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TIBIA, FIBULA AND ARTICULATED FOOT DISCUSSION FOR PGMEE
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00:07Welcome to this part 2 discussion about the osteology of lower limb.
00:11The first part we talked about the hip bone and the femur and the second part will be taking care
00:16of the bones of the leg and foot. So, as I already mentioned that these discussions are
00:20mainly targeted to the PGME examination. So, we don't have to look into every precise
00:25attachment. We are just looking at the important attachments from the exam point of view and some
00:29questions which again some clinical questions which can be derived from there. So, let's again
00:35start with the ossification first. Now, as you can see in the picture you're looking at the the tibia
00:40and the fibula bone. Just like most of the long bones even the tibia and fibula are having one
00:45primary center for ossification and two secondary center for ossification each. So, if I go with
00:52the tibia first. So, we have a primary center for ossification in the shaft of the tibia.
00:57So, we get one PC, one primary center and this primary center it appears in the sixth week
01:06of intrauterine line. It appears in the sixth week of the seventh week of the intrauterine line.
01:14The secondary center, if I talk about the secondary center for the tibia, we have one for the upper end
01:22and there's a secondary center one for the lower end including the medial mellular. So, the one which
01:28I've highlighted it is for the secondary center. So, guys, this is the secondary center for the upper
01:37end and we've got a secondary center for the lower end and the timing goes like if you look at
01:43the upper
01:43end, it appears just before birth. Just before birth, yeah. The secondary ossification center for
01:56the upper end of tibia, it appears just before birth and it fuses by the age of 17.
02:0417, 18, 17, it is fused. Whereas, if you look at the lower end of the tibia, lower end of
02:11the tibia,
02:12tibia, it again appears close to birth only again but yeah, I can say first year. First year, so it
02:18is
02:18later than the upper one. First year and the fusion for this takes place again at the age of 70.
02:29Now, this kind of resembles any other long bone that we have a primary center for the shaft,
02:34secondary center for the ends and then you can see the upper end usually is having the center which is
02:39appearing first and the secondary center for the lower end which is appearing later. But this is
02:46a bit different in case of fibula. Now, what is different in case of fibula if I go with the
02:50shaft
02:51first. Once again, just like tibia only, we have one primary center for the shaft of fibula
02:59and that primary center, it appears in the eighth week of intrauterine life.
03:08Coming to the interesting part, if you look at the secondary center of ossification for the fibula
03:12for the upper end and for the lower end, let me mark that first. So, we got a secondary center
03:17for the upper end of the fibula as well as the lower end of the fibula, just like any other
03:22long
03:22bone. But you will see something unusual here that if you look at the secondary center for the upper end,
03:32it appears, now look at that, it appears at the fourth year and it is fused at 18th year. 17th
03:41or 18th,
03:4218th is the best answer to go with, 18th year. But if you look at the lower end here, this
03:47one,
03:47the lower end, we got a secondary center for the lower end as well.
03:53And the interesting part is it appears in the first year only. And again, the fusion takes place
04:00at the age of 16. Now, look at this, it appears fourth year and fuses on 18th year and the
04:08lower
04:08end it appears in the first year and fuses on the 16th year. Now, this is a bit unusual. Why
04:13it is unusual?
04:14Because it is kind of violating the law of ossification. The lower end, it appears first
04:21and it is fusing first, which is not the case when you talk about the secondary center ossification.
04:26It is appearing first and it is fusing first also. The one which appears first, it fuses later. That's
04:31what the ossification law says. So, it is appearing at the age of first year and then it is fusing
04:36at
04:36the age of 16 years. Although there is explanation to this, the explanation is if you look at the,
04:40carefully look at the upper end, the lower end of the fibula, see upper end of the fibula,
04:44is attached to the tibia and tibia is the one which is contributing to the knee joint.
04:49So, upper end of the fibula is not basically a pressure epiphysis. But if you look at the lower
04:55end of the fibula, it is obviously helping in the formation of this ankle mortise, which will
04:59attach to the talus bone. That means it is an example of what? It is an example of the pressure
05:04epiphysis. Now, that is the important thing because the lower end of the fibula, that's the
05:10explanation to this. The lower end of the fibula is pressure epiphysis.
05:18The lower end of the fibula is the pressure epiphysis. So, as as per the rule goes, the
05:23pressure epiphysis is the one which appears first and that's why the appearance of this is at the
05:28age of first year, whereas the upper end is appearing at the age of four. Secondly, if you know the
05:34rule of the ossification, if you know the rule of the nutrient artery, the direction of the
05:39nutrient artery opposite to the nutrient artery is the growing end of the bone. So, there's a
05:43mnemonic which says that to the elbow I go from the knee, I flee. From the knee, I flee. So,
05:48if you
05:48look at the knee joint, the nutrient arteries are directed away from the knee. That means in case of
05:54tibia and fibula, the nutrient artery are directed downward. If the nutrient foramine or the nutrient
05:59arteries are directed downward, that means the growing end of the bone is the upper end.
06:03so fibula upper end is a growing end and that's why and that's why the fusion is later obviously
06:10the growing end will fuse later that's why we call it growing end here so that is a kind of
06:14explanation for both the upper and lower end the lower end it appears for the secondary center
06:19appears first because this one is a pressure epiphysis and not this one and why upper end is
06:25fusing later because the upper end of the fibula is a the growing end of this one because the
06:31nutrient arteries directed downward and the growing end is the upper end of the fibula so this is an
06:35exception that you should remember about this the fibula bone here another interesting thing about
06:41the the tibia bone that you should know about is guys if you look at the epiphysial lining i mean
06:47let's say if i'm putting this dotted line here which is going from the mid of the tibial tuberosity
06:53this let us say this is the epiphysial lining
07:00that's an epiphysial line you know where the epiphysial plate is present that is an epiphysial
07:03line and if you compare this epiphysial line with a capsule of the knee joint now the knee joint is
07:09present even more proximal like this the capsule of the knee joint is even more proximal
07:22the reason i'm telling you this because upper end of the tibia is the most common site for the acute
07:29osteomyelitis upper end of the tibia this upper end of the tibia is the most common site for the acute
07:35osteomyelitis but thankfully the capsule of the knee joint is attached even proximal to the epiphysial
07:40lining and that's why the knee joint is not affected in this case though the upper end of
07:46the tibia is the most common site for the acute osteomyelitis but because the capsule of the knee
07:51joint is attached not distal but proximal to the epiphysial line that keeps it out of the epiphysial
07:56line or that the growing end region and from that epiphysial plate region and that keeps the knee
08:03joint safe from the osteomyelitis thing so that is another important thing that you should know
08:07from this tibia and fibula so this is a bit about the ossification of the bone and some other thing
08:13let us now talk about the attachment on the tibia and the fibula now when you look at the upper
08:18end
08:18of the tibia and fibula there are some important tubercles and tuberosity there on which you should
08:23know the attachment as i already said in part one also that the upper end of these long bones is
08:28is automatically it's an important part so just like the femur upper end there was like a lot of
08:32attachment was present on the greater and the lesser trochanter and even on the upper
08:36the gluteal tuberosity and pectinial line similarly here the upper end of the tibia and even for that
08:42matter even fibula also is far more important than you know about the lower end of the same bone
08:47now what do you see you are looking at the anterior aspect right now that's an anterior view
08:51let me write that this is the anterior view
08:58now the tuberosity that you notice here this here is the
09:02look at this tuberosity guys this is called as the tibial tuberosity
09:10this is the tibial tuberosity the tuberosities and tubercles they're usually the examples of
09:16the traction epiphysis so that's a tibial tuberosity and this tibial tuberosity is giving
09:21attachment to the ligamentum patele we know that that's how the quadricep tendon is transmitting
09:27the force to the tibia through this ligament called as a ligamentum patele so that's where
09:40the ligamentum patele is attached on the tibial tuberosity although we can divide the tibial
09:44tuberosity in two parts the smooth part and the rough part but let's we don't have to go into
09:47that detail now if you look toward the lateral side i mean we are looking at the condyles of
09:53the tibia this is the anterior aspect of the the the tibial condyle and uh anterior aspect of the
09:59lateral tibial condyle and that's a medial tibial condyle now if you look at this anterior aspect of
10:03the lateral tibial condyle you will see a tubercle present over there the one which i marked here guys
10:07this here is called as the gurdies tubercle
10:13this tubercle is referred as the gurdies tubercle and what is the importance of this gurdies tubercle
10:18this is the attachment of very very important that is ileo tibial band or ileo tibial tract
10:26i'm sure you all know what is ileo tibial band it is a thickening of the facial lata
10:30of the thigh on the lateral aspect and that's how this ileo tibial band is going attached to the
10:36lateral surface of the lateral tibial condyle but to the anterior aspect of lateral tibial condyle
10:42and this ileo tibial band is important because it is giving attachment to gluteus maximus
10:46and also to the tensor facial latae muscle so when those muscles contract the ileo tibial band also
10:51get uh tout and the effect can be seen on the knee joint also because the ileo tibial band gets
10:56attached ultimately uh to the the gurdies tubercle which is on the anterior surface of lateral tibial
11:03condyle if you look at the medial surface of the tibia now you can feel the medial surface of the
11:10tibia
11:10it is a subcutaneous surface when when you feel the bones of the leg you can see the medial surface
11:16of
11:16the tibia can be felt because there is no attachment that is present on the medial surface in most of
11:20the aspect so this here is a medial surface and that is subcutaneous that's the medial surface and
11:30this is the subcutaneous surface of the tibia bone so you can feel it but there is one very very
11:39important attachment to be seen on the same medial surface but close to the upper end so that's the
11:43only part of the medial surface where we have some muscles attached there some tendons attached there
11:48so we have a tendon of the sartorius gracilis and semi-tendinosus attached all together here
11:57let me write that this is for the sartorius we got the tendon for the gracilis muscle
12:07and then we have for the semi-tendinosus now i hope you
12:12note that there is something special about these attachment here usually the different compartment
12:17muscles they have a different insertion also the anterior muscle goes mainly usually toward the
12:21anterior aspect the posterior toward the posterior aspect but that is not the case here these three
12:26muscles belong to three different compartments sartorius as we all know is the muscle of the
12:31anterior compartment gracilis as from the medial and semi-tendinosus from the posterior compartment
12:35so we got a three muscle from three different compartment and they're all converging toward one
12:41point they're all converging toward to have a common insertion that is on the medial surface
12:46of the tibia upper end of the medial surface of the tibia these three muscles together are called as a
12:51gai ropes muscle these are called as a gai ropes muscle the gai ropes they're having an anserene
13:02barsa also in that region here these muscles are the gai ropes muscle well the point is gai ropes what
13:10do you mean what is the meaning of the gai ropes it's a ropes of a tent i mean if
13:13you look at the tent
13:14there is a pillar in the center and that pillar is kind of supported by the three ropes which are
13:19running in three different direction here it's the same sort of arrangement we have here so we have
13:23a muscle coming from three different direction but they're all projecting to the same point only and
13:28that is to the medial surface toward the upper end of the tibia so these are some important attachment
13:34that you appreciate from the anterior aspect of the tibia now let me turn this tibia and fibula now what
13:40you're looking at is the posterior surface if you're looking at the posterior surface of upper end of
13:44the tibia and fibula that's how they look so let me write that first this here is the posterior view
13:55okay what is to be noted here guys uh when you look toward the we already saw semi tendinosis
14:00muscle was attached on the medial surface which can be appreciated more from the anterior side
14:04that's more of an anterior medial surface this is a posterior surface here now if you look at this
14:09medial tibial condyle on the posterior aspect of the medial tibial condyle there is the insertion of
14:15semi membranosis tendon so this is a site where the semi membranosis tendon will come and attach here
14:22there is something very important to understand from here semi membranosis tendon is to be seen which
14:30is attached to the posterior surface of the medial tibial condyle
14:39the thing is the semi membranosis tendon there is an extension from the semi membranosis tendon which
14:44runs behind the capsule of the knee joint presuming that there's a femur here and obviously there's a
14:49region of the knee joint so what you'll see that capsule of the knee joint from the posterior aspect
14:55is reinforced by an additional ligament or additional ligament over there and that is an extension of the
15:02semi membranosis tendon only so let's say this is the one which i'm destroying it schematically here
15:07so you've got an extension from the semi membranosis which as i said is reinforcing the capsule of the
15:14knee joint from posterior aspect we call it oblique
15:22popliteal ligament this is called as an oblique popliteal ligament so that's one question here
15:27that what is oblique popliteal ligament it is an extension of the tendon of semi membranosis be careful
15:32it is semi membranosis not tendinosis tendinosis is anyways is on the anteromedial surface not on the
15:37posterior side
15:40why we should know about this oblique popliteal ligament number one it is obviously forming the
15:44floor of the popliteal fossa it is giving an additional strength strength to the capsule of
15:49the knee joint posteriorly moreover this oblique popliteal ligament it allows a blood vessel
15:56and a nerve to go through it and supply certain structures inside what blood vessel guys this
16:02artery here is called as the middle genicular artery middle genicular artery is a direct branch
16:09from popliteal artery this is a middle genicular artery which comes from popliteal artery and then
16:16we have a genicular branch genicular branch of obturator nerve genicular branch of obturator nerve
16:25more precisely from the posterior division of the obturator nerve it's a genicular branch of
16:29obturator nerve so that could be another question here that what structures are piercing the oblique
16:33popliteal ligament which is an extension of semi membranosis and that is the middle genicular artery
16:38coming from popliteal and genicular branch of obturator nerve well what for what why these structures
16:44are piercing the oblique popliteal ligament so that once they go through this ligament and the
16:48capsule of the knee joint they go inside and they're going to supply the cruciate ligament the
16:52anterior cruciate and the posterior cruciate ligament are supplied by the same middle genicular
16:57artery only so this this kind of like two three questions can be answered from here oblique popliteal
17:03ligament is an extension of semi membranosis structure piercing oblique popliteal ligament is the
17:08middle genicular artery and genicular branch of obturator nerve and the function of these structures to go in
17:13the reason they're going in is to supply the the cruciate ligaments the acl and the pcl
17:21few more things that you will appreciate here in the posterior surface some as i said we just have
17:25to look into the important one i hope you all can appreciate this a line obliquely placed line on the
17:30posterior surface of the tibia in the upper part and this line here guys is called as a soleal line
17:36look at this one this here is called as a soleal line and of course the soleal line gives origin
17:41to
17:42the soleus muscle we do have origin of soleus from the fibula also i'm just talking about the
17:45attachment on the tibia so this is the origin of the soleus muscle
17:53from the soleal line another important attachment that you should know that above the soleal line
18:00on the posterior surface of the tibia this is the site where the popliteus muscle will insert i'm using
18:06a blue color for the insertion here see where the popliteus muscle is originating it is originating
18:11from the lateral femoral epicondyle lateral femoral epicondyle was given like somewhere here on this
18:17side on the lateral side the popliteus muscle will start and then the popliteus muscle will come down
18:21like this forming the floor of the popliteus foci and insert here the reason i'm telling you this
18:26direction of the popliteus muscle because this also tells me that every time the popliteus muscle
18:30will contract the reason you should know the attachment of the popliteus muscle here above
18:43the soleal line because knowing that the origin of popliteus is coming from the lateral side
18:47from there from the femur and then it is coming toward the popliteus muscle so every time this
18:52muscle will contract obviously it will pull the tibia and fibula in this direction that means it
18:59is causing what rotation it is causing the medial rotation it is causing the medial rotation of tibia
19:05and fibula now in locking and unlocking of the knee joint when we talk about locking and locking
19:11if the tibia and fibula are stable so locking and locking are described with respect of the femur
19:16with respect to femur like medial rotation of femur we say it is locking and lateral rotation of the
19:21femur is called as unlocking right but let's say if the foot is in non-weight bearing position
19:27so then we'll talk about the movement of tibia and fibula and not the femur so if i say medial
19:32rotation of femur it is equal to the lateral rotation of tibia and fibula similarly if i say
19:38lateral rotation of the femur it is equal to the medial rotation of the tibia and fibula so either
19:45you say the femur is rotated medially or you say the tibia fibula is rotated laterally it's a one and
19:51the same thing only it depends here talking about in weight bearing or non-weight bearing same story
19:56here when we say the unlocking of the knee joint unlocking of the knee joint usually is described
20:01as it is the lateral rotation of femur on tibia lateral rotation of femur on tibia but that is in
20:08what that is in weight bearing in non-weight bearing let's say the femur is not moving and
20:13we're talking about the movement of the tibia fibula so we'll not say the lateral rotation of
20:17the tibia we'll say the medial rotation of the tibia it is just like the lateral rotation of the femur
20:22only
20:22but that is the description in the non-weight bearing all in all populateus muscle contracts
20:28and that causes the rotation of this the tibia medially and that is what is happening in the
20:35unlocking and that's why the populateus is also called as the muscle of unlocking unlocking muscle
20:39of the knee joint is populateus whereas the locking muscle is the the quadricep muscle more
20:45precisely it's the vastus medialis now in the osteology of the lower limit is also important to
20:50understand that what structures are present in the intercondylar area now what you're looking at
20:54right now guys is the you're looking at the tibia and the fibula from the superior view that's a
20:58superior view of the tibia and the fibula so you can see the the medial tibial condyle you can see
21:03the lateral tibial condyle and obviously you can see the upper end of the fibula also so just just
21:07for the orientation sake first this picture is having here is the anterior you can see the tuberosity
21:14over there the tibial tuberosity tells you that is anterior this is posterior here and we got a lateral
21:20and medial which can very easily be identified just by looking at the tibia and fibula only so
21:24that is lateral and this is medial this area in between is called as an intercondylar area now
21:30between the two condyles we have an intercondylar area and you can see the two elevations in between
21:34we call them intercondylar eminence now there are certain structures which are arranged in a
21:38sequence in the intercondylar area which is a very good question to be asked well if you look at
21:44the medial meniscus let me start with that i'm going to draw this thing for you the medial
21:48meniscus anterior horn will lie in this manner whereas the posterior horn
21:59that's how the medial meniscus is i'm writing mm for the medial meniscus
22:05whereas lateral meniscus is more circular it's a smaller but more circular it's
22:09so when you look at the lateral meniscus the anterior horn and the posterior horn are more
22:13approximated toward each other so that is how
22:22the lateral meniscus will be
22:27so we've got a medial meniscus and the lateral meniscus
22:31so medial meniscus is like more open because it's a larger meniscus
22:35lateral meniscus is a smaller one so it is more circular you can see it is more circular one
22:39and then you will see the the highlighted area here these are showing you the attachment of the
22:43cruciate ligament this here is the attachment of anterior cruciate ligament and this one the
22:49most posterior placed this is the attachment of posterior cruciate ligament here let me write
22:53that here this is acl attachment that is anterior cruciate ligament and that is the attachment of
22:58posterior cruciate ligament we all know that attachment the nomenclature of the cruciate
23:02ligament is based on their attachment on the tibia and not on the femur because on the femur the
23:07direction is exactly other way around. The posterior cruciate will go toward the anterior
23:11side and anterior will come toward the posterior side. So, this nomenclature is based on the
23:15attachment on the tibia itself. Now, what kind of question can be asked from here is about the
23:20arrangement of the structures in the intercondylar area. Now, first you can see there is an anterior
23:25horn of medial meniscus followed by anterior cruciate ligament, followed by the anterior
23:30horn of lateral meniscus, followed by posterior horn of lateral meniscus, posterior horn of
23:35medial meniscus and most posteriorly we have posterior cruciate ligament. So, all these
23:41structures, they are in the intercondylar area. So, if I just write it for you, the mnemonic for this
23:49from the anterior to posterior, from anterior to posterior, if you look at the structures in the
23:56intercondylar area, the mnemonic goes like they say medical college Lucknow, Lucknow Medical College
24:04or medical college, Lahore, Lahore Medical College, whatever suits you. So, MCL and LMC.
24:11So, when I say M here, that means I am talking about which meniscus? Medial meniscus.
24:16Of course, which horn? Anterior horn. That is an anterior side, so anterior horn.
24:20C here stands for cruciate ligament. Again, obviously, which cruciate ligament? Anterior cruciate
24:27ligament. We are still in the anterior part. Then, L is for the lateral meniscus and once again it is
24:34the anterior horn. So, it was all in front of the intercondylar, the tubercles that we saw. So,
24:39everything is anterior here. Anterior horn, anterior cruciate, anterior horn. Then, once again,
24:44we have lateral meniscus again but this time we are in the posterior part. So, it is the posterior
24:49horn. We got medial meniscus. Again, the posterior horn and finally again we got cruciate ligament and
24:58of course, which cruciate ligament? That is a posterior cruciate ligament we are talking about.
25:02So, that is the arrangement of the structures in the intercondylar area of the tibia from anterior
25:07to posterior. Medical college Lucknow, Lucknow Medical College. You can remember it by this way
25:12or simply by looking at the picture here. If you just remember that posterior cruciate ligament is the
25:17most posterior thing and medial meniscus is larger than the lateral meniscus. Even if you don't know
25:22the mnemonic, you can still visualize that what structures would be with. Now, apart from the
25:27certain attachments that we discussed, let me tell you a bit about this interocious membrane. Also,
25:31there is something interesting about that membrane. Just for the recap purpose, to tell you that what
25:37important things that you can appreciate here. Now, this ligament here is guys, this is a tibial
25:42collateral ligament. That's a tibial collateral ligament or you can see the medial collateral
25:47ligament of the knee. And this here is a tibial collateral ligament. It's a tibial collateral
25:53ligament. Basically, it extends just below the adductor tubercle of the femur, if you remember.
25:59And adductor tubercle was giving attachment to the adductor magnus. So, it is believed that tibial
26:04collateral ligament or you can see the medial collateral ligament of the knee joint is an
26:10extension of the tendon of adductor magnus only. It is a remnant of or extension of adductor magnus
26:15tendon. This here is ligamentum patele. This is ligamentum patele, this one. And these are the
26:23cruciate ligament, anterior posterior cruciate ligament. But as I said, our focus right now here
26:28is to this membrane, the interocious membrane. If you look at the interocious membrane, you can see
26:33there are two openings which can be appreciated. You can see an opening in the upper part and opening
26:37in the lower part of this interocious membrane. So, they must be giving passes to something. That's why
26:41we got an opening there. Now, that opening over there is giving passes to the anterior tibial
26:47vessels. The tibial vessels obviously ultimately coming from the popliteal artery only. Popliteal
26:51artery is present posteriorly. So, when it gives off the anterior tibial vessels, they need to come
26:55in front. So, they are not winding around the tibial fibula. They come out from that aperture
26:59which is present in the upper part of interocious membrane. So, guys, this here, let us say,
27:05is the anterior tibial artery and obviously anterior tibial vessels are seen coming out
27:26from the aperture here. Why it is interesting? Just for your orientation sake because the anterior
27:31compartment is supplied by these vessels here. But when it comes to the muscles of the anterior
27:36compartment that which nerve is supplying them, it is supplied by the deep peroneal nerve. Now,
27:42how deep peroneal nerve reaches the anterior compartment? Well, that is not reaching here
27:45from this opening here. As we know that common peroneal nerve, the common peroneal nerve which is
27:50somewhere behind, it winds around this neck of the fibula and once it winds around the neck of the
27:55fibula, this is the one which is giving off the deep peroneal nerve for the anterior compartment
28:00and superficial peroneal nerve supplying the lateral compartment here. So, the nerve here is
28:05what? This is the deep peroneal nerve. This one is superficial peroneal nerve. Of course, this one is
28:11the common peroneal nerve and you can see they are winding around the neck of the fibula.
28:18They are winding around the neck of the fibula. Remember, recently someone asked me this question
28:25why that only common peroneal nerve is involved in case of the fracture of the neck of the fibula and
28:29not the interocious, this, the tibial vessels. Because tibial vessels are not coming that way.
28:35The tibial vessels, they come in front by the aperture in the interocious membrane in the upper
28:38part. Whereas, it is the common peroneal nerve which is winding around the neck of the fibula
28:42gives off superficial peroneal nerve for the lateral compartment and deep peroneal nerve will be supplying
28:47the muscles of the anterior compartment. So, that is how the nerves and vessels are in relation there.
28:53We also have a small aperture in the lower part. We got a blood vessel in the aperture below as
28:57well
28:57in the interocious membrane and that is for the perforating branch, for the perforating branch of
29:05peroneal artery. The aperture in the lower part of interocious membrane is for the perforating
29:12branch of peroneal artery. So, that is a little bit about the interocious membrane there. Now,
29:18there is something very interesting about the tibial fibular joint. Guys, when you look at the
29:21superior tibial fibular joint, middle tibial fibular joint, this one here and the inferior
29:25tibial fibular joint. Superior tibial fibular joint is a facet type of joint. It's a plain
29:30sinuble joint. The joint which is present in the upper part, that is a plain sinuble joint here.
29:35But the middle as well as the inferior tibial fibular joint, both are the example of fibrous
29:40joint. The middle makes sense obviously. There is an interocious membrane. So, obviously, the two bones
29:45are connected to each other by some fibrous structure. So, fine, that is a fibrous joint
29:49only. It is not a sinuble joint. But for information, even the inferior tibial fibular
29:55joint. Now, let me take this portion here and try to show you the tibia and fibula from the inferior
29:59aspect. Let's look at the tibia and fibula from the inferior aspect. Now, that's how they're going
30:03to look like. Let's say inferior of you guys. So, this here obviously is a tibia here and that one
30:08is
30:08the fibula. Now, what do you see? That first of all, if I mark this region for you, that's a
30:13tibia
30:13fibular joint you're looking at. Inferior tibia fibular joint. There is no capsule over there
30:20and there is no, obviously, no sinuble fluid or sinuble lining. Nothing is there. So, no capsule,
30:26no sinuble lining is a sign for what type of joint. It is a fibrous type of joint. There is
30:29no cartilage
30:29even. So, it is not neither cartilaginous joint. What do you see there is we have ligament present in
30:35that region which is connecting the two bones. Now, this ligament here is called as anterior.
30:40Similarly, this is posterior and because both these ligaments are present in the lower part.
30:45So, we have to use the word inferior also. This is anterior inferior and that is posterior inferior.
30:50Well, what ligament? Tibia fibular ligament.
30:57So, we have an anterior inferior tibia fibular ligament and we have posterior inferior tibia fibular
31:02ligament. We have an extension of posterior inferior tibia fibular ligament, that extension of the same
31:08posterior inferior tibia fibular ligament is called as a transverse tibia fibular ligament
31:14which is an extension of the same ligament only. That also is participating in the connection between
31:18the two bones. So, it is the ligaments only which are connecting the two bones. There is no cartilage in
31:25between. There is no capsule. There is no sinuble lining. So, obviously, it is a type of a fibrous joint.
31:30So, looking at these ligaments, we can say that inferior tibia fibular joint,
31:37inferior tibia fibular joint is a type of syndesmosis. Syndesmosis which is a variety of
31:46the fibra joint only. It is a variety of the fibra joint only. It is a syndesmosis. Middle tibia
31:51fibular and inferior tibia fibular is an example of syndesmosis. Superior tibia fibular, if you want to
31:57write that superior tibia fibular is an example of plain sinuble joint. And if I just try to compare
32:03it with the radius and ulnar, superior radial joint and inferior radial joint, they are different.
32:08Like superior radial joint and inferior radial joint, they are the pivot type of joints. They
32:11allow this pronation and supination. So, they are the pivot joints. Middle radial joint is again,
32:16we have interocious membrane. So, that is again a fibrous type of joint. Middle radial is also fibrous.
32:22So, that again could be a good question to be asked, especially on the inferior tibia fibular joint.
32:25It is a type of a fibrous joint, syndesmosis. Now, coming to the skeleton of the foot,
32:31we got to be very precise about that, what kind of questions can be asked from this part and
32:35because you cannot go into the details of every bone in the foot. So, we will be looking at the
32:40articulated foot only, not the individual bones for that matter. And we got to look at important
32:46tuberosities and tubercles which are providing attachment to some important muscles coming from
32:50the leg. As I said in my regular lectures also that when it comes to the sole of the foot
32:57for the
32:57PGM exam point of view, you should remember the name of the layer of sole, the muscles in the
33:02present, the layer of the sole and then innervation, not too much about their attachment. But there are,
33:08as I said, certain muscles which are forming the sling for the plantar arches like tibialis posterior,
33:14tibialis anterior, we got flexor hallucis, digitorum longer. So, how exactly these muscles,
33:19most of these tendons are reaching the foot, certain muscles which are inserting onto the
33:23dorsal aspect and some other few things here and there about certain ligaments that we need to talk
33:28about. So, as I said, we got to keep it very precise. So, just for the nomenclature sake first,
33:35you're looking at the dorsum of the foot guys. This here obviously is the talus bone. You can see
33:39this is the talus. There's the calcaneum on which the talus is placed. In front of the calcaneum,
33:45you can see the cuboid bone. So, there's a joint of this calcaneo-cuboid joint which is a type of
33:49a saddle joint. The calcaneo-cuboid is a type of a saddle joint. Here we have a navicular,
33:56the joint which is present between the head of the talus, navicular and then on the under surface,
34:00we have a calcaneum also. So, that's a tallo-calcaneo-navicular joint. One of the example of
34:05ball and socket joint, the talo-calcaneo-navicular. In front of the navicular, there are three facets
34:11for the cuneiform. As you can see, this here is a medial cuneiform. I'm writing MC here. That is an
34:15intermediate cuneiform and this one here is a lateral cuneiform and you should know out of all
34:21these three, the medial cuneiform is the largest. Though it doesn't look like in this picture because
34:25it is having more extension to be seen from the medial side. Medial cuneiform is the largest cuneiform
34:31here. This one is the largest cuneiform and intermediate is the smallest.
34:40Intermediate cuneiform is the smallest of three. The reason I'm telling you about this cuneiform is
34:46because if you look at the second metatarsal, please pay attention to the second metatarsal.
34:53You can see the second metatarsal is the longest metatarsal. You can appreciate that from the
34:57picture only. It is the longest metatarsal. Well, one of the reason is because the intermediate
35:01cuneiform is short. So, it has to come more proximally. So, it is the longest metatarsal.
35:07Secondly, because the intermediate cuneiform is short, so you can see a kind of socket which is
35:11formed here between the base of first and third metatarsal and the medial and lateral cuneiform.
35:16So, this sort of socket which is formed here will keep the base of the second metatarsal very fixed in
35:23its position. And that is why the most commonly fractured metatarsal is the second metatarsal.
35:29We all know about the march fracture, right? When we say march fracture, we talk about the fracture
35:34of the second and the third metatarsal and most commonly is the second. We got the two reasons for
35:39that and both the reasons are in front of you. One, second metatarsal is the longest and number two,
35:46the second metatarsal, if you look at the base of second metatarsal, it is the most fixed.
35:49So, being a most fixed and the longest metatarsal, it is also easily fractured.
35:57What else, what other important attachments that we can appreciate from this? Let me just
36:01rub this off.
36:06Well, as I said, certain muscles which are coming from the leg and receiving their insertion,
36:10few on the dorsal surface and many on the plantar surface. And we are more concerned about the
36:16muscle which are helping in the inversion or eversion movement. Because those muscles are
36:20not only the plantar and the dorsal flexors, they are also helping in these, the inversion
36:25eversion movements. Now, if you look at this, the navicular bone, on the medial side, there is a
36:30navicular tuberosity here, which is one of the insertion of tibialis posterior. It is one of the
36:39insertion of tibialis posterior that is to the navicular tuberosity. Then an extension that you will
36:44see on the medial side of navicular, medial side of navicular, that is a tibialis posterior muscle
36:49is attached. Although, we will discuss tibialis posterior in the next image, it is having an
36:54extensive attachment to many other bones on the, in the foot. But yeah, one of the attachment is to
36:59the navicular tuberosity. Similarly, if you look toward the lateral side, so obviously the muscle
37:04which are supposed to be present on the lateral side is the peroneus longus, peroneus bravis and
37:10peroneus tertius. Peroneal muscles are the one which are going toward the lateral side.
37:14Now, peroneus longus muscle, again, we will discuss it separately because that muscle will
37:17go toward the plantar surface and will be covering almost all the bones on the plantar surface to
37:22reach the medial side. The muscle that you should remember from this aspect here is on the tuberosity
37:29of this base of fifth metatarsal. This is the fifth metatarsal, of course. This is the fifth metatarsal.
37:34So, this tuberosity on the base of the fifth metatarsal, obviously toward the lateral side,
37:38is for the insertion of peroneus bravis, whereas on the dorsal surface, whereas on the dorsal surface
37:47here, we have insertion for peroneus tertius. The peroneus tertius. So, this is interesting
37:54to understand this, that peroneus bravis, we all know that it is a muscle for the eversion,
38:00it is a muscle of the lateral compartment. So, it is attached to this tuberosity which is toward
38:04the lateral side on the base of the fifth metatarsal. Peroneus tertius muscle, though it
38:09is a muscle of anterior compartment, it is a muscle of the anterior compartment, but it is also inserted
38:13on the same fifth metatarsal. Yes, it is on the dorsal surface, but on the fifth metatarsal only.
38:20And that's why the muscle is not going straight down, it is actually going toward the lateral side
38:23and thereby it can also help in the eversion of the foot. So, apart from peroneus longus and bravis,
38:30which are lateral compartment muscle, definitely helping in the eversion of the foot, even peroneus
38:35tertius can also partly help in the eversion movement. Tendo calcaneal tendon, we all know that
38:44it is attached to the posterior surface of this calcaneal bone. This is a site where we have the
38:49calcaneal tendon. Calcaneal tendon. We all know the tendoachilles, it is a cumulative tendon for the
38:59gastrocnemius, the soleus and the plantaris and that is attached to the posterior surface of calcaneum,
39:04another important attachment. If you look at this talus bone, guys, the talus bone, can you see
39:10those tubercles of the talus behind and there is a groove in between. Now, this groove behind this
39:16talus bone is providing the passage to the tendon of flexor hallucis longus. Now, you got to keep
39:26this flexor hallucis longest tendon in your mind because there are two important bony prominences
39:31to which you see the relation of this tendon. Like one, you can see it is giving between the two
39:36tubercles of talus, the FCH, the FHL tendon is going down and when it goes down, it will go under
39:42a bony projection called a sustentaculum telli. We will discuss that in the upcoming picture.
39:49So, I believe that if it is an image-based question, so they might ask you that especially
39:53from the talus bone and the calcaneum bone that how the tendon of flexor hallucis longus
39:57is related to them. So, it is passing from this groove, this is a groove of flexor hallucis
40:01longus and then this tendon goes down and passes under the sustentaculum telli. Now,
40:06what exactly sustentaculum telli? We will show it to you.
40:11Another important clinical thing that I should tell you here is that there is a ligament which
40:16is present here called as a bifurcate ligament. When you see the dorsum of the foot, there is a
40:20ligament called as a bifurcate ligament which is originating from this non-articular surface
40:24of the calcaneum on the superior aspect here. It is from the calcaneum guys and we call it
40:28bifurcate ligament because it furcates like this and having two stem, having these two
40:35attachments, one is toward the navicular bone on the dorsal surface of navicular and one
40:39is toward the dorsal surface of the medial side of cuboid bone. This is a cuboid bone.
40:44So, this ligament here is called as the bifurcate ligament. So, guys, this bifurcate ligament that
40:52you see which is having two stem, you can see it is one is going toward the navicular,
40:56one is going toward the cuboid. The importance of this ligament is it gets injured in the inversion
41:02injury of the foot. Now, we all know that the most commonly involved ligament in the inversion
41:08injury of the foot is the ligament present on the lateral side of the ankle and that ligament is
41:13called as the anterior talofibular ligament. That is anterior talofibular ligament. Fine. But if there
41:20is an extreme inversion injury of the foot and especially when the foot is in the plantar flex
41:24position, if the foot is in the plantar flex position, so even this bifurcate ligament can
41:29be involved. So, if it is an image-based question or simply a question in which they might ask you
41:35that in which injury the ligament might get involved, the bifurcate ligament, it can be
41:40involved in the inversion injury of the foot. Along with anterior talofibular ligament, the extreme
41:50inversion injury of the foot, especially in the plantar flex foot, the bifurcate ligament can
41:55also be involved. Another good clinical question which can be asked from the talus bone and which
42:02is quite, it is corresponding to the scaphoid bone as well. Now, this is the same thing that we read
42:08in the carpal bones. If you look at the artery which is supplying the talus bone, that artery
42:13actually goes from the distal to the proximal part in this manner. So, the artery supplying the talus
42:19bone, it enters from the distal portion and then going toward the proximal, something like that we
42:22have in the scaphoid also. Therefore, if there is a fracture of the neck of the talus, if there is
42:28a
42:28fracture of the neck of the talus, this portion because it is still having the blood supply can be
42:34spared but the distal portion because the blood supply will go off can undergo avascular necrosis
42:41here. So, this portion of the talus that is a proximal larger part of the talus is the one because
42:48of
42:48this fracture of the neck of the talus can undergo avascular necrosis. Can undergo avascular necrosis and
42:56the reason you already know that because the blood vessel is entering into the talus not from the
43:00distal to proximal but from the, not from the proximal to distal but from the distal to the
43:04proximal part. This is a little bit about some important things, stuff that you should know in
43:10the osteology from the dorsal aspect of this, the foot. Well, let me just turn this over. Let's look
43:18at the foot from the plantar surface and you'll find some other important attachments to be remembered
43:22there. So, I am going to take you to the next picture which is basically the, the plantar view.
43:28Now, you are looking at the plantar view guys. You are looking at the foot from the inferior aspect.
43:32Two, three things to be noted here guys. First of all, look at the calcaneum bone and can you see
43:36this medial projection of the calcaneum here which is sustaining the talus bone. That is the talus
43:41bone over there. So, it is sustaining the talus bone and that is why we call it sustentaculum
43:45tali. So, we call it sustentaculum tali. Let me mark it here only. This extension is called as the
43:59sustentaculum tali. So, it is a part of calcaneum bone but the name, the tali word is into it because
44:04it is sustaining the talus. So, we call it sustentaculum tali. Another very important thing
44:09to be noticed from the plantar surfaces. Now, what bone is that? This is obviously the, the cuboid
44:15bone, the one toward the lateral side. Now, I hope you all can appreciate this groove in the calcaneum
44:19bone, in this cuboid bone. Now, this groove is very important because as we know Peroneus longus
44:25and Peroneus brevis we already discussed that Peroneus brevis is attached to this tuberosity there
44:29to the fifth metatarsal. No harm in marking that again. So, this was the point where the Peroneus
44:34brevis was attached. Peroneus tertius we already said it is on the dorsal aspect of the same metatarsal
44:41toward the base but Peroneus longus tendon when it comes from the lateral side, when it descends
44:46downward from the lateral side, that Peroneus longus tendon will go through this groove of the
44:52cuboid bone, will go toward the medial side and attach to the base of first metatarsal and also to
44:59the medial cuneiform. This is the Peroneus longus tendon which is going through the groove. There is
45:07a groove which is present on the plantar surface of this cuboid bone and ultimately this tendon moves
45:13through this plantar surface and reach the base of first metatarsal. There is a base of first metatarsal
45:21and also to the medial cuneiform. To the medial cuneiform. So, the muscle which is the muscle of
45:31the lateral compartment of the leg, when it comes down from the lateral side, you can see it is
45:35ultimately inserted to the bone which are very much toward the medial side and that makes the
45:40Peroneus longus a very very strong inverter because you can see the muscle is coming all the way down
45:44and then going toward the medial side and that's why the muscle contract, it can bring the entire foot,
45:50produces a lot of torque in that region and bring the foot into the the everted position. It's a very
45:55very strong inverter because of this extended insertion going toward the base of first metatarsal
46:01and medial cuneiform. And a similar kind of thing, similar kind of approach or extended insertion is
46:07also seen by one of the inverter muscles. This is everter also seen by one of the inverter muscles that
46:14is TVLS posterior. Let me use a different picture to tell you more about the TVLS posterior than how it
46:19reaches the bone. I would say from the exam point of view, this groove is very important. They might
46:26ask you that what is present in this groove here and then about the Peroneus longus tendon that
46:30where it is inserted. So, it is not inserted to these metatarsal. I mean, when you think about it
46:34on the lateral side, we think about, okay, they should be going toward some lateral metatarsal. But
46:38no, when they go downward, they go toward the medial and to the most medial metatarsal that is the base
46:43of first one. Now, if, let me use another picture, the same picture exactly, but this time to describe
46:50you about the muscle that is TVLS posterior muscle. Now, before that, you already know this here is
46:57sustentaculum telli and that is a navicular bone. Now, on the plantar surface, guys, please look at
47:02this. On the plantar surface between the sustentaculum telli and navicular, there is a ligament
47:06here. There is a ligament which is stretching in between the two, which is supporting the head of the
47:12talus. Look at that. The blue thing there is a head of the talus only. So, this ligament is
47:16supporting the head of the talus and we call it the spring ligament. This here is a spring ligament.
47:26Based on its attachment, you can say it is also called as a planter. Obviously, it is a planter
47:30surface. Planter calcaneo-navicular ligament. This is planter calcaneo-navicular ligament. It is
47:38present on the plantar surface extending from sustentaculum telli which is a part of calcaneo
47:43only to the navicular bone. Planter calcaneo-navicular ligament and this ligament is very, very important
47:51because this ligament supports, it supports head of the talus. This ligament supports the head of the
48:00talus. It is a major ligament of the medial longitudinal arch, the spring ligament. They do ask
48:05about the attachment of the spring ligament. Well, as I said, my motive here is to tell you about
48:12another important muscle like we saw coming from the lateral side and all the way going toward the
48:15medial side was peroneus longus. Now, the muscle that we will talk about which will come from this
48:20medial side and then will go toward the lateral and other bones in fact in that region is the
48:26tbialis posterior. Now, this muscle, the tendon of this muscle is having an extensive attachment and
48:31this again could be a very good question that to which bone it is attached and to which bone it
48:35is not
48:36attached. Tbialis posterior, let me use a thicker marker for that. Tbialis posterior tendon, first of
48:42all, what you will see, it will be seen attached to the medial margin of the sustentaculum telli. Guys,
48:47look at this. Tbialis posterior tendon coming from this side, it is attached to the medial margin of the
48:53sustentaculum telli, not below the sustentaculum telli, not this groove because this groove that I left over
48:58there, this one here, is giving passage to the tendon of the same flexor hallucis longus.
49:08Just to remind you, flexor hallucis longus, let me take you back what we said here.
49:12Look at that. Flexor hallucis longus was present between the tubercles of the talus bone. I told you
49:18it goes down and when it runs on the plantar surface, that's what we just said, it is seen passing
49:24from
49:25this groove which is present below the sustentaculum telli, below. Because on the medial margin of
49:30sustentaculum telli is the attachment of this tbialis posterior. Not only this, tbialis posterior
49:41tendon will go further, will support the spring ligament from its plantar surface. Another
49:46function, they might ask you this also, that spring ligament is supported from its inferior
49:50aspect by which tendon. So, head of the talus is supported by spring ligament and spring ligament
49:55is supported in turn by the tendon of tbialis posterior. So, let's say, if they say, apart
50:02from spring ligament, what other structure can support the head of the talus or supporting
50:06the head of the talus from the inferior aspect, if the ligament is not in the option, you can
50:10always go with the tendon of tbialis posterior. Then what you will see, we already saw that tbialis
50:17posterior is having an attachment to the navicular tuberosity, that is a navicular bone. So, it
50:21goes to the navicular bone. It gives some extension to this cuboid and keep highlighting these bones
50:28and keep drawing it as well. So, it is giving an extension to the cuboid as well. It gives
50:35attachment to the base of second, third and fourth, second, third and fourth, second, third
50:44metatarsal and all cuneiforms also. All cuneiforms also, this one also. So, I better draw it like this.
50:56This one, this one, this to medial cuneiform, to the lateral and also to the intermediate cuneiform. So,
51:07you can see, basically, in simple words, what we can say, the question is asked about the attachment
51:12of tbialis posterior. It is attached, the tbialis posterior, it is inserted
51:23to all tarsals, to all tarsals, except which one? Except talus. And well, there is no surprise for that.
51:33We know that talus bone is not receiving any tendon. Talus is the, is one of the bone which
51:37is not having any muscle attachment. Ligaments are attached to it, but there is no muscle attached
51:40to it. So, all the tarsal bone, if you look at this starting from here, we saw it is attached
51:46to
51:46the medial surface of sustentaculum tali. So, calcaneum, to the cuboid, to the navicular,
51:53all the three cuneiforms. So, it is attached to all the tarsals except the talus. And it is also
51:59attached to all metatarsals, all metatarsal, except which one? Except first and last. Except
52:09the first one and the fifth one. Second, third and fourth are giving attachment to the tbialis
52:13posterior. So, I believe that this again could be a really good question to be asked that the bones
52:17which are providing or not providing attachment to the tbialis posterior. Peroneus longus and
52:22peroneus brevis, to me, when it comes to the inversion and aversion muscle, the two muscle,
52:26which we should know about attachment, where exactly they are attached to. You should know
52:31about them. Like we said, as peroneus longus was coming from this groove and coming all the
52:35way toward this side, attaching to the base of the first and to this medial cuneiform. Tbialis
52:41posterior, to all of them except first metatarsal, last metatarsal and to the talus. So, this
52:48is a bit about how exactly the tbialis posterior and peroneus longus muscle are to be seen on
52:55the plantar surface. Okay, now let me show you a picture from the medial aspect of the foot. I
53:01believe that when you look at the medial and lateral aspect, the medial aspect of the foot is
53:04having some good questions which can be asked from there. Like here's a picture showing the medial
53:08aspect and let me remind you of something that we already discussed. Now, you can looking at a
53:12calcaneum bone and here's the projection we talked about guys. This here is the sustentaculum
53:17telli. This here is sustentaculum telli. I am just marking it again. This is the sustentaculum
53:28telli. You can see it is supporting the talus. Undoubtedly, this here is a navicular bone, right?
53:35Let me highlight that also and we just talked about the ligament, the spring ligament or the
53:41plantar calcino-navicular ligament was something present in this way. This was the plantar calcino-navicular
53:46ligament, plantar calcino-navicular ligament or the spring ligament.
53:59Just another view of what we discussed and then we said the tendon of flexor
54:02hallucis longus, tendon of flexor hallucis longus was first going between the tubercles of the
54:08talus. So, it would be coming down like this between the tubercles of the talus and then it
54:11comes down it passes underneath the sustentaculum telli like this. This is what? This is flexor
54:18hallucis longus tendon. So, where you can see it is present between
54:27tubercles of the talus
54:30and this here it is present below. It is present below sustentaculum telli. So, it is not attached to it,
54:36it is passing underneath it. Which finally gives us to one more important question here which I
54:44believe is important here that what are the overall attachments of the sustentaculum telli?
54:48Because we can already see one thing attached to it is the spring ligament.
54:51We just discussed that even the TBL is posterior will attach to the sustentaculum telli. So, till now
54:57we can see two things over there but they are not two. There are four things which are attached to
55:01the
55:01sustentaculum telli. For that, let me show you one more picture to conclude this discussion.
55:08So, we are looking at the sustentaculum telli. Again, our focus is on this bony projection.
55:14Well, one is obviously the spring ligament. I just keep drawing it until it is. One is the
55:18spring ligament which is to the most anterior part here. Then you will see TBL is posterior which is
55:24attached to the medial margin and there is another ligament here coming from this talus bone only. We call it
55:31medial tallochalcineal. It is a medial side only medial tallochalcineal ligament
55:36and we have a superficial fibers of the deltoid ligament which are attached here. The deltoid
55:42ligament is one of the one of the strongest ligament that we have in the body. It is a
55:45huge triangular ligament we got and the middle fiber, the superficial fibers are the one which
55:49you will see also attached to the sustentaculum telli like this. Even if you don't remember the
55:55sequence that doesn't matter. What you need to remember the structures attached to the sustentaculum telli
56:00include number one is the spring ligament. Number two on the medial margin we have attachment of
56:07TBL is posterior. One of the attachment of TBL is posterior. Behind that we have attachment of for the
56:15medial
56:19tallochalcineal ligament
56:22and then finally we will see along the lower margin we have attachment of this deltoid ligament.
56:30Deltoid ligament. You know the reason why I am specifically telling you about this bone
56:34affidiction or something because there can be questions formulated from this part. Like as I
56:38already said that spring ligament it's a main ligament for the medial longitudinal arch.
56:42In any way that's a good question to ask because it is supporting the head of the talus.
56:46TBL is posterior. Now if the question is asked like this that the traction of which muscle if
56:52there is a if there is a aversion injury there so the traction of which muscle can cause the fracture
56:56of the sustentaculum telli if the muscle is mentioned there then obviously the muscle attached
57:00the only muscle that you see attached to the sustentaculum telli the answer would be TBL is
57:05posterior. Same story again if there is a the fracture toward this medial side like there's a
57:11the port's fracture is there. In that case well there is a fracture to the proximal bone like
57:15to the medial malulus to the lower end of the tibia. There could be an avulsion fracture of the medial
57:21or this what is a sustentaculum telli also. Although it's a very strong ligament the deltoid ligament
57:26but if there is a rupture of deltoid ligament there are chances it could lead to the avulsion fracture
57:30of the sustentaculum telli or to the medial malulus for that matter. So knowing attachment of
57:36these structures can help you fetch the answer to those question which looks like a clinical question
57:40but there is nothing in it. You know that what is attached to this so obviously the pull of those
57:45structures the tendon the ligament can lead to the the avulsion fracture of this bony projection
57:50the sustentaculum telli. So that's it about the discussion on the lower limb osteology. As I said
57:56I repeat the same thing again guys this discussion is is targeted mainly for the PGME
58:01uh crowd. So I've just like chosen a few important things that you should know about it.
58:07That's why we've like kept our discussion very precise to certain things. Thank you so much.
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