CHAPTER 6 BONTRAGER

Ankle Joint Lateral View True/False In positioning a lateral ankle is to rotate the ankle slightly so that the medial and lateral malleoli are directly superimposed; resulting in a partially oblique ankle, as these drawings illustrate

False - A true lateral requires the lateral malleolus to be about (3⁄8) inch (1 cm) posterior to the medial malleolus. - The lateral malleolus extends about 3⁄8 inch (1 cm) more distal than its counterpart, the medial malleolus (best seen on frontal view, Fig. 6.10).

Special PT considerations Pediatric Applications

Generally, exposure factors must be decreased because of reduced tissue quantity and density (brightness). Shorter exposure times, along with the highest mA possible, help to eliminate motion on the radiograph.

Fibula what is the enlarged distal end of the fibula and can be felt as a distinct "bump" on the lateral aspect of the ankle joint

Lateral Malleolus

Arches of Foot The bones of the foot are arranged in two types of arches, what are they?

Longitudinal and transverse arches providing a strong, shock-absorbing support for the weight of the body.

Joints of the Metatarsals What is a good center point or central ray (CR) location for anteroposterior (AP) and oblique foot projections?

The base of the third metatarsal or the third tarsometatarsal joint

Fibula What is the long, slender portion of the fibula between the two extremities

The body (shaft)

Ankle Joint Axial View demonstrated in fig 6.12 the smaller fibula is shown to be more ________________ (posterior/anterior)

more posterior

Lower Leg The second group of bones of the lower limb to be studied in this chapter consists of the two bones of the lower leg:

the tibia and fibula

Toes The distal phalanges of the ______ through _______ toes are very small and may be difficult to identify as separate bones on radiograph.

2nd, 5th

Tibia Proximal Extremity What are the two large processes that make up the medial and lateral aspects of the proximal tibia

The medial and Lateral condyles

Midfemur and Distal Femur -Posterior View The rounded distal portions of the medial and lateral condyles contain smooth articular surfaces for articulation with the tibia. Which condyle extends lower or more distally than the other?

The medial condyle extends lower or more distally than the lateral condyle when the femoral shaft is vertical This explains why the CR must be angled 5° to 7° cephalad for lateral knee to cause the two condyles to be directly superimposed when the femur is parallel to the IR (fig. parrallel to floor) The range is 5°to 15° ◆ more angle for short stature and wider pelvis ◆ less angle for tall stature with a narrow pelvis ◆ normally more angle on women than on males

What is a flattened, oval bone located on the medial side of the foot between the talus and the three cuneiforms?

The navicular

Radiographic Positioning Exposure factors

The principal exposure factors for radiographs of the lower limbs are as follows: 1. Low-to-medium kVp (50-85) 2. Short exposure time 3. Small focal spot 4. Adequate milliamperes (mAs) for sufficient density (brightness)

Ankle Joint Frontal View The ankle joint is formed by three bones:

The two long bones of the lower leg, the tibia and fibula, and one tarsal bone, the talus.

What is the largest and strongest bone of the foot?

calcaneus (heel bone) ∙ the most posterior-inferior part of the calcaneus contains a process called the tuberosity. ∙ the tuberosity is the common site for bone spurs (sharp outgrowths of bone; painful on WB)

Several small detachable bones often found in the feet and hands are ____________? These extra bones, which are embedded in certain tendons, are often present near various joints.

sesamoid bones In the upper limbs, sesamoid bones are quite small In the lower limbs, sesamoid bones tend to be larger and more significant radiographically.

Patella The patella is loose and movable in its more superior position when the leg is _____________ and the quadriceps muscles are ____________.

extended, relaxed However, as the leg is flexed and the muscles tighten, it moves distally and becomes locked into position. The patella articulates only with the femur, not with the tibia.

Ankle Joint Frontal View The expanded distal end of the slender fibula, which extends well down alongside the talus is called the

lateral malleolus

Fibula The smaller fibula is located ___________ and _________ to the larger tibia.

laterally, posteriorly

Ankle Joint structure Lateral stress can result in a "sprained" ankle with stretched or torn collateral ligaments and torn muscle tendons leading to__________________

leading to an increase in parts of the mortise joint space AP stress views of the ankle can be performed to evaluate the stability of the mortise joint space

Patella The patella serves to protect the anterior aspect of the knee joint and acts as a pivot to increase the _____________ of the large quadriceps femoris muscle, the tendon of which attaches to the tibial tuberosity of the lower leg.

leverage

Fibula The fibula articulates with the tibia ___________ and the tibia and talus _______________.

proximally, distally

Toes Similarities to the hand are obvious because there are also 14 phalanges in each hand. However, two noticeable differences exist: - the phalanges of the foot are ________, and their movements are more ____________ than those of the phalanges of the hand.

smaller, limited

Alternative Modalities and Procedures ARTHROGRAPHY

sometimes is used to image large diarthrodial joints such as the knee. This procedure requires the use of a contrast medium injected into the joint capsule under sterile conditions. Disease or traumatic damage to the menisci, ligaments, and articular cartilage may be evaluated with arthrography

Midfemur & Distal Femur -Anterior View The patella itself most often is _________ to the patellar surface with the leg fully extended. However, as the leg is flexed, the patella, which is attached to large muscle tendons, moves _______________________ the patellar surface.

superior, distally or downward over

Talus Articulations The talus articulates with four bones:

superiorly with the tibia and fibula inferiorly with the calcaneus, and anteriorly with the navicular

Synovial Membrane and Cavity ∙ The articular cavity or bursa of the knee joint extends upward under and superior to the patella, identified as the __________________. ∙ Distal to the patella, the infrapatellar bursa is separated by a large ________________, which can be identified on radiographs.

suprapatellar bursa, infrapatellar fat pad The spaces posterior and distal to the femur also can be seen and are filled with negative contrast media o n the lateral arthrogram radiograph.

Ankle Joint structure The ankle join is _________ joint of the ____________ type with flexion and extension (dorsiflexion and plantar flexion) movements only.

synovial joint, saddle (sellar)

Classification of Joints The joints or articulations of the lower limb all (with exception) are classified as ________________ and are one by a fibrous-type capsule that contains synovial fluid characterized (with one exception) _______________.

synovial joints, Diarthrodial or freely moveable. - The single exception to the synovial joint is the distal tibiofibular joint, which is classified as a fibrous joint with fibrous interconnections between the surfaces of the tibia and fibula. It is of the syndesmosis type and is only slightly moveable.

The seven large bones of the proximal foot are called_______?

tarsal bones (Ex.) mnemonics: Come to Colorado (the) next 3 Christmases Tall (Talus) Camels (Calcaneus) Never (Navicular) Consume (3 Cuneiforms- medial, intermediate, lateral) Cubes (Cuboid)

Proximal Tibiofibular Joint and Major Knee Ligaments In addition to these two major pairs of ligaments, an anteriorly located patellar ligament and various minor ligaments help to maintain the integrity of the knee joint. The patellar ligament is shown as part of the tendon of _______________

tendon of insertion of the large quadriceps femoris muscle, extending over the patella to the tibial tuberosity.

Midfemur and Distal Femur -Posterior View What are rough prominences for attachment that can be palpated, on the medial and lateral collateral ligaments and are located on the outermost portions of the condyles?

the Medial and Lateral epicondyles ∙ the medial epicondyles, along with the adductor tubercle is the more prominent of the two

Calcaneus Articulations The deep depression between the posterior and middle articular facets iS called the _____________________.

the calcaneal sulcus

Cuboid Articulations The cuboid articulates with five bones:

the calcaneus proximally the lateral cuneiform and navicular medially the fourth and fifth metatarsals distally

Tibia The tibia, as one of the larger bones of the body, is the weight-bearing bone of the lower leg. The tibia can be felt easily through the skin in the anteromedial part of the lower leg. It is made up of three parts: what are they?

the central body (shaft) and two extremities.

Calcaneus Articulations The calcaneus articulates with two bones: anteriorly with the __________ and superiorly with the _________.

the cuboid, the talus

Knee Joint The knee joint proper is a large complex joint that primarily involves the femorotibial joint between the two condyles of the_________________?

the femur and the corresponding condyles of the tibia The patellofemoral joint is also part of the knee joint, wherein the patella articulates with the anterior surface of the distal femur.

The bones of the distal lower limb are divided into

the foot, lower leg, distal femur, the ankle and knee

Joints of the Metatarsals When joints of the foot are described the name of the ________________ goes first, followed by the ____________ or metatarsal, and finally the ____________.

the joint, digit or metatarsal, foot (EX.) an injury or fracture may be described as near "the DIP joint of the fifth digit of the left foot"

Special PT considerations Bariatric PT

- increased compression due to improper clothing and added soft tissue can make it difficult to visualize fad pad signs indicative of fractures. - The increase in soft tissue does not change the position of the osseous anatomy. Increases in soft tissue may warrant changes in exposure factors. - may include an increase in kVp to improve penetration through additionally thick tissue. - may include an increase in kVp to improve

Special PT considerations Geriatric Applications

- must be handled carefully when they are being moved, and radiography of the lower limbs is no exception. Look for telltale signs of hip fracture - adjusted maneuvers to accommodate potential pathology and lack of joint flexibility - Exposure factors may require adjustment because of underlying pathologic conditions such as osteoarthritis or osteoporosis. Shorter exposure time and higher mA are desirable for reducing the possibility of imaging involuntary or voluntary motion.

Knee trauma The knee has great potential for traumatic injury, especially in activities such as skiing or snowboarding or in contact sports such as football or basketball. A tear of the tibial MCL frequently is associated with a tear of the...

-a tear of the ACL and a tear of the medial meniscus. Patients with these injuries typically come to the imaging department for magnetic resonance imaging (MRI) to visualize these soft tissue structures or for knee arthrography.

Foot The bones of the foot are fundamentally similar to the bones of the hand and wrist: The Bones of the Foot are divided into three groups, what are they?

1. Phalanges (toes or digits) 14 2. Metatarsals (instep) 5 3. Tarsals 7 total = 26

Midfemur & Distal Femur -Anterior View The most distal part of the patella is superior or proximal to the actual knee joint by approximately ______________ in (cm) in this position with the lower leg fully extended

1/2 in (1.25 cm) This relationship becomes important in positioning for the knee joint.

Tibia Proximal Extremity on the lateral view, the articular facets making up the tibial plateau slope posteriorly from __________ in relation to the long axis of the tibia

10° to 20° This is an important anatomic consideration because when an AP knee is positioned, the CR must be angled as needed in relation to the image receptor (IR) and the tabletop to be parallel to the tibial plateau. This CR angle is essential in demonstrating an "open" joint space on an AP knee projection.

Ankle Joint Axial View The lower leg and ankle must be rotated ___________________ to bring the intermalleolar plane parallel to the coronal plane.

15° to 20° This relationship of the distal tibia and fibula becomes important in positioning for various views of the ankle joint or ankle mortise, as described in the positioning sections of this chapter.

Ankle Joint Lateral View The ankle joint, seen in a true lateral position in Fig. 6.11, demonstrates that the distal fibula is located about _______________ in (cm) posterior in relation to the distal tibia.

3⁄8 inch (1 cm) This relationship becomes important in evaluation for a true lateral radiograph of the lower leg, ankle, or foot.

Tarsals Similarities to the upper limb are less obvious with the tarsals in that, there are only ___________ tarsal bones, compared with the ___________ carpal bones in the wrist.

7 tarsal bones, 8 carpal bones ∙ tarsals are larger and less mobile because they provide a basis of support for the body in an erect position ∙ carpals are more mobile in the hands/wrist than the tarsals

Proximal Tibiofibular Joint and Major Knee Ligaments major knee ligaments shown on this posterior view (fig 6.25) are the tibial what are the two pair of major ligaments used for stability?

ACL, PCL, LCL, and MCL - fibular (lateral) collateral ligament (LCL) extends from the femur to the lateral proximal fibula - (medial) collateral ligament (MCL), located medially and the major posterior and anterior cruciate - ligaments (PCL and ACL), located within the knee joint capsule

Calcaneus On the calcaneus, certain large tendons (the largest of tendons) are attached to the Calcaneal tuberosity (striated process bone spurs) what is this large tendon called?

Achilles Tendon ∙ attached to this rough and striated process, which at its widest point - includes two small, rounded processes. - The largest of these is labeled the lateral process. - The smaller and less pronounced is the medial process.

Ankle Joint Frontal View What is an expanded process at the distal anterior and lateral tibia that has been shown to articulate with the superolateral talus, while partially overlapping the fibula anteriorly

Anterior tubercle

Joints of digits Digits 2-5 have three phalanges bones these digits have two joints each: what are they?

Between the middle and distal phalanges the distal interphalangeal (DIP) joint. Between the proximal and middle phalanges is the proximal interphalangeal (PIP) joint.

Tibia What is the long portion of the tibia between the two extremities.

Body (shaft)

Proximal Tibiofibular Joint and Major Knee Ligaments The two collateral ligaments are strong bands at the sides of the knee that__________________. The two cruciate ligaments are strong, rounded cords that cross each other as they attach to the respective anterior and posterior aspects of the intercondylar eminence of the tibia. They stabalize the knee joint by __________________.

Collateral ligaments: prevent adduction and abduction movements at the knee. Cruciate ligaments: They stabilize the knee joint by preventing anterior or posterior movement within the knee joint.

The five bones of the instep of the foot; following the phalanges are the?

Metatarsal bones

Ankle Joint Frontal View What is the inferior portions of the tibia and fibula form a deep "socket," or three-sided opening, into which the superior talus fits.

Mortise

Distal femur what is a flat triangular bone approximately 2 inches (5 cm) in diameter

Patella (kneecap) The patella appears to be upside down apex is located along the inferior border base is the superior or upper border The outer or anterior surface is convex and rough the inner or posterior surface smooth and oval-shaped for articulation with the femur.

Midfemur & Distal Femur -Anterior View What is the largest sesamoid bone in the body?

Patella (kneecap) is located anteriorly to the distal femur

Distal Femur and Patella (Lateral View) What is the posterior surface of the distal femur just proximal to the intercondylar fossa?

Popliteal surface over which popliteal blood vessels and nerves pass

Calcaneus Articulations The superior articulation with the talus forms the important _______________ joint.

Subtalar (talocalcaneal) joint

What tarsal is located on the lateral aspect of the foot distal to the calcaneus and proximal to the forth and fifth metatarsal?

The cuboid

Cuneiforms The smallest of the cuniforms which articulates with the second metatarsal is the__________________.

The intermediate (second) cuneiform All three cuneiforms articulate with the navicular proximally.

Cuneiforms What is the cuneiform that articulates with the third metatarsal distally and with the cuboid laterlally?

The lateral (third) cuneiform All three cuneiforms articulate with the navicular proximally.

Cuneiforms The largest cuneiform, which articulates with the first metatarsal, is the_________________.

The medial (first) cuneiform. All three cuneiforms articulate with the navicular proximally.

Menisci (Articular Disks) The medial and lateral menisci are crescent-shaped fibrocartilage disks between the articular facets of the tibia (tibial plateau) and the femoral condyles. They are thicker at their external margins, tapering to a very thin center portion. They act as ____________________

They act as shock absorbers to reduce some of the direct impact and stress that occur at the knee joint. The synovial membrane and the menisci produce synovial fluid, which lubricates the articulating ends of the femur and tibia that are covered with a tough, slick hyaline membrane.

Tibia Proximal Extremity What is on the proximal extremity of the tibia, is a rough-texture prominence located on the mid-anterior surface of the tibia just distal to the condyles.

Tibial Tuberosity This tuberosity is the distal attachment of the patellar tendon, which connects to the large muscle of the anterior thigh. Sometimes in young persons the tibial tuberosity separates from the body of the tibia, a condition known as Osgood-Schlatterdisease

Patella True/False The patella articulates only with the femur, not with the tibia.

True

Ankle Joint Frontal View True/False The entire three-part joint space of the ankle mortise is not seen on a true frontal view (AP projection) because of overlapping of portions of the distal fibula and tibia by the talus.

True This overlapping is caused by the more posterior position of the distal fibula, as is shown on these drawings.

Toes True/False When any of the bones or joints of the foot are described, the specific digit and foot should also be identified. (EX.) "distal phalanx of the first digit of the right foot"

True referring to the would leave no doubt as to which bone being described.

Proximal Tibiofibular Joint and Major Knee Ligaments True/False The proximal fibula is not part of the knee joint

True -because it does not articulate with any aspect of the femur - even though the fibular (lateral) collateral ligament (LCL) extends from the femur to the lateral proximal fibula, the head of the fibula does articulate with the lateral condyle of the tibia, to which It is attached by this ligament.

Joints of the Metatarsals The joint at the base of the metatarsal is...

a tarsometatarsal (TMT) joint

Midfemur and Distal Femur -Posterior View A distinguishing difference between the medial and lateral condyles is the presence of the

adductor tubercle a slightly raised area that receives the tendon of an adductor muscle

Clinical Indications Reiter syndrome

affects the sacroiliac joints and lower limbs of young men; the radiographic hallmark is a specific area of bony erosion at the Achilles tendon insertion on the posterosuperior margin of the calcaneus. Involvement is usually bilateral, and arthritis, urethritis, and conjunctivitis are characteristic of this syndrome. Reiter syndrome is caused by a previous infection of the gastrointestinal tract, such as salmonella, or by a sexually transmitted infection. X-ray examination: AP and lateral of affected parts

Proximal Tibiofibular Joint and Major Knee Ligaments The infrapatellar fat pad, posterior to this ligament aids in______________

aids in protecting the anterior aspect of the knee joint.

Clinical Indications Osteoarthritis

also called degenerative joint disease (DJD), is a noninflammatory joint disease that is characterized by gradual deterioration of the articular cartilage with hypertrophic (enlargement or overgrown) bone formation. This is the most common type of arthritis and is considered part of the normal aging process. X-ray examination: AP, oblique, and lateral of affected part

Tibia Body Along the anterior surface of the body, tending from the tibial tuberosity to the medial malleolus, is a sharp ridge called the____________

anterior crest or border This sharp anterior crest is just under the skin surface and often is referred to as the shin or shin bone.

Fibula The extreme proximal aspect of the head is pointed and is known as the _________ of the head of the fibula. The tapered area just below the head is the ________ of the fibula.

apex, neck

Clinical Indications Osteoid osteomas

are benign bone lesions that usually occur in teenagers or young adults. Symptoms include localized pain that typically worsens at night but is relieved by over-the-counter anti-inflammatory or pain medications. The Tibia and the femur are the most likely locations of these lesions. X-ray examination: AP and lateral of affected part

Clinical Indications Osteoclastomas (giant cell tumors)

are benign lesions that typically occur in the long bones of young adults, they usually occur in the proximal tibia or distal femur after epiphyseal closure. These tumors appear on radiographs as large "bubbles" separated by thin strips of bone. X-ray examination: AP and lateral of affected part

Clinical Indications Bone cysts

are benign, neoplastic bone lesions filled with clear fluid that most often occur near the knee joint in children and adolescents. Generally, these are not detected on radiographs until pathologic fracture occurs. When bone cysts are detected on radiographs, they appear as lucent areas with a thin cortex and sharp boundaries. X-ray examination: AP and lateral of affected limb

Clinical Indications Fractures

are breaks in the structure of bone caused by force (direct or indirect). The types of fracture are named according to the extent of fracture, direction of fracture lines, alignment of bone fragments, and integrity of overlying skin

Clinical Indications Osteogenic sarcomas (osteosarcomas)

are highly malignant primary bone tumors that occur from childhood to young adulthood (peak age, 20 years). The neoplasm usually is seen long bones and may cause gross destruction of bone. X-ray examination: AP and lateral of affected part, CT, MRI

Clinical Indications Chondrosarcomas

are malignant tumors of the cartilage that usually occur in the pelvis and long bones of men older than 45 years. X-ray examination: AP and lateral of affected limb, CT, MRI

Synovial Membrane and Cavity The articular cavity of the knee joint is the largest joint space of the human body. The total knee joint is a synovial type enclosed in an

articular capsule, or bursa It is complex, saclike structure filled with a lubricating-type synovial fluid.

Tibia Proximal Extremity The upper articular surface of the condyles includes two smooth concave

articular facets, commonly called the tibial plateau, which articulate with the femur.

Joints of digits Why are joints/ articulations of the digits of the foot important to identify?

because fractures may involve the joint surfaces. Each joint of the foot has a name derived from the two bones on either side of that joint

Tarsals The calcaneus, talus, and navicular bones are sometimes known by alternative names:

calcaneus = os calcis talus = astragalus and scaphoid. Correct way is: ∙tarsal bone of foot is Navicular ∙carpal bone of the wrist is Scaphoid Carpal most often called navicular

Ankle Joint structure This Joint requires strong collateral ligaments that extend from the medial and lateral malleoli to the _____________ and _____________.

calcaneus and talus

Ankle Joint Axial View A horizontal plane drawn through the midportions of the two malleoli would be approximately 15° to 20° from the ______________________

coronal plane (the true side-to-side plane of the body).

what are the three ______________ wedge shaped tarsals located on the medial and mid aspect of the foot between the first three metatarsals distally and the navicular proximally

cuneiforms (meaning "wedge shaped")

Surface and Projections of the foot Surface The surfaces (top or anterior) of the foot is called the ____________.

dorsum Dorsal refers to the posterior part of the body. Dorsum, comes from the term dorsum pedis, refers to the upper surface, or the surface opposite the sole of the foot. - The sole of the foot is the posterior surface or plantar surface.

Tibia Distal Extremity The lateral aspect of the distal extremity of the tibia forms flattened, triangular ____________ notch for articulation with the distal fibula.

fibular notch

Sesamoid Bones Sesamoid bones also may be found near other joints of the foot. Sesamoid bones are important radiographically because ___________________.

fracturing these small bones is possible ∙ and due to the location such fractures can be quite painful and may cause discomfort when weight is placed on it. ∙ special tangential shots may be used to demonstrate a fracture of a sesamoid bone

Fibula The proximal extremity of the fibula is expanded into a ______________, which articulates with the lateral aspect of the posteroinferior surface of the lateral condyle of the tibia.

head

Radiographic Positioning Distance A common minimum source-image receptor distance (SID) is 40 inches(100cm) When you are radiographing with IRs directly on the tabletop, to maintain a constant SID,

increase the tube height, 3-4 inches

Midfemur and Distal Femur -Posterior View The posterior view of the distal femur best demonstrates the two large, rounded condyles that are separated distally and posteriorly by the deep ____________________, above which is the popliteal surface

intercondylar fossa or notch

Ankle Joint Axial View A horizontal plane drawn through the midportions of the two malleoli would be approximately 15° to 20° from the coronal plane (the true side-to-side plane of the body). this postion is called the ______________________

intermalleolar plane

Joints of digits Between the proximal and distal phalanges of the 1st digit is the....

interphalangeal (IP) joint

Clinical Indications Chondromalacia patellae (commonly known as runner's knee)

involves a softening of the cartilage under the patella, which results in erosion of this cartilage, causing pain and tenderness in this area. Cyclists and runners are vulnerable to this condition. X-ray examination: AP and lateral knee, tangential (axial) of patellofemoral joint

Clinical Indications Exostosis (osteochondroma)

is a benign, neoplastic bone lesion that is caused by consolidated overproduction of bone at a joint (usually the knee). The tumor grows parallel to the bone and away from the adjacent joint. Tumor growth stops as soon as the epiphyseal plates close. Pain is an associated symptom it the tumor is large enough to irritate surrounding soft tissues. X-ray examination: AP and lateral of affected limb

Clinical Indications Ewing sarcoma

is a common primary malignant bone tumor that arises from bone marrow in children and young adults. Symptoms are similar to those of osteomyelitis, with low-grade fever and pain. Bone has stratified new bone formation, resulting in an "onion peel" look on radiographs. Ewing sarcoma generally occurs in the diaphysis of long bones. The prognosisis poor by the time it is evident on radiographs. X-ray examination: AP and lateral of affected limb, CT, MRI

Clinical Indications Gout

is a form of arthritis that may be hereditary in which uric acid appears in excessive quantities in the blood and may be deposited in the joints and other tissues; common initial attacks occur in the first MtP joint of the foot. Later attacks may occur in other joints, such as the first metacarpophalangeal (MCP) joint of the hand, but generally these are not evident radiographically until more advanced conditions develop. Most cases occur in men, and first attacks rarely occur before the age of 30. X-ray examination: AP (oblique) and lateral of affected part (most common initially in MTP joint of foot)

Clinical Indications Lisfranc ligament

is a large band that spans the articulation of the medial cuneiform and the first and second metatarsal base. Because no transverse ligament exists between the first and second metatarsal bases, this region of the foot is prone to stress injury caused by motor vehicle crashes, twisting falls, and falls from high places. Athletes often may acquire a Lisfranc injury that is due to high stress placed on the midfoot. Lisfranc joint injuries range from sprains to fracture-dislocations of the bases of the first and second metatarsals. A moderate sprain of the Lisfranc ligament is characterized by an abnormal separation between the first and second metatarsals.A small avulsion fracture may indicate a more severe injury. Lisfranc joint injuries may be missed if weight-bearing AP and lateral foot projections are not performed. X-ray examination: Weight-bearing AP and lateral and 30° medial oblique projections, CT, MRI

Clinical Indications Enchondroma

is a slow-growing benign cartilaginous tumor that most often IS found in small bones of the hands and feet in adolescents and young adults. Generally, these are well-defined, radiolucent-appearing tumors with a thin cortex, and they often lead to pathologic fracture with only minimal trauma. X-ray examination: AP and lateral of affected limb

Clinical Indications Paget disease (osteitis deformans)

is one of the most common diseases of the skeleton. It is most com m on in midlife and is twice as common in men as in women. Is a non-neoplastic bone disease that disrupts new bone growth, resulting in over-production of very dense yet soft bone. Bone destruction creates lytic or lucent areas; this is followed by reconstruction of bone, by which sclerotic or dense areas are created. The result is a very characteristic radiographic appearance that sometimes is described as cotton wool. Lesions typically occur in the skull, pelvis, femurs, tibias, vertebrae, clavicles, and ribs. Long bones generally bow or fracture because of softening of the bone; the associated joint may develop arthritic changes. The pelvis is the most common initial site of this disease. X-ray examination: AP and lateral of affected limb

Clinical Indications Multiple myeloma

is the most common type of primary cancerous bone tumor. Generally, these tumors affect persons 40 to 70 years old. As the name implies, they occur in various parts of the body. Because this tumor arises from bone marrow or marrow plasma cells, it is not a truly exclusive bony tumor. Multiple myelomas are highly malignant and usually are fatal within a few years. The typical radiographic appearance consists of multiple "punched-out" osteolytic (loss of calcium in bone) lesions scattered throughout the affected bones. X-ray examination: AP and lateral of affected part

Clinical Indications osteomalacia (rickets)

literally means "bone softening." This disease is caused by lack of bone mineralization secondary to a deficiency of calcium, phosphorus, or vitamin D in the diet or an inability to absorb these minerals. Because of the softness of the bones, bowing defects in weight-bearing parts often result. This disease is known as rickets in children and commonly results in bowing of the tibia. X-ray examination: AP and lateral of affected limb

Alternative Modalities and Procedures BONE DENSITOMETRY

may be used to evaluate loss of bone in geriatric patients or in patients with lytic (bone-destroying) type of bone disease

Alternative Modalities and Procedures MAGNETIC RESONANCE IMAGING (MRI)

may be used to image the lower limbs when soft tissue injuries are suspected. The knee is the m o s t often evaluated portion of the lower limb, and MRI is invaluable in detecting ligament damage or meniscal tears of the joint capsule. MRI also may be used to evaluate lesions in the skeletal system.

Ankle Joint Axial View demonstrated in fig 6.12 are the relative positions of the lateral and ____________ of the fibula and tibia.

medial malleoli

Ankle Joint Frontal View The distal end of the larger and stronger tibia has a broad articular surface for articulation with the similarly shaped broad upper surface of the talus. The medial elongated process of the tibia that extends down alongside the medial talus is called the.....

medial malleolus

Arches of Foot Longitudinal Arch The springy longitudinal arch comprises a _______ and ___________ component with most of the arch located on the medial and mid aspect of the foot.

medial, lateral

Metatarsals These are numbered along with the digits, with number 1 on the ________ side and number 5 on the _________ side.

medial, lateral

Joints of the Metatarsals The Joint between the head of the metatarsal and the phalanges is the

metatarsophalangeal (MTP) joint

Radiographic Positioning Grids A general rule is that grids should be used with body parts that measure ___________________.

more than 10 cm recommends a non-grid technique on smaller patients with knees measuring 10 cm or less and grid for larger patients with knees measuring more than 10 cm, (AP knee.)

Clinical Indications Joint effusions

occur as accumulated fluid (synovial or hemorrhagic) in the joint cavity. These are signs of an underlying condition (e.g. fracture, dislocation, soft tissue damage).

Metatarsals The base of the fifth metatarsal is expanded laterally into a prominent rough tuberosity, which provides for the attachment ________________.

of a tendon The proximal portion of the fifth metatarsal, including this tuberosity, is readily visible on radiographs is a common trauma site for the foot; this area must be well visualized on radiographs.

Alternative Modalities and Procedures COMPUTED TOMOGRAPHY (CT)

often is used on the lower limbs to evaluates of soft tissue involvement of lesions. The cross-sectional images are also excellent for determining the extent of fractures and for evaluating bone mineralization.

Midfemur and Distal Femur -Posterior View Where is the adductor tubercle present?

on the posterolateral aspect of the medial condyle It is best seen on a slightly rotated lateral view of the distal femur and knee. The presence of this adductor tubercle on the medial condyle is important in critiquing a lateral knee for rotation. It allows the viewer to determine whether the knee is under-rotated or over-rotated to correct a positioning error when the knee is not in a true lateral position

Midfemur & Distal Femur -Anterior View What is the smooth, shallow, triangular depression at the distal portion of the anterior femur that extends up under the lower part of the patella

patellar surface ∙ This depression sometimes is referred to as the intercondylar sulcus. (Sulcus means a groove or depression.) ∙ this depression AKA as the trochlear groove. (Trochlea means pulley or pulley-shaped structure in reference to the medial and lateral condyles.) ★ All 3 of these terms should be recognized as referring to this smooth, shallow depression.

Distal Femur and Patella (Axial View) The axial or end-on view of the distal femur demonstrates the relationship of the patella to the _____________ of the distal femur.

patellar surface (intercondylar sulcus or trochlear groove) of the distal femur. also shown are: - of the distal femur - epicondyles - medial and lateral condyles.

Arches of Foot Transverse Arch The transverse arch is located primarily along the ___________________ of the distal tarsals and the tarsometatarsal joints.

plantar surface The transverse arch is primarily made up of the wedge-shaped cuneiforms, especially the smaller second and third cuneiforms, in combination with the larger first cuneiform and the cuboid

Sesamoid Bones The sesamoid bones are almost always present on the posterior or ______________________near the first MTP joint.

plantar surface at the head of the first metatarsal

Surface and Projections of the foot Projections The AP projection of the foot is the same as a dorsoplantar (DP) projection. The less common posteroanterior (PA) projection can also be called a _______________.

plantodorsal (PD) projection

Navicular Articulations The navicular articulates with 5 bones:

posteriorly with the talus laterally with the cuboid anteriorly with the three cuneiforms (Fig. 6.8).

Calcaneus Articulations Three specific articular facets appear at this joint with the talus through which the weight of the body is transmitted to the ground in a n erect position:

the larger posterior articular facet the smaller anterior and middle articular facets. The middle articular facet is the superior portion of the prominent sustentaculum tali, which provides medial support for this important weight-bearing joint.

Talus The talus, the second largest tarsal bone, is located between the ______________ and the __________________.

the lower leg, the calcaneus The weight of the body is transmitted by this bone through the important ankle and talocalcanealjoints.

Tibia Proximal Extremity The intercondylar eminence (also known as the tibial spine) includes two small pointed prominences

the medial and lateral intercondylar tubercles which are located on the superior surface of the tibial head between the two condyles.

Tibia Distal Extremity The distal extremity of the tibia is smaller than the proximal extremity and ends in a short pyramid-shaped process called _____________

the medial malleolus which is easily palpated on the medial aspect of the ankle.

Toes The five digits of each foot are numbered 1 through 5, starting on...?

the medial or big-toe side of the foot

Ankle Joint Frontal View A 15° internally rotated AP oblique projection, called _______________

the mortise position it is performed (see Fig. 6.15) to demonstrate the mortise of the joint, which should have an even space over the entire talar surface.

Cuneiforms Articulations The medial cuneiform articulates with four bones:

the navicular proximally the first and second metatarsals distally, the intermediate cuneiform laterally.

Cuneiforms Articulations The intermediate cuneiform also articulates with four bones:

the navicular proximally the second metatarsal distally the medial and lateral cuneiforms on each side

Cuneiforms Articulations The lateral cuneiform articulates with six bones:

the navicular proximally the second, third, and fourth metatarsals distally the intermediate cuneiform medially; and the cuboid laterally.

Sesamoid Bones In the lower limbs, sesamoid bones tend to be larger and more significant radiographically. What is the largest sesamoid bones in the body?

the patella (kneecap)

Distal Femur and Patella (Lateral View) The patella, as a large sesamoid bone, is embedded in the tendon of the large quadriceps femoris muscle. As the lower leg is flexed, the patella moved in what direction?

the patella moves downward and is drawn inward into the intercondylar groove or sulcus. A partial flexion of almost 45° as shown in Fig. 6.21, demonstrates the patella being pulled only partially downward. With 90° flexion, the patella would move down farther over the distal portion of the femur. This movement and the relationship of the patella to the distal femur become important in positioning for the knee joint and for the tangential projection of the patellofemoral (femoropatellar) joint (articulation between patella and distal femur).

Calcaneus Another ridge of bone that varies in size and shape and is visualized laterally on an axial projection is the______________

the peritoneal trochlea Sometimes in general, this is also called the trochlear process.

Toes What are the most distal bones of the foot?

the phalanges, which make up the toes, or digits.

Toes The large toe, or first digit, has only two phalanges, similar to the thumb: what are they called?

the proximal phalanx and the distal phalanx. Each of the 2nd through 5th has a middle phalanx, with their proximal and distal phalanx Because the 1st digit has two phalanges and digits 2 through 5 have three phalanges a piece, 14 phalanges are found in each foot. Similar to the hand

Calcaneus Articulations The calcaneal sulcus depression, combined with a similar groove or depression of the talus, forms an opening for certain ligaments to pass through. This opening in the middle of the subtalar joint is ____________________

the sinus tarsi, or tarsal sinus

Calcaneus On the medial proximal aspect is a larger, more prominent bony process called the________________-

the sustentaculum which literally means "a support for the talus"

Tarsals The seven tarsal bones sometimes are referred to as the ankle bones, although only one of the tarsals is directly involved in the ankle joint, what is it?

the talus Each of these tarsals is described individually, along with a list of the bones with which they articulate.

Ankle Joint Frontal View The distal tibial joint surface that forms the roof of the ankle mortise joint is called ______________

the tibial plafond (ceiling) Certain types of fractures of the ankle in children and youth involve the distal tibial epiphysis and the tibial plafond.

Sesamoid Bones Specifically the sesamoid bone on the medial side of the lower limb of the plantar surface at the head of the first metatarsal is termed the ________________ sesamoid bone. and the lateral side is the _______________, sesamoid bone

tibial, fibular

Alternative Modalities and Procedures NUCLEAR MEDICINE (NM)

uses radioisotopes injected into the bloodstream. These isotopes are absorbed in great concentration in areas where pathologic conditions exist. Nuclear medicine bone scans are particularly useful in showing, osteomyelitis and metastatic bone lesions

Clinical Indications Osgood-Schlatterdisease

which involves inflammation of the bone and cartilage of the anterior proximal tibia, is most common in boys 10 to 15 years old. The cause is believed to be an injury that occurs when the large patellar tendon detaches part of the tibial tuberosity to which it is attached. Severe cases may require immobilization by plaster cast. X-ray examination: AP and lateral of knee

Metatarsals Each of the metatarsals consists of three parts.

∙ The small, rounded distal part of each metatarsal is the head. ∙ The centrally located, long, slender portion is termed the body (shaft). ∙ The expanded, proximal end of each metatarsal is the base.