9 - Foot and Ankle Flashcards
Label the following nerves and artery of the anterior leg.
Label the following muscles and tendons.
Label the following muscles of the leg.
Fill in the labels for the nerves and add on labels for the veins and arteries.
Label the following structures of the popliteal fossa.
Label the following structures of the leg.
Label the inferior view of the foot.
Label the following.
Tom, Dick and A Very Nervous Harry
Label what nerves supplying the following parts of the foot.
Label what dermatomes supply each part of the foot.
What are the three parts of the foot and the bones involved in each part?
- Hindfoot: Calcaneus and Talus
- Mid-foot: Navicular, Cuboid and Cuneiforms
- Forefoot: Metatarsals and Phalanges
What are the three articulations of the talus?
- Ankle joint (talocrural): superior between talus, tibia and fibula
- Subtalar joint: inferior between talus and calcaneus
- Talonavicular joint: anteriorly between talus and navicular
What is an issue with talus fracture and why?
- Avascular necrosis as no muscle attachments improving vascularity and blood supply is retrograde
What are the different joints of the calcaneus?
- Subtalar: Superior
- Calcaneocuboid: Anterior
Takes full weight of body when heel is on the ground and is marked by the calcaneal tuberosity
What are the different rows of the tarsals?
Proximal: Calcaneus and Talus
Intermediate: Navicular
Distal: Cuneiform and Cuboid
What are the different joints in the forefoot?
- Tarsometatarsal
- Intermetatarsal
- Metatarsophalangeal
Explain the makeup of the ankle joint and what movement occurs here?
- Only plantar and dorsiflexion
- Joint more stable in dorsiflexion as anterior part of talus is wider
- Synovial hinge joint
What are the ligaments supporting the ankle joint?
Lateral:
- Anterior talofibular: between lateral malleolus and neck of talus
- Posterior talofibular: Between malleolar fossa and lateral tubercle of talus
- Calcaneofibular: Between lateral malleolus and lateral calcaneus
Medial:
- Deltoid: Fans from medial malleolus to talus, calcaneus and navicular. Stronger and resists eversion
What muscles are involved in dorsiflexion and plantarflexion?
Dorsiflexion: Tibialis anterior, Extensor hallucis longus, extensor digitorum longus, peroneus tertius
Plantarflexion: Gatrocnemius, Soleus, Plantaris, Tibialis Posterior
What joint does inversion and eversion of the foot occur in and what muscles allow this?
- Subtalar, calcaneocuboid and talocalcaneonavicular NOT ankle
- Mainly occurs in subtalar, no flexion whatsover only in/eversion here
- Eversion: Lateral muscles (brevis and longus) and peroneus tertius from anterior
- Inversion: Tibialis anterior and posterior
What are the arches of the foot?
What is the medial arch of the foot maintained by?
- Calcaneus, talus, navicular, three cuneiforms, spring ligament (plantar calcaneonavicular), tibialis anterior and peroneus longus tendons
- Muscle support: TA, PL, tibialis posterior, peroneus longus and flexor hallucis longus
What is the lateral longitudinal arch maintained by?
- Formed: Calcaneus, Cuboid and lateral two metatarsals
- Support: Contraction of fibularis brevis
- Arch flattens when standing and bones lock together, ligaments binding so they become and immobile pedestal
What muscles are in the anterior compartment of the leg, what are they innervated by and what is the blood supply?
What are the origins and insertions of the muscles in the anterior compartment? (all passing under extensor retinacula)
- TA: origin at lateral surface of anterior tibia, and inserts on medial cuneiform and base of first metatarsal
- EDL: origin lateral condyle of tibia, medial fibula and interosseous membrane and inserts on middle and distal phalanges of dorsal four toes
- EHL: origin at medial fibula and crosses anterior to ankle joint to insert on base of distal phalanx of great toe
- Fibularis Tertius: origin at medial fibula, inferior to EDL, and inserts on base of 5th metatarsal
What are the muscles in the lateral compartment of the leg, the blood supply, the nerve supply and the action of the muscles?
- Fibularis longus (superficial) and Fibularis brevis (deep)
- Nerve: Superficial peroneal nerve
- Blood: Fibular artery
- Action: Both evert the foot and prevent excess inversion. Longus plantarflexes and supports medial and transverse arches. Brevis supports lateral arch.
What is the innervation and blood supply of the posterior muscles of the leg, and the action they have?
- Tibial nerve
- Posterior tibial artery
- Collectively plantarflex and invert the foot
- Superficial and deep compartment separated by fascia
What are the muscles of the superficial posterior compartment, what are their actions, origins and insertions?
- Plantaris: origin at lateral supracondylar line of femur and blends to calcaneal tendon. Can be harvested to use for a tendon elsewhere
- Gatrocnemius: origin from each femoral condyle and blends to calcaneal tendon to insert on calcaneal tuberosity
- Soleus: origin at tibial soleal line and proximal fibula, inserting to calcaneal tendon
What is the anatomy of the calcaneal tendon?
- Formed from blending of tendons of superficial posterior muscles
- Deep and superficial bursae
What are the muscles of the deep posterior compartment of the leg, their innervation, blood supply, action and origin/insertion?
- Posterior tibial artery
- Popliteus: origin at posterior tibia and inserts on lateral femoral condyle
- TPL: origin at posterior interosseous membrane and inserts on plantar surface of navicular and medial cuneiform
- FHL: origin at posterior fibula and inserts on distal phalanx of great toe
- FDL: origin at medial surface of tibia and inserts onto base of distal phalanc for each four toes
What is the anatomy of the tarsal tunnel?
- Located at the medial malleolus where all the structures run posteriorly to get to sole of foot
- Tom Dick and A Very Nervous Harry
What is the structure of the popliteal fossa, including borders and what runs through it? What is the clinical relevance of it?
- Protective passageway for neurovascular structures to pass through knee joint to lower limb
What is the course of the tibial nerve in the leg and what does it innervate? (L4 to S3)
- Innervates: skin of posterolateral leg, lateral foot and sole of the foot. Innervates posterior muscles too
- Passes through popliteal fossa and gives off branch that becomes sural nerve (skin of leg and foot) and a branch to posterior muscles
- At ankle passes through flexor retinaculum behind medial malleolus and divides into medial and lateral plantar nerves to supply sole of foot
What are the sensory branches of the tibial nerve, and what else does it innervate apart from the posterior muscles of the lower limb?
- Medial sural cutaneous nerve (joins with lateral sural cutaneous nerve from common peroneal to form sural nerve)
- Medial calcaneal branch
- Medial and lateral plantar nerve (motor to intrinsic muscles of foot)
- Also supplies intrinsic muscles of the foot
What areas does the common peroneal nerve innervate and what does it split off into?
- Root values: L4-S2
- Innervates: Short head of biceps femoris, skin of upper lateral leg, lateral sural cutaneous nerve supplying dorsum of foot
What areas do each of the following nerves supply?
- Sural Nerve
- Deep Peroneal Nerve
- Superficial Peroneal Nerve
- Formed from branches of tibial and common peroneal, passes behind lateral malleolus to supply skin over lateral dorsal foot. Can be harvested in reconstructive surgery as small area of parasthesia
- L4-L5. Anterior leg muscles by piercing intermuscular septum. Lies adjacent to anterior tibial artery. Cutaneously supplies first webspace
- L4 to S1. Lateral leg muscles then supploes anterolateral leg then middle dorsum of foot
What do the anterior and posterior tibial arteries travel alongside?
- Anterior with the deep peroneal nerve
- Posterior with the tibial nerve and two vena comitantes (tibial nerve)
Describe the course of the main arteries from the knee downwards?
- After anterior tibial artery it is called the tibioperoneal trunk
- Anterior artery goes though interosseous membrane to anterior compartment of the leg, passes under the extensor retinaculum and becomes dorsals pedis
- Posterior artery bifurcates at inferior border of popliteus and descends in posterior compatment, passes behind medial malleolus to enter sole of foot via tatsal tunnel
- Peroneal artery descends on medial sie of fibula in fibrous canal within deep posterior compartment, gives rise to perforating branches to penetrate IM septum to supply lateral compartment
Explain the positions of each of the three main arteries of the leg.
Say which compartment each bundle is in and what muscles it runs between
What is the blood supply to the foot?
- Posterior tibial: through tarsal tunnel and splits into lateral and medial plantar arteries, lateral contributing to supply of toes via plantar arch
- Dorsalis Pedis: anterior into dorsum of foot. Deep branch between first and second metatarsals to sole of foot where it anastomoses with lateral plantar to make plantar arch
Where are the pulses in the lower lumb?
- Femoral pulse: as enters femoral triangle, MIPA
- Popliteal artery: hardest as deep in fossa. flex leg to relax fascia making easier to find
- Dorsalis pedis: dorsum of foot lateral to extensor hallucis longus tendon
- Posterior tibial: in tarsal tunnel below and behind medial malleolus
Describe the course of the veins in the lower leg.
- Dorsal venous arch in foot drains into great and small saphenous vein at medial and lateral ends
- Accompanying veins of dorsal venous arch continue to leg as AT vein to drain anterior compartment
- Medial and lateral plantar veins from plantar venous arch to form PT vein. Pass behind medial malleolis and go into deep posterior compartment and drain the superficial and deep compartment
- Peroneal vein drains into posterior tibial vein at knee, which unites with anterior tibial vein to form popliteal vein.
- Popliteal enters thigh via adductor hiatus and becomes femoral vein
What is the function of the extensor retinaculum?
The extensor retinacula bind down the tendons of the muscles in the antero-lateral compartments and prevent them from bowstringing during movements at the ankle.
What are the surface markings of the great (long) and small (short) saphenous veins at the ankle?
The great (long) saphenous vein is sited anterior to the medial malleolus while the small (short) saphenous vein is sited posterior to the lateral malleolus.
What is the differential diagnosis (list of possible causes that should be considered) for a mass (swelling) in the popliteal fossa? State four diagnoses.
- Popliteal aneurysm
- Baker’s cyst
- Abscess
- Popliteal lymphadenopathy
- Thrombophlebitis of pop or short saphenous vein
- Tumour of muscle, bone or tissue
What is the transverse arch of the foot?
- Tarsals and base of metatarsals
- Peroneus longus and brevis with TP
- Talus is keystone
