anatomy of ankle & foot - sono.or.krsono.or.kr/data/evts/201302/20130511_05.pdf · 1. distal...
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Chang-Hyung Lee, M.D., Ph.D.
Anatomy of Ankle & Foot
Ankle
Introduction
Most frequently injured major joint
3 main articulation: distal tibiofibular j (syndesmotic)
ankle j (talocrural)
subtalar j (talocalcaneal)
Coronal View of ankle js.
1. Distal Tibiofibular joint
Tibiofibular syndesmosis
Upward 3~5 mm prolongation of the synovium of the ankle j
Distal focal thickening of the inteross. Memb
Interosseous lig.
Ant.& pot. Tibiofibular lig., transverse lig.
2. Ankle Joint Articular surface of the talar dome, distal ends of the tibia &
fibula , covered with cartilage
Hinge type: dorsiflexion : ~ 30◦ DF, ~50 ◦ PF
In extreme PF: some lateral motion is allowed
(Ankle mortis - post. Half talar dome is narrower than ant.
Half )
Supporting structures: fibrous capsule, MCL, LCL
Capsule: medial & lateral malleoli, acetabular margin of the
tibia, talus
2. Ankle joint: LCL complex
Lateral Ligament Complex
Ant. Tibio-fibular l.
ATFL
CFL
Pos. Talofib.L
Transverse Tibiofibular
Pos. tibiofibul. L
ATFL : least strong, m/c injured prevents ant.talar motion
CF : longest prevents excessive inversion
PTF: strongest,deepest prevents post. Talar shift
2. Ankle Joint : MCL complex
2. Ankle Joint : MCL complex
Tibiotalar
Tibiocalcaneal
Tibionavicular
Superf. & deep l.
Deltoid: stronger, extensive
Ant : to navicular Post to talus
Interm : to sustentaculum tali
2. Ankle joint
Ankle stabilizer
Coronal view: CFL, deltoid
In ankle PF: A T F L (vertical), resist varus deformity
In ankle DF: TFL is stressed
3. Subtalar joint
1. Post. Talocalcaneal j.: post. Subtalar j.
: supported by a fibrous capsule, ant,lat, post. Talocalcaneal lig.
10~20% : communicate with the ankle j.
Inversion & eversion movement
2. Talocalcaneonavicular j.: ant. Subtalar j.
: reinforced by dorsal talonavicular lig.
Spring (plantar calcaneonavicular) lig.
: ant. Of sustentaculum tali~undersurface of the navicular
Major supporter of longitudinal arch
4. Anterior Tendons
Dorsiflexed
Dorsiflexed + Inversed
4. Anterior tendons
1. TA
: most medial side ~ medial surface of medial cuneiform,
plantar aspect of the base of the 1st metatarsal
DF, inversion of ankle
2. EHL
3. E D L : divides into 2~5th toes
4. P Tertius : aids in DF, eversion
• Superior & inferior extensor retinacula
: prevent tendon bowstring action
5. Lateral tendons
1. Peroneus longus
2. Peroneus brevis : smaller, lies anterior
(3) peroneus quartus: accessory m. from PB
Retinacular : superior & inferior
Peroneal tendons turn forward below the lateral malleolus
and rest on the lateral aspect of the calcaneus
6. Medial tendons
Ant~ post. Flexor tendons : TP, FDL, FHL
1. T. P.
: inverter, major stabilizer of the hindfoot
oval shape, twice larger than FDL..
below med. Malleolus , superficial to the spring lig.
to 3 cuneiform & base of the 1~4 metatarsals
if, ruptured acquired flat foot
2. FDL
3. FHL : most lateral, runs inferomedially of the tibia
inferior aspect of the sustentaculum tali.
6. Medial tendons
Flexor Retinaculum Tibial n.
6. Medial tendons
Tibialis Posterior
Medial Malleolus
Tibialis Anterior Flexor H. L
Achilles
7. Posterior tendons
1. Achilles tendons (tendo calcaneus)
: longest, thickest, strongest tendon in the body (12~15 cm)
Descends vertically in the midline to post. Of calcaneus
Cross section: flattened
crescent shape ( flat or concave in anterior margin &
convex posterior margin)
- at distal insertion: entirely convex
Fibers of tendon twist laterally (90°)
Karger triangle : separated from FHL by fat pad, just
proximal to its insertion
7. Posterior tendons
Not invested by a tendon sheath
Enveloped by a paratendon : dorsal, lateral, medially
2~6 cm cranial to its insertion : hypovascular area
: tendon rupture occurs
• Insertion
: enthesis made of a intervening layer of fibrocartilage,
intermeshing into the bone marrow of the calcaneus
(strong, less tendon rupture)
2. Plantaris : medial border of the Achilles
small, long tendon
7. Posterior tendons
Achilles
Plantaris
Kager fat pad
8. Neurovascular structures
Ant. : Deep peroneal n. , ant. Tibial a.
1. Deep peroneal. N
- Crosses interosseous memb. With a. & v.
2. Ant. Tibial a.
- ends at the ankle j. becomes dorsalis pedis a.
Lateral : superficial peroneal n.
Medial : tibial n. Passes deep to the flexor retinaculum
Tibial n. divides into medial & lateral plantar n.,
+ calcaneal n. (sensitive supply of the heel)
Plantar n. : supply intrinsic foot m.(Except for EDB : deep
peroneal n.)
8. Neurovascular structures
Posterior ankle
: sural n. : posterolateral aspect of the inferior third of the
leg, lateral margin of the foot & lateral side of the small toe
: between lateral malleolus & achilles tendon
with small saphenous vein
On the dorsum of the foot: sural n. anastomosis with br. Of
the superficial peroneal n.
Foot
Introduction
Supports body weight, absorbs shock
Congenital, inflammatory, infectious, degenerative causes
Clinical Anatomy
28 bones, 30 joints,100 muscles, tendos, ligaments
Midline : 2nd toe long axis
(Adduction: movement toward 2nd toe, abduction: away from
2nd toe)
Osseous and Articular Anatomy
1. Hindfoot: talus & calcaneus
2. midfoot: navicular, cuboid, 3 cuneiforms
3. forefoot: metatarsals & phalanges
Subtalar joint: talus (large concave facet on the inferior) &
calcaneus (convex posterior articular surface of the superior)
Transverse tarsal joint: talonavicular j~ calcaneocuboid j.
inversion & eversion
Navicular j. : j. with 3 cuneiforms
Tarsometatarsal j. : 3 cuneiforms & cuboid
Forfoot j.
Foot Anatomy
Talus
Calcaneus
navicular
cuneiforms
cuboid
Metatarsals & phalanges
Medial longitudinal Arch
Lateral longitudinal Arch
Plantar aponeurosis
Plantar aponeurosis
Plantar cal-na. L
3 Main arches
1. Medial longitudinal arch
: calcaneus, talus, navicular, 3 cuneiforms, 1~3 metatarsals
concave inferioly
ligaments & muscles
- plantar aponeurosis (calcaneus~ 3 medial prox. Phalanges)
- plantar calcaneonavicular lig. (spring lig.)
(navicular ~calcaneus)
- Flexor hallucis longus m. : bowstring of the arch
- Tibialis posterior & Tibialis anterior : inverting, adducting
3 Main arches
2. Lateral longitudinal arch
: calcaneus, cuboid, 4~5 th metatarsal
(calcaneus~lateral 2 metatarsal heads)
Inferior concavity
Ligaments, muscles & lateral extension of the plantar
aponeurosis
- Peroneus longus: bowstring action
3 Main arches
3. Transverse arch
: base of 5 metatarsals, cuboid, cuneiforms
Ligaments & peroneus longus tendon
At the level of the metatarsal head
- less concave, deep transverse ligament
Soft tissues - dorsal foot
Thin skin: 0.064mm epidermis + subcut. Fat
Dermatomes :
Saphenous n. – medial side
Superficial peroneal n. – central & lateral side
Sural n. – lateral border of the foot
1st web space – deep peroneal n.
Soft tissues – dorsal foot
Extrinsic tendons: TA, EHL, E.D.L
Intrinsic muscles : EDB, EHB
EDB- anterolateral part of the calcaneus ~ EDL tendon
EHB – into prox. Phalanx of the 1st toe
Dorsalis pedis a. : from ant. Tibial a.
Soft tissues - plantar foot
Significant thicker skin
8 times thicker epidermis
Innervation
1. medial plantar n.
2. lateral plantar n.
3. calcaneal branches of tibial & sural n. : sensory br. To heel
Heel pad
: ave. 18mm , multiple fat-containing cells
vertical fibrous & elastic septa shock absorber
Soft tissues - plantar foot
Midfoot level (skin becomes thinner) at the
metatarsophalangeal j.(thicker again for toe off)
Plantar fascia
: fibrous thickening of the superficial fascia: dynamic support
for longitudinal arch
network of compacted collagen fibers
arranged mostly longitudinally
Soft tissues - plantar foot
Plantar Fascia
3 cords of plantar fascia
1. Central: thickest, strongest, triangular
thick posterior and thin anterior, fans out
calcaneus~ flexor tendons of the toes
(into fibrous digital sheath, proximal phalanx)
2. Medial : thin, covers abductor hallucis
3. Lateral : thin, overlies abductor digiti minimi
- maintains medial and lateral longitudinal arch
- firm attachement to skin
Protects underlying skin, n. tendon
Intrinsic muscles & plantar tendons
1 layer
- most superficial : AH, FDB, ADM
AH
: medial calcaneus~ medial base of prox. Phalax of the 1st toe
: large abductor, partially flexor of the 1st toe
(in severe HV, if tendon moves to plantarward, no flexion)
FDB
: from plantar fascia & medial calcaneus~ 4 tendons
flexor of the PIP j.
ADM
:abductor, calcaneus & lateral plantar fascia~5th Prox. phalax
Foot Anatomy Extrinsic T. Intrinsic T.
EDB
EHB
Central-FDB
medial
lateral
Foot Anatomy
1st 2nd 3rd 4th
EHB
FDL
Q-plant ADM
FDB
AH
lumb
FHL
addH
FHB
FDM
P-I
D-I
TP
PL
Anatomy of the Foot- intrinsic
Lateral S Intermed S Medial S
1st Layer
Intrinsic muscles & plantar tendons
2nd layer
1. Quadratus plantae
: medial calcaneus (medial head), lateral calcaneus (lateral
head) ~ FDLtendon (4 tendons)
Assists the action of FDLongus (pulling tendons)
2. 4 Lumbricalis
: from respective tendinous slips of the FDLongus ~ medial
dorsal extensor hood of the 2~5 toes
2nd Layer of Foot
Intrinsic muscles & plantar tendons
3rd layer
1. FHB
: cuboid plantar surface,peroneal groove, lateral
cuneiform(lateral head), plantar surface of the medial &
intermediate cuneiforms, tibialis post. tendon (medial head),
~ proximal phalanx of the 1st toe (medial & lateral)
Flexor of the 1st metatarsophalangeal j.
2. Adductor hallucis
: larger transverse head + smaller oblique head
Adductor of the 1st toe , flexor and maintain transverse arch
3rd Layer of Foot
Intrinsic muscles & plantar tendons
3. FDMb
: plantar surface of the base of 5th metatarsal~ base of 5th
proximal phalanx
Flexor of the 5th toe (MP j)
Intrinsic muscles & plantar tendons
4th layer
Interosseous muscles (4 dorsal & 3 plantar)
1. Dorsal interossei m.
: metatarsal shat~lateral surface of the base of the proximal phalanx of the toes
(except 1st )
Action: Abduct 2nd , 3rd and 4th
Assist lumbricals in extending I-P joints
while flexing metatarso-phalangeal joints
2. plantar interosseous m.
: plantar and medial surface of the base of the 3,4,5 metatarsals~ medial surface
of the base of the prox. Phalanx
Action: Adduct 3rd 4th and 5th toes, Assist lumbricals in extending
interphalangeal joints while flexing metatarso-phalangeal joints
Dorsal Interossei muscles
Plantar Interossei muscle
Intrinsic muscles & plantar tendons
Several tendons : T.P, FHL, F.D.L, PL, PB
T.P – cross medial malleolus to cuneiform
inverter, plantar flexor
FHL – passes under sustentaculum tali, F.D.L~ medial &
lateral sesamoid at the base of the 1st metatarsal , distal 1st toe
flexor of the 1st toe, assists in plantar flexion of the foot
maintenance of medial longitudinal arch
F.D. L – superficial to susten. Tali~ 2 to 5th toe
flexes the phalanges, ankle PF
Intrinsic muscles & plantar tendons
PL, PB - ~ cuboid/ styloid process of the base of the 5th
metatarsal
enters an osteofibrous tunnel, sole of the foot
~ 1st metatarsal & medial cuneiform
evertors, plantar flexors
Plantar Vessels and Nerves
Main arteries
Posterior tibial a.
lateral plantar (large), medial plantar (small) artieries.
pass deep to AbHallucis (with tibial n. br.)
Lateral plantar a: ~ base of the 1st metatarsal bone, joins the
deep plantar br. Of the dorsalis pedis a. plantar a. arch
Joints & para-articular structures of the toes
Metatarsophalangeal, proximal & interphalangeal j.
Synovial- lined j. : flexion, extension
Thick fibrocartilaginous plantar plate
: insert into base of the proximal phalanx
- weight bearing platform, main stabilizer of the
metatarsophalangeal j. resisting dorsiflexion
connected with collateral ligaments
Deep transverse intermetatarsal ligament: connected with
plantar plate
Plantar Plate
PP
Deep tran intermet. L
FDP
PP
Joints & para-articular structures of the toes
1st toe : two phalanges
Two sesamoid bones : medial (tibial) and lateral (fibular) in
plantar aspect of the 1st toe
: embeded in the tendon of the FHB, AH
Capsuloligamentous sling : mechanical benefit during j.
flexion
absorbing weight bearing stress
Hallux sesamoids
Inter-ses L
Thin superfial L
prominence
Bipartite hallux sesamoid
medial
lateral
Usus larger than normal one Cf) same size in fracture