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Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
Anatomy of small joints of the foot
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Anatomy of small joints of the foot

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  • http://www.footandanklesurgery.info/images/backgr1.jpg
  • +Tibialtalar joint (Ankle Joint)
  • Moore KL et al. (2010): Clinically Orientated Anatomy. 6th Ed. Lippincott, Williams & Wilkins. Philadelphia.
  • To lessen ambiguity, some investigators (3) have suggested that the term “Lisfranc joint complex” should be used to refer to tarsometatarsal articulations and that the term “Lisfranc joint” should be applied to medial articulation involving the first and second metatarsals with the medial (first) and middle (second) cuneiforms
  • Myerson  M.  The diagnosis and treatment of injuries to the Lisfranc joint complex.  OrthopClin North Am.  1989;20:655–64.
  • Dorsal ligaments of Lisfranc joint complex. Schematic representation of dorsal ligaments (brown)of Lisfranc joint complex. Dorsal intertarsal(orange) and intermetatarsal(peach) ligaments are also represented
  • Castro, M., L. Melao, et al. 2010 "Lisfranc joint ligamentous complex: MRI with anatomic correlation in cadavers." AJR Am J Roentgenol195(6): W447-55.OBJECTIVE: The aim of our study was to clarify the ligamentous anatomy of the Lisfranc joint complex and show the diagnostic capability of MRI in the assessment of the Lisfranc joint complex with detailed anatomic correlation in cadavers. MATERIALS AND METHODS: Ten fresh cadaveric feet were studied with high-spatial-resolution MRI before and after the intraarticular injection of a gadopentetatedimeglumine solution. MR images were evaluated by two readers in consensus, with emphasis on the visibility of the ligamentous structures and their appearance. Readers also measured the dimensions (length, width, and thickness) of the Lisfranc ligament and of the first plantar tarsometatarsal ligament, or plantar Lisfranc ligament. For anatomic analysis, nine cadaveric specimens were sectioned in 3-mm-thick slices in the same planes used during MRI. One additional foot specimen was used for dissection. RESULTS: In all 10 cadaveric specimens we were able to identify and characterize with MRI the different ligamentous elements that contribute to the overall stability of the Lisfranc joint complex. CONCLUSION: By clearly defining the normal ligaments that contribute to the stability of the Lisfranc joint, MRI allows a more precise and correct diagnosis of the origin of the Lisfranc joint instability, perhaps permitting a more specific surgical management. MRI also allows a better understanding of the normal imaging anatomy of the different ligamentous components of the Lisfranc joint, mainly of the Lisfranc and plantar Lisfranc ligaments.
  • The Lisfranc ligament is a large band of plantar collagenous tissue that spans the articulation of the medial cuneiform and the second metatarsal base.4,6,7 While transverse ligaments connect the bases of the lateral four metatarsals, no transverse ligament exists between the first and second metatarsal bases. The joint capsule and dorsal ligaments form the only minimal support on the dorsal surface of the Lisfranc joint.3,6,7 The bony architecture of this joint, specifically the “keystone” wedging of the second metatarsal into the cuneiform, forms the focal point that supports the entire tarsometatarsal articulation.2 This anatomy establishes a “weak link” that, with stress, is prone to injury.
  • * Preidler KW, Wang YC, Brossmann J, Trudell D, Daenen B, Resnick D. Tarsometatarsal joint: anatomic details on MR images. Radiology 1996; 99:733–736* Delfaut EM, Rosenberg ZS, Demondion X. Malalignment at Lisfranc joint: MR features in asymptomatic patients and cadaveric specimens. Skeletal Radiol2002; 31:499–504** Chiodo CP, Myerson M. Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint. OrthopClin North Am 2001; 32:11–20** Kura H, Luo Z, Kitaoka HB, Smutz WP, An K. Mechanical behavior of Lisfranc and dorsal cuneometatarsal ligaments: in vitro biomechanical study. J Orthop Trauma 2001; 15:107–110
  •  Smith BR, Begeman PC, Leland R, et al. A mechanism of injury to the forefoot in car crashes. Traffic InjPrev 2005;6(2):156-169.
  • * Thompson MC, Mormino MA. Injury to the tarsometatarsal joint complex. J Am AcadOrthopSurg 2003;11(4):260-267.
  • Elftman H: The transverse tarsal joint and its control. ClinOrthop1960, 16:41-46.
  • Transcript

    • 1. MOHAMED ELADL 01/02/2013
    • 2. Dr M Eladl Small joints of the foot Forefoot Midfoot Hindfoot 1) IM joints 2) MP joints 3) IP joints 1) Tarsometatarsal joint (Lis Franc Joint) Distally 2) Mid-tarsal Joint (of chopart) Proximally 1) Subtalar Joint (Agility joint) 2) Talocalcaneonavicular Joint
    • 3. Dr M Eladl Forefoot
    • 4. Dr M Eladl Forefoot
    • 5. Dr M Eladl Midfoot • Five bones with numerous articular surfaces : Navicular, Cuboid & The 3 cuneiform bones • Possesses little mobility • Distally, • The 1st MT with the medial cuneiform (with 6 degrees mobility) • The 2nd & 3rd MT with the intermediate & lateral cuneiform (firmly fixed). • The 4th & 5th metatarsals articulate with cuboid bone (Mobile). • Each of these has an individual joint capsule but all are wrapped in one big capsule as well to form the tarso-metatarsal joint “LisFranc joint”. 1st, 2nd & 3rd Metatarsals with cuniform bones 4th & 5th metatarsals with cuboid bone
    • 6. Dr M Eladl Midfoot • Five bones with numerous articular surfaces : Navicular, Cuboid & The 3 cuneiform bones • Possesses little mobility • Proximally, Talonavicular & calcaneocuboid joints, together form the combined articulations of the midtarsal joint (of “Chopart”). Talonavicular joint Calcaneocuboid joint
    • 7. Dr M Eladl Lisfranc Joint • The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc (1790–1847), a field surgeon in Napoleon's army.
    • 8. Dr M Eladl Lisfranc Joint • The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc (1790–1847), a field surgeon in Napoleon's army. • Lisfranc described an amputation performed through this joint because of gangrene that developed after an injury incurred when a soldier fell off a horse with his foot caught in the stirrup. • (their foot stuck in the stirrup, they dislocated portions of the mid-foot).
    • 9. Dr M Eladl Lisfranc Joint • Some investigators have suggested that the term “Lisfranc joint complex” should be used to refer to tarsometatarsal articulations and that the term “Lisfranc joint” should be applied to medial articulation involving medial (first) and middle (second) cuneiforms with the first and second metatarsals .* • The Lisfranc joint complex has three separate articular capsules, creating three distinct articular compartments: medial, central, and lateral lacking communication with one another (**).
    • 10. Dr M Eladl Lisfranc’s Ligaments • The joint capsule and TMT ligaments provide limited soft-tissue support to the Lisfranc joint. • Ligaments are grouped according to anatomic location (dorsal, plantar, and interosseous) The dorsal ligaments: Are strong, flat bands. • The medial cuneiform is joined to the 1st metatarsal the by a broad, thin band; • The 2nd metatarsal has 3 ligaments; one from each cuneiform • The 3rd metatarsal has one ligament from the lateral cuneiform; • The 4th has one from the cuboid; and • The 5th has one from the cuboid. Castro M et al. AJR 2010;195:W447-W455
    • 11. Dr M Eladl Lisfranc’s Ligaments Castro M et al. AJR 2010;195:W447-W455 Dorsal ligaments of Lisfranc joint complex. Sagittal proton density MR image after intraarticular injection of gadolinium solution (B) and photograph of corresponding gross anatomic section (C) in cadaveric specimen show short and flat dorsal tarsometatarsal ligament between medial cuniform and 1st metatarsal (arrows). Note homogeneous low signal intensity at MR image.
    • 12. Dr M Eladl Lisfranc’s Ligaments The plantar ligaments: • They are stronger than on the dorsal aspect. • Consist of longitudinal and oblique bands, disposed with less regularity than the dorsal ligaments. • Those for the 1st & 2nd metatarsals are the strongest; • The 2nd & 3rd metatarsals are joined by oblique bands to the medial cuneiform; • The 4th & 5th metatarsals are connected by a few fibers to the cuboid • Note that there is no transverse metatarsal ligament from 1 to 2 Castro M et al. AJR 2010;195:W447-W455
    • 13. Dr M Eladl Lisfranc’s Ligaments • The relative importance of the different ligaments of the Lisfranc complex to the overall stability has been discussed in many reports.* • There is a general consensus that the most important ligaments are the ones coursing from the medial cuneiform to the 2nd metatarsal base; these are also the ones most often disrupted in midfoot injuries.** • Secondary stabilizers of the joint are the insertions of the peroneus longus, tibialis anterior and tibialis posterior tendons and plantar ligaments, and plantar fascia.* Castro M et al. AJR 2010;195:W447-W455
    • 14. Dr M Eladl Mechanism of injury of Lisfranc joint Direct Indirect - High energy blunt trauma to the dorsum of the foot. - Poorer clinical outcomes Motor car accidents High energy Low energy During athletic competition With direct injuries, the force vector dictates the fracture pattern and direction of dislocation. The more predictable indirect injuries most commonly involve failure of the weaker dorsal TMT ligaments in tension with subsequent dorsal or dorsolateral metatarsal dislocation*
    • 15. Dr M Eladl Mechanism of injury of Lisfranc joint • Smith et al (2005) performed impact testing on postmortem human lower legs and feet. The authors determined that Lisfranc injuries result from the forefoot being forcefully plantar flexed, as occurs during sudden braking in a car accident • Axial loading of a plantar flexed foot causes indirect injuries, such as those incurred in football players when one player falls onto the heel of another whose foot is in equinus and planted.
    • 16. Dr M Eladl Midtarsal joint (of “Chopart”). Is a compound joint formed by 2 separate joints aligned transversely: 1) Talonavicular part of the talo-calcaneo-navicular joint (Ball & Socket) and 2) Calcaneo-cuboid joint (Saddle).
    • 17. Dr M Eladl Midtarsal joint (of “Chopart”). - At this joint, the midfoot and forefoot rotate as a unit on the hindfoot around a longitudinal (AP) axis, augmenting the inversion and eversion movements occurring at the clinical subtalar joint. - Transection across the transverse tarsal joint is a standard method for surgical amputation of the foot. - The complex anatomy of the Chopart joint, optimally adapting to uneven surfaces upon first heel contact & forcefully pushing the foot off the ground at the end of the walk cycle.
    • 18. Dr M Eladl Subtalar Joint • known as the “Agility joint”. • Is between: the large posterior calcaneal facet on the inferior surface of the talus & the corresponding posterior talar facet on superior surface of calcaneus • The articular cavity is enclosed by synovial membrane, which is covered by a fibrous capsule. • Allows gliding and rotation, which are involved in inversion and eversion of the foot.
    • 19. Dr M Eladl Subtalar Joint ligaments Lateral, medial, posterior, and interosseous talocalcaneal ligaments stabilize the joint. Daftary A et al. Radiographics 2005;25:1215-1226 Drawing of the lateral surface of the calcaneus shows the peroneal tubercle (P), as well as the lateral talocalcaneal (LTL), interosseous (IOL), and bifurcate (B) ligaments.
    • 20. Dr M Eladl TaloCalcaneoNavicular Joint • A complex joint in which the head of talus articulates with calcaneus & plantar calcaneonavicular ligament (spring ligament) below & the navicular in front
    • 21. Dr M Eladl TaloCalcaneoNavicular Joint • A complex joint in which the head of talus articulates with calcaneus & plantar calcaneonavicular ligament (spring ligament) below & the navicular in front • Allows gliding & rotation movements, which together with subtalar joint are involved with inversion & eversion of the foot.
    • 22. Dr M Eladl TALOCALCANEONAVICULAR JOINT LIGAMENTS • Talonavicular ligament: superiorly, which passes between the neck of the talus and adjacent regions of the navicular; • Interosseous talocalcaneal ligament: posteriorly;
    • 23. Dr M Eladl TALOCALCANEONAVICULAR JOINT LIGAMENTS • Talonavicular ligament: superiorly by the, which passes between the neck of the talus and adjacent regions of the navicular; • Interosseous talocalcaneal ligament: posteriorly; • Plantar calcaneonavicular ligament (Spring): inferiorly
    • 24. Dr M Eladl Spring ligament - Called plantar calcaneonavicular ligament - Extends across and fills a wedge-shaped gap between the talar shelf and the inferior margin of the posterior articular surface of the navicular - It supports the head of the talus
    • 25. Dr M Eladl Short plantar ligament - Called Plantar calcaneocuboid ligament - Located on a plane between the plantar calcaneonavicular and the long plantar ligaments. - Extends from the anterior aspect of the inferior surface of the calcaneus to the inferior surface of cuboid.
    • 26. Dr M Eladl Long Planter ligament - Passes from the plantar surface of the calcaneus to the groove on the cuboid. - Some of its fibers extend to the bases of the metatarsals, thereby forming a tunnel for the tendon of the peroneus longus. - Important in maintaining the longitudinal arch of the foot.
    • 27. Dr M Eladl Plantar Fascia • Is an important stabilizer in the foot where a great deal of foot pathology begins. • It originates from the plantar surface of the calcaneus and attaches to the plantar surfaces of the five metatarsal heads and proximal phalanges of the toes. • Acts as a major stabilizer of the foot. It helps maintain the arch of the foot and is an antipronator. • In its function of maintaining the congruity of the relationship between the calcaneus and the metatarsal heads, it resists the torsion movement of the forefoot in relation to the hindfoot during pronation. Most of the eversion of pronation occurs in the mid and forefoot while the calcaneus remains stable in the hindfoot.
    • 28. Dr M Eladl References 1) Moore KL et al. (2010): Clinically Orientated Anatomy. 6th Ed. Lippincott, Williams & Wilkins. Philadelphia. 2) Castro, M., L. Melao, et al.(2010) "Lisfranc joint ligamentous complex: MRI with anatomic correlation in cadavers." AJR Am J Roentgenol 195(6): W447-55. 3) Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma. 1993;35:40–5. 4) Englanoff G, Anglin D, Hutson HR. Lisfranc fracture-dislocation: a frequently missed diagnosis in the emergency department. Ann Emerg Med. 1995;26:229–33. 5) Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am. 1989;20:655–64. 6) Burroughs, K. E., C. D. Reimer, et al. (1998). "Lisfranc injury of the foot: a commonly missed diagnosis." Am Fam Physician 58(1): 118-24. 7) Schulze, W; Richter, J; Russe, O; Ingelfinger, P; Muhr, G: Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1–15 years. Acta Orthop. Scand. 73:344 –351, 2002. 8) Suckel, A., O. Muller, et al. (2007). "Changes in Chopart joint load following tibiotalar arthrodesis: in vitro analysis of 8 cadaver specimens in a dynamic model." BMC Musculoskelet Disord 8: 80. 9) http://www.sportsinjuryclinic.net/anatomy/ankle-anatomy 10) http://www.footeducation.com/ligaments-of-foot-and-ankle-overview 11) Preidler KW, Wang YC, Brossmann J, Trudell D, Daenen B, Resnick D. Tarsometatarsal joint: anatomic details on MR images. Radiology 1996; 99:733–736 12) Delfaut EM, Rosenberg ZS, Demondion X. Malalignment at Lisfranc joint: MR features in asymptomatic patients and cadaveric specimens. Skeletal Radiol 2002; 31:499–504 13) Chiodo CP, Myerson M. Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint. Orthop Clin North Am 2001; 32:11–20 14) Kura H, Luo Z, Kitaoka HB, Smutz WP, An K. Mechanical behavior of Lisfranc and dorsal cuneometatarsal ligaments: in vitro biomechanical study. J Orthop Trauma 2001; 15:107–110

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