Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
MOB TCD

Anterior and Lateral and Posterior
Compartments of Calf
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK)...
MOB TCD

Cutaneous Supply of Calf
• Saphenous first branch is
infrapatellar branch it
• Supplies medial side of the
calf a...
MOB TCD

Fascial Compartments in Calf
• Subcutaneous surface of tibia
• Fascia anterior and posterior
intermuscular septa
...
MOB TCD

Extensor Retinacula
•
•
•
•
•
•
•
•

Superior retinaculum
Thickening deep fascia
Tibialis anterior pierces
Other ...
MOB TCD

Anterior Compartment of Calf
•
•
•
•
•

Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Pero...
MOB TCD

Tibialis Anterior
• Upper two thirds
• Lateral surface of tibia and
adjoining area of
interosseous membrane
• And...
MOB TCD

Tibialis Anterior
• Synovial sheath
• Passes under superior and
both limbs of inferior
extensor retinaculum
• Dor...
MOB TCD

Extensor Hallucis Longus
•
•
•
•

Middle two fourths
Anterior surface of fibula
Interosseous membrane
Base of dis...
MOB TCD

Extensor Hallucis Longus
• Upper three quarter anterior
surface of fibula
• Except the area for the
extensor hall...
MOB TCD

Extensor Digitorum Longus
• Main extensor tendon inserted into
base of middle phalanx, of the
lateral four toes
•...
MOB TCD

Peroneus Tertius
• Lower quarter of anterior surface of
the fibula
• Inserted into base and dorsum of
shaft of fi...
MOB TCD

Extensor Digitorum Brevis
•
•
•
•
•

Fleshy origin from calcaneus
Stem of inferior retinaculum
Divides into four ...
MOB TCD

Deep Peroneal Nerve
• Branch of the common peroneal at neck of
fibula
• Pierces anterior intermuscular septum
• R...
MOB TCD

Deep Peroneal Nerve
•
•
•
•
•
•
•
•

In anterior compartment
Supplies
Tibialis anterior
Extensor hallucis longus
...
MOB TCD

Anterior Tibial Artery
• Branch of popliteal
• Enters above interosseous
membrane
• Only supply of tibialis
anter...
MOB TCD

Dorsalis Pedis
•
•
•
•

Gives off
First dorsal metatarsal artery
Arcuate artery gives off
2-4th dorsal metatarsal...
MOB TCD

Blood Supply of Dorsum
• Arcuate artery
• Dorsal metatarsal arteries
• Posterior and anterior perforating
branche...
MOB TCD

Perforating Peroneal Artery
•
•
•
•

Perforating peroneal artery
Pierces interosseus membrane
Enters anterior com...
MOB TCD

Venous and Lymph Drainage of Foot
• Dorsal venous arch
• Medial, long saphenous
vein
• Anterior to medial
malleol...
MOB TCD

Lateral Compartment of Calf
• Between anterior and posterior
intermuscular septa
• Peroneus longus
• Peroneus bre...
MOB TCD

Peroneus Longus
• Upper two thirds lateral surface of fibula
• Adjoining area of interosseous
membrane
• Passes u...
MOB TCD

Peroneus Longus
•
•
•
•
•

May have a sesamoid bone
Runs in groove in the cuboid
Inserted into
Lateral aspect of ...
MOB TCD

Peroneus Longus
•
•
•
•
•
•

Plantar flexor and evertor
Supports lateral arch
Superficial peroneal nerve
Cuboid s...
MOB TCD

Peroneus Brevis
• Lower two thirds
• Lateral surface of fibula in front of
longus
• Passes under superior and inf...
MOB TCD

Peroneus Longus and Brevis
• Plantar flexors and
evertors
• Longus support the lateral
longitudinal arch
• Superf...
MOB TCD

Superficial Peroneal Nerve
•
•
•
•
•
•
•

Branch common peroneal
Neck of fibula
Supplies peroneus longus and brev...
Sensory Supply to
Posterior Aspect of Calf
•
•
•
•
•

Posterior cutaneous nerve of thigh
Lateral cutaneous of calf
Sural n...
MOB TCD

Dermatomes
MOB TCD

Posterior Surface of the Calf
• Short saphenous vein
• Posterior to lateral malleolus
pierces the roof of poplite...
Medial and Lateral Heads
of Gastrocnemii
• Medial head arises from popliteal
surface of femur above medial
condyle
• Later...
Medial and Lateral Heads
of Gastrocnemii
•
•
•
•
•
•

Bursa deep to the two heads
Medial belly is longer
Unite to form a t...
MOB TCD

Plantaris
• Short fleshy origin from
• The popliteal surface of femur
above the lateral femoral
condyle
• Long te...
MOB TCD

Plantaris
•
•
•
•
•
•
•
•

May be absent
May rupture
Used in tendon grafts
Sudden dorsiflexion
of ankle
Ballet da...
MOB TCD

Soleus
• Broad flat pennate muscle
• Arises from head and upper
fourth of posterior surface of the
fibula
• Fibro...
MOB TCD

Soleus
•
•
•
•
•

Two aponeurotic lamellae
Bulk of vascular multipennate muscle fibres
Deepest of achilles
Slow t...
MOB TCD

Achilles Tendon
• Extent of the fusion between the
gastronemii and soleus varies
• Inserted into middle of poster...
MOB TCD

Achilles Tendon
• Rotation occurs above
where the soleus tends to
join
• Rotation is greater if minimal
fusion
• ...
MOB TCD

Achilles Tendon
• The achilles tendon is subjected
to the highest loads in the body
• Tensile loads up to eight a...
MOB TCD

Achilles Tendon
• Superficial bursa may be
found posterior to achilles
between it and the deep
fascia
• The retro...
MOB TCD

Achilles Test
Medial and Lateral Heads
of Gastrocnemii
•
•
•
•
•

Sprinting
Jumping
Hopping
Skipping
Stretched with knee
extended and an...
MOB TCD

The Retrocalcaneal Bursa
• The area of fibro cartilage on the
tendon forms the posterior wall
• The anterior wall...
MOB TCD

Flexor Digitorum Longus
•
•
•
•

Posterior surface of tibia
Below soleal line
Medial to vertical line
Variable or...
MOB TCD

Flexor Digitorum Longus
Very extensive fibular
origins of FDL
Hislop M, 2003

FHL

Fibular origin of FDL

FDL
MOB TCD

Flexor Digitorum Longus
• Crosses tibialis posterior in calf
• Flexor hallucis longus in foot
• Foot receives ins...
MOB TCD

Flexor Digitorum Longus
• In the foot the tendon passes through
birfurcation of brevis
• Inserted into distal pha...
MOB TCD

Flexor Hallucis Longus
• Bulkiest and most powerful,
multipennate
• Arises from posterior surface of
fibula
• Pos...
MOB TCD

Flexor Hallucis Longus
• Grooves posterior process of talus
• Sustentaculum tali
• Crossed in foot by flexor digi...
MOB TCD

Flexor Hallucis Longus
•
•
•
•
•

Tibial nerve
Plantar flexes ankle
Flexes big toe
Supports medial longitudinal a...
MOB TCD

Tibialis Posterior
•
•
•
•
•
•

Deepest
Posterior surface of tibia
Below soleal line
Lateral to vertical line
Int...
MOB TCD

Tibialis Posterior
• Crossed by flexor digitorum longus in calf
• Posterior to medial malleolus
grooves bone, typ...
MOB TCD

Tibialis Posterior
•
•
•
•

Plantar flexor ankle
Invertor of foot
Supports medial arch
Avascular area behind
medi...
MOB TCD

Posterior Tibial Artery
• Branch popliteal
artery
• Lower border of
popliteus
• Under fibrous arch
of soleus
• Be...
MOB TCD

Posterior Tibial Artery
•
•
•
•
•
•
•

In the calf gives off
Nutrient artery to tibia
Peroneal artery
Nutrient ar...
MOB TCD

Tibial Nerve
•
•
•
•
•
•

Leaves the popliteal fossa
Runs in middle of calf
Deep to soleus
Accompaning artery
Bra...
MOB TCD

Flexor Retinaculum
•
•
•
•
•
•
•
•
•
•
•

Medial malleolus to calcaneus
Anterior to posterior
Tibialis posterior
...
MOB TCD

Causes of Compartment Syndromes
•
•
•
•
•

May be acute or chronic
Sudden increase in exercise
Haematoma
Callus
F...
MOB TCD

Compartment Syndromes
• Mainly anterior compartment
• Tibialis anterior main muscle
affected as only supplied by
...
MOB TCD

Posterior Compartment
• Posterior compartment
• Posterior border of tibia
• Posterior intermuscular septum
Divide...
MOB TCD

Posterior Compartment
• Superficial compartment
• Posterior intermuscular septum
• Posterior border of tibia
MOB TCD

Superficial Posterior Compartment
•
•
•
•
•

Medial and lateral gastrocnemii
Plantaris
Soleus
Forming the achille...
MOB TCD

Deep Posterior Compartment
•
•
•
•

Popliteus
Flexor digitorum longus
Flexor hallucis longus
Deepest is tibialis ...
Chronic Exertional Compartment
Syndrome (CECS)
• Significant morbidity/limitation activity to athletes
• Activity related,...
Chronic Exertional Compartment
Syndrome (CECS)
 The fibular origin of FDL can
partially (or sometimes almost
completely) ...
“BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”
Anterior lateral and_posterior_compartments_of_calf
Upcoming SlideShare
Loading in …5
×

Anterior lateral and_posterior_compartments_of_calf

1,358 views

Published on

website: http://www.am-medicine.com

Facebook page : https://www.facebook.com/pages/Am-medicine/207726329406832

Facebook group: https://www.facebook.com/groups/1409138472653811/

  • Be the first to comment

Anterior lateral and_posterior_compartments_of_calf

  1. 1. MOB TCD Anterior and Lateral and Posterior Compartments of Calf Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
  2. 2. MOB TCD Cutaneous Supply of Calf • Saphenous first branch is infrapatellar branch it • Supplies medial side of the calf and • Medial side of foot to ball of the hallux • Lateral cutaneous of calf • Superficial peroneal • Sural, lateral border of foot • Deep peroneal first cleft
  3. 3. MOB TCD Fascial Compartments in Calf • Subcutaneous surface of tibia • Fascia anterior and posterior intermuscular septa • Anterior compartment • Lateral compartment • Posterior compartment Divided • Superficial • Deep • Deep posterior
  4. 4. MOB TCD Extensor Retinacula • • • • • • • • Superior retinaculum Thickening deep fascia Tibialis anterior pierces Other tendons pass posterior Inferior extensor retinaculum Inferior stem attached to calcaneus Upper limb to medial malleolus Lower limb plantar aponeurosis
  5. 5. MOB TCD Anterior Compartment of Calf • • • • • Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius All muscles supplied by the deep peroneal nerve • Dorsi flexors • Anterior tibial and perforating peroneal arteries
  6. 6. MOB TCD Tibialis Anterior • Upper two thirds • Lateral surface of tibia and adjoining area of interosseous membrane • And deep fascia Inserted • Medial aspect of medial cuneiform • And adjoing base of first metatarsal
  7. 7. MOB TCD Tibialis Anterior • Synovial sheath • Passes under superior and both limbs of inferior extensor retinaculum • Dorsi flexor and invertor • Eccentric pays out, prevents foot slapping down • Supports medial arch • Deep peroneal nerve
  8. 8. MOB TCD Extensor Hallucis Longus • • • • Middle two fourths Anterior surface of fibula Interosseous membrane Base of distal phalanx of hallux • Dorsiflexor big toe and ankle • Deep peroneal nerve • Test for L5
  9. 9. MOB TCD Extensor Hallucis Longus • Upper three quarter anterior surface of fibula • Except the area for the extensor hallucis longus • Anterior intermuscular septum • Passes under retinacula • Divides into four tendons • Joined by slips from brevis • Lumbricals and interossei muscles
  10. 10. MOB TCD Extensor Digitorum Longus • Main extensor tendon inserted into base of middle phalanx, of the lateral four toes • Collateral slips formed by lumbricals and interossei inserted into distal phalanx • Dorsiflexor ankle • Extends proximal phalanx lateral four toes
  11. 11. MOB TCD Peroneus Tertius • Lower quarter of anterior surface of the fibula • Inserted into base and dorsum of shaft of fifth metatarsal • Dorsiflexor and evertor
  12. 12. MOB TCD Extensor Digitorum Brevis • • • • • Fleshy origin from calcaneus Stem of inferior retinaculum Divides into four tendons First is extensor hallucis brevis Other three join extensor expansion of second, third and fourth toes • Deep peroneal nerve
  13. 13. MOB TCD Deep Peroneal Nerve • Branch of the common peroneal at neck of fibula • Pierces anterior intermuscular septum • Runs between extensor digitorum longus and tibialis anterior • Then tibialis anterior and extensor hallucis longus
  14. 14. MOB TCD Deep Peroneal Nerve • • • • • • • • In anterior compartment Supplies Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius Extensor digitorum brevis Skin first cleft
  15. 15. MOB TCD Anterior Tibial Artery • Branch of popliteal • Enters above interosseous membrane • Only supply of tibialis anterior • Becomes dorsalis pedis at ankle joint
  16. 16. MOB TCD Dorsalis Pedis • • • • Gives off First dorsal metatarsal artery Arcuate artery gives off 2-4th dorsal metatarsal arteries • At base of first intermetatarsal space • Enters sole of foot • Joins lateral plantar artery to complete plantar arch
  17. 17. MOB TCD Blood Supply of Dorsum • Arcuate artery • Dorsal metatarsal arteries • Posterior and anterior perforating branches from metatarsals • Communicate plantar arch • And its digital branches • Perforating veins drain into dorsal venous arch
  18. 18. MOB TCD Perforating Peroneal Artery • • • • Perforating peroneal artery Pierces interosseus membrane Enters anterior compartment May replace dorsalis pedis
  19. 19. MOB TCD Venous and Lymph Drainage of Foot • Dorsal venous arch • Medial, long saphenous vein • Anterior to medial malleolus • Short saphenous vein • Posterior to lateral malleolus • Lymphatics follow superficial veins
  20. 20. MOB TCD Lateral Compartment of Calf • Between anterior and posterior intermuscular septa • Peroneus longus • Peroneus brevis • Superficial peroneal nerve
  21. 21. MOB TCD Peroneus Longus • Upper two thirds lateral surface of fibula • Adjoining area of interosseous membrane • Passes under superior and inferior peroneal retinaculum
  22. 22. MOB TCD Peroneus Longus • • • • • May have a sesamoid bone Runs in groove in the cuboid Inserted into Lateral aspect of medial cuneiform And adjoing base of first metatarsal
  23. 23. MOB TCD Peroneus Longus • • • • • • Plantar flexor and evertor Supports lateral arch Superficial peroneal nerve Cuboid syndrome Torn peroneal retinacula Snapping tendons
  24. 24. MOB TCD Peroneus Brevis • Lower two thirds • Lateral surface of fibula in front of longus • Passes under superior and inferior peroneal retinacula • Above peroneal trochlea on calcaneus • Inserted into base of fifth metatarsal
  25. 25. MOB TCD Peroneus Longus and Brevis • Plantar flexors and evertors • Longus support the lateral longitudinal arch • Superficial peroneal nerve
  26. 26. MOB TCD Superficial Peroneal Nerve • • • • • • • Branch common peroneal Neck of fibula Supplies peroneus longus and brevis Pierces deep fascia Dorsum of foot supplies Medial side of big toe All clefts except first and lateral side of little toe
  27. 27. Sensory Supply to Posterior Aspect of Calf • • • • • Posterior cutaneous nerve of thigh Lateral cutaneous of calf Sural nerve Saphenous nerve Medial calcaneal MOB TCD
  28. 28. MOB TCD Dermatomes
  29. 29. MOB TCD Posterior Surface of the Calf • Short saphenous vein • Posterior to lateral malleolus pierces the roof of popliteal fossa to enter popliteal vein • Deep fascia thickened medial between medial malleolus and calcaneum • Bursa anterior to achilles
  30. 30. Medial and Lateral Heads of Gastrocnemii • Medial head arises from popliteal surface of femur above medial condyle • Lateral is shorter, arises from posterior part of the lateral surface of the lateral femoral condyle and capsule of knee • Fabella is a sesamoid bone in lateral head MOB TCD
  31. 31. Medial and Lateral Heads of Gastrocnemii • • • • • • Bursa deep to the two heads Medial belly is longer Unite to form a tendinous raphe Unites with soleus to form achilles Fast twitch fibres Flex knee and plantar flex ankle MOB TCD
  32. 32. MOB TCD Plantaris • Short fleshy origin from • The popliteal surface of femur above the lateral femoral condyle • Long tendon passes between gastronemii and soleus • Inserted medial border of achilles • Tibial nerve
  33. 33. MOB TCD Plantaris • • • • • • • • May be absent May rupture Used in tendon grafts Sudden dorsiflexion of ankle Ballet dancing Gymnastics Basketball Sprinting
  34. 34. MOB TCD Soleus • Broad flat pennate muscle • Arises from head and upper fourth of posterior surface of the fibula • Fibrous arch • Soleal line of tibia • Middle third of medial border of tibia
  35. 35. MOB TCD Soleus • • • • • Two aponeurotic lamellae Bulk of vascular multipennate muscle fibres Deepest of achilles Slow twitch fibres Perforating veins from great saphenous enter soleus • Acts as a peripheral pump
  36. 36. MOB TCD Achilles Tendon • Extent of the fusion between the gastronemii and soleus varies • Inserted into middle of posterior surface of the calcaneus • Tendon twists • Gastronemii form the lateral and posterior part of the tendon
  37. 37. MOB TCD Achilles Tendon • Rotation occurs above where the soleus tends to join • Rotation is greater if minimal fusion • Stress marked 2-5 cm above insertion • Plantar flexor of ankle • Eccentric lower heels
  38. 38. MOB TCD Achilles Tendon • The achilles tendon is subjected to the highest loads in the body • Tensile loads up to eight and ten times body weight are experienced during running jumping hopping and skipping • The achilles tendon is subjected to stress when running up and downhill • A tight achilles tendon also limits dorsiflexion of the ankle
  39. 39. MOB TCD Achilles Tendon • Superficial bursa may be found posterior to achilles between it and the deep fascia • The retrocalcaneal bursa is just proximal to the insertion • Between the tuberosity on the posterior surface of the calcaneus and the achilles tendon
  40. 40. MOB TCD Achilles Test
  41. 41. Medial and Lateral Heads of Gastrocnemii • • • • • Sprinting Jumping Hopping Skipping Stretched with knee extended and ankle dorsiflexed • Tibial nerve MOB TCD
  42. 42. MOB TCD The Retrocalcaneal Bursa • The area of fibro cartilage on the tendon forms the posterior wall • The anterior wall of the retrocalcaneal bursa is the 0.5 to 1 mm thick cartilaginous layer on the posterior aspect of the calcaneus • The proximal wall of the synovial lined sac consists of folds, or villus synovial projections • Allows alterations in its form, produced by varying degrees of pressure on the fat above it during flexion and extension of the ankle
  43. 43. MOB TCD Flexor Digitorum Longus • • • • Posterior surface of tibia Below soleal line Medial to vertical line Variable origin by an aponeurosis from fibula
  44. 44. MOB TCD Flexor Digitorum Longus Very extensive fibular origins of FDL Hislop M, 2003 FHL Fibular origin of FDL FDL
  45. 45. MOB TCD Flexor Digitorum Longus • Crosses tibialis posterior in calf • Flexor hallucis longus in foot • Foot receives insertion flexor accessorius and two slips from flexor hallucis longus • Divides four tendons • Give origin to four lumbricals
  46. 46. MOB TCD Flexor Digitorum Longus • In the foot the tendon passes through birfurcation of brevis • Inserted into distal phalanges • Plantar flexes ankle • Plantar flexes lateral four toes • Supports medial arch • Tibial nerve
  47. 47. MOB TCD Flexor Hallucis Longus • Bulkiest and most powerful, multipennate • Arises from posterior surface of fibula • Posterior to medial crest • Beef to heel • Most posterior under retinaculum
  48. 48. MOB TCD Flexor Hallucis Longus • Grooves posterior process of talus • Sustentaculum tali • Crossed in foot by flexor digitorum longus to which it gives two slips • Inserted base of distal phalanx
  49. 49. MOB TCD Flexor Hallucis Longus • • • • • Tibial nerve Plantar flexes ankle Flexes big toe Supports medial longitudinal arch Take off muscle
  50. 50. MOB TCD Tibialis Posterior • • • • • • Deepest Posterior surface of tibia Below soleal line Lateral to vertical line Interosseous membrane Arises from posterior surface of fibula • Anterior to medial crest
  51. 51. MOB TCD Tibialis Posterior • Crossed by flexor digitorum longus in calf • Posterior to medial malleolus grooves bone, type II collagen, tends to have poor blood supply • Most anterior under the flexor retinaculum • Inserted into tuberosity of navicular • All bones of the tarsus except talus • Base of middle three metatarsals
  52. 52. MOB TCD Tibialis Posterior • • • • Plantar flexor ankle Invertor of foot Supports medial arch Avascular area behind medial malleolus • Tibial nerve
  53. 53. MOB TCD Posterior Tibial Artery • Branch popliteal artery • Lower border of popliteus • Under fibrous arch of soleus • Between flexor digitorum longus and flexor hallucis longus • Vena commitans
  54. 54. MOB TCD Posterior Tibial Artery • • • • • • • In the calf gives off Nutrient artery to tibia Peroneal artery Nutrient artery to fibula Perforating peroneal Passes under flexor retinaculum Gives off medial calcaneal artery which pierces flexor retinaculum • Then ends under flexor retinaculum • Dividing into medial and lateral plantar arteries
  55. 55. MOB TCD Tibial Nerve • • • • • • Leaves the popliteal fossa Runs in middle of calf Deep to soleus Accompaning artery Branches to soleus Flexor digitorum longus and flexor hallucis longus • Tibialis posterior
  56. 56. MOB TCD Flexor Retinaculum • • • • • • • • • • • Medial malleolus to calcaneus Anterior to posterior Tibialis posterior Flexor digitorum longus Posterior tibial artery Medial calcaneal artery pierces retinaculum Divides into medial and lateral plantar arteries Tibial nerve Gives off medial calcaneal nerve which accompanies artery Divides into medial lateral plantar nerves Flexor hallucis longus
  57. 57. MOB TCD Causes of Compartment Syndromes • • • • • May be acute or chronic Sudden increase in exercise Haematoma Callus Fracture
  58. 58. MOB TCD Compartment Syndromes • Mainly anterior compartment • Tibialis anterior main muscle affected as only supplied by anterior tibial, other muscles also supplied by perforating peroneal • Increasing pressure causes loss of sensation of first cleft due to pressure on deep peroneal nerve • Fasciotomy Or • Posterior or lateral compartments
  59. 59. MOB TCD Posterior Compartment • Posterior compartment • Posterior border of tibia • Posterior intermuscular septum Divided • Superficial • Deep • Deep posterior
  60. 60. MOB TCD Posterior Compartment • Superficial compartment • Posterior intermuscular septum • Posterior border of tibia
  61. 61. MOB TCD Superficial Posterior Compartment • • • • • Medial and lateral gastrocnemii Plantaris Soleus Forming the achilles tendon Tibial nerve
  62. 62. MOB TCD Deep Posterior Compartment • • • • Popliteus Flexor digitorum longus Flexor hallucis longus Deepest is tibialis posterior
  63. 63. Chronic Exertional Compartment Syndrome (CECS) • Significant morbidity/limitation activity to athletes • Activity related, reversible, myofascial intracompartmental pressure increase • Results in decreased tissue perfusion and neuromuscular function abnormalities • Predilection for the lower leg MOB TCD
  64. 64. Chronic Exertional Compartment Syndrome (CECS)  The fibular origin of FDL can partially (or sometimes almost completely) compartmentalize TP and acts to resist increases in intracompartmental volume and therefore cause increased pressure  The presence and extent of a fibular origin of FDL may act as an anatomical predisposition to the development of CECS MOB TCD
  65. 65. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

×