tibiofibular and ankle joint complex
DESCRIPTION
website: http://www.am-medicine.com Facebook page : https://www.facebook.com/pages/Am-medicine/207726329406832 Facebook group: https://www.facebook.com/groups/1409138472653811/TRANSCRIPT
MOB TCD
Tibifibular and Ankle Joint Complex
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
Superior and Inferior Tibio-Fibular Joints
• Superior is synovial plane joint• Inferior is a syndesmosis• Interosseous tibiofibular
ligament• Anterior and posterior tibiofibular
ligament
MOB TCD
Ankle Joint
• The ankle joint is one of the most common joints to be injured
• The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured
Bröstrom, 1966
MOB TCD
Tennis MOB TCD
• Dorsiflexion and plantar flexion take place at the ankle joint
• In plantar flexion there is some side-to-side movement
Last, 1963
Ankle Joint MOB TCD
• Uniaxial, modified synovial hinge joint
• Close pack• Dorsiflexion• Least pack• PlantarflexionWilliams & Warwick, 1980
Ankle Joint MOB TCD
Proximal Articular Surface
• Distal surface of the tibia • Medial malleolus has comma
shaped facet• Lateral malleolus triangular
facetWilliams & Warwick, 1980
MOB TCD
Proximal Articulation
• Inferior transverse tibiofibular ligament • Deepens it posteriorly• Passes from the lower margin of the
tibia • To the malleolar fossa of the fibulaWilliams & Warwick, 1980
MOB TCD
• Proximally the articulation depends on the integrity of the inferior tibiofibular joint
• Syndesmosis
Proximal Articular Surface MOB TCD
Distal Articular Surface
• The superior surface of the body of the talus is wider anteriorly
• Convex from before backwards • Concave from side to side • Medial comma shaped facet• Lateral triangular facetFrazer, 1965
MOB TCD
Capsule
• Is attached just beyond the articular margin
• Except anterior-inferiorly• Attached to the neck of the talusWilliams & Warwick, 1980
MOB TCD
• The capsule is thin and weak in front and behind
• It is strengthened on either side by the collateral ligaments
Williams & Warwick, 1980
Ankle Joint MOB TCD
Medial (Deltoid) Ligament
• A strong triangular ligament• Superiorly attached • The medial malleolus of the
tibiaWilliams & Warwick, 1980
MOB TCD
• The tuberosity of the navicular
• The edge of the spring ligament
• The sustentaculum tali • The body of the talusLast, 1963
Medial Ligament MOB TCD
Medial or Deltoid Ligament (Superficial)
• Cross two joints• Anterior tibionavicular pass
to the tuberosity of the navicular
• The free edge of the spring ligament
• The middle fibres• The tibiocalcaneal are attached to
the sustentaculum taliWilliams & Warwick, 1980
MOB TCD
Medial or Deltoid Ligament (Deep)
• The anterior tibiotalar to the nonarticular part of the medial surface of the talus
• The posterior tibiotalar to the medial side of the talus
• The medial tubercle of the talus
Williams & Warwick, 1980
MOB TCD
Lateral Ligaments of Ankle
• The anterior talofibular ligament (ATFL)
• The calcaneofibular ligament (CFL)
• The posterior talofibular ligament (PTF)
• They radiate like the spokes of a wheel
Liu & Jason, 1994
MOB TCD
Anterior Talofibular Ligament (ATFL)
• Is part of the capsule • An upper and lower bands• It is cylindrical• 6-10 mm long • 2 mm thickLiu & Jason, 1994
MOB TCD
ATFL
• The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion
• More perpendicular to the talus when the foot is equinus
MOB TCD
• It is the weakest ligament• Strain increases with
increasing plantar flexion and inversion
• The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion
Liu & Jason, 1994
ATFL MOB TCD
Calcaneofibular Ligament (CFL)
• A long rounded 20-25 mm long, 6-8 mm in diameter
• It contains the most elastic tissue
• It is attached in front of the apex of the fibular malleolus
• To a tubercle on the lateral aspect of the calcaneus
Williams & Warwick, 1980
MOB TCD
CFL
• It is separated from the capsule by fibro-fatty tissue
• Part of the medial wall of the peroneal tendon sheath
• Crosses both the ankle and subtalar joints
MOB TCD
• The CFL is perpendicular to the long axis of the talus
• Dorsiflexion and inversion result in an increased strain
• Talar tilt tests the CFL
CFL MOB TCD
Lateral Ligament
• The angle between the ATFL and CFL varies between 100o and 135o
• Increasing the potential instability of the lateral ligament
Hamilton, 1994; Peters, 1991
MOB TCD
Ankle Stability
• The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint
MOB TCD
ATFL and CFL
• A difference of 10o between the two ankles is significant
• A talar tilt of more than 10o is a lateral ligament injury in 99% of cases
• The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20%
• The CFL is a major stabiliser of the subtalar joint
Liu & Jason, 1994
MOB TCD
Posterior Talofibular (PTL)
• The PTL is the strongest part of the lateral ligament
• It runs almost horizontally from malleolar fossa to lateral tubercle of talus
MOB TCD
PTL
• During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge
• They separate during dorsiflexion
MOB TCD
Ankle Joint
• The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles
• In 7% the lateral tubercle has a separate ossification and is called an os trigonum
MOB TCD
Synovial Membrane
• Lines the capsule and the non articular area• Covers the neck of talus• The fatty pads inside the capsule• It extends upwards to the interosseous
ligament of the inferior tibiofibular jointPlastanga et al., 1980
MOB TCD
Blood Supply of Ankle
• Malleolar branches of the anterior tibial
• Perforating peroneal and posterior tibial arteries
MOB TCD
Nerve Supply of Ankle
• Nerve supply is via articular branches of the deep peroneal
• Tibial nerve from L4 - S2
MOB TCD
Anterior Aspect
• Dorsiflexors• Tibialis anterior• Flexor hallucis longus• Anterior tibial > dorsalis pedis artery• Deep peroneal nerve • Extensor digitorum longus• Peroneus tertius
MOB TCD
Postero-Medial Aspect of Ankle
• Tibialis posterior• Flexor digitorum longus• Posterior tibial vessels• Posterior tibial nerve and
branches• Flexor hallucis longus
MOB TCD
Posterior Aspect
• Posterolateral portal• Lateral to achilles tendon, sural
nerve, short saphenous vein at risk
• Posteromedial not used; flexor retinaculum structures at risk
Jaivin & Ferkel, 1994
MOB TCD
Lateral Aspect of Ankle
• The inferior extensor retinaculum
• Extensor digitorum brevis• Peroneus longus and brevis• Peroneal retinaculum• Ligament of the neck of talus• Bifurcate ligament
MOB TCD
• Plantar flexor and evertor– Peroneus longus– Peroneus brevis
• Dorsiflexor and evertor– Peroneus tertius
Lateral Aspect of Ankle MOB TCD
Nerves Related to Ankle Joint MOB TCD
• In the anatomical position the axis of the ankle joint is horizontal
• But is set at 20-25o obliquely to the frontal plane
• Running posteriorly as it passes laterallyPlastanga et al., 1990
Ankle Joint MOB TCD
• The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt)
Ankle Joint MOB TCD
Ankle Examination
• Anterior drawer• Suction sign• Inversion stress• Squeeze test• External rotation • Test
MOB TCD
• Achilles tendon• Peroneal tendons• Posterior tibial tendon• Anterior process of calcaneus• Talar dome• Sinus tarsi• Bifurcate ligament
Ankle Examination MOB TCD
Tests for Ankle Ligament Injury MOB TCD
Ottawa Ankle Rules
• Anteroposterior• Oblique• Lateral views• Bone tenderness• Medial or lateral• Malleolus• Unable to weight bear• Four steps post injury
MOB TCD
Tibialis Posterior / Superficial Peroneal Nerve
MOB TCD
• ATFL• CFL• Distal tibiofibular• Syndesmosis• Deltoid ligament• Lateral malleolus• Medial malleolus• Base 5th metatarsal
Ankle Examination MOB TCD
• Inversion or supination• Raising the medial
border• Sole faces medially
Inversion and Eversion
• Eversion or pronation• Raising the lateral
border• Sole faces laterally
MOB TCD
• Initiated at the transverse tarsal joint
• Calcaneocuboid• Anterior portion of the
talocalcaneonavicularLast, 1963
Inversion and Eversion MOB TCD
• Main movement take place at the clinical subtalar joint i.e.– talocalcaneal – inferior portion of the
talocalcaneonavicular• The pivot is the ligament
of the neck of the talusLast, 1963
Inversion and Eversion MOB TCD
• Axis passes through the middle of the convex posterior facet on calcaneus
• Upwards forwards and medially
• Through middle of convex articular facet of head of talus
Last, 1963
Inversion and Eversion MOB TCD
Talocalcaneal
• Synovial plane joint• Articular surface• Concave facet inferior body
of talus• Convex posterior facet,
superior aspect of calcaneus
MOB TCD
Talocalcaneal Joint
• Capsule attached just beyond articular margin ligaments
• Interosseous• Ligament of neck of talus
MOB TCD
Tarsal Canal and Tarsal Sinus MOB TCD
Inversion or Supination
• Invertor and dorsiflexion• Tibialis anterior• Invertor and plantarflexion• Tibialis posterior
MOB TCD
Eversion and Pronation
• Evertor and dorsiflexion• Peroneus tertius• Evertor and plantarflexion• Peroneus brevis• Peroneus longus
MOB TCD
Talocalcaneonavicular Joint
• Synovial ball and socket• Ball head of talus• Socket• Posterior aspect of the
navicular, two anterior facets on superior surface of calcaneus
• Spring ligament and CNL
MOB TCD
• Synovial ball and socket joint
• Ball is anterior and inferior aspect of the head of the talus
Talocalcaneonavicular Joint MOB TCD
• Socket• Two anterior facets on the
superior surface of the calcaneus
• Posterior aspect of the navicular
• Spring ligament• LCN ligament
Talocalcaneonavicular Joint MOB TCD
• Capsule attached just beyond the articular margin
• Interosseous ligament• Spring ligament• Superficial portion deltoid
ligament• LCL of bifurcate• Ligament neck of talus
Talocalcaneonavicular Joint MOB TCD
• Synovial membrane lines the capsule and non-articular structures
• Nerve supply• Tibial nerve• Deep and superficial
peroneal nerves
Talocalcaneonavicular Joint MOB TCD
Subtalar Interosseosus
• Capsule of both talocalcaneal
• Posterior portion of the talocalcanoeonavicular joint
MOB TCD
Ligaments of Subtalar Joint
• Inferior extensor retinaculum• Ligament of the neck of talus• Interosseous ligament• Bifurcate ligament
MOB TCD
Ligament of Neck of Talus
• Sinus tarsi• Lateral aspect of neck of talus• Pivot of inversion and
eversionLast, 1963
*
MOB TCD
Tarsal Canal and Tarsal Sinus
• Fat• Nerve endings• Branches of posterior tibial
and peroneal arteries • Capsules and ligaments of
talocalcaneal and talocalcaeonavicular joints
MOB TCD
Inferior Extensor Retinaculum
• Medial root inside the tarsal sinus
• Intermediate to talus with the interosseous ligament, inside sinus
• Lateral root to calcaneus outside sinus
Klein & Spreitzer, 1993
MOB TCD
Ligament Attachments MOB TCD
Bifurcate Ligament
• Lateral calcaneo- navicular ligament (CNL)
• Medial calcaneocuboid ligament (CCL)
MOB TCD
• Two individual ligaments• Separate attachments• Different fibre orientation• Different histology
Bifurcate Ligament MOB TCD
Talocalcaneonavicular Joint
• Invertors• In dorsiflexion• Tibialis anterior• In plantarflexion• Tibialis posterior
MOB TCD
• Evertor• In dorsiflexion• Peroneus tertius • In plantarflexion• Peroneus longus• Peroneus brevis
Talocalcaneonavicular Joint MOB TCD
Calcaneo Navicular Ligament
• Folded and twisted appearance• Prominent medial and lateral
edges / folds• Three groups of fibres
– Medial– Lateral (deep)– Intra-articular
N
A
C
MOB TCD
Calcaneocuboid Ligament
• Intra-capsular CC joint• Smaller than CNL, always
present• Hourglass shaped fibres,
twisted medially
MOB TCD
Calcaneocuboid Joint
• Plane synovial• Ligaments• Capsular• Ligament of neck of talus• Long and short plantar
ligament• Bifurcate ligament
MOB TCD
• The long and short plantar ligaments support the calcaneocuboids portion of the transverse tarsal joint
Calcaneocuboid Joint MOB TCD
“BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”