Anatomy of the ankle and joints of foot

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Objectives:
After completion of this presentation, it is expected that the students will be able to

Musculoskeletal Anatomy
Describe the distal end of the tibia and be able to identify:
• the shaft
• the sharp anterior border
• the subcutaneous anteromedial surface or “shin”
• the interosseous border
• the medial malleolus
• articular surfaces
Describe the distal end of the fibula and be able to identify:
• the shaft
• the interosseous border
• the lateral malleolus with grooves for peroneal tendons
• articular surface
Identify the key features of the seven tarsal bones:
• the calcaneus
 calcaneal tuberosity
 medial, lateral and anterior tubercles
 the sustentaculum tali
 peroneal trochlea
• the talus:
 head
 neck
 body
 dome
 posterior tubercle with groove for flexor hallucis longus
• the cuboid with groove for peroneus longus on the plantar surface
• the navicular with tuberosity for the insertion of tibialis posterior
• the five metatarsals with fifth tuberosity for peroneus brevis
• the phalanges with 2 on big toe, 3 on others
• sesamoid bones at base of 1st metatarsals
Describe the structure, function and maintenance (bones, muscles, tendons, ligaments) of the arches of the foot:
 medial longitudinal
 lateral longitudinal
 transverse
Identify the attachments and understand the functions of the deep fascia:
• plantar aponeurosis
• fibrous septa of the sole
• extensor, flexor and peroneal retinaculae

Describe the components & function of the foot & ankle joints:
• ankle joint:
 articular surfaces
 fibrous capsule
 synovial membrane
 Ligaments (medial/deltoid, lateral/tri-fascicular)
 Movements (plantar/dorsi flexion)
• subtalar joints:
• distal tibiofibular joint
• talo-calcaneo-navicular (mid-tarsal) joint
• tarso-metatarsal joints
• metatarsophalangeal
• interphalangeal
Recognise the shape, size and attachments of:
• the long plantar ligament
• the short plantar (plantar calcaneocuboid) ligament


Clinical Anatomy
Explain the relevant anatomy of:
• the differences between the superior and inferior tibiofibular joints
• fracture of the second & fifth metatarsals
• ankle sprain with fractured shaft of fibula
• the three degrees of ankle sprain
• the ratio of lateral to medial ankle ligament sprains
• plantar fasciitis and calcaneal spur
• pes planus
• hallux valgus and its predominance in females
• the ankle jerk and plantar reflex

Radiological Anatomy
Identify:
• the antero-posterior and lateral views of the distal tibia, fibula and foot bones
• the ankle joint space

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Anatomy of the ankle and joints of foot

  1. 1. The Ankle & Joints of the Foot Dr. Akram Jaffar Ph.D.Dr. Akram Jaffar Dr. Akram Jaffar
  2. 2. References and suggested reading • Moore KL & Dalley AF (2006): Clinically oriented anatomy. 5th ed. Lippincott Williams & Wilkins. Baltimore • Snell RS (2006): Clinical anatomy by systems. Lippincott Williams & Wilkins. BaltimoreDr. Akram Jaffar Dr. Akram Jaffar
  3. 3. Superior tibio-fibular joint • Plain type of synovial joint Lat condyle • Between the head of the fibula and the lateral condyle of the tibia. • Some passive rotation of the fibula around head tibia its own axis takes place at the proximal tibio-fibular joint during dorsi and plantar Sup. T.F. flexion at the ankle joint because of the fibula joint antero-posterior, convexity of the lateral articular surface of the talus. • Its cavity may communicate with popliteus bursa, which always communicate with the knee joint cavity. talus Lat articular surfaceDr. Akram Jaffar Popliteus bursa Dr. Akram Jaffar
  4. 4. Inferior tibio- fibular joint tibia fibula • Fibrous joint of syndesmosis type inf. T.F. • Between the inferior ends of the tibia and joint fibula. • Its integrity is important for the stability of the ankle joint • It holds the 2 malleoli together forming a socket for the talus. inf. T.F. jointDr. Akram Jaffar Dr. Akram Jaffar
  5. 5. tibia The talus fibula Groove for Flex hal long Lat tubercle • The trochlea of the talus has three articular med tubercle calcaneus surfaces – Inferior surface of the tibia: trochlea is wider anteriorly than posteriorly. talus trochlea neck – Medial malleolus head – Lateral malleolus navicular neck trochlea head talus calcaneusDr. Akram Jaffar No muscle is attached to the talus Dr. Akram Jaffar
  6. 6. tibia Ankle joint fibula • Type and articulation – Hinge type of synovial joint – Between the inferior ends of the talus tibia and fibula which form a deep socket (mortise) and the trochlea of the talus.Dr. Akram Jaffar Dr. Akram Jaffar
  7. 7. tibia Ankle joint Dorsiflexion (extension) fibula • Movements – Mainly dorsi flexion and plantar flexion talus – Some degree of rotation (inversion and eversion) is possible when the foot is Plantar flexion (flexion) plantar flexed. • The joint is relatively unstable during plantar flexion. WHY? inversion eversionDr. Akram Jaffar Dr. Akram Jaffar
  8. 8. capsule Capsule of the ankle joint • Extends anteriorly onto Med malleolus the neck of the talus. • Strengthened by collateral ligaments. – Medial collateral ligament (deltoid) • Delta-shaped • Very strong. talus navicular calcaneus – Lateral collateral ligament Lat malleolus Ant.. • Consists of 3 Post. Talofibular lig slips connecting Talofibular lig the lateral Calcaneo-fibular lig malleolus to the talus and calcaneus.Dr. Akram Jaffar Dr. Akram Jaffar
  9. 9. Ankle sprainDr. Akram Jaffar Dr. Akram Jaffar
  10. 10. Injury of lateral collateral ligament • When the foot is forcibly inverted as when the weight-bearing foot trips on an uneven surface. • The anterior talofibular ligament is the most vulnerable and most commonly torn. • In severe cases, the calcaneofibular ligament is torn and the lateral malleolus is fractured. Inf tibiofibular joint Lat malleolus fractureDr. Akram Jaffar Dr. Akram Jaffar
  11. 11. Injury of deltoid ligament • So strong that when the foot is forcibly everted the ligament is not torn but it causes – avulsion of the medial malleolus – talus moves laterally causing a break in the fibula superior to the inferior tibio-fibular joint (Pott fracture dislocation). eversionDr. Akram Jaffar Dr. Akram Jaffar
  12. 12. Posterior tibio-fibular ligament • Between malleolar fossa of the fibula to the posterior edge of the tibia. Post. Tibio-fibular lig. • Prevents the leg to slide foreword on the talus under the influence of gravity when the foot is plantar flexed at the take off stage in Post. Talo-fibular lig. walking. inf. T.F. joint Post. Tibio-fibular lig. Malleolar facetDr. Akram Jaffar Malleolar fossa Dr. Akram Jaffar
  13. 13. tibia Stability of the ankle joint • Bone: mortise fibula • Ligaments: collateral & tibiofibular • Muscle: surrounding tendons. • Forward sliding of the leg on the talus is prevented by: – The mortise is deepened at the back talus • Posterior lip of the tibia • Posterior tibio-fibular ligament – The superior articular surface of the talus is wider in front than behind. • The joint is unstable with the foot plantar flexed (walking downhill)  ankles are more commonly sprained whilst walking downstairs rather than when going upstairs.Dr. Akram Jaffar Dr. Akram Jaffar
  14. 14. Parts of the foot • Hindfoot • Midfoot • Forefoot Hindfoot Midfoot Forefoot cuneiforms navicular talus cuboid calcaneus metatarsals phalangesDr. Akram Jaffar Dr. Akram Jaffar
  15. 15. Joints of inversion and eversion: anatomical classification • Subtalar joint Subtalar j. – Synovial joint between the inferior talus surface of the body of the talus and the superior surface of the cuboid calcaneus. calcaneus • talocalcaneonavicular joint – Synovial joint between the head of Calcaneo-cuboid j. the talus on one side and the posterior surface of the navicular, superior surface of the spring ligament, and the talus navicular sustentaculum tali of the calcaneus on the other side. • calcaneocuboid joint calcaneus – Synovial joint between the anterior surface of the calcaneus and the posterior surface of the cuboid. Talo-calcaneo-cavicular j.Dr. Akram Jaffar Dr. Akram Jaffar
  16. 16. Spring ligament • Officially, plantar calcaneonavicular ligament • Between the sustentaculum tali and the navicular bone. • Forms part of the socket for the head of the talus. • Important in maintaining the medial longitudinal arch of the foot. Spring lig. Sustentaculum tali talus navicular calcaneus Sustentaculum taliDr. Akram Jaffar Sustentaculum tali Dr. Akram Jaffar
  17. 17. Joints of inversion and eversion: functional classification talus Subtalar j. calcaneus calcaneus Midtarsal j. talus talus cuboid navicular Subtalar j. calcaneus • Mid-tarsal joint (transverse tarsal joint): Articulation of the head of the talus with the navicular lies in line with the calcaneocuboid joint. • Subtalar joint: Articulation of the head of the talus with the spring ligament and the sustentaculum tali + anatomical subtalar jointDr. Akram Jaffar Dr. Akram Jaffar
  18. 18. Foot amputation • Transection across the transverse tarsal joint is a standard method for surgical amputation of the foot.Dr. Akram Jaffar Diabetic foot Dr. Akram Jaffar
  19. 19. Avulsion fracture of the 5th metatarsal • Forcible inversion of the foot  Avulsion of the tuberosity of the 5th metatarsal bone by the attached tendon on peroneus brevisDr. Akram Jaffar Dr. Akram Jaffar
  20. 20. “March” fracture of the 2nd metatarsal bone • The base of the 2nd metatarsal is firmly fixed between the anterior ends of the medial and lateral cuneiforms. • The 2nd metatarsal and toe form the axis of the foot. • The immobility of the 2nd metatarsal and the slenderness of its shaft contribute to its „spontaneous‟ fracture following mild repetitive trauma (stress fracture).Dr. Akram Jaffar Dr. Akram Jaffar
  21. 21. Hallux valgus • Lateral deviation of the great toe to an abnormal extent  prominent head of the 1st metatarsal. • Predisposed by pressure from ill-fitting shoes. • The first metatarsal shifts medially and the sesamoids shift laterally. • The distortion is increased by the action of the long flexor and extensor tendons and the adductor hallucis. • A bursa develops over the projecting head of the 1st metatarsal (bunion).Dr. Akram Jaffar > Dr. Akram Jaffar
  22. 22. Long and short plantar ligaments • Long plantar ligament – Passes from the plantar surface of the calcaneus to the cuboid bone – Bridges the groove on the cuboid and converts it into a tunnel for the passage of the tendon of peroneus longus muscle. cuboid Groove for • Short plantar ligament peroneus long. Peroneus longus – Deep to the long plantar ligament – From the plantar long plantar lig. surface of the calcaneus to the cuboid Short plantar lig. bone.Dr. Akram Jaffar Dr. Akram Jaffar
  23. 23. Formation of the arches of the foot lateral long. arch cuboid calcaneus 2 metatarsals cuneiforms cuboid Transverse arch Medial long. arch cuneiforms talus navicular 3 metatarsals calcaneus • Medial longitudinal arch – formed by the calcaneus, talus, navicular, 3 cuneiform bones, and the medial three metatarsals • Lateral longitudinal arch – formed by the calcaneus, cuboid, and the lateral two metatarsalsDr. Akram Jaffar • Transverse arch – formed by the cuneiforms, cuboid, and the bases of the metatarsals. Dr. Akram Jaffar
  24. 24. Function of the arches of the foot • Support and divide the body weight about equally between the calcaneus and the heads of the metatarsal 80 Kg bones. • Propel the body in walking or running: – Allow the long flexors and the muscles of the foot to act on the bones of the fore part of the foot and toes (take-off part) and greatly assist the propulsive force of gastricnemius and soleus muscles. • Shock absorption. • Adapt to changes when walking on uneven surfaces.Dr. Akram Jaffar Dr. Akram Jaffar
  25. 25. Mechanism of arch (bridge) support Tie beam Key stone staples • Shape of the stones: Wedge-shaped stones with the thin edge of the wedge lying inferiorly. This is especially true for the stone at the center of the arch “key stone”. suspension • Staples: Tie the inferior edges of the stones. • Tie beams: Connect the pillars and prevent their separation. • Suspension by slingsDr. Akram Jaffar Dr. Akram Jaffar
  26. 26. Mechanism of foot arch support • Shape of bones: e.g. head of the talus “key stone”. • Staples: e.g. the long and short plantar ligaments. • Tie beam: e.g. tendon of flexor hallucis longus. • Suspension: e.g. tendons of tibialis anterior, tibialis posterior, and the peroneii Short plantar lig. staples Long plantar lig. Tibialis ant. suspension Tibialis post. cuneiform talusDr. Akram Jaffar Key stones Tie beam Flex hal long Dr. Akram Jaffar
  27. 27. Factors maintaining the arches of the foot • Bones, ligaments, and muscles. • Passive support: Ligaments are sufficient to support the arches when standing still • Active support: muscles are brought into action to support the arches during running or walking ** ligamentsDr. Akram Jaffar muscles bones Dr. Akram Jaffar
  28. 28. Flat feet (pes planus) • The arch of the foot collapses, with the entire sole of the foot coming into contact with the ground. • Normal before age of 3 years. • Affects the medial longitudinal arch. • Causes: failure of factors maintining the arches – Bone: deformity  rigid flat foot – Ligaments: loose or degenerated  flexible flat foot (only when weight bearing) – Muscle: trauma, degeneration, or denervation  acquired flat foot.Dr. Akram Jaffar Dr. Akram Jaffar
  29. 29. head sesamoid head base Metatarsal 1 neck navicular tibia talus fibula phalanx Metatarsal 5 cuboid trochlea tuberosity condyle calcaneus Calcaneocuboid joint tuberosityDr. Akram Jaffar Dr. Akram Jaffar

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