Definições de marcadores esqueléticos

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Belgium, through Serge VAN SINT JAN, has the
full ownership of the 46 pages included in this
document (including all texts, images and
illustrations). Reproduction of any part for
commercial purposes is totally forbidden
without the written approval of the main
author.

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http://www.ulb.ac.be

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

Skeletal Landmark Definitions
by
Serge VAN SINT JAN, PhD

This work has been entirely performed at:

The Department of Anatomy
Faculty of Medicine
University of Brussels - ULB
Belgium

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

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

colleagues (by alphabetical order):
Mr. Christophe CIAVARELLA, MSc
Prof. Véronique FEIPEL, PhD
Prof. Stéphane LOURYAN, PhD
Mr. Jean-Louis LUFIMPADIO, Msc
Prof. Marcel ROOZE, MD, PhD
Mr. Patrick SALVIA, PhD
Prof. Victor SHOLUKHA, PhD
Mr. Stéphane SOBZACK, MSc


Table of Contents

Introduction________________________________________________________________________ 4
Sacral Bone________________________________________________________________________ 8
1. Sacrum - Spinous Process of 2nd sacral vertebrae (SS2)[M]____________________________ 10
Iliac Bone ________________________________________________________________________ 11
2. Iliac bone - Anterior Superior iliac spine (IAS)[R, L] ________________________________ 13
3. Iliac bone - Posterior Superior iliac spine (IPS)[R, L] ________________________________ 14
4. Iliac bone - Ischial Tuberosity, inferior angle (IIT)[R, L]______________________________ 15
5. Iliac bone - Pubic sYmphysis, upper edge (IPY)[M] _________________________________ 16
6. Iliac bone - Centre of Acetabulum (IAC)[R, L] _____________________________________ 17
Femur ___________________________________________________________________________ 18
7. Femur - greater Trochanter Center (FTC)[R, L] _____________________________________ 20
8. Femur - tubercle of the Adductor Magnus muscle (FAM)[R, L] ________________________ 21
9. Femur - Medial Epicondyle (FME)[R, L]__________________________________________ 22
10. Femur - Lateral Epicondyle (FLE)[R, L] ________________________________________ 23
11. Femur - antero-Medial ridge of the patellar surface Groove (FMG)[R, L]_______________ 24
12. Femur - antero-Lateral ridge of the patellar surface Groove (FLG)[R, L] _______________ 25
13. Femur - most distal point of the Medial Condyle (FMC)[R, L] _______________________ 26
14. Femur - most distal point of the Lateral Condyle (FLC)[R, L]________________________ 27
15. Femur - Center of Head (FCH)[R, L] ___________________________________________ 28
Tibia ____________________________________________________________________________ 29
16. Tibia - tibial Tuberosity (TTT)[R, L] ___________________________________________ 31
17. Tibia - Medial Ridge of tibial plateau (TMR)[R, L] ________________________________ 32
18. Tibia - Lateral Ridge of tibial plateau (TLR)[R, L] ________________________________ 33
19. Tibia - Gerdy’s Tubercle (TGT)[R, L] __________________________________________ 34
20. Tibia - Apex of the Medial malleolus (TAM)[R, L] ________________________________ 35
Fibula ___________________________________________________________________________ 36
21. Fibula - ApeX of the styloid process (FAX)[R, L] _________________________________ 38
22. Fibula - Apex of the Lateral malleolus (FAL)[R, L]________________________________ 39
Foot_____________________________________________________________________________ 40
23. Foot/Calcaneus - posterior surface (FCC)[R, L] ___________________________________ 42
24. Foot/Calcaneus - Sustentaculum Tali (FST)[R, L] _________________________________ 43
25. Foot/Calcaneus - Peroneal Trochlea (FPT)[R, L] __________________________________ 44
26. Foot/Metatarsus - Tuberosity of 5th metatarsal bone (FMT)[R, L] _____________________ 45
27. Foot/Metatarsus - 1st, 2nd, 3rd, 4th and 5th head (FM1, FM2, FM3, FM4, FM5)[R, L]_______ 46


Skeletal Landmark Definitions - Guidelines for Accurate and Reproducible Palpation

Introduction
This document presents definitions for the location of anatomical landmarks. Locating anatomical
landmarks is presented using two protocols: 1) manual palpation that allows spatial location of landmarks
when combined to three-dimensional (3D) digitizer, and 2) virtual palpation on 3D computer models
obtained, for example, from medical imaging.
Use of standardized definitions allows better result comparison and exchange; this is a key element for
patient follow-up or the elaboration of quality clinical or research databases. This document presents accurate
skeletal landmark definitions to help her/him achieving the above goals with better precision, higher
reproducibility and therefore, in most cases, less data post-processing.
This book includes description for both manual palpation, i.e. using fingertips, and virtual palpation, i.e.
using a computer input device like a mouse. Both manual and virtual descriptions of the same landmark have
been written in order to allow a palpator (i.e., the individual performing the palpation) to decrease the
difference resulting from both kinds of palpation protocols. This should also lead to better results if
combination of landmarks from both palpation protocols must be performed.
Finally, this guidebook would like to emphazise that palpation is an Art, and requests serious practise
before reaching acceptable accuracy. Unfortunately, palpation is often see as a secondary task probably
because it is cheap, simple of conception (compared to the costly high-tech hardware used for medical
imaging or to collect motion data) and does not require complicated setting (unlike some state-of-the-art
pieces of electronical equipment). The truth is different: spatial location of anatomical landmarks is
necessary for fundamental operations. For example, to measure some bone parameters, to define anatomical
frames in clinical motion analysis, or to perform data registration. Inacurracy in landmark selection will
always lead to serious discrepancies in the interpretation of the data whatever the quality of the hardware used
for measurements.
This document will help the reader to strive into that direction thanks to detailed definitions and
instructions related to palpation of skeletal landmarks. Each landmark is described in a way to increase the
reproducibility of its spatial location.

Warnings
One of the necessary conditions of efficiency of definitions is of course that they are scrupulously
followed to obtain reproducible results. It is also assumed that the palpator is seriously experienced with both
Human Anatomy and Palpation. The present guidelines aim at proposing accurate definitions to allow a better
repeatability and communication between scientists. On the other hand this document is neither a Human
Anatomy textbook, nor a guide to learn Manual or Virtual Palpation. The Art of Palpation should be obtained
from other sources, if possible, before using the following definitions.
The description given in the text for manual palpation assumes that the individual performing the
palpation (named as “the palpator”) uses a special table like those used by physiotherapists to manipulate

©
patients. The authors advise to use such table to perform better palpation by allowing the palpated subject to
be in a comfortable position. Muscle tension would therefore be decreased and bony landmarks will be better
palpable. Relative position of both palpator and palpated subject given in the following descriptions are

Copyright ©: the University of Brussels (ULB) 4
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indicative althought they are probably the most convenient ones. However, some environments might not let
applying these working position strictly (for example, some settings adopted in a motion analysis lab).
Some areas to palpate manually can be painfull, especially where muscles or ligaments are attaching.
Sensitive landmarks are indicated in the text. Manual palpation of these landmarks should be gently
performed to avoid reactions of the individual being palpated that could compromise any further palpation.

New ideas ? Please, send them !
The hope of the author is to keep this document updated with new definitions to follow new
standards and conventions. Therefore, feel free to communicate ideas to improve or to update the content of
this document.
Enjoy the reading!
Serge VAN SINT JAN

Copyright ©: the University of Brussels (ULB)
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Bone description
Landmarks are presented by bone. Each bone section starts with a general presentation of the current bone
including both bone orientation and a rough description of the position of the bone features used as
anatomical landmarks in this document.

Landmark description
Each anatomical landmark is described in various ways (spatial location, manual palpation, and virtual
palpation) that are related to one another and show some complementary. These descriptions are presented in
table format (page 7).
All landmarks are related to bony areas that can be palpated in a clinical or research context. Some landmarks
are recommended by the various standardization committees of the International Society of Biomechanics
(ISB, see http://www.isbweb.org/standards/index.shtml)1 in order to define both local and joint coordinate
systems. Description of such landmarks is indicated by the ISB logo (Figure 1, top). A few of these
recommended landmarks are, according to the author, difficult to palpate manually. Although palpation
directions are given, a warning sign (Figure 2) indicates that manual palpation is not accurate (one warning
sign indicates that manual palpation is approximate, two warning signs indicates that accurate manual
palpation is irrealistic).

Figure 1. ISB logo

Figure 2. Warning signs. Accuracy of such landmark location is
either low (one sign) or very poor (two signs).
Two signs also indicate that further experimental research
should be performed to validate the given definition.
Such definitions have been given, despite the inaccuracy,
because these landmarks are either recommended in the
literature or accessible by palpation but not in an accurate way.

1
Also see:
- Wu, G., Cavanagh, P., 1995. ISB recommendations for standardization in the reporting of kinematic data. J.
Biomech. 28, 1257-1261.

©
- Wu, G., Siegler, S., Allard, P., Kirtley, C., Leardini, A., Rosenbaum, D., Whittle, M., D'Lima, D., Cristofolini,
L., Witte, H., Schmid, O., Stokes, I., 2002. ISB recommendation on definitions of joint coordinate systems of
various joints for the reporting of human joint motion - Part I: ankle, hip, spine. J. Biomech. 35, 543-548.
- Wu, G., van der Helm, F.C., Veeger, H., Makhsous, M., Van Roy, P., Anglin, C., Nagels, J., Karduna, A.,
McQuade, K., Wang, X., Werner, F., Buchholz, B. IN PRESS. ISB recommendation on definitions of joint
coordinate systems of various joints for the reporting of human joint motion - Part II: shoulder, elbow, wrist and
hand. J. Biomech.
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Table format used for landmark description

Landmark Name (Landmark Acronym) [side prefix : R, L, M].
“Landmark Name” indicates both bone and landmark name.2
“Landmark acronym” proposes a 3-character acronym for the current landmark.3
“side prefix” indicates if the current landmark is even or odd.4

[link to relevant illustrations] A general anatomical definition to allow the
location on a dried bone is given.

Manual Palpation

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

Virtual Palpation

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

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

2

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For example: « Femur - Greater Trochanter ».
3
For example: « FTc » for the center of the great trochanter. Each acronym is unique and redundancy has been avoided
when writing this document. Using the given acronyms will make sure that all landmarks have different acronyms. Note:
the first letter of the acronym is the same as the first letter of the related bone (except for the hand).
4
Even markers are characterized with either « L » or « R » (left and right respectively), while odd markers are given by
« M » (i.e., middle). The full acronym of each landmark is therefore a 4-character string, e.g. « LFTc » for the center of
the left great trochanter.
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Sacral Bone
Orientation and general presentation (Figure 3 and Figure 4:
The sacral bone has a triangular shape; its base (1) is oriented proximally, while the apex (2) is distal. The
sacral bone is the result of the fusion of five sacral vertebrae (S1 to S5). Therefore, many characteristics of
this bone are related to features of a ‘normal’ vertebra. The median sacral crest (3) is actually the result of
the fusion of the spinous processes of the primitive sacral vertebrae. This crest is made of at least three
prominences, i.e. spinous processes (S1, SS2, S3). Note the spinous process of S2 is along a horizontal line
passing through the posterior superior iliac spine of the iliac bone (see this bone, page 11). Both posterior and
anterior faces show 4 pairs of sacral foramens (4) (only a few foramens are indicated on the illustrations).
The coccyx (5) is below the sacral bone. Other structures: iliac bones (6), femurs (7).

6
6 1
S1
SS2
3
4 S3
4

2
7 5 7 5

Figure 3. The sacral bone (3D model). Left (anterior view, slightly lateral): location in the pelvis. Right (posterior
view): sacral bone.

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6 1 6
4
5

7

7

1

S1

SS2
3
4
S3

2

Figure 4. The sacral bone (anatomical specimen). Top (anterior view, slightly lateral): location in the pelvis.
Bottom (posterior view): posterior aspect.

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1. Sacrum - Spinous Process of 2nd sacral vertebrae (SS2)[M]
Posterior eminence on the posterior aspect of the
Figure 3 and Figure 4, structure SS2. sacral bone.

SS2
S
L5 1
L4

The subject is lying prone. The palpator standing at the subject’s pelvis, one hand placed flat on the lateral
surface of the pelvis (left hand on 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 4th lumbar vertebra (L4).
With the forefinger of the opposite hand, glide down on the spinous process of the 5th lumbar vertebra (L5).
Keeping down, the next two bony eminences are respectively S1 and SS2.
Control of the selection can be obtained by verifying that the horizontal projection of a line starting from SS2
runs through the posterior superior iliac spine (see IAS, page 11).
Turn the sacral bone in
posterior frontal view.
Locate the median sacral
S1 crest. Along this crest,
S1
select the top of the second
spinous process S2, just
SS2 proximal to a horizontal
plane running through the
2nd pair of posterior

SS2 foramens (dotted blue line).
Then, turn the bone along a
lateral view and control the
selected point is on the S2
apex.

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Iliac Bone
Orientation and general presentation (Figure 5 and Figure 6):
To orient the iliac bone, turn the acetabulum (IAC) laterally, the obturator foramen (1) below, and behind
the greater sciatic notch (2). The iliac crest (3) is on top. The sharp anterior superior iliac spine (IAS) is
located on the anterior aspect of 3. The posterior superior iliac spine (IPS) is located on the other side of 3
and is less sharp. The postero-inferior aspect of the iliac bone shows a large tuberosity: the ischial tuberosity
(IIT). Both iliac bones articulate anteriorly by the pubic symphysis (IPY). Each iliac bone articulates with a
femur (4) by the joint surface located into IAC. This crescent-shaped joint surface is called the lunate
surface (5).

3

IAS

IAC

4 4
3 IPY 3

IAS

IPS
IPS
2 5 2

IAC 1
1 IPY
IIT
IIT

Figure 5. The iliac bone (3D model). Top (anterior view): position in the pelvis. Bottom left (lateral view) and
bottom right (medial view): isolated bone.

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IAS

IAC IAC
4
IPY 4 A 4 B IPY 4

C D

IPS

IAS
2
IAS

IIT
E IAS

F

5

1
IAC
IIT 1
IPY
Figure 6. The iliac bone (anatomical specimens). A (antero-lateral view) and B (anterior view): position in the
pelvis. C (latero-superior view): superior landmarks. D (latero-inferior view): the ischial tuberosity. E (anterior

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

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2. Iliac bone - Anterior Superior iliac spine (IAS)[R, L]
Prominent anterior and superior end of the
Figure 5 and Figure 6, structure IAS. iliac crest.
The subject is lying supine. The palpator
facing the subject’s pelvis.
Place your hand on the subject’s hip on the
side concerned, with your fingers on the
anterior part of the iliac crest. Follow the
anterior part of the iliac crest forwards
IAS (dotted blue arrow).
At the anterior extremity of the iliac crest,
your thumb will feel a prominent bony bump
under which it can get around, below and to
the side. This is IAS.
[note: IAS is just under the skin and is usually easily
palpable; however, this procedure may be more
difficult on obese subjects.]

Observe the iliac bone from a lateral point of
view. Follow anteriorly the anterior part of
the iliac crest until IAS (dotted blue arrow).

IAS

Then turn the model 90° to an anterior frontal
view, and make sure the selected landmark is
IAS correctly located on the center of AS.

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3. Iliac bone - Posterior Superior iliac spine (IPS)[R, L]
Prominent posterior and superior end of the
Figure 5 and Figure 6, structure IPS. iliac crest.

The subject is lying prone. The palpator
standing at the subject’s pelvis, hand placed
flat on the lateral surface of the pelvis.
Place your thumb on the posterior part of the
IPS
iliac crest. Move backwards over the iliac
crest just to the point where the thumb feels a
prominent bump: IPS.

Observe the iliac bone from a
lateral view. Go backwards
(dotted blue arrow) on the
posterior part of the iliac crest
until IPS is met.

IPS

Next, rotate the model 90° along
a posterior frontal view, and
control the selected landmark is
correctly located on the center of
IPS the posterior spine.

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4. Iliac bone - Ischial Tuberosity, inferior angle (IIT)[R, L]
Figure 5 and Figure 6, structure IIT. Large posterior tuberosity of the ischium.

The subject is lying prone. The palpator stands next
to the subject’s knees.
Place your forearm along the thigh axis, and the hand
flat on the lateral part of the buttocks-thigh junction
IIT
(i.e., buttocks fold, dotted blue line). With the thumb,
spread from the hand, goes up and pass under the
inferior edge of the gluteus major muscle. The thumb
reached the inferior angle of the ischium (IIT).

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

Observe the iliac bone from a
posterio-lateral point of view. Follow
both medial and lateral edges (dotted
arrows) of the ischium to their
intersection, which is ITT.

IIT
To verify your selection, turn the
model approximately 45° towards
the back of the screen. The selected
point should be on the angle made by
the medial and lateral edges of the
ischium.

IIT

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5. Iliac bone - Pubic sYmphysis, upper edge (IPY)[M]
The pubic symphysis is the anterior joint
Figure 5 and Figure 6, structure IPY. between the two iliac bones.

The subject is lying supine. The palpator
standing next to the subject’s pelvis, hand
IPY placed flat on the belly.
Put one thumb on the central part of the
belly above the pubic symphysis. With the
thumb, gently depress the belly and glides
down towards the pubic symphysis (blue
dotted area).
Find the upper edge of the latter and select
its anterior part.

IPY is not directly observable
on a 3D bone model and must
be interpolated.

At first, turn the iliac bone to
an anterior frontal view. Select
a point on each iliac bone next
to the pubic symphysis.

Next, turn the bones to an

RIPY LIPY upper view, and check both
selected landmarks (LPY and
RPY) are correctly located on
the anterior edge of bone.

IPY is the average of the
spatial coordinates of both
RIPY LIPY LIPY and RIPY landmarks.

[note: IPY is usually not directly
available from CT imaging because

©
it is made of fibrous tissu and
cartilage, which are not very X-ray
sensitive. This explains the gap
visible between both iliac bones on
the illustrations.]

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6. Iliac bone - Centre of Acetabulum (IAC)[R, L]
The acetabulum is the hip component of the hip joint.
Figure 5 and Figure 6, structure IAC.

This point is not palpable and is found after interpolation only. Because of the limitations of the manual palpation, IAC is
assumed equal to the centre of the femoral head (see FCH landmark, page 28). This is not the case when using virtual
palpation (see below).

An estimation of IAC can be found by averaging
the spatial coordinates of the following 6 ACi
points all located along the circumference of the
AC4 AC3 lunate surface (Figure 5, structure 5) within the
acetabulum:

AC5 AC2 1. anterior edge of the lunate surface (AC1).
2. center of anterior wall (AC2).
3. anterior part of roof (AC3).
AC6 4. posterior part of roof (AC4).
AC1
5. center of posterior wall (AC5).
6. posterior edge of the lunate surface (AC6).

AC3 AC4
AC5
AC2

AC1 AC6

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Femur
Orientation and standard presentation (Figure 7 and Figure 8):
The head of the femur (FCH) is oriented upwards and medially; it is part of the hip joint (1). The femoral
head is linked to the greater trochanter (FT) by the femoral neck (2). The inferior epiphysis shows a
posterior notch: the intercondylar notch (3). On both sides of the latter are the lateral (FLC) and medial
(FMC) condyles. Each condyle shows an epicondyle (FLE or FME). The lower part (anterior aspect) of the
femur supports the patellar groove (4) making up the femoral-patellar joint. This groove shows two edges:
one lateral (FLG) and one medial (FMG).
FT FT
2 2

1 FCH

FME

FLE
FLE

4 FME 3
FLG FMG
FME
FLE

4

FLC FMC
Figure 7. The femur (3D model). Top left (anterior view): femur with pelvic bone, patella and tibia. Top center
(anterior view) and top right (posterior view): isolated bone. Bottom left (anterior view), bottom center (anterior
view), bottm right (medial view): distal epiphysis.

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3


FT
FCH
FCH

FT
FT
2

FME

A B C D
E F G H
FLG FMG
FLE FME FLE
4
3

FLC I FLC
FMC FPS

FLC

FME

FMC
Figure 8. The femur (anatomical specimen). A (anterior wiew) and B (posterior view): full bone. C (anterior view)
and D (lateral view): proximal epiphysis. E (anterior view), F (medial view), G (posterior view), H (lateral view)
and I (distal view): distal epiphysis.

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7. Femur - greater Trochanter Center (FTC)[R, L]
Massive quadri-angular tubercle that extends to the top of the
Figure 7 and Figure 8, structure FTC. lateral face of the femoral diaphysis. It has three edges:
superior, anterior and posterior.

FTC

The subject is standing and the palpator behind him. The subject’s leg is slightly flexed and in abduction (foot on a
support).
Place first one thumb on the iliac crest (dotted line); the little finger meets the great trochanter. Once this performed, a
more accurate palpation is done with the three first fingers.
Both thumb and middle fingers pinch the greater trochanter on its posterior and anterior edges respectively. Place the
index finger in the middle of the virtual line traced between the thumb. The FTC landmark is pinpointed by the index
finger between both thumb and middle finger.
[note: with accuracy when soft tissue is well-develloped.]

Turn the femur to a lateral view (in this position the femoral
head is normally pointing forwards and both condyles are
aligned).

Locate the center of both anterior and posterior edges (dotted
FTC lines) of the great trochanter. The FTC landmark is located at
the center of the great trochanter between both edge centers.

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8. Femur - tubercle of the Adductor Magnus muscle (FAM)[R, L]
Bony spine situated on the superior edge of
Figure 7 and Figure 8, structure FAM. the medial condyle of the femur.
The subject is lying supine, knees extended,
the palpator at the subject’s knees.
Place the palm of the medial hand on the
FAM proximal tibial epiphysis in order to have
both fourth and fifth finger located behind the
knee. The second and third fingers of the
medial hand searches for the tendon of the
adductor magnus muscle (dotted blue arrow).
Followed the latter until FAM is reached.
[note: this tendon insertion is sometimes sensitive.]

Observe the femur from a
posterior (slightly medial)
view.
FAM
FAM FAM is on the center of a
protuberance above the
medial condyle.

Turn to a posterior view
to verify the selection.

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9. Femur - Medial Epicondyle (FME)[R, L]
This surface shows a small tubercle for the
Figure 7 and Figure 8, structure FME. medial collateral ligament of the knee.

The subject is lying supine, knee extended.
Place the thumb on FAM (see page 21) and
FME the middle finger on the knee joint (vertically

FAM along the virtual line running through FAM).
Place the index finger midway between the
thumb and the middle finger and move it
slightly forwards (towards the patella). The
index finger should locate a small tubercle,
which is FME.
[note: this point can be sensitive.]

FAM View the distal epiphysis from a
medio-sagittal view.
Find the center of the medial condyle
at the intersection of the following
virtual lines:
− a vertical line starting at
FAM (see page 21),
FME − an horizontal line passing
by the centre of the
posterior and anterior edges
of the condyle.
In relation to this intersection, the
landmark to select is found slightly
FME
forwards.
Verify the validity of the landmark
by turning the bone in a posterior-
frontal view. Check the selected
point is on the apex of the condyle.

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10. Femur - Lateral Epicondyle (FLE)[R, L]
The lateral condyle is a bony surface located
Figure 7 and Figure 8, structure FLE. laterally on the distal epiphysis of the femur.
This surface shows a crest.

The subject is lying supine, knee flexed.
FLE
Put your finger in the knee joint space and
glide backwards until you meet the lateral
collateral ligament. Follow the ligament up to
its proximal insertion point, which is the
FLE.

Observe the distal epiphysis from a lateral
point of view.
Locate a bumpy tubercle near the centre of
the lateral condyle. This tubercle is along a
horizontal line running between the furthest
FLE points of the condyle. Select the apex of the
tubercle (FLE).

Once the tubercle in selected, observe the
selection from an antero-frontal point of view
to control that FLE is on the apex of
FLE
epicondyle.

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11. Femur - antero-Medial ridge of the patellar surface Groove (FMG)[R, L]
Bony angle located in the upper medial area of the
Figure 7 and Figure 8, structure FMG. patellar surface.

The subject is lying supine, knees extended.
With the thumb of the proximal hand on the
central part of the lateral edge of the patella,
push the patella laterally (dotted blue arrow).
FMG The thumb of the distal hand passes under the
patella, and palpates the sharp edge of the
patellar groove until an angle is found: FMG.

Observe the distal epiphysis from an antero-
frontal view.
FLG From the most distal point of the inner edge of
FMG the patellar surface, follow this edge up (dotted
arrowed line). This inner edge bends forming an
angle; this angle is FMG.

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

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12. Femur - antero-Lateral ridge of the patellar surface Groove (FLG)[R, L]
Bony angle located in the upper lateral area of the
Figure 7 and Figure 8, structure FLG. patellar surface.

The subject is lying supine, knees extended.
With the thumb of the proximal hand on the central
part of the lateral edge of the patella, push the
patella medially (dotted blue arrow). The thumb of
FLG the distal hand passes under the kneecap, and
palpates the patellar groove until an angle is found:
FLG.

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

Place the distal extremity of the femur in an
anterior-frontal view.
FLG
From the most distal point of the lateral edge of the
FMG patellar groove, follow this edge up (dotted
arrowed line). This edge bends forming an angle;
this angle is the FLG.

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

© 25
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13. Femur - most distal point of the Medial Condyle (FMC)[R, L]
The point is located on the distal extremity of
Figure 7 and Figure 8, structure FMC. the medial condyle of the femur.

The subject is lying supine, with the hip
FMC flexed (100°) and the knee bent (120°). The
hip flexion compensates partially for the
quadriceps tension resulting from the knee
flexion. This facilitates the palpation of the
landmark.
Follow the medial edge of the patellar tendon
(dotted blue arrow) and follow it until you
reach the knee joint space. Press the thumb
into the joint cavity to palpate FMC.
[note: FMC is difficult to palpate with accuracy
because of the presence of the infrapatellar fat pad
filling the space behind the patellar ligament.]

View the femur from a medio-
sagittal view with the femoral shaft
FMC vertical.

Rotate the femur along the plane
perpendicular to the screen and
visualize the distal aspect of the
bone in a horizontal view. Select the
center of the medial condyle.

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

©
FMC

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14. Femur - most distal point of the Lateral Condyle (FLC)[R, L]
The point is located on the distal extremity of
Figure 7 and Figure 8, structure FLC. the lateral condyle of the femur.

The subject is lying supine, with the hip
flexed (100°) and the knee bent (120°). The
hip flexion compensates partially for the
quadriceps tension resulting from the knee
flexion. This facilitates the palpation of the
FLC landmark.
Follow the lateral edge of the patellar tendon
(dotted blue arrow) and follow it until you
reach the knee joint space. Press the thumb
into the joint cavity to palpate FLC.
[note: FLC is difficult to palpate with accuracy
because of the presence of the infrapatellar fat pad
filling the space behind the patellar ligament.]

FLC View the femur from a latero-sagittal
view with the femoral shaft vertical.

Rotate the femur along the plane
perpendicular to the screen and
visualize the distal aspect of the bone
in a horizontal view. Select the center
of the lateral condyle.

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

FLC

© 27
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15. Femur - Center of Head (FCH)[R, L]
Spherical structure located on the proximal
Figure 7 and Figure 8, structure FCH. epiphysis of the femur. It is part of the hip joint.

This point is not palpable and is found after interpolation (Bell
LIPS et al., 1990, Journal of Biomechanics, 23:617-621):
RIPS
• At first, a pelvic frame is defined: Op is the origin located
LIAS between both LIAS and RIAS (see page 13 for description); Zp is
RIAS oriented as the line passing through both IAS’s pointing from left
Op to right; Xp lies in the plane defined by both IAS’s and the
midpoint between the LIPS and RIPS (see page 14), Xp points
forwards; Yp is orthogonal to the XZ plan.
• RFCH and LFCH are given by: x = -019D; y = -0.3D; z = i 0.36
D, where D = distance between both IAS’s, i = -1 for LFCH and
RFCH LFCH i = 1 for RFCH.

FCH1
A good estimation of FCH can be
FCH2 found by averaging the spatial
FCH5 coordinates of the following 6 points
FCH4
all located around the femoral head:
1. top (FCH1).
2. anterior (FCH2).
FCH6 3. bottom (next to the neck)(FCH3).
4. posterior (FCH4).
FCH3 5. lateral (above the neck)(FCH5).
6. medial (FCH6).

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

FCH

© 28
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Tibia

The proximal epiphysis of the tibia shows the tibial plateau (1). The plateau shows two well-marked edges:
one lateral (TLR) and one medial (TMR). Two tubercles are visible on the plateau: the lateral
intercondylar tubercle (2) and the medial intercondylar tubercle (3). Anteriorly, a sharp tibial crest (full
line) is easily observable. The tibial tuberosity (TTT) is observable at the proximal end of the tibial crest.
From TT, two crests climb upwards towards the tibial plateau; the lateral crest (dotted line) is usually
sharper than the medial one. The Gerdy’s tubercle (TGT) is along the latter crest. The distal epiphysis
carries the medial malleolus (TAM).

2 3 2
3
TLR
1 TLR
1
TGT TMR

TT

TAM

©
Figure 9. Tibia (3D model). Left (ventral view, slightly medial) and right (dorsal view): isolated bone.

ulb


TMR TLR

1 1

TTT
TTT

A B C
1
TMR TLR
3
2
TAM

TMR
TLR

TGT

TTT D E

TAM
Figure 10. Tibia. A (anterior view) and B (posterior view): general view. C (proximal view): the tibial plateau. D
(anterior view): proximal epiphysis. E (medial view): the medial malleolus.

© 30
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16. Tibia - tibial Tuberosity (TTT)[R, L]
Three points are palpated.
Figure 9 and Figure 10, structure TTT Prominent oval tuberosity located at the
superior extremity of the anterior tibial
aspect. The patellar tendon inserts on this
tuberosity.

The subject is lying supine, knee extended.
Gently pinch the patellar tendon between the
thumb and the middle finger; follow distally
the tendon until its insertion on the tibial
tuberosity.
The thumb and the middle finger are located
on each side of the tuberosity on its lateral
and medial edges respectively.
TTT
Once this manoeuvre is completed, place the
index finger between the thumb and the
middle finger; this is TTT.

View the upper extremity of the tibia from
an anterior view; locate a bony oval bump

TTT on the anterior and proximal aspect of the
tibia: the tibial tuberosity.

The center of both lateral and medial
edges of the tuberosity are first located.

Then, find TTT at the intersection of an
horizontal line running through both
above-located points.

© 31
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17. Tibia - Medial Ridge of tibial plateau (TMR)[R, L]
Point situated on the medial edge of the tibial
Figure 9 and Figure 10, structure TMR. plateau and the furthest point from the medial
intercondylar tubercle.

The subject bends his knee to 90°; the
palpator is in front of the subject.
Place the 1st and 3rd fingers on the lateral and
medial edges of the patellar tendon
respectively (at the level of the tibial plateau).
TMR The two fingers then glides backwards along
the tibial plateau and reach for the greatest
distance between both fingers. Once the
greatest distance is found, press the middle
finger on the surface of the tibial plateau to
find TMR.

Orientate the tibial plateau in a superior
horizontal view. Draw a line running through
2 both lateral and medial intercondylar
3
tubercles (2 and 3, respectively, see also
Figure 9). TMR is the most medial point of
that line on the edge of the tibial plateau.

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

© 32
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18. Tibia - Lateral Ridge of tibial plateau (TLR)[R, L]
Point situated on the lateral edge of the tibial
Figure 9 and Figure 10, structure TLR. plateau and the furthest point from the lateral
intercondylar tubercle.

The subject bends his knee to 90°; the
palpator is in front of the subject.
Place the 1st and 3rd fingers on the medial and
lateral edges of the patellar tendon
TLR
respectively (at the level of the tibial plateau).
The two fingers then glides backwards along
the tibial plateau and reach for the greatest
distance between both fingers. Once the
greatest distance is found, press the middle
finger on the surface of the tibial plateau to
find TLR.
[tip: if possible locate both TLR and TMR (see page
32) simultaneously.]

2 3 Orientate the tibial plateau in a superior
TLR
horizontal view. Draw a line running through
both lateral and medial intercondylar
tubercles (2 and 3, respectively, see also
Figure 9). TLR is the most lateral point of
that line on the edge of the tibial plateau.

TLR

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

© 33
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19. Tibia - Gerdy’s Tubercle (TGT)[R, L]
Tubercle located on the lateral aspect of the
Figure 9 and Figure 10, structure TGT. tibial tuberosity. The iliotibial tract of the
fascia lata inserts on this tubercle.

TTl
Locate first the lateral edge of the
tibial tuberosity, (TTl, page 31). Then,
from this point, two bony ridges start:
one medial and one lateral. Follow the
TGT
lateral one until a thick tubercle is
located: this is TGT.

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

TGT

View the upper extremity of the tibia from
an anterior view; locate first TTl (see page
31). From TTl, follow a curved bony edge
(dotted blue arrow) running laterally
upward until a tubercule (its development is
variable) is found: TGT.
TTl

© 34
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20. Tibia - Apex of the Medial malleolus (TAM)[R, L]
The medial malleolus, located distally on the
Figure 9 and Figure 10, structure TAM. medial aspect the leg, is larger, less prominent, and
shorter than the lateral malleolus.

The subject is lying supine, the palpator
facing the subject’s leg.
Place the 1st and 2nd fingers on the anterior
and posterior aspects of the medial malleolus
respectively.

TAM Move both fingers distally along the
malleolus edges. The fingers when both
edges are joining (white dot in image): the
junction point is TAM.
[note: the palpated point is not strictly spoken the
real apex of the malleolus; indeed the latter is located
deeper in the soft tissue. This must be kept in mind if
virtual palpation is also performed (see below).]

View the lower part of the
tibia along medio-sagittal
view. Select a point of the
TAM malleolus slightly above its
apex.

Then, turn the tibia to a distal
horizontal view. Verify that
the selected point is located
TAM slightly medially next to the
real apex of the medial
malleolus.

© 35
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Fibula

The fibula is located lateral and posterior to the tibia. The distal epiphysis (1) is flatter than the proximal
epiphysis (2). The distal epiphysis shows the lateral malleolus (FAL). The articular facet of the talofibular
joint (3) is oriented medially, while the malleolar fossa (4) of the lateral malleolus is located behind the joint
surface. The fibula head has a styloid process (5) pointing upwards and showing a sharp fibula apex (FAX).
Vertically below the lateral aspect of the head, the lateral edge (dotted line) runs downwards.

FAX
FAX
2 2
5

3 1
1
4
FAL
Figure 11. Fibula (3D model). Left (lateral view): fibula and tibia (semi-transparent). Right (medial view): isolated
fibula.

© 36
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2

A

3
4
FAX
B C

2

1

FAL

Figure 12. Fibula (anatomical specimen). A (medial view): general view. B (lateral view): proximal epiphysis. C
(lateral view): distal epiphysis.

© 37
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21. Fibula - ApeX of the styloid process (FAX)[R, L]
Bony eminence located on the dorsal aspect
Figure 11 and Figure 12, structure FAX. of the fibula head (structure 2, Figure 11).
Both biceps femoris muscle and lateral
collateral ligament insert on the head next to
styloid process.

The head of the fibula is visible under the
skin when the knee is flexed with an internal
rotation of leg.
FAX
The subject, lying supine, flexes his knee at
about 90°, the palpator standing slightly
lateral in front of the knee.
Follow the tendon of the femoral biceps
(dotted blue arrow) with your index finger
until its insertion. FAX is the most lateral and
posterior part of the fibula head next to the
tendon.
[note: the palpated point is not strictly spoken the
real apex of the fibula head; indeed the latter is
located deeper within the tendon of the femoral
biceps. This must be kept in mind if virtual palpation
is also performed (see below).]

FAX
Observe the proximal epiphysis of the
fibula along a lateral sagittal view.
Select a point slightly below the apex of
the styloid process.

Then turn, the bone in a proximal
horizontal view and verify that the
selected point is located slightly
laterally to the apex.
FAX

© 38
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