LOWER

EXTREMITY
Extension of the trunk
Functions: Support weight
Locomotion
Balance
GLUTEAL REGION
Bones Clinical Correlation
Hip bone starts to fuse at 15-17 years of age
Fractures of hip bone common among elderly
Avulsion fractures of the hip bone
o A small part of bone with a piece of a tendon or ligament attached is avulsed away.
o Occur at apophyses (bony projections that lack secondary ossification centers).
o Occurs where muscles are attached:
Anterior superior and inferior iliac spines
Ischial tuberosities
Ischiopubic rami

Muscles
Muscles Function Innervation (arises Clinical Correlation
from sacral plexus and
all emerge inferior to
piriformis except
superior gluteal nerve)
Gluteus Maximus Extends thigh (especially from flexed Inferior Gluteal Nerve Injury to superior Gluteal nerve causes
position) gluteus medius limp and/or gluteal gait.
Assists in lateral rotation - Leads to weakness or loss of motor
Steadies thigh power to gluteus medius
Assist in rising from sitting position - Weakened abduction
Gluteus Medius Abducts thigh Superior G luteal N erve - When asked to stand on one leg, the
Gluteus Minimus Medial rotation pelvis of the unsupported side descends
Tensor Fascia Lata Keeps pelvis level when ipsilateral limb of ( Positive trendelberg test)
the weight-bearing and advance opposite - Other compensatory mechanisms:
side during swing phase in gait cycle. Steppage gait swing the foot-
Piriformis Lateral rotation of extended thigh Branches of anterior outward
 Abduction of flexed thigh rami of S1, S2 Food drop common in fibular
Obturator Internus Steady femoral head in acetabulum Nerve to obturator nerve paralysis
internus Throcanteric bursitis from repetitive
Superior and Superior Gemellus: actions such as climbing stairs while lifting a
Inferior Gemelli Nerve to obturator heavy object or running on a steeply
internus elevated threadmill.
Inferior Gemellus: - Causes deep diffuse pain in the lateral
Nerve to quadratus thigh
femoris Ischial bursitis recurrent trauma from
Quadratus Femoris Laterally Rotates thigh Nerve to quadratus activities that involve repetitive hip
femoris extension while seated


FEMORAL REGION
Bones clinical correlation
Coxa vara - decreased angle of inclination between the long axis of the femoral neck to the femoral shaft
- The shaft of the femur relative to the femoral neck deviates toward the midline
Coxa valga - increased angle of inclination between the long axis of the femoral neck to the femoral shaft
- The shaft of the femur relative to the femoral neck deviates away from the midline

Dislocated epiphysis of femoral head
- Due to weakened epiphyseal plate
- Slowly results in a progressive coxa vara
Femoral fractures type of fracture is age and sex related. Becomes increasingly vulnerable as age increases, especially in females,
secondary to osteoporosis.
- neck is the most frequently fractured
Types:
1. Transcervical middle of neck
- Due to indirect trauma
- Impaction occurs
2. Trochanteric
- Due to indirect trauma
- Impaction occurs
3. Intracapsular fractures occurs within hip joint capsule
- Degeneration of femoral head occurs because of vascular trauma
4. Fractures of greater trochanter and femoral shaft
- Due to direct trauma
5. Fractures of the distal femur
 -
Can be complicated by separation of condyles, resulting in misalignment of articular surface of the knee join or hemorrhage
of the popliteal artery.
- Compromises blood supply to the leg
Femoral triangle
o Boundaries:
Superior: inguinal ligament
Medial medial border of adductor longus
Lateral medial border of Sartorius
Floor adductor longus, pectineus, ilipsoas
Roof fascia lata
o Contents:
Femoral artery potentially disrupted when you fracture hip which will make hip irreparable/
Femoral veins
Femoral nerve
Lateral femoral cutaneous nerve
Femoral branch of genito-femoral nerve lymphatic vessels
Inguinal LN

Muscles Anterior Thigh: Flexors of hip joint
Muscles Function Innervation Clinical Correlation
Pectinues Abducts and flex thigh Femoral nerve; may Groin pull usually involves the flexor and
Assist in medial rotation of thigh receive branch from adductor thigh muscles. Usually occurs in
obturator nerve sports that require quick start or extreme
Iliopsoas Flex thigh to hip joint Anterior rami of stretching.
Psoas Major Stabilizes hip joint lumbar nerves (L1, L2,
L3)
Psoas Minor Anterior rami of
lumbar nerves (L1, L2)
Iliacus Femoral Nerve
Sartorius Abduct and flex thigh Femoral Nerve
Assist in lateral rotation of thigh
Flex leg at knee joint


Muscles Anterior Thigh: Extensors of knee
Muscles Function Innervation Clinical Correlation
Quadricpes Femoris Quadriceps paralysis cannot extend leg
Rectus Femoris Steadies hip joint Femoral Nerve against resistance
Helps flex thigh o Usually presses on the distal end of
Extend leg at knee joint the thigh during walking to prevent
Vatsus Femoris inadvertent flexion of the knee joint.
Vastus Medialis
Vatsus Intermedius

Muscles Medial thigh: Adductors of thigh
Muscles Function Innervation Clinical Correlation
Adductor longus Adducts thigh Obturator nerve Injury to adductor longus occurs in horse
Adductor brevis Adducts thigh riders.
Adductor magnus Adducts thigh Adductor part:
Two parts: obturator nerve
o Adductor part: flexes thigh Hamstring part: sciatic
o Hamstring part: extends thigh nerve, tibial part
Gracilis Adducts thigh Obturator nerve
Flexes leg
Helps in medial rotation of leg
Obturator internus Lateral rotation of thigh
Steadies head of femur in acetabulum

Muscles Posterior Thigh: Extensors of hip and flexors of knee
Muscles Function Innervation Clinical Correlation
Semitendinosus Extend thigh Sciatic nerve, tibial Hamstring injuries common in individuals
Semimembranosus Flex leg division who run and/or kick hard. Usually
Medial rotation of leg when knee is accompanied by contusion and tearing of
flexed muscle fibers resulting in rupture of blood
Extend trunk when knee is flexed vessels supplying the muscles.
Biceps femoris Flexes leg Long head: sciatic Ansesthetic block of sciatic nerve done a
Lateral rotation of leg when knee is nerve, tibial division few centemeters inferior to the midpoint of
 flexed Short head: sciatic the line joining the posterior superior iliac
Extends thigh during the first step of gait nerve, common fibular spine.
division Injury to sciatic nerve:
o Complete section leg is useless
because extension of the hips is
impaired. Feet movements are also
lost
o Incomplete section in the
buttocks, the nerve has a side of
safety (lateral) and side of danger
(medial) which will paralyze the
braches to the hamstring muscles
which can impair thigh extension
and leg flexion
Intragluteal injection safe only in the
superolateral quadrant of the buttocks or
superior to the line extending from the PSIS
to the superior border of the gluteus
maximus (to avoid the sciatic nerve).


KNEE AND LEG REGION
Bones clinical correlation
Patellar fractures results from blow to knee or sudden contraction of the quadriceps
Knee dislocation potentially limb threatening due to vascular injury compression of the popliteal artery and damage to the nerves in
the poplieteal fossa

Osgood- schlatter disease chronic recurring pain during adolescents due to disruption of epiphyseal plate at the tibial tuberosity
Tibial fractures
o Tibial shaft (especially and junction of its middle and inferior thirds)
Most common site of (compound or open) fracture
Has the poorest blood supply
Transverse stress fracture of the inferior third of tibia
Common in people who take long hikes before they are coordinated with this activity
 Diagonal fracture due to severe torsion during skiing
Boot-top fracture due to a high-speed forward fall
Fibular fractures
o Commonly occur 2-6 cm proximal to the distal end of the lateral malleolus and are often combined with tibial fractures/
o Can be painful due to disrupted muscle attachments
o Walking is compromised because it has a role in ankle stability

Muscles Anterior and lateral compartments
Muscles Function Innervation Clinical Correlation
Tibialis Anterior Dorsiflex ankle Deep fibular nerve Tibialis anterior strain (shin splints) occur
Invert foot during traumatic injury or athletic
overexertion of muscles in the anterior
compartment.
Extensor digitorum Extends lateral four digit Injury to common fibular nerve most often
longus Dorsiflex ankle injured in the lower limb.
Extensor hallucis Extends great toe o Severeance results in paralysis of
longus Dorsiflexes ankle all muscles in the anterior and
Fibularis tertius Dorsiflexes andkle lateral compartments of the leg
Aids in foot eversion o Foot drop due to loss of
dorsiflexion of ankle
o Compensation:
Waddling gait individual
leans to the side opposite
the long limb, hiking the hip
Swing-out gait long limb is
swung out laterally to allow
toes to clear the ground
Steppage gait high
stepping, extra flexion is
employed at the hip and
knee to raise as high as
necessary to keep the toes
from hitting the ground
Deep fibular nerve entrapment due to
 compression of the nerve and excessive use
of muscles it supplies
Fibularis longus Everts foot Superficial fibular Superficial fibular nerve entrapment due
Fibularis brevis Weakly plantar flexes ankle nerve to chronic ankle sprains

Muscles Superficial muscles of posterior compartment of leg
Muscles Function Innervation Clinical Correlation
Gastrocnemius Plantarflexes ankle when knee is Tibial nerve Gastrocnemius strain results from partial
extended tearing of the medial belly of the
Raises heel during walking gastrocnemius at or near it
Flexes leg at knee joint musculotendinous junction (tennis leg).

Soleus Plantarflexes ankle independent of Injury to tibial nerve may be due to deep
position of knee laceration of the fossa, posterior dislocation
Steadies leg on foot of the knee joint.
Plantaris Weakly assists gastrocnemius in - Produces paralysis of the flexor muscles
plantarflexing ankle of leg and in the intrinsic muscles in the
sole of the foot.
- They are unable to plantarflex their
ankle or flex their toes.
- Loss of sensation on the sole of the
foot.


Muscles Deep muscles of posterior compartment of leg
Muscles Function Innervation Clinical Correlation
Popliteus Weakly flexes knee Tibial nerve
Unlocks knee by rotating femur 5 on
fixed tibia
Medially rotates tibia of unplanted limb
Flexor hallucis Flexes great toe on all joints
longus Weakly plantarflexes ankle
Supports medial longitudinal arch of foot
Flexor digitorum Flexes lateral four digits
longus Plantarflexes ankle
Supports longitudinal arches of foot
Tibialis posterior Plantarflexes ankle
Inverts foot

ANKLE AND FOOT
Bones clinical correlation
Calcaneal fracture due to hard fall on the heel
Calcaneal tendon rupture most severe acute muscular problem of leg.
- Cannot plantarflex against resistance and passive dorsiflexion is excessive.
- Surgical intervention is usually advised for athletic people and those with active lifestyles.
Fractures of talar neck due to severe dorsiflexion of the ankles
Os trigonum the secondary ossification center of the talus, which becomes the lateral tubercle of the talus fails to unite with the talus.
o May be caused by applied stress during early teens
Fractures of metatarsals - occurs when a heave object falls on the foot
- In ballet dancers who use demi-pointe technique
- Prolonged walking (fatigue fractures)
- Avulsion fracture of the 5th metatarsal tuberosity when the food is suddenly and violently inverted
Arches of the foot:
o Median longitudinal
Calcaneus, talus, navicular, cuneiforms, 1st-3rd MT
Higher arch
More important than lateral arch
o Lateral longitudinal arch
Flatter, rest on ground during standing
Calcaneus, cuboid, 4th 5th MT
o Transverse arch
Cuboid, cuneiform, bases of MT

Hallux valgus
o Bunions
o Due to tight footwear and pointed shoes

Muscles

Muscles Function Innervation Clinical Correlation
1st layer
Abductor halluces Abducts and flexes 1st digit Medial plantar nerve Medial plantar nerve entrapment joggers
Flexor digitorum Flexes lateral four digits foot
brevis
Flexor digitorum Abducts and flexes little toe (5th digit) Lateral plantar nerve
minimi
2nd layer
Quadratus plantae Assists flexor digitorum longus in flexing Lateral plantar nerve
lateral four digits
Lumbricals Flex prominent phalanges, extend middle Medial one: medial
and distal phalanges of lateral four digit plantar nerve
Lateral three: lateral
plantar nerve
3rd layer
Flexor halluces Flexes proximal phalanx of 1st digit Medial plantar nerve
brevis
Adductor hallucis Traditionally said to adduct 1st digit Deep branch of lateral
Assist in transverse arch of foot by plantar nerve
metatarsals medially
Flexor digiti minimi Flexes proximal phalanx of 5th digit, Superficial branch of
brevis thereby assisting with its flexion lateral plantar nerve
4th layer
Plantar interossei Adducts digits (3-5) and flex Lateral plantar nerve
(three muscles) metatarsophalangeal joints
Dorsal interossei Abducts digits (2-4) and flex
(four muscles) metatarsophalangeal joints
Dorsum of foot
Extensor digitorum Aids the extensor digitorum longus in Deep fibular nerve
brevis extending the four medial toes at the
metatarsophalangeal and
 interphalangeal joints
Extensor halluces Aids the extensor halluces longus in
brevis extending the great toe at the
metatarsophalangeal joint



BACK
Bones clinical correlation
Fracture and dislocation of atlas
o Vertical forces- fractures one or both of the anterior or posterior arches
o Rupture of transverse ligament
More likely lead to spinal cord injury
Fracture and dislocation of axis - are one of the most common injuries of the cervical vertebrae
o Usually due to hyperextension of the head of the neck (hangmans fracture)
Injury of coccyx
o Due to abrupt fall onto the buttocks dislocation of sacrococcygeal joint
Joints clinical correlation
Herniation of Nucleus Pulposus due to degeneration of nucleus pulposus
o More likely herniate posterolateraly where annulus fibrosus is relatively thin
o Likeliness increase with aging
o Other causes:
Violent rotation
Chronic or sudden flexible hyperflexion of the cervical region
Fracture of Dens most commonly fracture at the base, its junction with the body of axis.
Rupture of alar ligaments due to combined flexion and rotation of head
Back pain
o Five categories of structures that receive innervation in the back and can be source of pain
Fibroskeletal structures: periosteum, ligaments, and the annuli fibrosis of IV discs
Meninges: covering of the spinal cord
Synovial joints: capsules of the zygapophysial joints
Muscles: intrinsic back muscles
Nervous tissue: spinal nerves or nerve roots exiting the IV foramina
o Muscular pain
 Relative to reflexive camping producing ischemia, often associated with guarding (contraction of muscles in anticipation of
pain)
Zygapophysial pain associated with aging (osteoarthritis) or disease of the joint
Abnormal curvatures of vertebral column
o Excess thoracic kyphosis
Abnormal increase in curvature due to osteoporosis
o Excess lumbar lordisis
Abnormal increase in curvature anterior
o Scoliosis lateral rotation of spine
If the angle is 40-50 above curve, then it requires surgery
Adams test bending forward test which illustrate scoliosis
Sciatica pain in the lower back or hip radiating down the back of the thigh into the leg
Spondolyloslisthesis anterior or posterior displacement/slippage of the vertebra, usually due to trauma
o Grade 1: <25% slippage, low grade isthmic
o Grade 4: 100% slippage, high grade isthmic
Spondylosis degenerative osteoarthritis of the joints between the spinal vertebrae or neural foramina

Muscles superficial layer of intrinsic back muscles
Muscles Function Innervation
Splenius Acting alone: laterally flex neck and rotate head to side of active Posterior rami of spinal nerves
muscles
Acting together: extend head and neck

Muscles intermediate layer of intrinsic back muscles
Muscles Function Innervation
Erector spinae Acting bilaterally: extend vertebral column and head Posterior rami of spinal nerves
Iliocostalis o As back is flexed, control movement via eccentric
Longissimus contraction
Spinalis Acting unilaterally: laterally flex vertebral column

Muscles Deep layer of intrinsic back muscles
Muscles Function Innervation
Deep Layer
Transversospinalis Extension Posterior rami of spinal nerves
 Semispinalis Semispinalis: extends head and thoracic and cervical regions
Multifidus o Rotate them contralaterally
Rotatores (brevis and Multifidus: stabilizes vertebra during local movements of vertebral
longus) column
Rotatores: stabilizes vertebrae and assist with local extension and
rotatory movements of vertebral column
Minor Deep Layer
Interspinales Aid in extension and rotation of vertebral column Posterior rami of spinal nerves
Intertransversarii Aid in lateral flexion of vertebral column, acting bilaterally, stabilize Posterior and anterior rami of spinal
vertebral column nerves
Levatores costarum Elevate ribs, assisting respiration Posterior rami of c8-t11 spinal
Assist with lateral flexion of vertebral column nerves


RADIOLOGY
Cervical Spine
7 Cervical bodies
o C1 or atlas ring shaped flat bone with no vertebral body; fuses with c2 to form dense or odontoid process
o C2 or axis visible inside open mouth teeth block imaging of closed mouth
o C7 has the largest spinous prominence
What to look for:
o Equidistant IVD with no IVD spaces
CT scan
o Will not be able to see spinal cord
MRI
o Axial view: can observe the cord inside the canal
Thoracic spine
12 vertebral bodies
o T12 where the last rib is connected
What to look for:
o In AP view: pedicles that are seen as ovoid structure: owl like
Eyes of owl: pedicles
Head of owl: rectangle of vertebral body
Beak of owl spinous process
 If the spine looks like a stack to owl head (winking owls eye) it suggests erosion or sclerosis of the pedicle.
o Scoliosis
Cobbs angle: determines the degree of curvature of the spine; used in the diagnosis of the severity of scoliosis
An angle of at least 10 denotes presence of mild scoliosis
o Ankylosing spondylitis
Fusing of bones which prevents patients from bending: bamboo spine
Lumbar spine
5 vertebral bodies
o Axial view sows ovoid or kidney shaped vertebral bodies
X-ray imaging
Left oblique: used to see the right pairs
Pars intercularis: neck or the area between the superior and inferior articular processes
scotty dog should be intact, pars intercularis is the neck of the dog
Sponylolysis: fracture of parts which leads to low back pain
o Seen as break or a collar in the scotty dog
CT scan
o Best modality for observing osseus lessions
MRI
o Preferred modality since more structures can be sseen
o Best for stenosis
o Used to diagnose for sponyloslisthesis
o What to look for:
Color of IVD denotes age of patient
Child IVD has higher water content so it shows as white/bright in T2
Adult IVD loses water so it may not be observed
Sacral spine
5 fused bones
o Sacral promontory: s1 vertebra
o Sacral hiatus: s4and s5 U shaped region on the posterior aspect of the sacrum
o Oblique view: to observe sacroiliac joint
Lower extremities:
Pelvimetry
o Performed for pregnant women with possible dystocia (difficult labor caused by narrow pelvic canal)
o requires AP/lateral view
 o pelvic inlet (line from sacral promontory to pubic symphysis) widest
development sysplasia of the HIP (DDH)
o hilgenreiners line: drawn from one tri-radiate ligament to another
must be straight, horizontal
o perkins line: drawn perpendicular to Hilgenreiners line near the acetabular roof
will form 4 quadrants
femoral head must lie in lower medial quadrant, anywhere else and there is hip dislocation
shentons line: drawn along inferior border of superior pubic ramus to inferomedial border of femoral neck
o must be continuous
imaging oh hip joint
o equidistant joint spaces are not present In osteoarthritis
imaging of the knee
o patella should point down on the dead center
sunrise view (AP view of the flexed knee): patella must be equidistant with femur, should be continuous without fracture
o osteosarcoma presents as sclerosis on bone medulla extending into soft tissue as sunburst appearance on x-ray, visible mass in
seen in T1 and T2 MRIs.
Imaging of the ankle
o Ankle mortis view
Used to observe joint spaces fully; lateral malleolus usually obstructs joint in AP view
Imaging of the foot
o Bohlers angle angle formed by lines drawn from the superior portion of the calcaneal tuberosity to the apex of the bone from the
anterior of bone to the apex
Normal: 20-40 degrees
Decrease may indicate a fracture of the calcaneus
o Calcaneal pitch angle: arch of the foot: angle formed by lines drawn from the plantar surface of the calcaneus to the inferior border
of the cuboid and from the calcaneus to the inferior surface of the 5th metatarsal head
Taken in standing view
Normal: 20-25 degrees
Decrease: flat foot, pes planus
Increase = high arch, pes alta/pes cavus