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The primary ossification center of the tibia appears at the 7th week of intra-uterine life.

Tibia is ossified from three centers: one primary center in the shaft and two secondary centers, one in each epiphysis.

• Primary center
• Ossification in the shaft appears at the 7th week of intrauterine life.
• Secondary center
• In the upper end, the ossification center is usually present at birth and fuses with the shaft in

years in females and 18 years in males.

• In the lower end, the ossification center appears early in the first year and fuses with the shaft in the 15th year in females and 17th year in males.

The image given below shows ossification centers of tibia.

The bone depicted here is the fibula. The biceps femoris is attached to the head of this bone. Important structures related to fibula:

• Fibular collateral ligament and biceps femoris are attached to the head
• The common peroneal nerve can be rolled against the neck
• The shaft has 3 surfaces and is related to the muscles of the leg:
• The lateral surface is related to fibular muscles
• The anteromedial surface is related to extensors
• The posterior surface is related to flexor muscles

The patient is likely to have a fracture involving the neck of the fibula, which is closely related to the common peroneal nerve (injury - foot drop).

Clinical considerations of the fibula:

• Since fibula does not take part in the transmission of body weight, it is a common source of bone for grafting. The lateral malleolus and the ligaments attached to it are very important in maintaining stability at the ankle joint.
• The common peroneal nerve can be rolled against the neck of the fibula. This nerve is commonly injured.
• In the first stage of Pott’s fracture, the lower end of the fibula is fractured spirally.

The navicular bone is interposed between the head of the talus and the cuneiforms.

There are 7 tarsal bones that occupy the proximal half of the foot. The proximal row is made up of the talus and calcaneum. The distal row, from medial to lateral, contains the medial, intermediate, and lateral cuneiforms and the cuboid. Medially the navicular bone is interposed between the head of the talus and the cuneiforms.

The images given below show the tarsal bones of the foot.

The sustentaculum tali is a projection present on the calcaneus, on its medial surface.

The superior surface has a facet, to articulate with the middle facet on the head of the talus. It supports the posterior part of the head of the talus.

The inferior surface of the sustentaculum tali has a groove along which the tendon of flexor hallucis longus muscle travels into the sole of the foot.

The image given below shows the sustentaculum tali on the calcaneus.

Given below are the 3 ligaments attached to the sustentaculum tali:

• Plantar calcaneonavicular ligament (anterior surface)
• Deltoid ligament (medial surface)
• Medial talocalcaneal ligament

Zona orbicularis is related to the neck of femur. They are the circular fibers of the capsule of hip joint.

Capsule of the hip joint is made up of 2 sets of fibers:

• Circular fibers or zona orbicularis - They are internal and form a collar around the neck of femur. They are blended with the pubofemoral and ischiofemoral ligaments
• Longitudinal fibers - They are external. These fibers are numerous in the anterosuperior region and are joined by iliofemoral ligament.

The image given below shows the zona orbicularis.

Transverse acetabular ligament does not contain cartilage cells. This ligament crosses the acetabular notch and continues peripherally with the labrum.

Ligaments of the hip joint are:

• Iliofemoral ligament - strongest ligament of hip joint
• Pubofemoral ligament - triangular in shape
• Ischiofemoral ligament - some fibers fuse with zona orbicularis and inferior fibers attach to the posterior circumference of femoral neck
• Transverse acetabular ligament - forms a foramen to allow vessels and nerves to enter the hip joint
• Ligament of head of femur - apex is attached to fovea and base is attached to the edges of acetabular notch

The images given below show the ligaments of the hip joint.

Note: Iliocapsularis is a muscle that lies immediately deep to the tendon of iliopsoas and above the anterior hip capsule. The function of the muscle is not clear and is thought to taut the hip capsule to prevent its impingement during the hip flexion.

The iliofemoral ligament resists the hyperextension of hip joint and hence, is likely to be injured.

Iliofemoral ligament or ligament of Bigelow is the strongest ligament of the hip joint. It is

an inverted-Y-shaped ligament. The apex is attached between the anterior inferior iliac spine and acetabular margin. The base is attached to the intertrochanteric line. This ligament prevents the hyperextension of the hip joint.

The image given below shows the iliofemoral ligament.

A patient with an effusion in the hip joint is has least pain in flexed and abducted position.

Joint capacity is maximal when the hip joint is held in a partially flexed and abducted

position. Hence, a patient with an effusion in the hip joint is therefore most comfortable in this position.

The image shown is the ligament of head of the femur and the artery passing through it is the foveal artery/ artery of ligament of head of femur. It is derived from the acetabular branch

of obturator artery.

The blood supply of the femoral head is derived from an arterial ring (trochanteric anastomosis) around the neck of femur constituted by:

• Medial circumflex femoral arteries
• Lateral circumflex femoral arteries
• Superior and inferior gluteal vessels (minor contributions)

The structures attached to the areas marked 1, 5, and 6 in the tibial plateau are anterior cruciate ligament, posterior cruciate ligament, anterior and posterior horns of medial meniscus respectively.

Remember the attachments of ligaments from anterior to posterior as: Mnemonic: Medical College Ludhiana Ludhiana Medical College

• M: Medial meniscus (Anterior horn)
• C: Cruciate ligament (Anterior)
• L: Lateral meniscus (Anterior horn)
• L: Lateral meniscus (Posterior horn)
• M: Medial meniscus (Posterior horn)
• C: Cruciate ligament (Posterior)

The unhappy triad of the knee involves:

• Medial meniscus
• Anterior cruciate ligament
• Tibial collateral ligament

Coronary ligaments are also known as meniscotibial ligaments. It refers to the tibial attachment of medial meniscus.

The medial meniscus is almost a semicircle in shape. It is attached by its anterior horn to the anterior tibial intercondylar area in front of the anterior cruciate ligament. The posterior horn is fixed to the posterior tibial intercondylar area, between the attachments of the lateral meniscus and posterior cruciate ligament.

These attachments ensure that the medial meniscus is relatively fixed and moves much less than the lateral meniscus.

The image given below shows the cranial and caudal meniscotibial ligament.

The movements of medial meniscus are restricted compared to the lateral meniscus Comparison between medial and lateral menisci:

Option C: Peripheral zone of menisci are vascularized by capillary loops and inner regions are less vascular. Hence, relative healing rate is better in peripheral zone.

Option D: Suprapatellar bursa is the superior extension of the knee joint cavity. It lies between the femur and suprapatellar part of quadriceps femoris.

Feature Mobility

Shape

Area covered

Additionalfeature s

Lateral meniscus More mobile

Forms approximately 4/5th o f a circle

Covers alarger area

Grooved posterolaterally by P opliteus tendon, which separ ates it from fibular collateral ligament

Medial meniscus

Relatively fixed and therefore moves much less than lateral meniscus

Semicircular in shape

Covers less area than lateral meniscus

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Locking of knee is medial rotation of femur on tibia during the later stages of extension.

When standing, the knee joint is locked into position to reduce the amount of muscle work needed to maintain the standing position. The muscle responsible for locking is vastus medialis.

The image given below shows the locking of knee joint on standing.

Unlocking of the knee joint is the lateral rotation of femur on tibia during the beginning of flexion. This is brought by the action of popliteus muscle.

Clergyman's knee and housemaid's knee results from inflammation of infrapatellar bursa and prepatellar bursa respectively.

Lower limb major bursitis:

• Prepatellar Bursitis (Housemaid's Knee)
• Infrapatellar bursitis (Clergyman's knee)
• Trochanteric Bursitis (Above hip abductor)

The image shows a sagittal section through the left knee joint (lateral aspect) with bursae.

Ligamentum mucosum is related to the knee joint. It is a plica present at the intercondylar notch of the knee joint.

Plicae are the embryological remnants of synovial folds. Major plicae around knee joint are:

• Ligamentum mucosum - intercondylar notch
• Suprapatellar plica - suprapatellar space
• Medial plica - extending from infrapatellar fat pad to medial wall of knee

Plica syndrome is a painful knee function due to thickened and inflamed synovial folds. It most commonly involves the medial plica.

The image given below shows the synovial plicae.

The anterior talofibular ligament is most commonly injured with inversion sprains.

Important ligaments of ankle present on the lateral side, and therefore likely to be injured in inversion sprains include:

• Anterior talofibular ligament (ATFL) - most commonly injured
• Posterior talofibular ligament (PTFL)
• Calcaneofibular ligament (CFL)

The image given below shows the ligaments attached to the lateral side of ankle.

Important ligaments of ankle present on the medial side, and therefore likely to be injured in eversion sprains include:

• Deltoid ligament (Medial collateral ligament)
• Spring ligament (calcaneonavicular ligament)

The image given below shows the ligaments attached to the medial side of ankle.

Superficial part of deltoid ligament is attached to all bones except fibula.

Deltoid ligament or medial collateral ligament is a strong triangular band, attached to the apex, the anterior and posterior borders of the medial malleolus. It has 2 layers, superficial and deep:

• Superficial layer consists of tibionavicular fibers anteriorly, tibiocalcaneal fibers in the
• middle, and superficial posterior tibiotalar fibers posteriorly.
• Deep layer consists of anterior tibiotalar fibres, tibiocalcaneal in the middle and deep posterior tibiotalar posteriorly.

The structure marked in the image is the head of talus. The ligament related to its inferior surface is the spring ligament/ calcaneonavicular ligament.

The inferior surface of the head of talus has three facets:

• Posterior facet - It is the largest facet and articulates with the sustentaculum tali of the calcaneus.
• Anterolateral facet - It articulates with the anterior facet of the calcaneus.
• Medial facet - It is related to the spring ligament.

In the given image, the structure marked is the spring ligament (plantar calcaneo-navicular ligament). It is a complex of three ligaments, namely:

• Superomedial calcaneonavicular ligament
• Medioplantar oblique calcaneonavicular ligament
• Inferoplantar longitudinal calcaneonavicular ligament

The spring ligament is a thick band connecting the anterior margin of the sustentaculum tali to the plantar surface of the navicular.

It is the stabilizer of medial longitudinal arch and the head of the talus. Disruption of this ligament leads to the collapse of medial longitudinal arch and causes flat foot.

The image given below shows the spring ligament.

Lisfranc's ligament is cuneometatarsal interosseous ligament.

There are three cuneometatarsal interosseous ligaments and the strongest ligament is Lisfranc's ligament. It passes from the lateral surface of the medial cuneiform to the adjacent angle of the second metatarsal bone. Deformity of this ligament can lead to instability and deformity of tarsometatarsal joint.

Chopart's ligament is related to both calcaneocuboid and calcaneonavicular joints.

Chopart's ligament/ Bifurcate ligament is a strong Y- shaped band, having a proximal stem and 2 distal limbs.

• The proximal limb is attached by a stem to the anterior part of upper calcaneal surface.
• The distal limb divides into calcaneocuboid and calcaneonavicular parts.
• The image given below shows the Chopart's ligament.

The sartorius muscle is the longest muscle in the body.

It originates from the anterior superior iliac spine and inserts into the superior aspect of the medial surface of the tibial shaft near the tibial tuberosity (joins gracilis and semitendinosus at the pes anserinus).

It flexes and laterally rotates the hip joint and flexes the knee and is innervated by the femoral nerve (L2, L3, and L4).

The gluteus maximus muscle is attached to the iliotibial tract of the fascia lata. Origin:

• Posterior aspect of dorsal ilium, posterior to posterior gluteal line
• Posterior superior iliac spine
• Posterior aspect of sacrum and coccyx
• Sacrotuberous ligament.

Insertion - It is inserted mainly in fascia lata at the iliotibial band and also into the gluteal tuberosity on the posterior femoral surface.

Action:

• Major extensor of hip joint
• Lateral rotation of hip joint
• Active in powerful abduction of thigh

Arterial Supply - Inferior and superior gluteal arteries and the first perforating branch of the profunda femoris artery.

Nerve Supply- Inferior gluteal nerve (L5, S1 and S2).