Definições de marcadores esqueléticos

Copyright

Copyright ©: the University of Brussels (ULB),

Belgium, through Serge VAN SINT JAN, has the

full ownership of the 46 pages included in this

document (including all texts, images and

illustrations). Reproduction of any part for

commercial purposes is totally forbidden

without the written approval of the main

autho

r.

©: the University of Brussels (ULB) ©ulb

http://www.ulb.ac.be

©ulb

Copyright ©: the University of Brussels (ULB) ©ulb

Skeletal Landmark Definitions by

Serge VAN SINT JAN, PhD

This work has been entirely performed at:

The Department of Anatomy Faculty of Medicine

University of Brussels - ULB Belgium

URL: www.ulb.ac.be/~anatemb

Email: [email protected]

Acknowledgments. This document was made possible thanks to the help of my

colleagues (by alphabetical order): Mr. Christophe CIAVARELLA, MSc

Prof. Véronique FEIPEL, PhD Prof. Stéphane LOURYAN, PhD

Mr. Jean-Louis LUFIMPADIO, Msc Prof. Marcel ROOZE, MD, PhD

Mr. Patrick SALVIA, PhD Prof. Victor SHOLUKHA, PhD Mr. Stéphane SOBZACK, MSc

Copyright ©: the University of Brussels (ULB)

©ulb

Table of Contents

Introduction________________________________________________________________________ 4 Sacral Bone________________________________________________________________________ 8

1. Sacrum - Spinous Process of 2nd sacral vertebrae (SS2)[M]____________________________ 10 Iliac Bone ________________________________________________________________________ 11

2. Iliac bone - Anterior Superior iliac spine (IAS)[R, L] ________________________________ 13 3. Iliac bone - Posterior Superior iliac spine (IPS)[R, L] ________________________________ 14 4. Iliac bone - Ischial Tuberosity, inferior angle (IIT)[R, L]______________________________ 15 5. Iliac bone - Pubic sYmphysis, upper edge (IPY)[M] _________________________________ 16 6. Iliac bone - Centre of Acetabulum (IAC)[R, L] _____________________________________ 17

Femur ___________________________________________________________________________ 18 7. Femur - greater Trochanter Center (FTC)[R, L] _____________________________________ 20 8. Femur - tubercle of the Adductor Magnus muscle (FAM)[R, L] ________________________ 21 9. Femur - Medial Epicondyle (FME)[R, L]__________________________________________ 22 10. Femur - Lateral Epicondyle (FLE)[R, L] ________________________________________ 23 11. Femur - antero-Medial ridge of the patellar surface Groove (FMG)[R, L]_______________ 24 12. Femur - antero-Lateral ridge of the patellar surface Groove (FLG)[R, L] _______________ 25 13. Femur - most distal point of the Medial Condyle (FMC)[R, L] _______________________ 26 14. Femur - most distal point of the Lateral Condyle (FLC)[R, L]________________________ 27 15. Femur - Center of Head (FCH)[R, L] ___________________________________________ 28

Tibia ____________________________________________________________________________ 29 16. Tibia - tibial Tuberosity (TTT)[R, L] ___________________________________________ 31 17. Tibia - Medial Ridge of tibial plateau (TMR)[R, L] ________________________________ 32 18. Tibia - Lateral Ridge of tibial plateau (TLR)[R, L] ________________________________ 33 19. Tibia - Gerdy’s Tubercle (TGT)[R, L] __________________________________________ 34 20. Tibia - Apex of the Medial malleolus (TAM)[R, L] ________________________________ 35

Fibula ___________________________________________________________________________ 36 21. Fibula - ApeX of the styloid process (FAX)[R, L] _________________________________ 38 22. Fibula - Apex of the Lateral malleolus (FAL)[R, L]________________________________ 39

Foot_____________________________________________________________________________ 40 23. Foot/Calcaneus - posterior surface (FCC)[R, L]___________________________________ 42 24. Foot/Calcaneus - Sustentaculum Tali (FST)[R, L] _________________________________ 43 25. Foot/Calcaneus - Peroneal Trochlea (FPT)[R, L] __________________________________ 44 26. Foot/Metatarsus - Tuberosity of 5th metatarsal bone (FMT)[R, L] _____________________ 45 27. Foot/Metatarsus - 1st, 2nd, 3rd, 4th and 5th head (FM1, FM2, FM3, FM4, FM5)[R, L]_______ 46

Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation


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Introduction

This document presents definitions for the location of anatomical landmarks. Locating anatomical

landmarks is presented using two protocols: 1) manual palpation that allows spatial location of landmarks

when combined to three-dimensional (3D) digitizer, and 2) virtual palpation on 3D computer models

obtained, for example, from medical imaging.

Use of standardized definitions allows better result comparison and exchange; this is a key element for

patient follow-up or the elaboration of quality clinical or research databases. This document presents accurate

skeletal landmark definitions to help her/him achieving the above goals with better precision, higher

reproducibility and therefore, in most cases, less data post-processing.

This book includes description for both manual palpation, i.e. using fingertips, and virtual palpation, i.e.

using a computer input device like a mouse. Both manual and virtual descriptions of the same landmark have

been written in order to allow a palpator (i.e., the individual performing the palpation) to decrease the

difference resulting from both kinds of palpation protocols. This should also lead to better results if

combination of landmarks from both palpation protocols must be performed.

Finally, this guidebook would like to emphazise that palpation is an Art, and requests serious practise

before reaching acceptable accuracy. Unfortunately, palpation is often see as a secondary task probably

because it is cheap, simple of conception (compared to the costly high-tech hardware used for medical

imaging or to collect motion data) and does not require complicated setting (unlike some state-of-the-art

pieces of electronical equipment). The truth is different: spatial location of anatomical landmarks is

necessary for fundamental operations. For example, to measure some bone parameters, to define anatomical

frames in clinical motion analysis, or to perform data registration. Inacurracy in landmark selection will

always lead to serious discrepancies in the interpretation of the data whatever the quality of the hardware used

for measurements.

This document will help the reader to strive into that direction thanks to detailed definitions and

instructions related to palpation of skeletal landmarks. Each landmark is described in a way to increase the

reproducibility of its spatial location.

Warnings One of the necessary conditions of efficiency of definitions is of course that they are scrupulously

followed to obtain reproducible results. It is also assumed that the palpator is seriously experienced with both

Human Anatomy and Palpation. The present guidelines aim at proposing accurate definitions to allow a better

repeatability and communication between scientists. On the other hand this document is neither a Human

Anatomy textbook, nor a guide to learn Manual or Virtual Palpation. The Art of Palpation should be obtained

from other sources, if possible, before using the following definitions.

The description given in the text for manual palpation assumes that the individual performing the

palpation (named as “the palpator”) uses a special table like those used by physiotherapists to manipulate

patients. The authors advise to use such table to perform better palpation by allowing the palpated subject to

be in a comfortable position. Muscle tension would therefore be decreased and bony landmarks will be better

palpable. Relative position of both palpator and palpated subject given in the following descriptions are



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indicative althought they are probably the most convenient ones. However, some environments might not let

applying these working position strictly (for example, some settings adopted in a motion analysis lab).

Some areas to palpate manually can be painfull, especially where muscles or ligaments are attaching.

Sensitive landmarks are indicated in the text. Manual palpation of these landmarks should be gently

performed to avoid reactions of the individual being palpated that could compromise any further palpation.

New ideas ? Please, send them ! The hope of the author is to keep this document updated with new definitions to follow new

standards and conventions. Therefore, feel free to communicate ideas to improve or to update the content of

this document.

Enjoy the reading! Serge VAN SINT JAN



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Bone description Landmarks are presented by bone. Each bone section starts with a general presentation of the current bone

including both bone orientation and a rough description of the position of the bone features used as

anatomical landmarks in this document.

Landmark description Each anatomical landmark is described in various ways (spatial location, manual palpation, and virtual

palpation) that are related to one another and show some complementary. These descriptions are presented in

table format (page 7).

All landmarks are related to bony areas that can be palpated in a clinical or research context. Some landmarks

are recommended by the various standardization committees of the International Society of Biomechanics

(ISB, see http://www.isbweb.org/standards/index.shtml)1 in order to define both local and joint coordinate

systems. Description of such landmarks is indicated by the ISB logo (Figure 1, top). A few of these

recommended landmarks are, according to the author, difficult to palpate manually. Although palpation

directions are given, a warning sign (Figure 2) indicates that manual palpation is not accurate (one warning

sign indicates that manual palpation is approximate, two warning signs indicates that accurate manual

palpation is irrealistic).

Figure 1. ISB logo

Figure 2. Warning signs. Accuracy of such landmark location is

either low (one sign) or very poor (two signs).

Two signs also indicate that further experimental research

should be performed to validate the given definition.

Such definitions have been given, despite the inaccuracy,

because these landmarks are either recommended in the

literature or accessible by palpation but not in an accurate way.

1 Also see:

- Wu, G., Cavanagh, P., 1995. ISB recommendations for standardization in the reporting of kinematic data. J. Biomech. 28, 1257-1261.

- Wu, G., Siegler, S., Allard, P., Kirtley, C., Leardini, A., Rosenbaum, D., Whittle, M., D'Lima, D., Cristofolini, L., Witte, H., Schmid, O., Stokes, I., 2002. ISB recommendation on definitions of joint coordinate systems of various joints for the reporting of human joint motion - Part I: ankle, hip, spine. J. Biomech. 35, 543-548.

- Wu, G., van der Helm, F.C., Veeger, H., Makhsous, M., Van Roy, P., Anglin, C., Nagels, J., Karduna, A., McQuade, K., Wang, X., Werner, F., Buchholz, B. IN PRESS. ISB recommendation on definitions of joint coordinate systems of various joints for the reporting of human joint motion - Part II: shoulder, elbow, wrist and hand. J. Biomech.



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Table format used for landmark description

Landmark Name (Landmark Acronym) [side prefix : R, L, M]. “Landmark Name” indicates both bone and landmark name.2

“Landmark acronym” proposes a 3-character acronym for the current landmark.3

“side prefix” indicates if the current landmark is even or odd.4

[link to relevant illustrations]

A general anatomical definition to allow the location on a dried bone is given.

Manual Palpation

Manual palpation definition for the location of the landmarks through soft tissue is given here. The palpation is generally done with either the pulp angle of the fingers. Use of forefinger (sometimes the thumb or the middle finger) is usually adviced. However, the reader should use the finger and pulp area which give her/him the greatest confidence. The subject being palpated is usually lying (prone or supine) to allow muscle relaxation and an easier palpation. These landmarks can be extended to the upright position althought the palpation will then be more difficult.

Virtual Palpation

Virtual palpation definition proved to be useful when using 3D modeling to locate a landmark (e.g. on data collected from medical imaging). The definition include point of view that must be strictly followed before selecting the landmark of interest. Two different views are sometimes used to compensate the loss of information on the 2D screen during virtual palpation. Virtual palpation is illustrated in this book using accurate 3D models of bones obtained from medical imaging (computed tomography - CT).

Table 1. Example of table description (see text for explanation).

2 For example: « Femur - Greater Trochanter ». 3 For example: « FTc » for the center of the great trochanter. Each acronym is unique and redundancy has been avoided when writing this document. Using the given acronyms will make sure that all landmarks have different acronyms. Note: the first letter of the acronym is the same as the first letter of the related bone (except for the hand). 4 Even markers are characterized with either « L » or « R » (left and right respectively), while odd markers are given by « M » (i.e., middle). The full acronym of each landmark is therefore a 4-character string, e.g. « LFTc » for the center of the left great trochanter.


Copyright ©: the University of Brussels (UL

Sacral Bone

Orientation and general presentation (Figure 3 and Figure 4:

The sacral bone has a triangular shape; its base (1) is oriented proximally, while the apex (2) is distal. The

sacral bone is the result of the fusion of five sacral vertebrae (S1 to S5). Therefore, many characteristics of

this bone are related to features of a ‘normal’ vertebra. The median sacral crest (3) is actually the result of

the fusion of the spinous processes of the primitive sacral vertebrae. This crest is made of at least three

prominences, i.e. spinous processes (S1, SS2, S3). Note the spinous process of S2 is along a horizontal line

passing through the posterior superior iliac spine of the iliac bone (see this bone, page 11). Both posterior and

anterior faces show 4 pairs of sacral foramens (4) (only a few foramens are indicated on the illustrations).

The coccyx (5) is below the sacral bone. Other structures: iliac bones (6), femurs (7).

Figure 3. The sacral bone (3D model). Left (anterior view, slightly lateralview): sacral bone.
3
B)

): location in the pelvi

S1

s

SS2
S3
1

. Right
2 5 5 7 7
6
6
4

4

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(posterior


Copyright ©: the University

Figure 4. The sacral bone (anatomical speBottom (

4

4
3
of Brusse

cimen). Top (anterposterior view): po

S1

l

iost

SS2

S3

6

s (UL

r view, erior as

6
1
7

7

5

1
2
B) 9©ulb

slightly lateral): location in the pelvis. pect.


Copyright ©: the Universi

1. Sacrum - Spinous Process of 2nd sacral vertebrae (SS2)[M]

Figure 3 and Figure 4, structure SS2.

Posterior eminence on the posterior aspect of the

sacral bone.

The subject is lying prone. The palpator

surface of the pelvis (left hand on image

the iliac crest. This projection on the spin

With the forefinger of the opposite hand

Keeping down, the next two bony eminen

Control of the selection can be obtained b

runs through the posterior superior iliac s

L4

ty

sta

). P

e (b

, gl

ces

y v

pin

L5S

nd

la

lu

id

a

e

e

1

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e a

e d

re

rify

(se

SS2

g at the subject’s pelvis, one hand placed flat on the lateral

the thumb near the spine along a horizontal projection from

rrow) indicates the level of the 4th lumbar vertebra (L4).

own on the spinous process of the 5th lumbar vertebra (L5).

respectively S1 and SS2.

ing that the horizontal projection of a line starting from SS2

e IAS, page 11).

Turn the sacral bone in

posterior frontal view.

Locate the median sacral

crest. Along this crest,

select the top of the second

spinous process S2, just

proximal to a horizontal
SS2
Brussels (ULB

plane running through the

2nd pair of posterior

foramens (dotted blue line).
SS2
S1
S1
) 10©ulb

Then, turn the bone along a

lateral view and control the

selected point is on the S2

apex.


Copyright ©: the Univ

Iliac Bone

Orientation and general presentation (Figure 5 and Figure 6):

To orient the iliac bone, turn the acetabulum (IAC) laterally, the obturator foramen (1) below, and behind

the greater sciatic notch (2). The iliac crest (3) is on top. The sharp anterior superior iliac spine (IAS) is

located on the anterior aspect of 3. The posterior superior iliac spine (IPS) is located on the other side of 3

and is less sharp. The postero-inferior aspect of the iliac bone shows a large tuberosity: the ischial tuberosity

(IIT). Both iliac bones articulate anteriorly by the pubic symphysis (IPY). Each iliac bone articulates with a

femur (4) by the joint surface located into IAC. This crescent-shaped joint surface is called the lunate

surface (5).

Figure 5. The iliac bone (3D mod

IAC

2

1

IAS

3

2

1

IAS

IPS

IAC

ersity of Brussels (UL

el). Top (anterior view): position in thbottom right (medial view): isolated

3

3

IPS

B)

e pelvis. Bottom left (latbone.
IIT
IPY

IPY
4 4
5

IIT

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eral view) and

IAS
C
IAC
opyright ©: the University of Brussels (ULB)

Figure 6. The iliac bone (anatomical specimens). A (antero-lateral view) andpelvis. C (latero-superior view): superior landmarks. D (latero-inferior view)

view). F (lateral view): the acetabulum.

IPY

IAS

IIT

2

1

1

5

IAC

IPY A B

C

E

F

IPY

IAC

4

4

4

B (anterior vie: the ischial tub

4

D

IPS

IAS

IAS
IIT
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w): position in the erosity. E (anterior


Copyright ©: th

2. Iliac bone - Anterior Superior iliac spine (IAS)[R, L]

Figure 5 and Figure 6, structure IAS.

Prominent anterior and superior end of the

iliac crest.

The subject is lying supine. The palpator

facing the subject’s pelvis.

Place your hand on the subject’s hip on the

side concerned, with your fingers on the

anterior part of the iliac crest. Follow the

anterior part of the iliac crest forwards

(dotted blue arrow).
IAS
e University of

At the anterior extremity of the iliac crest,

your thumb will feel a prominent bony bump

under which it can get around, below and to

the side. This is IAS.

[note: IAS is just under the skin and is usually easily palpable; however, this procedure may be more difficult on obese subjects.]

Observe the iliac bone from a lateral point of

view. Follow anteriorly the anterior part of

the iliac crest until IAS (dotted blue arrow).
IAS
Then turn the model 90° to an anterior frontal

view, and make sure the selected landmark is

correctly located on the center of AS.
IAS
Brussels (ULB) 13©ulb



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3. Iliac bone - Posterior Superior iliac spine (IPS)[R, L]

Figure 5 and Figure 6, structure IPS.

Prominent posterior and superior end of the

iliac crest.

The subject is lying prone. The palpator

standing at the subject’s pelvis, hand placed

flat on the lateral surface of the pelvis.

Place your thumb on the posterior part of the

iliac crest. Move backwards over the iliac

crest just to the point where the thumb feels a

prominent bump: IPS.

Observe the iliac bone from a

lateral view. Go backwards

(dotted blue arrow) on the

posterior part of the iliac crest

until IPS is met.

Next, rotate the model 90° along

a posterior frontal view, and

control the selected landmark is

correctly located on the center of

the posterior spine.

IPS

IPS

IPS


Copyright ©: the U

4. Iliac bone - Ischial Tuberosity, inferior angle (IIT)[R, L]

Figure 5 and Figure 6, structure IIT. Large posterior tuberosity of the ischium.

The subject is lying prone. The palpator stands next

to the subject’s knees.

Place your forearm along the thigh axis, and the hand

flat on the lateral part of the buttocks-thigh junction
IIT
nivers

(i.e., buttocks fold, dotted blue line). With the thumb,

spread from the hand, goes up and pass under the

inferior edge of the gluteus major muscle. The thumb

reached the inferior angle of the ischium (IIT).

[tip: to control the selection palpate both medial and lateral edges of the ischium. Then follow these edges down to their junction, which is the inferior angle.]

Observe the iliac bone from a

posterio-lateral point of view. Follow

both medial and lateral edges (dotted

arrows) of the ischium to their

intersection, which is ITT.
IIT
ity of Br

To verify your selection, turn the

model approximately 45° towards

the back of the screen. The selected

point should be on the angle made by

the medial and lateral edges of the

ischium.

IIT

ussels (ULB) 15©ulb



5. Iliac bone - Pubic sYmphysis, upper edge (IPY)[M]

Figure 5 and Figure 6, structure IPY.

The pubic symphysis is the anterior joint

between the two iliac bones.

The subject is lying supine. The palpator

standing next to the subject’s pelvis, hand

placed flat on the belly.

Put one thumb on the central part of the

belly above the pubic symphysis. With the

thumb, gently depress the belly and glides

down towards the pubic symphysis (blue

dotted area).

Find the upper edge of the latter and select

its anterior part.

IPY is not directly observable

on a 3D bone model and must

be interpolated.

At first, turn the iliac bone to

an anterior frontal view. Select

a point on each iliac bone next

to the pubic symphysis.

Next, turn the bones to an

upper view, and check both

selected landmarks (LPY and

RPY) are correctly located on

the anterior edge of bone.

IPY is the average of the

spatial coordinates of both

LIPY and RIPY landmarks.

IPY

RIPY LIPY

RIPY

ty of Bru

LIPY

ssels (ULB) 16©ulb

[note: IPY is usually not directly available from CT imaging because it is made of fibrous tissu and cartilage, which are not very X-ray sensitive. This explains the gap visible between both iliac bones on the illustrations.]


Copyright ©: the University

6. Iliac bone - Centre of Acetabulum (IAC)[R, L]

Figure 5 and Figure 6, structure IAC.

The acetabulum is the hip component of the hip joint.

This point is not palpable and is found after interpolation only. Because of the limitations of the manual palpation, IAC is

assumed equal to the centre of the femoral head (see FCH landmark, page 28). This is not the case when using virtual

palpation (see below).

An estimation of IAC can be found by averaging

the spatial coordinates of the following 6 ACi

points all located along the circumference of the

lunate surface (Figure 5, structure 5) within the

acetabulum:

1. anterior edge of the lunate surface (AC1).

2. center of anterior wall (AC2).

3. anterior part of roof (AC3).

4. posterior part of roof (AC4).

5

1

3

AC1

of

AC2

AC3
AC4
AC

AC6

5. center of posterior wall (AC5).

6. posterior edge of the lunate surface (AC6).

AC

AC2

AC
AC4
AC5

AC6



Copyright ©: the University of Brussels

Femur

Orientation and standard presentation (Figure 7 and Figure 8):

The head of the femur (FCH) is oriented upwards and medially; it is part of the hip joint (1). The femoral

head is linked to the greater trochanter (FT) by the femoral neck (2). The inferior epiphysis shows a

posterior notch: the intercondylar notch (3). On both sides of the latter are the lateral (FLC) and medial

(FMC) condyles. Each condyle shows an epicondyle (FLE or FME). The lower part (anterior aspect) of the

femur supports the patellar groove (4) making up the femoral-patellar joint. This groove shows two edges:

one lateral (FLG) and one medial (FMG).

Figure 7. The femur (3D model). Top left (anterior view): femur (anterior view) and top right (posterior view): isolated bone. Botto

view), bottm right (medial view): d

H

C

FC

(ULB) 18©ulb

with pelvic bone, patella and tibia. Top center m left (anterior view), bottom center (anterior istal epiphysis.

3

FLE

FMC
FL
FLE

1

3

2
2
4

FT
FT
FME

4
FME
FLE

FMG
FLG
FME


Copyright ©:

Figure 8. The femuand D (lateral view

H

A

the Univ

r (anatomical spe): proximal epip

B

ersity of Brussels (ULB)

cimen). A (anterior wiew) and B (posteriohysis. E (anterior view), F (medial view), G

and I (distal view): distal epiphysis.

C

r view): full bone. C (a (posterior view), H (

D
E F G H I
FME

FT

2

FC

FT

FCH

FT

FLE
4
FME
FLE
3

FLC

FMC

FME

FLG
FMG
FLC
FMC FLC
FPS

19©ulb

nterior view) lateral view)


Copyright ©

7. Femur - greater Trochanter Center (FTC)[R, L]

Figure 7 and Figure 8, structure FTC.

Massive quadri-angular tubercle that extends to the top of the

lateral face of the femoral diaphysis. It has three edges:

superior, anterior and posterior.

The subject is standing and the palpator behind him. The subject’s leg is slightly flexed and in abduction (foot on a

support).

Place first one thumb on the iliac crest (dotted line); the little finger meets the great trochanter. Once this performed, a

more accurate palpation is done with the three first fingers.

Both thumb and middle fingers pinch the greater trochanter on its posterior and anterior edges respectively. Place the

index finger in the middle of the virtual line traced between the thumb. The FTC landmark is pinpointed by the index

finger between both thumb and middle finger.

[note: with accuracy when soft tissue is well-develloped.]

Turn the femur to a lateral view (in this position the femoral

head is normally pointing forwards and both condyles are

aligned).

Locate the center of both anterior and posterior edges (dotted

lines) of the great trochanter. The FTC landmark is located at
FTC
: the University of Brussels (ULB)

the center of the great troc

FTC

20©ulb

hanter between both edge centers.


Copyright ©: the Un

8. Femur - tubercle of the Adductor Magnus muscle (FAM)[R, L]

Figure 7 and Figure 8, structure FAM.

Bony spine situated on the superior edge of

the medial condyle of the femur.

The subject is lying supine, knees extended,

the palpator at the subject’s knees.

Place the palm of the medial hand on the

FAM

proximal tibial epiphysis in order to have

both fourth and fifth finger located behind the

knee. The second and third fingers of the

medial hand searches for the tendon of the

adductor magnus muscle (dotted blue arrow).

Followed the latter until FAM is reached. [note: this tendon insertion is sometimes sensitive.]

Observe the femur from a

posterior (slightly medial)

view.

FAM is on the center of a
FAM
ivers

FAM

ity of Brussels (ULB) 21©ulb

protuberance above the

medial condyle.

Turn to a posterior view

to verify the selection.


Copyright ©: the Universit

9. Femur - Medial Epicondyle (FME)[R, L]

Figure 7 and Figure 8, structure FME.

This surface shows a small tubercle for the

medial collateral ligament of the knee.

The subject is lying supine, knee extended.

Place the thumb on FAM (see page 21) and

the middle finger on the knee joint (vertically

along the virtual line running through FAM).

FAM

FME

Place the index finger midway between the

thumb and the middle finger and move it

slightly forwards (towards the patella). The

index finger should locate a small tubercle,

which is FME. [note: this point can be sensitive.]

View the distal epiphysis from a
FAM
medio-sagittal view.

Find the center of the medial condyle

at the intersection of the following

virtual lines:

− a vertical line starting at

FAM (see page 21),

− an horizontal line passing

by the centre of the

posterior and anterior edges

of the condyle.

In relation to this intersection, the

landmark to select is found slightly
FME
FME

y of Brussels (ULB) 22©ulb

forwards.

Verify the validity of the landmark

by turning the bone in a posterior-

frontal view. Check the selected

point is on the apex of the condyle.


Copyright

10. Femur - Lateral Epicondyle (FLE)[R, L]

Figure 7 and Figure 8, structure FLE.

The lateral condyle is a bony surface located

laterally on the distal epiphysis of the femur.

This surface shows a crest.

The subject is lying supine, knee flexed.

FLE

©: the Unive

Put your finger in the knee joint space and

glide backwards until you meet the lateral

collateral ligament. Follow the ligament up to

its proximal insertion point, which is the

FLE.

Observe the distal epiphysis from a lateral

point of view.

Locate a bumpy tubercle near the centre of

the lateral condyle. This tubercle is along a

horizontal line running between the furthest
FLE
points of the condyle. Select the apex of the

tubercle (FLE).

Once the tubercle in selected, observe the

selection from an antero-frontal point of view

to control that FLE is on the apex of
FLE
rsity of Brussels (ULB) 23©ulb

epicondyle.


Copyright

11. Femur - antero-Medial ridge of the patellar surface Groove (FMG)[R, L]

Figure 7 and Figure 8, structure FMG.

Bony angle located in the upper medial area of the

patellar surface.

The subject is lying supine, knees extended.

With the thumb of the proximal hand on the

central part of the lateral edge of the patella,

push the patella laterally (dotted blue arrow).

The thumb of the distal hand passes under the

patella, and palpates the sharp edge of the

patellar groove until an angle is found: FMG.

Observe the distal epiphysis from an antero-

frontal view.

From the most distal point of the inner edge of

FMG

FLG

©: the University of Brussels (ULB) 24©ulb

the patellar surface, follow this edge up (dotted

arrowed line). This inner edge bends forming an

angle; this angle is FMG.

[note: FMG is located more distally then FLG (see page 25).]

FMG


Copyright ©: the Univer

12. Femur - antero-Lateral ridge of the patellar surface Groove (FLG)[R, L]

Figure 7 and Figure 8, structure FLG.

Bony angle located in the upper lateral area of the

patellar surface.

The subject is lying supine, knees extended.

With the thumb of the proximal hand on the central

part of the lateral edge of the patella, push the

patella medially (dotted blue arrow). The thumb of

the distal hand passes under the kneecap, and

FLG

palpates the patellar groove until an angle is found:

FLG.

[note: this point is difficult to palpate because of the orientation of the lateral aspect of the patellar surface.]

Place the distal extremity of the femur in an

anterior-frontal view.
FLG From the most distal point of the lateral edge of the
patellar groove, follow this edge up (dotted
FMG
sity of Brussels (ULB) 25©ulb

arrowed line). This edge bends forming an angle;

this angle is the FLG.

[note: FLG is located more proximally then FMG (see page 24).]


Copyright ©: the Unive

13. Femur - most distal point of the Medial Condyle (FMC)[R, L]

Figure 7 and Figure 8, structure FMC.

The point is located on the distal extremity of

the medial condyle of the femur.

The subject is lying supine, with the hip

flexed (100°) and the knee bent (120°). The

FMC

rsit

hip flexion compensates partially for the

quadriceps tension resulting from the knee

flexion. This facilitates the palpation of the

landmark.

Follow the medial edge of the patellar tendon

(dotted blue arrow) and follow it until you

reach the knee joint space. Press the thumb

into the joint cavity to palpate FMC. [note: FMC is difficult to palpate with accuracy because of the presence of the infrapatellar fat pad filling the space behind the patellar ligament.]

View the femur from a medio-

sagittal view with the femoral shaft
FMC
y of

vertical.

Rotate the femur along the plane

perpendicular to the screen and

visualize the distal aspect of the

bone in a horizontal view. Select the

center of the medial condyle.

Then, rotate the femur back to a

medio-sagittal view. Check that the

selected landmark is well the most

distal part of the medial condyle.

FMC




27©ulb

14. Femur - most distal point of the Lateral Condyle (FLC)[R, L]

Figure 7 and Figure 8, structure FLC.

The point is located on the distal extremity of

the lateral condyle of the femur.

The subject is lying supine, with the hip

flexed (100°) and the knee bent (120°). The

hip flexion compensates partially for the

quadriceps tension resulting from the knee

flexion. This facilitates the palpation of the

landmark.

Follow the lateral edge of the patellar tendon

(dotted blue arrow) and follow it until you

reach the knee joint space. Press the thumb

into the joint cavity to palpate FLC. [note: FLC is difficult to palpate with accuracy because of the presence of the infrapatellar fat pad filling the space behind the patellar ligament.]

View the femur from a latero-sagittal

view with the femoral shaft vertical.

Rotate the femur along the plane

perpendicular to the screen and

visualize the distal aspect of the bone

in a horizontal view. Select the center

of the lateral condyle.

Then, rotate the femur back to a latero-

sagittal view. Check that the selected

landmark is well the most distal part of

the lateral condyle.

FLC

FLC

FLC



15. Femur - Center of Head (FCH)[R, L]

Figure 7 and Figure 8, structure FCH.

Spherical structure located on the proximal

epiphysis of the femur. It is part of the hip joint.

This point is not palpable and is found after interpolation (Bell

et al., 1990, Journal of Biomechanics, 23:617-621):

• At first, a pelvic frame is defined: Op is the origin located

between both LIAS and RIAS (see page 13 for description); Zp is

H

LIAS

LIPS
RIPS
oriented as the line passing through both IAS’s pointing from left

to right; Xp lies in the plane defined by both IAS’s and the
Op midpoint between the LIPS and RIPS (see page 14), Xp points
forwards; Yp is orthogonal to the XZ plan.

• RFCH and LFCH are given by: x = -019D; y = -0.3D; z = i 0.36

D, where D = distance between both IAS’s, i = -1 for LFCH and

i = 1 for RFCH.
LFCH RFC
RIAS

1
FCH A good estimation of FCH can be
found by averaging the spatial
FCH2 coordinates of the following 6 points
all located around the femoral head:

1. top (FCH1).

2. anterior (FCH2).

3. bottom (next to the neck)(FCH3).

4. posterior (FCH4).

FCH3

ty of Brussel

H

FCH4
FCH5
FCH6

5. lateral (above the neck)(FCH5).

6. medial (FCH6).

[top left: anterior view; top right: medial view; bottom: posterior view with transparent femur to visualize the estimated FCH]

FC

s (ULB) 28©ulb



Tibia


The proximal epiphysis of the tibia shows the tibial plateau (1). The plateau shows two well-marked edges:

one lateral (TLR) and one medial (TMR). Two tubercles are visible on the plateau: the lateral

intercondylar tubercle (2) and the medial intercondylar tubercle (3). Anteriorly, a sharp tibial crest (full

line) is easily observable. The tibial tuberosity (TTT) is observable at the proximal end of the tibial crest.

From TT, two crests climb upwards towards the tibial plateau; the lateral crest (dotted line) is usually

sharper than the medial one. The Gerdy’s tubercle (TGT) is along the latter crest. The distal epiphysis

carries the medial malleolus (TAM).

Figure 9. Tibia (3D model). Left (ve

1

ty of Brussels (ULB) 29©ulb

ntral view, slightly medial) and right (dorsal view): isolated bone.

1

M

TT

TMR

TLR
TLR
TGT

TA

2
3 2 3


Copyright ©: th

Figure 10. Tibia. A (ant(ante

A

e Universi

erior view) and B rior view): proxim

M

B

ty of

(posterioral epiphy

C

Bru

view)sis. E (

D

ssels

: generamedial

E
TTT
TGT

TTT

TMR
TLR
1
1
(ULB

l view. Cview): th

1

3

)

(proximale medial m

2
TA
view): the talleolus.

M

TLR
TMR
TA

TLR
TMR
TTT

30©ulb

ibial plateau. D


Copyright ©: t

16. Tibia - tibial Tuberosity (TTT)[R, L]

Figure 9 and Figure 10, structure TTT

Three points are palpated.

Prominent oval tuberosity located at the

superior extremity of the anterior tibial

aspect. The patellar tendon inserts on this

tuberosity.

The subject is lying supine, knee extended.

Gently pinch the patellar tendon between the

thumb and the middle finger; follow distally

the tendon until its insertion on the tibial

tuberosity.

The thumb and the middle finger are located

on each side of the tuberosity on its lateral

and medial edges respectively.
TTT
he U

Once this manoeuvre is completed, place the

index finger between the thumb and the

middle finger; this is TTT.

View the upper extremity of the tibia from

an anterior view; locate a bony oval bump

on the anterior and proximal aspect of the
TTT
niversity of Brussels (ULB) 31©ulb

tibia: the tibial tuberosity.

The center of both lateral and medial

edges of the tuberosity are first located.

Then, find TTT at the intersection of an

horizontal line running through both

above-located points.


Copyright ©: th

17. Tibia - Medial Ridge of tibial plateau (TMR)[R, L]

Figure 9 and Figure 10, structure TMR.

Point situated on the medial edge of the tibial

plateau and the furthest point from the medial

intercondylar tubercle.

The subject bends his knee to 90°; the

palpator is in front of the subject.

Place the 1st and 3rd fingers on the lateral and

medial edges of the patellar tendon

respectively (at the level of the tibial plateau).

The two fingers then glides backwards along

the tibial plateau and reach for the greatest

distance between both fingers. Once the

greatest distance is found, press the middle

finger on the surface of the tibial plateau to

find TMR.

Orientate the tibial plateau in a superior

horizontal view. Draw a line running through

both lateral and medial intercondylar

TMR

3
2
e Univer

tubercles (2 and 3, respectively, see also

Figure 9). TMR is the most medial point of

that line on the edge of the tibial plateau.
TMR
sity of Brussels (ULB) 32©ulb

View the tibial plateau from a medial point of

view. Make sure the selected point is slightly

below the medial aspect of the tibial plateau.


Copyright ©: the

18. Tibia - Lateral Ridge of tibial plateau (TLR)[R, L]

Figure 9 and Figure 10, structure TLR.

Point situated on the lateral edge of the tibial

plateau and the furthest point from the lateral

intercondylar tubercle.

The subject bends his knee to 90°; the

palpator is in front of the subject.

Place the 1st and 3rd fingers on the medial and

lateral edges of the patellar tendon

respectively (at the level of the tibial plateau).

The two fingers then glides backwards along

the tibial plateau and reach for the greatest

distance between both fingers. Once the

greatest distance is found, press the middle

finger on the surface of the tibial plateau to

find TLR. [tip: if possible locate both TLR and TMR (see page 32) simultaneously.]

Orientate the tibial plateau in a superior

TLR

TLR

3
2
horizontal view. Draw a line running through

both lateral and medial intercondylar

tubercles (2 and 3, respectively, see also

Figure 9). TLR is the most lateral point of

that line on the edge of the tibial plateau.
TLR
University of Brussels (ULB) 33©ulb

View the tibial plateau from a lateral point of

view. Make sure the selected point is slightly

below the lateral aspect of the tibial plateau.



34©ulb

19. Tibia - Gerdy’s Tubercle (TGT)[R, L]

Figure 9 and Figure 10, structure TGT.

Tubercle located on the lateral aspect of the

tibial tuberosity. The iliotibial tract of the

fascia lata inserts on this tubercle.

Locate first the lateral edge of the

tibial tuberosity, (TTl, page 31). Then,

from this point, two bony ridges start:

one medial and one lateral. Follow the

lateral one until a thick tubercle is

located: this is TGT.

[note: the development of the Gerdy’s tubercle is variable. It is usually well palpable.]

View the upper extremity of the tibia from

an anterior view; locate first TTl (see page

31). From TTl, follow a curved bony edge

(dotted blue arrow) running laterally

upward until a tubercule (its development is

variable) is found: TGT.

TGT

TTl

TTl

TGT



35©ulb

20. Tibia - Apex of the Medial malleolus (TAM)[R, L]

Figure 9 and Figure 10, structure TAM.

The medial malleolus, located distally on the

medial aspect the leg, is larger, less prominent, and

shorter than the lateral malleolus.

The subject is lying supine, the palpator

facing the subject’s leg.

Place the 1st and 2nd fingers on the anterior

and posterior aspects of the medial malleolus

respectively.

Move both fingers distally along the

malleolus edges. The fingers when both

edges are joining (white dot in image): the

junction point is TAM. [note: the palpated point is not strictly spoken the real apex of the malleolus; indeed the latter is located deeper in the soft tissue. This must be kept in mind if virtual palpation is also performed (see below).]

View the lower part of the

tibia along medio-sagittal

view. Select a point of the

malleolus slightly above its

apex.

Then, turn the tibia to a distal

horizontal view. Verify that

the selected point is located

slightly medially next to the

real apex of the medial

malleolus.

TAM

TAM

TAM


Copyright ©: the Unive

Fibula


The fibula is located lateral and posterior to the tibia. The distal epiphysis (1) is flatter than the proximal

epiphysis (2). The distal epiphysis shows the lateral malleolus (FAL). The articular facet of the talofibular

joint (3) is oriented medially, while the malleolar fossa (4) of the lateral malleolus is located behind the joint

surface. The fibula head has a styloid process (5) pointing upwards and showing a sharp fibula apex (FAX).

Vertically below the lateral aspect of the head, the lateral edge (dotted line) runs downwards.

Figure 11. Fibula (3D model). Left (la

X

1

2

FAL

rsity of Brusse

teral view): fibula and tibifibula.

3

ls (ULB)

a (semi-transparent). R

4

FA

1

2

FAX

5

36©ulb

ight (medial view): isolated


Copyright ©: the University of

Figure 12. Fibula (anatomical specimen). A (medi(lateral v

2

A

B

B

al view

L

C
FAX
2

russel

iew): gene): distal ep

1
FA
4
3
s (ULB) 37©ulb

ral view. B (lateral view): proximal epiphysis. C iphysis.


Copyright ©: the

21. Fibula - ApeX of the styloid process (FAX)[R, L]

Figure 11 and Figure 12, structure FAX.

Bony eminence located on the dorsal aspect

of the fibula head (structure 2, Figure 11).

Both biceps femoris muscle and lateral

collateral ligament insert on the head next to

styloid process.

The head of the fibula is visible under the

skin when the knee is flexed with an internal

rotation of leg.

FAX

The subject, lying supine, flexes his knee at

about 90°, the palpator standing slightly

lateral in front of the knee.

Follow the tendon of the femoral biceps

(dotted blue arrow) with your index finger

until its insertion. FAX is the most lateral and

posterior part of the fibula head next to the

tendon. [note: the palpated point is not strictly spoken the real apex of the fibula head; indeed the latter is located deeper within the tendon of the femoral biceps. This must be kept in mind if virtual palpation is also performed (see below).]
FAX Observe the proximal epiphysis of the
fibula along a lateral sagittal view.

Select a point slightly below the apex of

the styloid process.

Then turn, the bone in a proximal

horizontal view and verify that the

selected point is located slightly

laterally to the apex. X
FA



39©ulb

22. Fibula - Apex of the Lateral malleolus (FAL)[R, L]

Figure 11 and Figure 12, structure FAL.

The lateral malleolus presents a triangular

prismatic form with both anterior and posterior

edges. Both edges join at the apex of the

malleolus. In neutral position of the foot, the

lateral malleolus is about 2 cm lower than the

medial malleolus.

The subject, lying supine, has his feet in a neutral

position; the palpator facing the feet of the

subject.

Place your index finger on the posterior edge of

the malleolus and your thumb on the anterior edge

of the malleolus.

Follow both edges distally until their junction

(black dot on image). The later is the apex of the

malleolus: FAL. [note: the palpated point is not strictly spoken the real apex of the malleolus; indeed the latter is located deeper in the soft tissue. This must be kept in mind if virtual palpation is also performed (see below).]

View the distal epiphysis along a latero-sagittal

view. Select a point of the malleolus slightly

above its apex.

Then, turn the fibula into a distal and horizontal

view. Verify that the selected point is located

slightly laterally next to the apex of the lateral

malleolus.

FAL

FAL

FAL


Copyright ©: the Univers

Foot


The bony foot consists of the seven tarsal bones, the five metatarsals and the phalanxes. The tarsus consists of

the following bones: talus (1), calcaneus (2), navicular (3), cuboid (4), medial cuneiform (5), intermediate

cuneiform (6) and lateral cuneiform (7). The five metatarsal bones (M1→M5) support the digital rays

through the metarsophalangeal joints (FM1→FM5). The calcaneus presents a large posterior surface

(FCC) and a prominent tubercle, the sustentaculum tali (FST) on its medial aspect. On its lateral aspect the

calcaneus shows the peroneal trochlea (FPT). The thickest digital ray is the hallux (8), which is medial. The

basis of the 5th metatarsal bone supports a sharp tuberosity (FMT).

Figure 13. Foot bones (3D model). Top (l

1

ity of Brussels

ateral view), center (medial v

1

1

C

1

2

(ULB)

iew), and b

23

4

5

2

2

3

3

3

4

5
6
7

M1

M2
M3
M4
M5
ottom (superior view

8

5

8

4
7
M1

M5

FST

FPT
FMT
FPT
FMT
FM

FM
FM
FM

FM

FM1

FM5

FC

40©ulb

): entire foot.


Copyrigh

Figure

B

C

A

t ©:

14. Foot

FPT

the Unive

bones (anatomi

FMT

2

1

r

ca

3

4

sity

l spec

7

im

M5

of Brussels (

ens). A (lateral view),

1

ULB)

B (medial v

2

3
5
M1

9
FST
8

2

3

4

5
6 7
M1

M2

M3
M4
M5

1
FPT FMT
iew) and C (su

FCC

FM1

FM2
FM3
FM4
FM5
41©ulb

perior view).



23. Foot/Calcaneus - posterior surface (FCC)[R, L]

Figure 13 and Figure 14, structure FCC.

The posterior face of the calcaneus can

be described as a square with four edges.

Both medial and lateral edges of the

square are well observable.

The subject is lying prone, feet slightly

extended and at rest.

Slightly pinch both lateral and medial edges

of the Achilles tendon between your thumb

and middle finger. Then, follow distally the

edges until you reach the upper ridge of the

calcaneus (dotted blue arrows).

Move your fingers further until you reach

the center of both medial and lateral

calcaneus edges.

FCC is located by pushing your forefinger

centrally between your thumb and middle

finger. [note: the upper rigde of the posterior face of the calcaneus is difficult to palpate with accuracy because of the insertion of the calcaneal (Achilles) tendon.]

View the calcaneus bone from a

medial point of view and select

the center of the medial edge.

Repeat the selection from a

lateral point of view for the

lateral edge.

View then the calcaneus from

from posterior view. FCC is

located on the posterior surface

at the center of an horizontal

line between both above-

selected points.

C

FCC

FC




24. Foot/Calcaneus - Sustentaculum Tali (FST)[R, L]

Figure 13 and Figure 14, structure FST.

The sustentaculum tali is a prominent tubercle

at the medial aspect of the calcaneus. It also

supports the medial part of the antero-medial

joint surface of the talus. It is located on the

border joining the superior and medial surfaces

of the calcaneus.

The subject is lying supine.

From TAM (see page 35), move distally in

direction of the medial border of the foot. The

tubercle located one finger-width distally to

TAM is the posterior edge of the sustentaculum

tali.

M

TA
FST
Leave the index on this point and move the

thumb anteriorly and distally to the anterior

edge of the sustentaculum (about one finger-

width). The mid-point between the posterior

and anterior edges constitutes FST.
FST
View the foot along a medial sagittal

view. Select the center of the

sustentaculum tali.
FST

Then, view the foot along a distal

horizontal view. Control the located

point is on the most prominent aspect

of the sustentaculum tali.



44©ulb

25. Foot/Calcaneus - Peroneal Trochlea (FPT)[R, L]

Figure 13 and Figure 14, structure FPT.

The peroneal trochlea (tubercle) is an oblong ridge

process of the lateral surface of the calcaneus. It

separates the tendons of peroneus longus and brevis

muscles. This ridge has an oblique orientation

(downwards and anteriorly). [note: another tubercle, for the calcaneofibular ligament insertion, can also be present on the lateral aspect of the calcaneus. This tubercle is more dorsal and posterior compared to FPT.]

The subject is lying supine, the palpator is lateral to the

foot being palpated.

Make sure that the peroneus muscles are relaxed. Place

your index finger on FAL (see page 39) and move

distally (downwards) and slightly anteriorly of about one

finger-width. A small ridge is met. Select its centre.

[note: keep in mind the variable development of a tubercle for the calcaneofibular ligament, see above note. Do not confuse the latter with FPT.]

Place the foot in lateral sagittal

view, locate the lateral surface of

the calcaneus. Select the midpoint

of the peroneal trochlea.

Then, turn the foot 90° to an

inferior horizontal view and verify

that the selected point is located on

the central, prominent part of the

trochlea.

[note: in some instances, the inferior view will show two tubercles on the lateral calcaneus. The peroneal trochlea is the most anterior of these processes (also see above notes).]

FAL FPT

FPT

FPT


Copyrigh

26. Foot/Metatarsus - Tuberosity of 5th metatarsal bone (FMT)[R, L]

Figure 13 and Figure 14, structure FMT

This tuberosity is located at the base

(proximal end) of the 5th metacarpal bone

(M5). It forms the midpoint of the lateral

border of the foot.

Also see Figure 13, structure FMT.

[note: the tendon of the peroneus brevis muscle inserts on this tuberosity apex. This real apex of this tuberosity is therefore hidden in the tendon.]

The subject is lying in supine position.

Place the thumb on the FAL (see page 39), and

L
FA
t ©: the

move it distally to the lateral border of the foot

(dotted blue arrow). Follow this border anteriorly.

FMT

Midway between the heel and the 5th toe, the

thumb hits the tuberosity. FMT is the posterior top

of the tuberosity, the first point hit by the thumb. [note: the palpated point is not strictly spoken the real apex of the tuberosity; indeed the latter is located deeper in the soft tissue. This must be kept in mind if virtual palpation is also performed (see below).]

Place the foot in lateral sagittal view

(slightly posterior). Locate the tuberosity of

the fifth metatarsal bone, and select the

point located just outside the tuberosity

apex.
FMT
Then, view the foot 90° along a superior

horizontal view, and verify that the selected

point is next to the tuberosity apex.

FMT



Copyright ©: the

27. Foot/Metatarsus - 1st, 2nd, 3rd, 4th and 5th head (FM1, FM2, FM3, FM4, FM5)[R, L]

Figure 13 and Figure 14, structure FM1, FM2, FM3,

FM4, FM5

The head of a metatarsal bone is the anterior

extremity of this bone, articulating with the first

phalanx of the digital ray.

For each digital ray, process as following.

The subject is lying supine, the palpator standing

contra-laterally to the foot being palpated.

Take the first phalanx of the digital ray between the

caudal thumb and index. Take the metacarpal head

between the cranial thumb and index, with the thumb

on the dorsal portion of the metacarpal bone. Move

the phalanx in flexion and extension to locate the

center of the dorsal aspect of the metatarsal head.

This point is the landmark to select.

For each digital ray, process as following.

View the foot along a dorsal (superior)

horizontal view. Select the most central point

of the metacarpal head (here FM1).

Then, view the foot along a medial sagittal

view. Check that the selected point is the most

prominent point of the margin between the

joint surface and the dorsal surface.

[note: FM2 is the most distal point; FM5 is the most

FM1

FM2
FM3
U

FM4

niv

FM5

FM1

FM1

ersity

FM1

of Brussels (ULB) 46©ulb

proximal point.]

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