Color Atlas of Skeletal Landmark Definitions 9780443103155

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Color Atlas of Skeletal Landmark Definitions

Guidelines for Reproducible Manual and Virtual Palpations Serge Van Sint Jan, PhD Associate Professor, Department of Anatomy Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium

CHURCHILL LIVINGSTONE

Front Matter Color Atlas of Skeletal Landmark Definitions Guidelines for Reproducible Manual and Virtual Palpations Serge Van Sint Jan PhD Associate Professor, Department of Anatomy, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium FOREWORDS BY Paul Allard PhD PEng Professor, Departments of Kinesiology and Surgery, University of

Montreal,

Mechanical

Quebec;

Adjunct

Engineering,

Ecole

Professor,

Department

Polytechnic

de

of

Montréal,

Quebec, Canada Ge Wu PhD Associate

Professor,

Department

of

Physical

University of Vermont, Burlington, Vermont, USA

Therapy,

EDINBURGH

LONDON

NEW

YORK

PHILADELPHIA ST LOUIS SYDNEY TORONTO 2007 For Elsevier: Commissioning Editor: Dinah Thom Associate Editor: Claire Wilson/Catherine Jackson Project Manager: Jane Dingwall

OXFORD

Senior Designer: George Ajayi Illustration Buyer: Merlyn Harvey Illustrations: Chartwell

Copyright CHURCHILL LIVINGSTONE ELSEVIER © 2007, Elsevier Limited. All rights reserved. The right of Serge Van Sint Jan to be identified as author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899, USA: phone: (+1) 215 239 3804; fax: (+1) 215 239 3805; or, e-mail: [email protected]. You may also complete

your

request

on-line

via

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homepage

(http://www.elsevier.com), by selecting ‘Support and contact’ and then ‘Copyright and Permission’. First published 2007 ISBN 978 0443 10315 5 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Neither the Publisher nor the Author assumes any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. The Publisher Printed in China

Forewords Professor Serge Van Sint Jan presents a novel and unique approach to the study of bone structures through manual palpation. This well-illustrated color atlas is the first of its kind to introduce the use of virtual reality as an accessory tool in the estimation of anatomic landmarks. This book should provide a valuable tool for the clinical diagnostic, fitting of orthopedic devices and clinical evaluation of patients with postural and gait disorders. The virtual palpation method is not only a complementary tool to manual palpation but can be applied to quantify personalized threedimensional morphologic parameters needed for both clinical applications and the creation and animation of virtual characters. The author emphasizes the need to perform palpations in a strict and standardized way. As such, both the manual and virtual palpation methods provide an accurate and reliable means of identifying skeletal landmarks. In so doing, it reduces the imprecision usually associated with highly intensive manual tasks and increases the quality of the evaluation whether it is performed by physiotherapists, engineers, medical doctors, kinesiologists, nurses, etc. Better measurement reproducibility, data comparison and data exchange are therefore achieved. This greater accuracy in bony

landmark

identification

constitutes

a

major

scientific

contribution to the analysis of human movement. Body segment parameters such as the location of the center mass and moment of inertia can be better estimated; joint kinematics are more realistic since their joint centers are accurately identified and placement of surface electrodes to measure muscle activity is simplified to name but a few examples. Though increased accuracy may not be essential to the animation industry, this attribute facilitates the wrapping of a skin-like structure to a motion file for animation sequences. Both the animation industry and medical professionals will benefit from these improvements. To

promote

communication

among

medical

specialists,

international anatomic nomenclature is applied throughout the book. This is enhanced by using bony landmarks recommended by the Standardization

Committee

of

the

International

Society

of

Biomechanics in the definition of joint coordinate systems. Because the manual and virtual palpation methods can be interfaced, additional skin and bone feature points are required and must coincide with a standard representing a humanoid structure, namely, that of the Humanoid Animation Working Group (H|Amin). This well-structured manuscript describes all the bones used for anatomic landmarks with the exception of small bones which are difficult to palpate with sufficient accuracy. Each bone segment such as the humerus or body segment like the hand is first described and illustrated. The diversity, quality and quantity of these illustrations is another unique feature of this book. Representations from a threedimensional model provide a clear and precise identification of the

bony landmarks whereas the photographs of the respective anatomic specimens enable the reader to appreciate nature’s natural fluffiness since some bony landmarks are often areas that smoothly merge with adjoining structures. Following the position and general description of the bone segment, landmarks to be identified by palpation are presented in a step-wise manner. First the palpator’s position is given with respect to that of the subject. This is followed with a detailed description of procedure that often includes palpation tips to clarify some technical difficulties. Again there is a wealth of illustrations depicting the subject’s position, the palpation itself and the bone structures to be identified. When applicable, additional anatomic landmark points required for virtual palpation are provided. Undergraduates in medicine, rehabilitation, kinesiology and sport sciences will benefit from this well-written and documented book on palpation anatomy. The detailed illustrations combined with the practical hands-on surface examination of skeletal landmarks contribute to the learning process in the understanding of muscle structure and functions. Graduate students in biomechanics, the field of interest where physical principles are applied to the study of all living organisms, are not all from the clinical or sport sciences. Many are engineers and computer scientists who have a limited knowledge of anatomy since their expertise lies in their technical skill for modeling the human body. This atlas will provide them with accurate and reliable methods to obtain the individualized skeletal landmarks required to model the shape, size and orientation of bone

segments. Human movement scientists as well as animation specialists will be pleased with the information provided in this atlas on skeletal landmark definitions. They will gain from the morphologic shaping capabilities generated through the accuracy and reliability of the palpation methods proposed by Serge Van Sint Jan. The classical stick diagrams representing either human gait or arm movement will soon become obsolete. Though several software packages are commercially available to perform an image rendering task, they are dependent on the quality of the input data. The palpation method has been extended to additional anatomic landmarks to be used in the wrapping technique encompassing a skin-like structure for animation using H|Amin. Clinicians, sport scientists, engineers and computer graphic specialists will be in a better position to appreciate the intricacies of human movement as well as that of virtual characters. I wish to express the views of readers by congratulating on their behalf as well as mine Serge Van Sint Jan for his initiative and outstanding work in body morphology. Professor Van Sint Jan has given us new prospects for improving our clinical assessments of ailing individuals, for acquiring more accurate body parameters for human movement analyses and for improving imaging techniques for animations through the integration of manual and virtual palpation methods. Paul Allard

Human anatomy has been an area of love and hate intertwining most of my career as a biomedical engineer. About 20 years ago when I started my doctoral study at Boston University, I had the ‘joy’ of opting out of the human anatomy course, one of the required courses for completing the degree. I did this not because I knew human anatomy well, but because I was afraid of the subject, and had hoped that I could learn it all by myself if I needed it. Well, the truth is, I did learn it by myself, I have been learning it all my life, and I have been learning it the hard way. Over the years, I have encountered many projects, big and small, in research and in teaching, which required me to identify skeletal landmarks on the human body. They ranged from attaching reflective markers for motion analysis, estimating anthropometric properties of human body segments for computing joint reaction forces and moments, attaching surface EMG electrodes on muscles, and constructing biomechanical models for the human musculoskeletal system. Every time I had to palpate and identify skeletal landmarks, whether to demonstrate to my students, or to write a manuscript, I wished there was a reference source I could refer to that provided a clear, accurate and reproducible guide to palpation. I could never forget the process for publishing my first paper that used surface EMG electrodes. After I submitted the manuscript for review, one reviewer requested that I add details about the landmarks and the procedures used to identify muscle bellies for attaching the EMG electrodes. Although I had a reference source to go by about which landmarks to use, I had to come up with my own description of how to locate these landmarks.

It was a painful process for an amateur. Nevertheless, I realized how important palpation is as a first step in achieving reliable results. In the early 1990s, I started a project with the Standardization and Terminology Committee of the International Society of Biomechanics to propose a set of standards for defining joint coordinate systems for upper and lower extremity joints and the spine. Obviously, the foundation of these joint coordinate systems was palpable skeletal landmarks. Once again, I was forced to pull out my human anatomy books, and all other reference books I could get hold of in the library. I wished desperately that I had one single book that provided an accurate and reproducible guide on skeletal system landmarks and palpation. Finally, my wish is granted by this wonderful book, Color Atlas of Skeletal Landmark Definitions. It would have smoothed out my rollercoaster quest to human anatomy had it been available some 20 years ago. It will be a must-have for the rest of my career. I’m sure I’m not alone. Ge Wu

Acknowledgements This book could not have become a reality without discussion and the help of my wonderful colleagues. My thanks go to all of them (in alphabetical order): Mr Christophe Ciavarella, MSc Mr Ugo Della Croce, PhD Mr Pierre-Michel Dugailly, MSc Professor Véronique Feipel, PhD Mr Alberto Leardini, PhD Mr Jean-Louis Lufimpadio, MSc Professor Marcel Rooze, MD, PhD Mr Patrick Salvia, PhD Professor Victor Sholukha, PhD Mr Stéphane Sobzack, MSc Mr Jean-Louis Sterckx Manual palpation was possible thanks to volunteers who agreed to lend their anatomy and to spend long periods of time on the palpation table for photography sessions. Many thanks to all of them for their patience: Marie V. Fien V. Akim B.

Xavier D. Jean-Louis S. Jean-Claude U. Virtual palpation was performed on anatomically accurate 3D models obtained by computed tomography. This quality was achievable thanks only to the generous individuals who donated their remains to Science for research purposes, to whom we give our grateful respects.

Table of Contents

Front Matter Copyright Forewords Acknowledgements Chapter 1: Introduction Chapter 2: Skull Chapter 3: Jaw Chapter 4: Spine Chapter 5: Sternum (thorax) Chapter 6: Ribs (thorax) Chapter 7: Clavicle Chapter 8: Scapula Chapter 9: Humerus Chapter 10: Ulna Chapter 11: Radius

Chapter 12: Hand Chapter 13: Sacrum Chapter 14: Ilium Chapter 15: Femur Chapter 16: Patella Chapter 17: Tibia Chapter 18: Fibula Chapter 19: Foot Chapter 20: Approximation of centroid and radius Index

1 Introduction This book defines the location of anatomic landmarks by means of two palpation protocols: manual palpation, which allows spatial location of landmarks using hands combined or not with threedimensional (3D) digitizing, and virtual palpation on 3D computer models obtained, for example, from medical imaging. These protocols can be used independently or in combination. Manual palpation is used clinically for various purposes: • Identification of painful areas • Positioning of particular pieces of equipment (electromyography electrodes, auscultation, external landmarks used in clinical motion analysis or body surface scanning) • Measurement of morphologic parameters – for example, limb length. Virtual palpation alone is useful to quantify individual morphologic parameters from medical imaging: • Limb length • Limb orientation

• Joint angle • Distance between various skeletal locations. The use of standardized definitions for the above activities allows better comparison and exchange of results (Van Sint Jan & Della Croce 2005); this is a key element for patient follow-up or for the elaboration of quality clinical and research databases. This book offers the reader accurate skeletal landmark definitions to help the above goals to be achieved with greater precision and reproducibility. Combining data from manual and virtual palpation protocols enables supplementary complex analyses to be undertaken: • Registration protocols aiming at building reference frames for motion representation according to reproducible clinical conventions • Accurate modeling of joint kinematics during musculoskeletal analysis • Precise alignment of orthopedic tools according to the individual anatomy of a patient • Wrapping and scaling of surface textures to motion data when creating animation characters. In order to help achieve the above tasks, this book includes descriptions of both manual (using the fingertips) and virtual (using a computer input device such as a mouse) palpations to identify the spatial location of the same landmarks. Such a twofold procedure enables the palpator (the individual performing the palpation) to minimize the discrepancy between the two palpation protocols, and therefore leads to better results if these protocols are to be combined

(Van Sint Jan et al 2006), as during the above examples of complex analyses. Another aim of this book is to define skeletal landmark locations accurately, to allow an acceptable level of repeatability by individuals with different backgrounds (physiotherapists, medical doctors, nurses, engineers, etc.). If applied strictly, these definitions should permit better data exchange and comparison of results. Finally, this book emphasizes that palpation is an Art, and that serious practice is required for an acceptable level of accuracy and precision to be reached. Unfortunately, palpation is often seen as a secondary task, probably because it is cheap, simple in concept (compared with the costly high-tech hardware used for medical imaging, to collect motion data or to scan a body surface) and does not require a complicated setting (unlike high-tech hardware). The truth is different: spatial location of anatomic landmarks is necessary for fundamental operations, for example to place electrodes accurately, to measure bone parameters, to define anatomic frames in clinical motion analysis, or to perform data registration. Inaccuracy in landmark selection will lead to discrepancies in the interpretation of the data, whatever the quality of the hardware used for measurements. Another example is wrapping a skin texture to a motion file when organizing animation sequences; such an operation can be performed much more quickly and precisely when accurate landmarks are used to perform the registration. For these reasons, palpation should be carried out with as much care, precision and conscientiousness as other data collection procedures. The detailed definitions and instructions regarding the palpation of

skeletal landmarks in this book will help the reader to improve his or her palpation ability. Each landmark is described in such a way as to increase the reproducibility of its spatial location. This is the fruit of the author’s long professional experience, and that of his colleagues working in the fields of anatomy, motion analysis (clinical and research), medical imaging, 3D modeling and computer graphics. This team also teaches manual palpation techniques at both the Faculty of Medicine and the School of Sports and Physiotherapy of the Université Libre de Bruxelles (ULB).

Warnings One of the necessary conditions for effective definitions is, of course, that they are followed scrupulously by the users to obtain reproducible results. It is also assumed that the palpator is highly experienced with respect to both human anatomy and palpation. These guidelines aim to propose accurate definitions to allow greater repeatability and communication between scientists. However, this publication is neither a human anatomy textbook nor a guide for learning manual or virtual palpation know-how. 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 uses a special table, such as those used by physiotherapists or chiropractors to manipulate patients. The author advises that such a table be used to perform better palpation, by allowing the palpated subject to be in a comfortable position. Muscle tension is thereby decreased and bony landmarks more palpable. Adjustable tables are also advised to allow

the palpator to find the best working position. The relative positions of both the palpator and the palpated subject given in the following chapters are indicative, but they are probably the most convenient ones. However, some environments might not permit these strict working positions (for example, some settings adopted in a motion analysis laboratory). Some areas can be painful when palpated manually, especially attachment points of muscles or ligaments. Sensitive landmark locations are indicated in the text. Manual palpation of these landmarks should be performed gently to avoid reactions of the individual being palpated that might compromise further palpations.

New ideas? Please send them! This book will not remain ‘fixed’ in time. The author hopes to be able to keep the book updated with new definitions that follow new standards and conventions. Therefore, feel free to communicate ideas that will improve or update the content of this text. Enjoy your reading!

Serge Van Sint Jan

Definition of anatomic planes

The following definitions (Fig. 1.1) show the conventions used in this book for orientation of the anatomic segments.

Figure 1.1

Anatomic planes used in this book.

A The sagittal plane runs from the posterior to the anterior aspects of the subject, and is vertical. B The coronal, or frontal, plane is vertical and perpendicular to the sagittal plane. C The transverse, or horizontal, plane is perpendicular to both of the above planes, and is thus horizontal (perpendicular to gravity in standing position).

Bone description Landmarks for each bone are presented independently in this book.

Each bone section starts with a general presentation of the bone being

considered, including bone orientation and a brief description of the position of the bone features used as anatomic landmarks in this book. Other bone features exist, but have not been included because their palpation was not considered sufficiently accurate.

Tips • All bones shown in the illustrations that have a symmetric pair (e.g. humerus) are from the right side of the body; however, palpation definitions are applicable for both right and left bones. • Before palpating a particular landmark, you should first read the general description relating to the bone of interest. Then read the landmark guidelines for both manual and virtual palpations. Both palpation descriptions provide useful information for better visualization, palpation and location of the described landmarks. • Remember that landmark acronyms have been written, as much as possible, in a mnemonic way. For example, ‘Sternum – Clavicular Surface’ is given the acronym ‘SCS’. • Names and acronyms are not always a description on their own. Indeed, for some landmarks the name of the landmark is not strictly the anatomic point to select. For example, for the above ‘Sternum – Clavicular Surface’ or ‘SCS’ (see p. 35), the description guides the reader to select the upper edge of the clavicular surface rather than the proper joint surface (which is not palpable manually). This may not please the reader, but it does avoid unnecessarily long landmark names (e.g. ‘upper edge of the clavicular surface’).

• Pulp spots – three different locations of the finger pulp surface can be used during manual palpation: – Tip (blue): most distal aspect of the pulp – Angle (green): curved angle between the tip and the pulp center – Center (red): the central point of the pulp.

• In the manual palpation descriptions, bear in mind that the location of the landmark is usually under the pulp angle of the finger indicated in the description. This is a personal preference of the author; you

may want to use other pulp locations if you feel more confident. • When the pulp tip or pulp center is used for palpation, this will be indicated clearly in the text. • ‘Finger-roll’ – A few landmarks are located using a finger-roll technique (the text description of such landmarks will mention this technique), which consists of three steps (see framed images below): 1. A first landmark is located using the pulp tip; keep the pulp tip on that location. 2. Then, from that point, the finger pulp rolls on the pulp angle. The landmark to locate is found under the pulp angle. 3. In some cases, the finger-roll starts from the tip until the pulp center reaches the subject’s skin.

Landmark description Each anatomic landmark is described in various ways – anatomic location, manual palpation, and virtual palpation – which are related and complementary to one another. All landmarks are related to bony areas that can be palpated in a clinical or research context. Some landmarks have been recommended previously by the standardization committee of the International Society of Biomechanics (ISB) to define both local and joint coordinate systems (Wu & Cavanagh 1995, Wu et al 2002, 2005). Description of such landmarks is indicated by an ISB text string (Fig. 1.2, top). The Humanoid Animation Working Group (H|Anim; see http://www.h-anim.org/) specified so-called feature points on both skin and bone surface for representing humanoids

within 3D graphics and multimedia environments. Descriptions of these landmarks are indicated in this book by an H-Anim text string (Fig. 1.2, bottom). The author finds a few of these recommended landmarks difficult to palpate manually. Although palpation directions are given, warning signs (Fig. 1.3) indicate that manual palpation is not accurate (one warning sign indicates that manual palpation is approximate; two warning signs indicate that accurate manual palpation is unrealistic but directions are given to approximate the landmark location as best as possible).

Figure 1.2

Symbol used to indicate landmarks recommended by the ISB (top) and H|Anim (bottom).

Figure 1.3

Warning signs. The accuracy of such landmark localizations is either low (one sign) or very poor (two signs). Such definitions have been given, despite the inaccuracy, because these landmarks are either recommended in the literature or accessible by palpation, although not in an accurate manner.

Color convention Landmarks are indicated in the illustrations by means of colored spheres or dots. Red indicates the current landmark of interest that must be palpated as described. Other colors (blue or green) indicate supplementary landmarks or particular anatomic features used for

better localization of the current landmark of interest.

Descriptions of the landmarks used in this book

References

Van Sint Jan S, Della Croce U. Identifying the location of human skeletal landmarks: why standardized definitions are necessary – a proposal. Clinical Biomechanics. 2005;20:659660. Van Sint Jan S, Salvia P, Feipel V, et al. In-vivo registration of both electrogoniometry and medical imaging: development and application on the ankle joint. IEEE Transactions on Biomedical Engineering. 2006;53:759-762. Wu G, Cavanagh P. ISB recommendations for standardization in the reporting of kinematic data. Journal of Biomechanics. 1995;28:1257-1261. Wu G, Siegler S, Allard P, et al. ISB recommendation on definitions of joint coordinate systems of various joints for the reporting of human joint motion – Part I: ankle, hip, spine. Journal of Biomechanics. 2002;35:543-548. Wu G, van der Helm FC, Veeger H, et al. 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. Journal of Biomechanics. 2005;38:981-992.

2 Skull Orientation and general presentation (Figs 2.1 & 2.2) The skull is a large, hollow, bony structure comprising several fused bones. (Note: The jaw is not part of the skull and is therefore described in a separate chapter.) Numerous palpable protuberances are present on the skull. The orbit (1) shows a sharp supraorbital edge (2) with a small supraorbital notch (SSN). The infraorbital foramen (SIF) is below the orbit. The center of the glabella (SGL) protuberance is located above a depression, i.e. the nasion (SNA) (or sellion) found at the intersection of both supraorbital edges. The anterior nasal spine (SNS) is located below the nostril cavities. Each zygomatic arch (SZR) is located on one of the lateral aspects of the skull, and runs horizontally towards the orbit. Each zygomatic arch shows palpable upper (3) and lower (4) edges, and a large anterior aspect supporting a vertical branch. The area between the horizontal and vertical branches of the SZR shows a sharp angle, the zygomatic angle (SZA). The mastoid process (SMP) is located at the posterolateral aspect of the skull. A large protuberance called the external occipital protuberance (SOP) is observable at the posterior aspect of the occiput at the intersection of both right and left superior nuchal lines (5).

Figure 2.1

Skull (3D model).

A Anterior view. B Lateral view. C Posterolateral view.

Figure 2.2

Skull (anatomic specimen).

A Posterior view. B Lateral view. C Anterolateral view. D Anterior view.

Skull – external Occipital Protuberance (SOP)[M] H|Anim Landmark SOP Large protuberance located at the posterior aspect of the occipital bone (see Figs 2.1 & 2.2).

the sitting

The palpator stands behind

Place one finger on each trapezius muscle. Follow both muscles up to their insertions on the skull (yellow arrows).

located between these insertions.

A bony protuberance is

The apex of this protuberance is the point to locate. Manual palpation tip • For better localization of the trapezius muscles, ask the subject to perform an active head extension. • Then, to facilitate palpation, ask the subject to relax and put his or her head in slight extension to relax the trapezius muscles.

Observe the posterior aspect of the skull. The SOP landmark is located in the inferior third on a usually well developed protuberance. Select the apex of the latter.

Skull – Zygomatic aRch (SZR)[R,L] Landmark SZR Each zygomatic arch is located laterally on the skull and runs horizontally (see Figs 2.1 & 2.2). The angle between both the horizontal branch and the vertical branch of the arch is selected.

the sitting subject.

The palpator stands behind

The zygomatic bone is delimited by the dotted blue line on this image (see also virtual palpation below). Locate the upper edge of the horizontal branch of the zygomatic arch. Glide forwards (green arrow) until the posterior edge of the vertical branch is reached.

Rotate the pulp of your finger slightly anteriorly, and select the angle between both branches.

Observe the skull from a lateral view.

Locate the upper edge of the horizontal branch and the posterior edge of the vertical branch of the zygomatic arch. Select the angle between both edges.

Skull – Zygomatic Angle (SZA)[R,L] Landmark SZA The zygomatic bone shows a relatively sharp angle, located below the inferior edge of the orbit (see Figs 2.1 & 2.2).

the sitting subject.

The palpator stands next to

The zygomatic bone is delimited by the dotted blue line on this image (see also virtual palpation below). Gently pinch the horizontal branch of the zygomatic arch between thumb (on the zygomatic lower edge) and forefinger (on the zygomatic upper edge). Both fingers then follow the horizontal branch forwards until the widest section of the bone is reached; the index path remains horizontal (orange arrow), while the thumb path

is inclined downwards (green arrow).

be on the zygomatic angle.

Now the pulp of the thumb should

The point to locate is at the apex of the angle. Manual palpation tip • The apex is relatively sharp and may be located deep in the soft tissue, depending on the development of the subject’s cheeks.

NOTE During manual palpation, the forefinger is on SZR (see p. 11).

Observe the skull from a lateral view. Follow the lower edge of the horizontal branch of the zygomatic arch forwards until the angle is found. Select the center of the angle. Rotate (approx. 90°) backwards and make sure the center of the angle has been selected.

Skull – Mastoid Process (SMP)[R,L] Landmark SMP The mastoid process is found at the posterolateral aspect of the skull. It is a large protuberance for the origin of the sternocleidomastoid (scm) muscle (see Figs 2.1 & 2.2).

the sitting subject.

The palpator stands next to

The mastoid process (dotted blue line) is located just behind the auricle. Follow the scm muscle (dotted red line) upwards to the mastoid process, which points downwards.

The point to locate is slightly lateral to the extreme tip of the mastoid process.

Manual palpation tip • To locate the scm muscle better, ask the subject to perform an active lateral flexion.

• Then, to facilitate palpation, the subject’s head can be placed passively in lateral flexion towards the palpated side. You can also ask the subject to rest his or her head in one of your hands (the one you are not using for palpation), to relax the scm muscle better.

NOTE The scm muscle has its origin all around SMP; this muscle must therefore be relaxed in order to palpate the process tip correctly. This point is often sensitive to palpation – be gentle during manual palpation!

View the skull from a posterolateral view. The mastoid process is easily observable pointing downwards. Select the point slightly lateral to the real tip of the process.

Skull – Supraorbital Notch (SSN)[R,L] Landmark SSN Small notch found on the superior edge of the orbit (see Figs 2.1 & 2.2). In some less common cases, the notch is replaced by a supraorbital foramen.

the sitting subject.

The palpator stands next to

Place one thumb on the lateral aspect of the subject’s eyebrow and push slightly to find the superior edge of the orbit (the supraorbital edge). The thumb pulp is oriented slightly upwards. Gently glide medially along the edge (green arrow).

medial part of the edge.

A small depression is found on the

This point (approximately above the center of the eye) is the landmark to locate.

Manual palpation tip • Mind the eye of the individual being palpated, especially the cornea, which is extremely sensitive. • Keep the thumb pulp pointing upwards when locating SSN. You can also ask the subject to close their eyes.

NOTE Some individuals do not have a notch, but a foramen instead. In subjects with a supraorbital foramen, the upper part of the hole is the point to select.

Observe the skull from an anterolateral view and locate the orbicular frame. The supraorbital edge shows a small depression on its medial third. Select the center of the depression.

Skull – Infraorbital Foramen (SIF)[R,L] H|Anim

Landmark SIF Foramen found below the orbit (see Figs 2.1 & 2.2).

sitting subject.

The palpator stands in front of the

First locate SSN with the thumb (see p. 14). Then glide downwards along a vertical line (blue arrow).

A foramen is found below the orbit (at the level of the nostril) and slightly lateral to the

vertical line. Select its bottom edge. Manual palpation tip • Mind the eye of the individual being palpated, especially the cornea, which is extremely sensitive.

NOTE • In case of a supraorbital foramen, the upper part of the foramen is the point to select.

Observe the skull from an anterolateral view and locate the orbicular frame. A foramen is visible below the infraorbital edge of the orbit. Select its bottom edge.

Skull – Lateral Corner of orbit (SLC)[R,L]

Landmark SLC The orbital frame usually shows a well pronounced lateral angle (see Figs 2.1 & 2.2).

front of the sitting subject.

The palpator stands in

Put your thumb on the upper edge of the orbital frame. Then follow this edge laterally (blue arrow).

eyelids meet, a bony angle can be felt. This is the point to select.

Below the point where the

Manual palpation tip • Mind the eye of the individual being palpated, especially the cornea, which is extremely sensitive.

Observe the skull from an anterior view and locate the orbicular frame and its lateral corner. Select this corner (slightly on its lateral aspect).

Skull – Lower Edge of orbit (SLE)[R,L] Landmark SLE The orbital frame shows a large inferior edge (see Figs 2.1 & 2.2). Note that this edge orientation may have important individual variations (from horizontal to oblique).

front of the sitting subject.

The palpator stands in

Ask the subject to close the eyes. Put the fourth finger on SLC (see p. 16) and the second finger on the medial angle of the orbit.

the inferior edge of the orbit.

With your forefinger, find

Select the edge point located just between your thumb and middle finger. Manual palpation tip

• Mind the eye of the individual being palpated, especially the cornea, which is extremely sensitive.

NOTE Do not select the deepest point of the inferior edge (in blue).

Observe the skull from an anterior view and locate the inferior edge of the orbicular frame. Select its center (in red).

Skull – NAsion (SNA)[M] H|Anim Landmark SNA The nasion (or sellion) is a bony depression located between the upper edges of both orbits (see Figs 2.1 & 2.2).

front of the sitting subject.

The palpator stands in

Place a thumb on the center of the forehead. Then glide down along a vertical line (blue arrow).

A deep depression is found along the vertical line, and slightly above a line running between the center of both eyes. Select the center of the depression.

Observe the skull from an anterior view. Locate the depression at the intersection of both supraorbital edges. Select the center of the depression.

Skull – GLabella (SGL)[M] H|Anim Landmark SGL The glabella is a protuberance located on the frontal bone, above the nasal bones (see Figs 2.1 & 2.2).

The palpator stands in

front of the sitting subject. First, locate SNA (see p. 18). Then glide upwards along a vertical line (blue arrow).

The protuberance of the glabella is found along the above vertical line. The point to palpate is the center of the protuberance.

Observe the skull from an anterior view.

First, locate SNA (in blue, see p. 18). The glabella is the tuberosity above this depression. The center of the glabella is the SGL point (in red).

Skull – anterior Nasal Spine (SNS)[M] Landmark SNS This landmark is located below and between both nasal cavities (see Figs 2.1 & 2.2).

the sitting subject.

The palpator is in front of

The pulp of one finger is placed on the upper lip of the subject, just below the nose. The finger pulp is then oriented slightly upwards (blue arrow) to find the lower edge of the nasal spine.

until the spine apex is found.

This edge is then followed

Observe the skull from an anterolateral view. The SNS landmark is the apex of the nasal spine located below both nasal cavities.

3 Jaw Orientation and general presentation (Figs 3.1 & 3.2) The jaw bone (or mandible) results from the fusion of two bony elements, the junction of which is found at the level of the mental protuberance (JMP), located on the anterior aspect of the bone. Above JMP, both lower central incisors indicate the upper limit of the junction (JIN). Each jaw side shows a horizontal part, or body (1), that is shared by both fused bony elements. A vertical branch, or ramus (2), is located on each side of the body. Each jaw angle (JAN) (or gonion) is located at the intersection of the inferior crest (3) of the jaw body and the posterior crest (4) of the ramus. The anterior part of the inferior crest (JIC) is located below JMP.

Figure 3.1

Jaw (3D model).

Figure 3.2

Jaw (anatomic specimen). A Anterior view. B Lateral view.

A Anterior view. B Laterosuperior view.

Jaw – ANgle (JAN)[R,L] ISB H|Anim Landmark JAN

This angle is at the intersection of the (horizontal) jaw body and the (vertical) ramus (see Figs 3.1 & 3.2).

behind the sitting subject.

The palpator stands slightly

Place one forefinger on the lower edge (dotted red line) of the jaw body (dotted blue line). The forefinger follows this edge backwards (green arrow).

An angle is met at the posterior aspect of the body (the ramus is above this angle). The point to locate is the center of the angle.

Manual palpation tip • This angle may be less sharp in elderly subjects, and therefore more difficult to palpate. • If this is the case, be sure to select the point located at the intersection between the ramus and jaw body.

Observe the jaw from a lateral view. The point to select is at the intersection of the lower and posterior edges of the body and ramus respectively.

Rotate the model slightly forward and make sure the selected point is well at the intersection of the abovementioned edges.

Jaw – Mental Protuberance (JMP)[M] H|Anim

Landmark JMP The anterior face of the jawbone has a protuberance (see Figs 3.1 & 3.2), the upper edge of which is palpable.

The palpator stands in front of

the sitting subject.

Put one forefinger in the depression below the center of the lower lip. Slightly turn the pulp downwards. Then glide the forefinger down slightly (blue arrow).

of the protuberance is found.

The finger glides until the upper crest

The crest center is the point to select. NOTE This point is above the protuberance apex (green arrow). The latter is not selected because it is not as sharp as the crest.

Observe the jaw from an anterior view. The mental protuberance is located on the inferior aspect of the body center. The point to select is the upper ridge of the protuberance (in red), and not its apex (in blue).

Jaw – Inferior Crest (JIC)[M] Landmark JIC The anterior face of the jawbone shows a protuberance (see Figs 3.1 & 3.2), the inferior edge of which can be palpated.

sitting subject.

The palpator stands in front of the

From JMP (see p. 25), glide down towards the jaw edge (blue arrow).

The inferior edge, or crest, of the jaw is found by turning the finger pulp slightly upwards. The edge center is selected.

First locate JMP (in blue; see p. 25). Then observe the jaw from an anteroinferior view. Below JMP, locate the inferior crest of the jaw (blue arrow). Select the crest point (JIC, in red) below JMP.

Jaw – INcisive (JIN)[M] Landmark JIN This point is located between the two lower central incisors (see Figs 3.1 & 3.2).

sitting subject.

The palpator stands in front of the

Ask the subject to open the mouth.

Gently pull the lower lip down. Locate the two lower central incisors (green arrows).

Put a forefinger into the subject’s mouth vertically above JMP (see p. 25).

Manual palpation tip • Make sure the subject has central incisors that are normally implanted. • If not, use JMP only to locate JIN along a vertical line.

Virtual palpation tip • Do not select the upper ridge of the bone. • The point to select is on the anterior aspect of the bone.

Observe the jaw from an anterosuperior view. First locate JMP (in blue; see p. 25). The point (in red) to select is on the upper aspect of the jaw body, vertically above JMP.

4 Spine Orientation and general presentation (Fig. 4.1) The spine consists of 33 vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 sacral fused into the sacrum, 4 coccygeal fused into the coccyx) (Fig. 4.1A,B). The only ‘easily’ palpable structures of the spine are the spinous processes of the vertebrae, except for the first cervical vertebra, which has no spinous process. (Palpation of the sacrum is described independently; see p. 104; palpation of the coccyx is not considered.)

Figure 4.1 are visible.

The relationships of the spine, with the skull above and the sacrum below,

A Posterior view. B Lateral view. C Lateroposterior view of cervical vertebra. D Lateroposterior view of thoracic vertebra. E Lateroposterior view of lumbar vertebra. Note the morphologic differences in the spinous process at each level (see text for explanation).

The spinous process is the most posterior part of the vertebra, and points backwards. Spinous processes have various shapes and orientations, according to the level considered: • Cervical vertebrae (acronym CV2–CV7) – short, horizontal, two small tubercles (Fig. 4.1C), except for C7 which has only one tubercle • Thoracic level (acronym TV1–TV12) – long, oblique, one small tubercle (Fig. 4.1D). The orientation of the spinous process is

variable: almost horizontal for the first two and last two thoracic vertebrae; oblique for the others • Lumbar level (acronym LV1–LV5) – short with massive horizontal spinous process carrying a broad vertical tubercle (Fig. 4.1E).

Spine – Spinous process (CV2–CV7, TV1–TV12, LV1–LV5) [M] ISB|Anim

The palpator sits behind the sitting subject. First locate the external occipital protuberance (SOP, see p. 10). From SOP, glide down vertically with your second finger towards the base of the skull, gently pushing into the soft tissue.

The first palpable spinous process in this area is CV2. Place your second finger on CV2, and put the other fingers below one another. In this position, the tip of your third, fourth and fifth fingers will be on CV3, CV4 and CV5 respectively, although actual palpation might be difficult (see note). Mark these landmarks if you are able to palpate them well (see note). Now, for each spinous process (illustrated here for CV6): • Put your second finger on the last located process (CV5 in this case). • Locate the next spinous process with your third finger (here CV6). • Locate the next process (here CV7) as well, with the fourth finger. • Ask the subject to perform slight motions of flexion/extension of the spine to feel the displacement of the spinous processes under the skin. • Mark the spinous process below your third finger. • Repeat the procedure for the whole spine. Once palpation is finished, ask the subject to adopt the position you require to perform further measurements (here, neutral position).

NOTE CV2, CV3, CV4 and CV5 are usually difficult to palpate with accuracy because of the cervical lordosis and the development of soft tissue. However, such palpation can be performed in lean subjects. If registration with virtual palpation is to be performed, lumbar landmarks should correspond to the inferior angle of spinous processes.

Manual palpation tip • After locating a particular landmark, mark it with a pencil or small sticker. Once all landmarks have been marked, perform the final measurement (e.g. digitization). • Mark each spinous process with the spine in a similar position; for example, avoid marking some vertebrae with the spine flexed and others with the spine in neutral position. Doing so would lead to discrepancies because of skin displacement between the two spine positions.

Manual palpation tip • Compared with other cervical vertebrae, CV7 has the most prominent spinous process. It is usually easily palpable, and is a good starting point for numbering the spinous processes you are palpating. The second lumbar vertebra can be located by projecting a horizontal plane below the 12th pair of ribs (red line). The fourth lumbar vertebra can be located by projecting a horizontal plane above the iliac crests (in green). • See also p. 63 for the spine projections of some scapula landmarks (SSA and SIA). • Remember that the above projections may be greatly modified according to the subject’s spine morphology. You should always verify each spinous process by systematic palpation, as described above.

All vertebrae are shown in posterolateral view. Cervical level. Both tubercles of the spinous process are found at each level (except CV7). (At each level the tubercle coordinates should be averaged if registration with manual palpation data is to be performed.) CV7 has a spinous process with only one tubercle, whose center is selected. Thoracic level The center of the tip of each spinous process is located. Remember that the orientation of spinous processes is variable at this level (see p. 28). The spinous process of the lowest thoracic vertebra (TV12) is largest; the lowest part of the posterior crest of this process is the landmark to select.

Lumbar level. The spinous process of lumbar vertebrae is larger than that of other vertebrae. The lowest part of the posterior crest of the process is the landmark to select (red landmarks). Virtual palpation tip • When registration between manual and virtual palpation is to be performed: keep in mind that spinous processes are well developed at lumbar level (and TV12). Therefore, do not select the region located in the space between two successive spinous processes (blue landmarks) because these points are not palpable manually.

5 Sternum (thorax) Orientation and general presentation (Figs 5.1 & 5.2) The sternum is a flat bone located in the anterior part of the thorax (1). It articulates with the seven (sometimes six) first pairs of ribs through the costal cartilages (2, second costal cartilage) and the two clavicles (3, right clavicle). The sternum shows three parts: the manubrium (4), the body or corpus (5) and the xiphoid process (6). Proximally, the manubrium shows laterally two clavicular surfaces (SCS) for the sternoclavicular joints, and medially the jugular notch (SJN). The manubrium and the sternal body are separated by the edge (or angle) of the manubriosternal joint (SME) at the level of the second costal cartilage (2). Both sternal body and xiphoid process articulate through the xiphisternal joint (SXS) at the level of the most distal sternocostal joints. The latter usually involves the costal cartilages of the seventh pair of ribs (7, seventh left costal cartilage). The angles between the seventh costal cartilages and the xiphoid process are the xiphicostal angles (in dotted blue).

Figure 5.1

Sternum (3D model, anterolateral view).

A The sternum (arrow) represents the anterior wall of the thorax. B Relationships of the sternum with other adjacent skeletal structures. See text for explanation.

Figure 5.2

Sternum (anatomic specimens).

Isolated bone: A anterior view; B anterolateral view. Dissection of the thorax: C anterior view; D anterolateral view. Note that the xiphoid process (6) is behind the frontal plane of the seventh costal cartilages (7).

Sternum – Jugular Notch (SJN)[M] ISB H|Anim Landmark SJN

The jugular notch is along the superior edge of the sternum between the two sternoclavicular joints (see Figs 5.1 & 5.2).

The subject is sitting or lying supine. Place one forefinger on the medial line of the neck. Glide down to reach the sternum between the clavicles (blue arrow). NOTE SJN is located between the sternal insertions of both sternocleidomastoid muscles (blue lines).

View the proximal aspect of the sternum along a horizontal view. Select the central point of the notch located between both clavicular joint surfaces.

A depression can be palpated just between the two clavicles. In this depression, orient the index pulp distally, and gently push the finger into the soft tissue to reach the deepest point of the notch, which is the point to locate.

Then rotate the sternum to a frontal view, and check that the selected point is centered correctly in the notch.

Sternum – Clavicular Surface (SCS)[R,L] Landmark SCS From an anterior point of view the clavicular surface of the sternum is concave. The upper edge of this surface is next to the upper edge of the sternum (see Figs 5.1 & 5.2).

sitting subject.

The palpator stands next to the

Manual palpation tip • The clavicular displacement in the joint is palpable when the subject is elevating the shoulder. • SCS is located next to the sternal insertion of the sternocleidomastoid muscle (blue line).

From SJN (see p. 34), glide slightly laterally towards the sternoclavicular joint. The point to locate is found on the sternal aspect of the joint by turning your finger pulp slightly downwards (green line: clavicle).

Observe the sternum from a horizontal view (if possible with the clavicle). Locate the sternoclavicular joint involving both clavicle and sternum. The SCS landmark is located at the center of the superior edge of the sternal joint component.

Then rotate the sternum to a frontal

view and check that the selected point is correctly located on the joint surface edge.

Sternum – Manubriosternal Edge (SME)[M] Landmark SME The manubriosternal joint separates both manubrium and sternal body. Its anterior edge is located at the level of the second pair of costal cartilages (see Figs 5.1 & 5.2).

sitting subject.

The palpator stands next to the

Manual palpation tip • Check you are at the level of the second rib by placing one finger on SME. • From SME, using the other hand, move laterally to reach the second costal cartilage (dotted green area).

• Now move upwards: after the first intercostal space (fis), you should reach the clavicle (clav) (the first rib is difficult to palpate because it is hidden below the clavicle.). • If you reach another rib, your SME selection was probably too low on the sternum, and you should repeat it.

Put the forefinger on SJN (see p. 34). Then glide down along the anterior face of the manubrium until the edge of the manubriosternal joint is met (blue arrow). The point to locate is the center of the edge.

Observe the sternum from an anterior view. Follow the second rib until you reach the manubriosternal joint, which usually shows a sharp edge on its anterior aspect. The point to select is located on the center of the edge.

Then rotate the sternum to a lateral view and check that the selected point is correctly located on the tip of the edge.

Sternum – XiphiSternal joint (SXS) [M] ISB H|Anim Landmark SXS The xiphisternal joint separates the sternal body and xiphoid process. It is located at the level of the seventh pair of ribs (normally the last rib pair articulating with the sternum) (see Figs 5.1 & 5.2).

The palpator stands next to the subject.

With four fingers, find the lower ridge of the last costal cartilages. Glide up along the eighth then the seventh costal cartilages until you reach the depression of the xiphicostal angle.

One finger-width above and medially to this angle, the edge of SXS can be palpated. Select its center. Manual palpation tip • In case of obesity, ask the subject to breathe deeply for easier location of the costal cartilages. • The extremity of the xiphoid process is usually behind the plane of the sternum and has a variable morphology (see also Fig. 5.2). The real xiphoid tip is therefore difficult to palpate manually with precision.

Observe the sternum from an anterior view. Follow (dotted blue arrows) the seventh pair of costal cartilages until they articulate with the sternum. These articulations are at the level of the edge of the xiphisternal joint. Select this edge center.

Then rotate the sternum to a more lateral view to check that the selected point is on the edge apex.

Landmark projections on spine

Figure 5.3

Projections of SJN, SME and SXS on the spine.

For some applications (e.g. defining anatomic planes), it is useful to find the projection of some sternal landmarks on the spine (with subject standing). It must be remembered that: • The spinous processes of the thoracic vertebrae have various orientations (see Chapter 4, p. 28). • Spine projections will vary during breathing as indicated below. Grossly, the sternum is raising during inspiration and lowering during expiration.

Landmark SJN

• At full expiration: projection on TV3. • At full inspiration: TV2.

Landmark SME • At full expiration and full inspiration: TV4.

Landmark SXS • At full expiration: TV9. • At full inspiration: TV8. NOTE Projections are also dependent on the individual morphology of the subject being palpated. Spine and thorax deformations may alter these relationships.

6 Ribs (thorax) Orientation and general presentation (Fig. 6.1) The thorax includes 12 pairs of ribs (1–12; left ribs are numbered in Figure 6.1; the ninth, tenth and 11th left ribs are superimposed in this view). Each rib articulates anteriorly, through a costal cartilage, with either the sternum (13) for the first seven ribs, or with the rib above (for the eighth to tenth ribs). The two last ribs (the so-called floating ribs) do not show any anterior joints with the sternum, and ‘float’ in the soft tissue of the abdomen. Posteriorly, the ribs articulate with the thoracic vertebrae. The first pair of ribs is difficult to palpate because the ribs are located below the clavicle (14). The second pair of ribs articulates with the sternum at the level of the manubriosternal joint (SME; see p. 36). The seventh pair articulates with the sternum at the level of the xiphisternal joint (SXS; see p. 37). The lateral faces of the ribs are located on the lateral aspect of the thorax (RL4–RL10), vertically above the tubercle of the iliac crest (ICT; see p. 112) found on the ilium (15). The anterior part of the second to seventh ribs (RA2–RA7) can be palpated vertically below the anterior convexity of the clavicle (CAE; see p. 47). The center of the costal cartilage of the second to seventh ribs (RM2–RM7) is found vertically below the anterior edge of the sternoclavicular joint (CAS; see p. 49).

Figure 6.1

Ribs (3D model).

A Anterior view. B Lateral view. See text for explanation.

Manual palpation tip • After locating a particular rib landmark, mark it with a pencil or small sticker. • Once all rib landmarks have been marked, make the final measurements or digitization. This will allow all landmarks to be processed with the thorax in a similar position.

NOTE Rib orientation shows important individual anatomic variations. This must be kept in mind when locating some landmarks in relation to one another. Therefore, the palpator should not rely solely on the relative location of rib landmarks relative to other adjacent anatomic features as explained in this chapter, but should also double-check the shape of the rib being palpated.

Ribs – Anterior aspect (RA2–RA7)[R,L]

Landmarks RA2–RA7 The anterior aspect of the second to seventh ribs is located below a vertical line running down from the anterior convexity of the clavicle (CAE) (see Fig. 6.1).

The palpator is lateral to the sitting subject. finger.

Put your middle finger between the forefinger and the annular

First locate CAE (see p. 47) and mark it. For each rib, glide down vertically from CAE, gently pushing with your finger pulp into the soft tissue of the intercostal space. Put your forefinger and annular finger into two successive intercostal spaces (illustrated here with the first and second spaces).

Mark the center of the rib (here, RA2 on the second rib). NOTE In female subjects, these landmarks can be difficult to palpate because of the volume of the breast.

Manual palpation tip • In male subjects, and females with a moderate breast volume, the nipple is usually at the level of the fourth intercostal space. In such subjects, you can therefore start your palpation from the nipple location: the fourth rib and fifth ribs are above and below the nipple, respectively.

Process the next five ribs in a similar way.

View the thorax from an anterior view; the clavicles should be seen as well. First locate CAE (in blue; see p. 47). Then, for the second to seventh ribs, select the center of the rib located along a vertical line (blue arrow) running through CAE.

Ribs – Medial aspect (RM2–RM7)[R,L] Landmarks RM2–RM7 These landmarks correpond to the center of the costal cartilage of the second to seventh ribs and are located on a vertical line starting from CAS and CSJ (see Fig. 6.1).

The palpator is lateral the sitting subject. Mark this point. First mark RA2–RA7 (see p. 40) and CAS (see p. 49). For each rib, starting from its RAi landmark, follow its anterior face until you intersect the vertical line running down from CAS. NOTE Remember that ribs are not purely horizontal (see Fig. 6.1). Their degree of obliqueness depends on: (1) the area of the thorax being considered; (2) inspiration/expiration (on inspiration the ribs are more horizontal than on expiration); and (3) individual variation. As a rule of thumb, the following relationships are usually found: • RM2 is slighty distal (i.e. lower) than RA2. • RM3 is at about the same horizontal level as RA3. • RM4 is at the same horizontal level as RA4, or more proximal (i.e. higher). • RM5, RM6 and RM7 are more proximal than RA5, RA6 and RA7 respectively. RM6 and RM7 can be difficult to palpate accurately.

Instead of CAS you can select CSJ (see p. 48) as a reference point.

Manual palpation tip • RM2 is on the same horizontal line as SME (see Fig. 6.1). • See RAi landmarks (p. 40) for the position of the fingers in the intercostal spaces when following a particular rib.

View the thorax from an anterior point of view. First locate CAS (see p. 49). Then select the center of the costal cartilage of the second to seventh ribs, vertically below CAS.

Ribs – Lateral aspect (RL4–RL10)[R,L] Landmarks RL4–RL10 The lateral aspect of the fourth to tenth ribs is located along a vertical line running down through the lateral aspect of the thorax (see Fig. 6.1).

The palpator is next to the sitting subject. First mark RA5 (see p. 40).

Then locate the axillary line (in blue) from ICT (see p. 112), found on the lateral aspect of the iliac crest (in pink). This line runs upwards through the axillary region.

Then, from RA5, follow the rib until you cross the (blue) axillary line. In this image the second and third fingers are on each side of the fifth rib, within the fourth and fifth intercostal spaces respectively. Mark the intersection point (between the second and third fingers) with the axillary line (RL5).

From RL5, move vertically to locate RL4 (above RL5) and RL6– RL10 (below RL5). NOTE Compared with the anterior aspect, the lateral aspect of the ribs is more proximal (i.e. higher), because of the obliqueness of the ribs (also see Fig. 6.1).

Similar landmarks are not palpable on the first, second and third ribs because of the interposition of soft tissue in the axillary area. Bear in mind that the axillary area contains large nerve bundles; palpation must therefore be performed gently. RL4 must be sought under the lower edge of the pectoralis major muscle (green line).

View the thorax from a lateral view. Locate ICT on the iliac crest (in blue; see p. 112). Select the center of the lateral faces of the fourth to tenth ribs, vertically above ICT.

Then observe the thorax from an anterior view to confirm that the selected landmarks have been located correctly on the lateral aspects of the ribs.

7 Clavicle Orientation and general presentation (Figs 7.1 & 7.2) The clavicle (1) is a sinuous bone located on the anterior aspect of the shoulder girdle. Its anterior face (2) presents a medial convexity (CAE) and a lateral concavity (CAA). The clavicle articulates with two bones: the scapula via the acromioclavicular joint (CAJ) and the sternum via the sternoclavicular joint (CSJ). The latter shows an anterior edge (CAS), palpable under the skin.

Figure 7.1

Clavicle (3D model).

Figure 7.2

Clavicle (anatomic specimen, superior view).

A Position within the brachial girdle – anterolateral view. B Anatomic features – superior view.

To facilitate manual palpation of the clavicle, the subject can be seated with the forearm flexed and resting on a support (e.g. a table corner), in order to relax the shoulder muscles.

Clavicle – Acromioclavicular Joint (CAJ)[R,L] ISB

Landmark CAJ The acromial joint surface of the clavicle is relatively flat. Its upper edge is next to the superior face of the clavicle (see Figs 7.1 & 7.2).

The palpator stands next to the sitting subject. With one forefinger, follow the superior face of the clavicle (green dotted area) until the depression of the acromioclavicular joint (black arrow) is reached.

The point to locate is found after rotating the finger pulp slightly towards the clavicle.

Observe the superior face of the clavicle (if possible together with the scapula). Locate the acromioclavicular joint. The point to select (in red) is the center of the superior edge of the clavicular component of the joint (facing SAJ, in blue; see p. 60).

Manual palpation tip • Gentle pushing on the lateral part of the clavicle with the other hand allows small displacements of the clavicle in this joint to be felt better. • Compare the pulp orientation for CAJ and SAJ (see p. 60) locations.

Clavicle – Anterior concAvity (CAA)[R,L] Landmark CAA The anterior face of the clavicle shows a large depression laterally (see Figs 7.1 & 7.2).

The palpator sits next to the sitting subject. First, observe the clavicle (green dotted area) under the subject’s skin, and spot its concavity in the lateral third of the bone (black arrow).

Then put a finger into the concavity depression. CAA is the deepest point of the depression.

Observe the clavicle together with the scapula from a superior view. The coracoid process should be vertical. Select the deepest point of the depression found in the lateral third of the anterior edge of the clavicle. This point is usually along a vertical line running through the coracoid process (blue line).

Then observe the clavicle from a frontal view. Check that the selected point is located in the center of the anterior aspect of the clavicle.

Clavicle – Anterior convExity (CAE)[R,L] Landmark CAE The anterior face of the clavicle is smoothly convex medially (see Figs 7.1 & 7.2).

The palpator sits next to the sitting subject. First, observe the anterior face of the clavicle (green dotted area) under the subject’s skin, and spot its convexity in the medial third of the bone (black arrow).

Put one finger on the summit of the convexity. CAE is located on this summit.

Observe the clavicle from a superior view. Select the summit of the convexity (blue curve), observed in the medial third of the anterior face.

Then observe the clavicle from a frontal view. Check that the selected point is located in the center of the anterior face.

Clavicle – Sternoclavicular Joint (CSJ)[R,L] Landmark CSJ The upper edge of the sternal joint surface is next to the superior face of the clavicle (see Figs 7.1 & 7.2).

The palpator stands next to the sitting subject. First locate SCS (see p. 35), which is on the medial aspect of the sternocleidomastoid muscle (scm) (blue line).

The upper edge of the clavicular component of the joint is located lateral to scm (dotted blue line) and above the clavicle. Turn your finger slightly laterally. Push gently into the soft tissue until the sharp CSJ edge is found.

Manual palpation tip • The clavicular displacements in this joint are readily palpated when the subject is elevating the shoulder.

Observe the clavicle from a horizontal view (if possible together with the sternum). Locate the sternoclavicular joint involving the clavicle and sternum. The CSJ landmark (in red) is located at the center of the superior edge of the clavicular joint component (facing SCS, in blue; see p. 35).

Then observe the clavicle from a medial view. Check that the selected point is correctly located on the center of the joint surface upper edge.

Clavicle – Anterior Sternoclavicular joint (CAS)[R,L] ISB

Landmark CAS The anterior edge of the sternal joint surface is palpable (see Figs 7.1 & 7.2).

The palpator is next to the sitting subject. First select CSJ (see p. 48).

Then glide down along the anterior edge of the joint surface.

Select the most anterior part of this edge.

Observe the clavicle from a medial view (if possible together with the sternum). Locate the sternoclavicular joint involving both clavicle and sternum. CAS is located at the apex of the anterior edge of the clavicular joint component.

Then observe the clavicle from an anterior view. Check that the selected point is correctly located on the center of the anterior edge of the joint surface.

8 Scapula Orientation and general presentation (Figs 8.1 & 8.2) The scapula or shoulder blade (1) is a triangular bone located on the lateroposterior aspect of the thorax and on the posterior aspect of the shoulder girdle (Figs 8.1 & 8.2). This bone presents three edges, medial or vertebral (2), lateral or axillary (3) and superior (4), and two angles, one inferior (SIA) and one superior (SSA).

Figure 8.1

Scapula (3D model).

A General position. B Posterior view. C Anterior view. D Superior view.

Figure 8.2

Scapula (anatomic specimen).

Isolated bone: A posterior view; B lateral view; C superior view.

The posterior aspect of the scapula is divided into two parts by the spine (6), which runs from the medial aspect (i.e. the spine root or SRS) to the lateral aspect of the bone. The most lateral part of the spine is called the acromion (7), which articulates with the clavicle (8) through the acromioclavicular joint (SAJ). The angle located between the spine and the acromion is called the acromial angle

(SAA). The most anterior part of the acromion is the acromial tip (SAT). The acromial edge (SAE) runs between both SAA and SAT. Note that the center of the glenoid cavity is approximatively below the acromion. The coracoid process (9) originates from the superior edge, and points forwards and laterally below the clavicle. The summit of the coracoid process is called the coracoid tip (SCT).

Scapula – Inferior Angle (SIA)[R,L] ISB Landmark SIA Both lateral and medial edges of the scapula merge into a sharp inferior angle (see Figs 8.1 & 8.2).

The subject is standing or lying prone. The palpator stands behind the subject. With one forefinger, glide down the medial edge of the scapula,

while your thumb follows the lateral edge (blue arrows). Forefinger and thumb meet at the apex of the inferior angle.

Select the angle apex (SIA) by orienting the forefinger pulp upwards. NOTE With the upper arm in neutral position, SIA is on approximately the same horizontal plane (blue line) as TV7 (in blue; see p. 31).

Observe the posterior face of the scapula. Select the most distal point of the inferior angle.

Then observe the bone from an inferior view. Check that the point has been located correctly at the center of the angle.

Scapula – Root of Spine (SRS)[R,L] ISB Landmark SRS

The root of the scapula spine is located next to the medial edge of the scapula. Keep in mind that the spine root has a triangular shape, the lateral apex of which indicates the true end of the scapula spine.

The subject is standing or lying prone with the shoulder in abduction. The palpator stands next to the subject. First find the scapula spine in the center of the shoulder region. Then glide along the scapula spine (blue arrow) with the pulps of all your fingers until the middle finger finds the medial edge (red line).

SRS is under your forefinger, at the intersection of the scapula spine (blue line) and the medial edge (red line), slightly lateral to this edge. Manual palpation tip • This landmark can be difficult to palpate when the rhomboid muscles are contracted. • Placing the subject’s arm along the body may help to relax the shoulder muscles and facilitate the palpation.

Observe the posterior face from a posterior (slightly medial) view. First locate the scapula spine and the triangular shape of its root (blue dotted line).

Select the apex of the root triangle, which is

closest to the scapula spine.

Scapula – Superior Angle (SSA)[R,L] Landmark CAS Both superior and medial edges of the scapula merge into the superior angle (see Figs 8.1 & 8.2)

The subject is standing or lying prone with the shoulder in abduction. The palpator stands behind the subject. From SRS (see p. 53), glide up along the medial edge towards the superior angle of the scapula (blue arrow) until you reach the horizontal upper edge.

Push relatively deep (but gently) into the soft tissue to locate the superior angle better. The SSA landmark is at the intersection of the medial and superior edges. Manual palpation tip • The subject’s arm must be resting along the body in order to relax the shoulder muscles, especially the levator scapulae muscle, as spasticity of this muscle compromises accurate palpation of SSA.

NOTE This point is often sensitive because of the insertion of the levator scapulae muscle. Because this landmark is often difficult to palpate with accuracy, this sensitivity can be used as an indicator of the rightness of the palpation.

NOTE With the upper arm in neutral position, SSA is approximately on the same

horizontal plane (blue line) as TV2 (in blue; see p. 31).

Observe the posterior face from a posterior view. The point to locate is at the intersection of the medial and superior edges.

Then observe the scapula from a superior view. Check that the selected point is in the center of the angle (slightly posterior).

Scapula – Acromial Angle (SAA)[R,L] ISB Landmark CAS The acromial angle is the posterior angle between the scapula spine and the acromion (see Figs 8.1 & 8.2).

The subject sits with the arm hanging. The palpator is behind the subject. First locate the scapula spine (blue area) (for this location see SRS, p. 53). Then glide laterally (blue arrow) until you pass an angle, to reach the lateral edge of the acromion.

Move back on the angle. The SAA landmark is located on this angle.

Observe the scapula from a horizontal view. The SAA point is at the intersection of the acromial edge (pointing upwards from this view) and the spine edge (transversal).

Then, from a posterolateral view, make sure that the selected point is at the center of the acromial posterior angle.

Scapula – Acromial Tip (SAT)[R,L] Landmark CAS The acromion has a small anterior face, which is the acromial tip (see Figs 8.1 & 8.2). The lateral angle of the tip is readily palpable.

The subject sits with the arm hanging. The palpator is behind the subject.

Put one thumb on SAA (see p. 56). With the forefinger of the same hand, glide forwards (green arrow) along the lateral edge of the acromion until the lateral angle of the acromial tip is met (blue area: scapula spine and acromion; green area: clavicle).

Select this angle. NOTE The true acromial tip (width ±2 cm) is located just after this angle. The angle is the point to select (not the tip!).

Observe the scapula from a horizontal view. The SAT point (in red) is at the most anterior part of the acromion, on the angle (lateral to the true acromial tip, in blue).

Then, from an anterior view (and slightly lateral), make sure that the selected point is on the acromion anterior angle (in red) and not on the tip (in blue).

Scapula – Acromial Edge (SAE)[R,L] H|Anim Landmark CAS The lateral edge of the acromion is readily palpable on the upper side of the shoulder joint (see Figs 8.1 & 8.2).

The subject sits with the arm hanging. The palpator is behind to the subject. First locate SAA (see p. 58) and SAT (see p. 59) with the thumb and middle finger respectively. Then place the forefinger between the thumb and middle finger, and locate the acromial edge.

The point to select is under the forefinger on the lateral edge of the acromion.

Observe the acromion from a horizontal view. The SAE point (in red) is along the lateral edge of the acromion between SAT (in blue; see p. 59) and SAA (in green; see p. 58).

Then, from a lateral view, make sure that the selected point is on the acromial edge.

Scapula – Coracoid Tip (SCT)[R,L] ISB Landmark CAS The coracoid process has a narrow tip oriented laterally and anteriorly (see Figs 8.1 & 8.2).

The palpator stands next to the sitting subject. From CAA (see p. 46), glide vertically until you reach the anterior face of the coracoid proccess (blue arrow).

Then move slightly laterally until the coracoid tip is reached. The center of the coracoid tip is the point to locate.

Manual palpation tip • The coracoid process points laterally and forwards; its tip is therefore lateral compared with the anterior face (green area). (This relationship can also be seen in Figure 8.1.)

Observe the scapula from a lateral (and slightly anterior) view. Select the tip of the coracoid process.

Scapula – Acromioclavicular Joint (SAJ)[R,L] Landmark CAS The edge of the clavicular joint surface is located in the same plane as the superior face of the clavicle (see Figs 8.1 & 8.2).

The palpator stands next to the sitting subject. With one forefinger, follow the superior face of the clavicle (green area) until the depression of the acromioclavicular joint (black arrow) is reached.

The point to locate is found after rotating the finger pulp slightly towards the scapula. Manual palpation tip • Gentle pushing on the lateral part of the clavicle allows small displacements of the clavicle in this joint to be felt. • Compare the pulp orientation of the palpating finger for SAJ and CAJ (see p. 45) locations.

Observe the superior face of the scapula (if possible together with the clavicle). Locate the acromioclavicular joint. The point to select (in red) is the center of the superior edge of the scapula joint component (facing CAJ, in blue; see p. 45).

Landmark projections on spine

Figure 8.3

Projections of SSA and SIA on spine. Some landmarks on the scapula can be used to locate landmarks on the spine (and vice versa) more easily during manual palpation. It must be remembered that:

• The spinous processes of the thoracic vertebrae have various orientations (see Chapter 4, p. 28). • The scapula rotates on the thorax during movement of the shoulder joint; therefore, the following points are valid only with the shoulder in neutral position (i.e. the upper arm aligned along the trunk).

Landmark SSA is on the same horizontal plane as TV2. Landmark SIA is on the same horizontal plane as TV7.

NOTE The projections are also dependent on the individual morphology of the subject being palpated. Spine and thorax deformations may alter these relationships.

9 Humerus Orientation and general presentation (Figs 9.1 & 9.2) The humerus (1) articulates medially with the scapula (2) through the scapulohumeral joint. The proximal epiphysis shows an intertubercular sulcus (3) limited by the greater tubercle (HGT) and the lesser tubercle (HLT) laterally and medially, respectively. The posterolateral aspect of the diaphysis presents a slightly V-shaped bony crest, the posterior (4) and anterior (5) branches of which are usually visible (dotted lines on figures are just next to the branches). The deltoid tuberosity (HDT) is at the intersection of both branches. The distal epiphysis has a medial epicondyle (HME) and a lateral epicondyle (HLE). Both upper (HMU) and lower (HML) angles of the medial epicondyle are usually well developed. The same epiphysis shows two joint surfaces: the humeral capitulum (6) and the humeral trochlea (7), articulating with the radius (8) and ulna (9) respectively.

Figure 9.1

Humerus (3D model).

A General position: anterior view. B Isolated bone: lateral view. C Proximal epiphysis: anterior view. D Distal epiphysis: anterior view.

Figure 9.2

Humerus (anatomic specimen).

A Humeral head and diaphysis: frontal view. B Humeral head: superior view. C Humeral head and diaphysis: posterior view. D Distal epiphysis: anterior view.

Humerus – Greater Tubercle (HGT)[R,L] Landmark HGT The greater tubercle is a large protuberance located laterally on the proximal epiphysis. The point to palpate is located on the center of its upper edge (see Figs 9.1 & 9.2).

The palpator stands behind the sitting subject, whose elbow is flexed. The upper arm is in neutral position (in this position, the forearm should be parallel to the sagittal plane).

First locate SAA, SAE and SAT (see pp 56, 58 and 57) with your first, second and third fingers respectively. Then, with your second finger, glide down and anteriorly (about half-a-finger-pulp width) to palpate the upper edge of the greater tubercle.

Select this point. Manual palpation tip • The deltoid muscle covers this tubercle and must be well relaxed to facilitate the palpation. To achieve this, support the subject’s forearm with your non-palpating hand. • Mobilize the subject’s shoulder joint with small motions of abduction/adduction in order to feel more easily the upper edge of the greater tubercle gliding under your second finger.

Observe the humerus from a lateral view.

Locate the greater tubercle and the edge above it (blue line). The point to select is the center of the edge.

Move to a posterior view. Check that the most lateral point of the edge has been selected.

Humerus – Lesser Tubercle (HLT)[R,L] Landmark HLT The lesser tubercle is a small protuberance located on the anterior aspect of the proximal epiphysis (see Figs 9.1 & 9.2).

The palpator stands behind the sitting subject, whose elbow is flexed. The upper arm is in neutral position (in this position, the forearm should be parallel to the sagittal plane).

First locate SCT (see p. 59). From this point, glide down and laterally (single-headed arrow) about one finger-pulp width to reach the lesser tubercle. The point to locate is the center of the tubercle. Manual palpation tip • By passively rotating the subject’s upper arm (double-headed arrow), you should be able to feel the lesser tubercle rolling under your finger more easily. • Be gentle: this point can be sensitive owing to the attachment of the subscapularis muscle here.

Observe the humerus from an anterior view.

Locate the lesser tubercle below and lateral to SCT (in blue; see p. 59). The point to select is the center of the tubercle (in red).

Control the selection from a superior view. Make sure that the anterior part of the tubercle has been selected (in red), and not the edge (in green) located next to the intertubercular sulcus.

Humerus – Deltoid Tuberosity (HDT)[R,L]

Landmark HDT This tuberosity is V-shaped, with its angle located halfway along the lateral part of the diaphysis (see Figs 9.1 & 9.2). The deltoid muscle inserts here.

The subject sits with the arm hanging outside the table. The palpator is next to the subject. Ask the subject to perform an abduction of the shoulder joint against a slight resistance applied on the lateral aspect of the arm. With the first and second fingers, locate respectively the anterior (red line) and posterior (blue line) edges of the deltoid muscle.

edges.

The point to select is at the V-shaped convergence of both

NOTE In some subjects, HDT is readily palpable as a bony landmark. In other subjects, palpating this tuberosity is more difficult because it is less developed. In this case, the V summit of the deltoid muscle is the point to select.

Observe the humerus from a lateral view.

The posterior branch of the deltoid V is visible (blue line).

The point to select is the most distal point of this branch, slightly anteriorly.

Move to a more anterior view. Confirm that the selected point is at the end of the anterior branch of the V (red line), slightly laterally.

Humerus – Medial Epicondyle (HME, HMU, HML)[R,L] ISB H|Anim Landmarks HME, HMU, HML This is the large tuberosity present on the medial aspect of the distal epiphysis (see Figs 9.1 & 9.2), and is frequently visible under the skin. Three points are palpated.

The subject sits with the upper arm on a table, elbow slightly flexed. The palpator faces the subject. Feel the medial aspect of the elbow with the second finger to find the well-developed medial epicondyle (green area). First select its upper angle (HMU). Then glide down until the apex is found. Select the center of the apex (HME). Continue gliding down to locate the lower edge, the angle of which is selected (HML).

Observe the humerus from a medial view.

Locate the medial epicondyle on the distal part of the bone. Select the center of the tubercle (HME, in red). Then select both upper (HMU, in purple) and lower (HML, in orange) epicondyle angles.

Then observe the humerus from an anterior view. Check that the selected points are correctly set on both angles and apex.

Humerus – Lateral Epicondyle (HLE)[R,L] ISB H|Anim Landmark HLE This is the large tuberosity visible on the lateral aspect of the distal epiphysis (see Figs 9.1 & 9.2).

The subject sits with the elbow extended. The palpator faces the subject. First observe the lateral aspect of the elbow joint. A hollow is usually visible. Close to the hollow center is the lateral aspect of the radiohumeral joint. The radial head is just distal to the hollow center (see p. 82), whereas the lateral epicondyle (blue line) is slightly proximal.

Place a middle finger on the radial head and the forefinger of the same hand on the lateral epicondyle. While keeping the forefinger on the lateral epicondyle, flex the subject’s elbow passively (about 90°). In this position you should be able to feel the epicondyle tubercle better.

Select the most distal aspect of the tubercle.

Observe the distal epiphysis from a lateral view.

Locate the tubercle of the lateral epicondyle. Select the most distal point of the tubercle.

Then observe the humerus from an anterior view. Check that the selected point is on the distal aspect of the lateral

epicondyle.

NOTE A line (in red) between HLE and HML (in blue; see p. 67) runs through the humeral capitulum (5) and the trochlea (6), slightly behind their centroid.

10 Ulna Orientation and general presentation (Figs 10.1 & 10.2) The ulna (1) is located on the medial aspect of the forearm. It articulates with the humerus (2) proximally, the wrist complex (3) distally, and the radius (4) laterally. The proximal epiphysis of the ulna bone shows a joint cavity, the semilunar notch or greater sigmoid cavity (5), which can be divided into two segments: a horizontal segment, the coronoid process (UCP), and a vertical segment, the olecranon (UOA, apex; UOM, medial aspect; UOL, lateral aspect). The lateral edge of the olecranon starts at UOL (green line). This edge meets the medial edge of the olecranon (blue line), starting from UOM. Both edges join at the base of the olecranon (UOB). The posterior ulnar edge (6, black line) runs below UOB. The distal epiphysis of the ulna comprises a head (UHE) and the ulnar styloid process (USP). The ulnar head (UHE) articulates with the radius via the distal radioulnar joint (URU). The most medial aspect of UHE is called the ulnar dome (UHD).

Figure 10.1

Ulna (3D model).

General position (foream in neutral position): A lateral view; B medial view. Isolated bone: C posterior view; D anterior view; E medial view.

Figure 10.2

Ulna (anatomic specimen).

Proximal epiphysis: A anterior view; B posterior view. Distal epiphysis: C lateral view; D posterior view; E medial view.

Ulna – OLecranon (UOA, UOM, UOL)[R,L] H|Anim Landmark UOA, UOM, UOL Large tuberosity located at the posterior aspect of the proximal epiphysis (see Figs 10.1 & 10.2). Three points are palpated.

The palpator is behind the sitting subject, whose elbow is flexed (90°). With a forefinger, locate the olecranon at the posterior aspect of the elbow joint. The finger pulp is placed on the apex of the olecranon (UOA).

Then place both thumb and middle finger of the same hand on the medial (UOM) and lateral (UOL) aspects of the olecranon respectively.

ulna bone from a posterior and slightly superior view.

Observe the

Select the apex of the olecranon (UOA, in red).

Rotate the ulna bone along a lateral view (the coronoid process must be horizontal; red line). Make sure UOA (in red) is on the apex of the olecranon. Then, from that point, draw a line (in green) running forward parallel to the coronoid process. UOL (in green) is midway between UOA and the semilunar notch. Observe the model from a medial view, and process in a similar way for UOM (in blue).

Ulna – Olecranon Basis (UOB)[R,L] Landmark UOB Point located at the basis of the posterior aspect of the olecranon (see Figs 10.1 & 10.2). This point is at the junction between the epiphysis and diaphysis of the bone.

The palpator is behind the sitting subject, whose shoulder is slightly extended and elbow flexed (90°). First locate UOL and UOM (see p. 72) with the first and second fingers respectively. Then glide down, following the lateral (in green) and medial (in blue) edges of the olecranon.

The point to select is at the junction where the two edges meet.

NOTE The medial and lateral edges of the olecranon join each other at this point to give the ulnar posterior edge, which runs distally (solid line).

and slightly superior view.

Observe the ulna bone from a posterior

From UOM (in blue; see p. 72), follow the medial edge (blue line) down until it joins the lateral edge (green line). The junction point is the landmark to select (in red). (In green: UOL, see p. 72.)

Ulna – Coronoid Process (UCP)[R,L] Landmark UCP

Horizontal part of the proximal epiphysis (see Figs 10.1 & 10.2).

The palpator faces the sitting subject, whose elbow is halfflexed, with forearm in supination. Place the second finger on UOA (see p. 72). Then place the third and fourth fingers next to the second finger, along the posterior edge of the ulna. The pulp of the thumb is on the other side of the forearm, facing the third finger in the same horizontal plane (dotted blue line). Push deeply into the soft tissue to try to reach UCP. Manual palpation tip • This landmark is covered by the flexor muscles of the forearm, and palpation can be painful. • UCP palpation is inaccurate owing to interposition of the muscle masses.

Observe the ulna bone from an anterior view.

Select the sharp tip of the coronoid process.

Ulna – Head Dome (UHD)[R,L] ISB Landmark UHD The ulnar head is the distal epiphysis. The dome is the most medial aspect of the head (see Figs 10.1 & 10.2).

The palpator faces the sitting subject, whose elbow is halfflexed, with forearm in supination. First observe the anterior aspect of the wrist. Locate the most proximal wrist fold (just above the dotted orange

line). The ulnar head usually protrudes under the skin above this fold (about one finger pulp), on the medial aspect of the forearm (blue arrow).

Palpate the medial aspect of the ulnar head above the most proximal wrist fold (on the medial aspect of the forearm). The point to locate is the most prominent and medial point of the head. NOTE This point can also be used to estimate the centroid of the ulnar head (see UHE, p. 76).

Observe the ulna from a medial view.

Locate the head of the ulna and select the middle of its visible surface.

Then observe the ulnar head from an anterior view. Check that the selected point is on the most prominent point of the

medial aspect of the head.

Ulna – HEad (UHE)[R,L] ISB Landmark UHE The ulnar head is the distal epiphysis. It has a cylindric shape (see Figs 10.1 & 10.2). At least, three points are located.

The palpator faces the sitting subject, whose elbow is halfflexed, with forearm in half-supination. First, with the forefinger, glide along (subcutaneous) of the ulna head (orange area).

the

medial

face

Locate UHD (see p. 75) and keep the forefinger there. Then place the thumb and middle finger on the anterior and posterior aspects of the head. Select the point below each finger (a total of three coordinates are located).

located homogeneously around the ulnar head.

Finding UHE location

Three points are

• The center of the ulnar head (UHE) is then estimated by using the coordinates of the three located landmarks, using the protocol described on page 176.

NOTE The point on the medial aspect of the ulnar head may be at the same location as UHD (see p. 75). Do not perform a selection on the side of the styloid process (blue arrow). Selecting a point of the styloid aspect will not lead to accurate estimation of a circle around the real head (red circle).

Ulna – Styloid Process (USP)[R,L] ISB H|Anim Landmark USP Narrow tuberosity located on the posterior (and slightly medial) aspect of the distal epiphysis (see Figs. 10.1 & 10.2).

The palpator faces the sitting subject, whose elbow is halfflexed, with forearm in supination. Place a finger on UHD (see p. 75).

Then glide (about half-a-finger pulp) posteriorly and distally to reach the styloid process (blue arrow).

The point to select is the most distal point of the medial edge of the ulna styloid process. NOTE The very tip of the styloid process is not easily palpable because it is partly hidden by the tendon of the muscle extensor carpi ulnaris.

Observe the ulna from a posterior view.

Locate the ulnar styloid process. The point to select is along the medial edge of the styloid process, just above its tip.

Ulna – distal RadioUlnar joint (URU)[R,L] Landmark URU The ulnar head usually shows a small edge on the dorsal aspect of the distal radioulnar joint (see Figs 10.1 & 10.2).

The palpator faces the sitting subject, whose elbow is half-

flexed, with forearm in pronation. From UHD (see p. 75), glide towards the dorsal aspect of the ulnar head (blue arrow).

Continue to glide laterally to find the depression between both ulna and radius. This is the dorsal aspect of the distal radioulnar joint. The point to palpate is found by orienting the finger pulp towards the ulna bone.

Observe the inferior extremity from a laterodorsal view (if possible together with the radius in pronation).

Locate the center of the dorsal aspect of the distal radioulnar joint. Then select, on the ulna bone, the most dorsal point of the joint surface.

11 Radius Orientation and general presentation (Figs 11.1 & 11.2) The radius (1) is located on the lateral aspect of the forearm. It articulates with the humerus (2) proximally, the wrist complex (3) distally and the ulna (4) medially. The proximal epiphysis shows the radial head (RHE), which has a cylindric shape. The radial head articulates with the humerus through the radiohumeral joint (5). The distal epiphysis presents the radial styloid process (RSP). The same epiphysis shows a tubercle on its dorsal aspect, the dorsal tubercle (RDT). The distal epiphysis of the radius articulates with the ulnar head via the distal radioulnar joint. The radial component of the joint is called the ulnar notch or sigmoid cavity (RUN), the dorsal edge (RDE) of which can be palpated.

Figure 11.1

Radius (3D model).

A General position: lateral view, forearm in neutral position. B Distal epiphysis: posterior view, forearm in neutral position. C Distal epiphysis of the radius: anterior view.

Figure 11.2

Radius (anatomic specimen).

A Radial head: proximal view. Distal epiphysis: B lateral view; C posterior view; D medial view.

Radius – HEad (RHE)[R,L] ISB H|Anim Landmark RHE

The radial head is the proximal epiphysis of the bone (see Figs 11.1 & 11.2). Several points need to be palpated to find the center of the radial head, which is seen as a cylinder (this is a slight simplification of the real shape of the head). There are at least three points to locate.

The palpator faces the sitting subject, whose forearm is extended and in neutral position. First observe the lateral aspect of the elbow to find the mass of both the brachioradialis muscle and the extensor carpi radialis longus muscle (between the dotted orange lines), and the olecranon (UOL; see p. 72). The radial head is in a hollow between UOL and the brachioradialis muscle (green dotted arrow).

Then palpate the lateral side of the forearm. Pitch the muscular mass described in (A) between the first and second fingers. Put the third finger (dotted blue arrow) next to the second to find the radial head. Keep your fingers on this location and flex the subject’s elbow passively. Then move your second finger to the spot previously located with the third finger. Put the first and third fingers on the anterior and posterior aspects

of the head respectively. Select the points located by your three first fingers.

Observe the radial head from any view (left). At least, three points (RHEi) are located homogeneously around the radial head periphery. The centroid of the radial head (RHE) is then found (right) (see Note). (This model is transparent to enable observation of the centroid RHE within the radial head.)

Manual palpation tip • A small motion of prono-supination of the subject’s forearm allows displacement of the head to be felt under the third finger pulp (see

for finger position).

NOTE The centroid of the radial head (RHE) is found by using the coordinates of the located RHEi landmarks (see protocol described on p. 176).

Radius – Styloid Process (RSP)[R,L] ISB H|Anim Landmark RSP Tuberosity located on the lateral aspect of the distal epiphysis (see

Figs 11.1 & 11.2).

The palpator faces the sitting subject, whose elbow is flexed with forearm in pronation. First observe the wrist. The protuberance of the UHD landmark (see p. 75) is usually well visible under the skin. The radial styloid process is on the other side of the forearm, more distally and at the base of the thumb (blue dotted arrow).

Put the forefinger in the depression of the radiocarpal joint at

the base of the thumb. Glide slightly upwards to find the lateral aspect of the styloid process. Select the most distal point of this process (push gently into the soft tissue to locate this point). NOTE The point being palpated is along the lateral aspect of the styloid process; the real tip of the styloid process is not easily manually palpable because it is relatively deep inside the wrist soft tissue.

Observe the distal epiphysis of the radius from a lateral view.

The point to select is along the lateral aspect of the styloid process, slightly above its tip.

Radius – Dorsal Tubercle (RDT)[R,L] ISB Landmark RDT Tubercle found in the central region of the dorsal aspect of the distal epiphysis (see Figs 11.1 & 11.2).

The palpator faces the subject, whose elbow is flexed with forearm in pronation and third finger aligned with the forearm.

Put your forefinger on the subject’s third finger. Then glide proximally towards the wrist joint (dotted blue arrows) and continue upwards. Stop when the finger intersects the horizontal plane (dotted orange line) passing through UHD (see p. 75).

With the finger on the horizontal plane described in (A), change the orientation of your pulp (by about 90°) to palpate better the vertical edge of RDT with your fingertip. The point to select is the center of that tubercle. Manual palpation tip • This landmark can be palpated better by passively flexing/extending the subject’s wrist, keeping the finger on the tubercle.

NOTE The alignment between RDT and the axis of the third metacarpal bone is true only

when the latter is aligned with the longitudinal axis of the forearm.

Observe the inferior epiphysis from a dorsal view.

Locate the largest tubercle and select its center.

Then control your selection from an inferior horizontal view, and make sure the selected point is on the apex of the dorsal tubercle.

Virtual palpation tip • Try to display the third metacarpal bone as well; the RDM landmark is along a line running through its longitudinal axis.

NOTE The dotted curved line indicates the position in the wrist joint of the ridge between the radioscaphoid fossa (rsf) and the radiolunate fossa (rlf).

Radius – Ulnar Notch (RUN)[R,L] ISB Landmark RUN This is the radial component of the distal radioulnar joint (see Figs 11.1 & 11.2). It is concave and shows two edges (one posterior, one anterior). There are two points to palpate.

The palpator faces the sitting subject, whose elbow is halfflexed with forearm in supination. First locate RDE (see p. 88) with the thumb. Keep the thumb there. Then place the forefinger on the other (ventral) side of the wrist, opposite the thumb pulp (just lateral and proximal to HPI; see p. 92). The second point (RUNs) to select is on the skin surface under the forefinger. The center of the ulnar notch (RUN) is approximately one-third of the way along a line running from RDE to RUNs.

from a medial point of view.

Observe the inferior epiphysis

NOTE The real ventral aspect of the ulnar notch is deep in the soft tissue and therefore difficult to palpate. Do not push too deeply, because the ulnar nerve and ulnar artery run there.

First select RDE (in blue; see p. 88). Then select the center of the anterior edge of the ulnar notch (RUNb, in green).

The center of the ulnar notch (RUN, in red) is halfway along a line running from RUNb to RDE.

NOTE Another approach is to select a third point in the center of the notch. The three points can then be used to estimate the centroid of the joint (see p. 176).

Radius – Dorsal Edge of distal radioulnar joint (RDE) [R,L] Landmark RDE The radial component of the inferior radioulnar joint shows two edges, one dorsal and one ventral (see Figs 11.1 & 11.2). The dorsal edge is more superficial than the ventral one, which is located deep within the wrist soft tissue.

The palpator faces the sitting subject, whose elbow is flexed with forearm in pronation. Place a forefinger on URU (see p. 78). Then rotate the pulp of your finger towards the radius to palpate the radial aspect of the joint. Select this point. NOTE This point is also used for interpolation of the RUN landmark (see p. 86).

from a medial view.

Observe the inferior epiphysis

Select the center of the dorsal edge of the ulnar notch, slightly on its posterior aspect.

Rotate the model to a more posterior view, and make sure the selected point is on the posterior edge of the joint (and not in the ulnar notch).

12 Hand Orientation and general presentation (Figs 12.1 & 12.2) The hand includes carpal bones (1) and digital rays (2), made of long bones (metacarpal bones and phalanges) (Figs 12.1 & 12.2). The most prominent carpal bone is the pisiform (HPI) on the medial aspect of the hand. More distally, the hook of the hamatum (HHH) points forwards. On the other aspect of the wrist, the navicular or scaphoid shows a large tubercle (HNT). Each metacarpus is located on the proximal aspect of a digital ray. A metacarpal bone shows a basis (MBi) and a head, the lateral (HLi) and medial (HMi) sides of which are palpable (i indicates the finger index: 1 = thumb, 2 = forefinger, 3 = middle finger, 4 = annular finger, 5 = auricular finger). Two sesamoid bones, one medial (MSM) and one lateral (MSL), are present on the volar aspect of the metacarpophalangeal joint of the thumb. Distal to each metacarpal bone, three (two for the thumb) phalanges are present in each digital ray. Each phalanx has a basis (BPi, proximal phalanx; BCi, middle phalanx; BDi, distal phalanx) and a head, of which both the lateral side (PLi, proximal phalanx; CLi, middle or central phalanx; DLi, distal phalanx) and the medial side (PMi, proximal phalanx; CMi, middle or central phalanx; DMi, distal phalanx) are palpable. The thumb has no middle phalanx.

Figure 12.1

Hand bones (3D model).

A Palmar view. B Superior view of the wrist. C Dorsal view (only the first and second digital rays are displayed). D Lateral view (only the first and second digital rays are displayed).

Figure 12.2

Hand bones (anatomic specimen).

A Carpal bones: frontal view. B General view of the hand: palmar view. C General view: dorsal view. (Metallic material visible on the illustrations was used to keep the various hand bones in a physiologic position.)

Hand/wrist – PIsiform (HPI)[R,L] Landmark HPI The pisiform is the most prominent carpal bone. It is located on the anteromedial aspect of the wrist (see Figs 12.1 & 12.2).

The palpator faces the sitting subject, whose elbow is flexed with forearm in supination. Observe the medial aspect of the subject’s wrist. The protuberance of the pisiform under the skin is usually visible (orange area).

Palpate the medial aspect of the wrist until the bony protuberance is found.

The center of the anterior aspect of the bone is the point to select.

Observe the pisiform from an anterior view (if possible with the other hand bones). Select the center of the pisiform (slightly lateral).

Then observe the selection from a horizontal view. Make sure the most anterior aspect of the bone has been selected.

Hand/wrist – Hamatum Hook (HHH)[R,L] Landmark HHH This hamatum is the most medial bone of the second row of the carpal bones (see Figs 12.1 & 12.2). It has a large tubercle (the hook)

pointing forwards.

The palpator faces the sitting subject, whose elbow is flexed with forearm in supination. First locate HPI (orange area; see p. 92) with your forefinger. Then glide distally and laterally for about half a pulp-width (blue arrow).

The hook of the hamatum is found by pressing the pulp into the muscular mass of the hypothenar eminence. Manual palpation tip • This point is aligned with the fourth interosseous space (space between the fourth and fifth metacarpal bones).

NOTE This point can be difficult to palpate in subjects with a well developed hypothenar eminence.

Observe the hamatum from an anterior view (if possible with the other hand bones). Select the apex of the hamatum hook, just medial to its edge.

Then observe the selection from a horizontal view. Make sure the most anterior aspect of the hook has been selected, just medial to the edge.

Hand/wrist – Navicular Tubercle (HNT)[R,L] Landmark HNT The navicular is the most lateral bone of the first row of the carpal bones (see Figs 12.1 & 12.2). A small tubercle is found on the most distal part of its anterior face.

The palpator faces the sitting subject, whose elbow is flexed with forearm in supination.

First locate HPI (orange area; see p. 92) with your forefinger. Then glide laterally towards the base of the thumb following the most distal wrist fold (blue arrow). Stop just lateral to the flexor carpi radialis tendon (running along the green arrow).

The tubercle of the scaphoid bone is palpable lateral to this tendon in the wrist fold. NOTE The palmaris longus tendon is located along the orange arrow.

Observe the navicular bone from an anterior view (if possible with the other hand bones). Select the center of its tubercle.

Then observe the selection from a horizontal view. Be sure to select the most anterior aspect of the bone tubercle.

Hand/Metacarpus – Basis (MBi)[R,L] ISB Landmarks Mbi The basis is the proximal epiphysis (see Figs 12.1 & 12.2). The following description should be used for each metacarpal bone (i indicates the finger index: 1 = thumb, 2 = forefinger, 3 = middle finger, 4 = annular finger, 5 = auricular finger).

The palpator faces the sitting subject, whose elbow is flexed with forearm in pronation and wrist in slight flexion. First place one forefinger on the dorsal aspect of the metacarpal diaphysis being palpated (here, on the third metacarpal bone). Then glide proximally (blue arrow) until a small edge is reached; this is the carpometacarpal joint. Palpate this edge with the pulp tip (see Tips, p. 4). Then finger-roll (see Tips, p. 4) until your pulp angle reaches the subject’s skin. The point to select is below the pulp angle.

Observe the proximal epiphysis of the metacarpal bone from a strictly dorsal view. The point to select is at the intersection of the longitudinal axis of the bone with the transverse axis of the basis (illustrated on MB3).

The digital ray of the thumb is usually not in the same plane as the other rays. Make sure you observe its posterior aspect before selecting MB1.

Hand/metacarpus – head (HLi, HMi)[R,L] ISB Landmarks HLi, HMi The head is the distal epiphysis (see Figs 12.1 & 12.2). Two points are

palpated. Averaging both points gives an estimate of the center of the

head. The following description should be used for each metacarpal bone (i represents the finger index: 1 = thumb, 2 = forefinger, 3 = middle finger, 4 = annular finger, 5 = auricular finger; HLi indicates the lateral aspect, HMi the medial aspect).

The palpator faces the sitting subject, whose elbow is flexed with forearm in pronation and metacarpophalangeal joint in slight flexion. Observe the distal aspect of the metacarpal bone (here illustrated on the third finger). The protuberance of the metacarpal head is usually readily observable (orange area). For HLi, place the forefinger on the lateral aspect of the metacarpal head with the pulp oriented medially. For HMi, place the forefinger on the medial aspect of the head with the pulp oriented laterally. Manual palpation tip • The metacarpophalangeal joint spaces are easier to locate when the first phalanx of the subject is flexed passively.

Observe the metacarpal head from a dorsal view. The two points to select are on either side of the broadest part of the head along a transverse line (blue lines). Select the intersections of this line with both medial and lateral edges of the bone (laterally, HLi; medially, HMi).

The thumb is usually not in the same plane as the other rays. Make sure you observe its posterior aspect before selecting both HL1 and HM1.

Hand/Metacarpus – Sesamoid bones (MSL, MSM)[R,L] Landmarks MSL, MSM These are two small bones located on the palmar aspect of the

metacarpophalangeal joint of the thumb (see Figs 12.1 & 12.2).

The palpator faces the subject, whose elbow is flexed with forearm in neutral position. Extend the subject’s thumb with one hand. With the forefinger of the other hand, glide from the basis of the palmar aspect of the thumb towards the metacarpophalangeal joint (blue arrow). Just before the joint space, one small bone can be found on each side of the longitudinal axis of the finger – the sesamoid bones.

The center of each sesamoid bone is selected (laterally, MSL; medially, MSM) on both sides of the finger. NOTE Usually

these

bones

are

found

metacarpophalangeal joint (orange line).

just

distal

to

the

skin-fold

of

the

Observe the palmar aspect of the thumb. Both sesamoid bones are located just below the metacarpophalangeal joint. Select the center of both bones (laterally, MSL; medially, MSM).

Hand/phalanges – Basis (BPi, BCi, BDi)[R,L] ISB Landmarks BPi, BCi, BDi The basis of a phalanx is equivalent to its proximal epiphysis (see Figs 12.1 & 12.2). The following description should be used for each phalanx (i represents the finger index: 1 = thumb, 2 = forefinger, 3 = middle finger, 4 = annular finger, 5 = auricular finger; BPi indicates the proximal phalanx, BCi the middle phalanx and BDi the distal phalanx).

The palpator faces the sitting subject, whose elbow is flexed with forearm in pronation and the palpated finger flexed. Observe the flexed phalanx (here the central phalanx of the second digital ray). The basis of the phalanx is located distal to the joint angle (blue arrow).

Palpate the joint edge of the phalanx with your fingertip. From that point, finger-roll distally (see Tips, p. 4) until the pulp angle touches the subject’s skin. The point of the basis to select is below your pulp angle.

Observe the proximal epiphysis of the phalanx from a dorsal view. The point to select is at the center of the proximal epiphysis, just distal to the joint edge.

Note that the thumb is usually not in the same plane as the other rays. Make sure you observe its posterior aspect before selecting BP1 or BD1.

Hand/Phalanges – head (PLi, PMi, CLi, CMi, DLi, DMi) [R,L] ISB Landmarks PLi, PMi, CLi, CMi, DLi, DMi The head is the distal epiphysis (see Figs 12.1 & 12.2). Two points are palpated. Averaging both points gives an estimate of the head center. The following description should be used for each phalanx (i represents the finger index: 1 = thumb, 2 = forefinger, 3 = middle finger, 4 = annular finger, 5 = auricular finger; PLi and PMi indicate the proximal (lateral, medial) phalanx, CLi and CMi the central (lateral, medial) phalanx, and DLi and DMi the distal (lateral, medial) phalanx).

The palpator faces the sitting subject, whose forearm is in pronation with the wrist in slight flexion. The phalanges of the palpated finger are slightly flexed.

Take the phalanx between thumb and forefinger (on each side).

Glide distally (arrows) along both sides of the phalanx until the broadest part of the phalanx head is reached (just before the interphalangeal (IP) joint). Select both sides of the phalanx head laterally and medially (here illustrated on CL3 and CM3 respectively). NOTE Passive movement of the IP joint allows better location of the head. The head of the distal phalanges is difficult to palpate accurately.

Observe the phalanx head from a dorsal view. The two points to select are on either side of the broadest part of the head along a

transverse line. Select the intersections of this line with both medial and lateral edges of the bone, laterally and medially.

Note that the thumb is usually not in the same plane as the other rays. Make sure you observe its posterior aspect before selecting PL1, DL1, PM1 or DM1.

13 Sacrum Orientation and general presentation (Figs 13.1 & 13.2) The sacrum has a triangular shape; its base (1) is oriented proximally, whereas the apex (2) is distal. This bone is the result of the fusion of five sacral vertebrae (S1–S5); therefore, many of its characteristics are related to the 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 comprised of at least three prominences (i.e. spinous processes – S1, SS2 and S3). The most developed process, the spinous process of S2 (SS2), is slightly above a horizontal line passing through the posterior superior iliac spine of both iliac bones (in blue; see also p. 103). Both posterior and anterior faces show four pairs of sacral foramina (4) (only a few foramina are indicated in the figures). The coccyx (5) is below the sacral bone. Other structures include the ilium (6) and femur (7). Spinous processes of both fourth and fifth lumbar vertebrae are above (3) (in green; see also p. 29).

Figure 13.1

Sacrum (3D model).

A Location in the pelvis: anterior view, slightly lateral. B Sacral bone in relation to ilia and fourth and fifth lumbar vertebrae: posterior view.

Figure 13.2

Sacrum (anatomic specimens).

A Location in the pelvis: anterior view, slightly lateral. B Posterior aspect: posterior view.

Sacrum – Spinous process of second sacral vertebra(SS2) [M] Landmark SS2 Second posterior eminence on the posterior aspect of the sacrum (see Figs 13.1 & 13.2).

The subject lies prone or stands. The palpator stands behind the subject’s pelvis. Place one hand flat on the lateral surface of the pelvis (left hand in image). Place the thumb near the spine along a horizontal projection from the iliac crest. This projection on the spine (blue arrow) indicates the level of the fourth lumbar vertebra (L4) (see also p. 30). With the middle finger of the opposite hand, glide down on the spinous process of the fifth lumbar vertebra (L5, right middle finger). Keeping down, the next two bony eminences are, respectively, S1 (right forefinger) and SS2 (right thumb). Select the latter point. Manual palpation tip • Control of the selection can be obtained by placing two fingers simultaneously on S1 and SS2. Then ask the subject to breathe deeply. If the space between your fingers is opening/closing during the breathing, it is probable that one of your fingers is on a lumbar vertebra, and you should repeat the S1–SS2 localization. If the space between

your fingers remains unchanged, your selection is correct. • A second check can be made by verifying that the horizontal projection of a line starting from SS2 runs slightly above the posterior superior iliac spine (see IPS, p. 107).

NOTE See Figure 13.1B to visualize the position of SS2 in relation to L4, L5 and both posterior superior iliac spines.

Observe the sacrum from a posterior view. Locate the median sacral crest. Along this crest, select the top of the second spinous process, SS2, just proximal to a horizontal plane running through the second pair of posterior foramina (blue line).

Then observe the bone from a lateral view, and check that the SS2 apex has been selected correctly (in blue, S1).

14 Ilium Orientation and general presentation (Figs 14.1 & 14.2) The joint cavity of the hip joint, or acetabulum (IAC), is oriented laterally, whereas the obturator foramen (1) and the greater sciatic notch (2) have an inferior and a posterior position, respectively. The iliac crest (3) is on top and shows a widening called the crest tubercle (ICT). 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 posterior inferior iliac spine (IPI) is found below IPS. The posteroinferior aspect of the ilium shows a large tuberosity – the ischium or ischial tuberosity (IIT). Both ilia articulate anteriorly by the pubic joint (IPJ), which has a well pronounced anterior pubic edge. The inferior ramus (4) runs between IPJ and ITT. The pubic spine (IPP) is located about 2 cm from IPJ. Each ilium articulates with a femur (5) through the joint surface found within IAC. This crescent-shaped joint surface is called the lunate surface (6).

Figure 14.1

Ilium (3D model).

A Position in pelvis: anterior view. Isolated bone: B lateral view; C medial view.

Figure 14.2

Ilium (anatomic specimens).

Position in the pelvis: A anterolateral view; B anterior view. C Superior landmarks: laterosuperior view. D Ischial tuberosity: lateroinferior view. E anterior view. F Acetabulum: lateral view.

Ilium – Anterior Superior iliac spine (IAS)[R,L] ISB H|Anim Landmark IAS Prominent anterior and superior end of the iliac crest (see Figs 14.1 & 14.2).

The palpator stands next to the standing subject. Place your hand on the subject’s flank, with your fingers on the anterior part of the iliac crest. Follow the anterior part of the iliac crest forwards (blue arrow).

At the anterior extremity of the iliac crest, your finger will feel a prominent bony bump, under which it can get around, below and to the side. This is IAS. Select the most prominent point of IAS. NOTE IAS is relatively superficial, just under the skin, and is usually easily palpable. However, palpation may be more difficult on obese subjects.

Observe the ilium from a lateral view. Follow the anterior part of the iliac crest anteriorly (blue arrow) until you reach the most

anterior point. Select the tip of the spine.

Then turn the model 90° to an anterior frontal view. Make sure that the selected landmark is positioned correctly on the center of IAS.

Ilium – Posterior Superior iliac spine (IPS)[R,L] ISB H|Anim Landmark IPS Prominent posterior and superior end of the iliac crest (see Figs 14.1 & 14.2).

The palpator stands behind the standing subject. Place your thumb on the posterior part of the iliac crest. Move down and backwards over the iliac crest just to the point where the thumb feels a prominent bony bump (IPS).

Select the tip of IPS (actually, your finger will reach the lateral aspect of IPS because of the orientation of the ilium). Manual palpation tip

• For some subjects, small cutaneous hollows are visible above the buttocks. Landmark IPS is found deep in these hollows.

Observe the ilium from a posterolateral view. Go backwards (dotted blue arrow) on the posterior part of the iliac crest until IPS is met. Select its center (slightly lateral).

Next, view the model from a posterior view. Make sure that the selected landmark is correctly located slightly lateral to the center of IPS.

Ilium – Posterior Inferior iliac spine (IPI)[R,L]

Landmark IPI Prominence located below the posterior superior iliac spine, at the superior limit of the greater sciatic notch (see Figs 14.1 & 14.2).

The palpator stands behind the standing subject. First locate IPS (see p. 107). Then glide down by about two thumb-widths (blue arrow).

While gliding, your thumb will first reach a soft depression, then a bony prominence (IPI). Turn the thumb slightly upwards to feel IPI better.

Turn the ilium to a posterior view. First locate IPS (in blue; see p. 107). From IPS, continue down the posterior edge of the ilium (blue arrow) until you reach a second spine, IPI. Select the lateral aspect of IPI.

Next, turn the model to a lateral view. Check that the selected point is on the lateral aspect of the IPI tip. NOTE

IPI is located at the most posterior aspect of the greater sciatic notch (2).

Ilium – Ischial Tuberosity, inferior angle (IIT)[R,L] Landmark IIT Large posterior tuberosity of the ischium. The inferior angle is usually well developed (see Figs 14.1 & 14.2).

The subject is lying prone or standing. The palpator stands next to the subject’s knees. Ask the subject to flex the knee slightly (to contract the muscles inserting on the ischial tuberosity). Feel the muscle tension on the medial aspect of the thigh, and move proximally along the muscles (blue arrow) until you reach the buttock fold (green line). At this point, press one forefinger in the buttock fold, to pass under the inferior edge of the gluteus major muscle and to reach the inferior angle of the ischium (IIT).

Manual palpation tip • To control the selection, palpate the medial and lateral edges of the ischium. Then follow these edges down to their junction, which is the inferior angle.

NOTE This point is relatively deep in the soft tissue (depending on the development of both fatty tissue and gluteus major muscle). You should therefore press your forefinger into the subject’s soft tissue. The point at which you should press your forefinger under the gluteus major muscle is located at the junction of the medial and central thirds of the buttock fold.

Observe the ilium from a posterolateral view. Follow the medial and lateral edges (blue arrows) of the ischium until they intersect. The point of intersection is ITT.

To verify the selection, observe the model from an inferior view. The selected point should be on the most inferior point of the ischium, just before the inferior ramus (4).

Ilium – Pubic Joint, anterior angle (IPJ)[M] H|Anim Landmark IPJ The pubic symphysis is the anterior joint between both ilia (see Figs 14.1 & 14.2).

The palpator stands next to the subject’s pelvis. Place your fingers on the central part of the belly, vertically below

the umbilicus. Gently depress the belly and glide vertically (blue arrow) towards the pubic area.

Find the anterior angle of the pubic joint and select its apex (under the forefinger in this figure).

IPJ is usually not directly observable on a 3D bone model (see Note) and must be therefore interpolated. First turn the model to an anterosuperior view. On both ilia, select a point on the anterior pubic edge located next to the pubic joint.

Next, turn the bones to an upper view. Check that both selected landmarks (in blue) are correctly located on the anterior edge of the bone. IPJ (in red) is the average of the spatial coordinates of both selected landmarks. NOTE IPJ is usually not visible on computed tomography because it consists of fibrous tissue and cartilage, which are almost transparent to X-rays, and therefore cannot be further processed for 3D modeling. This explains the gap that is visible between the ilia in the figures.

Ilium – Pubic sPine (IPP)[R,L] Landmark IPP This spine is lateral to the pubic symphysis and points slightly forwards (see Figs 14.1 & 14.2). The inguinal ligament has its distal insertion on this spine.

The palpator stands next to the standing subject. First locate the groove (blue arrow) of the inguinal ligament. Follow it distally and medially towards the pubis.

The distal end of the inguinal ligament is attached on IPP, pointing forwards. Select its tip (under the forefinger on this image). Manual palpation tip

• IPP is lateral to IPJ (approximately 2 cm).

NOTE This point is particularly difficult to locate in obese people.

Observe the iliac model from an anterolateral view. First observe IPJ (in blue; see p. 110). The pubic spine is located lateral to it. Select the center of the spine tip (IPP, in red).

Ilium – Crest Tubercle (ICT)[R,L] H|Anim Landmark ICT This tubercle is a widening of the anterior part of the iliac crest, about three or four thumb-widths behind the anterior superior iliac spine (see Figs 14.1 & 14.2).

The subject is lying supine (or standing), with the hip flexed in order to relax the surrounding soft tissue. The palpator stands at the level of the subject’s pelvis. First locate the iliac crest and follow it backwards (blue arrow) until you feel the thickening of the crest tubercle.

Move your forefinger laterally and distally (green arrow) until you reach the most lateral aspect of the tubercle. Orient your finger pulp slightly upwards, and select the summit of

the tubercle. NOTE In the figures, the thumb of the right hand is on IAS (see p. 106).

Observe the ilium from a lateral (slightly superior) view. Locate the wider section of the iliac crest (3). The ICT landmark is located on the most lateral aspect of this part of the crest.

Then rotate the bone to a superior view. Check that the selected landmark is on the most lateral part of the iliac crest.

Ilium – Center of Acetabulum (IAC)[R,L] Landmark IAC

The acetabulum is the hip component of the hip joint (see Figs 14.1 & 14.2). This point is not palpable manually and is found only after interpolation. Because of the limitations of manual palpation, spatial coordinates of IAC and the center of the femoral head (FCH) are assumed to be equivalent (see p. 132 for the FCH location). 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 six ACi points located along the circumference of the lunate surface (see Fig. 14.1B, point 6) within the acetabulum: • AC1: anterior edge • AC2: center of anterior wall • AC3: anterior part of roof • AC4: posterior part of roof • AC5: center of posterior wall • AC6: posterior edge.

IAC can also be located by a method that processes the acetabulum as a pure sphere (see p. 176). In this case you must select a point outside the plane running through the six ACi points: select the deepest point of the acetabulum (AC7, in green).

15 Femur Orientation and general presentation (Figs 15.1 & 15.2) The head of the femur (FCH) is oriented upwards and medially; it is part of the hip joint or coxal articulation (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 which are the lateral (FLC) and medial (FMC) condyles. Each condyle has an epicondyle (FLE or FME). The lateral epicondyle shows a vertical crest with an upper ridge (FUE), an apex (FLE) and a lower ridge (FBE). A sulcus is observable behind each epicondyle: the medial sulcus (FMS) and the popliteal sulcus (FPS). The adductor magnus muscle inserts on a tubercle (FAM) above FME. The lower part (anterior aspect) of the femur supports the patellar groove (4), making up the femoropatellar joint. This groove has two edges: one lateral (FLG) and one medial (FMG).

Figure 15.1

Femur (3D model).

A Femur with ilium, patella and tibia: anterior view. Isolated bone: B anterior view; C posterior view. Distal epiphysis: D lateral view; E anterior view; F medial view.

Figure 15.2

Femur (anatomic specimen).

Full bone: A anterior view; B posterior view. Proximal epiphysis: C anterior view; D lateral view. Distal epiphysis: E anterior view; F medial view; G posterior view; H lateral view; I distal view.

Femur – greater Trochanter (FTC, FTA, FTP)[R,L] Landmark FTC, FTA, FTP Massive quadri-angular tubercle that extends to the top of the lateral face of the femoral diaphysis (see Figs 15.1 & 15.2). It has three edges: superior, anterior and posterior.

The palpator stands behind the standing subject. The subject’s leg is slightly flexed and in abduction (the foot can be put on a support). First place a thumb on the iliac crest (blue line) and put the little finger along the axis of the thigh. Locate the greater trochanter in this area. A more accurate palpation can then be performed with the three first fingers.

The thumb and middle fingers pinch the greater trochanter on the center of its posterior (FTP) and anterior (FTA) edges respectively.

Then place the forefinger in the middle of the virtual line traced between the thumb and middle finger. The FTC landmark is pinpointed by the index finger between FTP

and FTA. Manual palpation tip • Moving the thumb and middle finger up and down allows the posterior and anterior edges of the greater trochanter (blue arrows) to be felt better.

NOTE FTP and FTA can be difficult to palpate with accuracy if the surrounding soft tissue is well developed.

Observe the femur from a lateral (slightly posterior) view (in this view the femoral head is partly hidden behind the greater trochanter).

Locate the center of the anterior (FTA) and posterior (FTP) edges (blue lines) of the greater trochanter. The FTC landmark is located at the center of the line running between FTA and FTP.

Femur – tubercle of the Adductor Magnus muscle(FAM) [R,L] Landmark FAM Bony protuberance situated on the superior edge of the medial condyle of the femur (see Figs 15.1 & 15.2).

Subject lying: The subject is lying supine, knee flexed, with the palpator at the subject’s knee. Subject standing: The palpator kneels and places the subject’s foot on a thigh to flex the subject’s knee. Place one hand flat on the distal medial aspect of the thigh. In the center of this area locate the tendon of the adductor magnus muscle and follow it distally (blue arrow).

This tendon attaches on a (usually well-developed) tubercle (FAM) above the medial epicondyle. Select the tubercle tip by orienting your finger pulp distally. NOTE This tendon insertion is often sensitive, so manual palpation should be performed gently.

Observe the femur from a posteromedial view.

FAM is at the center of a protuberance above the medial condyle.

Turn to a posterior view to verify that the selected point is on the superior angle of the condyle.

Femur – Medial Epicondyle (FME)[R,L] ISB H|Anim Landmark FME This surface shows a small tubercle for the medial collateral ligament of the knee (see Figs 15.1 & 15.2).

Subject lying: The subject is lying supine, knee flexed, with the palpator at the subject’s knee. Subject standing: The palpator kneels and places the subject’s foot on a thigh to flex the subject’s knee. Place the middle finger on FAM (see p. 118) and the thumb on the distal edge of the medial condyle along the virtual line running distally from FAM (blue arrow).

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 (FME). NOTE This point can be sensitive, so manual palpation should be performed gently.

Observe the distal epiphysis from a medial view.

Find the center of the medial condyle at the intersection of the

following virtual lines: • A vertical line starting at FAM (in blue; see p. 118) • A horizontal line running through the center of the posterior and anterior edges of the condyle. In relation to this intersection, the landmark (FME in red) to select is found slightly forwards.

Verify the validity of the landmark by turning the bone to a posterior view. Check that the selected point is on the apex of the condyle.

Femur – Medial Sulcus (FMS)[R,L] Landmark FMS Sulcus located behind and below the medial epicondyle (see Figs 15.1 & 15.2).

Subject lying: The subject is lying supine, knee flexed, with the palpator at the subject’s knee. Subject standing: The palpator kneels and puts the subject’s foot on a thigh to flex the subject’s knee. Place the middle finger on FAM (see p. 118) and the thumb on the distal edge of the medial condyle along the virtual line running distally from FAM (blue line). Place the tip (see p. 4) of the forefinger midway between the thumb and the middle finger.

Then roll the forefinger (see finger-rolling, p. 4) backwards

until its pulp center reaches the skin. Select the point just distal to the pulp center. NOTE Consider the size of the subject. For a small subject, the posterior displacement of the finger during the finger-rolling should be reduced.

View the distal epiphysis from a medial view.

First find FAM (in blue; see p. 118) and FME (in green; see p. 120). Locate the medial sulcus (red curved line) behind and below FME. Select the point (in red) of the medial sulcus below a horizontal line (green line), starting from FME.

Verify the landmark by turning the bone to a posterior view. Check that the selected point is just outside a vertical line (blue line) running through FAM. In addition, check that the selected point is about halfway along the height of the medial condyle (yellow arrows).

Femur – Lateral Epicondyle (FLE, FUE, FBE)[R,L] ISB H|Anim Landmark FLE, FUE, FBE The lateral condyle is a bony surface located laterally on the distal epiphysis of the femur (see Figs 15.1 & 15.2). This surface shows a crest.

Subject lying: The subject is lying supine, knee flexed, with the palpator at the subject’s knee. Subject standing: The palpator kneels and places the subject’s foot on a thigh to flex the subject’s knee. Put your forefinger in the knee joint space and glide backwards until you meet the lateral collateral ligament. Follow the ligament up to its femoral insertion point (blue arrow).

Here you should be able to locate a (usually well developed) tubercle (FLE).

In some subjects, a crest is palpable instead of a tubercle. In this case, you can pitch the upper ridge (FUE) and lower ridge (FBE) between the middle finger and thumb respectively (the forefinger is on the center of the crest on FLE).

Observe the distal epiphysis from a lateral view.

Locate a bumpy tubercle near the centre of the lateral condyle. This tubercle is along a horizontal line (in blue) running between the furthest points of the condyle. Select the apex of the tubercle (in red, FLE). Frequently, the crest of the lateral condyle is readily visible, and supplementary landmarks can be located. These landmarks are

located on the upper and lower parts of the crest (FUE and FBE, in blue and green, respectively).

Once the tubercle has been selected, observe the selection from an anterior view to check that FLE is on the apex of epicondyle. FUE and FBE should be on the superior and inferior crest angles respectively.

Femur – Popliteal Sulcus (FPS)[R,L] Landmark FPS Sulcus located behind and below the lateral epicondyle (see Figs 15.1 & 15.2). The popliteal muscle inserts in this sulcus.

Subject lying: The subject is lying supine, knee flexed, with the palpator at the subject’s knee. Subject standing: The palpator kneels and places the subject’s foot on a thigh to flex the subject’s knee. Place the tip (see p. 4) of the forefinger on FLE (see p. 122).

Then roll the forefinger (see finger-rolling, p. 4) backwards

until its pulp center reaches the skin. Select the point just distal to the pulp center. NOTE Consider the size of the subject. For a small subject, the posterior displacement of the finger during the finger-rolling should be reduced.

Observe the distal epiphysis from a lateral view.

First find FLE (in blue; see p. 124). Locate the lateral sulcus (red curved line) behind and below FLE. Select the point (in red) of the lateral sulcus below a horizontal line (blue line) running through FLE.

Verify the landmark by observing from a posterior view. Check that the selected point (in red) is about halfway along the height of the lateral condyle (orange arrows).

Femur – anteroMedial ridge of the patellar surface Groove (FMG)[R,L] Landmark FMG Bony angle located in the upper medial area of the patellar surface (see Figs 15.1 & 15.2).

Subject lying: The subject is lying supine, knee extended, with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the extended knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. With a thumb, push on the central part of the lateral edge of the patella, to move the patella laterally (blue arrow).

Use the forefinger of the other hand to palpate the femoral

bone next to the thumb (still pushing the patella), to locate the medial edge of the patellar groove. Then move the forefinger upwards along the medial edge until an angle is found; this is FMG.

Observe the distal epiphysis from an anterior view. From the most distal point of the inner edge of the patellar surface, follow this edge up (blue arrow). The first angle (usually not very well pronounced) is FMG (in red). NOTE FMG is located more distally than FLG (in blue; see p. 127).

Femur – anteroLateral ridge of the patellar surface Groove (FLG)[R,L] Landmark FLG Bony angle located in the upper lateral area of the patellar surface (see Figs 15.1 & 15.2).

Subject lying: The subject is lying supine, knee extended, with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the extended knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. With a thumb, push on the central part of the lateral edge of the patella to move the patella medially (blue arrow).

Use the forefinger of the other hand to palpate the femoral bone next to the thumb (still pushing the patella). Then move the forefinger upwards along the lateral edge until an angle is found; this is FLG. NOTE This point is difficult to palpate because of the orientation of the lateral aspect of the patellar surface.

Observe the distal extremity of the femur from an anterior view. From the most distal point of the lateral edge of the patellar groove, follow this edge up (blue arrow). The first angle is FLG (in red). NOTE FLG is located more proximally than FMG (in blue; see p. 126).

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

Landmark FMC The point is located on the distal extremity of the medial condyle of the femur (see Figs 15.1 & 15.2).

Subject lying: The subject is lying supine, with the hip flexed (about 90°) and the knee bent (about 90°).

Subject standing: The palpator kneels and places the subject’s foot on a thigh to flex the subject’s hip and knee. Follow the medial edge of the patellar tendon (blue arrow) until you reach the knee joint space and the femoral condyles (right hand on images).

Continue upwards and gently push your finger into the joint space to meet the medial condyle surface (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. The hip flexion compensates partially for the quadriceps tension that results from the knee flexion.

Observe the femur from a medial view with the femoral shaft vertical.

Rotate the femur along the plane perpendicular to the screen, and observe the distal aspect of the bone from an inferior view. Select the center of the medial condyle.

Then rotate the femur back to a medial view. Check that the selected landmark is the most distal part of the medial condyle.

Femur – most distal point of the Lateral Condyle(FLC) [R,L] Landmark FLC The point is located on the distal extremity of the lateral condyle of the femur (see Figs 15.1 & 15.2).

Subject lying: The subject is lying supine, with the hip flexed (about 90°) and the knee bent (about 90°).

Subject standing: The palpator kneels and places the subject’s foot on a thigh to flex the subject’s hip and knee. Follow the lateral edge of the patellar tendon (blue arrow) until you reach the knee joint space and the femoral condyles (left hand on images).

Continue upwards and gently push your finger into the joint space to meet the lateral condyle surface (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. The hip flexion compensates partially for the quadriceps tension that results from the knee flexion.

Observe the femur from a lateral view with the femoral shaft vertical.

Rotate the femur along the plane perpendicular to the screen and observe the distal aspect of the bone from an inferior view. Select the center of the lateral condyle.

Then rotate the femur back to a lateral view. Check that the selected landmark is the most distal part of the lateral condyle.

Femur – Center of Head (FCH)[R,L] ISB Landmark FCH Spherical structure located on the proximal epiphysis of the femur (see Figs 15.1 & 15.2). It is part of the hip joint. See also Note about IAC and FCH landmarks, page 134.

This point is not directly manually palpable. It is found from interpolation using other landmarks (Bell et al 1990): • First, a pelvic frame is defined: Op is the origin located between

LIAS and RIAS (for a description see p. 106); Zp (blue axis) is

oriented as the line passing through the IASs, pointing from left to right; Xp (red axis) lies in the plane defined by the IASs and the

midpoint between LIPS and RIPS (see p. 107), and points forwards; Yp (green axis) is orthogonal to the XZ plane and points upwards. • RFCH and LFCH are given by: x = −019D; y = −0.3D; z = i0.36D, where D is the distance between the IASs, and i is −1 for LFCH and 1 for RFCH. Note that this is a gross estimation of the real head center (in blue, interpolated RFCH; in red, real centroid of the femoral head found using virtual palpation). NOTE In this book, the description for locating FCH is based on the morphology of the bone segments. Other procedures, based on a functional approach, exist and interpolate FCH from analysis of the hip joint motions (see, for example, Cappozzo 1984, Leardini et al 1999).

Using virtual palpation, a good estimation of FCH (in green) can be found by averaging the spatial coordinates of the following six points (in red), located around the femoral head: • FCH1: top

• FCH2: anterior • FCH3: bottom (next to the femoral neck) • FCH4: posterior • FCH5: lateral (above the femoral neck) • FCH6: medial. Anterior view. Medial view. Posterior view with transparent femur to visualize the estimated FCH NOTE Another method for finding FCH is based on processing the femoral head as a pure sphere (see p. 176). This does not take into account possible deformation of the head.

Note regarding IAC and FCH landmarks The locations of both IAC and FCH lead to different spatial coordinates (Fig. 15.3).

Figure 15.3

Difference between interpolated IAC (large blue sphere) and FCH (large green sphere) after virtual palpation. Other landmarks (small spheres) in the figure are those used for the interpolation (in green, for FCH; in blue, for IAC; see the descriptions of these landmark for details).

For some applications (e.g. motion analysis of the hip joint), IAC and FCH should be located at the same position. In this case, the coordinates of IAC (see p. 113) should be made equal to those of FCH (see p. 132).

References Bell A, Pedersen D, Brand R. A comparison of the accuracy of several hip center prediction methods. Journal of Biomechanics. 1990;23:617-621.

Cappozzo A. Gait analysis methodology. Human Movement Sciences. 1984;3:27-50. Leardini A, Cappozzo A, Catani F, et al. Validation of a functional method for the estimation of hip joint centre location. Journal of Biomechanics. 1999;32:99-103.

16 Patella Orientation and general presentation (Figs 16.1 & 16.2) The patella (1) is a sesamoid bone included in the tendon of the quadriceps muscle. It articulates posteriorly with the patellar surface of the femur (2). It is shaped like an upside-down pyramid, with the base (3) oriented upwards. The lateral (4) and medial (5) edges converge, towards the patella apex (PAX), which is oriented downwards. These edges are convex, and both show a rounded apex on their central part: PLE and PME for lateral and medial edges respectively. The bone center (PCE) is between PLE and PME on the anterior side. The posterior aspect of the patella shows a large articular surface, part of the femoropatellar joint, separated into two components by an edge (dotted line). The largest joint component (6) is lateral.

Figure 16.1

Patella (3D model).

A Patella and femur: anterior view, slightly medial. Isolated bone: B anterior view; C posterior view.

Figure 16.2

Patella (anatomic specimen).

A Anterior face; B medial edge; C posterior face; D lateral edge.

Patella – ApeX (PAX)[R,L] Landmark PAX The apex of the patella is oriented downwards (see Figs 16.1 & 16.2).

Subject lying: The subject is lying supine, hip and knee slightly flexed (about 10°), with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the slightly flexed hip and knee (about 10°) of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. Follow distally the lateral and medial edges of the patella with your thumb and forefinger respectively. The fingers meet at the apex of the patella.

With one of the palpating fingers (the thumb on the image), select a point slightly above the patella apex on the anterior face of the patella. This is PAX. NOTE The real apex of the patella is included in the patellar tendon, and is therefore difficult to palpate with accuracy.

Observe the patella from an anterior view. The point to select is not on the real apex of the patella (in blue). Rather, select the anterior face of the apex (in red).

Then observe the patella from an inferior view. PAX (in red) is

located more anteriorly compared with the patella apex at the junction of both lateral (4) and medial (5) edges.

Patella – center of Medial Edge (PME)[R,L] Landmark PME Both patellar faces are separated by a thick medial edge (see Figs 16.1 & 16.2).

Subject lying: The subject is lying supine, knee extended, with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the extended, or slightly flexed, knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. With one finger (here the middle finger), palpate the medial edge

of the patella. PME is the prominent middle point of the medial edge.

Observe the patella from an anterior view. Select the most medial point of the patella face.

Then observe the patella from a strictly medial view. PME is located in the middle of the medial edge.

Patella – center of Lateral Edge (PLE)[R,L] Landmark PLE Both patellar faces are separated by a thick lateral edge (see Figs 16.1 & 16.2).

Subject lying: The subject is lying supine, knee extended, with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the extended, or slightly flexed, knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. With one finger (here the thumb), palpate the lateral edge of the patella. PLE is the prominent middle point of the lateral edge.

Observe the patella from an anterior view. Select the most lateral point of the anterior patellar face.

Then observe the patella from a strictly lateral view. PLE is located in the middle of the lateral edge.

Patella – CEnter (PCE)[R,L] Landmark PCE

The anterior face of the patella is relatively circular (see Figs 16.1 & 16.2). Its center is at the intersection of lines running through both lateral and medial patellar edges.

Subject lying: The subject is lying supine, knee extended, with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the extended, or slightly flexed, knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. First locate PLE (see p. 140) and PME (see p. 139) with the thumb and middle finger respectively.

Then place the forefinger between PLE and PME, vertically above PAX (see p. 138). PCE is below the pulp of the forefinger.

Observe the patella from an anterior point of view. The PCE point

(in red) is located at the intersection of two lines: a horizontal line running through both PME (see p. 139) and PLE (see p. 140), and a second vertical line starting from PAX (see p. 138).

17 Tibia Orientation and general presentation (Figs 17.1 & 17.2) The proximal epiphysis of the tibia shows the tibial plateau (1). The plateau has two well-marked edges: one lateral (TLR) and one medial (TMR). Two tubercles are visible on the plateau, the lateral (2) and medial (3) intercondylar tubercles. Anteriorly, a sharp tibial crest (green line) is readily visible. The center of the tibial tuberosity (TTC) is observable at the proximal end of the tibial crest. Both lateral (TTL) and medial (TTM) edges of this tubercle are usually well visible. From TTL, a crest, the oblique line (red line), runs proximally towards the tibial plateau. The Gerdy’s tubercle (TGT) is along this crest. The distal epiphysis carries the medial malleolus (TAM).

Figure 17.1

Tibia (3D model).

Isolated bone: A anterior view; B anterosuperior view.

Figure 17.2

Tibia (anatomic specimen).

General view: A anterior view; B posterior view. C The tibial plateau: proximal view. D Proximal epiphysis: anterior view. E The medial malleolus: medial view.

Tibia – tibial Tuberosity (TTC, TTM, TTL)[R,L] ISB Landmark TTC, TTM, TTL Prominent oval tuberosity located at the superior extremity of the anterior tibial aspect (see Figs 17.1 & 17.2). The patellar tendon

inserts on this tuberosity. Three points are palpated on this tuberosity.

Subject lying: The subject is lying supine, knee extended, with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the extended, or slightly flexed, knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. Gently pinch the patellar ligament between the thumb and middle finger. Follow the ligament distally (blue arrows) to its insertion on the tibial tuberosity.

The thumb and middle finger are located on each side of the tuberosity on its medial (TTM) and lateral (TTL) edges respectively.

Then place the forefinger between the thumb and the middle finger; this is TTC.

Observe the upper extremity of the tibia from an anterior view. Locate a bony oval bump on the anterior and proximal aspect of the tibia – the tibial tuberosity. TTL and TTM are located at the center of the lateral and medial edges of the tuberosity respectively. Then find TTC at the intersection of a horizontal line (in blue) running through both TTL and TTM, and a vertical line (in green) running along the tibial crest.

Tibia – Medial Ridge of tibial plateau (TMR)[R,L] ISB Landmark TMR Point situated on the medial edge of the tibial plateau. This is the most distant point of the tibial plateau from the medial intercondylar tubercle (see Figs 17.1 & 17.2).

Subject lying: The subject is lying supine, knee flexed (about 90°), with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the flexed knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. Locate the patellar ligament and follow it up to the joint space (thumb and forefinger on the medial and lateral sides respectively). The two fingers then glide backwards (blue arrows) along the tibial plateau, reaching for the greatest distance between both fingers.

Once the greatest distance has been found, press the thumb on the surface of the tibial plateau to find TMR. Manual palpation tip • If possible, locate TMR and TLR (see p. 146) simultaneously. • You might use your middle finger, instead of the forefinger as described in the text, to increase your palpation comfort if you feel the size of the subject’s tibial plateau is too large for your fingers.

NOTE See page 150 for the spatial orientation of the tibial plateau.

Observe the tibial plateau from a superior view. Draw a line running through both lateral (2) and medial (3) intercondylar tubercles (in blue; see also Fig. 17.1). TMR (in red) is the most medial point of that line on the edge of the tibial plateau. (TLR, in green, is on the other side of the tibial plateau; see p. 146).

Observe the tibial plateau from a medial view. Make sure the selected point is slightly below the medial aspect of the tibial plateau.

Tibia – Lateral Ridge of tibial plateau (TLR)[R,L] ISB Landmark TLR Point situated on the lateral edge of the tibial plateau. This is the most distant point of the tibial plateau from the lateral intercondylar tubercle (see Figs 17.1 & 17.2).

Subject lying: The subject is lying supine, knee flexed (about 90°), with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the flexed knee of the

subject, who is asked to put his or her bodyweight on the limb that is not being palpated.

Locate the patellar ligament and follow it up to the joint space (thumb and forefinger on the medial and lateral sides respectively). The two fingers then glide backwards along the tibial plateau, reaching for the greatest distance between both fingers.

Once the greatest distance has been found, press the forefinger on the surface of the tibial plateau to find TLR. Manual palpation tip • If possible, locate TLR and TMR (see p. 145) simultaneously. • You might use your middle finger, instead of the forefinger as described in the text, to increase your palpation comfort if you feel the size of the subject’s tibial plateau is too large for your fingers.

NOTE

See page 150 for the spatial orientation of the tibial plateau.

Observe the tibial plateau from a superior view. Draw a line running through the lateral (2) and medial (3) intercondylar tubercles (in blue; see also Fig. 17.1). TLR (in red) is the most lateral point of that line on the edge of the tibial plateau. (TMR, in green, is on the other side of the tibial plateau; see p. 145).

Observe the tibial plateau from a lateral view. Make sure the selected point is slightly below the lateral aspect of the tibial plateau.

Tibia – Gerdy’s Tubercle (TGT)[R,L] Landmark TGT

Tubercle located on the lateral aspect of the tibial tuberosity (see Figs 17.1 & 17.2). The iliotibial tract of the fascia lata inserts on this tubercle.

Subject lying: The subject is lying supine, knee flexed (about 90°), with the palpator at the subject’s knee. Subject standing: The palpator kneels, facing the flexed knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. First locate the lateral edge of the tibial tuberosity (TTL; see p. 144). From there, follow the oblique bony ridge (the oblique line; see Figs 17.1 & 17.2), running proximally.

Following the oblique line you will meet a thick tubercle; select its summit (TGT). NOTE The development of Gerdy’s tubercle is variable. It is usually readily palpable.

Observe the upper extremity of the tibia from an anterior (slightly lateral) view. First locate TTL (in blue; see p. 144). From TTL, follow

the oblique line (blue arrow) running laterally upwards until a tubercle is found; this is TGT (in red).

Tibia – Apex of the Medial malleolus (TAM)[R,L] ISB H|Anim Landmark TAM The medial malleolus, located distally on the medial aspect of the leg, is larger, less prominent, and shorter than the lateral malleolus (see Figs 17.1 & 17.2).

Subject lying: The subject is lying supine, knee extended, with the palpator at the subject’s ankle. Subject standing: The palpator kneels next to the extended lower limb of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. Place the thumb and forefinger on the anterior and posterior aspects of the medial malleolus respectively.

Move both fingers distally along the edges of the malleolus. They meet at the distal aspect of the medial malleolus.

At that location, gently push the forefinger into the soft tissue towards the apex of the malleolus (TAM). NOTE The manually palpated point is not, strictly speaking, the real apex of the malleolus, which is actually located deeper in the soft tissue. This must be kept in mind if virtual palpation is performed in parallel; in this case, the red landmark must be selected. If you wish to perform virtual palpation of the real apex, select the blue landmark.

Observe the lower part of the tibia from a medial view. Select a point (in red) of the malleolus slightly above and behind its real apex (in blue).

Then observe the tibia from an inferior view. Verify that the selected point (in red) is located slightly behind the real apex (in blue).

Note related to manual palpation of TMR and TLR landmarks The manual palpation of TMR (see p. 145) and TLR (see p. 146)

landmarks must be performed keeping in mind the physiologic spatial orientation of the tibial plateau, as described here.

Conventionally, both the tibial tuberosity (TTC, in blue) and the anterior edge of the tibia (blue line) indicate the anterior aspect of the bone. From this position, rotate the bone forwards along the sagittal plane in order to visualize the tibial plateau from a horizontal view.

Such a view shows that the TMR landmark is located more posteriorly than the TLR landmark (the green line indicates the frontal plane). Therefore, manual palpation of the TMR landmark must be performed by locating the edge of the tibial plateau behind the frontal plane (green line) running through TLR. The line (in red) running between the intercondylar tubercles is used to locate TLR and TMR during virtual palpation.

18 Fibula Orientation and general presentation (Figs 18.1 & 18.2) The fibula is 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, whereas the malleolar fossa (4) of the lateral malleolus is located behind the joint surface. The proximal epiphysis, or fibula head (2), is separated from the diaphysis by the neck of the fibula (FNE). 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 (blue line) runs downwards.

Figure 18.1

Fibula (3D model).

A Fibula and tibia (semitransparent): lateral view. B Isolated fibula: medial view.

Figure 18.2

Fibula (anatomic specimen).

A General view, medial. B Proximal epiphysis: lateral view. C Distal epiphysis: lateral view.

Fibula – ApeX of the styloid process (FAX)[R,L] Landmark FAX Bony eminence located on the dorsal aspect of the fibula head (see Fig. 18.1, structure 2). Both the biceps femoris muscle and the fibular collateral ligament insert on the head next to the styloid process (see Figs 18.1 & 18.2).

Subject lying: The subject is lying supine, knee flexed (about 90°), with the palpator standing slightly laterally in front of the knee. Subject standing: The palpator kneels, facing the flexed knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. Follow the tendon of the biceps femoris muscle (blue arrow) with your index finger until you reach its insertion.

FAX is the most lateral and posterior part of the fibula head, next to the tendon. Manual palpation tip • The head of the fibula might be seen better under the skin when the knee is flexed with an internal rotation of the shank.

Observe the proximal epiphysis of the fibula from a lateral view.

NOTE The manually palpated point is not strictly speaking the real apex of the fibula head, as this is located deeper under the tendon of the biceps femoris muscle. This must be kept in mind if virtual palpation is performed in parallel; in this case, the red landmark must be selected. If you wish to perform virtual palpation of the real apex, select the blue landmark.

Select a point (in red) slightly below the real apex (in blue) of the styloid process.

Then observe the bone from a proximal view. Verify that the selected point (in red) is lateral to the real apex (in blue).

Fibula – NEck (FNE)[R,L] Landmark FNE Intermediate area between the fibula head and the fibula diaphysis (see Figs 18.1 & 18.2).

Subject lying: The subject is lying supine, knee flexed (about 90°), with the palpator standing slightly laterally in front of the knee. Subject standing: The palpator kneels, facing the flexed knee of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. Place the forefinger on the fibula head slightly more anteriorly and distally in relation to FAX (see p. 154). Glide your finger downwards towards the fibula head.

The junction, or fibular neck, between the head and the diaphysis is usually readily palpable. Select this junction. Manual palpation tip • With a thin subject, you can first locate the lateral edge of the diaphysis and then move upwards until you reach the fibular neck (before the head).

NOTE Be gentle, as the common fibular nerve runs along the fibula neck and may be sensitive.

Observe the proximal epiphysis of the fibula from a lateral view.

Locate the lateral edge and follow it up (blue arrow) to the fibula neck (green curve). Select the intersection point between the neck and the lateral edge (FAX, in blue; see p. 154).

Fibula – Apex of the Lateral malleolus (FAL)[R,L] ISB H|Anim Landmark FAL The lateral malleolus has a triangular prismatic form with anterior and posterior edges, which join at the apex of the malleolus (see Figs 18.1 & 18.2). In the neutral position of the foot, the lateral malleolus is about 2 cm lower than the medial malleolus.

Subject lying: The subject is lying supine, knee extended, with the palpator at the subject’s ankle. Subject standing: The palpator kneels next to the extended lower limb of the subject, who is asked to put his or her bodyweight on the limb that is not being palpated. Place your forefinger and thumb on the posterior edge of the malleolus and the anterior edge of the lateral malleolus, respectively. Move both fingers distally along the edges of the malleolus until they meet at the distal aspect of the lateral malleolus.

At that location, gently push the forefinger into the soft tissue, towards the apex of the malleolus (FAL). NOTE The manually palpated point is not strictly speaking the real apex of the malleolus, which is located deeper in the soft tissue. This must be kept in mind if virtual palpation is performed in parallel; in this case, the red landmark must be selected. If you wish to perform virtual palpation of the real apex, select the blue landmark.

Observe the distal epiphysis from a lateral view.

Select a point (in red) on the malleolus slightly above its real apex (in blue).

Then observe the fibula from an

inferior view. Verify that the selected point (in red) is located slightly laterally to the real apex of the lateral malleolus (in blue).

19 Foot Orientation and general presentation (Figs 19.1 & 19.2) The bony foot consists of seven tarsal bones, five metatarsals and the phalanges. 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 via the metatarsophalangeal joints (FM1–FM5). The calcaneus presents a large posterior surface (FCC) with one medial (FCM) and one lateral (FCL) edge, and a prominent tubercle, the sustentaculum tali (FST), on its medial aspect. On its lateral aspect, the calcaneus shows an oblique ridge, the peroneal trochlea (FPT), which should not be confused with the insertion of the calcaneofibular ligament (8), located more posteriorly and dorsally (both FPT and [8] show variable individual development; FPT is usually the most developed). The greater apophysis (FGA) is the anterior part of the bone. The pulley-shaped articular surface of the talus, or trochlea (9), is superior. Anteriorly, the talus shows both a neck (FNK) and a head (FHE). The navicular presents a large tubercle (FNT) on its medial aspect. The basis of the fifth metatarsal bone supports a sharp tuberosity (FMT).

Figure 19.1

Foot bones (3D model).

Entire foot: A lateral view; B medial view; C superior view.

Figure 19.2

Foot bones (anatomic specimens).

Entire foot: A lateral view; B medial view; C superior view. D Isolated calcaneus: medial view. E Calcaneus, talus and navicular bone: medial view. Isolated calcaneus: F posterior view; G lateral view. (Metallic material visible in A–C was used to keep the various foot

bones in a physiologic position.)

Foot/Calcaneus – posterior surface (FCC, FCM, FCL)[R,L] H|Anim Landmarks FCC, FCM, FCL The posterior face of the calcaneus can be described as a square with four edges (see Figs 19.1 & 19.2). Both medial and lateral edges are palpated.

Subject lying: The subject is lying prone, with the foot slightly extended and at rest. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her bodyweight on the limb that is not being palpated. Slightly pinch both lateral and medial edges of the calcaneal tendon between your thumb and middle finger, respectively.

Then follow the edges distally until you reach the the calcaneus (blue arrows).

NOTE The upper ridge of the posterior face of the calcaneus is difficult to palpate with accuracy because of the insertion of the calcaneal (Achilles) tendon. The distance between FCL and FCM may be overestimated, depending on the development of soft tissue in this area.

Move your fingers further until their pulp centers reach the center of both lateral (FCL) and medial (FCM) edges of the calcaneus.

FCC is located by pushing your forefinger centrally between the thumb and middle finger.

Observe the calcaneus bone from a medial view. Select the center of the medial calcaneal edge (FCM).

Repeat the selection from a lateral view to select the lateral calcaneal edge (FCL).

Then observe the calcaneus from a posterior view. FCC is located on the posterior surface at the center of a horizontal line between FCL and FCM.

Foot/calcaneus – Sustentaculum Tali (FST)[R,L] H|Anim Landmark FST The sustentaculum tali is a prominent tubercle at the medial aspect of the calcaneus (see Figs 19.1 & 19.2). It also supports the medial part of the anteromedial joint surface of the talus. It is located on the

border joining the superior and medial surfaces of the calcaneus.

Subject lying: The subject is lying supine, foot at rest. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her

bodyweight on the limb that is not being palpated. Start with the forefinger from TAM (see p. 148). Move distally (blue arrow) in the direction of the medial border of the foot. The tubercle located about one fingerwidth distally and towards TAM is the posterior edge of the sustentaculum tali. Leave the index finger on this point, and move the thumb anteriorly and distally to the anterior edge of the sustentaculum (about one fingerwidth). The mid-point between the two fingers is FST.

Observe the foot from a medial view. Select the center of the sustentaculum tali.

Then observe the foot from an inferior view.

Make sure that the located point is on the most prominent aspect of the sustentaculum tali.

Foot/Navicular – Tuberosity (FNT)[R,L] Landmark FNT The navicular tuberosity is a prominence located on the medial aspect of the navicular bone, pointing towards the sole of the foot (see Figs 19.1 & 19.2). It receives one of the insertions of the tibialis posterior muscle.

Subject lying: The subject is lying supine, foot at rest. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her bodyweight on the limb that is not being palpated. From FST (see p. 164), move anteriorly (towards the toes; blue arrow).

The first bony prominence you meet is the navicular tuberosity. Select its tip. Manual palpation tip • Ask the subject to perform an inversion of the foot to feel the tension of the tibialis posterior tendon (green arrow), which runs towards the navicular tuberosity after passing behind the medial malleolus. • The direction of the tendon will lead you to FNT.

Observe the foot from a medial view (slightly posterior). Locate the center of the navicular tuberosity.

Then, observe the foot from an inferior view. Check that the selected point is the most medial point of the navicular tuberosity.

Foot/calcaneus – Greater Apophysis (FGA)[R,L] Landmark FGA The greater apophysis of the calcaneus is the most anterior part of the bone (see Figs 19.1 & 19.2).

Subject lying: The subject is lying supine, foot at rest. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her bodyweight on the limb that is not being palpated. Observe the ankle area at the angle between the anterior part of the shank and the superior aspect of the foot. Ask the subject to extend the toes. Locate the tendons of the extensor digitorum longus muscle (green lines).

Place the forefinger laterally to the tendons and gently push vertically into the soft tissue to reach the horizontal part of the greater apophysis.

Observe the foot from a superior view. Select the center of the superior face of the greater apophysis of the calcaneus just lateral to the talus neck (in blue; see p. 168).

Then observe the foot from a lateral view. Make sure that the selected point is on the uppermost part of the greater apophysis.

Foot/talus – NecK (FNK)[R,L]

Landmark FNK The neck of the talus is located between the head and the trochlea (see Figs 19.1 & 19.2).

Subject lying: The subject is lying supine, foot in extension. Subject standing: The palpator kneels next to the subject’s foot, which is in slight extension. The subject is asked to put his or her bodyweight on the limb that is not being palpated. Observe the ankle area at the angle between the anterior part of the shank and the superior aspect of the foot. Ask the subject to extend the toes. Locate the tendons of the extensor digitorum longus (edl) and extensor hallucis longus (ehl) muscles. (In this figure the palpator’s left forefinger is on ehl, indicated with a green line.)

Place the forefinger just lateral to ehl tendon (between ehl and edl) and gently push vertically into the soft tissue to reach the neck of the talus. Make sure you are on the most posterior part of the neck. NOTE The subject’s foot must be in extension (plantar flexion) in order for the posterior aspect of the talus neck to be reached more easily.

Observe the foot from a superior view. Select the center of the superior face of the neck of the talus.

Then observe the foot from a lateral view. Make sure that the selected point is on the uppermost part of the talus neck.

Foot/talus – HEad (FHE)[R,L] Landmark FHE The head of the talus is located on the most anterior aspect of the bone (see Figs 19.1 & 19.2). It has a relatively sharp superior edge.

Subject lying: The subject is lying supine, foot in extension. Subject standing: The palpator kneels next to the subject’s foot, which is in slight extension. The subject is asked to put his or her bodyweight on the limb that is not being palpated. Observe the ankle area at the angle between the anterior part of the shank and the superior aspect of the foot. First locate FNK (see p. 168), and move forwards about half a finger-pulp width (blue arrow) to find the edge of the head.

Select this edge center.

Observe the foot from a superior view. Select the center of the superior edge of the talus head.

Then observe the foot from a lateral view. Make sure that the selected point is on the uppermost edge of the talus head (compare with the location of FNK; see p. 168).

Foot/calcaneus – Peroneal Trochlea (FPT)[R,L] Landmark FPT The peroneal trochlea (tubercle) is an oblong ridge process of the lateral surface of the calcaneus (see Figs 19.1 & 19.2). It separates the tendons of the peroneus longus and brevis muscles. This ridge has an

oblique orientation (downwards and anteriorly).

Subject lying: The subject is lying supine, foot at rest, with the palpator standing lateral to the foot being palpated. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her bodyweight on the limb that is not being palpated. Place your forefinger behind the lateral malleolus. Then follow the path (in green) of the tendons of the fibularis longus and fibularis brevis muscles towards the lateral aspect of the rearfoot.

A ridge (of variable development) is met. Select its center.

NOTE Another tubercle, for the calcaneofibular ligament insertion, may also be present on the lateral aspect of the calcaneus. This tubercle is more dorsal and posterior than FPT (see Fig. 19.2, structure 8). Bear in mind the variable development of this tubercle, and do not confuse it with FPT, which is more anterior.

Observe the foot from a lateral view. Locate the lateral surface of the calcaneus. Select the midpoint of the peroneal trochlea.

Then observe the foot from an inferior view. Verify that the selected point is located on the central, prominent part of the trochlea.

Foot/Metatarsus – Tuberosity of the fifth metatarsal bone (FMT)[R,L] Landmark FMT

This tuberosity is located at the base (proximal end) of the fifth metatarsal bone (M5) (see Figs 19.1 & 19.2).

Subject lying: The subject is lying supine, foot at rest, with the palpator standing lateral to the foot being palpated. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her bodyweight on the limb that is not being palpated. Place one finger on the lateral edge of the foot (below the lateral malleolus) and glide forwards (blue arrow) along the edge of the foot. Manual palpation tip • FMT is approximately at the midpoint of the lateral edge of the foot (double green arrows).

Halfway along the edge you will feel a tuberosity. FMT is the posterior top of the tuberosity. NOTE The manually palpated point is not strictly speaking the real apex of the tuberosity, which is located deeper in the tendon of the peroneus brevis muscle. This must be kept in mind when virtual palpation is performed in parallel; in this case, the red landmark must be selected. If you wish to perform virtual palpation of the real apex of the tuberosity, select the blue landmark.

Observe the foot from a lateral (slightly posterior) view. Locate the tuberosity of the fifth metatarsal bone, and select the point (in red) located just outside the real apex of the tuberosity (in blue).

Then observe the foot from a superior view. Verify that the selected point (in red) is slightly distal to the real apex of the tuberosity (in blue).

Foot/Metatarsus – first, second, third, fourth and fifth head (FM1–FM5)[R,L] Landmarks FM1–FM5 The head of a metatarsal bone is the anterior extremity of this bone, articulating with the first phalanx of the digital ray (see Figs 19.1 & 19.2).

Subject lying: The subject is lying supine, foot at rest. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her bodyweight on the limb that is not being palpated.

Take the first phalanx of the digital ray between the thumb and index finger of one hand. Take the metatarsal head between the thumb and index finger of the other hand, with the thumb on the dorsal portion of the metatarsal bone. Move the subject’s phalanx along with small motions of flexion and extension (green arrows) for better localization of the center of the dorsal aspect of the metatarsal head.

This point is the landmark to select. For each digital ray, process as above. Manual palpation tip • In Figure 19.1, observe the relative location of the metatarsal heads with one another: FM2 is the most distal, FM1 and FM3 are at approximately the same level and FM5 is the most posterior. Similar relationships should be found during palpation. • To facilitate toe mobilization when the subject is standing, put the subject’s foot on a small box with the toes outside the box edges.

Observe the digital ray from a superior view. Select the most central point of the metatarsal head (here FM1).

Then observe the foot from a medial view. Check that the selected point is the most dorsal, prominent point of the margin between the joint surface and the dorsal surface.

The above palpation should be repeated to locate the head of the other metatarsal bones.

Foot/phalanges – Basis (BPi, BCi, BDi)[R,L] Landmarks BPi, BCi, BDi The basis of a phalanx is equivalent to its proximal epiphysis (see Figs 19.1 & 19.2). The following description is given for the first phalanx of the big toe; the other phalanges can be palpated in a similar way (i represents the toe index: 6 = big toe, 7 = second toe, 8 = third toe,

9 = fourth toe, 10 = fifth [little] toe; BPi indicates the proximal phalanx, BCi the middle phalanx, and BDi the distal phalanx).

Subject lying: The subject is lying supine, foot at rest. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her bodyweight on the limb that is not being palpated. Take the first phalanx of the digital ray between the thumb and index finger of one hand. Take the metatarsal head between the thumb and index finger of

the other hand, with the thumb on the dorsal portion of the metatarsal bone. Mobilize the subject’s phalanx with continuous small motions of flexion and extension (green arrows) for better localization of the dorsal aspect of the metatarsophalangeal joint. Palpate the joint edge of the phalanx with your pulp tip (here with the right forefinger). From that point, finger-roll distally (see Tips, p. 4) until the pulp angle touches the subject’s skin. The point of the basis to select is below your pulp angle. Manual palpation tip • To facilitate toe mobilization when the subject is standing, put the subject’s foot on a small box with the toes outside the box edges.

Observe the proximal epiphysis of the phalanx from a dorsal point of view. The point to select is at the center of the proximal epiphysis, just distal to the joint edge.

Foot/phalanges – head (PLi, PMi, CLi, CMi, DLi, DMi)

[R,L] Landmarks PLi, PMi, CLi, CMi, DLi, DMi The head is the distal epiphysis (see Figs 19.1 & 19.2). Two points are palpated; averaging both points gives an estimate of the center of the head. The following description is given for the first phalanx of the big toe. The other phalanges can be palpated in a similar way (i represents the toe index: 6 = big toe, 7 = second toe, 8 = third toe, 9 = fourth toe, 10 = fifth [little] toe; PLi and PMi indicate the proximal [lateral, medial] phalanx, CLi and CMi the central [lateral, medial] phalanx, and DLi and DMi the distal [lateral, medial] phalanx).

Subject lying: The subject is lying supine, foot at rest. Subject standing: The palpator kneels next to the subject’s foot, which is in neutral position. The subject is asked to put his or her bodyweight on the limb that is not being palpated. Take the palpated phalanx on each side between the thumb and forefinger (here with the left hand). Glide distally (arrows) along both sides until the broadest part of

the phalanx head is reached (just before the interphalangeal [IP] joint).

Select both sides of the phalanx head laterally and medially. Manual palpation tip • To facilitate toe mobilization when the subject is standing, put the subject’s foot on a small box with the toes outside the box edges. • Flexing the adjacent IP joint (here with the right hand) allows better localization of the head.

Observe the phalanx head from a dorsal view. The two points to select are on either side of the broadest part of the head along a transverse line (in red). Select the intersections

of this line with both medial (in blue) and lateral (in green) edges of the bone.

NOTE The heads of the distal phalanges are difficult to palpate with accuracy.

20 Approximation of centroid and radius The centroid and radius of both a circle and a sphere can be approximated from several points (three for a circle, four for a sphere) located on their circumference. The following must be kept in mind: • For a circle: the three points cannot be co-linear or no solution will be found (because the points are on a straight line, not a circle). • For a sphere: the four points cannot be co-planar or co-linear, or no solution will be found The solution for both circle and sphere equations is found from analytic geometry. A unique circle or sphere can be described from three (Pti, where i

= 1–3) or four (Pti, where i = 1–4) points respectively, located on their circumference:

The circle/sphere equation can be found from the following determinant equation (main matrix):

The general equations are given below. For the circle or sphere centroid (Pt0):

The radius of a circle is given by:

The radius of a sphere is given by:

Where Mij is the minor matrix of the n by n main matrix (n = 4 for

a circle, n = 5 for a sphere). The minor matrix (n – 1 by n – 1) is solved after removing the ith row and the jth column from the main matrix (see above determinant equation). This method can be used to estimate the centroid and radius of

several joint centers: p. 76) using three landmarks.

The ulnar head (UHE; see

The acetabulum (IAC; see p. 113) using four landmarks. Make sure you are not using co-planar landmarks. For example, use: Pt1 = AC1, Pt2 = AC4, Pt3 = AC7 and Pt4 = AC5.

landmarks.

The radial head (RHE; see p. 82) using three

The femoral head (FCH; see p. 132) using four landmarks. Make sure you are not using co-planar landmarks. For example, use: Pt1 = FCH1, Pt2 = FCH2, Pt3 = FCH6 and Pt4 = FCH3.

NOTE The above method assumes that the structures are strictly circular or spherical. Although this is an acceptable assumption for most applications, it must be remembered

that

anatomic

structures

are

never

true

circles

or

spheres.

Furthermore, some degenerative diseases (e.g. osteoarthritis) may affect physiologic joint shape. In these cases, the above method will not produce accurate results.

Index Page numbers in bold refer to main landmark descriptions.

A Acetabulum, 104 center (IAC), 104, 105, 113,, 134, 177 lunate surface, 104, 105, 113 Acromioclavicular joint clavicle (CAJ), 44, 45 scapula (SAJ), 50, 51, 60 Acromion, 50, 51, 56–58 See also Scapula Acronyms, landmark, 4, 6 Anatomic planes, 3 Animation, 1–2, 5 Anterior nasal spine (SNS), 8, 9, 20 Anterior superior iliac spine (IAS), 104, 105, 106 Art of palpation, 1, 2

B

Bone description, 3

C Calcaneofibular ligament, 160, 161, 171 Calcaneus, 160, 161 greater apophysis (FGA), 160, 161, 166–167 lateral edge (FCL), 160, 161, 162–163 medial edge (FCM), 160, 161, 162–163 peroneal trochlea (FPT), 160, 161, 171 posterior surface (FCC), 160, 161, 162–163 sustentaculum tali (FST), 160, 161, 164 Carpal bones, 90, 91, 92–94 Centroid, approximation of, 176–177 Cervical vertebrae (CV2–CV7), 28, 29, 31 spinous processes, 29–31 Clavicle, 44–49 acromioclavicular joint (CAJ), 44, 45 anterior concavity (CAA), 44, 46,, 59 anterior convexity (CAE), 39, 40, 44, 47 anterior face, 44, 46, 47 anterior sternoclavicular joint (CAS), 39, 41, 44, 49 articulations, 32, 44, 45, 48, 49, 50 relation to ribs, 39 sternoclavicular joint (CSJ), 41, 44, 48

Coccyx, 28, 102 Color conventions, 5 Coracoid process, 50, 51, 59, 65 Coracoid tip (SCT), 50, 51, 59,, 65 Coronoid process (UCP), 70, 71, 74 Coronal plane, 3 Costal cartilage(s), 32, 33, 36, 37, 39, 41 Coxal articulation (hip joint), 104, 114, 132, 177 Cuboid, 160, 161

D Deltoid muscle, 64, 66 Deltoid tuberosity (HDT), 62, 63, 66 Digital rays fingers (hand), 90, 91, 95–101 toes (foot), 160, 161, 173–175 Distal radioulnar joint (URU), 70, 71, 78,, 80, 88 dorsal edge (RDE), 80, 81, 86,, 88 Dome – ulnar head (UHD), 70, 71, 75,, 76–78

E Extensor digitorum longus tendon, 166, 168

Extensor hallucis longus tendon, 168 External occipital protuberance (SOP), 8, 9, 10,, 29

F Feature points, 5 Femoropatellar joint, 114, 136 Femur, 114–135 articulations, 104, 105, 114, 136 distal epiphysis, 114, 115 greater trochanter (FT), 114, 115, 116–117 head (center) (FCH), 113, 114, 115, 132–134,, 177 lateral condyle (FLC), 114, 115, 130–131 lateral epicondyle (FLE), 114, 115, 122–123 lower ridge (FBE), 114, 115, 122–123 upper ridge (FUE), 114, 115, 122–123 medial condyle (FMC), 114, 115, 128–129 medial epicondyle (FME), 114, 115, 120,, 121 medial sulcus (FMS), 114, 115, 121 neck, 114, 115 patellar surface groove, 114, 115 anterolateral ridge (FLG), 114, 115, 127 anteromedial ridge (FMG), 114, 115, 126 popliteal sulcus (FPS), 114, 115, 124–125 proximal epiphysis, 115, 132

tubercle of adductor magnus muscle (FAM), 114, 115, 118–119 Fibula, 152–159 distal epiphysis, 152, 153, 158, 159 lateral malleolus (FAL), 152, 153, 158–159 neck (FNE), 152, 153, 156–157 proximal epiphysis (head), 152, 153, 154, 155 styloid process (FAX), 152, 153, 154–155 Finger pulp See Pulp Finger-roll technique, 4 Fingers See Digital rays Foot, 160–175 metatarsal heads (FM1–FM5), 160, 161, 173 phalanges basis (BPi, BCi, BDi), 160, 161, 174 head (PLi, PMi, CLi, CMi, DLi, DMi), 160, 161, 175 tuberosity of fifth metatarsal (FMT), 160, 161, 172 See also Calcaneus; See also Talus; See also Metatarsal bones Frontal plane, 3

G Gerdy’s tubercle (TGT), 142, 143, 147 Glabella (SGL), 8, 9, 19 Glenoid cavity, 50

Gonion (jaw angle), 22, 23, 24 Greater sciatic notch, 104, 105, 108 Greater trochanter (FTC), 114, 115, 116–117

H Hamatum hook (HHH), 90, 91, 93 Hand, 90–100 hamatum hook (HHH), 90, 91, 93 metacarpal bones See Metacarpal bones navicular tubercle (HNT), 90, 91, 94 phalanges, 90, 91, 98, 99–100 basis (BPi, BCi, BDi), 90, 91, 98 head (PLi, PMi, CLi, CMi, DLi, DMi), 90, 91, 99–100 pisiform (HPI), 90, 91, 92,, 93, 94 Hip joint, 104, 113, 114, 177 Horizontal plane, 3 Humanoid Animation Working Group (H|Anim), 5 Humerus, 62–68 articulations, 62, 70, 71, 80 capitulum, 62, 63 deltoid tuberosity (HDT), 62, 63, 66 distal epiphysis, 62, 63, 67, 68 greater tubercle (HGT), 62, 63, 64

intertubercular sulcus, 62, 63 lateral epicondyle (HLE), 62, 63, 68 lesser tubercle (HLT), 62, 63, 65 medial epicondyle (HME), 62, 63, 67,, 68 lower angle (HML), 62, 63, 67 upper angle (HMU), 62, 63, 67 proximal epiphysis, 62, 63, 64, 65 trochlea, 62, 63, 68

I Iliac crest, 104, 105, 106–107 tubercle (ICT), 104, 105, 112 relation to ribs, 39, 42–43 Ilium, 102, 104–113 acetabulum See Acetabulum anterior superior iliac spine (IAS), 104, 105, 106,, 112 center of acetabulum See Acetabulum crest tubercle (ICT), 104, 105, 112 inferior ramus, 104, 105 ischial tuberosity, inferior angle (IIT), 104, 105, 109 posterior inferior iliac spine (IPI), 104, 105, 108 posterior superior iliac spine (IPS), 103, 104, 105, 107,, 108 pubic joint, anterior angle (IPJ), 104, 105, 110 pubic spine (IPP), 104, 105, 111 Incisive (JIN), 22, 23, 27

Infraorbital foramen (SIF), 8, 9, 15 Inguinal ligament, 111 Intermediate cuneiform, 160, 161 International Society of Biomechanics (ISB), 5 Interphalangeal (IP) joints hand, 99 foot, 175 Ischial tuberosity, inferior angle (IIT), 104, 105, 109

J Jaw, 22–27 angle (JAN), 22, 23, 24 body, 22, 23 incisive (JIN), 22, 23, 27 inferior crest (JIC), 22, 23, 26 mental protuberance (JMP), 22, 25,, 26, 27 ramus, 22, 23 Jugular notch (SJN), 32, 33, 34,, 35, 36, 38

L Landmarks, 6 acronyms, 4, 6 color conventions, 5

descriptions, 5, 6 names, 4, 6 side prefix, 6 Lateral corner of orbit (SLC), 16 Lateral cuneiform, 160, 161 Lateral epicondyle femur (FLE), 114, 115, 122–123 femur, lower ridge (FBE), 114, 115, 122–123 femur, upper ridge (FUE), 114, 115, 122–123 humerus (HLE), 62, 63, 68 Lateral malleolus (FAL), 152, 153, 158–159 Levator scapulae muscle, 54 Lower edge of orbit (SLE), 17 Lumbar vertebrae (LV1–LV5), 28–31 projections, 30 relation to sacrum, 102, 103 spinous processes, 29,, 31

M Malleolar fossa, 152, 153 Malleoli See Lateral malleolus; See also Medial malleolus Mandible See Jaw

Manual palpation, 1, 6 tips, 4 usefulness, 1 warning signs, 5 Manubriosternal joint or edge (SME), 32, 33, 38, 39, 41 Mastoid process (SMP), 8, 9, 13 Medial cuneiform, 160, 161 Medial epicondyle, femur (FME), 114, 115, 120,, 121 humerus (HME), 62, 63, 67,, 68 humerus, lower angle (HML), 62, 63, 67 humerus, upper angle (HMU), 62, 63, 67 Medial malleolus (TAM), 142, 143, 148–149 Median sacral crest, 102, 103 Mental protuberance (JMP), 22, 23, 25 Metacarpal bones (metacarpus), 90, 91, 95–97 basis (MBi), 90, 91, 95 head (HLi and HMi), 90, 91, 96 sesamoid bones (MSL and MSM), 90, 97 Metacarpophalangeal joint, 96, 97 Metatarsal bones (metatarsus), 160, 161, 172–173 head (FM1–FM5), 160, 161, 173 tuberosity of fifth (FMT), 160, 161, 172

Metatarsophalangeal joints, 160, 174 Motion analysis, 1

N Nasion (SNA), 8, 9, 18,, 19 Navicular (of foot) Navicular (of hand) tubercle (HNT), 90, 91, 94 Nipple, 40

O Obturator foramen, 104, 105 Olecranon (UOA), 70, 71, 72 basis (base) (UOB), 70, 71, 73 lateral aspect (UOL), 70, 71, 72,, 73 medial aspect (UOM), 70, 71, 72,, 73 Orbit, 8, 9, 14–17 lateral corner (SLC), 16,, 17 lower edge (SLE), 17

P Palpator, 1 Patella, 136–141 apex (PAX), 136, 137, 138,, 141

base, 136, 137 center (PCE), 136, 137, 141 lateral edge (PLE), 136, 137, 140,, 141 medial edge (PME), 136, 137, 139,, 141 posterior face, 136, 137 Phalanges See Foot; See also Hand Pisiform (HPI), 90, 91, 92 Planes, anatomic, 3 Popliteal sulcus (FPS), 114, 115, 124 Posterior inferior iliac spine (IPI), 104, 105, 108 Posterior superior iliac spine (IPS), 104, 105, 107 Pubic joint, anterior angle (IPJ), 104, 105, 110 Pubic spine (IPP), 104, 105, 111 Pulp (finger) angle, 4 center, 4 spots, 4 tip, 4

R Radiohumeral joint, 68, 80 Radioulnar joint, distal See Distal radioulnar joint

Radius (bone), 80–88 articulations, 62, 68, 70, 71, 80, 81, 86, 87 distal epiphysis, 80, 81, 83–88 dorsal edge of distal radioulnar joint (RDE), 80, 81, 86,, 88 dorsal tubercle (RDT), 80, 81, 84–85 head (RHE), 80, 81, 82,, 177 styloid process (RSP), 80, 81, 83 ulnar notch (sigmoid cavity) (RUN), 80, 86–87 Radius (of a circle/sphere), approximation, 176–177 Ribs, 39–43 anterior aspect (RA2–RA7), 39, 40,, 41 articulation with sternum, 32, 33, 36, 37, 39, 41 floating, 39 lateral aspect (RL4–RL10), 39, 42–43 medial aspect (RM2–RM7), 39, 41

S Sacral foramina, 102 Sacrum, 28, 102–103 apex, 102 base, 102 spinous process of second vertebra (SS2), 102, 103 Sagittal plane, 3 Scaphoid See Navicular

Scapula, 50–61 acromial angle (SAA), 50, 51, 56,, 57, 58 acromial edge (SAE), 50, 51, 58 acromial tip (SAT), 50, 51, 57,, 58 acromioclavicular joint (SAJ), 45, 50, 51, 60 articulations, 50, 51, 60, 62 coracoid tip (SCT), 50, 51, 59,, 65 edges, 50, 51 inferior angle (SIA), 50, 51, 52,, 61 landmark projections on spine, 61 root of spine (SRS), 50, 51, 53,, 54, 56 spine, 50, 51, 53 superior angle (SSA), 50, 51, 54–55,, 61 Scapulohumeral joint, 50, 62 Sellion See Nasion Sesamoid bones, hand (MSL and MSM), 90, 97 Shoulder blade See Scapula Skull, 8–20 anterior nasal spine (SNS), 8, 9, 20 external occipital protuberance (SOP), 8, 9, 10,, 29 glabella (SGL), 8, 9, 19 infraorbital foramen (SIF), 8, 9, 15 lateral corner of orbit (SLC), 16 lower edge of orbit (SLE), 17

mastoid process (SMP), 8, 9, 13 nasion (SNA), 8, 9, 18,, 19 supraorbital notch (SSN), 8, 9, 14,, 15 zygomatic angle (SZA), 8, 9, 12 zygomatic arch (SZR), 8, 9, 11,, 12 Spine, 28–31 projections, 30 sacrum landmark projections, 103 scapula landmark projections, 61 spinous processes, 28, 29–31 sternal landmark projections, 38 Sternoclavicular joint clavicle (CSJ), 41, 44, 48 anterior edge (CAS), 39, 41, 44, 49 sternum surface (SCS), 32, 33, 35 Sternocleidomastoid (scm) muscle, 13, 34, 35 Sternum, 32–38 articulation with ribs, 32, 33, 36, 37, 39 body, 32, 33 clavicular surface (SCS), 32, 33, 35 corpus, See Sternum, See also body jugular notch (SJN), 32, 33, 34,, 35, 36, 38 landmark projections on spine, 38 manubriosternal joint or edge (SME), 32, 33, 36,, 38, 39, 41

manubrium, 32, 33, 36 sternoclavicular joint, 32, 33, 35 xiphisternal joint (SXS), 32, 33, 37,, 38 xiphoid process, 32, 33 Superior nuchal lines, 8, 9 Supraorbital edge, 8, 9, 14 Supraorbital notch (SSN), 8, 9, 14,, 15 Sustentaculum tali (FST), 160, 161, 164,, 165

T Talofibular joint, 152, 153 Talus, 160, 161 head (FHE), 160, 161, 170 neck (FNK), 160, 161, 168–169 Tarsal bones, 160, 161, 162–171 Thoracic vertebrae (TV1–TV12), 28, 29, 31 scapula landmark projections, 61 spinous processes, 29–31 sternal landmark projections, 38 Thorax, 32–38, 39–43 Thumb, 90, 91 basis, 95 head, 96

phalanges, 98–100 sesamoid bones (MSL and MSM), 97 Tibia, 142–150 apex of medial malleolus (TAM), 142, 143, 148–150 distal epiphysis, 142 Gerdy’s tubercle (TGT), 142, 143, 147 plateau, 142, 143 lateral ridge (TLR), 142, 143, 145, 146,, 150 medial ridge (TMR), 142, 143, 145–146,, 150 proximal epiphysis, 142, 143, 144, 145, 146, 150 tuberosity (TTC), 142, 143, 144,, 150 lateral edge (TTL), 142, 143, 144 medial edge (TTM), 142, 143, 144 Tips, 4 Toes See Digital rays Transverse plane, 3 Trapezius muscle, 10 Tubercle of the adductor magnus muscle (FAM), 114, 115, 118

U Ulna, 70–78 articulations, 62, 70, 71, 76, 78, 80, 88 coronoid process (UCP), 70, 71, 74 distal epiphysis, 70, 71

distal radioulnar joint (URU), 70, 71, 78 greater sigmoid cavity (semilunar notch), 70, 71 head (center) (UHE), 70, 71, 75, 76,, 177 head dome (UHD), 70, 71, 75,, 76–78 olecranon See Olecranon posterior edge, 70, 71, 73, 74 proximal epiphysis, 70, 71, 72, 74 styloid process (USP), 70, 71, 77 Ulnar notch (sigmoid cavity) (RUN), 80, 86–87

V Vertebrae See Spine Virtual palpation, 1, 6 tips, 4 usefulness, 1

W Warning signs, 5 Wrist, 90, 91, 92–94 articulations, 70, 71, 80 hamatum hook (HHH), 90, 91, 93 navicular tubercle (HNT), 90, 91, 94 pisiform (HPI), 90, 91, 92,, 93, 94 See Hand

X Xiphicostal angles, 32, 37 Xiphisternal joint (SXS), 32, 33, 37,, 38 Xiphoid process, 32, 33, 37

Z Zygomatic angle (SZA), 8, 9, 12 Zygomatic arch (SZR), 8, 9, 11