Page 226 - Clinical Anatomy

ECA4 7/18/06 6:47 PM Page 211

The anatomy and surface markings of the lower limb 211

At the tibia
Compare the distance from the line of the knee joint to the medial malleolus
on each side.

Muscles and tendons

Quadriceps femoris forms the prominent muscle mass on the anterior aspect
of the thigh; its insertion into the medial aspect of the patella can be seen to
extend more distally than on the lateral side. In the well-developed subject,
sartorius can be defined when the hip is flexed and externally rotated
against resistance. It extends from the anterior superior iliac spine to the
medial side of the upper end of the tibia and, as the lateral border of the
femoral triangle; it is an important landmark.
Gluteus maximus forms the bulk of the buttock and can be felt to contract
in extension of the hip.
Gluteus medius and minimus and the adductors can be felt to tighten
respectively in resisted abduction and adduction of the hip.
Define the tendons around the knee with this joint comfortably flexed in
the sitting position:
•◊◊laterally—the biceps tendon passes to the head of the fibula, the iliotibial
tract lies about 0.5in (12mm) in front of this tendon and passes to the lateral
condyle of the tibia;
•◊◊medially—the bulge which one feels is the semimembranosus insertion on
which two tendons, semitendinosus laterally and gracilis medially and more
anteriorly, are readily palpable.
Between the tendons of biceps and semitendinosus can be felt the heads
of origin of gastrocnemius. This muscle, with soleus, forms the bulk of the
posterior bulge of the calf; the two end distally in the tendo Achillis
(calcaneal tendon).
At the front of the ankle (Fig. 151) the tendon of tibialis anterior lies
most medially, passing to its insertion at the base of the first metatarsal and
the medial cuneiform. More laterally, the tendons of extensor hallucis longus
and extensor digitorum longus are readily visible in the dorsiflexed foot. Per-
oneus longus and brevis tendons pass behind the lateral malleolus. Behind
the medial malleolus, from the medial to the lateral side, pass the tendons
of tibialis posterior and flexor digitorum longus, the posterior tibial artery
with its venae comitantes, the tibial nerve and, finally, flexor hallucis longus
(Fig. 152).

Vessels
The femoral artery (Fig. 153) can be felt pulsating at the mid-inguinal point,
half-way between the anterior superior iliac spine and the pubic symph-
ysis. The upper two-thirds of a line joining this point to the adductor tuber-
cle, with the hip somewhat flexed and externally rotated, accurately defines
the surface markings of this vessel. A finger on the femoral pulse lies
directly over the head of the femur, immediately lateral to the femoral vein