture.
3) The fibula may hold the ends
Treatment: Conservative
of a tibial fracture apart,
treatment may be
making healing used
less for
likely.
stable fractures but otherwise,
internal fixation by Clinical notes: peripheral pulses must be checked early. If
intramedullary nail or plate is the foot is pale and pulseless, immediate temporary
used. Isolated tibial fractures reduction is required.
 Distal leg: bones
Posterior Flexor
Anterior Ankle mortise
halluci Add X-ray
s Distal
longus TF joint
Tibialis
groov
posteri
Perone e
or
us groove
longus
groove

Lateral malleolus
Malleo Medial malleolus Eversion injuries to the ankle may cause high fibula
lar fractures (even at the fibular neck) due to sprining of
fossa the bone around the distal TF joint as the fulcrum.
 Distal Tibiofibular Joint
The bony mortise keeps the ankle joint
Ligaments of the Distal TF joint:
very solid but depends on an intact distal
tibiofibular joint (if it is not intact then Anterior inferior
there can be lateral shift of the talus). tibiofibular lig.
Interosse
ous
Posterior ligaments
inferior
tibiofibular
lig.

Posterior talo-
fibular ligament Anterior talo-
fibular ligamen
Calcaneo-fibular lig
 Clinical notes
Diastasis is complete disruption
of the strong fibrous distal
tibiofibular joint. It indicates
significant trauma and unstable
ankle (a serious injury). This
allows lateral shift of the talus
and needs fixation.

Rotational ankle injuries do Cross-sectional computed

often cause malleolar tomography scan showing
fractures: medial one is measurement of the
stressed in anterior, central, and
hyperinversion, while posterior width of the
lateral one in distal tibiofibular
hypereversion. joint(normal).
Leg: Clinical Anatomy
 The Leg: regions
is the part of the lower limb between the knee and ankle joint

Anterior region of the leg Posterior region of the leg

Surface Anatomy of the Leg
Anterior region Posterior region
 Superficial veins
Long (greater) saphenous
vein forms in front of the Short (lesser) saphenous There are
medial malleolus and ascends vein forms behind the numerous
up along the medial side of the lateral malleolus and goes perforating
lower limb till it opens into the toward the popliteal fossa, veins (30-40)
femoral vein 3-4 cm below the there it tributes into the connecting
inguinal ligament (saphenous popliteal vein. superficial veins
hiatus). with the deep
along their way.
The valves inside
the perforating
veins allow one-
directed blood
flow
The vascular wall of the superficial veins (from
is thin and is
superficial
able to resist only the minimal blood pressure. veins
In case
of development of venous hypertension,tothe the deep).
wall dilates
and become tortures.
This state is known as varices, or varicose disease.
 Compartments of the leg
Deep fascia attaches to the
Anterior
periosteum of the anterior and
Crural
medial borders of the tibia
Intermusc
ular
Septum

Investing Deep Fascia

Posterior
Transverse Intermuscular Septum Crural
Intermusc
ular
Septum
Transverse intermuscular septum
separates superficial and deep muscles of
the posterior compartment and gives rise
to retinacula around the ankle.
 Leg: compartments
Anterior Compartment (AC) Posterior Compartment (PC) Lateral Compartment (LC)

Muscles: Superficial muscles:

Muscles:
1. tibialis anterior, 1. gastrocnemius, 1. Peroneus longus,
2. extensor digitorum longus, 2. plantaris, and 2. Peroneus brevis;
3. extensor hallucis longus, 3. soleus
Blood supply: Perforating
4. peroneus tertius; Deep muscles: branches from the fibular
Popliteus, flexor digitorum longus, (peroneal) artery
Blood supply: Anterior tibial flexor hallucis longus, and tibialis
posterior. Nerve supply: Superficial
artery
fibular (peroneal) nerve
Nerve supply: Deep peroneal Blood supply: Posterior tibial artery
nerve Nerve supply: Tibial nerve
 AC muscles: Tibialis Anterior
Origin:
Lateral
surface of Nerve Supply:
shaft of tibia Deep peroneal
and nerve
interosseous
membrane.

Insertion:
Medial Action:
cuneiform and Extends foot at ankle joint;
base of 1st inverts foot at subtalar and
metatarsal transverse tarsal joints; holds up
bone. medial longitudinal arch of foot.
Extensor Digitorum Longus
Origin: Nerve Supply:
Anterior surface ofDeep peroneal
shaft of fibula nerve

Inserti
on: Action:
Extenso Extends toes;
r extends foot
expansi at ankle joint
on of
lateral
four
 Extensor Hallucis
Longus
Origin:
Anterior surface of shaft Insertion:
of fibula Base of
distal
phalanx of
great toe

Action:
Extends big toe;
Nerve Supply: extends
Deep peroneal foot at ankle joint;
nerve inverts
foot at subtalar and
transverse tarsal
 Peroneus (Fibularis) Tertius
Origin:
Anterior surface of
shaft of fibula
Nerve Supply:
Deep peroneal
nerve

Action:
Extends
foot at
ankle joint;
everts foot
at subtalar
Insertion: and
Base of 5th transverse
metatarsal bone tarsal
joints.
 Anterior compartment: vessels
It continues with the dorsal
Anterior Tibial Artery arises
from the popliteal artery within
the cruropopliteal canal.
Branches:
1) Anterior tibial
recurrent artery
(ascends to the
genicular
anastomosis);
2) Muscular branches;
3) Anterior (medial and
lateral) malleolar
arteries (descend to
It quits the canal viathe
theankle).
anterior outlet
(the opening in interosseous membrane)
and descends to the foot with the deep
fibular nerve.
 Anterior compartment: nerves
Deep fibular nerve

It one of the two divisions of the common fibular nerve.

Course: It passes through

the anterior crural
intermuscular septum and
descends toward the ankle
deep to the extensor digitorum
Supplies:
longus.

On the leg - all muscles of

the anterior compartment;
On the foot - extensor digitorum
brevis, first two dorsal interossei
muscles, + the skin between the great
and second toes.
 Deep Fibular Nerve Injury
The deep fibular nerve could be damaged as a part of the common peroneal nerve, because last one is extremely
vulnerable to injury as it winds around the neck of the fibula.

Injury to the common peroneal nerve (as well as the deep fibular
itself) causes foot drop.
 Anterior Compartment
of the Leg Syndrome
Compartment syndrome occurs
with a rise in pressure within a
compartment due to many causes
but often unrecognized trauma.
Symptoms:
Progressive ischemic pain;
Numbness and
paraesthesia;
Swelling and induration in
the leg;
Pale foot.

It is required urgent fasciotomy to

avoid muscle necrosis and distal
ischemia.
 PC muscles
Superficial Deep

Plantaris Popliteus
Gastrocnemius

Tibialis Posterior
Soleus

Flexor Hallucis Longus

Flexor Digitorum Longus
Origin:
Lateral head from
lateral condyle of Gastrocnemius
femur and medial
head from above
medial condyle

Insertion:
Via tendo calcaneus Action:
into posterior surface of Nerve Supply:
calcaneum. Plantar Tibial nerve
flexes foot
at ankle
joint;

flexes knee
joint.
 Soleus

Nerve Supply:
Tibial nerve
Origin:
Shafts of Action:
tibia and Together with
fibula gastrocnemius
and
plantaris is
Insertion: powerful
Via tendo plantar flexor of
calcaneus ankle joint;
into posterior provides
surface of main propulsive
calcaneum force in walking
and running
 Ruptured Tendo Calcaneus
Symptoms:
Common in middle-aged tennis players
Acute pain;
Impossible plantar flexion;
Palpable gape above calcaneus

The rupture occurs at its narrowest The tendon should be sutured as soon as possible
part, about 5 cm above its insertion. and the leg immobilized with the ankle joint plantar
flexed and the knee joint flexed.
 Plantaris
Action:
Plantar flexes foot at ankle joint;
Origin: flexes knee joint
Lateral
Plantari
supracondylar
s
ridge of femur

Nerve Supply:
Tibial nerve

Insertion:
Posterior surface of
calcaneum
 Popliteus
The popliteus muscle arises inside the capsule of the
knee joint and is inserted into the upper part of the
posterior
surface of the tibia.

The popliteus muscle

is responsible for
The tendon separates the lateral ligament of the knee unlocking the knee
joint from the lateral meniscus so that the meniscus is joint.
not tethered to the ligament and is freer to move and
adapt to the surfaces of the condyle of the femur and
Origin:
Posterior surface
Tibialis
of shafts of tibia
and fibula and Posterior
interosseous
membrane Flexor retinaculum
Tibialis
posteri
or
groove

Action:
Plantar flexes foot at ankle
joint; inverts foot at subtalar
Insertion: Nerve and transverse tarsal joints;
Tuberosity of navicular bone Supply: supports medial longitudinal
and other neighboring Tibial nervearch of foot
bones
 Tarsal Tunnel
Boundaries: Contents:
roof:flexor retinaculum Tibialis posterior
floor:medial surfaces of the talus and calcaneus tendon
Flexor digitorum longus
tendon
Posterior tibial artery
Posterior tibial vein
Tibial nerve
Flexor hallucis longus
tendon
 Flexor Digitorum Longus
Origin: Action:
Posterior surface of
shaft of tibia Nerve Supply: Flexes distal
Tibial nerve phalanges of
lateral four
toes;

plantar
flexes foot at
ankle joint;

supports
Insertion: medial
Bases of distal and lateral
phalanges of longitudinal
lateral four L R arches of
toes foot.
Origin: Flexor Hallucis Longus
Posterior surface of
shaft of fibula Nerve Supply:
Tibial nerve

Insertion: Action:
Flexes distal
Base of phalanx of big
distal toe; plantar
phalanx of flexes foot at
big toe. ankle joint;
supports medial L R
longitudinal arch
of foot.
 Posterior compartment: vessels
Peroneal (fibular) artery
Tibialis Posterior artery
It descends behind the fibula,
Passes downward along the either within the substance of
posterior surface of the tibialis the flexor hallucis longus muscle
posterior, accompanied by or posterior to it.
Branches:
deep veins and the tibial
Muscular branches
nerve.
Branches: Nutrient artery to the fibula
Peroneal artery Anastomotic branches (ankle
Muscular branches joint)
Nutrient artery to the Perforating branch (pierces
tibia. the interosseous membrane to
Anastomotic branches reach the muscles of the
Medial and lateral lateral compartment of the
1 -plantar
a. poplitea; 2 -
arteriesa. genu sup. lateralis; 3 - a. genu inf. lateralis; 4 - a. peronea (fibularis); 5 -
leg).
rami malleolares tat.; 6 - rami calcanei (lat.); 7 - rami calcanei (med.); 8 - rami malleolares
mediales; 9 - a. tibialis post.; 10 - a. genu inf. medialis; 11 - a. genu sup. medialis.
 Palpation of the posterior tibial artery
Goal: assessing a patient for peripheral
The point: posterior and inferior to
vascular disease.
themedial malleolus.
 Deep Veins: DVT - is the
formation of a blood
clot (thrombus)
Thrombosis within a deep vein,
predominantly in the
It passes rapidly to the heart and lungs, causing pulmonary embolism,legs.
which is often fatal.

Risk factors:
Older age;
Major surgery and orthopedic surgery;
Inactivity and immobilization, as with orthopedic Non-specific signs may
casts, sitting, travel, bed rest, and hospitalization; include pain, swelling,
Trauma, minor leg injury, and lower limb amputation; redness, warmness, and
Blood disorders; and others. engorged superficialveins.
 Tibial
nerve
Branches on the leg:
Muscular branches: soleus, flexor
digitorum longus, flexor hallucis longus,
and tibialis posterior.
Cutaneous: The medial calcaneal
branch supplies the skin over the
medial surface of the heel.
Articular branch to the ankle joint.
Medial and lateral plantar nerves

The cutaneous innervation of the

terminal branches of the sciatic
nerve.
 Tarsal Tunnel Syndrome
Definition:
TT - is a compression
neuropathy and painful
foot condition in which
thetibial nerveis
compressed as it travels
through thetarsal tunnel.
Symptoms:
Pain and tingling in and around ankles and
sometimes the toes
Swelling of the feet
Painful burning, tingling, or numb sensations
in the lower legs. Pain worsens and spreads
after standing for long periods; pain is worse
with activity and is relieved by rest.
Pain radiating up into the leg,and down into
the arch, heel, and toes
Pain along the Posterior Tibial nerve path
Burning sensation on the bottom of foot that
radiates upward reaching the knee
"Pins and needles"-type feeling and
increased sensation on the feet.
 Peroneus Longus
Origin:
Lateral Nerve
surface of Supply:
shaft of Superficial
fibula peroneal Action:
Insertion: nerve Plantar flexes
Base of 1st foot at ankle
metatarsal joint; everts foot
and the medial at subtalar and
cuneiform transverse tarsal
joints; supports
lateral
longitudinal and
transverse
arches of foot.
 Origin: Peroneus Brevis
Lateral
surface of
shaft of Nerve Supply:
fibula Superficial
peroneal nerve
Action:
Plantar flexes
Insertion foot at ankle
: joint; everts
Base of foot at subtalar
5th and transverse
metatarsa tarsal joint;
l bone supports
lateral
longitudinal
arch of foot.
 Tenosynovitis and Dislocation of the
Peroneus Longus and Brevis Tendons
Tenosynovitis can
affect the tendon
sheaths of the
peroneus longus
and brevis
muscles as they
Tendons of pass posterior to
peroneus longus the lateral
and brevis may malleolus.
dislocate forward.
For this condition
to occur, the
superior peroneal
eroneus longus; PB peroneus brevis; SPR superior retinaculum must
peroneal retinaculum; IPR inferior peroneal retin
 Lateral compartment: vessels
Numerous branches from the peroneal
(fibular) artery, which passes through
posterior compartment of the leg, pierce
the posterior fascial septum, and supply
the peroneal muscles.

NC-MRA(inflowinversionrecovery)showsnormalarterial
vasculatureofthelowerextremities.PA,poplitealartery;
AT,anteriortibialarteries;PT,posteriortibialarteries;and
PER,peronealarteries.
 Nerves
one of the terminal branches of the
common peroneal nerve
It arises in the substance
of the peroneus longus
muscle on the lateral side
of the neck of the fibula,
and then descends
between the peroneus
longus and brevis
muscles.
The superficial peroneal nerve is
Branches
Muscular:
to the peroneus longus and brevis
Cutaneous:
lower part of the
front of the leg;
dorsum of the
foot;
dorsal surfaces of
the skin of all the
toes (except the
adjacent sides of
the first and
second toes and
the lateral side of
the little toe).
Leg: Radiologic Anatomy
Sectional Anatomy of the Leg
 MRI

T1-weighted
axial image
through the
upper leg
(fatty tissues
bright, fluids
dark)
 T2W axial MR image through the
upper leg
(fatty tissues dark, fluids bright)
Note increased signal of all the
muscles, in all the
compartments.
This is edema.
There is also some edema of the
subcutaneous tissues.
It is very unusual for a trauma,
for example, to present with
edema in all compartments.
There are no fluid collections
within the muscles, but notice
the perifascial fluid collections.